ANALGESICS - TREATMENT OF PAIN ANALGESICS

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1 018 5 Tier Standard- Keystone First VIP Choice 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 10-1 /5 ml (5 ml), 10-1 /5 ml, /1.5 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 10-35,.5-35, 5-35, hydrocodone-ibuprofen oral tablet 10-00, 5-00, ibuprofen-oxycodone oral tablet oxycodone-acetaminophen oral tablet 10-35,.5-35, 5-35, PA; MO 1

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

3 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits naproxen oral tablet 50, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 75, 550 piroxicam oral capsule 10, 0 sulindac oral tablet 150, 00 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 /5 ml QL (100 ML per 30 days) methadone oral solution 5 /5 ml QL (400 ML per 30 days) methadone oral tablet 10 PA; QL (40 EA per 30 days) methadone oral tablet 5 QL (180 EA per 30 days) morphine oral tablet extended release 100, 00 morphine oral tablet extended release 15, 30, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 10, 15, 0, 30, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate injection solution 1 /ml, /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 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 (/ml) (5 ml), 10 /ml hydromorphone injection solution 1 /ml, /ml, 4 /ml hydromorphone injection syringe /ml PA; QL (10 EA per 30 days) hydromorphone oral tablet, 4, 8 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 /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 (10 EA per 30 days) nalbuphine injection solution 10 /ml, 0 /ml B/D oxycodone oral solution 5 /5 ml QL (5400 ML per 30 days) oxycodone oral tablet 10, 15, 0, 30, 5 QL (10 EA per 30 days) tramadol oral tablet 50 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 /ml (1 %), 5 /ml (0.5 %) lidocaine hcl injection solution 5 /ml (0.5 %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % 4

5 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits lidocaine hcl mucous membrane solution 4 % (40 /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 disulfiram oral tablet 50, 500 naltrexone oral tablet 50 OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml naloxone injection syringe 1 /ml 5

6 Drug Name Drug Tier Requirements/Limits SMOKING CESSATION AGENTS buproban oral tablet extended release 1 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 (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 /4 ml, 500 / ml gentak ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin injection solution 0 / ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin sulfate (ped) (pf) injection solution 0 / 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 50 streptomycin intramuscular recon soln 1 gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % 6

7 018 5 Tier Standard- Keystone First VIP Choice 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 /5 ml 5 B/D tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection recon soln 1. 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 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, 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 clindamycin palmitate hcl oral recon soln 75 /5 ml 4 MO clindamycin pediatric oral recon soln 75 /5 ml 7

8 Drug Name Drug Tier Requirements/Limits clindamycin phosphate injection solution 150 (/ml) (6 ml), 150 /ml clindamycin phosphate intravenous solution 300 / 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 % clindamycin-benzoyl peroxide topical gel 1. %(1 % base) -5 % colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln 500 lincomycin injection solution 300 /ml linezolid intravenous parenteral solution 600 /300 ml linezolid oral suspension for reconstitution 100 /5 ml ; MO linezolid oral tablet 600 ; MO linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml 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 50, 500 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

9 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits 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 40-00,000 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-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , unit-/ml nitrofurantoin macrocrystal oral capsule 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 nitrofurantoin monohyd/m-cryst oral capsule 100 (75/5) 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 ; QL (360 EA per 365 days) ; QL (180 EA per 365 days) ; QL (360 EA per 365 days) trimethoprim oral tablet 100 vancomycin in 0.9 % sodium chl intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin in 0.9 % sodium chl intravenous solution 1.5 gram/50 ml, 750 /150 ml B/D; MO B/D; MO 9

10 Drug Name Drug Tier Requirements/Limits vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml B/D vancomycin injection recon soln 100 gram B/D; MO vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 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, 500 cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /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 15 /5 ml, 50 /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 cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, gram 10

11 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 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, 500 ceftriaxone injection recon soln 100 gram ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium intravenous recon soln 1.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 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

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

13 018 5 Tier Standard- Keystone First VIP Choice 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, 500 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 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 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, 500 ( /ml) azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50, 50 (6 pack), 500, 500 (3 pack), 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 ery pads topical swab % 13

