ID del listado: 18395 Versión 13Actualizado 06/2018. Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los 7 días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
H8213_001_FOR_2634_Approved_09202017_Final6
Lista de medicamentos cubiertos para 2018 (Listado)
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
First Choice VIP Care Plus | Lista de medicamentos cubiertos para 2018 (Listado)
• Esta es una lista de los medicamentos que los miembros pueden obtener en First Choice VIP Care Plus.
• First Choice VIP Care Plus es un plan de salud que tiene contrato con Medicare y Medicaid de Healthy Connections de South Carolina para proporcionar los beneficios de ambos programas a los inscritos.
• La Lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar en cualquier momento durante el año. Le enviaremos una notificación antes de realizar un cambio que lo afecte.
• Los beneficios se pueden modificar el 1 de enero de cada año. Usted siempre puede comprobar la Lista de medicamentos cubiertos actualizada de First Choice VIP Care Plus en Internet en www.firstchoicevipcareplus.com.
• Pueden aplicarse limitaciones y restricciones. Para obtener más información, llame a Servicios al Miembro de First Choice VIP Care Plus o lea el Manual del Miembro de First Choice VIP Care Plus.
• Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a Servicios al Miembro de First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.
• Puede obtener esta información en otros formatos, como letra grande, braille, o audio de forma gratuita. Llame al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.
• Los miembros pueden solicitar materiales en un idioma que no sea el inglés o en un formato alternativo llamando a Servicios al Miembro al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
Preguntas frecuentes (FAQ)Encuentre aquí las respuestas a las preguntas que tiene sobre esta Lista de medicamentos cubiertos. Puede leer todas las FAQ para aprender más o buscar una pregunta y su respuesta.
1. ¿Qué medicamentos bajo receta están en la Lista de medicamentos cubiertos? (Llamamos “Lista de medicamentos” a la Lista de medicamentos cubiertos, para abreviar.)
Los medicamentos en la Lista de medicamentos cubiertos que comienza en la página 1 son los medicamentos cubiertos por First Choice VIP Care Plus. Estos medicamentos están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ella para que trabaje con nosotros y le preste servicios a usted. Nos referimos a estas farmacias como “farmacias de la red”.
➞ First Choice VIP Care Plus cubrirá todos los medicamentos médicamente necesarios en la Lista de medicamentos si:
• su médico u otro profesional que receta los medicamentos dice que usted los necesita para mejorar o mantenerse saludable, y
• usted surte la receta en una farmacia de la red de First Choice VIP Care Plus.
➞ Es posible que First Choice VIP Care Plus requiera medidas adicionales para poder acceder a ciertos medicamentos (ver pregunta 5 más abajo).
También puede encontrar una lista actualizada de los medicamentos que cubrimos en nuestro sitio de Internet indicado al final de la página o llame al número indicado al final de la página.
2. ¿Alguna vez cambia la Lista de medicamentos?Sí. First Choice VIP Care Plus puede agregar o retirar medicamentos de la Lista de medicamentos durante el año. En general, la Lista de medicamentos solo cambiará si:
• se desarrolla un medicamento más barato que funciona tan bien como uno de los medicamentos de la Lista de medicamentos actual, o
• nos enteramos de que un medicamento no es seguro.
También podemos cambiar nuestras normas sobre los medicamentos. Por ejemplo, podríamos:
• Decidir si un medicamento requiere o no requiere aprobación previa. (Aprobación previa es el permiso que otorga First Choice VIP Care Plus antes de que usted pueda obtener un medicamento).
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
• Agregar o cambiar la cantidad de un medicamento que usted puede obtener (llamado “límites a la cantidad”).
• Agregar o cambiar las restricciones de la terapia escalonada sobre un medicamento. (Terapia escalonada significa que usted debe probar un medicamento antes de que cubramos otro medicamento.)
(Para obtener más información sobre estas normas sobre los medicamentos, consulte la página iv.)
Cuando retiremos un medicamento que usted está tomando, se lo haremos saber. También le diremos cuando cambiemos nuestras normas sobre la cobertura de un medicamento. Las preguntas 3, 4 y 7, a continuación, tienen más información sobre lo que sucede cuando la Lista de medicamentos cambia.
➞ Usted siempre puede revisar la Lista de medicamentos actualizada de First Choice VIP Care Plus en nuestro sitio web indicado al final de la página. También puede llamar a Servicios al Miembro al número que aparece al final de la página para revisar la Lista de medicamentos actual.
3. ¿Qué sucede cuando se desarrolla un medicamento más barato que funciona tan bien como uno de los medicamentos de la Lista de medicamentos actual?
Si usted está tomando un medicamento que se retira porque se desarrolla un medicamento más barato que funciona igualmente bien, se lo diremos. Se lo diremos como mínimo 60 días antes de que lo retiremos de la Lista de medicamentos o cuando usted pida que le renueven la receta. Entonces usted puede obtener un suministro del medicamento que dure 60 días antes de que se realice el cambio en la Lista de medicamentos.
• Cuando usted utiliza sus beneficios de farmacia de la Parte D, le enviaremos un informe resumido para ayudarlo a entender y a hacer un seguimiento de los pagos de los medicamentos bajo receta de la Parte D. Este informe resumido se llama Explicación de Beneficios (o “EOB”).
• La Explicación de Beneficios le dice la cantidad total que usted ha gastado en los medicamentos bajo receta de la Parte D y la cantidad total que nosotros hemos pagado por cada uno de los medicamentos bajo receta de la Parte D durante el mes. La Sección 4 (las actualizaciones a la Lista de medicamentos del plan que afectarán los medicamentos que usted toma) ofrece más información sobre las actualizaciones del listado de medicamentos que afectan los medicamentos que usted está tomando, que es cualquier medicamento cubierto por el plan para el que usted surtió una receta durante el año calendario actual como miembro del plan.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
4. ¿Qué sucede cuando descubrimos que un medicamento no es seguro?
Si la Administración de Alimentos y Medicamentos (FDA) dice que el medicamento que usted está tomando no es seguro, lo eliminaremos de la Lista de medicamentos inmediatamente. También le enviaremos una carta diciéndole eso. Si usted recibe una carta, puede optar por:
• Comunicarse con Servicios al Miembro a través de la información de contacto que aparece al final de la página para que lo ayudemos con sus dudas.
• Comunicarse con el Coordinador de Atención Médica.
• Comunicarse con el profesional que le recetó el medicamento para hablar de la situación.
5. ¿Existen restricciones o límites a la cobertura de medicamentos? ¿O se debe tomar alguna medida para conseguir ciertos medicamentos?
Sí, algunos medicamentos tienen normas sobre la cobertura o límites en la cantidad que usted puede obtener. En algunos casos, usted, su médico u otro profesional que recete medicamentos deben hacer algo antes de poder obtener el medicamento. Por ejemplo:
• Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su médico u otro profesional que receta el medicamento deben obtener la aprobación de First Choice VIP Care Plus antes de surtir su receta. Si usted no recibe la aprobación, es posible que First Choice VIP Care Plus no cubra el medicamento.
• Límites a la cantidad: A veces, First Choice VIP Care Plus limita la cantidad de un medicamento que puede obtener.
• Terapia escalonada: A veces, First Choice VIP Care Plus requiere que usted realice una terapia escalonada. Esto significa que usted tendrá que probar medicamentos en un cierto orden para su condición médica. Es posible que usted tenga que probar un medicamento antes de que nosotros cubramos otro medicamento. Si su médico cree que el primer medicamento no funciona para usted, entonces cubriremos el segundo.
Usted puede averiguar si su medicamento tiene límites o requisitos adicionales buscándolo en las tablas en las páginas 1 – 160. Usted también puede obtener más información visitando nuestro sitio de Internet en www.firstchoicevipcareplus.com. Hemos publicado documentos en Internet que explican nuestras restricciones de autorización previa y terapia escalonada. Usted también puede pedirnos que le enviemos una copia.
Usted puede solicitar una “excepción” a estos límites. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
➞ Si usted está en un hogar de ancianos o en otro centro médico de atención prolongada y necesita un medicamento que no está en la Lista de medicamentos, o si usted no puede conseguir fácilmente el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que usted necesita (a menos que tenga una receta médica para menos días), sea o no un nuevo miembro de First Choice VIP Care Plus. Esto le dará tiempo para hablar con su médico u otro profesional que receta el medicamento. Pueden ayudarlo a decidir si existe un medicamento similar en la Lista de medicamentos con el que pueda reemplazarlo o si desea solicitar una excepción. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.
6. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si debe tomar alguna medida para conseguir el medicamento?
La Lista de medicamentos cubiertos en la página 1 tiene una columna denominada “Medidas necesarias, restricciones o límites de uso”.
7. ¿Qué sucede si cambiamos nuestras normas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos autorización previa (aprobación), límites a la cantidad y/o restricciones a la terapia escalonada sobre un medicamento.
Le diremos si agregamos autorización previa, límites a la cantidad y/o restricciones a la terapia escalonada de un medicamento. Se lo diremos como mínimo 60 días antes de agregar la restricción o la próxima vez que usted pida que le renueven la receta. Entonces usted puede obtener un suministro del medicamento que dure 60 días antes de que se realice el cambio en la Lista de medicamentos. Esto le da tiempo para hablar con su médico u otro profesional que receta el medicamento sobre qué hacer a continuación.
8. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?
Existen dos formas de encontrar un medicamento:
• Puede buscarlo por orden alfabético (si sabe cómo se escribe el medicamento), o
• Puede buscarlo por condición médica.
Para buscar alfabéticamente, vaya a la sección de Listado alfabético. Lo puede encontrar en el Índice que comienza en la página 161. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Los medicamentos de marca, los medicamentos genéricos y los medicamentos de venta libre se indican en el Índice. Busque en el Índice y encuentre
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
su medicamento. Al lado de cada medicamento, usted verá un número que le dice en qué página puede encontrar información sobre la cobertura.
Para buscar por condición médica, encuentre la sección denominada “Lista de medicamentos por condición médica” en la página xi. Los medicamentos de esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si usted tiene una enfermedad cardíaca, debe mirar en la categoría Medicamentos Cardiovasculares. Allí es donde encontrará los medicamentos que tratan las enfermedades cardíacas.
9. ¿Qué pasa si usted es miembro actualmente y el medicamento que quiere tomar no está en la Lista de medicamentos?
Si no ve su medicamento en la Lista de medicamentos, llame a Servicios al Miembro al número que aparece al final de la página y pregunte al respecto. Si usted se entera de que First Choice VIP Care Plus no cubrirá el medicamento, puede hacer una de estas cosas:
• Pida a Servicios al Miembro una lista de los medicamentos como el que usted quiere tomar. Luego muestre la lista a su médico o a otro profesional que receta el medicamento. Puede recetarle un medicamento de la Lista de medicamentos que sea como el que usted quiere tomar. O
• Usted puede pedir al plan de salud que haga una excepción para cubrir su medicamento. Por favor, consulte la pregunta 11 para obtener más información sobre las excepciones.
Los miembros que hayan sufrido un cambio en el nivel de atención (establecimiento) podrán recibir un único suministro de transición de 30 días por medicamento. Por ejemplo, los miembros que:
• Ingresan a establecimientos de atención médica prolongada (LTC) desde hospitales a veces tienen una lista de medicamentos de alta del listado de medicamentos del hospital, con una planificación a muy corto plazo (en general menos de 8 horas).
• Son dados de alta del hospital y trasladados a la casa.
• Finalizan su estadía en un establecimiento de enfermería especializada de la Parte A de Medicare (para la cual los pagos incluyen todos los gastos de farmacia) y que necesitan volver a su listado de medicamentos del plan de la Parte D.
• Finalizan una estadía en un establecimiento de atención médica prolongada y vuelven a la comunidad.
Si un miembro sufre más de un cambio en el nivel de atención en un mes, la farmacia deberá llamar a nuestro Plan para solicitar una extensión de la política de transición.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
10. ¿Qué sucede si usted es un miembro nuevo de First Choice VIP Care Plus y no puede encontrar su medicamento en la Lista de medicamentos o tiene problemas para obtener su medicamento?
Podemos ayudar. Cubriremos un suministro temporal de 30 días de su medicamento de la Parte D y un suministro de 90 días de su medicamento de Medicaid de Healthy Connections durante los primeros 180 días en que usted es miembro de First Choice VIP Care Plus. Esto le dará tiempo para hablar con su médico u otro profesional que receta el medicamento. Ellos determinarán si existe un medicamento similar en la Lista de medicamentos con el que pueda reemplazarlo o si desea solicitar una excepción.
Cubriremos un suministro temporal de su medicamento si:
• usted está tomando un medicamento que no está en nuestra Lista de medicamentos, o
• las normas del plan de salud no le permiten obtener la cantidad que pidió el profesional que recetó el medicamento, o
• el medicamento requiere la aprobación previa de First Choice VIP Care Plus, o
• usted está tomando un medicamento que es parte de una restricción de la terapia escalonada.
Si usted vive en un hogar de ancianos o en otro centro médico de atención prolongada, puede renovar su receta hasta un máximo de 98 días para los medicamentos de la Parte D y 98 días para medicamentos que no son de la Parte D. Usted puede renovar el medicamento varias veces durante este período de tiempo. Esto le da tiempo al profesional que receta el medicamento a cambiar sus medicamentos a aquellos que están en la Lista de medicamentos o solicitar una excepción.
11. ¿Usted puede pedir una excepción para cubrir su medicamento?Sí. Usted puede pedir a First Choice VIP Care Plus que haga una excepción para cubrir un medicamento que no está en la Lista de medicamentos.
También puede pedirnos que cambiemos las normas sobre su medicamento.
• Por ejemplo, First Choice VIP Care Plus puede limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, usted puede pedirnos que cambiemos el límite y cubramos más.
• Otros ejemplos: Puede solicitarnos que no apliquemos las restricciones de la terapia escalonada o los requisitos de la aprobación previa.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
12. ¿Cuánto tiempo lleva obtener una excepción?En primer lugar, debemos recibir una declaración del profesional que receta el medicamento que apoye su solicitud de excepción. Después de recibir la declaración, le haremos saber nuestra decisión sobre su solicitud de excepción dentro de las 72 horas.
Si usted o el profesional que receta el medicamento creen que su salud podría verse dañada si tiene que esperar una decisión durante 72 horas, usted puede pedir una excepción acelerada. Esta es una decisión más rápida. Si el profesional que receta el medicamento apoya su solicitud, le haremos conocer la decisión dentro de las 24 horas de recibir la declaración de apoyo del profesional que receta el medicamento.
13. ¿Cómo puede solicitar una excepción?Para solicitar una excepción, llame a Servicios al Miembro. Un representante de Servicios al Miembro trabajará con usted y su proveedor para ayudarlo a solicitar una excepción.
14. ¿Qué son los medicamentos genéricos?Los medicamentos genéricos se hacen con los mismos principios activos que los medicamentos de marca. Usualmente cuestan menos que los medicamentos de marca y generalmente no tienen nombres muy conocidos. Los medicamentos genéricos están aprobados por la Administración de Alimentos y Medicamentos (FDA).
First Choice VIP Care Plus cubre tanto medicamentos de marca como genéricos.
15. ¿Qué son los medicamentos OTC?OTC es la sigla en inglés para “de venta libre”. First Choice VIP Care Plus cubre algunos medicamentos OTC cuando su proveedor los receta.
Puede leer la Lista de medicamentos de First Choice VIP Care Plus para ver qué medicamentos OTC están cubiertos.
16. ¿First Choice VIP Care Plus cubre productos OTC que no son medicamentos?
First Choice VIP Care Plus cubre algunos productos OTC que no son medicamentos cuando su proveedor los receta.
Puede leer la Lista de medicamentos de First Choice VIP Care Plus para ver qué productos OTC que no son medicamentos están cubiertos.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
17. ¿Cuál es su copago?Como miembro de First Choice VIP Care Plus, usted no tiene copagos para medicamentos de venta bajo receta y medicamentos OTC siempre que siga las normas de First Choice VIP Care Plus.
18. ¿Qué son los niveles de medicamentos?Los niveles son grupos de medicamentos de nuestra Lista de medicamentos.
No hay copagos en ninguno de estos niveles, que son los siguientes:
• Los medicamentos del nivel 1 son los medicamentos genéricos cubiertos por Medicare.
• Los medicamentos del nivel 2 son los medicamentos de marca cubiertos por Medicare.
• Los medicamentos del nivel 3 son los medicamentos de venta bajo receta y de venta libre que no cubre Medicare. Estos medicamentos tienen la cobertura de Medicaid de Healthy Connections.
Lista de medicamentos cubiertosLa siguiente lista de medicamentos cubiertos le brinda información sobre los medicamentos que cubre First Choice VIP Care Plus. Si usted tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 161.
La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están escritos en mayúscula (por ejemplo, COUMADIN) y los medicamentos genéricos están escritos en letra cursiva minúscula (por ejemplo, warfarin).
La información en la columna “Medidas necesarias, restricciones o límites de uso” le indica si First Choice VIP Care Plus tiene normas para cubrir su medicamento.
A continuación, se enumeran los códigos usados en la columna “Medidas necesarias, restricciones o límites de uso”:
B/D: Este medicamento bajo receta puede estar cubierto por el beneficio médico o de farmacia, según cómo se use. La farmacia trabajará junto con el plan médico y su proveedor para determinar si el medicamento debe ser autorizado en virtud de su beneficio médico o de farmacia.
MO: Pedido por correo. Una farmacia de la red de First Choice VIP Care Plus que entrega pedidos por correo puede surtir esta receta. Consulte el Listado de Proveedores y Farmacias para obtener más información sobre qué farmacias ofrecen el servicio de pedidos por correo. Si desea más información, consulte su listado de Proveedores y Farmacias o llame al departamento de Servicios al Miembro al número que aparece al final de la página.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
QL: Límites a la cantidad. Para ciertos medicamentos, limitamos la cantidad del medicamento que usted puede recibir. Por ejemplo, el plan puede limitar la cantidad de reposiciones que usted puede obtener, o la cantidad de un medicamento que puede recibir cada vez que surte una receta. Por ejemplo, si en general no se considera seguro tomar más de una pastilla por día de cierto medicamento, podemos limitar la cobertura de su receta a no más de una pastilla por día.
ST: Terapia escalonada. En algunos casos, First Choice VIP Care Plus requiere que usted primero pruebe ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan su condición médica, es posible que First Choice VIP Care Plus no cubra el Medicamento B si usted primero no prueba el Medicamento A. Si el Medicamento A no funciona para usted, First Choice VIP Care Plus entonces cubrirá el Medicamento B.
PA: Autorización previa. First Choice VIP Care Plus requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación de First Choice VIP Care Plus antes de surtir sus recetas. Si usted no recibe la aprobación, es posible que First Choice VIP Care Plus no cubra el medicamento.
LA: Disponibilidad limitada. Esta receta puede estar disponible solo en determinadas farmacias. Para obtener más información, consulte el Directorio de Farmacias o llame a Servicios al Miembro al número que aparece al final de la página.
Nota: Las letras “DP” al lado de un medicamento significan que el medicamento no es un “Medicamento de la Parte D”. La cantidad que usted paga cuando surte una receta para este medicamento no cuenta para sus costos totales en medicamentos (es decir, la cantidad que usted paga no lo ayuda para cumplir con los requisitos para la cobertura catastrófica). Además, si usted está recibiendo Ayuda adicional para pagar sus medicamentos bajo receta, no obtendrá ninguna Ayuda adicional para pagar estos medicamentos. Estos medicamentos también tienen diferentes normas para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos una decisión de cobertura y que la cambiemos si usted cree que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted quiere no está cubierto o ya no está cubierto por Medicare o Medicaid de Healthy Connections. Si usted o su médico no están de acuerdo con nuestra decisión, usted puede apelarla. Para pedir instrucciones sobre cómo apelar, llame a Servicios al Miembro al número que aparece al final de la página. También puede leer el Manual del Miembro para saber cómo apelar una decisión.
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Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
Lista de medicamentos por condición médicaLos medicamentos de esta sección están agrupados en categorías según el tipo de condición médica que tratan. Por ejemplo, si usted tiene una enfermedad cardíaca, debe mirar en la categoría Medicamentos Cardiovasculares. Allí es donde encontrará los medicamentos que tratan las enfermedades cardíacas.
Clasificación de medicamentos bajo receta Condición médica
Analgésicos Tratamiento del dolor
Anestésicos Tratamiento local del dolor
Medicamentos contra las adicciones/ el abuso de sustancias tóxicas
Tratamiento de trastornos causados por abuso de sustancias tóxicas
Antibacterianos Tratamiento de infecciones bacterianas
Anticonvulsivos Tratamiento de convulsiones
Medicamentos contra la demencia Tratamiento de la demencia
Antidepresivos Tratamiento de la depresión
Antieméticos Tratamiento de vómitos o náuseas
Antimicóticos Tratamiento de micosis o candidiasis
Medicamentos contra la gota Tratamiento o prevención de la artritis gotosa
Medicamentos antiinflamatorios Tratamiento de la inflamación
Medicamentos contra la migraña Tratamiento de la migraña
Medicamentos contra la miastenia Tratamiento de la miastenia
Antimicobacterianos Tratamiento de infecciones por microorganismos del grupo M. tuberculosis
Antineoplásicos Tratamiento del cáncer
Antiparasitarios Antiparasitarios Tratamiento de infecciones parasitarias
Medicamentos antiparkinsoniano Tratamiento de la enfermedad de Parkinson
xii
Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
Clasificación de medicamentos bajo receta Condición médica
Antipsicóticos Tratamiento de trastornos del comportamiento y emocionales
Medicamentos antiespasmódicos Tratamiento de espasmos musculares
Antivirales Tratamiento de infecciones víricas
Ansiolíticos Tratamiento de la ansiedad o el nerviosismo
Medicamentos para el trastorno bipolar Tratamiento del trastorno bipolar
Reguladores de glucosa en sangre Control de la diabetes
Hemoderivados/modificadores/ expansores de volumen
Prevención de coagulación y aumento de producción de células sanguíneas
Medicamentos cardiovasculares Tratamiento de enfermedades cardíacas y de los vasos sanguíneos
Medicamentos para el sistema nervioso central
Tratamiento de trastornos cerebrales y de la columna vertebral
Medicamentos odontológicos y bucales Tratamiento de trastornos bucales y de las encías
Medicamentos dermatológicos Tratamiento de enfermedades de la piel
Suministros para la diabetes Suministros usados para tratar la diabetes
Reemplazo/modificadores enzimáticos Medicamentos para reemplazar la carencia o deficiencia de enzimas
Medicamentos gastrointestinales Tratamiento de enfermedades estomacales e intestinales
Medicamentos del aparato genitourinario Tratamiento de enfermedades de las vías urinarias y de la próstata
Medicamentos hormonales, estimulantes/reemplazantes/modificadores (suprarrenales)
Tratamiento de enfermedades mediante esteroides
Medicamentos hormonales, estimulantes/reemplazantes/modificadores (hipófisis)
Tratamiento de enfermedades de la hipófisis
xiii
Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
Clasificación de medicamentos bajo receta Condición médica
Medicamentos hormonales, estimulantes/reemplazantes/modificadores (hormonas sexuales/modificadores)
Para el reemplazo o modificación de hormonas sexuales
Medicamentos hormonales, estimulantes/reemplazantes/modificadores (tiroides)
Tratamiento de enfermedades de la tiroides
Medicamentos hormonales, supresores (suprarrenales)
Tratamiento del cáncer de glándulas suprarrenales no operable
Medicamentos hormonales, supresores (paratiroides)
Tratamiento de enfermedades de la paratiroides
Medicamentos hormonales, supresores (hipófisis)
Tratamiento o modificación de la secreción de la hormona hipofisaria
Medicamentos hormonales, supresores (tiroides)
Tratamiento del hipertiroidismo
Medicamentos inmunológicos Medicamentos para alterar el sistema inmunológico, incluso vacunas
Medicamentos para las enfermedades inflamatorias intestinales
Tratamiento de la colitis ulcerativa o la enfermedad de Crohn
Medicamentos para la osteopatía metabólica
Tratamiento de osteopatías, incluso osteoporosis
Medicamentos oftalmológicos Tratamiento de enfermedades oculares
Medicamentos para enfermedades del oído Tratamiento de enfermedades del oído
Medicamento para el tracto respiratorio Tratamiento de enfermedades respiratorias
Medicamentos para los pulmones/ vías respiratorias
Tratamiento de enfermedades respiratorias
Relajantes musculares Tratamiento de la tensión muscular
Medicamentos para trastornos del sueño Tratamiento del insomnio
Nutrientes/minerales/electrolitos terapéuticos
Reemplazo o suplemento de minerales, nutrientes y vitaminas
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
1
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ANALGESICS - TREATMENT OF PAIN
ANALGESICS
8 HOUR ER 650 MG CAPLET MUSCLE
ACHES & PAIN 650 MG
$0 (Tier 3) DP
ACEPHEN 325 MG SUPPOSITORY 325 MG $0 (Tier 3) DP
ACEPHEN 650 MG SUPPOSITORY OUTER
650 MG
$0 (Tier 3) DP
acetaminophen 120 mg suppos inner 120 mg $0 (Tier 3) DP
acetaminophen 160 mg/5 ml elx 160 mg/5 ml $0 (Tier 3) DP
acetaminophen 325 mg tablet 325 mg $0 (Tier 3) DP
acetaminophen 500 mg caplet caplet,ex-strength
500 mg
$0 (Tier 3) DP
acetaminophen 500 mg tablet asa-free,ex-str 500
mg
$0 (Tier 3) DP
acetaminophen 650 mg suppos 650 mg $0 (Tier 3) DP
acetaminophen-codeine oral solution 120 mg-12
mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg
/12.5 ml
$0 (Tier 1) MO
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg, 300-60 mg
$0 (Tier 1) MO
ARTHRITIS PAIN ER 650 MG CAPLT CAPLET
650 MG
$0 (Tier 3) DP
ARTHRITIS PAIN ER 650 MG CAPLT CAPLET
650 MG
$0 (Tier 3) DP
ARTHRITIS PAIN RELIEF ER 650 MG
CAPLET CAPLET 650 MG
$0 (Tier 3) DP
ascomp with codeine oral capsule 30-50-325-40
mg
$0 (Tier 1) PA; MO
butalbital compound w/codeine oral capsule 30-
50-325-40 mg
$0 (Tier 1) PA; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
2
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
$0 (Tier 1) PA; MO
butalbital-acetaminophen oral tablet 50-325 mg $0 (Tier 1) PA; MO
butalbital-acetaminophen-caff oral capsule 50-
325-40 mg
$0 (Tier 1) PA; MO
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
$0 (Tier 1) PA; MO
butalbital-aspirin-caffeine oral capsule 50-325-40
mg
$0 (Tier 1) PA; MO
capsaicin 0.025% cream 0.025 % $0 (Tier 3) DP
carisoprodol-asa-codeine oral tablet 200-325-16
mg
$0 (Tier 1) PA; MO
carisoprodol-aspirin oral tablet 200-325 mg $0 (Tier 1) PA; MO
codeine-butalbital-asa-caff oral capsule 30-50-
325-40 mg
$0 (Tier 1) PA; MO
GS PAIN RELIEF 500 MG CAPLET 500 MG $0 (Tier 3) DP
HM ARTHRITIS PAIN ER 650 MG CAPLET, 8
HOUR 650 MG
$0 (Tier 3) DP
HM PAIN RELIEF 500 MG CAPLET CAPLET,
EX-STRENGTH 500 MG
$0 (Tier 3) DP
HM PAIN RELIEF 500 MG TABLET EX-STR,
GLUTEN-FREE 500 MG
$0 (Tier 3) DP
HM PAIN RELIEVER 500 MG TABLET
EXTRA STRENGTH 500 MG
$0 (Tier 3) DP
hydrocodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
$0 (Tier 1) MO
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-
200 mg, 7.5-200 mg
$0 (Tier 1) MO
ibuprofen-oxycodone oral tablet 400-5 mg $0 (Tier 1)
MAPAP 325 MG TABLET U-D 325 MG $0 (Tier 3) DP
MAPAP 500 MG CAPLET CAPLET 500 MG $0 (Tier 3) DP
MAPAP 500 MG CAPLET CAPLET,BOXED
500 MG
$0 (Tier 3) DP
MAPAP ARTHRITIS ER 650 MG CPLT 650 MG $0 (Tier 3) DP
MAPAP PM CAPLET 25-500 MG $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
3
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
MUSCLE RUB CREAM 15-10 % $0 (Tier 3) DP
MUSCLE RUB CREAM ULTRA STRENGTH 4-
30-10 %
$0 (Tier 3) DP
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
$0 (Tier 1) MO
oxycodone-aspirin oral tablet 4.8355-325 mg $0 (Tier 1) MO
PAIN & FEVER 500 MG CAPLET CAPLET 500
MG
$0 (Tier 3) DP
PAIN & FEVER 500 MG CAPLET CAPTABS
500 MG
$0 (Tier 3) DP
PAIN RELIEF 500 MG CAPLET CAPLET, EX-
STRENGTH 500 MG
$0 (Tier 3) DP
PAIN RELIEF 500 MG CAPLET EXTRA STR,
CAPLET 500 MG
$0 (Tier 3) DP
PAIN RELIEF ER 650 MG CAPLET CAPLET, 8
HOUR 650 MG
$0 (Tier 3) DP
PAIN RELIEF ER 650 MG CAPLET CAPLET,
ARTHRITIS 650 MG
$0 (Tier 3) DP
PAIN RELIEVER 325 MG TABLET 325 MG $0 (Tier 3) DP
PAIN RELIEVER 500 MG CAPLET CAPLET,X-
STRENGTH 500 MG
$0 (Tier 3) DP
PAIN RELIEVER 500 MG CAPLET EX-STR,
CAPLET 500 MG
$0 (Tier 3) DP
PAIN RELIEVER 500 MG TABLET EXTRA
STRENGTH 500 MG
$0 (Tier 3) DP
pentazocine-naloxone oral tablet 50-0.5 mg $0 (Tier 1) PA; MO
pramoxine hcl 1% foam 12's, non-steroid 1 % $0 (Tier 3) DP
QC ARTHRITIS PAIN ER 650 MG CAPLET 650
MG
$0 (Tier 3) DP
QC NON-ASPIRIN 500 MG CAPLET
CAPLET,EX-STRENGTH 500 MG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
4
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
QC NON-ASPIRIN 500 MG CAPLET XTRA
STRENGTH,CAPLET 500 MG
$0 (Tier 3) DP
QC NON-ASPIRIN 500 MG TABLET EXTRA
STRENGTH 500 MG
$0 (Tier 3) DP
QC NON-ASPIRIN PAIN RELIEF TB EXTRA
STRENGTH 500 MG
$0 (Tier 3) DP
QC NON-ASPIRIN PM CAPLET CAPLET, EX-
STRENGTH 25-500 MG
$0 (Tier 3) DP
Q-PAP 325 MG TABLET 325 MG $0 (Tier 3) DP
Q-PAP EX-STR 500 MG TABLET 500 MG $0 (Tier 3) DP
Q-PAP EX-STR 500 MG TABLET ASPIRIN
FREE 500 MG
$0 (Tier 3) DP
SM 8 HOUR PAIN RELIEF 650 MG CAPLET
650 MG
$0 (Tier 3) DP
SM PAIN RELIEVER 325 MG TABLET 325 MG $0 (Tier 3) DP
SM PAIN RELIEVER 500 MG CAPLET
CAPLET, EXTRA STR 500 MG
$0 (Tier 3) DP
SM PAIN RELIEVER 500 MG CAPLET
CAPLET, EXTRA STR 500 MG
$0 (Tier 3) DP
SM PAIN RELIEVER 500 MG TABLET EXTRA
STRENGTH 500 MG
$0 (Tier 3) DP
tramadol-acetaminophen oral tablet 37.5-325 mg $0 (Tier 1) MO
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
ADVIL 200 MG LIQUI-GEL CAPSULE LIQUID
GEL 200 MG
$0 (Tier 3) DP
ALL DAY PAIN RELIEF 220 MG TAB 220 MG $0 (Tier 3) DP
ALL DAY PAIN RLF 220 MG CAPLET
CAPLET 220 MG
$0 (Tier 3) DP
aspirin 325 mg coated tablet coated 325 mg $0 (Tier 3) DP
aspirin 325 mg tablet 325 mg $0 (Tier 3) DP
aspirin 325 mg tablet 5 grain 325 mg $0 (Tier 3) DP
aspirin coated 325 mg tablet coated 325 mg $0 (Tier 3) DP
aspirin ec 325 mg tablet 325 mg $0 (Tier 3) DP
aspirin ec 325 mg tablet orange 325 mg $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
5
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
aspirin ec 325 mg tablet safety-coated 325 mg $0 (Tier 3) DP
celecoxib oral capsule 100 mg, 200 mg, 400 mg,
50 mg
$0 (Tier 1) MO
COMFORT PAC-IBUPROFEN KIT 800 MG $0 (Tier 1) MO
COMFORT PAC-MELOXICAM KIT 15 MG $0 (Tier 1) MO
COMFORT PAC-NAPROXEN KIT 500 MG $0 (Tier 1) MO
diclofenac potassium oral tablet 50 mg $0 (Tier 1) MO
diclofenac sodium oral tablet extended release 24
hr 100 mg
$0 (Tier 1) MO
diclofenac sodium oral tablet,delayed release
(dr/ec) 25 mg, 50 mg, 75 mg
$0 (Tier 1) MO
diclofenac sodium topical gel 1 %, 3 % $0 (Tier 1) MO
DICLOZOR TOPICAL KIT 1 % $0 (Tier 1) MO
diflunisal oral tablet 500 mg $0 (Tier 1) MO
etodolac oral capsule 200 mg, 300 mg $0 (Tier 1) MO
etodolac oral tablet 400 mg, 500 mg $0 (Tier 1) MO
etodolac oral tablet extended release 24 hr 400
mg, 500 mg, 600 mg
$0 (Tier 1) MO
flurbiprofen oral tablet 100 mg, 50 mg $0 (Tier 1) MO
gs aspirin 325 mg tablet 325 mg $0 (Tier 3) DP
gs ibuprofen 200 mg caplet 200 mg $0 (Tier 3) DP
hm aspirin ec 325 mg tablet reg strength 325 mg $0 (Tier 3) DP
IBU ORAL TABLET 600 MG, 800 MG $0 (Tier 1) MO
ibuprofen 200 mg caplet caplet 200 mg $0 (Tier 3) DP
ibuprofen 200 mg caplet coated caplet 200 mg $0 (Tier 3) DP
ibuprofen 200 mg tablet 200 mg $0 (Tier 3) DP
ibuprofen 200 mg tablet coated 200 mg $0 (Tier 3) DP
ibuprofen oral suspension 100 mg/5 ml $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
6
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0 (Tier 1) MO
indomethacin oral capsule 25 mg, 50 mg $0 (Tier 1) PA; MO
indomethacin oral capsule, extended release 75
mg
$0 (Tier 1) PA; MO
ketoprofen oral capsule 50 mg, 75 mg $0 (Tier 1) MO
ketorolac oral tablet 10 mg $0 (Tier 1) PA; MO
meclofenamate oral capsule 100 mg, 50 mg $0 (Tier 1) MO
meloxicam oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO
nabumetone oral tablet 500 mg, 750 mg $0 (Tier 1) MO
naproxen oral suspension 125 mg/5 ml $0 (Tier 1) MO
naproxen oral tablet 250 mg, 375 mg, 500 mg $0 (Tier 1) MO
naproxen oral tablet,delayed release (dr/ec) 375
mg, 500 mg
$0 (Tier 1) MO
naproxen sodium oral tablet 275 mg, 550 mg $0 (Tier 1) MO
piroxicam oral capsule 10 mg, 20 mg $0 (Tier 1) MO
qc aspirin ec 325 mg tablet regular strength 325
mg
$0 (Tier 3) DP
sm aspirin 325 mg tablet 325 mg $0 (Tier 3) DP
sm aspirin ec 325 mg tablet reg-str, gluten-free
325 mg
$0 (Tier 3) DP
sulindac oral tablet 150 mg, 200 mg $0 (Tier 1) MO
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
$0 (Tier 1) MO; 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
$0 (Tier 1) MO; QL (10 EA per 30 days)
fentanyl transdermal patch 72 hour 37.5
mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour
$0 (Tier 1) QL (10 EA per 30 days)
methadone oral solution 10 mg/5 ml $0 (Tier 1) MO; QL (1200 ML per 30 days)
methadone oral solution 5 mg/5 ml $0 (Tier 1) MO; QL (2400 ML per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
7
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
methadone oral tablet 10 mg $0 (Tier 1) PA; MO; QL (240 EA per 30 days)
methadone oral tablet 5 mg $0 (Tier 1) MO; QL (180 EA per 30 days)
morphine oral tablet extended release 100 mg, 200
mg
$0 (Tier 1) PA; MO; QL (60 EA per 30 days)
morphine oral tablet extended release 15 mg, 30
mg, 60 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
oxycodone oral tablet,oral only,ext.rel.12 hr 10
mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
$0 (Tier 1) PA; QL (60 EA per 30 days)
OPIOID ANALGESICS, SHORT-ACTING
butorphanol tartrate injection solution 1 mg/ml, 2
mg/ml
$0 (Tier 1) MO
butorphanol tartrate nasal spray,non-aerosol 10
mg/ml
$0 (Tier 1) QL (5 ML per 30 days)
duramorph (pf) injection solution 0.5 mg/ml, 1
mg/ml
$0 (Tier 1) B/D; MO
fentanyl citrate buccal lozenge on a handle 1,200
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
mcg
$0 (Tier 1) PA; MO; QL (120 EA per 30 days)
hydromorphone (pf) injection solution 10 (mg/ml)
(5 ml)
$0 (Tier 1)
hydromorphone (pf) injection solution 10 mg/ml $0 (Tier 1) MO
hydromorphone injection solution 1 mg/ml, 2
mg/ml, 4 mg/ml
$0 (Tier 1)
hydromorphone injection syringe 2 mg/ml $0 (Tier 1) MO
hydromorphone oral tablet 2 mg, 4 mg, 8 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
100 MCG/SPRAY
$0 (Tier 2) PA; MO; QL (600 EA per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
300 MCG/SPRAY
$0 (Tier 2) PA; QL (150 EA per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
400 MCG/SPRAY
$0 (Tier 2) PA; MO; QL (150 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
8
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
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)
morphine oral tablet 15 mg, 30 mg $0 (Tier 1) MO; 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 $0 (Tier 1) MO; QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
mg, 5 mg
$0 (Tier 1) MO; QL (120 EA per 30 days)
tramadol oral tablet 50 mg $0 (Tier 1) MO; QL (240 EA per 30 days)
ANESTHETICS - LOCAL TREATMENT OF PAIN
LOCAL ANESTHETICS
ACCUCAINE KIT KIT 10 MG/ML (1 %) $0 (Tier 1) MO
ANODYNE LPT TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO
dermacinrx empricaine topical kit 2.5-2.5 % $0 (Tier 1) MO
dibucaine 1% ointment 1 % $0 (Tier 3) DP
LEVA SET TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO
lidocaine (pf) injection solution 10 mg/ml (1 %), 5
mg/ml (0.5 %)
$0 (Tier 1) MO
lidocaine hcl injection solution 5 mg/ml (0.5 %) $0 (Tier 1) MO
lidocaine hcl laryngotracheal solution 4 % $0 (Tier 1) MO
lidocaine hcl mucous membrane jelly 2 % $0 (Tier 1) MO
lidocaine hcl mucous membrane jelly in applicator
2 %
$0 (Tier 1) MO
lidocaine hcl mucous membrane solution 4 % (40
mg/ml)
$0 (Tier 1) MO
lidocaine topical adhesive patch,medicated 5 % $0 (Tier 1) PA; MO; QL (90 EA per 30 days)
lidocaine topical ointment 5 % $0 (Tier 1) MO
lidocaine-prilocaine topical cream 2.5-2.5 % $0 (Tier 1) MO
lidocaine-prilocaine topical kit 2.5-2.5 % $0 (Tier 1) MO
LIDOPAC TOPICAL KIT 5 % $0 (Tier 1) MO
lidopril topical kit 2.5-2.5 % $0 (Tier 1) MO
lidopril xr topical kit 2.5-2.5 % $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
9
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
LIDO-PRILO CAINE PACK TOPICAL KIT 2.5-
2.5 %
$0 (Tier 1) MO
liprozonepak topical kit 2.5-2.5 % $0 (Tier 1) MO
livixil pak topical kit 2.5-2.5 % $0 (Tier 1) MO
MEDOLOR PAK TOPICAL KIT 2.5-2.5 % $0 (Tier 1) MO
prilolid topical kit 2.5-2.5 % $0 (Tier 1) MO
PUB HEMORRHOIDAL SUPPOSITORIES 0.25-
3 %
$0 (Tier 3) DP
SM HEMORRHOIDAL CREAM 0.25-1 % $0 (Tier 3) DP
ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS - TREATMENT OF
SUBSTANCE ABUSE DISORDERS
ALCOHOL DETERRENTS/ ANTI-CRAVING
acamprosate oral tablet,delayed release (dr/ec)
333 mg
$0 (Tier 1) MO
disulfiram oral tablet 250 mg, 500 mg $0 (Tier 1) MO
naltrexone oral tablet 50 mg $0 (Tier 1) MO
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl sublingual tablet 2 mg, 8 mg $0 (Tier 1) MO
buprenorphine-naloxone sublingual tablet 2-0.5
mg, 8-2 mg
$0 (Tier 1) MO
OPIOID REVERSAL AGENTS
naloxone injection solution 0.4 mg/ml $0 (Tier 1) MO
naloxone injection syringe 0.4 mg/ml, 1 mg/ml $0 (Tier 1) MO
SMOKING CESSATION AGENTS
buproban oral tablet extended release 12 hr 150
mg
$0 (Tier 1) MO
CHANTIX CONTINUING MONTH BOX ORAL
TABLET 1 MG
$0 (Tier 2) MO; QL (336 EA per 365 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG $0 (Tier 2) MO; QL (336 EA per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
10
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)
$0 (Tier 2) MO; QL (106 EA per 365 days)
NICODERM CQ 14 MG/24HR PATCH 14
MG/24 HR
$0 (Tier 3) DP
NICODERM CQ 21 MG/24HR PATCH 21
MG/24 HR
$0 (Tier 3) DP
NICODERM CQ 21 MG/24HR PATCH CLEAR
PATCH 21 MG/24 HR
$0 (Tier 3) DP
NICODERM CQ 7 MG/24HR PATCH 7 MG/24
HR
$0 (Tier 3) DP
nicotine 14 mg/24hr patch clear, step 2, outer (otc)
14 mg/24 hr
$0 (Tier 3) DP
nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr $0 (Tier 3) DP
nicotine 2 mg lozenge cinnamon,quittube 2 mg $0 (Tier 3) DP
nicotine 21 mg/24hr patch outer, clear, step 1 (otc)
21 mg/24 hr
$0 (Tier 3) DP
nicotine 4 mg chewing gum 4 mg $0 (Tier 3) DP
nicotine 4 mg lozenge mint 4 mg $0 (Tier 3) DP
nicotine 7 mg/24hr patch outer, clear, step 3 (otc)
7 mg/24 hr
$0 (Tier 3) DP
NICOTROL INHALATION CARTRIDGE 10
MG
$0 (Tier 2) MO
NICOTROL NS NASAL SPRAY,NON-
AEROSOL 10 MG/ML
$0 (Tier 2) MO
sm nicotine 2 mg chewing gum mint 2 mg $0 (Tier 3) DP
ANTIBACTERIALS - TREATMENT OF BACTERIAL INFECTIONS
AMINOGLYCOSIDES
amikacin injection solution 1,000 mg/4 ml, 500
mg/2 ml
$0 (Tier 1)
gentak ophthalmic (eye) ointment 0.3 % (3
mg/gram)
$0 (Tier 1) MO
gentamicin injection solution 20 mg/2 ml $0 (Tier 1)
gentamicin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO
gentamicin ophthalmic (eye) ointment 0.3 % (3
mg/gram)
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
11
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
gentamicin sulfate (ped) (pf) injection solution 20
mg/2 ml
$0 (Tier 1)
gentamicin sulfate (pf) intravenous solution 60
mg/6 ml
$0 (Tier 1)
gentamicin sulfate (pf) intravenous solution 80
mg/8 ml
$0 (Tier 1) MO
gentamicin topical cream 0.1 % $0 (Tier 1) MO
gentamicin topical ointment 0.1 % $0 (Tier 1) MO
neomycin oral tablet 500 mg $0 (Tier 1) MO
paromomycin oral capsule 250 mg $0 (Tier 1) MO
streptomycin intramuscular recon soln 1 gram $0 (Tier 1)
TOBRADEX OPHTHALMIC (EYE)
OINTMENT 0.3-0.1 %
$0 (Tier 2) MO
tobramycin in 0.225 % nacl inhalation solution for
nebulization 300 mg/5 ml
$0 (Tier 1) B/D
tobramycin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO
tobramycin sulfate injection recon soln 1.2 gram $0 (Tier 1)
tobramycin sulfate injection solution 10 mg/ml, 40
mg/ml
$0 (Tier 1)
tobramycin with nebulizer inhalation solution for
nebulization 300 mg/5 ml
$0 (Tier 1) B/D
tobramycin-dexamethasone ophthalmic (eye)
drops,suspension 0.3-0.1 %
$0 (Tier 1) MO
ANTIBACTERIALS, OTHER
acetic acid otic (ear) solution 2 % $0 (Tier 1) MO
ak-poly-bac ophthalmic (eye) ointment 500-10,000
unit/gram
$0 (Tier 1) MO
ANTIBIOTIC OINTMENT 3.5MG-400 UNIT-
5,000 UNIT/GRAM
$0 (Tier 3) DP
bacitracin 500 unit/gm ointmnt 500 unit/gram $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
12
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
bacitracin ophthalmic (eye) ointment 500
unit/gram
$0 (Tier 1) MO
bacitracin zn 500 unit/gm oint 5 panel carton 500
unit/gram
$0 (Tier 3) DP
bacitracin zn 500 unit/gm oint 500 unit/gram $0 (Tier 3) DP
bacitracin zn 500 unit/gm oint usp 500 unit/gram $0 (Tier 3) DP
bacitracin-polymyxin b ophthalmic (eye) ointment
500-10,000 unit/gram
$0 (Tier 1) MO
bacitracin-polymyxin ointment 500-10,000
unit/gram
$0 (Tier 3) DP
BACTROBAN NASAL NASAL OINTMENT 2
%
$0 (Tier 2) MO
BETADINE 10% SOLUTION ANTISEPTIC 10
%
$0 (Tier 3) DP
BETASEPT 4% SURGICAL SCRUB 4 % $0 (Tier 3) DP
CASTELLANI PAINT MODIFIED 1.5 % $0 (Tier 3) DP
chloramphenicol sod succinate intravenous recon
soln 1 gram
$0 (Tier 1) MO
clindamycin hcl oral capsule 150 mg, 300 mg, 75
mg
$0 (Tier 1) MO
clindamycin in 0.9 % sod chlor intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml, 900
mg/50 ml
$0 (Tier 1) MO
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml, 900
mg/50 ml
$0 (Tier 1)
clindamycin palmitate hcl oral recon soln 75 mg/5
ml
$0 (Tier 1) MO
clindamycin pediatric oral recon soln 75 mg/5 ml $0 (Tier 1) MO
clindamycin phosphate injection solution 150
(mg/ml) (6 ml), 150 mg/ml
$0 (Tier 1)
clindamycin phosphate intravenous solution 300
mg/2 ml, 600 mg/4 ml, 900 mg/6 ml
$0 (Tier 1)
clindamycin phosphate topical gel 1 % $0 (Tier 1) MO
clindamycin phosphate topical lotion 1 % $0 (Tier 1) MO
clindamycin phosphate topical solution 1 % $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
13
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
clindamycin phosphate topical swab 1 % $0 (Tier 1) MO
clindamycin phosphate vaginal cream 2 % $0 (Tier 1) MO
clindamycin-benzoyl peroxide topical gel 1.2 %(1
% base) -5 %
$0 (Tier 1) MO
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 3.5-
10,000-10 MG-UNIT-MG/GRAM
$0 (Tier 3) DP
lincomycin injection solution 300 mg/ml $0 (Tier 1)
linezolid in dextrose 5% intravenous parenteral
solution 600 mg/300 ml
$0 (Tier 1) PA
linezolid oral suspension for reconstitution 100
mg/5 ml
$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 $0 (Tier 1) MO
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 $0 (Tier 1) MO
metronidazole oral tablet 250 mg, 500 mg $0 (Tier 1) MO
metronidazole topical cream 0.75 % $0 (Tier 1) MO
metronidazole topical gel 0.75 %, 1 % $0 (Tier 1) MO
metronidazole topical gel with pump 1 % $0 (Tier 1) MO
metronidazole topical lotion 0.75 % $0 (Tier 1) MO
metronidazole vaginal gel 0.75 % $0 (Tier 1) MO
mupirocin topical ointment 2 % $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
14
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
neomycin-bacitracin-poly-hc ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit/g-1%
$0 (Tier 1) MO
neomycin-bacitracin-polymyxin ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit-unit/g
$0 (Tier 1) MO
neomycin-polymyxin b gu irrigation solution 40
mg-200,000 unit/ml
$0 (Tier 1) MO
neomycin-polymyxin b-dexameth ophthalmic (eye)
drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %
$0 (Tier 1) MO
neomycin-polymyxin b-dexameth ophthalmic (eye)
ointment 3.5 mg/g-10,000 unit/g-0.1 %
$0 (Tier 1) MO
neomycin-polymyxin-gramicidin ophthalmic (eye)
drops 1.75 mg-10,000 unit-0.025mg/ml
$0 (Tier 1) MO
neomycin-polymyxin-hc ophthalmic (eye)
drops,suspension 3.5-10,000-10 mg-unit-mg/ml
$0 (Tier 1) MO
nitrofurantoin macrocrystal oral capsule 100 mg,
25 mg, 50 mg
$0 (Tier 1) MO; QL (360 EA per 365 days)
nitrofurantoin monohyd/m-cryst oral capsule 100
mg
$0 (Tier 1) MO; QL (180 EA per 365 days)
nitrofurantoin monohyd/m-cryst oral capsule 100
mg (75/25)
$0 (Tier 1) MO; QL (360 EA per 365 days)
polymyxin b sulfate injection recon soln 500,000
unit
$0 (Tier 1)
polymyxin b sulf-trimethoprim ophthalmic (eye)
drops 10,000 unit- 1 mg/ml
$0 (Tier 1) MO
RA TRIPLE ANTIBIOTIC PLUS OINT 3.5-500-
10,000 MG-UNIT-UNIT/G
$0 (Tier 3) DP
SM ANTIBIOTIC 500 UNIT/GM OINT 500
UNIT/GRAM
$0 (Tier 3) DP
SYNERCID INTRAVENOUS RECON SOLN
500 MG
$0 (Tier 2) PA
trimethoprim oral tablet 100 mg $0 (Tier 1) MO
TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400
UNIT- 5,000 UNIT/GRAM
$0 (Tier 3) DP
TRIPLE ANTIBIOTIC OINTMENT CARTON
3.5MG-400 UNIT- 5,000 UNIT/GRAM
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
15
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
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
vancomycin in 0.9 % sodium chl intravenous
solution 1.25 gram/250 ml, 750 mg/150 ml
$0 (Tier 1) B/D; MO
vancomycin in dextrose 5 % intravenous
piggyback 1 gram/200 ml, 500 mg/100 ml, 750
mg/150 ml
$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) MO
