Triple-S Advantage 2016 Formulary (List of Covered Drugs)

Transcripción

Triple-S Advantage
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary ID: 00016470, Version 20
This formulary was updated on November 1, 2016. For more recent information or other questions,
please contact Triple-S Advantage Member Services at 1-888-620-1919 or, for TTY users, 1-866-6202520, 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 Platino Plus (HMO-SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of November 1,
2016. 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, 2017, and from time to
time during the year.
H5774_1085_16_085_E CMS Approved
Triple-S Advantage 2016 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 2016 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2016 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 November 1, 2016. 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 81. 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
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information. Turn to the page listed in the Index and find the name of your drug in the first column
of the list.
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 limits 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.
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If you learn that Triple-S Advantage does not cover your drug, you have two options:

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.
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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.
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 up to 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.
Level of Care Changes
For those member who have been:
a. Enter long-term care (LTC) facility from hospitals or other settings
b. Leave LTC facility and return to the community
c. Discharge from a hospital to a home
d. End a skilled nursing facility stay covered under Medicare Part A (including
pharmacy charges), and revert to coverage under Part D
e. Revert from hospice status to standard Medicare Part A and B benefits
Transition processes will allow a one 30 day transition supplies to be provided to current enrollees with
Level of Care Changes. For more information you can contact Member Services.
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).
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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
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 pre-authorization 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 (1800-633-4227) 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 81. The first column
of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic
drugs are listed in lower-case italics (e.g., diclofenac potassium). The information in the
Requirements/Limits column tells you if Triple-S 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:
ABBREVIATIONS DESCRIPTION REQUIREMENTS / LIMITS
[DESCRIPCIÓN DE ABREVIATURAS PARA REQUISITOS / LÍMITES]
Abreviatura
Descripción
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 Member 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 Member Services Department at 1-888-6201919, from Monday to Sunday from 8:00am to 8:00pm. TTY users should call 1-866620-2520.
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]
ST
This information is available for free in other languages. Please call our Member Services Department
at 1-888-620-1919, from Monday to Sunday from 8:00am to 8:00pm. TTY users should call 1-866-6202520.
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.
Audio-impedidos con equipo especializado de TTY deben llamar al 1-866-620-2520.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year.
The Formulary, pharmacy network, and provider network may change at any time. You will receive
notice when necessary.
Triple-S Advantage is an HMO and PPO organization with a Medicare contract, and a contract with the
Puerto Rico Government Health Insurance Plan (Medicaid). 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 ADMINISTRATIONS, ABBREVIATIONS
[ABREVIATURAS DE FORMAS DE DOSIFICACIÓN Y RUTAS DE ADMINISTRACIÓN]
Abbreviation
[Abreviatura]
Description [Descripción]
buccal tablet [tableta bucal]
bucc tab
concentrate [concentrado]
conc
cream [crema]
crm
delayed release [liberación tardía]
dr
emulsion [emulsión]
emul
extended release [liberación prolongada]
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
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
oral capsule [cápsula oral]
oral capsule delayed release particles [cápsula oral de partículas de
liberación tardía]
oral capsule sprinkle [cápsula oral para espolvorear]
cap
cap dr prt
cap sprinkle
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oral elixir [elixir oral]
Abbreviation
[Abreviatura]
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]
susp
td
transdermal patch [parcho transdermal]
td patch
transdermal patch biweekly [parcho transdermal bisemanal]
tdsw patch
transdermal patch weekly [parcho transdermal semanal]
tdwk patch
vaginal [vaginal]
vag
Description [Descripción]
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Reference Name
Requirements/Limits
[Nombre de
[Requisitos/Límites]¹
Referencia]
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)
acetaminophen-codeine #2 300-15
mg tab
2
QL(360 / 30)
TYLENOL WITH
mg tab
2
CODEINE
QL(360 / 30)
TYLENOL WITH
mg tab
2
CODEINE
QL(180 / 30)
butalbital-apap-caffeine 50-325-40
mg tab
1
ESGIC
PA, QL(180 / 30), HR
endocet 10-325 mg tab
2
PERCOCET
QL(180 / 30)
endocet 7.5-325 mg tab
2
PERCOCET
QL(240 / 30)
endocet 5-325 mg tab
2
PERCOCET
QL(360 / 30)
hydrocodone-acetaminophen 10325 mg tab, 7.5-325 mg tab
2
LORCET
QL(180 / 30)
hydrocodone-acetaminophen 2.5325 mg tab, 5-325 mg tab
2
LORTAB
QL(360 / 30)
oxycodone-acetaminophen 10-325
mg tab
2
ENDOCET
QL(180 / 30)
oxycodone-acetaminophen 7.5-325
mg tab
2
ENDOCET
QL(240 / 30)
oxycodone-acetaminophen 2.5-325
mg tab, 5-325 mg tab
2
ENDOCET
QL(360 / 30)
oxycodone-aspirin 4.8355-325 mg
tab
2
ENDODAN
QL(360 / 30)
oxycodone-ibuprofen 5-400 mg tab
2
QL(120 / 30)
tramadol-acetaminophen 37.5-325
mg tab
2
ULTRACET
QL(240 / 30)
Nonsteroidal Anti-Inflammatory Drugs [Medicamentos Antiinflamatorios No-Esteroidales]
CELEBREX 100 mg cap, 200 mg
cap, 400 mg cap, 50 mg cap
3
ST, MO
celecoxib 100 mg cap, 200 mg cap,
400 mg cap, 50 mg cap
2
CELEBREX
ST, MO
diclofenac potassium 50 mg tab
2
CATAFLAM
MO
diclofenac sodium 25 mg tab dr, 50
mg tab dr, 75 mg tab dr
2
VOLTAREN
MO
diclofenac sodium er 100 mg tab er
24 hr
1
VOLTAREN XL
MO
etodolac 200 mg cap, 400 mg tab,
500 mg tab
1
LODINE
MO
Drug Name
[Nombre del Medicamento]
Drug Tier
[Nivel]
¹ Please refer to page 7 for a list of abbreviations for requirements / limits
Page 10 of 95
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Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
LODINE
Requirements/Limits
etodolac 300 mg cap
2
MO
etodolac er 400 mg tab er 24 hr,
500 mg tab er 24 hr, 600 mg tab er
24 hr
2
LODINE XL
MO
flurbiprofen 100 mg tab, 50 mg tab
1
ANSAID
MO
ibuprofen 100 mg/5ml susp
1
MOTRIN
ibuprofen 400 mg tab, 600 mg tab,
800 mg tab
1
MOTRIN
MO
indomethacin 25 mg cap, 50 mg
cap
1
INDOCIN
PA, MO, HR
ketoprofen 50 mg cap, 75 mg cap
1
ORUDIS
MO
meloxicam 15 mg tab, 7.5 mg tab
1
MOBIC
MO
nabumetone 500 mg tab, 750 mg
tab
1
RELAFEN
MO
naproxen 125 mg/5ml susp, 250 mg
tab, 375 mg tab, 500 mg tab
1
NAPROSYN
MO
naproxen dr 375 mg tab dr, 500 mg
tab dr
1
NAPROSYN
MO
naproxen sodium 275 mg tab, 550
mg tab
1
ANAPROX
MO
piroxicam 10 mg cap, 20 mg cap
2
FELDENE
MO
sulindac 150 mg tab, 200 mg tab
1
MO
Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración]
fentanyl 100 mcg/hr td patch 72 hr,
12 mcg/hr td patch 72 hr, 25 mcg/hr
td patch 72 hr, 37.5 mcg/hr td patch
72 hr, 50 mcg/hr td patch 72 hr,
62.5 mcg/hr td patch 72 hr, 75
mcg/hr td patch 72 hr, 87.5 mcg/hr
td patch 72 hr
2
DURAGESIC
PA, QL(15 / 30)
morphine sulfate er 200 mg tab er
2
MS CONTIN
QL(60 / 30)
morphine sulfate er 100 mg tab er,
15 mg tab er, 30 mg tab er, 60 mg
tab er
2
MS CONTIN
QL(90 / 30)
oxycodone hcl er abuse-deterr 15
mg tab er 12 hr, 30 mg tab er 12 hr,
60 mg tab er 12 hr, 10 mg tab er 12
hr, 20 mg tab er 12 hr, 40 mg tab er
12 hr, 80 mg tab er 12 hr
2
OXYCONTIN
QL(120 / 30)
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,
hr, 80 mg tab er 12 hr
3
QL(120 / 30)
Opioid Analgesics, Short-Acting [Opioides Analgésicos, Corta Duración]
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Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
DEMEROL 50 mg/ml inj soln
4
PA, HR
duramorph 0.5 mg/ml inj soln, 1
mg/ml inj soln
4
DURAMORPH
PA(*), HI
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 2 mg/ml inj soln
2
QL(150 / 30)
hydromorphone hcl pf 500 mg/50ml
inj soln
2
DILAUDID
PA(*), QL(150 / 30)
LAZANDA 100 mcg/act nasal soln,
400 mcg/act nasal soln
5
PA, QL(150 / 30)
LAZANDA 300 mcg/act nasal soln
5
PA, QL(96 / 30)
meperidine hcl 50 mg/ml inj soln
2
DEMEROL
PA, HR
morphine sulfate 15 mg tab, 30 mg
tab
2
QL(180 / 30)
morphine sulfate (concentrate) 20
mg/ml soln
2
morphine sulfate (pf) 2 mg/ml iv
soln, 4 mg/ml iv soln
2
PA(*), HI
nalbuphine hcl 10 mg/ml inj soln, 20
mg/ml inj soln
2
PA(*), HI
tramadol hcl 50 mg tab
2
ULTRAM
QL(240 / 30)
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine 5 % oint
2
LIDODERM
lidocaine 5 % external patch
2
LIDODERM
PA
lidocaine hcl 2 % gel, 4 % soln
2
XYLOCAINE
lidocaine hcl 2 % inj soln
2
XYLOCAINE
PA(*), HI
lidocaine hcl (pf) 0.5 % inj soln
2
PA(*), HI
lidocaine viscous 2 % mouth/throat
soln
1
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
MO
disulfiram 250 mg tab, 500 mg tab
2
ANTABUSE
MO
Opioid Dependence Treatments [Tratamientos Para La Dependencia De Opiáceos]
buprenorphine hcl 2 mg tab subl
2
PA, QL(90 / 30)
buprenorphine hcl 8 mg tab subl
2
PA, QL(360 / 30)
buprenorphine hcl-naloxone hcl 8-2
mg tab subl
2
PA, QL(90 / 30)
buprenorphine hcl-naloxone hcl 20.5 mg tab subl
2
PA, QL(240 / 30)
Page 12 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
naltrexone hcl 50 mg tab
2
SUBOXONE 12-3 mg subl film
4
4
SUBOXONE 2-0.5 mg subl film
4
4
Opioid Reversal Agents [Agentes De Reversión De Opiáceos]
naloxone hcl 0.4 mg/ml inj soln, 1
mg/ml inj soln
2
Smoking Cessation Agents [Agentes Para La Cesación De Fumar]
bupropion hcl 100 mg tab, 75 mg
tab
1
WELLBUTRIN
bupropion hcl er (sr) 100 mg tab er
12 hr, 150 mg tab er 12 hr, 200 mg
tab er 12 hr
1
WELLBUTRIN
bupropion hcl er (smoking det) 150
mg tab er 12 hr
1
ZYBAN
bupropion hcl er (xl) 150 mg tab er
1
WELLBUTRIN
CHANTIX 0.5 mg tab, 1 mg tab
4
CHANTIX CONTINUING MONTH
PAK 1 mg tab
4
CHANTIX STARTING MONTH PAK
0.5 MG X 11 & 1 mg x 42 tab
4
NICOTROL 10 mg inhaler
4
NICOTROL NS 10 mg/ml nasal
soln
4
ANTIBACTERIALS [ANTIBACTERIANOS]
Aminoglycosides [Aminoglucósidos]
amikacin sulfate 500 mg/2ml inj
soln
2
GENTAK 0.3 % ophth oint
1
gentamicin sulfate 0.3 % ophth oint,
0.3 % ophth soln
1
GARAMYCIN
gentamicin sulfate 0.1 % crm, 0.1 %
oint
2
GENTAK
gentamicin sulfate 10 mg/ml iv soln,
40 mg/ml inj soln
2
GARAMYCIN
neomycin sulfate 500 mg tab
2
paromomycin sulfate 250 mg cap
2
streptomycin sulfate 1 gm im soln
2
TOBI 300 mg/5ml inh neb soln
5
tobramycin 0.3 % ophth soln
1
TOBREX
tobramycin 300 mg/5ml inh neb
soln
5
TOBI
Requirements/Limits
PA, QL(60 / 30)
PA, QL(90 / 30)
PA, QL(120 / 30)
PA, QL(180 / 30)
MO
MO
MO
PA, QL(336 / 365)
PA, QL(336 / 365)
PA, QL(56 / 28)
QL(360 / 365)
PA(*), HI
PA(*), HI
PA(*)
PA(*)
PA(*)
Page 13 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
tobramycin sulfate 10 mg/ml inj
soln, 80 mg/2ml inj soln
2
PA(*), HI
Antibacterials (Combination Product) [Antibacterianos (Productos En Combinación)]
SYNERCID 150-350 mg iv soln
4
PA(*), HI
Antibacterials, Other [Antibacterianos, Otros]
acetic acid 2 % otic soln
2
alcohol preps pad
2
baciim 50000 unit im soln
2
BACI-IM
PA(*)
bacitracin 500 unit/gm ophth oint
2
BACI-IM
bacitracin 50000 unit im soln
2
BACI-IM
PA(*)
chloramphenicol sod succinate 1
gm iv soln
2
PA(*), HI
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
clindamycin palmitate hcl 75
mg/5ml soln
2
CLEOCIN
clindamycin phosphate 1 % gel, 1
% lot, 1 % soln, 1 % swab, 2 % vag
crm
2
CLEOCIN-T
clindamycin phosphate 600 mg/4ml
iv soln
2
CLEOCIN
PA(*), HI
clindamycin phosphate in d5w 300
mg/50ml iv soln, 600 mg/50ml iv
soln, 900 mg/50ml iv soln
2
CLEOCIN
PA(*), HI
colistimethate sodium 150 mg inj
soln
2
PA(*), HI
CUBICIN 500 mg iv soln
5
PA(*), HI
daptomycin 500 mg iv soln
5
CUBICIN
PA(*), HI
linezolid 100 mg/5ml susp, 600 mg
tab
5
ZYVOX
PA
linezolid 600 mg/300ml iv soln
5
ZYVOX
PA(*), HI
methenamine hippurate 1 gm tab
2
HIPREX
metronidazole 250 mg tab, 500 mg
tab
1
FLAGYL
metronidazole 0.75 % crm, 0.75 %
gel, 0.75 % lot, 0.75 % vag gel, 1 %
gel
2
METROCREAM
metronidazole in nacl 500-0.79
mg/100ml-% iv soln
2
PA(*), HI
mupirocin 2 % oint
2
BACTROBAN
mupirocin calcium 2 % crm
2
BACTROBAN
Page 14 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
nitrofurantoin macrocrystal 25 mg
2
MACRODANTIN
nitrofurantoin monohyd macro 100
mg cap
2
MACROBID
polymyxin b sulfate 500000 unit inj
soln
2
SIVEXTRO 200 mg tab
5
SIVEXTRO 200 mg iv soln
5
trimethoprim 100 mg tab
1
TYGACIL 50 mg iv soln
5
vancomycin hcl 10 gm iv soln, 1000
mg iv soln, 500 mg iv soln
2
VANCOCIN
vancomycin hcl 125 mg cap, 250
mg cap
5
VANCOCIN
VANDAZOLE 0.75 % vag gel
2
XIFAXAN 550 mg tab
5
ZYVOX 600 mg/300ml iv soln
5
Beta-Lactam, Cephalosporins [Beta-Lactámicos, Cefalosporinas]
cefaclor 250 mg cap, 500 mg cap
2
cefaclor er 500 mg tab er 12 hr
2
cefadroxil 1 gm tab, 250 mg/5ml
susp, 500 mg cap, 500 mg/5ml
susp
2
cefazolin sodium 1 gm inj soln, 1-5
gm-% iv soln, 10 gm inj soln, 500
mg inj soln
2
cefdinir 125 mg/5ml susp, 250
mg/5ml susp, 300 mg cap
2
cefepime hcl 1 gm inj soln, 2 gm inj
soln
2
MAXIPIME
cefotaxime sodium 1 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
cefpodoxime proxetil 100 mg tab,
100 mg/5ml susp, 200 mg tab, 50
mg/5ml susp
2
cefprozil 125 mg/5ml susp, 250 mg
tab, 250 mg/5ml susp, 500 mg tab
2
ceftazidime 1 gm inj soln, 2 gm inj
soln, 6 gm inj soln
2
TAZICEF
ceftriaxone sodium 1 gm iv soln, 10
gm iv soln, 2 gm iv soln, 250 mg inj
soln, 500 mg inj soln
2
Requirements/Limits
QL(30 / 90), HR
QL(30 / 90), HR
PA(*), HI
PA
PA(*), HI
PA(*), HI
PA(*), HI
MO
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
Page 15 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
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
PA(*), HI
cephalexin 125 mg/5ml susp, 250
mg cap, 250 mg tab, 250 mg/5ml
susp, 500 mg cap, 500 mg tab
1
KEFLEX
SUPRAX 400 mg cap
4
TEFLARO 400 mg iv soln, 600 mg
iv soln
4
PA(*), HI
Beta-Lactam, Other [Beta-Lactámicos, Otros]
aztreonam 1 gm inj soln
2
AZACTAM
PA(*), HI
DORIBAX 500 mg iv soln
4
PA(*), HI
imipenem-cilastatin 250 mg iv soln,
500 mg iv soln
2
PRIMAXIN
PA(*), HI
INVANZ 1 gm inj soln
4
PA(*), HI
meropenem 500 mg iv soln
2
MERREM
PA(*), HI
Beta-Lactam, Penicillins [Beta-Lactámicos, Penicilinas]
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
1
amoxicillin-pot clavulanate 250-125
mg tab, 500-125 mg tab, 875-125
mg tab
1
amoxicillin-pot clavulanate 200-28.5
mg tab chew, 200-28.5 mg/5ml
susp, 250-62.5 mg/5ml susp, 40057 mg tab chew, 400-57 mg/5ml
susp, 600-42.9 mg/5ml susp
2
amoxicillin-pot clavulanate er 100062.5 mg tab er 12 hr
2
ampicillin 125 mg/5ml susp, 250 mg
cap, 250 mg/5ml susp, 500 mg cap
1
ampicillin sodium 1 gm inj soln, 10
gm iv soln, 125 mg inj soln
2
PA(*), HI
ampicillin-sulbactam sodium 1.5 (10.5) gm inj soln, 15 (10-5) gm iv
soln, 3 (2-1) gm inj soln
2
UNASYN
PA(*), HI
BICILLIN C-R 1200000 unit/2ml im
susp
4
PA(*)
BICILLIN C-R 900/300 900000300000 unit/2ml im susp
4
PA(*)
Page 16 of 95
Updated 11/2016
Drug Name
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
nafcillin sodium in dextrose 1
gm/50ml iv soln
oxacillin sodium 2 gm inj soln, 10
gm inj soln
penicillin g pot in dextrose 40000
unit/ml iv soln, 60000 unit/ml iv 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
piperacillin sod-tazobactam so 30.375 gm iv soln, 4-0.5 gm iv soln,
2-0.25 gm iv soln
TIMENTIN 3.1 gm/100ml iv soln, 31
gm iv soln
Macrolides [Macrólidos]
azithromycin 250 mg tab, 250 mg
tab pack
azithromycin 100 mg/5ml susp, 200
mg/5ml susp, 500 mg tab, 600 mg
tab
azithromycin 500 mg iv soln
clarithromycin 125 mg/5ml susp,
250 mg tab, 250 mg/5ml susp, 500
mg tab
clarithromycin er 500 mg tab er 24
hr
E.E.S. 400 400 mg tab
E.E.S. GRANULES 200 mg/5ml
susp
ery 2 % external pad
ERYPED 200 200 mg/5ml susp
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
4
2
2
PA(*), HI
2
PA(*), HI
2
PA(*), HI
2
PA(*), HI
2
PA(*), HI
2
2
PA(*), HI
1
2
ZOSYN
4
PA(*), HI
PA(*), HI
1
ZITHROMAX
2
2
ZITHROMAX
ZITHROMAX
2
BIAXIN
PA(*), HI
2
4
4
2
4
ERY
Page 17 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
ERYPED 400 400 mg/5ml susp
ERY-TAB 250 mg tab dr, 333 mg
tab dr, 500 mg tab dr
ERYTHROCIN LACTOBIONATE
500 mg iv soln
ERYTHROCIN STEARATE 250 mg
tab
erythromycin 5 mg/gm ophth oint
erythromycin 2 % gel, 2 % soln
erythromycin base 250 mg tab, 500
mg tab
erythromycin ethylsuccinate 400 mg
tab
ZMAX 2 gm susp
Quinolones [Quinolonas]
AVELOX 400 mg/250ml iv soln
ciprofloxacin 250 MG/5ML (5%)
susp, 500 MG/5ML (10%) susp
ciprofloxacin 400 mg/40ml iv soln
ciprofloxacin hcl 0.3 % ophth soln
ciprofloxacin hcl 100 mg tab, 250
mg tab, 500 mg tab, 750 mg tab
ciprofloxacin in d5w 200 mg/100ml
iv soln
ciprofloxacin-ciproflox hcl er 1000
mg tab er 24 hr
ciprofloxacin-ciproflox hcl er 500 mg
tab er 24 hr
levofloxacin 25 mg/ml soln, 250 mg
levofloxacin 25 mg/ml iv soln
levofloxacin in d5w 500 mg/100ml
iv soln
moxifloxacin hcl 400 mg tab
ofloxacin 0.3 % ophth soln
ofloxacin 0.3 % otic soln, 400 mg
tab
VIGAMOX 0.5 % ophth soln
Sulfonamides [Sulfonamidas]
silver sulfadiazine 1 % crm
SSD 1 % crm
sulfacetamide sodium 10 % ophth
soln
4
Reference Name
[Nombre de
Referencia]
Requirements/Limits
4
4
4
1
2
PA(*), HI
ILOTYCIN
ILOTYCIN
2
2
4
E.E.S.
