ANALGESICS - TREATMENT OF PAIN ANALGESICS

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1 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug ANALGESICS - TREATMENT OF PAIN ANALGESICS 8 HOUR ER 650 MG CAPLET MUSCLE ACHES & PAIN 650 MG ACEPHEN 325 MG SUPPOSITORY 325 MG ACEPHEN 650 MG SUPPOSITORY OUTER 650 MG acetaminophen 120 mg suppos inner 120 mg acetaminophen 160 mg/5 ml elx 160 mg/5 ml acetaminophen 325 mg tablet 325 mg acetaminophen 500 mg caplet caplet,ex-strength 500 mg acetaminophen 500 mg tablet asa-free,ex-str 500 mg acetaminophen 650 mg suppos 650 mg acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), mg/5 ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg, mg ARTHRITIS PAIN ER 650 MG CAPLT CAPLET 650 MG ARTHRITIS PAIN ER 650 MG CAPLT CAPLET 650 MG ARTHRITIS PAIN RELIEF ER 650 MG CAPLET CAPLET 650 MG ascomp with codeine oral capsule mg butalbital compound w/codeine oral capsule mg $0 (Tier 1) PA; MO $0 (Tier 1) PA; MO 1

2 Name of Drug butalbital-acetaminop-caf-cod oral capsule mg $0 (Tier 1) PA; MO butalbital-acetaminophen oral tablet mg $0 (Tier 1) PA; MO butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg $0 (Tier 1) PA; MO $0 (Tier 1) PA; MO $0 (Tier 1) PA; MO capsaicin 0.025% cream % carisoprodol-asa-codeine oral tablet mg $0 (Tier 1) PA; MO carisoprodol-aspirin oral tablet mg $0 (Tier 1) PA; MO codeine-butalbital-asa-caff oral capsule mg $0 (Tier 1) PA; MO GS PAIN RELIEF 500 MG CAPLET 500 MG HM ARTHRITIS PAIN ER 650 MG CAPLET, 8 HOUR 650 MG HM PAIN RELIEF 500 MG CAPLET CAPLET, EX-STRENGTH 500 MG HM PAIN RELIEF 500 MG TABLET EX-STR, GLUTEN-FREE 500 MG HM PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg ibuprofen-oxycodone oral tablet mg $0 (Tier 1) MAPAP 325 MG TABLET U-D 325 MG MAPAP 500 MG CAPLET CAPLET 500 MG MAPAP 500 MG CAPLET CAPLET,BOXED 500 MG MAPAP ARTHRITIS ER 650 MG CPLT 650 MG MAPAP PM CAPLET MG 2

3 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug MUSCLE RUB CREAM % MUSCLE RUB CREAM ULTRA STRENGTH % oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet mg PAIN & FEVER 500 MG CAPLET CAPLET 500 MG PAIN & FEVER 500 MG CAPLET CAPTABS 500 MG PAIN RELIEF 500 MG CAPLET CAPLET, EX- STRENGTH 500 MG PAIN RELIEF 500 MG CAPLET EXTRA STR, CAPLET 500 MG PAIN RELIEF ER 650 MG CAPLET CAPLET, 8 HOUR 650 MG PAIN RELIEF ER 650 MG CAPLET CAPLET, ARTHRITIS 650 MG PAIN RELIEVER 325 MG TABLET 325 MG PAIN RELIEVER 500 MG CAPLET CAPLET,X- STRENGTH 500 MG PAIN RELIEVER 500 MG CAPLET EX-STR, CAPLET 500 MG PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG pentazocine-naloxone oral tablet mg $0 (Tier 1) PA; MO pramoxine hcl 1% foam 12's, non-steroid 1 % QC ARTHRITIS PAIN ER 650 MG CAPLET 650 MG QC NON-ASPIRIN 500 MG CAPLET CAPLET,EX-STRENGTH 500 MG 3

