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Drug cverage is dependent n individual plan benets
TaBle o ConTenTS
Intrductin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Member Prescriptin Benet . . . . . . . . . . . . . . . . . . . . . . . 2
Pharmacy And Therapeutics (P&T) CmmitteeAnd Preerred Drug Cmmittee (PDC) . . . . . . . . . . . . . . 2
Hw T Use This Preerred Drug Guide . . . . . . . . . . . . . . 2
Cst Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Generic Substitutin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dispensing Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Pharmaclgic and Therapeutic Categries . . . . . . . . . . 6
ati-ictiv agts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Ccr Drgs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hrms, Dibts ad Rtd Drgs. . . . . . . . . . . 9
Hrt ad Circtry Drgs . . . . . . . . . . . . . . . . . . . . 12
Rspirtry agts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Gstritsti Drgs. . . . . . . . . . . . . . . . . . . . . . . . . . 16
Gitriry Drgs . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Ctr nrvs Systm Drgs . . . . . . . . . . . . . . . . . . 17
Pi Ri Drgs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
nrmscr Drgs . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Sppmts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Bd Mdiyig Drgs . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Tpic Prdcts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Miscs Ctgris . . . . . . . . . . . . . . . . . . . . . . 26
ConTaCT InoRMaTIon
I y hv y qstis rgrdig th B Crss d
B Shid Txs Prrrd Drg Gid, r i y hv
cmmts r sggstis tht c imprv th sss
this pbicti, ps dirct thm t:
Tm Tr, Phrm.D.
BCBSTX Dirctr Ciic Phrmcy Prgrms
901 S. Ctr exprssy, nrth Bdg. Mi Drp
Ds, TX 75080
Ph: 972-766-2725
x: 972-766-1656 r 800-986-9980
emi: [email protected]
KeY
caps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cpsschew tabs . . . . . . . . . . . . . . . . . . . . . . . . . chb tbts
cnc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cctrt
crm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . crm
delayed-release . . . . . . . . . . . . . . . . . . . . . . t r i c - c t d
DL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . dispsig imit
ext-release . . . . . . . . . . . . . . . . . . . . . . . xtdd-rs
inhal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ihti
inj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ijcti
ltn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ti
NP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .-prrrd
oDT. . . . . . . . . . . . . . . . . . . . . . . . ry disitgrtig tbs
int . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . itmt
oTC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vr-th-ctr
P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . prrrd
sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sti
supp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sppsitris
susp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sspsi
tabs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tbts
Blue Crss and Blue Shield Texas 2009 Preerred Drug Guide
2009Eective January 1, 2009Drug List by Therapeutic Class
B Crss d B Shid Txs mmbrs r rqstd t prst this Prrrd Drg Gid t thir physici t thir xt visit.
This dcmt rcts th B Crss d B Shid Txs Prrrd Drg Gid s Jry 1, 2009.
This gid is pdtd qrtry. Ps visit www.bcbstx.cm r rct pdts.
T srch r drg m ithi this PD dcmt, s th Cntrl d kys yr kybrd, r g t Edit i th
drp-d m d sct ind/Search. Typ i th rd r phrs y r kig r d cick Search.
I yu cannt nd the drug n this list it typically means that the drug is Nn-Preerred.
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Drug cverage is dependent n individual plan benets
InTRoDuCTIon
B Crss d B Shid Txs (BCBSTX) is psd
t prst th 2009 B Crss d B Shid Txs
Prrrd Drg Gid. Th Prrrd Drg Gid icds
Prrrd Brd drgs d prti ist Gr ic drgs
sctd by BCBSTX. Physicians are encuraged t
prescribe drugs listed in this Preerred Drug Guide.
Members are encuraged t shw this Preerred Drug
Guide t their physicians and pharmacists.
Prscripti drgs my b xcdd rm cvrg i
thr r vr-th-ctr (oTC) vrsis mrktd i th
sm strgth d dsg rm, v thgh th bd
idictis r th prscripti d ss r th oTC
prdcts r t th sm. r xmp, mtidi (Ppcid)
20 mg is xcdd bcs oTC vrsi th 20 mg
tbts, Ppcid aC Mximm Strgth, is mrktd r oTC
s. oTC drgs r t cvrd ith th xcpti isi,
r gcs g d tbs, d sctd dibtic sppis.
MeMBeR PReSCRIPTIon BeneITTh Prrrd Drg Gid is mti-tird, pcig prscripti
drgs it thr cpymt vs; gric, Prrrd
Brd (P) r n-prrrd Brd (nP). Th drg bft
icds mst prscripti drgs, thgh sm
xcsis rm cvrg d ppy. r xmp, drgs
idictd r csmtic prpss, .g., Prpci, r hir
grth, r t cvrd. Cvrg d cpymt vs
vry dpdig th p.
Lwest cpayment: Gric drgs istd d istd
gric drgsMiddle cpayment: Prrrd Brd drgs r istd
i this Prrrd Drg Gid
Highest cpayment: n-prrrd Brd drgs istd
brd drgs
Prscriptis fd thrgh rti phrmcy r gry
imitd t 90-dy sppy ith cpymt r vry
30-dy sppy. a 90-dy sppy is s vib r
mdictis btid thrgh th Mi ordr phrmcy.
Crti drgs hv dispsig imittis bsd p gdr
r qtity dispsd pr prscripti. Drgs tht hv
Dispsig limit r istd pgs 45.
PHaRMaCY anD THeRaPeuTICS (P&T)CoMMITTee anD PReeRReDDRuG CoMMITTee (PDC)
BCBSTX prticipts th Prim Thrptics nti
P&T Cmmitt hich srvs s rcmmdig bdy r
drg rmry icsi. Th Cmmitt sts physicis
d phrmcists rm thrght th ctry icdig
vtig mmbr rm BCBSTX. Prim Thrptics ds t
hv vtig privigs. Drgs r rvid i trms sty,fccy, d ciic iqss.
Th Prrrd Drg Cmmitt (PDC) is stdig cmmitt
Hth Cr Srvic Crprti (HCSC) cmpsd
divisi Mdic Dirctrs, Phrmcy Dirctrs,
d s dd, prctitirs spciizig i th r
phrmccmics d hth cr dmiistrti. Th
PDC its Prim Thrptics nti P&T Cmmitt
ciic ssssmts ith cst-ctiv thrpy mdig
csidrtis t mk f rmry pcmt dcisis r
HCSC, hich icds BCBSTX d HMo B Txs.
Mmbrs d physicis c rvi th mst p-t-dt
vrsi th Prrrd Drg Gid t www.bcbstx.cm.
How To uSe THIS PReeRReD DRuG GuIDe
This Prrrd Drg Gid is rgizd it brd thrptic
ctgris. withi mst ctgris, drgs r grpd
bsd p drg css, .g. Mcrids, r s r spcifc
mdic cditi, .g. Dibts. a th drgs istd, hthr
Gric r Prrrd Brd, r rcmmdd drgs.
Generic drugs r sh i rcs bdc typ.Mst gric drgs r d by rrc brd drg
(i prthss) t ssist i prdct rcgiti.
Example: atenll (Trmi)
Th brd rrc drg Trmi is mrktd s 25 mg,
50 mg d 100 mg tbts. ech strgth is vib
gricy. Th brd rrc drgs ik Trmi r
sy -prrrd d d tk th highst cpymt.
Sm gric prdcts hv brd rrc.
Preerred Brand drugs r sh i cpit ttrs.
Example: DIoVan vsrt
7/22/2019 4. PENGGOLONGAN OBAT 1
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Drug cverage is dependent n individual plan benets
Cipro is marketed as 250 mg, 500 mg, and 750 mg, and
250 mg/5 ml d 500 mg/5 ml r sspsi. Th tbts
hv gric vrsis vib d th r sspsi
is y vib s brd m Cipr. Th Prrrd Drg
Gid try icds gric tbts. Cipr sspsi
d rqir sprt try t b Prrrd Drg (tir 2).
Bcs th sspsi is -prrrd, it d tk th
highst cpymt (tir 3).
