PROSSAM 2020 Formulary (List of Covered Drugs)...PROSSAM - PROSSAM 2020 Page 1 of 171 Updated 11/2019 PROSSAM 2020 Formulary (List of Covered Drugs)

PROSSAM - PROSSAM 2020 Page 1 of 171

Updated 11/2019

PROSSAM

2020 Formulary

(List of Covered Drugs)

PROSSAM

Page 2 of 171 Updated 11/2019

PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]

Drug Name [Nombre del Medicamento]

Drug Tier

[Nivel]

Reference Name [Nombre de Referencia]

Requirements/Limits1

[Requisitos/Límites]

THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

Therapeutic Class [Clase Terapéutica]

5-ALPHA-REDUCTASE INHIBITORS [INHIBIDORES DE LA 5-ALFA-REDUCTASA]

5-alpha-reductase Inhibitors [Inhibidores De La 5-Alfa-Reductasa]

AVODART 0.5 mg cap 3

dutasteride 0.5 mg cap 1 AVODART

dutasteride-tamsulosin hcl 0.5-0.4 mg cap 1 JALYN

finasteride 5 mg tab 1 PROSCAR

JALYN 0.5-0.4 mg cap 3

PROSCAR 5 mg tab 3

ACIDIFYING AGENTS [AGENTES ACIDIFICANTES]

Acidifying Agents [Agentes Acidificantes]

K-PHOS NO 2 305-700 mg tab 3

ADRENALS [ADRENALES]

Adrenals [Adrenales]

betamethasone sod phos & acet 6 (3-3) mg/ml inj susp 1

budesonide 3 mg cap dr prt 4 ENTOCORT PA

budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp 1 PULMICORT QL(60 / 30), AL

CELESTONE SOLUSPAN 6 (3-3) mg/ml inj susp 3

CORTEF 10 mg tab, 20 mg tab, 5 mg tab 3

cortisone acetate 25 mg tab 1 CORTONE

DEPO-MEDROL 20 mg/ml inj susp, 40 mg/ml inj susp, 80 mg/ml inj susp 3

dexamethasone 1 mg tab, 2 mg tab 1

dexamethasone 0.5 mg/5ml soln 1

dexamethasone 0.5 mg/5ml oral elix 1 BAYCADRON

dexamethasone 0.5 mg tab, 0.75 mg tab, 1.5 mg tab, 4 mg tab, 6 mg tab 1 DECADRON

DEXAMETHASONE INTENSOL 1 mg/ml oral conc 3

dexamethasone sod phosphate pf 10 mg/ml inj soln 1

dexamethasone sodium phosphate 100 mg/10ml inj soln, 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln 1

dexamethasone sodium phosphate 10 mg/ml inj soln 1 HEXADROL

PROSSAM




Drug Tier

[Nivel]




DEXPAK 10 DAY 1.5 mg (35) tab pack 3



DULERA 100-5 mcg/act inh aer, 200-5 mcg/act inh aer 2 QL(8.8 / 30)

ENTOCORT EC 3 mg cap dr prt 5 PA

FLOVENT DISKUS 100 mcg/blist inh aer pwdr br act, 250 mcg/blist inh aer pwdr br act, 50 mcg/blist inh aer pwdr br act 3 QL(60 / 30)

FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer 3 QL(12 / 30)

FLOVENT HFA 220 mcg/act inh aer 3 QL(24 / 30)

fludrocortisone acetate 0.1 mg tab 1 FLORINEF

hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab 1 CORTEF

KENALOG 10 mg/ml inj susp, 40 mg/ml inj susp 3

MEDROL 16 mg tab, 2 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 3

methylprednisolone 16 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 1 MEDROL

methylprednisolone acetate 40 mg/ml inj susp, 80 mg/ml inj susp 1 DEPO-MEDROL

methylprednisolone sodium succ 1000 mg inj soln, 125 mg inj soln, 40 mg inj soln 1 SOLU-MEDROL

MILLIPRED 5 mg tab 3

MILLIPRED 10 mg/5ml soln 3

MILLIPRED DP 5 mg (21) tab pack, 5 mg (48) tab pack 3

MILLIPRED DP 12-DAY 5 mg (48) tab pack 3

ORAPRED ODT 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 3

PEDIAPRED 6.7 (5 Base) mg/5ml soln 3

prednisolone 15 mg/5ml soln, 15 mg/5ml syr 1 PRELONE

PROSSAM




Drug Tier

[Nivel]




prednisolone sodium phosphate 25 mg/5ml soln 1

prednisolone sodium phosphate 10 mg/5ml soln 1 MILLIPRED

prednisolone sodium phosphate 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 1 ORAPRED

prednisolone sodium phosphate 15 mg/5ml soln 1 ORAPRED

prednisolone sodium phosphate 6.7 (5 Base) mg/5ml soln 1 PEDIAPRED

prednisolone sodium phosphate 20 mg/5ml soln 1 VERIPRED

prednisone 1 mg tab, 10 mg (21) tab pack, 10 mg (48) tab pack, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg (21) tab pack, 5 mg (48) tab pack, 5 mg tab, 50 mg tab 1

prednisone 5 mg/5ml soln 1

PREDNISONE INTENSOL 5 mg/ml oral conc 3

QVAR 40 mcg/act inh aer soln, 80 mcg/act inh aer soln 2 QL(8.7 / 30)

QVAR REDIHALER 40 mcg/act inh aer br act, 80 mcg/act inh aer br act 2 QL(10.6 / 30)

RAYOS 1 mg tab dr, 2 mg tab dr, 5 mg tab dr 3

SOLU-CORTEF 100 mg inj soln, 1000 mg inj soln, 250 mg inj soln, 500 mg inj soln 3

SOLU-MEDROL 1000 mg inj soln, 125 mg inj soln, 2 gm inj soln, 40 mg inj soln, 500 mg inj soln 3

SYMBICORT 160-4.5 mcg/act inh aer, 80-4.5 mcg/act inh aer 2 QL(10.2 / 30)

triamcinolone acetonide 40 mg/ml inj susp 1 KENALOG

UCERIS 9 mg tab er 24 hr 4 PA

VERIPRED 20 20 mg/5ml soln 3

ALCOHOL DETERRENTS [DISUASIVOS DE ALCOHOL]

Alcohol Deterrents [Disuasivos De Alcohol]

ANTABUSE 250 mg tab, 500 mg tab 3

disulfiram 250 mg tab, 500 mg tab 1 ANTABUSE

ALKALINIZING AGENTS [AGENTES ALCALINIZANTES]

Alkalinizing Agents [Agentes Alcalinizantes]

PROSSAM




Drug Tier

[Nivel]




cytra k crystals 3300-1002 mg pckt 1

ORACIT 490-640 mg/5ml soln 3

pot & sod cit-cit ac 550-500-334 mg/5ml soln 1

potassium citrate er 10 MEQ (1080 mg) tab er, 15 MEQ (1620 mg) tab er, 5 MEQ (540 mg) tab er 1 UROCIT-K

potassium citrate-citric acid 1100-334 mg/5ml soln 1

SHOHLS MODIFIED 500-334 mg/5ml soln 3

sod citrate-citric acid 500-334 mg/5ml soln 1

TARON-CRYSTALS 3300-1002 mg pckt 3

tricitrates 550-500-334 mg/5ml soln 1

UROCIT-K 10 10 MEQ (1080 mg) tab er 3



ALPHA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES ALFA-ADRENÉRGICOS]

Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]

CARDURA 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 3

CARDURA XL 4 mg tab er 24 hr, 8 mg tab er 24 hr 3

doxazosin mesylate 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 CARDURA

MINIPRESS 1 mg cap, 2 mg cap, 5 mg cap 3

prazosin hcl 1 mg cap, 2 mg cap, 5 mg cap 1 MINIPRESS

terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 HYTRIN

AMMONIA DETOXICANTS [DETOXIFICANTES DE AMONÍACO]

Ammonia Detoxicants [Detoxificantes De Amoníaco]

CARBAGLU 200 mg tab 3

constulose 10 gm/15ml soln 1 CONSTULOSE

enulose 10 gm/15ml soln 1

generlac 10 gm/15ml soln 1

KRISTALOSE 10 gm pckt, 20 gm pckt 3

PROSSAM




Drug Tier

[Nivel]




lactulose 10 gm/15ml soln, 20 gm/30ml soln 1 CONSTULOSE

lactulose encephalopathy 10 gm/15ml soln 1

LITHOSTAT 250 mg tab 3

ANALGESICS AND ANTIPYRETICS [ANALGÉSICOS Y ANTIPIRÉTICOS]

Analgesics And Antipyretics, Misc [Analgésicos Y Antipiréticos, Misceláneos]

BUPAP 50-300 mg tab 3

butalbital-acetaminophen 50-300 mg tab 1 BUPAP

butalbital-acetaminophen 50-325 mg tab 1 TENCON

butalbital-apap 50-325 mg tab 1 TENCON

butalbital-apap-caffeine 50-325-40 mg cap, 50-325-40 mg tab 1 ESGIC

butalbital-apap-caffeine 50-300-40 mg cap 1 FIORICET

duraxin 300-200-20 mg cap 1

ESGIC 50-325-40 mg cap, 50-325-40 mg tab 3

FIORICET 50-300-40 mg cap 3

GRALISE 300 mg tab, 600 mg tab 3

GRALISE STARTER 300 & 600 mg oral misc 3

ILARIS 150 mg/ml sc soln 3

PHRENILIN FORTE 50-300-40 mg cap 3

PRIALT 100 mcg/ml it soln, 500 mcg/20ml it soln, 500 mcg/5ml it soln 3

TENCON 50-325 mg tab 3

VANATOL LQ 50-325-40 mg/15ml soln 3

VANATOL S 50-325-40 mg/15ml soln 3

ZEBUTAL 50-325-40 mg cap 3

Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]

ANAPROX DS 550 mg tab 3

ARTHROTEC 50-0.2 mg tab dr, 75-0.2 mg tab dr 3

butalbital-aspirin-caffeine 50-325-40 mg tab 1

butalbital-aspirin-caffeine 50-325-40 mg cap 1 FIORINAL

CAMBIA 50 mg pckt 3 QL(9 / 30)

PROSSAM




Drug Tier

[Nivel]




CELEBREX 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 3

celecoxib 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 1 CELEBREX

choline-mag trisalicylate 500 mg/5ml liq 1

DAYPRO 600 mg tab 3

diclofenac potassium 50 mg tab 1 CATAFLAM

diclofenac sodium 25 mg tab dr, 50 mg tab dr, 75 mg tab dr 1 VOLTAREN

diclofenac sodium er 100 mg tab er 24 hr 1 VOLTAREN

diclofenac-misoprostol 50-0.2 mg tab dr, 75-0.2 mg tab dr 1 ARTHROTEC

diflunisal 500 mg tab 1 DOLOBID

DUEXIS 800-26.6 mg tab 3

EC-NAPROSYN 375 mg tab dr, 500 mg tab dr 3

etodolac 200 mg cap, 300 mg cap, 400 mg tab, 500 mg tab 1 LODINE

etodolac er 400 mg tab er 24 hr, 500 mg tab er 24 hr, 600 mg tab er 24 hr 1 LODINE XL

FELDENE 10 mg cap, 20 mg cap 3

fenoprofen calcium 400 mg cap, 600 mg tab 1 NALFON

FIORINAL 50-325-40 mg cap 3

flurbiprofen 100 mg tab, 50 mg tab 1 ANSAID

IBU 400 mg tab, 600 mg tab, 800 mg tab 1

ibuprofen 400 mg tab, 600 mg tab, 800 mg tab 1 MOTRIN

IBUPROFEN COMFORT PAC 800 mg cmb kit 3

IC 400 400 mg oral kit 3

IC 800 800 mg oral kit 3

INDOCIN 50 mg rect supp 3

INDOCIN 25 mg/5ml susp 3

indomethacin 25 mg cap, 50 mg cap 1 INDOCIN

indomethacin er 75 mg cap er 1 INDOCIN

ketoprofen 75 mg cap 1 ORUDIS

ketoprofen er 200 mg cap er 24 hr 1 ORUVAIL

ketorolac tromethamine 60 mg/2ml im soln 1

ketorolac tromethamine 10 mg tab 1 TORADOL

PROSSAM




Drug Tier

[Nivel]




ketorolac tromethamine 15 mg/ml inj soln, 30 mg/ml inj soln 1 TORADOL

meclofenamate sodium 100 mg cap, 50 mg cap 1 MECLOMEN

mefenamic acid 250 mg cap 1 PONSTEL

meloxicam 15 mg tab, 7.5 mg tab 1 MOBIC

MELOXICAM COMFORT PAC 15 mg cmb kit 3

MOBIC 15 mg tab, 7.5 mg tab 3

nabumetone 500 mg tab, 750 mg tab 1 RELAFEN

NALFON 400 mg cap 3

NAPRELAN 375 mg tab er 24 hr, 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

NAPROSYN 500 mg tab 3

NAPROSYN 125 mg/5ml susp 3

naproxen 250 mg tab, 375 mg tab, 500 mg tab 1 NAPROSYN

naproxen 125 mg/5ml susp 1 NAPROSYN

NAPROXEN COMFORT PAC 500 mg cmb kit 3

naproxen dr 375 mg tab dr, 500 mg tab dr 1 NAPROSYN

naproxen sodium 275 mg tab, 550 mg tab 1 ANAPROX

naproxen sodium er 500 mg tab er 24 hr 1 NAPRELAN

oxaprozin 600 mg tab 1 DAYPRO

piroxicam 10 mg cap, 20 mg cap 1 FELDENE

salsalate 500 mg tab, 750 mg tab 1

SPRIX 15.75 mg/spray nasal soln 3

sulindac 150 mg tab, 200 mg tab 1 CLINORIL

tolmetin sodium 200 mg tab 1

tolmetin sodium 400 mg cap, 600 mg tab 1 TOLECTIN

VIMOVO 375-20 mg tab dr, 500-20 mg tab dr 3

ZIPSOR 25 mg cap 3

Opiate Agonists [Agonistas De Opiáceos]

ABSTRAL 100 mcg tab subl, 200 mcg tab subl, 300 mcg tab subl, 400 mcg tab subl, 600 mcg tab subl, 800 mcg tab subl 3

acetaminophen-codeine 300-15 mg tab, 300-60 mg tab 1

TYLENOL WITH CODEINE

PROSSAM




Drug Tier

[Nivel]




acetaminophen-codeine 120-12 mg/5ml soln 1


acetaminophen-codeine #2 300-15 mg tab 1






ACTIQ 1200 mcg bucc lozg on hd, 1600 mcg bucc lozg on hd, 200 mcg bucc lozg on hd, 400 mcg bucc lozg on hd, 600 mcg bucc lozg on hd, 800 mcg bucc lozg on hd 3

ASCOMP-CODEINE 50-325-40-30 mg cap 3

butalbital-apap-caff-cod 50-325-40-30 mg cap 1

FIORICET WITH CODEINE

butalbital-asa-caff-codeine 50-325-40-30 mg cap 1

FIORINAL WITH CODEINE

codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab 1

CONZIP 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3

DEMEROL 100 mg tab 3

DEMEROL 100 mg/2ml inj soln, 100 mg/ml inj soln, 25 mg/0.5ml inj soln, 25 mg/ml inj soln, 50 mg/ml inj soln, 75 mg/1.5ml inj soln, 75 mg/ml inj soln 3

DILAUDID 2 mg tab, 4 mg tab, 8 mg tab 3

DILAUDID 1 mg/ml liq 3

DURAGESIC-100 100 mcg/hr td patch 72 hr 3





duramorph 0.5 mg/ml inj soln, 1 mg/ml inj soln 1

PROSSAM




Drug Tier

[Nivel]




ENDOCET 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1

ENDOCET 2.5-325 mg tab 3

EXALGO 12 mg tab er 24 hr abuse-deterr, 16 mg tab er 24 hr abuse-deterr, 32 mg tab er 24 hr abuse-deterr, 8 mg tab er 24 hr abuse-deterr 3

fentanyl 100 mcg/hr td patch 72 hr, 12 mcg/hr td patch 72 hr, 25 mcg/hr td patch 72 hr, 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr 1 DURAGESIC

fentanyl citrate 1200 mcg bucc lozg on hd, 1600 mcg bucc lozg on hd, 200 mcg bucc lozg on hd, 400 mcg bucc lozg on hd, 600 mcg bucc lozg on hd, 800 mcg bucc lozg on hd 1 ACTIQ

FENTORA 100 mcg bucc tab, 200 mcg bucc tab, 400 mcg bucc tab, 600 mcg bucc tab, 800 mcg bucc tab 3

FIORINAL/CODEINE #3 50-325-40-30 mg cap 3

hydrocodone-acetaminophen 2.5-108 mg/5ml soln, 5-217 mg/10ml soln, 7.5-325 mg/15ml soln 1 HYCET

hydrocodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 NORCO

hydrocodone-acetaminophen 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 1 VICODIN

hydrocodone-ibuprofen 10-200 mg tab, 5-200 mg tab 1 REPREXAIN

hydrocodone-ibuprofen 7.5-200 mg tab 1 VICOPROFEN

hydromorphone hcl 1 mg/ml inj soln 1

hydromorphone hcl 2 mg tab, 4 mg tab, 8 mg tab 1 DILAUDID

hydromorphone hcl 1 mg/ml liq 1 DILAUDID

hydromorphone hcl er 12 mg tab er 24 hr abuse-deterr, 16 mg tab er 24 hr abuse-deterr, 32 mg tab er 24 hr abuse-deterr, 8 mg tab er 24 hr abuse-deterr 1 EXALGO

PROSSAM




Drug Tier

[Nivel]




hydromorphone hcl pf 10 mg/ml inj soln, 50 mg/5ml inj soln, 500 mg/50ml inj soln 1 DILAUDID-HP

IBUDONE 10-200 mg tab, 5-200 mg tab 3

KADIAN 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 200 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 3

LAZANDA 100 mcg/act nasal soln, 400 mcg/act nasal soln 3

levorphanol tartrate 2 mg tab 1

LORCET 5-325 mg tab 3

LORCET HD 10-325 mg tab 3

LORCET PLUS 7.5-325 mg tab 3

LORTAB 10-300 mg/15ml oral elix 3

MAXIDONE 10-750 mg tab 3

meperidine hcl 10 mg/ml inj soln 1

meperidine hcl 100 mg tab, 50 mg tab 1 DEMEROL

meperidine hcl 100 mg/ml inj soln, 25 mg/ml inj soln, 50 mg/5ml soln, 50 mg/ml inj soln 1 DEMEROL

morphine sulfate 15 mg tab, 30 mg tab 1

morphine sulfate 10 mg/5ml soln, 20 mg/5ml soln 1

morphine sulfate (concentrate) 100 mg/5ml soln 1

morphine sulfate (pf) 0.5 mg/ml inj soln, 1 mg/ml inj soln 1

morphine sulfate er 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 KADIAN

morphine sulfate er 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 1 MS CONTIN

morphine sulfate er beads 120 mg cap er 24 hr, 30 mg cap er 24 hr, 45 mg cap er 24 hr, 60 mg cap er 24 hr, 75 mg cap er 24 hr, 90 mg cap er 24 hr 1 AVINZA

PROSSAM




Drug Tier

[Nivel]




MS CONTIN 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 3

NORCO 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3

NUCYNTA 100 mg tab, 50 mg tab, 75 mg tab 3

NUCYNTA ER 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr, 250 mg tab er 12 hr, 50 mg tab er 12 hr 3

OXAYDO 5 mg tab abuse-deterr, 7.5 mg tab abuse-deterr 3

oxycodone hcl 10 mg tab, 20 mg tab, 5 mg cap 1

oxycodone hcl 15 mg tab, 30 mg tab, 5 mg tab 1 ROXICODONE

oxycodone hcl 100 mg/5ml oral conc, 5 mg/5ml soln 1 ROXICODONE

oxycodone hcl er 10 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 1 OXYCONTIN

oxycodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 PERCOCET

oxycodone-aspirin 4.8355-325 mg tab 1 PERCODAN

oxycodone-ibuprofen 5-400 mg tab 1 COMBUNOX

OXYCONTIN 10 mg tab er 12 hr abuse-deterr, 15 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 30 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 60 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 3

oxymorphone hcl 10 mg tab, 5 mg tab 1 OPANA

oxymorphone hcl er 15 mg tab er 12 hr, 7.5 mg tab er 12 hr 1 OPANA ER

PERCOCET 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3

PROSSAM




Drug Tier

[Nivel]




PRIMLEV 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 3

ROXICODONE 15 mg tab, 30 mg tab, 5 mg tab 3

SUBSYS 100 mcg subl liq, 1200 (600 X 2) mcg subl liq, 1600 (800 X 2) mcg subl liq, 200 mcg subl liq, 400 mcg subl liq, 600 mcg subl liq, 800 mcg subl liq 3

tramadol hcl 50 mg tab 1 ULTRAM

tramadol hcl er 150 mg cap er 24 hr 1

tramadol hcl er 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 1 CONZIP

tramadol hcl er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 ULTRAM ER

tramadol hcl er (biphasic) 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 RYZOLT

tramadol-acetaminophen 37.5-325 mg tab 1 ULTRACET

TYLENOL WITH CODEINE #3 300-30 mg tab 3

TYLENOL WITH CODEINE #4 300-60 mg tab 3

ULTRACET 37.5-325 mg tab 3

ULTRAM 50 mg tab 3

VICODIN 5-300 mg tab 3

VICODIN ES 7.5-300 mg tab 3

VICODIN HP 10-300 mg tab 3

Opiate Partial Agonists [Agonistas Parciales De Opiáceos]

buprenorphine 10 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch 1 BUTRANS PA

buprenorphine hcl 2 mg tab subl, 8 mg tab subl 1 SUBUTEX PA

buprenorphine hcl-naloxone hcl 2-0.5 mg tab subl, 8-2 mg tab subl 1 SUBOXONE PA

butorphanol tartrate 1 mg/ml inj soln, 10 mg/ml nasal soln, 2 mg/ml inj soln 1 STADOL PA

BUTRANS 10 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch 3 PA

nalbuphine hcl 10 mg/ml inj soln 1 NUBAIN PA

PROSSAM




Drug Tier

[Nivel]




pentazocine-naloxone hcl 50-0.5 mg tab 1 PA

SUBOXONE 12-3 mg subl film, 2-0.5 mg subl film, 4-1 mg subl film, 8-2 mg subl film 3 PA

ZUBSOLV 1.4-0.36 mg tab subl, 5.7-1.4 mg tab subl 3 PA

ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS [AGENTES ANOREXÍGENOS Y ESTIMULANTES RESPIRATORIOS Y DEL SNC]

Amphetamines [Anfetaminas]

ADDERALL 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 3 PA

ADDERALL XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA

amphetamine-dextroamphet er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 1 ADDERALL XR PA

amphetamine-dextroamphetamine 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 ADDERALL PA

DESOXYN 5 mg tab 3 PA

DEXEDRINE 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA

dextroamphetamine sulfate 5 mg/5ml soln 1 PA

dextroamphetamine sulfate 10 mg tab, 5 mg tab 1 DEXEDRINE PA

dextroamphetamine sulfate er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 1 DEXEDRINE PA

methamphetamine hcl 5 mg tab 1 DESOXYN PA

PROCENTRA 5 mg/5ml soln 3 PA

VYVANSE 10 mg cap, 10 mg tab chew, 20 mg cap, 20 mg tab chew, 30 mg cap, 30 mg tab chew, 40 mg cap, 40 mg tab chew, 50 mg cap, 50 mg tab chew, 60 mg cap, 60 mg tab chew, 70 mg cap 3 PA

Respiratory And Cns Stimulants [Estimulantes Del Snc Y Respiratorios]

PROSSAM




Drug Tier

[Nivel]




CONCERTA 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 3 PA

DAYTRANA 10 mg/9hr td patch, 15 mg/9hr td patch, 20 mg/9hr td patch, 30 mg/9hr td patch 3 PA

dexmethylphenidate hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 FOCALIN PA

dexmethylphenidate hcl er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 1 FOCALIN XR PA

FOCALIN 10 mg tab, 2.5 mg tab, 5 mg tab 3 PA

FOCALIN XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA

METADATE ER 20 mg tab er 3 PA

METHYLIN 10 mg/5ml soln, 5 mg/5ml soln 3 PA

methylphenidate hcl 10 mg tab chew, 2.5 mg tab chew, 5 mg tab chew 1 METHYLIN PA

methylphenidate hcl 10 mg/5ml soln, 5 mg/5ml soln 1 METHYLIN PA

methylphenidate hcl 10 mg tab, 20 mg tab, 5 mg tab 1 RITALIN PA

methylphenidate hcl er 18 mg tab er 24 hr, 27 mg tab er 24 hr, 36 mg tab er 24 hr, 54 mg tab er 24 hr 1 PA

methylphenidate hcl er 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 1 CONCERTA PA

methylphenidate hcl er 10 mg tab er 1 METADATE PA

methylphenidate hcl er 20 mg tab er 1 RITALIN SR PA

methylphenidate hcl er (cd) 30 mg cap er, 50 mg cap er, 60 mg cap er 1 METADATE PA

methylphenidate hcl er (cd) 10 mg cap er, 20 mg cap er, 40 mg cap er 1 METADATE CD PA

PROSSAM




Drug Tier

[Nivel]




methylphenidate hcl er (la) 30 mg cap er 24 hr 1 PA

methylphenidate hcl er (la) 20 mg cap er 24 hr, 40 mg cap er 24 hr 1 RITALIN LA PA

RITALIN 10 mg tab, 20 mg tab, 5 mg tab 3 PA

RITALIN LA 10 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr 3 PA

Wakefulness-promoting Agents [Agentes Promotores Del Estado De Vigilia]

modafinil 100 mg tab, 200 mg tab 1 PROVIGIL

NUVIGIL 150 mg tab, 250 mg tab, 50 mg tab 3

PROVIGIL 100 mg tab, 200 mg tab 3

ANTHELMINTICS [ANTIHELMÍNTICOS]

Anthelmintics [Antihelmínticos]

ALBENZA 200 mg tab 3

BILTRICIDE 600 mg tab 3

ivermectin 3 mg tab 1 STROMECTOL

STROMECTOL 3 mg tab 3

ANTIALLERGIC AGENTS [AGENTES ANTIALÉRGICOS]

Antiallergic Agents [Agentes Antialérgicos]

ALOMIDE 0.1 % ophth soln 3

ASTEPRO 0.15 % nasal soln 3

azelastine hcl 0.1 % nasal soln, 137 mcg/spray nasal soln 1 ASTELIN

azelastine hcl 0.15 % nasal soln 1 ASTEPRO

azelastine hcl 0.05 % ophth soln 1 OPTIVAR

BEPREVE 1.5 % ophth soln 3

cromolyn sodium 4 % ophth soln 1 OPTICROM

DYMISTA 137-50 mcg/act nasal susp 2

ELESTAT 0.05 % ophth soln 3

EMADINE 0.05 % ophth soln 3

epinastine hcl 0.05 % ophth soln 1 ELESTAT

LASTACAFT 0.25 % ophth soln 2

olopatadine hcl 0.6 % nasal soln 1 PATANASE

PATADAY 0.2 % ophth soln 2

PATANASE 0.6 % nasal soln 3

ANTIANEMIA DRUGS [MEDICAMENTOS CONTRA LA ANEMIA]

Iron Preparations [Preparaciones De Hierro]

BIFERARX 22-6-1-0.025 mg tab 3

BPROTECTED PEDIA IRON 75 (15 Fe) mg/ml soln 1 AL

CENTRATEX 106-1 mg cap 3

CHROMAGEN cap 3

PROSSAM




Drug Tier

[Nivel]




CORVITA 150 150-1.25 mg tab 3

CORVITE 150 150-1.25 mg tab 3

corvite fe tab 1

FER-IN-SOL 75 (15 Fe) mg/ml soln 1 AL

ferocon cap 1

ferotrinsic cap 1

FERRALET 90 90-1 mg tab 3

ferraplus 90 90-1 mg tab 1

FERREX 150 FORTE PLUS 50-100 mg cap 3

FERROCITE PLUS 106-1 mg tab 3

FERRO-PLEX HEMATINIC 115-1 mg tab 3

FERROTRIN cap 3

ferrous sulfate 75 (15 Fe) mg/ml soln 1 AL

FOLIVANE-F 125-1 mg cap 3

FOLIVANE-PLUS cap 3

foltrin cap 1

hematinic plus vit/minerals 106-1 mg tab 1

hematinic/folic acid 324-1 mg tab 1

HEMATOGEN cap 3

HEMATOGEN FA 200-250-0.01-1 mg cap 3

HEMATOGEN FORTE 460-60-0.01-1 mg cap 3

HEMATRON-AF 150-1 mg tab 3

hemetab 22-6-1-0.025 mg tab 1

HEMOCYTE PLUS 106-1 mg cap 3

HEMOCYTE-F 324-1 mg tab 3

hemocyte-plus 106-1 mg tab 1

ICAR-C PLUS 100-250-0.025-1 mg tab 3

IFEREX 150 FORTE 150-25-1 mg-mcg-mg cap 3

INTEGRA F 125-1 mg cap 3

INTEGRA PLUS cap 3

iron supplement childrens 75 (15 Fe) mg/ml soln 1 AL

IROSPAN 24/6 oral misc 3

IS 24/6 oral misc 3

K-TAN PLUS 162-115.2-1 mg cap 3

MULTIGEN 70 mg tab 3

MULTIGEN FOLIC 70-150-2-1 mg tab 3

PROSSAM




Drug Tier

[Nivel]




MULTIGEN PLUS 50-101-1 mg tab 3

myferon 150 forte 150-25-1 mg-mcg-mg cap 1

NEPHRON FA tab 3

poly-iron 150 forte 150-25-1 mg-mcg-mg cap 1

polysaccharide iron forte 150-25-1 mg-mcg-mg cap 1

PROFERRIN-FORTE 12-1 mg tab 3

PROTECTIRON 60-1 mg tab 3

purefe plus 106-1 mg cap 1

purevit dualfe plus 162-115.2-1 mg cap 1

RENATABS WITH IRON 1 & 100 mg oral misc 3

se-tan plus 162-115.2-1 mg cap 1

TANDEM F 162-115.2-1 mg cap 3

TANDEM PLUS 162-115.2-1 mg cap 3

taron forte cap 1

tl icon cap 1

tl-hem 150 150-1 mg tab 1

TRICON cap 3

trigels-f forte 460-60-0.01-1 mg cap 1

VITAFOL tab 3

ANTIBACTERIALS [ANTIBACTERIANOS]

Aminoglycosides [Aminoglucósidos]

amikacin sulfate 1 gm/4ml inj soln 1

amikacin sulfate 500 mg/2ml inj soln 1 AMIKIN

gentamicin sulfate 10 mg/ml inj soln 1

gentamicin sulfate 40 mg/ml inj soln 1 GENTAK

KITABIS PAK 300 mg/5ml inh neb soln 5 PA

neomycin sulfate 500 mg tab 1

streptomycin sulfate 1 gm im soln 1

TOBI 300 mg/5ml inh neb soln 5 PA

tobramycin 300 mg/5ml inh neb soln 5 TOBI PA

tobramycin sulfate 1.2 gm inj soln 1

tobramycin sulfate 1.2 gm/30ml inj soln, 10 mg/ml inj soln, 2 gm/50ml inj soln, 80 mg/2ml inj soln 1

Antibacterials, Miscellaneous [Antibacterianos, Misceláneos]

baciim 50000 unit im soln 1 BACI-IM

bacitracin 50000 unit im soln 1 BACI-IM

PROSSAM




Drug Tier

[Nivel]




CLEOCIN 150 mg cap, 300 mg cap, 75 mg cap 3

CLEOCIN 75 mg/5ml soln 3

CLEOCIN PHOSPHATE 900 mg/6ml inj soln 3

clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap 1 CLEOCIN

clindamycin palmitate hcl 75 mg/5ml soln 1 CLEOCIN

clindamycin phosphate 600 mg/4ml iv soln 1

clindamycin phosphate 900 mg/6ml inj soln 1 CLEOCIN

colistimethate sodium (cba) 150 mg inj soln 1

COLY-MYCIN M 150 mg inj soln 3

LINCOCIN 300 mg/ml inj soln 3

lincomycin hcl 300 mg/ml inj soln 1 LINCOCIN

linezolid 600 mg/300ml iv soln 4 ZYVOX PA

linezolid 600 mg tab 5 ZYVOX PA

linezolid 100 mg/5ml susp 5 ZYVOX PA

linezolid in sodium chloride 600-0.9 mg/300ml-% iv soln 4 PA

VANCOCIN HCL 125 mg cap, 250 mg cap 5 PA

vancomycin hcl 125 mg cap, 250 mg cap 1

XIFAXAN 200 mg tab, 550 mg tab 5 PA

ZYVOX 600 mg tab 5 PA

ZYVOX 100 mg/5ml susp, 200 mg/100ml iv soln, 600 mg/300ml iv soln 5 PA

Cephalosporins [Cefalosporinas]

cefaclor 250 mg cap, 500 mg cap 1 CECLOR

cefaclor er 500 mg tab er 12 hr 1 CECLOR CD

cefadroxil 1 gm tab, 500 mg cap 1 DURICEF

cefadroxil 250 mg/5ml susp, 500 mg/5ml susp 1 DURICEF

cefazolin sodium 1 gm inj soln, 500 mg inj soln 1 ANCEF

cefdinir 300 mg cap 1 OMNICEF

cefdinir 125 mg/5ml susp, 250 mg/5ml susp 1 OMNICEF

cefditoren pivoxil 200 mg tab, 400 mg tab 1 SPECTRACEF

PROSSAM




Drug Tier

[Nivel]




cefepime hcl 1 gm inj soln, 2 gm inj soln 1 MAXIPIME

cefixime 100 mg/5ml susp, 200 mg/5ml susp 1 SUPRAX

cefpodoxime proxetil 100 mg tab, 200 mg tab 1 VANTIN

cefpodoxime proxetil 100 mg/5ml susp, 50 mg/5ml susp 1 VANTIN

cefprozil 250 mg tab, 500 mg tab 1 CEFZIL

cefprozil 125 mg/5ml susp, 250 mg/5ml susp 1 CEFZIL

ceftazidime 1 gm inj soln 1 TAZICEF

CEFTIN 125 mg/5ml susp, 250 mg/5ml susp 3

ceftriaxone sodium 1 gm inj soln, 2 gm inj soln, 250 mg inj soln, 500 mg inj soln 1 ROCEPHIN

cefuroxime axetil 250 mg tab, 500 mg tab 1 CEFTIN

cefuroxime sodium 1.5 gm iv soln 1

cefuroxime sodium 750 mg inj soln 1 ZINACEF

cephalexin 250 mg tab, 500 mg tab 1

cephalexin 250 mg cap, 500 mg cap, 750 mg cap 1 KEFLEX

cephalexin 125 mg/5ml susp, 250 mg/5ml susp 1 KEFLEX

KEFLEX 250 mg cap, 500 mg cap, 750 mg cap 3

SPECTRACEF 400 mg tab 3

SUPRAX 100 mg tab chew, 200 mg tab chew 3

SUPRAX 100 mg/5ml susp, 200 mg/5ml susp 3

Macrolides [Macrólidos]

azithromycin 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 1 ZITHROMAX

azithromycin 100 mg/5ml susp, 200 mg/5ml susp 1 ZITHROMAX

clarithromycin 250 mg tab, 500 mg tab 1 BIAXIN

clarithromycin 125 mg/5ml susp, 250 mg/5ml susp 1 BIAXIN

clarithromycin er 500 mg tab er 24 hr 1 BIAXIN XL

DIFICID 200 mg tab 3

E.E.S. 400 400 mg tab 3

PROSSAM




Drug Tier

[Nivel]




E.E.S. GRANULES 200 mg/5ml susp 3

ERYPED 200 200 mg/5ml susp 3

ERYPED 400 400 mg/5ml susp 3

ERY-TAB 250 mg tab dr, 333 mg tab dr, 500 mg tab dr 3

ERYTHROCIN STEARATE 250 mg tab 3

erythromycin base 250 mg cap dr prt, 250 mg tab 1

erythromycin base 500 mg tab 1 ERY-TAB

erythromycin ethylsuccinate 400 mg tab 1 E.E.S.

erythromycin ethylsuccinate 200 mg/5ml susp 1 ERYPED

PCE 333 mg tab dr, 500 mg tab dr 3

ZITHROMAX 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 3

ZITHROMAX 100 mg/5ml susp, 200 mg/5ml susp 3

ZITHROMAX TRI-PAK 500 mg tab 3

ZITHROMAX Z-PAK 250 mg tab 3

Miscellaneous B-lactam Antibiotics [Antibióticos Betalactámicos Misceláneos]

AZACTAM 1 gm inj soln, 2 gm inj soln 3

aztreonam 1 gm inj soln, 2 gm inj soln 1

CAYSTON 75 mg inh soln 5 PA

Penicillins [Penicilinas]

amoxicillin 125 mg tab chew, 250 mg cap, 250 mg tab chew, 500 mg cap, 500 mg tab, 875 mg tab 1 AMOXIL

amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg/5ml susp, 400 mg/5ml susp 1 AMOXIL

amoxicillin-pot clavulanate 200-28.5 mg tab chew, 250-125 mg tab, 400-57 mg tab chew, 500-125 mg tab, 875-125 mg tab 1 AUGMENTIN

amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 250-62.5 mg/5ml susp, 400-57 mg/5ml susp, 600-42.9 mg/5ml susp 1 AUGMENTIN

amoxicillin-pot clavulanate er 1000-62.5 mg tab er 12 hr 1 AUGMENTIN XR

ampicillin 500 mg cap 1

PROSSAM




Drug Tier

[Nivel]




ampicillin sodium 10 gm inj soln, 10 gm iv soln, 125 mg inj soln, 2 gm inj soln, 2 gm iv soln, 250 mg inj soln, 500 mg inj soln 1

ampicillin sodium 1 gm inj soln 1 TOTACILLIN-N

AUGMENTIN 500-125 mg tab, 875-125 mg tab 3

AUGMENTIN 125-31.25 mg/5ml susp, 250-62.5 mg/5ml susp 3

AUGMENTIN ES-600 600-42.9 mg/5ml susp 3

AUGMENTIN XR 1000-62.5 mg tab er 12 hr 3

BICILLIN C-R 1200000 unit/2ml im susp 2

BICILLIN C-R 900/300 900000-300000 unit/2ml im susp 2

BICILLIN L-A 1200000 unit/2ml im susp, 2400000 unit/4ml im susp, 600000 unit/ml im susp 2

dicloxacillin sodium 250 mg cap, 500 mg cap 1 DYCILL

MOXATAG 775 mg tab er 24 hr 3

nafcillin sodium 10 gm iv soln, 2 gm inj soln 1

nafcillin sodium 1 gm inj soln 1 NALLPEN

oxacillin sodium 1 gm inj soln, 10 gm inj soln, 2 gm inj soln 1

penicillin g potassium 20000000 unit inj soln, 5000000 unit inj soln 1 PFIZERPEN

penicillin g procaine 600000 unit/ml im susp 1

penicillin g sodium 5000000 unit inj soln 1

penicillin v potassium 500 mg tab 1 PEN-VEE K

penicillin v potassium 250 mg tab 1 VEETIDS

penicillin v potassium 125 mg/5ml soln, 250 mg/5ml soln 1 VEETIDS

PFIZERPEN 20000000 unit inj soln, 5000000 unit inj soln 3

Quinolones [Quinolonas]

AVELOX 400 mg tab 3

CIPRO 250 mg tab, 500 mg tab 3

CIPRO 250 MG/5ML (5%) susp, 500 MG/5ML (10%) susp 3

PROSSAM




Drug Tier

[Nivel]




ciprofloxacin 500 MG/5ML (10%) susp 1 CIPRO

ciprofloxacin hcl 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 CIPRO

ciprofloxacin-ciproflox hcl er 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 CIPRO XR

LEVAQUIN 250 mg tab, 500 mg tab, 750 mg tab 3

levofloxacin 250 mg tab, 500 mg tab, 750 mg tab 1 LEVAQUIN

levofloxacin 25 mg/ml soln 1 LEVAQUIN

moxifloxacin hcl 400 mg tab 1 AVELOX

ofloxacin 300 mg tab, 400 mg tab 1 FLOXIN

Sulfonamides [Sulfonamidas]

AZULFIDINE 500 mg tab 3

AZULFIDINE EN-TABS 500 mg tab dr 3

BACTRIM 400-80 mg tab 3

BACTRIM DS 800-160 mg tab 3

sulfadiazine 500 mg tab 1

sulfamethoxazole-trimethoprim 400-80 mg tab, 800-160 mg tab 1 SEPTRA

sulfamethoxazole-trimethoprim 200-40 mg/5ml susp, 400-80 mg/5ml iv soln 1 SEPTRA

sulfasalazine 500 mg tab, 500 mg tab dr 1 AZULFIDINE

Tetracyclines [Tetraciclinas]

avidoxy 100 mg tab 1 ADOXA

AVIDOXY DK 100 mg cmb kit 3

demeclocycline hcl 150 mg tab, 300 mg tab 1 DECLOMYCIN

doxycycline hyclate 100 mg cap dr prt, 100 mg tab dr, 150 mg tab dr, 75 mg tab dr 1 DORYX

doxycycline hyclate 100 mg iv soln 1 DOXY

doxycycline hyclate 20 mg tab 1 PERIOSTAT

doxycycline hyclate 100 mg tab 1 VIBRA-TABS

doxycycline hyclate 100 mg cap, 50 mg cap 1 VIBRAMYCIN

doxycycline monohydrate 100 mg tab, 150 mg cap, 150 mg tab, 50 mg tab, 75 mg tab 1 ADOXA

doxycycline monohydrate 100 mg cap, 50 mg cap, 75 mg cap 1 MONODOX

PROSSAM




Drug Tier

[Nivel]




doxycycline monohydrate 25 mg/5ml susp 1 VIBRAMYCIN

MINOCIN 100 mg cap, 50 mg cap 3

minocycline hcl pwdr 1

minocycline hcl 100 mg tab, 50 mg tab, 75 mg tab 1 DYNACIN

minocycline hcl 100 mg cap, 50 mg cap, 75 mg cap 1 MINOCIN

MONDOXYNE NL 100 mg cap, 50 mg cap, 75 mg cap 3

MORGIDOX 1 x 100 mg cmb kit, 100 mg cap, 2 x 100 mg cmb kit 3

NUTRIDOX 75 mg oral kit 3

OKEBO 75 mg cap 3

tetracycline hcl 250 mg cap, 500 mg cap 1

VIBRAMYCIN 100 mg cap 3

VIBRAMYCIN 25 mg/5ml susp, 50 mg/5ml syr 3

ANTICHOLINERGIC AGENTS [AGENTES ANTICOLINÉRGICOS]

Antimuscarinics/antispasmodics [Antimuscarínicos/Antiespasmódicos]

ANASPAZ 0.125 mg tab disint 3

ATROPEN 0.25 mg/0.3ml im soln auto-inj, 0.5 mg/0.7ml im soln auto-inj, 1 mg/0.7ml im soln auto-inj, 2 mg/0.7ml im soln auto-inj 3

ATROVENT HFA 17 mcg/act inh aer soln 3 QL(12.9 / 25)

BENTYL 10 mg/ml im soln 3

BENTYL 10 mg cap 3 QL(90 / 365)

chlordiazepoxide-clidinium 5-2.5 mg cap 1

CUVPOSA 1 mg/5ml soln 3

dicyclomine hcl 10 mg/5ml soln, 10 mg/ml im soln 1 BENTYL

dicyclomine hcl 10 mg cap, 20 mg tab 1 BENTYL QL(90 / 365)

ed-spaz 0.125 mg tab disint 1

glycopyrrolate 0.2 mg/ml inj soln, 0.4 mg/2ml inj soln, 1 mg/5ml inj soln 1

glycopyrrolate 4 mg/20ml inj soln 1 ROBINUL

glycopyrrolate 1 mg tab, 2 mg tab 1 ROBINUL QL(90 / 365)

hyoscyamine sulfate 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1

PROSSAM




Drug Tier

[Nivel]




hyoscyamine sulfate 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1

hyoscyamine sulfate er 0.375 mg tab er 12 hr 1

hyoscyamine sulfate sl 0.125 mg tab subl 1

hyosyne 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1

ipratropium bromide 0.02 % inh soln, 0.03 % nasal soln, 0.06 % nasal soln 1 ATROVENT

LEVBID 0.375 mg tab er 12 hr 3

LEVSIN 0.125 mg tab 3

LEVSIN 0.5 mg/ml inj soln 3

LEVSIN/SL 0.125 mg tab subl 3

LIBRAX 5-2.5 mg cap 3

methscopolamine bromide 2.5 mg tab, 5 mg tab 1 PAMINE QL(90 / 365)

NULEV 0.125 mg tab disint 3

oscimin 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1

oscimin sr 0.375 mg tab er 12 hr 1

propantheline bromide 15 mg tab 1 PRO-BANTHINE

ROBINUL 0.2 mg/ml inj soln, 0.4 mg/2ml inj soln, 1 mg/5ml inj soln, 4 mg/20ml inj soln 3

ROBINUL 1 mg tab 3 QL(90 / 365)

ROBINUL-FORTE 2 mg tab 3 QL(90 / 365)

SPIRIVA HANDIHALER 18 mcg inh cap 2 QL(30 / 30)

SPIRIVA RESPIMAT 1.25 mcg/act inh aer soln, 2.5 mcg/act inh aer soln 2 QL(4 / 30)

SYMAX DUOTAB 0.375 mg tab er 3

SYMAX-SL 0.125 mg tab subl 3

SYMAX-SR 0.375 mg tab er 12 hr 3

TUDORZA PRESSAIR 400 mcg/act inh aer pwdr br act 3 QL(1 / 30)

ANTICONVULSANTS [ANTICONVULSIVOS]

Anticonvulsants, Miscellaneous [Anticonvulsivos, Misceláneos]

BANZEL 200 mg tab, 400 mg tab 3

BANZEL 40 mg/ml susp 3

carbamazepine 100 mg tab chew, 200 mg tab 1 TEGRETOL

carbamazepine 100 mg/5ml susp 1 TEGRETOL

PROSSAM




Drug Tier

[Nivel]




carbamazepine er 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 1 CARBATROL

carbamazepine er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 1 TEGRETOL

CARBATROL 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3

DEPAKENE 250 mg cap 3

DEPAKENE 250 mg/5ml soln 3

DEPAKOTE 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 3

DEPAKOTE ER 250 mg tab er 24 hr, 500 mg tab er 24 hr 3

DEPAKOTE SPRINKLES 125 mg cap dr sprinkle 3

divalproex sodium 125 mg cap dr sprinkle, 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 1 DEPAKOTE

divalproex sodium er 250 mg tab er 24 hr, 500 mg tab er 24 hr 1 DEPAKOTE

EPITOL 200 mg tab 3

EQUETRO 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3

felbamate 400 mg tab, 600 mg tab 1 FELBATOL

felbamate 600 mg/5ml susp 1 FELBATOL

FELBATOL 400 mg tab, 600 mg tab 3

FELBATOL 600 mg/5ml susp 3

gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 1 NEURONTIN

gabapentin 250 mg/5ml soln, 300 mg/6ml soln 1 NEURONTIN

GABITRIL 12 mg tab, 16 mg tab, 2 mg tab, 4 mg tab 3

HORIZANT 600 mg tab er 3

KEPPRA 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 3

KEPPRA 100 mg/ml soln 3

KEPPRA XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

PROSSAM




Drug Tier

[Nivel]




LAMICTAL 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab, 25 mg tab chew, 5 mg tab chew 3

LAMICTAL ODT 100 mg tab disint, 200 mg tab disint, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab disint, 50 (42)-100(14) mg oral kit, 50 mg tab disint 3

LAMICTAL STARTER 25 (35) mg oral kit, 25 (42)-100 (7) mg oral kit, 25 (84)-100(14) mg oral kit 3

LAMICTAL XR 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 & 100 & 200 mg oral kit, 50 mg tab er 24 hr 3

lamotrigine 100 mg tab, 100 mg tab disint, 150 mg tab, 200 mg tab, 200 mg tab disint, 25 mg tab, 25 mg tab chew, 25 mg tab disint, 5 mg tab chew, 50 mg tab disint 1 LAMICTAL

lamotrigine er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 mg tab er 24 hr 1 LAMICTAL

levetiracetam 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 KEPPRA

levetiracetam 100 mg/ml soln 1 KEPPRA

levetiracetam er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 KEPPRA

LYRICA 100 mg cap, 150 mg cap, 200 mg cap, 225 mg cap, 25 mg cap, 300 mg cap, 50 mg cap, 75 mg cap 3