14 Drug Name Drug Tier Requirements/Limits erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml 4 MO erythromycin ethylsuccinate oral tablet 400 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) erythromycin oral tablet 50, 500 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, ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100 ciprofloxacin hcl oral tablet 50, 500, 750 ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml levofloxacin in d5w intravenous piggyback 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500 levofloxacin oral tablet 750 MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin in nacl (iso-osm) intravenous piggyback 400 /50 ml moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 moxifloxacin-sod.ace,sul-water intravenous piggyback 400 /50 ml

15 018 5 Tier Standard- Keystone First VIP Choice 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, 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 100 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 150, 50, 75 minocycline oral capsule 100, 50, 75 15

16 Drug Name Drug Tier Requirements/Limits minocycline oral tablet 100, 50, 75 MORGIDOX 1X 50 KIT 50 MG morgidox oral capsule 50 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 /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, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 ROWEEPRA ORAL TABLET 1,000 MG, 750 MG ; MO 16 roweepra oral tablet 500 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 ethosuximide oral solution 50 /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)

17 018 5 Tier Standard- Keystone First VIP Choice 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, 5, 50 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 ; QL (40 EA per 30 days) diazepam rectal kit.5 ; QL (5 EA per 30 days) diazepam rectal kit ; QL (0 EA per 30 days) divalproex oral capsule, delayed rel sprinkle 15 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 15, 50, 500 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 50 /5 ml, 50 /5 ml (5 ml), 300 /6 ml (6 ml) gabapentin oral tablet 600, 800 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 /5 ml (4 /ml) PA; MO phenobarbital oral tablet 100, 15, 16., 30, 3.4, 60, 64.8, 97. PA; MO primidone oral tablet 50, 50 SABRIL ORAL POWDER IN PACKET 500 MG 4 PA SABRIL ORAL TABLET 500 MG 4 PA; QL (180 EA per 30 days) 17

18 Drug Name Drug Tier Requirements/Limits tiagabine oral tablet, 4 valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml, 50 /5 ml (5 ml), 500 /10 ml (10 ml) valproic acid oral capsule 50 vigabatrin oral powder in packet PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 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, 150, 00, 5 lamotrigine oral tablet extended release 4hr 100, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable dispersible 5, 5 4 ST; MO; QL (30 EA per 30 days) topiramate oral capsule, sprinkle 15, 5 topiramate oral tablet 100, 00, 5, 50 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, 00, 300 carbamazepine oral suspension 100 /5 ml carbamazepine oral tablet 00 18

19 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits carbamazepine oral tablet extended release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 DILANTIN ORAL CAPSULE 30 MG 4 MO epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 MG, 00 MG, 300 MG fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml oxcarbazepine oral suspension 300 /5 ml (60 /ml) 4 MO oxcarbazepine oral tablet 150, 300, 600 PEGANONE ORAL TABLET 50 MG 4 MO PHENYTEK ORAL CAPSULE 00 MG, 300 MG phenytoin oral suspension 100 /4 ml, 15 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 100, 00, 300 phenytoin sodium intravenous solution 50 /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 PA; MO CHOLINESTERASE INHIBITORS donepezil oral tablet 10, 3, ST; MO; QL (60 EA per 30 days) 19

20 Drug Name Drug Tier Requirements/Limits donepezil oral tablet,disintegrating 10, 5 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 rivastigmine transdermal patch 4 hour 13.3 /4 hour, 4.6 /4 hr, 9.5 /4 hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 4hr 14, 1, 8, 7 memantine oral tablet 10, 5 memantine oral tablets,dose pack 5-10 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 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, 75 bupropion hcl oral tablet extended release 1 hr 100, 150, 00 bupropion hcl oral tablet extended release 4 hr 150, 300 FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 MG mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 15, 30, 45 nefazodone oral tablet 100, 150, 00, 50, 50 perphenazine-amitriptyline oral tablet -10, - 5, 4-10, 4-5, 4-50 trazodone oral tablet 100, 150, 300, 50 MONOAMINE OXIDASE INHIBITORS 4 MO PA; MO 0

