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Eli Lilly 2019 Formulary (List of Covered Drugs)Lilly - Lilly Formulary Page 1 of 180 Updated...

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Lilly - Lilly Formulary Page 1 of 180 Updated 09/2018 Eli Lilly 2019 Formulary (List of Covered Drugs)
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Page 1: Eli Lilly 2019 Formulary (List of Covered Drugs)Lilly - Lilly Formulary Page 1 of 180 Updated 09/2018 Eli Lilly 2019 Formulary (List of Covered Drugs)File Size: 1MBPage Count: 180

Lilly - Lilly Formulary Page 1 of 180

Updated 09/2018

Eli Lilly

2019 Formulary

(List of Covered Drugs)

Page 2: Eli Lilly 2019 Formulary (List of Covered Drugs)Lilly - Lilly Formulary Page 1 of 180 Updated 09/2018 Eli Lilly 2019 Formulary (List of Covered Drugs)File Size: 1MBPage Count: 180

Lilly - Lilly Formulary

Page 2 of 180 Updated 09/2018

PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

Therapeutic Class [Clase Terapéutica]

5-ALPHA-REDUCTASE INHIBITORS [INHIBIDORES DE LA 5-ALFA-REDUCTASA]

5-alpha-reductase Inhibitors [Inhibidores De La 5-Alfa-Reductasa]

AVODART 0.5 mg cap 3

dutasteride 0.5 mg cap 1 AVODART

dutasteride-tamsulosin hcl 0.5-0.4 mg cap 1 JALYN

finasteride 5 mg tab 1 PROSCAR

JALYN 0.5-0.4 mg cap 3

PROSCAR 5 mg tab 3

ADRENALS [ADRENALES]

Adrenals [Adrenales]

active injection kl-3 40-1 mg/ml-% cmb kit 1

active injection km 40-0.5 mg/ml-% inj kit 1

ALVESCO 160 mcg/act inh aer soln, 80 mcg/act inh aer soln 3

ASMANEX 120 METERED DOSES 220 mcg/inh inh aer pwdr br act 3

ASMANEX 14 METERED DOSES 220 mcg/inh inh aer pwdr br act 3

ASMANEX 30 METERED DOSES 110 mcg/inh inh aer pwdr br act, 220 mcg/inh inh aer pwdr br act 3

ASMANEX 60 METERED DOSES 220 mcg/inh inh aer pwdr br act 3

ASMANEX 7 METERED DOSES 110 mcg/inh inh aer pwdr br act 3

ASMANEX HFA 100 mcg/act inh aer, 200 mcg/act inh aer 3

betamethasone sod phos & acet 6 (3-3) mg/ml inj susp 1

BREO ELLIPTA 100-25 mcg/inh inh aer pwdr br act, 200-25 mcg/inh inh aer pwdr br act 3

bt injection 40 & 0.5 mg/ml-% inj kit 1

budesonide 3 mg cap dr prt 1 ENTOCORT PA

budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp, 1 mg/2ml inh susp 1 PULMICORT

budesonide er 9 mg tab er 24 hr 1 PA

bupivilog 40 & 0.5 mg/ml-% inj kit 1

CELESTONE SOLUSPAN 6 (3-3) mg/ml inj susp 3

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Lilly - Lilly Formulary

Page 3 of 180 Updated 09/2018

PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CORTEF 10 mg tab, 20 mg tab, 5 mg tab 3

cortisone acetate 25 mg tab 1 CORTONE

DEPO-MEDROL 20 mg/ml inj susp, 40 mg/ml inj susp, 80 mg/ml inj susp 3

dexamethasone 1 mg tab, 1.5 mg (21) tab pack, 1.5 mg (35) tab pack, 1.5 mg (51) tab pack, 2 mg tab 1

dexamethasone 0.5 mg/5ml soln 1

dexamethasone 0.5 mg/5ml oral elix 1 BAYCADRON

dexamethasone 0.5 mg tab, 0.75 mg tab, 1.5 mg tab, 4 mg tab, 6 mg tab 1 DECADRON

DEXAMETHASONE INTENSOL 1 mg/ml oral conc 3

dexamethasone sod phosphate pf 10 mg/ml inj soln 1

dexamethasone sodium phosphate 100 mg/10ml inj soln, 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln 1

dexamethasone sodium phosphate 10 mg/ml inj soln 1 HEXADROL

DEXPAK 10 DAY 1.5 mg (35) tab pack 3

DEXPAK 13 DAY 1.5 mg (51) tab pack 3

DEXPAK 6 DAY 1.5 mg (21) tab pack 3

DULERA 100-5 mcg/act inh aer, 200-5 mcg/act inh aer 3

ENTOCORT EC 3 mg cap dr prt 3 PA

FLOVENT DISKUS 100 mcg/blist inh aer pwdr br act, 250 mcg/blist inh aer pwdr br act, 50 mcg/blist inh aer pwdr br act 3

FLOVENT HFA 110 mcg/act inh aer, 220 mcg/act inh aer, 44 mcg/act inh aer 3

fludrocortisone acetate 0.1 mg tab 1 FLORINEF

fluticasone-salmeterol 113-14 mcg/act inh aer pwdr br act, 232-14 mcg/act inh aer pwdr br act, 55-14 mcg/act inh aer pwdr br act 1 AIRDUO

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab 1 CORTEF

jtt physicians 40-1 mg/ml-% cmb kit 1

KENALOG 10 mg/ml inj susp, 40 mg/ml inj susp 3

lidolog 40 & 2 mg/ml-% inj kit 1

MEDROL 16 mg tab, 2 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 3

methylprednisolone 16 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 1 MEDROL

methylprednisolone acetate 40 mg/ml inj susp, 80 mg/ml inj susp 1 DEPO-MEDROL

methylprednisolone sodium succ 1000 mg inj soln, 125 mg inj soln, 40 mg inj soln 1 SOLU-MEDROL

MILLIPRED 5 mg tab 3

MILLIPRED 10 mg/5ml soln 3

MILLIPRED DP 5 mg (21) tab pack, 5 mg (48) tab pack 3

MILLIPRED DP 12-DAY 5 mg (48) tab pack 3

mlk f1 40 & 0.5 & 2 mg/ml-%-% inj kit 1

mlk f2 40 & 0.5 & 2 mg/ml-%-% inj kit 1

mlk f3 40 & 0.5 & 2 mg/ml-%-% inj kit 1

mlp a-1 40 & 0.5 & 2 mg/ml-%-% inj kit 1

multi-specialty 40 & 1 mg/ml-% inj kit 1

ORAPRED ODT 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 3

PEDIAPRED 6.7 (5 Base) mg/5ml soln 3

physicians ez use joint/tunnel 40-1 mg/ml-% cmb kit 1

physicians ez use m-pred 40-0.5 mg/ml-% inj kit 1

prednisolone 15 mg/5ml soln, 15 mg/5ml syr 1 PRELONE

prednisolone sodium phosphate 25 mg/5ml soln 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

prednisolone sodium phosphate 10 mg/5ml soln 1 MILLIPRED

prednisolone sodium phosphate 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 1 ORAPRED

prednisolone sodium phosphate 15 mg/5ml soln 1 ORAPRED

prednisolone sodium phosphate 6.7 (5 Base) mg/5ml soln 1 PEDIAPRED

prednisolone sodium phosphate 20 mg/5ml soln 1 VERIPRED

prednisone 1 mg tab, 10 mg (21) tab pack, 10 mg (48) tab pack, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg (21) tab pack, 5 mg (48) tab pack, 5 mg tab, 50 mg tab 1

prednisone 5 mg/5ml soln 1

PREDNISONE INTENSOL 5 mg/ml oral conc 3

PULMICORT 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp, 1 mg/2ml inh susp 3

PULMICORT FLEXHALER 180 mcg/act inh aer pwdr br act, 90 mcg/act inh aer pwdr br act 3

QVAR 40 mcg/act inh aer soln, 80 mcg/act inh aer soln 3

QVAR REDIHALER 40 mcg/act inh aer br act, 80 mcg/act inh aer br act 3

RAYOS 1 mg tab dr, 2 mg tab dr, 5 mg tab dr 3

SOLU-CORTEF 100 mg inj soln, 1000 mg inj soln, 250 mg inj soln, 500 mg inj soln 3

SOLU-MEDROL 1000 mg inj soln, 125 mg inj soln, 2 gm inj soln, 40 mg inj soln, 500 mg inj soln 3

SYMBICORT 160-4.5 mcg/act inh aer, 80-4.5 mcg/act inh aer 3

triamcinolone acetonide 40 mg/ml inj susp 1 KENALOG

UCERIS 9 mg tab er 24 hr 3 PA

VERIPRED 20 20 mg/5ml soln 3

ALCOHOL DETERRENTS [DISUASIVOS DE ALCOHOL]

Alcohol Deterrents [Disuasivos De Alcohol]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ANTABUSE 250 mg tab, 500 mg tab 3

disulfiram 250 mg tab, 500 mg tab 1 ANTABUSE

ALKALINIZING AGENTS [AGENTES ALCALINIZANTES]

Alkalinizing Agents [Agentes Alcalinizantes]

cytra k crystals 3300-1002 mg pckt 1

ORACIT 490-640 mg/5ml soln 3

pot & sod cit-cit ac 550-500-334 mg/5ml soln 1

potassium citrate er 10 MEQ (1080 mg) tab er, 15 MEQ (1620 mg) tab er, 5 MEQ (540 mg) tab er 1 UROCIT-K

potassium citrate monohydrate gr 1

potassium citrate-citric acid 1100-334 mg/5ml soln 1

SHOHLS MODIFIED 500-334 mg/5ml soln 3

sod citrate-citric acid 500-334 mg/5ml soln 1

TARON-CRYSTALS 3300-1002 mg pckt 3

tricitrates 550-500-334 mg/5ml soln 1

UROCIT-K 10 10 MEQ (1080 mg) tab er 3

UROCIT-K 15 15 MEQ (1620 mg) tab er 3

UROCIT-K 5 5 MEQ (540 mg) tab er 3

ALPHA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES ALFA-ADRENÉRGICOS]

Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]

CARDURA 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 3

CARDURA XL 4 mg tab er 24 hr, 8 mg tab er 24 hr 3

doxazosin mesylate 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 CARDURA

MINIPRESS 1 mg cap, 2 mg cap, 5 mg cap 3

prazosin hcl 1 mg cap, 2 mg cap, 5 mg cap 1 MINIPRESS

terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 HYTRIN

AMMONIA DETOXICANTS [DETOXIFICANTES DE AMONÍACO]

Ammonia Detoxicants [Detoxificantes De Amoníaco]

AMMONUL 10-10 % iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

BUPHENYL 500 mg tab 3 PA

BUPHENYL 3 gm/tsp oral pwdr 3 PA

CARBAGLU 200 mg tab 3 PA

constulose 10 gm/15ml soln 1 CONSTULOSE

enulose 10 gm/15ml soln 1

generlac 10 gm/15ml soln 1

KRISTALOSE 10 gm pckt, 20 gm pckt 3

lactulose 10 gm pckt 1

lactulose 10 gm/15ml soln, 20 gm/30ml soln 1 CONSTULOSE

lactulose encephalopathy 10 gm/15ml soln 1

LITHOSTAT 250 mg tab 3

RAVICTI 1.1 gm/ml liq 3 PA

sod benz-sod phenylacet 10-10 % iv soln 1 PA

sodium phenylbutyrate 500 mg tab 1 BUPHENYL PA

sodium phenylbutyrate 3 gm/tsp oral pwdr 1 BUPHENYL PA

ANALGESICS AND ANTIPYRETICS [ANALGÉSICOS Y ANTIPIRÉTICOS]

Analgesics And Antipyretics, Misc [Analgésicos Y Antipiréticos, Misceláneos]

BUPAP 50-300 mg tab 3

butalbital-acetaminophen 50-300 mg tab 1 BUPAP

butalbital-acetaminophen 50-325 mg tab 1 TENCON

butalbital-apap 50-325 mg tab 1 TENCON

butalbital-apap-caffeine 50-325-40 mg cap, 50-325-40 mg tab 1 ESGIC

butalbital-apap-caffeine 50-300-40 mg cap 1 FIORICET

ESGIC 50-325-40 mg cap, 50-325-40 mg tab 3

FIORICET 50-300-40 mg cap 3

ILARIS 150 mg/ml sc soln 3 PA

LYRICA CR 165 mg tab er 24 hr, 330 mg tab er 24 hr, 82.5 mg tab er 24 hr 3

PHRENILIN FORTE 50-300-40 mg cap 3

TENCON 50-325 mg tab 3

VANATOL LQ 50-325-40 mg/15ml soln 3

VANATOL S 50-325-40 mg/15ml soln 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ZEBUTAL 50-325-40 mg cap 3

Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]

ANAPROX DS 550 mg tab 3

ARTHROTEC 50-0.2 mg tab dr, 75-0.2 mg tab dr 3

butalbital-aspirin-caffeine 50-325-40 mg cap 1 FIORINAL

CAMBIA 50 mg pckt 3 QL(9 / 30)

CELEBREX 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 3

celecoxib 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 1 CELEBREX

DAYPRO 600 mg tab 3

diclofenac potassium 50 mg tab 1 CATAFLAM

diclofenac sodium 25 mg tab dr, 50 mg tab dr, 75 mg tab dr 1 VOLTAREN

diclofenac sodium er 100 mg tab er 24 hr 1 VOLTAREN

diclofenac-misoprostol 50-0.2 mg tab dr, 75-0.2 mg tab dr 1 ARTHROTEC

diflunisal 500 mg tab 1 DOLOBID

DUEXIS 800-26.6 mg tab 3

EC-NAPROSYN 375 mg tab dr, 500 mg tab dr 3

etodolac 200 mg cap, 300 mg cap, 400 mg tab, 500 mg tab 1 LODINE

etodolac er 400 mg tab er 24 hr, 500 mg tab er 24 hr, 600 mg tab er 24 hr 1 LODINE XL

FELDENE 10 mg cap, 20 mg cap 3

fenoprofen calcium 400 mg cap, 600 mg tab 1 NALFON

FIORINAL 50-325-40 mg cap 3

flurbiprofen 100 mg tab, 50 mg tab 1 ANSAID

IBU 400 mg tab, 600 mg tab, 800 mg tab 1

ibuprofen 400 mg tab, 600 mg tab, 800 mg tab 1 MOTRIN

ibuprofen 100 mg/5ml susp 1 MOTRIN

IBUPROFEN COMFORT PAC 800 mg cmb kit 3

IC 400 400 mg oral kit 3

IC 800 800 mg oral kit 3

INDOCIN 50 mg rect supp 3

INDOCIN 25 mg/5ml susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

indomethacin 25 mg cap, 50 mg cap 1 INDOCIN

indomethacin er 75 mg cap er 1 INDOCIN

ketoprofen 75 mg cap 1 ORUDIS

ketoprofen er 200 mg cap er 24 hr 1 ORUVAIL

ketorolac tromethamine 60 mg/2ml im soln 1

ketorolac tromethamine 10 mg tab 1 TORADOL

ketorolac tromethamine 15 mg/ml inj soln, 30 mg/ml inj soln 1 TORADOL

meclofenamate sodium 100 mg cap, 50 mg cap 1 MECLOMEN

mefenamic acid 250 mg cap 1 PONSTEL

meloxicam 15 mg tab, 7.5 mg tab 1 MOBIC

MELOXICAM COMFORT PAC 15 mg cmb kit 3

MOBIC 15 mg tab, 7.5 mg tab 3

nabumetone 500 mg tab, 750 mg tab 1 RELAFEN

NALFON 400 mg cap 3

NAPRELAN 375 mg tab er 24 hr, 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

NAPROSYN 500 mg tab 3

NAPROSYN 125 mg/5ml susp 3

naproxen 250 mg tab, 375 mg tab, 500 mg tab 1 NAPROSYN

naproxen 125 mg/5ml susp 1 NAPROSYN

NAPROXEN COMFORT PAC 500 mg cmb kit 3

naproxen dr 375 mg tab dr, 500 mg tab dr 1 NAPROSYN

naproxen sodium 275 mg tab, 550 mg tab 1 ANAPROX

naproxen sodium er 375 mg tab er 24 hr, 500 mg tab er 24 hr 1 NAPRELAN

oxaprozin 600 mg tab 1 DAYPRO

piroxicam 10 mg cap, 20 mg cap 1 FELDENE

salsalate 500 mg tab, 750 mg tab 1

SPRIX 15.75 mg/spray nasal soln 3

sulindac 150 mg tab, 200 mg tab 1 CLINORIL

tolmetin sodium 200 mg tab 1

tolmetin sodium 400 mg cap, 600 mg tab 1 TOLECTIN

VIMOVO 375-20 mg tab dr, 500-20 mg tab dr 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ZIPSOR 25 mg cap 3

ZORVOLEX 18 mg cap, 35 mg cap 3

Opiate Agonists [Agonistas De Opiáceos]

acetaminophen-codeine 300-15 mg tab, 300-60 mg tab 1

TYLENOL WITH CODEINE

acetaminophen-codeine 120-12 mg/5ml soln 1

TYLENOL WITH CODEINE

acetaminophen-codeine #2 300-15 mg tab 1

TYLENOL WITH CODEINE

acetaminophen-codeine #3 300-30 mg tab 1

TYLENOL WITH CODEINE

acetaminophen-codeine #4 300-60 mg tab 1

TYLENOL WITH CODEINE

ASCOMP-CODEINE 50-325-40-30 mg cap 3

butalbital-apap-caff-cod 50-300-40-30 mg cap, 50-325-40-30 mg cap 1

FIORICET WITH CODEINE

butalbital-asa-caff-codeine 50-325-40-30 mg cap 1

FIORINAL WITH CODEINE

CONZIP 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3

DEMEROL 100 mg tab 3

DEMEROL 100 mg/2ml inj soln, 100 mg/ml inj soln, 25 mg/0.5ml inj soln, 25 mg/ml inj soln, 50 mg/ml inj soln, 75 mg/1.5ml inj soln, 75 mg/ml inj soln 3

DILAUDID 2 mg tab 3

DURAGESIC-100 100 mcg/hr td patch 72 hr 3

DURAGESIC-12 12 mcg/hr td patch 72 hr 3

DURAGESIC-25 25 mcg/hr td patch 72 hr 3

DURAGESIC-50 50 mcg/hr td patch 72 hr 3

DURAGESIC-75 75 mcg/hr td patch 72 hr 3

ENDOCET 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1

ENDOCET 2.5-325 mg tab 3

fentanyl 100 mcg/hr td patch 72 hr, 12 mcg/hr td patch 72 hr, 25 mcg/hr td patch 72 hr, 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr 1 DURAGESIC

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

fentanyl citrate (pf) 100 mcg/2ml inj soln, 100 mcg/2ml inj soln cart, 1000 mcg/20ml inj soln, 250 mcg/5ml inj soln, 2500 mcg/50ml inj soln, 500 mcg/10ml inj soln 1

FIORICET/CODEINE 50-300-40-30 mg cap 3

FIORINAL/CODEINE #3 50-325-40-30 mg cap 3

hydrocodone-acetaminophen 2.5-108 mg/5ml soln, 5-217 mg/10ml soln, 7.5-325 mg/15ml soln 1 HYCET

hydrocodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 NORCO

hydrocodone-acetaminophen 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 1 VICODIN

hydrocodone-ibuprofen 10-200 mg tab, 5-200 mg tab 1 REPREXAIN

hydrocodone-ibuprofen 7.5-200 mg tab 1 VICOPROFEN

hydromorphone hcl 2 mg tab 1 DILAUDID

IBUDONE 10-200 mg tab, 5-200 mg tab 3

KADIAN 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 200 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 3

LORCET 5-325 mg tab 3

LORCET HD 10-325 mg tab 3

LORCET PLUS 7.5-325 mg tab 3

MAXIDONE 10-750 mg tab 3

meperidine hcl 10 mg/ml inj soln 1

meperidine hcl 100 mg tab, 50 mg tab 1 DEMEROL

meperidine hcl 100 mg/ml inj soln, 25 mg/ml inj soln, 50 mg/5ml soln, 50 mg/ml inj soln 1 DEMEROL

morphine sulfate 15 mg tab, 30 mg tab 1

morphine sulfate 10 mg/5ml soln, 20 mg/5ml soln 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

morphine sulfate (concentrate) 100 mg/5ml soln 1

morphine sulfate er 40 mg cap er 24 hr 1

morphine sulfate er 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 KADIAN

morphine sulfate er 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 1 MS CONTIN

morphine sulfate er beads 120 mg cap er 24 hr, 30 mg cap er 24 hr, 45 mg cap er 24 hr, 60 mg cap er 24 hr, 75 mg cap er 24 hr, 90 mg cap er 24 hr 1 AVINZA

MS CONTIN 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 3

NORCO 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3

NUCYNTA 100 mg tab, 50 mg tab, 75 mg tab 3

NUCYNTA ER 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr, 250 mg tab er 12 hr, 50 mg tab er 12 hr 3

oxycodone hcl 10 mg tab, 20 mg tab, 5 mg cap 1

oxycodone hcl 15 mg tab, 30 mg tab, 5 mg tab 1 ROXICODONE

oxycodone hcl 100 mg/5ml oral conc, 5 mg/5ml soln 1 ROXICODONE

oxycodone hcl er 10 mg tab er 12 hr abuse-deterr, 15 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 30 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 60 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 1 OXYCONTIN

oxycodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 PERCOCET

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

oxycodone-acetaminophen 5-325 mg/5ml soln 1 ROXICET

oxycodone-aspirin 4.8355-325 mg tab 1 PERCODAN

oxycodone-ibuprofen 5-400 mg tab 1 COMBUNOX

OXYCONTIN 10 mg tab er 12 hr abuse-deterr, 15 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 30 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 60 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 3

PERCOCET 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3

PRIMLEV 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 3

ROXICODONE 15 mg tab, 30 mg tab, 5 mg tab 3

tramadol hcl 50 mg tab 1 ULTRAM

tramadol hcl er 150 mg cap er 24 hr 1

tramadol hcl er 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 1 CONZIP

tramadol hcl er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 ULTRAM ER

tramadol hcl er (biphasic) 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 RYZOLT

tramadol-acetaminophen 37.5-325 mg tab 1 ULTRACET

TYLENOL WITH CODEINE #3 300-30 mg tab 3

TYLENOL WITH CODEINE #4 300-60 mg tab 3

ULTRACET 37.5-325 mg tab 3

ULTRAM 50 mg tab 3

VERDROCET 2.5-325 mg tab 3

VICODIN 5-300 mg tab 3

VICODIN ES 7.5-300 mg tab 3

VICODIN HP 10-300 mg tab 3

Opiate Partial Agonists [Agonistas Parciales De Opiáceos]

BELBUCA 150 mcg bucc film, 300 mcg bucc film, 450 mcg bucc film, 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

600 mcg bucc film, 75 mcg bucc film, 750 mcg bucc film, 900 mcg bucc film

BUNAVAIL 2.1-0.3 mg bucc film, 4.2-0.7 mg bucc film, 6.3-1 mg bucc film 3

BUPRENEX 0.3 mg/ml inj soln 3

buprenorphine 10 mcg/hr tdwk patch, 15 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch, 7.5 mcg/hr tdwk patch 1 BUTRANS

buprenorphine hcl 0.3 mg/ml inj soln 1 BUPRENEX

buprenorphine hcl 2 mg tab subl, 8 mg tab subl 1 SUBUTEX

buprenorphine hcl-naloxone hcl 8-2 mg subl film 1

buprenorphine hcl-naloxone hcl 2-0.5 mg tab subl, 8-2 mg tab subl 1 SUBOXONE

butorphanol tartrate 1 mg/ml inj soln, 10 mg/ml nasal soln, 2 mg/ml inj soln 1 STADOL

BUTRANS 10 mcg/hr tdwk patch, 15 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch, 7.5 mcg/hr tdwk patch 3

nalbuphine hcl 10 mg/ml inj soln, 20 mg/ml inj soln 1 NUBAIN

pentazocine-naloxone hcl 50-0.5 mg tab 1

SUBOXONE 12-3 mg subl film, 2-0.5 mg subl film, 4-1 mg subl film, 8-2 mg subl film 3

ZUBSOLV 1.4-0.36 mg tab subl, 11.4-2.9 mg tab subl, 2.9-0.71 mg tab subl, 5.7-1.4 mg tab subl, 8.6-2.1 mg tab subl 3

ANDROGENS [ANDRÓGENOS]

Androgens [Andrógenos]

testosterone 30 mg/act td soln 1 AXIRON

ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS [AGENTES ANOREXÍGENOS Y ESTIMULANTES RESPIRATORIOS Y DEL SNC]

Amphetamines [Anfetaminas]

ADDERALL 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ADDERALL XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 3

amphetamine-dextroamphet er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 1 ADDERALL XR

amphetamine-dextroamphetamine 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 ADDERALL

benzphetamine hcl 25 mg tab, 50 mg tab 1 PA

DESOXYN 5 mg tab 3

DEXEDRINE 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 3

dextroamphetamine sulfate 5 mg/5ml soln 1

dextroamphetamine sulfate 10 mg tab, 5 mg tab 1 DEXEDRINE

dextroamphetamine sulfate er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 1 DEXEDRINE

methamphetamine hcl 5 mg tab 1 DESOXYN

PROCENTRA 5 mg/5ml soln 3

REGIMEX 25 mg tab 3 PA

VYVANSE 10 mg cap, 10 mg tab chew, 20 mg cap, 20 mg tab chew, 30 mg cap, 30 mg tab chew, 40 mg cap, 40 mg tab chew, 50 mg cap, 50 mg tab chew, 60 mg cap, 60 mg tab chew, 70 mg cap 3

ZENZEDI 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 3

Anorexigenic Agents [Agentes Anorexígenos]

ADIPEX-P 37.5 mg cap, 37.5 mg tab 3 PA

BELVIQ 10 mg tab 3 PA

BELVIQ XR 20 mg tab er 24 hr 3 PA

CONTRAVE 8-90 mg tab er 12 hr 3 PA

diethylpropion hcl 25 mg tab 1 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

diethylpropion hcl er 75 mg tab er 24 hr 1 PA

phendimetrazine tartrate 35 mg tab 1 PA

phendimetrazine tartrate er 105 mg cap er 24 hr 1 PA

phentermine hcl 15 mg cap, 30 mg cap, 37.5 mg cap, 37.5 mg tab 1 PA

Anorexigenic Agents And Stimulants, Miscellaneous [Agentes Anorexígenos Y Estimulantes, Misceláneos]

QSYMIA 11.25-69 mg cap er 24 hr, 15-92 mg cap er 24 hr, 3.75-23 mg cap er 24 hr, 7.5-46 mg cap er 24 hr 3 PA

Respiratory And Cns Stimulants [Estimulantes Del Snc Y Respiratorios]

CONCERTA 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 3

DAYTRANA 10 mg/9hr td patch, 15 mg/9hr td patch, 20 mg/9hr td patch, 30 mg/9hr td patch 3

dexmethylphenidate hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 FOCALIN

dexmethylphenidate hcl er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 1 FOCALIN XR

FOCALIN 10 mg tab, 2.5 mg tab, 5 mg tab 3

FOCALIN XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 3

METADATE ER 20 mg tab er 3

METHYLIN 10 mg/5ml soln, 5 mg/5ml soln 3

methylphenidate hcl 10 mg tab chew, 2.5 mg tab chew, 5 mg tab chew 1 METHYLIN

methylphenidate hcl 10 mg/5ml soln, 5 mg/5ml soln 1 METHYLIN

methylphenidate hcl 10 mg tab, 20 mg tab, 5 mg tab 1 RITALIN

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

methylphenidate hcl er 18 mg tab er 24 hr, 27 mg tab er 24 hr, 36 mg tab er 24 hr, 54 mg tab er 24 hr 1

methylphenidate hcl er 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 1 CONCERTA

methylphenidate hcl er 10 mg tab er 1 METADATE

methylphenidate hcl er 20 mg tab er 1 RITALIN SR

methylphenidate hcl er (cd) 30 mg cap er, 50 mg cap er, 60 mg cap er 1 METADATE

methylphenidate hcl er (cd) 10 mg cap er, 20 mg cap er, 40 mg cap er 1 METADATE CD

methylphenidate hcl er (la) 30 mg cap er 24 hr 1

methylphenidate hcl er (la) 10 mg cap er 24 hr, 20 mg cap er 24 hr, 40 mg cap er 24 hr 1 RITALIN LA

QUILLICHEW ER 20 mg tab chew er, 30 mg tab chew er, 40 mg tab chew er 3

QUILLIVANT XR 25 mg/5ml susp 3

RITALIN 10 mg tab, 20 mg tab, 5 mg tab 3

RITALIN LA 10 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr 3

Wakefulness-promoting Agents [Agentes Promotores Del Estado De Vigilia]

modafinil 100 mg tab, 200 mg tab 1 PROVIGIL

ANTHELMINTICS [ANTIHELMÍNTICOS]

Anthelmintics [Antihelmínticos]

albendazole 200 mg tab 1

ALBENZA 200 mg tab 3

BILTRICIDE 600 mg tab 3

ivermectin 3 mg tab 1 STROMECTOL

praziquantel 600 mg tab 1 BILTRICIDE

STROMECTOL 3 mg tab 3

ANTIALLERGIC AGENTS [AGENTES ANTIALÉRGICOS]

Antiallergic Agents [Agentes Antialérgicos]

ALOCRIL 2 % ophth soln 3

ALOMIDE 0.1 % ophth soln 3

ASTEPRO 0.15 % nasal soln 3

azelastine hcl 0.1 % nasal soln, 137 mcg/spray nasal soln 1 ASTELIN

azelastine hcl 0.15 % nasal soln 1 ASTEPRO

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

azelastine hcl 0.05 % ophth soln 1 OPTIVAR

BEPREVE 1.5 % ophth soln 3

cromolyn sodium 4 % ophth soln 1 OPTICROM

DYMISTA 137-50 mcg/act nasal susp 3

ELESTAT 0.05 % ophth soln 3

EMADINE 0.05 % ophth soln 3

epinastine hcl 0.05 % ophth soln 1 ELESTAT

LASTACAFT 0.25 % ophth soln 3

olopatadine hcl 0.2 % ophth soln 1 PATADAY

olopatadine hcl 0.6 % nasal soln 1 PATANASE

olopatadine hcl 0.1 % ophth soln 1 PATANOL

PATADAY 0.2 % ophth soln 3

PATANASE 0.6 % nasal soln 3

PATANOL 0.1 % ophth soln 3

ANTIANEMIA DRUGS [MEDICAMENTOS CONTRA LA ANEMIA]

Iron Preparations [Preparaciones De Hierro]

BIFERARX 22-6-1-0.025 mg tab 3

CENTRATEX 106-1 mg cap 3

FERREX 150 FORTE PLUS 50-100 mg cap 3

FERRLECIT 12.5 mg/ml iv soln 3

FERROCITE PLUS 106-1 mg tab 3

FERRO-PLEX HEMATINIC 115-1 mg tab 3

FOLIVANE-F 125-1 mg cap 3

FOLIVANE-PLUS cap 3

FUSION PLUS cap 3

hematinic plus vit/minerals 106-1 mg tab 1

hematinic/folic acid 324-1 mg tab 1

HEMATRON-AF 150-1 mg tab 3

hemetab 22-6-1-0.025 mg tab 1

HEMOCYTE PLUS 106-1 mg cap 3

HEMOCYTE-F 324-1 mg tab 3

hemocyte-plus 106-1 mg tab 1

INFED 50 mg/ml inj soln 3

INTEGRA F 125-1 mg cap 3

INTEGRA PLUS cap 3

K-TAN PLUS 162-115.2-1 mg cap 3

MAXFE 160-1 mg tab 3

na ferric gluc cplx in sucrose 12.5 mg/ml iv soln 1

PROFERRIN-FORTE 12-1 mg tab 3

PROTECTIRON 60-1 mg tab 3

purefe plus 106-1 mg cap 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

purevit dualfe plus 162-115.2-1 mg cap 1

RENATABS WITH IRON 1 & 100 mg oral misc 3

se-tan plus 162-115.2-1 mg cap 1

TANDEM PLUS 162-115.2-1 mg cap 3

tl-hem 150 150-1 mg tab 1

VITAFOL tab 3

ANTIBACTERIALS [ANTIBACTERIANOS]

Aminoglycosides [Aminoglucósidos]

BETHKIS 300 mg/4ml inh neb soln 3

gentamicin sulfate 10 mg/ml inj soln 1

gentamicin sulfate 40 mg/ml inj soln 1 GENTAK

KITABIS PAK 300 mg/5ml inh neb soln 3

neomycin sulfate 500 mg tab 1

TOBI 300 mg/5ml inh neb soln 3

TOBI PODHALER 28 mg inh cap 3

tobramycin 300 mg/5ml inh neb soln 1 TOBI

Antibacterials, Miscellaneous [Antibacterianos, Misceláneos]

CLEOCIN 150 mg cap, 300 mg cap, 75 mg cap 3

CLEOCIN 75 mg/5ml soln 3

clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap 1 CLEOCIN

clindamycin palmitate hcl 75 mg/5ml soln 1 CLEOCIN

FIRST-VANCOMYCIN 25 25 mg/ml soln 3

FIRST-VANCOMYCIN 50 50 mg/ml soln 3

LINCOCIN 300 mg/ml inj soln 3

lincomycin hcl 300 mg/ml inj soln 1 LINCOCIN

linezolid 600 mg tab 1 ZYVOX PA

linezolid 100 mg/5ml susp 1 ZYVOX PA

SIVEXTRO 200 mg iv soln, 200 mg tab 3 PA

VANCOCIN HCL 125 mg cap, 250 mg cap 3

vancomycin hcl 125 mg cap, 250 mg cap 1

XIFAXAN 200 mg tab, 550 mg tab 3

ZYVOX 600 mg tab 3 PA

ZYVOX 100 mg/5ml susp 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

Cephalosporins [Cefalosporinas]

cefaclor 250 mg cap, 500 mg cap 1 CECLOR

cefaclor 125 mg/5ml susp, 250 mg/5ml susp, 375 mg/5ml susp 1 CECLOR

cefaclor er 500 mg tab er 12 hr 1 CECLOR CD

cefadroxil 1 gm tab, 500 mg cap 1 DURICEF

cefadroxil 250 mg/5ml susp, 500 mg/5ml susp 1 DURICEF

cefdinir 300 mg cap 1 OMNICEF

cefdinir 125 mg/5ml susp, 250 mg/5ml susp 1 OMNICEF

cefditoren pivoxil 200 mg tab, 400 mg tab 1 SPECTRACEF

cefixime 100 mg/5ml susp, 200 mg/5ml susp 1 SUPRAX

cefpodoxime proxetil 100 mg tab, 200 mg tab 1 VANTIN

cefpodoxime proxetil 100 mg/5ml susp, 50 mg/5ml susp 1 VANTIN

cefprozil 250 mg tab, 500 mg tab 1 CEFZIL

cefprozil 125 mg/5ml susp, 250 mg/5ml susp 1 CEFZIL

CEFTIN 125 mg/5ml susp, 250 mg/5ml susp 3

ceftriaxone sodium 1 gm inj soln, 2 gm inj soln, 250 mg inj soln, 500 mg inj soln 1 ROCEPHIN

cefuroxime axetil 250 mg tab, 500 mg tab 1 CEFTIN

cefuroxime sodium 750 mg inj soln 2 ZINACEF

cephalexin 250 mg tab, 500 mg tab 1

cephalexin 250 mg cap, 500 mg cap, 750 mg cap 1 KEFLEX

cephalexin 125 mg/5ml susp, 250 mg/5ml susp 1 KEFLEX

KEFLEX 250 mg cap, 500 mg cap, 750 mg cap 3

SPECTRACEF 400 mg tab 3

SUPRAX 100 mg tab chew, 200 mg tab chew, 400 mg cap 3

SUPRAX 100 mg/5ml susp, 200 mg/5ml susp, 500 mg/5ml susp 3

Macrolides [Macrólidos]

azithromycin 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 1 ZITHROMAX

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

azithromycin 100 mg/5ml susp, 200 mg/5ml susp 1 ZITHROMAX

clarithromycin 250 mg tab, 500 mg tab 1 BIAXIN

clarithromycin 125 mg/5ml susp, 250 mg/5ml susp 1 BIAXIN

clarithromycin er 500 mg tab er 24 hr 1 BIAXIN XL

DIFICID 200 mg tab 3

E.E.S. 400 400 mg tab 3

E.E.S. GRANULES 200 mg/5ml susp 3

ERYPED 200 200 mg/5ml susp 3

ERYPED 400 400 mg/5ml susp 3

ERY-TAB 250 mg tab dr, 333 mg tab dr, 500 mg tab dr 3

ERYTHROCIN STEARATE 250 mg tab 3

erythromycin base 250 mg cap dr prt, 250 mg tab 1

erythromycin base 500 mg tab 1 ERY-TAB

erythromycin ethylsuccinate 400 mg tab 1 E.E.S.

erythromycin ethylsuccinate 200 mg/5ml susp 1 ERYPED

PCE 333 mg tab dr, 500 mg tab dr 3

ZITHROMAX 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 3

ZITHROMAX 100 mg/5ml susp, 200 mg/5ml susp 3

ZITHROMAX TRI-PAK 500 mg tab 3

ZITHROMAX Z-PAK 250 mg tab 3

Miscellaneous B-lactam Antibiotics [Antibióticos Betalactámicos Misceláneos]

CAYSTON 75 mg inh soln 3 PA

Penicillins [Penicilinas]

amoxicillin 125 mg tab chew, 250 mg cap, 250 mg tab chew, 500 mg cap, 500 mg tab, 875 mg tab 1 AMOXIL

amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg/5ml susp, 400 mg/5ml susp 1 AMOXIL

amoxicillin-pot clavulanate 200-28.5 mg tab chew, 250-125 mg tab, 400-57 mg tab chew, 500-125 mg tab, 875-125 mg tab 1 AUGMENTIN

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 250-62.5 mg/5ml susp, 400-57 mg/5ml susp, 600-42.9 mg/5ml susp 1 AUGMENTIN

amoxicillin-pot clavulanate er 1000-62.5 mg tab er 12 hr 1 AUGMENTIN XR

ampicillin 500 mg cap 1

AUGMENTIN 500-125 mg tab, 875-125 mg tab 3

AUGMENTIN 125-31.25 mg/5ml susp, 250-62.5 mg/5ml susp 3

AUGMENTIN ES-600 600-42.9 mg/5ml susp 3

AUGMENTIN XR 1000-62.5 mg tab er 12 hr 3

BICILLIN C-R 1200000 unit/2ml im susp 3

BICILLIN C-R 900/300 900000-300000 unit/2ml im susp 3

BICILLIN L-A 1200000 unit/2ml im susp, 2400000 unit/4ml im susp, 600000 unit/ml im susp 3

dicloxacillin sodium 250 mg cap, 500 mg cap 1 DYCILL

MOXATAG 775 mg tab er 24 hr 3

penicillin g procaine 600000 unit/ml im susp 1

penicillin v potassium 500 mg tab 1 PEN-VEE K

penicillin v potassium 250 mg tab 1 VEETIDS

penicillin v potassium 125 mg/5ml soln, 250 mg/5ml soln 1 VEETIDS

Quinolones [Quinolonas]

AVELOX 400 mg tab 3

CIPRO 250 mg tab, 500 mg tab 3

CIPRO 250 MG/5ML (5%) susp, 500 MG/5ML (10%) susp 3

CIPRO XR 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3

ciprofloxacin 500 MG/5ML (10%) susp 1 CIPRO

ciprofloxacin hcl 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 CIPRO

ciprofloxacin-ciproflox hcl er 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 CIPRO XR

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

LEVAQUIN 250 mg tab, 500 mg tab, 750 mg tab 3

levofloxacin 250 mg tab, 500 mg tab, 750 mg tab 1 LEVAQUIN

levofloxacin 25 mg/ml iv soln, 25 mg/ml soln 1 LEVAQUIN

levofloxacin in d5w 250 mg/50ml iv soln 1

levofloxacin in d5w 500 mg/100ml iv soln, 750 mg/150ml iv soln 1 LEVAQUIN

moxifloxacin hcl 400 mg tab 1 AVELOX

ofloxacin 400 mg tab 1 FLOXIN

Sulfonamides [Sulfonamidas]

AZULFIDINE 500 mg tab 3

AZULFIDINE EN-TABS 500 mg tab dr 3

BACTRIM 400-80 mg tab 3

BACTRIM DS 800-160 mg tab 3

sulfadiazine 500 mg tab 1

sulfamethoxazole-trimethoprim 400-80 mg tab, 800-160 mg tab 1 SEPTRA

sulfamethoxazole-trimethoprim 200-40 mg/5ml susp, 400-80 mg/5ml iv soln 1 SEPTRA

sulfasalazine 500 mg tab, 500 mg tab dr 1 AZULFIDINE

SULFATRIM PEDIATRIC 200-40 mg/5ml susp 3

Tetracyclines [Tetraciclinas]

avidoxy 100 mg tab 1 ADOXA

AVIDOXY DK 100 mg cmb kit 3

demeclocycline hcl 150 mg tab, 300 mg tab 1 DECLOMYCIN

DORYX 200 mg tab dr 3

doxycycline hyclate 75 mg cap dr prt 1

doxycycline hyclate 100 mg cap dr prt, 100 mg tab dr, 150 mg tab dr, 200 mg tab dr, 75 mg tab dr 1 DORYX

doxycycline hyclate 20 mg tab 1 PERIOSTAT

doxycycline hyclate 100 mg tab 1 VIBRA-TABS

doxycycline hyclate 100 mg cap, 50 mg cap 1 VIBRAMYCIN

doxycycline monohydrate 100 mg tab, 150 mg cap, 150 mg tab, 50 mg tab, 75 mg tab 1 ADOXA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

doxycycline monohydrate 100 mg cap, 50 mg cap, 75 mg cap 1 MONODOX

doxycycline monohydrate 25 mg/5ml susp 1 VIBRAMYCIN

MINOCIN 100 mg cap, 50 mg cap 3

minocycline hcl 100 mg tab, 50 mg tab, 75 mg tab 1 DYNACIN

minocycline hcl 100 mg cap, 50 mg cap, 75 mg cap 1 MINOCIN

MONDOXYNE NL 100 mg cap, 75 mg cap 3

MORGIDOX 1 x 100 mg cmb kit, 100 mg cap, 2 x 100 mg cmb kit 3

NUTRIDOX 75 mg oral kit 3

OKEBO 75 mg cap 3

tetracycline hcl 250 mg cap, 500 mg cap 1

VIBRAMYCIN 100 mg cap 3

VIBRAMYCIN 25 mg/5ml susp, 50 mg/5ml syr 3

ANTICHOLINERGIC AGENTS [AGENTES ANTICOLINÉRGICOS]

Antimuscarinics/antispasmodics [Antimuscarínicos/Antiespasmódicos]

ANASPAZ 0.125 mg tab disint 3

ANORO ELLIPTA 62.5-25 mcg/inh inh aer pwdr br act 3

ATROVENT HFA 17 mcg/act inh aer soln 3

BENTYL 10 mg cap 3

BENTYL 10 mg/ml im soln 3

chlordiazepoxide-clidinium 5-2.5 mg cap 1

CUVPOSA 1 mg/5ml soln 3

dicyclomine hcl 10 mg cap, 20 mg tab 1 BENTYL

dicyclomine hcl 10 mg/5ml soln, 10 mg/ml im soln 1 BENTYL

DONNATAL 16.2 mg tab 3

DONNATAL 16.2 mg/5ml oral elix 3

ed-spaz 0.125 mg tab disint 1

GLYCATE 1.5 mg tab 3

glycopyrrolate 1.5 mg tab 1

glycopyrrolate 1 mg tab, 2 mg tab 1 ROBINUL

hyoscyamine sulfate 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

hyoscyamine sulfate 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1

hyoscyamine sulfate er 0.375 mg tab er 12 hr 1

hyoscyamine sulfate sl 0.125 mg tab subl 1

hyosyne 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1

ipratropium bromide 0.02 % inh soln, 0.03 % nasal soln 1 ATROVENT

LEVBID 0.375 mg tab er 12 hr 3

LEVSIN 0.125 mg tab 3

LEVSIN/SL 0.125 mg tab subl 3

LIBRAX 5-2.5 mg cap 3

me-pb-hyos 16.2 mg tab 1

me-pb-hyos 16.2 mg/5ml oral elix 1

methscopolamine bromide 2.5 mg tab, 5 mg tab 1 PAMINE

NULEV 0.125 mg tab disint 3

oscimin 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1

oscimin sr 0.375 mg tab er 12 hr 1

pb-hyoscy-atropine-scopolamine 16.2 mg tab 1

phenobarbital-belladonna alk 16.2 mg/5ml oral elix 1

PHENOHYTRO 16.2 mg tab 3

propantheline bromide 15 mg tab 1 PRO-BANTHINE

ROBINUL 1 mg tab 3

ROBINUL-FORTE 2 mg tab 3

SPIRIVA HANDIHALER 18 mcg inh cap 3

SPIRIVA RESPIMAT 1.25 mcg/act inh aer soln, 2.5 mcg/act inh aer soln 3

SYMAX DUOTAB 0.375 mg tab er 3

SYMAX-SL 0.125 mg tab subl 3

SYMAX-SR 0.375 mg tab er 12 hr 3

TUDORZA PRESSAIR 400 mcg/act inh aer pwdr br act 3

ANTICONVULSANTS [ANTICONVULSIVOS]

Anticonvulsants, Miscellaneous [Anticonvulsivos, Misceláneos]

APTIOM 200 mg tab, 400 mg tab, 600 mg tab, 800 mg tab 3

BANZEL 200 mg tab, 400 mg tab 3 PA

BANZEL 40 mg/ml susp 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

carbamazepine 100 mg tab chew, 200 mg tab 1 TEGRETOL

carbamazepine 100 mg/5ml susp 1 TEGRETOL

carbamazepine er 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 1 CARBATROL

carbamazepine er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 1 TEGRETOL

CARBATROL 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3

DEPAKENE 250 mg cap 3

DEPAKENE 250 mg/5ml soln 3

DEPAKOTE 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 3

DEPAKOTE ER 250 mg tab er 24 hr, 500 mg tab er 24 hr 3

DEPAKOTE SPRINKLES 125 mg cap dr sprinkle 3

divalproex sodium 125 mg cap dr sprinkle, 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 1 DEPAKOTE

divalproex sodium er 250 mg tab er 24 hr, 500 mg tab er 24 hr 1 DEPAKOTE

EPITOL 200 mg tab 3

EQUETRO 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3

felbamate 400 mg tab, 600 mg tab 1 FELBATOL

felbamate 600 mg/5ml susp 1 FELBATOL

FELBATOL 400 mg tab, 600 mg tab 3

FELBATOL 600 mg/5ml susp 3

FYCOMPA 10 mg tab, 12 mg tab, 2 mg tab, 4 mg tab, 6 mg tab, 8 mg tab 3

FYCOMPA 0.5 mg/ml susp 3

gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 1 NEURONTIN

gabapentin 250 mg/5ml soln, 300 mg/6ml soln 1 NEURONTIN

GABITRIL 12 mg tab, 16 mg tab, 2 mg tab, 4 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

KEPPRA 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 3

KEPPRA 100 mg/ml soln 3

KEPPRA XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

LAMICTAL 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab, 25 mg tab chew, 5 mg tab chew 3

LAMICTAL ODT 100 mg tab disint, 200 mg tab disint, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab disint, 50 (42)-100(14) mg oral kit, 50 mg tab disint 3

LAMICTAL STARTER 25 (35) mg oral kit, 25 (42)-100 (7) mg oral kit, 25 (84)-100(14) mg oral kit 3

LAMICTAL XR 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 & 100 & 200 mg oral kit, 50 mg tab er 24 hr 3

lamotrigine 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 50 (42)-100(14) mg oral kit 1

lamotrigine 100 mg tab, 100 mg tab disint, 150 mg tab, 200 mg tab, 200 mg tab disint, 25 mg tab, 25 mg tab chew, 25 mg tab disint, 5 mg tab chew, 50 mg tab disint 1 LAMICTAL

lamotrigine er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 mg tab er 24 hr 1 LAMICTAL

lamotrigine starter kit-blue 25 (35) mg oral kit 1

lamotrigine starter kit-green 25 (84)-100(14) mg oral kit 1

lamotrigine starter kit-orange 25 (42)-100 (7) mg oral kit 1

levetiracetam 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 KEPPRA

levetiracetam 100 mg/ml soln 1 KEPPRA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

levetiracetam er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 KEPPRA

LYRICA 100 mg cap, 150 mg cap, 200 mg cap, 225 mg cap, 25 mg cap, 300 mg cap, 50 mg cap, 75 mg cap 3

LYRICA 20 mg/ml soln 3

NEURONTIN 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 3

NEURONTIN 250 mg/5ml soln 3

oxcarbazepine 150 mg tab, 300 mg tab, 600 mg tab 1 TRILEPTAL

oxcarbazepine 300 mg/5ml susp 1 TRILEPTAL

OXTELLAR XR 150 mg tab er 24 hr, 300 mg tab er 24 hr, 600 mg tab er 24 hr 3

QUDEXY XR 100 mg cap er 24 hr sprinkle, 150 mg cap er 24 hr sprinkle, 200 mg cap er 24 hr sprinkle, 25 mg cap er 24 hr sprinkle, 50 mg cap er 24 hr sprinkle 3

ROWEEPRA 1000 mg tab, 500 mg tab, 750 mg tab 3

SABRIL 500 mg pckt, 500 mg tab 3

TEGRETOL 200 mg tab 3

TEGRETOL 100 mg/5ml susp 3

TEGRETOL-XR 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 3

tiagabine hcl 12 mg tab, 16 mg tab, 2 mg tab, 4 mg tab 1 GABITRIL

TOPAMAX 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 3

TOPAMAX SPRINKLE 15 mg cap sprinkle, 25 mg cap sprinkle 3

topiramate 100 mg tab, 15 mg cap sprinkle, 200 mg tab, 25 mg cap sprinkle, 25 mg tab, 50 mg tab 1 TOPAMAX

topiramate er 100 mg cap er 24 hr sprinkle, 150 mg cap er 24 hr sprinkle, 200 mg cap er 24 hr sprinkle, 25 mg cap er 24 hr sprinkle, 50 mg cap er 24 hr sprinkle 1 QUDEXY XR

