Triple-S Advantage 2016 Formulary (List of Covered Drugs)
Transcripción
Triple-S Advantage 2016 Formulary (List of Covered Drugs)
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 HPMS Approved Formulary ID: 00016470, Version 20 Page 1 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 2 of 95 Updated 11/2016 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. Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 3 of 95 Updated 11/2016 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. Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 4 of 95 Updated 11/2016 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). Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 5 of 95 Updated 11/2016 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. Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 6 of 95 Updated 11/2016 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. Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 7 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 cap dr prt cap sprinkle Page 8 of 95 Updated 11/2016 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] Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 9 of 95 Updated 11/2016 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) acetaminophen-codeine #3 300-30 TYLENOL WITH mg tab 2 CODEINE QL(360 / 30) acetaminophen-codeine #4 300-60 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 Triple-S Advantage 2016 Formulary Page 10 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] LODINE Requirements/Limits [Requisitos/Límites]¹ 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, 40 mg tab er 12 hr, 60 mg tab er 12 hr, 80 mg tab er 12 hr 3 QL(120 / 30) Opioid Analgesics, Short-Acting [Opioides Analgésicos, Corta Duración] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 11 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 12 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] naltrexone hcl 50 mg tab 2 SUBOXONE 12-3 mg subl film 4 SUBOXONE 8-2 mg subl film 4 SUBOXONE 2-0.5 mg subl film 4 SUBOXONE 4-1 mg subl film 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 24 hr, 300 mg tab er 24 hr 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 [Requisitos/Límites]¹ 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(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 13 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 14 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] nitrofurantoin macrocrystal 25 mg cap, 100 mg cap, 50 mg cap 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 15 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 16 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 17 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 tab, 500 mg tab, 750 mg tab 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 18 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 tab, 500 mg tab, 750 mg tab 1 levetiracetam 100 mg/ml soln 2 levetiracetam 500 mg/5ml iv soln 2 levetiracetam er 500 mg tab er 24 hr, 750 mg tab er 24 hr 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 19 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 24 hr, 500 mg tab er 24 hr 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 20 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 200 mg cap er 24 hr sprinkle, 25 mg cap er 24 hr sprinkle, 50 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 21 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 hr, 300 mg tab er 24 hr, 600 mg tab er 24 hr 4 MO PEGANONE 250 mg tab 4 MO phenytoin 125 mg/5ml susp, 50 mg tab chew 2 DILANTIN MO phenytoin sodium 50 mg/ml inj soln 2 PA(*), HI phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap 2 DILANTIN MO VIMPAT 10 mg/ml soln, 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 4 MO VIMPAT 200 mg/20ml iv soln 4 PA(*), HI ANTIDEMENTIA AGENTS [AGENTES 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 22 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 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 tab, 20 mg tab, 40 mg tab 1 CELEXA MO citalopram hydrobromide 10 mg/5ml soln 2 CELEXA MO desvenlafaxine er 100 mg tab er 24 hr, 50 mg tab er 24 hr 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 23 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] FETZIMA 120 mg cap er 24 hr, 20 mg cap er 24 hr, 40 mg cap er 24 hr, 80 mg cap er 24 hr 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, 25 mg tab, 50 mg tab maprotiline hcl 25 mg tab, 50 mg tab, 75 mg tab nefazodone hcl 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab, 50 mg tab paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 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 24 hr, 75 mg cap er 24 hr 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 24 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name Requirements/Limits [Nombre de [Requisitos/Límites]¹ 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, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 2 PA, MO, HR amoxapine 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab 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, 150 mg tab, 25 mg tab, 50 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 cap, 50 mg cap, 75 mg cap 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, 25 mg cap, 50 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 [Nombre del Medicamento] Drug Tier [Nivel] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 25 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 26 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 tab, 200 mg tab, 50 mg tab 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 27 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 25 mg tab, 50 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 28 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 cap, 40 mg cap, 5 mg cap 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 cap, 200 mg cap, 50 mg cap 5 Antiestrogens/Modifiers [Antiestrógenos/Modificadores] Requirements/Limits [Requisitos/Límites]¹ MO MO PA(*), HI PA PA(*) PA(*) PA(*) PA(*) PA(*) PA(*) PA PA PA PA, LA PA, MO ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 29 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name [Nombre de Referencia] Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Requirements/Limits [Requisitos/Límites]¹ 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(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 30 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] EFUDEX GEMZAR Requirements/Limits [Requisitos/Límites]¹ 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 mg tab, 25 mg tab, 5 mg tab 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 31 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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) AFINITOR DISPERZ 3 mg tab sol 5 PA, QL(180 / 30) AFINITOR DISPERZ 2 mg tab sol 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 mg tab, 25 mg tab, 5 mg tab 5 PA, LA KEYTRUDA 50 mg iv soln 3 PA(*) KEYTRUDA 100 mg/4ml iv soln 5 PA(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 32 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 LENVIMA 14 MG DAILY DOSE 10 & 4 mg cap pack 5 LENVIMA 18 MG DAILY DOSE 10 & 4 (2) mg cap pack 5 LENVIMA 20 MG DAILY DOSE 10 (2) mg cap pack 5 LENVIMA 24 MG DAILY DOSE 10 (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, 