4
PA(*), HI
2
2
1
CIPRO
CIPRO
CIPRO
2
CILOXAN
PA(*), HI
2
PA(*), HI
2
QL(14 / 30)
2
QL(28 / 30)
2
2
LEVAQUIN
LEVAQUIN
2
2
1
AVELOX
OCUFLOX
PA(*), HI
PA(*), HI
2
3
OCUFLOX
2
2
SSD
1
BLEPH-10
Page 18 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
sulfacetamide sodium 10 %
external susp, 10 % ophth oint
2
sulfadiazine 500 mg tab
2
sulfamethoxazole-tmp ds 800-160
mg tab
1
sulfamethoxazole-trimethoprim 40080 mg tab
1
sulfamethoxazole-trimethoprim 40080 mg/5ml iv soln
1
sulfamethoxazole-trimethoprim 20040 mg/5ml susp
2
Tetracyclines [Tetraciclinas]
demeclocycline hcl 150 mg tab, 300
mg tab
2
doxycycline hyclate 100 mg cap,
100 mg tab, 100 mg tab dr, 150 mg
tab dr, 50 mg cap, 75 mg tab dr
2
doxycycline hyclate 100 mg iv soln
2
doxycycline monohydrate 100 mg
cap, 100 mg tab, 150 mg tab, 25
mg/5ml susp, 50 mg cap, 50 mg
tab, 75 mg cap, 75 mg tab
2
minocycline hcl 100 mg cap, 50 mg
cap, 75 mg cap
2
VIBRAMYCIN 50 mg/5ml syr
4
ANTICONVULSANTS [ANTICONVULSIVOS]
Anticonvulsants, Other [Anticonvulsivos, Otros]
BRIVIACT 10 mg tab, 25 mg tab,
50 mg tab, 75 mg tab, 100 mg tab,
10 mg/ml soln
5
BRIVIACT 50 mg/5ml iv soln
4
levetiracetam 1000 mg tab, 250 mg
1
levetiracetam 100 mg/ml soln
2
levetiracetam 500 mg/5ml iv soln
2
levetiracetam er 500 mg tab er 24
2
levetiracetam in nacl 1000
mg/100ml iv soln, 1500 mg/100ml iv
soln, 500 mg/100ml iv soln
2
POTIGA 300 mg tab, 400 mg tab,
50 mg tab
4
POTIGA 200 mg tab
5
Reference Name
[Nombre de
Referencia]
Requirements/Limits
KLARON
BACTRIM
BACTRIM
BACTRIM
PA(*), HI
BACTRIM
DOXY
VIBRAMYCIN
PA(*), HI
VIBRAMYCIN
MINOCIN
MO
PA(*), HI
KEPPRA
KEPPRA
KEPPRA
MO
MO
PA(*), HI
KEPPRA
MO
PA(*), HI
MO
MO
Page 19 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
SPRITAM 1000 mg tab disint sol,
250 mg tab disint sol, 500 mg tab
disint sol, 750 mg tab disint sol
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
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
LYRICA 20 mg/ml soln
4
QL(900 / 30), MO
zonisamide 100 mg cap, 25 mg
cap, 50 mg cap
1
ZONEGRAN
MO
Gamma-Aminobutyric Acid (GABA) Augmenting Agents [Agentes Que Aumentan El Ácido
Gamma-Aminobutírico (GABA)]
clonazepam 0.125 mg odt, 0.25 mg
odt, 0.5 mg odt, 0.5 mg tab, 1 mg
odt, 1 mg tab
2
KLONOPIN
QL(120 / 30), MO
clonazepam 2 mg odt, 2 mg tab
2
KLONOPIN
QL(300 / 30), MO
diazepam 1 mg/ml soln, 10 mg rect
gel, 2.5 mg rect gel, 20 mg rect gel
2
VALIUM
diazepam 10 mg tab
2
DIASTAT
QL(120 / 30)
diazepam 5 mg tab
2
VALIUM
QL(240 / 30)
diazepam 2 mg tab
2
DIASTAT
QL(360 / 30)
DIAZEPAM INTENSOL 5 mg/ml
oral conc
2
divalproex sodium 125 mg tab dr,
250 mg tab dr, 500 mg tab dr
1
DEPAKOTE
MO
divalproex sodium 125 mg cap dr
sprinkle
2
DEPAKOTE
MO
divalproex sodium er 250 mg tab er
2
DEPAKOTE
MO
gabapentin 100 mg cap, 300 mg
cap, 400 mg cap
1
NEURONTIN
MO
gabapentin 250 mg/5ml soln, 600
mg tab, 800 mg tab
2
NEURONTIN
MO
GABITRIL 12 mg tab, 16 mg tab, 2
mg tab, 4 mg tab
4
MO
lorazepam 0.5 mg tab, 1 mg tab, 2
mg tab
2
ATIVAN
QL(90 / 30)
LORAZEPAM INTENSOL 2 mg/ml
oral conc
2
Page 20 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
ONFI 10 mg tab, 2.5 mg/ml susp,
20 mg tab
4
MO
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
MO, HR
primidone 250 mg tab, 50 mg tab
1
MYSOLINE
MO
SABRIL 500 mg pckt, 500 mg tab
5
LA, MO
tiagabine hcl 2 mg tab, 4 mg tab
2
GABITRIL
MO
valproate sodium 500 mg/5ml iv
soln
2
DEPACON
PA(*), HI
valproic acid 250 mg cap, 250
mg/5ml syr
1
DEPAKENE
MO
Glutamate Reducing Agents [Agentes Reductores De Glutamato]
felbamate 400 mg tab, 600 mg tab,
600 mg/5ml susp
2
FELBATOL
MO
FYCOMPA 0.5 mg/ml susp, 10 mg
tab, 12 mg tab, 2 mg tab, 4 mg tab,
6 mg tab, 8 mg tab
4
MO
lamotrigine 100 mg tab, 150 mg
tab, 200 mg tab, 25 mg tab, 25 mg
tab chew, 5 mg tab chew
1
LAMICTAL
MO
topiramate 100 mg tab, 15 mg cap
sprinkle, 200 mg tab, 25 mg cap
sprinkle, 25 mg tab, 50 mg tab
1
TOPAMAX
MO
topiramate er 100 mg cap er 24 hr
sprinkle, 150 mg cap er 24 hr
sprinkle
2
QUDEXY
MO
Sodium Channel Agents [Agentes De Los Canales De Sodio]
APTIOM 200 mg tab, 400 mg tab,
600 mg tab, 800 mg tab
4
MO
BANZEL 200 mg tab, 40 mg/ml
susp, 400 mg tab
4
MO
carbamazepine 100 mg tab chew,
200 mg tab
1
EPITOL
MO
carbamazepine 100 mg/5ml susp
2
TEGRETOL
MO
carbamazepine er 100 mg tab er 12
hr, 200 mg tab er 12 hr, 400 mg tab
er 12 hr
2
TEGRETOL
MO
CEREBYX 500 mg pe/10ml inj soln
4
PA(*), HI
DILANTIN 100 mg cap, 125 mg/5ml
susp, 30 mg cap
4
MO
Page 21 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
DILANTIN INFATABS 50 mg tab
chew
4
MO
oxcarbazepine 150 mg tab, 300 mg
tab, 600 mg tab
1
TRILEPTAL
MO
oxcarbazepine 300 mg/5ml susp
2
TRILEPTAL
MO
OXTELLAR XR 150 mg tab er 24
er 24 hr
4
MO
PEGANONE 250 mg tab
4
MO
phenytoin 125 mg/5ml susp, 50 mg
tab chew
2
DILANTIN
MO
phenytoin sodium 50 mg/ml inj soln
2
PA(*), HI
phenytoin sodium extended 100 mg
2
DILANTIN
MO
VIMPAT 10 mg/ml soln, 100 mg
tab
4
MO
VIMPAT 200 mg/20ml iv soln
4
PA(*), HI
ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]
Antidementia Agents, Other [Agentes Contra La Demencia, Otros]
ergoloid mesylates 1 mg tab
2
PA, MO, HR
Cholinesterase Inhibitors [Inhibidores De Colinesterasa]
donepezil hcl 10 mg odt, 10 mg tab,
5 mg odt, 5 mg tab
1
ARICEPT
MO
donepezil hcl 23 mg tab
2
ARICEPT
MO
galantamine hydrobromide 12 mg
tab, 4 mg tab, 4 mg/ml soln, 8 mg
tab
2
RAZADYNE
MO
galantamine hydrobromide er 16
mg cap er 24 hr, 24 mg cap er 24
hr, 8 mg cap er 24 hr
2
RAZADYNE
MO
rivastigmine 13.3 mg/24hr td patch
24hr, 4.6 mg/24hr td patch 24hr, 9.5
mg/24hr td patch 24hr
2
EXELON
MO
rivastigmine tartrate 1.5 mg cap, 3
mg cap, 4.5 mg cap, 6 mg cap
2
EXELON
MO
N-Methyl-D-Aspartate (Nmda) Receptor Antagonist [Antagonistas Del Receptor N-Metil-DAspartato (Nmda)]
memantine hcl 10 mg tab, 5 mg tab
1
NAMENDA
PA, MO
memantine hcl 5 (28)-10 (21) mg
tab
2
NAMENDA
PA
memantine hcl 2 mg/ml soln
2
NAMENDA
PA, MO
Page 22 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
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
PA, MO
NAMENDA XR TITRATION PACK
7 & 14 & 21 &28 mg cap er 24 hr
4
PA
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Antidepressants, Other [Antidepresivos, Otros]
ABILIFY MAINTENA 300 mg im
susp, 400 mg im susp
5
ST, MO
aripiprazole 10 mg odt, 10 mg tab,
15 mg odt, 15 mg tab, 2 mg tab, 20
mg tab, 30 mg tab, 5 mg tab, 1
mg/ml soln
2
ABILIFY
ST, MO
mirtazapine 15 mg tab, 30 mg tab,
45 mg tab, 7.5 mg tab
1
REMERON
MO
mirtazapine 15 mg odt, 30 mg odt,
45 mg odt
2
REMERON
MO
quetiapine fumarate 100 mg tab,
1
SEROQUEL
MO
REXULTI 0.25 mg tab, 0.5 mg tab,
1 mg tab, 2 mg tab, 3 mg tab, 4 mg
tab
5
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
tranylcypromine sulfate 10 mg tab
2
PARNATE
MO
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
1
CELEXA
MO
citalopram hydrobromide 10 mg/5ml
soln
2
CELEXA
MO
desvenlafaxine er 100 mg tab er 24
2
KHEDEZLA
QL(30 / 30), ST, MO
duloxetine hcl 20 mg cap dr prt, 40
mg cap dr prt
2
CYMBALTA
MO
escitalopram oxalate 10 mg tab, 20
mg tab, 5 mg tab, 5 mg/5ml soln
1
LEXAPRO
MO
Page 23 of 95
Updated 11/2016
Drug Name
FETZIMA 120 mg cap er 24 hr, 20
FETZIMA TITRATION 20 & 40 mg
cap er 24 hr pac
fluoxetine hcl 10 mg cap, 10 mg
tab, 20 mg cap, 20 mg tab, 20
mg/5ml soln, 40 mg cap
fluoxetine hcl 60 mg tab
fluvoxamine maleate 100 mg tab,
maprotiline hcl 25 mg tab, 50 mg
tab, 75 mg tab
nefazodone hcl 100 mg tab, 150 mg
tab
paroxetine hcl 10 mg tab, 20 mg
paroxetine hcl 10 mg/5ml susp
paroxetine hcl er 12.5 mg tab er 24
hr, 25 mg tab er 24 hr, 37.5 mg tab
er 24 hr
PAXIL 10 mg/5ml susp
PRISTIQ 100 mg tab er 24 hr, 25
mg tab er 24 hr, 50 mg tab er 24 hr
sertraline hcl 100 mg tab, 25 mg
tab, 50 mg tab
sertraline hcl 20 mg/ml oral conc
trazodone hcl 100 mg tab, 150 mg
tab, 50 mg tab
TRINTELLIX 5 mg tab, 10 mg tab,
20 mg tab
venlafaxine hcl 100 mg tab, 25 mg
tab, 37.5 mg tab, 50 mg tab, 75 mg
tab
venlafaxine hcl er 150 mg cap er 24
hr
venlafaxine hcl er 37.5 mg cap er
VIIBRYD 10 mg tab, 20 mg tab, 40
mg tab
VIIBRYD STARTER PACK 10 & 20
mg oral kit
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
4
ST, MO
4
ST
1
2
PROZAC
PROZAC
MO
MO
2
MO
2
MO
2
MO
1
2
PAXIL
PAXIL
MO
ST, MO
2
4
PAXIL
MO
ST, MO
4
1
2
QL(30 / 30), ST, MO
ZOLOFT
ZOLOFT
MO
MO
1
MO
4
MO
1
MO
1
EFFEXOR
QL(30 / 30), MO
1
EFFEXOR
QL(60 / 30), MO
4
ST, MO
4
ST
Page 24 of 95
Updated 11/2016
Reference Name
Requirements/Limits
[Nombre de
Referencia]
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)]
duloxetine hcl 20 mg cap dr prt, 30
mg cap dr prt, 60 mg cap dr prt
2
CYMBALTA
MO
Tricyclics [Tricíclicos]
amitriptyline hcl 10 mg tab, 100 mg
tab, 75 mg tab
2
PA, MO, HR
amoxapine 100 mg tab, 150 mg
2
MO
clomipramine hcl 25 mg cap, 50 mg
cap, 75 mg cap
2
ANAFRANIL
PA, MO, HR
desipramine hcl 10 mg tab, 100 mg
tab, 75 mg tab
2
NORPRAMIN
MO
doxepin hcl 10 mg cap, 10 mg/ml
oral conc, 100 mg cap, 150 mg cap,
25 mg cap, 50 mg cap, 75 mg cap
2
PA, MO, HR
imipramine hcl 10 mg tab, 25 mg
tab, 50 mg tab
2
TOFRANIL
PA, MO, HR
imipramine pamoate 100 mg cap,
125 mg cap, 150 mg cap, 75 mg
cap
2
TOFRANIL-PM
PA, MO, HR
nortriptyline hcl 10 mg cap, 25 mg
1
PAMELOR
MO
nortriptyline hcl 10 mg/5ml soln
2
PAMELOR
MO
protriptyline hcl 10 mg tab, 5 mg tab
2
MO
trimipramine maleate 100 mg cap,
2
SURMONTIL
PA, MO, HR
ANTIEMETICS [ANTIEMÉTICOS]
Antiemetics, Other [Antieméticos, Otros]
chlorpromazine hcl 10 mg tab, 100
mg tab, 200 mg tab, 25 mg tab, 50
mg tab
2
MO
chlorpromazine hcl 25 mg/ml inj
soln
2
PA(*), HI
diphenhydramine hcl 50 mg/ml inj
soln
2
PA(*), HI
meclizine hcl 12.5 mg tab, 25 mg
tab
1
metoclopramide hcl 10 mg tab, 5
mg tab, 5 mg/5ml soln
1
REGLAN
metoclopramide hcl 5 mg/ml inj soln
1
REGLAN
PA(*), HI
Drug Name
Drug Tier
[Nivel]
Page 25 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
perphenazine 16 mg tab, 2 mg tab,
4 mg tab, 8 mg tab
2
PHENADOZ 12.5 mg rect supp
2
prochlorperazine 25 mg rect supp
1
COMPRO
prochlorperazine edisylate 5 mg/ml
inj soln
2
prochlorperazine maleate 10 mg
tab, 5 mg tab
1
promethazine hcl 50 mg rect supp
2
PHENERGAN
promethazine hcl 12.5 mg rect
supp, 25 mg rect supp
2
PROMETHEGAN
promethazine hcl 12.5 mg tab
2
PHENERGAN
PROMETHEGAN 25 mg rect supp
2
TRANSDERM-SCOP 1 mg/3days
td patch 72 hr
4
Emetogenic Therapy Adjuncts [Terapias Adyuvantes Emetogénicas]
dronabinol 10 mg cap, 2.5 mg cap,
5 mg cap
2
MARINOL
EMEND 40 mg cap
4
EMEND 125 mg cap
4
EMEND 80 mg cap
4
EMEND 80 & 125 mg cap
4
granisetron hcl 0.1 mg/ml iv soln, 1
mg/ml iv soln
2
granisetron hcl 1 mg tab
2
ondansetron 4 mg odt, 8 mg odt
1
ZOFRAN
ondansetron hcl 4 mg tab, 8 mg tab
1
ZOFRAN
ondansetron hcl 24 mg tab, 4
mg/5ml soln
2
ZOFRAN
ondansetron hcl 4 mg/2ml inj soln
2
ZOFRAN
SANCUSO 3.1 mg/24hr td patch
4
ANTIFUNGALS [ANTIFUNGALES]
Antifungals [Antifungales]
ABELCET 5 mg/ml iv susp
5
amphotericin b 50 mg inj soln
2
CANCIDAS 50 mg iv soln, 70 mg iv
soln
5
ciclopirox 0.77 % gel, 1 %
shampoo, 8 % soln
2
LOPROX
ciclopirox olamine 0.77 % crm, 0.77
% external susp
2
clotrimazole 1 % crm, 1 % soln, 10
mg mouth/throat troche
2
CRESEMBA 186 mg cap
5
Requirements/Limits
MO
HR
MO
HR
HR
PA, HR
HR
QL(10 / 30)
PA(*)
PA(*), QL(1 / 30)
PA(*), QL(2 / 28)
PA(*), QL(3 / 30)
PA(*), QL(6 / 28)
PA(*), HI
PA(*)
PA(*)
PA(*)
PA(*)
PA(*), HI
PA(*)
PA(*), HI
PA(*), HI
PA(*), HI
PA
Page 26 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
CRESEMBA 372 mg iv soln
5
ERAXIS 50 mg iv soln, 100 mg iv
soln
5
fluconazole 100 mg tab, 150 mg
1
fluconazole 10 mg/ml susp, 40
mg/ml susp
2
fluconazole in dextrose 400
mg/200ml iv soln
2
fluconazole in sodium chloride 2000.9 mg/100ml-% iv soln
2
flucytosine 250 mg cap, 500 mg
cap
5
griseofulvin microsize 125 mg/5ml
susp, 500 mg tab
2
griseofulvin ultramicrosize 125 mg
tab, 250 mg tab
2
GRIS-PEG 125 mg tab, 250 mg tab
4
itraconazole 100 mg cap
2
ketoconazole 2 % crm, 2 %
shampoo, 200 mg tab
2
MYCAMINE 50 mg iv soln
4
MYCAMINE 100 mg iv soln
5
NOXAFIL 40 mg/ml susp
5
NYAMYC 100000 unit/gm external
pwdr
2
nystatin 100000 unit/gm crm,
100000 unit/gm external pwdr,
100000 unit/gm oint, 100000 unit/ml
mouth/throat susp, 500000 unit tab
2
nystatin-triamcinolone 100000-0.1
unit/gm-% crm, 100000-0.1 unit/gm% oint
2
NYSTOP 100000 unit/gm external
pwdr
2
terbinafine hcl 250 mg tab
2
terconazole 0.4 % vag crm, 0.8 %
vag crm, 80 mg vag supp
2
VFEND 40 mg/ml susp
5
VFEND IV 200 mg iv soln
4
voriconazole 200 mg iv soln
2
voriconazole 200 mg tab, 40 mg/ml
susp, 50 mg tab
5
ANTIGOUT AGENTS [AGENTES ANTIGOTA]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
PA(*), HI
PA(*), HI
DIFLUCAN
DIFLUCAN
PA(*), HI
PA(*), HI
ANCOBON
PA
GRIS-PEG
SPORANOX
QL(360 / 90)
NIZORAL
PA(*), HI
PA(*), HI
PA, MO
NYSTOP
LAMISIL
QL(90 / 90)
ZAZOLE
VFEND
PA
PA(*), HI
PA(*), HI
VFEND
PA
Page 27 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
Antigout Agents [Agentes Antigota]
allopurinol 100 mg tab, 300 mg tab
1
ZYLOPRIM
MO
colchicine 0.6 mg cap, 0.6 mg tab
2
COLCRYS
colchicine-probenecid 0.5-500 mg
tab
2
MO
COLCRYS 0.6 mg tab
4
probenecid 500 mg tab
2
MO
ULORIC 40 mg tab, 80 mg tab
4
ST, MO
ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]
Ergot Alkaloids [Alcaloides De Ergot]
dihydroergotamine mesylate 1
mg/ml inj soln
2
ERGOMAR 2 mg tab subl
4
Prophylactic [Profilaxis]
timolol maleate 10 mg tab, 20 mg
tab, 5 mg tab
2
MO
Serotonin (5-HT) 1b/1d Receptor Agonists [Agonistas Receptores De Serotonina (5-HT)
1b/1d]
naratriptan hcl 1 mg tab, 2.5 mg tab
2
AMERGE
QL(9 / 30), ST
rizatriptan benzoate 10 mg odt, 10
mg tab, 5 mg odt, 5 mg tab
1
MAXALT
QL(12 / 30)
sumatriptan succinate 6 mg/0.5ml
sc soln, 6 mg/0.5ml sc soln auto-inj,
4 mg/0.5ml sc soln auto-inj
2
IMITREX
QL(4 / 30)
sumatriptan succinate 100 mg tab,
2
IMITREX
QL(9 / 30)
sumatriptan succinate refill 4
mg/0.5ml sc soln cartridge, 6
mg/0.5ml sc soln cartridge
2
IMITREX
QL(4 / 30)
ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]
Parasympathomimetics [Parasimpatomiméticos]
guanidine hcl 125 mg tab
2
MESTINON 60 mg tab, 60 mg/5ml
syr
4
pyridostigmine bromide 60 mg tab
2
MESTINON
pyridostigmine bromide er 180 mg
tab er
2
MESTINON
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antimycobacterials, Other [Antimicobacterianos, Otros]
dapsone 100 mg tab, 25 mg tab
2
MO
PASER 4 gm pckt
4
rifabutin 150 mg cap
2
MYCOBUTIN
Antituberculars [Antituberculosos]
CAPASTAT SULFATE 1 gm inj soln
4
PA(*), HI
Page 28 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
SEROMYCIN
cycloserine 250 mg cap
2
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
isoniazid 50 mg/5ml syr
2
PRIFTIN 150 mg tab
4
pyrazinamide 500 mg tab
2
rifampin 150 mg cap, 300 mg cap
2
RIFADIN
rifampin 600 mg iv soln
2
RIFADIN
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, 50
mg cap
2
GLEOSTINE 10 mg cap, 100 mg
4
HEXALEN 50 mg cap
5
LEUKERAN 2 mg tab
4
MATULANE 50 mg cap
5
melphalan hcl 50 mg iv soln
5
ALKERAN
MUSTARGEN 10 mg inj soln
4
thiotepa 15 mg inj soln
5
YONDELIS 1 mg iv soln
5
Antiandrogens [Antiandrógenos]
bicalutamide 50 mg tab
2
CASODEX
flutamide 125 mg cap
2
NILANDRON 150 mg tab
4
nilutamide 150 mg tab
2
NILANDRON
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
5
Antiestrogens/Modifiers [Antiestrógenos/Modificadores]
Requirements/Limits
MO
MO
PA(*), HI
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA
PA
PA
PA, LA
PA, MO
Page 29 of 95
Updated 11/2016
Reference Name
[Nombre de
Referencia]
Drug Name
Drug Tier
[Nivel]
Requirements/Limits
EMCYT 140 mg cap
FARESTON 60 mg tab
SOLTAMOX 10 mg/5ml soln
tamoxifen citrate 10 mg tab, 20 mg
tab
Antimetabolites [Antimetabolitos]
DROXIA 200 mg cap, 300 mg cap,
400 mg cap
HYDREA 500 mg cap
hydroxyurea 500 mg cap
mercaptopurine 50 mg tab
PURIXAN 2000 mg/100ml susp
TABLOID 40 mg tab
Antineoplastics [Antineoplásicos]
ALIMTA 500 mg iv soln
amifostine 500 mg iv soln
AVASTIN 400 mg/16ml iv soln, 100
mg/4ml iv soln
azacitidine 100 mg inj susp
BICNU 100 mg iv soln
bleomycin sulfate 30 unit inj soln
carboplatin 150 mg/15ml iv soln
cisplatin 100 mg/100ml iv soln
cladribine 10 mg/10ml iv soln
COSMEGEN 0.5 mg iv soln
CYRAMZA 100 mg/10ml iv soln,
500 mg/50ml iv soln
cytarabine 20 mg/ml inj soln
dacarbazine 200 mg iv soln
dactinomycin 0.5 mg iv soln
daunorubicin hcl 5 mg/ml iv inj
decitabine 50 mg iv soln
dexrazoxane 250 mg iv soln
docetaxel 80 mg/4ml iv conc, 80
mg/8ml iv soln
DOXIL 2 mg/ml iv inj
doxorubicin hcl 2 mg/ml iv soln
doxorubicin hcl liposomal 2 mg/ml
iv inj
ELITEK 1.5 mg iv soln, 7.5 mg iv
soln
epirubicin hcl 50 mg/25ml iv soln
FASLODEX 250 mg/5ml im soln
4
4
4
MO
MO
1
MO
3
4
2
2
5
4
MO
HYDREA
5
5
PA
PA(*)
5
5
4
2
2
2
5
5
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
5
2
2
5
2
5
5
VIDAZA
DACOGEN
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
5
5
2
TAXOTERE
PA(*)
PA(*)
PA(*)
5
DOXIL
PA(*)
5
2
5
PA(*)
PA(*)
PA(*)
Page 30 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
EFUDEX
GEMZAR
Requirements/Limits
fluorouracil 2.5 gm/50ml iv soln
2
PA(*)
gemcitabine hcl 1 gm iv soln
5
PA(*)
HERCEPTIN 440 mg iv soln
5
PA(*)
idarubicin hcl 10 mg/10ml iv soln
5
PA(*)
IFEX 1 gm iv soln
4
PA(*)
ifosfamide 1 gm iv soln
2
IFEX
PA(*)
irinotecan hcl 100 mg/5ml iv soln
2
CAMPTOSAR
PA(*)
KADCYLA 100 mg iv soln
5
PA(*)
mesna 100 mg/ml iv soln
2
MESNEX
PA(*)
MESNEX 400 mg tab
5
mitomycin 20 mg iv soln
2
PA(*)
oxaliplatin 100 mg/20ml iv soln
5
ELOXATIN
PA(*)
paclitaxel 300 mg/50ml iv conc
2
PA(*)
PERJETA 420 mg/14ml iv soln
5
PA(*)
PROLEUKIN 22000000 unit iv soln
5
PA(*)
SYNRIBO 3.5 mg sc soln
5
PA(*)
TREANDA 100 mg iv soln
5
PA(*)
TRISENOX 10 mg/10ml iv soln
5
PA(*)
VELCADE 3.5 mg inj soln
5
PA(*)
VIDAZA 100 mg inj susp
5
PA(*)
vinblastine sulfate 1 mg/ml iv soln
2
PA(*)
VINCASAR PFS 1 mg/ml iv soln
2
PA(*)
vincristine sulfate 1 mg/ml iv soln
2
VINCASAR
PA(*)
vinorelbine tartrate 50 mg/5ml iv
soln
2
PA(*)
YERVOY 50 mg/10ml iv soln
5
PA(*)
ZALTRAP 100 mg/4ml iv soln
5
PA(*)
Antineoplastics, Other [Antineoplásicos, Otros]
fludarabine phosphate 50 mg iv
soln
2
PA(*)
leucovorin calcium 10 mg tab, 15
2
leucovorin calcium 100 mg inj soln,
350 mg inj soln
2
PA(*)
levoleucovorin calcium 175
mg/17.5ml iv soln
2
PA(*)
mitoxantrone hcl 25 mg/12.5ml iv
conc
2
PA(*)
ZOLINZA 100 mg cap
5
PA
Aromatase Inhibitors, 3rd Generation [Inhibidores De La Aromatasa, 3era Generación]
anastrozole 1 mg tab
2
ARIMIDEX
MO
exemestane 25 mg tab
2
AROMASIN
MO
letrozole 2.5 mg tab
2
FEMARA
MO
Page 31 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
Enzyme Inhibitors [Inhibidores De Enzimas]
etoposide 500 mg/25ml iv soln
2
PA(*)
HYCAMTIN 4 mg iv soln
4
PA(*)
TOPOSAR 1 gm/50ml iv soln
2
PA(*)
topotecan hcl 4 mg iv soln
5
HYCAMTIN
PA(*)
Molecular Target Inhibitors [Inhibidores Moleculares]
AFINITOR 10 mg tab, 7.5 mg tab
5
PA, QL(60 / 30)
AFINITOR 5 mg tab
5
PA, QL(120 / 30)
AFINITOR 2.5 mg tab
5
PA, QL(240 / 30)
AFINITOR DISPERZ 5 mg tab sol
5
PA, QL(120 / 30)
5
PA, QL(180 / 30)
5
PA, QL(300 / 30)
ALECENSA 150 mg cap
5
PA
BELEODAQ 500 mg iv soln
5
PA(*)
BOSULIF 100 mg tab, 500 mg tab
5
PA
CABOMETYX 60 mg tab, 20 mg
tab, 40 mg tab
5
PA
CAPRELSA 100 mg tab, 300 mg
tab
5
PA, LA
COMETRIQ (100 MG DAILY
DOSE) 1 X 80 & 1 X 20 mg oral kit
5
PA
COMETRIQ (140 MG DAILY
DOSE) 1 X 80 & 3 X 20 mg oral kit
5
PA
COMETRIQ (60 MG DAILY DOSE)
20 mg oral kit
5
PA
COTELLIC 20 mg tab
5
PA
DARZALEX 100 mg/5ml iv soln
5
PA(*)
ERIVEDGE 150 mg cap
5
PA, LA
FARYDAK 10 mg cap, 15 mg cap,
20 mg cap
5
PA
GILOTRIF 20 mg tab, 30 mg tab,
40 mg tab
5
PA
GLEEVEC 100 mg tab, 400 mg tab
5
PA
IBRANCE 100 mg cap, 125 mg
cap, 75 mg cap
4
PA
ICLUSIG 15 mg tab, 45 mg tab
5
PA
IMBRUVICA 140 mg cap
5
PA
INLYTA 1 mg tab
3
PA, LA
INLYTA 5 mg tab
5
PA, LA
IRESSA 250 mg tab
5
PA, LA
JAKAFI 10 mg tab, 15 mg tab, 20
5
PA, LA
KEYTRUDA 50 mg iv soln
3
PA(*)
KEYTRUDA 100 mg/4ml iv soln
5
PA(*)
Page 32 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
LENVIMA 8 MG DAILY DOSE 4 (2)
mg cap pack
5
LENVIMA 10 MG DAILY DOSE 10
mg cap pack
5
& 4 mg cap pack
5
& 4 (2) mg cap pack
5
(2) mg cap pack
5
(2) & 4 mg cap pack
5
LONSURF 15-6.14 mg tab, 20-8.19
mg tab
5
LYNPARZA 50 mg cap
5
MEKINIST 0.5 mg tab, 2 mg tab
5
NEXAVAR 200 mg tab
5
NINLARO 2.3 mg cap, 3 mg cap, 4
mg cap
5
ODOMZO 200 mg cap
5
SPRYCEL 100 mg tab, 140 mg tab,
80 mg tab
5
STIVARGA 40 mg tab
5
SUTENT 12.5 mg cap, 25 mg cap,
37.5 mg cap, 50 mg cap
5
TAFINLAR 50 mg cap, 75 mg cap
5
TAGRISSO 40 mg tab, 80 mg tab
5
TARCEVA 100 mg tab, 150 mg tab,
25 mg tab
5
TASIGNA 150 mg cap, 200 mg cap
5
TYKERB 250 mg tab
5
vandetanib 100 mg tab, 300 mg tab
5
CAPRELSA
VENCLEXTA 10 mg tab, 50 mg tab
4
VENCLEXTA 100 mg tab
5
VENCLEXTA STARTING PACK 10
& 50 & 100 mg tab pack
5
VOTRIENT 200 mg tab
5
XALKORI 200 mg cap, 250 mg cap
5
ZELBORAF 240 mg tab
5
ZYDELIG 100 mg tab, 150 mg tab
5
ZYKADIA 150 mg cap
5
Monoclonal Antibodies [Anticuerpos Monoclonales]
Requirements/Limits
PA, LA
PA, LA
PA, LA
PA, LA
PA, LA
PA, LA
PA
PA, LA
PA
PA, LA
PA
PA
PA
PA
PA
PA
PA, LA
PA
PA
PA, LA
PA, LA
PA
PA
PA
PA
PA, LA
PA, LA
PA, LA
LA
Page 33 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
EMPLICITI 300 mg iv soln, 400 mg
iv soln
5
OPDIVO 40 mg/4ml iv soln
5
RITUXAN 10 mg/ml iv conc
5
TECENTRIQ 1200 mg/20ml iv soln
5
Retinoids [Retinoides]
bexarotene 75 mg cap
5
TARGRETIN
PANRETIN 0.1 % gel
5
TARGRETIN 1 % gel
5
tretinoin 10 mg cap
5
ANTIPARASITICS [ANTIPARASITARIOS]
Antihelminthics [Antihelmínticos]
ALBENZA 200 mg tab
4
BILTRICIDE 600 mg tab
4
ivermectin 3 mg tab
1
STROMECTOL
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
chloroquine phosphate 250 mg tab,
500 mg tab
2
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
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 % shampoo
2
malathion 0.5 % lot
2
OVIDE
permethrin 5 % crm
2
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1
mg tab, 2 mg tab
1
COGENTIN
Requirements/Limits
PA
PA(*)
PA(*)
PA(*)
MO
MO
MO
PA(*)
PA(*), HI
PA, MO, HR
Page 34 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
benztropine mesylate 1 mg/ml inj
soln
2
COGENTIN
PA(*), HI
trihexyphenidyl hcl 2 mg tab, 5 mg
tab
1
MO, HR
trihexyphenidyl hcl 0.4 mg/ml oral
elix
2
MO, HR
Antiparkinson Agents, Other [Agentes Antiparkinson, Otros]
amantadine hcl 100 mg cap, 100
mg tab, 50 mg/5ml syr
2
MO
entacapone 200 mg tab
2
COMTAN
MO
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
MO
NEUPRO 1 mg/24hr td patch 24hr,
2 mg/24hr td patch 24hr, 3 mg/24hr
td patch 24hr, 4 mg/24hr td patch
24hr, 6 mg/24hr td patch 24hr, 8
mg/24hr td 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
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
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors [Precursores De Dopamina/
Inhibidores De La Decarboxylasa L-Amino Ácido]
carbidopa 25 mg tab
2
LODOSYN
MO
carbidopa-levodopa 10-100 mg tab,
25-100 mg tab
1
SINEMET
MO
carbidopa-levodopa 10-100 mg odt,
25-100 mg odt, 25-250 mg odt, 25250 mg tab
2
SINEMET
MO
carbidopa-levodopa er 25-100 mg
tab er, 50-200 mg tab er
2
SINEMET
MO
carbidopa-levodopa-entacapone
12.5-50-200 mg tab, 18.75-75-200
mg tab, 25-100-200 mg tab, 31.25125-200 mg tab, 37.5-150-200 mg
tab, 50-200-200 mg tab
2
STALEVO
MO
Monoamine Oxidase B (MAO-B) Inhibitors [Inhibidores De La Monoaminoxidasa B (MAOB)]
AZILECT 0.5 mg tab, 1 mg tab
3
MO
selegiline hcl 5 mg cap, 5 mg tab
2
ELDEPRYL
MO
Page 35 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
ANTIPSYCHOTICS [ANTIPSICÓTICOS]
1st Generation/Typical [1ra Generación/Típicos]
fluphenazine decanoate 25 mg/ml
inj soln
2
fluphenazine hcl 1 mg tab, 10 mg
tab, 2.5 mg tab, 5 mg tab
1
fluphenazine hcl 2.5 mg/5ml oral
elix, 5 mg/ml oral conc
2
fluphenazine hcl 2.5 mg/ml inj soln
2
haloperidol 0.5 mg tab, 1 mg tab,
10 mg tab, 2 mg tab, 20 mg tab, 5
mg tab
1
haloperidol decanoate 100 mg/ml
im soln, 50 mg/ml im soln
2
haloperidol lactate 5 mg/ml inj soln
2
haloperidol lactate 2 mg/ml oral
conc
2
loxapine succinate 5 mg cap
1
loxapine succinate 10 mg cap, 25
mg cap, 50 mg cap
2
molindone hcl 10 mg tab, 25 mg
tab, 5 mg tab
2
pimozide 1 mg tab, 2 mg tab
2
thioridazine hcl 10 mg tab, 100 mg
2
thiothixene 1 mg cap, 2 mg cap, 5
mg cap
1
thiothixene 10 mg cap
2
trifluoperazine hcl 1 mg tab, 10 mg
2
2nd Generation/Atypical [2da 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
FANAPT TITRATION PACK 1 & 2
& 4 & 6 mg tab
4
GEODON 20 mg im soln
4
INVEGA SUSTENNA 39 mg/0.25ml
im susp
4
im susp
4