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

TRILEPTAL 150 mg tab, 300 mg tab, 600 mg tab 3

TRILEPTAL 300 mg/5ml susp 3

TROKENDI XR 100 mg cap er 24 hr, 200 mg cap er 24 hr, 25 mg cap er 24 hr, 50 mg cap er 24 hr 3

valproate sodium 250 mg/5ml soln 1 DEPAKENE

valproic acid 250 mg cap 1 DEPAKENE

valproic acid 250 mg/5ml soln 1 DEPAKENE

vigabatrin 500 mg pckt 1 SABRIL

VIMPAT 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3

VIMPAT 10 mg/ml soln 3

ZONEGRAN 100 mg cap, 25 mg cap 3

zonisamide 100 mg cap, 25 mg cap, 50 mg cap 1 ZONEGRAN

Barbiturates [Barbitúricos]

MYSOLINE 250 mg tab, 50 mg tab 3

primidone 250 mg tab, 50 mg tab 1 MYSOLINE

Benzodiazepines [Benzodiazepinas]

clobazam 10 mg tab, 20 mg tab 1 PA

clonazepam 0.125 mg tab disint, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint 1 KLONOPIN

KLONOPIN 0.5 mg tab, 1 mg tab, 2 mg tab 3

ONFI 10 mg tab, 20 mg tab 3 PA

ONFI 2.5 mg/ml susp 3 PA

Hydantoins [Hidantoínas]

DILANTIN 100 mg cap, 30 mg cap 3

DILANTIN 125 mg/5ml susp 3

DILANTIN INFATABS 50 mg tab chew 3

PEGANONE 250 mg tab 3

PHENYTEK 200 mg cap, 300 mg cap 3

phenytoin 50 mg tab chew 1 DILANTIN

phenytoin 125 mg/5ml susp 1 DILANTIN

PHENYTOIN INFATABS 50 mg tab chew 3

phenytoin sodium 50 mg/ml inj soln 1 DILANTIN

phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap 1 DILANTIN

Succinimides [Succinimidas]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CELONTIN 300 mg cap 3

ethosuximide 250 mg cap 1 ZARONTIN

ethosuximide 250 mg/5ml soln 1 ZARONTIN

ZARONTIN 250 mg cap 3

ZARONTIN 250 mg/5ml soln 3

ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

Alpha-glucosidase Inhibitors [Inhibidores De La Alfa-Glucosidasa]

acarbose 100 mg tab, 25 mg tab, 50 mg tab 1 PRECOSE

GLYSET 100 mg tab, 25 mg tab, 50 mg tab 3

miglitol 100 mg tab, 25 mg tab, 50 mg tab 1 GLYSET

PRECOSE 100 mg tab, 25 mg tab, 50 mg tab 3

Amylinomimetics [Amilinomiméticos]

SYMLINPEN 120 2700 mcg/2.7ml sc soln pen-inj 3

SYMLINPEN 60 1500 mcg/1.5ml sc soln pen-inj 3

Antidiabetic Agents, Miscellaneous [Agentes Antidiabéticos, Misceláneos]

CYCLOSET 0.8 mg tab 3

KORLYM 300 mg tab 3 PA

Biguanides [Biguanidas]

FORTAMET 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3

GLUCOPHAGE 1000 mg tab, 500 mg tab, 850 mg tab 3

GLUCOPHAGE XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

GLUMETZA 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3

metformin hcl 500 mg/5ml soln 1

metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab 1 GLUCOPHAGE

metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 GLUCOPHAGE

metformin hcl er (mod) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 GLUMETZA

metformin hcl er (osm) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 FORTAMET

RIOMET 500 mg/5ml soln 3

XIGDUO XR 2.5-1000 mg tab er 24 hr 3

Dipeptidyl Peptidase-4 (dpp-4) Inhibitors [Inhibidores De La Dipeptidil Peptidasa-4 (Dpp-4)]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

JANUMET 50-1000 mg tab, 50-500 mg tab 3

JANUMET XR 100-1000 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 3

JANUVIA 100 mg tab, 25 mg tab, 50 mg tab 3

JENTADUETO 2.5-1000 mg tab, 2.5-500 mg tab, 2.5-850 mg tab 3

JENTADUETO XR 2.5-1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr 3

KAZANO 12.5-1000 mg tab, 12.5-500 mg tab 3

KOMBIGLYZE XR 2.5-1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr 3

NESINA 12.5 mg tab, 25 mg tab, 6.25 mg tab 3

ONGLYZA 2.5 mg tab, 5 mg tab 3

OSENI 12.5-15 mg tab, 12.5-30 mg tab, 12.5-45 mg tab, 25-15 mg tab, 25-30 mg tab, 25-45 mg tab 3

TRADJENTA 5 mg tab 3

Incretin Mimetics [Miméticos De Incretina]

BYDUREON 2 mg sc pen-inj, 2 mg sc susp er 3

BYDUREON BCISE 2 mg/0.85ml Subcutaneous Auto-injector 3

BYETTA 10 MCG PEN 10 mcg/0.04ml sc soln pen-inj 3

BYETTA 5 MCG PEN 5 mcg/0.02ml sc soln pen-inj 3

SAXENDA 18 mg/3ml sc soln pen-inj 3 PA

TANZEUM 30 mg sc pen-inj, 50 mg sc pen-inj 3

TRULICITY 0.75 mg/0.5ml sc soln pen-inj, 1.5 mg/0.5ml sc soln pen-inj 2

VICTOZA 18 mg/3ml sc soln pen-inj 3

Insulins [Insulinas]

APIDRA 100 unit/ml inj soln 3

APIDRA SOLOSTAR 100 unit/ml sc soln pen-inj 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

BASAGLAR KWIKPEN 100 unit/ml sc soln pen-inj 2

HUMALOG 100 unit/ml sc soln, 100 unit/ml sc soln cart 2

HUMALOG JUNIOR KWIKPEN 100 unit/ml sc soln pen-inj 2

HUMALOG KWIKPEN 100 unit/ml sc soln pen-inj, 200 unit/ml sc soln pen-inj 2

HUMALOG MIX 50/50 (50-50) 100 unit/ml sc susp 2

HUMALOG MIX 50/50 KWIKPEN (50-50) 100 unit/ml sc susp pen-inj 2

HUMALOG MIX 75/25 (75-25) 100 unit/ml sc susp 2

HUMALOG MIX 75/25 KWIKPEN (75-25) 100 unit/ml sc susp pen-inj 2

HUMULIN 70/30 (70-30) 100 unit/ml sc susp 2

HUMULIN 70/30 KWIKPEN (70-30) 100 unit/ml sc susp pen-inj 2

HUMULIN N 100 unit/ml sc susp 2

HUMULIN N KWIKPEN 100 unit/ml sc susp pen-inj 2

HUMULIN R 100 unit/ml inj soln 2

HUMULIN R U-500 (CONCENTRATED) 500 unit/ml sc soln 2

HUMULIN R U-500 KWIKPEN 500 unit/ml sc soln pen-inj 2

LANTUS 100 unit/ml sc soln 3

LANTUS SOLOSTAR 100 unit/ml sc soln pen-inj 3

LEVEMIR 100 unit/ml sc soln 3

LEVEMIR FLEXTOUCH 100 unit/ml sc soln pen-inj 3

NOVOLIN 70/30 (70-30) 100 unit/ml sc susp 3

NOVOLIN 70/30 RELION (70-30) 100 unit/ml sc susp 3

NOVOLIN N 100 unit/ml sc susp 3

NOVOLIN N RELION 100 unit/ml sc susp 3

NOVOLIN R 100 unit/ml inj soln 3

NOVOLIN R RELION 100 unit/ml inj soln 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NOVOLOG 100 unit/ml sc soln 3

NOVOLOG FLEXPEN 100 unit/ml sc soln pen-inj 3

NOVOLOG MIX 70/30 (70-30) 100 unit/ml sc susp 3

NOVOLOG MIX 70/30 FLEXPEN (70-30) 100 unit/ml sc susp pen-inj 3

NOVOLOG PENFILL 100 unit/ml sc soln cart 3

Meglitinides [Meglitinidas]

nateglinide 120 mg tab, 60 mg tab 1 STARLIX

PRANDIN 1 mg tab, 2 mg tab 3

repaglinide 0.5 mg tab, 1 mg tab, 2 mg tab 1 PRANDIN

repaglinide-metformin hcl 1-500 mg tab, 2-500 mg tab 1 PRANDIMET

STARLIX 120 mg tab, 60 mg tab 3

Sodium-glucose Cotransporter 2 (sglt2) Inhibitors [Inhibidores Del Cotransportador Sodio-Glucosa 2 (Sglt2)]

FARXIGA 10 mg tab, 5 mg tab 3

GLYXAMBI 10-5 mg tab, 25-5 mg tab 3

INVOKAMET 150-1000 mg tab, 150-500 mg tab, 50-1000 mg tab, 50-500 mg tab 3

INVOKAMET XR 150-1000 mg tab er 24 hr, 150-500 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 3

INVOKANA 100 mg tab, 300 mg tab 3

JARDIANCE 10 mg tab, 25 mg tab 3

SYNJARDY 12.5-1000 mg tab, 12.5-500 mg tab, 5-1000 mg tab, 5-500 mg tab 3

SYNJARDY XR 10-1000 mg tab er 24 hr, 12.5-1000 mg tab er 24 hr, 25-1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr 3

XIGDUO XR 10-1000 mg tab er 24 hr, 10-500 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr 3

Sulfonylureas [Sulfonilureas]

AMARYL 1 mg tab, 2 mg tab, 4 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

chlorpropamide 100 mg tab, 250 mg tab 1 DIABINESE

glimepiride 1 mg tab, 2 mg tab, 4 mg tab 1 AMARYL

glipizide 10 mg tab, 5 mg tab 1 GLUCOTROL

glipizide er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL

glipizide xl 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL

glipizide-metformin hcl 2.5-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 METAGLIP

GLUCOTROL 10 mg tab, 5 mg tab 3

GLUCOTROL XL 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 3

GLUCOVANCE 2.5-500 mg tab, 5-500 mg tab 3

glyburide 1.25 mg tab, 2.5 mg tab, 5 mg tab 1 DIABETA

glyburide micronized 1.5 mg tab, 3 mg tab, 6 mg tab 1 GLYNASE

glyburide-metformin 1.25-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 GLUCOVANCE

GLYNASE 1.5 mg tab, 3 mg tab, 6 mg tab 3

tolazamide 250 mg tab, 500 mg tab 1 TOLINASE

tolbutamide 500 mg tab 1 ORINASE

Thiazolidinediones [Tiazolidinedionas]

ACTOPLUS MET 15-500 mg tab, 15-850 mg tab 3

ACTOPLUS MET XR 15-1000 mg tab er 24 hr, 30-1000 mg tab er 24 hr 3

ACTOS 15 mg tab, 30 mg tab, 45 mg tab 3

AVANDIA 2 mg tab, 4 mg tab 3

DUETACT 30-2 mg tab, 30-4 mg tab 3

pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab 1 ACTOS

pioglitazone hcl-glimepiride 30-2 mg tab, 30-4 mg tab 1 DUETACT

pioglitazone hcl-metformin hcl 15-500 mg tab, 15-850 mg tab 1 ACTOPLUS MET

ANTIDIARRHEA AGENTS [AGENTES ANTIDIARREICOS]

Antidiarrhea Agents [Agentes Antidiarreicos]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

diphenoxylate-atropine 2.5-0.025 mg tab 1 LOMOTIL

diphenoxylate-atropine 2.5-0.025 mg/5ml liq 1 LOMOTIL

LOMOTIL 2.5-0.025 mg tab 3

loperamide hcl 2 mg cap 1 IMODIUM

MOTOFEN 1-0.025 mg tab 3

MYTESI 125 mg tab dr 3 PA

ANTIDOTES [ANTÍDOTOS]

Antidotes [Antídotos]

acetylcysteine 10 % inh soln, 20 % inh soln 1 MUCOMYST

leucovorin calcium 10 mg tab, 15 mg tab, 25 mg tab, 5 mg tab 1

ANTIEMETICS [ANTIEMÉTICOS]

5-ht3 Receptor Antagonists [Antagonistas Del Receptor 5-Ht3]

ANZEMET 100 mg tab, 50 mg tab 3

granisetron hcl 1 mg tab 1 KYTRIL

ondansetron 4 mg tab disint, 8 mg tab disint 1 ZOFRAN

ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab 1 ZOFRAN

ondansetron hcl 4 mg/2ml inj soln, 4 mg/5ml soln, 40 mg/20ml inj soln 1 ZOFRAN

SANCUSO 3.1 mg/24hr td patch 3

ZOFRAN 4 mg tab, 8 mg tab 3

ZOFRAN 4 mg/5ml soln 3

ZOFRAN ODT 4 mg tab disint, 8 mg tab disint 3

ZUPLENZ 4 mg oral film, 8 mg oral film 3

Antiemetics, Miscellaneous [Antieméticos, Misceláneos]

aprepitant 125 mg cap, 40 mg cap, 80 & 125 mg cap, 80 mg cap 1 EMEND

CESAMET 1 mg cap 3

DICLEGIS 10-10 mg tab dr 3

dronabinol 10 mg cap, 2.5 mg cap, 5 mg cap 1 MARINOL

EMEND 125 mg cap, 125 mg susp, 150 mg iv soln, 40 mg cap, 80 mg cap 3

EMEND TRI-PACK 80 & 125 mg cap 3

MARINOL 10 mg cap, 2.5 mg cap, 5 mg cap 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

scopolamine 1 mg/3days td patch 72 hr 1 TRANSDERM-SCOP

TRANSDERM-SCOP (1.5 MG) 1 mg/3days td patch 72 hr 3

Antihistamines [Antihistamínicos]

meclizine hcl 12.5 mg tab, 25 mg tab 1 ANTIVERT

TIGAN 300 mg cap 3

TIGAN 100 mg/ml im soln 3

trimethobenzamide hcl 300 mg cap 1 TIGAN

ANTIFUNGALS [ANTIFUNGALES]

Allylamines [Alilaminas]

LAMISIL 250 mg tab 3

terbinafine hcl 250 mg tab 1 LAMISIL

Antifungals, Miscellaneous [Antifungales, Misceláneos]

griseofulvin microsize 500 mg tab 1

griseofulvin microsize 125 mg/5ml susp 1 GRIFULVIN V

griseofulvin ultramicrosize 125 mg tab, 250 mg tab 1 GRIS-PEG

GRIS-PEG 125 mg tab, 250 mg tab 3

Azoles [Azoles]

DIFLUCAN 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3

DIFLUCAN 10 mg/ml susp, 40 mg/ml susp 3

fluconazole 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 1 DIFLUCAN

fluconazole 10 mg/ml susp, 40 mg/ml susp 1 DIFLUCAN

itraconazole 10 mg/ml soln 1

itraconazole 100 mg cap 1 SPORANOX

ketoconazole 200 mg tab 1 NIZORAL

NOXAFIL 100 mg tab dr 3

NOXAFIL 40 mg/ml susp 3

ONMEL 200 mg tab 3

SPORANOX 100 mg cap 3

SPORANOX 10 mg/ml soln 3

SPORANOX PULSEPAK 100 mg cap 3

VFEND 200 mg tab, 50 mg tab 3

VFEND 40 mg/ml susp 3

voriconazole 200 mg tab, 50 mg tab 1 VFEND

voriconazole 40 mg/ml susp 1 VFEND

Polyenes [Polienos]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

bio-statin 1000000 unit cap, 500000 unit cap 1

nystatin pwdr 1

nystatin 500000 unit tab 1 MYCOSTATIN

nystatin 100000 unit/ml m/t susp 1 MYCOSTATIN

Pyrimidines [Pirimidinas]

ANCOBON 250 mg cap, 500 mg cap 3

flucytosine 250 mg cap, 500 mg cap 1 ANCOBON

ANTIGLAUCOMA AGENTS [AGENTES ANTIGLAUCOMA]

Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]

ALPHAGAN P 0.1 % ophth soln, 0.15 % ophth soln 3

brimonidine tartrate 0.15 % ophth soln, 0.2 % ophth soln 1 ALPHAGAN

COMBIGAN 0.2-0.5 % ophth soln 3

SIMBRINZA 1-0.2 % ophth susp 3

Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]

BETAGAN 0.5 % ophth soln 3

betaxolol hcl 0.5 % ophth soln 1 BETOPTIC

BETIMOL 0.25 % ophth soln, 0.5 % ophth soln 3

BETOPTIC-S 0.25 % ophth susp 3

carteolol hcl 1 % ophth soln 1 OCUPRESS

ISTALOL 0.5 % ophth soln 3

levobunolol hcl 0.5 % ophth soln 1 BETAGAN

metipranolol 0.3 % ophth soln 1 OPTIPRANOLOL

timolol maleate 0.5 % (daily) ophth soln 1 ISTALOL

timolol maleate 0.25 % ophth gfs, 0.25 % ophth soln, 0.5 % ophth gfs, 0.5 % ophth soln 1 TIMOPTIC

TIMOPTIC 0.25 % ophth soln, 0.5 % ophth soln 3

TIMOPTIC OCUDOSE 0.25 % ophth soln, 0.5 % ophth soln 3

TIMOPTIC-XE 0.25 % ophth gfs, 0.5 % ophth gfs 3

Carbonic Anhydrase Inhibitors [Inhibidores De La Anhidrasa Carbónica]

acetazolamide 125 mg tab, 250 mg tab 1 DIAMOX

acetazolamide er 500 mg cap er 12 hr 1 DIAMOX

acetazolamide sodium 500 mg inj soln 1 DIAMOX

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

AZOPT 1 % ophth susp 3

COSOPT 22.3-6.8 mg/ml ophth soln 3

COSOPT PF 22.3-6.8 mg/ml ophth soln 3

dorzolamide hcl 2 % ophth soln 1 TRUSOPT

dorzolamide hcl-timolol mal 22.3-6.8 mg/ml ophth soln 1 COSOPT

dorzolamide hcl-timolol mal pf 22.3-6.8 mg/ml ophth soln 1

methazolamide 25 mg tab, 50 mg tab 1 NEPTAZANE

NEPTAZANE 25 mg tab 3

TRUSOPT 2 % ophth soln 3

Miotics [Mióticos]

ISOPTO CARPINE 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 3

MIOCHOL-E 20 mg i-ocul soln 3

MIOSTAT 0.01 % i-ocul soln 3

PHOSPHOLINE IODIDE 0.125 % ophth soln 3

pilocarpine hcl 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 1 ISOPTOCARPINE

Prostaglandin Analogs [Análogos De La Prostaglandina]

latanoprost 0.005 % ophth soln 1 XALATAN

LUMIGAN 0.01 % ophth soln 3

TRAVATAN Z 0.004 % ophth soln 3

XALATAN 0.005 % ophth soln 3

ZIOPTAN 0.0015 % ophth soln 3

ANTIGOUT AGENTS [AGENTES CONTRA LA GOTA]

Antigout Agents [Agentes Contra La Gota]

allopurinol 100 mg tab, 300 mg tab 1 ZYLOPRIM

colchicine 0.6 mg tab 1 COLCRYS

colchicine 0.6 mg cap 1 MITIGARE

COLCRYS 0.6 mg tab 3

KRYSTEXXA 8 mg/ml iv soln 3 PA

ULORIC 40 mg tab, 80 mg tab 3

ZYLOPRIM 100 mg tab, 300 mg tab 3

ANTIHEMORRHAGIC AGENTS [AGENTES ANTIHEMORRÁGICOS]

Hemostatics [Hemostáticos]

ADVATE 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 3000 unit iv soln, 4000 unit iv soln, 500 unit iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

adynovate 1000 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 500 unit iv soln 1 PA

ALPHANATE/VWF COMPLEX/HUMAN 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 500 unit iv soln 3 PA

ALPHANINE SD 1000 unit iv soln, 1500 unit iv soln, 500 unit iv soln 3 PA

ALPROLIX 1000 unit iv soln, 2000 unit iv soln, 3000 unit iv soln, 500 unit iv soln 3 PA

AMICAR 1000 mg tab, 500 mg tab 3 PA

AMICAR 0.25 gm/ml soln 3 PA

aminocaproic acid 250 mg/ml iv soln 1 PA

BEBULIN 200-1200 unit iv soln 3 PA

BENEFIX 1000 unit iv kit, 2000 unit iv kit, 250 unit iv kit, 3000 unit iv kit, 500 unit iv kit 3 PA

COAGADEX 250 unit iv soln, 500 unit iv soln 3 PA

CORIFACT 1000-1600 unit iv kit 3 PA

CYKLOKAPRON 1000 mg/10ml iv soln 3 PA

ELOCTATE 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 3000 unit iv soln, 500 unit iv soln, 750 unit iv soln 3 PA

FEIBA iv soln 3 PA

HELIXATE FS 1000 unit iv kit, 2000 unit iv kit, 250 unit iv kit, 3000 unit iv kit, 500 unit iv kit 3 PA

HEMOFIL M 1000 unit iv soln, 1700 unit iv soln, 250 unit iv soln, 500 unit iv soln 3 PA

HUMATE-P 1000-2400 unit iv soln, 250-600 unit iv soln, 500-1200 unit iv soln 3 PA

IXINITY 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 500 unit iv soln 3 PA

KCENTRA 1000 unit iv kit, 500 unit iv kit 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

KOATE 1000 unit iv soln, 250 unit iv soln, 500 unit iv soln 3 PA

KOATE-DVI 1000 unit iv soln, 250 unit iv soln, 500 unit iv soln 3 PA

KOGENATE FS 1000 unit iv kit, 2000 unit iv kit, 250 unit iv kit, 3000 unit iv kit, 500 unit iv kit 3 PA

KOGENATE FS BIO-SET 1000 unit iv kit, 2000 unit iv kit, 3000 unit iv kit 3 PA

KOVALTRY 1000 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 3000 unit iv soln, 500 unit iv soln 3 PA

LYSTEDA 650 mg tab 3 PA

MONOCLATE-P 1000 unit iv kit, 1500 unit iv kit 3 PA

MONONINE 1000 unit iv soln 3 PA

NOVOEIGHT 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 3000 unit iv soln, 500 unit iv soln 3 PA

NOVOSEVEN RT 1 mg iv soln, 2 mg iv soln, 5 mg iv soln, 8 mg iv soln 3 PA

NUWIQ 1000 unit iv kit, 1000 unit iv soln, 2000 unit iv kit, 2000 unit iv soln, 250 unit iv kit, 250 unit iv soln, 2500 unit iv kit, 2500 unit iv soln, 3000 unit iv kit, 3000 unit iv soln, 4000 unit iv kit, 4000 unit iv soln, 500 unit iv kit, 500 unit iv soln 3 PA

obizur 500 unit iv soln 1 PA

PROFILNINE 1000 unit iv soln, 1500 unit iv soln, 500 unit iv soln 3 PA

PROFILNINE SD 1000 unit iv soln, 1500 unit iv soln, 500 unit iv soln 3 PA

RECOMBINATE 1241-1800 unit iv soln, 1801-2400 unit iv soln, 220-400 unit iv soln, 401-800 unit iv soln, 801-1240 unit iv soln 3 PA

REFACTO 500 unit iv kit 3 PA

RIASTAP iv soln 3 PA

rixubis 1000 unit iv soln, 2000 unit iv soln, 250 unit iv soln, 3000 unit iv soln, 500 unit iv soln 1 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

tranexamic acid 1000 mg/10ml iv soln 1 CYKLOKAPRON PA

tranexamic acid 650 mg tab 1 LYSTEDA PA

TRETTEN 2000-3125 unit iv soln 3 PA

XYNTHA 1000 unit iv kit, 2000 unit iv kit, 250 unit iv kit, 500 unit iv kit 3 PA

XYNTHA SOLOFUSE 1000 unit iv kit, 2000 unit iv kit, 250 unit iv kit, 3000 unit iv kit, 500 unit iv kit 3 PA

ANTIHYPOGLYCEMIC AGENTS [AGENTES ANTIHIPOGLUCÉMICOS]

Antihypoglycemic Agents, Miscellaneous [Agentes Antihipoglucémicos, Misceláneos]

PROGLYCEM 50 mg/ml susp 3

Glycogenolytic Agents [Agentes Glucogenolíticos]

GLUCAGEN HYPOKIT 1 mg inj soln 3

GLUCAGON EMERGENCY 1 mg inj kit 2

ANTI-INFECTIVES [ANTIINFECCIOSOS]

Antibacterials [Antibacterianos]

ACANYA 1.2-2.5 % gel 3 AL

ak-poly-bac 500-10000 unit/gm ophth oint 1 POLYSPORIN

AKTIPAK 5-3 % ext pckt 3 AL

ALTABAX 1 % oint 3

AZASITE 1 % ophth soln 3

bacitracin 500 unit/gm ophth oint 1 BACI-IM

bacitracin-polymyxin b 500-10000 unit/gm ophth oint 1 POLYSPORIN

BACTROBAN 2 % crm 3

BACTROBAN NASAL 2 % nasal oint 3

BENZACLIN 1-5 % gel 3 AL

BENZACLIN WITH PUMP 1-5 % gel 3 AL

BENZAMYCIN 5-3 % gel 3 AL

benzoyl peroxide-erythromycin 5-3 % gel 1 BENZAMYCIN AL

BESIVANCE 0.6 % ophth susp 3

BLEPH-10 10 % ophth soln 3

CENTANY 2 % oint 3

CENTANY AT 2 % ext kit 3

CETRAXAL 0.2 % otic soln 3

CILOXAN 0.3 % ophth oint 3

CILOXAN 0.3 % ophth soln 3

ciprofloxacin hcl 0.2 % otic soln 1

ciprofloxacin hcl 0.3 % ophth soln 1 CILOXAN

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CLEOCIN 100 mg vag supp 3

CLEOCIN 2 % vag crm 3

CLEOCIN-T 1 % swab 3 AL

CLEOCIN-T 1 % gel 3 AL

CLEOCIN-T 1 % ext soln, 1 % lot 3 AL

CLINDACIN ETZ 1 % ext kit, 1 % swab 3 AL

CLINDACIN PAC 1 % ext kit 3 AL

CLINDACIN-P 1 % swab 3 AL

CLINDAGEL 1 % gel 3 AL

clindamycin phos-benzoyl perox 1.2-2.5 % gel 1 AL

clindamycin phos-benzoyl perox 1-5 % gel 1 BENZACLIN AL

clindamycin phos-benzoyl perox 1.2-5 % gel 1 DUAC AL

clindamycin phosphate 2 % vag crm 1 CLEOCIN

clindamycin phosphate 1 % swab 1 CLEOCIN-T AL

clindamycin phosphate 1 % gel 1 CLEOCIN-T AL

clindamycin phosphate 1 % ext soln, 1 % gel, 1 % lot 1 CLEOCIN-T AL

clindamycin phosphate 1 % foam 1 EVOCLIN AL

CLINDESSE 2 % vag crm 3

DUAC 1.2-5 % gel 3 AL

ery 2 % pad 1 AL

ERYGEL 2 % gel 3 AL

erythromycin 2 % pad 1 AL

erythromycin 2 % ext soln 1 ERYDERM AL

erythromycin 2 % gel 1 ERYGEL AL

erythromycin 5 mg/gm ophth oint 1 ILOTYCIN

EVOCLIN 1 % foam 3 AL

gatifloxacin 0.5 % ophth soln 1 ZYMAXID

GENTAK 0.3 % ophth oint 3

gentamicin sulfate 0.1 % crm, 0.1 % oint 1 GARAMYCIN

gentamicin sulfate 0.3 % ophth soln 1 GARAMYCIN

KLARON 10 % lot 3 AL

levofloxacin 0.5 % ophth soln 1 QUIXIN

METROCREAM 0.75 % crm 3 AL

METROGEL 1 % gel 3 AL

METROGEL-VAGINAL 0.75 % vag gel 3

METROLOTION 0.75 % lot 3 AL

metronidazole 0.75 % crm 1 METROCREAM AL

metronidazole 0.75 % vag gel 1 METROGEL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

metronidazole 0.75 % gel, 1 % gel 1 METROGEL AL

metronidazole 0.75 % lot 1 METROLOTION AL

MITOSOL 0.2 mg ophth kit 3

MOXEZA 0.5 % ophth soln 3

moxifloxacin hcl 0.5 % ophth soln 1 VIGAMOX

mupirocin 2 % oint 1 BACTROBAN

mupirocin calcium 2 % crm 1 BACTROBAN

neomycin-bacitracin zn-polymyx 5-400-10000 ophth oint 1 NEOSPORIN

neomycin-polymyxin-gramicidin 1.75-10000-.025 ophth soln 1 NEOSPORIN

NEO-POLYCIN 3.5-400-10000 ophth oint 3

NEOSPORIN 1.75-10000-.025 ophth soln 3

NEUAC 1.2-5 % ext kit, 1.2-5 % gel 3 AL

NORITATE 1 % crm 3 AL

OCUFLOX 0.3 % ophth soln 3

ofloxacin 0.3 % otic soln 1 FLOXIN

ofloxacin 0.3 % ophth soln 1 OCUFLOX

POLYCIN 500-10000 unit/gm ophth oint 3

polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln 1 POLYTRIM

POLYTRIM 10000-0.1 unit/ml-% ophth soln 3

ROSADAN 0.75 % (cream) ext kit, 0.75 % (gel) ext kit 3 AL

ROSADAN 0.75 % crm, 0.75 % gel 3 AL

sulfacetamide sodium 10 % ophth soln 1 BLEPH-10

sulfacetamide sodium 10 % ophth oint 1 SODIUM SULAMYD

sulfacetamide sodium (acne) 10 % lot 1 KLARON AL

tobramycin 0.3 % ophth soln 1 TOBREX

TOBREX 0.3 % ophth oint 3

TOBREX 0.3 % ophth soln 3

VANDAZOLE 0.75 % vag gel 3

VIGAMOX 0.5 % ophth soln 3

ZYMAXID 0.5 % ophth soln 3

Antifungals [Antifungales]

ALA-QUIN 3-0.5 % crm 3

CICLODAN 0.77 % crm 3

CICLODAN 8 % ext soln 3

CICLODAN CREAM 0.77 % ext kit 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CICLODAN SOLUTION 8 % ext kit 3

ciclopirox 0.77 % gel 1 LOPROX

ciclopirox 1 % shampoo 1 LOPROX

ciclopirox 8 % ext soln 1 PENLAC

ciclopirox olamine 0.77 % crm 1 LOPROX

ciclopirox olamine 0.77 % ext susp 1 LOPROX

ciclopirox treatment 8 % ext kit 1

clotrimazole 1 % crm 1 LOTRIMIN

clotrimazole 10 mg m/t lozg, 10 mg m/t troche 1 MYCELEX

clotrimazole 1 % ext soln 1 MYCELEX

clotrimazole-betamethasone 1-0.05 % crm 1 LOTRISONE

clotrimazole-betamethasone 1-0.05 % lot 1 LOTRISONE

econazole nitrate 1 % crm 1 SPECTAZOLE

ECOZA 1 % foam 3

ERTACZO 2 % crm 3

EXELDERM 1 % crm 3

EXELDERM 1 % ext soln 3

EXODERM 25-1 % lot 3

EXTINA 2 % foam 3

GYNAZOLE-1 2 % vag crm 3

HALOTIN 1 % crm 3

JUBLIA 10 % ext soln 3

ketoconazole 2 % foam 1 EXTINA

ketoconazole 2 % crm 1 NIZORAL

ketoconazole 2 % shampoo 1 NIZORAL

LOPROX 0.77 % crm, 0.77 % ext kit 3

LOPROX 1 % shampoo 3

LOTRISONE 1-0.05 % crm 3

luliconazole 1 % crm 1

LUZU 1 % crm 3

MENTAX 1 % crm 3

miconazole 3 200 mg vag supp 1 MONISTAT

naftifine hcl 1 % crm, 2 % crm 1 NAFTIN

NAFTIN 1 % gel, 2 % crm, 2 % gel 3

NATACYN 5 % ophth susp 3

NIZORAL 2 % shampoo 3

nystatin 100000 unit/gm crm, 100000 unit/gm oint 1 MYCOSTATIN

oxiconazole nitrate 1 % crm 1 OXISTAT

OXISTAT 1 % crm 3

OXISTAT 1 % lot 3

PENLAC 8 % ext soln 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

QUINJA 1.25-1 % gel 3

TERAZOL 7 0.4 % vag crm 3

terconazole 0.4 % vag crm, 0.8 % vag crm 1 TERAZOL

terconazole 80 mg vag supp 1 TERAZOL 3

VUSION 0.25-15-81.35 % oint 3

XOLEGEL 2 % gel 3

XOLEGEL COREPAK 2 & 1 % ext kit 3

XOLEGEL DUO/HEAD & SHOULDERS 2 & 1 % ext kit 3

XOLEGEL DUO/XOLEX 2 & 1 % ext kit 3

Antivirals [Antivirales]

acyclovir 5 % oint 1 ZOVIRAX

DENAVIR 1 % crm 3

trifluridine 1 % ophth soln 1 VIROPTIC

VIROPTIC 1 % ophth soln 3

ZIRGAN 0.15 % ophth gel 3

ZOVIRAX 5 % crm, 5 % oint 3

Eent Anti-infectives, Miscellaneous [Antiinfecciosos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

BETADINE OPHTHALMIC PREP 5 % ophth soln 3

chlorhexidine gluconate 0.12 % m/t soln 1 PERIOGARD

PAROEX 0.12 % m/t soln 3

PERIDEX 0.12 % m/t soln 3

PERIOGARD 0.12 % m/t soln 3

Local Anti-infectives, Miscellaneous [Antiinfecciosos Locales, Misceláneos]

ALCORTIN A 1-2-1 % gel 3

AVC VAGINAL 15 % vag crm 3

BENZAC AC WASH 5 % ext liq 3 AL

BENZEFOAM 5.3 % foam 3 AL

BENZEFOAMULTRA 9.8 % foam 3 AL

BENZEPRO 5.3 % foam 3 AL

BENZEPRO CREAMY WASH 7 % ext liq 3 AL

BENZEPRO SHORT CONTACT 9.8 % foam 3 AL

BENZIQ 5.25 % gel 3 AL

BENZIQ LS 2.75 % gel 3 AL

BENZIQ WASH 5.25 % ext liq 3 AL

benzoyl peroxide 8 % gel, 9.8 % foam 1 AL

bp foam 5.3 % foam, 9.8 % foam 1 AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

bp wash 2.5 % ext liq 1 AL

bp wash 7 % ext liq 1 AL

bpo 4 % gel, 8 % gel 1 AL

bpo foaming cloths 6 % ext misc 1 AL

BUCALSEP ext liq, ext soln 3

DERMAZENE 1-1 % crm 3

FEM PH 0.9-0.025 % vag gel 3

hydrocortisone-iodoquinol 1-1 % crm 1

INOVA 4 & 5 % ext kit, 8 & 5 % ext kit 3 AL

INOVA 4/1 ACNE CONTROL THERAPY 4 & 1 & 5 % ext kit 3 AL

INOVA 8/2 ACNE CONTROL THERAPY 8 & 2 & 5 % ext kit 3 AL

iodoquimez-hc 1-1.9 % crm 1

iodoquinol-hc-aloe polysacch 1-2-1 % gel 1

iodoquinol-hydrocortisone-aloe 1-1.9 % crm 1

PR BENZOYL PEROXIDE WASH 7 % ext liq 3 AL

RELAGARD 0.9-0.025 % vag gel 3

RIAX 5.5 % foam, 9.5 % foam 3 AL

SILVADENE 1 % crm 3

silver sulfadiazine 1 % crm 1 SILVADENE

SSD 1 % crm 3

VYTONE 1-1.9 % crm 3

ZACARE 4 & 0.2 % ext kit, 8 & 0.2 % ext kit 3 AL

zaclir cleansing 8 % lot 1 AL

Scabicides And Pediculicides [Escabicidas Y Pediculicidas]

ELIMITE 5 % crm 3

EURAX 10 % crm, 10 % lot 3

lindane 1 % shampoo 1

malathion 0.5 % lot 1 OVIDE

NATROBA 0.9 % ext susp 3

OVIDE 0.5 % lot 3

permethrin 5 % crm 1 ELIMITE

SKLICE 0.5 % lot 3

spinosad 0.9 % ext susp 1

sulfurated lime ext soln 1

ULESFIA 5 % lot 3

ANTI-INFLAMMATORY AGENTS [AGENTES ANTIINFLAMATORIOS]

Anti-inflammatory Agents [Agentes Antiinflamatorios]

ALA SCALP 2 % lot 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ala-cort 1 % crm 1 ALA-CORT

ala-cort 2.5 % crm 1 HYTONE

alclometasone dipropionate 0.05 % crm, 0.05 % oint 1 ACLOVATE

alosetron hcl 0.5 mg tab, 1 mg tab 1 LOTRONEX

amcinonide 0.1 % crm, 0.1 % oint 1 CYCLOCORT

amcinonide 0.1 % lot 1 CYCLOCORT

anucort-hc 25 mg rect supp 1

ANUSOL-HC 25 mg rect supp 3

ANUSOL-HC 2.5 % rect crm 3

APEXICON E 0.05 % crm 3

APRISO 0.375 gm cap er 24 hr 3

ASACOL HD 800 mg tab dr 3

balsalazide disodium 750 mg cap 1 COLAZAL

betamethasone dipropionate 0.05 % crm, 0.05 % oint 1 DIPROSONE

betamethasone dipropionate 0.05 % lot 1 DIPROSONE

betamethasone dipropionate aug 0.05 % crm, 0.05 % gel, 0.05 % oint 1 DIPROLENE

betamethasone dipropionate aug 0.05 % lot 1 DIPROLENE

betamethasone valerate 0.1 % crm, 0.1 % oint 1 BETA-VAL

betamethasone valerate 0.1 % lot 1 BETA-VAL

betamethasone valerate 0.12 % foam 1 LUXIQ

calcipotriene-betameth diprop 0.005-0.064 % oint 1 TACLONEX

CANASA 1000 mg rect supp 3

CAPEX 0.01 % shampoo 3

clobetasol prop emollient base 0.05 % crm 1 TEMOVATE-E

clobetasol propionate 0.05 % crm 1

clobetasol propionate 0.05 % oint 1 CLOBEX

clobetasol propionate 0.05 % ext soln 1 CLOBEX

clobetasol propionate 0.05 % ext liq, 0.05 % lot, 0.05 % shampoo 1 CLODAN

clobetasol propionate 0.05 % foam 1 OLUX

clobetasol propionate 0.05 % gel 1 TEMOVATE

clobetasol propionate e 0.05 % crm 1 TEMOVATE-E

clobetasol propionate emulsion 0.05 % foam 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CLOBEX 0.05 % lot, 0.05 % shampoo 3

CLOBEX SPRAY 0.05 % ext liq 3

clocortolone pivalate 0.1 % crm 1

clocortolone pivalate pump 0.1 % crm 1

CLODAN 0.05 % ext kit 3

CLODAN 0.05 % shampoo 3

CLODERM 0.1 % crm 3

CLODERM PUMP 0.1 % crm 3

COLAZAL 750 mg cap 3

COLOCORT 100 mg/60ml rect enema 3

CORDRAN 4 mcg/sqcm tape 3

CORDRAN 0.05 % crm, 0.05 % oint 3

CORDRAN 0.05 % lot 3

CORTANE-B 10-10-1 mg/ml lot 3

CORTENEMA 100 mg/60ml rect enema 3

CORTIFOAM 10 % rect foam 3

CUTIVATE 0.05 % lot 3

DELZICOL 400 mg cap dr 3

DERMA-SMOOTHE/FS BODY 0.01 % ext oil 3

DERMA-SMOOTHE/FS SCALP 0.01 % ext oil 3

DERMASORB HC 2 % ext kit 3

DERMASORB TA 0.1 % ext kit 3

DESONATE 0.05 % gel 3

desonide 0.05 % crm, 0.05 % oint 1 DESOWEN

desonide 0.05 % lot 1 DESOWEN

DESOWEN 0.05 % crm 3

DESOWEN 0.05 % lot 3

desoximetasone 0.25 % ext liq 1

desoximetasone 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 1 TOPICORT

diflorasone diacetate 0.05 % crm, 0.05 % oint 1 PSORCON

DIPENTUM 250 mg cap 3

DIPROLENE 0.05 % oint 3

DIPROLENE 0.05 % lot 3

DIPROLENE AF 0.05 % crm 3

ELOCON 0.1 % crm, 0.1 % oint 3

EPIFOAM 1-1 % foam 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

FIRST-HYDROCORTISONE 10 % gel 3

fluocinolone acetonide 0.01 % crm, 0.025 % crm, 0.025 % oint 1 SYNALAR

fluocinolone acetonide 0.01 % ext soln 1 SYNALAR

fluocinolone acetonide body 0.01 % ext oil 1 DERMA-SMOOTHE/FS

fluocinolone acetonide scalp 0.01 % ext oil 1

fluocinonide 0.05 % crm, 0.05 % gel, 0.05 % oint 1 LIDEX

fluocinonide 0.05 % ext soln 1 LIDEX

fluocinonide 0.1 % crm 1 VANOS

fluocinonide emulsified base 0.05 % crm 1 LIDEX-E

flurandrenolide 0.05 % crm, 0.05 % oint 1 CORDRAN

flurandrenolide 0.05 % lot 1 CORDRAN

fluticasone propionate 0.005 % oint, 0.05 % crm 1 CUTIVATE

fluticasone propionate 0.05 % lot 1 CUTIVATE

GIAZO 1.1 gm tab 3

halac 0.05 & 12 % ext kit 1

halobetasol propionate 0.05 % crm, 0.05 % oint 1 ULTRAVATE

HALOG 0.1 % crm, 0.1 % oint 3

HEMMOREX-HC 25 mg rect supp 3

hydrocortisone 1 % rect crm, 2.5 % rect crm 1

hydrocortisone 1 % crm, 1 % oint 1 ALA-CORT

hydrocortisone 100 mg/60ml rect enema 1 CORTENEMA

hydrocortisone 2.5 % crm, 2.5 % oint 1 HYTONE

hydrocortisone 2.5 % lot 1 HYTONE

hydrocortisone ace-pramoxine 2.5-1 % crm 1

hydrocortisone acetate 25 mg rect supp, 30 mg rect supp 1

hydrocortisone butyr lipo base 0.1 % crm 1 LOCOID LIPOCREAM

hydrocortisone butyrate 0.1 % crm, 0.1 % oint 1 LOCOID

hydrocortisone butyrate 0.1 % ext soln, 0.1 % lot 1 LOCOID

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

hydrocortisone valerate 0.2 % crm, 0.2 % oint 1 WESTCORT

KENALOG 0.147 mg/gm ext aer soln 3

LIALDA 1.2 gm tab dr 3

LOCOID 0.1 % crm, 0.1 % oint 3

LOCOID 0.1 % ext soln, 0.1 % lot 3

LOCOID LIPOCREAM 0.1 % crm 3

LOTRONEX 0.5 mg tab, 1 mg tab 3

LUXIQ 0.12 % foam 3

mesalamine 4 gm rect enema 1

mesalamine 800 mg tab dr 1 ASACOL HD

mesalamine 1.2 gm tab dr 1 LIALDA

mesalamine-cleanser 4 gm rect kit 1 ROWASA

mezparox-hc 1-2.5 % crm 1

mometasone furoate 0.1 % crm, 0.1 % oint 1 ELOCON

mometasone furoate 0.1 % ext soln 1 ELOCON

NOLIX 0.05 % lot 3

NUCORT 2 % lot 3

nystatin-triamcinolone 100000-0.1 unit/gm-% crm, 100000-0.1 unit/gm-% oint 1 MYCOLOG

OLUX 0.05 % foam 3

OLUX-E 0.05 % foam 3

ORALONE 0.1 % m/t paste 3

PANDEL 0.1 % crm 3

PENTASA 250 mg cap er, 500 mg cap er 3

PRAMOSONE 1-1 % crm, 1-1 % oint, 1-2.5 % crm, 1-2.5 % oint 3

PRAMOSONE 1-1 % lot, 1-2.5 % lot 3

PRAMOSONE E 1-2.5 % crm 3

prednicarbate 0.1 % crm, 0.1 % oint 1 DERMATOP

PROCTOCORT 30 mg rect supp 3

PROCTOCORT 1 % rect crm 3

PROCTO-MED HC 2.5 % rect crm 3

PROCTO-PAK 1 % rect crm 3

PROCTOSOL HC 2.5 % rect crm 3

PROCTOZONE-HC 2.5 % rect crm 3

psorcon 0.05 % crm 1 PSORCON

ROWASA 4 gm rect kit 3

SCALACORT DK 2 & 2-2 % ext kit 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

SFROWASA 4 gm/60ml rect enema 3

SYNALAR 0.025 % crm, 0.025 % oint 3

SYNALAR 0.01 % ext soln 3

SYNALAR (CREAM) 0.025 % ext kit 3

SYNALAR (OINTMENT) 0.025 % ext kit 3

SYNALAR TS 0.01 % ext kit 3

TACLONEX 0.005-0.064 % ext susp, 0.005-0.064 % oint 3

TEMOVATE 0.05 % crm, 0.05 % oint 3

TEXACORT 2.5 % ext soln 3

TOPICORT 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 3

TOPICORT SPRAY 0.25 % ext liq 3

triamcinolone acetonide 0.025 % oint, 0.1 % oint, 0.147 mg/gm ext aer soln, 0.5 % oint 1 KENALOG

triamcinolone acetonide 0.025 % lot, 0.1 % lot 1 KENALOG

triamcinolone acetonide 0.1 % m/t paste 1

KENALOG IN ORABASE

triamcinolone acetonide 0.025 % crm, 0.1 % crm, 0.5 % crm 1 TRIDERM

TRIANEX 0.05 % oint 3

TRIDERM 0.1 % crm 3

TRIDESILON 0.05 % crm 3

ULTRAVATE 0.05 % crm, 0.05 % oint 3

ULTRAVATE X (CREAM) 0.05 & 10 % ext kit 3

ULTRAVATE X (OINTMENT) 0.05 & 10 % ext kit 3

VANOS 0.1 % crm 3

VERDESO 0.05 % foam 3

Corticosteroids [Corticosteroides]

ACETASOL HC 2-1 % otic soln 3

ALREX 0.2 % ophth susp 3

bacitra-neomycin-polymyxin-hc 1 % ophth oint 1 CORTISPORIN

BECONASE AQ 42 mcg/spray nasal susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

benzoyl perox-hydrocortisone 5-0.5 % lot 1 AL

BLEPHAMIDE 10-0.2 % ophth susp 3

BLEPHAMIDE S.O.P. 10-0.2 % ophth oint 3

CIPRO HC 0.2-1 % otic susp 3

CIPRODEX 0.3-0.1 % otic susp 3

COLY-MYCIN S 3.3-3-10-0.5 mg/ml otic susp 3

CORTANE-B 10-10-1 mg/ml otic soln 3

CORTANE-B AQUEOUS 10-10-1 mg/ml otic soln 3

CORTIC-ND 10-10-1 mg/ml otic soln 3

CYOTIC 10-10-1 mg/ml otic soln 3

DERMOTIC 0.01 % otic oil 3

dexamethasone sodium phosphate 0.1 % ophth soln 1 MAXIDEX

DUREZOL 0.05 % ophth emul 3

exotic-hc 10-10-1 mg/ml otic soln 1

FLAREX 0.1 % ophth susp 3

flunisolide 25 MCG/ACT (0.025%) nasal soln 1 NASALIDE

fluocinolone acetonide 0.01 % otic oil 1 DERMOTIC

fluorometholone 0.1 % ophth susp 1 FML

fluticasone propionate 50 mcg/act nasal susp 1 FLONASE

FML 0.1 % ophth oint 3

FML FORTE 0.25 % ophth susp 3

FML LIQUIFILM 0.1 % ophth susp 3

hydrocortisone-acetic acid 1-2 % otic soln 1 ACETASOL HC

LOTEMAX 0.5 % ophth gel, 0.5 % ophth oint 3

LOTEMAX 0.5 % ophth susp 3

MAXIDEX 0.1 % ophth susp 3

MAXITROL 3.5-10000-0.1 ophth oint 3

MAXITROL 3.5-10000-0.1 ophth susp 3

mometasone furoate 50 mcg/act nasal susp 1 NASONEX

NASONEX 50 mcg/act nasal susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth oint 1 MAXITROL

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth susp 1 MAXITROL

neomycin-polymyxin-hc 1 % otic soln, 3.5-10000-1 ophth susp, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp 1 CORTISPORIN

NEO-POLYCIN HC 1 % ophth oint 3

OMNARIS 50 mcg/act nasal susp 3

OMNIPRED 1 % ophth susp 3

OTICIN HC NR 10-10-1 mg/ml otic soln 3

otomax-hc 10-10-1 mg/ml otic soln 1

OZURDEX 0.7 mg Intravitreal Implant 3

PRED FORTE 1 % ophth susp 3

PRED MILD 0.12 % ophth susp 3

PRED-G 0.3-1 % ophth susp 3

PRED-G S.O.P. 0.3-0.6 % ophth oint 3

prednisolone acetate 1 % ophth susp 1 PRED FORTE

prednisolone sodium phosphate 1 % ophth soln 1

QNASL 80 mcg/act nasal aer soln 3

QNASL CHILDRENS 40 mcg/act nasal aer soln 3

RETISERT 0.59 mg Intravitreal Implant 3

sulfacetamide-prednisolone 10-0.23 % ophth soln 1 VASOCIDIN

TOBRADEX 0.3-0.1 % ophth oint 3

TOBRADEX 0.3-0.1 % ophth susp 3

TOBRADEX ST 0.3-0.05 % ophth susp 3

tobramycin-dexamethasone 0.3-0.1 % ophth susp 1 TOBRADEX

triamcinolone acetonide 55 mcg/act nasal aer 1 NASACORT

TRIESENCE 40 mg/ml i-ocul susp 3

VANOXIDE-HC 5-0.5 % lot 3 AL

ZETONNA 37 mcg/act nasal aer soln 3

ZYLET 0.5-0.3 % ophth susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

Eent Anti-inflammatory Agents, Misc [Antiinflamatorios Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