Example: ciprfxacin tabs (Cipr)
Individual Preferred Drug Guide entries are required for
my dirt dsg rms r rts dmiistrti
icdig r immdit-rs, xtdd-rs, dyd-
rs, rct, ijctb, tic, phthmic, vgi, s,
ry disitgrtig tbts, trsdrm, d tpic. or
immdit-rs d trsdrm dsg rms strdi
rqir sprt tris i th Prrrd Drg Gid.
Example:estradil patches (Cimr)
estradil tabs (estrc)
CoST InDeX
Dr sigs r bsd p avrg whs Pric (awP)
r Mximm ab Cst (MaC) d rg rm ($) t
fv ($$$$$), rkig th drgs rm st t mst xpsiv.
withi th sm dr sig, drgs r istd phbticy.
Dr sigs r mitc drgs r typicy bsd p
30 dy sppy t cmmy prscribd dsg. r drgs
tht r t prscribd r mitc cditis, mr
pprprit bsis is sd t dtrmi dr sig ssigmt.
$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00 r ss
$$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$20.01 t $40
$$$. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40.01 t $80
$$$$. . . . . . . . . . . . . . . . . . . . . . . . . . . . $80.01 t $160
$$$$$ . . . . . . . . . . . . . . . . . . . . . . . . . Mr th $160
GeneRIC SuBSTITuTIon
BCBSTX crgs gric tiizti s y t prvid
high-qity drgs t rdcd cst. Gric drgs r s s
d ctiv s thir brd-m ctrprts, bt r sy
ss xpsiv. Gric drgs r mctrd dr th
sm strict stdrds Das Gd Mctrig Prctic
rgtis tht r rqird r brd prdcts icdig btch
rqirmts r idtity, strgth, prity, d qity.
a Da-pprvd gric drg my b sbstittd r th
brd ctrprt bcs it:
Contains the same active ingredient(s) as the brand drug
Is identical in strength, dosage form, and route of
dmiistrti
Is therapeutically equivalent and can be expected to have
th sm ciic ct d sty prf
T crg s gric drgs, Prrrd Brd drgs
typicy bcm -prrrd d rqir th highst
cpymt tr gric vrsi bcms vib. This
chg ccrs grps xt ivrsry dt r trJry 1, 2009. BCBSTX s crgs th s grics
by hvig th st cpymt ppy r gric drgs.
I dtrmiig th brd r gric cssifcti r cvrd
prscripti drgs, BCBSTX tiizs th gric/brd stts
s ssigd by tiy rcgizd prvidr drg
prdct irmti. Th brd/gric cssifcti
drg is sbjct t chg vr tim, hich sy chgs
th cpymt v.
7/22/2019 4. PENGGOLONGAN OBAT 1
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Drug cverage is dependent n individual plan benets
DISPenSInG lIMITS
Dispsig imits idtiy gdr rstrictis, d/r th mximm qtity tht c b dispsd vr spcifc prid tim.
limits r i pc t crg pprprit drg tiizti, hc mmbr tcms, d rdc drg bft csts.
limits r typicy dvpd bsd p Da-pprvd drg big.
The following brand drugs, and generic versions (shown in bold face type when available), have dispensing limits. This list is subject to change
Dispsig limitBrd (Gric nm) Strgth Drg Gid Stts Pr 30-Dy Sppy
accb (albuterl sulate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P= gric. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 ml
aciphx (rbprz dyd-rs) . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 0 tbs**
actiq (ty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . .n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 its
act (risdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 tbs
act (risdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
act (risdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 tbs
act (risdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 mg . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 tb
act ith Ccim (risdrt + ccim crbt). . . . . . . 35 mg, 1250 mg . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 dy pkg
advir Disks / Ha ( tics/smtr) . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
arbid /arbid- M (isid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ihr
albuterl sulate inhal sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.083%. . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 ml
albuterl sulate inhal sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 ml
ambi (zlpidem) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
ambi CR (zpidm xt-rs) . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 0 tbs*amrg (rtript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tbs
asmx (mmts) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
asti (zsti) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 btts
atrvt Ha (iprtrpim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihr
atrvt s (ipratrpium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.03. . . . . . . . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
atrvt s (ipratrpium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.06. . . . . . . . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 btts
axrt (mtript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tbs
azmcr t (trimci) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
Bcs aQ (bcmths) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
Biv (ibdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
Biv (ibdrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 mg . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 tb
butrphanl nasal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
Bytt (xtid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 mcg/ml. . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 p
Cvrjct (prstdi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 dss
Ciis (tdf). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tbs
Cmbivt ( iprtrpim/btr st ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihr
crmlyn sdium inhal sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 ml
Db (ipratrpium/albuterl sulate) . . . . . . . . . . . . . . . . . . . 0.5 mg/3 mg. . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 ml
edx (prstdi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 dss
ty zgs (ty citrt) . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 its
tr (ty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 its
s (futicasne) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
vt Disks (tics) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
vt H a ( tics). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 i hrs
funislide nasal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 mcg/spry. . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
rdi arizr (rmtr). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
rt (triprtid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 p
smx r s (drt). . . . . . . . . . . . . . . . . . . . . . . . . . . 70 mg/75 ml . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 btts
smx tbs (alendrnate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 mg, 70 mg . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 tbs
smx Ps D (drt/chccir) . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 tbs
rv (rvtript). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tbs
Imitrx ij (smtript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 mg/0.5 ml. . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 pkgs (10 vis
Imit rx k it s/rf s ( smtr ipt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 pkgs (12 dss
Imitrx s (smtript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 pkgs (12 its
7/22/2019 4. PENGGOLONGAN OBAT 1
5/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 5 o 27
Drug cverage is dependent n individual plan benets
Imitrx tbs (smtript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tbs
It ihr (crmy sdim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
ipratrpium inhal sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 ml
Jmt (sitgipti/mtrmi) . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 tbs
Jvi (sitgipti). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
ketrlac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . 20 tbs/ cvrg t m
ltiris (mbrist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
lvitr (vrdf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tbs
lst (szpic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs*
Mxir athr (pirbtr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
Mxt/Mxt-MlT (riztript) . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tbs
metaprterenl inhal sln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4%, 0.6% . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 ml
Migr (dihydrrgtmi). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg (8 btts
Ms (prstdi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 dss
nscr t aQ (trimci) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
nsr (funislide) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P = gric. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
nsx (mmts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 btt
nxim (smprz dyd-rs). . . . . . . . . . . . . . . . . . . . 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 cps/pckts**
Prvcid (sprz dyd-rs) . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 0 cps /pckts**
Prvcid Stb (sprz dyd-rs) . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 tbs**
Prisc (meprazle delayed-release) . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 cps**Pristiq (dsvxi xt-rs) . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
Prir Ha (btr st) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihr
Prtix tbs (pantprazle delayed-release) . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 tbs**
Prtix grs (ptprz dyd-rs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 pckts**
Prvti H a (btr st ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihr
Prvigi (mdfi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
Przc wky (xti dyd-rs) . . . . . . . . . . . . . . . . . 90 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 cps
Pmicrt xhr (bdsid) . . . . . . . . . . . . . . . . . . . . . . . . . . 90 mcg . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
Pmicrt xhr (bdsid) . . . . . . . . . . . . . . . . . . . . . . . . . . 180 mcg . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
Pmicrt Rsps (bdsid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 ml
QVaR (bcmths) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
Rz (zmivir) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 mg/bistr . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 bistrs pr 180 dys
Rpx (tript) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tbs
Rhicr t aq (bdsid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 bt t
Rzrm (rmt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 tbs
Srvt Disks (smtr). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 pkg
St (zalepln) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P = gric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 cps
Spir iv Hdih r (t itrpim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 bx (30 cps
Symbicrt ( bdsid/rmtr). . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ih
Tmi cps (stmivir) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 cps pr 180 dys
Tmi r ssp (stmivir). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 ml pr 180 dys
Trcr (bst) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 0 tbs
Trx imt ( smtr ipt/prx sdim) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 tbs
Vti Ha (btr st) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
Vrmyst (tics) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 bttVigr (sidf) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 tbs
Xpx (vbtr hc) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 ml
Xpx Cctrt ( vbtr hc ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 bxs (90 it ds
Xpx Ha (vbtr trtrt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ihrs
Xyrm (sdim xybt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 mg/ml. . . . . . . . . . . . . . . . . . . . . . . nP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 ml
Zgrid (mprz /sdim bicrbt) . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . n P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 cps /pckts**
Zmig s ( zmitr ipt) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . .P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 pkgs (12 its
Zmig/Zmig ZMT (zmitript) . . . . . . . . . . . . . . . . . . . . . . . . . . strgths . . . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 tbs
* Sdtivs r imitd t sdtiv gt pr 30 dys d 1 tb/cp pr dy.
