PROSSAM 2020 Formulary (List of Covered Drugs) · PROSSAM - PROSSAM 2020 Page 1 of 173 Updated...
Transcript of PROSSAM 2020 Formulary (List of Covered Drugs) · PROSSAM - PROSSAM 2020 Page 1 of 173 Updated...
PROSSAM - PROSSAM 2020 Page 1 of 173
Updated 03/2020
PROSSAM
2020 Formulary
(List of Covered Drugs)
PROSSAM - PROSSAM 2020 Page 2 of 173
Updated 03/2020
Comprensión de los copagos por niveles: Su plan de beneficios de farmacia ofrece diferentes niveles de medicamentos que determinan los copagos: Primer Nivel: Medicamentos Genéricos Segundo Nivel: Medicamentos de Marca Preferidos. Tercer Nivel: Medicamentos de Marca No Preferidos. Cuarto Nivel: Medicamentos Especializados Biosimilares o Biotecnológicos Preferidos
Quinto Nivel: Medicamentos Especializados Biosimilares o Biotecnológicos No Preferidos
PROSSAM
Page 3 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
5-ALPHA-REDUCTASE INHIBITORS [INHIBIDORES DE LA 5-ALFA-REDUCTASA]
5-alpha-reductase Inhibitors [Inhibidores De La 5-Alfa-Reductasa]
AVODART 0.5 mg cap 3
dutasteride 0.5 mg cap 1 AVODART
dutasteride-tamsulosin hcl 0.5-0.4 mg cap 1 JALYN
finasteride 5 mg tab 1 PROSCAR
JALYN 0.5-0.4 mg cap 3
PROSCAR 5 mg tab 3
ACIDIFYING AGENTS [AGENTES ACIDIFICANTES]
Acidifying Agents [Agentes Acidificantes]
K-PHOS NO 2 305-700 mg tab 3
ADRENALS [ADRENALES]
Adrenals [Adrenales]
betamethasone sod phos & acet 6 (3-3) mg/ml inj susp 1
budesonide 3 mg cap dr prt 4 ENTOCORT PA
budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp 1 PULMICORT QL(60 / 30), AL
CELESTONE SOLUSPAN 6 (3-3) mg/ml inj susp 3
CORTEF 10 mg tab, 20 mg tab, 5 mg tab 3
cortisone acetate 25 mg tab 1 CORTONE
DEPO-MEDROL 20 mg/ml inj susp, 40 mg/ml inj susp, 80 mg/ml inj susp 3
dexamethasone 1 mg tab, 2 mg tab 1
dexamethasone 0.5 mg/5ml soln 1
dexamethasone 0.5 mg/5ml oral elix 1 BAYCADRON
dexamethasone 0.5 mg tab, 0.75 mg tab, 1.5 mg tab, 4 mg tab, 6 mg tab 1 DECADRON
DEXAMETHASONE INTENSOL 1 mg/ml oral conc 3
dexamethasone sod phosphate pf 10 mg/ml inj soln 1
dexamethasone sodium phosphate 100 mg/10ml inj soln, 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln 1
dexamethasone sodium phosphate 10 mg/ml inj soln 1 HEXADROL
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DEXPAK 10 DAY 1.5 mg (35) tab pack 3
DEXPAK 13 DAY 1.5 mg (51) tab pack 3
DEXPAK 6 DAY 1.5 mg (21) tab pack 3
DULERA 100-5 mcg/act inh aer, 200-5 mcg/act inh aer 2 QL(8.8 / 30)
ENTOCORT EC 3 mg cap dr prt 5 PA
FLOVENT DISKUS 100 mcg/blist inh aer pwdr br act, 250 mcg/blist inh aer pwdr br act, 50 mcg/blist inh aer pwdr br act 3 QL(60 / 30)
FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer 3 QL(12 / 30)
FLOVENT HFA 220 mcg/act inh aer 3 QL(24 / 30)
fludrocortisone acetate 0.1 mg tab 1 FLORINEF
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab 1 CORTEF
KENALOG 10 mg/ml inj susp, 40 mg/ml inj susp 3
MEDROL 16 mg tab, 2 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 3
methylprednisolone 16 mg tab, 32 mg tab, 4 mg tab, 4 mg tab pack, 8 mg tab 1 MEDROL
methylprednisolone acetate 40 mg/ml inj susp, 80 mg/ml inj susp 1 DEPO-MEDROL
methylprednisolone sodium succ 1000 mg inj soln, 125 mg inj soln, 40 mg inj soln 1 SOLU-MEDROL
MILLIPRED 5 mg tab 3
MILLIPRED 10 mg/5ml soln 3
MILLIPRED DP 5 mg (21) tab pack, 5 mg (48) tab pack 3
MILLIPRED DP 12-DAY 5 mg (48) tab pack 3
ORAPRED ODT 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 3
PEDIAPRED 6.7 (5 Base) mg/5ml soln 3
prednisolone 15 mg/5ml soln, 15 mg/5ml syr 1 PRELONE
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
prednisolone sodium phosphate 25 mg/5ml soln 1
prednisolone sodium phosphate 10 mg/5ml soln 1 MILLIPRED
prednisolone sodium phosphate 10 mg tab disint, 15 mg tab disint, 30 mg tab disint 1 ORAPRED
prednisolone sodium phosphate 15 mg/5ml soln 1 ORAPRED
prednisolone sodium phosphate 6.7 (5 Base) mg/5ml soln 1 PEDIAPRED
prednisolone sodium phosphate 20 mg/5ml soln 1 VERIPRED
prednisone 1 mg tab, 10 mg (21) tab pack, 10 mg (48) tab pack, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg (21) tab pack, 5 mg (48) tab pack, 5 mg tab, 50 mg tab 1
prednisone 5 mg/5ml soln 1
PREDNISONE INTENSOL 5 mg/ml oral conc 3
QVAR 40 mcg/act inh aer soln, 80 mcg/act inh aer soln 2 QL(8.7 / 30)
QVAR REDIHALER 40 mcg/act inh aer br act, 80 mcg/act inh aer br act 2 QL(10.6 / 30)
RAYOS 1 mg tab dr, 2 mg tab dr, 5 mg tab dr 3
SOLU-CORTEF 100 mg inj soln, 1000 mg inj soln, 250 mg inj soln, 500 mg inj soln 3
SOLU-MEDROL 1000 mg inj soln, 125 mg inj soln, 2 gm inj soln, 40 mg inj soln, 500 mg inj soln 3
SYMBICORT 160-4.5 mcg/act inh aer, 80-4.5 mcg/act inh aer 2 QL(10.2 / 30)
triamcinolone acetonide 40 mg/ml inj susp 1 KENALOG
UCERIS 9 mg tab er 24 hr 4 PA
VERIPRED 20 20 mg/5ml soln 3
ALCOHOL DETERRENTS [DISUASIVOS DE ALCOHOL]
Alcohol Deterrents [Disuasivos De Alcohol]
ANTABUSE 250 mg tab, 500 mg tab 3
disulfiram 250 mg tab, 500 mg tab 1 ANTABUSE
ALKALINIZING AGENTS [AGENTES ALCALINIZANTES]
Alkalinizing Agents [Agentes Alcalinizantes]
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
cytra k crystals 3300-1002 mg pckt 1
ORACIT 490-640 mg/5ml soln 3
pot & sod cit-cit ac 550-500-334 mg/5ml soln 1
potassium citrate er 10 MEQ (1080 mg) tab er, 15 MEQ (1620 mg) tab er, 5 MEQ (540 mg) tab er 1 UROCIT-K
potassium citrate-citric acid 1100-334 mg/5ml soln 1
SHOHLS MODIFIED 500-334 mg/5ml soln 3
sod citrate-citric acid 500-334 mg/5ml soln 1
TARON-CRYSTALS 3300-1002 mg pckt 3
tricitrates 550-500-334 mg/5ml soln 1
UROCIT-K 10 10 MEQ (1080 mg) tab er 3
UROCIT-K 15 15 MEQ (1620 mg) tab er 3
UROCIT-K 5 5 MEQ (540 mg) tab er 3
ALPHA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES ALFA-ADRENÉRGICOS]
Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]
CARDURA 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 3
CARDURA XL 4 mg tab er 24 hr, 8 mg tab er 24 hr 3
doxazosin mesylate 1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 CARDURA
MINIPRESS 1 mg cap, 2 mg cap, 5 mg cap 3
prazosin hcl 1 mg cap, 2 mg cap, 5 mg cap 1 MINIPRESS
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 HYTRIN
AMMONIA DETOXICANTS [DETOXIFICANTES DE AMONÍACO]
Ammonia Detoxicants [Detoxificantes De Amoníaco]
CARBAGLU 200 mg tab 3
constulose 10 gm/15ml soln 1 CONSTULOSE
enulose 10 gm/15ml soln 1
generlac 10 gm/15ml soln 1
KRISTALOSE 10 gm pckt, 20 gm pckt 3
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
lactulose 10 gm/15ml soln, 20 gm/30ml soln 1 CONSTULOSE
lactulose encephalopathy 10 gm/15ml soln 1
LITHOSTAT 250 mg tab 3
ANALGESICS AND ANTIPYRETICS [ANALGÉSICOS Y ANTIPIRÉTICOS]
Analgesics And Antipyretics, Misc [Analgésicos Y Antipiréticos, Misceláneos]
BUPAP 50-300 mg tab 3
butalbital-acetaminophen 50-300 mg tab 1 BUPAP
butalbital-acetaminophen 50-325 mg tab 1 TENCON
butalbital-apap 50-325 mg tab 1 TENCON
butalbital-apap-caffeine 50-325-40 mg cap, 50-325-40 mg tab 1 ESGIC
butalbital-apap-caffeine 50-300-40 mg cap 1 FIORICET
duraxin 300-200-20 mg cap 1
ESGIC 50-325-40 mg cap, 50-325-40 mg tab 3
FIORICET 50-300-40 mg cap 3
GRALISE 300 mg tab, 600 mg tab 3
GRALISE STARTER 300 & 600 mg oral misc 3
ILARIS 150 mg/ml sc soln 3
PHRENILIN FORTE 50-300-40 mg cap 3
PRIALT 100 mcg/ml it soln, 500 mcg/20ml it soln, 500 mcg/5ml it soln 3
TENCON 50-325 mg tab 3
VANATOL LQ 50-325-40 mg/15ml soln 3
VANATOL S 50-325-40 mg/15ml soln 3
ZEBUTAL 50-325-40 mg cap 3
Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]
ANAPROX DS 550 mg tab 3
ARTHROTEC 50-0.2 mg tab dr, 75-0.2 mg tab dr 3
butalbital-aspirin-caffeine 50-325-40 mg tab 1
butalbital-aspirin-caffeine 50-325-40 mg cap 1 FIORINAL
CAMBIA 50 mg pckt 3 QL(9 / 30)
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CELEBREX 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 3
celecoxib 100 mg cap, 200 mg cap, 400 mg cap, 50 mg cap 1 CELEBREX
choline-mag trisalicylate 500 mg/5ml liq 1
DAYPRO 600 mg tab 3
diclofenac potassium 50 mg tab 1 CATAFLAM
diclofenac sodium 25 mg tab dr, 50 mg tab dr, 75 mg tab dr 1 VOLTAREN
diclofenac sodium er 100 mg tab er 24 hr 1 VOLTAREN
diclofenac-misoprostol 50-0.2 mg tab dr, 75-0.2 mg tab dr 1 ARTHROTEC
diflunisal 500 mg tab 1 DOLOBID
DUEXIS 800-26.6 mg tab 3
EC-NAPROSYN 375 mg tab dr, 500 mg tab dr 3
etodolac 200 mg cap, 300 mg cap, 400 mg tab, 500 mg tab 1 LODINE
etodolac er 400 mg tab er 24 hr, 500 mg tab er 24 hr, 600 mg tab er 24 hr 1 LODINE XL
FELDENE 10 mg cap, 20 mg cap 3
fenoprofen calcium 400 mg cap, 600 mg tab 1 NALFON
FIORINAL 50-325-40 mg cap 3
flurbiprofen 100 mg tab, 50 mg tab 1 ANSAID
IBU 400 mg tab, 600 mg tab, 800 mg tab 1
ibuprofen 400 mg tab, 600 mg tab, 800 mg tab 1 MOTRIN
IBUPROFEN COMFORT PAC 800 mg cmb kit 3
IC 400 400 mg oral kit 3
IC 800 800 mg oral kit 3
INDOCIN 50 mg rect supp 3
INDOCIN 25 mg/5ml susp 3
indomethacin 25 mg cap, 50 mg cap 1 INDOCIN
indomethacin er 75 mg cap er 1 INDOCIN
ketoprofen 75 mg cap 1 ORUDIS
ketoprofen er 200 mg cap er 24 hr 1 ORUVAIL
ketorolac tromethamine 60 mg/2ml im soln 1
ketorolac tromethamine 10 mg tab 1 TORADOL
PROSSAM
Page 9 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ketorolac tromethamine 15 mg/ml inj soln, 30 mg/ml inj soln 1 TORADOL
meclofenamate sodium 100 mg cap, 50 mg cap 1 MECLOMEN
mefenamic acid 250 mg cap 1 PONSTEL
meloxicam 15 mg tab, 7.5 mg tab 1 MOBIC
MELOXICAM COMFORT PAC 15 mg cmb kit 3
MOBIC 15 mg tab, 7.5 mg tab 3
nabumetone 500 mg tab, 750 mg tab 1 RELAFEN
NALFON 400 mg cap 3
NAPRELAN 375 mg tab er 24 hr, 500 mg tab er 24 hr, 750 mg tab er 24 hr 3
NAPROSYN 500 mg tab 3
NAPROSYN 125 mg/5ml susp 3
naproxen 250 mg tab, 375 mg tab, 500 mg tab 1 NAPROSYN
naproxen 125 mg/5ml susp 1 NAPROSYN
NAPROXEN COMFORT PAC 500 mg cmb kit 3
naproxen dr 375 mg tab dr, 500 mg tab dr 1 NAPROSYN
naproxen sodium 275 mg tab, 550 mg tab 1 ANAPROX
naproxen sodium er 500 mg tab er 24 hr 1 NAPRELAN
oxaprozin 600 mg tab 1 DAYPRO
piroxicam 10 mg cap, 20 mg cap 1 FELDENE
salsalate 500 mg tab, 750 mg tab 1
SPRIX 15.75 mg/spray nasal soln 3
sulindac 150 mg tab, 200 mg tab 1 CLINORIL
tolmetin sodium 200 mg tab 1
tolmetin sodium 400 mg cap, 600 mg tab 1 TOLECTIN
VIMOVO 375-20 mg tab dr, 500-20 mg tab dr 3
ZIPSOR 25 mg cap 3
Opiate Agonists [Agonistas De Opiáceos]
ABSTRAL 100 mcg tab subl, 200 mcg tab subl, 300 mcg tab subl, 400 mcg tab subl, 600 mcg tab subl, 800 mcg tab subl 3
acetaminophen-codeine 300-15 mg tab, 300-60 mg tab 1
TYLENOL WITH CODEINE
PROSSAM
Page 10 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
acetaminophen-codeine 120-12 mg/5ml soln 1
TYLENOL WITH CODEINE
acetaminophen-codeine #2 300-15 mg tab 1
TYLENOL WITH CODEINE
acetaminophen-codeine #3 300-30 mg tab 1
TYLENOL WITH CODEINE
acetaminophen-codeine #4 300-60 mg tab 1
TYLENOL WITH CODEINE
ACTIQ 1200 mcg bucc lozg on hd, 1600 mcg bucc lozg on hd, 200 mcg bucc lozg on hd, 400 mcg bucc lozg on hd, 600 mcg bucc lozg on hd, 800 mcg bucc lozg on hd 3
ASCOMP-CODEINE 50-325-40-30 mg cap 3
butalbital-apap-caff-cod 50-325-40-30 mg cap 1
FIORICET WITH CODEINE
butalbital-asa-caff-codeine 50-325-40-30 mg cap 1
FIORINAL WITH CODEINE
codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab 1
CONZIP 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3
DEMEROL 100 mg tab 3
DEMEROL 100 mg/2ml inj soln, 100 mg/ml inj soln, 25 mg/0.5ml inj soln, 25 mg/ml inj soln, 50 mg/ml inj soln, 75 mg/1.5ml inj soln, 75 mg/ml inj soln 3
DILAUDID 2 mg tab, 4 mg tab, 8 mg tab 3
DILAUDID 1 mg/ml liq 3
DURAGESIC-100 100 mcg/hr td patch 72 hr 3
DURAGESIC-12 12 mcg/hr td patch 72 hr 3
DURAGESIC-25 25 mcg/hr td patch 72 hr 3
DURAGESIC-50 50 mcg/hr td patch 72 hr 3
DURAGESIC-75 75 mcg/hr td patch 72 hr 3
duramorph 0.5 mg/ml inj soln, 1 mg/ml inj soln 1
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ENDOCET 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1
ENDOCET 2.5-325 mg tab 3
EXALGO 12 mg tab er 24 hr abuse-deterr, 16 mg tab er 24 hr abuse-deterr, 32 mg tab er 24 hr abuse-deterr, 8 mg tab er 24 hr abuse-deterr 3
fentanyl 100 mcg/hr td patch 72 hr, 12 mcg/hr td patch 72 hr, 25 mcg/hr td patch 72 hr, 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr 1 DURAGESIC
fentanyl citrate 1200 mcg bucc lozg on hd, 1600 mcg bucc lozg on hd, 200 mcg bucc lozg on hd, 400 mcg bucc lozg on hd, 600 mcg bucc lozg on hd, 800 mcg bucc lozg on hd 1 ACTIQ
FENTORA 100 mcg bucc tab, 200 mcg bucc tab, 400 mcg bucc tab, 600 mcg bucc tab, 800 mcg bucc tab 3
FIORINAL/CODEINE #3 50-325-40-30 mg cap 3
hydrocodone-acetaminophen 2.5-108 mg/5ml soln, 5-217 mg/10ml soln, 7.5-325 mg/15ml soln 1 HYCET
hydrocodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 NORCO
hydrocodone-acetaminophen 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 1 VICODIN
hydrocodone-ibuprofen 10-200 mg tab, 5-200 mg tab 1 REPREXAIN
hydrocodone-ibuprofen 7.5-200 mg tab 1 VICOPROFEN
hydromorphone hcl 1 mg/ml inj soln 1
hydromorphone hcl 2 mg tab, 4 mg tab, 8 mg tab 1 DILAUDID
hydromorphone hcl 1 mg/ml liq 1 DILAUDID
hydromorphone hcl er 12 mg tab er 24 hr abuse-deterr, 16 mg tab er 24 hr abuse-deterr, 32 mg tab er 24 hr abuse-deterr, 8 mg tab er 24 hr abuse-deterr 1 EXALGO
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
hydromorphone hcl pf 10 mg/ml inj soln, 50 mg/5ml inj soln, 500 mg/50ml inj soln 1 DILAUDID-HP
IBUDONE 10-200 mg tab, 5-200 mg tab 3
KADIAN 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 200 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 3
LAZANDA 100 mcg/act nasal soln, 400 mcg/act nasal soln 3
levorphanol tartrate 2 mg tab 1
LORCET 5-325 mg tab 3
LORCET HD 10-325 mg tab 3
LORCET PLUS 7.5-325 mg tab 3
LORTAB 10-300 mg/15ml oral elix 3
MAXIDONE 10-750 mg tab 3
meperidine hcl 10 mg/ml inj soln 1
meperidine hcl 100 mg tab, 50 mg tab 1 DEMEROL
meperidine hcl 100 mg/ml inj soln, 25 mg/ml inj soln, 50 mg/5ml soln, 50 mg/ml inj soln 1 DEMEROL
morphine sulfate 15 mg tab, 30 mg tab 1
morphine sulfate 10 mg/5ml soln, 20 mg/5ml soln 1
morphine sulfate (concentrate) 100 mg/5ml soln 1
morphine sulfate (pf) 0.5 mg/ml inj soln, 1 mg/ml inj soln 1
morphine sulfate er 10 mg cap er 24 hr, 100 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 50 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 KADIAN
morphine sulfate er 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 1 MS CONTIN
morphine sulfate er beads 120 mg cap er 24 hr, 30 mg cap er 24 hr, 45 mg cap er 24 hr, 60 mg cap er 24 hr, 75 mg cap er 24 hr, 90 mg cap er 24 hr 1 AVINZA
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MS CONTIN 100 mg tab er, 15 mg tab er, 200 mg tab er, 30 mg tab er, 60 mg tab er 3
NORCO 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3
NUCYNTA 100 mg tab, 50 mg tab, 75 mg tab 3
NUCYNTA ER 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr, 250 mg tab er 12 hr, 50 mg tab er 12 hr 3
OXAYDO 5 mg tab abuse-deterr, 7.5 mg tab abuse-deterr 3
oxycodone hcl 10 mg tab, 20 mg tab, 5 mg cap 1
oxycodone hcl 15 mg tab, 30 mg tab, 5 mg tab 1 ROXICODONE
oxycodone hcl 100 mg/5ml oral conc, 5 mg/5ml soln 1 ROXICODONE
oxycodone hcl er 10 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 1 OXYCONTIN
oxycodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 PERCOCET
oxycodone-aspirin 4.8355-325 mg tab 1 PERCODAN
oxycodone-ibuprofen 5-400 mg tab 1 COMBUNOX
OXYCONTIN 10 mg tab er 12 hr abuse-deterr, 15 mg tab er 12 hr abuse-deterr, 20 mg tab er 12 hr abuse-deterr, 30 mg tab er 12 hr abuse-deterr, 40 mg tab er 12 hr abuse-deterr, 60 mg tab er 12 hr abuse-deterr, 80 mg tab er 12 hr abuse-deterr 3
oxymorphone hcl 10 mg tab, 5 mg tab 1 OPANA
oxymorphone hcl er 15 mg tab er 12 hr, 7.5 mg tab er 12 hr 1 OPANA ER
PERCOCET 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 3
PROSSAM
Page 14 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PRIMLEV 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 3
ROXICODONE 15 mg tab, 30 mg tab, 5 mg tab 3
SUBSYS 100 mcg subl liq, 1200 (600 X 2) mcg subl liq, 1600 (800 X 2) mcg subl liq, 200 mcg subl liq, 400 mcg subl liq, 600 mcg subl liq, 800 mcg subl liq 3
tramadol hcl 50 mg tab 1 ULTRAM
tramadol hcl er 150 mg cap er 24 hr 1
tramadol hcl er 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 1 CONZIP
tramadol hcl er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 ULTRAM ER
tramadol hcl er (biphasic) 100 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr 1 RYZOLT
tramadol-acetaminophen 37.5-325 mg tab 1 ULTRACET
TYLENOL WITH CODEINE #3 300-30 mg tab 3
TYLENOL WITH CODEINE #4 300-60 mg tab 3
ULTRACET 37.5-325 mg tab 3
ULTRAM 50 mg tab 3
VICODIN 5-300 mg tab 3
VICODIN ES 7.5-300 mg tab 3
VICODIN HP 10-300 mg tab 3
Opiate Partial Agonists [Agonistas Parciales De Opiáceos]
buprenorphine 10 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch 1 BUTRANS PA
buprenorphine hcl 2 mg tab subl, 8 mg tab subl 1 SUBUTEX PA
buprenorphine hcl-naloxone hcl 2-0.5 mg tab subl, 8-2 mg tab subl 1 SUBOXONE PA
butorphanol tartrate 1 mg/ml inj soln, 10 mg/ml nasal soln, 2 mg/ml inj soln 1 STADOL PA
BUTRANS 10 mcg/hr tdwk patch, 20 mcg/hr tdwk patch, 5 mcg/hr tdwk patch 3 PA
nalbuphine hcl 10 mg/ml inj soln 1 NUBAIN PA
PROSSAM
Page 15 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
pentazocine-naloxone hcl 50-0.5 mg tab 1 PA
SUBOXONE 12-3 mg subl film, 2-0.5 mg subl film, 4-1 mg subl film, 8-2 mg subl film 3 PA
ZUBSOLV 1.4-0.36 mg tab subl, 5.7-1.4 mg tab subl 3 PA
ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS [AGENTES ANOREXÍGENOS Y ESTIMULANTES RESPIRATORIOS Y DEL SNC]
Amphetamines [Anfetaminas]
ADDERALL 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 3 PA
ADDERALL XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA
amphetamine-dextroamphet er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 5 mg cap er 24 hr 1 ADDERALL XR PA
amphetamine-dextroamphetamine 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 ADDERALL PA
DESOXYN 5 mg tab 3 PA
DEXEDRINE 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA
dextroamphetamine sulfate 5 mg/5ml soln 1 PA
dextroamphetamine sulfate 10 mg tab, 5 mg tab 1 DEXEDRINE PA
dextroamphetamine sulfate er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 5 mg cap er 24 hr 1 DEXEDRINE PA
methamphetamine hcl 5 mg tab 1 DESOXYN PA
PROCENTRA 5 mg/5ml soln 3 PA
VYVANSE 10 mg cap, 10 mg tab chew, 20 mg cap, 20 mg tab chew, 30 mg cap, 30 mg tab chew, 40 mg cap, 40 mg tab chew, 50 mg cap, 50 mg tab chew, 60 mg cap, 60 mg tab chew, 70 mg cap 3 PA
Respiratory And Cns Stimulants [Estimulantes Del Snc Y Respiratorios]
PROSSAM
Page 16 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CONCERTA 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 3 PA
DAYTRANA 10 mg/9hr td patch, 15 mg/9hr td patch, 20 mg/9hr td patch, 30 mg/9hr td patch 3 PA
dexmethylphenidate hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 FOCALIN PA
dexmethylphenidate hcl er 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 1 FOCALIN XR PA
FOCALIN 10 mg tab, 2.5 mg tab, 5 mg tab 3 PA
FOCALIN XR 10 mg cap er 24 hr, 15 mg cap er 24 hr, 20 mg cap er 24 hr, 25 mg cap er 24 hr, 30 mg cap er 24 hr, 35 mg cap er 24 hr, 40 mg cap er 24 hr, 5 mg cap er 24 hr 3 PA
METADATE ER 20 mg tab er 3 PA
METHYLIN 10 mg/5ml soln, 5 mg/5ml soln 3 PA
methylphenidate hcl 10 mg tab chew, 2.5 mg tab chew, 5 mg tab chew 1 METHYLIN PA
methylphenidate hcl 10 mg/5ml soln, 5 mg/5ml soln 1 METHYLIN PA
methylphenidate hcl 10 mg tab, 20 mg tab, 5 mg tab 1 RITALIN PA
methylphenidate hcl er 18 mg tab er 24 hr, 27 mg tab er 24 hr, 36 mg tab er 24 hr, 54 mg tab er 24 hr 1 PA
methylphenidate hcl er 18 mg tab er, 27 mg tab er, 36 mg tab er, 54 mg tab er 1 CONCERTA PA
methylphenidate hcl er 10 mg tab er 1 METADATE PA
methylphenidate hcl er 20 mg tab er 1 RITALIN SR PA
methylphenidate hcl er (cd) 30 mg cap er, 50 mg cap er, 60 mg cap er 1 METADATE PA
methylphenidate hcl er (cd) 10 mg cap er, 20 mg cap er, 40 mg cap er 1 METADATE CD PA
PROSSAM
Page 17 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
methylphenidate hcl er (la) 30 mg cap er 24 hr 1 PA
methylphenidate hcl er (la) 20 mg cap er 24 hr, 40 mg cap er 24 hr 1 RITALIN LA PA
RITALIN 10 mg tab, 20 mg tab, 5 mg tab 3 PA
RITALIN LA 10 mg cap er 24 hr, 20 mg cap er 24 hr, 30 mg cap er 24 hr, 40 mg cap er 24 hr 3 PA
Wakefulness-promoting Agents [Agentes Promotores Del Estado De Vigilia]
modafinil 100 mg tab, 200 mg tab 1 PROVIGIL
NUVIGIL 150 mg tab, 250 mg tab, 50 mg tab 3
PROVIGIL 100 mg tab, 200 mg tab 3
ANTHELMINTICS [ANTIHELMÍNTICOS]
Anthelmintics [Antihelmínticos]
ALBENZA 200 mg tab 3
BILTRICIDE 600 mg tab 3
ivermectin 3 mg tab 1 STROMECTOL
STROMECTOL 3 mg tab 3
ANTIALLERGIC AGENTS [AGENTES ANTIALÉRGICOS]
Antiallergic Agents [Agentes Antialérgicos]
ALOMIDE 0.1 % ophth soln 3
ASTEPRO 0.15 % nasal soln 3
azelastine hcl 0.1 % nasal soln, 137 mcg/spray nasal soln 1 ASTELIN
azelastine hcl 0.15 % nasal soln 1 ASTEPRO
azelastine hcl 0.05 % ophth soln 1 OPTIVAR
BEPREVE 1.5 % ophth soln 3
cromolyn sodium 4 % ophth soln 1 OPTICROM
DYMISTA 137-50 mcg/act nasal susp 2
ELESTAT 0.05 % ophth soln 3
EMADINE 0.05 % ophth soln 3
epinastine hcl 0.05 % ophth soln 1 ELESTAT
LASTACAFT 0.25 % ophth soln 2
olopatadine hcl 0.6 % nasal soln 1 PATANASE
PATADAY 0.2 % ophth soln 2
PATANASE 0.6 % nasal soln 3
ANTIANEMIA DRUGS [MEDICAMENTOS CONTRA LA ANEMIA]
Iron Preparations [Preparaciones De Hierro]
BIFERARX 22-6-1-0.025 mg tab 3
BPROTECTED PEDIA IRON 75 (15 Fe) mg/ml soln 1 AL
CENTRATEX 106-1 mg cap 3
CHROMAGEN cap 3
PROSSAM
Page 18 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CORVITA 150 150-1.25 mg tab 3
CORVITE 150 150-1.25 mg tab 3
corvite fe tab 1
FER-IN-SOL 75 (15 Fe) mg/ml soln 1 AL
ferocon cap 1
ferotrinsic cap 1
FERRALET 90 90-1 mg tab 3
ferraplus 90 90-1 mg tab 1
FERREX 150 FORTE PLUS 50-100 mg cap 3
FERROCITE PLUS 106-1 mg tab 3
FERRO-PLEX HEMATINIC 115-1 mg tab 3
FERROTRIN cap 3
ferrous sulfate 75 (15 Fe) mg/ml soln 1 AL
FOLIVANE-F 125-1 mg cap 3
FOLIVANE-PLUS cap 3
foltrin cap 1
hematinic plus vit/minerals 106-1 mg tab 1
hematinic/folic acid 324-1 mg tab 1
HEMATOGEN cap 3
HEMATOGEN FA 200-250-0.01-1 mg cap 3
HEMATOGEN FORTE 460-60-0.01-1 mg cap 3
HEMATRON-AF 150-1 mg tab 3
hemetab 22-6-1-0.025 mg tab 1
HEMOCYTE PLUS 106-1 mg cap 3
HEMOCYTE-F 324-1 mg tab 3
hemocyte-plus 106-1 mg tab 1
ICAR-C PLUS 100-250-0.025-1 mg tab 3
IFEREX 150 FORTE 150-25-1 mg-mcg-mg cap 3
INTEGRA F 125-1 mg cap 3
INTEGRA PLUS cap 3
iron supplement childrens 75 (15 Fe) mg/ml soln 1 AL
IROSPAN 24/6 oral misc 3
IS 24/6 oral misc 3
K-TAN PLUS 162-115.2-1 mg cap 3
MULTIGEN 70 mg tab 3
MULTIGEN FOLIC 70-150-2-1 mg tab 3
PROSSAM
Page 19 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MULTIGEN PLUS 50-101-1 mg tab 3
myferon 150 forte 150-25-1 mg-mcg-mg cap 1
NEPHRON FA tab 3
poly-iron 150 forte 150-25-1 mg-mcg-mg cap 1
polysaccharide iron forte 150-25-1 mg-mcg-mg cap 1
PROFERRIN-FORTE 12-1 mg tab 3
PROTECTIRON 60-1 mg tab 3
purefe plus 106-1 mg cap 1
purevit dualfe plus 162-115.2-1 mg cap 1
RENATABS WITH IRON 1 & 100 mg oral misc 3
se-tan plus 162-115.2-1 mg cap 1
TANDEM F 162-115.2-1 mg cap 3
TANDEM PLUS 162-115.2-1 mg cap 3
taron forte cap 1
tl icon cap 1
tl-hem 150 150-1 mg tab 1
TRICON cap 3
trigels-f forte 460-60-0.01-1 mg cap 1
VITAFOL tab 3
ANTIBACTERIALS [ANTIBACTERIANOS]
Aminoglycosides [Aminoglucósidos]
amikacin sulfate 1 gm/4ml inj soln 1
amikacin sulfate 500 mg/2ml inj soln 1 AMIKIN
gentamicin sulfate 10 mg/ml inj soln 1
gentamicin sulfate 40 mg/ml inj soln 1 GENTAK
KITABIS PAK 300 mg/5ml inh neb soln 5 PA
neomycin sulfate 500 mg tab 1
streptomycin sulfate 1 gm im soln 1
TOBI 300 mg/5ml inh neb soln 5 PA
tobramycin 300 mg/5ml inh neb soln 5 TOBI PA
tobramycin sulfate 1.2 gm inj soln 1
tobramycin sulfate 1.2 gm/30ml inj soln, 10 mg/ml inj soln, 2 gm/50ml inj soln, 80 mg/2ml inj soln 1
Antibacterials, Miscellaneous [Antibacterianos, Misceláneos]
baciim 50000 unit im soln 1 BACI-IM
bacitracin 50000 unit im soln 1 BACI-IM
PROSSAM
Page 20 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CLEOCIN 150 mg cap, 300 mg cap, 75 mg cap 3
CLEOCIN 75 mg/5ml soln 3
CLEOCIN PHOSPHATE 900 mg/6ml inj soln 3
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap 1 CLEOCIN
clindamycin palmitate hcl 75 mg/5ml soln 1 CLEOCIN
clindamycin phosphate 600 mg/4ml iv soln 1
clindamycin phosphate 900 mg/6ml inj soln 1 CLEOCIN
colistimethate sodium (cba) 150 mg inj soln 1
COLY-MYCIN M 150 mg inj soln 3
LINCOCIN 300 mg/ml inj soln 3
lincomycin hcl 300 mg/ml inj soln 1 LINCOCIN
linezolid 600 mg/300ml iv soln 4 ZYVOX PA
linezolid 600 mg tab 5 ZYVOX PA
linezolid 100 mg/5ml susp 5 ZYVOX PA
linezolid in sodium chloride 600-0.9 mg/300ml-% iv soln 4 PA
VANCOCIN HCL 125 mg cap, 250 mg cap 5 PA
vancomycin hcl 125 mg cap, 250 mg cap 1
XIFAXAN 200 mg tab, 550 mg tab 5 PA
ZYVOX 600 mg tab 5 PA
ZYVOX 100 mg/5ml susp, 200 mg/100ml iv soln, 600 mg/300ml iv soln 5 PA
Cephalosporins [Cefalosporinas]
cefaclor 250 mg cap, 500 mg cap 1 CECLOR
cefaclor er 500 mg tab er 12 hr 1 CECLOR CD
cefadroxil 1 gm tab, 500 mg cap 1 DURICEF
cefadroxil 250 mg/5ml susp, 500 mg/5ml susp 1 DURICEF
cefazolin sodium 1 gm inj soln, 500 mg inj soln 1 ANCEF
cefdinir 300 mg cap 1 OMNICEF
cefdinir 125 mg/5ml susp, 250 mg/5ml susp 1 OMNICEF
cefditoren pivoxil 200 mg tab, 400 mg tab 1 SPECTRACEF
PROSSAM
Page 21 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
cefepime hcl 1 gm inj soln, 2 gm inj soln 1 MAXIPIME
cefixime 100 mg/5ml susp, 200 mg/5ml susp 1 SUPRAX
cefpodoxime proxetil 100 mg tab, 200 mg tab 1 VANTIN
cefpodoxime proxetil 100 mg/5ml susp, 50 mg/5ml susp 1 VANTIN
cefprozil 250 mg tab, 500 mg tab 1 CEFZIL
cefprozil 125 mg/5ml susp, 250 mg/5ml susp 1 CEFZIL
ceftazidime 1 gm inj soln 1 TAZICEF
CEFTIN 125 mg/5ml susp, 250 mg/5ml susp 3
ceftriaxone sodium 1 gm inj soln, 2 gm inj soln, 250 mg inj soln, 500 mg inj soln 1 ROCEPHIN
cefuroxime axetil 250 mg tab, 500 mg tab 1 CEFTIN
cefuroxime sodium 1.5 gm iv soln 1
cefuroxime sodium 750 mg inj soln 1 ZINACEF
cephalexin 250 mg tab, 500 mg tab 1
cephalexin 250 mg cap, 500 mg cap, 750 mg cap 1 KEFLEX
cephalexin 125 mg/5ml susp, 250 mg/5ml susp 1 KEFLEX
KEFLEX 250 mg cap, 500 mg cap, 750 mg cap 3
SPECTRACEF 400 mg tab 3
SUPRAX 100 mg tab chew, 200 mg tab chew 3
SUPRAX 100 mg/5ml susp, 200 mg/5ml susp 3
Macrolides [Macrólidos]
azithromycin 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 1 ZITHROMAX
azithromycin 100 mg/5ml susp, 200 mg/5ml susp 1 ZITHROMAX
clarithromycin 250 mg tab, 500 mg tab 1 BIAXIN
clarithromycin 125 mg/5ml susp, 250 mg/5ml susp 1 BIAXIN
clarithromycin er 500 mg tab er 24 hr 1 BIAXIN XL
DIFICID 200 mg tab 3
E.E.S. 400 400 mg tab 3
PROSSAM
Page 22 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
E.E.S. GRANULES 200 mg/5ml susp 3
ERYPED 200 200 mg/5ml susp 3
ERYPED 400 400 mg/5ml susp 3
ERY-TAB 250 mg tab dr, 333 mg tab dr, 500 mg tab dr 3
ERYTHROCIN STEARATE 250 mg tab 3
erythromycin base 250 mg cap dr prt, 250 mg tab 1
erythromycin base 500 mg tab 1 ERY-TAB
erythromycin ethylsuccinate 400 mg tab 1 E.E.S.