RESTASIS 0.05 % ophth emul 3 PA

RESTASIS MULTIDOSE 0.05 % ophth emul 3 PA

Leukotriene Modifiers [Modificadores De Leucotrienos]

ACCOLATE 10 mg tab, 20 mg tab 3

montelukast sodium 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 1 SINGULAIR

SINGULAIR 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 3

zafirlukast 10 mg tab, 20 mg tab 1 ACCOLATE

zileuton er 600 mg tab er 12 hr 1 ZYFLO CR

ZYFLO 600 mg tab 3

ZYFLO CR 600 mg tab er 12 hr 3

Mast-cell Stabilizers [Estabilizadores De Los Mastocitos]

cromolyn sodium 100 mg/5ml oral conc 1 GASTROCROM

cromolyn sodium 20 mg/2ml inh neb soln 1 INTAL

GASTROCROM 100 mg/5ml oral conc 3

Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]

ACULAR 0.5 % ophth soln 3

ACULAR LS 0.4 % ophth soln 3

ACUVAIL 0.45 % ophth soln 3

bromfenac sodium (once-daily) 0.09 % ophth soln 1

diclofenac sodium 0.1 % ophth soln 1 VOLTAREN

flurbiprofen sodium 0.03 % ophth soln 1 OCUFEN

ILEVRO 0.3 % ophth susp 3

ketorolac tromethamine 0.4 % ophth soln, 0.5 % ophth soln 1 ACULAR

NEVANAC 0.1 % ophth susp 3

PROLENSA 0.07 % ophth soln 3

ANTILIPEMIC AGENTS [AGENTES ANTILIPÉMICOS]

Antilipemic Agents, Miscellaneous [Agentes Antilipémicos, Misceláneos]

JUXTAPID 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap, 5 mg cap, 60 mg cap 3 PA

LOVAZA 1 gm cap 3

niacin er (antihyperlipidemic) 1000 mg tab er, 500 mg tab er, 750 mg tab er 1 NIASPAN

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NIASPAN 1000 mg tab er, 500 mg tab er, 750 mg tab er 3

omega-3-acid ethyl esters 1 gm cap 1 LOVAZA

triklo 1 gm cap 1 LOVAZA

VASCEPA 1 gm cap 3

Bile Acid Sequestrants [Secuestradores Del Ácido Biliar]

cholestyramine 4 gm pckt 1

cholestyramine 4 gm/dose oral pwdr 1 QUESTRAN

cholestyramine light 4 gm pckt 1 QUESTRAN LIGHT

cholestyramine light 4 gm/dose oral pwdr 1 QUESTRAN LIGHT

colesevelam hcl 3.75 gm pckt, 625 mg tab 1 WELCHOL

COLESTID 1 gm tab, 5 gm pckt 3

COLESTID 5 gm oral gr 3

COLESTID FLAVORED 5 gm pckt 3

COLESTID FLAVORED 5 gm oral gr 3

colestipol hcl 5 gm pckt 1

colestipol hcl 1 gm tab 1 COLESTID

colestipol hcl 5 gm oral gr 1 COLESTID

PREVALITE 4 gm pckt 3

PREVALITE 4 gm/dose oral pwdr 3

QUESTRAN 4 gm pckt 3

QUESTRAN 4 gm/dose oral pwdr 3

QUESTRAN LIGHT 4 gm/dose oral pwdr 3

WELCHOL 3.75 gm pckt, 625 mg tab 3

Cholesterol Absorption Inhibitors [Inhibidores De La Absorción Del Colesterol]

ezetimibe 10 mg tab 1 ZETIA

ZETIA 10 mg tab 3

Fibric Acid Derivatives [Derivados De Ácido Fíbrico]

ANTARA 30 mg cap, 90 mg cap 3

choline fenofibrate 135 mg cap dr 1 TRILIPIX

fenofibrate 120 mg tab, 40 mg tab 1 FENOGLIDE

fenofibrate 150 mg cap, 50 mg cap 1 LIPOFEN

fenofibrate 145 mg tab, 160 mg tab, 48 mg tab, 54 mg tab 1 TRICOR

fenofibrate micronized 130 mg cap, 43 mg cap 1 ANTARA

fenofibrate micronized 134 mg cap, 200 mg cap, 67 mg cap 1 TRICOR

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

fenofibric acid 105 mg tab, 35 mg tab 1 FIBRICOR

fenofibric acid 135 mg cap dr, 45 mg cap dr 1 TRILIPIX

FENOGLIDE 120 mg tab, 40 mg tab 3

FIBRICOR 105 mg tab, 35 mg tab 3

gemfibrozil 600 mg tab 1 LOPID

LIPOFEN 150 mg cap, 50 mg cap 3

LOPID 600 mg tab 3

TRICOR 145 mg tab, 48 mg tab 3

TRIGLIDE 160 mg tab 3

TRILIPIX 135 mg cap dr, 45 mg cap dr 3

Hmg-coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]

ALTOPREV 20 mg tab er 24 hr, 40 mg tab er 24 hr, 60 mg tab er 24 hr 3

atorvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 LIPITOR

CRESTOR 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 3

ezetimibe-simvastatin 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab 1 VYTORIN

fluvastatin sodium 20 mg cap, 40 mg cap 1 LESCOL

fluvastatin sodium er 80 mg tab er 24 hr 1 LESCOL XL

LESCOL XL 80 mg tab er 24 hr 3

LIPITOR 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 3

LIVALO 1 mg tab, 2 mg tab, 4 mg tab 3

lovastatin 10 mg tab, 20 mg tab, 40 mg tab 1 MEVACOR

PRAVACHOL 20 mg tab, 40 mg tab, 80 mg tab 3

pravastatin sodium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 PRAVACHOL

rosuvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 CRESTOR

simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab 1 ZOCOR

VYTORIN 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ZOCOR 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab 3

ANTIMANIC AGENTS [AGENTES ANTIMANÍACOS]

Antimanic Agents [Agentes Antimaníacos]

lithium 8 meq/5ml soln 1

lithium carbonate 150 mg cap, 300 mg tab, 600 mg cap 1

lithium carbonate 300 mg cap 1 ESKALITH

lithium carbonate er 450 mg tab er 1 ESKALITH CR

lithium carbonate er 300 mg tab er 1 LITHOBID

LITHOBID 300 mg tab er 3

ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]

Antimigraine Agents, Miscellaneous [Agentes Antimigraña, Misceláneos]

CAFERGOT 1-100 mg tab 3 QL(30 / 30)

ergotamine-caffeine 1-100 mg tab 1 CAFERGOT QL(30 / 30)

isometheptene-dichloral-apap 65-100-325 mg cap 1 QL(30 / 30)

MIGERGOT 2-100 mg rect supp 3 QL(12 / 30)

Selective Serotonin Agonists [Agonistas Selectivos De Serotonina]

almotriptan malate 12.5 mg tab, 6.25 mg tab 1 AXERT QL(6 / 30)

AMERGE 1 mg tab, 2.5 mg tab 3 QL(9 / 30)

AXERT 12.5 mg tab, 6.25 mg tab 3 QL(6 / 30)

eletriptan hydrobromide 20 mg tab, 40 mg tab 1 RELPAX QL(6 / 30)

FROVA 2.5 mg tab 3 QL(9 / 30)

frovatriptan succinate 2.5 mg tab 1 FROVA QL(9 / 30)

IMITREX 6 mg/0.5ml sc soln 3 QL(2 / 30)

IMITREX 20 mg/act nasal soln, 5 mg/act nasal soln 3 QL(6 / 30)

IMITREX 100 mg tab, 25 mg tab, 50 mg tab 3 QL(9 / 30)

IMITREX STATDOSE REFILL 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 3 QL(2 / 30)

IMITREX STATDOSE SYSTEM 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln auto-inj 3 QL(2 / 30)

MAXALT 10 mg tab 3 QL(9 / 30)

MAXALT-MLT 10 mg tab disint, 5 mg tab disint 3 QL(9 / 30)

naratriptan hcl 1 mg tab, 2.5 mg tab 1 AMERGE QL(9 / 30)

RELPAX 20 mg tab, 40 mg tab 3 QL(6 / 30)

rizatriptan benzoate 10 mg tab, 10 mg tab disint, 5 mg tab, 5 mg tab disint 1 MAXALT QL(9 / 30)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

sumatriptan 20 mg/act nasal soln, 5 mg/act nasal soln 1 IMITREX QL(6 / 30)

sumatriptan succinate 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln, 6 mg/0.5ml sc soln auto-inj 1 IMITREX QL(2 / 30)

sumatriptan succinate 100 mg tab, 25 mg tab, 50 mg tab 1 IMITREX QL(9 / 30)

sumatriptan succinate refill 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 1 IMITREX QL(2 / 30)

sumatriptan-naproxen sodium 85-500 mg tab 1 TREXIMET QL(9 / 30)

SUMAVEL DOSEPRO 6 mg/0.5ml sc soln jet-inj 3 QL(2 / 30)

TREXIMET 85-500 mg tab 3 QL(9 / 30)

zolmitriptan 2.5 mg tab, 2.5 mg tab disint, 5 mg tab, 5 mg tab disint 1 ZOMIG QL(6 / 30)

ZOMIG 2.5 mg nasal soln, 2.5 mg tab, 5 mg nasal soln, 5 mg tab 3 QL(6 / 30)

ZOMIG ZMT 2.5 mg tab disint, 5 mg tab disint 3 QL(6 / 30)

ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

Antimycobacterials, Miscellaneous [Antimicobacterianos, Misceláneos]

dapsone 100 mg tab, 25 mg tab 1

Antituberculosis Agents [Agentes Antituberculosis]

CAPASTAT SULFATE 1 gm inj soln 3

cycloserine 250 mg cap 1

ethambutol hcl 100 mg tab, 400 mg tab 1 MYAMBUTOL

isoniazid 100 mg tab, 300 mg tab 1

isoniazid 100 mg/ml inj soln, 50 mg/5ml syr 1

MYAMBUTOL 100 mg tab, 400 mg tab 3

MYCOBUTIN 150 mg cap 3

PASER 4 gm pckt 3

PRIFTIN 150 mg tab 3

pyrazinamide 500 mg tab 1

rifabutin 150 mg cap 1 MYCOBUTIN

RIFADIN 150 mg cap, 300 mg cap 3

RIFAMATE 150-300 mg cap 3

rifampin 150 mg cap, 300 mg cap 1 RIFADIN

RIFATER 50-120-300 mg tab 3

SIRTURO 100 mg tab 3 PA

TRECATOR 250 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ANTINEOPLASTIC AGENTS [AGENTES ANTINEOPLÁSICOS]

Antineoplastic Agents [Agentes Antineoplásicos]

AFINITOR 10 mg tab, 2.5 mg tab, 5 mg tab, 7.5 mg tab 3 PA

AFINITOR DISPERZ 2 mg tab sol, 3 mg tab sol, 5 mg tab sol 3 PA

ALECENSA 150 mg cap 3 PA

ALIMTA 100 mg iv soln, 500 mg iv soln 2

ALKERAN 2 mg tab 3 PA

ALUNBRIG 30 mg tab 3 PA

anastrozole 1 mg tab 1 ARIMIDEX

ARIMIDEX 1 mg tab 3

AROMASIN 25 mg tab 3

bexarotene 75 mg cap 1 TARGRETIN

bicalutamide 50 mg tab 1 CASODEX

BOSULIF 100 mg tab, 400 mg tab, 500 mg tab 3 PA

BRAFTOVI 50 mg cap, 75 mg cap 3 PA

CABOMETYX 20 mg tab, 40 mg tab, 60 mg tab 3 PA

capecitabine 150 mg tab, 500 mg tab 1 PA

CAPRELSA 100 mg tab, 300 mg tab 3 PA

CASODEX 50 mg tab 3

COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 mg oral kit 3 PA

COMETRIQ (140 MG DAILY DOSE) 1 X 80 & 3 X 20 mg oral kit 3 PA

COMETRIQ (60 MG DAILY DOSE) 20 mg oral kit 3 PA

cyclophosphamide 25 mg cap, 50 mg cap 1

CYRAMZA 100 mg/10ml iv soln, 500 mg/50ml iv soln 2

ELIGARD 22.5 mg sc kit, 30 mg sc kit, 45 mg sc kit, 7.5 mg sc kit 3 PA

EMCYT 140 mg cap 3 PA

ERBITUX 100 mg/50ml iv soln, 200 mg/100ml iv soln 2

ERIVEDGE 150 mg cap 3 PA

ERLEADA 60 mg tab 3 PA

etoposide 50 mg cap 1

exemestane 25 mg tab 1 AROMASIN

FARESTON 60 mg tab 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

FARYDAK 10 mg cap, 15 mg cap, 20 mg cap 3 PA

FASLODEX 250 mg/5ml im soln 3

FEMARA 2.5 mg tab 3

FIRMAGON 120 mg sc soln, 80 mg sc soln 3

flutamide 125 mg cap 1 EULEXIN

gemcitabine hcl 200 mg iv soln 1

gemcitabine hcl 1 gm iv soln 1 GEMZAR

GEMZAR 1 gm iv soln, 200 mg iv soln 2

GILOTRIF 20 mg tab, 30 mg tab, 40 mg tab 3 PA

GLEEVEC 100 mg tab, 400 mg tab 3 PA

GLIADEL WAFER 7.7 mg implant wafer 3

HEXALEN 50 mg cap 3 PA

HYCAMTIN 0.25 mg cap, 1 mg cap 3 PA

HYDREA 500 mg cap 3

hydroxyurea 500 mg cap 1 HYDREA

IBRANCE 100 mg cap, 125 mg cap, 75 mg cap 3 PA

ICLUSIG 15 mg tab, 45 mg tab 3 PA

IDHIFA 100 mg tab, 50 mg tab 3 PA

imatinib mesylate 100 mg tab, 400 mg tab 1 GLEEVEC PA

IMBRUVICA 140 mg cap, 140 mg tab, 280 mg tab, 420 mg tab, 560 mg tab 3 PA

INLYTA 1 mg tab, 5 mg tab 3 PA

IRESSA 250 mg tab 3 PA

JAKAFI 10 mg tab, 15 mg tab, 20 mg tab, 25 mg tab, 5 mg tab 3 PA

LARTRUVO 190 mg/19ml iv soln, 500 mg/50ml iv soln 3 PA

LENVIMA 10 MG DAILY DOSE 10 mg cap pack 3 PA

LENVIMA 14 MG DAILY DOSE 10 & 4 mg cap pack 3 PA

LENVIMA 20 MG DAILY DOSE 10 (2) mg cap pack 3 PA

LENVIMA 24 MG DAILY DOSE 10 (2) & 4 mg cap pack 3 PA

letrozole 2.5 mg tab 1 FEMARA

LEUKERAN 2 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

LUPANETA PACK 11.25 & 5 mg cmb kit, 3.75 & 5 mg cmb kit 3

LUPRON DEPOT (1-MONTH) 3.75 mg im kit, 7.5 mg im kit 3 PA

LUPRON DEPOT (3-MONTH) 11.25 mg im kit, 22.5 mg im kit 3 PA

LUPRON DEPOT (4-MONTH) 30 mg im kit 3 PA

LUPRON DEPOT (6-MONTH) 45 mg im kit 3 PA

LUPRON DEPOT-PED (1-MONTH) 11.25 mg im kit, 15 mg im kit, 7.5 mg im kit 3 PA

LUPRON DEPOT-PED (3-MONTH) 11.25 mg (ped) im kit, 30 mg (ped) im kit 3 PA

LYNPARZA 100 mg tab, 150 mg tab, 50 mg cap 3 PA

LYSODREN 500 mg tab 3 PA

MATULANE 50 mg cap 3

megestrol acetate 20 mg tab, 40 mg tab 1 MEGACE

megestrol acetate 40 mg/ml susp, 400 mg/10ml susp 1 MEGACE

MEKINIST 0.5 mg tab, 2 mg tab 3 PA

MEKTOVI 15 mg tab 3 PA

melphalan 2 mg tab 1 ALKERAN PA

mercaptopurine 50 mg tab 1 PURINETHOL

methotrexate 2.5 mg tab 1

methotrexate sodium 2.5 mg tab 1

methotrexate sodium 1 gm inj soln 1 PA

methotrexate sodium 250 mg/10ml inj soln, 50 mg/2ml inj soln 1 PA

methotrexate sodium (pf) 1 gm/40ml inj soln, 250 mg/10ml inj soln, 50 mg/2ml inj soln 1 PA

MYLERAN 2 mg tab 3

NERLYNX 40 mg tab 3 PA

NEXAVAR 200 mg tab 3 PA

NILANDRON 150 mg tab 3 PA

nilutamide 150 mg tab 1 NILANDRON PA

NINLARO 2.3 mg cap, 3 mg cap, 4 mg cap 3 PA

POMALYST 1 mg cap, 2 mg cap, 3 mg cap, 4 mg cap 3 PA

PORTRAZZA 800 mg/50ml iv soln 2 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

PURIXAN 2000 mg/100ml susp 3 PA

REVLIMID 10 mg cap, 15 mg cap, 2.5 mg cap, 20 mg cap, 25 mg cap, 5 mg cap 3 PA

RUBRACA 200 mg tab, 300 mg tab 3 PA

RYDAPT 25 mg cap 3

SOLTAMOX 10 mg/5ml soln 3 PA

SPRYCEL 100 mg tab, 140 mg tab, 20 mg tab, 50 mg tab, 70 mg tab, 80 mg tab 3 PA

STIVARGA 40 mg tab 3 PA

SUTENT 12.5 mg cap, 25 mg cap, 37.5 mg cap, 50 mg cap 3 PA

SYLATRON 200 mcg sc kit, 300 mcg sc kit, 600 mcg sc kit 3 PA

SYNRIBO 3.5 mg sc soln 3

TABLOID 40 mg tab 3 PA

TAFINLAR 50 mg cap, 75 mg cap 3 PA

TAGRISSO 40 mg tab, 80 mg tab 3 PA

tamoxifen citrate 10 mg tab, 20 mg tab 1 NOLVADEX PA

TARCEVA 100 mg tab, 150 mg tab, 25 mg tab 3 PA

TARGRETIN 75 mg cap 3 PA

TASIGNA 150 mg cap, 200 mg cap, 50 mg cap 3 PA

TECENTRIQ 1200 mg/20ml iv soln 3 PA

TEMODAR 100 mg cap, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 3 PA

temozolomide 100 mg cap, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 1

TEPADINA 100 mg inj soln, 15 mg inj soln 3

thiotepa 15 mg inj soln 1 THIOPLEX

TRELSTAR MIXJECT 11.25 mg im susp, 22.5 mg im susp, 3.75 mg im susp 3 PA

tretinoin 10 mg cap 1 VESANOID

TREXALL 10 mg tab, 15 mg tab, 5 mg tab, 7.5 mg tab 3

TYKERB 250 mg tab 3 PA

VALSTAR 40 mg/ml i-vesic soln 3

VANTAS 50 mg sc kit 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

VENCLEXTA 10 mg tab, 100 mg tab, 50 mg tab 3 PA

VENCLEXTA STARTING PACK 10 & 50 & 100 mg tab pack 3 PA

VERZENIO 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 2 PA

VOTRIENT 200 mg tab 3 PA

XALKORI 200 mg cap, 250 mg cap 3 PA

XELODA 150 mg tab, 500 mg tab 3 PA

XTANDI 40 mg cap 3 PA

ZELBORAF 240 mg tab 3 PA

ZOLADEX 10.8 mg sc implant, 3.6 mg sc implant 3 PA

ZOLINZA 100 mg cap 3 PA

ZYDELIG 100 mg tab, 150 mg tab 3 PA

ZYKADIA 150 mg cap 3 PA

ZYTIGA 250 mg tab, 500 mg tab 3 PA

ANTIPARKINSONIAN AGENTS [AGENTES ANTIPARKINSONIANOS]

Adamantanes [Adamantanos]

amantadine hcl 100 mg cap, 100 mg tab 1 SYMMETREL

amantadine hcl 50 mg/5ml syr 1 SYMMETREL

Anticholinergic Agents [Agentes Anticolinérgicos]

benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab 1 COGENTIN

trihexyphenidyl hcl 2 mg tab, 5 mg tab 1 ARTANE

trihexyphenidyl hcl 0.4 mg/ml oral elix 1 ARTANE

Catechol-o-methyltransferase (comt) Inhibitors [Inhibidores De La Catecol-O-Metiltransferasa (Comt)]

COMTAN 200 mg tab 3

entacapone 200 mg tab 1 COMTAN

TASMAR 100 mg tab 3

tolcapone 100 mg tab 1 TASMAR

Dopamine Precursors [Precursores De Dopamina]

carbidopa 25 mg tab 1 LODOSYN

carbidopa-levodopa 10-100 mg tab disint, 25-100 mg tab disint, 25-250 mg tab disint 1 PARCOPA

carbidopa-levodopa 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 1 SINEMET

carbidopa-levodopa er 25-100 mg tab er, 50-200 mg tab er 1 SINEMET CR

carbidopa-levodopa-entacapone 12.5-50-200 mg tab, 18.75-75-200 1 STALEVO

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50-200-200 mg tab

LODOSYN 25 mg tab 3

SINEMET 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 3

SINEMET CR 25-100 mg tab er, 50-200 mg tab er 3

STALEVO 100 25-100-200 mg tab 3

STALEVO 125 31.25-125-200 mg tab 3

STALEVO 150 37.5-150-200 mg tab 3

STALEVO 200 50-200-200 mg tab 3

STALEVO 50 12.5-50-200 mg tab 3

STALEVO 75 18.75-75-200 mg tab 3

Dopamine Receptor Agonists [Agonistas Del Receptor De Dopamina]

bromocriptine mesylate 2.5 mg tab, 5 mg cap 1 PARLODEL

cabergoline 0.5 mg tab 1 DOSTINEX

MIRAPEX 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 3

MIRAPEX ER 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 3

NEUPRO 1 mg/24hr td patch 24hr, 2 mg/24hr td patch 24hr, 3 mg/24hr td patch 24hr, 4 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 8 mg/24hr td patch 24hr 3

PARLODEL 5 mg cap 3

pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 1 MIRAPEX

pramipexole dihydrochloride er 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 1 MIRAPEX ER

REQUIP 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

REQUIP XL 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 3

ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 1 REQUIP

ropinirole hcl er 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 1 REQUIP XL

Monoamine Oxidase B Inhibitors [Inhibidores De La Monoaminooxidasa B (Mao-B)]

AZILECT 0.5 mg tab, 1 mg tab 3

ELDEPRYL 5 mg cap 3

EMSAM 12 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 9 mg/24hr td patch 24hr 3

rasagiline mesylate 0.5 mg tab, 1 mg tab 1 AZILECT

selegiline hcl 5 mg tab 1

selegiline hcl 5 mg cap 1 ELDEPRYL

ZELAPAR 1.25 mg tab disint 3

ANTIPROTOZOALS [ANTIPROTOZOARIOS]

Amebicides [Amebicidas]

paromomycin sulfate 250 mg cap 1 HUMATIN

Antimalarials [Antimaláricos]

atovaquone-proguanil hcl 250-100 mg tab, 62.5-25 mg tab 1 MALARONE

chloroquine phosphate 250 mg tab, 500 mg tab 1

COARTEM 20-120 mg tab 3

DARAPRIM 25 mg tab 3 PA

hydroxychloroquine sulfate 200 mg tab 1 PLAQUENIL

MALARONE 250-100 mg tab, 62.5-25 mg tab 3

mefloquine hcl 250 mg tab 1

PLAQUENIL 200 mg tab 3

primaquine phosphate 26.3 mg tab 1

QUALAQUIN 324 mg cap 3

quinine sulfate 324 mg cap 1 QUALAQUIN

Antiprotozoals, Miscellaneous [Antiprotozoarios, Misceláneos]

ALINIA 500 mg tab 3

ALINIA 100 mg/5ml susp 3

atovaquone 750 mg/5ml susp 1 MEPRON

FLAGYL 250 mg tab, 375 mg cap, 500 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

MEPRON 750 mg/5ml susp 3

metronidazole 250 mg tab, 375 mg cap, 500 mg tab 1 FLAGYL

TINDAMAX 500 mg tab 3

tinidazole 250 mg tab, 500 mg tab 1 TINDAMAX

ANTIPRURITICS AND LOCAL ANESTHETICS [ANTIPRURÍTICOS Y ANESTÉSICOS LOCALES]

Antipruritics And Local Anesthetics [Antipruríticos Y Anestésicos Locales]

agoneaze 2.5-2.5 % ext kit 1

ANA-LEX 2-2 % rect kit 3

ANALPRAM HC 2.5-1 % rect crm 3

ANALPRAM HC SINGLES 2.5-1 % rect crm 3

ANALPRAM-HC 1-1 % rect crm 3

ANALPRAM-HC 2.5-1 % rect lot 3

anodyne lpt 2.5-2.5 % ext kit 1

DERMACINRX EMPRICAINE 2.5-2.5 % ext kit 3

DERMACINRX PRIZOPAK 2.5-2.5 % ext kit 3

FIRST-MOUTHWASH BLM m/t susp 3

GLYDO 2 % gel 3

hydrocortisone ace-pramoxine 1-1 % rect crm, 2.5-1 % rect crm 1

LIDO BDK 2.5-2.5 % ext kit 3

lidocaine 5 % oint 1

lidocaine 5 % patch 1 LIDODERM

lidocaine hcl 3 % crm 1

lidocaine hcl 3 % lot 1

lidocaine hcl 2 % gel, 4 % ext soln 1 XYLOCAINE

lidocaine pak 5 % oint 1

lidocaine-hydrocortisone ace 2-2 % rect kit, 3-0.5 % rect kit, 3-1 % rect kit, 3-2.5 % rect kit 1

lidocaine-hydrocortisone ace 2.8-0.55 % rect gel, 3-0.5 % rect crm 1

lidocaine-prilocaine 2.5-2.5 % ext kit 1

lidocaine-prilocaine 2.5-2.5 % crm 1 EMLA

LIDODERM 5 % patch 3

lido-k 3 % lot 1

lidopin 3 % crm 1

lidopril 2.5-2.5 % ext kit 1

lidopril xr 2.5-2.5 % ext kit 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

LIDO-PRILO CAINE PACK 2.5-2.5 % ext kit 3

lidorx 3 % gel 1

LIPROZONEPAK 2.5-2.5 % ext kit 3

LIVIXIL PAK 2.5-2.5 % ext kit 3

MEDOLOR PAK 2.5-2.5 % ext kit 3

PHENAZO 200 mg tab 3

phenazopyridine hcl 100 mg tab, 200 mg tab 1

pramcort 1-1 % rect crm 1

premium lidocaine 5 % oint 1

prilolid 2.5-2.5 % ext kit 1

PRILOXX LP 2.5-2.5 % ext kit 3

PROCORT 1.85-1.15 % rect crm 3

PROCTOFOAM HC 1-1 % rect foam 3

PYRIDIUM 100 mg tab, 200 mg tab 3

RELADOR PAK 2.5-2.5 % ext kit 3

RELADOR PAK PLUS 2.5-2.5 % ext kit 3

TOPEX TOPICAL ANESTHETIC 20 % Mouth/Throat Aerosol 3

ANTITHROMBOTIC AGENTS [AGENTES ANTITROMBÓTICOS]

Anticoagulants [Anticoagulantes]

ARIXTRA 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 3

COUMADIN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 3

ELIQUIS 2.5 mg tab, 5 mg tab 3 PA

ELIQUIS STARTER PACK 5 mg tab 3 PA

enoxaparin sodium 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 1 LOVENOX

fondaparinux sodium 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 1 ARIXTRA

FRAGMIN 10000 unit/ml sc soln, 12500 unit/0.5ml sc soln, 15000 unit/0.6ml sc soln, 18000 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

unt/0.72ml sc soln, 2500 unit/0.2ml sc soln, 5000 unit/0.2ml sc soln, 7500 unit/0.3ml sc soln

heparin sodium (porcine) 1000 unit/ml inj soln, 10000 unit/ml inj soln, 20000 unit/ml inj soln, 5000 unit/ml inj soln 1

heparin sodium (porcine) pf 5000 unit/0.5ml inj soln 1

JANTOVEN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 3

LOVENOX 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 3

PRADAXA 110 mg cap, 150 mg cap, 75 mg cap 3 PA

warfarin sodium 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 1 COUMADIN

XARELTO 10 mg tab, 15 mg tab, 20 mg tab 3 PA

XARELTO STARTER PACK 15 & 20 mg tab pack 3 PA

Platelet-aggregation Inhibitors [Inhibidores De La Agregación De Plaquetas]

AGGRENOX 25-200 mg cap er 12 hr 3

aspirin-dipyridamole er 25-200 mg cap er 12 hr 1 AGGRENOX

BRILINTA 60 mg tab, 90 mg tab 3 PA

cilostazol 100 mg tab, 50 mg tab 1 PLETAL

clopidogrel bisulfate 300 mg tab, 75 mg tab 1 PLAVIX

EFFIENT 10 mg tab, 5 mg tab 3

PLAVIX 300 mg tab, 75 mg tab 3

prasugrel hcl 10 mg tab, 5 mg tab 1 EFFIENT

ZONTIVITY 2.08 mg tab 3

Platelet-reducing Agents [Agentes Reductores De Plaquetas]

AGRYLIN 0.5 mg cap 3

anagrelide hcl 0.5 mg cap, 1 mg cap 1 AGRYLIN

ANTITUSSIVES [ANTITUSIVOS]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

Antitussives [Antitusivos]

benzonatate 100 mg cap, 150 mg cap, 200 mg cap 1

biotuss 10-15-300 mg/5ml liq 1

BIOTUSS PEDIATRIC 2.5-5-50 mg/ml liq 3

BROMFED DM 30-2-10 mg/5ml syr 3

CARBAPHEN 12 10-4-27.5 mg/5ml liq 3

CARBAPHEN 12 PED 2.5-1.25-7.5 mg/ml susp 3

CARBODEX DM 45-4-15 mg/5ml syr 3

DEXPHEN W/C 5-1-10 mg/5ml liq 3

EXACTUSS 10-28-388 mg/5ml liq 3

GILTUSS 10-28-388 mg/5ml liq 3

GILTUSS PEDIATRIC 2.5-7.5-88 mg/ml liq 3

GILTUSS TR 10-28-388 mg tab 3

hydrocod polst-cpm polst er 10-8 mg/5ml susp er 1

hydrocodone-homatropine 5-1.5 mg tab 1

hydrocodone-homatropine 5-1.5 mg/5ml syr 1

hydromet 5-1.5 mg/5ml syr 1

NEOTUSS PLUS 7.5-4-30 mg/5ml liq 3

NORTUSS-DE 2.5-5-50 mg/ml liq 3

nortuss-ex 20-200 mg/5ml liq 1

phenyleph-promethazine-cod 5-6.25-10 mg/5ml syr 1

promethazine vc/codeine 6.25-5-10 mg/5ml syr 1

promethazine-codeine 6.25-10 mg/5ml soln, 6.25-10 mg/5ml syr 1

promethazine-dm 6.25-15 mg/5ml syr 1

promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syr 1

pseudoeph-bromphen-dm 30-2-10 mg/5ml syr 1

pseudoeph-chlorphen-hydrocod 60-4-5 mg/5ml soln 1

TESSALON PERLES 100 mg cap 3

TUSNEL 60-30-400 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

TUSSICAPS 10-8 mg cap er 12 hr, 5-4 mg cap er 12 hr 3

TUSSIGON 5-1.5 mg tab 3

TUSSIONEX PENNKINETIC ER 10-8 mg/5ml susp er 3

ZUTRIPRO 60-4-5 mg/5ml soln 3

ANTIULCER AGENTS AND ACID SUPPRESSANTS [AGENTES ANTI-ÚLCERA Y SUPRESORES DE ÁCIDOS]

Antiulcer Agents And Acid Suppressants, Misc [Agentes Anti-Úlcera Y Supresores De Ácidos, Misceláneos]

PYLERA 140-125-125 mg cap 3

Histamine H2-antagonists [Antagonistas De Histamina H2]

cimetidine 200 mg tab, 300 mg tab, 400 mg tab, 800 mg tab 1 TAGAMET

cimetidine hcl 300 mg/5ml soln 1 TAGAMET

famotidine 200 mg/20ml iv soln, 40 mg/4ml iv soln 1

famotidine 20 mg tab, 40 mg tab 1 PEPCID

famotidine 20 mg/2ml iv soln, 40 mg/5ml susp 1 PEPCID

nizatidine 150 mg cap, 300 mg cap 1 AXID

nizatidine 15 mg/ml soln 1 AXID

PEPCID 20 mg tab, 40 mg tab 3

PEPCID 40 mg/5ml susp 3

ranitidine hcl 150 mg cap, 150 mg tab, 300 mg cap, 300 mg tab 1 ZANTAC

ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 150 mg/6ml inj soln, 50 mg/2ml inj soln, 75 mg/5ml syr 1 ZANTAC

ZANTAC 300 mg tab 3

ZANTAC 1000 mg/40ml inj soln, 150 mg/6ml inj soln, 50 mg/2ml inj soln 3

Prostaglandins [Prostaglandinas]

CYTOTEC 100 mcg tab, 200 mcg tab 3

misoprostol 100 mcg tab, 200 mcg tab 1 CYTOTEC

Protectants [Protectores]

CARAFATE 1 gm tab 3

CARAFATE 1 gm/10ml susp 3

sucralfate 1 gm tab 1 CARAFATE

Proton-pump Inhibitors [Inhibidores De La Bomba De Protones]

ACIPHEX 20 mg tab dr 3

amoxicill-clarithro-lansopraz oral misc 1 PREVPAC

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

DEXILANT 30 mg cap dr, 60 mg cap dr 3

esomeprazole magnesium 20 mg cap dr, 40 mg cap dr 1 NEXIUM

esomeprazole strontium 49.3 mg cap dr 1

FIRST-LANSOPRAZOLE 3 mg/ml susp 3

FIRST-OMEPRAZOLE 2 mg/ml susp 3

lansoprazole 15 mg tab disint, 30 mg tab disint 1

lansoprazole 15 mg cap dr, 30 mg cap dr 1 PREVACID

NEXIUM 10 mg pckt, 2.5 mg pckt, 20 mg cap dr, 20 mg pckt, 40 mg cap dr, 40 mg pckt, 5 mg pckt 3

OMECLAMOX-PAK 500-500-20 mg oral misc 3

OMEPPI 20-1100 mg cap 3

omeprazole 10 mg cap dr, 20 mg cap dr, 40 mg cap dr 1 PRILOSEC

OMEPRAZOLE+SYRSPEND SF ALKA 2 mg/ml susp 3

omeprazole-sodium bicarbonate 20-1100 mg cap, 20-1680 mg pckt, 40-1100 mg cap, 40-1680 mg pckt 1 ZEGERID

pantoprazole sodium 20 mg tab dr, 40 mg tab dr 1 PROTONIX

PREVACID 15 mg cap dr, 30 mg cap dr 3

PREVACID SOLUTAB 15 mg tab disint, 30 mg tab disint 3

PREVPAC oral misc 3

PRILOSEC 10 mg pckt, 2.5 mg pckt 3

PROTONIX 20 mg tab dr, 40 mg pckt, 40 mg tab dr 3

rabeprazole sodium 20 mg tab dr 1 ACIPHEX

ZEGERID 20-1100 mg cap, 20-1680 mg pckt, 40-1680 mg pckt 3

ANTIVIRALS [ANTIVIRALES]

Adamantanes [Adamantanos]

FLUMADINE 100 mg tab 3

rimantadine hcl 100 mg tab 1 FLUMADINE

Antiretrovirals [Antirretrovirales]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

abacavir sulfate 300 mg tab 1 ZIAGEN

abacavir sulfate 20 mg/ml soln 1 ZIAGEN

abacavir sulfate-lamivudine 600-300 mg tab 1 EPZICOM

abacavir-lamivudine-zidovudine 300-150-300 mg tab 1 TRIZIVIR

APTIVUS 250 mg cap 3 PA

APTIVUS 100 mg/ml soln 3 PA

atazanavir sulfate 150 mg cap, 200 mg cap, 300 mg cap 1 REYATAZ

ATRIPLA 600-200-300 mg tab 3

BIKTARVY 50-200-25 mg tab 3 PA

CIMDUO 300-300 mg tab 3

COMBIVIR 150-300 mg tab 3

COMPLERA 200-25-300 mg tab 3

CRIXIVAN 200 mg cap, 400 mg cap 3

didanosine 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 1 VIDEX

EDURANT 25 mg tab 3

efavirenz 200 mg cap, 50 mg cap, 600 mg tab 1 SUSTIVA

EMTRIVA 200 mg cap 3

EMTRIVA 10 mg/ml soln 3

EPIVIR 150 mg tab, 300 mg tab 3

EPIVIR 10 mg/ml soln 3

EPIVIR HBV 100 mg tab 3 PA

EPIVIR HBV 5 mg/ml soln 3 PA

EPZICOM 600-300 mg tab 3

fosamprenavir calcium 700 mg tab 1 LEXIVA

FUZEON 90 mg sc soln 3

INTELENCE 100 mg tab, 200 mg tab, 25 mg tab 3 PA

INVIRASE 200 mg cap, 500 mg tab 3

ISENTRESS 100 mg pckt, 100 mg tab chew, 25 mg tab chew, 400 mg tab 3

ISENTRESS HD 600 mg tab 3

JULUCA 50-25 mg tab 3

KALETRA 100-25 mg tab, 200-50 mg tab 3

KALETRA 400-100 mg/5ml soln 3

lamivudine 150 mg tab, 300 mg tab 1 EPIVIR

lamivudine 10 mg/ml soln 1 EPIVIR

lamivudine 100 mg tab 1 EPIVIR HBV PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

lamivudine-zidovudine 150-300 mg tab 1 COMBIVIR

LEXIVA 700 mg tab 3

LEXIVA 50 mg/ml susp 3

lopinavir-ritonavir 400-100 mg/5ml soln 1 KALETRA

nevirapine 200 mg tab 1 VIRAMUNE

nevirapine 50 mg/5ml susp 1 VIRAMUNE

nevirapine er 100 mg tab er 24 hr, 400 mg tab er 24 hr 1 VIRAMUNE XR

NORVIR 100 mg cap, 100 mg pckt, 100 mg tab 3

NORVIR 80 mg/ml soln 3

ODEFSEY 200-25-25 mg tab 3

PREZISTA 150 mg tab, 600 mg tab, 75 mg tab, 800 mg tab 3

PREZISTA 100 mg/ml susp 3

RESCRIPTOR 100 mg tab, 200 mg tab 3

RETROVIR 100 mg cap 3

RETROVIR 10 mg/ml iv soln, 50 mg/5ml syr 3

REYATAZ 150 mg cap, 200 mg cap, 300 mg cap 3

ritonavir 100 mg tab 1 NORVIR

SELZENTRY 150 mg tab, 25 mg tab, 300 mg tab, 75 mg tab 3 PA

SELZENTRY 20 mg/ml soln 3 PA

stavudine 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 1 ZERIT

STRIBILD 150-150-200-300 mg tab 3

SUSTIVA 200 mg cap, 50 mg cap, 600 mg tab 3

SYMFI 600-300-300 mg tab 3

SYMFI LO 400-300-300 mg tab 3

tenofovir disoproxil fumarate 300 mg tab 1 VIREAD PA

TIVICAY 50 mg tab 3

TRIZIVIR 300-150-300 mg tab 3

TROGARZO 200 mg/1.33ml iv soln 3 PA

TRUVADA 200-300 mg tab 3

VIDEX 2 gm soln, 4 gm soln 3

VIDEX EC 125 mg cap dr, 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 3

VIRACEPT 250 mg tab, 625 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

VIRAMUNE 200 mg tab 3

VIRAMUNE 50 mg/5ml susp 3

VIRAMUNE XR 100 mg tab er 24 hr, 400 mg tab er 24 hr 3

VIREAD 150 mg tab, 200 mg tab, 250 mg tab, 300 mg tab 3 PA

VIREAD 40 mg/gm oral pwdr 3 PA

ZERIT 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3

ZERIT 1 mg/ml soln 3

ZIAGEN 300 mg tab 3

ZIAGEN 20 mg/ml soln 3

zidovudine 100 mg cap, 300 mg tab 1 RETROVIR

zidovudine 50 mg/5ml syr 1 RETROVIR

Hcv Antivirals [Antivirales Para Vhc]

HARVONI 90-400 mg tab 3 PA

MAVYRET 100-40 mg tab 3 PA

SOVALDI 400 mg tab 3 PA

Interferons [Interferones]

PEGASYS 180 mcg/0.5ml sc soln, 180 mcg/ml sc soln 3 PA

PEGASYS PROCLICK 135 mcg/0.5ml sc soln, 180 mcg/0.5ml sc soln 3 PA

PEGINTRON 50 mcg/0.5ml sc kit 3 PA

PLEGRIDY 125 mcg/0.5ml sc soln pen-inj, 125 mcg/0.5ml sc soln pfs 3 PA

PLEGRIDY STARTER PACK 63 & 94 mcg/0.5ml sc soln pen-inj, 63 & 94 mcg/0.5ml sc soln pfs 3 PA

Neuraminidase Inhibitors [Inhibidores De La Neuraminidasa]

oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap 1 TAMIFLU

oseltamivir phosphate 6 mg/ml susp 1 TAMIFLU

RELENZA DISKHALER 5 mg/blister inh aer pwdr br act 3

TAMIFLU 30 mg cap, 45 mg cap, 75 mg cap 3

TAMIFLU 6 mg/ml susp 3

Nucleosides And Nucleotides [Nucleósidos Y Nucleótidos]

acyclovir 200 mg cap, 400 mg tab, 800 mg tab 1 ZOVIRAX

acyclovir 200 mg/5ml susp 1 ZOVIRAX

adefovir dipivoxil 10 mg tab 1 HEPSERA PA

BARACLUDE 0.5 mg tab, 1 mg tab 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

BARACLUDE 0.05 mg/ml soln 3 PA

entecavir 0.5 mg tab, 1 mg tab 1 BARACLUDE PA

famciclovir 125 mg tab, 250 mg tab, 500 mg tab 1 FAMVIR

HEPSERA 10 mg tab 3 PA

MODERIBA 200 & 400 mg tab pack, 200 mg tab, 400 & 600 mg tab pack 3 PA

MODERIBA 1200 DOSE PACK 600 mg tab 3 PA

MODERIBA 800 DOSE PACK 400 mg tab 3 PA

REBETOL 200 mg cap 3 PA

REBETOL 40 mg/ml soln 3 PA

RIBASPHERE 200 mg cap, 200 mg tab, 400 mg tab, 600 mg tab 3 PA

RIBASPHERE RIBAPAK 200 & 400 mg tab pack, 400 & 600 mg tab pack, 400 mg tab, 600 mg tab 3 PA

ribavirin 200 mg tab 1 COPEGUS PA

ribavirin 200 mg cap 1 REBETOL PA

SITAVIG 50 mg bucc tab 3

valacyclovir hcl 1 gm tab, 500 mg tab 1 VALTREX

VALCYTE 450 mg tab 3

VALCYTE 50 mg/ml soln 3

valganciclovir hcl 450 mg tab 1 VALCYTE

valganciclovir hcl 50 mg/ml soln 1 VALCYTE

VALTREX 1 gm tab, 500 mg tab 3

ZOVIRAX 200 mg cap, 400 mg tab, 800 mg tab 3

ZOVIRAX 200 mg/5ml susp 3

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS [ANSIOLÍTICOS, SEDANTES E HIPNÓTICOS]

Anxiolytics, Sedatives, & Hypnotics Misc [Ansiolíticos, Sedantes E Hipnóticos Misceláneos]

AMBIEN 10 mg tab, 5 mg tab 3

AMBIEN CR 12.5 mg tab er, 6.25 mg tab er 3

buspirone hcl 10 mg tab, 15 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 BUSPAR

EDLUAR 10 mg tab subl, 5 mg tab subl 3

eszopiclone 1 mg tab, 2 mg tab, 3 mg tab 1 LUNESTA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

hydroxyzine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 ATARAX

hydroxyzine hcl 10 mg/5ml syr 1 ATARAX

hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap 1 VISTARIL

INTERMEZZO 1.75 mg tab subl, 3.5 mg tab subl 3

LUNESTA 1 mg tab, 2 mg tab, 3 mg tab 3

meprobamate 200 mg tab, 400 mg tab 1

ROZEREM 8 mg tab 3

SONATA 10 mg cap, 5 mg cap 3

VISTARIL 25 mg cap, 50 mg cap 3

zaleplon 10 mg cap, 5 mg cap 1 SONATA

zolpidem tartrate 10 mg tab, 5 mg tab 1 AMBIEN

zolpidem tartrate 1.75 mg tab subl, 3.5 mg tab subl 1 INTERMEZZO

zolpidem tartrate er 12.5 mg tab er, 6.25 mg tab er 1 AMBIEN CR

ZOLPIMIST 5 mg/act soln 3

Barbiturates [Barbitúricos]

BUTISOL SODIUM 30 mg tab 3

phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab 1

phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln 1

SECONAL 100 mg cap 3

Benzodiazepines [Benzodiazepinas]

alprazolam 0.25 mg tab disint, 0.5 mg tab disint, 1 mg tab disint, 2 mg tab disint 1 NIRAVAM

alprazolam 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 1 XANAX

alprazolam er 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR

ALPRAZOLAM INTENSOL 1 mg/ml oral conc 3

alprazolam xr 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ATIVAN 0.5 mg tab, 1 mg tab, 2 mg tab 3

chlordiazepoxide hcl 10 mg cap, 25 mg cap, 5 mg cap 1 LIBRIUM

clorazepate dipotassium 15 mg tab, 3.75 mg tab, 7.5 mg tab 1 TRANXENE

DIASTAT ACUDIAL 10 mg rect gel, 20 mg rect gel 3

DIASTAT PEDIATRIC 2.5 mg rect gel 3

diazepam 5 mg/ml oral conc 1

diazepam 10 mg rect gel, 2.5 mg rect gel, 20 mg rect gel 1 DIASTAT

diazepam 10 mg tab, 2 mg tab, 5 mg tab 1 VALIUM

diazepam 5 mg/5ml soln 1 VALIUM

DIAZEPAM INTENSOL 5 mg/ml oral conc 3

DORAL 15 mg tab 3

estazolam 1 mg tab, 2 mg tab 1 PROSOM

flurazepam hcl 15 mg cap, 30 mg cap 1 DALMANE

HALCION 0.25 mg tab 3

lorazepam 2 mg/ml oral conc 1

lorazepam 0.5 mg tab, 1 mg tab, 2 mg tab 1 ATIVAN

LORAZEPAM INTENSOL 2 mg/ml oral conc 3

midazolam hcl 10 mg/10ml inj soln, 10 mg/2ml inj soln, 2 mg/2ml inj soln, 2 mg/ml syr, 25 mg/5ml inj soln, 5 mg/5ml inj soln, 5 mg/ml inj soln, 50 mg/10ml inj soln 1

oxazepam 10 mg cap, 15 mg cap, 30 mg cap 1 SERAX

quazepam 15 mg tab 1

RESTORIL 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 3

temazepam 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 1 RESTORIL

TRANXENE-T 7.5 mg tab 3

triazolam 0.125 mg tab, 0.25 mg tab 1 HALCION

VALIUM 10 mg tab, 2 mg tab, 5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

XANAX 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 3

XANAX XR 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr 3

AUTONOMIC DRUGS, MISCELLANEOUS [MEDICAMENTOS AUTONÓMICOS, MISCELÁNEOS]

Autonomic Drugs, Miscellaneous [Medicamentos Autonómicos, Misceláneos]

CHANTIX 0.5 mg tab, 1 mg tab 3

CHANTIX CONTINUING MONTH PAK 1 mg tab 3

CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 mg x 42 tab 3

NICOTROL 10 mg inhaler 3

NICOTROL NS 10 mg/ml nasal soln 3

BETA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES BETA-ADRENÉRGICOS]

Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]

acebutolol hcl 200 mg cap, 400 mg cap 1 SECTRAL

atenolol 100 mg tab, 25 mg tab, 50 mg tab 1 TENORMIN

atenolol-chlorthalidone 100-25 mg tab, 50-25 mg tab 1 TENORETIC

BETAPACE 120 mg tab, 160 mg tab, 80 mg tab 3

BETAPACE AF 120 mg tab, 160 mg tab, 80 mg tab 3

betaxolol hcl 10 mg tab, 20 mg tab 1 KERLONE

bisoprolol fumarate 10 mg tab, 5 mg tab 1 ZEBETA

bisoprolol-hydrochlorothiazide 10-6.25 mg tab, 2.5-6.25 mg tab, 5-6.25 mg tab 1 ZIAC

BYSTOLIC 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3

carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 1 COREG

carvedilol phosphate er 10 mg cap er 24 hr, 20 mg cap er 24 hr, 40 mg cap er 24 hr, 80 mg cap er 24 hr 1 COREG CR

COREG 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

COREG CR 10 mg cap er 24 hr, 20 mg cap er 24 hr, 40 mg cap er 24 hr, 80 mg cap er 24 hr 3

CORGARD 20 mg tab, 40 mg tab, 80 mg tab 3

CORZIDE 40-5 mg tab, 80-5 mg tab 3

DUTOPROL 100-12.5 mg tab er 24 hr, 25-12.5 mg tab er 24 hr, 50-12.5 mg tab er 24 hr 3

HEMANGEOL 4.28 mg/ml soln 3

INDERAL LA 120 mg cap er 24 hr, 160 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 3

