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

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Drug Name Dosage Form Notenitroglycerin transdermal (0.6mg/hr)NITROSTATNORPACE CRpaceronepentoxifylline erPINDOLOLpravastatin sodiumprazosin hclprevalitepropafenone hclPT24SUBLCP12TABSTBCRTABSTABSCAPSPOWDTABSpropranolol hcl *PROPRANOLOL HCL *propranolol hcl erquinapril hclquinapril/hydrochlorothiazidequinidine gluconate erquinidine sulfateramiprilCP24TABSTABSTBCRTABSCAPSRANEXA TB12 (ST)SIMCOR TB24 (ST)simvastatinsotalol hclsotalol hcl (af)spironolactonespironolactone/hydrochlorothiazidetaztia xtterazosin hclTIMOLOL MALEATETABSTABSTABSTABSTABSCP24CAPSTABStriamterene/hydrochlorothiazide *valsartan/hydrochlorothiazide TABS (ST)verapamil hclVERAPAMIL HCLTABSTABSverapamil hcl er *verapamil hcl srCP24VYTORIN TABS (ST)WELCHOL *ZETIATABSCentral Nervous System AgentsDrug Name Dosage Form Noteamphetamine/dextroamphetamine CP24 (AG) (QL) (ST)[MPC031203] Page 26 of 48 August 15, 2013
Drug Name Dosage Form Noteamphetamine/dextroamphetamine (1.25mg; 1.25mg; TABS1.25mg; 1.25mg)amphetamine/dextroamphetamine (1.875mg; 1.875mg; TABS1.875mg; 1.875mg)amphetamine/dextroamphetamine (2.5mg; 2.5mg; 2.5mg; TABS2.5mg)amphetamine/dextroamphetamine (3.125mg; 3.125mg; TABS3.125mg; 3.125mg)amphetamine/dextroamphetamine (3.75mg; 3.75mg; TABS3.75mg; 3.75mg)amphetamine/dextroamphetamine (5mg; 5mg; 5mg; 5mg) TABS(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)amphetamine/dextroamphetamine (7.5mg; 7.5mg; 7.5mg; TABS(AG) (QL)7.5mg)AMPYRA TB12 (PA) (QL) (SP)AVONEX KIT (SP)butalbital/acetaminophen/caffeine/codeine CAPS (QL)butalbital/asa/caffeinebutalbital/aspirin/caffeie/codeineBUTALBITAL/ASPIRIN/CAFFEINEcaffeine citrateCAPSCAPSTABSSOLNCOPAXONE KIT (SP)CYMBALTA (20MG) CPEP (PA) (QL)CYMBALTA (30MG) CPEP (PA) (QL)CYMBALTA (60MG) CPEP (PA) (QL)dextroamphetamine sulfate TABS (AG) (QL)dextroamphetamine sulfate er CP24 (AG) (QL)EXTAVIA SOLR (PA) (SP)LYRICA (100MG) CAPS (PA) (QL)LYRICA (150MG) CAPS (PA) (QL)LYRICA (200MG) CAPS (PA) (QL)LYRICA (225MG) CAPS (PA) (QL)LYRICA (25MG) CAPS (PA) (QL)LYRICA (300MG) CAPS (PA) (QL)LYRICA (50MG) CAPS (PA) (QL)LYRICA (75MG) CAPS (PA) (QL)methylphenidate hcl TABS (AG) (QL)methylphenidate hcl cd CPCR (AG) (QL)METHYLPHENIDATE HCL ER (10MG) TBCR (AG) (QL)methylphenidate hcl er (18mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (20mg) TBCR (AG) (QL)methylphenidate hcl er (27mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (36mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (54mg) TBCR (AG) (QL) (ST)REBIF SOLN (PA) (SP)REBIF TITRATION PACK SOLN (PA) (SP)STRATTERA CAPS (QL) (ST)[MPC031203] Page 27 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 and 24: Drug Name Dosage Form Noteenoxapari
Page 25: Drug Name Dosage Form Notefosinopri
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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