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

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Drug Name Dosage Form NoteATROVENT HFAAUVI-QAERSDEVIazelastine hcl SOLN (PA)broncho saline AERS (OTC)budesonide SUSP (AG)cetirizine hcl * (OTC)cetirizine hcl childrens allergy SYRP (OTC)childrens loratadine SYRP (OTC)COMBIVENTAEROCOMBIVENT RESPIMAT AERS (QL)cromolyn sodium AERS (OTC)cromolyn sodiumNEBUcyproheptadine hcl *DALIRESP TABS (PA) (QL)DULERA AERO (ST) (QL)ELIXOPHYLLINELIXfexofenadine hcl TABS (OTC)FLOVENT DISKUSFLOVENT HFAFLUNISOLIDEfluticasone propionateFORADIL AEROLIZERAEPBAEROSOLNSUSPCAPShydroxyzine hcl *hydroxyzine pamoateHYDROXYZINE PAMOATEipratropium bromideipratropium bromideipratropium bromide/albuterol sulfateCAPSCAPSSOLNSOLNSOLNLETAIRIS TABS (PA) (QL) (SP)loratadine TABS (OTC)METAPROTERENOL SULFATE *micronefrin NEBU (OTC)montelukast sodium * (QL)phenadozPROAIR HFASUPPAERSpromethazine hcl *promethazine hcl plainPROMETHEGANPULMICORT FLEXHALERPULMOZYMEQVARSEREVENT DISKUSSYRPSUPPAEPBSOLNAERSAEPBsildenafil citrate TABS (PA) (QL)sodium chloride (0.9%)NEBU[MPC031203] Page 42 of 48 August 15, 2013
Drug Name Dosage Form Notesodium chloride (7%)SPIRIVA HANDIHALERNEBUCAPSSYMBICORT (160MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)SYMBICORT (80MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)terbutaline sulfatetheophylline crTABSTB12theophylline er *triamcinolone acetonideTUDORZA PRESSAIRVENTOLIN HFAINHAAEPBAERSXOLAIR SOLR (PA) (SP)zafirlukastTABSSkeletal Muscle RelaxantsDrug Name Dosage Form Notecarisoprodolcarisoprodol/aspirincarisoprodol/aspirin/codeinechlorzoxazonecyclobenzaprine hclmethocarbamolTABSTABSTABSTABSTABSTABSSleep Disorder AgentsDrug Name Dosage Form NoteLUNESTA TABS (PA) (QL)modafinil TABS (PA) (QL)PHENOBARBITAL *phenobarbital *ROZEREM TABS (PA) (QL)temazepam CAPS (QL)triazolam TABS (QL)XYREMSOLNzaleplon CAPS (QL)zolpidem tartrate TABS (QL)zolpidem tartrate er TBCR (PA) (QL)Therapeutic Nutrients/Minerals/ElectrolytesDrug Name Dosage Form Note[MPC031203] Page 43 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 38 and 39: Drug Name Dosage Form NoteGAMMAGARD
Page 40 and 41: Drug Name Dosage Form NoteKALBITOR
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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