4 Name of Drug QC NON-ASPIRIN 500 MG CAPLET XTRA STRENGTH,CAPLET 500 MG QC NON-ASPIRIN 500 MG TABLET EXTRA STRENGTH 500 MG QC NON-ASPIRIN PAIN RELIEF TB EXTRA STRENGTH 500 MG QC NON-ASPIRIN PM CAPLET CAPLET, EX- STRENGTH MG Q-PAP 325 MG TABLET 325 MG Q-PAP EX-STR 500 MG TABLET 500 MG Q-PAP EX-STR 500 MG TABLET ASPIRIN FREE 500 MG SM 8 HOUR PAIN RELIEF 650 MG CAPLET 650 MG SM PAIN RELIEVER 325 MG TABLET 325 MG SM PAIN RELIEVER 500 MG CAPLET CAPLET, EXTRA STR 500 MG SM PAIN RELIEVER 500 MG CAPLET CAPLET, EXTRA STR 500 MG SM PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG tramadol-acetaminophen oral tablet mg NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ADVIL 200 MG LIQUI-GEL CAPSULE LIQUID GEL 200 MG ALL DAY PAIN RELIEF 220 MG TAB 220 MG ALL DAY PAIN RLF 220 MG CAPLET CAPLET 220 MG aspirin 325 mg coated tablet coated 325 mg aspirin 325 mg tablet 325 mg aspirin 325 mg tablet 5 grain 325 mg aspirin coated 325 mg tablet coated 325 mg aspirin ec 325 mg tablet 325 mg aspirin ec 325 mg tablet orange 325 mg 4

5 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug aspirin ec 325 mg tablet safety-coated 325 mg celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg COMFORT PAC-IBUPROFEN KIT 800 MG COMFORT PAC-MELOXICAM KIT 15 MG COMFORT PAC-NAPROXEN KIT 500 MG diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 %, 3 % DICLOZOR TOPICAL KIT 1 % diflunisal oral tablet 500 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg gs aspirin 325 mg tablet 325 mg hm aspirin ec 325 mg tablet reg strength 325 mg ibuprofen 200 mg caplet caplet 200 mg ibuprofen 200 mg caplet coated caplet 200 mg ibuprofen 200 mg tablet 200 mg ibuprofen 200 mg tablet coated 200 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg $0 (Tier 1) PA; MO 5

6 Name of Drug indomethacin oral capsule, extended release 75 mg $0 (Tier 1) PA; MO ketoprofen oral capsule 50 mg, 75 mg ketorolac oral tablet 10 mg $0 (Tier 1) PA; MO meclofenamate oral capsule 100 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 10 mg, 20 mg qc aspirin ec 325 mg tablet regular strength 325 mg sm aspirin 325 mg tablet 325 mg sm aspirin ec 325 mg tablet reg-str, gluten-free 325 mg sulindac oral tablet 150 mg, 200 mg ZORVOLEX ORAL CAPSULE 18 MG, 35 MG $0 (Tier 2) ST; MO 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 $0 (Tier 1) PA; MO; QL (10 EA per 30 days) fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour ; QL (10 EA per 30 days) $0 (Tier 1) QL (10 EA per 30 days) methadone oral solution 10 mg/5 ml ; QL (1200 ML per 30 days) methadone oral solution 5 mg/5 ml ; QL (2400 ML per 30 days) methadone oral tablet 10 mg $0 (Tier 1) PA; MO; QL (240 EA per 30 days) methadone oral tablet 5 mg ; QL (180 EA per 30 days) 6

7 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug morphine oral tablet extended release 100 mg, 200 mg morphine oral tablet extended release 15 mg, 30 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml butorphanol tartrate nasal spray,non-aerosol 10 mg/ml duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml 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 (mg/ml) (5 ml) $0 (Tier 1) PA; MO; QL (60 EA per 30 days) ; QL (60 EA per 30 days) $0 (Tier 1) PA; QL (60 EA per 30 days) $0 (Tier 1) QL (5 ML per 30 days) $0 (Tier 1) B/D; MO $0 (Tier 1) PA; MO; QL (120 EA per 30 days) $0 (Tier 1) hydromorphone (pf) injection solution 10 mg/ml hydromorphone injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml $0 (Tier 1) hydromorphone injection syringe 2 mg/ml hydromorphone oral tablet 2 mg, 4 mg, 8 mg ; QL (120 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 400 MCG/SPRAY ; MO; QL (600 EA per 30 days) ; QL (150 EA per 30 days) ; MO; QL (150 EA per 30 days) meperidine oral solution 50 mg/5 ml $0 (Tier 1) PA; MO; QL (900 ML per 30 days) meperidine oral tablet 100 mg, 50 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days) 7