**Prt Pmp Ihibitrs (PPIs) r imitd t PPI pr 30 dys d 2 tbs/cps/pckts pr dy.
Dispsig limitBrd (Gric nm) Strgth Drg Gid Stts Pr 30-Dy Sppy
7/22/2019 4. PENGGOLONGAN OBAT 1
6/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 6 o 27
Drug cverage is dependent n individual plan benets
ANTI-INECTIVE AGENTS
PenICIllInS
$ amxicillin
$ aMoXIl drps mxicii
$ ampicillin caps
$ aMPICIllIn ssp
$ penicillin v ptassium
$$ amxicillin/ptassium clavulanate (agmti)
$$ diclxacillin
CePHaloSPoRInS
$ ceadrxil
$ cetriaxne (Rcphi)
$ ceurxime (Cti)
$ cephalexin (Kx)
$$ cedinir (omic)
$$ cepdxime (Vti)
$$$ ceprzil
MaCRolIDeS
$ azithrmycin (Zithrmx)
$ clarithrmycin (Bixi)
$ eRY-TaB rythrmyci dyd-rs tbs
$ erythrmycin ethylsuccinate
$ eRYTHRoMYCIn IlMTaBS rythrmyci bs
$$ ZITHRoMaX pckts, 1 g zithrmyci
TeTRaCYClIneS
$ dxycycline hyclate
$ mincycline caps, tabs (Mici, Dyci)
$ tetracycline
$$$$$ demeclcycline (Dcmyci)
luoRoQuInoloneS
$ ciprfxacin tabs (Cipr)
$$$$ leVaQuIn vxci
aMInoGlYCoSIDeS
$ nemycin sulate
$$$$$ ToBI tbrmyci
TuBeRCuloSIS
$ isniazid tabs
$$$ ISonIaZID syrp
$$$$ ethambutl (Mymbt)
$$$$ isniazid/riampin (Rimt)
$$$$ pyrazinamide
$$$$ riampin (Ridi)
$$$$$ MYCoBuTIn ribti
Therapeutic Class Drug List
7/22/2019 4. PENGGOLONGAN OBAT 1
7/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 7 o 27
Drug cverage is dependent n individual plan benets
unGal IneCTIonS
$ fucnazle (Dic)
$ ketcnazle
$$ terbinane tabs (lmisi)
$$$ griseulvin micrsize susp (Grivi V)
$$$ GRIS-PeG grisvi trmicrsiz
$$$ nystatin tabs
$$$$ GRIulVIn V tbs grisvi micrsiz
$$$$$ itracnazle caps (Sprx)
$$$$$ laMISIl grs trbif
$$$$$ noXaIl pscz
$$$$$ VenD vricz
VIRal IneCTIonS
Cytomegalovirus
$$$$$ GanCICloVIR
$$$$$ ValCYTe vgcicvir
Hepatitis
$$$$$ BaRaCluDe tcvir
$$$$$ ePIVIR-HBV mivdi$$$$$ HePSeRa dvir
$$$$$ InTRon a itrr -2b
$$$$$ PeGaSYS pgitrr -2
$$$$$ PeG-InTRon pgitrr -2b
$$$$$ ribavirin caps (Rbt)
$$$$$ ribavirin tabs (Cpgs)
$$$$$ RoeRon-a itrr -2
Herpes
$ acyclvir (Zvirx)
$$$$$ amciclvir (mvir)
$$$$$ ValTReX vcycvir
HIV/AIDS
$$$$ VIDeX eC 125 mg didsi dyd-rs
$$$$ zidvudine (Rtrvir)
$$$$$ aPTIVuS tiprvir
$$$$$ aTRIPla virz/mtricitbi/tvir
$$$$$ CoMBIVIR mivdi/zidvdi
$$$$$ CRIXIVan idivir
$$$$$ didansine delayed-release (Vidx eC)
$$$$$ eMTRIVa mtricitbi
$$$$$ ePIVIR mivdi
$$$$$ ePZICoM bcvir/mivdi
$$$$$ uZeon virt id
$$$$$ InTelenCe trviri
$$$$$ InVIRaSe sqivir
$$$$$ ISenTReSS rtgrvir
$$$$$ KaleTRa pivir/ritvir
$$$$$ leXIVa smprvir
7/22/2019 4. PENGGOLONGAN OBAT 1
8/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 8 o 27
Drug cverage is dependent n individual plan benets
$$$$$ noRVIR ritvir
$$$$$ PReZISTa drvir
$$$$$ ReSCRIPToR dvirdi
$$$$$ ReYaTaZ tzvir
$$$$$ SelZenTRY mrvirc
$$$$$ SuSTIVa virz
$$$$$ TRIZIVIR bcvir/mivdi/zidvdi
$$$$$ TRuVaDa mtricitbi/tvir
$$$$$ VIDeX didsi
$$$$$ VIRaCePT fvir
$$$$$ VIRaMune virpi
$$$$$ VIReaD tvir
$$$$$ ZeRIT stvdi
$$$$$ ZIaGen bcvir
MalaRIa
$ chlrquine phsphate (ar)
$ hydrxychlrquine (Pqi)
$ PRIMaQuIne PHoSPHaTe
$$ mefquine (lrim)$$$$ MalaRone tvq/prgi
woRM IneCTIonS
$ mebendazle
$ STRoMeCTol ivrmcti
$$$$ alBenZa bdz
$$$$ BIlTRICIDe prziqt
oTHeR anTI-IneCTIVeS
$ clindamycin (Cci)
$ DaPSone
$ erythrmycin/sulsxazle (Pdiz)
$ metrnidazle tabs (gy)
$ sulamethxazle/trimethprim (Bctrim, Sptr)
$ trimethprim
$$$$$ ZYVoX izid
CANCER DRUGS
aleRon n itrr -3
alKeRan mph
aRIMIDeX strz
aRoMaSIn xmst
CaSoDeX bictmid
Ceenu msti
CYCloPHoSPHaMIDe tbs
eMCYT strmsti
etpsidecaps
aReSTon trmi
7/22/2019 4. PENGGOLONGAN OBAT 1
9/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 9 o 27
Drug cverage is dependent n individual plan benets
eMaRa trz
futamide
hydrxyurea (Hydr)
InTRon a itrr -2b
IReSSa gftiib
leucvrin calcium tabs 5 mg, 25 mg
leuCoVoRIn CalCIuM tbs 10 mg, 15 mg
leuKeRan chrmbci
leuprlide (lpr)
megestrl (Mgc)
mercaptpurine (Prith)
MeSneX tbs ms
methtrexate tabs
MYleRan bs
nIlanDRon itmid
RoeRon-a itrr -2
TaBloID thigi
tamxien
tretinin caps (Vsid)
TReXall mthtrxt
HoRMoNES, DIABETES AND RELATED DRUGS
CoRTICoSTeRoIDS
$ crtisne acetate
$ dexamethasne tabs, 1.5 mg, 4 mg, 6 mg
$ DeXaMeTHaSone s, 0.5 mg/5 ml; tbs, 0.5 mg
$ fudrcrtisne
$ hydrcrtisne (Crt)
$ methylprednislne (Mdr)
$ prednislne sdium phsphate sln (orprd, Pdiprd)
$ prednislne syrup (Pr)
$ prednisne
$$ PReDnISone s, 5 mg/5 ml; tbs, 50 mg
$$$ PReDnISone InTenSol
$$$$$ enToCoRT eC bdsid xt-rs
Male HoRMoneS
$$$$ anDRoXY xymstr
$$$$$ anDRoGel tststr
$$$$$ danazl
$$$$$ TeSTIM tststr
eSTRoGenS
$ estradil tabs (estrc)
$ estrpipate (og)
7/22/2019 4. PENGGOLONGAN OBAT 1
10/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 10 o 27
Drug cverage is dependent n individual plan benets
$$ estradil patches (Cimr)
$$ VIVelle-DoT strdi
$$$ aCTIVella 0.5/0.1 mg strdi/rthidr ctt
$$$ CeneSTIn cjgtd strgs, sythtic a
$$$ DIVIGel strdi
$$$ enJuVIa cjgtd strgs, sythtic B
$$$ eSTRaDeRM strdi
$$$ estradil/nrethindrne acetate 1/0.5 mg (activ)
$$$ PReMaRIn cjgtd strgs
$$$ PReMPHaSe cjgtd strgs/mdrxyprgstr
$$$ PReMPRo cjgtd strgs/mdrxyprgstr
PRoGeSTInS
$ medrxyprgesterne acetate (Prvr)
$ nrethindrne acetate (aygsti)
$$ PRoMeTRIuM prgstr micrizd
BIRTH ConTRol
Crvic cps, diphrgms, d IuDs r prrrd, bt t istd i this gid.
