Triple-S Advantage 2015 Formulary (Lista de medicamentos

Transcripción

Triple-S Advantage
2015 Formulary
(Lista de medicamentos cubiertos)
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary ID: 00015499, Version 8
This formulary was updated on August, 2014. For more recent information or other questions, please contact
Triple S Advantage Customer Service at 1-888-620-1919 or, for TTY users, 1-866-620-2520, Monday to
Sunday from 8:00am to 8:00pm, or visit www.sssadvantage.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Triple-S Advantage, Inc. When it refers
to “plan” or “our plan,” it means Royal (HMO), Classic (HMO), Vital (HMO-SNP), Vital Plus (HMO-SNP),
Triples-S Advantage-Plan Grupal (HMO) y Triples-S Advantage-Plan Grupal (PPO).
This document includes a list of the drugs (formulary) for our plan which is current as of August, 2014. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time
during the year.
Triple-S Advantage 2015 Formulary
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¿What is the Triple-S Advantage Formulary?
A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers,
which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our
plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the
prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on
how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will
not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness of
a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued access
for the remainder of the coverage year to the formulary drugs that were available when you chose our plan,
except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of August, 2014. To get updated information about the drugs covered by our
plan, please contact us. Our contact information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are
listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the
category name in the list that begins on page 10. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page 73. The Index provides an alphabetical list of all of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn to the page listed in the
Index and find the name of your drug in the first column of the list.
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What are generic drugs?
Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having
the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:

Prior Authorization: Our plan requires you or your physician to get prior authorization for certain
drugs. This means that you will need to get approval from our plan before you fill your prescriptions.
If you don’t get approval, our plan may not cover the drug.

Quantity Limits: For certain drugs, our plan limit the amount of the drug that we will cover. For
example, our plan provides 14 tablets for 30 days per prescription for ciprofloxacin-ciproflox hcl er
1000 mg tab er 24 hr. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A
does not work for you, our plan will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 10. You can also get more information about the restrictions applied to specific covered drugs by
visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy
restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that
may treat your health condition. See the section, “How do I request an exception to the Triple-S Advantage
formulary?” on page 4 for information about how to request an exception.
¿What are Over the Counter (OTC) items?
OTC items are non-prescription items that are not normally covered by the Medicare Part D prescription drug
benefit. Our plan covers certain OTC drugs as part of a Management Program for Use. Our plan will provide
these items at free of cost. The total cost of these OTC items does not count toward your total expenses for
medications.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact our Call Center
and ask if your drug is covered.
If you learn that Triple-S Advantage does not cover your drug, you have two options:
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
You can ask our Call Center for a list of similar drugs that are covered by our plan. When you receive
the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

You can ask our plan to make an exception and cover your drug. See below for information about how
to request an exception.
How do I request an exception to the Triple-S Advantage Formulary?
You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you
can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty
tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
our plan limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us
to waive the limit and cover a greater amount.
Generally, our plan will only approve your request for an exception if the alternative drugs included on the
plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in
treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction
exception. When you request a formulary, tiering or utilization restriction exception you should submit a
statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription.You should talk to your doctor to decide if you
should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
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If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you
are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply
of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
The following is the transition process for current members. For more information you can contact Customer
Service.
1. You will receive a Part D drug supply not in the drug list (formulary) from your Part D drug
coverage or drugs that has a type of utilization requirement such as pre-authorization, step therapy
or quantity limit, automatically at the moment you visit one of the pharmacies within the network contracted
by Triple-S Advantage . Remember that this transition process does not apply to drugs excluded from your
Medicare Part D drug coverage or those drugs covered through Medicare Part B coverage.
2. You obtain a part D drug supply that is not listed in your drug list (formulary), for a 30 day period.
You and your doctor (the one who prescribed the medication) will receive a letter informing that
you received a transition supply and recommending that you and your doctor evaluate the Part D drug list
(formulary) for you to determine if any of the alternative drugs from your drug list (those include in the
formulary) can be used to treat your health condition. If your doctor understands that the alternative drugs
included in the Part D drug list (formulary) cannot be used to treat your health condition, you and your
doctor can request an exception by including the medical information that indicates the reason why the
doctor understands that you have a medical necessity to use a Part D drug not in the drug list (formulary)
from your health plan. To request an exception, refer to the part that explains the application process for Part
D exceptions.
3. Triple-S Advantage will provide a transition supply according to the following programs and limitations:
a. At your pharmacy (Retail) –You will receive only one supply per Part D drug transition not in the drug
list (formulary) for 30 days or less (as written in your medical prescription), during the first 90 in
which you start your coverage with Triple-S Advantage (starting as of the date in which you are eligible
for the first time with Triple-S Advantage (Transition in a retail pharmacy).
b. In a Long Term Care facility (LTC) – You will receive only one supply per transition of Part D drug
that is not in the drug list (formulary) for 31 days or less (according to the written prescription), during
the first 90 days in which you start coverage with Triple-S Advantage (beginning from the date in
which you are eligible for the first time with Triple-S Advantage (transition in a Long Term
Care (LTC) pharmacy). You may receive an emergency supply of 31 days or less (as written in your
drug prescription), after the expiration of the first 90 days of transition, if a supply of a Part D drug is
needed that is not included in the drug list (formulary) while you apply for an exception or a
preauthorization. You may receive a transition supply if you are admitted or released from a Long Term
Care (LTC) facility.
c. Emergency Transition Supply – If you are a member in a Long Term Care (LTC) facility, in
which the 90 day period has finalized and have applied for a drug exception and is waiting for the
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response of your application or pre-authorization, Triple-S Advantage will provide you with a 31
day emergency supply transition for Part D medication that is not included in your drug list, while the
exception process is completed. The exception that you applied for will not affect that you receive an
emergency transition supply.
d. Emergency Supply for members that change from one care place to another such as a Long Term care
(LTC) facility – Triple-S Advantage will provide an emergency transition supply of 31 days for those
members that begin in a Long Term Care facility (that are entering new in LTC). If the member is a
resident of the Long Term Care (LTC) facility, they need not to apply for an exception or preauthorization to receive an emergency transition supply for a Part D drug that is not in the drug list
(formulary).
e. Members that are not in a Long Term Care (LTC) facility and that changed their level of care. Triple-S
Advantage will provide a transition supply of 30 days or less as written the prescription at a
pharmacy (that releases retail drugs or the mail).
For more information
For more detailed information about your Triple-S Advantage prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about Triple-S Advantage, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
If you have questions about Triple-S Advantage, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages. If you have general questions about
Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a
day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Triple-S Advantage Formulary
The formulary below provides coverage information about the drugs covered by Triple-S Advantage. If you
have trouble finding your drug in the list, turn to the Index that begins on page 73. The first column of the chart
lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lowercase italics (e.g., diclofenac potassium). The information in the Requirements/Limits column tells you if TripleS Advantage has any special requirements for coverage of your drug.
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You can find information on what the symbols and abbreviations on this table mean by going to the following
chart:
DESCRIPCIÓN DE ABREVIATURAS PARA REQUISITOS / LÍMITES
Descripción
Abreviatura
High Risk [Medicamento de Alto Riesgo]
Home Infusión [Infusión en el Hogar]
This prescription drug may be covered under our medical benefit. For more information, call
Customer Services Department at 1-888-620-1919, from Monday to Sunday from 8:00am to
8:00pm. TTY users should call 1-866-620-2520.
Limit Access [Acceso Limitado]
This prescription may be available only at certain pharmacies. For more information consult
your Pharmacy Directory or call Customer Services Department at 1-888-620-1919, from
Monday to Sunday from 8:00am to 8:00pm. TTY users should call 1-866-620-2520.
Mail Order [Servicio por Correo]
MO
Prior Authorization [Pre Autorización]
PA
Prior Authorization B vs D [Pre Autorización B vs D]
HR
HI
LA
PA(*)
Quantity Limit [Límite de Cantidad]
QL
Step Therapy [Terapia Escalonada]
Coverage Gap [Brecha de Cubierta]
Ofrecemos cobertura adicional de este medicamento recetado en la brecha de cobertura. Por
favor, consulte la evidencia de cubierta para obtener más información acerca de esta cobertura.
ST
CG
This information is available for free in other languages. Please call our Customer Services Department at
1-888-620-1919, from Monday to Sunday from 8:00am to 8:00pm. TTY users should call 1-866-620-2520.
Esta información está disponible libre de costo en otros idiomas. Por favor, comuníquese con nuestro
Departamento de Servicio al Cliente al 1-888-620-1919 de lunes a domingo de 8:00am a 8:00pm. Audioimpedidos con equipo especializado de TTY deben llamar al 1-866-620-2520.
Triple-S Advantage is an HMO and PPO organization with a Medicare contract. Triple-S Advantage is an
independent Licensee of the Blue Cross and Blue Shield Association. Enrollment in Triple-S Advantage
depends on contract renewal.
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DOSAGE FORM AND ROUTE OF ADMINISTRATION, ABBREVIATIONS
[ABREVIATURAS DE FORMAS DE DOSIFICACIÓN Y RUTAS DE ADMINISTRACIÓN]
buccal tablet [tableta bucal]
Abbreviation
[Abreviatura]
bucc tab
concentrate [concentrado]
cream [crema]
conc
crm
delayed release [liberación tardía]
dr
emulsion [emulsión]
extended release [liberación prolongada]
emul
er
external liquid [líquido externo]
external liq
external packet [paquete externo]
external pckt
external shampoo [shampoo externo]
shampoo
external swab [hisopo externo]
swab
gel [gel]
gel
granules oral suspension reconstituted [suspensión oral reconstituida]
gr susp
hydrochlorothiazide
hctz
inhalation aerosol solution [solución en aerosol para inhalación]
inh aer
inhalation capsule [cápsula para inhalación]
inh cap
inhalation inhaler [inhalador para inhalación]
inhaler
Description [Descripción]
inhalation nebulization solution [solución para inhalación por nebulización] inh neb soln
inhalation solution [solución para inhalación]
inh soln
inhalation suspension [suspension para inhalación]
inh susp
injection / injectable [inyección / inyectable]
inj
injection device [dispositivo inyectable]
inj dev
intramuscular injectable [inyectable intramuscular]
im
intramuscular oil [aceite intramuscular]
im oil
lotion [loción]
lot
nasal inhaler [inhalador nasal]
nasal inh
ointment [ungüento]
oint
ophthalmic [oftálmico]
ophth
ophthalmic gel forming solution [solución oftálmica en gel]
ophth gel soln
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Description [Descripción]
oral capsule [cápsula oral]
Abbreviation
[Abreviatura]
cap
oral capsule delayed release particles [cápsula oral de partículas de liberación tardía] cap dr prt
oral capsule sprinkle [cápsula oral para espolvorear]
cap sprinkle
oral elixir [elixir oral]
oral elix
oral granules [granulos orales]
oral gr
oral packet [paquete oral]
pckt
oral syrup [jarabe oral]
syr
oral tablet [tableta oral]
tab
oral tablet chewable [tableta oral masticable]
tab chew
oral tablet dispersible [tableta oral dispersable]
odt
oral tablet soluble [tableta oral soluble]
tab sol
powder [polvo]
pwdr
rectal [rectal]
rect
solution [solución]
soln
spray external liquid [spray líquido externo]
spray liq
subcutaneous [subcutáneo]
sc
sublingual film [cinta sublingual]
subl film
sublingual tablet [tableta sublingual]
tab subl
suppository [supositorio]
supp
suspension [suspensión]
transdermal [transdermal]
transdermal patch [parcho transdermal]
transdermal patch biweekly [parcho transdermal bisemanal]
transdermal patch weekly [parcho transdermal semanal]
vaginal [vaginal]
susp
td
td patch
tdsw patch
tdwk patch
vag
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Drug
Drug Name [Nombre del
Tier
Reference Name
Requirements/Limits
Medicamento]
[Nivel] [Nombre de Referencia] [Requisitos/Límites]1
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [ANALGÉSICOS]
Analgesics (Combination Product) [Analgésicos (Productos En Combinación)]
acetaminophen-codeine 120-12
mg/5ml soln
2
QL(4500 / 30), CG
acetaminophen-codeine #2 300-15
mg tab
2
TYLENOL/CODEINE #2
QL(360 / 30), CG
TYLENOL WITH
mg tab
2
CODEINE #3
QL(360 / 30), CG
TYLENOL WITH
mg tab
2
CODEINE #4
QL(180 / 30), CG
butalbital-apap-caffeine 50-325-40 mg
QL(180 / 30), HR,
tab
1
FIORICET
CG
endocet 10-325 mg tab
2
PERCOCET
CG
endocet 5-325 mg tab
2
ROXICET
QL(360 / 30), CG
endocet 7.5-325 mg tab
2
PERCOCET
QL(240 / 30), CG
hydrocodone-acetaminophen 10-325
mg tab, 7.5-325 mg tab
2
PROCET
QL(180 / 30), CG
hydrocodone-acetaminophen 5-325
mg tab
2
PROCET
QL(360 / 30), CG
oxycodone-acetaminophen 10-325
mg tab
2
PERCOCET
QL(180 / 30), CG
oxycodone-acetaminophen 7.5-325
mg tab
2
PERCOCET
QL(240 / 30), CG
oxycodone-acetaminophen 2.5-325
mg tab, 5-325 mg tab
2
ROXICET
QL(360 / 30), CG
oxycodone-aspirin 4.8355-325 mg tab
2
PERCODAN
QL(360 / 30), CG
oxycodone-ibuprofen 5-400 mg tab
2
COMBUNOX
QL(120 / 30), CG
tramadol-acetaminophen 37.5-325 mg
tab
2
ULTRACET
QL(240 / 30), CG
Nonsteroidal Anti-Inflammatory Drugs [Medicamentos Antiinflamatorios No-Esteroidales]
CELEBREX 100 mg cap, 200 mg cap,
400 mg cap, 50 mg cap
3
ST, MO
diclofenac potassium 50 mg tab
1
CATAFLAM
MO, CG
diclofenac sodium 25 mg tab dr, 50
mg tab dr, 75 mg tab dr
2
VOLTAREN
MO, CG
diclofenac sodium er 100 mg tab er 24
hr
1
VOLTAREN-XR
MO, CG
etodolac 300 mg cap
2
LODINE
MO, CG
etodolac 200 mg cap, 400 mg tab,
500 mg tab
1
LODINE
MO, CG
1
Please refer to page 7 for a list of abbreviations for requirements/ limits
Page 10 of 87
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Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
[Nombre de Referencia] [Requisitos/Límites]1
etodolac er 400 mg tab er 24 hr, 500
mg tab er 24 hr, 600 mg tab er 24 hr
2
LODINE XL
MO, CG
flurbiprofen 100 mg tab, 50 mg tab
1
ANSAID
MO, CG
ibuprofen 100 mg/5ml susp
1
PEDIACARE FEVER
CG
ibuprofen 400 mg tab, 600 mg tab,
800 mg tab
1
RUFEN
MO, CG
indomethacin 25 mg cap, 50 mg cap
1
INDOCIN
PA, MO, HR, CG
ketoprofen 50 mg cap, 75 mg cap
1
ORUDIS
MO, CG
meloxicam 15 mg tab, 7.5 mg tab
1
MOBIC
MO, CG
nabumetone 500 mg tab, 750 mg tab
1
RELAFEN
MO, CG
naproxen 125 mg/5ml susp, 250 mg
tab, 375 mg tab, 500 mg tab
1
NAPROSYN
MO, CG
naproxen dr 375 mg tab dr, 500 mg
tab dr
1
EC-NAPROSYN
MO, CG
naproxen sodium 275 mg tab, 550 mg
tab
1
ANAPROX DS
MO, CG
piroxicam 10 mg cap, 20 mg cap
2
FELDENE
MO, CG
sulindac 150 mg tab, 200 mg tab
1
CLINORIL
MO, CG
Opioid Analgesics, Long-Acting [Opioides Analgésicos, Larga Duración]
duramorph 0.5 mg/ml inj soln, 1 mg/ml
inj soln
4
ASTRAMORPH
PA(*), HI
fentanyl 100 mcg/hr td patch 72 hr, 12
mcg/hr td patch 72 hr, 25 mcg/hr td
patch 72 hr, 50 mcg/hr td patch 72 hr,
PA, QL(15 / 30),
75 mcg/hr td patch 72 hr
2
DURAGESIC-75
CG
morphine sulfate er 100 mg tab er, 15
mg tab er, 30 mg tab er, 60 mg tab er
2
ORAMORPH SR
QL(90 / 30), CG
morphine sulfate er 200 mg tab er
2
MS CONTIN
QL(60 / 30), CG
OXYCONTIN Abuse-Deterr 10 mg tab
er 12 hr, 15 mg tab er 12 hr, 20 mg
tab er 12 hr, 30 mg tab er 12 hr, 40
mg tab er 12 hr, 60 mg tab er 12 hr,
80 mg tab er 12 hr
3
QL(120 / 30)
Opioid Analgesics, Short-Acting [Opioides Analgésicos, Corta Duración]
DEMEROL 50 mg/ml inj soln
4
PA, HR
FENTORA 100 mcg bucc tab, 200
mcg bucc tab, 400 mcg bucc tab, 600
mcg bucc tab, 800 mcg bucc tab
4
PA, QL(240 / 30)
hydromorphone hcl pf 500 mg/50ml inj
PA(*), QL(150 /
soln
2
DILAUDID-HP
30), CG
LAZANDA 100 mcg/act nasal soln,
400 mcg/act nasal soln
5
PA, QL(150 / 30)
meperidine hcl 50 mg/ml inj soln
2
DEMEROL