LYRICA 20 mg/ml soln 3

NEURONTIN 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 3

NEURONTIN 250 mg/5ml soln 3

oxcarbazepine 150 mg tab, 300 mg tab, 600 mg tab 1 TRILEPTAL

oxcarbazepine 300 mg/5ml susp 1 TRILEPTAL

PROSSAM




Drug Tier

[Nivel]




ROWEEPRA 1000 mg tab, 500 mg tab, 750 mg tab 3

SABRIL 500 mg pckt, 500 mg tab 5 PA

TEGRETOL 200 mg tab 3

TEGRETOL 100 mg/5ml susp 3

TEGRETOL-XR 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 3

tiagabine hcl 2 mg tab, 4 mg tab 1 GABITRIL

TOPAMAX 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 3

TOPAMAX SPRINKLE 15 mg cap sprinkle, 25 mg cap sprinkle 3

topiramate 100 mg tab, 15 mg cap sprinkle, 200 mg tab, 25 mg cap sprinkle, 25 mg tab, 50 mg tab 1 TOPAMAX

TRILEPTAL 150 mg tab, 300 mg tab, 600 mg tab 3

TRILEPTAL 300 mg/5ml susp 3

valproate sodium 250 mg/5ml soln 1 DEPAKENE

valproic acid 250 mg cap 1 DEPAKENE

valproic acid 250 mg/5ml soln 1 DEPAKENE

VIMPAT 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3

VIMPAT 10 mg/ml soln 3

ZONEGRAN 100 mg cap, 25 mg cap 3

zonisamide 100 mg cap, 25 mg cap, 50 mg cap 1 ZONEGRAN

Barbiturates [Barbitúricos]

MYSOLINE 250 mg tab, 50 mg tab 3

primidone 250 mg tab, 50 mg tab 1 MYSOLINE

Benzodiazepines [Benzodiazepinas]

clonazepam 0.125 mg tab disint, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint 1 KLONOPIN

KLONOPIN 0.5 mg tab, 1 mg tab, 2 mg tab 3

ONFI 10 mg tab, 20 mg tab 3

ONFI 2.5 mg/ml susp 3

Hydantoins [Hidantoínas]

DILANTIN 100 mg cap, 30 mg cap 2

DILANTIN 125 mg/5ml susp 2

DILANTIN INFATABS 50 mg tab chew 3

PROSSAM




Drug Tier

[Nivel]




fosphenytoin sodium 500 mg pe/10ml inj soln 1

fosphenytoin sodium 100 mg pe/2ml inj soln 1 CEREBYX

PEGANONE 250 mg tab 3

PHENYTEK 200 mg cap, 300 mg cap 3

phenytoin 50 mg tab chew 1 DILANTIN

phenytoin 125 mg/5ml susp 1 DILANTIN

PHENYTOIN INFATABS 50 mg tab chew 3

phenytoin sodium 50 mg/ml inj soln 1 DILANTIN

phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap 1 DILANTIN

Succinimides [Succinimidas]

CELONTIN 300 mg cap 3

ethosuximide 250 mg cap 1 ZARONTIN

ethosuximide 250 mg/5ml soln 1 ZARONTIN

ZARONTIN 250 mg cap 3

ZARONTIN 250 mg/5ml soln 3

ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

Alpha-glucosidase Inhibitors [Inhibidores De La Alfa-Glucosidasa]

acarbose 100 mg tab, 25 mg tab, 50 mg tab 1 PRECOSE

GLYSET 100 mg tab, 25 mg tab, 50 mg tab 3

miglitol 100 mg tab, 25 mg tab, 50 mg tab 1 GLYSET

PRECOSE 100 mg tab, 25 mg tab, 50 mg tab 3

Amylinomimetics [Amilinomiméticos]

SYMLINPEN 120 2700 mcg/2.7ml sc soln pen-inj 3 ST

SYMLINPEN 60 1500 mcg/1.5ml sc soln pen-inj 3 ST

Antidiabetic Agents, Miscellaneous [Agentes Antidiabéticos, Misceláneos]

CYCLOSET 0.8 mg tab 3

KORLYM 300 mg tab 3

Biguanides [Biguanidas]

FORTAMET 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3

GLUCOPHAGE 1000 mg tab, 500 mg tab, 850 mg tab 3

GLUCOPHAGE XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3

PROSSAM




Drug Tier

[Nivel]




GLUMETZA 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3

metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab 1 GLUCOPHAGE

metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 GLUCOPHAGE

metformin hcl er (mod) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 GLUMETZA

metformin hcl er (osm) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 FORTAMET

RIOMET 500 mg/5ml soln 3

Dipeptidyl Peptidase-4 (dpp-4) Inhibitors [Inhibidores De La Dipeptidil Peptidasa-4 (Dpp-4)]

JANUMET 50-1000 mg tab, 50-500 mg tab 2

JANUMET XR 100-1000 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 2

JANUVIA 100 mg tab, 25 mg tab, 50 mg tab 2

JENTADUETO 2.5-1000 mg tab, 2.5-500 mg tab, 2.5-850 mg tab 2

TRADJENTA 5 mg tab 2

Incretin Mimetics [Miméticos De Incretina]

BYDUREON 2 mg sc pen-inj, 2 mg sc susp er 2 ST

TRULICITY 0.75 mg/0.5ml sc soln pen-inj, 1.5 mg/0.5ml sc soln pen-inj 2 ST

VICTOZA 18 mg/3ml sc soln pen-inj 2 ST

Insulins [Insulinas]

HUMALOG 100 unit/ml sc soln, 100 unit/ml sc soln cart 2 QL(20 / 30)

HUMALOG JUNIOR KWIKPEN 100 unit/ml sc soln pen-inj 2 QL(18 / 30)

HUMALOG KWIKPEN 200 unit/ml sc soln pen-inj 2 QL(12 / 30)

HUMALOG KWIKPEN 100 unit/ml sc soln pen-inj 2 QL(18 / 30)

HUMALOG MIX 50/50 (50-50) 100 unit/ml sc susp 2 QL(20 / 30)

HUMALOG MIX 50/50 KWIKPEN (50-50) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)

HUMALOG MIX 75/25 (75-25) 100 unit/ml sc susp 2 QL(20 / 30)

PROSSAM




Drug Tier

[Nivel]




HUMALOG MIX 75/25 KWIKPEN (75-25) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)

HUMULIN 70/30 (70-30) 100 unit/ml sc susp 2 QL(20 / 30)

HUMULIN 70/30 KWIKPEN (70-30) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)

HUMULIN N 100 unit/ml sc susp 2 QL(20 / 30)

HUMULIN N KWIKPEN 100 unit/ml sc susp pen-inj 2 QL(18 / 30)

HUMULIN R 100 unit/ml inj soln 2 QL(20 / 30)

HUMULIN R U-500 (CONCENTRATED) 500 unit/ml sc soln 2 QL(20 / 30)

HUMULIN R U-500 KWIKPEN 500 unit/ml sc soln pen-inj 2 QL(6 / 30)

LANTUS 100 unit/ml sc soln 2 QL(20 / 30)

LANTUS SOLOSTAR 100 unit/ml sc soln pen-inj 2 QL(18 / 30)

LEVEMIR 100 unit/ml sc soln 2 QL(20 / 30)

LEVEMIR FLEXTOUCH 100 unit/ml sc soln pen-inj 2 QL(18 / 30)

TOUJEO SOLOSTAR 300 unit/ml sc soln pen-inj 2 QL(18 / 30)

Meglitinides [Meglitinidas]

nateglinide 120 mg tab, 60 mg tab 1 STARLIX

PRANDIN 1 mg tab, 2 mg tab 3 ST

repaglinide 0.5 mg tab, 1 mg tab, 2 mg tab 1 PRANDIN ST

repaglinide-metformin hcl 1-500 mg tab, 2-500 mg tab 1 PRANDIMET

STARLIX 120 mg tab, 60 mg tab 3

Sodium-glucose Cotransporter 2 (sglt2) Inhibitors [Inhibidores Del Cotransportador Sodio-Glucosa 2 (Sglt2)]

FARXIGA 10 mg tab, 5 mg tab 2 ST

INVOKAMET 150-1000 mg tab, 150-500 mg tab, 50-1000 mg tab, 50-500 mg tab 2

INVOKAMET XR 150-1000 mg tab er 24 hr, 150-500 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 2

INVOKANA 100 mg tab, 300 mg tab 2

XIGDUO XR 10-1000 mg tab er 24 hr, 10-500 mg tab er 24 hr, 5-1000 2 ST

PROSSAM




Drug Tier

[Nivel]




mg tab er 24 hr, 5-500 mg tab er 24 hr

Sulfonylureas [Sulfonilureas]

AMARYL 1 mg tab, 2 mg tab, 4 mg tab 3

chlorpropamide 100 mg tab, 250 mg tab 1 DIABINESE

glimepiride 1 mg tab, 2 mg tab, 4 mg tab 1 AMARYL

glipizide 10 mg tab, 5 mg tab 1 GLUCOTROL

glipizide er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL

glipizide xl 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL

glipizide-metformin hcl 2.5-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 METAGLIP

GLUCOTROL 10 mg tab, 5 mg tab 3

GLUCOTROL XL 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 3

GLUCOVANCE 2.5-500 mg tab, 5-500 mg tab 3

glyburide 1.25 mg tab, 2.5 mg tab, 5 mg tab 1 DIABETA

glyburide micronized 1.5 mg tab, 3 mg tab, 6 mg tab 1 GLYNASE

glyburide-metformin 1.25-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 GLUCOVANCE

GLYNASE 1.5 mg tab, 3 mg tab, 6 mg tab 3

tolazamide 250 mg tab, 500 mg tab 1 TOLINASE

tolbutamide 500 mg tab 1 ORINASE

Thiazolidinediones [Tiazolidinedionas]

ACTOPLUS MET 15-500 mg tab, 15-850 mg tab 3

ACTOPLUS MET XR 15-1000 mg tab er 24 hr, 30-1000 mg tab er 24 hr 3

ACTOS 15 mg tab, 30 mg tab, 45 mg tab 3

DUETACT 30-2 mg tab, 30-4 mg tab 3

pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab 1 ACTOS

pioglitazone hcl-glimepiride 30-2 mg tab, 30-4 mg tab 1 DUETACT

PROSSAM




Drug Tier

[Nivel]




pioglitazone hcl-metformin hcl 15-500 mg tab, 15-850 mg tab 1 ACTOPLUS MET

ANTIDIARRHEA AGENTS [AGENTES ANTIDIARREICOS]

Antidiarrhea Agents [Agentes Antidiarreicos]

diphenoxylate-atropine 2.5-0.025 mg tab 1 LOMOTIL

diphenoxylate-atropine 2.5-0.025 mg/5ml liq 1 LOMOTIL

LOMOTIL 2.5-0.025 mg tab 3

loperamide hcl 2 mg cap 1 IMODIUM

MOTOFEN 1-0.025 mg tab 3

MYTESI 125 mg tab dr 3

paregoric 2 mg/5ml oral tinct 1

ANTIDOTES [ANTÍDOTOS]

Antidotes [Antídotos]

acetylcysteine 10 % inh soln, 20 % inh soln 1 MUCOMYST

FUSILEV 50 mg iv soln 4 PA

leucovorin calcium 10 mg tab, 100 mg inj soln, 15 mg tab, 200 mg inj soln, 25 mg tab, 350 mg inj soln, 5 mg tab, 50 mg inj soln, 500 mg inj soln 4 PA

levoleucovorin calcium 50 mg iv soln 4 PA

VORAXAZE 1000 unit iv soln 4 PA

ANTIEMETICS [ANTIEMÉTICOS]

5-ht3 Receptor Antagonists [Antagonistas Del Receptor 5-Ht3]

ANZEMET 100 mg tab, 50 mg tab 3

granisetron hcl 1 mg tab 1 KYTRIL

ondansetron 4 mg tab disint, 8 mg tab disint 1 ZOFRAN

ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab 1 ZOFRAN

ondansetron hcl 4 mg/2ml inj soln, 4 mg/5ml soln, 40 mg/20ml inj soln 1 ZOFRAN

SANCUSO 3.1 mg/24hr td patch 3

ZOFRAN 4 mg tab, 8 mg tab 3

ZOFRAN 4 mg/5ml soln 3

ZOFRAN ODT 4 mg tab disint, 8 mg tab disint 3

ZUPLENZ 4 mg oral film, 8 mg oral film 3

Antiemetics, Miscellaneous [Antieméticos, Misceláneos]

aprepitant 125 mg cap, 40 mg cap, 80 & 125 mg cap, 80 mg cap 1 EMEND

PROSSAM




Drug Tier

[Nivel]




CESAMET 1 mg cap 3

dronabinol 10 mg cap, 2.5 mg cap, 5 mg cap 1 MARINOL

EMEND 125 mg cap, 40 mg cap, 80 mg cap 3

EMEND TRI-PACK 80 & 125 mg cap 3

MARINOL 10 mg cap, 2.5 mg cap, 5 mg cap 3

scopolamine 1 mg/3days td patch 72 hr 1 TRANSDERM-SCOP

TRANSDERM-SCOP (1.5 MG) 1 mg/3days td patch 72 hr 3

Antihistamines [Antihistamínicos]

dimenhydrinate 50 mg/ml inj soln 1

meclizine hcl 12.5 mg tab, 25 mg tab 1 ANTIVERT

TIGAN 300 mg cap 3

TIGAN 100 mg/ml im soln 3

trimethobenzamide hcl 300 mg cap 1 TIGAN

ANTIFUNGALS [ANTIFUNGALES]

Allylamines [Alilaminas]

LAMISIL 250 mg tab 3 QL(84 / 90)

terbinafine hcl 250 mg tab 1 LAMISIL QL(84 / 90)

Antifungals, Miscellaneous [Antifungales, Misceláneos]

griseofulvin microsize 500 mg tab 1

griseofulvin microsize 125 mg/5ml susp 1 GRIFULVIN V

griseofulvin ultramicrosize 125 mg tab, 250 mg tab 1 GRIS-PEG

GRIS-PEG 125 mg tab, 250 mg tab 3

Azoles [Azoles]

CRESEMBA 186 mg cap, 372 mg iv soln 3 PA

DIFLUCAN 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3

DIFLUCAN 10 mg/ml susp, 40 mg/ml susp 3

fluconazole 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 1 DIFLUCAN

fluconazole 10 mg/ml susp, 40 mg/ml susp 1 DIFLUCAN

itraconazole 100 mg cap 1 SPORANOX

ketoconazole 200 mg tab 1 NIZORAL

NOXAFIL 40 mg/ml susp 3

SPORANOX 100 mg cap 3

PROSSAM




Drug Tier

[Nivel]




SPORANOX 10 mg/ml soln 3

SPORANOX PULSEPAK 100 mg cap 3

VFEND 200 mg tab, 50 mg tab 5 PA

VFEND 40 mg/ml susp 5 PA

voriconazole 200 mg tab, 50 mg tab 4 VFEND PA

voriconazole 40 mg/ml susp 4 VFEND PA

Echinocandins [Equinocandinas]

CANCIDAS 50 mg iv soln, 70 mg iv soln 5 PA

caspofungin acetate 50 mg iv soln, 70 mg iv soln 4 CANCIDAS PA

MYCAMINE 100 mg iv soln, 50 mg iv soln 5 PA

Polyenes [Polienos]

amphotericin b 50 mg inj soln 1 FUNGIZONE

bio-statin 1000000 unit cap, 500000 unit cap 1

nystatin 500000 unit tab 1 MYCOSTATIN

nystatin 100000 unit/ml m/t susp 1 MYCOSTATIN

Pyrimidines [Pirimidinas]

ANCOBON 250 mg cap, 500 mg cap 3

flucytosine 250 mg cap, 500 mg cap 1 ANCOBON

ANTIGLAUCOMA AGENTS [AGENTES ANTIGLAUCOMA]

Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]

ALPHAGAN P 0.1 % ophth soln 2

ALPHAGAN P 0.15 % ophth soln 3

brimonidine tartrate 0.15 % ophth soln, 0.2 % ophth soln 1 ALPHAGAN

COMBIGAN 0.2-0.5 % ophth soln 2

SIMBRINZA 1-0.2 % ophth susp 2

Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]

betaxolol hcl 0.5 % ophth soln 1 BETOPTIC

BETIMOL 0.25 % ophth soln, 0.5 % ophth soln 3

BETOPTIC-S 0.25 % ophth susp 3

carteolol hcl 1 % ophth soln 1 OCUPRESS

ISTALOL 0.5 % ophth soln 3

levobunolol hcl 0.5 % ophth soln 1 BETAGAN

metipranolol 0.3 % ophth soln 1 OPTIPRANOLOL

timolol maleate 0.25 % ophth gfs, 0.25 % ophth soln, 0.5 % ophth gfs, 0.5 % ophth soln 1 TIMOPTIC

PROSSAM




Drug Tier

[Nivel]




Carbonic Anhydrase Inhibitors [Inhibidores De La Anhidrasa Carbónica]

acetazolamide 125 mg tab, 250 mg tab 1 DIAMOX

acetazolamide er 500 mg cap er 12 hr 1 DIAMOX

acetazolamide sodium 500 mg inj soln 1 DIAMOX

AZOPT 1 % ophth susp 2

dorzolamide hcl 2 % ophth soln 1 TRUSOPT

dorzolamide hcl-timolol mal 22.3-6.8 mg/ml ophth soln 1 COSOPT

methazolamide 25 mg tab, 50 mg tab 1 NEPTAZANE

NEPTAZANE 25 mg tab 3

Miotics [Mióticos]

ISOPTO CARPINE 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 3

MIOCHOL-E 20 mg i-ocul soln 3

MIOSTAT 0.01 % i-ocul soln 3

PHOSPHOLINE IODIDE 0.125 % ophth soln 3

pilocarpine hcl 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 1 ISOPTOCARPINE

Prostaglandin Analogs [Análogos De La Prostaglandina]

bimatoprost 0.03 % ophth soln 1 LUMIGAN

latanoprost 0.005 % ophth soln 1 XALATAN

LUMIGAN 0.01 % ophth soln 2

TRAVATAN Z 0.004 % ophth soln 2

ZIOPTAN 0.0015 % ophth soln 3

ANTIGOUT AGENTS [AGENTES CONTRA LA GOTA]

Antigout Agents [Agentes Contra La Gota]

allopurinol 100 mg tab, 300 mg tab 1 ZYLOPRIM

colchicine 0.6 mg tab 1 COLCRYS

COLCRYS 0.6 mg tab 3

ULORIC 40 mg tab, 80 mg tab 3

ZYLOPRIM 100 mg tab, 300 mg tab 3

ANTIHEMORRHAGIC AGENTS [AGENTES ANTIHEMORRÁGICOS]

Hemostatics [Hemostáticos]

AMICAR 1000 mg tab, 500 mg tab 5 PA

AMICAR 0.25 gm/ml soln 5 PA

aminocaproic acid 250 mg/ml iv soln 1 PA

CYKLOKAPRON 1000 mg/10ml iv soln 5 PA

LYSTEDA 650 mg tab 5 PA

PROSSAM




Drug Tier

[Nivel]




tranexamic acid 1000 mg/10ml iv soln 1 CYKLOKAPRON PA

tranexamic acid 650 mg tab 1 LYSTEDA PA

ANTIHYPOGLYCEMIC AGENTS [AGENTES ANTIHIPOGLUCÉMICOS]

Antihypoglycemic Agents, Miscellaneous [Agentes Antihipoglucémicos, Misceláneos]

PROGLYCEM 50 mg/ml susp 3

Glycogenolytic Agents [Agentes Glucogenolíticos]

BAQSIMI 3 mg/dose one pack nasal pwdr, 3 mg/dose twoi pack nasal pwdr 2 PA

GLUCAGEN HYPOKIT 1 mg inj soln 2

GLUCAGON EMERGENCY 1 mg inj kit 2

ANTI-INFECTIVES [ANTIINFECCIOSOS]

Antibacterials [Antibacterianos]

ACANYA 1.2-2.5 % gel 3

ak-poly-bac 500-10000 unit/gm ophth oint 1 POLYSPORIN

AKTIPAK 5-3 % ext pckt 3

ALTABAX 1 % oint 3

AZASITE 1 % ophth soln 3

bacitracin 500 unit/gm ophth oint 1 BACI-IM

bacitracin-polymyxin b 500-10000 unit/gm ophth oint 1 POLYSPORIN

BACTROBAN 2 % crm 3

BACTROBAN NASAL 2 % nasal oint 3

BENZACLIN 1-5 % gel 3

BENZACLIN WITH PUMP 1-5 % gel 3

BENZAMYCIN 5-3 % gel 3

benzoyl peroxide-erythromycin 5-3 % gel 1 BENZAMYCIN AL

BESIVANCE 0.6 % ophth susp 3

BLEPH-10 10 % ophth soln 3

CENTANY 2 % oint 3

CENTANY AT 2 % ext kit 3

CETRAXAL 0.2 % otic soln 3

CILOXAN 0.3 % ophth oint 3

CILOXAN 0.3 % ophth soln 3

ciprofloxacin hcl 0.2 % otic soln 1

ciprofloxacin hcl 0.3 % ophth soln 1 CILOXAN

CLEOCIN 100 mg vag supp 3

CLEOCIN 2 % vag crm 3

CLEOCIN-T 1 % swab 3

PROSSAM




Drug Tier

[Nivel]




CLEOCIN-T 1 % gel 3

CLEOCIN-T 1 % ext soln, 1 % lot 3

CLINDACIN ETZ 1 % ext kit, 1 % swab 3

CLINDACIN PAC 1 % ext kit 3

CLINDACIN-P 1 % swab 3

CLINDAGEL 1 % gel 3

clindamycin phos-benzoyl perox 1-5 % gel 1 BENZACLIN AL

clindamycin phos-benzoyl perox 1.2-5 % gel 1 DUAC AL

clindamycin phosphate 2 % vag crm 1 CLEOCIN

clindamycin phosphate 1 % swab 1 CLEOCIN-T AL

clindamycin phosphate 1 % gel 1 CLEOCIN-T AL

clindamycin phosphate 1 % ext soln, 1 % gel, 1 % lot 1 CLEOCIN-T AL

clindamycin phosphate 1 % foam 1 EVOCLIN AL

DUAC 1.2-5 % gel 3

ery 2 % pad 1 AL

ERYGEL 2 % gel 3

erythromycin 2 % pad 1 AL

erythromycin 2 % ext soln 1 ERYDERM AL

erythromycin 2 % gel 1 ERYGEL AL

erythromycin 5 mg/gm ophth oint 1 ILOTYCIN

EVOCLIN 1 % foam 3

gatifloxacin 0.5 % ophth soln 1 ZYMAXID

GENTAK 0.3 % ophth oint 3

gentamicin sulfate 0.1 % crm, 0.1 % oint 1 GARAMYCIN

gentamicin sulfate 0.3 % ophth soln 1 GARAMYCIN

KLARON 10 % lot 3

levofloxacin 0.5 % ophth soln 1 QUIXIN

METROCREAM 0.75 % crm 3

METROGEL 1 % gel 3

METROGEL-VAGINAL 0.75 % vag gel 3

METROLOTION 0.75 % lot 3

metronidazole 0.75 % crm 1 METROCREAM

metronidazole 0.75 % gel, 0.75 % vag gel, 1 % gel 1 METROGEL

metronidazole 0.75 % lot 1 METROLOTION

MITOSOL 0.2 mg ophth kit 3

MOXEZA 0.5 % ophth soln 2

mupirocin 2 % oint 1 BACTROBAN

mupirocin calcium 2 % crm 1 BACTROBAN

PROSSAM




Drug Tier

[Nivel]




neomycin-bacitracin zn-polymyx 5-400-10000 ophth oint 1 NEOSPORIN

neomycin-polymyxin-gramicidin 1.75-10000-.025 ophth soln 1 NEOSPORIN

NEOSPORIN 1.75-10000-.025 ophth soln 3

NEUAC 1.2-5 % ext kit, 1.2-5 % gel 3

NORITATE 1 % crm 3

ofloxacin 0.3 % otic soln 1 FLOXIN

ofloxacin 0.3 % ophth soln 1 OCUFLOX

ONEXTON 1.2-3.75 % gel 3

POLYCIN 500-10000 unit/gm ophth oint 3

polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln 1 POLYTRIM

ROSADAN 0.75 % (cream) ext kit, 0.75 % (gel) ext kit 3

ROSADAN 0.75 % crm, 0.75 % gel 3

sulfacetamide sodium 10 % ophth soln 1 BLEPH-10

sulfacetamide sodium 10 % ophth oint 1 SODIUM SULAMYD

sulfacetamide sodium (acne) 10 % lot 1 KLARON AL

tobramycin 0.3 % ophth soln 1 TOBREX

TOBREX 0.3 % ophth oint 3

TOBREX 0.3 % ophth soln 3

VANDAZOLE 0.75 % vag gel 3

VIGAMOX 0.5 % ophth soln 2

ZYMAXID 0.5 % ophth soln 3

Antifungals [Antifungales]

ALA-QUIN 3-0.5 % crm 1

bensal hp 3-6 % oint 1

CICLODAN 0.77 % crm 3

CICLODAN 8 % ext soln 3

CICLODAN CREAM 0.77 % ext kit 3

CICLODAN SOLUTION 8 % ext kit 3

ciclopirox 0.77 % gel 1 LOPROX

ciclopirox 1 % shampoo 1 LOPROX

ciclopirox 8 % ext soln 1 PENLAC

ciclopirox olamine 0.77 % crm 1 LOPROX

ciclopirox olamine 0.77 % ext susp 1 LOPROX

ciclopirox treatment 8 % ext kit 1

clotrimazole 1 % crm 1 LOTRIMIN

clotrimazole 10 mg m/t lozg, 10 mg m/t troche 1 MYCELEX

PROSSAM




Drug Tier

[Nivel]




clotrimazole 1 % ext soln 1 MYCELEX

clotrimazole af 1 % crm 1 LOTRIMIN

clotrimazole anti-fungal 1 % crm 1 LOTRIMIN

clotrimazole-betamethasone 1-0.05 % crm 1 LOTRISONE

clotrimazole-betamethasone 1-0.05 % lot 1 LOTRISONE

cvs miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1

econazole nitrate 1 % crm 1 SPECTAZOLE

eq miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1

eql miconazole 3 200 & 2 mg-% (9gm) vag kit 1

ERTACZO 2 % crm 3

EXELDERM 1 % crm 3

EXELDERM 1 % ext soln 3

EXODERM 25-1 % lot 3

EXTINA 2 % foam 3

gnp miconazole 3 200 & 2 mg-% (9gm) vag kit 1

HALOTIN 1 % crm 3

ketoconazole 2 % foam 1 EXTINA

ketoconazole 2 % crm 1 NIZORAL

ketoconazole 2 % shampoo 1 NIZORAL

LOPROX 0.77 % crm, 0.77 % ext kit 3

LOPROX 1 % shampoo 3

LOTRISONE 1-0.05 % crm 3

MENTAX 1 % crm 3

miconazole 3 200 mg vag supp 1 MONISTAT

miconazole 3 applicator 200 & 2 mg-% (9gm) vag kit 1

miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1

miconazole 3 combo pack app 200 & 2 mg-% (9gm) vag kit 1

MONISTAT 3 COMBINATION PACK 200 & 2 mg-% (9gm) vag kit 1

MONISTAT 3 COMBO PACK APP 200 & 2 mg-% (9gm) vag kit 1

naftifine hcl 1 % crm, 2 % crm 1 NAFTIN

NAFTIN 1 % gel, 2 % crm 3

NIZORAL 2 % shampoo 3

NYAMYC 100000 unit/gm ext pwdr 3

PROSSAM




Drug Tier

[Nivel]




nystatin 100000 unit/gm crm, 100000 unit/gm ext pwdr, 100000 unit/gm oint 1 MYCOSTATIN

NYSTOP 100000 unit/gm ext pwdr 3

oxiconazole nitrate 1 % crm 1 OXISTAT

OXISTAT 1 % crm 3

OXISTAT 1 % lot 3

PENLAC 8 % ext soln 3

px miconazole 3-day combo 200 & 2 mg-% (9gm) vag kit 1

qc clotrimazole 1 % crm 1 LOTRIMIN

QUINJA 1.25-1 % gel 3

ra miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1

ra miconazole 3 combo pack app 200 & 2 mg-% (9gm) vag kit 1

sm antifungal clotrimazole 1 % crm 1 LOTRIMIN

sm miconazole 3 200 & 2 mg-% (9gm) vag kit 1

sm miconazole 3 applicator 200 & 2 mg-% (9gm) vag kit 1

TERAZOL 7 0.4 % vag crm 3

terconazole 0.4 % vag crm, 0.8 % vag crm 1 TERAZOL

terconazole 80 mg vag supp 1 TERAZOL 3

tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1

VUSION 0.25-15-81.35 % oint 3

XOLEGEL 2 % gel 3

XOLEGEL COREPAK 2 & 1 % ext kit 3

XOLEGEL DUO/HEAD & SHOULDERS 2 & 1 % ext kit 3

XOLEGEL DUO/XOLEX 2 & 1 % ext kit 3

Antivirals [Antivirales]

acyclovir 5 % oint 1 ZOVIRAX

DENAVIR 1 % crm 3

trifluridine 1 % ophth soln 1 VIROPTIC

VIROPTIC 1 % ophth soln 3

XERESE 5-1 % crm 3

ZIRGAN 0.15 % ophth gel 3

ZOVIRAX 5 % crm, 5 % oint 3

Eent Anti-infectives, Miscellaneous [Antiinfecciosos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

PROSSAM




Drug Tier

[Nivel]




BETADINE OPHTHALMIC PREP 5 % ophth soln 3

Local Anti-infectives, Miscellaneous [Antiinfecciosos Locales, Misceláneos]

ALCORTIN A 1-2-1 % gel 3

AVC VAGINAL 15 % vag crm 3

BENZAC AC WASH 5 % ext liq 3

BENZEFOAM 5.3 % foam 3

BENZEFOAMULTRA 9.8 % foam 3

BENZEPRO 5.3 % foam 3

BENZEPRO CREAMY WASH 7 % ext liq 3

BENZEPRO FOAMING CLOTHS 6 % ext misc 3

BENZEPRO SHORT CONTACT 9.8 % foam 3

BENZIQ 5.25 % gel 3

BENZIQ LS 2.75 % gel 3

BENZIQ WASH 5.25 % ext liq 3

benzoyl peroxide 8 % gel, 9.8 % foam 1 AL

bp foam 5.3 % foam, 9.8 % foam 1 AL

bp foaming wash 10 % ext liq 1 AL

bp wash 2.5 % ext liq 1 AL

bp wash 7 % ext liq 1 AL

bpo 4 % gel, 8 % gel 1 AL

bpo foaming cloths 6 % ext misc 1 AL

BUCALSEP ext liq, ext soln 3

DERMAZENE 1-1 % crm 3

FEM PH 0.9-0.025 % vag gel 3

hydrocortisone-iodoquinol 1-1 % crm 1

INOVA 4 & 5 % ext kit, 8 & 5 % ext kit 3

INOVA 4/1 ACNE CONTROL THERAPY 4 & 1 & 5 % ext kit 3

INOVA 8/2 ACNE CONTROL THERAPY 8 & 2 & 5 % ext kit 3

iodoquinol-hc-aloe polysacch 1-2-1 % gel 1

mafenide acetate 5 % ext pckt 1

PR BENZOYL PEROXIDE WASH 7 % ext liq 3

RELAGARD 0.9-0.025 % vag gel 3

RIAX 5.5 % foam, 9.5 % foam 3

SILVADENE 1 % crm 3

silver sulfadiazine 1 % crm 1 SILVADENE

PROSSAM




Drug Tier

[Nivel]




SSD 1 % crm 3

SULFAMYLON 5 % ext pckt 3

SULFAMYLON 85 mg/gm crm 3

ZACARE 4 & 0.2 % ext kit, 8 & 0.2 % ext kit 3

zaclir cleansing 8 % lot 1 AL

Scabicides And Pediculicides [Escabicidas Y Pediculicidas]

ELIMITE 5 % crm 3

EURAX 10 % crm, 10 % lot 3

lindane 1 % shampoo 1

malathion 0.5 % lot 1 OVIDE

NATROBA 0.9 % ext susp 3

OVIDE 0.5 % lot 3

permethrin 5 % crm 1 ELIMITE

SKLICE 0.5 % lot 3

SOOLANTRA 1 % crm 3

spinosad 0.9 % ext susp 1

sulfurated lime ext soln 1

ULESFIA 5 % lot 3

ANTI-INFLAMMATORY AGENTS [AGENTES ANTIINFLAMATORIOS]

Anti-inflammatory Agents [Agentes Antiinflamatorios]

ALA SCALP 2 % lot 3

ala-cort 1 % crm 1 ALA-CORT

ala-cort 2.5 % crm 1 HYTONE

alclometasone dipropionate 0.05 % crm, 0.05 % oint 1 ACLOVATE

alosetron hcl 0.5 mg tab, 1 mg tab 1 LOTRONEX

amcinonide 0.1 % crm, 0.1 % oint 1 CYCLOCORT

amcinonide 0.1 % lot 1 CYCLOCORT

anucort-hc 25 mg rect supp 1

ANUSOL-HC 25 mg rect supp 3

ANUSOL-HC 2.5 % rect crm 3

APEXICON E 0.05 % crm 3

APRISO 0.375 gm cap er 24 hr 3

ASACOL HD 800 mg tab dr 3

balsalazide disodium 750 mg cap 1 COLAZAL

betamethasone dipropionate 0.05 % crm, 0.05 % oint 1 DIPROSONE

betamethasone dipropionate 0.05 % lot 1 DIPROSONE

betamethasone dipropionate aug 0.05 % crm, 0.05 % gel, 0.05 % oint 1 DIPROLENE

betamethasone dipropionate aug 0.05 % lot 1 DIPROLENE

PROSSAM




Drug Tier

[Nivel]




betamethasone valerate 0.1 % crm, 0.1 % oint 1 BETA-VAL

betamethasone valerate 0.1 % lot 1 BETA-VAL

betamethasone valerate 0.12 % foam 1 LUXIQ

calcipotriene-betameth diprop 0.005-0.064 % oint 1 TACLONEX

CANASA 1000 mg rect supp 2

CAPEX 0.01 % shampoo 3

clobetasol prop emollient base 0.05 % crm 1 TEMOVATE-E

clobetasol propionate 0.05 % crm 1

clobetasol propionate 0.05 % oint 1 CLOBEX

clobetasol propionate 0.05 % ext soln 1 CLOBEX

clobetasol propionate 0.05 % ext liq, 0.05 % lot, 0.05 % shampoo 1 CLODAN

clobetasol propionate 0.05 % foam 1 OLUX

clobetasol propionate 0.05 % gel 1 TEMOVATE

clobetasol propionate e 0.05 % crm 1 TEMOVATE-E

clobetasol propionate emulsion 0.05 % foam 1

CLOBEX 0.05 % lot, 0.05 % shampoo 3

CLOBEX SPRAY 0.05 % ext liq 3

clocortolone pivalate 0.1 % crm 1

clocortolone pivalate pump 0.1 % crm 1

CLODAN 0.05 % shampoo 3

CLODERM 0.1 % crm 3

CLODERM PUMP 0.1 % crm 3

COLAZAL 750 mg cap 3

COLOCORT 100 mg/60ml rect enema 3

CORDRAN 4 mcg/sqcm tape 3

CORDRAN 0.05 % crm 3

CORDRAN 0.05 % lot 3

CORTANE-B 10-10-1 mg/ml lot 3

CORTENEMA 100 mg/60ml rect enema 3

CORTIFOAM 10 % rect foam 3

CORTISPORIN 1 % oint, 3.5-10000-0.5 crm 3

CUTIVATE 0.05 % lot 3

DELZICOL 400 mg cap dr 2

PROSSAM




Drug Tier

[Nivel]




DERMA-SMOOTHE/FS BODY 0.01 % ext oil 3

DERMA-SMOOTHE/FS SCALP 0.01 % ext oil 3

DERMASORB TA 0.1 % ext kit 3

DESONATE 0.05 % gel 3

desonide 0.05 % crm, 0.05 % oint 1 DESOWEN

desonide 0.05 % lot 1 DESOWEN

DESOWEN 0.05 % crm 3

DESOWEN 0.05 % lot 3

desoximetasone 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 1 TOPICORT

diflorasone diacetate 0.05 % crm, 0.05 % oint 1 PSORCON

DIPENTUM 250 mg cap 3

DIPROLENE 0.05 % oint 3

DIPROLENE 0.05 % lot 3

DIPROLENE AF 0.05 % crm 3

ELOCON 0.1 % crm, 0.1 % oint 3

EPIFOAM 1-1 % foam 3

FIRST-HYDROCORTISONE 10 % gel 3

fluocinolone acetonide 0.01 % crm, 0.025 % crm, 0.025 % oint 1 SYNALAR

fluocinolone acetonide 0.01 % ext soln 1 SYNALAR

fluocinolone acetonide body 0.01 % ext oil 1 DERMA-SMOOTHE/FS

fluocinolone acetonide scalp 0.01 % ext oil 1

fluocinonide 0.05 % crm, 0.05 % gel, 0.05 % oint 1 LIDEX

fluocinonide 0.05 % ext soln 1 LIDEX

fluocinonide 0.1 % crm 1 VANOS

fluocinonide emulsified base 0.05 % crm 1 LIDEX-E

flurandrenolide 0.05 % lot 1 CORDRAN

fluticasone propionate 0.005 % oint, 0.05 % crm 1 CUTIVATE

fluticasone propionate 0.05 % lot 1 CUTIVATE

halac 0.05 & 12 % ext kit 1

halobetasol propionate 0.05 % crm, 0.05 % oint 1 ULTRAVATE

HALOG 0.1 % crm, 0.1 % oint 3

HEMMOREX-HC 25 mg rect supp 3

PROSSAM




Drug Tier

[Nivel]




hydrocortisone 1 % rect crm, 2.5 % rect crm 1

hydrocortisone 1 % crm, 1 % oint 1 ALA-CORT

hydrocortisone 100 mg/60ml rect enema 1 CORTENEMA

hydrocortisone 2.5 % crm, 2.5 % oint 1 HYTONE

hydrocortisone 2.5 % lot 1 HYTONE

hydrocortisone ace-pramoxine 2.5-1 % crm 1

hydrocortisone acetate 25 mg rect supp, 30 mg rect supp 1

hydrocortisone butyr lipo base 0.1 % crm 1 LOCOID LIPOCREAM

hydrocortisone butyrate 0.1 % crm, 0.1 % oint 1 LOCOID

hydrocortisone butyrate 0.1 % ext soln 1 LOCOID

hydrocortisone valerate 0.2 % crm, 0.2 % oint 1 WESTCORT

KENALOG 0.147 mg/gm ext aer soln 3

LIALDA 1.2 gm tab dr 3

LOCOID 0.1 % crm, 0.1 % oint 3

LOCOID 0.1 % ext soln, 0.1 % lot 3

LOCOID LIPOCREAM 0.1 % crm 3

LOTRONEX 0.5 mg tab, 1 mg tab 2

LUXIQ 0.12 % foam 3

mesalamine 4 gm rect enema 1

mesalamine 800 mg tab dr 1 ASACOL HD

mesalamine-cleanser 4 gm rect kit 1 ROWASA

mezparox-hc 1-2.5 % crm 1

mometasone furoate 0.1 % crm, 0.1 % oint 1 ELOCON

mometasone furoate 0.1 % ext soln 1 ELOCON

napro 15 % crm 1

NOLIX 0.05 % lot 3

NUCORT 2 % lot 3

nystatin-triamcinolone 100000-0.1 unit/gm-% crm, 100000-0.1 unit/gm-% oint 1 MYCOLOG

OLUX 0.05 % foam 3

OLUX-E 0.05 % foam 3

ORALONE 0.1 % m/t paste 3

PANDEL 0.1 % crm 3

PROSSAM




Drug Tier

[Nivel]




PENTASA 250 mg cap er, 500 mg cap er 3

PRAMOSONE 1-1 % crm, 1-1 % oint, 1-2.5 % crm, 1-2.5 % oint 3

PRAMOSONE 1-1 % lot, 1-2.5 % lot 3

PRAMOSONE E 1-2.5 % crm 3

prednicarbate 0.1 % crm, 0.1 % oint 1 DERMATOP

PROCTOCORT 30 mg rect supp 3

PROCTOCORT 1 % rect crm 3

PROCTO-MED HC 2.5 % rect crm 3

PROCTO-PAK 1 % rect crm 3

PROCTOSOL HC 2.5 % rect crm 3

PROCTOZONE-HC 2.5 % rect crm 3

psorcon 0.05 % crm 1 PSORCON

ROWASA 4 gm rect kit 3

SCALACORT DK 2 & 2-2 % ext kit 3

SFROWASA 4 gm/60ml rect enema 3

SYNALAR 0.01 % ext soln 3

SYNALAR TS 0.01 % ext kit 3

TACLONEX 0.005-0.064 % ext susp, 0.005-0.064 % oint 3

TEMOVATE 0.05 % crm, 0.05 % oint 3

TEXACORT 2.5 % ext soln 3

TOPICORT 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 3

triamcinolone acetonide 0.025 % oint, 0.1 % oint, 0.147 mg/gm ext aer soln, 0.5 % oint 1 KENALOG

triamcinolone acetonide 0.025 % lot, 0.1 % lot 1 KENALOG

triamcinolone acetonide 0.1 % m/t paste 1

KENALOG IN ORABASE

triamcinolone acetonide 0.025 % crm, 0.1 % crm, 0.5 % crm 1 TRIDERM

TRIANEX 0.05 % oint 3

TRIDERM 0.1 % crm 3

TRIDESILON 0.05 % crm 3

ULTRAVATE 0.05 % crm, 0.05 % oint 3

ULTRAVATE X (CREAM) 0.05 & 10 % ext kit 3

PROSSAM




Drug Tier

[Nivel]




ULTRAVATE X (OINTMENT) 0.05 & 10 % ext kit 3

VANOS 0.1 % crm 3

VERDESO 0.05 % foam 3

Corticosteroids [Corticosteroides]

ACETASOL HC 2-1 % otic soln 3

allergy spray 24 hour 55 mcg/act nasal aer 1 NASACORT

ALREX 0.2 % ophth susp 3

bacitra-neomycin-polymyxin-hc 1 % ophth oint 1 CORTISPORIN

BECONASE AQ 42 mcg/spray nasal susp 3

benzoyl perox-hydrocortisone 5-0.5 % lot 1 AL

BLEPHAMIDE S.O.P. 10-0.2 % ophth oint 3

CIPRO HC 0.2-1 % otic susp 3

CIPRODEX 0.3-0.1 % otic susp 2

COLY-MYCIN S 3.3-3-10-0.5 mg/ml otic susp 3

CORTANE-B 10-10-1 mg/ml otic soln 3

CORTANE-B AQUEOUS 10-10-1 mg/ml otic soln 3

CORTIC-ND 10-10-1 mg/ml otic soln 3

CYOTIC 10-10-1 mg/ml otic soln 3

DERMOTIC 0.01 % otic oil 3

dexamethasone sodium phosphate 0.1 % ophth soln 1 MAXIDEX

DUREZOL 0.05 % ophth emul 2

eq nasal allergy 55 mcg/act nasal aer 1 NASACORT

exotic-hc 10-10-1 mg/ml otic soln 1

flunisolide 25 MCG/ACT (0.025%) nasal soln 1 NASALIDE

fluocinolone acetonide 0.01 % otic oil 1 DERMOTIC

fluorometholone 0.1 % ophth susp 1 FML

fluticasone propionate 50 mcg/act nasal susp 1 FLONASE

FML LIQUIFILM 0.1 % ophth susp 3

gnp 24 hour nasal allergy 55 mcg/act nasal aer 1 NASACORT

PROSSAM




Drug Tier

[Nivel]




goodsense nasal allergy spray 55 mcg/act nasal aer 1 NASACORT

hydrocortisone-acetic acid 1-2 % otic soln 1 ACETASOL HC

LOTEMAX 0.5 % ophth gel, 0.5 % ophth oint 3

LOTEMAX 0.5 % ophth susp 3

loteprednol etabonate 0.5 % ophth susp 1 LOTEMAX

MAXIDEX 0.1 % ophth susp 3

MAXITROL 3.5-10000-0.1 ophth oint 3

MAXITROL 3.5-10000-0.1 ophth susp 3

mometasone furoate 50 mcg/act nasal susp 1 NASONEX

NASACORT ALLERGY 24HR 55 mcg/act nasal aer 1

NASACORT ALLERGY 24HR CHILDREN 55 mcg/act nasal aer 1

nasal allergy 24 hour 55 mcg/act nasal aer 1 NASACORT

NASONEX 50 mcg/act nasal susp 3

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth oint 1 MAXITROL

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth susp 1 MAXITROL

neomycin-polymyxin-hc 1 % otic soln, 3.5-10000-1 ophth susp, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp 1 CORTISPORIN

OMNARIS 50 mcg/act nasal susp 3

OMNIPRED 1 % ophth susp 3

OTICIN HC NR 10-10-1 mg/ml otic soln 3

otomax-hc 10-10-1 mg/ml otic soln 1

PRED FORTE 1 % ophth susp 3

PRED MILD 0.12 % ophth susp 3

PRED-G 0.3-1 % ophth susp 3

PRED-G S.O.P. 0.3-0.6 % ophth oint 3

prednisolone acetate 1 % ophth susp 1 PRED FORTE

prednisolone sodium phosphate 1 % ophth soln 1

QNASL 80 mcg/act nasal aer soln 3

PROSSAM




Drug Tier

[Nivel]




RETISERT 0.59 mg Intravitreal Implant 3

sulfacetamide-prednisolone 10-0.23 % ophth soln 1 VASOCIDIN

TOBRADEX ST 0.3-0.05 % ophth susp 2

triamcinolone acetonide 55 mcg/act nasal aer 1 NASACORT

TRIESENCE 40 mg/ml i-ocul susp 3

VANOXIDE-HC 5-0.5 % lot 3

ZETONNA 37 mcg/act nasal aer soln 3

Eent Anti-inflammatory Agents, Misc [Antiinflamatorios Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

RESTASIS 0.05 % ophth emul 3 PA

RESTASIS MULTIDOSE 0.05 % ophth emul 3 PA

Leukotriene Modifiers [Modificadores De Leucotrienos]

ACCOLATE 10 mg tab, 20 mg tab 3

montelukast sodium 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 1 SINGULAIR

SINGULAIR 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 3

zafirlukast 10 mg tab, 20 mg tab 1 ACCOLATE

zileuton er 600 mg tab er 12 hr 1 ZYFLO CR

ZYFLO 600 mg tab 3

ZYFLO CR 600 mg tab er 12 hr 3

Mast-cell Stabilizers [Estabilizadores De Los Mastocitos]

cromolyn sodium 100 mg/5ml oral conc 1 GASTROCROM

cromolyn sodium 20 mg/2ml inh neb soln 1 INTAL

GASTROCROM 100 mg/5ml oral conc 3

Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]

ACUVAIL 0.45 % ophth soln 3

bromfenac sodium (once-daily) 0.09 % ophth soln 1

diclofenac sodium 0.1 % ophth soln 1 VOLTAREN

flurbiprofen sodium 0.03 % ophth soln 1 OCUFEN

ILEVRO 0.3 % ophth susp 2

ketorolac tromethamine 0.4 % ophth soln, 0.5 % ophth soln 1 ACULAR

ANTILIPEMIC AGENTS [AGENTES ANTILIPÉMICOS]

PROSSAM




Drug Tier

[Nivel]




Antilipemic Agents, Miscellaneous [Agentes Antilipémicos, Misceláneos]

LOVAZA 1 gm cap 3

niacin er (antihyperlipidemic) 1000 mg tab er, 500 mg tab er, 750 mg tab er 1 NIASPAN