erythromycin ethylsuccinate 200 mg/5ml susp 1 ERYPED
PCE 333 mg tab dr, 500 mg tab dr 3
ZITHROMAX 1 gm pckt, 250 mg tab, 500 mg tab, 600 mg tab 3
ZITHROMAX 100 mg/5ml susp, 200 mg/5ml susp 3
ZITHROMAX TRI-PAK 500 mg tab 3
ZITHROMAX Z-PAK 250 mg tab 3
Miscellaneous B-lactam Antibiotics [Antibióticos Betalactámicos Misceláneos]
AZACTAM 1 gm inj soln, 2 gm inj soln 3
aztreonam 1 gm inj soln, 2 gm inj soln 1
CAYSTON 75 mg inh soln 5 PA
Penicillins [Penicilinas]
amoxicillin 125 mg tab chew, 250 mg cap, 250 mg tab chew, 500 mg cap, 500 mg tab, 875 mg tab 1 AMOXIL
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg/5ml susp, 400 mg/5ml susp 1 AMOXIL
amoxicillin-pot clavulanate 200-28.5 mg tab chew, 250-125 mg tab, 400-57 mg tab chew, 500-125 mg tab, 875-125 mg tab 1 AUGMENTIN
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 250-62.5 mg/5ml susp, 400-57 mg/5ml susp, 600-42.9 mg/5ml susp 1 AUGMENTIN
amoxicillin-pot clavulanate er 1000-62.5 mg tab er 12 hr 1 AUGMENTIN XR
ampicillin 500 mg cap 1
PROSSAM
Page 23 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ampicillin sodium 10 gm inj soln, 10 gm iv soln, 125 mg inj soln, 2 gm inj soln, 2 gm iv soln, 250 mg inj soln, 500 mg inj soln 1
ampicillin sodium 1 gm inj soln 1 TOTACILLIN-N
AUGMENTIN 500-125 mg tab, 875-125 mg tab 3
AUGMENTIN 125-31.25 mg/5ml susp, 250-62.5 mg/5ml susp 3
AUGMENTIN ES-600 600-42.9 mg/5ml susp 3
AUGMENTIN XR 1000-62.5 mg tab er 12 hr 3
BICILLIN C-R 1200000 unit/2ml im susp 2
BICILLIN C-R 900/300 900000-300000 unit/2ml im susp 2
BICILLIN L-A 1200000 unit/2ml im susp, 2400000 unit/4ml im susp, 600000 unit/ml im susp 2
dicloxacillin sodium 250 mg cap, 500 mg cap 1 DYCILL
MOXATAG 775 mg tab er 24 hr 3
nafcillin sodium 10 gm iv soln, 2 gm inj soln 1
nafcillin sodium 1 gm inj soln 1 NALLPEN
oxacillin sodium 1 gm inj soln, 10 gm inj soln, 2 gm inj soln 1
penicillin g potassium 20000000 unit inj soln, 5000000 unit inj soln 1 PFIZERPEN
penicillin g procaine 600000 unit/ml im susp 1
penicillin g sodium 5000000 unit inj soln 1
penicillin v potassium 500 mg tab 1 PEN-VEE K
penicillin v potassium 250 mg tab 1 VEETIDS
penicillin v potassium 125 mg/5ml soln, 250 mg/5ml soln 1 VEETIDS
PFIZERPEN 20000000 unit inj soln, 5000000 unit inj soln 3
Quinolones [Quinolonas]
AVELOX 400 mg tab 3
CIPRO 250 mg tab, 500 mg tab 3
CIPRO 250 MG/5ML (5%) susp, 500 MG/5ML (10%) susp 3
PROSSAM
Page 24 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ciprofloxacin 500 MG/5ML (10%) susp 1 CIPRO
ciprofloxacin hcl 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 CIPRO
ciprofloxacin-ciproflox hcl er 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 CIPRO XR
LEVAQUIN 250 mg tab, 500 mg tab, 750 mg tab 3
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab 1 LEVAQUIN
levofloxacin 25 mg/ml soln 1 LEVAQUIN
moxifloxacin hcl 400 mg tab 1 AVELOX
ofloxacin 300 mg tab, 400 mg tab 1 FLOXIN
Sulfonamides [Sulfonamidas]
AZULFIDINE 500 mg tab 3
AZULFIDINE EN-TABS 500 mg tab dr 3
BACTRIM 400-80 mg tab 3
BACTRIM DS 800-160 mg tab 3
sulfadiazine 500 mg tab 1
sulfamethoxazole-trimethoprim 400-80 mg tab, 800-160 mg tab 1 SEPTRA
sulfamethoxazole-trimethoprim 200-40 mg/5ml susp, 400-80 mg/5ml iv soln 1 SEPTRA
sulfasalazine 500 mg tab, 500 mg tab dr 1 AZULFIDINE
Tetracyclines [Tetraciclinas]
avidoxy 100 mg tab 1 ADOXA
AVIDOXY DK 100 mg cmb kit 3
demeclocycline hcl 150 mg tab, 300 mg tab 1 DECLOMYCIN
doxycycline hyclate 100 mg cap dr prt, 100 mg tab dr, 150 mg tab dr, 75 mg tab dr 1 DORYX
doxycycline hyclate 100 mg iv soln 1 DOXY
doxycycline hyclate 20 mg tab 1 PERIOSTAT
doxycycline hyclate 100 mg tab 1 VIBRA-TABS
doxycycline hyclate 100 mg cap, 50 mg cap 1 VIBRAMYCIN
doxycycline monohydrate 100 mg tab, 150 mg cap, 150 mg tab, 50 mg tab, 75 mg tab 1 ADOXA
doxycycline monohydrate 100 mg cap, 50 mg cap, 75 mg cap 1 MONODOX
PROSSAM
Page 25 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
doxycycline monohydrate 25 mg/5ml susp 1 VIBRAMYCIN
MINOCIN 100 mg cap, 50 mg cap 3
minocycline hcl pwdr 1
minocycline hcl 100 mg tab, 50 mg tab, 75 mg tab 1 DYNACIN
minocycline hcl 100 mg cap, 50 mg cap, 75 mg cap 1 MINOCIN
MONDOXYNE NL 100 mg cap, 50 mg cap, 75 mg cap 3
MORGIDOX 1 x 100 mg cmb kit, 100 mg cap, 2 x 100 mg cmb kit 3
NUTRIDOX 75 mg oral kit 3
OKEBO 75 mg cap 3
tetracycline hcl 250 mg cap, 500 mg cap 1
VIBRAMYCIN 100 mg cap 3
VIBRAMYCIN 25 mg/5ml susp, 50 mg/5ml syr 3
ANTICHOLINERGIC AGENTS [AGENTES ANTICOLINÉRGICOS]
Antimuscarinics/antispasmodics [Antimuscarínicos/Antiespasmódicos]
ANASPAZ 0.125 mg tab disint 3
ATROPEN 0.25 mg/0.3ml im soln auto-inj, 0.5 mg/0.7ml im soln auto-inj, 1 mg/0.7ml im soln auto-inj, 2 mg/0.7ml im soln auto-inj 3
ATROVENT HFA 17 mcg/act inh aer soln 3 QL(12.9 / 25)
BENTYL 10 mg/ml im soln 3
BENTYL 10 mg cap 3 QL(90 / 365)
chlordiazepoxide-clidinium 5-2.5 mg cap 1
CUVPOSA 1 mg/5ml soln 3
dicyclomine hcl 10 mg/5ml soln, 10 mg/ml im soln 1 BENTYL
dicyclomine hcl 10 mg cap, 20 mg tab 1 BENTYL QL(90 / 365)
ed-spaz 0.125 mg tab disint 1
glycopyrrolate 0.2 mg/ml inj soln, 0.4 mg/2ml inj soln, 1 mg/5ml inj soln 1
glycopyrrolate 4 mg/20ml inj soln 1 ROBINUL
glycopyrrolate 1 mg tab, 2 mg tab 1 ROBINUL QL(90 / 365)
hyoscyamine sulfate 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1
PROSSAM
Page 26 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
hyoscyamine sulfate 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1
hyoscyamine sulfate er 0.375 mg tab er 12 hr 1
hyoscyamine sulfate sl 0.125 mg tab subl 1
hyosyne 0.125 mg/5ml oral elix, 0.125 mg/ml soln 1
ipratropium bromide 0.02 % inh soln, 0.03 % nasal soln, 0.06 % nasal soln 1 ATROVENT
LEVBID 0.375 mg tab er 12 hr 3
LEVSIN 0.125 mg tab 3
LEVSIN 0.5 mg/ml inj soln 3
LEVSIN/SL 0.125 mg tab subl 3
LIBRAX 5-2.5 mg cap 3
methscopolamine bromide 2.5 mg tab, 5 mg tab 1 PAMINE QL(90 / 365)
NULEV 0.125 mg tab disint 3
oscimin 0.125 mg tab, 0.125 mg tab disint, 0.125 mg tab subl 1
oscimin sr 0.375 mg tab er 12 hr 1
propantheline bromide 15 mg tab 1 PRO-BANTHINE
ROBINUL 0.2 mg/ml inj soln, 0.4 mg/2ml inj soln, 1 mg/5ml inj soln, 4 mg/20ml inj soln 3
ROBINUL 1 mg tab 3 QL(90 / 365)
ROBINUL-FORTE 2 mg tab 3 QL(90 / 365)
SPIRIVA HANDIHALER 18 mcg inh cap 2 QL(30 / 30)
SPIRIVA RESPIMAT 1.25 mcg/act inh aer soln, 2.5 mcg/act inh aer soln 2 QL(4 / 30)
SYMAX DUOTAB 0.375 mg tab er 3
SYMAX-SL 0.125 mg tab subl 3
SYMAX-SR 0.375 mg tab er 12 hr 3
TUDORZA PRESSAIR 400 mcg/act inh aer pwdr br act 3 QL(1 / 30)
ANTICONVULSANTS [ANTICONVULSIVOS]
Anticonvulsants, Miscellaneous [Anticonvulsivos, Misceláneos]
BANZEL 200 mg tab, 400 mg tab 3
BANZEL 40 mg/ml susp 3
carbamazepine 100 mg tab chew, 200 mg tab 1 TEGRETOL
carbamazepine 100 mg/5ml susp 1 TEGRETOL
PROSSAM
Page 27 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
carbamazepine er 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 1 CARBATROL
carbamazepine er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 1 TEGRETOL
CARBATROL 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3
DEPAKENE 250 mg cap 3
DEPAKENE 250 mg/5ml soln 3
DEPAKOTE 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 3
DEPAKOTE ER 250 mg tab er 24 hr, 500 mg tab er 24 hr 3
DEPAKOTE SPRINKLES 125 mg cap dr sprinkle 3
divalproex sodium 125 mg cap dr sprinkle, 125 mg tab dr, 250 mg tab dr, 500 mg tab dr 1 DEPAKOTE
divalproex sodium er 250 mg tab er 24 hr, 500 mg tab er 24 hr 1 DEPAKOTE
EPITOL 200 mg tab 3
EQUETRO 100 mg cap er 12 hr, 200 mg cap er 12 hr, 300 mg cap er 12 hr 3
felbamate 400 mg tab, 600 mg tab 1 FELBATOL
felbamate 600 mg/5ml susp 1 FELBATOL
FELBATOL 400 mg tab, 600 mg tab 3
FELBATOL 600 mg/5ml susp 3
gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 1 NEURONTIN
gabapentin 250 mg/5ml soln, 300 mg/6ml soln 1 NEURONTIN
GABITRIL 12 mg tab, 16 mg tab, 2 mg tab, 4 mg tab 3
HORIZANT 600 mg tab er 3
KEPPRA 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 3
KEPPRA 100 mg/ml soln 3
KEPPRA XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3
PROSSAM
Page 28 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
LAMICTAL 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab, 25 mg tab chew, 5 mg tab chew 3
LAMICTAL ODT 100 mg tab disint, 200 mg tab disint, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab disint, 50 (42)-100(14) mg oral kit, 50 mg tab disint 3
LAMICTAL STARTER 25 (35) mg oral kit, 25 (42)-100 (7) mg oral kit, 25 (84)-100(14) mg oral kit 3
LAMICTAL XR 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 & 50 & 100 mg oral kit, 25 (21)-50 (7) mg oral kit, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 & 100 & 200 mg oral kit, 50 mg tab er 24 hr 3
lamotrigine 100 mg tab, 100 mg tab disint, 150 mg tab, 200 mg tab, 200 mg tab disint, 25 mg tab, 25 mg tab chew, 25 mg tab disint, 5 mg tab chew, 50 mg tab disint 1 LAMICTAL
lamotrigine er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 250 mg tab er 24 hr, 300 mg tab er 24 hr, 50 mg tab er 24 hr 1 LAMICTAL
levetiracetam 1000 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1 KEPPRA
levetiracetam 100 mg/ml soln 1 KEPPRA
levetiracetam er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 KEPPRA
LYRICA 100 mg cap, 150 mg cap, 200 mg cap, 225 mg cap, 25 mg cap, 300 mg cap, 50 mg cap, 75 mg cap 3
LYRICA 20 mg/ml soln 3
NEURONTIN 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab 3
NEURONTIN 250 mg/5ml soln 3
oxcarbazepine 150 mg tab, 300 mg tab, 600 mg tab 1 TRILEPTAL
oxcarbazepine 300 mg/5ml susp 1 TRILEPTAL
PROSSAM
Page 29 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ROWEEPRA 1000 mg tab, 500 mg tab, 750 mg tab 3
SABRIL 500 mg pckt, 500 mg tab 5 PA
TEGRETOL 200 mg tab 3
TEGRETOL 100 mg/5ml susp 3
TEGRETOL-XR 100 mg tab er 12 hr, 200 mg tab er 12 hr, 400 mg tab er 12 hr 3
tiagabine hcl 2 mg tab, 4 mg tab 1 GABITRIL
TOPAMAX 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 3
TOPAMAX SPRINKLE 15 mg cap sprinkle, 25 mg cap sprinkle 3
topiramate 100 mg tab, 15 mg cap sprinkle, 200 mg tab, 25 mg cap sprinkle, 25 mg tab, 50 mg tab 1 TOPAMAX
TRILEPTAL 150 mg tab, 300 mg tab, 600 mg tab 3
TRILEPTAL 300 mg/5ml susp 3
valproate sodium 250 mg/5ml soln 1 DEPAKENE
valproic acid 250 mg cap 1 DEPAKENE
valproic acid 250 mg/5ml soln 1 DEPAKENE
VIMPAT 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3
VIMPAT 10 mg/ml soln 3
ZONEGRAN 100 mg cap, 25 mg cap 3
zonisamide 100 mg cap, 25 mg cap, 50 mg cap 1 ZONEGRAN
Barbiturates [Barbitúricos]
MYSOLINE 250 mg tab, 50 mg tab 3
primidone 250 mg tab, 50 mg tab 1 MYSOLINE
Benzodiazepines [Benzodiazepinas]
clonazepam 0.125 mg tab disint, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint 1 KLONOPIN
KLONOPIN 0.5 mg tab, 1 mg tab, 2 mg tab 3
ONFI 10 mg tab, 20 mg tab 3
ONFI 2.5 mg/ml susp 3
Hydantoins [Hidantoínas]
DILANTIN 100 mg cap, 30 mg cap 2
DILANTIN 125 mg/5ml susp 2
DILANTIN INFATABS 50 mg tab chew 3
PROSSAM
Page 30 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
fosphenytoin sodium 500 mg pe/10ml inj soln 1
fosphenytoin sodium 100 mg pe/2ml inj soln 1 CEREBYX
PEGANONE 250 mg tab 3
PHENYTEK 200 mg cap, 300 mg cap 3
phenytoin 50 mg tab chew 1 DILANTIN
phenytoin 125 mg/5ml susp 1 DILANTIN
PHENYTOIN INFATABS 50 mg tab chew 3
phenytoin sodium 50 mg/ml inj soln 1 DILANTIN
phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap 1 DILANTIN
Succinimides [Succinimidas]
CELONTIN 300 mg cap 3
ethosuximide 250 mg cap 1 ZARONTIN
ethosuximide 250 mg/5ml soln 1 ZARONTIN
ZARONTIN 250 mg cap 3
ZARONTIN 250 mg/5ml soln 3
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Alpha-glucosidase Inhibitors [Inhibidores De La Alfa-Glucosidasa]
acarbose 100 mg tab, 25 mg tab, 50 mg tab 1 PRECOSE
GLYSET 100 mg tab, 25 mg tab, 50 mg tab 3
miglitol 100 mg tab, 25 mg tab, 50 mg tab 1 GLYSET
PRECOSE 100 mg tab, 25 mg tab, 50 mg tab 3
Amylinomimetics [Amilinomiméticos]
SYMLINPEN 120 2700 mcg/2.7ml sc soln pen-inj 3 ST
SYMLINPEN 60 1500 mcg/1.5ml sc soln pen-inj 3 ST
Antidiabetic Agents, Miscellaneous [Agentes Antidiabéticos, Misceláneos]
CYCLOSET 0.8 mg tab 3
KORLYM 300 mg tab 3
Biguanides [Biguanidas]
FORTAMET 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3
GLUCOPHAGE 1000 mg tab, 500 mg tab, 850 mg tab 3
GLUCOPHAGE XR 500 mg tab er 24 hr, 750 mg tab er 24 hr 3
PROSSAM
Page 31 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
GLUMETZA 1000 mg tab er 24 hr, 500 mg tab er 24 hr 3
metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab 1 GLUCOPHAGE
metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr 1 GLUCOPHAGE
metformin hcl er (mod) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 GLUMETZA
metformin hcl er (osm) 1000 mg tab er 24 hr, 500 mg tab er 24 hr 1 FORTAMET
RIOMET 500 mg/5ml soln 3
Dipeptidyl Peptidase-4 (dpp-4) Inhibitors [Inhibidores De La Dipeptidil Peptidasa-4 (Dpp-4)]
JANUMET 50-1000 mg tab, 50-500 mg tab 2
JANUMET XR 100-1000 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 2
JANUVIA 100 mg tab, 25 mg tab, 50 mg tab 2
JENTADUETO 2.5-1000 mg tab, 2.5-500 mg tab, 2.5-850 mg tab 2
TRADJENTA 5 mg tab 2
Incretin Mimetics [Miméticos De Incretina]
BYDUREON 2 mg sc pen-inj, 2 mg sc susp er 2 ST
TRULICITY 0.75 mg/0.5ml sc soln pen-inj, 1.5 mg/0.5ml sc soln pen-inj 2 ST
VICTOZA 18 mg/3ml sc soln pen-inj 2 ST
Insulins [Insulinas]
HUMALOG 100 unit/ml sc soln, 100 unit/ml sc soln cart 2 QL(20 / 30)
HUMALOG JUNIOR KWIKPEN 100 unit/ml sc soln pen-inj 2 QL(18 / 30)
HUMALOG KWIKPEN 200 unit/ml sc soln pen-inj 2 QL(12 / 30)
HUMALOG KWIKPEN 100 unit/ml sc soln pen-inj 2 QL(18 / 30)
HUMALOG MIX 50/50 (50-50) 100 unit/ml sc susp 2 QL(20 / 30)
HUMALOG MIX 50/50 KWIKPEN (50-50) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)
HUMALOG MIX 75/25 (75-25) 100 unit/ml sc susp 2 QL(20 / 30)
PROSSAM
Page 32 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
HUMALOG MIX 75/25 KWIKPEN (75-25) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)
HUMULIN 70/30 (70-30) 100 unit/ml sc susp 2 QL(20 / 30)
HUMULIN 70/30 KWIKPEN (70-30) 100 unit/ml sc susp pen-inj 2 QL(18 / 30)
HUMULIN N 100 unit/ml sc susp 2 QL(20 / 30)
HUMULIN N KWIKPEN 100 unit/ml sc susp pen-inj 2 QL(18 / 30)
HUMULIN R 100 unit/ml inj soln 2 QL(20 / 30)
HUMULIN R U-500 (CONCENTRATED) 500 unit/ml sc soln 2 QL(20 / 30)
HUMULIN R U-500 KWIKPEN 500 unit/ml sc soln pen-inj 2 QL(6 / 30)
LANTUS 100 unit/ml sc soln 2 QL(20 / 30)
LANTUS SOLOSTAR 100 unit/ml sc soln pen-inj 2 QL(18 / 30)
LEVEMIR 100 unit/ml sc soln 2 QL(20 / 30)
LEVEMIR FLEXTOUCH 100 unit/ml sc soln pen-inj 2 QL(18 / 30)
TOUJEO SOLOSTAR 300 unit/ml sc soln pen-inj 2 QL(18 / 30)
Meglitinides [Meglitinidas]
nateglinide 120 mg tab, 60 mg tab 1 STARLIX
PRANDIN 1 mg tab, 2 mg tab 3 ST
repaglinide 0.5 mg tab, 1 mg tab, 2 mg tab 1 PRANDIN ST
repaglinide-metformin hcl 1-500 mg tab, 2-500 mg tab 1 PRANDIMET
STARLIX 120 mg tab, 60 mg tab 3
Sodium-glucose Cotransporter 2 (sglt2) Inhibitors [Inhibidores Del Cotransportador Sodio-Glucosa 2 (Sglt2)]
FARXIGA 10 mg tab, 5 mg tab 2 ST
INVOKAMET 150-1000 mg tab, 150-500 mg tab, 50-1000 mg tab, 50-500 mg tab 2
INVOKAMET XR 150-1000 mg tab er 24 hr, 150-500 mg tab er 24 hr, 50-1000 mg tab er 24 hr, 50-500 mg tab er 24 hr 2
INVOKANA 100 mg tab, 300 mg tab 2
XIGDUO XR 10-1000 mg tab er 24 hr, 10-500 mg tab er 24 hr, 5-1000 2 ST
PROSSAM
Page 33 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
mg tab er 24 hr, 5-500 mg tab er 24 hr
Sulfonylureas [Sulfonilureas]
AMARYL 1 mg tab, 2 mg tab, 4 mg tab 3
chlorpropamide 100 mg tab, 250 mg tab 1 DIABINESE
glimepiride 1 mg tab, 2 mg tab, 4 mg tab 1 AMARYL
glipizide 10 mg tab, 5 mg tab 1 GLUCOTROL
glipizide er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL
glipizide xl 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 GLUCOTROL
glipizide-metformin hcl 2.5-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 METAGLIP
GLUCOTROL 10 mg tab, 5 mg tab 3
GLUCOTROL XL 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 3
GLUCOVANCE 2.5-500 mg tab, 5-500 mg tab 3
glyburide 1.25 mg tab, 2.5 mg tab, 5 mg tab 1 DIABETA
glyburide micronized 1.5 mg tab, 3 mg tab, 6 mg tab 1 GLYNASE
glyburide-metformin 1.25-250 mg tab, 2.5-500 mg tab, 5-500 mg tab 1 GLUCOVANCE
GLYNASE 1.5 mg tab, 3 mg tab, 6 mg tab 3
tolazamide 250 mg tab, 500 mg tab 1 TOLINASE
tolbutamide 500 mg tab 1 ORINASE
Thiazolidinediones [Tiazolidinedionas]
ACTOPLUS MET 15-500 mg tab, 15-850 mg tab 3
ACTOPLUS MET XR 15-1000 mg tab er 24 hr, 30-1000 mg tab er 24 hr 3
ACTOS 15 mg tab, 30 mg tab, 45 mg tab 3
DUETACT 30-2 mg tab, 30-4 mg tab 3
pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab 1 ACTOS
pioglitazone hcl-glimepiride 30-2 mg tab, 30-4 mg tab 1 DUETACT
PROSSAM
Page 34 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
pioglitazone hcl-metformin hcl 15-500 mg tab, 15-850 mg tab 1 ACTOPLUS MET
ANTIDIARRHEA AGENTS [AGENTES ANTIDIARREICOS]
Antidiarrhea Agents [Agentes Antidiarreicos]
diphenoxylate-atropine 2.5-0.025 mg tab 1 LOMOTIL
diphenoxylate-atropine 2.5-0.025 mg/5ml liq 1 LOMOTIL
LOMOTIL 2.5-0.025 mg tab 3
loperamide hcl 2 mg cap 1 IMODIUM
MOTOFEN 1-0.025 mg tab 3
MYTESI 125 mg tab dr 3
paregoric 2 mg/5ml oral tinct 1
ANTIDOTES [ANTÍDOTOS]
Antidotes [Antídotos]
acetylcysteine 10 % inh soln, 20 % inh soln 1 MUCOMYST
FUSILEV 50 mg iv soln 4 PA
leucovorin calcium 10 mg tab, 100 mg inj soln, 15 mg tab, 200 mg inj soln, 25 mg tab, 350 mg inj soln, 5 mg tab, 50 mg inj soln, 500 mg inj soln 4 PA
levoleucovorin calcium 50 mg iv soln 4 PA
VORAXAZE 1000 unit iv soln 4 PA
ANTIEMETICS [ANTIEMÉTICOS]
5-ht3 Receptor Antagonists [Antagonistas Del Receptor 5-Ht3]
ANZEMET 100 mg tab, 50 mg tab 3
granisetron hcl 1 mg tab 1 KYTRIL
ondansetron 4 mg tab disint, 8 mg tab disint 1 ZOFRAN
ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab 1 ZOFRAN
ondansetron hcl 4 mg/2ml inj soln, 4 mg/5ml soln, 40 mg/20ml inj soln 1 ZOFRAN
SANCUSO 3.1 mg/24hr td patch 3
ZOFRAN 4 mg tab, 8 mg tab 3
ZOFRAN 4 mg/5ml soln 3
ZOFRAN ODT 4 mg tab disint, 8 mg tab disint 3
ZUPLENZ 4 mg oral film, 8 mg oral film 3
Antiemetics, Miscellaneous [Antieméticos, Misceláneos]
aprepitant 125 mg cap, 40 mg cap, 80 & 125 mg cap, 80 mg cap 1 EMEND
PROSSAM
Page 35 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CESAMET 1 mg cap 3
dronabinol 10 mg cap, 2.5 mg cap, 5 mg cap 1 MARINOL
EMEND 125 mg cap, 40 mg cap, 80 mg cap 3
EMEND TRI-PACK 80 & 125 mg cap 3
MARINOL 10 mg cap, 2.5 mg cap, 5 mg cap 3
scopolamine 1 mg/3days td patch 72 hr 1 TRANSDERM-SCOP
TRANSDERM-SCOP (1.5 MG) 1 mg/3days td patch 72 hr 3
Antihistamines [Antihistamínicos]
dimenhydrinate 50 mg/ml inj soln 1
meclizine hcl 12.5 mg tab, 25 mg tab 1 ANTIVERT
TIGAN 300 mg cap 3
TIGAN 100 mg/ml im soln 3
trimethobenzamide hcl 300 mg cap 1 TIGAN
ANTIFUNGALS [ANTIFUNGALES]
Allylamines [Alilaminas]
LAMISIL 250 mg tab 3 QL(84 / 90)
terbinafine hcl 250 mg tab 1 LAMISIL QL(84 / 90)
Antifungals, Miscellaneous [Antifungales, Misceláneos]
griseofulvin microsize 500 mg tab 1
griseofulvin microsize 125 mg/5ml susp 1 GRIFULVIN V
griseofulvin ultramicrosize 125 mg tab, 250 mg tab 1 GRIS-PEG
GRIS-PEG 125 mg tab, 250 mg tab 3
Azoles [Azoles]
CRESEMBA 186 mg cap, 372 mg iv soln 3 PA
DIFLUCAN 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 3
DIFLUCAN 10 mg/ml susp, 40 mg/ml susp 3
fluconazole 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab 1 DIFLUCAN
fluconazole 10 mg/ml susp, 40 mg/ml susp 1 DIFLUCAN
itraconazole 100 mg cap 1 SPORANOX
ketoconazole 200 mg tab 1 NIZORAL
NOXAFIL 40 mg/ml susp 3
SPORANOX 100 mg cap 3
PROSSAM
Page 36 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SPORANOX 10 mg/ml soln 3
SPORANOX PULSEPAK 100 mg cap 3
VFEND 200 mg tab, 50 mg tab 5 PA
VFEND 40 mg/ml susp 5 PA
voriconazole 200 mg tab, 50 mg tab 4 VFEND PA
voriconazole 40 mg/ml susp 4 VFEND PA
Echinocandins [Equinocandinas]
CANCIDAS 50 mg iv soln, 70 mg iv soln 5 PA
caspofungin acetate 50 mg iv soln, 70 mg iv soln 4 CANCIDAS PA
MYCAMINE 100 mg iv soln, 50 mg iv soln 5 PA
Polyenes [Polienos]
amphotericin b 50 mg inj soln 1 FUNGIZONE
bio-statin 1000000 unit cap, 500000 unit cap 1
nystatin 500000 unit tab 1 MYCOSTATIN
nystatin 100000 unit/ml m/t susp 1 MYCOSTATIN
Pyrimidines [Pirimidinas]
ANCOBON 250 mg cap, 500 mg cap 3
flucytosine 250 mg cap, 500 mg cap 1 ANCOBON
ANTIGLAUCOMA AGENTS [AGENTES ANTIGLAUCOMA]
Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]
ALPHAGAN P 0.1 % ophth soln 2
ALPHAGAN P 0.15 % ophth soln 3
brimonidine tartrate 0.15 % ophth soln, 0.2 % ophth soln 1 ALPHAGAN
COMBIGAN 0.2-0.5 % ophth soln 2
SIMBRINZA 1-0.2 % ophth susp 2
Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]
betaxolol hcl 0.5 % ophth soln 1 BETOPTIC
BETIMOL 0.25 % ophth soln, 0.5 % ophth soln 3
BETOPTIC-S 0.25 % ophth susp 3
carteolol hcl 1 % ophth soln 1 OCUPRESS
ISTALOL 0.5 % ophth soln 3
levobunolol hcl 0.5 % ophth soln 1 BETAGAN
metipranolol 0.3 % ophth soln 1 OPTIPRANOLOL
timolol maleate 0.25 % ophth gfs, 0.25 % ophth soln, 0.5 % ophth gfs, 0.5 % ophth soln 1 TIMOPTIC
PROSSAM
Page 37 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
Carbonic Anhydrase Inhibitors [Inhibidores De La Anhidrasa Carbónica]
acetazolamide 125 mg tab, 250 mg tab 1 DIAMOX
acetazolamide er 500 mg cap er 12 hr 1 DIAMOX
acetazolamide sodium 500 mg inj soln 1 DIAMOX
AZOPT 1 % ophth susp 2
dorzolamide hcl 2 % ophth soln 1 TRUSOPT
dorzolamide hcl-timolol mal 22.3-6.8 mg/ml ophth soln 1 COSOPT
methazolamide 25 mg tab, 50 mg tab 1 NEPTAZANE
NEPTAZANE 25 mg tab 3
Miotics [Mióticos]
ISOPTO CARPINE 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 3
MIOCHOL-E 20 mg i-ocul soln 3
MIOSTAT 0.01 % i-ocul soln 3
PHOSPHOLINE IODIDE 0.125 % ophth soln 3
pilocarpine hcl 1 % ophth soln, 2 % ophth soln, 4 % ophth soln 1 ISOPTOCARPINE
Prostaglandin Analogs [Análogos De La Prostaglandina]
bimatoprost 0.03 % ophth soln 1 LUMIGAN
latanoprost 0.005 % ophth soln 1 XALATAN
LUMIGAN 0.01 % ophth soln 2
TRAVATAN Z 0.004 % ophth soln 2
travoprost (bak free) 0.004 % ophth soln 1 TRAVATAN
ZIOPTAN 0.0015 % ophth soln 3
ANTIGOUT AGENTS [AGENTES CONTRA LA GOTA]
Antigout Agents [Agentes Contra La Gota]
allopurinol 100 mg tab, 300 mg tab 1 ZYLOPRIM
colchicine 0.6 mg tab 1 COLCRYS
COLCRYS 0.6 mg tab 3
ULORIC 40 mg tab, 80 mg tab 3
ZYLOPRIM 100 mg tab, 300 mg tab 3
ANTIHEMORRHAGIC AGENTS [AGENTES ANTIHEMORRÁGICOS]
Hemostatics [Hemostáticos]
AMICAR 1000 mg tab, 500 mg tab 5 PA
AMICAR 0.25 gm/ml soln 5 PA
aminocaproic acid 250 mg/ml iv soln 1 PA
PROSSAM
Page 38 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CYKLOKAPRON 1000 mg/10ml iv soln 5 PA
LYSTEDA 650 mg tab 5 PA
tranexamic acid 1000 mg/10ml iv soln 1 CYKLOKAPRON PA
tranexamic acid 650 mg tab 1 LYSTEDA PA
ANTIHYPOGLYCEMIC AGENTS [AGENTES ANTIHIPOGLUCÉMICOS]
Antihypoglycemic Agents, Miscellaneous [Agentes Antihipoglucémicos, Misceláneos]
PROGLYCEM 50 mg/ml susp 3
Glycogenolytic Agents [Agentes Glucogenolíticos]
BAQSIMI 3 mg/dose one pack nasal pwdr, 3 mg/dose twoi pack nasal pwdr 2 PA
GLUCAGEN HYPOKIT 1 mg inj soln 2
GLUCAGON EMERGENCY 1 mg inj kit 2
ANTI-INFECTIVES [ANTIINFECCIOSOS]
Antibacterials [Antibacterianos]
ACANYA 1.2-2.5 % gel 3
ak-poly-bac 500-10000 unit/gm ophth oint 1 POLYSPORIN
AKTIPAK 5-3 % ext pckt 3
ALTABAX 1 % oint 3
AZASITE 1 % ophth soln 3
bacitracin 500 unit/gm ophth oint 1 BACI-IM
bacitracin-polymyxin b 500-10000 unit/gm ophth oint 1 POLYSPORIN
BACTROBAN 2 % crm 3
BACTROBAN NASAL 2 % nasal oint 3
BENZACLIN 1-5 % gel 3
BENZACLIN WITH PUMP 1-5 % gel 3
BENZAMYCIN 5-3 % gel 3
benzoyl peroxide-erythromycin 5-3 % gel 1 BENZAMYCIN AL
BESIVANCE 0.6 % ophth susp 3
BLEPH-10 10 % ophth soln 3
CENTANY 2 % oint 3
CENTANY AT 2 % ext kit 3
CETRAXAL 0.2 % otic soln 3
CILOXAN 0.3 % ophth oint 3
CILOXAN 0.3 % ophth soln 3
ciprofloxacin hcl 0.2 % otic soln 1
ciprofloxacin hcl 0.3 % ophth soln 1 CILOXAN
PROSSAM
Page 39 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CLEOCIN 100 mg vag supp 3
CLEOCIN 2 % vag crm 3
CLEOCIN-T 1 % swab 3
CLEOCIN-T 1 % gel 3
CLEOCIN-T 1 % ext soln, 1 % lot 3
CLINDACIN ETZ 1 % ext kit, 1 % swab 3
CLINDACIN PAC 1 % ext kit 3
CLINDACIN-P 1 % swab 3
CLINDAGEL 1 % gel 3
clindamycin phos-benzoyl perox 1-5 % gel 1 BENZACLIN AL
clindamycin phos-benzoyl perox 1.2-5 % gel 1 DUAC AL
clindamycin phosphate 2 % vag crm 1 CLEOCIN
clindamycin phosphate 1 % swab 1 CLEOCIN-T AL
clindamycin phosphate 1 % gel 1 CLEOCIN-T AL
clindamycin phosphate 1 % ext soln, 1 % gel, 1 % lot 1 CLEOCIN-T AL
clindamycin phosphate 1 % foam 1 EVOCLIN AL
DUAC 1.2-5 % gel 3
ery 2 % pad 1 AL
ERYGEL 2 % gel 3
erythromycin 2 % pad 1 AL
erythromycin 2 % ext soln 1 ERYDERM AL
erythromycin 2 % gel 1 ERYGEL AL
erythromycin 5 mg/gm ophth oint 1 ILOTYCIN
EVOCLIN 1 % foam 3
gatifloxacin 0.5 % ophth soln 1 ZYMAXID
GENTAK 0.3 % ophth oint 3
gentamicin sulfate 0.1 % crm, 0.1 % oint 1 GARAMYCIN
gentamicin sulfate 0.3 % ophth soln 1 GARAMYCIN
KLARON 10 % lot 3
levofloxacin 0.5 % ophth soln 1 QUIXIN
METROCREAM 0.75 % crm 3
METROGEL 1 % gel 3
METROGEL-VAGINAL 0.75 % vag gel 3
METROLOTION 0.75 % lot 3
metronidazole 0.75 % crm 1 METROCREAM
metronidazole 0.75 % gel, 0.75 % vag gel, 1 % gel 1 METROGEL
metronidazole 0.75 % lot 1 METROLOTION
MITOSOL 0.2 mg ophth kit 3
PROSSAM
Page 40 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MOXEZA 0.5 % ophth soln 2
mupirocin 2 % oint 1 BACTROBAN
mupirocin calcium 2 % crm 1 BACTROBAN
neomycin-bacitracin zn-polymyx 5-400-10000 ophth oint 1 NEOSPORIN
neomycin-polymyxin-gramicidin 1.75-10000-.025 ophth soln 1 NEOSPORIN
NEOSPORIN 1.75-10000-.025 ophth soln 3
NEUAC 1.2-5 % ext kit, 1.2-5 % gel 3
NORITATE 1 % crm 3
ofloxacin 0.3 % otic soln 1 FLOXIN
ofloxacin 0.3 % ophth soln 1 OCUFLOX
ONEXTON 1.2-3.75 % gel 3
POLYCIN 500-10000 unit/gm ophth oint 3
polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln 1 POLYTRIM
ROSADAN 0.75 % (cream) ext kit, 0.75 % (gel) ext kit 3
ROSADAN 0.75 % crm, 0.75 % gel 3
sulfacetamide sodium 10 % ophth soln 1 BLEPH-10
sulfacetamide sodium 10 % ophth oint 1 SODIUM SULAMYD
sulfacetamide sodium (acne) 10 % lot 1 KLARON AL
tobramycin 0.3 % ophth soln 1 TOBREX
TOBREX 0.3 % ophth oint 3
TOBREX 0.3 % ophth soln 3
VANDAZOLE 0.75 % vag gel 3
VIGAMOX 0.5 % ophth soln 2
ZYMAXID 0.5 % ophth soln 3
Antifungals [Antifungales]
ALA-QUIN 3-0.5 % crm 1
bensal hp 3-6 % oint 1
CICLODAN 0.77 % crm 3
CICLODAN 8 % ext soln 3
CICLODAN CREAM 0.77 % ext kit 3
CICLODAN SOLUTION 8 % ext kit 3
ciclopirox 0.77 % gel 1 LOPROX
ciclopirox 1 % shampoo 1 LOPROX
ciclopirox 8 % ext soln 1 PENLAC
ciclopirox olamine 0.77 % crm 1 LOPROX
ciclopirox olamine 0.77 % ext susp 1 LOPROX
ciclopirox treatment 8 % ext kit 1
PROSSAM
Page 41 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
clotrimazole 1 % crm 1 LOTRIMIN
clotrimazole 10 mg m/t lozg, 10 mg m/t troche 1 MYCELEX
clotrimazole 1 % ext soln 1 MYCELEX
clotrimazole af 1 % crm 1 LOTRIMIN
clotrimazole anti-fungal 1 % crm 1 LOTRIMIN
clotrimazole-betamethasone 1-0.05 % crm 1 LOTRISONE
clotrimazole-betamethasone 1-0.05 % lot 1 LOTRISONE
cvs miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1
econazole nitrate 1 % crm 1 SPECTAZOLE
eq miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1
eql miconazole 3 200 & 2 mg-% (9gm) vag kit 1
ERTACZO 2 % crm 3
EXELDERM 1 % crm 3
EXELDERM 1 % ext soln 3
EXODERM 25-1 % lot 3
EXTINA 2 % foam 3
gnp miconazole 3 200 & 2 mg-% (9gm) vag kit 1
HALOTIN 1 % crm 3
ketoconazole 2 % foam 1 EXTINA
ketoconazole 2 % crm 1 NIZORAL
ketoconazole 2 % shampoo 1 NIZORAL
LOPROX 0.77 % crm, 0.77 % ext kit 3
LOPROX 1 % shampoo 3
LOTRISONE 1-0.05 % crm 3
MENTAX 1 % crm 3
miconazole 3 200 mg vag supp 1 MONISTAT
miconazole 3 applicator 200 & 2 mg-% (9gm) vag kit 1
miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1
miconazole 3 combo pack app 200 & 2 mg-% (9gm) vag kit 1
MONISTAT 3 COMBINATION PACK 200 & 2 mg-% (9gm) vag kit 1
MONISTAT 3 COMBO PACK APP 200 & 2 mg-% (9gm) vag kit 1
naftifine hcl 1 % crm, 2 % crm 1 NAFTIN
NAFTIN 1 % gel, 2 % crm 3
PROSSAM
Page 42 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NIZORAL 2 % shampoo 3
NYAMYC 100000 unit/gm ext pwdr 3
nystatin 100000 unit/gm crm, 100000 unit/gm ext pwdr, 100000 unit/gm oint 1 MYCOSTATIN
NYSTOP 100000 unit/gm ext pwdr 3
oxiconazole nitrate 1 % crm 1 OXISTAT
OXISTAT 1 % crm 3
OXISTAT 1 % lot 3
PENLAC 8 % ext soln 3
px miconazole 3-day combo 200 & 2 mg-% (9gm) vag kit 1
qc clotrimazole 1 % crm 1 LOTRIMIN
QUINJA 1.25-1 % gel 3
ra miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1
ra miconazole 3 combo pack app 200 & 2 mg-% (9gm) vag kit 1
sm antifungal clotrimazole 1 % crm 1 LOTRIMIN
sm miconazole 3 200 & 2 mg-% (9gm) vag kit 1
sm miconazole 3 applicator 200 & 2 mg-% (9gm) vag kit 1
TERAZOL 7 0.4 % vag crm 3
terconazole 0.4 % vag crm, 0.8 % vag crm 1 TERAZOL
terconazole 80 mg vag supp 1 TERAZOL 3
tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) vag kit 1
VUSION 0.25-15-81.35 % oint 3
XOLEGEL 2 % gel 3
XOLEGEL COREPAK 2 & 1 % ext kit 3
XOLEGEL DUO/HEAD & SHOULDERS 2 & 1 % ext kit 3
XOLEGEL DUO/XOLEX 2 & 1 % ext kit 3
Antivirals [Antivirales]
acyclovir 5 % oint 1 ZOVIRAX
DENAVIR 1 % crm 3
trifluridine 1 % ophth soln 1 VIROPTIC
VIROPTIC 1 % ophth soln 3
XERESE 5-1 % crm 3
ZIRGAN 0.15 % ophth gel 3
ZOVIRAX 5 % crm, 5 % oint 3
PROSSAM
Page 43 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
Eent Anti-infectives, Miscellaneous [Antiinfecciosos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]
BETADINE OPHTHALMIC PREP 5 % ophth soln 3
Local Anti-infectives, Miscellaneous [Antiinfecciosos Locales, Misceláneos]
ALCORTIN A 1-2-1 % gel 3
AVC VAGINAL 15 % vag crm 3
BENZAC AC WASH 5 % ext liq 3
BENZEFOAM 5.3 % foam 3
BENZEFOAMULTRA 9.8 % foam 3
BENZEPRO 5.3 % foam 3
BENZEPRO CREAMY WASH 7 % ext liq 3
BENZEPRO FOAMING CLOTHS 6 % ext misc 3
BENZEPRO SHORT CONTACT 9.8 % foam 3
BENZIQ 5.25 % gel 3
BENZIQ LS 2.75 % gel 3
BENZIQ WASH 5.25 % ext liq 3
benzoyl peroxide 8 % gel, 9.8 % foam 1 AL
bp foam 5.3 % foam, 9.8 % foam 1 AL
bp foaming wash 10 % ext liq 1 AL
bp wash 2.5 % ext liq 1 AL
bp wash 7 % ext liq 1 AL
bpo 4 % gel, 8 % gel 1 AL
bpo foaming cloths 6 % ext misc 1 AL
BUCALSEP ext liq, ext soln 3
DERMAZENE 1-1 % crm 3
FEM PH 0.9-0.025 % vag gel 3
hydrocortisone-iodoquinol 1-1 % crm 1
INOVA 4 & 5 % ext kit, 8 & 5 % ext kit 3
INOVA 4/1 ACNE CONTROL THERAPY 4 & 1 & 5 % ext kit 3
INOVA 8/2 ACNE CONTROL THERAPY 8 & 2 & 5 % ext kit 3
iodoquinol-hc-aloe polysacch 1-2-1 % gel 1
mafenide acetate 5 % ext pckt 1
PR BENZOYL PEROXIDE WASH 7 % ext liq 3
RELAGARD 0.9-0.025 % vag gel 3
RIAX 5.5 % foam, 9.5 % foam 3
PROSSAM
Page 44 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SILVADENE 1 % crm 3
silver sulfadiazine 1 % crm 1 SILVADENE
SSD 1 % crm 3
SULFAMYLON 5 % ext pckt 3
SULFAMYLON 85 mg/gm crm 3
ZACARE 4 & 0.2 % ext kit, 8 & 0.2 % ext kit 3
zaclir cleansing 8 % lot 1 AL
Scabicides And Pediculicides [Escabicidas Y Pediculicidas]
ELIMITE 5 % crm 3
EURAX 10 % crm, 10 % lot 3
lindane 1 % shampoo 1
malathion 0.5 % lot 1 OVIDE
NATROBA 0.9 % ext susp 3
OVIDE 0.5 % lot 3
permethrin 5 % crm 1 ELIMITE
SKLICE 0.5 % lot 3
SOOLANTRA 1 % crm 3
spinosad 0.9 % ext susp 1
sulfurated lime ext soln 1
ULESFIA 5 % lot 3
ANTI-INFLAMMATORY AGENTS [AGENTES ANTIINFLAMATORIOS]
Anti-inflammatory Agents [Agentes Antiinflamatorios]
ALA SCALP 2 % lot 3
ala-cort 1 % crm 1 ALA-CORT
ala-cort 2.5 % crm 1 HYTONE
alclometasone dipropionate 0.05 % crm, 0.05 % oint 1 ACLOVATE
alosetron hcl 0.5 mg tab, 1 mg tab 1 LOTRONEX
amcinonide 0.1 % crm, 0.1 % oint 1 CYCLOCORT
amcinonide 0.1 % lot 1 CYCLOCORT
anucort-hc 25 mg rect supp 1
ANUSOL-HC 25 mg rect supp 3
ANUSOL-HC 2.5 % rect crm 3
APEXICON E 0.05 % crm 3
APRISO 0.375 gm cap er 24 hr 3
ASACOL HD 800 mg tab dr 3
balsalazide disodium 750 mg cap 1 COLAZAL
betamethasone dipropionate 0.05 % crm, 0.05 % oint 1 DIPROSONE
betamethasone dipropionate 0.05 % lot 1 DIPROSONE
betamethasone dipropionate aug 0.05 % crm, 0.05 % gel, 0.05 % oint 1 DIPROLENE
PROSSAM
Page 45 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
betamethasone dipropionate aug 0.05 % lot 1 DIPROLENE
betamethasone valerate 0.1 % crm, 0.1 % oint 1 BETA-VAL
betamethasone valerate 0.1 % lot 1 BETA-VAL
betamethasone valerate 0.12 % foam 1 LUXIQ
calcipotriene-betameth diprop 0.005-0.064 % oint 1 TACLONEX
CANASA 1000 mg rect supp 2
CAPEX 0.01 % shampoo 3
clobetasol prop emollient base 0.05 % crm 1 TEMOVATE-E
clobetasol propionate 0.05 % crm 1
clobetasol propionate 0.05 % oint 1 CLOBEX
clobetasol propionate 0.05 % ext soln 1 CLOBEX
clobetasol propionate 0.05 % ext liq, 0.05 % lot, 0.05 % shampoo 1 CLODAN
clobetasol propionate 0.05 % foam 1 OLUX
clobetasol propionate 0.05 % gel 1 TEMOVATE
clobetasol propionate e 0.05 % crm 1 TEMOVATE-E
clobetasol propionate emulsion 0.05 % foam 1
CLOBEX 0.05 % lot, 0.05 % shampoo 3
CLOBEX SPRAY 0.05 % ext liq 3
clocortolone pivalate 0.1 % crm 1
clocortolone pivalate pump 0.1 % crm 1
CLODAN 0.05 % shampoo 3
CLODERM 0.1 % crm 3
CLODERM PUMP 0.1 % crm 3
COLAZAL 750 mg cap 3
COLOCORT 100 mg/60ml rect enema 3
CORDRAN 4 mcg/sqcm tape 3
CORDRAN 0.05 % crm 3
CORDRAN 0.05 % lot 3
CORTANE-B 10-10-1 mg/ml lot 3
CORTENEMA 100 mg/60ml rect enema 3
CORTIFOAM 10 % rect foam 3
CORTISPORIN 1 % oint, 3.5-10000-0.5 crm 3
CUTIVATE 0.05 % lot 3
PROSSAM
Page 46 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DELZICOL 400 mg cap dr 2
DERMA-SMOOTHE/FS BODY 0.01 % ext oil 3
DERMA-SMOOTHE/FS SCALP 0.01 % ext oil 3
DERMASORB TA 0.1 % ext kit 3
DESONATE 0.05 % gel 3
desonide 0.05 % crm, 0.05 % oint 1 DESOWEN
desonide 0.05 % lot 1 DESOWEN
DESOWEN 0.05 % crm 3
DESOWEN 0.05 % lot 3
desoximetasone 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 1 TOPICORT
diflorasone diacetate 0.05 % crm, 0.05 % oint 1 PSORCON
DIPENTUM 250 mg cap 3
DIPROLENE 0.05 % oint 3
DIPROLENE 0.05 % lot 3
DIPROLENE AF 0.05 % crm 3
ELOCON 0.1 % crm, 0.1 % oint 3
EPIFOAM 1-1 % foam 3
FIRST-HYDROCORTISONE 10 % gel 3
fluocinolone acetonide 0.01 % crm, 0.025 % crm, 0.025 % oint 1 SYNALAR
fluocinolone acetonide 0.01 % ext soln 1 SYNALAR
fluocinolone acetonide body 0.01 % ext oil 1 DERMA-SMOOTHE/FS
fluocinolone acetonide scalp 0.01 % ext oil 1
fluocinonide 0.05 % crm, 0.05 % gel, 0.05 % oint 1 LIDEX
fluocinonide 0.05 % ext soln 1 LIDEX
fluocinonide 0.1 % crm 1 VANOS
fluocinonide emulsified base 0.05 % crm 1 LIDEX-E
flurandrenolide 0.05 % lot 1 CORDRAN
fluticasone propionate 0.005 % oint, 0.05 % crm 1 CUTIVATE
fluticasone propionate 0.05 % lot 1 CUTIVATE
halac 0.05 & 12 % ext kit 1
halobetasol propionate 0.05 % crm, 0.05 % oint 1 ULTRAVATE
HALOG 0.1 % crm, 0.1 % oint 3
PROSSAM
Page 47 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
HEMMOREX-HC 25 mg rect supp 3
hydrocortisone 1 % rect crm, 2.5 % rect crm 1
hydrocortisone 1 % crm, 1 % oint 1 ALA-CORT
hydrocortisone 100 mg/60ml rect enema 1 CORTENEMA
hydrocortisone 2.5 % crm, 2.5 % oint 1 HYTONE
hydrocortisone 2.5 % lot 1 HYTONE
hydrocortisone ace-pramoxine 2.5-1 % crm 1
hydrocortisone acetate 25 mg rect supp, 30 mg rect supp 1
hydrocortisone butyr lipo base 0.1 % crm 1 LOCOID LIPOCREAM
hydrocortisone butyrate 0.1 % crm, 0.1 % oint 1 LOCOID
hydrocortisone butyrate 0.1 % ext soln 1 LOCOID
hydrocortisone valerate 0.2 % crm, 0.2 % oint 1 WESTCORT
KENALOG 0.147 mg/gm ext aer soln 3
LIALDA 1.2 gm tab dr 3
LOCOID 0.1 % crm, 0.1 % oint 3
LOCOID 0.1 % ext soln, 0.1 % lot 3
LOCOID LIPOCREAM 0.1 % crm 3
LOTRONEX 0.5 mg tab, 1 mg tab 2
LUXIQ 0.12 % foam 3
mesalamine 4 gm rect enema 1
mesalamine 800 mg tab dr 1 ASACOL HD
mesalamine-cleanser 4 gm rect kit 1 ROWASA
mezparox-hc 1-2.5 % crm 1
mometasone furoate 0.1 % crm, 0.1 % oint 1 ELOCON
mometasone furoate 0.1 % ext soln 1 ELOCON
napro 15 % crm 1
NOLIX 0.05 % lot 3
NUCORT 2 % lot 3
nystatin-triamcinolone 100000-0.1 unit/gm-% crm, 100000-0.1 unit/gm-% oint 1 MYCOLOG
OLUX 0.05 % foam 3
OLUX-E 0.05 % foam 3
ORALONE 0.1 % m/t paste 3
PANDEL 0.1 % crm 3
PROSSAM
Page 48 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PENTASA 250 mg cap er, 500 mg cap er 3
PRAMOSONE 1-1 % crm, 1-1 % oint, 1-2.5 % crm, 1-2.5 % oint 3
PRAMOSONE 1-1 % lot, 1-2.5 % lot 3
PRAMOSONE E 1-2.5 % crm 3
prednicarbate 0.1 % crm, 0.1 % oint 1 DERMATOP
PROCTOCORT 30 mg rect supp 3
PROCTOCORT 1 % rect crm 3
PROCTO-MED HC 2.5 % rect crm 3
PROCTO-PAK 1 % rect crm 3
PROCTOSOL HC 2.5 % rect crm 3
PROCTOZONE-HC 2.5 % rect crm 3
psorcon 0.05 % crm 1 PSORCON
ROWASA 4 gm rect kit 3
SCALACORT DK 2 & 2-2 % ext kit 3
SFROWASA 4 gm/60ml rect enema 3
SYNALAR 0.01 % ext soln 3
SYNALAR TS 0.01 % ext kit 3
TACLONEX 0.005-0.064 % ext susp, 0.005-0.064 % oint 3
TEMOVATE 0.05 % crm, 0.05 % oint 3
TEXACORT 2.5 % ext soln 3
TOPICORT 0.05 % crm, 0.05 % gel, 0.05 % oint, 0.25 % crm, 0.25 % oint 3
triamcinolone acetonide 0.025 % oint, 0.1 % oint, 0.147 mg/gm ext aer soln, 0.5 % oint 1 KENALOG
triamcinolone acetonide 0.025 % lot, 0.1 % lot 1 KENALOG
triamcinolone acetonide 0.1 % m/t paste 1
KENALOG IN ORABASE
triamcinolone acetonide 0.025 % crm, 0.1 % crm, 0.5 % crm 1 TRIDERM
TRIANEX 0.05 % oint 3
TRIDERM 0.1 % crm 3
TRIDESILON 0.05 % crm 3
ULTRAVATE 0.05 % crm, 0.05 % oint 3
ULTRAVATE X (CREAM) 0.05 & 10 % ext kit 3
PROSSAM
Page 49 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ULTRAVATE X (OINTMENT) 0.05 & 10 % ext kit 3
VANOS 0.1 % crm 3
VERDESO 0.05 % foam 3
Corticosteroids [Corticosteroides]
ACETASOL HC 2-1 % otic soln 3
allergy spray 24 hour 55 mcg/act nasal aer 1 NASACORT
ALREX 0.2 % ophth susp 3
bacitra-neomycin-polymyxin-hc 1 % ophth oint 1 CORTISPORIN
BECONASE AQ 42 mcg/spray nasal susp 3
benzoyl perox-hydrocortisone 5-0.5 % lot 1 AL
BLEPHAMIDE S.O.P. 10-0.2 % ophth oint 3
CIPRO HC 0.2-1 % otic susp 3
CIPRODEX 0.3-0.1 % otic susp 2
COLY-MYCIN S 3.3-3-10-0.5 mg/ml otic susp 3
CORTANE-B 10-10-1 mg/ml otic soln 3
CORTANE-B AQUEOUS 10-10-1 mg/ml otic soln 3
CORTIC-ND 10-10-1 mg/ml otic soln 3
CYOTIC 10-10-1 mg/ml otic soln 3
DERMOTIC 0.01 % otic oil 3
dexamethasone sodium phosphate 0.1 % ophth soln 1 MAXIDEX
DUREZOL 0.05 % ophth emul 2
eq nasal allergy 55 mcg/act nasal aer 1 NASACORT
exotic-hc 10-10-1 mg/ml otic soln 1
flunisolide 25 MCG/ACT (0.025%) nasal soln 1 NASALIDE
fluocinolone acetonide 0.01 % otic oil 1 DERMOTIC
fluorometholone 0.1 % ophth susp 1 FML
fluticasone propionate 50 mcg/act nasal susp 1 FLONASE
FML LIQUIFILM 0.1 % ophth susp 3
gnp 24 hour nasal allergy 55 mcg/act nasal aer 1 NASACORT
PROSSAM
Page 50 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
goodsense nasal allergy spray 55 mcg/act nasal aer 1 NASACORT
hydrocortisone-acetic acid 1-2 % otic soln 1 ACETASOL HC
LOTEMAX 0.5 % ophth gel, 0.5 % ophth oint 3
LOTEMAX 0.5 % ophth susp 3
loteprednol etabonate 0.5 % ophth susp 1 LOTEMAX
MAXIDEX 0.1 % ophth susp 3
MAXITROL 3.5-10000-0.1 ophth oint 3
MAXITROL 3.5-10000-0.1 ophth susp 3
mometasone furoate 50 mcg/act nasal susp 1 NASONEX
NASACORT ALLERGY 24HR 55 mcg/act nasal aer 1
NASACORT ALLERGY 24HR CHILDREN 55 mcg/act nasal aer 1
nasal allergy 24 hour 55 mcg/act nasal aer 1 NASACORT
NASONEX 50 mcg/act nasal susp 3
neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth oint 1 MAXITROL
neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth susp 1 MAXITROL
neomycin-polymyxin-hc 1 % otic soln, 3.5-10000-1 ophth susp, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp 1 CORTISPORIN
OMNARIS 50 mcg/act nasal susp 3
OMNIPRED 1 % ophth susp 3
OTICIN HC NR 10-10-1 mg/ml otic soln 3
otomax-hc 10-10-1 mg/ml otic soln 1
PRED FORTE 1 % ophth susp 3
PRED MILD 0.12 % ophth susp 3
PRED-G 0.3-1 % ophth susp 3
PRED-G S.O.P. 0.3-0.6 % ophth oint 3
prednisolone acetate 1 % ophth susp 1 PRED FORTE
prednisolone sodium phosphate 1 % ophth soln 1
QNASL 80 mcg/act nasal aer soln 3
PROSSAM
Page 51 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
RETISERT 0.59 mg Intravitreal Implant 3
sulfacetamide-prednisolone 10-0.23 % ophth soln 1 VASOCIDIN
TOBRADEX ST 0.3-0.05 % ophth susp 2
triamcinolone acetonide 55 mcg/act nasal aer 1 NASACORT
TRIESENCE 40 mg/ml i-ocul susp 3
VANOXIDE-HC 5-0.5 % lot 3
ZETONNA 37 mcg/act nasal aer soln 3
Eent Anti-inflammatory Agents, Misc [Antiinflamatorios Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]
RESTASIS 0.05 % ophth emul 3 PA
RESTASIS MULTIDOSE 0.05 % ophth emul 3 PA
Leukotriene Modifiers [Modificadores De Leucotrienos]
ACCOLATE 10 mg tab, 20 mg tab 3
montelukast sodium 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 1 SINGULAIR
SINGULAIR 10 mg tab, 4 mg pckt, 4 mg tab chew, 5 mg tab chew 3
zafirlukast 10 mg tab, 20 mg tab 1 ACCOLATE
zileuton er 600 mg tab er 12 hr 1 ZYFLO CR
ZYFLO 600 mg tab 3
ZYFLO CR 600 mg tab er 12 hr 3
Mast-cell Stabilizers [Estabilizadores De Los Mastocitos]
cromolyn sodium 100 mg/5ml oral conc 1 GASTROCROM
cromolyn sodium 20 mg/2ml inh neb soln 1 INTAL
GASTROCROM 100 mg/5ml oral conc 3
Nonsteroidal Anti-inflammatory Agents [Agentes Anti-Inflamatorios Noesteroidales]
ACUVAIL 0.45 % ophth soln 3
bromfenac sodium (once-daily) 0.09 % ophth soln 1
diclofenac sodium 0.1 % ophth soln 1 VOLTAREN
flurbiprofen sodium 0.03 % ophth soln 1 OCUFEN
ILEVRO 0.3 % ophth susp 2
ketorolac tromethamine 0.4 % ophth soln, 0.5 % ophth soln 1 ACULAR
ANTILIPEMIC AGENTS [AGENTES ANTILIPÉMICOS]
PROSSAM
Page 52 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
Antilipemic Agents, Miscellaneous [Agentes Antilipémicos, Misceláneos]
LOVAZA 1 gm cap 3
niacin er (antihyperlipidemic) 1000 mg tab er, 500 mg tab er, 750 mg tab er 1 NIASPAN
NIASPAN 1000 mg tab er, 500 mg tab er, 750 mg tab er 3
omega-3-acid ethyl esters 1 gm cap 1 LOVAZA
triklo 1 gm cap 1 LOVAZA
VASCEPA 1 gm cap 3
Bile Acid Sequestrants [Secuestradores Del Ácido Biliar]
cholestyramine 4 gm pckt 1
cholestyramine 4 gm/dose oral pwdr 1 QUESTRAN
cholestyramine light 4 gm pckt 1 QUESTRAN LIGHT
cholestyramine light 4 gm/dose oral pwdr 1 QUESTRAN LIGHT
COLESTID 1 gm tab, 5 gm pckt 3
COLESTID 5 gm oral gr 3
COLESTID FLAVORED 5 gm pckt 3
COLESTID FLAVORED 5 gm oral gr 3
colestipol hcl 5 gm pckt 1
colestipol hcl 1 gm tab 1 COLESTID
colestipol hcl 5 gm oral gr 1 COLESTID
PREVALITE 4 gm pckt 3
PREVALITE 4 gm/dose oral pwdr 3
QUESTRAN 4 gm pckt 3
QUESTRAN 4 gm/dose oral pwdr 3
QUESTRAN LIGHT 4 gm/dose oral pwdr 3
WELCHOL 3.75 gm pckt, 625 mg tab 3
Cholesterol Absorption Inhibitors [Inhibidores De La Absorción Del Colesterol]
ezetimibe 10 mg tab 1 ZETIA
ZETIA 10 mg tab 2
Fibric Acid Derivatives [Derivados De Ácido Fíbrico]
choline fenofibrate 135 mg cap dr 1 TRILIPIX
fenofibrate 120 mg tab, 40 mg tab 1 FENOGLIDE
fenofibrate 150 mg cap, 50 mg cap 1 LIPOFEN
fenofibrate 145 mg tab, 160 mg tab, 48 mg tab, 54 mg tab 1 TRICOR
fenofibrate micronized 130 mg cap, 43 mg cap 1 ANTARA
PROSSAM
Page 53 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
fenofibrate micronized 134 mg cap, 200 mg cap, 67 mg cap 1 TRICOR
fenofibric acid 105 mg tab, 35 mg tab 1 FIBRICOR
fenofibric acid 135 mg cap dr, 45 mg cap dr 1 TRILIPIX
FENOGLIDE 120 mg tab, 40 mg tab 3
FIBRICOR 105 mg tab, 35 mg tab 3
gemfibrozil 600 mg tab 1 LOPID
LIPOFEN 150 mg cap, 50 mg cap 3
LOPID 600 mg tab 3
TRICOR 145 mg tab, 48 mg tab 3
TRIGLIDE 160 mg tab 3
TRILIPIX 135 mg cap dr, 45 mg cap dr 3
Hmg-coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]
atorvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 LIPITOR
CRESTOR 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 3
fluvastatin sodium 20 mg cap, 40 mg cap 1 LESCOL
lovastatin 10 mg tab, 20 mg tab, 40 mg tab 1 MEVACOR
pravastatin sodium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 1 PRAVACHOL
rosuvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 CRESTOR
simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab 1 ZOCOR
ANTIMANIC AGENTS [AGENTES ANTIMANÍACOS]
Antimanic Agents [Agentes Antimaníacos]
lithium 8 meq/5ml soln 1
lithium carbonate 150 mg cap, 300 mg tab, 600 mg cap 1
lithium carbonate 300 mg cap 1 ESKALITH
lithium carbonate er 450 mg tab er 1 ESKALITH CR
lithium carbonate er 300 mg tab er 1 LITHOBID
LITHOBID 300 mg tab er 3
ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]
Antimigraine Agents, Miscellaneous [Agentes Antimigraña, Misceláneos]
CAFERGOT 1-100 mg tab 3 QL(30 / 30)
ergotamine-caffeine 1-100 mg tab 1 CAFERGOT QL(30 / 30)
isometheptene-dichloral-apap 65-100-325 mg cap 1 QL(30 / 30)
PROSSAM
Page 54 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MIGERGOT 2-100 mg rect supp 3 QL(12 / 30)
Selective Serotonin Agonists [Agonistas Selectivos De Serotonina]
almotriptan malate 12.5 mg tab, 6.25 mg tab 1 AXERT
AMERGE 1 mg tab, 2.5 mg tab 3 QL(9 / 30)
AXERT 12.5 mg tab, 6.25 mg tab 3 QL(6 / 30)
eletriptan hydrobromide 20 mg tab, 40 mg tab 1 RELPAX QL(6 / 30)
FROVA 2.5 mg tab 3
frovatriptan succinate 2.5 mg tab 1 FROVA QL(9 / 30)
IMITREX 6 mg/0.5ml sc soln 3 QL(5 / 30)
IMITREX 20 mg/act nasal soln, 5 mg/act nasal soln 3 QL(6 / 30)
IMITREX 100 mg tab 3 QL(9 / 30)
IMITREX 25 mg tab, 50 mg tab 3 QL(18 / 30)
IMITREX STATDOSE REFILL 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 3 QL(2 / 30)
IMITREX STATDOSE SYSTEM 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln auto-inj 3 QL(2 / 30)
MAXALT 10 mg tab 3 QL(12 / 30)
MAXALT-MLT 10 mg tab disint 3 QL(12 / 30)
MAXALT-MLT 5 mg tab disint 3 QL(24 / 30)
naratriptan hcl 1 mg tab, 2.5 mg tab 1 AMERGE QL(9 / 30)
RELPAX 20 mg tab, 40 mg tab 2 QL(6 / 30)
rizatriptan benzoate 10 mg tab, 10 mg tab disint 1 MAXALT QL(12 / 30)
rizatriptan benzoate 5 mg tab, 5 mg tab disint 1 MAXALT QL(24 / 30)
sumatriptan 20 mg/act nasal soln, 5 mg/act nasal soln 1 IMITREX QL(6 / 30)
sumatriptan succinate 4 mg/0.5ml sc soln auto-inj, 6 mg/0.5ml sc soln auto-inj 1 IMITREX QL(2 / 30)
sumatriptan succinate 6 mg/0.5ml sc soln 1 IMITREX QL(5 / 30)
sumatriptan succinate 100 mg tab 1 IMITREX QL(9 / 30)
sumatriptan succinate 25 mg tab, 50 mg tab 1 IMITREX QL(18 / 30)
sumatriptan succinate refill 4 mg/0.5ml sc soln cart, 6 mg/0.5ml sc soln cart 1 IMITREX QL(2 / 30)
SUMAVEL DOSEPRO 6 mg/0.5ml sc soln jet-inj 3 QL(3 / 30)
TREXIMET 85-500 mg tab 3 QL(9 / 30)
PROSSAM
Page 55 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
zolmitriptan 2.5 mg tab disint, 5 mg tab disint 1 ZOMIG
zolmitriptan 2.5 mg tab, 5 mg tab 1 ZOMIG QL(6 / 30)
ZOMIG 2.5 mg nasal soln, 2.5 mg tab, 5 mg nasal soln, 5 mg tab 3 QL(6 / 30)
ZOMIG ZMT 2.5 mg tab disint, 5 mg tab disint 3
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antimycobacterials, Miscellaneous [Antimicobacterianos, Misceláneos]
dapsone 100 mg tab, 25 mg tab 1
Antituberculosis Agents [Agentes Antituberculosis]
CAPASTAT SULFATE 1 gm inj soln 5 PA
cycloserine 250 mg cap 1
ethambutol hcl 100 mg tab, 400 mg tab 1 MYAMBUTOL
isoniazid 100 mg tab, 300 mg tab 1
isoniazid 100 mg/ml inj soln, 50 mg/5ml syr 1
MYAMBUTOL 100 mg tab, 400 mg tab 3
MYCOBUTIN 150 mg cap 3
PASER 4 gm pckt 3
PRIFTIN 150 mg tab 3
pyrazinamide 500 mg tab 1
rifabutin 150 mg cap 1 MYCOBUTIN
RIFADIN 150 mg cap, 300 mg cap 3
RIFAMATE 150-300 mg cap 3
rifampin 150 mg cap, 300 mg cap 1 RIFADIN
RIFATER 50-120-300 mg tab 3
TRECATOR 250 mg tab 3
ANTINEOPLASTIC AGENTS [AGENTES ANTINEOPLÁSICOS]
Antineoplastic Agents [Agentes Antineoplásicos]
ABRAXANE 100 mg iv susp 4 PA
ADCETRIS 50 mg iv soln 4 PA
adriamycin 10 mg iv soln 4 PA
ADRIAMYCIN 50 mg iv soln 4 PA
ADRIAMYCIN 2 mg/ml iv soln 4 PA
ADRUCIL 2.5 gm/50ml iv soln, 5 gm/100ml iv soln, 500 mg/10ml iv soln 4 PA
AFINITOR 10 mg tab, 2.5 mg tab, 5 mg tab, 7.5 mg tab 4 PA
AFINITOR DISPERZ 2 mg tab sol, 3 mg tab sol, 5 mg tab sol 4 PA
ALECENSA 150 mg cap 4 PA
PROSSAM
Page 56 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ALFERON N 5000000 unit/ml inj soln 4 PA
ALIMTA 100 mg iv soln, 500 mg iv soln 4 PA
ALKERAN 50 mg iv soln 4 PA
ALKERAN 2 mg tab 5 PA
anastrozole 1 mg tab 4 ARIMIDEX PA
ARIMIDEX 1 mg tab 4 PA
AROMASIN 25 mg tab 4 PA
ARRANON 5 mg/ml iv soln 4 PA
ARZERRA 100 mg/5ml iv conc, 1000 mg/50ml iv conc 4 PA
AVASTIN 100 mg/4ml iv soln, 400 mg/16ml iv soln 4 PA
azacitidine 100 mg inj susp 4 VIDAZA PA
BENDEKA 100 mg/4ml iv soln 4 PA
bexarotene 75 mg cap 4 TARGRETIN PA
bicalutamide 50 mg tab 4 CASODEX PA
BICNU 100 mg iv soln 4 PA
bleomycin sulfate 15 unit inj soln 4 PA
bleomycin sulfate 30 unit inj soln 4 BLENOXANE PA
BOSULIF 100 mg tab, 500 mg tab 4 PA
BRAFTOVI 50 mg cap, 75 mg cap 5 PA
busulfan 6 mg/ml iv soln 4 BUSULFEX PA
BUSULFEX 6 mg/ml iv soln 4 PA
CAMPATH 30 mg/ml iv soln 4 PA
CAMPTOSAR 100 mg/5ml iv soln, 300 mg/15ml iv soln, 40 mg/2ml iv soln 4 PA
capecitabine 150 mg tab, 500 mg tab 4 PA
CAPRELSA 100 mg tab, 300 mg tab 4 PA
carboplatin 450 mg/45ml iv soln, 50 mg/5ml iv soln, 600 mg/60ml iv soln 4 PA
carboplatin 150 mg/15ml iv soln 4 PARAPLATIN PA
CASODEX 50 mg tab 4 PA
cisplatin 100 mg/100ml iv soln, 200 mg/200ml iv soln, 50 mg/50ml iv soln 4 PA
cladribine 10 mg/10ml iv soln 4 LEUSTATIN PA
clofarabine 1 mg/ml iv soln 4 CLOLAR PA
CLOLAR 1 mg/ml iv soln 4 PA
COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 mg oral kit 4 PA
PROSSAM
Page 57 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
COMETRIQ (140 MG DAILY DOSE) 1 X 80 & 3 X 20 mg oral kit 4 PA
COMETRIQ (60 MG DAILY DOSE) 20 mg oral kit 4 PA
COSMEGEN 0.5 mg iv soln 4 PA
cyclophosphamide 1 gm inj soln, 2 gm inj soln, 500 mg inj soln 4 PA
cytarabine 20 mg/ml inj soln 4 PA
cytarabine (pf) 100 mg/ml inj soln, 20 mg/ml inj soln 4 PA
dacarbazine 100 mg iv soln, 200 mg iv soln 4 PA
DACOGEN 50 mg iv soln 4 PA
dactinomycin 0.5 mg iv soln 4 COSMEGEN PA
DARZALEX 100 mg/5ml iv soln, 400 mg/20ml iv soln 4 PA
daunorubicin hcl 20 mg/4ml iv soln 4 PA
decitabine 50 mg iv soln 4 DACOGEN PA
docetaxel 160 mg/16ml iv soln, 160 mg/8ml iv conc, 20 mg/0.5ml iv conc, 20 mg/2ml iv soln, 20 mg/ml iv conc, 80 mg/2ml iv conc 4 PA
docetaxel 80 mg/4ml iv conc, 80 mg/8ml iv soln 4 TAXOTERE PA
DOXIL 2 mg/ml iv inj 4 PA
doxorubicin hcl 10 mg iv soln, 50 mg iv soln 4 PA
doxorubicin hcl 2 mg/ml iv soln 4 ADRIAMYCIN PA
doxorubicin hcl liposomal 2 mg/ml iv inj 4 DOXIL PA
DROXIA 200 mg cap, 300 mg cap, 400 mg cap 3
ELIGARD 22.5 mg sc kit, 30 mg sc kit, 45 mg sc kit, 7.5 mg sc kit 4 PA
ELLENCE 200 mg/100ml iv soln, 50 mg/25ml iv soln 4 PA
EMCYT 140 mg cap 4 PA
EMPLICITI 300 mg iv soln, 400 mg iv soln 4 PA
epirubicin hcl 50 mg/25ml iv soln 4 PA
epirubicin hcl 200 mg/100ml iv soln 4 ELLENCE PA
ERBITUX 100 mg/50ml iv soln, 200 mg/100ml iv soln 4 PA
ERIVEDGE 150 mg cap 4 PA
erlotinib hcl 100 mg tab, 150 mg tab, 25 mg tab 4 PA
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ERWINAZE 10000 unit inj soln 4 PA
ETOPOPHOS 100 mg iv soln 4 PA
etoposide 50 mg cap 4 PA
etoposide 1 gm/50ml iv soln, 100 mg/5ml iv soln 4 PA
etoposide 500 mg/25ml iv soln 4 VEPESID PA
everolimus 7.5 mg tab, 5 mg tab 4 AFINITOR PA
exemestane 25 mg tab 4 AROMASIN PA
FARESTON 60 mg tab 4 PA
FASLODEX 250 mg/5ml im soln 4 PA
FEMARA 2.5 mg tab 4 PA
FIRMAGON 120 mg sc soln, 80 mg sc soln 4 PA
floxuridine 0.5 gm inj soln 4 PA
fludarabine phosphate 50 mg/2ml iv soln 4 PA
fludarabine phosphate 50 mg iv soln 4 FLUDARA PA
fluorouracil 1 gm/20ml iv soln, 2.5 gm/50ml iv soln, 5 gm/100ml iv soln, 500 mg/10ml iv soln 4 PA
flutamide 125 mg cap 4 EULEXIN PA
FOLOTYN 20 mg/ml iv soln, 40 mg/2ml iv soln 4 PA
fulvestrant 250 mg/5ml im soln 4 FASLODEX PA
gemcitabine hcl 2 gm iv soln, 200 mg iv soln 4 PA
gemcitabine hcl 1 gm/26.3ml iv soln, 2 gm/52.6ml iv soln, 200 mg/5.26ml iv soln 4 PA
gemcitabine hcl 1 gm iv soln 4 GEMZAR PA
GEMZAR 1 gm iv soln, 200 mg iv soln 4 PA
GILOTRIF 20 mg tab, 30 mg tab, 40 mg tab 4 PA
GLEEVEC 100 mg tab, 400 mg tab 4 PA
GLEOSTINE 10 mg cap, 100 mg cap, 40 mg cap 4 PA
GLIADEL WAFER 7.7 mg implant wafer 4 PA
HALAVEN 1 mg/2ml iv soln 4 PA
HERCEPTIN 150 mg iv soln, 440 mg iv soln 4 PA
HEXALEN 50 mg cap 4 PA
HYCAMTIN 0.25 mg cap, 1 mg cap, 4 mg iv soln 4 PA
PROSSAM
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Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
HYDREA 500 mg cap 3 PA
hydroxyurea 500 mg cap 4 HYDREA PA
ICLUSIG 15 mg tab, 45 mg tab 4 PA
IDAMYCIN PFS 10 mg/10ml iv soln, 20 mg/20ml iv soln, 5 mg/5ml iv soln 4 PA
idarubicin hcl 20 mg/20ml iv soln, 5 mg/5ml iv soln 4 PA
idarubicin hcl 10 mg/10ml iv soln 4 IDAMYCIN PA
IDHIFA 100 mg tab, 50 mg tab 4 PA
IFEX 1 gm iv soln, 3 gm iv soln 4 PA
ifosfamide 3 gm iv soln 4 PA
ifosfamide 1 gm/20ml iv soln, 3 gm/60ml iv soln 4 PA
ifosfamide 1 gm iv soln 4 IFEX PA
IMBRUVICA 140 mg cap 4 PA
INLYTA 1 mg tab, 5 mg tab 4 PA
INTRON A 10000000 unit inj soln, 18000000 unit inj soln, 50000000 unit inj soln 4 PA
INTRON A 10000000 unit/ml inj soln, 6000000 unit/ml inj soln 4 PA
IRESSA 250 mg tab 4 PA
irinotecan hcl 40 mg/2ml iv soln, 500 mg/25ml iv soln 4 PA
irinotecan hcl 100 mg/5ml iv soln 4 CAMPTOSAR PA
ISTODAX (OVERFILL) 10 mg iv soln 4 PA
IXEMPRA KIT 15 mg iv soln, 45 mg iv soln 4 PA
JAKAFI 10 mg tab, 15 mg tab, 20 mg tab, 25 mg tab, 5 mg tab 4 PA
JEVTANA 60 mg/1.5ml iv soln 4 PA
KADCYLA 100 mg iv soln, 160 mg iv soln 4 PA
KANJINTI 420 mg iv soln, 150 mg iv soln 4 PA
KEYTRUDA 100 mg/4ml iv soln 4 PA
KYPROLIS 60 mg iv soln 4 PA
letrozole 2.5 mg tab 4 FEMARA PA
LEUKERAN 2 mg tab 4 PA