8 Name of Drug morphine oral tablet 15 mg, 30 mg ; QL (120 EA per 30 days) nalbuphine injection solution 10 mg/ml, 20 mg/ml $0 (Tier 1) B/D oxycodone oral solution 5 mg/5 ml ; QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg ; QL (120 EA per 30 days) tramadol oral tablet 50 mg ; QL (240 EA per 30 days) ANESTHETICS - LOCAL TREATMENT OF PAIN LOCAL ANESTHETICS ACCUCAINE KIT KIT 10 MG/ML (1 %) ANODYNE LPT TOPICAL KIT % dermacinrx empricaine topical kit % dibucaine 1% ointment 1 % LEVA SET TOPICAL KIT % lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 5 mg/ml (0.5 %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane jelly in applicator 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % $0 (Tier 1) PA; MO; 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 % 8

9 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug livixil pak topical kit % MEDOLOR PAK TOPICAL KIT % prilolid topical kit % PUB HEMORRHOIDAL SUPPOSITORIES % SM HEMORRHOIDAL CREAM % ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF SUBSTANCE ABUSE DISORDERS ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone oral tablet 50 mg OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg OPIOID REVERSAL AGENTS naloxone injection solution 0.4 mg/ml naloxone injection syringe 1 mg/ml SMOKING CESSATION AGENTS buproban oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG ; QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) ; QL (106 EA per 365 days) 9

10 Name of Drug NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR NICODERM CQ 21 MG/24HR PATCH CLEAR PATCH 21 MG/24 HR NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR nicotine 14 mg/24hr patch clear, step 2, outer (otc) 14 mg/24 hr nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr nicotine 2 mg lozenge cinnamon,quittube 2 mg nicotine 21 mg/24hr patch outer, clear, step 1 (otc) 21 mg/24 hr nicotine 4 mg chewing gum 4 mg nicotine 4 mg lozenge mint 4 mg nicotine 7 mg/24hr patch outer, clear, step 3 (otc) 7 mg/24 hr NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML sm nicotine 2 mg chewing gum mint 2 mg ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS AMINOGLYCOSIDES amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) $0 (Tier 1) gentamicin injection solution 20 mg/2 ml $0 (Tier 1) gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml $0 (Tier 1) 10

11 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml $0 (Tier 1) gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % neomycin oral tablet 500 mg paromomycin oral capsule 250 mg streptomycin intramuscular recon soln 1 gram $0 (Tier 1) TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml $0 (Tier 1) B/D tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection recon soln 1.2 gram $0 (Tier 1) tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ANTIBACTERIALS, OTHER $0 (Tier 1) $0 (Tier 1) B/D acetic acid otic (ear) solution 2 % ak-poly-bac ophthalmic (eye) ointment ,000 unit/gram ANTIBIOTIC OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM bacitracin 500 unit/gm ointmnt 500 unit/gram bacitracin ophthalmic (eye) ointment 500 unit/gram 11

12 Name of Drug bacitracin zn 500 unit/gm oint 5 panel carton 500 unit/gram bacitracin zn 500 unit/gm oint 500 unit/gram bacitracin zn 500 unit/gm oint usp 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram bacitracin-polymyxin ointment ,000 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % BETADINE 10% SOLUTION ANTISEPTIC 10 % BETASEPT 4% SURGICAL SCRUB 4 % CASTELLANI PAINT MODIFIED 1.5 % chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 0.9 % sod chlor intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 mg/5 ml $0 (Tier 1) clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous solution 300 mg/2 ml, 600 mg/4 ml, 900 mg/6 ml $0 (Tier 1) $0 (Tier 1) clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % 12