PA, HR, CG
1
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Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
morphine sulfate 15 mg tab, 30 mg
tab
2
MSIR
QL(180 / 30), CG
morphine sulfate (concentrate) 20
mg/ml soln
2
ROXANOL-T
CG
morphine sulfate (pf) 2 mg/ml iv soln,
4 mg/ml iv soln
2
PA(*), CG
tramadol hcl 50 mg tab
2
ULTRAM
QL(240 / 30), CG
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine 5 % external patch
2
LIDODERM
PA, CG
lidocaine 5 % oint
2
CG
lidocaine hcl 2 % inj soln, 2 % gel, 4
% soln
2
XYLOCAINE
CG
lidocaine hcl (pf) 0.5 % inj soln, 1 %
inj soln
2
XYLOCAINE-MPF
CG
lidocaine viscous 2 % mouth/throat
soln
1
XYLOCAINE VISCOUS
CG
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS [AGENTES CONTRA LA
ADICCIÓN/TRATAMIENTO DE ABUSO DE SUSTANCIAS]
Alcohol Deterrents/Anti-Craving [Disuasivos Del Alcohol]
acamprosate calcium 333 mg tab dr
2
CAMPRAL
MO, CG
CAMPRAL 333 mg tab dr
4
MO
disulfiram 250 mg tab
1
ANTABUSE
MO, CG
disulfiram 500 mg tab
2
ANTABUSE
MO, CG
Opioid Dependence Treatments [Tratamientos Para La Dependencia De Opiáceos]
PA, QL(360 / 30),
buprenorphine hcl 8 mg tab subl
2
SUBUTEX
CG
PA, QL(90 / 30),
buprenorphine hcl 2 mg tab subl
2
SUBUTEX
CG
buprenorphine hcl-naloxone hcl 8-2
PA, QL(90 / 30),
mg tab subl
2
SUBOXONE
CG
buprenorphine hcl-naloxone hcl 2-0.5
PA, QL(240 / 30),
mg tab subl
2
SUBOXONE
CG
naltrexone hcl 50 mg tab
2
REVIA
CG
SUBOXONE 8-2 mg subl film
4
PA, QL(90 / 30)
SUBOXONE 2-0.5 mg subl film
4
PA, QL(120 / 30)
4
PA, QL(180 / 30)
4
PA, QL(60 / 30)
Opioid Reversal Agents [Agentes De Reversión De Opiáceos]
naloxone hcl 1 mg/ml inj soln
2
NARCAN
CG
Smoking Cessation Agents [Agentes Para La Cesación De Fumar]
buproban 150 mg tab er 12 hr
2
ZYBAN
CG
bupropion hcl 100 mg tab, 75 mg tab
1
WELLBUTRIN
MO, CG
1
Page 12 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
bupropion hcl er (sr) 100 mg tab er 12
hr, 150 mg tab er 12 hr, 200 mg tab er
12 hr
1
WELLBUTRIN SR
MO, CG
bupropion hcl er (xl) 150 mg tab er 24
hr, 300 mg tab er 24 hr
1
WELLBUTRIN XL
MO, CG
CHANTIX 0.5 mg tab, 1 mg tab
4
PA, QL(336 / 365)
CHANTIX STARTING MONTH PAK
0.5 mg x 11 & 1 mg x 42 tab
4
PA, QL(56 / 28)
NICOTROL 10 mg inhaler
4
NICOTROL NS 10 mg/ml nasal soln
4
QL(360 / 365)
ANTIBACTERIALS [ANTIBACTERIANOS]
Aminoglycosides [Aminoglucósidos]
amikacin sulfate 1 gm/4ml inj soln
2
AMIKIN
PA(*), HI, CG
GENTAK 0.3 % ophth oint
1
CG
gentamicin sulfate 0.1 % crm, 0.1 %
oint
2
GARAMYCIN
CG
gentamicin sulfate 10 mg/ml iv soln,
40 mg/ml inj soln
2
GARAMYCIN
PA(*), HI, CG
gentamicin sulfate 0.3 % ophth oint,
0.3 % ophth soln
1
GENTAK
CG
neomycin sulfate 500 mg tab
2
CG
paromomycin sulfate 250 mg cap
2
HUMATIN
CG
streptomycin sulfate 1 gm im soln
2
CG
TOBI 300 mg/5ml inh neb soln
5
PA(*)
tobramycin 300 mg/5ml inh neb soln
5
TOBI
PA(*)
tobramycin 0.3 % ophth soln
1
TOMYCINE
CG
tobramycin sulfate 10 mg/ml inj soln,
80 mg/2ml inj soln
2
NEBCIN
PA(*), HI, CG
Antibacterials (Combination Product) [Antibacterianos (Productos En Combinación)]
SYNERCID 150-350 mg iv soln
4
PA(*)
Antibacterials, Other [Antibacterianos, Otros]
acetic acid 2 % otic soln
2
VOSOL
CG
alcohol preps
2
CG
baciim 50000 unit im soln
2
CG
bacitracin 500 unit/gm ophth oint,
50000 unit im soln
2
CG
chloramphenicol sod succinate 1 gm
iv soln
2
CHLOROMYCETIN
PA(*), HI, CG
CLEOCIN 100 mg vag supp, 75 mg
cap, 75 mg/5ml soln
4
clindamycin hcl 150 mg cap, 300 mg
cap, 75 mg cap
2
CLEOCIN
CG
clindamycin palmitate hcl 75 mg/5ml
soln
2
CLEOCIN
CG
1
Page 13 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
[Nombre de Referencia]
clindamycin phosphate 600 mg/4ml iv
soln
2
CLEOCIN PHOSPHATE
clindamycin phosphate 1 % gel, 1 %
lot, 1 % soln, 1 % swab, 2 % vag crm
2
PLEDGACLIN
clindamycin phosphate in d5w 300
mg/50ml iv soln, 600 mg/50ml iv soln,
900 mg/50ml iv soln
2
CLEOCIN IN D5W
colistimethate sodium 150 mg inj soln
2
COLY-MYCIN M
CUBICIN 500 mg iv soln
5
MACRODANTIN 25 mg cap
4
methenamine hippurate 1 gm tab
2
UREX
metronidazole 250 mg tab, 500 mg
tab
1
PROTOSTAT
metronidazole 0.75 % crm, 0.75 %
gel, 0.75 % lot, 0.75 % vag gel, 1 %
gel
2
VITAZOL
metronidazole in nacl 500-0.79
mg/100ml-% iv soln
2
FLAGYL
mupirocin 2 % oint
2
CENTANY
mupirocin calcium 2 % crm
2
BACTROBAN
nitrofurantoin macrocrystal 50 mg cap
2
MACRODANTIN
nitrofurantoin macrocrystal 100 mg
cap
2
MACRODANTIN
nitrofurantoin monohyd macro 100 mg
cap
2
MACROBID
polymyxin b sulfate 500000 unit inj
soln
2
trimethoprim 100 mg tab
1
TRIMPEX
TYGACIL 50 mg iv soln
5
vancomycin hcl 125 mg cap, 250 mg
cap
5
VANCOCIN HCL
vancomycin hcl 10 gm iv soln, 1000
mg iv soln, 500 mg iv soln
2
VANCOCIN HCL
VANDAZOLE 0.75 % vag gel
2
XIFAXAN 550 mg tab
5
ZYVOX 2 mg/ml iv soln
5
ZYVOX 100 mg/5ml susp, 600 mg tab
5
Beta-Lactam, Cephalosporins [Beta-Lactámicos, Cefalosporinas]
cefaclor 250 mg cap, 500 mg cap
2
CECLOR
cefaclor er 500 mg tab er 12 hr
2
CECLOR CD
cefadroxil 1 gm tab, 250 mg/5ml susp,
500 mg cap, 500 mg/5ml susp
2
DURICEF
Requirements/Limits
[Requisitos/Límites]1
PA(*), HI, CG
CG
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI
HR
CG
CG
CG
PA(*), CG
CG
CG
HR, CG
QL(30 / 90), HR,
CG
QL(30 / 90), HR,
CG
PA(*), HI, CG
CG
PA(*), HI
PA(*), HI, CG
CG
MO
PA(*), HI
PA
CG
CG
CG
1
Page 14 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
cefazolin sodium 1 gm inj soln, 1-5
gm-% iv soln, 10 gm inj soln, 500 mg
inj soln
2
KEFZOL
cefdinir 125 mg/5ml susp, 250 mg/5ml
susp, 300 mg cap
2
OMNICEF
cefepime hcl 1 gm inj soln, 2 gm inj
soln
2
MAXIPIME
cefotaxime sodium 1 gm inj soln, 10
gm inj soln, 2 gm inj soln, 500 mg inj
soln
2
CLAFORAN
cefoxitin sodium 1 gm iv soln, 10 gm
inj soln, 2 gm iv soln
2
MEFOXIN
cefpodoxime proxetil 100 mg tab, 100
mg/5ml susp, 200 mg tab, 50 mg/5ml
susp
2
VANTIN
cefprozil 125 mg/5ml susp, 250 mg
tab, 250 mg/5ml susp, 500 mg tab
2
CEFZIL
ceftazidime 1 gm inj soln, 2 gm inj
soln, 6 gm inj soln
2
TAZIDIME
ceftriaxone sodium 1 gm iv soln, 10
gm iv soln, 2 gm iv soln, 250 mg inj
soln, 500 mg inj soln
2
ROCEPHIN
cefuroxime axetil 250 mg tab, 500 mg
tab
2
CEFTIN
cefuroxime sodium 1.5 gm inj soln,
7.5 gm inj soln, 750 mg inj soln
2
ZINACEF
cephalexin 500 mg tab
2
cephalexin 125 mg/5ml susp, 250 mg
cap, 250 mg tab, 250 mg/5ml susp,
500 mg cap
1
KEFLEX
SUPRAX 400 mg cap, 400 mg tab
4
TEFLARO 400 mg iv soln, 600 mg iv
soln
4
Beta-Lactam, Other [Beta-Lactámicos, Otros]
aztreonam 1 gm inj soln
2
AZACTAM
DORIBAX 500 mg iv soln
4
imipenem-cilastatin 250 mg iv soln,
500 mg iv soln
2
PRIMAXIN IV
INVANZ 1 gm inj soln
4
meropenem 500 mg iv soln
2
MERREM
Beta-Lactam, Penicillins [Beta-Lactámicos, Penicilinas]
Requirements/Limits
PA(*), HI, CG
CG
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI, CG
CG
CG
PA(*), HI, CG
CG
CG
PA(*), HI, CG
CG
CG
PA(*)
PA(*), CG
PA(*), HI
PA(*), HI, CG
PA(*), HI
HI, CG
1
Page 15 of 87
Updated 08/2014
Medicamento]
amoxicillin 125 mg tab chew, 125
mg/5ml susp, 200 mg/5ml susp, 250
mg cap, 250 mg tab chew, 250
mg/5ml susp, 400 mg/5ml susp, 500
mg cap, 500 mg tab, 875 mg tab
amoxicillin-pot clavulanate 200-28.5
mg tab chew, 200-28.5 mg/5ml susp,
250-125 mg tab, 250-62.5 mg/5ml
susp, 400-57 mg tab chew, 400-57
mg/5ml susp, 500-125 mg tab, 60042.9 mg/5ml susp, 875-125 mg tab
amoxicillin-pot clavulanate er 100062.5 mg tab er 12 hr
ampicillin 125 mg/5ml susp, 250 mg
cap, 250 mg/5ml susp, 500 mg cap
ampicillin sodium 1 gm inj soln, 10 gm
iv soln, 125 mg inj soln
ampicillin-sulbactam sodium 15 (10-5)
gm iv soln, 3 (2-1) gm inj soln
BICILLIN C-R 1200000 unit/2ml im
susp
BICILLIN C-R 900/300 900000300000 unit/2ml im susp
BICILLIN L-A 1200000 unit/2ml im
susp, 2400000 unit/4ml im susp,
600000 unit/ml im susp
dicloxacillin sodium 250 mg cap, 500
mg cap
nafcillin sodium 1 gm inj soln, 10 gm
inj soln
NALLPEN IN DEXTROSE 1 gm/50ml
iv soln
oxacillin sodium 1 gm inj soln, 10 gm
inj soln
penicillin g potassium 5000000 unit inj
soln
penicillin g procaine 600000 unit/ml im
susp
penicillin g sodium 5000000 unit inj
soln
penicillin v potassium 125 mg/5ml
soln, 250 mg tab, 250 mg/5ml soln,
500 mg tab
PFIZERPEN-G 20000000 unit inj soln
Drug
Tier
[Nivel]
Reference Name
1
WYMOX
CG
2
AUGMENTIN ES-600
CG
2
AUGMENTIN XR
CG
1
TOTACILLIN
CG
2
TOTACILLIN-N
PA(*), HI, CG
2
UNASYN
PA(*), HI, CG
2
DYNAPEN
CG
2
UNIPEN
PA(*), HI, CG
Requirements/Limits
4
4
4
2
PA(*), HI, CG
2
BACTOCILL
PA(*), HI, CG
2
PFIZERPEN-G
PA(*), HI, CG
2
WYCILLIN
CG
2
1
4
PA(*), HI, CG
VEETIDS 250
CG
PA(*), HI
1
Page 16 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
piperacillin sod-tazobactam so 30.375 gm iv soln, 4-0.5 gm iv soln
2
ZOSYN
PA(*), HI, CG
TIMENTIN 3.1 gm iv soln
4
PA(*), HI
Macrolides [Macrólidos]
azithromycin 500 mg iv soln
2
ZITHROMAX
PA(*), HI, CG
azithromycin 100 mg/5ml susp, 200
mg/5ml susp, 250 mg tab, 500 mg
tab, 600 mg tab
2
ZITHROMAX
CG
clarithromycin 125 mg/5ml susp, 250
mg tab, 250 mg/5ml susp, 500 mg tab
2
BIAXIN
CG
clarithromycin er 500 mg tab er 24 hr
2
BIAXIN XL PAC
CG
E.E.S. 400 400 mg tab
4
E.E.S. GRANULES 200 mg/5ml susp
4
ery 2 % external pad
2
T-STAT
CG
ERYPED 200 200 mg/5ml susp
4
ERYPED 400 400 mg/5ml susp
4
ERY-TAB 250 mg tab dr, 333 mg tab
dr, 500 mg tab dr
4
ERYTHROCIN LACTOBIONATE 500
mg iv soln
4
PA(*)
ERYTHROCIN STEARATE 250 mg
tab
4
erythromycin 2 % gel, 2 % soln
2
THERAMYCIN Z
CG
erythromycin 5 mg/gm ophth oint
1
ILOTYCIN
CG
erythromycin base 250 mg tab, 500
mg tab
2
ERY-TAB
CG
erythromycin ethylsuccinate 400 mg
tab
2
E.E.S. 400
CG
ZMAX 2 gm susp
4
Quinolones [Quinolonas]
AVELOX 400 mg/250ml iv soln
4
PA(*), HI
ciprofloxacin 400 mg/40ml iv soln
2
CIPRO
PA(*), HI, CG
ciprofloxacin 250 mg/5ml (5%) susp,
500 mg/5ml (10%) susp
2
CIPRO
CG
ciprofloxacin hcl 100 mg tab, 250 mg
2
CIPRO XR
CG
ciprofloxacin hcl 0.3 % ophth soln
1
CILOXAN
CG
ciprofloxacin in d5w 200 mg/100ml iv
soln
2
CIPRO IN D5W
PA(*), HI, CG
ciprofloxacin-ciproflox hcl er 500 mg
tab er 24 hr
2
CIPRO XR
QL(28 / 30), CG
ciprofloxacin-ciproflox hcl er 1000 mg
tab er 24 hr
2
CIPRO XR
QL(14 / 30), CG
levofloxacin 25 mg/ml iv soln
2
LEVAQUIN
PA(*), HI, CG
1
Page 17 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
levofloxacin 25 mg/ml soln, 250 mg
2
LEVAQUIN LEVA-PAK
CG
levofloxacin in d5w 500 mg/100ml iv
soln
2
LEVAQUIN
PA(*), HI, CG
moxifloxacin hcl 400 mg tab
2
AVELOX ABC PACK
CG
ofloxacin 0.3 % ophth soln
1
OCUFLOX
CG
ofloxacin 0.3 % otic soln, 200 mg tab,
300 mg tab, 400 mg tab
2
FLOXIN
CG
VIGAMOX 0.5 % ophth soln
3
Sulfonamides [Sulfonamidas]
silver sulfadiazine 1 % crm
2
THERMAZENE
CG
SSD 1 % crm
2
CG
sulfacetamide sodium 10 % ophth
soln
1
SULF-10
CG
sulfacetamide sodium 10 % ophth
oint, 10 % external susp
2
KLARON
CG
sulfadiazine 500 mg tab
2
MICROSULFON
CG
sulfamethoxazole-tmp ds 800-160 mg
tab
1
SEPTRA DS
CG
sulfamethoxazole-trimethoprim 20040 mg/5ml oral susp
2
SULFATRIM PEDIATRIC
CG
sulfamethoxazole-trimethoprim 40080 mg/5ml iv soln
1
SEPTRA
PA(*), HI, CG
sulfamethoxazole-trimethoprim 40080 mg tab
1
SEPTRA
CG
Tetracyclines [Tetraciclinas]
demeclocycline hcl 150 mg tab, 300
mg tab
2
DECLOMYCIN
CG
doxycycline hyclate 100 mg tab dr,
150 mg tab dr, 75 mg tab dr
2
DORYX
CG
doxycycline hyclate 100 mg cap, 100
mg tab, 50 mg cap
1
VIBRAMYCIN
CG
doxycycline monohydrate 150 mg tab,
25 mg/5ml susp, 50 mg tab, 75 mg
cap, 75 mg tab
2
VIBRAMYCIN
CG
minocycline hcl 100 mg cap, 50 mg
cap, 75 mg cap
2
VECTRIN
CG
VIBRAMYCIN 50 mg/5ml syr
4
ANTICONVULSANTS [ANTICONVULSIVOS]
Anticonvulsants, Other [Anticonvulsivos, Otros]
levetiracetam 1000 mg tab, 250 mg
1
KEPPRA
MO, CG
levetiracetam 500 mg/5ml iv soln
2
KEPPRA
PA(*), HI, CG
levetiracetam 100 mg/ml soln
2
KEPPRA
MO, CG
1
Page 18 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
levetiracetam er 500 mg tab er 24 hr,
750 mg tab er 24 hr
2
KEPPRA XR
MO, CG
POTIGA 200 mg tab
5
MO
POTIGA 300 mg tab, 400 mg tab, 50
mg tab
4
MO
Calcium Channel Modifying Agents [Agentes Modificadores De Los Canales De Calcio]
CELONTIN 300 mg cap
4
MO
ethosuximide 250 mg cap, 250
mg/5ml soln
2
ZARONTIN
MO, CG
LYRICA 20 mg/ml soln
4
QL(900 / 30), MO
LYRICA 100 mg cap, 150 mg cap,
200 mg cap, 225 mg cap, 25 mg cap,
300 mg cap, 50 mg cap, 75 mg cap
4
MO
zonisamide 100 mg cap, 25 mg cap,
50 mg cap
1
ZONEGRAN
MO, CG
Gamma-Aminobutyric Acid (Gaba) Augmenting Agents [Agentes Que Aumentan El Ácido
Gamma-Aminobutírico (Gaba)]
QL(300 / 30), MO,
clonazepam 2 mg tab, 2 mg odt
2
KLONOPIN WAFER
CG
clonazepam 0.125 mg odt, 0.25 mg
odt, 0.5 mg tab, 0.5 mg odt, 1 mg tab,
QL(120 / 30), MO,
1 mg odt
2
KLONOPIN WAFER
CG
diazepam 2 mg tab
2
VALIUM
QL(360 / 30), CG
diazepam 10 mg tab
2
VALIUM
QL(120 / 30), CG
diazepam 5 mg tab
2
VALIUM
QL(240 / 30), CG
diazepam 1 mg/ml soln, 10 mg rect
gel, 2.5 mg rect gel, 20 mg rect gel
2
DIASTAT UNIVERSAL
CG
DIAZEPAM INTENSOL 5 mg/ml oral
conc
2
CG
divalproex sodium 125 mg cap
sprinkle
2
DEPAKOTE SPRINKLES
MO, CG
divalproex sodium 125 mg tab dr, 250
mg tab dr, 500 mg tab dr
1
DEPAKOTE
MO, CG
divalproex sodium er 250 mg tab er
24 hr
1
DEPAKOTE ER
MO, CG
divalproex sodium er 500 mg tab er
24 hr
2
DEPAKOTE ER
MO, CG
gabapentin 100 mg cap, 300 mg cap,
400 mg cap
1
NEURONTIN
MO, CG
gabapentin 250 mg/5ml soln, 600 mg
tab, 800 mg tab
2
NEURONTIN
MO, CG
GABITRIL 12 mg tab, 16 mg tab, 2
mg tab, 4 mg tab
4
MO
1
Page 19 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
lorazepam 0.5 mg tab, 1 mg tab, 2 mg
tab
2
ATIVAN
LORAZEPAM INTENSOL 2 mg/ml
oral conc
2
ONFI 10 mg tab, 2.5 mg/ml susp, 20
mg tab
4
phenobarbital 100 mg tab, 15 mg tab,
16.2 mg tab, 20 mg/5ml oral elix, 30
mg tab, 32.4 mg tab, 60 mg tab, 64.8
mg tab, 97.2 mg tab
2
primidone 250 mg tab, 50 mg tab
1
MYSOLINE
SABRIL 500 mg pckt, 500 mg tab
5
tiagabine hcl 2 mg tab, 4 mg tab
2
GABITRIL
valproate sodium 100 mg/ml iv soln
2
DEPACON
valproic acid 250 mg cap, 250 mg/5ml
syr
1
DEPAKENE
Glutamate Reducing Agents [Agentes Reductores De Glutamato]
felbamate 400 mg tab, 600 mg tab,
600 mg/5ml susp
2
FELBATOL
FYCOMPA 10 mg tab, 12 mg tab, 2
mg tab, 4 mg tab, 6 mg tab, 8 mg tab
4
lamotrigine 100 mg tab, 150 mg tab,
200 mg tab, 25 mg tab chew, 25 mg
tab, 5 mg tab chew
1
LAMICTAL
topiramate 100 mg tab, 15 mg cap
sprinkle, 200 mg tab, 25 mg cap
sprinkle, 25 mg tab, 50 mg tab
1
TOPIRAGEN
Sodium Channel Agents [Agentes De Los Canales De Sodio]
APTIOM 200 mg tab, 400 mg tab, 600
mg tab, 800 mg tab
4
BANZEL 200 mg tab, 40 mg/ml susp,
400 mg tab
4
carbamazepine 100 mg tab chew, 200
mg tab
1
TEGRETOL
carbamazepine 100 mg/5ml susp
2
TEGRETOL
carbamazepine er 200 mg tab er 12
2
TEGRETOL-XR
DILANTIN 100 mg cap, 125 mg/5ml
susp, 30 mg cap
4
DILANTIN INFATABS 50 mg tab
chew
4
oxcarbazepine 150 mg tab, 300 mg
tab, 600 mg tab
1
TRILEPTAL
oxcarbazepine 300 mg/5ml susp
2
TRILEPTAL
Requirements/Limits
QL(90 / 30), CG
CG
MO
MO, HR, CG
MO, CG
LA, MO
MO, CG
PA(*), HI, CG
MO, CG
MO, CG
MO
MO, CG
MO, CG
MO
MO
MO, CG
MO, CG
MO, CG
MO
MO
MO, CG
MO, CG
1
Page 20 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
OXTELLAR XR 150 mg tab er 24 hr,
300 mg tab er 24 hr, 600 mg tab er 24
hr
4
MO
PEGANONE 250 mg tab
4
MO
phenytoin 125 mg/5ml susp, 50 mg
tab chew
2
PHENYTOIN INFATABS
MO, CG
phenytoin sodium 50 mg/ml inj soln
2
PA(*), HI, CG
phenytoin sodium extended 100 mg
cap, 200 mg cap, 300 mg cap
2
PHENYTEK
MO, CG
TEGRETOL-XR 100 mg tab er 12 hr
4
MO
VIMPAT 10 mg/ml soln, 100 mg tab,
150 mg tab, 200 mg tab, 50 mg tab
4
MO
VIMPAT 200 mg/20ml iv soln
4
PA(*), HI
ANTIDEMENTIA AGENTS [AGENTES CONTRA LA DEMENCIA]
Antidementia Agents, Other [Agentes Contra La Demencia, Otros]
ergoloid mesylates 1 mg tab
2
HYDERGINE
PA, MO, HR, CG
Cholinesterase Inhibitors [Inhibidores De La Colinesterasa]
donepezil hcl 23 mg tab
2
ARICEPT
MO, CG
donepezil hcl 10 mg tab, 10 mg odt, 5
mg tab, 5 mg odt
1
ARICEPT ODT
MO, CG
EXELON 13.3 mg/24hr td patch 24hr,
4.6 mg/24hr td patch 24hr, 9.5
mg/24hr td patch 24hr
4
MO
galantamine hydrobromide 12 mg tab,
4 mg tab, 4 mg/ml soln, 8 mg tab
2
REMINYL
MO, CG
galantamine hydrobromide er 16 mg
cap er 24 hr, 24 mg cap er 24 hr, 8
mg cap er 24 hr
2
RAZADYNE ER
MO, CG
rivastigmine tartrate 1.5 mg cap, 3 mg
cap, 4.5 mg cap, 6 mg cap
2
EXELON
MO, CG
N-Methyl-D-Aspartate (NMDA) Receptor Antagonist [Agonistas Del Receptor N-Metil-DAspartato (NMDA)]
NAMENDA 10 mg/5ml soln
3
MO
NAMENDA XR 14 mg cap er 24 hr, 21
mg cap er 24 hr, 28 mg cap er 24 hr,
7 mg cap er 24 hr
4
MO
NAMENDA XR TITRATION PACK 7 &
14 & 21 &28 mg cap er 24 hr
4
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Antidepressants, Other [Antidepresivos, Otros]
ABILIFY 9.75 mg/1.3ml im soln
4
ST
1
Page 21 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
ABILIFY 1 mg/ml soln, 10 mg tab, 15
mg tab, 2 mg tab, 20 mg tab, 30 mg
tab, 5 mg tab
4
ST, MO
ABILIFY DISCMELT 10 mg odt, 15
mg odt
4
ST, MO
ABILIFY MAINTENA 300 mg im susp
4
ST, MO
mirtazapine 15 mg tab, 30 mg tab, 45
mg tab, 7.5 mg tab
1
REMERON
MO, CG
mirtazapine 15 mg odt, 30 mg odt, 45
mg odt
2
REMERON SOLTAB
MO, CG
quetiapine fumarate 100 mg tab, 200
mg tab, 25 mg tab, 300 mg tab, 400
mg tab, 50 mg tab
1
SEROQUEL
MO, CG
SEROQUEL XR 150 mg tab er 24 hr,
24 hr
4
ST, MO
Monoamine Oxidase Inhibitors [Inhibidores De La Monoaminoxidasa]
EMSAM 12 mg/24hr td patch 24hr, 6
mg/24hr td patch 24hr, 9 mg/24hr td
patch 24hr
4
MO
MARPLAN 10 mg tab
4
MO
phenelzine sulfate 15 mg tab
2
NARDIL
MO, CG
tranylcypromine sulfate 10 mg tab
2
PARNATE
MO, CG
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin - Norepinephrine Reuptake
Inhibitors) [SSRIs/SNRIs (Inhibidores De La Recaptación De Serotonina/Inhibidores De La
Recaptación De Serotonina-Norepinefrina)]
citalopram hydrobromide 10 mg tab,
citalopram hydrobromide 10 mg/5ml
soln
desvenlafaxine er 100 mg tab er 24
escitalopram oxalate 10 mg tab, 20
mg tab, 5 mg tab, 5 mg/5ml soln
fluoxetine hcl 60 mg tab
fluoxetine hcl 10 mg cap, 10 mg tab,
20 mg cap, 20 mg tab, 20 mg/5ml
soln, 40 mg cap
fluvoxamine maleate 100 mg tab, 25
mg tab, 50 mg tab
maprotiline hcl 25 mg tab, 50 mg tab,
75 mg tab
1
CELEXA
MO, CG
2
CELEXA
2
KHEDEZLA
MO, CG
QL(30 / 30), ST,
MO, CG
1
2
LEXAPRO
MO, CG
MO, CG
1
RAPIFLUX
MO, CG
2
LUVOX
MO, CG
2
LUDIOMIL
MO, CG
1
Page 22 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
nefazodone hcl 100 mg tab, 150 mg
tab, 200 mg tab, 250 mg tab, 50 mg
tab
2
SERZONE
MO, CG
paroxetine hcl 10 mg tab, 20 mg tab,
1
PAXIL
MO, CG
paroxetine hcl er 12.5 mg tab er 24 hr,
25 mg tab er 24 hr, 37.5 mg tab er 24
hr
2
PAXIL CR
MO, CG
PAXIL 10 mg/5ml susp
4
ST, MO
PRISTIQ 100 mg tab er 24 hr, 50 mg
QL(30 / 30), ST,
tab er 24 hr
4
MO
sertraline hcl 100 mg tab, 25 mg tab,
50 mg tab
1
ZOLOFT
MO, CG
sertraline hcl 20 mg/ml oral conc
2
ZOLOFT
MO, CG
trazodone hcl 100 mg tab, 150 mg
tab, 50 mg tab
1
DESYREL
MO, CG
venlafaxine hcl 100 mg tab, 25 mg
tab, 37.5 mg tab, 50 mg tab, 75 mg
tab
1
EFFEXOR
MO, CG
venlafaxine hcl er 150 mg cap er 24 hr
1
EFFEXOR XR
MO, CG
venlafaxine hcl er 37.5 mg cap er 24
QL(60 / 30), MO,
hr, 75 mg cap er 24 hr
1
EFFEXOR XR
CG
VIIBRYD 10 mg tab, 20 mg tab, 40
mg tab
4
ST, MO
VIIBRYD 10 & 20 & 40 mg oral kit
4
ST
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin And Norepinephrine
Reuptake Inhibitor [SSRIs/SNRIs (Inhibidores de la Recaptación de Serotonina/Inhibidores
de la Recaptación de Serotonina y Norepinefrina)]
BRINTELLIX 10 mg tab, 20 mg tab, 5
mg tab
4
MO
duloxetine hcl 20 mg cap dr prt, 30 mg
cap dr prt, 60 mg cap dr prt
2
CYMBALTA
MO, CG