leuprolide acetate 1 mg/0.2ml inj kit 4 LUPRON PA
LIPODOX 50 2 mg/ml iv inj 4 PA
LUPRON DEPOT (1-MONTH) 3.75 mg im kit, 7.5 mg im kit 4 PA
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
LUPRON DEPOT (3-MONTH) 11.25 mg im kit, 22.5 mg im kit 4 PA
LUPRON DEPOT (4-MONTH) 30 mg im kit 4 PA
LUPRON DEPOT (6-MONTH) 45 mg im kit 4 PA
LUPRON DEPOT-PED (1-MONTH) 11.25 mg im kit, 15 mg im kit, 7.5 mg im kit 4 PA
LUPRON DEPOT-PED (3-MONTH) 11.25 mg (ped) im kit, 30 mg (ped) im kit 4 PA
LYSODREN 500 mg tab 4 PA
MATULANE 50 mg cap 4 PA
megestrol acetate 20 mg tab, 40 mg tab 4 MEGACE PA
megestrol acetate 40 mg/ml susp, 400 mg/10ml susp 4 MEGACE PA
MEKINIST 0.5 mg tab, 2 mg tab 4 PA
MEKTOVI 15 mg tab 5 PA
melphalan hcl 50 mg iv soln 4 ALKERAN PA
mercaptopurine 50 mg tab 4 PURINETHOL PA
methotrexate 2.5 mg tab 4 PA
methotrexate sodium 1 gm inj soln, 2.5 mg tab 4 PA
methotrexate sodium 250 mg/10ml inj soln, 50 mg/2ml inj soln 4 PA
methotrexate sodium (pf) 1 gm/40ml inj soln, 250 mg/10ml inj soln, 50 mg/2ml inj soln 4 PA
mitomycin 20 mg iv soln, 40 mg iv soln, 5 mg iv soln 4 MUTAMYCIN PA
mitoxantrone hcl 20 mg/10ml iv conc, 25 mg/12.5ml iv conc, 30 mg/15ml iv conc 4 PA
MUSTARGEN 10 mg inj soln 4 PA
MVASI 100 mg/4ml iv soln, 400 mg/16ml iv soln 4 PA
MYLERAN 2 mg tab 4 PA
NAVELBINE 10 mg/ml iv soln, 50 mg/5ml iv soln 4 PA
NERLYNX 40 mg tab 4 PA
NEXAVAR 200 mg tab 4 PA
NILANDRON 150 mg tab 4 PA
nilutamide 150 mg tab 4 NILANDRON PA
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NINLARO 2.3 mg cap, 3 mg cap, 4 mg cap 4 PA
NIPENT 10 mg iv soln 4 PA
ONCASPAR 750 unit/ml inj soln 4 PA
OPDIVO 100 mg/10ml iv soln, 240 mg/24ml iv soln, 40 mg/4ml iv soln 4 PA
oxaliplatin 100 mg iv soln, 50 mg iv soln 4 PA
oxaliplatin 50 mg/10ml iv soln 4 PA
oxaliplatin 100 mg/20ml iv soln 4 ELOXATIN PA
paclitaxel 100 mg/16.7ml iv conc, 150 mg/25ml iv conc, 30 mg/5ml iv conc 4 PA
paclitaxel 300 mg/50ml iv conc 4 TAXOL PA
PERJETA 420 mg/14ml iv soln 4 PA
PHOTOFRIN 75 mg iv soln 4 PA
POMALYST 1 mg cap, 2 mg cap, 3 mg cap, 4 mg cap 4 PA
PROLEUKIN 22000000 unit iv soln 4 PA
REVLIMID 10 mg cap, 15 mg cap, 2.5 mg cap, 25 mg cap, 5 mg cap 5 PA
RITUXAN 100 mg/10ml iv soln, 500 mg/50ml iv soln 4 PA
SOLTAMOX 10 mg/5ml soln 4 PA
SPRYCEL 100 mg tab, 140 mg tab, 20 mg tab, 50 mg tab, 70 mg tab, 80 mg tab 4 PA
STIVARGA 40 mg tab 4 PA
SUTENT 12.5 mg cap, 25 mg cap, 50 mg cap 4 PA
SYLATRON 200 mcg sc kit, 300 mcg sc kit, 600 mcg sc kit 4 PA
SYNRIBO 3.5 mg sc soln 4 PA
TABLOID 40 mg tab 4 PA
TAFINLAR 50 mg cap, 75 mg cap 4 PA
TAGRISSO 40 mg tab, 80 mg tab 4 PA
tamoxifen citrate 10 mg tab, 20 mg tab 4 NOLVADEX PA
TARCEVA 100 mg tab, 150 mg tab, 25 mg tab 4 PA
TARGRETIN 75 mg cap 4 PA
TASIGNA 150 mg cap, 200 mg cap 4 PA
TAXOTERE 20 mg/ml iv conc, 80 mg/4ml iv conc 4 PA
PROSSAM
Page 62 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
TEMODAR 100 mg cap, 100 mg iv soln, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 4 PA
temozolomide 100 mg cap, 140 mg cap, 180 mg cap, 20 mg cap, 250 mg cap, 5 mg cap 4 PA
teniposide 10 mg/ml iv soln 4 PA
thiotepa 15 mg inj soln 4 THIOPLEX PA
TOPOSAR 1 gm/50ml iv soln, 100 mg/5ml iv soln, 500 mg/25ml iv soln 4 PA
topotecan hcl 4 mg/4ml iv soln 4 PA
topotecan hcl 4 mg iv soln 4 HYCAMTIN PA
TORISEL 25 mg/ml iv soln 4 PA
TREANDA 100 mg iv soln, 25 mg iv soln 4 PA
TRELSTAR MIXJECT 11.25 mg im susp, 22.5 mg im susp, 3.75 mg im susp 4 PA
tretinoin 10 mg cap 4 VESANOID PA
TREXALL 10 mg tab, 15 mg tab, 5 mg tab, 7.5 mg tab 4 PA
TYKERB 250 mg tab 4 PA
VALSTAR 40 mg/ml i-vesic soln 4 PA
VANTAS 50 mg sc kit 4 PA
VECTIBIX 100 mg/5ml iv soln, 400 mg/20ml iv soln 4 PA
VELCADE 3.5 mg inj soln 4 PA
VIDAZA 100 mg inj susp 4 PA
vinblastine sulfate 1 mg/ml iv soln 4 PA
VINCASAR PFS 1 mg/ml iv soln 4 PA
vincristine sulfate 1 mg/ml iv soln 4 VINCASAR PA
vinorelbine tartrate 10 mg/ml iv soln 4 PA
vinorelbine tartrate 50 mg/5ml iv soln 4 NAVELBINE PA
VOTRIENT 200 mg tab 4 PA
XALKORI 200 mg cap, 250 mg cap 4 PA
XELODA 150 mg tab, 500 mg tab 4 PA
XTANDI 40 mg cap 4 PA
YERVOY 200 mg/40ml iv soln, 50 mg/10ml iv soln 4 PA
ZALTRAP 100 mg/4ml iv soln, 200 mg/8ml iv soln 4 PA
ZANOSAR 1 gm iv soln 4 PA
ZELBORAF 240 mg tab 4 PA
ZOLINZA 100 mg cap 4 PA
ZYTIGA 250 mg tab 4 PA
PROSSAM
Page 63 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ANTIPARKINSONIAN AGENTS [AGENTES ANTIPARKINSONIANOS]
Adamantanes [Adamantanos]
amantadine hcl 100 mg cap, 100 mg tab 1 SYMMETREL
amantadine hcl 50 mg/5ml syr 1 SYMMETREL
Anticholinergic Agents [Agentes Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab 1 COGENTIN
benztropine mesylate 1 mg/ml inj soln 1 COGENTIN
COGENTIN 1 mg/ml inj soln 3
trihexyphenidyl hcl 2 mg tab, 5 mg tab 1 ARTANE
trihexyphenidyl hcl 0.4 mg/ml oral elix 1 ARTANE
Catechol-o-methyltransferase (comt) Inhibitors [Inhibidores De La Catecol-O-Metiltransferasa (Comt)]
COMTAN 200 mg tab 3
entacapone 200 mg tab 1 COMTAN
TASMAR 100 mg tab 3
tolcapone 100 mg tab 1 TASMAR
Dopamine Precursors [Precursores De Dopamina]
carbidopa 25 mg tab 1 LODOSYN
carbidopa-levodopa 10-100 mg tab disint, 25-100 mg tab disint, 25-250 mg tab disint 1 PARCOPA
carbidopa-levodopa 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 1 SINEMET
carbidopa-levodopa er 25-100 mg tab er, 50-200 mg tab er 1 SINEMET CR
carbidopa-levodopa-entacapone 12.5-50-200 mg tab, 18.75-75-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50-200-200 mg tab 1 STALEVO
LODOSYN 25 mg tab 3
SINEMET 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 3
SINEMET CR 25-100 mg tab er, 50-200 mg tab er 3
STALEVO 100 25-100-200 mg tab 3
STALEVO 125 31.25-125-200 mg tab 3
STALEVO 150 37.5-150-200 mg tab 3
STALEVO 200 50-200-200 mg tab 3
PROSSAM
Page 64 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
STALEVO 50 12.5-50-200 mg tab 3
STALEVO 75 18.75-75-200 mg tab 3
Dopamine Receptor Agonists [Agonistas Del Receptor De Dopamina]
APOKYN 30 mg/3ml sc soln cart 5 PA
bromocriptine mesylate 2.5 mg tab, 5 mg cap 1 PARLODEL
cabergoline 0.5 mg tab 1 DOSTINEX
MIRAPEX 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 3
MIRAPEX ER 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 3
NEUPRO 1 mg/24hr td patch 24hr, 2 mg/24hr td patch 24hr, 3 mg/24hr td patch 24hr, 4 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 8 mg/24hr td patch 24hr 3
PARLODEL 2.5 mg tab, 5 mg cap 3
pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab 1 MIRAPEX
pramipexole dihydrochloride er 0.375 mg tab er 24 hr, 0.75 mg tab er 24 hr, 1.5 mg tab er 24 hr, 2.25 mg tab er 24 hr, 3 mg tab er 24 hr, 3.75 mg tab er 24 hr, 4.5 mg tab er 24 hr 1 MIRAPEX ER
REQUIP 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 3
REQUIP XL 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 3
ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab 1 REQUIP
ropinirole hcl er 12 mg tab er 24 hr, 2 mg tab er 24 hr, 4 mg tab er 24 hr, 6 mg tab er 24 hr, 8 mg tab er 24 hr 1 REQUIP XL
Monoamine Oxidase B Inhibitors [Inhibidores De La Monoaminooxidasa B (Mao-B)]
AZILECT 0.5 mg tab, 1 mg tab 3
ELDEPRYL 5 mg cap 3
PROSSAM
Page 65 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
EMSAM 12 mg/24hr td patch 24hr, 6 mg/24hr td patch 24hr, 9 mg/24hr td patch 24hr 3
rasagiline mesylate 0.5 mg tab, 1 mg tab 1 AZILECT
selegiline hcl 5 mg tab 1
selegiline hcl 5 mg cap 1 ELDEPRYL
ZELAPAR 1.25 mg tab disint 3
ANTIPROTOZOALS [ANTIPROTOZOARIOS]
Amebicides [Amebicidas]
paromomycin sulfate 250 mg cap 1 HUMATIN
Antimalarials [Antimaláricos]
atovaquone-proguanil hcl 250-100 mg tab, 62.5-25 mg tab 1 MALARONE
chloroquine phosphate 250 mg tab, 500 mg tab 1
COARTEM 20-120 mg tab 3
DARAPRIM 25 mg tab 3
hydroxychloroquine sulfate 200 mg tab 1 PLAQUENIL
MALARONE 250-100 mg tab, 62.5-25 mg tab 3
mefloquine hcl 250 mg tab 1
PLAQUENIL 200 mg tab 3
primaquine phosphate 26.3 mg tab 1
QUALAQUIN 324 mg cap 3 QL(42 / 365)
quinine sulfate 324 mg cap 1 QUALAQUIN QL(42 / 365)
Antiprotozoals, Miscellaneous [Antiprotozoarios, Misceláneos]
ALINIA 500 mg tab 3
ALINIA 100 mg/5ml susp 3
atovaquone 750 mg/5ml susp 4 MEPRON PA
FLAGYL 250 mg tab, 375 mg cap, 500 mg tab 3
MEPRON 750 mg/5ml susp 5 PA
metronidazole 250 mg tab, 375 mg cap, 500 mg tab 1 FLAGYL
NEBUPENT 300 mg inh soln 3
PENTAM 300 mg inj soln 3
TINDAMAX 500 mg tab 3
tinidazole 250 mg tab, 500 mg tab 1 TINDAMAX
ANTIPRURITICS AND LOCAL ANESTHETICS [ANTIPRURÍTICOS Y ANESTÉSICOS LOCALES]
Antipruritics And Local Anesthetics [Antipruríticos Y Anestésicos Locales]
agoneaze 2.5-2.5 % ext kit 1
ANACAINE 10 % oint 3
ANALPRAM HC 2.5-1 % rect crm 3
PROSSAM
Page 66 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ANALPRAM HC SINGLES 2.5-1 % rect crm 3
ANALPRAM-HC 1-1 % rect crm 3
ANALPRAM-HC 2.5-1 % rect lot 3
anodyne lpt 2.5-2.5 % ext kit 1
DERMACINRX EMPRICAINE 2.5-2.5 % ext kit 3
DERMACINRX PRIZOPAK 2.5-2.5 % ext kit 3
ethyl chloride ext aer 1
FIRST-MOUTHWASH BLM m/t susp 3
GEBAUERS PAIN EASE ext aer 3
GEBAUERS SPRAY AND STRETCH ext aer 3
GLYDO 2 % gel 3
hydrocortisone ace-pramoxine 1-1 % rect crm, 2.5-1 % rect crm 1
LIDO BDK 2.5-2.5 % ext kit 3
lidocaine 5 % oint 1
lidocaine 5 % patch 1 LIDODERM
lidocaine hcl 3 % crm 1
lidocaine hcl 3 % lot 1
lidocaine hcl 2 % gel, 4 % ext soln 1 XYLOCAINE
lidocaine pak 5 % oint 1
lidocaine-hydrocortisone ace 2-2 % rect kit, 3-0.5 % rect kit, 3-1 % rect kit, 3-2.5 % rect kit 1
lidocaine-hydrocortisone ace 2.8-0.55 % rect gel, 3-0.5 % rect crm 1
lidocaine-prilocaine 2.5-2.5 % ext kit 1
lidocaine-prilocaine 2.5-2.5 % crm 1 EMLA
LIDODERM 5 % patch 3
lido-k 3 % lot 1
lidopin 3 % crm 1
lidopril 2.5-2.5 % ext kit 1
lidopril xr 2.5-2.5 % ext kit 1
LIDO-PRILO CAINE PACK 2.5-2.5 % ext kit 3
LIPROZONEPAK 2.5-2.5 % ext kit 3
LIVIXIL PAK 2.5-2.5 % ext kit 3
MEDOLOR PAK 2.5-2.5 % ext kit 3
PHENAZO 200 mg tab 3
phenazopyridine hcl 100 mg tab, 200 mg tab 1
PROSSAM
Page 67 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
pramcort 1-1 % rect crm 1
PRAMOX 1 % gel 3
premium lidocaine 5 % oint 1
prilolid 2.5-2.5 % ext kit 1
PRILOXX LP 2.5-2.5 % ext kit 3
PROCORT 1.85-1.15 % rect crm 3
PROCTOFOAM HC 1-1 % rect foam 3
PRUDOXIN 5 % crm 3
PYRIDIUM 100 mg tab, 200 mg tab 3
RELADOR PAK 2.5-2.5 % ext kit 3
RELADOR PAK PLUS 2.5-2.5 % ext kit 3
SYNERA 70-70 mg patch 3
TOPEX TOPICAL ANESTHETIC 20 % Mouth/Throat Aerosol 3
ZONALON 5 % crm 3
ANTITHROMBOTIC AGENTS [AGENTES ANTITROMBÓTICOS]
Anticoagulants [Anticoagulantes]
ARIXTRA 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 5 PA
COUMADIN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 2
ELIQUIS 2.5 mg tab, 5 mg tab 2 PA
ELIQUIS STARTER PACK 5 mg tab 2 PA
enoxaparin sodium 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 4 LOVENOX PA
fondaparinux sodium 10 mg/0.8ml sc soln, 2.5 mg/0.5ml sc soln, 5 mg/0.4ml sc soln, 7.5 mg/0.6ml sc soln 5 ARIXTRA PA
FRAGMIN 10000 unit/ml sc soln, 12500 unit/0.5ml sc soln, 15000 unit/0.6ml sc soln, 18000 unt/0.72ml sc soln, 2500 unit/0.2ml sc soln, 5000 unit/0.2ml sc soln, 7500 unit/0.3ml sc soln 5 PA
heparin sodium (porcine) 1000 unit/ml inj soln, 10000 unit/ml inj 1
PROSSAM
Page 68 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
soln, 20000 unit/ml inj soln, 5000 unit/ml inj soln
JANTOVEN 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 3
LOVENOX 100 mg/ml sc soln, 120 mg/0.8ml sc soln, 150 mg/ml sc soln, 30 mg/0.3ml sc soln, 300 mg/3ml inj soln, 40 mg/0.4ml sc soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln 5 PA
PRADAXA 110 mg cap, 150 mg cap, 75 mg cap 2 PA
warfarin sodium 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab 1 COUMADIN
XARELTO 10 mg tab, 15 mg tab, 20 mg tab 2 PA
XARELTO STARTER PACK 15 & 20 mg tab pack 2 PA
Platelet-aggregation Inhibitors [Inhibidores De La Agregación De Plaquetas]
aspirin-dipyridamole er 25-200 mg cap er 12 hr 1 AGGRENOX
BRILINTA 60 mg tab, 90 mg tab 2 PA
cilostazol 100 mg tab, 50 mg tab 1 PLETAL
clopidogrel bisulfate 300 mg tab, 75 mg tab 1 PLAVIX
EFFIENT 10 mg tab, 5 mg tab 2 PA
PLAVIX 300 mg tab, 75 mg tab 3
prasugrel hcl 10 mg tab, 5 mg tab 1 EFFIENT PA
Platelet-reducing Agents [Agentes Reductores De Plaquetas]
AGRYLIN 0.5 mg cap 3
anagrelide hcl 0.5 mg cap, 1 mg cap 1 AGRYLIN
ANTITUSSIVES [ANTITUSIVOS]
Antitussives [Antitusivos]
ap-hist dm 7.5-4-15 mg/5ml liq 1
benzonatate 100 mg cap, 150 mg cap, 200 mg cap 1
biotuss 10-15-300 mg/5ml liq 1
BIOTUSS PEDIATRIC 2.5-5-50 mg/ml liq 3
BROMFED DM 30-2-10 mg/5ml syr 3
CARBAPHEN 12 10-4-27.5 mg/5ml liq 3
PROSSAM
Page 69 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CARBAPHEN 12 PED 2.5-1.25-7.5 mg/ml susp 3
cheratussin ac 100-10 mg/5ml syr 1
EXACTUSS 10-28-388 mg/5ml liq 3
g tussin ac 100-10 mg/5ml soln 1
GILTUSS 10-28-388 mg/5ml liq 3
GILTUSS PEDIATRIC 2.5-7.5-88 mg/ml liq 3
GILTUSS TR 10-28-388 mg tab 3
guaiatussin ac 100-10 mg/5ml syr 1
guaifenesin ac 100-10 mg/5ml syr 1
guaifenesin-codeine 100-10 mg/5ml soln 1
hydrocod polst-cpm polst er 10-8 mg/5ml susp er 1
hydrocodone-homatropine 5-1.5 mg tab 1
hydrocodone-homatropine 5-1.5 mg/5ml syr 1
hydromet 5-1.5 mg/5ml syr 1
m-hist dm 7.5-4-15 mg/5ml liq 1
NEOTUSS PLUS 7.5-4-30 mg/5ml liq 3
NIVA-HIST DM 7.5-4-15 mg/5ml liq 1
NORTUSS-DE 2.5-5-50 mg/ml liq 3
nortuss-ex 20-200 mg/5ml liq 1
phenyleph-promethazine-cod 5-6.25-10 mg/5ml syr 1
promethazine vc/codeine 6.25-5-10 mg/5ml syr 1
promethazine-codeine 6.25-10 mg/5ml soln, 6.25-10 mg/5ml syr 1
promethazine-dm 6.25-15 mg/5ml syr 1
promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syr 1
pseudoeph-bromphen-dm 30-2-10 mg/5ml syr 1
pseudoeph-chlorphen-hydrocod 60-4-5 mg/5ml soln 1
robafen ac 100-10 mg/5ml soln 1
TESSALON PERLES 100 mg cap 3
TUSNEL 60-30-400 mg tab 3
TUSSICAPS 10-8 mg cap er 12 hr, 5-4 mg cap er 12 hr 3
TUSSIGON 5-1.5 mg tab 3
PROSSAM
Page 70 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
TUSSIONEX PENNKINETIC ER 10-8 mg/5ml susp er 3
virtussin a/c 100-10 mg/5ml soln 1
ZUTRIPRO 60-4-5 mg/5ml soln 3
ANTIULCER AGENTS AND ACID SUPPRESSANTS [AGENTES ANTI-ÚLCERA Y SUPRESORES DE ÁCIDOS]
Antiulcer Agents And Acid Suppressants, Misc [Agentes Anti-Úlcera Y Supresores De Ácidos, Misceláneos]
PYLERA 140-125-125 mg cap 3
Histamine H2-antagonists [Antagonistas De Histamina H2]
cimetidine 300 mg tab, 400 mg tab, 800 mg tab 1 TAGAMET QL(90 / 365)
cimetidine hcl 300 mg/5ml soln 1 TAGAMET
famotidine 40 mg/5ml susp 1 PEPCID
famotidine 20 mg tab, 40 mg tab 1 PEPCID QL(90 / 365)
nizatidine 15 mg/ml soln 1 AXID
nizatidine 150 mg cap, 300 mg cap 1 AXID QL(90 / 365)
PEPCID 40 mg/5ml susp 3
PEPCID 20 mg tab, 40 mg tab 3 QL(90 / 365)
ranitidine hcl 150 mg cap, 300 mg cap 1 ZANTAC
ranitidine hcl 50 mg/2ml inj soln 1 ZANTAC
ranitidine hcl 150 mg tab, 300 mg tab 1 ZANTAC QL(90 / 365)
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 150 mg/6ml inj soln, 75 mg/5ml syr 1 ZANTAC QL(90 / 365)
ZANTAC 1000 mg/40ml inj soln, 50 mg/2ml inj soln 3
ZANTAC 300 mg tab 3 QL(90 / 365)
ZANTAC 150 mg/6ml inj soln 3 QL(90 / 365)
Prostaglandins [Prostaglandinas]
CYTOTEC 100 mcg tab, 200 mcg tab 3 QL(90 / 365)
misoprostol 100 mcg tab, 200 mcg tab 1 CYTOTEC QL(90 / 365)
Protectants [Protectores]
CARAFATE 1 gm/10ml susp 3
CARAFATE 1 gm tab 3 QL(90 / 365)
sucralfate 1 gm/10ml susp 1 CARAFATE
sucralfate 1 gm tab 1 CARAFATE QL(90 / 365)
Proton-pump Inhibitors [Inhibidores De La Bomba De Protones]
ACIPHEX 20 mg tab dr 3
amoxicill-clarithro-lansopraz oral misc 1 PREVPAC QL(90 / 365)
PROSSAM
Page 71 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DEXILANT 30 mg cap dr, 60 mg cap dr 2
esomeprazole magnesium 20 mg cap dr, 40 mg cap dr 1 NEXIUM QL(90 / 365)
FIRST-LANSOPRAZOLE 3 mg/ml susp 3
FIRST-OMEPRAZOLE 2 mg/ml susp 3
lansoprazole 15 mg tab disint, 30 mg tab disint 1
lansoprazole 15 mg cap dr, 30 mg cap dr 1 PREVACID QL(90 / 365)
NEXIUM 10 mg pckt, 2.5 mg pckt, 20 mg cap dr, 20 mg pckt, 40 mg cap dr, 40 mg pckt, 5 mg pckt 3 QL(90 / 365)
OMECLAMOX-PAK 500-500-20 mg oral misc 3
OMEPPI 20-1100 mg cap, 40-1100 mg cap 3 QL(90 / 365)
omeprazole 10 mg cap dr, 20 mg cap dr, 40 mg cap dr 1 PRILOSEC QL(90 / 365)
OMEPRAZOLE+SYRSPEND SF ALKA 2 mg/ml susp 3
omeprazole-sodium bicarbonate 20-1680 mg pckt, 40-1680 mg pckt 1 ZEGERID
omeprazole-sodium bicarbonate 20-1100 mg cap, 40-1100 mg cap 1 ZEGERID QL(90 / 365)
pantoprazole sodium 20 mg tab dr, 40 mg tab dr 1 PROTONIX QL(90 / 365)
PREVACID 15 mg cap dr, 30 mg cap dr 3 QL(90 / 365)
PREVACID SOLUTAB 15 mg tab disint, 30 mg tab disint 3
PREVPAC oral misc 3 QL(90 / 365)
PRILOSEC 10 mg pckt, 2.5 mg pckt 3
PROTONIX 40 mg pckt 3
PROTONIX 20 mg tab dr, 40 mg tab dr 3 QL(90 / 365)
rabeprazole sodium 20 mg tab dr 1 ACIPHEX
ZEGERID 20-1100 mg cap, 20-1680 mg pckt, 40-1100 mg cap, 40-1680 mg pckt 3 QL(90 / 365)
ANTIVIRALS [ANTIVIRALES]
Adamantanes [Adamantanos]
FLUMADINE 100 mg tab 3
PROSSAM
Page 72 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
rimantadine hcl 100 mg tab 1 FLUMADINE
Antiretrovirals [Antirretrovirales]
abacavir sulfate 300 mg tab 4 ZIAGEN PA
abacavir sulfate 20 mg/ml soln 4 ZIAGEN PA
abacavir sulfate-lamivudine 600-300 mg tab 4 EPZICOM PA
abacavir-lamivudine-zidovudine 300-150-300 mg tab 4 TRIZIVIR PA
APTIVUS 250 mg cap 4 PA
APTIVUS 100 mg/ml soln 4 PA
atazanavir sulfate 150 mg cap, 200 mg cap, 300 mg cap 4 REYATAZ PA
ATRIPLA 600-200-300 mg tab 4 PA
COMBIVIR 150-300 mg tab 5 PA
COMPLERA 200-25-300 mg tab 5 PA
CRIXIVAN 200 mg cap, 400 mg cap 4 PA
didanosine 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 4 VIDEX PA
EDURANT 25 mg tab 4 PA
efavirenz 200 mg cap, 50 mg cap 4 SUSTIVA PA
EMTRIVA 200 mg cap 4 PA
EMTRIVA 10 mg/ml soln 4 PA
EPIVIR 150 mg tab, 300 mg tab 5 PA
EPIVIR 10 mg/ml soln 5 PA
EPIVIR HBV 100 mg tab 5 PA
EPIVIR HBV 5 mg/ml soln 5 PA
EPZICOM 600-300 mg tab 4 PA
EVOTAZ 300-150 mg tab 4 PA
fosamprenavir calcium 700 mg tab 4 LEXIVA PA
FUZEON 90 mg sc soln 4 PA
INTELENCE 100 mg tab, 200 mg tab, 25 mg tab 4 PA
INVIRASE 200 mg cap, 500 mg tab 5 PA
ISENTRESS 100 mg tab chew, 25 mg tab chew, 400 mg tab 4 PA
ISENTRESS HD 600 mg tab 4 PA
KALETRA 100-25 mg tab, 200-50 mg tab 4 PA
KALETRA 400-100 mg/5ml soln 4 PA
lamivudine 150 mg tab, 300 mg tab 4 EPIVIR PA
lamivudine 10 mg/ml soln 4 EPIVIR PA
lamivudine 100 mg tab 4 EPIVIR HBV PA
lamivudine-zidovudine 150-300 mg tab 4 COMBIVIR PA
LEXIVA 700 mg tab 4 PA
PROSSAM
Page 73 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
LEXIVA 50 mg/ml susp 4 PA
lopinavir-ritonavir 400-100 mg/5ml soln 4 KALETRA PA
nevirapine 200 mg tab 4 VIRAMUNE PA
nevirapine 50 mg/5ml susp 4 VIRAMUNE PA
nevirapine er 100 mg tab er 24 hr, 400 mg tab er 24 hr 4 VIRAMUNE XR PA
NORVIR 100 mg cap, 100 mg tab 4 PA
NORVIR 80 mg/ml soln 4 PA
ODEFSEY 200-25-25 mg tab 4 PA
PREZCOBIX 800-150 mg tab 4 PA
PREZISTA 150 mg tab, 600 mg tab, 75 mg tab, 800 mg tab 5 PA
PREZISTA 100 mg/ml susp 5 PA
RESCRIPTOR 100 mg tab, 200 mg tab 4 PA
RETROVIR 100 mg cap 5 PA
RETROVIR 10 mg/ml iv soln, 50 mg/5ml syr 5 PA
REYATAZ 50 mg pckt 4 PA
REYATAZ 150 mg cap, 200 mg cap, 300 mg cap 5 PA
SELZENTRY 150 mg tab, 300 mg tab 4 PA
stavudine 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 4 ZERIT PA
STRIBILD 150-150-200-300 mg tab 4 PA
SUSTIVA 200 mg cap, 50 mg cap, 600 mg tab 4 PA
tenofovir disoproxil fumarate 300 mg tab 4 VIREAD PA
TIVICAY 50 mg tab 4 PA
TRIZIVIR 300-150-300 mg tab 5 PA
TRUVADA 200-300 mg tab 4 PA
VIDEX 2 gm soln, 4 gm soln 5 PA
VIDEX EC 125 mg cap dr, 200 mg cap dr, 250 mg cap dr, 400 mg cap dr 5 PA
VIRACEPT 250 mg tab, 625 mg tab 4 PA
VIRAMUNE 200 mg tab 5 PA
VIRAMUNE 50 mg/5ml susp 5 PA
VIRAMUNE XR 100 mg tab er 24 hr, 400 mg tab er 24 hr 5 PA
VIREAD 150 mg tab, 200 mg tab, 250 mg tab, 300 mg tab 4 PA
VIREAD 40 mg/gm oral pwdr 4 PA
PROSSAM
Page 74 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ZERIT 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 5 PA
ZERIT 1 mg/ml soln 5 PA
ZIAGEN 300 mg tab 5 PA
ZIAGEN 20 mg/ml soln 5 PA
zidovudine 100 mg cap, 300 mg tab 4 RETROVIR PA
zidovudine 50 mg/5ml syr 4 RETROVIR PA
Hcv Antivirals [Antivirales Para Vhc]
ledipasvir-sofosbuvir 90-400 mg tab 1 PA
HARVONI 90-400 mg tab 4 PA
MAVYRET 100-40 mg tab 4 PA
SOVALDI 400 mg tab 4 PA
Interferons [Interferones]
PEGASYS 180 mcg/ml sc soln 5 PA
PEGASYS PROCLICK 135 mcg/0.5ml sc soln 5 PA
PEGINTRON 50 mcg/0.5ml sc kit 5 PA
PLEGRIDY 125 mcg/0.5ml sc soln pen-inj, 125 mcg/0.5ml sc soln pfs 5 PA
PLEGRIDY STARTER PACK 63 & 94 mcg/0.5ml sc soln pen-inj, 63 & 94 mcg/0.5ml sc soln pfs 5 PA
Monoclonal Antibodies [Anticuerpos Monoclonales]
SYNAGIS 100 mg/ml im soln, 50 mg/0.5ml im soln 5 PA
Neuraminidase Inhibitors [Inhibidores De La Neuraminidasa]
oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap 1 TAMIFLU
oseltamivir phosphate 6 mg/ml susp 1 TAMIFLU
RELENZA DISKHALER 5 mg/blister inh aer pwdr br act 3
TAMIFLU 30 mg cap, 45 mg cap, 75 mg cap 3
TAMIFLU 6 mg/ml susp 3
Nucleosides And Nucleotides [Nucleósidos Y Nucleótidos]
acyclovir 200 mg cap, 400 mg tab, 800 mg tab 1 ZOVIRAX
acyclovir 200 mg/5ml susp 1 ZOVIRAX
adefovir dipivoxil 10 mg tab 1 HEPSERA PA
BARACLUDE 0.5 mg tab, 1 mg tab 5 PA
BARACLUDE 0.05 mg/ml soln 5 PA
entecavir 0.5 mg tab, 1 mg tab 1 BARACLUDE PA
famciclovir 125 mg tab, 250 mg tab, 500 mg tab 1 FAMVIR
HEPSERA 10 mg tab 5 PA
PROSSAM
Page 75 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MODERIBA 200 mg tab 5 PA
REBETOL 200 mg cap 5 PA
RIBASPHERE 200 mg cap, 200 mg tab 5 PA
ribavirin 200 mg tab 4 COPEGUS PA
ribavirin 200 mg cap 4 REBETOL PA
ribavirin 6 gm inh soln 1 VIRAZOLE
valacyclovir hcl 1 gm tab, 500 mg tab 1 VALTREX
VALCYTE 450 mg tab 5 PA
VALCYTE 50 mg/ml soln 5 PA
valganciclovir hcl 450 mg tab 4 VALCYTE PA
valganciclovir hcl 50 mg/ml soln 4 VALCYTE PA
VALTREX 1 gm tab, 500 mg tab 3
VIRAZOLE 6 gm inh soln 3
ZOVIRAX 200 mg cap, 400 mg tab, 800 mg tab 3
ZOVIRAX 200 mg/5ml susp 3
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS [ANSIOLÍTICOS, SEDANTES E HIPNÓTICOS]
Anxiolytics, Sedatives, & Hypnotics Misc [Ansiolíticos, Sedantes E Hipnóticos Misceláneos]
AMBIEN 10 mg tab, 5 mg tab 3
AMBIEN CR 12.5 mg tab er, 6.25 mg tab er 3
buspirone hcl 10 mg tab, 15 mg tab, 30 mg tab, 5 mg tab, 7.5 mg tab 1 BUSPAR
droperidol 2.5 mg/ml inj soln 1
EDLUAR 10 mg tab subl, 5 mg tab subl 3
eszopiclone 1 mg tab, 2 mg tab, 3 mg tab 1 LUNESTA
hydroxyzine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 ATARAX
hydroxyzine hcl 10 mg/5ml syr 1 ATARAX
hydroxyzine hcl 25 mg/ml im soln, 50 mg/ml im soln 1 VISTARIL
hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap 1 VISTARIL
INTERMEZZO 1.75 mg tab subl, 3.5 mg tab subl 3
LUNESTA 1 mg tab, 2 mg tab, 3 mg tab 3
meprobamate 200 mg tab, 400 mg tab 1
ROZEREM 8 mg tab 3
PROSSAM
Page 76 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SONATA 10 mg cap, 5 mg cap 3
VISTARIL 25 mg cap, 50 mg cap 3
zaleplon 10 mg cap, 5 mg cap 1 SONATA
zolpidem tartrate 10 mg tab, 5 mg tab 1 AMBIEN
zolpidem tartrate 1.75 mg tab subl, 3.5 mg tab subl 1 INTERMEZZO
zolpidem tartrate er 12.5 mg tab er, 6.25 mg tab er 1 AMBIEN CR
ZOLPIMIST 5 mg/act soln 3
Barbiturates [Barbitúricos]
BUTISOL SODIUM 30 mg tab 3
phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab 1
phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln 1
SECONAL 100 mg cap 3
Benzodiazepines [Benzodiazepinas]
alprazolam 0.25 mg tab disint, 0.5 mg tab disint, 1 mg tab disint 1 NIRAVAM
alprazolam 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 1 XANAX
alprazolam er 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR
ALPRAZOLAM INTENSOL 1 mg/ml oral conc 3
alprazolam xr 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 1 XANAX XR
ATIVAN 0.5 mg tab, 1 mg tab, 2 mg tab 3
ATIVAN 2 mg/ml inj soln, 4 mg/ml inj soln 3
chlordiazepoxide hcl 10 mg cap, 25 mg cap, 5 mg cap 1 LIBRIUM
clorazepate dipotassium 15 mg tab, 3.75 mg tab, 7.5 mg tab 1 TRANXENE
DIASTAT ACUDIAL 10 mg rect gel, 20 mg rect gel 3
DIASTAT PEDIATRIC 2.5 mg rect gel 3
diazepam 10 mg/2ml im soln auto-inj, 5 mg/ml inj soln, 5 mg/ml oral conc 1
PROSSAM
Page 77 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
diazepam 10 mg rect gel, 2.5 mg rect gel, 20 mg rect gel 1 DIASTAT
diazepam 10 mg tab, 2 mg tab, 5 mg tab 1 VALIUM
diazepam 5 mg/5ml soln 1 VALIUM
DIAZEPAM INTENSOL 5 mg/ml oral conc 1
DORAL 15 mg tab 3
estazolam 1 mg tab, 2 mg tab 1 PROSOM
flurazepam hcl 15 mg cap, 30 mg cap 1 DALMANE
HALCION 0.25 mg tab 3
lorazepam 2 mg/ml inj soln, 2 mg/ml oral conc, 4 mg/ml inj soln 1
lorazepam 0.5 mg tab, 1 mg tab, 2 mg tab 1 ATIVAN
LORAZEPAM INTENSOL 2 mg/ml oral conc 3
midazolam hcl 10 mg/10ml inj soln, 10 mg/2ml inj soln, 2 mg/2ml inj soln, 2 mg/ml syr, 25 mg/5ml inj soln, 5 mg/5ml inj soln, 5 mg/ml inj soln, 50 mg/10ml inj soln 1
oxazepam 10 mg cap, 15 mg cap, 30 mg cap 1 SERAX
quazepam 15 mg tab 1
RESTORIL 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 3
temazepam 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 1 RESTORIL
TRANXENE-T 7.5 mg tab 3
triazolam 0.125 mg tab, 0.25 mg tab 1 HALCION
VALIUM 10 mg tab, 2 mg tab, 5 mg tab 3
XANAX 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab 3
XANAX XR 0.5 mg tab er 24 hr, 1 mg tab er 24 hr, 3 mg tab er 24 hr 3
AUTONOMIC DRUGS, MISCELLANEOUS [MEDICAMENTOS AUTONÓMICOS, MISCELÁNEOS]
Autonomic Drugs, Miscellaneous [Medicamentos Autonómicos, Misceláneos]
CHANTIX 0.5 mg tab, 1 mg tab 3
CHANTIX CONTINUING MONTH PAK 1 mg tab 3
PROSSAM
Page 78 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 mg x 42 tab 3
NICOTROL 10 mg inhaler 2
NICOTROL NS 10 mg/ml nasal soln 2
BETA-ADRENERGIC BLOCKING AGENTS [AGENTES BLOQUEADORES BETA-ADRENÉRGICOS]
Beta-adrenergic Blocking Agents [Agentes Bloqueadores Beta-Adrenérgicos]
acebutolol hcl 200 mg cap, 400 mg cap 1 SECTRAL
atenolol 100 mg tab, 25 mg tab, 50 mg tab 1 TENORMIN
atenolol-chlorthalidone 100-25 mg tab, 50-25 mg tab 1 TENORETIC
betaxolol hcl 10 mg tab, 20 mg tab 1 KERLONE
bisoprolol fumarate 10 mg tab, 5 mg tab 1 ZEBETA
bisoprolol-hydrochlorothiazide 10-6.25 mg tab, 2.5-6.25 mg tab, 5-6.25 mg tab 1 ZIAC
BYSTOLIC 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3
carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 1 COREG
COREG 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 3
DUTOPROL 100-12.5 mg tab er 24 hr, 25-12.5 mg tab er 24 hr, 50-12.5 mg tab er 24 hr 3
labetalol hcl 100 mg tab, 200 mg tab, 300 mg tab 1 NORMODYNE
metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 TOPROL
metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab 1 LOPRESSOR
metoprolol-hydrochlorothiazide 100-25 mg tab, 100-50 mg tab, 50-25 mg tab 1 LOPRESSOR HCT
metoprolol- hydrochlorothiazide er 50-12.5 mg tab er 24 hr 1 DUTOPROL
nadolol 20 mg tab, 40 mg tab, 80 mg tab 1 CORGARD
nadolol-bendroflumethiazide 40-5 mg tab 1 CORZIDE
pindolol 10 mg tab, 5 mg tab 1 VISKEN
PROSSAM
Page 79 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 1 INDERAL
propranolol hcl 20 mg/5ml soln, 40 mg/5ml soln 1 INDERAL
propranolol hcl er 120 mg cap er 24 hr, 160 mg cap er 24 hr, 60 mg cap er 24 hr, 80 mg cap er 24 hr 1 INDERAL LA
propranolol-hctz 40-25 mg tab, 80-25 mg tab 1 INDERIDE
sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab 1 BETAPACE
sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab 1 BETAPACE AF
timolol maleate 10 mg tab, 20 mg tab, 5 mg tab 1 BLOCADREN
BONE RESORPTION INHIBITORS [INHIBIDORES DE LA RESORCIÓN ÓSEA]
Bone Resorption Inhibitors [Inhibidores De La Resorción Ósea]
ACTONEL 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 3
alendronate sodium 10 mg tab, 35 mg tab, 40 mg tab, 5 mg tab, 70 mg tab 1 FOSAMAX
ATELVIA 35 mg tab dr 3
BINOSTO 70 mg tab eff 3
BONIVA 150 mg tab 3
BONIVA 3 mg/3ml iv soln 5 PA
etidronate disodium 200 mg tab, 400 mg tab 1 DIDRONEL
ibandronate sodium 150 mg tab 1 BONIVA
ibandronate sodium 3 mg/3ml iv soln 4 BONIVA PA
pamidronate disodium 30 mg iv soln, 90 mg iv soln 1 PA
pamidronate disodium 30 mg/10ml iv soln, 6 mg/ml iv soln, 90 mg/10ml iv soln 1 PA
PROLIA 60 mg/ml sc soln 5 PA
RECLAST 5 mg/100ml iv soln 5 PA
risedronate sodium 150 mg tab, 30 mg tab, 35 mg tab, 5 mg tab 1 ACTONEL
risedronate sodium 35 mg tab dr 1 ATELVIA
XGEVA 120 mg/1.7ml sc soln 5 PA
zoledronic acid 4 mg/100ml iv soln 4 PA
zoledronic acid 5 mg/100ml iv soln 4 RECLAST PA
zoledronic acid 4 mg/5ml iv conc 4 ZOMETA PA
PROSSAM
Page 80 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ZOMETA 4 mg/100ml iv soln, 4 mg/5ml iv conc 5 PA
CALCIUM-CHANNEL BLOCKING AGENTS [AGENTES BLOQUEADORES DE LOS CANALES DE CALCIO]
Calcium-channel Blocking Agents, Misc [Agentes Bloqueadores De Los Canales De Calcio, Misceláneos]
CALAN 120 mg tab, 80 mg tab 3
CALAN SR 120 mg tab er, 180 mg tab er, 240 mg tab er 3
CARDIZEM 120 mg tab, 30 mg tab, 60 mg tab 3
CARDIZEM CD 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3
CARDIZEM LA 120 mg tab er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3
CARTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 3
diltiazem cd 180 mg cap er 24 hr 1
diltiazem cd 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM
diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1 CARDIZEM
diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1
diltiazem hcl er 120 mg cap er 12 hr, 60 mg cap er 12 hr, 90 mg cap er 12 hr 1 CARDIZEM
diltiazem hcl er beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1
diltiazem hcl er beads 180 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 1 TIAZAC
diltiazem hcl er coated beads 180 mg cap er 24 hr, 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg cap er 24 hr, 360 1
PROSSAM
Page 81 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
mg tab er 24 hr, 420 mg tab er 24 hr
diltiazem hcl er coated beads 120 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr 1 CARDIZEM
dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr 1
MATZIM LA 180 mg tab er 24 hr, 240 mg tab er 24 hr, 300 mg tab er 24 hr, 360 mg tab er 24 hr, 420 mg tab er 24 hr 3
TARKA 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 3
TAZTIA XT 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 3
TIAZAC 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr, 420 mg cap er 24 hr 3
trandolapril-verapamil hcl er 1-240 mg tab er, 2-180 mg tab er, 2-240 mg tab er, 4-240 mg tab er 1 TARKA
verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab 1 CALAN
verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er 1 CALAN
verapamil hcl er 100 mg cap er 24 hr, 120 mg cap er 24 hr, 180 mg cap er 24 hr, 200 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr 1 VERELAN
VERELAN 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr, 360 mg cap er 24 hr 3
VERELAN PM 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr 3
Dihydropyridines [Dihidropiridinas]
ADALAT CC 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3
AFEDITAB CR 30 mg tab er 24 hr, 60 mg tab er 24 hr 3
amlodipine besy-benazepril hcl 10-20 mg cap, 10-40 mg cap, 2.5-10 1 LOTREL
PROSSAM
Page 82 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
mg cap, 5-10 mg cap, 5-20 mg cap, 5-40 mg cap
amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab 1 NORVASC
amlodipine besylate-valsartan 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 1 EXFORGE
amlodipine-atorvastatin 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 1 CADUET
amlodipine-olmesartan 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 1 AZOR
amlodipine-valsartan-hctz 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 1 EXFORGE HCT
AZOR 10-20 mg tab, 10-40 mg tab, 5-20 mg tab, 5-40 mg tab 3
CADUET 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab, 5-10 mg tab, 5-20 mg tab, 5-40 mg tab, 5-80 mg tab 3
EXFORGE 10-160 mg tab, 10-320 mg tab, 5-160 mg tab, 5-320 mg tab 3
EXFORGE HCT 10-160-12.5 mg tab, 10-160-25 mg tab, 10-320-25 mg tab, 5-160-12.5 mg tab, 5-160-25 mg tab 3
felodipine er 10 mg tab er 24 hr, 2.5 mg tab er 24 hr, 5 mg tab er 24 hr 1 PLENDIL
isradipine 2.5 mg cap, 5 mg cap 1 DYNACIRC
LOTREL 10-20 mg cap, 10-40 mg cap, 5-10 mg cap, 5-20 mg cap 3
nicardipine hcl 20 mg cap, 30 mg cap 1 CARDENE
nifedipine 10 mg cap, 20 mg cap 1 PROCARDIA
nifedipine er 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 ADALAT CC
nifedipine er osmotic release 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 1 PROCARDIA XL
PROSSAM
Page 83 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
nimodipine 30 mg cap 1 NIMOTOP
nisoldipine er 17 mg tab er 24 hr, 20 mg tab er 24 hr, 25.5 mg tab er 24 hr, 30 mg tab er 24 hr, 34 mg tab er 24 hr, 40 mg tab er 24 hr, 8.5 mg tab er 24 hr 1 SULAR
NORVASC 10 mg tab, 2.5 mg tab, 5 mg tab 3
olmesartan-amlodipine-hctz 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 1 TRIBENZOR
PROCARDIA 10 mg cap 3
PROCARDIA XL 30 mg tab er 24 hr, 60 mg tab er 24 hr, 90 mg tab er 24 hr 3
SULAR 17 mg tab er 24 hr, 34 mg tab er 24 hr, 8.5 mg tab er 24 hr 3
telmisartan-amlodipine 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 1 TWYNSTA
TRIBENZOR 20-5-12.5 mg tab, 40-10-12.5 mg tab, 40-10-25 mg tab, 40-5-12.5 mg tab, 40-5-25 mg tab 3
TWYNSTA 40-10 mg tab, 40-5 mg tab, 80-10 mg tab, 80-5 mg tab 3
CARDIAC DRUGS [MEDICAMENTOS CARDÍACOS]
Antiarrhythmic Agents [Agentes Antiarrítmicos]
amiodarone hcl 200 mg tab 1 CORDARONE
amiodarone hcl 100 mg tab, 400 mg tab 1 PACERONE
disopyramide phosphate 100 mg cap, 150 mg cap 1 NORPACE
dofetilide 125 mcg cap, 250 mcg cap, 500 mcg cap 1 TIKOSYN
flecainide acetate 100 mg tab, 150 mg tab, 50 mg tab 1 TAMBOCOR
mexiletine hcl 150 mg cap, 200 mg cap, 250 mg cap 1 MEXITIL
MULTAQ 400 mg tab 3
NORPACE 100 mg cap, 150 mg cap 3
NORPACE CR 100 mg cap er 12 hr, 150 mg cap er 12 hr 3
PACERONE 100 mg tab, 200 mg tab, 400 mg tab 3
PROSSAM
Page 84 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
propafenone hcl 150 mg tab, 225 mg tab, 300 mg tab 1 RYTHMOL
propafenone hcl er 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 1 RYTHMOL
quinidine gluconate er 324 mg tab er 1
quinidine sulfate 200 mg tab, 300 mg tab 1
RYTHMOL SR 225 mg cap er 12 hr, 325 mg cap er 12 hr, 425 mg cap er 12 hr 3
TIKOSYN 125 mcg cap, 250 mcg cap, 500 mcg cap 3
Cardiac Drugs, Miscellaneous [Medicamentos Cardíacos, Misceláneos]
RANEXA 1000 mg tab er 12 hr, 500 mg tab er 12 hr 3
Cardiotonic Agents [Agentes Cardiotónicos]
DIGITEK 125 mcg tab, 250 mcg tab 3
DIGOX 125 mcg tab, 250 mcg tab 1
digoxin 125 mcg tab, 250 mcg tab 1 LANOXIN
digoxin 0.05 mg/ml soln 1 LANOXIN
LANOXIN 125 mcg tab, 250 mcg tab 3
CARIOSTATIC AGENTS [AGENTES CARIOSTÁTICOS]
Cariostatic Agents [Agentes Cariostáticos]
fluoritab 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew, 2.2 (1 F) mg tab chew 1 AL
sodium fluoride 0.55 (0.25 F) mg tab chew, 1.1 (0.5 F) mg tab chew, 2.2 (1 F) mg tab chew 1 AL
CATHARTICS AND LAXATIVES [PURGANTES Y LAXANTES]
Cathartics And Laxatives [Purgantes Y Laxantes]
COLYTE WITH FLAVOR PACKS 240 gm soln 3
GAVILYTE-C 240 gm soln 3
GAVILYTE-G 236 gm soln 3
GAVILYTE-H 5-210 mg-gm oral kit 3
GAVILYTE-N WITH FLAVOR PACK 420 gm soln 3
GOLYTELY 227.1 gm soln 3
GOLYTELY 236 gm soln 3
MOVIPREP 100 gm soln 3
NULYTELY WITH FLAVOR PACKS 420 gm soln 3
PROSSAM
Page 85 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
OSMOPREP 1.102-0.398 gm tab 3
peg 3350/electrolytes 240 gm soln 1
peg 3350-kcl-na bicarb-nacl 420 gm soln 1 NULYTELY
peg-3350/electrolytes 236 gm soln 1 GOLYTELY
PEG-PREP 5-210 mg-gm oral kit 3
polyethylene glycol 3350 pckt 1
polyethylene glycol 3350 oral pwdr 1 MIRALAX
PREPOPIK 10-3.5-12 mg-gm-gm pckt 3
SUPREP BOWEL PREP KIT 17.5-3.13-1.6 gm/177ml soln 3
TRILYTE 420 gm soln 3
CELL STIMULANTS AND PROLIFERANTS [ESTIMULANTES Y PROLIFERANTES CELULARES]
Cell Stimulants And Proliferants [Estimulantes Y Proliferantes Celulares]
ATRALIN 0.05 % gel 3 AL
AVITA 0.025 % crm, 0.025 % gel 3 AL
KEPIVANCE 6.25 mg iv soln 4 PA
RETIN-A 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 3 AL
RETIN-A MICRO 0.04 % gel, 0.1 % gel 3
RETIN-A MICRO PUMP 0.04 % gel, 0.08 % gel, 0.1 % gel 3
retinoic acid pwdr 1 AL
tretinoin pwdr 1 AL
tretinoin 0.05 % gel 1 ATRALIN AL
tretinoin 0.01 % gel, 0.025 % crm, 0.025 % gel, 0.05 % crm, 0.1 % crm 1 RETIN-A AL
tretinoin microsphere 0.04 % gel, 0.1 % gel 1 RETIN-A AL
tretinoin microsphere pump 0.04 % gel, 0.1 % gel 1 RETIN-A AL
TRETIN-X 0.075 % crm 3 AL
CELLULAR THERAPY [TERAPIA CELULAR]
Cellular Therapy [Terapia Celular]
PROVENGE iv susp 4 PA
CENTRAL NERVOUS SYSTEM AGENTS, MISC [AGENTES DEL SISTEMA NERVIOSO CENTRAL, MISCELÁNEOS]
Central Nervous System Agents, Misc [Agentes Del Sistema Nervioso Central, Misceláneos]
acamprosate calcium 333 mg tab dr 1 CAMPRAL
PROSSAM
Page 86 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
atomoxetine hcl 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 STRATTERA PA
guanfacine hcl er 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 1 INTUNIV PA
INTUNIV 1 mg tab er 24 hr, 2 mg tab er 24 hr, 3 mg tab er 24 hr, 4 mg tab er 24 hr 3 PA
memantine hcl 10 mg tab, 5 (28)-10 (21) mg tab, 5 mg tab 1 NAMENDA
memantine hcl 2 mg/ml soln 1 NAMENDA
NAMENDA 10 mg tab, 5 mg tab 2
NAMENDA TITRATION PAK 5 (28)-10 (21) mg tab 2
NUEDEXTA 20-10 mg cap 3
RILUTEK 50 mg tab 5 PA
riluzole 50 mg tab 4 RILUTEK PA
STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 2 PA
tetrabenazine 12.5 mg tab, 25 mg tab 5 XENAZINE PA
XENAZINE 12.5 mg tab, 25 mg tab 5 PA
XYREM 500 mg/ml soln 5 PA
Multiple Sclerosis [Esclerosis Múltiple]
VUMERITY 231 mg cap dr 4 PA
VUMERITY (STARTER) 231 mg cap dr 4 PA
CHOLELITHOLYTIC AGENTS [AGENTES COLELITOLÍTICO]
Cholelitholytic Agents [Agentes Colelitolítico]
ACTIGALL 300 mg cap 3
CHENODAL 250 mg tab 3
URSO 250 250 mg tab 3
URSO FORTE 500 mg tab 3
ursodiol 300 mg cap 1 ACTIGALL
ursodiol 250 mg tab, 500 mg tab 1 URSO
COMPLEMENT INHIBITORS [INHIBIDORES DEL COMPLEMENTO]
Complement Inhibitors [Inhibidores Del Complemento]
FIRAZYR 30 mg/3ml sc soln 5 PA
CONTRACEPTIVES [ANTICONCEPTIVOS]
Contraceptives [Anticonceptivos]
ALTAVERA 0.15-30 mg-mcg tab 3 QL(28 / 28)
alyacen 1/35 1-35 mg-mcg tab 1 QL(28 / 28)
AUBRA 0.1-20 mg-mcg tab 3 QL(28 / 28)
AVIANE 0.1-20 mg-mcg tab 3 QL(28 / 28)
PROSSAM
Page 87 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CAMILA 0.35 mg tab 3 QL(28 / 28)
CHATEAL 0.15-30 mg-mcg tab 3 QL(28 / 28)
CRYSELLE-28 0.3-30 mg-mcg tab 3 QL(28 / 28)
CYCLAFEM 1/35 1-35 mg-mcg tab 3 QL(28 / 28)
DASETTA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)
DEBLITANE 0.35 mg tab 3 QL(28 / 28)
DELYLA 0.1-20 mg-mcg tab 3 QL(28 / 28)
ELINEST 0.3-30 mg-mcg tab 3 QL(28 / 28)
ENPRESSE-28 tab 3 QL(28 / 28)
ERRIN 0.35 mg tab 3 QL(28 / 28)
ESTROSTEP FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)
ethynodiol diac-eth estradiol 1-35 mg-mcg tab 1 ZOVIA 1/35E QL(28 / 28)
FALMINA 0.1-20 mg-mcg tab 3 QL(28 / 28)
HEATHER 0.35 mg tab 3 QL(28 / 28)
INTROVALE 0.15-0.03 mg tab 3 QL(91 / 91)
JENCYCLA 0.35 mg tab 3 QL(28 / 28)
JOLESSA 0.15-0.03 mg tab 3 QL(91 / 91)
JOLIVETTE 0.35 mg tab 3 QL(28 / 28)
KELNOR 1/35 1-35 mg-mcg tab 3 QL(28 / 28)
KURVELO 0.15-30 mg-mcg tab 3 QL(28 / 28)
LARISSIA 0.1-20 mg-mcg tab 3 QL(28 / 28)
LESSINA 0.1-20 mg-mcg tab 3 QL(28 / 28)
LEVONEST tab 3 QL(28 / 28)
levonorgest-eth estrad 91-day 0.15-0.03 mg tab 1 SEASONALE QL(91 / 91)
levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 1 QL(28 / 28)
levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 1 AVIANE QL(28 / 28)
LEVORA 0.15/30 (28) 0.15-30 mg-mcg tab 3 QL(28 / 28)
LILLOW 0.15-30 mg-mcg tab 3 QL(28 / 28)
LOW-OGESTREL 0.3-30 mg-mcg tab 3 QL(28 / 28)
LUTERA 0.1-20 mg-mcg tab 3 QL(28 / 28)
LYZA 0.35 mg tab 3 QL(28 / 28)
marlissa 0.15-30 mg-mcg tab 1 QL(28 / 28)
MIRENA (52 MG) 20 mcg/24hr iud 4
MYZILRA tab 3 QL(28 / 28)
NORA-BE 0.35 mg tab 3 QL(28 / 28)
norethindrone 0.35 mg tab 1 NOR-QD QL(28 / 28)
norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35 mcg tab 1 ORTHO TRI-CYCLEN QL(28 / 28)
NORLYDA 0.35 mg tab 3 QL(28 / 28)
PROSSAM
Page 88 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NORLYROC 0.35 mg tab 3 QL(28 / 28)
NORTREL 1/35 (21) 1-35 mg-mcg tab 3 QL(28 / 28)
NORTREL 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)
NUVARING 0.12-0.015 mg/24hr vag ring 3 QL(1 / 28)
ORSYTHIA 0.1-20 mg-mcg tab 3 QL(28 / 28)
ORTHO MICRONOR 0.35 mg tab 3 QL(28 / 28)
ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)
ORTHO-NOVUM 1/35 (28) 1-35 mg-mcg tab 3 QL(28 / 28)
PARAGARD INTRAUTERINE COPPER iud 4
PIRMELLA 1/35 1-35 mg-mcg tab 3 QL(28 / 28)
PORTIA-28 0.15-30 mg-mcg tab 3 QL(28 / 28)
QUASENSE 0.15-0.03 mg tab 3 QL(91 / 91)
SETLAKIN 0.15-0.03 mg tab 3 QL(91 / 91)
SHAROBEL 0.35 mg tab 3 QL(28 / 28)
SRONYX 0.1-20 mg-mcg tab 3 QL(28 / 28)
TILIA FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)
TRI FEMYNOR 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
TRI-ESTARYLLA 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
TRI-LEGEST FE 1-20/1-30/1-35 mg-mcg tab 3 QL(28 / 28)
TRI-LINYAH 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
TRI-LO-ESTARYLLA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)
TRI-LO-MARZIA 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)
TRI-LO-SPRINTEC 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)
TRINESSA (28) 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
TRINESSA LO 0.18/0.215/0.25 mg-25 mcg tab 3 QL(28 / 28)
TRI-PREVIFEM 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
PROSSAM
Page 89 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
TRI-SPRINTEC 0.18/0.215/0.25 mg-35 mcg tab 3 QL(28 / 28)
TRIVORA (28) tab 3 QL(28 / 28)
VIENVA 0.1-20 mg-mcg tab 3 QL(28 / 28)
XULANE 150-35 mcg/24hr tdwk patch 3 QL(3 / 28)
ZOVIA 1/35E (28) 1-35 mg-mcg tab 3 QL(28 / 28)
CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS [MODULADORES REGULADORES DE LA CONDUCTANCIA TRANSMEMBRANA DE LA FIBROSIS QUÍSTICA]
Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators [Potenciadores Reguladores De La Conductancia Transmembrana De La Fibrosis Quística (Rtfq)]
KALYDECO 150 mg tab, 25mg, 50 mg pckt, 75 mg pckt 5 PA
DIGESTANTS [DIGESTIVOS]
Digestants [Digestivos]
CREON 12000 unit cap dr prt, 24000-76000 unit cap dr prt, 3000-9500 unit cap dr prt, 36000 unit cap dr prt, 6000 unit cap dr prt 2
PANCREAZE 10500 unit cap dr prt, 16800 unit cap dr prt, 21000 unit cap dr prt, 4200 unit cap dr prt 3
PERTZYE 16000 unit cap dr prt, 8000 unit cap dr prt 3
VIOKACE 10440 unit tab, 20880 unit tab 3
ZENPEP 10000-32000 unit cap dr prt, 15000-47000 unit cap dr prt, 20000-63000 unit cap dr prt, 25000-79000 unit cap dr prt, 3000-14000 unit cap dr prt, 5000-24000 unit cap dr prt 3
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS [MEDICAMENTOS ANTIRREUMÁTICOS MODIFICADORES DE LA ENFERMEDAD]
Disease-modifying Antirheumatic Drugs [Medicamentos Antirreumáticos Modificadores De La Enfermedad]
ACTEMRA 162 mg/0.9ml sc soln pfs, 200 mg/10ml iv soln, 400 mg/20ml iv soln, 80 mg/4ml iv soln 4 PA
ARAVA 10 mg tab, 20 mg tab 3
CIMZIA 2 X 200 mg sc kit 4 PA
CIMZIA PREFILLED 2 X 200 mg/ml sc kit 4 PA
CIMZIA STARTER KIT 6 X 200 mg/ml sc kit 4 PA
PROSSAM
Page 90 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ENBREL 25 mg sc soln 4 PA
ENBREL 25 mg/0.5ml sc soln pfs, 50 mg/ml sc soln pfs 4 PA
ENBREL SURECLICK 50 mg/ml sc soln auto-inj 4 PA
HUMIRA 10 mg/0.2ml sc pfs kit, 20 mg/0.4ml sc pfs kit, 40 mg/0.8ml sc pfs kit 4 PA
HUMIRA PEDIATRIC CROHNS START 40 mg/0.8ml sc pfs kit 4 PA
HUMIRA PEN 40 mg/0.8ml sc pen-inj kit 4 PA
HUMIRA PEN-CD/UC/HS STARTER 40 mg/0.8ml sc pen-inj kit, 80 mg/0.8ml sc pen-inj kit 4 PA
HUMIRA PEN-PS/UV STARTER 40 mg/0.8ml sc pen-inj kit, 80 MG/0.8ML & 40mg/0.4ml sc pen-inj kit 4 PA
leflunomide 10 mg tab, 20 mg tab 1 ARAVA
OTEZLA 10 & 20 & 30 mg tab pack, 30 mg tab 5 PA
SIMPONI 100 mg/ml sc soln auto-inj, 100 mg/ml sc soln pfs, 50 mg/0.5ml sc soln auto-inj, 50 mg/0.5ml sc soln pfs 4 PA
SIMPONI ARIA 50 mg/4ml iv soln 4 PA
XELJANZ 10 mg tab, 5 mg tab 4 PA
XELJANZ XR 11 mg tab er 24 hr 4 PA
DIURETICS [DIURÉTICOS]
Loop Diuretics [Diuréticos Del Asa De Henle]
bumetanide 0.5 mg tab, 1 mg tab, 2 mg tab 1 BUMEX
bumetanide 0.25 mg/ml inj soln 1 BUMEX
DEMADEX 10 mg tab, 20 mg tab 3
EDECRIN 25 mg tab 3
ethacrynic acid 25 mg tab 1 EDECRIN
furosemide 20 mg tab, 40 mg tab, 80 mg tab 1 LASIX
furosemide 10 mg/ml inj soln, 10 mg/ml soln, 8 mg/ml soln 1 LASIX
LASIX 20 mg tab, 40 mg tab, 80 mg tab 3
torsemide 10 mg tab, 100 mg tab, 20 mg tab, 5 mg tab 1 DEMADEX
Potassium-sparing Diuretics [Diuréticos Conservadores De Potasio]
PROSSAM
Page 91 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
amiloride hcl 5 mg tab 1 MIDAMOR
amiloride-hydrochlorothiazide 5-50 mg tab 1 MODURETIC
DYAZIDE 37.5-25 mg cap 3
DYRENIUM 100 mg cap, 50 mg cap 3
MAXZIDE 75-50 mg tab 3
MAXZIDE-25 37.5-25 mg tab 3
triamterene-hctz 37.5-25 mg cap 1 DYAZIDE
triamterene-hctz 37.5-25 mg tab, 75-50 mg tab 1 MAXZIDE
Thiazide Diuretics [Diuréticos Tiazídicos]
chlorothiazide 250 mg tab, 500 mg tab 1 DIURIL
DIURIL 250 mg/5ml susp 3
hydrochlorothiazide 25 mg tab, 50 mg tab 1 HYDRODIURIL
hydrochlorothiazide 12.5 mg cap, 12.5 mg tab 1 MICROZIDE
methyclothiazide 5 mg tab 1 ENDURON
MICROZIDE 12.5 mg cap 3
Thiazide-like Diuretics [Diuréticos Similares A Tiazida]
chlorthalidone 25 mg tab, 50 mg tab 1 HYGROTON
indapamide 1.25 mg tab, 2.5 mg tab 1 LOZOL
metolazone 10 mg tab, 2.5 mg tab, 5 mg tab 1 ZAROXOLYN
Vasopressin Antagonists [Antagonistas De Vasopresina]
SAMSCA 15 mg tab, 30 mg tab 3
EENT DRUGS, MISCELLANEOUS [MEDICAMENTOS PARA OJOS, OÍDOS, NARIZ Y GARGANTA, MISCELÁNEOS]
Eent Drugs, Miscellaneous [Medicamentos Para Ojos, Oídos, Nariz Y Garganta, Misceláneos]
acetic acid 2 % otic soln 1 VOSOL
apraclonidine hcl 0.5 % ophth soln 1 IOPIDINE
DEBACTEROL 30-50 % m/t soln 3
IOPIDINE 1 % ophth soln 3
IOPIDINE 0.5 % ophth soln 3
LACRISERT 5 mg ophth insert 3
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS [EMOLIENTES, DEMULCENTES Y PROTECTORES]
Basic Lotions And Liniments [Lociones Y Linimentos Básicos]
ammonium lactate 12 % crm, 12 % lot 1 LAC-HYDRIN
HYLIRA 0.1 % lot, 0.2 % gel 3
PROSSAM
Page 92 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
LAC-HYDRIN 12 % crm, 12 % lot 3
lactic acid 10 % lot 1
sodium hyaluronate 0.2 % gel 1
Basic Oils And Other Solvents [Aceites Básicos Y Otros Solventes]
lactic acid e 10-3500 %-unt/30gm crm 1
Basic Ointments And Protectants [Ungüentos Y Protectores Básicos]
NEOSALUS crm 3
ENZYMES [ENZIMAS]
Enzymes [Enzimas]
ADAGEN 250 unit/ml im soln 5 PA
ALDURAZYME 2.9 mg/5ml iv soln 5 PA
ELELYSO 200 unit iv soln 5 PA
ELITEK 1.5 mg iv soln, 7.5 mg iv soln 4 PA
NAGLAZYME 1 mg/ml iv soln 5 PA
SUCRAID 8500 unit/ml soln 5 PA
VPRIV 400 unit iv soln 5 PA
ESTROGENS AND ANTIESTROGENS [ESTRÓGENOS Y ANTIESTRÓGENOS]
Estrogen Agonist-antagonists [Agonistas-Antagonistas De Estrógeno]
EVISTA 60 mg tab 3
raloxifene hcl 60 mg tab 1 EVISTA
Estrogens [Estrógenos]
ACTIVELLA 0.5-0.1 mg tab, 1-0.5 mg tab 3
ALORA 0.025 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3
AMABELZ 0.5-0.1 mg tab, 1-0.5 mg tab 3
ANGELIQ 0.25-0.5 mg tab, 0.5-1 mg tab 3
CLIMARA 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 3
CLIMARA PRO 0.045-0.015 mg/day tdwk patch 3
COMBIPATCH 0.05-0.14 mg/day tdbiw patch, 0.05-0.25 mg/day tdbiw patch 3
COVARYX 1.25-2.5 mg tab 3
COVARYX HS 0.625-1.25 mg tab 3
PROSSAM
Page 93 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DELESTROGEN 10 mg/ml im oil, 20 mg/ml im oil, 40 mg/ml im oil 3
DEPO-ESTRADIOL 5 mg/ml im oil 3
DIVIGEL 0.25 mg/0.25gm td gel, 0.5 mg/0.5gm td gel 3
DIVIGEL 1 mg/gm td gel 3
EEMT 1.25-2.5 mg tab 3
EEMT HS 0.625-1.25 mg tab 3
ELESTRIN 0.52 MG/0.87 GM (0.06%) td gel 3
est estrogens-methyltest 1.25-2.5 mg tab 1
est estrogens-methyltest ds 1.25-2.5 mg tab 1
est estrogens-methyltest hs 0.625-1.25 mg tab 1
ESTRACE 0.5 mg tab, 1 mg tab, 2 mg tab 3
ESTRACE 0.1 mg/gm vag crm 3
estradiol 0.025 mg/24hr tdwk patch, 0.0375 mg/24hr tdwk patch, 0.05 mg/24hr tdwk patch, 0.06 mg/24hr tdwk patch, 0.075 mg/24hr tdwk patch, 0.1 mg/24hr tdwk patch 1 CLIMARA
estradiol 0.5 mg tab, 1 mg tab, 2 mg tab 1 ESTRACE
estradiol 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 1 VIVELLE-DOT
estradiol valerate 20 mg/ml im oil, 40 mg/ml im oil 1 DELESTROGEN
estradiol-norethindrone acet 0.5-0.1 mg tab, 1-0.5 mg tab 1 ACTIVELLA
ESTRING 2 mg vag ring 3
ESTROGEL 0.75 MG/1.25 GM (0.06%) td gel 3
estropipate 0.75 mg tab, 1.5 mg tab 1 OGEN
EVAMIST 1.53 mg/spray td soln 3
FEMHRT LOW DOSE 0.5-2.5 mg-mcg tab 3
FEMRING 0.05 mg/24hr vag ring, 0.1 mg/24hr vag ring 3
FYAVOLV 0.5-2.5 mg-mcg tab, 1-5 mg-mcg tab 3
PROSSAM
Page 94 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
jevantique lo 0.5-2.5 mg-mcg tab 1 FEMHRT 0.5/2.5 28
DAY
JINTELI 1-5 mg-mcg tab 3
LOPREEZA 0.5-0.1 mg tab, 1-0.5 mg tab 3
MENEST 0.3 mg tab, 0.625 mg tab, 1.25 mg tab, 2.5 mg tab 3
MENOSTAR 14 mcg/24hr tdwk patch 3
MIMVEY 1-0.5 mg tab 3
MIMVEY LO 0.5-0.1 mg tab 3
MINIVELLE 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3
norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1
FEMHRT 0.5/2.5 28 DAY
norethindrone-eth estradiol 1-5 mg-mcg tab 1 FYAVOLV
PREFEST 1/1-0.09 mg (15/15) tab 3
PREMARIN 0.3 mg tab, 0.45 mg tab, 0.625 mg tab, 0.9 mg tab, 1.25 mg tab 2
PREMARIN 0.625 mg/gm vag crm 2
PREMARIN 25 mg inj soln 3
PREMPHASE 0.625-5 mg tab 2
PREMPRO 0.3-1.5 mg tab, 0.45-1.5 mg tab, 0.625-2.5 mg tab, 0.625-5 mg tab 2
VAGIFEM 10 mcg vag tab 3
VIVELLE-DOT 0.025 mg/24hr tdbiw patch, 0.0375 mg/24hr tdbiw patch, 0.05 mg/24hr tdbiw patch, 0.075 mg/24hr tdbiw patch, 0.1 mg/24hr tdbiw patch 3
YUVAFEM 10 mcg vag tab 3
EXPECTORANTS [EXPECTORANTES]
Expectorants [Expectorantes]
GILPHEX TR 10-388 mg tab 3
phenylephrine-guaifenesin 1.5-20 mg/ml liq 1
FIBROMYALGIA AGENTS [AGENTES PARA FIBROMIALGIA]
Fibromyalgia Agents [Agentes Para Fibromialgia]
SAVELLA 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 3
PROSSAM
Page 95 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SAVELLA TITRATION PACK 12.5 & 25 & 50 mg oral misc 3
FIRST GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE PRIMERA GENERACIÓN]
Derivatives, Miscellaneous [Derivados, Misceláneos]
cyproheptadine hcl 4 mg tab 1 PERIACTIN
cyproheptadine hcl 2 mg/5ml syr 1 PERIACTIN
Ethanolamine Derivatives [Derivados De Etanolamina]
carbinoxamine maleate 4 mg tab 1 CLISTIN
carbinoxamine maleate 4 mg/5ml soln 1 CLISTIN
clemastine fumarate 2.68 mg tab 1 TAVIST
diphenhydramine hcl 12.5 mg/5ml oral elix, 50 mg/ml inj soln 1 BENADRYL
pharbedryl 50 mg cap 1
Phenothiazine Derivatives [Derivados De La Fenotiazina]
PHENADOZ 12.5 mg rect supp, 25 mg rect supp 3
PHENERGAN 25 mg/ml inj soln, 50 mg/ml inj soln 3
promethazine hcl 12.5 mg rect supp, 12.5 mg tab, 25 mg rect supp, 25 mg tab, 50 mg rect supp, 50 mg tab 1 PHENERGAN
promethazine hcl 25 mg/ml inj soln, 50 mg/ml inj soln, 6.25 mg/5ml soln, 6.25 mg/5ml syr 1 PHENERGAN
promethazine vc plain 6.25-5 mg/5ml soln 1 PHENERGAN VC
promethazine-phenylephrine 6.25-5 mg/5ml syr 1 PHENERGAN VC
PROMETHEGAN 12.5 mg rect supp, 25 mg rect supp, 50 mg rect supp 3
Propylamine Derivatives [Derivados De Propilamina]
brompheniramine tannate 12 mg tab chew 1
DECON-A 2-5 mg/5ml oral elix 3
GENITOURINARY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO GENITOURINARIO]
Antimuscarinics [Antimuscarínicos]
darifenacin hydrobromide er 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 1 ENABLEX
DETROL 1 mg tab, 2 mg tab 3
DETROL LA 2 mg cap er 24 hr, 4 mg cap er 24 hr 3
PROSSAM
Page 96 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DITROPAN XL 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 3
ENABLEX 15 mg tab er 24 hr, 7.5 mg tab er 24 hr 3
flavoxate hcl 100 mg tab 1
GELNIQUE 10 % td gel 3
GELNIQUE PUMP 10 % td gel 3
oxybutynin chloride 5 mg tab 1 DITROPAN
oxybutynin chloride 5 mg/5ml syr 1 DITROPAN
oxybutynin chloride er 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 1 DITROPAN
OXYTROL 3.9 mg/24hr tdbiw patch 3
solifenacin succinate 10 mg tab, 5 mg tab 1 VESICARE
tolterodine tartrate 1 mg tab, 2 mg tab 1 DETROL
tolterodine tartrate er 2 mg cap er 24 hr, 4 mg cap er 24 hr 1 DETROL
TOVIAZ 4 mg tab er 24 hr, 8 mg tab er 24 hr 2
trospium chloride 20 mg tab 1 SANCTURA
trospium chloride er 60 mg cap er 24 hr 1 SANCTURA XR
VESICARE 10 mg tab, 5 mg tab 3
B3-adrenergic Agonists [Agonistas B-3 Adrenérgicos]
MYRBETRIQ 25 mg tab er 24 hr, 50 mg tab er 24 hr 3
GI DRUGS, MISCELLANEOUS [MEDICAMENTOS GASTROINTESTINALES, MISCELÁNEOS]
Gi Drugs, Miscellaneous [Medicamentos Gastrointestinales, Misceláneos]
AMITIZA 24 mcg cap, 8 mcg cap 2 PA
ENTEREG 12 mg cap 3
LINZESS 145 mcg cap, 290 mcg cap 3 PA
MOVANTIK 12.5 mg tab, 25 mg tab 4 PA
RELISTOR 12 mg/0.6ml sc soln, 8 mg/0.4ml sc soln 3
GOLD COMPOUNDS [COMPUESTOS DE ORO]
Gold Compounds [Compuestos De Oro]
RIDAURA 3 mg cap 3
HEAVY METAL ANTAGONISTS [ANTAGONISTAS DE METALES PESADOS]
Heavy Metal Antagonists [Antagonistas De Metales Pesados]
CHEMET 100 mg cap 3
deferoxamine mesylate 2 gm inj soln, 500 mg inj soln 1
PROSSAM
Page 97 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DESFERAL 500 mg inj soln 3
EXJADE 125 mg tab sol, 250 mg tab sol, 500 mg tab sol 5 PA
FERRIPROX 500 mg tab 5 PA