INDERAL XL 120 mg cap er 24 hr, 80 mg cap er 24 hr 3

INNOPRAN XL 120 mg cap er 24 hr, 80 mg cap er 24 hr 3

labetalol hcl 100 mg tab, 200 mg tab, 300 mg tab 1 NORMODYNE

LOPRESSOR 100 mg tab, 50 mg tab 3

LOPRESSOR HCT 50-25 mg tab 3

metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 TOPROL

metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab 1 LOPRESSOR

metoprolol-hctz er 100-12.5 mg tab er 24 hr, 25-12.5 mg tab er 24 hr, 50-12.5 mg tab er 24 hr 1

metoprolol-hydrochlorothiazide 100-25 mg tab, 100-50 mg tab, 50-25 mg tab 1 LOPRESSOR HCT

nadolol 20 mg tab, 40 mg tab, 80 mg tab 1 CORGARD

nadolol-bendroflumethiazide 40-5 mg tab 1 CORZIDE

pindolol 10 mg tab, 5 mg tab 1 VISKEN

propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 1 INDERAL

propranolol hcl 20 mg/5ml soln, 40 mg/5ml soln 1 INDERAL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

propranolol hcl er 120 mg cap er 24 hr, 160 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 INDERAL LA

propranolol-hctz 40-25 mg tab, 80-25 mg tab 1 INDERIDE

SORINE 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab 3

sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab 1 BETAPACE

sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab 1 BETAPACE AF

TENORETIC 100 100-25 mg tab 3

TENORETIC 50 50-25 mg tab 3

TENORMIN 100 mg tab, 25 mg tab, 50 mg tab 3

timolol maleate 10 mg tab, 20 mg tab, 5 mg tab 1 BLOCADREN

TOPROL XL 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 3

ZIAC 10-6.25 mg tab, 2.5-6.25 mg tab, 5-6.25 mg tab 3

BONE RESORPTION INHIBITORS [INHIBIDORES DE LA RESORCIÓN ÓSEA]

Bone Resorption Inhibitors [Inhibidores De La Resorción Ósea]

ACTONEL 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 3

alendronate sodium 10 mg tab, 35 mg tab, 40 mg tab, 5 mg tab, 70 mg tab 1 FOSAMAX

alendronate sodium 70 mg/75ml soln 1 FOSAMAX

ATELVIA 35 mg tab dr 3

BINOSTO 70 mg tab eff 3

BONIVA 150 mg tab 3

BONIVA 3 mg/3ml iv soln 3 PA

etidronate disodium 200 mg tab, 400 mg tab 1 DIDRONEL

FOSAMAX 70 mg tab 3

FOSAMAX PLUS D 70-2800 mg-unit tab, 70-5600 mg-unit tab 3

ibandronate sodium 150 mg tab 1 BONIVA

ibandronate sodium 3 mg/3ml iv soln 1 BONIVA PA

PROLIA 60 mg/ml sc soln 3 PA

RECLAST 5 mg/100ml iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

risedronate sodium 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 1 ACTONEL

risedronate sodium 35 mg tab dr 1 ATELVIA

XGEVA 120 mg/1.7ml sc soln 3 PA

zoledronic acid 4 mg/100ml iv soln 1 PA

zoledronic acid 5 mg/100ml iv soln 1 RECLAST PA

zoledronic acid 4 mg/5ml iv conc 1 ZOMETA PA

ZOMETA 4 mg/100ml iv soln, 4 mg/5ml iv conc 3 PA

CALCIUM-CHANNEL BLOCKING AGENTS [AGENTES BLOQUEADORES DE LOS CANALES DE CALCIO]

Calcium-channel Blocking Agents, Misc [Agentes Bloqueadores De Los Canales De Calcio, Misceláneos]

CALAN 120 mg tab, 80 mg tab 3

CALAN SR 120 mg tab er, 180 mg tab er, 240 mg tab er 3

CARDIZEM 120 mg tab, 30 mg tab, 60 mg tab 3

CARDIZEM CD 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3

CARDIZEM LA 120 mg tab er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3

CARTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 3

diltiazem cd 180 mg cap er 24 hr 1

diltiazem cd 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM

diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1 CARDIZEM

diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1

diltiazem hcl er 120 mg cap er 12 hr, 60 mg cap er 12 hr, 90 mg cap er 12 hr 1 CARDIZEM

diltiazem hcl er beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

diltiazem hcl er beads 180 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 1 TIAZAC

diltiazem hcl er coated beads 180 mg cap er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg cap er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 1

diltiazem hcl er coated beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM

dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1

MATZIM LA 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3

TARKA 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 3

TAZTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3

TIAZAC 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 3

trandolapril-verapamil hcl er 1-240 mg tab er, 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 1 TARKA

verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab 1 CALAN

verapamil hcl 2.5 mg/ml iv soln 1 CALAN

verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er 1 CALAN

verapamil hcl er 100 mg cap er 24 hr, 120 mg cap er 24 hr, 180 mg cap er 24 hr, 200 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 1 VERELAN

VERELAN 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 360 mg cap er 24 hr 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

VERELAN PM 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3

Dihydropyridines [Dihidropiridinas]

ADALAT CC 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3

AFEDITAB CR 30 mg tab er 24 hr, 60 mg tab er 24 hr 3

amlodipine besy-benazepril hcl 10-20 mg cap, 10-40 mg cap, 2.5-10 mg cap, 5-10 mg cap, 5-20 mg cap, 5-40 mg cap 1 LOTREL

amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab 1 NORVASC

amlodipine besylate-valsartan 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 1 EXFORGE

amlodipine-atorvastatin 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 1 CADUET

amlodipine-olmesartan 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 1 AZOR

amlodipine-valsartan-hctz 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 1 EXFORGE HCT

AZOR 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 3

CADUET 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 3

EXFORGE 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 3

EXFORGE HCT 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 3

felodipine er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 PLENDIL

isradipine 2.5 mg cap, 5 mg cap 1 DYNACIRC

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

LOTREL 10-20 mg cap, 10-40 mg cap, 5-10 mg cap, 5-20 mg cap 3

nicardipine hcl 20 mg cap, 30 mg cap 1 CARDENE

nifedipine 10 mg cap, 20 mg cap 1 PROCARDIA

nifedipine er 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 ADALAT CC

nifedipine er osmotic release 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 PROCARDIA XL

nimodipine 30 mg cap 1 NIMOTOP

nisoldipine er 17 mg tab er 24 hr, 20 mg tab er 24 hr, 25.5 mg tab er 24 hr, 30 mg tab er 24 hr, 34 mg tab er 24 hr, 40 mg tab er 24 hr, 8.5 mg tab er 24 hr 1 SULAR

NORVASC 10 mg tab, 2.5 mg tab, 5 mg tab 3

NYMALIZE 30 mg/10ml soln, 60 mg/20ml soln 3

olmesartan-amlodipine-hctz 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 1 TRIBENZOR

PROCARDIA 10 mg cap 3

PROCARDIA XL 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3

SULAR 17 mg tab er 24 hr, 34 mg tab er 24 hr, 8.5 mg tab er 24 hr 3

telmisartan-amlodipine 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 1 TWYNSTA

TRIBENZOR 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 3

TWYNSTA 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 3

CARDIAC DRUGS [MEDICAMENTOS CARDÍACOS]

Antiarrhythmic Agents [Agentes Antiarrítmicos]

amiodarone hcl 200 mg tab 1 CORDARONE

amiodarone hcl 100 mg tab, 400 mg tab 1 PACERONE

disopyramide phosphate 100 mg cap, 150 mg cap 1 NORPACE

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

dofetilide 125 mcg cap, 250 mcg cap, 500 mcg cap 1 TIKOSYN

flecainide acetate 100 mg tab, 150 mg tab, 50 mg tab 1 TAMBOCOR

mexiletine hcl 150 mg cap, 200 mg cap, 250 mg cap 1 MEXITIL

MULTAQ 400 mg tab 3

NORPACE 100 mg cap, 150 mg cap 3

NORPACE CR 100 mg cap er 12 hr, 150 mg cap er 12 hr 3

PACERONE 100 mg tab, 200 mg tab, 400 mg tab 3

propafenone hcl 150 mg tab, 225 mg tab, 300 mg tab 1 RYTHMOL

propafenone hcl er 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 1 RYTHMOL

quinidine gluconate 80 mg/ml inj soln 1

quinidine gluconate er 324 mg tab er 1

quinidine sulfate 200 mg tab, 300 mg tab 1

RYTHMOL SR 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 3

TIKOSYN 125 mcg cap, 250 mcg cap, 500 mcg cap 3

Cardiac Drugs, Miscellaneous [Medicamentos Cardíacos, Misceláneos]

RANEXA 1000 mg tab er 12 hr, 500 mg tab er 12 hr 3 PA

Cardiotonic Agents [Agentes Cardiotónicos]

DIGITEK 125 mcg tab, 250 mcg tab 3

DIGOX 125 mcg tab, 250 mcg tab 1

digoxin 125 mcg tab, 250 mcg tab 1 LANOXIN

digoxin 0.05 mg/ml soln 1 LANOXIN

LANOXIN 125 mcg tab, 187.5 mcg tab, 250 mcg tab, 62.5 mcg tab 3

CARIOSTATIC AGENTS [AGENTES CARIOSTÁTICOS]

Cariostatic Agents [Agentes Cariostáticos]

CAVAREST 1.1 % dental gel 3

CLINPRO 5000 1.1 % dental paste 3

DENTA 5000 PLUS 1.1 % dental crm 3

DENTAGEL 1.1 % dental gel 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

EASYGEL 0.4 % dental gel 3

FLUORABON 0.55 (0.25 F) mg/0.6ml soln 3 AL

FLUORIDEX 1.1 % dental paste 3

FLUORIDEX DAILY RENEWAL 0.63 % m/t conc 3

FLUORIDEX ENHANCED WHITENING 1.1 % dental paste 3

fluoritab 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew 1 AL

fluoritab 0.275 (0.125 F) mg/drop soln 1 AL

FLURA-DROPS 0.55 (0.25 F) mg/drop soln 3 AL

GEL-KAM ORAL CARE RINSE 0.63 % m/t conc 3

LUDENT 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew 3 AL

NAFRINSE DAILY/NEUTRAL 0.05 % m/t soln 3

NAFRINSE DROPS 0.275 (0.125 F) mg/drop soln 3 AL

NAFRINSE WEEKLY 0.2 % m/t soln 3

NEUTRAGARD ADVANCED 1.1 % dental gel 3

neutral sodium fluoride 0.2 % m/t soln 1

PHOS-FLUR 1.1 % dental gel 3

PREVIDENT 1.1 % dental gel 3

PREVIDENT 0.2 % m/t soln 3

PREVIDENT 5000 BOOSTER 1.1 % dental paste 3

PREVIDENT 5000 BOOSTER PLUS 1.1 % dental paste 3

PREVIDENT 5000 DRY MOUTH 1.1 % dental gel 3

PREVIDENT 5000 PLUS 1.1 % dental crm 3

sf 1.1 % dental gel 1

sf 5000 plus 1.1 % dental crm 1

sodium fluoride 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab, 1.1 (0.5 F) mg tab chew 1 AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

sodium fluoride 0.275 (0.125 F) mg/drop soln, 1.1 (0.5 F) mg/ml soln 1 AL

THERA-FLUR-N 1.1 % dental gel 3

CATHARTICS AND LAXATIVES [PURGANTES Y LAXANTES]

Cathartics And Laxatives [Purgantes Y Laxantes]

CLENPIQ 10-3.5-12 MG-GM -gm/160ml soln 3

COLYTE WITH FLAVOR PACKS 240 gm soln 3

GAVILYTE-C 240 gm soln 3

GAVILYTE-G 236 gm soln 3

GAVILYTE-N WITH FLAVOR PACK 420 gm soln 3

GOLYTELY 227.1 gm soln 3

GOLYTELY 236 gm soln 3

MOVIPREP 100 gm soln 3

NULYTELY WITH FLAVOR PACKS 420 gm soln 3

peg 3350/electrolytes 240 gm soln 1

peg 3350-kcl-na bicarb-nacl 420 gm soln 1 NULYTELY

peg-3350/electrolytes 236 gm soln 1 GOLYTELY

PEGYLAX oral pwdr 3

polyethylene glycol 3350 pckt 1

polyethylene glycol 3350 oral pwdr 1 MIRALAX

PREPOPIK 10-3.5-12 mg-gm-gm pckt 3

SUPREP BOWEL PREP KIT 17.5-3.13-1.6 gm/177ml soln 3

TRILYTE 420 gm soln 3

CELL STIMULANTS AND PROLIFERANTS [ESTIMULANTES Y PROLIFERANTES CELULARES]

Cell Stimulants And Proliferants [Estimulantes Y Proliferantes Celulares]

ATRALIN 0.05 % gel 3 AL

AVITA 0.025 % crm, 0.025 % gel 3 AL

RETIN-A 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 3 AL

RETIN-A MICRO 0.04 % gel, 0.1 % gel 3 AL

RETIN-A MICRO PUMP 0.04 % gel, 0.08 % gel, 0.1 % gel 3 AL

tretinoin 0.05 % gel 1 ATRALIN AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

tretinoin 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 1 RETIN-A AL

tretinoin microsphere 0.04 % gel, 0.1 % gel 1 RETIN-A AL

tretinoin microsphere pump 0.04 % gel, 0.1 % gel 1 RETIN-A AL

TRETIN-X 0.075 % crm 3 AL

CENTRAL NERVOUS SYSTEM AGENTS, MISC [AGENTES DEL SISTEMA NERVIOSO CENTRAL, MISCELÁNEOS]

Central Nervous System Agents, Misc [Agentes Del Sistema Nervioso Central, Misceláneos]

acamprosate calcium 333 mg tab dr 1 CAMPRAL

atomoxetine hcl 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 STRATTERA

flumazenil 0.5 mg/5ml iv soln, 1 mg/10ml iv soln 1

guanfacine hcl er 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 1 INTUNIV

INTUNIV 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 3

memantine hcl 10 mg tab, 5 (28)-10 (21) mg tab, 5 mg tab 1 NAMENDA

memantine hcl 2 mg/ml soln 1 NAMENDA

memantine hcl er 14 mg cap er 24 hr, 21 mg cap er 24 hr, 28 mg cap er 24 hr, 7 mg cap er 24 hr 1 NAMENDA XR

NAMENDA 10 mg tab, 5 mg tab 3

NAMENDA TITRATION PAK 5 (28)-10 (21) mg tab 3

NAMENDA XR 14 mg cap er 24 hr, 21 mg cap er 24 hr, 28 mg cap er 24 hr, 7 mg cap er 24 hr 3

NAMENDA XR TITRATION PACK 7 & 14 & 21 &28 mg cap er 24 hr 3

STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 2

tetrabenazine 12.5 mg tab, 25 mg tab 1 XENAZINE PA

XENAZINE 12.5 mg tab, 25 mg tab 3 PA

XYREM 500 mg/ml soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CHOLELITHOLYTIC AGENTS [AGENTES COLELITOLÍTICO]

Cholelitholytic Agents [Agentes Colelitolítico]

ACTIGALL 300 mg cap 3

CHENODAL 250 mg tab 3

URSO 250 250 mg tab 3

URSO FORTE 500 mg tab 3

ursodiol 300 mg cap 1 ACTIGALL

ursodiol 250 mg tab, 500 mg tab 1 URSO

COMPLEMENT INHIBITORS [INHIBIDORES DEL COMPLEMENTO]

Complement Inhibitors [Inhibidores Del Complemento]

BERINERT 500 unit iv kit 3 PA

CINRYZE 500 unit iv soln 3 PA

FIRAZYR 30 mg/3ml sc soln 3 PA

KALBITOR 10 mg/ml sc soln 3 PA

RUCONEST 2100 unit iv soln 3 PA

SOLIRIS 300 mg/30ml iv soln 3 PA

CONTRACEPTIVES [ANTICONCEPTIVOS]

Contraceptives [Anticonceptivos]

ALTAVERA 0.15-30 mg-mcg tab 3 QL(28 / 28)

alyacen 1/35 1-35 mg-mcg tab 1 QL(28 / 28)

alyacen 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 QL(28 / 28)

AMETHIA 0.15-0.03 &0.01 mg tab 3 QL(91 / 91)

AMETHIA LO 0.1-0.02 & 0.01 mg tab 3 QL(91 / 91)

AMETHYST 90-20 mcg tab 3 QL(28 / 28)

APRI 0.15-30 mg-mcg tab 3 QL(28 / 28)

ARANELLE 0.5/1/0.5-35 mg-mcg tab 3 QL(28 / 28)

ASHLYNA 0.15-0.03 &0.01 mg tab 3 QL(91 / 91)

AUBRA 0.1-20 mg-mcg tab 3 QL(28 / 28)

AVIANE 0.1-20 mg-mcg tab 3 QL(28 / 28)

AZURETTE 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

BALZIVA 0.4-35 mg-mcg tab 3 QL(28 / 28)

BEKYREE 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

BEYAZ 3-0.02-0.451 mg tab 3 QL(28 / 28)

BLISOVI 24 FE 1-20 mg-mcg(24) tab 3 QL(28 / 28)

BLISOVI FE 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

BLISOVI FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

briellyn 0.4-35 mg-mcg tab 1 QL(28 / 28)

CAMRESE 0.15-0.03 &0.01 mg tab 3 QL(91 / 91)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CAMRESE LO 0.1-0.02 & 0.01 mg tab 3 QL(91 / 91)

CAZIANT 0.1/0.125/0.15 -0.025 mg tab 3 QL(28 / 28)

CHATEAL 0.15-30 mg-mcg tab 3 QL(28 / 28)

CRYSELLE-28 0.3-30 mg-mcg tab 3 QL(28 / 28)

CYCLAFEM 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

CYCLAFEM 7/7/7 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

CYRED 0.15-30 mg-mcg tab 3 QL(28 / 28)

DASETTA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

DASETTA 7/7/7 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

DAYSEE 0.15-0.03 &0.01 mg tab 3 QL(91 / 91)

DEBLITANE 0.35 mg tab 3 QL(28 / 28)

DELYLA 0.1-20 mg-mcg tab 3 QL(28 / 28)

DESOGEN 0.15-30 mg-mcg tab 3 QL(28 / 28)

desogestrel-ethinyl estradiol 0.15-30 mg-mcg tab 1 QL(28 / 28)

desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) tab 1 BEKYREE 28 DAY QL(28 / 28)

drospiren-eth estrad-levomefol 3-0.02-0.451 mg tab 1 BEYAZ QL(28 / 28)

drospiren-eth estrad-levomefol 3-0.03-0.451 mg tab 1 SAFYRAL QL(28 / 28)

drospirenone-ethinyl estradiol 3-0.03 mg tab 1 OCELLA 28 DAY QL(28 / 28)

drospirenone-ethinyl estradiol 3-0.02 mg tab 1 YAZ QL(28 / 28)

ELINEST 0.3-30 mg-mcg tab 3 QL(28 / 28)

ELLA 30 mg tab 3

EMOQUETTE 0.15-30 mg-mcg tab 3 QL(28 / 28)

ENPRESSE-28 tab 3 QL(28 / 28)

ENSKYCE 0.15-30 mg-mcg tab 3 QL(28 / 28)

ESTARYLLA 0.25-35 mg-mcg tab 3 QL(28 / 28)

ESTROSTEP FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

ethynodiol diac-eth estradiol 1-35 mg-mcg tab 1 ZOVIA 1/35E QL(28 / 28)

ethynodiol diac-eth estradiol 1-50 mg-mcg tab 1 ZOVIA 1/50E QL(28 / 28)

FALESSA 20-1-0.1 mcg-mg oral kit 3 QL(28 / 28)

FALMINA 0.1-20 mg-mcg tab 3 QL(28 / 28)

FAYOSIM 42-21-21-7 days tab 3 QL(91 / 91)

FEMCAP 22 mm vag dev 3

FEMYNOR 0.25-35 mg-mcg tab 3 QL(28 / 28)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

GENERESS FE 0.8-25 mg-mcg tab chew 3 QL(28 / 28)

GIANVI 3-0.02 mg tab 3 QL(28 / 28)

HEATHER 0.35 mg tab 3 QL(28 / 28)

INTROVALE 0.15-0.03 mg tab 3 QL(91 / 91)

ISIBLOOM 0.15-30 mg-mcg tab 3 QL(28 / 28)

JENCYCLA 0.35 mg tab 3 QL(28 / 28)

JOLESSA 0.15-0.03 mg tab 3 QL(91 / 91)

JOLIVETTE 0.35 mg tab 3 QL(28 / 28)

JULEBER 0.15-30 mg-mcg tab 3 QL(28 / 28)

JUNEL 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

JUNEL 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

JUNEL FE 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

JUNEL FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

JUNEL FE 24 1-20 mg-mcg(24) tab 3 QL(28 / 28)

KAITLIB FE 0.8-25 mg-mcg tab chew 3 QL(28 / 28)

KARIVA 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

KELNOR 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

KIMIDESS 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

KURVELO 0.15-30 mg-mcg tab 3 QL(28 / 28)

LARIN 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

LARIN 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

LARIN 24 FE 1-20 mg-mcg(24) tab 3 QL(28 / 28)

LARIN FE 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

LARIN FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

LARISSIA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LAYOLIS FE 0.8-25 mg-mcg tab chew 3 QL(28 / 28)

LEENA 0.5/1/0.5-35 mg-mcg tab 3 QL(28 / 28)

LESSINA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LEVONEST tab 3 QL(28 / 28)

levonorgest-eth est & eth est 42-21-21-7 days tab 1 QUARTETTE QL(91 / 91)

levonorgest-eth estrad 91-day 0.1-0.02 & 0.01 mg tab 1 QL(91 / 91)

levonorgest-eth estrad 91-day 0.15-0.03 &0.01 mg tab 1 AMETHIA 91 DAY QL(91 / 91)

levonorgest-eth estrad 91-day 0.15-0.03 mg tab 1 SEASONALE QL(91 / 91)

levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 1 QL(28 / 28)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

levonorgestrel-ethinyl estrad 90-20 mcg tab 1 AMETHYST 28 DAY QL(28 / 28)

levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 1 AVIANE QL(28 / 28)

levonorg-eth estrad triphasic tab 1 ENPRESSE 28 DAY QL(28 / 28)

LEVORA 0.15/30 (28) 0.15-30 mg-mcg tab 3 QL(28 / 28)

LILLOW 0.15-30 mg-mcg tab 3 QL(28 / 28)

LO LOESTRIN FE 1 MG-10 MCG / 10 mcg tab 3 QL(28 / 28)

LOESTRIN 1.5/30 (21) 1.5-30 mg-mcg tab 3 QL(28 / 28)

LOESTRIN 1/20 (21) 1-20 mg-mcg tab 3 QL(28 / 28)

LOESTRIN FE 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

LOESTRIN FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

LORYNA 3-0.02 mg tab 3 QL(28 / 28)

LOSEASONIQUE 0.1-0.02 & 0.01 mg tab 3 QL(91 / 91)

LOW-OGESTREL 0.3-30 mg-mcg tab 3 QL(28 / 28)

LUTERA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LYZA 0.35 mg tab 3 QL(28 / 28)

marlissa 0.15-30 mg-mcg tab 1 QL(28 / 28)

MELODETTA 24 FE 1-20 mg-mcg(24) tab chew 3 QL(28 / 28)

MIBELAS 24 FE 1-20 mg-mcg(24) tab chew 3 QL(28 / 28)

MICROGESTIN 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

MICROGESTIN 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

MICROGESTIN FE 1.5/30 1.5-30 mg-mcg tab 3 QL(28 / 28)

MICROGESTIN FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

MINASTRIN 24 FE 1-20 mg-mcg(24) tab chew 3 QL(28 / 28)

MIRCETTE 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

MONO-LINYAH 0.25-35 mg-mcg tab 3 QL(28 / 28)

MONONESSA 0.25-35 mg-mcg tab 3 QL(28 / 28)

MYZILRA tab 3 QL(28 / 28)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NATAZIA 3/2-2/2-3/1 mg tab 3 QL(28 / 28)

NECON 0.5/35 (28) 0.5-35 mg-mcg tab 3 QL(28 / 28)

NECON 7/7/7 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

NIKKI 3-0.02 mg tab 3 QL(28 / 28)

NORA-BE 0.35 mg tab 3 QL(28 / 28)

norethin ace-eth estrad-fe 1-20 mg-mcg tab 1 QL(28 / 28)

norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab 1

BLISOVI 24 FE 1/20 28 DAY QL(28 / 28)

norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab chew 1 MINASTRIN 24 FE QL(28 / 28)

norethindrone 0.35 mg tab 1 NOR-QD QL(28 / 28)

norethindrone acet-ethinyl est 1-20 mg-mcg tab 1 LOESTRIN 1/20 QL(28 / 28)

norethindrone acet-ethinyl est 1-20 mg-mcg(24) tab chew 1 MINASTRIN 24 FE QL(28 / 28)

norethin-eth estradiol-fe 0.4-35 mg-mcg tab chew 1 FEMCOM FE QL(28 / 28)

norethin-eth estradiol-fe 0.8-25 mg-mcg tab chew 1 GENERESS FE 28 QL(28 / 28)

norgestimate-eth estradiol 0.25-35 mg-mcg tab 1 QL(28 / 28)

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35 mcg tab 1 ORTHO TRI-CYCLEN QL(28 / 28)

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25 mcg tab 1

ORTHO TRI-CYCLEN LO 28 DAY QL(28 / 28)

NORLYROC 0.35 mg tab 3 QL(28 / 28)

NORTREL 0.5/35 (28) 0.5-35 mg-mcg tab 3 QL(28 / 28)

NORTREL 1/35 (21) 1-35 mg-mcg tab 3 QL(28 / 28)

NORTREL 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)

NORTREL 7/7/7 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

NUVARING 0.12-0.015 mg/24hr vag ring 3 QL(1 / 30)

OCELLA 3-0.03 mg tab 3 QL(28 / 28)

OGESTREL 0.5-50 mg-mcg tab 3 QL(28 / 28)

ORSYTHIA 0.1-20 mg-mcg tab 3 QL(28 / 28)

ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ORTHO-CYCLEN (28) 0.25-35 mg-mcg tab 3 QL(28 / 28)

ORTHO-NOVUM 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)

ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

PHILITH 0.4-35 mg-mcg tab 3 QL(28 / 28)

PIMTREA 0.15-0.02/0.01 mg (21/5) tab 3 QL(28 / 28)

PIRMELLA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

PIRMELLA 7/7/7 0.5/0.75/1-35 mg-mcg tab 3 QL(28 / 28)

PORTIA-28 0.15-30 mg-mcg tab 3 QL(28 / 28)

PREVIFEM 0.25-35 mg-mcg tab 3 QL(28 / 28)

QUARTETTE 42-21-21-7 days tab 3 QL(91 / 91)

QUASENSE 0.15-0.03 mg tab 3 QL(91 / 91)

RAJANI 3-0.02-0.451 mg tab 3 QL(28 / 28)

RECLIPSEN 0.15-30 mg-mcg tab 3 QL(28 / 28)

RIVELSA 42-21-21-7 days tab 3 QL(91 / 91)

SAFYRAL 3-0.03-0.451 mg tab 3 QL(28 / 28)

SEASONIQUE 0.15-0.03 &0.01 mg tab 3 QL(91 / 91)

SETLAKIN 0.15-0.03 mg tab 3 QL(91 / 91)

SHAROBEL 0.35 mg tab 3 QL(28 / 28)

SPRINTEC 28 0.25-35 mg-mcg tab 3 QL(28 / 28)

SRONYX 0.1-20 mg-mcg tab 3 QL(28 / 28)

SYEDA 3-0.03 mg tab 3 QL(28 / 28)

TARINA FE 1/20 1-20 mg-mcg tab 3 QL(28 / 28)

TILIA FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

TRI FEMYNOR 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-ESTARYLLA 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-LEGEST FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

TRI-LINYAH 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-LO-ESTARYLLA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-LO-MARZIA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-LO-SPRINTEC 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRINESSA (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

TRINESSA LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-NORINYL (28) 0.5/1/0.5-35 mg-mcg tab 3 QL(28 / 28)

TRI-PREVIFEM 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-SPRINTEC 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRIVORA (28) tab 3 QL(28 / 28)

VELIVET 0.1/0.125/0.15 -0.025 mg tab 3 QL(28 / 28)

VESTURA 3-0.02 mg tab 3 QL(28 / 28)

VIENVA 0.1-20 mg-mcg tab 3 QL(28 / 28)

viorele 0.15-0.02/0.01 mg (21/5) tab 1 BEKYREE 28 DAY QL(28 / 28)

VYFEMLA 0.4-35 mg-mcg tab 3 QL(28 / 28)

WERA 0.5-35 mg-mcg tab 3 QL(28 / 28)

WYMZYA FE 0.4-35 mg-mcg tab chew 3 QL(28 / 28)

XULANE 150-35 mcg/24hr tdwk patch 3 QL(3 / 30)

YASMIN 28 3-0.03 mg tab 3 QL(28 / 28)

YAZ 3-0.02 mg tab 3 QL(28 / 28)

ZARAH 3-0.03 mg tab 3 QL(28 / 28)

ZENCHENT 0.4-35 mg-mcg tab 3 QL(28 / 28)

ZOVIA 1/35E (28) 1-35 mg-mcg tab 3 QL(28 / 28)

CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS [MODULADORES REGULADORES DE LA CONDUCTANCIA TRANSMEMBRANA DE LA FIBROSIS QUÍSTICA]

Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Correctors [Correctores Reguladores De La Conductancia Transmembrana De La Fibrosis Quística (Rtfq)]

SYMDEKO 100-150 & 150 mg tab pack 3 PA

Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators [Potenciadores Reguladores De La Conductancia Transmembrana De La Fibrosis Quística (Rtfq)]

KALYDECO 150 mg tab 3 PA

DENTAL AGENTS [AGENTES DENTALES]

Dental Agents [Agentes Dentales]

FLUORIDEX SENSITIVITY RELIEF 1.1-5 % dental paste 3

PREVIDENT 5000 ENAMEL PROTECT 1.1-5 % dental paste 3

PREVIDENT 5000 SENSITIVE 1.1-5 % dental paste 3

DEPIGMENTING AND PIGMENTING AGENTS [AGENTES DESPIGMENTANTES Y PIGMENTANTES]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

Depigmenting Agents [Agentes Despigmentantes]

TRI-LUMA 0.01-4-0.05 % crm 3

Pigmenting Agents [Agentes Pigmentantes]

methoxsalen 10 mg cap 1 OXSORALEN-ULTRA

methoxsalen rapid 10 mg cap 1 OXSORALEN-ULTRA

OXSORALEN ULTRA 10 mg cap 3

DEVICES [DISPOSITIVOS]

Devices [Dispositivos]

ALCOH-GLOVE CONTOURED WIPE pad 3

alcoh-wipe sheet 1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ml misc 3

HUMAPEN LUXURA HD dev 2

HUMATROPEN FOR 12MG dev 2 PA

HUMATROPEN FOR 24MG dev 2 PA

HUMATROPEN FOR 6MG dev 2 PA

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ml misc, 29G X 1/2" 0.5 ml misc, 29G X 1/2" 1 ml misc, 30G X 5/16" 0.3 ml misc, 30G X 5/16" 0.5 ml misc, 30G X 5/16" 1 ml misc 3

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ml misc, 28G X 1/2" 0.5 ml misc, 28G X 1/2" 1 ml misc, 29G X 1/2" 0.3 ml misc, 29G X 1/2" 0.5 ml misc, 29G X 1/2" 1 ml misc, 30G X 5/16" 0.3 ml misc, 30G X 5/16" 0.5 ml misc, 30G X 5/16" 1 ml misc, U-100 1 ml misc 3

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ml misc, 28G X 1/2" 1 ml misc, 30G X 5/16" 0.3 ml misc, 30G X 5/16" 0.5 ml misc 3

pro comfort pen needles 31G X 8 MM misc, 32G X 4 MM misc, 32G X 5 MM misc 1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ml misc, 29G X 1/2" 1 ml misc 3

DIGESTANTS [DIGESTIVOS]

Digestants [Digestivos]

CREON 12000 unit cap dr prt, 24000-76000 unit cap dr prt, 3000- 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

9500 unit cap dr prt, 36000 unit cap dr prt, 6000 unit cap dr prt

PANCREAZE 10500 unit cap dr prt, 16800 unit cap dr prt, 21000 unit cap dr prt, 4200 unit cap dr prt 3

PERTZYE 16000 unit cap dr prt, 8000 unit cap dr prt 3

VIOKACE 10440 unit tab, 20880 unit tab 3

ZENPEP 10000-32000 unit cap dr prt, 15000-47000 unit cap dr prt, 20000-63000 unit cap dr prt, 25000-79000 unit cap dr prt, 3000-14000 unit cap dr prt, 40000-126000 unit cap dr prt, 5000-24000 unit cap dr prt 3

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS [MEDICAMENTOS ANTIRREUMÁTICOS MODIFICADORES DE LA ENFERMEDAD]

Disease-modifying Antirheumatic Drugs [Medicamentos Antirreumáticos Modificadores De La Enfermedad]

ACTEMRA 162 mg/0.9ml sc soln pfs, 200 mg/10ml iv soln, 400 mg/20ml iv soln, 80 mg/4ml iv soln 3 PA

ARAVA 10 mg tab, 20 mg tab 3

CIMZIA 2 X 200 mg sc kit 3 PA

CIMZIA PREFILLED 2 X 200 mg/ml sc kit 3 PA

CIMZIA STARTER KIT 6 X 200 mg/ml sc kit 3 PA

ENBREL 25 mg sc soln 3 PA

ENBREL 25 mg/0.5ml sc soln pfs, 50 mg/ml sc soln pfs 3 PA

ENBREL SURECLICK 50 mg/ml sc soln auto-inj 3 PA

HUMIRA 10 mg/0.2ml sc pfs kit, 20 mg/0.4ml sc pfs kit, 40 mg/0.8ml sc pfs kit 3 PA

HUMIRA PEDIATRIC CROHNS START 40 mg/0.8ml sc pfs kit 3 PA

HUMIRA PEN 40 mg/0.8ml sc pen-inj kit 3 PA

HUMIRA PEN-CD/UC/HS STARTER 40 mg/0.8ml sc pen-inj kit, 80 mg/0.8ml sc pen-inj kit 3 PA

HUMIRA PEN-PS/UV STARTER 40 mg/0.8ml sc pen-inj kit, 80 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

MG/0.8ML & 40mg/0.4ml sc pen-inj kit

KINERET 100 mg/0.67ml sc soln pfs 3 PA

leflunomide 10 mg tab, 20 mg tab 1 ARAVA

ORENCIA 250 mg iv soln 3 PA

ORENCIA 125 mg/ml sc soln pfs, 50 mg/0.4ml sc soln pfs, 87.5 mg/0.7ml sc soln pfs 3 PA

ORENCIA CLICKJECT 125 mg/ml sc soln auto-inj 3 PA

OTEZLA 10 & 20 & 30 mg tab pack, 30 mg tab 3 PA

OTREXUP 10 mg/0.4ml sc soln auto-inj, 15 mg/0.4ml sc soln auto-inj, 20 mg/0.4ml sc soln auto-inj, 25 mg/0.4ml sc soln auto-inj 3

RASUVO 20 mg/0.4ml sc soln auto-inj 3

SIMPONI 100 mg/ml sc soln auto-inj, 100 mg/ml sc soln pfs, 50 mg/0.5ml sc soln auto-inj, 50 mg/0.5ml sc soln pfs 3 PA

SIMPONI ARIA 50 mg/4ml iv soln 3 PA

XELJANZ 10 mg tab, 5 mg tab 3 PA

XELJANZ XR 11 mg tab er 24 hr 3 PA

DIURETICS [DIURÉTICOS]

Loop Diuretics [Diuréticos Del Asa De Henle]

bumetanide 0.5 mg tab, 1 mg tab, 2 mg tab 1 BUMEX

DEMADEX 10 mg tab, 20 mg tab 3

EDECRIN 25 mg tab 3

ethacrynic acid 25 mg tab 1 EDECRIN

furosemide 20 mg tab, 40 mg tab, 80 mg tab 1 LASIX

LASIX 20 mg tab, 40 mg tab, 80 mg tab 3

torsemide 10 mg tab, 100 mg tab, 20 mg tab, 5 mg tab 1 DEMADEX

Potassium-sparing Diuretics [Diuréticos Conservadores De Potasio]

amiloride hcl 5 mg tab 1 MIDAMOR

amiloride-hydrochlorothiazide 5-50 mg tab 1 MODURETIC

DYAZIDE 37.5-25 mg cap 3

DYRENIUM 100 mg cap, 50 mg cap 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

MAXZIDE 75-50 mg tab 3

MAXZIDE-25 37.5-25 mg tab 3

triamterene-hctz 37.5-25 mg cap 1 DYAZIDE

triamterene-hctz 37.5-25 mg tab, 75-50 mg tab 1 MAXZIDE

Thiazide Diuretics [Diuréticos Tiazídicos]

chlorothiazide 250 mg tab, 500 mg tab 1 DIURIL

DIURIL 250 mg/5ml susp 3

hydrochlorothiazide 25 mg tab, 50 mg tab 1 HYDRODIURIL

hydrochlorothiazide 12.5 mg cap, 12.5 mg tab 1 MICROZIDE

methyclothiazide 5 mg tab 1 ENDURON

MICROZIDE 12.5 mg cap 3

Thiazide-like Diuretics [Diuréticos Similares A Tiazida]

chlorthalidone 25 mg tab, 50 mg tab 1 HYGROTON

indapamide 1.25 mg tab, 2.5 mg tab 1 LOZOL

metolazone 10 mg tab, 2.5 mg tab, 5 mg tab 1 ZAROXOLYN

Vasopressin Antagonists [Antagonistas De Vasopresina]

SAMSCA 15 mg tab, 30 mg tab 3 PA

EENT DRUGS, MISCELLANEOUS [MEDICAMENTOS PARA OJOS, OÍDOS, NARIZ Y GARGANTA, MISCELÁNEOS]

Eent Drugs, Miscellaneous [Medicamentos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

acetic acid 2 % otic soln 1 VOSOL

apraclonidine hcl 0.5 % ophth soln 1 IOPIDINE

DEBACTEROL 30-50 % m/t soln 3

IOPIDINE 1 % ophth soln 3

IOPIDINE 0.5 % ophth soln 3

RESCULA 0.15 % ophth soln 3

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS [EMOLIENTES, DEMULCENTES Y PROTECTORES]

Basic Lotions And Liniments [Lociones Y Linimentos Básicos]

ammonium lactate 12 % crm, 12 % lot 1 LAC-HYDRIN

LAC-HYDRIN 12 % crm, 12 % lot 3

lactic acid 10 % lot 1

Basic Ointments And Protectants [Ungüentos Y Protectores Básicos]

NEOSALUS crm 3

ENZYMES [ENZIMAS]

Enzymes [Enzimas]

ALDURAZYME 2.9 mg/5ml iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CEREZYME 400 unit iv soln 3 PA

ELAPRASE 6 mg/3ml iv soln 3 PA

ELELYSO 200 unit iv soln 3 PA

FABRAZYME 35 mg iv soln, 5 mg iv soln 3 PA

LUMIZYME 50 mg iv soln 3 PA

NAGLAZYME 1 mg/ml iv soln 3 PA

SUCRAID 8500 unit/ml soln 3

VIMIZIM 5 mg/5ml iv soln 3 PA

VPRIV 400 unit iv soln 3 PA

ESTROGENS AND ANTIESTROGENS [ESTRÓGENOS Y ANTIESTRÓGENOS]

Estrogen Agonist-antagonists [Agonistas-Antagonistas De Estrógeno]

clomiphene citrate 50 mg tab 1

DUAVEE 0.45-20 mg tab 3

EVISTA 60 mg tab 2 PA

raloxifene hcl 60 mg tab 1 EVISTA PA

Estrogens [Estrógenos]

ACTIVELLA 0.5-0.1 mg tab, 1-0.5 mg tab 3

ALORA 0.025 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

AMABELZ 0.5-0.1 mg tab, 1-0.5 mg tab 3

ANGELIQ 0.25-0.5 mg tab, 0.5-1 mg tab 3

CLIMARA 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 3

CLIMARA PRO 0.045-0.015 mg/day tdwk patch 3

COMBIPATCH 0.05-0.14 mg/day tdbiw patch, 0.05-0.25 mg/day tdbiw patch 3

COVARYX 1.25-2.5 mg tab 3

COVARYX HS 0.625-1.25 mg tab 3

DELESTROGEN 10 mg/ml im oil, 20 mg/ml im oil, 40 mg/ml im oil 3

DEPO-ESTRADIOL 5 mg/ml im oil 3

DIVIGEL 0.25 mg/0.25gm td gel, 0.5 mg/0.5gm td gel 3

DIVIGEL 1 mg/gm td gel 3

EEMT 1.25-2.5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

EEMT HS 0.625-1.25 mg tab 3

ELESTRIN 0.52 MG/0.87 GM (0.06%) td gel 3

est estrogens-methyltest 1.25-2.5 mg tab 1

est estrogens-methyltest ds 1.25-2.5 mg tab 1

est estrogens-methyltest hs 0.625-1.25 mg tab 1

ESTRACE 0.5 mg tab, 1 mg tab, 2 mg tab 3

ESTRACE 0.1 mg/gm vag crm 3

estradiol 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 1 CLIMARA

estradiol 0.5 mg tab, 1 mg tab, 2 mg tab 1 ESTRACE

estradiol 0.1 mg/gm vag crm 1 ESTRACE

estradiol 10 mcg vag tab 1 VAGIFEM

estradiol 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 1 VIVELLE-DOT

estradiol valerate 20 mg/ml im oil, 40 mg/ml im oil 1 DELESTROGEN

estradiol-norethindrone acet 0.5-0.1 mg tab, 1-0.5 mg tab 1 ACTIVELLA

ESTROGEL 0.75 MG/1.25 GM (0.06%) td gel 3

estropipate 0.75 mg tab, 1.5 mg tab 1 OGEN

EVAMIST 1.53 mg/spray td soln 3

FEMHRT LOW DOSE 0.5-2.5 mg-mcg tab 3

FYAVOLV 0.5-2.5 mg-mcg tab, 1-5 mg-mcg tab 3

jevantique lo 0.5-2.5 mg-mcg tab 1 FEMHRT 0.5/2.5 28

DAY

JINTELI 1-5 mg-mcg tab 3

LOPREEZA 0.5-0.1 mg tab, 1-0.5 mg tab 3

MENEST 0.3 mg tab, 0.625 mg tab, 1.25 mg tab, 2.5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

MENOSTAR 14 mcg/24hr tdwk patch 3

MIMVEY 1-0.5 mg tab 3

MIMVEY LO 0.5-0.1 mg tab 3

MINIVELLE 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1

FEMHRT 0.5/2.5 28 DAY

norethindrone-eth estradiol 1-5 mg-mcg tab 1 FYAVOLV

PREFEST 1/1-0.09 mg (15/15) tab 3

PREMARIN 0.3 mg tab, 0.45 mg tab, 0.625 mg tab, 0.9 mg tab, 1.25 mg tab 3

PREMARIN 0.625 mg/gm vag crm 3

PREMPHASE 0.625-5 mg tab 3

PREMPRO 0.3-1.5 mg tab, 0.45-1.5 mg tab, 0.625-2.5 mg tab, 0.625-5 mg tab 3

VAGIFEM 10 mcg vag tab 3

VIVELLE-DOT 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

YUVAFEM 10 mcg vag tab 3

EXPECTORANTS [EXPECTORANTES]

Expectorants [Expectorantes]

DECON-G 2-1-40 mg/ml liq 3

GILPHEX TR 10-388 mg tab 3

phenylephrine-guaifenesin 1.5-20 mg/ml liq 1

FIBROMYALGIA AGENTS [AGENTES PARA FIBROMIALGIA]

Fibromyalgia Agents [Agentes Para Fibromialgia]

SAVELLA 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 3

SAVELLA TITRATION PACK 12.5 & 25 & 50 mg oral misc 3

FIRST GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE PRIMERA GENERACIÓN]

Derivatives, Miscellaneous [Derivados, Misceláneos]

cyproheptadine hcl 4 mg tab 1 PERIACTIN

cyproheptadine hcl 2 mg/5ml syr 1 PERIACTIN

Ethanolamine Derivatives [Derivados De Etanolamina]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

carbinoxamine maleate 4 mg tab 1 CLISTIN

carbinoxamine maleate 4 mg/5ml soln 1 CLISTIN

clemastine fumarate 2.68 mg tab 1 TAVIST

diphenhydramine hcl 12.5 mg/5ml oral elix, 50 mg/ml inj soln 1 BENADRYL

KARBINAL ER 4 mg/5ml susp er 3

Phenothiazine Derivatives [Derivados De La Fenotiazina]

PHENADOZ 12.5 mg rect supp, 25 mg rect supp 3

PHENERGAN 25 mg/ml inj soln, 50 mg/ml inj soln 3

promethazine hcl 12.5 mg rect supp, 12.5 mg tab, 25 mg rect supp, 25 mg tab, 50 mg rect supp, 50 mg tab 1 PHENERGAN

promethazine hcl 25 mg/ml inj soln, 50 mg/ml inj soln, 6.25 mg/5ml soln, 6.25 mg/5ml syr 1 PHENERGAN

promethazine vc plain 6.25-5 mg/5ml soln 1 PHENERGAN VC

promethazine-phenylephrine 6.25-5 mg/5ml syr 1 PHENERGAN VC

PROMETHEGAN 12.5 mg rect supp, 25 mg rect supp, 50 mg rect supp 3

Propylamine Derivatives [Derivados De Propilamina]

brompheniramine tannate 12 mg tab chew 1

DECON-A 2-5 mg/5ml oral elix 3

NALFRX 2.5-12.5-75 mg/5ml susp 3

GENITOURINARY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO GENITOURINARIO]

Antimuscarinics [Antimuscarínicos]

darifenacin hydrobromide er 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 1 ENABLEX

DETROL 1 mg tab, 2 mg tab 3

DETROL LA 2 mg cap er 24 hr, 4 mg cap er 24 hr 3

DITROPAN XL 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 3

ENABLEX 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 3

flavoxate hcl 100 mg tab 1

GELNIQUE 10 % td gel 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

GELNIQUE PUMP 10 % td gel 3

oxybutynin chloride 5 mg tab 1 DITROPAN

oxybutynin chloride 5 mg/5ml syr 1 DITROPAN

oxybutynin chloride er 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 1 DITROPAN

tolterodine tartrate 1 mg tab, 2 mg tab 1 DETROL

tolterodine tartrate er 2 mg cap er 24 hr, 4 mg cap er 24 hr 1 DETROL

TOVIAZ 4 mg tab er 24 hr, 8 mg tab er 24 hr 3

trospium chloride 20 mg tab 1 SANCTURA

trospium chloride er 60 mg cap er 24 hr 1 SANCTURA XR

VESICARE 10 mg tab, 5 mg tab 3

B3-adrenergic Agonists [Agonistas B-3 Adrenérgicos]

MYRBETRIQ 25 mg tab er 24 hr, 50 mg tab er 24 hr 3

GI DRUGS, MISCELLANEOUS [MEDICAMENTOS GASTROINTESTINALES, MISCELÁNEOS]

Gi Drugs, Miscellaneous [Medicamentos Gastrointestinales, Misceláneos]

AMITIZA 24 mcg cap, 8 mcg cap 3

ENTYVIO 300 mg iv soln 3 PA

GATTEX 5 mg sc kit 3 PA

LINZESS 145 mcg cap, 290 mcg cap, 72 mcg cap 3

RELISTOR 150 mg tab 3 PA

RELISTOR 12 mg/0.6ml sc soln, 8 mg/0.4ml sc soln 3 PA

STELARA 130 mg/26ml iv soln 3 PA

VIBERZI 100 mg tab, 75 mg tab 3

XENICAL 120 mg cap 3 PA

GOLD COMPOUNDS [COMPUESTOS DE ORO]

Gold Compounds [Compuestos De Oro]

RIDAURA 3 mg cap 3

GONADOTROPIN-RELEASING HORMONE ANTAGONISTS [ANTAGONISTAS DE LA HORMONA LIBERADORA DE GONADOTROPINA]

Gonadotropin-releasing Hormone Antagonists [Antagonistas De La Hormona Liberadora De Gonadotropina]

ganirelix acetate 250 mcg/0.5ml sc soln 3

GONADOTROPINS [GONADOTROPINAS]

Gonadotropins [Gonadotropinas]

BRAVELLE 75 unit inj soln 3

chorionic gonadotropin 10000 unit im soln 1 PREGNYL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

FOLLISTIM AQ 300 unt/0.36ml sc soln, 600 unt/0.72ml sc soln, 900 unt/1.08ml sc soln 3

GONAL-F 1050 unit inj soln, 450 unit inj soln 3

GONAL-F RFF 75 unit sc soln 3

GONAL-F RFF REDIJECT 300 unit/0.5ml sc soln, 450 unt/0.75ml sc soln, 900 unit/1.5ml sc soln 3

MENOPUR 75 unit sc soln 3

NOVAREL 10000 unit im soln 3

OVIDREL 250 mcg/0.5ml sc inj 3

PREGNYL 10000 unit im soln 3

SYNAREL 2 mg/ml nasal soln 3

HEAVY METAL ANTAGONISTS [ANTAGONISTAS DE METALES PESADOS]

Heavy Metal Antagonists [Antagonistas De Metales Pesados]

CHEMET 100 mg cap 3 PA

EXJADE 125 mg tab sol, 250 mg tab sol, 500 mg tab sol 3 PA

FERRIPROX 500 mg tab 3 PA

FERRIPROX 100 mg/ml soln 3 PA

JADENU 180 mg tab, 360 mg tab, 90 mg tab 3 PA

JADENU SPRINKLE 180 mg pckt, 360 mg pckt, 90 mg pckt 3 PA

pentetate calcium trisodium 200 mg/ml cmb soln 3 PA

pentetate zinc trisodium 200 mg/ml cmb soln 3 PA

HEMATOPOIETIC AGENTS [AGENTES HEMATOPOYÉTICOS]

Hematopoietic Agents [Agentes Hematopoyéticos]

ARANESP (ALBUMIN FREE) 10 mcg/0.4ml inj soln pfs, 100 mcg/0.5ml inj soln pfs, 100 mcg/ml inj soln, 150 mcg/0.3ml inj soln pfs, 200 mcg/0.4ml inj soln pfs, 200 mcg/ml inj soln, 25 mcg/0.42ml inj soln pfs, 25 mcg/ml inj soln, 300 mcg/0.6ml inj soln pfs, 300 mcg/ml inj soln, 40 mcg/0.4ml inj soln pfs, 40 mcg/ml inj soln, 500 mcg/ml inj soln pfs, 60 mcg/0.3ml inj soln pfs, 60 mcg/ml inj soln 3 PA