duloxetine hcl 20 mg cap dr prt, 30 mg
cap dr prt, 60 mg cap dr prt
2
CYMBALTA
MO, CG
FETZIMA 120 mg cap er 24 hr, 20 mg
mg cap er 24 hr
4
ST, MO
FETZIMA TITRATION 20 & 40 mg
cap er 24 hr
4
ST
Tricyclics [Tricíclicos]
amitriptyline hcl 10 mg tab, 100 mg
tab, 75 mg tab
2
ELAVIL
PA, MO, HR, CG
1
Page 23 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Medicamento]
amoxapine 100 mg tab, 150 mg tab,
2
clomipramine hcl 25 mg cap, 50 mg
cap, 75 mg cap
2
desipramine hcl 10 mg tab, 100 mg
tab, 75 mg tab
2
doxepin hcl 10 mg cap, 10 mg/ml oral
conc, 100 mg cap, 150 mg cap, 25 mg
cap, 75 mg cap
2
doxepin hcl 50 mg cap
1
imipramine hcl 10 mg tab, 25 mg tab,
50 mg tab
2
imipramine pamoate 100 mg cap, 125
mg cap, 150 mg cap, 75 mg cap
2
nortriptyline hcl 10 mg/5ml soln
2
nortriptyline hcl 10 mg cap, 25 mg
1
protriptyline hcl 10 mg tab, 5 mg tab
2
SURMONTIL 100 mg cap, 25 mg cap,
50 mg cap
4
ANTIEMETICS [ANTIEMÉTICOS]
Antiemetics, Other [Antieméticos, Otros]
chlorpromazine hcl 10 mg tab, 100 mg
tab, 200 mg tab, 25 mg tab, 50 mg tab
2
chlorpromazine hcl 25 mg/ml inj soln
2
diphenhydramine hcl 50 mg/ml inj soln
2
meclizine hcl 12.5 mg tab, 25 mg tab
1
metoclopramide hcl 5 mg/ml inj soln
1
metoclopramide hcl 10 mg tab, 5 mg
tab, 5 mg/5ml soln
1
perphenazine 16 mg tab, 2 mg tab, 4
mg tab, 8 mg tab
2
PHENADOZ 12.5 mg rect supp
1
prochlorperazine 25 mg rect supp
1
prochlorperazine edisylate 5 mg/ml inj
soln
2
prochlorperazine maleate 10 mg tab,
5 mg tab
1
promethazine hcl 12.5 mg rect supp,
25 mg rect supp
2
PROMETHEGAN 25 mg rect supp
2
TRANSDERM-SCOP 1.5 mg td patch
72 hr
4
Reference Name
Requirements/Limits
ASENDIN
MO, CG
ANAFRANIL
PA, MO, HR, CG
NORPRAMIN
MO, CG
SINEQUAN
SINEQUAN
PA, MO, HR, CG
PA, MO, HR, CG
TOFRANIL
PA, MO, HR, CG
TOFRANIL-PM
PAMELOR
PA, MO, HR, CG
MO, CG
PAMELOR
VIVACTIL
MO, CG
MO, CG
PA, MO, HR
THORAZINE
THORAZINE
BENADRYL
ANTIVERT
REGLAN
MO, CG
PA(*), HI, CG
PA(*), HI, CG
CG
PA(*), HI, CG
REGLAN
CG
TRILAFON
COMPRO
MO, CG
HR, CG
CG
COMPAZINE
CG
COMPAZINE
MO, CG
PROMETHEGAN
HR, CG
HR, CG
QL(10 / 30)
1
Page 24 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
Emetogenic Therapy Adjuncts [Terapias Adyuvantes Emetogénicas]
dronabinol 2.5 mg cap, 5 mg cap
2
MARINOL
PA(*), CG
dronabinol 10 mg cap
5
MARINOL
PA(*)
EMEND 125 mg cap
4
PA(*), QL(2 / 28)
EMEND 80 mg cap
4
PA(*), QL(3 / 30)
EMEND 80 & 125 mg cap
4
PA(*), QL(6 / 28)
EMEND 40 mg cap
4
PA(*), QL(1 / 30)
granisetron hcl 0. 1 mg tab
2
KYTRIL
PA(*), CG
granisetron hcl 0.1 mg/ml iv soln, 1
mg/ml iv soln
2
KYTRIL
PA(*), HI, CG
ondansetron 4 mg odt, 8 mg odt
1
ZOFRAN ODT
PA(*), CG
ondansetron hcl 24 mg tab, 4 mg/5ml
soln, 40 mg/20ml inj soln
2
ZOFRAN
PA(*), CG
ondansetron hcl 4 mg tab, 8 mg tab
1
ZOFRAN
PA(*), CG
SANCUSO 3.1 mg/24hr td patch
4
PA(*)
ANTIFUNGALS [ANTIFUNGALES]
Antifungals [Antifungales]
ABELCET 5 mg/ml iv susp
5
PA(*), HI
amphotericin b 50 mg inj soln
2
FUNGIZONE
PA(*), HI, CG
CANCIDAS 50 mg iv soln, 70 mg iv
soln
5
PA(*), HI
ciclopirox 0.77 % gel, 1 % shampoo, 8
% soln
2
PENLAC
CG
ciclopirox olamine 0.77 % crm, 0.77 %
external susp
2
LOPROX
CG
clotrimazole 1 % crm, 1 % soln, 10 mg
mouth/throat troche
2
MYCELEX
CG
econazole nitrate 1 % crm
2
SPECTAZOLE
CG
ERAXIS 100 mg iv soln
5
PA(*), HI
fluconazole 100 mg tab, 150 mg tab,
1
DIFLUCAN
CG
fluconazole 10 mg/ml susp, 40 mg/ml
susp
2
DIFLUCAN
CG
fluconazole in dextrose 400 mg/200ml
DIFLUCAN IN
iv soln
2
DEXTROSE
PA(*), CG
flucytosine 250 mg cap, 500 mg cap
5
ANCOBON
griseofulvin microsize 125 mg/5ml
susp, 500 mg tab
2
GRISACTIN
CG
griseofulvin ultramicrosize 125 mg
tab, 250 mg tab
2
GRISACTIN ULTRA
CG
GRIS-PEG 125 mg tab, 250 mg tab
4
itraconazole 100 mg cap
2
SPORANOX PULSEPAK
QL(360 / 90), CG
ketoconazole 2 % crm, 2 % shampoo,
200 mg tab
2
NIZORAL
CG
1
Page 25 of 87
Updated 08/2014
Drug
Tier
[Nivel]
4
5
5
Reference Name
Requirements/Limits
Medicamento]
MYCAMINE 50 mg iv soln
PA(*), HI
MYCAMINE 100 mg iv soln
PA(*), HI
NOXAFIL 40 mg/ml susp
PA, MO
NYAMYC 100000 unit/gm external
pwdr
2
CG
nystatin 100000 unit/gm crm, 100000
unit/gm oint, 100000 unit/gm external
pwdr, 100000 unit/ml mouth/throat
susp, 500000 unit tab
2
NYSTOP
CG
nystatin-triamcinolone 100000-0.1
unit/gm-% crm, 100000-0.1 unit/gm-%
oint
2
MYTREX
CG
NYSTOP 100000 unit/gm external
pwdr
2
CG
pedi-dri 100000 unit/gm external pwdr
2
NYSTOP
CG
terbinafine hcl 250 mg tab
2
LAMISIL
QL(84 / 90), CG
terconazole 0.4 % vag crm, 0.8 % vag
crm, 80 mg vag supp
2
ZAZOLE
CG
VFEND 40 mg/ml susp
5
PA
VFEND IV 200 mg iv soln
4
PA(*), HI
voriconazole 200 mg iv soln
2
VFEND IV
PA(*), HI, CG
voriconazole 200 mg tab, 40 mg/ml
susp, 50 mg tab
5
VFEND
PA
ANTIGOUT AGENTS [AGENTES CONTRA LA GOTA]
Antigout Agents [Agentes Contra La Gota]
allopurinol 100 mg tab, 300 mg tab
1
ZYLOPRIM
MO, CG
colchicine-probenecid 0.5-500 mg tab
2
COLBENEMID
MO, CG
COLCRYS 0.6 mg tab
4
probenecid 500 mg tab
2
MO, CG
ULORIC 40 mg tab, 80 mg tab
3
ST, MO
ANTIMIGRAINE AGENTS [AGENTES CONTRA LA MIGRAÑA]
Ergot Alkaloids [Alcaloides De Ergot]
dihydroergotamine mesylate 1 mg/ml
inj soln
2
D.H.E. 45
CG
ERGOMAR 2 mg tab subl
4
Prophylactic [Profilaxis]
timolol maleate 10 mg tab, 20 mg tab,
5 mg tab
2
BLOCADREN
MO, CG
Serotonin (5-Ht) 1B/1D Receptor Agonists [AGONISTAS RECEPTORES DE SEROTONINA (5HT) 1B/1D]
naratriptan hcl 1 mg tab, 2.5 mg tab
2
AMERGE
CG
RELPAX 40 mg tab
4
QL(6 / 30), ST
RELPAX 20 mg tab
4
QL(12 / 30), ST
1
Page 26 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
rizatriptan benzoate 10 mg tab, 10 mg
odt, 5 mg tab, 5 mg odt
1
MAXALT-MLT
sumatriptan succinate 100 mg tab, 25
mg tab
1
IMITREX
sumatriptan succinate 6 mg/0.5ml sc
IMITREX STATDOSE
soln
2
SYSTEM
sumatriptan succinate 50 mg tab
2
IMITREX
ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]
Parasympathomimetics [Parasimpatomiméticos]
guanidine hcl 125 mg tab
2
MESTINON 180 mg tab er, 60 mg tab,
60 mg/5ml syr
4
pyridostigmine bromide 60 mg tab
2
MESTINON
ANTIMYCOBACTERIALS [ANTIMICOBACTERIALES]
Antimycobacterials, Other [Antimicobacterianos, Otros]
dapsone 100 mg tab, 25 mg tab
2
PASER 4 gm pckt
4
rifabutin 150 mg cap
2
MYCOBUTIN
Antituberculars [Antituberculares]
CAPASTAT SULFATE 1 gm inj soln
5
ethambutol hcl 100 mg tab, 400 mg
tab
2
MYAMBUTOL
isoniazid 100 mg tab, 300 mg tab
1
isoniazid 100 mg/ml inj soln
2
NYDRAZID
isoniazid 50 mg/5ml syr
2
PRIFTIN 150 mg tab
4
pyrazinamide 500 mg tab
2
rifampin 600 mg iv soln
2
RIFADIN
rifampin 150 mg cap, 300 mg cap
2
RIMACTANE
RIFATER 50-120-300 mg tab
4
SIRTURO 100 mg tab
5
TRECATOR 250 mg tab
4
ANTINEOPLASTICS [ANTINEOPLÁSICOS]
Alkylating Agents [Agentes Alquilantes]
BUSULFEX 6 mg/ml iv soln
4
cyclophosphamide 25 mg cap, 25 mg
tab, 50 mg cap, 50 mg tab
2
CYTOXAN
HEXALEN 50 mg cap
5
LEUKERAN 2 mg tab
4
lomustine 10 mg cap, 100 mg cap, 40
mg cap
2
CEENU
MATULANE 50 mg cap
5
melphalan hcl 50 mg iv soln
5
ALKERAN
Requirements/Limits
CG
CG
QL(8 / 30), CG
CG
CG
CG
MO, CG
CG
PA(*), HI
CG
MO, CG
CG
MO, CG
CG
PA(*), HI, CG
CG
PA
PA(*)
PA(*), CG
CG
PA(*), HI
1
Page 27 of 87
Updated 08/2014
Drug
Tier
[Nivel]
4
Reference Name
Medicamento]
MUSTARGEN 10 mg inj soln
Antiandrogens [Antiandrógenos]
bicalutamide 50 mg tab
2
CASODEX
flutamide 125 mg cap
2
EULEXIN
NILANDRON 150 mg tab
4
XTANDI 40 mg cap
5
ZYTIGA 250 mg tab
5
Antiangiogenic Agents [Agentes Antiangiogénicos]
POMALYST 1 mg cap, 2 mg cap, 3
mg cap, 4 mg cap
5
REVLIMID 10 mg cap, 15 mg cap, 2.5
mg cap, 20 mg cap, 25 mg cap, 5 mg
cap
5
THALOMID 100 mg cap, 150 mg cap,
200 mg cap, 50 mg cap
5
Antiestrogens/Modifiers [Antiestrógenos/Modificadores]
EMCYT 140 mg cap
4
FARESTON 60 mg tab
4
SOLTAMOX 10 mg/5ml soln
4
tamoxifen citrate 10 mg tab, 20 mg
tab
1
NOLVADEX
Antimetabolites [Antimetabolitos]
DROXIA 200 mg cap, 300 mg cap,
400 mg cap
3
HYDREA 500 mg cap
4
hydroxyurea 500 mg cap
2
HYDREA
mercaptopurine 50 mg tab
2
PURINETHOL
PURINETHOL 50 mg tab
4
TABLOID 40 mg tab
4
Antineoplastics [Antineoplásicos]
ALIMTA 500 mg iv soln
5
amifostine 500 mg iv soln
5
ETHYOL
AVASTIN 100 mg/4ml iv soln
5
azacitidine 100 mg inj susp
5
VIDAZA
BICNU 100 mg iv soln
4
bleomycin sulfate 30 unit inj soln
2
BLENOXANE
carboplatin 150 mg/15ml iv soln
2
PARAPLATIN
cisplatin 100 mg/100ml iv soln
2
PLATINOL AQ
cladribine 1 mg/ml iv soln
5
LEUSTATIN
COSMEGEN 0.5 mg iv soln
5
cytarabine 20 mg/ml inj soln
2
dacarbazine 200 mg iv soln
2
DTIC-DOME
daunorubicin hcl 5 mg/ml iv inj
2
Requirements/Limits
PA(*)
CG
CG
PA
PA
PA
PA, LA
PA, MO
MO
MO
MO, CG
MO
CG
CG
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*), CG
PA(*), CG
PA(*), CG
PA(*)
PA(*)
PA(*), CG
PA(*), CG
PA(*), CG
1
Page 28 of 87
Updated 08/2014
Drug
Tier
[Nivel]
5
5
Reference Name
Medicamento]
decitabine 50 mg iv soln
DACOGEN
dexrazoxane 500 mg iv soln
ZINECARD
docetaxel 80 mg/4ml iv conc, 80
mg/8ml iv soln
5
TAXOTERE
DOXIL 2 mg/ml iv inj
5
doxorubicin hcl 2 mg/ml iv soln
2
ADRIAMYCIN PFS
ELITEK 1.5 mg iv soln
5
epirubicin hcl 50 mg/25ml iv soln
2
ELLENCE
FASLODEX 250 mg/5ml im soln
5
fluorouracil 2.5 gm/50ml iv soln
2
ADRUCIL
gemcitabine hcl 1 gm iv soln
5
GEMZAR
HERCEPTIN 440 mg iv soln
5
idarubicin hcl 10 mg/10ml iv soln
5
IDAMYCIN PFS
IFEX 3 gm iv soln
4
ifosfamide 1 gm iv soln
2
IFEX
irinotecan hcl 100 mg/5ml iv soln
5
CAMPTOSAR
KADCYLA 100 mg iv soln
5
mesna 100 mg/ml iv soln
2
MESNEX
MESNEX 400 mg tab
5
mitomycin 20 mg iv soln
2
MUTAMYCIN
oxaliplatin 100 mg/20ml iv soln
5
ELOXATIN
paclitaxel 300 mg/50ml iv conc
2
TAXOL
PERJETA 420 mg/14ml iv soln
5
PROLEUKIN 22000000 unit iv soln
5
SYNRIBO 3.5 mg sc soln
5
TREANDA 100 mg iv soln
5
TRISENOX 10 mg/10ml iv soln
5
VELCADE 3.5 mg inj soln
5
VIDAZA 100 mg inj susp
5
vinblastine sulfate 10 mg iv soln
2
VELBAN
VINCASAR PFS 1 mg/ml iv soln
2
vincristine sulfate 1 mg/ml iv soln
2
VINCASAR PFS
vinorelbine tartrate 50 mg/5ml iv soln
2
NAVELBINE
YERVOY 50 mg/10ml iv soln
5
ZALTRAP 100 mg/4ml iv soln
5
Antineoplastics, Other [Antineoplásicos, Otros]
fludarabine phosphate 50 mg iv soln
2
FLUDARA
leucovorin calcium 10 mg tab, 15 mg
2
leucovorin calcium 100 mg inj soln,
WELLCOVORIN
350 mg inj soln
2
CALCIUM
mitoxantrone hcl 25 mg/12.5ml iv
conc
2
NOVANTRONE
Requirements/Limits
PA(*), HI
PA(*)
PA(*)
PA(*)
PA(*), CG
PA(*)
PA(*), CG
PA(*)
PA(*), CG
PA(*)
PA(*)
PA(*)
PA(*)
PA(*), CG
PA(*)
PA(*)
PA(*), CG
PA(*), CG
PA(*)
PA(*), CG
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*), CG
PA(*), CG
PA(*), CG
PA(*), CG
PA(*)
PA(*)
PA(*), CG
CG
PA(*), CG
PA(*), CG
1
Page 29 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
ZOLINZA 100 mg cap
5
PA
Aromatase Inhibitors, 3Rd Generation [Inhibidores De La Aromatasa, 3era Generación]
anastrozole 1 mg tab
2
ARIMIDEX
exemestane 25 mg tab
2
AROMASIN
letrozole 2.5 mg tab
2
FEMARA
Enzyme Inhibitors [Inhibidores De Enzimas]
etoposide 500 mg/25ml iv soln
2
TOPOSAR
HYCAMTIN 4 mg iv soln
4
TOPOSAR 1 gm/50ml iv soln
2
topotecan hcl 4 mg iv soln
5
HYCAMTIN
Molecular Target Inhibitors [Inhibidores Moleculares]
AFINITOR 10 mg tab, 7.5 mg tab
5
AFINITOR 5 mg tab
5
AFINITOR 2.5 mg tab
5
AFINITOR DISPERZ 5 mg tab sol
5
5
5
BOSULIF 100 mg tab, 500 mg tab
5
CAPRELSA 100 mg tab, 300 mg tab
5
COMETRIQ (100 MG DAILY DOSE) 1
x 80 & 1 x 20 mg oral kit
5
x 80 & 3 x 20 mg oral kit
5
mg oral kit
5
ERIVEDGE 150 mg cap
5
GILOTRIF 20 mg tab, 30 mg tab, 40
mg tab
5
GLEEVEC 100 mg tab, 400 mg tab
5
IMBRUVICA 140 mg cap
5
INLYTA 1 mg tab, 5 mg tab
5
JAKAFI 10 mg tab, 15 mg tab, 20 mg
5
MEKINIST 0.5 mg tab, 2 mg tab
5
NEXAVAR 200 mg tab
5
SPRYCEL 100 mg tab, 140 mg tab,
20 mg tab, 50 mg tab, 70 mg tab, 80
mg tab
5
STIVARGA 40 mg tab
5
SUTENT 12.5 mg cap, 25 mg cap, 50
mg cap
5
TAFINLAR 50 mg cap, 75 mg cap
5
MO, CG
MO, CG
MO, CG
PA(*), CG
PA(*)
PA(*), CG
PA(*)
PA, QL(60 / 30)
PA, QL(120 / 30)
PA, QL(240 / 30)
PA, QL(120 / 30)
PA, QL(180 / 30)
PA, QL(300 / 30)
PA
PA, LA
PA
PA
PA
PA, LA
PA
PA
PA
PA, LA
PA, LA
PA
PA, LA
PA
PA
PA
PA
1
Page 30 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
TARCEVA 100 mg tab, 150 mg tab,
25 mg tab
5
TASIGNA 150 mg cap, 200 mg cap
5
TYKERB 250 mg tab
5
VOTRIENT 200 mg tab
5
XALKORI 200 mg cap, 250 mg cap
5
ZELBORAF 240 mg tab
5
ZYKADIA 150 mg cap
5
Monoclonal Antibodies [Anticuerpos Monoclonales]
ARZERRA 100 mg/5ml iv conc
5
RITUXAN 10 mg/ml iv conc
5
Retinoids [Retinoides]
PANRETIN 0.1 % gel
5
TARGRETIN 1 % gel, 75 mg cap
5
tretinoin 10 mg cap
5
VESANOID
ANTIPARASITICS [ANTIPARASÍTICOS]
Antihelminthics [Antihelmínticos]
ALBENZA 200 mg tab
4
BILTRICIDE 600 mg tab
4
STROMECTOL 3 mg tab
3
Antiprotozoals [Antiprotozoarios]
ALINIA 100 mg/5ml susp, 500 mg tab
4
atovaquone 750 mg/5ml susp
5
MEPRON
atovaquone-proguanil hcl 250-100 mg
tab, 62.5-25 mg tab
2
MALARONE PEDIATRIC
chloroquine phosphate 250 mg tab,
500 mg tab
2
ARALEN
COARTEM 20-120 mg tab
4
DARAPRIM 25 mg tab
4
hydroxychloroquine sulfate 200 mg
tab
1
PLAQUENIL
MALARONE 250-100 mg tab
4
mefloquine hcl 250 mg tab
2
LARIAM
MEPRON 750 mg/5ml susp
5
NEBUPENT 300 mg inh soln
4
PENTAM 300 mg inj soln
4
primaquine phosphate 26.3 mg tab
2
QUALAQUIN 324 mg cap
4
quinine sulfate 324 mg cap
2
QUALAQUIN
Pediculicides/Scabicides [Pediculicidas/Scabicidas]
lindane 1 % lot, 1 % shampoo
2
malathion 0.5 % lot
2
OVIDE
permethrin 5 % crm
2
ELIMITE
Requirements/Limits
PA
PA
PA, LA
PA
PA, LA
PA, LA
LA
PA(*)
PA(*)
CG
MO, CG
MO, CG
MO, CG
PA(*)
PA(*)
CG
CG
CG
CG
CG
1
Page 31 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1
mg tab, 2 mg tab
1
COGENTIN
MO, HR, CG
benztropine mesylate 1 mg/ml inj soln
2
COGENTIN
PA(*), HI, CG
trihexyphenidyl hcl 2 mg tab, 5 mg tab
1
ARTANE
MO, HR, CG
trihexyphenidyl hcl 0.4 mg/ml oral elix
2
ARTANE
MO, HR, CG
Antiparkinson Agents, Other [Agentes Antiparkinson, Otros]
amantadine hcl 100 mg cap, 100 mg
tab, 50 mg/5ml syr
2
SYMMETREL
MO, CG
entacapone 200 mg tab
2
COMTAN
MO, CG
TASMAR 100 mg tab
4
MO
Dopamine Agonists [Agonistas De Dopamina]
APOKYN 10 mg/ml sc soln
5
LA
bromocriptine mesylate 2.5 mg tab, 5
mg cap
2
PARLODEL
MO, CG
NEUPRO 1 mg/24hr td patch 24hr, 2
patch 24hr, 4 mg/24hr td patch 24hr, 6
patch 24hr
4
PA, MO
pramipexole dihydrochloride 0.125 mg
tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg
tab, 1 mg tab, 1.5 mg tab
1
MIRAPEX
MO, CG
ropinirole hcl 0.25 mg tab, 0.5 mg tab,
1 mg tab, 2 mg tab, 3 mg tab, 4 mg
tab, 5 mg tab
1
REQUIP
MO, CG
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors [Precursores De Dopamina/
Inhibidores De La Decarboxylasa L-Amino Ácido]
carbidopa 25 mg tab
2
LODOSYN
MO, CG
carbidopa-levodopa 10-100 mg tab,
25-100 mg tab
1
SINEMET
MO, CG
carbidopa-levodopa 10-100 mg odt,
25-100 mg odt, 25-250 mg tab, 25250 mg odt
2
SINEMET
MO, CG
carbidopa-levodopa er 50-200 mg tab
er
2
SINEMET CR
MO, CG
carbidopa-levodopa er 25-100 mg tab
er
1
SINEMET CR
MO, CG
carbidopa-levodopa-entacapone 12.550-200 mg tab, 18.75-75-200 mg tab,
25-100-200 mg tab, 31.25-125-200
mg tab, 37.5-150-200 mg tab, 50-200200 mg tab
2
STALEVO 75
MO, CG
1
Page 32 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
Monoamine Oxidase B (Mao-B) Inhibitors [Inhibidores De La Monoaminoxidasa B (Mao-B)]
AZILECT 0.5 mg tab, 1 mg tab
3
MO
selegiline hcl 5 mg cap, 5 mg tab
2
ELDEPRYL
MO, CG
ANTIPSYCHOTICS [ANTIPSICÓTICOS]
1St Generation/Typical [1era Generación/Típicos]
fluphenazine decanoate 25 mg/ml inj
soln
2
PROLIXIN DECANOATE
CG
fluphenazine hcl 2.5 mg/ml inj soln
2
PROLIXIN
CG
fluphenazine hcl 2.5 mg/5ml oral elix,
5 mg/ml oral conc
2
PROLIXIN
MO, CG
fluphenazine hcl 1 mg tab, 10 mg tab,
2.5 mg tab, 5 mg tab
1
PROLIXIN
MO, CG
haloperidol 0.5 mg tab, 1 mg tab, 10
1
MO, CG
haloperidol decanoate 100 mg/ml im
soln, 50 mg/ml im soln
2
HALDOL DECANOATE
CG
haloperidol lactate 2 mg/ml oral conc
2
HALDOL
MO, CG
haloperidol lactate 5 mg/ml inj soln
2
HALDOL
CG
loxapine succinate 5 mg cap
2
LOXITANE
MO, CG
loxapine succinate 10 mg cap, 25 mg
cap, 50 mg cap
1
LOXITANE
MO, CG
ORAP 1 mg tab, 2 mg tab
4
MO
thioridazine hcl 10 mg tab, 100 mg
2
MELLARIL
PA, MO, HR, CG
thiothixene 10 mg cap
2
NAVANE
MO, CG
thiothixene 1 mg cap, 2 mg cap, 5 mg
cap
1
NAVANE
MO, CG
trifluoperazine hcl 1 mg tab, 10 mg
2
STELAZINE
MO, CG
2Nd Generation/Atypical [2nda Generación/ Atípicos]
FANAPT 1 mg tab, 10 mg tab, 12 mg
tab, 2 mg tab, 4 mg tab, 6 mg tab, 8
mg tab
4
ST
FANAPT TITRATION PACK 1 & 2 & 4
& 6 mg tab
4
QL(8 / 30), ST
GEODON 20 mg im soln
4
INVEGA 1.5 mg tab er 24 hr, 3 mg tab
er 24 hr, 6 mg tab er 24 hr
4
ST, MO
INVEGA 9 mg tab er 24 hr
5
ST, MO
INVEGA SUSTENNA 117 mg/0.75ml
im susp
5
QL(0.75 / 28), ST
INVEGA SUSTENNA 78 mg/0.5ml im
susp
4
QL(0.5 / 28), ST
1
Page 33 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
im susp
5
QL(1.5 / 28), ST
INVEGA SUSTENNA 156 mg/ml im
susp
5
QL(1 / 28), ST
im susp
4
QL(0.25 / 28), ST
LATUDA 120 mg tab, 20 mg tab, 40
mg tab, 60 mg tab, 80 mg tab
4
ST, MO
olanzapine 10 mg im soln
2
ZYPREXA
CG
olanzapine 10 mg tab, 15 mg tab, 2.5
mg tab, 20 mg tab, 5 mg tab, 7.5 mg
tab
1
ZYPREXA
MO, CG
olanzapine 10 mg odt, 15 mg odt, 20
mg odt, 5 mg odt
2
ZYPREXA ZYDIS
MO, CG
RISPERDAL CONSTA 12.5 mg im
susp
4
QL(8 / 28)
RISPERDAL CONSTA 25 mg im susp
4
QL(4 / 28)
RISPERDAL CONSTA 37.5 mg im
susp, 50 mg im susp
5
QL(2 / 28)
risperidone 0.25 mg tab, 0.5 mg tab, 1
1
RISPERDAL
MO, CG
risperidone 0.25 mg odt, 0.5 mg odt, 1
mg odt, 1 mg/ml soln, 2 mg odt, 3 mg
odt, 4 mg odt
2
RISPERIDONE M-TAB
MO, CG
SAPHRIS 10 mg tab subl, 5 mg tab
subl
4
ST, MO
ziprasidone hcl 20 mg cap, 40 mg
2
GEODON
MO, CG
Treatment-Resistant [Resistentes A Tratamiento]
clozapine 100 mg tab, 200 mg tab, 25
mg tab, 50 mg tab
2
CLOZARIL
CG
FAZACLO 100 mg odt, 12.5 mg odt,
150 mg odt, 200 mg odt, 25 mg odt
4
VERSACLOZ 50 mg/ml susp
4
ANTISPASTICITY AGENTS [AGENTES CONTRA LA ESPASTICIDAD]
Antispasticity Agents [Agentes Contra La Espasticidad]
baclofen 10 mg tab, 20 mg tab
2
LIORESAL
MO, CG
dantrolene sodium 100 mg cap, 25
mg cap, 50 mg cap
2
DANTRIUM
CG
tizanidine hcl 2 mg tab
1
ZANAFLEX
MO, CG
tizanidine hcl 4 mg tab
2
ZANAFLEX
MO, CG
ANTIVIRALS [ANTIVIRALES]
Anti-Cytomegalovirus (CMV) Agents [Agentes Anticitomegalovirus (CMV)]
foscarnet sodium 24 mg/ml iv soln
2
FOSCAVIR
PA(*), CG
1
Page 34 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
ganciclovir sodium 500 mg iv soln
2
CYTOVENE
PA(*), CG
VALCYTE 450 mg tab, 50 mg/ml soln
5
MO
ZIRGAN 0.15 % ophth gel
4
Anti-Hepatitis B (HBV) Agents [Agentes Contra La Hepatitis B (HBV)]
adefovir dipivoxil 10 mg tab
5
HEPSERA
PA, MO
BARACLUDE 0.05 mg/ml soln
4
PA, MO
BARACLUDE 0.5 mg tab, 1 mg tab
5
PA, MO
COPEGUS 200 mg tab
5
EPIVIR HBV 100 mg tab, 5 mg/ml
soln
4
MO
HEPSERA 10 mg tab
5
PA, MO
INTRON-A 10000000 unit inj soln,
6000000 unit/ml inj soln
5
PA(*), MO
lamivudine 100 mg tab
2
EPIVIR HBV
MO, CG
PEGASYS 180 mcg/0.5ml sc soln,
180 mcg/ml sc soln
5
PA
PEGASYS PROCLICK 135 mcg/0.5ml
sc soln
5
PA
PEG-INTRON 120 mcg/0.5ml sc kit,
150 mcg/0.5ml sc kit, 50 mcg/0.5ml sc
kit, 80 mcg/0.5ml sc kit
5
PA
PEG-INTRON REDIPEN 120
mcg/0.5ml sc kit, 150 mcg/0.5ml sc
kit, 50 mcg/0.5ml sc kit, 80 mcg/0.5ml
sc kit
5
PA
REBETOL 200 mg cap, 40 mg/ml soln
5
PA
RIBASPHERE 600 mg tab
5
PA
RIBASPHERE 200 mg cap, 200 mg
tab
2
PA, CG
RIBASPHERE 400 mg tab
4
PA
RIBASPHERE RIBAPAK 400 mg tab,
400 & 600 mg tab, 600 mg tab
5
ribavirin 200 mg cap, 200 mg tab
2
RIBASPHERE
PA, CG
SYLATRON 296 mcg sc kit, 444 mcg
sc kit, 888 mcg sc kit
5
PA, MO
TYZEKA 600 mg tab
4
PA, MO
Anti-Hepatitis C (HCV) Agents [Agentes Contra La Hepatitis C (HCV)]
