H9312_Formulary SPA AZCA

FR E S E N I U S TO TAL HE ALTH ( PPO
S N P)
2 0 1 6 Formulario – Lista de M edicamentos Cubiertos
FAVO R DE LEER : ESTE DO CUMENTO CO NTI ENE I NFO R MACI Ó N ACER CA DE LO S
MEDI CAMENTO S Q UE CUBR I MO S EN ESTE PLAN
H9 312 16 334 , V
Este formulario se actualizó el 1 de marzo de 2 016. Para obtener información más reciente o si tiene
otras preguntas, póngase en contacto con Fresenius Total Health Servicio al Cliente llamando al
5 9 8 - 6 7 7 4 o, para los usuarios de TTY ,
2 09 - 9 09 4 ,
a
r
, de 8 a.m. a 11 p.m. (hora
de este) o visite www.esrdplan.com.
H9 312 _ Formulary0001_ SPA
Accepted 12 / 10/ 15
N ota a los miembros ex istentes: Este formulario ha cambiado desde el añ o pasado. Examine este documento para
asegurarse de que aún contiene lo medicamentos que usted toma.
uando esta lista de medicamentos formulario se refiere a “nosotros,” “nos,” o “nuestro,” quiere decir Fresenius Health
lans. uando se refiere a “plan” o “nuestro plan,” quiere decir Fresenius Total Health
.
Este documento incluye lista de medicamentos (formulario) para nuestro plan que está al día el 1 de a r de 2 016.
Para el formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de
la última vez que actualizamos el formulario, aparece en las cubiertas delantera y trasera.
eneralmente, debe utili ar farmacias de red para utili ar su beneficio de medicamentos de receta. os beneficios, el
formulario, la red de farmacias, y/ o los copagos/ el coseguro pueden cambiar el 1 de enero de 2 017 y de vez en cuando
durante el añ o.
¿Qué es el Formulario del Fresenius Total Health ?
Un formulario es una lista de medicamentos cubiertos seleccionados por Fresenius Total Health consultando con un
equipo de proveedores de atención médica, que representa las terapias de receta que se cree son parte necesaria de un
programa de tratamiento de calidad. Generalmente, Fresenius Total Health cubrirá los medicamentos enumerados en
nuestro formulario siempre que el medicamento sea necesario por motivos médicos, la receta se surta en una farmacia
de la red de Fresenius Total Health y se sigan otras reglas del plan. Para mayor información acerca de cómo surtir sus
recetas, examine su Evidencia de Cobertura.
¿Puede cambiar el Formulario ( lista de medicamentos) ?
Generalmente, si está tomando un medicamento de nuestro formulario de 2 016 que estaba cubierto al principio del añ o,
no eliminaremos ni reduciremos la cobertura del medicamento durante el añ o de cobertura 2 016 excepto cuando un
medicamento genérico nuevo y menos caro esté disponible o cuando se divulgue nueva información adversa acerca
de la seguridad o eficacia de un medicamento. tros tipos de cambios al formulario, tales como quitar un medicamento
del mismo, no afectarán a los miembros que estén tomando el medicamento actualmente. Seguirá estando disponible
al mismo costo compartido para los miembros que lo tomen durante el resto del añ o de cobertura. Creemos que es
importante que tenga acceso continuo durante el resto del añ o de cobertura a los medicamentos del formulario que
estaban disponibles cuando eligió nuestro plan, excepto en los casos en que pueda ahorrar más dinero o podamos
garantizar su seguridad.
Si quitamos medicamentos de nuestro formulario, añ adimos, después de obtener autorización, límites de cantidades y/ o
restricciones de terapia en pasos que afecten a un medicamento o trasladamos un medicamento a un nivel más alto de
costo compartido, debemos notificar a los miembros afectados del cambio al menos 0 días antes de que entre en vigor,
o en el momento en que el miembro solicite que se le repita la receta del medicamento, cuando el miembro recibirá un
suministro de 6 0 días del medicamento. Si la Administración de Alimentos y Medicamentos considera que uno de los
medicamentos de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, retiraremos
inmediatamente el medicamento de nuestro formulario notificaremos a los miembros que toman el medicamento.
El formulario adjunto está al día el 1 de a r de 2 016. Para obtener información actualizada acerca de los
medicamentos cubiertos por Fresenius Total Health, póngase en contacto con nosotros. Nuestra información de contacto
aparece en las cubiertas delantera y trasera.
Todos los meses actualizamos nuestro formulario impreso con un anexo mensual. Visite nuestro sitio web en
www.esrdplan.com o comuníquese con Servicio al Cliente para obtener más información.
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¿Cómo se utiliza el Formulario?
Hay dos maneras de encontrar su medicamento en el formulario:
Condición Médica
El formulario empieza en la página 1. Los medicamentos de este formulario están agrupados en categorías según
el tipo de condición médica para el tratamiento de la cual se utilizan. Por ejemplo, los medicamentos que se utilizan
para tratar una condición cardiaca se enumeran bajo la categoría, Cardiovascular Agent. Si sabe para qué se utiliza
su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Después, busque su
medicamento bajo el nombre de la categoría.
Lista Alfabética
Si no está seguro de la categoría bajo la cual buscar, debe buscar su medicamento en el Índice que empieza en la página
103. El Índice da una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos
de marca como los genéricos se enumeran en el Índice. Mire en el Índice para encontrar su medicamento. Al lado de su
medicamento verá el número de la página donde puede encontrar información de cobertura. Vaya a la página indicada en
el Índice y busque el nombre de su medicamento en la primera columna de la lista.
¿Qué son medicamentos genéricos?
Fresenius Total Health cubre tanto medicamentos de marca como los medicamentos genéricos. Un medicamento
genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) indicando que tiene el mismo
ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los
medicamentos de marca.
¿Hay restricciones en mi cobertura?
Es posible que algunos medicamentos cubiertos tengan requisitos adicionales o límites de cobertura. Estos requisitos y
límites pueden incluir:
•Autorización Previa: Fresenius Total Health requiere que usted [o su médico] obtenga autorización previa
para ciertos medicamentos. Esto quiere decir que necesitará obtener la aprobación de Fresenius Total Health
antes de surtir sus recetas. Si no obtiene aprobación, es posible que Fresenius Total Health no cubra el
medicamento.
•Límites de Cantidad: Para ciertos medicamentos, Fresenius Total Health limita la cantidad de medicamento que
cubrirá Fresenius Total Health. Por ejemplo, Fresenius Total Health proporciona 30 unidades por receta
para Digoxin. Esto puede ser además de un suministro estándar de un mes o tres meses.
• Terapia en Pasos: En algunos casos, Fresenius Total Health requiere que pruebe primero ciertos medicamentos
para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo,
si el Medicamento A y el Medicamento B tratan su condición médica, es posible que Fresenius Total Health no
cubra el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no le va
bien, Fresenius Total Health cubrirá entonces el Medicamento B.
Puede averiguar si su medicamento tiene requisitos o límites adicionales mirando en el formulario que empieza en la
página 1. También puede obtener más información acerca de las restricciones aplicadas a medicamentos específicos
cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra autorización previa y
las restricciones para la terapia escalonada.
También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última
actualización del vademécum, aparece en las cubiertas delantera y trasera.
Puede pedirle a Fresenius Total Health que haga una excepción a estas restricciones a límites, o pedirle una lista de
otros medicamentos parecidos que puedan tratar su condición médica. Vea la sección, “¿Qué tengo que hacer para
solicitar una excepción al formulario de Fresenius Total Health’s?” en la página 103 para ver información acerca de la
manera de solicitar una excepción.
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¿Qué pasa si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), lo primero que debe hacer es
ponerse en contacto con Servicios de Miembros y preguntar si está cubierto su medicamento.
Si averigua que Fresenius Total Health no cubre su medicamento, tiene dos opciones:
• Puede pedirle a Servicios de Cliente una lista de medicamentos parecidos que estén cubiertos por Fresenius
Total Health. Cuando reciba la lista, enséñ esela a su médico y pídale que le recete un medicamento parecido que
esté cubierto por Fresenius Total Health.
• Le puede pedir a Fresenius Total Health que haga una excepción y cubra su medicamento. Vea la información
que aparece a continuación para ver cómo solicitar una excepción.
¿Cómo se solicita una ex cepción al Formulario de Fresenius Total Health ’ s?
Le puede pedir a Fresenius Total Health que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de
excepciones que puede pedirnos que hagamos.
• Puede pedirnos que cubramos un medicamento aún si no está en nuestro formulario. Si se aprueba, este
medicamento se cubrirá a un nivel predeterminado de costo compartido, y usted no podría pedirnos que
proporcionemos el medicamento a un nivel más bajo de costo compartido.
• Puede pedirnos que cubramos un medicamento del formulario a un nivel más bajo de costo compartido. Si se
aprueba, esto reduciría la cantidad que debe pagar usted por su medicamento.
• Puede pedirnos que demos una exención para las restricciones o límites de cobertura de su medicamento. Por
ejemplo, para ciertos medicamentos, Fresenius Total Health limita la cantidad de medicamento que cubrimos. Si
su medicamento tiene un límite de cantidad, pude pedirnos que otorguemos una exención para el límite y
que cubramos una cantidad mayor.
Generalmente, Fresenius Total Health solamente aprobará su solicitud de excepción si los medicamentos
de alternativa incluidos en el formulario del plan, el medicamento de costo compartido más bajo o las restricciones de
utilización adicionales no serían tan efectivas en el tratamiento de su condición y/ o harían que usted tuviera efectos
médicos adversos.
Debe ponerse en contacto con nosotros para pedirnos una decisión de cobertura inicial para una excepción al formulario,
nevels o de las restricciones de utilización. Cuando solicite una ex cepción al f ormulario, nevels o de restricciones
de utilización, debe presentar una declaración de su recetador o médico apoyando su solicitud. Generalmente,
tenemos que tomar una decisión dentro de las 7 2 horas siguientes a recibir la declaración de apoyo de su recetador.
Puede solicitar una excepción acelerada (rápida) si usted o su médico cree que su salud podría verse severamente
dañ ada si espera 7 2 horas para recibir una decisión. Si su solicitud de acelerar se concede, debemos darle una decisión
no más de 2 4 horas después de recibir una declaración de apoyo de su médico u otro recetador.
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¿Qué h ago antes de poder h ablar con mi médico acerca de cambiar mis medicamentos o
solicitar una ex cepción?
Como miembro nuevo de o si continua en nuestro plan, puede que esté tomando medicamentos que no estén en nuestro
formulario. O puede que esté tomando un medicamento que esté en el formulario pero su habilidad de obtenerlo sea
limitada. Por ejemplo, puede que necesite autorización previa nuestra antes de poder surtir su receta. Debe hablar
con su médico para decidir si debería cambiar a un medicamento apropiado que cubramos o solicitar una excepción
al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el rumbo
correcto que seguir, puede que cubramos su medicamento en ciertos casos durante los primeros 9 0 días que sea
miembro de nuestro plan.
Para cada uno de sus medicamentos que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos
es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta que indique un número de
días menor) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos
medicamentos, aún si ha sido miembro del plan menos de 9 0 días.
Si es residente de una clínica de cuidado de largo plazo, permitiremos que repita su receta hasta que le hayamos
provisto un suministro de transición de 9 8 días, consistente con el incremento de suministro (a menos que tenga una
receta que indique un número menor de días). Cubriremos más de una repetición de estos medicamentos durante los
primeros 9 0 días que sea miembro de nuestro plan. Si necesita un medicamento que no esté en nuestro formulario o
si su habilidad de obtener sus medicamentos es limitada, pero ya han pasado los primeros 9 0 días de membresía en
nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta
que indique un número menor de días) mientras tramita una excepción al formulario.
Los miembros que tengan un cambio en su nivel de atención (entorno) tendrán permitido un suministro único para
transición de 30 días por medicamento.
Por ejemplo, los clientes que:
• ngresen a instituciones de cuidado a largo pla o por sus siglas en inglés, “ T ” provenientes de hospitales
en ocasiones reciben, junto con su alta, una lista de medicamentos del formulario del hospital que considera un
tiempo demasiado corto para planificación a menudo menos de horas .
• Sean dados de alta del hospital a un hogar.
•Terminen su estadía en una institución de enfermería especializada de Medicare Parte A (en donde los pagos
incluyen todos los cargos de farmacia) y que necesiten regresar a su formulario del plan de Parte D.
•Terminen una estadía en una institución de cuidado a largo plazo y regresen a la comunidad.
Si un miembro tiene más de un cambio en el nivel de atención en un mes, la farmacia tendrá que llamar a nuestro plan
para solicitar una extensión de la política de transición.
Para mayor inf ormación
Para obtener información más detallada acerca de su cobertura de medicamentos de receta de Fresenius Health Plans,
examine su Evidencia de Cobertura y otros materiales del plan.
Si tiene preguntas acerca de Fresenius Health Plans, póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera.
Si tiene preguntas generales acerca de la cobertura de medicamentos de receta de Medicare, llame a Medicare al
1- 8 00- MEDI CAR E (1- 8 00- 6 33- 4 2 2 7 ) 2 4 horas al día / 7 días a la semana. Los usuarios de TTY deben llamar al 1- 8 7 7 4 8 6 - 2 04 8 . O visite http:/ / www.medicare.gov.
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Formulario de Fresenius Total Health
El formulario empieza en la página 1 proporciona información de cobertura acerca de los medicamentos cubiertos por
Fresenius Total Health. i tiene dificultades para encontrar su medicamento en la lista, va a al ndice que empie a en la
página 103.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en letras
mayúsculas (por ejemplo, CO UMADI N) y los medicamentos genéricos aparecen en cursiva minúscula
(por ejemplo, warfarin).
La información de la columna de R equisitos/ Límites le dice si Fresenius Total Health tiene algún requisito especial para la
cobertura de su medicamento.
Lista de abreviaturas
B/ D:
Este medicamento de prescripción tiene un requisito administrativo de autorización previa de Parte B versus
D. Este medicamento puede estar cubierto por Medicare Parte B o Parte D, dependiendo de las circunstancias.
Q uizá sea necesario entregar información que describa el uso y el entorno del medicamento para hacer
la determinación.
Q L:
Límite de cantidad Para ciertos medicamentos, Fresenius Total Health limita la cantidad del fármaco que
cubrirá. Por ejemplo, Fresenius Total Health proporciona doce tabletas por receta de succinato de sumatriptán.
Estas pueden ser adicionales a un suministro estándar para un mes o para tres meses.
ST:
Terapia escalonada. En algunos casos, Fresenius Total Health requiere que primero pruebe ciertos
medicamentos para el tratamiento de su trastorno médico antes de que cubramos otro medicamento para ese
trastorno. Por ejemplo, si el Medicamento A y el Medicamento B sirven para tratar su trastorno médico,
Fresenius Total Health podría no cubrir el Medicamento B a menos que usted pruebe con
el Medicamento A antes. Si el Medicamento A no le da resultado, Fresenius Total Health
cubrirá el Medicamento B.
PA:
Autorización previa Fresenius Total Health requiere que usted o su médico obtengan autorización previa para
ciertos medicamentos. sto significa que usted deberá obtener la aprobación de Fresenius Total Health antes de
surtir sus recetas. Si no obtiene la aprobación, Fresenius Total Health podría no cubrir el medicamento.
Costo Compartido M inorista E stá ndar
NI VEL
vi
SUMNI STR O
PO R
UN MES
SUMI NI STR O
PO R TR ES MESES
N ivel 1 (Preferido genérico)
$ 0
N ivel 2 (Genérico)
2 5 %
del costo
2 5 %
del costo
N ivel 3 (De marca preferido)
2 5 %
del costo
2 5 %
del costo
N ivel 4 (De marca no preferido)
2 5 %
del costo
2 5 %
del costo
N ivel 5 (Nivel de especializado)
2 5 %
del costo
No se ofrece
vi
$ 0
2016 Fresenius 5 Tier Formulary
Formulary ID: 16330; 16334
Effective: 03/01/16
Last Updated: 02/01/16
D ruggNNaame
Nombre
del Medicamento
D rug
Requirements/Limits
Nivel de
Medicamento
gT T ier
q Requisitos/Límites
ts/L
Analgesics
Analgesics
Analgesics
Analgesics
acetaminophen-codeine oral
oral solution
solution 300
300 mg-30
mg-30
acetaminophen-codeine
mg /12.5
/12.5 ml
ml
mg
acetaminophen-codeine oral
oral tablet
tablet 300-15
300-15 mg,
mg,
acetaminophen-codeine
300-30
mg,
300-60
mg
300-30 mg, 300-60 mg
ascomp with
with codeine
codeine oral
oral capsule
capsule 30-50-325-40
30-50-325-40
ascomp
mg
mg
butalbital-acetaminop-caf-cod oral
oral capsule
capsule 5050butalbital-acetaminop-caf-cod
325-40-30
mg
325-40-30 mg
carisoprodol-asa-codeine oral
oral tablet
tablet 200-325-16
200-325-16
carisoprodol-asa-codeine
mg
mg
carisoprodol-aspirin oral
oral tablet
tablet 200-325
200-325 mg
mg
carisoprodol-aspirin
endocet oral
oral tablet
tablet 10-325
10-325 mg,
mg, 5-325
5-325 mg,
mg, 7.5-325
7.5-325
endocet
mg
mg
endodan oral
oral tablet
tablet 4.8355-325
4.8355-325 mg
mg
endodan
hydrocodone-acetaminophen oral
oral tablet
tablet 10-325
10-325
hydrocodone-acetaminophen
mg,
5-325
mg,
7.5-325
mg
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
hydrocodone-ibuprofen oral
oral tablet
tablet 7.5-200
10-200 mg,
hydrocodone-ibuprofen
mg 5200 mg, 7.5-200 mg
lorcet plus oral tablet 7.5-325 mg
lorcet plus oral tablet 7.5-325 mg
oxycodone-acetaminophen oral tablet 10-325 mg,
oxycodone-acetaminophen
oralmg
tablet 10-325 mg,
2.5-325
mg, 5-325 mg, 7.5-325
2.5-325 mg, 5-325 mg, 7.5-325 mg
oxycodone-aspirin oral tablet 4.8355-325 mg
oxycodone-aspirin oral tablet 4.8355-325 mg
pentazocine-naloxone oral tablet 50-0.5 mg
pentazocine-naloxone oral tablet 50-0.5 mg
tramadol-acetaminophen oral tablet 37.5-325 mg
tramadol-acetaminophen oral tablet 37.5-325 mg
Nonsteroidal Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs
celecoxib oral capsule 100 mg, 200 mg, 400 mg,
celecoxib
oral capsule 100 mg, 200 mg, 400 mg,
50
mg
50 mg
diclofenac potassium oral tablet 50 mg
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended release 24
diclofenac
hr
100 mg sodium oral tablet extended release 24
hr 100 mg
diclofenac sodium oral tablet,delayed release
(dr/ec) 25 mg, 50 mg, 75 mg
22
22
22
PA
PA
22
PA
PA
22
PA
PA
22
22
PA
PA
22
22
22
2
2
2
2
2
2
2
2
2
2
PA
PA
2
2
2
2
1
1
1
1
Puede
Puede encontrar
encontrar información
información sobre
sobre lo
lo que
que significan
significan las
las abreviaturas
abreviaturas as
as en
en esta
esta tabla,
tabla, vaya
vayaaala
lapágina
páginavi
vi
11
D Nombre
rug N ame
del Medicamento
T ier
Requirements/Limits
Nivel D derugMedicamento
Requisitos/Límites
diclofenac
tablet,delayed
release
diclofenacsodium
sodiumoral
topical
gel 3
(dr/ec) 25 mg, 50 mg, 75 mg
diflunisal oral tablet 500 mg
diflunisal oral tablet 500 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24 hr 400
etodolac
tablet
mg, 500 oral
mg, 600
mgextended release 24 hr 400
mg, 500 mg, 600 mg
fenoprofen oral tablet 600 mg
fenoprofen oral capsule 400 mg
flurbiprofen oral tablet 100 mg, 50 mg
fenoprofen oral tablet 600 mg
ibuprofen oral suspension 100 mg/5 ml
flurbiprofen oral tablet 100 mg, 50 mg
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
ibuprofen oral suspension 100 mg/5 ml
ibuprofen-oxycodone oral tablet 400-5 mg
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
indomethacin oral capsule 25 mg, 50 mg
ibuprofen-oxycodone oral tablet 400-5 mg
indomethacin oral capsule, extended release 75
indomethacin
oral capsule 25 mg, 50 mg
mg
15
2
2
2
2
1
2
1
1
2
1
2
2
2
2
PA
PA
indomethacin
oral
capsule,
release 75
etoprofen oral
capsule
50 extended
mg, 75 mg
mg
etoprofen oral capsule,ext rel. pellets 24 hr 200
ketoprofen
oral capsule 50 mg, 75 mg
mg
22
PA
ketoprofen
oral
capsule,ext
200 (1
etorolac in
ection
solutionrel.
15 pellets
mg/ml, 24
30 hr
mg/ml
mg
ml)
22
PA
ketorolac
solution
etorolacinjection
oral tablet
10 mg15 mg/ml, 30 mg/ml (1
ml)
meclofenamate oral capsule 100 mg, 50 mg
ketorolac oral tablet 10 mg
meloxicam oral suspension 7.5 mg/5 ml
meclofenamate oral capsule 100 mg, 50 mg
meloxicam oral tablet 15 mg, 7.5 mg
meloxicam oral suspension 7.5 mg/5 ml
nabumetone oral tablet 500 mg, 750 mg
meloxicam oral tablet 15 mg, 7.5 mg
NAPRELAN CR ORAL TABLET, ER
nabumetone
oral 24
tablet
MULTIPHASE
HR500
375mg,
MG,750
500mg
MG, 750
MG
NAPRELAN CR ORAL TABLET, ER
MULTIPHASE
24 HR 375125
MG,mg/5
500 ml
MG, 750
naproxen oral suspension
MG
naproxen oral tablet 250 mg, 375 mg, 500 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet,delayed release (dr/ec) 375
mg, 500 mg
naproxen
oral tablet 250 mg, 375 mg, 500 mg
22
PA
PA
naproxenoral
sodium
oral tablet release
275 mg,(dr/ec)
550 mg375
naproxen
tablet,delayed
mg, 500 mg
naproxen sodium oral tablet, er multiphase 24 hr
500 mg sodium oral tablet 275 mg, 550 mg
naproxen
22
oxaprozinsodium
oral tablet
mger multiphase 24 hr
naproxen
oral 600
tablet,
375 mg, 500 mg
piroxicam oral capsule 10 mg, 20 mg
22
2
2
2
2
2
2
2
2
PA
2
2
2
2
2
2
1
2
2
1
4
2
PA
4
1
1
1
2
1
2
2
2
2
22
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encontrarinformación
informaciónsobre
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quesignifican
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páginavivi Puede
del Medicamento
D Nombre
rug N ame
Nivel D derug
Medicamento
Requisitos/Límites
T ier
Requirements/Limits
oxaprozin
oraltablet
tablet150
600mg,
mg200 mg
sulindac oral
22
tolmetin oral
piroxicam
oralcapsule
capsule400
10mg
mg, 20 mg
22
tolmetin oral
sulindac
oral tablet
tablet 600
150 mg
mg, 200 mg
22
VOLTAREN
TOPICAL
tolmetin
oral capsule
400GEL
mg 1 %
24
ZORVOLEX
ORAL200
CAPSULE
18 MG, 35 MG
tolmetin
oral tablet
mg, 600 mg
23
ST
ZORVOLEX
ORAL CAPSULE
18 MG, 35 MG
Opioid Analgesics,
Long-Acting
3
ST
Opioid
Analgesics,
Long-Acting
duramorph
(pf) in ection
solution 0.5 mg/ml, 1
2
B/D
2
2
B/D
PA; QL (120 EA per 30 days)
2
QL (10 EA per 30 days)
2
QL (10 EA per 30 days)
2
QL (240 EA per 30 days)
2
2
2
2
2
2
2
2
B/D
QL (240 EA per 30 days)
2
2
QL (60 EA per 30 days)
QL (180 EA per 30 days)
2
2
QL (60 EA per 30 days)
QL (180 EA per 30 days)
2
2
QL (60 EA per 30 days)
PA; QL (60 EA per 30 days)
2
4
PA; QL (60 EA per 30 days)
PA; QL (60 EA per 30 days)
4
PA; QL (60 EA per 30 days)
2
B/D
2
2
B/D
2
4
B/D
4
2
B/D
PA; QL (120 EA per 30 days)
2
PA; QL (120 EA per 30 days)
mg/ml
duramorph (pf) injection solution 0.5 mg/ml, 1
fentanyl citrate buccal lozenge on a handle 1,200
mg/ml
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
fentanyl transdermal patch 72 hour 100 mcg/hr,
mcg
12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,
fentanyl
transdermal
patch87.5
72 hour
100 mcg/hr,
62.5
mcg/hour,
75 mcg/hr,
mcg/hour
12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,
levorphanol tartrate oral tablet 2 mg
62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour
methadone injection solution 10 mg/ml
le orphanol tartrate oral tablet 2 mg
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
methadone in ection solution 10 mg/ml
methadone oral tablet 10 mg, 5 mg
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
morphine oral capsule,extend.release pellets 10
methadone oral tablet 10 mg, 5 mg
mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
morphine oral capsule,extend.release pellets 10
morphine oral tablet 15 mg, 30 mg
mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
morphine oral tablet extended release 100 mg, 15
morphine oral tablet 15 mg, 30 mg
mg, 200 mg, 30 mg, 60 mg
morphine oral tablet extended release 100 mg, 15
oxycodone oral tablet,oral only,ext.rel.12 hr 10
mg, 200 mg, 30 mg, 60 mg
mg, 20 mg, 40 mg, 80 mg
oxycodone oral tablet,oral only,ext.rel.12 hr 10
OXYCONTIN ORAL TABLET,ORAL
mg, 20 mg, 40 mg, 80 mg
ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG
OXYCONTIN ORAL TABLET,ORAL
Opioid
Analgesics,HR
Short-Acting
ONLY,EXT.REL.12
15 MG, 30 MG, 60 MG
butorphanol tartrate injection solution 1 mg/ml, 2
Opioid Analgesics, Short-Acting
mg/ml
butorphanol tartrate in ection solution 1 mg/ml, 2
butorphanol tartrate nasal spray,non-aerosol 10
mg/ml
mg/ml
butorphanol tartrate nasal spray,non-aerosol 10
DILAUDID (PF) INJECTION SOLUTION 2
mg/ml
MG/ML, 4 MG/ML
DILAUDID (PF) INJECTION SOLUTION 2
fentanyl citrate buccal lozenge on a handle 1,200
MG/ML, 4 MG/ML
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
fentanyl citrate buccal lozenge on a handle 1,200
mcg
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
hydrocodone-acetaminophen oral tablet 2.5-325
mcg
mg
B/D
QL (60 EA per 30 days)
2
3
Puede
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informaciónsobre
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loque
quesignifican
significanlas
lasabreviaturas
abreviaturasas
asen
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páginavivi
33
del Medicamento
D Nombre
rug N ame
Nivel D derugMedicamento
Requisitos/Límites
T ier
Requirements/Limits
hydromorphone
(pf) injection
10mcg/hr,
mg/ml
fentanyl transdermal
patch 72solution
hour 100
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
hydrocodone-acetaminophen oral tablet 2.5-325
LAZANDA NASAL SPRAY,NON-AEROSOL
mg
100 MCG/SPRAY
hydromorphone (pf) in ection solution 10 mg/ml
LAZANDA NASAL SPRAY,NON-AEROSOL
hydromorphone
oral tablet 2 mg, 4 mg, 8 mg
400
MCG/SPRAY
22
QL (10 EA per 30 days)
2
2
3
QL (180 EA per 30 days)
2
3
2
PA; QL (150 EA per 30 days)
QL (180 EA per 30 days)
LAZANDAoral
NASAL
SPRAY,NON-AEROSOL
meperidine
solution
50 mg/5 ml
100 MCG/SPRAY
meperidine oral tablet 50 mg
LAZANDA NASAL SPRAY,NON-AEROSOL
meperitab oral tablet 100 mg
400 MCG/SPRAY
nalbuphine injection solution 10 mg/ml, 20 mg/ml
meperidine oral solution 50 mg/5 ml
oxycodone oral solution 5 mg/5 ml
meperidine oral tablet 50 mg
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
meperitab oral tablet 100 mg
mg, 5 mg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
tramadol oral tablet 50 mg
oxycodone oral solution 5 mg/5 ml
23
PA; QL
QL (3600
(600 EA
PA;
MLper
per3030days)
days)
2
3
2
PA; QL (240 EA per 30 days)
PA; QL (150 EA per 30 days)
PA; QL (240 EA per 30 days)
2
2
2
2
2
2
B/D
PA; QL (3600 ML per 30 days)
QL (5400 ML per 30 days)
PA; QL (240 EA per 30 days)
QL (180 EA per 30 days)
PA; QL (240 EA per 30 days)
2
2
2
B/D
QL (240 EA per 30 days)
QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
2
QL (180 EA per 30 days)
lidocaine
10 mg/ml (1 %), 5
tramadol (pf)
oralinjection
tablet 50solution
mg
mg/ml (0.5 %)
22
QL (240 EA per 30 days)
lidocaine hcl mucous membrane gel 2 %
Local Anesthetics
2
lidocaine hcl mucous membrane solution 4 % (40
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
mg/ml)
2
2
lidocainehcl
hclurethral
mucous membrane
lidocaine
gel 2 % gel 2
22
lidocainetopical
hcl mucous
membrane
solution 4 5 %(40
lidocaine
adhesive
patch,medicated
mg/ml)
lidocaine topical ointment 5 %
lidocaine hcl urethral gel 2
lidocaine-prilocaine topical cream 2.5-2.5 %
lidocaine topical adhesi e patch,medicated 5
Anti-Addiction/
(700 mg/patch) Substance Abuse Treatment Agents
22
PA; QL (90 EA per 30 days)
2
2
2
2
B/D
PA; QL (90 EA per 30 days)
Alcohol
Anti-Craving
lidocaine Deterrents/
topical ointment
5
2
acamprosate
oral tablet,delayed
release
(dr/ec)
lidocaine-prilocaine
topical cream
2.5-2.5
333 mg
22
disulfiram oral tablet 250 mg, 500 mg
2
naltrexone oral tablet 50 mg
acamprosate oral tablet,delayed release (dr/ec)
Opioid
333 mg Dependence Treatments
buprenorphine
sublingual
2 mg, 8 mg
disulfiram oralhcl
tablet
250 mg,tablet
500 mg
2
2
Anesthetics
Local
Anesthetics
mg, 5 mg
Anesthetics
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
buprenorphine-naloxone
tablet 2-0.5
naltrexone oral tablet 50sublingual
mg
mg, 8-2 mg
PA; QL (600 EA per 30 days)
PA
B/D
PA
22
22
4
44
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encontrarinformación
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significanlas
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vayaaalalapágina
páginavivi
Puede
del Medicamento
D Nombre
rug N ame
Nivel D derug
Medicamento
Requisitos/Límites
T ier
Requirements/Limits
fentanyl transdermal
patch 72 FILM
hour 100
mcg/hr,
SUBOXONE
SUBLINGUAL
12-3
MG, 212
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
0.5 MG, 4-1 MG, 8-2 MG
42
hydrocodone-acetaminophen
oral tablet
2.5-325
ZUBSOLV
SUBLINGUAL TABLET
1.4-0.36
mg 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6MG,
2.1
MG
hydromorphone
(pf) in ection solution 10 mg/ml
32
Opioid
Reversal
Agents
hydromorphone
oral
tablet 2 mg, 4 mg, 8 mg
2
23
QL (180 EA per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
CHANTIX CONTINUING MONTH BOX ORAL
400 MCG/SPRAY
TABLET 1 MG
meperidine oral solution 50 mg/5 ml
CHANTIX ORAL TABLET 0.5 MG, 1 MG
meperidine oral tablet 50 mg
CHANTIX STARTING MONTH BOX ORAL
meperitab oral tablet
100 0.5
mg MG (11)- 1 MG (42)
TABLETS,DOSE
PACK
3
4
PA; QL (150 EA per 30 days)
QL (336 EA per 168 days)
2
4
2
4
2
PA; QL (3600 ML per 30 days)
QL (336 EA per 168 days)
PA; QL (240 EA per 30 days)
QL (336 EA per 168 days)
PA; QL (240 EA per 30 days)
nalbuphine inINHALATION
ection solutionCARTRIDGE
10 mg/ml, 20 mg/ml
NICOTROL
10
MG
oxycodone oral solution 5 mg/5 ml
NICOTROL NS NASAL SPRAY,NONoxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
AEROSOL 10 MG/ML
mg, 5 mg
32
B/D
2
4
2
QL (5400 ML per 30 days)
Antibacterials
tramadol oral tablet 50 mg
2
QL (240 EA per 30 days)
naloxone
injection
syringe
1 mg/ml
LAZANDA
NASAL
SPRAY,NON-AEROSOL
100 MCG/SPRAY
Smoking
Cessation Agents
QL (10 EA per 30 days)
2
PA; QL (600 EA per 30 days)
QL (180 EA per 30 days)
Aminoglycosides
Anesthetics
amikacin
injection solution 500 mg/2 ml
Local Anesthetics
2
gentak
ophthalmic
ointment
0.3 %
(3 mg/gram)
lidocaine
(pf) in ection
solution
5 mg/ml
(0.5 )
gentamicin
ophthalmic
drops 0.3 gel
% 2
lidocaine hcl
mucous membrane
22
12
gentamicin
ophthalmic
ointment 0.3
% (3 4
lidocaine hcl
mucous membrane
solution
mg/gram)
mg/ml)
22
(40
gentamicin
sulfate
(pf)gel
intravenous
solution 80
lidocaine hcl
urethral
2
mg/8 ml
lidocaine topical adhesi e patch,medicated 5
gentamicin
topical cream 0.1 %
(700 mg/patch)
gentamicin
topicalointment
ointment5 0.1 %
lidocaine topical
22
2
1
12
22
B/D
2
22
PA
neomycin
oral tablet 500
mg cream 2.5-2.5
lidocaine-prilocaine
topical
neomycin-polymyxin b gu irrigation solution 40
Anti-Addiction/ Substance Abuse Treatment Agents 2
mg-200,000 unit/ml
Alcohol Deterrents/
Anti-Craving
paromomycin
oral capsule
250 mg
acamprosate intramuscular
oral tablet,delayed
streptomycin
reconrelease
soln 1 (dr/ec)
gram
333 mg
TOBRADEX OPHTHALMIC OINTMENT 0.3disulfiram
oral tablet 250 mg, 500 mg
0.1
%
naltrexone oral tablet 50 mg
PA; QL (90 EA per 30 days)
3
2
2
5
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del Medicamento
D Nombre
rug gNNa
ame
Nivel D derugMedicamento
Requirements/Limits
gT Tier
q Requisitos/Límites
ts/L
tobramycin
in intramuscular
0.225 % nacl inhalation
streptomycin
recon soln solution
1 gram for
nebulization 300 mg/5 ml
TOBRADEX OPHTHALMIC OINTMENT 0.3tobramycin
ophthalmic drops 0.3 %
0.1 %
52
tobramycin
injection
10solution
mg/ml, 40
tobramycinsulfate
in 0.225
nacl solution
inhalation
for
mg/ml
nebulization 300 mg/5 ml
25
PA
ZANOSAR
RECON SOLN 1
tobramycin INTRAVENOUS
ophthalmic drops 0.3
GRAM
tobramycin sulfate in ection solution 10 mg/ml, 40
mg/ml
Antibacterials
41
PA
ZANOSAR
INTRAVENOUS
RECON
SOLN
colistin
(colistimethate
na) injection
recon
soln 1
GRAM
150
mg
24
PA
SYNERCID
INTRAVENOUS RECON SOLN
Antibacterials
500 MG
colistin (colistimethate na) in ection recon soln
150 mg
Antibacterials,
Other
5
PA
SYNERCID
INTRAVENOUS
acetic
acid otic
solution 2 % RECON SOLN
500 MG
alcohol pads topical pads, medicated
25
bacitracin ophthalmic ointment 500 unit/gram
acetic acid otic solution 2
BACTROBAN NASAL NASAL OINTMENT 2
%
bacitracin ophthalmic ointment 500 unit/gram
2
2
4
2
QL (3 GM per 30 days)
chloramphenicol
sod succinate
intravenous
recon
BACTROBAN NASAL
NASAL
OINTMENT
2
soln
% 1 gram
24
QL (3 GM per 30 days)
chloramphenicol
sod succinate
intra 150
enous
recon
CLEOCIN
INJECTION
SOLUTION
MG/ML
soln 1 gram
clindamycin hcl oral capsule 150 mg, 300 mg, 75
CLEOCIN INJECTION SOLUTION 150 MG/ML
mg
42
PA
2
4
PA
clindamycinpediatric
hcl oral capsule
150soln
mg, 75
300mg/5
mg, ml
75
clindamycin
oral recon
mg
clindamycin phosphate topical gel 1 %
clindamycin pediatric oral recon soln 75 mg/5 ml
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical gel 1
clindamycin phosphate topical solution 1 %
clindamycin phosphate topical lotion 1
clindamycin phosphate topical swab 1 %
clindamycin phosphate topical solution 1
clindamycin phosphate vaginal cream 2 %
clindamycin phosphate topical swab 1
CUBICIN INTRAVENOUS RECON SOLN 500
clindamycin phosphate aginal cream 2
MG
22
CUBICIN INTRAVENOUS
RECON SOLN
LINCOCIN
INJECTION SOLUTION
300 500
MG
MG/ML
45
isopropyl alcohol-benzocaine
topical
pads,
lincomycin
injection solution 300
mg/ml
medicated 70-6
linezolid intravenous parenteral solution 600
LINCOCIN
mg/300
ml INJECTION SOLUTION 300
MG/ML
22
Antibacterials, Other
PA
3
1
2
2
PA
2
2
2
2
2
2
2
2
2
2
2
5
2
5
4
PA
PA
PA
6
66
Puedeencontrar
encontrarinformación
informaciónsobre
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quesignifican
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páginavivi
Puede
del Medicamento
D Nombre
rug N ame
Nivel D derugMedicamento
Requisitos/Límites
T ier
Requirements/Limits
fentanyl transdermal
patch
hour 100 mcg/hr,
linezolid
oral suspension
for72
reconstitution
100
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg/5 ml
52
QL (10 EA per 30 days)
PA
hydrocodone-acetaminophen
linezolid
oral tablet 600 mg oral tablet 2.5-325
mg
linezolid-0.9% sodium chloride intravenous
hydromorphone
(pf)600
in ection
10 mg/ml
parenteral
solution
mg/300solution
ml
52
PA
5
2
PA
hydromorphone
oral tablet
mg, 41mg,
8 mg
methenamine
hippurate
oral2tablet
gram
22
QL (180 EA per 30 days)
LAZANDA NASAL
metronidazole
in nacl SPRAY,NON-AEROSOL
(iso-os) intravenous
100
MCG/SPRAY
piggyback 500 mg/100 ml
23
PA; QL (600 EA per 30 days)
LAZANDA NASAL
SPRAY,NON-AEROSOL
metronidazole
oral capsule
375 mg
400 MCG/SPRAY
metronidazole oral tablet 250 mg, 500 mg
meperidine oral solution 50 mg/5 ml
metronidazole topical cream 0.75 %
meperidine oral tablet 50 mg
metronidazole topical gel 0.75 %, 1 %
meperitab oral tablet 100 mg
metronidazole topical lotion 0.75 %
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
metronidazole vaginal gel 0.75 %
oxycodone oral solution 5 mg/5 ml
mupirocin topical ointment 2 %
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
nitrofurantoin
macrocrystal oral capsule 100 mg,
mg, 5 mg
25 mg, 50 mg
tramadol oral tablet 50 mg
nitrofurantoin monohyd/m-cryst oral capsule 100
Anesthetics
mg,
100 mg (75/25)
23
PA; QL (150 EA per 30 days)
trimethoprim
oral tablet 100 mg
Local Anesthetics
2
vancomycin
intravenous
recon soln
1,000(0.5
mg, 10)
lidocaine (pf)
in ection solution
5 mg/ml
gram, 500 mg
lidocaine hcl mucous membrane gel 2
vancomycin oral capsule 125 mg, 250 mg
lidocaine hcl mucous membrane solution 4 (40
vandazole
mg/ml) vaginal gel 0.75 %
22
B/D
2
5
2
2
PA
ZYVOX
SUSPENSION
FOR
lidocaineORAL
hcl urethral
gel 2
RECONSTITUTION 100 MG/5 ML
lidocaine topical adhesi e patch,medicated 5
(700 mg/patch)
Beta-Lactam,
Cephalosporins
52
PA
2
PA; QL (90 EA per 30 days)
lidocaineoral
topical
ointment
5 500 mg
cefaclor
capsule
250 mg,
22
lidocaine-prilocaine
topical cream
cefaclor
oral tablet extended
release2.5-2.5
12 hr 500 mg
22
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (180 EA per 30 days)
PA; QL (360 EA per 365 days)
2
2
QL (240 EA per 30 days)
PA; QL (360 EA per 365 days)
PA; QL (3600 ML per 30 days)
PA; QL (240 EA per 30 days)
PA; QL (240 EA per 30 days)
B/D
QL (5400 ML per 30 days)
B/D
cefadroxil
oral capsule
500 mg Abuse Treatment Agents 2
Anti-Addiction/
Substance
cefadroxil
oral suspension
for reconstitution 250
Alcohol Deterrents/
Anti-Craving
mg/5 ml, 500 mg/5 ml
acamprosate oral tablet,delayed release (dr/ec)
cefadroxil
333 mg oral tablet 1 gram
cefazolin
recon
gram
disulfiraminjection
oral tablet
250soln
mg,1500
mg
cefdinir
oraloral
capsule
naltrexone
tablet300
50 mg
mg
2
2
2
PA
22
22
7
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del Medicamento
D Nombre
rug N ame
Nivel D derug
Medicamento
Requisitos/Límites
T ier
Requirements/Limits
cefdinir
suspension
reconstitution
125 1
cefepimeoral
in dextrose
5 for
intra
enous piggybac
mg/5
ml, 250
ml ml
gram/50
ml, 2mg/5
gram/50
22
cefepimein
indextrose
ection recon
1 gram,piggyback
2 gram 1
cefepime
5 % soln
intravenous
gram/50 ml, 2 gram/50 ml
cefotaxime in ection recon soln 1 gram, 2 gram,
500 mg injection recon soln 1 gram, 2 gram
cefepime
22
cefoxitin ininjection
dextrose,recon
iso-osm
enous
cefotaxime
solnintra
1 gram,
2 gram,
piggybac
1 gram/50 ml, 2 gram/50 ml
500
mg
22
cefoxitinin
intra
enousiso-osm
recon soln
1 gram, 10 gram,
cefoxitin
dextrose,
intravenous
2
gram
piggyback 1 gram/50 ml, 2 gram/50 ml
22
cefpodoxime
oral suspension
for1reconstitution
cefoxitin
intravenous
recon soln
gram, 10 gram,
mg/5 ml, 50 mg/5 ml
2100
gram
22
cefpodoximeoral
oral suspension
tablet 100 mg,
200 mg
cefpodoxime
for reconstitution
100
mg/5 oral
ml, 50
mg/5 ml for reconstitution 125
cefprozil
suspension
22
cefproziloral
oral suspension
tablet 250 mg,
500 mg
cefprozil
for reconstitution
125
mg/5
ml,
250
mg/5
ml
CEFTIN ORAL SUSPENSION FOR
22
ceftriaxone
in ection
recon soln FOR
500 mg
CEFTIN
ORAL
SUSPENSION
RECONSTITUTION
MG/5
cefuroxime axetil oral250
tablet
250ML
mg, 500 mg
42
mg/5 ml, 250oral
mg/5
ml 100 mg, 200 mg
cefpodoxime
tablet
RECONSTITUTION
250
MG/5
ML
cefprozil
oral tablet 250
mg,
500 mg
ceftriaxone
soln
500soln
mg 1.5 gram
cefuroxime injection
sodium inrecon
ection
recon
cefuroxime
oral tablet
cephalexin axetil
oral capsule
250 250
mg, mg,
500 500
mg mg
cefuroxime
injectionfor
recon
soln 1.5 gram
cephalexin sodium
oral suspension
reconstitution
125
mg/5 ml, 250
mg/5
ml 250 mg, 500 mg
cephalexin
oral
capsule
cephalexinoral
oral suspension
tablet 250 mg,
500 mg
cephalexin
for reconstitution
125
mg/5
ml, 250INTRAVENOUS
mg/5 ml
TEFLARO
RECON SOLN 400
MG, 600 MG
cephalexin
oral tablet 250 mg, 500 mg
TEFLARO
INTRAVENOUS
RECON SOLN 400
Beta-Lactam,
Other
MG, 600 MG
aztreonam in ection recon soln 1 gram
2
2
2
2
4
2
2
22
21
21
1
12
4
2
PA
4
PA
2
Beta-Lactam,
Other
DORIBAX INTRAVENOUS
RECON SOLN 500
4
2
PA
imipenem-cilastatin
intra enous
recon SOLN
soln 250
DORIBAX
INTRAVENOUS
RECON
500
mg, 500 mg
MG
42
PA
PA
INVANZ INJECTION
RECON recon
SOLNsoln
1 GRAM
imipenem-cilastatin
intravenous
250
mg,
500
mg
meropenem intra enous recon soln 500 mg
INVANZ
INJECTION
RECON SOLN 1 GRAM
Beta-Lactam,
Penicillins
24
2
4
PA
PA
meropenem intravenous recon soln 500 mg
amoxicillin oral capsule 250 mg, 500 mg
2
1
MG
aztreonam
injection recon soln 1 gram
PA
8
88
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abreviaturas
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del Medicamento
D Nombre
rug N ame
Nivel D derugMedicamento
Requisitos/Límites
T ier
Requirements/Limits
fentanyl transdermal
patch
72 hourintravenous
100 mcg/hr,
meropenem-0.9%
sodium
chloride
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
piggyback 1 gram/50 ml, 500 mg/50 ml
22
hydrocodone-acetaminophen
Beta-Lactam,
Penicillins oral tablet 2.5-325
2
mg
amoxicillin oral capsule 250 mg, 500 mg
hydromorphone (pf) in ection solution 10 mg/ml
amoxicillin oral suspension for reconstitution 125
hydromorphone
oral
2 mg,ml,
4 mg,
mg ml
mg/5
ml, 200 mg/5
ml,tablet
250 mg/5
4008mg/5
LAZANDAoral
NASAL
amoxicillin
tabletSPRAY,NON-AEROSOL
500 mg, 875 mg
100 MCG/SPRAY
amoxicillin oral tablet,chewable 125 mg, 250 mg
LAZANDA NASAL SPRAY,NON-AEROSOL
amoxicillin-pot
clavulanate oral suspension for
400 MCG/SPRAY
reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5
meperidine
oral ml,
solution
50 mg/5
ml,
400-57 mg/5
600-42.9
mg/5mlml
meperidine oralclavulanate
tablet 50 mg
amoxicillin-pot
oral tablet 250-125
mg,
500-125
mg,tablet
875-125
meperitab
oral
100 mg
mg
amoxicillin-pot
clavulanate
oral
nalbuphine in ection
solution
10 tablet
mg/ml,extended
20 mg/ml
release 12 hr 1,000-62.5 mg
oxycodone oral solution 5 mg/5 ml
amoxicillin-pot clavulanate oral tablet,chewable
oxycodone
oral
tabletmg
10 mg, 15 mg, 20 mg, 30
200-28.5
mg,
400-57
mg, 5 mg
ampicillin oral capsule 250 mg, 500 mg
tramadol oral tablet 50 mg
ampicillin oral suspension for reconstitution 125
Anesthetics
mg/5
ml, 250 mg/5 ml
Local Anesthetics
ampicillin
sodium injection recon soln 1 gram, 10
gram,
125 (pf)
mg in ection solution 5 mg/ml (0.5 )
lidocaine
ampicillin-sulbactam
recon
lidocaine hcl mucous injection
membrane
gel 2soln 15
gram, 3 gram
lidocaine hcl mucous membrane solution 4 (40
ampicillin-sulbactam
intravenous recon soln 1.5
mg/ml)
gram
lidocaine hcl urethral gel 2
BICILLIN L-A INTRAMUSCULAR SYRINGE
lidocaine topical
e patch,medicated
5
1,200,000
UNIT/2adhesi
ML, 2,400,000
UNIT/4 ML,
(700
mg/patch)
600,000 UNIT/ML
lidocaine topical
ointment250
5 mg, 500 mg
dicloxacillin
oral capsule
lidocaine-prilocaine
topical
nafcillin
injection recon
soln cream
1 gram2.5-2.5
QL (10 EA per 30 days)
1
2
1
2
QL (180 EA per 30 days)
13
PA; QL (600 EA per 30 days)
1
3
2
PA; QL (150 EA per 30 days)
2
PA; QL (3600 ML per 30 days)
22
2
PA; QL (240 EA per 30 days)
22
B/D
2
2
2
QL (5400 ML per 30 days)
1
2
1
QL (240 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (180 EA per 30 days)
2
2
22
2
2
2
4
2
PA; QL (90 EA per 30 days)
22
22
B/D
Anti-Addiction/
Abuse
Treatment
Agents 2
penicillin
g procaineSubstance
intramuscular
syringe
1.2
million unit/2 ml
Alcohol Deterrents/ Anti-Craving
penicillin g sodium injection recon soln 5 million
acamprosate oral tablet,delayed release (dr/ec)
unit
333 mg
penicillin v potassium oral recon soln 125 mg/5
disulfiram
oral
ml,
250 mg/5
mltablet 250 mg, 500 mg
naltrexonev potassium
oral tablet oral
50 mg
penicillin
tablet 250 mg, 500 mg
2
2
PA
1
2
12
9
-
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del Medicamento
D Nombre
rug N ame
Nivel D derugMedicamento
Requisitos/Límites
T ier
Requirements/Limits
piperacillin-tazobactam
intravenous
soln
azithromycin intra enous
recon solnrecon
500 mg,
500
3.375
4.5 gram
mg (2gram,
mg/ml)
22
azithromycin oral pac et 1 gram
Macrolides
2
azithromycin intravenous
oral suspension
reconstitution
azithromycin
reconforsoln
500 mg, 500
100
mg/5
ml,
200
mg/5
ml
mg (2 mg/ml)
azithromycin oral
oral packet
tablet 250
mg, 500 mg, 600 mg
azithromycin
1 gram
22
clarithromycin
oral
suspension
reconstitution
azithromycin
oral
suspension
forfor
reconstitution
125mg/5
mg/5 ml,
ml, 200
250 mg/5
mg/5 ml
ml
100
clarithromycin
oral
tablet
250
mg,
500
azithromycin
oral
tablet
250
mg,
250
mgmg
(6 pack),
500
mg, 600 mgoral tablet extended release 24 hr
clarithromycin
500 mg
clarithromycin
oral suspension for reconstitution
125
mg/5
ml,
250
mg/5
mlmg
e.e.s. 400 oral tablet
400
clarithromycin
oral tablet
250
mg, 500 mg FOR
E.E.S. GRANULES
ORAL
SUSPENSION
RECONSTITUTION
200 extended
MG/5 ML
clarithromycin
oral tablet
release 24 hr
500
mg
ery pads topical swab 2
e.e.s.