$ medrxyprgesterne acetate inj, 150 mg/mL (Dp-Prvr)
$$ desgestrel/ethinyl estradil (Cycss)$$ desgestrel/ethinyl estradil (orth-Cpt)
$$ ethyndil/ethinyl estradil (Dm)
$$ levnrgestrel/ethinyl estradil (ass)
$$ levnrgestrel/ethinyl estradil (lvit)
$$ levnrgestrel/ethinyl estradil (nrdtt)
$$ levnrgestrel/ethinyl estradil (Ss)
$$ levnrgestrel/ethinyl estradil (Triphsi)
$$ nrethindrne (nr-QD)
$$ nrethindrne (orth Micrr)
$$ nrethindrne acetate/ethinyl estradil (lstri)
$$ nrethindrne acetate/ethinyl estradil/e (lstri )
$$ nrethindrne/ethinyl estradil (Mdic)
$$ nrethindrne/ethinyl estradil (orth-nvm 1/35)
$$ nrethindrne/ethinyl estradil (orth-nvm 7/7/7)
$$ nrethindrne/ethinyl estradil (ovc 35)
$$ nrethindrne/ethinyl estradil (Tri-nriy)
$$ nrethindrne/mestranl (orth-nvm 1/50)
$$ nrgestimate/ethinyl estradil (orth-Cyc)
$$ nrgestimate/ethinyl estradil (orth Tri-Cyc)
$$ nrgestrel/ethinyl estradil (l/ovr)
$$ Plan B vrgstr$$$ desgestrel/ethinyl estradil (Mirctt)
$$$ drspirenne/ethinyl estradil (Ysmi)
$$$ nuVaRInG tgstr/thiy strdi
$$$ oRTHo TRI-CYClen lo rgstimt/thiy strdi
$$$ YaZ drspir/thiy strdi
7/22/2019 4. PENGGOLONGAN OBAT 1
11/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 11 o 27
Drug cverage is dependent n individual plan benets
IneRTIlITY
$$ clmiphene (Cmid)
$$$ chrinic gnadtrpin
$$$$$ ollISTIM aQ 300, 600, 900 its itrpi bt
$$$$$ GanIRelIX aCeTaTe
$$$$$ Gonal- itrpi
$$$$$ RePRoneX mtrpis
DIaBeTeS
oTC gcs ch tbs d dxtrs tbs r prrrd bt r t istd i this gid.
$ glimepiride (amry)
$ glipizide (Gctr)
$ glipizide ext-release (Gctr Xl)
$ glyburide (Micrs)
$ glyburide micrnized (Gys)
$ metrmin (Gcphg)
$ metrmin ext-release (Gcphg XR)
$$ glyburide/metrmin (Gcvc)
$$$ acarbse (Prcs)
$$$$ GluCaGon eMeRGenCY KIT$$$$ PRanDIn rpgiid
$$$$$ aCToPluS MeT pigitz/mtrmi
$$$$$ aCToS pigitz
$$$$$ aVanDaMeT rsigitz/mtrmi
$$$$$ aVanDIa rsigitz
$$$$$ DueTaCT pigitz/gimpirid
DIaBeTeS InSulInS
Rapid-Acting Insulins
$$$$ HuMaloG isi ispr
$$$$ noVoloG isi sprt
Short-Acting Insulins
$$$ HuMulIn R isi rgr
$$$ noVolIn R isi rgr
Intermediate-Acting Insulins
$$$ HuMulIn n isi isph
$$$ HuMulIn 50/50 isi isph/rgr
$$$ HuMulIn 70/30 isi isph/rgr
$$$ noVolIn n isi isph
$$$ noVolIn 70/30 isi isph/rgr
$$$$ HuMaloG MIX 50/50 isi ispr prtmi/ispr
$$$$ HuMaloG MIX 75/25 isi ispr prtmi/ispr
$$$$ noVoloG MIX 70/30 isi sprt prtmi/sprt
Basal Insulins
$$$$ lanTuS isi grgi
$$$$ leVeMIR isi dtmir
THYRoID ReGulaTIon
$ levthyrxine includes Levxyl (Sythrid)
$ prpylthiuracil
7/22/2019 4. PENGGOLONGAN OBAT 1
12/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 12 o 27
Drug cverage is dependent n individual plan benets
$$ CYToMel ithyri
$$ methimazle (Tpz)
GRowTH HoRMone
$$$$$ GenoTRoPIn smtrpi
$$$$$ InCReleX mcsrmi
$$$$$ nuTRoPIn smtrpi
$$$$$ nuTRoPIn aQ smtrpi
oTHeR HoRMoneS anD RelaTeD DRuGS
$ alendrnate tabs (smx) DL
$ MeTHeRGIne mthyrgvi
$$$ calcitnin-salmn nasal rtical
$$$$ aCTonel risdrt DL
$$$$ desmpressin nasal (DDaVP)
$$$$ eVISTa rxi
$$$$$ cabergline
$$$$$ CYSTaDane bti
$$$$$ desmpressin inj (DDaVP)
$$$$$ desmpressin tabs (DDaVP)
$$$$$ oRTeo triprtid DL$$$$$ HeCToRol dxrccir
$$$$$ BuPHenYl sdim phybtyrt
$$$$$ ctretide (Sdstti)
$$$$$ SenSIPaR cicct
$$$$$ STIMaTe dsmprssi
HEART AND CIRCULAToRY DRUGS
anGIoTenSIn ConVeRTInG enZYMe (aCe) InHIBIToRS anD CoMBInaTIonS
$ benazepril (ltsi)
$ benazepril/hydrchlrthiazide (ltsi HCT)
$ captpril (Cpt)
$ captpril/hydrchlrthiazide
$ enalapril (Vstc)
$ enalapril/hydrchlrthiazide (Vsrtic)
$ sinpril (Mpri)
$ lisinpril (Priivi)
$ lisinpril/hydrchlrthiazide (Prizid)
$ mexipril/hydrchlrthiazide (uirtic)
$ quinapril (accpri)
$ ramipril caps (atc)
$ trandlapril (Mvik)
$$ sinpril/hydrchlrthiazide (Mpri HCT)
$$ mexipril (uivsc)
$$ quinapril/hydrchlrthiazide (accrtic)
anGIoTenSIn II ReCePToR anTaGonISTS (aRBs) anD CoMBInaTIonS
$$$ BenICaR msrt
$$$ DIoVan vsrt
$$$$ BenICaR HCT msrt/hydrchrthizid
$$$$ DIoVan HCT vsrt/hydrchrthizid
7/22/2019 4. PENGGOLONGAN OBAT 1
13/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 13 o 27
Drug cverage is dependent n individual plan benets
BeTa BloCKeRS anD CoMBInaTIonS
$ acebutll (Sctr)
$ atenll (Trmi)
$ atenll/chlrthalidne (Trtic)
$ bisprll/hydrchlrthiazide (Zic)
$ labetall (Trdt)
$ metprll succinate ext-release (Tpr Xl)
$ metprll tartrate (lprssr)
$ nadll (Crgrd)
$ prpranll tabs
$ prpranll/hydrchlrthiazide 40/25
$$ bisprll (Zbt)
$$ carvedill (Crg)
$$ prpranll ext-release (Idr la)
$$ PRoPRanolol s
$$ TIMolol
$$$ InnoPRan Xl prpr xt-rs
$$$ PInDolol
CalCIuM CHannel BloCKeRS anD CoMBInaTIonS$ amldipine (nrvsc)
$ diltiazem (Crdizm)
$ verapamil (C)
$ verapamil ext-release (C SR)
$$ diltiazem ext-release (Dicr XR)