INCIVEK 375 mg tab
5
PA
OLYSIO 150 mg cap
5
PA
SOVALDI 400 mg tab
5
PA
VICTRELIS 200 mg cap
5
PA
VIRAZOLE 6 gm inh soln
5
PA(*)
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg/5ml susp, 5 % oint
2
ZOVIRAX
CG
1
Page 35 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
acyclovir 200 mg cap, 400 mg tab,
800 mg tab
1
ZOVIRAX
CG
acyclovir sodium 500 mg iv soln
2
ZOVIRAX
PA(*), HI, CG
DENAVIR 1 % crm
4
ST
famciclovir 125 mg tab, 250 mg tab,
500 mg tab
2
FAMVIR
CG
trifluridine 1 % ophth soln
2
VIROPTIC
CG
valacyclovir hcl 1 gm tab, 500 mg tab
2
VALTREX
CG
Anti-HIV Agents, Integrase Inhibitors (INSTI) [Agentes Anti-VIH, Inhibidores De La Integrasa
(INSTI)]
ISENTRESS 100 mg pckt
4
MO
ISENTRESS 100 mg tab chew, 25 mg
tab chew
3
MO
ISENTRESS 400 mg tab
5
MO
STRIBILD 150-150-200-300 mg tab
5
MO
TIVICAY 50 mg tab
5
MO
Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) [Agentes AntiVIH, Inhibidores No-Nucleósidos De La Transcriptasa Reversa (NNRTI)]
ATRIPLA 600-200-300 mg tab
5
MO
COMPLERA 200-25-300 mg tab
5
MO
EDURANT 25 mg tab
5
MO
INTELENCE 25 mg tab
4
MO
INTELENCE 100 mg tab, 200 mg tab
5
MO
nevirapine 200 mg tab, 50 mg/5ml
susp
2
VIRAMUNE
MO, CG
nevirapine er 400 mg tab er 24 hr
2
VIRAMUNE XR
MO, CG
RESCRIPTOR 100 mg tab, 200 mg
tab
4
MO
SUSTIVA 600 mg tab
4
MO
SUSTIVA 200 mg cap, 50 mg cap
3
MO
VIRAMUNE 200 mg tab
4
MO
VIRAMUNE XR 100 mg tab er 24 hr,
400 mg tab er 24 hr
4
MO
Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI)
[Agentes Anti-VIH, Inhibidores Nucleósidos Y Nucleósidos De La Transcriptasa Reversa
(NRTI)]
abacavir sulfate 300 mg tab
abacavir-lamivudine-zidovudine 300150-300 mg tab
COMBIVIR 150-300 mg tab
didanosine 125 mg cap dr, 200 mg
cap dr, 250 mg cap dr, 400 mg cap dr
EMTRIVA 10 mg/ml soln, 200 mg cap
2
ZIAGEN
MO, CG
5
5
TRIZIVIR
MO
MO
2
4
VIDEX EC
MO, CG
MO
1
Page 36 of 87
Updated 08/2014
Drug
Tier
[Nivel]
4
5
2
Reference Name
Requirements/Limits
Medicamento]
EPIVIR 10 mg/ml soln
MO
EPZICOM 600-300 mg tab
MO
lamivudine 150 mg tab, 300 mg tab
EPIVIR
MO, CG
lamivudine-zidovudine 150-300 mg
tab
5
COMBIVIR
MO
RETROVIR 10 mg/ml iv soln
3
HI
RETROVIR 100 mg cap, 50 mg/5ml
syr
3
MO
stavudine 1 mg/ml soln, 15 mg cap,
20 mg cap, 30 mg cap, 40 mg cap
2
ZERIT
MO, CG
TRIZIVIR 300-150-300 mg tab
5
MO
TRUVADA 200-300 mg tab
5
MO
VIDEX 2 gm soln
3
MO
VIREAD 150 mg tab, 200 mg tab, 250
mg tab, 300 mg tab, 40 mg/gm oral
pwdr
5
MO
ZERIT 1 mg/ml soln
4
MO
ZIAGEN 20 mg/ml soln, 300 mg tab
4
MO
zidovudine 100 mg cap, 300 mg tab,
50 mg/5ml syr
2
RETROVIR
MO, CG
Anti-HIV Agents, Other [Agentes Anti-VIH, Otros]
FUZEON 90 mg sc soln
5
MO
SELZENTRY 150 mg tab
5
MO
SELZENTRY 300 mg tab
3
MO
Anti-HIV Agents, Protease Inhibitors [Agentes Anti-VIH, Inhibidores De Proteasa]
APTIVUS 100 mg/ml soln, 250 mg
cap
5
MO
CRIXIVAN 200 mg cap, 400 mg cap
3
MO
INVIRASE 200 mg cap, 500 mg tab
5
MO
KALETRA 100-25 mg tab
3
MO
KALETRA 200-50 mg tab, 400-100
mg/5ml soln
5
MO
LEXIVA 700 mg tab
5
MO
LEXIVA 50 mg/ml susp
4
MO
NORVIR 100 mg cap, 100 mg tab, 80
mg/ml soln
4
MO
PREZISTA 100 mg/ml susp, 600 mg
tab, 800 mg tab
5
MO
PREZISTA 150 mg tab, 75 mg tab
4
MO
REYATAZ 150 mg cap, 200 mg cap,
300 mg cap
5
MO
VIRACEPT 250 mg tab, 625 mg tab
5
MO
Anti-Influenza Agents [Agentes Contra La Influenza]
1
Page 37 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
RELENZA DISKHALER 5 mg/blister
inh aer pwdr
3
rimantadine hcl 100 mg tab
2
FLUMADINE
CG
TAMIFLU 30 mg cap, 45 mg cap, 6
mg/ml susp, 75 mg cap
4
ANXIOLYTICS [ANSIOLÍTICOS]
Anxiolytics, Other [Ansiolíticos, Otros]
buspirone hcl 10 mg tab, 15 mg tab,
30 mg tab, 5 mg tab, 7.5 mg tab
2
VANSPAR
CG
hydroxyzine hcl 25 mg/ml im soln, 50
mg/ml im soln
2
VISTARIL
HR, CG
Benzodiazepines [Benzodiazepinas]
alprazolam 0.25 mg tab, 0.5 mg tab, 1
mg tab
2
XANAX
QL(120 / 30), CG
alprazolam 2 mg tab
2
XANAX
QL(150 / 30), CG
clorazepate dipotassium 3.75 mg tab
2
TRANXENE-T
QL(180 / 30), CG
clorazepate dipotassium 15 mg tab,
7.5 mg tab
1
TRANXENE-T
QL(180 / 30), CG
estazolam 1 mg tab, 2 mg tab
2
PROSOM
QL(30 / 30), CG
BIPOLAR AGENTS [Agentes Bipolares]
Mood Stabilizers [Estabilizadores Del Ánimo]
lithium carbonate 150 mg cap, 300 mg
cap, 300 mg tab, 600 mg cap
1
LITHOTABS
MO, CG
lithium carbonate er 450 mg tab er
2
ESKALITH CR
MO, CG
lithium carbonate er 300 mg tab er
1
LITHOBID
MO, CG
lithium citrate 8 meq/5ml soln
2
MO, CG
BLOOD GLUCOSE REGULATORS [REGULADORES DE GLUCOSA EN SANGRE]
Antidiabetic Agents [Agentes Antidiabéticos]
acarbose 100 mg tab, 25 mg tab, 50
mg tab
2
PRECOSE
MO, CG
BYDUREON 2 mg sc susp
3
ST, MO
QL(2.4 / 30), ST,
BYETTA 10 MCG PEN
4
MO
QL(1.2 / 30), ST,
BYETTA 5 MCG PEN
4
MO
CYCLOSET 0.8 mg tab
4
MO
glimepiride 1 mg tab, 2 mg tab, 4 mg
tab
1
AMARYL
MO, CG
glipizide 10 mg tab, 5 mg tab
1
GLUCOTROL
MO, CG
glipizide er 10 mg tab er 24 hr
2
GLUCOTROL XL
MO, CG
glipizide er 2.5 mg tab er 24 hr, 5 mg
tab er 24 hr
1
GLUCOTROL XL
MO, CG
1
Page 38 of 87
Updated 08/2014
Medicamento]
JANUVIA 100 mg tab, 25 mg tab, 50
mg tab
metformin hcl 1000 mg tab, 500 mg
tab, 850 mg tab
metformin hcl er 500 mg tab er 24 hr,
750 mg tab er 24 hr
nateglinide 120 mg tab, 60 mg tab
ONGLYZA 2.5 mg tab, 5 mg tab
pioglitazone hcl 15 mg tab, 30 mg tab,
45 mg tab
repaglinide 0.5 mg tab, 1 mg tab, 2
mg tab
RIOMET 500 mg/5ml soln
Drug
Tier
[Nivel]
Reference Name
3
Requirements/Limits
MO
1
GLUCOPHAGE
MO, CG
1
2
3
GLUCOPHAGE XR
STARLIX
MO, CG
MO, CG
MO
2
ACTOS
MO, CG
2
4
PRANDIN
MO, CG
MO
QL(10.8 / 30), ST,
SYMLINPEN 120
4
MO
SYMLINPEN 60
4
QL(9 / 25), ST, MO
WELCHOL 3.75 gm pckt, 625 mg tab
4
MO
Blood Glucose Regulators (Combination Product) [Reguladores De Glucosa En Sangre
(Productos En Combinación)]
glipizide-metformin hcl 2.5-250 mg
tab, 2.5-500 mg tab, 5-500 mg tab
2
METAGLIP
MO, CG
JANUMET 50-1000 mg tab, 50-500
mg tab
3
MO
JANUMET XR 100-1000 mg tab er 24
hr, 50-1000 mg tab er 24 hr, 50-500
mg tab er 24 hr
3
MO
KOMBIGLYZE XR 2.5-1000 mg tab er
24 hr, 5-1000 mg tab er 24 hr, 5-500
mg tab er 24 hr
3
MO
pioglitazone hcl-glimepiride 30-2 mg
tab, 30-4 mg tab
2
DUETACT
MO, CG
pioglitazone hcl-metformin hcl 15-500
mg tab, 15-850 mg tab
2
ACTOPLUS MET
MO, CG
Glycemic Agents [Agentes Glicémicos]
GLUCAGEN HYPOKIT 1 mg inj soln
3
GLUCAGON EMERGENCY 1 mg inj
kit
3
PROGLYCEM 50 mg/ml susp
4
MO
Insulins [Insulinas]
insulin pen needles
3
insulin syringe 29g x 1/2" 0.3 ml, 29g
x 1/2" 1 ml, 30g x 1/2" 0.5 ml
miscellaneous
3
gauze pads 2” x 2”
3
1
Page 39 of 87
Updated 08/2014
Drug
Tier
[Nivel]
3
3
Reference Name
Requirements/Limits
Medicamento]
HUMALOG 100 unit/ml sc soln
MO
HUMALOG KWIKPEN
MO
HUMALOG MIX 50/50 (50-50) 100
unit/ml sc susp
3
MO
HUMALOG MIX 50/50 KWIKPEN
3
MO
HUMALOG MIX 75/25 (75-25) 100
unit/ml sc susp
3
MO
HUMALOG MIX 75/25 KWIKPEN
3
MO
HUMULIN 70/30 (70-30) 100 unit/ml
sc susp
3
MO
HUMULIN 70/30 PEN
3
MO
HUMULIN N 100 unit/ml sc susp
3
MO
HUMULIN N PEN
3
MO
HUMULIN R 100 unit/ml inj soln
3
MO
HUMULIN R U-500
(CONCENTRATED) 500 unit/ml sc
soln
3
MO
LANTUS 100 unit/ml sc soln
3
MO
LANTUS SOLOSTAR
3
MO
LEVEMIR 100 unit/ml sc soln
3
MO
LEVEMIR FLEXPEN
3
MO
needles, insulin disp., safety
3
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS [PRODUCTOS PARA LA
SANGRE/MODIFICADORES/EXPANSORES DE VOLUMEN]
Anticoagulants [Anticoagulantes]
COUMADIN 1 mg tab, 10 mg tab, 2
mg tab, 2.5 mg tab, 3 mg tab, 4 mg
tab, 5 mg tab, 6 mg tab, 7.5 mg tab
3
MO
ELIQUIS 2.5 mg tab, 5 mg tab
3
PA, MO
enoxaparin sodium 30 mg/0.3ml sc
soln
2
LOVENOX
QL(9 / 30), CG
enoxaparin sodium 300 mg/3ml inj
soln
2
LOVENOX
QL(90 / 30), CG
soln
2
LOVENOX
QL(18 / 30), CG
soln, 80 mg/0.8ml sc soln
2
LOVENOX
QL(24 / 30), CG
enoxaparin sodium 100 mg/ml sc
soln, 150 mg/ml sc soln
2
LOVENOX
QL(30 / 30), CG
soln
2
LOVENOX
QL(12 / 30), CG
fondaparinux sodium 7.5 mg/0.6ml sc
soln
2
ARIXTRA
QL(18 / 30), CG
1
Page 40 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
fondaparinux sodium 10 mg/0.8ml sc
soln
2
ARIXTRA
QL(24 / 30), CG
fondaparinux sodium 2.5 mg/0.5ml sc
soln
2
ARIXTRA
QL(15 / 30), CG
fondaparinux sodium 5 mg/0.4ml sc
soln
2
ARIXTRA
QL(12 / 30), CG
heparin sodium (porcine) 1000 unit/ml
inj soln, 10000 unit/ml inj soln, 20000
unit/ml inj soln, 5000 unit/ml inj soln
2
PA(*), HI, CG
PRADAXA 150 mg cap, 75 mg cap
3
PA, MO
warfarin sodium 1 mg tab, 10 mg tab,
2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg
tab, 5 mg tab, 6 mg tab, 7.5 mg tab
1
JANTOVEN
MO, CG
XARELTO 10 mg tab, 15 mg tab, 20
mg tab
3
PA, MO
Blood Formation Modifiers [Modificadores De La Formación De La Sangre]
anagrelide hcl 0.5 mg cap, 1 mg cap
1
AGRYLIN
MO, CG
ARANESP (ALBUMIN FREE) 25
mcg/0.42ml inj soln, 25 mcg/ml inj
soln, 40 mcg/0.4ml inj soln, 40 mcg/ml
inj soln, 60 mcg/0.3ml inj soln, 60
mcg/ml inj soln
4
PA
ARANESP (ALBUMIN FREE) 100
soln, 150 mcg/0.3ml inj soln, 200
soln, 300 mcg/0.6ml inj soln, 300
mcg/ml inj soln, 500 mcg/ml inj soln
5
PA
LEUKINE 250 mcg iv soln
5
PA
MOZOBIL 24 mg/1.2ml sc soln
5
NEULASTA 6 mg/0.6ml sc soln
5
PA
NEUPOGEN 300 mcg/0.5ml inj soln,
480 mcg/0.8ml inj soln, 480
mcg/1.6ml inj soln
5
PA
PROCRIT 10000 unit/ml inj soln
4
PA
PROCRIT 20000 unit/ml inj soln,
40000 unit/ml inj soln
5
PA
PROCRIT 2000 unit/ml inj soln, 3000
unit/ml inj soln, 4000 unit/ml inj soln
3
PA
PROMACTA 12.5 mg tab, 25 mg tab,
5
PA, LA, MO
Blood Products/Modifiers/Volume Expanders [Productos Para La
Sangre/Modificadores/Expansores De Volumen]
ERWINAZE 10000 unit im soln
5
PA(*)
1
Page 41 of 87
Updated 08/2014
Drug
Tier
[Nivel]
5
5
Reference Name
Requirements/Limits
Medicamento]
NEUMEGA 5 mg sc soln
PA
ONCASPAR 750 unit/ml inj soln
PA(*)
Coagulants [Coagulantes]
tranexamic acid 100 mg/ml iv soln,
650 mg tab
2
LYSTEDA
CG
Platelet Modifying Agents [Agentes Modificadores De Plaquetas]
AGGRENOX 25-200 mg cap er 12 hr
3
MO
BRILINTA 90 mg tab
4
PA, MO
cilostazol 100 mg tab, 50 mg tab
1
PLETAL
MO, CG
clopidogrel bisulfate 75 mg tab
1
PLAVIX
MO, CG
EFFIENT 10 mg tab, 5 mg tab
4
PA, MO
CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]
Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]
clonidine hcl 0.1 mg tab, 0.2 mg tab,
0.3 mg tab
1
CATAPRES
MO, CG
clonidine hcl 0.1 mg/24hr tdwk patch,
0.2 mg/24hr tdwk patch, 0.3 mg/24hr
tdwk patch
2
CATAPRES-TTS-3
MO, CG
clonidine hcl er 0.1 mg tab er 12 hr
2
KAPVAY
MO, CG
guanfacine hcl 1 mg tab, 2 mg tab
2
TENEX
PA, MO, HR, CG
methyldopa 250 mg tab, 500 mg tab
1
ALDOMET
MO, HR, CG
midodrine hcl 10 mg tab, 2.5 mg tab,
5 mg tab
2
PROAMATINE
CG
Alpha-Adrenergic Blocking Agents [Agentes Bloqueadores Alfa Adrenérgicos]
doxazosin mesylate 1 mg tab, 2 mg
1
CARDURA
MO, CG
prazosin hcl 1 mg cap, 2 mg cap, 5
mg cap
1
MINIPRESS
MO, CG
terazosin hcl 1 mg cap, 10 mg cap, 2
mg cap, 5 mg cap
1
HYTRIN
MO, CG
Angiotensin II Receptor Antagonists [Antagonistas Del Receptor De Angiotensina II]
BENICAR 20 mg tab, 40 mg tab, 5 mg
tab
candesartan cilexetil 16 mg tab, 32
DIOVAN 160 mg tab, 320 mg tab, 40
mg tab, 80 mg tab
irbesartan 150 mg tab, 300 mg tab, 75
mg tab
losartan potassium 100 mg tab, 25 mg
tab, 50 mg tab
4
2
MO
ATACAND
4
MO, CG
MO
1
AVAPRO
MO, CG
1
COZAAR
MO, CG
1
Page 42 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores De La Enzima Convertidora
De Angiotensina (ECA)]
benazepril hcl 10 mg tab, 20 mg tab,
40 mg tab, 5 mg tab
1
LOTENSIN
MO, CG
captopril 100 mg tab, 12.5 mg tab, 25
mg tab, 50 mg tab
1
CAPOTEN
MO, CG
enalapril maleate 10 mg tab, 2.5 mg
1
VASOTEC
MO, CG
fosinopril sodium 10 mg tab, 20 mg
tab, 40 mg tab
1
MONOPRIL
MO, CG
lisinopril 10 mg tab, 2.5 mg tab, 20 mg
tab, 30 mg tab, 40 mg tab, 5 mg tab
1
ZESTRIL
MO, CG
moexipril hcl 15 mg tab, 7.5 mg tab
1
UNIVASC
MO, CG
perindopril erbumine 8 mg tab
1
ACEON
MO, CG
perindopril erbumine 2 mg tab, 4 mg
tab
2
ACEON
MO, CG
quinapril hcl 10 mg tab, 20 mg tab, 40
mg tab, 5 mg tab
1
ACCUPRIL
MO, CG
ramipril 1.25 mg cap, 10 mg cap, 2.5
mg cap, 5 mg cap
1
ALTACE
MO, CG
trandolapril 1 mg tab, 2 mg tab, 4 mg
tab
1
MAVIK
MO, CG
Antiarrhythmics [Antiarrítmicos]
amiodarone hcl 200 mg tab, 400 mg
tab
2
PACERONE
MO, CG
amiodarone hcl 150 mg/3ml iv soln
2
PA(*), HI, CG
disopyramide phosphate 100 mg cap,
150 mg cap
2
NORPACE
MO, HR, CG
flecainide acetate 100 mg tab, 150 mg
tab, 50 mg tab
2
TAMBOCOR
MO, CG
mexiletine hcl 150 mg cap, 200 mg
cap, 250 mg cap
2
MEXITIL
MO, CG
MULTAQ 400 mg tab
4
MO
NORPACE CR 100 mg cap er 12 hr,
150 mg cap er 12 hr
4
MO, HR
PACERONE 100 mg tab, 200 mg tab
4
MO
propafenone hcl 150 mg tab, 225 mg
tab, 300 mg tab
2
RYTHMOL
MO, CG
propafenone hcl er 225 mg cap er 12
hr, 325 mg cap er 12 hr, 425 mg cap
er 12 hr
2
RYTHMOL SR
MO, CG
QUINAGLUTE DURAquinidine gluconate er 324 mg tab er
2
TABS
MO, CG
1
Page 43 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
quinidine sulfate 200 mg tab, 300 mg
tab
2
MO, CG
quinidine sulfate er 300 mg tab er
2
QUINIDEX EXTENTABS
MO, CG
SORINE 120 mg tab, 160 mg tab, 240
mg tab, 80 mg tab
2
MO, CG
sotalol hcl 160 mg tab, 240 mg tab, 80
mg tab
2
SORINE
MO, CG
sotalol hcl (af) 120 mg tab
2
BETAPACE AF
MO, CG
TIKOSYN 125 mcg cap, 250 mcg cap,
500 mcg cap
4
MO
Beta-Adrenergic Blocking Agents [Agentes Bloqueadores Beta Adrenérgicos]
acebutolol hcl 200 mg cap
1
SECTRAL
MO, CG
acebutolol hcl 400 mg cap
2
SECTRAL
MO, CG
atenolol 100 mg tab, 25 mg tab, 50
mg tab
1
TENORMIN
MO, CG
betaxolol hcl 20 mg tab
1
KERLONE
MO, CG
betaxolol hcl 10 mg tab
2
KERLONE
MO, CG
bisoprolol fumarate 10 mg tab, 5 mg
tab
2
ZEBETA
MO, CG
carvedilol 12.5 mg tab, 25 mg tab,
3.125 mg tab, 6.25 mg tab
1
COREG
MO, CG
labetalol hcl 100 mg tab, 200 mg tab,
300 mg tab
2
TRANDATE
MO, CG
metoprolol succinate er 100 mg tab er
24 hr, 200 mg tab er 24 hr, 25 mg tab
2
TOPROL XL
MO, CG
metoprolol tartrate 100 mg tab, 25 mg
tab, 50 mg tab
1
LOPRESSOR
MO, CG
metoprolol tartrate 1 mg/ml iv soln
2
LOPRESSOR
PA(*), HI, CG
nadolol 40 mg tab
1
CORGARD
MO, CG
nadolol 20 mg tab, 80 mg tab
2
CORGARD
MO, CG
pindolol 10 mg tab, 5 mg tab
2
VISKEN
MO, CG
propranolol hcl 10 mg tab, 20 mg tab,
1
INDERAL
MO, CG
propranolol hcl 20 mg/5ml soln, 40
mg/5ml soln, 60 mg tab
2
INDERAL
MO, CG
propranolol hcl 1 mg/ml iv soln
2
INDERAL
PA(*), HI, CG
propranolol hcl er 120 mg cap er 24
hr, 160 mg cap er 24 hr, 60 mg cap er
24 hr, 80 mg cap er 24 hr
2
INDERAL LA
MO, CG
Calcium Channel Blocking Agents [Agentes Bloqueadores De Los Canales De Calcio]
AFEDITAB CR 30 mg tab er 24 hr, 60
mg tab er 24 hr
2
MO, CG
1
Page 44 of 87
Updated 08/2014
Medicamento]
amlodipine besylate 10 mg tab, 2.5
mg tab, 5 mg tab
CARTIA XT 120 mg cap er 24 hr, 180
300 mg cap er 24 hr
dilt-cd 120 mg cap er 24 hr
diltiazem hcl 50 mg/10ml iv soln
diltiazem hcl 120 mg tab, 30 mg tab,
diltiazem hcl er 120 mg cap er 12 hr,
60 mg cap er 12 hr, 90 mg cap er 12
hr
diltiazem hcl er beads 180 mg cap er
24 hr, 360 mg cap er 24 hr, 420 mg
cap er 24 hr
diltiazem hcl er coated beads 120 mg
cap er 24 hr, 240 mg cap er 24 hr,
300 mg cap er 24 hr
dilt-xr 180 mg cap er 24 hr, 240 mg
cap er 24 hr
felodipine er 10 mg tab er 24 hr, 2.5
mg tab er 24 hr, 5 mg tab er 24 hr
isradipine 2.5 mg cap, 5 mg cap
MATZIM LA 180 mg tab er 24 hr, 240
mg tab er 24 hr, 300 mg tab er 24 hr,
hr
nicardipine hcl 20 mg cap, 30 mg cap
NIFEDICAL XL 30 mg tab er 24 hr, 60
mg tab er 24 hr
nifedipine er osmotic 30 mg tab er 24
24 hr
nimodipine 30 mg cap
TAZTIA XT 120 mg cap er 24 hr, 180
300 mg cap er 24 hr, 360 mg cap er
24 hr
verapamil hcl 2.5 mg/ml iv soln
verapamil hcl 120 mg tab, 40 mg tab,
80 mg tab
Drug
Tier
[Nivel]
Reference Name
1
NORVASC
MO, CG
2
2
2
CARTIA XT
MO, CG
MO, CG
PA(*), HI, CG
1
CARDIZEM
MO, CG
2
CARDIZEM SR
MO, CG
2
TIAZAC
MO, CG
2
CARTIA XT
MO, CG
2
DILTIA XT
MO, CG
2
2
PLENDIL
DYNACIRC
MO, CG
MO, CG
CARDENE
MO, CG
MO, CG
2
2
Requirements/Limits
2
MO, CG
2
2
PROCARDIA XL
NIMOTOP
MO, CG
MO, CG
2
2
ISOPTIN
MO, CG
PA(*), HI, CG
1
CALAN
MO, CG
1
Page 45 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
verapamil hcl er 100 mg cap er 24 hr,
120 mg cap er 24 hr, 120 mg tab er,
180 mg cap er 24 hr, 180 mg tab er,
200 mg cap er 24 hr, 240 mg cap er
24 hr, 240 mg tab er, 300 mg cap er
24 hr, 360 mg cap er 24 hr
2
VERELAN PM
MO, CG
Cardiovascular Agents (Combination Product) [Agentes Cardiovasculares (Productos En
Combinación)]
ALDACTAZIDE 25-25 mg tab, 50-50
mg tab
4
ST, MO
amiloride-hydrochlorothiazide 5-50 mg
tab
2
MODURETIC
MO, CG
amlodipine besy-benazepril hcl 10-20
mg cap, 10-40 mg cap, 2.5-10 mg
cap, 5-10 mg cap, 5-20 mg cap, 5-40
mg cap
2
LOTREL
MO, CG
amlodipine-atorvastatin 10-10 mg tab,
10-20 mg tab, 10-40 mg tab, 10-80
mg tab, 2.5-10 mg tab, 2.5-20 mg tab,
2.5-40 mg tab, 5-10 mg tab, 5-20 mg
tab, 5-40 mg tab, 5-80 mg tab
2
CADUET
MO, CG
atenolol-chlorthalidone 100-25 mg tab
2
TENORETIC 100
MO, CG
atenolol-chlorthalidone 50-25 mg tab
1
TENORETIC 50
MO, CG
benazepril-hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25
mg tab, 5-6.25 mg tab
1
LOTENSIN HCT
MO, CG
BENICAR HCT 20-12.5 mg tab, 4012.5 mg tab, 40-25 mg tab
4
MO
bisoprolol-hydrochlorothiazide 10-6.25
mg tab, 2.5-6.25 mg tab, 5-6.25 mg
tab
1
ZIAC
MO, CG
candesartan cilexetil-hctz 16-12.5 mg
tab, 32-12.5 mg tab, 32-25 mg tab
2
ATACAND HCT
MO, CG
captopril-hydrochlorothiazide 25-15
mg tab, 25-25 mg tab, 50-15 mg tab,
50-25 mg tab
1
CAPOZIDE
MO, CG
enalapril-hydrochlorothiazide 10-25
mg tab, 5-12.5 mg tab
1
VASERETIC
MO, CG
fosinopril sodium-hctz 10-12.5 mg tab,
20-12.5 mg tab
2
MONOPRIL HCT
MO, CG
irbesartan-hydrochlorothiazide 30012.5 mg tab
2
AVALIDE
MO, CG
irbesartan-hydrochlorothiazide 15012.5 mg tab
1
AVALIDE
MO, CG
1
Page 46 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
lisinopril-hydrochlorothiazide 10-12.5
mg tab, 20-12.5 mg tab, 20-25 mg tab
1
ZESTORETIC
MO, CG
losartan potassium-hctz 100-12.5 mg
tab, 100-25 mg tab, 50-12.5 mg tab
1
HYZAAR
MO, CG
metoprolol-hydrochlorothiazide 10025 mg tab, 100-50 mg tab, 50-25 mg
tab
2
LOPRESSOR HCT
MO, CG
moexipril-hydrochlorothiazide 15-12.5
mg tab, 15-25 mg tab, 7.5-12.5 mg
tab
2
UNIRETIC
MO, CG
propranolol-hctz 40-25 mg tab, 80-25
mg tab
2
INDERIDE
MO, CG
quinapril-hydrochlorothiazide 10-12.5
mg tab, 20-12.5 mg tab, 20-25 mg tab
2
ACCURETIC
MO, CG
spironolactone-hctz 25-25 mg tab
1
ALDACTAZIDE
MO, CG
triamterene-hctz 37.5-25 mg cap,
37.5-25 mg tab, 50-25 mg cap, 75-50
mg tab
1
MAXZIDE-25
MO, CG
valsartan-hydrochlorothiazide 16012.5 mg tab, 160-25 mg tab, 320-12.5
mg tab, 320-25 mg tab, 80-12.5 mg
tab
2
DIOVAN HCT
MO, CG
VYTORIN 10-10 mg tab, 10-20 mg
tab, 10-40 mg tab
3
MO
VYTORIN 10-80 mg tab
3
PA, MO
Cardiovascular Agents, Other [Agentes Cardiovasculares, Otros]
DEMSER 250 mg cap
5
digoxin 0.25 mg/ml inj soln
2
LANOXIN
PA(*), HR, HI, CG
digoxin 125 mcg tab, 250 mcg tab
1
LANOXIN
MO, HR, CG
digoxin 0.05 mg/ml soln
2
LANOXIN
MO, HR, CG
LANOXIN 187.5 mcg tab, 250 mcg
tab, 62.5 mcg tab
4
MO
LANOXIN 125 mcg tab
4
MO, HR
pentoxifylline er 400 mg tab er
2
TRENTAL
MO, CG
RANEXA 1000 mg tab er 12 hr, 500
mg tab er 12 hr
4
PA, MO
Diuretics, Carbonic Anhydrase Inhibitors [Diuréticos, Inhibidores De La Anhidrasa
Carbónica]
acetazolamide 125 mg tab, 250 mg
tab
2
DIAMOX
MO, CG
acetazolamide er 500 mg cap er 12 hr
2
DIAMOX SEQUELS
MO, CG
methazolamide 25 mg tab, 50 mg tab
2
NEPTAZANE
MO, CG
Diuretics, Loop [Diuréticos, Asa De Henle]
bumetanide 0.25 mg/ml inj soln
2
BUMEX
HI, CG
1
Page 47 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
bumetanide 0.5 mg tab, 1 mg tab, 2
mg tab
1
BUMEX
MO, CG