21 018 5 Tier Standard- Keystone First VIP Choice 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 tranylcypromine oral tablet 10 SSRIS/ SNRIS citalopram oral solution 10 /5 ml citalopram oral tablet 10, 0, 40 desvenlafaxine succinate oral tablet extended release 4 hr 100, 5, 50 duloxetine oral capsule,delayed release(dr/ec) 0, 30, 60 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0, 5 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, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 10, 0 fluvoxamine oral tablet 100, 5, 50 maprotiline oral tablet 5, 50, 75 paroxetine hcl oral tablet 10, 0, 30, 40 paroxetine hcl oral tablet extended release 4 hr 1.5, 5, 37.5 PAXIL ORAL SUSPENSION 10 MG/5 ML 4 MO 1

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

23 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits chlorpromazine oral tablet 10, 100, 00, 5, 50 compro rectal suppository 5 diphenhydramine hcl injection solution 50 /ml PA; MO meclizine oral tablet 1.5, 5 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 10, 5 perphenazine oral tablet 16,, 4, 8 phenadoz rectal suppository 1.5 PA; MO prochlorperazine edisylate injection solution 10 / ml (5 /ml), 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 5 promethazine oral syrup 6.5 /5 ml PA; MO promethazine oral tablet 1.5, 5, 50 PA; MO promethazine rectal suppository 1.5, 5 PA; MO promethegan rectal suppository 5, 50 PA; MO scopolamine base transdermal patch 3 day 1 over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS 4 MO trimethobenzamide oral capsule 300 PA; MO EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 15, 40, 80 B/D; MO aprepitant oral capsule,dose pack 15 (1)- 80 () B/D; MO dronabinol oral capsule 10,.5, 5 B/D; MO EMEND ORAL SUSPENSION FOR RECONSTITUTION 15 MG (5 MG/ ML FINAL CONC.) 4 B/D; MO 3

24 Drug Name Drug Tier Requirements/Limits 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 granisetron hcl oral tablet 1 B/D; MO ondansetron hcl (pf) injection solution 4 / ml ondansetron hcl (pf) injection syringe 4 / ml ondansetron hcl intravenous solution /ml ondansetron hcl oral solution 4 /5 ml B/D; MO ondansetron hcl oral tablet 4 B/D; MO; QL (15 EA per 30 days) ondansetron hcl oral tablet 4, 8 1 B/D; MO ondansetron oral tablet,disintegrating 4, 8 B/D; MO SYNDROS ORAL SOLUTION 5 MG/ML ; MO ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS abelcet intravenous suspension 5 /ml B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 4 B/D amphotericin b injection recon soln 50 B/D CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50, 70 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 4 PA 4

25 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits fluconazole in dextrose(iso-o) intravenous piggyback 00 /100 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 100 /50 ml, 00 /100 ml, 400 /00 ml fluconazole oral suspension for reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 00, 50 flucytosine oral capsule 50 flucytosine oral capsule 500 griseofulvin microsize oral suspension 15 /5 ml itraconazole oral capsule 100 ketoconazole oral tablet 00 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

26 Drug Name Drug Tier Requirements/Limits nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) 5 MO voriconazole oral tablet 00 5 MO voriconazole oral tablet 50 ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS 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 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

27 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits 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 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.5 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.5 % dexamethasone intensol oral drops 1 /ml dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5,, 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 %, 0.05 % fluocinolone topical ointment 0.05 % 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 % 7

28 Drug Name Drug Tier Requirements/Limits fluocinonide-e topical cream 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 %,.5 % hydrocortisone topical cream with perineal applicator 1 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 %,.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 16, 3, 4, 8 8 methylprednisolone oral tablets,dose pack 4 methylprednisolone sodium succ injection recon soln 15, 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), 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml)

29 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits prednisone oral solution 5 /5 ml prednisone oral tablet 1, 10,.5, 0, 5, 50 prednisone oral tablets,dose pack 10, 10 (48 pack) prednisone oral tablets,dose pack 5, 5 (48 pack) RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, MG, 5 MG triamcinolone acetonide topical cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % 4 MO triderm topical cream 0.1 % ANTIMIGRAINE AGENTS - TREATMENT OF MIGRAINE HEADACHES ERGOT ALKALOIDS dihydroergotamine injection solution 1 /ml PA; MO 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 (1 EA per 30 days) rizatriptan oral tablet,disintegrating 10, 5 ; QL (1 EA per 30 days) sumatriptan nasal spray,non-aerosol 0 /actuation, 5 /actuation sumatriptan succinate oral tablet 100, 5, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml ; QL (1 EA per 30 days) ; QL (1 EA per 30 days) ; QL (4 ML per 30 days) 9