FERRIPROX 100 mg/ml soln 5 PA
HEMATOPOIETIC AGENTS [AGENTES HEMATOPOYÉTICOS]
Hematopoietic Agents [Agentes Hematopoyéticos]
ARANESP (ALBUMIN FREE) 10 mcg/0.4ml inj soln pfs, 100 mcg/0.5ml inj soln pfs, 100 mcg/ml inj soln, 150 mcg/0.3ml inj soln pfs, 200 mcg/0.4ml inj soln pfs, 200 mcg/ml inj soln, 25 mcg/0.42ml inj soln pfs, 25 mcg/ml inj soln, 300 mcg/0.6ml inj soln pfs, 300 mcg/ml inj soln, 40 mcg/0.4ml inj soln pfs, 40 mcg/ml inj soln, 500 mcg/ml inj soln pfs, 60 mcg/0.3ml inj soln pfs, 60 mcg/ml inj soln 5 PA
EPOGEN 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln 5 PA
GRANIX 300 mcg/0.5ml sc soln pfs, 480 mcg/0.8ml sc soln pfs 5 PA
LEUKINE 250 mcg iv soln 5 PA, QL(117.24 / 42)
MIRCERA 100 mcg/0.3ml inj soln pfs, 200 mcg/0.3ml inj soln pfs, 50 mcg/0.3ml inj soln pfs, 75 mcg/0.3ml inj soln pfs 5 PA
MOZOBIL 24 mg/1.2ml sc soln 5 PA
NEULASTA 6 mg/0.6ml sc soln pfs 5 PA
NEULASTA ONPRO 6 mg/0.6ml sc pfs kit 5 PA
NEUPOGEN 300 mcg/0.5ml inj soln pfs, 300 mcg/ml inj soln, 480 mcg/0.8ml inj soln pfs, 480 mcg/1.6ml inj soln 5 PA
NPLATE 250 mcg sc soln, 500 mcg sc soln 5 PA
PROCRIT 10000 unit/ml inj soln, 2000 unit/ml inj soln, 20000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln, 40000 unit/ml inj soln 4 PA
PROSSAM
Page 98 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PROMACTA 12.5 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 5 PA
ZARXIO 300 mcg/0.5ml inj soln pfs, 480 mcg/0.8ml inj soln pfs 5 PA
HEMORRHEOLOGIC AGENTS [AGENTES HEMORREOLÓGICOS]
Hemorrheologic Agents [Agentes Hemorreológicos]
pentoxifylline er 400 mg tab er 1 TRENTAL
HYPOTENSIVE AGENTS [AGENTES HIPOTENSORES]
Central Alpha-agonists [Agonistas Centrales Alfa]
CATAPRES 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 3
CATAPRES-TTS-1 0.1 mg/24hr tdwk patch 3
CATAPRES-TTS-2 0.2 mg/24hr tdwk patch 3
CATAPRES-TTS-3 0.3 mg/24hr tdwk patch 3
clonidine 0.1 mg/24hr tdwk patch, 0.2 mg/24hr tdwk patch, 0.3 mg/24hr tdwk patch 1
clonidine hcl 0.1 mg tab, 0.2 mg tab, 0.3 mg tab 1 CATAPRES
clonidine hcl er 0.1 mg tab er 12 hr 1 KAPVAY PA
guanfacine hcl 1 mg tab, 2 mg tab 1 TENEX
KAPVAY 0.1 mg tab er 12 hr 3 PA
methyldopa 250 mg tab, 500 mg tab 1 ALDOMET
methyldopa-hydrochlorothiazide 250-15 mg tab, 250-25 mg tab 1 ALDORIL
Direct Vasodilators [Vasodilatadores Directos]
hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 APRESOLINE
IMMUNOMODULATORY AGENTS [AGENTES INMUNOMODULADORES]
Immunomodulatory Agents [Agentes Inmunomoduladores]
ACTIMMUNE 2000000 unit/0.5ml sc soln 4 PA
AUBAGIO 14 mg tab, 7 mg tab 4 PA
AVONEX 30 mcg im kit 4 PA
AVONEX PEN 30 mcg/0.5ml im auto-inj kit 4 PA
AVONEX PREFILLED 30 mcg/0.5ml im pfs kit 4 PA
BETASERON 0.3 mg sc kit 4 PA
COPAXONE 20 mg/ml sc soln pfs, 40 mg/ml sc soln pfs 4 PA
EXTAVIA 0.3 mg sc kit 4 PA
PROSSAM
Page 99 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
GILENYA 0.25 mg cap, 0.5 mg cap 4 PA
MAYZENT 0.25 mg tab, 2 mg tap 4 PA
TECFIDERA 120 & 240 mg oral misc, 120 mg cap dr, 240 mg cap dr 4 PA
THALOMID 100 mg cap, 150 mg cap, 200 mg cap, 50 mg cap 5 PA
TYSABRI 300 mg/15ml iv conc 4 PA
IMMUNOSUPPRESSIVE AGENTS [AGENTES INMUNOSUPRESORES]
Immunosuppressive Agents [Agentes Inmunosupresores]
ASTAGRAF XL 0.5 mg cap er 24 hr, 1 mg cap er 24 hr, 5 mg cap er 24 hr 5 PA
AZASAN 100 mg tab, 75 mg tab 5 PA
azathioprine 50 mg tab 5 IMURAN
azathioprine sodium 100 mg inj soln 5 IMURAN PA
BENLYSTA 120 mg iv soln 5 PA
CELLCEPT 250 mg cap, 500 mg tab 5 PA
CELLCEPT 200 mg/ml susp 5 PA
cyclosporine 100 mg cap, 25 mg cap 5 SANDIMMUNE PA
cyclosporine 50 mg/ml iv soln 5 SANDIMMUNE PA
cyclosporine modified 100 mg cap, 25 mg cap, 50 mg cap 5 NEORAL PA
cyclosporine modified 100 mg/ml soln 5 NEORAL PA
GENGRAF 100 mg cap, 25 mg cap 5 PA
GENGRAF 100 mg/ml soln 5 PA
IMURAN 50 mg tab 5 PA
mycophenolate mofetil 250 mg cap, 500 mg tab 4 CELLCEPT PA
mycophenolate mofetil 200 mg/ml susp 4 CELLCEPT PA
mycophenolate sodium 180 mg tab dr, 360 mg tab dr 4 MYFORTIC PA
MYFORTIC 180 mg tab dr, 360 mg tab dr 5 PA
NEORAL 100 mg cap, 25 mg cap 5 PA
NEORAL 100 mg/ml soln 5 PA
NULOJIX 250 mg iv soln 5 PA
PROGRAF 0.5 mg cap, 1 mg cap, 5 mg cap 5 PA
RAPAMUNE 0.5 mg tab, 1 mg tab, 2 mg tab 5 PA
PROSSAM
Page 100 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
RAPAMUNE 1 mg/ml soln 5 PA
RINVOQ 15 mg tab er 24hr 4 PA
SANDIMMUNE 100 mg cap, 25 mg cap 5 PA
SANDIMMUNE 100 mg/ml soln, 50 mg/ml iv soln 5 PA
sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab 5 RAPAMUNE PA
tacrolimus 0.5 mg cap, 1 mg cap, 5 mg cap 5 PROGRAF PA
ZORTRESS 0.25 mg tab, 0.5 mg tab, 0.75 mg tab 5 PA
ION-REMOVING AGENTS [AGENTES REMOVEDORES DE IONES]
Phosphate-removing Agents [Agentes Removedores De Fosfato]
FOSRENOL 1000 mg pckt, 1000 mg tab chew, 500 mg tab chew, 750 mg pckt, 750 mg tab chew 2
RENAGEL 800 mg tab 3
RENVELA 0.8 gm pckt, 2.4 gm pckt 2
RENVELA 800 mg tab 3
sevelamer carbonate 800 mg tab 1 RENVELA
Potassium-removing Agents [Agentes Removedores De Potasio]
KIONEX oral pwdr 3
KIONEX 15 gm/60ml susp 3
sodium polystyrene sulfonate oral pwdr 1 KAYEXALATE
sodium polystyrene sulfonate 15 gm/60ml susp 1 SPS
SPS 15 gm/60ml susp 3
IRRIGATING SOLUTIONS [SOLUCIONES PARA IRRIGACIÓN]
Irrigating Solutions [Soluciones Para Irrigación]
sodium chloride 0.9 % irrig soln 1
KERATOLYTIC AGENTS [AGENTES QUERATOLÍTICOS]
Keratolytic Agents [Agentes Queratolíticos]
ALUVEA 40 % crm 3
AVAR 9.5-5 % pad 3 AL
AVAR 9.5-5 % foam 3 AL
AVAR CLEANSER 10-5 % ext emul 3 AL
AVAR LS 10-2 % pad 3 AL
AVAR LS 10-2 % foam 3 AL
AVAR LS CLEANSER 10-2 % ext liq 3 AL
AVAR-E EMOLLIENT 10-5 % crm 3 AL
AVAR-E GREEN 10-5 % crm 3 AL
AVAR-E LS 10-2 % crm 3 AL
PROSSAM
Page 101 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
bp 10-1 10-1 % ext emul 1 AL
bp cleansing wash 10-4 % ext emul 1 AL
CEM-UREA 45 % ext soln 3
CEROVEL 40 % lot 3
GORDOFILM 16.7-16.7 % ext soln 3
gordons urea 40 % oint 3
HYDRO 35 35 % foam 3
HYDRO 40 40 % foam 3
KERALYT 6 % gel 3
KERALYT SCALP 6 % ext kit 3
LATRIX XM 45 % ext emul 3
NUTRASEB crm 3
PLEXION 9.8-4.8 % crm, 9.8-4.8 % lot 3 AL
PLEXION CLEANSER 9.8-4.8 % ext liq 3 AL
PLEXION CLEANSING CLOTH 9.8-4.8 % pad 3 AL
pyrogallic acid 25-2 % oint 1
REA LO 40 40 % crm 3
REA LO 40 40 % lot 3
ROSANIL CLEANSER 10-5 % ext emul 3 AL
SALEX 6 % (cream) ext kit 3
SALEX 6 % (lotion) ext kit, 6 % shampoo 3
salicylic acid 6 % crm, 6 % foam, 6 % gel 1
salicylic acid 26 % ext liq, 27.5 % ext liq, 6 % lot, 6 % shampoo 1
salicylic acid wart remover 27.5 % ext liq 1
salicylic acid-cleanser 6 % (cream) ext kit 1
salicylic acid-cleanser 6 % (lotion) ext kit 1
salimez 6 % crm 1
salisol forte 26 % ext soln 1
salitech forte 6 % lot 1
salrix 50 % ext susp 1
SALVAX 6 % foam 3
SALVAX DUO PLUS 6 & 35 % ext kit 3
sss 10-5 10-5 % crm, 10-5 % foam 1 AL
sulfacetamide sodium-sulfur 10-4 % pad 1 AL
PROSSAM
Page 102 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
sulfacetamide sodium-sulfur 10-2 % crm, 10-2 % ext liq, 10-5 % crm, 10-5 % ext emul, 10-5 % ext susp, 10-5 % lot, 9-4.5 % ext liq, 9.8-4.8 % crm, 9.8-4.8 % ext liq, 9.8-4.8 % lot 1 AL
sulfacetamide sodium-sulfur 8-4 % ext susp, 9-4 % ext liq 1 AL
sulfacetamide sod-sulfur wash 9-4.5 % ext kit 1 AL
sulfacetamide-sulfur in urea 10-5 % ext emul 1 AL
sulfacetamide-sulfur-sunscreen 9-4.5 % ext kit 1 AL
SULFACLEANSE 8/4 8-4 % ext susp 3 AL
SUMADAN 9-4.5 % ext kit 3
SUMADAN WASH 9-4.5 % ext liq 3 AL
SUMADAN XLT 9-4.5 % ext kit 3
SUMAXIN 10-4 % pad 3 AL
SUMAXIN CP 10-4 % ext kit 3
SUMAXIN TS 8-4 % ext susp 3 AL
SUMAXIN WASH 9-4 % ext liq 3 AL
UMECTA MOUSSE 40 % foam 3
URAMAXIN 45 % gel 3
urea 39 % crm, 40 % crm, 40 % ext susp, 40 % lot, 45 % crm, 50 % crm 1
urea hydrating 35 % foam 1
urea in zn undecyl-lactic acid 50 % ext emul 1
urea nail 40 & 0.2 % ext kit 1
urea nail 45 % gel, 50 % stick 1
urea-c40 40 % lot 1
ure-k 50 % crm 1
uremez-40 40 % crm 1
VIRASAL 27.5 % ext liq 3
virti-sulf 10-5 % crm 1 AL
LOCAL ANESTHETICS [ANESTÉSICOS LOCALES]
Local Anesthetics [Anestésicos Locales]
lidocaine hcl 4 % m/t soln 1
lidocaine viscous 2 % m/t soln 1 XYLOCAINE
PRAMOTIC 1-0.1 % otic liq 3
MUCOLYTIC AGENTS [AGENTES MUCOLÍTICOS]
Mucolytic Agents [Agentes Mucolíticos]
HYPERSAL 3.5 % inh neb soln, 7 % inh neb soln 3
PROSSAM
Page 103 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NEBUSAL 3 % inh neb soln, 6 % inh neb soln 3
PULMOSAL 7 % inh neb soln 3
PULMOZYME 1 mg/ml inh soln 5 PA
sodium chloride 0.9 % inh neb soln, 10 % inh neb soln, 3 % inh neb soln, 7 % inh neb soln 1
MULTIVITAMIN PREPARATIONS [PREPARACIONES MULTIVITAMÍNICAS]
Multivitamin Preparations [Preparaciones Multivitamínicas]
ADRENAL C FORMULA tab 3
advanced am/pm oral misc 1
ap-zel tab 1
ATABEX EC 29-1 mg tab dr 3
b complex-c-folic acid tab 1
BACMIN tab 3
BAL-CARE DHA 27-1 & 430 mg oral misc 3
b-complex balanced tab 1
b-complex/vitamin c tab 1
b-complex-c tab 1
biocel tab 1
bp folinatal plus b 1 mg tab 1
bp multinatal plus 30-1 mg tab, 40-1 mg tab chew 1
b-plex tab 1
b-plex plus tab 1
BPROTECTED PEDIA POLY-VITE/FE 10 mg/ml soln 1 AL
CITRANATAL 90 DHA 90-1 & 300 mg oral misc 3
CITRANATAL ASSURE 35-1 & 300 mg oral misc 3
CITRANATAL B-CALM 20-1 & 25 (2) mg oral misc 3
CITRANATAL DHA 27-1 & 250 mg oral misc 3
CITRANATAL HARMONY 27-1-260 mg cap 3
CITRANATAL RX 27-1 mg tab 3
c-nate dha 28-1-200 mg cap 1
cod liver oil oral oil 1
complete natal dha 29-1-200 & 250 mg oral misc 1
completenate 29-1 mg tab chew 1
CO-NATAL FA tab 3
CONCEPT DHA 53.5-38-1 mg cap 3
PROSSAM
Page 104 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
CONCEPT OB 130-92.4-1 mg cap 3
CORVITA 1.25 mg tab 3
CORVITE 1.25 mg tab 3
CORVITE FREE tab 3
DIALYVITE tab 3
DIALYVITE 3000 3 mg tab 3
DIALYVITE 5000 5 mg tab 3
DIALYVITE SUPREME D 3 mg tab 3
DIALYVITE/ZINC tab 3
dothelle dha 53.5-38-1 mg cap 1
DUET DHA 400 25-1 & 400 mg oral misc 3
DUET DHA BALANCED 25-1 & 267 mg oral misc 3
ELITE-OB 50-1.25 mg tab 3
ENBRACE HR cap 3
eql super b complex/vitamin c tab 1
ESCAVITE 0.25-7.5 mg tab chew 3
ESCAVITE D 0.25-6 mg tab chew 3
escavite lq 0.25-6 mg/ml liq 3
FLORIVA 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3
FLORIVA PLUS 0.25 mg/ml soln 3
folbee plus tab 1
FOLBEE PLUS CZ 5 mg tab 3
FOLET DHA 38-1 & 350 mg pack 3
FOLET ONE 38-1-225 mg cap 3
FOLGARD OS 500-1.1 mg tab 3
FOLIVANE-OB 130-92.4-1 mg cap 3
FORTAVIT cap 3
hemenatal ob 28-6-1 mg tab 1
hemenatal ob + dha 28-6-1 & 203 mg oral misc 1
hm super vitamin b complex/c tab 1
hm vitamin b complex/vitamin c tab 1
INATAL GT tab 3
infanate balance 29-1-265 mg cap 1
INFUVITE ADULT iv inj 3
INFUVITE PEDIATRIC iv soln 3
kp b complex-c tab 1
LYSIPLEX PLUS tab 3
M.V.I. ADULT iv inj 3
M.V.I. PEDIATRIC iv soln 3
M.V.I.-12 (WITHOUT VITAMIN K) iv inj 3
MARNATAL-F 60-1 mg cap 3
PROSSAM
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PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
MILCO-B-FORTE tab 3
multi-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1
multi-vit/fluoride/iron 0.25-10 mg/ml soln 1
multi-vit/iron/fluoride 0.25-10 mg/ml soln 1
multi-vitamin drops/fe soln 1 AL
multivitamin/fluoride 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 1
multivitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1
multi-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1
multivitamin/fluoride/iron 0.25-10 mg/ml soln 1
multi-vitamin/fluoride/iron 0.25-10 mg/ml soln 1
multivitamins/fluoride 0.5 mg tab chew 1
MVC-FLUORIDE 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3
M-VIT tab 3
MYNATAL cap, 90-1 mg tab 3
MYNATAL ADVANCE tab 3
mynatal plus tab 1
mynatal-z tab 1
mynate 90 plus tab er 1
mynephrocaps 1 mg cap 1
MYNEPHRON 1 mg cap 3
NATACHEW 28-1 mg tab chew 3
NATALVIT tab 3
NATELLE ONE 28-1-250 mg cap 3
NEEVO DHA 27-1.13 mg cap 3
NEPHPLEX RX tab 3
NEPHROCAPS 1 mg cap 3
NEPHRONEX tab 3
NEPHRO-VITE RX 1 mg tab 3
NESTABS 32-1 mg tab 3
NESTABS ABC 32-1-200 mg oral misc 3
NESTABS DHA 32-1 mg oral misc 3
NEWGEN 32-1 mg tab 3
NEXA PLUS 29-1.25-350 mg cap 3
PROSSAM
Page 106 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NICADAN tab 3
NICADAN ZX tab 3
NICAZEL tab 3
NICAZEL FORTE tab 3
NICOMIDE 750-27-2-0.5 mg tab 3
NIVA-PLUS 27-1 mg tab 3
NUTRICAP tab 3
NUTRIFAC ZX tab 3
NUTRIVIT liq 3
OB COMPLETE 50-1.25 mg tab 3
OB COMPLETE ONE 50-1-476 mg cap 3
OB COMPLETE PETITE 35-5-1-200 mg cap 3
OB COMPLETE PREMIER 30-20-1 mg tab 3
OB COMPLETE/DHA 30-10-1-200 mg cap 3
OBSTETRIX DHA 29-1 & 387 mg oral misc 3
OBSTETRIX EC 29-1 mg tab 3
OBSTETRIX ONE 38-1-225 mg cap 3
O-CAL FA 27-1 mg tab 3
O-CAL PRENATAL tab 3
OCUVEL 0.5 mg cap 3
pnv folic acid + iron 27-1 mg tab 1
pnv ob+dha 27-1 & 250 mg oral misc 1
pnv prenatal plus multivitamin 27-1 mg tab 1
pnv tabs 29-1 29-1 mg tab 1
pnv-dha 27-0.6-0.4-300 mg cap 1
pnv-dha plus 27-1.13-0.4 mg cap 1
pnv-dha+docusate 27-1.25-300 mg cap 1
pnv-omega 28-0.6-0.4-340 mg cap 1
pnv-select 27-0.6-0.4 mg tab 1
pnv-total 35-5-1.2 mg cap 1
POLY-VI-FLOR 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3
POLY-VI-FLOR 0.25 mg/ml susp 3
POLY-VI-FLOR FS 0.25 mg Oral Strip, 0.5 mg Oral Strip, 1 mg Oral Strip 3
PROSSAM
Page 107 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
POLY-VI-FLOR/IRON 0.5-10 mg tab chew 3
POLY-VI-FLOR/IRON 0.25-7 mg/ml susp 3
POLY-VI-SOL/IRON soln 1 AL
PR NATAL 400 29-1-200 & 400 mg oral misc 3
PR NATAL 400 EC 29-1-200 & 400 mg (dr) oral misc 3
PR NATAL 430 29-1-200 & 430 mg oral misc 3
PR NATAL 430 EC 29-1-200 & 430 mg (dr) oral misc 3
PREFERA OB 34-1 mg tab 3
PREFERAOB +DHA 28-6-1 & 200 mg oral misc 3
PREFERAOB ONE 22-6-1-200 mg cap 3
prena1 1.4 mg tab chew 1
prena1 pearl 30-1.4-200 mg cap er 1
prenaissance 29-1.25-325 mg cap 1
prenaissance balance 30-1-260 mg cap 1
prenaissance harmony dha 27-1 & 380 mg oral misc 1
prenaissance next 1.2 mg tab 1
prenaissance next-b 1.22 mg tab 1
prenaissance plus 28-1-250 mg cap 1
PRENATA 29-1 mg tab chew 3
PRENATABS RX 29-1 mg tab 3
prenatal 27-1 mg tab 1
prenatal 19 tab, tab chew, 29-1 mg tab, 29-1 mg tab chew 1
prenatal plus 27-1 mg tab 1
prenatal plus iron 29-1 mg tab 1
prenatal vitamin plus low iron 27-1 mg tab 1
PRENATAL-U 106.5-1 mg cap 3
PRENATE 0.6-0.4 mg tab chew 3
PRENATE AM 1 mg tab 3
PRENATE DHA 18-0.6-0.4-300 mg cap 3
PRENATE ELITE 20-0.6-0.4 mg tab 3
PROSSAM
Page 108 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PRENATE ENHANCE 28-0.6-0.4-400 mg cap 3
PRENATE ESSENTIAL 18-0.6-0.4-300 mg cap 3
PRENATE MINI 18-0.6-0.4-350 mg cap 3
PRENATE PIXIE 10-0.6-0.4-200 mg cap 3
PRENATE RESTORE 27-0.6-0.4-400 mg cap 3
preplus 27-1 mg tab 1
pretab 29-1 mg tab 1
PROTECT PLUS cap 3
PROVIDA DHA 16-16-1.25-110 mg cap 3
PROVIDA OB 20-20-1.25 mg cap 3
purefe ob plus 162-115.2-1 mg cap 1
px b complex/vitamin c tab 1
QUFLORA PEDIATRIC 0.25 mg tab chew, 0.5 mg tab chew, 1 mg tab chew 3
QUFLORA PEDIATRIC 0.25 mg/ml soln, 0.5 mg/ml soln 3
relnate dha 28-1-200 mg cap 1
RENAL 1 mg cap 3
RENATABS 1 mg tab 3
reno caps 1 mg cap 1
REQ 49+ tab 3
R-NATAL OB 20-1-320 mg cap 3
SELECT-OB 29-0.6-0.4 mg tab chew, 29-1 mg tab chew 3
SELECT-OB+DHA 29-1 & 250 mg oral misc 3
se-natal 19 29-1 mg tab, 29-1 mg tab chew 1
SIDEROL tab 3
sm b super vitamin complex tab 1
sm b-complex/vitamin c tab 1
stress formula tab 1
STROVITE FORTE tab 3
STROVITE FORTE syr 3
STROVITE ONE tab 3
super b complex/fa/vit c tab 1
super b-complex/vit c/fa tab 1
SUPERVITE liq 3
support liq 1
PROSSAM
Page 109 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SUPPORT-500 cap 3
SYNAGEX 1.25 mg cap 3
SYNATEK 1.25 mg cap 3
TARON-BC 20-1 & 25 (2) mg oral misc 3
TARON-C DHA 53.5-38-1 mg cap 3
TARON-PREX 30-1.2-265 mg cap 3
TEXAVITE LQ 0.25-7-3 mg/ml liq 3
thrivite 19 29-1 mg tab 1
thrivite rx 29-1 mg tab 1
tl folate 27-0.5-0.5 mg tab 1
TL G-FOL OS 500-1.1 mg tab 3
tl-care dha 27-1-500 mg cap 1
tl-fluorivite 0.25-7.5 mg tab chew 1
tl-select 29-1.25-325 mg cap 1
TRICARE tab 3
TRICARE PRENATAL COMPLEAT 27-1 mg oral misc 3
TRICARE PRENATAL DHA ONE 27-1-500 mg cap 3
trinatal rx 1 60-1 mg tab 1
TRINATE tab 3
triphrocaps 1 mg cap 1
tristart dha 31-0.6-0.4-200 mg cap 1
tri-tabs dha 32-1 mg oral misc 1
TRIVEEN-DUO DHA 29-1-200 & 400 mg oral misc 3
TRI-VI-FLOR 0.25 mg/ml susp, 0.5 mg/ml susp 3
tri-vi-floro 0.25 mg/ml susp, 0.5 mg/ml susp 1
tri-vit/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1
tri-vit/fluoride/iron 0.25-10 mg/ml soln 1
tri-vitamin/fluoride 0.25 mg/ml soln, 0.5 mg/ml soln 1
UDAMIN SP 1 mg tab 3
ultimatecare one 27-1 mg cap 1
urosex tab 1
v-c forte cap 1
VEMAVITE-PRX 2 27-1.25-300 mg cap 3
vena-bal dha 27-1 & 430 mg oral misc 1
VIC-FORTE cap 3
PROSSAM
Page 110 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
VINATE DHA RF 27-1.13 mg cap 3
VINATE II 29-1 mg tab 3
VINATE M 27-1 mg tab 3
VINATE ONE 60-1 mg tab 3
virt nate 28-1 mg tab 1
virt-c dha 53.5-38-1 mg cap 1
virt-caps 1 mg cap 1
virt-nate dha 28-1-200 mg cap 1
virt-pn 27-0.6-0.4 mg tab 1
virt-pn dha 27-0.6-0.4-300 mg cap 1
virt-pn plus 28-0.6-0.4-340 mg cap 1
VITA S FORTE tab 3
vita-bee/c tab 1
VITACEL tab 3
VITAFOL FE+ 90-1-200 & 50 mg cap pack 3
VITAFOL ULTRA 29-0.6-0.4-200 mg cap 3
VITAFOL-NANO 18-0.6-0.4 mg tab 3
VITAFOL-OB tab 3
VITAFOL-OB+DHA 65-1 & 250 mg oral misc 3
VITAFOL-ONE 29-1-200 mg cap 3
vitaject inj 1
VITAL-D RX 1 mg tab 3
VITAMAX PEDIATRIC soln 3
VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 mg cap 3
VITAMEDMD REDICHEW RX 1.4 mg tab chew 3
vita-min cap 1
vitamins acd-fluoride 0.25 mg/ml soln 1
VITAPEARL 30-1.4-200 mg cap er 3
VITAROCA PLUS tab 3
vita-rx diabetic vitamin cap 1
VIVA DHA 28-1-200 mg cap 3
vol-care rx 1 mg tab 1
vol-nate 28-1 mg tab 1
vol-plus 27-1 mg tab 1
vol-tab rx 29-1 mg tab 1
vp-ggr-b6 prenatal 1.2 mg tab 1
vp-heme ob 28-6-1 mg tab 1
vp-heme ob + dha 28-6-1 & 203 mg oral misc 1
PROSSAM
Page 111 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
vp-heme one 22-6-1-200 mg cap 1
vp-pnv-dha 28-1-215.8 mg cap 1
vp-vite rx 1 mg tab 1
vp-zel tab 1
ZATEAN-PN DHA 27-0.6-0.4-300 mg cap 3
ZATEAN-PN PLUS 28-0.6-0.4-340 mg cap 3
MYDRIATICS [MIDRIÁTICOS]
Mydriatics [Midriáticos]
atropine sulfate 1 % ophth oint 1
atropine sulfate 1 % ophth soln 1
CYCLOGYL 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 3
CYCLOMYDRIL 0.2-1 % ophth soln 3
cyclopentolate hcl 0.5 % ophth soln, 1 % ophth soln, 2 % ophth soln 1
HOMATROPAIRE 5 % ophth soln 3
homatropine hbr 5 % ophth soln 1
ISOPTO ATROPINE 1 % ophth soln 3
MYDRIACYL 1 % ophth soln 3
tropicamide 0.5 % ophth soln, 1 % ophth soln 1
OPIATE ANTAGONISTS [ANTAGONISTAS DE OPIÁCEOS]
Opiate Antagonists [Antagonistas De Opiáceos]
naloxone hcl 0.4 mg/ml inj soln cart, 4 mg/10ml inj soln 1
naloxone hcl 0.4 mg/ml inj soln, 2 mg/2ml inj soln pfs 1 NARCAN
naltrexone hcl 50 mg tab 1
VIVITROL 380 mg im susp 5 PA
OTHER MISCELLANEOUS THERAPEUTIC AGENTS [OTROS AGENTES TERAPÉUTICOS MISCELÁNEOS]
Other Miscellaneous Therapeutic Agents [Otros Agentes Terapéuticos Misceláneos]
ARCALYST 220 mg sc soln 5 PA
CARNITOR 330 mg tab 3
CARNITOR 1 gm/10ml soln 3
CARNITOR SF 1 gm/10ml soln 3
CYSTADANE oral pwdr 5 PA
CYSTAGON 150 mg cap, 50 mg cap 3
DEMSER 250 mg cap 3
ELMIRON 100 mg cap 3
PROSSAM
Page 112 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
EUFLEXXA 20 mg/2ml i-artic soln pfs 5 PA
GENVISC 850 25 mg/2.5ml i-artic soln pfs 5 PA
HYALGAN 20 mg/2ml i-artic soln, 20 mg/2ml i-artic soln pfs 5 PA
KUVAN 100 mg tab sol 5 PA
levocarnitine 330 mg tab 1 CARNITOR
levocarnitine 1 gm/10ml soln 1 CARNITOR
ORFADIN 10 mg cap, 2 mg cap, 5 mg cap 5 PA
ORTHOVISC 30 mg/2ml i-artic soln pfs 5 PA
RIMSO-50 50 % i-vesic soln 3
SENSIPAR 30 mg tab, 60 mg tab, 90 mg tab 2
SUPARTZ FX 25 mg/2.5ml i-artic soln pfs 5 PA
SYNVISC 16 mg/2ml i-artic soln pfs 5 PA
SYNVISC ONE 48 mg/6ml i-artic soln pfs 5 PA
THIOLA 100 mg tab 3
TYBOST 150 mg tab 4 PA
ZAVESCA 100 mg cap 5 PA
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS [AGENTES PARASIMPATICOMIMÉTICOS (COLINÉRGICOS)]
Parasympathomimetic (cholinergic) Agents [Agentes Parasimpaticomiméticos (Colinérgicos)]
ARICEPT 10 mg tab, 23 mg tab, 5 mg tab 3
bethanechol chloride 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 1 URECHOLINE
cevimeline hcl 30 mg cap 1 EVOXAC
donepezil hcl 10 mg tab, 10 mg tab disint, 23 mg tab, 5 mg tab, 5 mg tab disint 1 ARICEPT
EVOXAC 30 mg cap 3
EXELON 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 2
galantamine hydrobromide 12 mg tab, 4 mg tab, 8 mg tab 1 RAZADYNE
galantamine hydrobromide 4 mg/ml soln 1 RAZADYNE
PROSSAM
Page 113 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
galantamine hydrobromide er 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 1 RAZADYNE
guanidine hcl 125 mg tab 1
MESTINON 180 mg tab er, 60 mg tab 3
MESTINON 60 mg/5ml syr 3
pilocarpine hcl 5 mg tab, 7.5 mg tab 1 SALAGEN
pyridostigmine bromide 60 mg tab 1 MESTINON
pyridostigmine bromide er 180 mg tab er 1 MESTINON
RAZADYNE 12 mg tab, 4 mg tab, 8 mg tab 3
RAZADYNE ER 16 mg cap er 24 hr, 24 mg cap er 24 hr, 8 mg cap er 24 hr 3
rivastigmine 13.3 mg/24hr td patch 24hr, 4.6 mg/24hr td patch 24hr, 9.5 mg/24hr td patch 24hr 1 EXELON
rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap 1 EXELON
SALAGEN 5 mg tab, 7.5 mg tab 3
URECHOLINE 10 mg tab, 25 mg tab, 5 mg tab, 50 mg tab 3
PARATHYROID [PARATIROIDEOS]
Parathyroid [Paratiroideos]
calcitonin (salmon) 200 unit/act nasal soln 1 MIACALCIN
FORTEO 600 mcg/2.4ml sc soln 4 PA
MIACALCIN 200 unit/ml inj soln 3
PHOSPHODIESTERASE TYPE 4 INHIBITORS [INHIBIDORES DE LA FOSFODIESTERASA TIPO 4]
Phosphodiesterase Type 4 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 4]
DALIRESP 500 mcg tab 3
PITUITARY [PITUITARIA]
Pituitary [Pituitaria]
DDAVP 0.1 mg tab, 0.2 mg tab 3
DDAVP 0.01 % nasal soln 3
DDAVP 4 mcg/ml inj soln 5 PA
DDAVP RHINAL TUBE 0.01 % nasal soln 3
desmopressin ace spray refrig 0.01 % nasal soln 1 MINIRIN
desmopressin acetate 0.1 mg tab, 0.2 mg tab 1 DDAVP
PROSSAM
Page 114 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
desmopressin acetate 4 mcg/ml inj soln 1 DDAVP
desmopressin acetate spray 0.01 % nasal soln 1
HP ACTHAR 80 unit/ml inj gel 5 PA
STIMATE 1.5 mg/ml nasal soln 3
PROGESTINS [PROGESTINAS]
Progestins [Progestinas]
AYGESTIN 5 mg tab 3
DEPO-PROVERA 150 mg/ml im susp, 150 mg/ml im susp pfs 3 QL(1 / 90)
DEPO-PROVERA 400 mg/ml im susp 4 PA
DEPO-SUBQ PROVERA 104 104 mg/0.65ml sc susp pfs 3 QL(1 / 90)
hydroxyprogesterone caproate 1.25 gm/5ml im soln 5 DELALUTIN PA
MAKENA 250 mg/ml im oil 5 PA
medroxyprogesterone acetate 150 mg/ml im susp pfs 1 QL(1 / 90)
medroxyprogesterone acetate 150 mg/ml im susp 1 DEPO-PROVERA QL(1 / 90)
medroxyprogesterone acetate 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROVERA
MEGACE ES 625 mg/5ml susp 5 PA
megestrol acetate 625 mg/5ml susp 5 MEGACE PA
norethindrone acetate 5 mg tab 1 AYGESTIN
progesterone 50 mg/ml im oil 1 PA
progesterone micronized 100 mg cap, 200 mg cap 1 PROMETRIUM PA
PROMETRIUM 100 mg cap, 200 mg cap 3 PA
PROVERA 10 mg tab, 2.5 mg tab, 5 mg tab 3
PROKINETIC AGENTS [AGENTES PROCINÉTICOS]
Prokinetic Agents [Agentes Procinéticos]
metoclopramide hcl 10 mg tab disint, 5 mg tab disint 1 METOZOLV QL(90 / 365)
metoclopramide hcl 10 mg tab, 5 mg tab 1 REGLAN QL(90 / 365)
metoclopramide hcl 10 mg/10ml soln, 5 mg/5ml soln, 5 mg/ml inj soln 1 REGLAN QL(90 / 365)
REGLAN 10 mg tab, 5 mg tab 3 QL(90 / 365)
PROTECTIVE AGENTS [AGENTES PROTECTORES]
Protective Agents [Agentes Protectores]
PROSSAM
Page 115 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
dexrazoxane 500 mg iv soln 4 PA
dexrazoxane 250 mg iv soln 4 ZINECARD PA
ETHYOL 500 mg iv soln 4 PA
mesna 100 mg/ml iv soln 4 MESNEX PA
MESNEX 400 mg tab 4 PA
MESNEX 100 mg/ml iv soln 4 PA
TOTECT 500 mg iv soln 4 PA
ZINECARD 250 mg iv soln, 500 mg iv soln 4 PA
PSYCHOTHERAPEUTIC AGENTS [AGENTES PSICOTERAPÉUTICOS]
Antidepressants [Antidepresivos]
amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 ELAVIL
amoxapine 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab 1 ASENDIN
ANAFRANIL 25 mg cap, 50 mg cap, 75 mg cap 3
APLENZIN 174 mg tab er 24 hr, 348 mg tab er 24 hr, 522 mg tab er 24 hr 3
bupropion hcl 100 mg tab, 75 mg tab 1 WELLBUTRIN
bupropion hcl er (smoking det) 150 mg tab er 12 hr 1 ZYBAN
bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 1 WELLBUTRIN SR
bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr 1 WELLBUTRIN XL
CELEXA 10 mg tab, 20 mg tab, 40 mg tab 3
chlordiazepoxide-amitriptyline 10-25 mg tab, 5-12.5 mg tab 1 LIMBITROL
citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab 1 CELEXA
citalopram hydrobromide 10 mg/5ml soln 1 CELEXA
clomipramine hcl 25 mg cap, 50 mg cap, 75 mg cap 1 ANAFRANIL
CYMBALTA 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 3
desipramine hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 NORPRAMIN
PROSSAM
Page 116 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
desvenlafaxine er 100 mg tab er 24 hr, 50 mg tab er 24 hr 1 KHEDEZLA
desvenlafaxine succinate er 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 1 PRISTIQ
doxepin hcl 10 mg cap, 100 mg cap, 150 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 SINEQUAN
doxepin hcl 10 mg/ml oral conc 1 SINEQUAN
duloxetine hcl 20 mg cap dr prt, 30 mg cap dr prt, 60 mg cap dr prt 1 CYMBALTA
EFFEXOR XR 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 3
escitalopram oxalate 10 mg tab, 20 mg tab, 5 mg tab 1 LEXAPRO
escitalopram oxalate 5 mg/5ml soln 1 LEXAPRO
fluoxetine hcl 10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab, 40 mg cap, 60 mg tab, 90 mg cap dr 1 PROZAC
fluoxetine hcl 20 mg/5ml soln 1 PROZAC
fluoxetine hcl (pmdd) 10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab 1
fluvoxamine maleate 100 mg tab, 25 mg tab, 50 mg tab 1 LUVOX
fluvoxamine maleate er 100 mg cap er 24 hr, 150 mg cap er 24 hr 1 LUVOX CR
FORFIVO XL 450 mg tab er 24 hr 3
imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 TOFRANIL
imipramine pamoate 100 mg cap, 125 mg cap, 150 mg cap, 75 mg cap 1 TOFRANIL-PM
LEXAPRO 10 mg tab, 20 mg tab, 5 mg tab 3
maprotiline hcl 25 mg tab, 50 mg tab, 75 mg tab 1 LUDIOMIL
MARPLAN 10 mg tab 3
mirtazapine 15 mg tab, 15 mg tab disint, 30 mg tab, 30 mg tab disint, 45 mg tab, 45 mg tab disint, 7.5 mg tab 1 REMERON
NARDIL 15 mg tab 3
nefazodone hcl 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab, 50 mg tab 1 SERZONE
PROSSAM
Page 117 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NORPRAMIN 10 mg tab, 25 mg tab 3
nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 PAMELOR
nortriptyline hcl 10 mg/5ml soln 1 PAMELOR
olanzapine-fluoxetine hcl 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 1 SYMBYAX
PAMELOR 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 3
PARNATE 10 mg tab 3
paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 1 PAXIL
paroxetine hcl er 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 1 PAXIL CR
PAXIL 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3
PAXIL 10 mg/5ml susp 3
PAXIL CR 12.5 mg tab er 24 hr, 25 mg tab er 24 hr, 37.5 mg tab er 24 hr 3
perphenazine-amitriptyline 2-10 mg tab, 2-25 mg tab, 4-10 mg tab, 4-25 mg tab, 4-50 mg tab 1 TRIAVIL
PEXEVA 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 3
phenelzine sulfate 15 mg tab 1 NARDIL
PRISTIQ 100 mg tab er 24 hr, 25 mg tab er 24 hr, 50 mg tab er 24 hr 2
protriptyline hcl 10 mg tab, 5 mg tab 1 VIVACTIL
PROZAC 10 mg cap, 20 mg cap, 40 mg cap 3
REMERON 15 mg tab, 30 mg tab 3
REMERON SOLTAB 15 mg tab disint, 30 mg tab disint, 45 mg tab disint 3
SARAFEM 10 mg tab, 20 mg tab 3
sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab 1 ZOLOFT
sertraline hcl 20 mg/ml oral conc 1 ZOLOFT
SILENOR 3 mg tab, 6 mg tab 3
SURMONTIL 100 mg cap, 25 mg cap, 50 mg cap 3
PROSSAM
Page 118 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SYMBYAX 12-25 mg cap, 12-50 mg cap, 3-25 mg cap, 6-25 mg cap, 6-50 mg cap 3
TOFRANIL 10 mg tab, 25 mg tab, 50 mg tab 3
tranylcypromine sulfate 10 mg tab 1 PARNATE
trazodone hcl 100 mg tab, 150 mg tab, 300 mg tab, 50 mg tab 1 DESYREL
trimipramine maleate 100 mg cap, 25 mg cap, 50 mg cap 1 SURMONTIL
venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab 1 EFFEXOR
venlafaxine hcl er 150 mg tab er 24 hr, 225 mg tab er 24 hr, 37.5 mg tab er 24 hr, 75 mg tab er 24 hr 1
venlafaxine hcl er 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr 1 EFFEXOR XR
VIIBRYD 10 mg tab, 20 mg tab, 40 mg tab 3
WELLBUTRIN SR 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr 3
WELLBUTRIN XL 150 mg tab er 24 hr, 300 mg tab er 24 hr 3
ZOLOFT 100 mg tab, 25 mg tab, 50 mg tab 3
ZOLOFT 20 mg/ml oral conc 3
ZYBAN 150 mg tab er 12 hr 3
Antipsychotics [Antipsicóticos]
ABILIFY 10 mg tab, 15 mg tab, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 3
ABILIFY MAINTENA 300 mg im pfs, 300 mg Intramuscular Suspension Reconstituted ER 3
aripiprazole 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ABILIFY
aripiprazole 1 mg/ml soln 1 ABILIFY
chlorpromazine hcl 25 mg/ml inj soln, 50 mg/2ml inj soln 1
PROSSAM
Page 119 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
chlorpromazine hcl 10 mg tab, 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 THORAZINE
clozapine 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 CLOZARIL
clozapine 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 1 FAZACLO
CLOZARIL 100 mg tab, 25 mg tab 3
COMPRO 25 mg rect supp 3
FANAPT 1 mg tab, 10 mg tab, 12 mg tab, 2 mg tab, 4 mg tab, 6 mg tab, 8 mg tab 3
FANAPT TITRATION PACK 1 & 2 & 4 & 6 mg tab 3
FAZACLO 100 mg tab disint, 12.5 mg tab disint, 150 mg tab disint, 200 mg tab disint, 25 mg tab disint 3
fluphenazine decanoate 25 mg/ml inj soln 1 PROLIXIN
fluphenazine hcl 1 mg tab, 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROLIXIN
fluphenazine hcl 2.5 mg/5ml oral elix, 2.5 mg/ml inj soln, 5 mg/ml oral conc 1 PROLIXIN
GEODON 20 mg cap, 20 mg im soln, 40 mg cap, 60 mg cap, 80 mg cap 3
HALDOL 5 mg/ml inj soln 3
HALDOL DECANOATE 100 mg/ml im soln, 50 mg/ml im soln 3
haloperidol 0.5 mg tab, 1 mg tab, 10 mg tab, 2 mg tab, 20 mg tab, 5 mg tab 1 HALDOL
haloperidol decanoate 100 mg/ml im soln, 50 mg/ml im soln 1 HALDOL
haloperidol lactate 2 mg/ml oral conc, 5 mg/ml inj soln 1 HALDOL
INVEGA 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 3
INVEGA SUSTENNA 117 mg/0.75ml im susp, 156 mg/ml im susp, 234 mg/1.5ml im susp, 39 mg/0.25ml im susp, 78 mg/0.5ml im susp 5 PA
PROSSAM
Page 120 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 80 mg tab 3
loxapine succinate 10 mg cap, 25 mg cap, 5 mg cap, 50 mg cap 1 LOXITANE
olanzapine 10 mg im soln, 10 mg tab, 10 mg tab disint, 15 mg tab, 15 mg tab disint, 2.5 mg tab, 20 mg tab, 20 mg tab disint, 5 mg tab, 5 mg tab disint, 7.5 mg tab 1 ZYPREXA
ORAP 1 mg tab, 2 mg tab 3
paliperidone er 1.5 mg tab er 24 hr, 3 mg tab er 24 hr, 6 mg tab er 24 hr, 9 mg tab er 24 hr 1 INVEGA
perphenazine 16 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 TRILAFON
pimozide 1 mg tab, 2 mg tab 1 ORAP
prochlorperazine 25 mg rect supp 1 COMPRO
prochlorperazine edisylate 5 mg/ml inj soln 1 COMPAZINE
prochlorperazine maleate 10 mg tab, 5 mg tab 1 COMPAZINE
quetiapine fumarate 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 1 SEROQUEL
quetiapine fumarate er 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 1 SEROQUEL XR
RISPERDAL 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab 3
RISPERDAL 1 mg/ml soln 3
RISPERDAL CONSTA 12.5 mg im susp, 25 mg im susp, 37.5 mg im susp, 50 mg im susp 5 PA
RISPERDAL M-TAB 0.5 mg tab disint 3
risperidone 0.25 mg tab, 0.25 mg tab disint, 0.5 mg tab, 0.5 mg tab disint, 1 mg tab, 1 mg tab disint, 2 mg tab, 2 mg tab disint, 3 mg tab, 3 mg tab disint, 4 mg tab, 4 mg tab disint 1 RISPERDAL
risperidone 1 mg/ml soln 1 RISPERDAL
PROSSAM
Page 121 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
RISPERIDONE M-TAB 0.5 mg tab disint, 1 mg tab disint, 2 mg tab disint 3
SAPHRIS 10 mg tab subl, 5 mg tab subl 3
SEROQUEL 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 3
SEROQUEL XR 150 mg tab er 24 hr, 200 mg tab er 24 hr, 300 mg tab er 24 hr, 400 mg tab er 24 hr, 50 mg tab er 24 hr 3
thioridazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 MELLARIL
thiothixene 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 NAVANE
trifluoperazine hcl 1 mg tab, 10 mg tab, 2 mg tab, 5 mg tab 1 STELAZINE
ziprasidone hcl 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 GEODON
ZYPREXA 10 mg im soln, 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab 3
ZYPREXA RELPREVV 210 mg im susp, 300 mg im susp, 405 mg im susp 3
ZYPREXA ZYDIS 10 mg tab disint, 15 mg tab disint, 20 mg tab disint, 5 mg tab disint 3
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS [INHIBIDORES DEL SISTEMA RENINA-ANGIOTENSINA-ALDOSTERONA]
Angiotensin Ii Receptor Antagonists [Antagonistas Del Receptor De Angiotensina Ii]
ATACAND HCT 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 3
AVALIDE 150-12.5 mg tab 3
BENICAR 20 mg tab, 40 mg tab, 5 mg tab 3
BENICAR HCT 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 3
candesartan cilexetil 16 mg tab, 32 mg tab, 4 mg tab, 8 mg tab 1 ATACAND
candesartan cilexetil-hctz 16-12.5 mg tab, 32-12.5 mg tab, 32-25 mg tab 1 ATACAND HCT
PROSSAM
Page 122 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
DIOVAN HCT 160-12.5 mg tab, 160-25 mg tab, 320-12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab 3
EDARBYCLOR 40-12.5 mg tab, 40-25 mg tab 3
eprosartan mesylate 600 mg tab 1 TEVETEN
HYZAAR 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 3
irbesartan 150 mg tab, 300 mg tab, 75 mg tab 1 AVAPRO
irbesartan-hydrochlorothiazide 150-12.5 mg tab, 300-12.5 mg tab 1 AVALIDE
losartan potassium 100 mg tab, 25 mg tab, 50 mg tab 1 COZAAR
losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab 1 HYZAAR
MICARDIS HCT 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 3
olmesartan medoxomil 20 mg tab, 40 mg tab, 5 mg tab 1 BENICAR
olmesartan medoxomil-hctz 20-12.5 mg tab, 40-12.5 mg tab, 40-25 mg tab 1 BENICAR HCT
telmisartan 20 mg tab, 40 mg tab, 80 mg tab 1 MICARDIS
telmisartan-hctz 40-12.5 mg tab, 80-12.5 mg tab, 80-25 mg tab 1 MICARDIS-HCT
valsartan 160 mg tab, 320 mg tab, 40 mg tab, 80 mg tab 1 DIOVAN
valsartan-hydrochlorothiazide 160-12.5 mg tab, 160-25 mg tab, 320-12.5 mg tab, 320-25 mg tab, 80-12.5 mg tab 1 DIOVAN HCT
Angiotensin-converting Enzyme Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina]
ACCURETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3
benazepril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 LOTENSIN
benazepril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab, 5-6.25 mg tab 1 LOTENSIN HCT
captopril 100 mg tab, 12.5 mg tab, 25 mg tab, 50 mg tab 1 CAPOTEN
PROSSAM
Page 123 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
captopril-hydrochlorothiazide 25-15 mg tab, 25-25 mg tab, 50-15 mg tab, 50-25 mg tab 1 CAPOZIDE
enalapril maleate 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 1 VASOTEC
enalapril-hydrochlorothiazide 10-25 mg tab, 5-12.5 mg tab 1 VASERETIC
fosinopril sodium 10 mg tab, 20 mg tab, 40 mg tab 1 MONOPRIL
fosinopril sodium-hctz 10-12.5 mg tab, 20-12.5 mg tab 1 MONOPRIL-HCT
lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab 1 ZESTRIL
lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ZESTORETIC
LOTENSIN HCT 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3
moexipril hcl 15 mg tab, 7.5 mg tab 1 UNIVASC
moexipril-hydrochlorothiazide 15-12.5 mg tab, 15-25 mg tab, 7.5-12.5 mg tab 1 UNIRETIC
perindopril erbumine 2 mg tab, 4 mg tab, 8 mg tab 1 ACEON
quinapril hcl 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab 1 ACCUPRIL
quinapril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 1 ACCURETIC
ramipril 1.25 mg cap, 10 mg cap, 2.5 mg cap, 5 mg cap 1 ALTACE
trandolapril 1 mg tab, 2 mg tab, 4 mg tab 1 MAVIK
VASERETIC 10-25 mg tab 3
ZESTORETIC 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab 3
Mineralocorticoid (aldosterone) Receptor Antagonists [Antagonistas Del Receptor De Mineralocorticoides (Aldosterona)]
ALDACTAZIDE 25-25 mg tab, 50-50 mg tab 3
ALDACTONE 100 mg tab, 25 mg tab, 50 mg tab 3
eplerenone 25 mg tab, 50 mg tab 1 INSPRA
INSPRA 25 mg tab, 50 mg tab 3
PROSSAM
Page 124 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
spironolactone 100 mg tab, 25 mg tab, 50 mg tab 1 ALDACTONE
spironolactone-hctz 25-25 mg tab 1 ALDACTAZIDE
Renin Inhibitors [Inhibidores De Renina]
aliskiren fumarate 150 mg tab, 300 mg tab 1 TEKTURNA
TEKTURNA 150 mg tab, 300 mg tab 3
TEKTURNA HCT 150-12.5 mg tab, 150-25 mg tab, 300-12.5 mg tab, 300-25 mg tab 3
REPLACEMENT PREPARATIONS [PREPARACIONES DE REEMPLAZO]
Replacement Preparations [Preparaciones De Reemplazo]
av-phos 250 neutral 155-852-130 mg tab 1
calcium acetate (phos binder) 667 mg tab 1
calcium acetate (phos binder) 667 mg cap 1 PHOSLO
EFFER-K 10 meq tab eff, 20 meq tab eff, 25 meq tab eff 3
effervescent pot chloride 25 meq tab eff 1
GALZIN 25 mg cap, 50 mg cap 3
k-effervescent 25 meq tab eff 1
KLOR-CON 20 meq pckt, 8 meq tab er 3
KLOR-CON 10 10 meq tab er 3
KLOR-CON M10 10 meq tab er 3
KLOR-CON M15 15 meq tab er 3
KLOR-CON M20 20 meq tab er 3
KLOR-CON SPRINKLE 10 meq cap er, 8 meq cap er 3
KLOR-CON/EF 25 meq tab eff 3
K-PHOS 500 mg tab 3
K-PHOS-NEUTRAL 155-852-130 mg tab 3
K-PRIME 25 meq tab eff 3
K-TAB 10 meq tab er, 8 meq tab er 3
k-vescent 25 meq tab eff 1
MAGNEBIND 400 400-200-1 mg tab 3
MICRO-K 10 meq cap er, 8 meq cap er 3
PHOSLYRA 667 mg/5ml soln 3
PROSSAM
Page 125 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PHOSPHA 250 NEUTRAL 155-852-130 mg tab 3
PHOSPHO-TRIN 250 NEUTRAL 155-852-130 mg tab 3
pot bicarb-pot chloride 25 meq tab eff 1
potassium bicarbonate 25 meq tab eff 1
potassium chloride 20 meq pckt 1
potassium chloride 20 MEQ/15ML (10%) soln, 40 MEQ/15ML (20%) soln 1 K-SOL
potassium chloride crys er 10 meq tab er 1
potassium chloride crys er 20 meq tab er 1 KLOR-CON
potassium chloride er 10 meq tab er, 8 meq tab er 1 KLOR-CON
potassium chloride er 10 meq cap er, 8 meq cap er 1 MICRO-K
virt-phos 250 neutral 155-852-130 mg tab 1
RESPIRATORY SMOOTH MUSCLE RELAXANTS [RELAJANTES DEL MÚSCULO LISO RESPIRATORIO]
Respiratory Smooth Muscle Relaxants [Relajantes Del Músculo Liso Respiratorio]
DIFIL-G FORTE 100-100 mg/5ml liq 3
ELIXOPHYLLIN 80 mg/15ml oral elix 3
THEO-24 100 mg cap er 24 hr, 200 mg cap er 24 hr, 300 mg cap er 24 hr, 400 mg cap er 24 hr 3
THEOCHRON 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr 3
theophylline 80 mg/15ml soln 1
theophylline er 100 mg tab er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr, 450 mg tab er 12 hr 1 THEO-DUR
theophylline er 400 mg tab er 24 hr, 600 mg tab er 24 hr 1 UNIPHYL
RESPIRATORY TRACT AGENTS, MISCELLANEOUS [AGENTES PARA EL TRACTO RESPIRATORIO, MISCELÁNEOS]
Respiratory Tract Agents, Miscellaneous [Agentes Para El Tracto Respiratorio, Misceláneos]
ARALAST NP 1000 mg iv soln 4 PA
PROSSAM
Page 126 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
FASENRA PEN 30 mg/ml sc soln auto-inj 4 PA
NUCALA 100 mg sc soln, 100 mg/ml sc auto-inj, 100 mg/ml pfs soln 4 PA
PROLASTIN-C 1000 mg iv soln 4 PA
XOLAIR 150 mg sc soln 5 PA
ZEMAIRA 1000 mg iv soln 4 PA
SECOND GENERATION ANTIHISTAMINES [ANTIHISTAMÍNICOS DE SEGUNDA GENERACIÓN]
Second Generation Antihistamines [Antihistamínicos De Segunda Generación]
cetirizine hcl 1 mg/ml soln, 5 mg/5ml soln 1 ZYRTEC
CLARINEX 5 mg tab 3
CLARINEX 0.5 mg/ml syr 3
CLARINEX-D 12 HOUR 2.5-120 mg tab er 12 hr 3
desloratadine 2.5 mg tab disint, 5 mg tab, 5 mg tab disint 1 CLARINEX
levocetirizine dihydrochloride 5 mg tab 1 XYZAL
levocetirizine dihydrochloride 2.5 mg/5ml soln 1 XYZAL
SEMPREX-D 8-60 mg cap 3
SERUMS [SUEROS]
Serums [Sueros]
BIVIGAM 10 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA
FLEBOGAMMA DIF 0.5 gm/10ml iv soln, 10 gm/100ml iv soln, 10 gm/200ml iv soln, 2.5 gm/50ml iv soln, 20 gm/200ml iv soln, 20 gm/400ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA
GAMMAGARD 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 30 gm/300ml inj soln, 5 gm/50ml inj soln 5 PA
GAMMAGARD S/D LESS IGA 10 gm iv soln, 5 gm iv soln 5 PA
GAMMAKED 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 5 gm/50ml inj soln 5 PA
PROSSAM
Page 127 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
GAMMAPLEX 10 gm/100ml iv soln, 10 gm/200ml iv soln, 20 gm/200ml iv soln, 20 gm/400ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA
GAMUNEX-C 1 gm/10ml inj soln, 10 gm/100ml inj soln, 2.5 gm/25ml inj soln, 20 gm/200ml inj soln, 5 gm/50ml inj soln 5 PA
HYPERRHO S/D 1500 unit im soln pfs, 250 unit im soln pfs 4 PA
MICRHOGAM ULTRA-FILTERED PLUS 250 unit im soln pfs 4 PA
OCTAGAM 10 gm/100ml iv soln, 10 gm/200ml iv soln, 2.5 gm/50ml iv soln, 20 gm/200ml iv soln, 5 gm/100ml iv soln, 5 gm/50ml iv soln 5 PA
PRIVIGEN 10 gm/100ml iv soln, 20 gm/200ml iv soln, 5 gm/50ml iv soln 5 PA
RHOGAM ULTRA-FILTERED PLUS 1500 unit im soln pfs 4 PA
RHOPHYLAC 1500 unit/2ml inj soln pfs 4 PA
WINRHO SDF 1500 unit/1.3ml inj soln, 15000 unit/13ml inj soln, 2500 unit/2.2ml inj soln, 5000 unit/4.4ml inj soln 4 PA
SKELETAL MUSCLE RELAXANTS [RELAJANTES MUSCULOESQUELÉTICOS]
Centrally Acting Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos De Acción Central]
AMRIX 15 mg cap er 24 hr, 30 mg cap er 24 hr 3
carisoprodol 250 mg tab, 350 mg tab 1 SOMA
carisoprodol-aspirin 200-325 mg tab 1 SOMA
carisoprodol-aspirin-codeine 200-325-16 mg tab 1
SOMA COMPOUND WITH CODEINE
chlorzoxazone 500 mg tab 1 PARAFON
cyclobenzaprine hcl 7.5 mg tab 1 FEXMID
cyclobenzaprine hcl 10 mg tab, 5 mg tab 1 FLEXERIL
enovarx-cyclobenzaprine hcl 20 mg/gm td crm 1
FEXMID 7.5 mg tab 3
LORZONE 375 mg tab, 750 mg tab 3
METAXALL 800 mg tab 3
PROSSAM
Page 128 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
metaxalone 800 mg tab 1 SKELAXIN
methocarbamol 500 mg tab, 750 mg tab 1 ROBAXIN
methocarbamol 1000 mg/10ml inj soln 1 ROBAXIN
ROBAXIN 500 mg tab 3
ROBAXIN 1000 mg/10ml inj soln 3
ROBAXIN-750 750 mg tab 3
SKELAXIN 800 mg tab 3
SOMA 250 mg tab, 350 mg tab 3
tizanidine hcl 2 mg cap, 2 mg tab, 4 mg cap, 4 mg tab, 6 mg cap 1 ZANAFLEX
ZANAFLEX 2 mg cap, 4 mg cap, 4 mg tab, 6 mg cap 3
Direct-acting Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos De Acción Directa]
DANTRIUM 25 mg cap, 50 mg cap 3
dantrolene sodium 100 mg cap, 25 mg cap, 50 mg cap 1 DANTRIUM
Gaba-derivative Skeletal Muscle Relaxants [Relajantes Musculoesqueléticos Derivados De Gaba]
baclofen 10 mg tab, 20 mg tab 1 LIORESAL
Skeletal Muscle Relaxants, Miscellaneous [Relajantes Musculoesqueléticos, Misceláneos]
orphenadrine citrate 30 mg/ml inj soln 1 NORFLEX
orphenadrine citrate er 100 mg tab er 12 hr 1 NORFLEX
SKIN AND MUCOUS MEMBRANE AGENTS, MISC [AGENTES PARA LA PIEL Y MEMBRANAS MUCOSAS, MISCELÁNEOS]
Skin And Mucous Membrane Agents, Misc [Agentes Para La Piel Y Membranas Mucosas, Misceláneos]
ABSORICA 10 mg cap, 20 mg cap, 25 mg cap, 30 mg cap, 35 mg cap, 40 mg cap 3
acitretin 10 mg cap, 17.5 mg cap, 25 mg cap 1 SORIATANE PA
ACZONE 5 % gel, 7.5 % gel 3
adapalene 0.1 % lot 1 AL
adapalene 0.1 % crm, 0.1 % gel, 0.3 % gel 1 DIFFERIN AL
adapalene-benzoyl peroxide 0.1-2.5 % gel 1 EPIDUO
ALDARA 5 % crm 3
ALEVICYN PLUS ext kit 3
AMNESTEEM 10 mg cap, 20 mg cap, 40 mg cap 3
PROSSAM
Page 129 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
ATOPICLAIR crm 3
AZELEX 20 % crm 3
calcipotriene 0.005 % crm, 0.005 % oint 1 DOVONEX
calcipotriene 0.005 % ext soln 1 DOVONEX
CALCITRENE 0.005 % oint 3
calcitriol 3 mcg/gm oint 1 VECTICAL
CARAC 0.5 % crm 5 PA
CLARAVIS 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3
clindamycin-tretinoin 1.2-0.025 % gel 1 ZIANA
CLINOIN 1.25-0.025-1 % crm 3
CONDYLOX 0.5 % gel 3
COSENTYX 150 mg/ml sc soln pfs 4 PA
COSENTYX 300 DOSE 150 mg/ml sc soln pfs 4 PA
COSENTYX SENSOREADY 300 DOSE 150 mg/ml sc soln auto-inj 4 PA
COSENTYX SENSOREADY PEN 150 mg/ml sc soln auto-inj 4 PA
dapsone 5 % gel 1 ACZONE
DEXERYL crm 3
diclofenac sodium 1.5 % td soln 1 PENNSAID
diclofenac sodium 3 % td gel 4 SOLARAZE PA
diclofenac sodium 1 % td gel 1 VOLTAREN
DIFFERIN 0.1 % crm, 0.1 % gel, 0.3 % gel 3
DIFFERIN 0.1 % lot 3
DOVONEX 0.005 % crm 3
doxycycline 40 mg cap dr 1
DRITHO-CREME HP 1 % crm 3
EFUDEX 5 % crm 5 PA
ELETONE crm 3
ELETONE TWINPACK crm 3
ELIDEL 1 % crm 3
EPIDUO 0.1-2.5 % gel 3
EPIDUO FORTE 0.3-2.5 % gel 3
FABIOR 0.1 % foam 3
FINACEA 15 % foam, 15 % gel 3
FLECTOR 1.3 % td patch 3
FLUOROPLEX 1 % crm 5 PA
fluorouracil 0.5 % crm 4 CARAC PA
fluorouracil 5 % crm 4 EFUDEX PA
fluorouracil 2 % ext soln, 5 % ext soln 4 EFUDEX PA
PROSSAM
Page 130 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
HPR foam 3
HPR PLUS crm, foam 3
HPR PLUS HYDROGEL ext kit 3
HYLATOPIC PLUS crm, foam 3
imiquimod 5 % crm 1 ALDARA
KLOFENSAID II 1.5 % td soln 3
LEVULAN KERASTICK 20 % ext soln 5 PA
MB HYDROGEL ext kit 3
minocycline hcl er 115 mg tab er 24 hr, 135 mg tab er 24 hr, 45 mg tab er 24 hr, 65 mg tab er 24 hr, 90 mg tab er 24 hr 1 SOLODYN
MIRVASO 0.33 % gel 3
MYORISAN 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3
NEOCERA crm 3
NEOSALUS crm, foam 3
NEOSALUS lot 3
NEOSALUS CP crm 3
NIVATOPIC PLUS crm 3
ORACEA 40 mg cap dr 3
PANRETIN 0.1 % gel 4 PA
PICATO 0.015 % gel, 0.05 % gel 5 PA
podocon 25 % ext soln 1
podofilox 0.5 % ext soln 1 CONDYLOX
PR CREAM ext kit 3
PRESERA foam 3
PROTOPIC 0.03 % oint, 0.1 % oint 3
PRUCLAIR crm 3
PRUMYX crm 3
QUTENZA 8 % ext kit 5 PA
QUTENZA (2 PATCH) 8 % ext kit 5 PA
RECTIV 0.4 % rect oint 3
SANTYL 250 unit/gm oint 3
SKYRIZI (150 mg/ml) sc pfs kit 75mg/0.83ml 4 PA
SOLODYN 105 mg tab er 24 hr, 115 mg tab er 24 hr, 55 mg tab er 24 hr, 65 mg tab er 24 hr, 80 mg tab er 24 hr 3
SORIATANE 10 mg cap, 17.5 mg cap, 25 mg cap 5 PA
SORILUX 0.005 % foam 3
tacrolimus 0.03 % oint, 0.1 % oint 1 PROTOPIC
TARGRETIN 1 % gel 5 PA
PROSSAM
Page 131 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
tazarotene 0.1 % crm 1 TAZORAC
TAZORAC 0.05 % crm, 0.05 % gel, 0.1 % crm, 0.1 % gel 3
TETRIX crm 3
VECTICAL 3 mcg/gm oint 3
VELTIN 1.2-0.025 % gel 3
VEREGEN 15 % oint 3
VOLTAREN 1 % td gel 3
XERALUX crm 3
ZENATANE 10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap 3
ZIANA 1.2-0.025 % gel 3
ZITHRANOL 1 % shampoo 3
ZYCLARA 3.75 % crm 3
ZYCLARA PUMP 2.5 % crm, 3.75 % crm 3
SOMATOSTATIN AGONISTS AND ANTAGONISTS [AGONISTAS Y ANTAGONISTAS DE SOMATOSTATINA]
Somatostatin Agonists [Agonistas De Somatostatina]
octreotide acetate 100 mcg/ml inj soln, 1000 mcg/ml inj soln, 200 mcg/ml inj soln, 50 mcg/ml inj soln, 500 mcg/ml inj soln 5 SANDOSTATIN PA
SANDOSTATIN 100 mcg/ml inj soln, 1000 mcg/ml inj soln, 50 mcg/ml inj soln, 500 mcg/ml inj soln 5 PA
SANDOSTATIN LAR DEPOT 10 mg im kit, 20 mg im kit, 30 mg im kit 5 PA
SIGNIFOR 0.3 mg/ml sc soln, 0.6 mg/ml sc soln, 0.9 mg/ml sc soln 5 PA
SIGNIFOR LAR 20 mg Intramuscular Suspension Reconstituted ER, 40 mg Intramuscular Suspension Reconstituted ER, 60 mg Intramuscular Suspension Reconstituted ER 5 PA
SOMATULINE DEPOT 120 mg/0.5ml sc soln, 60 mg/0.2ml sc soln, 90 mg/0.3ml sc soln 5 PA
SOMATOTROPIN AGONISTS AND ANTAGONISTS [AGONISTAS Y ANTAGONISTAS DE SOMATOTROPINA]
Somatotropin Agonists [Agonistas De Somatotropina]
EGRIFTA 1 mg sc soln 5 PA
INCRELEX 40 mg/4ml sc soln 5 PA
PROSSAM
Page 132 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS [AGENTES SIMPATICOLITICOS (BLOQUEADORES ADRENÉRGICOS)]
Alpha-adrenergic Blocking Agents [Agentes Bloqueadores Alfa-Adrenérgicos]
alfuzosin hcl er 10 mg tab er 24 hr 1 UROXATRAL
D.H.E. 45 1 mg/ml inj soln 3 QL(3 / 30)
DIBENZYLINE 10 mg cap 4 PA
dihydroergotamine mesylate 1 mg/ml inj soln 1 QL(3 / 30)
dihydroergotamine mesylate 4 mg/ml nasal soln 1 MIGRANAL QL(8 / 30)
ergoloid mesylates 1 mg tab 1 HYDERGINE
ERGOMAR 2 mg tab subl 3 QL(20 / 30)
FLOMAX 0.4 mg cap 3
MIGRANAL 4 mg/ml nasal soln 3 QL(8 / 30)
phenoxybenzamine hcl 10 mg cap 4 DIBENZYLINE PA
RAPAFLO 4 mg cap, 8 mg cap 3
tamsulosin hcl 0.4 mg cap 1 FLOMAX
UROXATRAL 10 mg tab er 24 hr 3
SYMPATHOMIMETIC (ADRENERGIC) AGENTS [AGENTES SIMPATICOMIMÉTICOS (ADRENÉRGICOS)]
Alpha- And Beta-adrenergic Agonists [Agonistas Alfa Y Beta Adrenérgicos]
AUVI-Q 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 3
epinephrine 0.15 mg/0.15ml inj soln auto-inj, 0.3 mg/0.3ml inj soln auto-inj 1 ADRENACLICK
epinephrine 0.15 mg/0.3ml inj soln auto-inj 1 EPIPEN JR
EPIPEN 2-PAK 0.3 mg/0.3ml inj soln auto-inj 3
EPIPEN JR 2-PAK 0.15 mg/0.3ml inj soln auto-inj 3
Alpha-adrenergic Agonists [Agonistas Alfa-Adrenérgicos]
midodrine hcl 10 mg tab, 2.5 mg tab, 5 mg tab 1 PROAMATINE
Beta-adrenergic Agonists [Agonistas Beta-Adrenérgicos]
ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr br act, 250-50 mcg/dose inh aer pwdr br act, 500-50 mcg/dose inh aer pwdr br act 2 QL(60 / 30)
ADVAIR HFA 115-21 mcg/act inh aer, 230-21 mcg/act inh aer, 45-21 mcg/act inh aer 2 QL(12 / 30)
albuterol sulfate 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 ACCUNEB
PROSSAM
Page 133 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg tab, 4 mg tab 1 PROVENTIL
albuterol sulfate (5 MG/ML) 0.5% inh neb soln, 2 mg/5ml syr 1 PROVENTIL
albuterol sulfate (2.5 MG/3ML) 0.083% inh neb soln 1 VENTOLIN
albuterol sulfate er 4 mg tab er 12 hr, 8 mg tab er 12 hr 1 VOSPIRE ER
ARCAPTA NEOHALER 75 mcg inh cap 3
BROVANA 15 mcg/2ml inh neb soln 3
ipratropium-albuterol 0.5-2.5 (3) mg/3ml inh soln 1 DUONEB
levalbuterol hcl 1.25 mg/0.5ml inh neb soln 1 XOPENEX
levalbuterol hcl 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 XOPENEX
levalbuterol tartrate 45 mcg/act inh aer 1 XOPENEX HFA
metaproterenol sulfate 10 mg tab, 20 mg tab 1 ALUPENT
metaproterenol sulfate 10 mg/5ml syr 1 ALUPENT
PERFOROMIST 20 mcg/2ml inh neb soln 3
PROAIR HFA 108 (90 Base) mcg/act inh aer soln 3 QL(17 / 30)
PROAIR RESPICLICK 108 (90 Base) mcg/act inh aer pwdr br act 3 QL(2 / 30)
PROVENTIL HFA 108 (90 Base) mcg/act inh aer soln 3 QL(36 / 30)
terbutaline sulfate 2.5 mg tab, 5 mg tab 1 BRETHINE
VENTOLIN HFA 108 (90 Base) mcg/act inh aer soln 2 QL(36 / 30)
XOPENEX 0.31 mg/3ml inh neb soln, 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 3
XOPENEX CONCENTRATE 1.25 mg/0.5ml inh neb soln 3
XOPENEX HFA 45 mcg/act inh aer 3
THYROID AND ANTITHYROID AGENTS [AGENTES TIROIDEOS Y ANTITIROIDEOS]
Antithyroid Agents [Agentes Antitiroideos]
methimazole 10 mg tab, 5 mg tab 1 TAPAZOLE
PROSSAM
Page 134 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
propylthiouracil 50 mg tab 1
TAPAZOLE 10 mg tab, 5 mg tab 3
Thyroid Agents [Agentes Tiroideos]
ARMOUR THYROID 120 mg tab, 15 mg tab, 180 mg tab, 240 mg tab, 30 mg tab, 300 mg tab, 60 mg tab, 90 mg tab 3
CYTOMEL 25 mcg tab, 5 mcg tab, 50 mcg tab 3
LEVO-T 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3
levothyroxine sodium 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 1 SYNTHROID
levothyroxine-liothyronine 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1
LEVOXYL 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3
liothyronine sodium 25 mcg tab, 5 mcg tab, 50 mcg tab 1 CYTOMEL
NATURE-THROID 113.75 mg tab, 130 mg tab, 146.25 mg tab, 16.25 mg tab, 162.5 mg tab, 195 mg tab, 260 mg tab, 32.5 mg tab, 325 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3
np thyroid 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab 1
SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 2
THYROLAR-1 60 (12.5-50) mg (mcg) tab 3
PROSSAM
Page 135 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
THYROLAR-1/2 30 (6.25-25) mg (mcg) tab 3
THYROLAR-1/4 15 (3.1-12.5) mg (mcg) tab 3
THYROLAR-2 120 (25-100) mg (mcg) tab 3
THYROLAR-3 180 (37.5-150) mg (mcg) tab 3
TIROSINT 100 mcg cap, 112 mcg cap, 125 mcg cap, 13 mcg cap, 137 mcg cap, 150 mcg cap, 25 mcg cap, 50 mcg cap, 75 mcg cap, 75 mcg cap, 88 mcg cap 3
UNITHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3
UNITHROID DIRECT 100 mcg tab, 112 mcg tab, 125 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab 3
WESTHROID 130 mg tab, 195 mg tab, 32.5 mg tab, 65 mg tab, 97.5 mg tab 3
WP THYROID 113.75 mg tab, 130 mg tab, 16.25 mg tab, 32.5 mg tab, 48.75 mg tab, 65 mg tab, 81.25 mg tab, 97.5 mg tab 3
TOXOIDS [TOXOIDES]
Toxoids [Toxoides]
ADACEL 5-2-15.5 lf-mcg/0.5 im susp 3
BOOSTRIX 5-2.5-18.5 lf-mcg/0.5 im susp 3
DAPTACEL 15-23-5 lf-mcg/0.5 im susp 3
diphtheria-tetanus toxoids dt 25-5 lfu/0.5ml im susp 1
INFANRIX 25-58-10 im susp 3
KINRIX im susp 3
QUADRACEL im susp 3
TENIVAC 5-2 lfu im inj 3
tetanus-diphtheria toxoids td 2-2 lf/0.5ml im susp 1
PROSSAM
Page 136 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
URICOSURIC AGENTS [AGENTES URICOSÚRICOS]
Uricosuric Agents [Agentes Uricosúricos]
colchicine-probenecid 0.5-500 mg tab 1 COLBENEMID
probenecid 500 mg tab 1 BENEMID
URINARY ANTI-INFECTIVES [ANTIINFECCIOSOS URINARIOS]
Urinary Anti-infectives [Antiinfecciosos Urinarios]
FURADANTIN 25 mg/5ml susp 3
HIPREX 1 gm tab 3
HYOPHEN 81.6 mg tab 3
MACROBID 100 mg cap 3
MACRODANTIN 100 mg cap, 25 mg cap, 50 mg cap 3
methenamine hippurate 1 gm tab 1 HIPREX
methenamine mandelate 0.5 gm tab, 1 gm tab 1
MONUROL 3 gm pckt 3
nitrofurantoin 25 mg/5ml susp 1 FURADANTIN
nitrofurantoin macrocrystal 100 mg cap, 50 mg cap 1 MACRODANTIN
