PA = Prior Authorization [Pre Autorización]; QL = Quantity ......Aminoglycosides - Antibiotics...

PA = Prior Authorization [Pre Autorización]; QL = Quantity Limit [Límite de Cantidad]

ACAA Formulario de Medicamentos of 24

Update Date: 6/2021



Update Date: 6/2021

Table of Contents

ANALGESICS - DRUGS TO TREAT PAIN, INFLAMMATION, AND MUSCLE AND JOINT

CONDITIONS [ANALGÉSICOS - MEDICAMENTOS PARA TRATAR DOLOR, INFLAMACIÓN Y

MÚSCULO Y CONDICIONES DE LAS ARTICULACIONES] .......................................................... 4

ANTIBACTERIALS - DRUGS TO TREAT BACTERIAL INFECTIONS [ANTIBACTERIANOS -

MEDICAMENTOS PARA TRATAR INFECCIONES BACTERIANAS] ............................................. 6

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES [ANTICONVULSIVOS - MEDICAMENTOS

PARA TRATAR CONVULSIONES] ................................................................................................. 8

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION [ANTIDEPRESIVOS -

MEDICAMENTOS PARA TRATAR LA DEPRESIÓN] ..................................................................... 9

ANTIEMETICS - DRUGS TO TREAT NAUSEA AND VOMITING [ANTIEMÉTICOS -

MEDICAMENTOS PARA TRATAR NÁUSEA Y VÓMITO] ............................................................ 11

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS [ANTIFUNGALES -

MEDICAMENTOS PARA TRATAR INFECCIONES FÚNGICAS] .................................................. 11

ANTIPSYCHOTICS - DRUGS TO TREAT MOOD DISORDERS [ANTIPSICÓTICOS -

MEDICAMENTOS PARA TRATAR TRASTORNOS DEL ESTADO DE ÁNIMO] ........................... 11

ANTISPASTICITY AGENTS [AGENTES CONTRA LA ESPASTICIDAD] ..................................... 12

ANXIOLYTICS - DRUGS TO TREAT ANXIETY [ANSIOLÍTICOS - MEDICAMENTOS PARA

TRATAR LA ANSIEDAD] .............................................................................................................. 12

BIPOLAR AGENTS - DRUGS TO TREAT MOOD DISORDERS [AGENTES PARA BIPOLARIDAD

- MEDICAMENTOS PARA TRATAR TRASTORNOS DEL ESTADO DE ÁNIMO] ......................... 13

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS - DRUGS TO TREAT BLOOD

DISORDERS [PRODUCTOS PARA LA SANGRE/MODIFICADORES/EXPANSORES DE

VOLUMEN - MEDICAMENTOS PARA TRATAR TRASTORNOS DE LA SANGRE] ..................... 13

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS TO TREAT NERVE CONDITIONS [AGENTES

DEL SISTEMA NERVIOSO CENTRAL - MEDICAMENTOS PARA TRATAR CONDICIONES DE

LOS NERVIOS] ............................................................................................................................. 13

GASTROINTESTINAL AGENTS - DRUGS TO TREAT BOWEL, INTESTINE AND STOMACH

CONDITIONS [AGENTES GASTROINTESTINALES - MEDICAMENTOS PARA TRATAR

CONDICIONES INTESTINALES, INTESTINO Y ESTÓMAGO] ..................................................... 14

GENITOURINARY AGENTS - DRUGS TO TREAT BLADDER, GENITAL AND KIDNEY

CONDITIONS [AGENTES GENITOURINARIOS - MEDICAMENTOS PARA TRATAR

CONDICIONES DE LA VEJIGA, GENITALES Y RENALES] ........................................................ 15

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) - DRUGS TO

REGULATE HORMONES [AGENTES HORMONALES,



Update Date: 6/2021

ESTIMULANTES/REEMPLAZO/MODIFICADOR (ADRENALES) - MEDICAMENTOS PARA

REGULAR LAS HORMONAS] ...................................................................................................... 16

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) - DRUGS TO

REGULATE HORMONES [AGENTES HORMONALES,

ESTIMULANTES/REEMPLAZO/MODIFICADOR (PITUITARIA) - MEDICAMENTOS PARA

REGULAR LAS HORMONAS] ...................................................................................................... 16

INFLAMMATORY BOWEL DISEASE AGENTS - DRUGS TO TREAT INFLAMMATORY BOWEL

DISEASE [AGENTES PARA LA ENFERMEDAD INFLAMATORIA DEL INTESTINO -

MEDICAMENTOS PARA TRATAR LA ENFERMEDAD INFLAMATORIA DEL INTESTINO] ........ 17

OPHTHALMIC AGENTS - DRUGS TO TREAT EYE CONDITIONS [AGENTES OFTÁLMICOS -

MEDICAMENTOS PARA TRATAR CONDICIONES DE LOS OJOS] ............................................ 17

RESPIRATORY TRACT/PULMONARY AGENTS - DRUGS TO TREAT ALLERGIES, COUGH,

COLD AND LUNG CONDITIONS [AGENTES PARA EL TRACTO RESPIRATORIO/PULMONAR -

MEDICAMENTOS PARA TRATAR ALERGIAS, TOS, RESFRIADO, Y CONDICIONES DEL

PULMÓN] ...................................................................................................................................... 18

SKELETAL MUSCLE RELAXANTS - DRUGS TO TREAT MUSCLE TENSION AND SPASM

[RELAJANTES MUSCULOESQUELÉTICOS - MEDICAMENTOS PARA TRATAR LA TENSIÓN

MUSCULAR Y ESPASMO] ........................................................................................................... 19

SLEEP DISORDER AGENTS - DRUGS FOR SEDATION AND SLEEP [AGENTES DEL SISTEMA

NERVIOSO CENTRAL - MEDICAMENTOS PARA TRATAR CONDICIONES DE LOS NERVIOS]

...................................................................................................................................................... 19

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES [NUTRIENTES/MINERALES Y

ELECTROLITOS TERAPÉUTICOS] .............................................................................................. 20

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES - DRUGS TO TREAT VITAMIN,

MINERAL AND BODY FLUID DEFICIENCIES [NUTRIENTES

TERAPÉUTICOS/MINERALES/ELECTROLITOS - MEDICAMENTOS PARA TRATAR

DEFICIENCIAS DE VITAMINAS, MINERALES Y FLUIDOS CORPORALES] .............................. 20



Update Date: 6/2021

Formulary Drug List

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]

ANALGESICS - DRUGS TO TREAT PAIN, INFLAMMATION, AND MUSCLE AND JOINT CONDITIONS [ANALGÉSICOS - MEDICAMENTOS PARA TRATAR DOLOR, INFLAMACIÓN Y MÚSCULO Y CONDICIONES DE LAS ARTICULACIONES]

