CIGNA-HEALTHSPRING® COMPREHENSIVE DRUG LIST

Transcripción

2015
CIGNA-HEALTHSPRING®
COMPREHENSIVE DRUG LIST
(Formulary)
Lista de medicamentos completa
de Cigna-HealthSpring
(Formulario)
Please read: This document contains information about all of the drugs we cover in this plan.
Favor de leer: Este documento incluye información sobre todos los medicamentos que se cubren
con este plan.
Plan covered / Plan en cobertura
Cigna-HealthSpring Rx℠ Secure-Xtra (PDP)
This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring Rx
Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m., local time, 7 days a week. (From February 15 – September 30,
Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST, customer service agents available. Messaging
service used weekends after hours). Or visit www.cignahealthspring.com. Esta lista de medicamentos se actualizó en agosto de 2014.
Para información más reciente u otras preguntas, favor de contactar al Departamento de servicio al cliente de Cigna-HealthSpring Rx,
al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de
septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros
representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio
de contestadora automática). O visite www.cignahealthspring.com.
Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid
programs. Enrollment in Cigna-HealthSpring depends on contract renewal. Cigna-HealthSpring tiene contrato con Medicare para
planes PDP, y planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción en Cigna-HealthSpring
depende de la renovación de contrato.
HPMS Approved Formulary File Submission ID 15150, Version Number 6 Y0036_15_18973bBL_Final_6 Approved 08152014
Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still
contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cigna-HealthSpring Rx. When it refers to “plan” or “our plan,”
it means Cigna-HealthSpring Rx Secure-Xtra (PDP).
This document includes a list of the drugs for our plan which is current as of August 2014. For an updated drug list, please contact
us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or
copayments/coinsurance may change on January 1, 2016, and from time to time during the year.
What is the Cigna-HealthSpring Rx Comprehensive Drug List?
A drug list is a list of covered drugs selected by Cigna-HealthSpring Rx in consultation with a team of health care providers, which
represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring Rx will
generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a CignaHealthSpring Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
Can the Drug List (formulary) change?
Generally, if you are taking a drug on our 2015 drug list that was covered at the beginning of the year, we will not discontinue or
reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available
or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such
as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the
same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have
continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for
cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a
drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes
effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the
drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.
The enclosed drug list is current as of August 2014. To get updated information about the drugs covered by Cigna-HealthSpring
Rx, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made
to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our
website are reviewed and updated on a monthly basis.
How do I use the Drug List?
There are two ways to find your drug within the drug list:
Medical Condition
The drug list begins on page 32. The drugs in this drug list are grouped into categories depending on the type of medical
conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category,
“CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on
page 32. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Alphabetical Drug List section that begins on
page 1. The Alphabetical Drug List provides a list of all of the drugs included in this document. Both brand name drugs and
generic drugs are in the Drug List. Look in the Alphabetical Drug List section of the document and find your drug. Next to your
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drug, you will see the drug tier, requirements/limits (Reqs./Limits), and page number where you can find coverage information.
Turn to the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.
What are generic drugs?
Cigna-HealthSpring Rx covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the
same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
 Prior Authorization: Cigna-HealthSpring Rx requires you or your doctor to get prior authorization for certain drugs. This
means that you will need to get approval from Cigna-HealthSpring Rx before you fill your prescriptions. If you don’t get
approval, Cigna-HealthSpring Rx may not cover the drug.
 Quantity Limits: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will
cover. For example, Cigna-HealthSpring Rx provides 30 (tablets) per prescription for CRESTOR. This may be in addition
to a standard one-month or three-month supply.
 Step Therapy: In some cases, Cigna-HealthSpring Rx requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical
condition, Cigna-HealthSpring Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you,
Cigna-HealthSpring Rx will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. You can
also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online
documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact
information, along with the date we last updated the drug list, appears on the front and back cover pages.
You can ask Cigna-HealthSpring Rx to make an exception to these restrictions or limits or for a list of other, similar drugs that may
treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring Rx’s drug list?” on page A4
for information about how to request an exception.
Options for Maintenance Medications
Taking the medications prescribed by your doctor is important to your health.
We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance
medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your
medications at least 80% of the time. There are several ways we can work together to accomplish this goal:
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Talk with your doctor about whether a 90 day supply of your ongoing, stable medications may be appropriate. Taking
these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these
medications can ensure that you don’t miss a dose.
You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.
Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.
How can I use my prescription drug coverage to save money on my medications?
There may be opportunities for you to save money on your medications using your Cigna-HealthSpring Rx coverage.
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Ask your doctor if there are any lower-cost generic alternatives available for any of your current medications.
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Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.
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If your medication is not covered on the Cigna-HealthSpring Rx drug list, talk with your doctor about alternative
medications which are covered in the drug list.
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What if my drug is not in the Drug List?
If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn
that Cigna-HealthSpring Rx does not cover your drug, you have two options:
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You can ask Customer Service for a list of similar drugs that are covered by Cigna-HealthSpring Rx. When you receive
the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring Rx.
You can ask Cigna-HealthSpring Rx to make an exception and cover your drug. See below for information about how to
request an exception.
How do I request an exception to the Cigna-HealthSpring Rx’s Drug List?
You can ask Cigna-HealthSpring Rx to make an exception to our coverage rules. There are several types of exceptions that you
can ask us to make.
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You can ask us to cover a drug even if it is not in our drug list. If approved, this drug will be covered at a pre-determined
cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
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You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring
Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and
cover a greater amount.
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You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier. If
your drug is contained in our Non-Preferred Brand tier or the Non-Preferred Generic tier, you can ask us to cover it at the
cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would
lower the amount you must pay for your drug. If your drug is contained in our Brand tier you can ask to cover it at the
cost-sharing amount that applies to drugs in the respective Generic tier if all generic alternatives in the lower cost tier
used to treat the same condition/disease are determined to be not as effective as the Brand. Please note, if we grant
your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the
drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.
Generally, Cigna-HealthSpring Rx will only approve your request for an exception if the alternative drugs included on the plan’s
drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or
would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you
request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or
doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed
by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours
after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug
that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can
fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request
a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action
for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.
For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day
supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply,
we will not pay for these drugs, even if you have been a customer of the plan less than 90 days.
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If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a
93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our
drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception.
In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as
level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring Rx will allow a onetime 31-day supply (unless the prescription is written for fewer days).
For more information
For more detailed information about your Cigna-HealthSpring Rx prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Cigna-HealthSpring Rx, please contact us. Our contact information, along with the date we last
updated the drug list, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Cigna-HealthSpring Rx’s Drug List
The comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx. If you have
trouble finding your drug in the list, turn to the Alphabetical Drug List that begins on page 1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed
in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Cigna-HealthSpring Rx has any special requirements for coverage
of your drug.
We provide quantity limits on certain drugs which are indicated with a QL in the Alphabetical Drug list on page 1 along with the
amount dispensed per the days supplied. (For example: CRESTOR 30/30; this means the drug CRESTOR is limited to 30 tablets
per 30 days).
Key:
B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be
covered under Medicare Part B or D depending on circumstances. Information may need to be submitted describing use
and setting of the drug to make the determination.
PA = This drug requires prior authorization
QL = This drug has quantity limits
ST = This drug has step therapy requirements
Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit
mailing a particular medication to your home.
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Nota para los clientes: Esta lista de medicamentos ha cambiado desde el año pasado. Favor de revisar el documento y
asegurarse de que los medicamentos que toma aún se encuentren en la lista.
Cuando esta lista de medicamentos (formulario) se refiera a “nosotros”, “nos”, o “nuestro”, esto significa Cigna-HealthSpring
Rx. Cuando se refiera al “plan” o “nuestro plan”, significa Cigna-HealthSpring Rx Secure-Xtra (PDP).
Este documento incluye una lista de los medicamentos para nuestro plan, la cual se actualizó en agosto de 2014. Para una
versión actualizada de la lista de medicamentos, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de
este folleto.
Por lo general, debe acudir a farmacias de la red para usar su beneficio de medicamentos recetados. Es posible que los
beneficios, el formulario, las farmacias de la red, y/o copagos/coseguros cambien el 1 de enero de 2016, y de vez en cuando
durante el año.
¿Qué es la Lista de medicamentos completa de Cigna-HealthSpring Rx?
Una lista de medicamentos es una lista de medicamentos que selecciona Cigna-HealthSpring Rx, en conjunto con un equipo de
proveedores de servicios de atención médica, y que representa las terapias con medicamentos recetados que se considera son
una parte esencial de un programa de tratamiento de calidad. En general, Cigna-HealthSpring Rx cubre los medicamentos
incluidos en nuestra lista de medicamentos, siempre que sean médicamente necesarios, la receta se surta en una farmacia de la
red de Cigna-HealthSpring Rx y se respeten las otras reglas del plan. Para más información sobre cómo surtir sus recetas,
consulte la Evidencia de cobertura.
¿Puede cambiar la Lista de medicamentos (Formulario)?
Por lo general, si está tomando un medicamento que se encontraba en nuestra Lista de medicamentos del 2015 a
principios del año, no dejaremos, ni reduciremos la cobertura del medicamento durante el año de cobertura del 2015, a
menos que ponga a la venta un medicamento genérico más económico o se presente información adversa sobre la
seguridad o efectividad del medicamento. Otros tipos de cambios que se hagan a la lista de medicamentos, como el retiro
de algún medicamento, no afectaran a clientes que estén tomando dicho medicamento. Éste seguirá estando disponible y
al mismo costo compartido para dichos clientes, por el resto del año de cobertura. Creemos que es muy importante que
tenga acceso continuo durante el año de cobertura a los medicamentos que estaban disponibles cuando seleccionó nuestro
plan, a menos que se presente la opción de que ahorre dinero o podamos garantizar su seguridad.
Si quitamos medicamentos de la lista de medicamentos, agregamos previa autorización, límites de cantidad y/o restricciones de
terapia escalonada a un medicamento o movemos un medicamento a un nivel de costo compartido más alto, debemos notificar a
los clientes que tomen dicho medicamento con al menos 60 días de anticipación a la fecha en que entre en vigencia el cambio o
cuando el cliente renueve el medicamento, momento en que recibirá un suministro de 60 días. Si la Food and Drug Administration
considera que un medicamento de nuestra lista de medicamentos es poco seguro o el fabricante lo retira del mercado,
retiraremos inmediatamente el medicamento de la lista de medicamentos y daremos aviso a los clientes que lo tomen. La lista de
medicamentos adjunta se actualizó en agosto de 2014. Para obtener información actualizada sobre los medicamentos que cubre
Cigna-HealthSpring Rx, por favor póngase en contacto con nosotros. Nuestra información aparece en la portada y al reverso de
este folleto. En caso de que se hagan cambios importantes a la lista de medicamentos impresa dentro del año en cobertura, es
posible que se le avise por correo sobre cuáles son los cambios. La lista de medicamentos de nuestra página de internet se
revisa y actualiza cada mes.
¿Cómo utilizo la Lista de medicamentos?
Existen dos formas de encontrar un medicamento en la lista de medicamentos:
Problema médico
La lista de medicamentos comienza en la página 32. Los medicamentos de esta lista de medicamentos están agrupados en
categorías por tipo de problema médico que tratan. Por ejemplo, los medicamentos para tratar una afección cardíaca se incluyen
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dentro de la categoría, “AGENTES CARDIOVASCULARES”. Si sabe para lo que se utiliza el medicamento, busque la categoría
en la lista que comienza en la página 32. Después, busque el medicamento bajo dicha categoría.
Lista por orden alfabético
Si no está seguro de la categoría bajo la cual debe buscar, busque el medicamento en la sección de la Lista por orden alfabético
de medicamentos que comienza en la página 1. La lista por orden alfabético de medicamentos proporciona un listado de todos
los medicamentos que aparecen en el documento. Tanto los medicamentos de marca como los genéricos están en la Lista de
medicamentos. Busque en la sección de la Lista por orden alfabético de medicamentos del documento y encuentre su
medicamento. Junto al medicamento, encontrará el nivel del medicamento, los límites/requisitos y el número de la página donde
puede encontrar información sobre la cobertura. Vaya a la página indicada en la sección de la Lista por orden alfabético de
medicamentos y localice el nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Cigna-HealthSpring Rx cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado
por la FDA por tener el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan
menos que los de marca.
¿Existe alguna restricción en la cobertura?
Algunos medicamentos que entran en cobertura pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y
límites pueden incluir:
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Autorización previa: Cigna-HealthSpring Rx exige que usted o su médico obtengan una autorización previa para ciertos
medicamentos. Esto significa que necesitará de la aprobación de Cigna-HealthSpring Rx antes de surtir sus recetas
médicas. Si no obtiene la aprobación, es posible que Cigna-HealthSpring Rx no cubra el medicamento.
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Límites de cantidad: Para ciertos medicamentos, Cigna-HealthSpring Rx limita la cantidad de medicamento que entran
en cobertura. Por ejemplo, Cigna-HealthSpring Rx proporciona 30 (tabletas) por receta médica de CRESTOR. Esto
puede ser, además de un suministro normal de un mes ó tres meses.
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Terapia escalonada: En algunos casos, Cigna-HealthSpring Rx le pedirá que pruebe primero con determinados
medicamentos para tratar su enfermedad, antes de cubrir otros. Por ejemplo, si un medicamento A y un medicamento B
sirven para tratar su condición médica, es posible que Cigna-HealthSpring Rx no cubra el medicamento B a menos que
usted pruebe el medicamento A, primero. Si el medicamento A no funciona, entonces Cigna-HealthSpring Rx cubrirá el
medicamento B.
Para saber si un medicamento tiene algún requisito o límite adicional, consulte la lista de medicamentos que comienza en la
página 1. Puede obtener más información sobre las restricciones que se aplican a ciertos medicamentos visitando nuestra
página de Internet. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y
terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la
fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este folleto.
Puede solicitarle a Cigna-HealthSpring Rx que haga una excepción a estas restricciones o límites, o pedirle una lista de otros
medicamentos similares que pueden tratar su condición de salud. Consulte la sección “¿Cómo solicito una excepción para la
Lista de medicamentos de Cigna-HealthSpring Rx?" en la página A8 para obtener información sobre cómo solicitar una
excepción.
Opciones para Medicamentos de Mantenimiento
Tomar los medicamentos que le receta su médico es importante para su salud.
Estamos comprometidos a ayudarle a que logre controlar sus enfermedades crónicas facilitándole la obtención de sus
medicamentos de mantenimiento. Como parte de nuestro compromiso para coordinar sus necesidades de atención médica, nos
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propusimos la meta de ayudarle a tomar sus medicamentos al menos el 80% del tiempo. Hay varias maneras en las que
podemos trabajar juntos para lograr esta meta:
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Hablar con su médico para saber si sería apropiado un suministro de 90 días de sus medicamentos fijos y regulares.
Tomar estos medicamentos todos los días exactamente como se los receta el médico es importante para su salud en
general, y recibir recetas por 90 días de estos medicamentos puede garantizar que usted no pierda ninguna dosis.
Puede recibir un suministro de 90 días en la mayoría de las farmacias de venta al menudeo o a través de una de
nuestras farmacias de orden por correo.
Hablar con su farmacéutico en caso de que tenga dificultades con sus medicamentos de mantenimiento.
¿Cómo puedo usar mi cobertura de medicamentos recetados para ahorrar dinero en la compra de mis medicamentos?
Es posible que haya oportunidades para que ahorre dinero en la compra de sus medicamentos al usar su cobertura de CignaHealthSpring Rx.
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Pregúntele a su médico si hay algunas alternativas genéricas de bajo costo disponibles para algunos de sus
medicamentos actuales.
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Investigue si el programa de ‘ayuda adicional de CMS’ puede ofrecer ayuda financiera adicional para sus medicamentos.
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Si su medicamento no entra en cobertura de la lista de medicamentos de Cigna-HealthSpring Rx, hable con su médico
sobre medicamentos alternos que entren en cobertura en la lista de medicamentos.
¿Qué pasa si mi medicamento no se encuentra la Lista de medicamentos?
En caso de que su medicamento no se incluya en esta lista de medicamentos, debe primero contactar al Departamento de
servicio al cliente y preguntar si su medicamento entra en cobertura. En caso de que le confirmen que Cigna-HealthSpring Rx no
cubre su medicamento, tiene dos opciones:
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Puede solicitar al Departamento de servicio al cliente una lista de medicamentos similares que entren en la cobertura de
Cigna-HealthSpring Rx. Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento similar que
entre en la cobertura de Cigna-HealthSpring Rx.
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Puede pedirle a Cigna-HealthSpring Rx que haga una excepción y cubra su medicamento. Consulte a continuación la
información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción a la Lista de medicamentos de Cigna-HealthSpring Rx?
Puede pedirle a Cigna-HealthSpring Rx que haga una excepción a sus reglas de cobertura. Existen varios tipos de excepciones
que puede solicitar que hagamos.
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Puede solicitarnos que cubramos un medicamento, incluso si no se encuentra en nuestra lista de medicamentos. Si lo
aprobamos, el medicamento se cubrirá a un nivel de costo compartido predeterminado, y no podrá solicitarnos que le
brindemos el medicamento a un nivel de costo compartido menor.
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Puede solicitarnos que retiremos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para
ciertos medicamentos, Cigna-HealthSpring Rx limita la cantidad de medicamento que cubrirá. Si su medicamento tiene
un límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.