XIFAXAN ORAL TABLET 200 MG, 550 MG $0 (Tier 2) PA; MO
BETA-LACTAM, CEPHALOSPORINS
cefaclor oral capsule 250 mg, 500 mg $0 (Tier 1) MO
cefaclor oral tablet extended release 12 hr 500 mg $0 (Tier 1) MO
cefadroxil oral capsule 500 mg $0 (Tier 1) MO
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
$0 (Tier 1) MO
cefadroxil oral tablet 1 gram $0 (Tier 1) MO
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 $0 (Tier 1) MO
cefdinir oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
$0 (Tier 1) MO
cefepime in dextrose 5 % intravenous piggyback 1
gram/50 ml, 2 gram/50 ml
$0 (Tier 1)
cefepime in dextrose,iso-osm intravenous
piggyback 1 gram/50 ml, 2 gram/100 ml
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
16
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
cefepime injection recon soln 1 gram, 2 gram $0 (Tier 1)
cefotaxime injection recon soln 1 gram, 2 gram,
500 mg
$0 (Tier 1)
cefoxitin in dextrose, iso-osm intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
$0 (Tier 1)
cefoxitin intravenous recon soln 1 gram, 10 gram,
2 gram
$0 (Tier 1)
cefpodoxime oral suspension for reconstitution
100 mg/5 ml, 50 mg/5 ml
$0 (Tier 1) MO
cefpodoxime oral tablet 100 mg, 200 mg $0 (Tier 1) MO
cefprozil oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
$0 (Tier 1) MO
cefprozil oral tablet 250 mg, 500 mg $0 (Tier 1) MO
ceftazidime in d5w intravenous piggyback 1
gram/50 ml, 2 gram/50 ml
$0 (Tier 1)
ceftazidime injection recon soln 1 gram, 2 gram, 6
gram
$0 (Tier 1)
ceftriaxone in dextrose,iso-os intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
$0 (Tier 1)
ceftriaxone injection recon soln 1 gram, 10 gram,
2 gram, 250 mg, 500 mg
$0 (Tier 1)
ceftriaxone injection recon soln 100 gram $0 (Tier 1) MO
ceftriaxone intravenous recon soln 1 gram, 2 gram $0 (Tier 1)
cefuroxime axetil oral tablet 250 mg, 500 mg $0 (Tier 1) MO
cefuroxime sodium intravenous recon soln 1.5
gram
$0 (Tier 1)
cephalexin oral capsule 250 mg, 500 mg $0 (Tier 1) MO
cephalexin oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
$0 (Tier 1) MO
cephalexin oral tablet 250 mg, 500 mg $0 (Tier 1) MO
SUPRAX ORAL CAPSULE 400 MG $0 (Tier 2) MO
TAZICEF INJECTION RECON SOLN 1 GRAM,
2 GRAM, 6 GRAM
$0 (Tier 1)
TAZICEF INTRAVENOUS RECON SOLN 1
GRAM, 2 GRAM
$0 (Tier 1)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
17
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
TEFLARO INTRAVENOUS RECON SOLN 400
MG, 600 MG
$0 (Tier 2) PA
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 $0 (Tier 2) PA
INVANZ INTRAVENOUS RECON SOLN 1
GRAM
$0 (Tier 2) PA
meropenem intravenous recon soln 1 gram, 500
mg
$0 (Tier 1)
meropenem-0.9% sodium chloride intravenous
piggyback 1 gram/50 ml, 500 mg/50 ml
$0 (Tier 1) MO
VABOMERE INTRAVENOUS RECON SOLN 2
GRAM
$0 (Tier 2) PA; MO
BETA-LACTAM, PENICILLINS
amoxicillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO
amoxicillin oral suspension for reconstitution 125
mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
$0 (Tier 1) MO
amoxicillin oral tablet 500 mg, 875 mg $0 (Tier 1) MO
amoxicillin oral tablet,chewable 125 mg, 250 mg $0 (Tier 1) MO
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5
ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml
$0 (Tier 1) MO
amoxicillin-pot clavulanate oral tablet 250-125
mg, 500-125 mg, 875-125 mg
$0 (Tier 1) MO
amoxicillin-pot clavulanate oral tablet extended
release 12 hr 1,000-62.5 mg
$0 (Tier 1) MO
amoxicillin-pot clavulanate oral tablet,chewable
200-28.5 mg, 400-57 mg
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
18
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ampicillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO
ampicillin oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
$0 (Tier 1) MO
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
$0 (Tier 1)
ampicillin-sulbactam intravenous recon soln 1.5
gram, 3 gram
$0 (Tier 1)
BICILLIN L-A INTRAMUSCULAR SYRINGE
1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML,
600,000 UNIT/ML
$0 (Tier 2) MO
dicloxacillin oral capsule 250 mg, 500 mg $0 (Tier 1) MO
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
$0 (Tier 1)
penicillin g sodium injection recon soln 5 million
unit
$0 (Tier 1)
penicillin v potassium oral recon soln 125 mg/5
ml, 250 mg/5 ml
$0 (Tier 1) MO
penicillin v potassium oral tablet 250 mg, 500 mg $0 (Tier 1) MO
piperacillin-tazobactam intravenous recon soln
13.5 gram
$0 (Tier 1) MO
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
$0 (Tier 1)
MACROLIDES
azithromycin intravenous recon soln 500 mg, 500
mg (2 mg/ml)
$0 (Tier 1) MO
azithromycin oral packet 1 gram $0 (Tier 1) MO
azithromycin oral suspension for reconstitution
100 mg/5 ml, 200 mg/5 ml
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
19
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
azithromycin oral tablet 250 mg, 250 mg (6 pack),
500 mg, 500 mg (3 pack), 600 mg
$0 (Tier 1) MO
clarithromycin oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
$0 (Tier 1) MO
clarithromycin oral tablet 250 mg, 500 mg $0 (Tier 1) MO
clarithromycin oral tablet extended release 24 hr
500 mg
$0 (Tier 1) MO
DIFICID ORAL TABLET 200 MG $0 (Tier 2) PA; MO
ery pads topical swab 2 % $0 (Tier 1) MO
erythrocin (as stearate) oral tablet 250 mg $0 (Tier 1) MO
ERYTHROCIN INTRAVENOUS RECON SOLN
500 MG
$0 (Tier 2) MO
erythromycin ethylsuccinate oral suspension for
reconstitution 200 mg/5 ml
$0 (Tier 1) MO
erythromycin ethylsuccinate oral tablet 400 mg $0 (Tier 1) MO
erythromycin ophthalmic (eye) ointment 5
mg/gram (0.5 %)
$0 (Tier 1) MO
erythromycin oral tablet 250 mg, 500 mg $0 (Tier 1) MO
erythromycin with ethanol topical gel 2 % $0 (Tier 1) MO
erythromycin with ethanol topical solution 2 % $0 (Tier 1) MO
QUINOLONES
AVELOX IN NACL (ISO-OSMOTIC)
INTRAVENOUS PIGGYBACK 400 MG/250 ML
$0 (Tier 2)
ciprofloxacin (mixture) oral tablet, er multiphase
24 hr 1,000 mg, 500 mg
$0 (Tier 1) MO
ciprofloxacin hcl ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500
mg, 750 mg
$0 (Tier 1) MO
ciprofloxacin lactate intravenous solution 200
mg/20 ml, 400 mg/40 ml
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
20
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
levofloxacin in d5w intravenous piggyback 500
mg/100 ml, 750 mg/150 ml
$0 (Tier 1)
levofloxacin intravenous solution 25 mg/ml $0 (Tier 1)
levofloxacin oral solution 250 mg/10 ml $0 (Tier 1) MO
levofloxacin oral tablet 250 mg, 500 mg, 750 mg $0 (Tier 1) MO
MOXEZA OPHTHALMIC (EYE) DROPS,
VISCOUS 0.5 %
$0 (Tier 2) MO
moxifloxacin in nacl (iso-osm) intravenous
piggyback 400 mg/250 ml
$0 (Tier 1)
moxifloxacin ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO
moxifloxacin oral tablet 400 mg $0 (Tier 1) MO
moxifloxacin-sod.ace,sul-water intravenous
piggyback 400 mg/250 ml
$0 (Tier 1) MO
ofloxacin ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO
ofloxacin oral tablet 300 mg, 400 mg $0 (Tier 1) MO
VIGAMOX OPHTHALMIC (EYE) DROPS 0.5
%
$0 (Tier 2) MO
SULFONAMIDES
silver sulfadiazine topical cream 1 % $0 (Tier 1) MO
ssd topical cream 1 % $0 (Tier 1) MO
sulfacetamide sodium (acne) topical suspension 10
%
$0 (Tier 1) MO
sulfacetamide sodium ophthalmic (eye) drops 10
%
$0 (Tier 1) MO
sulfacetamide sodium ophthalmic (eye) ointment
10 %
$0 (Tier 1) MO
sulfadiazine oral tablet 500 mg $0 (Tier 1) MO
sulfamethoxazole-trimethoprim intravenous
solution 400-80 mg/5 ml
$0 (Tier 1)
sulfamethoxazole-trimethoprim oral suspension
200-40 mg/5 ml
$0 (Tier 1) MO
sulfamethoxazole-trimethoprim oral tablet 400-80
mg, 800-160 mg
$0 (Tier 1) MO
TETRACYCLINES
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
21
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
demeclocycline oral tablet 150 mg, 300 mg $0 (Tier 1) MO
doxy-100 intravenous recon soln 100 mg $0 (Tier 1)
doxycycline hyclate intravenous recon soln 100 mg $0 (Tier 1)
doxycycline hyclate oral capsule 100 mg, 50 mg $0 (Tier 1) MO
doxycycline hyclate oral tablet 100 mg, 20 mg $0 (Tier 1) MO
doxycycline monohydrate oral capsule 100 mg, 50
mg
$0 (Tier 1) MO
doxycycline monohydrate oral tablet 100 mg, 150
mg, 50 mg, 75 mg
$0 (Tier 1) MO
minocycline oral capsule 100 mg, 50 mg, 75 mg $0 (Tier 1) MO
minocycline oral tablet 100 mg, 50 mg, 75 mg $0 (Tier 1) MO
MORGIDOX 1X 50 KIT 50 MG $0 (Tier 1) MO
morgidox oral capsule 50 mg $0 (Tier 1) MO
ANTICONVULSANTS - TREATMENT OF SEIZURES
ANTICONVULSANTS, OTHER
BRIVIACT INTRAVENOUS SOLUTION 50
MG/5 ML
$0 (Tier 2) PA; MO
BRIVIACT ORAL SOLUTION 10 MG/ML $0 (Tier 2) PA; MO
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25
MG, 50 MG, 75 MG
$0 (Tier 2) PA; MO
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500
mg/100 ml
$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)
$0 (Tier 1) MO
levetiracetam oral tablet 1,000 mg, 250 mg, 500
mg, 750 mg
$0 (Tier 1) MO
levetiracetam oral tablet extended release 24 hr
500 mg, 750 mg
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
22
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ROWEEPRA ORAL TABLET 1,000 MG, 750
MG
$0 (Tier 1) MO
roweepra oral tablet 500 mg $0 (Tier 1) MO
ROWEEPRA XR ORAL TABLET EXTENDED
RELEASE 24 HR 500 MG, 750 MG
$0 (Tier 1) MO
SPRITAM ORAL TABLET FOR SUSPENSION
1,000 MG, 250 MG, 500 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
SPRITAM ORAL TABLET FOR SUSPENSION
750 MG
$0 (Tier 2) ST; MO; QL (120 EA per 30 days)
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN ORAL CAPSULE 300 MG $0 (Tier 2) MO
ethosuximide oral capsule 250 mg $0 (Tier 1) MO
ethosuximide oral solution 250 mg/5 ml $0 (Tier 1) MO
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75
MG
$0 (Tier 2) MO
LYRICA ORAL SOLUTION 20 MG/ML $0 (Tier 2) MO
zonisamide oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DIASTAT ACUDIAL RECTAL KIT 12.5-15-
17.5-20 MG
$0 (Tier 2) MO; QL (40 EA per 30 days)
DIASTAT ACUDIAL RECTAL KIT 5-7.5-10
MG
$0 (Tier 2) MO; QL (20 EA per 30 days)
DIASTAT RECTAL KIT 2.5 MG $0 (Tier 2) MO; QL (5 EA per 30 days)
diazepam rectal kit 12.5-15-17.5-20 mg $0 (Tier 1) MO; QL (40 EA per 30 days)
diazepam rectal kit 2.5 mg $0 (Tier 1) MO; QL (5 EA per 30 days)
diazepam rectal kit 5-7.5-10 mg $0 (Tier 1) MO; QL (20 EA per 30 days)
divalproex oral capsule, delayed rel sprinkle 125
mg
$0 (Tier 1) MO
divalproex oral tablet extended release 24 hr 250
mg, 500 mg
$0 (Tier 1) MO
divalproex oral tablet,delayed release (dr/ec) 125
mg, 250 mg, 500 mg
$0 (Tier 1) MO
gabapentin oral capsule 100 mg, 300 mg, 400 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
23
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
gabapentin oral solution 250 mg/5 ml, 250 mg/5
ml (5 ml), 300 mg/6 ml (6 ml)
$0 (Tier 1) MO
gabapentin oral tablet 600 mg, 800 mg $0 (Tier 1) MO
GABITRIL ORAL TABLET 12 MG, 16 MG $0 (Tier 2) MO
ONFI ORAL SUSPENSION 2.5 MG/ML $0 (Tier 2) PA; MO; QL (480 ML per 30 days)
ONFI ORAL TABLET 10 MG, 20 MG $0 (Tier 2) PA; 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 $0 (Tier 1) MO
SABRIL ORAL POWDER IN PACKET 500 MG $0 (Tier 2) PA
SABRIL ORAL TABLET 500 MG $0 (Tier 2) PA; QL (180 EA per 30 days)
tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg $0 (Tier 1) MO
valproate sodium intravenous solution 500 mg/5
ml (100 mg/ml)
$0 (Tier 1)
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) MO
valproic acid oral capsule 250 mg $0 (Tier 1) MO
vigabatrin oral powder in packet 500 mg $0 (Tier 1) PA
GLUTAMATE REDUCING AGENTS
felbamate oral suspension 600 mg/5 ml $0 (Tier 1) MO
felbamate oral tablet 400 mg, 600 mg $0 (Tier 1) MO
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
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
25 mg
$0 (Tier 1) MO
lamotrigine oral tablet extended release 24hr 100
mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
24
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
lamotrigine oral tablet, chewable dispersible 25
mg, 5 mg
$0 (Tier 1) MO
lamotrigine oral tablets,dose pack 25 mg (35), 25
mg (42) -100 mg (7), 25 mg (84) -100 mg (14)
$0 (Tier 1) MO
topiramate oral capsule, sprinkle 15 mg, 25 mg $0 (Tier 1) MO
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
mg
$0 (Tier 1) MO
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 $0 (Tier 2) PA; MO; QL (2400 ML per 30 days)
BANZEL ORAL TABLET 200 MG, 400 MG $0 (Tier 2) PA; MO; QL (240 EA per 30 days)
carbamazepine oral capsule, er multiphase 12 hr
100 mg, 200 mg, 300 mg
$0 (Tier 1) MO
carbamazepine oral suspension 100 mg/5 ml $0 (Tier 1) MO
carbamazepine oral tablet 200 mg $0 (Tier 1) MO
carbamazepine oral tablet extended release 12 hr
100 mg, 200 mg, 400 mg
$0 (Tier 1) MO
carbamazepine oral tablet,chewable 100 mg $0 (Tier 1) MO
DILANTIN ORAL CAPSULE 30 MG $0 (Tier 2) MO
epitol oral tablet 200 mg $0 (Tier 1) MO
EQUETRO ORAL CAPSULE, ER
MULTIPHASE 12 HR 100 MG, 200 MG, 300
MG
$0 (Tier 2) MO
fosphenytoin injection solution 100 mg pe/2 ml,
500 mg pe/10 ml
$0 (Tier 1)
oxcarbazepine oral suspension 300 mg/5 ml (60
mg/ml)
$0 (Tier 1) MO
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg $0 (Tier 1) MO
PEGANONE ORAL TABLET 250 MG $0 (Tier 2) MO
PHENYTEK ORAL CAPSULE 200 MG, 300 MG $0 (Tier 2) MO
phenytoin oral suspension 100 mg/4 ml, 125 mg/5
ml
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
25
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
phenytoin oral tablet,chewable 50 mg $0 (Tier 1) MO
phenytoin sodium extended oral capsule 100 mg,
200 mg, 300 mg
$0 (Tier 1) MO
phenytoin sodium intravenous solution 50 mg/ml $0 (Tier 1)
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
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
ANTIDEMENTIA AGENTS - MANAGEMENT OF DEMENTIA
ANTIDEMENTIA AGENTS, OTHER
ergoloid oral tablet 1 mg $0 (Tier 1) PA; MO
CHOLINESTERASE INHIBITORS
donepezil oral tablet 10 mg, 23 mg, 5 mg $0 (Tier 1) MO
donepezil oral tablet,disintegrating 10 mg, 5 mg $0 (Tier 1) MO
rivastigmine tartrate oral capsule 1.5 mg, 3 mg,
4.5 mg, 6 mg
$0 (Tier 1) MO
rivastigmine transdermal patch 24 hour 13.3
mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr
$0 (Tier 1) MO
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine oral capsule,sprinkle,er 24hr 14 mg,
21 mg, 28 mg, 7 mg
$0 (Tier 1) ST; MO; QL (30 EA per 30 days)
memantine oral tablet 10 mg, 5 mg $0 (Tier 1) MO
memantine oral tablets,dose pack 5-10 mg $0 (Tier 1) MO
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK 7-14-21-28 MG
$0 (Tier 2) ST; MO
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG,
28 MG, 7 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
26
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ANTIDEPRESSANTS - TREATMENT OF DEPRESSION
ANTIDEPRESSANTS, OTHER
bupropion hcl (smoking deter) oral tablet extended
release 12 hr 150 mg
$0 (Tier 1) MO
bupropion hcl oral tablet 100 mg, 75 mg $0 (Tier 1) MO
bupropion hcl oral tablet extended release 12 hr
100 mg, 150 mg, 200 mg
$0 (Tier 1) MO
bupropion hcl oral tablet extended release 24 hr
150 mg, 300 mg
$0 (Tier 1) MO
FORFIVO XL ORAL TABLET EXTENDED
RELEASE 24 HR 450 MG
$0 (Tier 2) MO
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5
mg
$0 (Tier 1) MO
mirtazapine oral tablet,disintegrating 15 mg, 30
mg, 45 mg
$0 (Tier 1) MO
nefazodone oral tablet 100 mg, 150 mg, 200 mg,
250 mg, 50 mg
$0 (Tier 1) MO
perphenazine-amitriptyline oral tablet 2-10 mg, 2-
25 mg, 4-10 mg, 4-25 mg, 4-50 mg
$0 (Tier 1) PA; MO
trazodone oral tablet 100 mg, 150 mg, 300 mg, 50
mg
$0 (Tier 1) MO
MONOAMINE OXIDASE INHIBITORS
EMSAM TRANSDERMAL PATCH 24 HOUR
12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR
$0 (Tier 2) MO
MARPLAN ORAL TABLET 10 MG $0 (Tier 2) MO
phenelzine oral tablet 15 mg $0 (Tier 1) MO
tranylcypromine oral tablet 10 mg $0 (Tier 1) MO
SSRIS/ SNRIS
citalopram oral solution 10 mg/5 ml $0 (Tier 1) MO
citalopram oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO
desvenlafaxine succinate oral tablet extended
release 24 hr 100 mg, 25 mg, 50 mg
$0 (Tier 1) MO
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 30 mg, 60 mg
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
27
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
escitalopram oxalate oral solution 5 mg/5 ml $0 (Tier 1) MO
escitalopram oxalate oral tablet 10 mg, 20 mg, 5
mg
$0 (Tier 1) MO
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK 20 MG (2)- 40 MG (26)
$0 (Tier 2) ST; MO
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 $0 (Tier 1) MO
fluoxetine oral capsule,delayed release(dr/ec) 90
mg
$0 (Tier 1) MO
fluoxetine oral solution 20 mg/5 ml (4 mg/ml) $0 (Tier 1) MO
fluoxetine oral tablet 10 mg, 20 mg $0 (Tier 1) MO
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
maprotiline oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) MO
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40
mg
$0 (Tier 1) MO
paroxetine hcl oral tablet extended release 24 hr
12.5 mg, 25 mg, 37.5 mg
$0 (Tier 1) MO
PAXIL ORAL SUSPENSION 10 MG/5 ML $0 (Tier 2) MO
sertraline oral concentrate 20 mg/ml $0 (Tier 1) MO
sertraline oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5
MG
$0 (Tier 2) ST; MO
venlafaxine oral capsule,extended release 24hr
150 mg, 37.5 mg, 75 mg
$0 (Tier 1) MO
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50
mg, 75 mg
$0 (Tier 1) MO
venlafaxine oral tablet extended release 24hr 150
mg, 225 mg, 37.5 mg, 75 mg
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
28
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40
MG
$0 (Tier 2) ST; MO
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)- 20 MG (23)
$0 (Tier 2) ST; MO
TRICYCLICS
amitriptyline oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
$0 (Tier 1) PA; MO
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50
mg
$0 (Tier 1) 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
$0 (Tier 1) MO
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
$0 (Tier 1) PA; MO
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75
mg
$0 (Tier 1) MO
nortriptyline oral solution 10 mg/5 ml $0 (Tier 1) MO
protriptyline oral tablet 10 mg, 5 mg $0 (Tier 1) MO
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 $0 (Tier 1) MO
chlorpromazine oral tablet 10 mg, 100 mg, 200
mg, 25 mg, 50 mg
$0 (Tier 1) MO
compro rectal suppository 25 mg $0 (Tier 1) MO
dimenhydrinate 50 mg tablet (otc) 50 mg $0 (Tier 3) DP
diphenhydramine hcl injection solution 50 mg/ml $0 (Tier 1) PA; MO
meclizine oral tablet 12.5 mg, 25 mg $0 (Tier 1) MO
metoclopramide hcl injection solution 5 mg/ml $0 (Tier 1) MO
metoclopramide hcl oral solution 5 mg/5 ml $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
29
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
metoclopramide hcl oral tablet 10 mg, 5 mg $0 (Tier 1) MO
MOTION SICKNESS RELIEF TB CHEW
CHEWABLE TABLET 25 MG
$0 (Tier 3) DP
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO
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
$0 (Tier 1) MO
prochlorperazine maleate oral tablet 10 mg, 5 mg $0 (Tier 1) MO
prochlorperazine rectal suppository 25 mg $0 (Tier 1) MO
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
$0 (Tier 1) MO
TRANSDERM-SCOP TRANSDERMAL PATCH
3 DAY 1 MG OVER 3 DAYS
$0 (Tier 2) MO
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.)
$0 (Tier 2) B/D; MO
granisetron (pf) intravenous solution 1 mg/ml (1
ml), 100 mcg/ml
$0 (Tier 1) B/D
granisetron hcl intravenous solution 1 mg/ml, 1
mg/ml (1 ml)
$0 (Tier 1) B/D
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
30
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
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)
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 $0 (Tier 2) PA; 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 % $0 (Tier 3) DP
ANTIFUNGAL 2% CREAM 2 % $0 (Tier 3) DP
BAZA ANTIFUNGAL 2% CREAM 12'S 2 % $0 (Tier 3) DP
BREWER'S YEAST 680 MG TABLET 680 MG $0 (Tier 3) DP
CANCIDAS INTRAVENOUS RECON SOLN 50
MG, 70 MG
$0 (Tier 2) PA
caspofungin intravenous recon soln 50 mg, 70 mg $0 (Tier 1) PA
ciclopirox topical cream 0.77 % $0 (Tier 1) MO
ciclopirox topical solution 8 % $0 (Tier 1) MO
ciclopirox topical suspension 0.77 % $0 (Tier 1) MO
ciclopirox-ure-camph-menth-euc topical solution 8
%
$0 (Tier 1) MO
clotrim 1% vaginal cream 1 % $0 (Tier 3) DP
clotrimazole 1% cream w/7 applicators 1 % $0 (Tier 3) DP
clotrimazole 1% cream w/single applicator 1 % $0 (Tier 3) DP
CLOTRIMAZOLE 3 2% CREAM 2 % $0 (Tier 3) DP
clotrimazole mucous membrane troche 10 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
31
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
clotrimazole topical cream 1 % $0 (Tier 1) MO
clotrimazole topical solution 1 % $0 (Tier 1) MO
DESENEX 2% POWDER 2 % $0 (Tier 3) DP
econazole topical cream 1 % $0 (Tier 1) MO
ERAXIS(WATER DILUENT) INTRAVENOUS
RECON SOLN 100 MG, 50 MG
$0 (Tier 2) PA
fluconazole in dextrose(iso-o) intravenous
piggyback 200 mg/100 ml, 400 mg/200 ml
$0 (Tier 1)
fluconazole in nacl (iso-osm) intravenous
piggyback 100 mg/50 ml, 200 mg/100 ml, 400
mg/200 ml
$0 (Tier 1)
fluconazole oral suspension for reconstitution 10
mg/ml, 40 mg/ml
$0 (Tier 1) MO
fluconazole oral tablet 100 mg, 150 mg, 200 mg,
50 mg
$0 (Tier 1) MO
flucytosine oral capsule 250 mg $0 (Tier 1)
flucytosine oral capsule 500 mg $0 (Tier 1) MO
FUNGOID 2% TINCTURE 2 % $0 (Tier 3) DP
griseofulvin microsize oral suspension 125 mg/5
ml
$0 (Tier 1) MO
itraconazole oral capsule 100 mg $0 (Tier 1) MO
ketoconazole oral tablet 200 mg $0 (Tier 1) MO
ketoconazole topical cream 2 % $0 (Tier 1) MO
ketoconazole topical shampoo 2 % $0 (Tier 1) MO
LAMISIL AT 1% GEL 1 % $0 (Tier 3) DP
MENTAX TOPICAL CREAM 1 % $0 (Tier 2) MO
MICONAZOLE 7 100 MG VAG SUPP 100 MG $0 (Tier 3) DP
MICONAZOLE 7 CREAM 2 % $0 (Tier 3) DP
MICONAZOLE 7 CREAM W/7 DISP
APPLICATORS 2 %
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
32
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
miconazole nitrate 2% cream 2 % $0 (Tier 3) DP
miconazole nitrate 2% cream 2 % $0 (Tier 3) DP
miconazole nitrate 2% cream w/7 disp applicators
2 %
$0 (Tier 3) DP
miconazole nitrate 2% cream w/applicator 2 % $0 (Tier 3) DP
MICONAZORB AF 2% POWDER 2 % $0 (Tier 3) DP
MICRO-GUARD 2% POWDER
12'S,ANTIFUNGAL 2 %
$0 (Tier 3) DP
MYCAMINE INTRAVENOUS RECON SOLN
100 MG, 50 MG
$0 (Tier 2) PA
NOXAFIL ORAL SUSPENSION 200 MG/5 ML
(40 MG/ML)
$0 (Tier 2) PA; MO
NOXAFIL ORAL TABLET,DELAYED
RELEASE (DR/EC) 100 MG
$0 (Tier 2) PA; MO
nyamyc topical powder 100,000 unit/gram $0 (Tier 1) MO
nystatin oral suspension 100,000 unit/ml $0 (Tier 1) MO
nystatin oral tablet 500,000 unit $0 (Tier 1) MO
nystatin topical cream 100,000 unit/gram $0 (Tier 1) MO
nystatin topical ointment 100,000 unit/gram $0 (Tier 1) MO
nystatin topical powder 100,000 unit/gram $0 (Tier 1) MO
nystop topical powder 100,000 unit/gram $0 (Tier 1) MO
qc tolnaftate 1% cream 1 % $0 (Tier 3) DP
SM ATHLETE'S 1% FOOT CREAM 1 % $0 (Tier 3) DP
sm clotrimazole 1% cream 1 % $0 (Tier 3) DP
terbinafine 1% cream 1 % $0 (Tier 3) DP
terbinafine hcl oral tablet 250 mg $0 (Tier 1) MO
terconazole vaginal cream 0.4 %, 0.8 % $0 (Tier 1) MO
terconazole vaginal suppository 80 mg $0 (Tier 1) MO
TINACTIN 1% AEROSOL POWDER 1 % $0 (Tier 3) DP
tolnaftate 1% cream 1 % $0 (Tier 3) DP
voriconazole intravenous solution 200 mg $0 (Tier 1)
voriconazole oral suspension for reconstitution
200 mg/5 ml (40 mg/ml)
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
33
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
voriconazole oral tablet 200 mg, 50 mg $0 (Tier 1) MO
ANTIGOUT AGENTS - TREATMENT OR PREVENTION OF GOUTY ARTHRITIS
ANTIGOUT AGENTS
allopurinol oral tablet 100 mg, 300 mg $0 (Tier 1) MO
colchicine oral capsule 0.6 mg $0 (Tier 1) MO
colchicine oral tablet 0.6 mg $0 (Tier 1) MO
probenecid oral tablet 500 mg $0 (Tier 1) MO
probenecid-colchicine oral tablet 500-0.5 mg $0 (Tier 1) MO
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 % $0 (Tier 1) MO
alclometasone topical cream 0.05 % $0 (Tier 1) MO
alclometasone topical ointment 0.05 % $0 (Tier 1) MO
betamethasone dipropionate topical cream 0.05 % $0 (Tier 1) MO
betamethasone dipropionate topical lotion 0.05 % $0 (Tier 1) MO
betamethasone dipropionate topical ointment 0.05
%
$0 (Tier 1) MO
betamethasone valerate topical cream 0.1 % $0 (Tier 1) MO
betamethasone valerate topical lotion 0.1 % $0 (Tier 1) MO
betamethasone valerate topical ointment 0.1 % $0 (Tier 1) MO
betamethasone, augmented topical cream 0.05 % $0 (Tier 1) MO
betamethasone, augmented topical gel 0.05 % $0 (Tier 1) MO
betamethasone, augmented topical lotion 0.05 % $0 (Tier 1) MO
betamethasone, augmented topical ointment 0.05
%
$0 (Tier 1) MO
clobetasol scalp solution 0.05 % $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
34
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
clobetasol topical cream 0.05 % $0 (Tier 1) MO
clobetasol topical gel 0.05 % $0 (Tier 1) MO
clobetasol topical ointment 0.05 % $0 (Tier 1) MO
desonide topical cream 0.05 % $0 (Tier 1) MO
desonide topical lotion 0.05 % $0 (Tier 1) MO
desonide topical ointment 0.05 % $0 (Tier 1) MO
desoximetasone topical cream 0.05 %, 0.25 % $0 (Tier 1) MO
desoximetasone topical gel 0.05 % $0 (Tier 1) MO
desoximetasone topical ointment 0.05 %, 0.25 % $0 (Tier 1) MO
dexamethasone intensol oral drops 1 mg/ml $0 (Tier 1) MO
dexamethasone oral elixir 0.5 mg/5 ml $0 (Tier 1) MO
dexamethasone oral solution 0.5 mg/5 ml $0 (Tier 1) MO
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,
1.5 mg, 2 mg, 4 mg, 6 mg
$0 (Tier 1) MO
dexamethasone sodium phos (pf) injection solution
10 mg/ml
$0 (Tier 1)
dexamethasone sodium phosphate injection
solution 10 mg/ml, 4 mg/ml
$0 (Tier 1)
dexamethasone sodium phosphate injection
syringe 4 mg/ml
$0 (Tier 1) MO
fluocinolone topical cream 0.01 %, 0.025 % $0 (Tier 1) MO
fluocinolone topical ointment 0.025 % $0 (Tier 1) MO
fluocinolone topical solution 0.01 % $0 (Tier 1) MO
fluocinonide topical cream 0.05 % $0 (Tier 1) MO
fluocinonide topical gel 0.05 % $0 (Tier 1) MO
fluocinonide topical ointment 0.05 % $0 (Tier 1) MO
fluocinonide topical solution 0.05 % $0 (Tier 1) MO
fluocinonide-e topical cream 0.05 % $0 (Tier 1) MO
fluocinonide-emollient topical cream 0.05 % $0 (Tier 1) MO
fluticasone topical cream 0.05 % $0 (Tier 1) MO
fluticasone topical lotion 0.05 % $0 (Tier 1) MO
fluticasone topical ointment 0.005 % $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
35
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
halobetasol propionate topical cream 0.05 % $0 (Tier 1) MO
halobetasol propionate topical ointment 0.05 % $0 (Tier 1) MO
hydrocortisone butyrate topical cream 0.1 % $0 (Tier 1) MO
hydrocortisone butyrate topical ointment 0.1 % $0 (Tier 1) MO
hydrocortisone butyrate topical solution 0.1 % $0 (Tier 1) MO
hydrocortisone butyr-emollient topical cream 0.1
%
$0 (Tier 1) MO
hydrocortisone topical cream 1 %, 2.5 % $0 (Tier 1) MO
hydrocortisone topical cream with perineal
applicator 1 %
$0 (Tier 1) MO
hydrocortisone topical lotion 2.5 % $0 (Tier 1) MO
hydrocortisone topical ointment 1 %, 2.5 % $0 (Tier 1) MO
hydrocortisone valerate topical cream 0.2 % $0 (Tier 1) MO
hydrocortisone valerate topical ointment 0.2 % $0 (Tier 1) MO
hydrocortisone-aloe 1% cream 1 % $0 (Tier 3) DP
methylprednisolone acetate injection suspension
40 mg/ml, 80 mg/ml
$0 (Tier 1)
methylprednisolone oral tablet 16 mg, 32 mg, 4
mg, 8 mg
$0 (Tier 1) MO
methylprednisolone oral tablets,dose pack 4 mg $0 (Tier 1) MO
methylprednisolone sodium succ injection recon
soln 125 mg, 40 mg
$0 (Tier 1) MO
methylprednisolone sodium succ intravenous
recon soln 1,000 mg
$0 (Tier 1)
mometasone topical cream 0.1 % $0 (Tier 1) MO
mometasone topical ointment 0.1 % $0 (Tier 1) MO
mometasone topical solution 0.1 % $0 (Tier 1) MO
prednisolone oral solution 15 mg/5 ml $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
36
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
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)
$0 (Tier 1) MO
prednisone oral solution 5 mg/5 ml $0 (Tier 1) MO
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
$0 (Tier 1) MO
prednisone oral tablets,dose pack 10 mg, 10 mg
(48 pack), 5 mg, 5 mg (48 pack)
$0 (Tier 1) MO
RAYOS ORAL TABLET,DELAYED RELEASE
(DR/EC) 1 MG, 2 MG, 5 MG
$0 (Tier 2) MO
triamcinolone acetonide topical cream 0.025 %,
0.1 %, 0.5 %
$0 (Tier 1) MO
triamcinolone acetonide topical lotion 0.025 %,
0.1 %
$0 (Tier 1) MO
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
$0 (Tier 1) MO
triderm topical cream 0.1 % $0 (Tier 1) MO
ANTIMIGRAINE AGENTS - TREATMENT OF MIGRAINE HEADACHES
ANTIMIGRAINE AGENTS
MIGRAINE RELIEF CAPLET CAPLET,
COATED 250-250-65 MG
$0 (Tier 3) DP
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)
$0 (Tier 1) MO; QL (8 ML per 30 days)
ergotamine-caffeine oral tablet 1-100 mg $0 (Tier 1) MO
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
rizatriptan oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (12 EA per 30 days)
rizatriptan oral tablet,disintegrating 10 mg, 5 mg $0 (Tier 1) MO; QL (12 EA per 30 days)
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
$0 (Tier 1) MO; QL (12 EA per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg,
50 mg
$0 (Tier 1) MO; QL (12 EA per 30 days)
sumatriptan succinate subcutaneous cartridge 4
mg/0.5 ml, 6 mg/0.5 ml
$0 (Tier 1) MO; QL (4 ML per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
37
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
sumatriptan succinate subcutaneous pen injector 4
mg/0.5 ml, 6 mg/0.5 ml, 6 mg/0.5 ml (auto-
injector)
$0 (Tier 1) MO; QL (4 ML per 30 days)
sumatriptan succinate subcutaneous solution 6
mg/0.5 ml
$0 (Tier 1) MO; QL (4 ML per 30 days)
sumatriptan succinate subcutaneous syringe 6
mg/0.5 ml
$0 (Tier 1) MO; QL (4 ML per 30 days)
ANTIMYASTHENIC AGENTS - TREATMENT OF MYASTHENIA
PARASYMPATHOMIMETICS
guanidine oral tablet 125 mg $0 (Tier 1) MO
pyridostigmine bromide oral tablet 60 mg $0 (Tier 1) MO
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 $0 (Tier 1) MO
ANTITUBERCULARS
CAPASTAT INJECTION RECON SOLN 1
GRAM
$0 (Tier 2)
ethambutol oral tablet 100 mg, 400 mg $0 (Tier 1) MO
isoniazid injection solution 100 mg/ml $0 (Tier 1) MO
isoniazid oral tablet 100 mg, 300 mg $0 (Tier 1) MO
PASER ORAL GRANULES DR FOR SUSP IN
PACKET 4 GRAM
$0 (Tier 2) MO
PRIFTIN ORAL TABLET 150 MG $0 (Tier 2) MO
pyrazinamide oral tablet 500 mg $0 (Tier 1) MO
rifampin intravenous recon soln 600 mg $0 (Tier 1)
rifampin oral capsule 150 mg, 300 mg $0 (Tier 1) MO
RIFATER ORAL TABLET 50-120-300 MG $0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
38
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SIRTURO ORAL TABLET 100 MG $0 (Tier 2) PA; MO
TRECATOR ORAL TABLET 250 MG $0 (Tier 2) MO
ANTINEOPLASTICS - TREATMENT OF CANCER
ALKYLATING AGENTS
BICNU INTRAVENOUS RECON SOLN 100
MG
$0 (Tier 2) PA
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 $0 (Tier 2) PA; MO
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,
40 MG, 5 MG
$0 (Tier 2) PA
HEXALEN ORAL CAPSULE 50 MG $0 (Tier 2) PA
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
$0 (Tier 2) PA
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
$0 (Tier 2) PA
VALCHLOR TOPICAL GEL 0.016 % $0 (Tier 2) MO
ZANOSAR INTRAVENOUS RECON SOLN 1
GRAM
$0 (Tier 2) PA
ANTIANDROGENS
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
39
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
bicalutamide oral tablet 50 mg $0 (Tier 1) MO
ERLEADA ORAL TABLET 60 MG $0 (Tier 2) PA
flutamide oral capsule 125 mg $0 (Tier 1) MO
nilutamide oral tablet 150 mg $0 (Tier 1)
XTANDI ORAL CAPSULE 40 MG $0 (Tier 2) PA
ZYTIGA ORAL TABLET 250 MG, 500 MG $0 (Tier 2) PA
ANTIANGIOGENIC AGENTS
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3
MG, 4 MG
$0 (Tier 2) PA
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 20 MG, 25 MG, 5 MG
$0 (Tier 2) PA; LA
THALOMID ORAL CAPSULE 100 MG, 150
MG, 200 MG, 50 MG
$0 (Tier 2)
ANTIESTROGENS/MODIFIERS
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 400 MG/ML
$0 (Tier 2) PA; MO
FARESTON ORAL TABLET 60 MG $0 (Tier 2) PA; MO
FASLODEX INTRAMUSCULAR SYRINGE 250
MG/5 ML
$0 (Tier 2) PA; MO
SOLTAMOX ORAL SOLUTION 10 MG/5 ML $0 (Tier 2)
tamoxifen oral tablet 10 mg, 20 mg $0 (Tier 1) MO
ANTIMETABOLITES
ALIMTA INTRAVENOUS RECON SOLN 100
MG, 500 MG
$0 (Tier 2) PA
ARRANON INTRAVENOUS SOLUTION 250
MG/50 ML
$0 (Tier 2) PA
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
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
40
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
cytarabine injection solution 20 mg/ml $0 (Tier 1) B/D
DROXIA ORAL CAPSULE 200 MG, 300 MG,
400 MG
$0 (Tier 2) MO
FLUDARABINE INTRAVENOUS RECON
SOLN 50 MG
$0 (Tier 2) PA
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 % $0 (Tier 1) MO
fluorouracil topical solution 2 %, 5 % $0 (Tier 1) MO
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 $0 (Tier 1) MO
mercaptopurine oral tablet 50 mg $0 (Tier 1) MO
NIPENT INTRAVENOUS RECON SOLN 10
MG
$0 (Tier 2) PA
PURIXAN ORAL SUSPENSION 20 MG/ML $0 (Tier 2) MO
TABLOID ORAL TABLET 40 MG $0 (Tier 2) PA
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
$0 (Tier 2) PA
PICATO TOPICAL GEL 0.015 %, 0.05 % $0 (Tier 2) PA; MO
ANTINEOPLASTICS, OTHER
azacitidine injection recon soln 100 mg $0 (Tier 1) PA
BELEODAQ INTRAVENOUS RECON SOLN
500 MG
$0 (Tier 2) PA
bleomycin injection recon soln 30 unit $0 (Tier 1) B/D
BORTEZOMIB INTRAVENOUS RECON SOLN
3.5 MG
$0 (Tier 1) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
41
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
clofarabine intravenous solution 20 mg/20 ml $0 (Tier 2) PA
dactinomycin intravenous recon soln 0.5 mg $0 (Tier 2) PA; MO
daunorubicin intravenous solution 5 mg/ml $0 (Tier 1) B/D
decitabine intravenous recon soln 50 mg $0 (Tier 1) B/D
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
$0 (Tier 2) PA
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20
MG
$0 (Tier 2) PA
FLUDARABINE INTRAVENOUS SOLUTION
50 MG/2 ML
$0 (Tier 2) PA
FUSILEV INTRAVENOUS RECON SOLN 50
MG
$0 (Tier 2) B/D
HALAVEN INTRAVENOUS SOLUTION 1
MG/2 ML (0.5 MG/ML)
$0 (Tier 2) PA
idarubicin intravenous solution 1 mg/ml $0 (Tier 1) B/D
ISTODAX INTRAVENOUS RECON SOLN 10
MG/2 ML
$0 (Tier 2) PA
KADCYLA INTRAVENOUS RECON SOLN 100
MG
$0 (Tier 2) PA
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
$0 (Tier 2) PA
KISQALI ORAL TABLET 200 MG/DAY (200
MG X 1), 400 MG/DAY (200 MG X 2), 600
MG/DAY (200 MG X 3)
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
42
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
KYPROLIS INTRAVENOUS RECON SOLN 30
MG, 60 MG
$0 (Tier 2) PA
leucovorin calcium injection recon soln 100 mg,
200 mg, 350 mg, 50 mg, 500 mg
$0 (Tier 1) B/D
leucovorin calcium oral tablet 10 mg, 15 mg, 25
mg, 5 mg
$0 (Tier 1)
LEVOLEUCOVORIN INTRAVENOUS RECON
SOLN 50 MG
$0 (Tier 1) B/D
levoleucovorin intravenous solution 10 mg/ml $0 (Tier 1) B/D; MO
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19
MG
$0 (Tier 2) PA
LYNPARZA ORAL CAPSULE 50 MG $0 (Tier 2) PA
LYNPARZA ORAL TABLET 100 MG, 150 MG $0 (Tier 2) PA
mesna intravenous solution 100 mg/ml $0 (Tier 1) B/D
MESNEX ORAL TABLET 400 MG $0 (Tier 2)
mitomycin intravenous recon soln 20 mg, 40 mg, 5
mg
$0 (Tier 1) B/D
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4
MG
$0 (Tier 2) PA
ODOMZO ORAL CAPSULE 200 MG $0 (Tier 2) PA
PROLEUKIN INTRAVENOUS RECON SOLN
22 MILLION UNIT
$0 (Tier 2) PA
ROMIDEPSIN INTRAVENOUS RECON SOLN
10 MG/2 ML
$0 (Tier 1) PA
RUBRACA ORAL TABLET 200 MG, 250 MG,
300 MG
$0 (Tier 2) PA
SYLATRON SUBCUTANEOUS KIT 200 MCG,
300 MCG, 600 MCG
$0 (Tier 2) PA
SYLVANT INTRAVENOUS RECON SOLN 100
MG, 400 MG
$0 (Tier 2) PA
SYNRIBO SUBCUTANEOUS RECON SOLN
3.5 MG
$0 (Tier 2) PA
TOTECT INTRAVENOUS RECON SOLN 500
MG
$0 (Tier 2) PA
TRISENOX INTRAVENOUS SOLUTION 2
MG/ML
$0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
43
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VELCADE INJECTION RECON SOLN 3.5 MG $0 (Tier 2) PA
VENCLEXTA ORAL TABLET 10 MG, 100 MG,
50 MG
$0 (Tier 2) PA
VENCLEXTA STARTING PACK ORAL
TABLETS,DOSE PACK 10 MG-50 MG- 100 MG
$0 (Tier 2) PA
VERZENIO ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG
$0 (Tier 2) PA
vinblastine intravenous solution 1 mg/ml $0 (Tier 1) B/D
vincristine intravenous solution 1 mg/ml $0 (Tier 1) B/D
vinorelbine intravenous solution 50 mg/5 ml $0 (Tier 1) B/D
VYXEOS INTRAVENOUS RECON SOLN 44-
100 MG
$0 (Tier 2) PA
YONDELIS INTRAVENOUS RECON SOLN 1
MG
$0 (Tier 2) PA
ZALTRAP INTRAVENOUS SOLUTION 100
MG/4 ML (25 MG/ML), 200 MG/8 ML (25
MG/ML)
$0 (Tier 2) PA
ZOLINZA ORAL CAPSULE 100 MG $0 (Tier 2) PA
ZYDELIG ORAL TABLET 100 MG, 150 MG $0 (Tier 2) PA
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole oral tablet 1 mg $0 (Tier 1) MO
exemestane oral tablet 25 mg $0 (Tier 1)
letrozole oral tablet 2.5 mg $0 (Tier 1) MO
ENZYME INHIBITORS
ABRAXANE INTRAVENOUS SUSPENSION
FOR RECONSTITUTION 100 MG
$0 (Tier 2) PA
docetaxel intravenous solution 10 mg/ml $0 (Tier 1) B/D; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
44
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
docetaxel intravenous solution 160 mg/16 ml (10
mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10
mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml),
80 mg/8 ml (10 mg/ml)
$0 (Tier 1) B/D
ETOPOPHOS INTRAVENOUS RECON SOLN
100 MG
$0 (Tier 2) PA
etoposide intravenous solution 20 mg/ml $0 (Tier 1) B/D
IBRANCE ORAL CAPSULE 100 MG, 125 MG,
75 MG
$0 (Tier 2) PA
irinotecan intravenous solution 100 mg/5 ml $0 (Tier 1) B/D
JEVTANA INTRAVENOUS SOLUTION 10
MG/ML (FIRST DILUTION)
$0 (Tier 2) PA
mitoxantrone intravenous concentrate 2 mg/ml $0 (Tier 1)
paclitaxel intravenous concentrate 6 mg/ml $0 (Tier 1) B/D
topotecan intravenous recon soln 4 mg $0 (Tier 1) PA
topotecan intravenous solution 4 mg/4 ml (1
mg/ml)
$0 (Tier 1) PA
MOLECULAR TARGET INHIBITORS
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 2 MG, 3 MG, 5 MG
$0 (Tier 2) PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5
MG, 7.5 MG
$0 (Tier 2) PA
ALECENSA ORAL CAPSULE 150 MG $0 (Tier 2) PA
ALIQOPA INTRAVENOUS RECON SOLN 60
MG
$0 (Tier 2) PA
ALUNBRIG ORAL TABLET 180 MG, 30 MG,
90 MG
$0 (Tier 2) PA
ALUNBRIG ORAL TABLETS,DOSE PACK 90
MG (7)- 180 MG (23)
$0 (Tier 2) PA
BOSULIF ORAL TABLET 100 MG, 400 MG,
500 MG
$0 (Tier 2) PA
CABOMETYX ORAL TABLET 20 MG, 40 MG,
60 MG
$0 (Tier 2) PA
CALQUENCE ORAL CAPSULE 100 MG $0 (Tier 2) PA
CAPRELSA ORAL TABLET 100 MG, 300 MG $0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
45
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
COMETRIQ ORAL CAPSULE 100 MG/DAY(80
MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20
MG X3), 60 MG/DAY (20 MG X 3/DAY)
$0 (Tier 2) PA
COTELLIC ORAL TABLET 20 MG $0 (Tier 2) PA
ERIVEDGE ORAL CAPSULE 150 MG $0 (Tier 2) PA
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40
MG
$0 (Tier 2) PA
ICLUSIG ORAL TABLET 15 MG, 45 MG $0 (Tier 2) PA
IDHIFA ORAL TABLET 100 MG, 50 MG $0 (Tier 2) PA
imatinib oral tablet 100 mg, 400 mg $0 (Tier 1) PA
IMBRUVICA ORAL CAPSULE 140 MG, 70 MG $0 (Tier 2) PA
IMBRUVICA ORAL TABLET 140 MG, 280 MG,
420 MG, 560 MG
$0 (Tier 2) PA
INLYTA ORAL TABLET 1 MG, 5 MG $0 (Tier 2) PA
IRESSA ORAL TABLET 250 MG $0 (Tier 2) PA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 25 MG, 5 MG
$0 (Tier 2) PA
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X
1), 18 MG/DAY (10 MG X 1-4 MG X2), 20
MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X
2-4 MG X 1), 8 MG/DAY (4 MG X 2)
$0 (Tier 2) PA
MEKINIST ORAL TABLET 0.5 MG, 2 MG $0 (Tier 2) PA
NERLYNX ORAL TABLET 40 MG $0 (Tier 2) PA
NEXAVAR ORAL TABLET 200 MG $0 (Tier 2) PA
OFEV ORAL CAPSULE 100 MG, 150 MG $0 (Tier 2) PA
RYDAPT ORAL CAPSULE 25 MG $0 (Tier 2) PA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20
MG, 50 MG, 70 MG, 80 MG
$0 (Tier 2) PA
STIVARGA ORAL TABLET 40 MG $0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
46
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SUTENT ORAL CAPSULE 12.5 MG, 25 MG,
37.5 MG, 50 MG
$0 (Tier 2) PA
TAFINLAR ORAL CAPSULE 50 MG, 75 MG $0 (Tier 2) PA
TAGRISSO ORAL TABLET 40 MG, 80 MG $0 (Tier 2) PA
TARCEVA ORAL TABLET 100 MG, 150 MG,
25 MG
$0 (Tier 2) PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG,
50 MG
$0 (Tier 2) PA
TORISEL INTRAVENOUS RECON SOLN 30
MG/3 ML (10 MG/ML) (FIRST)
$0 (Tier 2) PA
TYKERB ORAL TABLET 250 MG $0 (Tier 2) PA
VOTRIENT ORAL TABLET 200 MG $0 (Tier 2) PA
XALKORI ORAL CAPSULE 200 MG, 250 MG $0 (Tier 2) PA
ZEJULA ORAL CAPSULE 100 MG $0 (Tier 2) PA
ZELBORAF ORAL TABLET 240 MG $0 (Tier 2) PA
ZYKADIA ORAL CAPSULE 150 MG $0 (Tier 2) PA
MONOCLONAL ANTIBODIES
AVASTIN INTRAVENOUS SOLUTION 25
MG/ML, 25 MG/ML (16 ML)
$0 (Tier 2) PA
BAVENCIO INTRAVENOUS SOLUTION 20
MG/ML
$0 (Tier 2) PA
BESPONSA INTRAVENOUS RECON SOLN 0.9
MG (0.25 MG/ML INITIAL)
$0 (Tier 2) PA
CYRAMZA INTRAVENOUS SOLUTION 10
MG/ML, 10 MG/ML (50 ML)
$0 (Tier 2) PA
DARZALEX INTRAVENOUS SOLUTION 20
MG/ML
$0 (Tier 2) PA
EMPLICITI INTRAVENOUS RECON SOLN
300 MG, 400 MG
$0 (Tier 2) PA
ERBITUX INTRAVENOUS SOLUTION 100
MG/50 ML
$0 (Tier 2) PA
HERCEPTIN INTRAVENOUS RECON SOLN
150 MG, 440 MG
$0 (Tier 2) PA
IMFINZI INTRAVENOUS SOLUTION 50
MG/ML, 50 MG/ML (10 ML)
$0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
47
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
KEYTRUDA INTRAVENOUS SOLUTION 25
MG/ML
$0 (Tier 2) PA
LARTRUVO INTRAVENOUS SOLUTION 10
MG/ML
$0 (Tier 2) PA
MYLOTARG INTRAVENOUS RECON SOLN
4.5 MG (1 MG/ML INITIAL CONC)
$0 (Tier 2) PA
OPDIVO INTRAVENOUS SOLUTION 100
MG/10 ML, 240 MG/24 ML, 40 MG/4 ML
$0 (Tier 2) PA
PERJETA INTRAVENOUS SOLUTION 420
MG/14 ML (30 MG/ML)
$0 (Tier 2) PA
RITUXAN HYCELA SUBCUTANEOUS
SOLUTION 1400 MG/11.7 ML (120 MG/ML),
1600 MG/13.4 ML (120 MG/ML)
$0 (Tier 2) PA
RITUXAN INTRAVENOUS CONCENTRATE
10 MG/ML, 10 MG/ML (10 ML)
$0 (Tier 2) PA
TECENTRIQ INTRAVENOUS SOLUTION
1,200 MG/20 ML (60 MG/ML)
$0 (Tier 2) PA
VECTIBIX INTRAVENOUS SOLUTION 100
MG/5 ML (20 MG/ML)
$0 (Tier 2) PA
YERVOY INTRAVENOUS SOLUTION 50
MG/10 ML (5 MG/ML)
$0 (Tier 2) PA
RETINOIDS
bexarotene oral capsule 75 mg $0 (Tier 1)
PANRETIN TOPICAL GEL 0.1 % $0 (Tier 2) PA; MO
TARGRETIN TOPICAL GEL 1 % $0 (Tier 2) PA
tretinoin (chemotherapy) oral capsule 10 mg $0 (Tier 1)
ANTIPARASITICS - TREATMENT OF INFECTIONS FROM PARASITES
ANTHELMINTICS
ALBENZA ORAL TABLET 200 MG $0 (Tier 2) MO
benznidazole oral tablet 100 mg, 12.5 mg $0 (Tier 1) PA; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
48
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
BILTRICIDE ORAL TABLET 600 MG $0 (Tier 2) MO
ivermectin oral tablet 3 mg $0 (Tier 1) MO
praziquantel oral tablet 600 mg $0 (Tier 1) MO
ANTIPROTOZOALS
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
$0 (Tier 2) MO
ALINIA ORAL TABLET 500 MG $0 (Tier 2) MO
atovaquone oral suspension 750 mg/5 ml $0 (Tier 1) MO
atovaquone-proguanil oral tablet 250-100 mg,
62.5-25 mg
$0 (Tier 1) MO
chloroquine phosphate oral tablet 250 mg, 500 mg $0 (Tier 1) MO
COARTEM ORAL TABLET 20-120 MG $0 (Tier 2) MO
DARAPRIM ORAL TABLET 25 MG $0 (Tier 2)
hydroxychloroquine oral tablet 200 mg $0 (Tier 1) MO
mefloquine oral tablet 250 mg $0 (Tier 1) MO
NEBUPENT INHALATION RECON SOLN 300
MG
$0 (Tier 2) B/D
PENTAM INJECTION RECON SOLN 300 MG $0 (Tier 2) PA
PRIMAQUINE ORAL TABLET 26.3 MG $0 (Tier 2) MO
quinine sulfate oral capsule 324 mg $0 (Tier 1) MO
PEDICULICIDES/ SCABICIDES
cvs permethrin 1% lotion 1 % $0 (Tier 3) DP
lindane topical shampoo 1 % $0 (Tier 1) MO
malathion topical lotion 0.5 % $0 (Tier 1) MO
permethrin topical cream 5 % $0 (Tier 1) MO
spinosad topical suspension 0.9 % $0 (Tier 1) MO
ANTIPARKINSON AGENTS - TREATMENT OF PARKINSON'S DISEASE
ANTICHOLINERGICS
benztropine oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) PA; MO
trihexyphenidyl oral elixir 0.4 mg/ml $0 (Tier 1) PA; MO
trihexyphenidyl oral tablet 2 mg, 5 mg $0 (Tier 1) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
49
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ANTIPARKINSON AGENTS, OTHER
amantadine hcl oral capsule 100 mg $0 (Tier 1) MO
amantadine hcl oral solution 50 mg/5 ml $0 (Tier 1) MO
amantadine hcl oral tablet 100 mg $0 (Tier 1) MO
APOKYN SUBCUTANEOUS CARTRIDGE 10
MG/ML
$0 (Tier 2) PA
entacapone oral tablet 200 mg $0 (Tier 1) MO
GOCOVRI ORAL CAPSULE,EXTENDED
RELEASE 24HR 137 MG, 68.5 MG
$0 (Tier 2) PA; MO
tolcapone oral tablet 100 mg $0 (Tier 1) MO
DOPAMINE AGONISTS
bromocriptine oral capsule 5 mg $0 (Tier 1) MO
bromocriptine oral tablet 2.5 mg $0 (Tier 1) MO
NEUPRO TRANSDERMAL PATCH 24 HOUR 1
MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24
HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8
MG/24 HOUR
$0 (Tier 2) PA; MO
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5 mg
$0 (Tier 1) MO
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg, 5 mg
$0 (Tier 1) MO
DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa-levodopa oral tablet 10-100 mg, 25-100
mg, 25-250 mg
$0 (Tier 1) MO
carbidopa-levodopa oral tablet extended release
25-100 mg, 50-200 mg
$0 (Tier 1) MO
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
rasagiline oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO
selegiline hcl oral capsule 5 mg $0 (Tier 1) MO
selegiline hcl oral tablet 5 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
50
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ANTIPSYCHOTICS - TREATMENT OF BEHAVIORAL AND EMOTIONAL
DISORDERS
1ST GENERATION/ TYPICAL
fluphenazine decanoate injection solution 25
mg/ml
$0 (Tier 1) MO
fluphenazine hcl injection solution 2.5 mg/ml $0 (Tier 1) MO
fluphenazine hcl oral concentrate 5 mg/ml $0 (Tier 1) MO
fluphenazine hcl oral elixir 2.5 mg/5 ml $0 (Tier 1) MO
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5
mg
$0 (Tier 1) MO
haloperidol decanoate intramuscular solution 100
mg/ml, 50 mg/ml
$0 (Tier 1) MO
haloperidol lactate injection solution 5 mg/ml $0 (Tier 1) MO
haloperidol lactate intramuscular syringe 5 mg/ml $0 (Tier 1) MO
haloperidol lactate oral concentrate 2 mg/ml $0 (Tier 1) MO
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg,
20 mg, 5 mg
$0 (Tier 1) MO
loxapine succinate oral capsule 10 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
loxapine succinate oral capsule 25 mg, 50 mg $0 (Tier 1) MO
loxapine succinate oral capsule 5 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
pimozide oral tablet 1 mg, 2 mg $0 (Tier 1) MO
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg
$0 (Tier 1) PA; MO
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0 (Tier 1) MO
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5
mg
$0 (Tier 1) MO
2ND GENERATION/ ATYPICAL
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 300
MG, 400 MG
$0 (Tier 2) PA; QL (1 EA per 28 days)
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 300
MG, 400 MG
$0 (Tier 2) PA; QL (1 EA per 28 days)
aripiprazole oral solution 1 mg/ml $0 (Tier 1) MO; QL (900 ML per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
51
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20
mg, 30 mg, 5 mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
aripiprazole oral tablet,disintegrating 10 mg, 15
mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 1,064
MG/3.9 ML
$0 (Tier 2) PA; QL (3.9 ML per 56 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 441
MG/1.6 ML
$0 (Tier 2) PA; QL (1.6 ML per 28 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 662
MG/2.4 ML
$0 (Tier 2) PA; QL (2.4 ML per 28 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 882
MG/3.2 ML
$0 (Tier 2) PA; QL (3.2 ML per 28 days)
FANAPT ORAL TABLET 1 MG, 10 MG, 12
MG, 2 MG, 4 MG, 6 MG, 8 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
FANAPT ORAL TABLETS,DOSE PACK
1MG(2)-2MG(2)- 4MG(2)-6MG(2)