Analgesics - Miscellaneous Analgesics [Analgésicos - Analgésicos Misceláneos]

compoz 50 mg cap 1 PA, QL(20 / 15)

cvs sleep aid nighttime 50 mg cap 1 PA, QL(20 / 15)

cvs sleep-aid nighttime 50 mg cap 1 PA, QL(20 / 15)

eq nighttime sleep aid max st 50 mg cap 1 PA, QL(20 / 15)

eql sleep aid 50 mg cap 1 PA, QL(20 / 15)

goodsense sleep aid 50 mg cap 1 PA, QL(20 / 15)

ormir 50 mg cap 1 PA, QL(20 / 15)

qc sleep aid max st 50 mg cap 1 PA, QL(20 / 15)

qc sleep-aid max st 50 mg cap 1 PA, QL(20 / 15)

ra sleep aid 50 mg cap 1 PA, QL(20 / 15)

sleep-aid 50 mg cap 1 PA, QL(20 / 15)

tgt sleep aid max strength 50 mg cap 1 PA, QL(20 / 15)

UNISOM SLEEPGELS 50 mg cap 1 PA, QL(20 / 15)

wal-som maximum strength 50 mg cap 1 PA, QL(20 / 15)

Nonsteroidal Anti-inflammatory Drugs - Pain/anti-inflammatory Drugs [Medicamentos Antiinflamatorios No-Esteroidales - Medicamentos Para Dolor/Antiinflamatorios]

diclofenac potassium 50 mg tab 1 CATAFLAM QL(45 / 30)

diclofenac sodium 25 mg tab dr, 50 mg tab dr, 75 mg tab dr 1 VOLTAREN QL(45 / 30)

diclofenac sodium er 100 mg tab er 24 hr 1 VOLTAREN XR QL(45 / 30)

flurbiprofen 100 mg tab, 50 mg tab 1 ANSAID QL(45 / 30)

IBU 400 mg tab, 600 mg tab, 800 mg tab 1 QL(45 / 30)

ibuprofen 400 mg tab, 600 mg tab, 800 mg tab 1 MOTRIN QL(45 / 30)

indomethacin 25 mg cap, 50 mg cap 1 INDOCIN QL(45 / 30)

indomethacin er 75 mg cap er 1 INDOCIN QL(45 / 30)

ketoprofen 50 mg cap, 75 mg cap 1 ORUDIS QL(45 / 30)

ketoprofen er 200 mg cap er 24 hr 1 ORUVAIL QL(45 / 30)



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




ketorolac tromethamine 60 mg/2ml im soln 1 QL(6 / 3)

ketorolac tromethamine 15 mg/ml inj soln, 30 mg/ml inj soln 1 TORADOL QL(6 / 3)

ketorolac tromethamine 10 mg tab 1 TORADOL QL(45 / 30)

meloxicam 15 mg tab, 7.5 mg tab 1 MOBIC QL(45 / 30)

nabumetone 500 mg tab, 750 mg tab 1 RELAFEN QL(45 / 30)

naproxen 250 mg tab, 375 mg tab, 500 mg tab, 500 mg tab dr 1 NAPROSYN QL(45 / 30)

naproxen 125 mg/5ml susp 1 NAPROSYN QL(800 / 30)

naproxen 375 mg tab dr 2 NAPROSYN QL(45 / 30)

naproxen sodium 275 mg tab 1 ANAPROX QL(45 / 30)

naproxen sodium 550 mg tab 1 ANAPROX DS QL(45 / 30)

piroxicam 10 mg cap, 20 mg cap 1 FELDENE QL(45 / 30)

sulindac 150 mg tab, 200 mg tab 1 CLINORIL QL(45 / 30)

Opioid Analgesics, Short-acting - Opioid Pain Relievers [Analgésicos Opioides, Corta Duración - Opioides Para Alivio De Dolor]

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

TYLENOL WITH CODEINE QL(20 / 15)

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


acetaminophen-codeine #2 300-15 mg tab 1






endocet 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 PERCOCET QL(20 / 15)

hydrocodone-acetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 NORCO QL(20 / 15)

hydrocodone-acetaminophen 10-300 mg tab, 5-300 mg tab, 7.5-300 mg tab 1 VICODIN QL(20 / 15)

LORCET 5-325 mg tab 1 QL(20 / 15)

NORCO 5-325 mg tab 1 QL(20 / 15)

oxycodone-acetaminophen 10-325 mg tab, 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab 1 PERCOCET QL(20 / 15)

tramadol hcl 50 mg tab 1 ULTRAM QL(20 / 15)



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




tramadol-acetaminophen 37.5-325 mg tab 1 ULTRACET QL(20 / 15)

ANTIBACTERIALS - DRUGS TO TREAT BACTERIAL INFECTIONS [ANTIBACTERIANOS - MEDICAMENTOS PARA TRATAR INFECCIONES BACTERIANAS]

Aminoglycosides - Antibiotics [Aminoglucósidos - Antibióticos]

gentamicin sulfate 0.1 % oint 1 GARAMYCIN PA, QL(15 / 14)

gentamicin sulfate 0.1 % crm 1 GARAMYCIN PA, QL(30 / 14)

neomycin sulfate 500 mg tab 1 QL(42 / 14)

Antibacterials, Other - Antibiotics [Antibacterianos, Otros - Antibióticos]

clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap 1 CLEOCIN QL(56 / 14)

metronidazole 250 mg tab, 500 mg tab 1 FLAGYL QL(56 / 14)

mupirocin 2 % oint 1 BACTROBAN PA, QL(22 / 14)

mupirocin calcium 2 % crm 1 BACTROBAN PA, QL(22 / 14)

nitrofurantoin 25 mg/5ml susp 1 QL(240 / 14)

nitrofurantoin macrocrystal 100 mg cap, 25 mg cap, 50 mg cap 1 MACRODANTIN QL(56 / 14)

nitrofurantoin monohyd macro 100 mg cap 1 MACROBID QL(56 / 14)

silver sulfadiazine 1 % crm 1 SILVADENE PA, QL(50 / 14)

Beta-lactam, Cephalosporins - Antibiotics [Beta-Lactámicos, Cefalosporinas - Antibióticos]

cefaclor 250 mg cap, 500 mg cap 1 CECLOR QL(42 / 14)

cefaclor er 500 mg tab er 12 hr 1 CECLOR CD QL(42 / 14)

cefadroxil 1 gm tab, 500 mg cap 1 DURICEF QL(28 / 14)

cefadroxil 250 mg/5ml susp, 500 mg/5ml susp 1 DURICEF QL(100 / 14)

cefdinir 300 mg cap 1 OMNICEF QL(28 / 14)

cefdinir 125 mg/5ml susp, 250 mg/5ml susp 1 OMNICEF QL(100 / 14)

cefpodoxime proxetil 100 mg tab, 200 mg tab 1 VANTIN QL(28 / 14)

cefpodoxime proxetil 100 mg/5ml susp, 50 mg/5ml susp 1 VANTIN QL(100 / 14)

cefprozil 250 mg tab, 500 mg tab 1 CEFZIL QL(28 / 14)

cefprozil 125 mg/5ml susp 1 CEFZIL QL(100 / 14)

cefprozil 250 mg/5ml susp 2 CEFZIL QL(100 / 14)

cefuroxime axetil 250 mg tab, 500 mg tab 1 CEFTIN QL(28 / 14)

cephalexin 250 mg tab, 500 mg tab 1 QL(56 / 14)

cephalexin 250 mg cap, 500 mg cap, 750 mg cap 1 KEFLEX QL(56 / 14)



