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

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Drug Name Dosage Form Noteamlodipine besylate/benazepril hydrochlorideatenololCAPSTABSatorvastatin calcium TABS (QL) (ST)benazepril hclbenazepril hcl/hydrochlorothiazidebetaxolol hclbisoprolol fumaratebisoprolol fumarate/hydrochlorothiazidebumetanideTABSTABSTABSTABSTABSTABScandesartan cilexetil TABS (ST)candesartan cilexetil/hydrochlorothiazide TABS (ST)captoprilCAPTOPRIL/HYDROCHLOROTHIAZIDEcartia xtcarvedilolCHLORTHALIDONETABSTABSCP24TABSTABScholestyramine *cholestyramine light *clonidine hclTABSdigoxin *DIGOXIN *DILATRATE SRdilt-cddiltiazem cdCPCRCP24CP24diltiazem hcl *diltiazem hclCP24diltiazem hcl er *diltiazem hcl erdiltiazem hcl erdiltzacCP24CP24CP24DIOVAN TABS (ST)disopyramide phosphatedoxazosin mesylateDUTOPROLDYRENIUMEDECRINenalapril maleateenalapril maleate/hydrochlorothiazidefelodipine erfenofibratefenofibrate micronizedCAPSTABSTB24CAPSTABSTABSTABSTB24TABSCAPSFIRAZYR SOLN (PA) (SP)flecainide acetatefosinopril sodiumTABSTABS[MPC031203] Page 24 of 48 August 15, 2013
Drug Name Dosage Form Notefosinopril sodium/hydrochlorothiazideTABSFUROSEMIDE *furosemide *gemfibrozilguanfacine hclhydralazine hclTABSTABSTABShydrochlorothiazide *indapamideTABSISOSORBIDE DINITRATE *isosorbide dinitrate *isosorbide dinitrate erisosorbide mononitrateisosorbide mononitrate erlabetalol hcllisinoprillisinopril/hydrochlorothiazidelosartan potassiumlosartan potassium/hydrochlorothiazidelovastatinmethyldopametolazonemetoprolol succinate ermetoprolol tartratemetoprolol/hydrochlorothiazidemexiletine hclmidodrine hclminoxidilmoexipril hclmoexipril/hydrochlorothiazideTBCRTABSTB24TABSTABSTABSTABSTABSTABSTABSTABSTB24TABSTABSCAPSTABSTABSTABSTABSMULTAQ TABS (PA) (QL)nadololNIASPANnifediac ccnifedical xlnifedipinenifedipine ernimodipineNISOLDIPINENITRO-BIDNITRO-DURnitroglycerin ernitroglycerin transdermal (0.1mg/hr)nitroglycerin transdermal (0.2mg/hr)nitroglycerin transdermal (0.4mg/hr)TABSTBCRTB24TB24CAPSTB24CAPSTB24OINTPT24CPCRPT24PT24PT24[MPC031203] Page 25 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 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: Drug Name Dosage Form Noteenoxapari
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.

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

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