EPOGEN 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln

GRANIX 300 mcg/0.5ml sc soln pfs, 480 mcg/0.8ml sc soln pfs 3 PA

LEUKINE 250 mcg iv soln 3 PA

MIRCERA 100 mcg/0.3ml inj soln pfs, 200 mcg/0.3ml inj soln pfs, 50 mcg/0.3ml inj soln pfs, 75 mcg/0.3ml inj soln pfs 3 PA

NEULASTA 6 mg/0.6ml sc soln pfs 3 PA

NEULASTA ONPRO 6 mg/0.6ml sc pfs kit 3 PA

NEUPOGEN 300 mcg/0.5ml inj soln pfs, 300 mcg/ml inj soln, 480 mcg/0.8ml inj soln pfs, 480 mcg/1.6ml inj soln 3 PA

NPLATE 250 mcg sc soln, 500 mcg sc soln 3 PA

PROCRIT 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln, 40000 unit/ml inj soln 3 PA

PROMACTA 12.5 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 3 PA

ZARXIO 300 mcg/0.5ml inj soln pfs, 480 mcg/0.8ml inj soln pfs 3 PA

HEMORRHEOLOGIC AGENTS [AGENTES HEMORREOLÓGICOS]

Hemorrheologic Agents [Agentes Hemorreológicos]

pentoxifylline er 400 mg tab er 1 TRENTAL

HYPOTENSIVE AGENTS [AGENTES HIPOTENSORES]

Central Alpha-agonists [Agonistas Centrales Alfa]

CATAPRES 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 3

CATAPRES-TTS-1 0.1 mg/24hr tdwk patch 3

CATAPRES-TTS-2 0.2 mg/24hr tdwk patch 3

CATAPRES-TTS-3 0.3 mg/24hr tdwk patch 3

clonidine 0.1 mg/24hr tdwk patch, 0.2 mg/24hr tdwk patch, 0.3 mg/24hr tdwk patch 1

clonidine hcl 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 1 CATAPRES

clonidine hcl er 0.1 mg tab er 12 hr 1 KAPVAY

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

guanfacine hcl 1 mg tab, 2 mg tab 1 TENEX

KAPVAY 0.1 mg tab er 12 hr 3

methyldopa 250 mg tab, 500 mg tab 1 ALDOMET

methyldopa-hydrochlorothiazide 250-15 mg tab, 250-25 mg tab 1 ALDORIL

Direct Vasodilators [Vasodilatadores Directos]

hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 APRESOLINE

hydralazine hcl 20 mg/ml inj soln 1 APRESOLINE

minoxidil 10 mg tab, 2.5 mg tab 1 LONITEN

IMMUNOMODULATORY AGENTS [AGENTES INMUNOMODULADORES]

Immunomodulatory Agents [Agentes Inmunomoduladores]

ACTIMMUNE 2000000 unit/0.5ml sc soln 3

AUBAGIO 14 mg tab, 7 mg tab 3 PA

AVONEX 30 mcg im kit 3 PA

AVONEX PEN 30 mcg/0.5ml im auto-inj kit 3 PA

AVONEX PREFILLED 30 mcg/0.5ml im pfs kit 3 PA

BETASERON 0.3 mg sc kit 3 PA

ENBREL MINI 50 mg/ml sc soln cart 3 PA

EXTAVIA 0.3 mg sc kit 3 PA

GILENYA 0.25 mg cap, 0.5 mg cap 3 PA

glatiramer acetate 20 mg/ml sc soln pfs 1 COPAXONE PA

GLATOPA 20 mg/ml sc soln pfs 1 PA

LEMTRADA 12 mg/1.2ml iv soln 3 PA

REBIF 22 mcg/0.5ml sc soln pfs, 44 mcg/0.5ml sc soln pfs 3 PA

REBIF REBIDOSE 22 mcg/0.5ml sc soln auto-inj, 44 mcg/0.5ml sc soln auto-inj 3 PA

REBIF REBIDOSE TITRATION PACK 6X8.8 & 6X22 mcg sc soln auto-inj 3 PA

REBIF TITRATION PACK 6X8.8 & 6X22 mcg sc soln pfs 3 PA

TECFIDERA 120 & 240 mg oral misc, 120 mg cap dr, 240 mg cap dr 3 PA

THALOMID 100 mg cap, 150 mg cap, 200 mg cap, 50 mg cap 3 PA

TYSABRI 300 mg/15ml iv conc 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

IMMUNOSUPPRESSIVE AGENTS [AGENTES INMUNOSUPRESORES]

Immunosuppressive Agents [Agentes Inmunosupresores]

ASTAGRAF XL 0.5 mg cap er 24 hr, 1 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA

ATGAM 50 mg/ml iv inj 3 PA

AZASAN 100 mg tab, 75 mg tab 3 PA

azathioprine pwdr 1 PA

azathioprine 50 mg tab 1 IMURAN PA

azathioprine sodium 100 mg inj soln 1 IMURAN PA

BENLYSTA 120 mg iv soln 3 PA

BENLYSTA 200 mg/ml sc soln auto-inj, 200 mg/ml sc soln pfs 3 PA

CELLCEPT 250 mg cap, 500 mg tab 3 PA

CELLCEPT 200 mg/ml susp 3 PA

CELLCEPT INTRAVENOUS 500 mg iv soln 3 PA

cyclosporine 100 mg cap, 25 mg cap 1 SANDIMMUNE PA

cyclosporine 50 mg/ml iv soln 1 SANDIMMUNE PA

cyclosporine modified 100 mg cap, 25 mg cap, 50 mg cap 1 NEORAL PA

cyclosporine modified 100 mg/ml soln 1 NEORAL PA

ENVARSUS XR 0.75 mg tab er 24 hr, 1 mg tab er 24 hr, 4 mg tab er 24 hr 3 PA

GENGRAF 100 mg cap, 25 mg cap 3 PA

GENGRAF 100 mg/ml soln 3 PA

IMURAN 50 mg tab 3 PA

mycophenolate mofetil 250 mg cap, 500 mg tab 1 CELLCEPT PA

mycophenolate mofetil 200 mg/ml susp 1 CELLCEPT PA

mycophenolate mofetil hcl 500 mg iv soln 1 CELLCEPT PA

mycophenolate sodium 180 mg tab dr, 360 mg tab dr 1 MYFORTIC PA

MYFORTIC 180 mg tab dr, 360 mg tab dr 3 PA

NEORAL 100 mg cap, 25 mg cap 3 PA

NEORAL 100 mg/ml soln 3 PA

NULOJIX 250 mg iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

PROGRAF 0.5 mg cap, 1 mg cap, 5 mg cap 3 PA

PROGRAF 5 mg/ml iv soln 3 PA

RAPAMUNE 0.5 mg tab, 1 mg tab, 2 mg tab 3 PA

RAPAMUNE 1 mg/ml soln 3 PA

SANDIMMUNE 100 mg cap, 25 mg cap 3 PA

SANDIMMUNE 100 mg/ml soln, 50 mg/ml iv soln 3 PA

SIMULECT 10 mg iv soln, 20 mg iv soln 3 PA

sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab 1 RAPAMUNE PA

tacrolimus 0.5 mg cap, 1 mg cap, 5 mg cap 1 PROGRAF PA

THYMOGLOBULIN 25 mg iv soln 3 PA

ZORTRESS 0.25 mg tab, 0.5 mg tab, 0.75 mg tab 3 PA

ION-REMOVING AGENTS [AGENTES REMOVEDORES DE IONES]

Phosphate-removing Agents [Agentes Removedores De Fosfato]

AURYXIA 1 GM 210 mg(fe) tab 3 PA

FOSRENOL 1000 mg pckt, 1000 mg tab chew, 500 mg tab chew, 750 mg pckt, 750 mg tab chew 3 PA

lanthanum carbonate 1000 mg tab chew, 500 mg tab chew, 750 mg tab chew 1 FOSRENOL PA

RENAGEL 800 mg tab 3 PA

RENVELA 0.8 gm pckt, 2.4 gm pckt, 800 mg tab 3 PA

sevelamer carbonate 0.8 gm pckt, 2.4 gm pckt 1 RENVELA PA

sevelamer carbonate 800 mg tab 1 RENVELA PA

VELPHORO 500 mg tab chew 3 PA

Potassium-removing Agents [Agentes Removedores De Potasio]

KIONEX oral pwdr 3

KIONEX 15 gm/60ml susp 3

sodium polystyrene sulfonate 30 gm/120ml Rectal Suspension, 50 gm/200ml Rectal Suspension 1

sodium polystyrene sulfonate oral pwdr 1 KAYEXALATE

sodium polystyrene sulfonate 15 gm/60ml susp 1 SPS

SPS 15 gm/60ml susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

KERATOLYTIC AGENTS [AGENTES QUERATOLÍTICOS]

Keratolytic Agents [Agentes Queratolíticos]

ALUVEA 40 % crm 3

AVAR 9.5-5 % pad 3 AL

AVAR CLEANSER 10-5 % ext emul 3 AL

AVAR LS 10-2 % pad 3 AL

AVAR LS CLEANSER 10-2 % ext liq 3 AL

AVAR-E EMOLLIENT 10-5 % crm 3 AL

AVAR-E GREEN 10-5 % crm 3 AL

AVAR-E LS 10-2 % crm 3 AL

bp 10-1 10-1 % ext emul 1 AL

bp cleansing wash 10-4 % ext emul 1 AL

CEROVEL 40 % lot 3

loutrex crm 1

NUTRASEB crm 3

PLEXION 9.8-4.8 % crm, 9.8-4.8 % lot 3 AL

PLEXION CLEANSER 9.8-4.8 % ext liq 3 AL

PLEXION CLEANSING CLOTH 9.8-4.8 % pad 3 AL

REA LO 40 40 % crm 3

REA LO 40 40 % lot 3

ROSANIL CLEANSER 10-5 % ext emul 3 AL

sss 10-5 10-5 % crm, 10-5 % foam 1 AL

sulfacetamide sodium-sulfur 10-4 % pad 1 AL

sulfacetamide sodium-sulfur 10-2 % crm, 10-2 % ext liq, 10-5 % crm, 10-5 % ext emul, 10-5 % ext susp, 10-5 % lot, 9-4.5 % ext liq, 9.8-4.8 % crm, 9.8-4.8 % ext liq, 9.8-4.8 % lot 1 AL

sulfacetamide sodium-sulfur 8-4 % ext susp, 9-4 % ext liq 1 AL

sulfacetamide sod-sulfur wash 9-4.5 % ext kit 1 AL

sulfacetamide-sulfur in urea 10-5 % ext emul 1 AL

sulfacetamide-sulfur-sunscreen 9-4.5 % ext kit 1 AL

SULFACLEANSE 8/4 8-4 % ext susp 3 AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

SUMADAN 9-4.5 % ext kit 3 AL

SUMADAN WASH 9-4.5 % ext liq 3 AL

SUMADAN XLT 9-4.5 % ext kit 3 AL

SUMAXIN 10-4 % pad 3 AL

SUMAXIN CP 10-4 % ext kit 3 AL

SUMAXIN TS 8-4 % ext susp 3 AL

SUMAXIN WASH 9-4 % ext liq 3 AL

urea 40 % crm, 40 % lot 1

urea-c40 40 % lot 1

uremez-40 40 % crm 1

virti-sulf 10-5 % crm 1 AL

LEPTINS [LEPTINAS]

Leptins [Leptinas]

MYALEPT 11.3 mg sc soln 3 PA

LOCAL ANESTHETICS [ANESTÉSICOS LOCALES]

Local Anesthetics [Anestésicos Locales]

lidocaine hcl 1 % inj soln, 4 % m/t soln 1

lidocaine hcl 2 % inj soln 1 XYLOCAINE

lidocaine viscous 2 % m/t soln 1 XYLOCAINE

PRAMOTIC 1-0.1 % otic liq 3

XYLOCAINE 1 % inj soln, 2 % inj soln 3

MUCOLYTIC AGENTS [AGENTES MUCOLÍTICOS]

Mucolytic Agents [Agentes Mucolíticos]

HYPERSAL 3.5 % inh neb soln, 7 % inh neb soln 3

NEBUSAL 3 % inh neb soln, 6 % inh neb soln 3

PULMOSAL 7 % inh neb soln 3

PULMOZYME 1 mg/ml inh soln 3

sodium chloride 0.9 % inh neb soln, 10 % inh neb soln, 3 % inh neb soln, 7 % inh neb soln 1

MULTIVITAMIN PREPARATIONS [PREPARACIONES MULTIVITAMÍNICAS]

Multivitamin Preparations [Preparaciones Multivitamínicas]

ADRENAL C FORMULA tab 3

advanced am/pm oral misc 1

ap-zel tab 1

ATABEX EC 29-1 mg tab dr 3

BACMIN tab 3

BAL-CARE DHA 27-1 & 430 mg oral misc 3

b-complex balanced tab 1

b-complex/vitamin c tab 1

b-complex-c tab 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

biocel tab 1

bp folinatal plus b 1 mg tab 1

bp multinatal plus 30-1 mg tab, 40-1 mg tab chew 1

b-plex tab 1

b-plex plus tab 1

CITRANATAL 90 DHA 90-1 & 300 mg oral misc 3

CITRANATAL ASSURE 35-1 & 300 mg oral misc 3

CITRANATAL B-CALM 20-1 & 25 (2) mg oral misc 3

CITRANATAL DHA 27-1 & 250 mg oral misc 3

CITRANATAL HARMONY 27-1-260 mg cap 3

CITRANATAL RX 27-1 mg tab 3

c-nate dha 28-1-200 mg cap 1

cod liver oil oral oil 1

complete natal dha 29-1-200 & 250 mg oral misc 1

completenate 29-1 mg tab chew 1

CO-NATAL FA tab 3

CONCEPT DHA 53.5-38-1 mg cap 3

CONCEPT OB 130-92.4-1 mg cap 3

CORVITA 1.25 mg tab 3

CORVITE 1.25 mg tab 3

CORVITE FREE tab 3

DIALYVITE tab 3

DIALYVITE 3000 3 mg tab 3

DIALYVITE 5000 5 mg tab 3

DIALYVITE SUPREME D 3 mg tab 3

DIALYVITE/ZINC tab 3

dothelle dha 53.5-38-1 mg cap 1

DUET DHA 400 25-1 & 400 mg oral misc 3

DUET DHA BALANCED 25-1 & 267 mg oral misc 3

ELITE-OB 50-1.25 mg tab 3

ENBRACE HR cap 3

eql super b complex/vitamin c tab 1

ESCAVITE 0.25-7.5 mg tab chew 3

ESCAVITE D 0.25-6 mg tab chew 3

escavite lq 0.25-6 mg/ml liq 1

FLORIVA 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

FLORIVA PLUS 0.25 mg/ml soln 3

folbee plus tab 1

FOLBEE PLUS CZ 5 mg tab 3

FOLET DHA 38-1 & 350 mg pack 3

FOLET ONE 38-1-225 mg cap 3

FOLGARD OS 500-1.1 mg tab 3

FOLIVANE-OB 130-92.4-1 mg cap 3

FORTAVIT cap 3

hemenatal ob 28-6-1 mg tab 1

hemenatal ob + dha 28-6-1 & 203 mg oral misc 1

hm vitamin b complex/vitamin c tab 1

INATAL GT tab 3

infanate balance 29-1-265 mg cap 1

INFUVITE ADULT iv inj 3

INFUVITE PEDIATRIC iv soln 3

kp b complex-c tab 1

LYSIPLEX PLUS tab 3

M.V.I. ADULT iv inj 3

M.V.I. PEDIATRIC iv soln 3

M.V.I.-12 (WITHOUT VITAMIN K) iv inj 3

MARNATAL-F 60-1 mg cap 3

MILCO-B-FORTE tab 1

multi-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

multi-vit/fluoride/iron 0.25-10 mg/ml soln 1

multi-vit/iron/fluoride 0.25-10 mg/ml soln 1

multivitamin/fluoride 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 1

multivitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

multi-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

multivitamin/fluoride/iron 0.25-10 mg/ml soln 1

multi-vitamin/fluoride/iron 0.25-10 mg/ml soln 1

multivitamins/fluoride 0.5 mg tab chew 1

MVC-FLUORIDE 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

M-VIT tab 3

MYNATAL cap, 90-1 mg tab 3

MYNATAL ADVANCE tab 3

mynatal plus tab 1

mynatal-z tab 1

mynate 90 plus tab er 1

mynephrocaps 1 mg cap 1

MYNEPHRON 1 mg cap 3

NATACHEW 28-1 mg tab chew 3

NATALVIT tab 3

NATELLE ONE 28-1-250 mg cap 3

NEEVO DHA 27-1.13 mg cap 3

NEPHPLEX RX tab 3

NEPHROCAPS 1 mg cap 3

NEPHRONEX tab 3

NEPHRO-VITE RX 1 mg tab 3

NESTABS 32-1 mg tab 3

NESTABS ABC 32-1-200 mg oral misc 3

NESTABS DHA 32-1 mg oral misc 3

NEWGEN 32-1 mg tab 3

NEXA PLUS 29-1.25-350 mg cap 3

NICADAN tab 3

NICADAN ZX tab 3

NICAZEL tab 3

NICAZEL FORTE tab 3

NICOMIDE 750-27-2-0.5 mg tab 3

NIVA-PLUS 27-1 mg tab 3

NUTRICAP tab 3

NUTRIFAC ZX tab 3

NUTRIVIT liq 3

OB COMPLETE 50-1.25 mg tab 3

OB COMPLETE ONE 50-1-476 mg cap 3

OB COMPLETE PETITE 35-5-1-200 mg cap 3

OB COMPLETE PREMIER 30-20-1 mg tab 3

OB COMPLETE/DHA 30-10-1-200 mg cap 3

OBSTETRIX DHA 29-1 & 387 mg oral misc 3

OBSTETRIX EC 29-1 mg tab 3

OBSTETRIX ONE 38-1-225 mg cap 3

O-CAL FA 27-1 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

O-CAL PRENATAL tab 3

OCUVEL 0.5 mg cap 3

pnv folic acid + iron 27-1 mg tab 1

pnv ob+dha 27-1 & 250 mg oral misc 1

pnv prenatal plus multivitamin 27-1 mg tab 1

pnv tabs 29-1 29-1 mg tab 1

pnv-dha 27-0.6-0.4-300 mg cap 1

pnv-dha plus 27-1.13-0.4 mg cap 1

pnv-dha+docusate 27-1.25-300 mg cap 1

pnv-omega 28-0.6-0.4-340 mg cap 1

pnv-select 27-0.6-0.4 mg tab 1

pnv-total 35-5-1.2 mg cap 1

POLY-VI-FLOR 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

POLY-VI-FLOR 0.25 mg/ml susp 3

POLY-VI-FLOR FS 0.25 mg Oral Strip, 0.5 mg Oral Strip, 1 mg Oral Strip 3

POLY-VI-FLOR/IRON 0.5-10 mg tab chew 3

POLY-VI-FLOR/IRON 0.25-7 mg/ml susp 3

PR NATAL 400 29-1-200 & 400 mg oral misc 3

PR NATAL 400 EC 29-1-200 & 400 mg (dr) oral misc 3

PR NATAL 430 29-1-200 & 430 mg oral misc 3

PR NATAL 430 EC 29-1-200 & 430 mg (dr) oral misc 3

PREFERAOB +DHA 28-6-1 & 200 mg oral misc 3

PREFERAOB ONE 22-6-1-200 mg cap 3

prena1 1.4 mg tab chew 1

prena1 pearl 30-1.4-200 mg cap er 1

prenaissance 29-1.25-325 mg cap 1

prenaissance balance 30-1-260 mg cap 1

prenaissance harmony dha 27-1 & 380 mg oral misc 1

prenaissance next 1.2 mg tab 1

prenaissance next-b 1.22 mg tab 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

prenaissance plus 28-1-250 mg cap 1

PRENATA 29-1 mg tab chew 3

PRENATABS RX 29-1 mg tab 3

prenatal 27-1 mg tab 1

prenatal 19 tab, tab chew, 29-1 mg tab, 29-1 mg tab chew 1

prenatal plus 27-1 mg tab 1

prenatal plus iron 29-1 mg tab 1

prenatal vitamin plus low iron 27-1 mg tab 1

PRENATAL-U 106.5-1 mg cap 3

PRENATE 0.6-0.4 mg tab chew 3

PRENATE AM 1 mg tab 3

PRENATE DHA 18-0.6-0.4-300 mg cap 3

PRENATE ELITE 20-0.6-0.4 mg tab 3

PRENATE ENHANCE 28-0.6-0.4-400 mg cap 3

PRENATE ESSENTIAL 18-0.6-0.4-300 mg cap 3

PRENATE MINI 18-0.6-0.4-350 mg cap 3

PRENATE PIXIE 10-0.6-0.4-200 mg cap 3

PRENATE RESTORE 27-0.6-0.4-400 mg cap 3

preplus 27-1 mg tab 1

pretab 29-1 mg tab 1

PROTECT PLUS cap 3

PROVIDA DHA 16-16-1.25-110 mg cap 3

PROVIDA OB 20-20-1.25 mg cap 3

purefe ob plus 162-115.2-1 mg cap 1

px b complex/vitamin c tab 1

QUFLORA PEDIATRIC 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

QUFLORA PEDIATRIC 0.25 mg/ml soln, 0.5 mg/ml soln 3

relnate dha 28-1-200 mg cap 1

RENAL 1 mg cap 3

RENATABS 1 mg tab 3

reno caps 1 mg cap 1

REQ 49+ tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

R-NATAL OB 20-1-320 mg cap 3

SELECT-OB 29-0.6-0.4 mg tab chew, 29-1 mg tab chew 3

SELECT-OB+DHA 29-1 & 250 mg oral misc 3

se-natal 19 29-1 mg tab, 29-1 mg tab chew 1

SIDEROL tab 3

sm b super vitamin complex tab 1

sm b-complex/vitamin c tab 1

stress formula tab 1

STROVITE FORTE tab 3

STROVITE FORTE syr 3

STROVITE ONE tab 3

super b complex/fa/vit c tab 1

super b-complex/vit c/fa tab 1

SUPERVITE liq 3

support liq 1

SUPPORT-500 cap 3

SYNAGEX 1.25 mg cap 3

SYNATEK 1.25 mg cap 3

TARON-BC 20-1 & 25 (2) mg oral misc 3

TARON-C DHA 53.5-38-1 mg cap 3

TARON-PREX 30-1.2-265 mg cap 3

TEXAVITE LQ 0.25-7-3 mg/ml liq 3

thrivite 19 29-1 mg tab 1

thrivite rx 29-1 mg tab 1

tl folate 27-0.5-0.5 mg tab 1

TL G-FOL OS 500-1.1 mg tab 3

tl-care dha 27-1-500 mg cap 1

tl-fluorivite 0.25-7.5 mg tab chew 1

tl-select 29-1.25-325 mg cap 1

TRICARE tab 3

TRICARE PRENATAL COMPLEAT 27-1 mg oral misc 3

TRICARE PRENATAL DHA ONE 27-1-500 mg cap 3

trinatal rx 1 60-1 mg tab 1

TRINATE tab 3

triphrocaps 1 mg cap 1

tristart dha 31-0.6-0.4-200 mg cap 1

tri-tabs dha 32-1 mg oral misc 1

TRIVEEN-DUO DHA 29-1-200 & 400 mg oral misc 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

TRI-VI-FLOR 0.25 mg/ml susp, 0.5 mg/ml susp 3

tri-vi-floro 0.25 mg/ml susp, 0.5 mg/ml susp 1

tri-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

tri-vit/fluoride/iron 0.25-10 mg/ml soln 1

tri-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

UDAMIN SP 1 mg tab 3

ultimatecare one 27-1 mg cap 1

urosex tab 1

v-c forte cap 1

VEMAVITE-PRX 2 27-1.25-300 mg cap 3

vena-bal dha 27-1 & 430 mg oral misc 1

VIC-FORTE cap 3

VINATE DHA RF 27-1.13 mg cap 3

VINATE II 29-1 mg tab 3

VINATE M 27-1 mg tab 3

VINATE ONE 60-1 mg tab 3

virt nate 28-1 mg tab 1

virt-c dha 53.5-38-1 mg cap 1

virt-caps 1 mg cap 1

virt-nate dha 28-1-200 mg cap 1

virt-pn 27-0.6-0.4 mg tab 1

virt-pn dha 27-0.6-0.4-300 mg cap 1

virt-pn plus 28-0.6-0.4-340 mg cap 1

VITA S FORTE tab 3

vita-bee/c tab 1

VITACEL tab 3

VITAFOL FE+ 90-1-200 & 50 mg cap pack 3

VITAFOL ULTRA 29-0.6-0.4-200 mg cap 3

VITAFOL-NANO 18-0.6-0.4 mg tab 3

VITAFOL-OB tab 3

VITAFOL-OB+DHA 65-1 & 250 mg oral misc 3

VITAFOL-ONE 29-1-200 mg cap 3

vitaject inj 1

VITAL-D RX 1 mg tab 3

VITAMAX PEDIATRIC soln 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 mg cap 3

VITAMEDMD REDICHEW RX 1.4 mg tab chew 3

vita-min cap 1

vitamins acd-fluoride 0.25 mg/ml soln 1

VITAPEARL 30-1.4-200 mg cap er 3

VITAROCA PLUS tab 3

vita-rx diabetic vitamin cap 1

VIVA DHA 28-1-200 mg cap 3

vol-care rx 1 mg tab 1

vol-nate 28-1 mg tab 1

vol-plus 27-1 mg tab 1

vol-tab rx 29-1 mg tab 1

vp-ggr-b6 prenatal 1.2 mg tab 1

vp-heme ob 28-6-1 mg tab 1

vp-heme ob + dha 28-6-1 & 203 mg oral misc 1

vp-heme one 22-6-1-200 mg cap 1

vp-pnv-dha 28-1-215.8 mg cap 1

vp-vite rx 1 mg tab 1

vp-zel tab 1

ZATEAN-PN DHA 27-0.6-0.4-300 mg cap 3

ZATEAN-PN PLUS 28-0.6-0.4-340 mg cap 3

MYDRIATICS [MIDRIÁTICOS]

Mydriatics [Midriáticos]

atropine sulfate 1 % ophth oint 1

atropine sulfate 1 % ophth soln 1

CYCLOGYL 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 3

CYCLOMYDRIL 0.2-1 % ophth soln 3

cyclopentolate hcl 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 1

HOMATROPAIRE 5 % ophth soln 3

homatropine hbr 5 % ophth soln 1

ISOPTO ATROPINE 1 % ophth soln 3

MYDRIACYL 1 % ophth soln 3

tropicamide 0.5 % ophth soln, 1 % ophth soln 1

OPIATE ANTAGONISTS [ANTAGONISTAS DE OPIÁCEOS]

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

Opiate Antagonists [Antagonistas De Opiáceos]

naloxone hcl 0.4 mg/ml inj soln cart, 4 mg/10ml inj soln 1

naloxone hcl 0.4 mg/ml inj soln, 2 mg/2ml inj soln pfs 1 NARCAN

OTHER MISCELLANEOUS THERAPEUTIC AGENTS [OTROS AGENTES TERAPÉUTICOS MISCELÁNEOS]

Other Miscellaneous Therapeutic Agents [Otros Agentes Terapéuticos Misceláneos]

AMPYRA 10 mg tab er 12 hr 3 PA

ARCALYST 220 mg sc soln 3 PA

CARNITOR 330 mg tab 3

CARNITOR 1 gm/10ml soln 3

CARNITOR 200 mg/ml iv soln 3 PA

CARNITOR SF 1 gm/10ml soln 3

CERDELGA 84 mg cap 3 PA

CYSTADANE oral pwdr 3

CYSTAGON 150 mg cap, 50 mg cap 3 PA

dalfampridine er 10 mg tab er 12 hr 1 PA

DEMSER 250 mg cap 3

ELMIRON 100 mg cap 3

KUVAN 100 mg pckt, 100 mg tab sol, 500 mg pckt 3 PA

levocarnitine 330 mg tab 1 CARNITOR

levocarnitine 1 gm/10ml soln 1 CARNITOR

miglustat 100 mg cap 1 ZAVESCA PA

ORFADIN 10 mg cap, 2 mg cap, 5 mg cap 3 PA

ORFADIN 4 mg/ml susp 3 PA

PROCYSBI 25 mg cap dr, 75 mg cap dr 3 PA

SENSIPAR 30 mg tab, 60 mg tab, 90 mg tab 3 PA

ZAVESCA 100 mg cap 3 PA

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS [AGENTES PARASIMPATICOMIMÉTICOS (COLINÉRGICOS)]

Parasympathomimetic (cholinergic) Agents [Agentes Parasimpaticomiméticos (Colinérgicos)]

ARICEPT 10 mg tab, 23 mg tab, 5 mg tab 3

bethanechol chloride 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 1 URECHOLINE

donepezil hcl 10 mg tab, 10 mg tab disint, 23 mg tab, 5 mg tab, 5 mg tab disint 1 ARICEPT

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

EXELON 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 3

galantamine hydrobromide 12 mg tab, 4 mg tab, 8 mg tab 1 RAZADYNE

galantamine hydrobromide 4 mg/ml soln 1 RAZADYNE

galantamine hydrobromide er 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 1 RAZADYNE

guanidine hcl 125 mg tab 1

MESTINON 180 mg tab er, 60 mg tab 3

MESTINON 60 mg/5ml syr 3

pyridostigmine bromide 60 mg tab 1 MESTINON

pyridostigmine bromide er 180 mg tab er 1 MESTINON

RAZADYNE 12 mg tab, 4 mg tab, 8 mg tab 3

RAZADYNE ER 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 3

rivastigmine 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 1 EXELON

rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap 1 EXELON

URECHOLINE 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 3

PARATHYROID [PARATIROIDEOS]

Parathyroid [Paratiroideos]

calcitonin (salmon) 200 unit/act nasal soln 1 MIACALCIN

FORTEO 600 mcg/2.4ml sc soln 2 PA

MIACALCIN 200 unit/ml inj soln 3

PHARMACEUTICAL AIDS [EXCIPIENTES FARMACÉUTICOS]

Pharmaceutical Aids [Excipientes Farmacéuticos]

vp dermabase crm 1

PHOSPHODIESTERASE TYPE 4 INHIBITORS [INHIBIDORES DE LA FOSFODIESTERASA TIPO 4]

Phosphodiesterase Type 4 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 4]

DALIRESP 250 mcg tab, 500 mcg tab 3 PA

PITUITARY [PITUITARIA]

Pituitary [Pituitaria]

DDAVP 0.1 mg tab, 0.2 mg tab 3

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

DDAVP 0.01 % nasal soln, 4 mcg/ml inj soln 3

DDAVP RHINAL TUBE 0.01 % nasal soln 3

desmopressin ace spray refrig 0.01 % nasal soln 1 MINIRIN

desmopressin acetate 0.1 mg tab, 0.2 mg tab 1 DDAVP

desmopressin acetate 4 mcg/ml inj soln 1 DDAVP

desmopressin acetate spray 0.01 % nasal soln 1

HP ACTHAR 80 unit/ml inj gel 3 PA

STIMATE 1.5 mg/ml nasal soln 3

PROGESTINS [PROGESTINAS]

Progestins [Progestinas]

AYGESTIN 5 mg tab 3

CRINONE 4 % vag gel, 8 % vag gel 3

DEPO-PROVERA 400 mg/ml im susp 3

DEPO-PROVERA 150 mg/ml im susp, 150 mg/ml im susp pfs 3 QL(1 / 90)

DEPO-SUBQ PROVERA 104 104 mg/0.65ml sc susp pfs 3 QL(1 / 90)

medroxyprogesterone acetate 150 mg/ml im susp pfs 1 QL(1 / 90)

medroxyprogesterone acetate 150 mg/ml im susp 1 DEPO-PROVERA QL(1 / 90)

medroxyprogesterone acetate 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROVERA

MEGACE ES 625 mg/5ml susp 3

megestrol acetate 625 mg/5ml susp 1 MEGACE

norethindrone acetate 5 mg tab 1 AYGESTIN

progesterone 50 mg/ml im oil 1

progesterone micronized 100 mg cap, 200 mg cap 1 PROMETRIUM

PROMETRIUM 100 mg cap, 200 mg cap 3

PROVERA 10 mg tab, 2.5 mg tab, 5 mg tab 3

PROKINETIC AGENTS [AGENTES PROCINÉTICOS]

Prokinetic Agents [Agentes Procinéticos]

metoclopramide hcl 5 mg tab disint 1 METOZOLV

metoclopramide hcl 10 mg tab 1 REGLAN

REGLAN 10 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

PROTECTIVE AGENTS [AGENTES PROTECTORES]

Protective Agents [Agentes Protectores]

MESNEX 400 mg tab 3

PSYCHOTHERAPEUTIC AGENTS [AGENTES PSICOTERAPÉUTICOS]

Antidepressants [Antidepresivos]

amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 ELAVIL

amoxapine 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab 1 ASENDIN

ANAFRANIL 25 mg cap, 50 mg cap, 75 mg cap 3

APLENZIN 174 mg tab er 24 hr, 348 mg tab er 24 hr, 522 mg tab er 24 hr 3

bupropion hcl 100 mg tab, 75 mg tab 1 WELLBUTRIN

bupropion hcl er (smoking det) 150 mg tab er 12 hr 1 ZYBAN

bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 1 WELLBUTRIN SR

bupropion hcl er (xl) 450 mg tab er 24 hr 1

bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr 1 WELLBUTRIN XL

CELEXA 10 mg tab, 20 mg tab, 40 mg tab 3

chlordiazepoxide-amitriptyline 10-25 mg tab, 5-12.5 mg tab 1 LIMBITROL

citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab 1 CELEXA

citalopram hydrobromide 10 mg/5ml soln 1 CELEXA

clomipramine hcl 25 mg cap, 50 mg cap, 75 mg cap 1 ANAFRANIL

CYMBALTA 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 2

desipramine hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 NORPRAMIN

desvenlafaxine er 100 mg tab er 24 hr, 50 mg tab er 24 hr 1 KHEDEZLA

desvenlafaxine succinate er 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 PRISTIQ

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

doxepin hcl 10 mg cap, 100 mg cap, 150 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 SINEQUAN

doxepin hcl 10 mg/ml oral conc 1 SINEQUAN

duloxetine hcl 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 1 CYMBALTA

EFFEXOR XR 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 3

escitalopram oxalate 10 mg tab, 20 mg tab, 5 mg tab 1 LEXAPRO

escitalopram oxalate 5 mg/5ml soln 1 LEXAPRO

FETZIMA 120 mg cap er 24 hr, 20 mg cap er 24 hr, 40 mg cap er 24 hr, 80 mg cap er 24 hr 3

FETZIMA TITRATION 20 & 40 mg cap er 24 hr pack 3

fluoxetine hcl 10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab, 40 mg cap, 60 mg tab, 90 mg cap dr 1 PROZAC

fluoxetine hcl 20 mg/5ml soln 1 PROZAC

fluvoxamine maleate 100 mg tab, 25 mg tab, 50 mg tab 1 LUVOX

fluvoxamine maleate er 100 mg cap er 24 hr, 150 mg cap er 24 hr 1 LUVOX CR

FORFIVO XL 450 mg tab er 24 hr 3

imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 TOFRANIL

imipramine pamoate 100 mg cap, 125 mg cap, 150 mg cap, 75 mg cap 1 TOFRANIL-PM

KHEDEZLA 100 mg tab er 24 hr, 50 mg tab er 24 hr 3

LEXAPRO 10 mg tab, 20 mg tab, 5 mg tab 3

maprotiline hcl 25 mg tab, 50 mg tab, 75 mg tab 1 LUDIOMIL

MARPLAN 10 mg tab 3

mirtazapine 15 mg tab, 15 mg tab disint, 30 mg tab, 30 mg tab disint, 45 mg tab, 45 mg tab disint, 7.5 mg tab 1 REMERON

NARDIL 15 mg tab 3

nefazodone hcl 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab, 50 mg tab 1 SERZONE

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NORPRAMIN 10 mg tab, 25 mg tab 3

nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 PAMELOR

nortriptyline hcl 10 mg/5ml soln 1 PAMELOR

olanzapine-fluoxetine hcl 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 1 SYMBYAX

PAMELOR 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 3

PARNATE 10 mg tab 3

paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 1 PAXIL

paroxetine hcl er 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 1 PAXIL CR

PAXIL 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3

PAXIL 10 mg/5ml susp 3

PAXIL CR 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 3

perphenazine-amitriptyline 2-10 mg tab, 2-25 mg tab, 4-10 mg tab, 4-25 mg tab, 4-50 mg tab 1 TRIAVIL

PEXEVA 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3

phenelzine sulfate 15 mg tab 1 NARDIL

PRISTIQ 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 3

protriptyline hcl 10 mg tab, 5 mg tab 1 VIVACTIL

PROZAC 10 mg cap, 20 mg cap, 40 mg cap 2

REMERON 15 mg tab, 30 mg tab 3

REMERON SOLTAB 15 mg tab disint, 30 mg tab disint, 45 mg tab disint 3

sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab 1 ZOLOFT

sertraline hcl 20 mg/ml oral conc 1 ZOLOFT

SILENOR 3 mg tab, 6 mg tab 3

SURMONTIL 100 mg cap, 25 mg cap, 50 mg cap 3

SYMBYAX 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 2

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

TOFRANIL 10 mg tab, 25 mg tab, 50 mg tab 3

tranylcypromine sulfate 10 mg tab 1 PARNATE

trazodone hcl 100 mg tab, 150 mg tab, 300 mg tab, 50 mg tab 1 DESYREL

trimipramine maleate 100 mg cap, 25 mg cap, 50 mg cap 1 SURMONTIL

TRINTELLIX 10 mg tab, 20 mg tab, 5 mg tab 3

venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab 1 EFFEXOR

venlafaxine hcl er 150 mg tab er 24 hr, 225 mg tab er 24 hr, 37.5 mg tab er 24 hr, 75 mg tab er 24 hr 1

venlafaxine hcl er 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 1 EFFEXOR XR

VIIBRYD 10 mg tab, 20 mg tab, 40 mg tab 3

WELLBUTRIN SR 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 3

WELLBUTRIN XL 150 mg tab er 24 hr, 300 mg tab er 24 hr 3

ZOLOFT 100 mg tab, 25 mg tab, 50 mg tab 3

ZOLOFT 20 mg/ml oral conc 3

ZYBAN 150 mg tab er 12 hr 3

Antipsychotics [Antipsicóticos]

ABILIFY 10 mg tab, 15 mg tab, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 3

ABILIFY MAINTENA 300 mg im pfs, 300 mg Intramuscular Suspension Reconstituted ER, 400 mg im pfs, 400 mg Intramuscular Suspension Reconstituted ER 3

ADASUVE 10 mg inh aer pwdr br act 3

aripiprazole 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ABILIFY

aripiprazole 1 mg/ml soln 1 ABILIFY

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

chlorpromazine hcl 25 mg/ml inj soln, 50 mg/2ml inj soln 1

chlorpromazine hcl 10 mg tab, 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 THORAZINE

clozapine 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 CLOZARIL

clozapine 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 1 FAZACLO

CLOZARIL 100 mg tab, 25 mg tab 3

COMPRO 25 mg rect supp 3

FANAPT 1 mg tab, 10 mg tab, 12 mg tab, 2 mg tab, 4 mg tab, 6 mg tab, 8 mg tab 3

FANAPT TITRATION PACK 1 & 2 & 4 & 6 mg tab 3

FAZACLO 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 3

fluphenazine decanoate 25 mg/ml inj soln 1 PROLIXIN

fluphenazine hcl 1 mg tab, 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROLIXIN

fluphenazine hcl 2.5 mg/5ml oral elix, 2.5 mg/ml inj soln, 5 mg/ml oral conc 1 PROLIXIN

GEODON 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 3

HALDOL 5 mg/ml inj soln 3

HALDOL DECANOATE 100 mg/ml im soln, 50 mg/ml im soln 3

haloperidol 0.5 mg tab, 1 mg tab, 10 mg tab, 2 mg tab, 20 mg tab, 5 mg tab 1 HALDOL

haloperidol decanoate 100 mg/ml im soln, 50 mg/ml im soln 1 HALDOL

haloperidol lactate 2 mg/ml oral conc, 5 mg/ml inj soln 1 HALDOL

INVEGA 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 3

INVEGA SUSTENNA 117 mg/0.75ml im susp, 156 mg/ml im susp, 234 mg/1.5ml im susp, 39 3

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

mg/0.25ml im susp, 78 mg/0.5ml im susp

LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 3

loxapine succinate 10 mg cap, 25 mg cap, 5 mg cap, 50 mg cap 1 LOXITANE

NUPLAZID 17 mg tab 3 PA

olanzapine 10 mg im soln, 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2.5 mg tab, 20 mg tab, 20 mg tab disint, 5 mg tab, 5 mg tab disint, 7.5 mg tab 1 ZYPREXA

paliperidone er 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 1 INVEGA

perphenazine 16 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 TRILAFON

prochlorperazine 25 mg rect supp 1 COMPRO

prochlorperazine edisylate 5 mg/ml inj soln 1 COMPAZINE

prochlorperazine maleate 10 mg tab, 5 mg tab 1 COMPAZINE

quetiapine fumarate 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 1 SEROQUEL

quetiapine fumarate er 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 1 SEROQUEL XR

RISPERDAL 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab 3

RISPERDAL 1 mg/ml soln 3

RISPERDAL CONSTA 12.5 mg im susp, 25 mg im susp, 37.5 mg im susp, 50 mg im susp 3

RISPERDAL M-TAB 0.5 mg tab disint 3

risperidone 0.25 mg tab, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint, 3 mg tab, 3 mg tab disint, 4 mg tab, 4 mg tab disint 1 RISPERDAL

risperidone 1 mg/ml soln 1 RISPERDAL

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

RISPERIDONE M-TAB 0.5 mg tab disint, 1 mg tab disint, 2 mg tab disint 3

SAPHRIS 10 mg tab subl, 5 mg tab subl 3

SEROQUEL 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 3

SEROQUEL XR 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 3

thioridazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 MELLARIL

thiothixene 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 NAVANE

trifluoperazine hcl 1 mg tab, 10 mg tab, 2 mg tab, 5 mg tab 1 STELAZINE

VERSACLOZ 50 mg/ml susp 3

ziprasidone hcl 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 GEODON

ZYPREXA 10 mg im soln, 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab 2

ZYPREXA RELPREVV 210 mg im susp, 300 mg im susp, 405 mg im susp 2

ZYPREXA ZYDIS 10 mg tab disint, 15 mg tab disint, 20 mg tab disint, 5 mg tab disint 2

RADIOACTIVE AGENTS [AGENTES RADIOACTIVOS]

Radioactive Agents [Agentes Radioactivos]

AMYVID 500-1900 mbq/ml iv soln 2

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS [INHIBIDORES DEL SISTEMA RENINA-ANGIOTENSINA-ALDOSTERONA]

Angiotensin Ii Receptor Antagonists [Antagonistas Del Receptor De Angiotensina Ii]

ATACAND 16 mg tab, 32 mg tab, 4 mg tab, 8 mg tab 3

ATACAND HCT 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 3

AVALIDE 150-12.5 mg tab, 300-12.5 mg tab 3

AVAPRO 150 mg tab, 300 mg tab, 75 mg tab 3

BENICAR 20 mg tab, 40 mg tab, 5 mg tab 3

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

BENICAR HCT 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 3

candesartan cilexetil 16 mg tab, 32 mg tab, 4 mg tab, 8 mg tab 1 ATACAND

candesartan cilexetil-hctz 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 1 ATACAND HCT

COZAAR 100 mg tab, 25 mg tab, 50 mg tab 3

DIOVAN 160 mg tab, 320 mg tab, 40 mg tab, 80 mg tab 3

DIOVAN HCT 160-12.5 mg tab, 160-25 mg tab, 320-12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab 3

EDARBI 40 mg tab, 80 mg tab 3

EDARBYCLOR 40-12.5 mg tab, 40-25 mg tab 3

eprosartan mesylate 600 mg tab 1 TEVETEN

HYZAAR 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 3

irbesartan 150 mg tab, 300 mg tab, 75 mg tab 1 AVAPRO

irbesartan-hydrochlorothiazide 150-12.5 mg tab, 300-12.5 mg tab 1 AVALIDE

losartan potassium 100 mg tab, 25 mg tab, 50 mg tab 1 COZAAR

losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 1 HYZAAR

MICARDIS 20 mg tab, 40 mg tab, 80 mg tab 3

MICARDIS HCT 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 3

olmesartan medoxomil 20 mg tab, 40 mg tab, 5 mg tab 1 BENICAR

olmesartan medoxomil-hctz 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 1 BENICAR HCT

telmisartan 20 mg tab, 40 mg tab, 80 mg tab 1 MICARDIS

telmisartan-hctz 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 1 MICARDIS-HCT

valsartan 160 mg tab, 320 mg tab, 40 mg tab, 80 mg tab 1 DIOVAN

valsartan-hydrochlorothiazide 160-12.5 mg tab, 160-25 mg tab, 320- 1 DIOVAN HCT

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Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab

Angiotensin-converting Enzyme Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina]

ACCUPRIL 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 3

ACCURETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

ALTACE 1.25 mg cap, 10 mg cap, 2.5 mg cap, 5 mg cap 3

benazepril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 LOTENSIN

benazepril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab, 5-6.25 mg tab 1 LOTENSIN HCT

captopril 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 1 CAPOTEN

captopril-hydrochlorothiazide 25-15 mg tab, 25-25 mg tab, 50-15 mg tab, 50-25 mg tab 1 CAPOZIDE

enalapril maleate 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 1 VASOTEC

enalapril-hydrochlorothiazide 10-25 mg tab, 5-12.5 mg tab 1 VASERETIC

fosinopril sodium 10 mg tab, 20 mg tab, 40 mg tab 1 MONOPRIL

fosinopril sodium-hctz 10-12.5 mg tab, 20-12.5 mg tab 1 MONOPRIL-HCT

lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab 1 ZESTRIL

lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ZESTORETIC

LOTENSIN 10 mg tab, 20 mg tab, 40 mg tab 3

LOTENSIN HCT 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

moexipril hcl 15 mg tab, 7.5 mg tab 1 UNIVASC

moexipril-hydrochlorothiazide 15-12.5 mg tab, 15-25 mg tab, 7.5-12.5 mg tab 1 UNIRETIC

perindopril erbumine 2 mg tab, 4 mg tab, 8 mg tab 1 ACEON

PRINIVIL 10 mg tab, 20 mg tab, 5 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

quinapril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 ACCUPRIL

quinapril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ACCURETIC

ramipril 1.25 mg cap, 10 mg cap, 2.5 mg cap, 5 mg cap 1 ALTACE

trandolapril 1 mg tab, 2 mg tab, 4 mg tab 1 MAVIK

VASERETIC 10-25 mg tab 3

VASOTEC 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3

ZESTORETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

ZESTRIL 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab 3

Mineralocorticoid (aldosterone) Receptor Antagonists [Antagonistas Del Receptor De Mineralocorticoides (Aldosterona)]

ALDACTAZIDE 25-25 mg tab, 50-50 mg tab 3

ALDACTONE 100 mg tab, 25 mg tab, 50 mg tab 3

eplerenone 25 mg tab, 50 mg tab 1 INSPRA

INSPRA 25 mg tab, 50 mg tab 3

spironolactone 100 mg tab, 25 mg tab, 50 mg tab 1 ALDACTONE

spironolactone-hctz 25-25 mg tab 1 ALDACTAZIDE

Renin Inhibitors [Inhibidores De Renina]

TEKTURNA 150 mg tab, 300 mg tab 3 PA

TEKTURNA HCT 150-12.5 mg tab, 150-25 mg tab, 300-12.5 mg tab, 300-25 mg tab 3 PA

REPLACEMENT PREPARATIONS [PREPARACIONES DE REEMPLAZO]

Replacement Preparations [Preparaciones De Reemplazo]

calcium acetate (phos binder) 667 mg tab 1

calcium acetate (phos binder) 667 mg cap 1 PHOSLO

KLOR-CON 8 meq tab er 3

KLOR-CON M10 10 meq tab er 3

KLOR-CON M15 15 meq tab er 3

KLOR-CON M20 20 meq tab er 3

KLOR-CON SPRINKLE 10 meq cap er, 8 meq cap er 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

K-TAB 8 meq tab er 3

MICRO-K 10 meq cap er, 8 meq cap er 3

PHOSLYRA 667 mg/5ml soln 3 PA

potassium chloride crys er 10 meq tab er 1

potassium chloride crys er 20 meq tab er 1 KLOR-CON

potassium chloride er 10 meq tab er, 8 meq tab er 1 KLOR-CON

potassium chloride er 10 meq cap er, 8 meq cap er 1 MICRO-K

RESPIRATORY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO RESPIRATORIO]

Respiratory Smooth Muscle Relaxants [Relajantes Del Músculo Liso Respiratorio]

DIFIL-G FORTE 100-100 mg/5ml liq 3

ELIXOPHYLLIN 80 mg/15ml oral elix 3

THEO-24 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr, 400 mg cap er 24 hr 3

THEOCHRON 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr 3

theophylline 80 mg/15ml soln 1

theophylline er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr, 450 mg tab er 12 hr 1 THEO-DUR

theophylline er 400 mg tab er 24 hr, 600 mg tab er 24 hr 1 UNIPHYL

RESPIRATORY TRACT AGENTS, MISCELLANEOUS [AGENTES PARA EL TRACTO RESPIRATORIO, MISCELÁNEOS]

Respiratory Tract Agents, Miscellaneous [Agentes Para El Tracto Respiratorio, Misceláneos]

ESBRIET 267 mg cap, 267 mg tab, 801 mg tab 3 PA

OFEV 100 mg cap, 150 mg cap 3 PA

XOLAIR 150 mg sc soln 3 PA

SECOND GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE SEGUNDA GENERACIÓN]

Second Generation Antihistamines [Antihistamínicos De Segunda Generación]

cetirizine hcl 1 mg/ml soln, 5 mg/5ml soln 1 ZYRTEC

CLARINEX 5 mg tab 3

CLARINEX 0.5 mg/ml syr 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

CLARINEX-D 12 HOUR 2.5-120 mg tab er 12 hr 3

desloratadine 2.5 mg tab disint, 5 mg tab, 5 mg tab disint 1 CLARINEX

levocetirizine dihydrochloride 5 mg tab 1 XYZAL

levocetirizine dihydrochloride 2.5 mg/5ml soln 1 XYZAL

SEMPREX-D 8-60 mg cap 3

SERUMS [SUEROS]