$$ niedipine ext-release (adt CC)
$$ niedipine ext-release (Prcrdi Xl)
$$ verapamil ext-release (Vr)
$$$ amldipine/benazepril (ltr)
$$$ diltiazem ext-release (Crdizm CD)
$$$ diltiazem ext-release (Tizc)
$$$ eldipine ext-release
$$$$ loTRel 5/40, 10/40 mdipi/bzpri
CHeST PaIn
$ issrbide dinitrate (Isrdi)
$ issrbide mnnitrate ext-release
$ nITRo-BID it itrgycri
$ nitrglycerin sublingual tabs (nitrstt)
$$ issrbide mnnitrate (Mkt)
$$ nitrglycerin patches (nitr-Dr)
CHoleSTeRol loweRInG$ gembrzil (lpid)
$ lvastatin (Mvcr)
$ pravastatin (Prvch)
$ simvastatin (Zcr)
$$$ chlestyramine (Qstr, Qstr light)
$$$ enbrate micrnized, caps, 67 mg, 134 mg, 200 mg (lfbr)
$$$ enbrate tabs, 54 mg, 160 mg (lfbr)
7/22/2019 4. PENGGOLONGAN OBAT 1
14/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 14 o 27
Drug cverage is dependent n individual plan benets
$$$$ CReSToR rsvstti
$$$$ nIaSPan ici xt-rs
$$$$ TRICoR fbrt
$$$$$ welCHol csvm
luID ReTenTIon
$ acetazlamide
$ amilride/hydrchlrthiazide
$ bumetanide (Bmx)
$ chlrthiazide
$ chlrthalidne 25 mg, 50 mg
$ ursemide sln, 10 mg/mL; tabs (lsix)
$ hydrchlrthiazide caps (Micrzid)
$ hydrchlrthiazide tabs, 25 mg, 50 mg
$ indapamide
$ methazlamide
$ spirnlactne (adct)
$ spirnlactne/hydrchlrthiazide 25/25 (adctzid)
$ triamterene/hydrchlrthiazide caps, 37.5/25 (Dyzid)
$ triamterene/hydrchlrthiazide tabs, 37.5/25 (Mxzid-25)$ triamterene/hydrchlrthiazide tabs, 75/50 (Mxzid)
$$ aMIloRIDe
$$ metlazne (Zrxy)
$$ trsemide (Dmdx)
$$ triamterene/hydrchlrthiazide caps, 50/25
HeaRT RHYTHM
$ stall (Btpc)
$$ amidarne
$$ quinidine sulate
$$$ dispyramide (nrpc)
$$$ dispyramide ext-release 150 mg (nrpc CR)
$$$ fecainide (Tmbcr)
$$$ prpaenne (Rythm)
$$$ quinidine glucnate ext-release
$$$ stall (Btpc a)
$$$$ MeXIleTIne
oTHeR HeaRT RelaTeD DRuGS
$ clnidine (Ctprs)
$ digxin tabs (lxi)
$ dxazsin (Crdr)
$ methyldpa$ terazsin
$$ DIGoXIn s
$$ guanacine (Tx)
$$ hydralazine
$$ minxidil
$$ prazsin (Miiprss)
$$$$ CaTaPReS-TTS cidi
7/22/2019 4. PENGGOLONGAN OBAT 1
15/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 15 o 27
Drug cverage is dependent n individual plan benets
$$$$ middrine (Prmti)
$$$$$ DIBenZYlIne phxybzmi
$$$$$ TRaCleeR bst DL
eReCTIle DYSunCTIon
$$$$ VIaGRa sidf DL
Bee STInG KITS
$$$ ePIPen piphri
$$$ ePIPen JR piphri
RESPIRAToRY AGENTS
anTIHISTaMIneS
$ prmethazine supp
$ prmethazine syrup, tabs
$$ cyprheptadine
$$$ exenadine (agr)
$$$$ DeXCHloRPHenIRaMIne MaleaTe syrp
naSal PRoDuCTS
$$ funislide (nsr) DL
$$ funislide 25 mcg/spray DL
$$ futicasne (s) DL
$$ ipratrpium (atrvt) DL
$$$$ aSTelIn zsti DL
$$$$ naSaCoRT aQ trimci DL
$$$$ naSoneX mmts DL
CouGH/ColD/alleRGY
$ brmpheniramine/pseudephedrine ext-release caps, 6/60
$ cdeine/guaienesin sln, 10/100 per 5 mL
$ cdeine/guaienesin tabs, 10/300 (Brtx)
$$$$ acetylcysteine
$$$$ alleGRa-D xdi/psdphdri xt-rs
aSTHMa/CoPD
$ albuterl sulate syrup, tabs
$ thephylline ext-release tabs 12 hr Thechrn
$$ albuterl sulate inhal sln DL
$$ PRoaIR Ha btr st DL
$$$ crmlyn sdium inhal sln DL
$$$ loVenT Ha tics DL
$$$ ipratrpium inhal sln DL
$$$ ipratrpium/albuterl sulate (Db) DL
$$$ MeTaPRoTeRenol tbs
$$$ PulMICoRT leXHaleR bdsid DL
$$$ QVaR bcmths DL
$$$ terbutaline (Brthi)
$$$ thephylline ext-release tabs 24 hr (uiphy)
$$$ XoPeneX Ha vbtr DL
$$$$ aTRoVenT Ha iprtrpim DL
$$$$ CoMBIVenT iprtrpim/btr st DL
$$$$ oRaDIl aeRolIZeR rmtr DL
7/22/2019 4. PENGGOLONGAN OBAT 1
16/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 16 o 27
Drug cverage is dependent n individual plan benets
$$$$ InTal InHaleR crmy sdim DL
$$$$ SeReVenT DISKuS smtr DL
$$$$ SInGulaIR mtkst
$$$$ SPIRIVa HanDIHaleR titrpim DL
$$$$$ aDVaIR DISKuS tics/smtr DL
$$$$$ aDVaIR Ha tics/smtr DL
$$$$$ PulMICoRT ReSPuleS bdsid DL
$$$$$ SYMBICoRT bdsid/rmtr DL
oTHeR ReSPIRaToRY DRuGS
$$$$$ PulMoZYMe drs
GASTRoINTESTINAL DRUGS
laXaTIVeS
$ lactulse
$ PEG electrlytes r sln (Cyt)
$ PEG electrlytes r sln (nyty)
ulCeR/GeRD
$ cimetidine, 200 mg nt cvered
$ dicyclmine (Bty)
$ amtidine (Ppcid), 20 mg nt cvered
$ meprazle delayed-release (Prisc) DL
$ ranitidine (Ztc), 150 mg nt cvered
$$ glycpyrrlate (Rbi)
$$$ CaRaaTe ssp scrt
$$$ hyscyamine ext-release caps (lvsix)
$$$ hyscyamine ext-release tabs (lvbid)
$$$ PRoPanTHelIne BRoMIDe 15 mg
$$$ sucralate tabs (Crt)
$$$$ hyscyamine (lvsi)
$$$$ misprstl (Cyttc)
$$$$ pantprazle delayed-release tabs (Prtix) DL
$$$$$ neXIuM 20 mg, 40 mg smprz dyd-rs DL
$$$$$ PReVPaC mxicii + crithrmyci + sprz dyd-rs
nauSea anD VoMITInG
$ meclizine (ativrt)
$ trimethbenzamide caps (Tig)
$$$ ndansetrn oDT (Zr oDT)
$$$ ndansetrn ral sln, tabs (Zr)
$$$$$ eMenD cps prpitt
DIGeSTIVe enZYMeS Mst pcrips prdcts r prrrd; y sggstd prdcts r istd.