nitrofurantoin monohyd macro 100 mg cap 1 MACROBID
PHOSPHASAL 81.6 mg tab 3
PRIMSOL 50 mg/5ml soln 3
trimethoprim 100 mg tab 1 PROLOPRIM
ur n-c 81.6 mg tab 1
URELLE 81 mg tab 3
URETRON D/S tab 3
URIBEL 118 mg cap 3
URIMAR-T 120 mg tab 3
urin ds tab 1
uro-458 81 mg tab 1
uroav-81 81 mg tab 1
uroav-b 118 mg cap 1
UROGESIC-BLUE 81.6 mg tab 3
uro-mp 118 mg cap 1
URYL 81.6 mg tab 3
USTELL 120 mg cap 3
uticap 120 mg cap 1
UTIRA-C 81.6 mg tab 3
UTRONA-C 81.6 mg tab 3
VILAMIT MB 118 mg cap 3
VILEVEV MB 81 mg tab 3
VACCINES [VACUNAS]
Vaccines [Vacunas]
PEDIARIX im susp 3
PROSSAM
Page 137 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
PENTACEL im susp 3
THERACYS 81 mg/vial i-vesic susp 4 PA
TICE BCG 50 mg i-vesic susp 4 PA
VASOCONSTRICTORS [VASOCONSTRICTORES]
Vasoconstrictors [Vasoconstrictores]
ADRENALIN 0.1 % nasal soln 3
ALTAFRIN 10 % ophth soln, 2.5 % ophth soln 3
phenylephrine hcl 2.5 % ophth soln 1
phenylephrine hcl 10 % ophth soln, 2.5 % ophth soln 1
VASODILATING AGENTS [AGENTES VASODILATADORES]
Nitrates And Nitrites [Nitratos Y Nitritos]
BIDIL 20-37.5 mg tab 3
DILATRATE-SR 40 mg cap er 3
ISORDIL TITRADOSE 40 mg tab, 5 mg tab 3
isosorbide dinitrate 10 mg tab, 20 mg tab, 30 mg tab, 5 mg tab 1 ISORDIL
isosorbide dinitrate er 40 mg tab er 1 ISORDIL
isosorbide mononitrate 10 mg tab, 20 mg tab 1 MONOKET
isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr 1 IMDUR
MINITRAN 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 3
NITRO-BID 2 % td oint 3
NITRO-DUR 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.3 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr, 0.8 mg/hr td patch 24hr 3
nitroglycerin 0.1 mg/hr td patch 24hr, 0.2 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr 1 NITRO-DUR
nitroglycerin 0.4 mg/spray tl soln 1 NITROLINGUAL
nitroglycerin 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 1 NITROSTAT
nitroglycerin er 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 1
NITROLINGUAL 0.4 mg/spray tl soln 3
PROSSAM
Page 138 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
NITROMIST 400 mcg/spray tl aer soln 3
NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl 2
NITRO-TIME 2.5 mg cap er, 6.5 mg cap er, 9 mg cap er 3
Phosphodiesterase Type 5 Inhibitors [Inhibidores De La Fosfodiesterasa Tipo 5]
ADCIRCA 20 mg tab 5 PA
CIALIS 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3 QL(6 / 30)
LEVITRA 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 3 QL(6 / 30)
REVATIO 20 mg tab 5 PA
REVATIO 10 mg/12.5ml iv soln, 10 mg/ml susp 5 PA
sildenafil citrate 20 mg tab 1 REVATIO PA
sildenafil citrate 10 mg/12.5ml iv soln 5 REVATIO PA
sildenafil citrate 100 mg tab, 25 mg tab, 50 mg tab 1 VIAGRA QL(6 / 30)
STAXYN 10 mg tab disint 3 QL(6 / 30)
STENDRA 100 mg tab, 200 mg tab, 50 mg tab 3 QL(6 / 30)
tadalafil 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab 1 QL(6 / 30)
VIAGRA 100 mg tab, 25 mg tab, 50 mg tab 3 QL(6 / 30)
Vasodilating Agents [Agentes Vasodilatadores]
ADEMPAS 0.5 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 2.5 mg tab 4 PA
ambrisentan 10 mg tab, 5 mg tab 4 PA
epoprostenol sodium 0.5 mg iv soln, 1.5 mg iv soln 5 PA
FLOLAN 0.5 mg iv soln, 1.5 mg iv soln 5 PA
LETAIRIS 10 mg tab, 5 mg tab 5 PA
OPSUMIT 10 mg tab 5 PA
ORENITRAM 0.125 mg tab er, 0.25 mg tab er, 1 mg tab er, 2.5 mg tab er 5 PA
REMODULIN 1 mg/ml inj soln, 10 mg/ml inj soln, 2.5 mg/ml inj soln, 5 mg/ml inj soln 4 PA
TRACLEER 125 mg tab, 62.5 mg tab 5 PA
TYVASO 0.6 mg/ml inh soln 5 PA
PROSSAM
Page 139 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
TYVASO REFILL 0.6 mg/ml inh soln 5 PA
TYVASO STARTER 0.6 mg/ml inh soln 5 PA
VELETRI 0.5 mg iv soln, 1.5 mg iv soln 5 PA
VENTAVIS 10 mcg/ml inh soln, 20 mcg/ml inh soln 5 PA
Vasodilating Agents, Miscellaneous [Agentes Vasodilatadores, Misceláneos]
dipyridamole 25 mg tab, 50 mg tab, 75 mg tab 1 PERSANTINE
isoxsuprine hcl 10 mg tab 1
VITAMIN A [VITAMINA A]
Vitamin A [Vitamina A]
AQUASOL A 50000 unit/ml im soln 3
VITAMIN B COMPLEX [VITAMINA DEL COMPLEJO B]
Vitamin B Complex [Vitamina Del Complejo B]
AIRAVITE 2.5-25-1 mg tab 3
aminobenzoate potassium 2 gm pckt 1
ANIMI-3 1 mg cap 3
ANIMI-3/VITAMIN D 1 mg cap 3
av-vite fb 2.5-25-1 mg tab 1
b-6 folic acid 400-1000-50 mcg-mcg-mg cap 1
bp vit 3 1 mg cap 1
CENFOL 2.3-24.5-2 mg tab 3
cyanocobalamin 1000 mcg/ml inj soln 1 PA
DIVISTA 1 mg cap 3
FA-8 800 mcg tab 1
FA-8 0.8 mg cap 3 AL
fabb 2.2-25-1 mg tab 1
fa-vitamin b-6-vitamin b-12 2.2-25-0.5 mg tab 1
folbee 2.5-25-1 mg tab 1
FOLGARD RX 2.2-25-1 mg tab 3
folic acid 1 mg tab, 800 mcg tab 1
folic acid 5 mg/ml inj soln 1
folic acid 400 mcg tab 1 AL
folic acid 0.8 mg cap 3 AL
folplex 2.2 2.2-25-0.5 mg tab 1
FOLTRATE 500-1 mcg-mg tab 3
gnp folic acid 400 mcg tab 1 AL
hm folic acid 400 mcg tab 1 AL
PROSSAM
Page 140 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
hydroxocobalamin acetate 1000 mcg/ml im soln 1
kp folic acid 800 mcg tab 1
NASCOBAL 500 mcg/0.1ml nasal soln 3
neurin-sl 600-600 mcg tab subl 1
niacin pwdr 1
NIACOR 500 mg tab 3
NUFOL 2.5-25-1 mg tab 3
POTABA 500 mg cap 3
px folic acid 400 mcg tab 1 AL
pyridoxine hcl 100 mg/ml inj soln 1
ra folic acid 800 mcg tab 1
ra folic acid 400 mcg tab 1 AL
sm folic acid 400 mcg tab 1 AL
tl gard rx 2.2-25-1 mg tab 1
VIRT-GARD 2.2-25-1 mg tab 3
VITAMEZ 1 mg cap 3
vitamin b complex 100 inj 1
vitamin b-complex 100 inj 1
yl folic acid 400 mcg tab 1 AL
VITAMIN C [VITAMINA C]
Vitamin C [Vitamina C]
ASCOR 25000 mg/50ml iv soln 3
ascorbic acid 500 mg/ml inj soln 1
VITAMIN D [VITAMINA D]
Vitamin D [Vitamina D]
calcitriol 0.25 mcg cap, 0.5 mcg cap 1 ROCALTROL
calcitriol 1 mcg/ml soln 1 ROCALTROL
doxercalciferol 0.5 mcg cap, 1 mcg cap, 2.5 mcg cap 1 HECTOROL
DRISDOL 50000 unit cap 3
ergocalciferol 50000 unit cap 1
paricalcitol 1 mcg cap, 2 mcg cap, 4 mcg cap 1 ZEMPLAR
paricalcitol 2 mcg/ml iv soln, 5 mcg/ml iv soln 1 ZEMPLAR
ROCALTROL 0.25 mcg cap, 0.5 mcg cap 3
ROCALTROL 1 mcg/ml soln 3
vitamin d (ergocalciferol) 50000 unit cap 1
ZEMPLAR 1 mcg cap, 2 mcg cap 3
ZEMPLAR 2 mcg/ml iv soln, 5 mcg/ml iv soln 3
PROSSAM
Page 141 of 173 Updated 03/2020
PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]; ST = Step Therapy [Terapia Escalonada]; AL = Age Limit [Límite de Edad]
Drug Name [Nombre del Medicamento]
Drug Tier
[Nivel]
Reference Name [Nombre de Referencia]
Requirements/Limits1
[Requisitos/Límites]
VITAMIN K ACTIVITY [ACTIVIDAD DE LA VITAMINA K]
Vitamin K Activity [Actividad De La Vitamina K]
MEPHYTON 5 mg tab 3
phytonadione 1 mg/0.5ml inj soln 1
vitamin k1 1 mg/0.5ml inj soln, 10 mg/ml inj soln 1
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A
Abacavir Sulfate ............................................ 72 Abacavir Sulfate-Lamivudine ........................ 72 Abacavir-Lamivudine-Zidovudine .................. 72 Abilify .......................................................... 118 Abilify Maintena ........................................... 118 Abraxane....................................................... 55 Absorica ...................................................... 128 Abstral ............................................................. 9 Acamprosate Calcium ................................... 85 Acanya .......................................................... 38 Acarbose ....................................................... 30 Accolate ........................................................ 51 Accuretic ..................................................... 122 Acebutolol HCl .............................................. 78 Acetaminophen-Codeine .......................... 9, 10 Acetaminophen-Codeine #2.......................... 10 Acetaminophen-Codeine #3.......................... 10 Acetaminophen-Codeine #4.......................... 10 Acetasol HC .................................................. 49 AcetaZOLAMIDE .......................................... 37 AcetaZOLAMIDE ER .................................... 37 AcetaZOLAMIDE Sodium ............................. 37 Acetic Acid .................................................... 91 Acetylcysteine ............................................... 34 Aciphex ......................................................... 70 Acitretin ....................................................... 128 Actemra......................................................... 89 Actigall .......................................................... 86 Actimmune .................................................... 98 Actiq .............................................................. 10 Activella......................................................... 92 Actonel .......................................................... 79 Actoplus Met ................................................. 33 Actoplus met XR ........................................... 33 Actos ............................................................. 33 Acuvail .......................................................... 51 Acyclovir.................................................. 42, 74 Aczone ........................................................ 128 Adacel ......................................................... 135 Adagen ......................................................... 92 Adalat CC...................................................... 81 Adapalene ................................................... 128 Adapalene-Benzoyl Peroxide ...................... 128 Adcetris ......................................................... 55 Adcirca ........................................................ 138 Adderall ......................................................... 15 Adderall XR ................................................... 15
Adefovir Dipivoxil ........................................... 74 Adempas ..................................................... 138 Adrenal C Formula ...................................... 103 Adrenalin ..................................................... 137 Adriamycin .................................................... 55 Adrucil ........................................................... 55 Advair Diskus .............................................. 132 Advair HFA .................................................. 132 Advanced AM/PM........................................ 103 Afeditab CR ................................................... 81 Afinitor ........................................................... 55 Afinitor Disperz .............................................. 55 AgonEaze ...................................................... 65 Agrylin ........................................................... 68 Airavite ........................................................ 139 AK-Poly-Bac .................................................. 38 Aktipak .......................................................... 38 Ala Scalp ....................................................... 44 Ala-Cort ......................................................... 44 Ala-Quin ........................................................ 40 Albenza ......................................................... 17 Albuterol Sulfate .................................. 132, 133 Albuterol Sulfate ER .................................... 133 Alclometasone Dipropionate ......................... 44 Alcortin A ....................................................... 43 Aldactazide .................................................. 123 Aldactone .................................................... 123 Aldara .......................................................... 128 Aldurazyme ................................................... 92 Alecensa ....................................................... 55 Alendronate Sodium ...................................... 79 Alevicyn Plus ............................................... 128 Alferon N ....................................................... 56 Alfuzosin HCl ER ......................................... 132 Alimta ............................................................ 56 Alinia ............................................................. 65 Aliskiren ....................................................... 124 Alkeran .......................................................... 56 Allergy Spray 24 Hour ................................... 49 Allopurinol ..................................................... 37 Almotriptan Malate ........................................ 54 Alomide ......................................................... 17 Alora .............................................................. 92 Alosetron HCl ................................................ 44 Alphagan P .................................................... 36 ALPRAZolam ................................................ 76 ALPRAZolam ER .......................................... 76 ALPRAZolam Intensol ................................... 76 ALPRAZolam XR .......................................... 76
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Alrex .............................................................. 49 Altabax .......................................................... 38 Altafrin ......................................................... 137 Altavera ......................................................... 86 Aluvea ......................................................... 100 Alyacen 1/35 ................................................. 86 Amabelz ........................................................ 92 Amantadine HCl ............................................ 63 Amaryl ........................................................... 33 Ambien .......................................................... 75 Ambien CR .................................................... 75 ambrisentan ................................................ 138 Amcinonide ................................................... 44 Amerge ......................................................... 54 Amicar ........................................................... 37 Amikacin Sulfate ........................................... 19 AMILoride HCl ............................................... 91 AMILoride-HydroCHLOROthiazide ............... 91 Aminobenzoate Potassium ......................... 139 Aminocaproic Acid ........................................ 37 Amiodarone HCl ............................................ 83 Amitiza .......................................................... 96 Amitriptyline HCl ......................................... 115 Amlodipine Besy-Benazepril HCl .................. 81 AmLODIPine Besylate .................................. 82 Amlodipine Besylate-Valsartan ..................... 82 Amlodipine-Atorvastatin ................................ 82 Amlodipine-Olmesartan ................................ 82 Amlodipine-Valsartan-HCTZ ......................... 82 Ammonium Lactate ....................................... 91 Amnesteem ................................................. 128 Amoxapine .................................................. 115 Amoxicill-Clarithro-Lansopraz ....................... 70 Amoxicillin ..................................................... 22 Amoxicillin-Pot Clavulanate........................... 22 Amoxicillin-Pot Clavulanate ER ..................... 22 Amphetamine-Dextroamphet ER .................. 15 Amphetamine-Dextroamphetamine .............. 15 Amphotericin B .............................................. 36 Ampicillin ....................................................... 22 Ampicillin Sodium .......................................... 23 Amrix ........................................................... 127 Anacaine ....................................................... 65 Anafranil ...................................................... 115 Anagrelide HCl .............................................. 68 Analpram HC ................................................ 65 Analpram HC Singles .................................... 66 Analpram-HC ................................................ 66 Anaprox DS ..................................................... 7 Anaspaz ........................................................ 25
Anastrozole ................................................... 56 Ancobon ........................................................ 36 Angeliq .......................................................... 92 Animi-3 ........................................................ 139 Animi-3/Vitamin D........................................ 139 Anodyne LPT ................................................ 66 Antabuse ......................................................... 5 Anucort-HC ................................................... 44 Anusol-HC ..................................................... 44 Anzemet ........................................................ 34 ApexiCon E ................................................... 44 AP-Hist DM ................................................... 68 Aplenzin ...................................................... 115 Apokyn .......................................................... 64 Apraclonidine HCl.......................................... 91 Aprepitant ...................................................... 34 Apriso ............................................................ 44 Aptivus .......................................................... 72 AP-Zel ......................................................... 103 Aquasol A .................................................... 139 Aralast NP ................................................... 125 Aranesp (Albumin Free) ................................ 97 Arava ............................................................. 89 Arcalyst ....................................................... 111 Arcapta Neohaler ........................................ 133 Aricept ......................................................... 112 Arimidex ........................................................ 56 ARIPiprazole ............................................... 118 Arixtra ............................................................ 67 Armour Thyroid ........................................... 134 Aromasin ....................................................... 56 Arranon ......................................................... 56 Arthrotec .......................................................... 7 Arzerra .......................................................... 56 Asacol HD ..................................................... 44 Ascomp-Codeine ........................................... 10 Ascor ........................................................... 140 Ascorbic Acid .............................................. 140 Aspirin-Dipyridamole ER ............................... 68 Astagraf XL ................................................... 99 Astepro .......................................................... 17 Atabex EC ................................................... 103 Atacand HCT ............................................... 121 Atazanavir Sulfate ......................................... 72 Atelvia ........................................................... 79 Atenolol ......................................................... 78 Atenolol-Chlorthalidone ................................. 78 Ativan ............................................................ 76 Atomoxetine HCl ........................................... 86 Atopiclair ..................................................... 129
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Atorvastatin Calcium ..................................... 53 Atovaquone ................................................... 65 Atovaquone-Proguanil HCl............................ 65 Atralin ............................................................ 85 Atripla ............................................................ 72 AtroPen ......................................................... 25 Atropine Sulfate .......................................... 111 Atrovent HFA ................................................ 25 Aubagio ......................................................... 98 Aubra ............................................................ 86 Augmentin ..................................................... 23 Augmentin ES-600 ........................................ 23 Augmentin XR ............................................... 23 Auvi-Q ......................................................... 132 Avalide ........................................................ 121 Avar ............................................................ 100 Avar Cleanser ............................................. 100 Avar LS ....................................................... 100 Avar LS Cleanser ........................................ 100 Avar-e Emollient .......................................... 100 Avar-e Green .............................................. 100 Avar-e LS .................................................... 100 Avastin .......................................................... 56 AVC Vaginal .................................................. 43 Avelox ........................................................... 23 Aviane ........................................................... 86 Avidoxy ......................................................... 24 Avidoxy DK ................................................... 24 Avita .............................................................. 85 Avodart ........................................................... 3 Avonex .......................................................... 98 Avonex Pen ................................................... 98 Avonex Prefilled ............................................ 98 Av-Phos 250 Neutral ................................... 124 Av-VITE FB ................................................. 139 Axert ............................................................. 54 Aygestin ...................................................... 114 AzaCITIDine .................................................. 56 Azactam ........................................................ 22 Azasan .......................................................... 99 AzaSite ......................................................... 38 AzaTHIOprine ............................................... 99 AzaTHIOprine Sodium .................................. 99 Azelastine HCl .............................................. 17 Azelex ......................................................... 129 Azilect ........................................................... 64 Azithromycin ................................................. 21 Azopt ............................................................. 37 Azor .............................................................. 82 Aztreonam..................................................... 22
Azulfidine ....................................................... 24 Azulfidine EN-tabs ......................................... 24
B
B Complex-C-Folic Acid .............................. 103 B-6 Folic Acid .............................................. 139 BACiiM .......................................................... 19 Bacitracin ................................................ 19, 38 Bacitracin-Polymyxin B .................................. 38 Bacitra-Neomycin-Polymyxin-HC .................. 49 Baclofen ...................................................... 128 Bacmin ........................................................ 103 Bactrim .......................................................... 24 Bactrim DS .................................................... 24 Bactroban ...................................................... 38 Bactroban Nasal ............................................ 38 Bal-Care DHA ............................................. 103 Balsalazide Disodium .................................... 44 Banzel ........................................................... 26 Baqsimi ......................................................... 38 Baraclude ...................................................... 74 B-Complex Balanced ................................... 103 B-Complex/Vitamin C .................................. 103 B-Complex-C ............................................... 103 Beconase AQ ................................................ 49 Benazepril HCl ............................................ 122 Benazepril-Hydrochlorothiazide .................. 122 Bendeka ........................................................ 56 Benicar ........................................................ 121 Benicar HCT ................................................ 121 Benlysta ........................................................ 99 Bensal HP ..................................................... 40 Bentyl ............................................................ 25 Benzac AC Wash .......................................... 43 BenzaClin ...................................................... 38 BenzaClin with Pump .................................... 38 Benzamycin ................................................... 38 BenzEFoam .................................................. 43 BenzEFoamUltra ........................................... 43 BenzePrO ...................................................... 43 BenzePrO Creamy Wash .............................. 43 BenzePrO Foaming Cloths ............................ 43 BenzePrO Short Contact ............................... 43 Benziq ........................................................... 43 Benziq LS ...................................................... 43 Benziq Wash ................................................. 43 Benzonatate .................................................. 68 Benzoyl Perox-Hydrocortisone ...................... 49 Benzoyl Peroxide .......................................... 43 Benzoyl Peroxide-Erythromycin .................... 38
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Benztropine Mesylate ................................... 63 Bepreve......................................................... 17 Besivance ..................................................... 38 Betadine Ophthalmic Prep ............................ 43 Betamethasone Dipropionate ........................ 44 Betamethasone Dipropionate Aug .......... 44, 45 Betamethasone Sod Phos & Acet ................... 3 Betamethasone Valerate............................... 45 Betaseron...................................................... 98 Betaxolol HCl .......................................... 36, 78 Bethanechol Chloride .................................. 112 Betimol .......................................................... 36 Betoptic-S ..................................................... 36 Bexarotene.................................................... 56 Bicalutamide ................................................. 56 Bicillin C-R .................................................... 23 Bicillin C-R 900/300 ...................................... 23 Bicillin L-A ..................................................... 23 BiCNU ........................................................... 56 BiDil ............................................................ 137 BiferaRx ........................................................ 17 Biltricide ........................................................ 17 Bimatoprost ................................................... 37 Binosto .......................................................... 79 Biocel .......................................................... 103 Bio-Statin ...................................................... 36 Biotuss .......................................................... 68 Biotuss Pediatric ........................................... 68 Bisoprolol Fumarate ...................................... 78 Bisoprolol-Hydrochlorothiazide ..................... 78 Bivigam ....................................................... 126 Bleomycin Sulfate ......................................... 56 Bleph-10........................................................ 38 Blephamide S.O.P. ....................................... 49 Boniva ........................................................... 79 Boostrix ....................................................... 135 Bosulif ........................................................... 56 BP 10-1 ....................................................... 101 BP Cleansing Wash .................................... 101 BP Foam ....................................................... 43 BP Foaming Wash ........................................ 43 BP FoliNatal Plus B ..................................... 103 BP MultiNatal Plus ...................................... 103 BP Vit 3 ....................................................... 139 BP Wash ....................................................... 43 B-Plex ......................................................... 103 B-Plex Plus ................................................. 103 BPO .............................................................. 43 BPO Foaming Cloths .................................... 43 BProtected Pedia Iron ................................... 17
BProtected Pedia Poly-Vite/Fe .................... 103 Braftovi .......................................................... 56 Brilinta ........................................................... 68 Brimonidine Tartrate ...................................... 36 Bromfed DM .................................................. 68 Bromfenac Sodium (Once-Daily) ................... 51 Bromocriptine Mesylate ................................. 64 Brompheniramine Tannate ............................ 95 Brovana ....................................................... 133 Bucalsep ....................................................... 43 Budesonide ..................................................... 3 Bumetanide ................................................... 90 Bupap .............................................................. 7 Buprenorphine ............................................... 14 Buprenorphine HCl ........................................ 14 Buprenorphine HCl-Naloxone HCl ................ 14 BuPROPion HCl .......................................... 115 BuPROPion HCl ER (Smoking Det) ............ 115 BuPROPion HCl ER (SR) ............................ 115 BuPROPion HCl ER (XL) ............................ 115 BusPIRone HCl ............................................. 75 Busulfan ........................................................ 56 Busulfex ........................................................ 56 Butalbital-Acetaminophen ............................... 7 Butalbital-APAP ............................................... 7 Butalbital-APAP-Caff-Cod ............................. 10 Butalbital-APAP-Caffeine ................................ 7 Butalbital-ASA-Caff-Codeine ......................... 10 Butalbital-Aspirin-Caffeine ............................... 7 Butisol Sodium .............................................. 76 Butorphanol Tartrate ..................................... 14 Butrans .......................................................... 14 Bydureon ....................................................... 31 Bystolic .......................................................... 78
C
Cabergoline ................................................... 64 Caduet ........................................................... 82 Cafergot ........................................................ 53 Calan ............................................................. 80 Calan SR ....................................................... 80 Calcipotriene ............................................... 129 Calcipotriene-Betameth Diprop ..................... 45 Calcitonin (Salmon) ..................................... 113 Calcitrene .................................................... 129 Calcitriol .............................................. 129, 140 Calcium Acetate (Phos Binder) ................... 124 Cambia ............................................................ 7 Camila ........................................................... 87 Campath ........................................................ 56
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Camptosar .................................................... 56 Canasa ......................................................... 45 Cancidas ....................................................... 36 Candesartan Cilexetil .................................. 121 Candesartan Cilexetil-HCTZ ....................... 121 Capastat Sulfate ........................................... 55 Capecitabine ................................................. 56 Capex ........................................................... 45 Caprelsa........................................................ 56 Captopril...................................................... 122 Captopril-Hydrochlorothiazide ..................... 123 Carac .......................................................... 129 Carafate ........................................................ 70 Carbaglu ......................................................... 6 CarBAMazepine ............................................ 26 CarBAMazepine ER ...................................... 27 Carbaphen 12 ............................................... 68 Carbaphen 12 Ped ........................................ 69 Carbatrol ....................................................... 27 Carbidopa ..................................................... 63 Carbidopa-Levodopa .................................... 63 Carbidopa-Levodopa ER .............................. 63 Carbidopa-Levodopa-Entacapone ................ 63 Carbinoxamine Maleate ................................ 95 CARBOplatin ................................................. 56 Cardizem....................................................... 80 Cardizem CD ................................................ 80 Cardizem LA ................................................. 80 Cardura ........................................................... 6 Cardura XL ...................................................... 6 Carisoprodol ................................................ 127 Carisoprodol-Aspirin ................................... 127 Carisoprodol-Aspirin-Codeine ..................... 127 Carnitor ....................................................... 111 Carnitor SF .................................................. 111 Carteolol HCl ................................................. 36 Cartia XT ....................................................... 80 Carvedilol ...................................................... 78 Casodex ........................................................ 56 Caspofungin Acetate ..................................... 36 Catapres ....................................................... 98 Catapres-TTS-1 ............................................ 98 Catapres-TTS-2 ............................................ 98 Catapres-TTS-3 ............................................ 98 Cayston ......................................................... 22 Cefaclor......................................................... 20 Cefaclor ER ................................................... 20 Cefadroxil ...................................................... 20 CeFAZolin Sodium ........................................ 20 Cefdinir ......................................................... 20
Cefditoren Pivoxil .......................................... 20 Cefepime HCl ................................................ 21 Cefixime ........................................................ 21 Cefpodoxime Proxetil .................................... 21 Cefprozil ........................................................ 21 CefTAZidime ................................................. 21 Ceftin ............................................................. 21 CefTRIAXone Sodium ................................... 21 Cefuroxime Axetil .......................................... 21 Cefuroxime Sodium ....................................... 21 CeleBREX ....................................................... 8 Celecoxib ........................................................ 8 Celestone Soluspan ........................................ 3 CeleXA ........................................................ 115 CellCept ........................................................ 99 Celontin ......................................................... 30 CEM-Urea ................................................... 101 CenFol ......................................................... 139 Centany ......................................................... 38 Centany AT ................................................... 38 Centratex ....................................................... 17 Cephalexin .................................................... 21 Cerovel ........................................................ 101 Cesamet ........................................................ 35 Cetirizine HCl .............................................. 126 Cetraxal ......................................................... 38 Cevimeline HCl ........................................... 112 Chantix .......................................................... 77 Chantix Continuing Month Pak ...................... 77 Chantix Starting Month Pak ........................... 78 Chateal .......................................................... 87 Chemet .......................................................... 96 Chenodal ....................................................... 86 Cheratussin AC ............................................. 69 ChlordiazePOXIDE HCl ................................. 76 Chlordiazepoxide-Amitriptyline .................... 115 Chlordiazepoxide-Clidinium ........................... 25 Chloroquine Phosphate ................................. 65 Chlorothiazide ............................................... 91 ChlorproMAZINE HCl .......................... 118, 119 ChlorproPAMIDE ........................................... 33 Chlorthalidone ............................................... 91 Chlorzoxazone ............................................ 127 Cholestyramine ............................................. 52 Cholestyramine Light ..................................... 52 Choline Fenofibrate ....................................... 52 Choline-Mag Trisalicylate ................................ 8 Chromagen ................................................... 17 Cialis ........................................................... 138 Ciclodan ........................................................ 40
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Ciclodan Cream ............................................ 40 Ciclodan Solution .......................................... 40 Ciclopirox ...................................................... 40 Ciclopirox Olamine ........................................ 40 Ciclopirox Treatment ..................................... 40 Cilostazol ...................................................... 68 Ciloxan .......................................................... 38 Cimetidine ..................................................... 70 Cimetidine HCl .............................................. 70 Cimzia ........................................................... 89 Cimzia Prefilled ............................................. 89 Cimzia Starter Kit .......................................... 89 Cipro ............................................................. 23 Cipro HC ....................................................... 49 Ciprodex........................................................ 49 Ciprofloxacin ................................................. 24 Ciprofloxacin HCl .................................... 24, 38 Ciprofloxacin-Ciproflox HCl ER ..................... 24 CISplatin ....................................................... 56 Citalopram Hydrobromide ........................... 115 CitraNatal 90 DHA ...................................... 103 CitraNatal Assure ........................................ 103 CitraNatal B-Calm ....................................... 103 CitraNatal DHA ........................................... 103 CitraNatal Harmony .................................... 103 CitraNatal Rx ............................................... 103 Cladribine ...................................................... 56 Claravis ....................................................... 129 Clarinex ....................................................... 126 Clarinex-D 12 Hour ..................................... 126 Clarithromycin ............................................... 21 Clarithromycin ER ......................................... 21 Clemastine Fumarate .................................... 95 Cleocin .................................................... 20, 39 Cleocin Phosphate ........................................ 20 Cleocin-T....................................................... 39 Climara ......................................................... 92 Climara Pro ................................................... 92 Clindacin ETZ ............................................... 39 Clindacin Pac ................................................ 39 Clindacin-P .................................................... 39 Clindagel ....................................................... 39 Clindamycin HCl ........................................... 20 Clindamycin Palmitate HCl............................ 20 Clindamycin Phos-Benzoyl Perox ................. 39 Clindamycin Phosphate .......................... 20, 39 Clindamycin-Tretinoin ................................. 129 Clinoin ......................................................... 129 Clobetasol Prop Emollient Base .................... 45 Clobetasol Propionate ................................... 45
Clobetasol Propionate E ................................ 45 Clobetasol Propionate Emulsion ................... 45 Clobex ........................................................... 45 Clobex Spray ................................................. 45 Clocortolone Pivalate .................................... 45 Clocortolone Pivalate Pump .......................... 45 Clodan ........................................................... 45 Cloderm ......................................................... 45 Cloderm Pump .............................................. 45 Clofarabine .................................................... 56 Clolar ............................................................. 56 ClomiPRAMINE HCl .................................... 115 ClonazePAM ................................................. 29 CloNIDine ...................................................... 98 CloNIDine HCl ............................................... 98 CloNIDine HCl ER ......................................... 98 Clopidogrel Bisulfate ..................................... 68 Clorazepate Dipotassium .............................. 76 Clotrimazole .................................................. 41 Clotrimazole AF ............................................. 41 Clotrimazole Anti-Fungal ............................... 41 Clotrimazole-Betamethasone ........................ 41 CloZAPine ................................................... 119 Clozaril ........................................................ 119 C-Nate DHA ................................................ 103 Coartem ........................................................ 65 Cod Liver Oil ............................................... 103 Codeine Sulfate ............................................. 10 Cogentin ........................................................ 63 Colazal .......................................................... 45 Colchicine ...................................................... 37 Colchicine-Probenecid ................................ 136 Colcrys .......................................................... 37 Colestid ......................................................... 52 Colestid Flavored .......................................... 52 Colestipol HCl ............................................... 52 Colistimethate Sodium (CBA) ........................ 20 Colocort ......................................................... 45 Coly-Mycin M ................................................ 20 Coly-Mycin S ................................................. 49 Colyte with Flavor Packs ............................... 84 Combigan ...................................................... 36 CombiPatch ................................................... 92 Combivir ........................................................ 72 Cometriq (100 mg Daily Dose) ...................... 56 Cometriq (140 mg Daily Dose) ...................... 57 Cometriq (60 mg Daily Dose) ........................ 57 Complera ....................................................... 72 Complete Natal DHA ................................... 103 CompleteNate ............................................. 103
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Compro ....................................................... 119 Comtan ......................................................... 63 Co-Natal FA ................................................ 103 Concept DHA .............................................. 103 Concept OB ................................................ 104 Concerta ....................................................... 16 Condylox ..................................................... 129 Constulose ...................................................... 6 ConZip .......................................................... 10 Copaxone...................................................... 98 Cordran ......................................................... 45 Coreg ............................................................ 78 Cortane-B................................................ 45, 49 Cortane-B Aqueous ...................................... 49 Cortef .............................................................. 3 Cortenema .................................................... 45 Cortic-ND ...................................................... 49 Cortifoam ...................................................... 45 Cortisone Acetate ........................................... 3 Cortisporin..................................................... 45 Corvita ........................................................ 104 Corvita 150 .................................................... 18 Corvite ........................................................ 104 Corvite 150 .................................................... 18 Corvite Fe ..................................................... 18 Corvite Free ................................................ 104 Cosentyx ..................................................... 129 Cosentyx 300 Dose ..................................... 129 Cosentyx Sensoready 300 Dose ................. 129 Cosentyx Sensoready Pen.......................... 129 Cosmegen..................................................... 57 Coumadin...................................................... 67 Covaryx ......................................................... 92 Covaryx HS ................................................... 92 Creon ............................................................ 89 Cresemba ..................................................... 35 Crestor .......................................................... 53 Crixivan ......................................................... 72 Cromolyn Sodium ................................... 17, 51 Cryselle-28 .................................................... 87 Cutivate ......................................................... 45 Cuvposa ........................................................ 25 CVS Miconazole 3 Combo Pack ................... 41 Cyanocobalamin ......................................... 139 Cyclafem 1/35 ............................................... 87 Cyclobenzaprine HCl .................................. 127 Cyclogyl ...................................................... 111 Cyclomydril ................................................. 111 Cyclopentolate HCl ..................................... 111 Cyclophosphamide ....................................... 57
CycloSERINE ................................................ 55 Cycloset ........................................................ 30 CycloSPORINE ............................................. 99 CycloSPORINE Modified ............................... 99 Cyklokapron .................................................. 38 Cymbalta ..................................................... 115 Cyotic ............................................................ 49 Cyproheptadine HCl ...................................... 95 Cystadane ................................................... 111 Cystagon ..................................................... 111 Cytarabine ..................................................... 57 Cytarabine (PF) ............................................. 57 Cytomel ....................................................... 134 Cytotec .......................................................... 70 Cytra K Crystals .............................................. 6
D
D.H.E. 45 ..................................................... 132 Dacarbazine .................................................. 57 Dacogen ........................................................ 57 DACTINomycin ............................................. 57 Daliresp ....................................................... 113 Dantrium ...................................................... 128 Dantrolene Sodium...................................... 128 Dapsone ................................................ 55, 129 Daptacel ...................................................... 135 Daraprim ....................................................... 65 Darifenacin Hydrobromide ER ....................... 95 Darzalex ........................................................ 57 Dasetta 1/35 .................................................. 87 DAUNOrubicin HCl ........................................ 57 Daypro ............................................................. 8 Daytrana ........................................................ 16 DDAVP ........................................................ 113 DDAVP Rhinal Tube.................................... 113 Debacterol ..................................................... 91 Deblitane ....................................................... 87 Decitabine ..................................................... 57 Decon-A ........................................................ 95 Deferoxamine Mesylate ................................. 96 Delestrogen ................................................... 93 Delyla ............................................................ 87 Delzicol .......................................................... 46 Demadex ....................................................... 90 Demeclocycline HCl ...................................... 24 Demerol ......................................................... 10 Demser ........................................................ 111 Denavir .......................................................... 42 Depakene ...................................................... 27 Depakote ....................................................... 27