Puede pedirnos que le demos una excepción de nivel para que cubramos un medicamento que tenga un costo
compartido mayor a un nivel de costo compartido menor. En caso de que su medicamento se encuentre en nuestro nivel
de medicamentos de marca no preferida o el nivel de medicamentos genéricos no preferidos, puede solicitarnos la
cobertura de su medicamento a la cantidad de pago compartido que se aplique al medicamento de marca preferida o
medicamentos genéricos preferidos. De esta manera se reduciría la cantidad que deba pagar por su medicamento. En
A8
caso de que su medicamento se encuentre en nuestro nivel de medicamentos de marca, puede solicitarnos la cobertura
de su medicamento a la cantidad de pago compartido que se aplique a los medicamentos en el nivel genérico respectivo
si todas las alternativas genéricas en el nivel de costo compartido menor usadas para tratar la misma
condición/enfermedad no son tan efectivas como el medicamento de marca. Recuerde que si aceptamos su solicitud
para cubrir un medicamento que no se encuentre en nuestra lista de medicamentos, es posible que no pueda pedirnos
que le demos un nivel más alto de cobertura para el medicamento. Además, es posible que no pueda pedirnos un nivel
más alto de cobertura por medicamentos que se encuentren en el nivel de medicamentos especiales.
Por lo general, Cigna-HealthSpring Rx sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en la
lista de medicamentos del plan, los medicamentos de un costo compartido más bajo o aquellos a los que se les aplican
restricciones de uso adicionales, no tuviesen la misma efectividad para tratar su enfermedad y/o le ocasionaran efectos médicos
adversos.
Póngase en contacto con nosotros para solicitar una decisión sobre la cobertura inicial en el caso de una excepción a la lista de
medicamentos, al nivel o a la restricción de uso. Cuando solicite una excepción a la lista de medicamentos, al nivel o a la
restricción de uso, debe presentar una declaración de su médico o la persona que le recete, que respalde su solicitud.
Por lo general, debemos tomar una decisión en un plazo de 72 horas, a partir del momento en que presente la declaración del
médico que le hizo la receta. Puede solicitar una respuesta más expedita (rápida) si usted o su médico creen que su salud
resultaría afectada por la espera del plazo de 72 horas para obtener una respuesta. En caso de que se autorice la respuesta
rápida, le daremos una respuesta en un término de 24 horas después de que recibamos la declaración de su médico o de la
persona que realizó la receta médica.
¿Qué debo hacer antes de decirle a mi médico que quiero cambiar mis medicamentos o solicitar una excepción?
Como cliente nuevo o continuo de nuestro plan, puede estar tomando medicamentos que no se encuentran en nuestra lista de
medicamentos. O bien, es posible que esté tomando un medicamento que se encuentre en nuestra lista de medicamentos, pero
su capacidad para obtenerlo es limitada. Por ejemplo, puede requerir de nuestra autorización previa antes de surtir sus recetas.
Hable con su médico para determinar si debe cambiar a un medicamento que entre en cobertura o solicitar una excepción a la
lista de medicamentos para que se cubra el medicamento que está tomando. Mientras habla con su médico para determinar la
medida correcta a seguir, podremos cubrir su medicamento en ciertos casos durante los primeros 90 días que sea cliente de
nuestro plan.
Para cada uno de los medicamentos que no se encuentran en nuestra lista de medicamentos, o que están limitados, daremos
una cobertura temporal de un suministro de 30 días (a menos que su receta indique un suministro de menos días) cuando acuda
a surtir su receta en un farmacia de la red. Después de su suministro de 30 días, dejaremos de cubrir el costo de estos
medicamentos, incluso si usted ha sido cliente de este plan por menos de 90 días.
Si usted vive en un centro de atención médica de largo plazo, le permitiremos volver a surtir su receta hasta que le hayamos
proporcionado un suministro de transición temporal de 93 días, consistente con el incremento de dispensación, (a menos que su
receta indique un suministro de menos días). Cubriremos más de un relleno (refill) de dichos medicamentos por los primeros 90
días que usted sea cliente de nuestro plan. En caso de que necesite de un medicamento que no se encuentre en la lista de
medicamentos o que esté limitado, y ya tenga más 90 días de su membresía en nuestro plan, cubriremos un suministro de
emergencia de 31 días del medicamento (a menos que su receta indique un suministro de menos días) mientras solicita que se
haga una excepción a la lista de medicamentos.
Para adaptar transiciones inesperadas de nuestros clientes que no permiten hacer planes con anticipación, como los cambios de
nivel de atención para pasar de un hospital a un centro de enfermería especializada o al hogar, Cigna-HealthSpring Rx permitirá
un único suministro de 31 días (a menos que la receta sea por menos días).
Para más información
Para obtener información más detallada sobre su cobertura de medicamentos recetados de Cigna-HealthSpring Rx, consulte su
Evidencia de cobertura y otros materiales del plan.
A9
Si tiene alguna pregunta sobre Cigna-HealthSpring Rx, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este
folleto.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE
(1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien,
visite http://www.medicare.gov.
Lista de medicamentos de Cigna-HealthSpring Rx
La lista de medicamentos completa siguiente ofrece información sobre la cobertura de todos los medicamentos que cubre CignaHealthSpring Rx. En caso de que tenga problemas para encontrar su medicamento en la lista, consulte la Lista por orden
alfabético de medicamentos que comienza en la página 1.
La primera columna de la tabla indica el nombre del medicamento. Los nombres de los medicamentos de marca están en
mayúscula (p. ej. CRESTOR) y los de medicamentos genéricos en minúscula y cursiva (p. ej. simvastatin).
La información en la columna de Requisitos/Límites indica si Cigna-HealthSpring Rx tiene algún requisito especial para la
cobertura de su medicamento.
Brindamos límites de cantidad para ciertos medicamentos que están indicados con QL en la lista por orden alfabético que
comienza en la página 1 junto con la cantidad despachada para los días suministrados. (Por ejemplo: CRESTOR 30/30; esto
significa que el medicamento CRESTOR está limitado a 30 cápsulas por 30 días).
Clave:
B/D = Este medicamento tiene un requisito de autorización de la Parte B vs la Parte D. El medicamento puede entrar en
cobertura con la Parte B o la D de Medicare, dependiendo de las circunstancias. Debe enviarse información que
describa el uso y la base del medicamento para tomar esta decisión.
PA =
Este medicamento requiere de autorización previa.
QL =
Este medicamento tiene límite de cantidad.
ST =
Este medicamento tiene requerimientos de terapia escalonada.
Generalmente todos los medicamentos de la lista de medicamentos están disponibles a través de la orden por correo, excepto
cuando existan situaciones o circunstancias especiales que prohíban el envío por correo de un medicamento en particular.
A10
Drug Tier and Cost-Share Table
The following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Non-Preferred Generic drugs. Tier number 3
is for Preferred Brand drugs. Tier number 4 is for Non-Preferred Brand drugs. Tier 5 is for Specialty tier drugs. You may also refer
to your Evidence of Coverage document for additional details.
To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in
which you are currently enrolled or would like to enroll.
Cigna-HealthSpring Rx Secure-Xtra (PDP) has pharmacies with preferred cost-shares. See your Pharmacy Directory for
information on which stores with preferred cost-shares are near you.
Tabla del nivel del medicamento y costo compartido
La siguiente tabla representa el nombre del plan, el área de servicio del plan, el número de nivel de medicamento, tal y como
aparece en la lista de medicamentos, y la cantidad de costo compartido para ese número de nivel. El nivel 1 es para los
medicamentos genéricos preferidos. El nivel 2 es el nivel para los medicamentos genéricos no preferidos. El nivel 3 es para los
medicamentos de marca preferida. El nivel 4 es el nivel para los medicamentos de marca no preferida. El nivel 5 es para los
medicamentos de especialidad. Su plan tiene un nivel llamado “Medicamentos en cobertura”. Por favor consulte la siguiente
tabla.] Para obtener más detalles, puede también consultar su Evidencia de cobertura
Para localizar el costo de su medicamento, por favor consulte la (s) tabla (s) que están a continuación para encontrar su
área de servicio y el plan de Medicamentos recetados en el que actualmente está inscrito o en el que le gustaría
inscribirse.
Cigna-HealthSpring Rx Secure-Xtra (PDP) tiene farmacias con costos compartidos preferidos. Consulte su Directorio de
farmacias para información sobre las tiendas con costos compartidos preferidos que están cerca de usted.
A11
All States
Todos los estados
Preferred Retail
Cost-Sharing
30, 60, 90 Days
Standard Retail
Cost-Sharing
30, 60, 90 Days
Preferred Mail
Order
Cost-Sharing
30 and 90 Days
Standard
Mail Order
CostSharing
30 and 90
Days
Long-Term
Care - 31 Days
Out-of-Network
- 30 Days*
Costo compartido
al menudeo
preferido
30, 60, 90 días
Costo
compartido al
menudeo
estándar
30, 60, 90 días
Costo
compartido
orden por
correo
preferido
30 y 90 días
30/60/90 Days
30/60/90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
30/90 Days
30/90 días
$1/$2/$3
$4/$8/$12
$1/$3
$4/$12
$4
$4/$8/$12
$10/$20/$30
$4/$12
$10/$30
$10
20%
22%
20%
22%
22%
35%
40%
35%
40%
40%
Cigna-HealthSpring Rx
Secure-Xtra (PDP)
Costo
compartido
orden por
correo
estándar
30 y 90 días
Atención a
largo plazo - 31
días
Fuera de la red
- 30 días*
Tier 1: Preferred
Generic Drugs
Nivel 1: Medicamentos
genéricos preferidos
Tier 2: Non-Preferred
Generic Drugs
genéricos no
preferidos
Tier 3: Preferred Brand
Drugs
de marca preferida
Tier 4: Non-Preferred
Brand Drugs
de marca no preferida
Tier 5: Specialty Tier
33%
33%
33%
33%
33%
de especialidad
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy
billed charge and our typical Standard Retail pharmacy billed costs.
*Pagará el copago o porcentaje del costo del medicamento que se menciona en la tabla, más la diferencia entre el monto que
cobra la farmacia fuera de la red y el costo típico de nuestra farmacia de venta al menudeo estándar.
A12
My Medications
In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug
list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before
this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer
Service, at 1-800-222-6700 or, for TTY users, 711, 8 am–8 pm, local time, 7 days a week. (From February 15–September 30,
Monday–Friday 8 am–8 pm local time, Saturday and Sunday 10 am–6 pm, EST, customer service agents available. Messaging
service used weekends after hours.) Or visit www.cignahealthspring.com.
Mis medicamentos
En esta sección puede escribir todos los medicamentos que toma actualmente; de esta manera, puede encontrar su
medicamento en las siguientes páginas de la lista de medicamentos, así como buscar y ver en qué nivel está su medicamento.
Una vez que encuentre el nivel en el que está su medicamento, puede buscar en las tablas anteriores a esta página y localizar su
costo compartido para ese medicamento. Si necesita ayuda para localizar sus medicamentos y el costo compartido, por favor
llame al Departamento de servicio al cliente al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 am a 8 pm, hora local, 7
días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y
domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al cliente estás disponibles. Si llama los fines
de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática). O visite www.cignahealthspring.com.
My Medications
Page Number in the Drug List
Mis medicamentos
Número de página en la Lista
de medicamentos
A13
Cost-Share through
Costo compartido a través de
Drug Name
A
abacavir
abacavir
sulfate/lamivudine/zidovudine
ABELCET
ABILIFY INJ
ABILIFY ORAL SOLN
ABILIFY TABS
ABILIFY DISCMELT
ABILIFY MAINTENA INJ
300MG
ABILIFY MAINTENA INJ
400MG
ABRAXANE
acamprosate calcium dr
acarbose
ACCUPRIL
ACCURETIC
acebutolol hcl
ACEON
acetaminophen/codeine oral
soln
acetaminophen/codeine tabs
300mg 60mg
acetaminophen/codeine tabs
300mg 15mg
acetaminophen/codeine #2
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine inhalation soln
acitretin
ACTHIB
acticin
ACTIMMUNE
ACTONEL TABS 35MG
ACTONEL TABS 30MG, 5MG
acyclovir
Drug Reqs./Limits
Tier
2
5
Page
42
42
5
4
4
5
5
5
PA
ST
QL(900/30) ST
QL(30/30) ST
QL(60/30) ST
QL(1.5/30)
38
41
41
41
41
41
5
QL(2/30)
41
5
2
2
4
4
2
4
2
B/D PA
PA
QL(90/30)
QL(5000/30)
39
33
43
45
45
46
45
32
2
QL(240/30)
32
2
QL(360/30)
32
2
2
2
2
2
2
4
2
2
5
4
2
5
3
3
2
QL(360/30)
QL(360/30)
QL(240/30)
32
32
32
55
47
54
47
55
56
48
53
40
53
54
54
43
B/D PA
PA
PA
QL(4/28)
QL(30/30)
Drug Name
acyclovir sodium inj 1000mg,
50mg/ml
ADACEL
ADAGEN
ADEFOVIR DIPIVOXIL
adriamycin
adrucil inj 2.5gm/50ml
afeditab cr
AFINITOR
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
ak-poly-bac
ala cort
ALA SCALP
ALBENZA
albuterol sulfate nebu
0.63mg/3ml, 1.25mg/3ml
albuterol sulfate nebu 0.5%
Drug Reqs./Limits
Tier
4
4
5
5
2
4
2
5
5
4
4
2
1
3
3
2
1
Page
PA
QL(30/30)
B/D PA
B/D PA
PA QL(30/30)
PA QL(60/30)
QL(60/30)
B/D PA
QL(375/30)
B/D PA
QL(360/30)
B/D PA
QL(375/30)
43
53
48
42
39
39
46
40
40
45
50
33
50
50
40
55
55
albuterol sulfate nebu 0.083%
1
albuterol sulfate syrp
albuterol sulfate tabs
albuterol sulfate er
alclometasone dipropionate
alcohol preps pads
ALDURAZYME
alendronate sodium tabs
35mg, 70mg
alendronate sodium tabs
10mg, 40mg, 5mg
ALIMTA INJ 500MG
ALINIA
allopurinol
ALOCRIL
ALORA
alphatrex
alprazolam tabs 0.25mg,
0.5mg
alprazolam tabs 1mg
alprazolam tabs 2mg
1
1
2
2
1
5
1
PA
QL(4/28)
55
55
55
50
33
48
54
2
QL(30/30)
54
5
3
1
3
3
2
2
B/D PA
QL(90/30)
39
40
38
54
51
50
43
2
2
QL(120/30)
QL(150/30)
43
43
PA QL(8/28)
55
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
1
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
QL(90/30)
Página
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
Página
alprazolam odt tbdp 0.25mg,
2
43
ammonium lactate
2
0.5mg
amnesteem
2
alprazolam odt tbdp 1mg
2 QL(120/30)
43
amoxapine
2
alprazolam odt tbdp 2mg
2 QL(150/30)
43
amoxicillin caps
1
ALTACE
4
45
amoxicillin chew
2
altavera
2
51
amoxicillin susr
1
alyacen 1/35
2
51
amoxicillin tabs
2
alyacen 7/7/7
2
51
amoxicillin/clavulanate
2
amantadine hcl
2
43
potassium
AMBISOME
4 PA
38
amoxicillin/clavulanate
2
potassium er
amcinonide
2
50
amphetamine/dextroampheta
2 QL(60/30)
a-methapred
4
50
mine
cp24
amifostine
5 B/D PA
39
amphetamine/dextroampheta
2 QL(90/30)
amikacin sulfate inj 500mg/2ml 4
33
mine tabs
amiloride hcl
2
47
AMPHOTEC INJ 50MG
4 PA
amiloride/hydrochlorothiazide
1
47
amphotericin b
4 PA
AMINO ACIDS
4 B/D PA
56
ampicillin
2
aminophylline
4
56
ampicillin sodium
4
AMINOSYN
4 B/D PA
56
ampicillin-sulbactam inj 10gm
4
AMINOSYN
4 B/D PA
56
5gm, 2gm 1gm
7%/ELECTROLYTES
AMPYRA
5 PA QL(60/30)
AMINOSYN
4 B/D PA
56
AMTURNIDE
3 ST
8.5%/ELECTROLYTES
ANADROL-50
5 PA
AMINOSYN II
4 B/D PA
56
anagrelide hydrochloride
2
AMINOSYN II
4 B/D PA
56
anastrozole
2 QL(30/30)
8.5%/ELECTROLYTES
ANDROXY
3 PA
AMINOSYN M
4 B/D PA
56
apexicon
2
AMINOSYN-HBC
4 B/D PA
56
APOKYN
5 PA QL(60/30)
AMINOSYN-HF
4 B/D PA
56
apraclonidine
2
AMINOSYN-PF
4 B/D PA
56
apri
2
AMINOSYN-PF 7%
4 B/D PA
56
APRISO
3
amiodarone hcl inj 50mg/ml
4
46
APTIOM TABS 200MG,
4 QL(30/30) ST
amiodarone hcl tabs
2
46
400MG, 800MG
AMITIZA
3 QL(60/30)
49
APTIOM TABS 600MG
4 QL(60/30) ST
amitriptyline hcl tabs 150mg
2 PA
37
APTIVUS
5
amitriptyline hcl tabs 100mg,
1 PA
37
ARALAST NP INJ 1000MG
5 B/D PA
10mg, 25mg, 50mg, 75mg
aranelle
2
amlodipine besylate
1
46
ARANESP ALBUMIN FREE
4 PA
amlodipine
2
46
INJ 25MCG/0.42ML,
besylate/benazepril hcl
25MCG/ML, 40MCG/0.4ML,
amlodipine
2
46
besylate/benazepril
60MCG/ML
hydrochloride
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D;
2
48
48
37
34
34
34
34
34
34
47
47
38
38
34
34
34
48
46
51
45
40
51
50
40
54
51
53
35
36
42
56
51
45
Drug Name
ARANESP ALBUMIN FREE
INJ 100MCG/0.5ML,
200MCG/0.4ML, 200MCG/ML,
300MCG/0.6ML, 300MCG/ML,
500MCG/ML
ARCALYST
ARRANON
ARZERRA
ascomp/codeine
ASTAGRAF XL
atenolol
atenolol/chlorthalidone
ATGAM
atorvastatin calcium
ATOVAQUONE
atovaquone/proguanil hcl
ATRIPLA
atropine sulfate inj 0.05mg/ml,
0.1mg/ml
ATROVENT HFA
aubra
augmented betamethasone
dipropionate
AUGMENTIN SUSR
125MG/5ML 31.25MG/5ML
AVALIDE
AVASTIN INJ 100MG/4ML
AVELOX INJ
aviane
AVODART
AVONEX
AVONEX PEN
AZACITIDINE
AZACTAM IN ISO-OSMOTIC
DEXTROSE
AZASAN
AZASITE
azathioprine
azelastine hcl ophthalmic soln
azelastine hcl nasal soln
AZILECT
Drug Reqs./Limits
Tier
5 PA
5
4
5
2
4
1
1
4
2
5
2
5
4
PA
3
2
2
QL(26/30)
B/D PA
PA QL(180/30)
B/D PA
B/D PA
QL(30/30)
Page
45
53
39
40
32
53
46
46
53
47
40
40
42
49
55
51
50
3
34
4
5
4
2
3
5
5
5
4
45
40
35
51
49
48
48
39
34
3
3
2
2
2
3
B/D PA
PA QL(4/28)
PA QL(4/28)
B/D PA
B/D PA
B/D PA
QL(60/30)
53
35
53
54
55
41
Drug Name
azithromycin inj 500mg
AZITHROMYCIN PACK
azithromycin susr 200mg/5ml
azithromycin susr 100mg/5ml
azithromycin tabs
AZOPT
aztreonam
azurette
B
baciim
BACITRACIN INJ
bacitracin ophthalmic oint
bacitracin/polymyxin b
baclofen tabs 10mg
baclofen tabs 20mg
BACTROBAN NASAL
balsalazide disodium
balziva
BANZEL SUSP
BANZEL TABS 400MG
BANZEL TABS 200MG
BARACLUDE ORAL SOLN
BARACLUDE TABS
benazepril hcl
benazepril
hcl/hydrochlorothiazide
BENICAR
BENICAR HCT
benztropine mesylate inj
benztropine mesylate tabs
2mg
benztropine mesylate tabs
0.5mg, 1mg
betamethasone dipropionate
betamethasone valerate
betaxolol hcl
betaxolol hcl
bethanechol chloride
bicalutamide
BICILLIN L-A
BICNU
Drug
Tier
4
3
2
2
2
3
4
2
4
4
2
2
1
2
3
2
2
5
5
4
3
5
1
2
Reqs./Limits
Page
QL(3/30)
QL(75/30)
QL(150/30)
QL(12/28)
ST
PA
PA
PA
35
35
35
35
35
54
34
51
33
33
33
33
42
42
33
53
51
36
36
36
42
42
45
45
3
3
4
1
QL(30/30) ST
QL(30/30) ST
PA
PA
45
45
40
40
2
PA
40
B/D PA
50
50
46
54
49
39
34
39
2
2
2
2
2
2
4
4
3
Nombre del
medicamento
Nivel del
medicamento
bisoprolol fumarate
bisoprolol
fumarate/hydrochlorothiazide
BIVIGAM
bleomycin sulfate
BLEPHAMIDE
blephamide s.o.p.
