1. No category

Tufts Health Together
Programa de farmacia y Lista de Medicamentos Preferidos
1 de agosto de 2016
Introducción ...................................................................................................................................... i
Programa de farmacia ................................................................................................................... i
Lista de Medicamentos Preferidos................................................................................................ i
Exclusiones ................................................................................................................................... i
Autorización previa ...................................................................................................................... ii
Programa de terapia escalonada .............................................................................................. ..ii
Límite a la cantidad ................................................................................................................... ii
Medicamentos genéricos ........................................................................................................... ii
Medicamentos nuevos en el mercado ...................................................................................... iii
Límite a la cobertura ................................................................................................................... iii
Medicare Parte D ........................................................................................................................ iii
Programa de farmacia de especialidades .................................................................................... iv
Synagis ..................................................................................................................................... iv
Medicamentos de especialidad ..................................................................................................v
Lista de Medicamentos Preferidos....................................................................................................1
Índice...............................................................................................................................................80
Apéndice: Límites a la cantidad ....................................................................................................109
Introducción
Programa de farmacia
Tratamos de proporcionar opciones de alta calidad y bajo costo para la terapia con medicamentos.
Trabajamos con sus proveedores médicos y farmacéuticos para estar seguros de que cubrimos los
medicamentos más útiles e importantes para una variedad de enfermedades y condiciones. Cubrimos
ambas, las primeras recetas de medicamentos y recetas adicionales. También cubrimos algunos
medicamentos de venta libre (OTC, por sus siglas en inglés) si su proveedor le entrega una receta y la
compra en una farmacia.
Nuestro programa de farmacia no cubre todos los medicamentos y recetas. Algunos medicamentos deben
cumplir algunas pautas clínicas antes de que los podamos cubrir. Su proveedor debe solicitarnos la
autorización previa antes de que cubramos estos medicamentos.
Lista de Medicamentos Preferidos (PDL, por sus siglas en inglés)
Listamos todos los medicamentos según su categoría terapéutica y clase de droga, seguido por el nombre
genérico o de marca. Use el índice para encontrar un medicamento según su nombre genérico o de marca.
Cubrimos medicamentos de marca solamente cuando un medicamento genérico no esté disponible o si
brindamos la autorización previa para usar el medicamento de marca.
Con la receta de un médico, los medicamentos cubiertos están a disposición de los miembros menores de
21 años de edad gratis y de los miembros de 21 años o mayores por un pequeño copago. Algunos miembros
de 21 años o más no necesitan pagar el copago. Para determinar si no necesita pagar un copago, consulte su
Manual del Miembro.
Los montos de los copagos para los medicamentos recetados por primera vez y por recetas adicionales para
miembros de 21 años o mayores son:
• Medicamentos del Nivel 1:
o $3.65 por medicamentos recetados genéricos (no son de marca) y selectos medicamentos
OTC (tales como algunos medicamentos para la tos, analgésicos y/o medicamentos para
alergias)
o $1 por medicamentos genéricos o de OTC usados para tratar la diabetes, hipertensión e
hiperlipidemia. Estos medicamentos se llaman antihiperglicémicos (como metformina),
antihipertensivos (como propanolol) y antihiperlipidémicos (como simvastatina)
• Medicamentos del Nivel 2: $3.65 por medicamentos recetados de marca
• Medicamentos del Nivel 4: $0
La PDL se aplica solamente a medicamentos que recibe en farmacias minoristas y de especialidades. La
PDL no se aplica a medicamentos que recibe si está en el hospital. Los medicamentos que usted recibe
mientras está en el hospital están cubiertos como parte de su estadía.
Para obtener la información más actualizada sobre la PDL, por favor visite tuftshealthplan.com o llámenos
al 888-257-1985 (TTY: 888-391-5535).
Exclusiones
No cubrimos:
• Medicamentos usados para propósitos cosméticos
• Medicamentos usados para la disfunción sexual masculina y femenina
• Medicamentos usados para la pérdida de peso
• Implantes anticonceptivos*
• Medicamentos experimentales y/o de investigación
i
•
•
•
•
•
Agentes de vacunación administrados o recibidos en una farmacia, excepto por:
o La vacuna contra el virus de la influenza a miembros que tienen por lo menos 18 años de
edad colocada por un farmacéutico entre el 1 de agosto y el 30 de abril en una farmacia
participante*
o La vacuna Zostavax a miembros que tienen 60 años de edad o mayor cuando se prepara la
receta y el medicamento se administra en una farmacia participante*
Agentes para la infertilidad*
Suministros médicos*
Mifepristona (Mifeprex)*
Medicamentos recetados sin la aprobación de la Administración de Alimentos y Medicamentos de
los Estados Unidos (FDA, por sus siglas en inglés)
* Podría estar cubierto como un beneficio que no es de farmacia
Si es médicamente necesario que usted tome un medicamento que no cubrimos, su proveedor debe
solicitarnos y recibir la autorización previa antes de que paguemos por el medicamento.
Autorización previa
Algunos medicamentos siempre requieren autorización previa, lo que quiere decir que su proveedor debe
solicitarnos la aprobación antes de que nosotros paguemos por el medicamento. Uno de nuestros clínicos
evaluará esta solicitud. Nosotros cubriremos el medicamento de acuerdo a nuestras directrices clínicas si:
• Existe una justificación médica por la que necesita un medicamento en particular
• Dependiendo del medicamento, otros medicamentos de la PDL no han sido útiles
Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno,
puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y
apelaciones.
Programa de terapia escalonada
Cubrimos algunos tipos de medicamentos solamente a través de nuestro programa de terapia escalonada.
Nuestro programa de terapia escalonada requiere que usted pruebe medicamentos de primer nivel antes de
que cubramos otro medicamento de dicho tipo. Si usted y su proveedor piensan que cierto medicamento no
es apropiado para tratar su enfermedad, su proveedor puede solicitarnos la autorización previa para usar el
otro medicamento. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el medicamento de
acuerdo a nuestras directrices clínicas. Si no aprobamos la solicitud de autorización previa, usted o su
representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para
obtener información sobre las quejas y apelaciones.
Límite a la cantidad
Para asegurar que los medicamentos que toma son seguros y que recibe la cantidad apropiada, podríamos
limitar cuánto recibe en cada oportunidad. Su proveedor puede pedirnos la autorización previa si usted
necesita más de lo que cubrimos. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el
medicamento de acuerdo a nuestras directrices clínicas si existe una razón médica por la que se necesita
esta cantidad en particular. Si no aprobamos la solicitud de autorización previa, usted o su representante
autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener
información sobre las quejas y apelaciones.
Medicamentos genéricos
Los medicamentos genéricos tienen los mismos ingredientes activos y funcionan de la misma manera que
los medicamentos de marca. Cuando hay medicamentos genéricos disponibles, no cubrimos el
medicamento de marca sin autorización previa. Si usted y su proveedor piensan que un medicamento
genérico no es apropiado para tratar su enfermedad y que un medicamento de marca es médicamente
necesario, su proveedor puede solicitarnos la autorización previa. Uno de nuestros clínicos evaluará la
solicitud. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si
ii
identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las
quejas y apelaciones.
Medicamentos nuevos en el mercado
Nosotros evaluamos nuevos medicamentos para determinar su eficacia y seguridad antes de agregarlos a
nuestra PDL. Un proveedor que piensa que un medicamento nuevo en el mercado es médicamente
necesario para usted antes de que lo hayamos evaluado, puede presentar una solicitud de autorización
previa. Uno de nuestros clínicos evaluará esta solicitud. Si no aprobamos la solicitud, usted o su
representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para
obtener información sobre las quejas y apelaciones.
Límites a la cobertura
La columna Requisitos/Límites en la PDL indica cuando un medicamento tiene un cierto requisito o límite
para la cobertura. Los límites a la cobertura incluyen:
• AGE (edad, en inglés) — Se puede aplicar restricción a la edad
Este medicamento requiere autorización previa, si el medicamento no está cubierto basado en la
edad del miembro. Su proveedor deberá solicitarnos la autorización previa si el medicamento es
médicamente necesario.
• GO (por sus siglas en inglés) — Genérico solamente
Solamente cubrimos el tipo genérico de este medicamento. Su proveedor deberá enviarnos una
solicitud de autorización previa por el medicamento de marca si usted y su proveedor piensan que
un medicamento genérico no es apropiado para su condición médica y el medicamento de marca es
médicamente necesario.
• PA (por sus siglas en inglés) — Autorización previa
Este medicamento requiere autorización previa. Su proveedor puede recetar un medicamento
diferente de la PDL o enviarnos una solicitud de autorización previa.
• QL (por sus siglas en inglés) — Límite a la cantidad
Este medicamento se limita a una cantidad específica. Si una mayor cantidad es médicamente
necesaria, su proveedor deberá enviar una solicitud de autorización previa.
• SP (por sus siglas en inglés) — Medicamento de especialidad
Este medicamento está disponible solamente a través de nuestro proveedor de farmacia de
especialidades, CVS/caremark.
• ST (por sus siglas en inglés) — Terapia escalonada
Este medicamento requiere una autorización previa si todavía no ha usado un medicamento de
primera línea de la PDL. Su proveedor puede recetar otro medicamento de la PDL o enviarnos una
solicitud de autorización previa.
Medicare Parte D
Si tiene la cobertura de Medicare, su cobertura de medicamentos recetados de Medicare (Parte D) cubrirá
gran parte de sus medicamentos recetados. Debería tener una tarjeta de identificación adicional para su
cobertura de medicamentos recetados de Medicare. Por favor, muéstrele a su farmacéutico su tarjeta de
identificación de Medicare Parte D cuando compra un medicamento recetado.
Aunque tenga Medicare Parte D, nosotros cubriremos algunos medicamentos, tales como ciertos
medicamentos OTC. Los montos del copago y las excepciones se siguen aplicando a estos medicamentos
cubiertos. Para más información, por favor llámenos al 888-257-1985 (TTY: 888-391-5535). También
puede encontrar más información sobre su cobertura de medicamentos recetados de Medicare llamando a
Medicare al 800-633-4227 (TTY: 877-486-2048), visitando el sitio web de Medicare en medicare.gov o
consultando su manual Medicare y Usted. Recuerde llevar todas sus tarjetas de identificación con usted
cuando visita la farmacia. Cuando compra un medicamento recetado, por favor muestre su tarjeta de
identificación como miembro de Tufts Health Together y MassHealth así como sus tarjetas de
identificación para medicamentos recetados de Medicare.
iii
Programa de farmacia de especialidades
1.00
Una farmacia de especialidades necesita entregarle ciertos medicamentos, como medicamentos inyectables
y por vía intravenosa (IV, por sus siglas en inglés), que a menudo se usan para tratar enfermedades crónicas
como la hepatitis C o la esclerosis múltiple. Estos tipos de medicamentos necesitan apoyo y conocimiento
adicional. Las farmacias de especialidades tienen conocimientos en estos campos. Estas farmacias pueden
brindar apoyo adicional a miembros y proveedores.
CVS/caremark es nuestra farmacia de especialidades y puede entregarle estos medicamentos. Además de
proporcionar medicamentos específicos de especialidad, CVS/caremark:
• Entregará los medicamentos a su domicilio, consultorio de su proveedor o cualquier dirección que
elija (excepto una casilla de correos)
• Responderá sus respuestas y ofrecerá ayuda con sus medicamentos
• Le brindará información, materiales y apoyo continuo para ayudarle a atender su enfermedad y a
tomar los medicamentos de la manera correcta
• Tendrá farmacéuticos que pueden ayudarle las 24 horas al día, siete días a la semana, en el
800-237-2767
Synagis
Cada año, desde el 1 de noviembre al 31 de marzo, CVS/caremark proporcionaraá a los miembros de
Tufts Health Together con Synagis, que se usa para prevenir una enfermedad respiratoria seria causada por
el virus respiratorio sincitial (RSV, por sus siglas en inglés). Evaluaremos las solicitudes de Synagis según
las directrices más recientes de la American Academy of Pediatrics.
iv
Medicamentos de especialidad
Estos medicamentos están disponibles solamente a través de nuestra proveedor de farmacia de
especialidades, CVS/caremark:
Actemra IV1,5
Actemra SQ1
Acthar HP5
Actimmune1
Adcirca1
Adempas1
Advate
Adynovate
Afinitor
Afinitor Disperz
Aldurazyme1,5
Alecensa1
Alferon N1
Alphanate
Alphanine SD
Alprolix
Ampyra1
Apokyn
Aralast NP1
Aranesp
Arcalyst1
Arzerra5
Aubagio1
Avastin5
Avonex
Azacitadine5
Bebulin VH
Beleodaq5
Benefix
Benlysta1,5
Berinert5
Betaseron
Bexarotene
Botox1
Bosulif
Cerezyme1,5
Cimzia1
Cinryze1
Copaxone
Copegus6
Corifact
Cosentyx1
Cotellic1
Cystagon1
Cytogam1,5
Dacogen5
Daklinza1
Decitabine5
Dysport1
Egrifta1
Elaprase5
Eligard1
Eloctate
Elspar5
Enbrel1
Entyvio1
Epogen
Epoprostenol1
Erbitux
Erivedge
Esbriet1
Euflexxa1,5
Exjade
Extavia
Eylea5
Farydak1
Feiba VH Immuno
Firazyr1
Firmagon5
Flebogamma1
Fuzeon
Gamastan S/D1
Gammagard Liquid1
Gammagard S/D1
Gamunex1
Gamunex-C1
Gattex1
Gazyva5
Gel-One5,6
Genotropin6
GenVisc 8505,6
Gilenya4
Glassia5
Glatopa
Gleevec
Granix
Halaven5
Harvoni1
Helixate FS
Hemofil M
Herceptin5
Hizentra1
Humate-P
Humatrope6
Humira1
Hyalgan5,6
Hycamtin
HyQvia1
Ibrance1
Iclusig
Idelvion
Ilaris1
Immune Globulin1
Increlex1
Inlyta
Cabometyx1
Flebogamma DIF1
Intron A1
Capecitabine
Forteo1
Istodax5
Carimune NF1
Fusilev5
Ixempra5
Ixinity
Jadenu
Jakafi
Jevtana5
Kadcyla5
Kalydeco1
Kalydeco Granules1
Koate-DVI
Kogenate FS
Kovaltry
Krystexxa1
Kuvan1
Kynamro1
Letairis1
Leukine
Leuprolide1
Lonsurf1
Lucentis5
Lumizyme5
Lupron Depot1
Lupron Depot-Ped1
Macugen5
Mekinist
Mitoxantrone1
Monoclate P
Mononine
Monovisc5,6
Myobloc1
Myozyme1,5
Naglazyme5
Natpara1
Neulasta
Neupogen
Nexavar
Ninlaro1
Norditropin
FlexPro1,2
Norditropin
Nordiflex1,2
NovoEight
NovoSeven
Nplate1,5
Nutropin6
Nutropin AQ6
Nuwiq
Obizur
Octagam1
Octreotide1
Omnitrope6
Oncaspar5
Opsumit1
Orencia IV1,5
Orencia SQ1
Orenitram
Orkambi1
Orthovisc5,6
Otezla1
Pegasys
Pegasys Proclick
Peg-Intron
Peg-Intron Redipen
Perjeta5
Plegridy6
Pomalyst
Praluent1,3
Privigen1
Procrit
Profilnine SD
Proleukin
Prolia1,5
Promacta1
Proplex T
Pulmozyme
Ravicti1
Rebetol1
Rebif
Rebif Rebidose
Recombinate
Remicade1
Remodulin1
Repatha1,3
Revatio1
Revlimid
Rhophylac1,5
RiaSTAP
Ribavirin1
Rituxan
Rixubis
Ruconest5
Sabril1
Saizen6
Samsca
Sandostatin1
Sandostatin
LAR1
Sensipar4
Serostim1
Sildenafil1
Simponi1
1
Simponi Aria1
Soliris1,5
Somatuline Depot1
Somavert1
Sovaldi1
Sprycel
Stelara1
Stimate
Stivarga
Supartz5,6
Supprelin LA1
Sutent
Sylatron
Synagis1
Synribo5
Targretin6
Tasigna
Tecfidera1
Temodar
Temozolomide
Tetrabenazine1
Thalomid
Thyrogen
Tikosyn
TOBI6
tobramycin inh soln
Torisel5
Tracleer1
Treanda5
Trelstar1
Tyvaso1
Uptravi1
Valstar
Vantas5
Vectibix5
Velcade5
Ventavis1
Vidaza5
Visudyne5
Votrient
VPRIV1
Wilate
WinRho SDF1,5
Xalkori
Xeljanz1
Synvisc5,6
Trelstar Depot1
Xeljanz XR1
Synvisc-One5,6
Tafinlar
Taltz1
Tarceva
Trelstar LA1
Tretten
Tykerb
Tysabri1
Xeloda
Xenazine1
Xeomin1
Xgeva1,5
Xolair1
Xtandi
Xyntha
Yervoy5
Zaltrap5
Zarxio
Zelboraf
Zoladex1
Zolinza
Zomacton6
Zorbtive1
Zortress
Zykadia
Zytiga
El medicamento requiere autorización previa.
Norditropin y Norditropin Nordiflex son agentes de la hormona de crecimiento preferidos de Tufts Health
Together.
3
Repatha es el inhibidor de PCSK9 preferido de Tufts Health Together.
4
El medicamento requiere autorización previa si no se cumple la terapia escalonada.
5
El medicamento está cubierto bajo el beneficio médico solamente.
6
El medicamento no está cubierto
2
MASSHEALTH_TOGETHER
Drug Name
Drug Tier Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
ADDERALL
ADDERALL XR
amphetamine-dextroamphetamine
DESOXYN
DEXEDRINE
dextroamphetamine sulfate
methamphetamine hcl
PROCENTRA
VYVANSE
Analeptics
CAFCIT
caffeine citrate
2
2
1
2
2
1
1
2
2
AGE, GO,
AGE, GO,
AGE, QL
AGE, GO,
AGE, GO,
AGE, QL
AGE, QL
AGE, GO,
PA; QL
2
1
GO
QL
QL
QL
QL
QL
Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
clonidine hcl (adhd)
guanfacine hcl (adhd)
INTUNIV
KAPVAY
STRATTERA
Stimulants - Misc.
armodafinil
CONCERTA
DAYTRANA
dexmethylphenidate hcl
FOCALIN
FOCALIN XR 5mg, 10mg, 15mg, 20mg,
30mg, 40mg
FOCALIN XR 25mg, 35mg
METADATE CD
METADATE ER
METHYLIN
methylphenidate hcl
NUVIGIL
PROVIGIL
QUILLIVANT XR
RITALIN
RITALIN SR
1
1
2
2
2
PA
ST;
ST;
PA;
PA;
1
2
2
1
2
2
PA; QL
AGE, GO, QL
PA; QL
AGE, QL
AGE, GO, QL
AGE, GO, QL
2
2
2
2
1
2
2
2
2
2
PA; QL
AGE, GO, QL
AGE, GO, QL
AGE, GO, QL
AGE, QL
PA; GO, QL
PA; GO, QL
PA; QL
AGE, GO, QL
AGE, GO, QL
AGE, QL
AGE, GO, QL
GO
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
1
Drug Name
AMEBICIDES
Amebicides
YODOXIN
AMINOGLYCOSIDES
Aminoglycosides
AMIKACIN SULFATE
NEO-FRADIN
neomycin sulfate
paromomycin sulfate
TOBI
TOBI PODHALER
tobramycin
TOBRAMYCIN SULFATE
Drug Tier Requirements/Limits
2
2
2
1
1
2
2
1
2
ANALGESICS - ANTI-INFLAMMATORY
Anti-TNF-alpha - Monoclonoal Antibodies
HUMIRA
HUMIRA PEN-CROHNS DISEASE
SIMPONI
SIMPONI ARIA
Antirheumatic - Enzyme Inhibitors
XELJANZ
XELJANZ XR
Antirheumatic Antimetabolites
RHEUMATREX
2
2
2
4
PA;
PA;
PA;
PA;
2
2
PA; QL, SP
PA; QL, SP
Interleukin-6 Receptor Inhibitors
ACTEMRA
QL,
QL,
QL,
QL,
SP
SP
SP
SP
2
Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET
GO, SP
PA; QL, SP
SP
2
PA; QL
4
PA; QL, SP
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ANAPROX
ANAPROX DS
CATAFLAM
CELEBREX
celecoxib
CLINORIL
DAYPRO
diclofenac potassium
diclofenac sodium
EC-NAPROSYN
2
2
2
2
1
2
2
1
1
2
GO
GO
GO
ST; GO, QL
ST; QL
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
2
Drug Name
etodolac
FELDENE
fenoprofen calcium
flurbiprofen TABS
ibuprofen
INDOCIN
indomethacin
ketoprofen
ketorolac tromethamine
meclofenamate sodium
meloxicam
MOBIC
nabumetone
NALFON
NAPROSYN
naproxen sodium
oxaprozin
piroxicam
PONSTEL
SPRIX
sulindac
tolmetin sodium
VOLTAREN-XR
Pyrimidine Synthesis Inhibitors
ARAVA
leflunomide
Selective Costimulation Modulators
ORENCIA
Drug Tier Requirements/Limits
1
2
GO
1
1
1
2
1
1
1
QL
1
1
2
GO
1
2
GO
2
GO
1
1
1
2
PA; GO
2
PA; QL
1
1
2
GO
2
1
GO
4
PA; QL, SP
Soluble Tumor Necrosis Factor Receptor Agents
ENBREL
ANALGESICS - NonNarcotic
ANALGESICS OTHER
acetaminophen
Analgesic Combinations
butalbital-acetaminophen
butalbital-acetaminophen-caffeine CAPS
BUTALBITAL-ACETAMINOPHEN-CAFFEINE
CAPS
butalbital-acetaminophen-caffeine TABS
butalbital-aspirin-caffeine
ESGIC
ESGIC-PLUS
FIORICET
PHRENILIN FORTE
2
PA; QL, SP
1
1
1
1
QL
QL
QL
1
1
2
2
2
2
QL
QL
GO, QL
GO, QL
GO, QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
3
Drug Name
Salicylates
aspirin
choline & mag salicylate
diflunisal
EASPRIN
salsalate
ANALGESICS - OPIOID
Opioid Agonists
ABSTRAL
ACTIQ
CODEINE PHOSPHATE
CODEINE SULFATE SOLN
codeine sulfate TABS
DEMEROL
DILAUDID
DOLOPHINE
DURAGESIC
EMBEDA
EXALGO 8mg, 12mg, 16mg
EXALGO 32mg
fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr, 100mcg/hr
FENTANYL 37.5mcg/hr, 62.5mcg/hr,
87.5mcg/hr
FENTORA
hydromorphone hcl LIQD; TABS
HYDROMORPHONE HCL SUPP
hydromorphone hcl T24A
KADIAN 10mg, 20mg, 30mg, 50mg,
80mg, 100mg
KADIAN 40mg, 70mg, 130mg, 150mg,
200mg
meperidine hcl
methadone hcl
METHADOSE
morphine sulfate
morphine sulfate beads
MS CONTIN
NUCYNTA
NUCYNTA ER
ONSOLIS
OPANA
OPANA ER
OPANA ER (CRUSH RESISTANT
oxycodone hcl
Drug Tier Requirements/Limits
1
1
1
2
1
2
2
2
2
1
2
2
2
2
2
2
2
1
PA
PA; GO, QL
QL
QL
QL
GO, QL
GO, QL
GO, QL
GO, QL
PA; QL
PA; GO, QL
PA; QL
QL
2
PA; QL
2
1
2
1
2
PA; QL
QL
QL
PA; QL
PA; GO, QL
2
PA; QL
1
1
2
1
1
2
2
2
2
2
2
2
1
QL
QL
GO, QL
QL
PA; QL
GO, QL
PA
PA
PA; QL
PA; GO, QL
PA; QL
PA; QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
4
Drug Name
OXYCONTIN
oxymorphone hcl
ROXICODONE
SUBSYS
tramadol hcl TABS
tramadol hcl TB24
ULTRAM
ULTRAM ER
ZOHYDRO ER
Opioid Combinations
acetaminophen w/ codeine
acetaminophen-caff-dihydrocod
aspirin-caffeine-dihydrocodeine bitartrate
butalbital-acetaminophen-caffeine w/
codeine
butalbital-aspirin-caffeine w/cod
CAPITAL/CODEINE
FIORICET/CODEINE
FIORINAL/CODEINE #3
HYCET
hydrocodone-acetaminophen
hydrocodone-ibuprofen
LIQUICET
LORCET 10/650
LORCET PLUS
LORTAB
MAXIDONE
NORCO
oxycodone w/ acetaminophen
oxycodone-aspirin
PERCOCET
PERCODAN
REPREXAIN
ROXICET
tramadol-acetaminophen
TYLENOL/CODEINE #3
TYLENOL/CODEINE #4
TYLOX
ULTRACET
VICOPROFEN
Opioid Partial Agonists
BELBUCA
BUNAVAIL
buprenorphine hcl
buprenorphine hcl-naloxone sub tabs
Drug Tier Requirements/Limits
2
QL
1
PA; QL
2
GO, QL
2
PA; QL
1
QL
1
PA; QL
2
GO, QL
2
PA; GO, QL
2
PA; QL
1
1
1
1
QL
QL
QL
QL
1
2
2
2
2
1
1
2
2
2
2
2
2
1
1
2
2
2
2
1
2
2
2
2
2
QL
QL
GO,
GO,
GO,
QL
QL
QL
GO,
GO,
GO,
GO,
GO,
QL
QL
GO,
GO,
GO,
GO,
QL
GO,
GO,
GO,
GO,
GO,
2
2
1
1
PA; QL
PA; QL
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
5
Drug Name
butorphanol tartrate 10mg/ml
BUTRANS
SUBOXONE FILM
ZUBSOLV
ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL-50
OXANDRIN
oxandrolone
Androgens
ANDRODERM
ANDROGEL
android
ANDROXY
AVEED
AXIRON
danazol
DEPO-TESTOSTERONE
FIRST-TESTOSTERONE
FIRST-TESTOSTERONE MC COM
FORTESTA
METHITEST
STRIANT
TESTIM
TESTOPEL
testosterone cypionate im inj in oil
testosterone enanthate im inj in oil
TESTRED
VOGELXO
VOGELXO PUMP
ANORECTAL AGENTS
Intrarectal Steroids
CORTENEMA
CORTIFOAM
hydrocortisone (intrarectal)
UCERIS FOAM
Rectal Combinations
ANALPRAM-HC
hydrocortisone acetate w/ pramoxine
PROCTOFOAM HC
Rectal Steroids
ANUSOL-HC
hydrocortisone (rectal)
hydrocortisone acetate (rectal)
Drug Tier Requirements/Limits
1
2
PA; QL
2
PA; QL
2
PA; QL
2
2
1
PA
PA; GO, QL
PA; QL
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
1
2
2
2
PA
PA
GO
2
2
1
2
GO
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
GO
PA
PA
PA
2
1
2
2
1
1
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
6
Drug Name
PROCTOCORT
ANTACID COMBINATIONS
ANTACID SIMETHICONE
alum & mag hydrox-simethicone
ANTHELMINTICS
Anthelmintics
ALBENZA
ivermectin
mebendazole
STROMECTOL
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
CAYSTON
DALVANCE
FLAGYL
FLAGYL ER
metronidazole
metronidazole in nacl
NEBUPENT
PRIMSOL
TINDAMAX
tinidazole
trimethoprim
VANCOCIN HCL
vancomycin hcl CAPS
vancomycin hcl SOLR
XIFAXAN
Anti-infective Misc. - Combinations
BACTRIM
BACTRIM DS
erythromycin-sulfisoxazole
SEPTRA DS
sulfamethoxazole-trimethoprim
Antiprotozoal Agents
ALINIA
atovaquone
MEPRON
Ketolides
KETEK
1
2
1
1
2
2
2
2
2
1
1
2
2
2
1
1
2
1
1
2
2
2
1
2
1
2
1
2
GO
GO
GO
GO, QL
QL
QL
GO
GO
GO
GO
2
Leprostatics
dapsone
Lincosamides
CLEOCIN
Drug Tier Requirements/Limits
2
GO
CAPS
1
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
7
Drug Name
CLEOCIN PEDIATRIC GRANULE
clindamycin hcl
clindamycin palmitate hydrochloride
Oxazolidinones
linezolid
SIVEXTRO
ZYVOX SUSR
ZYVOX TABS
ANTIANGINAL AGENTS
Antianginals-Other
RANEXA
Nitrates
DILATRATE SR
IMDUR
ISORDIL TITRADOSE
isosorbide dinitrate
isosorbide mononitrate
MONOKET
NITRO-BID
NITRO-DUR .1mg/hr, .2mg/hr, .4mg/hr,
.6mg/hr
NITRO-DUR .3mg/hr, .8mg/hr
nitroglycerin, aerosol, spray, patch
NITROLINGUAL PUMPSPRAY
NITROMIST
NITROSTAT
Drug Tier Requirements/Limits
2
GO
1
1
1
2
2
2
QL
QL
QL
GO, QL
2
PA; QL
2
2
2
1
1
2
2
2
2
1
2
2
2
GO
GO
GO
GO
GO
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone hcl 5mg, 7.5mg, 10mg, 15mg 1
buspirone hcl 30mg
1
CHOLBAM
2
hydroxyzine hcl
1
hydroxyzine pamoate
1
VISTARIL
2
Benzodiazepines
alprazolam
ALPRAZOLAM INTENSOL
ATIVAN
chlordiazepoxide hcl
clorazepate dipotassium
diazepam
lorazepam
oxazepam
TRANXENE T
1
2
2
1
1
1
1
1
2
PA
PA
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
8
Drug Name
VALIUM
XANAX
Drug Tier Requirements/Limits
2
GO
2
GO
ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide phosphate
NORPACE
NORPACE CR
quinidine sulfate
Antiarrhythmics Type I-B
mexiletine hcl
Antiarrhythmics Type I-C
flecainide acetate
propafenone hcl
RYTHMOL
RYTHMOL SR
TAMBOCOR
Antiarrhythmics Type III
amiodarone hcl
CORDARONE
dofetilide
MULTAQ
TIKOSYN
1
2
2
1
GO
1
1
1
2
2
2
1
2
1
2
2
GO
GO
GO
GO
SP
GO, SP
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Anti-Inflammatory Agents
cromolyn sodium
1
Antiasthmatic - Monoclonal Antibodies
XOLAIR
4
PA; QL, SP
Asthma and Bronchodilator Agent Combinations
dyphylline-guaifenesin
Bronchodilators - Anticholinergics
VENTOLIN HFA
ipratropium bromide
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
TUDORZA PRESSAIR
Leukotriene Modulators
ACCOLATE
montelukast
montelukast
SINGULAIR
SINGULAIR
zafirlukast
sodium CHEW; TABS
sodium PACK
CHEW; TABS
PACK
1
2
1
2
2
2
2
1
1
2
2
1
GO
QL
ST; QL
GO, QL
ST; GO, QL
Selective Phosphodiesterase 4 (PDE4) Inhibitors
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
9
Drug Name
DALIRESP
Steroid Inhalants
AEROSPAN
ALVESCO
ASMANEX HFA
ASMANEX TWISTHALER 30 MET
ASMANEX TWISTHALER 60 MET
ASMANEX TWISTHALER 120 ME
budesonide (inhalation)
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
PULMICORT FLEXHALER
QVAR
Sympathomimetics
ACCUNEB
ADVAIR DISKUS
ADVAIR DISKUS 100/50
ADVAIR HFA
albuterol sulfate, er, neb soln, syrup, tab
ANORO ELLIPTA
ARCAPTA NEOHALER
BREO ELLIPTA
COMBIVENT
COMBIVENT RESPIMAT
DULERA
DUONEB
epinephrine hcl
FORADIL AEROLIZER
ipratropium-albuterol
levalbuterol hcl
MAXAIR AUTOHALER
metaproterenol sulfate
PERFOROMIST
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
SEREVENT DISKUS
SYMBICORT
terbutaline sulfate
VENTOLIN HFA
VOSPIRE ER
XOPENEX
XOPENEX HFA
Drug Tier Requirements/Limits
2
ST
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
1
2
1
1
2
1
2
2
2
2
2
2
1
2
2
2
2
GO
GO
PA
PA; AGE
PA
PA
QL
PA; QL
GO
PA
PA
PA
GO
GO
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
10
Drug Name
Xanthines
aminophylline
ELIXOPHYLLIN
LUFYLLIN
THEO-24
THEOPHYLLINE ELIX
theophylline TB12; TB24
ANTICOAGULANTS
Coumarin Anticoagulants
COUMADIN
warfarin sodium
Direct Factor Xa Inhibitors
ELIQUIS
XARELTO
XARELTO STARTER PACK
Heparins And Heparinoid-Like Agents
ARIXTRA
enoxaparin sodium
fondaparinux sodium
FRAGMIN
HEPARIN SODIUM
heparin sodium (porcine)
heparin sodium (porcine) lock flush
LOVENOX
Thrombin Inhibitors
PRADAXA
Drug Tier Requirements/Limits
1
2
2
2
2
1
2
1
GO
2
2
2
QL
QL
QL
2
1
1
2
2
1
1
2
GO
2
QL
ANTICONVULSANTS
AMPA Glutamate Receptor Antagonists
FYCOMPA
Anticonvulsants - Benzodiazepines
clonazepam
DIASTAT ACUDIAL
DIASTAT PEDIATRIC
diazepam (anticonvulsant)
KLONOPIN
ONFI SUSP
ONFI TABS
PA
GO
2
PA
1
2
2
1
2
2
2
GO, QL
GO, QL
QL
GO
PA
PA; QL
Anticonvulsants - Misc.