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




cephalexin 125 mg/5ml susp, 250 mg/5ml susp 1 KEFLEX QL(100 / 14)

Beta-lactam, Penicillins - Antibiotics [Beta-Lactámicos, Penicilinas - Antibióticos]

amoxicillin 125 mg tab chew, 250 mg cap, 250 mg tab chew, 500 mg cap, 500 mg tab 1 AMOXIL QL(42 / 14)

amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg/5ml susp, 400 mg/5ml susp 1 AMOXIL QL(100 / 14)

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 QL(42 / 14)

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 QL(100 / 14)

ampicillin 500 mg cap 1 QL(56 / 14)

penicillin v potassium 500 mg tab 1 PEN-VEE K QL(56 / 14)

penicillin v potassium 250 mg tab 1 VEETIDS QL(56 / 14)

Macrolides - Antibiotics [Macrólidos - Antibióticos]

azithromycin 250 mg tab, 500 mg tab 1 ZITHROMAX QL(6 / 5)

azithromycin 100 mg/5ml susp, 200 mg/5ml susp 1 ZITHROMAX QL(100 / 14)

clarithromycin 250 mg tab, 500 mg tab 1 BIAXIN QL(28 / 14)

clarithromycin 125 mg/5ml susp, 250 mg/5ml susp 1 BIAXIN QL(28 / 14)

clarithromycin er 500 mg tab er 24 hr 1 BIAXIN XL QL(28 / 14)

ERYTHROCIN STEARATE 250 mg tab 1 QL(56 / 14)

erythromycin base 250 mg cap dr prt, 250 mg tab 1 QL(56 / 14)

erythromycin base 500 mg tab 1 ERY-TAB QL(56 / 14)

erythromycin ethylsuccinate pwdr 1 QL(56 / 14)

erythromycin ethylsuccinate 400 mg tab 1 E.E.S. QL(56 / 14)

erythromycin ethylsuccinate 200 mg/5ml susp 1 ERYPED QL(100 / 14)

Quinolones - Antibiotics [Quinolonas - Antibióticos]

ciprofloxacin hcl 250 mg tab 1 CIPRO QL(28 / 10)



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




ciprofloxacin hcl 100 mg tab, 500 mg tab, 750 mg tab 1 CIPRO QL(28 / 14)

levofloxacin 250 mg tab, 500 mg tab, 750 mg tab 1 LEVAQUIN QL(14 / 14)

moxifloxacin hcl 400 mg tab 1 AVELOX QL(14 / 14)

ofloxacin 300 mg tab, 400 mg tab 1 FLOXIN QL(28 / 14)

Sulfonamides - Antibiotics [Sulfonamidas - Antibióticos]

sulfamethoxazole-trimethoprim 400-80 mg tab, 800-160 mg tab 1 SEPTRA QL(28 / 14)

sulfamethoxazole-trimethoprim 200-40 mg/5ml susp 1 SEPTRA QL(100 / 14)

Tetracyclines - Antibiotics [Tetraciclinas - Antibióticos]

doxycycline hyclate 20 mg tab 1 PERIOSTAT QL(28 / 14)

doxycycline hyclate 100 mg tab 1 VIBRA-TABS QL(28 / 14)

doxycycline hyclate 100 mg cap, 50 mg cap 1 VIBRAMYCIN QL(28 / 14)

doxycycline monohydrate 25 mg/5ml susp 1 VIBRAMYCIN QL(100 / 14)

tetracycline hcl 250 mg cap, 500 mg cap 1 QL(56 / 14)

VIBRAMYCIN 50 mg/5ml syr 1 QL(100 / 14)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES [ANTICONVULSIVOS - MEDICAMENTOS PARA TRATAR CONVULSIONES]

Anticonvulsants, Other - Seizure Control Drugs [Anticonvulsivos, Otros - Medicamentos Para El Control De Convulsiones]

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

levetiracetam 100 mg/ml soln 1 KEPPRA PA

Calcium Channel Modifying Agents - Seizure Control Drugs [Agentes Modificadores De Los Canales De Calcio - Medicamentos Para El Control De Convulsiones]

ethosuximide 250 mg cap 1 ZARONTIN PA

Gamma-aminobutyric Acid (gaba) Augmenting Agents - Seizure Control Drugs [Agentes Que Aumentan El Ácido Gamma-Aminobutírico (Gaba) - Medicamentos Para El Control De Convulsiones]

clonazepam 0.5 mg tab, 1 mg tab, 2 mg tab 1 KLONOPIN PA

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

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

gabapentin 600 mg tab, 800 mg tab 1 NEURONTIN PA



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




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

gabapentin 100 mg cap, 300 mg cap, 400 mg cap 1 NEURONTIN PA, QL(60 / 30)

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 PA

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

primidone 250 mg tab, 50 mg tab 1 MYSOLINE PA

valproate sodium 100 mg/ml iv soln, 500 mg/5ml iv soln 1 DEPACON PA

valproic acid 250 mg cap 1 DEPAKENE PA

valproic acid 250 mg/5ml soln 1 DEPAKENE PA

Glutamate Reducing Agents - Seizure Control Drugs [Agentes Reductores De Glutamato - Medicamentos Para El Control De Convulsiones]

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

Sodium Channel Agents - Seizure Control Drugs [Agentes De Los Canales De Sodio - Medicamentos Para El Control De Convulsiones]

carbamazepine 100 mg tab chew, 200 mg tab 1 TEGRETOL PA

carbamazepine 100 mg/5ml susp 1 TEGRETOL PA

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

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

levetiracetam 500 mg/5ml iv soln 1 KEPPRA PA

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

oxcarbazepine 300 mg/5ml susp 2 TRILEPTAL PA

phenytoin 50 mg tab chew 1 DILANTIN PA

phenytoin 125 mg/5ml susp 1 DILANTIN PA

PHENYTOIN INFATABS 50 mg tab chew 1 PA

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

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION [ANTIDEPRESIVOS - MEDICAMENTOS PARA TRATAR LA DEPRESIÓN]