BOOSTRIX
BOSULIF
briellyn
BRILINTA
brimonidine tartrate
ophthalmic soln 0.2%
BRIMONIDINE TARTRATE
OPHTHALMIC SOLN 0.15%
BRINTELLIX
bromfenac
bromocriptine mesylate
budesonide cp24
budesonide susp 32mcg/act
budesonide susp 0.25mg/2ml,
0.5mg/2ml
bumetanide inj
bumetanide tabs 0.5mg, 1mg
bumetanide tabs 2mg
BUPHENYL TABS
buprenorphine hcl inj
buprenorphine hcl subl
buprenorphine hcl/naloxone
hcl
buproban
bupropion hcl
bupropion hcl er tb12 100mg,
200mg
bupropion hcl er tb12 150mg
bupropion hcl sr tb12 150mg
bupropion hcl sr tb12 100mg,
200mg
bupropion hcl sr tb12 150mg
bupropion hcl xl tb24 300mg
bupropion hcl xl tb24 150mg
buspirone hcl tabs 10mg, 5mg
Requ./
Límites
2
1
4
4
3
2
4
5
2
4
2
46
46
B/D PA
B/D PA
PA
QL(60/30)
3
4
2
2
2
2
2
4
1
2
5
4
2
2
Página
53
39
35
35
53
40
51
45
54
54
QL(30/30) ST
QL(17.2/30)
B/D PA
QL(120/30)
PA
PA QL(24/30)
PA QL(90/30)
36
54
41
50
55
55
47
47
47
48
33
33
33
2
2
2
QL(60/30)
QL(60/30)
33
36
36
2
2
2
QL(90/30)
QL(60/30)
QL(60/30)
37
33
37
2
2
2
1
QL(90/30)
QL(30/30)
QL(90/30)
37
37
37
43
Nombre del
medicamento
Nivel del
medicamento
buspirone hcl tabs 15mg,
30mg, 7.5mg
BUSULFEX
butal/asa/caff
butalbital/acetaminophen/caffe
ine
butalbital/acetaminophen/caffe
ine/codeine caps 325mg
50mg 40mg 30mg
butalbital/aspirin/caffeine/codei
ne
butorphanol tartrate inj
butorphanol tartrate nasal soln
BYDUREON
BYETTA
C
cabergoline
cafergot
calcipotriene crea
calcipotriene external soln
calcipotriene oint
calcitonin-salmon
calcitrene
CALCITRIOL OINT
calcitriol caps
calcitriol inj
calcitriol oral soln
calcium acetate caps
calcium acetate tabs 667mg
calcium folinate
camila
CANCIDAS
candesartan cilexetil
candesartan
cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
CARAC
CARAFATE SUSP
CARBAGLU
Requ./
Límites
Página
2
43
5
2
2
B/D PA
PA QL(180/30)
PA QL(180/30)
39
32
32
2
PA QL(180/30)
48
2
PA QL(180/30)
32
QL(6/30)
QL(2.6/28)
QL(2.4/30)
32
32
43
43
4
2
3
3
2
2
2
2
2
2
2
3
2
4
2
2
2
4
2
5
2
2
4
5
1
2
3
3
5
QL(120/30)
QL(3.7/30)
QL(120/30)
B/D PA
PA
PA
4
52
38
48
48
48
54
48
48
54
54
54
56
56
39
52
38
45
47
38
39
45
45
48
49
56
Drug Name
Drug Reqs./Limits
Tier
carbamazepine
2
carbamazepine er
2
carbidopa
2
carbidopa/levodopa
2
carbidopa/levodopa er
2
carbidopa/levodopa odt
2
CARBIDOPA/LEVODOPA/EN
3
TACAPONE
carboplatin
4 B/D PA
carteolol hcl
2
cartia xt
2
carvedilol
1
caziant
2
cefaclor caps
2
cefaclor er
2
cefadroxil
2
cefazolin sodium inj 10gm,
4
1gm, 1gm 5%, 500mg
cefazolin sodium/dextrose inj
4
2gm 3%
cefdinir
2
cefepime inj 1gm, 1gm/50ml
4
5%, 2gm, 2gm/100ml,
2gm/50ml 5%
cefotaxime sodium
4
cefotetan
4
cefoxitin sodium inj 10gm,
4
1gm, 2gm
cefpodoxime proxetil
2
cefprozil
2
ceftazidime inj 1gm, 2gm, 6gm 4
ceftazidime/dextrose
4
ceftriaxone in iso-osmotic
4
dextrose
ceftriaxone sodium
4
cefuroxime axetil
2
cefuroxime sodium inj 1.5gm,
4
7.5gm, 750mg
CELLCEPT SUSR
3 B/D PA
CELLCEPT INTRAVENOUS
4 B/D PA
CELONTIN
3
cephalexin caps 250mg,
1
Page
36
36
41
41
41
41
41
Drug Name
Drug Reqs./Limits
Tier
Page
500mg
cephalexin susr
2
cephalexin tabs
2
CEREZYME INJ 400UNIT
5 B/D PA
CERVARIX
4
CHANTIX
3 PA QL(336/365)
CHANTIX CONTINUING
3 PA QL(336/365)
MONTH PAK
CHANTIX STARTING MONTH 3 PA QL(106/365)
39
PAK
54
chateal
2
46
CHEMET
3
46
chloramphenicol sodium
1
51
succinate
34
chlorhexidine gluconate oral
1
34
rinse
34
chloroquine phosphate
2
34
chlorothiazide
2
chlorothiazide sodium
4
34
chlorpromazine hcl inj
4
chlorpromazine hcl tabs
2
34
chlorthalidone tabs 25mg,
1
34
50mg
chlorzoxazone
2 PA
cholestyramine
2
34
cholestyramine light
2
34
chorionic gonadotropin
4 PA
34
ciclopirox sham
2
34
ciclopirox susp
2
34
ciclopirox nail lacquer
2
34
ciclopirox olamine
2
34
cidofovir
5
34
cilostazol
2
CILOXAN OINT
3
34
cimetidine
2
34
cimetidine hcl
2
34
CINRYZE
5 PA
CIPRO HC
3
53
CIPRODEX
3
53
ciprofloxacin inj 400mg/40ml
4
36
ciprofloxacin susr
2
34
ciprofloxacin er
2
34
34
48
53
33
33
33
51
56
33
48
40
47
47
41
41
47
56
47
47
51
38
38
38
38
42
45
35
49
49
52
35
35
35
35
35
5
Nombre del
medicamento
Nivel del
medicamento
ciprofloxacin hcl ophthalmic
soln
ciprofloxacin hcl tabs 100mg,
750mg
ciprofloxacin hcl tabs 250mg,
500mg
ciprofloxacin i.v.-in d5w
cisplatin inj 100mg/100ml
citalopram hydrobromide oral
soln
citalopram hydrobromide tabs
40mg
citalopram hydrobromide tabs
10mg, 20mg
cladribine
claravis
clarithromycin
clarithromycin er
clindacin etz pledgets
clindacin-p
clindamax
clindamycin hcl
clindamycin phosphate crea
clindamycin phosphate inj
150mg/ml
clindamycin phosphate
external soln
clindamycin phosphate gel
clindamycin phosphate lotn
clindamycin phosphate swab
clindamycin phosphate addvantage
CLINDAMYCIN PHOSPHATE
IN D5W
CLINIMIX 2.75%/DEXTROSE
5%
clinimix 4.25%/dextrose 10%
CLINIMIX 4.25%/DEXTROSE
5%
CLINIMIX 5%/DEXTROSE
15%
Requ./
Límites
Página
2
35
2
35
1
35
4
4
1
B/D PA
QL(600/30)
35
39
37
1
QL(30/30)
37
1
QL(60/30)
37
4
2
2
2
2
2
2
2
2
4
B/D PA
39
48
35
35
48
48
33
33
33
34
QL(60/30)
2
48
2
2
2
4
48
48
48
33
4
33
4
B/D PA
56
4
4
4
4
B/D PA
B/D PA
B/D PA
B/D PA
56
43
56
56
4
B/D PA
43
Nombre del
medicamento
Nivel del
medicamento
20%
25%
CLINIMIX E
4.25%/DEXTROSE 25%
clinisol sf 15%
clobetasol propionate crea
clobetasol propionate external
soln
clobetasol propionate foam
clobetasol propionate gel
clobetasol propionate oint
clobetasol propionate e
clobetasol propionate
emollient crea
CLOLAR
clomipramine hcl
clonazepam tabs 0.5mg, 1mg
clonazepam tabs 2mg
clonazepam odt tbdp
0.125mg, 0.25mg, 0.5mg, 1mg
clonazepam odt tbdp 2mg
clonidine hcl ptwk 0.1mg/24hr,
0.2mg/24hr
clonidine hcl ptwk 0.3mg/24hr
clonidine hcl tabs 0.3mg
clonidine hcl tabs 0.1mg,
0.2mg
clonidine hcl er
clopidogrel tabs 300mg
clopidogrel tabs 75mg
clorazepate dipotassium tabs
3.75mg, 7.5mg
clorazepate dipotassium tabs
15mg
clotrimazole external crea
clotrimazole external soln
clotrimazole troc
clotrimazole/betamethasone
dipropionate
clozapine
CLOZAPINE ODT
4
Requ./
Límites
B/D PA
Página
4
B/D PA
56
3
B/D PA
43
4
2
2
B/D PA
56
50
50
2
2
2
2
2
50
50
50
50
50
4
2
2
2
2
B/D PA
PA
QL(90/30)
QL(300/30)
QL(90/30)
39
37
36
36
36
2
2
QL(300/30)
QL(4/28)
36
45
2
2
1
QL(8/28)
45
45
45
2
2
2
2
QL(1/30)
QL(30/30)
QL(90/30)
45
45
45
43
2
QL(120/30)
43
2
2
2
2
38
38
38
50
2
3
42
42
6
43
Drug Name
Drug
Tier
COARTEM
3
COLCRYS
3
colestipol hcl
2
colistimethate sodium
4
colocort
2
COLY-MYCIN S
3
COMBIGAN
3
COMBIVENT RESPIMAT
3
COMETRIQ
5
compazine supp
2
COMPLERA
5
compro
2
COMVAX
4
constulose
1
COPAXONE INJ 20MG/ML
5
COREG CR
4
cormax scalp application
2
cortisone acetate
2
CORTISPORIN-TC
3
COSMEGEN
5
COUMADIN
4
COZAAR TABS 100MG
4
COZAAR TABS 25MG, 50MG
4
CREON
3
CRESTOR
3
CRIXIVAN
3
cromolyn sodium conc
2
cromolyn sodium ophthalmic
2
soln
cromolyn sodium nebu
2
cryselle-28
2
CUBICIN
5
CUPRIMINE
5
curity gauze pads 2x2
2
cyclafem 1/35
2
cyclafem 7/7/7
2
cyclobenzaprine hcl tabs
2
10mg, 5mg
CYCLOPHOSPHAMIDE
3
CAPS
cyclophosphamide inj
4
Reqs./Limits
QL(8/30)
PA
QL(30/30)
B/D PA
QL(30/30)
QL(60/30)
QL(30/30)
B/D PA
Page
40
38
47
34
50
55
54
55
39
41
42
41
53
49
48
46
50
50
55
39
44
45
45
48
47
43
49
54
PA
56
51
34
56
48
51
51
56
B/D PA
39
B/D PA
39
B/D PA
Drug Name
cyclophosphamide tabs
cycloserine
cyclosporine caps
cyclosporine inj
cyclosporine modified
CYSTADANE
CYSTAGON
cytarabine
cytarabine aqueous
D
dacarbazine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL
DARAPRIM
dasetta 1/35
dasetta 7/7/7
daunorubicin hcl
DAUNOXOME
decitabine
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL INJ
20MG/ML
DEPO-PROVERA
desipramine hcl
desloratadine
desloratadine odt
desmopressin acetate inj
desmopressin acetate nasal
soln 0.01%
DESMOPRESSIN ACETATE
NASAL SOLN 0.01%
desmopressin acetate tabs
desogestrel/ethinyl estradiol
Drug
Tier
2
2
2
4
2
5
3
4
4
4
3
2
2
2
4
3
2
2
4
5
5
3
2
5
3
3
4
4
4
2
2
2
4
2
Reqs./Limits
Page
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(30/30)
B/D PA
B/D PA
QL(30/30)
QL(30/30)
39
38
53
53
53
48
48
39
39
39
56
51
42
38
53
40
51
51
39
39
39
53
35
46
43
56
51
50
52
37
55
55
51
51
3
51
2
2
51
51
7
Nombre del
medicamento
Nivel del
medicamento
tabs 0.15mg 30mcg
desonide lotn
desonide oint
desoximetasone crea
desoximetasone gel
desoximetasone oint 0.25%
dexamethasone elix
dexamethasone tabs 0.5mg,
0.75mg, 4mg
dexamethasone tabs 1.5mg,
1mg, 2mg, 6mg
DEXAMETHASONE
INTENSOL
dexamethasone sodium
phosphate inj 10mg/ml,
120mg/30ml
dexamethasone sodium
phosphate ophthalmic soln
dexmethylphenidate hcl
dexrazoxane inj 250mg
dextroamphetamine sulfate
oral soln
tabs 5mg
tabs 10mg
dextroamphetamine sulfate er
cp24 10mg, 5mg
dextroamphetamine sulfate er
cp24 15mg
dextrose 10%/nacl 0.45%
dextrose 5% /electrolyte #48
viaflex
dextrose 10% flex container
dextrose 2.5%/nacl 0.45%
dextrose 2.5%/sodium chloride
0.45%
dextrose 5%
Requ./
Límites
Página
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
B/D PA
B/D PA
Página
4
2
50
dextrose 5%/potassium
4
chloride 0.15%
2
50
dextrose 5%/sodium chloride
4 B/D PA
2
50
0.2%
2
50
dextrose 5%/sodium chloride
4 B/D PA
2
50
0.45%
2
50
DIAZEPAM GEL
3
1
50
diazepam oral soln
2 QL(1200/30)
diazepam tabs
2 QL(120/30)
2
50
DIBENZYLINE
3
diclofenac potassium
2
3
50
diclofenac sodium ophthalmic
2
soln
4
50
diclofenac sodium dr tbec
2
25mg, 50mg
diclofenac sodium dr tbec
1
2
54
75mg
2 QL(60/30)
48
diclofenac sodium er
2
dicloxacillin sodium
2
4 B/D PA
39
2 QL(1800/30)
48
dicyclomine hcl caps
1
dicyclomine hcl oral soln
2
2 QL(90/30)
48
dicyclomine hcl tabs
1
didanosine
2
2 QL(180/30)
48
diflorasone diacetate
2
diflunisal
2
2 QL(90/30)
48
digox tabs 125mcg
1 QL(30/30)
digox tabs 250mcg
1 PA
2 QL(120/30)
48
digoxin inj
4 PA
digoxin tabs 125mcg
1 QL(30/30)
4 B/D PA
44
digoxin tabs 250mcg
1 PA
4 B/D PA
56
dihydroergotamine mesylate
2
inj
4 B/D PA
44
dilantin caps 30mg
2
4 B/D PA
44
DILANTIN CAPS 100MG
4
4 B/D PA
44
DILANTIN INFATABS
4
4 B/D PA
44
diltiazem cd
2
diltiazem hcl inj 100mg,
4
4 B/D PA
44
25mg/5ml,
50mg/10ml
4 B/D PA
44
diltiazem hcl tabs
1
4 B/D PA
44
diltiazem hcl er cp12
2
4 B/D PA
44
diltiazem hcl er cp24
2
4 B/D PA
44
dilt-xr
2
8
44
56
44
44
36
43
43
45
32
54
32
32
32
34
49
49
49
42
50
32
46
46
46
46
46
38
36
36
36
46
46
46
46
46
46
Drug Name
diphenhydramine hcl inj
diphenoxylate/atropine
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
dipyridamole tabs
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
docetaxel inj 140mg/7ml,
20mg/ml, 80mg/4ml,
80mg/8ml
donepezil hcl tabs 23mg, 5mg
donepezil hcl tabs 10mg
donepezil hcl tbdp 5mg
donepezil hcl tbdp 10mg
dorzolamide hcl
dorzolamide hcl/timolol
maleate
doxazosin mesylate tabs 1mg,
2mg, 4mg
doxazosin mesylate tabs 8mg
doxepin hcl
doxercalciferol caps
doxercalciferol inj
doxorubicin hcl inj 2mg/ml
DOXORUBICIN HCL
LIPOSOME
doxycycline caps 75mg
doxycycline susr
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs
100mg
doxycycline hyclate tabs 20mg
doxycycline monohydrate
dronabinol
DROXIA
DULERA
duloxetine hcl cpep 20mg,
Drug Reqs./Limits
Tier
4
2
4
Page
55
49
53
2
2
2
2
2
5
5
PA
2
2
2
2
2
2
QL(30/30)
QL(60/30)
QL(30/30)
QL(60/30)
1
QL(30/30)
49
1
2
2
4
2
5
QL(60/30)
PA
49
37
54
54
39
39
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
45
33
36
36
36
39
39
36
36
36
36
54
54
Drug Name
60mg
duloxetine hcl cpep 30mg
duramorph
DUREZOL
E
e.e.s. 400
E.E.S. GRANULES
e.s.p.