NIASPAN 1000 mg tab er, 500 mg tab er, 750 mg tab er 3

omega-3-acid ethyl esters 1 gm cap 1 LOVAZA

triklo 1 gm cap 1 LOVAZA

VASCEPA 1 gm cap 3

Bile Acid Sequestrants [Secuestradores Del Ácido Biliar]

cholestyramine 4 gm pckt 1

cholestyramine 4 gm/dose oral pwdr 1 QUESTRAN

cholestyramine light 4 gm pckt 1 QUESTRAN LIGHT

cholestyramine light 4 gm/dose oral pwdr 1 QUESTRAN LIGHT

COLESTID 1 gm tab, 5 gm pckt 3

COLESTID 5 gm oral gr 3

COLESTID FLAVORED 5 gm pckt 3

COLESTID FLAVORED 5 gm oral gr 3

colestipol hcl 5 gm pckt 1

colestipol hcl 1 gm tab 1 COLESTID

colestipol hcl 5 gm oral gr 1 COLESTID

PREVALITE 4 gm pckt 3

PREVALITE 4 gm/dose oral pwdr 3

QUESTRAN 4 gm pckt 3

QUESTRAN 4 gm/dose oral pwdr 3

QUESTRAN LIGHT 4 gm/dose oral pwdr 3

WELCHOL 3.75 gm pckt, 625 mg tab 3

Cholesterol Absorption Inhibitors [Inhibidores De La Absorción Del Colesterol]

ezetimibe 10 mg tab 1 ZETIA

ZETIA 10 mg tab 2

Fibric Acid Derivatives [Derivados De Ácido Fíbrico]

choline fenofibrate 135 mg cap dr 1 TRILIPIX

fenofibrate 120 mg tab, 40 mg tab 1 FENOGLIDE

fenofibrate 150 mg cap, 50 mg cap 1 LIPOFEN

fenofibrate 145 mg tab, 160 mg tab, 48 mg tab, 54 mg tab 1 TRICOR

fenofibrate micronized 130 mg cap, 43 mg cap 1 ANTARA

PROSSAM




Drug Tier

[Nivel]




fenofibrate micronized 134 mg cap, 200 mg cap, 67 mg cap 1 TRICOR

fenofibric acid 105 mg tab, 35 mg tab 1 FIBRICOR

fenofibric acid 135 mg cap dr, 45 mg cap dr 1 TRILIPIX

FENOGLIDE 120 mg tab, 40 mg tab 3

FIBRICOR 105 mg tab, 35 mg tab 3

gemfibrozil 600 mg tab 1 LOPID

LIPOFEN 150 mg cap, 50 mg cap 3

LOPID 600 mg tab 3

TRICOR 145 mg tab, 48 mg tab 3

TRIGLIDE 160 mg tab 3

TRILIPIX 135 mg cap dr, 45 mg cap dr 3

Hmg-coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]

atorvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 LIPITOR

CRESTOR 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 3

fluvastatin sodium 20 mg cap, 40 mg cap 1 LESCOL

lovastatin 10 mg tab, 20 mg tab, 40 mg tab 1 MEVACOR

pravastatin sodium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 PRAVACHOL

rosuvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 CRESTOR

simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab 1 ZOCOR

ANTIMANIC AGENTS [AGENTES ANTIMANÍACOS]

Antimanic Agents [Agentes Antimaníacos]

lithium 8 meq/5ml soln 1

lithium carbonate 150 mg cap, 300 mg tab, 600 mg cap 1

lithium carbonate 300 mg cap 1 ESKALITH

lithium carbonate er 450 mg tab er 1 ESKALITH CR

lithium carbonate er 300 mg tab er 1 LITHOBID

LITHOBID 300 mg tab er 3

ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]

Antimigraine Agents, Miscellaneous [Agentes Antimigraña, Misceláneos]

CAFERGOT 1-100 mg tab 3 QL(30 / 30)

ergotamine-caffeine 1-100 mg tab 1 CAFERGOT QL(30 / 30)

isometheptene-dichloral-apap 65-100-325 mg cap 1 QL(30 / 30)

PROSSAM




Drug Tier

[Nivel]




MIGERGOT 2-100 mg rect supp 3 QL(12 / 30)

Selective Serotonin Agonists [Agonistas Selectivos De Serotonina]

almotriptan malate 12.5 mg tab, 6.25 mg tab 1 AXERT

AMERGE 1 mg tab, 2.5 mg tab 3 QL(9 / 30)

AXERT 12.5 mg tab, 6.25 mg tab 3 QL(6 / 30)

eletriptan hydrobromide 20 mg tab, 40 mg tab 1 RELPAX QL(6 / 30)

FROVA 2.5 mg tab 3

frovatriptan succinate 2.5 mg tab 1 FROVA QL(9 / 30)

IMITREX 6 mg/0.5ml sc soln 3 QL(5 / 30)

IMITREX 20 mg/act nasal soln, 5 mg/act nasal soln 3 QL(6 / 30)

IMITREX 100 mg tab 3 QL(9 / 30)

IMITREX 25 mg tab, 50 mg tab 3 QL(18 / 30)

IMITREX STATDOSE REFILL 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 3 QL(2 / 30)

IMITREX STATDOSE SYSTEM 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln auto-inj 3 QL(2 / 30)

MAXALT 10 mg tab 3 QL(12 / 30)

MAXALT-MLT 10 mg tab disint 3 QL(12 / 30)

MAXALT-MLT 5 mg tab disint 3 QL(24 / 30)

naratriptan hcl 1 mg tab, 2.5 mg tab 1 AMERGE QL(9 / 30)

RELPAX 20 mg tab, 40 mg tab 2 QL(6 / 30)

rizatriptan benzoate 10 mg tab, 10 mg tab disint 1 MAXALT QL(12 / 30)

rizatriptan benzoate 5 mg tab, 5 mg tab disint 1 MAXALT QL(24 / 30)

sumatriptan 20 mg/act nasal soln, 5 mg/act nasal soln 1 IMITREX QL(6 / 30)

sumatriptan succinate 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln auto-inj 1 IMITREX QL(2 / 30)

sumatriptan succinate 6 mg/0.5ml sc soln 1 IMITREX QL(5 / 30)

sumatriptan succinate 100 mg tab 1 IMITREX QL(9 / 30)

sumatriptan succinate 25 mg tab, 50 mg tab 1 IMITREX QL(18 / 30)

sumatriptan succinate refill 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 1 IMITREX QL(2 / 30)

SUMAVEL DOSEPRO 6 mg/0.5ml sc soln jet-inj 3 QL(3 / 30)

TREXIMET 85-500 mg tab 3 QL(9 / 30)

PROSSAM




Drug Tier

[Nivel]




zolmitriptan 2.5 mg tab disint, 5 mg tab disint 1 ZOMIG

zolmitriptan 2.5 mg tab, 5 mg tab 1 ZOMIG QL(6 / 30)

ZOMIG 2.5 mg nasal soln, 2.5 mg tab, 5 mg nasal soln, 5 mg tab 3 QL(6 / 30)

ZOMIG ZMT 2.5 mg tab disint, 5 mg tab disint 3

ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

Antimycobacterials, Miscellaneous [Antimicobacterianos, Misceláneos]

dapsone 100 mg tab, 25 mg tab 1

Antituberculosis Agents [Agentes Antituberculosis]

CAPASTAT SULFATE 1 gm inj soln 5 PA

cycloserine 250 mg cap 1

ethambutol hcl 100 mg tab, 400 mg tab 1 MYAMBUTOL

isoniazid 100 mg tab, 300 mg tab 1

isoniazid 100 mg/ml inj soln, 50 mg/5ml syr 1

MYAMBUTOL 100 mg tab, 400 mg tab 3

MYCOBUTIN 150 mg cap 3

PASER 4 gm pckt 3

PRIFTIN 150 mg tab 3

pyrazinamide 500 mg tab 1

rifabutin 150 mg cap 1 MYCOBUTIN

RIFADIN 150 mg cap, 300 mg cap 3

RIFAMATE 150-300 mg cap 3

rifampin 150 mg cap, 300 mg cap 1 RIFADIN

RIFATER 50-120-300 mg tab 3

TRECATOR 250 mg tab 3

ANTINEOPLASTIC AGENTS [AGENTES ANTINEOPLÁSICOS]

Antineoplastic Agents [Agentes Antineoplásicos]

ABRAXANE 100 mg iv susp 4 PA

ADCETRIS 50 mg iv soln 4 PA

adriamycin 10 mg iv soln 4 PA

ADRIAMYCIN 50 mg iv soln 4 PA

ADRIAMYCIN 2 mg/ml iv soln 4 PA

ADRUCIL 2.5 gm/50ml iv soln, 5 gm/100ml iv soln, 500 mg/10ml iv soln 4 PA

AFINITOR 10 mg tab, 2.5 mg tab, 5 mg tab, 7.5 mg tab 4 PA

AFINITOR DISPERZ 2 mg tab sol, 3 mg tab sol, 5 mg tab sol 4 PA

ALECENSA 150 mg cap 4 PA

PROSSAM




Drug Tier

[Nivel]




ALFERON N 5000000 unit/ml inj soln 4 PA

ALIMTA 100 mg iv soln, 500 mg iv soln 4 PA

ALKERAN 50 mg iv soln 4 PA

ALKERAN 2 mg tab 5 PA

anastrozole 1 mg tab 4 ARIMIDEX PA

ARIMIDEX 1 mg tab 4 PA

AROMASIN 25 mg tab 4 PA

ARRANON 5 mg/ml iv soln 4 PA

ARZERRA 100 mg/5ml iv conc, 1000 mg/50ml iv conc 4 PA

AVASTIN 100 mg/4ml iv soln, 400 mg/16ml iv soln 4 PA

azacitidine 100 mg inj susp 4 VIDAZA PA

BENDEKA 100 mg/4ml iv soln 4 PA

bexarotene 75 mg cap 4 TARGRETIN PA

bicalutamide 50 mg tab 4 CASODEX PA

BICNU 100 mg iv soln 4 PA

bleomycin sulfate 15 unit inj soln 4 PA

bleomycin sulfate 30 unit inj soln 4 BLENOXANE PA

BOSULIF 100 mg tab, 500 mg tab 4 PA

BRAFTOVI 50 mg cap, 75 mg cap 5 PA

busulfan 6 mg/ml iv soln 4 BUSULFEX PA

BUSULFEX 6 mg/ml iv soln 4 PA

CAMPATH 30 mg/ml iv soln 4 PA

CAMPTOSAR 100 mg/5ml iv soln, 300 mg/15ml iv soln, 40 mg/2ml iv soln 4 PA

capecitabine 150 mg tab, 500 mg tab 4 PA

CAPRELSA 100 mg tab, 300 mg tab 4 PA

carboplatin 450 mg/45ml iv soln, 50 mg/5ml iv soln, 600 mg/60ml iv soln 4 PA

carboplatin 150 mg/15ml iv soln 4 PARAPLATIN PA

CASODEX 50 mg tab 4 PA

cisplatin 100 mg/100ml iv soln, 200 mg/200ml iv soln, 50 mg/50ml iv soln 4 PA

cladribine 10 mg/10ml iv soln 4 LEUSTATIN PA

clofarabine 1 mg/ml iv soln 4 CLOLAR PA

CLOLAR 1 mg/ml iv soln 4 PA

COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 mg oral kit 4 PA

PROSSAM




Drug Tier

[Nivel]




COMETRIQ (140 MG DAILY DOSE) 1 X 80 & 3 X 20 mg oral kit 4 PA

COMETRIQ (60 MG DAILY DOSE) 20 mg oral kit 4 PA

COSMEGEN 0.5 mg iv soln 4 PA

cyclophosphamide 1 gm inj soln, 2 gm inj soln, 500 mg inj soln 4 PA

cytarabine 20 mg/ml inj soln 4 PA

cytarabine (pf) 100 mg/ml inj soln, 20 mg/ml inj soln 4 PA

dacarbazine 100 mg iv soln, 200 mg iv soln 4 PA

DACOGEN 50 mg iv soln 4 PA

dactinomycin 0.5 mg iv soln 4 COSMEGEN PA

DARZALEX 100 mg/5ml iv soln, 400 mg/20ml iv soln 4 PA

daunorubicin hcl 20 mg/4ml iv soln 4 PA

decitabine 50 mg iv soln 4 DACOGEN PA

docetaxel 160 mg/16ml iv soln, 160 mg/8ml iv conc, 20 mg/0.5ml iv conc, 20 mg/2ml iv soln, 20 mg/ml iv conc, 80 mg/2ml iv conc 4 PA

docetaxel 80 mg/4ml iv conc, 80 mg/8ml iv soln 4 TAXOTERE PA

DOXIL 2 mg/ml iv inj 4 PA

doxorubicin hcl 10 mg iv soln, 50 mg iv soln 4 PA

doxorubicin hcl 2 mg/ml iv soln 4 ADRIAMYCIN PA

doxorubicin hcl liposomal 2 mg/ml iv inj 4 DOXIL PA

DROXIA 200 mg cap, 300 mg cap, 400 mg cap 3

ELIGARD 22.5 mg sc kit, 30 mg sc kit, 45 mg sc kit, 7.5 mg sc kit 4 PA

ELLENCE 200 mg/100ml iv soln, 50 mg/25ml iv soln 4 PA

EMCYT 140 mg cap 4 PA

EMPLICITI 300 mg iv soln, 400 mg iv soln 4 PA

epirubicin hcl 50 mg/25ml iv soln 4 PA

epirubicin hcl 200 mg/100ml iv soln 4 ELLENCE PA

ERBITUX 100 mg/50ml iv soln, 200 mg/100ml iv soln 4 PA

ERIVEDGE 150 mg cap 4 PA

erlotinib hcl 100 mg tab, 150 mg tab, 25 mg tab 4 PA

PROSSAM




Drug Tier

[Nivel]




ERWINAZE 10000 unit inj soln 4 PA

ETOPOPHOS 100 mg iv soln 4 PA

etoposide 50 mg cap 4 PA

etoposide 1 gm/50ml iv soln, 100 mg/5ml iv soln 4 PA

etoposide 500 mg/25ml iv soln 4 VEPESID PA

exemestane 25 mg tab 4 AROMASIN PA

FARESTON 60 mg tab 4 PA

FASLODEX 250 mg/5ml im soln 4 PA

FEMARA 2.5 mg tab 4 PA

FIRMAGON 120 mg sc soln, 80 mg sc soln 4 PA

floxuridine 0.5 gm inj soln 4 PA

fludarabine phosphate 50 mg/2ml iv soln 4 PA

fludarabine phosphate 50 mg iv soln 4 FLUDARA PA

fluorouracil 1 gm/20ml iv soln, 2.5 gm/50ml iv soln, 5 gm/100ml iv soln, 500 mg/10ml iv soln 4 PA

flutamide 125 mg cap 4 EULEXIN PA

FOLOTYN 20 mg/ml iv soln, 40 mg/2ml iv soln 4 PA

fulvestrant 250 mg/5ml im soln 4 FASLODEX PA

gemcitabine hcl 2 gm iv soln, 200 mg iv soln 4 PA

gemcitabine hcl 1 gm/26.3ml iv soln, 2 gm/52.6ml iv soln, 200 mg/5.26ml iv soln 4 PA

gemcitabine hcl 1 gm iv soln 4 GEMZAR PA

GEMZAR 1 gm iv soln, 200 mg iv soln 4 PA

GILOTRIF 20 mg tab, 30 mg tab, 40 mg tab 4 PA

GLEEVEC 100 mg tab, 400 mg tab 4 PA

GLEOSTINE 10 mg cap, 100 mg cap, 40 mg cap 4 PA

GLIADEL WAFER 7.7 mg implant wafer 4 PA

HALAVEN 1 mg/2ml iv soln 4 PA

HERCEPTIN 150 mg iv soln, 440 mg iv soln 4 PA

HEXALEN 50 mg cap 4 PA

HYCAMTIN 0.25 mg cap, 1 mg cap, 4 mg iv soln 4 PA

HYDREA 500 mg cap 3 PA

PROSSAM




Drug Tier

[Nivel]




hydroxyurea 500 mg cap 4 HYDREA PA

ICLUSIG 15 mg tab, 45 mg tab 4 PA

IDAMYCIN PFS 10 mg/10ml iv soln, 20 mg/20ml iv soln, 5 mg/5ml iv soln 4 PA

idarubicin hcl 20 mg/20ml iv soln, 5 mg/5ml iv soln 4 PA

idarubicin hcl 10 mg/10ml iv soln 4 IDAMYCIN PA

IDHIFA 100 mg tab, 50 mg tab 4 PA

IFEX 1 gm iv soln, 3 gm iv soln 4 PA

ifosfamide 3 gm iv soln 4 PA

ifosfamide 1 gm/20ml iv soln, 3 gm/60ml iv soln 4 PA

ifosfamide 1 gm iv soln 4 IFEX PA

IMBRUVICA 140 mg cap 4 PA

INLYTA 1 mg tab, 5 mg tab 4 PA

INTRON A 10000000 unit inj soln, 18000000 unit inj soln, 50000000 unit inj soln 4 PA

INTRON A 10000000 unit/ml inj soln, 6000000 unit/ml inj soln 4 PA

IRESSA 250 mg tab 4 PA

irinotecan hcl 40 mg/2ml iv soln, 500 mg/25ml iv soln 4 PA

irinotecan hcl 100 mg/5ml iv soln 4 CAMPTOSAR PA

ISTODAX (OVERFILL) 10 mg iv soln 4 PA

IXEMPRA KIT 15 mg iv soln, 45 mg iv soln 4 PA

JAKAFI 10 mg tab, 15 mg tab, 20 mg tab, 25 mg tab, 5 mg tab 4 PA

JEVTANA 60 mg/1.5ml iv soln 4 PA

KADCYLA 100 mg iv soln, 160 mg iv soln 4 PA

KANJINTI 420 mg iv soln, 150 mg iv soln 4 PA

KEYTRUDA 100 mg/4ml iv soln 4 PA

KYPROLIS 60 mg iv soln 4 PA

letrozole 2.5 mg tab 4 FEMARA PA

LEUKERAN 2 mg tab 4 PA

leuprolide acetate 1 mg/0.2ml inj kit 4 LUPRON PA

LIPODOX 50 2 mg/ml iv inj 4 PA

LUPRON DEPOT (1-MONTH) 3.75 mg im kit, 7.5 mg im kit 4 PA

LUPRON DEPOT (3-MONTH) 11.25 mg im kit, 22.5 mg im kit 4 PA

PROSSAM




Drug Tier

[Nivel]




LUPRON DEPOT (4-MONTH) 30 mg im kit 4 PA

LUPRON DEPOT (6-MONTH) 45 mg im kit 4 PA

LUPRON DEPOT-PED (1-MONTH) 11.25 mg im kit, 15 mg im kit, 7.5 mg im kit 4 PA

LUPRON DEPOT-PED (3-MONTH) 11.25 mg (ped) im kit, 30 mg (ped) im kit 4 PA

LYSODREN 500 mg tab 4 PA

MATULANE 50 mg cap 4 PA

megestrol acetate 20 mg tab, 40 mg tab 4 MEGACE PA

megestrol acetate 40 mg/ml susp, 400 mg/10ml susp 4 MEGACE PA

MEKINIST 0.5 mg tab, 2 mg tab 4 PA

MEKTOVI 15 mg tab 5 PA

melphalan hcl 50 mg iv soln 4 ALKERAN PA

mercaptopurine 50 mg tab 4 PURINETHOL PA

methotrexate 2.5 mg tab 4 PA

methotrexate sodium 1 gm inj soln, 2.5 mg tab 4 PA

methotrexate sodium 250 mg/10ml inj soln, 50 mg/2ml inj soln 4 PA

methotrexate sodium (pf) 1 gm/40ml inj soln, 250 mg/10ml inj soln, 50 mg/2ml inj soln 4 PA

mitomycin 20 mg iv soln, 40 mg iv soln, 5 mg iv soln 4 MUTAMYCIN PA

mitoxantrone hcl 20 mg/10ml iv conc, 25 mg/12.5ml iv conc, 30 mg/15ml iv conc 4 PA

MUSTARGEN 10 mg inj soln 4 PA

MVASI 100 mg/4ml iv soln, 400 mg/16ml iv soln 4 PA

MYLERAN 2 mg tab 4 PA

NAVELBINE 10 mg/ml iv soln, 50 mg/5ml iv soln 4 PA

NERLYNX 40 mg tab 4 PA

NEXAVAR 200 mg tab 4 PA

NILANDRON 150 mg tab 4 PA

nilutamide 150 mg tab 4 NILANDRON PA

NINLARO 2.3 mg cap, 3 mg cap, 4 mg cap 4 PA

NIPENT 10 mg iv soln 4 PA

PROSSAM




Drug Tier

[Nivel]




ONCASPAR 750 unit/ml inj soln 4 PA

OPDIVO 100 mg/10ml iv soln, 240 mg/24ml iv soln, 40 mg/4ml iv soln 4 PA

oxaliplatin 100 mg iv soln, 50 mg iv soln 4 PA

oxaliplatin 50 mg/10ml iv soln 4 PA

oxaliplatin 100 mg/20ml iv soln 4 ELOXATIN PA

paclitaxel 100 mg/16.7ml iv conc, 150 mg/25ml iv conc, 30 mg/5ml iv conc 4 PA

paclitaxel 300 mg/50ml iv conc 4 TAXOL PA

PERJETA 420 mg/14ml iv soln 4 PA

PHOTOFRIN 75 mg iv soln 4 PA

POMALYST 1 mg cap, 2 mg cap, 3 mg cap, 4 mg cap 4 PA

PROLEUKIN 22000000 unit iv soln 4 PA

REVLIMID 10 mg cap, 15 mg cap, 2.5 mg cap, 25 mg cap, 5 mg cap 5 PA

RITUXAN 100 mg/10ml iv soln, 500 mg/50ml iv soln 4 PA

SOLTAMOX 10 mg/5ml soln 4 PA

SPRYCEL 100 mg tab, 140 mg tab, 20 mg tab, 50 mg tab, 70 mg tab, 80 mg tab 4 PA

STIVARGA 40 mg tab 4 PA

SUTENT 12.5 mg cap, 25 mg cap, 50 mg cap 4 PA

SYLATRON 200 mcg sc kit, 300 mcg sc kit, 600 mcg sc kit 4 PA

SYNRIBO 3.5 mg sc soln 4 PA

TABLOID 40 mg tab 4 PA

TAFINLAR 50 mg cap, 75 mg cap 4 PA

TAGRISSO 40 mg tab, 80 mg tab 4 PA

tamoxifen citrate 10 mg tab, 20 mg tab 4 NOLVADEX PA

TARCEVA 100 mg tab, 150 mg tab, 25 mg tab 4 PA

TARGRETIN 75 mg cap 4 PA

TASIGNA 150 mg cap, 200 mg cap 4 PA

TAXOTERE 20 mg/ml iv conc, 80 mg/4ml iv conc 4 PA

TEMODAR 100 mg cap, 100 mg iv soln, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 4 PA

PROSSAM




Drug Tier

[Nivel]




temozolomide 100 mg cap, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 4 PA

teniposide 10 mg/ml iv soln 4 PA

thiotepa 15 mg inj soln 4 THIOPLEX PA

TOPOSAR 1 gm/50ml iv soln, 100 mg/5ml iv soln, 500 mg/25ml iv soln 4 PA

topotecan hcl 4 mg/4ml iv soln 4 PA

topotecan hcl 4 mg iv soln 4 HYCAMTIN PA

TORISEL 25 mg/ml iv soln 4 PA

TREANDA 100 mg iv soln, 25 mg iv soln 4 PA

TRELSTAR MIXJECT 11.25 mg im susp, 22.5 mg im susp, 3.75 mg im susp 4 PA

tretinoin 10 mg cap 4 VESANOID PA

TREXALL 10 mg tab, 15 mg tab, 5 mg tab, 7.5 mg tab 4 PA

TYKERB 250 mg tab 4 PA

VALSTAR 40 mg/ml i-vesic soln 4 PA

VANTAS 50 mg sc kit 4 PA

VECTIBIX 100 mg/5ml iv soln, 400 mg/20ml iv soln 4 PA

VELCADE 3.5 mg inj soln 4 PA

VIDAZA 100 mg inj susp 4 PA

vinblastine sulfate 1 mg/ml iv soln 4 PA

VINCASAR PFS 1 mg/ml iv soln 4 PA

vincristine sulfate 1 mg/ml iv soln 4 VINCASAR PA

vinorelbine tartrate 10 mg/ml iv soln 4 PA

vinorelbine tartrate 50 mg/5ml iv soln 4 NAVELBINE PA

VOTRIENT 200 mg tab 4 PA

XALKORI 200 mg cap, 250 mg cap 4 PA

XELODA 150 mg tab, 500 mg tab 4 PA

XTANDI 40 mg cap 4 PA

YERVOY 200 mg/40ml iv soln, 50 mg/10ml iv soln 4 PA

ZALTRAP 100 mg/4ml iv soln, 200 mg/8ml iv soln 4 PA

ZANOSAR 1 gm iv soln 4 PA

ZELBORAF 240 mg tab 4 PA

ZOLINZA 100 mg cap 4 PA

ZYTIGA 250 mg tab 4 PA

ANTIPARKINSONIAN AGENTS [AGENTES ANTIPARKINSONIANOS]

Adamantanes [Adamantanos]

PROSSAM




Drug Tier

[Nivel]




amantadine hcl 100 mg cap, 100 mg tab 1 SYMMETREL

amantadine hcl 50 mg/5ml syr 1 SYMMETREL

Anticholinergic Agents [Agentes Anticolinérgicos]

benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab 1 COGENTIN

benztropine mesylate 1 mg/ml inj soln 1 COGENTIN

COGENTIN 1 mg/ml inj soln 3

trihexyphenidyl hcl 2 mg tab, 5 mg tab 1 ARTANE

trihexyphenidyl hcl 0.4 mg/ml oral elix 1 ARTANE

Catechol-o-methyltransferase (comt) Inhibitors [Inhibidores De La Catecol-O-Metiltransferasa (Comt)]

COMTAN 200 mg tab 3

entacapone 200 mg tab 1 COMTAN

TASMAR 100 mg tab 3

tolcapone 100 mg tab 1 TASMAR

Dopamine Precursors [Precursores De Dopamina]

carbidopa 25 mg tab 1 LODOSYN

carbidopa-levodopa 10-100 mg tab disint, 25-100 mg tab disint, 25-250 mg tab disint 1 PARCOPA

carbidopa-levodopa 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 1 SINEMET

carbidopa-levodopa er 25-100 mg tab er, 50-200 mg tab er 1 SINEMET CR

carbidopa-levodopa-entacapone 12.5-50-200 mg tab, 18.75-75-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50-200-200 mg tab 1 STALEVO

LODOSYN 25 mg tab 3

SINEMET 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 3

SINEMET CR 25-100 mg tab er, 50-200 mg tab er 3

STALEVO 100 25-100-200 mg tab 3

STALEVO 125 31.25-125-200 mg tab 3

STALEVO 150 37.5-150-200 mg tab 3

STALEVO 200 50-200-200 mg tab 3

STALEVO 50 12.5-50-200 mg tab 3

STALEVO 75 18.75-75-200 mg tab 3

PROSSAM




Drug Tier

[Nivel]




Dopamine Receptor Agonists [Agonistas Del Receptor De Dopamina]

APOKYN 30 mg/3ml sc soln cart 5 PA

bromocriptine mesylate 2.5 mg tab, 5 mg cap 1 PARLODEL

cabergoline 0.5 mg tab 1 DOSTINEX

MIRAPEX 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 3

MIRAPEX ER 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 3

NEUPRO 1 mg/24hr td patch 24hr, 2 mg/24hr td patch 24hr, 3 mg/24hr td patch 24hr, 4 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 8 mg/24hr td patch 24hr 3

PARLODEL 2.5 mg tab, 5 mg cap 3

pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 1 MIRAPEX

pramipexole dihydrochloride er 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 1 MIRAPEX ER

REQUIP 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 3

REQUIP XL 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 3

ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 1 REQUIP

ropinirole hcl er 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 1 REQUIP XL

Monoamine Oxidase B Inhibitors [Inhibidores De La Monoaminooxidasa B (Mao-B)]

AZILECT 0.5 mg tab, 1 mg tab 3

ELDEPRYL 5 mg cap 3

PROSSAM




Drug Tier

[Nivel]




EMSAM 12 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 9 mg/24hr td patch 24hr 3

rasagiline mesylate 0.5 mg tab, 1 mg tab 1 AZILECT

selegiline hcl 5 mg tab 1

selegiline hcl 5 mg cap 1 ELDEPRYL

ZELAPAR 1.25 mg tab disint 3

ANTIPROTOZOALS [ANTIPROTOZOARIOS]

Amebicides [Amebicidas]

paromomycin sulfate 250 mg cap 1 HUMATIN

Antimalarials [Antimaláricos]

atovaquone-proguanil hcl 250-100 mg tab, 62.5-25 mg tab 1 MALARONE

chloroquine phosphate 250 mg tab, 500 mg tab 1

COARTEM 20-120 mg tab 3

DARAPRIM 25 mg tab 3

hydroxychloroquine sulfate 200 mg tab 1 PLAQUENIL

MALARONE 250-100 mg tab, 62.5-25 mg tab 3

mefloquine hcl 250 mg tab 1

PLAQUENIL 200 mg tab 3

primaquine phosphate 26.3 mg tab 1

QUALAQUIN 324 mg cap 3 QL(42 / 365)

quinine sulfate 324 mg cap 1 QUALAQUIN QL(42 / 365)

Antiprotozoals, Miscellaneous [Antiprotozoarios, Misceláneos]

ALINIA 500 mg tab 3

ALINIA 100 mg/5ml susp 3

atovaquone 750 mg/5ml susp 4 MEPRON PA

FLAGYL 250 mg tab, 375 mg cap, 500 mg tab 3

MEPRON 750 mg/5ml susp 5 PA

metronidazole 250 mg tab, 375 mg cap, 500 mg tab 1 FLAGYL

NEBUPENT 300 mg inh soln 3

PENTAM 300 mg inj soln 3

TINDAMAX 500 mg tab 3

tinidazole 250 mg tab, 500 mg tab 1 TINDAMAX

ANTIPRURITICS AND LOCAL ANESTHETICS [ANTIPRURÍTICOS Y ANESTÉSICOS LOCALES]

Antipruritics And Local Anesthetics [Antipruríticos Y Anestésicos Locales]

agoneaze 2.5-2.5 % ext kit 1

ANACAINE 10 % oint 3

ANALPRAM HC 2.5-1 % rect crm 3

PROSSAM




Drug Tier

[Nivel]




ANALPRAM HC SINGLES 2.5-1 % rect crm 3

ANALPRAM-HC 1-1 % rect crm 3

ANALPRAM-HC 2.5-1 % rect lot 3

anodyne lpt 2.5-2.5 % ext kit 1

DERMACINRX EMPRICAINE 2.5-2.5 % ext kit 3

DERMACINRX PRIZOPAK 2.5-2.5 % ext kit 3

ethyl chloride ext aer 1

FIRST-MOUTHWASH BLM m/t susp 3

GEBAUERS PAIN EASE ext aer 3

GEBAUERS SPRAY AND STRETCH ext aer 3

GLYDO 2 % gel 3

hydrocortisone ace-pramoxine 1-1 % rect crm, 2.5-1 % rect crm 1

LIDO BDK 2.5-2.5 % ext kit 3

lidocaine 5 % oint 1

lidocaine 5 % patch 1 LIDODERM

lidocaine hcl 3 % crm 1

lidocaine hcl 3 % lot 1

lidocaine hcl 2 % gel, 4 % ext soln 1 XYLOCAINE

lidocaine pak 5 % oint 1

lidocaine-hydrocortisone ace 2-2 % rect kit, 3-0.5 % rect kit, 3-1 % rect kit, 3-2.5 % rect kit 1

lidocaine-hydrocortisone ace 2.8-0.55 % rect gel, 3-0.5 % rect crm 1

lidocaine-prilocaine 2.5-2.5 % ext kit 1

lidocaine-prilocaine 2.5-2.5 % crm 1 EMLA

LIDODERM 5 % patch 3

lido-k 3 % lot 1

lidopin 3 % crm 1

lidopril 2.5-2.5 % ext kit 1

lidopril xr 2.5-2.5 % ext kit 1

LIDO-PRILO CAINE PACK 2.5-2.5 % ext kit 3

LIPROZONEPAK 2.5-2.5 % ext kit 3

LIVIXIL PAK 2.5-2.5 % ext kit 3

MEDOLOR PAK 2.5-2.5 % ext kit 3

PHENAZO 200 mg tab 3

phenazopyridine hcl 100 mg tab, 200 mg tab 1

PROSSAM




Drug Tier

[Nivel]




pramcort 1-1 % rect crm 1

PRAMOX 1 % gel 3

premium lidocaine 5 % oint 1

prilolid 2.5-2.5 % ext kit 1

PRILOXX LP 2.5-2.5 % ext kit 3

PROCORT 1.85-1.15 % rect crm 3

PROCTOFOAM HC 1-1 % rect foam 3

PRUDOXIN 5 % crm 3

PYRIDIUM 100 mg tab, 200 mg tab 3

RELADOR PAK 2.5-2.5 % ext kit 3

RELADOR PAK PLUS 2.5-2.5 % ext kit 3

SYNERA 70-70 mg patch 3

TOPEX TOPICAL ANESTHETIC 20 % Mouth/Throat Aerosol 3

ZONALON 5 % crm 3

ANTITHROMBOTIC AGENTS [AGENTES ANTITROMBÓTICOS]

Anticoagulants [Anticoagulantes]

ARIXTRA 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 5 PA

COUMADIN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 2

ELIQUIS 2.5 mg tab, 5 mg tab 2 PA

ELIQUIS STARTER PACK 5 mg tab 2 PA

enoxaparin sodium 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 4 LOVENOX PA

fondaparinux sodium 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 5 ARIXTRA PA

FRAGMIN 10000 unit/ml sc soln, 12500 unit/0.5ml sc soln, 15000 unit/0.6ml sc soln, 18000 unt/0.72ml sc soln, 2500 unit/0.2ml sc soln, 5000 unit/0.2ml sc soln, 7500 unit/0.3ml sc soln 5 PA

heparin sodium (porcine) 1000 unit/ml inj soln, 10000 unit/ml inj 1

PROSSAM




Drug Tier

[Nivel]




soln, 20000 unit/ml inj soln, 5000 unit/ml inj soln

JANTOVEN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 3

LOVENOX 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 5 PA

PRADAXA 110 mg cap, 150 mg cap, 75 mg cap 2 PA

warfarin sodium 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 1 COUMADIN

XARELTO 10 mg tab, 15 mg tab, 20 mg tab 2 PA

XARELTO STARTER PACK 15 & 20 mg tab pack 2 PA

Platelet-aggregation Inhibitors [Inhibidores De La Agregación De Plaquetas]

aspirin-dipyridamole er 25-200 mg cap er 12 hr 1 AGGRENOX

BRILINTA 60 mg tab, 90 mg tab 2 PA

cilostazol 100 mg tab, 50 mg tab 1 PLETAL

clopidogrel bisulfate 300 mg tab, 75 mg tab 1 PLAVIX

EFFIENT 10 mg tab, 5 mg tab 2 PA

PLAVIX 300 mg tab, 75 mg tab 3

prasugrel hcl 10 mg tab, 5 mg tab 1 EFFIENT PA

Platelet-reducing Agents [Agentes Reductores De Plaquetas]

AGRYLIN 0.5 mg cap 3

anagrelide hcl 0.5 mg cap, 1 mg cap 1 AGRYLIN

ANTITUSSIVES [ANTITUSIVOS]

Antitussives [Antitusivos]

ap-hist dm 7.5-4-15 mg/5ml liq 1

benzonatate 100 mg cap, 150 mg cap, 200 mg cap 1

biotuss 10-15-300 mg/5ml liq 1

BIOTUSS PEDIATRIC 2.5-5-50 mg/ml liq 3

BROMFED DM 30-2-10 mg/5ml syr 3

CARBAPHEN 12 10-4-27.5 mg/5ml liq 3

PROSSAM




Drug Tier

[Nivel]




CARBAPHEN 12 PED 2.5-1.25-7.5 mg/ml susp 3

cheratussin ac 100-10 mg/5ml syr 1

EXACTUSS 10-28-388 mg/5ml liq 3

g tussin ac 100-10 mg/5ml soln 1

GILTUSS 10-28-388 mg/5ml liq 3

GILTUSS PEDIATRIC 2.5-7.5-88 mg/ml liq 3

GILTUSS TR 10-28-388 mg tab 3

guaiatussin ac 100-10 mg/5ml syr 1

guaifenesin ac 100-10 mg/5ml syr 1

guaifenesin-codeine 100-10 mg/5ml soln 1

hydrocod polst-cpm polst er 10-8 mg/5ml susp er 1

hydrocodone-homatropine 5-1.5 mg tab 1

hydrocodone-homatropine 5-1.5 mg/5ml syr 1

hydromet 5-1.5 mg/5ml syr 1

m-hist dm 7.5-4-15 mg/5ml liq 1

NEOTUSS PLUS 7.5-4-30 mg/5ml liq 3

NIVA-HIST DM 7.5-4-15 mg/5ml liq 1

NORTUSS-DE 2.5-5-50 mg/ml liq 3

nortuss-ex 20-200 mg/5ml liq 1

phenyleph-promethazine-cod 5-6.25-10 mg/5ml syr 1

promethazine vc/codeine 6.25-5-10 mg/5ml syr 1

promethazine-codeine 6.25-10 mg/5ml soln, 6.25-10 mg/5ml syr 1

promethazine-dm 6.25-15 mg/5ml syr 1

promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syr 1

pseudoeph-bromphen-dm 30-2-10 mg/5ml syr 1

pseudoeph-chlorphen-hydrocod 60-4-5 mg/5ml soln 1

robafen ac 100-10 mg/5ml soln 1

TESSALON PERLES 100 mg cap 3

TUSNEL 60-30-400 mg tab 3

TUSSICAPS 10-8 mg cap er 12 hr, 5-4 mg cap er 12 hr 3

TUSSIGON 5-1.5 mg tab 3

PROSSAM




Drug Tier

[Nivel]




TUSSIONEX PENNKINETIC ER 10-8 mg/5ml susp er 3

virtussin a/c 100-10 mg/5ml soln 1

ZUTRIPRO 60-4-5 mg/5ml soln 3

ANTIULCER AGENTS AND ACID SUPPRESSANTS [AGENTES ANTI-ÚLCERA Y SUPRESORES DE ÁCIDOS]

Antiulcer Agents And Acid Suppressants, Misc [Agentes Anti-Úlcera Y Supresores De Ácidos, Misceláneos]

PYLERA 140-125-125 mg cap 3

Histamine H2-antagonists [Antagonistas De Histamina H2]

cimetidine 300 mg tab, 400 mg tab, 800 mg tab 1 TAGAMET QL(90 / 365)

cimetidine hcl 300 mg/5ml soln 1 TAGAMET

famotidine 40 mg/5ml susp 1 PEPCID

famotidine 20 mg tab, 40 mg tab 1 PEPCID QL(90 / 365)

nizatidine 15 mg/ml soln 1 AXID

nizatidine 150 mg cap, 300 mg cap 1 AXID QL(90 / 365)

PEPCID 40 mg/5ml susp 3

PEPCID 20 mg tab, 40 mg tab 3 QL(90 / 365)

ranitidine hcl 150 mg cap, 300 mg cap 1 ZANTAC

ranitidine hcl 50 mg/2ml inj soln 1 ZANTAC

ranitidine hcl 150 mg tab, 300 mg tab 1 ZANTAC QL(90 / 365)

ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 150 mg/6ml inj soln, 75 mg/5ml syr 1 ZANTAC QL(90 / 365)

ZANTAC 1000 mg/40ml inj soln, 50 mg/2ml inj soln 3

ZANTAC 300 mg tab 3 QL(90 / 365)

ZANTAC 150 mg/6ml inj soln 3 QL(90 / 365)

Prostaglandins [Prostaglandinas]

CYTOTEC 100 mcg tab, 200 mcg tab 3 QL(90 / 365)

misoprostol 100 mcg tab, 200 mcg tab 1 CYTOTEC QL(90 / 365)

Protectants [Protectores]

CARAFATE 1 gm/10ml susp 3

CARAFATE 1 gm tab 3 QL(90 / 365)

sucralfate 1 gm tab 1 CARAFATE QL(90 / 365)

Proton-pump Inhibitors [Inhibidores De La Bomba De Protones]

ACIPHEX 20 mg tab dr 3

amoxicill-clarithro-lansopraz oral misc 1 PREVPAC QL(90 / 365)

DEXILANT 30 mg cap dr, 60 mg cap dr 2

PROSSAM




Drug Tier

[Nivel]




esomeprazole magnesium 20 mg cap dr, 40 mg cap dr 1 NEXIUM QL(90 / 365)

FIRST-LANSOPRAZOLE 3 mg/ml susp 3

FIRST-OMEPRAZOLE 2 mg/ml susp 3

lansoprazole 15 mg tab disint, 30 mg tab disint 1

lansoprazole 15 mg cap dr, 30 mg cap dr 1 PREVACID QL(90 / 365)

NEXIUM 10 mg pckt, 2.5 mg pckt, 20 mg cap dr, 20 mg pckt, 40 mg cap dr, 40 mg pckt, 5 mg pckt 3 QL(90 / 365)

OMECLAMOX-PAK 500-500-20 mg oral misc 3

OMEPPI 20-1100 mg cap, 40-1100 mg cap 3 QL(90 / 365)

omeprazole 10 mg cap dr, 20 mg cap dr, 40 mg cap dr 1 PRILOSEC QL(90 / 365)

OMEPRAZOLE+SYRSPEND SF ALKA 2 mg/ml susp 3

omeprazole-sodium bicarbonate 20-1680 mg pckt, 40-1680 mg pckt 1 ZEGERID

omeprazole-sodium bicarbonate 20-1100 mg cap, 40-1100 mg cap 1 ZEGERID QL(90 / 365)

pantoprazole sodium 20 mg tab dr, 40 mg tab dr 1 PROTONIX QL(90 / 365)

PREVACID 15 mg cap dr, 30 mg cap dr 3 QL(90 / 365)

PREVACID SOLUTAB 15 mg tab disint, 30 mg tab disint 3

PREVPAC oral misc 3 QL(90 / 365)

PRILOSEC 10 mg pckt, 2.5 mg pckt 3

PROTONIX 40 mg pckt 3

PROTONIX 20 mg tab dr, 40 mg tab dr 3 QL(90 / 365)

rabeprazole sodium 20 mg tab dr 1 ACIPHEX

ZEGERID 20-1100 mg cap, 20-1680 mg pckt, 40-1100 mg cap, 40-1680 mg pckt 3 QL(90 / 365)

ANTIVIRALS [ANTIVIRALES]

Adamantanes [Adamantanos]

FLUMADINE 100 mg tab 3

rimantadine hcl 100 mg tab 1 FLUMADINE

Antiretrovirals [Antirretrovirales]

PROSSAM




Drug Tier

[Nivel]




abacavir sulfate 300 mg tab 4 ZIAGEN PA

abacavir sulfate 20 mg/ml soln 4 ZIAGEN PA

abacavir sulfate-lamivudine 600-300 mg tab 4 EPZICOM PA

abacavir-lamivudine-zidovudine 300-150-300 mg tab 4 TRIZIVIR PA

APTIVUS 250 mg cap 4 PA

APTIVUS 100 mg/ml soln 4 PA

atazanavir sulfate 150 mg cap, 200 mg cap, 300 mg cap 4 REYATAZ PA

ATRIPLA 600-200-300 mg tab 4 PA

COMBIVIR 150-300 mg tab 5 PA

COMPLERA 200-25-300 mg tab 5 PA

CRIXIVAN 200 mg cap, 400 mg cap 4 PA

didanosine 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 4 VIDEX PA

EDURANT 25 mg tab 4 PA

efavirenz 200 mg cap, 50 mg cap 4 SUSTIVA PA

EMTRIVA 200 mg cap 4 PA

EMTRIVA 10 mg/ml soln 4 PA

EPIVIR 150 mg tab, 300 mg tab 5 PA

EPIVIR 10 mg/ml soln 5 PA

EPIVIR HBV 100 mg tab 5 PA

EPIVIR HBV 5 mg/ml soln 5 PA

EPZICOM 600-300 mg tab 4 PA

EVOTAZ 300-150 mg tab 4 PA

fosamprenavir calcium 700 mg tab 4 LEXIVA PA

FUZEON 90 mg sc soln 4 PA

INTELENCE 100 mg tab, 200 mg tab, 25 mg tab 4 PA

INVIRASE 200 mg cap, 500 mg tab 5 PA

ISENTRESS 100 mg tab chew, 25 mg tab chew, 400 mg tab 4 PA

ISENTRESS HD 600 mg tab 4 PA

KALETRA 100-25 mg tab, 200-50 mg tab 4 PA

KALETRA 400-100 mg/5ml soln 4 PA

lamivudine 150 mg tab, 300 mg tab 4 EPIVIR PA

lamivudine 10 mg/ml soln 4 EPIVIR PA

lamivudine 100 mg tab 4 EPIVIR HBV PA

lamivudine-zidovudine 150-300 mg tab 4 COMBIVIR PA

LEXIVA 700 mg tab 4 PA

LEXIVA 50 mg/ml susp 4 PA

PROSSAM




Drug Tier

[Nivel]




lopinavir-ritonavir 400-100 mg/5ml soln 4 KALETRA PA

nevirapine 200 mg tab 4 VIRAMUNE PA

nevirapine 50 mg/5ml susp 4 VIRAMUNE PA

nevirapine er 100 mg tab er 24 hr, 400 mg tab er 24 hr 4 VIRAMUNE XR PA

NORVIR 100 mg cap, 100 mg tab 4 PA

NORVIR 80 mg/ml soln 4 PA

ODEFSEY 200-25-25 mg tab 4 PA

PREZCOBIX 800-150 mg tab 4 PA

PREZISTA 150 mg tab, 600 mg tab, 75 mg tab, 800 mg tab 5 PA

PREZISTA 100 mg/ml susp 5 PA

RESCRIPTOR 100 mg tab, 200 mg tab 4 PA

RETROVIR 100 mg cap 5 PA

RETROVIR 10 mg/ml iv soln, 50 mg/5ml syr 5 PA

REYATAZ 50 mg pckt 4 PA

REYATAZ 150 mg cap, 200 mg cap, 300 mg cap 5 PA

SELZENTRY 150 mg tab, 300 mg tab 4 PA

stavudine 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 4 ZERIT PA

STRIBILD 150-150-200-300 mg tab 4 PA

SUSTIVA 200 mg cap, 50 mg cap, 600 mg tab 4 PA

tenofovir disoproxil fumarate 300 mg tab 4 VIREAD PA

TIVICAY 50 mg tab 4 PA

TRIZIVIR 300-150-300 mg tab 5 PA

TRUVADA 200-300 mg tab 4 PA

VIDEX 2 gm soln, 4 gm soln 5 PA

VIDEX EC 125 mg cap dr, 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 5 PA

VIRACEPT 250 mg tab, 625 mg tab 4 PA

VIRAMUNE 200 mg tab 5 PA

VIRAMUNE 50 mg/5ml susp 5 PA

VIRAMUNE XR 100 mg tab er 24 hr, 400 mg tab er 24 hr 5 PA

VIREAD 150 mg tab, 200 mg tab, 250 mg tab, 300 mg tab 4 PA

VIREAD 40 mg/gm oral pwdr 4 PA

PROSSAM




Drug Tier

[Nivel]




ZERIT 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 5 PA

ZERIT 1 mg/ml soln 5 PA

ZIAGEN 300 mg tab 5 PA

ZIAGEN 20 mg/ml soln 5 PA

zidovudine 100 mg cap, 300 mg tab 4 RETROVIR PA

zidovudine 50 mg/5ml syr 4 RETROVIR PA

Hcv Antivirals [Antivirales Para Vhc]

ledipasvir-sofosbuvir 90-400 mg tab 1 PA

HARVONI 90-400 mg tab 4 PA

MAVYRET 100-40 mg tab 4 PA

SOVALDI 400 mg tab 4 PA

Interferons [Interferones]

PEGASYS 180 mcg/ml sc soln 5 PA

PEGASYS PROCLICK 135 mcg/0.5ml sc soln 5 PA

PEGINTRON 50 mcg/0.5ml sc kit 5 PA

PLEGRIDY 125 mcg/0.5ml sc soln pen-inj, 125 mcg/0.5ml sc soln pfs 5 PA

PLEGRIDY STARTER PACK 63 & 94 mcg/0.5ml sc soln pen-inj, 63 & 94 mcg/0.5ml sc soln pfs 5 PA

Monoclonal Antibodies [Anticuerpos Monoclonales]

SYNAGIS 100 mg/ml im soln, 50 mg/0.5ml im soln 5 PA

Neuraminidase Inhibitors [Inhibidores De La Neuraminidasa]

oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap 1 TAMIFLU

oseltamivir phosphate 6 mg/ml susp 1 TAMIFLU

RELENZA DISKHALER 5 mg/blister inh aer pwdr br act 3

TAMIFLU 30 mg cap, 45 mg cap, 75 mg cap 3

TAMIFLU 6 mg/ml susp 3

Nucleosides And Nucleotides [Nucleósidos Y Nucleótidos]

acyclovir 200 mg cap, 400 mg tab, 800 mg tab 1 ZOVIRAX

acyclovir 200 mg/5ml susp 1 ZOVIRAX

adefovir dipivoxil 10 mg tab 1 HEPSERA PA

BARACLUDE 0.5 mg tab, 1 mg tab 5 PA

BARACLUDE 0.05 mg/ml soln 5 PA

entecavir 0.5 mg tab, 1 mg tab 1 BARACLUDE PA

famciclovir 125 mg tab, 250 mg tab, 500 mg tab 1 FAMVIR

HEPSERA 10 mg tab 5 PA

PROSSAM




Drug Tier

[Nivel]