APTIOM
2
PA
BANZEL
2
PA
carbamazepine
1
CARBATROL
2
GO
gabapentin CAPS; SOLN; TABS
1
KEPPRA
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
11
Drug Name
KEPPRA XR
LAMICTAL CHEW
LAMICTAL TABS 25mg, 100mg, 150mg
LAMICTAL TABS 200mg
LAMICTAL CHEWABLE DISPERS 5mg
LAMICTAL CHEWABLE DISPERS 25mg
LAMICTAL ODT
LAMICTAL XR
lamotrigine CHEW 5mg
lamotrigine CHEW 25mg
lamotrigine TABS 25mg, 100mg, 150mg
lamotrigine TABS 200mg
lamotrigine TB24
lamotrigine TBDP
levetiracetam SOLN; TABS
levetiracetam TB24
LYRICA
MYSOLINE
NEURONTIN
oxcarbazepine
OXTELLAR XR
POTIGA
primidone
QUDEXY XR
SPRITAM
TEGRETOL
TEGRETOL-XR
TOPAMAX 25mg, 50mg, 100mg
TOPAMAX 200mg
TOPAMAX SPRINKLE 15mg
TOPAMAX SPRINKLE 25mg
topiramate CPSP 15mg
topiramate CPSP 25mg
topiramate CS24
topiramate TABS 25mg, 50mg, 100mg
topiramate TABS 200mg
TRILEPTAL
TROKENDI XR
VIMPAT
ZONEGRAN
zonisamide
Carbamates
felbamate
FELBATOL
Drug Tier Requirements/Limits
2
PA; GO, QL
2
2
GO, QL
2
GO
2
GO
2
GO, QL
2
GO
2
PA; GO, QL
1
1
QL
1
QL
1
1
PA; QL
1
1
1
PA
2
PA; QL
2
GO
2
GO
1
2
PA; QL
2
PA
1
2
PA; GO
2
PA; QL
2
GO
2
GO
2
GO, QL
2
GO
2
GO
2
GO, QL
1
1
QL
1
PA
1
QL
1
2
GO
2
PA
2
PA; QL
2
GO
1
1
2
PA
PA; GO
GABA Modulators
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
12
Drug Name
GABITRIL 2mg, 4mg
GABITRIL 12mg, 16mg
SABRIL
tiagabine hcl
Hydantoins
DILANTIN
DILANTIN INFATABS
PEGANONE
PHENYTEK
phenytoin
phenytoin sodium extended
Succinimides
CELONTIN
ethosuximide
ZARONTIN
Valproic Acid
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
divalproex sodium
valproate sodium
valproic acid
Drug Tier Requirements/Limits
2
GO
2
2
PA; QL, SP
1
2
2
2
2
1
1
2
1
2
2
2
2
2
1
1
1
PA
GO
GO
GO
GO
GO
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine
REMERON
REMERON SOLTAB
Antidepressants - Misc.
bupropion hcl
maprotiline hcl
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
Modified Cyclics
nefazodone hcl
trazodone hcl
TRINTELLIX
VIIBRYD
1
2
2
GO
GO
1
1
2
2
2
GO
GO
GO
1
1
2
2
PA
PA; QL
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM
NARDIL
PARNATE
phenelzine sulfate
2
2
2
1
PA; QL
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
13
Drug Name
tranylcypromine sulfate
Drug Tier Requirements/Limits
1
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA
citalopram hydrobromide
escitalopram oxalate
fluoxetine hcl
fluvoxamine maleate CP24
fluvoxamine maleate TABS
LEXAPRO
LUVOX CR
paroxetine hcl TABS
paroxetine hcl TB24
PAXIL SUSP
PAXIL TABS
PAXIL CR
PROZAC
sertraline hcl
ZOLOFT
2
1
1
1
1
1
2
2
1
1
2
2
2
2
1
2
GO
PA; QL
GO
PA; GO, QL
PA; QL
GO
PA; GO, QL
GO
GO
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
CYMBALTA
DESVENLAFAXINE ER
duloxetine hcl 20mg, 30mg
duloxetine hcl 60mg
EFFEXOR XR
FETZIMA
FETZIMA TITRATION PACK
PRISTIQ
venlafaxine hcl TABS
venlafaxine hcl TB24
Tricyclic Agents
amitriptyline hcl
AMOXAPINE
ANAFRANIL
clomipramine hcl
desipramine hcl
doxepin hcl
imipramine hcl
imipramine pamoate
NORPRAMIN
nortriptyline hcl
PAMELOR
protriptyline hcl
SURMONTIL
TOFRANIL
2
2
1
1
2
2
2
2
1
1
1
1
2
1
1
1
1
1
2
1
2
1
2
2
ST; GO, QL
ST
ST; QL
PA, ST
GO
PA; QL
PA; QL
ST
ST
GO
PA
GO
GO
PA
PA; GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
14
Drug Name
TOFRANIL-PM
trimipramine maleate
VIVACTIL
ANTIDIABETICS
Alpha-Glucosidase Inhibitors
acarbose
GLYSET
miglitol
PRECOSE
Antidiabetic - Amylin Analogs
SYMLIN
SYMLINPEN 60
SYMLINPEN 120
Antidiabetic Combinations
ACTOPLUS MET
ACTOPLUS MET XR
alogliptin-metformin hcl
alogliptin-pioglitazone
AVANDAMET
AVANDARYL
DUETACT
glipizide-metformin hcl
GLUCOVANCE
glyburide-metformin
INVOKAMET
JANUMET
JANUMET XR
JENTADUETO
KAZANO
METAGLIP
OSENI
pioglitazone hcl-glimepiride
pioglitazone hcl-metformin hcl
PRANDIMET
XIGDUO XR
Biguanides
GLUCOPHAGE
GLUCOPHAGE XR
metformin hcl
RIOMET
Diabetic Other
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
KORLYM
Drug Tier Requirements/Limits
2
PA; GO
1
PA
2
PA; GO
1
2
1
2
GO
GO
2
2
2
2
2
1
1
2
2
2
1
2
1
2
2
2
2
2
2
2
1
1
2
2
GO
2
2
1
2
GO
GO
2
2
2
PA; QL
PA; QL
GO
GO
ST;
ST;
ST;
ST;
PA;
GO
PA;
QL
QL
QL
QL
GO, QL
GO, QL
PA
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
15
Drug Name
PROGLYCEM
Drug Tier Requirements/Limits
2
PA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
alogliptin benzoate
JANUVIA
NESINA
ONGLYZA
TRADJENTA
Endocrine and Metabolic
FARXIGA
INVOKANA
1
2
2
2
2
PA;
ST;
PA;
PA;
ST;
QL
QL
GO, QL
QL
QL
2
2
PA; QL
ST; QL
Incretin Mimetic Agents (GLP-1 Receptor Agonists)
BYDUREON
BYETTA
TANZEUM
TRULICITY
VICTOZA
Insulin
APIDRA
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTR
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
Insulin Sensitizing Agents
ACTOS
AVANDIA
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
16
Drug Name
Meglitinide Analogues
nateglinide
PRANDIN
repaglinide
STARLIX
Sulfonylureas
AMARYL
chlorpropamide
DIABETA
glipizide
GLUCOTROL
GLUCOTROL XL
glyburide
glyburide micronized
GLYNASE
tolazamide
tolbutamide
Drug Tier Requirements/Limits
1
2
1
2
2
1
2
1
2
2
1
1
2
1
1
GO
GO
GO
GO
GO
GO
GO
ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS
ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS
FULYZAQ
ANTIDIARRHEAL AGENTS - MISC.
ANTIDIARRHEAL AGENTS - MISC.
bismuth subsalicylate
CVS PROBIOTIC
lactobacillus
4X PROBIOTIC
ANTIDIARRHEALS
Antiperistaltic Agents
diphenoxylate w/ atropine
LOMOTIL
loperamide hcl
opium tincture
paregoric
ANTIDOTES
Antidotes - Chelating Agents
CHEMET
EXJADE
FERRIPROX
JADENU
Opioid Antagonists
EVZIO
naloxone hcl
naltrexone hcl
2
PA
1
2
1
2
AGE
AGE
AGE
1
2
1
1
1
2
2
2
2
2
1
1
GO
SP
PA
SP
PA; QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
17
Drug Name
NARCAN
REVIA
VIVITROL
ANTIEMETICS
5-HT3 Receptor Antagonists
ALOXI
ANZEMET
granisetron hcl
GRANISOL
ondansetron
ondansetron hcl SOLN 4mg/2ml
ondansetron hcl SOLN 4mg/5ml
ondansetron hcl TABS 4mg
ondansetron hcl TABS 8mg, 24mg
SANCUSO
ZOFRAN SOLN 4mg/5ml
ZOFRAN SOLN 40mg/20ml
ZOFRAN TABS
ZOFRAN ODT
Antiemetics - Anticholinergic
ANTIVERT
meclizine hcl
TIGAN
TRANSDERM-SCOP
trimethobenzamide hcl
Antiemetics - Miscellaneous
AKYNZEO
CESAMET
DICLEGIS
dronabinol
MARINOL
Drug Tier Requirements/Limits
2
QL
2
GO
4
2
2
1
2
1
1
1
1
1
2
2
2
2
2
QL
QL
2
1
2
2
1
GO
2
2
2
1
2
QL
PA
PA
QL
QL
QL
QL
PA
GO, QL
GO
GO, QL
GO, QL
GO
GO
Substance P/Neurokinin 1 (NK1) Receptor Antagonists
EMEND
VARUBI
ANTIFUNGALS
Antifungals
ANCOBON
flucytosine
GRIFULVIN V
GRIS-PEG
griseofulvin microsize
griseofulvin ultramicrosi
griseofulvin ultramicrosize
LAMISIL PACK
2
2
QL
QL
2
1
2
2
1
2
1
2
PA; GO
PA
GO
GO
PA; QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
18
Drug Name
LAMISIL TABS
nystatin
Imidazole-Related Antifungals
CRESEMBA
DIFLUCAN
fluconazole
itraconazole
ketoconazole
NOXAFIL
SPORANOX CAPS
SPORANOX SOLN
VFEND
voriconazole
ANTIHEMOPHILIC PRODUCTS
ANTIHEMOPHILIC PRODUCTS
ADYNOVATE
ALPHANATE/VON WILLEBRAND
ALPROLIX
COAGADEX
ELOCTATE
FEIBA NF
IXINITY
KOATE-DVI
KOGENATE FS
KOVALTRY
MONOCLATE-P
MONONINE
NOVOEIGHT
NOVOSEVEN RT
NUWIQ KIT
NUWIQ SOLR
OBIZUR
PROFILNINE SD
RECOMBINATE
RIXUBIS
TRETTEN
WILATE
XYNTHA
XYNTHA SOLOFUSE
ANTIHISTAMINES
Antihistamines - Alkylamines
dexchlorpheniramine maleate
Antihistamines - Ethanolamines
clemastine fumarate
Drug Tier Requirements/Limits
2
GO, QL
1
2
2
1
1
1
2
2
2
2
1
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
GO
PA
GO
PA; GO, QL
PA; QL
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
1
1
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
19
Drug Name
diphenhydramine hcl
Antihistamines - Non-Sedating
CLARINEX SYRP
CLARINEX TABS
cetirizine hcl syp
desloratadine
levocetirizine dihydrochloride
loratadine
XYZAL
Antihistamines - Phenothiazines
PHENERGAN
promethazine hcl
Antihistamines - Piperidines
cyproheptadine hcl
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Combinations
LIPTRUZET
VYTORIN
Antihyperlipidemics - Misc.
KYNAMRO
Bile Acid Sequestrants
cholestyramine
cholestyramine light
COLESTID
colestipol hcl
QUESTRAN
WELCHOL
Fibric Acid Derivatives
ANTARA 30mg, 90mg
ANTARA 43mg, 130mg
fenofibrate CAPS
fenofibrate TABS 40mg, 48mg, 145mg
fenofibrate TABS 54mg, 160mg
fenofibrate micronized 43mg, 130mg
fenofibrate micronized 67mg
fenofibric acid
FENOGLIDE 40mg
FENOGLIDE 120mg
gemfibrozil
LIPOFEN
LOFIBRA
LOPID
TRICOR
TRIGLIDE
Drug Tier Requirements/Limits
1
2
2
1
1
1
1
2
PA
PA; GO
PA
PA
PA
2
1
GO
PA; GO
1
2
2
PA
PA; QL
2
PA; QL
1
1
2
1
2
2
2
2
1
1
1
1
1
1
2
2
1
2
2
2
2
2
GO
GO
PA;
PA;
PA;
PA;
QL
PA;
QL
PA;
PA;
PA;
QL
GO, QL
QL
QL
QL
QL
GO, QL
QL
PA; GO, QL
GO, QL
GO
PA; GO, QL
PA; QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
20
Drug Name
TRILIPIX
HMG CoA Reductase Inhibitors
atorvastatin calcium
CRESTOR
fluvastatin sodium
LESCOL
LESCOL XL
LIPITOR
LIVALO
lovastatin
MEVACOR
PRAVACHOL
rosuvastatin calcium
simvastatin
ZOCOR
Drug Tier Requirements/Limits
2
PA; GO, QL
1
2
1
2
2
2
2
1
2
2
1
1
2
Intestinal Cholesterol Absorption Inhibitors
ZETIA
2
PA;
PA;
PA;
PA;
GO
PA;
GO, QL
QL
GO, QL
GO, QL
QL
GO
GO
PA; QL
GO
PA; QL
Microsomal Triglyceride Transfer Protein (MTP) Inhibitors
JUXTAPID
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
NIASPAN
ANTIHYPERTENSIVES
ACE Inhibitors
ACCUPRIL
ACEON
ALTACE
benazepril hcl
captopril
enalapril maleate
EPANED
fosinopril sodium
lisinopril
LOTENSIN
MAVIK
moexipril hcl
perindopril erbumine
PRINIVIL
quinapril hcl
ramipril
trandolapril
UNIVASC
VASOTEC
ZESTRIL
2
PA; QL
1
2
GO
2
2
2
1
1
1
2
1
1
2
2
1
1
2
1
1
1
2
2
2
GO
GO
GO
GO
GO
GO
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
21
Drug Name
Agents for Pheochromocytoma
DIBENZYLINE
Angiotensin II Receptor Antagonists
ATACAND
AVAPRO
BENICAR
candesartan cilexetil
COZAAR
DIOVAN
EDARBI
eprosartan mesylate
irbesartan
losartan potassium
MICARDIS
telmisartan
TEVETEN
valsartan
Antiadrenergic Antihypertensives
CARDURA
CATAPRES
CATAPRES-TTS-1
CATAPRES-TTS-2
CATAPRES-TTS-3
clonidine hcl
doxazosin mesylate
guanfacine hcl
methyldopa
MINIPRESS
prazosin hcl
reserpine
TENEX
terazosin hcl
Antihypertensive Combinations
ACCURETIC
amlodipine besylate-benazepril hcl
amlodipine besylate-valsartan
amlodipine-valsartan-hydrochlorothiazide
AMTURNIDE
atenolol & chlorthalidone
AVALIDE
AZOR
benazepril & hydrochlorothiazide
BENICAR HCT
bisoprolol & hydrochlorothiazide
Drug Tier Requirements/Limits
2
2
2
2
1
2
2
2
1
1
1
2
1
2
1
PA; GO
ST; GO
ST
PA
GO
ST; GO
PA
PA
PA, ST
2
2
2
2
2
1
1
1
1
2
1
1
2
1
GO
GO
GO
GO
GO
2
1
1
1
2
1
2
2
1
2
1
GO
QL
PA; QL
PA; QL
PA; QL
PA; GO
PA
PA; GO
ST
GO
GO
ST; GO
PA; QL
ST
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
22
Drug Name
captopril & hydrochlorothiazide
DIOVAN HCT
enalapril maleate & hydrochlorothiazide
EXFORGE
EXFORGE HCT
fosinopril sodium & hydrochlorothiazide
HYZAAR
irbesartan-hydrochlorothiazide
lisinopril & hydrochlorothiazide
losartan potassium & hydrochlorothiazide
LOTENSIN HCT
LOTREL
moexipril-hydrochlorothiazide
PRINZIDE
quinapril-hydrochlorothiazide
TEKAMLO
TEKTURNA HCT
TENORETIC 50
TENORETIC 100
UNIRETIC
valsartan-hydrochlorothiazide
VASERETIC
ZESTORETIC
ZIAC
Direct Renin Inhibitors
TEKTURNA
Drug Tier Requirements/Limits
1
2
ST; GO
1
2
PA; GO, QL
2
PA; GO, QL
1
2
GO
1
ST
1
1
2
GO
2
GO, QL
1
2
GO
1
2
PA; QL
2
PA; QL
2
GO
2
GO
2
GO
1
ST
2
GO
2
GO
2
GO
2
PA; QL
Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone
INSPRA
Vasodilators
hydralazine hcl
minoxidil
ANTIMALARIALS
Antimalarial Combinations
atovaquone-proguanil hcl
COARTEM
MALARONE
Antimalarials
ARALEN
chloroquine phosphate
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
PLAQUENIL
1
2
PA; QL
PA; GO, QL
1
1
1
2
2
2
1
2
1
1
2
QL
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
23
Drug Name
PRIMAQUINE PHOSPHATE
QUALAQUIN
quinine sulfate
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
GUANIDINE HCL
MESTINON SYRP
MESTINON TABS
MESTINON TIMESPAN
MYTELASE
PROSTIGMIN
pyridostigmine bromide
ANTIMYCOBACTERIAL AGENTS
Anti TB Combinations
isoniazid & rifampin
RIFAMATE
RIFATER
Antimycobacterial Agents
cycloserine
ethambutol hcl
isoniazid
MYAMBUTOL
MYCOBUTIN
PASER
PRIFTIN
pyrazinamide
rifabutin
RIFADIN
rifampin
SEROMYCIN
SIRTURO
TRECATOR
ANTINEOPLASTIC COMBINATIONS
Antineoplastic Combinations
LONSURF
Drug Tier Requirements/Limits
2
2
PA; GO, QL
1
PA; QL
2
2
2
2
2
2
1
GO
GO
PA
1
2
2
1
1
1
2
2
2
2
1
1
2
1
2
2
2
2
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN SOLR
ALKERAN TABS
BICNU
BUSULFEX
cisplatin
CYCLOPHOSPHAMIDE CAPS; SOLR
cyclophosphamide TABS
PA
4
2
4
4
4
4
1
GO
GO
PA
PA
GO
GO
PA
PA
PA; SP
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
24
Drug Name
ELOXATIN
GLIADEL WAFER
HEXALEN
IFEX
ifosfamide SOLN
ifosfamide SOLR
LEUKERAN
lomustine
melphalan hcl
MUSTARGEN
MYLERAN
oxaliplatin
TEMODAR CAPS
TEMODAR SOLR
THIOTEPA
TREANDA SOLN
TREANDA SOLR
ZANOSAR
Antimetabolites
ALIMTA
ARRANON
azacitidine
capecitabine
cladribine
CLOLAR
cytarabine
DACOGEN
decitabine
DEPOCYT
floxuridine
FLUDARA
fludarabine phosphate
fluorouracil
FOLOTYN
gemcitabine hcl
GEMZAR
LEUSTATIN
mercaptopurine
methotrexate sodium
PURINETHOL
PURIXAN
TABLOID
TREXALL
VIDAZA
XELODA
Drug Tier Requirements/Limits
4
GO
4
2
4
GO
1
4
2
1
1
4
2
4
2
GO, SP
4
SP
4
4
4
SP
4
4
4
4
1
4
4
4
4
4
4
4
4
4
4
4
1
4
4
1
1
2
4
2
2
4
2
SP
SP
GO, SP
SP
GO
GO
GO
GO
GO, SP
GO, SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
25
Drug Name
Drug Tier Requirements/Limits
Antineoplastic - Angiogenesis Inhibitors
AVASTIN
CYRAMZA
ZALTRAP
Antineoplastic - Antibodies
ADCETRIS
ARZERRA
BEXXAR
CAMPATH
ERBITUX
GAZYVA
HERCEPTIN
KADCYLA
KEYTRUDA
PERJETA
RITUXAN
VECTIBIX
YERVOY
4
4
4
SP
4
4
4
4
4
4
4
4
4
4
4
4
4
SP
SP
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE
ODOMZO
2
2
Antineoplastic - Hormonal and Related Agents
AROMASIN
CASODEX
DEPO-PROVERA
ELIGARD
EMCYT
exemestane
FARESTON
FASLODEX
FEMARA
flutamide
letrozole
leuprolide acetate
LUPRON DEPOT
LYSODREN
MEGACE ORAL
megestrol acetate
NILANDRON
SOLTAMOX
tamoxifen citrate
XTANDI
ZOLADEX
ZYTIGA
2
2
4
4
2
1
2
4
2
1
1
1
4
2
2
1
2
2
1
2
4
2
SP
SP
SP
SP
SP
SP
PA; SP
SP
SP
SP
PA
GO
GO
PA; SP
GO
PA; SP
PA; SP
GO
SP
PA; QL, SP
SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
26
Drug Name
Antineoplastic - Immunomodulators
POMALYST
Antineoplastic Antibiotics
bleomycin sulfate
CERUBIDINE
COSMEGEN
dactinomycin
daunorubicin hcl
DOXIL
doxorubicin hcl
doxorubicin hcl liposomal
ELLENCE
epirubicin hcl
IDAMYCIN PFS
idarubicin hcl
mitomycin
mitoxantrone hcl
VALSTAR
Antineoplastic Enzyme Inhibitors
AFINITOR
AFINITOR DISPERZ
ALECENSA
BELEODAQ
BOSULIF
CAPRELSA
COMETRIQ
COTELLIC
FARYDAK
GILOTRIF
GLEEVEC 100mg
GLEEVEC 400mg
IBRANCE
ICLUSIG
imatinib mesylate
IMBRUVICA
INLYTA
IRESSA
ISTODAX
JAKAFI
KYPROLIS 30mg
KYPROLIS 60mg
LENVIMA 8MG DAILY DOSE
LENVIMA 10MG DAILY DOSE
LENVIMA 14MG DAILY DOSE
Drug Tier Requirements/Limits
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
2
4
2
4
2
2
2
2
2
2
2
2
1
2
2
2
4
2
2
4
2
2
2
SP
GO
GO
GO
GO
GO
PA; SP
SP
SP
SP
PA
SP
PA; SP
PA; SP
GO, SP
SP
PA; SP
SP
SP
PA
SP
PA
SP
SP
PA
PA
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
27
Drug Name
LENVIMA 18MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
LYNPARZA
MEKINIST 2mg
MEKINIST .5mg
NEXAVAR
NINLARO
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO 40mg
TAGRISSO 80mg
TARCEVA
TASIGNA
TORISEL
TYKERB
VANDETANIB
VELCADE
VOTRIENT
XALKORI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
Antineoplastic Enzymes
ELSPAR
ERWINAZE
ONCASPAR
Antineoplastics Misc.
bexarotene
HYDREA
hydroxyurea
INTRON A
INTRON A W/DILUENT
MATULANE
PROLEUKIN
SYLATRON
SYNRIBO
TARGRETIN CAPS
tretinoin (chemotherapy)
Drug Tier Requirements/Limits
2
PA
2
PA
2
PA
2
PA
4
SP
2
2
SP
2
PA
2
SP
2
SP
2
SP
2
2
PA; QL
2
PA
2
SP
2
SP
4
SP
2
SP
2
4
SP
2
SP
2
SP
2
SP
2
SP
2
2
SP
4
4
4
1
2
1
4
4
2
4
2
2
2
1
Chemotherapy Rescue/Antidote Agents
FUSILEV
4
SP
SP
GO
SP
SP
SP
SP
SP
GO
SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
28
Drug Name
leucovorin calcium
MESNEX SOLN
MESNEX TABS
TABS
Mitotic Inhibitors
ABRAXANE
DOCEFREZ
DOCETAXEL CONC 20mg/0.5ml,
140mg/7ml
docetaxel CONC 20mg/ml
DOCETAXEL SOLN
ETOPOPHOS
etoposide
HALAVEN
JEVTANA
MARQIBO
NAVELBINE
paclitaxel
TAXOTERE 20mg/0.5ml
TAXOTERE 20mg/ml
VINBLASTINE SULFATE
vincristine sulfate
VUMON
Topoisomerase I Inhibitors
CAMPTOSAR
HYCAMTIN CAPS
HYCAMTIN SOLR
irinotecan hcl
topotecan hcl
ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
carbidopa
LODOSYN
Antiparkinson Anticholinergics
benztropine mesylate
trihexyphenidyl hcl
Antiparkinson COMT Inhibitors
COMTAN
entacapone
TASMAR
tolcapone
Antiparkinson Dopaminergics
amantadine hcl
APOKYN
bromocriptine mesylate
Drug Tier Requirements/Limits
1
2
GO
2
4
4
4
4
4
4
1
4
4
4
4
1
4
4
4
4
4
4
2
4
1
4
1
2
SP
SP
GO
GO
GO
SP
GO, SP
SP
GO
1
1
2
1
2
1
1
2
1
GO
PA; GO, QL
PA; QL
QL, SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
29
Drug Name
carbidopa-levodopa
carbidopa-levodopa-entacapone
DUOPA
MIRAPEX
MIRAPEX ER 3.75mg
MIRAPEX ER .375mg, .75mg, 1.5mg,
2.25mg, 3mg, 4.5mg
NEUPRO
PARCOPA
PARLODEL
pramipexole dihydrochloride
REQUIP
REQUIP XL
ropinirole hydrochloride
SINEMET
SINEMET CR
STALEVO 50
STALEVO 75
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
Drug Tier Requirements/Limits
1
1
2
2
GO
2
2
GO
2
2
2
1
2
2
1
2
2
2
2
2
2
2
2
PA; QL
GO
GO
GO
GO
GO
GO
GO
GO
GO
GO
GO
GO
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT
ELDEPRYL
selegiline hcl
ZELAPAR
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
LITHIUM
lithium carbonate
LITHOBID
Antipsychotics - Misc.