$0 (Tier 2) ST; MO
GEODON INTRAMUSCULAR RECON SOLN
20 MG/ML (FINAL CONC.)
$0 (Tier 2) PA; QL (12 EA per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML
$0 (Tier 2) PA; QL (0.75 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 156 MG/ML
$0 (Tier 2) PA; QL (1 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 234 MG/1.5 ML
$0 (Tier 2) PA; QL (1.5 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML
$0 (Tier 2) PA; QL (0.25 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 78 MG/0.5 ML
$0 (Tier 2) PA; QL (0.5 ML per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
52
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
$0 (Tier 2) PA; QL (0.875 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 410 MG/1.315 ML
$0 (Tier 2) PA; QL (1.315 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
$0 (Tier 2) PA; QL (1.75 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 819 MG/2.625 ML
$0 (Tier 2) PA; QL (2.625 ML per 84 days)
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG, 80 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET 17 MG $0 (Tier 2) PA; MO; QL (60 EA per 30 days)
olanzapine intramuscular recon soln 10 mg $0 (Tier 1) QL (90 EA per 30 days)
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
olanzapine oral tablet,disintegrating 10 mg, 15
mg, 20 mg, 5 mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
paliperidone oral tablet extended release 24hr 1.5
mg, 3 mg, 9 mg
$0 (Tier 1) PA; MO; QL (30 EA per 30 days)
paliperidone oral tablet extended release 24hr 6
mg
$0 (Tier 1) PA; MO; QL (60 EA per 30 days)
quetiapine oral tablet 100 mg, 200 mg, 300 mg,
400 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
quetiapine oral tablet 25 mg, 50 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
quetiapine oral tablet extended release 24 hr 150
mg, 200 mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
quetiapine oral tablet extended release 24 hr 300
mg, 400 mg, 50 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG, 3 MG, 4 MG
$0 (Tier 2) PA; MO; QL (30 EA per 30 days)
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5
MG/2 ML, 50 MG/2 ML
$0 (Tier 2) PA; QL (2 EA per 28 days)
RISPERDAL M-TAB ORAL
TABLET,DISINTEGRATING 0.5 MG, 2 MG
$0 (Tier 2) MO; QL (60 EA per 30 days)
risperidone oral solution 1 mg/ml $0 (Tier 1) MO; QL (240 ML per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
53
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
risperidone oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG, 2.5 MG, 5 MG
$0 (Tier 2) MO; QL (60 EA per 30 days)
VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5
MG, 6 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
VRAYLAR ORAL CAPSULE,DOSE PACK 1.5
MG (1)- 3 MG (6)
$0 (Tier 2) ST; MO; QL (28 EA per 28 days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg,
80 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 300 MG
$0 (Tier 2) PA; QL (2 EA per 28 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 405
MG
$0 (Tier 2) PA; QL (1 EA per 28 days)
TREATMENT-RESISTANT
clozapine oral tablet 100 mg $0 (Tier 1) MO; QL (270 EA per 30 days)
clozapine oral tablet 200 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
clozapine oral tablet 25 mg, 50 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
clozapine oral tablet,disintegrating 100 mg $0 (Tier 1) MO; QL (270 EA per 30 days)
clozapine oral tablet,disintegrating 12.5 mg, 25
mg
$0 (Tier 1) MO
clozapine oral tablet,disintegrating 150 mg $0 (Tier 1) MO; QL (180 EA per 30 days)
clozapine oral tablet,disintegrating 200 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
VERSACLOZ ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO; QL (540 ML per 30 days)
ANTISPASTICITY AGENTS - TREATMENT OF MUSCLE SPASMS
ANTISPASTICITY AGENTS
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
54
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
baclofen oral tablet 10 mg, 20 mg $0 (Tier 1) MO
COMFORT PAC-TIZANIDINE KIT 4 MG $0 (Tier 1) MO
dantrolene oral capsule 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
tizanidine oral tablet 2 mg, 4 mg $0 (Tier 1) MO
ANTIVIRALS - TREATMENT OF INFECTIONS BY VIRUSES
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir intravenous solution 75 mg/ml $0 (Tier 1)
ganciclovir sodium intravenous recon soln 500 mg $0 (Tier 1) B/D
ganciclovir sodium intravenous solution 50 mg/ml $0 (Tier 1) B/D; MO
PREVYMIS INTRAVENOUS SOLUTION 240
MG/12 ML, 480 MG/24 ML
$0 (Tier 2) PA
PREVYMIS ORAL TABLET 240 MG, 480 MG $0 (Tier 2) PA
valganciclovir oral recon soln 50 mg/ml $0 (Tier 1)
valganciclovir oral tablet 450 mg $0 (Tier 1)
ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % $0 (Tier 2) ST; MO
ANTI-HEPATITIS B (HBV) AGENTS
ADEFOVIR ORAL TABLET 10 MG $0 (Tier 2) PA
BARACLUDE ORAL SOLUTION 0.05 MG/ML $0 (Tier 2)
entecavir oral tablet 0.5 mg, 1 mg $0 (Tier 1)
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML
(5 MG/ML)
$0 (Tier 2)
INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML), 18 MILLION UNIT (1
ML), 50 MILLION UNIT (1 ML)
$0 (Tier 2) PA
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML, 6 MILLION UNIT/ML
$0 (Tier 2) PA
lamivudine oral solution 10 mg/ml $0 (Tier 1) MO
lamivudine oral tablet 100 mg $0 (Tier 1) QL (30 EA per 30 days)
lamivudine oral tablet 150 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
lamivudine oral tablet 300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)
tenofovir disoproxil fumarate oral tablet 300 mg $0 (Tier 1) MO
VEMLIDY ORAL TABLET 25 MG $0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
55
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VIREAD ORAL POWDER 40 MG/SCOOP (40
MG/GRAM)
$0 (Tier 2) MO
VIREAD ORAL TABLET 150 MG, 200 MG, 250
MG, 300 MG
$0 (Tier 2) MO
ANTI-HEPATITIS C (HCV) AGENTS
EPCLUSA ORAL TABLET 400-100 MG $0 (Tier 2) PA
MAVYRET ORAL TABLET 100-40 MG $0 (Tier 2) PA
PEGASYS PROCLICK SUBCUTANEOUS PEN
INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML
$0 (Tier 2) PA
PEGASYS SUBCUTANEOUS SOLUTION 180
MCG/ML
$0 (Tier 2) PA
PEGASYS SUBCUTANEOUS SYRINGE 180
MCG/0.5 ML
$0 (Tier 2) PA
RIBAVIRIN ORAL CAPSULE 200 MG $0 (Tier 2) PA
RIBAVIRIN ORAL TABLET 200 MG $0 (Tier 2) PA
VOSEVI ORAL TABLET 400-100-100 MG $0 (Tier 2) PA
ZEPATIER ORAL TABLET 50-100 MG $0 (Tier 2) PA
ANTIHERPETIC AGENTS
acyclovir oral capsule 200 mg $0 (Tier 1) MO
acyclovir oral suspension 200 mg/5 ml $0 (Tier 1) MO
acyclovir oral tablet 400 mg, 800 mg $0 (Tier 1) MO
acyclovir sodium intravenous recon soln 1,000 mg,
500 mg
$0 (Tier 1) B/D
acyclovir sodium intravenous solution 50 mg/ml $0 (Tier 1) B/D
acyclovir topical ointment 5 % $0 (Tier 1) MO
DENAVIR TOPICAL CREAM 1 % $0 (Tier 2) MO
famciclovir oral tablet 125 mg, 250 mg, 500 mg $0 (Tier 1) MO
trifluridine ophthalmic (eye) drops 1 % $0 (Tier 1) MO
valacyclovir oral tablet 1 gram, 500 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
56
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ZOVIRAX TOPICAL CREAM 5 % $0 (Tier 2) MO
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVY ORAL TABLET 50-200-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
ISENTRESS HD ORAL TABLET 600 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100
MG
$0 (Tier 2) MO
ISENTRESS ORAL TABLET 400 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 100
MG, 25 MG
$0 (Tier 2) MO; QL (180 EA per 30 days)
JULUCA ORAL TABLET 50-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
STRIBILD ORAL TABLET 150-150-200-300
MG
$0 (Tier 2) MO; QL (30 EA per 30 days)
TIVICAY ORAL TABLET 10 MG $0 (Tier 2) MO; QL (300 EA per 30 days)
TIVICAY ORAL TABLET 25 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
TIVICAY ORAL TABLET 50 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
(NNRTI)
COMPLERA ORAL TABLET 200-25-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
EDURANT ORAL TABLET 25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
efavirenz oral capsule 200 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
efavirenz oral capsule 50 mg $0 (Tier 1) MO; QL (360 EA per 30 days)
efavirenz oral tablet 600 mg $0 (Tier 1) MO; QL (30 EA per 30 days)
INTELENCE ORAL TABLET 100 MG, 25 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
nevirapine oral suspension 50 mg/5 ml $0 (Tier 1) MO
nevirapine oral tablet 200 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
nevirapine oral tablet extended release 24 hr 100
mg
$0 (Tier 1) MO; QL (120 EA per 30 days)
nevirapine oral tablet extended release 24 hr 400
mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
RESCRIPTOR ORAL TABLET 200 MG $0 (Tier 2) MO; QL (180 EA per 30 days)
RESCRIPTOR ORAL TABLET, DISPERSIBLE
100 MG
$0 (Tier 2) MO; QL (360 EA per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
57
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SUSTIVA ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
SUSTIVA ORAL CAPSULE 50 MG $0 (Tier 2) MO; QL (360 EA per 30 days)
SUSTIVA ORAL TABLET 600 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
VIDEX EC ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 125 MG
$0 (Tier 2) MO; QL (90 EA per 30 days)
VIRAMUNE ORAL SUSPENSION 50 MG/5 ML $0 (Tier 2) MO
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS (NRTI)
abacavir oral solution 20 mg/ml $0 (Tier 1) MO
abacavir oral tablet 300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
abacavir-lamivudine oral tablet 600-300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-
150-300 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
DESCOVY ORAL TABLET 200-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
didanosine oral capsule,delayed release(dr/ec)
200 mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
didanosine oral capsule,delayed release(dr/ec)
250 mg, 400 mg
$0 (Tier 1) MO; QL (30 EA per 30 days)
EMTRIVA ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
EMTRIVA ORAL SOLUTION 10 MG/ML $0 (Tier 2) MO
lamivudine-zidovudine oral tablet 150-300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
RETROVIR INTRAVENOUS SOLUTION 10
MG/ML
$0 (Tier 2) MO
stavudine oral capsule 15 mg, 20 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
stavudine oral capsule 30 mg, 40 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
TRUVADA ORAL TABLET 100-150 MG, 133-
200 MG, 167-250 MG, 200-300 MG
$0 (Tier 2) MO; QL (30 EA per 30 days)
VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
$0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
58
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VIDEX 4 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
$0 (Tier 2) MO
ZERIT ORAL RECON SOLN 1 MG/ML $0 (Tier 2) MO
ZIAGEN ORAL SOLUTION 20 MG/ML $0 (Tier 2) MO
zidovudine oral capsule 100 mg $0 (Tier 1) MO; QL (180 EA per 30 days)
zidovudine oral syrup 10 mg/ml $0 (Tier 1) MO
zidovudine oral tablet 300 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
ANTI-HIV AGENTS, OTHER
ATRIPLA ORAL TABLET 600-200-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90
MG
$0 (Tier 2)
GENVOYA ORAL TABLET 150-150-200-10
MG
$0 (Tier 2) MO; QL (30 EA per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
selzentry oral solution 20 mg/ml $0 (Tier 2) MO
SELZENTRY ORAL TABLET 150 MG, 75 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
SELZENTRY ORAL TABLET 25 MG, 300 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
SYMFI LO ORAL TABLET 400-300-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200
MG/1.33 ML (150 MG/ML)
$0 (Tier 2)
TYBOST ORAL TABLET 150 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS ORAL CAPSULE 250 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML $0 (Tier 2) MO
atazanavir oral capsule 150 mg, 300 mg $0 (Tier 1) MO; QL (30 EA per 30 days)
atazanavir oral capsule 200 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (360 EA per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG $0 (Tier 2) MO; QL (180 EA per 30 days)
EVOTAZ ORAL TABLET 300-150 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
fosamprenavir oral tablet 700 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
INVIRASE ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (300 EA per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
59
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
INVIRASE ORAL TABLET 500 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
KALETRA ORAL TABLET 100-25 MG $0 (Tier 2) MO; QL (240 EA per 30 days)
KALETRA ORAL TABLET 200-50 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
LEXIVA ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO
LEXIVA ORAL TABLET 700 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
lopinavir-ritonavir oral solution 400-100 mg/5 ml $0 (Tier 1) MO
NORVIR ORAL CAPSULE 100 MG $0 (Tier 2) MO; QL (360 EA per 30 days)
NORVIR ORAL SOLUTION 80 MG/ML $0 (Tier 2) MO
NORVIR ORAL TABLET 100 MG $0 (Tier 2) MO; QL (360 EA per 30 days)
PREZCOBIX ORAL TABLET 800-150 MG-MG $0 (Tier 2) MO; QL (30 EA per 30 days)
PREZISTA ORAL SUSPENSION 100 MG/ML $0 (Tier 2) MO
PREZISTA ORAL TABLET 150 MG $0 (Tier 2) MO; QL (180 EA per 30 days)
PREZISTA ORAL TABLET 600 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
PREZISTA ORAL TABLET 75 MG $0 (Tier 2) MO; QL (300 EA per 30 days)
PREZISTA ORAL TABLET 800 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
REYATAZ ORAL CAPSULE 150 MG, 300 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
REYATAZ ORAL CAPSULE 200 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
REYATAZ ORAL POWDER IN PACKET 50
MG
$0 (Tier 2) MO
ritonavir oral tablet 100 mg $0 (Tier 1) MO; QL (360 EA per 30 days)
VIRACEPT ORAL TABLET 250 MG $0 (Tier 2) MO; QL (300 EA per 30 days)
VIRACEPT ORAL TABLET 625 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
ANTI-INFLUENZA AGENTS
oseltamivir oral capsule 30 mg $0 (Tier 1) MO; QL (84 EA per 180 days)
oseltamivir oral capsule 45 mg $0 (Tier 1) MO; QL (42 EA per 180 days)
oseltamivir oral capsule 75 mg $0 (Tier 1) MO; QL (28 EA per 180 days)
oseltamivir oral suspension for reconstitution 6
mg/ml
$0 (Tier 1) MO; QL (540 ML per 180 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
60
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE 5 MG/ACTUATION
$0 (Tier 2) MO; QL (60 EA per 180 days)
rimantadine oral tablet 100 mg $0 (Tier 1) MO
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION 6 MG/ML
$0 (Tier 2) MO; QL (540 ML per 180 days)
ANTIVIRALS
SYNAGIS INTRAMUSCULAR SOLUTION 100
MG/ML, 50 MG/0.5 ML
$0 (Tier 2) PA
ANXIOLYTICS - TREATMENT OF ANXIETY OR NERVOUSNESS
ANXIOLYTICS, OTHER
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
7.5 mg
$0 (Tier 1) MO
hydroxyzine hcl oral solution 10 mg/5 ml $0 (Tier 1) PA; MO
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg $0 (Tier 1) PA; MO
hydroxyzine pamoate oral capsule 100 mg, 25 mg,
50 mg
$0 (Tier 1) PA; MO
meprobamate oral tablet 200 mg, 400 mg $0 (Tier 1) PA; MO
BENZODIAZEPINES
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
alprazolam oral tablet 2 mg $0 (Tier 1) MO; QL (150 EA per 30 days)
clonazepam oral tablet 0.5 mg, 1 mg $0 (Tier 1) PA; MO; QL (90 EA per 30 days)
clonazepam oral tablet 2 mg $0 (Tier 1) PA; MO; QL (300 EA per 30 days)
clonazepam oral tablet,disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
clonazepam oral tablet,disintegrating 2 mg $0 (Tier 1) PA; MO; QL (300 EA per 30 days)
clorazepate dipotassium oral tablet 15 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days)
clorazepate dipotassium oral tablet 3.75 mg, 7.5
mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
diazepam intensol oral concentrate 5 mg/ml $0 (Tier 1) PA; MO; QL (240 ML per 30 days)
diazepam oral concentrate 5 mg/ml $0 (Tier 1) PA; MO; QL (240 ML per 30 days)
diazepam oral solution 5 mg/5 ml (1 mg/ml), 5
mg/5 ml (1 mg/ml, 5 ml)
$0 (Tier 1) PA; MO; QL (1200 ML per 30 days)
diazepam oral tablet 10 mg, 2 mg, 5 mg $0 (Tier 1) PA; MO; QL (120 EA per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
61
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
lorazepam intensol oral concentrate 2 mg/ml $0 (Tier 1) MO; QL (150 ML per 30 days)
lorazepam oral concentrate 2 mg/ml $0 (Tier 1) MO; QL (150 ML per 30 days)
lorazepam oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
lorazepam oral tablet 2 mg $0 (Tier 1) MO; QL (150 EA per 30 days)
BIPOLAR AGENTS - TREATMENT FOR BIPOLAR ILLNESSES
MOOD STABILIZERS
lithium carbonate oral capsule 150 mg, 300 mg,
600 mg
$0 (Tier 1) MO
lithium carbonate oral tablet 300 mg $0 (Tier 1) MO
lithium carbonate oral tablet extended release 300
mg, 450 mg
$0 (Tier 1) MO
lithium citrate oral solution 8 meq/5 ml $0 (Tier 1) MO
BLOOD GLUCOSE REGULATORS - CONTROL OF DIABETES
ANTIDIABETIC AGENTS
acarbose oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) ST; MO; QL (90 EA per 30 days)
AVANDIA ORAL TABLET 2 MG, 4 MG $0 (Tier 2) ST; MO; QL (60 EA per 30 days)
DM2 COMBO PACK, TABLET AND STRIP 500
MG
$0 (Tier 1) MO; QL (60 EA per 30 days)
glimepiride oral tablet 1 mg $0 (Tier 1) MO; QL (240 EA per 30 days)
glimepiride oral tablet 2 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
glimepiride oral tablet 4 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
glipizide oral tablet 10 mg $0 (Tier 1) MO; QL (120 EA per 30 days)
glipizide oral tablet 5 mg $0 (Tier 1) MO; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 10 mg $0 (Tier 1) MO; QL (60 EA per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg $0 (Tier 1) MO; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 5 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
glipizide-metformin oral tablet 2.5-250 mg $0 (Tier 1) MO; QL (240 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
62
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
$0 (Tier 1) MO; QL (120 EA per 30 days)
glyburide micronized oral tablet 1.5 mg, 3 mg $0 (Tier 1) PA; MO; QL (90 EA per 30 days)
glyburide micronized oral tablet 6 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)
glyburide oral tablet 1.25 mg, 2.5 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)
glyburide oral tablet 5 mg $0 (Tier 1) PA; MO
glyburide-metformin oral tablet 1.25-250 mg $0 (Tier 1) PA; MO; QL (240 EA per 30 days)
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
$0 (Tier 1) PA; MO; QL (120 EA per 30 days)
GLYXAMBI ORAL TABLET 10-5 MG, 25-5
MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
INVOKAMET ORAL TABLET 150-1,000 MG,
150-500 MG, 50-1,000 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
INVOKAMET ORAL TABLET 50-500 MG $0 (Tier 2) ST; MO; QL (120 EA per 30 days)
INVOKAMET XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 150-1,000 MG, 150-500 MG,
50-1,000 MG, 50-500 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
INVOKANA ORAL TABLET 100 MG, 300 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)
JANUMET ORAL TABLET 50-1,000 MG, 50-
500 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50
MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
JARDIANCE ORAL TABLET 10 MG, 25 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)
JENTADUETO ORAL TABLET 2.5-1,000 MG,
2.5-500 MG, 2.5-850 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 2.5-1,000 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 5-1,000 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
metformin oral tablet 1,000 mg $0 (Tier 1) MO; QL (75 EA per 30 days)
metformin oral tablet 500 mg $0 (Tier 1) MO; QL (150 EA per 30 days)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
63
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
metformin oral tablet 850 mg $0 (Tier 1) MO; QL (90 EA per 30 days)
metformin oral tablet extended release 24 hr 500
mg
$0 (Tier 1) MO; QL (120 EA per 30 days)
metformin oral tablet extended release 24 hr 750
mg
$0 (Tier 1) MO; QL (60 EA per 30 days)
nateglinide oral tablet 120 mg, 60 mg $0 (Tier 1) ST; MO; QL (90 EA per 30 days)
pioglitazone oral tablet 15 mg, 30 mg, 45 mg $0 (Tier 1) ST; MO; QL (30 EA per 30 days)
pioglitazone-metformin oral tablet 15-500 mg, 15-
850 mg
$0 (Tier 1) ST; MO; QL (90 EA per 30 days)
repaglinide oral tablet 0.5 mg, 1 mg $0 (Tier 1) ST; MO; QL (120 EA per 30 days)
repaglinide oral tablet 2 mg $0 (Tier 1) ST; MO
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML
$0 (Tier 2) PA; MO
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR 1,500 MCG/1.5 ML
$0 (Tier 2) PA; MO
SYNJARDY ORAL TABLET 12.5-1,000 MG,
12.5-500 MG, 5-1,000 MG, 5-500 MG
$0 (Tier 2) ST; MO; QL (60 EA per 30 days)
TRADJENTA ORAL TABLET 5 MG $0 (Tier 2) ST; MO; QL (30 EA per 30 days)
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML
$0 (Tier 2) MO; QL (2 ML per 28 days)
VICTOZA 2-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
$0 (Tier 2) MO; QL (9 ML per 30 days)
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
$0 (Tier 2) MO; QL (9 ML per 30 days)
BLOOD GLUCOSE REGULATORS
KORLYM ORAL TABLET 300 MG $0 (Tier 2) PA; MO
GLYCEMIC AGENTS
GLUCAGEN DIAGNOSTIC KIT INJECTION
RECON SOLN 1 MG/ML
$0 (Tier 2) MO; QL (4 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
64
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
GLUCAGEN HYPOKIT INJECTION RECON
SOLN 1 MG
$0 (Tier 2) MO; QL (4 EA per 30 days)
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION KIT 1 MG
$0 (Tier 2) MO; QL (2 EA per 30 days)
GLUCAGON HCL INJECTION RECON SOLN 1
MG
$0 (Tier 2) MO; QL (2 EA per 30 days)
glucose 4 gram tablet chew na/f, caffeine free 4
gram
$0 (Tier 3) DP
INSTA-GLUCOSE GEL 24 GRAM/31 GRAM $0 (Tier 3) DP
PROGLYCEM ORAL SUSPENSION 50 MG/ML $0 (Tier 2) MO
INSULINS
BASAGLAR KWIKPEN U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
$0 (Tier 2) MO
HUMALOG JUNIOR KWIKPEN U-100
SUBCUTANEOUS INSULIN PEN, HALF-UNIT
100 UNIT/ML
$0 (Tier 2) MO
HUMALOG KWIKPEN INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML, 200 UNIT/ML (3 ML)
$0 (Tier 2) MO
HUMALOG MIX 50-50 INSULN U-100
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(50-50)
$0 (Tier 2) MO
HUMALOG MIX 50-50 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (50-50)
$0 (Tier 2) MO
HUMALOG MIX 75-25 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (75-25)
$0 (Tier 2) MO
HUMALOG MIX 75-25(U-100)INSULN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(75-25)
$0 (Tier 2) MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
$0 (Tier 2) MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML, 100 UNIT/ML
(PREFILLED SYRINGE)
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
65
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
HUMULIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(70-30)
$0 (Tier 2) MO
HUMULIN 70/30 U-100 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
$0 (Tier 2) MO
HUMULIN N NPH INSULIN KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
$0 (Tier 2) MO
HUMULIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
$0 (Tier 2) MO
HUMULIN R REGULAR U-100 INSULN
INJECTION SOLUTION 100 UNIT/ML
$0 (Tier 2) MO
HUMULIN R U-500 (CONC) INSULIN
SUBCUTANEOUS SOLUTION 500 UNIT/ML
$0 (Tier 2) MO
HUMULIN R U-500 (CONC) KWIKPEN
SUBCUTANEOUS INSULIN PEN 500
UNIT/ML (3 ML)
$0 (Tier 2) MO
LANTUS SOLOSTAR U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
$0 (Tier 2) MO
LANTUS U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML
$0 (Tier 2) MO
LEVEMIR FLEXTOUCH U-100 INSULN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
$0 (Tier 2) MO
LEVEMIR U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML
$0 (Tier 2) MO
NOVOLIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(70-30)
$0 (Tier 2) MO
NOVOLIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
$0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
66
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
NOVOLIN R REGULAR U-100 INSULN
INJECTION SOLUTION 100 UNIT/ML
$0 (Tier 2) MO
NOVOLOG FLEXPEN U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML
$0 (Tier 2) MO
NOVOLOG MIX 70-30 U-100 INSULN
SUBCUTANEOUS SOLUTION 100 UNIT/ML
(70-30)
$0 (Tier 2) MO
NOVOLOG MIX 70-30FLEXPEN U-100
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
$0 (Tier 2) MO
NOVOLOG PENFILL U-100 INSULIN
SUBCUTANEOUS CARTRIDGE 100 UNIT/ML
$0 (Tier 2) MO
NOVOLOG U-100 INSULIN ASPART
SUBCUTANEOUS SOLUTION 100 UNIT/ML
$0 (Tier 2) MO
BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS - PREVENTION OF
CLOTTING AND INCREASING BLOOD CELL PRODUCTION
ANTICOAGULANTS
argatroban in 0.9 % sod chlor intravenous
parenteral solution 250 mg/250 ml (1 mg/ml)
$0 (Tier 1) B/D; MO
argatroban in 0.9 % sod chlor intravenous
solution 1 mg/ml
$0 (Tier 1) B/D; MO
argatroban in nacl (iso-os) intravenous solution
50 mg/50 ml (1 mg/ml)
$0 (Tier 1) B/D; MO
argatroban intravenous solution 100 mg/ml $0 (Tier 1) B/D; MO
COUMADIN ORAL TABLET 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
$0 (Tier 2) MO
ELIQUIS ORAL TABLET 2.5 MG, 5 MG $0 (Tier 2) MO
ELIQUIS ORAL TABLETS,DOSE PACK 5 MG
(74 TABS)
$0 (Tier 2) MO
enoxaparin subcutaneous solution 300 mg/3 ml $0 (Tier 1)
enoxaparin subcutaneous syringe 100 mg/ml, 120
mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml,
60 mg/0.6 ml, 80 mg/0.8 ml
$0 (Tier 1)
fondaparinux subcutaneous syringe 10 mg/0.8 ml,
2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
$0 (Tier 1)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
67
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
FRAGMIN SUBCUTANEOUS SOLUTION
25,000 ANTI-XA UNIT/ML
$0 (Tier 2)
FRAGMIN SUBCUTANEOUS SYRINGE 10,000
ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5
ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000
ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA
UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML,
7,500 ANTI-XA UNIT/0.3 ML
$0 (Tier 2)
heparin (porcine) in 5 % dex intravenous
parenteral solution 20,000 unit/500 ml (40
unit/ml)
$0 (Tier 1)
heparin (porcine) injection cartridge 5,000 unit/ml
(1 ml)
$0 (Tier 1)
heparin (porcine) injection solution 1,000 unit/ml,
10,000 unit/ml, 5,000 unit/ml
$0 (Tier 1)
heparin, porcine (pf) injection solution 1,000
unit/ml, 5,000 unit/0.5 ml
$0 (Tier 1)
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
$0 (Tier 1) MO
PRADAXA ORAL CAPSULE 110 MG, 150 MG,
75 MG
$0 (Tier 2) MO
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
$0 (Tier 1) MO
XARELTO ORAL TABLET 10 MG, 15 MG, 20
MG
$0 (Tier 2) MO
XARELTO ORAL TABLETS,DOSE PACK 15
MG (42)- 20 MG (9)
$0 (Tier 2) MO
BLOOD FORMATION MODIFIERS
anagrelide oral capsule 0.5 mg, 1 mg $0 (Tier 1) MO
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 150 MCG/0.75 ML,
200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40
MCG/ML, 60 MCG/ML
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
68
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML,
150 MCG/0.3 ML, 200 MCG/0.4 ML, 25
MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4
ML, 500 MCG/ML, 60 MCG/0.3 ML
$0 (Tier 2) PA
cilostazol oral tablet 100 mg, 50 mg $0 (Tier 1) MO
EPOGEN INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
$0 (Tier 2) PA
GRANIX SUBCUTANEOUS SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
$0 (Tier 2) PA
LEUKINE INJECTION RECON SOLN 250 MCG $0 (Tier 2) PA
MOZOBIL SUBCUTANEOUS SOLUTION 24
MG/1.2 ML (20 MG/ML)
$0 (Tier 2) PA
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML
$0 (Tier 2) PA
NEULASTA SUBCUTANEOUS SYRINGE, W/
WEARABLE INJECTOR 6 MG/0.6 ML
$0 (Tier 2) PA
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6 ML
$0 (Tier 2) PA
NEUPOGEN INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
$0 (Tier 2) PA
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML, 40,000 UNIT/ML
$0 (Tier 2) PA
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
50 MG, 75 MG
$0 (Tier 2) QL (30 EA per 30 days)
ZARXIO INJECTION SYRINGE 300 MCG/0.5
ML, 480 MCG/0.8 ML
$0 (Tier 2) PA
COAGULANTS
MEPHYTON 5 MG TABLET 5 MG $0 (Tier 3) DP
phytonadione 1 mg/0.5 ml syr latex-free, p/f,sdv 1
mg/0.5 ml
$0 (Tier 3) DP
tranexamic acid intravenous solution 1,000 mg/10
ml (100 mg/ml)
$0 (Tier 1)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
69
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
tranexamic acid oral tablet 650 mg $0 (Tier 1) MO
VITAMIN K-1 1 MG/0.5 ML AMPUL
SDV,LATEX-FREE 1 MG/0.5 ML
$0 (Tier 3) DP
VITAMIN K-1 10 MG/ML AMPUL LATEX-
FREE, SDV 10 MG/ML
$0 (Tier 3) DP
VITAMIN K-1 10 MG/ML AMPUL
SDV,LATEX-FREE 10 MG/ML
$0 (Tier 3) DP
PLATELET MODIFYING AGENTS
ASPIR EC 81 MG TABLET 81 MG $0 (Tier 3) DP
aspirin 81 mg chewable tablet 81 mg $0 (Tier 3) DP
aspirin 81 mg chewable tablet low dose, cherry 81
mg
$0 (Tier 3) DP
aspirin 81 mg chewable tablet low strength,
orange 81 mg
$0 (Tier 3) DP
aspirin 81 mg chewable tablet orange 81 mg $0 (Tier 3) DP
aspirin ec 81 mg tablet 81 mg $0 (Tier 3) DP
aspirin ec 81 mg tablet adult low dose 81 mg $0 (Tier 3) DP
aspirin ec 81 mg tablet adult low strength 81 mg $0 (Tier 3) DP
aspirin ec 81 mg tablet low dose 81 mg $0 (Tier 3) DP
aspirin-dipyridamole oral capsule, er multiphase
12 hr 25-200 mg
$0 (Tier 1) MO
ASPIR-LOW EC 81 MG TABLET 81 MG $0 (Tier 3) DP
BRILINTA ORAL TABLET 60 MG, 90 MG $0 (Tier 2) MO
CHILD ASPIRIN 81 MG CHEW TAB 81 MG $0 (Tier 3) DP
CHILD ASPIRIN 81 MG CHEW TAB
CHILDREN'S 81 MG
$0 (Tier 3) DP
clopidogrel oral tablet 300 mg, 75 mg $0 (Tier 1) MO
dipyridamole oral tablet 25 mg, 50 mg, 75 mg $0 (Tier 1) PA; MO
FYCOMPA ORAL TABLETS,DOSE PACK 2
MG (7)- 4 MG (7)
$0 (Tier 2) ST; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
70
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
gs aspirin 81 mg chewable tab 81 mg $0 (Tier 3) DP
hm aspirin 81 mg chewable tab adlt low
dose,orange 81 mg
$0 (Tier 3) DP
hm aspirin ec 81 mg tablet low dose 81 mg $0 (Tier 3) DP
HM LOW DOSE ASPIRIN EC 81 MG 81 MG $0 (Tier 3) DP
prasugrel oral tablet 10 mg, 5 mg $0 (Tier 1) MO
QC LO-DOSE ASPIRIN EC 81 MG TB 81 MG $0 (Tier 3) DP
sm aspirin ec 81 mg tablet 81 mg $0 (Tier 3) DP
SM CHILD ASPIRIN 81 MG CHW TAB
CHILDREN'S 81 MG
$0 (Tier 3) DP
BULK PRODUCTS
BULK PRODUCTS
CAPSULE #0 $0 (Tier 3) DP
CAPSULE #1 BLUE/BLUE $0 (Tier 3) DP
CAPSULE #1 VEGGIE CLEAR $0 (Tier 3) DP
glucosamine-chondroitin cap p/f 500-400 mg $0 (Tier 3) DP
glucosamine-chondroitin cap s/f, p/f 500-400 mg $0 (Tier 3) DP
LUBRISOFT LOTION $0 (Tier 3) DP
mineral oil heavy $0 (Tier 3) DP
sodium chlor 0.9% bacteriostat injection solution
0.9 %
$0 (Tier 1) MO
CARDIOVASCULAR AGENTS - TREATMENT OF CONDITIONS AFFECTING THE
HEART AND BLOOD VESSELS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg $0 (Tier 1) MO
clonidine transdermal patch weekly 0.1 mg/24 hr,
0.2 mg/24 hr, 0.3 mg/24 hr
$0 (Tier 1) MO
guanfacine oral tablet 1 mg, 2 mg $0 (Tier 1) PA; MO
methyldopa oral tablet 250 mg, 500 mg $0 (Tier 1) PA; MO
methyldopate intravenous solution 250 mg/5 ml $0 (Tier 1) PA; MO
midodrine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO
ALPHA-ADRENERGIC BLOCKING AGENTS
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
71
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg $0 (Tier 1) MO
prazosin oral capsule 1 mg, 2 mg, 5 mg $0 (Tier 1) MO
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg $0 (Tier 1) MO
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan oral tablet 150 mg, 300 mg, 75 mg $0 (Tier 1) MO
losartan oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
olmesartan oral tablet 20 mg, 40 mg, 5 mg $0 (Tier 1) MO
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80
mg
$0 (Tier 1) MO
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 (Tier 1) MO
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50
mg
$0 (Tier 1) MO
enalapril maleate oral tablet 10 mg, 2.5 mg, 20
mg, 5 mg
$0 (Tier 1) MO
fosinopril oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg,
40 mg, 5 mg
$0 (Tier 1) MO
moexipril oral tablet 15 mg, 7.5 mg $0 (Tier 1) MO
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 (Tier 1) MO
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
mg
$0 (Tier 1) MO
trandolapril oral tablet 1 mg, 2 mg, 4 mg $0 (Tier 1) MO
ANTIARRHYTHMICS
amiodarone oral tablet 100 mg, 200 mg, 400 mg $0 (Tier 1) MO
disopyramide phosphate oral capsule 100 mg, 150
mg
$0 (Tier 1) PA; MO
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg $0 (Tier 1) MO
flecainide oral tablet 100 mg, 150 mg, 50 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
72
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
mexiletine oral capsule 150 mg, 200 mg, 250 mg $0 (Tier 1) MO
MULTAQ ORAL TABLET 400 MG $0 (Tier 2) MO
NORPACE CR ORAL CAPSULE, EXTENDED
RELEASE 100 MG, 150 MG
$0 (Tier 2) PA; MO
propafenone oral tablet 150 mg, 225 mg, 300 mg $0 (Tier 1) MO
quinidine gluconate oral tablet extended release
324 mg
$0 (Tier 1) MO
quinidine sulfate oral tablet 200 mg, 300 mg $0 (Tier 1) MO
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0 (Tier 1) MO
sotalol af oral tablet 120 mg, 160 mg, 80 mg $0 (Tier 1) MO
sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg $0 (Tier 1) MO
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol oral capsule 200 mg, 400 mg $0 (Tier 1) MO
atenolol oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
bisoprolol fumarate oral tablet 10 mg, 5 mg $0 (Tier 1) MO
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
6.25 mg
$0 (Tier 1) MO
labetalol oral tablet 100 mg, 200 mg, 300 mg $0 (Tier 1) MO
metoprolol succinate oral tablet extended release
24 hr 100 mg, 200 mg, 25 mg, 50 mg
$0 (Tier 1) MO
metoprolol tartrate oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
$0 (Tier 1) MO
nadolol oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO
propranolol oral capsule,extended release 24 hr
120 mg, 160 mg, 60 mg, 80 mg
$0 (Tier 1) MO
propranolol oral solution 20 mg/5 ml (4 mg/ml),
40 mg/5 ml (8 mg/ml)
$0 (Tier 1) MO
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60
mg, 80 mg
$0 (Tier 1) MO
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO
cartia xt oral capsule,extended release 24hr 120
mg, 180 mg, 240 mg, 300 mg
$0 (Tier 1) MO
diltiazem hcl intravenous recon soln 100 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
73
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
diltiazem hcl intravenous solution 5 mg/ml $0 (Tier 1) MO
diltiazem hcl oral capsule,ext.rel 24h degradable
120 mg, 180 mg, 240 mg
$0 (Tier 1) MO
diltiazem hcl oral capsule,extended release 12 hr
120 mg, 60 mg, 90 mg
$0 (Tier 1) MO
diltiazem hcl oral capsule,extended release 24 hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
$0 (Tier 1) MO
diltiazem hcl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
$0 (Tier 1) MO
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90
mg
$0 (Tier 1) MO
dilt-xr oral capsule,ext.rel 24h degradable 120
mg, 180 mg, 240 mg
$0 (Tier 1) MO
felodipine oral tablet extended release 24 hr 10
mg, 2.5 mg, 5 mg
$0 (Tier 1) MO
isradipine oral capsule 2.5 mg, 5 mg $0 (Tier 1) MO
nifedical xl oral tablet extended release 24hr 30
mg, 60 mg
$0 (Tier 1) MO
nifedipine oral capsule 10 mg, 20 mg $0 (Tier 1) PA; MO
nifedipine oral tablet extended release 24hr 30 mg,
60 mg, 90 mg
$0 (Tier 1) MO
nifedipine oral tablet extended release 30 mg, 60
mg, 90 mg
$0 (Tier 1) MO
nimodipine oral capsule 30 mg $0 (Tier 1) MO
taztia xt oral capsule,extended release 24 hr 120
mg, 180 mg, 240 mg, 300 mg, 360 mg
$0 (Tier 1) MO
verapamil oral capsule, 24 hr er pellet ct 100 mg,
200 mg, 300 mg
$0 (Tier 2) MO
verapamil oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg, 360 mg
$0 (Tier 1) MO
verapamil oral tablet 120 mg, 40 mg, 80 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
74
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
verapamil oral tablet extended release 120 mg,
120 mg (24 hours), 180 mg, 240 mg
$0 (Tier 1) MO
CARDIOVASCULAR AGENTS
amiloride-hydrochlorothiazide oral tablet 5-50 mg $0 (Tier 1) MO
amlodipine-benazepril oral capsule 10-20 mg, 10-
40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
$0 (Tier 1) MO
amlodipine-olmesartan oral tablet 10-20 mg, 10-
40 mg, 5-20 mg, 5-40 mg
$0 (Tier 1) MO
amlodipine-valsartan oral tablet 10-160 mg, 10-
320 mg, 5-160 mg, 5-320 mg
$0 (Tier 1) MO
amlodipine-valsartan-hcthiazid oral tablet 10-160-
12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5
mg, 5-160-25 mg
$0 (Tier 1) MO
atenolol-chlorthalidone oral tablet 100-25 mg, 50-
25 mg
$0 (Tier 1) MO
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
$0 (Tier 1) MO
bisoprolol-hydrochlorothiazide oral tablet 10-6.25
mg, 2.5-6.25 mg, 5-6.25 mg
$0 (Tier 1) MO
captopril-hydrochlorothiazide oral tablet 25-15
mg, 25-25 mg, 50-15 mg, 50-25 mg
$0 (Tier 1) MO
DEMSER ORAL CAPSULE 250 MG $0 (Tier 2) PA
enalapril-hydrochlorothiazide oral tablet 10-25
mg, 5-12.5 mg
$0 (Tier 1) MO
ENTRESTO ORAL TABLET 24-26 MG, 49-51
MG, 97-103 MG
$0 (Tier 2) MO
fosinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg
$0 (Tier 1) MO
irbesartan-hydrochlorothiazide oral tablet 150-
12.5 mg, 300-12.5 mg
$0 (Tier 1) MO
lisinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
$0 (Tier 1) MO
losartan-hydrochlorothiazide oral tablet 100-12.5
mg, 100-25 mg, 50-12.5 mg
$0 (Tier 1) MO
methyldopa-hydrochlorothiazide oral tablet 250-
15 mg, 250-25 mg
$0 (Tier 1) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
75
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
moexipril-hydrochlorothiazide oral tablet 15-12.5
mg, 15-25 mg, 7.5-12.5 mg
$0 (Tier 1) MO
NORTHERA ORAL CAPSULE 100 MG, 200
MG, 300 MG
$0 (Tier 2) MO
olmesartan-amlodipin-hcthiazid oral tablet 20-5-
12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5
mg, 40-5-25 mg
$0 (Tier 1) MO
olmesartan-hydrochlorothiazide oral tablet 20-
12.5 mg, 40-12.5 mg, 40-25 mg
$0 (Tier 1) MO
quinapril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
$0 (Tier 1) MO
spironolacton-hydrochlorothiaz oral tablet 25-25
mg
$0 (Tier 1) MO
TEKTURNA HCT ORAL TABLET 150-12.5
MG, 150-25 MG, 300-12.5 MG, 300-25 MG
$0 (Tier 2) MO
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg, 50-25 mg
$0 (Tier 1) MO
triamterene-hydrochlorothiazid oral tablet 37.5-25
mg, 75-50 mg
$0 (Tier 1) MO
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
mg
$0 (Tier 1) MO
CARDIOVASCULAR AGENTS, OTHER
CORLANOR ORAL TABLET 5 MG, 7.5 MG $0 (Tier 2) PA; MO
digitek oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)
digitek oral tablet 250 mcg $0 (Tier 1) PA; MO
digox oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)
digox oral tablet 250 mcg $0 (Tier 1) PA; MO
digoxin oral solution 50 mcg/ml $0 (Tier 1) PA; MO
digoxin oral tablet 125 mcg $0 (Tier 1) MO; QL (30 EA per 30 days)
digoxin oral tablet 250 mcg $0 (Tier 1) PA; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
76
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
pentoxifylline oral tablet extended release 400 mg $0 (Tier 1) MO
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR 1,000 MG, 500 MG
$0 (Tier 2) ST; MO
TEKTURNA ORAL TABLET 150 MG, 300 MG $0 (Tier 2) MO
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide oral capsule, extended release 500
mg
$0 (Tier 1) MO
acetazolamide oral tablet 125 mg, 250 mg $0 (Tier 1) MO
KEVEYIS ORAL TABLET 50 MG $0 (Tier 2) PA; MO
methazolamide oral tablet 25 mg, 50 mg $0 (Tier 1) MO
DIURETICS, LOOP
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO
furosemide injection solution 10 mg/ml $0 (Tier 1) MO
furosemide injection syringe 10 mg/ml $0 (Tier 1) MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)
$0 (Tier 1) MO
furosemide oral tablet 20 mg, 40 mg, 80 mg $0 (Tier 1) MO
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg $0 (Tier 1) MO
DIURETICS, POTASSIUM-SPARING
amiloride oral tablet 5 mg $0 (Tier 1) MO
eplerenone oral tablet 25 mg, 50 mg $0 (Tier 1) MO
spironolactone oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 1) MO
DIURETICS, THIAZIDE
chlorothiazide oral tablet 250 mg, 500 mg $0 (Tier 1) MO
chlorthalidone oral tablet 25 mg, 50 mg $0 (Tier 1) MO
hydrochlorothiazide oral capsule 12.5 mg $0 (Tier 1) MO
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50
mg
$0 (Tier 1) MO
indapamide oral tablet 1.25 mg, 2.5 mg $0 (Tier 1) MO
methyclothiazide oral tablet 5 mg $0 (Tier 1) MO
metolazone oral tablet 10 mg, 2.5 mg, 5 mg $0 (Tier 1) MO
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
77
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg
$0 (Tier 1) MO
fenofibrate nanocrystallized oral tablet 145 mg, 48
mg
$0 (Tier 1) MO
fenofibrate oral tablet 160 mg, 54 mg $0 (Tier 1) MO
fenofibric acid (choline) oral capsule,delayed
release(dr/ec) 135 mg, 45 mg
$0 (Tier 1) MO
gemfibrozil oral tablet 600 mg $0 (Tier 1) MO
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
$0 (Tier 1) MO
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG $0 (Tier 2) MO
lovastatin oral tablet 10 mg, 20 mg, 40 mg $0 (Tier 1) MO
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
$0 (Tier 1) MO
rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5
mg
$0 (Tier 1) MO
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg,
80 mg
$0 (Tier 1) MO
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) oral powder 4 gram $0 (Tier 1) MO
cholestyramine (with sugar) oral powder in packet
4 gram
$0 (Tier 1) MO
cholestyramine light oral powder 4 gram $0 (Tier 1) MO
cholestyramine light oral powder in packet 4 gram $0 (Tier 1) MO
cod liver oil capsule $0 (Tier 3) DP
colestipol oral granules 5 gram $0 (Tier 1) MO
colestipol oral packet 5 gram $0 (Tier 1) MO
colestipol oral tablet 1 gram $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
78
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ezetimibe oral tablet 10 mg $0 (Tier 1) MO
ezetimibe-simvastatin oral tablet 10-10 mg, 10-20
mg, 10-40 mg, 10-80 mg
$0 (Tier 1) MO
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30
MG, 40 MG, 5 MG, 60 MG
$0 (Tier 2) PA
KYNAMRO SUBCUTANEOUS SYRINGE 200
MG/ML
$0 (Tier 2) PA
niacin 100 mg tablet 100 mg $0 (Tier 3) DP
niacin 500 mg capsule sa 500 mg $0 (Tier 3) DP
niacin 500 mg tablet 500 mg $0 (Tier 3) DP
niacin er 1,000 mg caplet 1,000 mg $0 (Tier 3) DP
niacin er 1,000 mg tablet 1,000 mg $0 (Tier 3) DP
niacin er 500 mg caplet caplet 500 mg $0 (Tier 3) DP
niacin er 500 mg tablet 500 mg $0 (Tier 3) DP
niacin inositol 500 mg capsule 400 mg niacin (500
mg)
$0 (Tier 3) DP
niacin oral tablet extended release 24 hr 1,000 mg,
500 mg, 750 mg
$0 (Tier 1) MO
niacin sa 250 mg capsule (otc) 250 mg $0 (Tier 3) DP
niacin tr 500 mg caplet caplet 500 mg $0 (Tier 3) DP
niacin tr 500 mg capsule 500 mg $0 (Tier 3) DP
niacinamide 500 mg tablet 500 mg $0 (Tier 3) DP
omega-3 acid ethyl esters oral capsule 1 gram $0 (Tier 1) MO
PRALUENT PEN SUBCUTANEOUS PEN
INJECTOR 150 MG/ML, 75 MG/ML
$0 (Tier 2) PA
PRALUENT SYRINGE SUBCUTANEOUS
SYRINGE 75 MG/ML
$0 (Tier 2) PA; MO
prevalite oral powder 4 gram $0 (Tier 1) MO
prevalite oral powder in packet 4 gram $0 (Tier 1) MO
qc cod liver oil usp $0 (Tier 3) DP
REPATHA PUSHTRONEX SUBCUTANEOUS
WEARABLE INJECTOR 420 MG/3.5 ML
$0 (Tier 2) PA
REPATHA SURECLICK SUBCUTANEOUS
PEN INJECTOR 140 MG/ML
$0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
79
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
REPATHA SYRINGE SUBCUTANEOUS
SYRINGE 140 MG/ML
$0 (Tier 2) PA
TRIKLO ORAL CAPSULE 1 GRAM $0 (Tier 1) MO
v-r cod liver oil capsule $0 (Tier 3) DP
WELCHOL ORAL POWDER IN PACKET 3.75
GRAM
$0 (Tier 2) MO
WELCHOL ORAL TABLET 625 MG $0 (Tier 2) MO
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg
$0 (Tier 1) MO
minoxidil oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO
VASODILATORS, DIRECT-ACTING ARTERIAL/ VENOUS
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30
mg, 5 mg
$0 (Tier 1) MO
isosorbide dinitrate oral tablet extended release 40
mg
$0 (Tier 1) MO
isosorbide mononitrate oral tablet 10 mg, 20 mg $0 (Tier 1) MO
isosorbide mononitrate oral tablet extended
release 24 hr 120 mg, 30 mg, 60 mg
$0 (Tier 1) MO
NITRO-BID TRANSDERMAL OINTMENT 2 % $0 (Tier 2) MO
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
$0 (Tier 2) MO
nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6
mg
$0 (Tier 1) MO
nitroglycerin transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
$0 (Tier 1) MO
nitroglycerin translingual aerosol,spray 400
mcg/spray
$0 (Tier 1) MO
nitroglycerin translingual spray,non-aerosol 400
mcg/spray
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
80
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CENTRAL NERVOUS SYSTEM AGENTS - TREATMENT OF DISORDERS OF THE
BRAIN AND SPINAL COLUMN
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
dextroamphetamine oral capsule, extended release
10 mg
$0 (Tier 1) PA; MO; QL (150 EA per 30 days)
dextroamphetamine oral capsule, extended release
15 mg
$0 (Tier 1) PA; MO; QL (120 EA per 30 days)
dextroamphetamine oral capsule, extended release
5 mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
dextroamphetamine oral tablet 10 mg $0 (Tier 1) PA; MO; QL (180 EA per 30 days)
dextroamphetamine oral tablet 5 mg $0 (Tier 1) PA; MO; QL (60 EA per 30 days)
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
$0 (Tier 1) PA; MO; QL (30 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 10
mg, 20 mg, 30 mg, 5 mg, 7.5 mg
$0 (Tier 1) PA; MO; QL (60 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 12.5
mg
$0 (Tier 1) PA; MO; QL (120 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 15
mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-
AMPHETAMINES
atomoxetine oral capsule 10 mg, 100 mg, 18 mg,
25 mg, 40 mg, 60 mg, 80 mg
$0 (Tier 1) MO
clonidine hcl oral tablet extended release 12 hr 0.1
mg
$0 (Tier 1) MO; QL (120 EA per 30 days)
dexmethylphenidate oral capsule,er biphasic 50-
50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40
mg, 5 mg
$0 (Tier 1) PA; MO
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5
mg
$0 (Tier 1) PA; MO
guanfacine oral tablet extended release 24 hr 1
mg, 2 mg, 3 mg, 4 mg
$0 (Tier 1) MO
methylphenidate hcl oral tablet 10 mg, 20 mg, 5
mg
$0 (Tier 1) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
81
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
methylphenidate hcl oral tablet extended release
20 mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 18 mg
$0 (Tier 1) PA; MO; QL (120 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 27 mg
$0 (Tier 1) PA; MO; QL (90 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 36 mg
$0 (Tier 1) PA; MO; QL (60 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 54 mg
$0 (Tier 1) PA; MO; QL (30 EA per 30 days)
CENTRAL NERVOUS SYSTEM, OTHER
EXONDYS 51 INTRAVENOUS SOLUTION 50
MG/ML, 50 MG/ML (10 ML)
$0 (Tier 2) PA
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG, 600 MG
$0 (Tier 2) MO
INGREZZA ORAL CAPSULE 40 MG, 80 MG $0 (Tier 2) PA
NUEDEXTA ORAL CAPSULE 20-10 MG $0 (Tier 2) MO
RADICAVA INTRAVENOUS PIGGYBACK 30
MG/100 ML
$0 (Tier 2) PA
riluzole oral tablet 50 mg $0 (Tier 1)
tetrabenazine oral tablet 12.5 mg, 25 mg $0 (Tier 1)
FIBROMYALGIA AGENTS
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
25 MG, 50 MG
$0 (Tier 2) MO
SAVELLA ORAL TABLETS,DOSE PACK 12.5
MG (5)-25 MG(8)-50 MG(42)
$0 (Tier 2) MO
MULTIPLE SCLEROSIS AGENTS
AMPYRA ORAL TABLET EXTENDED
RELEASE 12 HR 10 MG
$0 (Tier 2) PA
AUBAGIO ORAL TABLET 14 MG, 7 MG $0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
82
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
BETASERON SUBCUTANEOUS KIT 0.3 MG $0 (Tier 2) PA
BETASERON SUBCUTANEOUS RECON
SOLN 0.3 MG
$0 (Tier 2) PA
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML, 40 MG/ML
$0 (Tier 2) PA
EXTAVIA SUBCUTANEOUS KIT 0.3 MG $0 (Tier 2) PA
EXTAVIA SUBCUTANEOUS RECON SOLN
0.3 MG
$0 (Tier 2) PA
GILENYA ORAL CAPSULE 0.5 MG $0 (Tier 2) PA
glatiramer subcutaneous syringe 20 mg/ml, 40
mg/ml
$0 (Tier 1) PA
REBIF (WITH ALBUMIN) SUBCUTANEOUS
SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
$0 (Tier 2) PA
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML,
8.8MCG/0.2ML-22 MCG/0.5ML (6)
$0 (Tier 2) PA
REBIF TITRATION PACK SUBCUTANEOUS
SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)
$0 (Tier 2) PA
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG, 120 MG (14)- 240
MG (46), 240 MG
$0 (Tier 2) PA
DENTAL AND ORAL AGENTS - TREATMENT OF MOUTH AND GUM DISORDERS
DENTAL AND ORAL AGENTS
cevimeline oral capsule 30 mg $0 (Tier 1) MO
chlorhexidine gluconate mucous membrane
mouthwash 0.12 %
$0 (Tier 1) MO
CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2
MG/ML)
$0 (Tier 2) MO
periogard mucous membrane mouthwash 0.12 % $0 (Tier 1) MO
pilocarpine hcl oral tablet 5 mg, 7.5 mg $0 (Tier 1) MO
triamcinolone acetonide dental paste 0.1 % $0 (Tier 1) MO
DERMATOLOGICAL AGENTS - TREATMENT OF SKIN CONDITIONS
DERMATOLOGICAL AGENTS
8-MOP ORAL CAPSULE 10 MG $0 (Tier 2) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
83
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
acitretin oral capsule 10 mg, 17.5 mg, 25 mg $0 (Tier 1) PA
ammonium lactate topical cream 12 % $0 (Tier 1) MO
ammonium lactate topical lotion 12 % $0 (Tier 1) MO
AMNESTEEM ORAL CAPSULE 10 MG, 20
MG, 40 MG
$0 (Tier 1) MO
ANTI-DANDRUFF 1% SHAMPOO 1 % $0 (Tier 3) DP
AQUA GLYCOLIC HAND-BODY LOT $0 (Tier 3) DP
calcipotriene scalp solution 0.005 % $0 (Tier 1) MO
calcipotriene topical cream 0.005 % $0 (Tier 1) MO
calcipotriene topical ointment 0.005 % $0 (Tier 1) MO
CERAVE MOISTURIZING CREAM $0 (Tier 3) DP
CETAPHIL GENTLE SKIN CLEANSER 16 OZ. $0 (Tier 3) DP
CETAPHIL MOISTURIZING CREAM $0 (Tier 3) DP
CETAPHIL MOISTURIZING LOTION $0 (Tier 3) DP
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg $0 (Tier 1) MO
clotrimazole-betamethasone topical cream 1-0.05
%
$0 (Tier 1) MO
clotrimazole-betamethasone topical lotion 1-0.05
%
$0 (Tier 1) MO
COMPLEX 15 HAND-BODY LOTION HAND &
BODY
$0 (Tier 3) DP
COMPOUND W 17% GEL 17 % $0 (Tier 3) DP
CRITIC-AID SKIN PASTE 20-51 % $0 (Tier 3) DP
DERMACERIN CREAM $0 (Tier 3) DP
DERMACLOUD OINTMENT $0 (Tier 3) DP
DML FORTE CREAM W-PANTHENOL $0 (Tier 3) DP
DOXEPIN TOPICAL CREAM 5 % $0 (Tier 1) MO
ELIDEL TOPICAL CREAM 1 % $0 (Tier 2) ST; MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
84
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
erythromycin-benzoyl peroxide topical gel 3-5 % $0 (Tier 1) MO
GS ITCH RELIEF CREAM 2-0.1 % $0 (Tier 3) DP
HEMORRHOIDAL OINTMENT $0 (Tier 3) DP
HYDRO SKIN 1% LOTION 1 % $0 (Tier 3) DP
hydrocortisone 0.5% cream (otc) 0.5 % $0 (Tier 3) DP
hydrocortisone 0.5% cream 0.5 % $0 (Tier 3) DP
hydrocortisone 0.5% ointment 0.5 % $0 (Tier 3) DP
hydrocortisone 1% cream 1 % $0 (Tier 3) DP
hydrocortisone-min oil-wht pet topical ointment 1
%
$0 (Tier 1) MO
imiquimod topical cream in packet 5 % $0 (Tier 1) MO
isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40
mg
$0 (Tier 1) MO
ITCH RELIEF CREAM 2-0.1 % $0 (Tier 3) DP
LACTINOL HX CREAM $0 (Tier 3) DP
LOTRIMIN AF 2% SPRAY POWDER 2 % $0 (Tier 3) DP
MEDERMA GEL $0 (Tier 3) DP
methoxsalen oral capsule,liqd-filled,rapid rel 10
mg
$0 (Tier 1) PA
MINERIN CREME $0 (Tier 3) DP
MINERIN LOTION $0 (Tier 3) DP
MOBISYL 10% CREAM 3.5OZ TUBE 10 % $0 (Tier 3) DP
myorisan oral capsule 10 mg, 20 mg, 30 mg, 40
mg
$0 (Tier 1) MO
nystatin-triamcinolone topical cream 100,000-0.1
unit/g-%
$0 (Tier 1) MO
nystatin-triamcinolone topical ointment 100,000-
0.1 unit/gram-%
$0 (Tier 1) MO
podofilox topical solution 0.5 % $0 (Tier 1) MO
prednicarbate topical cream 0.1 % $0 (Tier 1) MO
prednicarbate topical ointment 0.1 % $0 (Tier 1) MO
qc calamine lotion 8-8 % $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
85
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
RA DIAPER RASH OINTMENT BABY CARE
40 %
$0 (Tier 3) DP
REGRANEX TOPICAL GEL 0.01 % $0 (Tier 2) PA; MO; QL (15 GM per 30 days)
RISAMINE OINTMENT 0.44-20.6 % $0 (Tier 3) DP
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
$0 (Tier 2) MO
SARNA ANTI-ITCH LOTION 0.5-0.5 % $0 (Tier 3) DP
SCYTERA 2% FOAM NON-CALIFORNIA 2 % $0 (Tier 3) DP
SEBEX SHAMPOO 2-2 % $0 (Tier 3) DP
selenium sulfide topical lotion 2.5 % $0 (Tier 1) MO
SENSI-CARE PROTECTIVE OINTMENT 15-49
%
$0 (Tier 3) DP
SWEEN CREAM 12'S, W/PUMP $0 (Tier 3) DP
SWEEN CREAM WITH VIT A AND D 12'S $0 (Tier 3) DP
tacrolimus topical ointment 0.03 %, 0.1 % $0 (Tier 1) ST; MO
tazarotene topical cream 0.1 % $0 (Tier 1) MO
TAZORAC TOPICAL CREAM 0.05 % $0 (Tier 2) MO
TAZORAC TOPICAL GEL 0.05 %, 0.1 % $0 (Tier 2) MO
THERA-GEL 0.5% SHAMPOO 0.5 % $0 (Tier 3) DP
tretinoin (emollient) topical cream 0.05 % $0 (Tier 1) MO
tretinoin topical cream 0.025 %, 0.05 %, 0.1 % $0 (Tier 1) MO
tretinoin topical gel 0.01 %, 0.025 % $0 (Tier 1) MO
UREACIN-10 LOTION 10 % $0 (Tier 3) DP
VEREGEN TOPICAL OINTMENT 15 % $0 (Tier 2) MO
vitamin a and d ointment $0 (Tier 3) DP
WART REMOVER SOLUTION 17 % $0 (Tier 3) DP
ZENATANE ORAL CAPSULE 10 MG, 20 MG,
40 MG
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
86
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
zenatane oral capsule 30 mg $0 (Tier 1) MO
zinc oxide 20% ointment 20 % $0 (Tier 3) DP
ZYCLARA TOPICAL CREAM IN METERED-
DOSE PUMP 2.5 %, 3.75 %
$0 (Tier 2) PA; MO
ZYCLARA TOPICAL CREAM IN PACKET 3.75
%
$0 (Tier 2) PA; MO
DIABETIC SUPPLIES - SUPPLIES USED FOR DIABETES
DIABETIC SUPPLIES
alcohol pads topical pads, medicated $0 (Tier 1) MO
assure id insulin safety syringe 1 ml 29 gauge x
1/2"
$0 (Tier 1) MO
gauze pad topical bandage 2 x 2 " $0 (Tier 1) MO
insulin syringe-needle u-100 syringe 0.3 ml 29
gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge
$0 (Tier 1) MO
pen needle, diabetic needle 29 gauge x 1/2" $0 (Tier 1) MO
ENZYME REPLACEMENT/ MODIFIERS - MEDICATIONS TO REPLACE MISSING OR
DEFICIENT ENZYME PRODUCTION
ENZYME REPLACEMENT/ MODIFIERS
ADAGEN INTRAMUSCULAR SOLUTION 250
UNIT/ML
$0 (Tier 2) PA
ALDURAZYME INTRAVENOUS SOLUTION
2.9 MG/5 ML
$0 (Tier 2) PA
allopurinol sodium intravenous recon soln 500 mg $0 (Tier 1) B/D; MO
CERDELGA ORAL CAPSULE 84 MG $0 (Tier 2) PA
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT
$0 (Tier 2) PA
CHOLBAM ORAL CAPSULE 250 MG, 50 MG $0 (Tier 2) PA
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,
24,000-76,000 -120,000 UNIT, 3,000-9,500-
15,000 UNIT, 36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
$0 (Tier 2) MO
CYSTADANE ORAL POWDER 1 GRAM/1.7
ML
$0 (Tier 2)
CYSTAGON ORAL CAPSULE 150 MG, 50 MG $0 (Tier 2) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
87
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ELAPRASE INTRAVENOUS SOLUTION 6
MG/3 ML
$0 (Tier 2) PA
ELELYSO INTRAVENOUS RECON SOLN 200
UNIT
$0 (Tier 2) PA
ELITEK INTRAVENOUS RECON SOLN 1.5
MG, 7.5 MG
$0 (Tier 2) PA
FABRAZYME INTRAVENOUS RECON SOLN
35 MG, 5 MG
$0 (Tier 2) PA
KUVAN ORAL POWDER IN PACKET 100 MG,
500 MG
$0 (Tier 2) PA
KUVAN ORAL TABLET,SOLUBLE 100 MG $0 (Tier 2) PA
miglustat oral capsule 100 mg $0 (Tier 1) PA; MO
NAGLAZYME INTRAVENOUS SOLUTION 5
MG/5 ML
$0 (Tier 2) PA
NITYR ORAL TABLET 10 MG, 2 MG, 5 MG $0 (Tier 2) PA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20
MG, 5 MG
$0 (Tier 2) PA
ORFADIN ORAL SUSPENSION 4 MG/ML $0 (Tier 2) PA
RAVICTI ORAL LIQUID 1.1 GRAM/ML $0 (Tier 2) PA; MO
STRENSIQ SUBCUTANEOUS SOLUTION 100
MG/ML, 40 MG/ML
$0 (Tier 2) PA
SUCRAID ORAL SOLUTION 8,500 UNIT/ML $0 (Tier 2) PA
SYPRINE ORAL CAPSULE 250 MG $0 (Tier 2) PA
trientine oral capsule 250 mg $0 (Tier 1) PA
VPRIV INTRAVENOUS RECON SOLN 400
UNIT
$0 (Tier 2) PA
XURIDEN ORAL GRANULES IN PACKET 2
GRAM
$0 (Tier 2) PA; MO
ZAVESCA ORAL CAPSULE 100 MG $0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
88
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,
10,000-34,000 -55,000 UNIT, 15,000-47,000 -
63,000 UNIT, 15,000-51,000 -82,000 UNIT,
20,000-63,000- 84,000 UNIT, 20,000-68,000 -
109,000 UNIT, 25,000-79,000- 105,000 UNIT,
25,000-85,000- 136,000 UNIT, 3,000-10,000 -
14,000-UNIT, 3,000-10,000- 16,000 UNIT,
40,000-126,000- 168,000 UNIT, 40,000-136,000-
218,000 UNIT, 5,000-17,000 -27,000 UNIT,
5,000-17,000- 24,000 UNIT
$0 (Tier 2) MO
GASTROINTESTINAL AGENTS - TREATMENT OF STOMACH AND INTESTINAL
CONDITIONS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine oral capsule 10 mg $0 (Tier 1) MO
dicyclomine oral solution 10 mg/5 ml $0 (Tier 1) MO
dicyclomine oral tablet 20 mg $0 (Tier 1) MO
glycopyrrolate oral tablet 1 mg, 2 mg $0 (Tier 1) MO
GASTROINTESTINAL AGENTS
gavilyte-c oral recon soln 240-22.72-6.72 -5.84
gram
$0 (Tier 1) MO
methscopolamine oral tablet 2.5 mg $0 (Tier 1) MO
GASTROINTESTINAL AGENTS, OTHER
acidophilus caplet caplet 25 million cell -100 mg $0 (Tier 3) DP
ACIDOPHILUS-PECTIN CAPSULE 75
MILLION CELL -100 MG
$0 (Tier 3) DP
ANTACID 500 MG CHEW TABLET ASST
FRUIT FLAVORED 200 MG CALCIUM (500
MG)
$0 (Tier 3) DP
ANTACID 500 MG CHEWABLE TABLET
NA/F 200 MG CALCIUM (500 MG)
$0 (Tier 3) DP
ANTACID ANTI-GAS LIQUID MAXIMUM
STRENGTH 400-400-40 MG/5 ML
$0 (Tier 3) DP
ANTACID MAXIMUM STRENGTH LIQ 400-
400-40 MG/5 ML
$0 (Tier 3) DP
ANTACID SUSPENSION 200-200-20 MG/5 ML $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
89
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ANTACID XTRA STRENGTH CHEW TAB
EXTRA STRENGTH 300 MG (750 MG)
$0 (Tier 3) DP
ANTACID-ANTIGAS LIQUID 200-200-20 MG/5
ML
$0 (Tier 3) DP
ANTI-DIARRHEAL 2 MG CAPLET CAPLET 2
MG
$0 (Tier 3) DP
ANTI-DIARRHEAL 2 MG CAPLET CPLT
EASY TO SWALLOW 2 MG
$0 (Tier 3) DP
BISMATROL 525 MG/30 ML SUSP 262 MG/15
ML
$0 (Tier 3) DP
CALCIUM ANTACID EX-STR TABLET
EXTRA-STRENGTH 300 MG (750 MG)
$0 (Tier 3) DP
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5
ml
$0 (Tier 1) MO
diphenoxylate-atropine oral tablet 2.5-0.025 mg $0 (Tier 1) MO
ENDARI ORAL POWDER IN PACKET 5
GRAM
$0 (Tier 2) PA
enulose oral solution 10 gram/15 ml $0 (Tier 1) MO
EPSOM SALT GRANULES 6'S 495 MG/5
GRAM
$0 (Tier 3) DP
FLORANEX TABLET 1 MILLION CELL $0 (Tier 3) DP
GAS RELIEF 180 MG SOFTGEL ULTRA STR,
SOFTGEL 180 MG
$0 (Tier 3) DP
GAS RELIEF 180 MG SOFTGEL ULTRA
STR,SFTGEL 180 MG
$0 (Tier 3) DP
GAS RELIEF 80 MG TABLET CHEW 80 MG $0 (Tier 3) DP
GATTEX 30-VIAL SUBCUTANEOUS KIT 5
MG
$0 (Tier 2) PA
GATTEX ONE-VIAL SUBCUTANEOUS KIT 5
MG
$0 (Tier 2) PA
GAVISCON EXTRA STRENGTH LIQUID
EXTRA STR,COOL MINT 254-237.5 MG/5 ML
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
90
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
generlac oral solution 10 gram/15 ml $0 (Tier 1) MO
GS ANTACID 500 MG CHEWABLE TAB 215
MG CALCIUM (500 MG)
$0 (Tier 3) DP
GS ANTACID PLUS ANTI-GAS LIQ 200-200-
20 MG/5 ML
$0 (Tier 3) DP
GS ANTI-DIARRHEAL 2 MG CAPLET 2 MG $0 (Tier 3) DP
GS CAL ANTACID 500 MG CHEW TAB 200
MG CALCIUM (500 MG)
$0 (Tier 3) DP
gs simethicone 20 mg/0.3 ml 40 mg/0.6 ml $0 (Tier 3) DP
lactase 3,000 unit caplet caplet 3,000 unit $0 (Tier 3) DP
loperamide oral capsule 2 mg $0 (Tier 1) MO
MAG DELAY DR 70 MG TABLET 70 MG $0 (Tier 3) DP
MI ACID SUSPENSION 200-200-20 MG/5 ML $0 (Tier 3) DP
MI-ACID GAS 80 MG TAB CHEW 80 MG $0 (Tier 3) DP
MINTOX SUSPENSION MINT CREME 200-
200-20 MG/5 ML
$0 (Tier 3) DP
MYTAB GAS 80 MG TABLET CHEW 80 MG $0 (Tier 3) DP
MYTAB GAS MAX STR 125 MG TAB 125 MG $0 (Tier 3) DP
OCALIVA ORAL TABLET 10 MG, 5 MG $0 (Tier 2) PA
PINK BISMUTH 262 MG/15 ML SUSP 262
MG/15 ML
$0 (Tier 3) DP
PINK BISMUTH TABLET CHEW 262 MG $0 (Tier 3) DP
QC ANTACID SUSPENSION REGULAR
STRENGTH 200-200-20 MG/5 ML
$0 (Tier 3) DP
QC GAS RELIEF 125 MG TAB CHEW EXTRA
STRENGTH 125 MG
$0 (Tier 3) DP
QC PINK BISMUTH TABLET CHEW 262 MG $0 (Tier 3) DP
RA PINK BISMUTH CAPLET CAPLET,S/F 262
MG
$0 (Tier 3) DP
RECTIV RECTAL OINTMENT 0.4 % (W/W) $0 (Tier 2) MO
RELISTOR ORAL TABLET 150 MG $0 (Tier 2) PA; MO
RELISTOR SUBCUTANEOUS SOLUTION 12
MG/0.6 ML
$0 (Tier 2) PA; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
91
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
RELISTOR SUBCUTANEOUS SYRINGE 12
MG/0.6 ML, 8 MG/0.4 ML
$0 (Tier 2) PA; MO
RESTORA CAPSULE 120 MG-400 MG -4
BILLION CELL
$0 (Tier 3) DP
RISA-BID CAPLET 1 BILLION CELL- 250 MG $0 (Tier 3) DP
RISAQUAD CAPSULES 8 BILLION CELL $0 (Tier 3) DP
simethicone 80 mg tab chew anti gas 80 mg $0 (Tier 3) DP
SM ANTI-DIARRHEAL 2 MG CAPLET 2 MG $0 (Tier 3) DP
SM ANTI-DIARRHEAL 2 MG CAPLET
CAPLET 2 MG
$0 (Tier 3) DP
SM CAL ANTACID 500 MG CHEW TAB REG-
STR, FRUIT 200 MG CALCIUM (500 MG)
$0 (Tier 3) DP
SM EPSOM SALT GRANULES 495 MG/5
GRAM
$0 (Tier 3) DP
SM GAS RELIEF 125 MG SOFTGEL SOFTGEL,
EX-STRENGTH 125 MG
$0 (Tier 3) DP
sodium bicarb 325 mg tablet 325 mg $0 (Tier 3) DP
sodium bicarb 650 mg tablet 10 gr 650 mg $0 (Tier 3) DP
STOMACH RELIEF MAX STR LIQUID MAX.