13 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug clindamycin phosphate vaginal cream 2 % clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % colistin (colistimethate na) injection recon soln 150 mg $0 (Tier 1) daptomycin intravenous recon soln 500 mg $0 (Tier 1) PA FIRST AID ABX PAIN RELIEF CRM , MG-UNIT-MG/GRAM lincomycin injection solution 300 mg/ml $0 (Tier 1) linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml $0 (Tier 1) PA $0 (Tier 1) PA; MO linezolid oral tablet 600 mg $0 (Tier 1) PA; MO linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml $0 (Tier 1) PA methenamine hippurate oral tablet 1 gram metro i.v. intravenous piggyback 500 mg/100 ml $0 (Tier 1) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml $0 (Tier 1) metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical gel with pump 1 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment 2 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-1% 13

14 Name of Drug neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , mg-unit-mg/ml nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml RA TRIPLE ANTIBIOTIC PLUS OINT ,000 MG-UNIT-UNIT/G SM ANTIBIOTIC 500 UNIT/GM OINT 500 UNIT/GRAM SYNERCID INTRAVENOUS RECON SOLN 500 MG ; QL (360 EA per 365 days) ; QL (180 EA per 365 days) ; QL (360 EA per 365 days) $0 (Tier 1) trimethoprim oral tablet 100 mg TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM TRIPLE ANTIBIOTIC OINTMENT CARTON 3.5MG-400 UNIT- 5,000 UNIT/GRAM vancomycin in 0.9 % sodium chl intravenous piggyback 1 gram/200 ml, 500 mg/100 ml, 750 mg/150 ml $0 (Tier 1) B/D; MO 14

15 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug vancomycin in 0.9 % sodium chl intravenous solution 1.25 gram/250 ml, 750 mg/150 ml vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 500 mg/100 ml, 750 mg/150 ml $0 (Tier 1) B/D; MO $0 (Tier 1) B/D vancomycin injection recon soln 100 gram $0 (Tier 1) B/D; MO vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg $0 (Tier 1) B/D vancomycin oral capsule 125 mg, 250 mg $0 (Tier 1) PA; MO XIFAXAN ORAL TABLET 200 MG ; 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 250 mg, 500 mg cefaclor oral tablet extended release 12 hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml $0 (Tier 1) cefazolin injection recon soln 1 gram $0 (Tier 1) cefazolin intravenous recon soln 1 gram $0 (Tier 1) cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/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 $0 (Tier 1) $0 (Tier 1) cefepime injection recon soln 1 gram, 2 gram $0 (Tier 1) 15

16 Name of Drug cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg 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 mg, 500 mg $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) ceftriaxone injection recon soln 100 gram ceftriaxone intravenous recon soln 1 gram, 2 gram $0 (Tier 1) cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium intravenous recon soln 1.5 gram $0 (Tier 1) cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG TAZICEF INJECTION RECON SOLN 1 GRAM, 2 GRAM, 6 GRAM TAZICEF INTRAVENOUS RECON SOLN 1 GRAM, 2 GRAM $0 (Tier 1) $0 (Tier 1) 16

17 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG BETA-LACTAM, OTHER aztreonam injection recon soln 1 gram, 2 gram $0 (Tier 1) doripenem intravenous recon soln 250 mg, 500 mg $0 (Tier 1) PA imipenem-cilastatin intravenous recon soln 250 mg, 500 mg $0 (Tier 1) PA INVANZ INJECTION RECON SOLN 1 GRAM INVANZ INTRAVENOUS RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg meropenem-0.9% sodium chloride intravenous piggyback 1 gram/50 ml, 500 mg/50 ml VABOMERE INTRAVENOUS RECON SOLN 2 GRAM BETA-LACTAM, PENICILLINS $0 (Tier 1) ; MO amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg 17