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Depakote ER ................................................. 27 Depakote Sprinkles ....................................... 27 Depo-Estradiol .............................................. 93 DEPO-Medrol .................................................. 3 Depo-Provera .............................................. 114 Depo-SubQ Provera 104............................. 114 DermacinRx Empricaine ............................... 66 DermacinRx Prizopak ................................... 66 Derma-Smoothe/FS Body ............................. 46 Derma-Smoothe/FS Scalp ............................ 46 Dermasorb TA ............................................... 46 Dermazene ................................................... 43 DermOtic ....................................................... 49 Desferal......................................................... 97 Desipramine HCl ......................................... 115 Desloratadine .............................................. 126 Desmopressin Ace Spray Refrig ................. 113 Desmopressin Acetate ........................ 113, 114 Desmopressin Acetate Spray ...................... 114 Desonate....................................................... 46 Desonide ....................................................... 46 DesOwen ...................................................... 46 Desoximetasone ........................................... 46 Desoxyn ........................................................ 15 Desvenlafaxine ER ..................................... 116 Desvenlafaxine Succinate ER ..................... 116 Detrol ............................................................ 95 Detrol LA ....................................................... 95 Dexamethasone .............................................. 3 Dexamethasone Intensol ................................ 3 Dexamethasone Sod Phosphate PF ............... 3 Dexamethasone Sodium Phosphate ......... 3, 49 Dexedrine...................................................... 15 Dexeryl ........................................................ 129 Dexilant ......................................................... 71 Dexmethylphenidate HCl .............................. 16 Dexmethylphenidate HCl ER ........................ 16 DexPak 10 Day ............................................... 4 DexPak 13 Day ............................................... 4 DexPak 6 Day ................................................. 4 Dexrazoxane ............................................... 115 Dextroamphetamine Sulfate.......................... 15 Dextroamphetamine Sulfate ER .................... 15 Dialyvite ...................................................... 104 Dialyvite 3000 ............................................. 104 Dialyvite 5000 ............................................. 104 Dialyvite Supreme D ................................... 104 Dialyvite/Zinc ............................................... 104 Diastat AcuDial ............................................. 76 Diastat Pediatric ............................................ 76
DiazePAM ............................................... 76, 77 DiazePAM Intensol ........................................ 77 Dibenzyline .................................................. 132 Diclofenac Potassium ...................................... 8 Diclofenac Sodium ............................ 8, 51, 129 Diclofenac Sodium ER .................................... 8 Diclofenac-Misoprostol .................................... 8 Dicloxacillin Sodium ...................................... 23 Dicyclomine HCl ............................................ 25 Didanosine .................................................... 72 Differin ......................................................... 129 Dificid ............................................................ 21 Difil-G Forte ................................................. 125 Diflorasone Diacetate .................................... 46 Diflucan ......................................................... 35 Diflunisal .......................................................... 8 Digitek ........................................................... 84 Digox ............................................................. 84 Digoxin .......................................................... 84 Dihydroergotamine Mesylate ....................... 132 Dilantin .......................................................... 29 Dilantin Infatabs ............................................ 29 Dilatrate-SR ................................................. 137 Dilaudid ......................................................... 10 DilTIAZem CD ............................................... 80 DilTIAZem HCl .............................................. 80 DilTIAZem HCl ER ........................................ 80 DilTIAZem HCl ER Beads ............................. 80 DilTIAZem HCl ER Coated Beads ........... 80, 81 Dilt-XR ........................................................... 81 DimenhyDRINATE ........................................ 35 Diovan HCT ................................................. 122 Dipentum ....................................................... 46 DiphenhydrAMINE HCl .................................. 95 Diphenoxylate-Atropine ................................. 34 Diphtheria-Tetanus Toxoids DT .................. 135 Diprolene ....................................................... 46 Diprolene AF ................................................. 46 Dipyridamole ............................................... 139 Disopyramide Phosphate .............................. 83 Disulfiram ........................................................ 5 Ditropan XL ................................................... 96 Diuril .............................................................. 91 Divalproex Sodium ........................................ 27 Divalproex Sodium ER .................................. 27 Divigel ........................................................... 93 Divista ......................................................... 139 DOCEtaxel .................................................... 57 Dofetilide ....................................................... 83 Donepezil HCl ............................................. 112
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Doral ............................................................. 77 Dorzolamide HCl ........................................... 37 Dorzolamide HCl-Timolol Mal ....................... 37 Dothelle DHA .............................................. 104 Dovonex ...................................................... 129 Doxazosin Mesylate ........................................ 6 Doxepin HCl ................................................ 116 Doxercalciferol ............................................ 140 Doxil .............................................................. 57 DOXOrubicin HCl .......................................... 57 DOXOrubicin HCl Liposomal ......................... 57 Doxycycline ................................................. 129 Doxycycline Hyclate ...................................... 24 Doxycycline Monohydrate ....................... 24, 25 Drisdol ......................................................... 140 Dritho-Creme HP ........................................ 129 Dronabinol..................................................... 35 Droperidol ..................................................... 75 Droxia ........................................................... 57 Duac ............................................................. 39 Duet DHA 400 ............................................. 104 Duet DHA Balanced .................................... 104 Duetact ......................................................... 33 Duexis ............................................................. 8 Dulera ............................................................. 4 DULoxetine HCl .......................................... 116 Duragesic-100 ............................................... 10 Duragesic-12 ................................................. 10 Duragesic-25 ................................................. 10 Duragesic-50 ................................................. 10 Duragesic-75 ................................................. 10 Duramorph .................................................... 10 Duraxin ........................................................... 7 Durezol ......................................................... 49 Dutasteride ...................................................... 3 Dutasteride-Tamsulosin HCl ........................... 3 Dutoprol ........................................................ 78 Dyazide ......................................................... 91 Dymista ......................................................... 17 Dyrenium....................................................... 91
E
E.E.S. 400 ..................................................... 21 E.E.S. Granules ............................................ 22 EC-Naprosyn .................................................. 8 Econazole Nitrate .......................................... 41 Edarbyclor ................................................... 122 Edecrin .......................................................... 90 Edluar ........................................................... 75 Ed-Spaz ........................................................ 25
Edurant .......................................................... 72 EEMT ............................................................ 93 EEMT HS ...................................................... 93 Efavirenz ....................................................... 72 Effer-K ......................................................... 124 Effervescent Pot Chloride ............................ 124 Effexor XR ................................................... 116 Effient ............................................................ 68 Efudex ......................................................... 129 Egrifta .......................................................... 131 Eldepryl ......................................................... 64 Elelyso ........................................................... 92 Elestat ........................................................... 17 Elestrin .......................................................... 93 Eletone ........................................................ 129 Eletone Twinpack ........................................ 129 Eletriptan Hydrobromide ................................ 54 Elidel ........................................................... 129 Eligard ........................................................... 57 Elimite ........................................................... 44 Elinest ........................................................... 87 Eliquis ............................................................ 67 Eliquis Starter Pack ....................................... 67 Elitek ............................................................. 92 Elite-OB ....................................................... 104 Elixophyllin .................................................. 125 Ellence .......................................................... 57 Elmiron ........................................................ 111 Elocon ........................................................... 46 Emadine ........................................................ 17 Emcyt ............................................................ 57 Emend ........................................................... 35 Emend Tri-Pack ............................................ 35 Empliciti ......................................................... 57 Emsam .......................................................... 65 Emtriva .......................................................... 72 Enablex ......................................................... 96 Enalapril Maleate ........................................ 123 Enalapril-Hydrochlorothiazide ..................... 123 EnBrace HR ................................................ 104 Enbrel ............................................................ 90 Enbrel SureClick ........................................... 90 Endocet ......................................................... 11 EnovaRX-Cyclobenzaprine HCl .................. 127 Enoxaparin Sodium ....................................... 67 Enpresse-28 .................................................. 87 Entacapone ................................................... 63 Entecavir ....................................................... 74 Entereg .......................................................... 96 Entocort EC ..................................................... 4
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Enulose ........................................................... 6 Epiduo ......................................................... 129 Epiduo Forte ............................................... 129 Epifoam ......................................................... 46 Epinastine HCl .............................................. 17 EPINEPHrine .............................................. 132 EpiPen 2-Pak .............................................. 132 EpiPen Jr 2-Pak .......................................... 132 EpiRUBicin HCl ............................................. 57 Epitol ............................................................. 27 Epivir ............................................................. 72 Epivir HBV ..................................................... 72 Eplerenone.................................................. 123 Epogen ......................................................... 97 Epoprostenol Sodium .................................. 138 Eprosartan Mesylate ................................... 122 Epzicom ........................................................ 72 EQ Miconazole 3 Combo Pack ..................... 41 EQ Nasal Allergy ........................................... 49 EQL Miconazole 3 ......................................... 41 EQL Super B Complex/Vitamin C ............... 104 Equetro ......................................................... 27 Erbitux ........................................................... 57 Ergocalciferol .............................................. 140 Ergoloid Mesylates ...................................... 132 Ergomar ...................................................... 132 Ergotamine-Caffeine ..................................... 53 Erivedge ........................................................ 57 Erlotinib ......................................................... 57 Errin .............................................................. 87 Ertaczo .......................................................... 41 Erwinaze ....................................................... 58 Ery ................................................................ 39 Erygel ............................................................ 39 EryPed 200 ................................................... 22 EryPed 400 ................................................... 22 Ery-Tab ......................................................... 22 Erythrocin Stearate ....................................... 22 Erythromycin ................................................. 39 Erythromycin Base ........................................ 22 Erythromycin Ethylsuccinate ......................... 22 Escavite ...................................................... 104 Escavite D ................................................... 104 Escavite LQ ................................................. 104 Escitalopram Oxalate .................................. 116 Esgic ............................................................... 7 Esomeprazole Magnesium............................ 71 Est Estrogens-Methyltest .............................. 93 Est Estrogens-Methyltest DS ........................ 93 Est Estrogens-Methyltest HS ........................ 93
Estazolam ..................................................... 77 Estrace .......................................................... 93 Estradiol ........................................................ 93 Estradiol Valerate .......................................... 93 Estradiol-Norethindrone Acet ........................ 93 Estring ........................................................... 93 Estrogel ......................................................... 93 Estropipate .................................................... 93 Estrostep Fe .................................................. 87 Eszopiclone ................................................... 75 Ethacrynic Acid ............................................. 90 Ethambutol HCl ............................................. 55 Ethosuximide ................................................. 30 Ethyl Chloride ................................................ 66 Ethynodiol Diac-Eth Estradiol ........................ 87 Ethyol .......................................................... 115 Etidronate Disodium ...................................... 79 Etodolac .......................................................... 8 Etodolac ER .................................................... 8 Etopophos ..................................................... 58 Etoposide ...................................................... 58 Euflexxa ...................................................... 112 Eurax ............................................................. 44 Evamist ......................................................... 93 everolimus ..................................................... 58 Evista ............................................................ 92 Evoclin ........................................................... 39 Evotaz ........................................................... 72 Evoxac ........................................................ 112 Exactuss ........................................................ 69 Exalgo ........................................................... 11 Exelderm ....................................................... 41 Exelon ......................................................... 112 Exemestane .................................................. 58 Exforge .......................................................... 82 Exforge HCT ................................................. 82 Exjade ........................................................... 97 Exoderm ........................................................ 41 Exotic-HC ...................................................... 49 Extavia .......................................................... 98 Extina ............................................................ 41 Ezetimibe ...................................................... 52
F
FA-8 ............................................................ 139 FaBB ........................................................... 139 Fabior .......................................................... 129 Falmina ......................................................... 87 Famciclovir .................................................... 74 Famotidine .................................................... 70
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Fanapt ......................................................... 119 Fanapt Titration Pack .................................. 119 Fareston ........................................................ 58 Farxiga .......................................................... 32 Fasenra pen ................................................ 126 Faslodex ....................................................... 58 FA-Vitamin B-6-Vitamin B-12 ...................... 139 FazaClo....................................................... 119 Felbamate ..................................................... 27 Felbatol ......................................................... 27 Feldene ........................................................... 8 Felodipine ER ............................................... 82 Fem pH ......................................................... 43 Femara ......................................................... 58 Femhrt Low Dose .......................................... 93 Femring ......................................................... 93 Fenofibrate .................................................... 52 Fenofibrate Micronized ........................... 52, 53 Fenofibric Acid .............................................. 53 Fenoglide ...................................................... 53 Fenoprofen Calcium ........................................ 8 FentaNYL ...................................................... 11 FentaNYL Citrate .......................................... 11 Fentora ......................................................... 11 Fer-In-Sol ...................................................... 18 Ferocon ......................................................... 18 Ferotrinsic ..................................................... 18 Ferralet 90..................................................... 18 FerraPlus 90 ................................................. 18 Ferrex 150 Forte Plus ................................... 18 Ferriprox........................................................ 97 Ferrocite Plus ................................................ 18 FERRO-plex Hematinic ................................. 18 Ferrotrin ........................................................ 18 Ferrous Sulfate ............................................. 18 Fexmid ........................................................ 127 Fibricor .......................................................... 53 Finacea ....................................................... 129 Finasteride ...................................................... 3 Fioricet ............................................................ 7 Fiorinal ............................................................ 8 Fiorinal/Codeine #3 ....................................... 11 Firazyr ........................................................... 86 Firmagon ....................................................... 58 First-Hydrocortisone ...................................... 46 First-Lansoprazole ........................................ 71 First-Mouthwash BLM ................................... 66 First-Omeprazole .......................................... 71 Flagyl ............................................................ 65 FlavoxATE HCl ............................................. 96
Flebogamma DIF ........................................ 126 Flecainide Acetate ......................................... 83 Flector ......................................................... 129 Flolan .......................................................... 138 Flomax ........................................................ 132 Floriva ......................................................... 104 Floriva Plus ................................................. 104 Flovent Diskus ................................................. 4 Flovent HFA .................................................... 4 Floxuridine ..................................................... 58 Fluconazole ................................................... 35 Flucytosine .................................................... 36 Fludarabine Phosphate ................................. 58 Fludrocortisone Acetate .................................. 4 Flumadine ..................................................... 71 Flunisolide ..................................................... 49 Fluocinolone Acetonide ........................... 46, 49 Fluocinolone Acetonide Body ........................ 46 Fluocinolone Acetonide Scalp ....................... 46 Fluocinonide .................................................. 46 Fluocinonide Emulsified Base ....................... 46 Fluoritab ........................................................ 84 Fluorometholone ........................................... 49 Fluoroplex ................................................... 129 Fluorouracil ........................................... 58, 129 FLUoxetine HCl ........................................... 116 FLUoxetine HCl (PMDD) ............................. 116 FluPHENAZine Decanoate .......................... 119 FluPHENAZine HCl ..................................... 119 Flurandrenolide ............................................. 46 Flurazepam HCl ............................................ 77 Flurbiprofen ..................................................... 8 Flurbiprofen Sodium ...................................... 51 Flutamide ...................................................... 58 Fluticasone Propionate ............................ 46, 49 Fluvastatin Sodium ........................................ 53 FluvoxaMINE Maleate ................................. 116 FluvoxaMINE Maleate ER ........................... 116 FML Liquifilm ................................................. 49 Focalin ........................................................... 16 Focalin XR ..................................................... 16 Folbee ......................................................... 139 Folbee Plus ................................................. 104 Folbee Plus CZ ........................................... 104 Folet DHA .................................................... 104 Folet One .................................................... 104 Folgard OS .................................................. 104 Folgard RX .................................................. 139 Folic Acid ..................................................... 139 Folivane-F ..................................................... 18
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Folivane-OB ................................................ 104 Folivane-Plus ................................................ 18 Folotyn .......................................................... 58 Folplex 2.2 .................................................. 139 Foltrate ........................................................ 139 Foltrin ............................................................ 18 Fondaparinux Sodium ................................... 67 Forfivo XL.................................................... 116 Fortamet........................................................ 30 Fortavit ........................................................ 104 Forteo ......................................................... 113 Fosamprenavir Calcium ................................ 72 Fosinopril Sodium ....................................... 123 Fosinopril Sodium-HCTZ............................. 123 Fosphenytoin Sodium ................................... 30 Fosrenol ...................................................... 100 Fragmin ......................................................... 67 Frova ............................................................. 54 Frovatriptan Succinate .................................. 54 fulvestrant ..................................................... 58 Furadantin ................................................... 136 Furosemide ................................................... 90 Fusilev .......................................................... 34 Fuzeon .......................................................... 72 Fyavolv ......................................................... 93
G
G Tussin AC .................................................. 69 Gabapentin ................................................... 27 Gabitril .......................................................... 27 Galantamine Hydrobromide ........................ 112 Galantamine Hydrobromide ER .................. 113 Galzin .......................................................... 124 Gammagard ................................................ 126 Gammagard S/D Less IgA .......................... 126 Gammaked ................................................. 126 Gammaplex ................................................. 127 Gamunex-C ................................................. 127 Gastrocrom ................................................... 51 Gatifloxacin ................................................... 39 GaviLyte-C .................................................... 84 GaviLyte-G .................................................... 84 GaviLyte-H .................................................... 84 GaviLyte-N with Flavor Pack ......................... 84 Gebauers Pain Ease ..................................... 66 Gebauers Spray and Stretch ......................... 66 Gelnique........................................................ 96 Gelnique Pump ............................................. 96 Gemcitabine HCl ........................................... 58 Gemfibrozil .................................................... 53
Gemzar ......................................................... 58 Generlac .......................................................... 6 Gengraf ......................................................... 99 Gentak ........................................................... 39 Gentamicin Sulfate .................................. 19, 39 GenVisc 850 ................................................ 112 Geodon ....................................................... 119 Gilenya .......................................................... 99 Gilotrif ............................................................ 58 Gilphex TR .................................................... 94 Giltuss ........................................................... 69 Giltuss Pediatric ............................................ 69 Giltuss TR ..................................................... 69 Gleevec ......................................................... 58 Gleostine ....................................................... 58 Gliadel Wafer ................................................ 58 Glimepiride .................................................... 33 GlipiZIDE ....................................................... 33 GlipiZIDE ER ................................................. 33 GlipiZIDE XL ................................................. 33 GlipiZIDE-MetFORMIN HCl ........................... 33 GlucaGen HypoKit......................................... 38 Glucagon Emergency .................................... 38 Glucophage ................................................... 30 Glucophage XR ............................................. 30 Glucotrol ........................................................ 33 Glucotrol XL .................................................. 33 Glucovance ................................................... 33 Glumetza ....................................................... 31 GlyBURIDE ................................................... 33 GlyBURIDE Micronized ................................. 33 GlyBURIDE-MetFORMIN .............................. 33 Glycopyrrolate ............................................... 25 Glydo ............................................................. 66 Glynase ......................................................... 33 Glyset ............................................................ 30 GNP 24 Hour Nasal Allergy ........................... 49 GNP Folic Acid ............................................ 139 GNP Miconazole 3 ........................................ 41 Golytely ......................................................... 84 GoodSense Nasal Allergy Spray ................... 50 Gordofilm ..................................................... 101 Gordons Urea .............................................. 101 Gralise ............................................................. 7 Gralise Starter ................................................. 7 Granisetron HCl ............................................ 34 Granix ............................................................ 97 Griseofulvin Microsize ................................... 35 Griseofulvin Ultramicrosize ............................ 35 Gris-PEG ....................................................... 35
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Guaiatussin AC ............................................. 69 GuaiFENesin AC ........................................... 69 Guaifenesin-Codeine .................................... 69 GuanFACINE HCl ......................................... 98 GuanFACINE HCl ER ................................... 86 Guanidine HCl ............................................. 113
H
Halac ............................................................. 46 Halaven ......................................................... 58 Halcion .......................................................... 77 Haldol .......................................................... 119 Haldol Decanoate ....................................... 119 Halobetasol Propionate ................................. 46 Halog ............................................................ 46 Haloperidol .................................................. 119 Haloperidol Decanoate ............................... 119 Haloperidol Lactate ..................................... 119 Halotin ........................................................... 41 Harvoni ......................................................... 74 Heather ......................................................... 87 Hematinic Plus Vit/Minerals .......................... 18 Hematinic/Folic Acid ..................................... 18 Hematogen ................................................... 18 Hematogen FA .............................................. 18 Hematogen Forte .......................................... 18 Hematron-AF ................................................ 18 HemeNatal OB ............................................ 104 HemeNatal OB + DHA ................................ 104 HemeTab ...................................................... 18 Hemmorex-HC .............................................. 47 Hemocyte Plus .............................................. 18 Hemocyte-F .................................................. 18 Hemocyte-Plus .............................................. 18 Heparin Sodium (Porcine) ............................. 67 Hepsera ........................................................ 74 Herceptin....................................................... 58 Hexalen ......................................................... 58 Hiprex ......................................................... 136 HM Folic Acid .............................................. 139 HM Super Vitamin B Complex/C ................. 104 HM Vitamin B Complex/Vitamin C .............. 104 Homatropaire .............................................. 111 Homatropine HBr ........................................ 111 Horizant......................................................... 27 HP Acthar.................................................... 114 HPR ............................................................ 130 HPR Plus .................................................... 130 HPR PLUS HydroGel .................................. 130 HumaLOG ..................................................... 31
HumaLOG Junior KwikPen ........................... 31 HumaLOG KwikPen ...................................... 31 HumaLOG Mix 50/50 ..................................... 31 HumaLOG Mix 50/50 KwikPen ...................... 31 HumaLOG Mix 75/25 ..................................... 31 HumaLOG Mix 75/25 KwikPen ...................... 32 Humira ........................................................... 90 Humira Pediatric Crohns Start ....................... 90 Humira Pen ................................................... 90 Humira Pen-CD/UC/HS Starter ..................... 90 Humira Pen-Ps/UV Starter ............................ 90 HumuLIN 70/30 ............................................. 32 HumuLIN 70/30 KwikPen .............................. 32 HumuLIN N ................................................... 32 HumuLIN N KwikPen ..................................... 32 HumuLIN R ................................................... 32 HumuLIN R U-500 (CONCENTRATED) ........ 32 HumuLIN R U-500 KwikPen .......................... 32 Hyalgan ....................................................... 112 Hycamtin ....................................................... 58 HydrALAZINE HCl ......................................... 98 Hydrea ........................................................... 59 Hydro 35 ...................................................... 101 Hydro 40 ...................................................... 101 HydroCHLOROthiazide ................................. 91 Hydrocod Polst-CPM Polst ER ...................... 69 Hydrocodone-Acetaminophen ....................... 11 Hydrocodone-Homatropine ........................... 69 Hydrocodone-Ibuprofen ................................. 11 Hydrocortisone .......................................... 4, 47 Hydrocortisone Ace-Pramoxine ............... 47, 66 Hydrocortisone Acetate ................................. 47 Hydrocortisone Butyr Lipo Base .................... 47 Hydrocortisone Butyrate ................................ 47 Hydrocortisone Valerate ................................ 47 Hydrocortisone-Acetic Acid ........................... 50 Hydrocortisone-Iodoquinol ............................ 43 Hydromet ....................................................... 69 HYDROmorphone HCl .................................. 11 HYDROmorphone HCl ER ............................ 11 HYDROmorphone HCl PF ............................. 12 Hydroxocobalamin Acetate ......................... 140 Hydroxychloroquine Sulfate .......................... 65 HYDROXYprogesterone Caproate .............. 114 Hydroxyurea .................................................. 59 HydrOXYzine HCl.......................................... 75 HydrOXYzine Pamoate ................................. 75 Hylatopic Plus ............................................. 130 Hylira ............................................................. 91 Hyophen ...................................................... 136
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Hyoscyamine Sulfate .............................. 25, 26 Hyoscyamine Sulfate ER .............................. 26 Hyoscyamine Sulfate SL ............................... 26 Hyosyne ........................................................ 26 HyperRHO S/D ........................................... 127 HyperSal ..................................................... 102 Hyzaar ........................................................ 122
I
Ibandronate Sodium ...................................... 79 IBU .................................................................. 8 Ibudone ......................................................... 12 Ibuprofen ......................................................... 8 Ibuprofen Comfort Pac .................................... 8 IC 400 ............................................................. 8 IC 800 ............................................................. 8 Icar-C Plus .................................................... 18 Iclusig ............................................................ 59 Idamycin PFS ................................................ 59 IDArubicin HCl .............................................. 59 IDHIFA .......................................................... 59 iFerex 150 Forte ............................................ 18 Ifex ................................................................ 59 Ifosfamide ..................................................... 59 Ilaris ................................................................ 7 Ilevro ............................................................. 51 Imbruvica ...................................................... 59 Imipramine HCl ........................................... 116 Imipramine Pamoate ................................... 116 Imiquimod ................................................... 130 Imitrex ........................................................... 54 Imitrex STATdose Refill ................................ 54 Imitrex STATdose System ............................ 54 Imuran ........................................................... 99 Inatal GT ..................................................... 104 Increlex ....................................................... 131 Indapamide ................................................... 91 Indocin ............................................................ 8 Indomethacin .................................................. 8 Indomethacin ER ............................................ 8 Infanate Balance ......................................... 104 Infanrix ........................................................ 135 Infuvite Adult ............................................... 104 Infuvite Pediatric ......................................... 104 Inlyta ............................................................. 59 Inova ............................................................. 43 Inova 4/1 Acne Control Therapy ................... 43 Inova 8/2 Acne Control Therapy ................... 43 Inspra .......................................................... 123 Integra F........................................................ 18
Integra Plus ................................................... 18 Intelence ........................................................ 72 Intermezzo .................................................... 75 Intron A .......................................................... 59 Introvale ........................................................ 87 Intuniv ............................................................ 86 Invega ......................................................... 119 Invega Sustenna ......................................... 119 Invirase .......................................................... 72 Invokamet ...................................................... 32 Invokamet XR ................................................ 32 Invokana ........................................................ 32 Iodoquinol-HC-Aloe Polysacch ...................... 43 Iopidine .......................................................... 91 Ipratropium Bromide ...................................... 26 Ipratropium-Albuterol ................................... 133 Irbesartan .................................................... 122 Irbesartan-Hydrochlorothiazide ................... 122 Iressa ............................................................ 59 Irinotecan HCl ............................................... 59 Iron Supplement Childrens ............................ 18 Irospan 24/6 .................................................. 18 IS 24/6 ........................................................... 18 Isentress ........................................................ 72 Isentress HD ................................................. 72 Isometheptene-Dichloral-APAP ..................... 53 Isoniazid ........................................................ 55 Isopto Atropine ............................................ 111 Isopto Carpine ............................................... 37 Isordil Titradose ........................................... 137 Isosorbide Dinitrate ..................................... 137 Isosorbide Dinitrate ER ............................... 137 Isosorbide Mononitrate ................................ 137 Isosorbide Mononitrate ER .......................... 137 Isoxsuprine HCl ........................................... 139 Isradipine ....................................................... 82 Istalol ............................................................. 36 Istodax (Overfill) ............................................ 59 Itraconazole ................................................... 35 Ivermectin ...................................................... 17 Ixempra Kit .................................................... 59
J
Jakafi ............................................................. 59 Jalyn ................................................................ 3 Jantoven ........................................................ 68 Janumet ........................................................ 31 Janumet XR .................................................. 31 Januvia .......................................................... 31 Jencycla ........................................................ 87
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Jentadueto .................................................... 31 Jevantique Lo ................................................ 94 Jevtana ......................................................... 59 Jinteli ............................................................. 94 Jolessa .......................................................... 87 Jolivette ......................................................... 87
K
Kadcyla ......................................................... 59 Kadian ........................................................... 12 Kaletra .......................................................... 72 Kalydeco ....................................................... 89 Kanjinti .......................................................... 59 Kapvay .......................................................... 98 K-Effervescent ............................................ 124 Keflex ............................................................ 21 Kelnor 1/35.................................................... 87 Kenalog ..................................................... 4, 47 Kepivance ..................................................... 85 Keppra .......................................................... 27 Keppra XR .................................................... 27 Keralyt ......................................................... 101 Keralyt Scalp ............................................... 101 Ketoconazole .......................................... 35, 41 Ketoprofen ...................................................... 8 Ketoprofen ER ................................................ 8 Ketorolac Tromethamine ....................... 8, 9, 51 Keytruda........................................................ 59 Kinrix ........................................................... 135 Kionex ......................................................... 100 Kitabis Pak .................................................... 19 Klaron ........................................................... 39 Klofensaid II ................................................ 130 KlonoPIN ....................................................... 29 Klor-Con ...................................................... 124 Klor-Con 10 ................................................. 124 Klor-Con M10 .............................................. 124 Klor-Con M15 .............................................. 124 Klor-Con M20 .............................................. 124 Klor-Con Sprinkle ........................................ 124 Klor-Con/EF ................................................ 124 Korlym ........................................................... 30 KP B Complex-C ......................................... 104 KP Folic Acid ............................................... 140 K-Phos ........................................................ 124 K-Phos No 2 .................................................... 3 K-Phos-Neutral ........................................... 124 K-Prime ....................................................... 124 Kristalose ........................................................ 6 K-Tab .......................................................... 124
K-Tan Plus .................................................... 18 Kurvelo .......................................................... 87 Kuvan .......................................................... 112 K-Vescent .................................................... 124 Kyprolis ......................................................... 59
L
Labetalol HCl ................................................. 78 Lac-Hydrin ..................................................... 92 Lacrisert ........................................................ 91 Lactic Acid ..................................................... 92 Lactic Acid E ................................................. 92 Lactulose ......................................................... 7 Lactulose Encephalopathy .............................. 7 LaMICtal ........................................................ 28 LaMICtal ODT ............................................... 28 LaMICtal Starter ............................................ 28 LaMICtal XR .................................................. 28 LamISIL ......................................................... 35 LamiVUDine .................................................. 72 Lamivudine-Zidovudine ................................. 72 LamoTRIgine ................................................. 28 LamoTRIgine ER ........................................... 28 Lanoxin .......................................................... 84 Lansoprazole ................................................. 71 Lantus ........................................................... 32 Lantus SoloStar ............................................. 32 Larissia .......................................................... 87 Lasix .............................................................. 90 Lastacaft ........................................................ 17 Latanoprost ................................................... 37 Latrix XM ..................................................... 101 Latuda ......................................................... 120 Lazanda ........................................................ 12 ledipasvir-sofosbuvir...................................... 74 Leflunomide ................................................... 90 Lessina .......................................................... 87 Letairis ......................................................... 138 Letrozole ....................................................... 59 Leucovorin Calcium ....................................... 34 Leukeran ....................................................... 59 Leukine .......................................................... 97 Leuprolide Acetate ........................................ 59 Levalbuterol HCl .......................................... 133 Levalbuterol Tartrate ................................... 133 Levaquin ........................................................ 24 Levbid ............................................................ 26 Levemir ......................................................... 32 Levemir FlexTouch ........................................ 32 LevETIRAcetam ............................................ 28
