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

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Drug Name Dosage Form Notepramipexole dihydrochloride (1mg)ropinirole hclTABSTABSselegiline hcl *trihexyphenidyl hcl *AntipsychoticsDrug Name Dosage Form NoteABILIFY SOLN (PA) (QL)ABILIFY TABS (PA) (QL)ABILIFY DISCMELT TBDP (PA) (QL)ABILIFY MAINTENA SUSR (MB) (PA) (SP)chlorpromazine hclTABSclozapine (100mg) TABS (QL)clozapine (200mg) TABS (QL)clozapine (25mg) TABS (QL)clozapine (50mg) TABS (QL)CLOZAPINE ODT (100MG) TBDP (QL)CLOZAPINE ODT (12.5MG) TBDP (QL)CLOZAPINE ODT (25MG) TBDP (QL)comproSUPPfluphenazine hcl *FLUPHENAZINE HCL *haloperidolloxapine succinateTABSCAPSolanzapine (10mg) TABS (AG) (QL)olanzapine (15mg) TABS (AG) (QL)olanzapine (2.5mg) TABS (AG) (QL)olanzapine (20mg) TABS (AG) (QL)olanzapine (5mg) TABS (AG) (QL)olanzapine (7.5mg) TABS (AG) (QL)olanzapine odt TBDP (PA) (QL)perphenazinePERPHENAZINE/AMITRIPTYLINEprochlorperazinePROCHLORPERAZINE EDISYLATEprochlorperazine maleateTABSTABSSUPPSOLNTABSquetiapine fumarate (100mg) TABS (AG) (QL)quetiapine fumarate (200mg) TABS (AG) (QL)quetiapine fumarate (25mg) TABS (AG) (QL)quetiapine fumarate (300mg) TABS (AG) (QL)quetiapine fumarate (400mg) TABS (AG) (QL)quetiapine fumarate (50mg) TABS (AG) (QL)[MPC031203] Page 16 of 48 August 15, 2013
Drug Name Dosage Form NoteRISPERDAL CONSTA SUSR (PA) (QL) (SP)risperidone odt (0.25mg) TBDP (PA) (QL)thioridazine hclthiothixenetrifluoperazine hclTABSCAPSTABSziprasidone hcl CAPS (AG) (QL)Antispasticity AgentsDrug Name Dosage Form Notebaclofentizanidine hclTABSTABSAntiviralsDrug Name Dosage Form Noteabacavir TABS (QL)acyclovir *ALFERON N SOLN (SP)amantadine hcl *AMANTADINE HCL *APTIVUS SOLN (QL)APTIVUS CAPS (QL)ATRIPLA TABS (QL)COMPLERA TABS (SP)CRIXIVAN CAPS (QL)didanosine CPDR (QL)EDURANT TABS (SP)EMTRIVASOLNEMTRIVA CAPS (QL)EPIVIR SOLN (QL)EPIVIR HBV *EPZICOM TABS (QL)famciclovirTABSFUZEON KIT (QL)INCIVEK TABS (PA) (QL) (SP)INFERGEN INJ (SP)INTELENCE (100MG) TABS (QL) (SP)INTELENCE (200MG) TABS (QL) (SP)INTELENCE (25MG) TABS (QL) (SP)INTRON-A SOLN (SP)INTRON-A W/DILUENT SOLR (SP)[MPC031203] Page 17 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 and 12: Drug Name Dosage Form Notechlorprom
Page 13 and 14: Drug Name Dosage Form Notetopiramat
Page 15: Drug Name Dosage Form NoteZOLINZA C
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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