furosemide 10 mg/ml inj soln
2
PA(*), HI, CG
furosemide 10 mg/ml soln, 20 mg tab,
1
LASIX
MO, CG
torsemide 10 mg tab, 20 mg tab, 5 mg
tab
1
DEMADEX
MO, CG
torsemide 100 mg tab
2
DEMADEX
MO, CG
torsemide 20 mg/2ml iv soln
2
DEMADEX
PA(*), HI, CG
Diuretics, Potassium-Sparing [Diuréticos, Conservadores De Potasio]
ALDACTONE 100 mg tab, 25 mg tab,
50 mg tab
4
ST, MO
amiloride hcl 5 mg tab
2
MIDAMOR
MO, CG
eplerenone 25 mg tab, 50 mg tab
2
INSPRA
ST, MO, CG
spironolactone 100 mg tab, 25 mg
tab, 50 mg tab
2
ALDACTONE
MO, CG
Diuretics, Thiazide [Diuréticos, Tiazidas]
chlorothiazide 250 mg tab, 500 mg tab
1
DIURIL
MO, CG
chlorthalidone 25 mg tab, 50 mg tab
1
THALITONE
MO, CG
DIURIL 250 mg/5ml susp
4
MO
hydrochlorothiazide 12.5 mg cap, 12.5
1
ORETIC
MO, CG
indapamide 1.25 mg tab, 2.5 mg tab
1
LOZOL
MO, CG
methyclothiazide 5 mg tab
2
ENDURON
MO, CG
metolazone 10 mg tab, 2.5 mg tab, 5
mg tab
2
ZAROXOLYN
MO, CG
Dyslipidemics, Fibric Acid Derivatives [Dislipidémicos, Derivados Del Ácido Fíbrico]
fenofibrate 145 mg tab, 160 mg tab,
2
TRIGLIDE
MO, CG
fenofibrate micronized 130 mg cap,
134 mg cap, 200 mg cap, 43 mg cap,
67 mg cap
2
TRICOR
MO, CG
fenofibric acid 135 mg cap dr, 45 mg
cap dr
2
TRILIPIX
MO, CG
gemfibrozil 600 mg tab
1
LOPID
MO, CG
Dyslipidemics, Hmg Coa Reductase Inhibitors [Dislipidémicos, Inhibidores De La Hmg Coa
Reductasa]
atorvastatin calcium 10 mg tab, 20 mg
1
LIPITOR
MO, CG
lovastatin 10 mg tab, 20 mg tab, 40
mg tab
1
MEVACOR
MO, CG
pravastatin sodium 10 mg tab, 20 mg
1
PRAVACHOL
MO, CG
simvastatin 80 mg tab
1
ZOCOR
PA, MO, CG
1
Page 48 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
simvastatin 10 mg tab, 20 mg tab, 40
mg tab, 5 mg tab
1
ZOCOR
MO, CG
Dyslipidemics, Other [Dislipidémicos, Otros]
cholestyramine light 4 gm pckt
2
QUESTRAN LIGHT
MO, CG
colestipol hcl 1 gm tab, 5 gm oral gr
2
COLESTID FLAVORED
MO, CG
niacin er (antihyperlipidemic) 1000 mg
tab er, 500 mg tab er, 750 mg tab er
2
NIASPAN
MO, CG
omega-3-acid ethyl esters 1 gm cap
2
OMACOR
MO, CG
ZETIA 10 mg tab
3
MO
Vasodilators, Direct-Acting Arterial [Vasodilatadores Arteriales De Acción Directa]
hydralazine hcl 10 mg tab, 100 mg
1
APRESOLINE
MO, CG
hydralazine hcl 20 mg/ml inj soln
1
PA(*), HI, CG
minoxidil 10 mg tab, 2.5 mg tab
1
LONITEN
MO, CG
Vasodilators, Direct-Acting Arterial/Venous [Vasodilatadores Arteriovenosos De Acción
Directa]
isosorbide dinitrate 10 mg tab, 20 mg
tab, 5 mg tab
2
SORBITRATE
MO, CG
isosorbide dinitrate 30 mg tab
1
ISORDIL TITRADOSE
MO, CG
isosorbide dinitrate er 40 mg tab er
2
ISORDIL TEMBID
MO, CG
isosorbide mononitrate 10 mg tab
2
MONOKET
MO, CG
isosorbide mononitrate 20 mg tab
1
MONOKET
MO, CG
isosorbide mononitrate er 120 mg tab
er 24 hr
2
IMDUR
MO, CG
isosorbide mononitrate er 30 mg tab
1
ISOTRATE ER
MO, CG
MINITRAN 0.1 mg/hr td patch 24hr,
0.2 mg/hr td patch 24hr, 0.4 mg/hr td
patch 24hr, 0.6 mg/hr td patch 24hr
2
MO, CG
NITRO-DUR 0.1 mg/hr td patch 24hr,
patch 24hr, 0.4 mg/hr td patch 24hr,
patch 24hr
4
MO
nitroglycerin 0.1 mg/hr td patch 24hr,
patch 24hr, 0.6 mg/hr td patch 24hr
2
TRANSDERM-NITRO
MO, CG
NITROSTAT 0.3 mg tab subl, 0.4 mg
tab subl, 0.6 mg tab subl
4
MO
CENTRAL NERVOUS SYSTEM AGENTS [AGENTES DEL SISTEMA NERVIOSO CENTRAL]
Attention Deficit Hyperactivity Disorder Agents, Amphetamines [Agentes Para El Desorden
De Déficit De Atención E Hiperactividad, Anfetaminas]
1
Page 49 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
amphetamine-dextroamphet er 10 mg
30 mg cap er 24 hr, 5 mg cap er 24 hr
2
ADDERALL XR
MO, CG
amphetamine-dextroamphetamine 10
mg tab, 12.5 mg tab, 15 mg tab, 20
mg tab, 30 mg tab, 5 mg tab, 7.5 mg
tab
2
ADDERALL
MO, CG
dextroamphetamine sulfate 5 mg tab
1
ZENZEDI
MO, CG
dextroamphetamine sulfate er 10 mg
cap er 24 hr, 5 mg cap er 24 hr
2
DEXEDRINE
MO, CG
dextroamphetamine sulfate er 15 mg
cap er 24 hr
1
DEXEDRINE
MO, CG
Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines [Agentes Para El
Desorden De Déficit De Atención E Hiperactividad, No-Anfetaminas]
KAPVAY 0.1 mg tab er 12 hr
4
MO
METADATE ER 20 mg tab er
2
MO, CG
methylphenidate hcl 10 mg tab, 10
mg/5ml soln, 20 mg tab, 5 mg tab, 5
mg/5ml soln
2
RITALIN
MO, CG
methylphenidate hcl er 20 mg tab er
2
RITALIN SR
MO, CG
methylphenidate hcl er (cd) 10 mg cap
er
2
METADATE CD
MO, CG
STRATTERA 10 mg cap, 18 mg cap,
QL(120 / 30), ST,
25 mg cap
4
MO
QL(60 / 30), ST,
STRATTERA 40 mg cap
4
MO
STRATTERA 100 mg cap, 60 mg cap,
QL(30 / 30), ST,
80 mg cap
4
MO
Central Nervous System, Other [Sistema Nervioso Central, Otros]
NUEDEXTA 20-10 mg cap
4
PA, MO
riluzole 50 mg tab
2
RILUTEK
PA, MO, CG
XENAZINE 12.5 mg tab, 25 mg tab
5
LA, MO
Multiple Sclerosis Agents [Agentes Para La Esclerósis Múltiple]
AMPYRA 10 mg tab er 12 hr
5
LA, MO
AUBAGIO 14 mg tab, 7 mg tab
5
PA, MO
AVONEX 30 mcg im kit
5
PA, QL(4 / 28), MO
AVONEX PREFILLED 30 mcg/0.5ml
im kit
5
PA, QL(4 / 28), MO
BETASERON 0.3 mg sc kit
5
PA, MO
COPAXONE 20 mg/ml sc kit, 40
mg/ml sc soln
5
PA, MO
EXTAVIA 0.3 mg sc kit
5
PA, MO
GILENYA 0.5 mg cap
5
PA, MO
1
Page 50 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
REBIF 22 mcg/0.5ml sc soln, 44
mcg/0.5ml sc soln
5
REBIF TITRATION PACK 6x8.8 &
6x22 mcg sc soln
5
TECFIDERA 120 & 240 mg oral misc
5
TECFIDERA 120 mg cap dr, 240 mg
cap dr
5
TYSABRI 300 mg/15ml iv conc
5
DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]
Dental And Oral Agents [Agentes Dentales Y Orales]
cevimeline hcl 30 mg cap
2
EVOXAC
chlorhexidine gluconate 0.12 %
mouth/throat soln
1
PERISOL
doxycycline hyclate 20 mg tab
2
PERIOSTAT
pilocarpine hcl 5 mg tab, 7.5 mg tab
2
SALAGEN
triamcinolone acetonide 0.1 %
mouth/throat paste
2
ORALONE
DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Dermatological Agents [Agentes Dermatológicos]
acitretin 10 mg cap, 17.5 mg cap, 25
mg cap
5
SORIATANE
adapalene 0.1 % crm, 0.1 % gel, 0.3
% gel
2
DIFFERIN
ammonium lactate 12 % crm, 12 % lot
2
LACTREX
AMNESTEEM 10 mg cap, 20 mg cap,
40 mg cap
2
AVITA 0.025 % crm, 0.025 % gel
2
calcipotriene 0.005 % crm, 0.005 %
oint, 0.005 % soln
2
DOVONEX
CARAC 0.5 % crm
4
CLARAVIS 10 mg cap, 20 mg cap, 30
mg cap, 40 mg cap
2
CONDYLOX 0.5 % gel
4
DOVONEX 0.005 % crm
4
ELIDEL 1 % crm
4
fluorouracil 2 % soln, 5 % crm, 5 %
soln
2
EFUDEX
imiquimod 5 % crm
2
ALDARA
OXSORALEN ULTRA 10 mg cap
5
podofilox 0.5 % soln
2
CONDYLOX
PROTOPIC 0.03 % oint, 0.1 % oint
4
RETIN-A 0.01 % gel, 0.025 % crm,
0.025 % gel, 0.05 % crm, 0.1 % crm
4
Requirements/Limits
PA, MO
PA, MO
PA
PA, MO
PA(*)
MO, CG
CG
CG
MO, CG
CG
CG
CG
CG
CG
CG
CG
ST
CG
CG
CG
ST
PA
1
Page 51 of 87
Updated 08/2014
Drug
Tier
[Nivel]
4
1
Reference Name
Requirements/Limits
Medicamento]
SANTYL 250 unit/gm oint
selenium sulfide 2.5 % lot
SELSUN
CG
TAZORAC 0.05 % crm, 0.05 % gel,
0.1 % crm, 0.1 % gel
4
PA
tretinoin 0.01 % gel, 0.025 % crm,
0.025 % gel, 0.05 % crm, 0.1 % crm
2
RETIN-A
PA, CG
VOLTAREN 1 % td gel
4
Dermatological Agents (Combination Product) [Agentes Dermatológicos (Productos En
Combinación)]
benzoyl peroxide-erythromycin 5-3 %
gel
2
BENZAMYCIN
CG
clotrimazole-betamethasone 1-0.05 %
crm, 1-0.05 % lot
2
LOTRISONE
CG
EPIDUO 0.1-2.5 % gel
4
PA
ENZYME REPLACEMENT/MODIFIERS [REEMPLAZO DE ENZIMAS/MODIFICADORES]
Enzyme Replacement/Modifiers [Reemplazo De Enzimas/Modificadores]
ADAGEN 250 unit/ml im soln
5
PA, LA
ALDURAZYME 2.9 mg/5ml iv soln
5
PA, LA
CEREZYME 200 unit iv soln
5
PA(*)
CREON 12000 unit cap dr prt, 24000
unit cap dr prt, 6000 unit cap dr prt
4
MO
CYSTADANE oral pwdr
5
MO
CYSTAGON 150 mg cap, 50 mg cap
4
PA, MO
ELAPRASE 6 mg/3ml iv soln
5
PA
ELELYSO 200 unit iv soln
5
PA(*)
FABRAZYME 35 mg iv soln
5
PA
KUVAN 100 mg tab sol
5
PA, MO
MYOZYME 50 mg iv soln
5
PA(*)
NAGLAZYME 1 mg/ml iv soln
5
PA, LA
ORFADIN 10 mg cap, 2 mg cap, 5 mg
cap
5
PA, MO
PANCREAZE 10500 unit cap dr prt,
16800 unit cap dr prt, 21000 unit cap
dr prt, 4200 unit cap dr prt
3
MO
sodium phenylbutyrate 3 gm/tsp oral
pwdr
2
BUPHENYL
PA, MO, CG
VPRIV 400 unit iv soln
5
PA(*)
ZAVESCA 100 mg cap
5
PA, LA, MO
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Antispasmodics, Gastrointestinal [Antiespasmódicos, Gastrointestinales]
dicyclomine hcl 10 mg cap, 10 mg/5ml
soln, 20 mg tab
1
BENTYL
CG
glycopyrrolate 1 mg tab, 2 mg tab
2
ROBINUL-FORTE
CG
1
Page 52 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
methscopolamine bromide 2.5 mg tab,
5 mg tab
1
PAMINE FORTE
CG
Gastrointestinal Agents (Combination Product) [Agentes Gastrointestinales (Productos en
Combinación)]
CREON 3000-9500 unit cap dr prt,
36000 unit cap dr prt
4
MO
GAVILYTE-C 240 gm soln
2
CG
GAVILYTE-G 236 gm soln
2
CG
GAVILYTE-N WITH FLAVOR PACK
420 gm soln
2
CG
TRILYTE 420 gm soln
2
CG
Gastrointestinal Agents, Other [Agentes Gastrointestinales, Otros]
cromolyn sodium 100 mg/5ml oral
conc
2
GASTROCROM
MO, CG
diphenoxylate-atropine 2.5-0.025 mg
tab
1
LONOX
CG
FULYZAQ 125 mg tab dr
4
PA, MO
GENOTROPIN 12 mg sc soln
5
PA, MO
loperamide hcl 2 mg cap
1
IMODIUM
CG
NORDITROPIN NORDIFLEX PEN 30
mg/3ml sc soln
5
PA, MO
NUTROPIN AQ NUSPIN 5 5 mg/2ml
sc soln
5
PA, MO
RELISTOR 12 mg/0.6ml sc kit
4
PA, QL(21 / 30)
SEROSTIM 4 mg sc soln, 5 mg sc
soln, 6 mg sc soln
5
PA, MO
ursodiol 250 mg tab, 300 mg cap, 500
mg tab
2
URSO FORTE
MO, CG
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De Histamina2 (H2)]
cimetidine 200 mg tab
cimetidine 300 mg tab, 400 mg tab,
800 mg tab
famotidine 20 mg/2ml iv soln
1
TAGAMET HB
CG
1
2
TAGAMET
MO, CG
PA(*), HI, CG
famotidine 20 mg tab, 40 mg tab
famotidine 40 mg/5ml susp
famotidine premixed 20-0.9 mg/50ml% iv soln
ranitidine hcl 150 mg/6ml inj soln
1
2
2
2
PEPCID AC MAXIMUM
STRENGTH
PEPCID
MO, CG
MO, CG
PEPCID PREMIXED
PA(*), HI, CG
ZANTAC
CG
ZANTAC 150 MAXIMUM
ranitidine hcl 150 mg tab, 300 mg tab
1
STRENGTH
MO, CG
ranitidine hcl 15 mg/ml syr
2
ZANTAC
MO, CG
Irritable Bowel Syndrome Agents [Agentes Para El Síndrome Del Colón Irritable]
1
Page 53 of 87
Updated 08/2014
Drug
Tier
[Nivel]
4
3
5
Reference Name
Medicamento]
AMITIZA 24 mcg cap, 8 mcg cap
LINZESS 145 mcg cap, 290 mcg cap
LOTRONEX 0.5 mg tab, 1 mg tab
Laxatives [Laxantes]
constulose 10 gm/15ml soln
2
DUPHALAC
enulose 10 gm/15ml soln
2
lactulose 10 gm/15ml soln
2
DUPHALAC
polyethylene glycol 3350 oral pwdr
2
TGT POWDERLAX
Protectants [Protectores]
CARAFATE 1 gm/10ml susp
4
misoprostol 200 mcg tab
2
CYTOTEC
sucralfate 1 gm tab
2
CARAFATE
Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]
lansoprazole 15 mg cap dr, 30 mg cap
dr
2
PREVACID 24HR
omeprazole 10 mg cap dr, 20 mg cap
dr
1
PRILOSEC
Requirements/Limits
PA, MO
PA, MO
MO
MO, CG
MO, CG
MO, CG
CG
MO
MO, CG
MO, CG
ST, MO, CG
QL(60 / 30), MO,
CG
QL(30 / 30), MO,
CG
omeprazole 40 mg cap dr
1
PRILOSEC
pantoprazole sodium 20 mg tab dr, 40
mg tab dr
1
PROTONIX
MO, CG
pantoprazole sodium 40 mg iv soln
2
PROTONIX
PA(*), HI, CG
GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Antispasmodics, Urinary [Antiespasmódicos, Urinarios]
oxybutynin chloride 5 mg tab
1
MO, CG
oxybutynin chloride er 10 mg tab er 24
hr, 15 mg tab er 24 hr, 5 mg tab er 24
hr
2
DITROPAN XL
MO, CG
tolterodine tartrate 1 mg tab, 2 mg tab
2
DETROL
MO, CG
tolterodine tartrate er 2 mg cap er 24
hr, 4 mg cap er 24 hr
2
DETROL LA
MO, CG
TOVIAZ 4 mg tab er 24 hr, 8 mg tab
er 24 hr
3
MO
trospium chloride 20 mg tab
2
SANCTURA
MO, CG
trospium chloride er 60 mg cap er 24
hr
2
SANCTURA XR
MO, CG
Benign Prostatic Hypertrophy Agents [Agentes Para La Hipertrofia Prostática Benigna]
alfuzosin hcl er 10 mg tab er 24 hr
1
UROXATRAL
MO, CG
finasteride 5 mg tab
1
PROSCAR
MO, CG
tamsulosin hcl 0.4 mg cap
1
FLOMAX
MO, CG
Genitourinary Agents, Other [Agentes Genitourinarios, Otros]
bethanechol chloride 10 mg tab, 25
2
URECHOLINE
CG
1
Page 54 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
DEPEN TITRATABS 250 mg tab
4
ELMIRON 100 mg cap
4
methylergonovine maleate 0.2 mg tab
2
METHERGINE
CG
Phosphate Binders [Enlazadores De Fosfato]
calcium acetate 667 mg cap
2
PHOSLO
MO, CG
PHOSLYRA 667 mg/5ml soln
4
MO
RENVELA 0.8 gm pckt, 2.4 gm pckt,
800 mg tab
4
MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) [AGENTES
HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (ADRENALES)]
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) [Agentes Hormonales,
Estimulantes/Reemplazo/Modificador (Adrenales)]
A-HYDROCORT 100 mg inj soln
2
CG
SB HYDROCORTISONE
ala cort 1 % crm
1
1%
CG
alclometasone dipropionate 0.05 %
crm, 0.05 % oint
2
ACLOVATE
CG
amcinonide 0.1 % crm, 0.1 % lot
2
CYCLOCORT
CG
betamethasone dipropionate 0.05 %
crm, 0.05 % lot, 0.05 % oint
2
MAXIVATE
CG
betamethasone dipropionate aug 0.05
% crm, 0.05 % lot, 0.05 % oint
2
DIPROLENE AF
CG
betamethasone valerate 0.1 % crm,
0.1 % lot, 0.1 % oint
2
BETATREX
CG
budesonide er 3 mg cap er 24 hr
5
ENTOCORT EC
clobetasol propionate 0.05 % gel, 0.05
% lot, 0.05 % oint, 0.05 % shampoo,
0.05 % soln
2
TEMOVATE
CG
clobetasol propionate e 0.05 % crm
2
TEMOVATE E
CG
COLOCORT 100 mg/60ml rect enema
2
CG
cortisone acetate 25 mg tab
2
CG
desonide 0.05 % crm, 0.05 % lot, 0.05
% oint
2
TRIDESILON
CG
desoximetasone 0.05 % crm, 0.05 %
gel, 0.05 % oint, 0.25 % crm, 0.25 %
oint
2
TOPICORT LP
CG
dexamethasone 0.5 mg/5ml oral elix
2
HEXADROL
CG
dexamethasone 0.5 mg tab, 0.75 mg
tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4
mg tab, 6 mg tab
1
DECADRON
CG
dexamethasone sodium phosphate 10
mg/ml inj soln
1
HEXADROL
CG
dexamethasone sodium phosphate
120 mg/30ml inj soln
2
CG
1
Page 55 of 87
Updated 08/2014
Medicamento]
diflorasone diacetate 0.05 % crm,
0.05 % oint
fludrocortisone acetate 0.1 mg tab
fluocinolone acetonide 0.01 % otic oil
fluocinolone acetonide 0.01 % crm,
0.01 % soln, 0.025 % crm, 0.025 %
oint
fluocinolone acetonide body 0.01 %
external oil
fluocinonide 0.05 % gel, 0.05 % oint,
0.05 % soln
fluocinonide-e 0.05 % crm
fluticasone propionate 0.005 % oint,
0.05 % crm
halobetasol propionate 0.05 % crm,
0.05 % oint
hydrocortisone 10 mg tab, 100
mg/60ml rect enema, 2.5 % lot, 20 mg
tab, 5 mg tab
hydrocortisone 1 % crm, 1 % oint, 2.5
% crm, 2.5 % oint
hydrocortisone butyrate 0.1 % oint,
0.1 % soln
hydrocortisone valerate 0.2 % crm,
0.2 % oint
LOKARA 0.05 % lot
methylprednisolone 16 mg tab, 32 mg
methylprednisolone (pak) 4 mg tab
methylprednisolone acetate 40 mg/ml
inj susp, 80 mg/ml inj susp
methylprednisolone sodium succ 125
mg inj soln, 40 mg inj soln
mometasone furoate 0.1 % crm, 0.1
% oint, 0.1 % soln
prednisolone sodium phosphate 15
mg/5ml soln, 6.7 (5 base) mg/5ml soln
prednisone 5 mg/5ml soln
prednisone 1 mg tab, 10 mg tab, 2.5
mg tab, 20 mg tab, 5 mg tab, 50 mg
tab
PROCTOZONE-HC 2.5 % rect crm
Drug
Tier
[Nivel]
Reference Name
2
2
2
PSORCON
FLORINEF
DERMOTIC
CG
MO, CG
CG
2
SYNEMOL
CG
2
DERMA-SMOOTHE
CG
2
2
LIDEX
LIDEX-E
CG
CG
2
CUTIVATE
CG
2
ULTRAVATE
CG
2
CG
1
NUTRACORT
SB HYDROCORTISONE
1%
2
LOCOID
CG
2
2
WESTCORT
CG
CG
2
2
MEDROL
MEDROL (PAK)
CG
CG
1
DEPO-MEDROL
CG
2
SOLU-MEDROL
PA(*), HI, CG
2
ELOCON
CG
2
2
PEDIAPRED
CG
CG
1
4
ORASONE
CG
Requirements/Limits
CG
1
Page 56 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
triamcinolone acetonide 0.025 % lot,
0.025 % oint, 0.1 % crm, 0.1 % lot, 0.1
% oint, 0.5 % crm, 0.5 % oint
2
TRIDERM
CG
triamcinolone acetonide 55 mcg/act
nasal inh
2
NASACORT AQ
QL(16.5 / 25), CG
triamcinolone acetonide 0.025 % crm
1
ARISTOCORT LP
CG
TRIDERM 0.1 % crm
1
CG
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) [AGENTES
HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (PITUITARIA)]
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) [Agentes Hormonales,
Estimulantes/Reemplazo/Modificador (Pituitaria)]
chorionic gonadotropin 10000 unit im
soln
2
PROFASI HP
PA, CG
desmopressin ace spray refrig 0.01 %
QL(10 / 25), MO,
nasal soln
2
MINIRIN
CG
desmopressin acetate 4 mcg/ml inj
soln
2
DDAVP
CG
desmopressin acetate 0.1 mg tab, 0.2
mg tab
2
DDAVP
MO, CG
GENOTROPIN 5 mg sc soln
5
PA, MO
GENOTROPIN MINIQUICK 0.4 mg sc
soln, 0.6 mg sc soln, 0.8 mg sc soln, 1
mg sc soln, 1.2 mg sc soln, 1.4 mg sc
soln, 1.6 mg sc soln, 1.8 mg sc soln, 2
mg sc soln
5
PA, MO
GENOTROPIN MINIQUICK 0.2 mg sc
soln
4
PA, MO
HUMATROPE 12 mg inj soln, 24 mg
inj soln, 5 mg inj soln, 6 mg inj soln
5
PA, MO
INCRELEX 40 mg/4ml sc soln
5
PA, LA, MO
NORDITROPIN FLEXPRO 10
mg/1.5ml sc soln, 15 mg/1.5ml sc
soln, 5 mg/1.5ml sc soln
5
PA, MO
NUTROPIN AQ PEN 10 mg/2ml sc
soln, 20 mg/2ml sc soln
5
PA, MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX
HORMONES/MODIFIERS) [AGENTES HORMONALES,
ESTIMULANTES/REEMPLAZO/MODIFICADOR (HORMONAS SEXUALES/MODIFICADORES)]
Anabolic Steroids [Esteroides Anabólicos]
oxandrolone 10 mg tab, 2.5 mg tab
2
Androgens [Andrógenos]
OXANDRIN
PA, CG
PA, QL(300 / 30),
ANDROGEL 50 mg/5gm td gel
3
MO
1
Page 57 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
ANDROGEL PUMP 20.25 mg/act
PA, QL(150 / 30),
(1.62%) td gel
3
MO
ANDROXY 10 mg tab
4
PA, MO
danazol 100 mg cap, 200 mg cap, 50
mg cap
2
DANOCRINE
CG
DEPO-TESTOSTERONE 100 mg/ml
im oil, 200 mg/ml im oil
4
PA
STRIANT 30 mg bucc misc
4
PA, MO
testosterone cypionate 100 mg/ml im
oil, 200 mg/ml im oil
2
VIRILON IM
PA, CG
testosterone enanthate 200 mg/ml im
oil
2
DELATESTRYL
PA, CG
Estrogens [Estrogenos]
ESTRACE 0.1 mg/gm vag crm
4
MO
estradiol 0.5 mg tab, 1 mg tab, 2 mg
tab
1
GYNODIOL
PA, MO, HR, CG
estradiol valerate 40 mg/ml im oil
2
DELESTROGEN
CG
PREMARIN 0.3 mg tab, 0.45 mg tab,
0.625 mg tab, 0.9 mg tab, 1.25 mg tab
4
PA, MO, HR
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
(Combination Product) [Agentes Hormonales, Estimulantes/Reemplazo/Modificador
(Hormonas Sexuales/Modificadores) (Productos en Combinación]
ESTROSTEP FE 1-20/1-30/1-35 mgmcg tab
4
MO
ORTHO TRI-CYCLEN (28)
0.18/0.215/0.25 mg-35 mcg tab
4
MO
YAZ 3-0.02 mg tab
4
MO
Progesterone Agonists/Antagonists [Agonistas/Antagonistas De Progesterona]
ELLA 30 mg tab
3
Progestins [Progestinas]
DEPO-PROVERA 400 mg/ml im susp
4
PA(*)
medroxyprogesterone acetate 10 mg
tab, 2.5 mg tab, 5 mg tab
1
PROVERA
MO, CG
megestrol acetate 20 mg tab, 40 mg
tab, 40 mg/ml susp
2
MEGACE ORAL
HR, CG
norethindrone acetate 5 mg tab
2
AYGESTIN
MO, CG
Selective Estrogen Receptor Modifying Agents [Agentes Modificadores Selectivos Del
Receptor De Estrógeno]
raloxifene hcl 60 mg tab
2
EVISTA
MO, CG
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) [AGENTES
HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (TIROIDES)]
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) [Agentes Hormonales,
Estimulantes/Reemplazo/Modificador (Tiroides)]
1
Page 58 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
levothyroxine sodium 100 mcg tab,
112 mcg tab, 125 mcg tab, 137 mcg
tab, 150 mcg tab, 175 mcg tab, 200
mcg tab, 25 mcg tab, 300 mcg tab, 50
mcg tab, 75 mcg tab, 88 mcg tab
1
UNITHROID DIRECT
MO, CG
LEVOXYL 100 mcg tab, 112 mcg tab,
125 mcg tab, 137 mcg tab, 150 mcg
mcg tab, 50 mcg tab, 75 mcg tab, 88
mcg tab
1
MO, CG
liothyronine sodium 25 mcg tab, 5
mcg tab, 50 mcg tab
2
CYTOMEL
MO, CG
SYNTHROID 100 mcg tab, 112 mcg
mcg tab, 175 mcg tab, 200 mcg tab,
25 mcg tab, 300 mcg tab, 50 mcg tab,
75 mcg tab, 88 mcg tab
3
MO
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) [AGENTES HORMONALES, SUPRESORES
(ADRENALES)]
Hormonal Agents, Suppressant (Adrenal) [Agentes Hormonales, Supresores (Adrenales)]
LYSODREN 500 mg tab
3
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) [AGENTES HORMONALES,