400 oral
mg
ERYPED
200 tablet
ORAL400
SUSPENSION
FOR
RECONSTITUTION
200
MG/5
ML
E.E.S. GRANULES ORAL SUSPENSION FOR
RECONSTITUTION
200oral
MG/5
ML250 mg
erythrocin (as stearate)
tablet
ery
pads topical swab
2%
ERYTHROCIN
INTRAVENOUS
RECON SOLN
500 MG 200 ORAL SUSPENSION FOR
ERYPED
RECONSTITUTION
200 MG/5
erythromycin ethylsuccinate
oralML
tablet 400 mg
erythrocin
(as ophthalmic
stearate) oral
tablet 250
mg
erythromycin
ointment
5 mg/gram
(0.5
)
ERYTHROCIN INTRAVENOUS RECON SOLN
500
MG
erythromycin
oral tablet 250 mg, 500 mg
erythromycin
oral tablet
erythromycin ethylsuccinate
with ethanol topical
gel 2400 mg
erythromycin
5 mg/gram
erythromycin ophthalmic
with ethanolointment
topical solution
2 (0.5
%)
KETEK ORAL TABLET 300 MG, 400 MG
erythromycin oral tablet 250 mg, 500 mg
Quinolones
22
22
22
2
2
2
24
2
2
24
4
2
24
4
2
21
4
2
22
12
4
2
erythromycin with ethanol topical gel 2 %
AVELOX IN NACL (ISO-OSMOTIC)
erythromycin
with ethanol
topical 400
solution
2 % ML
INTRAVENOUS
PIGGYBACK
MG/250
KETEK
ORAL(mixture)
TABLET
300tablet,
MG, er
400multiphase
MG
ciprofloxacin
oral
2
4
2
ciprofloxacin
hcl ophthalmic
drops 0.3
AVELOX
IN NACL
(ISO-OSMOTIC)
INTRAVENOUS
PIGGYBACK
400 MG/250 ML
ciprofloxacin hcl oral
tablet 100 mg
42
2
ciprofloxacin
oral tablet,
er 500
multiphase
ciprofloxacin (mixture)
hcl oral tablet
250 mg,
mg, 750
24
hr
1,000
mg,
500
mg
mg
21
ciprofloxacin hcl ophthalmic drops 0.3 %
2
24 hr 1,000 mg, 500 mg
Quinolones
42
PA; QL (20 EA per 30 days)
PA; QL (20 EA per 30 days)
10
1010
Puedeencontrar
encontrarinformación
informaciónsobre
sobreloloque
quesignifican
significanlas
lasabreviaturas
abreviaturasasasen
enesta
estatabla,
tabla,vaya
vayaaalalapágina
páginavivi
Puede
del Medicamento
D Nombre
rug N ame
Nivel D derugMedicamento
Requisitos/Límites
T ier
Requirements/Limits
fentanyl transdermal
ciprofloxacin
hcl oral patch
tablet72
100hour
mg 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750
hydrocodone-acetaminophen oral tablet 2.5-325
mg
mg
ciprofloxacin lactate intravenous solution 400
hydromorphone
(pf) in ection solution 10 mg/ml
mg/40
ml
22
hydromorphone
tablet250
2 mg,
4 mg,
levofloxacin
oral oral
solution
mg/10
ml 8 mg
22
QL (180 EA per 30 days)
LAZANDA oral
NASAL
levofloxacin
tabletSPRAY,NON-AEROSOL
250 mg, 500 mg, 750 mg
100 MCG/SPRAY
MOXEZA OPHTHALMIC DROPS, VISCOUS
LAZANDA
NASAL SPRAY,NON-AEROSOL
0.5
%
400 MCG/SPRAY
moxifloxacin oral tablet 400 mg
meperidine oral solution 50 mg/5 ml
moxifloxacin-sod.ace,sul-water intravenous
meperidine400
oral
tablet ml
50 mg
piggyback
mg/250
23
PA; QL (600 EA per 30 days)
3
3
PA; QL (150 EA per 30 days)
meperitabophthalmic
oral tabletdrops
100 mg
ofloxacin
0.3 %
22
PA; QL (240 EA per 30 days)
nalbuphine
in tablet
ection400
solution
ofloxacin
oral
mg 10 mg/ml, 20 mg/ml
22
B/D
oxycodone
oral
solution
ofloxacin
otic
drops
0.3 %5 mg/5 ml
22
QL (5400 ML per 30 days)
oxycodone oral
tablet 10 mg,DROPS
15 mg, 20
VIGAMOX
OPHTHALMIC
0.5mg,
% 30
mg, 5 mg
32
QL (180 EA per 30 days)
tramadol oral tablet 50 mg
silver sulfadiazine topical cream 1 %
2
2
QL (240 EA per 30 days)
ssd topical cream 1 %
2
sulfacetamide sodium (acne) topical suspension 10
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
%
1
2
lidocaine hcl mucous
2 10 %
sulfacetamide
sodium membrane
ophthalmicgel
drops
12
lidocaine hcl mucous
sulfacetamide
sodium membrane
ophthalmicsolution
ointment4 10 (40
%
mg/ml)
sulfadiazine oral tablet 500 mg
lidocaine hcl urethral gel 2
sulfamethoxazole-trimethoprim intravenous
lidocaine400-80
topicalmg/5
adhesi
solution
ml e patch,medicated 5
(700 mg/patch)
sulfamethoxazole-trimethoprim oral suspension
lidocaine
topical
200-40
mg/5
ml ointment 5
22
lidocaine-prilocaine topical cream
sulfamethoxazole-trimethoprim
oral2.5-2.5
tablet 400-80
mg, 800-160 mg
12
B/D
demeclocycline oral tablet 150 mg, 300 mg
acamprosate oral tablet,delayed release (dr/ec)
doxy-100
333 mg intravenous recon soln 100 mg
2
2
2
PA
doxycycline
hyclate
intravenous
recon
disulfiram oral
tablet
250 mg, 500
mg soln 100 mg
22
doxycycline
hyclate
oral
100 mg, 50 mg
naltrexone oral
tablet
50capsule
mg
22
Sulfonamides
Anesthetics
Local Anesthetics
QL (10 EA per 30 days)
1
2
2
2
2
2
2
2
2
2
2
2
PA; QL (3600 ML per 30 days)
PA; QL (240 EA per 30 days)
PA; QL (90 EA per 30 days)
1
2
Anti-Addiction/ Substance Abuse Treatment Agents
Tetracyclines
Alcohol Deterrents/ Anti-Craving
11
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Nombre
del Medicamento
Drug
Name
minocyclinehyclate
oral capsule
100 mg,
doxycycline
oral tablet
10050
mg,mg,
2075
mg,mg50
mg
minocycline oral tablet 100 mg, 50 mg, 75 mg
doxycycline monohydrate oral capsule 100 mg, 50
Anticonvulsants
mg
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
21
1
2
Anticonvulsants,
Other
doxycycline
monohydrate
oral tablet 100 mg, 150
mg,
50 mg,rectal
75 mg it 12.5-15-17.5-20 mg
diazepam
2
2
PA; QL (40 EA per 30 days)
minocycline
oral capsule
100 mg, 50 mg, 75 mg
diazepam rectal
it 2.5 mg
12
PA; QL (5 EA per 30 days)
minocycline
oral tablet
100 mg,
diazepam rectal
it 5-7.5-10
mg50 mg, 75 mg
12
PA; QL (20 EA per 30 days)
Anticonvulsants
le etiracetam in nacl (iso-os) intra enous
2
piggybac 1,000 mg/100 ml, 1,500 mg/100 ml, 500
Anticonvulsants,
Other
mg/100 ml
diazepam
rectalintra
kit 12.5-15-17.5-20
mg mg/5 ml
le etiracetam
enous solution 500
diazepam
rectaloral
kit 2.5
mg 100 mg/ml
le etiracetam
solution
22
22
PA; QL (40 EA per 30 days)
diazepam
rectaloral
kit 5-7.5-10
mg mg, 250 mg, 500
le etiracetam
tablet 1,000
mg, 750 mg in nacl (iso-os) intravenous
levetiracetam
piggyback
1,000
mg/100
1,500 mg/100
ml,hr
500
le etiracetam
oral
tabletml,
extended
release 24
mg/100
ml
500 mg, 750 mg
levetiracetam
intravenous
500
mg/5
ml400
POTIGA ORAL
TABLETsolution
200 MG,
300
MG,
MG, 50 MG oral solution 100 mg/ml
levetiracetam
22
2
PA; QL (20 EA per 30 days)
Calcium Channel
Modifying
levetiracetam
oral tablet
1,000 mg,Agents
250 mg, 500
mg, 750 mg
CELONTIN ORAL CAPSULE 300 MG
levetiracetam oral tablet extended release 24 hr
ethosuximide oral capsule 250 mg
500 mg, 750 mg
ethosuximide oral solution 250 mg/5 ml
POTIGA ORAL TABLET 200 MG, 300 MG, 400
LYRICA
ORAL CAPSULE 100 MG, 150 MG,
MG,
50 MG
200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75
Calcium
Channel Modifying Agents
MG
CELONTIN
ORAL
CAPSULE20
300
MG
LYRICA ORAL
SOLUTION
MG/ML
PA; QL (5 EA per 30 days)
2
24
2
2
4
2
2
2
4
3
43
22
ethosuximide
oralcapsule
capsule100
250mg,
mg25 mg, 50 mg
zonisamide oral
ethosuximide
oral solution 250
mg/5
ml Augmenting Agents
2
Gamma-Aminobutyric
Acid
(Gaba)
zonisamide
100mg,
mg,125
clonazepamoral
oralcapsule
tablet 0.5
mgmg, 50 mg
22
Gamma-Aminobutyric
Acid (Gaba) Augmenting Agents
clonazepam oral tablet 2 mg
2
clonazepam
0.5 mg, 1 mg 0.125 mg,
clonazepamoral
oraltablet
tablet,disintegrating
0.25 mg, 0.5oral
mg,tablet
1 mg 2 mg
clonazepam
clonazepamoral
oraltablet,disintegrating
tablet,disintegrating0.125
2 mg mg,
clonazepam
0.25
mg, 0.5 mg,
1 mg oral tablet 15 mg
clorazepate
dipotassium
clonazepam oral tablet,disintegrating 2 mg
22
2
22
2
2
PA; QL (90 EA per 30 days)
PA; QL (300 EA per 30 days)
PA;
PA; QL
QL(90
(90 EA
EA per
per 30
30 days)
days)
PA; QL (300 EA per 30 days)
PA; QL
QL(90
(300EA
EAper
per3030days)
days)
PA;
PA; QL (180 EA per 30 days)
PA; QL (300 EA per 30 days)
12
1212
Puedeencontrar
encontrarinformación
informaciónsobre
sobreloloque
quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour
divalproex
oral capsule,
sprinkle
125100
mgmcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
divalproex oral tablet extended release 24 hr 250
hydrocodone-acetaminophen
oral tablet 2.5-325
mg,
500 mg
mg
divalproex oral tablet,delayed release (dr/ec) 125
hydromorphone
mg,
250 mg, 500 (pf)
mg in ection solution 10 mg/ml
22
hydromorphone
oral tablet
mg,300
4 mg,
mg mg
gabapentin
oral capsule
1002mg,
mg,8 400
22
QL (180 EA per 30 days)
LAZANDAoral
NASAL
SPRAY,NON-AEROSOL
gabapentin
solution
250 mg/5 ml
100 MCG/SPRAY
gabapentin oral tablet 600 mg, 800 mg
LAZANDA NASAL SPRAY,NON-AEROSOL
GABITRIL
ORAL TABLET 12 MG, 16 MG
400 MCG/SPRAY
HORIZANT
ORAL
TABLET
EXTENDED
meperidine oral
solution
50 mg/5
ml
RELEASE 300 MG
meperidine oral tablet 50 mg
lamotrigine oral tablet disintegrating, dose pk 25
meperitab
mg
mg
(21) -50oral
mg tablet
(7), 25100
mg(14)-50
mg (14)-100 mg
(7),
50
mg
(42)
-100
mg
(14)
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
23
PA; QL (600 EA per 30 days)
2
3
4
PA; QL (150 EA per 30 days)
42
PA; QL (3600 ML per 30 days)
2
2
2
PA; QL (240 EA per 30 days)
2
22
B/D
2
4
QL (180 EA per 30 days)
PA; QL (480 ML per 30 days)
42
2
PA;
QL (60
days)
QL (240
EAEA
perper
30 30
days)
PA
2
PA
lamotrigine
oral solution
tablet,disintegrating
oxycodone oral
5 mg/5 ml 100 mg, 200
mg, 25 mg, 50 mg
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
ONFI
SUSPENSION 2.5 MG/ML
mg, 5 ORAL
mg
ONFI
ORAL
tramadol
oralTABLET
tablet 50 10
mgMG, 20 MG
phenobarbital
Anesthetics oral elixir 20 mg/5 ml
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg,
Local
Anesthetics
30
mg, 32.4
mg, 60 mg, 64.8 mg, 97.2 mg
lidocaine (pf)
ection
solution
mg/ml (0.5 )
primidone
oralintablet
250
mg, 505mg
lidocaineORAL
hcl mucous
membrane
gel 2 500 MG
SABRIL
POWDER
IN PACKET
lidocaineORAL
hcl mucous
membrane
solution 4 (40
SABRIL
TABLET
500 MG
mg/ml)
tiagabine oral tablet 2 mg, 4 mg
lidocaine hcl urethral gel 2
valproate sodium intravenous solution 500 mg/5
lidocaine
topical adhesi e patch,medicated 5
ml
(100 mg/ml)
(700 mg/patch)
valproic acid (as sodium salt) oral solution 250
lidocaine
mg/5
ml topical ointment 5
lidocaine-prilocaine
topical
cream
valproic
acid oral capsule
250
mg 2.5-2.5
QL (10 EA per 30 days)
2
2
2
2
PA; QL (240 EA per 30 days)
QL (5400 ML per 30 days)
22
42
42
2
2
2
2
PA; QL (90 EA per 30 days)
2
2
22
B/D
22
PA
Anti-Addiction/
Substance
Glutamate
Reducing
AgentsAbuse Treatment Agents
Alcohol oral
Deterrents/
Anti-Craving
felbamate
suspension
600 mg/5 ml
2
acamprosate
tablet,delayed
felbamate
oraloral
tablet
400 mg, 600release
mg (dr/ec)
333 mg
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2
disulfiram
tablet
250 mg, 500 mg
MG,
4 MG,oral
6 MG,
8 MG
naltrexone oral tablet 50 mg
4
2
2
13
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Nombre
del Medicamento
Drug
Name
FYCOMPA
TABLETS,DOSE
PACK 2
GlutamateORAL
Reducing
Agents
MG (7)- 4 MG (7)
felbamate oral suspension 600 mg/5 ml
LAMICTAL STARTER (BLUE) KIT ORAL
felbamate oral tablet
40025
mg,MG
600(35)
mg
TABLETS,DOSE
PACK
FYCOMPA ORAL
TABLET
10 MG,
MG, 2
LAMICTAL
STARTER
(GREEN)
KIT12ORAL
MG,
4
MG,
6
MG,
8
MG
TABLETS,DOSE PACK 25 MG (84) -100 MG
(14)
LAMICTAL STARTER (BLUE) KIT ORAL
TABLETS,DOSE
PACK(ORANGE)
25 MG (35)KIT ORAL
LAMICTAL
STARTER
TABLETS,DOSE
PACK (GREEN)
25 MG (42)
-100
MG
LAMICTAL STARTER
KIT
ORAL
(7)
TABLETS,DOSE PACK 25 MG (84) -100 MG
(14)
LAMICTAL
XR STARTER (BLUE) ORAL
TABLET
EXTENDED
PACK
25 MG
LAMICTAL
STARTERREL,DOSE
(ORANGE)
KIT ORAL
(21)
-50 MG (7) PACK 25 MG (42) -100 MG
TABLETS,DOSE
(7)
LAMICTAL
XR STARTER (GREEN) ORAL
TABLET
EXTENDED
REL,DOSE
PACK
50
LAMICTAL
XR STARTER
(BLUE)
ORAL
MG(14)-100MG
(14)-200
MG (7) PACK 25 MG
TABLET EXTENDED
REL,DOSE
(21) -50 MGXR
(7) STARTER (ORANGE) ORAL
LAMICTAL
TABLET
EXTENDED
REL,DOSE
PACK
25MG
LAMICTAL
XR STARTER
(GREEN)
ORAL
(14)-50
MGEXTENDED
(14)-100MGREL,DOSE
(7)
TABLET
PACK 50
MG(14)-100MG (14)-200 MG (7)
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
25
mg
LAMICTAL
XR STARTER (ORANGE) ORAL
TABLET EXTENDED REL,DOSE PACK 25MG
lamotrigine oral tablet extended release 24hr 100
(14)-50 MG (14)-100MG (7)
mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
lamotrigine oral tablet, chewable dispersible 25
25 mg
mg, 5 mg
lamotrigine oral tablet extended release 24hr 100
topiramate oral capsule, sprinkle 15 mg, 25 mg
mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
lamotrigine oral tablet, chewable dispersible 25
mg
mg, 5 mg
TROKENDI XR ORAL CAPSULE,EXTENDED
topiramate oral capsule, sprin le 15 mg, 25 mg
RELEASE 24HR 100 MG, 200 MG, 25 MG, 50
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
MG
mg
Sodium Channel Agents
TROKENDI XR ORAL CAPSULE,EXTENDED
APTIOM
ORAL
MG,50
600
RELEASE
24HRTABLET
100 MG,200
200MG,
MG,400
25 MG,
MG,
800
MG
MG
Sodium Channel Agents
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
4
2
4
2
44
4
4
4
3
4
3
3
3
3
2
3
2
2
2
2
2
2
2
4
2
2
4
4
BANZEL ORAL SUSPENSION 40 MG/ML
4
BANZEL ORAL TABLET 200 MG, 400 MG
APTIOM ORAL TABLET 200 MG, 400 MG, 600
MG, 800 MG oral suspension 100 mg/5 ml
carbamazepine
4
4
1
BANZEL ORAL
SUSPENSION
carbamazepine
oral
tablet 200 mg40 MG/ML
14
BANZEL ORAL TABLET 200 MG, 400 MG
4
14
1414
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estatabla,
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patchextended
72 hour release
100 mcg/hr,
carbamazepine
oral tablet
12 hr
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
200 mg, 400 mg
22
hydrocodone-acetaminophen
oral tablet
carbamazepine
oral tablet,chewable
100 2.5-325
mg
mg
DILANTIN ORAL CAPSULE 30 MG
hydromorphone (pf) in ection solution 10 mg/ml
epitol oral tablet 200 mg
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
EQUETRO ORAL CAPSULE, ER
LAZANDA NASAL
MULTIPHASE
12 HRSPRAY,NON-AEROSOL
100 MG, 200 MG, 300
100
MCG/SPRAY
MG
12
4
2
1
2
4
3
QL (180 EA per 30 days)
LAZANDA NASAL
fosphenytoin
injectionSPRAY,NON-AEROSOL
solution 100 mg pe/2 ml
400 MCG/SPRAY
oxcarbazepine oral suspension 300 mg/5 ml
meperidine oral solution 50 mg/5 ml
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
meperidine oral tablet 50 mg
OXTELLAR XR ORAL TABLET EXTENDED
meperitab oral
tablet
RELEASE
24 HR
150100
MG,mg
300 MG, 600 MG
23
PA; QL (150 EA per 30 days)
nalbuphine inORAL
ection TABLET
solution 10250
mg/ml,
PEGANONE
MG 20 mg/ml
42
B/D
oxycodoneoral
oralsuspension
solution 5 125
mg/5mg/5
ml ml
phenytoin
22
QL (5400 ML per 30 days)
oxycodoneoral
oraltablet,chewable
tablet 10 mg, 1550mg,
phenytoin
mg20 mg, 30
mg, 5 mg
phenytoin sodium extended oral capsule 100 mg,
tramadol
oral
200
mg, 300
mgtablet 50 mg
22
QL (180 EA per 30 days)
2
2
QL (240 EA per 30 days)
Anesthetics
phenytoin
sodium intravenous solution 50 mg/ml
2
2
2
2
4
2
QL (10 EA per 30 days)
PA; QL (600 EA per 30 days)
PA; QL (3600 ML per 30 days)
PA; QL (240 EA per 30 days)
PA; QL (240 EA per 30 days)
2
TEGRETOL
XR ORAL TABLET EXTENDED
Local Anesthetics
RELEASE 12 HR 100 MG
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
VIMPAT INTRAVENOUS SOLUTION 200
lidocaine
MG/20
MLhcl mucous membrane gel 2
lidocaine ORAL
hcl mucous
membrane
VIMPAT
SOLUTION
10 solution
MG/ML4 (40
mg/ml)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200
lidocaine
hcl urethral gel 2
MG,
50 MG
lidocaine topical adhesi e patch,medicated 5
Antidementia
Agents
(700 mg/patch)
4
2
PA; QL (90 EA per 30 days)
Antidementia
lidocaine topicalAgents,
ointmentOther
5
2
22
PA
B/D
ergoloid
oral tablet 1topical
mg
lidocaine-prilocaine
cream 2.5-2.5
2
4
2
42
4
2
Cholinesterase
Anti-Addiction/Inhibitors
Substance Abuse Treatment Agents
donepezil
tablet 10 Anti-Craving
mg, 23 mg, 5 mg
Alcohol oral
Deterrents/
2
donepezil
oraloral
tablet,disintegrating
10 mg,
5 mg
acamprosate
tablet,delayed release
(dr/ec)
333 mg TRANSDERMAL PATCH 24 HOUR
EXELON
13.3
MG/24oral
HOUR,
MG/24
HR,
disulfiram
tablet4.6
250
mg, 500
mg9.5 MG/24
HR
naltrexone oral tablet 50 mg
22
3
PA
2
2
15
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Drug
Name
Nombre
del Medicamento
rivastigmine
tartrate oral capsule
1.5 mg,
mg,
EXELON TRANSDERMAL
PATCH
24 3HOUR
4.5
mg,
6 mg HOUR, 4.6 MG/24 HR, 9.5 MG/24
13.3
MG/24
HR
rivastigmine
transdermal patch 24 hour 13.3
mg/24
hour, 4.6
mg/24oral
hr, capsule
9.5 mg/24
ri astigmine
tartrate
1.5hrmg, 3 mg,
4.5 mg, 6 mg
Tier
Requirements/Limits
Nivel Drug
de Medicamento
Requisitos/Límites
23
2
2
N-Methyl-D-Aspartate (Nmda) Receptor Antagonist
N-Methyl-D-Aspartate
(Nmda)
memantine
oral tablet 10 mg,
5 mg Receptor Antagonist 2
NAMENDA
XRtablets,dose
ORAL CAP,SPRINKLE,ER
memantine
oral
pack 5-10 mg
24HR DOSE PACK 7-14-21-28 MG
NAMENDA XR ORAL CAP,SPRINKLE,ER
NAMENDA
XR ORAL
24HR
DOSE PACK
7-14-21-28 MG
CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG,
NAMENDA
XR ORAL
28 MG, 7 MG
CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG,
Antidepressants
28
MG, 7 MG
23
3
3
3
Antidepressants
Antidepressants
amitriptyline-chlordiazepoxide oral tablet 12.5-5
Antidepressants
mg, 25-10 mg
amitriptyline-chlordiazepoxide oral tablet 12.5-5
fluoxetine
oral tablet 60 mg
mg,
25-10 mg
olanzapine-fluoxetine
fluoxetine
oral tablet 60oral
mgcapsule 12-25 mg, 1250 mg, 3-25 mg, 6-25 mg, 6-50 mg
olanzapine-fluoxetine oral capsule 12-25 mg, 12perphenazine-amitriptyline
oralmg
tablet 2-10 mg, 250
mg, 3-25 mg, 6-25 mg, 6-50
25 mg, 4-10 mg, 4-25 mg, 4-50 mg
perphenazine-amitriptyline oral tablet 2-10 mg, 2Antidepressants,
25
mg, 4-10 mg, 4-25Other
mg, 4-50 mg
ABILIFY DISCMELT
ORAL
Antidepressants,
Other
TABLET,DISINTEGRATING 10 MG
ABILIFY MAINTENA INTRAMUSCULAR
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED
REL RECON 300
SUSPENSION,EXTENDED REL RECON 300
MG
MG
ABILIFY MAINTENA INTRAMUSCULAR
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 300
SUSPENSION,EXTENDED
REL SYRING 300
MG,
400 MG
MG, 400 MG
APLENZIN ORAL TABLET EXTENDED
APLENZIN ORAL TABLET EXTENDED
RELEASE 24 HR 174 MG, 348 MG, 522 MG
RELEASE 24 HR 174 MG, 348 MG, 522 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20
aripiprazole
mg, 30 mg, 5oral
mg tablet 10 mg, 15 mg, 2 mg, 20
mg, 30 mg, 5 mg
buproban oral tablet extended release 150 mg
aripiprazole oral tablet,disintegrating 10 mg, 15
bupropion hcl oral tablet 100 mg, 75 mg
mg
bupropion hcl oral tablet extended release 100 mg,
buproban oral tablet extended release 150 mg
150 mg, 200 mg
bupropion hcl oral tablet 100 mg, 75 mg
2
PA
2
2
PA
22
2
2
PA
2
PA
5
QL (60 EA per 30 days)
5
5
PA; QL (1 EA per 30 days)
PA; QL (1 EA per 30 days)
5
5
PA; QL (1 EA per 30 days)
PA; QL (1 EA per 30 days)
4
4
5
5
5
QL (900 ML per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
2
5
2
QL (60 EA per 30 days)
2
2
2
16
1616
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hourrelease
100 mcg/hr,
bupropion
hcl oral tablet
extended
100 mg,
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
150 mg, 200 mg
22
hydrocodone-acetaminophen
oral tablet
bupropion
hcl oral tablet extended
release2.5-325
24 hr
mg mg, 300 mg
150
22
hydromorphone
(pf) inTABLET
ection solution
10 mg/ml
FORFIVO
XL ORAL
EXTENDED
RELEASE
24 HRoral
450tablet
MG 2 mg, 4 mg, 8 mg
hydromorphone
42
maprotiline
tabletSPRAY,NON-AEROSOL
25 mg, 50 mg, 75 mg
LAZANDAoral
NASAL
100 MCG/SPRAY
mirtazapine
oral tablet 15 mg, 30 mg, 45 mg, 7.5
mg
LAZANDA NASAL SPRAY,NON-AEROSOL
400 MCG/SPRAY
mirtazapine
oral tablet,disintegrating 15 mg, 30
mg,
45 mg oral solution 50 mg/5 ml
meperidine
nefazodone
mg, 150 mg, 200 mg,
meperidine oral
oral tablet
tablet 100
50 mg
250 mg, 50 mg
meperitab oral tablet 100 mg
SEROQUEL XR ORAL TABLET EXTENDED
nalbuphine24
in HR
ection
10MG
mg/ml, 20 mg/ml
RELEASE
150solution
MG, 200
oxycodone oral
5 mg/5 ml EXTENDED
SEROQUEL
XRsolution
ORAL TABLET
RELEASE
HR
300 10
MG,
50 mg,
MG30
oxycodone 24
oral
tablet
mg,400
15MG,
mg, 20
mg, 5 mg oral tablet 100 mg, 150 mg, 300 mg, 50
trazodone
mg
tramadol oral tablet 50 mg
2
23
QL (10 EA per 30 days)
QL (180 EA per 30 days)
PA; QL (600 EA per 30 days)
2
3
2
PA; QL (150 EA per 30 days)
2
22
PA; QL (3600 ML per 30 days)
2
4
2
PA; QL (240 EA per 30 days)
QL (30 EA per 30 days)
B/D
42
2
1
2
QL (60
(5400
days)
QL
EAML
perper
30 30
days)
QL (180 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (240 EA per 30 days)
Monoamine
Anesthetics Oxidase Inhibitors
EMSAM
TRANSDERMAL PATCH 24 HOUR
Local Anesthetics
12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
MARPLAN ORAL TABLET 10 MG
lidocaine hcl mucous membrane gel 2
phenelzine oral tablet 15 mg
lidocaine hcl mucous membrane solution 4 (40
tranylcypromine
oral tablet 10 mg
mg/ml)
4
Ssris/
Snris
lidocaine
hcl urethral gel 2
2
42
PA; QL (90 EA per 30 days)
12
12
B/D
2
2
PA
BRINTELLIX
ORAL
TABLET
10 MG, 20 5MG, 5
lidocaine topical
adhesi
e patch,medicated
MG
(700 mg/patch)
citalopram
oral solution
105mg/5 ml
lidocaine topical
ointment
2
4
2
2
2
2
citalopram
oral tablettopical
10 mg,cream
20 mg,2.5-2.5
40 mg
lidocaine-prilocaine
desvenlafaxine
oral Substance
tablet extended
release
24 hr
Anti-Addiction/
Abuse
Treatment
Agents 2
100 mg, 50 mg
Alcohol Deterrents/ Anti-Craving
duloxetine oral capsule,delayed release(dr/ec) 20
acamprosate
mg,
30 mg, 60oral
mg tablet,delayed release (dr/ec)
333 mg
escitalopram oxalate oral solution 5 mg/5 ml
disulfiram oral tablet 250 mg, 500 mg
escitalopram oxalate oral tablet 10 mg, 20 mg, 5
naltrexone oral tablet 50 mg
mg
2
2
1
2
17
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Drug
Name
Nombre
del Medicamento
Tier
Requirements/Limits
Nivel Drug
de Medicamento
Requisitos/Límites
FETZIMA
FETZIMAORAL
ORALCAPSULE,EXT
CAPSULE,EXTREL
REL24HR
24HR
DOSE
DOSEPACK
PACK20
20MG
MG(2)(2)-40
40MG
MG(26)
(26)
44
FETZIMA
FETZIMAORAL
ORALCAPSULE,EXTENDED
CAPSULE,EXTENDED
RELEASE
24
HR
120
RELEASE 24 HR 120MG,
MG,20
20MG,
MG,40
40MG,
MG,80
80
MG
MG
44
fluoxetine
fluoxetineoral
oralcapsule
capsule10
10mg,
mg,20
20mg,
mg,40
40mg
mg
11
fluoxetine
fluoxetineoral
oralcapsule,delayed
capsule,delayedrelease(dr/ec)
release(dr/ec)900
mg
mg
22
fluoxetine
fluoxetineoral
oralsolution
solution20
20mg/5
mg/5ml
ml
22
fluoxetine
fluoxetineoral
oraltablet
tablet10
10mg
mg
11
fluoxetine
fluoxetineoral
oraltablet
tablet20
20mg
mg
22
fluvoxamine
flu oxamineoral
oraltablet
tablet100
100mg,
mg,25
25mg,
mg,50
50mg
mg
22
paroxetine
paroxetinehcl
hcloral
oraltablet
tablet10
10mg,
mg,20
20mg,
mg,30
30mg,
mg,40
40
mg
mg
11
paroxetine
paroxetinehcl
hcloral
oraltablet
tabletextended
extendedrelease
release24
24hr
hr
12.5
12.5mg,
mg,25
25mg
mg
22
PAXIL
PAXILORAL
ORALSUSPENSION
SUSPENSION10
10MG/5
MG/5ML
ML
44
PRISTIQ
PRISTIQORAL
ORALTABLET
TABLETEXTENDED
EXTENDED
RELEASE
RELEASE24
24HR
HR100
100MG,
MG,25
25MG,
MG,50
50MG
MG
33
sertraline
sertralineoral
oralconcentrate
concentrate20
20mg/ml
mg/ml
22
sertraline
sertralineoral
oraltablet
tablet100
100mg,
mg,25
25mg,
mg,50
50mg
mg
11
venlafaxine
enlafaxineoral
oralcapsule,extended
capsule,extendedrelease
release24hr
24hr
150
150mg,
mg,37.5
37.5mg,
mg,75
75mg
mg
22
venlafaxine
enlafaxineoral
oraltablet
tablet100
100mg,
mg,25
25mg,
mg,37.5
37.5mg,
mg,50
50
mg,
mg,75
75mg
mg
22
venlafaxine
enlafaxineoral
oraltablet
tabletextended
extendedrelease
release24hr
24hr150
150
mg,
mg,225
225mg,
mg,37.5
37.5mg,
mg,75
75mg
mg
22
VIIBRYD
VIIBRYDORAL
ORALTABLET
TABLET10
10MG,
MG,20
20MG,
MG,40
40
MG
MG
44
Tricyclics
Tricyclics
amitriptylineoral
oraltablet
tablet10
10mg,
mg,100
100mg,
mg,150
150mg,
mg,
amitriptyline
25mg,
mg,50
50mg,
mg,75
75mg
mg
25
22
amoxapineoral
oraltablet
tablet100
100mg,
mg,150
150mg,
mg,25
25mg,
mg,50
50
amoxapine
mg
mg
22
clomipramineoral
oralcapsule
capsule25
25mg,
mg,50
50mg,
mg,75
75mg
mg
clomipramine
22
desipramineoral
oraltablet
tablet10
10mg,
mg,100
100mg,
mg,150
150mg,
mg,
desipramine
25mg,
mg,50
50mg,
mg,75
75mg
mg
25
22
PA
PA
PA
PA
18
1818
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyloral
transdermal
patch
hour
doxepin
capsule 10
mg,72
100
mg,100
150mcg/hr,
mg, 25
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg, 50 mg, 75 mg
22
QL (10 EA per 30 days)
PA
hydrocodone-acetaminophen
oral tablet 2.5-325
doxepin
oral concentrate 10 mg/ml
mg
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
hydromorphone (pf) in ection solution 10 mg/ml
imipramine pamoate oral capsule 100 mg, 125 mg,
hydromorphone
150
mg, 75 mg oral tablet 2 mg, 4 mg, 8 mg
22
PA
2
2
2
2
PA
LAZANDA NASAL
SPRAY,NON-AEROSOL
nortriptyline
oral capsule
10 mg, 25 mg, 50 mg, 75
100
MCG/SPRAY
mg
13
PA; QL (600 EA per 30 days)
LAZANDA NASAL
SPRAY,NON-AEROSOL
nortriptyline
oral solution
10 mg/5 ml
400 MCG/SPRAY
protriptyline oral tablet 10 mg, 5 mg
meperidine oral solution 50 mg/5 ml
SURMONTIL ORAL CAPSULE 100 MG, 25
meperidine
MG,
50 MGoral tablet 50 mg
13
PA; QL (150 EA per 30 days)
2
2
4
2
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
meperitab oral
tablet
100 mg
trimipramine
oral
capsule
100 mg, 25 mg, 50 mg
22
PA; QL (240 EA per 30 days)
PA
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
Antiemetics
2
B/D
oxycodone oral solution 5 mg/5 ml
Antiemetics,
Other
2
QL (5400 ML per 30 days)
2
2
QL (180 EA per 30 days)
2
2
QL (240 EA per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
chlorpromazine injection solution 25 mg/ml
mg, 5 mg
chlorpromazine oral tablet 10 mg, 100 mg, 200
tramadol oral tablet 50 mg
mg, 25 mg, 50 mg
Anesthetics
compro
rectal suppository 25 mg
2
Local Anesthetics
diphenhydramine
hcl injection solution 50 mg/ml
lidocaine (pf)
ection
solution
mg/ml
hydroxyzine
hclinoral
solution
10 5mg/5
ml (0.5 )
2
22
lidocaine hclhcl
mucous
membrane
hydroxyzine
oral tablet
10 mg,gel
252mg, 50 mg
lidocaine hclpamoate
mucous oral
membrane
hydroxyzine
capsulesolution
100 mg,4 25 (40
mg,
mg/ml)
50
mg
lidocaine oral
hcl urethral
gel mg,
2 25 mg
meclizine
tablet 12.5
lidocaine topical
e patch,medicated
perphenazine
oraladhesi
tablet 16
mg, 2 mg, 4 mg,58 mg
(700 mg/patch)
phenadoz rectal suppository 12.5 mg
lidocaine topical ointment 5
prochlorperazine edisylate injection solution 10
lidocaine-prilocaine
mg/2
ml (5 mg/ml) topical cream 2.5-2.5
22
22
22
22
2
2
2
2
PA
QL (180 EA per 30 days)
PA
PA
PA
PA
PA; QL (90 EA per 30 days)
PA
B/D
Anti-Addiction/maleate
Substance
Abuse
prochlorperazine
oral tablet
10 Treatment
mg, 5 mg Agents 1
prochlorperazine
rectal Anti-Craving
suppository 25 mg
Alcohol Deterrents/
2
promethazine
oral tablet,delayed
syrup 6.25 mg/5
ml (dr/ec)
acamprosate oral
release
333 mg
promethazine
oral tablet 12.5 mg, 25 mg, 50 mg
22
PA
PA
2
22
PA
disulfiram oral
tabletsuppository
250 mg, 500
mgmg, 25 mg
promethazine
rectal
12.5
naltrexone oral
tablet
50 mg 25 mg, 50 mg
promethegan
rectal
suppository
22
PA
PA
19
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
TRANSDERM-SCOP
TRANSDERMAL
promethazine oral tablet
12.5 mg, 25 mg, PATCH
50 mg
3 DAY 1.5 MG (1 MG OVER 3 DAYS)
promethazine rectal suppository 12.5 mg, 25 mg
trimethobenzamide oral capsule 300 mg
promethegan rectal suppository 25 mg, 50 mg
42
PA
2
2
2
PA
PA
PA
Emetogenic
TherapyTRANSDERMAL
Adjuncts
TRANSDERM-SCOP
PATCH
4
2
42
B/D
PA
B/D
EMEND ORAL CAPSULE,DOSE PACK 125
CELLCEPT INTRAVENOUS INTRAVENOUS
MG
(1)- 80
MG (2)
RECON
SOLN
500 MG
4
4
B/D
PA
granisetron
(pf) intravenous solution 100 mcg/ml
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg
granisetron
hcl intravenous
mg/ml
EMEND ORAL
CAPSULEsolution
125 MG,1 40
MG,(180
ml)
MG
22
24
PA
B/D
PA
B/D
granisetron
hcl oral
tablet 1 mg
EMEND ORAL
CAPSULE,DOSE
PACK 125
MG (1)- 80 MG
(2) injection solution 4 mg/2 ml
ondansetron
hcl (pf)
24
2
PA
B/D
granisetron (pf)
intrainjection
enous solution
mcg/ml
ondansetron
hcl (pf)
syringe 100
4 mg/2
ml
22
PA
granisetron hcl
enous solution
ondansetron
hcl intra
oral solution
4 mg/5 1mlmg/ml (1
ml)
ondansetron hcl oral tablet 24 mg
granisetron hcl oral tablet 1 mg
ondansetron hcl oral tablet 4 mg, 8 mg
ondansetron hcl (pf) in ection solution 4 mg/2 ml
ondansetron oral tablet,disintegrating 4 mg, 8 mg
ondansetron hcl (pf) in ection syringe 4 mg/2 ml
22
PA
B/D
2
2
2
2
2
2
B/D; QL (15 EA per 30 days)
PA
B/D
ondansetron hcl oral solution 4 mg/5 ml
2
B/D
ondansetron hcl oral tablet 24 mg
abelcet intravenous suspension 5 mg/ml
ondansetron hcl oral tablet 4 mg, 8 mg
AMBISOME INTRAVENOUS SUSPENSION
ondansetron oral tablet,disintegrating 4 mg, 8 mg
FOR RECONSTITUTION 50 MG
2
2
2
4
2
B/D; QL (15 EA per 30 days)
B/D
B/D
B/D
B/D
Antifungalsb injection recon soln 50 mg
amphotericin
2
B/D
AntifungalsINTRAVENOUS RECON SOLN 50
CANCIDAS
MG,
70 MG
abelcet
intra enous suspension 5 mg/ml
5
PA
2
24
B/D
72 HOUR 1.5
(1 MG
DAYS)
dronabinol
oralMG
capsule
10OVER
mg, 2.53 mg,
5 mg
trimethobenzamide
oral capsule
300 mg
EMEND
ORAL CAPSULE
125 MG,
40 MG, 80
MG
Emetogenic Therapy Adjuncts
Antifungals
Antifungals
ciclopirox
topical
cream 0.77 % SUSPENSION
AMBISOME
INTRAVENOUS
FOR RECONSTITUTION
ciclopirox
topical solution 850
% MG
B/D
B/D
2
amphotericin
b insuspension
ection recon
soln
ciclopirox
topical
0.77
%50 mg
22
B/D
CANCIDASmucous
INTRAVENOUS
clotrimazole
membrane RECON
troche 10SOLN
mg 50
MG, 70 MG
clotrimazole topical cream 1 %
ciclopirox topical cream 0.77
clotrimazole topical solution 1 %
ciclopirox topical solution 8
econazole topical cream 1 %
ciclopirox topical suspension 0.77
25
PA
2
2
2
2
2
2
20
2020
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lasabreviaturas
abreviaturasasasen
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour
100 mcg/hr,
ERAXIS(WATER
DILUENT)
INTRAVENOUS
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
RECON SOLN 100 MG
42
hydrocodone-acetaminophen
tablet 2.5-325
fluconazole
in dextrose(iso-o) oral
intravenous
mg
piggyback
400 mg/200 ml
22
hydromorphone
(pf)(iso-osm)
in ectionintravenous
solution 10 mg/ml
fluconazole
in nacl
piggyback
100 mg/50
ml 2 mg, 4 mg, 8 mg
hydromorphone
oral tablet
22
QL (10 EA per 30 days)
PA
2
23
QL (180 EA per 30 days)
fluconazole
tabletSPRAY,NON-AEROSOL
100 mg, 150 mg, 200 mg,
LAZANDAoral
NASAL
50
400mg
MCG/SPRAY
23
PA; QL (150 EA per 30 days)
flucytosine
meperidineoral
oralcapsule
solution250
50 mg,
mg/5500
ml mg
griseofulvin
microsize
suspension 125 mg/5
meperidine oral
tabletoral
50 mg
ml
meperitab oral tablet 100 mg
itraconazole oral capsule 100 mg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
ketoconazole oral tablet 200 mg
oxycodone oral solution 5 mg/5 ml
ketoconazole topical cream 2 %
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
ketoconazole
topical shampoo 2 %
mg, 5 mg
LAMISIL
ORAL
GRANULES
IN PACKET 125
tramadol oral
tablet
50 mg
MG, 187.5 MG
22
22
PA; QL (3600 ML per 30 days)
2
2
2
2
2
2
2
2
PA; QL (240 EA per 30 days)
42
PA
QL (240 EA per 30 days)
MENTAX TOPICAL CREAM 1 %
4
fluconazole
suspension
for reconstitution 10
LAZANDAoral
NASAL
SPRAY,NON-AEROSOL
mg/ml,
40
mg/ml
100 MCG/SPRAY
Anesthetics
Local Anesthetics
MYCAMINE
INTRAVENOUS RECON SOLN
100
MG (pf) in ection solution 5 mg/ml (0.5 )
lidocaine
PA; QL (600 EA per 30 days)
PA; QL (240 EA per 30 days)
B/D
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
5
2
PA
MYCAMINE
INTRAVENOUS
lidocaine hcl mucous
membraneRECON
gel 2 SOLN
50 MG
lidocaine hcl mucous membrane solution 4 (40
NOXAFIL
ORAL SUSPENSION 200 MG/5 ML
mg/ml)
(40 MG/ML)
lidocaine hcl urethral gel 2
NOXAFIL ORAL TABLET,DELAYED
lidocaine topical adhesi e patch,medicated 5
RELEASE (DR/EC) 100 MG
(700 mg/patch)
nyamyc topical powder 100,000 unit/gram
lidocaine topical ointment 5
nystatin oral suspension 100,000 unit/ml
lidocaine-prilocaine topical cream 2.5-2.5
nystatin oral tablet 500,000 unit
42
PA
nystatin topical cream 100,000 unit/gram
2
nystatin topical ointment 100,000 unit/gram
acamprosate oral tablet,delayed release (dr/ec)
nystatin
333 mg topical powder 100,000 unit/gram
nystop
topical
100,000
unit/gram
disulfiram
oralpowder
tablet 250
mg, 500
mg
2
2
2
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
terbinafine
tablet
250 mg
naltrexone hcl
oraloral
tablet
50 mg
terconazole vaginal cream 0.4 %, 0.8 %
2
4
2
5
2
2
2
2
2
2
PA; QL (90 EA per 30 days)
B/D
PA
22
12
2
21
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
terconazole
vaginal
suppository
80 mg
nystop topical
powder
100,000 unit/gram
22
terbinafine hcl
oral tabletsolution
250 mg 200 mg
voriconazole
intravenous
21
terconazole oral
aginal
cream 0.4for reconstitution
, 0.8
voriconazole
suspension
200 mg/5 ml (40 mg/ml)
terconazole aginal suppository 80 mg
voriconazole oral tablet 200 mg
oriconazole intra enous solution 200 mg
voriconazole oral tablet 50 mg
oriconazole oral suspension for reconstitution
200 mg/5 ml
(40 mg/ml)
ZOLINZA
ORAL
CAPSULE 100 MG
52
oriconazole
oral tablet 200 mg
Antigout
Agents
5
oriconazole
oral tablet 50 mg
Antigout
Agents
2
ZOLINZA oral
ORAL
CAPSULE
allopurinol
tablet
100 mg, 100
300 MG
mg
Antigoutoral
Agents
colchicine
tablet 0.6 mg
2
5
2
2
5
5
15
2
allopurinoloral
oraltablet
tablet500
100mg
mg, 300 mg
probenecid
21
colchicineORAL
oral tablet
0.6 mg
ULORIC
TABLET
40 MG, 80 MG
31
colchicine-probenecidAgents
oral tablet 0.5-500 mg
Anti-Inflammatory
2
probenecid oral tablet 500 mg
Glucocorticoids
2
Anti-Inflammatory
Agents
betamethasone
dipropionate
topical cream 0.05 %
Glucocorticoids
betamethasone
dipropionate topical lotion 0.05 %
a-hydrocort in dipropionate
ection recon soln
100ointment
mg
betamethasone
topical
0.05
%betamethasone dipropionate topical cream 0.05
betamethasone
topical
creamlotion
0.1 %0.05
betamethasonevalerate
dipropionate
topical
betamethasone
topical
lotionointment
0.1 % 0.05
betamethasonevalerate
dipropionate
topical
23
2
2
22
2
22
betamethasone valerate topical ointment 0.1 %
22
2
betamethasone augmented
alerate topical
cream
0.10.05 %
betamethasone,
topical
cream
22
betamethasone augmented
alerate topical
lotion
0.1 %
betamethasone,
topical
gel 0.05
22
betamethasone augmented
alerate topical
ointment
0.1 %
betamethasone,
topical
lotion 0.05
22
betamethasone,augmented
augmentedtopical
topicalointment
cream 0.05
betamethasone,
0.05
%betamethasone, augmented topical gel 0.05
22
cortisone
oral tablet
25 mg topical lotion 0.05
betamethasone,
augmented
dexamethasone
oraltopical
drops 1ointment
mg/ml 0.05
betamethasone,intensol
augmented
dexamethasone oral elixir 0.5 mg/5 ml
cortisone oral tablet
25 mg0.5 mg, 0.75 mg, 1 mg,
dexamethasone
oral tablet
1.5
mg, 2 mg, 4 mg,
6 mgoral drops 1 mg/ml
dexamethasone
intensol
PA
1
Antigout Agents oral tablet 0.5-500 mg
colchicine-probenecid
ULORIC ORAL
TABLET
40 MG,
a-hydrocort
injection
recon soln
10080
mgMG
PA
2
22
22
2
12
2
22
2222