20 mg tab, 50 mg tab, 70 mg tab, 80 mg tab 5 STIVARGA 40 mg tab 5 SUTENT 12.5 mg cap, 25 mg cap, 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 33 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ PA PA(*) PA(*) PA(*) MO MO MO PA(*) PA(*), HI PA, MO, HR ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 34 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 35 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 tab, 25 mg tab, 50 mg tab 2 thiothixene 1 mg cap, 2 mg cap, 5 mg cap 1 thiothixene 10 mg cap 2 trifluoperazine hcl 1 mg tab, 10 mg tab, 2 mg tab, 5 mg tab 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 INVEGA SUSTENNA 78 mg/0.5ml im susp 4 INVEGA SUSTENNA 117 mg/0.75ml im susp 5 Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 36 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ INVEGA SUSTENNA 156 mg/ml im susp 5 QL(1 / 28), ST INVEGA SUSTENNA 234 mg/1.5ml im susp 5 QL(1.5 / 28), ST LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 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, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 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, 4.5 mg cap, 6 mg cap 5 ST, MO VRAYLAR 1.5 & 3 mg cap pack 4 ST ziprasidone hcl 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 37 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 38 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name Requirements/Limits [Nombre de [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 39 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ VIRAMUNE 200 mg tab 4 MO VIRAMUNE XR 100 mg tab er 24 hr, 400 mg tab er 24 hr 4 MO Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI) [Agentes Anti-VIH, Inhibidores Nucleósidos Y Nucleósidos De La Transcriptasa Reversa (NRTI)] abacavir sulfate 300 mg tab 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 40 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 41 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 hr, 750 mg tab er 24 hr 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 42 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 43 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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) enoxaparin sodium 40 mg/0.4ml sc soln 2 LOVENOX QL(12 / 30) enoxaparin sodium 60 mg/0.6ml sc 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) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 44 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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/0.5ml inj soln, 100 mcg/ml inj soln, 150 mcg/0.3ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 45 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 tab, 4 mg tab, 8 mg tab 1 CARDURA prazosin hcl 1 mg cap, 2 mg cap, 5 mg cap 1 MINIPRESS Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 46 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 mg tab, 4 mg tab, 8 mg tab 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, 40 mg tab, 80 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 tab, 40 mg tab, 5 mg tab 1 LOTENSIN MO enalapril maleate 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 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, 2.5 mg cap, 5 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 47 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 hr, 150 mg cap er 12 hr 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 mg tab er 24 hr, 50 mg tab er 24 hr 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 [Requisitos/Límites]¹ MO MO MO MO, HR MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO PA(*), HI PA(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 48 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 40 mg tab, 60 mg tab, 80 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, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 2 MO diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1 CARDIZEM MO diltiazem hcl 50 mg/10ml iv soln 2 CARDIZEM PA(*), HI diltiazem hcl er 120 mg cap er 12 hr, 60 mg cap er 12 hr, 90 mg cap 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 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 2 CARDIZEM MO diltiazem hcl er coated beads 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab 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 mg tab er 24 hr, 5 mg tab er 24 hr 2 MO isradipine 2.5 mg cap, 5 mg cap 2 MO MATZIM LA 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 2 MO ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 49 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 180 mg cap er 24 hr, 240 mg cap er 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, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 50 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 mg tab, 5-12.5 mg tab 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 51 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] LANOXIN Requirements/Limits [Requisitos/Límites]¹ 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 tab, 40 mg tab, 80 mg tab 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 52 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name Requirements/Limits [Nombre de [Requisitos/Límites]¹ 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, 200 mg cap, 67 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 mg tab, 40 mg tab, 80 mg tab 1 LIPITOR MO lovastatin 10 mg tab, 20 mg tab, 40 mg tab 1 MO pravastatin sodium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 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 tab, 25 mg tab, 50 mg tab 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 [Nombre del Medicamento] Drug Tier [Nivel] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 53 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ isosorbide dinitrate 10 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 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 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap 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 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 54 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 55 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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, 30 mg cap, 40 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)] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 56 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 cap, 2 mg cap, 5 mg cap 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 57 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 58 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 24 hr, 4 mg cap er 24 hr 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 mg tab, 5 mg tab, 50 mg tab 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] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 59 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 tab, 4 mg tab, 6 mg tab 1 dexamethasone 0.5 mg/5ml oral elix 2 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 60 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] dexamethasone sodium phosphate 10 mg/ml inj soln dexamethasone sodium phosphate 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 mg tab, 4 mg tab, 8 mg tab 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 [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 61 