SUPRESORES (PARATIROIDE)]
Hormonal Agents, Suppressant (Parathyroid) [Agentes Hormonales, Supresores
(Paratiroide)]
SENSIPAR 30 mg tab
3
MO
SENSIPAR 60 mg tab, 90 mg tab
5
MO
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) [AGENTES HORMONALES,
SUPRESORES (PITUITARIA)]
Hormonal Agents, Suppressant (Pituitary) [Agentes Hormonales, Supresores (Pituitaria)]
cabergoline 0.5 mg tab
2
DOSTINEX
CG
ELIGARD 22.5 mg sc kit, 30 mg sc kit,
45 mg sc kit, 7.5 mg sc kit
4
PA(*)
leuprolide acetate 1 mg/0.2ml inj kit
2
LUPRON
PA(*), CG
LUPRON DEPOT 3.75 mg im kit, 7.5
mg im kit
5
PA(*), QL(1 / 28)
LUPRON DEPOT 45 mg im kit
5
PA(*), QL(1 / 168)
LUPRON DEPOT 22.5 mg im kit
5
PA(*), QL(1 / 84)
LUPRON DEPOT 30 mg im kit
5
PA(*), QL(1 / 90)
LUPRON DEPOT-PED 11.25 mg
(ped) im kit
5
PA(*), QL(1 / 84)
LUPRON DEPOT-PED 11.25 mg im
kit, 15 mg im kit
5
PA(*), QL(1 / 28)
1
Page 59 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
octreotide acetate 1000 mcg/ml inj
soln, 500 mcg/ml inj soln
5
SANDOSTATIN
PA, MO
octreotide acetate 100 mcg/ml inj
soln, 200 mcg/ml inj soln, 50 mcg/ml
inj soln
2
SANDOSTATIN
PA, MO, CG
SANDOSTATIN 100 mcg/ml inj soln,
1000 mcg/ml inj soln, 200 mcg/ml inj
soln
5
PA, MO
SANDOSTATIN 50 mcg/ml inj soln,
500 mcg/ml inj soln
4
PA, MO
SANDOSTATIN LAR DEPOT 10 mg
im kit, 20 mg im kit, 30 mg im kit
5
PA
SOMATULINE DEPOT 120 mg/0.5ml
sc soln, 60 mg/0.2ml sc soln, 90
mg/0.3ml sc soln
5
PA
SOMAVERT 10 mg sc soln, 15 mg sc
soln, 20 mg sc soln
5
PA, LA, MO
SYNAREL 2 mg/ml nasal soln
5
HORMONAL AGENTS, SUPPRESSANT (THYROID) [AGENTES HORMONALES, SUPRESORES
(TIROIDE)]
Antithyroid Agents [Agentes Antitiroideos]
methimazole 10 mg tab, 5 mg tab
1
TAPAZOLE
MO, CG
propylthiouracil 50 mg tab
1
MO, CG
IMMUNOLOGICAL AGENTS [AGENTES INMUNOLÓGICOS]
Angioedema (HAE) Agents [Agentes De La Angioedema (HAE)]
CINRYZE 500 unit iv soln
5
PA(*)
FIRAZYR 30 mg/3ml sc soln
5
PA
Immune Suppressants [Inmunosupresores]
AZASAN 100 mg tab, 75 mg tab
4
PA(*), MO
azathioprine 50 mg tab
1
IMURAN
PA(*), MO, CG
CELLCEPT 200 mg/ml susp
4
PA(*), MO
CIMZIA 2 x 200 mg sc kit
5
PA
CIMZIA PREFILLED 2 x 200 mg/ml sc
kit
5
PA, MO
cyclosporine 100 mg cap, 25 mg cap
2
SANDIMMUNE
PA(*), MO, CG
cyclosporine 50 mg/ml iv soln
2
SANDIMMUNE
PA(*), HI, CG
cyclosporine modified 100 mg cap,
100 mg/ml soln, 25 mg cap, 50 mg
cap
2
SANGCYA
PA(*), MO, CG
PA, QL(4.08 / 28),
ENBREL 25 mg/0.5ml sc soln
5
MO
ENBREL 25 mg sc kit, 50 mg/ml sc
soln
5
PA, QL(8 / 28), MO
1
Page 60 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Medicamento]
GENGRAF 100 mg cap, 100 mg/ml
soln, 25 mg cap
2
HUMIRA 40 mg/0.8ml sc kit
5
HUMIRA 20 mg/0.4ml sc kit
5
HUMIRA PEN-CROHNS STARTER
40 mg/0.8ml sc kit
5
KINERET 100 mg/0.67ml sc soln
5
methotrexate 2.5 mg tab
2
methotrexate sodium 1 gm inj soln
2
methotrexate sodium (pf) 25 mg/ml inj
soln
2
mycophenolate mofetil 250 mg cap,
500 mg tab
2
CELLCEPT
mycophenolic acid 180 mg tab dr
2
MYFORTIC
mycophenolic acid 360 mg tab dr
5
MYFORTIC
MYFORTIC 180 mg tab dr
4
MYFORTIC 360 mg tab dr
5
NULOJIX 250 mg iv soln
5
ORENCIA 250 mg iv soln
5
ORENCIA 125 mg/ml sc soln
5
RAPAMUNE 0.5 mg tab
4
RAPAMUNE 1 mg tab, 1 mg/ml soln,
2 mg tab
5
REMICADE 100 mg iv soln
5
SANDIMMUNE 100 mg cap, 100
mg/ml soln, 25 mg cap
4
SIMPONI 50 mg/0.5ml sc soln
5
SIMPONI ARIA 50 mg/4ml iv soln
5
sirolimus 0.5 mg tab
2
RAPAMUNE
tacrolimus 0.5 mg cap, 1 mg cap, 5
mg cap
2
PROGRAF
XELJANZ 5 mg tab
5
ZORTRESS 0.5 mg tab, 0.75 mg tab
5
ZORTRESS 0.25 mg tab
4
Immunizing Agents, Passive [Agentes Inmunizantes, Pasivos]
CARIMUNE NF 3 gm iv soln
5
GAMMAGARD 2.5 gm/25ml inj soln
5
GAMMAPLEX 10 gm/200ml iv soln
3
GAMUNEX-C 1 gm/10ml inj soln
4
PRIVIGEN 20 gm/200ml iv soln
5
SYNAGIS 50 mg/0.5ml im soln
4
Immunomodulators [Inmunomoduladores]
ACTEMRA 162 mg/0.9ml sc soln
5
Requirements/Limits
PA(*), MO, CG
PA, QL(6 / 28), MO
PA, QL(2 / 28), MO
PA, MO
PA, MO
CG
PA(*), CG
PA(*), CG
PA(*), MO, CG
PA(*), MO, CG
PA(*), MO
PA(*), MO
PA(*), MO
PA(*)
PA(*), MO
PA, MO
PA(*), MO
PA(*), MO
PA(*)
PA(*), MO
PA, MO
PA, MO
PA(*), MO, CG
PA(*), MO, CG
PA, MO
PA(*), MO
PA(*), MO
PA
PA
PA
PA
PA(*)
PA, MO
1
Page 61 of 87
Updated 08/2014
Drug
Tier
[Nivel]
5
Reference Name
Requirements/Limits
Medicamento]
ACTEMRA 200 mg/10ml iv soln
PA(*)
ACTIMMUNE 2000000 unit/0.5ml sc
soln
5
PA, LA, MO
ARCALYST 220 mg sc soln
5
PA, MO
ILARIS 180 mg sc soln
5
PA
leflunomide 10 mg tab, 20 mg tab
1
ARAVA
MO, CG
Vaccines [Vacunas]
ACTHIB
4
ADACEL 5-2-15.5 im susp
4
BOOSTRIX 5-2.5-18.5 im susp
4
CERVARIX
4
PA
COMVAX 7.5-5 mcg/0.5ml im susp
4
DAPTACEL 10-15-5 im susp
4
diphtheria-tetanus toxoids dt 25-5
lfu/0.5ml im susp
2
PA(*), CG
ENGERIX-B 10 mcg/0.5ml inj susp,
20 mcg/ml inj susp
4
PA(*)
GARDASIL
4
PA, QL(1.5 / 365)
HAVRIX 1440 el u/ml im susp, 720 el
u/0.5ml im susp
4
IMOVAX RABIES 2.5 unit/ml im
4
PA(*)
INFANRIX 25-58-10 im susp
4
IPOL
4
IXIARO
4
MENACTRA
4
MENOMUNE
4
MENVEO
4
M-M-R II
4
PEDVAX HIB
4
PROQUAD
4
RABAVERT
4
RECOMBIVAX HB 10 mcg/ml inj
susp, 40 mcg/ml inj susp
4
PA(*)
ROTARIX
4
ROTATEQ
4
tetanus toxoid adsorbed 5 lfu im soln
2
PA(*), CG
tetanus-diphtheria toxoids td 2-2
lf/0.5ml im susp
2
PA(*), CG
TWINRIX 720-20 im susp
4
PA(*)
TYPHIM VI 25 mcg/0.5ml im soln
4
VAQTA 25 unit/0.5ml im susp
4
VARIVAX 1350 pfu/0.5ml sc inj
4
YF-VAX
4
ZOSTAVAX 19400 unt/0.65ml sc soln
4
PA, QL(1 / 999)
1
Page 62 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
INFLAMMATORY BOWEL DISEASE AGENTS [AGENTES PARA LA ENFERMEDAD
INFLAMATORIA DEL INTESTINO]
Aminosalicylates [Aminosalicilatos]
ASACOL HD 800 mg tab dr
3
balsalazide disodium 750 mg cap
2
COLAZAL
CG
CANASA 1000 mg rect supp
3
DELZICOL 400 mg cap dr
3
MO
DIPENTUM 250 mg cap
5
MO
mesalamine-cleanser 4 gm rect kit
2
ROWASA
CG
PENTASA 250 mg cap er, 500 mg
cap er
3
MO
Sulfonamides [Sulfonamidas]
sulfasalazine 500 mg tab
2
SULFAZINE
MO, CG
SULFAZINE EC 500 mg tab dr
2
MO, CG
METABOLIC BONE DISEASE AGENTS [AGENTES PARA LA ENFERMEDAD METABÓLICA DEL
HUESO]
Metabolic Bone Disease Agents [Agentes Para La Enfermedad Metabólica Del Hueso]
alendronate sodium 10 mg tab, 5 mg
tab
1
FOSAMAX
MO, CG
alendronate sodium 70 mg/75ml soln
2
FOSAMAX
MO, CG
alendronate sodium 40 mg tab
2
FOSAMAX
CG
alendronate sodium 35 mg tab, 70 mg
QL(4 / 28), MO,
tab
1
FOSAMAX
CG
calcitonin (salmon) 200 unit/act nasal
QL(3.7 / 30), MO,
soln
2
MIACALCIN
CG
calcitriol 0.25 mcg cap, 0.5 mcg cap, 1
mcg/ml soln
2
ROCALTROL
MO, CG
calcitriol 1 mcg/ml iv soln
2
CALCIJEX
PA(*), HI, CG
PA, QL(2.4 / 28),
FORTEO 600 mcg/2.4ml sc soln
5
MO
PA(*), QL(3 / 90),
ibandronate sodium 3 mg/3ml iv soln
2
BONIVA
CG
QL(1 / 30), ST,
ibandronate sodium 150 mg tab
2
BONIVA
MO, CG
MIACALCIN 200 unit/ml inj soln
4
paricalcitol 1 mcg cap, 2 mcg cap, 4
mcg cap
2
ZEMPLAR
PA, MO, CG
PROLIA 60 mg/ml sc soln
4
PA(*), QL(1 / 180)
risedronate sodium 150 mg tab
2
ACTONEL
ST, MO, CG
XGEVA 120 mg/1.7ml sc soln
5
PA(*), QL(1.7 / 28)
PA(*), QL(100 /
zoledronic acid 5 mg/100ml iv soln
2
RECLAST
365), CG
zoledronic acid 4 mg/5ml iv conc
2
ZOMETA
PA(*), CG
1
Page 63 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]
Ophthalmic Agents (Combination Product) [Agentes Oftálmicos (Productos En
Combinación]
bacitracin-polymyxin b 500-10000
unit/gm ophth oint
2
POLYSPORIN
CG
bacitra-neomycin-polymyxin-hc 1 %
ophth oint
2
NEO-POLYCIN HC
CG
COMBIGAN 0.2-0.5 % ophth soln
3
MO
dorzolamide hcl-timolol mal 22.3-6.8
mg/ml ophth soln
1
COSOPT
MO, CG
neomycin-bacitracin zn-polymyx 5400-10000 ophth oint
2
NEOSPORIN
CG
neomycin-polymyxin-dexameth 3.510000-0.1 ophth oint, 3.5-10000-0.1
ophth susp
1
MAXITROL
CG
neomycin-polymyxin-gramicidin 1.7510000-0.025 ophth soln
2
NEOSPORIN
CG
neomycin-polymyxin-hc ophth soln
2
CORTISPORIN
CG
polymyxin b-trimethoprim 10000-0.1
unit/ml-% ophth soln
1
POLYTRIM
CG
sulfacetamide-prednisolone 10-0.23
% ophth soln
2
VASOCIDIN
CG
TOBRADEX ST 0.3-0.05 % ophth
susp
3
tobramycin-dexamethasone 0.3-0.1 %
ophth susp
2
TOBRADEX
CG
Ophthalmic Agents, Other [Agentes Oftálmicos, Otros]
naphazoline hcl 0.1 % ophth soln
1
VASOCON
CG
proparacaine hcl 0.5 % ophth soln
1
OPHTHETIC
CG
PA, QL(60 / 30),
RESTASIS 0.05 % ophth emul
4
MO
Ophthalmic Anti-Allergy Agents [Agentes Oftálmicos Antialérgicos]
cromolyn sodium 4 % ophth soln
2
OPTICROM
CG
PATADAY 0.2 % ophth soln
3
ST
Ophthalmic Antiglaucoma Agents [Agentes Oftálmicos Antiglaucoma]
ALPHAGAN P 0.1 % ophth soln
3
MO
AZOPT 1 % ophth susp
3
QL(15 / 30), MO
betaxolol hcl 0.5 % ophth soln
2
BETOPTIC
MO, CG
brimonidine tartrate 0.15 % ophth
soln, 0.2 % ophth soln
1
ALPHAGAN P
MO, CG
dorzolamide hcl 2 % ophth soln
1
TRUSOPT
MO, CG
BETAGAN WITHOUT C
levobunolol hcl 0.5 % ophth soln
1
CAP
MO, CG
1
Page 64 of 87
Updated 08/2014
Drug
Tier
[Nivel]
1
Reference Name
Requirements/Limits
Medicamento]
metipranolol 0.3 % ophth soln
OPTIPRANOLOL
MO, CG
PHOSPHOLINE IODIDE 0.125 %
ophth soln
4
MO
timolol maleate 0.25 % ophth soln, 0.5
% ophth soln
1
TIMOPTIC
MO, CG
Ophthalmic Anti-Inflammatories [Oftálmicos Antiinflamatorios]
dexamethasone sodium phosphate
0.1 % ophth soln
1
DECADRON
CG
diclofenac sodium 0.1 % ophth soln
1
VOLTAREN
CG
flurbiprofen sodium 0.03 % ophth soln
1
OCUFEN
CG
ketorolac tromethamine 0.5 % ophth
soln
1
ACULAR PF
QL(10 / 25), CG
ketorolac tromethamine 0.4 % ophth
soln
1
ACULAR LS
QL(5 / 15), CG
NEVANAC 0.1 % ophth susp
3
prednisolone acetate 1 % ophth susp
2
PRED FORTE
CG
Ophthalmic Prostaglandin And Prostamide Analogs [Análogos Oftálmicos De
Prostaglandinas Y Prostamidas]
QL(2.5 / 25), MO,
latanoprost 0.005 % ophth soln
1
XALATAN
CG
TRAVATAN Z 0.004 % ophth soln
3
QL(2.5 / 25), MO
QL(2.5 / 25), MO,
travoprost 0.004 % ophth soln
2
TRAVATAN
CG
OTIC AGENTS [AGENTES ÓTICOS]
Otic Agents (Combination Product) [Agentes Óticos (Productos En Combinación)]
CIPRODEX 0.3-0.1 % otic susp
3
hydrocortisone-acetic acid 1-2 % otic
soln
2
VOSOL HC
CG
neomycin-polymyxin-hc 1 % otic soln
2
UAD OTIC
CG
neomycin-polymyxin-hc 3.5-10000-1
otic susp
2
CORTISPORIN
CG
RESPIRATORY TRACT/PULMONARY AGENTS [AGENTES PARA EL TRACTO
RESPIRATORIO/PULMONAR]
Antihistamines [Antihistamínicos]
azelastine hcl 137 mcg/spray nasal
soln
2
ASTEPRO
QL(30 / 25), CG
azelastine hcl 0.15 % nasal soln
2
ASTEPRO
QL(60 / 30), CG
cetirizine hcl 5 mg/5ml syr
2
ZYRTEC
CG
cyproheptadine hcl 2 mg/5ml syr, 4
mg tab
2
PERIACTIN
PA, HR, CG
desloratadine 5 mg tab
2
CLARINEX
ST, CG
levocetirizine dihydrochloride 2.5
mg/5ml soln, 5 mg tab
2
XYZAL
ST, CG
1
Page 65 of 87
Updated 08/2014
Drug
Tier
Reference Name
Requirements/Limits
Medicamento]
Anti-Inflammatories, Inhaled Corticosteroids [Antiinflamatorios, Corticoesteroides
Inhalados]
FLOVENT DISKUS 100 mcg/blist inh
aer pwdr, 250 mcg/blist inh aer pwdr
3
QL(120 / 30), MO
FLOVENT DISKUS 50 mcg/blist inh
aer pwdr
3
QL(240 / 30), MO
FLOVENT HFA 110 mcg/act inh aer,
220 mcg/act inh aer, 44 mcg/act inh
aer
3
MO
flunisolide 25 mcg/act (0.025%) nasal
soln
2
NASALIDE
QL(50 / 30), CG
fluticasone propionate 50 mcg/act
nasal susp
2
FLONASE
QL(16 / 30), CG
QVAR 40 mcg/act inh aer, 80 mcg/act
inh aer
3
QL(26.1 / 25), MO
Antileukotrienes [Antileucotrienos]
montelukast sodium 10 mg tab, 4 mg
tab chew, 4 mg pckt, 5 mg tab chew
1
SINGULAIR
MO, CG
zafirlukast 10 mg tab, 20 mg tab
2
ACCOLATE
MO, CG
Bronchodilators, Anticholinergic [Broncodilatadores, Anticolinérgicos]
ATROVENT 0.03 % nasal soln
4
MO
ATROVENT HFA 17 mcg/act inh aer
4
QL(25.8 / 25), MO
ipratropium bromide 0.02 % inh soln
1
ATROVENT
PA(*), MO, CG
ipratropium bromide 0.03 % nasal
soln, 0.06 % nasal soln
2
ATROVENT
MO, CG
SPIRIVA HANDIHALER 18 mcg inh
cap
3
MO
Bronchodilators, Sympathomimetic [Broncodilatadores, Simpatomiméticos]
albuterol sulfate 2 mg tab, 4 mg tab
1
VENTOLIN
MO, CG
albuterol sulfate (5 mg/ml) 0.5% inh
PA(*), QL(60 / 30),
neb soln
2
VENTOLIN
MO, CG
albuterol sulfate (2.5 mg/3ml) 0.083%
PA(*), QL(360 /
inh neb soln
1
VENTOLIN
30), MO, CG
albuterol sulfate 0.63 mg/3ml inh neb
PA(*), QL(360 /
soln, 1.25 mg/3ml inh neb soln
2
ACCUNEB
30), MO, CG
albuterol sulfate 2 mg/5ml syr
2
VENTOLIN
MO, CG
albuterol sulfate er 4 mg tab er 12 hr,
8 mg tab er 12 hr
2
VOSPIRE ER
MO, CG
EPIPEN 2-PAK 0.3 mg/0.3ml inj dev
4
EPIPEN JR 2-PAK 0.15 mg/0.3ml inj
dev
4
FORADIL AEROLIZER 12 mcg inh
cap
3
MO
1
Page 66 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
PROAIR HFA 108 (90 base) mcg/act
inh aer
3
QL(17 / 25), MO
SEREVENT DISKUS 50 mcg/dose inh
aer pwdr
4
QL(60 / 30), MO
terbutaline sulfate 1 mg/ml inj soln
2
BRICANYL
CG
terbutaline sulfate 2.5 mg tab, 5 mg
tab
2
BRICANYL
MO, CG
VENTOLIN HFA 108 (90 base)
mcg/act inh aer
3
MO
Cystic Fibrosis Agents [Agentes Para La Fibrosis Quística]
CAYSTON 75 mg inh soln
5
PA
TOBI PODHALER 28 mg inh cap
5
PA
Mast Cell Stabilizers [Estabilizadores De Los Mastocitos]
cromolyn sodium 20 mg/2ml inh neb
PA(*), QL(240 /
soln
2
INTAL
30), MO, CG
Phosphodiesterase Inhibitors, Airways Disease [Inhibidores De La Fosfodiesterasa,
Enfermedad De Las Vías Respiratorias]
aminophylline 25 mg/ml iv soln
2
PA(*), HI, CG
DALIRESP 500 mcg tab
4
MO
ELIXOPHYLLIN 80 mg/15ml oral elix
4
MO
theophylline er 100 mg tab er 12 hr,
hr
1
THEOLAIR-SR
MO, CG
theophylline er 400 mg tab er 24 hr,
hr
2
UNIPHYL
MO, CG
Pulmonary Antihypertensives [Antihipertensivos Pulmonar]
ADCIRCA 20 mg tab
5
PA, MO
ADEMPAS 0.5 mg tab, 1 mg tab, 1.5
mg tab, 2 mg tab, 2.5 mg tab
5
PA, MO
LETAIRIS 10 mg tab, 5 mg tab
5
PA, LA, MO
OPSUMIT 10 mg tab
5
PA, MO
sildenafil citrate 20 mg tab
2
REVATIO
PA, MO, CG
TRACLEER 125 mg tab, 62.5 mg tab
5
PA, LA, MO
VENTAVIS 10 mcg/ml inh soln, 20
mcg/ml inh soln
5
PA, LA, MO
Respiratory Tract Agents, Other [Agentes Del Tracto Respiratorio, Otros]
acetylcysteine 10 % inh soln, 20 % inh
soln
2
MUCOMYST-10
PA(*), CG
ADVAIR DISKUS 100-50 mcg/dose
inh aer pwdr, 250-50 mcg/dose inh
aer pwdr, 500-50 mcg/dose inh aer
PA, QL(60 / 30),
pwdr
3
MO
1
Page 67 of 87
Updated 08/2014
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
Medicamento]
ADVAIR HFA 115-21 mcg/act inh aer,
230-21 mcg/act inh aer, 45-21
PA, QL(12 / 30),
mcg/act inh aer
3
MO
COMBIVENT RESPIMAT 20-100
mcg/act inh aer
3
QL(8 / 30), MO
ipratropium-albuterol 0.5-2.5 (3)
mg/3ml inh soln
2
DUONEB
PA(*), MO, CG
PROLASTIN-C 1000 mg iv soln
5
PA, LA
PULMOZYME 1 mg/ml inh soln
5
PA(*), MO
SYMBICORT 160-4.5 mcg/act inh aer,
80-4.5 mcg/act inh aer
4
MO
SKELETAL MUSCLE RELAXANTS [RELAJANTES MUSCULOESQUELETALES]
Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]
cyclobenzaprine hcl 10 mg tab, 5 mg
tab, 7.5 mg tab
2
FLEXERIL
PA, HR, CG
methocarbamol 500 mg tab, 750 mg
tab
1
ROBAXIN-750
PA, HR, CG
SLEEP DISORDER AGENTS [AGENTES PARA DESORDENES DEL SUEÑO]
GABA Receptor Modulators [Moduladores Del Receptor De GABA]
flurazepam hcl 15 mg cap, 30 mg cap
1
DALMANE
CG
temazepam 15 mg cap, 22.5 mg cap,
30 mg cap, 7.5 mg cap
2
RESTORIL
QL(90 / 365), CG
Sleep Disorders, Other [Desordenes Del Sueño, Otros]
BUTISOL SODIUM 30 mg tab, 30
mg/5ml oral elix, 50 mg tab
4
HR
modafinil 100 mg tab, 200 mg tab
2
PROVIGIL
PA, MO, CG
PROVIGIL 100 mg tab, 200 mg tab
5
PA, MO
ROZEREM 8 mg tab
4
MO
XYREM 500 mg/ml soln
5
PA, LA
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES [NUTRIENTES
TERAPEUTICOS/MINERALES/ELECTROLITOS]
Electrolyte/Mineral Modifiers [Electrólitos/Modificadores De Minerales]
CHEMET 100 mg cap
4
EXJADE 125 mg tab sol, 250 mg tab
sol, 500 mg tab sol
5
PA, LA, MO
FERRIPROX 500 mg tab
5
PA, MO
KIONEX oral pwdr
2
CG
sodium polystyrene sulfonate 15
gm/60ml susp
2
SPS
CG
SYPRINE 250 mg cap
5
Electrolyte/Mineral Replacement [Electrólitos/Reemplazo De Minerales]
ISOLYTE-S
2
PA(*), HI, CG
KLOR-CON 8 meq tab er
2
MO, CG
1
Page 68 of 87
Updated 08/2014
Medicamento]
KLOR-CON 10 10 meq tab er
KLOR-CON M15 15 meq tab er
KLOR-CON M20 20 meq tab er
NORMOSOL-R PH 7.4
PLASMA-LYTE 148
PLASMA-LYTE A
potassium chloride 10 meq/100ml iv
soln, 2 meq/ml iv soln, 20 meq/100ml
iv soln, 40 meq/100ml iv soln
potassium chloride crys er 10 meq tab
er, 20 meq tab er
potassium chloride er 10 meq cap er,
8 meq cap er
potassium chloride in nacl 20-0.9
meq/l-% iv soln
potassium citrate er 10 meq (1080
mg) tab er, 5 meq (540 mg) tab er
PR NATAL 440 EC 30-1 & 440 oral
misc
Drug
Tier
[Nivel]
2
2
2
2
2
2
Reference Name
Requirements/Limits
MO, CG
MO, CG
MO, CG
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI, CG
2
PA(*), HI, CG
2
KLOR-CON M20
MO, CG
2
MICRO-K
MO, CG
2
2
PA(*), HI, CG
UROCIT-K 5
2
CG
CG
CURITY STERILE
sodium chloride 0.9 % irrigation soln
2
SALINE
CG
sodium chloride 0.45 % iv soln, 0.9 %
iv soln, 2.5 meq/ml inj soln, 3 % iv
MONOJECT PREFILL
soln, 5 % iv soln
2
ADVANCED NACL
PA(*), HI, CG
sodium fluoride 2.2 (1 f) mg tab
2
FLURA-TAB
MO, CG
Therapeutic Nutrients/Minerals/Electrolytes [Nutrientes Terapeuticos/Minerales/Electrolitos]
levocarnitine 1 gm/10ml soln, 330 mg
tab
2
VITACARN
MO, CG
sterile water for irrigation
2
CG
Therapeutic Nutrients/Minerals/Electrolytes (Combination Product) [Nutrientes
Terapeuticos/Minerales/Electrolitos (Productos En Combinación)]
AMINOSYN II 10 % iv soln, 15 % iv
soln, 7 % iv soln, 8.5 % iv soln
4
PA(*), HI
AMINOSYN II/ELECTROLYTES 8.5
% iv soln
2
PA(*), HI, CG
AMINOSYN M 3.5 % iv soln
4
PA(*), HI
AMINOSYN/ELECTROLYTES 8.5 %
iv soln
2
PA(*), HI, CG
AMINOSYN-HBC 7 % iv soln
4
PA(*), HI
AMINOSYN-PF 10 % iv soln, 7 % iv
soln
4
PA(*), HI
CLINIMIX E/DEXTROSE (2.75/10)
2.75 % iv soln
4
PA(*), HI
1
Page 69 of 87
Updated 08/2014
Medicamento]
CLINIMIX E/DEXTROSE (2.75/5) 2.75
% iv soln
CLINIMIX E/DEXTROSE (4.25/25)
4.25 % iv soln
CLINIMIX E/DEXTROSE (4.25/5) 4.25
% iv soln
CLINIMIX E/DEXTROSE (5/15) 5 % iv
soln
soln
soln
CLINIMIX/DEXTROSE (2.75/5) 2.75
% iv soln
% iv soln
% iv soln
% iv soln
% iv soln
CLINIMIX/DEXTROSE (5/15) 5 % iv
soln
soln
soln
CLINISOL SF 15 % iv soln
dextrose 10 % iv soln, 5 % iv soln
dextrose in lactated ringers 5 % iv
soln
dextrose-nacl 10-0.2 % iv soln, 100.45 % iv soln, 2.5-0.45 % iv soln, 50.2 % iv soln, 5-0.225 % iv soln, 50.33 % iv soln, 5-0.45 % iv soln, 5-0.9
% iv soln
HEPATAMINE 8 % iv soln
HEPATASOL 8 % iv soln
INTRALIPID 30 % iv emul
INTRALIPID 20 % iv emul
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
PA(*), HI
4
2
2
PA(*), HI
PA(*), HI, CG
PA(*), HI, CG
2
PA(*), HI, CG
2
2
4
4
2
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI
PA(*), HI
PA(*), HI, CG
1
Page 70 of 87
Updated 08/2014
Medicamento]
kcl in dextrose-nacl 10-5-0.45 meq/l%-% iv soln, 20-5-0.2 meq/l-%-% iv
soln, 20-5-0.33 meq/l-%-% iv soln, 205-0.45 meq/l-%-% iv soln, 20-5-0.9
meq/l-%-% iv soln, 30-5-0.45 meq/l%-% iv soln, 40-5-0.45 meq/l-%-% iv
soln
lactated ringers
NEPHRAMINE 5.4 % iv soln
NORMOSOL-M IN D5W
PLASMA-LYTE-56 IN D5W
potassium chloride in dextrose 20-5
meq/l-% iv soln, 40-5 meq/l-% iv soln
PREMASOL 10 % iv soln, 6 % iv soln
PROCALAMINE 3 % iv soln
ringers iv soln
SUPREP BOWEL PREP
TPN ELECTROLYTES
TRAVASOL 10 % iv soln
TROPHAMINE 10 % iv soln
Drug
Tier
[Nivel]
Reference Name
Requirements/Limits
2
2
4
2
2
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI
PA(*), HI, CG
PA(*), HI, CG
2
4
4
2
4
2
4
4
PA(*), HI, CG
PA(*), HI
PA(*), HI
PA(*), HI, CG
PA(*), HI, CG
PA(*), HI
PA(*), HI
1
Page 71 of 87
Updated 08/2014
OVER THE COUNTER (OTC) COVERED DRUG LIST
[LISTADO DE MEDICAMENTOS CUBIERTOS FUERA DEL RECETARIO]
Drug Name
Reference Name
[Nombre del Medicamento]
Our plan requires a prescription in order for you to obtain your OTC medications.