GEODON CAPS
GEODON SOLR
LATUDA
ziprasidone hcl
Benzisoxazoles
FANAPT
FANAPT TITRATION PACK
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
paliperidone
2
2
1
2
GO
PA; QL
2
1
2
GO
2
2
2
1
GO, QL
QL
PA; QL
QL
2
2
2
4
2
1
PA;
PA;
PA;
PA;
PA
PA;
QL
QL
GO, QL
QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
30
Drug Name
RISPERDAL
RISPERDAL CONSTA
RISPERDAL M-TAB
risperidone
Butyrophenones
HALDOL
HALDOL DECANOATE 50
HALDOL DECANOATE 100
haloperidol
haloperidol decanoate
haloperidol lactate
Dibenzapines
clozapine
CLOZARIL
FAZACLO
loxapine succinate
LOXITANE
olanzapine
quetiapine fumarate
SAPHRIS 2.5mg
SAPHRIS 5mg, 10mg
SEROQUEL
SEROQUEL XR
VERSACLOZ
ZYPREXA SOLR
ZYPREXA TABS
ZYPREXA RELPREVV
ZYPREXA ZYDIS
Phenothiazines
chlorpromazine hcl
fluphenazine decanoate
fluphenazine hcl
perphenazine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
thioridazine hcl
trifluoperazine hcl
Quinolinone Derivatives
ABILIFY SOLN 1mg/ml
ABILIFY SOLN 9.75mg/1.3ml
ABILIFY TABS
ABILIFY DISCMELT
ABILIFY MAINTENA
Drug Tier Requirements/Limits
2
GO, QL
4
QL
2
GO, QL
1
QL
2
2
2
1
1
1
1
2
2
1
2
1
1
2
2
2
2
2
2
2
4
2
GO
GO
GO
GO
GO
QL
PA
PA; QL
GO, QL
PA; QL
GO
GO, QL
QL
GO, QL
1
1
1
1
1
1
1
1
1
2
2
2
2
2
PA;
PA;
PA;
PA;
PA;
GO, QL
QL
GO, QL
QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
31
Drug Name
aripiprazole
REXULTI
Thioxanthenes
thiothixene
ANTISEPTICS DISINFECTANTS
ANTISEPTICS DISINFECTANTS
hydrogen peroxide
Chlorine Antiseptics
PHISOHEX
SILVER ANTISEPTICS
SILVER PROTEIN MILD
ANTIVIRALS
Antiretrovirals
abacavir sulfate
abacavir sulfate-lamivudine-zidovudine
APTIVUS
ATRIPLA
COMBIVIR
COMPLERA
CRIXIVAN
DESCOVY
didanosine
EDURANT
EMTRIVA
EPIVIR
EPIVIR HBV SOLN
EPIVIR HBV TABS
EPZICOM
EVOTAZ
FUZEON
GENVOYA
INTELENCE
INVIRASE
ISENTRESS CHEW; TABS
ISENTRESS PACK
KALETRA
lamivudine
lamivudine (hbv)
lamivudine-zidovudine
LEXIVA
nevirapine
NORVIR
ODEFSEY
PREZCOBIX
Drug Tier Requirements/Limits
1
PA; QL
2
PA; QL
1
1
2
QL
2
1
1
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
1
2
2
2
GO
GO
GO
SP
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
32
Drug Name
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRIZIVIR
TRUVADA
TYBOST
VIDEX EC
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
VITEKTA
ZERIT
ZIAGEN SOLN
ZIAGEN TABS
zidovudine
CMV Agents
ganciclovir
VALCYTE SOLR
VALCYTE TABS
valganciclovir hcl
Drug Tier Requirements/Limits
2
2
2
GO
2
2
1
2
2
2
2
2
GO
2
2
2
GO
2
2
2
GO
2
2
2
2
GO
2
2
GO
1
2
2
2
1
GO
Hepatitis Agents
adefovir dipivoxil
1
BARACLUDE SOLN
2
BARACLUDE TABS
2
GO
COPEGUS
2
GO, QL, SP
entecavir
1
DAKLINZA
2
PA; QL, SP
HARVONI
2
PA; QL, SP
HEPSERA
2
GO
INFERGEN
2
PA; SP
PEGASYS
2
QL, SP
PEGASYS PROCLICK
2
QL, SP
REBETOL CAPS
2
GO, QL, SP
REBETOL SOLN
2
QL, SP
RIBASPHERE RIBAPAK
2
PA; QL, SP
RIBATAB
2
PA; QL, SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
33
Drug Name
Drug Tier Requirements/Limits
ribavirin (hepatitis c) CAPS
1
QL, SP
ribavirin (hepatitis c) TABS 200mg
1
QL, SP
ribavirin (hepatitis c) TABS 400mg, 600mg1
PA; QL, SP
SOVALDI
2
PA; QL, SP
TYZEKA
2
Herpes Agents
acyclovir
FAMVIR
valacyclovir hcl
VALTREX
ZOVIRAX CAPS; SUSP; TABS
Influenza Agents
FLUMADINE
RELENZA DISKHALER
TAMIFLU
1
2
1
2
2
2
2
2
GO
GO
GO
GO
QL
QL
Respiratory Syncytial Virus (RSV) Agents
VIRAZOLE
ARTIFICIAL TEARS AND LUBRICANTS
ARTIFICIAL TEAR SOLUTIONS
artificial tear solution
carboxymethylcellulose sodium (ophth)
ASSORTED CLASSES
Chelating Agents
CUPRIMINE
DEPEN TITRATABS
SYPRINE
Immunomodulators
REVLIMID
THALOMID
2
1
1
2
2
2
PA
2
2
SP
SP
Immunosuppressive Agents
ASTAGRAF XL
2
PA; QL
azathioprine
1
CELLCEPT
2
GO
cyclosporine
1
cyclosporine modified (for microemulsion) 1
IMURAN
2
GO
mycophenolate mofetil
1
mycophenolate sodium
1
MYFORTIC
2
GO
NEORAL
2
PROGRAF
2
RAPAMUNE SOLN
2
RAPAMUNE TABS
2
GO
SANDIMMUNE CAPS
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
34
Drug Name
SANDIMMUNE SOLN
sirolimus
tacrolimus
ZORTRESS
Lymphatic Agents
SYLVANT
Potassium Removing Resins
KAYEXALATE
sodium polystyrene sulfonate
BETA BLOCKERS
Alpha-Beta Blockers
carvedilol
COREG
COREG CR
labetalol hcl
TRANDATE
Beta Blockers Cardio-Selective
acebutolol hcl
atenolol
betaxolol hcl
bisoprolol fumarate
BYSTOLIC
KERLONE
LOPRESSOR
metoprolol succinate
metoprolol tartrate 37.5mg, 75mg
metoprolol tartrate 25mg, 50mg, 100mg
SECTRAL
TENORMIN
TOPROL XL
ZEBETA
Beta Blockers Non-Selective
BETAPACE
CORGARD
INDERAL LA
LEVATOL
nadolol
pindolol
propranolol hcl
sotalol hcl
SOTYLIZE
timolol maleate
Drug Tier Requirements/Limits
2
1
1
2
SP
4
2
1
1
2
2
1
2
1
1
1
1
2
2
2
1
1
1
2
2
2
2
2
2
2
2
1
1
1
1
2
1
GO
GO
ST; QL
GO
ST; QL
GO
GO
PA
GO
GO
GO
GO
GO
GO
GO
PA
BIOLOGICALS MISC
Allergenic Extracts
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
35
Drug Name
GRASTEK
ORALAIR
RAGWITEK
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
ADALAT CC
CALAN
CALAN SR
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA 120mg
CARDIZEM LA 180mg, 240mg, 300mg,
360mg, 420mg
DILACOR XR
diltiazem hcl
diltiazem hcl coated beads CP24
diltiazem hcl coated beads TB24
diltiazem hcl extended release beads
felodipine
ISOPTIN SR
isradipine
nicardipine hcl
nifedipine
nimodipine
nisoldipine
NORVASC
NYMALIZE
PROCARDIA
PROCARDIA XL
SULAR
TIAZAC
verapamil hcl
VERELAN
VERELAN PM
CARDIOTONICS
Cardiac Glycosides
digoxin
LANOXIN
LANOXIN
62.5mcg, 187.5mcg
125mcg, 250mcg
Drug Tier Requirements/Limits
2
PA; QL
2
PA; QL
2
PA; QL
2
2
2
2
2
2
2
2
GO
GO
GO
PA
GO
GO
PA
PA; GO
2
1
1
1
1
1
2
1
1
1
1
1
2
2
2
2
2
2
1
2
2
GO
1
2
2
CARDIOVASCULAR AGENTS - MISC.
Cardiovascular Agents Misc. - Combinations
amlodipine besylate-atorvastatin calcium
BIDIL
1
2
PA
GO
PA
PA
GO
PA
GO
GO
GO
GO
GO
GO
GO
PA; QL
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
36
Drug Name
CADUET
ENTRESTO
Prostaglandin Vasodilators
epoprostenol sodium
FLOLAN
ORENITRAM
REMODULIN
TYVASO STARTER
VELETRI
VENTAVIS
Drug Tier Requirements/Limits
2
PA; GO, QL
2
PA
1
2
2
2
2
2
2
PA;
PA;
PA;
PA;
PA;
PA
PA;
QL, SP
GO, QL, SP
SP
QL, SP
QL, SP
QL, SP
Pulmonary Hypertension - Endothelin Receptor Antagonists
LETAIRIS
OPSUMIT
TRACLEER
2
2
2
PA; QL, SP
PA; SP
PA; QL, SP
Pulmonary Hypertension - Phosphodiesterase Inhibitors
ADCIRCA
REVATIO SOLN
REVATIO SUSR
REVATIO TABS
sildenafil citrate (pulmonary hypertension)
CEPHALOSPORINS
Cephalosporins - 1st Generation
cefadroxil
cephalexin
KEFLEX
Cephalosporins - 2nd Generation
cefaclor
CEFACLOR ER
cefprozil
CEFTIN SUSR 125mg/5ml
CEFTIN SUSR 250mg/5ml
CEFTIN TABS
cefuroxime axetil
Cephalosporins - 3rd Generation
CEDAX CAPS
CEDAX SUSR
cefdinir
cefditoren pivoxil
cefixime
cefpodoxime proxetil
ceftibuten
ceftriaxone sodium
SPECTRACEF
SUPRAX CAPS
2
4
2
2
1
PA;
PA;
PA;
PA;
PA;
1
1
2
GO
1
2
1
2
2
2
1
2
2
1
1
1
1
1
1
2
2
QL, SP
QL, SP
QL, SP
GO, QL, SP
QL, SP
GO
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
37
Drug Name
SUPRAX CHEW
SUPRAX SUSR 100mg/5ml, 200mg/5ml
SUPRAX SUSR 500mg/5ml
SUPRAX TABS
Cephalosporins - 4th Generation
MAXIPIME
CONTRACEPTIVES
Combination Contraceptives - Oral
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia lo
apri
aranelle
aviane
azurette
balziva
briellyn
camrese
camrese lo
caziant
cesia
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
drospirenone/ethinyl estr
elinest
emoquette
enpresse-28
estarylla
falmina
gianvi
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
introvale
jolessa
junel fe 1.5/30
junel fe 1/20
Drug Tier Requirements/Limits
2
2
GO
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
38
Drug Name
kariva
kelnor 1/35
kurvelo
leena
lessina
levonest
levonorgestrel and ethiny
levonorgestrel/ethinyl es
levora 0.15/30-28
loryna
low-ogestrel
lutera
marlissa
microgestin 1/20
microgestin fe
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 7/7/7
norgestimate-ethinyl estradiol (triphasic)
norgestimate/ethinyl estr
norgestrel/ethinyl estrad
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
ogestrel
orsythia
philith
portia-28
previfem
quasense
reclipsen
solia
sprintec 28
sronyx
syeda
tilia fe
tri-linyah
tri-previfem
tri-sprintec
trinessa
Drug Tier Requirements/Limits
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
39
Drug Name
trivora-28
velivet
vestura
viorele
wera
wymzya fe
zarah
zenchent
zeosa
zovia 1/35e
zovia 1/50e
Drug Tier Requirements/Limits
4
4
4
4
4
4
4
4
4
4
4
Combination Contraceptives - Transdermal
norelgestromin-ethinyl estradiol
ORTHO EVRA
Combination Contraceptives - Vaginal
NUVARING
Emergency Contraceptives
ELLA
levonorgestrel (emergency oc)
PLAN B
PLAN B ONE-STEP
Progestin Contraceptives - Injectable
DEPO-PROVERA CONTRACEPTIV
DEPO-SUBQ PROVERA 104
medroxyprogesterone acetate
(contraceptive)
Progestin Contraceptives - Oral
norethindrone (contraceptive)
CORTICOSTEROIDS
Glucocorticosteroids
budesonide
CELESTONE
CORTEF
cortisone acetate
dexamethasone
DEXAMETHASONE INTENSOL
dexamethasone sodium phosphate
DEXPAK 6 DAY
DEXPAK 10 DAY
DEXPAK 13 DAY
ENTOCORT EC
hydrocortisone
hydrocortisone sod succinate
KENALOG-10
4
4
GO
4
4
4
4
4
4
4
4
GO
GO
GO
4
1
2
2
1
1
2
1
2
2
2
2
1
1
2
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
40
Drug Name
KENALOG-40
MEDROL 2mg
MEDROL 4mg, 8mg, 16mg, 32mg
MEDROL DOSEPAK
methylprednisolone
methylprednisolone sod succ
MILLIPRED
MILLIPRED DP
ORAPRED
ORAPRED ODT
PEDIAPRED
prednisolone
prednisolone sodium phosphate
prednisone
PREDNISONE INTENSOL
PRELONE
SOLU-CORTEF
SOLU-MEDROL
UCERIS TB24
Mineralocorticoids
fludrocortisone acetate
COUGH/COLD/ALLERGY
Antitussives
benzonatate
hydrocodone w/ homatropine
TESSALON
TESSALON PERLES
Cough/Cold/Allergy Combinations
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
dextromethorphan-guaifenesin
GILPHEX TR
hydrocodone polistirex-chlorpheniramine
polistirex
NORTUSS-EX
promethazine w/codeine
promethazine-dm
pseudoephedrine w/ codeine-gg
SEMPREX-D
SUTTAR-SF
TUSSIONEX PENNKINETIC EXT
EXPECTORANTS
guaifenesin
Drug Tier Requirements/Limits
2
2
2
GO
2
GO
1
1
2
2
2
GO
2
GO
2
GO
1
1
1
2
2
GO
2
GO
2
GO
2
PA
1
1
1
2
2
2
2
1
2
1
2
1
1
1
2
2
2
GO
GO
PA
PA
PA
GO
GO
1
Misc. Respiratory Inhalants
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
41
Drug Name
HYPER-SAL
HYPERSAL
NEBUSAL
sodium chloride (inhalant)
Mucolytics
acetylcysteine
Drug Tier Requirements/Limits
2
GO
2
2
1
1
DERMATOLOGICALS
Acne Products
ABSORICA
ACZONE
adapalene
ATRALIN
AZELEX
BENZACLIN
benzoyl peroxide
benzoyl peroxide-erythromycin
CLEOCIN-T
clindamycin phosphate (topical)
clindamycin phosphate-benzoyl peroxide
DIFFERIN CREA
DIFFERIN GEL .1%
DIFFERIN GEL .3%
DIFFERIN LOTN
erythromycin (acne aid)
FABIOR
isotretinoin
KLARON
RETIN-A
RETIN-A MICRO PUMP
sulfacetamide sodium w/ sulfur
tretinoin
tretinoin microsphere
2
2
1
2
2
2
1
1
2
1
1
2
2
2
2
1
2
1
2
2
2
1
1
1
Agents for External Genital and Perianal Warts
VEREGEN
Anti-inflammatory Agents - Topical
diclofenac sodium (topical)
FLECTOR
PENNSAID
VOLTAREN GEL
Antibiotics - Topical
ALTABAX
BACTROBAN
BACTROBAN
CENTANY
CREA
OINT
PA;
PA;
ST
PA;
QL
PA;
QL
QL
AGE, GO
GO, QL
QL
GO
PA;
ST;
ST;
ST
ST;
QL
GO
GO
GO
PA
PA; QL
GO
PA; AGE, GO
PA; AGE
PA; AGE
PA; AGE
2
PA
1
2
2
2
ST, QL
PA; QL
PA
ST; ST, GO, QL
2
2
2
2
ST; QL
PA; GO, QL
GO
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
42
Drug Name
CENTANY AT
CORTISPORIN CREA
gentamicin sulfate (topical)
mupirocin
mupirocin calcium (topical)
Antifungals - Topical
ciclopirox GEL; SOLN
ciclopirox SHAM
ciclopirox olamine CREA
ciclopirox olamine SUSP
clotrimazole (topical)
clotrimazole w/ betamethasone
econazole nitrate
ECOZA
EXELDERM
JUBLIA
ketoconazole (topical)
LOPROX
LOPROX SHAMPOO
LOTRISONE
LUZU
miconazole nitrate (topical)
naftifine hcl
NAFTIN CREA 1%
NAFTIN CREA 2%
NAFTIN GEL
NIZORAL
nystatin (topical)
nystatin-triamcinolone
oxiconazole nitrate
OXISTAT CREA
OXISTAT LOTN
Drug Tier Requirements/Limits
2
PA
2
1
1
1
PA; QL
1
1
1
1
1
1
1
2
2
2
1
2
2
2
2
1
1
2
2
2
2
1
1
1
2
2
PA
PA
PA
PA
PA
PA; GO
PA; GO
PA; GO
PA
PA
PA
PA; GO
PA
PA; GO
PA
PA; GO
PA
Antineoplastic or Premalignant Lesion Agents - Topical
CARAC
diclofenac sodium (actinic keratoses)
EFUDEX
FLUOROPLEX
fluorouracil (topical)
PANRETIN
PICATO
SOLARAZE
TARGRETIN GEL
VALCHLOR
2
1
2
2
1
2
2
2
2
2
GO
GO
PA
PA; QL
QL
Antipruritics - Topical
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
43
Drug Name
prudoxin
Antipsoriatics
acitretin
calcipotriene
calcitriol (topical)
COSENTYX
COSENTYX SENSOREADY PEN
DOVONEX
DRITHO-CREME HP
DRITHO-SCALP
methoxsalen rapid
8-MOP
OXSORALEN ULTRA
SORIATANE
STELARA
TAZORAC
VECTICAL
Drug Tier Requirements/Limits
2
QL
1
1
1
2
2
2
2
2
1
2
2
2
4
2
2
QL
PA; QL, SP
PA; QL, SP
GO
GO
GO, QL
PA; QL, SP
ST
GO
Antiseborrheic Products
selenium sulfide
1
SELENIUM SULFIDE-PYRITHIONE ZINC IN 1
UREA VEHICLE
Antivirals - Topical
acyclovir topical
DENAVIR
ZOVIRAX CREA
ZOVIRAX OINT
Burn Products
mafenide acetate
SILVADENE
silver sulfadiazine
SULFAMYLON CREA
SULFAMYLON PACK
Corticosteroids - Topical
ACLOVATE
alclometasone dipropionate
amcinonide CREA; LOTN
AMCINONIDE OINT
APEXICON E
betamethasone dipropionate (topical)
betamethasone dipropionate augmented
betamethasone valerate
calcipotriene-betamethasone dipropionate
CAPEX
1
2
2
2
QL
PA; QL
PA; QL
GO, QL
1
2
1
2
2
PA
GO
2
1
1
2
2
1
1
1
1
2
PA; GO
PA
PA; GO
PA
PA
PA
PA
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
44
Drug Name
Drug Tier Requirements/Limits
clobetasol propionate CREA; GEL; LIQD; 1
PA
OINT; SOLN
clobetasol propionate FOAM; LOTN; SHAM 1
CLOBEX
2
PA; GO
clocortolone pivalate
1
PA
CLODERM PUMP
2
PA; GO
CORDRAN CREA
2
PA; GO
CORDRAN LOTN
2
PA
CORDRAN TAPE
2
PA
CUTIVATE
2
PA; GO
DERMA-SMOOTHE/FS SCALP OI
2
GO
DERMATOP
2
PA; GO
desonide
1
PA
DESOWEN
2
PA; GO
desoximetasone CREA .05%
1
PA
desoximetasone CREA .25%
1
desoximetasone GEL
1
PA
desoximetasone OINT .05%
1
PA
desoximetasone OINT .25%
1
diflorasone diacetate
1
PA
DIPROLENE
2
PA; GO
DIPROLENE AF
2
PA; GO
ELOCON
2
PA; GO
EPIFOAM
2
fluocinolone acetonide
1
fluocinonide CREA .1%
1
PA
fluocinonide CREA .05%
1
fluocinonide GEL
1
fluocinonide OINT
1
fluocinonide SOLN
1
flurandrenolide
1
PA
fluticasone propionate
1
halobetasol propionate
1
PA
HALOG
2
PA
hydrocortisone (topical)
1
hydrocortisone butyrate
1
PA
hydrocortisone valerate
1
KENALOG
2
PA; GO
LOCOID CREA; OINT; SOLN
2
PA; GO
LOCOID LOTN
2
PA
LUXIQ
2
PA; GO
PRAMOSONE
2
PRAMOSONE E
2
prednicarbate
1
SYNALAR
2
PA; GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
45
Drug Name
TACLONEX
TEMOVATE
TOPICORT CREA; GEL; OINT
TOPICORT LIQD
triamcinolone acetonide (topical)
triamcinolone acetonide (topical)
LOTN; OINT
ULTRAVATE
VANOS
WESTCORT
AERS
CREA;
Emollient/Keratolytic Agents
urea
Emollients
LAC-HYDRIN
lactic acid (ammonium lactate)
Enzymes - Topical
SANTYL
Immunomodulating Agents - Topical
ALDARA
imiquimod cre 5%
ZYCLARA
ZYCLARA PUMP
Immunosuppressive Agents - Topical
ELIDEL
PROTOPIC
tacrolimus (topical)
Keratolytic/Antimitotic Agents
CONDYLOX GEL
CONDYLOX SOLN
podofilox
Local Anesthetics - Topical
benzocaine-benzethonium
capsaicin
lidocaine CREA; OINT; PTCH
lidocaine hcl
lidocaine-prilocaine
LIDODERM
XYLOCAINE JELLY
Misc. Topical
DRYSOL
XERAC AC
Pigmenting-Depigmenting Agents
OXSORALEN
Drug Tier Requirements/Limits
2
PA; GO
2
PA; GO
2
PA; GO
2
PA
1
PA
1
2
2
2
PA; GO
PA; GO
PA; GO
1
2
1
GO
2
QL
2
1
2
2
GO
2
2
1
PA; QL
PA; GO, QL
PA; QL
2
2
1
GO
1
1
1
1
1
2
2
PA; QL
PA; QL
GO
GO
2
2
2
Rosacea Agents
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
46
Drug Name
FINACEA
METROCREAM
METROGEL
METROLOTION
metronidazole (topical)
metronidazole (topical)
MIRVASO
NORITATE
SOOLANTRA
CREA; LOTN
GEL
Scabicides Pediculicides
ELIMITE
EURAX
lindane
malathion
NATROBA
OVIDE
permethrin
SKLICE
spinosad
ULESFIA
Wound Care Products
REGRANEX
DIAGNOSTIC PRODUCTS
Diagnostic Drugs
GLUCAGON HCL DIAGNOSTIC
Diagnostic Tests
FREESTYLE TEST STRIPS
PRECISION XTRA BLOOD GLUC
DIGESTIVE AIDS
Digestive Enzymes
CREON
PANCREAZE
pancrelipase (lipase-protease-amylase)
ZENPEP
ZENPEP
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide
DIAMOX
KEVEYIS
methazolamide
NEPTAZANE
Drug Tier Requirements/Limits
2
QL
2
GO
2
PA; GO
2
GO
1
1
PA
2
PA
2
PA
2
PA
2
2
1
1
2
2
1
2
1
2
GO
ST; GO, QL
GO
ST; QL
ST; QL
QL
2
2
4
4
QL
QL
2
2
1
2
2
GO
1
2
2
1
2
GO
PA
GO
Diuretic Combinations
ALDACTAZIDE
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
47
Drug Name
amiloride & hydrochlorothiazide
DYAZIDE
MAXZIDE
MAXZIDE-25
spironolactone & hydrochlorothiazide
triamterene & hydrochlorothiazide
Loop Diuretics
DEMADEX
EDECRIN
ethacrynate sodium
FUROSEMIDE SOLN 8mg/ml
furosemide SOLN 10mg/ml
furosemide TABS
LASIX
torsemide
Potassium Sparing Diuretics
ALDACTONE
amiloride hcl
DYRENIUM
MIDAMOR
spironolactone
Thiazides and Thiazide-Like Diuretics
chlorothiazide
chlorthalidone
DIURIL
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
MICROZIDE
THALITONE
ZAROXOLYN
Drug Tier Requirements/Limits
1
2
GO
2
GO
2
GO
1
1
2
2
1
1
1
1
2
1
GO
PA
PA
2
1
2
2
1
GO
1
1
2
1
1
1
1
2
2
2
ENDOCRINE AND METABOLIC AGENTS - MISC.
Bone Density Regulators
ACTONEL 5mg, 30mg, 35mg
ACTONEL 150mg
alendronate sodium
AREDIA
ATELVIA
BONIVA
calcitonin (salmon)
DIDRONEL
etidronate disodium
FORTEO
2
2
1
2
2
2
1
2
1
2
GO
GO
GO
GO
PA;
PA;
QL
GO
PA;
PA;
QL
GO, QL
GO, QL
GO, QL
GO
PA; QL, SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
48
Drug Name
FORTICAL
FOSAMAX
FOSAMAX PLUS D
MIACALCIN
NATPARA
pamidronate disodium
PROLIA
RECLAST
risedronate sodium
SKELID
XGEVA
zoledronic acid CONC; SOLN
ZOLEDRONIC ACID SOLR
ZOMETA CONC
ZOMETA SOLN
Drug Tier Requirements/Limits
2
2
GO, QL
2
PA; QL
2
GO
2
PA; QL
1
4
PA; QL, SP
4
GO, QL, SP
1
PA; QL
2
PA; QL
4
PA; QL, SP
4
QL, SP
4
PA; QL, SP
4
GO, QL, SP
4
QL, SP
Growth Hormone Receptor Antagonists
SOMAVERT
2
Growth Hormone Releasing Hormones (GHRH)
EGRIFTA
Growth Hormones
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
SEROSTIM
ZORBTIVE
Hormone Receptor Modulators
EVISTA
OSPHENA
raloxifene hcl
2
PA; SP
2
2
2
2
PA;
PA;
PA;
PA;
2
2
1
GO
PA
Insulin-Like Growth Factors (Somatomedins)
INCRELEX
PA; QL, SP
2
SP
SP
SP
SP
PA; SP
LHRH/GnRH Agonist Analog Pituitary Suppressants
LUPRON DEPOT-PED
SUPPRELIN LA
SYNAREL
Metabolic Modifiers
calcitriol
CARBAGLU
CARNITOR
doxercalciferol
HECTOROL
levocarnitine (metabolic modifiers)
MYALEPT
paricalcitol
ROCALTROL
4
2
2
1
2
2
1
2
1
2
1
2
PA; SP
PA; SP
PA
PA
GO
GO
PA; QL
PA
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
49
Drug Name
SENSIPAR
STRENSIQ
ZEMPLAR
Drug Tier Requirements/Limits
2
ST; SP
1
PA; QL
2
PA; GO
Posterior Pituitary Hormones
DDAVP
desmopressin
desmopressin
desmopressin
desmopressin
acetate
acetate refrigerated
acetate spray
acetate spray refrigerated
Prolactin Inhibitors
cabergoline
Somatostatic Agents
octreotide acetate
SANDOSTATIN
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
Vasopressin Receptor Antagonists
SAMSCA
ESTROGENS
Estrogen Combinations
ACTIVELLA
CLIMARA PRO
COMBIPATCH
esterified estrogens & methyltestosterone
estradiol & norethindrone acetate
FEMHRT 1/5
FEMHRT LOW DOSE
norethindrone acetate-ethinyl estradiol
norethindrone acetate-ethinyl estradiol
PREMPHASE
PREMPRO
Estrogens
ALORA
CLIMARA
DIVIGEL
ELESTRIN
ESTRACE TABS
estradiol
ESTRASORB
ESTROGEL
estropipate
EVAMIST
MENEST
2
1
1
1
1
GO
1
1
2
4
2
2
PA;
PA;
PA;
PA;
PA;
2
QL, SP
2
2
2
1
1
2
2
1
1
2
2
GO
2
2
2
2
2
1
2
2
1
2
2
QL, SP
GO, QL, SP
QL, SP
QL
QL, SP
GO
PA; GO
PA
GO
PA
PA
GO
PA
PA
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
50
Drug Name
MINIVELLE
PREMARIN TABS
VIVELLE-DOT
FLUOROQUINOLONES
Fluoroquinolones
AVELOX
AVELOX ABC PACK
CIPRO
CIPRO XR
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin-ciprofloxacin hcl
FACTIVE
LEVAQUIN
levofloxacin
moxifloxacin hcl
NOROXIN
ofloxacin
GASTROINTESTINAL AGENTS - MISC.