MODERIBA 200 mg tab 5 PA

REBETOL 200 mg cap 5 PA

RIBASPHERE 200 mg cap, 200 mg tab 5 PA

ribavirin 200 mg tab 4 COPEGUS PA

ribavirin 200 mg cap 4 REBETOL PA

ribavirin 6 gm inh soln 1 VIRAZOLE

valacyclovir hcl 1 gm tab, 500 mg tab 1 VALTREX

VALCYTE 450 mg tab 5 PA

VALCYTE 50 mg/ml soln 5 PA

valganciclovir hcl 450 mg tab 4 VALCYTE PA

valganciclovir hcl 50 mg/ml soln 4 VALCYTE PA

VALTREX 1 gm tab, 500 mg tab 3

VIRAZOLE 6 gm inh soln 3

ZOVIRAX 200 mg cap, 400 mg tab, 800 mg tab 3

ZOVIRAX 200 mg/5ml susp 3

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS [ANSIOLÍTICOS, SEDANTES E HIPNÓTICOS]

Anxiolytics, Sedatives, & Hypnotics Misc [Ansiolíticos, Sedantes E Hipnóticos Misceláneos]

AMBIEN 10 mg tab, 5 mg tab 3

AMBIEN CR 12.5 mg tab er, 6.25 mg tab er 3

buspirone hcl 10 mg tab, 15 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 BUSPAR

droperidol 2.5 mg/ml inj soln 1

EDLUAR 10 mg tab subl, 5 mg tab subl 3

eszopiclone 1 mg tab, 2 mg tab, 3 mg tab 1 LUNESTA

hydroxyzine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 ATARAX

hydroxyzine hcl 10 mg/5ml syr 1 ATARAX

hydroxyzine hcl 25 mg/ml im soln, 50 mg/ml im soln 1 VISTARIL

hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap 1 VISTARIL

INTERMEZZO 1.75 mg tab subl, 3.5 mg tab subl 3

LUNESTA 1 mg tab, 2 mg tab, 3 mg tab 3

meprobamate 200 mg tab, 400 mg tab 1

ROZEREM 8 mg tab 3

PROSSAM




Drug Tier

[Nivel]




SONATA 10 mg cap, 5 mg cap 3

VISTARIL 25 mg cap, 50 mg cap 3

zaleplon 10 mg cap, 5 mg cap 1 SONATA

zolpidem tartrate 10 mg tab, 5 mg tab 1 AMBIEN

zolpidem tartrate 1.75 mg tab subl, 3.5 mg tab subl 1 INTERMEZZO

zolpidem tartrate er 12.5 mg tab er, 6.25 mg tab er 1 AMBIEN CR

ZOLPIMIST 5 mg/act soln 3

Barbiturates [Barbitúricos]

BUTISOL SODIUM 30 mg tab 3

phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab 1

phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln 1

SECONAL 100 mg cap 3

Benzodiazepines [Benzodiazepinas]

alprazolam 0.25 mg tab disint, 0.5 mg tab disint, 1 mg tab disint 1 NIRAVAM

alprazolam 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 1 XANAX

alprazolam er 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR

ALPRAZOLAM INTENSOL 1 mg/ml oral conc 3

alprazolam xr 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR

ATIVAN 0.5 mg tab, 1 mg tab, 2 mg tab 3

ATIVAN 2 mg/ml inj soln, 4 mg/ml inj soln 3

chlordiazepoxide hcl 10 mg cap, 25 mg cap, 5 mg cap 1 LIBRIUM

clorazepate dipotassium 15 mg tab, 3.75 mg tab, 7.5 mg tab 1 TRANXENE

DIASTAT ACUDIAL 10 mg rect gel, 20 mg rect gel 3

DIASTAT PEDIATRIC 2.5 mg rect gel 3

diazepam 10 mg/2ml im soln auto-inj, 5 mg/ml inj soln, 5 mg/ml oral conc 1

PROSSAM




Drug Tier

[Nivel]




diazepam 10 mg rect gel, 2.5 mg rect gel, 20 mg rect gel 1 DIASTAT

diazepam 10 mg tab, 2 mg tab, 5 mg tab 1 VALIUM

diazepam 5 mg/5ml soln 1 VALIUM

DIAZEPAM INTENSOL 5 mg/ml oral conc 1

DORAL 15 mg tab 3

estazolam 1 mg tab, 2 mg tab 1 PROSOM

flurazepam hcl 15 mg cap, 30 mg cap 1 DALMANE

HALCION 0.25 mg tab 3

lorazepam 2 mg/ml inj soln, 2 mg/ml oral conc, 4 mg/ml inj soln 1

lorazepam 0.5 mg tab, 1 mg tab, 2 mg tab 1 ATIVAN

LORAZEPAM INTENSOL 2 mg/ml oral conc 3

midazolam hcl 10 mg/10ml inj soln, 10 mg/2ml inj soln, 2 mg/2ml inj soln, 2 mg/ml syr, 25 mg/5ml inj soln, 5 mg/5ml inj soln, 5 mg/ml inj soln, 50 mg/10ml inj soln 1

oxazepam 10 mg cap, 15 mg cap, 30 mg cap 1 SERAX

quazepam 15 mg tab 1

RESTORIL 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 3

temazepam 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 1 RESTORIL

TRANXENE-T 7.5 mg tab 3

triazolam 0.125 mg tab, 0.25 mg tab 1 HALCION

VALIUM 10 mg tab, 2 mg tab, 5 mg tab 3

XANAX 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 3

XANAX XR 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 3

AUTONOMIC DRUGS, MISCELLANEOUS [MEDICAMENTOS AUTONÓMICOS, MISCELÁNEOS]

Autonomic Drugs, Miscellaneous [Medicamentos Autonómicos, Misceláneos]

CHANTIX 0.5 mg tab, 1 mg tab 3

CHANTIX CONTINUING MONTH PAK 1 mg tab 3

PROSSAM




Drug Tier

[Nivel]




CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 mg x 42 tab 3

NICOTROL 10 mg inhaler 2

NICOTROL NS 10 mg/ml nasal soln 2

BETA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES BETA-ADRENÉRGICOS]

Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]

acebutolol hcl 200 mg cap, 400 mg cap 1 SECTRAL

atenolol 100 mg tab, 25 mg tab, 50 mg tab 1 TENORMIN

atenolol-chlorthalidone 100-25 mg tab, 50-25 mg tab 1 TENORETIC

betaxolol hcl 10 mg tab, 20 mg tab 1 KERLONE

bisoprolol fumarate 10 mg tab, 5 mg tab 1 ZEBETA

bisoprolol-hydrochlorothiazide 10-6.25 mg tab, 2.5-6.25 mg tab, 5-6.25 mg tab 1 ZIAC

BYSTOLIC 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3

carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 1 COREG

COREG 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 3

DUTOPROL 100-12.5 mg tab er 24 hr, 25-12.5 mg tab er 24 hr, 50-12.5 mg tab er 24 hr 3

labetalol hcl 100 mg tab, 200 mg tab, 300 mg tab 1 NORMODYNE

metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 TOPROL

metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab 1 LOPRESSOR

metoprolol-hydrochlorothiazide 100-25 mg tab, 100-50 mg tab, 50-25 mg tab 1 LOPRESSOR HCT

metoprolol- hydrochlorothiazide er 50-12.5 mg tab er 24 hr 1 DUTOPROL

nadolol 20 mg tab, 40 mg tab, 80 mg tab 1 CORGARD

nadolol-bendroflumethiazide 40-5 mg tab 1 CORZIDE

pindolol 10 mg tab, 5 mg tab 1 VISKEN

PROSSAM




Drug Tier

[Nivel]




propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 1 INDERAL

propranolol hcl 20 mg/5ml soln, 40 mg/5ml soln 1 INDERAL

propranolol hcl er 120 mg cap er 24 hr, 160 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 INDERAL LA

propranolol-hctz 40-25 mg tab, 80-25 mg tab 1 INDERIDE

sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab 1 BETAPACE

sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab 1 BETAPACE AF

timolol maleate 10 mg tab, 20 mg tab, 5 mg tab 1 BLOCADREN

BONE RESORPTION INHIBITORS [INHIBIDORES DE LA RESORCIÓN ÓSEA]

Bone Resorption Inhibitors [Inhibidores De La Resorción Ósea]

ACTONEL 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 3

alendronate sodium 10 mg tab, 35 mg tab, 40 mg tab, 5 mg tab, 70 mg tab 1 FOSAMAX

ATELVIA 35 mg tab dr 3

BINOSTO 70 mg tab eff 3

BONIVA 150 mg tab 3

BONIVA 3 mg/3ml iv soln 5 PA

etidronate disodium 200 mg tab, 400 mg tab 1 DIDRONEL

ibandronate sodium 150 mg tab 1 BONIVA

ibandronate sodium 3 mg/3ml iv soln 4 BONIVA PA

pamidronate disodium 30 mg iv soln, 90 mg iv soln 1 PA

pamidronate disodium 30 mg/10ml iv soln, 6 mg/ml iv soln, 90 mg/10ml iv soln 1 PA

PROLIA 60 mg/ml sc soln 5 PA

RECLAST 5 mg/100ml iv soln 5 PA

risedronate sodium 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 1 ACTONEL

risedronate sodium 35 mg tab dr 1 ATELVIA

XGEVA 120 mg/1.7ml sc soln 5 PA

zoledronic acid 4 mg/100ml iv soln 4 PA

zoledronic acid 5 mg/100ml iv soln 4 RECLAST PA

zoledronic acid 4 mg/5ml iv conc 4 ZOMETA PA

PROSSAM




Drug Tier

[Nivel]




ZOMETA 4 mg/100ml iv soln, 4 mg/5ml iv conc 5 PA

CALCIUM-CHANNEL BLOCKING AGENTS [AGENTES BLOQUEADORES DE LOS CANALES DE CALCIO]

Calcium-channel Blocking Agents, Misc [Agentes Bloqueadores De Los Canales De Calcio, Misceláneos]

CALAN 120 mg tab, 80 mg tab 3

CALAN SR 120 mg tab er, 180 mg tab er, 240 mg tab er 3

CARDIZEM 120 mg tab, 30 mg tab, 60 mg tab 3

CARDIZEM CD 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3

CARDIZEM LA 120 mg tab er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3

CARTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 3

diltiazem cd 180 mg cap er 24 hr 1

diltiazem cd 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM

diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1 CARDIZEM

diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1

diltiazem hcl er 120 mg cap er 12 hr, 60 mg cap er 12 hr, 90 mg cap er 12 hr 1 CARDIZEM

diltiazem hcl er beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1

diltiazem hcl er beads 180 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 1 TIAZAC

diltiazem hcl er coated beads 180 mg cap er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg cap er 24 hr, 360 1

PROSSAM




Drug Tier

[Nivel]




mg tab er 24 hr, 420 mg tab er 24 hr

diltiazem hcl er coated beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM

dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1

MATZIM LA 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3

TARKA 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 3

TAZTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3

TIAZAC 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 3

trandolapril-verapamil hcl er 1-240 mg tab er, 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 1 TARKA

verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab 1 CALAN

verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er 1 CALAN

verapamil hcl er 100 mg cap er 24 hr, 120 mg cap er 24 hr, 180 mg cap er 24 hr, 200 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 1 VERELAN

VERELAN 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 360 mg cap er 24 hr 3

VERELAN PM 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3

Dihydropyridines [Dihidropiridinas]

ADALAT CC 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3

AFEDITAB CR 30 mg tab er 24 hr, 60 mg tab er 24 hr 3

amlodipine besy-benazepril hcl 10-20 mg cap, 10-40 mg cap, 2.5-10 1 LOTREL

PROSSAM




Drug Tier

[Nivel]




mg cap, 5-10 mg cap, 5-20 mg cap, 5-40 mg cap

amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab 1 NORVASC

amlodipine besylate-valsartan 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 1 EXFORGE

amlodipine-atorvastatin 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 1 CADUET

amlodipine-olmesartan 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 1 AZOR

amlodipine-valsartan-hctz 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 1 EXFORGE HCT

AZOR 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 3

CADUET 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 3

EXFORGE 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 3

EXFORGE HCT 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 3

felodipine er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 PLENDIL

isradipine 2.5 mg cap, 5 mg cap 1 DYNACIRC

LOTREL 10-20 mg cap, 10-40 mg cap, 5-10 mg cap, 5-20 mg cap 3

nicardipine hcl 20 mg cap, 30 mg cap 1 CARDENE

nifedipine 10 mg cap, 20 mg cap 1 PROCARDIA

nifedipine er 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 ADALAT CC

nifedipine er osmotic release 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 PROCARDIA XL

PROSSAM




Drug Tier

[Nivel]




nimodipine 30 mg cap 1 NIMOTOP

nisoldipine er 17 mg tab er 24 hr, 20 mg tab er 24 hr, 25.5 mg tab er 24 hr, 30 mg tab er 24 hr, 34 mg tab er 24 hr, 40 mg tab er 24 hr, 8.5 mg tab er 24 hr 1 SULAR

NORVASC 10 mg tab, 2.5 mg tab, 5 mg tab 3

olmesartan-amlodipine-hctz 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 1 TRIBENZOR

PROCARDIA 10 mg cap 3

PROCARDIA XL 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3

SULAR 17 mg tab er 24 hr, 34 mg tab er 24 hr, 8.5 mg tab er 24 hr 3

telmisartan-amlodipine 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 1 TWYNSTA

TRIBENZOR 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 3

TWYNSTA 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 3

CARDIAC DRUGS [MEDICAMENTOS CARDÍACOS]

Antiarrhythmic Agents [Agentes Antiarrítmicos]

amiodarone hcl 200 mg tab 1 CORDARONE

amiodarone hcl 100 mg tab, 400 mg tab 1 PACERONE

disopyramide phosphate 100 mg cap, 150 mg cap 1 NORPACE

dofetilide 125 mcg cap, 250 mcg cap, 500 mcg cap 1 TIKOSYN

flecainide acetate 100 mg tab, 150 mg tab, 50 mg tab 1 TAMBOCOR

mexiletine hcl 150 mg cap, 200 mg cap, 250 mg cap 1 MEXITIL

MULTAQ 400 mg tab 3

NORPACE 100 mg cap, 150 mg cap 3

NORPACE CR 100 mg cap er 12 hr, 150 mg cap er 12 hr 3

PACERONE 100 mg tab, 200 mg tab, 400 mg tab 3

PROSSAM




Drug Tier

[Nivel]




propafenone hcl 150 mg tab, 225 mg tab, 300 mg tab 1 RYTHMOL

propafenone hcl er 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 1 RYTHMOL

quinidine gluconate er 324 mg tab er 1

quinidine sulfate 200 mg tab, 300 mg tab 1

RYTHMOL SR 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 3

TIKOSYN 125 mcg cap, 250 mcg cap, 500 mcg cap 3

Cardiac Drugs, Miscellaneous [Medicamentos Cardíacos, Misceláneos]

RANEXA 1000 mg tab er 12 hr, 500 mg tab er 12 hr 3

Cardiotonic Agents [Agentes Cardiotónicos]

DIGITEK 125 mcg tab, 250 mcg tab 3

DIGOX 125 mcg tab, 250 mcg tab 1

digoxin 125 mcg tab, 250 mcg tab 1 LANOXIN

digoxin 0.05 mg/ml soln 1 LANOXIN

LANOXIN 125 mcg tab, 250 mcg tab 3

CARIOSTATIC AGENTS [AGENTES CARIOSTÁTICOS]

Cariostatic Agents [Agentes Cariostáticos]

fluoritab 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew, 2.2 (1 F) mg tab chew 1 AL

sodium fluoride 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew, 2.2 (1 F) mg tab chew 1 AL

CATHARTICS AND LAXATIVES [PURGANTES Y LAXANTES]

Cathartics And Laxatives [Purgantes Y Laxantes]

COLYTE WITH FLAVOR PACKS 240 gm soln 3

GAVILYTE-C 240 gm soln 3

GAVILYTE-G 236 gm soln 3

GAVILYTE-H 5-210 mg-gm oral kit 3

GAVILYTE-N WITH FLAVOR PACK 420 gm soln 3

GOLYTELY 227.1 gm soln 3

GOLYTELY 236 gm soln 3

MOVIPREP 100 gm soln 3

NULYTELY WITH FLAVOR PACKS 420 gm soln 3

PROSSAM




Drug Tier

[Nivel]




OSMOPREP 1.102-0.398 gm tab 3

peg 3350/electrolytes 240 gm soln 1

peg 3350-kcl-na bicarb-nacl 420 gm soln 1 NULYTELY

peg-3350/electrolytes 236 gm soln 1 GOLYTELY

PEG-PREP 5-210 mg-gm oral kit 3

polyethylene glycol 3350 pckt 1

polyethylene glycol 3350 oral pwdr 1 MIRALAX

PREPOPIK 10-3.5-12 mg-gm-gm pckt 3

SUPREP BOWEL PREP KIT 17.5-3.13-1.6 gm/177ml soln 3

TRILYTE 420 gm soln 3

CELL STIMULANTS AND PROLIFERANTS [ESTIMULANTES Y PROLIFERANTES CELULARES]

Cell Stimulants And Proliferants [Estimulantes Y Proliferantes Celulares]

ATRALIN 0.05 % gel 3 AL

AVITA 0.025 % crm, 0.025 % gel 3 AL

KEPIVANCE 6.25 mg iv soln 4 PA

RETIN-A 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 3 AL

RETIN-A MICRO 0.04 % gel, 0.1 % gel 3

RETIN-A MICRO PUMP 0.04 % gel, 0.08 % gel, 0.1 % gel 3

retinoic acid pwdr 1 AL

tretinoin pwdr 1 AL

tretinoin 0.05 % gel 1 ATRALIN AL

tretinoin 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 1 RETIN-A AL

tretinoin microsphere 0.04 % gel, 0.1 % gel 1 RETIN-A AL

tretinoin microsphere pump 0.04 % gel, 0.1 % gel 1 RETIN-A AL

TRETIN-X 0.075 % crm 3 AL

CELLULAR THERAPY [TERAPIA CELULAR]

Cellular Therapy [Terapia Celular]

PROVENGE iv susp 4 PA

CENTRAL NERVOUS SYSTEM AGENTS, MISC [AGENTES DEL SISTEMA NERVIOSO CENTRAL, MISCELÁNEOS]

Central Nervous System Agents, Misc [Agentes Del Sistema Nervioso Central, Misceláneos]

acamprosate calcium 333 mg tab dr 1 CAMPRAL

PROSSAM




Drug Tier

[Nivel]




atomoxetine hcl 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 STRATTERA PA

guanfacine hcl er 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 1 INTUNIV PA

INTUNIV 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 3 PA

memantine hcl 10 mg tab, 5 (28)-10 (21) mg tab, 5 mg tab 1 NAMENDA

memantine hcl 2 mg/ml soln 1 NAMENDA

NAMENDA 10 mg tab, 5 mg tab 2

NAMENDA TITRATION PAK 5 (28)-10 (21) mg tab 2

NUEDEXTA 20-10 mg cap 3

RILUTEK 50 mg tab 5 PA

riluzole 50 mg tab 4 RILUTEK PA

STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 2 PA

tetrabenazine 12.5 mg tab, 25 mg tab 5 XENAZINE PA

XENAZINE 12.5 mg tab, 25 mg tab 5 PA

XYREM 500 mg/ml soln 5 PA

CHOLELITHOLYTIC AGENTS [AGENTES COLELITOLÍTICO]

Cholelitholytic Agents [Agentes Colelitolítico]

ACTIGALL 300 mg cap 3

CHENODAL 250 mg tab 3

URSO 250 250 mg tab 3

URSO FORTE 500 mg tab 3

ursodiol 300 mg cap 1 ACTIGALL

ursodiol 250 mg tab, 500 mg tab 1 URSO

COMPLEMENT INHIBITORS [INHIBIDORES DEL COMPLEMENTO]

Complement Inhibitors [Inhibidores Del Complemento]

FIRAZYR 30 mg/3ml sc soln 5 PA

CONTRACEPTIVES [ANTICONCEPTIVOS]

Contraceptives [Anticonceptivos]

ALTAVERA 0.15-30 mg-mcg tab 3 QL(28 / 28)

alyacen 1/35 1-35 mg-mcg tab 1 QL(28 / 28)

AUBRA 0.1-20 mg-mcg tab 3 QL(28 / 28)

AVIANE 0.1-20 mg-mcg tab 3 QL(28 / 28)

CAMILA 0.35 mg tab 3 QL(28 / 28)

CHATEAL 0.15-30 mg-mcg tab 3 QL(28 / 28)

CRYSELLE-28 0.3-30 mg-mcg tab 3 QL(28 / 28)

CYCLAFEM 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

PROSSAM




Drug Tier

[Nivel]




DASETTA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

DEBLITANE 0.35 mg tab 3 QL(28 / 28)

DELYLA 0.1-20 mg-mcg tab 3 QL(28 / 28)

ELINEST 0.3-30 mg-mcg tab 3 QL(28 / 28)

ENPRESSE-28 tab 3 QL(28 / 28)

ERRIN 0.35 mg tab 3 QL(28 / 28)

ESTROSTEP FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

ethynodiol diac-eth estradiol 1-35 mg-mcg tab 1 ZOVIA 1/35E QL(28 / 28)

FALMINA 0.1-20 mg-mcg tab 3 QL(28 / 28)

HEATHER 0.35 mg tab 3 QL(28 / 28)

INTROVALE 0.15-0.03 mg tab 3 QL(91 / 91)

JENCYCLA 0.35 mg tab 3 QL(28 / 28)

JOLESSA 0.15-0.03 mg tab 3 QL(91 / 91)

JOLIVETTE 0.35 mg tab 3 QL(28 / 28)

KELNOR 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

KURVELO 0.15-30 mg-mcg tab 3 QL(28 / 28)

LARISSIA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LESSINA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LEVONEST tab 3 QL(28 / 28)

levonorgest-eth estrad 91-day 0.15-0.03 mg tab 1 SEASONALE QL(91 / 91)

levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 1 QL(28 / 28)

levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 1 AVIANE QL(28 / 28)

LEVORA 0.15/30 (28) 0.15-30 mg-mcg tab 3 QL(28 / 28)

LILLOW 0.15-30 mg-mcg tab 3 QL(28 / 28)

LOW-OGESTREL 0.3-30 mg-mcg tab 3 QL(28 / 28)

LUTERA 0.1-20 mg-mcg tab 3 QL(28 / 28)

LYZA 0.35 mg tab 3 QL(28 / 28)

marlissa 0.15-30 mg-mcg tab 1 QL(28 / 28)

MIRENA (52 MG) 20 mcg/24hr iud 4

MYZILRA tab 3 QL(28 / 28)

NORA-BE 0.35 mg tab 3 QL(28 / 28)

norethindrone 0.35 mg tab 1 NOR-QD QL(28 / 28)

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35 mcg tab 1 ORTHO TRI-CYCLEN QL(28 / 28)

NORLYDA 0.35 mg tab 3 QL(28 / 28)

NORLYROC 0.35 mg tab 3 QL(28 / 28)

NORTREL 1/35 (21) 1-35 mg-mcg tab 3 QL(28 / 28)

PROSSAM




Drug Tier

[Nivel]




NORTREL 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)

NUVARING 0.12-0.015 mg/24hr vag ring 3 QL(1 / 28)

ORSYTHIA 0.1-20 mg-mcg tab 3 QL(28 / 28)

ORTHO MICRONOR 0.35 mg tab 3 QL(28 / 28)

ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

ORTHO-NOVUM 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)

PARAGARD INTRAUTERINE COPPER iud 4

PIRMELLA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)

PORTIA-28 0.15-30 mg-mcg tab 3 QL(28 / 28)

QUASENSE 0.15-0.03 mg tab 3 QL(91 / 91)

SETLAKIN 0.15-0.03 mg tab 3 QL(91 / 91)

SHAROBEL 0.35 mg tab 3 QL(28 / 28)

SRONYX 0.1-20 mg-mcg tab 3 QL(28 / 28)

TILIA FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

TRI FEMYNOR 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-ESTARYLLA 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-LEGEST FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)

TRI-LINYAH 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-LO-ESTARYLLA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-LO-MARZIA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-LO-SPRINTEC 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRINESSA (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRINESSA LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)

TRI-PREVIFEM 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRI-SPRINTEC 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)

TRIVORA (28) tab 3 QL(28 / 28)

VIENVA 0.1-20 mg-mcg tab 3 QL(28 / 28)

PROSSAM




Drug Tier

[Nivel]




XULANE 150-35 mcg/24hr tdwk patch 3 QL(3 / 28)

ZOVIA 1/35E (28) 1-35 mg-mcg tab 3 QL(28 / 28)

CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS [MODULADORES REGULADORES DE LA CONDUCTANCIA TRANSMEMBRANA DE LA FIBROSIS QUÍSTICA]

Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators [Potenciadores Reguladores De La Conductancia Transmembrana De La Fibrosis Quística (Rtfq)]

KALYDECO 150 mg tab, 25mg, 50 mg pckt, 75 mg pckt 5 PA

DIGESTANTS [DIGESTIVOS]

Digestants [Digestivos]

CREON 12000 unit cap dr prt, 24000-76000 unit cap dr prt, 3000-9500 unit cap dr prt, 36000 unit cap dr prt, 6000 unit cap dr prt 2

PANCREAZE 10500 unit cap dr prt, 16800 unit cap dr prt, 21000 unit cap dr prt, 4200 unit cap dr prt 3

PERTZYE 16000 unit cap dr prt, 8000 unit cap dr prt 3

VIOKACE 10440 unit tab, 20880 unit tab 3

ZENPEP 10000-32000 unit cap dr prt, 15000-47000 unit cap dr prt, 20000-63000 unit cap dr prt, 25000-79000 unit cap dr prt, 3000-14000 unit cap dr prt, 5000-24000 unit cap dr prt 3

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS [MEDICAMENTOS ANTIRREUMÁTICOS MODIFICADORES DE LA ENFERMEDAD]

Disease-modifying Antirheumatic Drugs [Medicamentos Antirreumáticos Modificadores De La Enfermedad]

ACTEMRA 162 mg/0.9ml sc soln pfs, 200 mg/10ml iv soln, 400 mg/20ml iv soln, 80 mg/4ml iv soln 4 PA

ARAVA 10 mg tab, 20 mg tab 3

CIMZIA 2 X 200 mg sc kit 4 PA

CIMZIA PREFILLED 2 X 200 mg/ml sc kit 4 PA

CIMZIA STARTER KIT 6 X 200 mg/ml sc kit 4 PA

ENBREL 25 mg sc soln 4 PA

ENBREL 25 mg/0.5ml sc soln pfs, 50 mg/ml sc soln pfs 4 PA

PROSSAM




Drug Tier

[Nivel]




ENBREL SURECLICK 50 mg/ml sc soln auto-inj 4 PA

HUMIRA 10 mg/0.2ml sc pfs kit, 20 mg/0.4ml sc pfs kit, 40 mg/0.8ml sc pfs kit 4 PA

HUMIRA PEDIATRIC CROHNS START 40 mg/0.8ml sc pfs kit 4 PA

HUMIRA PEN 40 mg/0.8ml sc pen-inj kit 4 PA

HUMIRA PEN-CD/UC/HS STARTER 40 mg/0.8ml sc pen-inj kit, 80 mg/0.8ml sc pen-inj kit 4 PA

HUMIRA PEN-PS/UV STARTER 40 mg/0.8ml sc pen-inj kit, 80 MG/0.8ML & 40mg/0.4ml sc pen-inj kit 4 PA

leflunomide 10 mg tab, 20 mg tab 1 ARAVA

OTEZLA 10 & 20 & 30 mg tab pack, 30 mg tab 5 PA

SIMPONI 100 mg/ml sc soln auto-inj, 100 mg/ml sc soln pfs, 50 mg/0.5ml sc soln auto-inj, 50 mg/0.5ml sc soln pfs 4 PA

SIMPONI ARIA 50 mg/4ml iv soln 4 PA

XELJANZ 10 mg tab, 5 mg tab 4 PA

XELJANZ XR 11 mg tab er 24 hr 4 PA

DIURETICS [DIURÉTICOS]

Loop Diuretics [Diuréticos Del Asa De Henle]

bumetanide 0.5 mg tab, 1 mg tab, 2 mg tab 1 BUMEX

bumetanide 0.25 mg/ml inj soln 1 BUMEX

DEMADEX 10 mg tab, 20 mg tab 3

EDECRIN 25 mg tab 3

ethacrynic acid 25 mg tab 1 EDECRIN

furosemide 20 mg tab, 40 mg tab, 80 mg tab 1 LASIX

furosemide 10 mg/ml inj soln, 10 mg/ml soln, 8 mg/ml soln 1 LASIX

LASIX 20 mg tab, 40 mg tab, 80 mg tab 3

torsemide 10 mg tab, 100 mg tab, 20 mg tab, 5 mg tab 1 DEMADEX

Potassium-sparing Diuretics [Diuréticos Conservadores De Potasio]

amiloride hcl 5 mg tab 1 MIDAMOR

amiloride-hydrochlorothiazide 5-50 mg tab 1 MODURETIC

PROSSAM




Drug Tier

[Nivel]




DYAZIDE 37.5-25 mg cap 3

DYRENIUM 100 mg cap, 50 mg cap 3

MAXZIDE 75-50 mg tab 3

MAXZIDE-25 37.5-25 mg tab 3

triamterene-hctz 37.5-25 mg cap 1 DYAZIDE

triamterene-hctz 37.5-25 mg tab, 75-50 mg tab 1 MAXZIDE

Thiazide Diuretics [Diuréticos Tiazídicos]

chlorothiazide 250 mg tab, 500 mg tab 1 DIURIL

DIURIL 250 mg/5ml susp 3

hydrochlorothiazide 25 mg tab, 50 mg tab 1 HYDRODIURIL

hydrochlorothiazide 12.5 mg cap, 12.5 mg tab 1 MICROZIDE

methyclothiazide 5 mg tab 1 ENDURON

MICROZIDE 12.5 mg cap 3

Thiazide-like Diuretics [Diuréticos Similares A Tiazida]

chlorthalidone 25 mg tab, 50 mg tab 1 HYGROTON

indapamide 1.25 mg tab, 2.5 mg tab 1 LOZOL

metolazone 10 mg tab, 2.5 mg tab, 5 mg tab 1 ZAROXOLYN

Vasopressin Antagonists [Antagonistas De Vasopresina]

SAMSCA 15 mg tab, 30 mg tab 3

EENT DRUGS, MISCELLANEOUS [MEDICAMENTOS PARA OJOS, OÍDOS, NARIZ Y GARGANTA, MISCELÁNEOS]

Eent Drugs, Miscellaneous [Medicamentos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]

acetic acid 2 % otic soln 1 VOSOL

apraclonidine hcl 0.5 % ophth soln 1 IOPIDINE

DEBACTEROL 30-50 % m/t soln 3

IOPIDINE 1 % ophth soln 3

IOPIDINE 0.5 % ophth soln 3

LACRISERT 5 mg ophth insert 3

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS [EMOLIENTES, DEMULCENTES Y PROTECTORES]

Basic Lotions And Liniments [Lociones Y Linimentos Básicos]

ammonium lactate 12 % crm, 12 % lot 1 LAC-HYDRIN

HYLIRA 0.1 % lot, 0.2 % gel 3

LAC-HYDRIN 12 % crm, 12 % lot 3

lactic acid 10 % lot 1

sodium hyaluronate 0.2 % gel 1

PROSSAM




Drug Tier

[Nivel]




Basic Oils And Other Solvents [Aceites Básicos Y Otros Solventes]

lactic acid e 10-3500 %-unt/30gm crm 1

Basic Ointments And Protectants [Ungüentos Y Protectores Básicos]

NEOSALUS crm 3

ENZYMES [ENZIMAS]

Enzymes [Enzimas]

ADAGEN 250 unit/ml im soln 5 PA

ALDURAZYME 2.9 mg/5ml iv soln 5 PA

ELELYSO 200 unit iv soln 5 PA

ELITEK 1.5 mg iv soln, 7.5 mg iv soln 4 PA

NAGLAZYME 1 mg/ml iv soln 5 PA

SUCRAID 8500 unit/ml soln 5 PA

VPRIV 400 unit iv soln 5 PA

ESTROGENS AND ANTIESTROGENS [ESTRÓGENOS Y ANTIESTRÓGENOS]

Estrogen Agonist-antagonists [Agonistas-Antagonistas De Estrógeno]

EVISTA 60 mg tab 3

raloxifene hcl 60 mg tab 1 EVISTA

Estrogens [Estrógenos]

ACTIVELLA 0.5-0.1 mg tab, 1-0.5 mg tab 3

ALORA 0.025 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

AMABELZ 0.5-0.1 mg tab, 1-0.5 mg tab 3

ANGELIQ 0.25-0.5 mg tab, 0.5-1 mg tab 3

CLIMARA 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 3

CLIMARA PRO 0.045-0.015 mg/day tdwk patch 3

COMBIPATCH 0.05-0.14 mg/day tdbiw patch, 0.05-0.25 mg/day tdbiw patch 3

COVARYX 1.25-2.5 mg tab 3

COVARYX HS 0.625-1.25 mg tab 3

DELESTROGEN 10 mg/ml im oil, 20 mg/ml im oil, 40 mg/ml im oil 3

DEPO-ESTRADIOL 5 mg/ml im oil 3

PROSSAM




Drug Tier

[Nivel]




DIVIGEL 0.25 mg/0.25gm td gel, 0.5 mg/0.5gm td gel 3

DIVIGEL 1 mg/gm td gel 3

EEMT 1.25-2.5 mg tab 3

EEMT HS 0.625-1.25 mg tab 3

ELESTRIN 0.52 MG/0.87 GM (0.06%) td gel 3

est estrogens-methyltest 1.25-2.5 mg tab 1

est estrogens-methyltest ds 1.25-2.5 mg tab 1

est estrogens-methyltest hs 0.625-1.25 mg tab 1

ESTRACE 0.5 mg tab, 1 mg tab, 2 mg tab 3

ESTRACE 0.1 mg/gm vag crm 3

estradiol 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 1 CLIMARA

estradiol 0.5 mg tab, 1 mg tab, 2 mg tab 1 ESTRACE

estradiol 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 1 VIVELLE-DOT

estradiol valerate 20 mg/ml im oil, 40 mg/ml im oil 1 DELESTROGEN

estradiol-norethindrone acet 0.5-0.1 mg tab, 1-0.5 mg tab 1 ACTIVELLA

ESTRING 2 mg vag ring 3

ESTROGEL 0.75 MG/1.25 GM (0.06%) td gel 3

estropipate 0.75 mg tab, 1.5 mg tab 1 OGEN

EVAMIST 1.53 mg/spray td soln 3

FEMHRT LOW DOSE 0.5-2.5 mg-mcg tab 3

FEMRING 0.05 mg/24hr vag ring, 0.1 mg/24hr vag ring 3

FYAVOLV 0.5-2.5 mg-mcg tab, 1-5 mg-mcg tab 3

jevantique lo 0.5-2.5 mg-mcg tab 1 FEMHRT 0.5/2.5 28

DAY

JINTELI 1-5 mg-mcg tab 3

PROSSAM




Drug Tier

[Nivel]




LOPREEZA 0.5-0.1 mg tab, 1-0.5 mg tab 3

MENEST 0.3 mg tab, 0.625 mg tab, 1.25 mg tab, 2.5 mg tab 3

MENOSTAR 14 mcg/24hr tdwk patch 3

MIMVEY 1-0.5 mg tab 3

MIMVEY LO 0.5-0.1 mg tab 3

MINIVELLE 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1

FEMHRT 0.5/2.5 28 DAY

norethindrone-eth estradiol 1-5 mg-mcg tab 1 FYAVOLV

PREFEST 1/1-0.09 mg (15/15) tab 3

PREMARIN 0.3 mg tab, 0.45 mg tab, 0.625 mg tab, 0.9 mg tab, 1.25 mg tab 2

PREMARIN 0.625 mg/gm vag crm 2

PREMARIN 25 mg inj soln 3

PREMPHASE 0.625-5 mg tab 2

PREMPRO 0.3-1.5 mg tab, 0.45-1.5 mg tab, 0.625-2.5 mg tab, 0.625-5 mg tab 2

VAGIFEM 10 mcg vag tab 3

VIVELLE-DOT 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3

YUVAFEM 10 mcg vag tab 3

EXPECTORANTS [EXPECTORANTES]

Expectorants [Expectorantes]

GILPHEX TR 10-388 mg tab 3

phenylephrine-guaifenesin 1.5-20 mg/ml liq 1

FIBROMYALGIA AGENTS [AGENTES PARA FIBROMIALGIA]

Fibromyalgia Agents [Agentes Para Fibromialgia]

SAVELLA 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 3

SAVELLA TITRATION PACK 12.5 & 25 & 50 mg oral misc 3

FIRST GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE PRIMERA GENERACIÓN]

PROSSAM




Drug Tier

[Nivel]




Derivatives, Miscellaneous [Derivados, Misceláneos]

cyproheptadine hcl 4 mg tab 1 PERIACTIN

cyproheptadine hcl 2 mg/5ml syr 1 PERIACTIN

Ethanolamine Derivatives [Derivados De Etanolamina]

carbinoxamine maleate 4 mg tab 1 CLISTIN

carbinoxamine maleate 4 mg/5ml soln 1 CLISTIN

clemastine fumarate 2.68 mg tab 1 TAVIST

diphenhydramine hcl 12.5 mg/5ml oral elix, 50 mg/ml inj soln 1 BENADRYL

pharbedryl 50 mg cap 1

Phenothiazine Derivatives [Derivados De La Fenotiazina]

PHENADOZ 12.5 mg rect supp, 25 mg rect supp 3

PHENERGAN 25 mg/ml inj soln, 50 mg/ml inj soln 3

promethazine hcl 12.5 mg rect supp, 12.5 mg tab, 25 mg rect supp, 25 mg tab, 50 mg rect supp, 50 mg tab 1 PHENERGAN

promethazine hcl 25 mg/ml inj soln, 50 mg/ml inj soln, 6.25 mg/5ml soln, 6.25 mg/5ml syr 1 PHENERGAN

promethazine vc plain 6.25-5 mg/5ml soln 1 PHENERGAN VC

promethazine-phenylephrine 6.25-5 mg/5ml syr 1 PHENERGAN VC

PROMETHEGAN 12.5 mg rect supp, 25 mg rect supp, 50 mg rect supp 3

Propylamine Derivatives [Derivados De Propilamina]

brompheniramine tannate 12 mg tab chew 1

DECON-A 2-5 mg/5ml oral elix 3

GENITOURINARY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO GENITOURINARIO]

Antimuscarinics [Antimuscarínicos]

darifenacin hydrobromide er 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 1 ENABLEX

DETROL 1 mg tab, 2 mg tab 3

DETROL LA 2 mg cap er 24 hr, 4 mg cap er 24 hr 3

DITROPAN XL 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 3

PROSSAM




Drug Tier

[Nivel]




ENABLEX 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 3

flavoxate hcl 100 mg tab 1

GELNIQUE 10 % td gel 3

GELNIQUE PUMP 10 % td gel 3

oxybutynin chloride 5 mg tab 1 DITROPAN

oxybutynin chloride 5 mg/5ml syr 1 DITROPAN

oxybutynin chloride er 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 1 DITROPAN

OXYTROL 3.9 mg/24hr tdbiw patch 3

tolterodine tartrate 1 mg tab, 2 mg tab 1 DETROL

tolterodine tartrate er 2 mg cap er 24 hr, 4 mg cap er 24 hr 1 DETROL

TOVIAZ 4 mg tab er 24 hr, 8 mg tab er 24 hr 2

trospium chloride 20 mg tab 1 SANCTURA

trospium chloride er 60 mg cap er 24 hr 1 SANCTURA XR

VESICARE 10 mg tab, 5 mg tab 3

B3-adrenergic Agonists [Agonistas B-3 Adrenérgicos]

MYRBETRIQ 25 mg tab er 24 hr, 50 mg tab er 24 hr 3

GI DRUGS, MISCELLANEOUS [MEDICAMENTOS GASTROINTESTINALES, MISCELÁNEOS]

Gi Drugs, Miscellaneous [Medicamentos Gastrointestinales, Misceláneos]

AMITIZA 24 mcg cap, 8 mcg cap 2 PA

ENTEREG 12 mg cap 3

LINZESS 145 mcg cap, 290 mcg cap 3 PA

MOVANTIK 12.5 mg tab, 25 mg tab 4 PA

RELISTOR 12 mg/0.6ml sc soln, 8 mg/0.4ml sc soln 3

GOLD COMPOUNDS [COMPUESTOS DE ORO]

Gold Compounds [Compuestos De Oro]

RIDAURA 3 mg cap 3

HEAVY METAL ANTAGONISTS [ANTAGONISTAS DE METALES PESADOS]

Heavy Metal Antagonists [Antagonistas De Metales Pesados]

CHEMET 100 mg cap 3

deferoxamine mesylate 2 gm inj soln, 500 mg inj soln 1

DESFERAL 500 mg inj soln 3

EXJADE 125 mg tab sol, 250 mg tab sol, 500 mg tab sol 5 PA

FERRIPROX 500 mg tab 5 PA

FERRIPROX 100 mg/ml soln 5 PA

PROSSAM




Drug Tier

[Nivel]




HEMATOPOIETIC AGENTS [AGENTES HEMATOPOYÉTICOS]

Hematopoietic Agents [Agentes Hematopoyéticos]

ARANESP (ALBUMIN FREE) 10 mcg/0.4ml inj soln pfs, 100 mcg/0.5ml inj soln pfs, 100 mcg/ml inj soln, 150 mcg/0.3ml inj soln pfs, 200 mcg/0.4ml inj soln pfs, 200 mcg/ml inj soln, 25 mcg/0.42ml inj soln pfs, 25 mcg/ml inj soln, 300 mcg/0.6ml inj soln pfs, 300 mcg/ml inj soln, 40 mcg/0.4ml inj soln pfs, 40 mcg/ml inj soln, 500 mcg/ml inj soln pfs, 60 mcg/0.3ml inj soln pfs, 60 mcg/ml inj soln 5 PA

EPOGEN 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln 5 PA

GRANIX 300 mcg/0.5ml sc soln pfs, 480 mcg/0.8ml sc soln pfs 5 PA

LEUKINE 250 mcg iv soln 5 PA, QL(117.24 / 42)

MIRCERA 100 mcg/0.3ml inj soln pfs, 200 mcg/0.3ml inj soln pfs, 50 mcg/0.3ml inj soln pfs, 75 mcg/0.3ml inj soln pfs 5 PA

MOZOBIL 24 mg/1.2ml sc soln 5 PA

NEULASTA 6 mg/0.6ml sc soln pfs 5 PA

NEULASTA ONPRO 6 mg/0.6ml sc pfs kit 5 PA

NEUPOGEN 300 mcg/0.5ml inj soln pfs, 300 mcg/ml inj soln, 480 mcg/0.8ml inj soln pfs, 480 mcg/1.6ml inj soln 5 PA

NPLATE 250 mcg sc soln, 500 mcg sc soln 5 PA

PROCRIT 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln, 40000 unit/ml inj soln 4 PA

PROMACTA 12.5 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 5 PA

ZARXIO 300 mcg/0.5ml inj soln pfs, 480 mcg/0.8ml inj soln pfs 5 PA

HEMORRHEOLOGIC AGENTS [AGENTES HEMORREOLÓGICOS]

Hemorrheologic Agents [Agentes Hemorreológicos]

PROSSAM




Drug Tier

[Nivel]




pentoxifylline er 400 mg tab er 1 TRENTAL

HYPOTENSIVE AGENTS [AGENTES HIPOTENSORES]

Central Alpha-agonists [Agonistas Centrales Alfa]

CATAPRES 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 3

CATAPRES-TTS-1 0.1 mg/24hr tdwk patch 3



clonidine 0.1 mg/24hr tdwk patch, 0.2 mg/24hr tdwk patch, 0.3 mg/24hr tdwk patch 1

clonidine hcl 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 1 CATAPRES

clonidine hcl er 0.1 mg tab er 12 hr 1 KAPVAY PA

guanfacine hcl 1 mg tab, 2 mg tab 1 TENEX

KAPVAY 0.1 mg tab er 12 hr 3 PA

methyldopa 250 mg tab, 500 mg tab 1 ALDOMET

methyldopa-hydrochlorothiazide 250-15 mg tab, 250-25 mg tab 1 ALDORIL

Direct Vasodilators [Vasodilatadores Directos]

hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 APRESOLINE

IMMUNOMODULATORY AGENTS [AGENTES INMUNOMODULADORES]

Immunomodulatory Agents [Agentes Inmunomoduladores]

ACTIMMUNE 2000000 unit/0.5ml sc soln 4 PA

AUBAGIO 14 mg tab, 7 mg tab 4 PA

AVONEX 30 mcg im kit 4 PA

AVONEX PEN 30 mcg/0.5ml im auto-inj kit 4 PA

AVONEX PREFILLED 30 mcg/0.5ml im pfs kit 4 PA

BETASERON 0.3 mg sc kit 4 PA

COPAXONE 20 mg/ml sc soln pfs, 40 mg/ml sc soln pfs 4 PA

EXTAVIA 0.3 mg sc kit 4 PA

GILENYA 0.25 mg cap, 0.5 mg cap 4 PA

MAYZENT 0.25 mg tab, 2 mg tap 4 PA

TECFIDERA 120 & 240 mg oral misc, 120 mg cap dr, 240 mg cap dr 4 PA

PROSSAM




Drug Tier

[Nivel]




THALOMID 100 mg cap, 150 mg cap, 200 mg cap, 50 mg cap 5 PA

TYSABRI 300 mg/15ml iv conc 4 PA

IMMUNOSUPPRESSIVE AGENTS [AGENTES INMUNOSUPRESORES]

Immunosuppressive Agents [Agentes Inmunosupresores]

ASTAGRAF XL 0.5 mg cap er 24 hr, 1 mg cap er 24 hr, 5 mg cap er 24 hr 5 PA

AZASAN 100 mg tab, 75 mg tab 5 PA

azathioprine 50 mg tab 5 IMURAN

azathioprine sodium 100 mg inj soln 5 IMURAN PA

BENLYSTA 120 mg iv soln 5 PA

CELLCEPT 250 mg cap, 500 mg tab 5 PA

CELLCEPT 200 mg/ml susp 5 PA

cyclosporine 100 mg cap, 25 mg cap 5 SANDIMMUNE PA

cyclosporine 50 mg/ml iv soln 5 SANDIMMUNE PA

cyclosporine modified 100 mg cap, 25 mg cap, 50 mg cap 5 NEORAL PA

cyclosporine modified 100 mg/ml soln 5 NEORAL PA

GENGRAF 100 mg cap, 25 mg cap 5 PA

GENGRAF 100 mg/ml soln 5 PA

IMURAN 50 mg tab 5 PA

mycophenolate mofetil 250 mg cap, 500 mg tab 4 CELLCEPT PA

mycophenolate mofetil 200 mg/ml susp 4 CELLCEPT PA

mycophenolate sodium 180 mg tab dr, 360 mg tab dr 4 MYFORTIC PA

MYFORTIC 180 mg tab dr, 360 mg tab dr 5 PA

NEORAL 100 mg cap, 25 mg cap 5 PA

NEORAL 100 mg/ml soln 5 PA

NULOJIX 250 mg iv soln 5 PA

PROGRAF 0.5 mg cap, 1 mg cap, 5 mg cap 5 PA

RAPAMUNE 0.5 mg tab, 1 mg tab, 2 mg tab 5 PA

RAPAMUNE 1 mg/ml soln 5 PA

RINVOQ 15 mg tab er 24hr 4 PA

SANDIMMUNE 100 mg cap, 25 mg cap 5 PA

PROSSAM




Drug Tier

[Nivel]




SANDIMMUNE 100 mg/ml soln, 50 mg/ml iv soln 5 PA

sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab 5 RAPAMUNE PA

tacrolimus 0.5 mg cap, 1 mg cap, 5 mg cap 5 PROGRAF PA

ZORTRESS 0.25 mg tab, 0.5 mg tab, 0.75 mg tab 5 PA

ION-REMOVING AGENTS [AGENTES REMOVEDORES DE IONES]

Phosphate-removing Agents [Agentes Removedores De Fosfato]

FOSRENOL 1000 mg pckt, 1000 mg tab chew, 500 mg tab chew, 750 mg pckt, 750 mg tab chew 2

RENAGEL 800 mg tab 3

RENVELA 0.8 gm pckt, 2.4 gm pckt 2

RENVELA 800 mg tab 3

sevelamer carbonate 800 mg tab 1 RENVELA

Potassium-removing Agents [Agentes Removedores De Potasio]