[Nuestro plan requiere una receta para que usted pueda obtener sus medicamentos OTC].
ABREVA crm 10 %
ALAVERT ALLERGY/SINUS tab er 12 hr 5-120 mg
ALAWAY ophth soln 0.025%
all day allergy tab 10 mg
ZYRTEC
ALLEGRA ALLERGY odt 30 mg, tab 30 mg, tab 60 mg, tab 180 mg,
susp 30 mg/5 ml
ALLEGRA-D ALLERGY & CONGESTION tab er 12 hr 60-120 mg,
24 hr 180-240 mg
allergy relief 10 mg tab, syr 5 mg/5 ml
CLARITIN
cetirizine tab 5 mg, tab chew 5mg, tab chew 10 mg, syr 5 mg/5 ml
ZYRTEC
cetirizine-pseudoephedrine er tab 12 hr 5-120 mg
ZYRTEC-D
CLARITIN ophth soln 0.025 %
CLARITIN cap 10 mg, tab 10 mg, tab chew 5 mg, syr 5mg/5 ml
CLARITIN REDITABS odt 5 mg, 10 mg
CLARITIN-D tab er 12 hr 5-120 mg
CLARITIN-D tab er 24 hr 10-240 mg
CVS Loratadine-D 24 Hour tab er 24 hr 10-240 mg
fexofenadine-pseudoephedrine er tab 24 hr 180-240 mg
ALLEGRA-D
ALAWAY, CLARITIN EYE,
ZADITOR, ZYRTEC
ketotifen fumarate ophth soln 0.025 %
ITCHY
lanzoprazole cap dr 15 mg
PREVACID
omeprazole cap dr 20.6 (20 base)mg, tab dr 20 mg
PREVACID 24 hr cap dr 15 mg
PRILOSEC OTC cap dr 20 mg
sm allergy relief odt 10 mg
ALAVERT, CLARITIN
wal-fex allergy tab 60 mg, 180 mg
ALLEGRA
ZADITOR ophth soln 0.025 %
ZEGERID OTC cap 20-1100 mg
ZYRTEC ALLERGY cap 10 mg, tab 10 mg, tab chew 5 mg, syr
1mg/1 ml
ZYRTEC ITCHY ophth soln 0.025 %
ZYRTEC-D ALLERGY & CONGESTION tab er 12 hr 5-120 mg
Page 72 of 87
Updated 08/2014
A
abacavir sulfate................................................... 36
abacavir-lamivudine-zidovudine ...................... 36
ABELCET ............................................................ 25
ABILIFY.......................................................... 21, 22
ABILIFY DISCMELT .......................................... 22
ABILIFY MAINTENA .......................................... 22
ABREVA (OTC) .................................................. 72
acamprosate calcium ......................................... 12
acarbose .............................................................. 38
acebutolol hcl ...................................................... 44
acetaminophen-codeine .................................... 10
acetaminophen-codeine #2 .............................. 10
acetazolamide ..................................................... 47
acetazolamide er ................................................ 47
acetic acid............................................................ 13
acetylcysteine ..................................................... 67
acitretin................................................................. 51
ACTEMRA ..................................................... 61, 62
ACTHIB ................................................................ 62
ACTIMMUNE ...................................................... 62
acyclovir ......................................................... 35, 36
acyclovir sodium ................................................. 36
ADACEL............................................................... 62
ADAGEN.............................................................. 52
adapalene ............................................................ 51
ADCIRCA............................................................. 67
adefovir dipivoxil ................................................. 35
ADEMPAS ........................................................... 67
ADVAIR DISKUS................................................ 67
ADVAIR HFA....................................................... 68
AFEDITAB CR .................................................... 44
AFINITOR ............................................................ 30
AFINITOR DISPERZ ......................................... 30
AGGRENOX ....................................................... 42
A-HYDROCORT ................................................. 55
ala cort ................................................................. 55
ALAVERT ............................................................ 72
ALAWAY (OTC).................................................. 72
ALBENZA ............................................................ 31
albuterol sulfate .................................................. 66
albuterol sulfate er.............................................. 66
alclometasone dipropionate.............................. 55
alcohol preps ....................................................... 13
ALDACTAZIDE ................................................... 46
ALDACTONE ...................................................... 48
ALDURAZYME ................................................... 52
alendronate sodium ........................................... 63
alfuzosin hcl er .................................................... 54
ALIMTA ................................................................ 28
ALINIA .................................................................. 31
all day allergy (OTC) .......................................... 72
ALLEGRA (OTC) ................................................ 72
ALLEGRA-D (OTC)............................................ 72
allergy relief (OTC) ............................................. 72
allopurinol ............................................................ 26
ALPHAGAN P ..................................................... 64
alprazolam ........................................................... 38
amantadine hcl ................................................... 32
amcinonide .......................................................... 55
amifostine ............................................................ 28
amikacin sulfate .................................................. 13
amiloride hcl ........................................................ 48
amiloride-hydrochlorothiazide .......................... 46
aminophylline ...................................................... 67
AMINOSYN II ...................................................... 69
AMINOSYN II/ELECTROLYTES ..................... 69
AMINOSYN M ..................................................... 69
AMINOSYN/ELECTROLYTES ........................ 69
AMINOSYN-HBC ............................................... 69
AMINOSYN-PF ................................................... 69
amiodarone hcl ................................................... 43
AMITIZA ............................................................... 54
amitriptyline hcl ................................................... 23
amlodipine besy-benazepril hcl ........................ 46
amlodipine besylate ........................................... 45
amlodipine-atorvastatin ..................................... 46
ammonium lactate .............................................. 51
AMNESTEEM ..................................................... 51
amoxapine ........................................................... 24
amoxicillin ............................................................ 16
amoxicillin-pot clavulanate ................................ 16
amoxicillin-pot clavulanate er ........................... 16
amphetamine-dextroamphet er ........................ 50
amphetamine-dextroamphetamine .................. 50
amphotericin b .................................................... 25
ampicillin .............................................................. 16
ampicillin sodium ................................................ 16
ampicillin-sulbactam sodium............................. 16
AMPYRA .............................................................. 50
anagrelide hcl...................................................... 41
anastrozole .......................................................... 30
Page 73 of 87
Updated 08/2014
ANDROGEL ........................................................ 57
ANDROGEL PUMP ........................................... 58
ANDROXY ........................................................... 58
APOKYN .............................................................. 32
APTIOM ............................................................... 20
APTIVUS ............................................................. 37
ARANESP (ALBUMIN FREE) .......................... 41
ARCALYST ......................................................... 62
ARZERRA ........................................................... 31
ASACOL HD ....................................................... 63
atenolol................................................................. 44
atenolol-chlorthalidone ...................................... 46
atorvastatin calcium ........................................... 48
atovaquone.......................................................... 31
atovaquone-proguanil hcl.................................. 31
ATRIPLA .............................................................. 36
ATROVENT ......................................................... 66
ATROVENT HFA................................................ 66
AUBAGIO ............................................................ 50
AVASTIN ............................................................. 28
AVELOX............................................................... 17
AVITA ................................................................... 51
AVONEX .............................................................. 50
AVONEX PREFILLED ....................................... 50
azacitidine ............................................................ 28
AZASAN............................................................... 60
azathioprine ......................................................... 60
azelastine hcl ...................................................... 65
AZILECT .............................................................. 33
azithromycin ........................................................ 17
AZOPT ................................................................. 64
aztreonam............................................................ 15
B
baciim ................................................................... 13
bacitracin ............................................................. 13
bacitracin-polymyxin b ....................................... 64
bacitra-neomycin-polymyxin-hc ....................... 64
baclofen ............................................................... 34
balsalazide disodium ......................................... 63
BANZEL ............................................................... 20
BARACLUDE ...................................................... 35
benazepril hcl ...................................................... 43
benazepril-hydrochlorothiazide ........................ 46
BENICAR ............................................................. 42
BENICAR HCT ................................................... 46
benzoyl peroxide-erythromycin ........................ 52
benztropine mesylate ........................................ 32
betamethasone dipropionate ............................ 55
betamethasone dipropionate aug .................... 55
betamethasone valerate .................................... 55
BETASERON ...................................................... 50
betaxolol hcl .................................................. 44, 64
bethanechol chloride.......................................... 54
bicalutamide ........................................................ 28
BICILLIN C-R ...................................................... 16
BICILLIN C-R 900/300 ...................................... 16
BICILLIN L-A ....................................................... 16
BICNU .................................................................. 28
BILTRICIDE......................................................... 31
bisoprolol fumarate ............................................ 44
bisoprolol-hydrochlorothiazide ......................... 46
bleomycin sulfate................................................ 28
BOOSTRIX .......................................................... 62
BOSULIF ............................................................. 30
BRILINTA............................................................. 42
brimonidine tartrate ............................................ 64
BRINTELLIX........................................................ 23
bromocriptine mesylate ..................................... 32
budesonide er ..................................................... 55
bumetanide.................................................... 47, 48
buprenorphine hcl .............................................. 12
buprenorphine hcl-naloxone hcl ....................... 12
buproban.............................................................. 12
bupropion hcl....................................................... 12
bupropion hcl er (sr) ........................................... 13
bupropion hcl er (xl) ........................................... 13
buspirone hcl ....................................................... 38
BUSULFEX ......................................................... 27
butalbital-apap-caffeine ..................................... 10
BUTISOL SODIUM ............................................ 68
BYDUREON ........................................................ 38
BYETTA 10 MCG PEN...................................... 38
BYETTA 5 MCG PEN ........................................ 38
C
cabergoline .......................................................... 59
calcipotriene ........................................................ 51
calcitonin (salmon) ............................................. 63
calcitriol ................................................................ 63
calcium acetate ................................................... 55
CAMPRAL ........................................................... 12
CANASA .............................................................. 63
CANCIDAS .......................................................... 25
candesartan cilexetil .......................................... 42
candesartan cilexetil-hctz.................................. 46
Page 74 of 87
Updated 08/2014
CAPASTAT SULFATE ...................................... 27
CAPRELSA ......................................................... 30
captopril ............................................................... 43
captopril-hydrochlorothiazide ........................... 46
CARAC................................................................. 51
CARAFATE ......................................................... 54
carbamazepine ................................................... 20
carbamazepine er .............................................. 20
carbidopa ............................................................. 32
carbidopa-levodopa ........................................... 32
carbidopa-levodopa er ....................................... 32
carbidopa-levodopa-entacapone ..................... 32
carboplatin ........................................................... 28
CARIMUNE NF ................................................... 61
CARTIA XT .......................................................... 45
carvedilol.............................................................. 44
CAYSTON ........................................................... 67
cefaclor................................................................. 14
cefaclor er ............................................................ 14
cefadroxil ............................................................. 14
cefazolin sodium ................................................. 15
cefdinir.................................................................. 15
cefepime hcl ........................................................ 15
cefotaxime sodium ............................................. 15
cefoxitin sodium .................................................. 15
cefpodoxime proxetil .......................................... 15
cefprozil ................................................................ 15
ceftazidime .......................................................... 15
ceftriaxone sodium ............................................. 15
cefuroxime axetil................................................. 15
cefuroxime sodium ............................................. 15
CELEBREX ......................................................... 10
CELLCEPT .......................................................... 60
CELONTIN .......................................................... 19
cephalexin ........................................................... 15
CEREZYME ........................................................ 52
CERVARIX .......................................................... 62
cetirizine (OTC)................................................... 72
cetirizine hcl......................................................... 65
cetirizine-pseudoephedrine (OTC) .................. 72
cevimeline hcl ..................................................... 51
CHANTIX ............................................................. 13
CHANTIX STARTING MONTH PAK ............... 13
CHEMET .............................................................. 68
chloramphenicol sod succinate ........................ 13
chlorhexidine gluconate .................................... 51
chloroquine phosphate ...................................... 31
chlorothiazide ...................................................... 48
chlorpromazine hcl ............................................. 24
chlorthalidone...................................................... 48
cholestyramine light ........................................... 49
chorionic gonadotropin ...................................... 57
ciclopirox .............................................................. 25
ciclopirox olamine ............................................... 25
cilostazol .............................................................. 42
cimetidine............................................................. 53
CIMZIA ................................................................. 60
CIMZIA PREFILLED .......................................... 60
CINRYZE ............................................................. 60
CIPRODEX.......................................................... 65
ciprofloxacin ........................................................ 17
ciprofloxacin hcl .................................................. 17
ciprofloxacin in d5w............................................ 17
ciprofloxacin-ciproflox hcl er ............................. 17
cisplatin ................................................................ 28
citalopram hydrobromide................................... 22
cladribine ............................................................. 28
CLARAVIS ........................................................... 51
clarithromycin ...................................................... 17
clarithromycin er ................................................. 17
CLARITIN (OTC) ................................................ 72
CLARITIN ophth (OTC) ..................................... 72
CLARITIN REDITABS (OTC) ........................... 72
CLARITIN-D (OTC) ............................................ 72
CLEOCIN ............................................................. 13
clindamycin hcl ................................................... 13
clindamycin palmitate hcl .................................. 13
clindamycin phosphate ...................................... 14
clindamycin phosphate in d5w ......................... 14
CLINIMIX E/DEXTROSE (2.75/10) ................. 69
CLINIMIX E/DEXTROSE (2.75/5) ................... 70
CLINIMIX E/DEXTROSE (4.25/25) ................. 70
CLINIMIX E/DEXTROSE (4.25/5) ................... 70
CLINIMIX E/DEXTROSE (5/15) ....................... 70
CLINIMIX/DEXTROSE (2.75/5) ....................... 70
CLINIMIX/DEXTROSE (4.25/10) ..................... 70
CLINIMIX/DEXTROSE (4.25/5) ....................... 70
CLINIMIX/DEXTROSE (5/15)........................... 70
Page 75 of 87
Updated 08/2014
CLINISOL SF ...................................................... 70
clobetasol propionate ........................................ 55
clobetasol propionate e ..................................... 55
clomipramine hcl................................................. 24
clonazepam ......................................................... 19
clonidine hcl......................................................... 42
clonidine hcl er .................................................... 42
clopidogrel bisulfate ........................................... 42
clorazepate dipotassium ................................... 38
clotrimazole ......................................................... 25
clotrimazole-betamethasone ............................ 52
clozapine .............................................................. 34
COARTEM........................................................... 31
colchicine-probenecid ........................................ 26
COLCRYS ........................................................... 26
colestipol hcl........................................................ 49
colistimethate sodium ........................................ 14
COLOCORT ........................................................ 55
COMBIGAN ......................................................... 64
COMBIVENT RESPIMAT ................................. 68
COMBIVIR ........................................................... 36
COMETRIQ (100 MG DAILY DOSE) .............. 30
COMETRIQ (140 MG DAILY DOSE) .............. 30
COMETRIQ (60 MG DAILY DOSE) ................ 30
COMPLERA ........................................................ 36
COMVAX ............................................................. 62
CONDYLOX ........................................................ 51
constulose ........................................................... 54
COPAXONE ........................................................ 50
COPEGUS........................................................... 35
cortisone acetate ................................................ 55
COSMEGEN ....................................................... 28
COUMADIN ......................................................... 40
CREON .......................................................... 52, 53
CRIXIVAN ............................................................ 37
cromolyn sodium .................................... 53, 64, 67
CUBICIN .............................................................. 14
CVS Loratadine (OTC) ...................................... 72
cyclobenzaprine hcl ........................................... 68
cyclophosphamide ............................................. 27
CYCLOSET ......................................................... 38
cyclosporine ........................................................ 60
cyclosporine modified ........................................ 60
cyproheptadine hcl ............................................. 65
CYSTADANE ...................................................... 52
CYSTAGON ........................................................ 52
cytarabine ............................................................ 28
D
dacarbazine ......................................................... 28
DALIRESP ........................................................... 67
danazol................................................................. 58
dantrolene sodium.............................................. 34
dapsone ............................................................... 27
DAPTACEL ......................................................... 62
DARAPRIM ......................................................... 31
daunorubicin hcl ................................................. 28
decitabine ............................................................ 29
DELZICOL ........................................................... 63
demeclocycline hcl ............................................. 18
DEMEROL ........................................................... 11
DEMSER ............................................................. 47
DENAVIR ............................................................. 36
DEPEN TITRATABS .......................................... 55
DEPO-PROVERA .............................................. 58
DEPO-TESTOSTERONE ................................. 58
desipramine hcl................................................... 24
desloratadine....................................................... 65
desmopressin ace spray refrig ......................... 57
desmopressin acetate ....................................... 57
desonide .............................................................. 55
desoximetasone ................................................. 55
desvenlafaxine er ............................................... 22
dexamethasone .................................................. 55
dexamethasone sodium phosphate .......... 55, 65
dexrazoxane ........................................................ 29
dextroamphetamine sulfate .............................. 50
dextroamphetamine sulfate er .......................... 50
dextrose ............................................................... 70
dextrose in lactated ringers .............................. 70
dextrose-nacl....................................................... 70
diazepam ............................................................. 19
DIAZEPAM INTENSOL ..................................... 19
diclofenac potassium ......................................... 10
diclofenac sodium ........................................ 10, 65
diclofenac sodium er .......................................... 10
dicloxacillin sodium ............................................ 16
dicyclomine hcl ................................................... 52
didanosine ........................................................... 36
diflorasone diacetate.......................................... 56
digoxin .................................................................. 47
dihydroergotamine mesylate ............................ 26
DILANTIN ............................................................ 20
DILANTIN INFATABS........................................ 20
dilt-cd .................................................................... 45
Page 76 of 87
Updated 08/2014
diltiazem hcl......................................................... 45
diltiazem hcl er .................................................... 45
diltiazem hcl er beads ........................................ 45
diltiazem hcl er coated beads ........................... 45
dilt-xr ..................................................................... 45
DIOVAN ............................................................... 42
DIPENTUM.......................................................... 63
diphenhydramine hcl.......................................... 24
diphenoxylate-atropine ...................................... 53
diphtheria-tetanus toxoids dt ............................ 62
disopyramide phosphate ................................... 43
disulfiram ............................................................. 12
DIURIL ................................................................. 48
divalproex sodium .............................................. 19
divalproex sodium er.......................................... 19
docetaxel ............................................................. 29
donepezil hcl ....................................................... 21
DORIBAX............................................................. 15
dorzolamide hcl................................................... 64
dorzolamide hcl-timolol mal .............................. 64
DOVONEX........................................................... 51
doxazosin mesylate ........................................... 42
doxepin hcl .......................................................... 24
DOXIL................................................................... 29
doxorubicin hcl .................................................... 29
doxycycline hyclate ...................................... 18, 51
doxycycline monohydrate ................................. 18
dronabinol ............................................................ 25
DROXIA ............................................................... 28
duloxetine hcl ...................................................... 23
duramorph ........................................................... 11
E
E.E.S. 400 ........................................................... 17
E.E.S. GRANULES ............................................ 17
econazole nitrate ................................................ 25
EDURANT ........................................................... 36
EFFIENT .............................................................. 42
ELAPRASE ......................................................... 52
ELELYSO ............................................................ 52
ELIDEL ................................................................. 51
ELIGARD ............................................................. 59
ELIQUIS ............................................................... 40
ELITEK ................................................................. 29
ELIXOPHYLLIN .................................................. 67
ELLA ..................................................................... 58
ELMIRON ............................................................ 55
EMCYT................................................................. 28
EMEND ................................................................ 25
EMSAM ................................................................ 22
EMTRIVA ............................................................. 36
enalapril maleate ................................................ 43
enalapril-hydrochlorothiazide ........................... 46
ENBREL............................................................... 60
endocet ................................................................ 10
ENGERIX-B......................................................... 62
enoxaparin sodium ............................................. 40
entacapone.......................................................... 32
enulose................................................................. 54
EPIDUO ............................................................... 52
EPIPEN 2-PAK ................................................... 66
EPIPEN JR 2-PAK ............................................. 66
epirubicin hcl ....................................................... 29
EPIVIR ................................................................. 37
EPIVIR HBV ........................................................ 35
eplerenone........................................................... 48
EPZICOM ............................................................ 37
ERAXIS ................................................................ 25
ergoloid mesylates ............................................. 21
ERGOMAR .......................................................... 26
ERIVEDGE .......................................................... 30
ERWINAZE ......................................................... 41
ery ......................................................................... 17
ERYPED 200 ...................................................... 17
ERYPED 400 ...................................................... 17
ERY-TAB ............................................................. 17
ERYTHROCIN LACTOBIONATE .................... 17
ERYTHROCIN STEARATE .............................. 17
erythromycin ........................................................ 17
erythromycin base .............................................. 17
erythromycin ethylsuccinate ............................. 17
escitalopram oxalate .......................................... 22
estazolam ............................................................ 38
ESTRACE............................................................ 58
estradiol ............................................................... 58
estradiol valerate ................................................ 58
ESTROSTEP FE ................................................ 58
ethambutol hcl..................................................... 27
ethosuximide ....................................................... 19
etodolac ............................................................... 10
etodolac er ........................................................... 11
etoposide ............................................................. 30
EXELON .............................................................. 21
exemestane ......................................................... 30
EXJADE ............................................................... 68
Page 77 of 87
Updated 08/2014
EXTAVIA.............................................................. 50
F
FABRAZYME ...................................................... 52
famciclovir ............................................................ 36
famotidine ............................................................ 53
famotidine premixed .......................................... 53
FANAPT ............................................................... 33
FANAPT TITRATION PACK............................. 33
FARESTON ......................................................... 28
FASLODEX ......................................................... 29
FAZACLO ............................................................ 34
felbamate ............................................................. 20
felodipine er ......................................................... 45
fenofibrate............................................................ 48
fenofibrate micronized ....................................... 48
fenofibric acid ...................................................... 48
fentanyl................................................................. 11
FENTORA ........................................................... 11
FERRIPROX ....................................................... 68
FETZIMA ............................................................. 23
FETZIMA TITRATION ....................................... 23
fexofenadine-pseudoephedrine (OTC) ........... 72
finasteride ............................................................ 54
FIRAZYR ............................................................. 60
flecainide acetate ............................................... 43
FLOVENT DISKUS ............................................ 66
FLOVENT HFA ................................................... 66
fluconazole .......................................................... 25
fluconazole in dextrose...................................... 25
flucytosine............................................................ 25
fludarabine phosphate ....................................... 29
fludrocortisone acetate ...................................... 56
flunisolide ............................................................. 66
fluocinolone acetonide ....................................... 56
fluocinolone acetonide body ............................. 56
fluocinonide ......................................................... 56
fluocinonide-e...................................................... 56
fluorouracil ..................................................... 29, 51
fluoxetine hcl ....................................................... 22
fluphenazine decanoate .................................... 33
fluphenazine hcl.................................................. 33
flurazepam hcl..................................................... 68
flurbiprofen........................................................... 11
flurbiprofen sodium ............................................ 65
flutamide .............................................................. 28
fluticasone propionate ................................. 56, 66
fluvoxamine maleate .......................................... 22
fondaparinux sodium ................................... 40, 41
FORADIL AEROLIZER ..................................... 66
FORTEO .............................................................. 63
foscarnet sodium ................................................ 34
fosinopril sodium................................................. 43
fosinopril sodium-hctz ........................................ 46
FULYZAQ ............................................................ 53
furosemide ........................................................... 48
FUZEON .............................................................. 37
FYCOMPA ........................................................... 20
G
gabapentin ........................................................... 19
GABITRIL ............................................................ 19
galantamine hydrobromide ............................... 21
galantamine hydrobromide er........................... 21
GAMMAGARD .................................................... 61
GAMMAPLEX ..................................................... 61
GAMUNEX-C ...................................................... 61
ganciclovir sodium.............................................. 35
GARDASIL .......................................................... 62
gauze pads .......................................................... 39
GAVILYTE-C ....................................................... 53
GAVILYTE-G....................................................... 53
GAVILYTE-N WITH FLAVOR PACK .............. 53
gemcitabine hcl ................................................... 29
gemfibrozil ........................................................... 48
GENGRAF ........................................................... 61
GENOTROPIN.............................................. 53, 57
GENOTROPIN MINIQUICK ............................. 57
GENTAK .............................................................. 13
gentamicin sulfate .............................................. 13
GEODON ............................................................. 33
GILENYA ............................................................. 50
GILOTRIF ............................................................ 30
GLEEVEC............................................................ 30
glimepiride ........................................................... 38
glipizide ................................................................ 38
glipizide er ........................................................... 38
glipizide-metformin hcl ....................................... 39
GLUCAGEN HYPOKIT ..................................... 39
GLUCAGON EMERGENCY ............................. 39
glycopyrrolate...................................................... 52
granisetron hcl .................................................... 25
griseofulvin microsize ........................................ 25
griseofulvin ultramicrosize ................................ 25
GRIS-PEG ........................................................... 25
guanfacine hcl ..................................................... 42
Page 78 of 87
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guanidine hcl ....................................................... 27
H
halobetasol propionate ...................................... 56
haloperidol ........................................................... 33
haloperidol decanoate ....................................... 33
haloperidol lactate .............................................. 33
HAVRIX................................................................ 62
heparin sodium (porcine) .................................. 41
HEPATAMINE..................................................... 70
HEPATASOL....................................................... 70
HEPSERA ........................................................... 35
HERCEPTIN ....................................................... 29
HEXALEN ............................................................ 27
HUMALOG .......................................................... 40
HUMALOG KWIKPEN ....................................... 40
HUMALOG MIX 50/50 ....................................... 40
HUMALOG MIX 50/50 KWIKPEN ................... 40
HUMALOG MIX 75/25 ....................................... 40
HUMALOG MIX 75/25 KWIKPEN ................... 40
HUMATROPE ..................................................... 57
HUMIRA ............................................................... 61
HUMIRA PEN-CROHNS STARTER ............... 61
HUMULIN 70/30 ................................................. 40
HUMULIN 70/30 PEN ........................................ 40
HUMULIN N ........................................................ 40
HUMULIN N PEN ............................................... 40
HUMULIN R ........................................................ 40
HUMULIN R U-500 (CONCENTRATED) ....... 40
HYCAMTIN .......................................................... 30
hydralazine hcl .................................................... 49
HYDREA .............................................................. 28
hydrochlorothiazide ............................................ 48
hydrocodone-acetaminophen ........................... 10
hydrocortisone .................................................... 56
hydrocortisone butyrate ..................................... 56
hydrocortisone valerate ..................................... 56
hydrocortisone-acetic acid ................................ 65
hydromorphone hcl pf ........................................ 11
hydroxychloroquine sulfate ............................... 31
hydroxyurea......................................................... 28
hydroxyzine hcl ................................................... 38
I
ibandronate sodium ........................................... 63
ibuprofen .............................................................. 11
idarubicin hcl ....................................................... 29
IFEX...................................................................... 29
ifosfamide ............................................................ 29
ILARIS .................................................................. 62
IMBRUVICA ........................................................ 30
imipenem-cilastatin ............................................ 15
imipramine hcl ..................................................... 24
imipramine pamoate .......................................... 24
imiquimod ............................................................ 51
IMOVAX RABIES ............................................... 62
INCIVEK............................................................... 35
INCRELEX........................................................... 57
indapamide .......................................................... 48
indomethacin ....................................................... 11
INFANRIX ............................................................ 62
INLYTA................................................................. 30
insulin pen needles ............................................ 39
insulin syringe ..................................................... 39
INTELENCE ........................................................ 36
INTRALIPID......................................................... 70
INTRON-A ........................................................... 35
INVANZ ................................................................ 15
INVEGA ............................................................... 33
INVEGA SUSTENNA................................... 33, 34
INVIRASE ............................................................ 37
IPOL ..................................................................... 62
ipratropium bromide ........................................... 66
ipratropium-albuterol .......................................... 68
irbesartan ............................................................. 42
irbesartan-hydrochlorothiazide ......................... 46
irinotecan hcl ....................................................... 29
ISENTRESS ........................................................ 36
ISOLYTE-S.......................................................... 68
isoniazid ............................................................... 27
isosorbide dinitrate ............................................. 49
isosorbide dinitrate er ........................................ 49
isosorbide mononitrate ...................................... 49
isosorbide mononitrate er ................................. 49
isradipine ............................................................. 45
itraconazole ......................................................... 25
IXIARO ................................................................. 62
J
JAKAFI ................................................................. 30
JANUMET ............................................................ 39
JANUMET XR ..................................................... 39
JANUVIA.............................................................. 39
K
KADCYLA ............................................................ 29
KALETRA ............................................................ 37