18 Name of Drug ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg $0 (Tier 1) ampicillin sodium intravenous recon soln 1 gram $0 (Tier 1) 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 $0 (Tier 1) $0 (Tier 1) dicloxacillin oral capsule 250 mg, 500 mg nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml $0 (Tier 1) nafcillin injection recon soln 1 gram, 2 gram $0 (Tier 1) nafcillin intravenous recon soln 1 gram, 2 gram $0 (Tier 1) 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 mg/5 ml, 250 mg/5 ml $0 (Tier 1) $0 (Tier 1) penicillin v potassium oral tablet 250 mg, 500 mg 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 mg, 500 mg (2 mg/ml) $0 (Tier 1) azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml 18

19 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg ery pads topical swab 2 % erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral tablet 250 mg, 500 mg 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 mg, 500 mg $0 (Tier 2) ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml $0 (Tier 1) $0 (Tier 1) 19

20 Name of Drug levofloxacin intravenous solution 25 mg/ml $0 (Tier 1) levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/250 ml $0 (Tier 1) moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 mg moxifloxacin-sod.ace,sul-water intravenous piggyback 400 mg/250 ml ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 300 mg, 400 mg VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % SULFONAMIDES silver sulfadiazine topical cream 1 % ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg TETRACYCLINES $0 (Tier 1) demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg $0 (Tier 1) 20

21 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug doxycycline hyclate intravenous recon soln 100 mg $0 (Tier 1) doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg MORGIDOX 1X 50 KIT 50 MG morgidox oral capsule 50 mg ANTICONVULSANTS - TREATMENT OF SEIZURES ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML ; MO BRIVIACT ORAL SOLUTION 10 MG/ML ; MO BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml ; MO $0 (Tier 1) levetiracetam intravenous solution 500 mg/5 ml $0 (Tier 1) levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg ROWEEPRA ORAL TABLET 1,000 MG, 750 MG 21

22 Name of Drug roweepra oral tablet 500 mg ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG CALCIUM CHANNEL MODIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5 ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG $0 (Tier 2) ST; MO; QL (60 EA per 30 days) $0 (Tier 2) ST; MO; QL (120 EA per 30 days) LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100 mg, 25 mg, 50 mg 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 mg ; QL (40 EA per 30 days) diazepam rectal kit 2.5 mg ; QL (5 EA per 30 days) diazepam rectal kit mg ; QL (20 EA per 30 days) divalproex oral capsule, delayed rel sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 22

23 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION 2.5 MG/ML ; MO; QL (480 ML per 30 days) ONFI ORAL TABLET 10 MG, 20 MG ; MO; QL (60 EA per 30 days) phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) $0 (Tier 1) PA; MO phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg $0 (Tier 1) PA; MO primidone oral tablet 250 mg, 50 mg SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG ; QL (180 EA per 30 days) tiagabine oral tablet 2 mg, 4 mg valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) $0 (Tier 1) valproic acid oral capsule 250 mg vigabatrin oral powder in packet 500 mg $0 (Tier 1) PA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML $0 (Tier 2) ST; MO FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg $0 (Tier 2) ST; MO; QL (30 EA per 30 days) 23

24 Name of Drug topiramate oral capsule, sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG $0 (Tier 2) ST; MO; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML ; MO; QL (2400 ML per 30 days) BANZEL ORAL TABLET 200 MG, 400 MG ; MO; QL (240 EA per 30 days) carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg DILANTIN ORAL CAPSULE 30 MG epitol oral tablet 200 mg EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) $0 (Tier 1) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml $0 (Tier 1) 24

25 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML $0 (Tier 2) VIMPAT ORAL SOLUTION 10 MG/ML $0 (Tier 2) ST; MO; QL (1200 ML per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA ANTIDEMENTIA AGENTS, OTHER $0 (Tier 2) ST; MO; QL (60 EA per 30 days) ergoloid oral tablet 1 mg $0 (Tier 1) PA; MO CHOLINESTERASE INHIBITORS donepezil oral tablet 10 mg, 23 mg, 5 mg donepezil oral tablet,disintegrating 10 mg, 5 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg memantine oral tablet 10 mg, 5 mg memantine oral tablets,dose pack 5-10 mg 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 - TREATMENT OF DEPRESSION ANTIDEPRESSANTS, OTHER bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg $0 (Tier 1) ST; MO; QL (30 EA per 30 days) $0 (Tier 2) ST; MO $0 (Tier 2) ST; MO; QL (30 EA per 30 days) 25