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encontrarinformación
informaciónsobre
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quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hourinjection
100 mcg/hr,
dexamethasone
sodiumpatch
phosphate
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
solution 10 mg/ml, 4 mg/ml
22
hydrocodone-acetaminophen
oral5tablet
hydrocortisone
oral tablet 20 mg,
mg 2.5-325
mg
methylprednisolone acetate injection suspension
hydromorphone
(pf) in ection solution 10 mg/ml
40
mg/ml, 80 mg/ml
22
hydromorphone oraloral
tablet
2 mg,
mg,328 mg,
mg 4
methylprednisolone
tablet
16 4mg,
mg,
8 mg
LAZANDA
NASAL SPRAY,NON-AEROSOL
22
QL (180 EA per 30 days)
3
2
PA; QL (600 EA per 30 days)
3
2
PA; QL (150 EA per 30 days)
2
22
PA; QL (3600 ML per 30 days)
2
PA; QL (240 EA per 30 days)
22
12
B/D
2
4
2
2
QL (180 EA per 30 days)
100 MCG/SPRAY sodium succ injection recon
methylprednisolone
soln
125 mg, NASAL
40 mg SPRAY,NON-AEROSOL
LAZANDA
400 MCG/SPRAY
prednisolone
acetate ophthalmic drops,suspension
1meperidine
%
oral solution 50 mg/5 ml
prednisolone
sodium
phosphate
meperidine oral
tablet
50 mg oral solution 15
mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml
meperitab
oral tablet 100 mg
(6.7
mg/5 ml)
nalbuphineoral
in ection
solution
10ml
mg/ml, 20 mg/ml
prednisone
solution
5 mg/5
oxycodone oral
oral tablet
solution
5 mg/5
ml 2.5 mg, 20
prednisone
1 mg,
10 mg,
mg,
5 mg, 50oral
mgtablet 10 mg, 15 mg, 20 mg, 30
oxycodone
mg, 5 mgORAL TABLET,DELAYED RELEASE
RAYOS
(DR/EC)
MG,tablet
2 MG,
MG
tramadol1oral
505mg
sulfacetamide-prednisolone
ophthalmic drops 10
Anesthetics
%-0.23 % (0.25 %)
Local Anesthetics
Antimigraine Agents
lidocaine hcl mucous membrane gel 2
TREXIMET ORAL TABLET 85-500 MG
lidocaine hcl mucous membrane solution 4
Ergot
mg/ml)Alkaloids
2
2
)
2
(40
2
3
2
lidocaine (pf) in ection solution 5 mg/ml (0.5
Antimigraine Agents
QL (10 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (5400 ML per 30 days)
QL (240 EA per 30 days)
dihydroergotamine
injection
lidocaine hcl urethral
gel 2 solution 1 mg/ml
22
PA
dihydroergotamine
nasal espray,non-aerosol
lidocaine topical adhesi
patch,medicated 50.5
mg/pump
act. (4 mg/ml)
(700 mg/patch)
22
PA;
PA; QL
QL (8
(90ML
EAper
per30
30days)
days)
ERGOMAR
SUBLINGUAL
lidocaine topical
ointment 5 TABLET 2 MG
42
PA; QL (20 EA per 30 days)
lidocaine-prilocaine
topical Receptor
cream 2.5-2.5
2
Serotonin
(5-Ht) 1B/1D
Agonists
Anti-Addiction/
Substance
Abuse Treatment Agents 4
IMITREX
STATDOSE
KIT REFILL
SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML,
Deterrents/ Anti-Craving
6Alcohol
MG/0.5 ML
acamprosate
oraltablet
tablet,delayed
release (dr/ec)
naratriptan
oral
1 mg, 2.5 mg
333 mg
sumatriptan nasal spray,non-aerosol 20
disulfiram oral5 tablet
250 mg, 500 mg
mg/actuation,
mg/actuation
naltrexone oral tablet 50 mg
B/D
PA; QL (4 ML per 30 days)
22
PA (12 EA per 30 days)
QL
2
2
QL (12 EA per 30 days)
2
23
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
sumatriptan
succinate
oral tablet
100 mg,
25400
mg,
etodolac oral
tablet extended
release
24 hr
50
mg500 mg, 600 mg
mg,
22
QL (12 EA per 30 days)
fenoprofen oral
tabletsubcutaneous
600 mg
sumatriptan
succinate
cartridge 4
mg/0.5 ml, 6 mg/0.5 ml
flurbiprofen oral tablet 100 mg, 50 mg
sumatriptan succinate subcutaneous pen injector 6
ibuprofen oral suspension 100 mg/5 ml
mg/0.5 ml, 6 mg/0.5 ml (auto-injector)
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
sumatriptan succinate subcutaneous solution 6
ibuprofen-oxycodone
oral tablet 400-5 mg
mg/0.5
ml
22
QL (4 ML per 30 days)
2
2
1
QL (4 ML per 30 days)
1
2
2
QL (4 ML per 30 days)
indomethacin
oral capsule
25 mg, 50 mg
SUMAVEL
DOSEPRO
SUBCUTANEOUS
NEEDLE-FREE
INJECTOR
4 MG/0.5release
ML, 675
indomethacin oral
capsule, extended
MG/0.5
ML
mg
42
PA(4 ML per 30 days)
QL
2
PA
Antimyasthenic
Agents
etoprofen oral capsule
50 mg, 75 mg
2
Parasympathomimetics
etoprofen oral capsule,ext rel. pellets 24 hr 200
2
mg
guanidine oral tablet 125 mg
etorolac in ection solution 15 mg/ml, 30 mg/ml (1
pyridostigmine bromide oral tablet 60 mg
ml)
2
2
2
PA
Antimycobacterials
etorolac oral tablet 10 mg
2
PA
Antimycobacterials,
Other100 mg, 50 mg
meclofenamate oral capsule
2
21
dapsone
oraloral
tablet
10015
mg,
257.5
mgmg
meloxicam
tablet
mg,
PRIFTIN
ORAL
nabumetone
oralTABLET
tablet 500150
mg,MG
750 mg
rifabutin
oral capsule
150TABLET,
mg
NAPRELAN
CR ORAL
ER
MULTIPHASE 24 HR 375 MG, 500 MG, 750
Antituberculars
MG
CAPASTAT INJECTION RECON SOLN 1
naproxen oral suspension 125 mg/5 ml
GRAM
naproxen oral tablet 250 mg, 375 mg, 500 mg
ethambutol oral tablet 100 mg, 400 mg
naproxen oral tablet,delayed release (dr/ec) 375
isoniazid injection solution 100 mg/ml
mg, 500 mg
isoniazid oral tablet 100 mg, 300 mg
naproxen sodium oral tablet 275 mg, 550 mg
PASER ORAL GRANULES DR FOR SUSP IN
naproxen sodium oral tablet, er multiphase 24 hr
PACKET 4 GRAM
500 mg
pyrazinamide oral tablet 500 mg
oxaprozin oral tablet 600 mg
rifampin intravenous recon soln 600 mg
piroxicam oral capsule 10 mg, 20 mg
rifampin oral capsule 150 mg, 300 mg
sulindac oral tablet 150 mg, 200 mg
RIFATER ORAL TABLET 50-120-300 MG
tolmetin oral capsule 400 mg
SIRTURO ORAL TABLET 100 MG
tolmetin oral tablet 600 mg
TRECATOR ORAL TABLET 250 MG
Antimigraine Agents
Antineoplastics
42
24
4
1
1
2
2
2
1
2
4
2
2
2
2
2
2
2
4
2
5
2
4
PA
24
2424
Puedeencontrar
encontrarinformación
informaciónsobre
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quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
2
QL (10 EA per 30 days)
5
2
PA
2
2
4
2
3
3
2
B/D
400 MCG/SPRAY
melphalan
hcl intravenous recon soln 50 mg
meperidine
oral solution
50 mg/5
thiotepa
injection
recon soln
15 mgml
43
5
52
PA; QL (150 EA per 30 days)
PA
meperidine oral
tablet 50 mg SOLUTION 45
TREANDA
INTRAVENOUS
MG/0.5
MLoral tablet 100 mg
meperitab
52
2
Antiandrogens
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
2
B/D
bicalutamide
oralsolution
tablet 50
mg ml
oxycodone oral
5 mg/5
22
QL (5400 ML per 30 days)
flutamide
125mg,
mg15 mg, 20 mg, 30
oxycodoneoral
oralcapsule
tablet 10
mg, 5 mg
NILANDRON
ORAL TABLET 150 MG
22
QL (180 EA per 30 days)
4
52
QL (240 EA per 30 days)
PA
5
PA
fentanyl transdermal
Alkylating
Agents patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
BUSULFEX INTRAVENOUS SOLUTION 60
hydrocodone-acetaminophen
oral tablet 2.5-325
MG/10
ML
mg
cyclophosphamide oral capsule 25 mg, 50 mg
hydromorphone (pf) in ection solution 10 mg/ml
HEXALEN ORAL CAPSULE 50 MG
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
LEUKERAN ORAL TABLET 2 MG
LAZANDA NASAL SPRAY,NON-AEROSOL
lomustine
oral capsule 10 mg, 100 mg, 40 mg
100 MCG/SPRAY
MATULANE
ORAL CAPSULE
50 MG
LAZANDA NASAL
SPRAY,NON-AEROSOL
tramadol ORAL
oral tablet
50 mg 40 MG
XTANDI
CAPSULE
Anesthetics
ZYTIGA
ORAL TABLET 250 MG
PA
QL (180 EA per 30 days)
PA; QL (600 EA per 30 days)
PA; QL (3600 ML per 30 days)
B/D
PA; QL (240 EA per 30 days)
PA
PA; QL (240 EA per 30 days)
Local Anesthetics
Antiangiogenic
Agents
lidocaine (pf)ORAL
in ection
solution 51mg/ml
POMALYST
CAPSULE
MG, 2(0.5
MG, 3)
MG,
4 MGhcl mucous membrane gel 2
lidocaine
REVLIMID
CAPSULE
MG, 154 MG,
lidocaine hclORAL
mucous
membrane10solution
(40
25
MG,
5
MG
mg/ml)
THALOMID
100 MG, 150
lidocaine hcl ORAL
urethralCAPSULE
gel 2
MG, 200 MG, 50 MG
lidocaine topical adhesi e patch,medicated 5
Antiestrogens/Modifiers
(700 mg/patch)
52
2
52
2
PA; QL (90 EA per 30 days)
EMCYT
lidocaineORAL
topicalCAPSULE
ointment 5140 MG
42
PA
FARESTON
ORAL TABLET
60 MG
lidocaine-prilocaine
topical cream
2.5-2.5
42
PA
B/D
PA
PA; LA
52
SOLTAMOX
ORAL
SOLUTION
10 MG/5
ML
Anti-Addiction/
Substance
Abuse
Treatment
Agents 4
tamoxifen
tablet 10 Anti-Craving
mg, 20 mg
Alcohol oral
Deterrents/
1
Antimetabolites
acamprosate oral tablet,delayed release (dr/ec)
2
4
2
52
333 mg ORAL CAPSULE 200 MG, 300 MG,
DROXIA
400
MG oral tablet 250 mg, 500 mg
disulfiram
gemcitabine
intravenous
naltrexone oral
tablet 50recon
mg soln 1 gram
PA
PA
25
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
hydroxyurea
oral capsule 500 mg
Parasympathomimetics
2
PURIXAN
ORAL
SUSPENSION
20 MG/ML
guanidine oral
tablet
125 mg
52
TABLOID
ORAL
TABLET
MG 60 mg
pyridostigmine
bromide
oral40
tablet
42
PA
adrucil
intravenous solution
500 mg/10 ml
Antimycobacterials,
Other
2
B/D
ALIMTA
INTRAVENOUS
dapsone oral
tablet 100 mg,RECON
25 mg SOLN 500
MG
PRIFTIN ORAL TABLET 150 MG
ARRANON INTRAVENOUS SOLUTION 250
rifabutin
MG/50
MLoral capsule 150 mg
52
PA
4
5
2
PA
5
PA
4
5
PA
52
PA
Antineoplastics
Antimycobacterials
Antituberculars
AVASTIN
INTRAVENOUS SOLUTION 25
MG/ML,
25 MG/ML
(16 ML)
CAPASTAT
INJECTION
RECON SOLN 1
GRAM injection recon soln 100 mg
azacitidine
ethambutol oral
tablet 100 mg, RECON
400 mg SOLN
BELEODAQ
INTRAVENOUS
500
MG in ection solution 100 mg/ml
isoniazid
BICNU
INTRAVENOUS
RECON
SOLN 100
isoniazid
oral tablet 100 mg,
300 mg
MG
PASER ORAL GRANULES DR FOR SUSP IN
bleomycin
PACKET injection
4 GRAMrecon soln 30 unit
carboplatin
intravenous
pyrazinamide
oral tabletsolution
500 mg10 mg/ml
2
41
4
2
PA
B/D
22
22
B/D
52
54
PA
5
5
4
PA
PA
5
PA
cytarabine
(pf)Agents
injection solution 2 gram/20 ml
Alkylating
(100 mg/ml)
BUSULFEX INTRAVENOUS SOLUTION 60
cytarabine
injection solution 20 mg/ml
MG/10 ML
2
B/D
5
2
PA
B/D
dacarbazine
intravenous
recon soln
200 50
mgmg
cyclophosphamide
oral capsule
25 mg,
22
B/D
B/D
daunorubicin
intravenous
solution
mg/ml
HEXALEN ORAL
CAPSULE
50 5MG
24
B/D
PA
DAUNOXOME
INTRAVENOUS
SOLUTION 2
LEUKERAN ORAL
TABLET 2 MG
MG/ML
lomustine oral capsule 10 mg, 100 mg, 40 mg
decitabine intravenous recon soln 50 mg
MATULANE ORAL CAPSULE 50 MG
dexrazoxane hcl intravenous recon soln 250 mg
melphalan hcl intra enous recon soln 50 mg
DOCEFREZ INTRAVENOUS RECON SOLN 20
TREANDA INTRAVENOUS SOLUTION 45
MG
MG/0.5 ML
53
B/D
cisplatin
1 mg/ml
rifampinintravenous
intra enoussolution
recon soln
600 mg
cladribine
intravenous
solution
10 mg/10
rifampin oral
capsule 150
mg, 300
mg ml
CLOLAR
20
RIFATERINTRAVENOUS
ORAL TABLETSOLUTION
50-120-300 MG
MG/20 ML
SIRTURO ORAL TABLET 100 MG
COSMEGEN INTRAVENOUS RECON SOLN
TRECATOR
ORAL TABLET 250 MG
0.5
MG
Antineoplastics
COTELLIC
ORAL TABLET 20 MG
2
5
4
4
5
4
5
B/D
PA
B/D
B/D
PA
PA
PA
26
26
26
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páginavivi Puede
información
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour
100 mcg/hr,
DOCETAXEL
INTRAVENOUS
SOLUTION
80
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
MG/4 ML (20 MG/ML), 80 MG/8 ML (10
MG/ML)
hydrocodone-acetaminophen oral tablet 2.5-325
mg
DOXIL
INTRAVENOUS SUSPENSION 2
MG/ML
hydromorphone (pf) in ection solution 10 mg/ml
doxorubicin
intravenous
solution
mg/25
ml
hydromorphone
oral tablet
2 mg, 50
4 mg,
8 mg
ELITEK
INTRAVENOUS
RECON SOLN 1.5
LAZANDA
NASAL SPRAY,NON-AEROSOL
MG
100 MCG/SPRAY
52
QL (10 EA per 30 days)
PA
2
5
PA
2
22
43
B/D
QL (180 EA per 30 days)
PA
PA; QL (600 EA per 30 days)
ELLENCE
SOLUTION 200
LAZANDAINTRAVENOUS
NASAL SPRAY,NON-AEROSOL
MG/100
ML
400 MCG/SPRAY
53
PA
PA; QL (150 EA per 30 days)
epirubicin
solution
50ml
mg/25 ml
meperidineintravenous
oral solution
50 mg/5
ERBITUX
meperidineINTRAVENOUS
oral tablet 50 mg SOLUTION 100
MG/50 ML
meperitab oral tablet 100 mg
ERWINAZE INJECTION RECON SOLN 10,000
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
UNIT
oxycodone oral
solution 5 mg/5 ml SYRINGE 250
FASLODEX
INTRAMUSCULAR
MG/5
ML oral tablet 10 mg, 15 mg, 20 mg, 30
oxycodone
mg, 5 mg
GLEOSTINE
ORAL CAPSULE 10 MG, 100 MG,
40
MG, 5 MG
tramadol
oral tablet 50 mg
42
52
PA
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
2
5
2
PA; QL (240 EA per 30 days)
PA
B/D
52
2
4
2
5
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
PA
QL (240 EA per 30 days)
PA
HERCEPTIN INTRAVENOUS RECON SOLN
440
MG (pf) in ection solution 5 mg/ml (0.5 )
lidocaine
5
2
PA
idarubicin
intravenous
solution 1gel
mg/ml
lidocaine hcl
mucous membrane
2
52
PA
ifosfamide
intravenous
recon solnsolution
1 gram 4 (40
lidocaine hcl
mucous membrane
mg/ml)
irinotecan intravenous solution 100 mg/5 ml
lidocaine hcl urethral gel 2
ISTODAX INTRAVENOUS RECON SOLN 10
lidocaine
MG/2
ML topical adhesi e patch,medicated 5
(700 mg/patch)
IXEMPRA INTRAVENOUS RECON SOLN 45
lidocaine topical ointment 5
MG
42
PA
4
2
5
2
PA
5
2
PA
lidocaine-prilocaine
topical cream
2.5-2.5 10
JEVTANA
INTRAVENOUS
SOLUTION
MG/ML (FIRST DILUTION)
52
B/D
PA
KADCYLA INTRAVENOUS RECON SOLN 100
Alcohol Deterrents/ Anti-Craving
MG
acamprosate oral
tablet,delayed
release
(dr/ec)
levoleucovorin
calcium
intravenous
solution
10
333
mg
mg/ml
disulfiram oral
tablet
250 mg,15-6.14
500 mgMG, 20-8.19
LONSURF
ORAL
TABLET
MG
naltrexone oral tablet 50 mg
5
PA
22
PA
B/D
52
2
PA
HALAVEN
AnestheticsINTRAVENOUS SOLUTION 1
MG/2 ML (0.5 MG/ML)
Local Anesthetics
Anti-Addiction/ Substance Abuse Treatment Agents
PA
PA; QL (90 EA per 30 days)
27
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
LYNPARZA
CAPSULE 50
MG SOLN
BELEODAQORAL
INTRAVENOUS
RECON
500 MG
mesna intravenous solution 100 mg/ml
BICNU INTRAVENOUS RECON SOLN 100
MESNEX ORAL TABLET 400 MG
MG
mitomycin intravenous recon soln 20 mg
bleomycin in ection recon soln 30 unit
MUSTARGEN INJECTION RECON SOLN 10
carboplatin intra enous solution 10 mg/ml
MG
cisplatin intra enous solution 1 mg/ml
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4
cladribine intra enous solution 10 mg/10 ml
MG
55
PA
PA
2
4
4
B/D
PA
2
2
4
2
B/D
B/D
PA
B/D
2
5
5
B/D
PA
PA
CLOLAR INTRAVENOUS
20
ODOMZO
ORAL CAPSULESOLUTION
200 MG
MG/20 ML
oxaliplatin intravenous solution 100 mg/20 ml
COSMEGEN INTRAVENOUS RECON SOLN
PACLITAXEL INTRAVENOUS
0.5 MG
CONCENTRATE 6 MG/ML
cytarabine (pf) in ection solution 2 gram/20 ml
PERJETA INTRAVENOUS SOLUTION 420
(100 mg/ml)
MG/14 ML (30 MG/ML)
cytarabine in ection solution 20 mg/ml
PROLEUKIN INTRAVENOUS RECON SOLN
dacarbazine
22
MILLION intra
UNITenous recon soln 200 mg
55
PA
PA
5
5
4
PA
PA
PA
2
5
B/D
PA
2
5
2
B/D
PA
B/D
daunorubicin
intra enous solution
5 mg/ml
TREANDA
INTRAVENOUS
RECON
SOLN 100
MG
DAUNOXOME INTRAVENOUS SOLUTION 2
52
B/D
PA
5
4
B/D
PA
5
54
B/D
PA
B/D
4
5
PA
PA
45
PA
PA
2
B/D
DOXIL INTRAVENOUS
SUSPENSION
vincristine
intravenous solution
1 mg/ml 2
MG/ML
vinorelbine intravenous solution 50 mg/5 ml
doxorubicin intra enous solution 50 mg/25 ml
25
PA
B/D
2
2
B/D
B/D
ELITEK INTRAVENOUS RECON SOLN 1.5
ABRAXANE
INTRAVENOUS SUSPENSION
MG
FOR RECONSTITUTION 100 MG
ELLENCE INTRAVENOUS SOLUTION 200
amifostine
crystalline intravenous recon soln 500
MG/100 ML
mg
epirubicin intra enous solution 50 mg/25 ml
fludarabine intravenous recon soln 50 mg
ERBITUX INTRAVENOUS SOLUTION 100
FUSILEV
INTRAVENOUS RECON SOLN 50
MG/50 ML
MG
4
5
PA
PA
5
5
PA
PA
4
4
5
5
PA
PA
PA
PA
leucovorin calcium injection recon soln 100 mg
2
B/D
MG/ML INTRAVENOUS SOLUTION 10
TRISENOX
MG/10
ML intra enous recon soln 50 mg
decitabine
VECTIBIX
INTRAVENOUS
SOLUTION
dexrazoxane
hcl intra enous recon
soln 250100
mg
MG/5 ML (20 MG/ML)
DOCEFREZ INTRAVENOUS RECON SOLN 20
VELCADE
INJECTION RECON SOLN 3.5 MG
MG
VINBLASTINE
INTRAVENOUSSOLUTION
SOLUTION80
1
DOCETAXEL INTRAVENOUS
MG/ML
MG/4 ML (20 MG/ML), 80 MG/8 ML (10
MG/ML)pfs intravenous solution 1 mg/ml
vincasar
Antineoplastics, Other
28
2828
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 10
hour
leucovorin
calcium oral
tablet
mg,100
15mcg/hr,
mg, 25
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg, 5 mg
22
hydrocodone-acetaminophen
oral tablet
2.5-325
mitoxantrone
intravenous concentrate
2 mg/ml
mg
ONCASPAR INJECTION SOLUTION 750
hydromorphone (pf) in ection solution 10 mg/ml
UNIT/ML
22
5
2
PA
hydromorphone
oralCAPSULE
tablet 2 mg,
mg, 820mgMG
REVLIMID
ORAL
2.54 MG,
52
QL (180
PA;
LA EA per 30 days)
LAZANDASUBCUTANEOUS
NASAL SPRAY,NON-AEROSOL
SYNRIBO
RECON SOLN
100
MCG/SPRAY
3.5 MG
53
PA; QL (600 EA per 30 days)
PA
LAZANDA
NASAL SPRAY,NON-AEROSOL
YERVOY
INTRAVENOUS
SOLUTION 50
400 MCG/SPRAY
MG/10
ML (5 MG/ML)
53
PA; QL (150 EA per 30 days)
PA
meperidine INTRAVENOUS
oral solution 50 mg/5
ml
ZALTRAP
SOLUTION
100
MG/4
ML (25
MG/ML)
meperidine
oral
tablet 50 mg
52
PA; QL (3600 ML per 30 days)
PA
2
PA; QL (240 EA per 30 days)
Aromatase
Inhibitors,
meperitab oral
tablet 1003Rd
mg Generation
2
PA; QL (240 EA per 30 days)
anastrozole
tabletsolution
1 mg 10 mg/ml, 20 mg/ml
nalbuphine oral
in ection
12
B/D
exemestane
oral solution
tablet 255mg
oxycodone oral
mg/5 ml
22
QL (5400 ML per 30 days)
letrozole
oral
tablet
2.510mg
oxycodone
oral
tablet
mg, 15 mg, 20 mg, 30
mg, 5 mg
22
QL (180 EA per 30 days)
tramadol oral tablet 50 mg
ETOPOPHOS INTRAVENOUS RECON SOLN
100
MG
Anesthetics
2
4
QL (240 EA per 30 days)
PA
etoposide
intravenous solution 20 mg/ml
Local Anesthetics
2
B/D
FARYDAK
ORAL
CAPSULE
MG, 15
MG,)20
lidocaine (pf)
in ection
solution10
5 mg/ml
(0.5
MG
lidocaine hcl mucous membrane gel 2
IBRANCE ORAL CAPSULE 100 MG, 125 MG,
lidocaine
75
MG hcl mucous membrane solution 4 (40
mg/ml)
toposar intravenous solution 20 mg/ml
lidocaine hcl urethral gel 2
topotecan intravenous recon soln 4 mg
lidocaine topical adhesi e patch,medicated 5
ZYDELIG
ORAL TABLET 100 MG, 150 MG
(700 mg/patch)
52
PA
2
5
2
PA
Molecular
Target
Inhibitors
lidocaine topical
ointment
5
2
AFINITOR
ORAL TABLET
10 MG,
2.5 MG, 5
lidocaine-prilocaine
topical cream
2.5-2.5
MG, 7.5 MG
52
PA
B/D
ALECENSA ORAL CAPSULE 150 MG
5
PA
BOSULIF ORAL TABLET 100 MG, 500 MG
acamprosate oral tablet,delayed release (dr/ec)
CAPRELSA
ORAL TABLET 100 MG, 300 MG
333 mg
COMETRIQ
ORAL
100mg
MG/DAY(80
disulfiram oral
tabletCAPSULE
250 mg, 500
MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20
naltrexone
tablet 50
MG[3]),
60 oral
MG/DAY
(20mg
MG [3]/DAY)
5
2
5
PA
PA
PA
52
PA
Enzyme Inhibitors
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
2
2
5
2
5
QL (10 EA per 30 days)
B/D
PA
PA; QL (90 EA per 30 days)
PA
2
29
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
ERIVEDGE
CAPSULESOLUTION
150 MG
TREANDA ORAL
INTRAVENOUS
45
MG/0.5 ML
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40
TRISENOX INTRAVENOUS SOLUTION 10
MG
MG/10 ML
GLEEVEC ORAL TABLET 100 MG, 400 MG
VECTIBIX INTRAVENOUS SOLUTION 100
ICLUSIG ORAL TABLET 15 MG, 45 MG
MG/5 ML (20 MG/ML)
imatinib oral tablet 100 mg, 400 mg
VELCADE INJECTION RECON SOLN 3.5 MG
IMBRUVICA ORAL CAPSULE 140 MG
VINBLASTINE INTRAVENOUS SOLUTION 1
INLYTA
MG/ML ORAL TABLET 1 MG, 5 MG
55
PA
PA
5
4
PA
PA
5
5
5
PA
PA
PA
5
5
5
4
5
PA
PA
PA
PA
PA
IRESSA
TABLET
250 MG1 mg/ml
incasarORAL
pfs intra
enous solution
52
PA
B/D
JAKAFI
ORAL
10 MG,
15 MG, 20
incristine
intraTABLET
enous solution
1 mg/ml
MG, 25 MG, 5 MG
inorelbine intra enous solution 50 mg/5 ml
LENVIMA ORAL CAPSULE 10 MG/DAY (10
Antineoplastics,
Other
MG
[1]/DAY), 14 MG
(10 MG[1] -4
MG[1])/DAY,
20 MG/DAY (10 MG
[2]/DAY), 24
ABRAXANE INTRAVENOUS
SUSPENSION
MG
MG[2] -4 MG[1])/DAY
FOR(10
RECONSTITUTION
100 MG
52
PA
B/D
2
5
B/D
PA
5
PA
MEKINIST
ORAL TABLET
0.5 MG,
2 MG
amifostine crystalline
intra enous
recon
soln 500
mg
NEXAVAR
ORAL TABLET 200 MG
55
PA
PA
5
54
PA
PA
PA
52
52
B/D
PA
fludarabine
enous recon
soln 150
50 mg
OFEV
ORALintra
CAPSULE
100 MG,
MG
FUSILEV INTRAVENOUS
RECON
SOLN
5020
SPRYCEL
ORAL TABLET 100
MG, 140
MG,
MG
MG, 50 MG, 70 MG, 80 MG
leuco orin calcium
ection recon
soln 100 mg
STIVARGA
ORAL in
TABLET
40 MG
leuco orinORAL
calcium
oral tablet
10 MG,
mg, 15
SUTENT
CAPSULE
12.5
25mg,
MG,25
mg,
5
mg
37.5 MG, 50 MG
55
PA
PA
PA
mitoxantroneORAL
intra CAPSULE
enous concentrate
mg/ml
TAFINLAR
50 MG,275
MG
ONCASPAR
INJECTION
SOLUTION
750
TAGRISSO ORAL TABLET 40 MG, 80 MG
UNIT/ML
TARCEVA ORAL TABLET 100 MG, 150 MG,
REVLIMID ORAL CAPSULE 2.5 MG, 20 MG
25 MG
SYNRIBO SUBCUTANEOUS RECON SOLN
TASIGNA ORAL CAPSULE 150 MG, 200 MG
3.5 MG
TYKERB ORAL TABLET 250 MG
YERVOY INTRAVENOUS SOLUTION 50
VOTRIENT
ORAL
TABLET 200 MG
MG/10 ML (5
MG/ML)
52
55
PA
PA
PA
5
5
PA
PA; LA
5
5
PA
PA
5
5
5
PA
PA
PA
XALKORI
CAPSULE SOLUTION
200 MG, 250100
MG
ZALTRAPORAL
INTRAVENOUS
MG/4 ML (25
MG/ML)
ZELBORAF
ORAL
TABLET 240 MG
55
PA
PA
5
PA
5
1
PA
AromataseORAL
Inhibitors,
3Rd150
Generation
ZYKADIA
CAPSULE
MG
anastrozole oral
tablet 1 mg
Monoclonal
Antibodies
exemestane oral tablet 25 mg
ARZERRA INTRAVENOUS SOLUTION 100
MG/5
MLoral tablet 2.5 mg
letrozole
2
5
2
PA
30
3030
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour
100 mcg/hr,
CYRAMZA
INTRAVENOUS
SOLUTION
10
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
MG/ML, 10 MG/ML (50 ML)
52
QL (10 EA per 30 days)
PA
hydrocodone-acetaminophen
oral
tablet 2.5-325
DARZALEX
INTRAVENOUS
SOLUTION
20
mg
MG/ML
52
PA
hydromorphone
(pf) in ection solution
mg/ml
EMPLICITI
INTRAVENOUS
RECON10
SOLN
300
MG, 400 MGoral tablet 2 mg, 4 mg, 8 mg
hydromorphone
52
PA
2
53
QL (180 EA per 30 days)
PA
PA; QL (600 EA per 30 days)
KEYTRUDA
INTRAVENOUS
SOLUTION 100
LAZANDA NASAL
SPRAY,NON-AEROSOL
MG/4
ML (25 MG/ML)
400 MCG/SPRAY
53
PA
PA; QL (150 EA per 30 days)
OPDIVO
INTRAVENOUS
40 MG/4
meperidine
oral solution 50 SOLUTION
mg/5 ml
ML
meperidine oral tablet 50 mg
RITUXAN INTRAVENOUS CONCENTRATE
meperitab
10
MG/MLoral tablet 100 mg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
Retinoids
52
PA
PA; QL (3600 ML per 30 days)
2
5
2
PA; QL (240 EA per 30 days)
PA
PA; QL (240 EA per 30 days)
2
B/D
oxycodone oral
oral capsule
solution 75
5 mg/5
bexarotene
mg ml
oxycodone oral
tablet 10GEL
mg,0.1
15 %
mg, 20 mg, 30
PANRETIN
TOPICAL
mg, 5 mg
TARGRETIN ORAL CAPSULE 75 MG
tramadol oral tablet 50 mg
TARGRETIN TOPICAL GEL 1 %
52
32
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
PA
5
2
3
QL (240 EA per 30 days)
PA
tretinoin (chemotherapy) oral capsule 10 mg
5
KEYTRUDA
INTRAVENOUS
RECON SOLN
LAZANDA NASAL
SPRAY,NON-AEROSOL
50
MG
100 MCG/SPRAY
Anesthetics
Local Anesthetics
Antiparasitics
lidocaine (pf) in ection solution 5 mg/ml (0.5
Anthelmintics
lidocaine hcl mucous membrane gel 2
ALBENZA ORAL TABLET 200 MG
lidocaine hcl mucous membrane solution 4
BILTRICIDE
ORAL TABLET 600 MG
mg/ml)
)
2
(40
2
4
2
3
lidocaine hcl urethral gel 2
Antiprotozoals
2
lidocaineORAL
topicalSUSPENSION
adhesi e patch,medicated
5
ALINIA
FOR
(700 mg/patch)
RECONSTITUTION
100 MG/5 ML
42
lidocaineORAL
topicalTABLET
ointment 500
5 MG
ALINIA
42
lidocaine-prilocaine
topical 750
cream
2.5-2.5
atovaquone
oral suspension
mg/5
ml
52
PA; QL (90 EA per 30 days)
B/D
atovaquone-proguanil
oral tabletAbuse
62.5-25
mg
Anti-Addiction/ Substance
Treatment
Agents 2
chloroquine
phosphate oral
tablet 250 mg, 500 mg
Alcohol Deterrents/
Anti-Craving
2
COARTEM
TABLET 20-120
MG(dr/ec)
acamprosateORAL
oral tablet,delayed
release
333 mg
DARAPRIM
ORAL TABLET 25 MG
42
4
12
disulfiram oral tabletoral
250tablet
mg, 500
hydroxychloroquine
200mg
mg
naltrexone oralORAL
tabletTABLET
50 mg 250-100 MG
MALARONE
PA
42
31
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31 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
mefloquine
tablet
250 mg100 MG, 140 MG, 20
SPRYCELoral
ORAL
TABLET
MG, 50 MG, 70 MG, 80 MG
NEBUPENT INHALATION RECON SOLN 300
STIVARGA ORAL TABLET 40 MG
MG
25
PA
4
5
B/D
PA
SUTENT INJECTION
ORAL CAPSULE
12.5SOLN
MG, 25
PENTAM
RECON
300MG,
MG
37.5 MG, 50 MG
PRIMAQUINE ORAL TABLET 26.3 MG
TAFINLAR ORAL CAPSULE 50 MG, 75 MG
quinine sulfate oral capsule 324 mg
TARCEVA ORAL TABLET 100 MG, 150 MG,
Pediculicides/
Scabicides
25 MG
lindane
topical
lotion
1%
TASIGNA
ORAL
CAPSULE
150 MG, 200 MG
45
PA
PA
4
5
2
5
PA
PA
25
25
PA
PA
permethrin
5 % 200 MG, 250 MG
XALKORItopical
ORALcream
CAPSULE
25
25
Antiparkinson
Agents
ZELBORAF ORAL
TABLET 240 MG
5
PA
ZYKADIA ORAL CAPSULE 150 MG
Anticholinergics
5
PA
benztropine
oralAntibodies
tablet 0.5 mg, 1 mg, 2 mg
Monoclonal
2
PA
trihexyphenidyl
oral elixir 0.4 mg/ml
ARZERRA INTRAVENOUS
SOLUTION 100
MG/5
ML
trihexyphenidyl oral tablet 2 mg, 5 mg
25
PA
PA
2
5
PA
PA
entacapone oral tablet 200 mg
OPDIVO INTRAVENOUS SOLUTION 40 MG/4
ML
tolcapone
oral tablet 100 mg
2
5
2
PA
RITUXAN INTRAVENOUS
CONCENTRATE
Dopamine
Agonists
10 MG/ML
APOKYN SUBCUTANEOUS CARTRIDGE 10
Retinoids
MG/ML
5
PA
5
PA
PANRETIN TOPICAL
GEL
0.1 %
bromocriptine
oral capsule
5 mg
23
PA
TARGRETINoral
ORAL
CAPSULE
bromocriptine
tablet
2.5 mg 75 MG
25
TARGRETIN
GEL 1EXTENDED
%
MIRAPEX
ER TOPICAL
ORAL TABLET
RELEASE
24 HR 0.375 MG,
MG, 3.75
tretinoin (chemotherapy)
oral3capsule
10 MG,
mg 4.5
MG
tretinoin topical cream 0.025 , 0.05 , 0.1
mirapex er oral tablet extended release 24 hr 2.25
tretinoin topical gel 0.01 , 0.025
mg
43
lindane
topical
shampoo
1 %250 MG
TYKERB
ORAL
TABLET
malathion
topical
lotion
0.5 % 200 MG
VOTRIENT
ORAL
TABLET
KEYTRUDA INTRAVENOUS RECON SOLN
Antiparkinson
Agents, Other
50 MG
Antiparasitics
NEUPRO
TRANSDERMAL PATCH 24 HOUR 1
MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24
Anthelmintics
HOUR,
4 MG/24 HOUR, 6 MG/24 HOUR, 8
MG/24
HOUR
ALBENZA ORAL TABLET 200 MG
pramipexole
oral
tabletTABLET
0.125 mg,
0.25
mg, 0.5
BILTRICIDE
ORAL
600
MG
mg, 0.75 mg, 1 mg, 1.5 mg
PA
PA
PA
5
2
4
2
4
PA
4
23
Antiprotozoals
32
3232
Puedeencontrar
encontrarinformación
informaciónsobre
sobreloloque
quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
tabla,vaya
vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour
100 mcg/hr,
pramipexole
oral tablet
extended
release
24 hr
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg
22
hydrocodone-acetaminophen
tablet
2.5-325
ropinirole
oral tablet 0.25 mg,oral
0.5 mg,
1 mg,
2 mg,
3mg
mg, 4 mg, 5 mg
22
QL (10 EA per 30 days)
2
hydromorphone
(pf) in ection
solutionAcid
10 mg/ml
Dopamine
Precursors/
L-Amino
Decarboxylase Inhibitors
22
3
2
3
QL (180 EA per 30 days)
meperidine oral solution 50 mg/5 ml
AZILECT ORAL TABLET 0.5 MG, 1 MG
meperidine oral tablet 50 mg
selegiline hcl oral capsule 5 mg
meperitab oral tablet 100 mg
selegiline hcl oral tablet 5 mg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
2
4
2
2
2
2
2
PA; QL (3600 ML per 30 days)
ST
PA; QL (240 EA per 30 days)
oxycodone oral solution 5 mg/5 ml
2
QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
fluphenazine
mg, 5 mg decanoate injection solution 25
mg/ml
tramadol oral tablet 50 mg
fluphenazine hcl injection solution 2.5 mg/ml
2
2
QL (180 EA per 30 days)
2
2
QL (240 EA per 30 days)
fluphenazine hcl oral concentrate 5 mg/ml
2
fluphenazine hcl oral elixir 2.5 mg/5 ml
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5
lidocaine hcl mucous membrane gel 2
mg
2
2
1
2
lidocaine hcldecanoate
mucous membrane
solution
4 100
(40
haloperidol
intramuscular
solution
mg/ml)50 mg/ml
mg/ml,
22
lidocaine hcllactate
urethral
gel 2 solution 5 mg/ml
haloperidol
injection
22
lidocaine topical
e patch,medicated
haloperidol
lactateadhesi
oral concentrate
2 mg/ml5
(700 mg/patch)
haloperidol oral tablet 0.5 mg, 2 mg, 5 mg
lidocaine topical ointment 5
haloperidol oral tablet 1 mg
lidocaine-prilocaine topical cream 2.5-2.5
haloperidol oral tablet 10 mg, 20 mg
22
PA; QL (90 EA per 30 days)
1
2
1
2
1
QL (90 EA per 30 days)
hydromorphone oraloral
tablet
2 mg,
4 mg,mg,
8 mg
carbidopa-levodopa
tablet
10-100
25-100
mg,
25-250
mg
LAZANDA NASAL SPRAY,NON-AEROSOL
100 MCG/SPRAY oral tablet extended release
carbidopa-levodopa
25-100
mg, 50-200
mgSPRAY,NON-AEROSOL
LAZANDA
NASAL
400 MCG/SPRAY
Monoamine
Oxidase B (Mao-B) Inhibitors
Antipsychotics
1St Generation/ Typical
Anesthetics
Local Anesthetics
Anti-Addiction/
Substance
Abuse
loxapine
succinate oral
capsule 10
mg Treatment Agents 2
Alcoholsuccinate
Deterrents/
Anti-Craving
loxapine
oral capsule
25 mg, 5 mg
acamprosate
oral tablet,delayed
release
loxapine
succinate
oral capsule 50
mg (dr/ec)
333 mg
molindone oral tablet 10 mg, 5 mg
disulfiram oral tablet 250 mg, 500 mg
molindone oral tablet 25 mg
naltrexone oral tablet 50 mg
ORAP ORAL TABLET 1 MG, 2 MG
PA; QL (600 EA per 30 days)
PA; QL (150 EA per 30 days)
PA; QL (240 EA per 30 days)
B/D
QL (270 EA per 30 days)
B/D
QL (150 EA per 30 days)
QL (120 EA per 30 days)
2
22
QL (90 EA per 30 days)
PA (150 EA per 30 days)
QL
2
2
2
2
4
QL (120 EA per 30 days)
QL (270 EA per 30 days)
33
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33 vi
Nombre
Drug
Namedel Medicamento
Nivel
de Medicamento
Requisitos/Límites
Drug
Tier
Requirements/Limits
pimozide
oral tablet
1 mg, 2 mg
Dopamine
Agonists
2
thioridazine
tablet 10 mg, 100CARTRIDGE
mg, 25 mg, 5010
APOKYNoral
SUBCUTANEOUS
mgMG/ML
2 5
thiothixene
oral capsule
1 mg, 510mg
mg, 2 mg, 5 mg
bromocriptine
oral capsule
1 2
PAPA
trifluoperazine
oral
tablet
1 mg,
10 mg, 2 mg, 5
2 2
bromocriptine
oral
tablet
2.5 mg
mg
MIRAPEX ER ORAL TABLET EXTENDED
4
RELEASE
24 HRAtypical
0.375 MG, 2.25 MG, 3 MG,
2Nd
Generation/
3.75 MG, 4.5 MG
FANAPT ORAL TABLET 1 MG, 10 MG, 12
4
QL (60 EA per 30 days)
NEUPRO
4
PA
MG,
2 MG, 4TRANSDERMAL
MG, 6 MG, 8 MG PATCH 24 HOUR 1
MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24
FANAPT ORAL TABLETS,DOSE PACK
4
HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8
1MG(2)-2MG(2)- 4MG(2)-6MG(2)
MG/24 HOUR
GEODON INTRAMUSCULAR RECON SOLN
4
PA; QL (12 EA per 30 days)
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5
2
20 MG/ML (FINAL CONC.)
mg, 0.75 mg, 1 mg, 1.5 mg
INVEGA ORAL TABLET EXTENDED
4
PA; QL (30 EA per 30 days)
pramipexole oral tablet extended release 24 hr
2
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
0.75 mg, 1.5 mg
INVEGA ORAL TABLET EXTENDED
4
PA; QL (60 EA per 30 days)
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
2
RELEASE 24HR 6 MG
3 mg, 4 mg, 5 mg
INVEGA SUSTENNA INTRAMUSCULAR
5
PA; QL (0.75 ML per 28 days)
Dopamine
Precursors/
SYRINGE
117 MG/0.75
ML L-Amino Acid Decarboxylase Inhibitors
carbidopa-le
odopa oral
tablet 10-100 mg, 25-100
INVEGA
SUSTENNA
INTRAMUSCULAR
5 2
PA; QL (1 ML per 28 days)
mg,
25-250
mg
SYRINGE 156 MG/ML
carbidopa-le
odopa oral
tablet extended release
INVEGA
SUSTENNA
INTRAMUSCULAR
25-100 mg,
SYRINGE
23450-200
MG/1.5mg
ML
Monoamine
Oxidase
B (Mao-B) Inhibitors
INVEGA
SUSTENNA
INTRAMUSCULAR
SYRINGE
39ORAL
MG/0.25
ML 0.5 MG, 1 MG
AZILECT
TABLET
5 2
4
4
PA; QL (1.5 ML per 28 days)
PA; QL (0.25 ML per 28 days)
ST
PA; QL (0.5 ML per 28 days)
INVEGA
SUSTENNA
INTRAMUSCULAR
selegiline
hcl oral capsule
5 mg
SYRINGE 78 MG/0.5 ML
selegiline hcl oral tablet 5 mg
LATUDA ORAL TABLET 120 MG
4 2
LATUDA ORAL TABLET 20 MG, 40 MG, 60
1St
Typical
MG,
80Generation/
MG
4
QL (30 EA per 30 days)
chlorpromazine
in ection
solution
olanzapine
intramuscular
recon
soln 25
10 mg/ml
mg
2 2
QL (90 EA per 30 days)
chlorpromazine
oral10tablet
10 mg,
mg, 2.5
100mg,
mg,20
200
olanzapine
oral tablet
mg, 15
25 mg,
50 mg
mg,mg,
5 mg,
7.5 mg
2 2
QL (30 EA per 30 days)
fluphenazine
in ection solution
25
olanzapine
oral decanoate
tablet,disintegrating
10 mg, 15
mg,mg/ml
20 mg, 5 mg
2 2
QL (30 EA per 30 days)
fluphenazine
hcltablet
in ection
solution
2.5 mg/ml
paliperidone
oral
extended
release
24hr 1.5
mg,fluphenazine
3 mg, 9 mg hcl oral concentrate 5 mg/ml
2 2
PA; QL (30 EA per 30 days)
Antipsychotics
fluphenazine hcl oral elixir 2.5 mg/5 ml
5
2
QL (30 EA per 30 days)
2
2
34
34
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vi vi -
vi -
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour
100 mcg/hr,
paliperidone
oral tablet
extended
release
24hr 6
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg
22
QL (10
PA;
QL EA
(60 per
EA 30
perdays)
30 days)
hydrocodone-acetaminophen
2.5-325
quetiapine
oral tablet 100 mg,oral
200 tablet
mg, 300
mg,
mg mg
400
22
QL (60 EA per 30 days)
hydromorphone
(pf) in25ection
solution
quetiapine
oral tablet
mg, 50
mg 10 mg/ml
22
QL (90 EA per 30 days)
hydromorphone
tablet 20.25
mg, MG,
4 mg,0.5
8 mg
REXULTI
ORALoral
TABLET
MG, 1
MG,
2 MG, 3NASAL
MG, 4 MG
LAZANDA
SPRAY,NON-AEROSOL
52
QL (30
(180EA
EAper
per3030days)
days)
QL
3
4
PA; QL (600 EA per 30 days)
PA; QL (2 EA per 28 days)
3
5
PA; QL (150 EA per 30 days)
PA; QL (2 EA per 28 days)
2
22
PA; QL (3600 ML per 30 days)
QL
ML per
PA;(240
QL (240
EA 30
perdays)
30 days)
22
QL
perEA
30per
days)
PA;(60
QLEA
(240
30 days)
2
2
2
B/D
QL (60 EA per 30 days)
QL (5400 ML per 30 days)
32
QL (60
(180EA
EAper
per3030days)
days)
QL
22
QL (60
(240EA
EAper
per3030days)
days)
QL
ZYPREXA RELPREVV INTRAMUSCULAR
Local Anesthetics
SUSPENSION FOR RECONSTITUTION 210
MG
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
5
PA
lidocaine hcl mucous membrane gel 2
Treatment-Resistant
2
lidocaine oral
hcl mucous
membrane
solution 4 (40
clozapine
tablet 100
mg
mg/ml)
clozapine oral tablet 200 mg
lidocaine hcl urethral gel 2
clozapine oral tablet 25 mg, 50 mg
lidocaine topical adhesi e patch,medicated 5
clozapine
oral tablet,disintegrating 100 mg, 12.5
(700 mg/patch)
mg, 25 mg
lidocaine topical ointment 5
clozapine oral tablet,disintegrating 150 mg
lidocaine-prilocaine topical cream 2.5-2.5
clozapine oral tablet,disintegrating 200 mg
22
2
2
2
2
QL (180 EA per 30 days)
B/D
QL (120 EA per 30 days)
VERSACLOZ ORAL SUSPENSION 50 MG/ML
5
QL (540 ML per 30 days)
acamprosate oral tablet,delayed release (dr/ec)
2
PA
baclofen
oral
tablet
10250
mg,mg,
20 mg
disulfiram
oral
tablet
500 mg
dantrolene
naltrexone oral
oral capsule
tablet 50100
mgmg, 25 mg, 50 mg
12
22
tizanidine oral tablet 2 mg, 4 mg
1
100 MCG/SPRAY
RISPERDAL
CONSTA INTRAMUSCULAR
SYRINGE
12.5
MG/2SPRAY,NON-AEROSOL
ML, 25 MG/2 ML
LAZANDA NASAL
400 MCG/SPRAY
RISPERDAL
CONSTA INTRAMUSCULAR
SYRINGE
ML,
MG/2
meperidine37.5
oralMG/2
solution
5050
mg/5
ml ML
risperidone
mg/ml
meperidine oral
oral solution
tablet 501mg
risperidone
oraltablet
tablet100
0.25mg
mg, 0.5 mg, 1 mg, 2
meperitab oral
mg, 3 mg, 4 mg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
risperidone oral tablet,disintegrating 0.25 mg, 0.5
oxycodone
5 mg/5 ml
mg,
1 mg, 2 oral
mg, solution
3 mg, 4 mg
oxycodone(BLACK
oral tablet
10 mg, 15SUBLINGUAL
mg, 20 mg, 30
SAPHRIS
CHERRY)
mg, 5 mg 10 MG, 2.5 MG, 5 MG
TABLET
tramadol oral
50 mg 20 mg, 40 mg, 60 mg,
ziprasidone
hcltablet
oral capsule
80
mg
Anesthetics
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
Antispasticity Agents
Antispasticity
Agents
333 mg
2
2
2
2
2
2
QL (270 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
PA; QL (90 EA per 30 days)