ANTIFLATULENTS
simethicone
Gallstone Solubilizing Agents
ACTIGALL
URSO 250
URSO FORTE
ursodiol
Gastrointestinal Antiallergy Agents
cromolyn sodium (mastocytosis)
GASTROCROM
Drug Tier Requirements/Limits
2
2
2
GO
2
2
2
2
1
1
1
2
2
1
1
2
1
Gastrointestinal Stimulants
metoclopramide hcl
REGLAN
GO
1
2
2
2
1
1
2
Gastrointestinal Chloride Channel Activators
AMITIZA
GO
GO
GO
GO
GO
GO
GO
GO
2
PA; QL
1
2
GO
Inflammatory Bowel Agents
APRISO
2
ASACOL HD
2
AZULFIDINE
2
GO
AZULFIDINE EN-TABS
2
GO
balsalazide disodium
1
CANASA
2
CIMZIA
2
PA; QL, SP
COLAZAL
2
GO
DELZICOL
2
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
51
Drug Name
DIPENTUM
ENTYVIO
GIAZO
LIALDA
mesalamine
PENTASA
REMICADE
sulfasalazine
Intestinal Acidifiers
lactulose (encephalopathy)
Drug Tier Requirements/Limits
2
4
PA; QL, SP
2
PA
2
ST; QL
1
2
4
PA; SP
1
1
Irritable Bowel Syndrome (IBS) Agents
alosetron hcl
LINZESS
LOTRONEX
1
2
2
Peripheral Opioid Receptor Antagonists
MOVANTIK
RELISTOR
Phosphate Binder Agents
AURYXIA
calcium acetate (phosphate binder)
ELIPHOS
FOSRENOL
PHOSLO
PHOSLYRA
RENAGEL
RENVELA PACK
RENVELA TABS
sevelamer carbonate
Short Bowel Syndrome (SBS) Agents
GATTEX
GATTEX
5mg
5mg
GENITOURINARY
Miscellaneous
bethanechol chloride
URECHOLINE
Urinary Antispasmodics
darifenacin hydrobromide
DETROL
DETROL LA
DITROPAN XL
ENABLEX
GELNIQUE
oxybutynin chloride
OXYTROL
PA; QL
PA; QL
PA; GO, QL
2
2
PA
PA
2
1
2
2
2
2
2
2
2
1
PA
2
2
PA; QL
PA; QL, SP
1
2
GO
1
2
2
2
2
2
1
2
GO
GO
GO
PA
GO
GO
GO
PA; GO
PA
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
52
Drug Name
SANCTURA
SANCTURA XR
tolterodine tartrate
TOVIAZ
trospium chloride
VESICARE
Drug Tier Requirements/Limits
2
GO
2
GO
1
2
1
2
PA
GENITOURINARY AGENTS - MISCELLANEOUS
Acidifiers
K-PHOS MF
K-PHOS NO 2
Alkalinizers
potassium citrate (alkalinizer)
Genitourinary Irrigants
sodium chloride (gu irrigant)
Interstitial Cystitis Agents
ELMIRON
Prostatic Hypertrophy Agents
alfuzosin hcl
AVODART
CARDURA XL
CIALIS TAB 5mg
dutasteride
dutasteride-tamsulosin hcl
finasteride
FLOMAX
JALYN
PROSCAR
RAPAFLO
tamsulosin hcl
UROXATRAL
Urinary Analgesics
phenazopyridine hcl
PYRIDIUM
GOUT AGENTS
Gout Agent Combinations
colchicine w/ probenecid
Gout Agents
allopurinol
colchicine
COLCRYS
KRYSTEXXA
ULORIC
ZYLOPRIM
2
2
1
1
PA
2
1
2
2
2
1
1
1
2
2
2
2
1
2
1
2
PA; GO, QL
PA
PA; QL
PA; QL
GO
PA; GO, QL
GO
PA; QL
GO
GO
1
1
1
2
4
2
2
PA; QL, SP
PA; QL
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
53
Drug Name
Uricosurics
probenecid
HEMATOLOGICAL AGENTS - MISC.
Bradykinin B2 Receptor Antagonists
FIRAZYR
Hematorheologic Agents
pentoxifylline
TRENTAL
Platelet Aggregation Inhibitors
AGGRENOX
AGRYLIN
aspirin-dipyridamole
BRILINTA
cilostazol
clopidogrel bisulfate
dipyridamole
EFFIENT
PERSANTINE
PLAVIX
PLETAL
ticlopidine hcl
ZONTIVITY
HEMATOPOIETIC AGENTS
Agents for Gaucher Disease
CERDELGA
Agents for Sickle Cell Anemia
DROXIA
Cobalamins
cyanocobalamin
FOLIC ACID/FOLATES
folic acid
Hematopoietic Growth Factors
ARANESP ALBUMIN FREE
EPOGEN
GRANIX
LEUKINE
MIRCERA
NEULASTA
NEUPOGEN
NPLATE
PROCRIT
PROMACTA
ZARXIO
Drug Tier Requirements/Limits
1
2
PA; SP
1
2
GO
2
2
1
2
1
1
1
2
2
2
2
1
2
PA; GO, QL
GO
PA; QL
PA; QL
2
PA; QL
GO
GO
GO
4
1
1
2
2
2
2
2
2
2
4
2
2
2
QL,
SP
SP
SP
PA;
SP
SP
PA;
SP
PA;
SP
SP
QL
SP
SP
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
54
Drug Name
Drug Tier Requirements/Limits
Iron
FERAHEME
4
FERRLECIT
4
ferrous sulfate dried
1
infed
4
INJECTAFER
2
iron dextran
4
sodium ferric gluconate complex in sucrose 4
VENOFER
4
HEMOSTATICS
Hemostatics - Systemic
AMICAR
aminocaproic acid
LYSTEDA
tranexamic acid
HYPNOTICS
Barbiturate Hypnotics
MEBARAL
phenobarbital
Non-Barbiturate Hypnotics
AMBIEN
AMBIEN CR
EDLUAR
eszopiclone
flurazepam hcl
INTERMEZZO
LUNESTA
RESTORIL
SONATA
temazepam
zaleplon
zolpidem tartrate
zolpidem tartrate
SUBL; TBCR
TABS
2
1
2
1
LAXATIVES
Laxative Combinations
COLYTE-FLAVOR PACKS
GOLYTELY
GOLYTELY
HALFLYTELY BOWEL PREP/FLA
MOVIPREP
NULYTELY/FLAVOR PACKS
GO
PA; GO
PA
2
1
2
2
2
1
1
2
2
2
2
1
1
1
1
Selective Melatonin Receptor Agonists
HETLIOZ
ROZEREM
GO
GO, QL
PA; GO, QL
PA; QL
PA; QL
PA; GO, QL
PA; GO, QL
GO
GO, QL
QL
PA; QL
QL
2
2
PA; QL
PA; QL
2
2
2
2
2
2
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
55
Drug Name
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
PREPOPIK
sennosides-docusate sodium
SUPREP BOWEL PREP
Laxatives - Miscellaneous
glycerin (laxative)
lactulose
Saline Laxatives
magnesium citrate
OSMOPREP
sodium phosphates
LOCAL ANESTHETICS-Parenteral
Local Anesthetics - Amides
lidocaine hcl (local anesth.)
XYLOCAINE
LUBRICANT LAXATIVES
LUBRICANT LAXATIVES
mineral oil ENEM
MACROLIDES
Azithromycin
azithromycin
ZITHROMAX
ZITHROMAX TRI-PAK
ZITHROMAX Z-PAK
ZMAX
Clarithromycin
BIAXIN
BIAXIN XL
BIAXIN XL PAC
clarithromycin
Erythromycins
E.E.S. GRANULES
ERYPED 200
ERYPED 400
erythromycin base CPEP; TABS
ERYTHROMYCIN BASE TBEC
erythromycin ethylsuccinate
erythromycin stearate
PCE
Fidaxomicin
DIFICID
Drug Tier Requirements/Limits
1
2
1
2
1
1
1
2
1
1
2
QL
GO
1
1
2
2
2
2
2
2
2
1
GO
GO
GO
GO
GO
GO
2
2
2
1
1
1
1
2
2
QL
MAGNESIUM
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
56
Drug Name
MAGNESIUM
magnesium sulfate
MEDICAL DEVICES
Contraceptives
CAYA
Diabetic Supplies
FREESTYLE SYSTEM KIT
PRECISION XTRA
Misc. Devices
ORTHO ALL-FLEX DIAPHRAGM
Parenteral Therapy Supplies
NORDIPEN 5 INJECTION DEVI
Drug Tier Requirements/Limits
1
PA
4
4
4
QL
QL
4
2
PA; SP
MIGRAINE PRODUCTS
Migraine Combinations
CAFERGOT
2
ERGOTAMINE W/ CAFFEINE
1
isometheptene-dichloralphenazone-acetam 1
inophen
Migraine Products
D.H.E. 45
dihydroergotamine mesylate
ERGOMAR
MIGRANAL
Serotonin Agonists
AMERGE
AXERT
FROVA
frovatriptan succinate
IMITREX
IMITREX STATDOSE SYSTEM
MAXALT
MAXALT-MLT
naratriptan hcl
RELPAX
rizatriptan benzoate
sumatriptan
sumatriptan succinate
zolmitriptan
ZOMIG SOLN
ZOMIG TABS
ZOMIG ZMT
QL
2
1
2
2
GO, QL
QL
2
2
2
1
2
2
2
2
1
2
1
1
1
1
2
2
2
ST; GO, QL
PA; QL
PA; PA, GO, QL
PA; PA, QL
GO, QL
GO, QL
ST; GO, QL
ST; GO, QL
ST; QL
PA; QL
ST; QL
QL
QL
ST; QL
ST; QL
ST; GO, QL
ST; GO, QL
GO, QL
MINERALS ELECTROLYTES
Phosphate
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
57
Drug Name
Drug Tier Requirements/Limits
K-PHOS
2
pot phosphate monobasic w/ sod phosphate1
dibasic & monobasic
Potassium
K-TAB
KLOR-CON M15
MICRO-K
potassium bicarb & chloride
potassium bicarbonate
potassium chloride
potassium chloride microencapsulated
crystals cr
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine hcl (mouth-throat)
Anti-infectives - Throat
clotrimazole
MYCELEX
nystatin (mouth-throat)
chlorhexidine gluconate (mouth-throat)
PERIDEX
Steroids - Mouth/Throat
triamcinolone acetonide (mouth)
Throat Products - Misc.
cevimeline hcl
EVOXAC
pilocarpine hcl (oral)
SALAGEN
multiple vitamins w/ minerals
MULTIVITAMIN ADULTS
OCUVITE ADULT 50+
MULTIVITAMINS
B-Complex w/ Folic Acid
b-complex w/ c & folic acid
NEPHROCAPS
NEPHROCAPS QT
pediatric multivitamins w/fl
GO
GO
GO
1
GO
GO
1
2
2
1
2
2
Ped MV w/ Fluoride
ESCAVITE
1
2
1
2
1
2
MULTIPLE VITAMINS W/ MINERALS
MULTIPLE VITAMINS W/ MINERALS
GO
1
1
2
1
Antiseptics - Mouth/Throat
Ped Multi Vitamins w/Fl
2
2
2
1
1
1
1
GO
1
FE
2
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
58
Drug Name
ESCAVITE D
Ped Multi Vitamins w/Fl FE
PED MULTIVITAMINS W/FL & IRON
pediatric vitamins acd fluoride & iron
Prenatal Vitamins
generic prenatal vitamins
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
baclofen
chlorzoxazone
FLEXERIL
metaxalone
methocarbamol
orphenadrine citrate
PARAFON FORTE DSC
ROBAXIN
ROBAXIN-750
SKELAXIN
SOMA
tizanidine hcl
ZANAFLEX
Drug Tier Requirements/Limits
2
1
1
1
1
1
2
1
1
1
2
2
2
2
2
1
2
Direct Muscle Relaxants
DANTRIUM
2
dantrolene sodium 25mg, 50mg, 100mg 1
DANTROLENE SODIUM 100mg
1
Muscle Relaxant Combinations
carisoprodol w/ aspirin
orphenadrine w/ aspirin & caff
GO
QL
GO
GO
GO
GO, QL
GO
GO
GO
1
1
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Anti-infectives
BACTROBAN NASAL
Nasal Antiallergy
ASTELIN
azelastine hcl
Nasal Anticholinergics
ATROVENT
ipratropium bromide (nasal)
Nasal Steroids
BECONASE AQ
budesonide (nasal)
FLONASE
flunisolide (nasal)
mometasone furoate (nasal)
2
2
1
GO
2
1
GO
2
1
2
1
1
PA
PA
GO
PA
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
59
Drug Name
NASACORT AQ
NASONEX
OMNARIS
QNASL
QNASL CHILDRENS
RHINOCORT AQUA
triamcinolone acetonide (nasal)
VERAMYST
ZETONNA
NEUROMUSCULAR AGENTS
ALS Agents
RILUTEK
riluzole
Drug Tier Requirements/Limits
2
PA; GO
2
PA; GO
2
PA
2
PA
2
PA
2
PA; GO
1
PA
2
PA
2
PA
2
1
Neuromuscular Blocking Agent - Neurotoxins
BOTOX
DYSPORT
MYOBLOC
XEOMIN
OPHTHALMIC AGENTS
Beta-blockers - Ophthalmic
BETAGAN
betaxolol hcl (ophth)
BETIMOL
BETOPTIC-S
carteolol hcl (ophth)
COMBIGAN
COSOPT
dorzolamide hcl-timolol maleate
levobunolol hcl
metipranolol
OPTIPRANOLOL
timolol maleate (ophth)
TIMOPTIC
TIMOPTIC-XE
Cycloplegic Mydriatics
ATROPINE SULFATE OINT
atropine sulfate (ophthalmic)
CYCLOGYL
cyclopentolate hcl
homatropine hbr
ISOPTO ATROPINE
ISOPTO HYOSCINE
MYDRIACYL
tropicamide
GO
4
4
4
4
PA;
PA;
PA;
PA;
2
1
2
2
1
2
2
1
1
1
2
1
2
2
GO
2
1
2
1
1
2
2
2
1
SP
SP
SP
SP
PA
GO
GO
GO
GO
GO, QL
QL
GO
QL
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
60
Drug Name
Miotics
ISOPTO CARBACHOL
ISOPTO CARPINE
PHOSPHOLINE IODIDE
pilocarpine hcl
PILOPINE HS
Ophthalmic Adrenergic Agents
ALPHAGAN P .1%
ALPHAGAN P .15%
brimonidine tartrate .2%
brimonidine tartrate .15%
SIMBRINZA
Ophthalmic Anti-infectives
AZASITE
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
BLEPH-10
CILOXAN OINT
CILOXAN SOLN
ciprofloxacin hcl (ophth)
erythromycin (ophth)
GARAMYCIN
gatifloxacin (ophth)
gentamicin sulfate (ophth)
levofloxacin (ophth)
MOXEZA
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
NEOSPORIN
OCUFLOX
ofloxacin (ophth)
polymyxin b-trimethoprim
POLYTRIM
sulfacetamide sodium (ophth)
tobramycin (ophth)
TOBREX OINT
TOBREX SOLN
trifluridine
VIGAMOX
VIROPTIC
ZIRGAN
ZYMAXID
Drug Tier Requirements/Limits
2
2
2
1
2
GO
2
2
1
1
2
PA
PA; GO
2
1
1
2
2
2
2
1
1
2
1
1
1
2
2
1
1
2
2
1
1
2
1
1
2
2
1
2
2
2
2
QL
PA
PA
GO
GO
GO
PA
GO
GO
GO
GO
GO
PA
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
61
Drug Name
Ophthalmic Decongestants
naphazoline hcl
Ophthalmic Immunomodulators
RESTASIS
Ophthalmic Local Anesthetics
ALCAINE
proparacaine hcl
Drug Tier Requirements/Limits
1
2
PA; QL
2
1
GO
Ophthalmic Steroids
ALREX
2
BLEPHAMIDE
2
BLEPHAMIDE S.O.P.
2
dexamethasone sodium phosphate (ophth) 1
DUREZOL
2
FLAREX
2
fluorometholone (ophth)
1
FML
2
FML FORTE
2
FML LIQUIFILM
2
LOTEMAX
2
MAXIDEX
2
MAXITROL
2
neomycin-polymy-dexameth
1
neomycin-polymyxin-hc (ophth)
1
OMNIPRED
2
PRED FORTE
2
PRED MILD
2
PRED-G
2
PRED-G S.O.P.
2
prednisolone acetate (ophth)
1
PREDNISOLONE SODIUM PHOSP
2
sulfacetamide sod-prednisolone
1
TOBRADEX OINT
2
TOBRADEX SUSP
2
tobramycin-dexamethasone
1
VEXOL
2
ZYLET
2
Ophthalmics - Misc.
ACULAR
ACULAR LS
ALOCRIL
ALOMIDE
azelastine hcl (ophth)
AZOPT
BROMDAY
2
2
2
2
1
2
2
GO
GO
GO
GO
GO
QL
GO
GO
PA
PA
PA
PA
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
62
Drug Name
bromfenac sodium (ophth)
cromolyn sodium (ophth)
diclofenac sodium (ophth)
dorzolamide hcl
ELESTAT
EMADINE
flurbiprofen sodium
ILEVRO
ketorolac tromethamine (ophth)
LASTACAFT
NEVANAC
OCUFEN
olopatadine hcl
OPTIVAR
PATADAY
PATANOL
TRUSOPT
VOLTAREN SOLN
Prostaglandins - Ophthalmic
latanoprost
LUMIGAN
RESCULA
TRAVATAN Z
XALATAN
ZIOPTAN
OREXIN RECEPTOR ANTAGONISTS
OREXIN RECEPTOR ANTAGONISTS
BELSOMRA
OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid (otic)
Otic Anti-infectives
ofloxacin (otic)
Otic Combinations
antipyrine-benzocaine
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN SOLN
neomycin-polymyxin-hc (otic)
Otic Steroids
DERMOTIC
fluocinolone acetonide (otic)
hydrocortisone w/acetic acid
Drug Tier Requirements/Limits
1
1
1
1
2
PA; GO
2
PA
1
2
1
2
PA
2
2
GO
1
PA
2
PA; GO
2
PA
2
PA; GO
2
GO
2
GO
1
2
2
2
2
2
PA
PA
PA
GO
PA
2
PA; QL
1
1
1
2
2
2
2
1
2
1
1
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
63
Drug Name
VOSOL HC
OXYTOCICS
Oxytocics
METHERGINE
methylergonovine maleate
PASSIVE IMMUNIZING AGENTS
Immune Serums
GAMUNEX-C
HIZENTRA
OCTAGAM
Monoclonal Antibodies
SYNAGIS
PENICILLINS
Aminopenicillins
amoxicillin
ampicillin
Natural Penicillins
BICILLIN L-A
PENICILLIN G PROCAINE
penicillin v potassium
Penicillin Combinations
amoxicillin & pot clavulanate
AUGMENTIN SUSR
AUGMENTIN SUSR
AUGMENTIN TABS
AUGMENTIN ES-600
AUGMENTIN XR
piperacillin sodium-tazobactam sodium
Penicillinase-Resistant Penicillins
dicloxacillin sodium
PHARMACEUTICAL ADJUVANTS
Liquid Vehicles
glycine diluent
saline, bacteriostatic
STERILE DILUENT FOR FLOLA
Semi Solid Vehicles
POLYETHYLENE GLYCOL 3350
Drug Tier Requirements/Limits
2
GO
2
1
GO
4
4
4
PA; SP
PA; SP
PA; SP
4
PA; QL, SP
1
1
2
2
1
1
2
2
2
2
2
1
1
1
1
2
PA
PA
PA; GO
2
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
OTEZLA
GO
GO
GO
GO
2
PA; QL, SP
PROGESTINS
Progestins
AYGESTIN
2
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
64
Drug Name
medroxyprogesterone acetate
MEGACE ES
megestrol acetate (appetite)
norethindrone acetate
progesterone
PROMETRIUM
PROVERA
Drug Tier Requirements/Limits
1
2
GO
1
1
1
PA
2
GO
2
GO
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS
PCSK9 INHIBITORS
PRALUENT
2
REPATHA
REPATHA SURECLICK
2
2
PROTEINS
AMINO ACIDS-SINGLE
GLUTATHIONE-L REDUCED
PA; QL, SP,
Non-Preferred
PA; QL, SP, Preferred
PA; QL, SP, Preferred
2
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Chemical Dependency
acamprosate calcium
ANTABUSE
CAMPRAL
disulfiram
Anti-Cataplectic Agents
XYREM
Antidementia Agents
ARICEPT
ARICEPT ODT
donepezil hydrochloride
EXELON CAPS
EXELON PT24; SOLN
galantamine hydrobromide
memantine hcl
NAMENDA
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
RAZADYNE
RAZADYNE ER
rivastigmine
Combination Psychotherapeutics
olanzapine-fluoxetine hcl
SYMBYAX
1
2
2
1
QL
GO
GO, QL
2
PA; QL
2
2
1
2
2
1
1
2
2
2
2
2
2
1
GO
GO
1
2
PA; QL
PA; GO, QL
GO
GO
GO
GO
GO
Fibromyalgia Agents
SAVELLA
2
ST; QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
65
Drug Name
SAVELLA TITRATION PACK
Movement Disorder Drug Therapy
tetrabenazine
XENAZINE
Multiple Sclerosis Agents
AMPYRA
AUBAGIO
AVONEX
BETASERON
COPAXONE 20mg/ml
COPAXONE 40mg/ml
EXTAVIA
GILENYA
glatiramer acetate 20mg/ml
REBIF
REBIF REBIDOSE TITRATION
TECFIDERA
TECFIDERA STARTER PACK
TYSABRI
Postherpetic Neuralgia (PHN) Agents
GRALISE
GRALISE STARTER
Drug Tier Requirements/Limits
2
ST; QL
1
2
PA; QL, SP
PA; GO, QL, SP
2
2
2
2
2
2
2
2
1
2
2
2
2
4
PA; QL,
PA; QL,
SP
QL, SP
GO, SP
SP
QL, SP
ST; QL,
SP
SP
SP
PA; QL,
PA; QL,
PA; QL,
2
2
PA; QL
PA; QL
SP
SP
SP
SP
SP
SP
Premenstrual Dysphoric Disorder (PMDD) Agents
BRISDELLE
fluoxetine hcl (pmdd)
SARAFEM
Pseudobulbar Affect (PBA) Agents
NUEDEXTA
2
1
2
PA
2
PA
PA
Psychotherapeutic and Neurological Agents - Misc.
ergoloid mesylates
ORAP
pimozide
Restless Leg Syndrome (RLS) Agents
HORIZANT
Smoking Deterrents
buproban tab 150mg
bupropion tab 150mg
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTING MONTH PA
nicotine
nicotine polacrilex
NICOTROL INHALER
NICOTROL NS
1
2
1
PA
PA
2
PA; QL
1
1
2
2
2
1
1
2
2
QL
QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
66
Drug Name
ZYBAN
Drug Tier Requirements/Limits
2
GO
PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR
PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR
(SGC)
ADEMPAS
RESPIRATORY AGENTS - MISC.