STRENGTH 525 MG/15 ML
$0 (Tier 3) DP
TUMS ULTRA TABLET CHEWABLE 400 MG
CALCIUM (1,000 MG)
$0 (Tier 3) DP
ursodiol oral capsule 300 mg $0 (Tier 1) MO
ursodiol oral tablet 250 mg, 500 mg $0 (Tier 1) MO
XERMELO ORAL TABLET 250 MG $0 (Tier 2) PA
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
ACID CONTROL 75 MG TABLET 75 MG $0 (Tier 3) DP
ACID REDUCER 10 MG TABLET 10 MG $0 (Tier 3) DP
ACID REDUCER 10 MG TABLET ORIGINAL
STRENGTH 10 MG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
92
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
cimetidine hcl oral solution 300 mg/5 ml $0 (Tier 1) MO
cimetidine oral tablet 200 mg, 300 mg, 400 mg,
800 mg
$0 (Tier 1) MO
famotidine (pf) intravenous solution 20 mg/2 ml $0 (Tier 1)
famotidine intravenous solution 10 mg/ml $0 (Tier 1)
famotidine oral tablet 20 mg, 40 mg $0 (Tier 1) MO
hm famotidine 10 mg tablet original strength 10
mg
$0 (Tier 3) DP
nizatidine oral capsule 150 mg, 300 mg $0 (Tier 1) MO
ranitidine hcl oral syrup 15 mg/ml $0 (Tier 1) MO
ranitidine hcl oral tablet 150 mg, 300 mg $0 (Tier 1) MO
IRRITABLE BOWEL SYNDROME AGENTS
alosetron oral tablet 0.5 mg, 1 mg $0 (Tier 1) MO
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG $0 (Tier 2) MO; QL (60 EA per 30 days)
LINZESS ORAL CAPSULE 145 MCG, 290
MCG, 72 MCG
$0 (Tier 2) MO; QL (30 EA per 30 days)
LAXATIVES
BENEFIBER SUGAR FREE POWDER 38
SERVINGS, S/F 3 GRAM/3.5 GRAM
$0 (Tier 3) DP
BENEFIBER SUGAR FREE POWDER 62
SERVINGS, S/F 3 GRAM/3.5 GRAM
$0 (Tier 3) DP
bisacodyl 10 mg suppository 10 mg $0 (Tier 3) DP
bisacodyl ec 5 mg tablet 5 mg $0 (Tier 3) DP
BISA-LAX EC 5 MG TABLET 5 MG $0 (Tier 3) DP
BISCOLAX 10 MG SUPPOSITORY 10 MG $0 (Tier 3) DP
CITRUCEL 500 MG CAPLET 500 MG $0 (Tier 3) DP
CITRUCEL POWDER $0 (Tier 3) DP
CITRUCEL POWDER S-F S/F $0 (Tier 3) DP
COLACE CLEAR 50 MG SOFTGEL 50 MG $0 (Tier 3) DP
constulose oral solution 10 gram/15 ml $0 (Tier 1) MO
DOC-Q-LACE 100 MG SOFTGEL 100 MG $0 (Tier 3) DP
DOC-Q-LAX TABLET 8.6-50 MG $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
93
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
DOCU LIQUID 50 MG/5 ML 50 MG/5 ML $0 (Tier 3) DP
docusate cal 240 mg softgel softgel 240 mg $0 (Tier 3) DP
docusate sodium 100 mg softgel softgel 100 mg $0 (Tier 3) DP
docusate sodium 250 mg softgel softgel 250 mg $0 (Tier 3) DP
DOCUSATE SODIUM-SENNA TABLET 8.6-50
MG
$0 (Tier 3) DP
DOCUSIL 100 MG SOFTGEL 100 MG $0 (Tier 3) DP
ENEMA DISPOSABLE 19-7 GRAM/118 ML $0 (Tier 3) DP
ENEMEEZ MINI ENEMA 5CC TUBES, OUTER
283 MG/5 ML
$0 (Tier 3) DP
EX-LAX MAXIMUM STR 25 MG TAB 25 MG $0 (Tier 3) DP
FIBER LAXATIVE 625 MG CAPLET CAPLET
625 MG
$0 (Tier 3) DP
FIBER LAXATIVE 625 MG TABLET 625 MG $0 (Tier 3) DP
FIBER THERAPY POWDER 2 GRAM/19
GRAM
$0 (Tier 3) DP
FIBER-LAX CAPTABS 500MG
POLYCARBOPHIL 625 MG
$0 (Tier 3) DP
FLEET GLYCERIN ADULT SUPPOS $0 (Tier 3) DP
gavilyte-g oral recon soln 236-22.74-6.74 -5.86
gram
$0 (Tier 1) MO
gavilyte-n oral recon soln 420 gram $0 (Tier 1) MO
GS MILK OF MAGNESIA SUSPENSION 400
MG/5 ML
$0 (Tier 3) DP
HEALTHYLAX POWDER PACKET 14X17GM,
INNER 17 GRAM
$0 (Tier 3) DP
HM SENNA 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP
HM STOOL SOFTENER 100 MG SFTGL
SOFTGEL 100 MG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
94
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
KRISTALOSE ORAL PACKET 10 GRAM, 20
GRAM
$0 (Tier 2) ST; MO
lactulose oral solution 10 gram/15 ml, 10 gram/15
ml (15 ml), 20 gram/30 ml
$0 (Tier 1) MO
LAXATIVE 10 MG SUPPOSITORY 10 MG $0 (Tier 3) DP
LAXATIVE 15 MG PILLS 15 MG $0 (Tier 3) DP
LAXATIVE EC 5 MG TABLET 5 MG $0 (Tier 3) DP
magnesium citrate solution lemon $0 (Tier 3) DP
METAMUCIL FIBER SINGLES PACKET 3.4
GRAM
$0 (Tier 3) DP
METAMUCIL PACKET GLUTEN-FREE,
OUTER 3.4 GRAM
$0 (Tier 3) DP
METAMUCIL POWDER $0 (Tier 3) DP
METAMUCIL SUGAR-FREE POWDER S/F,
ORANGE FLAVOR 3.4 GRAM/5.8 GRAM
$0 (Tier 3) DP
MILK OF MAGNESIA SUSPENSION 400 MG/5
ML
$0 (Tier 3) DP
MILK OF MAGNESIA SUSPENSION NA/F 400
MG/5 ML
$0 (Tier 3) DP
MILK OF MAGNESIA SUSPENSION
STIMULANT FREE 400 MG/5 ML
$0 (Tier 3) DP
MINERAL OIL, HEAVY $0 (Tier 3) DP
NATURAL FIBER LAX POWDER $0 (Tier 3) DP
peg 3350-electrolytes oral recon soln 240-22.72-
6.72 -5.84 gram
$0 (Tier 1) MO
peg-3350 with flavor packs oral recon soln 420
gram
$0 (Tier 1) MO
peg-electrolyte soln oral recon soln 420 gram $0 (Tier 1) MO
polyethylene glycol 3350 oral powder 17
gram/dose
$0 (Tier 1) MO
polyethylene glycol 3350 oral powder in packet 17
gram
$0 (Tier 1) MO
qc docusate cal 240 mg capsule 240 mg $0 (Tier 3) DP
QC FIBERLAX 625 MG CAPLET CAPLET 625
MG
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
95
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
QC GENTLE LAXATIVE 10 MG SUPP 10 MG $0 (Tier 3) DP
QC GENTLE LAXATIVE EC 5 MG TAB 5 MG $0 (Tier 3) DP
QC MILK OF MAGNESIA SUSPENSION MINT
FLAVOR 400 MG/5 ML
$0 (Tier 3) DP
QC NATURAL VEGETABLE POWDER $0 (Tier 3) DP
QC READY TO USE ENEMA TWIN PACK 19-7
GRAM/118 ML
$0 (Tier 3) DP
QC SENNA LAXATIVE 8.6 MG TAB 8.6 MG $0 (Tier 3) DP
QC SENNA-S TABLET 8.6-50 MG $0 (Tier 3) DP
QC STOOL SOFTENER 100 MG CAP LIQUID
CAPS 100 MG
$0 (Tier 3) DP
QC STOOL SOFTENER-LAXATIVE TAB 8.6-
50 MG
$0 (Tier 3) DP
REGULOID CAPSULE 0.52 GRAM $0 (Tier 3) DP
REGULOID LAXATIVE POWDER $0 (Tier 3) DP
REGULOID POWDER $0 (Tier 3) DP
REGULOID POWDER ORANGE $0 (Tier 3) DP
SENNA 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP
SENNA 8.8 MG/5 ML SYRUP A/F,
CHOCOLATE 8.8 MG/5 ML
$0 (Tier 3) DP
SENNA PLUS TABLET 8.6-50 MG $0 (Tier 3) DP
SENNA SYRUP 176 MG/5 ML $0 (Tier 3) DP
SENNA-LAX 8.6 MG TABLET 8.6 MG $0 (Tier 3) DP
SENNALAX-S TABLET 8.6-50 MG $0 (Tier 3) DP
SENNA-S TABLET 8.6-50 MG $0 (Tier 3) DP
SILACE 50 MG/5 ML LIQUID 50 MG/5 ML $0 (Tier 3) DP
SILACE 60 MG/15 ML SYRUP 60 MG/15 ML $0 (Tier 3) DP
sm docusate cal 240 mg softgel softgel 240 mg $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
96
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SM FIBER LAXATIVE 625 MG TAB CAPLET
625 MG
$0 (Tier 3) DP
SM FIBER POWDER $0 (Tier 3) DP
SM FIBER POWDER 3.4 GRAM/11 GRAM $0 (Tier 3) DP
SM FIBER SMOOTH TEXTURE PWD $0 (Tier 3) DP
SM GENTLE LAXATIVE EC 5 MG TAB 5 MG $0 (Tier 3) DP
sm magnesium citrate solution $0 (Tier 3) DP
SM NAT LAX PLUS STOOL SOFTENER 8.6-50
MG
$0 (Tier 3) DP
SM SENNA LAXATIVE 8.6 MG TAB 8.6 MG $0 (Tier 3) DP
SM STOOL SOFTENER 100 MG SFTGL
SOFTGEL 100 MG
$0 (Tier 3) DP
SM STOOL SOFTENER-STIM LAX TAB 8.6-50
MG
$0 (Tier 3) DP
STOOL SOFTENER 100 MG CAPSULE 100 MG $0 (Tier 3) DP
STOOL SOFTENER 50 MG/5 ML LIQ 50 MG/5
ML
$0 (Tier 3) DP
STOOL SOFTENER-LAXATIVE TABLET 8.6-
50 MG
$0 (Tier 3) DP
STOOL SOFTENER-STIM LAX TABLET 8.6-50
MG
$0 (Tier 3) DP
trilyte with flavor packets oral recon soln 420
gram
$0 (Tier 1) MO
WOMANS LAXATIVE TABLET 5 MG $0 (Tier 3) DP
PROTECTANTS
misoprostol oral tablet 100 mcg, 200 mcg $0 (Tier 1) MO
sucralfate oral tablet 1 gram $0 (Tier 1) MO
PROTON PUMP INHIBITORS
lansoprazole oral capsule,delayed release(dr/ec)
15 mg, 30 mg
$0 (Tier 1) MO
omeprazole oral capsule,delayed release(dr/ec) 10
mg, 20 mg, 40 mg
$0 (Tier 1) MO
pantoprazole intravenous recon soln 40 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
97
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
pantoprazole oral tablet,delayed release (dr/ec) 20
mg, 40 mg
$0 (Tier 1) MO
GENITOURINARY AGENTS - TREATMENT OF URINARY TRACT AND PROSTATE
CONDITIONS
ANTISPASMODICS, URINARY
darifenacin oral tablet extended release 24 hr 15
mg, 7.5 mg
$0 (Tier 1) ST; MO
flavoxate oral tablet 100 mg $0 (Tier 1) MO
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HR 25 MG, 50 MG
$0 (Tier 2) ST; MO; QL (30 EA per 30 days)
oxybutynin chloride oral syrup 5 mg/5 ml $0 (Tier 1) MO
oxybutynin chloride oral tablet 5 mg $0 (Tier 1) MO
oxybutynin chloride oral tablet extended release
24hr 10 mg, 15 mg, 5 mg
$0 (Tier 1) MO
tolterodine oral capsule,extended release 24hr 2
mg, 4 mg
$0 (Tier 1) ST; MO
tolterodine oral tablet 1 mg, 2 mg $0 (Tier 1) ST; MO
TOVIAZ ORAL TABLET EXTENDED
RELEASE 24 HR 4 MG, 8 MG
$0 (Tier 2) MO
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin oral tablet extended release 24 hr 10 mg $0 (Tier 1) MO
dutasteride oral capsule 0.5 mg $0 (Tier 1) MO
finasteride oral tablet 5 mg $0 (Tier 1) MO
tamsulosin oral capsule 0.4 mg $0 (Tier 1) MO
GENITOURINARY AGENTS, OTHER
bethanechol chloride oral tablet 10 mg, 25 mg, 5
mg, 50 mg
$0 (Tier 1) MO
DEPEN TITRATABS ORAL TABLET 250 MG $0 (Tier 2) PA; MO
ELMIRON ORAL CAPSULE 100 MG $0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
98
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
potassium citrate oral tablet extended release 10
meq (1,080 mg), 15 meq, 5 meq (540 mg)
$0 (Tier 1) MO
sodium phenylbutyrate oral powder 0.94
gram/gram
$0 (Tier 1) PA; MO
sodium phenylbutyrate oral tablet 500 mg $0 (Tier 1) PA
PHOSPHATE BINDERS
calcium acetate oral capsule 667 mg $0 (Tier 1) MO
FOSRENOL ORAL POWDER IN PACKET
1,000 MG, 750 MG
$0 (Tier 2) MO
FOSRENOL ORAL TABLET,CHEWABLE
1,000 MG, 500 MG, 750 MG
$0 (Tier 2) MO
lanthanum oral tablet,chewable 1,000 mg, 500 mg,
750 mg
$0 (Tier 1) MO
RENVELA ORAL TABLET 800 MG $0 (Tier 2) MO
sevelamer carbonate oral powder in packet 0.8
gram, 2.4 gram
$0 (Tier 1) MO
sevelamer carbonate oral tablet 800 mg $0 (Tier 1) MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) -
TREATMENT OF CONDITIONS REQUIRING STEROIDS
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
ACTHAR H.P. INJECTION GEL 80 UNIT/ML $0 (Tier 2) PA; MO
clobetasol-emollient topical cream 0.05 % $0 (Tier 1) MO
cortisone oral tablet 25 mg $0 (Tier 1) MO
fludrocortisone oral tablet 0.1 mg $0 (Tier 1) MO
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg $0 (Tier 1) MO
TRIDERM TOPICAL CREAM 0.5 % $0 (Tier 1) MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) -
TREATMENT OF PITUITARY GLAND CONDITIONS
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)
chorionic gonadotropin, human intramuscular
recon soln 10,000 unit
$0 (Tier 1) PA; MO
desmopressin injection solution 4 mcg/ml $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
99
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
$0 (Tier 1) MO
desmopressin nasal spray with pump 10 mcg/spray
(0.1 ml)
$0 (Tier 1) MO
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
$0 (Tier 1) MO
desmopressin oral tablet 0.1 mg, 0.2 mg $0 (Tier 1) MO
EGRIFTA SUBCUTANEOUS RECON SOLN 1
MG, 2 MG
$0 (Tier 2) PA
GENOTROPIN MINIQUICK SUBCUTANEOUS
SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML,
0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25
ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML
$0 (Tier 2) PA
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36 UNIT/ML), 5
MG/ML (15 UNIT/ML)
$0 (Tier 2) PA
HUMATROPE INJECTION CARTRIDGE 12
MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18
UNIT)
$0 (Tier 2) PA
HUMATROPE INJECTION RECON SOLN 5 (15
UNIT) MG
$0 (Tier 2) PA
INCRELEX SUBCUTANEOUS SOLUTION 10
MG/ML
$0 (Tier 2) PA
NOCTIVA NASAL SPRAY,NON-AEROSOL
0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY
(0.1 ML)
$0 (Tier 2) PA; MO
NORDITROPIN FLEXPRO SUBCUTANEOUS
PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML),
15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
100
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
NUTROPIN AQ NUSPIN SUBCUTANEOUS
PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20
MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5
MG/ML)
$0 (Tier 2) PA
NUTROPIN AQ SUBCUTANEOUS
CARTRIDGE 20 MG/2 ML (10 MG/ML)
$0 (Tier 2) PA; MO
OMNITROPE SUBCUTANEOUS CARTRIDGE
10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
$0 (Tier 2) PA
OMNITROPE SUBCUTANEOUS RECON
SOLN 5.8 MG
$0 (Tier 2) PA
SEROSTIM SUBCUTANEOUS RECON SOLN 4
MG, 5 MG, 6 MG
$0 (Tier 2) PA
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS) - FOR THE REPLACEMENT OR MODIFICATION OF SEX
HORMONES
ANABOLIC STEROIDS
ANADROL-50 ORAL TABLET 50 MG $0 (Tier 2) PA; MO
oxandrolone oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO
ANDROGENS
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62
% (40.5 MG/2.5 GRAM)
$0 (Tier 2) ST; MO
ANDROXY ORAL TABLET 10 MG $0 (Tier 2) MO
DANAZOL ORAL CAPSULE 100 MG, 200 MG,
50 MG
$0 (Tier 2) MO
methyltestosterone oral capsule 10 mg $0 (Tier 1) PA; MO
testosterone cypionate intramuscular oil 100
mg/ml, 200 mg/ml
$0 (Tier 1)
testosterone transdermal gel 50 mg/5 gram (1 %) $0 (Tier 1) MO
testosterone transdermal gel in metered-dose
pump 12.5 mg/ 1.25 gram (1 %)
$0 (Tier 1) MO
testosterone transdermal gel in packet 1 % (25
mg/2.5gram), 1 % (50 mg/5 gram)
$0 (Tier 1) MO
ESTROGENS
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
101
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
DUAVEE ORAL TABLET 0.45-20 MG $0 (Tier 2) MO
ESTRACE VAGINAL CREAM 0.01 % (0.1
MG/GRAM)
$0 (Tier 2) MO
estradiol oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) MO
estradiol transdermal patch semiweekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
$0 (Tier 1) MO
estradiol transdermal patch weekly 0.025 mg/24
hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24
hr, 0.075 mg/24 hr, 0.1 mg/24 hr
$0 (Tier 1) MO
estradiol vaginal cream 0.01 % (0.1 mg/gram) $0 (Tier 1) MO
estradiol vaginal tablet 10 mcg $0 (Tier 1) MO
estradiol valerate intramuscular oil 20 mg/ml, 40
mg/ml
$0 (Tier 1)
ESTRING VAGINAL RING 2 MG (7.5 MCG /24
HOUR)
$0 (Tier 2) MO
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg $0 (Tier 1) PA; MO
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
1.25 MG, 2.5 MG
$0 (Tier 2) PA; MO
PREMARIN INJECTION RECON SOLN 25 MG $0 (Tier 2) MO
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG
$0 (Tier 2) MO
PREMARIN VAGINAL CREAM 0.625
MG/GRAM
$0 (Tier 2) MO
yuvafem vaginal tablet 10 mcg $0 (Tier 1) MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
ALTAVERA (28) ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO
alyacen 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
102
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
apri oral tablet 0.15-0.03 mg $0 (Tier 1) MO
aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg $0 (Tier 1) MO
aubra oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
aviane oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
balziva (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO
bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg
x 5
$0 (Tier 1) MO
blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
$0 (Tier 1) MO
blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
$0 (Tier 1) MO
briellyn oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO
caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg $0 (Tier 1) MO
CLIMARA PRO TRANSDERMAL PATCH
WEEKLY 0.045-0.015 MG/24 HR
$0 (Tier 2) MO
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25
MG/24 HR
$0 (Tier 2) MO
cryselle (28) oral tablet 0.3-30 mg-mcg $0 (Tier 1) MO
cyclafem 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35
mcg
$0 (Tier 1) MO
delyla (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
$0 (Tier 1) MO
desogestrel-ethinyl estradiol oral tablet 0.15-0.03
mg
$0 (Tier 1) MO
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
$0 (Tier 1) MO
emoquette oral tablet 0.15-0.03 mg $0 (Tier 1) MO
enpresse oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
$0 (Tier 1) MO
ENSKYCE ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO
estradiol-norethindrone acet oral tablet 0.5-0.1
mg
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
103
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
estradiol-norethindrone acet oral tablet 1-0.5 mg $0 (Tier 1) MO
ethynodiol diac-eth estradiol oral tablet 1-35 mg-
mcg, 1-50 mg-mcg
$0 (Tier 1) MO
falmina (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
femynor oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO
fyavolv oral tablet 1-5 mg-mcg $0 (Tier 1) MO
gildagia oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO
gildess 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO
introvale oral tablets,dose pack,3 month 0.15 mg-
30 mcg
$0 (Tier 1) MO
ISIBLOOM ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO
jinteli oral tablet 1-5 mg-mcg $0 (Tier 1) MO
juleber oral tablet 0.15-0.03 mg $0 (Tier 1) MO
junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO
junel 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
$0 (Tier 1) MO
junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
$0 (Tier 1) MO
kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x
5
$0 (Tier 1) MO
kelnor 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
KELNOR 1-50 ORAL TABLET 1-50 MG-MCG $0 (Tier 1) MO
kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01
mg x 5
$0 (Tier 1) MO
KURVELO ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO
larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO
larin 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
104
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
$0 (Tier 1) MO
larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
$0 (Tier 1) MO
larissia oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg $0 (Tier 1) MO
lessina oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
$0 (Tier 1) MO
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-0.03 mg
$0 (Tier 1) MO
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month 0.15 mg-30 mcg
$0 (Tier 1) MO
levonorg-eth estrad triphasic oral tablet 50-30
(6)/75-40 (5)/125-30(10)
$0 (Tier 1) MO
levora-28 oral tablet 0.15-0.03 mg $0 (Tier 1) MO
LILLOW ORAL TABLET 0.15-0.03 MG $0 (Tier 1) MO
lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg $0 (Tier 1) MO
low-ogestrel (28) oral tablet 0.3-30 mg-mcg $0 (Tier 1) MO
lutera (28) oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
marlissa oral tablet 0.15-0.03 mg $0 (Tier 1) MO
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg $0 (Tier 1) MO
microgestin 1/20 (21) oral tablet 1-20 mg-mcg $0 (Tier 1) MO
microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
$0 (Tier 1) MO
microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
$0 (Tier 1) MO
mimvey lo oral tablet 0.5-0.1 mg $0 (Tier 1) MO
MIMVEY ORAL TABLET 1-0.5 MG $0 (Tier 2) MO
mononessa (28) oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0 (Tier 1) MO
necon 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
necon 10/11 (28) oral tablet 0.5-35/1-35 mg-
mcg/mg-mcg
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
105
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg $0 (Tier 1) MO
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg, 1-5 mg-mcg
$0 (Tier 1) MO
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg
$0 (Tier 1) MO
NORLYDA ORAL TABLET 0.35 MG $0 (Tier 1) MO
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg $0 (Tier 1) MO
nortrel 1/35 (21) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
nortrel 1/35 (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35
mcg
$0 (Tier 1) MO
ocella oral tablet 3-0.03 mg $0 (Tier 1) MO
orsythia oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg
x 5
$0 (Tier 1) MO
pirmella oral tablet 1-35 mg-mcg $0 (Tier 1) MO
portia oral tablet 0.15-0.03 mg $0 (Tier 1) MO
PREMPHASE ORAL TABLET 0.625 MG (14)/
0.625MG-5MG(14)
$0 (Tier 2) MO
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-
1.5 MG, 0.625-2.5 MG, 0.625-5 MG
$0 (Tier 2) MO
previfem oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO
quasense oral tablets,dose pack,3 month 0.15 mg-
30 mcg
$0 (Tier 1) MO
reclipsen (28) oral tablet 0.15-0.03 mg $0 (Tier 1) MO
setlakin oral tablets,dose pack,3 month 0.15 mg-30
mcg
$0 (Tier 1) MO
sprintec (28) oral tablet 0.25-35 mg-mcg $0 (Tier 1) MO
sronyx oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
106
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
$0 (Tier 1) MO
TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25
MG-35 MCG (28)
$0 (Tier 1) MO
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-
35mcg (9)
$0 (Tier 1) MO
TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-
35 MCG (28)
$0 (Tier 1) MO
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
$0 (Tier 1) MO
tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
$0 (Tier 1) MO
tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
$0 (Tier 1) MO
trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
$0 (Tier 1) MO
TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25
MG-35 MCG (28)
$0 (Tier 1) MO
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
$0 (Tier 1) MO
vienva oral tablet 0.1-20 mg-mcg $0 (Tier 1) MO
vyfemla (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO
VYLIBRA ORAL TABLET 0.25-35 MG-MCG $0 (Tier 1) MO
xulane transdermal patch weekly 150-35 mcg/24
hr
$0 (Tier 1) MO
zarah oral tablet 3-0.03 mg $0 (Tier 1) MO
zenchent (28) oral tablet 0.4-35 mg-mcg $0 (Tier 1) MO
zovia 1/35e (28) oral tablet 1-35 mg-mcg $0 (Tier 1) MO
zovia 1/50e (28) oral tablet 1-50 mg-mcg $0 (Tier 1) MO
PROGESTINS
camila oral tablet 0.35 mg $0 (Tier 1) MO
deblitane oral tablet 0.35 mg $0 (Tier 1) MO
DEPO-SUBQ PROVERA 104
SUBCUTANEOUS SYRINGE 104 MG/0.65 ML
$0 (Tier 2) MO
errin oral tablet 0.35 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
107
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
jolivette oral tablet 0.35 mg $0 (Tier 1) MO
lyza oral tablet 0.35 mg $0 (Tier 1) MO
medroxyprogesterone intramuscular suspension
150 mg/ml
$0 (Tier 1) MO
medroxyprogesterone intramuscular syringe 150
mg/ml
$0 (Tier 1) MO
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5
mg
$0 (Tier 1) MO
megestrol oral suspension 400 mg/10 ml (10 ml),
400 mg/10 ml (40 mg/ml), 625 mg/5 ml
$0 (Tier 1) PA; MO
megestrol oral tablet 20 mg, 40 mg $0 (Tier 1) PA; MO
nora-be oral tablet 0.35 mg $0 (Tier 1) MO
norethindrone (contraceptive) oral tablet 0.35 mg $0 (Tier 1) MO
norethindrone acetate oral tablet 5 mg $0 (Tier 1) MO
norlyroc oral tablet 0.35 mg $0 (Tier 1) MO
progesterone micronized oral capsule 100 mg, 200
mg
$0 (Tier 1) MO
sharobel oral tablet 0.35 mg $0 (Tier 1) MO
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene oral tablet 60 mg $0 (Tier 1) MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) -
TREATMENT OF THYROID CONDITIONS
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)
levothyroxine intravenous recon soln 100 mcg $0 (Tier 1) MO
levothyroxine oral tablet 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
$0 (Tier 1) MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
108
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
liothyronine intravenous solution 10 mcg/ml $0 (Tier 1) MO
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg $0 (Tier 1) MO
SYNTHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
75 MCG, 88 MCG
$0 (Tier 2) MO
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,
150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50
mcg, 75 mcg, 88 mcg
$0 (Tier 1) MO
unithroid oral tablet 137 mcg $0 (Tier 1)
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) - TREATMENT OF INOPERABLE
ADRENAL CANCER
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
LYSODREN ORAL TABLET 500 MG $0 (Tier 2)
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) - TREATMENT OF
PARATHYROID CONDITIONS
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR ORAL TABLET 30 MG, 60 MG $0 (Tier 2) MO; QL (60 EA per 30 days)
SENSIPAR ORAL TABLET 90 MG $0 (Tier 2) MO; QL (120 EA per 30 days)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) - TREATMENT OF OR
MODIFICATION OF PITUITARY HORMONE SECRETION
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline oral tablet 0.5 mg $0 (Tier 1) MO
ELIGARD (3 MONTH) SUBCUTANEOUS
SYRINGE 22.5 MG
$0 (Tier 2) PA
ELIGARD (4 MONTH) SUBCUTANEOUS
SYRINGE 30 MG
$0 (Tier 2) PA
ELIGARD (6 MONTH) SUBCUTANEOUS
SYRINGE 45 MG
$0 (Tier 2) PA
ELIGARD SUBCUTANEOUS SYRINGE 7.5
MG (1 MONTH)
$0 (Tier 2) PA
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120 MG, 80
MG
$0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
109
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
FIRMAGON SUBCUTANEOUS RECON SOLN
120 MG
$0 (Tier 2) PA
leuprolide subcutaneous kit 1 mg/0.2 ml $0 (Tier 1)
leuprolide subcutaneous solution 1 mg/0.2 ml $0 (Tier 1) MO
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG,
22.5 MG
$0 (Tier 2) PA
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT 30 MG
$0 (Tier 2) PA
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT 45 MG
$0 (Tier 2) PA
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG, 7.5 MG
$0 (Tier 2) PA
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG,
30 MG
$0 (Tier 2) PA
LUPRON DEPOT-PED INTRAMUSCULAR KIT
11.25 MG, 15 MG, 7.5 MG (PED)
$0 (Tier 2) PA
octreotide acetate injection solution 1,000 mcg/ml,
500 mcg/ml
$0 (Tier 1) PA
OCTREOTIDE ACETATE INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML, 50
MCG/ML
$0 (Tier 2) PA
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 10
MG, 20 MG, 30 MG
$0 (Tier 2) PA
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3
MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML
(1 ML)
$0 (Tier 2) PA
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
110
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SOMAVERT SUBCUTANEOUS RECON SOLN
10 MG, 15 MG, 20 MG, 25 MG, 30 MG
$0 (Tier 2) PA
SYNAREL NASAL SPRAY,NON-AEROSOL 2
MG/ML
$0 (Tier 2) PA
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 11.25 MG, 22.5 MG,
3.75 MG
$0 (Tier 2) PA
TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML
$0 (Tier 2) PA
HORMONAL AGENTS, SUPPRESSANT (THYROID) - TREATMENT FOR
OVERACTIVE THYROID
ANTITHYROID AGENTS
IOSAT 130 MG TABLET INNER 130 MG $0 (Tier 3) DP
methimazole oral tablet 10 mg, 5 mg $0 (Tier 1) MO
propylthiouracil oral tablet 50 mg $0 (Tier 1) MO
THYROSAFE 65 MG TABLET 65 MG $0 (Tier 3) DP
IMMUNOLOGICAL AGENTS - MEDICATIONS THAT ALTER THE IMMUNE SYSTEM
INCLUDING VACCINATIONS
ANGIOEDEMA (HAE) AGENTS
CINRYZE INTRAVENOUS RECON SOLN 500
UNIT (5 ML)
$0 (Tier 2) PA
FIRAZYR SUBCUTANEOUS SYRINGE 30
MG/3 ML
$0 (Tier 2) PA
HAEGARDA SUBCUTANEOUS RECON SOLN
2,000 UNIT, 3,000 UNIT
$0 (Tier 2) PA
IMMUNE SUPPRESSANTS
ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.5 MG, 1 MG, 5 MG
$0 (Tier 2) B/D
ATGAM INTRAVENOUS SOLUTION 50
MG/ML
$0 (Tier 2) B/D
AZASAN ORAL TABLET 100 MG, 75 MG $0 (Tier 2) PA; MO
azathioprine oral tablet 50 mg $0 (Tier 1) B/D; MO
azathioprine sodium injection recon soln 100 mg $0 (Tier 1) B/D; MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
111
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200 MG X 2
VIALS)
$0 (Tier 2) PA
CIMZIA STARTER KIT SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)
$0 (Tier 2) PA
CIMZIA SUBCUTANEOUS SYRINGE KIT 400
MG/2 ML (200 MG/ML X 2)
$0 (Tier 2) PA
cyclosporine intravenous solution 250 mg/5 ml $0 (Tier 1) B/D
cyclosporine modified oral capsule 100 mg, 25
mg, 50 mg
$0 (Tier 1) B/D; MO
cyclosporine modified oral solution 100 mg/ml $0 (Tier 1) B/D; MO
cyclosporine oral capsule 100 mg, 25 mg $0 (Tier 1) B/D; MO
ENBREL MINI SUBCUTANEOUS
CARTRIDGE 50 MG/ML (0.98 ML)
$0 (Tier 2) PA
ENBREL SUBCUTANEOUS RECON SOLN 25
MG (1 ML)
$0 (Tier 2) PA
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
$0 (Tier 2) PA
ENBREL SURECLICK SUBCUTANEOUS PEN
INJECTOR 50 MG/ML (0.98 ML)
$0 (Tier 2) PA
ENVARSUS XR ORAL TABLET EXTENDED
RELEASE 24 HR 0.75 MG, 1 MG, 4 MG
$0 (Tier 2) B/D; MO
gengraf oral capsule 100 mg, 25 mg $0 (Tier 1) B/D; MO
gengraf oral solution 100 mg/ml $0 (Tier 1) B/D; MO
HUMIRA PEDIATRIC CROHN'S START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML, 40 MG/0.8 ML (6 PACK), 80 MG/0.8 ML,
80 MG/0.8 ML-40 MG/0.4 ML
$0 (Tier 2) PA
HUMIRA PEN CROHN'S-UC-HS START
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
112
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
HUMIRA PEN PSORIASIS-UVEITIS
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
$0 (Tier 2) PA
HUMIRA PEN SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML
$0 (Tier 2) PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML
$0 (Tier 2) PA
INFLECTRA INTRAVENOUS RECON SOLN
100 MG
$0 (Tier 2) PA
KINERET SUBCUTANEOUS SYRINGE 100
MG/0.67 ML
$0 (Tier 2) PA
methotrexate sodium (pf) injection recon soln 1
gram
$0 (Tier 1)
methotrexate sodium (pf) injection solution 25
mg/ml
$0 (Tier 1)
methotrexate sodium injection solution 25 mg/ml $0 (Tier 1)
methotrexate sodium oral tablet 2.5 mg $0 (Tier 1) MO
mycophenolate mofetil hcl intravenous recon soln
500 mg
$0 (Tier 1) PA
mycophenolate mofetil oral capsule 250 mg $0 (Tier 1) B/D; MO
mycophenolate mofetil oral suspension for
reconstitution 200 mg/ml
$0 (Tier 1) B/D; MO
mycophenolate mofetil oral tablet 500 mg $0 (Tier 1) B/D; MO
mycophenolate sodium oral tablet,delayed release
(dr/ec) 180 mg, 360 mg
$0 (Tier 1) B/D; MO
NULOJIX INTRAVENOUS RECON SOLN 250
MG
$0 (Tier 2) B/D
ORENCIA (WITH MALTOSE) INTRAVENOUS
RECON SOLN 250 MG
$0 (Tier 2) PA
ORENCIA CLICKJECT SUBCUTANEOUS
AUTO-INJECTOR 125 MG/ML
$0 (Tier 2) PA
ORENCIA SUBCUTANEOUS SYRINGE 125
MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML
$0 (Tier 2) PA
OTEZLA ORAL TABLET 30 MG $0 (Tier 2) PA
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
113
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG (47)
$0 (Tier 2) PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG(19)
$0 (Tier 2) PA
PROGRAF INTRAVENOUS SOLUTION 5
MG/ML
$0 (Tier 2) PA
RAPAMUNE ORAL SOLUTION 1 MG/ML $0 (Tier 2) B/D
REMICADE INTRAVENOUS RECON SOLN
100 MG
$0 (Tier 2) PA
RENFLEXIS INTRAVENOUS RECON SOLN
100 MG
$0 (Tier 2) PA
SANDIMMUNE ORAL SOLUTION 100 MG/ML $0 (Tier 2) B/D; MO
SIMPONI ARIA INTRAVENOUS SOLUTION
12.5 MG/ML
$0 (Tier 2) PA
SIMPONI SUBCUTANEOUS PEN INJECTOR
100 MG/ML, 50 MG/0.5 ML
$0 (Tier 2) PA
SIMPONI SUBCUTANEOUS SYRINGE 100
MG/ML, 50 MG/0.5 ML
$0 (Tier 2) PA
SIMULECT INTRAVENOUS RECON SOLN 10
MG, 20 MG
$0 (Tier 2) PA
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg $0 (Tier 1) B/D
STELARA INTRAVENOUS SOLUTION 130
MG/26 ML
$0 (Tier 2) PA
STELARA SUBCUTANEOUS SOLUTION 45
MG/0.5 ML
$0 (Tier 2) PA; MO
STELARA SUBCUTANEOUS SYRINGE 45
MG/0.5 ML, 90 MG/ML
$0 (Tier 2) PA
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg $0 (Tier 1) B/D
TREMFYA SUBCUTANEOUS SYRINGE 100
MG/ML
$0 (Tier 2) PA
TREXALL ORAL TABLET 10 MG, 15 MG, 5
MG, 7.5 MG
$0 (Tier 2) PA
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
114
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
XATMEP ORAL SOLUTION 2.5 MG/ML $0 (Tier 2) PA; MO
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,
0.75 MG
$0 (Tier 2) B/D
IMMUNIZING AGENTS, PASSIVE
BIVIGAM INTRAVENOUS SOLUTION 10 % $0 (Tier 2) B/D
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM, 6
GRAM
$0 (Tier 2) B/D
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 10 %
$0 (Tier 2) B/D
GAMASTAN S/D INTRAMUSCULAR
SOLUTION 15-18 % RANGE, 15-18 % RANGE
(10 ML), 15-18 % RANGE (2 ML)
$0 (Tier 2) B/D
GAMMAGARD LIQUID INJECTION
SOLUTION 10 %
$0 (Tier 2) B/D
GAMMAGARD S-D (IGA < 1 MCG/ML)
INTRAVENOUS RECON SOLN 10 GRAM, 5
GRAM
$0 (Tier 2) B/D
GAMMAKED INJECTION SOLUTION 1
GRAM/10 ML (10 %), 10 GRAM/100 ML (10
%), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML
(10 %), 5 GRAM/50 ML (10 %)
$0 (Tier 2) B/D
GAMMAPLEX (WITH SORBITOL)
INTRAVENOUS SOLUTION 5 %
$0 (Tier 2) B/D
GAMMAPLEX INTRAVENOUS SOLUTION 10
%, 10 % (100 ML), 10 % (200 ML)
$0 (Tier 2) B/D
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %), 10 GRAM/100 ML (10
%), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML
(10 %), 5 GRAM/50 ML (10 %)
$0 (Tier 2) B/D
GAMUNEX-C INJECTION SOLUTION 40
GRAM/400 ML (10 %)
$0 (Tier 2) B/D; MO
HYPERRAB (PF) INTRAMUSCULAR
SOLUTION 300 UNIT/ML
$0 (Tier 2) MO
HYPERRAB S/D (PF) INTRAMUSCULAR
SOLUTION 150 UNIT/ML, 150 UNIT/ML (10
ML)
$0 (Tier 2)
PRIVIGEN INTRAVENOUS SOLUTION 10 % $0 (Tier 2) B/D
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
115
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
THYMOGLOBULIN INTRAVENOUS RECON
SOLN 25 MG
$0 (Tier 2) B/D
IMMUNOMODULATORS
ACTEMRA INTRAVENOUS SOLUTION 200
MG/10 ML (20 MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20 MG/ML)
$0 (Tier 2) PA
ACTEMRA SUBCUTANEOUS SYRINGE 162
MG/0.9 ML
$0 (Tier 2) PA; MO
ACTIMMUNE SUBCUTANEOUS SOLUTION
100 MCG/0.5 ML
$0 (Tier 2) PA
ARCALYST SUBCUTANEOUS RECON SOLN
220 MG
$0 (Tier 2) PA
BENLYSTA INTRAVENOUS RECON SOLN
120 MG, 400 MG
$0 (Tier 2) PA
BENLYSTA SUBCUTANEOUS AUTO-
INJECTOR 200 MG/ML
$0 (Tier 2) PA
BENLYSTA SUBCUTANEOUS SYRINGE 200
MG/ML
$0 (Tier 2) PA
ILARIS (PF) SUBCUTANEOUS RECON SOLN
180 MG/1.2 ML (150 MG/ML)
$0 (Tier 2) PA
ILARIS (PF) SUBCUTANEOUS SOLUTION
150 MG/ML
$0 (Tier 2) PA
leflunomide oral tablet 10 mg, 20 mg $0 (Tier 1) MO
TYSABRI INTRAVENOUS SOLUTION 300
MG/15 ML
$0 (Tier 2) PA; LA
VACCINES
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
$0 (Tier 2) MO
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-
3-5 MCG)-5LF/0.5 ML
$0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
116
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
$0 (Tier 2) MO
BCG VACCINE, LIVE (PF) PERCUTANEOUS
SUSPENSION FOR RECONSTITUTION 50 MG
$0 (Tier 2) MO
BEXSERO INTRAMUSCULAR SYRINGE 50-
50-50-25 MCG/0.5 ML
$0 (Tier 2) MO
BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML
$0 (Tier 2) MO
BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML
$0 (Tier 2) MO
DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION 15-10-5 LF-
MCG-LF/0.5ML
$0 (Tier 2) MO
ENGERIX-B (PF) INTRAMUSCULAR
SUSPENSION 20 MCG/ML
$0 (Tier 2) B/D; MO
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE 20 MCG/ML
$0 (Tier 2) B/D; MO
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION 10 MCG/0.5
ML
$0 (Tier 2) B/D; MO
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML
$0 (Tier 2) B/D; MO
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION 20-40-40-20 MCG/0.5 ML
$0 (Tier 2) MO
GARDASIL (PF) INTRAMUSCULAR
SYRINGE 20-40-40-20 MCG/0.5 ML
$0 (Tier 2) MO
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION 0.5 ML
$0 (Tier 2) MO
GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE 0.5 ML
$0 (Tier 2) MO
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
$0 (Tier 2) MO
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5
ML
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
117
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
HEPLISAV-B INTRAMUSCULAR SOLUTION
20 MCG/0.5 ML
$0 (Tier 2) B/D; MO
HIBERIX (PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
$0 (Tier 2) MO
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN 2.5 UNIT
$0 (Tier 2) MO
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
$0 (Tier 2) MO
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SYRINGE 25-58-10 LF-MCG-LF/0.5ML
$0 (Tier 2) MO
IPOL INJECTION SUSPENSION 40-8-32
UNIT/0.5 ML
$0 (Tier 2) MO
IXIARO (PF) INTRAMUSCULAR SYRINGE 6
MCG/0.5 ML
$0 (Tier 2) MO
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML
$0 (Tier 2) MO
KINRIX (PF) INTRAMUSCULAR SYRINGE 25
LF-58 MCG-10 LF/0.5 ML
$0 (Tier 2) MO
MENACTRA (PF) INTRAMUSCULAR
SOLUTION 4 MCG/0.5 ML
$0 (Tier 2) MO
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50 MCG
$0 (Tier 2) MO
MENOMUNE - A/C/Y/W-135
SUBCUTANEOUS RECON SOLN 50 MCG
$0 (Tier 2) MO
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5 MCG/0.5 ML
$0 (Tier 2) MO
M-M-R II (PF) SUBCUTANEOUS RECON
SOLN 1,000-12,500 TCID50/0.5 ML
$0 (Tier 2) MO
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
10 MCG-25LF-25 MCG-10LF/0.5 ML
$0 (Tier 2) MO
PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION 7.5 MCG/0.5 ML
$0 (Tier 2) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
118
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
PENTACEL ACTHIB COMPONENT (PF)
INTRAMUSCULAR RECON SOLN 10 MCG/0.5
ML
$0 (Tier 2) MO
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
10EXP3-4.3-3- 3.99 TCID50/0.5
$0 (Tier 2) MO
QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION 15 LF-48 MCG- 5 LF
UNIT/0.5ML
$0 (Tier 2) MO
RABAVERT (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 2.5
UNIT
$0 (Tier 2) MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML, 5
MCG/0.5 ML
$0 (Tier 2) B/D; MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML, 5 MCG/0.5 ML
$0 (Tier 2) B/D; MO
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML
$0 (Tier 2) MO
ROTATEQ VACCINE ORAL SOLUTION 2 ML $0 (Tier 2) MO
SHINGRIX (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 50
MCG/0.5 ML
$0 (Tier 2) MO
SHINGRIX GE ANTIGEN COMPONENT
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 50 MCG
$0 (Tier 2) MO
TENIVAC (PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML
$0 (Tier 2) MO
TENIVAC (PF) INTRAMUSCULAR SYRINGE
5-2 LF UNIT/0.5 ML
$0 (Tier 2) MO
tetanus,diphtheria tox ped(pf) intramuscular
suspension 5-25 lf unit/0.5 ml
$0 (Tier 1) MO
tetanus-diphtheria toxoids-td intramuscular
suspension 2-2 lf unit/0.5 ml
$0 (Tier 1) MO
TICE BCG INTRAVESICAL SUSPENSION
FOR RECONSTITUTION 50 MG
$0 (Tier 2)
TRUMENBA INTRAMUSCULAR SYRINGE
120 MCG/0.5 ML
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
119
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
TWINRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT- 20 MCG/ML
$0 (Tier 2) MO
TYPHIM VI INTRAMUSCULAR SOLUTION 25
MCG/0.5 ML
$0 (Tier 2) MO
TYPHIM VI INTRAMUSCULAR SYRINGE 25
MCG/0.5 ML
$0 (Tier 2) MO
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML
$0 (Tier 2) MO
VAQTA (PF) INTRAMUSCULAR SYRINGE 25
UNIT/0.5 ML, 50 UNIT/ML
$0 (Tier 2) MO
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 1,350
UNIT/0.5 ML
$0 (Tier 2) MO
VARIZIG INTRAMUSCULAR RECON SOLN
125 UNIT
$0 (Tier 2)
VARIZIG INTRAMUSCULAR SOLUTION 125
UNIT/1.2 ML
$0 (Tier 2) MO
VAXCHORA BUFFER COMPONENT ORAL
SUSPENSION FOR RECONSTITUTION
$0 (Tier 2) MO
VAXCHORA VACCINE ORAL SUSPENSION
FOR RECONSTITUTION 4X10EXP8 TO 2X
10EXP9 CF UNIT
$0 (Tier 2) MO
YF-VAX (PF) SUBCUTANEOUS SUSPENSION
FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5
ML
$0 (Tier 2) MO
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 19,400
UNIT/0.65 ML
$0 (Tier 2) MO
INFLAMMATORY BOWEL DISEASE AGENTS - TREATMENT OF ULCERATIVE
COLITIS OR CROHN?S DISEASE
AMINOSALICYLATES
balsalazide oral capsule 750 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
120
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CANASA RECTAL SUPPOSITORY 1,000 MG $0 (Tier 2) MO
DELZICOL ORAL CAPSULE (WITH DEL REL
TABLETS) 400 MG
$0 (Tier 2) MO
DELZICOL ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
$0 (Tier 2) MO
DIPENTUM ORAL CAPSULE 250 MG $0 (Tier 2) MO
LIALDA ORAL TABLET,DELAYED RELEASE
(DR/EC) 1.2 GRAM
$0 (Tier 2) MO
mesalamine oral tablet,delayed release (dr/ec) 1.2
gram
$0 (Tier 1) MO
mesalamine rectal enema 4 gram/60 ml $0 (Tier 1) MO
mesalamine with cleansing wipe rectal enema kit 4
gram/60 ml
$0 (Tier 1) MO
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 250 MG, 500 MG
$0 (Tier 2) MO
GLUCOCORTICOIDS
BUDESONIDE ORAL
CAPSULE,DELAYED,EXTEND.RELEASE 3
MG
$0 (Tier 1) MO
colocort rectal enema 100 mg/60 ml $0 (Tier 1) MO
hydrocortisone rectal enema 100 mg/60 ml $0 (Tier 1) MO
hydrocortisone topical cream with perineal
applicator 2.5 %
$0 (Tier 1) MO
prednisone intensol oral concentrate 5 mg/ml $0 (Tier 1) MO
procto-med hc topical cream with perineal
applicator 2.5 %
$0 (Tier 1) MO
procto-pak topical cream with perineal applicator
1 %
$0 (Tier 1) MO
proctosol hc topical cream with perineal
applicator 2.5 %
$0 (Tier 1) MO
proctozone-hc topical cream with perineal
applicator 2.5 %
$0 (Tier 1) MO
SULFONAMIDES
sulfasalazine oral tablet 500 mg $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
121
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
sulfasalazine oral tablet,delayed release (dr/ec)
500 mg
$0 (Tier 1) MO
METABOLIC BONE DISEASE AGENTS - TREATMENT OF BONE DISEASES
INCLUDING OSTEOPOROSIS
METABOLIC BONE DISEASE AGENTS
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5
mg, 70 mg
$0 (Tier 1) MO
calcitonin (salmon) nasal spray,non-aerosol 200
unit/actuation
$0 (Tier 1) MO
calcitriol oral capsule 0.25 mcg, 0.5 mcg $0 (Tier 1) MO
calcitriol oral solution 1 mcg/ml $0 (Tier 1) MO
doxercalciferol intravenous solution 4 mcg/2 ml $0 (Tier 1) MO
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5
mcg
$0 (Tier 1) MO
etidronate disodium oral tablet 200 mg, 400 mg $0 (Tier 1) MO
FORTEO SUBCUTANEOUS PEN INJECTOR
20 MCG/DOSE - 600 MCG/2.4 ML
$0 (Tier 2) PA
ibandronate intravenous solution 3 mg/3 ml $0 (Tier 1) B/D
ibandronate intravenous syringe 3 mg/3 ml $0 (Tier 1) B/D
ibandronate oral tablet 150 mg $0 (Tier 1) MO
MIACALCIN INJECTION SOLUTION 200
UNIT/ML
$0 (Tier 2) B/D
NATPARA SUBCUTANEOUS CARTRIDGE
100 MCG/DOSE, 25 MCG/DOSE, 50
MCG/DOSE, 75 MCG/DOSE
$0 (Tier 2) PA; MO
pamidronate intravenous recon soln 30 mg, 90 mg $0 (Tier 1)
pamidronate intravenous solution 30 mg/10 ml (3
mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9
mg/ml)
$0 (Tier 1)
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
122
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
PROLIA SUBCUTANEOUS SYRINGE 60
MG/ML
$0 (Tier 2) PA
risedronate oral tablet 150 mg, 30 mg, 35 mg, 35
mg (12 pack), 35 mg (4 pack), 5 mg
$0 (Tier 1) MO
TYMLOS SUBCUTANEOUS PEN INJECTOR
80 MCG (3,120 MCG/1.56 ML)
$0 (Tier 2) PA
XGEVA SUBCUTANEOUS SOLUTION 120
MG/1.7 ML (70 MG/ML)
$0 (Tier 2) PA
zoledronic acid intravenous recon soln 4 mg $0 (Tier 1) PA
zoledronic acid intravenous solution 4 mg/5 ml $0 (Tier 1) PA
zoledronic acid-mannitol-water intravenous
piggyback 5 mg/100 ml
$0 (Tier 1) PA
ZOMETA INTRAVENOUS PIGGYBACK 4
MG/100 ML
$0 (Tier 2) PA
MISCELLANEOUS
MISCELLANEOUS
ISOLYTE S PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
$0 (Tier 2)
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
$0 (Tier 2)
water for irrigation, sterile irrigation solution $0 (Tier 1) MO
OPHTHALMIC AGENTS - TREATMENT OF EYE CONDITIONS
OPHTHALMIC AGENTS, OTHER
ARTIFICIAL TEARS 1.4 % DROPS 1.4 % $0 (Tier 3) DP
ARTIFICIAL TEARS DROPS 0.5-0.6 % $0 (Tier 3) DP
atropine ophthalmic (eye) drops 1 % $0 (Tier 1) MO
CYSTARAN OPHTHALMIC (EYE) DROPS
0.44 %
$0 (Tier 2)
FRESHKOTE EYE DROPS 2-0.9-1.8 % $0 (Tier 3) DP
GENTEAL GEL DROPS 0.25-0.3 % $0 (Tier 3) DP
GENTEAL MILD-MODERATE EYE DROP P/F,
DRY EYE RELIEF 0.3 %
$0 (Tier 3) DP
GENTEAL PM OINTMENT 94-3 % $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
123
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
GENTEAL SEVERE 0.3% EYE GEL P/F, STRL,
INNER 0.3 %
$0 (Tier 3) DP
MURO-128 2% EYE DROPS 2 % $0 (Tier 3) DP
MURO-128 5% EYE DROPS 5 % $0 (Tier 3) DP
MURO-128 5% EYE OINTMENT 5 % $0 (Tier 3) DP
naphazoline ophthalmic (eye) drops 0.1 % $0 (Tier 1) MO
NATACYN OPHTHALMIC (EYE)
DROPS,SUSPENSION 5 %
$0 (Tier 2) MO
proparacaine ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO
REFRESH CLASSIC EYE DROPS U-
D,P/F,30X.4ML 1.4-0.6 %
$0 (Tier 3) DP
REFRESH LACRI-LUBE OINTMENT 56.8-42.5
%
$0 (Tier 3) DP
REFRESH LIQUIGEL 1% EYE DROP 1 % $0 (Tier 3) DP
REFRESH LIQUIGEL 1% EYE DROPS 1 % $0 (Tier 3) DP
REFRESH OPTIVE EYE DROPS 0.5-0.9 % $0 (Tier 3) DP
REFRESH OPTIVE SENSITIVE DROPS
30X0.4ML, P/F 0.5-0.9 %
$0 (Tier 3) DP
REFRESH P.M. OINTMENT 57.3-42.5 % $0 (Tier 3) DP
REFRESH PLUS 0.5% EYE DROPS 30X0.4ML
0.5 %
$0 (Tier 3) DP
REFRESH PLUS 0.5% EYE DROPS U-
D,50X.4ML 0.5 %
$0 (Tier 3) DP
REFRESH TEARS 0.5% EYE DROP 0.5 % $0 (Tier 3) DP
RESTASIS MULTIDOSE OPHTHALMIC (EYE)
DROPS 0.05 %
$0 (Tier 2) MO; QL (11 ML per 30 days)
RESTASIS OPHTHALMIC (EYE)
DROPPERETTE 0.05 %
$0 (Tier 2) MO; QL (60 EA per 30 days)
sodium chloride 5% eye drop 5 % $0 (Tier 3) DP
sodium chloride 5% eye oint 5 % $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
124
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % $0 (Tier 3) DP
SYSTANE 0.3-0.4% EYE DROPS U-
D,P/F,0.014X28 VL 0.4-0.3 %
$0 (Tier 3) DP
SYSTANE BALANCE 0.6% EYE DROP 0.6 % $0 (Tier 3) DP
SYSTANE ULTRA 0.4-0.3% EYE DRP 0.4-0.3
%
$0 (Tier 3) DP
TEARS NATURALE FORTE DROPS 0.1-0.3-0.2
%
$0 (Tier 3) DP
TEARS PURE DROPS $0 (Tier 3) DP
XIIDRA OPHTHALMIC (EYE) DROPPERETTE
5 %
$0 (Tier 2) MO; QL (60 EA per 30 days)
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) MO
cromolyn ophthalmic (eye) drops 4 % $0 (Tier 1) MO
epinastine ophthalmic (eye) drops 0.05 % $0 (Tier 1) ST; MO
EYESCRUB CLEANSING PADS $0 (Tier 3) DP
NAPHCON-A EYE DROPS DROPTAINER
0.025-0.3 %
$0 (Tier 3) DP
NAPHCON-A EYE DROPS DROPTAINER,
2X5ML 0.025-0.3 %
$0 (Tier 3) DP
olopatadine ophthalmic (eye) drops 0.1 % $0 (Tier 1) ST; MO
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.1 %
$0 (Tier 2) MO
AZOPT OPHTHALMIC (EYE)
DROPS,SUSPENSION 1 %
$0 (Tier 2) ST; MO
brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % $0 (Tier 1) MO
carteolol ophthalmic (eye) drops 1 % $0 (Tier 1) MO
COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-
0.5 %
$0 (Tier 2) MO
dorzolamide ophthalmic (eye) drops 2 % $0 (Tier 1) MO
dorzolamide-timolol ophthalmic (eye) drops 22.3-
6.8 mg/ml
$0 (Tier 1) MO
levobunolol ophthalmic (eye) drops 0.5 % $0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
125
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
metipranolol ophthalmic (eye) drops 0.3 % $0 (Tier 1) MO
PHOSPHOLINE IODIDE OPHTHALMIC (EYE)
DROPS 0.125 %
$0 (Tier 2) MO
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,
4 %
$0 (Tier 1) MO
SIMBRINZA OPHTHALMIC (EYE)
DROPS,SUSPENSION 1-0.2 %
$0 (Tier 2) MO
timolol maleate ophthalmic (eye) drops 0.25 %,
0.5 %
$0 (Tier 1) MO
timolol maleate ophthalmic (eye) gel forming
solution 0.25 %, 0.5 %
$0 (Tier 1) MO
OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone sodium phosphate ophthalmic
(eye) drops 0.1 %
$0 (Tier 1) MO
diclofenac sodium ophthalmic (eye) drops 0.1 % $0 (Tier 1) MO
DUREZOL OPHTHALMIC (EYE) DROPS 0.05
%
$0 (Tier 2) MO
fluorometholone ophthalmic (eye)
drops,suspension 0.1 %
$0 (Tier 1) MO
flurbiprofen sodium ophthalmic (eye) drops 0.03
%
$0 (Tier 1) MO
FML FORTE OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.25 %
$0 (Tier 2) MO
ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % $0 (Tier 1) MO
prednisolone acetate ophthalmic (eye)
drops,suspension 1 %
$0 (Tier 1) MO
prednisolone sodium phosphate ophthalmic (eye)
drops 1 %
$0 (Tier 1) MO
sulfacetamide-prednisolone ophthalmic (eye)
drops 10 %-0.23 % (0.25 %)
$0 (Tier 1) MO
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
126
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
latanoprost ophthalmic (eye) drops 0.005 % $0 (Tier 1) MO
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01
%
$0 (Tier 2) MO
TRAVATAN Z OPHTHALMIC (EYE) DROPS
0.004 %
$0 (Tier 2) MO
OTIC AGENTS - TREATMENT OF EAR CONDITIONS
OTIC AGENTS
acetic acid-aluminum acetate otic (ear) drops 2 % $0 (Tier 1) MO
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
0.3-0.1 %
$0 (Tier 2) MO
EAR DROPS 6.5% 6.5 % $0 (Tier 3) DP
EAR WAX REMOVAL 6.5% DROP 6.5 % $0 (Tier 3) DP
hydrocortisone-acetic acid otic (ear) drops 1-2 % $0 (Tier 1) MO
neomycin-polymyxin-hc otic (ear)
drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%
$0 (Tier 1) MO
neomycin-polymyxin-hc otic (ear) solution 3.5-
10,000-1 mg/ml-unit/ml-%
$0 (Tier 1) MO
ofloxacin otic (ear) drops 0.3 % $0 (Tier 1) MO
QC EAR WAX REMOVAL 6.5% DROP 6.5 % $0 (Tier 3) DP
RESPIRATORY TRACT AGENTS - TREATMENT OF BREATHING CONDITIONS
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine solution 100 mg/ml (10 %), 200
mg/ml (20 %)
$0 (Tier 1) B/D
ALA-HIST PE TABLET 2-10 MG $0 (Tier 3) DP
ARALAST NP INTRAVENOUS RECON SOLN
1,000 MG, 500 MG
$0 (Tier 2) PA
AYR SALINE 0.65% NOSE DROPS 0.65 % $0 (Tier 3) DP
AYR SALINE NASAL GEL $0 (Tier 3) DP
DEEP SEA 0.65% NOSE SPRAY 0.65 % $0 (Tier 3) DP
GLASSIA INTRAVENOUS SOLUTION 1
GRAM/50 ML (2 %)
$0 (Tier 2) PA
GS CHILD COLD-ALLERGY SOLUTION 1-2.5
MG/5 ML
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
127
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
GS NASAL SPRAY 0.05% 0.05 % $0 (Tier 3) DP
LUMIZYME INTRAVENOUS RECON SOLN 50
MG
$0 (Tier 2) PA
NASAL DECONGESTANT 0.05% SPRAY
12HR, MAXIMUM STR. 0.05 %
$0 (Tier 3) DP
ODACTRA SUBLINGUAL TABLET 12 SQ-
HDM
$0 (Tier 2) PA; MO
PROLASTIN-C INTRAVENOUS RECON SOLN
1,000 MG
$0 (Tier 2) PA
PROLASTIN-C INTRAVENOUS SOLUTION
1,000 MG (+/-)/20 ML
$0 (Tier 2) PA; MO
promethazine vc oral syrup 6.25-5 mg/5 ml $0 (Tier 1) PA; MO
promethazine-phenylephrine oral syrup 6.25-5
mg/5 ml
$0 (Tier 1) PA; MO
SALINE MIST 0.65% NOSE SPRY 0.65 % $0 (Tier 3) DP
ZEMAIRA INTRAVENOUS RECON SOLN
1,000 MG
$0 (Tier 2) PA
RESPIRATORY TRACT/ PULMONARY AGENTS - TREATMENT OF BREATHING
CONDITIONS
ANTIHISTAMINES
azelastine nasal aerosol,spray 137 mcg (0.1 %) $0 (Tier 1) MO
azelastine nasal spray,non-aerosol 0.15 % (205.5
mcg)
$0 (Tier 1) MO
BANOPHEN 12.5 MG/5 ML SOLUTION 12.5
MG/5 ML
$0 (Tier 3) DP
BANOPHEN 25 MG TABLET 25 MG $0 (Tier 3) DP
BANOPHEN ANTI-ITCH 2% CREAM 2-0.1 % $0 (Tier 3) DP
cetirizine hcl 10 mg tablet 10 mg $0 (Tier 3) DP
cetirizine hcl 5 mg tablet indoor/outdoor, 24hr 5
mg
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
128
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CHILD ALL DAY ALLERGY 1 MG/ML
CHILDREN'S 1 MG/ML
$0 (Tier 3) DP
clemastine oral tablet 2.68 mg $0 (Tier 1) PA; MO
cyproheptadine oral syrup 2 mg/5 ml $0 (Tier 1) PA; MO
cyproheptadine oral tablet 4 mg $0 (Tier 1) PA; MO
DIPHEDRYL ALLERGY CAPSULE 25 MG $0 (Tier 3) DP
DIPHENHIST 12.5 MG/5 ML SOLN 12.5 MG/5
ML
$0 (Tier 3) DP
diphenhydramine 25 mg capsule (otc) 25 mg $0 (Tier 3) DP
diphenhydramine 25 mg capsule u-d, 10x10 (otc)
25 mg
$0 (Tier 3) DP
fexofenadine hcl 180 mg tablet 24 hour, non-
drowsy (otc) 180 mg
$0 (Tier 3) DP
fexofenadine hcl 60 mg tablet 12 hour, non-drowsy
(otc) 60 mg
$0 (Tier 3) DP
GS ALLERGY RELIEF 25 MG TABLET 25 MG $0 (Tier 3) DP
levocetirizine oral solution 2.5 mg/5 ml $0 (Tier 1) MO
levocetirizine oral tablet 5 mg $0 (Tier 1) MO
loratadine 10 mg tablet non-drowsy 10 mg $0 (Tier 3) DP
loratadine 5 mg/5 ml soln child's,a/f,s/f,d/f 5 mg/5
ml
$0 (Tier 3) DP
qc chlorpheniramine 4 mg tab 4 mg $0 (Tier 3) DP
QC COMPLETE ALLERGY 25 MG CPLT
CAPLET 25 MG
$0 (Tier 3) DP
Q-DRYL 25 MG CAPSULE 25 MG $0 (Tier 3) DP
SM ALLERGY RELIEF 25 MG TABLET 25 MG $0 (Tier 3) DP
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 200
MCG/ACTUATION
$0 (Tier 2) MO
budesonide inhalation suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
$0 (Tier 1) B/D; MO
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 250
MCG/ACTUATION, 50 MCG/ACTUATION
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
129
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION, 220
MCG/ACTUATION, 44 MCG/ACTUATION
$0 (Tier 2) MO
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
$0 (Tier 1) MO
fluticasone nasal spray,suspension 50
mcg/actuation
$0 (Tier 1) MO
fluticasone-salmeterol inhalation aerosol powdr
breath activated 113-14 mcg/actuation, 232-14
mcg/actuation, 55-14 mcg/actuation
$0 (Tier 1) MO
mometasone nasal spray,non-aerosol 50
mcg/actuation
$0 (Tier 1) MO
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80 MCG/ACTUATION
$0 (Tier 2) MO
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 40
MCG/ACTUATION, 80 MCG/ACTUATION
$0 (Tier 2) MO
ANTILEUKOTRIENES
montelukast oral granules in packet 4 mg $0 (Tier 1) MO
montelukast oral tablet 10 mg $0 (Tier 1) MO
montelukast oral tablet,chewable 4 mg, 5 mg $0 (Tier 1) MO
zafirlukast oral tablet 10 mg, 20 mg $0 (Tier 1) ST; MO
zileuton oral tablet, er multiphase 12 hr 600 mg $0 (Tier 1) PA; MO
ZYFLO ORAL TABLET 600 MG $0 (Tier 2) PA; MO
BRONCHODILATORS, ANTICHOLINERGIC
INCRUSE ELLIPTA INHALATION BLISTER
WITH DEVICE 62.5 MCG/ACTUATION
$0 (Tier 2) MO
ipratropium bromide inhalation solution 0.02 % $0 (Tier 1) B/D; MO
ipratropium bromide nasal spray,non-aerosol 0.03
%, 42 mcg (0.06 %)
$0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
130
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SPIRIVA RESPIMAT INHALATION MIST 1.25
MCG/ACTUATION, 2.5 MCG/ACTUATION
$0 (Tier 2) MO
SPIRIVA WITH HANDIHALER INHALATION
CAPSULE, W/INHALATION DEVICE 18 MCG
$0 (Tier 2) MO
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH ACTIVATED 400
MCG/ACTUATION, 400 MCG/ACTUATION
(30 ACTUAT)
$0 (Tier 2) MO
BRONCHODILATORS, SYMPATHOMIMETICS
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3
ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml
$0 (Tier 1) B/D; MO
albuterol sulfate oral syrup 2 mg/5 ml $0 (Tier 1) MO
albuterol sulfate oral tablet 2 mg, 4 mg $0 (Tier 1) MO
albuterol sulfate oral tablet extended release 12 hr
4 mg, 8 mg
$0 (Tier 1) MO
BROVANA INHALATION SOLUTION FOR
NEBULIZATION 15 MCG/2 ML
$0 (Tier 2) PA; MO
epinephrine injection auto-injector 0.15 mg/0.15
ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml
$0 (Tier 1) MO; QL (2 EA per 30 days)
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
0.3 MG/0.3 ML
$0 (Tier 2) ST; MO; QL (2 EA per 30 days)
EPIPEN INJECTION AUTO-INJECTOR 0.3
MG/0.3 ML
$0 (Tier 2) ST; MO; QL (2 EA per 30 days)
EPIPEN JR 2-PAK INJECTION AUTO-
INJECTOR 0.15 MG/0.3 ML
$0 (Tier 2) ST; MO; QL (2 EA per 30 days)
EPIPEN JR INJECTION AUTO-INJECTOR 0.15
MG/0.3 ML
$0 (Tier 2) ST; MO; QL (2 EA per 30 days)
levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml
$0 (Tier 1) PA; MO
metaproterenol oral syrup 10 mg/5 ml $0 (Tier 1) MO
metaproterenol oral tablet 10 mg, 20 mg $0 (Tier 1) MO
SEREVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/DOSE
$0 (Tier 2) MO
STRIVERDI RESPIMAT INHALATION MIST
2.5 MCG/ACTUATION
$0 (Tier 2) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
131
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
terbutaline oral tablet 2.5 mg, 5 mg $0 (Tier 1) MO
terbutaline subcutaneous solution 1 mg/ml $0 (Tier 1) MO
VENTOLIN HFA INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION
$0 (Tier 2) MO
CYSTIC FIBROSIS AGENTS
KALYDECO ORAL GRANULES IN PACKET
50 MG, 75 MG
$0 (Tier 2) PA
KALYDECO ORAL TABLET 150 MG $0 (Tier 2) PA
ORKAMBI ORAL TABLET 100-125 MG, 200-
125 MG
$0 (Tier 2) PA
PULMOZYME INHALATION SOLUTION 1
MG/ML
$0 (Tier 2) B/D
SYMDEKO ORAL TABLETS, SEQUENTIAL
100-150 MG (D)/ 150 MG (N)
$0 (Tier 2) PA
MAST CELL STABILIZERS
cromolyn inhalation solution for nebulization 20
mg/2 ml
$0 (Tier 1) B/D; MO
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline intravenous solution 250 mg/10 ml,
500 mg/20 ml
$0 (Tier 1) MO
DALIRESP ORAL TABLET 250 MCG, 500
MCG
$0 (Tier 2) MO
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML $0 (Tier 2)
theophylline oral elixir 80 mg/15 ml $0 (Tier 1) MO
theophylline oral solution 80 mg/15 ml $0 (Tier 1) MO
theophylline oral tablet extended release 12 hr 100
mg, 200 mg, 300 mg, 450 mg
$0 (Tier 1) MO
theophylline oral tablet extended release 24 hr 400
mg, 600 mg
$0 (Tier 1) MO
theophylline oral tablet extended release 600 mg $0 (Tier 1) MO
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
132
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
PULMONARY ANTIHYPERTENSIVES
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5
MG, 2 MG, 2.5 MG
$0 (Tier 2) PA
LETAIRIS ORAL TABLET 10 MG, 5 MG $0 (Tier 2) PA
REMODULIN INJECTION SOLUTION 1
MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
$0 (Tier 2) PA
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION 10 MG/ML
$0 (Tier 2) PA
sildenafil (antihypertensive) intravenous solution
10 mg/12.5 ml
$0 (Tier 1) PA
sildenafil (antihypertensive) oral tablet 20 mg $0 (Tier 1) PA
TRACLEER ORAL TABLET 125 MG, 62.5 MG $0 (Tier 2) PA; LA
TRACLEER ORAL TABLET FOR
SUSPENSION 32 MG
$0 (Tier 2) PA
VENTAVIS INHALATION SOLUTION FOR
NEBULIZATION 10 MCG/ML, 20 MCG/ML
$0 (Tier 2) PA
RESPIRATORY TRACT AGENTS, OTHER
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
$0 (Tier 2) MO
ADVAIR HFA INHALATION HFA AEROSOL
INHALER 115-21 MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21 MCG/ACTUATION
$0 (Tier 2) MO
ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE 62.5-25 MCG/ACTUATION
$0 (Tier 2) MO
BREO ELLIPTA INHALATION BLISTER
WITH DEVICE 100-25 MCG/DOSE, 200-25
MCG/DOSE
$0 (Tier 2) MO
DULERA INHALATION HFA AEROSOL
INHALER 100-5 MCG/ACTUATION, 200-5
MCG/ACTUATION
$0 (Tier 2) MO
SYMBICORT INHALATION HFA AEROSOL
INHALER 160-4.5 MCG/ACTUATION, 80-4.5
MCG/ACTUATION
$0 (Tier 2) MO
RESPIRATORY TRACT/ PULMONARY AGENTS
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
133
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
COMBIVENT RESPIMAT INHALATION MIST
20-100 MCG/ACTUATION
$0 (Tier 2) ST; MO
ESBRIET ORAL CAPSULE 267 MG $0 (Tier 2) PA
ESBRIET ORAL TABLET 267 MG, 801 MG $0 (Tier 2) PA
ipratropium-albuterol inhalation solution for
nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml
$0 (Tier 1) B/D; MO
XOLAIR SUBCUTANEOUS RECON SOLN 150
MG
$0 (Tier 2) PA
RESPIRATORY TRACT/ PULMONARY AGENTS, OTHER
cetirizine oral solution 1 mg/ml $0 (Tier 1) MO
STIOLTO RESPIMAT INHALATION MIST 2.5-
2.5 MCG/ACTUATION
$0 (Tier 2) MO
SKELETAL MUSCLE RELAXANTS - TREATMENT OF MUSCLE TIGHTNESS
SKELETAL MUSCLE RELAXANTS
carisoprodol oral tablet 250 mg, 350 mg $0 (Tier 1) PA; MO
chlorzoxazone oral tablet 500 mg $0 (Tier 1) PA; MO
COMFORT PAC-CYCLOBENZAPRINE KIT 10
MG
$0 (Tier 2) PA; MO
cyclobenzaprine oral tablet 10 mg, 5 mg $0 (Tier 1) PA; MO
CYCLOTENS REFILL COMBO PACK 10 MG $0 (Tier 1) PA; MO
CYCLOTENS STARTER COMBO PACK 10
MG
$0 (Tier 1) PA; MO
methocarbamol oral tablet 500 mg, 750 mg $0 (Tier 1) PA; MO
orphenadrine citrate oral tablet extended release
100 mg
$0 (Tier 1) PA; MO
SLEEP DISORDER AGENTS - TREATMENT OF INSOMNIA
GABA RECEPTOR MODULATORS
temazepam oral capsule 15 mg, 30 mg, 7.5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)
zaleplon oral capsule 10 mg, 5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
134
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
zolpidem oral tablet 10 mg, 5 mg $0 (Tier 1) MO; QL (90 EA per 365 days)
SLEEP DISORDERS, OTHER
armodafinil oral tablet 150 mg, 200 mg, 250 mg,
50 mg
$0 (Tier 1) PA; MO
HETLIOZ ORAL CAPSULE 20 MG $0 (Tier 2) PA
melatonin 3 mg tablet 3 mg $0 (Tier 3) DP
melatonin 5 mg tablet s/f, p/f, na/f 5 mg $0 (Tier 3) DP
MODAFINIL ORAL TABLET 100 MG, 200 MG $0 (Tier 1) PA; MO
ROZEREM ORAL TABLET 8 MG $0 (Tier 2) MO; QL (30 EA per 30 days)
XYREM ORAL SOLUTION 500 MG/ML $0 (Tier 2) LA
THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES - REPLACEMENT OR
SUPPLEMENTATION OF MINERALS, NUTRIENTS, AND VITAMINS
ELECTROLYTE/ MINERAL MODIFIERS
EXJADE ORAL TABLET, DISPERSIBLE 125
MG, 250 MG, 500 MG
$0 (Tier 2) PA
FERRIPROX ORAL TABLET 500 MG $0 (Tier 2) PA
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION 5
%
$0 (Tier 2)
JADENU ORAL TABLET 180 MG, 360 MG, 90
MG
$0 (Tier 2) PA
JADENU SPRINKLE ORAL GRANULES IN
PACKET 180 MG, 360 MG, 90 MG
$0 (Tier 2) PA
kionex (with sorbitol) oral suspension 15-19.3
gram/60 ml
$0 (Tier 1) MO
kionex oral powder $0 (Tier 1) MO
SAMSCA ORAL TABLET 15 MG, 30 MG $0 (Tier 2)
sodium polystyrene (sorb free) oral suspension 15
gram/60 ml
$0 (Tier 1) MO
sodium polystyrene sulfonate oral powder $0 (Tier 1) MO
sodium polystyrene sulfonate oral suspension 15
gram/60 ml
$0 (Tier 1) MO
sodium polystyrene sulfonate rectal enema 30
gram/120 ml, 50 gram/200 ml
$0 (Tier 1) MO
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
135
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
sps (with sorbitol) oral suspension 15-20 gram/60
ml
$0 (Tier 1) MO
sps (with sorbitol) rectal enema 30-40 gram/120
ml
$0 (Tier 1) MO
ELECTROLYTE/ MINERAL REPLACEMENT
ALIGN 4 MG CAPSULE 4 MG $0 (Tier 3) DP
AMINO ACIDS 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
$0 (Tier 1) B/D
AMINOSYN 7 % WITH ELECTROLYTES
INTRAVENOUS PARENTERAL SOLUTION 7
%
$0 (Tier 2) B/D
aminosyn 8.5 %-electrolytes intravenous
parenteral solution 8.5 %
$0 (Tier 1) B/D
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
$0 (Tier 2) B/D
AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
$0 (Tier 2) B/D
AMINOSYN II 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
$0 (Tier 2) B/D
aminosyn ii 8.5 %-electrolytes intravenous
parenteral solution 8.5 %
$0 (Tier 1) B/D
AMINOSYN M 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
$0 (Tier 2) B/D
AMINOSYN-HBC 7% INTRAVENOUS
PARENTERAL SOLUTION 7 %
$0 (Tier 2) B/D
AMINOSYN-PF 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
$0 (Tier 2) B/D
AMINOSYN-PF 7 % (SULFITE-FREE)
INTRAVENOUS PARENTERAL SOLUTION 7
%
$0 (Tier 2) B/D
AMINOSYN-RF 5.2 % INTRAVENOUS
PARENTERAL SOLUTION 5.2 %
$0 (Tier 2) B/D
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
136
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
APATATE FORTE LIQUID $0 (Tier 3) DP
AQUADEKS PEDIATRIC LIQUID 400
MCG/ML
$0 (Tier 3) DP
BEELITH TABLET 362-20 MG $0 (Tier 3) DP
CALCIONATE 1.8 GM/5 ML SYRUP 115 MG/5
ML (1.8 GRAM/5 ML)
$0 (Tier 3) DP
CALCITRATE 200 MG (950 MG) TAB 200 MG
(950 MG)
$0 (Tier 3) DP
calcium 500 mg chewable tablet p/f,s/f,gluten-f
500-100 mg-unit
$0 (Tier 3) DP
CALCIUM 600-VIT D3 200 TABLET 600
MG(1,500MG) -200 UNIT
$0 (Tier 3) DP
calcium 600-vit d3 200 tablet p/f, s/f 600
mg(1,500mg) -200 unit
$0 (Tier 3) DP
calcium carb 1,250 mg/5 ml sus 500 mg/5 ml
(1,250 mg/5 ml)
$0 (Tier 3) DP
calcium carb 1,250 mg/5 ml sus s/f, a/f, na/f 500
mg/5 ml (1,250 mg/5 ml)
$0 (Tier 3) DP
CARBAGLU ORAL TABLET, DISPERSIBLE
200 MG
$0 (Tier 2) PA
CENTRUM SPECIALIST HEART TAB 3-200-
400 MG-MCG-MG
$0 (Tier 3) DP
clinisol sf 15 % intravenous parenteral solution 15
%
$0 (Tier 1) B/D
d10 %-0.45 % sodium chloride intravenous
parenteral solution
$0 (Tier 1)
d2.5 %-0.45 % sodium chloride intravenous
parenteral solution
$0 (Tier 1)
d5 % and 0.9 % sodium chloride intravenous
parenteral solution
$0 (Tier 1)
d5 %-0.45 % sodium chloride intravenous
parenteral solution
$0 (Tier 1)
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
$0 (Tier 1)
dextrose 10 % in water (d10w) intravenous
parenteral solution 10 %
$0 (Tier 1)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
137
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
dextrose 5 % in water (d5w) intravenous
parenteral solution
$0 (Tier 1)
dextrose 5 % in water (d5w) intravenous
piggyback 5 %
$0 (Tier 1)
dextrose 5 %-lactated ringers intravenous
parenteral solution
$0 (Tier 1) MO
dextrose 5%-0.2 % sod chloride intravenous
parenteral solution
$0 (Tier 1)
dextrose 5%-0.3 % sod.chloride intravenous
parenteral solution