INVEGA SUSTENNA 117
mg/0.75ml im susp
5
Requirements/Limits
PA(*)
MO
MO
PA(*)
MO
HALDOL
HALDOL
PA(*)
HALDOL
MO
MO
MO
ORAP
MO
MO
PA, MO, HR
MO
MO
MO
ST
QL(8 / 30), ST
PA(*)
QL(0.25 / 28), ST
QL(0.5 / 28), ST
QL(0.75 / 28), ST
Page 36 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
INVEGA SUSTENNA 156 mg/ml im
susp
5
QL(1 / 28), ST
im susp
5
QL(1.5 / 28), ST
LATUDA 120 mg tab, 20 mg tab, 40
4
ST, MO
NUPLAZID 17 mg tab
5
PA, MO
olanzapine 10 mg tab, 15 mg tab,
2.5 mg tab, 20 mg tab, 5 mg tab,
7.5 mg tab
1
ZYPREXA
MO
olanzapine 10 mg odt, 15 mg odt,
20 mg odt, 5 mg odt
2
ZYPREXA
MO
olanzapine 10 mg im soln
2
ZYPREXA
PA(*)
paliperidone er 1.5 mg tab er 24 hr,
2
INVEGA
ST, MO
RISPERDAL CONSTA 25 mg im
susp
4
QL(4 / 28)
RISPERDAL CONSTA 12.5 mg im
susp
4
QL(8 / 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 mg tab, 2 mg tab, 3 mg tab, 4
mg tab
1
RISPERDAL
MO
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
RISPERDAL
MO
SAPHRIS 10 mg tab subl, 2.5 mg
tab subl, 5 mg tab subl
4
ST, MO
VRAYLAR 1.5 mg cap, 3 mg cap,
5
ST, MO
VRAYLAR 1.5 & 3 mg cap pack
4
ST
ziprasidone hcl 20 mg cap, 40 mg
2
GEODON
MO
ZYPREXA RELPREVV 210 mg im
susp
5
Treatment-Resistant [Resistentes A Tratamiento]
clozapine 100 mg odt, 100 mg tab,
12.5 mg odt, 150 mg odt, 200 mg
odt, 200 mg tab, 25 mg odt, 25 mg
tab, 50 mg tab
2
CLOZARIL
FAZACLO 100 mg odt, 12.5 mg
odt, 150 mg odt, 200 mg odt, 25 mg
odt
4
Page 37 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
VERSACLOZ 50 mg/ml susp
4
ANTISPASTICITY AGENTS [AGENTES ANTIESPASTICIDAD]
Antispasticity Agents [Agentes Antiespasticidad]
baclofen 10 mg tab, 20 mg tab
2
dantrolene sodium 100 mg cap, 25
mg cap, 50 mg cap
2
DANTRIUM
tizanidine hcl 2 mg tab, 4 mg tab
1
ZANAFLEX
ANTIVIRALS [ANTIVIRALES]
Anti-Cytomegalovirus (CMV) Agents [Agentes Anti-Citomegalovirus (CMV)]
ganciclovir sodium 500 mg iv soln
2
CYTOVENE
VALCYTE 450 mg tab, 50 mg/ml
soln
5
valganciclovir hcl 450 mg tab
5
VALCYTE
valganciclovir hcl 50 mg/ml soln
5
VALCYTE
ZIRGAN 0.15 % ophth gel
4
Anti-Hepatitis B (HBV) Agents [Agentes Contra La Hepatitis B (HBV)]
adefovir dipivoxil 10 mg tab
5
HEPSERA
BARACLUDE 0.05 mg/ml soln
4
BARACLUDE 0.5 mg tab, 1 mg tab
5
entecavir 0.5 mg tab, 1 mg tab
5
BARACLUDE
EPIVIR HBV 100 mg tab, 5 mg/ml
soln
4
HEPSERA 10 mg tab
5
INTRON A 10000000 unit inj soln,
18000000 unit inj soln, 50000000
unit inj soln, 6000000 unit/ml inj
soln
5
lamivudine 100 mg tab
2
EPIVIR
PEGASYS 180 mcg/0.5ml sc soln,
180 mcg/ml sc soln
5
PEGASYS PROCLICK 135
mcg/0.5ml sc soln, 180 mcg/0.5ml
sc soln
5
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
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
ribavirin 200 mg cap, 200 mg tab
2
REBETOL
SYLATRON 200 mcg sc kit, 300
mcg sc kit, 600 mcg sc kit
5
TYZEKA 600 mg tab
4
MO
MO
PA(*), HI
MO
MO
MO
PA, MO
PA, MO
PA, MO
PA, MO
MO
PA, MO
PA(*), MO
MO
PA
PA
PA
PA
PA
PA, MO
PA, MO
Page 38 of 95
Updated 11/2016
Reference Name
Requirements/Limits
[Nombre de
Referencia]
Anti-Hepatitis C (HCV) Agents [Agentes Contra La Hepatitis C (HCV)]
EPCLUSA 400-100 mg tab
5
PA
HARVONI 90-400 mg tab
5
PA
SOVALDI 400 mg tab
5
PA
VIRAZOLE 6 gm inh soln
5
PA(*)
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400 mg tab,
800 mg tab
1
ZOVIRAX
acyclovir 200 mg/5ml susp, 5 % oint
2
ZOVIRAX
acyclovir sodium 50 mg iv soln
2
PA(*), HI
DENAVIR 1 % crm
4
ST
famciclovir 125 mg tab, 250 mg tab,
500 mg tab
2
FAMVIR
trifluridine 1 % ophth soln
2
VIROPTIC
valacyclovir hcl 1 gm tab, 500 mg
tab
2
VALTREX
Anti-HIV Agents, Integrase Inhibitors (INSTI) [Agentes Anti-VIH, Inhibidores De La Integrasa
(INSTI)]
ISENTRESS 100 mg tab chew, 25
mg tab chew
3
MO
ISENTRESS 100 mg pckt
4
MO
ISENTRESS 400 mg tab
5
MO
PREZCOBIX 800-150 mg tab
5
MO
STRIBILD 150-150-200-300 mg tab
5
MO
TIVICAY 10 mg tab
4
MO
TIVICAY 25 mg tab, 50 mg tab
5
MO
VITEKTA 150 mg tab, 85 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
nevirapine er 100 mg tab er 24 hr,
400 mg tab er 24 hr
2
VIRAMUNE
MO
ODEFSEY 200-25-25 mg tab
5
MO
RESCRIPTOR 100 mg tab, 200 mg
tab
4
MO
SUSTIVA 200 mg cap, 50 mg cap
3
MO
SUSTIVA 600 mg tab
4
MO
Page 39 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
VIRAMUNE 200 mg tab
4
MO
VIRAMUNE XR 100 mg tab er 24
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
2
ZIAGEN
MO
abacavir-lamivudine-zidovudine
300-150-300 mg tab
5
TRIZIVIR
MO
COMBIVIR 150-300 mg tab
5
MO
DESCOVY 200-25 mg tab
5
MO
didanosine 125 mg cap dr, 200 mg
cap dr, 250 mg cap dr, 400 mg cap
dr
2
VIDEX
MO
EMTRIVA 10 mg/ml soln, 200 mg
cap
4
MO
EPIVIR 10 mg/ml soln
4
MO
EPZICOM 600-300 mg tab
5
MO
lamivudine 10 mg/ml soln, 150 mg
tab, 300 mg tab
2
EPIVIR HBV
MO
lamivudine-zidovudine 150-300 mg
tab
5
COMBIVIR
MO
RETROVIR 10 mg/ml iv soln
3
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
TRIZIVIR 300-150-300 mg tab
5
MO
TRUVADA 200-300 mg tab, 100150 mg tab, 133-200 mg tab, 167250 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
Anti-HIV Agents, Other [Agentes Anti-VIH, Otros]
EVOTAZ 300-150 mg tab
5
MO
FUZEON 90 mg sc soln
5
MO
GENVOYA 150-150-200-10 mg tab
5
MO
SELZENTRY 300 mg tab
3
MO
Page 40 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
SELZENTRY 150 mg tab
5
MO
TYBOST 150 mg tab
4
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 50 mg/ml susp
4
MO
LEXIVA 700 mg tab
5
MO
NORVIR 100 mg cap, 100 mg tab,
80 mg/ml soln
4
MO
PREZISTA 150 mg tab, 75 mg tab
4
MO
PREZISTA 100 mg/ml susp, 600
mg tab, 800 mg tab
5
MO
REYATAZ 150 mg cap, 200 mg
cap, 300 mg cap, 50 mg pckt
5
MO
TRIUMEQ 600-50-300 mg tab
5
MO
VIRACEPT 250 mg tab, 625 mg tab
5
MO
Anti-Influenza Agents [Agentes Antiinfluenza]
RELENZA DISKHALER 5
mg/blister inh aer pwdr
3
rimantadine hcl 100 mg tab
2
FLUMADINE
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
hydroxyzine hcl 25 mg/ml im soln,
50 mg/ml im soln
2
PA(*), HR
Benzodiazepines [Benzodiazepinas]
alprazolam 0.25 mg tab, 0.5 mg
tab, 1 mg tab
2
XANAX
QL(120 / 30)
alprazolam 2 mg tab
2
XANAX
QL(150 / 30)
clorazepate dipotassium 15 mg tab,
3.75 mg tab, 7.5 mg tab
1
TRANXENE
QL(180 / 30)
estazolam 1 mg tab, 2 mg tab
2
QL(30 / 30)
BIPOLAR AGENTS [AGENTES PARA BIPOLARIDAD]
Mood Stabilizers [Estabilizadores Del Ánimo]
lithium 8 meq/5ml soln
2
MO
Page 41 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
lithium carbonate 150 mg cap, 300
mg cap, 300 mg tab, 600 mg cap
1
MO
lithium carbonate er 300 mg tab er,
450 mg tab er
1
LITHOBID
MO
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
BYDUREON 2 mg sc susp er, 2 mg
sc pen-inj
3
ST, MO
BYETTA 10 MCG PEN 10
mcg/0.04ml sc soln pen-inj
4
QL(2.4 / 30), ST, MO
BYETTA 5 MCG PEN 5 mcg/0.02ml
sc soln pen-inj
4
QL(1.2 / 30), ST, MO
CYCLOSET 0.8 mg tab
4
MO
glimepiride 1 mg tab, 2 mg tab, 4
mg tab
1
AMARYL
MO
glipizide 10 mg tab, 5 mg tab
1
GLUCOTROL
MO
glipizide er 2.5 mg tab er 24 hr, 5
mg tab er 24 hr
1
GLUCOTROL
MO
glipizide er 10 mg tab er 24 hr
2
GLUCOTROL
MO
INVOKANA 100 mg tab, 300 mg
tab
3
MO
JANUVIA 100 mg tab, 25 mg tab,
50 mg tab
3
MO
metformin hcl 1000 mg tab, 500 mg
tab, 850 mg tab
1
GLUCOPHAGE
MO
metformin hcl er 500 mg tab er 24
1
GLUCOPHAGE
MO
metformin hcl er (osm) 1000 mg tab
er 24 hr
2
FORTAMET
MO
nateglinide 120 mg tab, 60 mg tab
2
STARLIX
MO
ONGLYZA 2.5 mg tab, 5 mg tab
3
MO
pioglitazone hcl 15 mg tab, 30 mg
tab, 45 mg tab
2
ACTOS
MO
repaglinide 0.5 mg tab, 1 mg tab, 2
mg tab
2
PRANDIN
MO
RIOMET 500 mg/5ml soln
4
MO
SYMLINPEN 120 2700 mcg/2.7ml
sc soln pen-inj
4
QL(10.8 / 30), ST, MO
SYMLINPEN 60 1500 mcg/1.5ml sc
soln pen-inj
4
QL(9 / 25), ST, MO
TANZEUM 30 mg sc pen-inj, 50 mg
sc pen-inj
3
ST, MO
Page 42 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
TRADJENTA 5 mg tab
3
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
MO
INVOKAMET 150-1000 mg tab,
150-500 mg tab, 50-1000 mg tab,
50-500 mg tab
3
MO
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, 50500 mg tab er 24 hr
3
MO
JENTADUETO 2.5-1000 mg tab,
2.5-500 mg tab, 2.5-850 mg tab
3
MO
JENTADUETO XR 2.5-1000 mg tab
er 24 hr, 5-1000 mg tab er 24 hr
3
MO
KOMBIGLYZE XR 2.5-1000 mg tab
er 24 hr, 5-1000 mg tab er 24 hr, 5500 mg tab er 24 hr
3
MO
pioglitazone hcl-glimepiride 30-2
mg tab, 30-4 mg tab
2
DUETACT
MO
pioglitazone hcl-metformin hcl 15500 mg tab, 15-850 mg tab
2
ACTOPLUS MET
MO
Glycemic Agents [Agentes Glicémicos]
GLUCAGEN HYPOKIT 1 mg inj
soln
3
GLUCAGON EMERGENCY 1 mg
inj kit
3
KORLYM 300 mg tab
5
PA, MO
PROGLYCEM 50 mg/ml susp
4
MO
Insulins [Insulinas]
gauze pads 2” x 2”
3
HUMALOG 100 unit/ml sc soln, 100
unit/ml sc soln cartridge
3
MO
HUMALOG KWIKPEN 100 unit/ml
sc soln pen-inj, 200 unit/ml sc soln
pen-inj
3
MO
HUMALOG MIX 50/50 (50-50) 100
unit/ml sc susp
3
MO
HUMALOG MIX 50/50 KWIKPEN
(50-50) 100 unit/ml sc susp pen-inj
3
MO
Page 43 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
HUMALOG MIX 75/25 (75-25) 100
unit/ml sc susp
3
MO
HUMALOG MIX 75/25 KWIKPEN
(75-25) 100 unit/ml sc susp pen-inj
3
MO
HUMULIN 70/30 (70-30) 100
unit/ml sc susp
3
MO
HUMULIN 70/30 KWIKPEN (70-30)
100 unit/ml sc susp pen-inj
3
MO
HUMULIN N 100 unit/ml sc susp
3
MO
HUMULIN N KWIKPEN 100 unit/ml
sc susp pen-inj
3
MO
HUMULIN R 100 unit/ml inj soln
3
MO
HUMULIN R U-500
(CONCENTRATED) 500 unit/ml sc
soln
3
MO
insulin pen needles
3
insulin syringe 29g x ½” 0.3 ml, 29g
x ½” 1 ml, 29g x ½” 0.5 ml
miscellaneous
3
LANTUS 100 unit/ml sc soln
3
MO
LANTUS SOLOSTAR 100 unit/ml
sc soln pen-inj
3
MO
LEVEMIR 100 unit/ml sc soln
3
MO
LEVEMIR FLEXTOUCH 100 unit/ml
sc soln pen-inj
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)
soln
2
LOVENOX
QL(12 / 30)
soln
2
LOVENOX
QL(18 / 30)
enoxaparin sodium 120 mg/0.8ml
sc soln, 80 mg/0.8ml sc soln
2
LOVENOX
QL(24 / 30)
enoxaparin sodium 100 mg/ml sc
soln, 150 mg/ml sc soln
2
LOVENOX
QL(30 / 30)
Page 44 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
enoxaparin sodium 300 mg/3ml inj
soln
2
LOVENOX
fondaparinux sodium 5 mg/0.4ml sc
soln
2
ARIXTRA
fondaparinux sodium 2.5 mg/0.5ml
sc soln
2
ARIXTRA
fondaparinux sodium 7.5 mg/0.6ml
sc soln
2
ARIXTRA
fondaparinux sodium 10 mg/0.8ml
sc soln
2
ARIXTRA
heparin sodium (porcine) 1000
unit/ml inj soln, 10000 unit/ml inj
soln, 20000 unit/ml inj soln, 5000
unit/ml inj soln
2
PRADAXA 110 mg cap, 150 mg
cap, 75 mg cap
3
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
COUMADIN
XARELTO 10 mg tab, 15 mg tab,
20 mg tab
3
XARELTO STARTER PACK 15 &
20 mg tab pack
3
Blood Formation Modifiers [Modificadores De La Formación De La Sangre]
anagrelide hcl 0.5 mg cap, 1 mg
cap
1
AGRYLIN
ARANESP (ALBUMIN FREE) 10
mcg/0.4ml inj soln, 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
ARANESP (ALBUMIN FREE) 100
mcg/ml inj soln, 500 mcg/ml inj soln
5
LEUKINE 250 mcg iv soln
5
MOZOBIL 24 mg/1.2ml sc soln
5
NEULASTA 6 mg/0.6ml sc soln
5
NEUPOGEN 300 mcg/0.5ml inj
soln, 300 mcg/ml inj soln, 480
5
QL(90 / 30)
QL(12 / 30)
QL(15 / 30)
QL(18 / 30)
QL(24 / 30)
PA(*), HI
PA, MO
MO
PA, MO
PA
MO
PA
PA
PA, HI
PA(*)
PA
PA
Page 45 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
mcg/0.8ml inj soln, 480 mcg/1.6ml
inj soln
PROCRIT 10000 unit/ml inj soln,
2000 unit/ml inj soln, 3000 unit/ml
inj soln, 4000 unit/ml inj soln
3
PROCRIT 20000 unit/ml inj soln,
40000 unit/ml inj soln
5
PROMACTA 12.5 mg tab, 25 mg
tab, 50 mg tab
5
Blood Products/Modifiers/Volume Expanders [Productos Para La
Sangre/Modificadores/Expansores De Volumen]
ERWINAZE 10000 unit im soln
5
ONCASPAR 750 unit/ml inj soln
5
Coagulants [Coagulantes]
tranexamic acid 650 mg tab
2
CYKLOKAPRON
tranexamic acid 1000/10mg/ml iv
soln
2
LYSTEDA
Platelet Modifying Agents [Modificadores de Plaquetas]
aspirin-dipyridamole er 25-200 mg
cap er 12 hr
2
AGGRENOX
BRILINTA 60 mg tab, 90 mg tab
3
cilostazol 100 mg tab, 50 mg tab
1
PLETAL
clopidogrel bisulfate 75 mg tab
1
PLAVIX
EFFIENT 10 mg tab, 5 mg tab
3
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
clonidine hcl 0.1 mg/24hr tdwk
patch, 0.2 mg/24hr tdwk patch, 0.3
mg/24hr tdwk patch
2
CATAPRES-TTS-2
clonidine hcl er 0.1 mg tab er 12 hr
2
KAPVAY
guanfacine hcl 1 mg tab, 2 mg tab
2
TENEX
methyldopa 250 mg tab, 500 mg
tab
1
midodrine hcl 10 mg tab, 2.5 mg
tab, 5 mg tab
2
NORTHERA 100 mg cap, 200 mg
cap, 300 mg cap
5
Alpha-adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
doxazosin mesylate 1 mg tab, 2 mg
1
CARDURA
prazosin hcl 1 mg cap, 2 mg cap, 5
mg cap
1
MINIPRESS
Requirements/Limits
PA
PA
PA, LA, MO
PA(*)
PA(*)
PA(*), HI
MO
PA, MO
MO
MO
PA, MO
MO
MO
MO
PA, MO, HR
MO, HR
PA
MO
MO
Page 46 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
terazosin hcl 1 mg cap, 10 mg cap,
2 mg cap, 5 mg cap
1
MO
Angiotensin II Receptor Antagonists [Antagonistas Del Receptor De Angiotensina II]
BENICAR 20 mg tab, 40 mg tab, 5
mg tab
3
MO
candesartan cilexetil 16 mg tab, 32
2
ATACAND
MO
irbesartan 150 mg tab, 300 mg tab,
75 mg tab
1
AVAPRO
MO
losartan potassium 100 mg tab, 25
mg tab, 50 mg tab
1
COZAAR
MO
valsartan 160 mg tab, 320 mg tab,
2
DIOVAN
MO
Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores De La Enzima Convertidora
De Angiotensina (ECA)]
benazepril hcl 10 mg tab, 20 mg
1
LOTENSIN
MO
enalapril maleate 10 mg tab, 2.5 mg
1
VASOTEC
MO
fosinopril sodium 10 mg tab, 20 mg
tab, 40 mg tab
1
MO
lisinopril 10 mg tab, 2.5 mg tab, 20
mg tab, 30 mg tab, 40 mg tab, 5 mg
tab
1
ZESTRIL
MO
moexipril hcl 15 mg tab, 7.5 mg tab
1
MO
perindopril erbumine 2 mg tab, 4
mg tab, 8 mg tab
2
MO
quinapril hcl 10 mg tab, 20 mg tab,
40 mg tab, 5 mg tab
1
ACCUPRIL
MO
ramipril 1.25 mg cap, 10 mg cap,
1
ALTACE
MO
trandolapril 1 mg tab, 2 mg tab, 4
mg tab
1
MAVIK
MO
Antiarrhythmics [Antiarrítmicos]
amiodarone hcl 100 mg tab, 200
mg tab, 400 mg tab
2
PACERONE
MO
amiodarone hcl 150 mg/3ml iv soln
2
PACERONE
PA(*), HI
disopyramide phosphate 100 mg
cap, 150 mg cap
2
NORPACE
MO, HR
disopyramide phosphate er 150 mg
cap er 12 hr
2
NORPACE
MO, HR
dofetilide 500 mcg cap, 250 mcg
cap, 125 mcg cap
2
TIKOSYN
MO
Page 47 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
flecainide acetate 100 mg tab, 150
mg tab, 50 mg tab
2
mexiletine hcl 150 mg cap, 200 mg
cap, 250 mg cap
2
MULTAQ 400 mg tab
4
NORPACE CR 100 mg cap er 12
4
PACERONE 100 mg tab, 200 mg
tab
4
propafenone hcl 150 mg tab, 225
mg tab, 300 mg tab
2
RYTHMOL
propafenone hcl er 225 mg cap er
12 hr, 325 mg cap er 12 hr, 425 mg
cap er 12 hr
2
RYTHMOL
quinidine gluconate er 324 mg tab
er
2
quinidine sulfate 200 mg tab, 300
mg tab
2
sotalol hcl 160 mg tab, 240 mg tab,
80 mg tab
2
SORINE
sotalol hcl (af) 120 mg tab
2
BETAPACE
TIKOSYN 125 mcg cap, 250 mcg
cap, 500 mcg cap
4
Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]
acebutolol hcl 200 mg cap, 400 mg
cap
1
SECTRAL
atenolol 100 mg tab, 25 mg tab, 50
mg tab
1
TENORMIN
betaxolol hcl 10 mg tab, 20 mg tab
1
bisoprolol fumarate 10 mg tab, 5
mg tab
2
ZEBETA
carvedilol 12.5 mg tab, 25 mg tab,
3.125 mg tab, 6.25 mg tab
1
COREG
labetalol hcl 100 mg tab, 200 mg
tab, 300 mg tab
2
metoprolol succinate er 100 mg tab
er 24 hr, 200 mg tab er 24 hr, 25
2
TOPROL
metoprolol tartrate 100 mg tab, 25
mg tab, 50 mg tab
1
LOPRESSOR
metoprolol tartrate 1 mg/ml iv soln
ampule
2
LOPRESSOR
metoprolol tartrate 1 mg/ml iv soln
cartridge
2
LOPRESSOR
Requirements/Limits
MO
MO
MO
MO, HR
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA(*), HI
PA(*)
Page 48 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
nadolol 20 mg tab, 40 mg tab, 80
mg tab
2
CORGARD
MO
pindolol 10 mg tab, 5 mg tab
2
MO
propranolol hcl 10 mg tab, 20 mg
tab
1
MO
propranolol hcl 20 mg/5ml soln, 40
mg/5ml soln
2
MO
propranolol hcl 1 mg/ml iv soln
2
PA(*), HI
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
MO
Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]
AFEDITAB CR 30 mg tab er 24 hr,
60 mg tab er 24 hr
2
MO
amlodipine besylate 10 mg tab, 2.5
mg tab, 5 mg tab
1
NORVASC
MO
CARTIA XT 120 mg cap er 24 hr,
2
MO
diltiazem hcl 120 mg tab, 30 mg
1
CARDIZEM
MO
diltiazem hcl 50 mg/10ml iv soln
2
CARDIZEM
PA(*), HI
diltiazem hcl er 120 mg cap er 12
er 12 hr
2
MO
diltiazem hcl er beads 180 mg cap
er 24 hr, 360 mg cap er 24 hr, 420
mg cap er 24 hr
2
TIAZAC
MO
diltiazem hcl er coated beads 120
2
CARDIZEM
MO
diltiazem hcl er coated beads 180
mg tab er 24 hr, 240 mg tab er 24
er 24 hr, 420 mg tab er 24 hr
2
MATZIM LA
MO
dilt-xr 120 mg cap er 24 hr,180 mg
cap er 24 hr, 240 mg cap er 24 hr
2
DILT
MO
felodipine er 10 mg tab er 24 hr, 2.5
2
MO
isradipine 2.5 mg cap, 5 mg cap
2
MO
MATZIM LA 180 mg tab er 24 hr,
24 hr, 360 mg tab er 24 hr, 420 mg
tab er 24 hr
2
MO
Page 49 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
nicardipine hcl 20 mg cap, 30 mg
cap
2
MO
NIFEDICAL XL 30 mg tab er 24 hr,
60 mg tab er 24 hr
2
MO
nifedipine er osmotic 30 mg tab er
24 hr, 60 mg tab er 24 hr, 90 mg
tab er 24 hr
2
PROCARDIA
MO
nimodipine 30 mg cap
2
MO
TAZTIA XT 120 mg cap er 24 hr,
24 hr, 300 mg cap er 24 hr, 360 mg
cap er 24 hr
2
MO
verapamil hcl 120 mg tab, 40 mg
tab, 80 mg tab
1
CALAN
MO
verapamil hcl 2.5 mg/ml iv soln
2
CALAN
PA(*), HI
verapamil hcl er 120 mg tab er, 180
mg tab er, 240 mg tab er
1
CALAN
MO
verapamil hcl er 100 mg cap er 24
hr, 120 mg cap er 24 hr, 180 mg
cap er 24 hr, 200 mg cap er 24 hr,
2
CALAN
MO
Cardiovascular Agents (Combination Product) [Agentes Cardiovasculares (Productos En
Combinación)]
ALDACTAZIDE 25-25 mg tab, 5050 mg tab
4
ST, MO
amiloride-hydrochlorothiazide 5-50
mg tab
2
MO
amlodipine besy-benazepril hcl 1020 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
amlodipine-atorvastatin 10-10 mg
tab, 10-20 mg tab, 10-40 mg tab,
10-80 mg tab, 2.5-10 mg tab, 2.520 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
atenolol-chlorthalidone 100-25 mg
tab, 50-25 mg tab
1
TENORETIC
MO
benazepril-hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25
mg tab, 5-6.25 mg tab
1
MO
BENICAR HCT 20-12.5 mg tab, 4012.5 mg tab, 40-25 mg tab
3
MO
Page 50 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
bisoprolol-hydrochlorothiazide 106.25 mg tab, 2.5-6.25 mg tab, 56.25 mg tab
1
ZIAC
MO
candesartan cilexetil-hctz 16-12.5
mg tab, 32-12.5 mg tab, 32-25 mg
tab
2
ATACAND HCT
MO
enalapril-hydrochlorothiazide 10-25
1
VASERETIC
MO
fosinopril sodium-hctz 10-12.5 mg
tab, 20-12.5 mg tab
2
MO
irbesartan-hydrochlorothiazide 15012.5 mg tab, 300-12.5 mg tab
1
AVALIDE
MO
lisinopril-hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25
mg tab
1
ZESTORETIC
MO
losartan potassium-hctz 100-12.5
mg tab, 100-25 mg tab, 50-12.5 mg
tab
1
HYZAAR
MO
metoprolol-hydrochlorothiazide 10025 mg tab, 100-50 mg tab, 50-25
mg tab
2
LOPRESSOR HCT
MO
moexipril-hydrochlorothiazide 1512.5 mg tab, 15-25 mg tab, 7.5-12.5
mg tab
2
MO
propranolol-hctz 40-25 mg tab, 8025 mg tab
2
MO
quinapril-hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25
mg tab
2
ACCURETIC
MO
spironolactone-hctz 25-25 mg tab
1
ALDACTAZIDE
MO
triamterene-hctz 37.5-25 mg cap,
37.5-25 mg tab, 50-25 mg cap, 7550 mg tab
1
DYAZIDE
MO
valsartan-hydrochlorothiazide 16012.5 mg tab, 160-25 mg tab, 32012.5 mg tab, 320-25 mg tab, 8012.5 mg tab
2
DIOVAN HCT
MO
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
digox 125 mcg tab, 250 mcg tab
1
LANOXIN
MO, HR
digoxin 125 mcg tab, 250 mcg tab
1
DIGITEK
MO, HR
digoxin 0.05 mg/ml soln
2
LANOXIN
MO, HR
Page 51 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
LANOXIN
Requirements/Limits
digoxin 0.25 mg/ml inj soln
2
PA(*), HR, HI
ENTRESTO 24-26 mg tab, 97-103
mg tab, 49-51 mg tab
3
PA, MO
LANOXIN 125 mcg tab, 187.5 mcg
tab, 250 mcg tab, 62.5 mcg tab
4
MO, HR
pentoxifylline er 400 mg tab er
2
MO
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
MO
acetazolamide er 500 mg cap er 12
hr
2
DIAMOX
MO
methazolamide 25 mg tab, 50 mg
tab
2
MO
Diuretics, Loop [Diuréticos, Asa De Henle]
bumetanide 0.5 mg tab, 1 mg tab, 2
mg tab
1
MO
bumetanide 0.25 mg/ml inj soln
2
PA(*), HI
furosemide 10 mg/ml soln, 20 mg
1
LASIX
MO
furosemide 10 mg/ml inj soln
2
LASIX
PA(*), HI
torsemide 10 mg tab, 20 mg tab, 5
mg tab
1
DEMADEX
MO
torsemide 100 mg tab
2
DEMADEX
MO
Diuretics, Potassium-Sparing [Diuréticos, Conservadores De Potasio]
amiloride hcl 5 mg tab
2
MO
eplerenone 25 mg tab, 50 mg tab
2
INSPRA
ST, MO
spironolactone 25 mg tab, 50 mg
tab
1
ALDACTONE
MO
spironolactone 100 mg tab
2
ALDACTONE
MO
Diuretics, Thiazide [Diuréticos, Tiazidas]
chlorothiazide 250 mg tab, 500 mg
tab
1
MO
chlorthalidone 25 mg tab, 50 mg tab
1
MO
DIURIL 250 mg/5ml susp
4
MO
hydrochlorothiazide 12.5 mg cap,
12.5 mg tab, 25 mg tab, 50 mg tab
1
MICROZIDE
MO
indapamide 1.25 mg tab, 2.5 mg
tab
1
MO
methyclothiazide 5 mg tab
2
MO
metolazone 10 mg tab, 2.5 mg tab,
5 mg tab
2
MO
Page 52 of 95
Updated 11/2016
Reference Name
Requirements/Limits
[Nombre de
Referencia]
Dyslipidemics, Fibric Acid Derivatives [Dislipidémicos, Derivados Del Ácido Fíbrico]
fenofibrate 145 mg tab, 48 mg tab
2
TRICOR
MO
fenofibrate 160 mg tab, 54 mg tab
2
LOFIBRA
MO
fenofibrate micronized 130 mg cap,
43 mg cap
2
MO
fenofibrate micronized 134 mg cap,
2
LOFIBRA
MO
fenofibric acid 135 mg cap dr, 45
mg cap dr
2
TRILIPIX
MO
gemfibrozil 600 mg tab
1
LOPID
MO
Dyslipidemics, Hmg Coa Reductase Inhibitors [Dislipidémicos, Inhibidores De La Hmg Coa
Reductasa]
atorvastatin calcium 10 mg tab, 20
1
LIPITOR
MO
lovastatin 10 mg tab, 20 mg tab, 40
mg tab
1
MO
pravastatin sodium 10 mg tab, 20
1
PRAVACHOL
MO
simvastatin 10 mg tab, 20 mg tab,
40 mg tab, 5 mg tab
1
ZOCOR
MO
simvastatin 80 mg tab
1
ZOCOR
PA, MO
Dyslipidemics, Other [Dislipidémicos, Otros]
cholestyramine light 4 gm pckt, 4
gm/dose oral pwdr
2
MO
colestipol hcl 1 gm tab, 5 gm oral gr
2
COLESTID
MO
JUXTAPID 10 mg cap, 20 mg cap,
5 mg cap
5
PA, MO
JUXTAPID 30 mg cap, 40 mg cap,
60 mg cap
5
PA, MO
KYNAMRO 200 mg/ml sc soln
prefilled syringe
5
PA, LA, MO
niacin er (antihyperlipidemic) 1000
mg tab er, 500 mg tab er, 750 mg
tab er
2
NIASPAN
MO
omega-3-acid ethyl esters 1 gm cap
2
LOVAZA
MO
ZETIA 10 mg tab
3
MO
Vasodilators, Direct-Acting Arterial [Vasodilatadores Arteriales De Acción Directa]
hydralazine hcl 10 mg tab, 100 mg
1
MO
hydralazine hcl 20 mg/ml inj soln
1
PA(*), HI
minoxidil 10 mg tab, 2.5 mg tab
1
MO
Vasodilators, Direct-Acting Arterial/Venous [Vasodilatadores Arteriovenosos De Acción
Directa]
Drug Name
Drug Tier
[Nivel]
Page 53 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
isosorbide dinitrate 10 mg tab, 20
2
ISORDIL
MO
isosorbide dinitrate er 40 mg tab er
2
MO
isosorbide mononitrate 10 mg tab,
20 mg tab
1
MO
isosorbide mononitrate er 120 mg
tab er 24 hr, 30 mg tab er 24 hr, 60
mg tab er 24 hr
1
MO
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
NITRO-DUR 0.1 mg/hr td patch
24hr, 0.2 mg/hr td patch 24hr, 0.3
mg/hr td patch 24hr, 0.4 mg/hr td
patch 24hr, 0.6 mg/hr td patch 24hr,
0.8 mg/hr td patch 24hr
4
MO
nitroglycerin 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
NITRO-DUR
MO
nitroglycerin 0.3 mg tab subl, 0.4
mg tab subl, 0.6 mg tab subl
1
NITROSTAT
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
amphetamine-dextroamphet er 10
er 24 hr, 30 mg cap er 24 hr, 5 mg
cap er 24 hr
2
ADDERALL
MO
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
dextroamphetamine sulfate 10 mg
tab, 5 mg tab
2
ZENZEDI
MO
dextroamphetamine sulfate er 10
2
DEXEDRINE
MO
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
Page 54 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
METADATE ER 20 mg tab er
2
methylphenidate hcl 10 mg tab, 10
mg/5ml soln, 20 mg tab, 5 mg tab, 5
mg/5ml soln
2
RITALIN
methylphenidate hcl er 20 mg tab er
2
METADATE
methylphenidate hcl er (cd) 10 mg
cap er
2
METADATE
STRATTERA 100 mg cap, 60 mg
cap, 80 mg cap
4
STRATTERA 40 mg cap
4
STRATTERA 10 mg cap, 18 mg
cap, 25 mg cap
4
Central Nervous System, Other [Sistema Nervioso Central, Otros]
NUEDEXTA 20-10 mg cap
4
riluzole 50 mg tab
2
RILUTEK
tetrabenazine 12.5 mg tab, 25 mg
tab
5
XENAZINE
Multiple Sclerosis Agents [Agentes Para Esclerosis Múltiple]
AMPYRA 10 mg tab er 12 hr
5
AVONEX 30 mcg im kit
5
AVONEX PEN 30 mcg/0.5ml im
auto-inj kit
5
AVONEX PREFILLED 30
mcg/0.5ml im prefilled syringe kit
5
BETASERON 0.3 mg sc kit
5
COPAXONE 20 mg/ml sc soln
prefilled syringe, 40 mg/ml sc soln
prefilled syringe
5
GILENYA 0.5 mg cap
5
glatopa 20 mg/ml sc soln prefilled
syringe
5
GLATOPA
PLEGRIDY 125 mcg/0.5ml sc soln
prefilled syringe, 125 mcg/0.5ml sc
soln pen-inj
5
PLEGRIDY STARTER PACK 63 &
94 mcg/0.5ml sc soln pen-inj
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