KAPVAY............................................................... 50
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kcl in dextrose-nacl ............................................ 71
ketoconazole ....................................................... 25
ketoprofen............................................................ 11
ketorolac tromethamine ..................................... 65
ketotifen (OTC) ................................................... 72
KINERET ............................................................. 61
KIONEX ............................................................... 68
KLOR-CON ......................................................... 68
KLOR-CON 10 .................................................... 69
KLOR-CON M15................................................. 69
KLOR-CON M20................................................. 69
KOMBIGLYZE XR .............................................. 39
KUVAN ................................................................. 52
L
labetalol hcl ......................................................... 44
lactated ringers ................................................... 71
lactulose ............................................................... 54
lamivudine ..................................................... 35, 37
lamivudine-zidovudine ....................................... 37
lamotrigine ........................................................... 20
LANOXIN ............................................................. 47
lansoprazole ........................................................ 54
LANTUS ............................................................... 40
LANTUS SOLOSTAR ........................................ 40
lanzoprazole (OTC)............................................ 72
latanoprost ........................................................... 65
LATUDA ............................................................... 34
LAZANDA ............................................................ 11
leflunomide .......................................................... 62
LETAIRIS ............................................................. 67
letrozole ............................................................... 30
leucovorin calcium.............................................. 29
LEUKERAN ......................................................... 27
LEUKINE ............................................................. 41
leuprolide acetate ............................................... 59
LEVEMIR ............................................................. 40
LEVEMIR FLEXPEN.......................................... 40
levetiracetam ....................................................... 18
levetiracetam er .................................................. 19
levobunolol hcl .................................................... 64
levocarnitine ........................................................ 69
levocetirizine dihydrochloride ........................... 65
levofloxacin.................................................... 17, 18
levofloxacin in d5w ............................................. 18
levothyroxine sodium ......................................... 59
LEVOXYL ............................................................ 59
LEXIVA................................................................. 37
lidocaine ............................................................... 12
lidocaine hcl......................................................... 12
lidocaine hcl (pf) ................................................. 12
lidocaine viscous ................................................ 12
lindane.................................................................. 31
LINZESS .............................................................. 54
liothyronine sodium ............................................ 59
lisinopril ................................................................ 43
lisinopril-hydrochlorothiazide ............................ 47
lithium carbonate ................................................ 38
lithium carbonate er ........................................... 38
lithium citrate ....................................................... 38
LOKARA .............................................................. 56
lomustine ............................................................. 27
loperamide hcl..................................................... 53
lorazepam ............................................................ 20
LORAZEPAM INTENSOL ................................. 20
losartan potassium ............................................. 42
losartan potassium-hctz .................................... 47
LOTRONEX......................................................... 54
lovastatin.............................................................. 48
loxapine succinate.............................................. 33
LUPRON DEPOT ............................................... 59
LUPRON DEPOT-PED ..................................... 59
LYRICA ................................................................ 19
LYSODREN......................................................... 59
M
MACRODANTIN ................................................. 14
MALARONE ........................................................ 31
malathion ............................................................. 31
maprotiline hcl ..................................................... 22
MARPLAN ........................................................... 22
MATULANE ......................................................... 27
MATZIM LA ......................................................... 45
meclizine hcl ........................................................ 24
medroxyprogesterone acetate ......................... 58
mefloquine hcl ..................................................... 31
megestrol acetate ............................................... 58
MEKINIST ............................................................ 30
meloxicam ........................................................... 11
melphalan hcl ...................................................... 27
MENACTRA ........................................................ 62
MENOMUNE ....................................................... 62
MENVEO ............................................................. 62
meperidine hcl..................................................... 11
MEPRON ............................................................. 31
mercaptopurine ................................................... 28
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meropenem ......................................................... 15
mesalamine-cleanser......................................... 63
mesna................................................................... 29
MESNEX.............................................................. 29
MESTINON ......................................................... 27
METADATE ER .................................................. 50
metformin hcl....................................................... 39
metformin hcl er .................................................. 39
methazolamide ................................................... 47
methenamine hippurate .................................... 14
methimazole ........................................................ 60
methocarbamol ................................................... 68
methotrexate ....................................................... 61
methotrexate sodium ......................................... 61
methotrexate sodium (pf) .................................. 61
methscopolamine bromide ................................ 53
methyclothiazide ................................................. 48
methyldopa .......................................................... 42
methylergonovine maleate................................ 55
methylphenidate hcl ........................................... 50
methylphenidate hcl er ...................................... 50
methylphenidate hcl er (cd) .............................. 50
methylprednisolone ............................................ 56
methylprednisolone (pak).................................. 56
methylprednisolone acetate.............................. 56
methylprednisolone sodium succ .................... 56
metipranolol ......................................................... 65
metoclopramide hcl ............................................ 24
metolazone .......................................................... 48
metoprolol succinate er ..................................... 44
metoprolol tartrate .............................................. 44
metoprolol-hydrochlorothiazide ........................ 47
metronidazole ..................................................... 14
metronidazole in nacl ......................................... 14
mexiletine hcl ...................................................... 43
MIACALCIN ......................................................... 63
midodrine hcl ....................................................... 42
MINITRAN ........................................................... 49
minocycline hcl ................................................... 18
minoxidil ............................................................... 49
mirtazapine .......................................................... 22
misoprostol .......................................................... 54
mitomycin............................................................. 29
mitoxantrone hcl ................................................. 29
M-M-R II ............................................................... 62
modafinil............................................................... 68
moexipril hcl ........................................................ 43
moexipril-hydrochlorothiazide .......................... 47
mometasone furoate .......................................... 56
montelukast sodium ........................................... 66
morphine sulfate ................................................. 12
morphine sulfate (concentrate) ........................ 12
morphine sulfate (pf) .......................................... 12
morphine sulfate er ............................................ 11
moxifloxacin hcl .................................................. 18
MOZOBIL............................................................. 41
MULTAQ .............................................................. 43
mupirocin ............................................................. 14
mupirocin calcium............................................... 14
MUSTARGEN ..................................................... 28
MYCAMINE ......................................................... 26
mycophenolate mofetil ...................................... 61
mycophenolic acid.............................................. 61
MYFORTIC .......................................................... 61
MYOZYME .......................................................... 52
N
nabumetone ........................................................ 11
nadolol.................................................................. 44
nafcillin sodium ................................................... 16
NAGLAZYME ...................................................... 52
NALLPEN IN DEXTROSE ................................ 16
naloxone hcl ........................................................ 12
naltrexone hcl...................................................... 12
NAMENDA........................................................... 21
NAMENDA XR .................................................... 21
NAMENDA XR TITRATION PACK .................. 21
naphazoline hcl ................................................... 64
naproxen .............................................................. 11
naproxen dr ......................................................... 11
naproxen sodium ................................................ 11
naratriptan hcl ..................................................... 26
nateglinide ........................................................... 39
NEBUPENT ......................................................... 31
needles, insulin disp., safety ............................ 40
nefazodone hcl ................................................... 23
neomycin sulfate................................................. 13
neomycin-bacitracin zn-polymyx ...................... 64
neomycin-polymyxin-dexameth ....................... 64
neomycin-polymyxin-gramicidin ....................... 64
neomycin-polymyxin-hc ............................... 64, 65
NEPHRAMINE .................................................... 71
NEULASTA ......................................................... 41
NEUMEGA .......................................................... 42
NEUPOGEN........................................................ 41
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NEUPRO ............................................................. 32
NEVANAC ........................................................... 65
nevirapine ............................................................ 36
nevirapine er ....................................................... 36
NEXAVAR ........................................................... 30
niacin er (antihyperlipidemic) ............................ 49
nicardipine hcl ..................................................... 45
NICOTROL .......................................................... 13
NICOTROL NS ................................................... 13
NIFEDICAL XL.................................................... 45
nifedipine er osmotic .......................................... 45
NILANDRON ....................................................... 28
nimodipine ........................................................... 45
NITRO-DUR ........................................................ 49
nitrofurantoin macrocrystal ............................... 14
nitrofurantoin monohyd macro ......................... 14
nitroglycerin ......................................................... 49
NITROSTAT ........................................................ 49
NORDITROPIN FLEXPRO ............................... 57
NORDITROPIN NORDIFLEX PEN ................. 53
norethindrone acetate........................................ 58
NORMOSOL-M IN D5W ................................... 71
NORMOSOL-R PH 7.4...................................... 69
NORPACE CR .................................................... 43
nortriptyline hcl.................................................... 24
NORVIR ............................................................... 37
NOXAFIL ............................................................. 26
NUEDEXTA ......................................................... 50
NULOJIX.............................................................. 61
NUTROPIN AQ NUSPIN 5 ............................... 53
NUTROPIN AQ PEN ......................................... 57
NYAMYC ............................................................. 26
nystatin ................................................................. 26
nystatin-triamcinolone........................................ 26
NYSTOP .............................................................. 26
O
octreotide acetate ............................................... 60
ofloxacin ............................................................... 18
olanzapine ........................................................... 34
OLYSIO................................................................ 35
omega-3-acid ethyl esters ................................ 49
omeprazole .......................................................... 54
omeprazole (OTC) ............................................. 72
ONCASPAR ........................................................ 42
ondansetron ........................................................ 25
ondansetron hcl .................................................. 25
ONFI ..................................................................... 20
ONGLYZA ........................................................... 39
OPSUMIT ............................................................ 67
ORAP ................................................................... 33
ORENCIA ............................................................ 61
ORFADIN............................................................. 52
ORTHO TRI-CYCLEN (28) ............................... 58
oxacillin sodium .................................................. 16
oxaliplatin ............................................................. 29
oxandrolone......................................................... 57
oxcarbazepine..................................................... 20
OXSORALEN ULTRA ....................................... 51
OXTELLAR XR ................................................... 21
oxybutynin chloride ............................................ 54
oxybutynin chloride er........................................ 54
oxycodone-acetaminophen............................... 10
oxycodone-aspirin .............................................. 10
oxycodone-ibuprofen ......................................... 10
OXYCONTIN ....................................................... 11
P
PACERONE ........................................................ 43
paclitaxel .............................................................. 29
PANCREAZE ...................................................... 52
PANRETIN .......................................................... 31
pantoprazole sodium ......................................... 54
paricalcitol............................................................ 63
paromomycin sulfate.......................................... 13
paroxetine hcl...................................................... 23
paroxetine hcl er ................................................. 23
PASER ................................................................. 27
PATADAY ............................................................ 64
PAXIL ................................................................... 23
pedi-dri ................................................................. 26
PEDVAX HIB....................................................... 62
PEGANONE ........................................................ 21
PEGASYS ........................................................... 35
PEGASYS PROCLICK ...................................... 35
PEG-INTRON ..................................................... 35
PEG-INTRON REDIPEN................................... 35
penicillin g potassium ........................................ 16
penicillin g procaine ........................................... 16
penicillin g sodium .............................................. 16
penicillin v potassium ......................................... 16
PENTAM .............................................................. 31
PENTASA ............................................................ 63
pentoxifylline er ................................................... 47
perindopril erbumine .......................................... 43
PERJETA............................................................. 29
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permethrin ........................................................... 31
perphenazine ...................................................... 24
PFIZERPEN-G.................................................... 16
PHENADOZ ........................................................ 24
phenelzine sulfate .............................................. 22
phenobarbital ...................................................... 20
phenytoin ............................................................. 21
phenytoin sodium ............................................... 21
phenytoin sodium extended.............................. 21
PHOSLYRA ......................................................... 55
PHOSPHOLINE IODIDE ................................... 65
pilocarpine hcl ..................................................... 51
pindolol ................................................................. 44
pioglitazone hcl ................................................... 39
pioglitazone hcl-glimepiride .............................. 39
pioglitazone hcl-metformin hcl.......................... 39
piperacillin sod-tazobactam so ......................... 17
piroxicam ............................................................. 11
PLASMA-LYTE 148 ........................................... 69
PLASMA-LYTE A ............................................... 69
PLASMA-LYTE-56 IN D5W .............................. 71
podofilox............................................................... 51
polyethylene glycol 3350 ................................... 54
polymyxin b sulfate............................................. 14
polymyxin b-trimethoprim .................................. 64
POMALYST ......................................................... 28
potassium chloride ............................................. 69
potassium chloride crys er ................................ 69
potassium chloride er ........................................ 69
potassium chloride in dextrose ........................ 71
potassium chloride in nacl ................................ 69
potassium citrate er............................................ 69
POTIGA ............................................................... 19
PR NATAL 440 EC............................................. 69
PRADAXA ........................................................... 41
pramipexole dihydrochloride ............................ 32
pravastatin sodium ............................................. 48
prazosin hcl ......................................................... 42
prednisolone acetate ......................................... 65
prednisolone sodium phosphate ...................... 56
prednisone ........................................................... 56
PREMARIN ......................................................... 58
PREMASOL ........................................................ 71
PREVACID (OTC) .............................................. 72
PREZISTA ........................................................... 37
PRIFTIN ............................................................... 27
PRILOSEC (OTC) .............................................. 72
primaquine phosphate ....................................... 31
primidone ............................................................. 20
PRISTIQ............................................................... 23
PRIVIGEN ........................................................... 61
PROAIR HFA ...................................................... 67
probenecid ........................................................... 26
PROCALAMINE ................................................. 71
prochlorperazine ................................................. 24
prochlorperazine edisylate ................................ 24
prochlorperazine maleate ................................. 24
PROCRIT............................................................. 41
PROCTOZONE-HC ........................................... 56
PROGLYCEM ..................................................... 39
PROLASTIN-C.................................................... 68
PROLEUKIN ....................................................... 29
PROLIA ................................................................ 63
PROMACTA ........................................................ 41
promethazine hcl ................................................ 24
PROMETHEGAN ............................................... 24
propafenone hcl .................................................. 43
propafenone hcl er ............................................. 43
proparacaine hcl ................................................. 64
propranolol hcl .................................................... 44
propranolol hcl er................................................ 44
propranolol-hctz .................................................. 47
propylthiouracil.................................................... 60
PROQUAD .......................................................... 62
PROTOPIC.......................................................... 51
protriptyline hcl.................................................... 24
PROVIGIL............................................................ 68
PULMOZYME ..................................................... 68
PURINETHOL ..................................................... 28
pyrazinamide ....................................................... 27
pyridostigmine bromide ..................................... 27
Q
QUALAQUIN ....................................................... 31
quetiapine fumarate ........................................... 22
quinapril hcl ......................................................... 43
quinapril-hydrochlorothiazide ........................... 47
quinidine gluconate er ....................................... 43
quinidine sulfate.................................................. 44
quinidine sulfate er ............................................. 44
quinine sulfate ..................................................... 31
QVAR ................................................................... 66
R
RABAVERT ......................................................... 62
raloxifene hcl ....................................................... 58
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ramipril ................................................................. 43
RANEXA .............................................................. 47
ranitidine hcl ........................................................ 53
RAPAMUNE ........................................................ 61
REBETOL ............................................................ 35
REBIF ................................................................... 51
REBIF TITRATION PACK................................. 51
RECOMBIVAX HB ............................................. 62
RELENZA DISKHALER .................................... 38
RELISTOR........................................................... 53
RELPAX ............................................................... 26
REMICADE ......................................................... 61
RENVELA ............................................................ 55
repaglinide ........................................................... 39
RESCRIPTOR .................................................... 36
RESTASIS ........................................................... 64
RETIN-A............................................................... 51
RETROVIR .......................................................... 37
REVLIMID............................................................ 28
REYATAZ ............................................................ 37
RIBASPHERE ..................................................... 35
RIBASPHERE RIBAPAK .................................. 35
ribavirin................................................................. 35
rifabutin ................................................................ 27
rifampin ................................................................ 27
RIFATER ............................................................. 27
riluzole .................................................................. 50
rimantadine hcl ................................................... 38
ringers .................................................................. 71
RIOMET ............................................................... 39
risedronate sodium ............................................ 63
RISPERDAL CONSTA ...................................... 34
risperidone ........................................................... 34
RITUXAN ............................................................. 31
rivastigmine tartrate ........................................... 21
rizatriptan benzoate ........................................... 27
ropinirole hcl ........................................................ 32
ROTARIX ............................................................. 62
ROTATEQ ........................................................... 62
ROZEREM........................................................... 68
S
SABRIL ................................................................ 20
SANCUSO ........................................................... 25
SANDIMMUNE ................................................... 61
SANDOSTATIN .................................................. 60
SANDOSTATIN LAR DEPOT .......................... 60
SANTYL ............................................................... 52
SAPHRIS ............................................................. 34
selegiline hcl........................................................ 33
selenium sulfide .................................................. 52
SELZENTRY ....................................................... 37
SENSIPAR .......................................................... 59
SEREVENT DISKUS ......................................... 67
SEROQUEL XR.................................................. 22
SEROSTIM.......................................................... 53
sertraline hcl ........................................................ 23
sildenafil citrate ................................................... 67
silver sulfadiazine ............................................... 18
SIMPONI.............................................................. 61
SIMPONI ARIA ................................................... 61
simvastatin..................................................... 48, 49
sirolimus ............................................................... 61
SIRTURO............................................................. 27
sm allergy (OTC) ................................................ 72
sodium chloride................................................... 69
sodium fluoride ................................................... 69
sodium phenylbutyrate ...................................... 52
sodium polystyrene sulfonate ........................... 68
SOLTAMOX ........................................................ 28
SOMATULINE DEPOT ...................................... 60
SOMAVERT ........................................................ 60
SORINE ............................................................... 44
sotalol hcl ............................................................. 44
sotalol hcl (af)...................................................... 44
SOVALDI ............................................................. 35
SPIRIVA HANDIHALER .................................... 66
spironolactone..................................................... 48
spironolactone-hctz ............................................ 47
SPRYCEL ............................................................ 30
SSD ...................................................................... 18
stavudine ............................................................. 37
sterile water for irrigation ................................... 69
STIVARGA .......................................................... 30
STRATTERA ....................................................... 50
streptomycin sulfate ........................................... 13
STRIANT ............................................................. 58
STRIBILD............................................................. 36
STROMECTOL ................................................... 31
SUBOXONE ........................................................ 12
sucralfate ............................................................. 54
sulfacetamide sodium ........................................ 18
sulfacetamide-prednisolone.............................. 64
sulfadiazine ......................................................... 18
sulfamethoxazole-tmp ds .................................. 18
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sulfamethoxazole-trimethoprim ........................ 18
sulfasalazine ....................................................... 63
SULFAZINE EC .................................................. 63
sulindac ................................................................ 11
sumatriptan succinate........................................ 27
SUPRAX .............................................................. 15
SUPREP BOWEL PREP................................... 71
SURMONTIL ....................................................... 24
SUSTIVA ............................................................. 36
SUTENT............................................................... 30
SYLATRON ......................................................... 35
SYMBICORT ....................................................... 68
SYMLINPEN 120................................................ 39
SYMLINPEN 60 .................................................. 39
SYNAGIS ............................................................. 61
SYNAREL ............................................................ 60
SYNERCID .......................................................... 13
SYNRIBO............................................................. 29
SYNTHROID ....................................................... 59
SYPRINE ............................................................. 68
T
TABLOID ............................................................. 28
tacrolimus ............................................................ 61
TAFINLAR ........................................................... 30
TAMIFLU ............................................................. 38
tamoxifen citrate ................................................. 28
tamsulosin hcl ..................................................... 54
TARCEVA............................................................ 31
TARGRETIN ....................................................... 31
TASIGNA ............................................................. 31
TASMAR .............................................................. 32
TAZORAC ........................................................... 52
TAZTIA XT........................................................... 45
TECFIDERA ........................................................ 51
TEFLARO ............................................................ 15
TEGRETOL-XR .................................................. 21
temazepam.......................................................... 68
terazosin hcl ........................................................ 42
terbinafine hcl...................................................... 26
terbutaline sulfate ............................................... 67
terconazole .......................................................... 26
testosterone cypionate ...................................... 58
testosterone enanthate...................................... 58
tetanus toxoid adsorbed .................................... 62
tetanus-diphtheria toxoids td ............................ 62
THALOMID .......................................................... 28
theophylline er..................................................... 67
thioridazine hcl .................................................... 33
thiothixene ........................................................... 33
tiagabine hcl ........................................................ 20
TIKOSYN ............................................................. 44
TIMENTIN............................................................ 17
timolol maleate .............................................. 26, 65
TIVICAY ............................................................... 36
tizanidine hcl ....................................................... 34
TOBI ..................................................................... 13
TOBI PODHALER .............................................. 67
TOBRADEX ST .................................................. 64
tobramycin ........................................................... 13
tobramycin sulfate .............................................. 13
tobramycin-dexamethasone ............................. 64
tolterodine tartrate .............................................. 54
tolterodine tartrate er ......................................... 54
topiramate ............................................................ 20
TOPOSAR ........................................................... 30
topotecan hcl ....................................................... 30
torsemide ............................................................. 48
TOVIAZ ................................................................ 54
TPN ELECTROLYTES ...................................... 71
TRACLEER ......................................................... 67
tramadol hcl ......................................................... 12
tramadol-acetaminophen .................................. 10
trandolapril ........................................................... 43
tranexamic acid................................................... 42
TRANSDERM-SCOP......................................... 24
tranylcypromine sulfate ..................................... 22
TRAVASOL ......................................................... 71
TRAVATAN Z...................................................... 65
travoprost ............................................................. 65
trazodone hcl....................................................... 23
TREANDA ........................................................... 29
TRECATOR......................................................... 27
tretinoin .......................................................... 31, 52
triamcinolone acetonide .............................. 51, 57
triamterene-hctz.................................................. 47
TRIDERM ............................................................ 57
trifluoperazine hcl ............................................... 33
trifluridine ............................................................. 36
trihexyphenidyl hcl.............................................. 32
TRILYTE .............................................................. 53
trimethoprim ........................................................ 14
TRISENOX .......................................................... 29
TRIZIVIR .............................................................. 37
TROPHAMINE .................................................... 71
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trospium chloride ................................................ 54
trospium chloride er ........................................... 54
TRUVADA ........................................................... 37
TWINRIX.............................................................. 62
TYGACIL ............................................................. 14
TYKERB............................................................... 31
TYPHIM VI........................................................... 62
TYSABRI ............................................................. 51
TYZEKA ............................................................... 35
U
ULORIC ............................................................... 26
ursodiol................................................................. 53
V
valacyclovir hcl.................................................... 36
VALCYTE ............................................................ 35
valproate sodium ................................................ 20
valproic acid ........................................................ 20
valsartan-hydrochlorothiazide .......................... 47
vancomycin hcl ................................................... 14
VANDAZOLE ...................................................... 14
VAQTA ................................................................. 62
VARIVAX ............................................................. 62
VELCADE ............................................................ 29
venlafaxine hcl .................................................... 23
venlafaxine hcl er ............................................... 23
VENTAVIS ........................................................... 67
VENTOLIN HFA ................................................. 67
verapamil hcl ....................................................... 45
verapamil hcl er .................................................. 46
VERSACLOZ ...................................................... 34
VFEND ................................................................. 26
VFEND IV ............................................................ 26
VIBRAMYCIN ...................................................... 18
VICTRELIS .......................................................... 35
VIDAZA ................................................................ 29
VIDEX................................................................... 37
VIGAMOX ............................................................ 18
VIIBRYD............................................................... 23
VIMPAT ................................................................ 21
vinblastine sulfate ............................................... 29
VINCASAR PFS ................................................. 29
vincristine sulfate ................................................ 29
vinorelbine tartrate ............................................. 29
VIRACEPT........................................................... 37
VIRAMUNE ......................................................... 36
VIRAMUNE XR ................................................... 36
VIRAZOLE ........................................................... 35
VIREAD................................................................ 37
VOLTAREN ......................................................... 52
voriconazole ........................................................ 26
VOTRIENT .......................................................... 31
VPRIV................................................................... 52
VYTORIN ............................................................. 47
W
walfex (OTC) ....................................................... 72
warfarin sodium .................................................. 41
WELCHOL ........................................................... 39
X
XALKORI ............................................................. 31
XARELTO ............................................................ 41
XELJANZ ............................................................. 61
XENAZINE........................................................... 50
XGEVA ................................................................. 63
XIFAXAN ............................................................. 14
XTANDI ................................................................ 28
XYREM ................................................................ 68
Y
YAZ ....................................................................... 58
YERVOY .............................................................. 29
YF-VAX ................................................................ 62
Z
ZADITOR (OTC) ................................................. 72
zafirlukast............................................................. 66
ZALTRAP............................................................. 29
ZAVESCA ............................................................ 52
ZEGERID (OTC)................................................. 72
ZELBORAF ......................................................... 31
ZERIT ................................................................... 37
ZETIA ................................................................... 49
ZIAGEN................................................................ 37
zidovudine ........................................................... 37
ziprasidone hcl .................................................... 34
ZIRGAN ............................................................... 35
ZMAX ................................................................... 17
zoledronic acid .................................................... 63
ZOLINZA.............................................................. 30
zonisamide .......................................................... 19
ZORTRESS ......................................................... 61
ZOSTAVAX ......................................................... 62
ZYKADIA ............................................................. 31
ZYRTEC (OTC) .................................................. 72
ZYRTEC ITCHY (OTC) ..................................... 72
ZYRTEC-D (OTC) .............................................. 72
ZYTIGA ................................................................ 28
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ZYVOX ................................................................. 14
Page 87 of 87
Updated 08/2014

Triple-S Advantage 2015 Formulary (Lista de medicamentos

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