Cystic Fibrosis Agents
KALYDECO
ORKAMBI
PULMOZYME
Pulmonary Fibrosis Agents
ESBRIET
OFEV
2
PA; SP
2
2
2
PA; QL, SP
PA; QL, SP
SP
2
2
PA; QL, SP
PA; QL
RESPIRATORY THERAPY SUPPLIES
SPACER/AEROSOL-HOLDING CHAMBERS
INSPIRACHAMBER/LARGE
SINUS NODE INHIBITORS
SINUS NODE INHIBITORS
CORLANOR
STIMULANT LAXATIVES
STIMULANT LAXATIVES
bisacodyl
sennosides
SULFONAMIDES
Sulfonamides
SULFADIAZINE
SURFACTANT LAXATIVES
SURFACTANT LAXATIVES
docusate sodium
SYMPATHOMIMETIC DECONGESTANTS
TOPICAL DECONGESTANTS
oxymetazoline hcl
TETRACYCLINES
Tetracyclines
ADOXA
ADOXA PAK 1/100
ADOXA PAK 2/100
demeclocycline hcl
doxycycline (monohydrate)
doxycycline hyclate CAPS; TABS
DOXYCYCLINE HYCLATE POWD
MINOCIN
2
2
SUPPLIES
QL
PA
1
1
2
1
1
2
2
2
1
1
1
2
2
GO
GO
GO
PA
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
67
Drug Name
minocycline hcl
MONODOX
ORAXYL
PERIOSTAT
tetracycline hcl
VIBRAMYCIN
Drug Tier Requirements/Limits
1
2
GO
2
2
GO
1
2
GO
THROMBIN INHIBITORS
THROMBIN INHIBITORS - SELECTIVE DIRECT
PRADAXA 110mg
THYROID AGENTS
Antithyroid Agents
methimazole
propylthiouracil
TAPAZOLE
Thyroid Hormones
ARMOUR THYROID
CYTOMEL
levothyroxine sodium
liothyronine sodium
NATURE-THROID
NATURE-THROID NT-2.5
SYNTHROID
thyroid
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
WESTHROID
WESTHROID-P
ULCER DRUGS
Antispasmodics
ANASPAZ
atropine sulfate SOLN
BENTYL
chlordiazepoxide hcl-clidinium bromide
CUVPOSA
dicyclomine hcl
DONNATAL
glycopyrrolate
hyoscyamine sulfate
LEVBID
LEVSIN
LEVSIN/SL
2
1
1
2
2
2
1
1
2
2
2
1
2
2
2
2
2
2
2
2
1
2
1
2
1
2
1
1
2
2
2
REVERSIBLE
QL
GO
GO
GO
GO
GO
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
68
Drug Name
Drug Tier Requirements/Limits
LIBRAX
2
GO
methscopolamine bromide
1
PA
PAMINE
2
PA; GO
PAMINE FORTE
2
PA; GO
phenobarbital-hyoscyamine-atropine-scopo 1
lamine
ROBINUL
2
GO
ROBINUL FORTE
2
GO
H-2 Antagonists
AXID
cimetidine
cimetidine hcl
famotidine
nizatidine
PEPCID
ranitidine hcl
ZANTAC
Misc. Anti-Ulcer
CARAFATE SUSP
CARAFATE TABS
SUCRALFATE
Proton Pump Inhibitors
ACIPHEX
ACIPHEX SPRINKLE
DEXILANT
esomeprazole magnesium
ESOMEPRAZOLE STRONTIUM
FIRST-LANSOPRAZOLE
FIRST-OMEPRAZOLE
lansoprazole CPDR
lansoprazole TBDP
NEXIUM CPDR
NEXIUM PACK
omeprazole CPDR
OMEPRAZOLE + SYRSPEND SF
pantoprazole sodium SOLR
pantoprazole sodium TBEC
PREVACID
PREVACID SOLUTAB
PRILOSEC CPDR
PRILOSEC PACK
PROTONIX PACK
PROTONIX TBEC
rabeprazole sodium
2
1
1
1
1
2
1
2
2
2
2
2
2
2
1
2
2
2
1
1
2
2
1
2
1
1
2
2
2
2
2
2
1
GO
GO
GO
GO
PA;
PA
PA
PA
PA
PA;
PA;
PA
PA;
PA;
PA
GO
AGE
AGE
AGE
GO
PA; AGE
PA
PA;
PA;
GO
PA;
PA;
GO
PA
GO
AGE
QL
QL
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
69
Drug Name
Ulcer Drugs - Prostaglandins
CYTOTEC
misoprostol
Drug Tier Requirements/Limits
2
1
GO
Ulcer Therapy Combinations
amoxicillin-clarithromycin w/ lansoprazole 1
HELIDAC
2
PREVPAC
2
PYLERA
2
URINARY ANTI-INFECTIVES
Urinary Anti-infective Combinations
methenamine-hyosc-methylene
blue-benzoic acid-phenyl sal
methenamine-hyosc-methylene blue-sod
phos-phenyl sal
methenamine-hyoscamine-methylene
blue-sodium phosphate
PROSED/DS
URETRON D/S
Urinary Anti-infectives
FURADANTIN
HIPREX
MACROBID
MACRODANTIN
methenamine hippurate
methenamine mandelate
MONUROL
nitrofurantoin
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
UREX
URINARY ANTISPASMODICS
Beta-3 Adrenergic Agonists
MYRBETRIQ
Urinary Antispasmodics
flavoxate hcl
VAGINAL PRODUCTS
Vaginal Anti-infectives
AVC
CLEOCIN CREA
CLEOCIN SUPP
clindamycin phosphate vaginal
clotrimazole vaginal
GYNAZOLE-1
METROGEL-VAGINAL
GO
1
1
1
2
2
GO
2
2
2
2
1
1
2
1
1
1
2
GO
GO
GO
GO
2
PA
GO
1
2
2
2
1
1
2
2
GO
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
70
Drug Name
metronidazole vaginal
miconazole nitrate vaginal
TERAZOL 3
TERAZOL 7
terconazole vaginal
Vaginal Estrogens
ESTRACE CREA
ESTRING
FEMRING
PREMARIN CREA
VAGIFEM
Vaginal Progestins
CRINONE
VASOPRESSORS
Anaphylaxis Therapy Agents
ADRENACLICK
ADRENALIN
AUVI-Q
epinephrine
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
Vasopressors
midodrine hcl
NORTHERA
VITAMINS
Oil Soluble Vitamins
baby vitamin d3 drops
DECARA
DRISDOL
ergocalciferol
MEPHYTON
vitamin e
Drug Tier Requirements/Limits
1
1
2
GO
2
GO
1
2
2
2
2
2
QL
2
PA
2
2
2
1
2
2
PA; GO, QL
1
2
1
2
2
1
2
1
PA; QL
QL
PA; QL
PA; QL
PA
GO
AGE – Se puede aplicar restricción a la edad GO – Genérico solamente
PA – Autorización previa QL – Límite a la cantidad SP – Medicamento de especialidad
ST – Terapia escalonada
71
Index
4
4X PROBIOTIC ..................................17
8
8-MOP .............................................42
A
abacavir sulfate ................................31
abacavir sulfate-lamivudine-zidovudine31
ABILIFY ...........................................31
ABILIFY DISCMELT ............................31
ABILIFY MAINTENA ...........................31
ABRAXANE .......................................28
ABSORICA .......................................40
ABSTRAL .......................................... 4
acamprosate calcium .........................64
acarbose ..........................................14
ACCOLATE ........................................ 9
ACCUNEB .........................................10
ACCUPRIL ........................................21
ACCURETIC ......................................22
acebutolol hcl ...................................34
ACEON ............................................21
acetaminophen .................................. 3
acetaminophen w/ codeine .................. 5
acetaminophen-caff-dihydrocod ........... 5
acetazolamide ..................................46
acetic acid (otic) ...............................62
acetylcysteine ..................................40
ACIPHEX ..........................................68
ACIPHEX SPRINKLE ...........................68
acitretin ...........................................42
ACLOVATE .......................................43
ACTEMRA .......................................... 2
ACTIGALL ........................................50
ACTIQ .............................................. 4
ACTIVELLA .......................................49
ACTONEL .........................................47
ACTOPLUS MET.................................15
ACTOPLUS MET XR ............................15
ACTOS.............................................16
ACULAR ...........................................61
ACULAR LS.......................................61
acyclovir ..........................................33
acyclovir topical ................................43
ACZONE ..........................................40
ADALAT CC ......................................36
adapalene ........................................40
ADCETRIS ........................................25
ADCIRCA......................................... 37
ADDERALL ......................................... 1
ADDERALL XR .................................... 1
adefovir dipivoxil .............................. 33
ADEMPAS ........................................ 66
ADOXA ........................................... 67
ADOXA PAK 1/100 ............................ 67
ADOXA PAK 2/100 ............................ 67
ADRENACLICK ................................. 70
ADRENALIN ..................................... 70
ADVAIR DISKUS............................... 10
ADVAIR HFA .................................... 10
ADYNOVATE .................................... 19
AEROSPAN ...................................... 10
AFINITOR ........................................ 27
AFINITOR DISPERZ .......................... 27
AGGRENOX ..................................... 52
AGRYLIN ......................................... 52
AKYNZEO ........................................ 18
ALBENZA........................................... 7
albuterol sulfate ............................... 10
ALCAINE ......................................... 60
alclometasone dipropionate ............... 43
ALCOHOL BASE GEL ......................... 63
ALDACTAZIDE.................................. 46
ALDACTONE .................................... 47
ALDARA .......................................... 45
ALECENSA ....................................... 27
alendronate sodium .......................... 47
ALIMTA ........................................... 25
ALINIA .............................................. 7
ALKERAN ........................................ 24
allopurinol ....................................... 52
ALOCRIL ......................................... 61
ALOE VERA ...................................... 35
alogliptin benzoate ........................... 15
alogliptin-metformin hcl .................... 15
alogliptin-pioglitazone ....................... 15
ALOMIDE ........................................ 61
ALORA ............................................ 49
alosetron hcl .................................... 51
ALOXI ............................................. 17
ALPHAGAN P .................................... 59
ALPHANATE/VON WILLEBRAND .......... 19
alprazolam ........................................ 8
ALPRAZOLAM INTENSOL ..................... 8
ALPROLIX ........................................ 19
72
ALREX .............................................60
ALTABAX .........................................41
ALTACE ...........................................21
alum & mag hydrox-simethicone .......... 7
ALVESCO .........................................10
amantadine hcl .................................29
AMARYL ...........................................16
AMBIEN ...........................................54
AMBIEN CR ......................................54
amcinonide ......................................43
AMCINONIDE ...................................43
AMERGE ..........................................56
AMICAR ...........................................54
AMIKACIN SULFATE ........................... 2
amiloride & hydrochlorothiazide ..........46
amiloride hcl ....................................47
aminocaproic acid .............................54
aminophylline ...................................10
amiodarone hcl .................................. 9
AMITIZA ..........................................50
amitriptyline hcl ................................14
amlodipine besylate-atorvastatin calcium
......................................................37
amlodipine besylate-benazepril hcl ......22
amlodipine besylate-valsartan ............22
amlodipine-valsartan-hydrochlorothiazide
......................................................22
AMOXAPINE .....................................14
amoxicillin .......................................63
amoxicillin & pot clavulanate ..............63
amoxicillin-clarithromycin w/ lansoprazole
......................................................69
amphetamine-dextroamphetamine ....... 1
ampicillin .........................................63
AMPYRA ...........................................65
AMTURNIDE .....................................22
ANADROL-50 ..................................... 6
ANAFRANIL ......................................14
ANALPRAM-HC ................................... 6
ANAPROX .......................................... 2
ANAPROX DS..................................... 2
ANASPAZ .........................................67
ANCOBON ........................................18
ANDRODERM ..................................... 6
ANDROGEL ....................................... 6
android ............................................. 6
ANDROXY ......................................... 6
ANHYDROUS BASE ............................63
ANORO ELLIPTA ............................... 10
ANTABUSE ...................................... 64
ANTARA .......................................... 20
antipyrine-benzocaine ....................... 62
ANTIVERT ....................................... 18
ANUSOL-HC ....................................... 6
ANZEMET ........................................ 17
APEXICON E .................................... 43
APIDRA ........................................... 16
APOKYN .......................................... 29
APRISO ........................................... 50
APTIOM........................................... 11
APTIVUS ......................................... 31
ARALEN .......................................... 23
ARANESP ALBUMIN FREE .................. 53
ARAVA .............................................. 3
ARCAPTA NEOHALER ........................ 10
AREDIA ........................................... 47
ARICEPT ......................................... 64
ARICEPT ODT .................................. 64
aripiprazole ..................................... 31
ARISTADA ....................................... 31
ARIXTRA ......................................... 11
armodafinil ........................................ 1
ARMOUR THYROID ........................... 67
AROMASIN ...................................... 26
ARRANON........................................ 25
artificial tear solution ........................ 33
ARZERRA ........................................ 25
ASACOL HD ..................................... 50
ASMANEX HFA ................................. 10
ASMANEX TWISTHALER 120 ME ......... 10
ASMANEX TWISTHALER 30 MET ......... 10
ASMANEX TWISTHALER 60 MET ......... 10
aspirin .............................................. 4
aspirin-caffeine-dihydrocodeine bitartrate
........................................................ 5
aspirin-dipyridamole ......................... 53
ASTAGRAF XL .................................. 34
ASTELIN ......................................... 58
ATACAND ........................................ 21
ATELVIA .......................................... 47
atenolol .......................................... 34
atenolol & chlorthalidone ................... 22
ATIVAN ............................................. 8
atorvastatin calcium ......................... 20
atovaquone ....................................... 7
atovaquone-proguanil hcl .................. 23
73
ATRALIN ..........................................41
ATRIPLA ..........................................31
atropine sulfate ................................67
ATROPINE SULFATE ..........................59
atropine sulfate (ophthalmic) .............59
ATROVENT .......................................58
ATROVENT HFA ................................. 9
AUBAGIO .........................................65
AUGMENTIN .....................................63
AUGMENTIN ES-600 ..........................63
AUGMENTIN XR ................................63
AURYXIA ..........................................51
AUVI-Q ............................................70
AVALIDE ..........................................22
AVANDAMET.....................................15
AVANDARYL .....................................15
AVANDIA .........................................16
AVAPRO ...........................................21
AVASTIN ..........................................25
AVC ................................................69
AVEED .............................................. 6
AVELOX ...........................................49
AVELOX ABC PACK ............................49
AVODART.........................................52
AVONEX ..........................................65
AXERT .............................................56
AXID ...............................................68
AXIRON ............................................ 6
AYGESTIN ........................................64
azacitidine .......................................25
AZASITE ..........................................60
azathioprine .....................................34
azelastine hcl ...................................58
azelastine hcl (ophth) ........................61
AZELEX ...........................................41
AZILECT ..........................................30
azithromycin ....................................55
AZOPT .............................................61
AZOR ..............................................22
AZULFIDINE .....................................50
AZULFIDINE EN-TABS .......................50
B
baby vitamin d3 drops .......................70
bacitracin (ophthalmic) ......................60
bacitracin-polymyxin b (ophth) ...........60
baclofen ..........................................58
BACTRIM .......................................... 7
BACTRIM DS ..................................... 7
BACTROBAN .................................... 41
BACTROBAN NASAL .......................... 58
balsalazide disodium ......................... 50
BANZEL .......................................... 11
BARACLUDE .................................... 33
BASE CREAM WITH LIPOSOME ........... 63
b-complex w/ c & folic acid ................ 57
BECONASE AQ ................................. 58
BELBUCA........................................... 5
BELEODAQ ...................................... 27
BELSOMRA ...................................... 62
benazepril & hydrochlorothiazide ........ 22
benazepril hcl .................................. 21
BENICAR ......................................... 21
BENICAR HCT .................................. 22
BENTYL ........................................... 67
BENZACLIN ..................................... 41
benzocaine-benzethonium ................. 45
benzonatate .................................... 40
benzoyl peroxide .............................. 41
benzoyl peroxide-erythromycin .......... 41
benztropine mesylate ....................... 29
BESIVANCE ..................................... 60
BETAGAN ........................................ 59
betamethasone dipropionate (topical) . 43
betamethasone dipropionate augmented
...................................................... 43
betamethasone valerate .................... 43
BETAPACE ....................................... 35
BETASERON .................................... 65
betaxolol hcl .................................... 34
betaxolol hcl (ophth) ........................ 59
bethanechol chloride......................... 51
BETIMOL ......................................... 59
BETOPTIC-S .................................... 59
bexarotene ...................................... 28
BEXXAR .......................................... 25
BIAXIN ........................................... 55
BIAXIN XL ....................................... 55
BIAXIN XL PAC ................................ 55
BICILLIN L-A ................................... 63
BICNU ............................................ 24
BIDIL.............................................. 37
bisacodyl ......................................... 66
bismuth subsalicylate ....................... 17
bisoprolol & hydrochlorothiazide ......... 22
bisoprolol fumarate .......................... 34
bleomycin sulfate ............................. 26
74
BLEPH-10 ........................................60
BLEPHAMIDE ....................................60
BLEPHAMIDE S.O.P. ..........................60
BONIVA ...........................................47
BOSULIF ..........................................27
BOTOX ............................................59
BREO ELLIPTA ..................................10
BRILINTA .........................................53
brimonidine tartrate ..........................60
BRISDELLE.......................................65
BROMDAY ........................................61
bromfenac sodium (ophth) .................61
bromocriptine mesylate .....................29
budesonide ......................................39
budesonide (inhalation) .....................10
budesonide (nasal) ...........................58
BUNAVAIL ......................................... 5
buprenorphine hcl .............................. 6
buprenorphine hcl-naloxone hcl dihydrate
....................................................... 6
bupropion hcl ...................................13
buspirone hcl..................................... 8
BUSULFEX........................................24
butalbital-acetaminophen.................... 3
butalbital-acetaminophen-caffeine ....... 3
BUTALBITAL-ACETAMINOPHEN-CAFFEINE
....................................................... 3
butalbital-acetaminophen-caffeine w/
codeine ............................................ 5
butalbital-aspirin-caffeine ................... 3
butalbital-aspirin-caffeine w/cod .......... 5
butorphanol tartrate ........................... 6
BUTRANS .......................................... 6
BYDUREON ......................................16
BYETTA ...........................................16
BYSTOLIC ........................................35
C
cabergoline ......................................48
CADUET ...........................................37
CAFCIT ............................................. 1
CAFERGOT .......................................56
caffeine citrate .................................. 1
CALAN .............................................36
CALAN SR ........................................36
calcipotriene.....................................42
calcipotriene-betamethasone
dipropionate .....................................43
calcitonin (salmon)............................47
calcitriol .......................................... 48
calcitriol (topical) ............................. 42
calcium acetate (phosphate binder) .... 51
calcium carbonate-cholecalciferol ....... 36
calcium carbonate-vitamin d w/ minerals
...................................................... 36
calcium citrate-vitamin d ................... 36
CAMPATH ........................................ 25
CAMPRAL ........................................ 64
CAMPTOSAR .................................... 29
CANASA .......................................... 50
candesartan cilexetil ......................... 21
capecitabine .................................... 25
CAPEX ............................................ 43
CAPITAL/CODEINE ............................. 5
CAPRELSA ....................................... 27
capsaicin ......................................... 45
captopril & hydrochlorothiazide .......... 22
CARAC ............................................ 42
CARAFATE ....................................... 68
CARBAGLU ...................................... 48
carbamazepine ................................ 11
CARBATROL..................................... 11
carbidopa ........................................ 29
carbidopa-levodopa .......................... 29
carbidopa-levodopa-entacapone ......... 29
CARBOPOL 940 NF ........................... 35
carboxymethylcellulose sodium (ophth)
...................................................... 33
CARDENE SR ................................... 36
CARDIZEM ...................................... 36
CARDIZEM CD ................................. 36
CARDIZEM LA .................................. 36
CARDURA ........................................ 22
CARDURA XL ................................... 52
carisoprodol w/ aspirin ...................... 58
CARNITOR ....................................... 48
carteolol hcl (ophth) ......................... 59
carvedilol ........................................ 34
CASODEX ........................................ 26
CATAFLAM ......................................... 2
CATAPRES ....................................... 22
CATAPRES-TTS-1 ............................. 22
CATAPRES-TTS-2 ............................. 22
CATAPRES-TTS-3 ............................. 22
CAYA .............................................. 55
CAYSTON .......................................... 7
CEDAX ............................................ 38
75
cefaclor ...........................................38
CEFACLOR ER ...................................38
cefadroxil .........................................37
cefdinir ............................................38
cefditoren pivoxil ..............................38
cefixime ...........................................38
cefpodoxime proxetil .........................38
cefprozil...........................................38
ceftibuten ........................................38
CEFTIN ............................................38
ceftriaxone sodium ............................38
cefuroxime axetil ..............................38
CELEBREX ......................................... 2
celecoxib .......................................... 2
CELESTONE......................................39
CELEXA ...........................................13
CELLCEPT ........................................34
CELLULOSE MICROCRYSTALLIN ..........35
CELONTIN ........................................13
CENTANY .........................................41
CENTANY AT ....................................41
cephalexin .......................................37
CERDELGA .......................................53
CERUBIDINE ....................................26
CESAMET .........................................18
cevimeline hcl ..................................57
CHANTIX .........................................66
CHANTIX CONTINUING MONTH ..........66
CHANTIX STARTING MONTH PA ..........66
CHEMET ...........................................17
chlordiazepoxide hcl ........................... 8
chlordiazepoxide hcl-clidinium bromide 67
chlorhexidine gluconate (mouth-throat)
......................................................57
chloroquine phosphate ......................23
chlorothiazide ...................................47
chlorpromazine hcl ............................31
chlorpropamide ................................17
chlorthalidone ..................................47
chlorzoxazone ..................................58
CHOLBAM ......................................... 8
cholestyramine .................................20
cholestyramine light ..........................20
choline & mag salicylate ..................... 4
CHRYSIN .........................................35
CIALIS.............................................52
ciclopirox .........................................41
ciclopirox olamine .............................41
cilostazol ......................................... 53
CILOXAN ......................................... 60
cimetidine ....................................... 68
cimetidine hcl .................................. 68
CIMZIA ........................................... 50
CIPRO ............................................. 49
CIPRO HC ........................................ 62
CIPRO XR ........................................ 50
CIPRODEX ....................................... 62
ciprofloxacin .................................... 50
ciprofloxacin hcl ............................... 50
ciprofloxacin hcl (ophth).................... 60
ciprofloxacin-ciprofloxacin hcl ............ 50
CISAPRIDE ...................................... 35
cisplatin .......................................... 24
citalopram hydrobromide .................. 13
cladribine ........................................ 25
CLARINEX ....................................... 19
CLARINEX-D 12 HOUR ...................... 40
CLARINEX-D 24 HOUR ...................... 40
clarithromycin .................................. 55
clemastine fumarate ......................... 19
CLEOCIN ..................................... 8, 69
CLEOCIN PEDIATRIC GRANULE ............ 8
CLEOCIN-T ...................................... 41
CLIMARA ......................................... 49
CLIMARA PRO .................................. 49
clindamycin hcl .................................. 8
clindamycin palmitate hydrochloride ..... 8
clindamycin phosphate (topical) ......... 41
clindamycin phosphate vaginal ........... 69
clindamycin phosphate-benzoyl peroxide
...................................................... 41
CLINORIL .......................................... 2
clobetasol propionate ........................ 43
CLOBEX .......................................... 43
clocortolone pivalate ......................... 43
CLODERM PUMP ............................... 43
CLOLAR .......................................... 25
clomipramine hcl .............................. 14
clonazepam ..................................... 11
clonidine hcl .................................... 22
clonidine hcl (adhd) ............................ 1
clopidogrel bisulfate.......................... 53
clorazepate dipotassium ...................... 8
clotrimazole ..................................... 57
clotrimazole (topical) ........................ 41
clotrimazole vaginal .......................... 70
76
clotrimazole w/ betamethasone ..........41
clozapine .........................................30
CLOZARIL ........................................30
COAGADEX ......................................19
COARTEM ........................................23
CODEINE PHOSPHATE ........................ 4
codeine sulfate .................................. 4
CODEINE SULFATE ............................. 4
coenzyme q10 (ubidecarenone) ........... 2
COLAZAL .........................................50
colchicine .........................................52
colchicine w/ probenecid ....................52
COLCRYS .........................................52
COLESTID ........................................20
colestipol hcl ....................................20
COLY-MYCIN S .................................62
COLYTE-FLAVOR PACKS .....................54
COMBIGAN.......................................59
COMBIPATCH ...................................49
COMBIVENT .....................................10
COMBIVENT RESPIMAT ......................10
COMBIVIR ........................................31
COMETRIQ .......................................27
COMPLERA .......................................31
COMTAN ..........................................29
CONCERTA ........................................ 1
CONDYLOX ......................................45
COPAXONE.......................................65
COPEGUS.........................................33
CORDARONE ..................................... 9
CORDRAN ........................................43
CORDRAN TAPE ................................43
COREG ............................................34
COREG CR .......................................34
CORGARD ........................................35
CORLANOR ......................................66
CORTEF ...........................................39
CORTENEMA...................................... 6
CORTIFOAM ...................................... 6
cortisone acetate ..............................39
CORTISPORIN ............................ 41, 62
COSENTYX .......................................42
COSENTYX SENSOREADY PEN ............42
COSMEGEN ......................................26
COSOPT...........................................59
COTELLIC ........................................27
COUMADIN ......................................11
COZAAR ..........................................21
CREON ............................................ 46
CRESEMBA ...................................... 18
CRESTOR ........................................ 20
CRINONE ........................................ 70
CRIXIVAN........................................ 32
cromolyn sodium................................ 9
cromolyn sodium (mastocytosis) ........ 50
cromolyn sodium (ophth) .................. 61
CUPRIMINE ..................................... 34
CUTIVATE ....................................... 43
CUVPOSA ........................................ 67
CVS PROBIOTIC ............................... 17
cyanocobalamin ............................... 53
CYCLANDELATE................................ 35
CYCLOGYL ....................................... 59
cyclopentolate hcl ............................ 59
cyclophosphamide ............................ 24
CYCLOPHOSPHAMIDE ....................... 24
cycloserine ...................................... 24
cyclosporine .................................... 34
cyclosporine modified (for microemulsion)
...................................................... 34
CYMBALTA....................................... 14
cyproheptadine hcl ........................... 20
CYRAMZA ........................................ 25
cytarabine ....................................... 25
CYTOMEL ........................................ 67
CYTOTEC......................................... 69
D
D.H.E. 45 ........................................ 56
DACOGEN ....................................... 25
dactinomycin ................................... 26
DAKLINZA ....................................... 33
DALIRESP ......................................... 9
DALVANCE ........................................ 7
danazol ............................................. 6
DANTRIUM ...................................... 58
dantrolene sodium ........................... 58
DANTROLENE SODIUM ...................... 58
dapsone ............................................ 7
DARAPRIM....................................... 23
darifenacin hydrobromide .................. 51
daunorubicin hcl............................... 26
DAYPRO ............................................ 2
DAYTRANA ........................................ 1
DDAVP ............................................ 48
DECARA .......................................... 70
decitabine ....................................... 25
77
DELZICOL ........................................50
DEMADEX ........................................46
demeclocycline hcl ............................67
DEMEROL.......................................... 4
DENAVIR .........................................43
DEPAKENE .......................................13
DEPAKOTE .......................................13
DEPAKOTE ER ..................................13
DEPAKOTE SPRINKLES ......................13
DEPEN TITRATABS ............................34
DEPOCYT .........................................25
DEPO-PROVERA ................................26
DEPO-PROVERA CONTRACEPTIV .........39
DEPO-SUBQ PROVERA 104.................39
DEPO-TESTOSTERONE........................ 6
DERMA-SMOOTHE/FS SCALP OI ..........43
DERMATOP.......................................43
DERMOTIC .......................................62
DESCOVY .........................................32
desipramine hcl ................................14
desloratadine ...................................19
desmopressin acetate ........................48
desmopressin acetate refrigerated ......48
desmopressin acetate spray ...............48
desmopressin acetate spray refrigerated
......................................................48
desogestrel & ethinyl estradiol ............38
desogestrel-ethinyl estradiol (biphasic) 38
desogestrel-ethinyl estradiol (triphasic)
......................................................38
desonide ..........................................43
DESOWEN ........................................43
desoximetasone .......................... 43, 44
DESOXYN.......................................... 1
DESVENLAFAXINE ER ........................14
DETROL ...........................................51
DETROL LA ......................................51
dexamethasone ................................39
DEXAMETHASONE INTENSOL .............39
dexamethasone sodium phosphate .....39
dexamethasone sodium phosphate
(ophth) ............................................61
dexchlorpheniramine maleate .............19
DEXEDRINE....................................... 1
DEXILANT ........................................68
dexmethylphenidate hcl ...................... 1
DEXPAK 10 DAY ................................39
DEXPAK 13 DAY ................................39
DEXPAK 6 DAY ................................. 39
dextroamphetamine sulfate ................. 1
dextromethorphan-guaifenesin .......... 40
DIABETA ......................................... 17
DIAMOX .......................................... 46
DIASTAT ACUDIAL ........................... 11
DIASTAT PEDIATRIC ......................... 11
diazepam .......................................... 8
diazepam (anticonvulsant) ................ 11
DIBENZYLINE .................................. 21
DICLEGIS ........................................ 18
diclofenac potassium .......................... 2
diclofenac sodium............................... 2
diclofenac sodium (actinic keratoses) .. 42
diclofenac sodium (ophth) ................. 61
diclofenac sodium (topical) ................ 41
dicloxacillin sodium .......................... 63
dicyclomine hcl ................................ 67
didanosine....................................... 32
DIDRONEL....................................... 47
DIFFERIN ........................................ 41
DIFICID .......................................... 55
diflorasone diacetate ........................ 44
DIFLUCAN ....................................... 18
diflunisal ........................................... 4
digoxin ........................................... 37
dihydroergotamine mesylate.............. 56
DILACOR XR .................................... 36
DILANTIN ........................................ 13
DILANTIN INFATABS......................... 13
DILATRATE SR ................................... 8
DILAUDID ......................................... 4
diltiazem hcl .................................... 36
diltiazem hcl coated beads ................ 36
diltiazem hcl extended release beads .. 36