35
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Nombre
del Medicamento
Drug
Name
GEODON INTRAMUSCULAR RECON SOLN
Antivirals
20 MG/ML (FINAL CONC.)
Anti-Cytomegalovirus (Cmv) Agents
INVEGA ORAL TABLET EXTENDED
cidofovir
intravenous
75 mg/ml
RELEASE
24HR 1.5 solution
MG, 3 MG,
9 MG
ganciclovir
sodiumTABLET
intravenous
recon soln 500 mg
INVEGA ORAL
EXTENDED
RELEASE ORAL
24HR 6RECON
MG
VALCYTE
SOLN 50 MG/ML
INVEGA SUSTENNA
valganciclovir
oral tabletINTRAMUSCULAR
450 mg
SYRINGE 117 MG/0.75 ML
ZIRGAN OPHTHALMIC GEL 0.15 %
INVEGA SUSTENNA INTRAMUSCULAR
Anti-Hepatitis
B (Hbv) Agents
SYRINGE 156 MG/ML
ADEFOVIR
ORAL TABLET
10 MG
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 234ORAL
MG/1.5SOLUTION
ML
BARACLUDE
0.05 MG/ML
INVEGA SUSTENNA INTRAMUSCULAR
entecavir oral tablet 0.5 mg, 1 mg
SYRINGE 39 MG/0.25 ML
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML
INVEGA SUSTENNA INTRAMUSCULAR
(5 MG/ML)
SYRINGE 78 MG/0.5 ML
INTRON A INJECTION RECON SOLN 10
LATUDA ORAL TABLET 120 MG
MILLION UNIT (1 ML)
LATUDA ORAL TABLET 20 MG, 40 MG, 60
INTRON A INJECTION SOLUTION 6
MG, 80 MG
MILLION UNIT/ML
olanzapine intramuscular recon soln 10 mg
TYZEKA ORAL TABLET 600 MG
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
Anti-Hepatitis
mg, 5 mg, 7.5 mgC (Hcv) Agents
DAKLINZA
ORAL
TABLET 30 MG,1060mg,
MG
olanzapine oral
tablet,disintegrating
15
mg, 20 mg, ORAL
5 mg TABLET 90-400 MG
HARVONI
uetiapineAoral
tablet 100RECON
mg, 200SOLN
mg, 300
INTRON
INJECTION
18mg,
400
mg
MILLION UNIT (1 ML), 50 MILLION UNIT (1
ML)
uetiapine oral tablet 25 mg, 50 mg
MODERIBA
PACK
ORAL
RISPERDALDOSE
CONSTA
INTRAMUSCULAR
TABLETS,DOSE
PACK
40025MG
(7)-ML
400 MG
SYRINGE 12.5 MG/2
ML,
MG/2
(7), 600 MG (7)- 600 MG (7)
RISPERDAL CONSTA INTRAMUSCULAR
moderiba
oral
tablet
200
mg50 MG/2 ML
SYRINGE
37.5
MG/2
ML,
OLYSIO
ORAL
150 MG
risperidone
oral CAPSULE
solution 1 mg/ml
PEGASYS
SUBCUTANEOUS
PEN
risperidonePROCLICK
oral tablet 0.25
mg, 0.5 mg, 1 mg,
2
INJECTOR
135
MCG/0.5
ML,
180
MCG/0.5
ML
mg, 3 mg, 4 mg
PEGASYS
SOLUTION
180
risperidoneSUBCUTANEOUS
oral tablet,disintegrating
0.25 mg,
0.5
MCG/ML
mg, 1 mg, 2 mg, 3 mg, 4 mg
PEGASYS
SUBCUTANEOUS
180
SAPHRIS (BLACK
CHERRY)SYRINGE
SUBLINGUAL
MCG/0.5
TABLETML
10 MG, 2.5 MG, 5 MG
NivelDrug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
4
PA; QL (12 EA per 30 days)
4
2
PA; QL (30 EA per 30 days)
24
5
55
PA; QL (60 EA per 30 days)
4
5
PA; QL (1 ML per 28 days)
45
PA
PA; QL (1.5 ML per 28 days)
3
4
5
PA; QL (0.25 ML per 28 days)
4
4
PA; QL (0.5 ML per 28 days)
4
5
PA
QL (30 EA per 30 days)
4
4
QL (30 EA per 30 days)
PA
2
4
2
QL (90 EA per 30 days)
52
5
PA
QL (30 EA per 30 days)
PA
42
QL (60 EA per 30 days)
PA
2
54
QL (90 EA per 30 days)
PA
PA; QL (2 EA per 28 days)
5
3
PA; QL (2 EA per 28 days)
PA
52
52
PA
QL (240 ML per 30 days)
PA
QL (60 EA per 30 days)
52
PA
QL (60 EA per 30 days)
53
PA
QL (60 EA per 30 days)
PA; QL (0.75 ML per 28 days)
QL (30 EA per 30 days)
36
3636
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
fentanyl transdermal
patch
72 hour 100 mcg/hr,
PEGINTRON
REDIPEN
SUBCUTANEOUS
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75ML,
mcg/hr
PEN INJECTOR KIT 120 MCG/0.5
150
MCG/0.5
ML,
50
MCG/0.5
ML,
80
MCG/0.5
ML
hydrocodone-acetaminophen oral tablet 2.5-325
mg
PEGINTRON
SUBCUTANEOUS KIT 120
MCG/0.5
ML, 150
50 MCG/0.5
hydromorphone
(pf)MCG/0.5
in ectionML,
solution
10 mg/ml
ML, 80 MCG/0.5 ML
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
REBETOL ORAL SOLUTION 40 MG/ML
LAZANDA NASAL SPRAY,NON-AEROSOL
ribasphere
oral capsule 200 mg
100 MCG/SPRAY
ribasphere
tablet SPRAY,NON-AEROSOL
200 mg
LAZANDAoral
NASAL
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
52
QL (10 EA per 30 days)
PA
2
5
PA
2
2
4
3
3
QL (180 EA per 30 days)
PA
PA; QL (600 EA per 30 days)
PA
400 MCG/SPRAY
RIBASPHERE
ORAL TABLET 400 MG
33
4
PA
PA; QL (150 EA per 30 days)
PA
meperidine oralORAL
solution
50 mg/5600
ml MG
RIBASPHERE
TABLET
52
PA; QL (3600 ML per 30 days)
PA
meperidine oralRIBAPAK
tablet 50 mg
RIBASPHERE
ORAL
TABLETS,DOSE
PACK
MG (28)-MG
meperitab oral tablet
100400-400
mg
(28), 600-400 MG (28)-MG (28), 600-600 MG
nalbuphine
in ection solution 10 mg/ml, 20 mg/ml
(28)-MG
(28)
oxycodone
oral
solution
mg/5 ml
ribavirin
oral
capsule
2005 mg
52
PA; QL (240 EA per 30 days)
PA
2
PA; QL (240 EA per 30 days)
2
B/D
32
32
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
PA
5
2
5
PA
QL (240 EA per 30 days)
PA
5
PA
2
5
2
PA
oxycodone
oral
tablet
10mg
mg, 15 mg, 20 mg, 30
ribavirin
oral
tablet
200
mg, 5 mg
SOVALDI ORAL TABLET 400 MG
tramadol oral tablet 50 mg
SYLATRON SUBCUTANEOUS KIT 200 MCG,
Anesthetics
300
MCG, 600 MCG
VIEKIRA
PAK ORAL TABLETS,DOSE PACK
Local Anesthetics
12.5 MG-75 MG -50 MG/250 MG
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
VIRAZOLE INHALATION RECON SOLN 6
lidocaine hcl mucous membrane gel 2
GRAM
lidocaine hcl mucous membrane solution 4 (40
Antiherpetic
Agents
mg/ml)
acyclovir
capsule gel
2002mg
lidocaineoral
hcl urethral
acyclovir
suspension
mg/5 ml
lidocaineoral
topical
adhesi e200
patch,medicated
5
(700
mg/patch)
acyclovir oral tablet 400 mg, 800 mg
2
12
12
PA; QL (90 EA per 30 days)
1
lidocainesodium
topical intravenous
ointment 5 solution 50 mg/ml
acyclovir
22
B/D
lidocaine-prilocaine
topical
cream 2.5-2.5
acyclovir
topical ointment
5%
22
B/D
DENAVIR
TOPICAL
CREAM Abuse
1%
Anti-Addiction/
Substance
Treatment Agents 4
famciclovir
oral tablet 125
mg, 250 mg, 500 mg
Alcohol Deterrents/
Anti-Craving
2
trifluridine
ophthalmic
drops 1 %release (dr/ec)
acamprosate
oral tablet,delayed
333 mg
valacyclovir
oral tablet 1 gram, 500 mg
22
2
42
disulfiram oral
tablet 250
mg, 500
ZOVIRAX
TOPICAL
CREAM
5 %mg
naltrexone oral tablet 50 mg
Anti-Hiv Agents, Integrase Inhibitors (Insti)
PA
2
37
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
GENVOYA
ORAL
TABLET
150-150-200-10
EPIVIR HBV
ORAL
SOLUTION
25 MG/5 ML
MG
(5 MG/ML)
54
INTRON A INJECTION
RECON
SOLN 10 100
ISENTRESS
ORAL POWDER
IN PACKET
MILLION UNIT (1 ML)
MG
34
PA
INTRON A INJECTION
SOLUTION
ISENTRESS
ORAL TABLET
400 MG 6
MILLION UNIT/ML
ISENTRESS ORAL TABLET,CHEWABLE 100
lami25
udine
MG,
MG oral solution 10 mg/ml
54
PA
lami udineORAL
oral tablet
100 mg,
150 mg, 300 mg
STRIBILD
TABLET
150-150-200-300
MG
REBETOL ORAL SOLUTION 40 MG/ML
52
TIVICAY
TABLET
ribasphereORAL
oral capsule
20050
mgMG
VITEKTA
TABLET
150 MG, 85 MG
ribasphereORAL
oral tablet
200 mg
3
2
4
53
53
PA
PA
PA
Anti-Hiv
Agents,
Non-Nucleoside
Reverse Transcriptase
RIBASPHERE
ORAL
TABLET 400 MG
4 Inhibitors
PA (Nnrti)
COMPLERA
ORAL
TABLET
200-25-300
RIBASPHERE
ORAL
TABLET
600 MG MG
EDURANT
ORAL
TABLET
riba irin oral
capsule
200 mg25 MG
55
53
PA
INTELENCE
TABLET
riba irin oralORAL
tablet 200
mg 100 MG, 25 MG
INTELENCE
ORAL
TABLET
TYZEKA ORAL
TABLET
600200
MGMG
43
54
PA
nevirapine
oral
suspension 50RECON
mg/5 ml SOLN 6
VIRAZOLE
INHALATION
GRAM oral tablet 200 mg
nevirapine
25
2
25
PA
VIREAD ORAL
POWDER
40release
MG/SCOOP
(40
nevirapine
oral tablet
extended
24 hr 100
MG/GRAM)
mg, 400 mg
VIREAD ORAL
TABLET
150 MG,
200 MG, 250
RESCRIPTOR
ORAL
TABLET
200 MG
MG, 300 MG
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Anti-Hepatitis
C (Hcv) Agents
100
MG
HARVONI
ORAL
TABLET 200
90-400
SUSTIVA
ORAL
CAPSULE
MG,MG
50 MG
PA
45
4
35
PA
INTRON A
INJECTION
RECON
SOLN 10
PA
SUSTIVA
ORAL
TABLET
600 MG
34
MILLION UNIT (1 ML), 18 MILLION UNIT (1
VIRAMUNE
XR ORAL
TABLET
3
ML), 50 MILLION
UNIT
(1 ML) EXTENDED
RELEASE 24 HR 100 MG
INTRON A INJECTION SOLUTION 6
4
PA
Anti-Hiv
Agents,
Nucleoside
And
Nucleotide
Reverse
Transcriptase
Inhibitors (Nrti)
MILLION UNIT/ML
abacavir
oral tablet
mg ORAL
25
MODERIBA
DOSE300
PACK
PA
TABLETS,DOSE
PACK
400
MG
(7)400
MG
abacavir-lamivudine-zidovudine oral tablet 3002
(7),
600
MG
(7)600
MG
(7)
150-300 mg
moderiba oral
tablet
200 mg600-200-300 MG
PA
ATRIPLA
ORAL
TABLET
53
OLYSIO ORAL
CAPSULE 150release(dr/ec)
MG
didanosine
oral capsule,delayed
125
mg, 200 PROCLICK
mg, 250 mg, SUBCUTANEOUS
400 mg
PEGASYS
PEN
INJECTOR
135
MCG/0.5
ML,
180
MCG/0.5
ML
EMTRIVA ORAL CAPSULE 200 MG
25
5
3
EMTRIVA ORAL SOLUTION 10 MG/ML
3
PA
PA
38
3838
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72
hour 100
EPZICOM
ORAL TABLET
600-300
MGmcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
lamivudine oral solution 10 mg/ml
hydrocodone-acetaminophen oral tablet 2.5-325
lamivudine oral tablet 100 mg, 150 mg, 300 mg
mg
lamivudine-zidovudine
tablet
150-300
mg
hydromorphone (pf) in oral
ection
solution
10 mg/ml
RETROVIR
INTRAVENOUS
SOLUTION
hydromorphone
oral tablet 2 mg,
4 mg, 8 mg10
MG/ML
LAZANDA NASAL SPRAY,NON-AEROSOL
stavudine
oral capsule 15 mg, 20 mg, 30 mg, 40
100 MCG/SPRAY
mg
LAZANDA NASAL SPRAY,NON-AEROSOL
stavudine
oral recon soln 1 mg/ml
400 MCG/SPRAY
TRUVADA
ORAL
TABLET
200-300
meperidine oral
solution
50 mg/5
ml MG
52
QL (10 EA per 30 days)
2
2
2
22
32
QL (180 EA per 30 days)
3
2
PA; QL (600 EA per 30 days)
3
2
PA; QL (150 EA per 30 days)
52
42
PA; QL (3600 ML per 30 days)
2
5
2
PA; QL (240 EA per 30 days)
52
QL (5400 ML per 30 days)
mg, 5 mg ORAL SOLUTION 20 MG/ML
ZIAGEN
tramadol oral
50 mg
zidovudine
oraltablet
capsule
100 mg
2
4
22
QL (180 EA per 30 days)
Anesthetics
zidovudine
oral syrup 10 mg/ml
2
zidovudine
oral tablet 300 mg
Local Anesthetics
2
Anti-Hiv
Agents,
Other
lidocaine (pf)
in ection
solution 5 mg/ml (0.5 )
2
lidocaine SUBCUTANEOUS
hcl mucous membrane
gel 2 SOLN 90
FUZEON
RECON
MG
lidocaine hcl mucous membrane solution 4 (40
52
mg/ml)
SELZENTRY
ORAL TABLET 150 MG, 300 MG
2
5
lidocaine hcl
urethral
gel 2 600-50-300 MG
TRIUMEQ
ORAL
TABLET
52
lidocaine ORAL
topical TABLET
adhesi e patch,medicated
5
TYBOST
150 MG
(700 mg/patch)
32
PA; QL (90 EA per 30 days)
lidocaine topical ointment 5
APTIVUS ORAL CAPSULE 250 MG
lidocaine-prilocaine topical cream 2.5-2.5
APTIVUS ORAL SOLUTION 100 MG/ML
2
3
2
3
B/D
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
3
VIDEX
2 GRAM
PEDIATRIC
meperidine
oral tablet
50 mg ORAL RECON
SOLN 10 MG/ML (FINAL)
meperitab oral tablet 100 mg
VIREAD ORAL POWDER 40 MG/SCOOP (40
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
MG/GRAM)
oxycodoneORAL
oral solution
5 mg/5
ml 200 MG, 250
VIREAD
TABLET
150 MG,
MG,
300 MG
oxycodone
oral tablet 10 mg, 15 mg, 20 mg, 30
Anti-Hiv Agents, Protease Inhibitors
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol ORAL
Deterrents/
Anti-Craving
EVOTAZ
TABLET
300-150 MG
acamprosateORAL
oral tablet,delayed
release
INVIRASE
CAPSULE 200
MG (dr/ec)
333 mg
INVIRASE ORAL TABLET 500 MG
disulfiram oral tablet 250 mg, 500 mg
KALETRA ORAL SOLUTION 400-100 MG/5
naltrexone oral tablet 50 mg
ML
5
32
PA; QL (240 EA per 30 days)
B/D
QL (240 EA per 30 days)
PA
3
2
3
2
39
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
KALETRA
TABLET
100-25
MG, 200-50
alacyclo irORAL
oral tablet
1 gram,
500 mg
MG
ZOVIRAX TOPICAL CREAM 5 %
LEXIVA ORAL SUSPENSION 50 MG/ML
32
LEXIVA ORAL TABLET 700 MG
ISENTRESS ORAL POWDER IN PACKET 100
NORVIR
ORAL CAPSULE 100 MG
MG
4
3
4
NORVIR
ORAL
SOLUTION
MG/ML
ISENTRESS
ORAL
TABLET80
400
MG
45
NORVIR
ORAL
TABLET
100 MG
ISENTRESS
ORAL
TABLET,CHEWABLE
100
MG, 25 MG ORAL TABLET 800-150 MG-MG
PREZCOBIX
43
Anti-Hiv Agents, Integrase Inhibitors (Insti)
STRIBILD ORAL
ORAL SUSPENSION
TABLET 150-150-200-300
PREZISTA
100 MG/ML
MG
PREZISTA ORAL TABLET 150 MG, 600 MG,
TIVICAY
75
MG, 800ORAL
MG TABLET 50 MG
VITEKTA ORAL
REYATAZ
ORAL TABLET
CAPSULE150
150MG,
MG85 MG
4
4
5
35
5
5
35
Anti-Hiv Agents,
Non-Nucleoside
Reverse
Inhibitors (Nnrti)
REYATAZ
ORAL CAPSULE
200 MG, 300
MG Transcriptase
5
COMPLERA
ORAL
TABLETIN200-25-300
MG
REYATAZ
ORAL
POWDER
PACKET 50
55
MG
EDURANT ORAL TABLET 25 MG
5
VIRACEPT
ORAL
TABLET
250
MG,
625
INTELENCE
ORAL
TABLET
100
MG,
25MG
MG
44
Anti-Influenza
Agents
INTELENCE ORAL
TABLET 200 MG
5
amantadine
hcl oral
capsule50
100
mg ml
ne irapine oral
suspension
mg/5
22
amantadine
hcl oral
solution
ne irapine oral
tablet
200 mg50 mg/5 ml
22
amantadine
hcl oral
tablet
100 mg
ne irapine oral
tablet
extended
release 24 hr 400
mg
RELENZA
DISKHALER INHALATION
22
rimantadine
oralORAL
tablet TABLET,
100 mg DISPERSIBLE
RESCRIPTOR
100
MG
TAMIFLU ORAL CAPSULE 30 MG
24
BLISTER
WITHORAL
DEVICE
5 MG/ACTUATION
RESCRIPTOR
TABLET
200 MG
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
TAMIFLU ORAL CAPSULE 45 MG
SUSTIVA ORAL TABLET 600 MG
TAMIFLU ORAL CAPSULE 75 MG
VIRAMUNE XR ORAL TABLET EXTENDED
TAMIFLU ORAL SUSPENSION FOR
RELEASE 24 HR 100 MG
RECONSTITUTION 6 MG/ML
4
4
4
3
4
3
4
3
4
QL (60 EA per 180 days)
QL (84 EA per 180 days)
QL (42 EA per 180 days)
QL (28 EA per 180 days)
QL (540 ML per 180 days)
Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti)
Anxiolytics
abaca ir oral tablet 300 mg
2
abaca ir-lami udine-zido udine oral tablet 300buspirone
oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
150-300 mg
7.5 mg
ATRIPLA ORAL TABLET 600-200-300 MG
meprobamate oral tablet 200 mg, 400 mg
didanosine oral capsule,delayed release(dr/ec)
Benzodiazepines
125 mg, 200 mg, 250 mg, 400 mg
2
1
Anxiolytics, Other
5
2
2
PA
40
4040
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hour
100 1mcg/hr,
alprazolam
oral tabletpatch
0.25 mg,
0.5 mg,
mg
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
alprazolam oral tablet 2 mg
hydrocodone-acetaminophen oral tablet 2.5-325
clorazepate dipotassium oral tablet 15 mg
mg
clorazepate
dipotassium
oral tablet
3.7510mg,
7.5
hydromorphone
(pf) in ection
solution
mg/ml
mg
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
diazepam intensol oral concentrate 5 mg/ml
LAZANDA NASAL SPRAY,NON-AEROSOL
diazepam
oral solution 5 mg/5 ml (1 mg/ml)
100 MCG/SPRAY
diazepam
oralNASAL
tablet 10
mg, 2 mg, 5 mg
LAZANDA
SPRAY,NON-AEROSOL
22
QL (120
(10 EA
QL
EAper
per30
30days)
days)
2
2
2
QL (150 EA per 30 days)
22
PA; QL (90 EA per 30 days)
2
2
3
2
QL (180 EA per 30 days)
PA; QL (240 ML per 30 days)
PA; QL (600 EA per 30 days)
PA; QL (1200 ML per 30 days)
400 MCG/SPRAY
lorazepam
intensol oral concentrate 2 mg/ml
23
2
PA;
PA; QL
QL (120
(150 EA
EA per
per 30
30 days)
days)
QL (150 ML per 30 days)
meperidineoral
oraltablet
solution
lorazepam
0.5 50
mg,mg/5
1 mgml
22
PA;(90
QLEA
(3600
per 30 days)
QL
perML
30 days)
meperidineoral
oraltablet
tablet250
lorazepam
mgmg
22
PA;(150
QL (240
EA30
perdays)
30 days)
QL
EA per
meperitabAgents
oral tablet 100 mg
Bipolar
2
PA; QL (240 EA per 30 days)
nalbuphine
in ection solution 10 mg/ml, 20 mg/ml
Mood
Stabilizers
2
B/D
oxycodone oral solution 5 mg/5 ml
carbamazepine
oral capsule, er multiphase 12 hr
100
mg, 200oral
mg,tablet
300 mg
oxycodone
10 mg, 15 mg, 20 mg, 30
mg, 5 mg
lithium carbonate oral capsule 150 mg, 300 mg,
600
mg oral tablet 50 mg
tramadol
22
2
QL (5400 ML per 30 days)
lithium
carbonate oral tablet 300 mg
Anesthetics
2
lithium
oral tablet extended release 300
Local carbonate
Anesthetics
mg, 450 mg
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
lithium citrate oral solution 8 meq/5 ml
lidocaine hcl mucous membrane gel 2
2
lidocaine hcl mucous membrane solution 4
Antidiabetic
Agents
mg/ml)
2
Blood Glucose Regulators
(40
2
2
PA; QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
2
2
2
lidocaineoral
hcl urethral
gelmg,
2 25 mg, 50 mg
acarbose
tablet 100
22
ST
lidocaine topical
e patch,medicated
5
AVANDIA
ORALadhesi
TABLET
2 MG
(700 mg/patch)
AVANDIA ORAL TABLET 4 MG
lidocaine topical ointment 5
AVANDIA ORAL TABLET 8 MG
lidocaine-prilocaine topical cream 2.5-2.5
BYDUREON SUBCUTANEOUS PEN
INJECTOR
2 MG/0.65
ML
Anti-Addiction/
Substance
Abuse Treatment Agents
42
PA; QL
QL(120
(90 EA
ST;
EAper
per30
30days)
days)
4
2
4
2
4
ST; QL (60 EA per 30 days)
BYDUREON
SUBCUTANEOUS
Alcohol Deterrents/
Anti-Craving
SUSPENSION,EXTENDED REL RECON 2 MG
acamprosate oral tablet,delayed release (dr/ec)
BYETTA
333 mg SUBCUTANEOUS PEN INJECTOR
10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5
disulfiram oral
tablet
250 mg,1.2
500ML
mg
MCG/DOSE
(250
MCG/ML)
naltrexone oral
mg
glimepiride
oral tablet
tablet 50
1 mg
4
PA
2
4
PA
PA
ST; QL (30 EA per 30 days)
B/D
PA
2
12
QL (240 EA per 30 days)
41
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
glimepiride
tablet
2 mg
KALETRAoral
ORAL
SOLUTION
400-100 MG/5
ML
glimepiride oral tablet 4 mg
KALETRA ORAL TABLET 100-25 MG, 200-50
glipizide oral tablet 10 mg
MG
glipizide oral tablet 5 mg
LEXIVA ORAL SUSPENSION 50 MG/ML
glipizide oral tablet extended release 24hr 10 mg
LEXIVA ORAL TABLET 700 MG
glipizide oral tablet extended release 24hr 2.5 mg
NORVIR ORAL CAPSULE 100 MG
glipizide oral tablet extended release 24hr 5 mg
NORVIR ORAL SOLUTION 80 MG/ML
glyburide micronized oral tablet 1.5 mg
NORVIR ORAL TABLET 100 MG
glyburide micronized oral tablet 3 mg
PREZCOBIX ORAL TABLET 800-150 MG-MG
glyburide micronized oral tablet 6 mg
PREZISTA ORAL SUSPENSION 100 MG/ML
glyburide oral tablet 1.25 mg
PREZISTA ORAL TABLET 150 MG, 600 MG,
75 MG, 800
glyburide
oralMG
tablet 2.5 mg
13
QL (120 EA per 30 days)
1
3
1
QL (60 EA per 30 days)
1
4
1
4
1
4
1
4
2
4
2
5
2
3
2
5
2
QL (240 EA per 30 days)
REYATAZ
ORAL
150 MG
glyburide
oral
tabletCAPSULE
5 mg
23
PA; QL (120 EA per 30 days)
REYATAZ ORAL
CAPSULE
MG, 300MG,
MG
INVOKAMET
ORAL
TABLET200
150-1,000
150-500 MG, 50-1,000 MG
REYATAZ ORAL POWDER IN PACKET 50
MG
INVOKAMET
ORAL TABLET 50-500 MG
35
ST; QL (60 EA per 30 days)
5
3
ST; QL (120 EA per 30 days)
VIRACEPT ORAL
INVOKANA
ORALTABLET
TABLET250
100MG,
MG 625 MG
34
ST; QL (90 EA per 30 days)
INVOKANA
ORAL
TABLET 300 MG
Anti-Influenza
Agents
3
ST; QL (30 EA per 30 days)
JANUVIA
TABLET
amantadineORAL
hcl oral
capsule100
100MG
mg
32
ST; QL (30 EA per 30 days)
JANUVIA
TABLET
amantadineORAL
hcl oral
solution25
50MG
mg/5 ml
32
ST; QL (120 EA per 30 days)
JANUVIA
TABLET
50 mg
MG
amantadineORAL
hcl oral
tablet 100
32
ST; QL (60 EA per 30 days)
JENTADUETO
ORAL TABLET
2.5-1,000 MG,
RELENZA DISKHALER
INHALATION
2.5-500
MG,
2.5-850
MG 5 MG/ACTUATION
BLISTER
WITH
DEVICE
34
ST;
per 30
days)
QL QL
(60 (60
EA EA
per 180
days)
metformin
oral
tablet
1,000
rimantadine
oral
tablet
100mg
mg
12
QL (75 EA per 30 days)
metformin
tablet
500 mg 30 MG
TAMIFLUoral
ORAL
CAPSULE
14
QL
EAper
per180
30 days)
QL (150
(84 EA
days)
metformin
tablet
850 mg 45 MG
TAMIFLUoral
ORAL
CAPSULE
14
QL
QL (90
(42 EA
EA per
per 30
180days)
days)
metformin
tablet
extended 75
release
TAMIFLUoral
ORAL
CAPSULE
MG 24 hr 500
mg
TAMIFLU ORAL SUSPENSION FOR
metformin
oral tablet extended
release 24 hr 750
RECONSTITUTION
6 MG/ML
mg
14
QL
EAper
per180
30 days)
QL (120
(28 EA
days)
4
1
QL (540 ML per 180 days)
QL (75 EA per 30 days)
nateglinide oral tablet 120 mg, 60 mg
2
ST
ONGLYZA ORAL TABLET 2.5 MG
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
ONGLYZA
ORAL TABLET 5 MG
7.5 mg
pioglitazone oral tablet 15 mg
3
1
3
ST; QL (60 EA per 30 days)
2
ST; QL (90 EA per 30 days)
Anxiolytics
Anxiolytics, Other
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (240 EA per 30 days)
QL (120 EA per 30 days)
PA; QL (240 EA per 30 days)
PA; QL (120 EA per 30 days)
PA; QL (60 EA per 30 days)
PA; QL (480 EA per 30 days)
PA; QL (240 EA per 30 days)
ST; QL (30 EA per 30 days)
42
4242
Puedeencontrar
encontrarinformación
informaciónsobre
sobreloloque
quesignifican
significanlas
lasabreviaturas
abreviaturasasasen
enesta
estatabla,
tabla,vaya
vayaaalalapágina
páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
22
QL (10
ST;
QL EA
(45 per
EA 30
perdays)
30 days)
2
2
1
ST; QL (30 EA per 30 days)
42
PA
2
4
3
QL (180 EA per 30 days)
PA
PA; QL (600 EA per 30 days)
2
3
2
QL (120 EA per 30 days)
PA; QL (150 EA per 30 days)
QL (60 EA per 30 days)
22
32
QL
EA perML
30per
days)
PA;(180
QL (3600
30 days)
ST;
PA; QL
QL(30
(240EA
EAper
per3030days)
days)
32
PA; QL (240 EA per 30 days)
2
B/D
2
3
2
QL (5400 ML per 30 days)
ST; QL (60 EA per 30 days)
QL (180 EA per 30 days)
3
2
ST; QL (30 EA per 30 days)
QL (240 EA per 30 days)
Anesthetics ORAL TABLET 2-1,000 MG
AVANDAMET
4
ST; QL (60 EA per 30 days)
Local Anestheticsoral tablet 2.5-250 mg
glipizide-metformin
1
QL (240 EA per 30 days)
12
QL (120 EA per 30 days)
2
22
PA; QL (240 EA per 30 days)
2
PA; QL (120 EA per 30 days)
2
32
ST;
PA; QL
QL(60
(90 EA
EA per
per 30
30 days)
days)
fentanyl transdermal
patch
72 hour 100 mcg/hr,
pioglitazone
oral tablet
30 mg
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
pioglitazone oral tablet 45 mg
hydrocodone-acetaminophen oral tablet 2.5-325
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
mg
SYMLINPEN
120
SUBCUTANEOUS
PEN
hydromorphone
(pf)
in ection solution 10
mg/ml
INJECTOR 2,700 MCG/2.7 ML
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
SYMLINPEN 60 SUBCUTANEOUS PEN
LAZANDA1,500
NASAL
SPRAY,NON-AEROSOL
INJECTOR
MCG/1.5
ML
100 MCG/SPRAY
tolazamide oral tablet 250 mg
LAZANDA NASAL SPRAY,NON-AEROSOL
tolazamide
oral tablet 500 mg
400 MCG/SPRAY
tolbutamide
oral solution
tablet 500
meperidine oral
50mg
mg/5 ml
TRADJENTA
ORAL
meperidine oral
tabletTABLET
50 mg 5 MG
VICTOZA
3-PAK
SUBCUTANEOUS
PEN
meperitab oral
tablet
100 mg
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
Blood Glucose Regulators
oxycodone oral solution 5 mg/5 ml
ACTOPLUS MET XR ORAL TABLET, ER
oxycodone oral 24
tablet
mg, 15 MG
mg, 20 mg, 30
MULTIPHASE
HR10
15-1,000
mg, 5 mg
ACTOPLUS MET XR ORAL TABLET, ER
tramadol oral tablet
5030-1,000
mg
MULTIPHASE
24 HR
MG
lidocaine (pf) in ection
5 mg/mlmg,
(0.55-500
)
glipizide-metformin
oralsolution
tablet 2.5-500
mg
lidocaine hcl mucous membrane gel 2
glyburide-metformin
tablet 1.25-250
lidocaine hcl mucousoral
membrane
solution mg
4 (40
mg/ml)
glyburide-metformin
oral tablet 2.5-500 mg, 5-500
mg
lidocaine hcl urethral gel 2
JANUMET
ORALadhesi
TABLET
50-1,000 MG, 550lidocaine topical
e patch,medicated
500(700
MGmg/patch)
ST
JANUMET
XR ORAL
TABLET,
ER
lidocaine topical
ointment
5
MULTIPHASE 24 HR 100-1,000 MG
lidocaine-prilocaine topical cream 2.5-2.5
JANUMET XR ORAL TABLET, ER
MULTIPHASE
24 HR
50-1,000Abuse
MG, 50-500
MG Agents
Anti-Addiction/
Substance
Treatment
32
ST; QL (30 EA per 30 days)
2
3
B/D
ST; QL (60 EA per 30 days)
KOMBIGLYZE
XR ORAL
TABLET, ER
Alcohol Deterrents/
Anti-Craving
MULTIPHASE 24 HR 2.5-1,000 MG
acamprosate oral tablet,delayed release (dr/ec)
KOMBIGLYZE
XR ORAL TABLET, ER
333 mg
MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
disulfiram oral tablet 250 mg, 500 mg
pioglitazone-glimepiride oral tablet 30-2 mg, 30-4
naltrexone oral tablet 50 mg
mg
3
ST; QL (60 EA per 30 days)
2
3
PA
ST; QL (30 EA per 30 days)
2
2
2
ST; QL (45 EA per 30 days)
43
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
pioglitazone-metformin
oral tablet
15-500ML
mg, 15PAXIL ORAL SUSPENSION
10 MG/5
850 mg
sertraline oral concentrate 20 mg/ml
24
Glycemic
Agents
sertraline oral
tablet 100 mg, 25 mg, 50 mg
1
32
QL (4 EA per 30 days)
32
QL (2 EA per 30 days)
52
4
PA
GLUCAGEN
HYPOKIT
INJECTION
RECON
enlafaxine oral
capsule,extended
release
24hr
SOLN
1
MG
150 mg, 37.5 mg, 75 mg
GLUCAGON
EMERGENCY
enlafaxine oral
tablet 100 mg,KIT
25 (HUMAN)
mg, 37.5 mg, 50
INJECTION
KIT
1
MG
mg, 75 mg
KORLYM
TABLET
300 MG
enlafaxineORAL
oral tablet
extended
release 24hr 150
mg, 225 mg, 37.5
mg, 75
mg
PROGLYCEM
ORAL
SUSPENSION
50 MG/ML
Bipolar Agents
Insulins
Bipolar SOLOSTAR
Agents, Other
APIDRA
SUBCUTANEOUS
INSULIN
100 UNIT/ML RECON SOLN
GEODONPEN
INTRAMUSCULAR
20 MG/ML
(FINAL CONC.) SOLUTION 100
APIDRA
SUBCUTANEOUS
UNIT/ML
olanzapine intramuscular recon soln 10 mg
ST; QL (90 EA per 30 days)
2
3
4
3
PA; QL (12 EA per 30 days)
2
22
QL (90 EA per 30 days)
gauze
pad topical
bandage 2 x 2 "
olanzapine
oral tablet,disintegrating
10 mg, 15
mg, 20 mg, 5KWIKPEN
mg
HUMALOG
SUBCUTANEOUS
INSULIN
PEN
100
UNIT/ML,
200 mg,
UNIT/ML
uetiapine oral tablet 100 mg, 200
300 mg,(3
ML)
400 mg
22
3
QL (30 EA per 30 days)
2
QL (60 EA per 30 days)
HUMALOG
MIX
50-50
uetiapine oral
tablet
25KWIKPEN
mg, 50 mg
SUBCUTANEOUS INSULIN PEN 100
RISPERDAL
CONSTA INTRAMUSCULAR
UNIT/ML
(50-50)
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML
HUMALOG MIX 50-50 SUBCUTANEOUS
RISPERDAL CONSTA
INTRAMUSCULAR
SUSPENSION
100 UNIT/ML
(50-50)
SYRINGE 37.5 MG/2 ML, 50 MG/2 ML
HUMALOG MIX 75-25 KWIKPEN
risperidone oral solution
1 mg/ml
SUBCUTANEOUS
INSULIN
PEN 100
UNIT/ML
(75-25)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
HUMALOG
MIX 75-25 SUBCUTANEOUS
SUSPENSION
100
UNIT/ML (75-25)0.25 mg, 0.5
risperidone oral
tablet,disintegrating
mg, 1 mg, 2 mg,
3 mg, 4 mg
HUMALOG
SUBCUTANEOUS
CARTRIDGE
100
UNIT/ML
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10SUBCUTANEOUS
MG, 2.5 MG, 5 MGSOLUTION 100
HUMALOG
UNIT/ML,
100XR
UNIT/ML
(PREFILLED
SEROQUEL
ORAL TABLET
EXTENDED
SYRINGE)
RELEASE 24 HR 150 MG, 200 MG
HUMULIN
70/30
KWIKPEN
SUBCUTANEOUS
SEROQUEL
XR ORAL
TABLET
EXTENDED
INSULIN
PEN
100
UNIT/ML
(70-30)
RELEASE 24 HR 300 MG, 400 MG, 50 MG
HUMULIN
SUBCUTANEOUS
ziprasidone70/30
hcl oral
capsule 20 mg, 40 mg, 60 mg,
SUSPENSION
100
UNIT/ML (70-30)
80 mg
32
QL (90 EA per 30 days)
4
PA; QL (2 EA per 28 days)
3
5
PA; QL (2 EA per 28 days)
3
2
QL (240 ML per 30 days)
assure
id insulin
syringe
1 ml
gauge
x
olanzapine
oral safety
tablet 10
mg, 15
mg,292.5
mg, 20
1/2"
mg, 5 mg, 7.5 mg
QL (30 EA per 30 days)
2
3
2
3
3
3
4
QL (60 EA per 30 days)
34
QL (60 EA per 30 days)
32
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
44
4444
Puedeencontrar
encontrarinformación
informaciónsobre
sobreloloque
quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
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vayaaalalapágina
páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patchSUBCUTANEOUS
72 hour 100 mcg/hr,
HUMULIN
N KWIKPEN
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75 mcg/hr
INSULIN PEN 100 UNIT/ML (3 ML)
32
hydrocodone-acetaminophen
oral tablet
2.5-325
HUMULIN
N SUBCUTANEOUS
SUSPENSION
mg UNIT/ML
100
32
hydromorphone
(pf) in ection
solution 10100
mg/ml
HUMULIN
R INJECTION
SOLUTION
UNIT/ML
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
32
QL (10 EA per 30 days)
2
33
QL (180 EA per 30 days)
insulin
syringe-needle
u-100 syringe 0.3 ml 29, 1
LAZANDA
NASAL SPRAY,NON-AEROSOL
ml
x 1/2", 1/2 ml 28 gauge
40029MCG/SPRAY
23
PA; QL (150 EA per 30 days)
LANTUS
SOLOSTAR
meperidine
oral solutionSUBCUTANEOUS
50 mg/5 ml
INSULIN PEN 100 UNIT/ML (3 ML)
meperidine oral tablet 50 mg
LANTUS SUBCUTANEOUS SOLUTION 100
meperitab oral tablet 100 mg
UNIT/ML
nalbuphineFLEXTOUCH
in ection solution
10 mg/ml, 20 mg/ml
LEVEMIR
SUBCUTANEOUS
INSULIN
UNIT/ML
oxycodonePEN
oral100
solution
5 mg/5(3mlML)
32
PA; QL (3600 ML per 30 days)
2
3
2
PA; QL (240 EA per 30 days)
32
2
32
B/D
32
QL (240 EA per 30 days)
HUMULIN
U-500 (CONCENTRATED)
LAZANDARNASAL
SPRAY,NON-AEROSOL
SUBCUTANEOUS
100 MCG/SPRAY SOLUTION 500 UNIT/ML
LEVEMIR
100
oxycodone SUBCUTANEOUS
oral tablet 10 mg, 15SOLUTION
mg, 20 mg, 30
UNIT/ML
mg, 5 mg
NOVOLIN
70/30
SUBCUTANEOUS
tramadol oral
tablet
50 mg
SUSPENSION 100 UNIT/ML (70-30)
Anesthetics
NOVOLIN N SUBCUTANEOUS SUSPENSION
100
UNIT/ML
Local
Anesthetics
3
NOVOLIN
R INJECTION
SOLUTION
lidocaine (pf)
in ection solution
5 mg/ml100
(0.5 )
UNIT/ML
lidocaine hcl mucous membrane gel 2
NOVOLOG FLEXPEN SUBCUTANEOUS
lidocaine hcl mucous membrane solution 4 (40
INSULIN PEN 100 UNIT/ML
mg/ml)
NOVOLOG MIX 70-30 FLEXPEN
lidocaine hcl urethral gel 2
SUBCUTANEOUS INSULIN PEN 100
lidocaine topical
UNIT/ML
(70-30)adhesi e patch,medicated 5
(700 mg/patch)
NOVOLOG MIX 70-30 SUBCUTANEOUS
lidocaine topical
ointment 5(70-30)
SOLUTION
100 UNIT/ML
32
lidocaine-prilocaine
topical
cream 2.5-2.5
NOVOLOG
PENFILL
SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
32
NOVOLOG SUBCUTANEOUS SOLUTION 100
Alcohol Deterrents/ Anti-Craving
UNIT/ML
acamprosate
oral tablet,delayed
release
(dr/ec)
pen
needle, diabetic
needle 29 gauge
x 1/2
"
333 mg
3
Blood Products/ Modifiers/ Volume Expanders
disulfiram oral tablet 250 mg, 500 mg
2
Anticoagulants
naltrexone oral tablet 50 mg
2
PA; QL (600 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
2
3
2
3
2
2
PA; QL (90 EA per 30 days)
3
2
B/D
Anti-Addiction/ Substance Abuse Treatment Agents
22
PA
45
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
argatroban
0.9 tablet,disintegrating
% sod chlor intravenous
lamotrigineinoral
100 mg, 200
solution
125 50
mg/125
mg, 25 mg,
mg ml (1 mg/ml)
22
B/D
lithium carbonate
oral capsule
300 mg,
argatroban
intravenous
solution150
100mg,
mg/ml
600 mg
COUMADIN ORAL TABLET 1 MG, 10 MG, 2
lithium
oral
tablet5 300
MG,
2.5 carbonate
MG, 3 MG,
4 MG,
MG,mg
6 MG, 7.5 MG
52
B/D
lithium carbonate
oral tablet
release 300
ELIQUIS
ORAL TABLET
2.5extended
MG, 5 MG
mg, 450 mg
enoxaparin subcutaneous solution 300 mg/3 ml
lithium citrate oral solution 8 me /5 ml
enoxaparin subcutaneous syringe 100 mg/ml, 120
TEGRETOL
XR ORAL
TABLET
mg/0.8
ml, 30 mg/0.3
ml, 40
mg/0.4 EXTENDED
ml, 60 mg/0.6
RELEASE
HR 100 MG
ml,
80 mg/0.812ml
32
alproic acid
(as sodium syringe
salt) oral150
solution
enoxaparin
subcutaneous
mg/ml250
mg/5 ml
fondaparinux subcutaneous syringe 10 mg/0.8 ml,
7.5alproic
mg/0.6acid
ml oral capsule 250 mg
52
fondaparinux
subcutaneous
syringe 2.5 mg/0.5 ml,
Blood Glucose
Regulators
5 mg/0.4 ml
2
FRAGMIN SUBCUTANEOUS SOLUTION
acarbose
oral tablet
100 mg, 25 mg, 50 mg
25,000
ANTI-XA
UNIT/ML
AVANDIASUBCUTANEOUS
ORAL TABLET 2 MG
FRAGMIN
SYRINGE 10,000
ANTI-XA
UNIT/ML,
12,500 ANTI-XA
UNIT/0.5
AVANDIA
ORAL TABLET
4 MG
ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000
AVANDIA
ORAL TABLET
8 MG
ANTI-XA
UNIT/0.72
ML, 7,500
ANTI-XA
UNIT/0.3
ML SUBCUTANEOUS PEN
BYDUREON
INJECTORSUBCUTANEOUS
2 MG/0.65 ML
FRAGMIN
SYRINGE 2,500
5
2
ST
54
4
ST; QL (120 EA per 30 days)
4
ST; QL (30 EA per 30 days)
4
PA
4
4
PA
heparin
(porcine)
in 5 % dex intravenous
BYETTA
SUBCUTANEOUS
PEN INJECTOR
parenteral
solution
20,000
unit/500
(405
10 MCG/DOSE(250 MCG/ML) 2.4ml
ML,
unit/ml)
MCG/DOSE (250 MCG/ML) 1.2 ML
24
PA
heparin
(porcine)
injection
solution 1,000 unit/ml,
glimepiride
oral tablet
1 mg
10,000 unit/ml, 5,000 unit/ml
glimepiride oral tablet 2 mg
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
glimepiride oral tablet 4 mg
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
glipizide oral tablet 10 mg
PRADAXA ORAL CAPSULE 110 MG, 150 MG,
glipizide
75
MG oral tablet 5 mg
21
QL (240 EA per 30 days)
1
1
1
QL (120 EA per 30 days)
1
3
1
QL (120 EA per 30 days)
glipizideoral
oraltablet
tablet1extended
release
warfarin
mg, 10 mg,
2 mg,24hr
2.5 10
mg,mg
3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
glipizide oral tablet extended release 24hr 2.5 mg
XARELTO ORAL TABLET 10 MG, 15 MG, 20
glipizide oral tablet extended release 24hr 5 mg
MG
glyburide micronized oral tablet 1.5 mg
XARELTO ORAL TABLETS,DOSE PACK 15
glyburide
micronized
MG
(42)- 20
MG (9) oral tablet 3 mg
11
QL (60 EA per 30 days)
1
3
1
QL (240 EA per 30 days)
2
3
2
PA; QL (240 EA per 30 days)
Antidiabetic Agents
ANTI-XA
UNIT/0.2
ML, 5,000 ANTI-XA
BYDUREON
SUBCUTANEOUS
UNIT/0.2
ML
SUSPENSION,EXTENDED
REL RECON 2 MG
4
2
2
2
2
4
5
2
ST; QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (240 EA per 30 days)
QL (120 EA per 30 days)
PA; QL (120 EA per 30 days)
46
4646
Puedeencontrar
encontrarinformación
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significanlas
lasabreviaturas
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vayaa alalapágina
páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanylFormation
transdermalModifiers
patch 72 hour 100 mcg/hr,
Blood
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
anagrelide oral capsule 0.5 mg, 1 mg
hydrocodone-acetaminophen oral tablet 2.5-325
ARANESP
(IN POLYSORBATE) INJECTION
mg
SOLUTION 100 MCG/ML, 200 MCG/ML, 300
hydromorphone (pf) in ection solution 10 mg/ml
MCG/ML
hydromorphone
oral tablet 2 mg, 4INJECTION
mg, 8 mg
ARANESP
(IN POLYSORBATE)
SOLUTION
MCG/ML,
40 MCG/ML, 60
LAZANDA 25
NASAL
SPRAY,NON-AEROSOL
MCG/ML
100 MCG/SPRAY
ARANESP
POLYSORBATE)
INJECTION
LAZANDA(IN
NASAL
SPRAY,NON-AEROSOL
SYRINGE
10
MCG/0.4
ML,
25
MCG/0.42
ML,
400 MCG/SPRAY
40 MCG/0.4 ML, 60 MCG/0.3 ML
meperidine oral solution 50 mg/5 ml
ARANESP (IN POLYSORBATE) INJECTION
meperidine100
oralMCG/0.5
tablet 50ML,
mg 150 MCG/0.3 ML,
SYRINGE
200
MCG/0.4
300100
MCG/0.6
ML, 500
meperitab
oralML,
tablet
mg
MCG/ML
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
EPOGEN INJECTION SOLUTION 2,000
oxycodone oral solution 5 mg/5 ml
UNIT/ML,
20,000 UNIT/2 ML, 20,000 UNIT/ML,
3,000
UNIT/ML,
4,00010UNIT/ML
oxycodone
oral tablet
mg, 15 mg, 20 mg, 30
mg, 5 mg
GRANIX SUBCUTANEOUS SYRINGE 300
MCG/0.5
480 MCG/0.8
tramadol ML,
oral tablet
50 mg ML
2
QL (10 EA per 30 days)
2
2
5
PA
2
42
3
QL (180 EA per 30 days)
PA
PA; QL (600 EA per 30 days)
43
PA
PA; QL (150 EA per 30 days)
2
5
2
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
2
PA; QL (240 EA per 30 days)
2
4
2
B/D
PA
QL (5400 ML per 30 days)
2
QL (180 EA per 30 days)
5
2
PA
QL (240 EA per 30 days)
LEUKINE
INJECTION RECON SOLN 250 MCG
Anesthetics
5
PA
MOZOBIL
SUBCUTANEOUS SOLUTION 24
Local Anesthetics
MG/1.2 ML (20 MG/ML)
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
NEULASTA SUBCUTANEOUS SYRINGE 6
lidocaine hcl mucous membrane gel 2
MG/0.6ML
lidocaine hcl INJECTION
mucous membrane
solution300
4 (40
NEUPOGEN
SOLUTION
mg/ml)
MCG/ML,
480 MCG/1.6 ML
lidocaine hcl INJECTION
urethral gel 2SYRINGE 300
NEUPOGEN
MCG/0.5
480adhesi
MCG/0.8
ML
lidocaine ML,
topical
e patch,medicated
5
(700
mg/patch)
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML,
2,000 UNIT/ML,
lidocaine topical
ointment 5 3,000 UNIT/ML,
4,000 UNIT/ML
lidocaine-prilocaine topical cream 2.5-2.5
PROCRIT INJECTION SOLUTION 20,000
Anti-Addiction/
Substance Abuse Treatment Agents
UNIT/ML,
40,000 UNIT/ML
5
PA
2
5
2
PA
52
PA
52
2
3
2
PA
PA; QL (90 EA per 30 days)
PA
2
5
B/D
PA
Alcohol Deterrents/
Anti-Craving
PROMACTA
ORAL TABLET
12.5 MG, 25 MG,
50 MG, 75 MG
acamprosate oral tablet,delayed release (dr/ec)
ZARXIO
333 mg INJECTION SYRINGE 300 MCG/0.5
ML, 480 MCG/0.8 ML
disulfiram oral tablet 250 mg, 500 mg
Coagulants
naltrexone oral tablet 50 mg
5
2
5
PA
PA
2
2
47
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47 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
tranexamic
acidORAL
intravenous
solution
TRADJENTA
TABLET
5 MG1,000 mg/10
ml (100 mg/ml)
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTORacid
0.6 oral
MG/0.1
ML650
(18mg
MG/3 ML)
tranexamic
tablet
23
WELCHOL
ORAL POWDER
Platelet
Modifying
Agents IN PACKET 3.75
3
GRAM
AGGRENOX ORAL CAPSULE, ER
WELCHOL ORAL
TABLET
MULTIPHASE
12 HR
25-200 625
MGMG
Blood Glucose Regulators
aspirin-dipyridamole
oral capsule, er multiphase
12
hr
25-200
mg
ACTOPLUS MET XR ORAL TABLET, ER
ST; QL (30 EA per 30 days)
3
2
4
4
2
3
4
ST; QL (60 EA per 30 days)
ACTOPLUS
ER
cilostazol
oralMET
tabletXR
100ORAL
mg, 50TABLET,
mg
MULTIPHASE 24 HR 30-1,000 MG
clopidogrel oral tablet 300 mg
AVANDAMET ORAL TABLET 2-1,000 MG
clopidogrel oral tablet 75 mg
glipizide-metformin oral tablet 2.5-250 mg
dipyridamole oral tablet 25 mg, 50 mg, 75 mg
glipizide-metformin oral tablet 2.5-500 mg, 5-500
EFFIENT ORAL TABLET 10 MG, 5 MG
mg
23
ST; QL (30 EA per 30 days)
Cardiovascular
Agents
glyburide-metformin
oral tablet 1.25-250 mg
2
PA; QL (240 EA per 30 days)
Alpha-Adrenergic
Agonists
glyburide-metformin oral
tablet 2.5-500 mg, 5-500
2
PA; QL (120 EA per 30 days)
1
23
ST; QL (60 EA per 30 days)
JANUMEToral
XR tablet
ORAL1 TABLET,
guanfacine
mg, 2 mg ER
MULTIPHASE 24 HR 100-1,000 MG
methyldopa oral tablet 250 mg, 500 mg
JANUMET XR ORAL TABLET, ER
methyldopate
intravenous
solutionMG,
250 50-500
mg/5 mlMG
MULTIPHASE
24 HR 50-1,000
23
ST; QL (30 EA per 30 days)
PA
2
3
2
PA
ST; QL (60 EA per 30 days)
PA
midodrine
oral tablet
10 mg, TABLET,
2.5 mg, 5 mg
KOMBIGLYZE
XR ORAL
ER
MULTIPHASE
24 HR
2.5-1,000100
MGMG, 200
NORTHERA
ORAL
CAPSULE
23
ST; QL (60 EA per 30 days)
4
3
ST; QL (30 EA per 30 days)
pioglitazone-glimepiride oral tablet 30-2 mg, 30-4
prazosin oral capsule 1 mg, 2 mg, 5 mg
mg
2
1
ST; QL (45 EA per 30 days)
Angiotensin
Ii Receptor
pioglitazone-metformin
oralAntagonists
tablet 15-500 mg, 15-
2
3
ST; QL (90 EA per 30 days)
ST
irbesartan oral tablet 150 mg, 300 mg, 75 mg
GLUCAGEN HYPOKIT INJECTION RECON
SOLN 1oral
MG tablet 100 mg, 25 mg, 50 mg
losartan
1
3
1
QL (4 EA per 30 days)
GLUCAGON
EMERGENCY
KIT
(HUMAN)
valsartan
oral tablet
160 mg, 320
mg,
40 mg, 80
INJECTION KIT 1 MG
mg
13
QL (2 EA per 30 days)
ST
KORLYM ORAL TABLET Enzyme
300 MG (Ace) Inhibitors
Angiotensin-Converting
5
PA
MULTIPHASE
24 TABLET
HR 15-1,000
MG 90 MG
BRILINTA
ORAL
60 MG,
mg
clonidine
hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
JANUMET
ORAL TABLET
50-1,000
clonidine
transdermal
patch weekly
0.1 MG,
mg/2450hr,
500
MG
0.2 mg/24 hr, 0.3 mg/24 hr
MG,
300 MG
KOMBIGLYZE
XR ORAL TABLET, ER
MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
Alpha-Adrenergic Blocking Agents
850 mg ORAL TABLET 20 MG, 40 MG, 5
BENICAR
MG
Glycemic Agents
2
4
1
2
2
2
3
ST; QL (60 EA per 30 days)
QL (240 EA per 30 days)
PA
QL (120 EA per 30 days)
48
4848
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abreviaturasasasen
enesta
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
mcg/hr,
benazepril
oral tablet patch
10 mg,7220hour
mg, 100
40 mg,
5 mg
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50
hydrocodone-acetaminophen oral tablet 2.5-325
mg
mg
enalapril maleate oral tablet 10 mg, 2.5 mg, 20
hydromorphone
(pf) in ection solution 10 mg/ml
mg,
5 mg
12
hydromorphone
oral 10
tablet
mg,
4 mg,
8 mg
fosinopril
oral tablet
mg,220
mg,
40 mg
12
QL (180 EA per 30 days)
LAZANDA
SPRAY,NON-AEROSOL
lisinopril
oralNASAL
tablet 10
mg, 2.5 mg, 20 mg, 30 mg,
100
MCG/SPRAY
40 mg, 5 mg
13
PA; QL (600 EA per 30 days)
LAZANDA
SPRAY,NON-AEROSOL
moexipril
oralNASAL
tablet 15
mg, 7.5 mg
400 MCG/SPRAY
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg
meperidine oral solution 50 mg/5 ml
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
meperidine oral tablet 50 mg
mg
23
PA; QL (150 EA per 30 days)
meperitab oral
mg 2 mg, 4 mg
trandolapril
oraltablet
tablet100
1 mg,
12
PA; QL (240 EA per 30 days)
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
Antiarrhythmics
2
B/D
oxycodone oral
5 mg/5
ml mg
amiodarone
oralsolution
tablet 200
mg, 400
oxycodone oral
tablet 10oral
mg, capsule
15 mg, 20
disopyramide
phosphate
100mg,
mg,30150
mg, 5 mg
mg
22
22
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
PA
tramadol oral
flecainide
oral tablet
tablet 50
100mg
mg, 150 mg, 50 mg
22
QL (240 EA per 30 days)
Anesthetics
mexiletine
oral capsule 150 mg, 200 mg, 250 mg
2
Local Anesthetics
MULTAQ
ORAL TABLET 400 MG
4
lidocaine (pf)
ection CAPSULE,
solution 5 mg/ml
(0.5 )
NORPACE
CRinORAL
EXTENDED
RELEASE 100 MG, 150 MG
lidocaine hcl mucous membrane gel 2
PACERONE
100
MG, 200
lidocaine hcl ORAL
mucousTABLET
membrane
solution
4 MG
(40
mg/ml)
propafenone
oral tablet 150 mg, 225 mg, 300 mg
QL (10 EA per 30 days)
1
2
1
2
1
2
1
2
42
PA; QL (3600 ML per 30 days)
PA; QL (240 EA per 30 days)
PA
2
42
2
lidocaine gluconate
hcl urethral
geltablet
2
quinidine
oral
extended release
324
mg
lidocaine topical adhesi e patch,medicated 5
22
(700 mg/patch)
quinidine
sulfate oral tablet 200 mg, 300 mg
2
2
lidocaine
ointment
5 mg, 240 mg, 80 mg
sorine
oraltopical
tablet 120
mg, 160
12
lidocaine-prilocaine
topical
sotalol
af oral tablet 120
mg cream 2.5-2.5
12
PA; QL (90 EA per 30 days)
B/D
sotalol
oral tablet 160
mg, 240 mg,
80 mg
Anti-Addiction/
Substance
Abuse
Treatment Agents 1
TIKOSYN
ORAL CAPSULE
125 MCG, 250
Alcohol Deterrents/
Anti-Craving
MCG, 500 MCG
acamprosate oral tablet,delayed release (dr/ec)
Beta-Adrenergic
Blocking Agents
333 mg
4
acebutolol
200mg,
mg,500
400mg
mg
disulfiram oral
oral capsule
tablet 250
22
atenolol
oraloral
tablet
10050mg,
naltrexone
tablet
mg25 mg, 50 mg
12
2
PA
49
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
betaxolol
oral tablet 10u-100
mg, 20syringe
mg 0.3 ml 2 , 1
insulin syringe-needle
ml 2 x 1/2 , 1/2 ml 28
bisoprolol fumarate oral tablet 10 mg, 5 mg
LANTUS SOLOSTAR SUBCUTANEOUS
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
INSULIN PEN 100 UNIT/ML (3 ML)
6.25 mg
LANTUS SUBCUTANEOUS SOLUTION 100
COREG CR ORAL CAPSULE, ER
UNIT/ML
MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG,
LEVEMIR
FLEXTOUCH SUBCUTANEOUS
80
MG
INSULIN PEN 100 UNIT/ML (3 ML)
labetalol oral tablet 100 mg, 200 mg, 300 mg
LEVEMIR SUBCUTANEOUS SOLUTION 100
metoprolol succinate oral tablet extended release
UNIT/ML
24 hr 100 mg, 200 mg, 25 mg, 50 mg
NOVOLIN 70/30 SUBCUTANEOUS
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
SUSPENSION 100 UNIT/ML (70-30)
mg
NOVOLIN N SUBCUTANEOUS SUSPENSION
nadolol oral tablet 20 mg, 40 mg, 80 mg
100 UNIT/ML
pindolol oral tablet 10 mg, 5 mg
NOVOLIN R INJECTION SOLUTION 100
UNIT/ML oral capsule,extended release 24 hr
propranolol
120 mg, 160 mg, 60 mg, 80 mg
NOVOLOG FLEXPEN SUBCUTANEOUS
INSULIN PEN
UNIT/ML
propranolol
oral100
solution
20 mg/5 ml, 40 mg/5 ml
22
NOVOLOGoral
MIXtablet
70-3010FLEXPEN
propranolol
mg, 20 mg, 40 mg, 60
SUBCUTANEOUS
INSULIN PEN 100
mg,
80 mg
UNIT/ML (70-30)
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
NOVOLOG MIX 70-30 SUBCUTANEOUS
Calcium
Channel
Blocking
Agents
SOLUTION
100 UNIT/ML
(70-30)
afeditab
cr oral
tablet extended
release 30 mg, 60
NOVOLOG
PENFILL
SUBCUTANEOUS
mg
CARTRIDGE 100 UNIT/ML
amlodipine
tablet 10 mg, 2.5 mg,
5 mg
NOVOLOGoral
SUBCUTANEOUS
SOLUTION
100
UNIT/ML
cartia
xt oral capsule,extended release 24hr 120
mg,
180
mg, 240
mg, 300
safety needles
needle
18 xmg
1 1/2
23
diltiazem
hcl intravenous
recon soln
100 mgExpanders
Blood Products/
Modifiers/
Volume
2
3
1
3
3
3
2
3
2
3
1
3
2
2
3
2
3
2
2
3
23
ST
13
2
2
2
diltiazem hcl intravenous solution 5 mg/ml
2
diltiazem hcl oral capsule, extended release 180
argatroban
0. mg sod chlor intra enous
mg,
360 mg, in
420
solution 125 mg/125 ml (1 mg/ml)
diltiazem hcl oral capsule,extended release 12 hr
argatroban
intra
120
mg, 60 mg,
90 enous
mg solution 100 mg/ml
COUMADIN
ORAL
TABLET 1 MG,
10 MG,
diltiazem
hcl oral
capsule,extended
release
24hr2
MG,
2.5
MG,
3
MG,
4
MG,
5
MG,
6
MG,
7.5
MG
120 mg, 240 mg, 300 mg
2
2
B/D
2
5
B/D
Anticoagulants
ELIQUIShcl
ORAL
TABLET
5 MG
diltiazem
oral tablet
120 2.5
mg,MG,
30 mg,
60 mg, 90
mg
enoxaparin subcutaneous solution 300 mg/3 ml
24
13
2
50
5050
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informaciónsobre
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significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl
transdermal
72 hour
100 mcg/hr,
dilt-xr
oral
capsule,extpatch
release
degradable
120
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg, 180 mg, 240 mg
22
hydrocodone-acetaminophen
tablet
felodipine
oral tablet extendedoral
release
242.5-325
hr 10
mg 2.5 mg, 5 mg
mg,
22
hydromorphone
(pf) in 2.5
ection
isradipine
oral capsule
mg,solution
5 mg 10 mg/ml
22
ST
hydromorphone
oral tablet
mg,304 mg
mg, 8 mg
nicardipine
oral capsule
20 2mg,
22
QL (180 EA per 30 days)
LAZANDA
NASAL
nifedical
xl oral
tabletSPRAY,NON-AEROSOL
extended release 24hr 30
100
MCG/SPRAY
mg, 60 mg
23
PA; QL (600 EA per 30 days)
ST
LAZANDA
NASAL
nifedipine
oral
capsuleSPRAY,NON-AEROSOL
10 mg, 20 mg
400 MCG/SPRAY
nifedipine oral tablet extended release 24hr 30 mg,
meperidine
60
mg, 90 mgoral solution 50 mg/5 ml
23
PA; QL (150 EA per 30 days)
PA
2
2
ST
PA; QL (3600 ML per 30 days)
meperidine oral
oral capsule
tablet 5030mg
nimodipine
mg
22
PA; QL (240 EA per 30 days)
meperitab
oral
tablet extended
100 mg release 120 mg,
taztia
xt oral
capsule,
180
mg, 240in
mg,
300 mg,
360 10
mgmg/ml, 20 mg/ml
nalbuphine
ection
solution
22
PA; QL (240 EA per 30 days)
2
22
B/D
2
2
QL (180 EA per 30 days)
2
1
QL (240 EA per 30 days)
verapamil
hr er ml
pellet ct 100 mg,
oxycodoneoral
oralcapsule,
solution24
5 mg/5
200 mg, 300 mg
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
verapamil
mg, 5 mg oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg, 360 mg
tramadol oral tablet 50 mg
verapamil oral tablet 120 mg, 40 mg, 80 mg
Anesthetics
verapamil oral tablet extended release 120 mg,
120
mg Anesthetics
(24 hours), 180 mg, 240 mg
Local
2
lidocaine (pf) in ection
solution 5 mg/ml (0.5 )
Cardiovascular
Agents
2
lidocaine hcl
mucous
membrane
2
ADVICOR
ORAL
TABLET,
ERgel
MULTIPHASE
24
HR 1,000-20
MG, 1,000-40
500-20
lidocaine
hcl mucous
membraneMG,
solution
4 MG,
(40
750-20
MG
mg/ml)
42
ALDACTAZIDE
ORAL
50-50 MG
lidocaine hcl urethral
gelTABLET
2
amiloride-hydrochlorothiazide
oral tablet 5-50
lidocaine topical adhesi e patch,medicated
5 mg
42
12
(700 mg/patch)
amlodipine-atorvastatin
oral tablet 10-10 mg, 1020
mg,
10-40
mg,
10-80
mg,
lidocaine topical ointment 5 2.5-10 mg, 2.5-20 mg,
2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