Requirements/Limits
MO
MO
MO
MO
QL(30 / 30), ST, MO
QL(60 / 30), ST, MO
QL(120 / 30), ST, MO
PA, MO
PA, MO
LA, MO
LA, MO
PA, MO
PA, MO
PA, MO
PA, MO
PA, MO
PA, MO
PA, MO
PA, MO
PA
PA
PA, MO
PA, HI
MO
Page 55 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
chlorhexidine gluconate 0.12 %
mouth/throat soln
1
PERIOGARD
doxycycline hyclate 20 mg tab
2
pilocarpine hcl 5 mg tab, 7.5 mg tab
2
SALAGEN
MO
triamcinolone acetonide 0.1 %
mouth/throat paste
2
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
AVITA 0.025 % crm, 0.025 % gel
2
PA
calcipotriene 0.005 % crm, 0.005 %
oint, 0.005 % soln
2
DOVONEX
CARAC 0.5 % crm
4
CLARAVIS 10 mg cap, 20 mg cap,
2
CONDYLOX 0.5 % gel
4
COSENTYX 150 mg/ml sc soln
prefilled syringe
5
PA, MO
COSENTYX SENSOREADY PEN
150 mg/ml sc soln auto-inj
5
PA, MO
diclofenac sodium 1 % td gel
2
VOLTAREN
DOVONEX 0.005 % crm
4
ELIDEL 1 % crm
4
ST
fluorouracil 2 % soln, 5 % crm, 5 %
soln
2
EFUDEX
imiquimod 5 % crm
2
ALDARA
methoxsalen rapid 10 mg cap
5
OXSORALEN-ULTRA
OXSORALEN ULTRA 10 mg cap
5
podofilox 0.5 % soln
2
SANTYL 250 unit/gm oint
4
selenium sulfide 2.5 % lot
1
tacrolimus 0.03 % oint, 0.1 % oint
2
PROTOPIC
ST
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
VALCHLOR 0.016 % gel
5
Dermatological Agents (Combination Product) [Agentes Dermatológicos (Productos En
Combinación)]
Page 56 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
benzoyl peroxide-erythromycin 5-3
% gel
2
BENZAMYCIN
clotrimazole-betamethasone 1-0.05
% crm, 1-0.05 % lot
2
LOTRISONE
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 400 unit iv soln
5
PA(*), HI
CREON 12000 unit cap dr prt,
24000 unit cap dr prt, 3000-9500
unit cap dr prt, 36000 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(*), HI
FABRAZYME 35 mg iv soln
5
PA, HI
KUVAN 100 mg tab sol, 100 mg
pckt, 500 mg pckt
5
PA, MO
NAGLAZYME 1 mg/ml iv soln
5
PA, LA, HI
ORFADIN 4 mg/ml susp, 10 mg
5
PA, MO
pancrelipase (lip-prot-amyl) 5000
unit cap dr prt
2
ZENPEP
MO
RAVICTI 1.1 gm/ml liq
5
PA, MO
sodium phenylbutyrate 3 gm/tsp
oral pwdr
2
PA, MO
VPRIV 400 unit iv soln
5
PA(*), HI
ZAVESCA 100 mg cap
5
PA, LA, MO
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Antispasmodics, Gastrointestinal [Antiespasmódicos, Gastrointestinales]
dicyclomine hcl 10 mg cap, 20 mg
tab
1
BENTYL
dicyclomine hcl 10 mg/5ml soln
2
BENTYL
glycopyrrolate 1 mg tab, 2 mg tab
2
ROBINUL
methscopolamine bromide 2.5 mg
tab, 5 mg tab
1
Gastrointestinal Agents (Combination Product) [Agentes Gastrointestinales (Productos En
Combinación)]
GAVILYTE-C 240 gm soln
2
GAVILYTE-G 236 gm soln
2
Page 57 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
GAVILYTE-N WITH FLAVOR
PACK 420 gm soln
2
peg 3350-kcl-na bicarb-nacl 420 gm
soln
1
GAVILYTE-N
peg-3350/electrolytes 236 gm soln
1
GAVILTYE-G
peg-3350/electrolytes 240 gm soln
1
GAVILTYE-C
TRILYTE 420 gm soln
2
Gastrointestinal Agents, Other [Agentes Gastrointestinales, Otros]
cromolyn sodium 100 mg/5ml oral
conc
2
GASTROCROM
MO
diphenoxylate-atropine 2.5-0.025
mg tab
1
LOMOTIL
GATTEX 5 mg sc kit
5
PA, LA, MO
loperamide hcl 2 mg cap
1
MOVANTIK 12.5 mg tab, 25 mg tab
4
PA
RELISTOR 8 mg/0.4ml sc soln
4
PA, QL(12 / 30)
RELISTOR 12 mg/0.6ml sc soln
4
PA, QL(18 / 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
ACTIGALL
MO
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
cimetidine 200 mg tab
1
cimetidine 300 mg tab, 400 mg tab,
800 mg tab
1
MO
famotidine 20 mg tab, 40 mg tab
1
PEPCID
MO
famotidine 40 mg/5ml susp
2
PEPCID
MO
famotidine 20 mg/2ml iv soln
2
PEPCID
PA(*), HI
famotidine premixed 20-0.9
mg/50ml-% iv soln
2
PA(*), HI
ranitidine hcl 150 mg tab, 300 mg
tab
1
ZANTAC
MO
ranitidine hcl 15 mg/ml syr
2
ZANTAC
MO
Irritable Bowel Syndrome Agents [Agentes Para El Síndrome Del Colon Irritable]
alosetron hcl 0.5 mg tab
2
LOTRONEX
MO
alosetron hcl 1 mg tab
5
LOTRONEX
MO
AMITIZA 24 mcg cap, 8 mcg cap
4
PA, MO
LINZESS 145 mcg cap, 290 mcg
cap
3
PA, MO
Laxatives [Laxantes]
constulose 10 gm/15ml soln
2
CONSTULOSE
MO
enulose 10 gm/15ml soln
2
ENULOSE
MO
lactulose 10 gm/15ml soln
2
CONSTULOSE
MO
polyethylene glycol 3350 oral pwdr
2
Page 58 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
Protectants [Protectores]
CARAFATE 1 gm/10ml susp
4
MO
misoprostol 200 mcg tab
2
CYTOTEC
MO
sucralfate 1 gm tab
2
CARAFATE
MO
Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]
lansoprazole 15 mg cap dr, 30 mg
cap dr
2
PREVACID
ST, MO
omeprazole 40 mg cap dr
1
PRILOSEC
QL(30 / 30), MO
omeprazole 10 mg cap dr, 20 mg
cap dr
1
PRILOSEC
QL(60 / 30), MO
pantoprazole sodium 20 mg tab dr,
40 mg tab dr
1
PROTONIX
MO
pantoprazole sodium 40 mg iv soln
2
PROTONIX
PA(*), HI
PROTONIX 40 mg iv soln
4
PA(*), HI
GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Antispasmodics, Urinary [Antiespasmódicos, Urinarios]
MYRBETRIQ 25 mg tab er 24 hr,
50 mg tab er 24 hr
4
MO
oxybutynin chloride 5 mg tab
1
MO
oxybutynin chloride er 10 mg tab er
24 hr, 15 mg tab er 24 hr, 5 mg tab
er 24 hr
2
DITROPAN
MO
tolterodine tartrate 1 mg tab, 2 mg
tab
2
DETROL
MO
tolterodine tartrate er 2 mg cap er
2
DETROL
MO
TOVIAZ 4 mg tab er 24 hr, 8 mg tab
er 24 hr
3
MO
trospium chloride 20 mg tab
2
MO
trospium chloride er 60 mg cap er
24 hr
2
MO
Benign Prostatic Hypertrophy Agents [Agentes Para Hipertrofia Prostática Benigna]
alfuzosin hcl er 10 mg tab er 24 hr
1
UROXATRAL
MO
finasteride 5 mg tab
1
PROSCAR
MO
tamsulosin hcl 0.4 mg cap
1
FLOMAX
MO
Genitourinary Agents, Other [Agentes Genitourinarios, Otros]
bethanechol chloride 10 mg tab, 25
2
URECHOLINE
DEPEN TITRATABS 250 mg tab
4
ELMIRON 100 mg cap
4
LITHOSTAT 250 mg tab
4
methylergonovine maleate 0.2 mg
tab
2
Phosphate Binders [Enlazadores De Fosfato]
Page 59 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
calcium acetate (phos binder) 667
mg cap
2
PHOSLO
MO
PHOSLYRA 667 mg/5ml soln
4
MO
RENVELA 0.8 gm pckt, 2.4 gm
pckt, 800 mg tab
4
MO
sevelamer carbonate 800 mg tab
2
RENVELA
MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/MODIFIERS) [AGENTES HORMONALES, ESTIMULANTES/ REEMPLAZO/
MODIFICADOR (HORMONAS SEXUALES/MODIFICADORES)]
Contraceptives [Contraceptivos]
norethindrone 0.35 mg tab
2
ERRIN 28 DAY
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
PA(*)
ala cort 1 % crm
1
ALA-CORT
alclometasone dipropionate 0.05 %
crm, 0.05 % oint
2
amcinonide 0.1 % crm, 0.1 % lot
2
betamethasone dipropionate 0.05
% crm, 0.05 % lot, 0.05 % oint
2
betamethasone dipropionate aug
0.05 % crm, 0.05 % lot, 0.05 % oint
2
DIPROLENE
betamethasone valerate 0.1 % crm,
0.1 % lot, 0.1 % oint
2
clobetasol propionate 0.05 % gel,
0.05 % lot, 0.05 % oint, 0.05 %
shampoo, 0.05 % soln
2
CORMAX
clobetasol propionate e 0.05 % crm
2
COLOCORT 100 mg/60ml rect
enema
2
cortisone acetate 25 mg tab
2
desonide 0.05 % crm, 0.05 % lot,
0.05 % oint
2
DESOWEN
desoximetasone 0.05 % crm, 0.05
% gel, 0.05 % oint, 0.25 % crm,
0.25 % oint
2
TOPICORT
dexamethasone 0.5 mg tab, 0.75
mg tab, 1 mg tab, 1.5 mg tab, 2 mg
1
dexamethasone 0.5 mg/5ml oral
elix
2
Page 60 of 95
Updated 11/2016
Drug Name
dexamethasone sodium phosphate
10 mg/ml inj soln
120 mg/30ml inj soln
diflorasone diacetate 0.05 % crm,
0.05 % oint
fludrocortisone acetate 0.1 mg tab
fluocinolone acetonide 0.01 % crm,
0.01 % otic oil, 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
hydrocortisone 1 % crm, 1 % oint,
2.5 % crm, 2.5 % oint
hydrocortisone 10 mg tab, 100
mg/60ml rect enema, 2.5 % lot, 20
mg tab, 5 mg tab
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
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
ORAPRED ODT 10 mg odt
prednisolone sodium phosphate 15
mg/5ml soln, 6.7 (5 Base) mg/5ml
soln
prednisone 1 mg tab, 10 mg tab,
2.5 mg tab, 20 mg tab, 5 mg tab, 50
mg tab
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
1
PA(*), HI
2
PA(*)
2
2
APEXICON
MO
2
2
2
2
2
1
ALA-CORT
2
CORTEF
2
LOCOID
2
2
2
2
MEDROL
MEDROL DOSEPAK
1
DEPO-MEDROL
PA(*)
2
SOLU-MEDROL
PA(*), HI
2
4
ELOCON
2
1
Page 61 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
prednisone 5 mg (48) tab pack, 5
mg (21) tab pack,10 mg (48) tab
pack, 10 mg (21) tab pack
1
prednisone 5 mg/5ml soln
2
PROCTOZONE-HC 2.5 % rect crm
4
triamcinolone acetonide 0.025 %
crm, 0.025 % lot, 0.025 % oint, 0.1
% crm, 0.1 % lot, 0.1 % oint, 0.5 %
crm, 0.5 % oint
2
TRIDERM
TRIDERM 0.1 % crm
4
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
PREGNYL
PA
desmopressin ace rhinal tube 0.01
% nasal soln
2
DDAVP
QL(12.5 / 30), MO
desmopressin ace spray refrig 0.01
% nasal soln
2
QL(10 / 25), MO
desmopressin acetate 0.1 mg tab,
0.2 mg tab
2
DDAVP
MO
desmopressin acetate 4 mcg/ml inj
soln
2
DDAVP
PA(*), HI
GENOTROPIN 12 mg sc soln, 5 mg
sc soln
5
PA, MO
GENOTROPIN MINIQUICK 0.2 mg
sc soln
4
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
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
NORDITROPIN NORDIFLEX PEN
30 mg/3ml sc soln
5
PA, MO
NUTROPIN AQ NUSPIN 10 10
mg/2ml sc soln
5
PA, MO
Page 62 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
mg/2ml sc soln
5
PA, MO
mg/2ml sc soln
5
PA, MO
NUTROPIN AQ PEN 10 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]
ANADROL-50 50 mg tab
4
PA
oxandrolone 10 mg tab, 2.5 mg tab
2
PA
Androgens [Andrógenos]
ANDROGEL 20.25 MG/1.25GM
(1.62%) td gel, 40.5 MG/2.5GM
(1.62%) td gel
3
PA, QL(150 / 30), MO
ANDROGEL 50 MG/5GM (1%) td
gel
3
PA, QL(300 / 30), MO
ANDROGEL 25 MG/2.5GM (1%) td
gel
3
PA, QL(300 / 30), MO
ANDROGEL PUMP 20.25 MG/ACT
(1.62%) td gel
3
PA, QL(150 / 30), MO
danazol 100 mg cap, 200 mg cap,
50 mg cap
2
DEPO-TESTOSTERONE 100
mg/ml im soln, 200 mg/ml im soln
4
PA
STRIANT 30 mg bucc misc
4
PA, MO
testosterone 25 MG/2.5GM (1%) td
gel
2
ANDROGEL
PA, QL(300 / 30), MO
testosterone cypionate 100 mg/ml
DEPOim soln, 200 mg/ml im soln
2
TESTOSTERONE
PA
testosterone enanthate 200 mg/ml
im soln
2
PA
Estrogens [Estrógenos]
ESTRACE 0.1 mg/gm vag crm
4
MO
estradiol 0.5 mg tab, 1 mg tab, 2
mg tab
1
ESTRACE
PA, MO, HR
estradiol valerate 40 mg/ml im oil
2
DELESTROGEN
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
VAGIFEM 10 mcg vag tab
4
MO
Page 63 of 95
Updated 11/2016
Reference Name
Requirements/Limits
[Nombre de
Referencia]
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
(Combination Product) [Agentes Hormonales, Estimulantes/Reemplazo/Modificador
(Hormonas Sexuales/Modificadores) (Productos En Combinación)]
estradiol-norethindrone acet 0.5-0.1
2
MIMVEY LO 28 DAY
PA, MO, HR
norgestim-eth estrad triphasic
0.18/0.215/0.25 mg-35 mcg tab
1
ORTHO TRI-CYCLEN
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
Progestins [Progestinas]
DEPO-PROVERA 400 mg/ml im
susp
4
PA(*)
hydroxyprogesterone caproate 1.25
gm/5ml im soln
5
medroxyprogesterone acetate 10
mg tab, 2.5 mg tab, 5 mg tab
1
PROVERA
MO
medroxyprogesterone acetate 150
mg/ml im susp
1
DEPO-PROVERA
QL(1 / 90)
megestrol acetate 40 mg/ml susp
2
MEGACE
PA, HR
megestrol acetate 20 mg tab, 40
mg tab
2
MEGACE
PA, HR
norethindrone acetate 5 mg tab
2
AYGESTIN
MO
Selective Estrogen Receptor Modifying Agents [Agentes Modificadores Selectivos Del
Receptor De Estrógeno]
raloxifene hcl 60 mg tab
2
EVISTA
MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) [AGENTES
HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (TIROIDES)]
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) [Agentes Hormonales,
Estimulantes/Reemplazo/Modificador (Tiroides)]
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
SYNTHROID
MO
LEVOXYL 100 mcg tab, 112 mcg
tab, 88 mcg tab
3
MO
liothyronine sodium 25 mcg tab, 5
mcg tab, 50 mcg tab
2
CYTOMEL
MO
SYNTHROID 100 mcg tab, 112
3
MO
Page 64 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
mcg tab, 75 mcg tab, 88 mcg tab
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
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
PA(*)
LUPRON DEPOT 3.75 mg im kit,
7.5 mg im kit
5
PA(*), QL(1 / 28)
LUPRON DEPOT 11.25 mg im kit,
22.5 mg im kit
5
PA(*), QL(1 / 84)
LUPRON DEPOT 30 mg im kit
5
PA(*), QL(1 / 90)
LUPRON DEPOT 45 mg im kit
5
PA(*), QL(1 / 168)
LUPRON DEPOT-PED 11.25 mg
im kit, 15 mg im kit
5
PA(*), QL(1 / 28)
octreotide acetate 100 mcg/ml inj
mcg/ml inj soln
2
SANDOSTATIN
PA, MO
octreotide acetate 1000 mcg/ml inj
soln, 500 mcg/ml inj soln
5
SANDOSTATIN
PA, MO
SANDOSTATIN 50 mcg/ml inj soln,
500 mcg/ml inj soln
4
PA, MO
SANDOSTATIN 100 mcg/ml inj
mcg/ml inj soln
5
PA, MO
SANDOSTATIN LAR DEPOT 10
mg im kit, 20 mg im kit, 30 mg im kit
5
PA
SIGNIFOR 0.3 mg/ml sc soln, 0.6
mg/ml sc soln, 0.9 mg/ml sc soln
5
PA, MO
SIGNIFOR LAR 20 mg im susp, 40
mg im susp, 60 mg im susp
5
PA, MO
Page 65 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
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, 25 mg sc
soln, 30 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 Antitiroide]
methimazole 10 mg tab, 5 mg tab
1
TAPAZOLE
MO
propylthiouracil 50 mg tab
1
MO
IMMUNOLOGICAL AGENTS [AGENTES INMUNOLÓGICOS]
Angioedema (HAE) Agents [Agentes De La Angioedema (HAE)]
CINRYZE 500 unit iv soln
5
PA(*), HI
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
azathioprine sodium 100 mg inj soln
2
PA(*)
CELLCEPT 200 mg/ml susp
4
PA(*), MO
cyclosporine 50 mg/ml iv soln
2
SANDIMMUNE
PA(*), HI
cyclosporine 100 mg cap, 25 mg
cap, 100 mg/ml soln
2
SANDIMMUNE
PA(*), MO
cyclosporine modified 100 mg cap,
100 mg/ml soln, 25 mg cap, 50 mg
cap
2
GENGRAF
PA(*), MO
ENBREL 25 mg/0.5ml sc soln
prefilled syringe
5
PA, QL(4.08 / 28), MO
ENBREL 25 mg sc soln, 50 mg/ml
sc soln prefilled syringe
5
PA, QL(8 / 28), MO
ENBREL SURECLICK 50 mg/ml sc
soln auto-inj
5
PA, QL(8 / 28), MO
GENGRAF 100 mg cap, 100 mg/ml
soln, 25 mg cap
2
PA(*), MO
HUMIRA 10 mg/0.2ml sc prefilled
syringe kit, 20 mg/0.4ml sc prefilled
syringe kit
5
PA, QL(2 / 28), MO
HUMIRA 40 mg/0.8ml sc prefilled
syringe kit
5
PA, QL(6 / 28), MO
HUMIRA PEN 40 mg/0.8ml sc peninj kit
5
PA, MO
HUMIRA PEN-CROHNS STARTER
40 mg/0.8ml sc pen-inj
5
PA, MO
Page 66 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
HUMIRA PEN-PSORIASIS
STARTER 40 mg/0.8ml sc pen-inj
kit
5
PA, MO
KINERET 100 mg/0.67ml sc soln
prefilled syringe
5
PA, MO
methotrexate 2.5 mg tab
2
methotrexate sodium 1 gm inj soln
2
PA(*)
methotrexate sodium (pf) 1
mg/40ml inj soln
2
PA(*)
mycophenolate mofetil 200 mg/ml
susp, 250 mg cap, 500 mg tab
2
CELLCEPT
PA(*), MO
mycophenolic acid 180 mg tab dr
2
MYFORTIC
PA(*), MO
mycophenolic acid 360 mg tab dr
5
MYFORTIC
PA(*), MO
MYFORTIC 180 mg tab dr
4
PA(*), MO
MYFORTIC 360 mg tab dr
5
PA(*), MO
NULOJIX 250 mg iv soln
5
PA(*), HI
ORENCIA 125 mg/ml sc soln
prefilled syringe
5
PA, MO
ORENCIA CLICKJECT 125 mg/ml
sc soln auto-inj
5
PA, MO
OTEZLA 10 & 20 & 30 mg tab pack
5
PA
OTEZLA 30 mg tab
5
PA, MO
RAPAMUNE 0.5 mg tab
4
PA(*), MO
RAPAMUNE 1 mg tab, 1 mg/ml
soln, 2 mg tab
5
PA(*), MO
SANDIMMUNE 100 mg cap, 100
mg/ml soln, 25 mg cap
4
PA(*), MO
sirolimus 0.5 mg tab, 1 mg tab
2
RAPAMUNE
PA(*), MO
sirolimus 2 mg tab
5
RAPAMUNE
PA(*), MO
tacrolimus 0.5 mg cap, 1 mg cap, 5
mg cap
2
PROGRAF
PA(*), MO
XELJANZ 5 mg tab
5
PA, MO
XELJANZ XR 11 mg tab er 24 hr
5
PA, MO
ZORTRESS 0.25 mg tab
4
PA(*), MO
ZORTRESS 0.5 mg tab, 0.75 mg
tab
5
PA(*), MO
Immunizing Agents, Passive [Agentes Inmunizantes, Pasivos]
CARIMUNE NF 6 gm iv soln
5
PA, HI
GAMMAGARD 2.5 gm/25ml inj soln
5
PA, HI
GAMMAPLEX 10 gm/200ml iv soln
3
PA, HI
GAMUNEX-C 1 gm/10ml inj soln
4
PA, HI
PRIVIGEN 20 gm/200ml iv soln
5
PA(*)
SYNAGIS 50 mg/0.5ml im soln
4
PA(*)
Immunomodulators [Inmunomoduladores]
Page 67 of 95
Updated 11/2016
Drug Name
ACTIMMUNE 2000000 unit/0.5ml
sc soln
ARCALYST 220 mg sc soln
BENLYSTA 120 mg iv soln, 400 mg
iv soln
ILARIS 180 mg sc soln
leflunomide 10 mg tab, 20 mg tab
Vaccines [Vacunas]
ACTHIB im soln
ADACEL 5-2-15.5 lf-mcg/0.5 im
susp
BOOSTRIX 5-2.5-18.5 im susp
CERVARIX im susp
DAPTACEL 10-15-5 im susp
diphtheria-tetanus toxoids dt 25-5
lfu/0.5ml im susp
ENGERIX-B 10 mcg/0.5ml inj susp,
20 mcg/ml inj susp
GARDASIL im susp
GARDASIL 9 im susp, im susp
prefilled syringe
HAVRIX 1440 el u/ml im susp, 720
el u/0.5ml im susp
IMOVAX RABIES 2.5 unit/ml im
INFANRIX 25-58-10 im susp
IPOL inj
IXIARO im susp
MENACTRA im
MENOMUNE sc inj
MENVEO im soln
M-M-R II sc inj
PEDVAX HIB 7.5 mcg/0.5ml im
susp
PROQUAD sc inj
RABAVERT im susp
RECOMBIVAX HB 10 mcg/ml inj
susp, 40 mcg/ml inj susp, 5
mcg/0.5ml inj susp
ROTARIX susp
ROTATEQ soln
tetanus-diphtheria toxoids td 2-2
lf/0.5ml im susp
TWINRIX 720-20 im susp
TYPHIM VI 25 mcg/0.5ml im soln
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
5
5
PA, LA, MO
PA, MO
5
5
1
PA(*), HI
PA
MO
ARAVA
4
4
4
4
4
PA
2
PA(*)
4
4
PA(*)
PA, QL(1.5 / 365)
4
PA, QL(1.5 / 365)
4
4
4
4
4
4
4
4
4
4
4
4
PA(*)
PA(*)
4
4
4
PA(*)
2
4
4
PA(*)
PA(*)
Page 68 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
VAQTA 25 unit/0.5ml im susp, 50
unit/ml im susp
4
VARIVAX 1350 pfu/0.5ml sc inj
4
YF-VAX sc inj
4
ZOSTAVAX 19400 unt/0.65ml sc
soln
4
PA, QL(1 / 999)
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
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
mesalamine 800 mg tab dr
2
ASACOL HD
PENTASA 250 mg cap er, 500 mg
cap er
3
MO
Glucocorticoids [Glucocorticoides]
budesonide 3 mg cap dr prt
5
ENTOCORT
Sulfonamides [Sulfonamidas]
sulfasalazine 500 mg tab, 500 mg
tab dr
2
AZULFIDINE
MO
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
alendronate sodium 35 mg tab, 70
mg tab
1
FOSAMAX
QL(4 / 28), MO
alendronate sodium 40 mg tab
2
FOSAMAX
alendronate sodium 70 mg/75ml
soln
2
FOSAMAX
MO
calcitonin (salmon) 200 unit/act
nasal soln
2
MIACALCIN
QL(3.7 / 30), MO
calcitriol 0.25 mcg cap, 0.5 mcg
cap, 1 mcg/ml soln
2
ROCALTROL
MO
calcitriol 1 mcg/ml iv soln
2
ROCALTROL
PA(*), HI
FORTEO 600 mcg/2.4ml sc soln
5
PA, QL(2.4 / 28), MO
ibandronate sodium 150 mg tab
2
BONIVA
QL(1 / 30), ST, MO
ibandronate sodium 3 mg/3ml iv
soln
2
BONIVA
PA(*), QL(3 / 90)
MIACALCIN 200 unit/ml inj soln
4
Page 69 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
NATPARA 100 mcg sc cartridge, 25
mcg sc cartridge, 50 mcg sc
cartridge, 75 mcg sc cartridge
5
PA, LA, MO
paricalcitol 2 mcg/ml iv soln
2
ZEMPLAR
PA
paricalcitol 1 mcg cap, 2 mcg cap, 4
mcg cap
2
ZEMPLAR
PA, MO
PROLIA 60 mg/ml sc soln
4
PA(*), QL(1 / 180)
risedronate sodium 150 mg tab, 35
mg tab
2
ACTONEL
ST, MO
XGEVA 120 mg/1.7ml sc soln
5
PA(*), QL(1.7 / 28)
zoledronic acid 4 mg/5ml iv conc
2
ZOMETA
PA(*)
zoledronic acid 4 mg/100ml iv soln
5
ZOMETA
PA(*)
zoledronic acid 5 mg/100ml iv soln
2
RECLAST
PA(*), QL(100 / 365)
OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]
Ophthalmic Agents (Combination Product) [Agentes Oftálmicos (Productos En
Combinación]
bacitracin-polymyxin b 500-10000
unit/gm ophth oint
2
bacitra-neomycin-polymyxin-hc 1 %
ophth oint
2
COMBIGAN 0.2-0.5 % ophth soln
3
MO
dorzolamide hcl-timolol mal 22.36.8 mg/ml ophth soln
1
COSOPT
MO
neomycin-bacitracin zn-polymyx 5400-10000 ophth oint
2
neomycin-polymyxin-dexameth 3.510000-0.1 ophth oint, 3.5-10000-0.1
ophth susp
1
MAXITROL
neomycin-polymyxin-gramicidin
NEOSPORIN
1.75-10000-.025 ophth soln
2
SOLUTION
neomycin-polymyxin-hc 3.5-100001 ophth susp
2
CORTISPORIN
polymyxin b-trimethoprim 10000-0.1
unit/ml-% ophth soln
1
POLYTRIM
sulfacetamide-prednisolone 10-0.23
% ophth soln
2
tobramycin-dexamethasone 0.3-0.1
% ophth susp
2
TOBRADEX
Ophthalmic Agents, Other [Agentes Oftálmicos, Otros]
atropine sulfate 1 % ophth soln
1
MO
proparacaine hcl 0.5 % ophth soln
1
ALCAINE
RESTASIS 0.05 % ophth emul
4
PA, QL(60 / 30), MO
Ophthalmic Anti-Allergy Agents [Agentes Oftálmicos Antialérgicos]
cromolyn sodium 4 % ophth soln
2
GASTROCROM
Page 70 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
PATADAY 0.2 % ophth soln
4
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
MO
brimonidine tartrate 0.15 % ophth
soln, 0.2 % ophth soln
1
ALPHAGAN
MO
dorzolamide hcl 2 % ophth soln
1
TRUSOPT
MO
levobunolol hcl 0.5 % ophth soln
1
BETAGAN
MO
metipranolol 0.3 % ophth soln
1
MO
PHOSPHOLINE IODIDE 0.125 %
ophth soln
4
MO
timolol maleate 0.25 % ophth soln,
0.5 % ophth soln
1
MO
Ophthalmic Anti-Inflammatories [Antiinflamatorios Oftálmicos]
0.1 % ophth soln
1
diclofenac sodium 0.1 % ophth soln
1
DUREZOL 0.05 % ophth emul
3
QL(7.5 / 25)
fluorometholone 0.1 % ophth susp
2
FML
flurbiprofen sodium 0.03 % ophth
soln
1
OCUFEN
ketorolac tromethamine 0.4 %
ophth soln
1
ACULAR
QL(5 / 15)
ketorolac tromethamine 0.5 %
ophth soln
1
ACULAR
QL(10 / 25)
NEVANAC 0.1 % ophth susp
3
prednisolone acetate 1 % ophth
susp
2
OMNIPRED
Ophthalmic Prostaglandin And Prostamide Analogs [Análogos Oftálmicos De
Prostaglandinas Y Prostamidas]
bimatoprost 0.03 % ophth soln
2
QL(5 / 25), MO
latanoprost 0.005 % ophth soln
1
XALATAN
QL(2.5 / 25), MO
LUMIGAN 0.01 % ophth soln
3
QL(2.5 / 25), MO
TRAVATAN Z 0.004 % ophth soln
3
QL(2.5 / 25), MO
travoprost 0.004 % ophth soln
2
QL(2.5 / 25), MO
OTIC AGENTS [AGENTES OTICOS]
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
ACETASOL HC
neomycin-polymyxin-hc 1 % otic
soln, 3.5-10000-1 otic susp
2
CORTISPORIN
Page 71 of 95
Updated 11/2016
Reference Name
Requirements/Limits
[Nombre de
Referencia]
RESPIRATORY TRACT/PULMONARY AGENTS [AGENTES PARA EL TRACTO
RESPIRATORIO/PULMONAR]
Antihistamines [Antihistamínicos]
azelastine hcl 0.1 % nasal soln
2
ASTEPRO
QL(30 / 25)
azelastine hcl 0.15 % nasal soln
2
ASTEPRO
QL(60 / 30)
cetirizine hcl 1 mg/ml syr
2
cyproheptadine hcl 2 mg/5ml syr, 4
mg tab
2
PA, HR
desloratadine 5 mg tab
2
CLARINEX
ST
levocetirizine dihydrochloride 2.5
mg/5ml soln, 5 mg tab
2
XYZAL
ST
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 44 mcg/act inh aer
3
QL(21.2 / 30), MO
FLOVENT HFA 110 mcg/act inh
aer, 220 mcg/act inh aer
3
QL(24 / 30), MO
fluticasone propionate 50 mcg/act
nasal susp
1
QL(16 / 30)
QVAR 40 mcg/act inh aer, 80
mcg/act inh aer
3
QL(26.1 / 25), MO
Antileukotrienes [Antileukotrienos]
montelukast sodium 10 mg tab, 4
mg pckt, 4 mg tab chew, 5 mg tab
chew
1
SINGULAIR
MO
zafirlukast 10 mg tab, 20 mg tab
2
ACCOLATE
MO
Bronchodilators, Anticholinergic [Broncodilatadores, Anticolinérgicos]
INCRUSE ELLIPTA 62.5 mcg/inh
inh aer pwdr
4
MO
ipratropium bromide 0.02 % inh
soln
1
ATROVENT
PA(*), MO
ipratropium bromide 0.03 % nasal
soln, 0.06 % nasal soln
2
ATROVENT
MO
SPIRIVA HANDIHALER 18 mcg inh
cap
3
MO
SPIRIVA RESPIMAT 1.25 mcg/act
inh aer soln, 2.5 mcg/act inh aer
3
MO
Bronchodilators, Sympathomimetic [Broncodilatadores, Simpatomiméticos]
albuterol sulfate 2 mg tab, 4 mg tab
1
MO
Drug Name
Drug Tier
[Nivel]
Page 72 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
albuterol sulfate (2.5 MG/3ML)
PA(*), QL(360 / 30),
0.083% inh neb soln
1
MO
albuterol sulfate 2 mg/5ml syr
2
MO
albuterol sulfate (5 MG/ML) 0.5%
inh neb soln
2
PA(*), QL(60 / 30), MO
albuterol sulfate 0.63 mg/3ml inh
PA(*), QL(360 / 30),
neb soln, 1.25 mg/3ml inh neb soln
2
MO
albuterol sulfate er 4 mg tab er 12
2
VOSPIRE
MO
epinephrine 0.3 mg/0.3ml inj soln
auto-inj
2
AUVI-Q
EPIPEN 2-PAK 0.3 mg/0.3ml inj
soln auto-inj
4
EPIPEN JR 2-PAK 0.15 mg/0.3ml
inj soln auto-inj
4
PROAIR HFA 108 (90 Base)
mcg/act inh aer
3
QL(17 / 25), MO
PROAIR RESPICLICK 108 (90
Base) mcg/act inh aer pwdr
3
QL(1.3 / 25), MO
terbutaline sulfate 2.5 mg tab, 5 mg
tab
2
MO
terbutaline sulfate 1 mg/ml inj soln
2
PA(*)
VENTOLIN HFA 108 (90 Base)
mcg/act inh aer
3
QL(36 / 30), MO
Cystic Fibrosis Agents [Agentes Para La Fibrosis Quística]
CAYSTON 75 mg inh soln
5
PA
ESBRIET 267 mg cap
5
PA, MO
KALYDECO 150 mg tab, 50 mg
pckt, 75 mg pckt
5
PA, MO
OFEV 100 mg cap, 150 mg cap
5
PA, MO
TOBI PODHALER 28 mg inh cap
5
PA
Mast Cell Stabilizers [Estabilizadores De Los Mastocitos]
cromolyn sodium 20 mg/2ml inh
PA(*), QL(240 / 30),
neb soln
2
GASTROCROM
MO
Phosphodiesterase Inhibitors, Airways Disease [Inhibidores De La Fosfodiesterasa,
Enfermedad De Las Vías Respiratorias]
aminophylline 25 mg/ml iv soln
2
PA(*), HI
DALIRESP 500 mcg tab
4
MO
ELIXOPHYLLIN 80 mg/15ml oral
elix
4
MO
theophylline er 100 mg tab er 12 hr,
12 hr
1
MO
Page 73 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
theophylline er 400 mg tab er 24 hr,
24 hr
2
MO
Pulmonary Antihypertensives [Antihipertensivos Pulmonares]
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, LA, MO
OPSUMIT 10 mg tab
5
PA, LA, MO
sildenafil citrate 20 mg tab
2
REVATIO
PA, 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
PA(*)
ADVAIR DISKUS 100-50 mcg/dose