DIMERCAPTO-1-PROPANESULFO ........ 66
DIOVAN .......................................... 21
DIOVAN HCT ................................... 22
DIPENTUM ....................................... 50
diphenhydramine hcl ........................ 19
diphenoxylate w/ atropine ................. 17
DIPROLENE ..................................... 44
DIPROLENE AF ................................. 44
dipyridamole ................................... 53
disopyramide phosphate ..................... 9
disulfiram ........................................ 64
DITROPAN XL .................................. 51
DIURIL............................................ 47
78
divalproex sodium .............................13
DIVIGEL ..........................................49
DOCEFREZ .......................................28
docetaxel .........................................28
DOCETAXEL .....................................28
docusate sodium ...............................66
dofetilide .......................................... 9
DOLOPHINE ...................................... 4
donepezil hydrochloride .....................64
DONNATAL .......................................68
dorzolamide hcl ................................61
dorzolamide hcl-timolol maleate .........59
DOVONEX ........................................42
doxazosin mesylate ...........................22
doxepin hcl ......................................14
doxercalciferol ..................................48
DOXIL .............................................26
doxorubicin hcl .................................26
doxorubicin hcl liposomal ...................26
doxycycline (monohydrate) ................67
doxycycline hyclate ...........................67
DOXYCYCLINE HYCLATE ....................67
DRISDOL .........................................70
DRITHO-CREME HP ...........................42
DRITHO-SCALP .................................42
dronabinol .......................................18
DROPLET PEN NEEDLES 32GX5...........62
DROPLET PEN NEEDLES 32GX6...........62
DROPLET PEN NEEDLES 32GX8...........62
drospirenone-ethinyl estradiol ............38
DROXIA ...........................................53
DRYSOL ...........................................45
DUETACT .........................................15
DULERA ...........................................10
duloxetine hcl ...................................14
DUONEB ..........................................10
DUOPA ............................................29
DURAGESIC ...................................... 4
DUREZOL .........................................61
dutasteride ......................................52
dutasteride-tamsulosin hcl .................52
DYAZIDE .........................................46
dyphylline-guaifenesin ........................ 9
DYRENIUM .......................................47
DYSPORT .........................................59
E
E.E.S. GRANULES .............................55
EASPRIN ........................................... 4
EC-NAPROSYN ................................... 2
econazole nitrate.............................. 42
ECOZA ............................................ 42
EDARBI ........................................... 21
EDECRIN ......................................... 46
EDLUAR .......................................... 54
EDURANT ........................................ 32
EFFEXOR XR .................................... 14
EFFIENT .......................................... 53
EFUDEX .......................................... 42
EGRIFTA ......................................... 48
ELDEPRYL ....................................... 30
ELESTAT ......................................... 61
ELESTRIN ........................................ 49
ELIDEL ............................................ 45
ELIGARD ......................................... 26
ELIMITE .......................................... 45
ELIPHOS ......................................... 51
ELIQUIS .......................................... 11
ELIXOPHYLLIN ................................. 11
ELLA ............................................... 39
ELLENCE ......................................... 26
ELMIRON......................................... 52
ELOCON .......................................... 44
ELOCTATE ....................................... 19
ELOXATIN ....................................... 24
ELSPAR ........................................... 28
EMADINE ........................................ 61
EMBEDA ............................................ 4
EMCYT ............................................ 26
EMEND ........................................... 18
EMSAM ........................................... 13
EMTRIVA ......................................... 32
ENABLEX ......................................... 51
enalapril maleate ............................. 21
enalapril maleate & hydrochlorothiazide
...................................................... 22
ENBREL............................................. 3
enoxaparin sodium ........................... 11
entacapone ..................................... 29
entecavir ......................................... 33
ENTOCORT EC ................................. 39
ENTRESTO ...................................... 37
ENTYVIO ......................................... 50
EPANED .......................................... 21
EPIFOAM ......................................... 44
epinephrine ..................................... 70
epinephrine hcl ................................ 10
79
EPIPEN 2-PAK...................................70
EPIPEN-JR 2-PAK ..............................70
epirubicin hcl ....................................26
EPIVIR .............................................32
EPIVIR HBV ......................................32
eplerenone .......................................23
EPOGEN...........................................53
epoprostenol sodium .........................37
eprosartan mesylate .........................21
EPZICOM .........................................32
ERBITUX ..........................................25
ergocalciferol....................................70
ergoloid mesylates ............................65
ERGOMAR ........................................56
ERGOTAMINE W/ CAFFEINE ...............56
ERIVEDGE ........................................26
ERWINAZE .......................................28
ERYPED 200 .....................................55
ERYPED 400 .....................................55
erythromycin (acne aid).....................41
erythromycin (ophth) ........................60
erythromycin base ............................55
ERYTHROMYCIN BASE .......................55
erythromycin ethylsuccinate ...............55
erythromycin stearate .......................55
erythromycin-sulfisoxazole .................. 7
ESBRIET ..........................................66
ESCAVITE ........................................57
ESCAVITE D .....................................57
escitalopram oxalate .........................13
ESGIC .............................................. 3
ESGIC-PLUS ...................................... 3
esomeprazole magnesium ..................68
ESOMEPRAZOLE STRONTIUM .............68
esterified estrogens & methyltestosterone
......................................................49
ESTRACE ................................... 49, 70
estradiol ..........................................49
estradiol & norethindrone acetate .......49
ESTRASORB .....................................49
ESTRING .........................................70
ESTROGEL .......................................49
estropipate ......................................49
eszopiclone ......................................54
ethacrynate sodium ..........................46
ethambutol hcl .................................24
ethosuximide....................................13
ethynodiol diacet & eth estrad ............38
etidronate disodium .......................... 47
etodolac ............................................ 2
ETOPOPHOS .................................... 28
etoposide ........................................ 28
EURAX ............................................ 45
EVAMIST ......................................... 49
EVISTA ........................................... 48
EVOTAZ .......................................... 32
EVOXAC .......................................... 57
EVZIO ............................................. 17
EXALGO ............................................ 4
EXELDERM ...................................... 42
EXELON .......................................... 64
exemestane..................................... 26
EXFORGE ........................................ 22
EXFORGE HCT.................................. 22
EXJADE ........................................... 17
EXTAVIA ......................................... 65
F
FABIOR ........................................... 41
FACTIVE.......................................... 50
famotidine ....................................... 68
FAMVIR ........................................... 33
FANAPT ........................................... 30
FANAPT TITRATION PACK .................. 30
FARESTON ...................................... 26
FARXIGA ......................................... 16
FARYDAK ........................................ 27
FASLODEX ....................................... 26
FAZACLO......................................... 30
FEIBA ............................................. 19
felbamate ........................................ 12
FELBATOL ....................................... 12
FELDENE ........................................... 2
felodipine ........................................ 36
FEMARA .......................................... 26
FEMHRT 1/5 .................................... 49
FEMHRT LOW DOSE .......................... 49
FEMRING ........................................ 70
fenofibrate ...................................... 20
fenofibrate micronized ...................... 20
fenofibric acid .................................. 20
FENOGLIDE ..................................... 20
fenoprofen calcium ............................. 3
fentanyl ............................................ 4
FENTANYL ......................................... 4
fentanyl citrate .................................. 4
FENTORA .......................................... 4
80
FERAHEME .......................................53
FERRIPROX ......................................17
FERRLECIT .......................................53
ferrous sulfate dried ..........................53
FETZIMA ..........................................14
FETZIMA TITRATION PACK .................14
FINACEA ..........................................45
finasteride .......................................52
FIORICET .......................................... 3
FIORICET/CODEINE ........................... 5
FIORINAL/CODEINE #3 ...................... 5
FIRAZYR ..........................................52
FIRST-LANSOPRAZOLE ......................68
FIRST-TESTOSTERONE ....................... 6
FIRST-TESTOSTERONE MC COM .......... 6
FLAGYL ............................................. 7
FLAGYL ER ........................................ 7
FLAREX............................................61
flavoxate hcl ....................................69
flecainide acetate ............................... 9
FLECTOR..........................................41
FLEXERIL .........................................58
FLOLAN ...........................................37
FLOMAX ...........................................52
FLONASE .........................................58
FLOVENT DISKUS .............................10
FLOVENT HFA ...................................10
floxuridine .......................................25
fluconazole.......................................18
flucytosine .......................................18
FLUDARA .........................................25
fludarabine phosphate .......................25
fludrocortisone acetate ......................40
FLUMADINE ......................................33
flunisolide (nasal) .............................58
fluocinolone acetonide .......................44
fluocinolone acetonide (otic)...............62
fluocinonide .....................................44
fluorometholone (ophth) ....................61
FLUOROPLEX ....................................42
fluorouracil.......................................25
fluorouracil (topical) ..........................42
fluoxetine hcl ...................................14
fluoxetine hcl (pmdd) ........................65
fluphenazine decanoate .....................31
fluphenazine hcl................................31
flurandrenolide .................................44
flurazepam hcl ..................................54
flurbiprofen ....................................... 3
FLURBIPROFEN .................................. 3
flurbiprofen sodium .......................... 61
flutamide ........................................ 26
fluticasone propionate....................... 44
fluvastatin sodium ............................ 20
fluvoxamine maleate ........................ 14
FML ................................................ 61
FML FORTE ...................................... 61
FML LIQUIFILM ................................ 61
FOCALIN ........................................... 1
FOCALIN XR ...................................... 1
folic acid ......................................... 53
FOLOTYN ........................................ 25
fondaparinux sodium ........................ 11
FORADIL AEROLIZER ........................ 10
FORTEO .......................................... 47
FORTESTA ......................................... 6
FORTICAL........................................ 47
FOSAMAX ........................................ 47
FOSAMAX PLUS D............................. 47
fosinopril sodium & hydrochlorothiazide
...................................................... 22
FOSRENOL ...................................... 51
FRAGMIN ........................................ 11
FREESTYLE SYSTEM KIT .................... 55
FREESTYLE TEST STRIPS................... 46
FROVA ............................................ 56
frovatriptan succinate ....................... 56
FULYZAQ ......................................... 17
FURADANTIN ................................... 69
furosemide ...................................... 47
FUROSEMIDE ................................... 46
FUSILEV .......................................... 28
FUZEON .......................................... 32
FYCOMPA ........................................ 11
G
gabapentin ...................................... 11
GABAPENTIN ................................... 35
GABITRIL ........................................ 12
galantamine hydrobromide ................ 64
GAMUNEX-C .................................... 63
ganciclovir ....................................... 33
GARAMYCIN .................................... 60
GASTROCROM ................................. 50
gatifloxacin (ophth) .......................... 60
GATTEX .......................................... 51
GAZYVA .......................................... 25
81
GELNIQUE .......................................51
gemcitabine hcl ................................25
gemfibrozil .......................................20
GEMZAR ..........................................25
gentamicin sulfate (ophth) .................60
gentamicin sulfate (topical) ................41
GENVOYA ........................................32
GEODON ..........................................30
GIAZO .............................................50
GILENYA ..........................................65
GILOTRIF .........................................27
GILPHEX TR .....................................40
glatiramer acetate.............................65
GLEEVEC .........................................27
GLIADEL WAFER ...............................24
glipizide ...........................................17
glipizide-metformin hcl ......................15
GLUCAGEN HYPOKIT .........................15
GLUCAGON EMERGENCY KIT ..............15
GLUCAGON HCL DIAGNOSTIC ............46
GLUCOPHAGE ...................................15
GLUCOPHAGE XR ..............................15
GLUCOSE .........................................15
GLUCOTROL .....................................17
GLUCOTROL XL.................................17
GLUCOVANCE ...................................15
GLUTATHIONE-L REDUCED ................64
glyburide .........................................17
glyburide micronized .........................17
glyburide-metformin .........................15
glycerin (laxative) .............................54
glycine diluent ..................................63
glycopyrrolate ..................................68
GLYNASE .........................................17
GLYSET ...........................................15
GOLYTELY ........................................54
GRALISE ..........................................65
GRALISE STARTER ............................65
granisetron hcl .................................17
GRANISOL .......................................18
GRANIX ...........................................53
GRASTEK .........................................35
GRIFULVIN V ....................................18
griseofulvin microsize ........................18
griseofulvin ultramicrosi .....................18
griseofulvin ultramicrosize..................18
GRIS-PEG ........................................18
guaifenesin ......................................40
guanfacine hcl ................................. 22
guanfacine hcl (adhd) ......................... 1
GUANIDINE HCL .............................. 23
GYNAZOLE-1 ................................... 70
H
HALAVEN ........................................ 28
HALDOL .......................................... 30
HALDOL DECANOATE 100 ................. 30
HALDOL DECANOATE 50 ................... 30
HALFLYTELY BOWEL PREP/FLA ........... 54
halobetasol propionate ...................... 44
HALOG ............................................ 44
haloperidol ...................................... 30
haloperidol decanoate ....................... 30
haloperidol lactate ............................ 30
HARVONI ........................................ 33
HECTOROL ...................................... 48
HELIDAC ......................................... 69
HEPARIN SODIUM ............................ 11
heparin sodium (porcine) .................. 11
heparin sodium (porcine) lock flush .... 11
HEPSERA......................................... 33
HERCEPTIN ..................................... 25
HETLIOZ ......................................... 54
HEXALEN ........................................ 24
HIPREX ........................................... 69
HIZENTRA ....................................... 63
homatropine hbr .............................. 59
HORIZANT....................................... 65
HORMONE CREAM BASE .................... 63
HUMALOG ....................................... 16
HUMALOG KWIKPEN ......................... 16
HUMALOG MIX 50/50........................ 16
HUMALOG MIX 75/25........................ 16
HUMIRA ............................................ 2
HUMIRA PEN-CROHNS DISEASE ........... 2
HUMULIN 70/30 ............................... 16
HUMULIN 70/30 PEN ........................ 16
HUMULIN N ..................................... 16
HUMULIN N U-100 PEN ..................... 16
HUMULIN R ..................................... 16
HUMULIN R U-500 (CONCENTR .......... 16
HYCAMTIN....................................... 29
HYCET .............................................. 5
hydralazine hcl................................. 23
HYDREA .......................................... 28
hydrochlorothiazide .......................... 47
HYDROCODONE BITARTRATE/AC ......... 5
82
hydrocodone polistirex-chlorpheniramine
polistirex .........................................40
hydrocodone w/ homatropine .............40
hydrocodone-acetaminophen ............... 5
hydrocodone-ibuprofen ....................... 5
hydrocortisone .................................39
hydrocortisone (intrarectal) ................. 6
hydrocortisone (rectal) ....................... 6
hydrocortisone (topical) .....................44
hydrocortisone acetate (rectal) ............ 7
hydrocortisone acetate w/ pramoxine ... 6
hydrocortisone butyrate .....................44
hydrocortisone sod succinate ..............39
hydrocortisone valerate .....................44
hydrocortisone w/acetic acid ..............62
hydrogen peroxide ............................31
hydromorphone hcl ............................ 4
HYDROMORPHONE HCL ...................... 4
hydroxychloroquine sulfate ................23
hydroxyurea .....................................28
hydroxyzine hcl ................................. 8
hydroxyzine pamoate ......................... 8
hyoscyamine sulfate ..........................68
HYPERSAL ........................................40
HYPER-SAL ......................................40
HYZAAR ...........................................22
I
IBRANCE..........................................27
ibuprofen .......................................... 3
ICLUSIG ..........................................27
IDAMYCIN PFS ..................................26
idarubicin hcl ....................................26
IFEX ................................................24
ifosfamide ........................................24
ILEVRO ............................................61
imatinib mesylate .............................27
IMBRUVICA ......................................27
IMDUR.............................................. 8
imipramine hcl..................................14
imipramine pamoate .........................14
IMITREX ..........................................56
IMITREX STATDOSE SYSTEM ..............56
IMURAN ...........................................34
INCRELEX ........................................48
indapamide ......................................47
INDERAL LA .....................................35
INDOCIN .......................................... 3
indomethacin .................................... 3
infed ............................................... 53
INFERGEN ....................................... 33
INJECTAFER .................................... 53
INLYTA ........................................... 27
INSPIRACHAMBER/LARGE ................. 66
INSPRA ........................................... 23
INTELENCE ...................................... 32
INTERMEZZO ................................... 54
INTRON A ....................................... 28
INTRON A W/DILUENT ...................... 28
INTUNIV ........................................... 1
INVEGA........................................... 30
INVEGA SUSTENNA .......................... 30
INVEGA TRINZA ............................... 30
INVIRASE ........................................ 32
INVOKAMET..................................... 15
INVOKANA ...................................... 16
ipratropium bromide ........................... 9
ipratropium bromide (nasal) .............. 58
ipratropium-albuterol ........................ 10
irbesartan ....................................... 21
irbesartan-hydrochlorothiazide ........... 22
IRESSA ........................................... 27
irinotecan hcl ................................... 29
iron dextran .................................... 53
ISENTRESS ..................................... 32
isometheptene-dichloralphenazone-aceta
minophen ........................................ 56
isoniazid ......................................... 24
isoniazid & rifampin .......................... 23
ISOPTIN SR ..................................... 36
ISOPTO ATROPINE ........................... 59
ISOPTO CARBACHOL ........................ 59
ISOPTO CARPINE ............................. 59
ISOPTO HYOSCINE ........................... 59
ISORDIL TITRADOSE .......................... 8
isosorbide dinitrate ............................. 8
isosorbide mononitrate ....................... 8
isotretinoin ...................................... 41
isradipine ........................................ 36
ISTODAX ......................................... 27
itraconazole ..................................... 18
ivermectin ......................................... 7
IXINITY........................................... 19
J
JADENU .......................................... 17
JAKAFI ............................................ 27
JALYN ............................................. 52
83
JANUMET .........................................15
JANUMET XR ....................................15
JANUVIA ..........................................15
JENTADUETO ....................................15
JEVTANA ..........................................28
JUBLIA ............................................42
JUXTAPID ........................................21
K
KADCYLA .........................................25
KADIAN ............................................ 4
KALETRA..........................................32
KALYDECO .......................................66
KAPVAY ............................................ 1
KAYEXALATE ....................................34
KAZANO ..........................................15
KEFLEX ............................................38
KENALOG .........................................44
KENALOG-10 ....................................39
KENALOG-40 ....................................39
KEPPRA ...........................................11
KEPPRA XR.......................................11
KERLONE .........................................35
KETEK .............................................. 7
ketoconazole ....................................18
ketoconazole (topical) .......................42
ketoprofen ........................................ 3
KETOPROFEN MICRONIZED ................. 3
ketorolac tromethamine ...................... 3
ketorolac tromethamine (ophth) .........61
KEVEYIS ..........................................46
KEYTRUDA .......................................25
KINERET ........................................... 2
KLARON ...........................................41
KLONOPIN .......................................11
KLOR-CON M15 ................................56
KOATE-DVI ......................................19
KOGENATE FS ..................................19
KOJIC ACID......................................66
KORLYM...........................................15
KOVALTRY .......................................19
K-PHOS ...........................................56
K-PHOS MF ......................................52
K-PHOS NO 2 ...................................52
KRYSTEXXA......................................52
K-TAB .............................................56
KYNAMRO ........................................20
KYPROLIS ........................................27
L
labetalol hcl ..................................... 34
LAC-HYDRIN .................................... 44
lactic acid (ammonium lactate) .......... 44
lactobacillus..................................... 17
lactulose ......................................... 54
lactulose (encephalopathy) ................ 51
LAMICTAL .................................. 11, 12
LAMICTAL CHEWABLE DISPERS ......... 12
LAMICTAL ODT ................................ 12
LAMICTAL XR ................................... 12
LAMISIL .......................................... 18
lamivudine ...................................... 32
lamivudine (hbv) .............................. 32
lamivudine-zidovudine ...................... 32
lamotrigine ...................................... 12
LANCETS 30G .................................. 46
LANOXIN ......................................... 37
lansoprazole .................................... 68
LANTUS .......................................... 16
LANTUS SOLOSTAR .......................... 16
LASIX ............................................. 47
L-ASPARTIC ACID SODIUM SA ........... 36
LASTACAFT ..................................... 61
latanoprost ...................................... 62
LATUDA .......................................... 30
LECITHIN ........................................ 36
LECITHIN ISOPROPYL PALMIT ............ 63
leflunomide ....................................... 3
LENVIMA 10MG DAILY DOSE ............. 27
LENVIMA 14MG DAILY DOSE ............. 27
LENVIMA 18MG DAILY DOSE ............. 27
LENVIMA 20MG DAILY DOSE ............. 27
LENVIMA 24MG DAILY DOSE ............. 27
LENVIMA 8MG DAILY DOSE ............... 27
LESCOL ........................................... 20
LESCOL XL ...................................... 20
LETAIRIS ........................................ 37
letrozole.......................................... 26
leucovorin calcium ............................ 28
LEUCOVORIN CALCIUM ..................... 35
LEUKERAN ....................................... 24
LEUKINE ......................................... 53
leuprolide acetate............................. 26
LEUSTATIN ...................................... 25
levalbuterol hcl ................................ 10
LEVAQUIN ....................................... 50
LEVATOL ......................................... 35
84
LEVBID ............................................68
LEVEMIR ..........................................16
LEVEMIR FLEXPEN ............................16
levetiracetam ...................................12
levobunolol hcl .................................59
levocarnitine (metabolic modifiers) .....48
levocetirizine dihydrochloride .............19
levofloxacin ......................................50
levofloxacin (ophth) ..........................60
levonorgestrel & eth estradiol .............38
levonorgestrel (emergency oc) ...........39
levonorgestrel-eth estradiol (triphasic) 38
levonorgestrel-ethinyl estradiol (91-day)
......................................................38
levothyroxine sodium ........................67
LEVSIN ............................................68
LEVSIN/SL .......................................68
LEXAPRO .........................................14
LEXIVA ............................................32
LIALDA ............................................50
LIBRAX ............................................68
lidocaine ..........................................45
LIDOCAINE ......................................36
lidocaine hcl .....................................45
lidocaine hcl (local anesth.) ................55
lidocaine hcl (mouth-throat) ...............57
lidocaine-prilocaine ...........................45
LIDODERM .......................................45
lindane ............................................45
linezolid ............................................ 8
LINZESS ..........................................51
liothyronine sodium ...........................67
LIPITOR ...........................................20
LIPOFEN ..........................................20
LIPOIC ACID ....................................35
LIPTRUZET .......................................20
LIQUICET .......................................... 5
lisinopril...........................................21
lisinopril & hydrochlorothiazide ...........22
LITHIUM ..........................................30
lithium carbonate ..............................30
LITHOBID ........................................30
LIVALO ............................................20
LOCOID ...........................................44
LODOSYN ........................................29
LOFIBRA ..........................................20
LOMOTIL .........................................17
lomustine.........................................24
LONSURF ........................................ 24
loperamide hcl ................................. 17
LOPID ............................................. 20
LOPRESSOR..................................... 35
LOPROX .......................................... 42
LOPROX SHAMPOO ........................... 42
loratadine........................................ 19
lorazepam ......................................... 8
LORCET 10/650 ................................. 5
LORCET PLUS .................................... 5
LORTAB ............................................ 5
losartan potassium ........................... 21
losartan potassium & hydrochlorothiazide
...................................................... 22
LOTEMAX ........................................ 61
LOTENSIN ....................................... 21
LOTENSIN HCT ................................ 22
LOTREL ........................................... 22
LOTRISONE ..................................... 42
LOTRONEX ...................................... 51
lovastatin ........................................ 21
LOVENOX ........................................ 11
loxapine succinate ............................ 30
LOXITANE ....................................... 30
L-SELENOMETHIONINE BLEND ........... 36
LUFYLLIN ........................................ 11
LUMIGAN ........................................ 62
LUNESTA......................................... 54
LUPRON DEPOT ................................ 26
LUPRON DEPOT-PED ......................... 48
LUVOX CR ....................................... 14
LUXIQ ............................................. 44
LUZU .............................................. 42
LYNPARZA ....................................... 27
LYRICA ........................................... 12
LYSODREN ...................................... 26
LYSTEDA ......................................... 54
M
MACROBID ...................................... 69
MACRODANTIN ................................ 69
mafenide acetate ............................. 43
magnesium citrate ........................... 54
magnesium sulfate ........................... 55
MALARONE ...................................... 23
malathion ........................................ 45
maprotiline hcl ................................. 13
MARINOL ........................................ 18
MARQIBO ........................................ 28
85
MATULANE .......................................28
MAVIK .............................................21
MAXAIR AUTOHALER .........................10
MAXALT ...........................................56
MAXALT-MLT ....................................56
MAXIDEX .........................................61
MAXIDONE ........................................ 5
MAXIPIME ........................................38
MAXITROL .......................................61
MAXZIDE .........................................46
MAXZIDE-25 ....................................46
MEBARAL .........................................54
mebendazole ..................................... 7
meclizine hcl ....................................18
meclofenamate sodium ....................... 3
MEDROL ..........................................39
MEDROL DOSEPAK ............................39
medroxyprogesterone acetate ............64
medroxyprogesterone acetate
(contraceptive) .................................39
mefloquine hcl ..................................23
MEGACE ES ......................................64
MEGACE ORAL ..................................26
megestrol acetate .............................26
megestrol acetate (appetite) ..............64
MEKINIST ........................................27
melatonin ......................................... 2
meloxicam ........................................ 3
melphalan hcl ...................................24
memantine hcl .................................64
MENEST ...........................................49
meperidine hcl ................................... 4
MEPHYTON .......................................70
MEPRON ........................................... 7
mercaptopurine ................................25
mesalamine .....................................50
MESNEX ..........................................28
MESTINON .......................................23
MESTINON TIMESPAN .......................23
METADATE CD ................................... 1
METADATE ER ................................... 1
METAGLIP ........................................15
metaproterenol sulfate ......................10
metaxalone ......................................58
metformin hcl ...................................15
methadone hcl................................... 4
METHADOSE ..................................... 4
methamphetamine hcl ........................ 1
methazolamide ................................ 46
methenamine hippurate .................... 69
methenamine mandelate ................... 69
methenamine-hyoscamine-methylene
blue-sodium phosphate ..................... 69
methenamine-hyosc-methylene
blue-benzoic acid-phenyl sal .............. 69
methenamine-hyosc-methylene blue-sod
phos-phenyl sal ............................... 69
METHERGINE ................................... 62
methimazole .................................... 67
METHITEST ....................................... 6
methocarbamol ................................ 58
methotrexate sodium........................ 25