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




Antidepressants, Other - Antidepressants [Antidepresivos, Otros - Antidepresivos]

bupropion hcl 100 mg tab, 75 mg tab 1 WELLBUTRIN PA

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 PA

bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr 1 WELLBUTRIN XL PA

Ssris/snris (selective Serotonin Reuptake Inhibitors/serotonin And Norepinephrine Reuptake Inhibitor) - Antidepressants [Isrss/Irsns (Inhibidores Selectivos De La Recaptación De Serotonina/Inhibidores De La Recaptación De Serotonina Y Norepinefrina) - Antidepresivos]

citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab 1 CELEXA PA

fluoxetine hcl 10 mg cap, 20 mg cap, 40 mg cap 1 PROZAC PA

nefazodone hcl 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab, 50 mg tab 1 SERZONE PA

paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab 1 PAXIL PA

sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab 1 ZOLOFT PA

trazodone hcl 100 mg tab, 150 mg tab, 300 mg tab, 50 mg tab 1 DESYREL PA

venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab 1 EFFEXOR PA

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 PA

Tricyclics - Antidepressants [Tricíclicos - Antidepresivos]

amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab 1 ELAVIL PA

chlordiazepoxide-amitriptyline 10-25 mg tab, 5-12.5 mg tab 1 LIMBITROL PA

doxepin hcl 10 mg cap, 100 mg cap, 150 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 SINEQUAN PA

imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab 1 TOFRANIL PA



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 PAMELOR PA

ANTIEMETICS - DRUGS TO TREAT NAUSEA AND VOMITING [ANTIEMÉTICOS - MEDICAMENTOS PARA TRATAR NÁUSEA Y VÓMITO]

Antiemetics, Other - Nausea And Vomiting Drugs [Antieméticos, Otros - Medicamentos Para Náusea Y Vómito]

meclizine hcl 12.5 mg tab, 25 mg tab 1 ANTIVERT PA, QL(20 / 15)

metoclopramide hcl 10 mg tab, 5 mg tab 1 REGLAN PA, QL(20 / 15)

promethazine hcl 12.5 mg rect supp, 12.5 mg tab, 25 mg rect supp, 25 mg tab, 50 mg tab 1 PHENERGAN PA, QL(20 / 15)

promethazine hcl 6.25 mg/5ml soln, 6.25 mg/5ml syr 1 PHENERGAN PA, QL(20 / 15)

PROMETHEGAN 12.5 mg rect supp, 25 mg rect supp, 50 mg rect supp 1 PA, QL(20 / 15)

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS [ANTIFUNGALES - MEDICAMENTOS PARA TRATAR INFECCIONES FÚNGICAS]

Antifungals - Fungal Infection Drugs [Antifungales - Medicamentos Para Infección Fúngica]

clotrimazole-betamethasone 1-0.05 % crm 1 LOTRISONE PA

clotrimazole-betamethasone 1-0.05 % lot 1 LOTRISONE PA

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

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

nystatin pwdr 1 PA

nystatin 500000 unit tab 1 MYCOSTATIN

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

nystatin 100000 unit/ml m/t susp 1 MYCOSTATIN PA

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

ANTIPSYCHOTICS - DRUGS TO TREAT MOOD DISORDERS [ANTIPSICÓTICOS - MEDICAMENTOS PARA TRATAR TRASTORNOS DEL ESTADO DE ÁNIMO]

1st Generation/typical - Mood Disorder Drugs [1Era Generación/Típicos - Medicamentos Para Trastornos Del Estado De Ánimo]



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




chlorpromazine hcl 10 mg tab, 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 THORAZINE PA

haloperidol 0.5 mg tab, 1 mg tab, 10 mg tab, 2 mg tab, 20 mg tab, 5 mg tab 1 HALDOL PA

haloperidol decanoate 100 mg/ml im soln, 50 mg/ml im soln 1 HALDOL PA

haloperidol lactate 2 mg/ml oral conc, 5 mg/ml inj soln 1 HALDOL PA

perphenazine 16 mg tab, 2 mg tab, 4 mg tab, 8 mg tab 1 TRILAFON PA

thioridazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab 1 MELLARIL PA

thiothixene 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap 1 NAVANE PA

trifluoperazine hcl 1 mg tab, 10 mg tab, 2 mg tab, 5 mg tab 1 STELAZINE PA

2nd Generation/atypical - Mood Disorder Drugs [2Da Generación/Atípicos - Medicamentos Para Trastornos Del Estado De Ánimo]

quetiapine fumarate 100 mg tab, 200 mg tab, 25 mg tab, 300 mg tab, 400 mg tab, 50 mg tab 1 SEROQUEL PA

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 PA

risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab 1 RISPERDAL PA

ziprasidone hcl 20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap 1 GEODON PA

ANTISPASTICITY AGENTS [AGENTES CONTRA LA ESPASTICIDAD]

Antispasticity Agents [Agentes Contra La Espasticidad]

baclofen 10 mg tab, 20 mg tab 1 LIORESAL PA, QL(20 / 15)

dantrolene sodium 100 mg cap, 25 mg cap, 50 mg cap 1 DANTRIUM PA, QL(20 / 15)

tizanidine hcl 2 mg cap, 2 mg tab, 4 mg cap, 4 mg tab, 6 mg cap 1 ZANAFLEX PA, QL(20 / 15)

ANXIOLYTICS - DRUGS TO TREAT ANXIETY [ANSIOLÍTICOS - MEDICAMENTOS PARA TRATAR LA ANSIEDAD]

Anxiolytics, Other - Anxiety Drugs [Ansiolíticos, Otros - Medicamentos Para Ansiedad]



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




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

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

BIPOLAR AGENTS - DRUGS TO TREAT MOOD DISORDERS [AGENTES PARA BIPOLARIDAD - MEDICAMENTOS PARA TRATAR TRASTORNOS DEL ESTADO DE ÁNIMO]

Mood Stabilizers - Mood Disorder Drugs [Estabilizadores Del Ánimo - Medicamentos Para Trastornos Del Estado De Ánimo]

lithium 8 meq/5ml soln 1 PA

lithium carbonate 150 mg cap, 600 mg cap 1 PA

lithium carbonate 300 mg cap 1 ESKALITH PA

lithium carbonate 300 mg tab 1 LITHOBID PA

lithium carbonate er 450 mg tab er 1 ESKALITH CR PA

lithium carbonate er 300 mg tab er 1 LITHOBID PA

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS - DRUGS TO TREAT BLOOD DISORDERS [PRODUCTOS PARA LA SANGRE/MODIFICADORES/EXPANSORES DE VOLUMEN - MEDICAMENTOS PARA TRATAR TRASTORNOS DE LA SANGRE]

Anticoagulants - Blood Thinners [Anticoagulantes - Diluyentes De La Sangre]

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 1 LOVENOX PA, QL(42 / 21)