KIONEX oral pwdr 3

KIONEX 15 gm/60ml susp 3

sodium polystyrene sulfonate oral pwdr 1 KAYEXALATE

sodium polystyrene sulfonate 15 gm/60ml susp 1 SPS

SPS 15 gm/60ml susp 3

IRRIGATING SOLUTIONS [SOLUCIONES PARA IRRIGACIÓN]

Irrigating Solutions [Soluciones Para Irrigación]

sodium chloride 0.9 % irrig soln 1

KERATOLYTIC AGENTS [AGENTES QUERATOLÍTICOS]

Keratolytic Agents [Agentes Queratolíticos]

ALUVEA 40 % crm 3

AVAR 9.5-5 % pad 3 AL

AVAR 9.5-5 % foam 3 AL

AVAR CLEANSER 10-5 % ext emul 3 AL

AVAR LS 10-2 % pad 3 AL

AVAR LS 10-2 % foam 3 AL

AVAR LS CLEANSER 10-2 % ext liq 3 AL

AVAR-E EMOLLIENT 10-5 % crm 3 AL

AVAR-E GREEN 10-5 % crm 3 AL

AVAR-E LS 10-2 % crm 3 AL

bp 10-1 10-1 % ext emul 1 AL

bp cleansing wash 10-4 % ext emul 1 AL

CEM-UREA 45 % ext soln 3

CEROVEL 40 % lot 3

PROSSAM




Drug Tier

[Nivel]




GORDOFILM 16.7-16.7 % ext soln 3

gordons urea 40 % oint 3

HYDRO 35 35 % foam 3

HYDRO 40 40 % foam 3

KERALYT 6 % gel 3

KERALYT SCALP 6 % ext kit 3

LATRIX XM 45 % ext emul 3

NUTRASEB crm 3

PLEXION 9.8-4.8 % crm, 9.8-4.8 % lot 3 AL

PLEXION CLEANSER 9.8-4.8 % ext liq 3 AL

PLEXION CLEANSING CLOTH 9.8-4.8 % pad 3 AL

pyrogallic acid 25-2 % oint 1

REA LO 40 40 % crm 3

REA LO 40 40 % lot 3

ROSANIL CLEANSER 10-5 % ext emul 3 AL

SALEX 6 % (cream) ext kit 3

SALEX 6 % (lotion) ext kit, 6 % shampoo 3

salicylic acid 6 % crm, 6 % foam, 6 % gel 1

salicylic acid 26 % ext liq, 27.5 % ext liq, 6 % lot, 6 % shampoo 1

salicylic acid wart remover 27.5 % ext liq 1

salicylic acid-cleanser 6 % (cream) ext kit 1

salicylic acid-cleanser 6 % (lotion) ext kit 1

salimez 6 % crm 1

salisol forte 26 % ext soln 1

salitech forte 6 % lot 1

salrix 50 % ext susp 1

SALVAX 6 % foam 3

SALVAX DUO PLUS 6 & 35 % ext kit 3

sss 10-5 10-5 % crm, 10-5 % foam 1 AL

sulfacetamide sodium-sulfur 10-4 % pad 1 AL

sulfacetamide sodium-sulfur 10-2 % crm, 10-2 % ext liq, 10-5 % crm, 10-5 % ext emul, 10-5 % ext susp, 10-5 % lot, 9-4.5 % ext liq, 9.8-4.8 1 AL

PROSSAM




Drug Tier

[Nivel]




% crm, 9.8-4.8 % ext liq, 9.8-4.8 % lot

sulfacetamide sodium-sulfur 8-4 % ext susp, 9-4 % ext liq 1 AL

sulfacetamide sod-sulfur wash 9-4.5 % ext kit 1 AL

sulfacetamide-sulfur in urea 10-5 % ext emul 1 AL

sulfacetamide-sulfur-sunscreen 9-4.5 % ext kit 1 AL

SULFACLEANSE 8/4 8-4 % ext susp 3 AL

SUMADAN 9-4.5 % ext kit 3

SUMADAN WASH 9-4.5 % ext liq 3 AL

SUMADAN XLT 9-4.5 % ext kit 3

SUMAXIN 10-4 % pad 3 AL

SUMAXIN CP 10-4 % ext kit 3

SUMAXIN TS 8-4 % ext susp 3 AL

SUMAXIN WASH 9-4 % ext liq 3 AL

UMECTA MOUSSE 40 % foam 3

URAMAXIN 45 % gel 3

urea 39 % crm, 40 % crm, 40 % ext susp, 40 % lot, 45 % crm, 50 % crm 1

urea hydrating 35 % foam 1

urea in zn undecyl-lactic acid 50 % ext emul 1

urea nail 40 & 0.2 % ext kit 1

urea nail 45 % gel, 50 % stick 1

urea-c40 40 % lot 1

ure-k 50 % crm 1

uremez-40 40 % crm 1

VIRASAL 27.5 % ext liq 3

virti-sulf 10-5 % crm 1 AL

LOCAL ANESTHETICS [ANESTÉSICOS LOCALES]

Local Anesthetics [Anestésicos Locales]

lidocaine hcl 4 % m/t soln 1

lidocaine viscous 2 % m/t soln 1 XYLOCAINE

PRAMOTIC 1-0.1 % otic liq 3

MUCOLYTIC AGENTS [AGENTES MUCOLÍTICOS]

Mucolytic Agents [Agentes Mucolíticos]

HYPERSAL 3.5 % inh neb soln, 7 % inh neb soln 3

NEBUSAL 3 % inh neb soln, 6 % inh neb soln 3

PULMOSAL 7 % inh neb soln 3

PULMOZYME 1 mg/ml inh soln 5 PA

PROSSAM




Drug Tier

[Nivel]




sodium chloride 0.9 % inh neb soln, 10 % inh neb soln, 3 % inh neb soln, 7 % inh neb soln 1

MULTIVITAMIN PREPARATIONS [PREPARACIONES MULTIVITAMÍNICAS]

Multivitamin Preparations [Preparaciones Multivitamínicas]

ADRENAL C FORMULA tab 3

advanced am/pm oral misc 1

ap-zel tab 1

ATABEX EC 29-1 mg tab dr 3

b complex-c-folic acid tab 1

BACMIN tab 3

BAL-CARE DHA 27-1 & 430 mg oral misc 3

b-complex balanced tab 1

b-complex/vitamin c tab 1

b-complex-c tab 1

biocel tab 1

bp folinatal plus b 1 mg tab 1

bp multinatal plus 30-1 mg tab, 40-1 mg tab chew 1

b-plex tab 1

b-plex plus tab 1

BPROTECTED PEDIA POLY-VITE/FE 10 mg/ml soln 1 AL

CITRANATAL 90 DHA 90-1 & 300 mg oral misc 3

CITRANATAL ASSURE 35-1 & 300 mg oral misc 3

CITRANATAL B-CALM 20-1 & 25 (2) mg oral misc 3

CITRANATAL DHA 27-1 & 250 mg oral misc 3

CITRANATAL HARMONY 27-1-260 mg cap 3

CITRANATAL RX 27-1 mg tab 3

c-nate dha 28-1-200 mg cap 1

cod liver oil oral oil 1

complete natal dha 29-1-200 & 250 mg oral misc 1

completenate 29-1 mg tab chew 1

CO-NATAL FA tab 3

CONCEPT DHA 53.5-38-1 mg cap 3

CONCEPT OB 130-92.4-1 mg cap 3

CORVITA 1.25 mg tab 3

CORVITE 1.25 mg tab 3

CORVITE FREE tab 3

PROSSAM




Drug Tier

[Nivel]




DIALYVITE tab 3

DIALYVITE 3000 3 mg tab 3

DIALYVITE 5000 5 mg tab 3

DIALYVITE SUPREME D 3 mg tab 3

DIALYVITE/ZINC tab 3

dothelle dha 53.5-38-1 mg cap 1

DUET DHA 400 25-1 & 400 mg oral misc 3

DUET DHA BALANCED 25-1 & 267 mg oral misc 3

ELITE-OB 50-1.25 mg tab 3

ENBRACE HR cap 3

eql super b complex/vitamin c tab 1

ESCAVITE 0.25-7.5 mg tab chew 3

ESCAVITE D 0.25-6 mg tab chew 3

escavite lq 0.25-6 mg/ml liq 3

FLORIVA 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

FLORIVA PLUS 0.25 mg/ml soln 3

folbee plus tab 1

FOLBEE PLUS CZ 5 mg tab 3

FOLET DHA 38-1 & 350 mg pack 3

FOLET ONE 38-1-225 mg cap 3

FOLGARD OS 500-1.1 mg tab 3

FOLIVANE-OB 130-92.4-1 mg cap 3

FORTAVIT cap 3

hemenatal ob 28-6-1 mg tab 1

hemenatal ob + dha 28-6-1 & 203 mg oral misc 1

hm super vitamin b complex/c tab 1

hm vitamin b complex/vitamin c tab 1

INATAL GT tab 3

infanate balance 29-1-265 mg cap 1

INFUVITE ADULT iv inj 3

INFUVITE PEDIATRIC iv soln 3

kp b complex-c tab 1

LYSIPLEX PLUS tab 3

M.V.I. ADULT iv inj 3

M.V.I. PEDIATRIC iv soln 3

M.V.I.-12 (WITHOUT VITAMIN K) iv inj 3

MARNATAL-F 60-1 mg cap 3

MILCO-B-FORTE tab 3

multi-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

PROSSAM




Drug Tier

[Nivel]




multi-vit/fluoride/iron 0.25-10 mg/ml soln 1

multi-vit/iron/fluoride 0.25-10 mg/ml soln 1

multi-vitamin drops/fe soln 1 AL

multivitamin/fluoride 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 1

multivitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

multi-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

multivitamin/fluoride/iron 0.25-10 mg/ml soln 1

multi-vitamin/fluoride/iron 0.25-10 mg/ml soln 1

multivitamins/fluoride 0.5 mg tab chew 1

MVC-FLUORIDE 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

M-VIT tab 3

MYNATAL cap, 90-1 mg tab 3

MYNATAL ADVANCE tab 3

mynatal plus tab 1

mynatal-z tab 1

mynate 90 plus tab er 1

mynephrocaps 1 mg cap 1

MYNEPHRON 1 mg cap 3

NATACHEW 28-1 mg tab chew 3

NATALVIT tab 3

NATELLE ONE 28-1-250 mg cap 3

NEEVO DHA 27-1.13 mg cap 3

NEPHPLEX RX tab 3

NEPHROCAPS 1 mg cap 3

NEPHRONEX tab 3

NEPHRO-VITE RX 1 mg tab 3

NESTABS 32-1 mg tab 3

NESTABS ABC 32-1-200 mg oral misc 3

NESTABS DHA 32-1 mg oral misc 3

NEWGEN 32-1 mg tab 3

NEXA PLUS 29-1.25-350 mg cap 3

NICADAN tab 3

NICADAN ZX tab 3

NICAZEL tab 3

PROSSAM




Drug Tier

[Nivel]




NICAZEL FORTE tab 3

NICOMIDE 750-27-2-0.5 mg tab 3

NIVA-PLUS 27-1 mg tab 3

NUTRICAP tab 3

NUTRIFAC ZX tab 3

NUTRIVIT liq 3

OB COMPLETE 50-1.25 mg tab 3

OB COMPLETE ONE 50-1-476 mg cap 3

OB COMPLETE PETITE 35-5-1-200 mg cap 3

OB COMPLETE PREMIER 30-20-1 mg tab 3

OB COMPLETE/DHA 30-10-1-200 mg cap 3

OBSTETRIX DHA 29-1 & 387 mg oral misc 3

OBSTETRIX EC 29-1 mg tab 3

OBSTETRIX ONE 38-1-225 mg cap 3

O-CAL FA 27-1 mg tab 3

O-CAL PRENATAL tab 3

OCUVEL 0.5 mg cap 3

pnv folic acid + iron 27-1 mg tab 1

pnv ob+dha 27-1 & 250 mg oral misc 1

pnv prenatal plus multivitamin 27-1 mg tab 1

pnv tabs 29-1 29-1 mg tab 1

pnv-dha 27-0.6-0.4-300 mg cap 1

pnv-dha plus 27-1.13-0.4 mg cap 1

pnv-dha+docusate 27-1.25-300 mg cap 1

pnv-omega 28-0.6-0.4-340 mg cap 1

pnv-select 27-0.6-0.4 mg tab 1

pnv-total 35-5-1.2 mg cap 1

POLY-VI-FLOR 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

POLY-VI-FLOR 0.25 mg/ml susp 3

POLY-VI-FLOR FS 0.25 mg Oral Strip, 0.5 mg Oral Strip, 1 mg Oral Strip 3

POLY-VI-FLOR/IRON 0.5-10 mg tab chew 3

POLY-VI-FLOR/IRON 0.25-7 mg/ml susp 3

PROSSAM




Drug Tier

[Nivel]




POLY-VI-SOL/IRON soln 1 AL

PR NATAL 400 29-1-200 & 400 mg oral misc 3

PR NATAL 400 EC 29-1-200 & 400 mg (dr) oral misc 3

PR NATAL 430 29-1-200 & 430 mg oral misc 3

PR NATAL 430 EC 29-1-200 & 430 mg (dr) oral misc 3

PREFERA OB 34-1 mg tab 3

PREFERAOB +DHA 28-6-1 & 200 mg oral misc 3

PREFERAOB ONE 22-6-1-200 mg cap 3

prena1 1.4 mg tab chew 1

prena1 pearl 30-1.4-200 mg cap er 1

prenaissance 29-1.25-325 mg cap 1

prenaissance balance 30-1-260 mg cap 1

prenaissance harmony dha 27-1 & 380 mg oral misc 1

prenaissance next 1.2 mg tab 1

prenaissance next-b 1.22 mg tab 1

prenaissance plus 28-1-250 mg cap 1

PRENATA 29-1 mg tab chew 3

PRENATABS RX 29-1 mg tab 3

prenatal 27-1 mg tab 1

prenatal 19 tab, tab chew, 29-1 mg tab, 29-1 mg tab chew 1

prenatal plus 27-1 mg tab 1

prenatal plus iron 29-1 mg tab 1

prenatal vitamin plus low iron 27-1 mg tab 1

PRENATAL-U 106.5-1 mg cap 3

PRENATE 0.6-0.4 mg tab chew 3

PRENATE AM 1 mg tab 3

PRENATE DHA 18-0.6-0.4-300 mg cap 3

PRENATE ELITE 20-0.6-0.4 mg tab 3

PRENATE ENHANCE 28-0.6-0.4-400 mg cap 3

PRENATE ESSENTIAL 18-0.6-0.4-300 mg cap 3

PROSSAM




Drug Tier

[Nivel]




PRENATE MINI 18-0.6-0.4-350 mg cap 3

PRENATE PIXIE 10-0.6-0.4-200 mg cap 3

PRENATE RESTORE 27-0.6-0.4-400 mg cap 3

preplus 27-1 mg tab 1

pretab 29-1 mg tab 1

PROTECT PLUS cap 3

PROVIDA DHA 16-16-1.25-110 mg cap 3

PROVIDA OB 20-20-1.25 mg cap 3

purefe ob plus 162-115.2-1 mg cap 1

px b complex/vitamin c tab 1

QUFLORA PEDIATRIC 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3

QUFLORA PEDIATRIC 0.25 mg/ml soln, 0.5 mg/ml soln 3

relnate dha 28-1-200 mg cap 1

RENAL 1 mg cap 3

RENATABS 1 mg tab 3

reno caps 1 mg cap 1

REQ 49+ tab 3

R-NATAL OB 20-1-320 mg cap 3

SELECT-OB 29-0.6-0.4 mg tab chew, 29-1 mg tab chew 3

SELECT-OB+DHA 29-1 & 250 mg oral misc 3

se-natal 19 29-1 mg tab, 29-1 mg tab chew 1

SIDEROL tab 3

sm b super vitamin complex tab 1

sm b-complex/vitamin c tab 1

stress formula tab 1

STROVITE FORTE tab 3

STROVITE FORTE syr 3

STROVITE ONE tab 3

super b complex/fa/vit c tab 1

super b-complex/vit c/fa tab 1

SUPERVITE liq 3

support liq 1

SUPPORT-500 cap 3

SYNAGEX 1.25 mg cap 3

SYNATEK 1.25 mg cap 3

PROSSAM




Drug Tier

[Nivel]




TARON-BC 20-1 & 25 (2) mg oral misc 3

TARON-C DHA 53.5-38-1 mg cap 3

TARON-PREX 30-1.2-265 mg cap 3

TEXAVITE LQ 0.25-7-3 mg/ml liq 3

thrivite 19 29-1 mg tab 1

thrivite rx 29-1 mg tab 1

tl folate 27-0.5-0.5 mg tab 1

TL G-FOL OS 500-1.1 mg tab 3

tl-care dha 27-1-500 mg cap 1

tl-fluorivite 0.25-7.5 mg tab chew 1

tl-select 29-1.25-325 mg cap 1

TRICARE tab 3

TRICARE PRENATAL COMPLEAT 27-1 mg oral misc 3

TRICARE PRENATAL DHA ONE 27-1-500 mg cap 3

trinatal rx 1 60-1 mg tab 1

TRINATE tab 3

triphrocaps 1 mg cap 1

tristart dha 31-0.6-0.4-200 mg cap 1

tri-tabs dha 32-1 mg oral misc 1

TRIVEEN-DUO DHA 29-1-200 & 400 mg oral misc 3

TRI-VI-FLOR 0.25 mg/ml susp, 0.5 mg/ml susp 3

tri-vi-floro 0.25 mg/ml susp, 0.5 mg/ml susp 1

tri-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

tri-vit/fluoride/iron 0.25-10 mg/ml soln 1

tri-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1

UDAMIN SP 1 mg tab 3

ultimatecare one 27-1 mg cap 1

urosex tab 1

v-c forte cap 1

VEMAVITE-PRX 2 27-1.25-300 mg cap 3

vena-bal dha 27-1 & 430 mg oral misc 1

VIC-FORTE cap 3

VINATE DHA RF 27-1.13 mg cap 3

VINATE II 29-1 mg tab 3

VINATE M 27-1 mg tab 3

PROSSAM




Drug Tier

[Nivel]




VINATE ONE 60-1 mg tab 3

virt nate 28-1 mg tab 1

virt-c dha 53.5-38-1 mg cap 1

virt-caps 1 mg cap 1

virt-nate dha 28-1-200 mg cap 1

virt-pn 27-0.6-0.4 mg tab 1

virt-pn dha 27-0.6-0.4-300 mg cap 1

virt-pn plus 28-0.6-0.4-340 mg cap 1

VITA S FORTE tab 3

vita-bee/c tab 1

VITACEL tab 3

VITAFOL FE+ 90-1-200 & 50 mg cap pack 3

VITAFOL ULTRA 29-0.6-0.4-200 mg cap 3

VITAFOL-NANO 18-0.6-0.4 mg tab 3

VITAFOL-OB tab 3

VITAFOL-OB+DHA 65-1 & 250 mg oral misc 3

VITAFOL-ONE 29-1-200 mg cap 3

vitaject inj 1

VITAL-D RX 1 mg tab 3

VITAMAX PEDIATRIC soln 3

VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 mg cap 3

VITAMEDMD REDICHEW RX 1.4 mg tab chew 3

vita-min cap 1

vitamins acd-fluoride 0.25 mg/ml soln 1

VITAPEARL 30-1.4-200 mg cap er 3

VITAROCA PLUS tab 3

vita-rx diabetic vitamin cap 1

VIVA DHA 28-1-200 mg cap 3

vol-care rx 1 mg tab 1

vol-nate 28-1 mg tab 1

vol-plus 27-1 mg tab 1

vol-tab rx 29-1 mg tab 1

vp-ggr-b6 prenatal 1.2 mg tab 1

vp-heme ob 28-6-1 mg tab 1

vp-heme ob + dha 28-6-1 & 203 mg oral misc 1

vp-heme one 22-6-1-200 mg cap 1

vp-pnv-dha 28-1-215.8 mg cap 1

vp-vite rx 1 mg tab 1

PROSSAM




Drug Tier

[Nivel]




vp-zel tab 1

ZATEAN-PN DHA 27-0.6-0.4-300 mg cap 3

ZATEAN-PN PLUS 28-0.6-0.4-340 mg cap 3

MYDRIATICS [MIDRIÁTICOS]

Mydriatics [Midriáticos]

atropine sulfate 1 % ophth oint 1

atropine sulfate 1 % ophth soln 1

CYCLOGYL 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 3

CYCLOMYDRIL 0.2-1 % ophth soln 3

cyclopentolate hcl 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 1

HOMATROPAIRE 5 % ophth soln 3

homatropine hbr 5 % ophth soln 1

ISOPTO ATROPINE 1 % ophth soln 3

MYDRIACYL 1 % ophth soln 3

tropicamide 0.5 % ophth soln, 1 % ophth soln 1

OPIATE ANTAGONISTS [ANTAGONISTAS DE OPIÁCEOS]

Opiate Antagonists [Antagonistas De Opiáceos]

naloxone hcl 0.4 mg/ml inj soln cart, 4 mg/10ml inj soln 1

naloxone hcl 0.4 mg/ml inj soln, 2 mg/2ml inj soln pfs 1 NARCAN

naltrexone hcl 50 mg tab 1

VIVITROL 380 mg im susp 5 PA

OTHER MISCELLANEOUS THERAPEUTIC AGENTS [OTROS AGENTES TERAPÉUTICOS MISCELÁNEOS]

Other Miscellaneous Therapeutic Agents [Otros Agentes Terapéuticos Misceláneos]

ARCALYST 220 mg sc soln 5 PA

CARNITOR 330 mg tab 3

CARNITOR 1 gm/10ml soln 3

CARNITOR SF 1 gm/10ml soln 3

CYSTADANE oral pwdr 5 PA

CYSTAGON 150 mg cap, 50 mg cap 3

DEMSER 250 mg cap 3

ELMIRON 100 mg cap 3

EUFLEXXA 20 mg/2ml i-artic soln pfs 5 PA

GENVISC 850 25 mg/2.5ml i-artic soln pfs 5 PA

PROSSAM




Drug Tier

[Nivel]




HYALGAN 20 mg/2ml i-artic soln, 20 mg/2ml i-artic soln pfs 5 PA

KUVAN 100 mg tab sol 5 PA

levocarnitine 330 mg tab 1 CARNITOR

levocarnitine 1 gm/10ml soln 1 CARNITOR

ORFADIN 10 mg cap, 2 mg cap, 5 mg cap 5 PA

ORTHOVISC 30 mg/2ml i-artic soln pfs 5 PA

RIMSO-50 50 % i-vesic soln 3

SENSIPAR 30 mg tab, 60 mg tab, 90 mg tab 2

SUPARTZ FX 25 mg/2.5ml i-artic soln pfs 5 PA

SYNVISC 16 mg/2ml i-artic soln pfs 5 PA

SYNVISC ONE 48 mg/6ml i-artic soln pfs 5 PA

THIOLA 100 mg tab 3

TYBOST 150 mg tab 4 PA

ZAVESCA 100 mg cap 5 PA

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS [AGENTES PARASIMPATICOMIMÉTICOS (COLINÉRGICOS)]

Parasympathomimetic (cholinergic) Agents [Agentes Parasimpaticomiméticos (Colinérgicos)]

ARICEPT 10 mg tab, 23 mg tab, 5 mg tab 3

bethanechol chloride 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 1 URECHOLINE

cevimeline hcl 30 mg cap 1 EVOXAC

donepezil hcl 10 mg tab, 10 mg tab disint, 23 mg tab, 5 mg tab, 5 mg tab disint 1 ARICEPT

EVOXAC 30 mg cap 3

EXELON 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 2

galantamine hydrobromide 12 mg tab, 4 mg tab, 8 mg tab 1 RAZADYNE

galantamine hydrobromide 4 mg/ml soln 1 RAZADYNE

galantamine hydrobromide er 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 1 RAZADYNE

guanidine hcl 125 mg tab 1

MESTINON 180 mg tab er, 60 mg tab 3

PROSSAM




Drug Tier

[Nivel]




MESTINON 60 mg/5ml syr 3

pilocarpine hcl 5 mg tab, 7.5 mg tab 1 SALAGEN

pyridostigmine bromide 60 mg tab 1 MESTINON

pyridostigmine bromide er 180 mg tab er 1 MESTINON

RAZADYNE 12 mg tab, 4 mg tab, 8 mg tab 3

RAZADYNE ER 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 3

rivastigmine 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 1 EXELON

rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap 1 EXELON

SALAGEN 5 mg tab, 7.5 mg tab 3

URECHOLINE 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 3

PARATHYROID [PARATIROIDEOS]

Parathyroid [Paratiroideos]

calcitonin (salmon) 200 unit/act nasal soln 1 MIACALCIN

FORTEO 600 mcg/2.4ml sc soln 4 PA

MIACALCIN 200 unit/ml inj soln 3

PHOSPHODIESTERASE TYPE 4 INHIBITORS [INHIBIDORES DE LA FOSFODIESTERASA TIPO 4]

Phosphodiesterase Type 4 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 4]

DALIRESP 500 mcg tab 3

PITUITARY [PITUITARIA]

Pituitary [Pituitaria]

DDAVP 0.1 mg tab, 0.2 mg tab 3

DDAVP 0.01 % nasal soln 3

DDAVP 4 mcg/ml inj soln 5 PA

DDAVP RHINAL TUBE 0.01 % nasal soln 3

desmopressin ace spray refrig 0.01 % nasal soln 1 MINIRIN

desmopressin acetate 0.1 mg tab, 0.2 mg tab 1 DDAVP

desmopressin acetate 4 mcg/ml inj soln 1 DDAVP

desmopressin acetate spray 0.01 % nasal soln 1

HP ACTHAR 80 unit/ml inj gel 5 PA

STIMATE 1.5 mg/ml nasal soln 3

PROGESTINS [PROGESTINAS]

PROSSAM




Drug Tier

[Nivel]




Progestins [Progestinas]

AYGESTIN 5 mg tab 3

DEPO-PROVERA 150 mg/ml im susp, 150 mg/ml im susp pfs 3 QL(1 / 90)

DEPO-PROVERA 400 mg/ml im susp 4 PA

DEPO-SUBQ PROVERA 104 104 mg/0.65ml sc susp pfs 3 QL(1 / 90)

hydroxyprogesterone caproate 1.25 gm/5ml im soln 5 DELALUTIN PA

MAKENA 250 mg/ml im oil 5 PA

medroxyprogesterone acetate 150 mg/ml im susp pfs 1 QL(1 / 90)

medroxyprogesterone acetate 150 mg/ml im susp 1 DEPO-PROVERA QL(1 / 90)

medroxyprogesterone acetate 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROVERA

MEGACE ES 625 mg/5ml susp 5 PA

megestrol acetate 625 mg/5ml susp 5 MEGACE PA

norethindrone acetate 5 mg tab 1 AYGESTIN

progesterone 50 mg/ml im oil 1 PA

progesterone micronized 100 mg cap, 200 mg cap 1 PROMETRIUM PA

PROMETRIUM 100 mg cap, 200 mg cap 3 PA

PROVERA 10 mg tab, 2.5 mg tab, 5 mg tab 3

PROKINETIC AGENTS [AGENTES PROCINÉTICOS]

Prokinetic Agents [Agentes Procinéticos]

metoclopramide hcl 10 mg tab disint, 5 mg tab disint 1 METOZOLV QL(90 / 365)

metoclopramide hcl 10 mg tab, 5 mg tab 1 REGLAN QL(90 / 365)

metoclopramide hcl 10 mg/10ml soln, 5 mg/5ml soln, 5 mg/ml inj soln 1 REGLAN QL(90 / 365)

REGLAN 10 mg tab, 5 mg tab 3 QL(90 / 365)

PROTECTIVE AGENTS [AGENTES PROTECTORES]

Protective Agents [Agentes Protectores]

dexrazoxane 500 mg iv soln 4 PA

dexrazoxane 250 mg iv soln 4 ZINECARD PA

ETHYOL 500 mg iv soln 4 PA

mesna 100 mg/ml iv soln 4 MESNEX PA

MESNEX 400 mg tab 4 PA

MESNEX 100 mg/ml iv soln 4 PA

TOTECT 500 mg iv soln 4 PA

PROSSAM




Drug Tier

[Nivel]




ZINECARD 250 mg iv soln, 500 mg iv soln 4 PA

PSYCHOTHERAPEUTIC AGENTS [AGENTES PSICOTERAPÉUTICOS]

Antidepressants [Antidepresivos]

amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 ELAVIL

amoxapine 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab 1 ASENDIN

ANAFRANIL 25 mg cap, 50 mg cap, 75 mg cap 3

APLENZIN 174 mg tab er 24 hr, 348 mg tab er 24 hr, 522 mg tab er 24 hr 3

bupropion hcl 100 mg tab, 75 mg tab 1 WELLBUTRIN

bupropion hcl er (smoking det) 150 mg tab er 12 hr 1 ZYBAN

bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 1 WELLBUTRIN SR

bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr 1 WELLBUTRIN XL

CELEXA 10 mg tab, 20 mg tab, 40 mg tab 3

chlordiazepoxide-amitriptyline 10-25 mg tab, 5-12.5 mg tab 1 LIMBITROL

citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab 1 CELEXA

citalopram hydrobromide 10 mg/5ml soln 1 CELEXA

clomipramine hcl 25 mg cap, 50 mg cap, 75 mg cap 1 ANAFRANIL

CYMBALTA 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 3

desipramine hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 NORPRAMIN

desvenlafaxine er 100 mg tab er 24 hr, 50 mg tab er 24 hr 1 KHEDEZLA

desvenlafaxine succinate er 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 PRISTIQ

doxepin hcl 10 mg cap, 100 mg cap, 150 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 SINEQUAN

PROSSAM




Drug Tier

[Nivel]




doxepin hcl 10 mg/ml oral conc 1 SINEQUAN

duloxetine hcl 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 1 CYMBALTA

EFFEXOR XR 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 3

escitalopram oxalate 10 mg tab, 20 mg tab, 5 mg tab 1 LEXAPRO

escitalopram oxalate 5 mg/5ml soln 1 LEXAPRO

fluoxetine hcl 10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab, 40 mg cap, 60 mg tab, 90 mg cap dr 1 PROZAC

fluoxetine hcl 20 mg/5ml soln 1 PROZAC

fluoxetine hcl (pmdd) 10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab 1

fluvoxamine maleate 100 mg tab, 25 mg tab, 50 mg tab 1 LUVOX

fluvoxamine maleate er 100 mg cap er 24 hr, 150 mg cap er 24 hr 1 LUVOX CR

FORFIVO XL 450 mg tab er 24 hr 3

imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 TOFRANIL

imipramine pamoate 100 mg cap, 125 mg cap, 150 mg cap, 75 mg cap 1 TOFRANIL-PM

LEXAPRO 10 mg tab, 20 mg tab, 5 mg tab 3

maprotiline hcl 25 mg tab, 50 mg tab, 75 mg tab 1 LUDIOMIL

MARPLAN 10 mg tab 3

mirtazapine 15 mg tab, 15 mg tab disint, 30 mg tab, 30 mg tab disint, 45 mg tab, 45 mg tab disint, 7.5 mg tab 1 REMERON

NARDIL 15 mg tab 3

nefazodone hcl 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab, 50 mg tab 1 SERZONE

NORPRAMIN 10 mg tab, 25 mg tab 3

nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 PAMELOR

nortriptyline hcl 10 mg/5ml soln 1 PAMELOR

olanzapine-fluoxetine hcl 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 1 SYMBYAX

PROSSAM




Drug Tier

[Nivel]




PAMELOR 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 3

PARNATE 10 mg tab 3

paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 1 PAXIL

paroxetine hcl er 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 1 PAXIL CR

PAXIL 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3

PAXIL 10 mg/5ml susp 3

PAXIL CR 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 3

perphenazine-amitriptyline 2-10 mg tab, 2-25 mg tab, 4-10 mg tab, 4-25 mg tab, 4-50 mg tab 1 TRIAVIL

PEXEVA 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3

phenelzine sulfate 15 mg tab 1 NARDIL

PRISTIQ 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 2

protriptyline hcl 10 mg tab, 5 mg tab 1 VIVACTIL

PROZAC 10 mg cap, 20 mg cap, 40 mg cap 3

REMERON 15 mg tab, 30 mg tab 3

REMERON SOLTAB 15 mg tab disint, 30 mg tab disint, 45 mg tab disint 3

SARAFEM 10 mg tab, 20 mg tab 3

sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab 1 ZOLOFT

sertraline hcl 20 mg/ml oral conc 1 ZOLOFT

SILENOR 3 mg tab, 6 mg tab 3

SURMONTIL 100 mg cap, 25 mg cap, 50 mg cap 3

SYMBYAX 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 3

TOFRANIL 10 mg tab, 25 mg tab, 50 mg tab 3

tranylcypromine sulfate 10 mg tab 1 PARNATE

trazodone hcl 100 mg tab, 150 mg tab, 300 mg tab, 50 mg tab 1 DESYREL

PROSSAM




Drug Tier

[Nivel]




trimipramine maleate 100 mg cap, 25 mg cap, 50 mg cap 1 SURMONTIL

venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab 1 EFFEXOR

venlafaxine hcl er 150 mg tab er 24 hr, 225 mg tab er 24 hr, 37.5 mg tab er 24 hr, 75 mg tab er 24 hr 1

venlafaxine hcl er 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 1 EFFEXOR XR

VIIBRYD 10 mg tab, 20 mg tab, 40 mg tab 3

WELLBUTRIN SR 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 3

WELLBUTRIN XL 150 mg tab er 24 hr, 300 mg tab er 24 hr 3

ZOLOFT 100 mg tab, 25 mg tab, 50 mg tab 3

ZOLOFT 20 mg/ml oral conc 3

ZYBAN 150 mg tab er 12 hr 3

Antipsychotics [Antipsicóticos]

ABILIFY 10 mg tab, 15 mg tab, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 3

ABILIFY MAINTENA 300 mg im pfs, 300 mg Intramuscular Suspension Reconstituted ER 3

aripiprazole 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ABILIFY

aripiprazole 1 mg/ml soln 1 ABILIFY

chlorpromazine hcl 25 mg/ml inj soln, 50 mg/2ml inj soln 1

chlorpromazine hcl 10 mg tab, 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 THORAZINE

clozapine 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 CLOZARIL

clozapine 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 1 FAZACLO

CLOZARIL 100 mg tab, 25 mg tab 3

COMPRO 25 mg rect supp 3

PROSSAM




Drug Tier

[Nivel]




FANAPT 1 mg tab, 10 mg tab, 12 mg tab, 2 mg tab, 4 mg tab, 6 mg tab, 8 mg tab 3

FANAPT TITRATION PACK 1 & 2 & 4 & 6 mg tab 3

FAZACLO 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 3

fluphenazine decanoate 25 mg/ml inj soln 1 PROLIXIN

fluphenazine hcl 1 mg tab, 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROLIXIN

fluphenazine hcl 2.5 mg/5ml oral elix, 2.5 mg/ml inj soln, 5 mg/ml oral conc 1 PROLIXIN

GEODON 20 mg cap, 20 mg im soln, 40 mg cap, 60 mg cap, 80 mg cap 3

HALDOL 5 mg/ml inj soln 3

HALDOL DECANOATE 100 mg/ml im soln, 50 mg/ml im soln 3

haloperidol 0.5 mg tab, 1 mg tab, 10 mg tab, 2 mg tab, 20 mg tab, 5 mg tab 1 HALDOL

haloperidol decanoate 100 mg/ml im soln, 50 mg/ml im soln 1 HALDOL

haloperidol lactate 2 mg/ml oral conc, 5 mg/ml inj soln 1 HALDOL

INVEGA 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 3

INVEGA SUSTENNA 117 mg/0.75ml im susp, 156 mg/ml im susp, 234 mg/1.5ml im susp, 39 mg/0.25ml im susp, 78 mg/0.5ml im susp 5 PA

LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 3

loxapine succinate 10 mg cap, 25 mg cap, 5 mg cap, 50 mg cap 1 LOXITANE

olanzapine 10 mg im soln, 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2.5 mg tab, 20 mg tab, 20 mg tab disint, 5 mg tab, 5 mg tab disint, 7.5 mg tab 1 ZYPREXA

ORAP 1 mg tab, 2 mg tab 3

PROSSAM




Drug Tier

[Nivel]




paliperidone er 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 1 INVEGA

perphenazine 16 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 TRILAFON

pimozide 1 mg tab, 2 mg tab 1 ORAP

prochlorperazine 25 mg rect supp 1 COMPRO

prochlorperazine edisylate 5 mg/ml inj soln 1 COMPAZINE

prochlorperazine maleate 10 mg tab, 5 mg tab 1 COMPAZINE

quetiapine fumarate 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 1 SEROQUEL

quetiapine fumarate er 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 1 SEROQUEL XR

RISPERDAL 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab 3

RISPERDAL 1 mg/ml soln 3

RISPERDAL CONSTA 12.5 mg im susp, 25 mg im susp, 37.5 mg im susp, 50 mg im susp 5 PA

RISPERDAL M-TAB 0.5 mg tab disint 3

risperidone 0.25 mg tab, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint, 3 mg tab, 3 mg tab disint, 4 mg tab, 4 mg tab disint 1 RISPERDAL

risperidone 1 mg/ml soln 1 RISPERDAL

RISPERIDONE M-TAB 0.5 mg tab disint, 1 mg tab disint, 2 mg tab disint 3

SAPHRIS 10 mg tab subl, 5 mg tab subl 3

SEROQUEL 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 3

SEROQUEL XR 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 3

PROSSAM




Drug Tier

[Nivel]




thioridazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 MELLARIL

thiothixene 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 NAVANE

trifluoperazine hcl 1 mg tab, 10 mg tab, 2 mg tab, 5 mg tab 1 STELAZINE

ziprasidone hcl 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 GEODON

ZYPREXA 10 mg im soln, 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab 3

ZYPREXA RELPREVV 210 mg im susp, 300 mg im susp, 405 mg im susp 3

ZYPREXA ZYDIS 10 mg tab disint, 15 mg tab disint, 20 mg tab disint, 5 mg tab disint 3

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS [INHIBIDORES DEL SISTEMA RENINA-ANGIOTENSINA-ALDOSTERONA]

Angiotensin Ii Receptor Antagonists [Antagonistas Del Receptor De Angiotensina Ii]

ATACAND HCT 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 3

AVALIDE 150-12.5 mg tab 3

BENICAR 20 mg tab, 40 mg tab, 5 mg tab 3

BENICAR HCT 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 3

candesartan cilexetil 16 mg tab, 32 mg tab, 4 mg tab, 8 mg tab 1 ATACAND

candesartan cilexetil-hctz 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 1 ATACAND HCT

DIOVAN HCT 160-12.5 mg tab, 160-25 mg tab, 320-12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab 3

EDARBYCLOR 40-12.5 mg tab, 40-25 mg tab 3

eprosartan mesylate 600 mg tab 1 TEVETEN

HYZAAR 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 3

irbesartan 150 mg tab, 300 mg tab, 75 mg tab 1 AVAPRO

irbesartan-hydrochlorothiazide 150-12.5 mg tab, 300-12.5 mg tab 1 AVALIDE

losartan potassium 100 mg tab, 25 mg tab, 50 mg tab 1 COZAAR

PROSSAM




Drug Tier

[Nivel]




losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 1 HYZAAR

MICARDIS HCT 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 3

olmesartan medoxomil 20 mg tab, 40 mg tab, 5 mg tab 1 BENICAR

olmesartan medoxomil-hctz 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 1 BENICAR HCT

telmisartan 20 mg tab, 40 mg tab, 80 mg tab 1 MICARDIS

telmisartan-hctz 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 1 MICARDIS-HCT

valsartan 160 mg tab, 320 mg tab, 40 mg tab, 80 mg tab 1 DIOVAN

valsartan-hydrochlorothiazide 160-12.5 mg tab, 160-25 mg tab, 320-12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab 1 DIOVAN HCT

Angiotensin-converting Enzyme Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina]

ACCURETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

benazepril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 LOTENSIN

benazepril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab, 5-6.25 mg tab 1 LOTENSIN HCT

captopril 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 1 CAPOTEN

captopril-hydrochlorothiazide 25-15 mg tab, 25-25 mg tab, 50-15 mg tab, 50-25 mg tab 1 CAPOZIDE

enalapril maleate 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 1 VASOTEC

enalapril-hydrochlorothiazide 10-25 mg tab, 5-12.5 mg tab 1 VASERETIC

fosinopril sodium 10 mg tab, 20 mg tab, 40 mg tab 1 MONOPRIL

fosinopril sodium-hctz 10-12.5 mg tab, 20-12.5 mg tab 1 MONOPRIL-HCT

lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab 1 ZESTRIL

PROSSAM




Drug Tier

[Nivel]




lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ZESTORETIC

LOTENSIN HCT 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

moexipril hcl 15 mg tab, 7.5 mg tab 1 UNIVASC

moexipril-hydrochlorothiazide 15-12.5 mg tab, 15-25 mg tab, 7.5-12.5 mg tab 1 UNIRETIC

perindopril erbumine 2 mg tab, 4 mg tab, 8 mg tab 1 ACEON

quinapril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 ACCUPRIL

quinapril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ACCURETIC

ramipril 1.25 mg cap, 10 mg cap, 2.5 mg cap, 5 mg cap 1 ALTACE

trandolapril 1 mg tab, 2 mg tab, 4 mg tab 1 MAVIK

VASERETIC 10-25 mg tab 3

ZESTORETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3

Mineralocorticoid (aldosterone) Receptor Antagonists [Antagonistas Del Receptor De Mineralocorticoides (Aldosterona)]

ALDACTAZIDE 25-25 mg tab, 50-50 mg tab 3

ALDACTONE 100 mg tab, 25 mg tab, 50 mg tab 3

eplerenone 25 mg tab, 50 mg tab 1 INSPRA

INSPRA 25 mg tab, 50 mg tab 3

spironolactone 100 mg tab, 25 mg tab, 50 mg tab 1 ALDACTONE

spironolactone-hctz 25-25 mg tab 1 ALDACTAZIDE

Renin Inhibitors [Inhibidores De Renina]

aliskiren fumarate 150 mg tab, 300 mg tab 1 TEKTURNA

TEKTURNA 150 mg tab, 300 mg tab 3

TEKTURNA HCT 150-12.5 mg tab, 150-25 mg tab, 300-12.5 mg tab, 300-25 mg tab 3

REPLACEMENT PREPARATIONS [PREPARACIONES DE REEMPLAZO]

Replacement Preparations [Preparaciones De Reemplazo]

av-phos 250 neutral 155-852-130 mg tab 1

PROSSAM




Drug Tier

[Nivel]




calcium acetate (phos binder) 667 mg tab 1

calcium acetate (phos binder) 667 mg cap 1 PHOSLO

EFFER-K 10 meq tab eff, 20 meq tab eff, 25 meq tab eff 3

effervescent pot chloride 25 meq tab eff 1

GALZIN 25 mg cap, 50 mg cap 3

k-effervescent 25 meq tab eff 1

KLOR-CON 20 meq pckt, 8 meq tab er 3

KLOR-CON 10 10 meq tab er 3

KLOR-CON M10 10 meq tab er 3



KLOR-CON SPRINKLE 10 meq cap er, 8 meq cap er 3

KLOR-CON/EF 25 meq tab eff 3

K-PHOS 500 mg tab 3

K-PHOS-NEUTRAL 155-852-130 mg tab 3

K-PRIME 25 meq tab eff 3

K-TAB 10 meq tab er, 8 meq tab er 3

k-vescent 25 meq tab eff 1

MAGNEBIND 400 400-200-1 mg tab 3

MICRO-K 10 meq cap er, 8 meq cap er 3

PHOSLYRA 667 mg/5ml soln 3

PHOSPHA 250 NEUTRAL 155-852-130 mg tab 3

PHOSPHO-TRIN 250 NEUTRAL 155-852-130 mg tab 3

pot bicarb-pot chloride 25 meq tab eff 1

potassium bicarbonate 25 meq tab eff 1

potassium chloride 20 meq pckt 1

potassium chloride 20 MEQ/15ML (10%) soln, 40 MEQ/15ML (20%) soln 1 K-SOL

potassium chloride crys er 10 meq tab er 1

potassium chloride crys er 20 meq tab er 1 KLOR-CON

PROSSAM




Drug Tier

[Nivel]




potassium chloride er 10 meq tab er, 8 meq tab er 1 KLOR-CON

potassium chloride er 10 meq cap er, 8 meq cap er 1 MICRO-K

virt-phos 250 neutral 155-852-130 mg tab 1

RESPIRATORY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO RESPIRATORIO]

Respiratory Smooth Muscle Relaxants [Relajantes Del Músculo Liso Respiratorio]

DIFIL-G FORTE 100-100 mg/5ml liq 3

ELIXOPHYLLIN 80 mg/15ml oral elix 3

THEO-24 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr, 400 mg cap er 24 hr 3

THEOCHRON 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr 3

theophylline 80 mg/15ml soln 1

theophylline er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr, 450 mg tab er 12 hr 1 THEO-DUR

theophylline er 400 mg tab er 24 hr, 600 mg tab er 24 hr 1 UNIPHYL

RESPIRATORY TRACT AGENTS, MISCELLANEOUS [AGENTES PARA EL TRACTO RESPIRATORIO, MISCELÁNEOS]

Respiratory Tract Agents, Miscellaneous [Agentes Para El Tracto Respiratorio, Misceláneos]

ARALAST NP 1000 mg iv soln 4 PA

NUCALA 100 mg sc soln, 100 mg/ml sc auto-inj, 100 mg/ml pfs soln 4 PA

PROLASTIN-C 1000 mg iv soln 4 PA

XOLAIR 150 mg sc soln 5 PA

ZEMAIRA 1000 mg iv soln 4 PA

SECOND GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE SEGUNDA GENERACIÓN]

Second Generation Antihistamines [Antihistamínicos De Segunda Generación]

cetirizine hcl 1 mg/ml soln, 5 mg/5ml soln 1 ZYRTEC

CLARINEX 5 mg tab 3

CLARINEX 0.5 mg/ml syr 3

CLARINEX-D 12 HOUR 2.5-120 mg tab er 12 hr 3

PROSSAM




Drug Tier

[Nivel]




desloratadine 2.5 mg tab disint, 5 mg tab, 5 mg tab disint 1 CLARINEX

levocetirizine dihydrochloride 5 mg tab 1 XYZAL

levocetirizine dihydrochloride 2.5 mg/5ml soln 1 XYZAL

SEMPREX-D 8-60 mg cap 3

SERUMS [SUEROS]

Serums [Sueros]

BIVIGAM 10 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA

FLEBOGAMMA DIF 0.5 gm/10ml iv soln, 10 gm/100ml iv soln, 10 gm/200ml iv soln, 2.5 gm/50ml iv soln, 20 gm/200ml iv soln, 20 gm/400ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA

GAMMAGARD 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 30 gm/300ml inj soln, 5 gm/50ml inj soln 5 PA

GAMMAGARD S/D LESS IGA 10 gm iv soln, 5 gm iv soln 5 PA

GAMMAKED 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 5 gm/50ml inj soln 5 PA

GAMMAPLEX 10 gm/100ml iv soln, 10 gm/200ml iv soln, 20 gm/200ml iv soln, 20 gm/400ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA

GAMUNEX-C 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 5 gm/50ml inj soln 5 PA

HYPERRHO S/D 1500 unit im soln pfs, 250 unit im soln pfs 4 PA

MICRHOGAM ULTRA-FILTERED PLUS 250 unit im soln pfs 4 PA

OCTAGAM 10 gm/100ml iv soln, 10 gm/200ml iv soln, 2.5 gm/50ml iv soln, 20 gm/200ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA

PRIVIGEN 10 gm/100ml iv soln, 20 gm/200ml iv soln, 5 gm/50ml iv soln 5 PA

PROSSAM




Drug Tier

[Nivel]




RHOGAM ULTRA-FILTERED PLUS 1500 unit im soln pfs 4 PA

RHOPHYLAC 1500 unit/2ml inj soln pfs 4 PA

WINRHO SDF 1500 unit/1.3ml inj soln, 15000 unit/13ml inj soln, 2500 unit/2.2ml inj soln, 5000 unit/4.4ml inj soln 4 PA

SKELETAL MUSCLE RELAXANTS [RELAJANTES MUSCULOESQUELÉTICOS]

Centrally Acting Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos De Acción Central]

