2013 PHP Salud Formulary/Preferred Drug Listing By Therapeutic ...

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Drug Name Dosage Form NoteketoconazoleTABSketoconazole *nyamycnystatinPOWDSUSPnystatin *nystatinNYSTATIN VAGINALTABSTABSnystatin/triamcinolone *NYSTATIN/TRIAMCINOLONE *nystoppedi-driPOWDPOWDterbinafine hcl TABS (QL)terconazole *VFEND SUSR (PA) (QL)voriconazole TABS (PA) (QL)Antigout AgentsDrug Name Dosage Form NoteallopurinolCOLCRYSprobenecidprobenecid/colchicineTABSTABSTABSTABSULORIC TABS (PA) (QL)Antimigraine AgentsDrug Name Dosage Form Notebutalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (500mg; 50mg; 40mg) TABS (QL)CAFERGOTdivalproex sodiumdivalproex sodium drdivalproex sodium erMIGERGOTTABSCPSPTBECTB24SUPPnaratriptan hcl TABS (QL) (ST)rizatriptan benzoate TABS (ST) (QL)SUMATRIPTAN SOLN (QL)sumatriptan succinate SOLN (QL)sumatriptan succinate TABS (QL)[MPC031203] Page 12 of 48 August 15, 2013
Drug Name Dosage Form Notetopiramate *valproic acidCAPSAntimyasthenic AgentsDrug Name Dosage Form NoteMESTINONpyridostigmine bromideSYRPTABSAntimycobacterialsDrug Name Dosage Form NoteCYCLOSERINEDAPSONEethambutol hclISONIAZIDisoniazidMYCOBUTINPASERpyrazinamiderifampinSEROMYCINCAPSTABSTABSSYRPTABSCAPSPACKTABSCAPSCAPSAntineoplasticsDrug Name Dosage Form NoteAFINITOR TABS (PA) (SP)AFINITOR DISPERZ TBSO (PA) (SP)ALIMTA SOLR (PA)ALKERANanastrozoleTABSTABSAVASTIN SOLN (PA)BOSULIF TABS (PA) (QL) (SP)CAMPATH SOLN (PA)CAPRELSA TABS (PA)CEENU CAPS (PA) (SP)COMETRIQ KIT (PA)CYCLOPHOSPHAMIDETABSEMCYT CAPS (PA) (SP)ERIVEDGE CAPS (PA) (QL) (SP)ERWINAZE SOLR (PA) (SP)[MPC031203] Page 13 of 48 August 15, 2013
Page 1 and 2: 2013 PHP Salud Formulary/Preferred
Page 3 and 4: Drug Name Dosage Form NoteMETHADONE
Page 5 and 6: Drug Name Dosage Form Noteibuprofen
Page 7 and 8: Drug Name Dosage Form NoteMACRODANT
Page 9 and 10: Drug Name Dosage Form NoteDrug Name
Page 11: Drug Name Dosage Form Notechlorprom
Page 15 and 16: Drug Name Dosage Form NoteZOLINZA C
Page 17 and 18: Drug Name Dosage Form NoteRISPERDAL
Page 19 and 20: Drug Name Dosage Form NoteVIREAD *
Page 21 and 22: Drug Name Dosage Form Notequetiapin
Page 23 and 24: Drug Name Dosage Form Noteenoxapari
Page 25 and 26: Drug Name Dosage Form Notefosinopri
Page 27: Drug Name Dosage Form Noteamphetami
Page 30 and 31: Drug Name Dosage Form Notetretinoin
Page 32 and 33: Drug Name Dosage Form Notebetametha
Page 34 and 35: Drug Name Dosage Form Notedrospiren
Page 36 and 37: Drug Name Dosage Form NotevelivetTA
Page 38 and 39: Drug Name Dosage Form NoteGAMMAGARD
Page 40 and 41: Drug Name Dosage Form NoteKALBITOR
Page 42 and 43: Drug Name Dosage Form NoteATROVENT
Page 44 and 45: Drug Name Dosage Form Notecalcifero
Page 46 and 47: Drug Name Dosage Form NoteFERAHEME
Page 48: Pharmacy Prior Authorization Form.

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