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 PA

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS TO TREAT NERVE CONDITIONS [AGENTES DEL SISTEMA NERVIOSO CENTRAL - MEDICAMENTOS PARA TRATAR CONDICIONES DE LOS NERVIOS]

Benzodiazepines - Anxiety Drugs [Benzodiazepinas - Medicamentos Para Ansiedad]

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

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

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

diazepam 5 mg/ml oral conc 1 PA



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




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

diazepam 5 mg/5ml soln 1 VALIUM PA

DIAZEPAM INTENSOL 5 mg/ml oral conc 1 PA

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

GASTROINTESTINAL AGENTS - DRUGS TO TREAT BOWEL, INTESTINE AND STOMACH CONDITIONS [AGENTES GASTROINTESTINALES - MEDICAMENTOS PARA TRATAR CONDICIONES INTESTINALES, INTESTINO Y ESTÓMAGO]

Laxatives - Drugs To Treat Constipation [Laxantes - Medicamentos Para Tratar El Estreñimiento]

ALOPHEN 5 mg tab dr 1 PA, QL(15 / 30)

bisacodyl 10 mg rect supp 1 PA, QL(15 / 30)

bisacodyl ec 5 mg tab dr 1 PA, QL(15 / 30)

bisacodyl laxative 10 mg rect supp 1 PA, QL(15 / 30)

constulose 10 gm/15ml soln 2 CONSTULOSE PA

correct 5 mg tab dr 1 PA, QL(15 / 30)

CORRECTOL 5 mg tab dr 1 PA, QL(15 / 30)

cvs bisacodyl 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

cvs c-lax laxative 5 mg tab dr 1 PA, QL(15 / 30)

cvs gentle laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

cvs gentle laxative womens 5 mg tab dr 1 PA, QL(15 / 30)

ducodyl 5 mg tab dr 1 PA, QL(15 / 30)

DULCOLAX 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

enulose 10 gm/15ml soln 1 CONSTULOSE PA

eq gentle laxative 5 mg tab dr 1 PA, QL(15 / 30)

eql gentle laxative 5 mg tab dr 1 PA, QL(15 / 30)

eql laxative 5 mg tab dr 1 PA, QL(15 / 30)

EX-LAX ULTRA 5 mg tab dr 1 PA, QL(15 / 30)

FEENAMINT 5 mg tab dr 1 PA, QL(15 / 30)

generlac 10 gm/15ml soln 1 CONSTULOSE PA

gentle laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

GNP BISA-LAX 5 mg tab dr 1 PA, QL(15 / 30)

gnp gentle laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




gnp womens gentle laxative 5 mg tab dr 1 PA, QL(15 / 30)

goodsense bisacodyl ec 5 mg tab dr 1 PA, QL(15 / 30)

goodsense womens laxative 5 mg tab dr 1 PA, QL(15 / 30)

hm laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

kp bisacodyl 5 mg tab dr 1 PA, QL(15 / 30)

lactulose 10 gm/15ml soln 1 CONSTULOSE PA

lactulose encephalopathy 10 gm/15ml soln 1 CONSTULOSE PA

laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

px laxative 5 mg tab dr 1 PA, QL(15 / 30)

qc gentle laxative 10 mg rect supp, 5 mg tab dr 1 PA, QL(15 / 30)

ra fast relief laxative 10 mg rect supp 1 PA, QL(15 / 30)

ra laxative 5 mg tab dr 1 PA, QL(15 / 30)

ra womens laxative 5 mg tab dr 1 PA, QL(15 / 30)

sb bisacodyl laxative ec 5 mg tab dr 1 PA, QL(15 / 30)

sb gentle lax-women 5 mg tab dr 1 PA, QL(15 / 30)

sb laxative 10 mg rect supp 1 PA, QL(15 / 30)

sm gentle laxative 5 mg tab dr 1 PA, QL(15 / 30)

sm laxative 10 mg rect supp 1 PA, QL(15 / 30)

tgt gentle laxative 5 mg tab dr 1 PA, QL(15 / 30)

tgt womens laxative 5 mg tab dr 1 PA, QL(15 / 30)

THE MAGIC BULLET 10 mg rect supp 1 PA, QL(15 / 30)

veracolate 5 mg tab dr 1 PA, QL(15 / 30)

womans laxative 5 mg tab dr 1 PA, QL(15 / 30)

womens laxative 5 mg tab dr 1 PA, QL(15 / 30)

Proton Pump Inhibitors - Ulcer And Stomach Acid Drugs [Inhibidores De La Bomba De Protones - Medicamentos Para Úlceras Y Ácido Estomacal]

omeprazole 20 mg cap dr 1 PRILOSEC PA, QL(180 / 365)

GENITOURINARY AGENTS - DRUGS TO TREAT BLADDER, GENITAL AND KIDNEY CONDITIONS [AGENTES GENITOURINARIOS - MEDICAMENTOS PARA TRATAR CONDICIONES DE LA VEJIGA, GENITALES Y RENALES]

Antispasmodics, Urinary - Bladder Control Drugs [Antiespasmódicos, Urinarios - Medicamentos Para Control De La Vejiga]

oxybutynin chloride 5 mg tab 1 DITROPAN PA



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




oxybutynin chloride er 10 mg tab er 24 hr, 15 mg tab er 24 hr, 5 mg tab er 24 hr 1 DITROPAN PA

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, And Kidney Conditions Drugs [Agentes Genitourinarios, Otros - Medicamentos Para Condiciones De La Vejiga, Genitales Y Renales Misceláneos]

phenazopyridine hcl 100 mg tab, 200 mg tab 1 PA, QL(42 / 14)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) - DRUGS TO REGULATE HORMONES [AGENTES HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (ADRENALES) - MEDICAMENTOS PARA REGULAR LAS HORMONAS]

Hormonal Agents, Stimulant/replacement/modifying (adrenal) - Hormone Replacement/modifying Drugs [Agentes Hormonales, Estimulantes/Reemplazo/Modificador (Adrenales) - Medicamentos Para Reemplazo/Modificación De Hormonas]

dexamethasone 1 mg tab, 2 mg tab 1 PA

dexamethasone 0.5 mg/5ml soln 1 PA

dexamethasone 0.5 mg/5ml oral elix 1 BAYCADRON PA

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

KENALOG 40 mg/ml inj susp 2 PA, QL(1 / 30)

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

methylprednisolone acetate 40 mg/ml inj susp, 80 mg/ml inj susp 1 DEPO-MEDROL PA, QL(1 / 30)

prednisolone 15 mg/5ml soln 1 PRELONE PA

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 PA

triamcinolone acetonide 40 mg/ml inj susp 1 KENALOG PA, QL(1 / 30)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) - DRUGS TO REGULATE HORMONES [AGENTES HORMONALES, ESTIMULANTES/REEMPLAZO/MODIFICADOR (PITUITARIA) - MEDICAMENTOS PARA REGULAR LAS HORMONAS]