AMRIX 15 mg cap er 24 hr, 30 mg cap er 24 hr 3

carisoprodol 250 mg tab, 350 mg tab 1 SOMA

carisoprodol-aspirin 200-325 mg tab 1 SOMA

carisoprodol-aspirin-codeine 200-325-16 mg tab 1

SOMA COMPOUND WITH CODEINE

chlorzoxazone 500 mg tab 1 PARAFON

cyclobenzaprine hcl 7.5 mg tab 1 FEXMID

cyclobenzaprine hcl 10 mg tab, 5 mg tab 1 FLEXERIL

enovarx-cyclobenzaprine hcl 20 mg/gm td crm 1

FEXMID 7.5 mg tab 3

LORZONE 375 mg tab, 750 mg tab 3

METAXALL 800 mg tab 3

metaxalone 800 mg tab 1 SKELAXIN

methocarbamol 500 mg tab, 750 mg tab 1 ROBAXIN

methocarbamol 1000 mg/10ml inj soln 1 ROBAXIN

ROBAXIN 500 mg tab 3

ROBAXIN 1000 mg/10ml inj soln 3

ROBAXIN-750 750 mg tab 3

SKELAXIN 800 mg tab 3

SOMA 250 mg tab, 350 mg tab 3

tizanidine hcl 2 mg cap, 2 mg tab, 4 mg cap, 4 mg tab, 6 mg cap 1 ZANAFLEX

ZANAFLEX 2 mg cap, 4 mg cap, 4 mg tab, 6 mg cap 3

Direct-acting Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos De Acción Directa]

DANTRIUM 25 mg cap, 50 mg cap 3

PROSSAM




Drug Tier

[Nivel]




dantrolene sodium 100 mg cap, 25 mg cap, 50 mg cap 1 DANTRIUM

Gaba-derivative Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos Derivados De Gaba]

baclofen 10 mg tab, 20 mg tab 1 LIORESAL

Skeletal Muscle Relaxants, Miscellaneous [Relajantes Musculoesqueléticos, Misceláneos]

orphenadrine citrate 30 mg/ml inj soln 1 NORFLEX

orphenadrine citrate er 100 mg tab er 12 hr 1 NORFLEX

SKIN AND MUCOUS MEMBRANE AGENTS, MISC [AGENTES PARA LA PIEL Y MEMBRANAS MUCOSAS, MISCELÁNEOS]

Skin And Mucous Membrane Agents, Misc [Agentes Para La Piel Y Membranas Mucosas, Misceláneos]

ABSORICA 10 mg cap, 20 mg cap, 25 mg cap, 30 mg cap, 35 mg cap, 40 mg cap 3

acitretin 10 mg cap, 17.5 mg cap, 25 mg cap 1 SORIATANE PA

ACZONE 5 % gel, 7.5 % gel 3

adapalene 0.1 % lot 1 AL

adapalene 0.1 % crm, 0.1 % gel, 0.3 % gel 1 DIFFERIN AL

adapalene-benzoyl peroxide 0.1-2.5 % gel 1 EPIDUO

ALDARA 5 % crm 3

ALEVICYN PLUS ext kit 3

AMNESTEEM 10 mg cap, 20 mg cap, 40 mg cap 3

ATOPICLAIR crm 3

AZELEX 20 % crm 3

calcipotriene 0.005 % crm, 0.005 % oint 1 DOVONEX

calcipotriene 0.005 % ext soln 1 DOVONEX

CALCITRENE 0.005 % oint 3

calcitriol 3 mcg/gm oint 1 VECTICAL

CARAC 0.5 % crm 5 PA

CLARAVIS 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3

clindamycin-tretinoin 1.2-0.025 % gel 1 ZIANA

CLINOIN 1.25-0.025-1 % crm 3

CONDYLOX 0.5 % gel 3

COSENTYX 150 mg/ml sc soln pfs 4 PA

COSENTYX 300 DOSE 150 mg/ml sc soln pfs 4 PA

PROSSAM




Drug Tier

[Nivel]




COSENTYX SENSOREADY 300 DOSE 150 mg/ml sc soln auto-inj 4 PA

COSENTYX SENSOREADY PEN 150 mg/ml sc soln auto-inj 4 PA

dapsone 5 % gel 1 ACZONE

DEXERYL crm 3

diclofenac sodium 1.5 % td soln 1 PENNSAID

diclofenac sodium 3 % td gel 4 SOLARAZE PA

diclofenac sodium 1 % td gel 1 VOLTAREN

DIFFERIN 0.1 % crm, 0.1 % gel, 0.3 % gel 3

DIFFERIN 0.1 % lot 3

DOVONEX 0.005 % crm 3

doxycycline 40 mg cap dr 1

DRITHO-CREME HP 1 % crm 3

EFUDEX 5 % crm 5 PA

ELETONE crm 3

ELETONE TWINPACK crm 3

ELIDEL 1 % crm 3

EPIDUO 0.1-2.5 % gel 3

EPIDUO FORTE 0.3-2.5 % gel 3

FABIOR 0.1 % foam 3

FINACEA 15 % foam, 15 % gel 3

FLECTOR 1.3 % td patch 3

FLUOROPLEX 1 % crm 5 PA

fluorouracil 0.5 % crm 4 CARAC PA

fluorouracil 5 % crm 4 EFUDEX PA

fluorouracil 2 % ext soln, 5 % ext soln 4 EFUDEX PA

HPR foam 3

HPR PLUS crm, foam 3

HPR PLUS HYDROGEL ext kit 3

HYLATOPIC PLUS crm, foam 3

imiquimod 5 % crm 1 ALDARA

KLOFENSAID II 1.5 % td soln 3

LEVULAN KERASTICK 20 % ext soln 5 PA

MB HYDROGEL ext kit 3

minocycline hcl er 115 mg tab er 24 hr, 135 mg tab er 24 hr, 45 mg tab er 24 hr, 65 mg tab er 24 hr, 90 mg tab er 24 hr 1 SOLODYN

MIRVASO 0.33 % gel 3

MYORISAN 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3

NEOCERA crm 3

PROSSAM




Drug Tier

[Nivel]




NEOSALUS crm, foam 3

NEOSALUS lot 3

NEOSALUS CP crm 3

NIVATOPIC PLUS crm 3

ORACEA 40 mg cap dr 3

PANRETIN 0.1 % gel 4 PA

PICATO 0.015 % gel, 0.05 % gel 5 PA

podocon 25 % ext soln 1

podofilox 0.5 % ext soln 1 CONDYLOX

PR CREAM ext kit 3

PRESERA foam 3

PROTOPIC 0.03 % oint, 0.1 % oint 3

PRUCLAIR crm 3

PRUMYX crm 3

QUTENZA 8 % ext kit 5 PA

QUTENZA (2 PATCH) 8 % ext kit 5 PA

RECTIV 0.4 % rect oint 3

SANTYL 250 unit/gm oint 3

SKYRIZI (150 mg/ml) sc pfs kit 75mg/0.83ml 4 PA

SOLODYN 105 mg tab er 24 hr, 115 mg tab er 24 hr, 55 mg tab er 24 hr, 65 mg tab er 24 hr, 80 mg tab er 24 hr 3

SORIATANE 10 mg cap, 17.5 mg cap, 25 mg cap 5 PA

SORILUX 0.005 % foam 3

tacrolimus 0.03 % oint, 0.1 % oint 1 PROTOPIC

TARGRETIN 1 % gel 5 PA

tazarotene 0.1 % crm 1 TAZORAC

TAZORAC 0.05 % crm, 0.05 % gel, 0.1 % crm, 0.1 % gel 3

TETRIX crm 3

VECTICAL 3 mcg/gm oint 3

VELTIN 1.2-0.025 % gel 3

VEREGEN 15 % oint 3

VOLTAREN 1 % td gel 3

XERALUX crm 3

ZENATANE 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3

ZIANA 1.2-0.025 % gel 3

ZITHRANOL 1 % shampoo 3

ZYCLARA 3.75 % crm 3

ZYCLARA PUMP 2.5 % crm, 3.75 % crm 3

PROSSAM




Drug Tier

[Nivel]




SOMATOSTATIN AGONISTS AND ANTAGONISTS [AGONISTAS Y ANTAGONISTAS DE SOMATOSTATINA]

Somatostatin Agonists [Agonistas De Somatostatina]

octreotide acetate 100 mcg/ml inj soln, 1000 mcg/ml inj soln, 200 mcg/ml inj soln, 50 mcg/ml inj soln, 500 mcg/ml inj soln 5 SANDOSTATIN PA

SANDOSTATIN 100 mcg/ml inj soln, 1000 mcg/ml inj soln, 50 mcg/ml inj soln, 500 mcg/ml inj soln 5 PA

SANDOSTATIN LAR DEPOT 10 mg im kit, 20 mg im kit, 30 mg im kit 5 PA

SIGNIFOR 0.3 mg/ml sc soln, 0.6 mg/ml sc soln, 0.9 mg/ml sc soln 5 PA

SIGNIFOR LAR 20 mg Intramuscular Suspension Reconstituted ER, 40 mg Intramuscular Suspension Reconstituted ER, 60 mg Intramuscular Suspension Reconstituted ER 5 PA

SOMATULINE DEPOT 120 mg/0.5ml sc soln, 60 mg/0.2ml sc soln, 90 mg/0.3ml sc soln 5 PA

SOMATOTROPIN AGONISTS AND ANTAGONISTS [AGONISTAS Y ANTAGONISTAS DE SOMATOTROPINA]

Somatotropin Agonists [Agonistas De Somatotropina]

EGRIFTA 1 mg sc soln 5 PA

INCRELEX 40 mg/4ml sc soln 5 PA

SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS [AGENTES SIMPATICOLITICOS (BLOQUEADORES ADRENÉRGICOS)]

Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]

alfuzosin hcl er 10 mg tab er 24 hr 1 UROXATRAL

D.H.E. 45 1 mg/ml inj soln 3 QL(3 / 30)

DIBENZYLINE 10 mg cap 4 PA

dihydroergotamine mesylate 1 mg/ml inj soln 1 QL(3 / 30)

dihydroergotamine mesylate 4 mg/ml nasal soln 1 MIGRANAL QL(8 / 30)

ergoloid mesylates 1 mg tab 1 HYDERGINE

ERGOMAR 2 mg tab subl 3 QL(20 / 30)

FLOMAX 0.4 mg cap 3

MIGRANAL 4 mg/ml nasal soln 3 QL(8 / 30)

phenoxybenzamine hcl 10 mg cap 4 DIBENZYLINE PA

RAPAFLO 4 mg cap, 8 mg cap 3

PROSSAM




Drug Tier

[Nivel]




tamsulosin hcl 0.4 mg cap 1 FLOMAX

UROXATRAL 10 mg tab er 24 hr 3

SYMPATHOMIMETIC (ADRENERGIC) AGENTS [AGENTES SIMPATICOMIMÉTICOS (ADRENÉRGICOS)]

Alpha- And Beta-adrenergic Agonists [Agonistas Alfa Y Beta Adrenérgicos]

AUVI-Q 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 3

epinephrine 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 1 ADRENACLICK

epinephrine 0.15 mg/0.3ml inj soln auto-inj 1 EPIPEN JR

EPIPEN 2-PAK 0.3 mg/0.3ml inj soln auto-inj 3

EPIPEN JR 2-PAK 0.15 mg/0.3ml inj soln auto-inj 3

Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]

midodrine hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROAMATINE

Beta-adrenergic Agonists [Agonistas Beta-Adrenérgicos]

ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr br act, 250-50 mcg/dose inh aer pwdr br act, 500-50 mcg/dose inh aer pwdr br act 2 QL(60 / 30)

ADVAIR HFA 115-21 mcg/act inh aer, 230-21 mcg/act inh aer, 45-21 mcg/act inh aer 2 QL(12 / 30)

albuterol sulfate 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 ACCUNEB

albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg tab, 4 mg tab 1 PROVENTIL

albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg/5ml syr 1 PROVENTIL

albuterol sulfate (2.5 MG/3ML) 0.083% inh neb soln 1 VENTOLIN

albuterol sulfate er 4 mg tab er 12 hr, 8 mg tab er 12 hr 1 VOSPIRE ER

ARCAPTA NEOHALER 75 mcg inh cap 3

BROVANA 15 mcg/2ml inh neb soln 3

ipratropium-albuterol 0.5-2.5 (3) mg/3ml inh soln 1 DUONEB

levalbuterol hcl 1.25 mg/0.5ml inh neb soln 1 XOPENEX

PROSSAM




Drug Tier

[Nivel]




levalbuterol hcl 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 XOPENEX

levalbuterol tartrate 45 mcg/act inh aer 1 XOPENEX HFA

metaproterenol sulfate 10 mg tab, 20 mg tab 1 ALUPENT

metaproterenol sulfate 10 mg/5ml syr 1 ALUPENT

PERFOROMIST 20 mcg/2ml inh neb soln 3

PROAIR HFA 108 (90 Base) mcg/act inh aer soln 3 QL(17 / 30)

PROAIR RESPICLICK 108 (90 Base) mcg/act inh aer pwdr br act 3 QL(2 / 30)

PROVENTIL HFA 108 (90 Base) mcg/act inh aer soln 3 QL(36 / 30)

terbutaline sulfate 2.5 mg tab, 5 mg tab 1 BRETHINE

VENTOLIN HFA 108 (90 Base) mcg/act inh aer soln 2 QL(36 / 30)

XOPENEX 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 3

XOPENEX CONCENTRATE 1.25 mg/0.5ml inh neb soln 3

XOPENEX HFA 45 mcg/act inh aer 3

THYROID AND ANTITHYROID AGENTS [AGENTES TIROIDEOS Y ANTITIROIDEOS]

Antithyroid Agents [Agentes Antitiroideos]

methimazole 10 mg tab, 5 mg tab 1 TAPAZOLE

propylthiouracil 50 mg tab 1

TAPAZOLE 10 mg tab, 5 mg tab 3

Thyroid Agents [Agentes Tiroideos]

ARMOUR THYROID 120 mg tab, 15 mg tab, 180 mg tab, 240 mg tab, 30 mg tab, 300 mg tab, 60 mg tab, 90 mg tab 3

CYTOMEL 25 mcg tab, 5 mcg tab, 50 mcg tab 3

LEVO-T 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

levothyroxine sodium 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 1 SYNTHROID

PROSSAM




Drug Tier

[Nivel]




mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

levothyroxine-liothyronine 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1

LEVOXYL 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

liothyronine sodium 25 mcg tab, 5 mcg tab, 50 mcg tab 1 CYTOMEL

NATURE-THROID 113.75 mg tab, 130 mg tab, 146.25 mg tab, 16.25 mg tab, 162.5 mg tab, 195 mg tab, 260 mg tab, 32.5 mg tab, 325 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3

np thyroid 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1

SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 2

THYROLAR-1 60 (12.5-50) mg (mcg) tab 3

THYROLAR-1/2 30 (6.25-25) mg (mcg) tab 3

THYROLAR-1/4 15 (3.1-12.5) mg (mcg) tab 3

THYROLAR-2 120 (25-100) mg (mcg) tab 3

THYROLAR-3 180 (37.5-150) mg (mcg) tab 3

TIROSINT 100 mcg cap, 112 mcg cap, 125 mcg cap, 13 mcg cap, 137 mcg cap, 150 mcg cap, 25 mcg cap, 50 mcg cap, 75 mcg cap, 75 mcg cap, 88 mcg cap 3

UNITHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg 3

PROSSAM




Drug Tier

[Nivel]




tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

UNITHROID DIRECT 100 mcg tab, 112 mcg tab, 125 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3

WESTHROID 130 mg tab, 195 mg tab, 32.5 mg tab, 65 mg tab, 97.5 mg tab 3

WP THYROID 113.75 mg tab, 130 mg tab, 16.25 mg tab, 32.5 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3

TOXOIDS [TOXOIDES]

Toxoids [Toxoides]

ADACEL 5-2-15.5 lf-mcg/0.5 im susp 3

BOOSTRIX 5-2.5-18.5 lf-mcg/0.5 im susp 3

DAPTACEL 15-23-5 lf-mcg/0.5 im susp 3

diphtheria-tetanus toxoids dt 25-5 lfu/0.5ml im susp 1

INFANRIX 25-58-10 im susp 3

KINRIX im susp 3

QUADRACEL im susp 3

TENIVAC 5-2 lfu im inj 3

tetanus-diphtheria toxoids td 2-2 lf/0.5ml im susp 1

URICOSURIC AGENTS [AGENTES URICOSÚRICOS]

Uricosuric Agents [Agentes Uricosúricos]

colchicine-probenecid 0.5-500 mg tab 1 COLBENEMID

probenecid 500 mg tab 1 BENEMID

URINARY ANTI-INFECTIVES [ANTIINFECCIOSOS URINARIOS]

Urinary Anti-infectives [Antiinfecciosos Urinarios]

FURADANTIN 25 mg/5ml susp 3

HIPREX 1 gm tab 3

HYOPHEN 81.6 mg tab 3

MACROBID 100 mg cap 3

MACRODANTIN 100 mg cap, 25 mg cap, 50 mg cap 3

methenamine hippurate 1 gm tab 1 HIPREX

methenamine mandelate 0.5 gm tab, 1 gm tab 1

PROSSAM




Drug Tier

[Nivel]




MONUROL 3 gm pckt 3

nitrofurantoin 25 mg/5ml susp 1 FURADANTIN

nitrofurantoin macrocrystal 100 mg cap, 50 mg cap 1 MACRODANTIN

nitrofurantoin monohyd macro 100 mg cap 1 MACROBID

PHOSPHASAL 81.6 mg tab 3

PRIMSOL 50 mg/5ml soln 3

trimethoprim 100 mg tab 1 PROLOPRIM

ur n-c 81.6 mg tab 1

URELLE 81 mg tab 3

URETRON D/S tab 3

URIBEL 118 mg cap 3

URIMAR-T 120 mg tab 3

urin ds tab 1

uro-458 81 mg tab 1

uroav-81 81 mg tab 1

uroav-b 118 mg cap 1

UROGESIC-BLUE 81.6 mg tab 3

uro-mp 118 mg cap 1

URYL 81.6 mg tab 3

USTELL 120 mg cap 3

uticap 120 mg cap 1

UTIRA-C 81.6 mg tab 3

UTRONA-C 81.6 mg tab 3

VILAMIT MB 118 mg cap 3

VILEVEV MB 81 mg tab 3

VACCINES [VACUNAS]

Vaccines [Vacunas]

PEDIARIX im susp 3

PENTACEL im susp 3

THERACYS 81 mg/vial i-vesic susp 4 PA

TICE BCG 50 mg i-vesic susp 4 PA

VASOCONSTRICTORS [VASOCONSTRICTORES]

Vasoconstrictors [Vasoconstrictores]

ADRENALIN 0.1 % nasal soln 3

ALTAFRIN 10 % ophth soln, 2.5 % ophth soln 3

phenylephrine hcl 2.5 % ophth soln 1

phenylephrine hcl 10 % ophth soln, 2.5 % ophth soln 1

VASODILATING AGENTS [AGENTES VASODILATADORES]

Nitrates And Nitrites [Nitratos Y Nitritos]

BIDIL 20-37.5 mg tab 3

DILATRATE-SR 40 mg cap er 3

PROSSAM




Drug Tier

[Nivel]




ISORDIL TITRADOSE 40 mg tab, 5 mg tab 3

isosorbide dinitrate 10 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ISORDIL

isosorbide dinitrate er 40 mg tab er 1 ISORDIL

isosorbide mononitrate 10 mg tab, 20 mg tab 1 MONOKET

isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr 1 IMDUR

MINITRAN 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 3

NITRO-BID 2 % td oint 3

NITRO-DUR 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.3 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr, 0.8 mg/hr td patch 24hr 3

nitroglycerin 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 1 NITRO-DUR

nitroglycerin 0.4 mg/spray tl soln 1 NITROLINGUAL

nitroglycerin 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 1 NITROSTAT

nitroglycerin er 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 1

NITROLINGUAL 0.4 mg/spray tl soln 3

NITROMIST 400 mcg/spray tl aer soln 3

NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 2

NITRO-TIME 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 3

Phosphodiesterase Type 5 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 5]

ADCIRCA 20 mg tab 5 PA

CIALIS 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3 QL(6 / 30)

LEVITRA 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3 QL(6 / 30)

REVATIO 20 mg tab 5 PA

REVATIO 10 mg/12.5ml iv soln, 10 mg/ml susp 5 PA

PROSSAM




Drug Tier

[Nivel]




sildenafil citrate 20 mg tab 1 REVATIO PA

sildenafil citrate 10 mg/12.5ml iv soln 5 REVATIO PA

sildenafil citrate 100 mg tab, 25 mg tab, 50 mg tab 1 VIAGRA QL(6 / 30)

STAXYN 10 mg tab disint 3 QL(6 / 30)

STENDRA 100 mg tab, 200 mg tab, 50 mg tab 3 QL(6 / 30)

tadalafil 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 1 QL(6 / 30)

VIAGRA 100 mg tab, 25 mg tab, 50 mg tab 3 QL(6 / 30)

Vasodilating Agents [Agentes Vasodilatadores]

ADEMPAS 0.5 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 2.5 mg tab 4 PA

ambrisentan 10 mg tab, 5 mg tab 4 PA

epoprostenol sodium 0.5 mg iv soln, 1.5 mg iv soln 5 PA

FLOLAN 0.5 mg iv soln, 1.5 mg iv soln 5 PA

LETAIRIS 10 mg tab, 5 mg tab 5 PA

OPSUMIT 10 mg tab 5 PA

ORENITRAM 0.125 mg tab er, 0.25 mg tab er, 1 mg tab er, 2.5 mg tab er 5 PA

REMODULIN 1 mg/ml inj soln, 10 mg/ml inj soln, 2.5 mg/ml inj soln, 5 mg/ml inj soln 4 PA

TRACLEER 125 mg tab, 62.5 mg tab 5 PA

TYVASO 0.6 mg/ml inh soln 5 PA

TYVASO REFILL 0.6 mg/ml inh soln 5 PA

TYVASO STARTER 0.6 mg/ml inh soln 5 PA

VELETRI 0.5 mg iv soln, 1.5 mg iv soln 5 PA

VENTAVIS 10 mcg/ml inh soln, 20 mcg/ml inh soln 5 PA

Vasodilating Agents, Miscellaneous [Agentes Vasodilatadores, Misceláneos]

dipyridamole 25 mg tab, 50 mg tab, 75 mg tab 1 PERSANTINE

isoxsuprine hcl 10 mg tab 1

VITAMIN A [VITAMINA A]

Vitamin A [Vitamina A]

AQUASOL A 50000 unit/ml im soln 3

PROSSAM




Drug Tier

[Nivel]




VITAMIN B COMPLEX [VITAMINA DEL COMPLEJO B]

Vitamin B Complex [Vitamina Del Complejo B]

AIRAVITE 2.5-25-1 mg tab 3

aminobenzoate potassium 2 gm pckt 1

ANIMI-3 1 mg cap 3

ANIMI-3/VITAMIN D 1 mg cap 3

av-vite fb 2.5-25-1 mg tab 1

b-6 folic acid 400-1000-50 mcg-mcg-mg cap 1

bp vit 3 1 mg cap 1

CENFOL 2.3-24.5-2 mg tab 3

cyanocobalamin 1000 mcg/ml inj soln 1 PA

DIVISTA 1 mg cap 3

FA-8 800 mcg tab 1

FA-8 0.8 mg cap 3 AL

fabb 2.2-25-1 mg tab 1

fa-vitamin b-6-vitamin b-12 2.2-25-0.5 mg tab 1

folbee 2.5-25-1 mg tab 1

FOLGARD RX 2.2-25-1 mg tab 3

folic acid 1 mg tab, 800 mcg tab 1

folic acid 5 mg/ml inj soln 1

folic acid 400 mcg tab 1 AL

folic acid 0.8 mg cap 3 AL

folplex 2.2 2.2-25-0.5 mg tab 1

FOLTRATE 500-1 mcg-mg tab 3

gnp folic acid 400 mcg tab 1 AL

hm folic acid 400 mcg tab 1 AL

hydroxocobalamin acetate 1000 mcg/ml im soln 1

kp folic acid 800 mcg tab 1

NASCOBAL 500 mcg/0.1ml nasal soln 3

neurin-sl 600-600 mcg tab subl 1

niacin pwdr 1

NIACOR 500 mg tab 3

NUFOL 2.5-25-1 mg tab 3

POTABA 500 mg cap 3

px folic acid 400 mcg tab 1 AL

pyridoxine hcl 100 mg/ml inj soln 1

ra folic acid 800 mcg tab 1

ra folic acid 400 mcg tab 1 AL

sm folic acid 400 mcg tab 1 AL

tl gard rx 2.2-25-1 mg tab 1

PROSSAM




Drug Tier

[Nivel]




VIRT-GARD 2.2-25-1 mg tab 3

VITAMEZ 1 mg cap 3

vitamin b complex 100 inj 1

vitamin b-complex 100 inj 1

yl folic acid 400 mcg tab 1 AL

VITAMIN C [VITAMINA C]

Vitamin C [Vitamina C]

ASCOR 25000 mg/50ml iv soln 3

ascorbic acid 500 mg/ml inj soln 1

VITAMIN D [VITAMINA D]

Vitamin D [Vitamina D]

calcitriol 0.25 mcg cap, 0.5 mcg cap 1 ROCALTROL

calcitriol 1 mcg/ml soln 1 ROCALTROL

doxercalciferol 0.5 mcg cap, 1 mcg cap, 2.5 mcg cap 1 HECTOROL

DRISDOL 50000 unit cap 3

ergocalciferol 50000 unit cap 1

paricalcitol 1 mcg cap, 2 mcg cap, 4 mcg cap 1 ZEMPLAR

paricalcitol 2 mcg/ml iv soln, 5 mcg/ml iv soln 1 ZEMPLAR

ROCALTROL 0.25 mcg cap, 0.5 mcg cap 3

ROCALTROL 1 mcg/ml soln 3

vitamin d (ergocalciferol) 50000 unit cap 1

ZEMPLAR 1 mcg cap, 2 mcg cap 3

ZEMPLAR 2 mcg/ml iv soln, 5 mcg/ml iv soln 3

VITAMIN K ACTIVITY [ACTIVIDAD DE LA VITAMINA K]

Vitamin K Activity [Actividad De La Vitamina K]

MEPHYTON 5 mg tab 3

phytonadione 1 mg/0.5ml inj soln 1

vitamin k1 1 mg/0.5ml inj soln, 10 mg/ml inj soln 1


Updated 11/2019

A

Abacavir Sulfate ............................................ 71 Abacavir Sulfate-Lamivudine ........................ 71 Abacavir-Lamivudine-Zidovudine .................. 71 Abilify .......................................................... 117 Abilify Maintena ........................................... 117 Abraxane....................................................... 54 Absorica ...................................................... 127 Abstral ............................................................. 8 Acamprosate Calcium ................................... 84 Acanya .......................................................... 37 Acarbose ....................................................... 29 Accolate ........................................................ 50 Accuretic ..................................................... 121 Acebutolol HCl .............................................. 77 Acetaminophen-Codeine ............................ 8, 9 Acetaminophen-Codeine #2............................ 9 Acetaminophen-Codeine #3............................ 9 Acetaminophen-Codeine #4............................ 9 Acetasol HC .................................................. 48 AcetaZOLAMIDE .......................................... 36 AcetaZOLAMIDE ER .................................... 36 AcetaZOLAMIDE Sodium ............................. 36 Acetic Acid .................................................... 90 Acetylcysteine ............................................... 33 Aciphex ......................................................... 69 Acitretin ....................................................... 127 Actemra......................................................... 88 Actigall .......................................................... 85 Actimmune .................................................... 97 Actiq ................................................................ 9 Activella......................................................... 91 Actonel .......................................................... 78 Actoplus Met ................................................. 32 Actoplus met XR ........................................... 32 Actos ............................................................. 32 Acuvail .......................................................... 50 Acyclovir.................................................. 41, 73 Aczone ........................................................ 127 Adacel ......................................................... 134 Adagen ......................................................... 91 Adalat CC...................................................... 80 Adapalene ................................................... 127 Adapalene-Benzoyl Peroxide ...................... 127 Adcetris ......................................................... 54 Adcirca ........................................................ 136 Adderall ......................................................... 14 Adderall XR ................................................... 14

Adefovir Dipivoxil ........................................... 73 Adempas ..................................................... 137 Adrenal C Formula ...................................... 102 Adrenalin ..................................................... 135 Adriamycin .................................................... 54 Adrucil ........................................................... 54 Advair Diskus .............................................. 131 Advair HFA .................................................. 131 Advanced AM/PM........................................ 102 Afeditab CR ................................................... 80 Afinitor ........................................................... 54 Afinitor Disperz .............................................. 54 AgonEaze ...................................................... 64 Agrylin ........................................................... 67 Airavite ........................................................ 138 AK-Poly-Bac .................................................. 37 Aktipak .......................................................... 37 Ala Scalp ....................................................... 43 Ala-Cort ......................................................... 43 Ala-Quin ........................................................ 39 Albenza ......................................................... 16 Albuterol Sulfate .......................................... 131 Albuterol Sulfate ER .................................... 131 Alclometasone Dipropionate ......................... 43 Alcortin A ....................................................... 42 Aldactazide .................................................. 122 Aldactone .................................................... 122 Aldara .......................................................... 127 Aldurazyme ................................................... 91 Alecensa ....................................................... 54 Alendronate Sodium ...................................... 78 Alevicyn Plus ............................................... 127 Alferon N ....................................................... 55 Alfuzosin HCl ER ......................................... 130 Alimta ............................................................ 55 Alinia ............................................................. 64 Aliskiren ....................................................... 122 Alkeran .......................................................... 55 Allergy Spray 24 Hour ................................... 48 Allopurinol ..................................................... 36 Almotriptan Malate ........................................ 53 Alomide ......................................................... 16 Alora .............................................................. 91 Alosetron HCl ................................................ 43 Alphagan P .................................................... 35 ALPRAZolam ................................................ 75 ALPRAZolam ER .......................................... 75 ALPRAZolam Intensol ................................... 75 ALPRAZolam XR .......................................... 75


Updated 11/2019

Alrex .............................................................. 48 Altabax .......................................................... 37 Altafrin ......................................................... 135 Altavera ......................................................... 85 Aluvea ........................................................... 99 Alyacen 1/35 ................................................. 85 Amabelz ........................................................ 91 Amantadine HCl ............................................ 62 Amaryl ........................................................... 32 Ambien .......................................................... 74 Ambien CR .................................................... 74 ambrisentan ................................................ 137 Amcinonide ................................................... 43 Amerge ......................................................... 53 Amicar ........................................................... 36 Amikacin Sulfate ........................................... 18 AMILoride HCl ............................................... 89 AMILoride-HydroCHLOROthiazide ............... 89 Aminobenzoate Potassium ......................... 138 Aminocaproic Acid ........................................ 36 Amiodarone HCl ............................................ 82 Amitiza .......................................................... 95 Amitriptyline HCl ......................................... 114 Amlodipine Besy-Benazepril HCl .................. 80 AmLODIPine Besylate .................................. 81 Amlodipine Besylate-Valsartan ..................... 81 Amlodipine-Atorvastatin ................................ 81 Amlodipine-Olmesartan ................................ 81 Amlodipine-Valsartan-HCTZ ......................... 81 Ammonium Lactate ....................................... 90 Amnesteem ................................................. 127 Amoxapine .................................................. 114 Amoxicill-Clarithro-Lansopraz ....................... 69 Amoxicillin ..................................................... 21 Amoxicillin-Pot Clavulanate........................... 21 Amoxicillin-Pot Clavulanate ER ..................... 21 Amphetamine-Dextroamphet ER .................. 14 Amphetamine-Dextroamphetamine .............. 14 Amphotericin B .............................................. 35 Ampicillin ....................................................... 21 Ampicillin Sodium .......................................... 22 Amrix ........................................................... 126 Anacaine ....................................................... 64 Anafranil ...................................................... 114 Anagrelide HCl .............................................. 67 Analpram HC ................................................ 64 Analpram HC Singles .................................... 65 Analpram-HC ................................................ 65 Anaprox DS ..................................................... 6 Anaspaz ........................................................ 24

Anastrozole ................................................... 55 Ancobon ........................................................ 35 Angeliq .......................................................... 91 Animi-3 ........................................................ 138 Animi-3/Vitamin D........................................ 138 Anodyne LPT ................................................ 65 Antabuse ......................................................... 4 Anucort-HC ................................................... 43 Anusol-HC ..................................................... 43 Anzemet ........................................................ 33 ApexiCon E ................................................... 43 AP-Hist DM ................................................... 67 Aplenzin ...................................................... 114 Apokyn .......................................................... 63 Apraclonidine HCl.......................................... 90 Aprepitant ...................................................... 33 Apriso ............................................................ 43 Aptivus .......................................................... 71 AP-Zel ......................................................... 102 Aquasol A .................................................... 137 Aralast NP ................................................... 124 Aranesp (Albumin Free) ................................ 96 Arava ............................................................. 88 Arcalyst ....................................................... 110 Arcapta Neohaler ........................................ 131 Aricept ......................................................... 111 Arimidex ........................................................ 55 ARIPiprazole ............................................... 117 Arixtra ............................................................ 66 Armour Thyroid ........................................... 132 Aromasin ....................................................... 55 Arranon ......................................................... 55 Arthrotec .......................................................... 6 Arzerra .......................................................... 55 Asacol HD ..................................................... 43 Ascomp-Codeine ............................................. 9 Ascor ........................................................... 139 Ascorbic Acid .............................................. 139 Aspirin-Dipyridamole ER ............................... 67 Astagraf XL ................................................... 98 Astepro .......................................................... 16 Atabex EC ................................................... 102 Atacand HCT ............................................... 120 Atazanavir Sulfate ......................................... 71 Atelvia ........................................................... 78 Atenolol ......................................................... 77 Atenolol-Chlorthalidone ................................. 77 Ativan ............................................................ 75 Atomoxetine HCl ........................................... 85 Atopiclair ..................................................... 127


Updated 11/2019

Atorvastatin Calcium ..................................... 52 Atovaquone ................................................... 64 Atovaquone-Proguanil HCl............................ 64 Atralin ............................................................ 84 Atripla ............................................................ 71 AtroPen ......................................................... 24 Atropine Sulfate .......................................... 110 Atrovent HFA ................................................ 24 Aubagio ......................................................... 97 Aubra ............................................................ 85 Augmentin ..................................................... 22 Augmentin ES-600 ........................................ 22 Augmentin XR ............................................... 22 Auvi-Q ......................................................... 131 Avalide ........................................................ 120 Avar .............................................................. 99 Avar Cleanser ............................................... 99 Avar LS ......................................................... 99 Avar LS Cleanser .......................................... 99 Avar-e Emollient ............................................ 99 Avar-e Green ................................................ 99 Avar-e LS ...................................................... 99 Avastin .......................................................... 55 AVC Vaginal .................................................. 42 Avelox ........................................................... 22 Aviane ........................................................... 85 Avidoxy ......................................................... 23 Avidoxy DK ................................................... 23 Avita .............................................................. 84 Avodart ........................................................... 2 Avonex .......................................................... 97 Avonex Pen ................................................... 97 Avonex Prefilled ............................................ 97 Av-Phos 250 Neutral ................................... 122 Av-VITE FB ................................................. 138 Axert ............................................................. 53 Aygestin ...................................................... 113 AzaCITIDine .................................................. 55 Azactam ........................................................ 21 Azasan .......................................................... 98 AzaSite ......................................................... 37 AzaTHIOprine ............................................... 98 AzaTHIOprine Sodium .................................. 98 Azelastine HCl .............................................. 16 Azelex ......................................................... 127 Azilect ........................................................... 63 Azithromycin ................................................. 20 Azopt ............................................................. 36 Azor .............................................................. 81 Aztreonam..................................................... 21

Azulfidine ....................................................... 23 Azulfidine EN-tabs ......................................... 23

B

B Complex-C-Folic Acid .............................. 102 B-6 Folic Acid .............................................. 138 BACiiM .......................................................... 18 Bacitracin ................................................ 18, 37 Bacitracin-Polymyxin B .................................. 37 Bacitra-Neomycin-Polymyxin-HC .................. 48 Baclofen ...................................................... 127 Bacmin ........................................................ 102 Bactrim .......................................................... 23 Bactrim DS .................................................... 23 Bactroban ...................................................... 37 Bactroban Nasal ............................................ 37 Bal-Care DHA ............................................. 102 Balsalazide Disodium .................................... 43 Banzel ........................................................... 25 Baqsimi ......................................................... 37 Baraclude ...................................................... 73 B-Complex Balanced ................................... 102 B-Complex/Vitamin C .................................. 102 B-Complex-C ............................................... 102 Beconase AQ ................................................ 48 Benazepril HCl ............................................ 121 Benazepril-Hydrochlorothiazide .................. 121 Bendeka ........................................................ 55 Benicar ........................................................ 120 Benicar HCT ................................................ 120 Benlysta ........................................................ 98 Bensal HP ..................................................... 39 Bentyl ............................................................ 24 Benzac AC Wash .......................................... 42 BenzaClin ...................................................... 37 BenzaClin with Pump .................................... 37 Benzamycin ................................................... 37 BenzEFoam .................................................. 42 BenzEFoamUltra ........................................... 42 BenzePrO ...................................................... 42 BenzePrO Creamy Wash .............................. 42 BenzePrO Foaming Cloths ............................ 42 BenzePrO Short Contact ............................... 42 Benziq ........................................................... 42 Benziq LS ...................................................... 42 Benziq Wash ................................................. 42 Benzonatate .................................................. 67 Benzoyl Perox-Hydrocortisone ...................... 48 Benzoyl Peroxide .......................................... 42 Benzoyl Peroxide-Erythromycin .................... 37


Updated 11/2019

Benztropine Mesylate ................................... 62 Bepreve......................................................... 16 Besivance ..................................................... 37 Betadine Ophthalmic Prep ............................ 42 Betamethasone Dipropionate ........................ 43 Betamethasone Dipropionate Aug ................ 43 Betamethasone Sod Phos & Acet ................... 2 Betamethasone Valerate............................... 44 Betaseron...................................................... 97 Betaxolol HCl .......................................... 35, 77 Bethanechol Chloride .................................. 111 Betimol .......................................................... 35 Betoptic-S ..................................................... 35 Bexarotene.................................................... 55 Bicalutamide ................................................. 55 Bicillin C-R .................................................... 22 Bicillin C-R 900/300 ...................................... 22 Bicillin L-A ..................................................... 22 BiCNU ........................................................... 55 BiDil ............................................................ 135 BiferaRx ........................................................ 16 Biltricide ........................................................ 16 Bimatoprost ................................................... 36 Binosto .......................................................... 78 Biocel .......................................................... 102 Bio-Statin ...................................................... 35 Biotuss .......................................................... 67 Biotuss Pediatric ........................................... 67 Bisoprolol Fumarate ...................................... 77 Bisoprolol-Hydrochlorothiazide ..................... 77 Bivigam ....................................................... 125 Bleomycin Sulfate ......................................... 55 Bleph-10........................................................ 37 Blephamide S.O.P. ....................................... 48 Boniva ........................................................... 78 Boostrix ....................................................... 134 Bosulif ........................................................... 55 BP 10-1 ......................................................... 99 BP Cleansing Wash ...................................... 99 BP Foam ....................................................... 42 BP Foaming Wash ........................................ 42 BP FoliNatal Plus B ..................................... 102 BP MultiNatal Plus ...................................... 102 BP Vit 3 ....................................................... 138 BP Wash ....................................................... 42 B-Plex ......................................................... 102 B-Plex Plus ................................................. 102 BPO .............................................................. 42 BPO Foaming Cloths .................................... 42 BProtected Pedia Iron ................................... 16

BProtected Pedia Poly-Vite/Fe .................... 102 Braftovi .......................................................... 55 Brilinta ........................................................... 67 Brimonidine Tartrate ...................................... 35 Bromfed DM .................................................. 67 Bromfenac Sodium (Once-Daily) ................... 50 Bromocriptine Mesylate ................................. 63 Brompheniramine Tannate ............................ 94 Brovana ....................................................... 131 Bucalsep ....................................................... 42 Budesonide ..................................................... 2 Bumetanide ................................................... 89 Bupap .............................................................. 6 Buprenorphine ............................................... 13 Buprenorphine HCl ........................................ 13 Buprenorphine HCl-Naloxone HCl ................ 13 BuPROPion HCl .......................................... 114 BuPROPion HCl ER (Smoking Det) ............ 114 BuPROPion HCl ER (SR) ............................ 114 BuPROPion HCl ER (XL) ............................ 114 BusPIRone HCl ............................................. 74 Busulfan ........................................................ 55 Busulfex ........................................................ 55 Butalbital-Acetaminophen ............................... 6 Butalbital-APAP ............................................... 6 Butalbital-APAP-Caff-Cod ............................... 9 Butalbital-APAP-Caffeine ................................ 6 Butalbital-ASA-Caff-Codeine ........................... 9 Butalbital-Aspirin-Caffeine ............................... 6 Butisol Sodium .............................................. 75 Butorphanol Tartrate ..................................... 13 Butrans .......................................................... 13 Bydureon ....................................................... 30 Bystolic .......................................................... 77

C

Cabergoline ................................................... 63 Caduet ........................................................... 81 Cafergot ........................................................ 52 Calan ............................................................. 79 Calan SR ....................................................... 79 Calcipotriene ............................................... 127 Calcipotriene-Betameth Diprop ..................... 44 Calcitonin (Salmon) ..................................... 112 Calcitrene .................................................... 127 Calcitriol .............................................. 127, 139 Calcium Acetate (Phos Binder) ................... 123 Cambia ............................................................ 6 Camila ........................................................... 85 Campath ........................................................ 55


Updated 11/2019

Camptosar .................................................... 55 Canasa ......................................................... 44 Cancidas ....................................................... 35 Candesartan Cilexetil .................................. 120 Candesartan Cilexetil-HCTZ ....................... 120 Capastat Sulfate ........................................... 54 Capecitabine ................................................. 55 Capex ........................................................... 44 Caprelsa........................................................ 55 Captopril...................................................... 121 Captopril-Hydrochlorothiazide ..................... 121 Carac .......................................................... 127 Carafate ........................................................ 69 Carbaglu ......................................................... 5 CarBAMazepine ............................................ 25 CarBAMazepine ER ...................................... 26 Carbaphen 12 ............................................... 67 Carbaphen 12 Ped ........................................ 68 Carbatrol ....................................................... 26 Carbidopa ..................................................... 62 Carbidopa-Levodopa .................................... 62 Carbidopa-Levodopa ER .............................. 62 Carbidopa-Levodopa-Entacapone ................ 62 Carbinoxamine Maleate ................................ 94 CARBOplatin ................................................. 55 Cardizem....................................................... 79 Cardizem CD ................................................ 79 Cardizem LA ................................................. 79 Cardura ........................................................... 5 Cardura XL ...................................................... 5 Carisoprodol ................................................ 126 Carisoprodol-Aspirin ................................... 126 Carisoprodol-Aspirin-Codeine ..................... 126 Carnitor ....................................................... 110 Carnitor SF .................................................. 110 Carteolol HCl ................................................. 35 Cartia XT ....................................................... 79 Carvedilol ...................................................... 77 Casodex ........................................................ 55 Caspofungin Acetate ..................................... 35 Catapres ....................................................... 97 Catapres-TTS-1 ............................................ 97 Catapres-TTS-2 ............................................ 97 Catapres-TTS-3 ............................................ 97 Cayston ......................................................... 21 Cefaclor......................................................... 19 Cefaclor ER ................................................... 19 Cefadroxil ...................................................... 19 CeFAZolin Sodium ........................................ 19 Cefdinir ......................................................... 19

Cefditoren Pivoxil .......................................... 19 Cefepime HCl ................................................ 20 Cefixime ........................................................ 20 Cefpodoxime Proxetil .................................... 20 Cefprozil ........................................................ 20 CefTAZidime ................................................. 20 Ceftin ............................................................. 20 CefTRIAXone Sodium ................................... 20 Cefuroxime Axetil .......................................... 20 Cefuroxime Sodium ....................................... 20 CeleBREX ....................................................... 7 Celecoxib ........................................................ 7 Celestone Soluspan ........................................ 2 CeleXA ........................................................ 114 CellCept ........................................................ 98 Celontin ......................................................... 29 CEM-Urea ..................................................... 99 CenFol ......................................................... 138 Centany ......................................................... 37 Centany AT ................................................... 37 Centratex ....................................................... 16 Cephalexin .................................................... 20 Cerovel .......................................................... 99 Cesamet ........................................................ 34 Cetirizine HCl .............................................. 124 Cetraxal ......................................................... 37 Cevimeline HCl ........................................... 111 Chantix .......................................................... 76 Chantix Continuing Month Pak ...................... 76 Chantix Starting Month Pak ........................... 77 Chateal .......................................................... 85 Chemet .......................................................... 95 Chenodal ....................................................... 85 Cheratussin AC ............................................. 68 ChlordiazePOXIDE HCl ................................. 75 Chlordiazepoxide-Amitriptyline .................... 114 Chlordiazepoxide-Clidinium ........................... 24 Chloroquine Phosphate ................................. 64 Chlorothiazide ............................................... 90 ChlorproMAZINE HCl .................................. 117 ChlorproPAMIDE ........................................... 32 Chlorthalidone ............................................... 90 Chlorzoxazone ............................................ 126 Cholestyramine ............................................. 51 Cholestyramine Light ..................................... 51 Choline Fenofibrate ....................................... 51 Choline-Mag Trisalicylate ................................ 7 Chromagen ................................................... 16 Cialis ........................................................... 136 Ciclodan ........................................................ 39


Updated 11/2019

Ciclodan Cream ............................................ 39 Ciclodan Solution .......................................... 39 Ciclopirox ...................................................... 39 Ciclopirox Olamine ........................................ 39 Ciclopirox Treatment ..................................... 39 Cilostazol ...................................................... 67 Ciloxan .......................................................... 37 Cimetidine ..................................................... 69 Cimetidine HCl .............................................. 69 Cimzia ........................................................... 88 Cimzia Prefilled ............................................. 88 Cimzia Starter Kit .......................................... 88 Cipro ............................................................. 22 Cipro HC ....................................................... 48 Ciprodex........................................................ 48 Ciprofloxacin ................................................. 23 Ciprofloxacin HCl .................................... 23, 37 Ciprofloxacin-Ciproflox HCl ER ..................... 23 CISplatin ....................................................... 55 Citalopram Hydrobromide ........................... 114 CitraNatal 90 DHA ...................................... 102 CitraNatal Assure ........................................ 102 CitraNatal B-Calm ....................................... 102 CitraNatal DHA ........................................... 102 CitraNatal Harmony .................................... 102 CitraNatal Rx ............................................... 102 Cladribine ...................................................... 55 Claravis ....................................................... 127 Clarinex ....................................................... 124 Clarinex-D 12 Hour ..................................... 124 Clarithromycin ............................................... 20 Clarithromycin ER ......................................... 20 Clemastine Fumarate .................................... 94 Cleocin .................................................... 19, 37 Cleocin Phosphate ........................................ 19 Cleocin-T................................................. 37, 38 Climara ......................................................... 91 Climara Pro ................................................... 91 Clindacin ETZ ............................................... 38 Clindacin Pac ................................................ 38 Clindacin-P .................................................... 38 Clindagel ....................................................... 38 Clindamycin HCl ........................................... 19 Clindamycin Palmitate HCl............................ 19 Clindamycin Phos-Benzoyl Perox ................. 38 Clindamycin Phosphate .......................... 19, 38 Clindamycin-Tretinoin ................................. 127 Clinoin ......................................................... 127 Clobetasol Prop Emollient Base .................... 44 Clobetasol Propionate ................................... 44

Clobetasol Propionate E ................................ 44 Clobetasol Propionate Emulsion ................... 44 Clobex ........................................................... 44 Clobex Spray ................................................. 44 Clocortolone Pivalate .................................... 44 Clocortolone Pivalate Pump .......................... 44 Clodan ........................................................... 44 Cloderm ......................................................... 44 Cloderm Pump .............................................. 44 Clofarabine .................................................... 55 Clolar ............................................................. 55 ClomiPRAMINE HCl .................................... 114 ClonazePAM ................................................. 28 CloNIDine ...................................................... 97 CloNIDine HCl ............................................... 97 CloNIDine HCl ER ......................................... 97 Clopidogrel Bisulfate ..................................... 67 Clorazepate Dipotassium .............................. 75 Clotrimazole ............................................ 39, 40 Clotrimazole AF ............................................. 40 Clotrimazole Anti-Fungal ............................... 40 Clotrimazole-Betamethasone ........................ 40 CloZAPine ................................................... 117 Clozaril ........................................................ 117 C-Nate DHA ................................................ 102 Coartem ........................................................ 64 Cod Liver Oil ............................................... 102 Codeine Sulfate ............................................... 9 Cogentin ........................................................ 62 Colazal .......................................................... 44 Colchicine ...................................................... 36 Colchicine-Probenecid ................................ 134 Colcrys .......................................................... 36 Colestid ......................................................... 51 Colestid Flavored .......................................... 51 Colestipol HCl ............................................... 51 Colistimethate Sodium (CBA) ........................ 19 Colocort ......................................................... 44 Coly-Mycin M ................................................ 19 Coly-Mycin S ................................................. 48 Colyte with Flavor Packs ............................... 83 Combigan ...................................................... 35 CombiPatch ................................................... 91 Combivir ........................................................ 71 Cometriq (100 mg Daily Dose) ...................... 55 Cometriq (140 mg Daily Dose) ...................... 56 Cometriq (60 mg Daily Dose) ........................ 56 Complera ....................................................... 71 Complete Natal DHA ................................... 102 CompleteNate ............................................. 102