inh aer pwdr, 250-50 mcg/dose inh
aer pwdr, 500-50 mcg/dose inh aer
pwdr
3
PA, QL(60 / 30), MO
ADVAIR HFA 115-21 mcg/act inh
aer, 230-21 mcg/act inh aer, 45-21
mcg/act inh aer
3
PA, QL(12 / 30), MO
ANORO ELLIPTA 62.5-25 mcg/inh
inh aer pwdr
4
MO
ATROVENT HFA 17 mcg/act inh
aer
4
MO
BREO ELLIPTA 100-25 mcg/inh inh
aer pwdr, 200-25 mcg/inh inh aer
pwdr
3
PA, 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
PA(*), MO
PROLASTIN-C 1000 mg iv soln
5
LA, HI
PROLASTIN-C 1000 mg iv soln
reconstituted
5
HI
PULMOZYME 1 mg/ml inh soln
5
PA(*), MO
SYMBICORT 160-4.5 mcg/act inh
aer, 80-4.5 mcg/act inh aer
3
PA, MO
SKELETAL MUSCLE RELAXANTS [RELAJANTES MUSCULOESQUELETALES]
Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]
cyclobenzaprine hcl 7.5 mg tab
2
FEXMID
PA, HR
cyclobenzaprine hcl 10 mg tab, 5
mg tab
2
FEXMID
PA, HR
Page 74 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
methocarbamol 500 mg tab, 750
mg tab
1
PA, HR
SLEEP DISORDER AGENTS [DESÓRDENES DEL SUEÑO]
GABA Receptor Modulators [Moduladores Del Receptor De GABA]
flurazepam hcl 15 mg cap, 30 mg
cap
1
temazepam 15 mg cap, 22.5 mg
cap, 30 mg cap, 7.5 mg cap
2
RESTORIL
Sleep Disorders, Other [Desórdenes Del Sueño, Otros]
BUTISOL SODIUM 30 mg tab
4
HR
HETLIOZ 20 mg cap
5
PA, QL(30 / 30), MO
modafinil 100 mg tab, 200 mg tab
2
PROVIGIL
PA, MO
PROVIGIL 100 mg tab, 200 mg tab
5
PA, MO
ROZEREM 8 mg tab
4
MO
SILENOR 3 mg tab, 6 mg tab
4
QL(30 / 30), MO, HR
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
sodium polystyrene sulfonate 15
gm/60ml susp
2
SPS 15 gm/60ml susp
2
SYPRINE 250 mg cap
5
Electrolyte/Mineral Replacement [Electrólitos/Reemplazo De Minerales]
CARBAGLU 200 mg tab
5
PA, LA, MO
ISOLYTE-S iv soln
2
PA(*), HI
KLOR-CON 8 meq tab er
2
MO
KLOR-CON 10 10 meq tab er
2
MO
KLOR-CON M15 15 meq tab er
2
MO
KLOR-CON M20 20 meq tab er
2
MO
magnesium sulfate 50 % inj soln
2
PA(*), HI
NORMOSOL-R PH 7.4 iv soln
2
PA(*), HI
PLASMA-LYTE 148 iv soln
2
PA(*), HI
PLASMA-LYTE A iv soln
2
PA(*), HI
potassium chloride 20 MEQ/15ML
(10%) liq, 40 MEQ/15ML (20%) liq
2
MO
potassium chloride 10 meq/100ml iv
soln, 2 meq/ml iv soln, 20
2
PA(*), HI
Page 75 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
meq/100ml iv soln, 40 meq/100ml iv
soln
potassium chloride crys er 10 meq
tab er, 20 meq tab er
1
KLOR-CON
MO
potassium chloride er 10 meq cap
er, 8 meq cap er, 8 meq tab er
2
K-TAB
MO
potassium chloride in nacl 20-0.45
meq/l-% iv soln, 20-0.9 meq/l-% iv
soln
2
PA(*), HI
potassium citrate er 10 MEQ (1080
mg) tab er, 15 MEQ (1620 mg) tab
er, 5 MEQ (540 mg) tab er
2
UROCIT-K
prenatal vitamins tabs
2
VINATE
sodium chloride 0.9 % irrigation
soln
2
sodium chloride 0.45 % iv soln, 0.9
% iv soln, 2.5 meq/ml inj soln, 3 %
iv soln, 5 % iv soln
2
PA(*), HI
sodium fluoride 2.2 (1 F) mg tab
2
FLURA-TAB
MO
Therapeutic Nutrients/Minerals/Electrolytes [Nutrientes
Terapéuticos/Minerales/Electrolitos]
levocarnitine 1 gm/10ml soln, 330
mg tab
2
CARNITOR
MO
sterile water for irrigation soln
2
Therapeutic Nutrients/Minerals/Electrolytes (Combination Product) [Nutrientes
Terapéuticos/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
AMINOSYN M 3.5 % iv soln
4
PA(*), HI
AMINOSYN/ELECTROLYTES 8.5
% iv soln
2
PA(*), HI
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
2.75 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
Page 76 of 95
Updated 11/2016
Drug Name
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
CLINIMIX E/DEXTROSE (5/15) 5 %
iv soln
4
PA(*), HI
iv soln
4
PA(*), HI
iv soln
4
PA(*), HI
CLINIMIX/DEXTROSE (2.75/5)
2.75 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
4.25 % iv soln
4
PA(*), HI
CLINIMIX/DEXTROSE (5/15) 5 %
iv soln
4
PA(*), HI
iv soln
4
PA(*), HI
iv soln
4
PA(*), HI
CLINISOL SF 15 % iv soln
2
PA(*), HI
dextrose 10 % iv soln, 5 % iv soln
2
PA(*), HI
dextrose in lactated ringers 5 % iv
soln
2
PA(*), HI
dextrose-nacl 10-0.2 % iv soln, 100.45 % iv soln, 2.5-0.45 % iv soln,
5-0.2 % iv soln, 5-0.225 % iv soln,
5-0.33 % iv soln, 5-0.45 % iv soln,
5-0.9 % iv soln
2
PA(*), HI
HEPATAMINE 8 % iv soln
2
PA(*), HI
INTRALIPID 20 % iv emul, 30 % iv
emul
4
PA(*), HI
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, 20-5-0.45 meq/l-%-% iv
soln, 20-5-0.9 meq/l-%-% iv soln,
30-5-0.45 meq/l-%-% iv soln, 40-50.45 meq/l-%-% iv soln
2
PA(*), HI
lactated ringers iv soln
2
PA(*), HI
NEPHRAMINE 5.4 % iv soln
4
PA(*), HI
NORMOSOL-M IN D5W iv soln
2
PA(*), HI
PLASMA-LYTE-56 IN D5W iv soln
2
PA(*), HI
Page 77 of 95
Updated 11/2016
Drug Name
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 soln
TPN ELECTROLYTES iv soln
TRAVASOL 10 % iv soln
TROPHAMINE 10 % iv soln
Drug Tier
[Nivel]
Reference Name
[Nombre de
Referencia]
Requirements/Limits
2
PA(*), HI
4
4
2
4
2
4
4
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
PA(*), HI
Page 78 of 95
Updated 11/2016
OVER THE COUNTER (OTC) COVERED DRUG LIST
[LISTADO DE MEDICAMENTOS CUBIERTOS FUERA DEL RECETARIO]
Drug Name
Reference Name
[Nombre de Referencia]
This plan requires a prescription in order for you to obtain your OTC medications.
[Este 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 CHILDRENS odt 30 mg,
susp 30 mg/5ml, tab 30 mg,
ALLEGRA ALLERGY tab 60 mg, tab 180 mg
ALLEGRA-D ALLERGY & CONGESTION tab er
12 hr 60-120 mg, 24 hr 180-240 mg
allergy relief child syr 5 mg/5 ml
CLARITIN
allergy relief 10 mg tab
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 Eye 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
fexofenadine-pseudoephedrine er tab 24 hr 180240 mg
ketotifen fumarate ophth soln 0.025 %
ALLEGRA-D
ALAWAY, CLARITIN EYE, ZADITOR,
ZYRTEC ITCHY
lanzoprazole cap dr 15 mg
PREVACID
loratadine tab 10 mg
CLARITIN
loratadine-d er 24 hr tab 10-240 mg
Page 79 of 95
Updated 11/2016
Drug Name
Reference Name
[Nombre de Referencia]
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
wal-fex allergy tab 60 mg, 180 mg
ALAVERT, CLARITIN
ALLEGRA
ZADITOR ophth soln 0.025 %
ZEGERID OTC cap 20-1100 mg
ZYRTEC ALLERGY cap 10 mg, tab 10 mg
ZYRTEC CHILDRENS ALLERGY 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 80 of 95
Updated 11/2016
A
Abacavir Sulfate ............................................ 40
Abacavir-Lamivudine-Zidovudine .................. 40
Abelcet .......................................................... 26
Abilify Maintena............................................. 23
Abreva (OTC)................................................ 79
Acamprosate Calcium ................................... 12
Acarbose ....................................................... 42
Acebutolol HCl .............................................. 48
Acetaminophen-Codeine .............................. 10
Acetaminophen-Codeine #2.......................... 10
AcetaZOLAMIDE .......................................... 52
AcetaZOLAMIDE ER .................................... 52
Acetic Acid .................................................... 14
Acetylcysteine ............................................... 74
Acitretin ......................................................... 56
ActHIB ........................................................... 68
Actimmune .................................................... 68
Acyclovir........................................................ 39
Acyclovir Sodium .......................................... 39
Adacel ........................................................... 68
Adagen ......................................................... 57
Adapalene ..................................................... 56
Adcirca .......................................................... 74
Adefovir Dipivoxil .......................................... 38
Adempas ....................................................... 74
Advair Diskus ................................................ 74
Advair HFA.................................................... 74
Afeditab CR................................................... 49
Afinitor ........................................................... 32
Afinitor Disperz.............................................. 32
A-Hydrocort ................................................... 60
Ala Cort ......................................................... 60
Alavert ........................................................... 79
Alaway (OTC) ............................................... 79
Albenza ......................................................... 34
Albuterol Sulfate...................................... 72, 73
Albuterol Sulfate ER ...................................... 73
Alclometasone Dipropionate ......................... 60
Alcohol Preps ................................................ 14
Aldactazide ................................................... 50
Aldurazyme ................................................... 57
Alecensa ....................................................... 32
Alendronate Sodium ..................................... 69
Alfuzosin HCl ER ........................................... 59
Alimta ............................................................ 30
Alinia ............................................................. 34
All Day Allergy (OTC) .................................... 79
Allegra (OTC) ................................................ 79
Allegra-D (OTC) ............................................ 79
Allergy Relief (OTC) ...................................... 79
Allopurinol ..................................................... 28
Alosetron HCl ................................................ 58
Alphagan P .................................................... 71
ALPRAZolam ................................................ 41
Amantadine HCl ............................................ 35
Amcinonide ................................................... 60
Amifostine ..................................................... 30
Amikacin Sulfate ........................................... 13
AMILoride HCl ............................................... 52
Amiloride-Hydrochlorothiazide ...................... 50
Aminophylline ................................................ 73
Aminosyn II ................................................... 76
Aminosyn II/Electrolytes ................................ 76
Aminosyn M .................................................. 76
Aminosyn/Electrolytes ................................... 76
Aminosyn-HBC .............................................. 76
Aminosyn-PF ................................................. 76
Amiodarone HCl ............................................ 47
Amitiza .......................................................... 58
Amitriptyline HCl ............................................ 25
Amlodipine Besy-Benazepril HCl .................. 50
AmLODIPine Besylate................................... 49
Amlodipine-Atorvastatin ................................ 50
Ammonium Lactate ....................................... 56
Amoxapine .................................................... 25
Amoxicillin ..................................................... 16
Amoxicillin-Pot Clavulanate ........................... 16
Amoxicillin-Pot Clavulanate ER ..................... 16
Amphetamine-Dextroamphet ER .................. 54
Amphetamine-Dextroamphetamine ............... 54
Amphotericin B .............................................. 26
Ampicillin ....................................................... 16
Ampicillin Sodium .......................................... 16
Ampicillin-Sulbactam Sodium ........................ 16
Ampyra .......................................................... 55
Anadrol-50..................................................... 63
Anagrelide HCl .............................................. 45
Anastrozole ................................................... 31
AndroGel ....................................................... 63
AndroGel Pump ............................................. 63
Page 81 of 95
Updated 11/2016
Anoro Ellipta.................................................. 74
Apokyn .......................................................... 35
Aptiom ........................................................... 21
Aptivus .......................................................... 41
Aranesp (Albumin Free) ................................ 45
Arcalyst ......................................................... 68
ARIPiprazole ................................................. 23
Asacol HD ..................................................... 69
Aspirin-Dipyridamole ER ............................... 46
Atenolol ......................................................... 48
Atenolol-Chlorthalidone ................................. 50
Atorvastatin Calcium ..................................... 53
Atovaquone ................................................... 34
Atovaquone-Proguanil HCl............................ 34
Atripla ............................................................ 39
Atropine Sulfate ............................................ 70
Atrovent HFA ................................................ 74
Avastin .......................................................... 30
Avelox ........................................................... 18
Avita .............................................................. 56
Avonex .......................................................... 55
Avonex Pen................................................... 55
Avonex Prefilled ............................................ 55
AzaCITIDine.................................................. 30
Azasan .......................................................... 66
AzaTHIOprine ............................................... 66
AzaTHIOprine Sodium .................................. 66
Azelastine HCl .............................................. 72
Azilect ........................................................... 35
Azithromycin ................................................. 17
Azopt ............................................................. 71
Aztreonam..................................................... 16
B
BACiiM .......................................................... 14
Bacitracin ...................................................... 14
Bacitracin-Polymyxin B ................................. 70
Bacitra-Neomycin-Polymyxin-HC .................. 70
Baclofen ........................................................ 38
Balsalazide Disodium .................................... 69
Banzel ........................................................... 21
Baraclude ...................................................... 38
Beleodaq ....................................................... 32
Benazepril HCl .............................................. 47
Benazepril-Hydrochlorothiazide .................... 50
Benicar .......................................................... 47
Benicar HCT ................................................. 50
Benlysta ........................................................ 68
Benzoyl Peroxide-Erythromycin .................... 57
Benztropine Mesylate .............................. 34, 35
Betamethasone Dipropionate ........................ 60
Betamethasone Dipropionate Aug ................ 60
Betamethasone Valerate ............................... 60
Betaseron ...................................................... 55
Betaxolol HCl .......................................... 48, 71
Bethanechol Chloride .................................... 59
Bexarotene .................................................... 34
Bicalutamide .................................................. 29
Bicillin C-R ..................................................... 16
Bicillin C-R 900/300 ....................................... 16
Bicillin L-A ..................................................... 17
BiCNU ........................................................... 30
Biltricide......................................................... 34
Bimatoprost ................................................... 71
Bisoprolol Fumarate ...................................... 48
Bisoprolol-Hydrochlorothiazide ...................... 51
Bleomycin Sulfate.......................................... 30
Boostrix ......................................................... 68
Bosulif ........................................................... 32
Breo Ellipta .................................................... 74
Brilinta ........................................................... 46
Brimonidine Tartrate ...................................... 71
Briviact .......................................................... 19
Bromocriptine Mesylate ................................. 35
Budesonide ................................................... 69
Bumetanide ................................................... 52
Buprenorphine HCl ........................................ 12
Buprenorphine HCl-Naloxone HCl ................ 12
BuPROPion HCl ............................................ 13
BuPROPion HCl ER (Smoking Det) .............. 13
BuPROPion HCl ER (SR) .............................. 13
BuPROPion HCl ER (XL) .............................. 13
BusPIRone HCl ............................................. 41
Busulfex ........................................................ 29
Butalbital-APAP-Caffeine .............................. 10
Butisol Sodium .............................................. 75
Bydureon ....................................................... 42
Byetta 10 MCG Pen ...................................... 42
Byetta 5 MCG Pen ........................................ 42
C
Cabergoline ................................................... 65
Cabometyx .................................................... 32
Calcipotriene ................................................. 56
Calcitonin (Salmon) ....................................... 69
Calcitriol ........................................................ 69
Page 82 of 95
Updated 11/2016
Calcium Acetate (Phos Binder) ..................... 60
Chantix Starting Month Pak ........................... 13
Canasa ......................................................... 69
Chemet.......................................................... 75
Cancidas ....................................................... 26
Chloramphenicol Sod Succinate ................... 14
Candesartan Cilexetil .................................... 47
Chlorhexidine Gluconate ............................... 56
Candesartan Cilexetil-HCTZ ......................... 51
Chloroquine Phosphate ................................. 34
Capastat Sulfate ........................................... 28
Chlorothiazide ............................................... 52
Caprelsa........................................................ 32
ChlorproMAZINE HCl .................................... 25
Carac ............................................................ 56
Chlorthalidone ............................................... 52
Carafate ........................................................ 59
Cholestyramine Light..................................... 53
Carbaglu ....................................................... 75
Chorionic Gonadotropin ................................ 62
CarBAMazepine ............................................ 21
Ciclopirox ...................................................... 26
CarBAMazepine ER ...................................... 21
Ciclopirox Olamine ........................................ 26
Carbidopa ..................................................... 35
Cilostazol ....................................................... 46
Carbidopa-Levodopa .................................... 35
Cimetidine ..................................................... 58
Carbidopa-Levodopa ER .............................. 35
Cinryze .......................................................... 66
Carbidopa-Levodopa-Entacapone ................ 35
Ciprodex ........................................................ 71
CARBOplatin................................................. 30
Ciprofloxacin ................................................. 18
Carimune NF................................................. 67
Ciprofloxacin HCl .......................................... 18
Cartia XT ....................................................... 49
Ciprofloxacin in D5W ..................................... 18
Carvedilol ...................................................... 48
Ciprofloxacin-Ciproflox HCl ER ..................... 18
Cayston ......................................................... 73
CISplatin........................................................ 30
Cefaclor......................................................... 15
Citalopram Hydrobromide ............................. 23
Cefaclor ER................................................... 15
Cladribine ...................................................... 30
Cefadroxil ...................................................... 15
Claravis ......................................................... 56
CeFAZolin Sodium ........................................ 15
Clarithromycin ............................................... 17
Cefdinir ......................................................... 15
Clarithromycin ER ......................................... 17
Cefepime HCl................................................ 15
Claritin (OTC) ................................................ 79
Cefotaxime Sodium ....................................... 15
Claritin Eye (OTC) ......................................... 79
CefOXitin Sodium ......................................... 15
Claritin Reditabs (OTC) ................................. 79
Cefpodoxime Proxetil .................................... 15
Claritin-D ....................................................... 79
Cefprozil ........................................................ 15
Claritin-D (OTC) ............................................ 79
CefTAZidime ................................................. 15
Cleocin .......................................................... 14
CefTRIAXone Sodium ................................... 15
Clindamycin HCl ............................................ 14
Cefuroxime Axetil .......................................... 16
Clindamycin Palmitate HCl ............................ 14
Cefuroxime Sodium ...................................... 16
Clindamycin Phosphate................................. 14
CeleBREX ..................................................... 10
Clindamycin Phosphate in D5W .................... 14
Celecoxib ...................................................... 10
Clinimix E/Dextrose (2.75/10) ........................ 76
CellCept ........................................................ 66
Clinimix E/Dextrose (2.75/5).......................... 76
Celontin ......................................................... 20
Clinimix E/Dextrose (4.25/25) ........................ 76
Cephalexin .................................................... 16
Clinimix E/Dextrose (4.25/5).......................... 76
Cerebyx......................................................... 21
Clinimix E/Dextrose (5/15)............................. 77
Cerezyme...................................................... 57
Cervarix......................................................... 68
Cetirizine (OTC) ............................................ 79
Clinimix/Dextrose (2.75/5) ............................. 77
Cetirizine HCl ................................................ 72
Clinimix/Dextrose (4.25/10) ........................... 77
Cetirizine-Pseudoephedrine (OTC) ............... 79
Cevimeline HCl ............................................. 55
Chantix .......................................................... 13
Clinimix/Dextrose (4.25/5) ............................. 77
Chantix Continuing Month Pak...................... 13
Clinimix/Dextrose (5/15) ................................ 77
Page 83 of 95
Updated 11/2016
Cyramza ........................................................ 30
Cystadane ..................................................... 57
Clinisol SF ..................................................... 77