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 62 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ NUTROPIN AQ NUSPIN 20 20 mg/2ml sc soln 5 PA, MO NUTROPIN AQ NUSPIN 5 5 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 63 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name Requirements/Limits [Nombre de [Requisitos/Límites]¹ 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 mg tab, 1-0.5 mg tab 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, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 50 mcg tab, 75 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 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg 3 MO ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 64 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ tab, 25 mcg tab, 300 mcg tab, 50 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 soln, 200 mcg/ml inj soln, 50 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 soln, 1000 mcg/ml inj soln, 200 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 65 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 66 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 67 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ 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(*) ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 68 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 69 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 70 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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] dexamethasone sodium phosphate 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 71 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Reference Name Requirements/Limits [Nombre de [Requisitos/Límites]¹ 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 [Nombre del Medicamento] Drug Tier [Nivel] ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 72 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 hr, 8 mg tab er 12 hr 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, 200 mg tab er 12 hr, 300 mg tab er 12 hr 1 MO ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 73 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ theophylline er 400 mg tab er 24 hr, 450 mg tab er 12 hr, 600 mg tab er 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 74 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 75 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ 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 CLINIMIX E/DEXTROSE (2.75/5) 2.75 % iv soln 4 PA(*), HI CLINIMIX E/DEXTROSE (4.25/25) 4.25 % iv soln 4 PA(*), HI CLINIMIX E/DEXTROSE (4.25/5) 4.25 % iv soln 4 PA(*), HI ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 76 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] Drug Tier [Nivel] Reference Name [Nombre de Referencia] Requirements/Limits [Requisitos/Límites]¹ CLINIMIX E/DEXTROSE (5/15) 5 % iv soln 4 PA(*), HI CLINIMIX E/DEXTROSE (5/20) 5 % iv soln 4 PA(*), HI CLINIMIX E/DEXTROSE (5/25) 5 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (2.75/5) 2.75 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (4.25/10) 4.25 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (4.25/20) 4.25 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (4.25/25) 4.25 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (4.25/5) 4.25 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (5/15) 5 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (5/20) 5 % iv soln 4 PA(*), HI CLINIMIX/DEXTROSE (5/25) 5 % 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 ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 77 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Drug Name [Nombre del Medicamento] 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 [Requisitos/Límites]¹ 2 PA(*), HI 4 4 2 4 2 4 4 PA(*), HI PA(*), HI PA(*), HI PA(*), HI PA(*), HI PA(*), HI ¹ Please refer to page 7 for a list of abbreviations for requirements / limits Triple-S Advantage 2016 Formulary Page 78 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 OVER THE COUNTER (OTC) COVERED DRUG LIST [LISTADO DE MEDICAMENTOS CUBIERTOS FUERA DEL RECETARIO] Drug Name Reference Name [Nombre del Medicamento] [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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 79 of 95 Updated 11/2016 Drug Name Reference Name [Nombre del Medicamento] [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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 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 Acetaminophen-Codeine #3.......................... 10 Acetaminophen-Codeine #4.......................... 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 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 Clinimix E/Dextrose (5/20)............................. 77 Cervarix......................................................... 68 Clinimix E/Dextrose (5/25)............................. 77 Cetirizine (OTC) ............................................ 79 Clinimix/Dextrose (2.75/5) ............................. 77 Cetirizine HCl ................................................ 72 Clinimix/Dextrose (4.25/10) ........................... 77 Cetirizine-Pseudoephedrine (OTC) ............... 79 Clinimix/Dextrose (4.25/20) ........................... 77 Cevimeline HCl ............................................. 55 Clinimix/Dextrose (4.25/25) ........................... 77 Chantix .......................................................... 13 Clinimix/Dextrose (4.25/5) ............................. 77 Chantix Continuing Month Pak...................... 13 Clinimix/Dextrose (5/15) ................................ 77 Triple-S Advantage 2016 Formulary Page 83 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 Clinimix/Dextrose (5/20) ................................ 77 Cyramza ........................................................ 30 Clinimix/Dextrose (5/25) ................................ 77 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 Triple-S Advantage 2016 Formulary Page 84 of 95 HPMS Approved Formulary ID: 00016470, Version 20 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 Triple-S Advantage 2016 Formulary Page 85 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 86 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 87 of 95 Updated 11/2016 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 14 MG Daily Dose ........................... 33 Lenvima 18 MG Daily Dose ........................... 33 Lenvima 20 MG Daily Dose ........................... 33 Lenvima 24 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 88 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary Page 89 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 90 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary Page 91 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 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 Triple-S Advantage 2016 Formulary Page 92 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 93 of 95 Updated 11/2016 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 Triple-S Advantage 2016 Formulary Page 94 of 95 HPMS Approved Formulary ID: 00016470, Version 20 Updated 11/2016 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 Triple-S Advantage 2016 Formulary HPMS Approved Formulary ID: 00016470, Version 20 Page 95 of 95 Updated 11/2016