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

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Drug Name Dosage Form NoteGAMMAGARD LIQUID SOLN (PA)GAMMAGARD S/D SOLR (PA)GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR (PA)GAMMAPLEXSOLNGAMUNEX SOLN (PA)GAMUNEX-C SOLN (PA)gengraf *hecoriaCAPSHEPAGAM B SOLN (PA)HIZENTRA SOLN (PA) (SP)HUMIRA KIT (PA) (SP)leflunomidemercaptopurinemethotrexateTABSTABSTABSmethotrexate sodium *mycophenolate mofetil *ORENCIA * (PA) (SP)PRIVIGEN SOLN (PA)PROTOPIC OINT (PA) (QL)PROVENGESUSPREBIF SOLN (PA) (SP)REBIF TITRATION PACK SOLN (PA) (SP)REMICADE SOLR (PA) (SP)RIDAURASANDIMMUNESYNAGIStacrolimusTREXALLCAPSSOLNSOLNCAPSTABSTYSABRI CONC (PA) (SP)ZOSTAVAX SOLR (AG)Inflammatory Bowel Disease AgentsDrug Name Dosage Form Notea-hydrocortSOLRAPRISO CP24 (QL) (ST)ASACOL TBEC (ST)balsalazide disodiumCANASACAPSSUPPDEXAMETHASONE *dexamethasone *DEXAMETHASONE INTENSOLhydrocortisoneCONCENEM[MPC031203] Page 38 of 48 August 15, 2013
Drug Name Dosage Form NotehydrocortisoneMEDROLmesalaminemesalaminemethylprednisolonemethylprednisolone dose packMILLIPREDMILLIPRED DPTABSTABSENEMKITTABSTABSTABSTABSPENTASA CPCR (ST)prednisoloneprednisolone sodium phosphateSOLNSOLNPREDNISONE *prednisone *SOLU-CORTEFSOLRsulfasalazine *Metabolic Bone Disease AgentsDrug Name Dosage Form Notealendronate sodiumALENDRONATE SODIUMcalcitonin-salmonTABSTABSSOLNcalcitriol *FORTEO SOLN (PA) (SP)HECTOROLCAPSibandronate sodium TABS (QL) (ST)PROLIA SOLN (PA) (SP)XGEVA SOLN (PA) (SP)zoledronic acid * (MB) (PA)Miscellaneous Therapeutic AgentsDrug Name Dosage Form NoteACCU-CHEK ACTIVE STRIPS STRP (QL)ACCU-CHEK AVIVA STRP (QL)ACCU-CHEK COMFORT CURVE TEST STRIPS STRP (QL)ACCU-CHEK COMPACT STRIPS STRP (QL)ASSESS PEAK FLOW METER LOW RANGEBD INSULIN SYRINGESBD PEN NEEDLESDEVIMISCMISCBOTOX SOLR (PA)EUFLEXXA SOLN (SP)[MPC031203] Page 39 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 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 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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