Cystagon ....................................................... 57
Clobetasol Propionate ................................... 60
Cytarabine ..................................................... 30
Clobetasol Propionate E ............................... 60
D
ClomiPRAMINE HCl ..................................... 25
ClonazePAM ................................................. 20
Dacarbazine .................................................. 30
CloNIDine HCl............................................... 46
Dactinomycin ................................................. 30
CloNIDine HCl ER ......................................... 46
Daliresp ......................................................... 73
Clopidogrel Bisulfate ..................................... 46
Danazol ......................................................... 63
Clorazepate Dipotassium .............................. 41
Dantrolene Sodium........................................ 38
Clotrimazole .................................................. 26
Dapsone ........................................................ 28
Clotrimazole-Betamethasone ........................ 57
Daptacel ........................................................ 68
CloZAPine ..................................................... 37
Daptomycin ................................................... 14
Coartem ........................................................ 34
Daraprim ....................................................... 34
Colchicine ..................................................... 28
Darzalex ........................................................ 32
Colchicine-Probenecid .................................. 28
DAUNOrubicin HCl ........................................ 30
Colcrys .......................................................... 28
Decitabine ..................................................... 30
Colestipol HCl ............................................... 53
Delzicol .......................................................... 69
Colistimethate Sodium .................................. 14
Demeclocycline HCl ...................................... 19
Colocort......................................................... 60
Demerol......................................................... 12
Combigan...................................................... 70
Demser.......................................................... 51
Combivent Respimat ..................................... 74
Denavir .......................................................... 39
Combivir ........................................................ 40
Depen Titratabs ............................................. 59
Cometriq (100 mg Daily Dose) ...................... 32
Depo-Provera ................................................ 64
Cometriq (140 mg Daily Dose) ...................... 32
Depo-Testosterone........................................ 63
Cometriq (60 mg Daily Dose) ........................ 32
Descovy ........................................................ 40
Complera ...................................................... 39
Desipramine HCl ........................................... 25
Condylox ....................................................... 56
Desloratadine ................................................ 72
Constulose .................................................... 58
Desmopressin Ace Rhinal Tube .................... 62
Copaxone...................................................... 55
Desmopressin Ace Spray Refrig ................... 62
Cortisone Acetate ......................................... 60
Desmopressin Acetate .................................. 62
Cosentyx ....................................................... 56
Desonide ....................................................... 60
Cosentyx Sensoready Pen............................ 56
Desoximetasone ........................................... 60
Cosmegen..................................................... 30
Desvenlafaxine ER ........................................ 23
Cotellic .......................................................... 32
Dexamethasone ............................................ 60
Coumadin...................................................... 44
Dexamethasone Sodium Phosphate ....... 61, 71
Creon ............................................................ 57
Dexrazoxane ................................................. 30
Cresemba ............................................... 26, 27
Dextroamphetamine Sulfate .......................... 54
Crixivan ......................................................... 41
Dextroamphetamine Sulfate ER .................... 54
Cromolyn Sodium ............................. 58, 70, 73
Dextrose ........................................................ 77
Cubicin .......................................................... 14
Dextrose in Lactated Ringers ........................ 77
Cyclobenzaprine HCl .................................... 74
Dextrose-NaCl ............................................... 77
Cyclophosphamide ....................................... 29
Diazepam ...................................................... 20
Cycloserine ................................................... 29
Diazepam Intensol......................................... 20
Cycloset ........................................................ 42
Diclofenac Potassium .................................... 10
CycloSPORINE ............................................. 66
Diclofenac Sodium ............................ 10, 56, 71
CycloSPORINE Modified .............................. 66
Diclofenac Sodium ER .................................. 10
Cyproheptadine HCl ...................................... 72
Page 84 of 95
Updated 11/2016
Dicloxacillin Sodium ...................................... 17
Dicyclomine HCl............................................ 57
Didanosine .................................................... 40
Diflorasone Diacetate .................................... 61
Digox ............................................................. 51
Digoxin .................................................... 51, 52
Dihydroergotamine Mesylate ........................ 28
Dilantin .......................................................... 21
Dilantin Infatabs ............................................ 22
Diltiazem HCl ................................................ 49
Diltiazem HCl ER .......................................... 49
Diltiazem HCl ER Beads ............................... 49
Diltiazem HCl ER Coated Beads................... 49
Dilt-XR .......................................................... 49
Dipentum....................................................... 69
DiphenhydrAMINE HCl ................................. 25
Diphenoxylate-Atropine ................................. 58
Diphtheria-Tetanus Toxoids DT .................... 68
Disopyramide Phosphate .............................. 47
Disopyramide Phosphate ER ........................ 47
Disulfiram ...................................................... 12
Diuril .............................................................. 52
Divalproex Sodium ........................................ 20
Divalproex Sodium ER .................................. 20
DOCEtaxel .................................................... 30
Dofetilide ....................................................... 47
Donepezil HCl ............................................... 22
Doribax ......................................................... 16
Dorzolamide HCl ........................................... 71
Dorzolamide HCl-Timolol Mal ....................... 70
Dovonex ........................................................ 56
Doxazosin Mesylate ...................................... 46
Doxepin HCl .................................................. 25
Doxil .............................................................. 30
DOXOrubicin HCl .......................................... 30
DOXOrubicin HCl Liposomal......................... 30
Doxycycline Hyclate ................................ 19, 56
Doxycycline Monohydrate ............................. 19
Dronabinol..................................................... 26
Droxia ........................................................... 30
DULoxetine HCl ...................................... 23, 25
Duramorph .................................................... 12
Durezol ......................................................... 71
Effient ............................................................ 46
Elaprase ........................................................ 57
Elelyso........................................................... 57
Elidel ............................................................. 56
Eligard ........................................................... 65
Eliquis............................................................ 44
Elitek ............................................................. 30
Elixophyllin .................................................... 73
Elmiron .......................................................... 59
Emcyt ............................................................ 30
Emend ........................................................... 26
Empliciti ......................................................... 34
Emsam .......................................................... 23
Emtriva .......................................................... 40
Enalapril Maleate .......................................... 47
Enalapril-Hydrochlorothiazide ....................... 51
Enbrel ............................................................ 66
Enbrel SureClick ........................................... 66
Endocet ......................................................... 10
Engerix-B ...................................................... 68
Enoxaparin Sodium ................................. 44, 45
Entacapone ................................................... 35
Entecavir ....................................................... 38
Entresto ......................................................... 52
Enulose ......................................................... 58
Epclusa ......................................................... 39
Epiduo ........................................................... 57
EPINEPHrine ................................................ 73
EpiPen 2-Pak ................................................ 73
EpiPen Jr 2-Pak ............................................ 73
Epirubicin HCl ............................................... 30
Epivir ............................................................. 40
Epivir HBV ..................................................... 38
Eplerenone .................................................... 52
Epzicom ........................................................ 40
Eraxis ............................................................ 27
Ergoloid Mesylates ........................................ 22
Ergomar ........................................................ 28
Erivedge ........................................................ 32
Erwinaze ....................................................... 46
Ery ................................................................. 17
EryPed 200 ................................................... 17
EryPed 400 ................................................... 18
Ery-Tab ......................................................... 18
E
Erythrocin Lactobionate................................. 18
Erythrocin Stearate........................................ 18
E.E.S. 400 ..................................................... 17
Erythromycin ................................................. 18
E.E.S. Granules ............................................ 17
Erythromycin Base ........................................ 18
Edurant ......................................................... 39
Erythromycin Ethylsuccinate ......................... 18
Page 85 of 95
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Esbriet ........................................................... 73
Escitalopram Oxalate .................................... 23
Estazolam ..................................................... 41
Estrace .......................................................... 63
Estradiol ........................................................ 63
Estradiol Valerate .......................................... 63
Estradiol-Norethindrone Acet ........................ 64
Ethambutol HCl ............................................. 29
Ethosuximide ................................................ 20
Etodolac .................................................. 10, 11
Etodolac ER .................................................. 11
Etoposide ...................................................... 32
Evotaz ........................................................... 40
Exemestane .................................................. 31
Exjade ........................................................... 75
F
Fabrazyme .................................................... 57
Famciclovir .................................................... 39
Famotidine .................................................... 58
Famotidine Premixed .................................... 58
Fanapt ........................................................... 36
Fanapt Titration Pack .................................... 36
Fareston ........................................................ 30
Farydak ......................................................... 32
Faslodex ....................................................... 30
FazaClo......................................................... 37
Felbamate ..................................................... 21
Felodipine ER ............................................... 49
Fenofibrate .................................................... 53
Fenofibrate Micronized ................................. 53
Fenofibric Acid .............................................. 53
FentaNYL ...................................................... 11
Fentora ......................................................... 12
Ferriprox........................................................ 75
Fetzima ......................................................... 24
Fetzima Titration ........................................... 24
Fexofenadine-Pseudoephedrine (OTC) ........ 79
Finasteride .................................................... 59
Firazyr ........................................................... 66
Flecainide Acetate ........................................ 48
Flovent Diskus .............................................. 72
Flovent HFA .................................................. 72
Fluconazole................................................... 27
Fluconazole in Dextrose ............................... 27
Fluconazole In Sodium Chloride ................... 27
Flucytosine .................................................... 27
Fludarabine Phosphate ................................. 31
Fludrocortisone Acetate ................................ 61
Fluocinolone Acetonide ................................. 61
Fluocinolone Acetonide Body ........................ 61
Fluocinonide .................................................. 61
Fluocinonide-E .............................................. 61
Fluorometholone ........................................... 71
Fluorouracil ............................................. 31, 56
FLUoxetine HCl ............................................. 24
FluPHENAZine Decanoate............................ 36
FluPHENAZine HCl ....................................... 36
Flurazepam HCl ............................................ 75
Flurbiprofen ................................................... 11
Flurbiprofen Sodium ...................................... 71
Flutamide ...................................................... 29
Fluticasone Propionate............................ 61, 72
FluvoxaMINE Maleate ................................... 24
Fondaparinux Sodium ................................... 45
Forteo ............................................................ 69
Fosinopril Sodium.......................................... 47
Fosinopril Sodium-HCTZ ............................... 51
Furosemide ................................................... 52
Fuzeon .......................................................... 40
Fycompa ....................................................... 21
G
Gabapentin.................................................... 20
Gabitril ........................................................... 20
Galantamine Hydrobromide .......................... 22
Galantamine Hydrobromide ER .................... 22
Gammagard .................................................. 67
Gammaplex ................................................... 67
Gamunex-C ................................................... 67
Ganciclovir Sodium ....................................... 38
Gardasil ......................................................... 68
Gardasil 9 ...................................................... 68
Gattex............................................................ 58
Gauze Pads .................................................. 43
GaviLyte-C .................................................... 57
GaviLyte-G .................................................... 57
GaviLyte-N with Flavor Pack ......................... 58
Gemcitabine HCl ........................................... 31
Gemfibrozil .................................................... 53
Gengraf ......................................................... 66
Genotropin .................................................... 62
Genotropin MiniQuick .................................... 62
Gentak........................................................... 13
Gentamicin Sulfate ........................................ 13
Genvoya ........................................................ 40
Page 86 of 95
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Geodon ......................................................... 36
Gilenya .......................................................... 55
Gilotrif ........................................................... 32
Glatopa ......................................................... 55
Gleevec ......................................................... 32
Gleostine ....................................................... 29
Glimepiride .................................................... 42
GlipiZIDE....................................................... 42
GlipiZIDE ER................................................. 42
GlipiZIDE-MetFORMIN HCl .......................... 43
GlucaGen HypoKit ........................................ 43
Glucagon Emergency ................................... 43
Glycopyrrolate ............................................... 57
Granisetron HCl ............................................ 26
Griseofulvin Microsize ................................... 27
Griseofulvin Ultramicrosize ........................... 27
Gris-PEG....................................................... 27
GuanFACINE HCl ......................................... 46
Guanidine HCl............................................... 28
H
Haloperidol .................................................... 36
Haloperidol Decanoate ................................. 36
Haloperidol Lactate ....................................... 36
Harvoni ......................................................... 39
Havrix ............................................................ 68
Heparin Sodium (Porcine) ............................. 45
Hepatamine................................................... 77
Hepsera ........................................................ 38
Herceptin....................................................... 31
Hetlioz ........................................................... 75
Hexalen ......................................................... 29
HumaLOG ..................................................... 43
HumaLOG KwikPen ...................................... 43
HumaLOG Mix 50/50 .................................... 43
HumaLOG Mix 50/50 KwikPen ..................... 43
HumaLOG Mix 75/25 .................................... 44
HumaLOG Mix 75/25 KwikPen ..................... 44
Humatrope .................................................... 62
Humira .......................................................... 66
Humira Pen ................................................... 66
Humira Pen-Crohns Starter........................... 66
Humira Pen-Psoriasis Starter........................ 67
HumuLIN 70/30 ............................................. 44
HumuLIN 70/30 KwikPen .............................. 44
HumuLIN N ................................................... 44
HumuLIN N KwikPen .................................... 44
HumuLIN R ................................................... 44
HumuLIN R U-500 (CONCENTRATED)........ 44
Hycamtin ....................................................... 32
HydrALAZINE HCl ......................................... 53
Hydrea........................................................... 30
Hydrochlorothiazide....................................... 52
Hydrocodone-Acetaminophen ....................... 10
Hydrocortisone .............................................. 61
Hydrocortisone Butyrate ................................ 61
Hydrocortisone Valerate ................................ 61
Hydrocortisone-Acetic Acid ........................... 71
HYDROmorphone HCl .................................. 12
HYDROmorphone HCl PF............................. 12
Hydroxychloroquine Sulfate .......................... 34
HYDROXYprogesterone Caproate ................ 64
Hydroxyurea .................................................. 30
HydrOXYzine HCl.......................................... 41
I
Ibandronate Sodium ...................................... 69
Ibrance .......................................................... 32
Ibuprofen ....................................................... 11
Iclusig ............................................................ 32
IDArubicin HCl ............................................... 31
Ifex ................................................................ 31
Ifosfamide...................................................... 31
Ilaris............................................................... 68
Imbruvica....................................................... 32
Imipenem-Cilastatin....................................... 16
Imipramine HCl ............................................. 25
Imipramine Pamoate ..................................... 25
Imiquimod...................................................... 56
Imovax Rabies .............................................. 68
Increlex.......................................................... 62
Incruse Ellipta ................................................ 72
Indapamide ................................................... 52
Indomethacin ................................................. 11
Infanrix .......................................................... 68
Inlyta.............................................................. 32
Insulin Pen Needles ...................................... 44
Insulin Syringe ............................................... 44
Intelence........................................................ 39
Intralipid......................................................... 77
Intron A.......................................................... 38
INVanz .......................................................... 16
Invega Sustenna ..................................... 36, 37
Invirase.......................................................... 41
Invokamet...................................................... 43
Invokana........................................................ 42
Page 87 of 95