Hormonal Agents, Stimulant/replacement/modifying (pituitary) - Hormone Replacement/modifying Drugs [Agentes Hormonales, Estimulantes/Reemplazo/Modificador (Pituitaria) - Medicamentos Para Reemplazo/Modificación De Hormonas]



Update Date: 6/2021

Drug Name


Drug Tier

[Nivel]

Reference Name




desmopressin ace spray refrig 0.01 % nasal soln 1 MINIRIN PA

desmopressin acetate spray 0.01 % nasal soln 1 DDVAP PA

INFLAMMATORY BOWEL DISEASE AGENTS - DRUGS TO TREAT INFLAMMATORY BOWEL DISEASE [AGENTES PARA LA ENFERMEDAD INFLAMATORIA DEL INTESTINO - MEDICAMENTOS PARA TRATAR LA ENFERMEDAD INFLAMATORIA DEL INTESTINO]

Glucocorticoids - Drugs To Treat Inflammation [Glucocorticoides - Medicamentos Para Tratar Inflamación]

dexamethasone sod phosphate pf 10 mg/ml inj soln 1 PA

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

dexamethasone sodium phosphate 4 mg/ml inj soln 1 PA, QL(1 / 30)

dexamethasone sodium phosphate 10 mg/ml inj soln 1 HEXADROL PA

OPHTHALMIC AGENTS - DRUGS TO TREAT EYE CONDITIONS [AGENTES OFTÁLMICOS - MEDICAMENTOS PARA TRATAR CONDICIONES DE LOS OJOS]

Ophthalmic Agents, Other - Miscellaneous Eye Drugs [Agentes Oftálmicos, Otros - Medicamentos Misceláneos Para Los Ojos]

ak-poly-bac 500-10000 unit/gm ophth oint 2 POLYSPORIN PA, QL(3.5 / 14)

bacitracin-polymyxin b 500-10000 unit/gm ophth oint 1 POLYSPORIN PA, QL(3.5 / 14)

neomycin-bacitracin zn-polymyx 5-400-10000 ophth oint 1 NEOSPORIN PA, QL(3.5 / 14)

neomycin-polymyxin-gramicidin 1.75-10000-.025 ophth soln 1 NEOSPORIN PA, QL(5 / 14)

POLYCIN 500-10000 unit/gm ophth oint 1 PA, QL(3.5 / 14)

polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln 1 POLYTRIM PA, QL(10 / 14)

Ophthalmic Antibiotics - Drugs To Treat Eye Infections [Antibióticos Oftálmicos - Medicamentos Para Tratar Infecciones De Los Ojos]

bacitracin 500 unit/gm ophth oint 1 BACI-IM PA, QL(3.5 / 14)

ciprofloxacin hcl 0.3 % ophth soln 1 CILOXAN PA, QL(5 / 14)

erythromycin 5 mg/gm ophth oint 1 ILOTYCIN PA, QL(3.5 / 14)

gentamicin sulfate 0.3 % ophth soln 1 GARAMYCIN PA, QL(5 / 14)

ofloxacin 0.3 % ophth soln 1 OCUFLOX PA, QL(5 / 14)

tobramycin 0.3 % ophth soln 1 TOBREX PA, QL(5 / 14)



Update Date: 6/2021

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Drug Tier

[Nivel]

Reference Name




Ophthalmic Antiglaucoma Agents - Glaucoma Drugs [Agentes Oftálmicos Antiglaucoma - Medicamentos Para Glaucoma]

brimonidine tartrate 0.2 % ophth soln 1 ALPHAGAN PA

brimonidine tartrate 0.15 % ophth soln 1 ALPHAGAN P PA

carteolol hcl 1 % ophth soln 1 OCUPRESS PA

levobunolol hcl 0.5 % ophth soln 1 BETAGAN PA

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

Ophthalmic Anti-inflammatories - Allergy, Infection And Inflammation Drugs [Antiinflamatorios Oftálmicos - Medicamentos Para Alergia, Infección E Inflamación]

bacitra-neomycin-polymyxin-hc 1 % ophth oint 1 CORTISPORIN PA, QL(3.5 / 14)

dexamethasone sodium phosphate 0.1 % ophth soln 1 MAXIDEX PA

fluorometholone 0.1 % ophth susp 1 FML PA

flurbiprofen sodium 0.03 % ophth soln 1 OCUFEN PA

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth oint 1 MAXITROL PA, QL(3.5 / 14)

neomycin-polymyxin-dexameth 3.5-10000-0.1 ophth susp 1 MAXITROL PA, QL(5 / 14)

neomycin-polymyxin-hc 3.5-10000-1 ophth susp 1 CORTISPORIN PA, QL(7.5 / 14)

NEO-POLYCIN HC 1 % ophth oint 1 PA, QL(3.5 / 14)

prednisolone acetate 1 % ophth susp 1 PRED FORTE PA

prednisolone sodium phosphate 1 % ophth soln 1 PA

sulfacetamide-prednisolone 10-0.23 % ophth soln 1 VASOCIDIN PA

tobramycin-dexamethasone 0.3-0.1 % ophth susp 1 TOBRADEX PA, QL(5 / 14)

RESPIRATORY TRACT/PULMONARY AGENTS - DRUGS TO TREAT ALLERGIES, COUGH, COLD AND LUNG CONDITIONS [AGENTES PARA EL TRACTO RESPIRATORIO/PULMONAR - MEDICAMENTOS PARA TRATAR ALERGIAS, TOS, RESFRIADO, Y CONDICIONES DEL PULMÓN]

Antihistamines - Drugs To Treat Allergies [Antihistamínicos - Medicamentos Para Tratar Alergias]

BANOPHEN 50 mg cap 1 PA, QL(20 / 15)

diphenhydramine hcl 50 mg cap 1 PA, QL(20 / 15)

kp diphenhydramine hcl 50 mg cap 1 PA, QL(20 / 15)



Update Date: 6/2021

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[Nivel]

Reference Name




pharbedryl 50 mg cap 1 PA, QL(20 / 15)

Anti-inflammatories, Inhaled Corticosteroids - Asthma/lung Drugs [Antiinflamatorios, Corticosteroides Inhalados - Medicamentos Para Asma/Pulmón]

fluticasone propionate 50 mcg/act nasal susp 1 FLONASE PA, QL(1 / 730)

Bronchodilators, Sympathomimetic - Asthma/lung Drugs [Broncodilatadores, Simpatomiméticos - Medicamentos Para Asma/Pulmón]

albuterol sulfate 0.63 mg/3ml inh neb soln, 1.25 mg/3ml inh neb soln 1 ACCUNEB PA

albuterol sulfate 2.5 mg/0.5ml inh neb soln 1 PROVENTIL PA

albuterol sulfate (5 MG/ML) 0.5% inh neb soln 1 PROVENTIL PA

albuterol sulfate (2.5 MG/3ML) 0.083% inh neb soln 1 VENTOLIN PA

SKELETAL MUSCLE RELAXANTS - DRUGS TO TREAT MUSCLE TENSION AND SPASM [RELAJANTES MUSCULOESQUELÉTICOS - MEDICAMENTOS PARA TRATAR LA TENSIÓN MUSCULAR Y ESPASMO]