methoxsalen rapid ............................ 42
methscopolamine bromide................. 68
methyclothiazide .............................. 47
METHYLCOBALAMIN ......................... 36
methyldopa ..................................... 22
methylergonovine maleate ................ 62
METHYLIN ......................................... 1
methylphenidate hcl ........................... 1
methylprednisolone .......................... 39
methylprednisolone sod succ ............. 39
methyltestosterone ............................ 6
metipranolol .................................... 59
metoclopramide hcl .......................... 50
metolazone ..................................... 47
metoprolol succinate......................... 35
metoprolol tartrate ........................... 35
METROCREAM .................................. 45
METROGEL ...................................... 45
METROGEL-VAGINAL ........................ 70
METROLOTION ................................. 45
metronidazole .................................... 7
metronidazole (topical) ..................... 45
metronidazole in nacl .......................... 7
metronidazole vaginal ....................... 70
MEVACOR........................................ 21
mexiletine hcl .................................... 9
MIACALCIN...................................... 47
MICARDIS ....................................... 21
miconazole nitrate (topical) ............... 42
miconazole nitrate vaginal ................. 70
MICRO-K ......................................... 56
MICROZIDE ..................................... 47
MIDAMOR........................................ 47
midodrine hcl ................................... 70
86
miglitol ............................................15
MIGRANAL .......................................56
MILLIPRED .......................................39
MILLIPRED DP ..................................39
mineral oil .......................................55
MINIPRESS ......................................22
MINIVELLE .......................................49
MINOCIN .........................................67
minocycline hcl .................................67
minoxidil ..........................................23
MIRAPEX..........................................29
MIRAPEX ER .....................................29
MIRCERA .........................................53
mirtazapine ......................................13
MIRVASO .........................................45
misoprostol ......................................69
mitomycin ........................................26
mitoxantrone hcl...............................26
MOBIC .............................................. 3
moexipril hcl ....................................21
moexipril-hydrochlorothiazide .............22
mometasone furoate (nasal) ..............58
MONOCLATE-P..................................19
MONODOX .......................................67
MONOKET ......................................... 8
MONONINE ......................................19
montelukast sodium ........................... 9
MONUROL ........................................69
morphine sulfate ................................ 4
morphine sulfate beads ...................... 4
MOVANTIK .......................................51
MOVIPREP........................................54
MOXEZA ..........................................60
moxifloxacin hcl ................................50
MS CONTIN ....................................... 4
MULTAQ ........................................... 9
multiple vitamins w/ minerals .............57
multiple vitamins with folic acid ..........57
MULTIVITAMIN ADULTS .....................57
mupirocin ........................................41
mupirocin calcium (topical) ................41
MUSTARGEN ....................................24
MYALEPT..........................................48
MYAMBUTOL.....................................24
MYCELEX .........................................57
MYCOBUTIN .....................................24
mycophenolate mofetil ......................34
mycophenolate sodium ......................34
MYDRIACYL ..................................... 59
MYFORTIC ....................................... 34
MYLERAN ........................................ 24
MYOBLOC ........................................ 59
MYRBETRIQ ..................................... 69
MYSOLINE ....................................... 12
MYTELASE ....................................... 23
N
nabumetone ...................................... 3
nadolol ........................................... 35
naftifine hcl ..................................... 42
NAFTIN ........................................... 42
NALFON ............................................ 3
naloxone hcl .................................... 17
naltrexone hcl .................................. 17
NAMENDA ....................................... 64
NAMENDA TITRATION PAK ................ 64
NAMENDA XR................................... 64
NAMENDA XR TITRATION PACK.......... 65
naphazoline hcl ................................ 60
NAPROSYN ........................................ 3
naproxen sodium ............................... 3
naratriptan hcl ................................. 56
NARCAN .......................................... 17
NARDIL ........................................... 13
NASACORT AQ ................................. 58
NASONEX ........................................ 58
NATACYN ........................................ 60
nateglinide ...................................... 16
NATPARA ........................................ 47
NATROBA ........................................ 45
NATURE-THROID.............................. 67
NATURE-THROID NT-2.5 ................... 67
NAVELBINE ..................................... 28
NEBUPENT......................................... 7
NEBUSAL ........................................ 40
nefazodone hcl................................. 13
NEO-FRADIN ..................................... 2
neomycin sulfate ................................ 2
neomycin-bacitracin zn-polymyxin...... 60
neomycin-polymy-dexameth.............. 61
neomycin-polymyxin-gramicidin ......... 60
neomycin-polymyxin-hc (ophth)......... 61
neomycin-polymyxin-hc (otic)............ 62
NEORAL .......................................... 34
NEOSPORIN..................................... 60
NEPHROCAPS .................................. 57
NEPHROCAPS QT.............................. 57
87
NEPTAZANE .....................................46
NESINA ...........................................15
NEULASTA .......................................53
NEUPOGEN ......................................53
NEUPRO...........................................29
NEURONTIN .....................................12
NEVANAC .........................................61
nevirapine ........................................32
NEXAVAR .........................................27
NEXIUM ...........................................68
niacin (antihyperlipidemic) .................21
NIASPAN .........................................21
nicardipine hcl ..................................36
nicotine ...........................................66
nicotine polacrilex .............................66
NICOTROL INHALER ..........................66
NICOTROL NS ..................................66
nifedipine .........................................36
NILANDRON .....................................26
nimodipine .......................................37
NINLARO .........................................27
nisoldipine .......................................37
NITRO-BID........................................ 8
NITRO-DUR ....................................... 8
nitrofurantoin ...................................69
nitrofurantoin macrocrystal ................69
nitrofurantoin monohyd macro ...........69
nitroglycerin ...................................... 8
NITROLINGUAL PUMPSPRAY ................ 8
NITROMIST ....................................... 8
NITROSTAT ....................................... 8
nizatidine .........................................68
NIZORAL .........................................42
NORCO ............................................. 5
NORDIPEN 5 INJECTION DEVI ............56
NORDITROPIN FLEXPRO ....................48
NORDITROPIN NORDIFLEX PEN ..........48
norelgestromin-ethinyl estradiol .........39
norethin acet & estrad-fe ...................38
norethindrone & eth estradiol .............38
norethindrone & ethinyl estradiol-fe ....38
norethindrone & mestranol.................38
norethindrone (contraceptive) ............39
norethindrone acet & eth estra ...........38
norethindrone acetate .......................64
norethindrone acetate-ethinyl estradiol 49
norethindrone acetate-ethinyl estradiol-fe
......................................................38
norethindrone-eth estradiol (triphasic) 38
norgestimate-ethinyl estradiol ........... 38
norgestimate-ethinyl estradiol (triphasic)
...................................................... 38
norgestrel & ethinyl estradiol ............. 39
NORITATE ....................................... 45
NOROXIN ........................................ 50
NORPACE .......................................... 9
NORPACE CR ..................................... 9
NORPRAMIN .................................... 14
NORTHERA ...................................... 70
nortriptyline hcl ............................... 14
NORTUSS-EX ................................... 40
NORVASC ........................................ 37
NORVIR .......................................... 32
NOVOEIGHT .................................... 19
NOVOLIN 70/30 ............................... 16
NOVOLIN N ..................................... 16
NOVOLIN R ..................................... 16
NOVOLOG ....................................... 16
NOVOLOG MIX 70/30........................ 16
NOVOLOG MIX 70/30 PREFILL ........... 16
NOVOLOG PENFILL ........................... 16
NOVOSEVEN RT ............................... 19
NOXAFIL ......................................... 18
NPLATE ........................................... 53
NUCYNTA .......................................... 4
NUCYNTA ER ..................................... 4
NUEDEXTA ...................................... 65
NULYTELY/FLAVOR PACKS ................. 54
NUVARING ...................................... 39
NUVIGIL ........................................... 1
NUWIQ ........................................... 19
NYMALIZE ....................................... 37
nystatin .......................................... 18
nystatin (mouth-throat) .................... 57
nystatin (topical) .............................. 42
nystatin-triamcinolone ...................... 42
O
OBIZUR .......................................... 19
OCTAGAM ....................................... 63
octreotide acetate ............................ 49
OCUFEN .......................................... 61
OCUFLOX ........................................ 60
OCUVITE ADULT 50+ ........................ 57
ODEFSEY ........................................ 32
ODOMZO......................................... 26
OFEV .............................................. 66
88
ofloxacin ..........................................50
ofloxacin (otic) .................................62
olanzapine .......................................30
olanzapine-fluoxetine hcl ...................65
olopatadine hcl .................................62
omeprazole ......................................68
OMEPRAZOLE ...................................36
OMEPRAZOLE + SYRSPEND SF ...........68
OMNARIS .........................................58
OMNIPRED .......................................61
ONCASPAR .......................................28
ondansetron .....................................18
ondansetron hcl ................................18
ONFI ...............................................11
ONGLYZA .........................................15
ONSOLIS .......................................... 4
OPANA ............................................. 4
OPANA ER ......................................... 4
OPANA ER (CRUSH RESISTANT ............ 4
opium tincture ..................................17
OPSUMIT .........................................37
OPTIPRANOLOL ................................59
OPTIVAR ..........................................62
ORALAIR ..........................................35
ORAP ..............................................65
ORAPRED .........................................39
ORAPRED ODT ..................................39
ORAXYL ...........................................67
ORENCIA .......................................... 3
ORENITRAM .....................................37
ORKAMBI .........................................66
orphenadrine citrate ..........................58
orphenadrine w/ aspirin & caff ............58
ORTHO ALL-FLEX DIAPHRAGM ............56
ORTHO EVRA....................................39
OSENI .............................................15
OSMOPREP.......................................54
OSPHENA .........................................48
OTEZLA ...........................................64
OVIDE .............................................45
oxaliplatin ........................................24
OXANDRIN ........................................ 6
oxaprozin.......................................... 3
oxazepam ......................................... 8
oxcarbazepine ..................................12
oxiconazole nitrate ............................42
OXISTAT ..........................................42
OXSORALEN .....................................45
OXSORALEN ULTRA .......................... 42
OXTELLAR XR .................................. 12
oxybutynin chloride .......................... 51
oxycodone hcl .................................... 5
oxycodone w/ acetaminophen .............. 5
oxycodone-aspirin .............................. 5
OXYCONTIN....................................... 5
oxymetazoline hcl ............................ 66
oxymorphone hcl ............................... 5
OXYTROL ........................................ 51
P
paclitaxel ........................................ 28
paliperidone .................................... 30
PAMELOR ........................................ 14
pamidronate disodium ...................... 47
PAMINE ........................................... 68
PAMINE FORTE ................................ 68
PANCREAZE ..................................... 46
pancrelipase (lipase-protease-amylase)
...................................................... 46
PANRETIN ....................................... 42
pantoprazole sodium ........................ 68
PARAFON FORTE DSC ....................... 58
PARCOPA ........................................ 29
paregoric ........................................ 17
paricalcitol....................................... 48
PARLODEL ....................................... 29
PARNATE......................................... 13
paromomycin sulfate .......................... 2
paroxetine hcl .................................. 14
PASER ............................................ 24
PATADAY ......................................... 62
PATANOL......................................... 62
PAXIL ............................................. 14
PAXIL CR ........................................ 14
PCE ................................................ 55
PEDIAPRED ..................................... 39
pediatric vitamins acd fluoride & iron .. 57
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate ............................................ 54
PEGANONE ...................................... 13
PEGASYS......................................... 33
PEGASYS PROCLICK ......................... 33
PEN NEEDLES 29G X 12MM ............... 62
PEN NEEDLES 31G X 5MM ................. 62
PENICILLIN G PROCAINE ................... 63
penicillin v potassium ....................... 63
PENNSAID ....................................... 41
89
PENTASA .........................................50
PENTOSAN POLYSULFATE SODI ..........36
pentoxifylline....................................52
PEPCID ............................................68
PERCOCET ........................................ 5
PERCODAN........................................ 5
PERFOROMIST ..................................10
PERIDEX ..........................................57
perindopril erbumine .........................21
PERIOSTAT ......................................67
PERJETA ..........................................25
permethrin .......................................46
perphenazine ...................................31
PERSANTINE ....................................53
phenazopyridine hcl ..........................52
phenelzine sulfate .............................13
PHENERGAN .....................................20
phenobarbital ...................................54
phenobarbital-hyoscyamine-atropine-sco
polamine .........................................68
PHENYLBUTAZONE ............................. 3
PHENYTEK .......................................13
phenytoin ........................................13
phenytoin sodium extended ...............13
PHISOHEX .......................................31
PHOSLO ...........................................51
PHOSLYRA .......................................51
PHOSPHOLINE IODIDE ......................59
PHRENILIN FORTE.............................. 4
PICATO ............................................42
pilocarpine hcl ..................................59
pilocarpine hcl (oral) .........................57
PILOPINE HS ....................................59
pimozide ..........................................65
pindolol ...........................................35
pioglitazone hcl-glimepiride ................15
pioglitazone hcl-metformin hcl ............15
piperacillin sodium-tazobactam sodium 63
piroxicam .......................................... 3
PLAN B ............................................39
PLAN B ONE-STEP .............................39
PLAQUENIL ......................................23
PLASTICIZED BASE ...........................63
PLAVIX ............................................53
PLETAL ............................................53
PLURONIC ........................................64
PLURONIC F127 ................................63
podofilox..........................................45
POLYETHYLENE GLYCOL 3350 ............ 63
polymyxin b-trimethoprim ................. 60
POLYTRIM ....................................... 60
POMALYST....................................... 26
PONSTEL ........................................... 3
pot phosphate monobasic w/ sod
phosphate dibasic & monobasic .......... 56
potassium bicarb & chloride ............... 56
potassium bicarbonate ...................... 56
potassium chloride ........................... 56
potassium chloride microencapsulated
crystals cr ....................................... 57
potassium citrate (alkalinizer) ............ 52
POTIGA ........................................... 12
PRADAXA ........................................ 11
PRALUENT ....................................... 64
pramipexole dihydrochloride .............. 29
PRAMOSONE.................................... 44
PRAMOSONE E ................................. 44
PRANDIMET ..................................... 15
PRANDIN......................................... 16
PRAVACHOL .................................... 21
prazosin hcl ..................................... 22
PRECISION XTRA ............................. 55
PRECISION XTRA BLOOD GLUC .......... 46
PRECOSE ........................................ 15
PRED FORTE .................................... 61
PRED MILD ...................................... 61
PRED-G ........................................... 61
PRED-G S.O.P. ................................. 61
prednicarbate .................................. 44
prednisolone .................................... 40
prednisolone acetate (ophth) ............. 61
PREDNISOLONE SODIUM PHOSP ........ 61
prednisolone sodium phosphate ......... 40
prednisone ...................................... 40
PREDNISONE INTENSOL ................... 40
PRELONE......................................... 40
PREMARIN .................................. 49, 70
PREMPHASE .................................... 49
PREMPRO ........................................ 49
PRENATAL ....................................... 57
PRENATAL PLUS ............................... 57
prenatal vit w/ docusate-fe fumarate-folic
acid ................................................ 57
prenatal vit w/ ferrous fumarate-folic acid
...................................................... 57
prenatal vit w/ iron carbonyl-folic acid 57
90
PREPOPIK ........................................54
PREVACID ........................................68
PREVACID SOLUTAB ..........................68
PREVPAC .........................................69
PREZCOBIX ......................................32
PREZISTA ........................................32
PRIFTIN ...........................................24
PRILOSEC .................................. 68, 69
PRIMAQUINE PHOSPHATE ..................23
primidone ........................................12
PRIMSOL .......................................... 7
PRINIVIL..........................................21
PRINZIDE ........................................22
PRISTIQ ..........................................14
PROAIR HFA .....................................10
PROAIR RESPICLICK .........................10
probenecid .......................................52
PROCARDIA .....................................37
PROCARDIA XL .................................37
PROCENTRA ...................................... 1
prochlorperazine ...............................31
prochlorperazine edisylate .................31
prochlorperazine maleate ...................31
PROCRIT ..........................................53
PROCTOCORT .................................... 7
PROCTOFOAM HC............................... 6
PROFILNINE .....................................19
progesterone ....................................64
PROGLYCEM .....................................15
PROGRAF .........................................34
PROLEUKIN ......................................28
PROLIA ............................................47
PROMACTA.......................................53
promethazine hcl ..............................20
promethazine w/codeine ....................40
promethazine-dm .............................40
PROMETRIUM ...................................64
propafenone hcl ................................. 9
proparacaine hcl ...............................60
propranolol hcl .................................35
PROPYLENE GLYCOL ..........................36
propylthiouracil.................................67
PROSCAR .........................................52
PROSED/DS .....................................69
PROSTIGMIN ....................................23
PROTONIX .......................................69
PROTOPIC ........................................45
protriptyline hcl ................................14
PROVENTIL HFA ............................... 10
PROVERA ........................................ 64
PROVIGIL .......................................... 1
PROZAC .......................................... 14
prudoxin ......................................... 42
pseudoephedrine w/ codeine-gg ......... 40
PULMICORT ..................................... 10
PULMICORT FLEXHALER .................... 10
PULMOZYME .................................... 66
PURINETHOL ................................... 25
PURIXAN ......................................... 25
PYLERA ........................................... 69
pyrazinamide ................................... 24
PYRIDIUM ....................................... 52
pyridostigmine bromide .................... 23
Q
QNASL ............................................ 58
QNASL CHILDRENS .......................... 58
QUALAQUIN .................................... 23
QUDEXY XR ..................................... 12
QUESTRAN ...................................... 20
quetiapine fumarate ......................... 30
QUILLIVANT XR ................................. 1
quinapril-hydrochlorothiazide ............. 22
quinidine sulfate ................................ 9
quinine sulfate ................................. 23
QVAR .............................................. 10
R
rabeprazole sodium .......................... 69
RAGWITEK ...................................... 35
raloxifene hcl ................................... 48
RANEXA ............................................ 8
ranitidine hcl ................................... 68
RAPAFLO ......................................... 52
RAPAMUNE ...................................... 34
RAZADYNE ...................................... 65
RAZADYNE ER.................................. 65
REBETOL ......................................... 33
REBIF ............................................. 65
REBIF REBIDOSE TITRATION ............. 65
RECLAST ......................................... 47
RECOMBINATE ................................. 19
REGLAN .......................................... 50
REGRANEX ...................................... 46
RELENZA DISKHALER ....................... 33
RELION 2-IN-1 LANCING DEV ............ 46
RELISTOR ....................................... 51
RELPAX ........................................... 56
91
REMERON ........................................13
REMERON SOLTAB ............................13
REMICADE .......................................50
REMODULIN .....................................37
RENAGEL .........................................51
RENVELA .........................................51
repaglinide .......................................16
REPATHA .........................................64
REPATHA SURECLICK ........................64
REPREXAIN ....................................... 5
REQUIP ...........................................29
REQUIP XL .......................................29
RESCRIPTOR ....................................32
RESCULA .........................................62
reserpine .........................................22
RESTASIS ........................................60
RESTORIL ........................................54
RETIN-A ..........................................41
RETIN-A MICRO PUMP .......................41
RETROVIR ........................................32
REVATIO ..........................................37
REVIA..............................................17
REVLIMID ........................................34
REXULTI ..........................................31
REYATAZ .........................................32
RHEUMATREX .................................... 2
RHINOCORT AQUA ............................58
RIBASPHERE RIBAPAK .......................33
RIBATAB ..........................................33
ribavirin (hepatitis c) .........................33
rifabutin ..........................................24
RIFADIN ..........................................24
RIFAMATE ........................................23
rifampin ...........................................24
RIFATER ..........................................24
RIFAXIMIN .......................................36
RILUTEK ..........................................59
riluzole ............................................59
RIOMET ...........................................15
risedronate sodium ...........................47
RISPERDAL ......................................30
RISPERDAL CONSTA..........................30
RISPERDAL M-TAB ............................30
risperidone .......................................30
RITALIN ............................................ 1
RITALIN LA ....................................... 1
RITALIN SR ....................................... 1
RITUXAN .........................................25
rivastigmine .................................... 65
RIXUBIS.......................................... 19
rizatriptan benzoate ......................... 56
ROBAXIN ........................................ 58
ROBAXIN-750 .................................. 58
ROBINUL ......................................... 68
ROBINUL FORTE............................... 68
ROCALTROL ..................................... 48
ropinirole hydrochloride .................... 29
rosuvastatin calcium ......................... 21
ROXICET ........................................... 5
ROXICODONE .................................... 5
ROZEREM ........................................ 54
RYTHMOL .......................................... 9
RYTHMOL SR ..................................... 9
S
SABRIL ........................................... 12
SALAGEN ........................................ 57
saline, bacteriostatic ....................... 63
salsalate ........................................... 4
SAMSCA .......................................... 49
SANCTURA ...................................... 51
SANCTURA XR ................................. 51
SANCUSO ........................................ 18
SANDIMMUNE .................................. 34
SANDOSTATIN ................................. 49
SANDOSTATIN LAR DEPOT ................ 49
SANTYL ........................................... 45
SAPHRIS .................................... 30, 31
SARAFEM ........................................ 65
SAVELLA ......................................... 65
SAVELLA TITRATION PACK ................ 65
SECTRAL ......................................... 35
selegiline hcl .................................... 30
selenium sulfide ............................... 43
SELENIUM SULFIDE-PYRITHIONE ZINC IN
UREA VEHICLE ................................. 43
SELZENTRY ..................................... 32
SEMPREX-D ..................................... 40
sennosides ...................................... 66
sennosides-docusate sodium ............. 54
SENSIPAR ....................................... 48
SEPINEO P 600 ................................ 64
SEPTRA DS ........................................ 7
SEREVENT DISKUS ........................... 10
SEROMYCIN..................................... 24
SEROQUEL ...................................... 31
SEROQUEL XR ................................. 31
92
SEROSTIM .......................................48
sertraline hcl ....................................14
sevelamer carbonate .........................51
SFROWASA ......................................50
SIGNIFOR ........................................49
sildenafil citrate (pulmonary
hypertension) ...................................37
SILVADENE ......................................43
SILVER PROTEIN MILD ......................31
silver sulfadiazine .............................43
SIMBRINZA ......................................60
simethicone .....................................50
SIMPONI ........................................... 2
SIMPONI ARIA ................................... 2
simvastatin ......................................21
SINEMET .........................................29
SINEMET CR .....................................29
SINGULAIR ....................................... 9
sirolimus ..........................................34
SIRTURO .........................................24
SIVEXTRO ......................................... 8
SKELAXIN ........................................58
SKELID ............................................47
SKLICE ............................................46
SM ISOPROPYL ALCOHOL RUBB ..........55
sodium chloride (gu irrigant) ..............52
sodium chloride (inhalant) .................40
sodium ferric gluconate complex in
sucrose............................................53
sodium phosphates ...........................54
sodium polystyrene sulfonate .............34
SOLARAZE .......................................42
SOLTAMOX.......................................26
SOLU-CORTEF ..................................40
SOLU-MEDROL .................................40
SOMA ..............................................58
SOMATULINE DEPOT .........................49
SOMAVERT.......................................48
SONATA...........................................54
SOOLANTRA .....................................45
SORBITAN MONOOLEATE ...................36
SORIATANE ......................................43
sotalol hcl ........................................35
SOTYLIZE ........................................35
SOVALDI .........................................33
SPECTRACEF ....................................38
spinosad ..........................................46
SPIRIVA HANDIHALER ........................ 9
SPIRIVA RESPIMAT............................. 9
spironolactone ................................. 47
spironolactone & hydrochlorothiazide .. 46
SPORANOX ...................................... 19
SPRITAM ......................................... 12
SPRIX ............................................... 3
SPRYCEL ......................................... 27
STALEVO 100 .................................. 29
STALEVO 125 .................................. 29
STALEVO 150 .................................. 29
STALEVO 200 .................................. 30
STALEVO 50 .................................... 29
STALEVO 75 .................................... 29
STARLIX ......................................... 16
stavudine ........................................ 32
STELARA ......................................... 43
STERILE DILUENT FOR FLOLA ............ 63
STIVARGA ....................................... 27
STRATTERA ....................................... 1
STRENSIQ ....................................... 48
STRIANT ........................................... 6
STRIBILD ........................................ 32
STROMECTOL .................................... 7
SUBOXONE........................................ 6
SUBSYS ............................................ 5
SUCRALFATE ................................... 68
SULAR ............................................ 37
sulfacetamide sodium (ophth) ............ 60
sulfacetamide sodium w/ sulfur .......... 41
sulfacetamide sod-prednisolone ......... 61
SULFADIAZINE ................................ 66
sulfamethoxazole-trimethoprim............ 7
SULFAMYLON ................................... 43
sulfasalazine .................................... 50
sulindac ............................................ 3
sumatriptan ..................................... 56
sumatriptan succinate ....................... 56
SUPPRELIN LA ................................. 48
SUPRAX .......................................... 38
SUPREP BOWEL PREP ....................... 54
SURMONTIL ..................................... 14
SUSTIVA ......................................... 32
SUTENT .......................................... 27
SUTTAR-SF...................................... 40
SWEET CORN FLAVOR CONCENT ........ 49
SYLATRON....................................... 28
SYLVANT ......................................... 34
SYMBICORT ..................................... 10
93
SYMBYAX .........................................65
SYMLIN ...........................................15
SYMLINPEN 120 ................................15
SYMLINPEN 60 .................................15
SYNAGIS .........................................63
SYNALAR .........................................44
SYNAREL .........................................48
SYNRIBO .........................................28
SYNTHROID .....................................67
SYPRINE ..........................................34
T
TABLOID..........................................25
TACLONEX .......................................44
tacrolimus ........................................34
tacrolimus (topical) ...........................45
TAFINLAR ........................................27
TAGRISSO .......................................27
TAMBOCOR ....................................... 9
TAMIFLU ..........................................33
tamoxifen citrate ..............................26
TANZEUM ........................................16
TAPAZOLE........................................67
TARCEVA .........................................27
TARGRETIN ................................ 28, 42
TASIGNA .........................................27
TASMAR ..........................................29
TAXOTERE .......................................28
TAZORAC .........................................43
TECFIDERA ......................................65
TECFIDERA STARTER PACK ................65
TEGRETOL .......................................12
TEGRETOL-XR ..................................12
TEKAMLO .........................................22
TEKTURNA .......................................23
TEKTURNA HCT ................................23
telmisartan ......................................21
temazepam ......................................54
TEMODAR ........................................24
TEMOVATE .......................................44
TENEX .............................................22
TENORETIC 100 ................................23