$0 (Tier 1)
DEXTROSE WITH SODIUM CHLORIDE
INTRAVENOUS PARENTERAL SOLUTION 5-
0.2 %
$0 (Tier 1)
DUOFER 28 MG TABLET 28 MG $0 (Tier 3) DP
EZFE 200 CAPSULE 200 MG IRON $0 (Tier 3) DP
FERAHEME 510 MG/17 ML VIAL SDV, P/F
510 MG/17 ML (30 MG/ML)
$0 (Tier 3) DP
FERAHEME 510 MG/17 ML VIAL SDV, P/F,
10'S 510 MG/17 ML (30 MG/ML)
$0 (Tier 3) DP
FERATE 27 MG TABLET 240 MG (27 MG
IRON)
$0 (Tier 3) DP
FERGON 27 MG TABLET 240 MG (27 MG
IRON)
$0 (Tier 3) DP
FEROSUL 325 MG TABLET F/C 325 MG (65
MG IRON)
$0 (Tier 3) DP
FEROSUL 325 MG TABLET F/C,BLISTER
PACK 325 MG (65 MG IRON)
$0 (Tier 3) DP
FERRETTS 325 MG TABLET 325 MG (106 MG
IRON)
$0 (Tier 3) DP
FERRETTS IPS LIQUID 40 MG/15 ML $0 (Tier 3) DP
FERREX 150 CAPSULE 150 MG IRON $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
138
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
FERREX 150 CAPSULE INNER, U-D 150 MG
IRON
$0 (Tier 3) DP
FERREX 150 CAPSULE OUTER, U-D 150 MG
IRON
$0 (Tier 3) DP
FERREX 150 CAPSULE U-D,10X10 150 MG
IRON
$0 (Tier 3) DP
FERRIMIN 150 TAB 456 MG (150 MG IRON) $0 (Tier 3) DP
FERRLECIT 62.5 MG/5 ML VIAL 10'S,SUV,NO
LATEX 62.5 MG/5 ML
$0 (Tier 3) DP
FERRO-TIME 325 MG TABLET F/C, GREEN
325 MG (65 MG IRON)
$0 (Tier 3) DP
FERRO-TIME 325 MG TABLET F/C, RED 325
MG (65 MG IRON)
$0 (Tier 3) DP
ferrous fumarate 324 mg tab 324 mg (106 mg
iron)
$0 (Tier 3) DP
ferrous gluconate 324 mg tab 324 mg (38 mg iron) $0 (Tier 3) DP
ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5
ml
$0 (Tier 3) DP
ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) $0 (Tier 3) DP
ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) $0 (Tier 3) DP
ferrous sulf ec 325 mg tablet u-d, inner 325 mg (65
mg iron)
$0 (Tier 3) DP
ferrous sulf ec 325 mg tablet u-d, outer 325 mg (65
mg iron)
$0 (Tier 3) DP
ferrous sulfate 325 mg tablet 325 mg (65 mg iron) $0 (Tier 3) DP
ferrous sulfate 325 mg tablet f/c 325 mg (65 mg
iron)
$0 (Tier 3) DP
ferrous sulfate 325 mg tablet f/c, 4x25,outer 325
mg (65 mg iron)
$0 (Tier 3) DP
ferrous sulfate 325 mg tablet f/c, green 325 mg (65
mg iron)
$0 (Tier 3) DP
ferrous sulfate 325 mg tablet f/c, red 325 mg (65
mg iron)
$0 (Tier 3) DP
ferrous sulfate 325 mg tablet inner,f/c 325 mg (65
mg iron)
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
139
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ferrous sulfate 325 mg tablet u-d,10x10, film coat
325 mg (65 mg iron)
$0 (Tier 3) DP
FERROUSUL 325 MG TABLET 325 MG (65
MG IRON)
$0 (Tier 3) DP
FISH OIL 1,000 MG CAPSULE 340-1,000 MG $0 (Tier 3) DP
fish oil 1,000 mg softgel softgel 300-1,000 mg $0 (Tier 3) DP
FLORANEX GRANULES PACKET
LACTOBACILLUS,OUTER 100 MILLION
CELL
$0 (Tier 3) DP
FLUORIDE (SODIUM) ORAL TABLET 1 MG
(2.2 MG SOD. FLUORIDE)
$0 (Tier 1) MO
fluoride (sodium) oral tablet,chewable 0.5 mg (1.1
mg sodium fluorid)
$0 (Tier 1) MO
FOLITAB 500 CAPLET (OTC) 105 MG IRON-
500 MG-800 MCG
$0 (Tier 3) DP
glucosamine 500 mg capsule capsule 500 mg $0 (Tier 3) DP
glucosamine-chondroit cplt caplet,dbl str,s/f 500-
400 mg
$0 (Tier 3) DP
glucosamine-chondroitin cplt caplet, dbl strength
500-400 mg
$0 (Tier 3) DP
HEMOCYTE TABLET 324 MG (106 MG IRON) $0 (Tier 3) DP
HM SLOW RELEASE IRON TABLET 143 MG
(45 MG IRON)
$0 (Tier 3) DP
ICAPS MV TABLET 100-1.66-0.83 MCG-MG-
MG
$0 (Tier 3) DP
ICAPS TABLET 3,300-5-200-75 UNIT-MG-MG-
UNIT
$0 (Tier 3) DP
IFEREX 150 CAPSULE 150 MG IRON $0 (Tier 3) DP
INFED 100 MG/2 ML VIAL
10S,OUTER,L/F,SDV 50 MG/ML
$0 (Tier 3) DP
INFUVITE ADULT BULK VIAL P/F,L/F, MUV
3,300 UNIT- 150 MCG/10 ML
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
140
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
INFUVITE ADULT VIAL 2X5ML, L/F, SUV
3,300 UNIT- 150 MCG/10 ML
$0 (Tier 3) DP
INJECTAFER 750 MG/15 ML VIAL 50 IRON
MG/ML
$0 (Tier 3) DP
iron 27 mg tablet 236 mg (27 mg iron) $0 (Tier 3) DP
IRON 325 MG TABLET 325 MG (65 MG IRON) $0 (Tier 3) DP
IRON 65 MG TABLET 325 MG (65 MG IRON) $0 (Tier 3) DP
IRON TABLET COATED 325 MG (65 MG
IRON)
$0 (Tier 3) DP
klor-con 10 oral tablet extended release 10 meq $0 (Tier 1) MO
klor-con 8 oral tablet extended release 8 meq $0 (Tier 1) MO
klor-con m10 oral tablet,er particles/crystals 10
meq
$0 (Tier 1) MO
KLOR-CON M15 ORAL TABLET,ER
PARTICLES/CRYSTALS 15 MEQ
$0 (Tier 2) MO
klor-con m20 oral tablet,er particles/crystals 20
meq
$0 (Tier 1) MO
KLOR-CON SPRINKLE ORAL CAPSULE,
EXTENDED RELEASE 10 MEQ, 8 MEQ
$0 (Tier 2) MO
K-SOL ORAL LIQUID 20 MEQ/15 ML, 40
MEQ/15 ML
$0 (Tier 1) MO
M.V.I.-12 VIAL MDV,LATEX-FREE,OUTER
3,300 UNIT-200 UNIT/10 ML
$0 (Tier 3) DP
magnesium 250 mg tablet 250 mg $0 (Tier 3) DP
magnesium oxide 400 mg tablet 400 mg $0 (Tier 3) DP
magnesium oxide 400 mg tablet u-d 400 mg $0 (Tier 3) DP
magnesium oxide 500 mg tablet p/f,s/f,lactose-free
500 mg
$0 (Tier 3) DP
magnesium sulfate injection solution 4 meq/ml (50
%)
$0 (Tier 1)
MYKIDZ IRON SUSPENSION A/F, D/F 10-
1,500-400 MG -UNIT-UNIT/2 ML
$0 (Tier 3) DP
normosol-r intravenous parenteral solution $0 (Tier 1)
normosol-r ph 7.4 intravenous parenteral solution $0 (Tier 1)
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
141
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
NOVAFERRUM 125 LIQUID RASPBERRY
GRAPE, S/F 125 MG IRON- 100 UNIT/5 ML
$0 (Tier 3) DP
NOVAFERRUM 15 MG/ML DROPS
PEDIATRIC, S/F,A/F 15 MG IRON/ML
$0 (Tier 3) DP
NOVAFERRUM 50 MG CAPSULE 50 MG
IRON
$0 (Tier 3) DP
ONE DAILY TABLET 0.4-600 MG-MCG $0 (Tier 3) DP
PHOS-NAK PACKET OUTER 280-160-250 MG $0 (Tier 3) DP
PLENAMINE INTRAVENOUS PARENTERAL
SOLUTION 15 %
$0 (Tier 1) B/D
POLY-IRON 150 MG CAPSULE 150 MG IRON $0 (Tier 3) DP
potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l
$0 (Tier 1) MO
potassium chloride in water intravenous
piggyback 20 meq/50 ml, 40 meq/100 ml
$0 (Tier 1) MO
potassium chloride oral capsule, extended release
10 meq, 8 meq
$0 (Tier 1) MO
potassium chloride oral liquid 20 meq/15 ml, 40
meq/15 ml
$0 (Tier 1) MO
potassium chloride oral tablet extended release 10
meq, 20 meq, 8 meq
$0 (Tier 1) MO
potassium chloride oral tablet,er particles/crystals
10 meq, 20 meq
$0 (Tier 1) MO
PRESERVISION LUTEIN SOFTGEL SOFTGEL
226 MG-200 UNIT -5 MG-0.8 MG
$0 (Tier 3) DP
PRESERVISION LUTEIN SOFTGEL
W/LUTEIN, SOFTGEL 226 MG-200 UNIT -5
MG-0.8 MG
$0 (Tier 3) DP
PRO FE 180 MG CAPSULE 180 MG IRON $0 (Tier 3) DP
RA FISH OIL 120-180 SOFTGEL
SOFTGEL,NATURAL,P/F 120-180 MG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
142
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SEA-OMEGA 1,000 MG SOFTGEL 200 MG-300
MG- 100 MG-1,000 MG
$0 (Tier 3) DP
SEA-OMEGA 30 CAPSULE P/F,S/F,GLUTEN
FREE 360-1,200 MG
$0 (Tier 3) DP
SLOW FE 142 MG TABLET 142 MG (45 MG
IRON)
$0 (Tier 3) DP
sod fer gluc cplx 62.5 mg/5 ml 10's, sdv, outer 62.5
mg/5 ml
$0 (Tier 3) DP
sod fer gluc cplx 62.5 mg/5 ml 10's,sdv,outer 62.5
mg/5 ml
$0 (Tier 3) DP
sod fer gluc cplx 62.5 mg/5 ml sdv, inner 62.5
mg/5 ml
$0 (Tier 3) DP
sod fer gluc cplx 62.5 mg/5 ml sdv,inner 62.5 mg/5
ml
$0 (Tier 3) DP
sodium chloride 0.45 % intravenous parenteral
solution 0.45 %
$0 (Tier 1) MO
sodium chloride 0.9 % injection solution $0 (Tier 1) MO
sodium chloride 0.9 % intravenous parenteral
solution
$0 (Tier 1) MO
sodium chloride 0.9 % intravenous piggyback $0 (Tier 1) MO
sodium chloride 1,000 mg tab 1,000 mg $0 (Tier 3) DP
sodium chloride 3 % intravenous parenteral
solution 3 %
$0 (Tier 1) MO
sodium chloride intravenous parenteral solution
2.5 meq/ml
$0 (Tier 1) B/D; MO
sodium chloride irrigation solution 0.9 % $0 (Tier 1) MO
STRESS FORMULA TABLET $0 (Tier 3) DP
STRESS FORMULA WITH ZINC TAB $0 (Tier 3) DP
STRESS FORMULA-ZINC TABLET $0 (Tier 3) DP
TANDEM DUAL ACTION CAPSULE 162-115.2
(106) MG
$0 (Tier 3) DP
THERA-M CAPLET $0 (Tier 3) DP
VENOFER 200 MG/10 ML VIAL 200 MG
IRON/10 ML
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
143
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VENOFER 50 MG/2.5 ML VIAL 10'S,SDV,P/F
50 MG IRON/2.5 ML
$0 (Tier 3) DP
VENOFER 50 MG/2.5 ML VIAL 25'S,SUV,P/F
50 MG IRON/2.5 ML
$0 (Tier 3) DP
VITAMIN D3 2,000 UNIT SOFTGEL 2,000
UNIT
$0 (Tier 3) DP
VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL
2,000 UNIT
$0 (Tier 3) DP
VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL,
SUPER STR 2,000 UNIT
$0 (Tier 3) DP
V-R FATIGUE REL COMPLEX CPL 150-125-75
MG
$0 (Tier 3) DP
WEE CARE 15 MG/1.25 ML SUSP 15 MG/1.25
ML
$0 (Tier 3) DP
zinc 50 mg capsule (otc) 220 (50) mg $0 (Tier 3) DP
zinc gluconate 50 mg tablet 50 mg $0 (Tier 3) DP
zinc sulfate 220 mg tablet 220 mg $0 (Tier 3) DP
THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES
AQUASOL E 50 UNIT/ML DROPS 50 UNIT/ML $0 (Tier 3) DP
b-complex plus vitamin c cplt caplet $0 (Tier 3) DP
biotin 5 mg capsule p/f, gluten/f 5 mg $0 (Tier 3) DP
biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP
biotin 5,000 mcg capsule mx-str 5 mg $0 (Tier 3) DP
biotin 5,000 mcg capsule s/f 5 mg $0 (Tier 3) DP
biotin 5,000 mcg capsule s/f, p/f,gluten-free 5 mg $0 (Tier 3) DP
biotin 5,000 mcg softgel s/f, p/f,gluten-free 5 mg $0 (Tier 3) DP
biotin 5,000 mcg softgel softgel, s/f 5 mg $0 (Tier 3) DP
CALCI-CHEW TABLET 500 MG CALCIUM
(1,250 MG)
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
144
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CALCITRATE + VIT D CAPLET 315-250 MG-
UNIT
$0 (Tier 3) DP
calcium 500+d tablet chew 500 mg(1,250mg) -400
unit
$0 (Tier 3) DP
calcium 500-vit d3 200 tablet 500 mg(1,250mg) -
200 unit
$0 (Tier 3) DP
calcium 600 mg tablet 600 mg calcium (1,500 mg) $0 (Tier 3) DP
CALCIUM 600 MG TABLET 600 MG
CALCIUM (1,500 MG)
$0 (Tier 3) DP
CALCIUM 600 MG TABLET 600MG
ELEMENTAL 600 MG CALCIUM (1,500 MG)
$0 (Tier 3) DP
CALCIUM 600 MG TABLET P/F 600 MG
CALCIUM (1,500 MG)
$0 (Tier 3) DP
calcium 600-vit d3 400 tablet 600 mg(1,500mg) -
400 unit
$0 (Tier 3) DP
CALCIUM 600-VIT D3 400 TABLET 600
MG(1,500MG) -400 UNIT
$0 (Tier 3) DP
CALCIUM 600-VIT D3 400 TABLET S/F 600
MG(1,500MG) -400 UNIT
$0 (Tier 3) DP
calcium carb 500 (1,250) mg tb 500 mg calcium
(1,250 mg)
$0 (Tier 3) DP
calcium carbonate 648 mg tab 260 mg calcium
(648 mg)
$0 (Tier 3) DP
calcium citrate - vit d caplet 315-250 mg-unit $0 (Tier 3) DP
calcium citrate - vit d caplet p/f, caplet 315-250
mg-unit
$0 (Tier 3) DP
CALTRATE 600 PLUS D3 TABLET 600
MG(1,500MG) -800 UNIT
$0 (Tier 3) DP
CENTRUM COMPLETE MULTIVIT TAB 18-
400 MG-MCG
$0 (Tier 3) DP
CENTRUM SILVER ULTRA WOMEN TAB $0 (Tier 3) DP
CENTRUM SPECIALIST ENERGY TAB 18 MG
IRON-400 MCG-25 MCG-75MG
$0 (Tier 3) DP
CENTRUM ULTRA WOMEN'S TABLET 18-
400 MG-MCG
$0 (Tier 3) DP
CENTURY ADVANCED FORMULA TABS $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
145
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CENTURY ENERGY TABLET 18 MG IRON-
400 MCG-50 MG
$0 (Tier 3) DP
CENTURY ULTIMATE MEN'S TABLET 300-
600-300 MCG
$0 (Tier 3) DP
CERTAVITE-ANTIOXIDANT TABLET 18-400
MG-MCG
$0 (Tier 3) DP
CHILD CHEW + IRON TAB CHEW $0 (Tier 3) DP
CHILD VITAMIN-IRON TAB CHEW $0 (Tier 3) DP
CITRUS CALCIUM + D TABLET 315-250 MG-
UNIT
$0 (Tier 3) DP
CITRUS CALCIUM 200-VIT D3 250 200 MG
CALCIUM -250 UNIT
$0 (Tier 3) DP
clinimix 4.25%/d10w sulf free intravenous
parenteral solution 4.25 %
$0 (Tier 1) B/D
clinimix 4.25%-d20w sulf-free intravenous
parenteral solution 4.25 %
$0 (Tier 1) B/D
clinimix 4.25%-d25w sulf-free intravenous
parenteral solution 4.25 %
$0 (Tier 1) B/D
clinimix n14g30e 4.25%-d15w sf intravenous
parenteral solution 4.25-15 %
$0 (Tier 1) B/D; MO
clinimix n9g15e 2.75%-d7.5w sf intravenous
parenteral solution 2.75-7.5 %
$0 (Tier 1) B/D; MO
cvs biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP
ELITE-OB ORAL TABLET 50 MG IRON- 1.25
MG
$0 (Tier 2) MO
folic acid 0.4 mg tablet 400 mcg $0 (Tier 3) DP
folic acid 0.8 mg tablet 800 mcg $0 (Tier 3) DP
folic acid 400 mcg tablet 400 mcg $0 (Tier 3) DP
folic acid 400 mcg tablet s/f,p/f,lactose-free 400
mcg
$0 (Tier 3) DP
gnp biotin 5,000 mcg capsule 5 mg $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
146
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
hi potency b-comp-c caplet caplet $0 (Tier 3) DP
ICAPS PLUS TABLET LACTOSE FREE $0 (Tier 3) DP
INTEGRA CAPSULE 125-40-3 MG $0 (Tier 3) DP
intralipid intravenous emulsion 20 % $0 (Tier 1) B/D
IRON 100 PLUS TABLET 100-250-25-1 MG-
MG-MCG-MG
$0 (Tier 3) DP
IRON 45 MG TABLET 159 MG (45 MG IRON) $0 (Tier 3) DP
lactated ringers intravenous parenteral solution $0 (Tier 1)
L-CARNITINE 250 MG CAPSULE 250 MG $0 (Tier 3) DP
levocarnitine (with sugar) oral solution 100 mg/ml $0 (Tier 1)
levocarnitine oral tablet 330 mg $0 (Tier 1)
MAG-G 500 MG TABLET 27 MG (500 MG) $0 (Tier 3) DP
MEGA MULTI FOR MEN TABLET HIGH
POTENCY 200-175-250 MCG
$0 (Tier 3) DP
MEGA MULTIVIT FOR MEN CAPLET
CAPLET 200-175-250 MCG
$0 (Tier 3) DP
MULTI-DELYN LIQUID S/F,A/F $0 (Tier 3) DP
OCUVITE LUTEIN & ZEAXANTHIN CP 60
MG-30 UNIT- 15 MG-2 MG-6 MG
$0 (Tier 3) DP
ONE DAILY ESSENTIAL TABLET 400 MCG $0 (Tier 3) DP
ONE DAILY MAXIMUM TABLET 18-0.4 MG $0 (Tier 3) DP
ONE DAILY MEN'S 50+ TABLET 400-600-120
MCG-MCG-MG
$0 (Tier 3) DP
ONE DAILY PLUS IRON TABLET 18-400 MG-
MCG
$0 (Tier 3) DP
ONE DAILY WOMEN'S HEALTH TAB 18 MG
IRON-400 MCG-450 MG CA
$0 (Tier 3) DP
ONE DAILY WOMEN'S TABLET 27-0.4 MG $0 (Tier 3) DP
OS-CAL 500-VIT D3 200 CAPLET CAPLET 500
MG(1,250MG) -200 UNIT
$0 (Tier 3) DP
OYSCO 500-VIT D3 200 TABLET 500
MG(1,250MG) -200 UNIT
$0 (Tier 3) DP
OYSCO-500 TABLET 500 MG CALCIUM
(1,250 MG)
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
147
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
OYSTER SHELL 500-VIT D3 200 TB 500
MG(1,250MG) -200 UNIT
$0 (Tier 3) DP
OYSTER SHELL CALCIUM 500 MG TB
500MG ELEMENTAL CA 500 MG CALCIUM
(1,250 MG)
$0 (Tier 3) DP
OYSTER SHELL CALCIUM 500 MG TB
500MG ELEMTL,NATURAL 500 MG
CALCIUM (1,250 MG)
$0 (Tier 3) DP
OYSTER SHELL CALCIUM-VIT D TAB 500
MG(1,250MG) -400 UNIT
$0 (Tier 3) DP
OYSTER SHELL CALCIUM-VIT D TAB
CAPLET 500 MG(1,250MG) -400 UNIT
$0 (Tier 3) DP
pantothenic acid 500 mg tabs 500 mg $0 (Tier 3) DP
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
$0 (Tier 1) MO
PRENATAL VITAMIN PLUS LOW IRON
ORAL TABLET 27 MG IRON- 1 MG
$0 (Tier 2) MO
PRESERVISION AREDS SOFTGEL 14,320-226-
200 UNIT-MG-UNIT
$0 (Tier 3) DP
qc calcium 600-vit d3 400 tab high potency 600
mg(1,500mg) -400 unit
$0 (Tier 3) DP
RISACAL-D TABLET 105-120 MG-UNIT $0 (Tier 3) DP
RISANOID PLUS TABLET 200-100 MG $0 (Tier 3) DP
selenium dr 200 mcg tablet 200 mcg $0 (Tier 3) DP
SENTRY MULTIVIT & MINERAL CPLT 18-
500-300-250 MG-MCG-MCG-MCG
$0 (Tier 3) DP
SENTRY SENIOR MULTIVIT CAPLET
CAPLET 500-300-250 MCG
$0 (Tier 3) DP
SM CALCIUM 500-VIT D3 400 TAB 500
MG(1,250MG) -400 UNIT
$0 (Tier 3) DP
SM COMPLETE MULTI-VIT-MINERAL
ADVANCED FORMULA 18-400 MG-MCG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
148
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
SM GLUCOSAMINE-CHONDR-MSM CPLT
CAPLET, TRIPLE STR 750-625-30 MG
$0 (Tier 3) DP
sv biotin 5,000 mcg softgel softgel, s/f 5 mg $0 (Tier 3) DP
THERA M PLUS TABLET 9 MG IRON-400
MCG
$0 (Tier 3) DP
THERA-M CAPLET CAPLET 27-0.4 MG $0 (Tier 3) DP
THERA-M CAPLET CAPLET,U-D,10X10 27-0.4
MG
$0 (Tier 3) DP
THERA-M TABLET W/BETA CAROTENE 9
MG IRON-400 MCG
$0 (Tier 3) DP
THERAPEUTIC-M CAPLET 27-0.4 MG $0 (Tier 3) DP
THERAPEUTIC-M CAPLET P/F, S/F, CAPLET
9 MG IRON-400 MCG
$0 (Tier 3) DP
THEREMS-M TABLET 27-0.4 MG $0 (Tier 3) DP
VENOFER 100 MG/5 ML VIAL 10'S,SDV,P/F
100 MG IRON/5 ML
$0 (Tier 3) DP
VENOFER 100 MG/5 ML VIAL 25'S,SDV,P/F
100 MG IRON/5 ML
$0 (Tier 3) DP
VITAMIN AND MINERALS TABLET $0 (Tier 3) DP
ZINC 15 MG LOZENGES NATURAL 15 MG $0 (Tier 3) DP
ZOO FRIENDS ORIGINAL TAB CHEW 300
MCG
$0 (Tier 3) DP
VITAMINS
ANIMAL CHEWS TABLET $0 (Tier 3) DP
ANIMAL SHAPES TABLET CHEW
CHILDREN'S
$0 (Tier 3) DP
ANTIOXIDANT VITAMIN TABLET $0 (Tier 3) DP
APATATE LIQUID $0 (Tier 3) DP
AQUADEKS CHEWABLE TABLET 100-350-5
MCG-MCG-MG
$0 (Tier 3) DP
AQUASOL A 50,000 UNITS/ML VIAL SDV,
LATEX-FREE 50,000 UNIT/ML
$0 (Tier 3) DP
ascorbic acid 500 mg tablet 500 mg $0 (Tier 3) DP
BALANCED B-100 TABLET 100 MG $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
149
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
BALANCED B-50 TABLET $0 (Tier 3) DP
B-COMPLEX WITH B12 TABLET $0 (Tier 3) DP
beta carotene 10,000 units cap 10,000 unit $0 (Tier 3) DP
biotin 300 mcg tablet 300 mcg $0 (Tier 3) DP
biotin 300 mcg tablet p/f,na/f,s/f 300 mcg $0 (Tier 3) DP
biotin 300 mcg tablet s/f,p/f,lactose-free 300 mcg $0 (Tier 3) DP
biotin 800 mcg tablet 800 mcg $0 (Tier 3) DP
CALCIFEROL 8,000 UNIT/ML DROPS 8,000
UNIT/ML
$0 (Tier 3) DP
CALCIUM 250+D TABLET OYSTER SHELL
250-125 MG-UNIT
$0 (Tier 3) DP
calcium 250-vit d3 125 tablet 250-125 mg-unit $0 (Tier 3) DP
calcium gluconate 500 mg tab 45 mg (500 mg) $0 (Tier 3) DP
CALTRATE 600 + D SOFT CHEW TAB
CHOCOLATE TRUFFLE 600 MG (1,500 MG)-
800 UNIT
$0 (Tier 3) DP
CALTRATE 600 + D SOFT CHEW TAB
VANILLA CREME 600 MG (1,500 MG)-800
UNIT
$0 (Tier 3) DP
CALTRATE 600+D PLUS TAB CHEW 600 MG
CALCIUM- 800 UNIT-40 MG
$0 (Tier 3) DP
CALTRATE 600+D PLUS TABLET 600 MG
CALCIUM- 800 UNIT-50 MG
$0 (Tier 3) DP
CARDIAMIN MULTIVITAMIN SOFTGEL 200
MCG-500 UNIT-200 MG
$0 (Tier 3) DP
CENTAMIN LIQUID 9 MG IRON/15 ML $0 (Tier 3) DP
CENTRAL-VITE TABLET VALU-SIZE $0 (Tier 3) DP
CENTRUM CHEWABLE TABLET 3,500-18-0.4
UNIT-MG-MG
$0 (Tier 3) DP
CENTRUM KIDS CHEW TAB TAB CHEW 18
MG IRON
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
150
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
CENTRUM MULTIVITAMIN TAB CHEW
3,500-18-0.4 UNIT-MG-MG
$0 (Tier 3) DP
CENTRUM MULTIVIT-MINERAL LIQ 9 MG
IRON/15 ML
$0 (Tier 3) DP
CENTRUM SILVER CHEWABLE TABLET
400-250 MCG
$0 (Tier 3) DP
CENTRUM SILVER TABLET ADULT 50+ 0.4-
300-250 MG-MCG-MCG
$0 (Tier 3) DP
CENTRUM SILVER TABLET ADULTS 50 +
0.4-300-250 MG-MCG-MCG
$0 (Tier 3) DP
CENTRUM SILVER TABLET FOR ADULT 50+
0.4-300-250 MG-MCG-MCG
$0 (Tier 3) DP
CENTRUM SILVER ULTRA MEN'S TAB FOR
MEN 50+ 300-600-300 MCG
$0 (Tier 3) DP
CENTRUM SPECIALIST VISION TAB 100-5-1
MCG-MG-MG
$0 (Tier 3) DP
CENTURY MATURE TABLET $0 (Tier 3) DP
CEROVITE LIQUID 9 MG IRON/15 ML $0 (Tier 3) DP
CERTA PLUS TABLET 18-0.4-250 MG-MG-
MCG
$0 (Tier 3) DP
CERTAVITE SR-ANTIOXIDANT TAB 0.4-300-
250 MG-MCG-MCG
$0 (Tier 3) DP
CERTAVITE-ANTIOXIDANT LIQUID 9 MG
IRON/15 ML
$0 (Tier 3) DP
CHILD CHEW VITAMIN TABLET $0 (Tier 3) DP
child ferrous sulfate 15 mg/ml 15 mg iron (75
mg)/ml
$0 (Tier 3) DP
CHILDRENS CHEW VITAMIN TAB $0 (Tier 3) DP
CHILDREN'S CHEWABLES 15 MG $0 (Tier 3) DP
CHILDREN'S CHEWABLES 300 MCG $0 (Tier 3) DP
CHILDREN'S CHEWABLES 300 MCG $0 (Tier 3) DP
CHILDREN'S CHEWABLES 9-200 MG IRON-
MCG
$0 (Tier 3) DP
coenzyme q-10 100 mg softgel s/f,p/f,na/f 100 mg $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
151
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
coenzyme q-10 100 mg softgel softgel,l/f,s/f,p/f 100
mg
$0 (Tier 3) DP
COMPETE TABLET $0 (Tier 3) DP
COMPLETE MULTIVITAMIN TAB $0 (Tier 3) DP
COMPLETE SENIOR TABLET $0 (Tier 3) DP
cyanocobalamin 1,000 mcg/ml 25's, latex-free,suv
1,000 mcg/ml
$0 (Tier 3) DP
cyanocobalamin 1,000 mcg/ml 25's, mdv 1,000
mcg/ml
$0 (Tier 3) DP
cyanocobalamin 1,000 mcg/ml mdv,5's 1,000
mcg/ml
$0 (Tier 3) DP
CYTO B-2 POWDER 343 MG/GRAM $0 (Tier 3) DP
DAILY VITAMIN + IRON TABLET $0 (Tier 3) DP
DAILY VITAMIN FORMULA TABLET $0 (Tier 3) DP
DAILY VITAMIN FORMULA TABLET $0 (Tier 3) DP
DAILY VITAMIN TABLET P/F,NA/F $0 (Tier 3) DP
DECARA 25,000 UNIT VEGICAP 25,000 UNIT $0 (Tier 3) DP
DECARA 50,000 UNIT SOFTGEL 50,000 UNIT $0 (Tier 3) DP
DIALYVITE 800 TABLET 0.8 MG $0 (Tier 3) DP
DIALYVITE 800-ULTRA D TABLET 0.8-2,000
MG-UNIT
$0 (Tier 3) DP
DIALYVITE 800-ZINC 15 MG TAB 0.8-15 MG $0 (Tier 3) DP
DIALYVITE 800-ZINC 50 MG TAB 0.8-50 MG $0 (Tier 3) DP
DIALYVITE VIT D3 50,000 UNIT 50,000 UNIT $0 (Tier 3) DP
DIALYVITE VITAMIN D 5,000 UNIT 5,000
UNIT
$0 (Tier 3) DP
D-VI-SOL 400 UNITS/ML DROP 400 UNIT/ML $0 (Tier 3) DP
D-VITA 400 UNIT/ML DROP 400 UNIT/ML $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
152
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
ECEE PLUS TABLET 200-100-10-18 UNIT-MG-
MG-MG
$0 (Tier 3) DP
ELDERTONIC ELIXIR 0.5-0.6-7-0.7 MG $0 (Tier 3) DP
ergocalciferol 8,000 units/ml 8,000 unit/ml $0 (Tier 3) DP
FER-IN-SOL 15 MG/ML DROPS 15 MG IRON
(75 MG)/ML
$0 (Tier 3) DP
FEROSUL 220 MG/5 ML ELIXIR 220 MG (44
MG IRON)/5 ML
$0 (Tier 3) DP
ferrous gluconate 324 mg tab 324 mg (37.5 mg
iron)
$0 (Tier 3) DP
ferrous sulf 15 mg iron/ml drp 15 mg iron (75
mg)/ml
$0 (Tier 3) DP
ferrous sulf 15 mg iron/ml drp gluten-free 15 mg
iron (75 mg)/ml
$0 (Tier 3) DP
ferrous sulf 220 mg/5 ml elix 220 mg (44 mg
iron)/5 ml
$0 (Tier 3) DP
ferrous sulf 220 mg/5 ml liq 220 mg (44 mg iron)/5
ml
$0 (Tier 3) DP
ferrous sulfate er 140 mg tab
2x15,f/c,140mg(45mg) 140 mg (45 mg iron)
$0 (Tier 3) DP
ferrous sulfate er 140 mg tab
4x15,f/c,140mg(45mg) 140 mg (45 mg iron)
$0 (Tier 3) DP
FOLGARD TABLET 2,000-800-0.32 UNIT-
MCG-MG
$0 (Tier 3) DP
folic acid 1 mg tablet (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet 10x10, u-d, inner (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet 10x10, u-d, outer (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet inner,u-d,robot-rdy (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet outer,u-d,robot-rdy (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet u-d,inner,10x10 (rx) 1 mg $0 (Tier 3) DP
folic acid 1 mg tablet u-d,outer,10x10 (rx) 1 mg $0 (Tier 3) DP
folic acid 5 mg/ml vial latex-free, mdv 5 mg/ml $0 (Tier 3) DP
GERIATON LIQUID $0 (Tier 3) DP
HEALTHY EYES CAPLET CAPLET 1,000
UNIT-200 MG-60 UNIT-2 MG
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
153
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
HEALTHY EYES TABLET ADVANCED
ANTIOXIDANT 1,000 UNIT-200 MG-60 UNIT-
2 MG
$0 (Tier 3) DP
hydroxocobalamin 1,000 mcg/ml 1,000 mcg/ml $0 (Tier 3) DP
I.L.X. B-12 ELIXIR 102 MG IRON-10 MCG-98
MG/15 ML
$0 (Tier 3) DP
ICAPS AREDS FORMULA DR TABLET 7,160-
113-100 UNIT-MG-UNIT
$0 (Tier 3) DP
ICAPS AREDS SOFTGEL LACTOSE-FREE
14,320-226-200 UNIT-MG-UNIT
$0 (Tier 3) DP
ICAPS AREDS SOFTGEL SOFTGEL, L/F
14,320-226-200 UNIT-MG-UNIT
$0 (Tier 3) DP
I-CAPS WITH LUTEIN-OMEGA 3 SFG 280-10-
2 MG
$0 (Tier 3) DP
INFUVITE PEDIATRIC BULK VIAL SUV 80
MG-400 UNIT- 200 MCG/5 ML
$0 (Tier 3) DP
INFUVITE PEDIATRIC VIAL SUV 80 MG-400
UNIT- 200 MCG/5 ML
$0 (Tier 3) DP
iron 100-vitamin c tablet 100-250 mg $0 (Tier 3) DP
iron 28 mg tablet 256 mg (28 mg iron) $0 (Tier 3) DP
KENWOOD THERAPEUTIC LIQUID $0 (Tier 3) DP
LIPOFLAVOVIT CAPLET $0 (Tier 3) DP
M.V.I. ADULT VIAL MDV, LATEX-FREE
3,300 UNIT- 150 MCG/10 ML
$0 (Tier 3) DP
M.V.I. ADULT VIAL SDV, LATEX-FREE 3,300
UNIT- 150 MCG/10 ML
$0 (Tier 3) DP
M.V.I. PEDIATRIC VIAL 10'S,SDV,LATEX-
FREE 80-400-200 MG-UNIT-MCG
$0 (Tier 3) DP
MAXIMUM D3 10,000 UNIT CAPSULE 10,000
UNIT
$0 (Tier 3) DP
MEGA MULTI FOR WOMEN TAB 13.5-200-
250 MG-MCG-MCG
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
154
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
MEGA MULTIVIT FOR WOMEN CAPLET
13.5-200-250 MG-MCG-MCG
$0 (Tier 3) DP
MULTI-DELYN WITH IRON LIQUID 10 MG
IRON/5 ML
$0 (Tier 3) DP
MULTILEX TABLET $0 (Tier 3) DP
MULTILEX-T-M-MINERALS TAB $0 (Tier 3) DP
MULTIPLE VITAMIN TABLET $0 (Tier 3) DP
MULTIPLE VITAMIN-CA-IRON TB $0 (Tier 3) DP
multivitamins men tablet $0 (Tier 3) DP
multivitamins tablet $0 (Tier 3) DP
NAIL-EX ORAL TABLET 2,500 MCG $0 (Tier 3) DP
NASCOBAL 500 MCG NASAL SPRAY OUTER
500 MCG/SPRAY
$0 (Tier 3) DP
OCUVITE SOFTGEL 150-30-5-150 MG-UNIT-
MG-MG
$0 (Tier 3) DP
OCUVITE WITH LUTEIN TABLET 1,000
UNIT-200 MG-60 UNIT-2 MG
$0 (Tier 3) DP
omega-3 1,000 mg softgel softgel,l/f,s/f 300-1,000
mg
$0 (Tier 3) DP
ONCE DAILY TABLET $0 (Tier 3) DP
ONCE DAILY WITH IRON TABLET $0 (Tier 3) DP
ONCOVITE TABLET $0 (Tier 3) DP
ONE DAILY ESSENTIAL TABLET $0 (Tier 3) DP
ONE DAILY TABLET $0 (Tier 3) DP
ONE DAILY TABLET $0 (Tier 3) DP
ONE DAILY TABLET MEN'S FORMULA $0 (Tier 3) DP
OPTIMAL D3 50,000 UNITS CAP 50,000 UNIT $0 (Tier 3) DP
OYSCO 500+D TABLET CHEWABLE 500
MG(1,250MG) -600 UNIT
$0 (Tier 3) DP
POLY-VI-SOL DROPS 750-35-400 UNIT-MG-
UNIT/ML
$0 (Tier 3) DP
POLY-VI-SOL WITH IRON DROPS 750 UNIT-
400 UNIT-10 MG/ML
$0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
155
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
POLY-VITA DROPS 1,500-35-400 UNIT-MG-
UNIT/ML
$0 (Tier 3) DP
POLY-VITA WITH IRON DROPS 1,500 UNIT-
400 UNIT-10 MG/ML
$0 (Tier 3) DP
PRESERVISION AREDS 2 SOFTGEL 250-2.5-
0.5 MG
$0 (Tier 3) DP
PRESERVISION AREDS TABLET 7,160-113-
100 UNIT-MG-UNIT
$0 (Tier 3) DP
PRORENAL MULTIVITAMIN TABLET 8 MG
IRON-800 MCG-1,000 UNIT
$0 (Tier 3) DP
PRORENAL QD SOFTGEL 400-500 MCG-UNIT $0 (Tier 3) DP
PROSIGHT TABLET 5,000-60-30 UNIT-MG-
UNIT
$0 (Tier 3) DP
pyridoxine 100 mg/ml vial 25's, mdv 100 mg/ml $0 (Tier 3) DP
pyridoxine 25 mg tablet 25 mg $0 (Tier 3) DP
pyridoxine 50 mg tablet (otc) 50 mg $0 (Tier 3) DP
RENA-VITE TABLET 0.8 MG $0 (Tier 3) DP
SB C-500 TABLET S/F, P/F,GLUTEEN-FRE 500
MG
$0 (Tier 3) DP
SLOW-MAG 71.5 MG TABLET 71.5 MG $0 (Tier 3) DP
SM COMPLETE 50+ TABLET 0.4-300-250 MG-
MCG-MCG
$0 (Tier 3) DP
SM COMPLETE SENIOR FORMULA TAB 0.4-
300-250 MG-MCG-MCG
$0 (Tier 3) DP
SM ULTIMATE WOMEN'S 50+ TABLET 8 MG
IRON-400 MCG-300 MCG
$0 (Tier 3) DP
SM VITAMIN B-1 100 MG TABLET 100 MG $0 (Tier 3) DP
sm vitamin c sr 500 mg tablet 500 mg $0 (Tier 3) DP
SM VITAMIN D3 1,000 UNIT TAB P/F 1,000
UNIT
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
156
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
sm vitamin e 1,000 unit sftgel softgel, gluten-free
1,000 unit
$0 (Tier 3) DP
sm vitamin e 400 unit softgel sftgel,natural blend
400 unit
$0 (Tier 3) DP
STRESS FORMULA WITH IRON TAB 500 MG-
400 MCG- 18 MG IRON
$0 (Tier 3) DP
SUPERPLEX-T TABLET $0 (Tier 3) DP
SV VITAMIN D3 400 UNIT SOFTGEL
SOFTGEL , P/F, S/F 400 UNIT
$0 (Tier 3) DP
TAB-A-VITE TABLET $0 (Tier 3) DP
TAB-A-VITE WITH IRON TABLET $0 (Tier 3) DP
TAB-A-VITE-MINERALS TABLET $0 (Tier 3) DP
THERA CAPLET $0 (Tier 3) DP
THERA TABLET 400 MCG $0 (Tier 3) DP
THERAPEUTIC-M TABLET 9-0.4 MG $0 (Tier 3) DP
thiamine 200 mg/2 ml vial 25's, mdv 100 mg/ml $0 (Tier 3) DP
thiamine 200 mg/2 ml vial 25's,mdv,outer 100
mg/ml
$0 (Tier 3) DP
thiamine 200 mg/2 ml vial mdv 100 mg/ml $0 (Tier 3) DP
thiamine 200 mg/2 ml vial mdv,inner 100 mg/ml $0 (Tier 3) DP
TOTAL B WITH VIT C CAPLET $0 (Tier 3) DP
TRI-VI-SOL DROPS 750 UNIT-35 MG -400
UNIT/ML
$0 (Tier 3) DP
TRI-VITA DROPS 1,500-35-400 UNIT-MG-
UNIT/ML
$0 (Tier 3) DP
UNICOMPLEX-M TABLET $0 (Tier 3) DP
vit d2 1.25 mg (50,000 unit) 50,000 unit $0 (Tier 3) DP
VIT D2 1.25 MG (50,000 UNIT) 50,000 UNIT $0 (Tier 3) DP
vit d2 1.25 mg (50,000 unit) softgel 50,000 unit $0 (Tier 3) DP
VIT D2 1.25 MG (50,000 UNIT) U-
D,10X10,OUTER 50,000 UNIT
$0 (Tier 3) DP
VIT E NAT'L BLND 1,000 UNIT CP 1,000 UNIT $0 (Tier 3) DP
vitamin a 10,000 unit capsule soluble 10,000 unit $0 (Tier 3) DP
vitamin a 25,000 units capsule softgel 25,000 unit $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
157
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
vitamin a 8,000 units softgel softgel, p/f 8,000 unit $0 (Tier 3) DP
VITAMIN B COMPLEX CAPSULE $0 (Tier 3) DP
vitamin b-1 100 mg tablet 100 mg $0 (Tier 3) DP
VITAMIN B-1 100 MG TABLET 100 MG $0 (Tier 3) DP
VITAMIN B-1 50 MG TABLET 50 MG $0 (Tier 3) DP
VITAMIN B-12 1,000 MCG TABLET 1,000
MCG
$0 (Tier 3) DP
VITAMIN B-12 1,000 MCG TABLET
NATURAL 1,000 MCG
$0 (Tier 3) DP
VITAMIN B-12 100 MCG TABLET 100 MCG $0 (Tier 3) DP
VITAMIN B-12 2,000 MCG TAB SA 2,000 MCG $0 (Tier 3) DP
VITAMIN B-12 250 MCG TABLET 250 MCG $0 (Tier 3) DP
VITAMIN B12 500 MCG TABLET 500 MCG $0 (Tier 3) DP
VITAMIN B-12 500 MCG TABLET 500 MCG $0 (Tier 3) DP
VITAMIN B-12 500 MCG TABLET NATURAL
500 MCG
$0 (Tier 3) DP
VITAMIN B-12 TR 1,000 MCG TAB TIMED
RELEASE 1,000 MCG
$0 (Tier 3) DP
VITAMIN B-2 100 MG TABLET GLUTEN-
FREE 100 MG
$0 (Tier 3) DP
VITAMIN B-2 100 MG TABLET
S/F,L/F,Y/F,GLUTEN/F 100 MG
$0 (Tier 3) DP
VITAMIN B-2 100 MG TABLET S/F,P/F 100
MG
$0 (Tier 3) DP
VITAMIN B-2 25 MG TABLET 25 MG $0 (Tier 3) DP
VITAMIN B-2 50 MG TABLET 50 MG $0 (Tier 3) DP
VITAMIN B-2 50 MG TABLET S/F 50 MG $0 (Tier 3) DP
VITAMIN B-2 50 MG TABLET S/F, P/F 50 MG $0 (Tier 3) DP
VITAMIN B-6 100 MG TABLET 100 MG $0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
158
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
VITAMIN B-6 100 MG TABLET SYNTHETIC
100 MG
$0 (Tier 3) DP
VITAMIN B-6 25 MG TABLET 25 MG $0 (Tier 3) DP
VITAMIN B-6 50 MG TABLET 50 MG $0 (Tier 3) DP
vitamin c 1,000 mg caplet caplet, w/ rose hips
1,000 mg
$0 (Tier 3) DP
VITAMIN C 1,000 MG TABLET 1,000 MG $0 (Tier 3) DP
VITAMIN C 250 MG TABLET 250 MG $0 (Tier 3) DP
VITAMIN C 250 MG TABLET CHEW 250 MG $0 (Tier 3) DP
VITAMIN C 250 MG TABLET CHEW 250 MG $0 (Tier 3) DP
VITAMIN C 500 MG CAPLET COATED
CAPLET 500 MG
$0 (Tier 3) DP
VITAMIN C 500 MG CHEW TABLET 500 MG $0 (Tier 3) DP
VITAMIN C 500 MG TABLET 10X10, U-D 500
MG
$0 (Tier 3) DP
vitamin c 500 mg tablet 500 mg $0 (Tier 3) DP
VITAMIN C 500 MG TABLET 500 MG $0 (Tier 3) DP
VITAMIN C 500 MG TABLET CHEW 500 MG $0 (Tier 3) DP
VITAMIN C 500 MG TABLET SYNTHETIC 500
MG
$0 (Tier 3) DP
VITAMIN C 500 MG TABLET U-D 500 MG $0 (Tier 3) DP
VITAMIN C 500 MG TABLET WITH ROSE
HIPS 500 MG
$0 (Tier 3) DP
VITAMIN C 500 MG/5 ML LIQUID 500 MG/5
ML
$0 (Tier 3) DP
VITAMIN C DROPS 60 MG $0 (Tier 3) DP
VITAMIN C-500 MG TR CAPSULE
NA/F,GLUTEN-FREE,P/F 500 MG
$0 (Tier 3) DP
vitamin d3 1,000 unit softgel softgel 1,000 unit $0 (Tier 3) DP
VITAMIN D3 1,000 UNIT SOFTGEL SOFTGEL
1,000 UNIT
$0 (Tier 3) DP
VITAMIN D3 1,000 UNIT TAB CHEW P/F,
PEACH VANILLA 1,000 UNIT
$0 (Tier 3) DP
vitamin d3 1,000 unit tablet 1,000 unit $0 (Tier 3) DP
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
159
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
vitamin d3 1,000 unit tablet gluten/f, d/f 1,000 unit $0 (Tier 3) DP
vitamin d3 1,000 unit tablet s/f, p/f 1,000 unit $0 (Tier 3) DP
VITAMIN D3 1,000 UNIT TABLET S/F,P/F
1,000 UNIT
$0 (Tier 3) DP
VITAMIN D3 1,000 UNIT TABLET U-D, 10X10
1,000 UNIT
$0 (Tier 3) DP
vitamin d3 10,000 unit softgel softgel 10,000 unit $0 (Tier 3) DP
vitamin d3 2,000 unit tablet 2,000 unit $0 (Tier 3) DP
vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit $0 (Tier 3) DP
VITAMIN D3 400 UNIT SOFTGEL SOFTGEL
400 UNIT
$0 (Tier 3) DP
vitamin d3 400 unit tablet gluten free 400 unit $0 (Tier 3) DP
VITAMIN D3 400 UNIT TABLET S/F, P/F 400
UNIT
$0 (Tier 3) DP
VITAMIN D3 400 UNIT TABLET S/F,P/F 400
UNIT
$0 (Tier 3) DP
vitamin d3 400 unit/ml drop a/f, s/f, fruit 400
unit/ml
$0 (Tier 3) DP
vitamin d3 400 unit/ml drop s/f,w/dropper 400
unit/ml
$0 (Tier 3) DP
vitamin d3 400 unit/ml drop supplement drop 400
unit/ml
$0 (Tier 3) DP
vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit $0 (Tier 3) DP
vitamin d3 5,000 unit tablet 5,000 unit $0 (Tier 3) DP
vitamin e 1,000 units capsule 1,000 unit $0 (Tier 3) DP
vitamin e 100 unit softgel softgel 100 unit $0 (Tier 3) DP
vitamin e 200 unit capsule 200 unit $0 (Tier 3) DP
vitamin e 400 unit capsule 400 unit $0 (Tier 3) DP
vitamin e 400 unit capsule p/f, sf, gluten-free 400
unit
$0 (Tier 3) DP
You can find information on what the symbols and abbreviations in this table mean by going to page ix.