Updated 11/2019

Compro ....................................................... 117 Comtan ......................................................... 62 Co-Natal FA ................................................ 102 Concept DHA .............................................. 102 Concept OB ................................................ 102 Concerta ....................................................... 15 Condylox ..................................................... 127 Constulose ...................................................... 5 ConZip ............................................................ 9 Copaxone...................................................... 97 Cordran ......................................................... 44 Coreg ............................................................ 77 Cortane-B................................................ 44, 48 Cortane-B Aqueous ...................................... 48 Cortef .............................................................. 2 Cortenema .................................................... 44 Cortic-ND ...................................................... 48 Cortifoam ...................................................... 44 Cortisone Acetate ........................................... 2 Cortisporin..................................................... 44 Corvita ........................................................ 102 Corvita 150 .................................................... 17 Corvite ........................................................ 102 Corvite 150 .................................................... 17 Corvite Fe ..................................................... 17 Corvite Free ................................................ 102 Cosentyx ..................................................... 127 Cosentyx 300 Dose ..................................... 127 Cosentyx Sensoready 300 Dose ................. 128 Cosentyx Sensoready Pen.......................... 128 Cosmegen..................................................... 56 Coumadin...................................................... 66 Covaryx ......................................................... 91 Covaryx HS ................................................... 91 Creon ............................................................ 88 Cresemba ..................................................... 34 Crestor .......................................................... 52 Crixivan ......................................................... 71 Cromolyn Sodium ................................... 16, 50 Cryselle-28 .................................................... 85 Cutivate ......................................................... 44 Cuvposa ........................................................ 24 CVS Miconazole 3 Combo Pack ................... 40 Cyanocobalamin ......................................... 138 Cyclafem 1/35 ............................................... 85 Cyclobenzaprine HCl .................................. 126 Cyclogyl ...................................................... 110 Cyclomydril ................................................. 110 Cyclopentolate HCl ..................................... 110 Cyclophosphamide ....................................... 56

CycloSERINE ................................................ 54 Cycloset ........................................................ 29 CycloSPORINE ............................................. 98 CycloSPORINE Modified ............................... 98 Cyklokapron .................................................. 36 Cymbalta ..................................................... 114 Cyotic ............................................................ 48 Cyproheptadine HCl ...................................... 94 Cystadane ................................................... 110 Cystagon ..................................................... 110 Cytarabine ..................................................... 56 Cytarabine (PF) ............................................. 56 Cytomel ....................................................... 132 Cytotec .......................................................... 69 Cytra K Crystals .............................................. 5

D

D.H.E. 45 ..................................................... 130 Dacarbazine .................................................. 56 Dacogen ........................................................ 56 DACTINomycin ............................................. 56 Daliresp ....................................................... 112 Dantrium ...................................................... 126 Dantrolene Sodium...................................... 127 Dapsone ................................................ 54, 128 Daptacel ...................................................... 134 Daraprim ....................................................... 64 Darifenacin Hydrobromide ER ....................... 94 Darzalex ........................................................ 56 Dasetta 1/35 .................................................. 86 DAUNOrubicin HCl ........................................ 56 Daypro ............................................................. 7 Daytrana ........................................................ 15 DDAVP ........................................................ 112 DDAVP Rhinal Tube.................................... 112 Debacterol ..................................................... 90 Deblitane ....................................................... 86 Decitabine ..................................................... 56 Decon-A ........................................................ 94 Deferoxamine Mesylate ................................. 95 Delestrogen ................................................... 91 Delyla ............................................................ 86 Delzicol .......................................................... 44 Demadex ....................................................... 89 Demeclocycline HCl ...................................... 23 Demerol ........................................................... 9 Demser ........................................................ 110 Denavir .......................................................... 41 Depakene ...................................................... 26 Depakote ....................................................... 26


Updated 11/2019

Depakote ER ................................................. 26 Depakote Sprinkles ....................................... 26 Depo-Estradiol .............................................. 91 DEPO-Medrol .................................................. 2 Depo-Provera .............................................. 113 Depo-SubQ Provera 104............................. 113 DermacinRx Empricaine ............................... 65 DermacinRx Prizopak ................................... 65 Derma-Smoothe/FS Body ............................. 45 Derma-Smoothe/FS Scalp ............................ 45 Dermasorb TA ............................................... 45 Dermazene ................................................... 42 DermOtic ....................................................... 48 Desferal......................................................... 95 Desipramine HCl ......................................... 114 Desloratadine .............................................. 125 Desmopressin Ace Spray Refrig ................. 112 Desmopressin Acetate ................................ 112 Desmopressin Acetate Spray ...................... 112 Desonate....................................................... 45 Desonide ....................................................... 45 DesOwen ...................................................... 45 Desoximetasone ........................................... 45 Desoxyn ........................................................ 14 Desvenlafaxine ER ..................................... 114 Desvenlafaxine Succinate ER ..................... 114 Detrol ............................................................ 94 Detrol LA ....................................................... 94 Dexamethasone .............................................. 2 Dexamethasone Intensol ................................ 2 Dexamethasone Sod Phosphate PF ............... 2 Dexamethasone Sodium Phosphate ......... 2, 48 Dexedrine...................................................... 14 Dexeryl ........................................................ 128 Dexilant ......................................................... 69 Dexmethylphenidate HCl .............................. 15 Dexmethylphenidate HCl ER ........................ 15 DexPak 10 Day ............................................... 3 DexPak 13 Day ............................................... 3 DexPak 6 Day ................................................. 3 Dexrazoxane ............................................... 113 Dextroamphetamine Sulfate.......................... 14 Dextroamphetamine Sulfate ER .................... 14 Dialyvite ...................................................... 103 Dialyvite 3000 ............................................. 103 Dialyvite 5000 ............................................. 103 Dialyvite Supreme D ................................... 103 Dialyvite/Zinc ............................................... 103 Diastat AcuDial ............................................. 75 Diastat Pediatric ............................................ 75

DiazePAM ............................................... 75, 76 DiazePAM Intensol ........................................ 76 Dibenzyline .................................................. 130 Diclofenac Potassium ...................................... 7 Diclofenac Sodium ............................ 7, 50, 128 Diclofenac Sodium ER .................................... 7 Diclofenac-Misoprostol .................................... 7 Dicloxacillin Sodium ...................................... 22 Dicyclomine HCl ............................................ 24 Didanosine .................................................... 71 Differin ......................................................... 128 Dificid ............................................................ 20 Difil-G Forte ................................................. 124 Diflorasone Diacetate .................................... 45 Diflucan ......................................................... 34 Diflunisal .......................................................... 7 Digitek ........................................................... 83 Digox ............................................................. 83 Digoxin .......................................................... 83 Dihydroergotamine Mesylate ....................... 130 Dilantin .......................................................... 28 Dilantin Infatabs ............................................ 28 Dilatrate-SR ................................................. 135 Dilaudid ........................................................... 9 DilTIAZem CD ............................................... 79 DilTIAZem HCl .............................................. 79 DilTIAZem HCl ER ........................................ 79 DilTIAZem HCl ER Beads ............................. 79 DilTIAZem HCl ER Coated Beads ........... 79, 80 Dilt-XR ........................................................... 80 DimenhyDRINATE ........................................ 34 Diovan HCT ................................................. 120 Dipentum ....................................................... 45 DiphenhydrAMINE HCl .................................. 94 Diphenoxylate-Atropine ................................. 33 Diphtheria-Tetanus Toxoids DT .................. 134 Diprolene ....................................................... 45 Diprolene AF ................................................. 45 Dipyridamole ............................................... 137 Disopyramide Phosphate .............................. 82 Disulfiram ........................................................ 4 Ditropan XL ................................................... 94 Diuril .............................................................. 90 Divalproex Sodium ........................................ 26 Divalproex Sodium ER .................................. 26 Divigel ........................................................... 92 Divista ......................................................... 138 DOCEtaxel .................................................... 56 Dofetilide ....................................................... 82 Donepezil HCl ............................................. 111


Updated 11/2019

Doral ............................................................. 76 Dorzolamide HCl ........................................... 36 Dorzolamide HCl-Timolol Mal ....................... 36 Dothelle DHA .............................................. 103 Dovonex ...................................................... 128 Doxazosin Mesylate ........................................ 5 Doxepin HCl ........................................ 114, 115 Doxercalciferol ............................................ 139 Doxil .............................................................. 56 DOXOrubicin HCl .......................................... 56 DOXOrubicin HCl Liposomal ......................... 56 Doxycycline ................................................. 128 Doxycycline Hyclate ...................................... 23 Doxycycline Monohydrate ....................... 23, 24 Drisdol ......................................................... 139 Dritho-Creme HP ........................................ 128 Dronabinol..................................................... 34 Droperidol ..................................................... 74 Droxia ........................................................... 56 Duac ............................................................. 38 Duet DHA 400 ............................................. 103 Duet DHA Balanced .................................... 103 Duetact ......................................................... 32 Duexis ............................................................. 7 Dulera ............................................................. 3 DULoxetine HCl .......................................... 115 Duragesic-100 ................................................. 9 Duragesic-12 ................................................... 9 Duragesic-25 ................................................... 9 Duragesic-50 ................................................... 9 Duragesic-75 ................................................... 9 Duramorph ...................................................... 9 Duraxin ........................................................... 6 Durezol ......................................................... 48 Dutasteride ...................................................... 2 Dutasteride-Tamsulosin HCl ........................... 2 Dutoprol ........................................................ 77 Dyazide ......................................................... 90 Dymista ......................................................... 16 Dyrenium....................................................... 90

E

E.E.S. 400 ..................................................... 20 E.E.S. Granules ............................................ 21 EC-Naprosyn .................................................. 7 Econazole Nitrate .......................................... 40 Edarbyclor ................................................... 120 Edecrin .......................................................... 89 Edluar ........................................................... 74 Ed-Spaz ........................................................ 24

Edurant .......................................................... 71 EEMT ............................................................ 92 EEMT HS ...................................................... 92 Efavirenz ....................................................... 71 Effer-K ......................................................... 123 Effervescent Pot Chloride ............................ 123 Effexor XR ................................................... 115 Effient ............................................................ 67 Efudex ......................................................... 128 Egrifta .......................................................... 130 Eldepryl ......................................................... 63 Elelyso ........................................................... 91 Elestat ........................................................... 16 Elestrin .......................................................... 92 Eletone ........................................................ 128 Eletone Twinpack ........................................ 128 Eletriptan Hydrobromide ................................ 53 Elidel ........................................................... 128 Eligard ........................................................... 56 Elimite ........................................................... 43 Elinest ........................................................... 86 Eliquis ............................................................ 66 Eliquis Starter Pack ....................................... 66 Elitek ............................................................. 91 Elite-OB ....................................................... 103 Elixophyllin .................................................. 124 Ellence .......................................................... 56 Elmiron ........................................................ 110 Elocon ........................................................... 45 Emadine ........................................................ 16 Emcyt ............................................................ 56 Emend ........................................................... 34 Emend Tri-Pack ............................................ 34 Empliciti ......................................................... 56 Emsam .......................................................... 64 Emtriva .......................................................... 71 Enablex ......................................................... 95 Enalapril Maleate ........................................ 121 Enalapril-Hydrochlorothiazide ..................... 121 EnBrace HR ................................................ 103 Enbrel ............................................................ 88 Enbrel SureClick ........................................... 89 Endocet ......................................................... 10 EnovaRX-Cyclobenzaprine HCl .................. 126 Enoxaparin Sodium ....................................... 66 Enpresse-28 .................................................. 86 Entacapone ................................................... 62 Entecavir ....................................................... 73 Entereg .......................................................... 95 Entocort EC ..................................................... 3


Updated 11/2019

Enulose ........................................................... 5 Epiduo ......................................................... 128 Epiduo Forte ............................................... 128 Epifoam ......................................................... 45 Epinastine HCl .............................................. 16 EPINEPHrine .............................................. 131 EpiPen 2-Pak .............................................. 131 EpiPen Jr 2-Pak .......................................... 131 EpiRUBicin HCl ............................................. 56 Epitol ............................................................. 26 Epivir ............................................................. 71 Epivir HBV ..................................................... 71 Eplerenone.................................................. 122 Epogen ......................................................... 96 Epoprostenol Sodium .................................. 137 Eprosartan Mesylate ................................... 120 Epzicom ........................................................ 71 EQ Miconazole 3 Combo Pack ..................... 40 EQ Nasal Allergy ........................................... 48 EQL Miconazole 3 ......................................... 40 EQL Super B Complex/Vitamin C ............... 103 Equetro ......................................................... 26 Erbitux ........................................................... 56 Ergocalciferol .............................................. 139 Ergoloid Mesylates ...................................... 130 Ergomar ...................................................... 130 Ergotamine-Caffeine ..................................... 52 Erivedge ........................................................ 56 Erlotinib ......................................................... 56 Errin .............................................................. 86 Ertaczo .......................................................... 40 Erwinaze ....................................................... 57 Ery ................................................................ 38 Erygel ............................................................ 38 EryPed 200 ................................................... 21 EryPed 400 ................................................... 21 Ery-Tab ......................................................... 21 Erythrocin Stearate ....................................... 21 Erythromycin ................................................. 38 Erythromycin Base ........................................ 21 Erythromycin Ethylsuccinate ......................... 21 Escavite ...................................................... 103 Escavite D ................................................... 103 Escavite LQ ................................................. 103 Escitalopram Oxalate .................................. 115 Esgic ............................................................... 6 Esomeprazole Magnesium............................ 70 Est Estrogens-Methyltest .............................. 92 Est Estrogens-Methyltest DS ........................ 92 Est Estrogens-Methyltest HS ........................ 92

Estazolam ..................................................... 76 Estrace .......................................................... 92 Estradiol ........................................................ 92 Estradiol Valerate .......................................... 92 Estradiol-Norethindrone Acet ........................ 92 Estring ........................................................... 92 Estrogel ......................................................... 92 Estropipate .................................................... 92 Estrostep Fe .................................................. 86 Eszopiclone ................................................... 74 Ethacrynic Acid ............................................. 89 Ethambutol HCl ............................................. 54 Ethosuximide ................................................. 29 Ethyl Chloride ................................................ 65 Ethynodiol Diac-Eth Estradiol ........................ 86 Ethyol .......................................................... 113 Etidronate Disodium ...................................... 78 Etodolac .......................................................... 7 Etodolac ER .................................................... 7 Etopophos ..................................................... 57 Etoposide ...................................................... 57 Euflexxa ...................................................... 110 Eurax ............................................................. 43 Evamist ......................................................... 92 Evista ............................................................ 91 Evoclin ........................................................... 38 Evotaz ........................................................... 71 Evoxac ........................................................ 111 Exactuss ........................................................ 68 Exalgo ........................................................... 10 Exelderm ....................................................... 40 Exelon ......................................................... 111 Exemestane .................................................. 57 Exforge .......................................................... 81 Exforge HCT ................................................. 81 Exjade ........................................................... 95 Exoderm ........................................................ 40 Exotic-HC ...................................................... 48 Extavia .......................................................... 97 Extina ............................................................ 40 Ezetimibe ...................................................... 51

F

FA-8 ............................................................ 138 FaBB ........................................................... 138 Fabior .......................................................... 128 Falmina ......................................................... 86 Famciclovir .................................................... 73 Famotidine .................................................... 69 Fanapt ......................................................... 118


Updated 11/2019

Fanapt Titration Pack .................................. 118 Fareston ........................................................ 57 Farxiga .......................................................... 31 Faslodex ....................................................... 57 FA-Vitamin B-6-Vitamin B-12 ...................... 138 FazaClo....................................................... 118 Felbamate ..................................................... 26 Felbatol ......................................................... 26 Feldene ........................................................... 7 Felodipine ER ............................................... 81 Fem pH ......................................................... 42 Femara ......................................................... 57 Femhrt Low Dose .......................................... 92 Femring ......................................................... 92 Fenofibrate .................................................... 51 Fenofibrate Micronized ........................... 51, 52 Fenofibric Acid .............................................. 52 Fenoglide ...................................................... 52 Fenoprofen Calcium ........................................ 7 FentaNYL ...................................................... 10 FentaNYL Citrate .......................................... 10 Fentora ......................................................... 10 Fer-In-Sol ...................................................... 17 Ferocon ......................................................... 17 Ferotrinsic ..................................................... 17 Ferralet 90..................................................... 17 FerraPlus 90 ................................................. 17 Ferrex 150 Forte Plus ................................... 17 Ferriprox........................................................ 95 Ferrocite Plus ................................................ 17 FERRO-plex Hematinic ................................. 17 Ferrotrin ........................................................ 17 Ferrous Sulfate ............................................. 17 Fexmid ........................................................ 126 Fibricor .......................................................... 52 Finacea ....................................................... 128 Finasteride ...................................................... 2 Fioricet ............................................................ 6 Fiorinal ............................................................ 7 Fiorinal/Codeine #3 ....................................... 10 Firazyr ........................................................... 85 Firmagon ....................................................... 57 First-Hydrocortisone ...................................... 45 First-Lansoprazole ........................................ 70 First-Mouthwash BLM ................................... 65 First-Omeprazole .......................................... 70 Flagyl ............................................................ 64 FlavoxATE HCl ............................................. 95 Flebogamma DIF ........................................ 125 Flecainide Acetate ........................................ 82

Flector ......................................................... 128 Flolan .......................................................... 137 Flomax ........................................................ 130 Floriva ......................................................... 103 Floriva Plus ................................................. 103 Flovent Diskus ................................................. 3 Flovent HFA .................................................... 3 Floxuridine ..................................................... 57 Fluconazole ................................................... 34 Flucytosine .................................................... 35 Fludarabine Phosphate ................................. 57 Fludrocortisone Acetate .................................. 3 Flumadine ..................................................... 70 Flunisolide ..................................................... 48 Fluocinolone Acetonide ........................... 45, 48 Fluocinolone Acetonide Body ........................ 45 Fluocinolone Acetonide Scalp ....................... 45 Fluocinonide .................................................. 45 Fluocinonide Emulsified Base ....................... 45 Fluoritab ........................................................ 83 Fluorometholone ........................................... 48 Fluoroplex ................................................... 128 Fluorouracil ........................................... 57, 128 FLUoxetine HCl ........................................... 115 FLUoxetine HCl (PMDD) ............................. 115 FluPHENAZine Decanoate .......................... 118 FluPHENAZine HCl ..................................... 118 Flurandrenolide ............................................. 45 Flurazepam HCl ............................................ 76 Flurbiprofen ..................................................... 7 Flurbiprofen Sodium ...................................... 50 Flutamide ...................................................... 57 Fluticasone Propionate ............................ 45, 48 Fluvastatin Sodium ........................................ 52 FluvoxaMINE Maleate ................................. 115 FluvoxaMINE Maleate ER ........................... 115 FML Liquifilm ................................................. 48 Focalin ........................................................... 15 Focalin XR ..................................................... 15 Folbee ......................................................... 138 Folbee Plus ................................................. 103 Folbee Plus CZ ........................................... 103 Folet DHA .................................................... 103 Folet One .................................................... 103 Folgard OS .................................................. 103 Folgard RX .................................................. 138 Folic Acid ..................................................... 138 Folivane-F ..................................................... 17 Folivane-OB ................................................ 103 Folivane-Plus ................................................ 17


Updated 11/2019

Folotyn .......................................................... 57 Folplex 2.2 .................................................. 138 Foltrate ........................................................ 138 Foltrin ............................................................ 17 Fondaparinux Sodium ................................... 66 Forfivo XL.................................................... 115 Fortamet........................................................ 29 Fortavit ........................................................ 103 Forteo ......................................................... 112 Fosamprenavir Calcium ................................ 71 Fosinopril Sodium ....................................... 121 Fosinopril Sodium-HCTZ............................. 121 Fosphenytoin Sodium ................................... 29 Fosrenol ........................................................ 99 Fragmin ......................................................... 66 Frova ............................................................. 53 Frovatriptan Succinate .................................. 53 fulvestrant ..................................................... 57 Furadantin ................................................... 134 Furosemide ................................................... 89 Fusilev .......................................................... 33 Fuzeon .......................................................... 71 Fyavolv ......................................................... 92

G

G Tussin AC .................................................. 68 Gabapentin ................................................... 26 Gabitril .......................................................... 26 Galantamine Hydrobromide ........................ 111 Galantamine Hydrobromide ER .................. 111 Galzin .......................................................... 123 Gammagard ................................................ 125 Gammagard S/D Less IgA .......................... 125 Gammaked ................................................. 125 Gammaplex ................................................. 125 Gamunex-C ................................................. 125 Gastrocrom ................................................... 50 Gatifloxacin ................................................... 38 GaviLyte-C .................................................... 83 GaviLyte-G .................................................... 83 GaviLyte-H .................................................... 83 GaviLyte-N with Flavor Pack ......................... 83 Gebauers Pain Ease ..................................... 65 Gebauers Spray and Stretch ......................... 65 Gelnique........................................................ 95 Gelnique Pump ............................................. 95 Gemcitabine HCl ........................................... 57 Gemfibrozil .................................................... 52 Gemzar ......................................................... 57 Generlac ......................................................... 5

Gengraf ......................................................... 98 Gentak ........................................................... 38 Gentamicin Sulfate .................................. 18, 38 GenVisc 850 ................................................ 110 Geodon ....................................................... 118 Gilenya .......................................................... 97 Gilotrif ............................................................ 57 Gilphex TR .................................................... 93 Giltuss ........................................................... 68 Giltuss Pediatric ............................................ 68 Giltuss TR ..................................................... 68 Gleevec ......................................................... 57 Gleostine ....................................................... 57 Gliadel Wafer ................................................ 57 Glimepiride .................................................... 32 GlipiZIDE ....................................................... 32 GlipiZIDE ER ................................................. 32 GlipiZIDE XL ................................................. 32 GlipiZIDE-MetFORMIN HCl ........................... 32 GlucaGen HypoKit......................................... 37 Glucagon Emergency .................................... 37 Glucophage ................................................... 29 Glucophage XR ............................................. 29 Glucotrol ........................................................ 32 Glucotrol XL .................................................. 32 Glucovance ................................................... 32 Glumetza ....................................................... 30 GlyBURIDE ................................................... 32 GlyBURIDE Micronized ................................. 32 GlyBURIDE-MetFORMIN .............................. 32 Glycopyrrolate ............................................... 24 Glydo ............................................................. 65 Glynase ......................................................... 32 Glyset ............................................................ 29 GNP 24 Hour Nasal Allergy ........................... 48 GNP Folic Acid ............................................ 138 GNP Miconazole 3 ........................................ 40 Golytely ......................................................... 83 GoodSense Nasal Allergy Spray ................... 49 Gordofilm ..................................................... 100 Gordons Urea .............................................. 100 Gralise ............................................................. 6 Gralise Starter ................................................. 6 Granisetron HCl ............................................ 33 Granix ............................................................ 96 Griseofulvin Microsize ................................... 34 Griseofulvin Ultramicrosize ............................ 34 Gris-PEG ....................................................... 34 Guaiatussin AC ............................................. 68 GuaiFENesin AC ........................................... 68


Updated 11/2019

Guaifenesin-Codeine .................................... 68 GuanFACINE HCl ......................................... 97 GuanFACINE HCl ER ................................... 85 Guanidine HCl ............................................. 111

H

Halac ............................................................. 45 Halaven ......................................................... 57 Halcion .......................................................... 76 Haldol .......................................................... 118 Haldol Decanoate ....................................... 118 Halobetasol Propionate ................................. 45 Halog ............................................................ 45 Haloperidol .................................................. 118 Haloperidol Decanoate ............................... 118 Haloperidol Lactate ..................................... 118 Halotin ........................................................... 40 Harvoni ......................................................... 73 Heather ......................................................... 86 Hematinic Plus Vit/Minerals .......................... 17 Hematinic/Folic Acid ..................................... 17 Hematogen ................................................... 17 Hematogen FA .............................................. 17 Hematogen Forte .......................................... 17 Hematron-AF ................................................ 17 HemeNatal OB ............................................ 103 HemeNatal OB + DHA ................................ 103 HemeTab ...................................................... 17 Hemmorex-HC .............................................. 45 Hemocyte Plus .............................................. 17 Hemocyte-F .................................................. 17 Hemocyte-Plus .............................................. 17 Heparin Sodium (Porcine) ............................. 66 Hepsera ........................................................ 73 Herceptin....................................................... 57 Hexalen ......................................................... 57 Hiprex ......................................................... 134 HM Folic Acid .............................................. 138 HM Super Vitamin B Complex/C ................. 103 HM Vitamin B Complex/Vitamin C .............. 103 Homatropaire .............................................. 110 Homatropine HBr ........................................ 110 Horizant......................................................... 26 HP Acthar.................................................... 112 HPR ............................................................ 128 HPR Plus .................................................... 128 HPR PLUS HydroGel .................................. 128 HumaLOG ..................................................... 30 HumaLOG Junior KwikPen ........................... 30 HumaLOG KwikPen ...................................... 30

HumaLOG Mix 50/50 ..................................... 30 HumaLOG Mix 50/50 KwikPen ...................... 30 HumaLOG Mix 75/25 ..................................... 30 HumaLOG Mix 75/25 KwikPen ...................... 31 Humira ........................................................... 89 Humira Pediatric Crohns Start ....................... 89 Humira Pen ................................................... 89 Humira Pen-CD/UC/HS Starter ..................... 89 Humira Pen-Ps/UV Starter ............................ 89 HumuLIN 70/30 ............................................. 31 HumuLIN 70/30 KwikPen .............................. 31 HumuLIN N ................................................... 31 HumuLIN N KwikPen ..................................... 31 HumuLIN R ................................................... 31 HumuLIN R U-500 (CONCENTRATED) ........ 31 HumuLIN R U-500 KwikPen .......................... 31 Hyalgan ....................................................... 111 Hycamtin ....................................................... 57 HydrALAZINE HCl ......................................... 97 Hydrea ........................................................... 57 Hydro 35 ...................................................... 100 Hydro 40 ...................................................... 100 HydroCHLOROthiazide ................................. 90 Hydrocod Polst-CPM Polst ER ...................... 68 Hydrocodone-Acetaminophen ....................... 10 Hydrocodone-Homatropine ........................... 68 Hydrocodone-Ibuprofen ................................. 10 Hydrocortisone .......................................... 3, 46 Hydrocortisone Ace-Pramoxine ............... 46, 65 Hydrocortisone Acetate ................................. 46 Hydrocortisone Butyr Lipo Base .................... 46 Hydrocortisone Butyrate ................................ 46 Hydrocortisone Valerate ................................ 46 Hydrocortisone-Acetic Acid ........................... 49 Hydrocortisone-Iodoquinol ............................ 42 Hydromet ....................................................... 68 HYDROmorphone HCl .................................. 10 HYDROmorphone HCl ER ............................ 10 HYDROmorphone HCl PF ............................. 11 Hydroxocobalamin Acetate ......................... 138 Hydroxychloroquine Sulfate .......................... 64 HYDROXYprogesterone Caproate .............. 113 Hydroxyurea .................................................. 58 HydrOXYzine HCl.......................................... 74 HydrOXYzine Pamoate ................................. 74 Hylatopic Plus ............................................. 128 Hylira ............................................................. 90 Hyophen ...................................................... 134 Hyoscyamine Sulfate ............................... 24, 25 Hyoscyamine Sulfate ER ............................... 25


Updated 11/2019

Hyoscyamine Sulfate SL ............................... 25 Hyosyne ........................................................ 25 HyperRHO S/D ........................................... 125 HyperSal ..................................................... 101 Hyzaar ........................................................ 120

I

Ibandronate Sodium ...................................... 78 IBU .................................................................. 7 Ibudone ......................................................... 11 Ibuprofen ......................................................... 7 Ibuprofen Comfort Pac .................................... 7 IC 400 ............................................................. 7 IC 800 ............................................................. 7 Icar-C Plus .................................................... 17 Iclusig ............................................................ 58 Idamycin PFS ................................................ 58 IDArubicin HCl .............................................. 58 IDHIFA .......................................................... 58 iFerex 150 Forte ............................................ 17 Ifex ................................................................ 58 Ifosfamide ..................................................... 58 Ilaris ................................................................ 6 Ilevro ............................................................. 50 Imbruvica ...................................................... 58 Imipramine HCl ........................................... 115 Imipramine Pamoate ................................... 115 Imiquimod ................................................... 128 Imitrex ........................................................... 53 Imitrex STATdose Refill ................................ 53 Imitrex STATdose System ............................ 53 Imuran ........................................................... 98 Inatal GT ..................................................... 103 Increlex ....................................................... 130 Indapamide ................................................... 90 Indocin ............................................................ 7 Indomethacin .................................................. 7 Indomethacin ER ............................................ 7 Infanate Balance ......................................... 103 Infanrix ........................................................ 134 Infuvite Adult ............................................... 103 Infuvite Pediatric ......................................... 103 Inlyta ............................................................. 58 Inova ............................................................. 42 Inova 4/1 Acne Control Therapy ................... 42 Inova 8/2 Acne Control Therapy ................... 42 Inspra .......................................................... 122 Integra F........................................................ 17 Integra Plus ................................................... 17 Intelence ....................................................... 71

Intermezzo .................................................... 74 Intron A .......................................................... 58 Introvale ........................................................ 86 Intuniv ............................................................ 85 Invega ......................................................... 118 Invega Sustenna ......................................... 118 Invirase .......................................................... 71 Invokamet ...................................................... 31 Invokamet XR ................................................ 31 Invokana ........................................................ 31 Iodoquinol-HC-Aloe Polysacch ...................... 42 Iopidine .......................................................... 90 Ipratropium Bromide ...................................... 25 Ipratropium-Albuterol ................................... 131 Irbesartan .................................................... 120 Irbesartan-Hydrochlorothiazide ................... 120 Iressa ............................................................ 58 Irinotecan HCl ............................................... 58 Iron Supplement Childrens ............................ 17 Irospan 24/6 .................................................. 17 IS 24/6 ........................................................... 17 Isentress ........................................................ 71 Isentress HD ................................................. 71 Isometheptene-Dichloral-APAP ..................... 52 Isoniazid ........................................................ 54 Isopto Atropine ............................................ 110 Isopto Carpine ............................................... 36 Isordil Titradose ........................................... 136 Isosorbide Dinitrate ..................................... 136 Isosorbide Dinitrate ER ............................... 136 Isosorbide Mononitrate ................................ 136 Isosorbide Mononitrate ER .......................... 136 Isoxsuprine HCl ........................................... 137 Isradipine ....................................................... 81 Istalol ............................................................. 35 Istodax (Overfill) ............................................ 58 Itraconazole ................................................... 34 Ivermectin ...................................................... 16 Ixempra Kit .................................................... 58

J

Jakafi ............................................................. 58 Jalyn ................................................................ 2 Jantoven ........................................................ 67 Janumet ........................................................ 30 Janumet XR .................................................. 30 Januvia .......................................................... 30 Jencycla ........................................................ 86 Jentadueto .................................................... 30 Jevantique Lo ................................................ 92


Updated 11/2019

Jevtana ......................................................... 58 Jinteli ............................................................. 92 Jolessa .......................................................... 86 Jolivette ......................................................... 86

K

Kadcyla ......................................................... 58 Kadian ........................................................... 11 Kaletra .......................................................... 71 Kalydeco ....................................................... 88 Kanjinti .......................................................... 58 Kapvay .......................................................... 97 K-Effervescent ............................................ 123 Keflex ............................................................ 20 Kelnor 1/35.................................................... 86 Kenalog ..................................................... 3, 46 Kepivance ..................................................... 84 Keppra .......................................................... 26 Keppra XR .................................................... 26 Keralyt ......................................................... 100 Keralyt Scalp ............................................... 100 Ketoconazole .......................................... 34, 40 Ketoprofen ...................................................... 7 Ketoprofen ER ................................................ 7 Ketorolac Tromethamine ....................... 7, 8, 50 Keytruda........................................................ 58 Kinrix ........................................................... 134 Kionex ........................................................... 99 Kitabis Pak .................................................... 18 Klaron ........................................................... 38 Klofensaid II ................................................ 128 KlonoPIN ....................................................... 28 Klor-Con ...................................................... 123 Klor-Con 10 ................................................. 123 Klor-Con M10 .............................................. 123 Klor-Con M15 .............................................. 123 Klor-Con M20 .............................................. 123 Klor-Con Sprinkle ........................................ 123 Klor-Con/EF ................................................ 123 Korlym ........................................................... 29 KP B Complex-C ......................................... 103 KP Folic Acid ............................................... 138 K-Phos ........................................................ 123 K-Phos No 2 .................................................... 2 K-Phos-Neutral ........................................... 123 K-Prime ....................................................... 123 Kristalose ........................................................ 5 K-Tab .......................................................... 123 K-Tan Plus .................................................... 17 Kurvelo .......................................................... 86

Kuvan .......................................................... 111 K-Vescent .................................................... 123 Kyprolis ......................................................... 58

L

Labetalol HCl ................................................. 77 Lac-Hydrin ..................................................... 90 Lacrisert ........................................................ 90 Lactic Acid ..................................................... 90 Lactic Acid E ................................................. 91 Lactulose ......................................................... 6 Lactulose Encephalopathy .............................. 6 LaMICtal ........................................................ 27 LaMICtal ODT ............................................... 27 LaMICtal Starter ............................................ 27 LaMICtal XR .................................................. 27 LamISIL ......................................................... 34 LamiVUDine .................................................. 71 Lamivudine-Zidovudine ................................. 71 LamoTRIgine ................................................. 27 LamoTRIgine ER ........................................... 27 Lanoxin .......................................................... 83 Lansoprazole ................................................. 70 Lantus ........................................................... 31 Lantus SoloStar ............................................. 31 Larissia .......................................................... 86 Lasix .............................................................. 89 Lastacaft ........................................................ 16 Latanoprost ................................................... 36 Latrix XM ..................................................... 100 Latuda ......................................................... 118 Lazanda ........................................................ 11 ledipasvir-sofosbuvir...................................... 73 Leflunomide ................................................... 89 Lessina .......................................................... 86 Letairis ......................................................... 137 Letrozole ....................................................... 58 Leucovorin Calcium ....................................... 33 Leukeran ....................................................... 58 Leukine .......................................................... 96 Leuprolide Acetate ........................................ 58 Levalbuterol HCl .................................. 131, 132 Levalbuterol Tartrate ................................... 132 Levaquin ........................................................ 23 Levbid ............................................................ 25 Levemir ......................................................... 31 Levemir FlexTouch ........................................ 31 LevETIRAcetam ............................................ 27 LevETIRAcetam ER ...................................... 27 Levitra ......................................................... 136


Updated 11/2019

Levobunolol HCl ............................................ 35 LevOCARNitine ........................................... 111 Levocetirizine Dihydrochloride .................... 125 LevoFLOXacin ........................................ 23, 38 LEVOleucovorin Calcium .............................. 33 Levonest ....................................................... 86 Levonorgest-Eth Estrad 91-Day .................... 86 Levonorgestrel-Ethinyl Estrad ....................... 86 Levora 0.15/30 (28) ....................................... 86 Levorphanol Tartrate ..................................... 11 Levo-T ......................................................... 132 Levothyroxine Sodium ................................ 132 Levothyroxine-Liothyronine ......................... 133 Levoxyl ........................................................ 133 Levsin ........................................................... 25 Levsin/SL ...................................................... 25 Levulan Kerastick ........................................ 128 Lexapro ....................................................... 115 Lexiva ........................................................... 71 Lialda ............................................................ 46 Librax ............................................................ 25 Lido BDK ....................................................... 65 Lidocaine....................................................... 65 Lidocaine HCl ........................................ 65, 101 Lidocaine PAK .............................................. 65 Lidocaine Viscous ....................................... 101 Lidocaine-Hydrocortisone Ace ...................... 65 Lidocaine-Prilocaine ...................................... 65 Lidoderm ....................................................... 65 Lido-K ........................................................... 65 Lidopin .......................................................... 65 Lidopril .......................................................... 65 Lidopril XR .................................................... 65 Lido-Prilo Caine Pack ................................... 65 Lillow ............................................................. 86 Lincocin ......................................................... 19 Lincomycin HCl ............................................. 19 Lindane ......................................................... 43 Linezolid ........................................................ 19 Linezolid in Sodium Chloride......................... 19 Linzess .......................................................... 95 Liothyronine Sodium ................................... 133 Lipodox 50 .................................................... 58 Lipofen .......................................................... 52 LiProZonePak ............................................... 65 Lisinopril ...................................................... 121 Lisinopril-Hydrochlorothiazide ..................... 122 Lithium .......................................................... 52 Lithium Carbonate ......................................... 52 Lithium Carbonate ER ................................... 52

Lithobid .......................................................... 52 Lithostat ........................................................... 6 Livixil Pak ...................................................... 65 Locoid ............................................................ 46 Locoid Lipocream .......................................... 46 Lodosyn ......................................................... 62 Lomotil ........................................................... 33 Loperamide HCl ............................................ 33 Lopid ............................................................. 52 Lopinavir-Ritonavir ........................................ 72 Lopreeza ....................................................... 93 Loprox ........................................................... 40 LORazepam .................................................. 76 LORazepam Intensol ..................................... 76 Lorcet ............................................................ 11 Lorcet HD ...................................................... 11 Lorcet Plus .................................................... 11 Lortab ............................................................ 11 Lorzone ....................................................... 126 Losartan Potassium..................................... 120 Losartan Potassium-HCTZ .......................... 121 Lotemax ........................................................ 49 Lotensin HCT .............................................. 122 Loteprednol etabonate .................................. 49 Lotrel ............................................................. 81 Lotrisone ....................................................... 40 Lotronex ........................................................ 46 Lovastatin ...................................................... 52 Lovaza ........................................................... 51 Lovenox ......................................................... 67 Low-Ogestrel ................................................. 86 Loxapine Succinate ..................................... 118 Lumigan ........................................................ 36 Lunesta ......................................................... 74 Lupron Depot (1-Month) ................................ 58 Lupron Depot (3-Month) ................................ 58 Lupron Depot (4-Month) ................................ 59 Lupron Depot (6-Month) ................................ 59 Lupron Depot-Ped (1-Month) ........................ 59 Lupron Depot-Ped (3-Month) ........................ 59 Lutera ............................................................ 86 Luxiq .............................................................. 46 Lyrica ............................................................. 27 Lysiplex Plus ............................................... 103 Lysodren ....................................................... 59 Lysteda .......................................................... 36 Lyza ............................................................... 86

M

M.V.I. Adult .................................................. 103


Updated 11/2019

M.V.I. Pediatric ............................................ 103 M.V.I.-12 (without Vitamin K) ...................... 103 Macrobid ..................................................... 134 Macrodantin ................................................ 134 Mafenide Acetate .......................................... 42 MagneBind 400 ........................................... 123 Makena ....................................................... 113 Malarone ....................................................... 64 Malathion ...................................................... 43 Maprotiline HCl ........................................... 115 Marinol .......................................................... 34 Marlissa......................................................... 86 Marnatal-F ................................................... 103 Marplan ....................................................... 115 Matulane ....................................................... 59 Matzim LA ..................................................... 80 Mavyret ......................................................... 73 Maxalt ........................................................... 53 Maxalt-MLT ................................................... 53 Maxidex......................................................... 49 Maxidone ...................................................... 11 Maxitrol ......................................................... 49 Maxzide......................................................... 90 Maxzide-25 ................................................... 90 Mayzent ........................................................ 97 MB HydroGel .............................................. 128 Meclizine HCl ................................................ 34 Meclofenamate Sodium .................................. 8 Medolor Pak .................................................. 65 Medrol ............................................................. 3 MedroxyPROGESTERone Acetate ............. 113 Mefenamic Acid .............................................. 8 Mefloquine HCl ............................................. 64 Megace ES ................................................. 113 Megestrol Acetate ................................. 59, 113 Mekinist ......................................................... 59 Mektovi ......................................................... 59 Meloxicam ....................................................... 8 Meloxicam Comfort Pac .................................. 8 Melphalan HCl .............................................. 59 Memantine HCl ............................................. 85 Menest .......................................................... 93 Menostar ....................................................... 93 Mentax .......................................................... 40 Meperidine HCl ............................................. 11 Mephyton .................................................... 139 Meprobamate ................................................ 74 Mepron .......................................................... 64 Mercaptopurine ............................................. 59 Mesalamine ................................................... 46

Mesalamine-Cleanser ................................... 46 Mesna ......................................................... 113 Mesnex ........................................................ 113 Mestinon .............................................. 111, 112 Metadate ER ................................................. 15 Metaproterenol Sulfate ................................ 132 Metaxall ....................................................... 126 Metaxalone .................................................. 126 MetFORMIN HCl ........................................... 30 MetFORMIN HCl ER ..................................... 30 MetFORMIN HCl ER (MOD) ......................... 30 MetFORMIN HCl ER (OSM) .......................... 30 Methamphetamine HCl .................................. 14 MethazolAMIDE ............................................ 36 Methenamine Hippurate .............................. 134 Methenamine Mandelate ............................. 134 MethIMAzole ............................................... 132 Methocarbamol ........................................... 126 Methotrexate ................................................. 59 Methotrexate Sodium .................................... 59 Methotrexate Sodium (PF) ............................ 59 Methscopolamine Bromide ............................ 25 Methyclothiazide ........................................... 90 Methyldopa .................................................... 97 Methyldopa-Hydrochlorothiazide ................... 97 Methylin ......................................................... 15 Methylphenidate HCl ..................................... 15 Methylphenidate HCl ER ............................... 15 Methylphenidate HCl ER (CD) ...................... 15 Methylphenidate HCl ER (LA) ....................... 16 MethylPREDNISolone ..................................... 3 MethylPREDNISolone Acetate ........................ 3 MethylPREDNISolone Sodium Succ ............... 3 Metipranolol ................................................... 35 Metoclopramide HCl .................................... 113 MetOLazone .................................................. 90 Metoprolol Succinate ER ............................... 77 Metoprolol Tartrate ........................................ 77 Metoprolol-Hydrochlorothiazide ..................... 77 Metoprolol-Hydrochlorothiazide ER ............... 77 MetroCream .................................................. 38 Metrogel ........................................................ 38 MetroGel-Vaginal .......................................... 38 MetroLotion ................................................... 38 MetroNIDAZOLE ..................................... 38, 64 Mexiletine HCl ............................................... 82 Mezparox-HC ................................................ 46 M-Hist DM ..................................................... 68 Miacalcin ..................................................... 112 Micardis HCT .............................................. 121


Updated 11/2019

Miconazole 3 ................................................. 40 Miconazole 3 Applicator ................................ 40 Miconazole 3 Combo Pack ........................... 40 Miconazole 3 Combo Pack App .................... 40 MICRhoGAM Ultra-Filtered Plus ................. 125 Micro-K........................................................ 123 Microzide....................................................... 90 Midazolam HCl .............................................. 76 Midodrine HCl ............................................. 131 Migergot ........................................................ 53 Miglitol ........................................................... 29 Migranal ...................................................... 130 Milco-B-Forte .............................................. 103 Millipred........................................................... 3 Millipred DP ..................................................... 3 Millipred DP 12-Day ........................................ 3 Mimvey.......................................................... 93 Mimvey Lo ..................................................... 93 Minipress......................................................... 5 Minitran ....................................................... 136 Minivelle ........................................................ 93 Minocin ......................................................... 24 Minocycline HCl ............................................ 24 Minocycline HCl ER .................................... 128 Miochol-E ...................................................... 36 Miostat .......................................................... 36 Mirapex ......................................................... 63 Mirapex ER ................................................... 63 Mircera .......................................................... 96 Mirena (52 MG) ............................................. 86 Mirtazapine ................................................. 115 Mirvaso ....................................................... 128 MiSOPROStol ............................................... 69 MitoMYcin ..................................................... 59 Mitosol .......................................................... 38 MitoXANTRONE HCl .................................... 59 Mobic .............................................................. 8 Modafinil........................................................ 16 Moderiba ....................................................... 74 Moexipril HCl ............................................... 122 Moexipril-Hydrochlorothiazide ..................... 122 Mometasone Furoate .............................. 46, 49 Mondoxyne NL .............................................. 24 Monistat 3 Combination Pack ....................... 40 Monistat 3 Combo Pack App......................... 40 Montelukast Sodium ..................................... 50 Monurol ....................................................... 135 Morgidox ....................................................... 24 Morphine Sulfate ........................................... 11 Morphine Sulfate (Concentrate) .................... 11

Morphine Sulfate (PF) ................................... 11 Morphine Sulfate ER ..................................... 11 Morphine Sulfate ER Beads .......................... 11 Motofen ......................................................... 33 Movantik ........................................................ 95 MoviPrep ....................................................... 83 Moxatag ........................................................ 22 Moxeza .......................................................... 38 Moxifloxacin HCl ........................................... 23 Mozobil .......................................................... 96 MS Contin ..................................................... 12 Multaq ........................................................... 82 Multigen ......................................................... 17 Multigen Folic ................................................ 17 Multigen Plus ................................................. 18 Multi-Vit/Fluoride ......................................... 103 Multi-Vit/Fluoride/Iron .................................. 104 Multi-Vit/Iron/Fluoride .................................. 104 Multi-Vitamin Drops/FE ............................... 104 Multivitamin/Fluoride ................................... 104 Multi-Vitamin/Fluoride .................................. 104 Multivitamin/Fluoride/Iron ............................ 104 Multi-Vitamin/Fluoride/Iron .......................... 104 Multivitamins/Fluoride .................................. 104 Mupirocin ....................................................... 38 Mupirocin Calcium ......................................... 38 Mustargen ..................................................... 59 Mvasi ............................................................. 59 MVC-Fluoride .............................................. 104 M-Vit ............................................................ 104 Myambutol ..................................................... 54 Mycamine ...................................................... 35 Mycobutin ...................................................... 54 Mycophenolate Mofetil .................................. 98 Mycophenolate Sodium ................................. 98 Mydriacyl ..................................................... 110 Myferon 150 Forte ......................................... 18 Myfortic .......................................................... 98 Myleran ......................................................... 59 Mynatal ........................................................ 104 Mynatal Advance ......................................... 104 Mynatal Plus ................................................ 104 Mynatal-Z .................................................... 104 Mynate 90 Plus ........................................... 104 Mynephrocaps ............................................. 104 Mynephron .................................................. 104 Myorisan ...................................................... 128 Myrbetriq ....................................................... 95 Mysoline ........................................................ 28 Mytesi ............................................................ 33


Updated 11/2019

Myzilra .......................................................... 86

N

Nabumetone ................................................... 8 Nadolol .......................................................... 77 Nadolol-Bendroflumethiazide ........................ 77 Nafcillin Sodium ............................................ 22 Naftifine HCl .................................................. 40 Naftin ............................................................ 40 Naglazyme .................................................... 91 Nalbuphine HCl ............................................. 13 Nalfon ............................................................. 8 Naloxone HCl .............................................. 110 Naltrexone HCl ............................................ 110 Namenda ...................................................... 85 Namenda Titration Pak ................................. 85 Naprelan ......................................................... 8 NaPro ............................................................ 46 Naprosyn......................................................... 8 Naproxen ........................................................ 8 Naproxen Comfort Pac ................................... 8 Naproxen DR .................................................. 8 Naproxen Sodium ........................................... 8 Naproxen Sodium ER ..................................... 8 Naratriptan HCl ............................................. 53 Nardil .......................................................... 115 Nasacort Allergy 24HR ................................. 49 Nasacort Allergy 24HR Children ................... 49 Nasal Allergy 24 Hour ................................... 49 Nascobal ..................................................... 138 Nasonex ........................................................ 49 NataChew ................................................... 104 Natalvit ........................................................ 104 Nateglinide .................................................... 31 Natelle ONE ................................................ 104 Natroba ......................................................... 43 Nature-Throid .............................................. 133 Navelbine ...................................................... 59 Nebupent ...................................................... 64 Nebusal ....................................................... 101 Neevo DHA ................................................. 104 Nefazodone HCl .......................................... 115 Neocera ...................................................... 128 Neomycin Sulfate .......................................... 18 Neomycin-Bacitracin Zn-Polymyx ................. 39 Neomycin-Polymyxin-Dexameth ................... 49 Neomycin-Polymyxin-Gramicidin .................. 39 Neomycin-Polymyxin-HC .............................. 49 Neoral ........................................................... 98 Neosalus ............................................... 91, 129