30 Drug Name Drug Tier Requirements/Limits 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 - TREATMENT OF MYASTHENIA PARASYMPATHOMIMETICS guanidine oral tablet 15 pyridostigmine bromide oral tablet 60 ; QL (4 ML per 30 days) ; QL (4 ML per 30 days) ; QL (4 ML per 30 days) ANTIMYCOBACTERIALS - TREATMENT FOR INFECTIONS BY TUBERCULOSIS- TYPE ORGANISMS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100, 5 rifabutin oral capsule 150 ANTITUBERCULARS CAPASTAT INJECTION RECON SOLN 1 GRAM ethambutol oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM 4 4 MO PRIFTIN ORAL TABLET 150 MG 4 MO pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG 4 MO SIRTURO ORAL TABLET 100 MG ; MO TRECATOR ORAL TABLET 50 MG 4 MO ANTINEOPLASTICS - TREATMENT OF CANCER ALKYLATING AGENTS 30

31 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits BICNU INTRAVENOUS RECON SOLN 100 MG 4 PA busulfan intravenous solution 60 /10 ml carboplatin intravenous recon soln 150 B/D carboplatin intravenous solution 10 /ml B/D cisplatin intravenous solution 1 /ml B/D cyclophosphamide oral capsule 5, 50 B/D; MO dacarbazine intravenous recon soln 00 B/D EMCYT ORAL CAPSULE 140 MG 4 PA; MO GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG 4 PA HEXALEN ORAL CAPSULE 50 MG 4 PA ifosfamide intravenous recon soln 1 gram 4 B/D LEUKERAN ORAL TABLET MG 3 MATULANE ORAL CAPSULE 50 MG 4 melphalan hcl intravenous recon soln 50 5 B/D MUSTARGEN INJECTION RECON SOLN 10 MG 4 PA oxaliplatin intravenous recon soln 100 B/D oxaliplatin intravenous solution 100 /0 ml B/D TEPADINA INJECTION RECON SOLN 100 MG, 15 MG 5 B/D thiotepa injection recon soln 15 5 B/D TREANDA INTRAVENOUS RECON SOLN 100 MG, 5 MG VALCHLOR TOPICAL GEL % 5 MO ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ANTIANDROGENS 4 PA bicalutamide oral tablet 50 31

32 Drug Name Drug Tier Requirements/Limits ERLEADA ORAL TABLET 60 MG flutamide oral capsule 15 nilutamide oral tablet 150 XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 50 MG, 500 MG ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG ANTIESTROGENS/MODIFIERS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML ; LA PA; MO FARESTON ORAL TABLET 60 MG 4 PA; MO FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML 4 ; MO tamoxifen oral tablet 10, 0 ANTIMETABOLITES ALIMTA INTRAVENOUS RECON SOLN 500 MG ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML cladribine intravenous solution 10 /10 ml 5 B/D cytarabine (pf) injection solution 100 /5 ml (0 /ml), gram/0 ml (100 /ml), 0 /ml B/D cytarabine injection solution 0 /ml B/D DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG 4 MO fludarabine intravenous recon soln 50 4 PA fluorouracil intravenous solution 1 gram/0 ml,.5 gram/50 ml, 5 gram/100 ml, 500 /10 ml B/D fluorouracil topical cream 0.5 %, 5 %

33 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits fluorouracil topical solution %, 5 % gemcitabine intravenous recon soln 1 gram, gram, 00 gemcitabine intravenous solution 1 gram/6.3 ml (38 /ml), gram/5.6 ml (38 /ml), 00 /5.6 ml (38 /ml) 5 B/D 5 B/D gemcitabine intravenous solution 100 /ml B/D hydroxyurea oral capsule 500 mercaptopurine oral tablet 50 NIPENT INTRAVENOUS RECON SOLN 10 MG PURIXAN ORAL SUSPENSION 0 MG/ML 5 MO TABLOID ORAL TABLET 40 MG 4 PA ANTINEOPLASTICS adriamycin intravenous solution 0 /10 ml B/D docetaxel intravenous solution 0 /ml 4 B/D KADCYLA INTRAVENOUS RECON SOLN 160 MG PICATO TOPICAL GEL %, 0.05 % ; MO ANTINEOPLASTICS, OTHER azacitidine injection recon soln 100 BELEODAQ INTRAVENOUS RECON SOLN 500 MG bleomycin injection recon soln 30 unit B/D BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG clofarabine intravenous solution 0 /0 ml dactinomycin intravenous recon soln 0.5 ; MO daunorubicin intravenous solution 5 /ml B/D decitabine intravenous recon soln 50 5 B/D dexrazoxane hcl intravenous recon soln 50 4 B/D 33