160
Name of Drug What the drug will
cost you (Tier
Level)
Necessary actions, restrictions, or
limits on use
vitamin e 400 unit capsule softgel, synthetic 400
unit
$0 (Tier 3) DP
vitamin e 400 unit softgel softgel 400 unit $0 (Tier 3) DP
vitamin e 400 unit softgel softgel,s/f,na/f,p/f 400
unit
$0 (Tier 3) DP
vitamin e 400 unit softgel softgel,s/f,p/f,na/f 400
unit
$0 (Tier 3) DP
vitamin e 400 unit softgel water dispersible 400
unit
$0 (Tier 3) DP
vitamin e 50 unit/ml drops 50 unit/ml $0 (Tier 3) DP
V-R VIT C 250 MG TABLET CHEW 250 MG $0 (Tier 3) DP
V-R VIT C 500 MG TABLET CHEW 500 MG $0 (Tier 3) DP
V-R VITAMIN C 1,000 MG TABLET 1,000 MG $0 (Tier 3) DP
V-R VITAMIN C 500 MG TABLET VALU-SIZE
500 MG
$0 (Tier 3) DP
ZOO FRIENDS COMPLETE TAB CHEW 9-200
MG-MCG
$0 (Tier 3) DP
ZOO FRIENDS GUMMIES $0 (Tier 3) DP
ZOO FRIENDS TABLET CHEWABLE 15 MG,
300 MCG
$0 (Tier 3) DP
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Effective Date: 07-01-2018
161
Index
8 8 HOUR PAIN RELIEVER .. 1,
4
8-MOP .................................. 82
A abacavir ................................ 57
abacavir-lamivudine ............. 57
abacavir-lamivudine-
zidovudine ........................ 57
abelcet................................... 30
ABILIFY MAINTENA ........ 50
ABRAXANE ........................ 43
acamprosate ............................ 9
acarbose ................................ 61
ACCUCAINE KIT ................. 8
acebutolol ............................. 72
ACEPHEN ............................. 1
acetaminophen ........................ 1
acetaminophen-codeine .......... 1
acetazolamide ....................... 76
acetic acid ............................. 11
acetic acid-aluminum acetate
........................................ 126
acetylcysteine ..................... 126
ACID CONTROL
(RANITIDINE) ................ 91
ACID REDUCER
(FAMOTIDINE) .............. 91
ACIDOPHILUS-PECTIN .... 88
acidophilus-pectin, citrus ..... 88
acitretin ................................. 83
ACTEMRA ........................ 115
ACTHAR H.P. ..................... 98
ACTHIB (PF) ..................... 115
ACTIMMUNE ................... 115
acyclovir ............................... 55
acyclovir sodium .................. 55
ADACEL(TDAP
ADOLESN/ADULT)(PF)
................................ 115, 116
ADAGEN ............................. 86
ADEFOVIR .......................... 54
ADEMPAS ......................... 132
adriamycin ............................ 40
ADVAIR DISKUS ............. 132
ADVAIR HFA ................... 132
ADVIL LIQUI-GEL............... 4
AFINITOR ........................... 44
AFINITOR DISPERZ .......... 44
ak-poly-bac ........................... 11
ala-cort .................................. 33
ALA-HIST PE .................... 126
ALBENZA ........................... 47
albuterol sulfate .................. 130
alclometasone ....................... 33
alcohol pads .......................... 86
ALDURAZYME .................. 86
ALECENSA ......................... 44
alendronate ......................... 121
alfuzosin ............................... 97
ALIGN................................ 135
ALIMTA .............................. 39
ALINIA ................................ 48
ALIQOPA ............................ 44
ALL DAY PAIN RELIEF ...... 4
ALLERGY
RELIEF(DIPHENHYDRA
MIN) ............................... 128
allopurinol ............................ 33
allopurinol sodium ................ 86
alosetron ............................... 92
ALPHAGAN P ................... 124
alprazolam ............................ 60
ALTAVERA (28) ............... 101
ALUNBRIG ......................... 44
alyacen 1/35 (28) ................ 101
amabelz ............................... 101
amantadine hcl ...................... 49
AMBISOME ........................ 30
amikacin ............................... 10
amiloride ............................... 76
amiloride-hydrochlorothiazide
.......................................... 74
AMINO ACIDS 15 % ........ 135
aminophylline ..................... 131
AMINOSYN 7 % WITH
ELECTROLYTES .......... 135
aminosyn 8.5 %-electrolytes
........................................ 135
AMINOSYN II 10 % .......... 135
AMINOSYN II 15 % .......... 135
AMINOSYN II 8.5 % ......... 135
aminosyn ii 8.5 %-electrolytes
........................................ 135
AMINOSYN M 3.5 % ........ 135
AMINOSYN-HBC 7% ....... 135
AMINOSYN-PF 10 % ....... 135
AMINOSYN-PF 7 %
(SULFITE-FREE) .......... 135
AMINOSYN-RF 5.2 % ...... 135
amiodarone ........................... 71
AMITIZA ............................. 92
amitriptyline ......................... 28
amlodipine ............................ 72
amlodipine-benazepril .......... 74
amlodipine-olmesartan ......... 74
amlodipine-valsartan ............ 74
amlodipine-valsartan-hcthiazid
.......................................... 74
ammonium lactate ................ 83
AMNESTEEM ..................... 83
amoxapine ............................. 28
amoxicillin ............................ 17
amoxicillin-pot clavulanate .. 17
amphotericin b ...................... 30
ampicillin .............................. 18
ampicillin sodium ................. 18
ampicillin-sulbactam ............ 18
AMPYRA ............................. 81
ANADROL-50 ................... 100
anagrelide ............................. 67
anastrozole ............................ 43
ANDROGEL ...................... 100
ANDROXY ........................ 100
ANIMAL CHEWS ............. 148
162
ANIMAL SHAPE VITAMINS
........................................ 148
ANODYNE LPT .................... 8
ANORO ELLIPTA ............ 132
ANTACID ............................ 90
ANTACID (CALCIUM
CARBONATE) .......... 88, 90
ANTACID ANTI-GAS .. 88, 89
ANTACID EXTRA-
STRENGTH ............... 88, 89
ANTACID MAXIMUM
STRENGTH ..................... 88
ANTACID PLUS ANTI-GAS
.......................................... 90
ANTIBIOTIC (BACITRACIN
ZINC) ............................... 14
ANTIBIOTIC (NEOMY-
BACIT-POLYM) ............. 11
ANTI-DANDRUFF ............. 83
ANTI-DIARRHEAL
(LOPERAMIDE) . 89, 90, 91
ANTIFUNGAL
(TOLNAFTATE) ............. 30
ANTIFUNGAL CREAM ..... 30
ANTIOXIDANT VITAMINS
........................................ 148
APATATE .......................... 148
APATATE FORTE ............ 136
APOKYN ............................. 49
aprepitant .............................. 29
apri ...................................... 102
APTIOM............................... 24
APTIVUS ............................. 58
AQUA GLYCOLIC ............. 83
AQUADEKS ...................... 148
AQUADEKS PEDIATRIC 136
AQUASOL A ..................... 148
AQUASOL E (D-ALPHA
TOCOPHEROL) ............ 143
ARALAST NP ................... 126
aranelle (28)........................ 102
ARANESP (IN
POLYSORBATE) ...... 67, 68
ARCALYST ....................... 115
argatroban ............................. 66
argatroban in 0.9 % sod chlor
.......................................... 66
argatroban in nacl (iso-os) .... 66
aripiprazole ..................... 50, 51
ARISTADA .......................... 51
armodafinil ......................... 134
ARNUITY ELLIPTA ......... 128
ARRANON .......................... 39
ARTHRITIS PAIN RELIEF
(ACETAM) ................ 1, 2, 3
ARTHRITIS PAIN
RELIEVER ......................... 1
ARTIFICIAL TEARS
(POLYVIN ALC) ........... 122
ARTIFICIAL
TEARS(PVALCH-POVID)
........................................ 122
ascomp with codeine .............. 1
ascorbic acid (vitamin c) ... 148,
155, 158
ASPIR-81 ............................. 69
aspirin ................. 4, 5, 6, 69, 70
ASPIRIN LOW DOSE ......... 70
aspirin-dipyridamole ............ 69
ASPIR-LOW ........................ 69
assure id insulin safety ......... 86
ASTAGRAF XL................. 110
atazanavir.............................. 58
atenolol ................................. 72
atenolol-chlorthalidone ......... 74
ATGAM ............................. 110
ATHLETE'S FOOT
(TERBINAFINE) ............. 32
atomoxetine .......................... 80
atorvastatin ........................... 77
atovaquone............................ 48
atovaquone-proguanil ........... 48
ATRIPLA ............................. 58
atropine ............................... 122
AUBAGIO............................ 81
aubra ................................... 102
AVANDIA ........................... 61
AVASTIN ............................ 46
AVELOX IN NACL (ISO-
OSMOTIC) ....................... 19
aviane.................................. 102
AYR SALINE .................... 126
azacitidine ............................. 40
AZASAN ............................ 110
azathioprine ........................ 110
azathioprine sodium ........... 110
azelastine .................... 124, 127
azithromycin ................... 18, 19
AZOPT ............................... 124
aztreonam ............................. 17
B B COMPLEX-VITAMIN B12
........................................ 149
bacitracin ........................ 11, 12
bacitracin zinc ....................... 12
bacitracin-polymyxin b ......... 12
baclofen ................................ 54
BACTROBAN NASAL ....... 12
BALANCED B-100 ........... 148
BALANCED B-50 ............. 149
balsalazide .......................... 119
balziva (28) ......................... 102
BANOPHEN ...................... 127
BANOPHEN ANTI-ITCH . 127
BANZEL .............................. 24
BARACLUDE ...................... 54
BASAGLAR KWIKPEN U-
100 INSULIN ................... 64
BAVENCIO ......................... 46
BAZA ANTIFUNGAL ........ 30
BCG VACCINE, LIVE (PF)
........................................ 116
b-complex with vitamin c .. 143,
146
BEELITH ........................... 136
bekyree (28) ........................ 102
BELEODAQ ......................... 40
benazepril ............................. 71
benazepril-hydrochlorothiazide
.......................................... 74
BENEFIBER SUGAR FREE
(DEXTRIN) ...................... 92
BENLYSTA ....................... 115
benznidazole ......................... 47
benztropine ........................... 48
BESPONSA .......................... 46
beta carotene ....................... 149
BETADINE .......................... 12
betamethasone dipropionate . 33
betamethasone valerate ......... 33
betamethasone, augmented ... 33
BETASEPT SURGICAL
SCRUB ............................. 12
BETASERON ....................... 82
bethanechol chloride ............. 97
bexarotene ............................. 47
BEXSERO .......................... 116
bicalutamide ......................... 39
BICILLIN L-A ..................... 18
BICNU .................................. 38
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BIKTARVY ......................... 56
BILTRICIDE ........................ 48
biotin........... 143, 145, 148, 149
bisacodyl............................... 92
BISA-LAX ........................... 92
BISCOLAX .......................... 92
BISMATROL ....................... 89
bisoprolol fumarate .............. 72
bisoprolol-hydrochlorothiazide
.......................................... 74
BIVIGAM .......................... 114
bleomycin ............................. 40
blisovi fe 1.5/30 (28) .......... 102
blisovi fe 1/20 (28) ............. 102
BOOSTRIX TDAP ............ 116
BORTEZOMIB .................... 40
BOSULIF ............................. 44
BREO ELLIPTA ................ 132
BREWER'S YEAST ............ 30
briellyn ............................... 102
BRILINTA ........................... 69
brimonidine ........................ 124
BRIVIACT ........................... 21
bromocriptine ....................... 49
BROVANA ........................ 130
budesonide .......................... 128
BUDESONIDE .................. 120
bumetanide ........................... 76
buprenorphine......................... 6
buprenorphine hcl ................... 9
buprenorphine-naloxone......... 9
buproban ................................. 9
bupropion hcl........................ 26
bupropion hcl (smoking deter)
.......................................... 26
buspirone .............................. 60
busulfan ................................ 38
butalbital compound w/codeine
............................................ 1
butalbital-acetaminop-caf-cod 2
butalbital-acetaminophen ....... 2
butalbital-acetaminophen-caff 2
butalbital-aspirin-caffeine ...... 2
butorphanol tartrate ................ 7
C C-500 .................................. 155
cabergoline ......................... 108
CABOMETYX ..................... 44
calamine-zinc oxide .............. 84
CALCI-CHEW ................... 143
CALCIFEROL ................... 149
CALCIONATE .................. 136
calcipotriene ......................... 83
calcitonin (salmon) ............. 121
CALCITRATE ................... 136
CALCITRATE-VITAMIN D
........................................ 144
calcitriol .............................. 121
CALCIUM 500 WITH D ... 147
CALCIUM 600................... 144
CALCIUM 600 + D(3) ...... 136,
144
calcium acetate ..................... 98
CALCIUM ANTACID.. 89, 90,
91
calcium carbonate ....... 136, 144
calcium carbonate-vitamin d3
................ 136, 144, 147, 149
calcium citrate-vitamin d3 .. 144
calcium gluconate ............... 149
CALQUENCE ...................... 44
CALTRATE 600 + D ......... 149
CALTRATE 600+D PLUS
MINERALS.................... 149
CALTRATE WITH VITAMIN
D3 ................................... 144
camila ................................. 106
CANASA............................ 120
CANCIDAS.......................... 30
CAPASTAT ......................... 37
CAPRELSA.......................... 44
capsaicin ................................. 2
CAPSULE #0 (CELLULOSE)
.......................................... 70
CAPSULE #1 ....................... 70
CAPSULE #1
(HYPROMELLOSE) ....... 70
captopril ................................ 71
captopril-hydrochlorothiazide
.......................................... 74
CARBAGLU ...................... 136
carbamazepine ...................... 24
carbidopa-levodopa .............. 49
carboplatin ............................ 38
CARDIAMIN ..................... 149
CARIMUNE NF
NANOFILTERED .......... 114
carisoprodol ........................ 133
carisoprodol-asa-codeine ........ 2
carisoprodol-aspirin ................ 2
carteolol .............................. 124
cartia xt ................................. 72
carvedilol .............................. 72
caspofungin ........................... 30
CASTELLANI PAINT
MODIFIED ....................... 12
caziant (28) ......................... 102
cefaclor ................................. 15
cefadroxil .............................. 15
cefazolin ............................... 15
cefazolin in dextrose (iso-os) 15
cefdinir .................................. 15
cefepime ............................... 16
cefepime in dextrose 5 % ..... 15
cefepime in dextrose,iso-osm
.......................................... 15
cefotaxime ............................ 16
cefoxitin ................................ 16
cefoxitin in dextrose, iso-osm
.......................................... 16
cefpodoxime ......................... 16
cefprozil ................................ 16
ceftazidime ........................... 16
ceftazidime in d5w ............... 16
ceftriaxone ............................ 16
ceftriaxone in dextrose,iso-os
.......................................... 16
cefuroxime axetil .................. 16
cefuroxime sodium ............... 16
celecoxib ................................. 5
CELONTIN .......................... 22
CENTAMIN ....................... 149
CENTRAL-VITE ............... 149
164
CENTRUM ................ 149, 150
CENTRUM COMPLETE .. 144
CENTRUM KIDS .............. 149
CENTRUM SILVER ......... 150
CENTRUM SILVER ULTRA
MEN'S ............................ 150
CENTRUM SILVER ULTRA
WOMEN'S ..................... 144
CENTRUM SPECIALIST
ENERGY ........................ 144
CENTRUM SPECIALIST
HEART........................... 136
CENTRUM SPECIALIST
VISION .......................... 150
CENTRUM ULTRA
WOMEN'S ..................... 144
CENTURY ADVANCED
FORMULA .................... 144
CENTURY ENERGY
METABOLISM ............. 145
CENTURY MATURE ....... 150
CENTURY ULTIMATE
MEN'S ............................ 145
cephalexin............................. 16
CERAVE .............................. 83
CERDELGA......................... 86
CEREZYME ........................ 86
CEROVITE ........................ 150
CERTA PLUS .................... 150
CERTAVITE SENIOR-
ANTIOXIDANT ............ 150
CERTAVITE-ANTIOXID
(IRON GLUC)................ 150
CERTAVITE-
ANTIOXIDANT ............ 145
CETAPHIL GENTLE
CLEANSER ..................... 83
CETAPHIL MOISTURIZING
.......................................... 83
cetirizine ..................... 127, 133
cevimeline ............................ 82
CHANTIX .............................. 9
CHANTIX CONTINUING
MONTH BOX .................... 9
CHANTIX STARTING
MONTH BOX .................. 10
CHEWABLE VITAMIN C 158
CHILDREN'S ASPIRIN 69, 70
CHILDREN'S CHEWABLE
COMPLETE ................... 150
CHILDREN'S CHEWABLE
VITAMIN ....................... 150
CHILDREN'S CHEWABLES
........................................ 150
CHILDREN'S CHEWABLES
EXTRA C ....................... 150
CHILDREN'S CHEWABLES
WITH IRON ................... 150
CHILDREN'S COLD-
ALLERGY (PE) ............. 126
CHILD'S ALL DAY
ALLERGY(CETIR) ....... 128
CHILDS CHEW VITE ....... 150
CHILD'S CHEWABLE
VITAMINS/IRON.......... 145
CHILDS/IRON ................... 145
chloramphenicol sod succinate
.......................................... 12
chlorhexidine gluconate ....... 82
chloroquine phosphate .......... 48
chlorothiazide ....................... 76
chlorpheniramine maleate .. 128
chlorpromazine ..................... 28
chlorthalidone ....................... 76
chlorzoxazone ..................... 133
CHOLBAM .......................... 86
cholecalciferol (vitamin d3)
................................ 158, 159
cholestyramine (with sugar) . 77
cholestyramine light ............. 77
chorionic gonadotropin, human
.......................................... 98
ciclopirox .............................. 30
ciclopirox-ure-camph-menth-
euc .................................... 30
cidofovir ............................... 54
cilostazol ............................... 68
cimetidine ............................. 92
cimetidine hcl ....................... 92
CIMZIA .............................. 111
CIMZIA POWDER FOR
RECONST ...................... 111
CIMZIA STARTER KIT ... 111
CINRYZE ........................... 110
CIPRODEX ........................ 126
ciprofloxacin (mixture)......... 19
ciprofloxacin hcl ................... 19
ciprofloxacin lactate ............. 19
cisplatin ................................ 38
citalopram ............................. 26
CITRUCEL ........................... 92
CITRUCEL (SUCROSE) ..... 92
CITRUCEL SUGAR FREE . 92
CITRUS CALCIUM .......... 145
cladribine .............................. 39
claravis .................................. 83
clarithromycin ....................... 19
clemastine ........................... 128
CLIMARA PRO ................. 102
clindamycin hcl .................... 12
clindamycin in 0.9 % sod chlor
.......................................... 12
clindamycin in 5 % dextrose 12
clindamycin palmitate hcl ..... 12
clindamycin pediatric ........... 12
clindamycin phosphate ... 12, 13
clindamycin-benzoyl peroxide
.......................................... 13
clinimix 4.25%/d10w sulf free
........................................ 145
clinimix 4.25%-d20w sulf-free
........................................ 145
clinimix 4.25%-d25w sulf-free
........................................ 145
clinimix n14g30e 4.25%-d15w
sf ..................................... 145
clinimix n9g15e 2.75%-d7.5w
sf ..................................... 145
clinisol sf 15 % ................... 136
clobetasol ........................ 33, 34
clobetasol-emollient ............. 98
clofarabine ............................ 41
clomipramine ........................ 28
clonazepam ........................... 60
clonidine ............................... 70
clonidine hcl ................... 70, 80
clopidogrel ............................ 69
clorazepate dipotassium ........ 60
clotrimazole .............. 30, 31, 32
CLOTRIMAZOLE 3 DAY .. 30
clotrimazole-betamethasone . 83
clozapine ............................... 53
COARTEM ........................... 48
cod liver oil ............... 77, 78, 79
codeine-butalbital-asa-caff ..... 2
coenzyme q10 ............. 150, 151
COLACE CLEAR ................ 92
colchicine .............................. 33
colestipol ............................... 77
colistin (colistimethate na) ... 13
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165
colocort ............................... 120
COMBIGAN ...................... 124
COMBIPATCH .................. 102
COMBIVENT RESPIMAT 133
COMETRIQ ......................... 45
COMFORT PAC-
CYCLOBENZAPRINE . 133
COMFORT PAC-
IBUPROFEN ...................... 5
COMFORT PAC-
MELOXICAM ................... 5
COMFORT PAC-
NAPROXEN ...................... 5
COMFORT PAC-
TIZANIDINE ................... 54
COMPETE ......................... 151
COMPLERA ........................ 56
COMPLETE 50+ ............... 155
COMPLETE ALLERGY ... 128
COMPLETE
MULTIVITAMIN .......... 151
COMPLETE
MULTIVITAMIN-
MINERAL ...................... 147
COMPLETE SENIOR 151, 155
COMPLEX 15 ...................... 83
COMPOUND W .................. 83
compro .................................. 28
constulose ............................. 92
COPAXONE ........................ 82
CORLANOR ........................ 75
cortisone ............................... 98
COTELLIC........................... 45
COUMADIN ........................ 66
CREON ................................ 86
CRITIC-AID ........................ 83
CRIXIVAN .......................... 58
cromolyn..................... 124, 131
cryselle (28) ........................ 102
CUVPOSA ........................... 82
cyanocobalamin (vitamin b-12)
........................................ 151
cyclafem 1/35 (28) ............. 102
cyclafem 7/7/7 (28) ............ 102
cyclobenzaprine .................. 133
cyclophosphamide ................ 38
cyclosporine........................ 111
cyclosporine modified ........ 111
CYCLOTENS REFILL ...... 133
CYCLOTENS STARTER .. 133
cyproheptadine ................... 128
CYRAMZA .......................... 46
CYSTADANE ...................... 86
CYSTAGON ........................ 86
CYSTARAN ...................... 122
cytarabine ............................. 40
cytarabine (pf) ...................... 39
CYTO B-2 .......................... 151
D d10 %-0.45 % sodium chloride
........................................ 136
d2.5 %-0.45 % sodium
chloride ........................... 136
d5 % and 0.9 % sodium
chloride ........................... 136
d5 %-0.45 % sodium chloride
........................................ 136
dacarbazine ........................... 38
dactinomycin ........................ 41
DAILY VITAMIN ............. 151
DAILY VITAMIN
FORMULA .................... 151
DAILY VITAMIN
FORMULA-MINERALS
........................................ 151
DAILY VITAMIN WITH
IRON .............................. 151
DAILY VITAMIN WITH
IRON AND CA .............. 154
DALIRESP ......................... 131
DANAZOL ......................... 100
dantrolene ............................. 54
dapsone ................................. 37
DAPTACEL (DTAP
PEDIATRIC) (PF) .......... 116
daptomycin ........................... 13
DARAPRIM ......................... 48
darifenacin ............................ 97
DARZALEX ........................ 46
daunorubicin ......................... 41
deblitane ............................. 106
DECARA ............................ 151
decitabine .............................. 41
DEEP SEA NASAL ........... 126
delyla (28) ........................... 102
DELZICOL ......................... 120
demeclocycline ..................... 21
DEMSER .............................. 74
DENAVIR ............................ 55
DEPEN TITRATABS .......... 97
DEPO-PROVERA ................ 39
DEPO-SUBQ PROVERA 104
........................................ 106
DERMACERIN .................... 83
dermacinrx empricaine ........... 8
DERMACLOUD .................. 83
DESCOVY ........................... 57
DESENEX ............................ 31
desipramine ........................... 28
desmopressin .................. 98, 99
desog-e.estradiol/e.estradiol
........................................ 102
desogestrel-ethinyl estradiol
........................................ 102
desonide ................................ 34
desoximetasone ..................... 34
desvenlafaxine succinate ...... 26
dexamethasone ..................... 34
dexamethasone intensol ........ 34
dexamethasone sodium phos
(pf) .................................... 34
dexamethasone sodium
phosphate .................. 34, 125
dexmethylphenidate .............. 80
dexrazoxane hcl .................... 41
dextroamphetamine .............. 80
dextroamphetamine-
amphetamine ..................... 80
dextrose 10 % and 0.2 % nacl
........................................ 136
dextrose 10 % in water (d10w)
........................................ 136
dextrose 5 % in water (d5w)
........................................ 137
166
dextrose 5 %-lactated ringers
........................................ 137
dextrose 5%-0.2 % sod
chloride ........................... 137
dextrose 5%-0.3 %
sod.chloride .................... 137
DEXTROSE WITH SODIUM
CHLORIDE .................... 137
DIALYVITE 800 ............... 151
DIALYVITE 800 WITH ZINC
15 .................................... 151
DIALYVITE 800 WITH ZINC
50 .................................... 151
DIALYVITE 800-ULTRA D
........................................ 151
DIALYVITE VITAMIN D 151
DIALYVITE VITAMIN D3
MAX............................... 151
DIAPER RASH .................... 85
DIASTAT ............................. 22
DIASTAT ACUDIAL .......... 22
diazepam......................... 22, 60
diazepam intensol ................. 60
dibucaine ................................ 8
diclofenac potassium .............. 5
diclofenac sodium .......... 5, 125
dicloxacillin .......................... 18
DICLOZOR ............................ 5
dicyclomine .......................... 88
didanosine............................. 57
DIFICID ............................... 19
diflunisal ................................. 5
digitek ................................... 75
digox ..................................... 75
digoxin .................................. 75
dihydroergotamine ............... 36
DILANTIN ........................... 24
diltiazem hcl ................... 72, 73
dilt-xr .................................... 73
dimenhydrinate ..................... 28
DIPENTUM ....................... 120
DIPHEDRYL ..................... 128
DIPHENHIST .................... 128
diphenhydramine hcl .... 28, 128
diphenoxylate-atropine ......... 89
dipyridamole......................... 69
disopyramide phosphate ....... 71
disulfiram ............................... 9
divalproex ............................. 22
DM2 ..................................... 61
DML FORTE ....................... 83
docetaxel ................... 40, 43, 44
DOC-Q-LACE...................... 92
DOC-Q-LAX ........................ 92
DOCU ................................... 93
docusate calcium ...... 93, 94, 95
docusate sodium ................... 93
DOCUSIL ............................. 93
dofetilide ............................... 71
donepezil .............................. 25
doripenem ............................. 17
dorzolamide ........................ 124
dorzolamide-timolol ........... 124
doxazosin .............................. 71
doxepin ................................. 28
DOXEPIN ............................ 83
doxercalciferol .................... 121
doxorubicin ........................... 41
doxorubicin, peg-liposomal .. 41
doxy-100 ............................... 21
doxycycline hyclate .............. 21
doxycycline monohydrate .... 21
dronabinol ............................. 29
drospirenone-ethinyl estradiol
........................................ 102
DROXIA .............................. 40
DUAVEE............................ 101
DULERA ............................ 132
duloxetine ............................. 26
DUOFER ............................ 137
duramorph (pf) ....................... 7
DUREZOL ......................... 125
dutasteride ............................ 97
D-VI-SOL ........................... 151
D-VITA .............................. 151
E EAR DROPS (CARBAMIDE
PEROXIDE) ................... 126
EAR WAX REMOVAL
DROPS ........................... 126
ECEE PLUS ....................... 152
econazole .............................. 31
EDURANT ........................... 56
efavirenz ............................... 56
EGRIFTA ............................. 99
ELAPRASE .......................... 87
ELDERTONIC ................... 152
ELELYSO ............................ 87
ELIDEL ................................ 83
ELIGARD .......................... 108
ELIGARD (3 MONTH) ..... 108
ELIGARD (4 MONTH) ..... 108
ELIGARD (6 MONTH) ..... 108
ELIQUIS ............................... 66
ELITEK ................................ 87
ELITE-OB .......................... 145
ELIXOPHYLLIN ............... 131
ELMIRON ............................ 97
EMCYT ................................ 38
EMEND ................................ 29
emoquette ........................... 102
EMPLICITI .......................... 46
EMSAM ............................... 26
EMTRIVA ............................ 57
enalapril maleate ................... 71
enalapril-hydrochlorothiazide
.......................................... 74
ENBREL ............................. 111
ENBREL MINI .................. 111
ENBREL SURECLICK ..... 111
ENDARI ............................... 89
ENEMA ................................ 95
ENEMA DISPOSABLE ....... 93
ENEMEEZ ........................... 93
ENGERIX-B (PF) .............. 116
ENGERIX-B PEDIATRIC
(PF) ................................. 116
enoxaparin ............................ 66
enpresse .............................. 102
ENSKYCE .......................... 102
entacapone ............................ 49
entecavir ............................... 54
ENTRESTO .......................... 74
enulose .................................. 89
ENVARSUS XR ................ 111
EPCLUSA ............................ 55
epinastine ............................ 124
epinephrine ......................... 130
EPIPEN ............................... 130
EPIPEN 2-PAK .................. 130
EPIPEN JR ......................... 130
EPIPEN JR 2-PAK ............. 130
epirubicin .............................. 41
epitol ..................................... 24
EPIVIR HBV ........................ 54
eplerenone ............................. 76
EPOGEN .............................. 68
EPSOM SALT ................ 89, 91
EQUETRO ........................... 24
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Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
167
ERAXIS(WATER DILUENT)
.......................................... 31
ERBITUX............................. 46
ergocalciferol (vitamin d2) 152,
156
ergoloid................................. 25
ergotamine-caffeine .............. 36
ERIVEDGE .......................... 45
ERLEADA ........................... 39
errin .................................... 106
ERWINAZE ......................... 41
ery pads ................................ 19
ERYTHROCIN .................... 19
erythrocin (as stearate) ......... 19
erythromycin ........................ 19
erythromycin ethylsuccinate 19
erythromycin with ethanol ... 19
erythromycin-benzoyl peroxide
.......................................... 84
ESBRIET ............................ 133
escitalopram oxalate ............. 27
ESTRACE .......................... 101
estradiol .............................. 101
estradiol valerate ................ 101
estradiol-norethindrone acet
................................ 102, 103
ESTRING ........................... 101
estropipate .......................... 101
ethambutol ............................ 37
ethosuximide ........................ 22
ethynodiol diac-eth estradiol
........................................ 103
etidronate disodium ............ 121
etodolac .................................. 5
ETOPOPHOS ....................... 44
etoposide............................... 44
EVOTAZ .............................. 58
exemestane ........................... 43
EXJADE ............................. 134
EX-LAX MAXIMUM
STRENGTH ..................... 93
EXONDYS 51 ...................... 81
EXTAVIA ............................ 82
EYESCRUB ....................... 124
ezetimibe .............................. 78
ezetimibe-simvastatin ........... 78
EZFE 200 ........................... 137
F FABRAZYME ..................... 87
falmina (28) ........................ 103
famciclovir............................ 55
famotidine ............................. 92
famotidine (pf) ...................... 92
FANAPT .............................. 51
FARESTON ......................... 39
FARYDAK ........................... 41
FASLODEX ......................... 39
FATIGUE RELIEF
COMPLEX ..................... 143
felbamate .............................. 23
felodipine .............................. 73
femynor .............................. 103
fenofibrate ............................ 77
fenofibrate micronized ......... 77
fenofibrate nanocrystallized . 77
fenofibric acid (choline) ....... 77
fentanyl ................................... 6
fentanyl citrate ........................ 7
FERAHEME ...................... 137
FERATE ............................. 137
FERGON ............................ 137
FER-IN-SOL ...................... 152
FEROSUL .................. 137, 152
FERRETTS ........................ 137
FERRETTS IPS .................. 137
FERREX 150 .............. 137, 138
FERRIMIN 150 .................. 138
FERRIPROX ...................... 134
FERRLECIT ....................... 138
FERRO-TIME .................... 138
ferrous fumarate ................. 138
ferrous gluconate ....... 138, 140,
152, 153
ferrous sulfate .... 138, 139, 150,
152
FERROUSUL ..................... 139
FETZIMA ............................. 27
fexofenadine ....................... 128
FIBER ................................... 96
FIBER (PSYLLIUM
HUSK/SUGAR) ............... 96
FIBER LAXATIVE (CA
POLYCARBO) ........... 93, 96
FIBER SMOOTH
(SUCROSE) ..................... 96
FIBER THERAPY (M-
CELL/SUGAR) ................ 93
FIBER-LAX ................... 93, 94
finasteride ............................. 97
FIRAZYR ........................... 110
FIRMAGON ....................... 109
FIRMAGON KIT W
DILUENT SYRINGE .... 108
FIRST AID ABX PAIN
RELIEF ............................. 13
FISH OIL .................... 139, 141
flavoxate ............................... 97
FLEBOGAMMA DIF ........ 114
flecainide .............................. 71
FLEET GLYCERIN (ADULT)
.......................................... 93
FLORANEX ................. 89, 139
FLOVENT DISKUS .......... 128
FLOVENT HFA ................. 129
fluconazole ........................... 31
fluconazole in dextrose(iso-o)
.......................................... 31
fluconazole in nacl (iso-osm)31
flucytosine ............................ 31
FLUDARABINE ............ 40, 41
fludrocortisone ...................... 98
flunisolide ........................... 129
fluocinolone .......................... 34
fluocinonide .......................... 34
fluocinonide-e ....................... 34
fluocinonide-emollient ......... 34
fluoride (sodium) ................ 139
FLUORIDE (SODIUM) ..... 139
fluorometholone ................. 125
fluorouracil ........................... 40
fluoxetine .............................. 27
fluphenazine decanoate ........ 50
fluphenazine hcl .................... 50
flurbiprofen ............................. 5
168
flurbiprofen sodium ............ 125
flutamide............................... 39
fluticasone .................... 34, 129
fluticasone-salmeterol ........ 129
fluvoxamine .......................... 27
FML FORTE ...................... 125
FOLGARD ......................... 152
folic acid ..................... 145, 152
FOLITAB ........................... 139
fondaparinux......................... 66
FORFIVO XL ...................... 26
FORTEO ............................ 121
fosamprenavir ....................... 58
fosinopril .............................. 71
fosinopril-hydrochlorothiazide
.......................................... 74
fosphenytoin ......................... 24
FOSRENOL ......................... 98
FRAGMIN ........................... 67
FRESHKOTE ..................... 122
FUNGOID TINCTURE ....... 31
furosemide ............................ 76
FUSILEV ............................. 41
FUZEON .............................. 58
fyavolv ................................ 103
FYCOMPA .................... 23, 69
G gabapentin ...................... 22, 23
GABITRIL ........................... 23
GAMASTAN S/D .............. 114
GAMMAGARD LIQUID .. 114
GAMMAGARD S-D (IGA < 1
MCG/ML) ...................... 114
GAMMAKED .................... 114
GAMMAPLEX .................. 114
GAMMAPLEX (WITH
SORBITOL) ................... 114
GAMUNEX-C ................... 114
ganciclovir sodium ............... 54
GARDASIL (PF)................ 116
GARDASIL 9 (PF)............. 116
GAS RELIEF ................. 89, 90
GAS RELIEF EXTRA
STRENGTH ..................... 91
GAS RELIEF ULTRA
STRENGTH ..................... 89
GATTEX 30-VIAL .............. 89
GATTEX ONE-VIAL .......... 89
gauze pad .............................. 86
gavilyte-c .............................. 88
gavilyte-g .............................. 93
gavilyte-n .............................. 93
GAVISCON EXTRA
STRENGTH ..................... 89
gemcitabine .......................... 40
gemfibrozil ........................... 77
generlac ................................ 90
gengraf ................................ 111
GENOTROPIN .................... 99
GENOTROPIN MINIQUICK
.......................................... 99
gentak ................................... 10
gentamicin ...................... 10, 11
gentamicin sulfate (ped) (pf) 11
gentamicin sulfate (pf).......... 11
GENTEAL MILD TO
MODERATE .................. 122
GENTEAL GEL ................. 122
GENTEAL PM ................... 122
GENTEAL SEVERE ......... 123
GENTLE LAXATIVE ... 95, 96
GENVOYA .......................... 58
GEODON ............................. 51
GERIATON........................ 152
gildagia ............................... 103
gildess 1.5/30 (21) .............. 103
GILENYA ............................ 82
GILOTRIF ............................ 45
GLASSIA ........................... 126
glatiramer.............................. 82
GLEOSTINE ........................ 38
glimepiride............................ 61
glipizide ................................ 61
glipizide-metformin ........ 61, 62
GLUCAGEN DIAGNOSTIC
KIT ................................... 63
GLUCAGEN HYPOKIT ..... 64
GLUCAGON EMERGENCY
KIT (HUMAN)................. 64
GLUCAGON HCL............... 64
glucosamine sulfate ............ 139
glucosamine-chondroitin ..... 70,
139
GLUCOSAMINE-
CHONDROITIN 3X ...... 148
glucose .................................. 64
glyburide ............................... 62
glyburide micronized ............ 62
glyburide-metformin ............ 62
glycopyrrolate ....................... 88
GLYXAMBI ......................... 62
GOCOVRI ............................ 49
granisetron (pf) ..................... 29
granisetron hcl ................ 29, 30
GRANIX ............................... 68
griseofulvin microsize .......... 31
guanfacine ....................... 70, 80
guanidine .............................. 37
H HAEGARDA ...................... 110
HALAVEN ........................... 41
halobetasol propionate .......... 35
haloperidol ............................ 50
haloperidol decanoate ........... 50
haloperidol lactate ................ 50
HAVRIX (PF) .................... 116
HEALTHY EYES ...... 152, 153
HEALTHYLAX ................... 93
HEMOCYTE ...................... 139
HEMORRHOID ................... 84
HEMORRHOIDAL ................ 9
HEMORRHOIDAL CREAM 9
heparin (porcine) .................. 67
heparin (porcine) in 5 % dex 67
heparin, porcine (pf) ............. 67
HEPLISAV-B ..................... 117
HERCEPTIN ........................ 46
HETLIOZ ........................... 134
HEXALEN ........................... 38
HIBERIX (PF) .................... 117
HORIZANT .......................... 81
HUMALOG JUNIOR
KWIKPEN U-100 ............ 64
HUMALOG KWIKPEN
INSULIN .......................... 64
HUMALOG MIX 50-50
INSULN U-100 ................ 64
HUMALOG MIX 50-50
KWIKPEN ........................ 64
HUMALOG MIX 75-25
KWIKPEN ........................ 64
HUMALOG MIX 75-25(U-
100)INSULN .................... 64
HUMALOG U-100 INSULIN
.......................................... 64
HUMATROPE ..................... 99
HUMIRA ............................ 112
HUMIRA PEDIATRIC
CROHN'S START.......... 111
HUMIRA PEN ................... 112
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
169
HUMIRA PEN CROHN'S-
UC-HS START .............. 111
HUMIRA PEN PSORIASIS-
UVEITIS ........................ 112
HUMULIN 70/30 U-100
INSULIN .......................... 65
HUMULIN 70/30 U-100
KWIKPEN ....................... 65
HUMULIN N NPH INSULIN
KWIKPEN ....................... 65
HUMULIN N NPH U-100
INSULIN .......................... 65
HUMULIN R REGULAR U-
100 INSULN .................... 65
HUMULIN R U-500 (CONC)
INSULIN .......................... 65
HUMULIN R U-500 (CONC)
KWIKPEN ....................... 65
hydralazine ........................... 79
hydrochlorothiazide .............. 76
hydrocodone-acetaminophen . 2
hydrocodone-ibuprofen .......... 2
hydrocortisone .. 35, 84, 98, 120
hydrocortisone acetate .......... 84
hydrocortisone butyrate ........ 35
hydrocortisone butyr-emollient
.......................................... 35
hydrocortisone valerate ........ 35
hydrocortisone-acetic acid.. 126
hydrocortisone-aloe vera ...... 35
hydrocortisone-min oil-wht pet
.......................................... 84
hydromorphone ...................... 7
hydromorphone (pf) ............... 7
HYDROSKIN ...................... 84
hydroxocobalamin .............. 153
hydroxychloroquine ............. 48
hydroxyurea .......................... 40
hydroxyzine hcl .................... 60
hydroxyzine pamoate ........... 60
HYPERRAB (PF) .............. 114
HYPERRAB S/D (PF) ....... 114
I I.L.X. B-12 ......................... 153
ibandronate ......................... 121
IBRANCE ............................ 44
IBU ......................................... 5
ibuprofen ............................ 5, 6
ibuprofen-oxycodone.............. 2
ICAPS ................................. 139
I-CAPS ............................... 153
ICAPS AREDS................... 153
ICAPS MV ......................... 139
ICAPS PLUS ...................... 146
ICLUSIG .............................. 45
idarubicin .............................. 41
IDHIFA ................................ 45
IFEREX 150 ....................... 139
ifosfamide ............................. 38
ILARIS (PF) ....................... 115
imatinib ................................. 45
IMBRUVICA ....................... 45
IMFINZI ............................... 46
imipenem-cilastatin .............. 17
imipramine hcl ...................... 28
imipramine pamoate ............. 28
imiquimod ............................ 84
IMOVAX RABIES VACCINE
(PF) ................................. 117
INCRELEX .......................... 99
INCRUSE ELLIPTA .......... 129
indapamide ........................... 76
indomethacin .......................... 6
INFANRIX (DTAP) (PF) ... 117
INFED ................................ 139
INFLECTRA ...................... 112
INFUVITE ADULT ... 139, 140
INFUVITE PEDIATRIC .... 153
INGREZZA .......................... 81
INJECTAFER .................... 140
INLYTA ............................... 45
INSTA-GLUCOSE (WITH
DEXTRIN) ....................... 64
insulin syringe-needle u-100 86
INTEGRA .......................... 146
INTELENCE ........................ 56
intralipid ............................. 146
INTRON A ........................... 54
introvale .............................. 103
INVANZ ............................... 17
INVEGA SUSTENNA ......... 51
INVEGA TRINZA ............... 52
INVIRASE ..................... 58, 59
INVOKAMET ...................... 62
INVOKAMET XR ............... 62
INVOKANA ......................... 62
IOSAT ................................ 110
IPOL ................................... 117
ipratropium bromide ........... 129
ipratropium-albuterol .......... 133
irbesartan .............................. 71
irbesartan-hydrochlorothiazide
.......................................... 74
IRESSA ................................ 45
irinotecan .............................. 44
IRON .......................... 140, 146
IRON 100 PLUS ................. 146
iron,carbonyl-vitamin c ...... 153
ISENTRESS ......................... 56
ISENTRESS HD .................. 56
ISIBLOOM ......................... 103
ISOLYTE S PH 7.4 ............ 122
ISOLYTE-P IN 5 %
DEXTROSE ................... 134
ISOLYTE-S ........................ 122
isoniazid ................................ 37
isosorbide dinitrate ............... 79
isosorbide mononitrate ......... 79
isotretinoin ............................ 84
isradipine .............................. 73
ISTODAX ............................. 41
ITCH RELIEF ...................... 84
itraconazole ........................... 31
ivermectin ............................. 48
IXIARO (PF) ...................... 117
J JADENU ............................. 134
JADENU SPRINKLE ........ 134
JAKAFI ................................ 45
jantoven ................................ 67
JANUMET ........................... 62
JANUMET XR ..................... 62
JANUVIA ............................. 62
JARDIANCE ........................ 62
JENTADUETO .................... 62
170
JENTADUETO XR.............. 62
JEVTANA ............................ 44
jinteli................................... 103
jolivette ............................... 107
juleber ................................. 103
JULUCA............................... 56
junel 1.5/30 (21) ................. 103
junel 1/20 (21) .................... 103
junel fe 1.5/30 (28) ............. 103
junel fe 1/20 (28) ................ 103
JUXTAPID ........................... 78
K KADCYLA .................... 40, 41
KALETRA ........................... 59
KALYDECO ...................... 131
kariva (28) .......................... 103