econazole nitrate
EDECRIN
EDURANT
ELAPRASE
ELIDEL
ELIGARD INJ 30MG
ELIGARD INJ 45MG
ELIGARD INJ 7.5MG
ELIGARD INJ 22.5MG
elinest
ELIQUIS
ELITEK
ELLA
ELLENCE INJ 200MG/100ML
ELMIRON
EMCYT
EMEND CAPS 40MG
EMEND CAPS 125MG
EMEND CAPS 80MG
EMEND CAPS
Drug Reqs./Limits
Tier
2
4
3
2
3
2
2
3
3
5
3
4
4
4
4
2
3
5
3
4
3
3
3
3
3
3
Page
QL(90/30)
PA
PA QL(1/120)
PA QL(1/180)
PA QL(1/30)
PA QL(1/90)
PA QL(60/30)
B/D PA
B/D PA
B/D PA QL(2/30)
B/D PA QL(4/30)
B/D PA QL(8/30)
B/D PA
QL(12/30)
emoquette
2
EMSAM
3
EMTRIVA
3
enalapril maleate
1
enalapril
1
maleate/hydrochlorothiazide
ENBREL
5 PA QL(8/28)
2
35
ENBREL SURECLICK
5 PA QL(8/28)
2
35
endocet tabs 325mg 10mg,
2 QL(360/30)
2 PA QL(90/30)
38
325mg 5mg, 325mg 7.5mg
3
39
ENGERIX-B
4 B/D PA
3 QL(13/30)
55
enoxaparin sodium inj
5 QL(24/30)
2 QL(60/30)
37
120mg/0.8ml
2
2
1
4
1
35
35
35
35
35
37
32
54
35
35
35
38
47
42
48
48
52
52
52
52
51
44
39
52
39
49
39
38
38
38
38
51
37
42
45
45
53
53
32
53
44
9
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
QL(30/30)
Página
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
Página
5
44
erythromycin pads
2
100mg/ml, 150mg/ml
erythromycin base
2
4 QL(9/30)
44
erythromycin ethylsuccinate
2
30mg/0.3ml
erythromycin/benzoyl peroxide 2
4 QL(12/30)
44
escitalopram oxalate oral soln
2 QL(600/30)
40mg/0.4ml
escitalopram oxalate tabs
2 QL(60/30)
4 QL(18/30)
44
ESOMEPRAZOLE SODIUM
4
60mg/0.6ml
estarylla
2
4 QL(24/30)
44
estradiol ptwk
2 PA QL(4/28)
80mg/0.8ml
estradiol tabs
2 PA
4 QL(90/30)
44
estradiol valerate
4
300mg/3ml
estradiol/norethindrone
2 PA
enpresse-28
2
51
acetate
enskyce
2
51
ESTRING
3 QL(1/90)
entacapone
2
40
ethambutol hcl
2
enulose
1
49
ethosuximide
2
epinastine hcl
2
54
etidronate disodium
2
EPINEPHRINE HCL INJ
4
55
etodolac
2
0.1MG/ML
etodolac er
2
epinephrine hcl inj 1mg/ml
4
55
ETOPOPHOS
4 B/D PA
EPIPEN 2-PAK
3 QL(2/30)
55
ETOPOSIDE INJ
3 B/D PA
EPIPEN-JR 2-PAK
3 QL(2/30)
55
EXELON PT24
3 QL(30/30)
epirubicin hcl inj 50mg/25ml
4 B/D PA
39
exemestane
2
epirubicin hcl inj 200mg/100ml
5 B/D PA
39
EXFORGE
3
epitol
2
36
EXFORGE HCT
3
EPIVIR ORAL SOLN
3
42
EXJADE
5
EPIVIR HBV ORAL SOLN
3
42
F
EPZICOM
5
42
FABRAZYME
5 B/D PA
ERBITUX
5 B/D PA
40
falmina
2
ergoloid mesylates
2 PA
36
famciclovir
2 QL(21/7)
ERIVEDGE
5 PA QL(30/30)
39
famotidine inj 20mg/2ml
4
errin
2
52
famotidine tabs 20mg
1
ERWINAZE
5 B/D PA
39
famotidine tabs 40mg
2
ery
2
35
famotidine premixed
4
ERYPED 200
3
35
FANAPT TABS 10MG, 12MG,
5 QL(60/30) ST
ERYPED 400
3
35
6MG, 8MG
ERY-TAB
3
35
FANAPT TABS 1MG, 2MG,
4 QL(60/30) ST
ERYTHROCIN
4
35
4MG
LACTOBIONATE
FANAPT TITRATION PACK
4 QL(16/30) ST
erythrocin stearate
2
35
FARESTON
5
erythromycin external soln
2
35
FASLODEX
5 B/D PA
erythromycin gel
2
35
FAZACLO
4 ST
erythromycin oint
2
35
10
35
35
35
48
37
37
49
51
51
51
51
51
51
38
36
54
32
32
40
40
36
40
46
46
56
49
51
43
49
49
49
49
41
41
41
39
39
42
Drug Name
Drug
Tier
felbamate
2
felodipine er
2
FEMRING
3
fenofibrate caps 130mg, 43mg 2
fenofibrate tabs
2
fenofibrate micronized
2
fenofibric acid dr
2
fenoprofen calcium
2
fentanyl
2
fentanyl citrate
4
FENTANYL CITRATE ORAL
5
TRANSMUCOSAL
FETZIMA
4
FETZIMA TITRATION PACK
4
finasteride tabs 5mg
2
FIRAZYR
5
firmagon inj 80mg
4
FIRMAGON INJ 120MG
5
flavoxate hcl
FLEBOGAMMA DIF
flecainide acetate
FLOVENT DISKUS AEPB
250MCG/BLIST,
50MCG/BLIST
FLOVENT DISKUS AEPB
100MCG/BLIST
FLOVENT HFA AERO
44MCG/ACT
FLOVENT HFA AERO
110MCG/ACT, 220MCG/ACT
fluconazole susr
fluconazole tabs 100mg,
200mg, 50mg
fluconazole tabs 150mg
fluconazole in dextrose
fluconazole in nacl
FLUCYTOSINE
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide crea
2
4
2
3
Reqs./Limits
Page
QL(15/30)
B/D PA
PA QL(120/30)
36
46
51
47
47
47
47
32
32
32
32
QL(30/30) ST
QL(28/28) ST
QL(30/30)
PA
B/D PA QL(4/28)
B/D PA
QL(6/365)
37
37
49
53
52
52
QL(120/30)
49
53
46
55
3
QL(180/30)
55
3
QL(22/30)
55
3
QL(24/30)
55
B/D PA
2
2
1
4
4
5
4
2
1
2
38
38
QL(8/30)
B/D PA
38
38
38
38
39
50
55
50
Drug Name
fluocinolone acetonide
external soln
fluocinolone acetonide oint
fluocinolone acetonide oil
fluocinonide
fluocinonide-e
fluoride chew 0.25mg, 1.1mg,
2.2mg
fluoritab chew
FLUOROMETHOLONE
FLUOROPLEX
fluorouracil inj 2.5gm/50ml
fluorouracil crea
fluorouracil external soln
fluoxetine dr
fluoxetine hcl caps
fluoxetine hcl oral soln
fluoxetine hcl tabs 10mg,
20mg
fluphenazine decanoate
fluphenazine hcl conc
fluphenazine hcl elix
fluphenazine hcl inj
fluphenazine hcl tabs 1mg
fluphenazine hcl tabs 10mg,
2.5mg, 5mg
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate crea
fluticasone propionate oint
fluticasone propionate susp
fluvastatin caps 20mg
fluvastatin caps 40mg
fluvoxamine maleate
fluvoxamine maleate er cp24
150mg
fluvoxamine maleate er cp24
100mg
FOLOTYN
fomepizole
fondaparinux sodium inj
Drug Reqs./Limits
Tier
1
Page
50
2
2
2
2
1
50
55
50
50
56
1
3
3
4
2
2
2
2
2
2
56
54
48
39
48
48
37
37
37
37
B/D PA
4
2
2
4
1
2
41
41
41
41
41
41
2
2
2
2
2
2
2
2
2
2
QL(60/30)
32
54
39
50
50
55
47
47
37
37
2
QL(90/30)
37
5
5
4
B/D PA
39
54
44
QL(16/30)
QL(30/30)
QL(60/30)
QL(15/30)
11
Nombre del
medicamento
Nivel del
medicamento
2.5mg/0.5ml
5mg/0.4ml
7.5mg/0.6ml
10mg/0.8ml
FORADIL AEROLIZER
FORTEO
foscarnet sodium
fosinopril sodium
fosinopril
sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FREAMINE III
FREAMINE III 3%
furosemide inj
furosemide oral soln
furosemide tabs
FUSILEV
FUZEON
FYCOMPA
G
gabapentin
GABITRIL TABS 16MG
GABITRIL TABS 12MG
galantamine
galantamine hydrobromide
cp24
oral soln
tabs
gamastan s/d
GAMMAGARD LIQUID
GAMMAKED
GAMMAPLEX INJ
10GM/200ML, 2.5GM/50ML,
5GM/100ML
GAMUNEX-C
ganciclovir
GARDASIL
5
Requ./
Límites
QL(12/30)
Página
44
5
QL(18/30)
44
5
QL(24/30)
44
3
5
4
2
2
QL(60/30)
PA QL(2.4/28)
55
54
42
45
45
4
5
4
4
4
2
1
5
5
4
QL(60/30)
ST
36
50
56
56
47
47
47
39
42
36
2
3
3
2
2
QL(90/30) ST
QL(120/30) ST
QL(60/30)
QL(30/30)
36
36
36
36
36
2
QL(200/30)
36
2
QL(60/30)
36
4
4
4
4
B/D PA
B/D PA
B/D PA
B/D PA
53
53
53
53
4
4
4
B/D PA
B/D PA
53
42
53
ST
B/D PA
B/D PA
Nombre del
medicamento
Nivel del
medicamento
gavilyte-c
gavilyte-n/flavor pack
GAZYVA
gemcitabine
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate crea
gentamicin sulfate inj
gentamicin sulfate oint
gentamicin sulfate ophthalmic
soln
gentamicin sulfate pediatric
gentamicin sulfate/0.9%
sodium chloride
gentamicin sulfate/sodium
chloride
GEODON INJ
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
GILOTRIF
GLEEVEC
glimepiride tabs 1mg, 2mg
glimepiride tabs 4mg
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
glyburide/metformin hcl
glycopyrrolate inj 4mg/20ml
glycopyrrolate tabs
GLYSET
granisetron hcl inj 0.1mg/ml,
1mg/ml
granisetron hcl tabs
2
2
5
4
5
2
1
2
2
2
4
2
4
griseofulvin microsize
2
Requ./
Límites
Página
PA
B/D PA
B/D PA
B/D PA
4
4
33
33
4
33
4
2
2
2
2
2
5
5
1
1
1
1
1
4
2
4
2
3
4
QL(60/30)
2
B/D PA
QL(60/30)
PA QL(30/30)
PA QL(60/30)
QL(30/30)
QL(60/30)
PA
B/D PA
12
49
49
40
39
39
47
49
53
33
33
33
33
33
41
51
51
51
51
51
40
40
43
43
43
43
43
44
43
49
49
43
38
38
38
Drug Name
griseofulvin ultramicrosize
GUANIDINE HCL
H
HALAVEN
halobetasol propionate
haloperidol conc
haloperidol tabs 0.5mg, 1mg,
2mg, 5mg
haloperidol tabs 10mg, 20mg
haloperidol decanoate
haloperidol lactate
HAVRIX
heather
hecoria
heparin sodium inj
10000unit/ml, 1000unit/ml,
20000unit/ml, 2000unit/ml,
2500unit/ml, 5000unit/ml
heparin sodium/d5w
heparin sodium/nacl 0.9%
hepatamine
HEPATASOL
HERCEPTIN
HEXALEN
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMIRA INJ 20MG/0.4ML
HUMIRA INJ 40MG/0.8ML
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N KWIKPEN
Drug Reqs./Limits
Tier
2
3
5
2
2
1
2
4
4
4
2
2
4
4
4
4
4
5
5
3
3
3
3
PA
B/D PA
B/D PA
B/D PA
B/D PA
3
3
5
5
5
5
3
3
3
3
3
Page
38
38
39
50
41
41
41
41
41
53
52
53
44
44
44
56
56
40
39
44
44
44
44
44
44
PA QL(2/28)
PA QL(6/28)
PA QL(6/28)
PA QL(6/28)
53
53
53
53
44
44
44
44
44
Drug Name
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
hydralazine hcl inj
hydralazine hcl tabs
hydrochlorothiazide caps
hydrochlorothiazide tabs
25mg, 50mg
hydrochlorothiazide tabs
12.5mg
hydrocodone
bitartrate/acetaminophen oral
soln
hydrocodone
bitartrate/acetaminophen tabs
325mg 2.5mg
hydrocodone
bitartrate/acetaminophen tabs
300mg 10mg, 300mg 5mg,
300mg 7.5mg
hydrocodone/acetaminophen
tabs
hydrocodone/ibuprofen tabs
7.5mg 200mg
hydrocortisone crea 1%, 2.5%
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
hydrocortisone tabs
hydrocortisone butyrate
hydrocortisone butyrate
(lipophilic)
hydrocortisone in absorbase
hydrocortisone valerate
hydrocortisone/acetic acid
HYDROMORPHONE HCL INJ
1MG/ML, 2MG/ML
hydromorphone hcl inj 2mg/ml,
500mg/50ml
hydromorphone hcl liqd
hydromorphone hcl tabs
hydroxychloroquine sulfate
hydroxyurea
Drug Reqs./Limits
Tier
3
3
3
Page
44
44
44
4
2
1
1
47
47
47
47
2
47
2
QL(5400/30)
32
2
QL(360/30)
32
2
QL(390/30)
32
2
QL(360/30)
32
2
QL(150/30)
32
1
2
2
2
2
2
50
50
50
50
50
50
2
2
2
4
50
50
55
32
4
32
2
2
2
2
QL(1200/30)
QL(240/30)
32
32
40
39
13
Nombre del
medicamento
Nivel del
medicamento
HYZAAR TABS 12.5MG
100MG, 25MG 100MG
HYZAAR TABS 12.5MG
50MG
I
ibandronate sodium tabs
ibuprofen susp
ibuprofen tabs 400mg, 600mg,
800mg
ICLUSIG
idarubicin hcl inj 10mg/10ml
ifosfamide inj 1gm, 3gm
ifosfamide/mesna
ILARIS
ilotycin
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMOVAX RABIES (H.D.C.V.)