26 Name of Drug bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR $0 (Tier 1) PA; MO MARPLAN ORAL TABLET 10 MG phenelzine oral tablet 15 mg tranylcypromine oral tablet 10 mg SSRIS/ SNRIS citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) $0 (Tier 2) ST; MO 26

27 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG $0 (Tier 2) ST; MO fluoxetine oral capsule 10 mg, 20 mg, 40 mg fluoxetine oral capsule,delayed release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 20 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 mg/ml sertraline oral tablet 100 mg, 25 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) TRICYCLICS $0 (Tier 2) ST; MO $0 (Tier 2) ST; MO $0 (Tier 2) ST; MO 27

28 Name of Drug amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO clomipramine oral capsule 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO doxepin oral concentrate 10 mg/ml $0 (Tier 1) PA; MO imipramine hcl oral tablet 10 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO nortriptyline oral solution 10 mg/5 ml protriptyline oral tablet 10 mg, 5 mg trimipramine oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO ANTIEMETICS - TREATMENT OF VOMITING OR NAUSEA ANTIEMETICS, OTHER chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg compro rectal suppository 25 mg dimenhydrinate 50 mg tablet (otc) 50 mg diphenhydramine hcl injection solution 50 mg/ml $0 (Tier 1) PA; MO meclizine oral tablet 12.5 mg, 25 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg MOTION SICKNESS RELIEF TB CHEW CHEWABLE TABLET 25 MG perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 28

29 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug phenadoz rectal suppository 12.5 mg $0 (Tier 1) PA; MO prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml), 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral syrup 6.25 mg/5 ml $0 (Tier 1) PA; MO promethazine oral tablet 12.5 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO promethazine rectal suppository 12.5 mg, 25 mg $0 (Tier 1) PA; MO promethegan rectal suppository 25 mg, 50 mg $0 (Tier 1) PA; MO scopolamine base transdermal patch 3 day 1 mg over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS trimethobenzamide oral capsule 300 mg $0 (Tier 1) PA; MO EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125 mg, 40 mg, 80 mg $0 (Tier 1) B/D; MO aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) $0 (Tier 1) B/D; MO dronabinol oral capsule 10 mg, 2.5 mg, 5 mg $0 (Tier 1) B/D; MO EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 1 mg/ml (1 ml), 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) $0 (Tier 2) B/D; MO $0 (Tier 1) B/D $0 (Tier 1) B/D granisetron hcl oral tablet 1 mg $0 (Tier 1) B/D; MO ondansetron hcl (pf) injection solution 4 mg/2 ml $0 (Tier 1) ondansetron hcl (pf) injection syringe 4 mg/2 ml $0 (Tier 1) ondansetron hcl intravenous solution 2 mg/ml $0 (Tier 1) 29

30 Name of Drug ondansetron hcl oral solution 4 mg/5 ml $0 (Tier 1) B/D; MO ondansetron hcl oral tablet 24 mg $0 (Tier 1) B/D; MO; QL (15 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg $0 (Tier 1) B/D; MO ondansetron oral tablet,disintegrating 4 mg, 8 mg $0 (Tier 1) B/D; MO SYNDROS ORAL SOLUTION 5 MG/ML ; MO ANTIFUNGALS - TREATMENT OF FUNGAL OR YEAST INFECTIONS ANTIFUNGALS abelcet intravenous suspension 5 mg/ml $0 (Tier 1) B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG $0 (Tier 2) B/D amphotericin b injection recon soln 50 mg $0 (Tier 1) B/D ANTI-FUNGAL 1% POWDER 1 % ANTIFUNGAL 2% CREAM 2 % BAZA ANTIFUNGAL 2% CREAM 12'S 2 % BREWER'S YEAST 680 MG TABLET 680 MG CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50 mg, 70 mg $0 (Tier 1) PA ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrim 1% vaginal cream 1 % clotrimazole 1% cream w/7 applicators 1 % clotrimazole 1% cream w/single applicator 1 % CLOTRIMAZOLE 3 2% CREAM 2 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % DESENEX 2% POWDER 2 % econazole topical cream 1 % 30