34 Drug Name Drug Tier Requirements/Limits doxorubicin intravenous solution 50 /5 ml B/D doxorubicin, peg-liposomal intravenous suspension /ml PA epirubicin intravenous solution 00 /100 ml 4 B/D ERWINAZE INJECTION RECON SOLN 10,000 UNIT FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG fludarabine intravenous solution 50 / ml 4 PA FUSILEV INTRAVENOUS RECON SOLN 50 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/ ML (0.5 MG/ML) 5 B/D idarubicin intravenous solution 1 /ml B/D ISTODAX INTRAVENOUS RECON SOLN 10 MG/ ML KADCYLA INTRAVENOUS RECON SOLN 100 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG, 400 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG leucovorin calcium injection recon soln 100, 00, 350, 50, 500 leucovorin calcium oral tablet 10, 15, 5, 5 B/D levoleucovorin intravenous recon soln 50 B/D levoleucovorin intravenous solution 10 /ml B/D; MO LONSURF ORAL TABLET MG, MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG 34

35 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits mesna intravenous solution 100 /ml B/D MESNEX ORAL TABLET 400 MG 4 mitomycin intravenous recon soln 0, 40, 5 NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG B/D ODOMZO ORAL CAPSULE 00 MG PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT ROMIDEPSIN INTRAVENOUS RECON SOLN 10 MG/ ML RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG SYLATRON SUBCUTANEOUS KIT 00 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, MG/ML 4 PA VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 PA VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG vinblastine intravenous solution 1 /ml B/D vincristine intravenous solution 1 /ml B/D vinorelbine intravenous solution 50 /5 ml 4 B/D 35

36 Drug Name Drug Tier Requirements/Limits VYXEOS INTRAVENOUS RECON SOLN MG YONDELIS INTRAVENOUS RECON SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 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 5 letrozole oral tablet.5 ENZYME INHIBITORS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG docetaxel intravenous solution 10 /ml 4 B/D; MO docetaxel intravenous solution 160 /16 ml (10 /ml), 160 /8 ml (0 /ml), 0 / ml (10 /ml), 0 /ml (1 ml), 80 /4 ml (0 /ml), 80 /8 ml (10 /ml) ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG 4 B/D 4 PA etoposide intravenous solution 0 /ml B/D IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG irinotecan intravenous solution 100 /5 ml 4 B/D JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) mitoxantrone intravenous concentrate /ml paclitaxel intravenous concentrate 6 /ml B/D topotecan intravenous recon soln 4 topotecan intravenous solution 4 /4 ml (1 /ml) MOLECULAR TARGET INHIBITORS 36

37 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (3) BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAPRELSA ORAL TABLET 100 MG, 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 140 MG/DAY(80 MG X1-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG ERIVEDGE ORAL CAPSULE 150 MG GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG ICLUSIG ORAL TABLET 15 MG, 45 MG IDHIFA ORAL TABLET 100 MG, 50 MG imatinib oral tablet 100, PA IMBRUVICA ORAL CAPSULE 140 MG INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 37

38 Drug Name Drug Tier Requirements/Limits 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 X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) MEKINIST ORAL TABLET 0.5 MG, MG NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 00 MG OFEV ORAL CAPSULE 100 MG, 150 MG RYDAPT ORAL CAPSULE 5 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 1.5 MG, 5 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, 5 MG TASIGNA ORAL CAPSULE 150 MG, 00 MG TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TYKERB ORAL TABLET 50 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 40 MG ZYKADIA ORAL CAPSULE 150 MG MONOCLONAL ANTIBODIES AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) 38

39 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 0 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML HERCEPTIN INTRAVENOUS RECON SOLN 150 MG 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 5 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, 40 MG/4 ML PERJETA INTRAVENOUS SOLUTION 40 MG/14 ML (30 MG/ML) RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (10 MG/ML), 1600 MG/13.4 ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML, 10 MG/ML (10 ML) TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) 39