lidocaine-prilocaine topical cream 2.5-2.5
amlodipine-benazepril oral capsule 10-20 mg, 10Anti-Addiction/
Substance
Treatment
Agents
40
mg, 2.5-10 mg, 5-10
mg, 5-20Abuse
mg, 5-40
mg
amlodipine-valsartan
tablet 10-160 mg, 10Alcohol Deterrents/oral
Anti-Craving
320 mg, 5-160 mg, 5-320 mg
acamprosate oral tablet,delayed release (dr/ec)
amlodipine-valsartan-hcthiazid
oral tablet 10-160333 mg
12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5
disulfiram
oral
mg,
5-160-25
mgtablet 250 mg, 500 mg
naltrexone oral tablet 50 mg
QL (10 EA per 30 days)
QL (5400 ML per 30 days)
2
PA; QL (90 EA per 30 days)
2
2
2
1
B/D
1
2
2
PA
2
2
51
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Nombre
del Medicamento
Drug
Name
atenolol-chlorthalidone
oral tablet 100-25
mg, 50ARANESP (IN POLYSORBATE)
INJECTION
25
mg
SYRINGE
10 MCG/0.4 ML, 25 MCG/0.42 ML,
40 MCG/0.4 ML, 60 MCG/0.3 ML
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5ARANESP
20
MG, 5-40(IN
MGPOLYSORBATE) INJECTION
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML,
benazepril-hydrochlorothiazide oral tablet 10-12.5
200 MCG/0.4 ML, 300 MCG/0.6 ML, 500
mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
MCG/ML
BENICAR HCT ORAL TABLET 20-12.5 MG,
EPOGEN INJECTION SOLUTION 2,000
40-12.5 MG, 40-25 MG
UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML,
bisoprolol-hydrochlorothiazide
oral tablet 10-6.25
3,000 UNIT/ML, 4,000 UNIT/ML
mg, 2.5-6.25 mg, 5-6.25 mg
GRANIX SUBCUTANEOUS SYRINGE 300
captopril-hydrochlorothiazide
oral tablet 25-15
MCG/0.5 ML, 480 MCG/0.8 ML
mg, 25-25 mg, 50-15 mg, 50-25 mg
LEUKINE INJECTION RECON SOLN 250 MCG
DEMSER ORAL CAPSULE 250 MG
MOZOBIL SUBCUTANEOUS SOLUTION 24
MG/1.2 ML (20 MG/ML)
enalapril-hydrochlorothiazide
oral tablet 10-25
mg, 5-12.5 mg
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML ORAL TABLET 24-26 MG, 49-51
ENTRESTO
MG, 97-103 MG
NEUMEGA SUBCUTANEOUS RECON SOLN
5 MG
fosinopril-hydrochlorothiazide
oral tablet 10-12.5
mg, 20-12.5 mg
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6 ML oral tablet 150irbesartan-hydrochlorothiazide
12.5
mg, 300-12.5 mg
NEUPOGEN INJECTION SYRINGE 300
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
14
PA
3
5
PA
1
3
4
ST
PA
1
5
1
PA
5
4
5
1
PA
PA
PA
5
4
PA
5
2
PA
5
1
PA
5
1
PA
3
1
PA
PROCRIT INJECTION SOLUTION
20,000250methyldopa-hydrochlorothiazide
oral tablet
UNIT/ML,
40,000
15
mg, 250-25
mg UNIT/ML
25
PA
PA
PROMACTA
ORAL TABLET oral
12.5tablet
MG, 25
MG,
metoprolol
ta-hydrochlorothiaz
100-25
50 MG,
75 mg,
MG50-25 mg
mg,
100-50
25
moexipril-hydrochlorothiazide
oral tablet 15-12.5
Coagulants
mg, 15-25 mg, 7.5-12.5 mg
tranexamic acid intra enous solution 1,000 mg/10
nadolol-bendroflumethiazide
oral tablet 40-5 mg,
ml (100 mg/ml)
80-5 mg
tranexamic acid oral tablet 650 mg
propranolol-hydrochlorothiazid oral tablet 40-25
Platelet
Agents
mg,
80-25 Modifying
mg
AGGRENOX ORAL CAPSULE,
quinapril-hydrochlorothiazide
oralER
tablet 10-12.5
MULTIPHASE
12
HR
25-200
MG
mg, 20-12.5 mg, 20-25 mg
2
BRILINTA
90 MG
reserpine
oralORAL
tabletTABLET
0.1 mg, 0.25
mg
cilostazol oral tablet 100 mg, 50 mg
24
2
MCG/0.5 ML, 480 MCG/0.8 ML
lisinopril-hydrochlorothiazide
oral tablet 10-12.5
mg,
20-12.5INJECTION
mg, 20-25 mgSOLUTION 10,000
PROCRIT
UNIT/ML, 2,000 UNIT/ML, oral
3,000tablet
UNIT/ML,
losartan-hydrochlorothiazide
100-12.5
4,000
UNIT/ML
mg,
100-25
mg, 50-12.5 mg
2
2
2
2
24
PA
52
5252
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significanlas
lasabreviaturas
abreviaturasasasenenesta
estatabla,
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72
100 mcg/hr,
SIMCOR
ORAL TABLET,
ERhour
MULTIPHASE
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
24 HR 500-20 MG, 750-20 MG
32
hydrocodone-acetaminophen oral
tablet
2.5-325
spironolacton-hydrochlorothiaz
oral
tablet
25-25
mg
mg
22
hydromorphone
(pf)ORAL
in ection
solution
10 mg/ml
TEKTURNA
HCT
TABLET
150-12.5
MG,
150-25 MG,oral
300-12.5
hydromorphone
tablet MG,
2 mg,300-25
4 mg, 8MG
mg
32
QL (10 EA per 30 days)
2
23
QL (180 EA per 30 days)
triamterene-hydrochlorothiazid
oral capsule 37.5LAZANDA NASAL SPRAY,NON-AEROSOL
25
50-25 mg
400mg,
MCG/SPRAY
13
PA; QL (150 EA per 30 days)
triamterene-hydrochlorothiazid
oral
meperidine oral solution 50 mg/5
ml tablet 37.5-25
mg, 75-50 mg
meperidine oral tablet 50 mg
TRIBENZOR ORAL TABLET 20-5-12.5 MG,
meperitab oral
100 mg
40-10-12.5
MG,tablet
40-10-25
MG, 40-5-12.5 MG, 405-25
MG
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
valsartan-hydrochlorothiazide
oxycodone oral solution 5 mg/5oral
ml tablet 160-12.5
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
mg
mg, 5 mg
VYTORIN 10-10 ORAL TABLET 10-10 MG
tramadol oral tablet 50 mg
VYTORIN 10-20 ORAL TABLET 10-20 MG
12
PA; QL (3600 ML per 30 days)
2
3
2
PA; QL (240 EA per 30 days)
2
12
B/D
ST
QL (5400 ML per 30 days)
2
QL (180 EA per 30 days)
3
2
3
QL (240 EA per 30 days)
VYTORIN 10-40 ORAL TABLET 10-40 MG
3
VYTORIN 10-80 ORAL TABLET 10-80 MG
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
3
2
lidocaine hcl mucous membrane gel 2
digitek oral tablet 125 mcg
lidocaine hcl mucous membrane solution 4
digitek
mg/ml)oral tablet 250 mcg
digoxin
oral
lidocaine
hclsolution
urethral50gelmcg/ml
2
2
1
2
1
trandolapril-verapamil
oral tablet, ir - er, biphasic
LAZANDA NASAL SPRAY,NON-AEROSOL
24hr
1-240
mg,
2-180
mg,
2-240 mg, 4-240 mg
100 MCG/SPRAY
Anesthetics
Local Anesthetics
Cardiovascular Agents, Other
(40
digoxin
oral
tabletadhesi
125 mcg
lidocaine
topical
e patch,medicated 5
(700
mg/patch)
digoxin oral tablet 250 mcg
22
12
1
lidocaine topical
5
pentoxifylline
oralointment
tablet extended
release 400 mg
22
lidocaine-prilocaine
topical EXTENDED
cream 2.5-2.5
RANEXA
ORAL TABLET
RELEASE 12 HR 1,000 MG, 500 MG
42
TEKTURNA ORAL TABLET 150 MG, 300 MG
3
acamprosate oral tablet,delayed release (dr/ec)
acetazolamide
oral capsule, extended release 500
333 mg
mg
disulfiram oral tablet 250 mg, 500 mg
KEVEYIS ORAL TABLET 50 MG
naltrexone oral tablet 50 mg
2
2
PA; QL (600 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (30 EA per 30 days)
PA
PA
QL
PA;(30
QLEA
(90per
EA30
perdays)
30 days)
PA
B/D
PA
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
Diuretics, Carbonic Anhydrase Inhibitors
2
5
2
PA
PA
Diuretics, Loop
53
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
bumetanide
oraltablet
tablet100.5
mg,20
2 mg
lisinopril oral
mg,mg,
2.51mg,
mg, 30 mg,
40 mg, 5 mg
furosemide injection solution 10 mg/ml
moexipril oral tablet 15 mg, 7.5 mg
furosemide injection syringe 10 mg/ml
uinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg
furosemide oral solution 10 mg/ml, 40 mg/5 ml
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
furosemide oral tablet 20 mg, 40 mg, 80 mg
mg
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
11
2
2
2
1
2
1
1
2
1
Diuretics,
Potassium-Sparing
Antiarrhythmics
amiloride oral tablet 5 mg
amiodarone oral tablet 200 mg, 400 mg
eplerenone oral tablet 25 mg, 50 mg
disopyramide phosphate oral capsule 100 mg, 150
spironolactone
oral tablet 100 mg, 25 mg, 50 mg
mg
2
2
2
2
1
flecainide oral
tablet 100 mg, 150 mg, 50 mg
Diuretics,
Thiazide
2
mexiletine oraloral
capsule
chlorothiazide
tablet150
250mg,
mg,200
500mg,
mg250 mg
MULTAQ ORAL
400 50
MGmg
chlorthalidone
oralTABLET
tablet 25 mg,
12
14
NORPACE CR ORAL
EXTENDED
hydrochlorothiazide
oralCAPSULE,
capsule 12.5
mg
RELEASE 100 MG, 150 MG
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50
PACERONE ORAL TABLET 100 MG, 200 MG
mg
propafenoneoral
oraltablet
tablet1.25
150mg,
mg,2.5
225mg
mg, 300 mg
indapamide
14
uinidine gluconate
tablet
extended release
methyclothiazide
oraloral
tablet
5 mg
324 mg
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
uinidine sulfate oral tablet 200 mg, 300 mg
Dyslipidemics, Fibric Acid Derivatives
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg
fenofibrate micronized oral capsule 134 mg, 200
sotalol
af oral tablet 120 mg
mg,
67 mg
sotalol oraloral
tablet
160160
mg,mg,
24054
mg,
fenofibrate
tablet
mg80 mg
TIKOSYN
ORAL
CAPSULE
125 MCG, 250
fenofibric
acid
(choline)
oral capsule,delayed
MCG,
500
MCG
release(dr/ec) 135 mg, 45 mg
Beta-Adrenergic
Blocking
gemfibrozil
oral tablet
600 mg Agents
acebutolol oral capsule
200 mg,
400 mg Inhibitors
Dyslipidemics,
Hmg Coa
Reductase
ST
PA
PA
1
4
12
22
2
2
1
2
1
21
24
2
2
atenolol oraloral
tablet
10010
mg,
2520
mg,
5040
mgmg, 80
atorvastatin
tablet
mg,
mg,
mg
betaxolol oral tablet 10 mg, 20 mg
11
2
CRESTOR
ORAL TABLET
10 10
MG,
bisoprolol fumarate
oral tablet
mg,205MG,
mg 5
MG
car edilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
CRESTOR
6.25 mg ORAL TABLET 40 MG
42
LIVALO
ORAL
TABLET
1 MG,ER
2 MG, 4 MG
COREG CR
ORAL
CAPSULE,
MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG,
lovastatin oral tablet 10 mg, 20 mg, 40 mg
80 MG
33
ST
1
4
1
54
5454
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significanlas
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
7220
hour
pravastatin
oral tabletpatch
10 mg,
mg,100
40 mcg/hr,
mg, 80
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg
12
hydrocodone-acetaminophen
tablet
2.5-325
simvastatin
oral tablet 10 mg, oral
20 mg,
40 mg,
5 mg,
mgmg
80
12
hydromorphone (pf)
in ection solution 10 mg/ml
Dyslipidemics,
Other
2
hydromorphonelight
oraloral
tablet
2 mg, in
4 mg,
8 mg
cholestyramine
powder
packet
4 gram
LAZANDA
NASAL
SPRAY,NON-AEROSOL
colestipol
oral
granules
5 gram
100 MCG/SPRAY
colestipol oral tablet 1 gram
LAZANDA NASAL SPRAY,NON-AEROSOL
JUXTAPID
ORAL CAPSULE 10 MG, 20 MG, 30
400 MCG/SPRAY
MG, 40 MG, 5 MG, 60 MG
meperidine oral solution 50 mg/5 ml
KYNAMRO SUBCUTANEOUS SYRINGE 200
meperidine oral tablet 50 mg
MG/ML
meperitab
tablet
100 mg
niacin
oral oral
tablet
extended
release 24 hr 1,000 mg,
22
23
QL (180 EA per 30 days)
2
3
5
PA; QL (150 EA per 30 days)
PA
2
5
2
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
PA; QL (240 EA per 30 days)
500
mg, 750in
mgection solution 10 mg/ml, 20 mg/ml
nalbuphine
22
2
omega-3
acid
ethyl
esters5oral
1 gram
oxycodone
oral
solution
mg/5capsule
ml
22
QL (5400 ML per 30 days)
prevalite
oral
powder
oxycodone
oral
tablet 410gram
mg, 15 mg, 20 mg, 30
mg, 5 mg
QUESTRAN
ORAL POWDER IN PACKET 4
22
QL (180 EA per 30 days)
GRAM
tramadol oral tablet 50 mg
4
2
PA
QL (240 EA per 30 days)
SIMCOR
ORAL TABLET, ER MULTIPHASE
Anesthetics
24 HR 1,000-20 MG, 1,000-40 MG, 500-40 MG
3
WELCHOL ORAL POWDER IN PACKET 3.75
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
GRAM
3
2
lidocaine hclORAL
mucous
membrane
2
WELCHOL
TABLET
625gel
MG
42
Local Anesthetics
(40
32
lidocaine hcl urethral gel 2
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50
lidocaine topical adhesi e patch,medicated 5
mg
(700 mg/patch)
minoxidil oral tablet 10 mg, 2.5 mg
lidocaine topical ointment 5
2
2
2
lidocaine
hcl mucous
membrane
ZETIA
ORAL
TABLET
10 MG solution 4
mg/ml)
Vasodilators, Direct-Acting Arterial
Vasodilators, Direct-Acting Arterial/ Venous
333 mg mononitrate oral tablet 10 mg, 20 mg
isosorbide
disulfiram mononitrate
oral tablet 250
500 extended
mg
isosorbide
oralmg,
tablet
release
24 hr
120tablet
mg, 30
naltrexone
oral
50 mg,
mg 60 mg
PA; QL (600 EA per 30 days)
B/D
PA; QL (90 EA per 30 days)
2
2
lidocaine-prilocaine topical cream 2.5-2.5
2
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30
1
Anti-Addiction/
Substance Abuse Treatment Agents
mg,
5 mg
Alcohol Deterrents/
isosorbide
dinitrate oralAnti-Craving
tablet extended release 40
mg
acamprosate oral tablet,delayed release (dr/ec)
QL (10 EA per 30 days)
B/D
1
2
1
PA
12
2
55
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
minitran
transdermal
patch
24 hour
nifedipine
oral capsule
10 mg,
20 mg0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6 mg/hr
nifedipine oral tablet extended release 24hr 30 mg,
60 mg, 0 mgTRANSDERMAL OINTMENT 2 %
NITRO-BID
22
PA
2
4
ST
nimodipine oral
capsule 30 mg PATCH 24
NITRO-DUR
TRANSDERMAL
HOUR 0.3 MG/HR, 0.8 MG/HR
taztia xt oral capsule, extended release 120 mg,
180 mg, 240 transdermal
mg, 300 mg, patch
360 mg
nitroglycerin
24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
erapamil oral capsule, 24 hr er pellet ct 100 mg,
200 mg, 300 translingual
mg
nitroglycerin
spray,non-aerosol 400
mcg/spray
erapamil oral capsule,ext rel. pellets 24 hr 120
42
mg, 180 mg, 240
mg, 360 mg TABLET 0.3 MG,
NITROSTAT
SUBLINGUAL
0.4
MG, 0.6oral
MGtablet 120 mg, 40 mg, 80 mg
erapamil
RECTIV
OINTMENT
0.4 % 120
(W/W)
erapamilRECTAL
oral tablet
extended release
mg,
180 mg, Nervous
240 mg System Agents
Central
2
2
2
2
2
4
1
42
Cardiovascular
Attention
DeficitAgents
Hyperactivity Disorder Agents, Amphetamines
ADVICOR ORAL
TABLET,
ER MULTIPHASE
amphetamine
salt combo
oral tablet
10 mg, 20 mg,
24
PA; QL (60 EA per 30 days)
24
HR
1,000-20
MG,
1,000-40
MG,
500-20
MG,
30 mg, 5 mg, 7.5 mg
750-20 MG
amphetamine salt combo oral tablet 12.5 mg
2
PA; QL (120 EA per 30 days)
ALDACTAZIDE ORAL TABLET 50-50 MG
4
amphetamine salt combo oral tablet 15 mg
2
PA; QL (90 EA per 30 days)
amiloride-hydrochlorothiazide oral tablet 5-50 mg
1
dextroamphetamine oral capsule, extended release
2
PA; QL (150 EA per 30 days)
amlodipine-ator
astatin oral tablet 10-10 mg, 102
10
mg
20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg,
dextroamphetamine
extended
release
2
PA; QL (120 EA per 30 days)
2.5-40 mg, 5-10 mg,oral
5-20capsule,
mg, 5-40
mg, 5-80
mg
15 mg
amlodipine-benazepril oral capsule 10-20 mg, 102
dextroamphetamine
oral
capsule,
extended
release
2
PA; QL (90 EA per 30 days)
40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
5 mg
amlodipine- alsartan oral tablet 10-160 mg, 102
dextroamphetamine
oral tablet
2
PA; QL (180 EA per 30 days)
320 mg, 5-160 mg, 5-320
mg 10 mg
dextroamphetamine
oral tablet 5oral
mg tablet 10-16022
PA; QL (60 EA per 30 days)
amlodipine- alsartan-hcthiazid
12.5 mg, 10-160-25 mg, 10-320-25oral
mg, 5-160-12.5
dextroamphetamine-amphetamine
2
PA; QL (30 EA per 30 days)
mg,
5-160-25
mg
capsule,extended release 24hr 10 mg, 15 mg, 20
mg,
25 mg, 30 mg, 5 mg oral tablet 100-25 mg, 50atenolol-chlorthalidone
1
25 mg
Attention
Deficit Hyperactivity Disorder Agents, Non-Amphetamines
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5clonidine
hcl oral tablet extended release 12 hr 0.1
20 MG, 5-40 MG
mg
benazepril-hydrochlorothiazide oral tablet 10-12.5
dexmethylphenidate oral capsule,er biphasic 50mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg
BENICAR HCT ORAL TABLET 20-12.5 MG,
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5
40-12.5 MG, 40-25 MG
mg
bisoprolol-hydrochlorothiazide oral tablet 10-6.25
mg, 2.5-6.25 mg, 5-6.25 mg
23
QL (120 EA per 30 days)
1
2
PA
3
2
ST
PA
1
56
5656
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informaciónsobre
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quesignifican
significanlas
lasabreviaturas
abreviaturasasasenenesta
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hour 100
mcg/hr,
FOCALIN
XR ORALpatch
CAPSULE,ER
BIPHASIC
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
50-50 25 MG, 35 MG
42
QL (10 EA per 30 days)
PA
hydrocodone-acetaminophen
oral
tablet 20
2.5-325
metadate
er oral tablet extended
release
mg
mg
methylphenidate oral tablet 10 mg, 20 mg, 5 mg
hydromorphone (pf) in ection solution 10 mg/ml
methylphenidate oral tablet extended release 20
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
mg
22
PA
2
2
2
2
PA
LAZANDA NASAL
SPRAY,NON-AEROSOL
methylphenidate
oral tablet
extended release 24hr
100
MCG/SPRAY
18 mg, 27 mg, 36 mg, 54 mg
23
PA; QL (600 EA per 30 days)
PA
LAZANDA NASAL
STRATTERA
ORAL SPRAY,NON-AEROSOL
CAPSULE 10 MG, 100
400 MCG/SPRAY
MG,
18 MG, 25 MG, 40 MG, 60 MG, 80 MG
33
PA; QL (150 EA per 30 days)
meperidine
oral solution
50 mg/5
ml
Central
Nervous
System,
Other
2
PA; QL (3600 ML per 30 days)
meperidine oral
tablet
50 mg EXTENDED
HORIZANT
ORAL
TABLET
RELEASE
600 MG
meperitab oral
tablet 100 mg
42
2
PA; QL (240 EA per 30 days)
NUEDEXTA
nalbuphine inORAL
ection CAPSULE
solution 10 20-10
mg/ml,MG
20 mg/ml
42
B/D
riluzole
oraloral
tablet
50 mg5 mg/5 ml
oxycodone
solution
22
QL (5400 ML per 30 days)
tetrabenazine
oral
tablet
mg,mg,
25 20
mgmg, 30
oxycodone oral
tablet
1012.5
mg, 15
mg, 5 mg ORAL TABLET 12.5 MG, 25 MG
XENAZINE
52
QL (180 EA per 30 days)
5
2
QL (240 EA per 30 days)
tramadol oral tablet 50 mg
Fibromyalgia
Agents
Anesthetics
LYRICA
ORAL CAPSULE 100 MG, 150 MG,
200
MG,Anesthetics
225 MG, 25 MG, 300 MG, 50 MG, 75
Local
MG
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
LYRICA ORAL SOLUTION 20 MG/ML
lidocaine hcl mucous membrane gel 2
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
lidocaine
mucous membrane solution 4 (40
25
MG, 50hcl
MG
mg/ml)
SAVELLA ORAL TABLETS,DOSE PACK 12.5
lidocaine
urethral MG(42)
gel 2
MG
(5)-25hcl
MG(8)-50
lidocaine topical
adhesi
e patch,medicated 5
Multiple
Sclerosis
Agents
(700 mg/patch)
AMPYRA ORAL TABLET EXTENDED
lidocaine topical ointment 5
RELEASE 12 HR 10 MG
lidocaine-prilocaine topical cream 2.5-2.5
AUBAGIO ORAL TABLET 14 MG, 7 MG
PA
QL (180 EA per 30 days)
PA; QL (240 EA per 30 days)
3
2
3
2
4
2
4
2
2
PA; QL (90 EA per 30 days)
5
2
PA
2
5
B/D
PA
Anti-Addiction/
Substance Abuse Treatment Agents 5
AVONEX
(WITH ALBUMIN)
INTRAMUSCULAR
30 MCG
Alcohol Deterrents/KIT
Anti-Craving
PA
AVONEX
INTRAMUSCULAR
INJECTOR
acamprosate
oral tablet,delayed PEN
release
(dr/ec)
KIT
333 30
mgMCG/0.5 ML
52
PA
PA
AVONEX
SYRINGE
KIT
disulfiram INTRAMUSCULAR
oral tablet 250 mg, 500
mg
30 MCG/0.5 ML
naltrexone oral tablet 50 mg
BETASERON SUBCUTANEOUS KIT 0.3 MG
52
PA
2
5
PA
57
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asaenlaesta
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57 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
COPAXONE
SYRINGE
20
TRIBENZORSUBCUTANEOUS
ORAL TABLET 20-5-12.5
MG,
MG/ML,
40 MG,
MG/ML
40-10-12.5
40-10-25 MG, 40-5-12.5 MG, 405-25 MG
EXTAVIA SUBCUTANEOUS KIT 0.3 MG
alsartan-hydrochlorothiazide oral tablet 160-12.5
GILENYA ORAL CAPSULE 0.5 MG
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
REBIF
(WITH ALBUMIN) SUBCUTANEOUS
mg
SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
VYTORIN 10-10 ORAL TABLET 10-10 MG
REBIF REBIDOSE SUBCUTANEOUS PEN
VYTORIN 10-20 ORAL TABLET 10-20 MG
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML,
VYTORIN 10-40 ORAL
TABLET
8.8MCG/0.2ML-22
MCG/0.5ML
(6)10-40 MG
53
PA
5
2
5
PA
ST
PA
5
PA
3
5
3
PA
VYTORIN
10-80 ORAL
TABLET
10-80 MG
REBIF
TITRATION
PACK
SUBCUTANEOUS
SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)
53
PA
TECFIDERA ORAL CAPSULE,DELAYED
digite oral tablet 125
RELEASE(DR/EC)
120mcg
MG, 120 MG (14)- 240
MG
(46),
240tablet
MG 250 mcg
digite
oral
5
1
PA
QL (30 EA per 30 days)
1
PA
TYSABRI
INTRAVENOUS
SOLUTION 300
digoxin oral
solution 50 mcg/ml
MG/15 ML
digoxin oral tablet 125 mcg
52
PA;
PA LA
1
QL (30 EA per 30 days)
Dental
Oral 250
Agents
digoxin And
oral tablet
mcg
1
PA
Dental
And Oral
Agents
pentoxifylline
oral tablet
extended release 400 mg
2
cevimeline
capsule
30 mgEXTENDED
RANEXA oral
ORAL
TABLET
RELEASE 12gluconate
HR 1,000mucous
MG, 500
MG
chlorhexidine
membrane
24
3
Cardiovascular Agents, Other
mouthwash
0.12
% TABLET 150 MG, 300 MG
TEKTURNA
ORAL
CUVPOSA
SOLUTION
1 MG/5
ML (0.2
Diuretics, ORAL
Carbonic
Anhydrase
Inhibitors
MG/ML)
acetazolamide oral capsule, extended release 500
periogard
mucous membrane mouthwash 0.12 %
mg
pilocarpine
hcl oral
oral tablet
tablet 125
5 mg,
7.5250
mgmg
acetazolamide
mg,
PA
1
3
4
2
1
triamcinolone
dental
paste
methazolamideacetonide
oral tablet
25 mg,
50 0.1
mg %
22
22
Dermatological
Diuretics, LoopAgents
Dermatological
Agents
bumetanide oral tablet
0.5 mg, 1 mg, 2 mg
1
8-MOP
ORAL
CAPSULE
10 MG
furosemide
in ection
solution
10 mg/ml
42
PA
acitretin
oralincapsule
10 mg, 17.5
mg, 25 mg
furosemide
ection syringe
10 mg/ml
52
PA
ammonium
topical10
cream
12 40
% mg/5 ml
furosemidelactate
oral solution
mg/ml,
22
ammonium
topical
lotion
%80 mg
furosemidelactate
oral tablet
20 mg,
4012
mg,
21
amnesteem
oral tablet
capsule
mg,2040mg,
mg5 mg
torsemide oral
1010
mg,mg,
10020mg,
22
calcipotriene
scalp solution 0.005 %
Diuretics, Potassium-Sparing
2
calcipotriene
topical
amiloride oral
tabletcream
5 mg 0.005 %
calcipotriene topical ointment 0.005 %
22
2
58
5858
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 720.5
hour
CARAC
TOPICAL CREAM
% 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg
hydrocodone-acetaminophen oral tablet 2.5-325
clotrimazole-betamethasone topical cream 1-0.05
mg
%
hydromorphone (pf) in ection solution 10 mg/ml
clotrimazole-betamethasone topical lotion 1-0.05
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
%
42
2
2
2
QL (180 EA per 30 days)
LAZANDA
cormax
scalpNASAL
solutionSPRAY,NON-AEROSOL
0.05 %
100 MCG/SPRAY
diclofenac sodium topical gel 3 %
LAZANDA NASAL SPRAY,NON-AEROSOL
ELIDEL
TOPICAL CREAM 1 %
400 MCG/SPRAY
erythromycin-benzoyl
peroxide
topical
meperidine oral solution
50 mg/5
ml gel 3-5 %
23
PA; QL (600 EA per 30 days)
5
3
4
PA; QL (150 EA per 30 days)
ST
22
22
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
22
22
B/D
PA; QL (240 EA per 30 days)
22
22
QL (5400 ML per 30 days)
fluocinonide
topical
cream
0.1 %
meperidine oral
tablet
50 mg
fluorouracil
intravenous
2.5 gram/50 ml
meperitab oral
tablet 100solution
mg
fluorouracil
topical
0.5 10
%,mg/ml,
5 % 20 mg/ml
nalbuphine in
ectioncream
solution
fluorouracil
topical
solution
2 %,ml5 %
oxycodone oral
solution
5 mg/5
fluticasone
cream
0.0515
% mg, 20 mg, 30
oxycodone topical
oral tablet
10 mg,
mg, 5 mg topical lotion 0.05 %
fluticasone
QL (10 EA per 30 days)
2
2
2
B/D
QL (180 EA per 30 days)
2
tramadol oral
tablet
50 mg 0.005 %
fluticasone
topical
ointment
22
imiquimod
topical cream in packet 5 %
Anesthetics
2
methoxsalen
rapid oral capsule 10 mg
Local Anesthetics
2
myorisan
capsule
mg, 205mg,
30 mg,
lidocaine oral
(pf) in
ection10
solution
mg/ml
(0.540 )
mg
lidocaine hcl mucous membrane gel 2
nystatin-triamcinolone topical cream 100,000-0.1
lidocaine hcl mucous membrane solution 4 (40
unit/g-%
mg/ml)
nystatin-triamcinolone topical ointment 100,000lidocaine
hcl urethral gel 2
0.1
unit/gram-%
lidocaine topical
topical solution
adhesi e0.5
patch,medicated
5
podofilox
%
(700 mg/patch)
prednicarbate topical cream 0.1 %
lidocaine topical ointment 5
PRUDOXIN TOPICAL CREAM 5 %
lidocaine-prilocaine topical cream 2.5-2.5
REGRANEX TOPICAL GEL 0.01 %
22
SANTYL TOPICAL OINTMENT 250
Alcohol Deterrents/ Anti-Craving
UNIT/GRAM
3
acamprosate
oral
tablet,delayed
(dr/ec)
selenium
sulfide
topical
lotion 2.5release
%
333 mg
STELARA SUBCUTANEOUS SYRINGE 45
disulfiram
oral
250 mg, 500 mg
MG/0.5
ML,
90 tablet
MG/ML
22
PA
5
2
PA
naltrexone topical
oral tablet
50 mg0.03 %, 0.1 %
tacrolimus
ointment
22
ST
Anti-Addiction/ Substance Abuse Treatment Agents
QL (240 EA per 30 days)
PA
2
2
2
2
2
22
PA; QL (90 EA per 30 days)
2
2
4
2
4
PA
B/D
PA; QL (15 GM per 30 days)
59
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
TAZORAC
TOPICAL
0.05 %, 0.1 %
colestipol oral
tablet 1 CREAM
gram
42
JUXTAPIDTOPICAL
ORAL CAPSULE
MG,
TAZORAC
GEL 0.0510%,
0.1 20
% MG, 30
MG, 40 MG, 5 MG, 60 MG
tretinoin topical cream 0.025 %, 0.05 %, 0.1 %
KYNAMRO SUBCUTANEOUS SYRINGE 200
tretinoin topical gel 0.01 %, 0.025 %
MG/ML
UVADEX INJECTION SOLUTION 20 MCG/ML
niacin oral tablet extended release 24 hr 1,000 mg,
VALCHLOR
TOPICAL GEL 0.016 %
500 mg, 750 mg
45
PA
2
5
2
PA
VEREGEN
TOPICAL
OINTMENT
15 1%gram
omega-3 acid
ethyl esters
oral capsule
42
VOLTAREN
GEL 1 %
pre alite oralTOPICAL
powder 4 gram
42
zenatane
oral capsule
30 mg
QUESTRAN
ORAL POWDER
IN PACKET 4
GRAM
ZONALON TOPICAL CREAM 5 %
SIMCOR ORAL TABLET, ER MULTIPHASE
ZYCLARA TOPICAL CREAM IN METERED24 HR 1,000-20 MG, 1,000-40 MG, 500-40 MG
DOSE PUMP 2.5 %
WELCHOL ORAL POWDER IN PACKET 3.75
ZYCLARA TOPICAL CREAM IN PACKET 3.75
GRAM
%
WELCHOL ORAL TABLET 625 MG
24
PA
4
3
5
PA
ZETIA ORAL TABLET 10 MG
3
ADAGEN INTRAMUSCULAR SOLUTION 250
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50
UNIT/ML
mg
ALDURAZYME INTRAVENOUS SOLUTION
minoxidil
oral tablet 10 mg, 2.5 mg
2.9
MG/5 ML
5
2
PA
5
2
PA
5
PA
Enzyme Replacement/ Modifiers
Enzyme Replacement/ Modifiers
Vasodilators, Direct-Acting Arterial
Vasodilators,
Direct-ActingRECON
Arterial/
Venous
CEREZYME
INTRAVENOUS
SOLN
400
UNIT dinitrate oral tablet 10 mg, 20 mg, 30
isosorbide
mg, 5 mgORAL CAPSULE,DELAYED
CREON
RELEASE(DR/EC)
-60,000
UNIT,
isosorbide dinitrate 12,000-38,000
oral tablet extended
release
40
24,000-76,000
-120,000 UNIT, 3,000-9,500mg
15,000 UNIT, 36,000-114,000- 180,000 UNIT,
isosorbide mononitrate
oral tablet 10 mg, 20 mg
6,000-19,000
-30,000 UNIT
4
2
4
3
5
B/D
PA
PA
4
1
3
1
1
isosorbide mononitrate
oral tablet1extended
CYSTADANE
ORAL POWDER
GRAM/1.7
release 24 hr 120 mg, 30 mg, 60 mg
ML
41
minitran transdermal
patch 24 hour
mg/hr,
0.2
CYSTAGON
ORAL CAPSULE
150 0.1
MG,
50 MG
mg/hr, 0.4 mg/hr, 0.6 mg/hr
ELAPRASE INTRAVENOUS SOLUTION 6
NITRO-BID
MG/3
ML TRANSDERMAL OINTMENT 2 %
NITRO-DUR
TRANSDERMAL
PATCH
24 200
ELELYSO
INTRAVENOUS
RECON
SOLN
HOUR 0.3 MG/HR, 0.8 MG/HR
UNIT
42
54
PA
nitroglycerin transdermal
patch 24
hour 0.1
FABRAZYME
INTRAVENOUS
RECON
SOLN
mg/hr,
0.2
mg/hr,
0.4
mg/hr,
0.6
mg/hr
35 MG
52
PA
KUVAN ORAL POWDER IN PACKET 500 MG
5
PA
5
4
PA
PA
60
6060
Puedeencontrar
encontrarinformación
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quesignifican
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enesta
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour 100100
mcg/hr,
KUVAN
ORAL TABLET,SOLUBLE
MG
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
NAGLAZYME INTRAVENOUS SOLUTION 5
hydrocodone-acetaminophen
oral tablet 2.5-325
MG/5
ML
mg
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5
hydromorphone (pf) in ection solution 10 mg/ml
MG
52
QL (10 EA per 30 days)
PA
5
2
PA
5
2
PA
hydromorphone
tablet1.1
2 mg,
4 mg, 8 mg
RAVICTI
ORALoral
LIQUID
GRAM/ML
52
QL (180 EA per 30 days)
PA
LAZANDASUBCUTANEOUS
NASAL SPRAY,NON-AEROSOL
STRENSIQ
SOLUTION 40
100
MCG/SPRAY
MG/ML, 80 MG/0.8 ML
53
PA; QL (600 EA per 30 days)
PA
LAZANDAORAL
NASAL
SPRAY,NON-AEROSOL
SUCRAID
SOLUTION
8,500 UNIT/ML
400 MCG/SPRAY
VPRIV INTRAVENOUS RECON SOLN 400
meperidine oral solution 50 mg/5 ml
UNIT
43
PA; QL (150 EA per 30 days)
PA
5
2
B/D
PA; QL (3600 ML per 30 days)
meperidine ORAL
oral tablet
50 mg 100 MG
ZAVESCA
CAPSULE
42
PA; QL (240 EA per 30 days)
PA
meperitabORAL
oral tablet
100 mg
ZENPEP
CAPSULE,DELAYED
RELEASE(DR/EC)
-55,000
UNIT,
nalbuphine in ection10,000-34,000
solution 10 mg/ml,
20 mg/ml
15,000-51,000 -82,000 UNIT, 20,000-68,000 oxycodone
oral25,000-85,000solution 5 mg/5136,000
ml
109,000
UNIT,
UNIT,
3,000-10,00016,000
UNIT,
40,000-136,000oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
218,000
mg, 5 mgUNIT, 5,000-17,000 -27,000 UNIT
32
PA; QL (240 EA per 30 days)
2
B/D
2
QL (5400 ML per 30 days)
2
QL (180 EA per 30 days)
Gastrointestinal
Agents
tramadol oral tablet
50 mg
2
QL (240 EA per 30 days)
Antispasmodics,
Gastrointestinal
Anesthetics
dicyclomine
oral capsule 10 mg
Local Anesthetics
dicyclomine
oral
solution
10 mg/5
ml
lidocaine (pf)
in ection
solution
5 mg/ml
(0.5
dicyclomine
tabletmembrane
20 mg gel 2
lidocaine hcloral
mucous
glycopyrrolate
oral tablet
1 mg, 2solution
mg
lidocaine hcl mucous
membrane
4
mg/ml)
methscopolamine
oral tablet 2.5 mg, 5 mg
2
)
22
22
(40
22
2
2
lidocaine hcl urethral
gel 2 Other
Gastrointestinal
Agents,
lidocaine topical adhesi e patch,medicated 5
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5
(700 mg/patch)
ml
lidocaine topical ointment 5
diphenoxylate-atropine oral tablet 2.5-0.025 mg
lidocaine-prilocaine topical cream 2.5-2.5
FULYZAQ ORAL TABLET,DELAYED
RELEASE
(DR/EC)Substance
125 MG Abuse Treatment Agents
Anti-Addiction/
2
2
PA; QL (90 EA per 30 days)
2
2
2
4
B/D
GATTEX
Alcohol ONE-VIAL
Deterrents/SUBCUTANEOUS
Anti-Craving KIT 5
MG
acamprosate oral tablet,delayed release (dr/ec)
loperamide
oral capsule 2 mg
333 mg
metoclopramide
hcl injection
disulfiram oral tablet
250 mg,solution
500 mg 5 mg/ml
5
PA
2
2
PA
metoclopramide
hcl oral
5 mg/5 ml
naltrexone oral tablet
50solution
mg
metoclopramide hcl oral tablet 10 mg, 5 mg
22
12
1
61
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61 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
proctozone-hc
2.5 % 10 MG, 100
STRATTERArectal
ORALcream
CAPSULE
MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG
RELISTOR SUBCUTANEOUS SOLUTION 12
MG/0.6
CentralML
Nervous System, Other
13
4
PA
RELISTOR
SYRINGE 12
HORIZANTSUBCUTANEOUS
ORAL TABLET EXTENDED
MG/0.6
ML,
8
MG/0.4
ML
RELEASE 600 MG
44
PA
ursodiol
oral capsule
mg
NUEDEXTA
ORAL 300
CAPSULE
20-10 MG
24
ursodiol
250mg
mg, 500 mg
riluzole oral
oral tablet
tablet 50
22
XENAZINE ORAL
TABLET 12.5
MG, 25 MG
Histamine2
(H2) Receptor
Antagonists
5
cimetidine
hcl oral
solution 300 mg/5 ml
Fibromyalgia
Agents
1
cimetidine
200 mg, 300
mg, 400 mg, 20
duloxetineoral
oraltablet
capsule,delayed
release(dr/ec)
800
mg,mg
30 mg, 60 mg
12
famotidine
(pf) intravenous
20 150
mg/2MG,
ml
LYRICA ORAL
CAPSULEsolution
100 MG,
200 MG, 225
2520
MG,
famotidine
oralMG,
tablet
mg,300
40 MG,
mg 50 MG, 75
MG
nizatidine oral capsule 150 mg, 300 mg
LYRICA ORAL SOLUTION 20 MG/ML
ranitidine hcl oral syrup 15 mg/ml
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
ranitidine
oral tablet 150 mg, 300 mg
25 MG, 50hcl
MG
23
SAVELLA
ORALSyndrome
TABLETS,DOSE
Irritable
Bowel
AgentsPACK 12.5
4
MG (5)-25 MG(8)-50 MG(42)
alosetron oral tablet 0.5 mg, 1 mg
Multiple ORAL
Sclerosis
Agents24 MCG, 8 MCG
AMITIZA
CAPSULE
AMPYRA ORAL
TABLET EXTENDED
BUDESONIDE
ORAL
RELEASE
12
HR
10 MG
CAPSULE,DELAYED,EXTEND.RELEASE
3
1
2
3
2
4
2
2
3
35
PA
MG
AUBAGIO ORAL TABLET 14 MG, 7 MG
5
PA
LINZESS
145 MCG, 290 MCG
AVONEXORAL
(WITHCAPSULE
ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
35
PA
AVONEX INTRAMUSCULAR PEN INJECTOR
constulose oral solution 10 gram/15 ml
KIT 30 MCG/0.5 ML
enulose oral solution 10 gram/15 ml
AVONEX INTRAMUSCULAR SYRINGE KIT
30 MCG/0.5
gavilyte-c
oralML
recon soln 240-22.72-6.72 -5.84
gram
BETASERON SUBCUTANEOUS KIT 0.3 MG
gavilyte-g
oral recon soln 236-22.74-6.74 -5.86
COPAXONE SUBCUTANEOUS SYRINGE 20
gram
MG/ML, 40 MG/ML
5
2
PA
2
5
2
PA
5
25
PA
gavilyte-n
recon soln 420 gram
EXTAVIAoral
SUBCUTANEOUS
KIT 0.3 MG
generlac
oralORAL
solution
10 gram/15
GILENYA
CAPSULE
0.5 ml
MG
25
25
PA
KRISTALOSE
ORAL
PACKET
10 GRAM,
20
mitoxantrone intra
enous
concentrate
2 mg/ml
GRAM
REBIF (WITH ALBUMIN) SUBCUTANEOUS
lactulose
oral
10ML,
gram/15
ml
SYRINGE
22solution
MCG/0.5
44 MCG/0.5
ML
42
Laxatives
5
2
PA
PA
PA
PA
62
6262
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour
100 gram
mcg/hr,
peg-electrolyte
soln oral
recon
soln 420
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
polyethylene glycol 3350 oral powder 17
hydrocodone-acetaminophen oral tablet 2.5-325
gram/dose
mg
trilyte with flavor packets oral recon soln 420
hydromorphone (pf) in ection solution 10 mg/ml
gram
22
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
Protectants
2
QL (180 EA per 30 days)
LAZANDAoral
NASAL
misoprostol
tabletSPRAY,NON-AEROSOL
100 mcg, 200 mcg
100 MCG/SPRAY
sucralfate oral tablet 1 gram
LAZANDA NASAL SPRAY,NON-AEROSOL
Proton
Pump Inhibitors
400 MCG/SPRAY
23
PA; QL (600 EA per 30 days)
2
3
PA; QL (150 EA per 30 days)
ACIPHEX
CAPSULE,
meperidineSPRINKLE
oral solutionORAL
50 mg/5
ml
DELAYED REL SPRINKLE 10 MG, 5 MG
meperidine oral tablet 50 mg
DEXILANT ORAL CAPSULE,BIPHASE
meperitab oral tablet 100 mg
DELAYED RELEAS 30 MG, 60 MG
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
esomeprazole magnesium oral capsule,delayed
oxycodone oral
5 mg/5 ml
release(dr/ec)
20solution
mg, 40 mg
42
ST
PA; QL (3600 ML per 30 days)
2
4
2
PA; QL (240 EA per 30 days)
ST
PA; QL (240 EA per 30 days)
2
2
2
B/D
ST
QL (5400 ML per 30 days)
oxycodone oral
10 mg, 15 mg,
20 mg, 30
lansoprazole
oraltablet
capsule,delayed
release(dr/ec)
mg,mg,
5 mg
15
30 mg
22
QL (180 EA per 30 days)
ST
tramadol oral
tablet ORAL
50 mg GRANULES DR
NEXIUM
PACKET
FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG,
Anesthetics
40
MG, 5 MG
42
QL (240 EA per 30 days)
ST
Local Anesthetics
omeprazole
oral capsule,delayed release(dr/ec) 10
mg,
20
mg,
40
mgection solution 5 mg/ml (0.5 )
lidocaine (pf) in
pantoprazole
tablet,delayed
lidocaine hcl oral
mucous
membrane release
gel 2 (dr/ec) 20
mg, 40 mg
lidocaine hcl mucous membrane solution 4 (40
protonix
mg/ml) intravenous recon soln 40 mg
rabeprazole
tablet,delayed
release (dr/ec) 20
lidocaine hcloral
urethral
gel 2
mg
lidocaine topical adhesi e patch,medicated 5
Genitourinary
(700 mg/patch)Agents
QL (10 EA per 30 days)
2
2
2
2
1
2
22
2
2
22
ST
2
PA; QL (90 EA per 30 days)
lidocaine topical ointment
5
Antispasmodics,
Urinary
2
lidocaine-prilocaine
topical cream
2.5-2.5
ENABLEX
ORAL TABLET
EXTENDED
RELEASE 24 HR 15 MG, 7.5 MG
32
flavoxate oral tablet 100 mg
2
MYRBETRIQ ORAL TABLET EXTENDED
acamprosate
tablet,delayed
RELEASE
24oral
HR 25
MG, 50 MGrelease (dr/ec)
333 mg
oxybutynin chloride oral syrup 5 mg/5 ml
disulfiram oral tablet 250 mg, 500 mg
oxybutynin chloride oral tablet 5 mg
naltrexone oral tablet 50 mg
4
2
B/D
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
QL (30 EA per 30 days)
PA
2
2
1
2
63
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63 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
oxybutynin
chloride
tablet 0.005
extended release
calcipotriene
topicaloral
ointment
24hr 10 mg, 15 mg, 5 mg
calcipotriene topical solution 0.005
tolterodine oral capsule,extended release 24hr 2
CARAC TOPICAL CREAM 0.5 %
mg, 4 mg
clara is oral capsule 10 mg, 20 mg, 30 mg, 40 mg
tolterodine oral tablet 1 mg, 2 mg
clotrimazole-betamethasone topical cream 1-0.05
TOVIAZ ORAL TABLET EXTENDED
RELEASE 24 HR 4 MG, 8 MG
clotrimazole-betamethasone topical lotion 1-0.05
VESICARE ORAL TABLET 10 MG, 5 MG
22
Benign
Prostatic
Hypertrophy
Agents
cormax topical
solution
0.05
2
25
alfuzosin
oral
tablettopical
extended
24 hr 10 mg
diclofenac
sodium
gel release
3
AVODART
0.5
doxycycline ORAL
hyclateCAPSULE
oral capsule
50MG
mg
doxazosin
oral
tablet 1 mg,oral
2 mg,
4 mg, 100
8 mgmg, 50
doxycycline
monohydrate
capsule
mg
dutasteride
oral capsule 0.5 mg
doxycycline monohydrate
tableter
100
mg, 50
dutasteride-tamsulosin
oraloral
capsule,
multiphase
mg
24 hr 0.5-0.4 mg
ELIDEL TOPICAL
finasteride
oral tabletCREAM
5 mg 1 %
erythromycin-benzoyl
peroxide
topical gel 3-5 24
JALYN
ORAL CAPSULE,
ER MULTIPHASE
HR
0.5-0.4 MG
fluocinonide
topical cream 0.1
tamsulosin
oral
capsule,extended
24hr ml
0.4
fluorouracil
intra
enous solution release
2.5 gram/50
mg
fluorouracil topical cream 0.5 , 5
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg
fluorouracil topical solution 2 , 5
Genitourinary Agents, Other
2
2
4
ST
2
2
2
3
ST
2
3
42
12
2
22
24
42
ST
2
22
PA
2
1
2
fluticasone topical cream 0.05
bethanechol chloride oral tablet 10 mg, 25 mg, 5
fluticasone topical lotion 0.05
mg, 50 mg
fluticasone topical ointment 0.005
DEPEN TITRATABS ORAL TABLET 250 MG
imi uimod topical cream in pac et 5
ELMIRON ORAL CAPSULE 100 MG
methoxsalen rapid oral capsule 10 mg
potassium citrate oral tablet extended release 10
myorisan
105mg,
mg,mg)
40 mg
meq
(1,080oral
mg),capsule
15 meq,
meq20(540
2
2
2
nystatin-triamcinolone
topical
cream
100,000-0.1
sodium
phenylbutyrate oral
powder
0.94
unit/ggram/gram
52
nystatin-triamcinolone
Phosphate
Binders topical ointment 100,000-
2
0.1 unit/gramcalcium acetate oral capsule 667 mg
podofilox topical solution 0.5
FOSRENOL ORAL POWDER IN PACKET
prednicarbate
1,000
MG, 750 topical
MG cream 0.1
PRUDOXINORAL
TOPICAL
CREAM 5 %
FOSRENOL
TABLET,CHEWABLE
1,000
MG, 500TOPICAL
MG, 750 MG
REGRANEX
GEL 0.01 %
B/D
2
4
2
4
2
2
2
PA
PA
PA
2
2
3
2
34
4
PA
PA; QL (15 GM per 30 days)
64
6464
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour
100
mcg/hr,
PHOSLYRA
ORAL SOLUTION
667
MG
(169
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
MG CALCIUM)/5 ML
32
hydrocodone-acetaminophen
oralMG,
tablet800
2.5-325
RENAGEL
ORAL TABLET 400
MG
mg
RENVELA ORAL POWDER IN PACKET 0.8
hydromorphone
(pf) in ection solution 10 mg/ml
GRAM,
2.4 GRAM
42
hydromorphone
oral
tablet 2 800
mg, MG
4 mg, 8 mg
RENVELA
ORAL
TABLET
32
QL (10 EA per 30 days)
4
2
QL (180 EA per 30 days)
3 (Adrenal)PA; QL (600 EA per 30 days)
LAZANDAAgents,
NASAL SPRAY,NON-AEROSOL
Hormonal
Stimulant/ Replacement/ Modifying
100 MCG/SPRAY
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
LAZANDA NASAL SPRAY,NON-AEROSOL
ala-cort
topical cream 1 %
400 MCG/SPRAY
3
1
PA; QL (150 EA per 30 days)
alclometasone
topical
cream
0.05 %
meperidine oral
solution
50 mg/5
ml
22
PA; QL (3600 ML per 30 days)
alclometasone
topical
meperidine oral
tabletointment
50 mg 0.05 %
22
PA; QL (240 EA per 30 days)
amcinonide
topical
cream
0.1 %
meperitab oral
tablet
100 mg
22
PA; QL (240 EA per 30 days)
amcinonide
lotion
0.1 %
nalbuphine topical
in ection
solution
10 mg/ml, 20 mg/ml
22
B/D
amcinonide
topical
ointment
0.1 ml
%
oxycodone oral
solution
5 mg/5
22
QL (5400 ML per 30 days)
clobetasol
solution
% mg, 20 mg, 30
oxycodonescalp
oral tablet
10 0.05
mg, 15
mg, 5 mg
clobetasol topical gel 0.05 %
tramadol oral tablet 50 mg
clobetasol topical ointment 0.05 %
22
QL (180 EA per 30 days)
2
2
2
QL (240 EA per 30 days)
Anesthetics
clobetasol-emollient
topical cream 0.05 %
2
Local Anesthetics
desonide
topical cream 0.05 %
lidocainetopical
(pf) in lotion
ection 0.05
solution
desonide
% 5 mg/ml (0.5
2
)
22
lidocainetopical
hcl mucous
membrane
desonide
ointment
0.05 %gel 2
22
lidocaine hcl mucous
solution
4 % (40
desoximetasone
topicalmembrane
cream 0.05
%, 0.25
mg/ml)
desoximetasone topical gel 0.05 %
lidocaine hcl urethral gel 2
desoximetasone topical ointment 0.05 %, 0.25 %
lidocaine topical adhesi e patch,medicated 5
diflorasone
topical cream 0.05 %
(700 mg/patch)
diflorasone
topicalointment
ointment5 0.05 %
lidocaine topical
22
fludrocortisone
oral tablet
0.1cream
mg 2.5-2.5
lidocaine-prilocaine
topical
fluocinolone topical cream 0.01 %, 0.025 %
2
2
2
2
2
22
22
PA; QL (90 EA per 30 days)
B/D
Anti-Addiction/ Substance Abuse Treatment Agents 2
fluocinolone topical ointment 0.025 %
2
fluocinolone topical solution 0.01 %
acamprosate oral tablet,delayed release (dr/ec)
fluocinonide
topical gel 0.05 %
333 mg
fluocinonide
topical
disulfiram oral
tabletointment
250 mg,0.05
500 %
mg
2
2
2
Alcohol Deterrents/ Anti-Craving
fluocinonide
topical
solution
naltrexone oral
tablet
50 mg 0.05 %
PA
22
22
65
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
ELAPRASE INTRAVENOUS
SOLUTION
6
fluocinonide-e
topical cream 0.05
%
MG/3 ML
halobetasol propionate topical cream 0.05 %
ELELYSO INTRAVENOUS RECON SOLN 200
halobetasol propionate topical ointment 0.05 %
UNIT
hydrocortisone butyrate topical ointment 0.1 %
FABRAZYME INTRAVENOUS RECON SOLN
35 MG
hydrocortisone
butyrate topical solution 0.1 %
15
PA
2
5
2
PA
2
5
2
PA
KUVAN ORAL
POWDER IN topical
PACKET
5000.1
MG
hydrocortisone
butyr-emollient
cream
%
KUVAN ORAL TABLET,SOLUBLE 100 MG
hydrocortisone oral tablet 10 mg
NAGLAZYME INTRAVENOUS SOLUTION 5
MG/5 ML
hydrocortisone
topical cream 1 %, 2.5 %
25
PA
5
2
5
1
PA
ORFADIN ORAL
CAPSULE
10%MG, 2 MG, 5
hydrocortisone
topical
lotion 2.5
MG
hydrocortisone topical ointment 1 %, 2.5 %
RAVICTI ORAL LIQUID 1.1 GRAM/ML
hydrocortisone valerate topical cream 0.2 %
SUCRAID ORAL SOLUTION 8,500 UNIT/ML
hydrocortisone valerate topical ointment 0.2 %
VPRIV INTRAVENOUS RECON SOLN 400
lokara topical lotion 0.05 %
UNIT
methylprednisolone oral tablets,dose pack 4 mg
ZAVESCA ORAL CAPSULE 100 MG
mometasone topical cream 0.1 %
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
10,000-34,000
mometasone
topical ointment
0.1 % -55,000 UNIT,
15,000-51,000 -82,000 UNIT, 20,000-68,000 mometasone topical solution 0.1 %
109,000 UNIT, 25,000-85,000- 136,000 UNIT,
prednicarbate
0.1 %
3,000-10,000-topical
16,000ointment
UNIT, 40,000-136,000218,000 UNIT, 5,000-17,000 -27,000 UNIT
procto-pak rectal cream 1 %
15
PA
Gastrointestinal
Agents
TEMOVATE
TOPICAL
CREAM 0.05 %
1
5
2
4
2
5
2
2
4
2
3
2
PA
PA
PA
B/D
PA
2
2
2
4
Antispasmodics,
Gastrointestinal
triamcinolone
acetonide
topical cream 0.025 %,
0.1
%, 0.5 % oral capsule 10 mg
dicyclomine
2
triamcinolone
acetonide
lotion
dicyclomine oral
solutiontopical
10 mg/5
ml 0.025 %,
0.1 %
dicyclomine oral tablet 20 mg
triamcinolone acetonide topical ointment 0.025 %,
glycopyrrolate
0.1
%, 0.5 % oral tablet 1 mg, 2 mg
methscopolamine
oral0.1
tablet
triderm
topical cream
% 2.5 mg, 5 mg
2
2
2
PA
2
22
22
TRANSDERM-SCOP
TRANSDERMAL
PATCH Modifying
4 (Pituitary)
Hormonal
Agents, Stimulant/
Replacement/
72 HOUR 1.5 MG (1 MG OVER 3 DAYS)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Gastrointestinal Agents, Other
chorionic gonadotropin, human intramuscular
diphenoxylate-atropine
recon
soln 10,000 unit oral li uid 2.5-0.025 mg/5
ml
desmopressin injection solution 4 mcg/ml
diphenoxylate-atropine oral tablet 2.5-0.025 mg
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
2
2
2
2
2
66
6666
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estatabla,
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour 10010mcg/hr,
desmopressin
nasal spray,non-aerosol
12
mcg/hr,
25
mcg/hr,
50 mcg/hr, 75 mcg/hr
mcg/spray (0.1 ml)
22
hydrocodone-acetaminophen
oral0.2
tablet
desmopressin
oral tablet 0.1 mg,
mg 2.5-325
mg
EGRIFTA SUBCUTANEOUS RECON SOLN 1
hydromorphone (pf) in ection solution 10 mg/ml
MG
22
5
2
PA
hydromorphone MINIQUICK
oral tablet 2 mg,
4 mg, 8 mg
GENOTROPIN
SUBCUTANEOUS
SYRINGE
MG/0.25
ML
LAZANDA0.2
NASAL
SPRAY,NON-AEROSOL
42
QL (180 EA per 30 days)
PA
3
5
PA; QL (600 EA per 30 days)
PA
3
PA; QL (150 EA per 30 days)
2
PA; QL (3600 ML per 30 days)
52
2
PA; QL (240 EA per 30 days)
PA
PA; QL (240 EA per 30 days)
2
5
2
B/D
PA
QL (5400 ML per 30 days)
42
QL (180 EA per 30 days)
PA
52
QL (240 EA per 30 days)
PA
INCRELEX SUBCUTANEOUS SOLUTION 10
Local Anesthetics
MG/ML
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
NORDITROPIN FLEXPRO SUBCUTANEOUS
lidocaine
hcl mucous
membrane
PEN
INJECTOR
10 MG/1.5
ML gel
(6.72MG/ML),
15
MG/1.5hcl
ML
(10 MG/ML),
30 solution
MG/3 ML
lidocaine
mucous
membrane
4 (10(40
MG/ML),
5
MG/1.5
ML
(3.3
MG/ML)
mg/ml)
5
PA
2
5
2
PA
NUTROPIN
NUSPIN
lidocaine hclAQ
urethral
gel 2SUBCUTANEOUS
PEN INJECTOR 5 MG/2 ML (2.5 MG/ML)
lidocaine topical adhesi e patch,medicated 5
NUTROPIN
AQ SUBCUTANEOUS
(700 mg/patch)
CARTRIDGE 20 MG/2 ML (10 MG/ML)
lidocaine topical ointment 5
OMNITROPE SUBCUTANEOUS CARTRIDGE
lidocaine-prilocaine
topical cream
2.5-2.5
10
MG/1.5 ML (6.7 MG/ML),
5 MG/1.5
ML (3.3
MG/ML)
52
PA
2
5
PA; QL (90 EA per 30 days)
PA
2
4
2
PA
B/D
OMNITROPE SUBCUTANEOUS RECON
Alcohol
Anti-Craving
SOLN
5.8 Deterrents/
MG
acamprosateSUBCUTANEOUS
oral tablet,delayed release
SEROSTIM
RECON(dr/ec)
SOLN 4
333
mg
MG, 5 MG, 6 MG
5
PA
52
PA
PA
100 MCG/SPRAY
GENOTROPIN
MINIQUICK SUBCUTANEOUS
SYRINGE
0.4
MG/0.25
ML, 0.6 MG/0.25 ML,
LAZANDA NASAL SPRAY,NON-AEROSOL
0.8
ML, 1 MG/0.25 ML, 1.2 MG/0.25
400MG/0.25
MCG/SPRAY
ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
meperidine
oral
solution 50
MG/0.25
ML,
2 MG/0.25
MLmg/5 ml
meperidine oralSUBCUTANEOUS
tablet 50 mg
GENOTROPIN
CARTRIDGE
MG/ML
(36 UNIT/ML), 5
meperitab oral12
tablet
100 mg
MG/ML (15 UNIT/ML)
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
HUMATROPE INJECTION CARTRIDGE 12
oxycodone
oral solution
5 mg/5
ml
MG
(36 UNIT),
24 MG (72
UNIT)
oxycodone oral INJECTION
tablet 10 mg,CARTRIDGE
15 mg, 20 mg,630MG
HUMATROPE
mg,UNIT)
5 mg
(18
tramadol oral tablet
50 mg RECON SOLN 5 (15
HUMATROPE
INJECTION
UNIT)
MG
Anesthetics
QL (10 EA per 30 days)
2
Anti-Addiction/ Substance Abuse Treatment Agents
disulfiram oral tablet 250 mg, 500 mg
2
Hormonal
Agents, Stimulant/ Replacement/ Modifying
(Sex Hormones/ Modifiers)
naltrexone oral tablet 50 mg
Anabolic Steroids
2
67
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
ANADROL-50
ORAL10
TABLET
enulose oral solution
gram/1550
mlMG
52
ga ilyte-c oral
recon
soln
-5.84
oxandrolone
oral
tablet
10 240-22.72-6.72
mg, 2.5 mg
gram
22
ga ilyte-g oral recon soln 236-22.74-6.74 -5.86
ANDROGEL
TRANSDERMAL GEL IN
gram
METERED-DOSE PUMP 1.25 GRAM/
ga ilyte-n oral(1recon
soln 420
gram GRAM
ACTUATION
%), 20.25
MG/1.25
(1.62
%) oral solution 10 gram/15 ml
generlac
ANDROGEL
TRANSDERMAL
IN
KRISTALOSE
ORAL PACKETGEL
10 GRAM,
20
PACKET
1
%
(25
MG/2.5GRAM),
1
%
(50
MG/5
GRAM
GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 %
lactulose
oralGRAM)
solution 10 gram/15 ml
(40.5
MG/2.5
polyethylene
glycol10
3350
androxy
oral tablet
mg oral powder 17