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LevETIRAcetam ER ...................................... 28 Levitra ......................................................... 138 Levobunolol HCl ............................................ 36 LevOCARNitine ........................................... 112 Levocetirizine Dihydrochloride .................... 126 LevoFLOXacin ........................................ 24, 39 LEVOleucovorin Calcium .............................. 34 Levonest ....................................................... 87 Levonorgest-Eth Estrad 91-Day .................... 87 Levonorgestrel-Ethinyl Estrad ....................... 87 Levora 0.15/30 (28) ....................................... 87 Levorphanol Tartrate ..................................... 12 Levo-T ......................................................... 134 Levothyroxine Sodium ................................ 134 Levothyroxine-Liothyronine ......................... 134 Levoxyl ........................................................ 134 Levsin ........................................................... 26 Levsin/SL ...................................................... 26 Levulan Kerastick ........................................ 130 Lexapro ....................................................... 116 Lexiva ..................................................... 72, 73 Lialda ............................................................ 47 Librax ............................................................ 26 Lido BDK ....................................................... 66 Lidocaine....................................................... 66 Lidocaine HCl ........................................ 66, 102 Lidocaine PAK .............................................. 66 Lidocaine Viscous ....................................... 102 Lidocaine-Hydrocortisone Ace ...................... 66 Lidocaine-Prilocaine ...................................... 66 Lidoderm ....................................................... 66 Lido-K ........................................................... 66 Lidopin .......................................................... 66 Lidopril .......................................................... 66 Lidopril XR .................................................... 66 Lido-Prilo Caine Pack ................................... 66 Lillow ............................................................. 87 Lincocin ......................................................... 20 Lincomycin HCl ............................................. 20 Lindane ......................................................... 44 Linezolid ........................................................ 20 Linezolid in Sodium Chloride......................... 20 Linzess .......................................................... 96 Liothyronine Sodium ................................... 134 Lipodox 50 .................................................... 59 Lipofen .......................................................... 53 LiProZonePak ............................................... 66 Lisinopril ...................................................... 123 Lisinopril-Hydrochlorothiazide ..................... 123 Lithium .......................................................... 53
Lithium Carbonate ......................................... 53 Lithium Carbonate ER ................................... 53 Lithobid .......................................................... 53 Lithostat ........................................................... 7 Livixil Pak ...................................................... 66 Locoid ............................................................ 47 Locoid Lipocream .......................................... 47 Lodosyn ......................................................... 63 Lomotil ........................................................... 34 Loperamide HCl ............................................ 34 Lopid ............................................................. 53 Lopinavir-Ritonavir ........................................ 73 Lopreeza ....................................................... 94 Loprox ........................................................... 41 LORazepam .................................................. 77 LORazepam Intensol ..................................... 77 Lorcet ............................................................ 12 Lorcet HD ...................................................... 12 Lorcet Plus .................................................... 12 Lortab ............................................................ 12 Lorzone ....................................................... 127 Losartan Potassium..................................... 122 Losartan Potassium-HCTZ .......................... 122 Lotemax ........................................................ 50 Lotensin HCT .............................................. 123 Loteprednol etabonate .................................. 50 Lotrel ............................................................. 82 Lotrisone ....................................................... 41 Lotronex ........................................................ 47 Lovastatin ...................................................... 53 Lovaza ........................................................... 52 Lovenox ......................................................... 68 Low-Ogestrel ................................................. 87 Loxapine Succinate ..................................... 120 Lumigan ........................................................ 37 Lunesta ......................................................... 75 Lupron Depot (1-Month) ................................ 59 Lupron Depot (3-Month) ................................ 60 Lupron Depot (4-Month) ................................ 60 Lupron Depot (6-Month) ................................ 60 Lupron Depot-Ped (1-Month) ........................ 60 Lupron Depot-Ped (3-Month) ........................ 60 Lutera ............................................................ 87 Luxiq .............................................................. 47 Lyrica ............................................................. 28 Lysiplex Plus ............................................... 104 Lysodren ....................................................... 60 Lysteda .......................................................... 38 Lyza ............................................................... 87
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M
M.V.I. Adult ................................................. 104 M.V.I. Pediatric ............................................ 104 M.V.I.-12 (without Vitamin K) ...................... 104 Macrobid ..................................................... 136 Macrodantin ................................................ 136 Mafenide Acetate .......................................... 43 MagneBind 400 ........................................... 124 Makena ....................................................... 114 Malarone ....................................................... 65 Malathion ...................................................... 44 Maprotiline HCl ........................................... 116 Marinol .......................................................... 35 Marlissa......................................................... 87 Marnatal-F ................................................... 104 Marplan ....................................................... 116 Matulane ....................................................... 60 Matzim LA ..................................................... 81 Mavyret ......................................................... 74 Maxalt ........................................................... 54 Maxalt-MLT ................................................... 54 Maxidex......................................................... 50 Maxidone ...................................................... 12 Maxitrol ......................................................... 50 Maxzide......................................................... 91 Maxzide-25 ................................................... 91 Mayzent ........................................................ 99 MB HydroGel .............................................. 130 Meclizine HCl ................................................ 35 Meclofenamate Sodium .................................. 9 Medolor Pak .................................................. 66 Medrol ............................................................. 4 MedroxyPROGESTERone Acetate ............. 114 Mefenamic Acid .............................................. 9 Mefloquine HCl ............................................. 65 Megace ES ................................................. 114 Megestrol Acetate ................................. 60, 114 Mekinist ......................................................... 60 Mektovi ......................................................... 60 Meloxicam ....................................................... 9 Meloxicam Comfort Pac .................................. 9 Melphalan HCl .............................................. 60 Memantine HCl ............................................. 86 Menest .......................................................... 94 Menostar ....................................................... 94 Mentax .......................................................... 41 Meperidine HCl ............................................. 12 Mephyton .................................................... 141 Meprobamate ................................................ 75 Mepron .......................................................... 65
Mercaptopurine ............................................. 60 Mesalamine ................................................... 47 Mesalamine-Cleanser ................................... 47 Mesna ......................................................... 115 Mesnex ........................................................ 115 Mestinon ...................................................... 113 Metadate ER ................................................. 16 Metaproterenol Sulfate ................................ 133 Metaxall ....................................................... 127 Metaxalone .................................................. 128 MetFORMIN HCl ........................................... 31 MetFORMIN HCl ER ..................................... 31 MetFORMIN HCl ER (MOD) ......................... 31 MetFORMIN HCl ER (OSM) .......................... 31 Methamphetamine HCl .................................. 15 MethazolAMIDE ............................................ 37 Methenamine Hippurate .............................. 136 Methenamine Mandelate ............................. 136 MethIMAzole ............................................... 133 Methocarbamol ........................................... 128 Methotrexate ................................................. 60 Methotrexate Sodium .................................... 60 Methotrexate Sodium (PF) ............................ 60 Methscopolamine Bromide ............................ 26 Methyclothiazide ........................................... 91 Methyldopa .................................................... 98 Methyldopa-Hydrochlorothiazide ................... 98 Methylin ......................................................... 16 Methylphenidate HCl ..................................... 16 Methylphenidate HCl ER ............................... 16 Methylphenidate HCl ER (CD) ...................... 16 Methylphenidate HCl ER (LA) ....................... 17 MethylPREDNISolone ..................................... 4 MethylPREDNISolone Acetate ........................ 4 MethylPREDNISolone Sodium Succ ............... 4 Metipranolol ................................................... 36 Metoclopramide HCl .................................... 114 MetOLazone .................................................. 91 Metoprolol Succinate ER ............................... 78 Metoprolol Tartrate ........................................ 78 Metoprolol-Hydrochlorothiazide ..................... 78 Metoprolol-Hydrochlorothiazide ER ............... 78 MetroCream .................................................. 39 Metrogel ........................................................ 39 MetroGel-Vaginal .......................................... 39 MetroLotion ................................................... 39 MetroNIDAZOLE ..................................... 39, 65 Mexiletine HCl ............................................... 83 Mezparox-HC ................................................ 47 M-Hist DM ..................................................... 69
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Miacalcin ..................................................... 113 Micardis HCT .............................................. 122 Miconazole 3 ................................................. 41 Miconazole 3 Applicator ................................ 41 Miconazole 3 Combo Pack ........................... 41 Miconazole 3 Combo Pack App .................... 41 MICRhoGAM Ultra-Filtered Plus ................. 127 Micro-K........................................................ 124 Microzide....................................................... 91 Midazolam HCl .............................................. 77 Midodrine HCl ............................................. 132 Migergot ........................................................ 54 Miglitol ........................................................... 30 Migranal ...................................................... 132 Milco-B-Forte .............................................. 105 Millipred........................................................... 4 Millipred DP ..................................................... 4 Millipred DP 12-Day ........................................ 4 Mimvey.......................................................... 94 Mimvey Lo ..................................................... 94 Minipress......................................................... 6 Minitran ....................................................... 137 Minivelle ........................................................ 94 Minocin ......................................................... 25 Minocycline HCl ............................................ 25 Minocycline HCl ER .................................... 130 Miochol-E ...................................................... 37 Miostat .......................................................... 37 Mirapex ......................................................... 64 Mirapex ER ................................................... 64 Mircera .......................................................... 97 Mirena (52 MG) ............................................. 87 Mirtazapine ................................................. 116 Mirvaso ....................................................... 130 MiSOPROStol ............................................... 70 MitoMYcin ..................................................... 60 Mitosol .......................................................... 39 MitoXANTRONE HCl .................................... 60 Mobic .............................................................. 9 Modafinil........................................................ 17 Moderiba ....................................................... 75 Moexipril HCl ............................................... 123 Moexipril-Hydrochlorothiazide ..................... 123 Mometasone Furoate .............................. 47, 50 Mondoxyne NL .............................................. 25 Monistat 3 Combination Pack ....................... 41 Monistat 3 Combo Pack App......................... 41 Montelukast Sodium ..................................... 51 Monurol ....................................................... 136 Morgidox ....................................................... 25
Morphine Sulfate ........................................... 12 Morphine Sulfate (Concentrate) .................... 12 Morphine Sulfate (PF) ................................... 12 Morphine Sulfate ER ..................................... 12 Morphine Sulfate ER Beads .......................... 12 Motofen ......................................................... 34 Movantik ........................................................ 96 MoviPrep ....................................................... 84 Moxatag ........................................................ 23 Moxeza .......................................................... 40 Moxifloxacin HCl ........................................... 24 Mozobil .......................................................... 97 MS Contin ..................................................... 13 Multaq ........................................................... 83 Multigen ......................................................... 18 Multigen Folic ................................................ 18 Multigen Plus ................................................. 19 Multi-Vit/Fluoride ......................................... 105 Multi-Vit/Fluoride/Iron .................................. 105 Multi-Vit/Iron/Fluoride .................................. 105 Multi-Vitamin Drops/FE ............................... 105 Multivitamin/Fluoride ................................... 105 Multi-Vitamin/Fluoride .................................. 105 Multivitamin/Fluoride/Iron ............................ 105 Multi-Vitamin/Fluoride/Iron .......................... 105 Multivitamins/Fluoride .................................. 105 Mupirocin ....................................................... 40 Mupirocin Calcium ......................................... 40 Mustargen ..................................................... 60 Mvasi ............................................................. 60 MVC-Fluoride .............................................. 105 M-Vit ............................................................ 105 Myambutol ..................................................... 55 Mycamine ...................................................... 36 Mycobutin ...................................................... 55 Mycophenolate Mofetil .................................. 99 Mycophenolate Sodium ................................. 99 Mydriacyl ..................................................... 111 Myferon 150 Forte ......................................... 19 Myfortic .......................................................... 99 Myleran ......................................................... 60 Mynatal ........................................................ 105 Mynatal Advance ......................................... 105 Mynatal Plus ................................................ 105 Mynatal-Z .................................................... 105 Mynate 90 Plus ........................................... 105 Mynephrocaps ............................................. 105 Mynephron .................................................. 105 Myorisan ...................................................... 130 Myrbetriq ....................................................... 96
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Mysoline ........................................................ 29 Mytesi ........................................................... 34 Myzilra .......................................................... 87
N
Nabumetone ................................................... 9 Nadolol .......................................................... 78 Nadolol-Bendroflumethiazide ........................ 78 Nafcillin Sodium ............................................ 23 Naftifine HCl .................................................. 41 Naftin ............................................................ 41 Naglazyme .................................................... 92 Nalbuphine HCl ............................................. 14 Nalfon ............................................................. 9 Naloxone HCl .............................................. 111 Naltrexone HCl ............................................ 111 Namenda ...................................................... 86 Namenda Titration Pak ................................. 86 Naprelan ......................................................... 9 NaPro ............................................................ 47 Naprosyn......................................................... 9 Naproxen ........................................................ 9 Naproxen Comfort Pac ................................... 9 Naproxen DR .................................................. 9 Naproxen Sodium ........................................... 9 Naproxen Sodium ER ..................................... 9 Naratriptan HCl ............................................. 54 Nardil .......................................................... 116 Nasacort Allergy 24HR ................................. 50 Nasacort Allergy 24HR Children ................... 50 Nasal Allergy 24 Hour ................................... 50 Nascobal ..................................................... 140 Nasonex ........................................................ 50 NataChew ................................................... 105 Natalvit ........................................................ 105 Nateglinide .................................................... 32 Natelle ONE ................................................ 105 Natroba ......................................................... 44 Nature-Throid .............................................. 134 Navelbine ...................................................... 60 Nebupent ...................................................... 65 Nebusal ....................................................... 103 Neevo DHA ................................................. 105 Nefazodone HCl .......................................... 116 Neocera ...................................................... 130 Neomycin Sulfate .......................................... 19 Neomycin-Bacitracin Zn-Polymyx ................. 40 Neomycin-Polymyxin-Dexameth ................... 50 Neomycin-Polymyxin-Gramicidin .................. 40 Neomycin-Polymyxin-HC .............................. 50
Neoral ............................................................ 99 Neosalus ............................................... 92, 130 Neosalus CP ............................................... 130 Neosporin ...................................................... 40 NeoTuss Plus ................................................ 69 Nephplex Rx ................................................ 105 Nephrocaps ................................................. 105 Nephron FA ................................................... 19 Nephronex ................................................... 105 Nephro-Vite Rx ............................................ 105 Neptazane ..................................................... 37 Nerlynx .......................................................... 60 Nestabs ....................................................... 105 Nestabs ABC ............................................... 105 Nestabs DHA .............................................. 105 Neuac ............................................................ 40 Neulasta ........................................................ 97 Neulasta Onpro ............................................. 97 Neupogen ...................................................... 97 Neupro .......................................................... 64 Neurin-SL .................................................... 140 Neurontin ....................................................... 28 Nevirapine ..................................................... 73 Nevirapine ER ............................................... 73 Newgen ....................................................... 105 Nexa Plus .................................................... 105 NexAVAR ...................................................... 60 NexIUM ......................................................... 71 Niacin .......................................................... 140 Niacin ER (Antihyperlipidemic) ...................... 52 Niacor .......................................................... 140 Niaspan ......................................................... 52 Nicadan ....................................................... 106 Nicadan ZX ................................................. 106 NiCARdipine HCl ........................................... 82 Nicazel ........................................................ 106 NicAzel Forte ............................................... 106 Nicomide ..................................................... 106 Nicotrol .......................................................... 78 Nicotrol NS .................................................... 78 NIFEdipine .................................................... 82 NIFEdipine ER .............................................. 82 NIFEdipine ER Osmotic Release .................. 82 Nilandron ....................................................... 60 Nilutamide ..................................................... 60 NiMODipine ................................................... 83 Ninlaro ........................................................... 61 Nipent ............................................................ 61 Nisoldipine ER ............................................... 83 Nitro-Bid ...................................................... 137
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Nitro-Dur ..................................................... 137 Nitrofurantoin .............................................. 136 Nitrofurantoin Macrocrystal ......................... 136 Nitrofurantoin Monohyd Macro .................... 136 Nitroglycerin ................................................ 137 Nitroglycerin ER .......................................... 137 Nitrolingual .................................................. 137 NitroMist ...................................................... 138 Nitrostat....................................................... 138 Nitro-Time ................................................... 138 Niva-Hist DM ................................................. 69 Niva-Plus..................................................... 106 Nivatopic Plus ............................................. 130 Nizatidine ...................................................... 70 Nizoral ........................................................... 42 Nolix .............................................................. 47 Nora-BE ........................................................ 87 Norco ............................................................ 13 Norethindrone ............................................... 87 Norethindrone Acetate ................................ 114 Norethindrone-Eth Estradiol .......................... 94 Norgestim-Eth Estrad Triphasic .................... 87 Noritate ......................................................... 40 Norlyda ......................................................... 87 Norlyroc......................................................... 88 Norpace ........................................................ 83 Norpace CR .................................................. 83 Norpramin ................................................... 117 Nortrel 1/35 (21) ............................................ 88 Nortrel 1/35 (28) ............................................ 88 Nortriptyline HCl .......................................... 117 Nortuss-DE ................................................... 69 Nortuss-Ex .................................................... 69 Norvasc ......................................................... 83 Norvir ............................................................ 73 Noxafil ........................................................... 35 NP Thyroid .................................................. 134 Nplate ........................................................... 97 Nucala ......................................................... 126 NuCort .......................................................... 47 Nucynta ......................................................... 13 Nucynta ER ................................................... 13 Nuedexta....................................................... 86 NuFol .......................................................... 140 NuLev ........................................................... 26 Nulojix ........................................................... 99 Nulytely with Flavor Packs ............................ 84 Nutraseb ..................................................... 101 Nutricap....................................................... 106 NutriDox ........................................................ 25
Nutrifac ZX .................................................. 106 Nutrivit ......................................................... 106 NuvaRing ...................................................... 88 Nuvigil ........................................................... 17 Nyamyc ......................................................... 42 Nystatin ................................................... 36, 42 Nystatin-Triamcinolone .................................. 47 Nystop ........................................................... 42
O
OB Complete ............................................... 106 OB Complete One ....................................... 106 OB Complete Petite..................................... 106 OB Complete Premier ................................. 106 OB Complete/DHA ...................................... 106 Obstetrix DHA ............................................. 106 Obstetrix EC ................................................ 106 Obstetrix One .............................................. 106 O-Cal FA ..................................................... 106 O-Cal Prenatal ............................................ 106 Octagam ...................................................... 127 Octreotide Acetate....................................... 131 Ocuvel ......................................................... 106 Odefsey ......................................................... 73 Ofloxacin ................................................. 24, 40 Okebo ............................................................ 25 OLANZapine ............................................... 120 OLANZapine-FLUoxetine HCl ..................... 117 Olmesartan Medoxomil ............................... 122 Olmesartan Medoxomil-HCTZ ..................... 122 Olmesartan-Amlodipine-HCTZ ...................... 83 Olopatadine HCl ............................................ 17 Olux ............................................................... 47 Olux-E ........................................................... 47 Omeclamox-Pak ............................................ 71 Omega-3-acid Ethyl Esters ........................... 52 OmePPi ......................................................... 71 Omeprazole ................................................... 71 Omeprazole+Syrspend SF Alka .................... 71 Omeprazole-Sodium Bicarbonate ................. 71 Omnaris ......................................................... 50 Omnipred ...................................................... 50 Oncaspar ....................................................... 61 Ondansetron ................................................. 34 Ondansetron HCl .......................................... 34 Onexton ......................................................... 40 Onfi ................................................................ 29 Opdivo ........................................................... 61 Opsumit ....................................................... 138 Oracea ........................................................ 130
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Oracit .............................................................. 6 Oralone ......................................................... 47 Orap ............................................................ 120 Orapred ODT .................................................. 4 Orenitram .................................................... 138 Orfadin ........................................................ 112 Orphenadrine Citrate .................................. 128 Orphenadrine Citrate ER ............................ 128 Orsythia......................................................... 88 Ortho Micronor .............................................. 88 Ortho Tri-Cyclen (28) .................................... 88 Ortho Tri-Cyclen Lo ....................................... 88 Ortho-Novum 1/35 (28) ................................. 88 OrthoVisc .................................................... 112 Oscimin ......................................................... 26 Oscimin SR ................................................... 26 Oseltamivir Phosphate .................................. 74 OsmoPrep ..................................................... 85 Otezla ........................................................... 90 Oticin HC NR ................................................ 50 Otomax-HC ................................................... 50 Ovide ............................................................ 44 Oxacillin Sodium ........................................... 23 Oxaliplatin ..................................................... 61 Oxaprozin........................................................ 9 Oxaydo ......................................................... 13 Oxazepam..................................................... 77 OXcarbazepine ............................................. 28 Oxiconazole Nitrate ....................................... 42 Oxistat ........................................................... 42 Oxybutynin Chloride ...................................... 96 Oxybutynin Chloride ER ................................ 96 OxyCODONE HCl ......................................... 13 OxyCODONE HCl ER ................................... 13 Oxycodone-Acetaminophen .......................... 13 Oxycodone-Aspirin ........................................ 13 Oxycodone-Ibuprofen ................................... 13 OxyCONTIN .................................................. 13 OxyMORphone HCl ...................................... 13 OxyMORphone HCl ER ................................ 13 Oxytrol .......................................................... 96
P
Pacerone....................................................... 83 PACLitaxel .................................................... 61 Paliperidone ER .......................................... 120 Pamelor....................................................... 117 Pamidronate Disodium .................................. 79 Pancreaze ..................................................... 89 Pandel ........................................................... 47
Panretin ....................................................... 130 Pantoprazole Sodium .................................... 71 Paragard Intrauterine Copper ........................ 88 Paregoric ....................................................... 34 Paricalcitol ................................................... 140 Parlodel ......................................................... 64 Parnate ........................................................ 117 Paromomycin Sulfate .................................... 65 PARoxetine HCl .......................................... 117 PARoxetine HCl ER .................................... 117 Paser ............................................................. 55 Pataday ......................................................... 17 Patanase ....................................................... 17 Paxil ............................................................ 117 Paxil CR ...................................................... 117 PCE ............................................................... 22 Pediapred ........................................................ 4 Pediarix ....................................................... 136 PEG 3350/Electrolytes .................................. 85 PEG 3350-KCl-Na Bicarb-NaCl ..................... 85 PEG-3350/Electrolytes .................................. 85 Peganone ...................................................... 30 Pegasys ........................................................ 74 Pegasys ProClick .......................................... 74 PegIntron ....................................................... 74 PEG-Prep ...................................................... 85 Penicillin G Potassium ................................... 23 Penicillin G Procaine ..................................... 23 Penicillin G Sodium ....................................... 23 Penicillin V Potassium ................................... 23 Penlac ........................................................... 42 Pentacel ...................................................... 137 Pentam .......................................................... 65 Pentasa ......................................................... 48 Pentazocine-Naloxone HCl ........................... 15 Pentoxifylline ER ........................................... 98 Pepcid ........................................................... 70 Percocet ........................................................ 13 Perforomist .................................................. 133 Perindopril Erbumine ................................... 123 Perjeta ........................................................... 61 Permethrin ..................................................... 44 Perphenazine .............................................. 120 Perphenazine-Amitriptyline ......................... 117 Pertzye .......................................................... 89 Pexeva ........................................................ 117 Pfizerpen ....................................................... 23 Pharbedryl ..................................................... 95 Phenadoz ...................................................... 95 Phenazo ........................................................ 66
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Phenazopyridine HCl .................................... 66 Phenelzine Sulfate ...................................... 117 Phenergan .................................................... 95 PHENobarbital .............................................. 76 Phenoxybenzamine HCl.............................. 132 Phenyleph-Promethazine-Cod ...................... 69 Phenylephrine HCl ...................................... 137 Phenylephrine-Guaifenesin ........................... 94 Phenytek ....................................................... 30 Phenytoin ...................................................... 30 Phenytoin Infatabs ........................................ 30 Phenytoin Sodium ......................................... 30 Phenytoin Sodium Extended ......................... 30 Phoslyra ...................................................... 124 Phospha 250 Neutral .................................. 125 Phosphasal ................................................. 136 Phospholine Iodide ....................................... 37 Phospho-Trin 250 Neutral ........................... 125 Photofrin........................................................ 61 Phrenilin Forte ................................................. 7 Phytonadione .............................................. 141 Picato .......................................................... 130 Pilocarpine HCl ..................................... 37, 113 Pimozide ..................................................... 120 Pindolol ......................................................... 78 Pioglitazone HCl ........................................... 33 Pioglitazone HCl-Glimepiride ........................ 33 Pioglitazone HCl-Metformin HCl ................... 34 Pirmella 1/35 ................................................. 88 Piroxicam ........................................................ 9 Plaquenil ....................................................... 65 Plavix ............................................................ 68 Plegridy ......................................................... 74 Plegridy Starter Pack .................................... 74 Plexion ........................................................ 101 Plexion Cleanser ......................................... 101 Plexion Cleansing Cloth .............................. 101 PNV Folic Acid + Iron .................................. 106 PNV OB+DHA ............................................. 106 PNV Prenatal Plus Multivitamin .................. 106 PNV Tabs 29-1 ........................................... 106 PNV-DHA .................................................... 106 PNV-DHA Plus ............................................ 106 PNV-DHA+Docusate ................................... 106 PNV-Omega ................................................ 106 PNV-Select ................................................. 106 PNV-Total ................................................... 106 Podocon ...................................................... 130 Podofilox ..................................................... 130 Polycin .......................................................... 40
Polyethylene Glycol 3350 .............................. 85 Poly-Iron 150 Forte........................................ 19 Polymyxin B-Trimethoprim ............................ 40 Polysaccharide Iron Forte ............................. 19 Poly-Vi-Flor ................................................. 106 Poly-Vi-Flor FS ............................................ 106 Poly-Vi-Flor/Iron .......................................... 107 Poly-Vi-Sol/Iron ........................................... 107 Pomalyst ....................................................... 61 Portia-28 ........................................................ 88 Pot & Sod Cit-Cit Ac ........................................ 6 Pot Bicarb-Pot Chloride ............................... 125 Potaba ......................................................... 140 Potassium Bicarbonate ............................... 125 Potassium Chloride ..................................... 125 Potassium Chloride Crys ER ....................... 125 Potassium Chloride ER ............................... 125 Potassium Citrate ER ...................................... 6 Potassium Citrate-Citric Acid ........................... 6 PR Benzoyl Peroxide Wash .......................... 43 PR Cream ................................................... 130 PR Natal 400 ............................................... 107 PR Natal 400 ec .......................................... 107 PR Natal 430 ............................................... 107 PR Natal 430 ec .......................................... 107 Pradaxa ......................................................... 68 PramCort ....................................................... 67 Pramipexole Dihydrochloride ........................ 64 Pramipexole Dihydrochloride ER .................. 64 Pramosone .................................................... 48 Pramosone E ................................................ 48 PramOtic ..................................................... 102 Pramox .......................................................... 67 Prandin .......................................................... 32 Prasugrel HCl ................................................ 68 Pravastatin Sodium ....................................... 53 Prazosin HCl ................................................... 6 Precose ......................................................... 30 Pred Forte ..................................................... 50 Pred Mild ....................................................... 50 Pred-G ........................................................... 50 Pred-G S.O.P. ............................................... 50 Prednicarbate ................................................ 48 PrednisoLONE ................................................ 4 PrednisoLONE Acetate ................................. 50 PrednisoLONE Sodium Phosphate ........... 5, 50 PredniSONE .................................................... 5 PredniSONE Intensol ...................................... 5 Prefera OB .................................................. 107 PreferaOB +DHA ......................................... 107
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PreferaOB One ........................................... 107 Prefest .......................................................... 94 Premarin ....................................................... 94 Premium Lidocaine ....................................... 67 Premphase .................................................... 94 Prempro ........................................................ 94 Prena1 ........................................................ 107 Prena1 Pearl ............................................... 107 Prenaissance .............................................. 107 Prenaissance Balance ................................ 107 Prenaissance Harmony DHA ...................... 107 Prenaissance Next ...................................... 107 Prenaissance Next-B .................................. 107 Prenaissance Plus ...................................... 107 PreNata ....................................................... 107 Prenatabs Rx .............................................. 107 Prenatal....................................................... 107 Prenatal 19.................................................. 107 Prenatal Plus ............................................... 107 Prenatal Plus Iron ....................................... 107 Prenatal Vitamin Plus Low Iron ................... 107 Prenatal-U ................................................... 107 Prenate ....................................................... 107 Prenate AM ................................................. 107 Prenate DHA ............................................... 107 Prenate Elite ............................................... 107 Prenate Enhance ........................................ 108 Prenate Essential ........................................ 108 Prenate Mini ................................................ 108 Prenate Pixie ............................................... 108 Prenate Restore .......................................... 108 PrePLUS ..................................................... 108 Prepopik ........................................................ 85 Presera ....................................................... 130 PreTAB ....................................................... 108 Prevacid ........................................................ 71 Prevacid SoluTab .......................................... 71 Prevalite ........................................................ 52 Prevpac ......................................................... 71 Prezcobix ...................................................... 73 Prezista ......................................................... 73 Prialt ................................................................ 7 Priftin ............................................................. 55 Prilolid ........................................................... 67 PriLOSEC ..................................................... 71 Priloxx LP ...................................................... 67 Primaquine Phosphate .................................. 65 Primidone ...................................................... 29 Primlev .......................................................... 14 Primsol ........................................................ 136
Pristiq .......................................................... 117 Privigen ....................................................... 127 ProAir HFA .................................................. 133 ProAir RespiClick ........................................ 133 Probenecid .................................................. 136 Procardia ....................................................... 83 Procardia XL ................................................. 83 ProCentra ...................................................... 15 Prochlorperazine ......................................... 120 Prochlorperazine Edisylate .......................... 120 Prochlorperazine Maleate ........................... 120 ProCort .......................................................... 67 Procrit ............................................................ 97 Proctocort ...................................................... 48 Proctofoam HC .............................................. 67 Procto-Med HC ............................................. 48 Procto-Pak .................................................... 48 Proctosol HC ................................................. 48 Proctozone-HC .............................................. 48 Proferrin-Forte ............................................... 19 Progesterone ............................................... 114 Progesterone Micronized ............................ 114 Proglycem ..................................................... 38 Prograf .......................................................... 99 Prolastin-C .................................................. 126 Proleukin ....................................................... 61 Prolia ............................................................. 79 Promacta ....................................................... 98 Promethazine HCl ......................................... 95 Promethazine VC Plain ................................. 95 Promethazine VC/Codeine ............................ 69 Promethazine-Codeine .................................. 69 Promethazine-DM ......................................... 69 Promethazine-Phenyleph-Codeine ............... 69 Promethazine-Phenylephrine ........................ 95 Promethegan ................................................. 95 Prometrium .................................................. 114 Propafenone HCl ........................................... 84 Propafenone HCl ER ..................................... 84 Propantheline Bromide .................................. 26 Propranolol HCl ............................................. 79 Propranolol HCl ER ....................................... 79 Propranolol-HCTZ ......................................... 79 Propylthiouracil ............................................ 134 Proscar ............................................................ 3 Protect Plus ................................................. 108 ProtectIron ..................................................... 19 Protonix ......................................................... 71 Protopic ....................................................... 130 Protriptyline HCl .......................................... 117
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Provenge....................................................... 85 Proventil HFA .............................................. 133 Provera ....................................................... 114 Provida DHA ............................................... 108 Provida OB .................................................. 108 Provigil .......................................................... 17 PROzac....................................................... 117 PruClair ....................................................... 130 Prudoxin ........................................................ 67 PruMyx ........................................................ 130 Pseudoeph-Bromphen-DM ........................... 69 Pseudoeph-Chlorphen-Hydrocod .................. 69 Psorcon ......................................................... 48 PulmoSal..................................................... 103 Pulmozyme ................................................. 103 PureFe OB Plus .......................................... 108 PureFe Plus .................................................. 19 PureVit DualFe Plus ...................................... 19 PX B Complex/Vitamin C ............................ 108 PX Folic Acid ............................................... 140 PX Miconazole 3-Day Combo ....................... 42 Pylera ............................................................ 70 Pyrazinamide ................................................ 55 Pyridium ........................................................ 67 Pyridostigmine Bromide .............................. 113 Pyridostigmine Bromide ER ........................ 113 Pyridoxine HCl ............................................ 140 Pyrogallic Acid ............................................ 101
Q