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Ipol ................................................................ 68
Ipratropium Bromide ..................................... 72
Ipratropium-Albuterol .................................... 74
Irbesartan ...................................................... 47
Irbesartan-Hydrochlorothiazide ..................... 51
Iressa ............................................................ 32
Irinotecan HCl ............................................... 31
Isentress ....................................................... 39
Isolyte-S ........................................................ 75
Isoniazid ........................................................ 29
Isosorbide Dinitrate ....................................... 54
Isosorbide Dinitrate ER ................................. 54
Isosorbide Mononitrate ................................. 54
Isosorbide Mononitrate ER............................ 54
Isradipine ...................................................... 49
Itraconazole .................................................. 27
Ivermectin ..................................................... 34
Ixiaro ............................................................. 68
J
Jakafi ............................................................ 32
Janumet ........................................................ 43
Janumet XR .................................................. 43
Januvia ......................................................... 42
Jentadueto .................................................... 43
Jentadueto XR .............................................. 43
Juxtapid......................................................... 53
K
Kadcyla ......................................................... 31
Kaletra .......................................................... 41
Kalydeco ....................................................... 73
Kapvay .......................................................... 54
KCl in Dextrose-NaCl .................................... 77
Ketoconazole ................................................ 27
Ketoprofen .................................................... 11
Ketorolac Tromethamine ............................... 71
Ketotifen (OTC) ............................................. 79
Keytruda........................................................ 32
Kineret .......................................................... 67
Kionex ........................................................... 75
Klor-Con ........................................................ 75
Klor-Con 10 ................................................... 75
Klor-Con M15 ................................................ 75
Klor-Con M20 ................................................ 75
Kombiglyze XR ............................................. 43
Korlym ........................................................... 43
Kuvan ............................................................ 57
Kynamro ........................................................ 53
L
Labetalol HCl ................................................. 48
Lactated Ringers ........................................... 77
Lactulose ....................................................... 58
LamiVUDine ............................................ 38, 40
Lamivudine-Zidovudine ................................. 40
LamoTRIgine ................................................. 21
Lanoxin.......................................................... 52
Lansoprazole ................................................. 59
Lantus ........................................................... 44
Lantus SoloStar ............................................. 44
Lanzoprazole (OTC) ...................................... 79
Latanoprost ................................................... 71
Latuda ........................................................... 37
Lazanda ........................................................ 12
Leflunomide ................................................... 68
Lenvima 10 MG Daily Dose ........................... 33
Lenvima 8 MG Daily Dose ............................. 33
Letrozole ....................................................... 31
Leucovorin Calcium ....................................... 31
Leukeran ....................................................... 29
Leukine.......................................................... 45
Leuprolide Acetate ........................................ 65
Levemir ......................................................... 44
Levemir FlexTouch ........................................ 44
LevETIRAcetam ............................................ 19
LevETIRAcetam ER ...................................... 19
Levetiracetam in NaCl ................................... 19
Levobunolol HCl ............................................ 71
LevOCARNitine ............................................. 76
Levocetirizine Dihydrochloride ...................... 72
Levofloxacin .................................................. 18
Levofloxacin in D5W...................................... 18
Levoleucovorin Calcium ................................ 31
Levothyroxine Sodium ................................... 64
Levoxyl .......................................................... 64
Lexiva ............................................................ 41
Lidocaine ....................................................... 12
Lidocaine HCl ................................................ 12
Lidocaine HCl (PF) ........................................ 12
Lidocaine Viscous ......................................... 12
Lindane ......................................................... 34
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Linezolid ........................................................ 14
Linzess .......................................................... 58
Liothyronine Sodium ..................................... 64
Lisinopril ........................................................ 47
Lisinopril-Hydrochlorothiazide ....................... 51
Lithium .......................................................... 41
Lithium Carbonate ......................................... 42
Lithium Carbonate ER ................................... 42
Lithostat ........................................................ 59
LoKara .......................................................... 61
Lonsurf .......................................................... 33
Loperamide HCl ............................................ 58
Loratadine (OTC) .......................................... 79
Loratadine-D (OTC) ...................................... 79
LORazepam .................................................. 20
LORazepam Intensol .................................... 20
Losartan Potassium ...................................... 47
Losartan Potassium-HCTZ............................ 51
Lovastatin...................................................... 53
Loxapine Succinate ....................................... 36
Lumigan ........................................................ 71
Lupron Depot ................................................ 65
Lupron Depot-Ped......................................... 65
Lynparza ....................................................... 33
Lyrica ............................................................ 20
Lysodren ....................................................... 65
Mercaptopurine ............................................. 30
Meropenem ................................................... 16
Mesalamine ................................................... 69
Mesalamine-Cleanser ................................... 69
Mesna ........................................................... 31
Mesnex.......................................................... 31
Mestinon........................................................ 28
Metadate ER ................................................. 55
MetFORMIN HCl ........................................... 42
MetFORMIN HCl ER ..................................... 42
MetFORMIN HCl ER (OSM) .......................... 42
Methazolamide .............................................. 52
Methenamine Hippurate ................................ 14
Methimazole .................................................. 66
Methocarbamol ............................................. 75
Methotrexate ................................................. 67
Methotrexate Sodium .................................... 67
Methotrexate Sodium (PF) ............................ 67
Methoxsalen Rapid........................................ 56
Methscopolamine Bromide ............................ 57
Methyclothiazide ........................................... 52
Methyldopa.................................................... 46
Methylergonovine Maleate ............................ 59
Methylphenidate HCl ..................................... 55
Methylphenidate HCl ER ............................... 55
Methylphenidate HCl ER (CD) ...................... 55
MethylPREDNISolone ................................... 61
M
MethylPREDNISolone (Pak) ......................... 61
MethylPREDNISolone Acetate ...................... 61
Magnesium Sulfate ....................................... 75
MethylPREDNISolone Sodium Succ ............. 61
Malarone ....................................................... 34
Metipranolol................................................... 71
Malathion ...................................................... 34
Metoclopramide HCl ...................................... 25
Maprotiline HCl ............................................. 24
Metolazone.................................................... 52
Marplan ......................................................... 23
Metoprolol Succinate ER ............................... 48
Matulane ....................................................... 29
Metoprolol Tartrate ........................................ 48
Matzim LA ..................................................... 49
Metoprolol-Hydrochlorothiazide ..................... 51
Meclizine HCl ................................................ 25
MetroNIDAZOLE ........................................... 14
MedroxyPROGESTERone Acetate ............... 64
MetroNIDAZOLE in NaCl .............................. 14
Mefloquine HCl ............................................. 34
Mexiletine HCl ............................................... 48
Megestrol Acetate ......................................... 64
Miacalcin ....................................................... 69
Mekinist ......................................................... 33
Midodrine HCl ............................................... 46
Meloxicam ..................................................... 11
Minitran ......................................................... 54
Melphalan HCl .............................................. 29
Minocycline HCl ............................................ 19
Memantine HCl ............................................. 22
Minoxidil ........................................................ 53
Menactra ....................................................... 68
Mirtazapine .................................................... 23
Menomune .................................................... 68
Misoprostol .................................................... 59
Menveo ......................................................... 68
Mitomycin ...................................................... 31
Meperidine HCl ............................................. 12
Mitoxantrone HCl .......................................... 31
Mepron .......................................................... 34
M-M-R II ........................................................ 68
Page 89 of 95
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Modafinil........................................................ 75
Moexipril HCl................................................. 47
Moexipril-Hydrochlorothiazide ....................... 51
Molindone HCl .............................................. 36
Mometasone Furoate .................................... 61
Montelukast Sodium ..................................... 72
Morphine Sulfate ........................................... 12
Morphine Sulfate (Concentrate) .................... 12
Morphine Sulfate (PF) ................................... 12
Morphine Sulfate ER ..................................... 11
Movantik........................................................ 58
Moxifloxacin HCl ........................................... 18
Mozobil ......................................................... 45
Multaq ........................................................... 48
Mupirocin ...................................................... 14
Mupirocin Calcium ........................................ 14
Mustargen ..................................................... 29
Mycamine...................................................... 27
Mycophenolate Mofetil .................................. 67
Mycophenolic Acid ........................................ 67
Myfortic ......................................................... 67
Myrbetriq ....................................................... 59
N
Nabumetone ................................................. 11
Nadolol .......................................................... 49
Nafcillin Sodium ............................................ 17
Nafcillin Sodium In Dextrose ......................... 17
Naglazyme .................................................... 57
Nalbuphine HCl ............................................. 12
Naloxone HCl ................................................ 13
Naltrexone HCl.............................................. 13
Namenda XR ................................................ 23
Namenda XR Titration Pack.......................... 23
Naproxen ...................................................... 11
Naproxen DR ................................................ 11
Naproxen Sodium ......................................... 11
Naratriptan HCl ............................................. 28
Nateglinide .................................................... 42
Natpara ......................................................... 70
Nebupent ...................................................... 34
Needles, Insulin disp., Safety ........................ 44
Nefazodone HCl............................................ 24
Neomycin Sulfate .......................................... 13
Neomycin-Bacitracin Zn-Polymyx ................. 70
Neomycin-Polymyxin-Dexameth ................... 70
Neomycin-Polymyxin-Gramicidin .................. 70
Neomycin-Polymyxin-HC ........................ 70, 71
NephrAmine .................................................. 77
Neulasta ........................................................ 45
Neupogen...................................................... 45
Neupro .......................................................... 35
Nevanac ........................................................ 71
Nevirapine ..................................................... 39
Nevirapine ER ............................................... 39
NexAVAR ...................................................... 33
Niacin ER (Antihyperlipidemic) ...................... 53
NiCARdipine HCl ........................................... 50
Nicotrol .......................................................... 13
Nicotrol NS .................................................... 13
Nifedical XL ................................................... 50
NIFEdipine ER Osmotic ................................ 50
Nilandron ....................................................... 29
Nilutamide ..................................................... 29
NiMODipine ................................................... 50
Ninlaro ........................................................... 33
Nitro-Dur........................................................ 54
Nitrofurantoin Macrocrystal ........................... 15
Nitrofurantoin Monohyd Macro ...................... 15
Nitroglycerin .................................................. 54
Nitrostat ......................................................... 54
Norditropin FlexPro ....................................... 62
Norditropin NordiFlex Pen ............................. 62
Norethindrone ............................................... 60
Norethindrone Acetate .................................. 64
Norgestim-Eth Estrad Triphasic .................... 64
Normosol-M in D5W ...................................... 77
Normosol-R pH 7.4........................................ 75
Norpace CR .................................................. 48
Northera ........................................................ 46
Nortriptyline HCl ............................................ 25
Norvir............................................................. 41
Noxafil ........................................................... 27
Nuedexta ....................................................... 55
Nulojix ........................................................... 67
Nuplazid ........................................................ 37
Nutropin AQ NuSpin 10 ................................. 62
Nutropin AQ NuSpin 20 ................................. 63
Nutropin AQ NuSpin 5 ................................... 63
Nutropin AQ Pen ........................................... 63
Nyamyc ......................................................... 27
Nystatin ......................................................... 27
Nystatin-Triamcinolone.................................. 27
Nystop ........................................................... 27
Page 90 of 95
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O
Paser ............................................................. 28
Pataday ......................................................... 71
Octreotide Acetate ........................................ 65
Paxil .............................................................. 24
Odefsey......................................................... 39
Pedvax HIB ................................................... 68
Odomzo ........................................................ 33
PEG 3350-KCl-Na Bicarb-NaCl ..................... 58
Ofev .............................................................. 73
PEG-3350/Electrolytes .................................. 58
Ofloxacin ....................................................... 18
Peganone ...................................................... 22
OLANZapine ................................................. 37
Pegasys ........................................................ 38
Omega-3-acid Ethyl Esters ........................... 53
Pegasys ProClick .......................................... 38
Omeprazole .................................................. 59
Peg-Intron ..................................................... 38
Omeprazole (OTC) ....................................... 80
Peg-Intron Redipen ....................................... 38
Oncaspar ...................................................... 46
Penicillin G Pot in Dextrose ........................... 17
Ondansetron ................................................. 26
Penicillin G Potassium................................... 17
Ondansetron HCl .......................................... 26
Penicillin G Procaine ..................................... 17
Onfi ............................................................... 21
Penicillin G Sodium ....................................... 17
Onglyza ......................................................... 42
Penicillin V Potassium ................................... 17
Opdivo .......................................................... 34
Pentam .......................................................... 34
Opsumit......................................................... 74
Pentasa ......................................................... 69
Orapred ODT ................................................ 61
Pentoxifylline ER ........................................... 52
Orencia ......................................................... 67
Perindopril Erbumine ..................................... 47
Orencia ClickJect .......................................... 67
Perjeta ........................................................... 31
Orfadin .......................................................... 57
Permethrin..................................................... 34
Ortho Tri-Cyclen (28) .................................... 64
Perphenazine ................................................ 26
Otezla ........................................................... 67
Phenadoz ...................................................... 26
Oxacillin Sodium ........................................... 17
Phenelzine Sulfate ........................................ 23
Oxaliplatin ..................................................... 31
PHENobarbital .............................................. 21
Oxandrolone ................................................. 63
Phenytoin ...................................................... 22
OXcarbazepine ............................................. 22
Phenytoin Sodium ......................................... 22
Oxsoralen Ultra ............................................. 56
Phenytoin Sodium Extended ......................... 22
Oxtellar XR.................................................... 22
Phoslyra ........................................................ 60
Oxybutynin Chloride ...................................... 59
Phospholine Iodide ........................................ 71
Oxybutynin Chloride ER ................................ 59
Pilocarpine HCl ............................................. 56
OxyCODONE HCl ER ................................... 11
Pimozide ....................................................... 36
Oxycodone-Acetaminophen .......................... 10
Pindolol ......................................................... 49
Oxycodone-Aspirin........................................ 10
Pioglitazone HCl ............................................ 42
Oxycodone-Ibuprofen ................................... 10
Pioglitazone HCl-Glimepiride ........................ 43
OxyCONTIN .................................................. 11
Pioglitazone HCl-Metformin HCl .................... 43
Piperacillin Sod-Tazobactam So ................... 17
P
Piroxicam ...................................................... 11
Pacerone....................................................... 48
Plasma-Lyte 148 ........................................... 75
PACLitaxel .................................................... 31
Plasma-Lyte A ............................................... 75
Paliperidone ER ............................................ 37
Plasma-Lyte-56 in D5W ................................ 77
Pancrelipase (Lip-Prot-Amyl) ........................ 57
Plegridy ......................................................... 55
Panretin......................................................... 34
Plegridy Starter Pack..................................... 55
Pantoprazole Sodium .................................... 59
Podofilox ....................................................... 56
Paricalcitol..................................................... 70
Polyethylene Glycol 3350 .............................. 58
Paromomycin Sulfate .................................... 13
Polymyxin B Sulfate ...................................... 15
PARoxetine HCl ............................................ 24
Polymyxin B-Trimethoprim ............................ 70
PARoxetine HCl ER ...................................... 24
Pomalyst ....................................................... 29
Page 91 of 95
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Potassium Chloride ....................................... 75
ProQuad ........................................................ 68