Neosalus CP ............................................... 129 Neosporin ...................................................... 39 NeoTuss Plus ................................................ 68 Nephplex Rx ................................................ 104 Nephrocaps ................................................. 104 Nephron FA ................................................... 18 Nephronex ................................................... 104 Nephro-Vite Rx ............................................ 104 Neptazane ..................................................... 36 Nerlynx .......................................................... 59 Nestabs ....................................................... 104 Nestabs ABC ............................................... 104 Nestabs DHA .............................................. 104 Neuac ............................................................ 39 Neulasta ........................................................ 96 Neulasta Onpro ............................................. 96 Neupogen ...................................................... 96 Neupro .......................................................... 63 Neurin-SL .................................................... 138 Neurontin ....................................................... 27 Nevirapine ..................................................... 72 Nevirapine ER ............................................... 72 Newgen ....................................................... 104 Nexa Plus .................................................... 104 NexAVAR ...................................................... 59 NexIUM ......................................................... 70 Niacin .......................................................... 138 Niacin ER (Antihyperlipidemic) ...................... 51 Niacor .......................................................... 138 Niaspan ......................................................... 51 Nicadan ....................................................... 104 Nicadan ZX ................................................. 104 NiCARdipine HCl ........................................... 81 Nicazel ........................................................ 104 NicAzel Forte ............................................... 105 Nicomide ..................................................... 105 Nicotrol .......................................................... 77 Nicotrol NS .................................................... 77 NIFEdipine .................................................... 81 NIFEdipine ER .............................................. 81 NIFEdipine ER Osmotic Release .................. 81 Nilandron ....................................................... 59 Nilutamide ..................................................... 59 NiMODipine ................................................... 82 Ninlaro ........................................................... 59 Nipent ............................................................ 59 Nisoldipine ER ............................................... 82 Nitro-Bid ...................................................... 136 Nitro-Dur ...................................................... 136 Nitrofurantoin ............................................... 135


Updated 11/2019

Nitrofurantoin Macrocrystal ......................... 135 Nitrofurantoin Monohyd Macro .................... 135 Nitroglycerin ................................................ 136 Nitroglycerin ER .......................................... 136 Nitrolingual .................................................. 136 NitroMist ...................................................... 136 Nitrostat....................................................... 136 Nitro-Time ................................................... 136 Niva-Hist DM ................................................. 68 Niva-Plus..................................................... 105 Nivatopic Plus ............................................. 129 Nizatidine ...................................................... 69 Nizoral ........................................................... 40 Nolix .............................................................. 46 Nora-BE ........................................................ 86 Norco ............................................................ 12 Norethindrone ............................................... 86 Norethindrone Acetate ................................ 113 Norethindrone-Eth Estradiol .......................... 93 Norgestim-Eth Estrad Triphasic .................... 86 Noritate ......................................................... 39 Norlyda ......................................................... 86 Norlyroc......................................................... 86 Norpace ........................................................ 82 Norpace CR .................................................. 82 Norpramin ................................................... 115 Nortrel 1/35 (21) ............................................ 86 Nortrel 1/35 (28) ............................................ 87 Nortriptyline HCl .......................................... 115 Nortuss-DE ................................................... 68 Nortuss-Ex .................................................... 68 Norvasc ......................................................... 82 Norvir ............................................................ 72 Noxafil ........................................................... 34 NP Thyroid .................................................. 133 Nplate ........................................................... 96 Nucala ......................................................... 124 NuCort .......................................................... 46 Nucynta ......................................................... 12 Nucynta ER ................................................... 12 Nuedexta....................................................... 85 NuFol .......................................................... 138 NuLev ........................................................... 25 Nulojix ........................................................... 98 Nulytely with Flavor Packs ............................ 83 Nutraseb ..................................................... 100 Nutricap....................................................... 105 NutriDox ........................................................ 24 Nutrifac ZX .................................................. 105 Nutrivit ......................................................... 105

NuvaRing ...................................................... 87 Nuvigil ........................................................... 16 Nyamyc ......................................................... 40 Nystatin ................................................... 35, 41 Nystatin-Triamcinolone .................................. 46 Nystop ........................................................... 41

O

OB Complete ............................................... 105 OB Complete One ....................................... 105 OB Complete Petite..................................... 105 OB Complete Premier ................................. 105 OB Complete/DHA ...................................... 105 Obstetrix DHA ............................................. 105 Obstetrix EC ................................................ 105 Obstetrix One .............................................. 105 O-Cal FA ..................................................... 105 O-Cal Prenatal ............................................ 105 Octagam ...................................................... 125 Octreotide Acetate....................................... 130 Ocuvel ......................................................... 105 Odefsey ......................................................... 72 Ofloxacin ................................................. 23, 39 Okebo ............................................................ 24 OLANZapine ............................................... 118 OLANZapine-FLUoxetine HCl ..................... 115 Olmesartan Medoxomil ............................... 121 Olmesartan Medoxomil-HCTZ ..................... 121 Olmesartan-Amlodipine-HCTZ ...................... 82 Olopatadine HCl ............................................ 16 Olux ............................................................... 46 Olux-E ........................................................... 46 Omeclamox-Pak ............................................ 70 Omega-3-acid Ethyl Esters ........................... 51 OmePPi ......................................................... 70 Omeprazole ................................................... 70 Omeprazole+Syrspend SF Alka .................... 70 Omeprazole-Sodium Bicarbonate ................. 70 Omnaris ......................................................... 49 Omnipred ...................................................... 49 Oncaspar ....................................................... 60 Ondansetron ................................................. 33 Ondansetron HCl .......................................... 33 Onexton ......................................................... 39 Onfi ................................................................ 28 Opdivo ........................................................... 60 Opsumit ....................................................... 137 Oracea ........................................................ 129 Oracit ............................................................... 5 Oralone ......................................................... 46


Updated 11/2019

Orap ............................................................ 118 Orapred ODT .................................................. 3 Orenitram .................................................... 137 Orfadin ........................................................ 111 Orphenadrine Citrate .................................. 127 Orphenadrine Citrate ER ............................ 127 Orsythia......................................................... 87 Ortho Micronor .............................................. 87 Ortho Tri-Cyclen (28) .................................... 87 Ortho Tri-Cyclen Lo ....................................... 87 Ortho-Novum 1/35 (28) ................................. 87 OrthoVisc .................................................... 111 Oscimin ......................................................... 25 Oscimin SR ................................................... 25 Oseltamivir Phosphate .................................. 73 OsmoPrep ..................................................... 84 Otezla ........................................................... 89 Oticin HC NR ................................................ 49 Otomax-HC ................................................... 49 Ovide ............................................................ 43 Oxacillin Sodium ........................................... 22 Oxaliplatin ..................................................... 60 Oxaprozin........................................................ 8 Oxaydo ......................................................... 12 Oxazepam..................................................... 76 OXcarbazepine ............................................. 27 Oxiconazole Nitrate ....................................... 41 Oxistat ........................................................... 41 Oxybutynin Chloride ...................................... 95 Oxybutynin Chloride ER ................................ 95 OxyCODONE HCl ......................................... 12 OxyCODONE HCl ER ................................... 12 Oxycodone-Acetaminophen .......................... 12 Oxycodone-Aspirin ........................................ 12 Oxycodone-Ibuprofen ................................... 12 OxyCONTIN .................................................. 12 OxyMORphone HCl ...................................... 12 OxyMORphone HCl ER ................................ 12 Oxytrol .......................................................... 95

P

Pacerone....................................................... 82 PACLitaxel .................................................... 60 Paliperidone ER .......................................... 119 Pamelor....................................................... 116 Pamidronate Disodium .................................. 78 Pancreaze ..................................................... 88 Pandel ........................................................... 46 Panretin....................................................... 129 Pantoprazole Sodium .................................... 70

Paragard Intrauterine Copper ........................ 87 Paregoric ....................................................... 33 Paricalcitol ................................................... 139 Parlodel ......................................................... 63 Parnate ........................................................ 116 Paromomycin Sulfate .................................... 64 PARoxetine HCl .......................................... 116 PARoxetine HCl ER .................................... 116 Paser ............................................................. 54 Pataday ......................................................... 16 Patanase ....................................................... 16 Paxil ............................................................ 116 Paxil CR ...................................................... 116 PCE ............................................................... 21 Pediapred ........................................................ 3 Pediarix ....................................................... 135 PEG 3350/Electrolytes .................................. 84 PEG 3350-KCl-Na Bicarb-NaCl ..................... 84 PEG-3350/Electrolytes .................................. 84 Peganone ...................................................... 29 Pegasys ........................................................ 73 Pegasys ProClick .......................................... 73 PegIntron ....................................................... 73 PEG-Prep ...................................................... 84 Penicillin G Potassium ................................... 22 Penicillin G Procaine ..................................... 22 Penicillin G Sodium ....................................... 22 Penicillin V Potassium ................................... 22 Penlac ........................................................... 41 Pentacel ...................................................... 135 Pentam .......................................................... 64 Pentasa ......................................................... 47 Pentazocine-Naloxone HCl ........................... 14 Pentoxifylline ER ........................................... 97 Pepcid ........................................................... 69 Percocet ........................................................ 12 Perforomist .................................................. 132 Perindopril Erbumine ................................... 122 Perjeta ........................................................... 60 Permethrin ..................................................... 43 Perphenazine .............................................. 119 Perphenazine-Amitriptyline ......................... 116 Pertzye .......................................................... 88 Pexeva ........................................................ 116 Pfizerpen ....................................................... 22 Pharbedryl ..................................................... 94 Phenadoz ...................................................... 94 Phenazo ........................................................ 65 Phenazopyridine HCl ..................................... 65 Phenelzine Sulfate ...................................... 116


Updated 11/2019

Phenergan .................................................... 94 PHENobarbital .............................................. 75 Phenoxybenzamine HCl.............................. 130 Phenyleph-Promethazine-Cod ...................... 68 Phenylephrine HCl ...................................... 135 Phenylephrine-Guaifenesin ........................... 93 Phenytek ....................................................... 29 Phenytoin ...................................................... 29 Phenytoin Infatabs ........................................ 29 Phenytoin Sodium ......................................... 29 Phenytoin Sodium Extended ......................... 29 Phoslyra ...................................................... 123 Phospha 250 Neutral .................................. 123 Phosphasal ................................................. 135 Phospholine Iodide ....................................... 36 Phospho-Trin 250 Neutral ........................... 123 Photofrin........................................................ 60 Phrenilin Forte ................................................. 6 Phytonadione .............................................. 139 Picato .......................................................... 129 Pilocarpine HCl ..................................... 36, 112 Pimozide ..................................................... 119 Pindolol ......................................................... 77 Pioglitazone HCl ........................................... 32 Pioglitazone HCl-Glimepiride ........................ 32 Pioglitazone HCl-Metformin HCl ................... 33 Pirmella 1/35 ................................................. 87 Piroxicam ........................................................ 8 Plaquenil ....................................................... 64 Plavix ............................................................ 67 Plegridy ......................................................... 73 Plegridy Starter Pack .................................... 73 Plexion ........................................................ 100 Plexion Cleanser ......................................... 100 Plexion Cleansing Cloth .............................. 100 PNV Folic Acid + Iron .................................. 105 PNV OB+DHA ............................................. 105 PNV Prenatal Plus Multivitamin .................. 105 PNV Tabs 29-1 ........................................... 105 PNV-DHA .................................................... 105 PNV-DHA Plus ............................................ 105 PNV-DHA+Docusate ................................... 105 PNV-Omega ................................................ 105 PNV-Select ................................................. 105 PNV-Total ................................................... 105 Podocon ...................................................... 129 Podofilox ..................................................... 129 Polycin .......................................................... 39 Polyethylene Glycol 3350.............................. 84 Poly-Iron 150 Forte ....................................... 18

Polymyxin B-Trimethoprim ............................ 39 Polysaccharide Iron Forte ............................. 18 Poly-Vi-Flor ................................................. 105 Poly-Vi-Flor FS ............................................ 105 Poly-Vi-Flor/Iron .......................................... 105 Poly-Vi-Sol/Iron ........................................... 106 Pomalyst ....................................................... 60 Portia-28 ........................................................ 87 Pot & Sod Cit-Cit Ac ........................................ 5 Pot Bicarb-Pot Chloride ............................... 123 Potaba ......................................................... 138 Potassium Bicarbonate ............................... 123 Potassium Chloride ..................................... 123 Potassium Chloride Crys ER ....................... 123 Potassium Chloride ER ............................... 124 Potassium Citrate ER ...................................... 5 Potassium Citrate-Citric Acid ........................... 5 PR Benzoyl Peroxide Wash .......................... 42 PR Cream ................................................... 129 PR Natal 400 ............................................... 106 PR Natal 400 ec .......................................... 106 PR Natal 430 ............................................... 106 PR Natal 430 ec .......................................... 106 Pradaxa ......................................................... 67 PramCort ....................................................... 66 Pramipexole Dihydrochloride ........................ 63 Pramipexole Dihydrochloride ER .................. 63 Pramosone .................................................... 47 Pramosone E ................................................ 47 PramOtic ..................................................... 101 Pramox .......................................................... 66 Prandin .......................................................... 31 Prasugrel HCl ................................................ 67 Pravastatin Sodium ....................................... 52 Prazosin HCl ................................................... 5 Precose ......................................................... 29 Pred Forte ..................................................... 49 Pred Mild ....................................................... 49 Pred-G ........................................................... 49 Pred-G S.O.P. ............................................... 49 Prednicarbate ................................................ 47 PrednisoLONE ................................................ 3 PrednisoLONE Acetate ................................. 49 PrednisoLONE Sodium Phosphate ........... 4, 49 PredniSONE .................................................... 4 PredniSONE Intensol ...................................... 4 Prefera OB .................................................. 106 PreferaOB +DHA ......................................... 106 PreferaOB One ........................................... 106 Prefest ........................................................... 93


Updated 11/2019

Premarin ....................................................... 93 Premium Lidocaine ....................................... 66 Premphase .................................................... 93 Prempro ........................................................ 93 Prena1 ........................................................ 106 Prena1 Pearl ............................................... 106 Prenaissance .............................................. 106 Prenaissance Balance ................................ 106 Prenaissance Harmony DHA ...................... 106 Prenaissance Next ...................................... 106 Prenaissance Next-B .................................. 106 Prenaissance Plus ...................................... 106 PreNata ....................................................... 106 Prenatabs Rx .............................................. 106 Prenatal....................................................... 106 Prenatal 19.................................................. 106 Prenatal Plus ............................................... 106 Prenatal Plus Iron ....................................... 106 Prenatal Vitamin Plus Low Iron ................... 106 Prenatal-U ................................................... 106 Prenate ....................................................... 106 Prenate AM ................................................. 106 Prenate DHA ............................................... 106 Prenate Elite ............................................... 106 Prenate Enhance ........................................ 106 Prenate Essential ........................................ 106 Prenate Mini ................................................ 107 Prenate Pixie ............................................... 107 Prenate Restore .......................................... 107 PrePLUS ..................................................... 107 Prepopik ........................................................ 84 Presera ....................................................... 129 PreTAB ....................................................... 107 Prevacid ........................................................ 70 Prevacid SoluTab .......................................... 70 Prevalite ........................................................ 51 Prevpac ......................................................... 70 Prezcobix ...................................................... 72 Prezista ......................................................... 72 Prialt ................................................................ 6 Priftin ............................................................. 54 Prilolid ........................................................... 66 PriLOSEC ..................................................... 70 Priloxx LP ...................................................... 66 Primaquine Phosphate .................................. 64 Primidone ...................................................... 28 Primlev .......................................................... 13 Primsol ........................................................ 135 Pristiq .......................................................... 116 Privigen ....................................................... 125

ProAir HFA .................................................. 132 ProAir RespiClick ........................................ 132 Probenecid .................................................. 134 Procardia ....................................................... 82 Procardia XL ................................................. 82 ProCentra ...................................................... 14 Prochlorperazine ......................................... 119 Prochlorperazine Edisylate .......................... 119 Prochlorperazine Maleate ........................... 119 ProCort .......................................................... 66 Procrit ............................................................ 96 Proctocort ...................................................... 47 Proctofoam HC .............................................. 66 Procto-Med HC ............................................. 47 Procto-Pak .................................................... 47 Proctosol HC ................................................. 47 Proctozone-HC .............................................. 47 Proferrin-Forte ............................................... 18 Progesterone ............................................... 113 Progesterone Micronized ............................ 113 Proglycem ..................................................... 37 Prograf .......................................................... 98 Prolastin-C .................................................. 124 Proleukin ....................................................... 60 Prolia ............................................................. 78 Promacta ....................................................... 96 Promethazine HCl ......................................... 94 Promethazine VC Plain ................................. 94 Promethazine VC/Codeine ............................ 68 Promethazine-Codeine .................................. 68 Promethazine-DM ......................................... 68 Promethazine-Phenyleph-Codeine ............... 68 Promethazine-Phenylephrine ........................ 94 Promethegan ................................................. 94 Prometrium .................................................. 113 Propafenone HCl ........................................... 83 Propafenone HCl ER ..................................... 83 Propantheline Bromide .................................. 25 Propranolol HCl ............................................. 78 Propranolol HCl ER ....................................... 78 Propranolol-HCTZ ......................................... 78 Propylthiouracil ............................................ 132 Proscar ............................................................ 2 Protect Plus ................................................. 107 ProtectIron ..................................................... 18 Protonix ......................................................... 70 Protopic ....................................................... 129 Protriptyline HCl .......................................... 116 Provenge ....................................................... 84 Proventil HFA .............................................. 132


Updated 11/2019

Provera ....................................................... 113 Provida DHA ............................................... 107 Provida OB .................................................. 107 Provigil .......................................................... 16 PROzac....................................................... 116 PruClair ....................................................... 129 Prudoxin ........................................................ 66 PruMyx ........................................................ 129 Pseudoeph-Bromphen-DM ........................... 68 Pseudoeph-Chlorphen-Hydrocod .................. 68 Psorcon ......................................................... 47 PulmoSal..................................................... 101 Pulmozyme ................................................. 101 PureFe OB Plus .......................................... 107 PureFe Plus .................................................. 18 PureVit DualFe Plus ...................................... 18 PX B Complex/Vitamin C ............................ 107 PX Folic Acid ............................................... 138 PX Miconazole 3-Day Combo ....................... 41 Pylera ............................................................ 69 Pyrazinamide ................................................ 54 Pyridium ........................................................ 66 Pyridostigmine Bromide .............................. 112 Pyridostigmine Bromide ER ........................ 112 Pyridoxine HCl ............................................ 138 Pyrogallic Acid ............................................ 100

Q

QC Clotrimazole ............................................ 41 Qnasl ............................................................ 49 Quadracel ................................................... 134 Qualaquin...................................................... 64 Quasense...................................................... 87 Quazepam .................................................... 76 Questran ....................................................... 51 Questran Light .............................................. 51 QUEtiapine Fumarate ................................. 119 QUEtiapine Fumarate ER ........................... 119 Quflora Pediatric ......................................... 107 Quinapril HCl ............................................... 122 Quinapril-Hydrochlorothiazide ..................... 122 QuiNIDine Gluconate ER .............................. 83 QuiNIDine Sulfate ......................................... 83 QuiNINE Sulfate ............................................ 64 Quinja ........................................................... 41 Qutenza ...................................................... 129 Qutenza (2 Patch) ....................................... 129 Qvar ................................................................ 4 Qvar RediHaler ............................................... 4

R

RA Folic Acid ............................................... 138 RA Miconazole 3 Combo Pack ...................... 41 RA Miconazole 3 Combo Pack App .............. 41 RABEprazole Sodium .................................... 70 Raloxifene HCl .............................................. 91 Ramipril ....................................................... 122 Ranexa .......................................................... 83 RaNITidine HCl ............................................. 69 Rapaflo ........................................................ 130 Rapamune ..................................................... 98 Rasagiline Mesylate ...................................... 64 Rayos .............................................................. 4 Razadyne .................................................... 112 Razadyne ER .............................................. 112 Rea Lo 40 .................................................... 100 Rebetol .......................................................... 74 Reclast .......................................................... 78 Rectiv .......................................................... 129 Reglan ......................................................... 113 Relador Pak .................................................. 66 Relador Pak Plus .......................................... 66 Relagard ........................................................ 42 Relenza Diskhaler ......................................... 73 Relistor .......................................................... 95 Relnate DHA ............................................... 107 Relpax ........................................................... 53 Remeron ..................................................... 116 Remeron SolTab ......................................... 116 Remodulin ................................................... 137 Renagel ......................................................... 99 Renal ........................................................... 107 Renatabs ..................................................... 107 Renatabs with Iron ........................................ 18 Reno Caps .................................................. 107 Renvela ......................................................... 99 Repaglinide ................................................... 31 Repaglinide-Metformin HCl ........................... 31 REQ 49+ ..................................................... 107 Requip ........................................................... 63 Requip XL ..................................................... 63 Rescriptor ...................................................... 72 Restasis ........................................................ 50 Restasis Multidose ........................................ 50 Restoril .......................................................... 76 Retin-A .......................................................... 84 Retin-A Micro ................................................ 84 Retin-A Micro Pump ...................................... 84 Retinoic Acid ................................................. 84 Retisert .......................................................... 50


Updated 11/2019

Retrovir ......................................................... 72 Revatio ........................................................ 136 Revlimid ........................................................ 60 Reyataz ......................................................... 72 RhoGAM Ultra-Filtered Plus ........................ 126 Rhophylac ................................................... 126 Riax ............................................................... 42 Ribasphere .................................................... 74 Ribavirin ........................................................ 74 Ridaura ......................................................... 95 Rifabutin ........................................................ 54 Rifadin ........................................................... 54 Rifamate........................................................ 54 RifAMPin ....................................................... 54 Rifater ........................................................... 54 Rilutek ........................................................... 85 Riluzole ......................................................... 85 RiMANTAdine HCl ........................................ 70 Rimso-50..................................................... 111 Rinvoq ........................................................... 98 Riomet .......................................................... 30 Risedronate Sodium ..................................... 78 RisperDAL................................................... 119 RisperDAL Consta ...................................... 119 RisperDAL M-TAB ...................................... 119 RisperiDONE .............................................. 119 RisperiDONE M-TAB .................................. 119 Ritalin ............................................................ 16 Ritalin LA....................................................... 16 Rituxan .......................................................... 60 Rivastigmine ............................................... 112 Rivastigmine Tartrate .................................. 112 Rizatriptan Benzoate ..................................... 53 R-Natal OB .................................................. 107 Robafen AC .................................................. 68 Robaxin ....................................................... 126 Robaxin-750 ................................................ 126 Robinul .......................................................... 25 Robinul-Forte ................................................ 25 Rocaltrol ...................................................... 139 ROPINIRole HCl ........................................... 63 ROPINIRole HCl ER ..................................... 63 Rosadan........................................................ 39 Rosanil Cleanser ......................................... 100 Rosuvastatin Calcium ................................... 52 Rowasa ......................................................... 47 Roweepra...................................................... 28 Roxicodone ................................................... 13 Rozerem ....................................................... 74 Rythmol SR ................................................... 83

S

Sabril ............................................................. 28 Salagen ....................................................... 112 Salex ........................................................... 100 Salicylic Acid ............................................... 100 Salicylic Acid Wart Remover ....................... 100 Salicylic Acid-Cleanser ................................ 100 Salimez ....................................................... 100 Salisol Forte ................................................ 100 Salitech Forte .............................................. 100 Salrix ........................................................... 100 Salsalate ......................................................... 8 Salvax ......................................................... 100 Salvax Duo Plus .......................................... 100 Samsca ......................................................... 90 Sancuso ........................................................ 33 SandIMMUNE ......................................... 98, 99 SandoSTATIN ............................................. 130 SandoSTATIN LAR Depot ........................... 130 Santyl .......................................................... 129 Saphris ........................................................ 119 Sarafem ....................................................... 116 Savella .......................................................... 93 Savella Titration Pack .................................... 93 Scalacort DK ................................................. 47 Scopolamine ................................................. 34 Seconal ......................................................... 75 Select-OB .................................................... 107 Select-OB+DHA .......................................... 107 Selegiline HCl ................................................ 64 Selzentry ....................................................... 72 Semprex-D .................................................. 125 Se-Natal 19 ................................................. 107 Sensipar ...................................................... 111 SEROquel ................................................... 119 SEROquel XR ............................................. 119 Sertraline HCl .............................................. 116 Se-Tan PLUS ................................................ 18 Setlakin ......................................................... 87 Sevelamer Carbonate ................................... 99 SfRowasa ...................................................... 47 Sharobel ........................................................ 87 Shohls Modified ............................................... 5 Siderol ......................................................... 107 Signifor ........................................................ 130 Signifor LAR ................................................ 130 Sildenafil Citrate .......................................... 137 Silenor ......................................................... 116 Silvadene ...................................................... 42 Silver Sulfadiazine ......................................... 42


Updated 11/2019

Simbrinza ...................................................... 35 Simponi ......................................................... 89 Simponi Aria .................................................. 89 Simvastatin ................................................... 52 Sinemet ......................................................... 62 Sinemet CR ................................................... 62 Singulair ........................................................ 50 Sirolimus ....................................................... 99 Skelaxin ...................................................... 126 Sklice ............................................................ 43 Skyrizi ......................................................... 129 SM Antifungal Clotrimazole ........................... 41 SM B Super Vitamin Complex ..................... 107 SM B-Complex/Vitamin C ........................... 107 SM Folic Acid .............................................. 138 SM Miconazole 3 .......................................... 41 SM Miconazole 3 Applicator .......................... 41 Sod Citrate-Citric Acid ..................................... 5 Sodium Chloride ................................... 99, 102 Sodium Fluoride ............................................ 83 Sodium Hyaluronate ..................................... 90 Sodium Polystyrene Sulfonate ...................... 99 Solodyn ....................................................... 129 Soltamox ....................................................... 60 Solu-CORTEF ................................................. 4 SOLU-medrol .................................................. 4 Soma .......................................................... 126 Somatuline Depot ....................................... 130 Sonata .......................................................... 75 Soolantra....................................................... 43 Soriatane..................................................... 129 Sorilux ......................................................... 129 Sotalol HCl .................................................... 78 Sotalol HCl (AF) ............................................ 78 Sovaldi .......................................................... 73 Spectracef ..................................................... 20 Spinosad ....................................................... 43 Spiriva HandiHaler ........................................ 25 Spiriva Respimat ........................................... 25 Spironolactone ............................................ 122 Spironolactone-HCTZ ................................. 122 Sporanox................................................. 34, 35 Sporanox Pulsepak ....................................... 35 Sprix ................................................................ 8 Sprycel .......................................................... 60 SPS ............................................................... 99 Sronyx ........................................................... 87 SSD .............................................................. 43 SSS 10-5..................................................... 100 Stalevo 100 ................................................... 62

Stalevo 125 ................................................... 62 Stalevo 150 ................................................... 62 Stalevo 200 ................................................... 62 Stalevo 50 ..................................................... 62 Stalevo 75 ..................................................... 62 Starlix ............................................................ 31 Stavudine ...................................................... 72 Staxyn ......................................................... 137 Stendra ........................................................ 137 Stimate ........................................................ 112 Stivarga ......................................................... 60 Strattera ........................................................ 85 Streptomycin Sulfate ..................................... 18 Stress Formula ............................................ 107 Stribild ........................................................... 72 Stromectol ..................................................... 16 Strovite Forte ............................................... 107 Strovite ONE ............................................... 107 Suboxone ...................................................... 14 Subsys .......................................................... 13 Sucraid .......................................................... 91 Sucralfate ...................................................... 69 Sular .............................................................. 82 Sulfacetamide Sodium .................................. 39 Sulfacetamide Sodium (Acne) ....................... 39 Sulfacetamide Sodium-Sulfur .............. 100, 101 Sulfacetamide Sod-Sulfur Wash ................. 101 Sulfacetamide-Prednisolone ......................... 50 Sulfacetamide-Sulfur in Urea ...................... 101 Sulfacetamide-Sulfur-Sunscreen ................. 101 SulfaCleanse 8/4 ......................................... 101 SulfADIAZINE ............................................... 23 Sulfamethoxazole-Trimethoprim ................... 23 Sulfamylon .................................................... 43 SulfaSALAzine .............................................. 23 Sulfurated Lime ............................................. 43 Sulindac .......................................................... 8 Sumadan ..................................................... 101 Sumadan Wash ........................................... 101 Sumadan XLT ............................................. 101 SUMAtriptan .................................................. 53 SUMAtriptan Succinate ................................. 53 SUMAtriptan Succinate Refill ........................ 53 Sumavel DosePro ......................................... 53 Sumaxin ...................................................... 101 Sumaxin CP ................................................ 101 Sumaxin TS ................................................. 101 Sumaxin Wash ............................................ 101 Supartz FX .................................................. 111 Super B Complex/FA/Vit C .......................... 107


Updated 11/2019

Super B-Complex/Vit C/FA ......................... 107 Supervite ..................................................... 107 Support ....................................................... 107 Support-500 ................................................ 107 Suprax .......................................................... 20 Suprep Bowel Prep Kit .................................. 84 Surmontil ..................................................... 116 Sustiva .......................................................... 72 Sutent ........................................................... 60 Sylatron ......................................................... 60 Symax Duotab .............................................. 25 Symax-SL ..................................................... 25 Symax-SR ..................................................... 25 Symbicort ........................................................ 4 Symbyax ..................................................... 116 SymlinPen 120 .............................................. 29 SymlinPen 60 ................................................ 29 Synagex ...................................................... 107 Synagis ......................................................... 73 Synalar .......................................................... 47 Synalar TS .................................................... 47 SynaTek ...................................................... 107 Synera .......................................................... 66 Synribo .......................................................... 60 Synthroid ..................................................... 133 Synvisc ....................................................... 111 Synvisc One ................................................ 111

T

Tabloid .......................................................... 60 Taclonex ....................................................... 47 Tacrolimus ............................................ 99, 129 Tadalafil ...................................................... 137 Tafinlar .......................................................... 60 Tagrisso ........................................................ 60 Tamiflu .......................................................... 73 Tamoxifen Citrate .......................................... 60 Tamsulosin HCl ........................................... 131 Tandem F...................................................... 18 Tandem Plus ................................................. 18 Tapazole ..................................................... 132 Tarceva ......................................................... 60 Targretin................................................ 60, 129 Tarka ............................................................. 80 Taron Forte ................................................... 18 Taron-Bc ..................................................... 108 Taron-C DHA .............................................. 108 Taron-Crystals ................................................ 5 Taron-Prex .................................................. 108 Tasigna ......................................................... 60

Tasmar .......................................................... 62 Taxotere ........................................................ 60 Tazarotene .................................................. 129 Tazorac ....................................................... 129 Taztia XT ....................................................... 80 Tecfidera ....................................................... 97 TEGretol ........................................................ 28 TEGretol-XR .................................................. 28 Tekturna ...................................................... 122 Tekturna HCT .............................................. 122 Telmisartan ................................................. 121 Telmisartan-Amlodipine ................................. 82 Telmisartan-HCTZ ....................................... 121 Temazepam .................................................. 76 Temodar ........................................................ 60 Temovate ...................................................... 47 Temozolomide ............................................... 61 Tencon ............................................................ 6 Teniposide ..................................................... 61 Tenivac ........................................................ 134 Tenofovir Disoproxil Fumarate ...................... 72 Terazol 7 ....................................................... 41 Terazosin HCl ................................................. 5 Terbinafine HCl ............................................. 34 Terbutaline Sulfate ...................................... 132 Terconazole .................................................. 41 Tessalon Perles ............................................ 68 Tetanus-Diphtheria Toxoids Td ................... 134 Tetrabenazine ............................................... 85 Tetracycline HCl ............................................ 24 Tetrix ........................................................... 129 Texacort ........................................................ 47 TexaVite LQ ................................................ 108 TGT Miconazole 3 Combo Pack ................... 41 Thalomid ....................................................... 98 Theo-24 ....................................................... 124 Theochron ................................................... 124 Theophylline ................................................ 124 Theophylline ER .......................................... 124 TheraCys ..................................................... 135 Thiola .......................................................... 111 Thioridazine HCl .......................................... 120 Thiotepa ........................................................ 61 Thiothixene .................................................. 120 Thrivite 19 ................................................... 108 Thrivite Rx ................................................... 108 Thyrolar-1 .................................................... 133 Thyrolar-1/2 ................................................. 133 Thyrolar-1/4 ................................................. 133 Thyrolar-2 .................................................... 133


Updated 11/2019

Thyrolar-3.................................................... 133 TiaGABine HCl .............................................. 28 Tiazac ........................................................... 80 Tice BCG .................................................... 135 Tigan ............................................................. 34 Tikosyn ......................................................... 83 Tilia Fe .......................................................... 87 Timolol Maleate ....................................... 35, 78 Tindamax ...................................................... 64 Tinidazole...................................................... 64 Tirosint ........................................................ 133 Tivicay ........................................................... 72 TiZANidine HCl ........................................... 126 TL Folate ..................................................... 108 TL Gard Rx ................................................. 138 TL G-Fol OS ................................................ 108 TL Icon .......................................................... 18 TL-Care DHA .............................................. 108 TL-Fluorivite ................................................ 108 TL-Hem 150 .................................................. 18 TL-Select..................................................... 108 Tobi ............................................................... 18 TobraDex ST ................................................. 50 Tobramycin ............................................. 18, 39 Tobramycin Sulfate ....................................... 18 Tobrex ........................................................... 39 Tofranil ........................................................ 116 TOLAZamide ................................................. 32 TOLBUTamide .............................................. 32 Tolcapone ..................................................... 62 Tolmetin Sodium ............................................. 8 Tolterodine Tartrate ...................................... 95 Tolterodine Tartrate ER ................................ 95 Topamax ....................................................... 28 Topamax Sprinkle ......................................... 28 Topex Topical Anesthetic .............................. 66 Topicort ......................................................... 47 Topiramate .................................................... 28 Toposar ......................................................... 61 Topotecan HCl .............................................. 61 Torisel ........................................................... 61 Torsemide ..................................................... 89 Totect .......................................................... 113 Toujeo SoloStar ............................................ 31 Toviaz ........................................................... 95 Tracleer ....................................................... 137 Tradjenta ....................................................... 30 TraMADol HCl ............................................... 13 TraMADol HCl ER ......................................... 13 TraMADol HCl ER (Biphasic) ........................ 13

Tramadol-Acetaminophen ............................. 13 Trandolapril ................................................. 122 Trandolapril-Verapamil HCl ER ..................... 80 Tranexamic Acid ........................................... 37 Transderm-Scop (1.5 MG) ............................ 34 Tranxene-T .................................................... 76 Tranylcypromine Sulfate .............................. 116 Travatan Z ..................................................... 36 TraZODone HCl .......................................... 116 Treanda ......................................................... 61 Trecator ......................................................... 54 Trelstar Mixject .............................................. 61 Tretinoin .................................................. 61, 84 Tretinoin Microsphere .................................... 84 Tretinoin Microsphere Pump ......................... 84 Tretin-X ......................................................... 84 Trexall ........................................................... 61 Treximet ........................................................ 53 Tri Femynor ................................................... 87 Triamcinolone Acetonide ..................... 4, 47, 50 Triamterene-HCTZ ........................................ 90 Trianex .......................................................... 47 Triazolam ...................................................... 76 Tribenzor ....................................................... 82 TriCare ........................................................ 108 TriCare Prenatal Compleat .......................... 108 TriCare Prenatal DHA ONE ......................... 108 Tricitrates ........................................................ 5 Tricon ............................................................ 18 Tricor ............................................................. 52 Triderm .......................................................... 47 Tridesilon ....................................................... 47 Triesence ...................................................... 50 Tri-Estarylla ................................................... 87 Trifluoperazine HCl...................................... 120 Trifluridine ..................................................... 41 Trigels-F Forte ............................................... 18 Triglide .......................................................... 52 Trihexyphenidyl HCl ...................................... 62 Triklo ............................................................. 51 Tri-Legest Fe ................................................. 87 Trileptal ......................................................... 28 Tri-Linyah ...................................................... 87 Trilipix ............................................................ 52 Tri-Lo-Estarylla .............................................. 87 Tri-Lo-Marzia ................................................. 87 Tri-Lo-Sprintec .............................................. 87 TriLyte ........................................................... 84 Trimethobenzamide HCl ................................ 34 Trimethoprim ............................................... 135


Updated 11/2019

Trimipramine Maleate ................................. 117 Trinatal Rx 1 ................................................ 108 Trinate ......................................................... 108 TriNessa (28) ................................................ 87 TriNessa Lo ................................................... 87 Triphrocaps ................................................. 108 Tri-Previfem .................................................. 87 Tri-Sprintec ................................................... 87 TriStart DHA ................................................ 108 Tri-Tabs DHA .............................................. 108 Triveen-Duo DHA ........................................ 108 Tri-Vi-Flor .................................................... 108 Tri-Vi-Floro .................................................. 108 Tri-Vit/Fluoride ............................................ 108 Tri-Vit/Fluoride/Iron ..................................... 108 Tri-Vitamin/Fluoride ..................................... 108 Trivora (28) ................................................... 87 Trizivir ........................................................... 72 Tropicamide ................................................ 110 Trospium Chloride ......................................... 95 Trospium Chloride ER ................................... 95 Trulicity.......................................................... 30 Truvada ......................................................... 72 Tudorza Pressair ........................................... 25 Tusnel ........................................................... 68 TussiCaps ..................................................... 68 Tussigon ....................................................... 68 Tussionex Pennkinetic ER ............................ 69 Twynsta......................................................... 82 Tybost ......................................................... 111 Tykerb ........................................................... 61 Tylenol with Codeine #3 ................................ 13 Tylenol with Codeine #4 ................................ 13 Tysabri .......................................................... 98 Tyvaso ........................................................ 137 Tyvaso Refill ............................................... 137 Tyvaso Starter ............................................. 137

U

Uceris .............................................................. 4 Udamin SP .................................................. 108 Ulesfia ........................................................... 43 Uloric ............................................................. 36 UltimateCare ONE ...................................... 108 Ultracet ......................................................... 13 Ultram ........................................................... 13 Ultravate........................................................ 47 Ultravate X (Cream) ...................................... 47 Ultravate X (Ointment) .................................. 48 Umecta Mousse .......................................... 101

Unithroid ...................................................... 133 Unithroid Direct ........................................... 134 Ur N-C ......................................................... 135 Uramaxin ..................................................... 101 Urea ............................................................ 101 Urea Hydrating ............................................ 101 Urea in Zn Undecyl-Lactic Acid ................... 101 Urea Nail ..................................................... 101 Urea-C40 ..................................................... 101 Urecholine ................................................... 112 Ure-K ........................................................... 101 Urelle ........................................................... 135 Uremez-40 .................................................. 101 Uretron D/S ................................................. 135 Uribel ........................................................... 135 Urimar-T ...................................................... 135 Urin DS ........................................................ 135 Uro-458 ....................................................... 135 UroAv-81 ..................................................... 135 UroAv-B ....................................................... 135 Urocit-K 10 ...................................................... 5 Urocit-K 15 ...................................................... 5 Urocit-K 5 ........................................................ 5 Urogesic-Blue .............................................. 135 Uro-MP ........................................................ 135 Urosex ......................................................... 108 Uroxatral ...................................................... 131 Urso 250 ........................................................ 85 Urso Forte ..................................................... 85 Ursodiol ......................................................... 85 Uryl .............................................................. 135 Ustell ........................................................... 135 Uticap .......................................................... 135 Utira-C ......................................................... 135 Utrona-C ...................................................... 135

V

Vagifem ......................................................... 93 ValACYclovir HCl .......................................... 74 Valcyte .......................................................... 74 ValGANciclovir HCl ....................................... 74 Valium ........................................................... 76 Valproate Sodium .......................................... 28 Valproic Acid ................................................. 28 Valsartan ..................................................... 121 Valsartan-Hydrochlorothiazide .................... 121 Valstar ........................................................... 61 Valtrex ........................................................... 74 Vanatol LQ ...................................................... 6 Vanatol S ......................................................... 6


Updated 11/2019

Vancocin HCl ................................................ 19 Vancomycin HCl ........................................... 19 Vandazole ..................................................... 39 Vanos ............................................................ 48 Vanoxide-HC ................................................. 50 Vantas ........................................................... 61 Vascepa ........................................................ 51 Vaseretic ..................................................... 122 V-C Forte .................................................... 108 Vectibix ......................................................... 61 Vectical ....................................................... 129 Velcade ......................................................... 61 Veletri .......................................................... 137 Veltin ........................................................... 129 VemaVite-PRx 2 ......................................... 108 Vena-Bal DHA ............................................. 108 Venlafaxine HCl .......................................... 117 Venlafaxine HCl ER .................................... 117 Ventavis ...................................................... 137 Ventolin HFA ............................................... 132 Verapamil HCl ............................................... 80 Verapamil HCl ER ......................................... 80 Verdeso......................................................... 48 Veregen ...................................................... 129 Verelan ......................................................... 80 Verelan PM ................................................... 80 Veripred 20 ..................................................... 4 VESIcare ....................................................... 95 Vfend ............................................................ 35 Viagra ......................................................... 137 Vibramycin .................................................... 24 VIC-Forte .................................................... 108 Vicodin .......................................................... 13 Vicodin ES .................................................... 13 Vicodin HP .................................................... 13 Victoza .......................................................... 30 Vidaza ........................................................... 61 Videx ............................................................. 72 Videx EC ....................................................... 72 Vienva ........................................................... 87 Vigamox ........................................................ 39 Viibryd ......................................................... 117 Vilamit MB ................................................... 135 Vilevev MB .................................................. 135 Vimovo ............................................................ 8 Vimpat ........................................................... 28 Vinate DHA RF ........................................... 108 Vinate II ....................................................... 108 Vinate M ...................................................... 108 Vinate One .................................................. 109

VinBLAStine Sulfate ...................................... 61 Vincasar PFS ................................................ 61 VinCRIStine Sulfate....................................... 61 Vinorelbine Tartrate ....................................... 61 Viokace ......................................................... 88 Viracept ......................................................... 72 Viramune ....................................................... 72 Viramune XR ................................................. 72 Virasal ......................................................... 101 Virazole ......................................................... 74 Viread ............................................................ 72 Viroptic .......................................................... 41 Virt Nate ...................................................... 109 Virt-C DHA .................................................. 109 Virt-Caps ..................................................... 109 Virt-Gard ...................................................... 139 Virti-Sulf ....................................................... 101 Virt-Nate DHA ............................................. 109 Virt-Phos 250 Neutral .................................. 124 Virt-PN ......................................................... 109 Virt-PN DHA ................................................ 109 Virt-PN Plus ................................................. 109 Virtussin A/C ................................................. 69 Vistaril ........................................................... 75 Vita S Forte ................................................. 109 Vita-Bee/C ................................................... 109 Vitacel ......................................................... 109 Vitafol ............................................................ 18 Vitafol FE+................................................... 109 Vitafol Ultra .................................................. 109 Vitafol-Nano ................................................ 109 Vitafol-OB .................................................... 109 Vitafol-OB+DHA .......................................... 109 Vitafol-One .................................................. 109 Vitaject ........................................................ 109 Vital-D Rx .................................................... 109 Vitamax Pediatric ........................................ 109 VitaMedMD One Rx/Quatrefolic .................. 109 VitaMedMD RediChew Rx ........................... 109 Vitamez ....................................................... 139 Vita-Min ....................................................... 109 Vitamin B Complex 100 ............................... 139 Vitamin B-Complex 100 ............................... 139 Vitamin D (Ergocalciferol) ............................ 139 Vitamin K1 ................................................... 139 Vitamins ACD-Fluoride ................................ 109 VitaPearl ...................................................... 109 Vitaroca Plus ............................................... 109 Vita-Rx Diabetic Vitamin .............................. 109 Viva DHA ..................................................... 109


Updated 11/2019

Vivelle-Dot..................................................... 93 Vivitrol ......................................................... 110 Vol-Care Rx ................................................ 109 Vol-Nate ...................................................... 109 Vol-Plus....................................................... 109 Vol-Tab Rx .................................................. 109 Voltaren....................................................... 129 Voraxaze ....................................................... 33 Voriconazole ................................................. 35 Votrient ......................................................... 61 VP-GGR-B6 Prenatal .................................. 109 VP-Heme OB .............................................. 109 VP-Heme OB + DHA ................................... 109 VP-HEME One ............................................ 109 VP-PNV-DHA .............................................. 109 Vpriv .............................................................. 91 VP-Vite Rx .................................................. 109 VP-ZEL ....................................................... 110 Vusion ........................................................... 41 Vyvanse ........................................................ 14

W

Warfarin Sodium ........................................... 67 Welchol ......................................................... 51 Wellbutrin SR .............................................. 117 Wellbutrin XL ............................................... 117 Westhroid .................................................... 134 WinRho SDF ............................................... 126 WP Thyroid ................................................. 134

X

Xalkori ........................................................... 61 Xanax ............................................................ 76 Xanax XR ...................................................... 76 Xarelto .......................................................... 67 Xarelto Starter Pack ...................................... 67 Xeljanz .......................................................... 89 Xeljanz XR .................................................... 89 Xeloda ........................................................... 61 Xenazine ....................................................... 85 Xeralux ........................................................ 129 Xerese .......................................................... 41 Xgeva ............................................................ 78 Xifaxan .......................................................... 19 Xigduo XR ..................................................... 31 Xolair ........................................................... 124 Xolegel .......................................................... 41 Xolegel CorePak ........................................... 41 Xolegel Duo/Head & Shoulders .................... 41 Xolegel Duo/Xolex ........................................ 41 Xopenex ...................................................... 132

Xopenex Concentrate .................................. 132 Xopenex HFA .............................................. 132 Xtandi ............................................................ 61 Xulane ........................................................... 88 Xyrem ............................................................ 85

Y

Yervoy ........................................................... 61 YL Folic Acid ............................................... 139 Yuvafem ........................................................ 93

Z

Zacare ........................................................... 43 Zaclir Cleansing ............................................ 43 Zafirlukast ...................................................... 50 Zaleplon ........................................................ 75 Zaltrap ........................................................... 61 Zanaflex ...................................................... 126 Zanosar ......................................................... 61 Zantac ........................................................... 69 Zarontin ......................................................... 29 Zarxio ............................................................ 96 Zatean-Pn DHA ........................................... 110 Zatean-Pn Plus ........................................... 110 Zavesca ....................................................... 111 Zebutal ............................................................ 6 Zegerid .......................................................... 70 Zelapar .......................................................... 64 Zelboraf ......................................................... 61 Zemaira ....................................................... 124 Zemplar ....................................................... 139 Zenatane ..................................................... 129 Zenpep .......................................................... 88 Zerit ............................................................... 73 Zestoretic .................................................... 122 Zetia .............................................................. 51 Zetonna ......................................................... 50 Ziagen ........................................................... 73 Ziana ........................................................... 129 Zidovudine ..................................................... 73 Zileuton ER ................................................... 50 Zinecard ...................................................... 114 Zioptan .......................................................... 36 Ziprasidone HCl .......................................... 120 Zipsor .............................................................. 8 Zirgan ............................................................ 41 Zithranol ...................................................... 129 Zithromax ...................................................... 21 Zithromax Tri-Pak .......................................... 21 Zithromax Z-Pak ............................................ 21 Zofran ............................................................ 33


Updated 11/2019

Zofran ODT ................................................... 33 Zoledronic Acid ............................................. 78 Zolinza .......................................................... 61 ZOLMitriptan ................................................. 54 Zoloft ........................................................... 117 Zolpidem Tartrate .......................................... 75 Zolpidem Tartrate ER .................................... 75 Zolpimist........................................................ 75 Zometa .......................................................... 79 Zomig ............................................................ 54 Zomig ZMT .................................................... 54 Zonalon ......................................................... 66 Zonegran....................................................... 28 Zonisamide ................................................... 28 Zortress ......................................................... 99 Zovia 1/35E (28) ........................................... 88

Zovirax .................................................... 41, 74 Zubsolv .......................................................... 14 Zuplenz ......................................................... 33 Zutripro .......................................................... 69 Zyban .......................................................... 117 Zyclara ........................................................ 129 Zyclara Pump .............................................. 129 Zyflo .............................................................. 50 Zyflo CR ........................................................ 50 Zyloprim ........................................................ 36 Zymaxid ......................................................... 39 ZyPREXA .................................................... 120 ZyPREXA Relprevv ..................................... 120 ZyPREXA Zydis .......................................... 120 Zytiga ............................................................ 61 Zyvox ............................................................. 19

Documents

PROSSAM 2020 Formulary (List of Covered Drugs)...PROSSAM - PROSSAM 2020 Page 1 of 171 Updated 11/2019 PROSSAM 2020 Formulary (List of Covered Drugs)