kelnor 1/35 (28) .................. 103
KELNOR 1-50 ................... 103
ketoconazole ......................... 31
ketoprofen............................... 6
ketorolac ......................... 6, 125
KEVEYIS ............................. 76
KEYTRUDA ........................ 47
kimidess (28) ...................... 103
KINERET ........................... 112
KINRIX (PF) ...................... 117
kionex ................................. 134
kionex (with sorbitol) ......... 134
KISQALI .............................. 41
KISQALI FEMARA CO-
PACK ............................... 41
klor-con 10 ......................... 140
klor-con 8 ........................... 140
klor-con m10 ...................... 140
KLOR-CON M15 ............... 140
klor-con m20 ...................... 140
KLOR-CON SPRINKLE ... 140
KORLYM............................. 63
KRISTALOSE ..................... 94
K-SOL ................................ 140
KURVELO ......................... 103
KUVAN ............................... 87
KYNAMRO ......................... 78
KYPROLIS .......................... 42
L labetalol ................................ 72
lactase ................................... 90
lactated ringers ................... 146
LACTINOL HX ................... 84
lactulose ................................ 94
LAMISIL AT ....................... 31
lamivudine ............................ 54
lamivudine-zidovudine ......... 57
lamotrigine...................... 23, 24
lansoprazole .......................... 96
lanthanum ............................. 98
LANTUS SOLOSTAR U-100
INSULIN .......................... 65
LANTUS U-100 INSULIN .. 65
larin 1.5/30 (21) .................. 103
larin 1/20 (21) ..................... 103
larin fe 1.5/30 (28) .............. 104
larin fe 1/20 (28) ................. 104
larissia ................................. 104
LARTRUVO ........................ 47
latanoprost .......................... 126
LATUDA.............................. 52
LAXATIVE (BISACODYL)94
LAXATIVE PILLS
REGULAR ....................... 94
LAXATIVE PLUS STOOL
SOFTENER ...................... 96
LAZANDA ............................. 7
L-CARNITINE (TARTRATE)
........................................ 146
leena 28............................... 104
leflunomide ......................... 115
LENVIMA............................ 45
lessina ................................. 104
LETAIRIS .......................... 132
letrozole ................................ 43
leucovorin calcium ............... 42
LEUKERAN ........................ 38
LEUKINE ............................. 68
leuprolide ............................ 109
LEVA SET ............................. 8
levalbuterol hcl ................... 130
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 65
LEVEMIR U-100 INSULIN 65
levetiracetam ........................ 21
levetiracetam in nacl (iso-os) 21
levobunolol ......................... 124
levocarnitine ....................... 146
levocarnitine (with sugar) ... 146
levocetirizine ...................... 128
levofloxacin .......................... 20
levofloxacin in d5w .............. 20
levoleucovorin ...................... 42
LEVOLEUCOVORIN ......... 42
levonest (28) ....................... 104
levonorgestrel-ethinyl estrad
........................................ 104
levonorg-eth estrad triphasic
........................................ 104
levora-28 ............................. 104
levothyroxine ...................... 107
levoxyl ................................ 107
LEXIVA ............................... 59
LIALDA ............................. 120
lidocaine ................................. 8
lidocaine (pf) .......................... 8
lidocaine hcl ............................ 8
lidocaine-prilocaine ................ 8
LIDOPAC ............................... 8
lidopril .................................... 8
lidopril xr ................................ 8
LIDO-PRILO CAINE PACK . 9
LILLOW ............................. 104
lincomycin ............................ 13
lindane .................................. 48
linezolid ................................ 13
linezolid in dextrose 5% ....... 13
linezolid-0.9% sodium chloride
.......................................... 13
LINZESS .............................. 92
liothyronine ......................... 108
LIPOFLAVOVIT ............... 153
liprozonepak ........................... 9
lisinopril ................................ 71
lisinopril-hydrochlorothiazide
.......................................... 74
lithium carbonate .................. 61
lithium citrate ........................ 61
LIVALO ............................... 77
livixil pak ................................ 9
LO-DOSE ASPIRIN ............ 70
LONSURF ............................ 42
loperamide ............................ 90
lopinavir-ritonavir ................. 59
lopreeza ............................... 104
loratadine ............................ 128
lorazepam ............................. 61
lorazepam intensol ................ 61
losartan ................................. 71
losartan-hydrochlorothiazide 74
LOTRIMIN AF POWDER ... 84
lovastatin ............................... 77
low-ogestrel (28) ................ 104
loxapine succinate ................ 50
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Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
171
LUBRISOFT ........................ 70
LUMIGAN ......................... 126
LUMIZYME ...................... 127
LUPRON DEPOT .............. 109
LUPRON DEPOT (3
MONTH) ........................ 109
LUPRON DEPOT (4
MONTH) ........................ 109
LUPRON DEPOT (6
MONTH) ........................ 109
LUPRON DEPOT-PED ..... 109
LUPRON DEPOT-PED (3
MONTH) ........................ 109
lutera (28) ........................... 104
LYNPARZA......................... 42
LYRICA ............................... 22
LYSODREN....................... 108
lyza ..................................... 107
M M.V.I. ADULT................... 153
M.V.I. PEDIATRIC ........... 153
M.V.I.-12 (WITHOUT
VITAMIN K) ................. 140
MAG-DELAY ...................... 90
MAG-G .............................. 146
magnesium ......................... 140
magnesium citrate .......... 94, 96
magnesium oxide................ 140
magnesium sulfate .............. 140
malathion .............................. 48
MAPAP
(ACETAMINOPHEN) ....... 2
MAPAP ARTHRITIS PAIN .. 2
MAPAP EXTRA STRENGTH
............................................ 2
MAPAP PM ........................... 2
maprotiline ........................... 27
marlissa............................... 104
MARPLAN .......................... 26
MATULANE ....................... 38
MAVYRET .......................... 55
MAXIMUM D3 ................. 153
meclizine .............................. 28
meclofenamate ....................... 6
MEDERMA ......................... 84
MEDOLOR PAK ................... 9
medroxyprogesterone ......... 107
mefloquine ............................ 48
MEGA MULTI FOR WOMEN
........................................ 153
MEGA MULTIVITAMIN
FOR MEN ...................... 146
MEGA MULTIVITAMIN
WITH MINERAL .......... 154
megestrol ............................ 107
MEKINIST ........................... 45
melatonin ............................ 134
meloxicam .............................. 6
melphalan hcl ....................... 38
memantine ............................ 25
MENACTRA (PF) ............. 117
MENEST ............................ 101
MENOMUNE - A/C/Y/W-135
........................................ 117
MENOMUNE - A/C/Y/W-135
(PF) ................................. 117
MENTAX ............................. 31
MENVEO A-C-Y-W-135-DIP
(PF) ................................. 117
meperidine .............................. 8
MEPHYTON ........................ 68
meprobamate ........................ 60
mercaptopurine ..................... 40
meropenem ........................... 17
meropenem-0.9% sodium
chloride ............................. 17
mesalamine ......................... 120
mesalamine with cleansing
wipe ................................ 120
mesna .................................... 42
MESNEX.............................. 42
METAMUCIL (WITH
SUGAR) ........................... 94
METAMUCIL FIBER
SINGLES.......................... 94
METAMUCIL SUGAR-FREE
(ASPART) ........................ 94
METAMUCIL SUNRISE .... 94
metaproterenol .................... 130
metformin ....................... 62, 63
methadone ........................... 6, 7
methazolamide ...................... 76
methenamine hippurate ........ 13
methimazole ....................... 110
methocarbamol ................... 133
methotrexate sodium .......... 112
methotrexate sodium (pf) ... 112
methoxsalen .......................... 84
methscopolamine .................. 88
methyclothiazide ................... 76
methyldopa ........................... 70
methyldopa-
hydrochlorothiazide .......... 74
methyldopate ........................ 70
methylphenidate hcl ........ 80, 81
methylprednisolone .............. 35
methylprednisolone acetate .. 35
methylprednisolone sodium
succ ................................... 35
methyltestosterone .............. 100
metipranolol ........................ 125
metoclopramide hcl ........ 28, 29
metolazone ............................ 76
metoprolol succinate ............. 72
metoprolol tartrate ................ 72
metro i.v. ............................... 13
metronidazole ....................... 13
metronidazole in nacl (iso-os)
.......................................... 13
mexiletine ............................. 72
MIACALCIN ..................... 121
MI-ACID .............................. 90
MI-ACID GAS RELIEF ....... 90
MICONAZOLE 7 ................. 31
miconazole nitrate ................ 32
MICONAZORB AF ............. 32
microgestin 1.5/30 (21) ...... 104
microgestin 1/20 (21) ......... 104
microgestin fe 1.5/30 (28) .. 104
microgestin fe 1/20 (28) ..... 104
MICRO-GUARD ................. 32
midodrine .............................. 70
miglustat ............................... 87
MIGRAINE RELIEF ............ 36
172
MILK OF MAGNESIA 93, 94,
95
MIMVEY ........................... 104
mimvey lo ........................... 104
mineral oil ............................ 70
MINERAL OIL HEAVY ..... 94
MINERIN ............................. 84
MINERIN CREME .............. 84
minocycline .......................... 21
minoxidil .............................. 79
MINTOX .............................. 90
mirtazapine ........................... 26
misoprostol ........................... 96
mitomycin............................. 42
mitoxantrone......................... 44
M-M-R II (PF) .................... 117
MOBISYL ............................ 84
MODAFINIL ..................... 134
moexipril .............................. 71
moexipril-hydrochlorothiazide
.......................................... 75
mometasone .................. 35, 129
mononessa (28) .................. 104
montelukast ........................ 129
morgidox .............................. 21
MORGIDOX 1X 50 ............. 21
morphine............................. 7, 8
MOTION SICKNESS
RELIEF(MECLIZ) ........... 29
MOXEZA ............................. 20
moxifloxacin......................... 20
moxifloxacin in nacl (iso-osm)
.......................................... 20
moxifloxacin-sod.ace,sul-water
.......................................... 20
MOZOBIL ............................ 68
MULTAQ ............................. 72
MULTI-DELYN ................ 146
MULTI-DELYN WITH IRON
........................................ 154
MULTILEX ....................... 154
MULTILEX-T AND M ..... 154
MULTIPLE VITAMIN
ESSENTIAL................... 154
multivitamin ....................... 154
mupirocin ............................. 13
MURO 128 ......................... 123
MUSCLE RUB ...................... 3
MUSCLE RUB (WITH
CAMPHOR) ....................... 3
MUSTARGEN ..................... 38
MYCAMINE ........................ 32
mycophenolate mofetil ....... 112
mycophenolate mofetil hcl . 112
mycophenolate sodium ....... 112
MYKIDZ IRON ................. 140
MYLOTARG ....................... 47
myorisan ............................... 84
MYRBETRIQ ...................... 97
MYTAB GAS....................... 90
MYTAB GAS MAXIMUM
STRENGTH ..................... 90
N nabumetone ............................ 6
nadolol .................................. 72
nafcillin ................................. 18
nafcillin in dextrose iso-osm 18
NAGLAZYME ..................... 87
NAIL-EX ............................ 154
nalbuphine .............................. 8
naloxone ................................. 9
naltrexone ............................... 9
NAMENDA XR ................... 25
naphazoline ......................... 123
NAPHCON-A .................... 124
naproxen ................................. 6
naproxen sodium .................... 6
NASAL SPRAY
(OXYMETAZOLINE) ... 127
NASAL SPRAY 12 HOUR 127
NASCOBAL ...................... 154
NATACYN ........................ 123
nateglinide ............................ 63
NATPARA ......................... 121
NATURAL FIBER
LAXATIVE THERAPY .. 94
NATURAL VEGETABLE
(PSYLLIUM) ................... 95
NEBUPENT ......................... 48
necon 0.5/35 (28) ................ 104
necon 1/35 (28) ................... 104
necon 10/11 (28) ................. 104
necon 7/7/7 (28).................. 105
nefazodone............................ 26
neomycin .............................. 11
neomycin-bacitracin-poly-hc 14
neomycin-bacitracin-
polymyxin ......................... 14
neomycin-polymyxin b gu.... 14
neomycin-polymyxin b-
dexameth ........................... 14
neomycin-polymyxin-
gramicidin ......................... 14
neomycin-polymyxin-hc ...... 14,
126
NERLYNX ........................... 45
NEULASTA ......................... 68
NEUPOGEN ......................... 68
NEUPRO .............................. 49
nevirapine ............................. 56
NEXAVAR ........................... 45
niacin .................................... 78
niacin (inositol niacinate) ..... 78
niacinamide ........................... 78
NICODERM CQ .................. 10
nicotine ................................. 10
nicotine (polacrilex) .............. 10
NICOTROL .......................... 10
NICOTROL NS .................... 10
nifedical xl ............................ 73
nifedipine .............................. 73
nilutamide ............................. 39
nimodipine ............................ 73
NINLARO ............................ 42
NIPENT ................................ 40
NITRO-BID .......................... 79
NITRO-DUR ........................ 79
nitrofurantoin macrocrystal .. 14
nitrofurantoin monohyd/m-
cryst .................................. 14
nitroglycerin ......................... 79
NITYR .................................. 87
nizatidine .............................. 92
NOCTIVA ............................ 99
NON-ASPIRIN PAIN RELIEF
........................................ 3, 4
NON-ASPIRIN PM ................ 4
nora-be ................................ 107
NORDITROPIN FLEXPRO 99
norethindrone (contraceptive)
........................................ 107
norethindrone acetate .......... 107
norethindrone ac-eth estradiol
........................................ 105
norgestimate-ethinyl estradiol
........................................ 105
NORLYDA ......................... 105
norlyroc ............................... 107
normosol-r .......................... 140
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Document: 2018 Formulary
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Last Updated: 06/2018
Effective Date: 07-01-2018
173
normosol-r ph 7.4 ............... 140
NORPACE CR ..................... 72
NORTHERA ........................ 75
nortrel 0.5/35 (28) .............. 105
nortrel 1/35 (21) ................. 105
nortrel 1/35 (28) ................. 105
nortrel 7/7/7 (28) ................ 105
nortriptyline .......................... 28
NORVIR............................... 59
NOVAFERRUM ................ 141
NOVAFERRUM 125 ......... 141
NOVAFERRUM 50 ........... 141
NOVOLIN 70/30 U-100
INSULIN .......................... 65
NOVOLIN N NPH U-100
INSULIN .......................... 65
NOVOLIN R REGULAR U-
100 INSULN .................... 66
NOVOLOG FLEXPEN U-100
INSULIN .......................... 66
NOVOLOG MIX 70-30 U-100
INSULN ........................... 66
NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 66
NOVOLOG PENFILL U-100
INSULIN .......................... 66
NOVOLOG U-100 INSULIN
ASPART........................... 66
NOXAFIL ............................ 32
NUEDEXTA ........................ 81
NULOJIX ........................... 112
NUPLAZID .......................... 52
NUTROPIN AQ ................. 100
NUTROPIN AQ NUSPIN . 100
nyamyc ................................. 32
nystatin ................................. 32
nystatin-triamcinolone .......... 84
nystop ................................... 32
O OCALIVA ............................ 90
ocella .................................. 105
octreotide acetate ................ 109
OCTREOTIDE ACETATE 109
OCUVITE .......................... 154
OCUVITE LUTEIN AND
ZEAXANTHIN .............. 146
OCUVITE WITH LUTEIN 154
ODACTRA ......................... 127
ODEFSEY ............................ 58
ODOMZO ............................ 42
OFEV.................................... 45
ofloxacin ....................... 20, 126
olanzapine ............................. 52
olmesartan ............................ 71
olmesartan-amlodipin-
hcthiazid ........................... 75
olmesartan-
hydrochlorothiazide .......... 75
olopatadine ......................... 124
omega 3-dha-epa-fish oil .... 139
omega-3 acid ethyl esters ..... 78
omega-3 fatty acids-fish oil 154
omeprazole ........................... 96
OMNITROPE ..................... 100
ONCE DAILY .................... 154
ONCOVITE........................ 154
ondansetron .......................... 30
ondansetron hcl..................... 30
ondansetron hcl (pf).............. 30
ONE DAILY .............. 141, 154
ONE DAILY ESSENTIAL
................................ 146, 154
ONE DAILY MAXIMUM . 146
ONE DAILY MEN'S 50 PLUS
MEMORY ...................... 146
ONE DAILY PLUS IRON . 146
ONE DAILY WITH IRON 154
ONE DAILY WOMEN'S ... 146
ONE DAILY WOMEN'S
HEALTH ........................ 146
ONFI ..................................... 23
OPDIVO ............................... 47
OPTIMAL D3 .................... 154
ORENCIA .......................... 112
ORENCIA (WITH
MALTOSE) .................... 112
ORENCIA CLICKJECT .... 112
ORFADIN ............................ 87
ORKAMBI ......................... 131
orphenadrine citrate ............ 133
orsythia ............................... 105
OS-CAL 500 + D3.............. 146
oseltamivir ............................ 59
OTEZLA ............................. 112
OTEZLA STARTER .......... 113
oxaliplatin ............................. 38
oxandrolone ........................ 100
oxcarbazepine ....................... 24
oxybutynin chloride .............. 97
oxycodone ........................... 7, 8
oxycodone-acetaminophen ..... 3
oxycodone-aspirin .................. 3
OYSCO 500/D ............ 146, 154
OYSCO-500 ....................... 146
OYSTER SHELL + D3 ...... 149
OYSTER SHELL CALCIUM
500 .................................. 147
OYSTER SHELL CALCIUM-
VIT D3 ............................ 147
P paclitaxel ............................... 44
PAIN AND FEVER ............... 3
PAIN RELIEF .................... 2, 3
PAIN RELIEF EXTRA
STRENGTH ................... 2, 3
PAIN RELIEVER .............. 3, 4
PAIN RELIEVER EXTRA
STRENGTH ............... 2, 3, 4
paliperidone .......................... 52
pamidronate ........................ 121
PANRETIN .......................... 47
pantoprazole ................... 96, 97
pantothenic acid (vit b5) ..... 147
paricalcitol .......................... 121
paromomycin ........................ 11
paroxetine hcl ....................... 27
PASER .................................. 37
PAXIL .................................. 27
PEDIARIX (PF) ................. 117
PEDVAX HIB (PF) ............ 117
peg 3350-electrolytes ............ 94
peg-3350 with flavor packs .. 94
PEGANONE ......................... 24
PEGASYS ............................ 55
174
PEGASYS PROCLICK ....... 55
peg-electrolyte soln .............. 94
pen needle, diabetic .............. 86
penicillin g procaine ............. 18
penicillin g sodium ............... 18
penicillin v potassium........... 18
PENTACEL ACTHIB
COMPONENT (PF) ....... 118
PENTAM ............................. 48
PENTASA .......................... 120
pentazocine-naloxone ............. 3
pentoxifylline ....................... 76
periogard............................... 82
PERJETA ............................. 47
permethrin ............................ 48
perphenazine......................... 29
perphenazine-amitriptyline... 26
phenadoz............................... 29
phenelzine............................. 26
phenobarbital ........................ 23
PHENYTEK ......................... 24
phenytoin ........................ 24, 25
phenytoin sodium ................. 25
phenytoin sodium extended .. 25
PHOS-NAK ........................ 141
PHOSPHOLINE IODIDE .. 125
phytonadione (vitamin k1) ... 68
PICATO ............................... 40
pilocarpine hcl .............. 82, 125
pimozide ............................... 50
pimtrea (28) ........................ 105
PINK BISMUTH.................. 90
pioglitazone .......................... 63
pioglitazone-metformin ........ 63
piperacillin-tazobactam ........ 18
pirmella............................... 105
piroxicam ................................ 6
PLENAMINE ..................... 141
podofilox .............................. 84
polyethylene glycol 3350 ..... 94
POLY-IRON ...................... 141
polymyxin b sulfate .............. 14
polymyxin b sulf-trimethoprim
.......................................... 14
POLY-VI-SOL ................... 154
POLY-VI-SOL WITH IRON
........................................ 154
POLY-VITA....................... 155
POLY-VITA (IRON) ......... 155
POMALYST ........................ 39
portia ................................... 105
potassium chlorid-d5-
0.45%nacl ....................... 147
potassium chloride .............. 141
potassium chloride in lr-d5 . 141
potassium chloride in water 141
potassium citrate ................... 98
PRADAXA ........................... 67
PRALUENT PEN................. 78
PRALUENT SYRINGE ....... 78
pramipexole .......................... 49
pramoxine ............................... 3
prasugrel ............................... 70
pravastatin ............................ 77
praziquantel .......................... 48
prazosin ................................ 71
prednicarbate ........................ 84
prednisolone ......................... 35
prednisolone acetate ........... 125
prednisolone sodium phosphate
.................................. 36, 125
prednisone ............................ 36
prednisone intensol ............. 120
PREMARIN ....................... 101
PREMPHASE .................... 105
PREMPRO ......................... 105
PRENATAL VITAMIN PLUS
LOW IRON .................... 147
PRESERVISION AREDS . 147,
155
PRESERVISION AREDS 2
(OMEGA-3) ................... 155
PRESERVISION LUTEIN 141
prevalite ................................ 78
previfem.............................. 105
PREVYMIS .......................... 54
PREZCOBIX ........................ 59
PREZISTA ........................... 59
PRIFTIN ............................... 37
prilolid .................................... 9
PRIMAQUINE ..................... 48
primidone.............................. 23
PRIVIGEN ......................... 114
PRO FE............................... 141
probenecid ............................ 33
probenecid-colchicine .......... 33
prochlorperazine ................... 29
prochlorperazine edisylate .... 29
prochlorperazine maleate ..... 29
PROCRIT ............................. 68
procto-med hc ..................... 120
procto-pak ........................... 120
proctosol hc ........................ 120
proctozone-hc ..................... 120
progesterone micronized .... 107
PROGLYCEM ..................... 64
PROGRAF .......................... 113
PROLASTIN-C .................. 127
PROLEUKIN ....................... 42
PROLIA .............................. 122
PROMACTA ........................ 68
promethazine ........................ 29
promethazine vc .................. 127
promethazine-phenylephrine
........................................ 127
promethegan ......................... 29
propafenone .......................... 72
proparacaine ....................... 123
propranolol ........................... 72
propylthiouracil .................. 110
PROQUAD (PF) ................. 118
PRORENAL ....................... 155
PRORENAL QD ................ 155
PROSIGHT ......................... 155
protriptyline .......................... 28
PULMOZYME ................... 131
PURIXAN ............................ 40
pyrazinamide ........................ 37
pyridostigmine bromide ........ 37
pyridoxine (vitamin b6) ...... 155
Q Q-DRYL ............................. 128
Q-PAP ..................................... 4
Q-PAP EXTRA STRENGTH 4
QUADRACEL (PF) ........... 118
quasense .............................. 105
quetiapine ............................. 52
quinapril ................................ 71
quinapril-hydrochlorothiazide
.......................................... 75
quinidine gluconate .............. 72
quinidine sulfate ................... 72
quinine sulfate ...................... 48
QVAR ................................. 129
QVAR REDIHALER ......... 129
R RABAVERT (PF) .............. 118
RADICAVA ......................... 81
raloxifene ............................ 107
ramipril ................................. 71
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Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
175
RANEXA ............................. 76
ranitidine hcl ......................... 92
RAPAMUNE ..................... 113
rasagiline .............................. 49
RAVICTI .............................. 87
RAYOS ................................ 36
REBIF (WITH ALBUMIN) . 82
REBIF REBIDOSE .............. 82
REBIF TITRATION PACK 82
reclipsen (28) ...................... 105
RECOMBIVAX HB (PF) .. 118
RECTIV ............................... 90
REFRESH CLASSIC (PF) . 123
REFRESH LACRI-LUBE.. 123
REFRESH LIQUIGEL ....... 123
REFRESH OPTIVE ........... 123
REFRESH OPTIVE
SENSITIVE (PF)............ 123
REFRESH P.M. ................. 123
REFRESH PLUS ............... 123
REFRESH TEARS ............. 123
REGRANEX ........................ 85
REGULOID ......................... 95
REGULOID (PSYLLIUM
HUSK) .............................. 95
REGULOID, SUGAR FREE95
RELENZA DISKHALER .... 60
RELISTOR ..................... 90, 91
REMICADE ....................... 113
REMODULIN .................... 132
RENA-VITE....................... 155
RENFLEXIS ...................... 113
RENVELA ........................... 98
repaglinide ............................ 63
REPATHA PUSHTRONEX 78
REPATHA SURECLICK .... 78
REPATHA SYRINGE ......... 79
RESCRIPTOR ...................... 56
RESTASIS ......................... 123
RESTASIS MULTIDOSE . 123
RESTORA ............................ 91
RETROVIR .......................... 57
REVATIO .......................... 132
REVLIMID .......................... 39
REXULTI ............................. 52
REYATAZ ........................... 59
RIBAVIRIN ......................... 55
rifabutin ................................ 37
rifampin ................................ 37
RIFATER ............................. 37
riluzole .................................. 81
rimantadine ........................... 60
RISA-BID ............................. 91
RISACAL-D ....................... 147
RISAMINE ........................... 85
RISANOID PLUS .............. 147
RISAQUAD ......................... 91
risedronate .......................... 122
RISPERDAL CONSTA ....... 52
RISPERDAL M-TAB .......... 52
risperidone ...................... 52, 53
ritonavir ................................ 59
RITUXAN ............................ 47
RITUXAN HYCELA ........... 47
rivastigmine .......................... 25
rivastigmine tartrate .............. 25
rizatriptan.............................. 36
ROMIDEPSIN...................... 42
ropinirole .............................. 49
rosuvastatin ........................... 77
ROTARIX .......................... 118
ROTATEQ VACCINE....... 118
roweepra ............................... 22
ROWEEPRA ........................ 22
ROWEEPRA XR ................. 22
ROZEREM ......................... 134
RUBRACA ........................... 42
RYDAPT .............................. 45
S SABRIL ................................ 23
SALINE MIST ................... 127
SAMSCA............................ 134
SANDIMMUNE ................ 113
SANDOSTATIN LAR
DEPOT ........................... 109
SANTYL .............................. 85
SAPHRIS (BLACK
CHERRY) ........................ 53
SARNA ANTI-ITCH ........... 85
SAVELLA ............................ 81
scopolamine base .................. 29
SCYTERA ............................ 85
SEA-OMEGA ..................... 142
SEA-OMEGA 30 ................ 142
SEBEX ................................. 85
selegiline hcl ......................... 49
selenium .............................. 147
selenium sulfide .................... 85
selzentry ................................ 58
SELZENTRY ....................... 58
SENNA ........................... 93, 95
SENNA LAX ........................ 95
SENNA LAXATIVE ............ 96
SENNA PLUS ...................... 95
SENNA WITH DOCUSATE
SODIUM .......................... 93
SENNALAX-S ..................... 95
SENNA-S ............................. 95
SENSI-CARE ....................... 85
SENSIPAR ......................... 108
SENTRY (WITH LUTEIN)
........................................ 147
SENTRY SENIOR ............. 147
SEREVENT DISKUS ........ 130
SEROSTIM ........................ 100
sertraline ............................... 27
setlakin ................................ 105
sevelamer carbonate ............. 98
sharobel ............................... 107
SHINGRIX (PF) ................. 118
SHINGRIX GE ANTIGEN
COMPONENT ............... 118
SIGNIFOR .......................... 109
SILACE ................................ 95
sildenafil (antihypertensive)
........................................ 132
silver sulfadiazine ................. 20
SIMBRINZA ...................... 125
simethicone ..................... 90, 91
SIMPONI ............................ 113
SIMPONI ARIA ................. 113
SIMULECT ........................ 113
simvastatin ............................ 77
sirolimus ............................. 113
SIRTURO ............................. 38
176
SLOW FE ........................... 142
SLOW RELEASE IRON ... 139
SLOW-MAG ...................... 155
sodium bicarbonate .............. 91
sodium chlor 0.9% bacteriostat
.......................................... 70
sodium chloride .......... 123, 142
sodium chloride 0.45 % ...... 142
sodium chloride 0.9 % ........ 142
sodium chloride 3 % ........... 142
sodium ferric gluconat-sucrose
........................................ 142
sodium phenylbutyrate ......... 98
sodium polystyrene (sorb free)
........................................ 134
sodium polystyrene sulfonate
........................................ 134
SOLTAMOX ........................ 39
SOMATULINE DEPOT .... 109
SOMAVERT ...................... 110
sorine .................................... 72
sotalol ................................... 72
sotalol af ............................... 72
spinosad ................................ 48
SPIRIVA RESPIMAT ....... 130
SPIRIVA WITH
HANDIHALER .............. 130
spironolactone ...................... 76
spironolacton-hydrochlorothiaz
.......................................... 75
sprintec (28)........................ 105
SPRITAM............................. 22
SPRYCEL ............................ 45
sps (with sorbitol) ............... 135
sronyx ................................. 105
ssd ......................................... 20
stavudine............................... 57
STELARA .......................... 113
STIOLTO RESPIMAT ...... 133
STIVARGA .......................... 45
STOMACH RELIEF MAX
STRENGTH ..................... 91
STOOL SOFTENER 93, 95, 96
STOOL SOFTENER-
LAXATIVE ................ 95, 96
STOOL SOFTENER-
STIMULANT LAXAT .... 96
STRENSIQ ........................... 87
streptomycin ......................... 11
STRESS FORMULA ......... 142
STRESS FORMULA WITH
IRON .............................. 156
STRESS FORMULA WITH
ZINC ............................... 142
STRIBILD ............................ 56
STRIVERDI RESPIMAT .. 130
SUCRAID ............................ 87
sucralfate .............................. 96
sulfacetamide sodium ........... 20
sulfacetamide sodium (acne) 20
sulfacetamide-prednisolone 125
sulfadiazine ........................... 20
sulfamethoxazole-trimethoprim
.......................................... 20
sulfasalazine ............... 120, 121
sulindac ................................... 6
sumatriptan ........................... 36
sumatriptan succinate ..... 36, 37
SUPERPLEX-T .................. 156
SUPRAX .............................. 16
SUSTIVA ............................. 57
SUTENT ............................... 46
SWEEN CREAM ................. 85
SYLATRON ......................... 42
SYLVANT ........................... 42
SYMBICORT ..................... 132
SYMDEKO ........................ 131
SYMFI LO ........................... 58
SYMLINPEN 120 ................ 63
SYMLINPEN 60 .................. 63
SYNAGIS ............................. 60
SYNAREL.......................... 110
SYNDROS ........................... 30
SYNERCID .......................... 14
SYNJARDY ......................... 63
SYNRIBO ............................ 42
SYNTHROID ..................... 108
SYPRINE ............................. 87
SYSTANE (PF) .................. 124
SYSTANE (PROPYLENE
GLYCOL) ...................... 124
SYSTANE BALANCE ...... 124
SYSTANE ULTRA (PF).... 124
T TAB-A-VITE ..................... 156
TAB-A-VITE/IRON .......... 156
TAB-A-VITE-MINERALS 156
TABLOID ............................ 40
tacrolimus ..................... 85, 113
TAFINLAR .......................... 46
TAGRISSO ........................... 46
TAMIFLU ............................ 60
tamoxifen .............................. 39
tamsulosin ............................. 97
TANDEM DUAL ACTION
........................................ 142
TARCEVA ........................... 46
TARGRETIN ....................... 47
tarina fe 1/20 (28) ............... 106
TASIGNA ............................. 46
tazarotene .............................. 85
TAZICEF .............................. 16
TAZORAC ........................... 85
taztia xt ................................. 73
TEARS NATURALE FORTE
........................................ 124
TEARS PURE .................... 124
TECENTRIQ ........................ 47
TECFIDERA ........................ 82
TEFLARO ............................ 17
TEKTURNA ......................... 76
TEKTURNA HCT ................ 75
temazepam .......................... 133
TENIVAC (PF) .................. 118
tenofovir disoproxil fumarate
.......................................... 54
TEPADINA .......................... 38
terazosin ................................ 71
terbinafine hcl ....................... 32
terbutaline ........................... 131
terconazole ............................ 32
testosterone ......................... 100
testosterone cypionate ........ 100
tetanus,diphtheria tox ped(pf)
........................................ 118
tetanus-diphtheria toxoids-td
........................................ 118
tetrabenazine ......................... 81
THALOMID ......................... 39
theophylline ........................ 131
THERA ............................... 156
THERA M PLUS (FERROUS
FUMARAT) ................... 148
THERA-GEL ........................ 85
THERA-M .................. 142, 148
THERAPEUTIC LIQUID .. 153
THERAPEUTIC-M .... 148, 156
THEREMS-M ..................... 148
thiamine hcl (vitamin b1) ... 156
2018 First Choice VIP Care Plus Formulary
Document: 2018 Formulary
Formulary ID: 18395
Last Updated: 06/2018
Effective Date: 07-01-2018
177
thiamine mononitrate (vit b1)
........................................ 157
thioridazine ........................... 50
thiotepa ................................. 38
thiothixene ............................ 50
THYMOGLOBULIN ......... 115
THYROSAFE .................... 110
tiagabine ............................... 23
TICE BCG .......................... 118
timolol maleate ................... 125
TINACTIN ........................... 32
TIVICAY ............................. 56
tizanidine .............................. 54
TOBRADEX ........................ 11
tobramycin ............................ 11
tobramycin in 0.225 % nacl . 11
tobramycin sulfate ................ 11
tobramycin with nebulizer .... 11
tobramycin-dexamethasone .. 11
tolcapone .............................. 49
tolnaftate ............................... 32
tolterodine............................. 97
topiramate ............................. 24
topotecan .............................. 44
TORISEL ............................. 46
torsemide .............................. 76
TOTAL B/C ....................... 156
TOTECT............................... 42
TOVIAZ ............................... 97
TRACLEER ....................... 132
TRADJENTA ....................... 63
tramadol .................................. 8
tramadol-acetaminophen ........ 4
trandolapril ........................... 71
tranexamic acid .............. 68, 69
TRANSDERM-SCOP .......... 29
tranylcypromine ................... 26
TRAVATAN Z .................. 126
trazodone .............................. 26
TREANDA ........................... 38
TRECATOR ......................... 38
TRELSTAR ........................ 110
TREMFYA ......................... 113
tretinoin ................................ 85
tretinoin (chemotherapy) ...... 47
tretinoin (emollient) .............. 85
TREXALL .......................... 113
TRI FEMYNOR ................. 106
triamcinolone acetonide . 36, 82
triamterene-hydrochlorothiazid
.......................................... 75
triderm .................................. 36
TRIDERM ............................ 98
trientine ................................. 87
trifluoperazine ...................... 50
trifluridine ............................. 55
trihexyphenidyl ..................... 48
TRIKLO ............................... 79
tri-legest fe .......................... 106
trilyte with flavor packets ..... 96
trimethobenzamide ............... 29
trimethoprim ......................... 14
TRI-MILI............................ 106
trimipramine ......................... 28
trinessa (28) ........................ 106
TRINTELLIX ....................... 27
TRIPLE ANTIBIOTIC......... 14
TRIPLE ANTIBIOTIC PLUS
.......................................... 14
tri-previfem (28) ................. 106
TRISENOX .......................... 42
tri-sprintec (28) ................... 106
TRIUMEQ ............................ 58
TRI-VI-SOL ....................... 156
TRI-VITA ........................... 156
trivora (28) .......................... 106
TRI-VYLIBRA .................. 106
TROGARZO ........................ 58
TRULICITY ......................... 63
TRUMENBA...................... 118
TRUVADA .......................... 57
TUDORZA PRESSAIR ..... 130
TUMS ULTRA..................... 91
TWINRIX (PF)................... 119
TYBOST .............................. 58
TYKERB .............................. 46
TYMLOS............................ 122
TYPHIM VI ....................... 119
TYSABRI ........................... 115
U ULORIC ............................... 33
ULTIMATE WOMEN'S
COMPLETE 50+ ............ 155
UNICOMPLEX-M ............. 156
unithroid ............................. 108
UREACIN-10 ....................... 85
ursodiol ................................. 91
V VABOMERE ........................ 17
valacyclovir .......................... 55
VALCHLOR ........................ 38
valganciclovir ....................... 54
valproate sodium .................. 23
valproic acid ......................... 23
valproic acid (as sodium salt)
.......................................... 23
valsartan ................................ 71
valsartan-hydrochlorothiazide
.......................................... 75
vancomycin ........................... 15
vancomycin in 0.9 % sodium
chl ..................................... 15
vancomycin in dextrose 5 % . 15
VAQTA (PF) ...................... 119
VARIVAX (PF) .................. 119
VARIZIG ............................ 119
VAXCHORA BUFFER
COMPONENT ............... 119
VAXCHORA VACCINE ... 119
VECTIBIX ........................... 47
VELCADE ........................... 43
velivet triphasic regimen (28)
........................................ 106
VEMLIDY ............................ 54
VENCLEXTA ...................... 43
VENCLEXTA STARTING
PACK ............................... 43
venlafaxine ........................... 27
VENOFER .......... 142, 143, 148
VENTAVIS ........................ 132
VENTOLIN HFA ............... 131
verapamil ........................ 73, 74
VEREGEN ........................... 85
VERSACLOZ ....................... 53
178
VERZENIO .......................... 43
VICTOZA 2-PAK ................ 63
VICTOZA 3-PAK ................ 63
VIDEX 2 GRAM PEDIATRIC
.......................................... 57
VIDEX 4 GRAM PEDIATRIC
.......................................... 58
VIDEX EC ........................... 57
vienva ................................. 106
vigabatrin .............................. 23
VIGAMOX........................... 20
VIIBRYD ............................. 28
VIMPAT............................... 25
vinblastine ............................ 43
vincristine ............................. 43
vinorelbine ............................ 43
VIRACEPT .......................... 59
VIRAMUNE ........................ 57
VIREAD ............................... 55
vitamin a ..................... 156, 157
VITAMIN B-1............ 155, 157
VITAMIN B-12.................. 157
VITAMIN B-2.................... 157
VITAMIN B-6............ 157, 158
VITAMIN C ............... 158, 160
VITAMIN C DROPS ......... 158
VITAMIN D2 ..................... 156
VITAMIN D3 .... 143, 155, 156,
158, 159
vitamin e ............. 156, 159, 160
vitamin e (dl, acetate) 156, 159,
160
VITAMIN E NATURAL
BLEND........................... 156
VITAMIN K ......................... 69
VITAMIN K1 ....................... 69
VITAMINS AND MINERALS
........................................ 148
VITAMINS B COMPLEX. 157
vits a and d-white pet-lanolin
.......................................... 85
voriconazole ................... 32, 33
VOSEVI ............................... 55
VOTRIENT .......................... 46
VPRIV .................................. 87
VRAYLAR ........................... 53
vyfemla (28) ....................... 106
VYLIBRA .......................... 106
VYXEOS .............................. 43
W warfarin ................................ 67
WART REMOVER .............. 85
water for irrigation, sterile .. 122
WEE CARE ........................ 143
WELCHOL .......................... 79
WOMAN'S LAXATIVE ...... 96
X XALKORI ............................ 46
XARELTO ........................... 67
XATMEP............................ 114
XERMELO ........................... 91
XGEVA .............................. 122
XIFAXAN ............................ 15
XIIDRA .............................. 124
XOLAIR ............................. 133
XTANDI ............................... 39
xulane ................................. 106
XURIDEN ............................ 87
XYREM.............................. 134
Y YERVOY ............................. 47
YF-VAX (PF) ..................... 119
YONDELIS .......................... 43
yuvafem .............................. 101
Z zafirlukast ........................... 129
zaleplon .............................. 133
ZALTRAP ............................ 43
ZANOSAR ........................... 38
zarah ................................... 106
ZARXIO ............................... 68
ZAVESCA............................ 87
ZEJULA ............................... 46
ZELBORAF ......................... 46
ZEMAIRA .......................... 127
zenatane ................................ 86
ZENATANE ......................... 85
zenchent (28) ...................... 106
ZENPEP ............................... 88
ZEPATIER ........................... 55
ZERIT ................................... 58
ZIAGEN ............................... 58
zidovudine ............................ 58
zileuton ............................... 129
zinc gluconate ..................... 143
zinc oxide .............................. 86
zinc sulfate .......................... 143
ZINC WITH VITAMINS A
AND C ............................ 148
ziprasidone hcl ...................... 53
ZIRGAN ............................... 54
zoledronic acid .................... 122
zoledronic acid-mannitol-water
........................................ 122
ZOLINZA ............................. 43
zolpidem ............................. 134
ZOMETA ........................... 122
zonisamide ............................ 22
ZOO FRIENDS .................. 160
ZOO FRIENDS COMPLETE
........................................ 160
ZOO FRIENDS ORIGINAL
........................................ 148
ZORTRESS ........................ 114
ZORVOLEX ........................... 6
ZOSTAVAX (PF) .............. 119
zovia 1/35e (28) .................. 106
zovia 1/50e (28) .................. 106
ZOVIRAX ............................ 56
ZYCLARA ........................... 86
ZYDELIG ............................. 43
ZYFLO ............................... 129
ZYKADIA ............................ 46
ZYPREXA RELPREVV ...... 53
ZYTIGA ............................... 39
xiv
Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), los siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
FCVIPCPSC-17203 CS 2313
Actualizado 06/2018. Si tiene alguna pregunta, llame a First Choice VIP Care Plus al 1-888-978-0862 (TTY 711), de 8 a.m. a 8 p.m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.firstchoicevipcareplus.com.
H8213_001_FOR_2634_Approved_09202017_Final6
Todas las imágenes son utilizadas bajo licencia únicamente con fines ilustrativos. Cualquier persona representada es un modelo.