Potassium Chloride Crys ER......................... 76
Protonix ......................................................... 59
Potassium Chloride ER ................................. 76
Protriptyline HCl ............................................ 25
Potassium Chloride in Dextrose .................... 78
Provigil .......................................................... 75
Potassium Chloride in NaCl .......................... 76
Pulmozyme ................................................... 74
Potassium Citrate ER .................................... 76
Purixan .......................................................... 30
Potiga ............................................................ 19
Pyrazinamide ................................................ 29
Pradaxa......................................................... 45
Pyridostigmine Bromide ................................ 28
Pramipexole Dihydrochloride ........................ 35
Pyridostigmine Bromide ER .......................... 28
Pravastatin Sodium ....................................... 53
Q
Prazosin HCl ................................................. 46
PrednisoLONE Acetate ................................. 71
Qualaquin ...................................................... 34
PrednisoLONE Sodium Phosphate ............... 61
QUEtiapine Fumarate.................................... 23
PredniSONE ........................................... 61, 62
Quinapril HCl ................................................. 47
Premarin ....................................................... 63
Quinapril-Hydrochlorothiazide ....................... 51
Premasol ....................................................... 78
QuiNIDine Gluconate ER .............................. 48
Prenatal Vitamins .......................................... 76
QuiNIDine Sulfate.......................................... 48
Prevacid (OTC) ............................................. 80
QuiNINE Sulfate ............................................ 34
Prezcobix ...................................................... 39
Qvar .............................................................. 72
Prezista ......................................................... 41
Priftin ............................................................. 29
R
Prilosec (OTC) .............................................. 80
RabAvert ....................................................... 68
Primaquine Phosphate .................................. 34
Raloxifene HCl .............................................. 64
Primidone ...................................................... 21
Ramipril ......................................................... 47
Pristiq ............................................................ 24
Ranexa .......................................................... 52
Privigen ......................................................... 67
Ranitidine HCl ............................................... 58
ProAir HFA .................................................... 73
Rapamune..................................................... 67
ProAir RespiClick .......................................... 73
Ravicti ........................................................... 57
Probenecid .................................................... 28
Recombivax HB ............................................ 68
Procalamine .................................................. 78
Relenza Diskhaler ......................................... 41
Prochlorperazine ........................................... 26
Relistor .......................................................... 58
Prochlorperazine Edisylate ........................... 26
Renvela ......................................................... 60
Prochlorperazine Maleate ............................. 26
Repaglinide ................................................... 42
Procrit ........................................................... 46
Rescriptor ...................................................... 39
Proctozone-HC ............................................. 62
Restasis ........................................................ 70
Proglycem ..................................................... 43
Retrovir.......................................................... 40
Prolastin-C .................................................... 74
Revlimid ........................................................ 29
Proleukin ....................................................... 31
Rexulti ........................................................... 23
Prolia ............................................................. 70
Reyataz ......................................................... 41
Promacta....................................................... 46
Ribavirin ........................................................ 38
Promethazine HCl ......................................... 26
Rifabutin ........................................................ 28
Promethegan ................................................ 26
Rifampin ........................................................ 29
Propafenone HCl .......................................... 48
Rifater............................................................ 29
Propafenone HCl ER .................................... 48
Riluzole ......................................................... 55
Proparacaine HCl.......................................... 70
Rimantadine HCl ........................................... 41
Propranolol HCl............................................. 49
Ringers .......................................................... 78
Propranolol HCl ER ....................................... 49
Riomet ........................................................... 42
Propranolol-HCTZ ......................................... 51
Risedronate Sodium ...................................... 70
Propylthiouracil ............................................. 66
Page 92 of 95
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RisperDAL Consta ........................................ 37
RisperiDONE ................................................ 37
Rituxan .......................................................... 34
Rivastigmine ................................................. 22
Rivastigmine Tartrate .................................... 22
Rizatriptan Benzoate ..................................... 28
ROPINIRole HCl ........................................... 35
Rotarix .......................................................... 68
RotaTeq ........................................................ 68
Rozerem ....................................................... 75
S
Sabril ............................................................. 21
Sancuso ........................................................ 26
SandIMMUNE ............................................... 67
SandoSTATIN ............................................... 65
SandoSTATIN LAR Depot ............................ 65
Santyl ............................................................ 56
Saphris .......................................................... 37
Selegiline HCl ............................................... 35
Selenium Sulfide ........................................... 56
Selzentry ................................................. 40, 41
Sensipar ........................................................ 65
Serostim ........................................................ 58
Sertraline HCl................................................ 24
Sevelamer Carbonate ................................... 60
Signifor .......................................................... 65
Signifor LAR .................................................. 65
Sildenafil Citrate ............................................ 74
Silenor ........................................................... 75
Silver Sulfadiazine ........................................ 18
Simvastatin ................................................... 53
Sirolimus ....................................................... 67
Sirturo ........................................................... 29
Sivextro ......................................................... 15
Sm Allergy Relief (OTC) ............................... 80
Sodium Chloride ........................................... 76
Sodium Fluoride ............................................ 76
Sodium Phenylbutyrate ................................. 57
Sodium Polystyrene Sulfonate ...................... 75
Soltamox ....................................................... 30
Somatuline Depot ......................................... 66
Somavert....................................................... 66
Sotalol HCl .................................................... 48
Sotalol HCl (AF) ............................................ 48
Sovaldi .......................................................... 39
Spiriva HandiHaler ........................................ 72
Spiriva Respimat ........................................... 72
Spironolactone .............................................. 52
Spironolactone-HCTZ.................................... 51
Spritam .......................................................... 20
Sprycel .......................................................... 33
SPS ............................................................... 75
SSD ............................................................... 18
Stavudine ...................................................... 40
Sterile Water for Irrigation ............................. 76
Stivarga ......................................................... 33
Strattera ........................................................ 55
Streptomycin Sulfate ..................................... 13
Striant ............................................................ 63
Stribild ........................................................... 39
Suboxone ...................................................... 13
Sucralfate ...................................................... 59
Sulfacetamide Sodium ............................ 18, 19
Sulfacetamide-Prednisolone ......................... 70
SulfADIAZINE ............................................... 19
Sulfamethoxazole-TMP DS ........................... 19
Sulfamethoxazole-Trimethoprim ................... 19
SulfaSALAzine .............................................. 69
Sulindac ........................................................ 11
SUMAtriptan Succinate ................................. 28
SUMAtriptan Succinate Refill ........................ 28
Suprax ........................................................... 16
Suprep Bowel Prep ....................................... 78
Sustiva .......................................................... 39
Sutent ............................................................ 33
Sylatron ......................................................... 38
Symbicort ...................................................... 74
SymlinPen 120 .............................................. 42
SymlinPen 60 ................................................ 42
Synagis ......................................................... 67
Synarel .......................................................... 66
Synercid ........................................................ 14
Synribo .......................................................... 31
Synthroid ....................................................... 64
Syprine .......................................................... 75
T
Tabloid .......................................................... 30
Tacrolimus............................................... 56, 67
Tafinlar .......................................................... 33
Tagrisso ........................................................ 33
Tamiflu .......................................................... 41
Tamoxifen Citrate .......................................... 30
Tamsulosin HCl ............................................. 59
Tanzeum ....................................................... 42
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Tarceva ......................................................... 33
Transderm-Scop ........................................... 26
Targretin........................................................ 34
Tranylcypromine Sulfate................................ 23
Tasigna ......................................................... 33
Travasol ........................................................ 78
Tasmar .......................................................... 35
Travatan Z ..................................................... 71
Tazorac ......................................................... 56
Travoprost ..................................................... 71
Taztia XT....................................................... 50
TraZODone HCl ............................................ 24
Tecentriq ....................................................... 34
Treanda ......................................................... 31
Tecfidera ....................................................... 55
Trecator ......................................................... 29
Teflaro ........................................................... 16
Tretinoin .................................................. 34, 56
Temazepam .................................................. 75
Triamcinolone Acetonide ......................... 56, 62
Terazosin HCl ............................................... 47
Triamterene-HCTZ ........................................ 51
Terbinafine HCl ............................................. 27
Triderm .......................................................... 62
Terbutaline Sulfate ........................................ 73
Trifluoperazine HCl........................................ 36
Terconazole .................................................. 27
Trifluridine ..................................................... 39
Testosterone ................................................. 63
Trihexyphenidyl HCl ...................................... 35
Testosterone Cypionate ................................ 63
TriLyte ........................................................... 58
Testosterone Enanthate ................................ 63
Trimethoprim ................................................. 15
Tetanus-Diphtheria Toxoids Td ..................... 68
Trimipramine Maleate.................................... 25
Tetrabenazine ............................................... 55
Trintellix ......................................................... 24
Thalomid ....................................................... 29
Trisenox ........................................................ 31
Theophylline ER...................................... 73, 74
Triumeq ......................................................... 41
Thioridazine HCl ........................................... 36
Trizivir............................................................ 40
Thiotepa ........................................................ 29
TrophAmine ................................................... 78
Thiothixene ................................................... 36
Trospium Chloride ......................................... 59
TiaGABine HCl.............................................. 21
Trospium Chloride ER ................................... 59
Tikosyn ......................................................... 48
Truvada ......................................................... 40
Timentin ........................................................ 17
Twinrix ........................................................... 68
Timolol Maleate....................................... 28, 71
Tybost ........................................................... 41
Tivicay ........................................................... 39
Tygacil ........................................................... 15
TiZANidine HCl ............................................. 38
Tykerb ........................................................... 33
Tobi ............................................................... 13
Typhim VI ...................................................... 68
Tobi Podhaler................................................ 73
Tysabri .......................................................... 55
Tobramycin ................................................... 13
Tyzeka........................................................... 38
Tobramycin Sulfate ....................................... 14
U
Tobramycin-Dexamethasone ........................ 70
Tolterodine Tartrate ...................................... 59
Uloric ............................................................. 28
Tolterodine Tartrate ER ................................ 59
Ursodiol ......................................................... 58
Topiramate .................................................... 21
Topiramate ER .............................................. 21
V
Toposar ......................................................... 32
Vagifem ......................................................... 63
Topotecan HCl .............................................. 32
ValACYclovir HCl .......................................... 39
Torsemide ..................................................... 52
Valchlor ......................................................... 56
Toviaz ........................................................... 59
Valcyte .......................................................... 38
TPN Electrolytes ........................................... 78
ValGANciclovir HCl ....................................... 38
Tradjenta ....................................................... 43
Valproate Sodium .......................................... 21
TraMADol HCl ............................................... 12
Valproic Acid ................................................. 21
Tramadol-Acetaminophen ............................. 10
Valsartan ....................................................... 47
Trandolapril ................................................... 47
Valsartan-Hydrochlorothiazide ...................... 51
Tranexamic Acid ........................................... 46
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Vancomycin HCl ........................................... 15
Vandazole ..................................................... 15
Vandetanib .................................................... 33
Vaqta ............................................................ 69
Varivax .......................................................... 69
Velcade ......................................................... 31
Venclexta ...................................................... 33
Venclexta Starting Pack ................................ 33
Venlafaxine HCl ............................................ 24
Venlafaxine HCl ER ...................................... 24
Ventavis ........................................................ 74
Ventolin HFA ................................................. 73
Verapamil HCl ............................................... 50
Verapamil HCl ER ......................................... 50
Versacloz ...................................................... 38
Vfend ............................................................ 27
Vfend IV ........................................................ 27
Vibramycin .................................................... 19
Vidaza ........................................................... 31
Videx ............................................................. 40
Vigamox ........................................................ 18
Viibryd ........................................................... 24
Viibryd Starter Pack ...................................... 24
Vimpat ........................................................... 22
VinBLAStine Sulfate ...................................... 31
Vincasar PFS ................................................ 31
VinCRIStine Sulfate ...................................... 31
Vinorelbine Tartrate ...................................... 31
Viracept ......................................................... 41
Viramune....................................................... 40
Viramune XR................................................. 40
Virazole ......................................................... 39
Viread ........................................................... 40
Vitekta ........................................................... 39
Voriconazole ................................................. 27
Votrient ......................................................... 33
Vpriv .............................................................. 57
Vraylar .......................................................... 37
Vytorin ........................................................... 51
W
Wal-Fex (OTC).............................................. 80
Warfarin Sodium ........................................... 45
Welchol ......................................................... 43
X
Xalkori ........................................................... 33
Xarelto ........................................................... 45
Xarelto Starter Pack ...................................... 45
Xeljanz .......................................................... 67
Xeljanz XR .................................................... 67
Xgeva ............................................................ 70
Xifaxan .......................................................... 15
Xtandi ............................................................ 29
Xyrem ............................................................ 75
Y
YAZ ............................................................... 64
Yervoy ........................................................... 31
YF-VAX ......................................................... 69
Yondelis ........................................................ 29
Z
Zaditor (OTC) ................................................ 80
Zafirlukast...................................................... 72
Zaltrap ........................................................... 31
Zavesca......................................................... 57
Zegerid (OTC) ............................................... 80
Zelboraf ......................................................... 33
Zerit ............................................................... 40
Zetia .............................................................. 53
Ziagen ........................................................... 40
Zidovudine ..................................................... 40
Ziprasidone HCl ............................................ 37
Zirgan ............................................................ 38
Zmax ............................................................. 18
Zoledronic Acid ............................................. 70
Zolinza........................................................... 31
Zonisamide .................................................... 20
Zortress ......................................................... 67
Zostavax........................................................ 69
Zydelig........................................................... 33
Zykadia.......................................................... 33
ZyPREXA Relprevv ....................................... 37
Zyrtec ............................................................ 80
Zyrtec (OTC) ................................................. 80
Zyrtec Itchy (OTC) ......................................... 80
Zyrtec-D (OTC) ............................................. 80
Zytiga ............................................................ 29
Zyvox............................................................. 15
Page 95 of 95
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Triple-S Advantage 2016 Formulary (List of Covered Drugs)

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