Skeletal Muscle Relaxants - Drugs For Muscle Pain And Spasm [Relajantes Musculoesqueléticos - Medicamentos Para Dolor Muscular Y Espasmo]

carisoprodol 350 mg tab 1 SOMA QL(30 / 30)

chlorzoxazone 500 mg tab 1 PARAFON QL(30 / 30)

cyclobenzaprine hcl 10 mg tab 1 FLEXERIL QL(30 / 30)

methocarbamol 500 mg tab, 750 mg tab 1 ROBAXIN QL(30 / 30)

orphenadrine citrate 30 mg/ml inj soln 1 NORFLEX QL(6 / 25)

orphenadrine citrate er 100 mg tab er 12 hr 1 NORFLEX QL(30 / 30)

SLEEP DISORDER AGENTS - DRUGS FOR SEDATION AND SLEEP [AGENTES DEL SISTEMA NERVIOSO CENTRAL - MEDICAMENTOS PARA TRATAR CONDICIONES DE LOS NERVIOS]

Gaba Receptor Modulators - Drugs For Sleeping [Benzodiazepinas - Medicamentos Para Ansiedad]

estazolam 1 mg tab, 2 mg tab 1 PROSOM PA, QL(30 / 30)

flurazepam hcl 15 mg cap, 30 mg cap 1 DALMANE PA, QL(30 / 30)

temazepam 15 mg cap, 22.5 mg cap, 30 mg cap, 7.5 mg cap 1 RESTORIL PA, QL(30 / 30)

zolpidem tartrate 10 mg tab, 5 mg tab 1 AMBIEN PA



Update Date: 6/2021

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Drug Tier

[Nivel]

Reference Name




THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES [NUTRIENTES/MINERALES Y ELECTROLITOS TERAPÉUTICOS]

Electrolyte/mineral Replacement - Vitamin, Mineral And Body Fluid Deficiency Drugs [Reemplazo De Electrolitos/Minerales - Medicamentos Para Deficiencia De Vitaminas, Minerales Y Fluidos Corporales]

ferrous sulfate 325 (65 Fe) mg tab 1

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES - DRUGS TO TREAT VITAMIN, MINERAL AND BODY FLUID DEFICIENCIES [NUTRIENTES TERAPÉUTICOS/MINERALES/ELECTROLITOS - MEDICAMENTOS PARA TRATAR DEFICIENCIAS DE VITAMINAS, MINERALES Y FLUIDOS CORPORALES]

Electrolyte/mineral Replacement - Vitamin, Mineral And Body Fluid Deficiency Drugs [Reemplazo De Electrolitos/Minerales - Medicamentos Para Deficiencia De Vitaminas, Minerales Y Fluidos Corporales]

folic acid 1 mg tab 1



Update Date: 6/2021

Index

A

acetaminophen-codeine .................................. 5 acetaminophen-codeine #2 ............................. 5 acetaminophen-codeine #3 ............................. 5 acetaminophen-codeine #4 ............................. 5 ak-poly-bac ................................................... 17 albuterol sulfate ............................................. 19 ALOPHEN ..................................................... 14 alprazolam .................................................... 13 amitriptyline hcl ............................................. 10 amoxicillin ....................................................... 7 amoxicillin-pot clavulanate .............................. 7 ampicillin ......................................................... 7 azithromycin .................................................... 7

B

bacitracin....................................................... 17 bacitracin-polymyxin b .................................. 17 bacitra-neomycin-polymyxin-hc ..................... 18 baclofen ........................................................ 12 BANOPHEN .................................................. 18 bisacodyl ....................................................... 14 bisacodyl ec .................................................. 14 bisacodyl laxative .......................................... 14 brimonidine tartrate ....................................... 18 bupropion hcl ................................................ 10 bupropion hcl er (sr) ...................................... 10 bupropion hcl er (xl) ...................................... 10 buspirone hcl ................................................. 13

C

carbamazepine ............................................... 9 carbamazepine er ........................................... 9 carisoprodol .................................................. 19 carteolol hcl ................................................... 18 cefaclor ........................................................... 6 cefaclor er ....................................................... 6 cefadroxil......................................................... 6 cefdinir ............................................................ 6 cefpodoxime proxetil ....................................... 6 cefprozil........................................................... 6 cefuroxime axetil ............................................. 6 cephalexin ................................................... 6, 7 chlordiazepoxide hcl ..................................... 13 chlordiazepoxide-amitriptyline ....................... 10 chlorpromazine hcl ........................................ 12 chlorzoxazone ............................................... 19

ciprofloxacin hcl ..................................... 7, 8, 17 citalopram hydrobromide ............................... 10 clarithromycin .................................................. 7 clarithromycin er .............................................. 7 clindamycin hcl ................................................ 6 clonazepam ..................................................... 8 clorazepate dipotassium ................................ 13 clotrimazole-betamethasone ......................... 11 compoz ............................................................ 4 constulose ..................................................... 14 correct ........................................................... 14 CORRECTOL ................................................ 14 cvs bisacodyl ................................................. 14 cvs c-lax laxative ........................................... 14 cvs gentle laxative ......................................... 14 cvs gentle laxative womens ........................... 14 cvs sleep aid nighttime .................................... 4 cvs sleep-aid nighttime .................................... 4 cyclobenzaprine hcl ....................................... 19

D

dantrolene sodium ......................................... 12 desmopressin ace spray refrig ...................... 17 desmopressin acetate spray ......................... 17 dexamethasone ............................................. 16 dexamethasone sod phosphate pf ................ 17 dexamethasone sodium phosphate ........ 17, 18 diazepam ................................................. 13, 14 DIAZEPAM INTENSOL ................................. 14 diclofenac potassium ....................................... 4 diclofenac sodium ........................................... 4 diclofenac sodium er ....................................... 4 diphenhydramine hcl ..................................... 18 divalproex sodium ........................................... 8 divalproex sodium er ....................................... 8 doxepin hcl .................................................... 10 doxycycline hyclate ......................................... 8 doxycycline monohydrate ................................ 8 ducodyl .......................................................... 14 DULCOLAX ................................................... 14

E

endocet ........................................................... 5 enoxaparin sodium ........................................ 13 enulose .......................................................... 14 eq gentle laxative .......................................... 14 eq nighttime sleep aid max st .......................... 4