Serums [Sueros]

HYPERRHO S/D 1500 unit im soln pfs, 250 unit im soln pfs 3 PA

MICRHOGAM ULTRA-FILTERED PLUS 250 unit im soln pfs 3 PA

RHOGAM ULTRA-FILTERED PLUS 1500 unit im soln pfs 3 PA

RHOPHYLAC 1500 unit/2ml inj soln pfs 3 PA

WINRHO SDF 1500 unit/1.3ml inj soln, 15000 unit/13ml inj soln, 2500 unit/2.2ml inj soln, 5000 unit/4.4ml inj soln 3 PA

SKELETAL MUSCLE RELAXANTS [RELAJANTES MUSCULOESQUELÉTICOS]

Centrally Acting Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos De Acción Central]

AMRIX 15 mg cap er 24 hr 3

carisoprodol 250 mg tab, 350 mg tab 1 SOMA

carisoprodol-aspirin 200-325 mg tab 1 SOMA

chlorzoxazone 500 mg tab 1 PARAFON

cyclobenzaprine hcl 7.5 mg tab 1 FEXMID

cyclobenzaprine hcl 10 mg tab, 5 mg tab 1 FLEXERIL

FEXMID 7.5 mg tab 3

LORZONE 375 mg tab, 750 mg tab 3

METAXALL 800 mg tab 3

metaxalone 800 mg tab 1 SKELAXIN

methocarbamol 500 mg tab, 750 mg tab 1 ROBAXIN

ROBAXIN 500 mg tab 3

ROBAXIN-750 750 mg tab 3

SKELAXIN 800 mg tab 3

SOMA 250 mg tab, 350 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

tizanidine hcl 2 mg cap, 2 mg tab, 4 mg cap, 4 mg tab, 6 mg cap 1 ZANAFLEX

ZANAFLEX 2 mg cap, 4 mg cap, 4 mg tab, 6 mg cap 3

Gaba-derivative Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos Derivados De Gaba]

baclofen 10 mg tab, 20 mg tab 1 LIORESAL

Skeletal Muscle Relaxants, Miscellaneous [Relajantes Musculoesqueléticos, Misceláneos]

orphenadrine citrate 30 mg/ml inj soln 1 NORFLEX

orphenadrine citrate er 100 mg tab er 12 hr 1 NORFLEX

SKIN AND MUCOUS MEMBRANE AGENTS, MISC [AGENTES PARA LA PIEL Y MEMBRANAS MUCOSAS, MISCELÁNEOS]

Skin And Mucous Membrane Agents, Misc [Agentes Para La Piel Y Membranas Mucosas, Misceláneos]

ABSORICA 10 mg cap, 20 mg cap, 25 mg cap, 30 mg cap, 35 mg cap, 40 mg cap 3 PA, AL

acitretin 10 mg cap, 17.5 mg cap, 25 mg cap 1 SORIATANE

ACZONE 5 % gel, 7.5 % gel 3 AL

adapalene 0.1 % lot 1 AL

adapalene 0.1 % crm, 0.1 % gel, 0.3 % gel 1 DIFFERIN AL

adapalene-benzoyl peroxide 0.1-2.5 % gel 1 EPIDUO AL

ALDARA 5 % crm 3

alevamax crm 1

AMNESTEEM 10 mg cap, 20 mg cap, 40 mg cap 3 PA, AL

atopaderm crm 1

ATOPICLAIR crm 3

AZELEX 20 % crm 3 AL

calcipotriene 0.005 % crm, 0.005 % oint 1 DOVONEX

calcipotriene 0.005 % ext soln 1 DOVONEX

CALCITRENE 0.005 % oint 3

calcitriol 3 mcg/gm oint 1 VECTICAL

CARAC 0.5 % crm 3

CLARAVIS 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3 PA, AL

clindamycin-tretinoin 1.2-0.025 % gel 1 ZIANA AL

CONDYLOX 0.5 % gel 3

COSENTYX 150 mg/ml sc soln pfs 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

COSENTYX 300 DOSE 150 mg/ml sc soln pfs 3 PA

COSENTYX SENSOREADY 300 DOSE 150 mg/ml sc soln auto-inj 3 PA

COSENTYX SENSOREADY PEN 150 mg/ml sc soln auto-inj 3 PA

dapsone 5 % gel 1 ACZONE AL

DEXERYL crm 3

diclofenac sodium 1.5 % td soln 1 PENNSAID

diclofenac sodium 3 % td gel 1 SOLARAZE

diclofenac sodium 1 % td gel 1 VOLTAREN

DIFFERIN 0.1 % crm, 0.1 % gel, 0.3 % gel 3 AL

DIFFERIN 0.1 % lot 3 AL

DOVONEX 0.005 % crm 3

doxycycline 40 mg cap dr 1 AL

DRITHO-CREME HP 1 % crm 3

EFUDEX 5 % crm 3

ELETONE crm 3

ELETONE TWINPACK crm 3

ELIDEL 1 % crm 3

EPIDUO 0.1-2.5 % gel 3 AL

FABIOR 0.1 % foam 3 AL

FINACEA 15 % gel 3 AL

finasteride 1 mg tab 1

FLECTOR 1.3 % td patch 3

FLUOROPLEX 1 % crm 3

fluorouracil 0.5 % crm 1 CARAC

fluorouracil 5 % crm 1 EFUDEX

fluorouracil 2 % ext soln, 5 % ext soln 1 EFUDEX

HPR PLUS crm 3

HYLATOPIC PLUS crm 3

imiquimod 5 % crm 1 ALDARA

isotretinoin 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 1 CLARAVIS PA, AL

KLOFENSAID II 1.5 % td soln 3

LEVULAN KERASTICK 20 % ext soln 3

minocycline hcl er 115 mg tab er 24 hr, 135 mg tab er 24 hr, 45 mg tab er 24 hr, 65 mg tab er 24 hr, 90 mg tab er 24 hr 1 SOLODYN

MIRVASO 0.33 % gel 3 AL

MYORISAN 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3 PA, AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NEOCERA crm 3

NEOSALUS crm 3

NEOSALUS lot 3

NEOSALUS CP crm 3

NIVATOPIC PLUS crm 3

ORACEA 40 mg cap dr 3 AL

PANRETIN 0.1 % gel 3

PENNSAID 2 % td soln 3

PICATO 0.015 % gel, 0.05 % gel 3

podocon 25 % ext soln 1

podofilox 0.5 % ext soln 1 CONDYLOX

PROPECIA 1 mg tab 3

PROTOPIC 0.03 % oint, 0.1 % oint 3

PRUCLAIR crm 3

PRUMYX crm 3

QUTENZA 8 % ext kit 3 PA

QUTENZA (2 PATCH) 8 % ext kit 3 PA

REGRANEX 0.01 % gel 3 PA

remigen crm 1

SANTYL 250 unit/gm oint 3

SOLODYN 105 mg tab er 24 hr, 115 mg tab er 24 hr, 55 mg tab er 24 hr, 65 mg tab er 24 hr, 80 mg tab er 24 hr 3

SORIATANE 10 mg cap, 17.5 mg cap, 25 mg cap 3

SORILUX 0.005 % foam 3

STELARA 45 mg/0.5ml sc soln, 45 mg/0.5ml sc soln pfs, 90 mg/ml sc soln pfs 3 PA

tacrolimus 0.03 % oint, 0.1 % oint 1 PROTOPIC

TALTZ 80 mg/ml sc soln auto-inj, 80 mg/ml sc soln pfs 2

TARGRETIN 1 % gel 3

tazarotene 0.1 % crm 1 TAZORAC

TAZORAC 0.05 % crm, 0.05 % gel, 0.1 % crm, 0.1 % gel 3

TETRIX crm 3

VALCHLOR 0.016 % gel 3 PA

VECTICAL 3 mcg/gm oint 3

VELTIN 1.2-0.025 % gel 3 AL

VOLTAREN 1 % td gel 3

XERALUX crm 3

ZENATANE 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3 PA, AL

ZIANA 1.2-0.025 % gel 3 AL

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

ZITHRANOL 1 % shampoo 3

SOMATOTROPIN AGONISTS AND ANTAGONISTS [AGONISTAS Y ANTAGONISTAS DE SOMATOTROPINA]

Somatotropin Agonists [Agonistas De Somatotropina]

GENOTROPIN 12 mg sc soln, 5 mg sc soln 3 PA

GENOTROPIN MINIQUICK 0.2 mg sc soln, 0.4 mg sc soln, 0.6 mg sc soln, 0.8 mg sc soln, 1 mg sc soln, 1.2 mg sc soln, 1.4 mg sc soln, 1.6 mg sc soln, 1.8 mg sc soln, 2 mg sc soln 3 PA

HUMATROPE 12 mg inj soln, 24 mg inj soln, 5 mg inj soln, 6 mg inj soln 2 PA

SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS [AGENTES SIMPATICOLITICOS (BLOQUEADORES ADRENÉRGICOS)]

Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]

alfuzosin hcl er 10 mg tab er 24 hr 1 UROXATRAL

D.H.E. 45 1 mg/ml inj soln 3 QL(3 / 30)

DIBENZYLINE 10 mg cap 3

dihydroergotamine mesylate 1 mg/ml inj soln 1 QL(3 / 30)

dihydroergotamine mesylate 4 mg/ml nasal soln 1 MIGRANAL QL(8 / 30)

ERGOMAR 2 mg tab subl 3 QL(20 / 30)

FLOMAX 0.4 mg cap 3

MIGRANAL 4 mg/ml nasal soln 3 QL(8 / 30)

phenoxybenzamine hcl 10 mg cap 1 DIBENZYLINE

RAPAFLO 4 mg cap, 8 mg cap 3

tamsulosin hcl 0.4 mg cap 1 FLOMAX

UROXATRAL 10 mg tab er 24 hr 3

SYMPATHOMIMETIC (ADRENERGIC) AGENTS [AGENTES SIMPATICOMIMÉTICOS (ADRENÉRGICOS)]

Alpha- And Beta-adrenergic Agonists [Agonistas Alfa Y Beta Adrenérgicos]

ADRENALIN 1 mg/ml inj soln, 30 mg/30ml inj soln 3

AUVI-Q 0.1 mg/0.1ml inj soln auto-inj, 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 3

epinephrine 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 1 ADRENACLICK

epinephrine 0.15 mg/0.3ml inj soln auto-inj 1 EPIPEN JR

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

EPIPEN 2-PAK 0.3 mg/0.3ml inj soln auto-inj 3

EPIPEN JR 2-PAK 0.15 mg/0.3ml inj soln auto-inj 3

NORTHERA 100 mg cap, 200 mg cap, 300 mg cap 3 PA

Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]

midodrine hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROAMATINE

Beta-adrenergic Agonists [Agonistas Beta-Adrenérgicos]

ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr br act, 250-50 mcg/dose inh aer pwdr br act, 500-50 mcg/dose inh aer pwdr br act 3

ADVAIR HFA 115-21 mcg/act inh aer, 230-21 mcg/act inh aer, 45-21 mcg/act inh aer 3

albuterol sulfate 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 ACCUNEB

albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg tab, 4 mg tab 1 PROVENTIL

albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg/5ml syr 1 PROVENTIL

albuterol sulfate (2.5 MG/3ML) 0.083% inh neb soln 1 VENTOLIN

albuterol sulfate er 4 mg tab er 12 hr, 8 mg tab er 12 hr 1 VOSPIRE ER

ARCAPTA NEOHALER 75 mcg inh cap 3

BROVANA 15 mcg/2ml inh neb soln 3

COMBIVENT RESPIMAT 20-100 mcg/act inh aer soln 3

ipratropium-albuterol 0.5-2.5 (3) mg/3ml inh soln 1 DUONEB

levalbuterol hcl 1.25 mg/0.5ml inh neb soln 1 XOPENEX

levalbuterol hcl 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 XOPENEX

levalbuterol tartrate 45 mcg/act inh aer 1 XOPENEX HFA

metaproterenol sulfate 10 mg tab, 20 mg tab 1 ALUPENT

metaproterenol sulfate 10 mg/5ml syr 1 ALUPENT

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

PERFOROMIST 20 mcg/2ml inh neb soln 3

PROAIR HFA 108 (90 Base) mcg/act inh aer soln 3

PROAIR RESPICLICK 108 (90 Base) mcg/act inh aer pwdr br act 3

PROVENTIL HFA 108 (90 Base) mcg/act inh aer soln 3

SEREVENT DISKUS 50 mcg/dose inh aer pwdr br act 3

terbutaline sulfate 2.5 mg tab, 5 mg tab 1 BRETHINE

VENTOLIN HFA 108 (90 Base) mcg/act inh aer soln 3

XOPENEX 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 3

XOPENEX CONCENTRATE 1.25 mg/0.5ml inh neb soln 3

XOPENEX HFA 45 mcg/act inh aer 3

THYROID AND ANTITHYROID AGENTS [AGENTES TIROIDEOS Y ANTITIROIDEOS]

Antithyroid Agents [Agentes Antitiroideos]

methimazole 10 mg tab, 5 mg tab 1 TAPAZOLE

propylthiouracil 50 mg tab 1

TAPAZOLE 10 mg tab, 5 mg tab 3

Thyroid Agents [Agentes Tiroideos]

ARMOUR THYROID 120 mg tab, 15 mg tab, 180 mg tab, 240 mg tab, 30 mg tab, 300 mg tab, 60 mg tab, 90 mg tab 3

CYTOMEL 25 mcg tab, 5 mcg tab, 50 mcg tab 3

LEVO-T 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

levothyroxine sodium 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 1 SYNTHROID

levothyroxine-liothyronine 120 mg tab, 15 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

LEVOXYL 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

liothyronine sodium 25 mcg tab, 5 mcg tab, 50 mcg tab 1 CYTOMEL

NATURE-THROID 113.75 mg tab, 130 mg tab, 146.25 mg tab, 16.25 mg tab, 162.5 mg tab, 195 mg tab, 260 mg tab, 32.5 mg tab, 325 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3

np thyroid 120 mg tab, 15 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1

SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

THYROLAR-1 60 (12.5-50) mg (mcg) tab 3

THYROLAR-1/2 30 (6.25-25) mg (mcg) tab 3

THYROLAR-1/4 15 (3.1-12.5) mg (mcg) tab 3

THYROLAR-2 120 (25-100) mg (mcg) tab 3

THYROLAR-3 180 (37.5-150) mg (mcg) tab 3

TIROSINT 100 mcg cap, 112 mcg cap, 125 mcg cap, 13 mcg cap, 137 mcg cap, 150 mcg cap, 25 mcg cap, 50 mcg cap, 75 mcg cap, 88 mcg cap 3

UNITHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

UNITHROID DIRECT 100 mcg tab, 112 mcg tab, 125 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

WESTHROID 130 mg tab, 195 mg tab, 32.5 mg tab, 65 mg tab, 97.5 mg tab 3

WP THYROID 113.75 mg tab, 130 mg tab, 16.25 mg tab, 32.5 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3

TOXOIDS [TOXOIDES]

Toxoids [Toxoides]

diphtheria-tetanus toxoids dt 25-5 lfu/0.5ml im susp 1

TENIVAC 5-2 lfu im inj 3

tetanus-diphtheria toxoids td 2-2 lf/0.5ml im susp 1

URICOSURIC AGENTS [AGENTES URICOSÚRICOS]

Uricosuric Agents [Agentes Uricosúricos]

colchicine-probenecid 0.5-500 mg tab 1 COLBENEMID

probenecid 500 mg tab 1 BENEMID

URINARY ANTI-INFECTIVES [ANTIINFECCIOSOS URINARIOS]

Urinary Anti-infectives [Antiinfecciosos Urinarios]

FURADANTIN 25 mg/5ml susp 3

HIPREX 1 gm tab 3

HYOPHEN 81.6 mg tab 3

MACROBID 100 mg cap 3

MACRODANTIN 100 mg cap, 25 mg cap, 50 mg cap 3

me/naphos/mb/hyo1 81.6 mg tab 1

methenamine hippurate 1 gm tab 1 HIPREX

methenamine mandelate 0.5 gm tab, 1 gm tab 1

MONUROL 3 gm pckt 3

nitrofurantoin 25 mg/5ml susp 1 FURADANTIN

nitrofurantoin macrocrystal 100 mg cap, 25 mg cap, 50 mg cap 1 MACRODANTIN

nitrofurantoin monohyd macro 100 mg cap 1 MACROBID

PHOSPHASAL 81.6 mg tab 3

PRIMSOL 50 mg/5ml soln 3

trimethoprim 100 mg tab 1 PROLOPRIM

trimpex 50 mg/5ml soln 1

ur n-c 81.6 mg tab 1

URELLE 81 mg tab 3

URETRON D/S tab 3

URIBEL 118 mg cap 3

URIMAR-T 120 mg tab 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

urin ds tab 1

uro-458 81 mg tab 1

uroav-81 81 mg tab 1

uroav-b 118 mg cap 1

UROGESIC-BLUE 81.6 mg tab 3

uro-mp 118 mg cap 1

URYL 81.6 mg tab 3

USTELL 120 mg cap 3

uticap 120 mg cap 1

UTIRA-C 81.6 mg tab 3

UTRONA-C 81.6 mg tab 3

VILAMIT MB 118 mg cap 3

VILEVEV MB 81 mg tab 3

VACCINES [VACUNAS]

Vaccines [Vacunas]

AFLURIA im susp 3

AFLURIA PRESERVATIVE FREE 0.5 ml im susp pfs 3

AFLURIA QUADRIVALENT im susp, 0.5 ml im susp pfs 3

ENGERIX-B 10 mcg/0.5ml im inj, 10 mcg/0.5ml inj susp, 20 mcg/ml im inj, 20 mcg/ml inj susp 3

EZ FLU SHOT-FLUCELVAX QUAD 0.5 ml im pfs kit 3

FLUARIX QUADRIVALENT 0.5 ml im susp pfs 3

FLUBLOK im soln 3

FLULAVAL QUADRIVALENT im susp, 0.5 ml im susp pfs 3

FLUMIST QUADRIVALENT nasal susp 3

FLUVIRIN im susp, 0.5 ml im susp pfs 3

FLUZONE HIGH-DOSE 0.5 ml im susp pfs 3

FLUZONE QUADRIVALENT im susp, 0.25 ml im susp pfs, 0.5 ml im susp, 0.5 ml im susp pfs, 9 mcg/strain i-dermal susp pen-inj 3

HAVRIX 1440 el u/ml im susp, 720 el u/0.5ml im susp 3

HIBERIX 10 mcg inj soln 3

PNEUMOVAX 23 25 mcg/0.5ml inj 3

PREVNAR 13 im susp 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

RECOMBIVAX HB 10 mcg/ml inj susp, 40 mcg/ml inj susp, 5 mcg/0.5ml inj susp 3

THERACYS 81 mg/vial i-vesic susp 3

TICE BCG 50 mg i-vesic susp 3

TWINRIX 720-20 im susp 3

VAQTA 25 unit/0.5ml im susp, 50 unit/ml im susp 3

ZOSTAVAX 19400 unt/0.65ml sc susp 3

VASODILATING AGENTS [AGENTES VASODILATADORES]

Nitrates And Nitrites [Nitratos Y Nitritos]

BIDIL 20-37.5 mg tab 3

DILATRATE-SR 40 mg cap er 3

ISORDIL TITRADOSE 40 mg tab, 5 mg tab 3

isosorbide dinitrate 10 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ISORDIL

isosorbide dinitrate er 40 mg tab er 1 ISORDIL

isosorbide mononitrate 10 mg tab, 20 mg tab 1 MONOKET

isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr 1 IMDUR

MINITRAN 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 3

NITRO-BID 2 % td oint 3

NITRO-DUR 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.3 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr, 0.8 mg/hr td patch 24hr 3

nitroglycerin 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 1 NITRO-DUR

nitroglycerin 0.4 mg/spray tl soln 1 NITROLINGUAL

nitroglycerin 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 1 NITROSTAT

nitroglycerin er 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 1

NITROLINGUAL 0.4 mg/spray tl soln 3

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

NITROMIST 400 mcg/spray tl aer soln 3

NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 3

NITRO-TIME 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 3

Phosphodiesterase Type 5 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 5]

ADCIRCA 20 mg tab 3 PA

CIALIS 10 mg tab, 20 mg tab 2 QL(8 / 30), AL

CIALIS 2.5 mg tab, 5 mg tab 2 PA, AL

LEVITRA 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3 PA

REVATIO 20 mg tab 3 PA

REVATIO 10 mg/ml susp 3 PA

sildenafil citrate 20 mg tab 1 REVATIO PA

sildenafil citrate 10 mg/12.5ml iv soln 1 REVATIO PA

sildenafil citrate 100 mg tab, 25 mg tab, 50 mg tab 1 VIAGRA PA

STAXYN 10 mg tab disint 3 PA

STENDRA 100 mg tab, 200 mg tab, 50 mg tab 3 PA

tadalafil 10 mg tab, 20 mg tab 1 QL(8 / 30), AL

tadalafil 2.5 mg tab, 5 mg tab 1 PA, AL

tadalafil (pah) 20 mg tab 1 PA

VIAGRA 100 mg tab, 25 mg tab, 50 mg tab 3 PA

Vasodilating Agents [Agentes Vasodilatadores]

ADEMPAS 0.5 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 2.5 mg tab 3 PA

epoprostenol sodium 0.5 mg iv soln, 1.5 mg iv soln 1 PA

FLOLAN 0.5 mg iv soln, 1.5 mg iv soln 3 PA

LETAIRIS 10 mg tab, 5 mg tab 3 PA

OPSUMIT 10 mg tab 3 PA

ORENITRAM 0.125 mg tab er, 0.25 mg tab er, 1 mg tab er, 2.5 mg tab er 3 PA

REMODULIN 1 mg/ml inj soln, 10 mg/ml inj soln, 2.5 mg/ml inj soln, 5 mg/ml inj soln 3 PA

TRACLEER 125 mg tab, 32 mg tab sol, 62.5 mg tab 3 PA

VELETRI 0.5 mg iv soln, 1.5 mg iv soln 3 PA

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

VENTAVIS 10 mcg/ml inh soln, 20 mcg/ml inh soln 3 PA

Vasodilating Agents, Miscellaneous [Agentes Vasodilatadores, Misceláneos]

dipyridamole 25 mg tab, 50 mg tab, 75 mg tab 1 PERSANTINE

isoxsuprine hcl 10 mg tab, 20 mg tab 1

VITAMIN A [VITAMINA A]

Vitamin A [Vitamina A]

AQUASOL A 50000 unit/ml im soln 3

VITAMIN B COMPLEX [VITAMINA DEL COMPLEJO B]

Vitamin B Complex [Vitamina Del Complejo B]

ABANEU-SL 600-600 mcg tab subl 3

AIRAVITE 2.5-25-1 mg tab 3

av-vite fb 2.5-25-1 mg tab 1

calcium pantothenate pwdr 1

calcium-d-pantothenate pwdr 1

cyanocobalamin 1000 mcg/ml inj soln 1

folbee 2.5-25-1 mg tab 1

folic acid 1 mg tab 1

kp folic acid 1 mg tab 1

neurin-sl 600-600 mcg tab subl 1

niacin pwdr 1

NIACOR 500 mg tab 3

NUFOL 2.5-25-1 mg tab 3

pyridoxine hcl 100 mg/ml inj soln 1

thiamine hcl 100 mg/ml inj soln 1

vitamin b complex 100 inj 1

vitamin b-complex 100 inj 1

VITAMIN C [VITAMINA C]

Vitamin C [Vitamina C]

ASCOR 25000 mg/50ml iv soln 3

ascorbic acid 500 mg/ml inj soln 1

sodium ascorbate gr 1

VITAMIN D [VITAMINA D]

Vitamin D [Vitamina D]

calcitriol 1 mcg/ml iv soln 1 CALCIJEX

calcitriol 0.25 mcg cap, 0.5 mcg cap 1 ROCALTROL

calcitriol 1 mcg/ml soln 1 ROCALTROL

doxercalciferol 0.5 mcg cap, 1 mcg cap, 2.5 mcg cap 1 HECTOROL PA

doxercalciferol 4 mcg/2ml iv soln 1 HECTOROL PA

DRISDOL 50000 unit cap 3

ergocalciferol 50000 unit cap 1

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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

HECTOROL 2 mcg/ml iv soln, 4 mcg/2ml iv soln 3 PA

paricalcitol 1 mcg cap, 2 mcg cap, 4 mcg cap 1 ZEMPLAR PA

paricalcitol 2 mcg/ml iv soln, 5 mcg/ml iv soln 1 ZEMPLAR PA

ROCALTROL 0.25 mcg cap, 0.5 mcg cap 3

ROCALTROL 1 mcg/ml soln 3

vitamin d (ergocalciferol) 50000 unit cap 1

ZEMPLAR 1 mcg cap, 2 mcg cap 3 PA

ZEMPLAR 2 mcg/ml iv soln, 5 mcg/ml iv soln 3 PA

VITAMIN E [VITAMINA E]

Vitamin E [Vitamina E]

wheat germ oil oral oil 1

VITAMIN K ACTIVITY [ACTIVIDAD DE LA VITAMINA K]

Vitamin K Activity [Actividad De La Vitamina K]

MEPHYTON 5 mg tab 3

phytonadione 5 mg tab 1

phytonadione 1 mg/0.5ml inj soln 1

vitamin k1 1 mg/0.5ml inj soln, 10 mg/ml inj soln 1

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A

Abacavir Sulfate ............................................ 72 Abacavir Sulfate-Lamivudine ........................ 72 Abacavir-Lamivudine-Zidovudine .................. 72 Abaneu-SL .................................................. 146 Abilify .......................................................... 126 Abilify Maintena ........................................... 126 Absorica ...................................................... 135 Acamprosate Calcium ................................... 88 Acanya .......................................................... 41 Acarbose ....................................................... 30 Accolate ........................................................ 54 Accupril ....................................................... 131 Accuretic ..................................................... 131 Acebutolol HCl .............................................. 78 Acetaminophen-Codeine .............................. 10 Acetaminophen-Codeine #2.......................... 10 Acetaminophen-Codeine #3.......................... 10 Acetaminophen-Codeine #4.......................... 10 Acetasol HC .................................................. 51 AcetaZOLAMIDE .......................................... 37 AcetaZOLAMIDE ER .................................... 37 AcetaZOLAMIDE Sodium ............................. 37 Acetic Acid .................................................... 99 Acetylcysteine ............................................... 35 Aciphex ......................................................... 70 Acitretin ....................................................... 135 Actemra......................................................... 97 Actigall .......................................................... 89 Actimmune .................................................. 107 Active Injection KL-3 ....................................... 2 Active Injection KM ......................................... 2 Activella....................................................... 100 Actonel .......................................................... 80 Actoplus Met ................................................. 34 Actoplus met XR ........................................... 34 Actos ............................................................. 34 Acular ............................................................ 54 Acular LS ...................................................... 54 Acuvail .......................................................... 54 Acyclovir.................................................. 45, 74 Aczone ........................................................ 135 Adalat CC...................................................... 83 Adapalene ................................................... 135 Adapalene-Benzoyl Peroxide ...................... 135 Adasuve ...................................................... 126 Adcirca ........................................................ 145 Adderall ......................................................... 14

Adderall XR ................................................... 15 Adefovir Dipivoxil ........................................... 74 Adempas ..................................................... 145 Adipex-P ........................................................ 15 Adrenal C Formula ...................................... 111 Adrenalin ..................................................... 138 Advair Diskus .............................................. 139 Advair HFA .................................................. 139 Advanced AM/PM........................................ 111 Advate ........................................................... 38 Adynovate ..................................................... 39 Afeditab CR ................................................... 83 Afinitor ........................................................... 59 Afinitor Disperz .............................................. 59 Afluria .......................................................... 143 Afluria Preservative Free ............................. 143 Afluria Quadrivalent ..................................... 143 Aggrenox ....................................................... 68 AgonEaze ...................................................... 66 Agrylin ........................................................... 68 Airavite ........................................................ 146 AK-Poly-Bac .................................................. 41 Aktipak .......................................................... 41 Ala Scalp ....................................................... 46 Ala-Cort ......................................................... 47 Ala-Quin ........................................................ 43 Albendazole .................................................. 17 Albenza ......................................................... 17 Albuterol Sulfate .......................................... 139 Albuterol Sulfate ER .................................... 139 Alclometasone Dipropionate ......................... 47 Alcoh-Glove Contoured Wipe ........................ 96 Alcoh-Wipe .................................................... 96 Alcortin A ....................................................... 45 Aldactazide .................................................. 132 Aldactone .................................................... 132 Aldara .......................................................... 135 Aldurazyme ................................................... 99 Alecensa ....................................................... 59 Alendronate Sodium ...................................... 80 AlevaMax .................................................... 135 Alfuzosin HCl ER ......................................... 138 Alimta ............................................................ 59 Alinia ............................................................. 65 Alkeran .......................................................... 59 Allopurinol ..................................................... 38 Almotriptan Malate ........................................ 57 Alocril ............................................................ 17 Alomide ......................................................... 17

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Alora ........................................................... 100 Alosetron HCl ................................................ 47 Alphagan P ................................................... 37 Alphanate/VWF Complex/Human ................. 39 AlphaNine SD ............................................... 39 ALPRAZolam ................................................ 76 ALPRAZolam ER .......................................... 76 ALPRAZolam Intensol ................................... 76 ALPRAZolam XR .......................................... 76 Alprolix .......................................................... 39 Alrex .............................................................. 51 Altabax .......................................................... 41 Altace .......................................................... 131 Altavera ......................................................... 89 Altoprev ......................................................... 56 Alunbrig ......................................................... 59 Aluvea ......................................................... 110 Alvesco ........................................................... 2 Alyacen 1/35 ................................................. 89 Alyacen 7/7/7 ................................................ 89 Amabelz ...................................................... 100 Amantadine HCl ............................................ 63 Amaryl ........................................................... 33 Ambien .......................................................... 75 Ambien CR .................................................... 75 Amcinonide ................................................... 47 Amerge ......................................................... 57 Amethia ......................................................... 89 Amethia Lo .................................................... 89 Amethyst ....................................................... 89 Amicar ........................................................... 39 AMILoride HCl ............................................... 98 AMILoride-HydroCHLOROthiazide ............... 98 Aminocaproic Acid ........................................ 39 Amiodarone HCl ............................................ 84 Amitiza ........................................................ 104 Amitriptyline HCl ......................................... 123 Amlodipine Besy-Benazepril HCl .................. 83 AmLODIPine Besylate .................................. 83 Amlodipine Besylate-Valsartan ..................... 83 Amlodipine-Atorvastatin ................................ 83 Amlodipine-Olmesartan ................................ 83 Amlodipine-Valsartan-HCTZ ......................... 83 Ammonium Lactate ....................................... 99 Ammonul ......................................................... 6 Amnesteem ................................................. 135 Amoxapine .................................................. 123 Amoxicill-Clarithro-Lansopraz ....................... 70 Amoxicillin ..................................................... 21 Amoxicillin-Pot Clavulanate..................... 21, 22

Amoxicillin-Pot Clavulanate ER ..................... 22 Amphetamine-Dextroamphet ER .................. 15 Amphetamine-Dextroamphetamine ............... 15 Ampicillin ....................................................... 22 Ampyra ........................................................ 120 Amrix ........................................................... 134 Amyvid ........................................................ 129 Anafranil ...................................................... 123 Anagrelide HCl .............................................. 68 Ana-Lex ......................................................... 66 Analpram HC ................................................. 66 Analpram HC Singles .................................... 66 Analpram-HC ................................................ 66 Anaprox DS ..................................................... 8 Anaspaz ........................................................ 24 Anastrozole ................................................... 59 Ancobon ........................................................ 37 Angeliq ........................................................ 100 Anodyne LPT ................................................ 66 Anoro Ellipta .................................................. 24 Antabuse ......................................................... 6 Antara ............................................................ 55 Anucort-HC ................................................... 47 Anusol-HC ..................................................... 47 Anzemet ........................................................ 35 ApexiCon E ................................................... 47 Apidra ............................................................ 31 Apidra SoloStar ............................................. 31 Aplenzin ...................................................... 123 Apraclonidine HCl.......................................... 99 Aprepitant ...................................................... 35 Apri ................................................................ 89 Apriso ............................................................ 47 Aptiom ........................................................... 25 Aptivus .......................................................... 72 AP-Zel ......................................................... 111 Aquasol A .................................................... 146 Aranelle ......................................................... 89 Aranesp (Albumin Free) .............................. 105 Arava ............................................................. 97 Arcalyst ....................................................... 120 Arcapta Neohaler ........................................ 139 Aricept ......................................................... 120 Arimidex ........................................................ 59 ARIPiprazole ............................................... 126 Arixtra ............................................................ 67 Armour Thyroid ........................................... 140 Aromasin ....................................................... 59 Arthrotec .......................................................... 8 Asacol HD ..................................................... 47

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Ascomp-Codeine .......................................... 10 Ascor ........................................................... 146 Ascorbic Acid .............................................. 146 Ashlyna ......................................................... 89 Asmanex 120 Metered Doses ......................... 2 Asmanex 14 Metered Doses ........................... 2 Asmanex 30 Metered Doses ........................... 2 Asmanex 60 Metered Doses ........................... 2 Asmanex 7 Metered Doses ............................. 2 Asmanex HFA ................................................. 2 Aspirin-Dipyridamole ER ............................... 68 Assure ID Insulin Safety Syr ......................... 96 Astagraf XL ................................................. 108 Astepro ......................................................... 17 Atabex EC ................................................... 111 Atacand ....................................................... 129 Atacand HCT .............................................. 129 Atazanavir Sulfate ......................................... 72 Atelvia ........................................................... 80 Atenolol ......................................................... 78 Atenolol-Chlorthalidone ................................. 78 Atgam ......................................................... 108 Ativan ............................................................ 77 Atomoxetine HCl ........................................... 88 Atopaderm .................................................. 135 Atopiclair ..................................................... 135 Atorvastatin Calcium ..................................... 56 Atovaquone ................................................... 65 Atovaquone-Proguanil HCl............................ 65 Atralin ............................................................ 87 Atripla ............................................................ 72 Atropine Sulfate .......................................... 119 Atrovent HFA ................................................ 24 Aubagio ....................................................... 107 Aubra ............................................................ 89 Augmentin ..................................................... 22 Augmentin ES-600 ........................................ 22 Augmentin XR ............................................... 22 Auryxia ........................................................ 109 Auvi-Q ......................................................... 138 Avalide ........................................................ 129 Avandia ......................................................... 34 Avapro ........................................................ 129 Avar ............................................................ 110 Avar Cleanser ............................................. 110 Avar LS ....................................................... 110 Avar LS Cleanser ........................................ 110 Avar-e Emollient .......................................... 110 Avar-e Green .............................................. 110 Avar-e LS .................................................... 110

AVC Vaginal .................................................. 45 Avelox ........................................................... 22 Aviane ........................................................... 89 Avidoxy .......................................................... 23 Avidoxy DK .................................................... 23 Avita .............................................................. 87 Avodart ............................................................ 2 Avonex ........................................................ 107 Avonex Pen ................................................. 107 Avonex Prefilled .......................................... 107 Av-VITE FB ................................................. 146 Axert .............................................................. 57 Aygestin ...................................................... 122 Azasan ........................................................ 108 AzaSite .......................................................... 41 AzaTHIOprine ............................................. 108 AzaTHIOprine Sodium ................................ 108 Azelastine HCl ......................................... 17, 18 Azelex ......................................................... 135 Azilect ............................................................ 65 Azithromycin ............................................ 20, 21 Azopt ............................................................. 38 Azor ............................................................... 83 Azulfidine ....................................................... 23 Azulfidine EN-tabs ......................................... 23 Azurette ......................................................... 89

B

Bacitracin ...................................................... 41 Bacitracin-Polymyxin B .................................. 41 Bacitra-Neomycin-Polymyxin-HC .................. 51 Baclofen ...................................................... 135 Bacmin ........................................................ 111 Bactrim .......................................................... 23 Bactrim DS .................................................... 23 Bactroban ...................................................... 41 Bactroban Nasal ............................................ 41 Bal-Care DHA ............................................. 111 Balsalazide Disodium .................................... 47 Balziva ........................................................... 89 Banzel ........................................................... 25 Baraclude ................................................ 74, 75 Basaglar KwikPen ......................................... 32 B-Complex Balanced ................................... 111 B-Complex/Vitamin C .................................. 111 B-Complex-C ............................................... 111 Bebulin .......................................................... 39 Beconase AQ ................................................ 51 Bekyree ......................................................... 89 Belbuca ......................................................... 13

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Belviq ............................................................ 15 Belviq XR ...................................................... 15 Benazepril HCl ............................................ 131 Benazepril-Hydrochlorothiazide .................. 131 BeneFIX ........................................................ 39 Benicar ........................................................ 129 Benicar HCT ............................................... 130 Benlysta ...................................................... 108 Bentyl ............................................................ 24 Benzac AC Wash .......................................... 45 BenzaClin...................................................... 41 BenzaClin with Pump .................................... 41 Benzamycin .................................................. 41 BenzEFoam .................................................. 45 BenzEFoamUltra ........................................... 45 BenzePrO ..................................................... 45 BenzePrO Creamy Wash .............................. 45 BenzePrO Short Contact .............................. 45 Benziq ........................................................... 45 Benziq LS...................................................... 45 Benziq Wash ................................................. 45 Benzonatate .................................................. 69 Benzoyl Perox-Hydrocortisone ...................... 52 Benzoyl Peroxide .......................................... 45 Benzoyl Peroxide-Erythromycin .................... 41 Benzphetamine HCl ...................................... 15 Benztropine Mesylate ................................... 63 Bepreve......................................................... 18 Berinert ......................................................... 89 Besivance ..................................................... 41 Betadine Ophthalmic Prep ............................ 45 Betagan ........................................................ 37 Betamethasone Dipropionate ........................ 47 Betamethasone Dipropionate Aug ................ 47 Betamethasone Sod Phos & Acet ................... 2 Betamethasone Valerate............................... 47 Betapace ....................................................... 78 Betapace AF ................................................. 78 Betaseron.................................................... 107 Betaxolol HCl .......................................... 37, 78 Bethanechol Chloride .................................. 120 Bethkis .......................................................... 19 Betimol .......................................................... 37 Betoptic-S ..................................................... 37 Bexarotene.................................................... 59 Beyaz ............................................................ 89 Bicalutamide ................................................. 59 Bicillin C-R .................................................... 22 Bicillin C-R 900/300 ...................................... 22 Bicillin L-A ..................................................... 22

BiDil ............................................................. 144 BiferaRx ........................................................ 18 Biktarvy ......................................................... 72 Biltricide ......................................................... 17 Binosto .......................................................... 80 Biocel .......................................................... 112 Bio-Statin ....................................................... 37 Biotuss .......................................................... 69 Biotuss Pediatric ........................................... 69 Bisoprolol Fumarate ...................................... 78 Bisoprolol-Hydrochlorothiazide ...................... 78 Bleph-10 ........................................................ 41 Blephamide ................................................... 52 Blephamide S.O.P. ........................................ 52 Blisovi 24 Fe .................................................. 89 Blisovi Fe 1.5/30 ............................................ 89 Blisovi FE 1/20 .............................................. 89 Boniva ........................................................... 80 Bosulif ........................................................... 59 BP 10-1 ....................................................... 110 BP Cleansing Wash .................................... 110 BP Foam ....................................................... 45 BP FoliNatal Plus B ..................................... 112 BP MultiNatal Plus....................................... 112 BP Wash ....................................................... 46 B-Plex .......................................................... 112 B-Plex Plus .................................................. 112 BPO ............................................................... 46 BPO Foaming Cloths ..................................... 46 Braftovi .......................................................... 59 Bravelle ....................................................... 104 Breo Ellipta ...................................................... 2 Briellyn .......................................................... 89 Brilinta ........................................................... 68 Brimonidine Tartrate ...................................... 37 Bromfed DM .................................................. 69 Bromfenac Sodium (Once-Daily) ................... 54 Bromocriptine Mesylate ................................. 64 Brompheniramine Tannate .......................... 103 Brovana ....................................................... 139 BT Injection ..................................................... 2 Bucalsep ....................................................... 46 Budesonide ..................................................... 2 Budesonide ER ............................................... 2 Bumetanide ................................................... 98 Bunavail ........................................................ 14 Bupap .............................................................. 7 Buphenyl ......................................................... 7 Bupivilog .......................................................... 2 Buprenex ....................................................... 14

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Buprenorphine .............................................. 14 Buprenorphine HCl ....................................... 14 Buprenorphine HCl-Naloxone HCl ................ 14 BuPROPion HCl .......................................... 123 BuPROPion HCl ER (Smoking Det) ............ 123 BuPROPion HCl ER (SR) ........................... 123 BuPROPion HCl ER (XL) ............................ 123 BusPIRone HCl ............................................. 75 Butalbital-Acetaminophen ............................... 7 Butalbital-APAP .............................................. 7 Butalbital-APAP-Caff-Cod ............................. 10 Butalbital-APAP-Caffeine ................................ 7 Butalbital-ASA-Caff-Codeine......................... 10 Butalbital-Aspirin-Caffeine............................... 8 Butisol Sodium .............................................. 76 Butorphanol Tartrate ..................................... 14 Butrans ......................................................... 14 Bydureon....................................................... 31 Bydureon BCise ............................................ 31 Byetta 10 MCG Pen ...................................... 31 Byetta 5 MCG Pen ........................................ 31 Bystolic ......................................................... 78

C

Cabergoline ................................................... 64 Cabometyx .................................................... 59 Caduet .......................................................... 83 Cafergot ........................................................ 57 Calan ............................................................ 81 Calan SR....................................................... 81 Calcipotriene ............................................... 135 Calcipotriene-Betameth Diprop ..................... 47 Calcitonin (Salmon) ..................................... 121 Calcitrene .................................................... 135 Calcitriol .............................................. 135, 146 Calcium Acetate (Phos Binder) ................... 132 Calcium Pantothenate ................................. 146 Calcium-D-Pantothenate ............................. 146 Cambia ........................................................... 8 Camrese ....................................................... 89 Camrese Lo .................................................. 90 Canasa ......................................................... 47 Candesartan Cilexetil .................................. 130 Candesartan Cilexetil-HCTZ ....................... 130 Capastat Sulfate ........................................... 58 Capecitabine ................................................. 59 Capex ........................................................... 47 Caprelsa........................................................ 59 Captopril...................................................... 131 Captopril-Hydrochlorothiazide ..................... 131

Carac ........................................................... 135 Carafate ........................................................ 70 Carbaglu .......................................................... 7 CarBAMazepine ............................................ 26 CarBAMazepine ER ...................................... 26 Carbaphen 12 ............................................... 69 Carbaphen 12 Ped ........................................ 69 Carbatrol ....................................................... 26 Carbidopa ...................................................... 63 Carbidopa-Levodopa ..................................... 63 Carbidopa-Levodopa ER ............................... 63 Carbidopa-Levodopa-Entacapone ................ 63 Carbinoxamine Maleate .............................. 103 Carbodex DM ................................................ 69 Cardizem ....................................................... 81 Cardizem CD ................................................. 81 Cardizem LA ................................................. 81 Cardura ........................................................... 6 Cardura XL ...................................................... 6 Carisoprodol ................................................ 134 Carisoprodol-Aspirin .................................... 134 Carnitor ....................................................... 120 Carnitor SF .................................................. 120 Carteolol HCl ................................................. 37 Cartia XT ....................................................... 81 Carvedilol ...................................................... 78 Carvedilol Phosphate ER .............................. 78 Casodex ........................................................ 59 Catapres ...................................................... 106 Catapres-TTS-1 .......................................... 106 Catapres-TTS-2 .......................................... 106 Catapres-TTS-3 .......................................... 106 Cavarest ........................................................ 85 Cayston ......................................................... 21 Caziant .......................................................... 90 Cefaclor ......................................................... 20 Cefaclor ER ................................................... 20 Cefadroxil ...................................................... 20 Cefdinir .......................................................... 20 Cefditoren Pivoxil .......................................... 20 Cefixime ........................................................ 20 Cefpodoxime Proxetil .................................... 20 Cefprozil ........................................................ 20 Ceftin ............................................................. 20 CefTRIAXone Sodium ................................... 20 Cefuroxime Axetil .......................................... 20 Cefuroxime Sodium ....................................... 20 CeleBREX ....................................................... 8 Celecoxib ........................................................ 8 Celestone Soluspan ........................................ 2

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CeleXA ........................................................ 123 CellCept ...................................................... 108 CellCept Intravenous .................................. 108 Celontin ......................................................... 30 Centany......................................................... 41 Centany AT ................................................... 41 Centratex ...................................................... 18 Cephalexin .................................................... 20 Cerdelga ..................................................... 120 Cerezyme.................................................... 100 Cerovel ....................................................... 110 Cesamet........................................................ 35 Cetirizine HCl .............................................. 133 Cetraxal......................................................... 41 Chantix .......................................................... 78 Chantix Continuing Month Pak ...................... 78 Chantix Starting Month Pak .......................... 78 Chateal ......................................................... 90 Chemet ....................................................... 105 Chenodal....................................................... 89 ChlordiazePOXIDE HCl ................................ 77 Chlordiazepoxide-Amitriptyline .................... 123 Chlordiazepoxide-Clidinium .......................... 24 Chlorhexidine Gluconate ............................... 45 Chloroquine Phosphate ................................ 65 Chlorothiazide ............................................... 99 ChlorproMAZINE HCl .................................. 127 ChlorproPAMIDE .......................................... 34 Chlorthalidone ............................................... 99 Chlorzoxazone ............................................ 134 Cholestyramine ............................................. 55 Cholestyramine Light .................................... 55 Choline Fenofibrate ....................................... 55 Chorionic Gonadotropin .............................. 104 Cialis ........................................................... 145 Ciclodan ........................................................ 43 Ciclodan Cream ............................................ 43 Ciclodan Solution .......................................... 44 Ciclopirox ...................................................... 44 Ciclopirox Olamine ........................................ 44 Ciclopirox Treatment ..................................... 44 Cilostazol ...................................................... 68 Ciloxan .......................................................... 41 Cimduo ......................................................... 72 Cimetidine ..................................................... 70 Cimetidine HCl .............................................. 70 Cimzia ........................................................... 97 Cimzia Prefilled ............................................. 97 Cimzia Starter Kit .......................................... 97 Cinryze .......................................................... 89

Cipro .............................................................. 22 Cipro HC ....................................................... 52 Cipro XR ........................................................ 22 Ciprodex ........................................................ 52 Ciprofloxacin ................................................. 22 Ciprofloxacin HCl .................................... 22, 41 Ciprofloxacin-Ciproflox HCl ER ..................... 22 Citalopram Hydrobromide ........................... 123 CitraNatal 90 DHA ....................................... 112 CitraNatal Assure ........................................ 112 CitraNatal B-Calm ....................................... 112 CitraNatal DHA ............................................ 112 CitraNatal Harmony ..................................... 112 CitraNatal Rx ............................................... 112 Claravis ....................................................... 135 Clarinex ....................................................... 133 Clarinex-D 12 Hour...................................... 134 Clarithromycin ............................................... 21 Clarithromycin ER ......................................... 21 Clemastine Fumarate .................................. 103 Clenpiq .......................................................... 87 Cleocin .................................................... 19, 42 Cleocin-T ....................................................... 42 Climara ........................................................ 100 Climara Pro ................................................. 100 Clindacin ETZ ................................................ 42 Clindacin Pac ................................................ 42 Clindacin-P .................................................... 42 Clindagel ....................................................... 42 Clindamycin HCl ............................................ 19 Clindamycin Palmitate HCl ............................ 19 Clindamycin Phos-Benzoyl Perox ................. 42 Clindamycin Phosphate ................................. 42 Clindamycin-Tretinoin .................................. 135 Clindesse ...................................................... 42 Clinpro 5000 .................................................. 85 CloBAZam ..................................................... 29 Clobetasol Prop Emollient Base .................... 47 Clobetasol Propionate ................................... 47 Clobetasol Propionate E ................................ 47 Clobetasol Propionate Emulsion ................... 47 Clobex ........................................................... 48 Clobex Spray ................................................. 48 Clocortolone Pivalate .................................... 48 Clocortolone Pivalate Pump .......................... 48 Clodan ........................................................... 48 Cloderm ......................................................... 48 Cloderm Pump .............................................. 48 ClomiPHENE Citrate ................................... 100 ClomiPRAMINE HCl .................................... 123

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ClonazePAM ................................................. 29 CloNIDine.................................................... 106 CloNIDine HCl ............................................. 106 CloNIDine HCl ER ....................................... 106 Clopidogrel Bisulfate ..................................... 68 Clorazepate Dipotassium .............................. 77 Clotrimazole .................................................. 44 Clotrimazole-Betamethasone ........................ 44 CloZAPine ................................................... 127 Clozaril ........................................................ 127 C-Nate DHA ................................................ 112 Coagadex...................................................... 39 Coartem ........................................................ 65 Cod Liver Oil ............................................... 112 Colazal .......................................................... 48 Colchicine ..................................................... 38 Colchicine-Probenecid ................................ 142 Colcrys .......................................................... 38 Colesevelam HCl .......................................... 55 Colestid ......................................................... 55 Colestid Flavored .......................................... 55 Colestipol HCl ............................................... 55 Colocort......................................................... 48 Coly-Mycin S ................................................. 52 Colyte with Flavor Packs ............................... 87 Combigan...................................................... 37 CombiPatch ................................................ 100 Combivent Respimat ................................... 139 Combivir ........................................................ 72 Cometriq (100 mg Daily Dose) ...................... 59 Cometriq (140 mg Daily Dose) ...................... 59 Cometriq (60 mg Daily Dose) ........................ 59 Complera ...................................................... 72 Complete Natal DHA ................................... 112 CompleteNate ............................................. 112 Compro ....................................................... 127 Comtan ......................................................... 63 Co-Natal FA ................................................ 112 Concept DHA .............................................. 112 Concept OB ................................................ 112 Concerta ....................................................... 16 Condylox ..................................................... 135 Constulose ...................................................... 7 Contrave ....................................................... 15 ConZip .......................................................... 10 Cordran ......................................................... 48 Coreg ............................................................ 78 Coreg CR ...................................................... 79 Corgard ......................................................... 79 Corifact ......................................................... 39