INCIVEK
INCRELEX
indapamide
INFANRIX
infumorph 200
infumorph 500
INLYTA TABS 5MG
INLYTA TABS 1MG
INTELENCE TABS 200MG
INTELENCE TABS 100MG
INTELENCE TABS 25MG
intralipid inj 2.25% 20%
INTRON-A
INTRON-A W/DILUENT INJ
10MU, 18MU
introvale
INVANZ
INVEGA TB24 9MG
INVEGA TB24 1.5MG, 3MG
INVEGA TB24 6MG
INVEGA SUSTENNA INJ
4
4
Requ./
Límites
QL(30/30)
QL(60/30)
2
1
1
QL(1/28)
5
5
4
5
5
2
5
2
2
2
2
4
5
4
1
4
4
4
5
5
5
5
4
4
5
5
PA
B/D PA
B/D PA
B/D PA
PA
2
4
5
4
4
4
PA QL(120/30)
PA
PA
PA QL(180/30)
PA
PA QL(120/30)
PA QL(240/30)
QL(60/30)
QL(120/30)
QL(180/30)
B/D PA
QL(30/30) ST
QL(30/30) ST
QL(60/30) ST
QL(0.25/28)
Página
45
45
54
32
32
39
39
39
39
53
35
40
34
37
37
48
53
42
51
47
53
32
32
40
40
42
42
42
58
42
42
51
34
41
41
41
41
Nombre del
medicamento
Nivel del
medicamento
39MG/0.25ML
INVEGA SUSTENNA INJ
78MG/0.5ML
INVEGA SUSTENNA INJ
117MG/0.75ML
INVEGA SUSTENNA INJ
156MG/ML
INVEGA SUSTENNA INJ
234MG/1.5ML
INVIRASE
IPOL INACTIVATED IPV
ipratropium bromide inhalation
soln
ipratropium bromide nasal soln
0.06%
ipratropium bromide nasal soln
0.03%
ipratropium bromide/albuterol
sulfate
irbesartan
irbesartan/hydrochlorothiazide
irinotecan inj 100mg/5ml
ISENTRESS CHEW 25MG
ISENTRESS CHEW 100MG
ISENTRESS PACK
ISENTRESS TABS
isoditrate er
isolyte-m/dextrose 5%
isoniazid inj
isoniazid syrp
isoniazid tabs 100mg
isoniazid tabs 300mg
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin inj
0.8mg/ml 0.9%, 1.2mg/ml
0.9%, 1.6mg/ml 0.9%, 1mg/ml
0.9%
isradipine
ISTODAX
itraconazole
Requ./
Límites
Página
4
QL(0.5/28)
41
5
QL(0.75/28)
41
5
QL(1/28)
41
5
QL(1.5/28)
41
5
4
2
2
B/D PA
QL(300/30)
QL(30/30)
2
QL(60/30)
55
2
B/D PA
QL(540/30)
55
1
1
4
3
5
3
5
2
4
4
2
2
1
2
2
2
2
4
2
5
2
B/D PA
QL(360/30)
QL(180/30)
QL(60/30)
B/D PA
PA
PA QL(120/30)
14
43
53
55
55
45
45
39
42
42
42
42
47
57
38
39
39
39
47
47
47
47
33
46
39
38
Drug Name
Drug Reqs./Limits
Tier
5 B/D PA
4
Page
Drug Name
Drug Reqs./Limits
Tier
2
1
1
2
5 PA
2
5 PA QL(6/28)
Page
IXEMPRA KIT
39
klor-con
IXIARO
53
klor-con m10
klor-con m20
J
JAKAFI
5 PA QL(60/30)
39
kurvelo
JALYN
3
49
KUVAN
jantoven
1
44
k-vescent pack
JANUMET
3 QL(60/30)
43
KYPROLIS
JANUMET XR TB24 1000MG
3 QL(30/30)
43
L
100MG
labetalol hcl inj
4
JANUMET XR TB24 1000MG
3 QL(60/30)
43
labetalol hcl tabs
2
50MG, 500MG 50MG
laclotion
2
JANUVIA
3 QL(30/30)
43
LACRISERT
3
jencycla
2
52
lactated ringers inj 3meq/l
4
JENTADUETO
3 QL(60/30)
43
109meq/l 28meq/l 4meq/l
JEVTANA
5 B/D PA
39
130meq/l
junel 1.5/30
2
51
lactated ringers dextrose 5%
4
viaflex
junel 1/20
2
51
lactated ringers irrigation
4
junel fe 1.5/30
2
51
lactated ringers viaflex
4
junel fe 1/20
2
51
lactulose
1
K
lamivudine
2
KADCYLA
5 PA
40
lamivudine/zidovudine
5
KALETRA ORAL SOLN
5
43
lamotrigine
2
KALETRA TABS 200MG
5
43
50MG
lamotrigine er
2
KALETRA TABS 100MG
4
43
LANOXIN TABS 125MCG
4 QL(30/30)
25MG
LANOXIN TABS 250MCG
4 PA
kariva
2
51
LANOXIN PEDIATRIC
4 PA
kcl 0.075%/d5w/nacl 0.45%
4 B/D PA
44
lansoprazole
2 QL(60/30)
kcl 0.15%/d5w/ nacl 0.3%
4 B/D PA
44
lansoprazole/amoxicillin/clarith 2
kcl 0.15%/d5w/lr
4 B/D PA
44
romycin
kcl 0.15%/d5w/nacl 0.2%
4 B/D PA
44
LANTUS
3
kcl 0.15%/d5w/nacl 0.45%
4 B/D PA
44
LANTUS SOLOSTAR
3
kcl 0.15%/d5w/nacl 0.9%
4 B/D PA
44
larin 1/20
2
kcl 0.3%/d5w/nacl 0.45%
4 B/D PA
44
larin fe 1.5/30
2
kelnor 1/35
2
51
larin fe 1/20
2
KETEK
3 QL(20/30)
35
latanoprost
2 QL(5/30)
ketoconazole
2
38
LATUDA TABS 120MG,
4 QL(30/30) ST
20MG, 40MG, 60MG
ketoprofen
2
32
LATUDA TABS 80MG
4 QL(60/30) ST
ketoprofen er
2
32
LAZANDA
5 PA QL(44/28)
ketorolac tromethamine
2
54
ophthalmic soln
leflunomide
2 QL(30/30)
kionex
2
56
lessina
2
57
57
57
51
49
57
39
46
46
48
54
57
57
54
57
49
42
42
36
36
46
46
46
49
34
44
44
51
51
51
54
41
41
32
53
51
15
Nombre del
medicamento
Nivel del
medicamento
LETAIRIS
letrozole
leucovorin calcium inj 100mg,
350mg, 500mg, 50mg
leucovorin calcium tabs
LEUKERAN
LEUKINE
leuprolide acetate
LEVEMIR
LEVEMIR FLEXPEN
levetiracetam inj
levetiracetam oral soln
levetiracetam tabs
levetiracetam er
LEVOBUNOLOL HCL
OPHTHALMIC SOLN 0.25%
levobunolol hcl ophthalmic
soln 0.5%
levocarnitine inj
levocarnitine oral soln
levocarnitine tabs
levocetirizine dihydrochloride
oral soln
levocetirizine dihydrochloride
tabs
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
levofloxacin in d5w
levonest
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium tabs
LEVOXYL
LEXIVA SUSP
LEXIVA TABS
lidocaine oint
lidocaine ptch
lidocaine hcl external soln
lidocaine hcl gel
lidocaine hcl inj 0.5%, 1%, 2%
5
2
4
2
3
5
4
3
3
4
2
2
2
3
Requ./
Límites
PA QL(30/30)
QL(30/30)
PA
PA QL(30/30)
1
Página
56
40
39
39
39
45
52
44
44
36
36
36
36
55
55
4
2
2
2
B/D PA
QL(300/30)
54
54
54
55
2
QL(30/30)
55
4
2
2
4
2
2
2
2
1
4
4
5
2
2
2
2
4
QL(180/30)
PA QL(90/30)
35
35
35
35
51
51
51
32
52
52
43
43
33
33
33
33
33
Nombre del
medicamento
Nivel del
medicamento
lidocaine hcl inj 10mg/ml
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine crea
LINCOCIN
lindane
liothyronine sodium inj
liothyronine sodium tabs
LIPODOX
LIPODOX 50
LIPOFEN
liposyn iii inj 2.5% 30%
lisinopril
lisinopril/hydrochlorothiazide
lithium carbonate caps 300mg
lithium carbonate caps 150mg,
600mg
lithium carbonate tabs
lithium carbonate er
lofene
LOMUSTINE
lonox
loperamide hcl caps
lorazepam conc
lorazepam inj 2mg/ml, 4mg/ml
lorazepam tabs
lorcet
lorcet hd
lorcet plus
lortab tabs
losartan potassium tabs
100mg
losartan potassium tabs 50mg
losartan potassium tabs 25mg
losartan
potassium/hydrochlorothiazide
tabs 12.5mg 100mg, 25mg
100mg
losartan
potassium/hydrochlorothiazide
tabs 12.5mg 50mg
LOTENSIN
4
2
1
2
4
2
4
2
5
5
3
4
1
1
1
2
2
2
2
3
2
2
2
4
2
2
2
2
2
1
Requ./
Límites
Página
B/D PA
B/D PA
B/D PA
QL(120/30)
QL(360/30)
QL(360/30)
QL(360/30)
QL(360/30)
QL(30/30)
43
43
49
39
49
49
43
43
43
32
32
32
32
45
1
1
1
QL(60/30)
QL(90/30)
QL(30/30)
45
45
45
1
QL(60/30)
45
QL(120/30)
4
16
46
33
33
33
34
40
52
52
40
40
47
58
45
46
43
43
46
Drug Name
LOTENSIN HCT
LOTRONEX
lovastatin tabs 40mg
lovastatin tabs 10mg, 20mg
low-ogestrel
loxapine
loxapine succinate
ludent
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
LYRICA CAPS 225MG,
25MG, 300MG
LYRICA CAPS 100MG,
150MG, 200MG, 50MG, 75MG
LYRICA ORAL SOLN
LYSODREN
lyza
M
magnesium sulfate inj 50%
MAKENA
malathion
maprotiline hcl
margesic
marlissa
MARPLAN
MATULANE
matzim la
MAVIK
meclizine hcl tabs
meclofenamate sodium
MEDROL TABS 2MG
medroxyprogesterone acetate
inj
medroxyprogesterone acetate
tabs
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam tabs
Drug
Tier
4
5
2
1
2
2
2
1
5
5
5
2
3
Reqs./Limits
Page
46
49
47
47
51
41
41
57
49
52
52
51
36
Drug Name
Drug
Tier
5
4
3
4
3
4
2
2
2
2
5
3
2
2
1
1
Reqs./Limits
Page
melphalan hydrochloride
B/D PA
MENACTRA
PA QL(60/30)
QL(60/30)
MENEST
PA
QL(90/30)
MENOMUNE-A/C/Y/W-135
MENOSTAR
PA QL(4/28)
MENVEO
mercaptopurine
meropenem
PA
mesalamine
PA QL(1/30)
mesna
B/D PA
PA QL(1/30)
MESNEX TABS
MESTINON TIMESPAN
QL(60/30)
metadate er
QL(90/30)
metaproterenol sulfate
3 QL(90/30)
36
metformin hcl
metformin hcl er tb24 500mg,
3 QL(900/30)
36
750mg
3
52
methadone hcl conc
2 QL(500/30)
2
52
methadone hcl inj
4
methadone hcl oral soln
2 QL(2000/30)
4 B/D PA
57
10mg/5ml
5
52
methadone hcl oral soln
2 QL(4000/30)
5mg/5ml
2
40
methadone hcl tabs
2 QL(360/30)
2
37
methadose tabs
2 QL(360/30)
2 PA QL(180/30)
32
methazolamide
2
2
51
methenamine hippurate
2
4
37
methimazole
2
5
39
methotrexate
2
2
46
methotrexate sodium
4
4
46
methoxsalen
5
2
37
methscopolamine bromide
2
2
32
methyldopate hcl
2 PA
3
50
methylphenidate hcl
2 QL(90/30)
4 QL(1/90)
52
methylphenidate hcl er tbcr
2 QL(90/30)
20mg
1
52
methylphenidate hcl er tbcr
2 QL(180/30)
10mg
2
40
methylphenidate hcl sr
2 QL(90/30)
2 PA
52
methylprednisolone
2
5 PA
40
methylprednisolone acetate
4
1
32
methylprednisolone dose pack 2
39
53
40
53
51
53
39
34
53
40
40
38
48
55
43
43
32
32
32
32
32
32
55
34
52
53
53
48
49
45
48
48
48
48
50
50
50
17
Nombre del
medicamento
Nivel del
medicamento
methylprednisolone
sodiumsuccinate inj 125mg,
40mg
metipranolol
metoclopramide hcl inj
metoclopramide hcl oral soln
metoclopramide hcl tabs 10mg
metoclopramide hcl tabs 5mg
metolazone
metoprolol succinate er
metoprolol tartrate inj
metoprolol tartrate tabs
metoprolol/hydrochlorothiazide
metronidazole crea
metronidazole gel
metronidazole lotn
metronidazole tabs
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN INJ
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
mimvey
mimvey lo
minitran
MINIVELLE PTTW
0.1MG/24HR
minocycline hcl
minoxidil tabs
mirtazapine
mirtazapine odt
misoprostol
mitomycin
MITOXANTRONE HCL
M-M-R II W/DILUENT 10
DOSE
MODAFINIL TABS 100MG
Requ./
Límites
Página
4
50
2
4
1
1
2
2
2
4
1
2
2
2
2
1
4
2
2
4
2
2
2
2
2
2
2
2
2
3
55
49
49
49
49
47
46
46
46
46
34
34
34
34
34
34
46
54
51
51
51
51
45
38
51
51
47
51
2
2
2
2
2
4
3
4
4
PA
PA
PA QL(8/28)
QL(30/30)
QL(30/30)
B/D PA
B/D PA
PA QL(30/30)
35
47
37
37
49
40
40
53
56
Nombre del
medicamento
Nivel del
medicamento
modafinil tabs 200mg
MODERIBA MISC
moderiba tabs
MODERIBA 1200 DOSE
PACK
MODERIBA 800 DOSE PACK
moexipril hcl
moexipril/hydrochlorothiazide
mometasone furoate
mono-linyah
montelukast sodium
morgidox 1x100mg caps
morgidox 2x100mg caps
morphine sulfate inj 0.5mg/ml,