31 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG fluconazole in dextrose(iso-o) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg $0 (Tier 1) $0 (Tier 1) flucytosine oral capsule 250 mg $0 (Tier 1) flucytosine oral capsule 500 mg FUNGOID 2% TINCTURE 2 % griseofulvin microsize oral suspension 125 mg/5 ml itraconazole oral capsule 100 mg ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % LAMISIL AT 1% GEL 1 % MENTAX TOPICAL CREAM 1 % MICONAZOLE MG VAG SUPP 100 MG MICONAZOLE 7 CREAM 2 % MICONAZOLE 7 CREAM W/7 DISP APPLICATORS 2 % miconazole nitrate 2% cream 2 % miconazole nitrate 2% cream 2 % miconazole nitrate 2% cream w/7 disp applicators 2 % 31

32 Name of Drug miconazole nitrate 2% cream w/applicator 2 % MICONAZORB AF 2% POWDER 2 % MICRO-GUARD 2% POWDER 12'S,ANTIFUNGAL 2 % 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 ; 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 nystop topical powder 100,000 unit/gram qc tolnaftate 1% cream 1 % SM ATHLETE'S 1% FOOT CREAM 1 % sm clotrimazole 1% cream 1 % terbinafine 1% cream 1 % terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg TINACTIN 1% AEROSOL POWDER 1 % tolnaftate 1% cream 1 % voriconazole intravenous solution 200 mg $0 (Tier 1) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS ANTIGOUT AGENTS 32

33 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG $0 (Tier 2) ST; MO ANTI-INFLAMMATORY AGENTS - TREATMENT OF INFLAMMATION GLUCOCORTICOIDS 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 % desonide topical cream 0.05 % 33

34 Name of Drug 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 mg/ml dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral solution 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phos (pf) injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection syringe 4 mg/ml $0 (Tier 1) $0 (Tier 1) 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 % 34

35 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug 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 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % hydrocortisone-aloe 1% cream 1 % methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg $0 (Tier 1) methylprednisolone oral tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg $0 (Tier 1) mometasone topical cream 0.1 % mometasone topical ointment 0.1 % mometasone topical solution 0.1 % prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 35

36 Name of Drug prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (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 - TREATMENT OF MIGRAINE HEADACHES ANTIMIGRAINE AGENTS MIGRAINE RELIEF CAPLET CAPLET, COATED MG ERGOT ALKALOIDS dihydroergotamine injection solution 1 mg/ml $0 (Tier 1) PA; MO dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ergotamine-caffeine oral tablet mg SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS ; QL (8 ML per 30 days) rizatriptan oral tablet 10 mg, 5 mg ; QL (12 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg ; QL (12 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml, 6 mg/0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml ; 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) 36

37 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (4 ML per 30 days) ANTIMYASTHENIC AGENTS - TREATMENT OF MYASTHENIA PARASYMPATHOMIMETICS guanidine oral tablet 125 mg pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS - TREATMENT FOR INFECTIONS BY TUBERCULOSIS- TYPE ORGANISMS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100 mg, 25 mg $0 (Tier 1) rifabutin oral capsule 150 mg ANTITUBERCULARS CAPASTAT INJECTION RECON SOLN 1 GRAM $0 (Tier 2) ethambutol oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifampin intravenous recon soln 600 mg $0 (Tier 1) rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG ; MO TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS - TREATMENT OF CANCER ALKYLATING AGENTS 37