Cortane-B ................................................ 48, 52 Cortane-B Aqueous ....................................... 52 Cortef .............................................................. 3 Cortenema .................................................... 48 Cortic-ND ...................................................... 52 Cortifoam ....................................................... 48 Cortisone Acetate ............................................ 3 Corvita ......................................................... 112 Corvite ......................................................... 112 Corvite Free ................................................ 112 Corzide .......................................................... 79 Cosentyx ..................................................... 135 Cosentyx 300 Dose ..................................... 136 Cosentyx Sensoready 300 Dose ................. 136 Cosentyx Sensoready Pen .......................... 136 Cosopt ........................................................... 38 Cosopt PF ..................................................... 38 Coumadin ...................................................... 67 Covaryx ....................................................... 100 Covaryx HS ................................................. 100 Cozaar ......................................................... 130 Creon ............................................................ 96 Crestor .......................................................... 56 Crinone ........................................................ 122 Crixivan ......................................................... 72 Cromolyn Sodium .................................... 18, 54 Cryselle-28 .................................................... 90 Cutivate ......................................................... 48 Cuvposa ........................................................ 24 Cyanocobalamin ......................................... 146 Cyclafem 1/35 ............................................... 90 Cyclafem 7/7/7 .............................................. 90 Cyclobenzaprine HCl ................................... 134 Cyclogyl ....................................................... 119 Cyclomydril .................................................. 119 Cyclopentolate HCl...................................... 119 Cyclophosphamide ........................................ 59 CycloSERINE ................................................ 58 Cycloset ........................................................ 30 CycloSPORINE ........................................... 108 CycloSPORINE Modified ............................. 108 Cyklokapron .................................................. 39 Cymbalta ..................................................... 123 Cyotic ............................................................ 52 Cyproheptadine HCl .................................... 102 Cyramza ........................................................ 59 Cyred ............................................................. 90 Cystadane ................................................... 120 Cystagon ..................................................... 120 Cytomel ....................................................... 140

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Cytotec .......................................................... 70 Cytra K Crystals .............................................. 6

D

D.H.E. 45 .................................................... 138 Dalfampridine ER ........................................ 120 Daliresp ....................................................... 121 Dapsone................................................ 58, 136 Daraprim ....................................................... 65 Darifenacin Hydrobromide ER .................... 103 Dasetta 1/35 .................................................. 90 Dasetta 7/7/7 ................................................. 90 Daypro ............................................................ 8 Daysee .......................................................... 90 Daytrana ....................................................... 16 DDAVP ............................................... 121, 122 DDAVP Rhinal Tube ................................... 122 Debacterol..................................................... 99 Deblitane ....................................................... 90 Decon-A ...................................................... 103 Decon-G...................................................... 102 Delestrogen ................................................. 100 Delyla ............................................................ 90 Delzicol ......................................................... 48 Demadex....................................................... 98 Demeclocycline HCl ...................................... 23 Demerol ........................................................ 10 Demser ....................................................... 120 Denavir ......................................................... 45 Denta 5000 Plus ........................................... 85 DentaGel ....................................................... 85 Depakene...................................................... 26 Depakote....................................................... 26 Depakote ER ................................................. 26 Depakote Sprinkles ....................................... 26 Depo-Estradiol ............................................ 100 DEPO-Medrol .................................................. 3 Depo-Provera .............................................. 122 Depo-SubQ Provera 104............................. 122 DermacinRx Empricaine ............................... 66 DermacinRx Prizopak ................................... 66 Derma-Smoothe/FS Body ............................. 48 Derma-Smoothe/FS Scalp ............................ 48 Dermasorb HC .............................................. 48 Dermasorb TA ............................................... 48 Dermazene ................................................... 46 DermOtic ....................................................... 52 Desipramine HCl ......................................... 123 Desloratadine .............................................. 134 Desmopressin Ace Spray Refrig ................. 122

Desmopressin Acetate ................................ 122 Desmopressin Acetate Spray ...................... 122 Desogen ........................................................ 90 Desogestrel-Ethinyl Estradiol ........................ 90 Desonate ....................................................... 48 Desonide ....................................................... 48 DesOwen ...................................................... 48 Desoximetasone ........................................... 48 Desoxyn ........................................................ 15 Desvenlafaxine ER ...................................... 123 Desvenlafaxine Succinate ER ..................... 123 Detrol ........................................................... 103 Detrol LA ..................................................... 103 Dexamethasone .............................................. 3 Dexamethasone Intensol ................................. 3 Dexamethasone Sod Phosphate PF ............... 3 Dexamethasone Sodium Phosphate ......... 3, 52 Dexedrine ...................................................... 15 Dexeryl ........................................................ 136 Dexilant ......................................................... 71 Dexmethylphenidate HCl ............................... 16 Dexmethylphenidate HCl ER ......................... 16 DexPak 10 Day ............................................... 3 DexPak 13 Day ............................................... 3 DexPak 6 Day ................................................. 3 Dexphen w/C ................................................. 69 Dextroamphetamine Sulfate .......................... 15 Dextroamphetamine Sulfate ER .................... 15 Dialyvite ....................................................... 112 Dialyvite 3000 .............................................. 112 Dialyvite 5000 .............................................. 112 Dialyvite Supreme D .................................... 112 Dialyvite/Zinc ............................................... 112 Diastat AcuDial .............................................. 77 Diastat Pediatric ............................................ 77 DiazePAM ..................................................... 77 DiazePAM Intensol ........................................ 77 Dibenzyline .................................................. 138 Diclegis .......................................................... 35 Diclofenac Potassium ...................................... 8 Diclofenac Sodium ............................ 8, 54, 136 Diclofenac Sodium ER .................................... 8 Diclofenac-Misoprostol .................................... 8 Dicloxacillin Sodium ...................................... 22 Dicyclomine HCl ............................................ 24 Didanosine .................................................... 72 Diethylpropion HCl ........................................ 15 Diethylpropion HCl ER .................................. 16 Differin ......................................................... 136 Dificid ............................................................ 21

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Difil-G Forte ................................................. 133 Diflorasone Diacetate .................................... 48 Diflucan ......................................................... 36 Diflunisal ......................................................... 8 Digitek ........................................................... 85 Digox ............................................................. 85 Digoxin .......................................................... 85 Dihydroergotamine Mesylate ...................... 138 Dilantin .......................................................... 29 Dilantin Infatabs ............................................ 29 Dilatrate-SR ................................................ 144 Dilaudid ......................................................... 10 DilTIAZem CD ............................................... 81 DilTIAZem HCl .............................................. 81 DilTIAZem HCl ER ........................................ 81 DilTIAZem HCl ER Beads ....................... 81, 82 DilTIAZem HCl ER Coated Beads ................ 82 Dilt-XR .......................................................... 82 Diovan ......................................................... 130 Diovan HCT ................................................ 130 Dipentum....................................................... 48 DiphenhydrAMINE HCl ............................... 103 Diphenoxylate-Atropine ................................. 35 Diphtheria-Tetanus Toxoids DT .................. 142 Diprolene....................................................... 48 Diprolene AF ................................................. 48 Dipyridamole ............................................... 146 Disopyramide Phosphate .............................. 84 Disulfiram ........................................................ 6 Ditropan XL ................................................. 103 Diuril .............................................................. 99 Divalproex Sodium ........................................ 26 Divalproex Sodium ER .................................. 26 Divigel ......................................................... 100 Dofetilide ....................................................... 85 Donepezil HCl ............................................. 120 Donnatal........................................................ 24 Doral ............................................................. 77 Doryx ............................................................ 23 Dorzolamide HCl ........................................... 38 Dorzolamide HCl-Timolol Mal ....................... 38 Dorzolamide HCl-Timolol Mal PF .................. 38 Dothelle DHA .............................................. 112 Dovonex ...................................................... 136 Doxazosin Mesylate ........................................ 6 Doxepin HCl ................................................ 124 Doxercalciferol ............................................ 146 Doxycycline ................................................. 136 Doxycycline Hyclate ...................................... 23 Doxycycline Monohydrate ....................... 23, 24

Drisdol ......................................................... 146 Dritho-Creme HP ......................................... 136 Dronabinol ..................................................... 35 Drospiren-Eth Estrad-Levomefol ................... 90 Drospirenone-Ethinyl Estradiol ...................... 90 Duac .............................................................. 42 Duavee ........................................................ 100 Duet DHA 400 ............................................. 112 Duet DHA Balanced .................................... 112 Duetact .......................................................... 34 Duexis ............................................................. 8 Dulera .............................................................. 3 DULoxetine HCl .......................................... 124 Duragesic-100 ............................................... 10 Duragesic-12 ................................................. 10 Duragesic-25 ................................................. 10 Duragesic-50 ................................................. 10 Duragesic-75 ................................................. 10 Durezol .......................................................... 52 Dutasteride ...................................................... 2 Dutasteride-Tamsulosin HCl ........................... 2 Dutoprol ......................................................... 79 Dyazide ......................................................... 98 Dymista ......................................................... 18 Dyrenium ....................................................... 98

E

E.E.S. 400 ..................................................... 21 E.E.S. Granules ............................................ 21 Easygel ......................................................... 86 EC-Naprosyn ................................................... 8 Econazole Nitrate .......................................... 44 Ecoza ............................................................ 44 Edarbi .......................................................... 130 Edarbyclor ................................................... 130 Edecrin .......................................................... 98 Edluar ............................................................ 75 Ed-Spaz ........................................................ 24 Edurant .......................................................... 72 EEMT .......................................................... 100 EEMT HS .................................................... 101 Efavirenz ....................................................... 72 Effexor XR ................................................... 124 Effient ............................................................ 68 Efudex ......................................................... 136 Elaprase ...................................................... 100 Eldepryl ......................................................... 65 Elelyso ......................................................... 100 Elestat ........................................................... 18 Elestrin ........................................................ 101

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Eletone ........................................................ 136 Eletone Twinpack ........................................ 136 Eletriptan Hydrobromide ............................... 57 Elidel ........................................................... 136 Eligard ........................................................... 59 Elimite ........................................................... 46 Elinest ........................................................... 90 Eliquis ........................................................... 67 Eliquis Starter Pack ....................................... 67 Elite-OB....................................................... 112 Elixophyllin .................................................. 133 Ella ................................................................ 90 Elmiron ........................................................ 120 Elocon ........................................................... 48 Eloctate ......................................................... 39 Emadine ........................................................ 18 Emcyt ............................................................ 59 Emend .......................................................... 35 Emend Tri-Pack ............................................ 35 Emoquette..................................................... 90 Emsam .......................................................... 65 Emtriva .......................................................... 72 Enablex ....................................................... 103 Enalapril Maleate ........................................ 131 Enalapril-Hydrochlorothiazide ..................... 131 EnBrace HR ................................................ 112 Enbrel ........................................................... 97 Enbrel Mini .................................................. 107 Enbrel SureClick ........................................... 97 Endocet ......................................................... 10 Engerix-B .................................................... 143 Enoxaparin Sodium ....................................... 67 Enpresse-28 .................................................. 90 Enskyce ........................................................ 90 Entacapone ................................................... 63 Entecavir ....................................................... 75 Entocort EC ..................................................... 3 Entyvio ........................................................ 104 Enulose ........................................................... 7 Envarsus XR ............................................... 108 Epiduo ......................................................... 136 Epifoam ......................................................... 48 Epinastine HCl .............................................. 18 EPINEPHrine .............................................. 138 EpiPen 2-Pak .............................................. 139 EpiPen Jr 2-Pak .......................................... 139 Epitol ............................................................. 26 Epivir ............................................................. 72 Epivir HBV ..................................................... 72 Eplerenone.................................................. 132

Epogen ........................................................ 105 Epoprostenol Sodium .................................. 145 Eprosartan Mesylate ................................... 130 Epzicom ........................................................ 72 EQL Super B Complex/Vitamin C ............... 112 Equetro .......................................................... 26 Erbitux ........................................................... 59 Ergocalciferol .............................................. 146 Ergomar ...................................................... 138 Ergotamine-Caffeine ..................................... 57 Erivedge ........................................................ 59 Erleada .......................................................... 59 Ertaczo .......................................................... 44 Ery ................................................................. 42 Erygel ............................................................ 42 EryPed 200 ................................................... 21 EryPed 400 ................................................... 21 Ery-Tab ......................................................... 21 Erythrocin Stearate........................................ 21 Erythromycin ................................................. 42 Erythromycin Base ........................................ 21 Erythromycin Ethylsuccinate ......................... 21 Esbriet ......................................................... 133 Escavite ....................................................... 112 Escavite D ................................................... 112 Escavite LQ ................................................. 112 Escitalopram Oxalate .................................. 124 Esgic ............................................................... 7 Esomeprazole Magnesium ............................ 71 Esomeprazole Strontium ............................... 71 Est Estrogens-Methyltest ............................ 101 Est Estrogens-Methyltest DS ...................... 101 Est Estrogens-Methyltest HS ...................... 101 Estarylla ........................................................ 90 Estazolam ..................................................... 77 Estrace ........................................................ 101 Estradiol ...................................................... 101 Estradiol Valerate ........................................ 101 Estradiol-Norethindrone Acet ...................... 101 Estrogel ....................................................... 101 Estropipate .................................................. 101 Estrostep Fe .................................................. 90 Eszopiclone ................................................... 75 Ethacrynic Acid ............................................. 98 Ethambutol HCl ............................................. 58 Ethosuximide ................................................. 30 Ethynodiol Diac-Eth Estradiol ........................ 90 Etidronate Disodium ...................................... 80 Etodolac .......................................................... 8 Etodolac ER .................................................... 8

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Etoposide ...................................................... 59 Eurax ............................................................ 46 Evamist ....................................................... 101 Evista .......................................................... 100 Evoclin .......................................................... 42 Exactuss ....................................................... 69 Exelderm ....................................................... 44 Exelon ......................................................... 121 Exemestane .................................................. 59 Exforge ......................................................... 83 Exforge HCT ................................................. 83 Exjade ......................................................... 105 Exoderm........................................................ 44 Exotic-HC ...................................................... 52 Extavia ........................................................ 107 Extina ............................................................ 44 EZ Flu Shot-Flucelvax Quad ....................... 143 Ezetimibe ...................................................... 55 Ezetimibe-Simvastatin .................................. 56

F

Fabior .......................................................... 136 Fabrazyme .................................................. 100 FaLessa ........................................................ 90 Falmina ......................................................... 90 Famciclovir .................................................... 75 Famotidine .................................................... 70 Fanapt ......................................................... 127 Fanapt Titration Pack .................................. 127 Fareston ........................................................ 59 Farxiga .......................................................... 33 Farydak ......................................................... 60 Faslodex ....................................................... 60 Fayosim ........................................................ 90 FazaClo....................................................... 127 Feiba ............................................................. 39 Felbamate ..................................................... 26 Felbatol ......................................................... 26 Feldene ........................................................... 8 Felodipine ER ............................................... 83 Fem pH ......................................................... 46 Femara ......................................................... 60 FemCap ........................................................ 90 Femhrt Low Dose ........................................ 101 Femynor ........................................................ 90 Fenofibrate .................................................... 55 Fenofibrate Micronized ................................. 55 Fenofibric Acid .............................................. 56 Fenoglide ...................................................... 56 Fenoprofen Calcium ........................................ 8

FentaNYL ...................................................... 10 FentaNYL Citrate (PF) ................................... 11 Ferrex 150 Forte Plus .................................... 18 Ferriprox ...................................................... 105 Ferrlecit ......................................................... 18 Ferrocite Plus ................................................ 18 FERRO-plex Hematinic ................................. 18 Fetzima ....................................................... 124 Fetzima Titration ......................................... 124 Fexmid ........................................................ 134 Fibricor .......................................................... 56 Finacea ....................................................... 136 Finasteride .............................................. 2, 136 Fioricet ............................................................ 7 Fioricet/Codeine ............................................ 11 Fiorinal ............................................................ 8 Fiorinal/Codeine #3 ....................................... 11 Firazyr ........................................................... 89 Firmagon ....................................................... 60 First-Hydrocortisone ...................................... 49 First-Lansoprazole......................................... 71 First-Mouthwash BLM ................................... 66 First-Omeprazole........................................... 71 First-Vancomycin 25 ...................................... 19 First-Vancomycin 50 ...................................... 19 Flagyl ............................................................. 65 Flarex ............................................................ 52 FlavoxATE HCl ............................................ 103 Flecainide Acetate ......................................... 85 Flector ......................................................... 136 Flolan .......................................................... 145 Flomax ........................................................ 138 Floriva ......................................................... 112 Floriva Plus ................................................. 113 Flovent Diskus ................................................. 3 Flovent HFA .................................................... 3 Fluarix Quadrivalent .................................... 143 Flublok ......................................................... 143 Fluconazole ................................................... 36 Flucytosine .................................................... 37 Fludrocortisone Acetate .................................. 3 Flulaval Quadrivalent ................................... 143 Flumadine ..................................................... 71 Flumazenil ..................................................... 88 FluMist Quadrivalent ................................... 143 Flunisolide ..................................................... 52 Fluocinolone Acetonide ........................... 49, 52 Fluocinolone Acetonide Body ........................ 49 Fluocinolone Acetonide Scalp ....................... 49 Fluocinonide .................................................. 49

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Fluocinonide Emulsified Base ....................... 49 Fluorabon ...................................................... 86 Fluoridex ....................................................... 86 Fluoridex Daily Renewal ............................... 86 Fluoridex Enhanced Whitening ..................... 86 Fluoridex Sensitivity Relief ............................ 95 Fluoritab ........................................................ 86 Fluorometholone ........................................... 52 Fluoroplex ................................................... 136 Fluorouracil ................................................. 136 FLUoxetine HCl ........................................... 124 FluPHENAZine Decanoate ......................... 127 FluPHENAZine HCl ..................................... 127 Flura-Drops ................................................... 86 Flurandrenolide ............................................. 49 Flurazepam HCl ............................................ 77 Flurbiprofen ..................................................... 8 Flurbiprofen Sodium ...................................... 54 Flutamide ...................................................... 60 Fluticasone Propionate ........................... 49, 52 Fluticasone-Salmeterol ................................... 3 Fluvastatin Sodium ....................................... 56 Fluvastatin Sodium ER ................................. 56 Fluvirin ........................................................ 143 FluvoxaMINE Maleate ................................. 124 FluvoxaMINE Maleate ER ........................... 124 Fluzone High-Dose ..................................... 143 Fluzone Quadrivalent .................................. 143 FML ............................................................... 52 FML Forte ..................................................... 52 FML Liquifilm ................................................. 52 Focalin .......................................................... 16 Focalin XR .................................................... 16 Folbee ......................................................... 146 Folbee Plus ................................................. 113 Folbee Plus CZ ........................................... 113 Folet DHA ................................................... 113 Folet One .................................................... 113 Folgard OS .................................................. 113 Folic Acid .................................................... 146 Folivane-F ..................................................... 18 Folivane-OB ................................................ 113 Folivane-Plus ................................................ 18 Follistim AQ ................................................. 105 Fondaparinux Sodium ................................... 67 Forfivo XL.................................................... 124 Fortamet........................................................ 30 Fortavit ........................................................ 113 Forteo ......................................................... 121 Fosamax ....................................................... 80

Fosamax Plus D ............................................ 80 Fosamprenavir Calcium ................................ 72 Fosinopril Sodium........................................ 131 Fosinopril Sodium-HCTZ ............................. 131 Fosrenol ...................................................... 109 Fragmin ......................................................... 67 Frova ............................................................. 57 Frovatriptan Succinate .................................. 57 Furadantin ................................................... 142 Furosemide ................................................... 98 Fusion Plus ................................................... 18 Fuzeon .......................................................... 72 Fyavolv ........................................................ 101 Fycompa ....................................................... 26

G

Gabapentin .................................................... 26 Gabitril ........................................................... 26 Galantamine Hydrobromide ........................ 121 Galantamine Hydrobromide ER .................. 121 Ganirelix Acetate ......................................... 104 Gastrocrom ................................................... 54 Gatifloxacin ................................................... 42 Gattex .......................................................... 104 GaviLyte-C .................................................... 87 GaviLyte-G .................................................... 87 GaviLyte-N with Flavor Pack ......................... 87 Gel-Kam Oral Care Rinse ............................. 86 Gelnique ...................................................... 103 Gelnique Pump ........................................... 104 Gemcitabine HCl ........................................... 60 Gemfibrozil .................................................... 56 Gemzar ......................................................... 60 Generess FE ................................................. 91 Generlac .......................................................... 7 Gengraf ....................................................... 108 Genotropin .................................................. 138 Genotropin MiniQuick .................................. 138 Gentak ........................................................... 42 Gentamicin Sulfate .................................. 19, 42 Geodon ....................................................... 127 Gianvi ............................................................ 91 Giazo ............................................................. 49 Gilenya ........................................................ 107 Gilotrif ............................................................ 60 Gilphex TR .................................................. 102 Giltuss ........................................................... 69 Giltuss Pediatric ............................................ 69 Giltuss TR ..................................................... 69 Glatiramer Acetate ...................................... 107

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Glatopa ....................................................... 107 Gleevec ......................................................... 60 Gliadel Wafer ................................................ 60 Glimepiride .................................................... 34 GlipiZIDE....................................................... 34 GlipiZIDE ER ................................................. 34 GlipiZIDE XL ................................................. 34 GlipiZIDE-MetFORMIN HCl .......................... 34 GlucaGen HypoKit ........................................ 41 Glucagon Emergency ................................... 41 Glucophage ................................................... 30 Glucophage XR ............................................. 30 Glucotrol........................................................ 34 Glucotrol XL .................................................. 34 Glucovance ................................................... 34 Glumetza....................................................... 30 GlyBURIDE ................................................... 34 GlyBURIDE Micronized ................................. 34 GlyBURIDE-MetFORMIN .............................. 34 Glycate .......................................................... 24 Glycopyrrolate ............................................... 24 Glydo ............................................................ 66 Glynase ......................................................... 34 Glyset ............................................................ 30 Glyxambi ....................................................... 33 Golytely ......................................................... 87 Gonal-f ........................................................ 105 Gonal-f RFF ................................................ 105 Gonal-f RFF Rediject .................................. 105 Granisetron HCl ............................................ 35 Granix ......................................................... 106 Griseofulvin Microsize ................................... 36 Griseofulvin Ultramicrosize ........................... 36 Gris-PEG....................................................... 36 GuanFACINE HCl ....................................... 107 GuanFACINE HCl ER ................................... 88 Guanidine HCl ............................................. 121 Gynazole-1 .................................................... 44

H

Halac ............................................................. 49 Halcion .......................................................... 77 Haldol .......................................................... 127 Haldol Decanoate ....................................... 127 Halobetasol Propionate ................................. 49 Halog ............................................................ 49 Haloperidol .................................................. 127 Haloperidol Decanoate ............................... 127 Haloperidol Lactate ..................................... 127 Halotin ........................................................... 44

Harvoni .......................................................... 74 Havrix .......................................................... 143 Heather ......................................................... 91 Hectorol ....................................................... 147 Helixate FS .................................................... 39 Hemangeol .................................................... 79 Hematinic Plus Vit/Minerals ........................... 18 Hematinic/Folic Acid ...................................... 18 Hematron-AF ................................................. 18 HemeNatal OB ............................................ 113 HemeNatal OB + DHA ................................ 113 HemeTab ...................................................... 18 Hemmorex-HC .............................................. 49 Hemocyte Plus .............................................. 18 Hemocyte-F ................................................... 18 Hemocyte-Plus .............................................. 18 Hemofil M ...................................................... 39 Heparin Sodium (Porcine) ............................. 68 Heparin Sodium (Porcine) PF ....................... 68 Hepsera ......................................................... 75 Hexalen ......................................................... 60 Hiberix ......................................................... 143 Hiprex .......................................................... 142 HM Vitamin B Complex/Vitamin C ............... 113 Homatropaire .............................................. 119 Homatropine HBr ........................................ 119 HP Acthar .................................................... 122 HPR Plus ..................................................... 136 HumaLOG ..................................................... 32 HumaLOG Junior KwikPen ........................... 32 HumaLOG KwikPen ...................................... 32 HumaLOG Mix 50/50 ..................................... 32 HumaLOG Mix 50/50 KwikPen ...................... 32 HumaLOG Mix 75/25 ..................................... 32 HumaLOG Mix 75/25 KwikPen ...................... 32 HumaPen LUXURA HD ................................. 96 Humate-P ...................................................... 39 Humatrope .................................................. 138 HumatroPen for 12mg ................................... 96 HumatroPen for 24mg ................................... 96 HumatroPen for 6mg ..................................... 96 Humira ........................................................... 97 Humira Pediatric Crohns Start ....................... 97 Humira Pen ................................................... 97 Humira Pen-CD/UC/HS Starter ..................... 97 Humira Pen-Ps/UV Starter ............................ 97 HumuLIN 70/30 ............................................. 32 HumuLIN 70/30 KwikPen .............................. 32 HumuLIN N ................................................... 32 HumuLIN N KwikPen ..................................... 32

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HumuLIN R ................................................... 32 HumuLIN R U-500 (CONCENTRATED) ....... 32 HumuLIN R U-500 KwikPen.......................... 32 Hycamtin ....................................................... 60 HydrALAZINE HCl ...................................... 107 Hydrea .......................................................... 60 HydroCHLOROthiazide ................................. 99 Hydrocod Polst-CPM Polst ER ...................... 69 Hydrocodone-Acetaminophen ....................... 11 Hydrocodone-Homatropine ........................... 69 Hydrocodone-Ibuprofen ................................ 11 Hydrocortisone .......................................... 4, 49 Hydrocortisone Ace-Pramoxine .............. 49, 66 Hydrocortisone Acetate ................................. 49 Hydrocortisone Butyr Lipo Base .................... 49 Hydrocortisone Butyrate ............................... 49 Hydrocortisone Valerate ............................... 50 Hydrocortisone-Acetic Acid ........................... 52 Hydrocortisone-Iodoquinol ............................ 46 Hydromet ...................................................... 69 HYDROmorphone HCl .................................. 11 Hydroxychloroquine Sulfate .......................... 65 Hydroxyurea .................................................. 60 HydrOXYzine HCl ......................................... 76 HydrOXYzine Pamoate ................................. 76 Hylatopic Plus ............................................. 136 Hyophen...................................................... 142 Hyoscyamine Sulfate .............................. 24, 25 Hyoscyamine Sulfate ER .............................. 25 Hyoscyamine Sulfate SL ............................... 25 Hyosyne ........................................................ 25 HyperRHO S/D ........................................... 134 HyperSal ..................................................... 111 Hyzaar ........................................................ 130

I

Ibandronate Sodium ...................................... 80 Ibrance .......................................................... 60 IBU .................................................................. 8 Ibudone ......................................................... 11 Ibuprofen ......................................................... 8 Ibuprofen Comfort Pac .................................... 8 IC 400 ............................................................. 8 IC 800 ............................................................. 8 Iclusig ............................................................ 60 IDHIFA .......................................................... 60 Ilaris ................................................................ 7 Ilevro ............................................................. 54 Imatinib Mesylate .......................................... 60 Imbruvica ...................................................... 60

Imipramine HCl ........................................... 124 Imipramine Pamoate ................................... 124 Imiquimod .................................................... 136 Imitrex ........................................................... 57 Imitrex STATdose Refill ................................. 57 Imitrex STATdose System ............................. 57 Imuran ......................................................... 108 Inatal GT ..................................................... 113 Indapamide ................................................... 99 Inderal LA ...................................................... 79 Inderal XL ...................................................... 79 Indocin ............................................................. 8 Indomethacin ................................................... 9 Indomethacin ER ............................................. 9 Infanate Balance ......................................... 113 Infed .............................................................. 18 Infuvite Adult ............................................... 113 Infuvite Pediatric .......................................... 113 Inlyta .............................................................. 60 InnoPran XL .................................................. 79 Inova ............................................................. 46 Inova 4/1 Acne Control Therapy .................... 46 Inova 8/2 Acne Control Therapy .................... 46 Inspra .......................................................... 132 Integra F ........................................................ 18 Integra Plus ................................................... 18 Intelence ........................................................ 72 Intermezzo .................................................... 76 Introvale ........................................................ 91 Intuniv ............................................................ 88 Invega ......................................................... 127 Invega Sustenna ......................................... 127 Invirase .......................................................... 72 Invokamet ...................................................... 33 Invokamet XR ................................................ 33 Invokana ........................................................ 33 IODOQUIMEZ-HC ......................................... 46 Iodoquinol-HC-Aloe Polysacch ...................... 46 Iodoquinol-Hydrocortisone-Aloe .................... 46 Iopidine .......................................................... 99 Ipratropium Bromide ...................................... 25 Ipratropium-Albuterol ................................... 139 Irbesartan .................................................... 130 Irbesartan-Hydrochlorothiazide ................... 130 Iressa ............................................................ 60 Isentress ........................................................ 72 Isentress HD ................................................. 72 Isibloom ......................................................... 91 Isometheptene-Dichloral-APAP ..................... 57 Isoniazid ........................................................ 58

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Isopto Atropine ............................................ 119 Isopto Carpine ............................................... 38 Isordil Titradose .......................................... 144 Isosorbide Dinitrate ..................................... 144 Isosorbide Dinitrate ER ............................... 144 Isosorbide Mononitrate ............................... 144 Isosorbide Mononitrate ER.......................... 144 ISOtretinoin ................................................. 136 Isoxsuprine HCl ........................................... 146 Isradipine ...................................................... 83 Istalol ............................................................ 37 Itraconazole .................................................. 36 Ivermectin ..................................................... 17 Ixinity ............................................................. 39

J

Jadenu ........................................................ 105 Jadenu Sprinkle .......................................... 105 Jakafi ............................................................ 60 Jalyn ............................................................... 2 Jantoven ....................................................... 68 Janumet ........................................................ 31 Janumet XR .................................................. 31 Januvia ......................................................... 31 Jardiance ...................................................... 33 Jencycla ........................................................ 91 Jentadueto .................................................... 31 Jentadueto XR .............................................. 31 Jevantique Lo .............................................. 101 Jinteli ........................................................... 101 Jolessa .......................................................... 91 Jolivette ......................................................... 91 JTT Physicians ................................................ 4 Jublia ............................................................ 44 Juleber .......................................................... 91 Juluca ........................................................... 72 Junel 1.5/30 .................................................. 91 Junel 1/20 ..................................................... 91 Junel FE 1.5/30 ............................................. 91 Junel FE 1/20 ................................................ 91 Junel Fe 24 ................................................... 91 Juxtapid......................................................... 54

K

Kadian ........................................................... 11 Kaitlib Fe ....................................................... 91 Kalbitor .......................................................... 89 Kaletra .......................................................... 72 Kalydeco ....................................................... 95 Kapvay ........................................................ 107 Karbinal ER ................................................. 103

Kariva ............................................................ 91 Kazano .......................................................... 31 Kcentra .......................................................... 39 Keflex ............................................................ 20 Kelnor 1/35 .................................................... 91 Kenalog ..................................................... 4, 50 Keppra ........................................................... 27 Keppra XR ..................................................... 27 Ketoconazole .......................................... 36, 44 Ketoprofen ....................................................... 9 Ketoprofen ER ................................................. 9 Ketorolac Tromethamine ........................... 9, 54 Khedezla ..................................................... 124 Kimidess ........................................................ 91 Kineret ........................................................... 98 Kionex ......................................................... 109 Kitabis Pak .................................................... 19 Klaron ............................................................ 42 Klofensaid II ................................................ 136 KlonoPIN ....................................................... 29 Klor-Con ...................................................... 132 Klor-Con M10 .............................................. 132 Klor-Con M15 .............................................. 132 Klor-Con M20 .............................................. 132 Klor-Con Sprinkle ........................................ 132 Koate ............................................................. 40 Koate-DVI ...................................................... 40 Kogenate FS ................................................. 40 Kogenate FS Bio-Set..................................... 40 Kombiglyze XR .............................................. 31 Korlym ........................................................... 30 Kovaltry ......................................................... 40 KP B Complex-C ......................................... 113 KP Folic Acid ............................................... 146 Kristalose ........................................................ 7 Krystexxa ...................................................... 38 K-Tab .......................................................... 133 K-Tan Plus .................................................... 18 Kurvelo .......................................................... 91 Kuvan .......................................................... 120

L

Labetalol HCl ................................................. 79 Lac-Hydrin ..................................................... 99 Lactic Acid ..................................................... 99 Lactulose ......................................................... 7 Lactulose Encephalopathy .............................. 7 LaMICtal ........................................................ 27 LaMICtal ODT ............................................... 27 LaMICtal Starter ............................................ 27

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LaMICtal XR .................................................. 27 LamISIL......................................................... 36 LamiVUDine .................................................. 72 Lamivudine-Zidovudine ................................. 73 LamoTRIgine ................................................ 27 LamoTRIgine ER .......................................... 27 LamoTRIgine Starter Kit-Blue ....................... 27 LamoTRIgine Starter Kit-Green .................... 27 LamoTRIgine Starter Kit-Orange .................. 27 Lanoxin ......................................................... 85 Lansoprazole ................................................ 71 Lanthanum Carbonate ................................ 109 Lantus ........................................................... 32 Lantus SoloStar ............................................ 32 Larin 1.5/30 ................................................... 91 Larin 1/20 ...................................................... 91 Larin 24 FE ................................................... 91 Larin Fe 1.5/30 .............................................. 91 Larin Fe 1/20 ................................................. 91 Larissia ......................................................... 91 Lartruvo ......................................................... 60 Lasix ............................................................. 98 Lastacaft ....................................................... 18 Latanoprost ................................................... 38 Latuda ......................................................... 128 Layolis FE ..................................................... 91 Leena ............................................................ 91 Leflunomide .................................................. 98 Lemtrada ..................................................... 107 Lenvima 10 MG Daily Dose .......................... 60 Lenvima 14 MG Daily Dose .......................... 60 Lenvima 20 MG Daily Dose .......................... 60 Lenvima 24 MG Daily Dose .......................... 60 Lescol XL ...................................................... 56 Lessina ......................................................... 91 Letairis ........................................................ 145 Letrozole ....................................................... 60 Leucovorin Calcium ...................................... 35 Leukeran ....................................................... 60 Leukine ....................................................... 106 Levalbuterol HCl ......................................... 139 Levalbuterol Tartrate ................................... 139 Levaquin ....................................................... 23 Levbid ........................................................... 25 Levemir ......................................................... 32 Levemir FlexTouch ....................................... 32 LevETIRAcetam ............................................ 27 LevETIRAcetam ER ...................................... 28 Levitra ......................................................... 145 Levobunolol HCl ............................................ 37

LevOCARNitine ........................................... 120 Levocetirizine Dihydrochloride .................... 134 LevoFLOXacin ........................................ 23, 42 LevoFLOXacin in D5W .................................. 23 Levonest ........................................................ 91 Levonorgest-Eth Est & Eth Est ...................... 91 Levonorgest-Eth Estrad 91-Day .................... 91 Levonorgestrel-Ethinyl Estrad ................. 91, 92 Levonorg-Eth Estrad Triphasic ...................... 92 Levora 0.15/30 (28) ....................................... 92 Levo-T ......................................................... 140 Levothyroxine Sodium ................................. 140 Levothyroxine-Liothyronine ......................... 140 Levoxyl ........................................................ 141 Levsin ............................................................ 25 Levsin/SL ...................................................... 25 Levulan Kerastick ........................................ 136 Lexapro ....................................................... 124 Lexiva ............................................................ 73 Lialda ............................................................. 50 Librax ............................................................ 25 Lido BDK ....................................................... 66 Lidocaine ....................................................... 66 Lidocaine HCl ........................................ 66, 111 Lidocaine PAK ............................................... 66 Lidocaine Viscous ....................................... 111 Lidocaine-Hydrocortisone Ace ...................... 66 Lidocaine-Prilocaine ...................................... 66 Lidoderm ....................................................... 66 Lido-K ............................................................ 66 Lidolog ............................................................. 4 Lidopin ........................................................... 66 Lidopril ........................................................... 66 Lidopril XR ..................................................... 66 Lido-Prilo Caine Pack .................................... 67 LidoRx ........................................................... 67 Lillow ............................................................. 92 Lincocin ......................................................... 19 Lincomycin HCl ............................................. 19 Lindane ......................................................... 46 Linezolid ........................................................ 19 Linzess ........................................................ 104 Liothyronine Sodium.................................... 141 Lipitor ............................................................ 56 Lipofen .......................................................... 56 LiProZonePak ............................................... 67 Lisinopril ...................................................... 131 Lisinopril-Hydrochlorothiazide ..................... 131 Lithium ........................................................... 57 Lithium Carbonate ......................................... 57

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Lithium Carbonate ER ................................... 57 Lithobid ......................................................... 57 Lithostat .......................................................... 7 Livalo ............................................................ 56 Livixil Pak ...................................................... 67 Lo Loestrin Fe ............................................... 92 Locoid ........................................................... 50 Locoid Lipocream .......................................... 50 Lodosyn ........................................................ 64 Loestrin 1.5/30 (21) ....................................... 92 Loestrin 1/20 (21) .......................................... 92 Loestrin Fe 1.5/30 ......................................... 92 Loestrin Fe 1/20 ............................................ 92 Lomotil .......................................................... 35 Loperamide HCl ............................................ 35 Lopid ............................................................. 56 Lopinavir-Ritonavir ........................................ 73 Lopreeza ..................................................... 101 Lopressor ...................................................... 79 Lopressor HCT .............................................. 79 Loprox ........................................................... 44 LORazepam .................................................. 77 LORazepam Intensol .................................... 77 Lorcet ............................................................ 11 Lorcet HD ...................................................... 11 Lorcet Plus .................................................... 11 Loryna ........................................................... 92 Lorzone ....................................................... 134 Losartan Potassium .................................... 130 Losartan Potassium-HCTZ .......................... 130 LoSeasonique ............................................... 92 Lotemax ........................................................ 52 Lotensin ...................................................... 131 Lotensin HCT .............................................. 131 Lotrel ............................................................. 84 Lotrisone ....................................................... 44 Lotronex ........................................................ 50 Loutrex ........................................................ 110 Lovastatin...................................................... 56 Lovaza .......................................................... 54 Lovenox ........................................................ 68 Low-Ogestrel ................................................. 92 Loxapine Succinate ..................................... 128 Ludent ........................................................... 86 Luliconazole .................................................. 44 Lumigan ........................................................ 38 Lumizyme.................................................... 100 Lunesta ......................................................... 76 Lupaneta Pack .............................................. 61 Lupron Depot (1-Month) ................................ 61

Lupron Depot (3-Month) ................................ 61 Lupron Depot (4-Month) ................................ 61 Lupron Depot (6-Month) ................................ 61 Lupron Depot-Ped (1-Month) ........................ 61 Lupron Depot-Ped (3-Month) ........................ 61 Lutera ............................................................ 92 Luxiq .............................................................. 50 Luzu .............................................................. 44 Lynparza ....................................................... 61 Lyrica ............................................................. 28 Lyrica CR ........................................................ 7 Lysiplex Plus ............................................... 113 Lysodren ....................................................... 61 Lysteda .......................................................... 40 Lyza ............................................................... 92

M

M.V.I. Adult .................................................. 113 M.V.I. Pediatric ............................................ 113 M.V.I.-12 (without Vitamin K) ....................... 113 Macrobid ..................................................... 142 Macrodantin ................................................ 142 Magellan Insulin Safety Syr ........................... 96 Malarone ....................................................... 65 Malathion ....................................................... 46 Maprotiline HCl ............................................ 124 Marinol .......................................................... 35 Marlissa ......................................................... 92 Marnatal-F ................................................... 113 Marplan ....................................................... 124 Matulane ....................................................... 61 Matzim LA ..................................................... 82 Mavyret ......................................................... 74 Maxalt ............................................................ 57 Maxalt-MLT ................................................... 57 MaxFe ........................................................... 18 Maxidex ......................................................... 52 Maxidone ....................................................... 11 Maxitrol .......................................................... 52 Maxzide ......................................................... 99 Maxzide-25 .................................................... 99 ME/NaPhos/MB/Hyo1 ................................. 142 Meclizine HCl ................................................ 36 Meclofenamate Sodium ................................... 9 Medolor Pak .................................................. 67 Medrol ............................................................. 4 MedroxyPROGESTERone Acetate ............. 122 Mefenamic Acid ............................................... 9 Mefloquine HCl .............................................. 65 Megace ES .................................................. 122

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Megestrol Acetate ................................. 61, 122 Mekinist ......................................................... 61 Mektovi ......................................................... 61 Melodetta 24 Fe ............................................ 92 Meloxicam ....................................................... 9 Meloxicam Comfort Pac .................................. 9 Melphalan ..................................................... 61 Memantine HCl ............................................. 88 Memantine HCl ER ....................................... 88 Menest ........................................................ 101 Menopur ...................................................... 105 Menostar ..................................................... 102 Mentax .......................................................... 44 Me-PB-Hyos .................................................. 25 Meperidine HCl ............................................. 11 Mephyton .................................................... 147 Meprobamate ................................................ 76 Mepron .......................................................... 66 Mercaptopurine ............................................. 61 Mesalamine ................................................... 50 Mesalamine-Cleanser ................................... 50 Mesnex ....................................................... 123 Mestinon ..................................................... 121 Metadate ER ................................................. 16 Metaproterenol Sulfate ................................ 139 Metaxall....................................................... 134 Metaxalone ................................................. 134 MetFORMIN HCl ........................................... 30 MetFORMIN HCl ER ..................................... 30 MetFORMIN HCl ER (MOD) ......................... 30 MetFORMIN HCl ER (OSM) ......................... 30 Methamphetamine HCl ................................. 15 MethazolAMIDE ............................................ 38 Methenamine Hippurate .............................. 142 Methenamine Mandelate............................. 142 MethIMAzole ............................................... 140 Methocarbamol ........................................... 134 Methotrexate ................................................. 61 Methotrexate Sodium .................................... 61 Methotrexate Sodium (PF) ............................ 61 Methoxsalen .................................................. 96 Methoxsalen Rapid ....................................... 96 Methscopolamine Bromide............................ 25 Methyclothiazide ........................................... 99 Methyldopa ................................................. 107 Methyldopa-Hydrochlorothiazide ................. 107 Methylin......................................................... 16 Methylphenidate HCl ..................................... 16 Methylphenidate HCl ER ............................... 17 Methylphenidate HCl ER (CD) ...................... 17

Methylphenidate HCl ER (LA) ....................... 17 MethylPREDNISolone ..................................... 4 MethylPREDNISolone Acetate ........................ 4 MethylPREDNISolone Sodium Succ ............... 4 Metipranolol ................................................... 37 Metoclopramide HCl .................................... 122 MetOLazone .................................................. 99 Metoprolol Succinate ER ............................... 79 Metoprolol Tartrate ........................................ 79 Metoprolol-HCTZ ER ..................................... 79 Metoprolol-Hydrochlorothiazide ..................... 79 MetroCream .................................................. 42 Metrogel ........................................................ 42 MetroGel-Vaginal .......................................... 42 MetroLotion ................................................... 42 MetroNIDAZOLE ............................... 42, 43, 66 Mexiletine HCl ............................................... 85 Mezparox-HC ................................................ 50 Miacalcin ..................................................... 121 Mibelas 24 Fe ................................................ 92 Micardis ....................................................... 130 Micardis HCT .............................................. 130 Miconazole 3 ................................................. 44 MICRhoGAM Ultra-Filtered Plus ................. 134 Microgestin 1.5/30 ......................................... 92 Microgestin 1/20 ............................................ 92 Microgestin FE 1.5/30 ................................... 92 Microgestin FE 1/20 ...................................... 92 Micro-K ........................................................ 133 Microzide ....................................................... 99 Midazolam HCl .............................................. 77 Midodrine HCl ............................................. 139 Migergot ........................................................ 57 Miglitol ........................................................... 30 Miglustat ...................................................... 120 Migranal ...................................................... 138 Milco-B-Forte ............................................... 113 Millipred ........................................................... 4 Millipred DP ..................................................... 4 Millipred DP 12-Day ........................................ 4 Mimvey ........................................................ 102 Mimvey Lo ................................................... 102 Minastrin 24 Fe ............................................. 92 Minipress ......................................................... 6 Minitran ....................................................... 144 Minivelle ...................................................... 102 Minocin .......................................................... 24 Minocycline HCl ............................................ 24 Minocycline HCl ER..................................... 136 Minoxidil ...................................................... 107

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Miochol-E ...................................................... 38 Miostat .......................................................... 38 Mirapex ......................................................... 64 Mirapex ER ................................................... 64 Mircera ........................................................ 106 Mircette ......................................................... 92 Mirtazapine ................................................. 124 Mirvaso ....................................................... 136 MiSOPROStol ............................................... 70 Mitosol .......................................................... 43 MLK F1 ........................................................... 4 MLK F2 ........................................................... 4 MLK F3 ........................................................... 4 MLP A-1 .......................................................... 4 Mobic .............................................................. 9 Modafinil........................................................ 17 Moderiba ....................................................... 75 Moderiba 1200 Dose Pack ............................ 75 Moderiba 800 Dose Pack .............................. 75 Moexipril HCl ............................................... 131 Moexipril-Hydrochlorothiazide ..................... 131 Mometasone Furoate .............................. 50, 52 Mondoxyne NL .............................................. 24 Monoclate-P .................................................. 40 Monoject Insulin Syringe ............................... 96 Monoject Ultra Comfort Syringe .................... 96 Mono-Linyah ................................................. 92 MonoNessa ................................................... 92 Mononine ...................................................... 40 Montelukast Sodium ..................................... 54 Monurol ....................................................... 142 Morgidox ....................................................... 24 Morphine Sulfate ........................................... 11 Morphine Sulfate (Concentrate) .................... 12 Morphine Sulfate ER ..................................... 12 Morphine Sulfate ER Beads .......................... 12 Motofen ......................................................... 35 MoviPrep ....................................................... 87 Moxatag ........................................................ 22 Moxeza ......................................................... 43 Moxifloxacin HCl ..................................... 23, 43 MS Contin ..................................................... 12 Multaq ........................................................... 85 Multi-Specialty ................................................. 4 Multi-Vit/Fluoride ......................................... 113 Multi-Vit/Fluoride/Iron .................................. 113 Multi-Vit/Iron/Fluoride .................................. 113 Multivitamin/Fluoride ................................... 113 Multi-Vitamin/Fluoride ................................. 113 Multivitamin/Fluoride/Iron ............................ 113

Multi-Vitamin/Fluoride/Iron .......................... 113 Multivitamins/Fluoride .................................. 113 Mupirocin ....................................................... 43 Mupirocin Calcium ......................................... 43 MVC-Fluoride .............................................. 113 M-Vit ............................................................ 114 Myalept ........................................................ 111 Myambutol ..................................................... 58 Mycobutin ...................................................... 58 Mycophenolate Mofetil ................................ 108 Mycophenolate Mofetil HCl ......................... 108 Mycophenolate Sodium ............................... 108 Mydriacyl ..................................................... 119 Myfortic ........................................................ 108 Myleran ......................................................... 61 Mynatal ........................................................ 114 Mynatal Advance ......................................... 114 Mynatal Plus ................................................ 114 Mynatal-Z .................................................... 114 Mynate 90 Plus ........................................... 114 Mynephrocaps ............................................. 114 Mynephron .................................................. 114 Myorisan ...................................................... 136 Myrbetriq ..................................................... 104 Mysoline ........................................................ 29 Mytesi ............................................................ 35 Myzilra ........................................................... 92

N

Na Ferric Gluc Cplx in Sucrose ..................... 18 Nabumetone .................................................... 9 Nadolol .......................................................... 79 Nadolol-Bendroflumethiazide ........................ 79 NaFrinse Daily/Neutral .................................. 86 NaFrinse Drops ............................................. 86 NaFrinse Weekly ........................................... 86 Naftifine HCl .................................................. 44 Naftin ............................................................. 44 Naglazyme .................................................. 100 Nalbuphine HCl ............................................. 14 Nalfon .............................................................. 9 Nalfrx ........................................................... 103 Naloxone HCl .............................................. 120 Namenda ....................................................... 88 Namenda Titration Pak .................................. 88 Namenda XR ................................................. 88 Namenda XR Titration Pack .......................... 88 Naprelan .......................................................... 9 Naprosyn ......................................................... 9 Naproxen ......................................................... 9

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Naproxen Comfort Pac ................................... 9 Naproxen DR .................................................. 9 Naproxen Sodium ........................................... 9 Naproxen Sodium ER ..................................... 9 Naratriptan HCl ............................................. 57 Nardil .......................................................... 124 Nasonex ........................................................ 52 NataChew ................................................... 114 Natacyn ......................................................... 44 Natalvit ........................................................ 114 Natazia .......................................................... 93 Nateglinide .................................................... 33 Natelle ONE ................................................ 114 Natroba ......................................................... 46 Nature-Throid .............................................. 141 Nebusal ....................................................... 111 Necon 0.5/35 (28) ......................................... 93 Necon 7/7/7 ................................................... 93 Neevo DHA ................................................. 114 Nefazodone HCl .......................................... 124 Neocera ...................................................... 137 Neomycin Sulfate .......................................... 19 Neomycin-Bacitracin Zn-Polymyx ................. 43 Neomycin-Polymyxin-Dexameth ................... 53 Neomycin-Polymyxin-Gramicidin .................. 43 Neomycin-Polymyxin-HC .............................. 53 Neo-Polycin ................................................... 43 Neo-Polycin HC ............................................ 53 Neoral ......................................................... 108 Neosalus ............................................... 99, 137 Neosalus CP ............................................... 137 Neosporin...................................................... 43 NeoTuss Plus ................................................ 69 Nephplex Rx ............................................... 114 Nephrocaps ................................................. 114 Nephronex .................................................. 114 Nephro-Vite Rx ........................................... 114 Neptazane..................................................... 38 Nerlynx .......................................................... 61 Nesina ........................................................... 31 Nestabs ....................................................... 114 Nestabs ABC .............................................. 114 Nestabs DHA .............................................. 114 Neuac ........................................................... 43 Neulasta ...................................................... 106 Neulasta Onpro ........................................... 106 Neupogen ................................................... 106 Neupro .......................................................... 64 Neurin-SL .................................................... 146 Neurontin ...................................................... 28