10mg/ml, 1mg/ml, 5mg/ml
morphine sulfate oral soln
20mg/ml
20mg/5ml
10mg/5ml
MORPHINE SULFATE TABS
morphine sulfate er tbcr
MOVIPREP
MOXEZA
moxifloxacin hcl
MOZOBIL
MULTAQ
mupirocin
mupirocin calcium
MUSTARGEN
mycophenolate mofetil
mycophenolic acid dr
mydral
myorisan
myzilra
N
nabumetone
nadolol tabs 80mg
nadolol tabs 20mg, 40mg
nadolol/bendroflumethiazide
nafcillin sodium
5
5
2
5
Requ./
Límites
PA QL(60/30)
PA
PA
PA
Página
5
2
2
2
2
2
1
1
4
PA
2
QL(540/30)
32
2
QL(2700/30)
32
2
QL(5400/30)
33
3
2
4
3
2
5
3
2
2
4
2
2
2
2
2
QL(360/30)
QL(90/30)
33
32
49
35
35
57
46
34
34
39
53
53
54
48
51
QL(30/30)
QL(9.6/30)
QL(60/30)
B/D PA
B/D PA
B/D PA
2
2
1
2
4
18
56
42
42
42
42
46
46
50
51
55
35
35
32
32
46
46
46
34
Drug Name
nafrinse
NAFTIN
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA ORAL SOLN
NAMENDA XR
NAMENDA XR TITRATION
PACK
naphazoline hcl
naproxen susp
naproxen tabs 250mg
naproxen tabs 375mg, 500mg
naproxen dr
naproxen sodium tabs 275mg,
550mg
naratriptan hcl
NATACYN
nateglinide
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin
zinc
neomycin/polymyxin/bacitracin
/hydrocortisone
neomycin/polymyxin/dexameth
asone
neomycin/polymyxin/gramicidi
n
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocorti
sone
neomycin/polymyxin/hydrocorti
sone
Drug
Tier
1
3
5
4
2
2
3
3
3
Reqs./Limits
PA
PA
QL(300/30)
QL(30/30)
QL(28/28)
2
2
2
1
2
2
2
3
2
3
2
2
2
2
2
2
2
4
2
Page
57
38
49
33
33
33
36
36
36
54
32
32
32
32
32
QL(9/30)
QL(90/30)
B/D PA
QL(60/30)
38
38
43
40
51
51
51
51
37
33
34
33
54
2
34
2
54
2
34
2
2
55
34
2
55
Drug Name
neo-polycin
NEULASTA
NEUMEGA
NEUPOGEN INJ
300MCG/0.5ML,
480MCG/0.8ML,
480MCG/1.6ML
NEUPRO
NEUTREXIN
NEVIRAPINE SUSP
nevirapine tabs
nevirapine er
NEXAVAR
niacin er tbcr 500mg
niacin er tbcr 1000mg, 750mg
niacor
nicardipine hcl caps
nicardipine hcl inj
NICOTROL INHALER
NICOTROL NS
nifediac cc tb24 30mg, 60mg
nifedical xl
nifedipine er
NILANDRON
nimodipine
nisoldipine
nisoldipine er
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitroglycerin inj
nitroglycerin pt24
nitroglycerin lingual
translingual soln
nitroglycerin transdermal
NITROSTAT
nizatidine caps
norethindrone
norethindrone acetate
norgestimate/ethinyl estradiol
NORITATE
Drug
Tier
2
5
5
5
4
5
3
2
2
5
2
2
2
2
4
3
3
2
2
2
5
2
2
2
2
2
2
4
2
2
Reqs./Limits
Page
PA
PA
PA
PA QL(30/30)
PA
QL(30/30)
QL(60/30)
PA QL(504/30)
PA QL(40/30)
QL(900/365)
QL(90/365)
QL(90/365)
2
3
2
2
2
2
3
54
45
45
45
41
40
42
42
42
40
47
47
47
46
46
33
33
46
46
46
39
46
46
46
34
34
34
47
47
47
47
47
49
52
52
51
34
19
Nombre del
medicamento
Nivel del
medicamento
normosol-m in d5w
4
NORMOSOL-R
4
normosol-r in d5w
4
nortrel 0.5/35 (28)
2
nortrel 1/35
2
nortrel 7/7/7
2
nortriptyline hcl caps
1
nortriptyline hcl oral soln
2
NORVIR
3
novarel
4
novofine 30gx8mm
2
novofine 31
2
novofine 32gx6mm
2
novofine autocover 30gx8mm
2
novotwist 30gx8mm
2
novotwist 32gx5mm
2
NOXAFIL SUSP
5
NOXAFIL TBEC
5
NUEDEXTA
3
NULOJIX
5
nyamyc
2
nystatin crea
2
nystatin oint
2
nystatin powd 100000unit/gm
2
nystatin susp
2
nystatin tabs
2
nystatin/triamcinolone
2
nystop
2
NEEDLES AND SYRINGES
bd insulin syringe
2
safetyglide/1ml/29g x 1/2
bd insulin syringe
2
ultrafine/0.3ml/31g x 5/16
bd insulin syringe
2
ultrafine/0.5ml/30g x 1/2
bd insulin syringe
2
ultrafine/1ml/31g x 5/16
bd insulin syringe ultrafine/u2
100/0.3ml/31g x 15/64
100/0.5ml/31g x 15/64
Requ./
Límites
B/D PA
B/D PA
B/D PA
PA
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
PA QL(600/30)
PA QL(93/30)
PA
PA
Página
57
57
44
51
51
51
37
37
43
51
54
54
54
54
54
54
38
38
48
53
38
38
38
38
38
38
38
38
QL(200/30)
59
QL(200/30)
59
QL(200/30)
59
QL(200/30)
59
QL(200/30)
59
QL(200/30)
59
QL(200/30)
59
Nombre del
medicamento
Nivel del
medicamento
100/1ml/31g x 15/64
bd pen
needle/mini/ultrafine/31g x
3/16
bd pen needle/nano/ultra
fine/32g x 4mm
bd pen needle/ultrafine/29g x
12.7mm
monoject insulin
syringe/detach needle/1ml/27g
x 1/2
monoject insulin
syringe/safety/perm
needle/0.3ml/29g x 1/2
monoject insulin syringe/u100/0.5ml/30g x 5/16
monoject insulin syringe/u100/1ml/30g x 5/16
monoject ultra comfort insulin
syringe/0.3ml/30g x 5/16
syringe/1ml/28g x 1/2
ulticare insulin syringe/u100/0.3ml/30g x 1/2
ulticare insulin syringe/u100/0.5ml/31g x 5/16
ulticare insulin syringe/u100/1ml/30g x 1/2
O
OB COMPLETE 400
OB COMPLETE/DHA
OCTAGAM INJ 10GM/200ML,
2.5GM/50ML, 5GM/100ML
octreotide acetate inj
1000mcg/ml, 500mcg/ml
octreotide acetate inj
100mcg/ml, 200mcg/ml,
50mcg/ml
ofloxacin
ogestrel
Requ./
Límites
Página
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
2
QL(200/30)
59
3
3
4
B/D PA
58
58
53
5
PA
52
4
PA
52
2
2
20
35
51
Drug Name
olanzapine inj
olanzapine tabs
olanzapine odt
olanzapine/fluoxetine
OLYSIO
omega-3-acid ethyl esters
omeprazole cpdr
ONCASPAR
ondansetron hcl inj 4mg/2ml
ondansetron hcl oral soln
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg,
8mg
ondansetron odt
ONFI SUSP
ONFI TABS 10MG
ONFI TABS 20MG
oralone
ORAP
ORFADIN
orphenadrine citrate er
orsythia
OSMOPREP
oxacillin sodium inj 10gm, 2gm
oxaliplatin inj 100mg/20ml
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
oxaprozin
oxazepam
oxcarbazepine
oxybutynin chloride
oxybutynin chloride er tb24
5mg
oxybutynin chloride er tb24
10mg, 15mg
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl oral soln
oxycodone hcl tabs
oxycodone/acetaminophen
tabs 325mg 10mg, 325mg
Drug
Tier
4
2
2
2
5
2
2
5
4
2
2
2
2
3
3
3
2
3
5
2
2
4
4
5
2
2
2
2
2
1
2
Reqs./Limits
QL(30/30)
QL(30/30)
QL(30/30)
PA QL(30/30)
QL(120/30)
QL(60/30)
B/D PA
B/D PA
B/D PA QL(5/30)
B/D PA
QL(90/30)
B/D PA
QL(90/30)
QL(480/30)
QL(60/30)
QL(120/30)
PA
B/D PA
PA QL(60/30)
PA QL(120/30)
QL(120/30)
QL(30/30)
Page
41
41
41
37
42
47
49
40
38
38
38
38
38
36
36
36
48
41
49
56
51
49
34
40
51
51
32
43
36
49
49
2
QL(60/30)
49
2
2
2
2
2
QL(240/30)
QL(360/30)
QL(1200/30)
QL(240/30)
QL(360/30)
33
33
33
33
33
Drug Name
5mg, 325mg 7.5mg
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN
oxymorphone hydrochloride er
P
pacerone
paclitaxel inj 300mg/50ml
pamidronate disodium inj
30mg/10ml, 6mg/ml,
90mg/10ml
PANCRELIPASE
PANRETIN
pantoprazole sodium tbec
parcaine
paricalcitol
paromomycin sulfate
paroxetine hcl tabs 30mg,
40mg
paroxetine hcl tabs 10mg
paroxetine hcl tabs 20mg
paroxetine hcl er tb24 12.5mg
paroxetine hcl er tb24 37.5mg
paroxetine hcl er tb24 25mg
PASER
PATADAY
PATANOL
PAXIL SUSP
pedi-dri
PEDVAX HIB
peg 3350/electrolytes
peg-3350/nacl/na
bicarbonate/kcl
PEGANONE
PEG-INTRON
PEG-INTRON REDIPEN
PEG-INTRON REDIPEN PAK
4
penicillin g potassium inj
20000000unit, 5mu
penicillin v potassium oral soln
penicillin v potassium tabs
Drug Reqs./Limits
Tier
2
2
4
2
2
4
4
3
5
2
2
2
2
2
1
1
2
2
2
3
3
3
3
2
4
2
2
3
5
5
5
Page
QL(360/30)
QL(150/30)
PA QL(60/30)
QL(60/30)
33
32
32
32
B/D PA
B/D PA
46
40
54
QL(60/30)
QL(60/30)
QL(30/30)
QL(60/30)
QL(30/30)
QL(60/30)
QL(90/30)
QL(900/30)
PA
PA
PA
49
40
49
54
54
33
37
37
37
37
37
37
39
54
54
37
38
53
49
49
36
42
42
42
4
35
1
1
35
35
21
Nombre del
medicamento
Nivel del
medicamento
250mg
penicillin v potassium tabs
500mg
PENTAM 300
pentoxifylline er
PERFOROMIST
perindopril erbumine
periogard
PERJETA
permethrin crea
perphenazine
perphenazine/amitriptyline
PFIZERPEN-G INJ 5MU
phenadoz
phenelzine sulfate
phenobarbital
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
philith
PHOSLYRA
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
PICATO
pilocarpine hcl tabs
PILOCARPINE HCL
OPHTHALMIC SOLN
pilocarpine hydrochloride
pimtrea
pindolol
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin sodium/
tazobactam sodium
piperacillin sodium/tazobactam
sodium
PIPERACILLIN/TAZOBACTA
M
Requ./
Límites
Página
2
35
3
2
3
40
46
55
1
1
5
2
2
2
4
2
2
2
2
2
4
2
2
4
4
4
4
4
2
3
2
2
1
2
2
2
4
4
4
B/D PA
QL(120/30)
PA
PA
PA
B/D PA
ST
QL(30/30)
QL(90/30)
QL(30/30)
46
48
40
40
41
37
35
37
37
36
36
36
36
36
51
57
55
54
54
40
48
55
48
51
46
43
43
43
35
35
35
Nombre del
medicamento
Nivel del
medicamento
pirmella 1/35
pirmella 7/7/7
piroxicam
podofilox
polycin
polycin b
poly-dex
polyethylene glycol 3350 powd
polymyxin b sulfate
polymyxin b
sulfate/trimethoprim sulfate
POMALYST
portia-28
potassium chloride inj
10meq/100ml, 20meq/100ml,
2meq/ml, 40meq/100ml
potassium chloride liqd
potassium chloride pack
potassium chloride 0.15%
d5w/nacl 0.33%
d5w/nacl 0.45%
potassium chloride 0.15%/d5w
potassium chloride 0.15%/nacl
0.9%
d5w/nacl 0.45%
potassium chloride
0.224%/d5w/nacl 0.45%
POTASSIUM CHLORIDE
0.3%/ NACL 0.9%
potassium chloride 0.3%/d5w
potassium chloride 0.3%/nacl
0.9%/viaflex
potassium chloride cr
potassium chloride er cpcr
POTASSIUM CHLORIDE ER
TBCR 10MEQ
potassium chloride er tbcr
10meq, 20meq
POTASSIUM CHLORIDE SR
POTASSIUM CITRATE
POTIGA
Requ./
Límites
Página
2
2
2
2
2
2
2
2
4
2
5
2
4
51
51
32
48
54
34
54
49
34
34
PA QL(21/28)
B/D PA
40
51
57
2
2
4
B/D PA
57
57
44
4
B/D PA
44
4
4
B/D PA
57
57
4
B/D PA
44
4
B/D PA
44
4
B/D PA
57
4
4
B/D PA
B/D PA
57
57
1
2
3
57
57
57
1
57
3
3
3
57
57
36
PA QL(90/30)
22
Drug Name
Drug
Tier
PRADAXA
3
pramipexole dihydrochloride
2
pravastatin sodium tabs 80mg
1
pravastatin sodium tabs 40mg
1
pravastatin sodium tabs 10mg, 1
20mg
prazosin hcl
1
PRED MILD
3
PRED-G
3
PRED-G S.O.P.