gram/dose
danazol oral capsule 100 mg, 200 mg, 50 mg
trilyte with fla or pac ets oral recon soln 420
methyltestosterone
oral capsule 10 mg
gram
TESTIM
TRANSDERMAL GEL 50 MG/5
Protectants
GRAM (1 %)
misoprostol oral tablet 100 mcg, 200 mcg
testosterone cypionate intramuscular oil 100
sucralfate
tablet 1 gram
mg/ml,
200 oral
mg/ml
2
4
Androgens
Proton Pump
Inhibitors
testosterone
transdermal
gel in metered-dose
pump 1.25 gram/ actuation (1 %)
ACIPHEX SPRINKLE ORAL CAPSULE,
testosterone
gel in10
packet
(25
DELAYED transdermal
REL SPRINKLE
MG, 15 %
MG
mg/2.5gram), 1 % (50 mg/5 gram)
DEXILANT ORAL CAPSULE,BIPHASE
DELAYED RELEAS 30 MG, 60 MG
Estrogens
PA
ST
2
2
44
ST
PA
2
22
4
2
5
PA
4
ST
2
2
2
2
4
2
ST
4
ST
esomeprazole
magnesium oralGEL
capsule,delayed
DIVIGEL
TRANSDERMAL
IN PACKET
release(dr/ec)
0.5
MG (0.1 %)20 mg, 40 mg
42
ST
lansoprazole
oralTABLET
capsule,delayed
DUAVEE
ORAL
0.45-20release(dr/ec)
MG
15 mg, 30 mg
ESTRACE VAGINAL CREAM 0.01 % (0.1
NEXIUM PACKET ORAL GRANULES DR
MG/GRAM)
FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG,
estradiol
40 MG, 5oral
MGtablet 0.5 mg, 1 mg, 2 mg
estradiol
transdermal
patch semiweekly
0.025 10
omeprazole
oral capsule,delayed
release(dr/ec)
mg/24
hr,
0.05
mg/24
hr,
0.075
mg/24
hr,
0.1
mg, 20 mg, 40 mg
mg/24 hr
pantoprazole oral tablet,delayed release (dr/ec) 20
estradiol
transdermal patch weekly 0.025 mg/24
mg, 40 mg
hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24
protonix
intra enous
soln
hr,
0.075 mg/24
hr, 0.1recon
mg/24
hr 40 mg
rabeprazole
oral tablet,delayed
(dr/ec) 20
estradiol
valerate
intramuscular release
oil 20 mg/ml
mg
ESTRING VAGINAL RING 2 MG
32
ST
4
4
ST
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
2
Genitourinary Agents
1
21
2
2
2
22
ST
4
PA
68
6868
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72mg
hour 100 mcg/hr,
marlissa
oral tablet 0.15-0.03
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
hydrocodone-acetaminophen
oral tablet 2.5-325
1.25
MG, 2.5 MG
mg
MENOSTAR TRANSDERMAL PATCH
hydromorphone
(pf) in HR
ection solution 10 mg/ml
WEEKLY
14 MCG/24
22
QL (10 EA per 30 days)
4
2
PA
hydromorphone
oral tabletRECON
2 mg, 4 SOLN
mg, 8 mg
PREMARIN
INJECTION
25 MG
32
QL (180 EA per 30 days)
LAZANDA NASAL
SPRAY,NON-AEROSOL
PREMARIN
ORAL TABLET
0.3 MG, 0.45 MG,
100
MCG/SPRAY
0.625 MG, 0.9 MG, 1.25 MG
33
PA; QL (600 EA per 30 days)
LAZANDA NASAL
SPRAY,NON-AEROSOL
PREMARIN
VAGINAL
CREAM 0.625
400 MCG/SPRAY
MG/GRAM
33
PA; QL (150 EA per 30 days)
meperidine VAGINAL
oral solutionTABLET
50 mg/5 10
ml MCG
VAGIFEM
42
PA; QL (3600 ML per 30 days)
3
2
2 (Sex Hormones/
meperidine oral
tabletStimulant/
50 mg
PA; QL (240
EA per 30 days)
Hormonal
Agents,
Replacement/ Modifying
Modifiers)
meperitab
oral 0.15-0.03
tablet 100mg
mg
apri
oral tablet
nalbuphine
ection
solution
10 mg/ml,
20 mg/ml
aranelle
(28)inoral
tablet
0.5/1/0.5-35
mg-mcg
22
22
PA; QL (240 EA per 30 days)
oxycodone
oral solution
5 mg/5 ml
aubra
oral tablet
0.1-20 mg-mcg
oxycodone
10 mg-mcg
mg, 15 mg, 20 mg, 30
aviane
oral oral
tablettablet
0.1-20
mg, 5 mg
balziva (28) oral tablet 0.4-35 mg-mcg
tramadol oral tablet 50 mg
bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg
xAnesthetics
5
22
22
QL (5400 ML per 30 days)
2
2
2
QL (240 EA per 30 days)
blisovi
1/20 (28) oral tablet 1 mg-20 mcg
LocalfeAnesthetics
(21)/75 mg (7)
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
briellyn oral tablet 0.4-35 mg-mcg
lidocaine hcl mucous membrane gel 2
CLIMARA PRO TRANSDERMAL PATCH
lidocaine hcl mucous membrane solution 4 (40
WEEKLY 0.045-0.015 MG/24 HR
mg/ml)
COMBIPATCH TRANSDERMAL PATCH
lidocaine hcl urethral gel 2
SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25
lidocaine
MG/24
HRtopical adhesi e patch,medicated 5
(700 mg/patch)
cryselle (28) oral tablet 0.3-30 mg-mcg
lidocaine topical ointment 5
cyclafem 1/35 (28) oral tablet 1-35 mg-mcg
lidocaine-prilocaine topical cream 2.5-2.5
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35
mcg
Anti-Addiction/ Substance Abuse Treatment Agents
2
deblitane
tablet 0.35Anti-Craving
mg
Alcoholoral
Deterrents/
2
delyla
(28) oral
tablet
0.1-20 mg-mcg
acamprosate
oral
tablet,delayed
release (dr/ec)
333
mg
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02
mgx21
/0.01oral
mg tablet
x 5 250 mg, 500 mg
disulfiram
22
2
2
22
drospirenone-ethinyl
naltrexone oral tabletestradiol
50 mg oral tablet 3-0.03
mg
B/D
QL (180 EA per 30 days)
2
2
2
3
2
3
2
2
2
2
2
2
2
PA; QL (90 EA per 30 days)
B/D
PA
69
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69 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
emoquette
oral
tablet 0.15-0.03 mg
Phosphate
Binders
2
enpresse
oral tablet
(6)/75-40
calcium acetate
oral50-30
capsule
667 mg(5)/12530(10)
FOSRENOL ORAL POWDER IN PACKET
estradiol
valerate
intramuscular oil 40 mg/ml
1,000 MG,
750 MG
22
estradiol-norethindrone
acet oral tablet 1-0.5 mg
FOSRENOL ORAL TABLET,CHEWABLE
1,000 MG,
7500.1-20
MG mg-mcg
falmina
(28)500
oralMG,
tablet
23
PHOSLYRA
ORAL0.4-35
SOLUTION
gildagia
oral tablet
mg-mcg667 MG (169
MG CALCIUM)/5 ML
gildess 1.5/30 (21) oral tablet 1.5-30 mg-mcg
RENAGEL ORAL TABLET 400 MG, 800 MG
introvale oral tablets,dose pack,3 month 0.15-30
RENVELA ORAL POWDER IN PACKET 0.8
mg-mcg
GRAM, 2.4 GRAM
jinteli oral tablet 1-5 mg-mcg
RENVELA ORAL TABLET 800 MG
juleber oral tablet 0.15-0.03 mg
3
2
2
23
2
4
2
4
2
4
2
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg
2
junel 1/20 (21) oral tablet 1-20 mg-mcg
a-hydrocort in ection recon soln 100 mg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
ala-cortmg
topical
(21)/75
(7) cream 1
2
2
2
1
alclometasone
topical
cream10.05
junel
fe 1/20 (28)
oral tablet
mg-20 mcg (21)/75
mg
(7)
alclometasone
topical ointment 0.05
22
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
kariva
(28) oral
tablet
0.15-0.02
amcinonide
topical
cream
0.1 mgx21 /0.01 mg x
5
amcinonide topical lotion 0.1
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
amcinonide topical ointment 0.1
kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01
betamethasone
dipropionate topical cream 0.05
mg
x5
2
22
2
2
2
2
2
betamethasone
topicalmg-mcg
ointment 0.05
larin
1.5/30 (21)dipropionate
oral tablet 1.5-30
22
larin 1/20 (21) oral tablet 1-20 mg-mcg
betamethasone alerate topical cream 0.1
larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
betamethasone
(21)/75
mg (7) alerate topical lotion 0.1
betamethasone
topical
ointment
larin
fe 1/20 (28)alerate
oral tablet
1 mg-20
mcg0.1
(21)/75
mg
(7)
betamethasone, augmented topical cream 0.05
2
2
2
2
leena
28 oral tablet
0.5/1/0.5-35
mg-mcg
betamethasone,
augmented
topical
gel 0.05
lessina
oral tablet
0.1-20 mg-mcg
betamethasone,
augmented
topical lotion 0.05
levonest
(28) oralaugmented
tablet 50-30
(6)/75-40
(5)/125betamethasone,
topical
ointment
0.05
30(10)
levonorgestrel-ethinyl
estrad oral tablet 0.1-20
clobetasol topical gel 0.05
mg-mcg
clobetasol topical ointment 0.05
levonorgestrel-ethinyl estrad oral tablets,dose
clobetasol
topical
solution
0.05
pack,3
month
0.15-30
mg-mcg
22
2
22
22
22
12
2
2
2
70
7070
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lasabreviaturas
abreviaturasas
asen
enesta
estatabla,
tabla,vaya
vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72oral
hour
100 50-30
mcg/hr,
levonorg-eth
estrad triphasic
tablet
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
(6)/75-40 (5)/125-30(10)
22
hydrocodone-acetaminophen
levora-28
oral tablet 0.15-0.03oral
mg tablet 2.5-325
mg
lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg
hydromorphone (pf) in ection solution 10 mg/ml
lutera (28) oral tablet 0.1-20 mg-mcg
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg
LAZANDA NASAL SPRAY,NON-AEROSOL
microgestin
1/20 (21) oral tablet 1-20 mg-mcg
100 MCG/SPRAY
microgestin
1.5/30 (28)
oral tablet 1.5 mg-30
LAZANDAfeNASAL
SPRAY,NON-AEROSOL
mcg
(21)/75
mg
(7)
400 MCG/SPRAY
22
QL (10 EA per 30 days)
2
2
2
2
2
3
2
QL (180 EA per 30 days)
23
PA; QL (150 EA per 30 days)
microgestin
fe 1/20
(28) oral
tabletml1 mg-20 mcg
meperidine oral
solution
50 mg/5
(21)/75 mg (7)
meperidine oral tablet 50 mg
mimvey lo oral tablet 0.5-0.1 mg
meperitab oral tablet 100 mg
mononessa (28) oral tablet 0.25-35 mg-mcg
nalbuphine in ection solution 10 mg/ml, 20 mg/ml
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg
oxycodone oral solution 5 mg/5 ml
necon 1/35 (28) oral tablet 1-35 mg-mcg
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
necon
mg, 5 10/11
mg (28) oral tablet 0.5-35/1-35 mgmcg/mg-mcg
tramadol oral tablet 50 mg
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
22
PA; QL (3600 ML per 30 days)
2
2
2
2
2
2
2
2
2
2
PA; QL (240 EA per 30 days)
2
2
QL (240 EA per 30 days)
nora-be oral tablet 0.35 mg
2
Anesthetics
Local Anesthetics
norethindrone
ac-eth estradiol oral tablet 1-5 mgmcg
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
22
nortrel
0.5/35
(28) oralmembrane
tablet 0.5-35
mg-mcg
lidocaine
hcl mucous
solution
4 (40
mg/ml)1/35 (21) oral tablet 1-35 mg-mcg
nortrel
22
lidocaine topical
ointmentRING
5
NUVARING
VAGINAL
0.12-0.015
MG/24
HR
lidocaine-prilocaine
topical cream 2.5-2.5
PA; QL (240 EA per 30 days)
B/D
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
2
2
norlyroc
0.35
mg
lidocaineoral
hcl tablet
mucous
membrane
gel 2
lidocaine
hcl(28)
urethral
gel 2 1-35 mg-mcg
nortrel
1/35
oral tablet
lidocaine
topical
e patch,medicated
nortrel
7/7/7
(28) adhesi
oral tablet
0.5/0.75/1 mg- 535
(700
mg/patch)
mcg
PA; QL (600 EA per 30 days)
2
22
22
PA; QL (90 EA per 30 days)
32
2
B/D
ocella
oral tablet 3-0.03
mg
Anti-Addiction/
Substance
Abuse Treatment Agents 2
orsythia
tablet 0.1-20
mg-mcg
Alcoholoral
Deterrents/
Anti-Craving
2
pimtrea
(28) oral
0.15-0.02release
mgx21 (dr/ec)
/0.01 mg
acamprosate
oraltablet
tablet,delayed
x333
5 mg
22
pirmella
oral
tablet
1-35
disulfiram
oral
tablet
250mg-mcg
mg, 500 mg
portia
oral tablet
0.15-0.03
naltrexone
oral tablet
50 mgmg
22
22
PA
71
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71 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
PREFEST
ORAL
TABLET
1 MG
(15)/1
hydrocortisone
oral
tablet 10
mg, 20
mg, MG5 mg
0.09 MG (15)
hydrocortisone topical cream 1 , 2.5
PREMPHASE ORAL TABLET 0.625 MG (14)/
hydrocortisone topical lotion 2.5
0.625MG-5MG(14)
hydrocortisone topical ointment 1 , 2.5
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45hydrocortisone
topical cream
1.5
MG, 0.625-2.5alerate
MG, 0.625-5
MG 0.2
42
hydrocortisone
alerate
topical
ointment 0.2
previfem
oral tablet
0.25-35
mg-mcg
22
lo ara topical
lotion 0.05 pack,3 month 0.15-30
quasense
oral tablets,dose
mg-mcg
methylprednisolone acetate in ection suspension
22
methylprednisolone
oral pack,3
tablet 16
mg, 32
mg, 4
setlakin
oral tablets,dose
month
0.15-30
mg,
8
mg
mg-mcg
22
methylprednisolone
oral mg
tablets,dose pac 4 mg
sharobel
oral tablet 0.35
22
methylprednisolone
sodium
succmg-mcg
in ection recon
sprintec
(28) oral tablet
0.25-35
soln 125 mg, 40 mg
sronyx oral tablet 0.1-20 mg-mcg
mometasone topical cream 0.1
tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mometasone
topical ointment 0.1
mg
(7)
22
mometasone
topical
0.1
tri-legest
fe oral
tabletsolution
1-20(5)/1-30(7)
/1mg35mcg
(9)
prednicarbate topical ointment 0.1
22
40 mg/ml,(28)
80 mg/ml
reclipsen
oral tablet 0.15-0.03 mg
trinessa
(28) oral
tablet
0.18/0.215/0.25
mg-3515
prednisolone
sodium
phosphate
oral solution
mcg
mg/5(28)
ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml
(6.7 mg/5 ml)
tri-previfem
(28) oral tablet 0.18/0.215/0.25 mg-35
mcg
(28)
prednisone intensol oral concentrate 5 mg/ml
tri-sprintec
tablet
0.18/0.215/0.25
mg-35
prednisone(28)
oraloral
solution
5 mg/5
ml
mcg (28)
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20
trivora
(28)50
oral
mg, 5 mg,
mgtablet 50-30 (6)/75-40 (5)/12530(10)
procto-pa rectal cream 1
velivet triphasic regimen (28) oral tablet
proctozone-hc rectal
cream 2.5
0.1/.125/.15-25
mg-mcg
RAYOS(28)
ORAL
vyfemla
oralTABLET,DELAYED
tablet 0.4-35 mg-mcg RELEASE
(DR/EC) 1 MG, 2 MG, 5 MG
xulane transdermal patch weekly 150-35 mcg/24
TEMOVATE TOPICAL CREAM 0.05 %
hr
triamcinolone
acetonide
topicalmg-mcg
cream 0.025 ,
zenchent
(28) oral
tablet 0.4-35
0.1 , 0.5
zovia 1/35e (28) oral tablet 1-35 mg-mcg
triamcinolone acetonide topical lotion 0.025 ,
zovia
0.1 1/50e (28) oral tablet 1-50 mg-mcg
Progestins
triamcinolone acetonide topical ointment 0.025 ,
0.1 , oral
0.5 tablet 0.35 mg
camila
1
3
1
1
3
2
2
2
2
2
2
2
2
22
2
2
22
1
2
2
2
1
24
2
4
PA
22
2
2
2
2
2
72
7272
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quesignifican
significanlas
lasabreviaturas
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour 100 mcg/hr,
DEPO-PROVERA
INTRAMUSCULAR
12
mcg/hr,
25
mcg/hr,
50 mcg/hr, 75 mcg/hr
SOLUTION 400 MG/ML
42
QL (10 EA per 30 days)
PA
hydrocodone-acetaminophen
DEPO-SUBQ
PROVERA 104oral tablet 2.5-325
mg
SUBCUTANEOUS
SYRINGE 104 MG/0.65 ML
42
PA
hydromorphone
(pf) in
errin
oral tablet 0.35
mgection solution 10 mg/ml
22
hydromorphone
oral
tablet
jolivette
oral tablet
0.35
mg 2 mg, 4 mg, 8 mg
22
QL (180 EA per 30 days)
LAZANDA
NASAL
SPRAY,NON-AEROSOL
lyza
oral tablet
0.35 mg
100 MCG/SPRAY
medroxyprogesterone intramuscular suspension
LAZANDA
150
mg/ml NASAL SPRAY,NON-AEROSOL
400 MCG/SPRAY
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5
meperidine oral solution 50 mg/5 ml
mg
23
PA; QL (600 EA per 30 days)
2
3
PA; QL (150 EA per 30 days)
1
2
PA; QL (3600 ML per 30 days)
meperidineES
oral
tabletSUSPENSION
50 mg
MEGACE
ORAL
625 MG/5
ML
meperitab oral tablet 100 mg
52
PA; QL (240 EA per 30 days)
PA
2
22
PA; QL (240 EA per 30 days)
PA
B/D
2
2
2
2
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
22
2
QL (240 EA per 30 days)
megestrol
oral
suspension
40010
mg/10
ml 20
(40mg/ml
nalbuphine
in ection
solution
mg/ml,
mg/ml), 625 mg/5 ml
oxycodone oral solution 5 mg/5 ml
megestrol oral tablet 20 mg, 40 mg
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
norethindrone
(contraceptive) oral tablet 0.35 mg
mg, 5 mg
norethindrone
tramadol oral acetate
tablet 50oral
mgtablet 5 mg
progesterone
Anestheticsmicronized oral capsule 100 mg, 200
mg
Local Anesthetics
Selective Estrogen Receptor Modifying Agents
lidocaine (pf) in ection solution 5 mg/ml (0.5
raloxifene oral tablet 60 mg
lidocaine hcl mucous membrane gel 2
)
lidocaine hcl mucous membrane solution 4
(40
2
2
2
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
2
Hormonal
Agents, Stimulant/ Replacement/ Modifying (Thyroid)
mg/ml)
levothyroxine
intravenous
lidocaine hcl urethral
gel 2recon soln 100 mcg
22
levothyroxine
oraladhesi
tablet 100
mcg, 112 mcg,5125
lidocaine topical
e patch,medicated
mcg,
137
mcg, 150 mcg, 175 mcg, 200 mcg, 25
(700
mg/patch)
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
lidocaine topical ointment 5
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
lidocaine-prilocaine topical cream 2.5-2.5
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg,
75 mcg, 88 mcg
Anti-Addiction/
Substance Abuse Treatment Agents
12
PA; QL (90 EA per 30 days)
2
1
2
B/D
liothyronine
intravenousAnti-Craving
solution 10 mcg/ml
Alcohol Deterrents/
2
liothyronine
25 mcg, 5release
mcg, 50(dr/ec)
mcg
acamprosateoral
oraltablet
tablet,delayed
333 mg
SYNTHROID
ORAL TABLET 100 MCG, 112
MCG,
125 MCG,
137 250
MCG,
disulfiram
oral tablet
mg,150
500MCG,
mg 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
naltrexone
tablet 50 mg
75
MCG, 88oral
MCG
22
4
PA
2
2
73
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
unithroid
oralAQ
tablet
100 mcg, 112 mcg, 125 mcg,
NUTROPIN
SUBCUTANEOUS
CARTRIDGE
20 MG/2
ML 25
(10mcg,
MG/ML)
150
mcg, 175 mcg,
200 mcg,
300 mcg, 50
mcg, 75 mcg, 88 mcg
OMNITROPE SUBCUTANEOUS CARTRIDGE
10 MG/1.5 ML
(6.7 MG/ML),
5 MG/1.5
ML (3.3
Hormonal
Agents,
Suppressant
(Adrenal)
MG/ML)
15
PA
4
PA
OMNITROPE SUBCUTANEOUS RECON
LYSODREN
ORAL TABLET 500 MG
SOLN 5.8 MG
5
3
PA
Hormonal
Suppressant
(Parathyroid)
SEROSTIMAgents,
SUBCUTANEOUS
RECON
SOLN 4
5
PA
Hormonal Agents, Suppressant (Adrenal)
MG, 5 MG, 6 MG
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)
SENSIPAR ORAL TABLET 30 MG
3
HormonalORAL
Agents,
Stimulant/
Replacement/
Modifying
SENSIPAR
TABLET
60 MG,
90 MG
5 (Prostaglandins)
misoprostol oral tablet 200 mcg
2
Hormonal Agents, Suppressant (Pituitary)
HormonalAgents,
Agents,Suppressant
Stimulant/ Replacement/
Hormonal
(Pituitary) Modifying (Sex Hormones/ Modifiers)
Anabolic Steroids
cabergoline
oral tablet 0.5 mg
ANADROL-50
ORAL TABLET
50 MG 22.5
ELIGARD
SUBCUTANEOUS
SYRINGE
2
45
MG
(3 MONTH),
MG10(4mg,
MONTH),
oxandrolone
oral 30
tablet
2.5 mg 45 MG (6
MONTH), 7.5 MG (1 MONTH)
2
FIRMAGON KIT W DILUENT SYRINGE
ANDROGEL TRANSDERMAL
GEL
SUBCUTANEOUS
RECON SOLN
120IN
MG
METERED-DOSE PUMP 1.25 GRAM/
FIRMAGON
KIT
W DILUENT
SYRINGE
ACTUATION
(1 %),
20.25 MG/1.25
GRAM
SUBCUTANEOUS
RECON
SOLN
80 MG
(1.62 %)
leuprolide
subcutaneous
kit 1 mg/0.2
mlIN
ANDROGEL
TRANSDERMAL
GEL
PACKET DEPOT
1 % (25 (3
MG/2.5GRAM),
1 % (50 MG/5
LUPRON
MONTH)
GRAM),
1.62
%
(20.25
MG/1.25
GRAM),
INTRAMUSCULAR SYRINGE KIT 11.25 1.62
MG %
(40.5 MG/2.5 GRAM)
LUPRON DEPOT (3 MONTH)
danazol oral capsule SYRINGE
100 mg, 200KIT
mg,22.5
50 mg
INTRAMUSCULAR
MG
TESTIM TRANSDERMAL
GEL 50 MG/5
LUPRON
DEPOT (4 MONTH)
GRAM
(1
%)
INTRAMUSCULAR SYRINGE KIT 30 MG
testosterone
cypionate
intramuscular oil 100
LUPRON
DEPOT
(6 MONTH)
mg/ml, 200 mg/ml SYRINGE KIT 45 MG
INTRAMUSCULAR
testosterone
transdermal
gel in metered-dose
LUPRON
DEPOT
INTRAMUSCULAR
pump
1.25
gram/
actuation
SYRINGE KIT 3.75 MG, 7.5(1MG)
testosterone
transdermalINTRAMUSCULAR
gel in pac et 1 (25KIT
LUPRON
DEPOT-PED
mg/2.5gram),
1 (50 mg/5 gram)
11.25
MG, 15 MG
5
4
PA
ST
4
PA
24
4
ST
PA
5
4
PA
54
ST
PA
52
PA
42
PA
52
PA
5
PA
4
4
PA
Androgens
Estrogens
octreotide
acetate injection solution 1,000 mcg/ml,
500
mcg/ml
DIVIGEL TRANSDERMAL GEL IN PACKET
0.5 MG (0.1
%) injection solution 100 mcg/ml,
octreotide
acetate
200 mcg/ml, 50 mcg/ml
PA
PA
74
7474
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lasabreviaturas
abreviaturasasasenenesta
estatabla,
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hour 100 mcg/hr,
SANDOSTATIN
LARpatch
DEPOT
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75 mcg/hr
INTRAMUSCULAR
SUSPENSION,EXTENDED
RECON
10
hydrocodone-acetaminophen REL
oral tablet
2.5-325
MG,
20
MG,
30
MG
mg
52
SIGNIFOR
SUBCUTANEOUS
SOLUTION
0.3
hydromorphone
(pf) in ection solution
10 mg/ml
MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML
hydromorphone
oral tablet 2 mg, 4 mg, 8 mg
(1
ML)
52
PA
2
QL (180 EA per 30 days)
LAZANDA NASAL
SPRAY,NON-AEROSOL
SOMATULINE
DEPOT
SUBCUTANEOUS
100
MCG/SPRAY
SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3
ML NASAL SPRAY,NON-AEROSOL
LAZANDA
400 MCG/SPRAY
SOMAVERT
SUBCUTANEOUS RECON SOLN
10
MG,
15
MG,
MG, 25
meperidine oral 20
solution
50MG,
mg/530
mlMG
SYNAREL
SPRAY,NON-AEROSOL
2
meperidine NASAL
oral tablet
50 mg
MG/ML
meperitab oral tablet 100 mg
TRELSTAR INTRAMUSCULAR SUSPENSION
nalbuphine
in ection solution
10MG
mg/ml, 20 mg/ml
FOR
RECONSTITUTION
22.5
oxycodone oral
solution 5 mg/5 ml SYRINGE
TRELSTAR
INTRAMUSCULAR
11.25
MG/2oral
ML,tablet
3.75 MG/2
oxycodone
10 mg,ML
15 mg, 20 mg, 30
mg, 5 mg Agents, Suppressant (Thyroid)
Hormonal
53
PA; QL (600 EA per 30 days)
PA
3
5
2
52
PA; QL (150 EA per 30 days)
PA
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
2
5
2
PA; QL (240 EA per 30 days)
PA
B/D
42
2
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
2
QL (240 EA per 30 days)
tramadol oral tablet 50 mg
2
Antithyroid Agents
Anesthetics
methimazole oral tablet 10 mg, 5 mg
2
Immunological Agents
2
2
Local Anesthetics
propylthiouracil
oral tablet 50 mg
lidocaine (pf) in ection solution 5 mg/ml (0.5
)
QL (10 EA per 30 days)
PA
lidocaine hcl mucous membrane gel 2
2
lidocaine hcl mucous membrane solution 4 (40
CINRYZE
INTRAVENOUS RECON SOLN 500
mg/ml)
UNIT (5 ML)
lidocaine hcl urethral gel 2
FIRAZYR SUBCUTANEOUS SYRINGE 30
lidocaine
MG/3
ML topical adhesi e patch,medicated 5
(700 mg/patch)
2
5
PA
2
5
2
PA
PA; QL (90 EA per 30 days)
lidocaine topical ointment 5
ACTEMRA SUBCUTANEOUS SYRINGE 162
lidocaine-prilocaine
topical cream 2.5-2.5
MG/0.9
ML
2
5
2
PA
B/D
Angioedema (Hae) Agents
Immune Suppressants
Anti-Addiction/
Substance
Abuse Treatment
Agents 5
AFINITOR
DISPERZ
ORAL TABLET
FOR
SUSPENSION
2 MG, 3 Anti-Craving
MG, 5 MG
Alcohol Deterrents/
PA
ASTAGRAF
CAPSULE,EXTENDED
acamprosate XL
oralORAL
tablet,delayed
release (dr/ec)
RELEASE
333 mg 24HR 0.5 MG, 1 MG, 5 MG
42
B/D
PA
ATGAM
SOLUTION
disulfiramINTRAVENOUS
oral tablet 250 mg,
500 mg 50
MG/ML
naltrexone oral tablet 50 mg
AZASAN ORAL TABLET 100 MG, 75 MG
52
B/D
2
4
PA
75
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
azathioprine
oral
tablet
mg 0.5/0.75/1 mg- 35
cyclafem 7/7/7
(28)
oral50
tablet
mcg
BENLYSTA INTRAVENOUS RECON SOLN
deblitane
120
MG oral tablet 0.35 mg
22
B/D
5
2
PA
delyla (28) oral
tablet 0.1-20 mg-mcg
CELLCEPT
INTRAVENOUS
INTRAVENOUS
RECON SOLN 500 MG
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02
mgx21 /0.01
mg x 5 FOR RECONST
CIMZIA
POWDER
SUBCUTANEOUS KIT 400 MG (200 MG X 2
drospirenone-ethinyl estradiol oral tablet 3-0.03
VIALS)
mg
CIMZIA
SUBCUTANEOUS
SYRINGE
KIT 400
emo uette
oral tablet 0.15-0.03
mg
MG/2 ML (200 MG/ML X 2)
enpresse oral tablet 50-30 (6)/75-40 (5)/125cyclosporine
intravenous solution 250 mg/5 ml
30(10)
cyclosporine
modified
oral capsule
mg, 25
estradiol alerate
intramuscular
oil100
40 mg/ml
mg, 50 mg
estradiol-norethindrone acet oral tablet 1-0.5 mg
cyclosporine modified oral solution 100 mg/ml
falmina (28) oral tablet 0.1-20 mg-mcg
cyclosporine oral capsule 100 mg, 25 mg
gildagia oral tablet 0.4-35 mg-mcg
ENBREL SUBCUTANEOUS RECON SOLN 25
gildess
oral tablet 1.5-30 mg-mcg
MG
(1 ML)
42
PA
2
5
PA
intro ale oral
tablets,dose pacSYRINGE
,3 month 0.15-30
ENBREL
SUBCUTANEOUS
25
mg-mcg
MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
52
PA
inteli oralSURECLICK
tablet 1-5 mg-mcg
ENBREL
SUBCUTANEOUS PEN
INJECTOR
50
MG/ML
(0.98
ML) mg-mcg
unel 1.5/30 (21) oral tablet 1.5-30
52
PA
2
32
B/D
2
2
B/D
ENVARSUS
XR
ORAL
EXTENDED
unel 1/20 (21)
oral
tabletTABLET
1-20 mg-mcg
RELEASE 24 HR 0.75 MG, 1 MG, 4 MG
unel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
gengraf
capsule 100 mg, 25 mg
(21)/75 oral
mg (7)
gengraf
mg/ml
unel fe oral
1/20 solution
(28) oral100
tablet
1 mg-20 mcg (21)/75
mg
(7)
HUMIRA PEN CROHN'S-UC-HS START
SUBCUTANEOUS
PEN
INJECTOR
KIT
40 mg x
ari a (28) oral tablet
0.15-0.02
mgx21
/0.01
MG/0.8
ML
5
HUMIRA
SYRINGE
elnor 1/35SUBCUTANEOUS
(28) oral tablet 1-35
mg-mcg KIT 10
MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML
larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg
KINERET SUBCUTANEOUS SYRINGE 100
larin 1/20ML
(21) oral tablet 1-20 mg-mcg
MG/0.67
larin fe oral tablet
mg-2050
mcg
mercaptopurine
oral1 tablet
mg(21)/75 mg (7),
1.5 mg-30 mcg (21)/75 mg (7)
methotrexate sodium (pf) injection recon soln 1
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
gram
lessina oral tablet
0.1-20
mg-mcg solution 25
methotrexate
sodium
(pf) injection
mg/ml
le onest (28) oral tablet 50-30 (6)/75-40 (5)/12530(10)
methotrexate
sodium oral tablet 2.5 mg
2
52
2
2
22
2
2
2
2
2
5
2
PA
B/D
B/D
B/D
B/D
PA
22
5
2
B/D
52
PA
2
5
2
PA
PA
22
2
2
22
2
1
76
7676
Puedeencontrar
encontrarinformación
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enesta
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vayaaalalapágina
páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hour 250
100 mg
mcg/hr,
mycophenolate
mofetilpatch
oral capsule
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
mycophenolate mofetil oral suspension for
hydrocodone-acetaminophen
oral tablet 2.5-325
reconstitution
200 mg/ml
mg
mycophenolate mofetil oral tablet 500 mg
hydromorphone (pf) in ection solution 10 mg/ml
mycophenolate sodium oral tablet,delayed release
hydromorphone
oralmg
tablet 2 mg, 4 mg, 8 mg
(dr/ec)
180 mg, 360
22
QL (10 EA per 30 days)
B/D
2
2
B/D
2
2
2
2
B/D
LAZANDA
NASAL SPRAY,NON-AEROSOL
NULOJIX
INTRAVENOUS
RECON SOLN 250
100
MCG/SPRAY
MG
53
PA; QL (600 EA per 30 days)
B/D
LAZANDA(WITH
NASAL
SPRAY,NON-AEROSOL
ORENCIA
MALTOSE)
INTRAVENOUS
400 MCG/SPRAY
RECON
SOLN 250 MG
53
PA; QL (150 EA per 30 days)
PA
meperidineSUBCUTANEOUS
oral solution 50 mg/5
ml
ORENCIA
SYRINGE
125
MG/ML
meperidine oral tablet 50 mg
52
PA; QL (3600 ML per 30 days)
PA
2
52
PA; QL (240 EA per 30 days)
PA
PA; QL (240 EA per 30 days)
52
PA
B/D
2
QL (5400 ML per 30 days)
42
QL (180 EA per 30 days)
PA
tramadol oral ORAL
tablet 50
mg
RAPAMUNE
SOLUTION
1 MG/ML
42
QL (240 EA per 30 days)
PA
AnestheticsINTRAVENOUS RECON SOLN
REMICADE
100 MG
5
PA
RHEUMATREX ORAL TABLETS,DOSE PACK
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
2.5 MG, 2.5 MG (DOSE PACK 12), 2.5 MG
(DOSE
PACK
16), 2.5membrane
MG (DOSE
20),
lidocaine
hcl mucous
gelPACK
2
2.5 MG (DOSE PACK 8)
lidocaine hcl mucous membrane solution 4 (40
SANDIMMUNE
ORAL SOLUTION 100 MG/ML
mg/ml)
4
2
PA
2
3
B/D
SIMPONI
ARIA
INTRAVENOUS
SOLUTION
lidocaine hcl
urethral
gel 2
12.5 MG/ML
lidocaine topical adhesi e patch,medicated 5
(700 mg/patch)
SIMPONI
SUBCUTANEOUS PEN INJECTOR
100 MG/ML, 50 MG/0.5 ML
lidocaine topical ointment 5
SIMPONI SUBCUTANEOUS SYRINGE 50
lidocaine-prilocaine topical cream 2.5-2.5
MG/0.5 ML
52
PA
2
5
PA; QL (90 EA per 30 days)
PA
2
5
2
PA
B/D
OTEZLA
TABLET
30 MG
meperitabORAL
oral tablet
100 mg
OTEZLA
STARTER
ORAL TABLETS,DOSE
nalbuphine
in ection solution
10 mg/ml, 20 mg/ml
PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG
oxycodone
oral solution
5 mg/5 ml
(4)-20
MG (4)-30
MG(19)
oxycodone oral
tablet 10 mg, 15
mg, 20 mg,5 30
PROGRAF
INTRAVENOUS
SOLUTION
mg, 5 mg
MG/ML
B/D
QL (180 EA per 30 days)
Local Anesthetics
2
Anti-Addiction/
SubstanceRECON
Abuse Treatment
SIMULECT
INTRAVENOUS
SOLN 20 Agents 5
MG
Alcohol Deterrents/ Anti-Craving
sirolimus
oraloral
tablet
0.5 mg, 1 mg,release
2 mg (dr/ec)
acamprosate
tablet,delayed
333 mg oral capsule 0.5 mg, 1 mg, 5 mg
tacrolimus
disulfiramINTRAVENOUS
oral tablet 250 mg,RECON
500 mgSOLN 30
TORISEL
MG/3
ML (10
naltrexone
oralMG/ML)
tablet 50(FIRST)
mg
22
2
52
PA
PA
PA
B/D
PA
2
77
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
pirmella oral
tabletTABLET
1-35 mg-mcg
TREXALL
ORAL
10 MG, 15 MG, 5
MG, 7.5 MG
portia oral tablet 0.15-0.03 mg
ZORTRESS ORAL TABLET 0.25 MG
PREFEST ORAL TABLET 1 MG (15)/1 MG0.09 MG (15)ORAL TABLET 0.5 MG, 0.75 MG
ZORTRESS
42
PA
2
4
4
5
B/D
PREMPHASEAgents,
ORAL TABLET
Immunizing
Passive0.625 MG (14)/
3
0.625MG-5MG(14)
BIVIGAM INTRAVENOUS SOLUTION 10 %
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45CARIMUNE
NF NANOFILTERED
1.5 MG, 0.625-2.5
MG, 0.625-5 MG
INTRAVENOUS RECON SOLN 6 GRAM
pre ifem oral tablet 0.25-35 mg-mcg
FLEBOGAMMA DIF INTRAVENOUS
uasense oral
pac ,3 month 0.15-30
SOLUTION
10tablets,dose
%
mg-mcg
GAMASTAN S/D INTRAMUSCULAR
reclipsen (28)
oral %
tablet
0.15-0.03 mg
SOLUTION
15-18
RANGE
sharobel oral tablet
0.35 mg
GAMMAGARD
LIQUID
INJECTION
SOLUTION
10
%
sprintec (28) oral tablet 0.25-35 mg-mcg
GAMMAKED
INJECTION
SOLUTION 1
sronyx oral tablet
0.1-20 mg-mcg
GRAM/10 ML (10 %)
tarina fe oral tablet 1 mg-20 mcg (21)/75 mg (7)
GAMMAPLEX INTRAVENOUS SOLUTION 5
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg%
35mcg ( )
GAMUNEX-C INJECTION SOLUTION 1
trinessa (28)
oral
GRAM/10
ML
(10tablet
%) 0.18/0.215/0.25 mg-35
mcg (28)
HYPERRAB S/D (PF) INTRAMUSCULAR
tri-pre ifem 150
(28) UNIT/ML,
oral tablet 0.18/0.215/0.25
mg-35
SOLUTION
150 UNIT/ML (10
mcg (28)
ML)
tri-sprintec INTRAVENOUS
(28) oral tablet 0.18/0.215/0.25
mg-35
PRIVIGEN
SOLUTION 10
%
mcg (28)
SYNAGIS INTRAMUSCULAR SOLUTION 50
tri ora (28)
MG/0.5
ML oral tablet 50-30 (6)/75-40 (5)/12530(10)
THYMOGLOBULIN INTRAVENOUS RECON
eli et 25
triphasic
SOLN
MG regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
5
3
5
B/D
B/D
B/D
2
5
2
B/D
3
2
B/D
52
2
42
B/D
B/D
2
5
2
B/D
4
2
B/D
3
2
52
B/D
4
2
PA
5
2
B/D
2
5
2
PA
2
5
2
PA
zo ia 1/50e (28)
oral tablet 1-50 mg-mcg
ARCALYST
SUBCUTANEOUS
RECON SOLN
220 MG
52
PA
ILARIS (PF) SUBCUTANEOUS RECON SOLN
camila oral tablet 0.35 mg
180 MG/1.2 ML (150 MG/ML)
5
2
PA
Immunomodulators
yfemla (28) oral tablet 0.4-35 mg-mcg
ACTEMRA INTRAVENOUS SOLUTION 200
xulane transdermal patch wee ly 150-35 mcg/24
MG/10 ML (20 MG/ML), 400 MG/20 ML (20
hr
MG/ML), 80 MG/4 ML (20 MG/ML)
zenchent (28) oral tablet 0.4-35 mg-mcg
ACTIMMUNE SUBCUTANEOUS SOLUTION
zo ia
1/35e (28)
100
MCG/0.5
MLoral tablet 1-35 mg-mcg
Progestins
78
78
78
Puede encontrar información sobre lo que significan las abreviaturas as en esta tabla, vaya a la página vi Puede encontrar información sobre lo que significan las abreviaturas as en esta tabla, vaya a la página vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 20
hour
leflunomide
oral tabletpatch
10 mg,
mg100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
SIMPONI SUBCUTANEOUS SYRINGE 100
hydrocodone-acetaminophen oral tablet 2.5-325
MG/ML
mg
22
QL (10 EA per 30 days)
5
2
PA
hydromorphone (pf) in ection solution 10 mg/ml
ACTHIB (PF) INTRAMUSCULAR RECON
hydromorphone
oralML
tablet 2 mg, 4 mg, 8 mg
SOLN
10 MCG/0.5
LAZANDA NASAL
SPRAY,NON-AEROSOL
ADACEL(TDAP
ADOLESN/ADULT)(PF)
100
MCG/SPRAY
INTRAMUSCULAR SUSPENSION 2 LF-(2.5-53-5
MCG)-5LF/0.5
ML
LAZANDA
NASAL
SPRAY,NON-AEROSOL
400 MCG/SPRAY
BCG
VACCINE, LIVE (PF) PERCUTANEOUS
SUSPENSION
RECONSTITUTION
50 MG
meperidine oralFOR
solution
50 mg/5 ml
BEXSERO
SYRINGE
meperidine (PF)
oral INTRAMUSCULAR
tablet 50 mg
50-50-50-25 MCG/0.5 ML
meperitab oral tablet 100 mg
BOOSTRIX TDAP INTRAMUSCULAR
nalbuphine in ection
solution
10 mg/ml, 20 mg/ml
SUSPENSION
2.5-8-5
LF-MCG-LF/0.5ML
oxycodone oral
solution
5 mg/5 ml
BOOSTRIX
TDAP
INTRAMUSCULAR
2
3
2
QL (180 EA per 30 days)
33
PA; QL (600 EA per 30 days)
3
3
2
32
PA; QL (150 EA per 30 days)
2
3
2
PA; QL (240 EA per 30 days)
32
2
QL (5400 ML per 30 days)
Vaccines
SYRINGE
LF-MCG-LF/0.5ML
oxycodone 2.5-8-5
oral tablet
10 mg, 15 mg, 20 mg, 30
mg, 5 mg VACCINE (PF)
CERVARIX
INTRAMUSCULAR
SYRINGE
20-20 MCG/0.5
tramadol oral tablet 50
mg
ML
Anesthetics
3
2
COMVAX (PF) INTRAMUSCULAR
Local Anesthetics
SUSPENSION
5-7.5-125 MCG/0.5 ML
3
lidocaine (pf)(DTAP
in ection
solution 5 mg/ml
DAPTACEL
PEDIATRIC)
(PF) (0.5 )
INTRAMUSCULAR
lidocaine hcl mucous SUSPENSION
membrane gel 215-10-5 LFMCG-LF/0.5ML
lidocaine hcl mucous membrane solution 4 (40
ENGERIX-B
(PF) INTRAMUSCULAR
mg/ml)
SYRINGE 20 MCG/ML
lidocaine hcl urethral gel 2
ENGERIX-B PEDIATRIC (PF)
lidocaine topical adhesi
e patch,medicated
5
INTRAMUSCULAR
SUSPENSION
10 MCG/0.5
(700
mg/patch)
ML
lidocaine topical
ointment 5(PF)
ENGERIX-B
PEDIATRIC
INTRAMUSCULAR
SYRINGE
102.5-2.5
MCG/0.5 ML
lidocaine-prilocaine topical
cream
32
PA; QL (240 EA per 30 days)
B/D
QL (180 EA per 30 days)
QL (240 EA per 30 days)
2
2
3
B/D
2
3
2
B/D
PA; QL (90 EA per 30 days)
32
2
GARDASIL
(PF) INTRAMUSCULAR
Anti-Addiction/
Substance Abuse Treatment Agents 3
SUSPENSION 20-40-40-20 MCG/0.5 ML
Alcohol Deterrents/ Anti-Craving
PA; QL (3600 ML per 30 days)
GARDASIL (PF) INTRAMUSCULAR
SYRINGE
20-40-40-20
MCG/0.5release
ML (dr/ec)
acamprosate
oral tablet,delayed
333 mg
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION
ML250 mg, 500 mg
disulfiram oral 0.5
tablet
3
2
naltrexone oral
tablet
50 mg
GARDASIL
9 (PF)
INTRAMUSCULAR
SYRINGE 0.5 ML
32
B/D
B/D
PA
3
2
79
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las abreviaturas
as enlas
esta
tabla, vayaasa en
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vi vaya a la página
79 vi
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
SYNTHROID
ORAL TABLET 100 MCG, 112
HAVRIX
(PF) INTRAMUSCULAR
MCG, 125 MCG,
137ELISA
MCG, UNIT/ML
150 MCG, 175
SUSPENSION
1,440
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
HAVRIX (PF) INTRAMUSCULAR SYRINGE
75 MCG, 88 MCG
720 ELISA UNIT/0.5 ML
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,
IMOVAX RABIES VACCINE (PF)
150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50
INTRAMUSCULAR RECON SOLN 2.5 UNIT
mcg, 75 mcg, 88 mcg
INFANRIX (DTAP) (PF) INTRAMUSCULAR
Hormonal Agents,
Suppressant
(Adrenal)
SUSPENSION
25-58-10
LF-MCG-LF/0.5ML
Hormonal
Agents,
Suppressant
(Adrenal)
IPOL
INJECTION
SUSPENSION
40-8-32
UNIT/0.5
ML ORAL TABLET 500 MG
LYSODREN
IXIARO
(PF)Agents,
INTRAMUSCULAR
6
Hormonal
SuppressantSYRINGE
(Parathyroid)
MCG/0.5 ML
Hormonal Agents,
Suppressant (Parathyroid)
MENACTRA
(PF) INTRAMUSCULAR
SOLUTION
4 MCG/0.5
ML 30 MG
SENSIPAR ORAL
TABLET
34
3
1
3
3
3
3
3
3
3
MENOMUNE
- A/C/Y/W-135
(PF)
SENSIPAR ORAL
TABLET 60
MG, 90 MG
SUBCUTANEOUS RECON SOLN 50 MCG
35
MENVEO A-C-Y-W-135-DIP (PF)
Hormonal Agents,KIT
Suppressant
(Pituitary)
INTRAMUSCULAR
10-5 MCG/0.5
ML
3
bromocriptine
capsule 5 mg RECON
M-M-R
II (PF) oral
SUBCUTANEOUS
SOLN
1,000-12,500
TCID50/0.5
bromocriptine
oral tablet
2.5 mg ML
PEDVAX
HIB
(PF)
INTRAMUSCULAR
cabergoline
oral
tablet
0.5 mg
SOLUTION 7.5 MCG/0.5 ML
ELIGARD SUBCUTANEOUS SYRINGE 22.5
PROQUAD
(PF) SUBCUTANEOUS
MG (3 MONTH),
30 MG (4 MONTH), 45 MG (6
SUSPENSION
FOR(1RECONSTITUTION
MONTH), 7.5 MG
MONTH)
10EXP3-4.3-3- 3.99 TCID50/0.5
FIRMAGON KIT W DILUENT SYRINGE
QUADRACEL
(PF) INTRAMUSCULAR
SUBCUTANEOUS
RECON SOLN 120 MG
SUSPENSION 15 LF-48 MCG- 5 LF
FIRMAGON KIT W DILUENT SYRINGE
UNIT/0.5ML
SUBCUTANEOUS RECON SOLN 80 MG
RABAVERT (PF) INTRAMUSCULAR
leuprolide subcutaneous
it 1 mg/0.2 ml 2.5
SUSPENSION
FOR RECONSTITUTION
UNIT
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR
SYRINGE
KIT 11.25 MG
RECOMBIVAX
HB (PF)
INTRAMUSCULAR
SUSPENSION
10 MCG/ML,
40 MCG/ML
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULAR
SYRINGE
KIT 22.5 MG
RECOMBIVAX
HB (PF)
INTRAMUSCULAR
SYRINGE
10 MCG/ML,
5 MCG/0.5 ML
LUPRON DEPOT
(4 MONTH)
INTRAMUSCULAR
SYRINGE KIT
ROTARIX
ORAL SUSPENSION
FOR30 MG
32
2
32
Hormonal Agents, Suppressant (Pituitary)
RECONSTITUTION
CCID50/ML
LUPRON DEPOT (6 10EXP6
MONTH)
INTRAMUSCULAR
KIT 45 MG 2
ROTATEQ
VACCINESYRINGE
ORAL SUSPENSION
ML
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG, 7.5 MG
4
3
PA
5
3
PA
4
PA
3
2
4
3
5
3
5
3
5
3
4
PA
B/D
PA
B/D
PA
PA
PA
80
80
80
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch 72 hour 100
mcg/hr,
TENIVAC
(PF) INTRAMUSCULAR
SYRINGE
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
5-2 LF UNIT/0.5 ML
32
hydrocodone-acetaminophen
tablet 2.5-325
tetanus,diphtheria
tox ped(pf) oral
intramuscular
mg
suspension
5-25 lf unit/0.5 ml
22
hydromorphone (pf)
in ectionintramuscular
solution 10 mg/ml
tetanus-diphtheria
toxoids-td
suspension
2-2 lf oral
unit/0.5
ml2 mg, 4 mg, 8 mg
hydromorphone
tablet
22
QL (10 EA per 30 days)
2
33
QL (180 EA per 30 days)
TWINRIX
INTRAMUSCULAR
LAZANDA(PF)
NASAL
SPRAY,NON-AEROSOL
SUSPENSION
720
ELISA
UNIT -20 MCG/ML
400 MCG/SPRAY
33
B/D
PA; QL (150 EA per 30 days)
TYPHIM
VIoral
INTRAMUSCULAR
SOLUTION 25
meperidine
solution 50 mg/5 ml
MCG/0.5 ML
meperidine oral tablet 50 mg
TYPHIM VI INTRAMUSCULAR SYRINGE 25
meperitabML
oral tablet 100 mg
MCG/0.5
nalbuphine
in INTRAMUSCULAR
ection solution 10 mg/ml,
20 mg/ml
VAQTA
(PF)
SYRINGE
25
UNIT/0.5
ML,
50
UNIT/ML
oxycodone oral solution 5 mg/5 ml
32
PA; QL (3600 ML per 30 days)
2
3
2
PA; QL (240 EA per 30 days)
32
2
32
B/D
2
3
QL (240 EA per 30 days)
TRUMENBA
INTRAMUSCULAR
SYRINGE
LAZANDA NASAL
SPRAY,NON-AEROSOL
120
MCG/0.5
ML
100 MCG/SPRAY
VARIVAX
(PF)tablet
SUBCUTANEOUS
oxycodone oral
10 mg, 15 mg, 20 mg, 30
SUSPENSION
FOR
RECONSTITUTION
1,350
mg, 5 mg
UNIT/0.5 ML
tramadol oral tablet 50 mg
VARIZIG INTRAMUSCULAR SOLUTION 125
Anesthetics
UNIT/1.2
ML
YF-VAX
(PF) SUBCUTANEOUS SUSPENSION
Local Anesthetics
FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
ML
lidocaine hcl mucous membrane gel 2
ZOSTAVAX (PF) SUBCUTANEOUS
lidocaine hcl mucous
membrane solution 419,400
(40
SUSPENSION
FOR RECONSTITUTION
mg/ml)
UNIT/0.65
ML
PA; QL (600 EA per 30 days)
PA; QL (240 EA per 30 days)
QL (5400 ML per 30 days)
QL (180 EA per 30 days)
3
2
2
3
2
lidocaine hcl urethral
gelDisease
2
Inflammatory
Bowel
Agents
2
lidocaine topical adhesi e patch,medicated 5
Aminosalicylates
2
(700 mg/patch)
balsalazide oral capsule 750 mg
lidocaine topical ointment 5
CANASA RECTAL SUPPOSITORY 1,000 MG
lidocaine-prilocaine topical cream 2.5-2.5
DELZICOL ORAL CAPSULE,DELAYED
Anti-Addiction/ Substance
RELEASE(DR/EC)
400 MG Abuse Treatment Agents
2
2
3
2
3
Alcohol Deterrents/
Anti-Craving
DIPENTUM
ORAL CAPSULE
250 MG
4
acamprosate
oralTABLET,DELAYED
tablet,delayed releaseRELEASE
(dr/ec)
LIALDA
ORAL
333 mg 1.2 GRAM
(DR/EC)
32
disulfiram oral
250 mg,
500
mg enema kit 4
mesalamine
withtablet
cleansing
wipe
rectal
gram/60
ml oral tablet 50 mg
naltrexone
22
PA; QL (90 EA per 30 days)
B/D
PA
2
81
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
ASTAGRAF
XL ORAL
CAPSULE,EXTENDED
PENTASA
ORAL
CAPSULE,
EXTENDED
RELEASE
24HR
0.5
MG,
1
MG,
5 MG
RELEASE 250 MG, 500 MG
34
B/D
ATGAM INTRAVENOUS
INJECTABLE
50 ML
SFROWASA
RECTAL ENEMA
4 GRAM/60
MG/ML
45
B/D
PA
AZASAN ORAL TABLET 100 MG, 75 MG
colocort rectal enema 100 mg/60 ml
azathioprine oral tablet 50 mg
hydrocortisone rectal enema 100 mg/60 ml
BENLYSTA INTRAVENOUS RECON SOLN
prednisone
120 MG intensol oral concentrate 5 mg/ml
4
2
2
2
5
2
PA
proctosol
hc rectal
cream 2.5 %INTRAVENOUS
CELLCEPT
INTRAVENOUS
RECON SOLN 500 MG
Sulfonamides
14
PA
CIMZIA POWDER
FOR
RECONST
sulfasalazine
oral tablet
500
mg
SUBCUTANEOUS KIT 400 MG (200 MG X 2
sulfazine
VIALS) ec oral tablet,delayed release (dr/ec) 500
mg
CIMZIA SUBCUTANEOUS SYRINGE KIT 400
MG/2 ML (200
MG/ML
X 2)Agents
Metabolic
Bone
Disease
25
PA
5
PA
cyclosporineBone
intra Disease
enous solution
250 mg/5 ml
Metabolic
Agents
2
B/D
cyclosporineoral
modified
capsule
100
alendronate
tablet oral
10 mg,
35 mg,
40mg,
mg,25
5
mg,
50
mg
mg, 70 mg
cyclosporine
modified
oral
solution 100 mg/ml
calcitonin
(salmon)
nasal
spray,non-aerosol
200
unit/actuation
cyclosporine oral capsule 100 mg, 25 mg
12
B/D
22
2
24
B/D
24
25
ST
Glucocorticoids
calcitriol
oral capsule 0.25
mcg,
0.5 mcg 250 MG
DEPEN TITRATABS
ORAL
TABLET
calcitriol
solution
1 mcg/ml
ELIDEL oral
TOPICAL
CREAM
1%
doxercalciferol
intravenous solution
4 mcg/2
ml25
ENBREL SUBCUTANEOUS
RECON
SOLN
MG (1 ML) oral capsule 0.5 mcg, 1 mcg, 2.5
doxercalciferol
mcg
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML
(0.51), 50
MG/ML
(0.98
ML)
etidronate
disodium
oral
tablet 200
mg,
400 mg
ENBRELSUBCUTANEOUS
SURECLICK SUBCUTANEOUS
PEN
FORTEO
PEN INJECTOR
INJECTOR
50 MG/ML
(0.98 ML)
20
MCG/DOSE
- 600 MCG/2.4
ML
gengrafnasal
oral capsule
100 mg, 25200
mg
fortical
spray,non-aerosol
unit/actuation
gengraf oral solution 100 mg/ml
ibandronate
intravenous
solution
mg/3 ml
HUMIRA CROHN'S
DIS
START3 PCK
SUBCUTANEOUS
PEN INJECTOR
KIT
MIACALCIN
INJECTION
SOLUTION
20040
MG/0.8 ML
UNIT/ML
HUMIRA SUBCUTANEOUS
KIT 10
NATPARA
SUBCUTANEOUSSYRINGE
CARTRIDGE
MG/0.2
ML,
20
MG/0.4
ML,
40
MG/0.8
ML
100 MCG/DOSE, 25 MCG/DOSE, 50
MCG/DOSE,
75 MCG/DOSE SYRINGE 100
KINERET SUBCUTANEOUS
MG/0.67 ML
mercaptopurine oral tablet 50 mg
B/D
PA
2
2
5
2
55
B/D
PA
PA
PA
PA
PA
22
2
25
B/D
B/D
PA
PA
4
B/D
55
PA
PA
5
PA
2
82
8282
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significanlas
lasabreviaturas
abreviaturasasasenenesta
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour
mcg/hr,
pamidronate
intravenous
solution
30100
mg/10
ml (3
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9
mg/ml)
hydrocodone-acetaminophen oral tablet 2.5-325
22
hydromorphone
(pf) in ection SYRINGE
solution 1060
mg/ml
PROLIA
SUBCUTANEOUS
MG/ML
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
42
PA
2
23
QL (180 EA per 30 days)
XGEVA
SUBCUTANEOUS
SOLUTION 120
LAZANDA
NASAL SPRAY,NON-AEROSOL
MG/1.7
ML (70 MG/ML)
400 MCG/SPRAY
53
PA
PA; QL (150 EA per 30 days)
zoledronic
meperidineacid
oralintravenous
solution 50 solution
mg/5 ml 4 mg/5 ml
zoledronic
meperidineacid-mannitol-water
oral tablet 50 mg intravenous
solution 5 mg/100 ml
meperitab oral tablet 100 mg
ZOMETA INTRAVENOUS SOLUTION 4
nalbuphine
MG/100
MLin ection solution 10 mg/ml, 20 mg/ml
oxycodone oral solution 5 mg/5 ml
Non-Frf
22
22
PA
PA; QL (3600 ML per 30 days)
PA
PA; QL (240 EA per 30 days)
2
5
2
PA; QL (240 EA per 30 days)
PA
B/D
2
QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
2
QL (180 EA per 30 days)
ARISTADA INTRAMUSCULAR
tramadol oral tablet 50 mg
SUSPENSION,EXTENDED REL SYRING 441
MG/1.6
ML
Anesthetics
5
2
PA; QL (1.6 ML per 28 days)
QL (240 EA per 30 days)
ARISTADA
INTRAMUSCULAR
Local Anesthetics
SUSPENSION,EXTENDED REL SYRING 662
lidocaine
(pf) in ection solution 5 mg/ml (0.5 )
MG/2.4
ML
lidocaine hclINTRAMUSCULAR
mucous membrane gel 2
ARISTADA
5
PA; QL (2.4 ML per 28 days)
mg
paricalcitol
oral capsule 1 mcg, 2 mcg, 4 mcg
risedronate
tabletSPRAY,NON-AEROSOL
150 mg, 30 mg, 35 mg, 35
LAZANDAoral
NASAL
mg
(12
pack),
35
mg
(4
pack), 5 mg
100 MCG/SPRAY
Non-Frf
mg, 5 mg
SUSPENSION,EXTENDED
RELsolution
SYRING
lidocaine hcl mucous membrane
4 882
(40
MG/3.2
ML
mg/ml)
HUMIRA
PEDIATRIC
CROHN'S
START
lidocaine hcl
urethral gel
2
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
lidocaine topical adhesi e patch,medicated 5
ML
(700 mg/patch)
HUMIRA PEN PSORIASIS STARTER
lidocaine topical ointment
5
SUBCUTANEOUS
PEN INJECTOR
KIT 40
MG/0.8
ML
lidocaine-prilocaine
topical cream 2.5-2.5
QL (10 EA per 30 days)
2
2
PA; QL (600 EA per 30 days)
2
52
2
PA; QL (3.2 ML per 28 days)
52
PA
2
PA; QL (90 EA per 30 days)
5
2
PA
2
B/D
HUMIRA
PEN SUBCUTANEOUS
PENTreatment Agents 5
Anti-Addiction/
Substance Abuse
INJECTOR KIT 40 MG/0.8 ML
PA
ONIVYDE INTRAVENOUS DISPERSION 4.3
acamprosate oral tablet,delayed release (dr/ec)
MG/ML
333 mg
YONDELIS INTRAVENOUS RECON SOLN 1
disulfiram oral tablet 250 mg, 500 mg
MG
naltrexone oral
tablet 50 mg
Ophthalmic
Agents
5
2
PA
PA
5
2
PA
Alcohol Deterrents/ Anti-Craving
2
83
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
sirolimus oralAgents
tablet 0.5 mg, 1 mg, 2 mg
Ophthalmic
2
PA
tacrolimus oral capsule
0.5 mg, 1 mg,
5 mg 500bacitracin-polymyxin
b ophthalmic
ointment
10,000
unit/gram
TORISEL
INTRAVENOUS RECON SOLN 30
22
B/D
5
1
PA
TREXALL ORAL TABLETophthalmic
10 MG, 15 ointment
MG, 5
neomycin-bacitracin-poly-hc
MG,
7.5
MG
3.5-400-10,000 mg-unit/g-1%
24
PA
ZORTRESS ORAL TABLET 0.25
MG
neomycin-bacitracin-polymyxin
ophthalmic
ointment
3.5-400-10,000
mg-unit-unit/g
ZORTRESS
ORAL TABLET
0.5 MG, 0.75 MG
24
B/D
5
1
B/D
5
1
5
B/D
MG/3 ML ophthalmic
(10 MG/ML)
(FIRST)
garamycin
drops
0.3 %
neomycin-polymyxin b-dexameth ophthalmic
Immunizing Agents, Passive
drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %
BIVIGAM INTRAVENOUS SOLUTION 10 %
neomycin-polymyxin b-dexameth ophthalmic
CARIMUNE
NF NANOFILTERED
ointment
3.5 mg/g-10,000
unit/g-0.1 %
INTRAVENOUS RECON SOLN 6 GRAM
neomycin-polymyxin-gramicidin ophthalmic drops
FLEBOGAMMA
DIF INTRAVENOUS
1.75
mg-10,000 unit-0.025mg/ml
SOLUTION 10 %
neomycin-polymyxin-hc ophthalmic
GAMASTAN S/D
INTRAMUSCULAR
drops,suspension
3.5-10,000-10
mg-unit-mg/ml
SOLUTION 15-18 % RANGE
polymyxin b sulf-trimethoprim ophthalmic drops
GAMMAGARD
LIQUID INJECTION
10,000
unit- 1 mg/ml
SOLUTION 10 %
tobramycin-dexamethasone ophthalmic
GAMMAKED INJECTION
drops,suspension
0.3-0.1 % SOLUTION 1
GRAM/10 ML (10 %)
B/D
2
5
B/D
2
3
B/D
1
5
B/D
2
4
B/D
GAMMAPLEX INTRAVENOUS SOLUTION 5
naphazoline
ophthalmic drops 0.1 %
%
proparacaine
ophthalmic
drops
0.5 %
GAMUNEX-C
INJECTION
SOLUTION
1
GRAM/10
ML
(10
%)
RESTASIS OPHTHALMIC DROPPERETTE
0.05
%
HYPERRAB
S/D (PF) INTRAMUSCULAR
SOLUTION 150
UNIT/ML, 150
UNIT/ML (10
Ophthalmic
Anti-Allergy
Agents
ML)
azelastine ophthalmic drops 0.05 %
PRIVIGEN INTRAVENOUS SOLUTION 10 %
cromolyn ophthalmic drops 4 %
SYNAGIS INTRAMUSCULAR SOLUTION 50
epinastine
ophthalmic drops 0.05 %
MG/0.5 ML
5
2
B/D
24
3
3
B/D
QL (60 EA per 30 days)
2
5
2
4
2
ST
B/D
olopatadine
ophthalmicINTRAVENOUS
drops 0.1 %
THYMOGLOBULIN
RECON
SOLN
25
MG
PATADAY OPHTHALMIC DROPS 0.2 %
25
B/D
Ophthalmic Agents, Other
Immunological
Agents DROPS 0.1 %
PATANOL
OPHTHALMIC
leflunomide oral
tablet 10 mg, 20
mg
Ophthalmic
Antiglaucoma
Agents
SYNAGIS INTRAMUSCULAR
50
acetazolamide
oral tablet 125 mg,SOLUTION
250 mg
MG/0.5 ML
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
Immunomodulators
PA
ST
3
3
2
24
PA
3
84
8484
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significanlas
lasabreviaturas
abreviaturasasasenenesta
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl OPHTHALMIC
transdermal patch
72 hour 100 mcg/hr,
AZOPT
DROPS,SUSPENSION
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75 mcg/hr
1%
32
hydrocodone-acetaminophen
brimonidine
ophthalmic dropsoral
0.15tablet
% 2.5-325
mg
brimonidine ophthalmic drops 0.2 %