$$$$$ CReon
$$$$$ lIPRaM/Pn/ul
$$$$$ PanCReaSe MT
$$$$$ PanCRelIPaSe tbs, 30-8-30
$$$$$ PlaReTaSe 8000
$$$$$ ulTRaSe/MT
$$$$$ VIoKaSe
7/22/2019 4. PENGGOLONGAN OBAT 1
17/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 17 o 27
Drug cverage is dependent n individual plan benets
oTHeR GaSTRoInTeSTInal DRuGS
$ diphenxylate/atrpine (lmti)
$ lactulse encephalpathy
$ metclpramide (Rg)
$ sulasalazine (azfdi)
$$$$ calcium acetate (Phs)
$$$$ PHoSlo ccim ctt
$$$$ ursdil (actig)
$$$$$ aSaCol msmi dyd-rs
$$$$$ CanaSa msmi spp
$$$$$ DIPenTuM szi
$$$$$ lIalDa msmi dyd-rs
$$$$$ mesalamine enema
$$$$$ PenTaSa msmi xt-rs
$$$$$ RenaGel svmr hc
$$$$$ RenVela svmr crbt
$$$$$ uRSo rsdi
GENIToURINARY DRUGS
uRInaRY TRaCT IneCTIonS
$ nitrurantin mnhydrate/macrcrystals (Mcrbid)
$$ nitrurantin macrcrystals (Mcrdti)
uRInaRY TRaCT SPaSMS
$ xybutynin
$$$$ DeTRol ttrdi
$$$$ DeTRol la ttrdi xt-rs
$$$$ xybutynin ext-release (Ditrp Xl)
$$$$ VeSICaRe sici
VaGInal PRoDuCTS
$$ aCID JellY ctic cid
$$ clindamycin crm (Cci)
$$ eSTRaCe crm strdi
$$ metrnidazle (MtrG-Vgi)
$$ PReMaRIn crm cjgtd strgs
$$$ VaGIeM strdi vgi tbs
$$$$$ CRInone 8% prgstr g
oTHeR GenITouRInaRY DRuGS
$$ ptassium citrate ext-release (urcit-K)
$$ sdium citrate/citric acid (Bicitr)
$$$ nasteride (Prscr)
$$$ ptassium citrate/citric acid pwder, sln (Pycitr-K)
$$$$ aVoDaRT dtstrid
$$$$ loMaX tmssi
$$$$$ CYSTaGon cystmi
CENTRAL NERVoUS SYSTEM DRUGS
anXIeTY
$ alprazlam (Xx)
$ buspirne (Bspr)
7/22/2019 4. PENGGOLONGAN OBAT 1
18/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 18 o 27
Drug cverage is dependent n individual plan benets
$ DIaZePaM r s, 5 mg/5 ml
$ diazepam (Vim)
$ hydrxyzine hcl
$ hydrxyzine pamate (Vistri)
$ lrazepam (ativ)
DePReSSIon
$ amitriptyline
$ citalpram (Cx)
$ dxepin
$ fuxetine (Przc)
$ mirtazapine (Rmr)
$ nrtriptyline (Pmr)
$ parxetine hcl (Pxi)
$ sertraline (Zt)
$ trazdne
$$ buprpin (wbtri)
$$ clmipramine (ari)
$$ desipramine (nrprmi)
$$ imipramine hcl (Tri)$$$ buprpin ext-release 12 hr (wbtri SR)
$$$ buprpin ext-release 24 hr (wbtri Xl)
$$$ tranylcyprmine (Prt)
$$$$ eeXoR XR vxi xt-rs
$$$$ leXaPRo scitprm
$$$$ naRDIl phzi
$$$$ parxetine hcl ext-release, 12.5 mg, 25 mg (Pxi CR)
$$$$ venlaaxine (exr)
PSYCHoTIC anD BIPolaR DISoRDeRS
$ chlrprmazine
$ fuphenazine decanate
$ fuphenazine hcl
$ halperidl decanate (Hd)
$ halperidl lactate ral sln
$ halperidl tabs
$ lithium carbnate caps
$ prchlrperazine supp
$ prchlrperazine tabs
$ thithixene (nv)
$$ lithium carbnate ext-release 300 mg (lithbid)
$$ lithium carbnate ext-release 450 mg$$ perphenazine
$$ trifuperazine
$$$ clzapine 25 mg, 50 mg, 100 mg (Czri)
$$$ lithium citrate
$$$ lxapine
$$$$$ GeoDon ziprsid
$$$$$ RISPeRDal s risprid
7/22/2019 4. PENGGOLONGAN OBAT 1
19/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 19 o 27
Drug cverage is dependent n individual plan benets
$$$$$ RISPeRDal M-TaB risprid
$$$$$ risperidne tabs (Risprd)
$$$$$ SeRoQuel qtipi
$$$$$ SeRoQuel XR qtipi xt-rs
SleeP aIDS
$ CHloRal HYDRaTe spp
$ chlral hydrate syrup
$ estazlam
$ temazepam (Rstri)
$ zlpidem (ambi) DL
$ zalepln (St) DL
$$$$ ReSToRIl 7.5 mg tmzpm
HYPeRaCTIVITY/naRColePSY
$$ amphetamine/dextramphetamine mixed salts (addr)
$$ dextramphetamine
$$ methylphenidate (Riti)
$$ methylphenidate ext-release (Mtdt eR, Riti SR)
$$$$ ConCeRTa mthyphidt xt-rs
$$$$ dextramphetamine ext-release (Dxdri Sps)MulTIPle SCleRoSIS
$$$$$ aVoneX itrr bt-1
$$$$$ CoPaXone gtirmr
$$$$$ ReBI itrr bt-1
oTHeR CenTRal neRVouS SYSTeM DRuGS
$$$ buprpin ext-release (Zyb)
$$$ oRaP pimzid
$$$$ anTaBuSe disfrm
$$$$ CHanTIX vrici
$$$$$ aRICePT dpzi
$$$$$ aRICePT oDT dpzi
$$$$$ eXelon cps, s rivstigmi
$$$$$ eXelon ptchs rivstigmi
PAIN RELIE DRUGS
non-naRCoTIC DRuGS
$ butalbital/acetaminphen tabs, 50/325 (Phrii)
$ butalbital/acetaminphen/caeine caps, 50/325/40 (esgic)
$ butalbital/acetaminphen/caeine tabs, 50/325/40 (irict)
$ butalbital/aspirin/caeine caps, 50/325/40 (iri)
$ butalbital/aspirin/caeine tabs, 50/325/40
$ salsalate
$$ butalbital/acetaminphen tabs, 50/650 (Sdpp)
$$$ butalbital/acetaminphen/caeine tabs, 50/500/40 (esgic Ps)
naRCoTIC DRuGS
$ acetaminphen/cdeine (Ty /Cdi)
$ aspirin/cdeine
$ CoDeIne SulaTe 15 mg
$ cdeine sulate 30 mg, 60 mg
7/22/2019 4. PENGGOLONGAN OBAT 1
20/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 20 o 27
Drug cverage is dependent n individual plan benets
$ DIlauDID-5 hydrmrph
$ hydrcdne/acetaminphen caps, 5/500
$ hydrcdne/acetaminphen tabs, 2.5/500, 5/500, 7.5/500, 10/500 (lrtb)
$ hydrcdne/acetaminphen tabs, 5/325, 7.5/325, 10/325 (nrc)
$ hydrcdne/acetaminphen tabs, 5/500, 7.5/750, 10/660 (Vicdi, Vicdi eS, Vicdi HP)
$ hydrcdne/acetaminphen tabs, 7.5/650, 10/650 (lrct, lrct Ps)
$ methadne cnc, tabs