3
prednicarbate oint
2
PREDNISOLONE ACETATE
3
prednisolone sodium
2
phosphate oral soln
prednisolone sodium
1
phosphate ophthalmic soln
prednisone oral soln
2
prednisone tabs 50mg
2
prednisone tabs 10mg, 1mg,
1
2.5mg, 20mg, 5mg
PREDNISONE INTENSOL
3
pregnyl w/diluent benzyl
4
alcohol/nacl
PREMARIN CREA
3
PREMARIN INJ
4
PREMARIN TABS
4
PREMASOL INJ 52MEQ/L
4
1760MG/100ML
880MG/100ML 34MEQ/L
1760MG/100ML
372MG/100ML
406MG/100ML
526MG/100ML
492MG/100ML
492MG/100ML
526MG/100ML
356MG/100ML
356MG/100ML
390MG/100ML 34MG/100ML
152MG/100ML
premasol inj 56meq/l
4
320mg/100ml 730mg/100ml
190mg/100ml 3meq/l
20mg/100ml 300mg/100ml
Reqs./Limits
PA QL(60/30)
QL(90/30)
QL(30/30)
QL(60/30)
QL(90/30)
Page
44
41
47
47
47
45
54
54
54
50
54
50
54
50
50
50
PA
50
51
PA QL(30/30)
B/D PA
52
52
52
57
B/D PA
57
Drug Name
220mg/100ml 290mg/100ml
490mg/100ml 840mg/100ml
490mg/100ml 200mg/100ml
290mg/100ml 410mg/100ml
230mg/100ml 5meq/l
15mg/100ml 250mg/100ml
120mg/100ml 140mg/100ml
470mg/100ml
PRENATABS OBN
prevalite
previfem
PREZISTA SUSP
PREZISTA TABS 800MG
PREZISTA TABS 600MG
PREZISTA TABS 150MG
PREZISTA TABS 75MG
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRIMSOL
PRINIVIL
PRISTIQ
PRIVIGEN INJ 10GM/100ML,
20GM/200ML, 5GM/50ML
PROAIR HFA
probenecid
probenecid/colchicine
PROCALAMINE
procentra
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate tabs
10mg
prochlorperazine maleate tabs
5mg
PROCRIT INJ 20000UNIT/ML,
40000UNIT/ML
PROCRIT INJ 10000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
procto-pak
proctosol hc
proctozone-hc
Drug Reqs./Limits
Tier
3
2
2
5
5
5
4
4
3
3
2
3
4
4
4
3
2
2
4
2
2
4
1
Page
QL(400/30)
QL(30/30)
QL(60/30)
QL(180/30)
QL(360/30)
QL(30/30) ST
B/D PA
QL(17/30)
B/D PA
QL(1800/30)
2
58
47
52
43
43
43
43
43
39
40
36
34
46
37
53
55
38
38
57
48
41
41
41
41
5
PA
45
4
PA
45
2
2
2
50
50
50
23
Nombre del
medicamento
Nivel del
medicamento
progesterone caps
PROGLYCEM
PROGRAF INJ
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl supp
12.5mg, 25mg
promethazine hcl inj
promethazine hcl syrp
promethazine hcl tabs 12.5mg,
50mg
promethazine hcl tabs 25mg
promethazine hcl plain
promethegan
propafenone hcl
propafenone hcl er
propantheline bromide
proparacaine hcl
propranolol hcl inj
propranolol hcl oral soln
propranolol hcl tabs 60mg
propranolol hcl tabs 10mg,
20mg, 40mg, 80mg
propranolol hcl er
propranolol/hydrochlorothiazid
e
propylthiouracil
PROQUAD
PROSOL
PROTOPIC
protriptyline hcl
PROVENGE
PRUDOXIN
PULMOZYME
pyrazinamide
pyridostigmine bromide
Q
quasense
quetiapine fumarate
quinapril hcl
Requ./
Límites
Página
2
3
4
5
5
4
5
2
B/D PA
B/D PA
B/D PA
QL(1/180) ST
PA QL(30/30)
PA
52
44
53
56
40
54
45
37
4
2
2
PA
PA
PA
55
55
55
1
2
2
2
2
2
2
4
2
2
1
PA
PA
PA
55
37
37
46
46
49
54
46
46
46
46
2
2
2
4
4
3
2
5
3
5
2
2
2
2
1
46
46
B/D PA
B/D PA
B/D PA
QL(90/30)
52
53
57
48
37
53
48
56
39
38
52
41
46
Nombre del
medicamento
Nivel del
medicamento
quinapril/hydrochlorothiazide
2
quinidine sulfate
2
quinine sulfate
1
QVAR
3
R
RABAVERT
4
raloxifene hydrochloride
2
ramipril
1
RANEXA TB12 1000MG
3
RANEXA TB12 500MG
3
ranitidine hcl caps
2
ranitidine hcl inj 150mg/6ml
4
ranitidine hcl syrp
2
ranitidine hcl tabs
1
RAPAFLO
4
RAPAMUNE ORAL SOLN
3
RAPAMUNE TABS 1MG,
3
2MG
REBETOL ORAL SOLN
4
REBIF
5
REBIF REBIDOSE
5
REBIF REBIDOSE
5
TITRATION PACK
REBIF TITRATION PACK
5
reclipsen
2
RECOMBIVAX HB INJ
4
10MCG/ML, 40MCG/ML
regonol
4
REGRANEX
5
RELISTOR INJ 8MG/0.4ML
4
RELISTOR INJ VIAL 12MG/0.6ML4
RELISTOR INJ KIT 12MG/0.6ML 4
REMICADE
5
REMODULIN
5
RENVELA PACK 2.4GM
5
RENVELA PACK 0.8GM
3
RENVELA TABS
3
repaglinide
2
RESCRIPTOR
3
RESTASIS
3
RETROVIR IV INFUSION
4
REVLIMID
5
Requ./
Límites
Página
QL(18/30)
QL(30/30)
B/D PA
B/D PA
53
52
46
46
47
49
49
49
49
49
53
53
PA
PA QL(6/28)
PA QL(6/28)
PA QL(4.2/28)
42
48
48
48
PA QL(4.2/28)
48
52
53
QL(30/30)
QL(60/30) ST
QL(120/30) ST
B/D PA
PA
PA QL(12/30)
PA QL(18/30)
PA QL(28/28)
PA
B/D PA
QL(180/30)
QL(180/30)
QL(540/30)
QL(64/30)
PA QL(28/28)
24
46
46
40
55
38
48
49
49
49
53
56
50
50
50
43
42
54
42
39
Drug Name
Drug
Tier
5
2
5
2
4
5
5
2
5
2
2
4
3
4
2
4
4
3
2
4
Reqs./Limits
Page
Drug Name
Drug Reqs./Limits
Tier
2 QL(360/30)
3 QL(30/30)
Page
REYATAZ
43
roxicet tabs
ROZEREM
ribasphere caps
PA
42
RIBASPHERE TABS 600MG
PA
42
S
ribasphere tabs 200mg
PA
42
SABRIL PACK
5 PA QL(200/30)
RIBASPHERE TABS 400MG
PA
42
SABRIL TABS
5 PA QL(180/30)
RIBASPHERE RIBAPAK
PA
42
SAIZEN
5 PA
RIBATAB
PA
42
SAIZEN CLICK.EASY
5 PA
ribavirin
PA
42
SAMSCA TABS 30MG
5 PA QL(60/30)
RIDAURA
53
SAMSCA TABS 15MG
5 PA QL(90/30)
rifabutin
38
SANDOSTATIN LAR DEPOT
5 PA
SANTYL
3
rifampin caps
39
SAPHRIS
3 QL(60/30) ST
rifampin inj
39
selegiline hcl
2
RIFATER
39
selenium sulfide lotn
1
riluzole
48
SELZENTRY TABS 150MG
5 QL(60/30)
rimantadine hcl
43
SELZENTRY
TABS
300MG
5 QL(120/30)
ringers injection
57
SENSIPAR TABS 30MG
3 QL(60/30)
ringers irrigation
54
SENSIPAR TABS 60MG
5 QL(60/30)
RIOMET
43
SENSIPAR TABS 90MG
5 QL(120/30)
risedronate sodium
QL(1/28)
54
SEREVENT DISKUS
3 QL(60/30)
RISPERDAL CONSTA INJ
41
12.5MG, 25MG
sertraline hcl conc
2 QL(300/30)
RISPERDAL CONSTA INJ
5
41
sertraline hcl tabs 25mg
2 QL(30/30)
37.5MG, 50MG
2 QL(60/30)
risperidone oral soln
2 QL(360/30)
41
2 QL(90/30)
risperidone tabs 0.25mg,
2 QL(90/30)
42
sildenafil
2 PA QL(90/30)
0.5mg, 1mg, 2mg, 3mg
SILENOR
3 QL(30/30)
risperidone tabs 4mg
2 QL(120/30)
42
SILVER SULFADIAZINE
3
risperidone m-tab tbdp 0.5mg,
2 QL(90/30)
41
SIMULECT
5 B/D PA
1mg, 2mg, 3mg
simvastatin tabs 20mg, 40mg,
1 QL(30/30)
risperidone m-tab tbdp 4mg
2 QL(120/30)
41
80mg
risperidone odt tbdp 0.25mg,
2 QL(90/30)
41
simvastatin tabs 10mg, 5mg
1 QL(90/30)
0.5mg, 1mg, 2mg, 3mg
sirolimus
2 B/D PA
risperidone odt tbdp 4mg
2 QL(120/30)
41
SIRTURO
4 PA
RITUXAN
5 PA
40
sodium bicarbonate inj 7.5%,
4
rivastigmine tartrate
2 QL(60/30)
36
8.4%
rizatriptan benzoate
2 QL(12/30)
38
sodium chloride inj 0.9%,
4 B/D PA
rizatriptan benzoate odt
2 QL(12/30)
38
2.5meq/ml, 3%, 5%
romycin
2
35
sodium chloride 0.45% viaflex
4 B/D PA
ropinirole hcl
2
41
sodium chloride 0.9%
4
rosadan gel
2
34
SODIUM EDECRIN
4
ROTARIX
3
53
sodium fluoride chew 0.25mg,
1
ROTATEQ
3
53
0.5mg, 1mg, 2.2mg
33
56
36
36
51
51
56
56
52
48
42
41
48
42
42
52
52
52
55
37
37
37
37
56
56
34
53
47
47
53
39
56
57
57
54
47
57
25
Nombre del
medicamento
Nivel del
medicamento
sodium fluoride tabs
sodium lactate
SODIUM PHENYLBUTYRATE
sodium polystyrene sulfonate
powd
sodium polystyrene sulfonate
susp 15gm/60ml
sodium sulfacetamide
ophthalmic soln
SOLTAMOX
SOLU-CORTEF INJ 1000MG,
250MG, 500MG
SOMATULINE DEPOT
SOMAVERT INJ 15MG, 20MG
SOMAVERT INJ 10MG
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
spironolactone tabs 25mg
spironolactone tabs 100mg,
50mg
spironolactone/hydrochlorothia
zide
SPORANOX ORAL SOLN
sprintec 28
SPRYCEL
sps
sronyx
SSD
stavudine
sterile water irrigation
STIMATE
STIVARGA
STRATTERA
streptomycin sulfate
STRIBILD
STROMECTOL
SUBOXONE
sucralfate
sulfacetamide sodium
1
4
5
2
Requ./
Límites
B/D PA
Página
57
56
49
56
2
56
2
35
3
4
5
5
5
2
2
2
5
3
1
2
39
50
PA
PA QL(60/30)
PA QL(90/30)
PA QL(30/30)
QL(30/30)
2
3
2
5
2
2
3
2
4
3
5
3
4
5
3
3
2
2
52
52
52
46
46
46
42
55
47
47
47
PA
PA
PA QL(84/21)
PA QL(90/30)
38
52
40
56
52
34
42
54
51
40
48
33
42
40
33
49
35
Nombre del
medicamento
Nivel del
medicamento
ophthalmic soln
sulfacetamide sodium susp
sulfacetamide
sodium/prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
inj
susp
tabs
ds
sulfasalazine tabs
sulfazine
sulfazine ec
sulindac
SUMATRIPTAN
sumatriptan succinate inj
4mg/0.5ml
sumatriptan succinate inj
4mg/0.5ml, 6mg/0.5ml
sumatriptan succinate tabs
sumatriptan succinate refill inj
6mg/0.5ml
sumatriptan succinate refill inj
4mg/0.5ml
SUPRAX SUSR
SUPRAX TABS
SURMONTIL
SUSTIVA
SUTENT CAPS 12.5MG,
25MG, 50MG
SYLATRON
SYMBICORT AERO
160MCG/ACT 4.5MCG/ACT
SYMBICORT AERO
80MCG/ACT 4.5MCG/ACT
SYNAGIS INJ 50MG/0.5ML
SYNAREL
SYNERCID
SYNRIBO
Requ./
Límites
Página
2
2
48
35
2
4
35
35
1
35
1
35
1
35
2
2
2
2
3
2
QL(12/30)
QL(4/30)
53
53
53
32
38
38
2
QL(8/30)
38
2
2
QL(9/30)
QL(4/30)
38
38
2
QL(8/30)
38
3
3
4
3
5
PA
PA
34
34
37
42
40
5
3
PA
QL(11/30)
40
55
3
QL(14/30)
55
5
5
4
5
PA
PA
53
52
34
40
PA
26
Drug Name
SYNTHROID
SYPRINE
T
TABLOID
tacrolimus
TAFINLAR
TAMIFLU CAPS 75MG
TAMIFLU CAPS 45MG
TAMIFLU CAPS 30MG
TAMIFLU SUSR
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TASIGNA
TASMAR
TAXOTERE
TAZICEF INJ 1GM/50ML
4.4%
tazicef inj 1gm, 2gm, 6gm
TAZORAC CREA
TAZORAC GEL
taztia xt
TEFLARO
TEGRETOL TABS
TEGRETOL-XR TB12 200MG,
400MG
TEGRETOL-XR TB12 100MG
TEKAMLO
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazid
e
temazepam
TEMODAR INJ
tenivac
TERAZOL 3 CREA
TERAZOL 7
Drug Reqs./Limits
Tier
4
5
3
2
5
3
3
3
3
2
2
5
5
5
5
5
4
4
3
3
2
4
4
4
3
3
3
3
2
2
2
2
2
5
4
4
4
B/D PA
PA
QL(56/365)
QL(60/365)
QL(120/365)
QL(700/365)
PA
PA
B/D PA
QL(120/30)
QL(100/30)
ST
ST
ST
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(90/365)
B/D PA
Page
52
56
39
53
40
43
43
43
43
39
49
40
40
40
40
40
34
34
48
48
46
34
36
36
36
47
47
47
45
45
45
45
43
39
53
38
38
Drug Name
Drug
Tier
terazosin hcl caps 1mg, 5mg
1
terazosin hcl caps 10mg, 2mg
1
terbinafine hcl tabs
1
terbutaline sulfate inj
4
terbutaline sulfate tabs
2
terconazole
2
TESTIM
3
testosterone cypionate
4
testosterone enanthate
4
tetanus toxoid adsorbed
4
tetanus/diphtheria toxoids4
adsorbed adult
tetracycline hcl
1
TEXACORT
3
THALOMID CAPS 150MG,
5
200MG, 50MG
THALOMID CAPS 100MG
5
THEO-24
4
theochron
2
theophylline cr
2
theophylline er tb12 200mg,
2
300mg, 450mg
theophylline er tb24
2
THERMAZENE
3
thioridazine hcl
2
thiothixene caps 10mg, 1mg,
2
5mg
thiothixene caps 2mg
1
THYMOGLOBULIN
3
THYROLAR-1
3
THYROLAR-1/2
3
THYROLAR-1/4
3
THYROLAR-2
3
THYROLAR-3
3
tiagabine hydrochloride tabs
2
2mg
tiagabine hydrochloride tabs
2
4mg
TIKOSYN
3
tilia fe
2
TIMENTIN
4
timolol maleate tabs
2
Reqs./Limits
Page
QL(30/30)
QL(60/30)
QL(180/365)
PA
PA
PA
PA QL(60/30)
PA QL(90/30)
PA
49
49
38
55
55
38
51
51
51
53
53
35
50
39
39
56
56
56
56
56
34
41
41
QL(240/30) ST
41
53
52
52
52
52
52
36
QL(420/30) ST
36
B/D PA
46
52
35
46
27
Nombre del
medicamento
Nivel del
medicamento
timolol maleate ophthalmic
soln
tis-u-sol
TIVICAY
tizanidine hcl tabs
TOBI PODHALER
TOBRADEX OINT
tobramycin
tobramycin sulfate inj
10mg/ml, 80mg/2ml
tobramycin sulfate inj 1.2gm
tobramycin sulfate ophthalmic
soln
tobramycin/dexamethasone
TOBREX OINT
tolmetin sodium
tolterodine tartrate
topiragen
topiramate
TOPOSAR
topotecan hcl inj 4mg
TORISEL
torsemide tabs
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hcl er tb24
tramadol
hydrochloride/acetaminophen
trandolapril
tranexamic acid inj
tranexamic acid tabs
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
TRAVATAN Z
trazodone hcl tabs 300mg
trazodone hcl tabs 100mg,
150mg, 50mg
TREANDA
TRECATOR
Requ./
Límites
Página
1
55
4
5
2
5
3
4
4
54
42
42
56
54
56
33
4
2
2
3
2
1
2
2
3
5
3
2
4
5
3
2
2
2
2
2
2
3
2
4
3
2
1
5
3
QL(60/30)
QL(1568/365)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(60/30)
QL(30/30)
QL(240/30)
QL(30/30)
QL(240/30)
PA
QL(12/36)
B/D PA
QL(5/30) ST
B/D PA
33
33
54
33
32
49
36
36
40
40
53
47
57
56
43
33
32
33
46
45
45
37
37
57
54
37
37
39
39
Nombre del
medicamento
Nivel del
medicamento
TRELSTAR DEPOT
TRELSTAR DEPOT MIXJECT
TRELSTAR LA
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
TRETINOIN CAPS
tretinoin crea
tretinoin gel
tretinoin microsphere
tretinoin microsphere pump
gel 0.04%
triamcinolone acetonide pste
triamcinolone acetonide crea
0.1%
triamcinolone acetonide crea
0.025%, 0.5%
triamcinolone acetonide lotn
triamcinolone acetonide oint
triamcinolone acetonide inha
triamcinolone in orabase
triamterene/hydrochlorothiazid
e caps 25mg 50mg
e caps 25mg 37.5mg
e tabs
triderm
tri-estarylla
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl elix
trihexyphenidyl hcl tabs 5mg
trihexyphenidyl hcl tabs 2mg
tri-legest fe
tri-linyah
trilyte
trimethoprim
trimethoprim sulfate/polymyxin
b sulfate
tri-previfem
TRISENOX
tri-sprintec
5
5
5
5
5
5
2
2
2
2
Requ./
Límites
PA QL(1/28)
PA QL(2/28)
PA QL(1/84)
PA QL(2/84)
PA QL(2/168)
Página
PA QL(45/30)
PA QL(45/30)
PA QL(50/30)
PA QL(50/30)
2
1
48
50
2
51
2
2
2
2
2
51
51
55
48
47
QL(16.5/30)
1
47
1
47
1
2
2
2
2
2
1
2
2
2
2
2
51
52
41
43
40
40
40
52
52
49
34
54
2
4
2
PA
PA
PA
B/D PA
28
52
52
52
52
52
40
48
48
48
48
52
40
52
Drug Name
trivora-28
TROPHAMINE INJ 97MEQ/L
0.54GM/100ML
1.2GM/100ML
0.32GM/100ML 0 0
0.5GM/100ML
0.36GM/100ML
0.48GM/100ML
0.82GM/100ML
1.4GM/100ML 1.2GM/100ML
0.34GM/100ML
0.48GM/100ML
0.68GM/100ML
0.38GM/100ML 5MEQ/L
0.025GM/100ML