Update Date: 6/2021

eql gentle laxative ......................................... 14 eql laxative .................................................... 14 eql sleep aid .................................................... 4 ERYTHROCIN STEARATE ............................ 7 erythromycin ................................................. 17 erythromycin base ........................................... 7 erythromycin ethylsuccinate ............................ 7 estazolam...................................................... 19 ethosuximide ................................................... 8 EX-LAX ULTRA ............................................ 14

F

FEENAMINT ................................................. 14 ferrous sulfate ............................................... 20 fluconazole .................................................... 11 fluorometholone ............................................ 18 fluoxetine hcl ................................................. 10 flurazepam hcl ............................................... 19 flurbiprofen ...................................................... 4 flurbiprofen sodium ....................................... 18 fluticasone propionate ................................... 19 folic acid ........................................................ 20

G

gabapentin .................................................. 8, 9 generlac ........................................................ 14 gentamicin sulfate ..................................... 6, 17 gentle laxative ............................................... 14 GNP BISA-LAX ............................................. 14 gnp gentle laxative ........................................ 14 gnp womens gentle laxative .......................... 15 goodsense bisacodyl ec ................................ 15 goodsense sleep aid ....................................... 4 goodsense womens laxative ......................... 15

H

haloperidol .................................................... 12 haloperidol decanoate ................................... 12 haloperidol lactate ......................................... 12 hm laxative .................................................... 15 hydrocodone-acetaminophen .......................... 5 hydroxyzine pamoate .................................... 13

I

IBU .................................................................. 4 ibuprofen ......................................................... 4 imipramine hcl ............................................... 10 indomethacin ................................................... 4 indomethacin er .............................................. 4

K

KENALOG ..................................................... 16 ketoprofen ....................................................... 4 ketoprofen er ................................................... 4 ketorolac tromethamine ................................... 5 kp bisacodyl .................................................. 15 kp diphenhydramine hcl ................................ 18

L

lactulose ........................................................ 15 lactulose encephalopathy .............................. 15 lamotrigine ....................................................... 9 laxative .......................................................... 15 levetiracetam ............................................... 8, 9 levobunolol hcl .............................................. 18 levofloxacin ..................................................... 8 lithium ............................................................ 13 lithium carbonate ........................................... 13 lithium carbonate er ....................................... 13 lorazepam ..................................................... 14 LORCET .......................................................... 5

M

meclizine hcl .................................................. 11 meloxicam ....................................................... 5 methocarbamol ............................................. 19 methylprednisolone ....................................... 16 methylprednisolone acetate .......................... 16 metoclopramide hcl ....................................... 11 metronidazole .................................................. 6 moxifloxacin hcl ............................................... 8 mupirocin ......................................................... 6 mupirocin calcium............................................ 6

N

nabumetone .................................................... 5 naproxen ......................................................... 5 naproxen sodium ............................................. 5 nefazodone hcl .............................................. 10 neomycin sulfate ............................................. 6 neomycin-bacitracin zn-polymyx ................... 17 neomycin-polymyxin-dexameth ..................... 18 neomycin-polymyxin-gramicidin .................... 17 neomycin-polymyxin-hc ................................. 18 NEO-POLYCIN HC ....................................... 18 nitrofurantoin ................................................... 6 nitrofurantoin macrocrystal .............................. 6 nitrofurantoin monohyd macro ......................... 6 NORCO ........................................................... 5



Update Date: 6/2021

nortriptyline hcl .............................................. 11 nystatin ......................................................... 11 nystatin-triamcinolone ................................... 11

O

ofloxacin .................................................... 8, 17 omeprazole ................................................... 15 ormir ................................................................ 4 orphenadrine citrate ...................................... 19 orphenadrine citrate er .................................. 19 oxcarbazepine ................................................. 9 oxybutynin chloride ....................................... 15 oxybutynin chloride er ................................... 16 oxycodone-acetaminophen ............................. 5

P

paroxetine hcl ................................................ 10 penicillin v potassium ...................................... 7 perphenazine ................................................ 12 pharbedryl ..................................................... 19 phenazopyridine hcl ...................................... 16 phenobarbital .................................................. 9 phenytoin ........................................................ 9 PHENYTOIN INFATABS................................. 9 phenytoin sodium extended ............................ 9 piroxicam......................................................... 5 POLYCIN ...................................................... 17 polymyxin b-trimethoprim .............................. 17 prednisolone ................................................. 16 prednisolone acetate ..................................... 18 prednisolone sodium phosphate ................... 18 prednisone .................................................... 16 primidone ........................................................ 9 promethazine hcl ........................................... 11 PROMETHEGAN .......................................... 11 px laxative ..................................................... 15

Q

qc gentle laxative .......................................... 15 qc sleep aid max st ......................................... 4 qc sleep-aid max st ......................................... 4 quetiapine fumarate ...................................... 12 quetiapine fumarate er .................................. 12

R

ra fast relief laxative ...................................... 15 ra laxative...................................................... 15 ra sleep aid ..................................................... 4 ra womens laxative ....................................... 15

risperidone .................................................... 12

S

sb bisacodyl laxative ec ................................. 15 sb gentle lax-women ..................................... 15 sb laxative ..................................................... 15 sertraline hcl .................................................. 10 silver sulfadiazine ............................................ 6 sleep-aid .......................................................... 4 sm gentle laxative.......................................... 15 sm laxative .................................................... 15 sulfacetamide-prednisolone .......................... 18 sulfamethoxazole-trimethoprim ....................... 8 sulindac ........................................................... 5

T

temazepam ................................................... 19 tetracycline hcl ................................................ 8 tgt gentle laxative .......................................... 15 tgt sleep aid max strength ............................... 4 tgt womens laxative ....................................... 15 THE MAGIC BULLET .................................... 15 thioridazine hcl .............................................. 12 thiothixene ..................................................... 12 timolol maleate .............................................. 18 tizanidine hcl ................................................. 12 tobramycin ..................................................... 17 tobramycin-dexamethasone .......................... 18 tramadol hcl ..................................................... 5 tramadol-acetaminophen ................................. 6 trazodone hcl ................................................. 10 triamcinolone acetonide ................................ 16 trifluoperazine hcl .......................................... 12

U

UNISOM SLEEPGELS .................................... 4

V

valproate sodium ............................................. 9 valproic acid .................................................... 9 venlafaxine hcl .............................................. 10 venlafaxine hcl er .......................................... 10 veracolate ...................................................... 15 VIBRAMYCIN .................................................. 8

W

wal-som maximum strength ............................ 4 warfarin sodium ............................................. 13 womans laxative ............................................ 15 womens laxative ............................................ 15



Update Date: 6/2021

Z

ziprasidone hcl .............................................. 12

zolpidem tartrate ........................................... 19

PA = Prior Authorization [Pre Autorización]; QL = Quantity ......Aminoglycosides - Antibiotics...

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Transcript of PA = Prior Authorization [Pre Autorización]; QL = Quantity ......Aminoglycosides - Antibiotics...