$ mrphine sulate cnc, 20 mg/mL; tabs
$ xycdne caps (oxyIR)
$ xycdne cnc, sln, tabs (Rxicd)
$ xycdne/acetaminphen caps, 5/500 (Tyx)
$ xycdne/acetaminphen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 (Prcct)
$ prpxyphene hcl/acetaminphen tabs, 65/650
$ prpxyphene napsylate/acetaminphen 50/325, 100/650 (Drvct-n)
$ tramadl (utrm)
$$ butalbital/aspirin/caeine/cdeine caps (iri /Cdi)
$$ hydrcdne/acetaminphen sln, 7.5/500 per 15 mL (lrtb)
$$ hydrcdne/acetaminphen tabs, 10/750 (Mxid)
$$ MoRPHIne SulaTe s, 20 mg/5 ml; spp, 30 mg$$ mrphine sulate supp, 5 mg, 10 mg, 20 mg
$$ xycdne/aspirin tabs, 5/325 (Prcd)
$$$ hydrmrphne supp (Didid)
$$$ mrphine sulate ext-release (MS Cti)
$$$$$ entanyl patches (Drgsic)
$$$$$ KaDIan mrphi st xt-rs
$$$$$ xycdne ext-release (oxyCti)
$$$$$ SuBoXone bprrphi/x
$$$$$ SuBuTeX bprrphi
RHeuMaToID anD oSTeoaRTHRITIS
$ diclenac sdium delayed-release (Vtr)
$ etdlac
$ ibupren susp, 100 mg/5 mL nt cvered
$ ketpren
$ melxicam tabs (Mbic)
$ naprxen (nprsy)
$ naprxen sdium (aprx)
$ pirxicam (d)
$ sulindac (Ciri)
$$ diclenac sdium ext-release (Vtr XR)
$$ indmethacin caps$$ lefunmide (arv)
$$$ nabumetne
$$$$ CeleBReX ccxib
$$$$ DICloenaC SoDIuM dyd-rs tbs, 25 mg
$$$$$ enBRel trcpt
$$$$$ HuMIRa dimmb
7/22/2019 4. PENGGOLONGAN OBAT 1
21/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 21 o 27
Drug cverage is dependent n individual plan benets
MIGRaIne HeaDaCHeS
$ acetaminphen/ismetheptene/dichlralphenazne (Midri)
$$$$$ IMITReX ij smtript DL
$$$$$ IMITReX s smtript DL
$$$$$ IMITReX tbs smtript DL
$$$$$ MaXalT riztript DL
$$$$$ MaXalT-MlT riztript DL
$$$$$ MIGRanal dihydrrgtmi DL
$$$$$ ZoMIG s zmitript DL
$$$$$ ZoMIG tbs zmitript DL
$$$$$ ZoMIG ZMT zmitript DL
GouT
$ allpurinl
$ clchicine
$$ prbenecid
$$$ prbenecid/clchicine
NEURoMUSCULAR DRUGS
SeIZuReS
$ carbamazepine (Tgrt)
$ clnazepam (Kpi)
$ phenbarbital
$ phenytin susp (Diti)
$$ DIlanTIn 30 mg phyti sdim xtdd
$$ gabapentin caps, tabs (nrti)
$$ PHenYTeK phyti sdim xtdd
$$$ DIlanTIn InaTaBS phyti
$$$ divalprex delayed-release (Dpkt)
$$$ phenytin sdium extended (Diti)
$$$ primidne (Mysi)
$$$ valpric acid (Dpk)
$$$ znisamide (Zgr)
$$$$ CelonTIn mthsximid
$$$$ DePaKoTe SPRInKleS divprx
$$$$ ethsuximide (Zrti)
$$$$ neuRonTIn s gbpti
$$$$ TeGReTol-XR crbmzpi xt-rs
$$$$$ DePaKoTe eR divprx xt-rs
$$$$$ DIaSTaT dizpm
$$$$$ GaBITRIl tigbi
$$$$$ KePPRa vtirctm
$$$$$ laMICTal Strtr Kit mtrigi
$$$$$ lamtrigine (lmict)
$$$$$ levetiracetam tabs, 250 mg, 500 mg, 750 mg (Kppr)
$$$$$ xcarbazepine tabs (Tript)
$$$$$ ToPaMaX tpirmt
$$$$$ TRIlePTal ssp xcrbzpi
7/22/2019 4. PENGGOLONGAN OBAT 1
22/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 22 o 27
Drug cverage is dependent n individual plan benets
PaRKInSonS DISeaSe
$ benztrpine
$ trihexyphenidyl
$$ amantadine caps, syrup
$$ selegiline caps (edpry)
$$$ carbidpa/levdpa (Simt)
$$$ rpinirle (Rqip)
$$$$ brmcriptine (Prd)
$$$$ carbidpa/levdpa ext-release (Simt CR)
$$$$$ aPoKYn pmrphi
$$$$$ carbidpa/levdpa oDT (Prcp)
$$$$$ CoMTan tcp
$$$$$ MIRaPeX prmipx
$$$$$ PaRCoPa crbidp/vdp
MuSCle RelaXanTS
$ baclen
$ chlrzxazne
$ cyclbenzaprine (xri)
$ methcarbaml (Rbxi)$ rphenadrine citrate ext-release
$ tizanidine tabs (Zx)
$$ rphenadrine/aspirin/caeine 25/385/30
$$$$ dantrlene (Dtrim)
oTHeR neuRoMuSCulaR DRuGS
$$$ pyridstigmine tabs (Msti)
$$$$ MeSTInon syrp pyridstigmi
$$$$ MeSTInon TIMeSPan pyridstigmi xt-rs
$$$$$ RIluTeK riz
SUPPLEMENTS
VITaMInS
$ MePHYTon phytdi
$$$ calcitril (Rctr)
$$$ ergcalcierl (Drisd)
MulTIVITaMInS
$ pediatric multivitamins/furide
$ pediatric multivitamins/furide/irn
$ pediatric vitamins ADC/furide
$ pediatric vitamins ADC/furide/irn
$ prenatal multivitamins/1 mg lic acid
MIneRalS anD eleCTRolYTeS
$ ptassium chlride ext-release tabs, 8 mEq
$ ptassium chlride ext-release tabs, 10 mEq (K-Tbs)
$ ptassium chlride ext-release tabs, 10 mEq, 20 mEq
$ ptassium chlride packets, 20 mEq (K-lr)
$ ptassium chlride sln, 10%, 20%
$ ptassium phsphate/sdium phsphates (K-Phs ntr)
$$ K-PHoS ptssim phspht mbsic
7/22/2019 4. PENGGOLONGAN OBAT 1
23/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 23 o 27
Drug cverage is dependent n individual plan benets
$$ ptassium chlride ext-release caps, 10 mEq (Micr-K 10)
$$ ptassium bicarbnate/chlride eervescent tabs, 25 mEq (K-lyt/C)
BLooD MoDIYING DRUGS
$ lic acid tabs, 1 mg
$ heparin sdium inj
$ heparin sdium lck fush
$ pentxiylline ext-release (Trt)
$ wararin (Cmdi)
$$$ anagrelide (agryi)
$$$ cilstazl (Pt)
$$$$ DRoXIa hydrxyr
$$$$ PlaVIX 75 mg cpidgr
$$$$$ aRaneSP drbpti
$$$$$ ePoGen pti
$$$$$ loVenoX xpri
$$$$$ neulaSTa pgfgrstim
$$$$$ neuPoGen fgrstim
$$$$$ PRoCRIT pti
ToPICAL PRoDUCTSeYe
Anti-infectives
$ bacitracin int
$ bacitracin/plymyxin B int
$ ciprfxacin sln (Cix)