38 Name of Drug BICNU INTRAVENOUS RECON SOLN 100 MG busulfan intravenous solution 60 mg/10 ml $0 (Tier 1) PA carboplatin intravenous recon soln 150 mg $0 (Tier 1) B/D carboplatin intravenous solution 10 mg/ml $0 (Tier 1) B/D cisplatin intravenous solution 1 mg/ml $0 (Tier 1) B/D cyclophosphamide oral capsule 25 mg, 50 mg $0 (Tier 1) B/D; MO dacarbazine intravenous recon soln 200 mg $0 (Tier 1) B/D EMCYT ORAL CAPSULE 140 MG ; MO GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG ifosfamide intravenous recon soln 1 gram $0 (Tier 1) B/D LEUKERAN ORAL TABLET 2 MG $0 (Tier 2) MATULANE ORAL CAPSULE 50 MG $0 (Tier 2) melphalan hcl intravenous recon soln 50 mg $0 (Tier 1) B/D MUSTARGEN INJECTION RECON SOLN 10 MG oxaliplatin intravenous recon soln 100 mg $0 (Tier 1) B/D oxaliplatin intravenous solution 100 mg/20 ml $0 (Tier 1) B/D TEPADINA INJECTION RECON SOLN 100 MG, 15 MG $0 (Tier 2) B/D thiotepa injection recon soln 15 mg $0 (Tier 1) B/D TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG VALCHLOR TOPICAL GEL % ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ANTIANDROGENS bicalutamide oral tablet 50 mg ERLEADA ORAL TABLET 60 MG flutamide oral capsule 125 mg nilutamide oral tablet 150 mg $0 (Tier 1) 38

39 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug 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 SUSPENSION 400 MG/ML ; LA $0 (Tier 2) ; MO FARESTON ORAL TABLET 60 MG ; MO FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML $0 (Tier 2) ; MO tamoxifen oral tablet 10 mg, 20 mg ANTIMETABOLITES ALIMTA INTRAVENOUS RECON SOLN 500 MG ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML cladribine intravenous solution 10 mg/10 ml $0 (Tier 1) B/D cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml), 20 mg/ml $0 (Tier 1) B/D cytarabine injection solution 20 mg/ml $0 (Tier 1) B/D DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG FLUDARABINE INTRAVENOUS RECON SOLN 50 MG 39

40 Name of Drug fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml $0 (Tier 1) B/D fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % gemcitabine intravenous recon soln 1 gram, 2 gram $0 (Tier 1) B/D gemcitabine intravenous recon soln 200 mg $0 (Tier 1) B/D; MO gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) $0 (Tier 1) B/D hydroxyurea oral capsule 500 mg mercaptopurine oral tablet 50 mg NIPENT INTRAVENOUS RECON SOLN 10 MG PURIXAN ORAL SUSPENSION 20 MG/ML TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS adriamycin intravenous solution 20 mg/10 ml $0 (Tier 1) B/D docetaxel intravenous solution 20 mg/ml $0 (Tier 1) B/D KADCYLA INTRAVENOUS RECON SOLN 160 MG PICATO TOPICAL GEL %, 0.05 % ; MO ANTINEOPLASTICS, OTHER azacitidine injection recon soln 100 mg $0 (Tier 1) PA BELEODAQ INTRAVENOUS RECON SOLN 500 MG bleomycin injection recon soln 30 unit $0 (Tier 1) B/D BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG $0 (Tier 1) PA clofarabine intravenous solution 20 mg/20 ml dactinomycin intravenous recon soln 0.5 mg ; MO daunorubicin intravenous solution 5 mg/ml $0 (Tier 1) B/D decitabine intravenous recon soln 50 mg $0 (Tier 1) B/D 40

41 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: Last Updated: 03/2018 Effective Date: Name of Drug dexrazoxane hcl intravenous recon soln 250 mg $0 (Tier 1) B/D doxorubicin intravenous solution 50 mg/25 ml $0 (Tier 1) B/D doxorubicin, peg-liposomal intravenous suspension 2 mg/ml $0 (Tier 1) PA epirubicin intravenous solution 200 mg/100 ml $0 (Tier 1) 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) $0 (Tier 2) B/D idarubicin intravenous solution 1 mg/ml $0 (Tier 1) 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 mg, 200 mg, 350 mg, 50 mg, 500 mg $0 (Tier 1) B/D 41

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