40 Drug Name Drug Tier Requirements/Limits VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) RETINOIDS bexarotene oral capsule 75 5 PANRETIN TOPICAL GEL 0.1 % 3 PA; MO TARGRETIN TOPICAL GEL 1 % 3 PA tretinoin (chemotherapy) oral capsule 10 5 ANTIPARASITICS - TREATMENT OF INFECTIONS FROM PARASITES ANTHELMINTICS ALBENZA ORAL TABLET 00 MG 4 MO benznidazole oral tablet 100, PA; MO BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 ANTIPROTOZOALS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 4 MO ALINIA ORAL TABLET 500 MG 4 MO atovaquone oral suspension 750 /5 ml 5 MO atovaquone-proguanil oral tablet , chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-10 MG 4 MO DARAPRIM ORAL TABLET 5 MG 4 hydroxychloroquine oral tablet 00 mefloquine oral tablet 50 NEBUPENT INHALATION RECON SOLN 300 MG 4 B/D PENTAM INJECTION RECON SOLN 300 MG 4 PA PRIMAQUINE ORAL TABLET 6.3 MG 4 MO quinine sulfate oral capsule 34 PEDICULICIDES/ SCABICIDES 40

41 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % ANTIPARKINSON AGENTS - TREATMENT OF PARKINSON'S DISEASE ANTICHOLINERGICS benztropine oral tablet 0.5, 1, PA; MO trihexyphenidyl oral elixir 0.4 /ml PA; MO trihexyphenidyl oral tablet, 5 PA; MO 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 00 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 4HR 137 MG, 68.5 MG ; MO tolcapone oral tablet 100 DOPAMINE AGONISTS bromocriptine oral capsule 5 bromocriptine oral tablet.5 NEUPRO TRANSDERMAL PATCH 4 HOUR 1 MG/4 HOUR, MG/4 HOUR, 3 MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR pramipexole oral tablet 0.15, 0.5, 0.5, 0.75, 1, 1.5 pramipexole oral tablet extended release 4 hr 0.375, 0.75, 1.5,.5, 3, 3.75, PA; MO 41

42 Drug Name Drug Tier Requirements/Limits ropinirole oral tablet 0.5, 0.5, 1,, 3, 4, 5 DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa oral tablet , 5-100, 5-50 carbidopa-levodopa oral tablet extended release 5-100, MONOAMINE OXIDASE B (MAO-B) INHIBITORS rasagiline oral tablet 0.5, 1 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS - TREATMENT OF BEHAVIORAL AND EMOTIONAL DISORDERS 1ST GENERATION/ TYPICAL fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet 1, 10,.5, 5 haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5, 1, 10,, 0, 5 loxapine succinate oral capsule 10 ; QL (10 EA per 30 days) loxapine succinate oral capsule 5, 50 loxapine succinate oral capsule 5 ; QL (90 EA per 30 days) pimozide oral tablet 1, thioridazine oral tablet 10, 100, 5, 50 PA; MO thiothixene oral capsule 1, 10,, 5 4

43 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: Updated: 03/018 Effective Date: Drug Name Drug Tier Requirements/Limits trifluoperazine oral tablet 1, 10,, 5 ND GENERATION/ ATYPICAL abilify maintena intramuscular suspension,extended rel recon 300 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG abilify maintena intramuscular suspension,extended rel syring 300, 400 ; QL (1 EA per 8 days) ; QL (1 EA per 8 days) ; QL (1 EA per 8 days) aripiprazole oral solution 1 /ml 5 MO; QL (900 ML per 30 days) aripiprazole oral tablet 10, 15,, 0, 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 66 MG/.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/3. ML ; QL (30 EA per 30 days) 5 MO; QL (60 EA per 30 days) ; QL (3.9 ML per 56 days) ; QL (1.6 ML per 8 days) ; QL (.4 ML per 8 days) ; QL (3. ML per 8 days) FANAPT ORAL TABLET 1 MG, MG, 4 MG 4 ST; MO; QL (60 EA per 30 days) FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG()-MG()- 4MG()-6MG() GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) 5 ST; MO; QL (60 EA per 30 days) 4 ST; MO 4 PA; QL (1 EA per 30 days) 43

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