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

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Drug Name Dosage Form Notebetamethasone valerate *clobetasol propionate *clobetasol propionate eCREAclotrimazole/betamethasone dipropionate *cormax scalp applicationSOLNcortaid intensive therapycooling spray SOLN (OTC)desonide *DEXAMETHASONE *dexamethasone *DEXAMETHASONE INTENSOLfludrocortisone acetateCONCTABSfluocinolone acetonide *fluocinolone acetonidefluocinolone acetonide bodyfluocinolone acetonide scalpOILOILOILfluocinonide *fluticasone propionate *hydrocortisoneENEMhydrocortisone * (OTC)hydrocortisoneTABShydrocortisone *hydrocortisone valerate *lanacort 10 CREA (OTC)lidocaine hcl/hydrocortisone acetatelokaraMEDROLmethylprednisolonemethylprednisolone dose packMILLIPREDMILLIPRED DPCREALOTNTABSTABSTABSTABSTABSmometasone furoate *prednisoloneprednisolone sodium phosphateSOLNSOLNPREDNISONE *prednisone *proctocream hcproctosol hcSOLU-CORTEFCREACREASOLRTRIAMCINOLONE ACETONIDE *triamcinolone acetonide *TRIANEXOINTHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)[MPC031203] Page 32 of 48 August 15, 2013
Drug Name Dosage Form NoteDrug Name Dosage Form Notedesmopressin acetatedesmopressin acetatedesmopressin acetateSOLNTABSSOLNINCRELEX SOLN (PA) (SP)NORDITROPIN FLEXPRO SOLN (PA) (SP)NORDITROPIN NORDIFLEX PEN SOLN (PA) (SP)OMNITROPE SOLN (PA) (SP)TEV-TROPIN SOLR (PA) (SP)Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)Drug Name Dosage Form NotemisoprostolTABSHormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)Drug Name Dosage Form NoteALORA PTTW (QL)altaveraalyacen 1/35TABSTABSANDRODERM (2MG/24HR) PT24 (PA) (QL)ANDRODERM (4MG/24HR) PT24 (PA) (QL)ANDROGEL (25MG/2.5GM) GEL (PA) (QL)ANDROGEL (50MG/5GM) GEL (PA) (QL)ANDROGEL PUMP (1%) GEL (PA) (QL)ANDROGEL PUMP (1.62%) GEL (PA) (QL)ANDROXY TABS (PA)apriaranelleavianeazurettebalzivacamilacaziantcesiaTABSTABSTABSTABSTABSTABSTABSTABSCOMBIPATCH PTTW (ST)cryselle-28cyclafem 1/35cyclafem 7/7/7danazolTABSTABSTABSCAPS[MPC031203] Page 33 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 and 26: Drug Name Dosage Form Notefosinopri
Page 27: Drug Name Dosage Form Noteamphetami
Page 30 and 31: Drug Name Dosage Form Notetretinoin
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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