TENORETIC 50 .................................23
TENORMIN .......................................35
TERAZOL 3.......................................70
TERAZOL 7.......................................70
terazosin hcl.....................................22
terbutaline sulfate .............................10
terconazole vaginal ...........................70
TESSALON....................................... 40
TESSALON PERLES ........................... 40
TESTIM ............................................. 6
TESTOPEL ......................................... 6
testosterone ...................................... 6
testosterone enanthate ....................... 6
TESTRED........................................... 6
tetrabenazine .................................. 65
tetracycline hcl ................................ 67
TEVETEN ......................................... 22
THALITONE ..................................... 47
THALOMID ...................................... 34
THEO-24 ......................................... 11
theophylline .................................... 11
THEOPHYLLINE ................................ 11
thioridazine hcl ................................ 31
THIOTEPA ....................................... 24
thiothixene ...................................... 31
thyroid ............................................ 67
THYROLAR-1 ................................... 67
THYROLAR-1/2 ................................ 67
THYROLAR-1/4 ................................ 67
THYROLAR-2 ................................... 67
THYROLAR-3 ................................... 67
tiagabine hcl .................................... 12
TIAZAC ........................................... 37
ticlopidine hcl .................................. 53
TIGAN............................................. 18
TIKOSYN ........................................... 9
timolol maleate ................................ 35
timolol maleate (ophth) .................... 59
TIMOPTIC ........................................ 59
TIMOPTIC-XE ................................... 59
TINDAMAX ........................................ 7
tinidazole .......................................... 7
TIVICAY .......................................... 32
tizanidine hcl ................................... 58
TOBI................................................. 2
TOBI PODHALER ................................ 2
TOBRADEX ...................................... 61
tobramycin ........................................ 2
tobramycin (ophth) .......................... 60
TOBRAMYCIN SULFATE ....................... 2
tobramycin-dexamethasone .............. 61
TOBREX .......................................... 60
TOFRANIL ....................................... 14
TOFRANIL-PM .................................. 14
tolazamide ...................................... 17
94
tolbutamide......................................17
tolcapone .........................................29
tolmetin sodium ................................. 3
tolterodine tartrate ...........................51
TOPAMAX.........................................12
TOPAMAX SPRINKLE ..........................12
TOPICORT ........................................44
topiramate .......................................12
topotecan hcl ...................................29
TOPROL XL.......................................35
TORISEL ..........................................27
torsemide ........................................47
TOUJEO SOLOSTAR ...........................16
TOVIAZ ...........................................51
TRACLEER ........................................37
TRADJENTA ......................................16
tramadol hcl ...................................... 5
tramadol-acetaminophen .................... 5
TRANDATE .......................................34
tranexamic acid ................................54
TRANSDERM-SCOP............................18
TRANXENE T ..................................... 8
tranylcypromine sulfate .....................13
TRAVATAN Z ....................................62
trazodone hcl ...................................13
TREANDA .........................................24
TRECATOR .......................................24
TRENTAL..........................................52
TRESIBA FLEXTOUCH ........................16
tretinoin ..........................................41
tretinoin (chemotherapy) ...................28
tretinoin microsphere ........................41
TRETTEN..........................................19
TREXALL ..........................................25
triamcinolone acetonide (mouth) ........57
triamcinolone acetonide (nasal) ..........58
triamcinolone acetonide (topical) ........44
triamterene & hydrochlorothiazide ......46
TRICOR ...........................................20
trifluoperazine hcl .............................31
trifluridine ........................................60
TRIGLIDE.........................................20
trihexyphenidyl hcl ............................29
TRILEPTAL .......................................12
TRILIPIX ..........................................20
trimethobenzamide hcl ......................18
trimethoprim ..................................... 7
trimipramine maleate ........................14
TRINTELLIX ..................................... 13
TRIUMEQ ........................................ 32
TRIZIVIR ......................................... 32
TROKENDI XR .................................. 12
tropicamide ..................................... 59
trospium chloride ............................. 51
TRULICITY....................................... 16
TRUSOPT ........................................ 62
TRUVADA ........................................ 32
TUDORZA PRESSAIR........................... 9
TUSSIONEX PENNKINETIC EXT .......... 40
TYBOST .......................................... 32
TYKERB........................................... 27
TYLENOL/CODEINE #3 ........................ 5
TYLENOL/CODEINE #4 ........................ 5
TYLOX .............................................. 5
TYSABRI ......................................... 65
TYVASO STARTER ............................ 37
TYZEKA........................................... 33
U
UCERIS ....................................... 6, 40
ULESFIA .......................................... 46
ULORIC ........................................... 52
ULTICARE MICRO PEN NEEDLE .......... 63
ULTICARE MINI PEN NEEDLES ........... 63
ULTRACET ......................................... 5
ULTRAM ............................................ 5
ULTRAM ER ....................................... 5
ULTRAVATE ..................................... 44
UNIRETIC ........................................ 23
UNISTIK 3 EXTRA SINGLE US ............ 46
UNIVASC ......................................... 21
urea ............................................... 44
URECHOLINE ................................... 51
URETRON D/S.................................. 69
UREX .............................................. 69
UROXATRAL .................................... 52
URSO 250 ....................................... 50
URSO FORTE ................................... 50
ursodiol .......................................... 50
V
VAGIFEM ......................................... 70
valacyclovir hcl ................................ 33
VALCHLOR ...................................... 42
VALCYTE ......................................... 33
valganciclovir hcl .............................. 33
VALIUM ............................................. 9
valproate sodium ............................. 13
95
valsartan .........................................22
valsartan-hydrochlorothiazide .............23
VALSTAR .........................................26
VALTREX..........................................33
VANCOCIN HCL ................................. 7
vancomycin hcl .................................. 7
VANCOMYCIN HCL ............................. 7
VANDETANIB ....................................27
VANISHING CREAM ...........................63
VANOS ............................................44
VARUBI ...........................................18
VASERETIC ......................................23
VASOTEC .........................................21
VECTIBIX .........................................25
VECTICAL ........................................43
VELCADE .........................................28
VELETRI ..........................................37
venlafaxine hcl .................................14
VENOFER .........................................53
VENTAVIS ........................................37
VENTOLIN HFA .................................10
VERAMYST .......................................58
verapamil hcl ...................................37
VEREGEN .........................................41
VERELAN .........................................37
VERELAN PM ....................................37
VERSACLOZ .....................................31
VESICARE ........................................51
VEXOL .............................................61
VFEND .............................................19
VIBRAMYCIN ....................................67
VICOPROFEN ..................................... 5
VICTOZA .........................................16
VIDAZA ...........................................25
VIDEX EC .........................................32
VIDEX PEDIATRIC .............................32
VIGAMOX .........................................60
VIIBRYD ..........................................13
VIMPAT ...........................................12
VINBLASTINE SULFATE ......................28
vincristine sulfate ..............................29
VIRACEPT ........................................32
VIRAMUNE .......................................32
VIRAMUNE XR ..................................32
VIRAZOLE ........................................33
VIREAD ...........................................32
VIROPTIC ........................................60
VISTARIL .......................................... 8
vitamin e ........................................ 70
VITEKTA ......................................... 32
VIVACTIL ........................................ 14
VIVELLE-DOT ................................... 49
VIVITROL ........................................ 17
VOGELXO .......................................... 6
VOGELXO PUMP ................................. 6
VOLTAREN.................................. 41, 62
VOLTAREN-XR ................................... 3
voriconazole .................................... 19
VOSOL HC ....................................... 62
VOSPIRE ER .................................... 10
VOTRIENT ....................................... 28
VUMON ........................................... 29
VYTORIN ......................................... 20
VYVANSE .......................................... 1
W
WELCHOL ........................................ 20
WELLBUTRIN ................................... 13
WELLBUTRIN SR .............................. 13
WELLBUTRIN XL ............................... 13
WESTCORT ...................................... 44
WESTHROID .................................... 67
WESTHROID-P ................................. 67
WILATE ........................................... 19
X
XALATAN......................................... 62
XALKORI ......................................... 28
XANAX .............................................. 9
XARELTO......................................... 11
XARELTO STARTER PACK .................. 11
XELJANZ ........................................... 2
XELJANZ XR ...................................... 2
XELODA .......................................... 25
XENAZINE ....................................... 65
XEOMIN .......................................... 59
XERAC AC ....................................... 45
XGEVA ............................................ 47
XIFAXAN ........................................... 7
XIGDUO XR ..................................... 15
XOLAIR ............................................. 9
XOPENEX ........................................ 10
XOPENEX HFA .................................. 10
XTANDI........................................... 26
XYLOCAINE ..................................... 55
XYLOCAINE JELLY............................. 45
XYNTHA .......................................... 19
XYNTHA SOLOFUSE .......................... 19
96
XYREM.............................................64
XYZAL .............................................19
Y
YERVOY ...........................................26
YODOXIN .......................................... 2
Z
zafirlukast ......................................... 9
zaleplon ...........................................54
ZALTRAP..........................................25
ZANAFLEX ........................................58
ZANOSAR ........................................25
ZANTAC ...........................................68
ZARONTIN .......................................13
ZAROXOLYN .....................................47
ZARXIO ...........................................53
ZEBETA ...........................................35
ZELAPAR..........................................30
ZELBORAF .......................................28
ZEMPLAR .........................................48
ZENPEP ...........................................46
ZERIT ..............................................32
ZESTORETIC ....................................23
ZESTRIL ..........................................21
ZETIA ..............................................21
ZETONNA.........................................58
ZIAC ...............................................23
ZIAGEN ...........................................33
zidovudine .......................................33
ZIOPTAN..........................................62
ziprasidone hcl .................................30
ZIRGAN ...........................................60
ZITHROMAX .....................................55
ZITHROMAX TRI-PAK.........................55
ZITHROMAX Z-PAK ...........................55
ZMAX ..............................................55
ZOCOR ........................................... 21
ZOFRAN .......................................... 18
ZOFRAN ODT ................................... 18
ZOHYDRO ER ..................................... 5
ZOLADEX ........................................ 26
zoledronic acid ................................. 48
ZOLEDRONIC ACID........................... 48
ZOLINZA ......................................... 28
zolmitriptan ..................................... 56
ZOLOFT .......................................... 14
zolpidem tartrate ............................. 54
ZOMETA .......................................... 48
ZOMIG ............................................ 56
ZOMIG ZMT ..................................... 56
ZONEGRAN...................................... 12
zonisamide ...................................... 12
ZONTIVITY ...................................... 53
ZORBTIVE ....................................... 48
ZORTRESS ...................................... 34
ZOVIRAX .................................... 33, 43
ZUBSOLV .......................................... 6
ZYBAN ............................................ 66
ZYCLARA ......................................... 45
ZYCLARA PUMP ................................ 45
ZYDELIG ......................................... 28
ZYKADIA ......................................... 28
ZYLET ............................................. 61
ZYLOPRIM ....................................... 52
ZYMAXID ........................................ 60
ZYPREXA ......................................... 31
ZYPREXA RELPREVV ......................... 31
ZYPREXA ZYDIS ............................... 31
ZYTIGA ........................................... 26
ZYVOX .............................................. 8
97
Apéndice: Límites a la cantidad*
Generic name
Brand name
Limitation
Abatacept
Acamprosate
Acetaminophen
Orencia
Campral
Tylenol
4 vials/syringes per 28 days
6 tablets per day
4 gm acetaminophen per day
Acetaminophen w/ Codeine
Acitretin
Acyclovir Cream
Adalimumab
Adalimumab
Alendronate 10 mg
Alendronate 35 mg
Alendronate 40 mg
Alendronate 5 mg
Alendronate 70 mg
Alendronate/ Cholecalciferol
Alirocumab
Aliskerin
Aliskerin/Amlodipine
Aliskerin/Amlodipine/HCTZ
Aliskerin/HCTZ
Almotriptan
Alogliptin
Alogliptin/metformin
Alogliptin/pioglitazone
Alosetron
Ambrisentan
Amlodipine/Atorvastatin
Amlodipine/Olmesartan
Amlodipine/Olmesartan/HCTZ
Amlodipine/Valsartan
Amlodipine/Valsartan/HCTZ
Amphetamine/
Dextroamphetamine IR
Amphetamine/
Dextroamphetamine XR
Anakinra
Apixaban
Apomorphine
Apremilast
Aprepitant
Aripiprazole Intramuscular Suspension
Aripiprazole Oral Solution
Aripiprazole tablets
Armodafinil 150 mg and 250 mg
Armodafinil 50 mg
Artemether/Lumefantrine
Asenapine
Tylenol w/ Codeine
Soriatane
Zovirax Cream
Humira
Humira
Fosamax
Fosamax
Fosamax
Fosamax
Fosamax
Fosamax-D
Praluent
Tekturna
Tekamlo
Amturnide
Tekturna HCT
Axert
Nesina
Kazano
Oseni
Lotronex
Letairis
Caduet
Azor
Tribenzor
Exforge
Exforge HCT
360 mg codeine per day
2 capsules per day
5 gm tube per Rx
2 syringes per 28 days
Starter Kit: 1 per life of plan
1 tablet per day
4 tablets per 28 days
1 tablet per 6 months
1 tablet per day
4 tablets per 28 days
4 tablets per 28 days
2 pens/syringes per 28 days
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
9 tablets per 30 days
1 tablet per day
2 tablets per day
1 tablet per day
2 tablets per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
1 tablet per day
Adderall
3 tablets per day
Adderall XR
Kineret
Eliquis
Apokyn
Otezla
Emend
Abilify Maintena
Abilify
Abilify
Nuvigil
Nuvigil
Coartem
Saphris
2 capsules per day
1 (100 mg) vial daily
2 tablets per day
15 cartridges (450 mg) per 30 days
2 tablets per day
6 capsules per Rx
1 vial per 28 days
25 mL per day
1 tablet per day
1 tablet per day
2 tablets per day
24 tablets per 30 days
2 tablets per day
Generic name
Brand name
Limitation
Asfotase alfa
Atomoxetine
Azelaic Acid 15% Gel
Azelaic Acid 20% Cream
Azithromycin
Benazepril/Amlodipine
Benzyl Alcohol 5% Lotion
Blood Glucose Meters
Blood Glucose Meters
Blood Glucose Test Strips
Blood Glucose Test Strips
Blood Ketone Test Strips
Bosentan
Buprenorphine Buccal Film
Buprenorphine Trandermal
Buprenorphine/Naloxone 4.2 mg/0.7 mg
Buccal Film
Buprenorphine/Naloxone 1.4 mg/0.36 mg
SL Tablet
Buprenorphine/Naloxone 11.4 mg/2.9 mg
SL Tablet
Buprenorphine/Naloxone 12 mg/3 mg SL
Film
Buprenorphine/Naloxone 2 mg/0.5 mg SL
Film
Buprenorphine/Naloxone 2 mg/0.5 mg SL
Tablet
Buprenorphine/Naloxone 2.1 mg/0.3 mg
Buccal Film
Buprenorphine/Naloxone 2.9 mg/0.71 mg
SL Tablet
Buprenorphine/Naloxone 4 mg/1 mg SL
Film
Buprenorphine/Naloxone 5.7 mg/1.4 mg SL
Tablet
Buprenorphine/Naloxone 6.3 mg/1 mg
Buccal Film
Buprenorphine/Naloxone 8 mg/2 mg SL
Film
Buprenorphine/Naloxone 8 mg/2 mg SL
Tablet
Buprenorphine/Naloxone 8.6 mg/2.1 mg SL
Tablet
Butalbital/Acetaminophen 50 mg/325 mg
Tablets
Butalbital/Acetaminophen 50 mg/650 mg
Capsules
Butalbital/Acetaminophen/
Strensiq
Strattera
Finacea
Azelex
AzaSite
Lotrel
Ulesfia
Freestyle
Precision
Freestyle
Precision
Precision Xtra Test Strips
Tracleer
Belbuca
Butrans
Zubsolv
24 vials per 28 days
2 capsules per day
50 gm per Rx
30 gm per Rx
2.5 mL per Rx
1 capsule per day
12 bottles per Rx
2 meters per year
2 meters per year
5 strips per day
5 strips per day
20 strips per 30 days
2 tablets per day
2 units per day
4 patches per 28 days
32 mg/day for 6 months, then 2 films per day
for maintenance dosing
32 mg/day for 6 months, then 2 tablets per day
for maintenance dosing
32 mg/day for 6 months, then 1 tablet per day
for maintenance dosing
32 mg/day for 6 months, then 1 strip per day
for maintenance dosing
32 mg/day for 6 months, then 3 strips per day
for maintenance dosing
32 mg/day for 6 months, then 3 tablets per day
for maintenance dosing
32 mg/day for 6 months, then 1 film per day
for maintenance dosing
32 mg/day for 6 months, then 2 tablets per day
for maintenance dosing
32 mg/day for 6 months, then 1 strip per day
for maintenance dosing
32 mg/day for 6 months, then 2 tablets per day
for maintenance dosing
32 mg/day for 6 months, then 1 film per day
for maintenance dosing
32 mg/day for 6 months, then 2 strips per day
for maintenance dosing
32 mg/day for 6 months, then 2 tablets per day
for maintenance dosing
32 mg/day for 6 months, then 1 tablet per day
for maintenance dosing
Phrenilin
6 tablets per day
Phrenilin Forte
Esgic
6 capsules per day
6 tablets or capsules per day; 90 mL per day
Bunavail
Zubsolv
Zubsolv
Suboxone Film
Suboxone Film
Buprenorphine/Naloxone
Bunavail
Zubsolv
Suboxone Film
Zubsolv
Bunavail
Suboxone Film
Buprenorphine/Naloxone
Generic name
Caffeine 50 mg/325 mg/40 mg
Butalbital/Acetaminophen/
Caffeine 50 mg/500 mg/40 mg
Butalbital/Acetaminophen/
Caffeine/Codeine 50 mg/325 mg/40 mg/30
mg
Butalbital/Aspirin/Caffeine 50 mg/325
mg/40 mg
Butalbital/Aspirin/Caffeine/Codeine 50
mg/325 mg/40 mg/30 mg
Canagliflozin 100 mg
Canagliflozin 300 mg
Canagliflozin/metformin
Carvedilol
Celecoxib
Certolizumab
Clindamycin 1%/ Benzoyl Peroxide 5%
Clobazam
Clonidine HCl ER
Clozapine Oral Dispersible Tablet
Codeine
Collagenase
Cyclopentolate
Cyclosporine Ophthalmic Emulsion
Dabigatran
Daclatasvir
Dalfampridine
Dapagliflozin
Dapsone Gel 5%
Darbepoetin
Denosumab
Denosumab
Desirudin
Dexmethylphenidate HCl IR
Dexmethylphenidate HCl XR
Dextroamphetamine Sulfate ER
Dextroamphetamine Sulfate IR
Dextroamphetamine Sulfate Soln
Diazepam
Diazepam
Diclofenac 1% Gel
Diclofenac 1.3% Patch
Diclofenac 3% Gel
Dihydrocodeine 16 mg/Acetaminophen
356 mg/Caffeine 30 mg
Dihydrocodeine 32 mg/Acetaminophen
712 mg/Caffeine 60 mg
Brand name
Limitation
Zebutal
6 tablets or capsules per day
Butalbital/Acetaminophen
/Caffeine/Codeine
6 capsules per day
Fiorinal
6 capsules per day
Fiorinal w/Codeine
Invokana
Invokana
Invokamet
Coreg CR
Celebrex
Cimzia
Clindamycin/ Benzoyl
Peroxide
Onfi
Kapvay
FazaClo
Codeine
Santyl
Cyclogyl
Restasis
Pradaxa
Daklinza
Ampyra
Farxiga
Aczone
Aranesp
Prolia
Xgeva
Iprivask
Focalin
Focalin XR
Dexedrine ER
Dexedrine IR
ProCentra
Diastat
Diastat AcuDial
Voltaren Gel
Flector
Solaraze
6 capsules per day
1 tablet per day
2 tablets per day
2 tablets per day
1 tablet per day
2 tablets per day
2 injections per 28 days
Trezix
10 capsules per day
Panlor SS
5 tablets per day
50 gm per 30 days
2 tablets per day
2 tablets per day
2 tablets per day
360 mg codeine per day
30 gm per Rx
2 mL per 30 days
60 vials per Rx
2 tablets per day
1 tablet per day
2 tablets per day
1 tablet per day
30 gm per 30 days
4 mL per 30 days
1 vial/syringe per 180 days
1 vial per 30 days
24 vials for 12 days
2 tablets per day
1 capsule per day
3 capsules per day
3 tablets per day
40 mL per day
1 twin pack (2 doses) per Rx
1 twin pack (2 doses) per Rx
32 gm per day
2 patches per day for 3 months
1 tube per Rx; 90-day supply per year
Generic name
Brand name
Limitation
Dihydroergotamine
Dihydroergotamine 1 mg/mL
Dihydroergotamine 4 mg/mL
Dimethyl Fumarate
Dipyridamole/Aspirin
Dolasetron 100 mg Tablet
Dolasetron 20 mg/mL IV Soln
Dolasetron 50 mg Tablet
Doxepin Cream
Duloxetine 20 mg and 60 mg
Duloxetine 30 mg
Dutasteride
Dutasteride/Tamsulosin
Eletriptan
Eliglustat
Epineprhine Auto-injectors
Eplerenone
Epoprostenol
Migranal
D.H.E. 45
Migranal Nasal
Tecfidera
Aggrenox
Anzemet
Anzemet
Anzemet
Prudoxin
Cymbalta
Cymbalta
Avodart
Jalyn
Relpax
Cerdelga
EpiPen
Inspra
Flolan
Erythromycin/Benzoyl
Peroxide
Lunesta
Enbrel
Enbrel
Repatha
Zetia
Vytorin
Uloric
Antara
Fenoglide
Lipofen
Lofibra
Tricor
Triglide
Trilipix
Fibricor
Onsolis
Fentora
Actiq
Lazanda
Duragesic
Subsys
Dificid
Gilenya
Prozac Weekly
Breo Ellipta
Lescol
Lescol XL
Luvox CR
1 pack (4) per 30 days
1 pack (4) per 30 days
1 package of 8 units per 30 days
2 tablets per day
2 tablets per day
5 tablets per Rx
1 box or 25 mL per Rx
10 tablets per Rx
45 gm per Rx
2 capsules per day
1 capsule per day
1 tablet per day
1 tablet per day
9 tablets per 30 days
1 capsule per day
2 vials/syringes per Rx
2 tablets per day
4 (0.5 mg) vials or 2 (1.5 mg) vials per 30 days
Erythromycin/Benzoyl Peroxide
Eszopiclone
Etancercept 25 mg/0.5 mL
Etancercept 50 mg/mL
Evolocumab
Ezetimibe
Ezetimibe/Simvastatin
Febuxostat
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibrate
Fenofibric Acid
Fentanyl Buccal Film
Fentanyl Buccal Tablet
Fentanyl Lozenge
Fentanyl Nasal Spray
Fentanyl Patch
Fentanyl Sublingual Spray
Fidaxomicin
Fingolimod
Fluoxetine 90 mg Delayed-Release Capsule
Fluticasone/Vilanterol
Fluvastatin
Fluvastatin
Fluvoxamine
23 gm per 30 days
1 tablet per day
8 syringes per 28 days
4 syringes per 28 days
2 pens/syringes per 28 days
1 tablet per day
1 tablet per day
1 tablet per day
1 capsule per day
1 tablet per day
1 capsule per day
1 tablet/capsule per day
1 tablet per day
1 tablet per day
1 capsule per day
1 tablet per day
4 films per day
4 tablets per day
4 lozenges per day
4 sprays per day
75 mcg per hr
4 sprays per day
20 tablets per Rx
1 tablet per 30 days
4 capsules per 28 days
1 inhaler per 30 days
1 tablet per day
1 tablet per day
1 capsule per day
Generic name
Brand name
Limitation
Fosaprepitant
Frovatriptan
Gabapentin 300 mg & 600 mg Tablet
Gabapentin Enacarbil 300 mg & 600 mg ER
Tablets
Golimumab
Golimumab
Goserelin 10.8 mg
Goserelin 3.6 mg
Granisetron Oral Solution
Granisetron Tablet
Guanfacine ER
Hexachlorophene
Hydrocodone
Hydrocodone Extended-Release
Emend Injection
Frova
Gralise
2 vials per Rx
9 tablets per 30 days
3 tablets per day
Horizant
Simponi
Simponi Aria
Zoladex
Zoladex
Kytril
Kytril
Intuniv
Phisohex
Hydrocodone
Zohydro ER
Hydrocodon/
Acetaminophen
Reprexain; Vicoprofen
Exalgo
Dilaudid
Makena
Boniva
Boniva
Boniva
Fanapt
Ventavis
Zyclara
Arcapta
Picato
2 tablets per day
1 syringe per 28 days
5 vials per 8 weeks
1 implant per 3 months for 1 year
1 implant per 28 days for 1 year
70 mL per Rx
14 tablets per Rx
1 tablet per day
148 mL per Rx
240 mg hydrocodone per day
120 mg hydrocodone per day
Vicodin, Vicodin ES, Vicodin HP not covered;
4 gm acetaminophen per day
5 tablets per day
64 mg hydromorphone per day
120 mg hydromorphone per day
1 vial per 35 days
1 tablet per 28 days
1 tablet per day
3 mL per 3 months
2 tablets per day
9 vials per day
2 pumps per day or 28 packets per 14 days for
up to 2 months
1 inhaler per 30 days
1 box per Rx for a single treatment course
Midrin, Nodolor
Amnesteem
Claravis
Myorisan
Sotret
Kalydeco
Kalydeco
Toradol
Toradol Injection
Sprix
Vimpat
Vimpat
10 capsules per day
2 tablets per day for up to 5 months
2 tablets per day for up to 5 months
2 tablets per day for up to 5 months
2 tablets per day for up to 5 months
2 tablets per day
2 packets per day
20 tablets per 30 days
120 mg per day; 5 days per Rx
4 units per day for up to 5 days
2 tablets per day
40 mL per day
Lamictal
3 tablets per day
Lamictal
Lamictal XR
6 tablets per day
3 tablets per day
Hydrocodone/Acetaminophen
Hydrocodone/Ibuprofen
Hydromorphone Extended-Release
Hydromorphone Immediate-Release
Hydroxyprogesterone Caproate
Ibandronate 150 mg Tablet
Ibandronate 2.5 mg Tablet
Ibandronate 3 mg/3 mL
Iloperidone
Iloprost
Imiquimod
Indacaterol
Ingenol
Isometheptene/Dichloralphenazone/Acetaminophen
Isotretinoin
Isotretinoin
Isotretinoin
Isotretinoin
Ivacaftor
Ivacaftor
Ketorolac
Ketorolac
Ketorolac Nasal Spray
Lacosamide
Lacosamide Oral Solution
Lamotrigine 100 mg & 150 mg ImmediateRelease Tablets
Lamotrigine 25 mg Immediate-Release
Tablets
Lamotrigine ER Tablets
Generic name
Brand name
Limitation
Lamotrigine Immediate-Release 5 mg
Lanreotide
Levetiracetam 500 mg ER Tablets
Levetiracetam 750 mg ER Tablets
Levofloxacin 0.5% Solution
Levomilnacipran
Linaclotide
Linagliptin
Linagliptin/Metformin
Linezolid
Lisdexamfetamine
Lomitamide
Lotedrepnol/Tobramycin Ophth Susp
Lubiprostone
Lumacaftor/Ivacaftor
Lurasidone
Meperidine
Mesalamine DR
Metaxalone
Methadone
Methamphetamine HCl
Methoxy polyethylene glycol-epoetin beta
Methylphenidate HCl ER
Methylphenidate HCl ER
Methylphenidate HCl ER 10 mg, 20 mg, 40
mg
Methylphenidate HCl ER 18 mg, 27 mg, 54
mg
Methylphenidate HCl ER 20 mg
Methylphenidate HCl ER 30 mg
Methylphenidate HCl ER 36 mg
Methylphenidate HCl ER Chewable Tablet
Methylphenidate HCl IR
Methylphenidate HCl Solution
Methylphenidate HCl Suspension
Methylphenidate Transdermal
Metreleptin
Milnacipran
Mipomersen
Modafinil
Montelukast
Morphine ER
Morphine ER
Morphine IR
Morphine sulfate ER/Naltrexone
Mupirocin Cream
Naloxone Injection Solution
Naloxone Nasal Spray
Lamictal
Somatuline
Keppra XR
Keppra XR
Iquix
Fetzima
Linzess
Tradjenta
Jentadueto
Zyvox
Vyvanse
Juxtapid
Zylet
Amitiza
Orkambi
Latuda
Demerol
Lialda
Skelaxin
Methadose
Desoxyn
Mircera
Metadate CD
Ritalin SR
6 tablets per day
1 syringe per 28 days
6 tablets per day; up to 3 gm per day
4 tablets per day; up to 3 gm per day
5 mL per 30 days
1 tablet per day
1 tablet per day
1 tablet per day
2 tablets per day
1.2 gm/day for 14 days, then PA
1 capsule per day
1 capsule per day
5 mL per 30 days
2 tablets per day
4 tablets per day
1 tablet per day
1,200 mg meperidine per day
4 tablets per day
4 tablets per day
60 mg methadone per day
5 tablets per day
2 prefilled syringes/28 days
1 capsule per day
1 tablet per day
Ritalin LA
1 capsule per day
Concerta
Metadate ER
Ritalin LA
Concerta
Quillichew ER
Ritalin
Methylin solution
Quillivant XR suspension
Daytrana
Myalept
Savella
Kynamro
Provigil
Singulair
Avinza
Kadian
MSIR
Embeda
Bactroban
Naloxone (generic)
Narcan
1 tablet per day
1 tablet per day
2 capsules per day
2 tablets per day
1 tablet per day
3 tablets per day
30 mL per day
12 mL per day
1 patch per day
1 vial per day
2 tablets per day
4 tablets per 28 days
1 tablet per day
1 tablet per day
240 mg morphine per day
240 mg morphine per day
240 mg morphine per day
240 mg morphine per day
30 gm per Rx
2 vials per Rx
2 units per Rx, 4 units per 30 days
Generic name
Brand name
Limitation
Naltrexone
Nandrolone Decanoate
Naratriptan
Natalizumab
Nebivolol
Netupitant/palonosetron
Niacin ER/Simvastatin
Nintedanib
Octreotide Immediate-Release
Octreotide LAR depot
Olanzapine
Olanzapine
Olanzapine 210 mg and 300 mg
Olanzapine 405 mg
Olanzapine/Fluoxetine
Omalizumab
Omega-3 Ethyl Esters
Ondansetron HCl
Ondansetron HCl
Ondansetron HCl
Oral Bowel Evacuation Tablets
Oseltamivir
Oseltamivir 30 mg Capsules
Oseltamivir 45 mg and 75 mg Capsules
Osimertinib
Oxandrolone
Oxcarbazepine 150 mg and 300 mg ER
Tablets
Oxcarbazepine 600 mg ER Tablets
Oxycodone Controlled-Release
Oxycodone Immediate-Release
Oxycodone Controlled-Release
Vivitrol
Nandrolone
Amerge Tabs
Tysabri
Bystolic
Akynzeo
Simcor
Ofev
Sandostatin
Sandostatin
Zyprexa
Zyprexa Zydis
Zyprexa Relprevv
Zyprexa Relprevv
Symbyax
Xolair
Lovaza
Zofran ODT
Zofran Solution
Zofran Tablet
OsmoPrep
Tamiflu
Tamiflu
Tamiflu
Tagrisso 40 mg
Oxandrin
1 vial per 28 days
4 tablets per 28 days
9 tablets per 30 days
1 (300 mg) vial per 28 days
1 tablet per day
1 capsule/Rx; Maximum: 3 capsules/28 days
1 tablet per day
2 capsules per day
1 multi-dose vial or 3 single-dose vials per day
1 vial per 28 days
1 tablet per day
1 tablet per day
2 vials per 28 days
1 vial per 28 days
1 capsule per day
6 (150 mg) vials per 28 days
4 capsules per day
21 tablets per Rx
105 mL per Rx
21 tablets per Rx
32 tablets per Rx
Suspension: 180 mL per Rx; 2 Rxs per year
20 capsules per Rx; 2 Rxs per year
10 capsules per Rx; 2 Rxs per year
1 tablet per day
8 tablets (20 mg) per day
Oxtellar XR
Oxtellar XR
Oxycontin
Oxycodone
OxyContin
Oxycodone/Acetaminophen
Percocet
Oxycodone/Acetaminophen
Oxycodone/Ibuprofen
Oxymorphone ER
Oxymorphone Immediate-Release
Paliperidone
Paliperidone Inj
Palivizumab
Palonosetron 0.25 mg/5 mL Solution
Paroxetine
Pasireotide
Peg-interferon alfa-2a
Peg-interferon alfa-2b
Pegvisomant
Tylox
Oxycodone/Ibuprofen
Opana ER
Opana
Invega
Invega Sustenna
Synagis
Aloxi Injection
Paxil CR
Signifor
Pegasys
PegIntron
Somavert
1 tablet per day
4 tablets per day
3 tablets per day; 160 mg oxycodone per day
160 mg oxycodone per day
3 tablets per day
4 gm acetaminophen or 160 mg oxycodone per
day
4 gm acetaminophen or 160 mg oxycodone per
day
4 tablets per day
80 mg oxymorphone per day
80 mg oxymorphone per day
1 tablet per day
1 vial per month; 2 vials for 1st month
5 doses per season
1 box or 20 mL per Rx
1 tablet per day
2 mL per day
4 units per 28 days
4 units per 28 days
1 vial per day
Generic name
Brand name
Limitation
Penciclovir Cream
Pimecrolimus
Pirfenidone
Pitavastatin
Denavir
Elidel
Esbriet
Livalo
Oralair, Grastek,
Ragwitek
Lyrica
Seroquel
Seroquel XR
Seroquel XR
Qualaquin
Isentress
Rozerem
Ranexa
Altabax
Copegus, Rebetol
Xifaxan
Xifaxan
Actonel
Actonel
Actonel
Atelvia
Actonel
Actonel
Risperdal
Risperdal Consta
Xarelto
Maxalt
Crestor
Neupro
Onglyza
Isopto Hyoscine
Zelapar
Emsam
Revatio Injection
Revatio tablets
Rapaflo
Januvia
Janumet
Janumet XR
Xyrem
Spacers
Natroba
Imitrex Injection
Sumavel DosePro
Alsuma
Zembrace Symtouch
Onzetra Xsail
5 gm tube per Rx
100 gm per 30 days
9 capsules per day
1 tablet per day
Pollen allergen extract
Pregabalin
Quetiapine
Quetiapine 150 mg, 200 mg ER
Quetiapine 50 mg, 300 mg, 400 mg ER
Quinine Sulfate
Raltegravir
Ramelteon
Ranolazine
Retapamulin
Ribavirin 200 mg
Rifaximin 200 mg
Rifaximin 550 mg
Risedronate 150 mg
Risedronate 30 mg
Risedronate 35 mg
Risedronate 35 mg DR
Risedronate 5 mg
Risedronate 75 mg
Risperidone
Risperidone Injection
Rivaroxaban
Rizatriptan
Rosuvastatin
Rotigotine
Saxagliptin
Scopolamine
Selegiline ODT
Selegiline Transdermal
Sildenafil 10 mg/12.5 mL
Sildenafil 20 mg
Silodosin
Sitagliptin
Sitagliptin/Metformin
Sitagliptin/Metformin ER
Sodium Oxybate
Spacers
Spinosad
Sumatriptan
Sumatriptan 6 mg/0.5 mL
Sumatriptan 6 mg/0.5 mL Pen Inj.
Sumatriptan 3 mg/0.5 mL Injection
Sumatriptan Nasal Powder
1 tablet per day
2 capsules per day or 30 mL per day
3 tablets per day
1 tablet per day
2 tablets per day
1 capsule per day or 42 capsules per 7 days
2 packets per day
1 tablet per day
2 tablets per day
15 gm per Rx
7 tablets per day
9 tablets per 30 days
6 tablets per 30 days
1 tablet per 30 days
1 tablet per day for 2 months
4 tablets per 28 days
4 tablets per 28 days
1 tablet per day
2 tablets per 30 days
2 tablets per day
2 injections per 28 days
1 tablet per day or 42 tablets per 21 days
9 tablets per 30 days
1 tablet per day
1 patch per day
1 tablet per day
5 mL per 30 days
2 tablets per day
1 patch per day
3 vials per day
3 tablets per day
1 capsule per day
1 tablet per day
2 tablets per day
1 tablet per day
18 mL per day
2 spacers per 365 days
120 mL per Rx
5 vials per 30 days
5 syringes per 30 days
5 syringes per 30 days
4 pens per 30 days
8 units per 30 days
Generic name
Brand name
Limitation
Sumatriptan Nasal Spray
Sumatriptan Tablets
Sumatriptan/Naproxen
Suvorexant
Tacrolimus
Tacrolimus ER Capsules
Tadalafil
Tadalafil 5 mg Tablet
Tasimelteon
Tedizolid phosphate
Teduglutide
Terbinafine Granules
Terbinafine Tablets
Teriflunomide
Teriparatide
Tetrabenazine 12.5 mg
Tetrabenazine 25 mg
Ticagrelor
Tiludronate 200 mg
Tobramycin Inhaler
Tobramycin/Loteprednol
Tocilizumab 162 mg/0.9 mL
Tocilizumab 200 mg/10 mL
Tocilizumab 400 mg/20 mL
Tocilizumab 80 mg/4 mL
Tofacitinib
Tocfacitinib Extended-release
Tolcapone
Tolvaptan 15 mg
Tolvaptan 30 mg
Topiramate 25 mg Immediate-Release
Tablets
Topiramate 50 mg & 100 mg ImmediateRelease Tablets
Tramadol
Tramadol 24HR
Tramadol/Acetaminophen
Ustekinumab
Vancomycin
Varenicline
Vedolizumab
Vigabatrin
Vilazodone
Voriconazole
Vortioxetine
Zaleplon
Zanamivir
Ziprasidone
Imitrex Nasal Spray
Imitrex
Treximet
Belsomra
Protopic
Astagraf XL
Adcirca
Cialis
Hetlioz
Sivextro
Gattex
Lamisil Granules
Lamisil Tablets
Aubagio
Forteo
Xenazine
Xenazine
Brilinta
Skelid
Tobi Podhaler
Zylet
Actemra
Actemra
Actemra
Actemra
Xeljanz
Xeljanz XR
Tasmar
Samsca
Samsca
6 units per 30 days
9 tablets per 30 days
9 tablets per 30 days
30 tablets/30 days
1 (30 gm or 60 gm) tube per Rx
1 capsule per day
2 tablets per day
1 tablet per day
1 capsule per day
6 tablets per 365 days
1 kit per day
2 packets per day for 6 weeks
1 tablet per day; 90 tablets per 365 days
1 tablet per day
1 vial per 30 days
8 tablets per day
4 tablets per day
2 tablets per day
2 tablets per day for 3 months
1 unit per 60 days
5 mL per 30 days
4 syringes per 28 days
4 vials per 28 days
2 vials per 28 days
10 vials per 28 days
2 tablets per day
1 tablet per day
6 tablets per day
1 tablet per day
2 tablets per day
Topamax
6 tablets or capsules per day
Topamax
Ultram
Ultram ER
Ultracet
Stelara
Vancomycin
Chantix
Entyvio
Sabril
Viibryd
Vfend
Brintellix
Sonata
Relenza
Geodon
3 tablets per day
8 tablets per day
1 tablet per day
8 tablets per day
1 syringe per 28 days
40 capsules per 10 days
2 tablets per day
1 vial every 8 weeks
6 tablets per day
1 tablet per day
6 tablets per day
1 tablet per day
1 capsule per day
20 blisters per Rx; 2 Rxs per year
2 capsules per day
Generic name
Brand name
Limitation
Zoledronic Acid
Zoledronic Acid
Zolmitriptan
Zolmitriptan
Zolpidem ER Capsules
Zolpidem Immediate-Release
Zolpidem SL Tablets
Zolpidem, Oral Spray
Reclast
Zometa
Zomig Nasal
Zomig Tabs
Ambien CR
Ambien CR
Edluar
Zolpimist
1 (100 mL) vial per year
1 (4 mg/5 mL) per 21 days
6 units per 30 days
9 tablets per 30 days
1 capsule per day
1 tablet per day
1 tablet per day
7.7 mL per 30 days