hydromorphone (pf) in ection solution 10 mg/ml
carteolol ophthalmic drops 1 %
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
COMBIGAN OPHTHALMIC DROPS 0.2-0.5 %
LAZANDA NASAL SPRAY,NON-AEROSOL
dorzolamide
ophthalmic drops 2 %
100 MCG/SPRAY
dorzolamide-timolol
drops 22.3-6.8
LAZANDA NASALophthalmic
SPRAY,NON-AEROSOL
mg/ml
400 MCG/SPRAY
22
QL (10 EA per 30 days)
1
2
2
2
3
3
2
QL (180 EA per 30 days)
23
PA; QL (150 EA per 30 days)
levobunolol
ophthalmic
0.5 %
meperidine oral
solutiondrops
50 mg/5
ml
methazolamide
tablet
25 mg, 50 mg
meperidine oraloral
tablet
50 mg
12
22
PA; QL (3600 ML per 30 days)
metipranolol
ophthalmic
meperitab oral
tablet 100drops
mg 0.3 %
PHOSPHOLINE
IODIDE
OPHTHALMIC
nalbuphine in ection
solution
10 mg/ml, 20 mg/ml
DROPS 0.125 %
oxycodone oral solution 5 mg/5 ml
SIMBRINZA OPHTHALMIC
oxycodone oral tablet 101-0.2
mg, %
15 mg, 20 mg, 30
DROPS,SUSPENSION
mg, 5 mg
timolol maleate ophthalmic drops 0.25 %, 0.5 %
tramadol oral tablet 50 mg
timolol maleate ophthalmic gel forming solution
Anesthetics
0.25
%, 0.5 %
22
32
PA; QL (240 EA per 30 days)
2
3
2
QL (5400 ML per 30 days)
TIMOPTIC
OCUDOSE (PF) OPHTHALMIC
Local Anesthetics
DROPPERETTE 0.25 %, 0.5 %
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
4
Ophthalmic
Anti-Inflammatories
lidocaine hcl mucous membrane gel 2
2
22
dexamethasone
sodiummembrane
phosphatesolution
ophthalmic
lidocaine hcl mucous
4 (40
drops
0.1
%
mg/ml)
diclofenac
sodium
ophthalmic
lidocaine hcl
urethral
gel 2 drops 0.1 %
DUREZOL
OPHTHALMIC
DROPS 0.05 %5
lidocaine topical
adhesi e patch,medicated
(700 mg/patch)ophthalmic drops,suspension 0.1
fluorometholone
%
lidocaine topical ointment 5
1
2
2
naltrexone oral tablet 50 mg
latanoprost ophthalmic drops 0.005 %
PA; QL (240 EA per 30 days)
B/D
QL (180 EA per 30 days)
QL (240 EA per 30 days)
2
22
32
PA; QL (90 EA per 30 days)
2
2
22
B/D
2
22
PA
flurbiprofen
sodium ophthalmic
drops
0.03 %
lidocaine-prilocaine
topical cream
2.5-2.5
FML FORTE OPHTHALMIC
4
Anti-Addiction/ Substance Abuse Treatment Agents
DROPS,SUSPENSION 0.25 %
Alcohol ophthalmic
Deterrents/
Anti-Craving
ketorolac
drops
0.4 %, 0.5 %
acamprosate sodium
oral tablet,delayed
release (dr/ec)
prednisolone
phosphate ophthalmic
drops
333
mg
1%
disulfiram oralProstaglandin
tablet 250 mg, 500
Ophthalmic
Andmg
Prostamide Analogs
PA; QL (600 EA per 30 days)
2
2
1
85
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
LUMIGAN
OPHTHALMIC
DROPS 0.01 %
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION 10 MCG/0.5
TRAVATAN Z OPHTHALMIC DROPS 0.004 %
ML
33
Otic
Agents PEDIATRIC (PF)
ENGERIX-B
3
GARDASILOTIC
(PF) INTRAMUSCULAR
CIPRODEX
DROPS,SUSPENSION 0.3-0.1
SUSPENSION
20-40-40-20 MCG/0.5 ML
%
GARDASIL (PF) INTRAMUSCULAR
hydrocortisone-acetic
acid otic drops 1-2 %
SYRINGE 20-40-40-20 MCG/0.5 ML
neomycin-polymyxin-hc otic drops,suspension 3.5GARDASIL
9 (PF) INTRAMUSCULAR
10,000-1
mg/ml-unit/ml-%
SUSPENSION 0.5 ML
neomycin-polymyxin-hc otic solution 3.5-10,000-1
GARDASIL 9 (PF) INTRAMUSCULAR
mg/ml-unit/ml-%
SYRINGE 0.5 ML
33
INTRAMUSCULAR
SYRINGE 10 MCG/0.5 ML
Otic
Agents
Respiratory Tract/ Pulmonary Agents
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
Antihistamines
3
2
3
2
3
3
23
IPOL INJECTION
SYRINGE
levocetirizine
oral tablet
5 mg 40-8-32 UNIT/0.5
ML
23
IXIARO (PF) INTRAMUSCULAR SYRINGE 6
ADVAIR
INHALATION BLISTER
MCG/0.5DISKUS
ML
WITH DEVICE 100-50 MCG/DOSE, 250-50
MENACTRA500-50
(PF) INTRAMUSCULAR
MCG/DOSE,
MCG/DOSE
SOLUTION 4 MCG/0.5 ML
ADVAIR HFA INHALATION HFA AEROSOL
MENOMUNE
- A/C/Y/W-135
(PF)
INHALER
115-21
MCG/ACTUATION,
230-21
SUBCUTANEOUS RECON
SOLN 50 MCG
MCG/ACTUATION,
45-21 MCG/ACTUATION
MENVEO A-C-Y-W-135-DIP
(PF)
ASMANEX
HFA INHALATION
HFA
INTRAMUSCULAR
KIT
10-5
MCG/0.5
ML
AEROSOL INHALER 100 MCG/ACTUATION,
3
3
200
MCG/ACTUATION
M-M-R
II (PF) SUBCUTANEOUS RECON
SOLN 1,000-12,500
TCID50/0.5
ML
ASMANEX
TWISTHALER
INHALATION
3
Anti-Inflammatories, Inhaled Corticosteroids
AEROSOL
POWDR
BREATH ACTIVATED 110
PEDVAX HIB
(PF) INTRAMUSCULAR
MCG
(30 DOSES),
220 MCG
SOLUTION
7.5 MCG/0.5
ML(120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
PROQUAD (PF) SUBCUTANEOUS
budesonide
inhalation
suspension for nebulization
SUSPENSION
FOR RECONSTITUTION
0.25
mg/2 ml, 0.53.99
mg/2
ml
10EXP3-4.3-3TCID50/0.5
B/D
23
HAVRIX nasal
(PF) INTRAMUSCULAR
SYRINGE
azelastine
aerosol,spray 137 mcg
(0.1 %)
720 ELISA UNIT/0.5 ML
azelastine nasal spray,non-aerosol 0.15 % (205.5
IMOVAX RABIES VACCINE (PF)
mcg)
INTRAMUSCULAR RECON SOLN 2.5 UNIT
clemastine oral tablet 2.68 mg
INFANRIX (DTAP) (PF) INTRAMUSCULAR
cyproheptadine
syrupLF-MCG-LF/0.5ML
2 mg/5 ml
SUSPENSION oral
25-58-10
cyproheptadine
oralSUSPENSION
tablet 4 mg 40-8-32
IPOL INJECTION
UNIT/0.5 MLoral solution 2.5 mg/5 ml
levocetirizine
B/D
2
3
2
3
2
PA
23
2
PA
PA
3
3
3
33
3
3
3
2
B/D
86
8686
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
72 hour
mcg/hr,
budesonide
inhalationpatch
suspension
for100
nebulization
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
75
mcg/hr
1 mg/2 ml
22
hydrocodone-acetaminophen
oral tablet
2.5-325
FLOVENT
DISKUS INHALATION
BLISTER
mg DEVICE 100 MCG/ACTUATION, 250
WITH
MCG/ACTUATION,
MCG/ACTUATION
hydromorphone (pf) in50ection
solution 10 mg/ml
32
FLOVENT
HFA oral
INHALATION
hydromorphone
tablet 2 mg, HFA
4 mg,AEROSOL
8 mg
INHALER 110 MCG/ACTUATION, 220
LAZANDA NASAL SPRAY,NON-AEROSOL
MCG/ACTUATION,
44 MCG/ACTUATION
100 MCG/SPRAY
flunisolide nasal spray,non-aerosol 25 mcg (0.025
LAZANDA NASAL SPRAY,NON-AEROSOL
%)
400 MCG/SPRAY
fluticasone nasal spray,suspension 50
meperidine oral solution 50 mg/5 ml
mcg/actuation
meperidine oral
tablet
50 mg
NASONEX
NASAL
SPRAY,NON-AEROSOL
50
MCG/ACTUATION
meperitab oral tablet 100 mg
PULMICORT
INHALATION
SUSPENSION
nalbuphine in ection
solution 10
mg/ml, 20 mg/ml
FOR NEBULIZATION 1 MG/2 ML
oxycodone oral solution 5 mg/5 ml
QVAR INHALATION AEROSOL 40
oxycodone oral tablet80
10MCG/ACTUATION
mg, 15 mg, 20 mg, 30
MCG/ACTUATION,
mg, 5 mg
triamcinolone acetonide nasal aerosol,spray 55
tramadol oral tablet 50 mg
mcg
Anesthetics
Antileukotrienes
Local Anesthetics
montelukast
oral granules in packet 4 mg
lidocaine (pf)
in ection
solution
montelukast
oral
tablet 10
mg 5 mg/ml (0.5
QL (10 EA per 30 days)
2
32
QL (180 EA per 30 days)
3
PA; QL (600 EA per 30 days)
2
3
PA; QL (150 EA per 30 days)
2
2
PA; QL (3600 ML per 30 days)
42
2
42
PA; QL (240 EA per 30 days)
2
3
2
QL (5400 ML per 30 days)
2
2
QL (240 EA per 30 days)
PA; QL (240 EA per 30 days)
B/D
QL (180 EA per 30 days)
1
)
12
lidocaine hcloral
mucous
membrane gel
2 5 mg
montelukast
tablet,chewable
4 mg,
12
lidocaine hcl
mucous
membrane
solution 4 (40
zafirlukast
oral
tablet 10
mg, 20 mg
mg/ml)
ZYFLO CR ORAL TABLET, ER MULTIPHASE
lidocaine
urethral gel 2
12
HR 600hcl
MG
22
4
2
PA
lidocaineORAL
topical
adhesi e600
patch,medicated
5
ZYFLO
TABLET
MG
(700 mg/patch)
42
PA; QL (90 EA per 30 days)
PA
lidocaine topical ointment 5
ATROVENT HFA INHALATION HFA
lidocaine-prilocaine
topical
cream 2.5-2.5
AEROSOL
INHALER
17 MCG/ACTUATION
2
3
2
B/D
Anti-Addiction/
Agents 2
ipratropium
bromideSubstance
inhalation Abuse
solutionTreatment
0.02 %
B/D
Alcohol Deterrents/
Anti-Craving
ipratropium
bromide nasal
spray,non-aerosol 0.03
%,
0.06
%
acamprosate oral tablet,delayed release (dr/ec)
PA
Bronchodilators, Anticholinergic
333 mg RESPIMAT INHALATION MIST 1.25
SPIRIVA
MCG/ACTUATION,
disulfiram oral tablet 2.5
250MCG/ACTUATION
mg, 500 mg
SPIRIVA
HANDIHALER
INHALATION
naltrexoneWITH
oral tablet
50 mg
CAPSULE, W/INHALATION DEVICE 18 MCG
PA
2
2
3
2
32
87
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
TUDORZA
PRESSAIR
INHALATION
ZOSTAVAX
(PF) SUBCUTANEOUS
AEROSOL
POWDR
ACTIVATED
400
SUSPENSION
FOR BREATH
RECONSTITUTION
19,400
UNIT/0.65 ML
MCG/ACTUATION,
400 MCG/ACTUATION
(30 ACTUAT)
33
albuterol sulfate inhalation solution for
balsalazide oral
mgmg/3 ml, 2.5 mg /3
nebulization
0.63 capsule
mg/3 ml,750
1.25
ml
(0.083 %),
5 mg/mlSUPPOSITORY 1,000 MG
CANASA
RECTAL
1
2
albuterol
sulfate
oralCAPSULE,DELAYED
syrup 2 mg/5 ml
DELZICOL
ORAL
RELEASE(DR/EC)
MG
albuterol
sulfate oral400
tablet
2 mg, 4 mg
13
Inflammatory Bowel Disease Agents
Bronchodilators, Sympathomimetic
Aminosalicylates
DIPENTUM
ORAL
250 release
MG
albuterol
sulfate
oral CAPSULE
tablet extended
12 hr
4LIALDA
mg, 8 mgORAL TABLET,DELAYED RELEASE
(DR/EC)
GRAM
DULERA 1.2
INHALATION
HFA AEROSOL
INHALER
200-5 it 4
mesalamine100-5
with MCG/ACTUATION,
cleansing wipe rectal enema
MCG/ACTUATION
gram/60 ml
B/D
3
1
24
3
3
2
EPIPEN
2-PAK
INJECTION
AUTO-INJECTOR
PENTASA
ORAL
CAPSULE,
EXTENDED
0.3
MG/0.3 ML
RELEASE
250 MG, 500 MG
43
QL (2 EA per 30 days)
EPIPEN
JR 2-PAK
INJECTION
SFROWASA
RECTAL
ENEMAAUTO4 GRAM/60 ML
INJECTOR 0.15 MG/0.3 ML
44
QL
PA (2 EA per 30 days)
FORADIL AEROLIZER INHALATION
a-hydrocortW/INHALATION
in ection recon soln
100 mg 12 MCG
CAPSULE,
DEVICE
BUDESONIDEoral
ORAL
metaproterenol
syrup 10 mg/5 ml
CAPSULE,DELAYED,EXTEND.RELEASE 3
metaproterenol
oral tablet 10 mg, 20 mg
MG
3
2
PROVENTIL
INHALATION
colocort rectalHFA
enema
100 mg/60 mlHFA
AEROSOL INHALER 90 MCG/ACTUATION
cortisone oral tablet 25 mg
SEREVENT DISKUS INHALATION BLISTER
dexamethasone
oral drops 1 mg/ml
WITH
DEVICE intensol
50 MCG/DOSE
dexamethasone
oral elixir
0.5 5mg/5
terbutaline
oral tablet
2.5 mg,
mg ml
32
Glucocorticoids
dexamethasone
oral tablet
0.5 mg,10.75
mg, 1 mg,
terbutaline
subcutaneous
solution
mg/ml
1.5 mg, 2 mg, 4 mg, 6 mg
VENTOLIN HFA INHALATION HFA
hydrocortisone
oral tablet
10 mg, 20 mg, 5 mg
AEROSOL
INHALER
90 MCG/ACTUATION
hydrocortisone rectal enema 100 mg/60 ml
Cystic Fibrosis Agents
methylprednisolone acetate in ection suspension
KALYDECO
40 mg/ml, 80 ORAL
mg/ml GRANULES IN PACKET
50 MG, 75 MG
methylprednisolone oral tablet 16 mg, 32 mg, 4
KALYDECO
ORAL TABLET 150 MG
mg, 8 mg
ORKAMBI
ORAL TABLET
200-125pac
MG 4 mg
methylprednisolone
oral tablets,dose
PULMOZYME
INHALATION
1
prednisolone acetate
ophthalmicSOLUTION
drops,suspension
MG/ML
1
23
2
2
3
2
22
21
3
2
2
2
5
PA
2
5
PA
52
52
PA
PA
88
8888
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lasabreviaturas
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páginavivi
Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
cromolyn inhalation solution for nebulization 20
hydrocodone-acetaminophen
oral tablet 2.5-325
mg/2
ml
mg
2
QL (10 EA per 30 days)
2
2
B/D
hydromorphone (pf) in ection solution 10 mg/ml
aminophylline intravenous solution 250 mg/10 ml
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
DALIRESP ORAL TABLET 500 MCG
LAZANDA NASAL SPRAY,NON-AEROSOL
ELIXOPHYLLIN
100 MCG/SPRAYORAL ELIXIR 80 MG/15 ML
2
2
2
4
3
4
QL (180 EA per 30 days)
theophylline
tablet
extended release 12 hr 100
LAZANDA oral
NASAL
SPRAY,NON-AEROSOL
mg,
200
mg,
300
mg,
450
mg
400 MCG/SPRAY
23
PA; QL (150 EA per 30 days)
theophylline
oralsolution
tablet extended
400 mg,
meperidine oral
50 mg/5release
ml
600 mg
meperidine oral tablet 50 mg
22
PA; QL (3600 ML per 30 days)
2
PA; QL (240 EA per 30 days)
Pulmonary
Antihypertensives
meperitab oral tablet 100 mg
2
52
PA; QL (240 EA per 30 days)
PA
B/D
2
5
2
5
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
PA
2
5
QL (240 EA per 30 days)
PA
sildenafil
intravenous solution 10 mg/12.5 ml
Local Anesthetics
5
PA
sildenafil
tablet
20 solution
mg
lidocaine oral
(pf) in
ection
5 mg/ml (0.5 )
TRACLEER
125
lidocaine hclORAL
mucousTABLET
membrane
gelMG,
2 62.5 MG
22
52
PA
VENTAVIS
SOLUTION
lidocaine hclINHALATION
mucous membrane
solution 4FOR(40
NEBULIZATION
10
MCG/ML,
20 MCG/ML
mg/ml)
52
PA
Respiratory
Tract Agents,
lidocaine hcl urethral
gel 2 Other
2
lidocaine topical
adhesi100
e patch,medicated
5
acetylcysteine
solution
mg/ml (10 %), 200
(700(20
mg/patch)
mg/ml
%)
22
fentanyl
transdermal
patch 72 hour 100 mcg/hr,
Mast
Cell
Stabilizers
Phosphodiesterase Inhibitors, Airways Disease
ADEMPAS
ORAL
MG, 1 20
MG,
1.5
nalbuphine in
ectionTABLET
solution 0.5
10 mg/ml,
mg/ml
MG, 2 MG, 2.5 MG
oxycodone oral solution 5 mg/5 ml
LETAIRIS ORAL TABLET 10 MG, 5 MG
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
REMODULIN
INJECTION SOLUTION 1
mg, 5 mg
MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
tramadol oral tablet 50 mg
REVATIO ORAL SUSPENSION FOR
Anesthetics
RECONSTITUTION
10 MG/ML
PA; QL (600 EA per 30 days)
PA; LA
PA; QL (90 EA per 30 days)
B/D
lidocaine topical
ointment 5
ARALAST
NP INTRAVENOUS
RECON SOLN
42
500 MG
lidocaine-prilocaine topical cream 2.5-2.5
2
GLASSIA INTRAVENOUS SOLUTION 1
4
Anti-Addiction/
Substance Abuse Treatment Agents
GRAM/50
ML (2 %)
PA
5
2
4
2
42
PA
PA
PA
Alcohol Deterrents/
Anti-Craving
LUMIZYME
INTRAVENOUS
RECON SOLN 50
MG
acamprosate oral tablet,delayed release (dr/ec)
333 mg
PROLASTIN-C
INTRAVENOUS RECON SOLN
1,000
MG
disulfiram oral tablet 250 mg, 500 mg
ZEMAIRA
INTRAVENOUS
naltrexone oral
tablet 50 mg RECON SOLN
1,000 MG
B/D
PA
PA
89
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
PROLIA SUBCUTANEOUS
SYRINGE
60
Respiratory
Tract/ Pulmonary
Agents
MG/ML
COMBIVENT RESPIMAT INHALATION MIST
risedronate
oral tablet 150 mg, 30 mg, 35 mg, 35
20-100
MCG/ACTUATION
mg (12 pac ), 5 mg
ESBRIET ORAL CAPSULE 267 MG
XGEVA SUBCUTANEOUS SOLUTION 120
ipratropium-albuterol
inhalation solution for
MG/1.7 ML (70 MG/ML)
nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml
zoledronic acid intra enous solution 4 mg/5 ml
promethazine vc oral syrup 6.25-5 mg/5 ml
zoledronic acid-mannitol-water intra enous
SYMBICORT
INHALATION
HFA AEROSOL
solution 5 mg/100
ml
INHALER 160-4.5 MCG/ACTUATION, 80-4.5
ZOMETA INTRAVENOUS SOLUTION 4
MCG/ACTUATION
MG/100 ML
XOLAIR SUBCUTANEOUS RECON SOLN 150
Non-Frf
MG
4
PA
3
2
5
5
2
PA
PA
B/D
2
2
2
3
PA
PA
PA
5
PA
5
PA
Non-Frf Muscle Relaxants
Skeletal
TABLET,DISINTEGRATING 15 MG
carisoprodol oral tablet 350 mg
ABILIFY INTRAMUSCULAR SOLUTION 9.75
chlorzoxazone
MG/1.3 ML oral tablet 500 mg
cyclobenzaprine
tablet 10 mg,
5 mg
ABILIFY ORALoral
SOLUTION
1 MG/ML
5
QL (60 EA per 30 days)
2
4
2
PA
PA; QL (117 ML per 30 days)
PA
methocarbamol
oral solution
tablet 500
750 mg
adrucil intra enous
2.5mg,
gram/50
ml, 5
gram/100
ml
orphenadrine citrate oral tablet extended release
100
mg
ampicillin-sulbactam
intra enous recon soln 3
gram
25
22
PA
QL (900 ML per 30 days)
PA
B/D
2
2
PA
ABILIFYMuscle
DISCMELT
ORAL
Skeletal
Relaxants
Sleep Disorder Agents
ANDROXY ORAL TABLET 10 MG
4
AVANDAMET ORAL TABLET 2-500 MG
zaleplon oral capsule 10 mg, 5 mg
AVANDAMET ORAL TABLET 4-1,000 MG, 4zolpidem
500 MG oral tablet 10 mg, 5 mg
4
2
4
2
ST; QL (30 EA per 30 days)
QL (90 EA per 365 days)
ST; QL (60 EA per 30 days)
QL (90 EA per 365 days)
Sleep
Disorders,
Other
AVANDARYL
ORAL
TABLET 4-1 MG, 4-2
4
ST; QL (60 EA per 30 days)
PA
ST; QL (30 EA per 30 days)
PA
Gaba Receptor Modulators
MG
HETLIOZ
ORAL CAPSULE 20 MG
AVANDARYL
ORAL
TABLET
4-4MG,
MG,200
8-2MG
MODAFINIL
ORAL
TABLET
100
MG, 8-4 MG
ROZEREM ORAL TABLET 8 MG
cefepime in dextrose,iso-osm intra enous
XYREM
SOLUTION
500 MG/ML
piggybac ORAL
1 gram/50
ml, 2 gram/100
ml
5
34
4
2
4
QL (30 EA per 30 days)
3
PA
clemastine oral syrup 0.67 mg/5 ml
AMINOSYN 7 % WITH ELECTROLYTES
COUMADIN INTRAVENOUS
RECON
SOLN75
INTRAVENOUS
PARENTERAL
SOLUTION
MG
%
2
4
4
PA
B/D
cyclophosphamide oral tablet 25 mg, 50 mg
2
B/D
Therapeutic
Nutrients/
Minerals/
CENESTIN ORAL
TABLET
0.3 MG, Electrolytes
0.45 MG,
0.625 MG, 0.9 MG
Electrolyte/ Mineral Modifiers
LA
90
90
90
Puede encontrar información sobre lo que significan las abreviaturas as en esta tabla, vaya a la página vi
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Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
fentanyl transdermal
patch
72 hour 100 mcg/hr,
AMINOSYN-RF
5.2 %
INTRAVENOUS
12
mcg/hr,
25
mcg/hr,
50
mcg/hr,
PARENTERAL SOLUTION 5.2 %75 mcg/hr
42
QL (10 EA per 30 days)
B/D
hydrocodone-acetaminophen
oral tablet 2.5-325
EXJADE
ORAL TABLET, DISPERSIBLE
125
mg 250 MG, 500 MG
MG,
52
PA
hydromorphone
(pf) in
ection solution
FERRIPROX
ORAL
TABLET
500 MG10 mg/ml
52
PA
hydromorphone
oral tablet 2 mg, 4 mg, 8 mg
kionex
oral powder
22
QL (180 EA per 30 days)
LAZANDA
NASAL
SPRAY,NON-AEROSOL
SAMSCA
ORAL
TABLET
15 MG, 30 MG
100 MCG/SPRAY
sodium polystyrene (sorb free) oral suspension 15
LAZANDA
gram/60
ml NASAL SPRAY,NON-AEROSOL
400 MCG/SPRAY
SYPRINE ORAL CAPSULE 250 MG
meperidine oral solution 50 mg/5 ml
VELPHORO ORAL TABLET,CHEWABLE 500
meperidine oral tablet 50 mg
MG
53
PA; QL (600 EA per 30 days)
2
3
PA; QL (150 EA per 30 days)
4
2
3
2
PA
PA; QL (3600 ML per 30 days)
meperitab oralMineral
tablet 100
mg
Electrolyte/
Replacement
2
PA; QL (240 EA per 30 days)
nalbuphinechloride
in ectionintravenous
solution 10 solution
mg/ml, 20
mg/ml
ammonium
5 meq/ml
oxycodone oral
solution
5 mg/5 DISPERSIBLE
ml
CARBAGLU
ORAL
TABLET,
22
52
B/D
200
MG oral tablet 10 mg, 15 mg, 20 mg, 30
oxycodone
mg, 5 mg10 oral tablet extended release 10 meq
klor-con
2
QL (5400 ML per 30 days)
PA
QL (180 EA per 30 days)
2
22
QL (240 EA per 30 days)
tramadol8oral
mg
klor-con
oraltablet
tablet50
extended
release 8 meq
AnestheticsM15 ORAL TABLET,ER
KLOR-CON
PARTICLES/CRYSTALS
15 MEQ
Local Anesthetics
PA; QL (240 EA per 30 days)
3
klor-con m20 oral tablet,er particles/crystals 20
lidocaine (pf) in ection solution 5 mg/ml (0.5 )
meq
lidocaine hcl mucous membrane gel 2
klor-con sprinkle oral capsule, extended release
lidocaine
hcl mucous membrane solution 4 (40
10
meq, 8 meq
mg/ml)
magnesium sulfate injection solution 4 meq/ml (50
lidocaine hcl urethral gel 2
%)
2
2
lidocaine topical
e patch,medicated
5
normosol-r
ph 7.4adhesi
intravenous
parenteral solution
(700 mg/patch)
potassium chloride intravenous piggyback 40
lidocaineml
topical ointment 5
meq/100
22
lidocaine-prilocaine
topical
cream
2.5-2.5release
potassium
chloride oral
capsule,
extended
10 meq, 8 meq
22
potassium chloride oral tablet extended release 8
Alcohol Deterrents/ Anti-Craving
meq
acamprosate
oral tablet,delayed
(dr/ec)
potassium
chloride
oral tablet,er release
particles/crystals
333
mg
10 meq, 20 meq
2
disulfiram
oral tablet
mg, 500 mg
sodium
chloride
0.9 %250
intravenous
parenteral
solution
0.9oral
% tablet 50 mg
naltrexone
22
2
2
1
2
2
2
PA; QL (90 EA per 30 days)
2
2
B/D
Anti-Addiction/ Substance Abuse Treatment Agents
22
PA
91
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91 vi
Nombre
del Medicamento
Drug
Name
tolmetinchloride
oral tablet
mg
sodium
3 %200
intravenous
parenteral
solution 3 %
u-cort topical cream 1-10
sodium chloride intravenous parenteral solution
VAQTA (PF) INTRAMUSCULAR
2.5 meq/ml
SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML
sodium chloride irrigation solution 0.9 %
VICTRELIS ORAL CAPSULE 200 MG
SODIUM FLUORIDE ORAL TABLET 1 MG
ZYPREXA RELPREVV INTRAMUSCULAR
FLUORIDE
(2.2FOR
MG)RECONSTITUTION 300
SUSPENSION
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
22
2
2
3
B/D
2
5
4
5
PA
2
B/D
aminosyn 8.5 %-electrolytes intravenous
bacitracin-polymyxin
parenteral
solution 8.5b%ophthalmic ointment 50010,000 unit/gram
AMINOSYN II 10 % INTRAVENOUS
garamycin ophthalmic drops 0.3
PARENTERAL SOLUTION 10 %
neomycin-bacitracin-poly-hc ophthalmic ointment
AMINOSYN II 15 % INTRAVENOUS
3.5-400-10,000 mg-unit/g-1
PARENTERAL SOLUTION 15 %
neomycin-bacitracin-polymyxin ophthalmic
AMINOSYN II 7 % INTRAVENOUS
ointment 3.5-400-10,000 mg-unit-unit/g
PARENTERAL SOLUTION 7 %
neomycin-polymyxin b-dexameth ophthalmic
AMINOSYN II 8.5 % INTRAVENOUS
drops,suspension 3.5mg/ml-10,000 unit/ml-0.1
PARENTERAL SOLUTION 8.5 %
neomycin-polymyxin b-dexameth ophthalmic
aminosyn ii 8.5 %-electrolytes intravenous
ointment 3.5 mg/g-10,000 unit/g-0.1
parenteral solution 8.5 %
neomycin-polymyxin-gramicidin ophthalmic drops
AMINOSYN M 3.5 % INTRAVENOUS
1.75 mg-10,000 unit-0.025mg/ml
PARENTERAL SOLUTION 3.5 %
neomycin-polymyxin-hc ophthalmic
AMINOSYN-HBC 7% INTRAVENOUS
drops,suspension 3.5-10,000-10 mg-unit-mg/ml
PARENTERAL SOLUTION 7 %
polymyxin b sulf-trimethoprim ophthalmic drops
AMINOSYN-PF 10 % INTRAVENOUS
10,000 unit- 1 mg/ml
PARENTERAL SOLUTION 10 %
sulfacetamide sodium ophthalmic ointment 10
AMINOSYN-PF 7 % (SULFITE-FREE)
sulfacetamide-prednisolone
ophthalmic
drops 10
INTRAVENOUS
PARENTERAL
SOLUTION
7
-0.23
(0.25
)
%
2
2
B/D
4
1
B/D
2
4
B/D
2
4
B/D
1
4
B/D
1
2
B/D
2
4
B/D
2
4
B/D
1
4
B/D
2
4
2
B/D
tobramycin-dexamethasone
clinimix
4.25%/d10w sulf freeophthalmic
intravenous
drops,suspension
parenteral
solution0.3-0.1
4.25 %
22
B/D
clinimix
4.25%-d20w
sulf-free
Ophthalmic
Agents,
Otherintravenous
parenteral solution 4.25 %
naphazoline ophthalmic drops 0.1
clinimix 4.25%-d25w sulf-free intravenous
proparacaine ophthalmic drops 0.5
parenteral solution 4.25 %
RESTASIS OPHTHALMIC DROPPERETTE
clinisol sf 15 % intravenous parenteral solution 15
0.05 %
%
2
B/D
2
2
2
B/D
3
2
QL (60 EA per 30 days)
B/D
MG, 405 MG Nutrients/ Minerals/ Electrolytes
Therapeutic
Ophthalmic
amino
acids 15Agents
% intravenous parenteral solution
PA
15 %
Ophthalmic Agents
92
9292
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páginavivi Puede
Nombre
del Medicamento
Drug
Name
Nivel Drug
de Medicamento
Requisitos/Límites
Tier
Requirements/Limits
d10 %-0.45 %sodium
sodiumophthalmic
chloride intravenous
sulfacetamide
ointment 10
parenteral solution
22
d2.5 %-0.45 % sodium chloride intravenous
azelastine
parenteralophthalmic
solution drops 0.05
cromolyn
drops
4
d5 % and ophthalmic
0.9 % sodium
chloride
intravenous
parenteral
solution
epinastine ophthalmic drops 0.05
2
2
ST
22
2
32
ST
Ophthalmic Anti-Allergy Agents
d5 %-0.45 %OPHTHALMIC
sodium chlorideDROPS
intravenous
PATADAY
0.2 %
parenteral solution
PATANOL OPHTHALMIC DROPS 0.1 %
dextrose 10 % and 0.2 % nacl intravenous
Ophthalmic
Antiglaucoma Agents
parenteral solution
acetazolamide
tablet
125 mg,
250 mg
dextrose 10 % oral
in water
(d10w)
intravenous
parenteral solution
10 %
ALPHAGAN
P OPHTHALMIC
DROPS 0.1 %
dextroseOPHTHALMIC
5 % in water (d5w)
intravenous
AZOPT
DROPS,SUSPENSION
parenteral
solution
1%
dextrose 5 %-lactated
ringers
brimonidine
ophthalmic
drops intravenous
0.15
parenteral solution
brimonidine ophthalmic drops 0.2
dextrose 5%-0.2 % sod chloride intravenous
carteolol
parenteralophthalmic
solution drops 1
COMBIGAN
OPHTHALMIC
0.2-0.5 %
dextrose 5%-0.3
% sod.chlorideDROPS
intravenous
parenteral solution
dorzolamide
ophthalmic drops 2
dextrose with sodiumophthalmic
chloride intravenous
dorzolamide-timolol
drops 22.3-6.8
parenteral
solution
5-0.2
%
mg/ml
intralipid
intravenous
20 %
le
obunolol
ophthalmicemulsion
drops 0.5
lactated ringersoral
intravenous
methazolamide
tablet 25parenteral
mg, 50 mgsolution
levocarnitine ophthalmic
(with sugar)drops
oral solution
100 mg/ml
metipranolol
0.3
levocarnitine oralIODIDE
tablet 330
mg
PHOSPHOLINE
OPHTHALMIC
DROPS
0.125
%
potassium
chlorid-d5-0.45%nacl
intravenous
parenteral
solution
20
meq/l
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION
PRENATAL VITAMIN1-0.2
PLUS%LOW IRON
ORAL TABLET
27 MG IRONMG , 0.5
timolol
maleate ophthalmic
drops10.25
water for irrigation, sterile irrigation solution
timolol maleate ophthalmic gel forming solution
0.25 , 0.5
TIMOPTIC OCUDOSE (PF) OPHTHALMIC
DROPPERETTE 0.25 %, 0.5 %
3
2
22
3
32
22
1
2
2
32
2
22
12
22
B/D
22
32
2
3
4
PA
1
2
2
4
Ophthalmic Anti-Inflammatories
dexamethasone sodium phosphate ophthalmic
drops 0.1
2
diclofenac sodium ophthalmic drops 0.1
2
93
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93
93
Indice de Medicamentos
Index
8
8-MOP .................................. 58
A
abacavir ................................ 38
abacavir-lamivudinezidovudine ........................ 38
abelcet................................... 20
ABILIFY MAINTENA ........ 16
ABRAXANE ........................ 28
acamprosate ............................ 4
acarbose ................................ 41
acebutolol ............................. 49
acetaminophen-codeine .......... 1
acetazolamide ................. 53, 84
acetic acid ............................... 6
acetylcysteine ....................... 89
ACIPHEX SPRINKLE ........ 63
acitretin ................................. 58
ACTEMRA .................... 75, 78
ACTHIB (PF) ....................... 79
ACTIMMUNE ..................... 78
ACTOPLUS MET XR ......... 43
acyclovir ............................... 37
acyclovir sodium .................. 37
ADACEL(TDAP
ADOLESN/ADULT)(PF) 79
ADAGEN ............................. 60
ADEFOVIR .......................... 36
ADEMPAS ........................... 89
adrucil ................................... 26
ADVAIR DISKUS ............... 86
ADVAIR HFA ..................... 86
ADVICOR ............................ 51
afeditab cr ............................. 50
AFINITOR ........................... 29
AFINITOR DISPERZ .......... 75
AGGRENOX ....................... 48
a-hydrocort ........................... 22
ala-cort .................................. 65
ALBENZA ........................... 31
albuterol sulfate .................... 88
alclometasone ....................... 65
alcohol pads ............................ 6
ALDACTAZIDE .................. 51
ALDURAZYME .................. 60
ALECENSA ......................... 29
94
94
alendronate ........................... 82
alfuzosin ............................... 64
ALIMTA .............................. 26
ALINIA ................................ 31
allopurinol ............................ 22
alosetron ............................... 62
ALPHAGAN P ..................... 84
alprazolam ............................ 41
amantadine hcl ...................... 40
AMBISOME ........................ 20
amcinonide ........................... 65
amifostine crystalline ........... 28
amikacin ................................. 5
amiloride............................... 54
amiloride-hydrochlorothiazide
.......................................... 51
amino acids 15 % ................. 92
aminophylline ....................... 89
AMINOSYN 7 % WITH
ELECTROLYTES............ 90
aminosyn 8.5 %-electrolytes 92
AMINOSYN II 10 % ........... 92
AMINOSYN II 15 % ........... 92
AMINOSYN II 7 % ............. 92
AMINOSYN II 8.5 % .......... 92
aminosyn ii 8.5 %-electrolytes
.......................................... 92
AMINOSYN M 3.5 %.......... 92
AMINOSYN-HBC 7%......... 92
AMINOSYN-PF 10 % ......... 92
AMINOSYN-PF 7 %
(SULFITE-FREE) ............ 92
AMINOSYN-RF 5.2 % ........ 91
amiodarone ........................... 49
AMITIZA ............................. 62
amitriptyline ......................... 18
amitriptyline-chlordiazepoxide
.......................................... 16
amlodipine ............................ 50
amlodipine-atorvastatin ........ 51
amlodipine-benazepril .......... 51
amlodipine-valsartan ............ 51
amlodipine-valsartan-hcthiazid
.......................................... 51
ammonium chloride.............. 91
ammonium lactate ................ 58
amnesteem ............................ 58
amoxapine............................. 18
amoxicillin .............................. 9
amoxicillin-pot clavulanate .... 9
amphetamine salt combo ...... 56
amphotericin b ...................... 20
ampicillin ................................ 9
ampicillin sodium ................... 9
ampicillin-sulbactam .............. 9
AMPYRA ............................. 57
ANADROL-50 ..................... 68
anagrelide ............................. 47
anastrozole ............................ 29
ANDROGEL ........................ 68
androxy ................................. 68
APIDRA ............................... 44
APIDRA SOLOSTAR.......... 44
APLENZIN........................... 16
APOKYN ............................. 32
apri ........................................ 69
APTIOM ............................... 14
APTIVUS ............................. 39
ARALAST NP...................... 89
aranelle (28) .......................... 69
ARANESP (IN
POLYSORBATE) ............ 47
ARCALYST ......................... 78
argatroban ............................. 46
argatroban in 0.9 % sod chlor
.......................................... 46
aripiprazole ........................... 16
ARISTADA .......................... 83
ARRANON .......................... 26
ARZERRA ........................... 30
ascomp with codeine .............. 1
ASMANEX HFA ................. 86
ASMANEX TWISTHALER 86
aspirin-dipyridamole............. 48
assure id insulin safety.......... 44
ASTAGRAF XL ................... 75
atenolol ................................. 49
atenolol-chlorthalidone ......... 52
ATGAM ............................... 75
atorvastatin ........................... 54
atovaquone ............................ 31
atovaquone-proguanil ........... 31
ATRIPLA ............................. 38
ATROVENT HFA ............... 87
AUBAGIO ........................... 57
aubra ..................................... 69
AVANDAMET .................... 43
AVANDIA ........................... 41
AVASTIN ............................ 26
AVELOX IN NACL (ISOOSMOTIC)....................... 10
aviane ................................... 69
AVODART .......................... 64
AVONEX ............................. 57
AVONEX (WITH ALBUMIN)
.......................................... 57
azacitidine............................. 26
AZASAN.............................. 75
azathioprine .......................... 76
azelastine ........................ 84, 86
AZILECT ............................. 33
azithromycin ......................... 10
AZOPT ................................. 85
AZOR ................................... 52
aztreonam ............................... 8
B
bacitracin ................................ 6
bacitracin-polymyxin b ........ 84
baclofen ................................ 35
BACTROBAN NASAL ......... 6
balsalazide ............................ 81
balziva (28)........................... 69
BANZEL .............................. 14
BARACLUDE ..................... 36
BCG VACCINE, LIVE (PF) 79
bekyree (28).......................... 69
BELEODAQ ........................ 26
benazepril ............................. 49
benazepril-hydrochlorothiazide
.......................................... 52
BENICAR ............................ 48
BENICAR HCT ................... 52
BENLYSTA ......................... 76
benztropine ........................... 32
betamethasone dipropionate . 22
betamethasone valerate ........ 22
betamethasone, augmented... 22
BETASERON ...................... 57
betaxolol ............................... 50
bethanechol chloride ............ 64
bexarotene ............................ 31
BEXSERO (PF).................... 79
bicalutamide ......................... 25
BICILLIN L-A ....................... 9
BICNU.................................. 26
BILTRICIDE ........................ 31
bisoprolol fumarate............... 50
bisoprolol-hydrochlorothiazide
.......................................... 52
BIVIGAM ............................ 78
bleomycin ............................. 26
blisovi fe 1/20 (28) ............... 69
BOOSTRIX TDAP............... 79
BOSULIF ............................. 29
briellyn.................................. 69
BRILINTA ........................... 48
brimonidine .......................... 85
BRINTELLIX ...................... 17
bromocriptine ....................... 32
budesonide ...................... 86, 87
BUDESONIDE .................... 62
bumetanide ........................... 54
buprenorphine hcl ................... 4
buprenorphine-naloxone......... 4
buproban ............................... 16
bupropion hcl .................. 16, 17
buspirone .............................. 40
BUSULFEX ......................... 25
butalbital-acetaminop-caf-cod 1
butorphanol tartrate ................ 3
BYDUREON ........................ 41
BYETTA .............................. 41
C
cabergoline ........................... 74
calcipotriene ......................... 58
calcitonin (salmon) ............... 82
calcitriol ................................ 82
calcium acetate ..................... 64
camila ................................... 72
CANASA.............................. 81
CANCIDAS.......................... 20
CAPASTAT ......................... 24
CAPRELSA.......................... 29
captopril ................................ 49
captopril-hydrochlorothiazide
.......................................... 52
CARAC ................................ 59
CARBAGLU ........................ 91
carbamazepine .......... 14, 15, 41
carbidopa-levodopa .............. 33
carboplatin ............................ 26
CARIMUNE NF
NANOFILTERED ............ 78
carisoprodol .......................... 90
carisoprodol-asa-codeine ........ 1
carisoprodol-aspirin ................ 1
carteolol ................................ 85
cartia xt ................................. 50
carvedilol .............................. 50
cefaclor ................................... 7
cefadroxil ................................ 7
cefazolin ................................. 7
cefdinir ................................ 7, 8
cefepime ................................. 8
cefepime in dextrose 5 % ....... 8
cefotaxime .............................. 8
cefoxitin .................................. 8
cefoxitin in dextrose, iso-osm. 8
cefpodoxime ........................... 8
cefprozil .................................. 8
CEFTIN .................................. 8
ceftriaxone .............................. 8
cefuroxime axetil .................... 8
cefuroxime sodium ................. 8
celecoxib ................................. 1
CELLCEPT INTRAVENOUS
.......................................... 76
CELONTIN .......................... 12
cephalexin ............................... 8
CEREZYME......................... 60
CERVARIX VACCINE (PF)
.......................................... 79
cevimeline............................. 58
CHANTIX .............................. 5
CHANTIX CONTINUING
MONTH BOX .................... 5
CHANTIX STARTING
MONTH BOX .................... 5
chloramphenicol sod succinate
............................................ 6
chlorhexidine gluconate........ 58
chloroquine phosphate .......... 31
chlorothiazide ....................... 54
chlorpromazine ..................... 19
chlorthalidone ....................... 54
chlorzoxazone ....................... 90
cholestyramine light ............. 55
chorionic gonadotropin, human
.......................................... 66
ciclopirox .............................. 20
cidofovir ............................... 36
95
95
cilostazol............................... 48
cimetidine ............................. 62
cimetidine hcl ....................... 62
CIMZIA ................................ 76
CIMZIA POWDER FOR
RECONST........................ 76
CINRYZE............................. 75
CIPRODEX .......................... 86
ciprofloxacin (mixture) ........ 10
ciprofloxacin hcl ............. 10, 11
ciprofloxacin lactate ............. 11
cisplatin ................................ 26
citalopram ............................. 17
cladribine .............................. 26
claravis ................................. 59
clarithromycin ...................... 10
clemastine ............................. 86
CLEOCIN............................... 6
CLIMARA PRO ................... 69
clindamycin hcl ...................... 6
clindamycin pediatric ............. 6
clindamycin phosphate ........... 6
clinimix 4.25%/d10w sulf free
.......................................... 92
clinimix 4.25%-d20w sulf-free
.......................................... 92
clinimix 4.25%-d25w sulf-free
.......................................... 92
clinisol sf 15 % ..................... 92
clobetasol .............................. 65
clobetasol-emollient ............. 65
CLOLAR .............................. 26
clomipramine ........................ 18
clonazepam ........................... 12
clonidine ............................... 48
clonidine hcl ................... 48, 56
clopidogrel ............................ 48
clorazepate dipotassium ....... 41
clotrimazole .......................... 20
clotrimazole-betamethasone . 59
clozapine............................... 35
COARTEM .......................... 31
colchicine ............................. 22
colchicine-probenecid .......... 22
colestipol .............................. 55
colistin (colistimethate na) ..... 6
colocort ................................. 82
COMBIGAN ........................ 85
COMBIPATCH .................... 69
COMBIVENT RESPIMAT . 90
96
96
COMETRIQ ......................... 29
COMPLERA ........................ 38
compro .................................. 19
COMVAX (PF) .................... 79
constulose ............................. 62
COPAXONE ........................ 58
COREG CR .......................... 50
cormax .................................. 59
cortisone ............................... 22
COSMEGEN ........................ 26
COTELLIC ........................... 26
COUMADIN ........................ 46
CREON ................................ 60
CRESTOR ............................ 54
CRIXIVAN .......................... 39
cromolyn ......................... 84, 89
cryselle (28) .......................... 69
CUBICIN................................ 6
CUVPOSA ........................... 58
cyclafem 1/35 (28)................ 69
cyclafem 7/7/7 (28) .............. 69
cyclobenzaprine .................... 90
cyclophosphamide ................ 25
cyclosporine.......................... 76
cyclosporine modified .......... 76
cyproheptadine ..................... 86
CYRAMZA .......................... 31
CYSTADANE ...................... 60
CYSTAGON ........................ 60
cytarabine ............................. 26
cytarabine (pf) ...................... 26
D
d10 %-0.45 % sodium chloride
.......................................... 93
d2.5 %-0.45 % sodium
chloride ............................. 93
d5 % and 0.9 % sodium
chloride ............................. 93
d5 %-0.45 % sodium chloride
.......................................... 93
dacarbazine ........................... 26
DAKLINZA ......................... 36
DALIRESP ........................... 89
danazol.................................. 68
dantrolene ............................. 35
dapsone ................................. 24
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 79
DARAPRIM ......................... 31
DARZALEX ........................ 31
daunorubicin ......................... 26
DAUNOXOME .................... 26
deblitane ............................... 69
decitabine .............................. 26
delyla (28) ............................. 69
DELZICOL........................... 81
demeclocycline ..................... 11
DEMSER .............................. 52
DENAVIR ............................ 37
DEPEN TITRATABS .......... 64
DEPO-PROVERA ................ 73
DEPO-SUBQ PROVERA 104
.......................................... 73
desipramine........................... 18
desmopressin .................. 66, 67
desog-e.estradiol/e.estradiol . 69
desonide ................................ 65
desoximetasone..................... 65
desvenlafaxine ...................... 17
dexamethasone ..................... 22
dexamethasone intensol ........ 22
dexamethasone sodium
phosphate .................... 23, 85
DEXILANT .......................... 63
dexmethylphenidate .............. 56
dexrazoxane hcl .................... 26
dextroamphetamine .............. 56
dextroamphetamineamphetamine..................... 56
dextrose 10 % and 0.2 % nacl
.......................................... 93
dextrose 10 % in water (d10w)
.......................................... 93
dextrose 5 % in water (d5w) . 93
dextrose 5 %-lactated ringers93
dextrose 5%-0.2 % sod
chloride ............................. 93
dextrose 5%-0.3 %
sod.chloride ...................... 93
dextrose with sodium chloride
.......................................... 93
diazepam ......................... 12, 41
diazepam intensol ................. 41
diclofenac potassium .............. 1
diclofenac sodium ... 1, 2, 59, 85
dicloxacillin ............................ 9
dicyclomine .......................... 61
didanosine ............................. 38
diflorasone ............................ 65
diflunisal ................................. 2
digitek ................................... 53
digoxin.................................. 53
dihydroergotamine ............... 23
DILANTIN ........................... 15
DILAUDID (PF) .................... 3
diltiazem hcl ......................... 50
dilt-xr .................................... 51
DIPENTUM ......................... 81
diphenhydramine hcl ............ 19
diphenoxylate-atropine ......... 61
dipyridamole......................... 48
disopyramide phosphate ....... 49
disulfiram ............................... 4
divalproex ............................. 13
DIVIGEL .............................. 68
DOCEFREZ ......................... 26
DOCETAXEL ...................... 27
donepezil .............................. 15
DORIBAX .............................. 8
dorzolamide .......................... 85
dorzolamide-timolol ............. 85
doxazosin.............................. 64
doxepin ................................. 19
doxercalciferol ...................... 82
DOXIL ................................. 27
doxorubicin........................... 27
doxy-100............................... 11
doxycycline hyclate ........ 11, 12
doxycycline monohydrate .... 12
dronabinol............................. 20
drospirenone-ethinyl estradiol
.......................................... 69
DROXIA .............................. 25
DUAVEE ............................. 68
DULERA .............................. 88
duloxetine ............................. 17
duramorph (pf) ....................... 3
DUREZOL ........................... 85
dutasteride ............................ 64
dutasteride-tamsulosin .......... 64
E
e.e.s. 400 ............................... 10
E.E.S. GRANULES ............. 10
econazole .............................. 20
EDURANT ........................... 38
EFFIENT .............................. 48
EGRIFTA ............................. 67
ELAPRASE .......................... 60
ELELYSO ............................ 60
ELIDEL ................................ 59
ELIGARD ............................ 74
ELIQUIS .............................. 46
ELITEK ................................ 27
ELIXOPHYLLIN ................. 89
ELLENCE ............................ 27
ELMIRON ............................ 64
EMCYT ................................ 25
EMEND ................................ 20
emoquette ............................. 70
EMPLICITI .......................... 31
EMSAM ............................... 17
EMTRIVA ............................ 38
ENABLEX ........................... 63
enalapril maleate................... 49
enalapril-hydrochlorothiazide
.......................................... 52
ENBREL .............................. 76
ENBREL SURECLICK ....... 76
endocet.................................... 1
endodan .................................. 1
ENGERIX-B (PF) ................ 79
ENGERIX-B PEDIATRIC
(PF) ................................... 79
enoxaparin ............................ 46
enpresse ................................ 70
entacapone ............................ 32
entecavir ............................... 36
ENTRESTO.......................... 52
enulose .................................. 62
ENVARSUS XR .................. 76
epinastine .............................. 84
EPIPEN 2-PAK .................... 88
EPIPEN JR 2-PAK ............... 88
epirubicin .............................. 27
epitol ..................................... 15
EPIVIR HBV ........................ 36
eplerenone ............................ 54
EPOGEN .............................. 47
EPZICOM ............................ 39
EQUETRO ........................... 15
ERAXIS(WATER DILUENT)
.......................................... 21
ERBITUX ............................. 27
ergoloid ................................. 15
ERGOMAR .......................... 23
ERIVEDGE .......................... 30
errin ...................................... 73
ERWINAZE ......................... 27
ery pads................................. 10
ERYPED 200 ....................... 10
ERYTHROCIN .................... 10
erythrocin (as stearate) ......... 10
erythromycin......................... 10
erythromycin ethylsuccinate . 10
erythromycin with ethanol .... 10
erythromycin-benzoyl peroxide
.......................................... 59
ESBRIET .............................. 90
escitalopram oxalate ............. 17
esomeprazole magnesium ..... 63