NeutraGard Advanced ................................... 86 Neutral Sodium Fluoride ................................ 86 Nevanac ........................................................ 54 Nevirapine ..................................................... 73 Nevirapine ER ............................................... 73 Newgen ....................................................... 114 Nexa Plus .................................................... 114 NexAVAR ...................................................... 61 NexIUM ......................................................... 71 Niacin .......................................................... 146 Niacin ER (Antihyperlipidemic) ...................... 54 Niacor .......................................................... 146 Niaspan ......................................................... 55 Nicadan ....................................................... 114 Nicadan ZX ................................................. 114 NiCARdipine HCl ........................................... 84 Nicazel ........................................................ 114 NicAzel Forte ............................................... 114 Nicomide ..................................................... 114 Nicotrol .......................................................... 78 Nicotrol NS .................................................... 78 NIFEdipine .................................................... 84 NIFEdipine ER .............................................. 84 NIFEdipine ER Osmotic Release .................. 84 Nikki .............................................................. 93 Nilandron ....................................................... 61 Nilutamide ..................................................... 61 NiMODipine ................................................... 84 Ninlaro ........................................................... 61 Nisoldipine ER ............................................... 84 Nitro-Bid ...................................................... 144 Nitro-Dur ...................................................... 144 Nitrofurantoin ............................................... 142 Nitrofurantoin Macrocrystal ......................... 142 Nitrofurantoin Monohyd Macro .................... 142 Nitroglycerin ................................................ 144 Nitroglycerin ER .......................................... 144 Nitrolingual .................................................. 144 NitroMist ...................................................... 145 Nitrostat ....................................................... 145 Nitro-Time ................................................... 145 Niva-Plus ..................................................... 114 Nivatopic Plus ............................................. 137 Nizatidine ...................................................... 70 Nizoral ........................................................... 44 Nolix .............................................................. 50 Nora-BE ........................................................ 93 Norco ............................................................. 12 Norethin Ace-Eth Estrad-FE .......................... 93 Norethindrone ............................................... 93

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Norethindrone Acetate ................................ 122 Norethindrone Acet-Ethinyl Est ..................... 93 Norethindrone-Eth Estradiol ........................ 102 Norethin-Eth Estradiol-Fe ............................. 93 Norgestimate-Eth Estradiol ........................... 93 Norgestim-Eth Estrad Triphasic .................... 93 Noritate ......................................................... 43 Norlyroc......................................................... 93 Norpace ........................................................ 85 Norpace CR .................................................. 85 Norpramin ................................................... 125 Northera ...................................................... 139 Nortrel 0.5/35 (28) ......................................... 93 Nortrel 1/35 (21) ............................................ 93 Nortrel 1/35 (28) ............................................ 93 Nortrel 7/7/7 .................................................. 93 Nortriptyline HCl .......................................... 125 Nortuss-DE ................................................... 69 Nortuss-Ex .................................................... 69 Norvasc ......................................................... 84 Norvir ............................................................ 73 Novarel ....................................................... 105 Novoeight ...................................................... 40 NovoLIN 70/30 .............................................. 32 NovoLIN 70/30 ReliOn .................................. 32 NovoLIN N .................................................... 32 NovoLIN N ReliOn ........................................ 32 NovoLIN R .................................................... 32 NovoLIN R ReliOn ........................................ 32 NovoLOG ...................................................... 33 NovoLOG FlexPen ........................................ 33 NovoLOG Mix 70/30 ..................................... 33 NovoLOG Mix 70/30 FlexPen ....................... 33 NovoLOG PenFill .......................................... 33 NovoSeven RT .............................................. 40 Noxafil ........................................................... 36 NP Thyroid .................................................. 141 Nplate ......................................................... 106 NuCort .......................................................... 50 Nucynta ......................................................... 12 Nucynta ER ................................................... 12 NuFol .......................................................... 146 NuLev ........................................................... 25 Nulojix ......................................................... 108 Nulytely with Flavor Packs ............................ 87 Nuplazid ...................................................... 128 Nutraseb ..................................................... 110 Nutricap....................................................... 114 NutriDox ........................................................ 24 Nutrifac ZX .................................................. 114

Nutrivit ......................................................... 114 NuvaRing ...................................................... 93 Nuwiq ............................................................ 40 Nymalize ....................................................... 84 Nystatin ................................................... 37, 44 Nystatin-Triamcinolone .................................. 50

O

OB Complete ............................................... 114 OB Complete One ....................................... 114 OB Complete Petite..................................... 114 OB Complete Premier ................................. 114 OB Complete/DHA ...................................... 114 Obizur ............................................................ 40 Obstetrix DHA ............................................. 114 Obstetrix EC ................................................ 114 Obstetrix One .............................................. 114 O-Cal FA ..................................................... 114 O-Cal Prenatal ............................................ 115 Ocella ............................................................ 93 Ocuflox .......................................................... 43 Ocuvel ......................................................... 115 Odefsey ......................................................... 73 Ofev ............................................................. 133 Ofloxacin ................................................. 23, 43 Ogestrel ......................................................... 93 Okebo ............................................................ 24 OLANZapine ............................................... 128 OLANZapine-FLUoxetine HCl ..................... 125 Olmesartan Medoxomil ............................... 130 Olmesartan Medoxomil-HCTZ ..................... 130 Olmesartan-Amlodipine-HCTZ ...................... 84 Olopatadine HCl ............................................ 18 Olux ............................................................... 50 Olux-E ........................................................... 50 Omeclamox-Pak ............................................ 71 Omega-3-acid Ethyl Esters ........................... 55 OmePPi ......................................................... 71 Omeprazole ................................................... 71 Omeprazole+Syrspend SF Alka .................... 71 Omeprazole-Sodium Bicarbonate ................. 71 Omnaris ......................................................... 53 Omnipred ...................................................... 53 Ondansetron ................................................. 35 Ondansetron HCl .......................................... 35 Onfi ................................................................ 29 Onglyza ......................................................... 31 Onmel ............................................................ 36 Opsumit ....................................................... 145 Oracea ........................................................ 137

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Oracit .............................................................. 6 Oralone ......................................................... 50 Orapred ODT .................................................. 4 Orencia ......................................................... 98 Orencia ClickJect .......................................... 98 Orenitram .................................................... 145 Orfadin ........................................................ 120 Orphenadrine Citrate .................................. 135 Orphenadrine Citrate ER ............................ 135 Orsythia......................................................... 93 Ortho Tri-Cyclen (28) .................................... 93 Ortho Tri-Cyclen Lo ....................................... 93 Ortho-Cyclen (28) ......................................... 94 Ortho-Novum 1/35 (28) ................................. 94 Ortho-Novum 7/7/7 (28) ................................ 94 Oscimin ......................................................... 25 Oscimin SR ................................................... 25 Oseltamivir Phosphate .................................. 74 Oseni ............................................................ 31 Otezla ........................................................... 98 Oticin HC NR ................................................ 53 Otomax-HC ................................................... 53 Otrexup ......................................................... 98 Ovide ............................................................ 46 Ovidrel ........................................................ 105 Oxaprozin........................................................ 9 Oxazepam..................................................... 77 OXcarbazepine ............................................. 28 Oxiconazole Nitrate ....................................... 44 Oxistat ........................................................... 44 Oxsoralen Ultra ............................................. 96 Oxtellar XR .................................................... 28 Oxybutynin Chloride .................................... 104 Oxybutynin Chloride ER .............................. 104 OxyCODONE HCl ......................................... 12 OxyCODONE HCl ER ................................... 12 Oxycodone-Acetaminophen .................... 12, 13 Oxycodone-Aspirin ........................................ 13 Oxycodone-Ibuprofen ................................... 13 OxyCONTIN .................................................. 13 Ozurdex ........................................................ 53

P

Pacerone....................................................... 85 Paliperidone ER .......................................... 128 Pamelor....................................................... 125 Pancreaze ..................................................... 97 Pandel ........................................................... 50 Panretin....................................................... 137 Pantoprazole Sodium .................................... 71

Paricalcitol ................................................... 147 Parlodel ......................................................... 64 Parnate ........................................................ 125 Paroex ........................................................... 45 Paromomycin Sulfate .................................... 65 PARoxetine HCl .......................................... 125 PARoxetine HCl ER .................................... 125 Paser ............................................................. 58 Pataday ......................................................... 18 Patanase ....................................................... 18 Patanol .......................................................... 18 Paxil ............................................................ 125 Paxil CR ...................................................... 125 PB-Hyoscy-Atropine-Scopolamine ................ 25 PCE ............................................................... 21 Pediapred ........................................................ 4 PEG 3350/Electrolytes .................................. 87 PEG 3350-KCl-Na Bicarb-NaCl ..................... 87 PEG-3350/Electrolytes .................................. 87 Peganone ...................................................... 29 Pegasys ........................................................ 74 Pegasys ProClick .......................................... 74 PegIntron ....................................................... 74 PEGyLAX ...................................................... 87 Penicillin G Procaine ..................................... 22 Penicillin V Potassium ................................... 22 Penlac ........................................................... 44 Pennsaid ..................................................... 137 Pentasa ......................................................... 50 Pentazocine-Naloxone HCl ........................... 14 Pentetate Calcium Trisodium ...................... 105 Pentetate Zinc Trisodium ............................ 105 Pentoxifylline ER ......................................... 106 Pepcid ........................................................... 70 Percocet ........................................................ 13 Perforomist .................................................. 140 Peridex .......................................................... 45 Perindopril Erbumine ................................... 131 Periogard ....................................................... 45 Permethrin ..................................................... 46 Perphenazine .............................................. 128 Perphenazine-Amitriptyline ......................... 125 Pertzye .......................................................... 97 Pexeva ........................................................ 125 Phenadoz .................................................... 103 Phenazo ........................................................ 67 Phenazopyridine HCl ..................................... 67 Phendimetrazine Tartrate .............................. 16 Phendimetrazine Tartrate ER ........................ 16 Phenelzine Sulfate ...................................... 125

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Phenergan .................................................. 103 PHENobarbital .............................................. 76 Phenobarbital-Belladonna Alk ....................... 25 Phenohytro.................................................... 25 Phenoxybenzamine HCl.............................. 138 Phentermine HCl ........................................... 16 Phenyleph-Promethazine-Cod ...................... 69 Phenylephrine-Guaifenesin ......................... 102 Phenytek ....................................................... 29 Phenytoin ...................................................... 29 Phenytoin Infatabs ........................................ 29 Phenytoin Sodium ......................................... 29 Phenytoin Sodium Extended ......................... 29 Philith ............................................................ 94 Phos-Flur ...................................................... 86 Phoslyra ...................................................... 133 Phosphasal ................................................. 142 Phospholine Iodide ....................................... 38 Phrenilin Forte ................................................. 7 Physicians EZ Use Joint/Tunnel ..................... 4 Physicians EZ Use M-Pred ............................. 4 Phytonadione .............................................. 147 Picato .......................................................... 137 Pilocarpine HCl ............................................. 38 Pimtrea ......................................................... 94 Pindolol ......................................................... 79 Pioglitazone HCl ........................................... 34 Pioglitazone HCl-Glimepiride ........................ 34 Pioglitazone HCl-Metformin HCl ................... 34 Pirmella 1/35 ................................................. 94 Pirmella 7/7/7 ................................................ 94 Piroxicam ........................................................ 9 Plaquenil ....................................................... 65 Plavix ............................................................ 68 Plegridy ......................................................... 74 Plegridy Starter Pack .................................... 74 Plexion ........................................................ 110 Plexion Cleanser ......................................... 110 Plexion Cleansing Cloth .............................. 110 Pneumovax 23 ............................................ 143 PNV Folic Acid + Iron .................................. 115 PNV OB+DHA ............................................. 115 PNV Prenatal Plus Multivitamin .................. 115 PNV Tabs 29-1 ........................................... 115 PNV-DHA .................................................... 115 PNV-DHA Plus ............................................ 115 PNV-DHA+Docusate ................................... 115 PNV-Omega ................................................ 115 PNV-Select ................................................. 115 PNV-Total ................................................... 115

Podocon ...................................................... 137 Podofilox ..................................................... 137 Polycin ........................................................... 43 Polyethylene Glycol 3350 .............................. 87 Polymyxin B-Trimethoprim ............................ 43 Polytrim ......................................................... 43 Poly-Vi-Flor ................................................. 115 Poly-Vi-Flor FS ............................................ 115 Poly-Vi-Flor/Iron .......................................... 115 Pomalyst ....................................................... 61 Portia-28 ........................................................ 94 Portrazza ....................................................... 61 Pot & Sod Cit-Cit Ac ........................................ 6 Potassium Chloride Crys ER ....................... 133 Potassium Chloride ER ............................... 133 Potassium Citrate ER ...................................... 6 Potassium Citrate Monohydrate ...................... 6 Potassium Citrate-Citric Acid ........................... 6 PR Benzoyl Peroxide Wash .......................... 46 PR Natal 400 ............................................... 115 PR Natal 400 ec .......................................... 115 PR Natal 430 ............................................... 115 PR Natal 430 ec .......................................... 115 Pradaxa ......................................................... 68 PramCort ....................................................... 67 Pramipexole Dihydrochloride ........................ 64 Pramipexole Dihydrochloride ER .................. 64 Pramosone .................................................... 50 Pramosone E ................................................ 50 PramOtic ..................................................... 111 Prandin .......................................................... 33 Prasugrel HCl ................................................ 68 Pravachol ...................................................... 56 Pravastatin Sodium ....................................... 56 Praziquantel .................................................. 17 Prazosin HCl ................................................... 6 Precose ......................................................... 30 Pred Forte ..................................................... 53 Pred Mild ....................................................... 53 Pred-G ........................................................... 53 Pred-G S.O.P. ............................................... 53 Prednicarbate ................................................ 50 PrednisoLONE ................................................ 4 PrednisoLONE Acetate ................................. 53 PrednisoLONE Sodium Phosphate ....... 4, 5, 53 PredniSONE .................................................... 5 PredniSONE Intensol ...................................... 5 PreferaOB +DHA ......................................... 115 PreferaOB One ........................................... 115 Prefest ......................................................... 102

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Pregnyl ........................................................ 105 Premarin ..................................................... 102 Premium Lidocaine ....................................... 67 Premphase .................................................. 102 Prempro ...................................................... 102 Prena1 ........................................................ 115 Prena1 Pearl ............................................... 115 Prenaissance .............................................. 115 Prenaissance Balance ................................ 115 Prenaissance Harmony DHA ...................... 115 Prenaissance Next ...................................... 115 Prenaissance Next-B .................................. 115 Prenaissance Plus ...................................... 116 PreNata ....................................................... 116 Prenatabs Rx .............................................. 116 Prenatal....................................................... 116 Prenatal 19.................................................. 116 Prenatal Plus ............................................... 116 Prenatal Plus Iron ....................................... 116 Prenatal Vitamin Plus Low Iron ................... 116 Prenatal-U ................................................... 116 Prenate ....................................................... 116 Prenate AM ................................................. 116 Prenate DHA ............................................... 116 Prenate Elite ............................................... 116 Prenate Enhance ........................................ 116 Prenate Essential ........................................ 116 Prenate Mini ................................................ 116 Prenate Pixie ............................................... 116 Prenate Restore .......................................... 116 PrePLUS ..................................................... 116 Prepopik ........................................................ 87 PreTAB ....................................................... 116 Prevacid ........................................................ 71 Prevacid SoluTab .......................................... 71 Prevalite ........................................................ 55 PreviDent ...................................................... 86 PreviDent 5000 Booster ................................ 86 PreviDent 5000 Booster Plus ........................ 86 PreviDent 5000 Dry Mouth ............................ 86 PreviDent 5000 Enamel Protect .................... 95 PreviDent 5000 Plus ..................................... 86 PreviDent 5000 Sensitive .............................. 95 Previfem ........................................................ 94 Prevnar 13 .................................................. 143 Prevpac ......................................................... 71 Prezista ......................................................... 73 Priftin ............................................................. 58 Prilolid ........................................................... 67 PriLOSEC ..................................................... 71

Priloxx LP ...................................................... 67 Primaquine Phosphate .................................. 65 Primidone ...................................................... 29 Primlev .......................................................... 13 Primsol ........................................................ 142 Prinivil .......................................................... 131 Pristiq .......................................................... 125 Pro Comfort Pen Needles ............................. 96 ProAir HFA .................................................. 140 ProAir RespiClick ........................................ 140 Probenecid .................................................. 142 Procardia ....................................................... 84 Procardia XL ................................................. 84 ProCentra ...................................................... 15 Prochlorperazine ......................................... 128 Prochlorperazine Edisylate .......................... 128 Prochlorperazine Maleate ........................... 128 ProCort .......................................................... 67 Procrit .......................................................... 106 Proctocort ...................................................... 50 Proctofoam HC .............................................. 67 Procto-Med HC ............................................. 50 Procto-Pak .................................................... 50 Proctosol HC ................................................. 50 Proctozone-HC .............................................. 50 Procysbi ...................................................... 120 Proferrin-Forte ............................................... 18 Profilnine ....................................................... 40 Profilnine SD ................................................. 40 Progesterone ............................................... 122 Progesterone Micronized ............................ 122 Proglycem ..................................................... 41 Prograf ........................................................ 109 Prolensa ........................................................ 54 Prolia ............................................................. 80 Promacta ..................................................... 106 Promethazine HCl ....................................... 103 Promethazine VC Plain ............................... 103 Promethazine VC/Codeine ............................ 69 Promethazine-Codeine .................................. 69 Promethazine-DM ......................................... 69 Promethazine-Phenyleph-Codeine ............... 69 Promethazine-Phenylephrine ...................... 103 Promethegan ............................................... 103 Prometrium .................................................. 122 Propafenone HCl ........................................... 85 Propafenone HCl ER ..................................... 85 Propantheline Bromide .................................. 25 Propecia ...................................................... 137 Propranolol HCl ............................................. 79

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Propranolol HCl ER ....................................... 80 Propranolol-HCTZ ......................................... 80 Propylthiouracil ........................................... 140 Proscar ........................................................... 2 Protect Plus ................................................. 116 ProtectIron .................................................... 18 Protonix ......................................................... 71 Protopic ....................................................... 137 Protriptyline HCl .......................................... 125 Proventil HFA .............................................. 140 Provera ....................................................... 122 Provida DHA ............................................... 116 Provida OB .................................................. 116 PROzac....................................................... 125 PruClair ....................................................... 137 PruMyx ........................................................ 137 Pseudoeph-Bromphen-DM ........................... 69 Pseudoeph-Chlorphen-Hydrocod .................. 69 Psorcon ......................................................... 50 Pulmicort ......................................................... 5 Pulmicort Flexhaler ......................................... 5 PulmoSal..................................................... 111 Pulmozyme ................................................. 111 PureFe OB Plus .......................................... 116 PureFe Plus .................................................. 18 PureVit DualFe Plus ...................................... 19 Purixan .......................................................... 62 PX B Complex/Vitamin C ............................ 116 Pylera ............................................................ 70 Pyrazinamide ................................................ 58 Pyridium ........................................................ 67 Pyridostigmine Bromide .............................. 121 Pyridostigmine Bromide ER ........................ 121 Pyridoxine HCl ............................................ 146

Q

Qnasl ............................................................ 53 Qnasl Childrens ............................................ 53 Qsymia .......................................................... 16 Qualaquin...................................................... 65 Quartette ....................................................... 94 Quasense...................................................... 94 Quazepam .................................................... 77 Qudexy XR .................................................... 28 Questran ....................................................... 55 Questran Light .............................................. 55 QUEtiapine Fumarate ................................. 128 QUEtiapine Fumarate ER ........................... 128 Quflora Pediatric ......................................... 116 QuilliChew ER ............................................... 17

Quillivant XR ................................................. 17 Quinapril HCl ............................................... 132 Quinapril-Hydrochlorothiazide ..................... 132 QuiNIDine Gluconate .................................... 85 QuiNIDine Gluconate ER .............................. 85 QuiNIDine Sulfate.......................................... 85 QuiNINE Sulfate ............................................ 65 Quinja ............................................................ 45 Qutenza ....................................................... 137 Qutenza (2 Patch) ....................................... 137 Qvar ................................................................ 5 Qvar RediHaler ............................................... 5

R

RABEprazole Sodium .................................... 71 Rajani ............................................................ 94 Raloxifene HCl ............................................ 100 Ramipril ....................................................... 132 Ranexa .......................................................... 85 RaNITidine HCl ............................................. 70 Rapaflo ........................................................ 138 Rapamune ................................................... 109 Rasagiline Mesylate ...................................... 65 Rasuvo .......................................................... 98 Ravicti ............................................................. 7 Rayos .............................................................. 5 Razadyne .................................................... 121 Razadyne ER .............................................. 121 Rea Lo 40 .................................................... 110 Rebetol .......................................................... 75 Rebif ............................................................ 107 Rebif Rebidose ............................................ 107 Rebif Rebidose Titration Pack ..................... 107 Rebif Titration Pack ..................................... 107 Reclast .......................................................... 80 Reclipsen ...................................................... 94 Recombinate ................................................. 40 Recombivax HB .......................................... 144 Refacto .......................................................... 40 Regimex ........................................................ 15 Reglan ......................................................... 122 Regranex ..................................................... 137 Relador Pak .................................................. 67 Relador Pak Plus .......................................... 67 Relagard ........................................................ 46 Relenza Diskhaler ......................................... 74 Relistor ........................................................ 104 Relnate DHA ............................................... 116 Relpax ........................................................... 57 Remeron ..................................................... 125

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Remeron SolTab ......................................... 125 Remigen...................................................... 137 Remodulin ................................................... 145 Renagel ...................................................... 109 Renal .......................................................... 116 Renatabs..................................................... 116 Renatabs with Iron ........................................ 19 Reno Caps .................................................. 116 Renvela ....................................................... 109 Repaglinide ................................................... 33 Repaglinide-Metformin HCl ........................... 33 REQ 49+ ..................................................... 116 Requip .......................................................... 64 Requip XL ..................................................... 65 Rescriptor...................................................... 73 Rescula ......................................................... 99 Restasis ........................................................ 54 Restasis Multidose ........................................ 54 Restoril .......................................................... 77 Retin-A .......................................................... 87 Retin-A Micro ................................................ 87 Retin-A Micro Pump ...................................... 87 Retisert ......................................................... 53 Retrovir ......................................................... 73 Revatio ........................................................ 145 Revlimid ........................................................ 62 Reyataz ......................................................... 73 RhoGAM Ultra-Filtered Plus ........................ 134 Rhophylac ................................................... 134 RiaSTAP ....................................................... 40 Riax ............................................................... 46 Ribasphere .................................................... 75 Ribasphere RibaPak ..................................... 75 Ribavirin ........................................................ 75 Ridaura ....................................................... 104 Rifabutin ........................................................ 58 Rifadin ........................................................... 58 Rifamate........................................................ 58 RifAMPin ....................................................... 58 Rifater ........................................................... 58 RiMANTAdine HCl ........................................ 71 Riomet .......................................................... 30 Risedronate Sodium ..................................... 81 RisperDAL................................................... 128 RisperDAL Consta ...................................... 128 RisperDAL M-TAB ...................................... 128 RisperiDONE .............................................. 128 RisperiDONE M-TAB .................................. 129 Ritalin ............................................................ 17 Ritalin LA....................................................... 17

Ritonavir ........................................................ 73 Rivastigmine ................................................ 121 Rivastigmine Tartrate .................................. 121 Rivelsa .......................................................... 94 Rixubis .......................................................... 40 Rizatriptan Benzoate ..................................... 57 R-Natal OB .................................................. 117 Robaxin ....................................................... 134 Robaxin-750 ................................................ 134 Robinul .......................................................... 25 Robinul-Forte ................................................ 25 Rocaltrol ...................................................... 147 ROPINIRole HCl ........................................... 65 ROPINIRole HCl ER ...................................... 65 Rosadan ........................................................ 43 Rosanil Cleanser ......................................... 110 Rosuvastatin Calcium .................................... 56 Rowasa ......................................................... 50 Roweepra ...................................................... 28 Roxicodone ................................................... 13 Rozerem ........................................................ 76 Rubraca ......................................................... 62 Ruconest ....................................................... 89 Rydapt ........................................................... 62 Rythmol SR ................................................... 85

S

Sabril ............................................................. 28 Safyral ........................................................... 94 Salsalate ......................................................... 9 Samsca ......................................................... 99 Sancuso ........................................................ 35 SandIMMUNE ............................................. 109 Santyl .......................................................... 137 Saphris ........................................................ 129 Savella ........................................................ 102 Savella Titration Pack .................................. 102 Saxenda ........................................................ 31 Scalacort DK ................................................. 50 Scopolamine ................................................. 36 Seasonique ................................................... 94 Seconal ......................................................... 76 Select-OB .................................................... 117 Select-OB+DHA .......................................... 117 Selegiline HCl ................................................ 65 Selzentry ....................................................... 73 Semprex-D .................................................. 134 Se-Natal 19 ................................................. 117 Sensipar ...................................................... 120 Serevent Diskus .......................................... 140

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SEROquel ................................................... 129 SEROquel XR ............................................. 129 Sertraline HCl .............................................. 125 Se-Tan PLUS ................................................ 19 Setlakin ......................................................... 94 Sevelamer Carbonate ................................. 109 SF ................................................................. 86 SF 5000 Plus ................................................ 86 SfRowasa...................................................... 51 Sharobel........................................................ 94 Shohls Modified .............................................. 6 Siderol ......................................................... 117 Sildenafil Citrate .......................................... 145 Silenor ......................................................... 125 Silvadene ...................................................... 46 Silver Sulfadiazine ........................................ 46 Simbrinza ...................................................... 37 Simponi ......................................................... 98 Simponi Aria .................................................. 98 Simulect ...................................................... 109 Simvastatin ................................................... 56 Sinemet ......................................................... 64 Sinemet CR ................................................... 64 Singulair ........................................................ 54 Sirolimus ..................................................... 109 Sirturo ........................................................... 58 Sitavig ........................................................... 75 Sivextro ......................................................... 19 Skelaxin ...................................................... 134 Sklice ............................................................ 46 SM B Super Vitamin Complex ..................... 117 SM B-Complex/Vitamin C ........................... 117 Sod Benz-Sod Phenylacet .............................. 7 Sod Citrate-Citric Acid ..................................... 6 Sodium Ascorbate ....................................... 146 Sodium Chloride ......................................... 111 Sodium Fluoride ...................................... 86, 87 Sodium Phenylbutyrate ................................... 7 Sodium Polystyrene Sulfonate .................... 109 Soliris ............................................................ 89 Solodyn ....................................................... 137 Soltamox ....................................................... 62 Solu-CORTEF ................................................. 5 SOLU-medrol .................................................. 5 Soma .......................................................... 134 Sonata .......................................................... 76 Soriatane..................................................... 137 Sorilux ......................................................... 137 Sorine ........................................................... 80 Sotalol HCl .................................................... 80

Sotalol HCl (AF) ............................................ 80 Sovaldi .......................................................... 74 Spectracef ..................................................... 20 Spinosad ....................................................... 46 Spiriva HandiHaler ........................................ 25 Spiriva Respimat ........................................... 25 Spironolactone ............................................ 132 Spironolactone-HCTZ .................................. 132 Sporanox ....................................................... 36 Sporanox Pulsepak ....................................... 36 Sprintec 28 .................................................... 94 Sprix ................................................................ 9 Sprycel .......................................................... 62 SPS ............................................................. 109 Sronyx ........................................................... 94 SSD ............................................................... 46 SSS 10-5 ..................................................... 110 Stalevo 100 ................................................... 64 Stalevo 125 ................................................... 64 Stalevo 150 ................................................... 64 Stalevo 200 ................................................... 64 Stalevo 50 ..................................................... 64 Stalevo 75 ..................................................... 64 Starlix ............................................................ 33 Stavudine ...................................................... 73 Staxyn ......................................................... 145 Stelara ................................................. 104, 137 Stendra ........................................................ 145 Stimate ........................................................ 122 Stivarga ......................................................... 62 Strattera ........................................................ 88 Stress Formula ............................................ 117 Stribild ........................................................... 73 Stromectol ..................................................... 17 Strovite Forte ............................................... 117 Strovite ONE ............................................... 117 Suboxone ...................................................... 14 Sucraid ........................................................ 100 Sucralfate ...................................................... 70 Sular .............................................................. 84 Sulfacetamide Sodium .................................. 43 Sulfacetamide Sodium (Acne) ....................... 43 Sulfacetamide Sodium-Sulfur ...................... 110 Sulfacetamide Sod-Sulfur Wash ................. 110 Sulfacetamide-Prednisolone ......................... 53 Sulfacetamide-Sulfur in Urea ...................... 110 Sulfacetamide-Sulfur-Sunscreen ................. 110 SulfaCleanse 8/4 ......................................... 110 SulfADIAZINE ............................................... 23 Sulfamethoxazole-Trimethoprim ................... 23

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SulfaSALAzine .............................................. 23 Sulfatrim Pediatric ......................................... 23 Sulfurated Lime ............................................. 46 Sulindac .......................................................... 9 Sumadan..................................................... 111 Sumadan Wash .......................................... 111 Sumadan XLT ............................................. 111 SUMAtriptan .................................................. 58 SUMAtriptan Succinate ................................. 58 SUMAtriptan Succinate Refill ........................ 58 Sumatriptan-Naproxen Sodium ..................... 58 Sumavel DosePro ......................................... 58 Sumaxin ...................................................... 111 Sumaxin CP ................................................ 111 Sumaxin TS ................................................ 111 Sumaxin Wash ............................................ 111 Super B Complex/FA/Vit C.......................... 117 Super B-Complex/Vit C/FA ......................... 117 Supervite ..................................................... 117 Support ....................................................... 117 Support-500 ................................................ 117 Suprax .......................................................... 20 Suprep Bowel Prep Kit .................................. 87 Surmontil ..................................................... 125 Sustiva .......................................................... 73 Sutent ........................................................... 62 Syeda ............................................................ 94 Sylatron ......................................................... 62 Symax Duotab .............................................. 25 Symax-SL ..................................................... 25 Symax-SR ..................................................... 25 Symbicort ........................................................ 5 Symbyax ..................................................... 125 Symdeko ....................................................... 95 Symfi ............................................................. 73 Symfi Lo ........................................................ 73 SymlinPen 120 .............................................. 30 SymlinPen 60 ................................................ 30 Synagex ...................................................... 117 Synalar .......................................................... 51 Synalar (Cream) ............................................ 51 Synalar (Ointment) ........................................ 51 Synalar TS .................................................... 51 Synarel ........................................................ 105 SynaTek ...................................................... 117 Synjardy ........................................................ 33 Synjardy XR .................................................. 33 Synribo .......................................................... 62 Synthroid ..................................................... 141

T

Tabloid .......................................................... 62 Taclonex ........................................................ 51 Tacrolimus ........................................... 109, 137 Tadalafil ....................................................... 145 Tadalafil (PAH) ............................................ 145 Tafinlar .......................................................... 62 Tagrisso ........................................................ 62 Taltz ............................................................ 137 Tamiflu .......................................................... 74 Tamoxifen Citrate .......................................... 62 Tamsulosin HCl ........................................... 138 Tandem Plus ................................................. 19 Tanzeum ....................................................... 31 Tapazole ..................................................... 140 Tarceva ......................................................... 62 Targretin ................................................ 62, 137 Tarina FE 1/20 .............................................. 94 Tarka ............................................................. 82 Taron-Bc ..................................................... 117 Taron-C DHA .............................................. 117 Taron-Crystals ................................................. 6 Taron-Prex .................................................. 117 Tasigna ......................................................... 62 Tasmar .......................................................... 63 Tazarotene .................................................. 137 Tazorac ....................................................... 137 Taztia XT ....................................................... 82 Tecentriq ....................................................... 62 Tecfidera ..................................................... 107 TEGretol ........................................................ 28 TEGretol-XR .................................................. 28 Tekturna ...................................................... 132 Tekturna HCT .............................................. 132 Telmisartan ................................................. 130 Telmisartan-Amlodipine ................................. 84 Telmisartan-HCTZ ....................................... 130 Temazepam .................................................. 77 Temodar ........................................................ 62 Temovate ...................................................... 51 Temozolomide ............................................... 62 Tencon ............................................................ 7 Tenivac ........................................................ 142 Tenofovir Disoproxil Fumarate ...................... 73 Tenoretic 100 ................................................ 80 Tenoretic 50 .................................................. 80 Tenormin ....................................................... 80 Tepadina ....................................................... 62 Terazol 7 ....................................................... 45 Terazosin HCl ................................................. 6

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Terbinafine HCl ............................................. 36 Terbutaline Sulfate ...................................... 140 Terconazole .................................................. 45 Tessalon Perles ............................................ 69 Testosterone ................................................. 14 Tetanus-Diphtheria Toxoids Td ................... 142 Tetrabenazine ............................................... 88 Tetracycline HCl ............................................ 24 Tetrix ........................................................... 137 Texacort ........................................................ 51 TexaVite LQ ................................................ 117 Thalomid ..................................................... 107 Theo-24....................................................... 133 Theochron ................................................... 133 Theophylline ................................................ 133 Theophylline ER .......................................... 133 TheraCys .................................................... 144 Thera-Flur-N ................................................. 87 Thiamine HCl .............................................. 146 Thioridazine HCl ......................................... 129 Thiotepa ........................................................ 62 Thiothixene ................................................. 129 Thrivite 19 ................................................... 117 Thrivite Rx ................................................... 117 Thymoglobulin ............................................. 109 Thyrolar-1.................................................... 141 Thyrolar-1/2 ................................................. 141 Thyrolar-1/4 ................................................. 141 Thyrolar-2.................................................... 141 Thyrolar-3.................................................... 141 TiaGABine HCl .............................................. 28 Tiazac ........................................................... 82 Tice BCG .................................................... 144 Tigan ............................................................. 36 Tikosyn ......................................................... 85 Tilia Fe .......................................................... 94 Timolol Maleate ....................................... 37, 80 Timoptic ........................................................ 37 Timoptic Ocudose ......................................... 37 Timoptic-XE .................................................. 37 Tindamax ...................................................... 66 Tinidazole...................................................... 66 Tirosint ........................................................ 141 Tivicay ........................................................... 73 TiZANidine HCl ........................................... 135 TL Folate ..................................................... 117 TL G-Fol OS ................................................ 117 TL-Care DHA .............................................. 117 TL-Fluorivite ................................................ 117 TL-Hem 150 .................................................. 19

TL-Select ..................................................... 117 Tobi ............................................................... 19 Tobi Podhaler ................................................ 19 TobraDex ...................................................... 53 TobraDex ST ................................................. 53 Tobramycin ............................................. 19, 43 Tobramycin-Dexamethasone ........................ 53 Tobrex ........................................................... 43 Tofranil ........................................................ 126 TOLAZamide ................................................. 34 TOLBUTamide .............................................. 34 Tolcapone ..................................................... 63 Tolmetin Sodium ............................................. 9 Tolterodine Tartrate ..................................... 104 Tolterodine Tartrate ER ............................... 104 Topamax ....................................................... 28 Topamax Sprinkle ......................................... 28 Topex Topical Anesthetic .............................. 67 Topicort ......................................................... 51 Topicort Spray ............................................... 51 Topiramate .................................................... 28 Topiramate ER .............................................. 28 Toprol XL ....................................................... 80 Torsemide ..................................................... 98 Toviaz .......................................................... 104 Tracleer ....................................................... 145 Tradjenta ....................................................... 31 TraMADol HCl ............................................... 13 TraMADol HCl ER ......................................... 13 TraMADol HCl ER (Biphasic) ........................ 13 Tramadol-Acetaminophen ............................. 13 Trandolapril ................................................. 132 Trandolapril-Verapamil HCl ER ..................... 82 Tranexamic Acid ........................................... 41 Transderm-Scop (1.5 MG) ............................ 36 Tranxene-T .................................................... 77 Tranylcypromine Sulfate .............................. 126 Travatan Z ..................................................... 38 TraZODone HCl .......................................... 126 Trecator ......................................................... 58 Trelstar Mixject .............................................. 62 Tretinoin ............................................ 62, 87, 88 Tretinoin Microsphere .................................... 88 Tretinoin Microsphere Pump ......................... 88 Tretin-X ......................................................... 88 Tretten ........................................................... 41 Trexall ........................................................... 62 Treximet ........................................................ 58 Tri Femynor ................................................... 94 Triamcinolone Acetonide ..................... 5, 51, 53

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Triamterene-HCTZ ........................................ 99 Trianex .......................................................... 51 Triazolam ...................................................... 77 Tribenzor ....................................................... 84 TriCare ........................................................ 117 TriCare Prenatal Compleat ......................... 117 TriCare Prenatal DHA ONE ........................ 117 Tricitrates ........................................................ 6 Tricor ............................................................. 56 Triderm.......................................................... 51 Tridesilon ...................................................... 51 Triesence ...................................................... 53 Tri-Estarylla ................................................... 94 Trifluoperazine HCl ..................................... 129 Trifluridine ..................................................... 45 Triglide .......................................................... 56 Trihexyphenidyl HCl ...................................... 63 Triklo ............................................................. 55 Tri-Legest Fe ................................................. 94 Trileptal ......................................................... 29 Tri-Linyah ...................................................... 94 Trilipix ........................................................... 56 Tri-Lo-Estarylla .............................................. 94 Tri-Lo-Marzia ................................................. 94 Tri-Lo-Sprintec .............................................. 94 Tri-Luma........................................................ 96 TriLyte ........................................................... 87 Trimethobenzamide HCl ............................... 36 Trimethoprim ............................................... 142 Trimipramine Maleate ................................. 126 Trimpex ....................................................... 142 Trinatal Rx 1 ................................................ 117 Trinate ......................................................... 117 TriNessa (28) ................................................ 94 TriNessa Lo ................................................... 95 Tri-Norinyl (28) .............................................. 95 Trintellix....................................................... 126 Triphrocaps ................................................. 117 Tri-Previfem .................................................. 95 Tri-Sprintec ................................................... 95 TriStart DHA ................................................ 117 Tri-Tabs DHA .............................................. 117 Triveen-Duo DHA ........................................ 117 Tri-Vi-Flor .................................................... 118 Tri-Vi-Floro .................................................. 118 Tri-Vit/Fluoride ............................................ 118 Tri-Vit/Fluoride/Iron ..................................... 118 Tri-Vitamin/Fluoride ..................................... 118 Trivora (28) ................................................... 95 Trizivir ........................................................... 73

Trogarzo ........................................................ 73 Trokendi XR .................................................. 29 Tropicamide ................................................ 119 Trospium Chloride ....................................... 104 Trospium Chloride ER ................................. 104 Trulicity .......................................................... 31 Trusopt .......................................................... 38 Truvada ......................................................... 73 Tudorza Pressair ........................................... 25 Tusnel ........................................................... 69 TussiCaps ..................................................... 70 Tussigon ........................................................ 70 Tussionex Pennkinetic ER ............................ 70 Twinrix ......................................................... 144 Twynsta ......................................................... 84 Tykerb ........................................................... 62 Tylenol with Codeine #3 ................................ 13 Tylenol with Codeine #4 ................................ 13 Tysabri ........................................................ 107

U

Uceris .............................................................. 5 Udamin SP .................................................. 118 Ulesfia ........................................................... 46 Uloric ............................................................. 38 UltiCare Insulin Safety Syr ............................ 96 UltimateCare ONE....................................... 118 Ultracet .......................................................... 13 Ultram ............................................................ 13 Ultravate ........................................................ 51 Ultravate X (Cream) ...................................... 51 Ultravate X (Ointment) ................................... 51 Unithroid ...................................................... 141 Unithroid Direct ........................................... 141 Ur N-C ......................................................... 142 Urea ............................................................ 111 Urea-C40 ..................................................... 111 Urecholine ................................................... 121 Urelle ........................................................... 142 Uremez-40 .................................................. 111 Uretron D/S ................................................. 142 Uribel ........................................................... 142 Urimar-T ...................................................... 142 Urin DS ........................................................ 143 Uro-458 ....................................................... 143 UroAv-81 ..................................................... 143 UroAv-B ....................................................... 143 Urocit-K 10 ...................................................... 6 Urocit-K 15 ...................................................... 6 Urocit-K 5 ........................................................ 6

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Urogesic-Blue ............................................. 143 Uro-MP........................................................ 143 Urosex ........................................................ 118 Uroxatral ..................................................... 138 Urso 250 ....................................................... 89 Urso Forte ..................................................... 89 Ursodiol ......................................................... 89 Uryl ............................................................. 143 Ustell ........................................................... 143 Uticap .......................................................... 143 Utira-C ........................................................ 143 Utrona-C ..................................................... 143

V

Vagifem ....................................................... 102 ValACYclovir HCl .......................................... 75 Valchlor ....................................................... 137 Valcyte .......................................................... 75 ValGANciclovir HCl ....................................... 75 Valium ........................................................... 77 Valproate Sodium ......................................... 29 Valproic Acid ................................................. 29 Valsartan ..................................................... 130 Valsartan-Hydrochlorothiazide .................... 130 Valstar ........................................................... 62 Valtrex ........................................................... 75 Vanatol LQ ...................................................... 7 Vanatol S ........................................................ 7 Vancocin HCl ................................................ 19 Vancomycin HCl ........................................... 19 Vandazole ..................................................... 43 Vanos ............................................................ 51 Vanoxide-HC ................................................. 53 Vantas ........................................................... 62 Vaqta .......................................................... 144 Vascepa ........................................................ 55 Vaseretic ..................................................... 132 Vasotec ....................................................... 132 V-C Forte .................................................... 118 Vectical ....................................................... 137 Veletri .......................................................... 145 Velivet ........................................................... 95 Velphoro...................................................... 109 Veltin ........................................................... 137 VemaVite-PRx 2 ......................................... 118 Vena-Bal DHA ............................................. 118 Venclexta ...................................................... 63 Venclexta Starting Pack ................................ 63 Venlafaxine HCl .......................................... 126 Venlafaxine HCl ER .................................... 126

Ventavis ...................................................... 146 Ventolin HFA ............................................... 140 Verapamil HCl ............................................... 82 Verapamil HCl ER ......................................... 82 Verdeso ......................................................... 51 Verdrocet ....................................................... 13 Verelan .......................................................... 82 Verelan PM ................................................... 83 Veripred 20 ...................................................... 5 Versacloz .................................................... 129 Verzenio ........................................................ 63 VESIcare ..................................................... 104 Vestura .......................................................... 95 Vfend ............................................................. 36 Viagra .......................................................... 145 Viberzi ......................................................... 104 Vibramycin .................................................... 24 VIC-Forte ..................................................... 118 Vicodin .......................................................... 13 Vicodin ES ..................................................... 13 Vicodin HP .................................................... 13 Victoza .......................................................... 31 Videx ............................................................. 73 Videx EC ....................................................... 73 Vienva ........................................................... 95 Vigabatrin ...................................................... 29 Vigamox ........................................................ 43 Viibryd ......................................................... 126 Vilamit MB ................................................... 143 Vilevev MB .................................................. 143 Vimizim ........................................................ 100 Vimovo ............................................................ 9 Vimpat ........................................................... 29 Vinate DHA RF ............................................ 118 Vinate II ....................................................... 118 Vinate M ...................................................... 118 Vinate One .................................................. 118 Viokace ......................................................... 97 Viorele ........................................................... 95 Viracept ......................................................... 73 Viramune ....................................................... 74 Viramune XR ................................................. 74 Viread ............................................................ 74 Viroptic .......................................................... 45 Virt Nate ...................................................... 118 Virt-C DHA .................................................. 118 Virt-Caps ..................................................... 118 Virti-Sulf ....................................................... 111 Virt-Nate DHA ............................................. 118 Virt-PN ......................................................... 118

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Virt-PN DHA ................................................ 118 Virt-PN Plus ................................................ 118 Vistaril ........................................................... 76 Vita S Forte ................................................. 118 Vita-Bee/C................................................... 118 Vitacel ......................................................... 118 Vitafol ............................................................ 19 Vitafol FE+ .................................................. 118 Vitafol Ultra ................................................. 118 Vitafol-Nano ................................................ 118 Vitafol-OB.................................................... 118 Vitafol-OB+DHA .......................................... 118 Vitafol-One .................................................. 118 Vitaject ........................................................ 118 Vital-D Rx .................................................... 118 Vitamax Pediatric ........................................ 118 VitaMedMD One Rx/Quatrefolic .................. 119 VitaMedMD RediChew Rx .......................... 119 Vita-Min ....................................................... 119 Vitamin B Complex 100 .............................. 146 Vitamin B-Complex 100 .............................. 146 Vitamin D (Ergocalciferol) ........................... 147 Vitamin K1................................................... 147 Vitamins ACD-Fluoride ............................... 119 VitaPearl ..................................................... 119 Vitaroca Plus ............................................... 119 Vita-Rx Diabetic Vitamin ............................. 119 Viva DHA .................................................... 119 Vivelle-Dot................................................... 102 Vol-Care Rx ................................................ 119 Vol-Nate ...................................................... 119 Vol-Plus....................................................... 119 Vol-Tab Rx .................................................. 119 Voltaren....................................................... 137 Voriconazole ................................................. 36 Votrient ......................................................... 63 VP DermaBase ........................................... 121 VP-GGR-B6 Prenatal .................................. 119 VP-Heme OB .............................................. 119 VP-Heme OB + DHA ................................... 119 VP-HEME One ............................................ 119 VP-PNV-DHA .............................................. 119 Vpriv ............................................................ 100 VP-Vite Rx .................................................. 119 VP-ZEL ....................................................... 119 Vusion ........................................................... 45 Vyfemla ......................................................... 95 Vytone ........................................................... 46 Vytorin ........................................................... 56 Vyvanse ........................................................ 15

W

Warfarin Sodium ........................................... 68 Welchol ......................................................... 55 Wellbutrin SR .............................................. 126 Wellbutrin XL ............................................... 126 Wera .............................................................. 95 Westhroid .................................................... 142 Wheat Germ Oil .......................................... 147 WinRho SDF ............................................... 134 WP Thyroid ................................................. 142 Wymzya Fe ................................................... 95

X

Xalatan .......................................................... 38 Xalkori ........................................................... 63 Xanax ............................................................ 78 Xanax XR ...................................................... 78 Xarelto ........................................................... 68 Xarelto Starter Pack ...................................... 68 Xeljanz .......................................................... 98 Xeljanz XR .................................................... 98 Xeloda ........................................................... 63 Xenazine ....................................................... 88 Xenical ........................................................ 104 Xeralux ........................................................ 137 Xgeva ............................................................ 81 Xifaxan .......................................................... 19 Xigduo XR ............................................... 30, 33 Xolair ........................................................... 133 Xolegel .......................................................... 45 Xolegel CorePak ........................................... 45 Xolegel Duo/Head & Shoulders ..................... 45 Xolegel Duo/Xolex ......................................... 45 Xopenex ...................................................... 140 Xopenex Concentrate .................................. 140 Xopenex HFA .............................................. 140 Xtandi ............................................................ 63 Xulane ........................................................... 95 Xylocaine ..................................................... 111 Xyntha ........................................................... 41 Xyntha Solofuse ............................................ 41 Xyrem ............................................................ 88

Y

Yasmin 28 ..................................................... 95 YAZ ............................................................... 95 Yuvafem ...................................................... 102

Z

Zacare ........................................................... 46 Zaclir Cleansing ............................................ 46

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Zafirlukast ..................................................... 54 Zaleplon ........................................................ 76 Zanaflex ...................................................... 135 Zantac ........................................................... 70 Zarah ............................................................ 95 Zarontin ......................................................... 30 Zarxio .......................................................... 106 Zatean-Pn DHA ........................................... 119 Zatean-Pn Plus ........................................... 119 Zavesca ...................................................... 120 Zebutal ............................................................ 8 Zegerid .......................................................... 71 Zelapar .......................................................... 65 Zelboraf ......................................................... 63 Zemplar ....................................................... 147 Zenatane ..................................................... 137 Zenchent ....................................................... 95 Zenpep .......................................................... 97 Zenzedi ......................................................... 15 Zerit ............................................................... 74 Zestoretic .................................................... 132 Zestril .......................................................... 132 Zetia .............................................................. 55 Zetonna ......................................................... 53 Ziac ............................................................... 80 Ziagen ........................................................... 74 Ziana ........................................................... 137 Zidovudine .................................................... 74 Zileuton ER ................................................... 54 Zioptan .......................................................... 38 Ziprasidone HCl .......................................... 129 Zipsor ............................................................ 10 Zirgan ............................................................ 45 Zithranol ...................................................... 138 Zithromax ...................................................... 21 Zithromax Tri-Pak ......................................... 21 Zithromax Z-Pak ........................................... 21 Zocor ............................................................. 57

Zofran ............................................................ 35 Zofran ODT ................................................... 35 Zoladex ......................................................... 63 Zoledronic Acid ............................................. 81 Zolinza ........................................................... 63 ZOLMitriptan ................................................. 58 Zoloft ........................................................... 126 Zolpidem Tartrate .......................................... 76 Zolpidem Tartrate ER .................................... 76 Zolpimist ........................................................ 76 Zometa .......................................................... 81 Zomig ............................................................ 58 Zomig ZMT .................................................... 58 Zonegran ....................................................... 29 Zonisamide .................................................... 29 Zontivity ......................................................... 68 Zortress ....................................................... 109 Zorvolex ........................................................ 10 Zostavax ...................................................... 144 Zovia 1/35E (28) ............................................ 95 Zovirax .................................................... 45, 75 Zubsolv .......................................................... 14 Zuplenz ......................................................... 35 Zutripro .......................................................... 70 Zyban .......................................................... 126 Zydelig ........................................................... 63 Zyflo .............................................................. 54 Zyflo CR ........................................................ 54 Zykadia .......................................................... 63 Zylet .............................................................. 53 Zyloprim ........................................................ 38 Zymaxid ......................................................... 43 ZyPREXA .................................................... 129 ZyPREXA Relprevv ..................................... 129 ZyPREXA Zydis .......................................... 129 Zytiga ............................................................ 63 Zyvox ............................................................. 19


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