QC Clotrimazole ............................................ 42 Qnasl ............................................................ 50 Quadracel ................................................... 135 Qualaquin...................................................... 65 Quasense...................................................... 88 Quazepam .................................................... 77 Questran ....................................................... 52 Questran Light .............................................. 52 QUEtiapine Fumarate ................................. 120 QUEtiapine Fumarate ER ........................... 120 Quflora Pediatric ......................................... 108 Quinapril HCl ............................................... 123 Quinapril-Hydrochlorothiazide ..................... 123 QuiNIDine Gluconate ER .............................. 84 QuiNIDine Sulfate ......................................... 84 QuiNINE Sulfate ............................................ 65 Quinja ........................................................... 42 Qutenza ...................................................... 130 Qutenza (2 Patch) ....................................... 130 Qvar ................................................................ 5
Qvar RediHaler ............................................... 5
R
RA Folic Acid ............................................... 140 RA Miconazole 3 Combo Pack ...................... 42 RA Miconazole 3 Combo Pack App .............. 42 RABEprazole Sodium .................................... 71 Raloxifene HCl .............................................. 92 Ramipril ....................................................... 123 Ranexa .......................................................... 84 RaNITidine HCl ............................................. 70 Rapaflo ........................................................ 132 Rapamune ............................................. 99, 100 Rasagiline Mesylate ...................................... 65 Rayos .............................................................. 5 Razadyne .................................................... 113 Razadyne ER .............................................. 113 Rea Lo 40 .................................................... 101 Rebetol .......................................................... 75 Reclast .......................................................... 79 Rectiv .......................................................... 130 Reglan ......................................................... 114 Relador Pak .................................................. 67 Relador Pak Plus .......................................... 67 Relagard ........................................................ 43 Relenza Diskhaler ......................................... 74 Relistor .......................................................... 96 Relnate DHA ............................................... 108 Relpax ........................................................... 54 Remeron ..................................................... 117 Remeron SolTab ......................................... 117 Remodulin ................................................... 138 Renagel ....................................................... 100 Renal ........................................................... 108 Renatabs ..................................................... 108 Renatabs with Iron ........................................ 19 Reno Caps .................................................. 108 Renvela ....................................................... 100 Repaglinide ................................................... 32 Repaglinide-Metformin HCl ........................... 32 REQ 49+ ..................................................... 108 Requip ........................................................... 64 Requip XL ..................................................... 64 Rescriptor ...................................................... 73 Restasis ........................................................ 51 Restasis Multidose ........................................ 51 Restoril .......................................................... 77 Retin-A .......................................................... 85 Retin-A Micro ................................................ 85 Retin-A Micro Pump ...................................... 85
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Retinoic Acid ................................................. 85 Retisert ......................................................... 51 Retrovir ......................................................... 73 Revatio ........................................................ 138 Revlimid ........................................................ 61 Reyataz ......................................................... 73 RhoGAM Ultra-Filtered Plus ........................ 127 Rhophylac ................................................... 127 Riax ............................................................... 43 Ribasphere .................................................... 75 Ribavirin ........................................................ 75 Ridaura ......................................................... 96 Rifabutin ........................................................ 55 Rifadin ........................................................... 55 Rifamate........................................................ 55 RifAMPin ....................................................... 55 Rifater ........................................................... 55 Rilutek ........................................................... 86 Riluzole ......................................................... 86 RiMANTAdine HCl ........................................ 72 Rimso-50..................................................... 112 Rinvoq ......................................................... 100 Riomet .......................................................... 31 Risedronate Sodium ..................................... 79 RisperDAL................................................... 120 RisperDAL Consta ...................................... 120 RisperDAL M-TAB ...................................... 120 RisperiDONE .............................................. 120 RisperiDONE M-TAB .................................. 121 Ritalin ............................................................ 17 Ritalin LA....................................................... 17 Rituxan .......................................................... 61 Rivastigmine ............................................... 113 Rivastigmine Tartrate .................................. 113 Rizatriptan Benzoate ..................................... 54 R-Natal OB .................................................. 108 Robafen AC .................................................. 69 Robaxin ....................................................... 128 Robaxin-750 ................................................ 128 Robinul .......................................................... 26 Robinul-Forte ................................................ 26 Rocaltrol ...................................................... 140 ROPINIRole HCl ........................................... 64 ROPINIRole HCl ER ..................................... 64 Rosadan........................................................ 40 Rosanil Cleanser ......................................... 101 Rosuvastatin Calcium ................................... 53 Rowasa ......................................................... 48 Roweepra...................................................... 29 Roxicodone ................................................... 14
Rozerem ........................................................ 75 Rythmol SR ................................................... 84
S
Sabril ............................................................. 29 Salagen ....................................................... 113 Salex ........................................................... 101 Salicylic Acid ............................................... 101 Salicylic Acid Wart Remover ....................... 101 Salicylic Acid-Cleanser ................................ 101 Salimez ....................................................... 101 Salisol Forte ................................................ 101 Salitech Forte .............................................. 101 Salrix ........................................................... 101 Salsalate ......................................................... 9 Salvax ......................................................... 101 Salvax Duo Plus .......................................... 101 Samsca ......................................................... 91 Sancuso ........................................................ 34 SandIMMUNE ............................................. 100 SandoSTATIN ............................................. 131 SandoSTATIN LAR Depot ........................... 131 Santyl .......................................................... 130 Saphris ........................................................ 121 Sarafem ....................................................... 117 Savella .......................................................... 94 Savella Titration Pack .................................... 95 Scalacort DK ................................................. 48 Scopolamine ................................................. 35 Seconal ......................................................... 76 Select-OB .................................................... 108 Select-OB+DHA .......................................... 108 Selegiline HCl ................................................ 65 Selzentry ....................................................... 73 Semprex-D .................................................. 126 Se-Natal 19 ................................................. 108 Sensipar ...................................................... 112 SEROquel ................................................... 121 SEROquel XR ............................................. 121 Sertraline HCl .............................................. 117 Se-Tan PLUS ................................................ 19 Setlakin ......................................................... 88 Sevelamer Carbonate ................................. 100 SfRowasa ...................................................... 48 Sharobel ........................................................ 88 Shohls Modified ............................................... 6 Siderol ......................................................... 108 Signifor ........................................................ 131 Signifor LAR ................................................ 131 Sildenafil Citrate .......................................... 138
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Silenor ......................................................... 117 Silvadene ...................................................... 44 Silver Sulfadiazine ........................................ 44 Simbrinza ...................................................... 36 Simponi ......................................................... 90 Simponi Aria .................................................. 90 Simvastatin ................................................... 53 Sinemet ......................................................... 63 Sinemet CR ................................................... 63 Singulair ........................................................ 51 Sirolimus ..................................................... 100 Skelaxin ...................................................... 128 Sklice ............................................................ 44 Skyrizi ......................................................... 130 SM Antifungal Clotrimazole ........................... 42 SM B Super Vitamin Complex ..................... 108 SM B-Complex/Vitamin C ........................... 108 SM Folic Acid .............................................. 140 SM Miconazole 3 .......................................... 42 SM Miconazole 3 Applicator .......................... 42 Sod Citrate-Citric Acid ..................................... 6 Sodium Chloride ................................. 100, 103 Sodium Fluoride ............................................ 84 Sodium Hyaluronate ..................................... 92 Sodium Polystyrene Sulfonate .................... 100 solifenacin succinate ..................................... 96 Solodyn ....................................................... 130 Soltamox ....................................................... 61 Solu-CORTEF ................................................. 5 SOLU-medrol .................................................. 5 Soma .......................................................... 128 Somatuline Depot ....................................... 131 Sonata .......................................................... 76 Soolantra....................................................... 44 Soriatane..................................................... 130 Sorilux ......................................................... 130 Sotalol HCl .................................................... 79 Sotalol HCl (AF) ............................................ 79 Sovaldi .......................................................... 74 Spectracef ..................................................... 21 Spinosad ....................................................... 44 Spiriva HandiHaler ........................................ 26 Spiriva Respimat ........................................... 26 Spironolactone ............................................ 124 Spironolactone-HCTZ ................................. 124 Sporanox................................................. 35, 36 Sporanox Pulsepak ....................................... 36 Sprix ................................................................ 9 Sprycel .......................................................... 61 SPS ............................................................. 100
Sronyx ........................................................... 88 SSD ............................................................... 44 SSS 10-5 ..................................................... 101 Stalevo 100 ................................................... 63 Stalevo 125 ................................................... 63 Stalevo 150 ................................................... 63 Stalevo 200 ................................................... 63 Stalevo 50 ..................................................... 64 Stalevo 75 ..................................................... 64 Starlix ............................................................ 32 Stavudine ...................................................... 73 Staxyn ......................................................... 138 Stendra ........................................................ 138 Stimate ........................................................ 114 Stivarga ......................................................... 61 Strattera ........................................................ 86 Streptomycin Sulfate ..................................... 19 Stress Formula ............................................ 108 Stribild ........................................................... 73 Stromectol ..................................................... 17 Strovite Forte ............................................... 108 Strovite ONE ............................................... 108 Suboxone ...................................................... 15 Subsys .......................................................... 14 Sucraid .......................................................... 92 Sucralfate ...................................................... 70 Sular .............................................................. 83 Sulfacetamide Sodium .................................. 40 Sulfacetamide Sodium (Acne) ....................... 40 Sulfacetamide Sodium-Sulfur .............. 101, 102 Sulfacetamide Sod-Sulfur Wash ................. 102 Sulfacetamide-Prednisolone ......................... 51 Sulfacetamide-Sulfur in Urea ...................... 102 Sulfacetamide-Sulfur-Sunscreen ................. 102 SulfaCleanse 8/4 ......................................... 102 SulfADIAZINE ............................................... 24 Sulfamethoxazole-Trimethoprim ................... 24 Sulfamylon .................................................... 44 SulfaSALAzine .............................................. 24 Sulfurated Lime ............................................. 44 Sulindac .......................................................... 9 Sumadan ..................................................... 102 Sumadan Wash ........................................... 102 Sumadan XLT ............................................. 102 SUMAtriptan .................................................. 54 SUMAtriptan Succinate ................................. 54 SUMAtriptan Succinate Refill ........................ 54 Sumavel DosePro ......................................... 54 Sumaxin ...................................................... 102 Sumaxin CP ................................................ 102
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Sumaxin TS ................................................ 102 Sumaxin Wash ............................................ 102 Supartz FX .................................................. 112 Super B Complex/FA/Vit C.......................... 108 Super B-Complex/Vit C/FA ......................... 108 Supervite ..................................................... 108 Support ....................................................... 108 Support-500 ................................................ 109 Suprax .......................................................... 21 Suprep Bowel Prep Kit .................................. 85 Surmontil ..................................................... 117 Sustiva .......................................................... 73 Sutent ........................................................... 61 Sylatron ......................................................... 61 Symax Duotab .............................................. 26 Symax-SL ..................................................... 26 Symax-SR ..................................................... 26 Symbicort ........................................................ 5 Symbyax ..................................................... 118 SymlinPen 120 .............................................. 30 SymlinPen 60 ................................................ 30 Synagex ...................................................... 109 Synagis ......................................................... 74 Synalar .......................................................... 48 Synalar TS .................................................... 48 SynaTek ...................................................... 109 Synera .......................................................... 67 Synribo .......................................................... 61 Synthroid ..................................................... 134 Synvisc ....................................................... 112 Synvisc One ................................................ 112
T
Tabloid .......................................................... 61 Taclonex ....................................................... 48 Tacrolimus .......................................... 100, 130 Tadalafil ...................................................... 138 Tafinlar .......................................................... 61 Tagrisso ........................................................ 61 Tamiflu .......................................................... 74 Tamoxifen Citrate .......................................... 61 Tamsulosin HCl ........................................... 132 Tandem F...................................................... 19 Tandem Plus ................................................. 19 Tapazole ..................................................... 134 Tarceva ......................................................... 61 Targretin................................................ 61, 130 Tarka ............................................................. 81 Taron Forte ................................................... 19 Taron-Bc ..................................................... 109
Taron-C DHA .............................................. 109 Taron-Crystals ................................................. 6 Taron-Prex .................................................. 109 Tasigna ......................................................... 61 Tasmar .......................................................... 63 Taxotere ........................................................ 61 Tazarotene .................................................. 131 Tazorac ....................................................... 131 Taztia XT ....................................................... 81 Tecfidera ....................................................... 99 TEGretol ........................................................ 29 TEGretol-XR .................................................. 29 Tekturna ...................................................... 124 Tekturna HCT .............................................. 124 Telmisartan ................................................. 122 Telmisartan-Amlodipine ................................. 83 Telmisartan-HCTZ ....................................... 122 Temazepam .................................................. 77 Temodar ........................................................ 62 Temovate ...................................................... 48 Temozolomide ............................................... 62 Tencon ............................................................ 7 Teniposide ..................................................... 62 Tenivac ........................................................ 135 Tenofovir Disoproxil Fumarate ...................... 73 Terazol 7 ....................................................... 42 Terazosin HCl ................................................. 6 Terbinafine HCl ............................................. 35 Terbutaline Sulfate ...................................... 133 Terconazole .................................................. 42 Tessalon Perles ............................................ 69 Tetanus-Diphtheria Toxoids Td ................... 135 Tetrabenazine ............................................... 86 Tetracycline HCl ............................................ 25 Tetrix ........................................................... 131 Texacort ........................................................ 48 TexaVite LQ ................................................ 109 TGT Miconazole 3 Combo Pack ................... 42 Thalomid ....................................................... 99 Theo-24 ....................................................... 125 Theochron ................................................... 125 Theophylline ................................................ 125 Theophylline ER .......................................... 125 TheraCys ..................................................... 137 Thiola .......................................................... 112 Thioridazine HCl .......................................... 121 Thiotepa ........................................................ 62 Thiothixene .................................................. 121 Thrivite 19 ................................................... 109 Thrivite Rx ................................................... 109
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Thyrolar-1.................................................... 134 Thyrolar-1/2 ................................................. 135 Thyrolar-1/4 ................................................. 135 Thyrolar-2.................................................... 135 Thyrolar-3.................................................... 135 TiaGABine HCl .............................................. 29 Tiazac ........................................................... 81 Tice BCG .................................................... 137 Tigan ............................................................. 35 Tikosyn ......................................................... 84 Tilia Fe .......................................................... 88 Timolol Maleate ....................................... 36, 79 Tindamax ...................................................... 65 Tinidazole...................................................... 65 Tirosint ........................................................ 135 Tivicay ........................................................... 73 TiZANidine HCl ........................................... 128 TL Folate ..................................................... 109 TL Gard Rx ................................................. 140 TL G-Fol OS ................................................ 109 TL Icon .......................................................... 19 TL-Care DHA .............................................. 109 TL-Fluorivite ................................................ 109 TL-Hem 150 .................................................. 19 TL-Select..................................................... 109 Tobi ............................................................... 19 TobraDex ST ................................................. 51 Tobramycin ............................................. 19, 40 Tobramycin Sulfate ....................................... 19 Tobrex ........................................................... 40 Tofranil ........................................................ 118 TOLAZamide ................................................. 33 TOLBUTamide .............................................. 33 Tolcapone ..................................................... 63 Tolmetin Sodium ............................................. 9 Tolterodine Tartrate ...................................... 96 Tolterodine Tartrate ER ................................ 96 Topamax ....................................................... 29 Topamax Sprinkle ......................................... 29 Topex Topical Anesthetic .............................. 67 Topicort ......................................................... 48 Topiramate .................................................... 29 Toposar ......................................................... 62 Topotecan HCl .............................................. 62 Torisel ........................................................... 62 Torsemide ..................................................... 90 Totect .......................................................... 115 Toujeo SoloStar ............................................ 32 Toviaz ........................................................... 96 Tracleer ....................................................... 138
Tradjenta ....................................................... 31 TraMADol HCl ............................................... 14 TraMADol HCl ER ......................................... 14 TraMADol HCl ER (Biphasic) ........................ 14 Tramadol-Acetaminophen ............................. 14 Trandolapril ................................................. 123 Trandolapril-Verapamil HCl ER ..................... 81 Tranexamic Acid ........................................... 38 Transderm-Scop (1.5 MG) ............................ 35 Tranxene-T .................................................... 77 Tranylcypromine Sulfate .............................. 118 Travatan Z ..................................................... 37 travoprost (bak free) ...................................... 37 TraZODone HCl .......................................... 118 Treanda ......................................................... 62 Trecator ......................................................... 55 Trelstar Mixject .............................................. 62 Tretinoin .................................................. 62, 85 Tretinoin Microsphere .................................... 85 Tretinoin Microsphere Pump ......................... 85 Tretin-X ......................................................... 85 Trexall ........................................................... 62 Treximet ........................................................ 54 Tri Femynor ................................................... 88 Triamcinolone Acetonide ..................... 5, 48, 51 Triamterene-HCTZ ........................................ 91 Trianex .......................................................... 48 Triazolam ...................................................... 77 Tribenzor ....................................................... 83 TriCare ........................................................ 109 TriCare Prenatal Compleat .......................... 109 TriCare Prenatal DHA ONE ......................... 109 Tricitrates ........................................................ 6 Tricon ............................................................ 19 Tricor ............................................................. 53 Triderm .......................................................... 48 Tridesilon ....................................................... 48 Triesence ...................................................... 51 Tri-Estarylla ................................................... 88 Trifluoperazine HCl...................................... 121 Trifluridine ..................................................... 42 Trigels-F Forte ............................................... 19 Triglide .......................................................... 53 Trihexyphenidyl HCl ...................................... 63 Triklo ............................................................. 52 Tri-Legest Fe ................................................. 88 Trileptal ......................................................... 29 Tri-Linyah ...................................................... 88 Trilipix ............................................................ 53 Tri-Lo-Estarylla .............................................. 88
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Tri-Lo-Marzia ................................................. 88 Tri-Lo-Sprintec .............................................. 88 TriLyte ........................................................... 85 Trimethobenzamide HCl ............................... 35 Trimethoprim ............................................... 136 Trimipramine Maleate ................................. 118 Trinatal Rx 1 ................................................ 109 Trinate ......................................................... 109 TriNessa (28) ................................................ 88 TriNessa Lo ................................................... 88 Triphrocaps ................................................. 109 Tri-Previfem .................................................. 88 Tri-Sprintec ................................................... 89 TriStart DHA ................................................ 109 Tri-Tabs DHA .............................................. 109 Triveen-Duo DHA ........................................ 109 Tri-Vi-Flor .................................................... 109 Tri-Vi-Floro .................................................. 109 Tri-Vit/Fluoride ............................................ 109 Tri-Vit/Fluoride/Iron ..................................... 109 Tri-Vitamin/Fluoride ..................................... 109 Trivora (28) ................................................... 89 Trizivir ........................................................... 73 Tropicamide ................................................ 111 Trospium Chloride ......................................... 96 Trospium Chloride ER ................................... 96 Trulicity.......................................................... 31 Truvada ......................................................... 73 Tudorza Pressair ........................................... 26 Tusnel ........................................................... 69 TussiCaps ..................................................... 69 Tussigon ....................................................... 69 Tussionex Pennkinetic ER ............................ 70 Twynsta......................................................... 83 Tybost ......................................................... 112 Tykerb ........................................................... 62 Tylenol with Codeine #3 ................................ 14 Tylenol with Codeine #4 ................................ 14 Tysabri .......................................................... 99 Tyvaso ........................................................ 138 Tyvaso Refill ............................................... 139 Tyvaso Starter ............................................. 139
U
Uceris .............................................................. 5 Udamin SP .................................................. 109 Ulesfia ........................................................... 44 Uloric ............................................................. 37 UltimateCare ONE ...................................... 109 Ultracet ......................................................... 14
Ultram ............................................................ 14 Ultravate ........................................................ 48 Ultravate X (Cream) ...................................... 48 Ultravate X (Ointment) ................................... 49 Umecta Mousse .......................................... 102 Unithroid ...................................................... 135 Unithroid Direct ........................................... 135 Ur N-C ......................................................... 136 Uramaxin ..................................................... 102 Urea ............................................................ 102 Urea Hydrating ............................................ 102 Urea in Zn Undecyl-Lactic Acid ................... 102 Urea Nail ..................................................... 102 Urea-C40 ..................................................... 102 Urecholine ................................................... 113 Ure-K ........................................................... 102 Urelle ........................................................... 136 Uremez-40 .................................................. 102 Uretron D/S ................................................. 136 Uribel ........................................................... 136 Urimar-T ...................................................... 136 Urin DS ........................................................ 136 Uro-458 ....................................................... 136 UroAv-81 ..................................................... 136 UroAv-B ....................................................... 136 Urocit-K 10 ...................................................... 6 Urocit-K 15 ...................................................... 6 Urocit-K 5 ........................................................ 6 Urogesic-Blue .............................................. 136 Uro-MP ........................................................ 136 Urosex ......................................................... 109 Uroxatral ...................................................... 132 Urso 250 ........................................................ 86 Urso Forte ..................................................... 86 Ursodiol ......................................................... 86 Uryl .............................................................. 136 Ustell ........................................................... 136 Uticap .......................................................... 136 Utira-C ......................................................... 136 Utrona-C ...................................................... 136
V
Vagifem ......................................................... 94 ValACYclovir HCl .......................................... 75 Valcyte .......................................................... 75 ValGANciclovir HCl ....................................... 75 Valium ........................................................... 77 Valproate Sodium .......................................... 29 Valproic Acid ................................................. 29 Valsartan ..................................................... 122
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Valsartan-Hydrochlorothiazide .................... 122 Valstar ........................................................... 62 Valtrex ........................................................... 75 Vanatol LQ ...................................................... 7 Vanatol S ........................................................ 7 Vancocin HCl ................................................ 20 Vancomycin HCl ........................................... 20 Vandazole ..................................................... 40 Vanos ............................................................ 49 Vanoxide-HC ................................................. 51 Vantas ........................................................... 62 Vascepa ........................................................ 52 Vaseretic ..................................................... 123 V-C Forte .................................................... 109 Vectibix ......................................................... 62 Vectical ....................................................... 131 Velcade ......................................................... 62 Veletri .......................................................... 139 Veltin ........................................................... 131 VemaVite-PRx 2 ......................................... 109 Vena-Bal DHA ............................................. 109 Venlafaxine HCl .......................................... 118 Venlafaxine HCl ER .................................... 118 Ventavis ...................................................... 139 Ventolin HFA ............................................... 133 Verapamil HCl ............................................... 81 Verapamil HCl ER ......................................... 81 Verdeso......................................................... 49 Veregen ...................................................... 131 Verelan ......................................................... 81 Verelan PM ................................................... 81 Veripred 20 ..................................................... 5 VESIcare ....................................................... 96 Vfend ............................................................ 36 Viagra ......................................................... 138 Vibramycin .................................................... 25 VIC-Forte .................................................... 109 Vicodin .......................................................... 14 Vicodin ES .................................................... 14 Vicodin HP .................................................... 14 Victoza .......................................................... 31 Vidaza ........................................................... 62 Videx ............................................................. 73 Videx EC ....................................................... 73 Vienva ........................................................... 89 Vigamox ........................................................ 40 Viibryd ......................................................... 118 Vilamit MB ................................................... 136 Vilevev MB .................................................. 136 Vimovo ............................................................ 9
Vimpat ........................................................... 29 Vinate DHA RF ............................................ 110 Vinate II ....................................................... 110 Vinate M ...................................................... 110 Vinate One .................................................. 110 VinBLAStine Sulfate ...................................... 62 Vincasar PFS ................................................ 62 VinCRIStine Sulfate....................................... 62 Vinorelbine Tartrate ....................................... 62 Viokace ......................................................... 89 Viracept ......................................................... 73 Viramune ....................................................... 73 Viramune XR ................................................. 73 Virasal ......................................................... 102 Virazole ......................................................... 75 Viread ............................................................ 73 Viroptic .......................................................... 42 Virt Nate ...................................................... 110 Virt-C DHA .................................................. 110 Virt-Caps ..................................................... 110 Virt-Gard ...................................................... 140 Virti-Sulf ....................................................... 102 Virt-Nate DHA ............................................. 110 Virt-Phos 250 Neutral .................................. 125 Virt-PN ......................................................... 110 Virt-PN DHA ................................................ 110 Virt-PN Plus ................................................. 110 Virtussin A/C ................................................. 70 Vistaril ........................................................... 76 Vita S Forte ................................................. 110 Vita-Bee/C ................................................... 110 Vitacel ......................................................... 110 Vitafol ............................................................ 19 Vitafol FE+................................................... 110 Vitafol Ultra .................................................. 110 Vitafol-Nano ................................................ 110 Vitafol-OB .................................................... 110 Vitafol-OB+DHA .......................................... 110 Vitafol-One .................................................. 110 Vitaject ........................................................ 110 Vital-D Rx .................................................... 110 Vitamax Pediatric ........................................ 110 VitaMedMD One Rx/Quatrefolic .................. 110 VitaMedMD RediChew Rx ........................... 110 Vitamez ....................................................... 140 Vita-Min ....................................................... 110 Vitamin B Complex 100 ............................... 140 Vitamin B-Complex 100 ............................... 140 Vitamin D (Ergocalciferol) ............................ 140 Vitamin K1 ................................................... 141
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Vitamins ACD-Fluoride ............................... 110 VitaPearl ..................................................... 110 Vitaroca Plus ............................................... 110 Vita-Rx Diabetic Vitamin ............................. 110 Viva DHA .................................................... 110 Vivelle-Dot..................................................... 94 Vivitrol ......................................................... 111 Vol-Care Rx ................................................ 110 Vol-Nate ...................................................... 110 Vol-Plus....................................................... 110 Vol-Tab Rx .................................................. 110 Voltaren....................................................... 131 Voraxaze ....................................................... 34 Voriconazole ................................................. 36 Votrient ......................................................... 62 VP-GGR-B6 Prenatal .................................. 110 VP-Heme OB .............................................. 110 VP-Heme OB + DHA ................................... 110 VP-HEME One ............................................ 111 VP-PNV-DHA .............................................. 111 Vpriv .............................................................. 92 VP-Vite Rx .................................................. 111 VP-ZEL ....................................................... 111 VUMVERITY ................................................. 86 VUMVERITY STARTER ............................... 86 Vusion ........................................................... 42 Vyvanse ........................................................ 15
W
Warfarin Sodium ........................................... 68 Welchol ......................................................... 52 Wellbutrin SR .............................................. 118 Wellbutrin XL ............................................... 118 Westhroid .................................................... 135 WinRho SDF ............................................... 127 WP Thyroid ................................................. 135
X
Xalkori ........................................................... 62 Xanax ............................................................ 77 Xanax XR ...................................................... 77 Xarelto .......................................................... 68 Xarelto Starter Pack ...................................... 68 Xeljanz .......................................................... 90 Xeljanz XR .................................................... 90 Xeloda ........................................................... 62 Xenazine ....................................................... 86 Xeralux ........................................................ 131 Xerese .......................................................... 42 Xgeva ............................................................ 79 Xifaxan .......................................................... 20
Xigduo XR ..................................................... 32 Xolair ........................................................... 126 Xolegel .......................................................... 42 Xolegel CorePak ........................................... 42 Xolegel Duo/Head & Shoulders ..................... 42 Xolegel Duo/Xolex ......................................... 42 Xopenex ...................................................... 133 Xopenex Concentrate .................................. 133 Xopenex HFA .............................................. 133 Xtandi ............................................................ 62 Xulane ........................................................... 89 Xyrem ............................................................ 86
Y
Yervoy ........................................................... 62 YL Folic Acid ............................................... 140 Yuvafem ........................................................ 94
Z
Zacare ........................................................... 44 Zaclir Cleansing ............................................ 44 Zafirlukast ...................................................... 51 Zaleplon ........................................................ 76 Zaltrap ........................................................... 62 Zanaflex ...................................................... 128 Zanosar ......................................................... 62 Zantac ........................................................... 70 Zarontin ......................................................... 30 Zarxio ............................................................ 98 Zatean-Pn DHA ........................................... 111 Zatean-Pn Plus ........................................... 111 Zavesca ....................................................... 112 Zebutal ............................................................ 7 Zegerid .......................................................... 71 Zelapar .......................................................... 65 Zelboraf ......................................................... 62 Zemaira ....................................................... 126 Zemplar ....................................................... 140 Zenatane ..................................................... 131 Zenpep .......................................................... 89 Zerit ............................................................... 74 Zestoretic .................................................... 123 Zetia .............................................................. 52 Zetonna ......................................................... 51 Ziagen ........................................................... 74 Ziana ........................................................... 131 Zidovudine ..................................................... 74 Zileuton ER ................................................... 51 Zinecard ...................................................... 115 Zioptan .......................................................... 37 Ziprasidone HCl .......................................... 121
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Zipsor .............................................................. 9 Zirgan ............................................................ 42 Zithranol ...................................................... 131 Zithromax ...................................................... 22 Zithromax Tri-Pak ......................................... 22 Zithromax Z-Pak ........................................... 22 Zofran ........................................................... 34 Zofran ODT ................................................... 34 Zoledronic Acid ............................................. 79 Zolinza .......................................................... 62 ZOLMitriptan ................................................. 55 Zoloft ........................................................... 118 Zolpidem Tartrate .......................................... 76 Zolpidem Tartrate ER .................................... 76 Zolpimist........................................................ 76 Zometa .......................................................... 80 Zomig ............................................................ 55 Zomig ZMT .................................................... 55 Zonalon ......................................................... 67 Zonegran....................................................... 29
Zonisamide .................................................... 29 Zortress ....................................................... 100 Zovia 1/35E (28) ............................................ 89 Zovirax .................................................... 42, 75 Zubsolv .......................................................... 15 Zuplenz ......................................................... 34 Zutripro .......................................................... 70 Zyban .......................................................... 118 Zyclara ........................................................ 131 Zyclara Pump .............................................. 131 Zyflo .............................................................. 51 Zyflo CR ........................................................ 51 Zyloprim ........................................................ 37 Zymaxid ......................................................... 40 ZyPREXA .................................................... 121 ZyPREXA Relprevv ..................................... 121 ZyPREXA Zydis .......................................... 121 Zytiga ............................................................ 62 Zyvox ............................................................. 20