$ erythrmycin int
$ gentamicin int, sln
$ nemycin/plymyxin B/bacitracin int
$ nemycin/plymyxin B/gramicidin sln (nspri)
$ fxacin sln (ocx)
$ plymyxin B/trimethprim sln (Pytrim)
$ sulacetamide sdium sln (Bph-10)
$ tbramycin sln (Tbrx)
$$$ CIloXan it ciprxci
$$$ VIGaMoX mxixci
$$$$ trifuridine sln (Virptic)
$$$$$ naTaCYn tmyci
Steroids and Combination Products
$ dexamethasne sdium phsphate sln
$ furmethlne susp (Ml)
$ nemycin/plymyxin B/bacitracin/hydrcrtisne int$ nemycin/plymyxin B/dexamethasne int, susp (Mxitr)
$ prednislne acetate susp (Prd rt)
$ PReDnISolone SoDIuM PHoSPHaTe s, 1%
$ sulacetamide sdium/prednislne sln
$$$ loTeMaX tprd
$$$ ZYleT tprd/tbrmyci
$$$$ ToBRaDeX tbrmyci/dxmths
7/22/2019 4. PENGGOLONGAN OBAT 1
24/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 24 o 27
Drug cverage is dependent n individual plan benets
Glaucoma
$ cartell sln
$ levbunll sln (Btg)
$ metipranll sln (optipr)
$ pilcarpine sln (Ispt Crpi)
$ timll maleate gel-rming sln (Timptic-Xe)
$ timll maleate sln (Timptic)
$$ BeTaXolol s, 0.5%
$$ brimnidine sln, 0.2%
$$ drzlamide sln (Trspt)
$$ TRuSoPT drzmid
$$$ alPHaGan P brimidi
$$$ aZoPT brizmid
$$$ BeToPTIC-S btx
$$$ drzlamide/timll maleate sln (Cspt)
$$$ TRaVaTan trvprst
$$$ TRaVaTan Z trvprst
$$$ XalaTan tprst
Other Eye Products$ atrpine sulate int, sln (Ispt atrpi)
$ cyclpentlate sln (Cycgy)
$ diclenac sln (Vtr)
$ furbipren sln (oc)
$ hmatrpine sln (Ispt Hmtrpi)
$$ crmlyn sdium sln (Crm)
$$$ aCulaR P ktrc
$$$$ aCulaR ktrc
$$$$ aCulaR lS ktrc
$$$$ oPTIVaR zsti
$$$$ PaTanol ptdi
eaR
$ acetic acid
$ benzcaine/antipyrine
$ hydrcrtisne/acetic acid
$ nemycin/plymyxin B/hydrcrtisne (Crtispri)
$$$ fxacin (xi otic)
$$$$ CIPRo HC ciprxci/hydrcrtis
$$$$ CIPRoDeX ciprxci/dxmths
MouTH anD THRoaT (c)
$ lidcaine viscus
$ triamcinlne paste
$$ nystatin susp
$$$$$ eVoXaC cvimi
$$$$$ pilcarpine tabs (Sg)
anoReCTal aGenTS
$ hydrcrtisne acetate supp, 25 mg (as-HC)
$ hydrcrtisne crm, 2.5% (as-HC)
7/22/2019 4. PENGGOLONGAN OBAT 1
25/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 25 o 27
Drug cverage is dependent n individual plan benets
$$$$ CoRTIoaM hydrcrtis ctt
$$$$$ hydrcrtisne enema
SKIn ConDITIonS/PRoDuCTS
Acne
$ clindamycin (Cci T)
$ erythrmycin gel
$ erythrmycin pads, sln, 2%
$$ erythrmycin/benzyl perxide (Bzmyci)
$$ sulacetamide sdium/sulur crm, emulsin (Pxi)
$$ tretinin (Rti-a)
$$$ metrnidazle (Mtrti)
$$$ metrnidazle 0.75% (Mtrcrm)
$$$ metrnidazle gel, 0.75%
$$$ sulacetamide sdium/sulur ltn
$$$$ DIeRIn dp
$$$$ InaCea zic cid
$$$$ TaZoRaC tzrt
$$$$$ istretinin caps (acct)
Anti-infectives$ ecnazle
$ gentamicin
$ ketcnazle shamp, 2% (nizr)
$ mupircin int (Bctrb)
$ nystatin (Mycstti)
$ silver suladiazine (Sivd)
$$ ciclpirx (lprx)
$$ ketcnazle crm
$$$ loPRoX g cicpirx
$$$ loPRoX shmp cicpirx
$$$ ZoVIRaX cycvir
Corticosteroids
$ betamethasne diprpinate
$ betamethasne diprpinate, augmented (Dipr)
$ betamethasne valerate
$ clbetasl (Tmvt)
$ desnide (Ds)
$ fucinnide (lidx)
$ futicasne prpinate (Ctivt)
$ hydrcrtisne 2.5%
$ hydrcrtisne valerate (wstcrt)
$ nystatin/triamcinlne
$ triamcinlne
$ TRIaMCInolone it, 0.05%
$$ alclmetasne (acvt)
$$ desximetasne (Tpicrt)
$$ difrasne
$$ halbetasl (utrvt)
7/22/2019 4. PENGGOLONGAN OBAT 1
26/27
B Crss d B Shid Txs 2009 Prrrd Drg Gid 26 o 27
Drug cverage is dependent n individual plan benets
$$ mmetasne (ec)
$$$ clbetasl (ox)
Other Skin Products
$ aluminum chlride sln (Drys)
$ lidcaine jelly, 2%; int, 5%; sln, 4% (Xyci)
$ selenium sulde 2.5% (Ss)
$ XeRaC aC mim chrid
$$ lidcaine/prilcaine crm (em)
$$ permethrin crm, 5% (eimit)
$$ PYRoGallIC aCID pyrg/chrbt
$$$ dxepin crm (Z)
$$$ elIDel pimcrims
$$$$ anthralin (Drith-Crm HP)
$$$$ CaRaC rrci
$$$$ luoRoPleX rrci
$$$$ fururacilcrm, sln, 5% (edx)
$$$$ lindane ltn
$$$$ pdlx sln (Cdyx)
$$$$ PRoToPIC tcrims$$$$$ alDaRa imiqimd
$$$$$ calciptriene sln (Dvx)
$$$$$ DoVoneX crm cciptri
$$$$$ ReGRaneX bcprmi
$$$$$ SolaRaZe dicc sdim
$$$$$ SoRIaTane CK Kit citrti
MISCELLANEoUS CATEGoRIES
DIaBeTIC SuPPlIeS Byr Digstics d Rch Digstics mtrs, bd gcs ctr rgts, d bd gcs tst strips r prrrd.
aCCu-CHeK aCTIVe
aCCu-CHeK aDVanTaGeaCCu-CHeK aVIVa
aCCu-CHeK CoMoRT CuRVe
aCCu-CHeK CoMPaCT
aCCu-CHeK InSTanT
aSCenSIa auToDISC
aSCenSIa BReeZe/BReeZe 2
aSCenSIa ConTouR
aSCenSIa elITe/elITe Xl
BD InSulIn SYRInGeS
BD ulTRaIne Pen neeDleS
lanCeTS & lanCeT DeVICeS
ReSPIRaToRY InHaleR aSSIST DeVICeS
BReaTHeRITe
7/22/2019 4. PENGGOLONGAN OBAT 1
27/27
MISCellaneouS DRuGS
$$ azathiprine (Imr)
$$$ sdium plystyrene sulnate pwder, rectal susp
$$$$$ CellCePT mycpht mti
$$$$$ CHeMeT sccimr
$$$$$ CuPRIMIne picimi
$$$$$ cyclsprine (Sdimm)
$$$$$ cyclsprine mdied caps, 25 mg, 100 mg; sln (nr)
$$$$$ MYoRTIC mycpht dyd-rs
$$$$$ PRoGRa tcrims
$$$$$ RaPaMune sirims