ESTRACE ............................ 68
estradiol ................................ 68
estradiol valerate ............. 68, 70
estradiol-norethindrone acet . 70
ESTRING ............................. 68
estropipate............................. 68
ethambutol ............................ 24
ethosuximide......................... 12
etidronate disodium .............. 82
etodolac................................... 2
ETOPOPHOS ....................... 29
etoposide ............................... 29
EVOTAZ .............................. 39
EXELON .............................. 15
exemestane ........................... 29
EXJADE ............................... 91
EXTAVIA ............................ 58
F
FABRAZYME ..................... 60
falmina (28) .......................... 70
famciclovir ............................ 37
famotidine ............................. 62
famotidine (pf) ...................... 62
FANAPT............................... 34
FARESTON ......................... 25
FARYDAK ........................... 29
FASLODEX ......................... 27
felbamate .............................. 13
felodipine .............................. 51
fenofibrate............................. 54
fenofibrate micronized.......... 54
fenofibric acid (choline) ....... 54
fenoprofen............................... 2
fentanyl ................................... 3
fentanyl citrate ........................ 3
FERRIPROX ........................ 91
FETZIMA ............................. 18
finasteride ............................. 64
FIRAZYR ............................. 75
97
97
FIRMAGON KIT W
DILUENT SYRINGE ...... 74
flavoxate ............................... 63
FLEBOGAMMA DIF .......... 78
flecainide .............................. 49
FLOVENT DISKUS ............ 87
FLOVENT HFA ................... 87
fluconazole ........................... 21
fluconazole in dextrose(iso-o)
.......................................... 21
fluconazole in nacl (iso-osm)21
flucytosine ............................ 21
fludarabine ............................ 28
fludrocortisone ..................... 65
flunisolide ............................. 87
fluocinolone.......................... 65
fluocinonide.................... 59, 65
fluocinonide-e....................... 66
fluorometholone ................... 85
fluorouracil ........................... 59
fluoxetine........................ 16, 18
fluphenazine decanoate ........ 33
fluphenazine hcl ................... 33
flurbiprofen............................. 2
flurbiprofen sodium .............. 85
flutamide............................... 25
fluticasone ...................... 59, 87
fluvoxamine.......................... 18
FML FORTE ........................ 85
FOCALIN XR ...................... 57
fondaparinux......................... 46
FORADIL AEROLIZER ..... 88
FORFIVO XL ...................... 17
FORTEO .............................. 82
fortical .................................. 82
fosinopril .............................. 49
fosinopril-hydrochlorothiazide
.......................................... 52
fosphenytoin ......................... 15
FOSRENOL ......................... 64
FRAGMIN ........................... 46
FULYZAQ ........................... 61
furosemide ............................ 54
FUSILEV ............................. 28
FUZEON .............................. 39
FYCOMPA .................... 13, 14
G
gabapentin ............................ 13
GABITRIL ........................... 13
GAMASTAN S/D ................ 78
98
98
GAMMAGARD LIQUID .... 78
GAMMAKED ...................... 78
GAMMAPLEX .................... 78
GAMUNEX-C...................... 78
ganciclovir sodium ............... 36
garamycin ............................. 84
GARDASIL (PF) .................. 79
GARDASIL 9 (PF) ............... 79
GATTEX ONE-VIAL .......... 61
gauze pad .............................. 44
gavilyte-c .............................. 62
gavilyte-g .............................. 62
gavilyte-n .............................. 62
gemcitabine .......................... 25
gemfibrozil ........................... 54
generlac ................................ 62
gengraf .................................. 76
GENOTROPIN .................... 67
GENOTROPIN MINIQUICK
.......................................... 67
gentak ..................................... 5
gentamicin .............................. 5
gentamicin sulfate (pf)............ 5
GENVOYA .......................... 38
GEODON ............................. 34
gildagia ................................. 70
gildess 1.5/30 (21) ................ 70
GILENYA ............................ 58
GILOTRIF ............................ 30
GLASSIA ............................. 89
GLEEVEC ............................ 30
GLEOSTINE ........................ 27
glimepiride...................... 41, 42
glipizide ................................ 42
glipizide-metformin .............. 43
GLUCAGEN HYPOKIT ..... 44
GLUCAGON EMERGENCY
KIT (HUMAN)................. 44
glyburide ............................... 42
glyburide micronized ............ 42
glyburide-metformin ............ 43
glycopyrrolate ....................... 61
granisetron (pf) ..................... 20
granisetron hcl ...................... 20
GRANIX .............................. 47
griseofulvin microsize .......... 21
guanfacine ............................ 48
guanidine .............................. 24
H
HALAVEN ........................... 27
halobetasol propionate .......... 66
haloperidol ............................ 33
haloperidol decanoate ........... 33
haloperidol lactate ................ 33
HARVONI ............................ 36
HAVRIX (PF) ...................... 80
heparin (porcine) .................. 46
heparin (porcine) in 5 % dex 46
HERCEPTIN ........................ 27
HETLIOZ ............................. 90
HEXALEN ........................... 25
HORIZANT .................... 13, 57
HUMALOG .......................... 44
HUMALOG KWIKPEN ...... 44
HUMALOG MIX 50-50....... 44
HUMALOG MIX 50-50
KWIKPEN ........................ 44
HUMALOG MIX 75-25....... 44
HUMALOG MIX 75-25
KWIKPEN ........................ 44
HUMATROPE ..................... 67
HUMIRA .............................. 76
HUMIRA PEDIATRIC
CROHN'S START............ 83
HUMIRA PEN ..................... 83
HUMIRA PEN CROHN'SUC-HS START ................ 76
HUMIRA PEN PSORIASIS
STARTER ........................ 83
HUMULIN 70/30 ................. 44
HUMULIN 70/30 KWIKPEN
.......................................... 44
HUMULIN N ....................... 45
HUMULIN N KWIKPEN .... 45
HUMULIN R........................ 45
HUMULIN R U-500
(CONCENTRATED) ....... 45
hydralazine ........................... 55
hydrochlorothiazide .............. 54
hydrocodone-acetaminophen . 1,
3
hydrocodone-ibuprofen .......... 1
hydrocortisone .......... 23, 66, 82
hydrocortisone butyrate ........ 66
hydrocortisone butyr-emollient
.......................................... 66
hydrocortisone valerate ........ 66
hydrocortisone-acetic acid .... 86
hydromorphone....................... 4
hydromorphone (pf)................ 4
hydroxychloroquine ............. 31
hydroxyurea .......................... 26
hydroxyzine hcl .................... 19
hydroxyzine pamoate ........... 19
HYPERRAB S/D (PF) ......... 78
I
ibandronate ........................... 82
IBRANCE ............................ 29
ibuprofen ................................ 2
ibuprofen-oxycodone ............. 2
ICLUSIG .............................. 30
idarubicin .............................. 27
ifosfamide ............................. 27
ILARIS (PF) ......................... 78
imatinib................................. 30
IMBRUVICA ....................... 30
imipenem-cilastatin ................ 8
imipramine hcl...................... 19
imipramine pamoate ............. 19
imiquimod ............................ 59
IMITREX STATDOSE KIT
REFILL ............................ 23
IMOVAX RABIES VACCINE
(PF) ................................... 80
INCRELEX .......................... 67
indapamide ........................... 54
indomethacin .......................... 2
INFANRIX (DTAP) (PF)..... 80
INLYTA ............................... 30
insulin syringe-needle u-100 45
INTELENCE ........................ 38
intralipid ............................... 93
INTRON A ........................... 36
introvale ................................ 70
INVANZ................................. 8
INVEGA............................... 34
INVEGA SUSTENNA ......... 34
INVIRASE ........................... 39
INVOKAMET ...................... 42
INVOKANA ........................ 42
IPOL ..................................... 80
ipratropium bromide ............. 87
ipratropium-albuterol ........... 90
irbesartan .............................. 48
irbesartan-hydrochlorothiazide
.......................................... 52
IRESSA ................................ 30
irinotecan .............................. 27
ISENTRESS ......................... 38
isoniazid ............................... 24
isosorbide dinitrate ............... 55
isosorbide mononitrate ......... 55
isradipine .............................. 51
ISTODAX ............................ 27
itraconazole .......................... 21
IXEMPRA ............................ 27
IXIARO (PF) ........................ 80
J
JAKAFI ................................ 30
JALYN ................................. 64
jantoven ................................ 46
JANUMET ........................... 43
JANUMET XR ..................... 43
JANUVIA ............................. 42
JENTADUETO .................... 42
JEVTANA ............................ 27
jinteli..................................... 70
jolivette ................................. 73
juleber ................................... 70
junel 1.5/30 (21) ................... 70
junel 1/20 (21) ...................... 70
junel fe 1.5/30 (28) ............... 70
junel fe 1/20 (28) .................. 70
JUXTAPID ........................... 55
K
KADCYLA .......................... 27
KALETRA ..................... 39, 40
KALYDECO ........................ 88
kariva (28) ............................ 70
kelnor 1/35 (28) .................... 70
KETEK ................................. 10
ketoconazole ......................... 21
ketoprofen ............................... 2
ketorolac ........................... 2, 85
KEVEYIS ............................. 53
KEYTRUDA ........................ 31
kimidess (28) ........................ 70
KINERET ............................. 76
kionex ................................... 91
klor-con 10 ........................... 91
klor-con 8 ............................. 91
KLOR-CON M15 ................. 91
klor-con m20 ........................ 91
klor-con sprinkle................... 91
KOMBIGLYZE XR ............. 43
KORLYM ............................. 44
KRISTALOSE...................... 62
KUVAN.......................... 60, 61
KYNAMRO ......................... 55
L
labetalol ................................ 50
lactated ringers...................... 93
lactulose ................................ 62
LAMICTAL STARTER
(BLUE) KIT ..................... 14
LAMICTAL STARTER
(GREEN) KIT .................. 14
LAMICTAL STARTER
(ORANGE) KIT ............... 14
LAMICTAL XR STARTER
(BLUE) ............................. 14
LAMICTAL XR STARTER
(GREEN) .......................... 14
LAMICTAL XR STARTER
(ORANGE) ....................... 14
LAMISIL .............................. 21
lamivudine ............................ 39
lamivudine-zidovudine ......... 39
lamotrigine ...................... 13, 14
lansoprazole .......................... 63
LANTUS .............................. 45
LANTUS SOLOSTAR ......... 45
larin 1.5/30 (21) .................... 70
larin 1/20 (21) ....................... 70
larin fe 1.5/30 (28) ................ 70
larin fe 1/20 (28) ................... 70
latanoprost ............................ 85
LATUDA .............................. 34
LAZANDA ............................. 4
leena 28 ................................. 70
leflunomide ........................... 79
LENVIMA ............................ 30
lessina ................................... 70
LETAIRIS ............................ 89
letrozole ................................ 29
leucovorin calcium ......... 28, 29
LEUKERAN......................... 25
LEUKINE ............................. 47
leuprolide .............................. 74
LEVEMIR ............................ 45
LEVEMIR FLEXTOUCH.... 45
levetiracetam......................... 12
levetiracetam in nacl (iso-os) 12
levobunolol ........................... 85
levocarnitine ......................... 93
levocarnitine (with sugar) ..... 93
levocetirizine ........................ 86
levofloxacin .......................... 11
levoleucovorin calcium ........ 27
99
99
levonest (28) ......................... 70
levonorgestrel-ethinyl estrad 70
levonorg-eth estrad triphasic 71
levora-28............................... 71
levorphanol tartrate ................ 3
levothyroxine ........................ 73
levoxyl .................................. 73
LEXIVA ............................... 40
LIALDA ............................... 81
lidocaine ................................. 4
lidocaine (pf) .......................... 4
lidocaine hcl ........................... 4
lidocaine-prilocaine ................ 4
LINCOCIN ............................. 6
lincomycin .............................. 6
lindane .................................. 32
linezolid .............................. 6, 7
linezolid-0.9% sodium chloride
............................................ 7
LINZESS .............................. 62
liothyronine .......................... 73
lisinopril ............................... 49
lisinopril-hydrochlorothiazide
.......................................... 52
lithium carbonate .................. 41
lithium citrate ....................... 41
LIVALO ............................... 54
lokara .................................... 66
lomustine .............................. 25
LONSURF............................ 27
loperamide ............................ 61
lopreeza ................................ 71
lorazepam ............................. 41
lorazepam intensol................ 41
lorcet plus ............................... 1
losartan ................................. 48
losartan-hydrochlorothiazide 52
lovastatin .............................. 54
loxapine succinate ................ 33
LUMIGAN ........................... 86
LUMIZYME ........................ 89
LUPRON DEPOT ................ 74
LUPRON DEPOT (3
MONTH) .......................... 74
LUPRON DEPOT (4
MONTH) .......................... 74
LUPRON DEPOT (6
MONTH) .......................... 74
LUPRON DEPOT-PED ....... 74
lutera (28) ............................. 71
100
100
LYNPARZA ......................... 28
LYRICA ............................... 57
LYSODREN ......................... 74
lyza ....................................... 73
M
magnesium sulfate ................ 91
MALARONE ....................... 31
malathion .............................. 32
maprotiline............................ 17
marlissa................................. 69
MARPLAN .......................... 17
MATULANE........................ 25
meclizine .............................. 19
meclofenamate........................ 2
medroxyprogesterone ........... 73
mefloquine ............................ 32
MEGACE ES ....................... 73
megestrol .............................. 73
MEKINIST ........................... 30
meloxicam .............................. 2
melphalan hcl ....................... 25
memantine ............................ 16
MENACTRA (PF) ............... 80
MENEST .............................. 69
MENOMUNE - A/C/Y/W-135
(PF) ................................... 80
MENOSTAR ........................ 69
MENTAX ............................. 21
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 80
meperidine .............................. 4
meperitab ................................ 4
meprobamate ........................ 40
mercaptopurine ..................... 76
meropenem ............................. 8
meropenem-0.9% sodium
chloride ............................... 9
mesalamine with cleansing
wipe .................................. 81
mesna .................................... 28
MESNEX.............................. 28
metadate er ........................... 57
metaproterenol ...................... 88
metformin ............................. 42
methadone .............................. 3
methazolamide...................... 85
methenamine hippurate .......... 7
methimazole ......................... 75
methocarbamol ..................... 90
methotrexate sodium ............ 76
methotrexate sodium (pf) ..... 76
methoxsalen rapid ................. 59
methscopolamine .................. 61
methyclothiazide................... 54
methyldopa ........................... 48
methyldopahydrochlorothiazide .......... 52
methyldopate ........................ 48
methylphenidate ................... 57
methylprednisolone ........ 23, 66
methylprednisolone acetate .. 23
methylprednisolone sodium
succ ................................... 23
methyltestosterone ................ 68
metipranolol .......................... 85
metoclopramide hcl .............. 61
metolazone ............................ 54
metoprolol succinate ............. 50
metoprolol ta-hydrochlorothiaz
.......................................... 52
metoprolol tartrate ................ 50
metronidazole ......................... 7
metronidazole in nacl (iso-os) 7
mexiletine ............................. 49
MIACALCIN ....................... 82
microgestin 1.5/30 (21) ........ 71
microgestin 1/20 (21) ........... 71
microgestin fe 1.5/30 (28) .... 71
microgestin fe 1/20 (28) ....... 71
midodrine .............................. 48
mimvey lo ............................. 71
minitran................................. 56
minocycline .......................... 12
minoxidil............................... 55
mirapex er ............................. 32
MIRAPEX ER ...................... 32
mirtazapine ........................... 17
misoprostol ........................... 63
mitomycin ............................. 28
mitoxantrone ......................... 29
M-M-R II (PF) ...................... 80
MODAFINIL ........................ 90
moderiba ............................... 36
MODERIBA DOSE PACK .. 36
moexipril............................... 49
moexipril-hydrochlorothiazide
.......................................... 52
molindone ............................. 33
mometasone .......................... 66
mononessa (28) ..................... 71
montelukast .......................... 87
morphine................................. 3
MOXEZA ............................. 11
moxifloxacin......................... 11
moxifloxacin-sod.ace,sul-water
.......................................... 11
MOZOBIL............................ 47
MULTAQ ............................. 49
mupirocin ............................... 7
MUSTARGEN ..................... 28
MYCAMINE ........................ 21
mycophenolate mofetil ......... 77
mycophenolate sodium ......... 77
myorisan ............................... 59
MYRBETRIQ ...................... 63
N
nabumetone ............................ 2
nadolol .................................. 50
nadolol-bendroflumethiazide 52
nafcillin................................... 9
NAGLAZYME..................... 61
nalbuphine .............................. 4
naloxone ................................. 5
naltrexone ............................... 4
NAMENDA XR ................... 16
naphazoline........................... 84
NAPRELAN CR .................... 2
naproxen ................................. 2
naproxen sodium .................... 2
naratriptan............................. 23
NASONEX ........................... 87
nateglinide ............................ 42
NATPARA ........................... 82
NEBUPENT ......................... 32
necon 0.5/35 (28).................. 71
necon 1/35 (28)..................... 71
necon 10/11 (28)................... 71
necon 7/7/7 (28) ................... 71
nefazodone ........................... 17
neomycin ................................ 5
neomycin-bacitracin-poly-hc 84
neomycin-bacitracinpolymyxin......................... 84
neomycin-polymyxin b gu ..... 5
neomycin-polymyxin bdexameth .......................... 84
neomycin-polymyxingramicidin......................... 84
neomycin-polymyxin-hc 84, 86
NEULASTA ......................... 47
NEUPOGEN ........................ 47
NEUPRO .............................. 32
nevirapine ............................. 38
NEXAVAR .......................... 30
NEXIUM PACKET ............. 63
niacin .................................... 55
nicardipine ............................ 51
NICOTROL ............................ 5
NICOTROL NS ...................... 5
nifedical xl ............................ 51
nifedipine .............................. 51
NILANDRON ...................... 25
nimodipine ............................ 51
NINLARO ............................ 28
NITRO-BID.......................... 56
NITRO-DUR ........................ 56
nitrofurantoin macrocrystal .... 7
nitrofurantoin monohyd/mcryst .................................... 7
nitroglycerin ......................... 56
NITROSTAT ........................ 56
nizatidine .............................. 62
nora-be .................................. 71
NORDITROPIN FLEXPRO 67
norethindrone (contraceptive)
.......................................... 73
norethindrone acetate ........... 73
norethindrone ac-eth estradiol
.......................................... 71
norlyroc ................................ 71
normosol-r ph 7.4 ................. 91
NORPACE CR ..................... 49
NORTHERA ........................ 48
nortrel 0.5/35 (28)................. 71
nortrel 1/35 (21).................... 71
nortrel 1/35 (28).................... 71
nortrel 7/7/7 (28) .................. 71
nortriptyline .......................... 19
NORVIR ............................... 40
NOVOLIN 70/30 .................. 45
NOVOLIN N ........................ 45
NOVOLIN R ........................ 45
NOVOLOG .......................... 45
NOVOLOG FLEXPEN ........ 45
NOVOLOG MIX 70-30 ....... 45
NOVOLOG MIX 70-30
FLEXPEN ........................ 45
NOVOLOG PENFILL ......... 45
NOXAFIL ............................ 21
NUEDEXTA ........................ 57
NULOJIX ............................. 77
NUTROPIN AQ ................... 67
NUTROPIN AQ NUSPIN .... 67
NUVARING ......................... 71
nyamyc ................................. 21
nystatin ................................. 21
nystatin-triamcinolone .......... 59
nystop ................................... 21
O
ocella..................................... 71
octreotide acetate .................. 74
ODOMZO............................. 28
OFEV .................................... 30
ofloxacin ............................... 11
olanzapine ............................. 34
olanzapine-fluoxetine ........... 16
olopatadine ........................... 84
OLYSIO ............................... 36
omega-3 acid ethyl esters ..... 55
omeprazole ........................... 63
OMNITROPE ....................... 67
ONCASPAR ......................... 29
ondansetron........................... 20
ondansetron hcl ..................... 20
ondansetron hcl (pf) .............. 20
ONFI ..................................... 13
ONGLYZA ........................... 42
ONIVYDE ............................ 83
OPDIVO ............................... 31
ORAP ................................... 33
ORENCIA ............................ 77
ORENCIA (WITH
MALTOSE) ...................... 77
ORFADIN ............................ 61
ORKAMBI ........................... 88
orphenadrine citrate .............. 90
orsythia ................................. 71
OTEZLA............................... 77
OTEZLA STARTER ............ 77
oxaliplatin ............................. 28
oxandrolone .......................... 68
oxaprozin ................................ 3
oxcarbazepine ....................... 15
OXTELLAR XR .................. 15
oxybutynin chloride ........ 63, 64
oxycodone........................... 3, 4
oxycodone-acetaminophen ..... 1
oxycodone-aspirin .................. 1
OXYCONTIN ........................ 3
101
101
P
PACERONE ......................... 49
PACLITAXEL ..................... 28
paliperidone .................... 34, 35
pamidronate .......................... 83
PANRETIN .......................... 31
pantoprazole ......................... 63
paricalcitol ............................ 83
paromomycin .......................... 5
paroxetine hcl ....................... 18
PASER ................................. 24
PATADAY ........................... 84
PATANOL ........................... 84
PAXIL .................................. 18
PEDVAX HIB (PF) .............. 80
PEGANONE ........................ 15
PEGASYS ............................ 36
PEGASYS PROCLICK ....... 36
peg-electrolyte soln .............. 63
PEGINTRON ....................... 37
PEGINTRON REDIPEN ..... 37
pen needle, diabetic .............. 45
penicillin g procaine ............... 9
penicillin g sodium ................. 9
penicillin v potassium............. 9
PENTAM ............................. 32
PENTASA ............................ 82
pentazocine-naloxone ............. 1
pentoxifylline ....................... 53
periogard............................... 58
PERJETA ............................. 28
permethrin ............................ 32
perphenazine......................... 19
perphenazine-amitriptyline... 16
phenadoz............................... 19
phenelzine............................. 17
phenobarbital ........................ 13
phenytoin .............................. 15
phenytoin sodium ................. 15
phenytoin sodium extended .. 15
PHOSLYRA ......................... 65
PHOSPHOLINE IODIDE .... 85
pilocarpine hcl ...................... 58
pimozide ............................... 34
pimtrea (28) .......................... 71
pindolol................................. 50
pioglitazone .................... 42, 43
pioglitazone-glimepiride ...... 43
pioglitazone-metformin ........ 44
piperacillin-tazobactam ........ 10
102
102
pirmella................................. 71
piroxicam ................................ 3
podofilox .............................. 59
polyethylene glycol 3350 ..... 63
polymyxin b sulf-trimethoprim
.......................................... 84
POMALYST ........................ 25
portia..................................... 71
potassium chlorid-d50.45%nacl ......................... 93
potassium chloride................ 91
potassium citrate ................... 64
POTIGA ............................... 12
PRADAXA ........................... 46
pramipexole .................... 32, 33
pravastatin ............................ 55
prazosin ................................ 48
prednicarbate .................. 59, 66
prednisolone acetate ............. 23
prednisolone sodium phosphate
.................................... 23, 85
prednisone ............................ 23
prednisone intensol ............... 82
PREFEST ............................. 72
PREMARIN ......................... 69
PREMPHASE ...................... 72
PREMPRO ........................... 72
PRENATAL VITAMIN PLUS
LOW IRON ...................... 93
prevalite ................................ 55
previfem................................ 72
PREZCOBIX ........................ 40
PREZISTA ........................... 40
PRIFTIN ............................... 24
PRIMAQUINE ..................... 32
primidone.............................. 13
PRISTIQ ............................... 18
PRIVIGEN ........................... 78
probenecid ............................ 22
prochlorperazine ................... 19
prochlorperazine edisylate .... 19
prochlorperazine maleate ..... 19
PROCRIT ............................. 47
procto-pak ............................. 66
proctosol hc .......................... 82
proctozone-hc ....................... 62
progesterone micronized ...... 73
PROGLYCEM ..................... 44
PROGRAF............................ 77
PROLASTIN-C .................... 89
PROLEUKIN ....................... 28
PROLIA ................................ 83
PROMACTA ........................ 47
promethazine ........................ 19
promethazine vc.................... 90
promethegan ......................... 19
propafenone .......................... 49
proparacaine ......................... 84
propranolol ........................... 50
propranolol-hydrochlorothiazid
.......................................... 52
propylthiouracil .................... 75
PROQUAD (PF) ................... 80
protonix................................. 63
protriptyline .......................... 19
PROVENTIL HFA ............... 88
PRUDOXIN ......................... 59
PULMICORT ....................... 87
PULMOZYME ..................... 88
PURIXAN ............................ 26
pyrazinamide ........................ 24
pyridostigmine bromide........ 24
Q
QUADRACEL (PF) ............. 80
quasense ................................ 72
QUESTRAN ......................... 55
quetiapine ............................. 35
quinapril ................................ 49
quinapril-hydrochlorothiazide
.......................................... 52
quinidine gluconate .............. 49
quinidine sulfate ................... 49
quinine sulfate ...................... 32
QVAR ................................... 87
R
RABAVERT (PF) ................ 80
rabeprazole ........................... 63
raloxifene .............................. 73
ramipril ................................. 49
RANEXA ............................. 53
ranitidine hcl ......................... 62
RAPAMUNE ........................ 77
RAVICTI .............................. 61
RAYOS................................. 23
REBETOL ............................ 37
REBIF (WITH ALBUMIN) . 58
REBIF REBIDOSE .............. 58
REBIF TITRATION PACK . 58
reclipsen (28) ........................ 72
RECOMBIVAX HB (PF)..... 80
RECTIV ............................... 56
REGRANEX ........................ 59
RELENZA DISKHALER .... 40
RELISTOR ........................... 62
REMICADE ......................... 77
REMODULIN ...................... 89
RENAGEL ........................... 65
RENVELA ........................... 65
repaglinide ............................ 43
RESCRIPTOR ...................... 38
reserpine ............................... 52
RESTASIS ........................... 84
RETROVIR .......................... 39
REVATIO ............................ 89
REVLIMID .................... 25, 29
REXULTI ............................. 35
REYATAZ ........................... 40
RHEUMATREX .................. 77
ribasphere ............................. 37
RIBASPHERE ..................... 37
RIBASPHERE RIBAPAK ... 37
ribavirin ................................ 37
rifabutin ................................ 24
rifampin ................................ 24
RIFATER ............................. 24
riluzole.................................. 57
rimantadine ........................... 40
risedronate ............................ 83
RISPERDAL CONSTA ....... 35
risperidone ............................ 35
RITUXAN ............................ 31
rivastigmine .......................... 16
rivastigmine tartrate.............. 16
ropinirole .............................. 33
ROTARIX ............................ 80
ROTATEQ VACCINE ........ 80
ROZEREM ........................... 90
S
SABRIL................................ 13
SAMSCA ............................. 91
SANDIMMUNE .................. 77
SANDOSTATIN LAR
DEPOT ............................. 75
SANTYL .............................. 59
SAPHRIS (BLACK
CHERRY) ........................ 35
SAVELLA ............................ 57
selegiline hcl ......................... 33
selenium sulfide.................... 59
SELZENTRY ....................... 39
SENSIPAR ........................... 74
SEREVENT DISKUS .......... 88
SEROQUEL XR................... 17
SEROSTIM .......................... 67
sertraline ............................... 18
setlakin.................................. 72
SFROWASA ........................ 82
sharobel ................................ 72
SIGNIFOR............................ 75
sildenafil ............................... 89
silver sulfadiazine ................. 11
SIMBRINZA ........................ 85
SIMCOR ......................... 53, 55
SIMPONI........................ 77, 79
SIMPONI ARIA ................... 77
SIMULECT .......................... 77
simvastatin ............................ 55
sirolimus ............................... 77
SIRTURO ............................. 24
sodium chloride .................... 92
sodium chloride 0.9 % .......... 91
sodium chloride 3 % ............. 92
SODIUM FLUORIDE ......... 92
sodium phenylbutyrate ......... 64
sodium polystyrene (sorb free)
.......................................... 91
SOLTAMOX ........................ 25
SOMATULINE DEPOT ...... 75
SOMAVERT ........................ 75
sorine .................................... 49
sotalol ................................... 49
sotalol af ............................... 49
SOVALDI ............................ 37
SPIRIVA RESPIMAT .......... 87
SPIRIVA WITH
HANDIHALER ................ 87
spironolactone ...................... 54
spironolacton-hydrochlorothiaz
.......................................... 53
sprintec (28) .......................... 72
SPRYCEL ............................ 30
sronyx ................................... 72
ssd ......................................... 11
stavudine............................... 39
STELARA ............................ 59
STIVARGA .......................... 30
STRATTERA ....................... 57
STRENSIQ ........................... 61
streptomycin ........................... 5
STRIBILD ............................ 38
SUBOXONE .......................... 5
SUCRAID............................. 61
sucralfate............................... 63
sulfacetamide sodium ........... 11
sulfacetamide sodium (acne) 11
sulfacetamide-prednisolone .. 23
sulfadiazine ........................... 11
sulfamethoxazole-trimethoprim
.......................................... 11
sulfasalazine ......................... 82
sulfazine ec ........................... 82
sulindac ................................... 3
sumatriptan ........................... 23
sumatriptan succinate ........... 24
SUMAVEL DOSEPRO........ 24
SURMONTIL ....................... 19
SUSTIVA ............................. 38
SUTENT ............................... 30
SYLATRON ......................... 37
SYMBICORT ....................... 90
SYMLINPEN 120 ................ 43
SYMLINPEN 60 .................. 43
SYNAGIS ............................. 78
SYNAREL ............................ 75
SYNERCID ............................ 6
SYNRIBO............................. 29
SYNTHROID ....................... 73
SYPRINE ............................. 91
T
TABLOID............................. 26
tacrolimus ....................... 59, 77
TAFINLAR .......................... 30
TAGRISSO........................... 30
TAMIFLU ............................ 40
tamoxifen .............................. 25
tamsulosin ............................. 64
TARCEVA ........................... 30
TARGRETIN .......................31
tarina fe 1/20 (28) ................. 72
TASIGNA............................. 30
TAZORAC ........................... 60
taztia xt ................................. 51
TECFIDERA ........................ 58
TEFLARO .............................. 8
TEGRETOL XR ................... 15
TEKTURNA......................... 53
TEKTURNA HCT................ 53
TEMOVATE ........................ 66
TENIVAC (PF) .................... 81
terazosin ................................ 64
103
103
terbinafine hcl ....................... 21
terbutaline ............................. 88
terconazole ..................... 21, 22
TESTIM ............................... 68
testosterone ........................... 68
testosterone cypionate .......... 68
tetanus,diphtheria tox ped(pf)
.......................................... 81
tetanus-diphtheria toxoids-td 81
tetrabenazine......................... 57
THALOMID......................... 25
theophylline .......................... 89
thioridazine ........................... 34
thiotepa ................................. 25
thiothixene ............................ 34
THYMOGLOBULIN ........... 78
tiagabine ............................... 13
TIKOSYN ............................ 49
timolol maleate ............... 50, 85
TIMOPTIC OCUDOSE (PF)
.......................................... 85
TIVICAY ............................. 38
tizanidine .............................. 35
TOBRADEX .......................... 5
tobramycin .............................. 6
tobramycin in 0.225 % nacl ... 6
tobramycin sulfate .................. 6
tobramycin-dexamethasone.. 84
tolazamide ............................ 43
tolbutamide ........................... 43
tolcapone .............................. 32
tolmetin................................... 3
tolterodine............................. 64
topiramate ............................. 14
toposar .................................. 29
topotecan .............................. 29
TORISEL ............................. 77
torsemide .............................. 54
TOVIAZ ............................... 64
TRACLEER ......................... 89
TRADJENTA ....................... 43
tramadol .................................. 4
tramadol-acetaminophen ........ 1
trandolapril ........................... 49
trandolapril-verapamil .......... 53
tranexamic acid .................... 48
TRANSDERM-SCOP .......... 20
tranylcypromine ................... 17
TRAVATAN Z .................... 86
trazodone .............................. 17
104
104
TREANDA ..................... 25, 28
TRECATOR ......................... 24
TRELSTAR .......................... 75
tretinoin ................................ 60
tretinoin (chemotherapy) ...... 31
TREXALL ............................ 78
TREXIMET .......................... 23
triamcinolone acetonide 58, 66,
87
triamterene-hydrochlorothiazid
.......................................... 53
TRIBENZOR........................ 53
triderm .................................. 66
trifluoperazine ...................... 34
trifluridine............................. 37
trihexyphenidyl ..................... 32
tri-legest fe ............................ 72
trilyte with flavor packets ..... 63
trimethobenzamide ............... 20
trimethoprim ........................... 7
trimipramine ......................... 19
trinessa (28) .......................... 72
tri-previfem (28) ................... 72
TRISENOX .......................... 28
tri-sprintec (28) ..................... 72
TRIUMEQ ............................ 39
trivora (28) ............................ 72
TROKENDI XR ................... 14
TRUMENBA........................ 81
TRUVADA .......................... 39
TUDORZA PRESSAIR ....... 88
TWINRIX (PF)..................... 81
TYBOST .............................. 39
TYKERB .............................. 30
TYPHIM VI ......................... 81
TYSABRI ............................. 58
TYZEKA .............................. 36
U
ULORIC ............................... 22
unithroid ............................... 74
ursodiol ................................. 62
UVADEX ............................. 60
V
VAGIFEM ............................ 69
valacyclovir .......................... 37
VALCHLOR ........................ 60
VALCYTE ........................... 36
valganciclovir ....................... 36
valproate sodium .................. 13
valproic acid ......................... 13
valproic acid (as sodium salt)
.......................................... 13
valsartan ................................ 48
valsartan-hydrochlorothiazide
.......................................... 53
vancomycin............................. 7
vandazole ................................ 7
VAQTA (PF) ........................ 81
VARIVAX (PF).................... 81
VARIZIG .............................. 81
VECTIBIX ........................... 28
VELCADE ........................... 28
velivet triphasic regimen (28)
.......................................... 72
VELPHORO ......................... 91
venlafaxine ........................... 18
VENTAVIS .......................... 89
VENTOLIN HFA ................. 88
verapamil .............................. 51
VEREGEN ........................... 60
VERSACLOZ....................... 35
VESICARE........................... 64
VICTOZA 3-PAK ................ 43
VIDEX 2 GRAM PEDIATRIC
.......................................... 39
VIEKIRA PAK ..................... 37
VIGAMOX ........................... 11
VIIBRYD ............................. 18
VIMPAT ............................... 15
VINBLASTINE .................... 28
vincasar pfs ........................... 28
vincristine ............................. 28
vinorelbine ............................ 28
VIRACEPT........................... 40
VIRAMUNE XR .................. 38
VIRAZOLE .......................... 37
VIREAD ............................... 39
VITEKTA ............................. 38
VOLTAREN......................... 60
voriconazole ......................... 22
VOTRIENT .......................... 30
VPRIV .................................. 61
vyfemla (28) ......................... 72
VYTORIN 10-10 .................. 53
VYTORIN 10-20 .................. 53
VYTORIN 10-40 .................. 53
VYTORIN 10-80 .................. 53
W
warfarin................................. 46
water for irrigation, sterile .... 93
WELCHOL .......................... 55
X
XALKORI ............................ 30
XARELTO ........................... 46
XENAZINE .......................... 57
XGEVA ................................ 83
XOLAIR ............................... 90
XTANDI............................... 25
xulane ................................... 72
XYREM ............................... 90
Y
YERVOY ............................. 29
YF-VAX (PF) ....................... 81
YONDELIS .......................... 83
Z
zafirlukast ............................. 87
zaleplon ................................ 90
ZALTRAP ............................ 29
ZANOSAR ............................. 6
ZARXIO ............................... 47
ZAVESCA............................ 61
ZELBORAF ......................... 30
ZEMAIRA ............................ 89
zenatane ................................ 60
zenchent (28) ........................ 72
ZENPEP ............................... 61
ZETIA .................................. 55
ZIAGEN ............................... 39
zidovudine ............................ 39
ziprasidone hcl ...................... 35
ZIRGAN ............................... 36
zoledronic acid ..................... 83
zoledronic acid-mannitol-water
.......................................... 83
ZOLINZA ............................. 22
zolpidem ............................... 90
ZOMETA ............................. 83
ZONALON ........................... 60
zonisamide ............................ 12
ZORTRESS .......................... 78
ZORVOLEX........................... 3
ZOSTAVAX (PF) ................ 81
zovia 1/35e (28) .................... 72
zovia 1/50e (28) .................... 72
ZOVIRAX ............................ 37
ZUBSOLV .............................. 5
ZYCLARA ........................... 60
ZYDELIG ............................. 29
ZYFLO ................................. 87
ZYFLO CR ........................... 87
ZYKADIA ............................ 30
ZYPREXA RELPREVV ...... 35
ZYTIGA ............................... 25
ZYVOX .................................. 7
105
105
106
107
108
109
Fresenius Total Health es un plan PPO , SNP, ofrecido por Fresenius Health Plans I nsurance Company. Fresenius Health
Plans es un plan PPO con un contrato de Medicare. La inscripción en Fresenius Health Plans depende de la renovación
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Este formulario se actualizó el 1 de abril de 2 01 6. Para obtener información más reciente o si tiene otras preguntas,
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