0.42GM/100ML
0.2GM/100ML
0.24GM/100ML
0.78GM/100ML
tropicamide
TRUVADA
TWINRIX
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
TYZINE
TYZINE PEDIATRIC NASAL
DROPS
U
u-cort
ULORIC
UNIRETIC
UNITHROID
UNITHROID DIRECT
UNIVASC
ursodiol
UVADEX
V
valacyclovir hcl tabs 1000mg
valacyclovir hcl tabs 500mg
VALCHLOR
Drug Reqs./Limits
Tier
2
4 B/D PA
2
5
4
5
5
4
5
5
3
3
2
3
4
4
4
4
2
4
2
2
5
PA
PA
PA
Page
52
58
54
42
53
34
40
53
48
42
56
56
B/D PA
51
38
46
52
52
46
49
48
QL(30/30)
QL(60/30)
PA
43
43
39
ST
Drug Name
VALCYTE
valproate sodium
valproic acid
valsartan/hydrochlorothiazide
VANCOMYCIN HCL CAPS
125MG
VANCOMYCIN HCL CAPS
250MG
VANCOMYCIN HCL INJ
5000MG, 750MG
vancomycin hcl inj 1000mg,
10gm, 500mg
VANCOMYCIN HCL IN
DEXTROSE
VAQTA
VARIVAX
VASERETIC
VASOTEC TABS 10MG,
2.5MG, 20MG
VECTIBIX INJ 100MG/5ML
VECTICAL
VELCADE
velivet
venlafaxine hcl
venlafaxine hcl er cp24
150mg, 37.5mg
venlafaxine hcl er cp24 75mg
venlafaxine hcl er tb24 150mg,
37.5mg
venlafaxine hcl er tb24 75mg
VENTOLIN HFA
verapamil hcl inj
verapamil hcl tabs 120mg,
80mg
verapamil hcl tabs 40mg
verapamil hcl er
VERSACLOZ
VESICARE
vicodin
vicodin es
vicodin hp
VICTRELIS
Drug Reqs./Limits
Tier
5
4
2
2
5 QL(40/10)
5
Page
QL(80/10)
42
36
36
45
34
34
5
34
4
34
4
34
4
4
4
4
53
53
46
46
3
3
5
2
2
2
B/D PA
QL(120/30)
QL(30/30)
40
48
40
52
37
37
2
2
QL(90/30)
QL(30/30)
37
37
2
4
4
1
QL(90/30)
QL(36/30)
37
55
46
46
2
2
5
3
2
2
2
5
B/D PA
QL(30/30)
QL(390/30)
QL(390/30)
QL(390/30)
PA QL(360/30)
46
46
42
49
33
33
33
42
29
Nombre del
medicamento
Nivel del
medicamento
VIDEX PEDIATRIC
VIGAMOX
VIIBRYD
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
viorele
VIRACEPT
VIRAMUNE XR TB24 100MG
VIRAZOLE
VIREAD
VIVELLE-DOT
VOLTAREN
VORAXAZE
voriconazole inj
voriconazole susr
voriconazole tabs
VOTRIENT
VPRIV
vyfemla
W
warfarin sodium
WELCHOL
wera
X
XALKORI
XARELTO TABS 10MG,
20MG
XARELTO TABS 15MG
XENAZINE TABS 12.5MG
XENAZINE TABS 25MG
XGEVA
XIFAXAN TABS 550MG
XIFAXAN TABS 200MG
XOLAIR
XOLEGEL
XTANDI
XYREM
3
3
4
4
3
3
4
4
4
4
2
5
3
5
5
3
3
5
4
5
5
5
5
2
Requ./
Límites
QL(30/30) ST
QL(1200/30) ST
QL(1200/30) ST
QL(60/30) ST
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(8/28)
QL(1000/30) ST
PA
PA
PA
PA QL(120/30)
PA
1
4
2
Página
42
35
37
36
36
36
40
40
40
40
52
43
42
42
42
52
48
54
38
38
38
40
49
52
44
47
52
5
3
PA QL(60/30)
PA QL(30/30)
40
44
3
5
5
5
5
4
5
3
5
5
PA QL(60/30)
PA QL(90/30)
PA QL(120/30)
PA
PA QL(60/30)
PA QL(9/30)
PA
44
48
48
54
34
34
56
38
39
56
PA QL(120/30)
PA QL(540/30)
Nombre del
medicamento
Nivel del
medicamento
Y
YERVOY
yf-vax
Z
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZAVESCA
zazole supp
ZELBORAF
ZEMAIRA
zenatane
zenchent
ZENPEP
ZESTORETIC
ZESTRIL
ZETIA
ZIAGEN ORAL SOLN
zidovudine
ZINECARD INJ 250MG
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid inj 4mg/5ml
zoledronic acid inj 5mg/100ml
ZOLINZA
zolpidem tartrate
ZOMETA INJ 4MG/100ML
ZONALON
zonisamide
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG,
0.75MG
ZOSTAVAX
ZOSYN INJ 5% 2GM/50ML
0.25GM/50ML, 5%
3GM/50ML 0.375GM/50ML
zovia 1/35e
zovia 1/50e
ZYCLARA
ZYKADIA
5
4
2
2
5
4
5
2
5
5
2
2
3
4
4
3
3
2
4
2
3
4
5
4
5
2
5
3
2
4
5
Requ./
Límites
Página
B/D PA
QL(90/365)
PA
B/D PA
PA QL(240/30)
B/D PA
QL(30/30)
B/D PA
QL(60/30)
ST
QL(60/30)
B/D PA
B/D PA
QL(120/30)
PA QL(90/365)
B/D PA
B/D PA
B/D PA
55
56
39
39
49
38
40
56
48
52
49
46
46
47
42
42
40
42
42
35
54
54
40
56
54
48
36
53
53
4
4
53
35
2
2
5
5
52
52
48
40
PA
30
40
53
Drug Name
ZYLET
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
Drug
Tier
3
5
5
5
Reqs./Limits
ST
PA QL(120/30)
PA
Page
Drug Name
Drug Reqs./Limits
Tier
Page
33
42
39
34
31
Drug Name
Drug Reqs/Limits Drug Name
Tier
ANALGESICS
ANALGESICS
butal/asa/caff
2 PA
QL(180/30)
butalbital/acetamino
2 PA
phen/caffeine
QL(180/30)
margesic
2 PA
QL(180/30)
NONSTEROIDAL ANTIINFLAMMATORY DRUGS
diclofenac
2
potassium
diclofenac sodium
2
dr tbec 25mg, 50mg
diclofenac sodium
1
dr tbec 75mg
diclofenac sodium
2
er
diflunisal
2
etodolac
2
etodolac er
2
fenoprofen calcium
2
flurbiprofen
2
ibuprofen susp
1
ibuprofen tabs
1
400mg, 600mg,
800mg
ketoprofen
2
ketoprofen er
2
meclofenamate
2
sodium
meloxicam tabs
1
nabumetone
2
naproxen dr
2
naproxen sodium
2
tabs 275mg, 550mg
naproxen susp
2
naproxen tabs
2
250mg
naproxen tabs
1
375mg, 500mg
oxaprozin
2
oxycodone/ibuprofe
2 QL(150/30)
n
piroxicam
2
sulindac
2
tolmetin sodium
2
Drug Reqs/Limits
Tier
Tier
2 QL(360/30)
OPIOID ANALGESICS, LONG-ACTING endocet tabs
325mg;
10mg,
fentanyl
2 QL(15/30)
325mg; 5mg,
infumorph 200
4
325mg; 7.5mg
infumorph 500
4
fentanyl citrate
4 B/D PA
levorphanol tartrate
2 QL(180/30)
FENTANYL
5 PA
methadone hcl conc
2 QL(500/30)
CITRATE ORAL
QL(120/30)
methadone hcl inj
4
TRANSMUCOSAL
methadone hcl oral
2 QL(2000/30)
hydrocodone
2 QL(5400/30)
soln 10mg/5ml
methadone hcl oral
2 QL(4000/30) bitartrate/acetamino
phen oral soln
soln 5mg/5ml
hydrocodone
2 QL(360/30)
methadone hcl tabs
2 QL(360/30)
bitartrate/acetamino
methadose tabs
2 QL(360/30)
phen tabs 325mg;
morphine sulfate er
2 QL(90/30)
2.5mg
tbcr
hydrocodone
2 QL(390/30)
OXYCONTIN
4 PA
bitartrate/acetamino
QL(60/30)
phen tabs 300mg;
oxymorphone
2 QL(60/30)
10mg, 300mg; 5mg,
hydrochloride er
300mg; 7.5mg
tramadol hcl er tb24
2 QL(30/30)
hydrocodone/aceta
2 QL(360/30)
OPIOID ANALGESICS, SHORTminophen
tabs
ACTING
hydrocodone/ibupro
2 QL(150/30)
acetaminophen/cod
2 QL(360/30)
fen
tabs
7.5mg;
eine #2
200mg
acetaminophen/cod
2 QL(360/30)
HYDROMORPHON
4
eine #3
E
HCL
INJ
acetaminophen/cod
2 QL(240/30)
1MG/ML, 2MG/ML
eine #4
4
acetaminophen/cod
2 QL(5000/30) hydromorphone hcl
inj 2mg/ml,
eine oral soln
500mg/50ml
acetaminophen/cod
2 QL(240/30)
hydromorphone hcl
2 QL(1200/30)
eine tabs 300mg;
liqd
60mg
hydromorphone hcl
2 QL(240/30)
acetaminophen/cod
2 QL(360/30)
tabs
eine tabs 300mg;
LAZANDA
5 PA
15mg
QL(44/28)
ascomp/codeine
2 PA
lorcet
2
QL(360/30)
QL(180/30)
lorcet hd
2 QL(360/30)
butalbital/aspirin/caf
2 PA
lorcet
plus
2 QL(360/30)
feine/codeine
QL(180/30)
lortab tabs
2 QL(360/30)
butorphanol tartrate
4
morphine
sulfate
inj
4
inj
0.5mg/ml, 10mg/ml,
butorphanol tartrate
2 QL(6/30)
1mg/ml, 5mg/ml
nasal soln
morphine sulfate
2 QL(540/30)
duramorph
4
oral soln 20mg/ml
morphine sulfate
2 QL(2700/30)
oral soln 20mg/5ml
32
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
morphine sulfate
2 QL(5400/30)
oral soln 10mg/5ml
MORPHINE
3 QL(360/30)
SULFATE TABS
nalbuphine hcl
4
oxycodone hcl caps
2 QL(240/30)
oxycodone hcl conc
2 QL(360/30)
oxycodone hcl oral
2 QL(1200/30)
soln
oxycodone hcl tabs
2 QL(240/30)
oxycodone/acetami
2 QL(360/30)
nophen tabs
325mg; 10mg,
325mg; 5mg,
325mg; 7.5mg
oxycodone/aspirin
2 QL(360/30)
roxicet tabs
2 QL(360/30)
tramadol hcl
2 QL(240/30)
tramadol
2 QL(240/30)
hydrochloride/aceta
minophen
vicodin
2 QL(390/30)
vicodin es
2 QL(390/30)
vicodin hp
2 QL(390/30)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl
2
external soln
lidocaine hcl gel
2
lidocaine hcl inj
4
0.5%, 1%, 2%
lidocaine hcl jelly
2
lidocaine oint
2
lidocaine ptch
2 PA
QL(90/30)
lidocaine viscous
1
lidocaine/prilocaine
2
crea
ANTI-ADDICTION/SUBSTANCE
ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTICRAVING
acamprosate
2 PA
calcium dr
disulfiram
2
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl
inj
buprenorphine hcl
subl
buprenorphine
hcl/naloxone hcl
naltrexone hcl
SUBOXONE
gentamicin
4
sulfate/sodium
chloride
isotonic gentamicin
4
inj 0.8mg/ml; 0.9%,
1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%,
1mg/ml; 0.9%
neomycin sulfate
2
neomycin/polymyxi
4
n b sulfates
paromomycin
2
sulfate
streptomycin sulfate
4
tobramycin sulfate
4
inj 10mg/ml,
80mg/2ml
tobramycin sulfate
4 B/D PA
inj 1.2gm
tobramycin sulfate
2
ophthalmic soln
TOBREX OINT
3
ZYLET
3 ST
ANTIBACTERIALS, OTHER
ak-poly-bac
2
alcohol preps pads
1
baciim
4
BACITRACIN INJ
4
bacitracin
2
ophthalmic oint
bacitracin/polymyxi
2
nb
BACTROBAN
3
NASAL
chloramphenicol
1
sodium succinate
clindamax
2
clindamycin hcl
2
clindamycin
4
phosphate addvantage
clindamycin
2
phosphate crea
CLINDAMYCIN
4
PHOSPHATE IN
D5W
4 PA
2 PA
QL(24/30)
2 PA
QL(90/30)
2 PA
3 PA
QL(90/30)
OPIOID REVERSAL AGENTS
naloxone hcl
2
SMOKING CESSATION AGENTS
buproban
2 QL(60/30)
bupropion hcl sr
2 QL(60/30)
tb12 150mg
CHANTIX
3 PA
QL(336/365)
CHANTIX
3 PA
CONTINUING
QL(336/365)
MONTH PAK
CHANTIX
3 PA
STARTING
QL(106/365)
MONTH PAK
NICOTROL
3 PA
INHALER
QL(504/30)
NICOTROL NS
3 PA
QL(40/30)
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate inj
4
500mg/2ml
gentak
2
gentamicin sulfate
2
crea
gentamicin sulfate
4
inj
gentamicin sulfate
2
oint
gentamicin sulfate
4
ophthalmic soln
gentamicin sulfate
4
pediatric
gentamicin
4
sulfate/0.9%
sodium chloride
33
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
clindamycin
4
trimethoprim
2
cefuroxime axetil
2
phosphate inj
TYGACIL
5
cefuroxime sodium
4
150mg/ml
VANCOMYCIN
5 QL(40/10)
inj 1.5gm, 7.5gm,
colistimethate
4
HCL CAPS 125MG
750mg
sodium
VANCOMYCIN
5 QL(80/10)
cephalexin caps
1
CUBICIN
5 B/D PA
HCL CAPS 250MG
250mg, 500mg
lansoprazole/amoxi
2
VANCOMYCIN
4
cephalexin susr
2
cillin/clarithromycin
HCL IN
cephalexin tabs
2
LINCOCIN
4
DEXTROSE
SUPRAX SUSR
3
methenamine
2
VANCOMYCIN
5
SUPRAX TABS
3
hippurate
HCL INJ 5000MG,
TAZICEF INJ
4
metronidazole crea
2
750MG
1GM/50ML; 4.4%
metronidazole gel
2
vancomycin hcl inj
4
tazicef inj 1gm,
4
metronidazole in
4
1000mg, 10gm,
2gm, 6gm
nacl 0.79%
500mg
TEFLARO
4
metronidazole lotn
2
XIFAXAN TABS
5 PA
BETA-LACTAM, OTHER
metronidazole tabs
1
550MG
QL(60/30)
AZACTAM IN ISO4
metronidazole
2
XIFAXAN TABS
4 PA QL(9/30) OSMOTIC
vaginal
200MG
DEXTROSE
mupirocin
2
ZYVOX
5 PA
aztreonam
4
mupirocin calcium
2
BETA-LACTAM, CEPHALOSPORINS
cefotetan
4
neomycin/bacitracin
2
cefaclor caps
2
imipenem/cilastatin
2
/polymyxin
cefaclor er
2
INVANZ
4
neomycin/polymyxi
2
cefadroxil
2
meropenem
2
n/bacitracin/hydroco
cefazolin sodium inj
4
BETA-LACTAM, PENICILLINS
rtisone
10gm, 1gm, 1gm;
amoxicillin caps
1
neomycin/polymyxi
2
5%, 500mg
amoxicillin chew
2
n/gramicidin
cefazolin
4
amoxicillin susr
1
neomycin/polymyxi
2
sodium/dextrose inj
amoxicillin tabs
2
n/hydrocortisone
2gm; 3%
amoxicillin/clavulan
2
nitrofurantoin
2 QL(900/365) cefdinir
2
ate potassium
nitrofurantoin
2 QL(90/365)
cefepime inj 1gm,
4
amoxicillin/clavulan
2
macrocrystals
1gm/50ml; 5%,
ate potassium er
nitrofurantoin
2 QL(90/365)
2gm, 2gm/100ml,
ampicillin
2
monohydrate
2gm/50ml; 5%
ampicillin sodium
4
NORITATE
3
cefotaxime sodium
4
ampicillin4
polycin b
2
cefoxitin sodium inj
4
sulbactam inj 10gm;
polymyxin b sulfate
4
10gm, 1gm, 2gm
5gm, 2gm; 1gm
polymyxin b
2
cefpodoxime
2
AUGMENTIN
3
sulfate/trimethoprim
proxetil
SUSR 125MG/5ML;
sulfate
cefprozil
2
31.25MG/5ML
PRIMSOL
3
ceftazidime inj 1gm,
4
BICILLIN L-A
4
rosadan gel
2
2gm, 6gm
dicloxacillin sodium
2
SILVER
3
ceftazidime/dextros
4
nafcillin sodium
4
SULFADIAZINE
e
oxacillin sodium inj
4
SSD
3
ceftriaxone in iso4
10gm, 2gm
SYNERCID
4
osmotic dextrose
THERMAZENE
3
ceftriaxone sodium
4
34
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
penicillin g
4
potassium inj
20000000unit, 5mu
penicillin v
1
potassium oral soln
penicillin v
1
potassium tabs
250mg
penicillin v
2
potassium tabs
500mg
PFIZERPEN-G INJ
4
5MU
piperacillin sodium/
4
tazobactam sodium
piperacillin
4
sodium/tazobactam
sodium
PIPERACILLIN/TAZ
4
OBACTAM
TIMENTIN
4
ZOSYN INJ 5%;
4
2GM/50ML;
0.25GM/50ML, 5%;
3GM/50ML;
0.375GM/50ML
MACROLIDES
AZASITE
3
azithromycin inj
4
500mg
AZITHROMYCIN
3 QL(3/30)
PACK
azithromycin susr
2 QL(75/30)
200mg/5ml
azithromycin susr
2 QL(150/30)
100mg/5ml
azithromycin tabs
2 QL(12/28)
clarithromycin
2
clarithromycin er
2 QL(60/30)
e.e.s. 400
2
E.E.S. GRANULES
3
e.s.p.
2
ery
2
ERY-TAB
3
ERYPED 200
3
ERYPED 400
3
ERYTHROCIN
4
LACTOBIONATE
erythrocin stearate
2
erythromycin base
2
erythromycin
2
ethylsuccinate
erythromycin
2
external soln
erythromycin gel
2
erythromycin oint
2
erythromycin pads
2
ilotycin
2
KETEK
3 QL(20/30)
romycin
2
ZMAX
4 QL(60/30)
QUINOLONES
AVELOX INJ
4
CILOXAN OINT
3
CIPRO HC
3
CIPRODEX
3
ciprofloxacin er
2
ciprofloxacin hcl
2
ophthalmic soln
ciprofloxacin hcl
2
tabs 100mg, 750mg
ciprofloxacin hcl
1
tabs 250mg, 500mg
ciprofloxacin i.v.-in
4
d5w
ciprofloxacin inj
4
400mg/40ml
ciprofloxacin susr
2
levofloxacin in d5w
4
levofloxacin inj
4
levofloxacin oral
2
soln
levofloxacin tabs
2
MOXEZA
3
moxifloxacin hcl
2
ofloxacin
2
VIGAMOX
3
SULFONAMIDES
BLEPHAMIDE
3
blephamide s.o.p.
2
sodium
2
sulfacetamide
ophthalmic soln
sulfacetamide
2
sodium ophthalmic
soln
sulfacetamide
2
sodium/prednisolon
e sodium
phosphate
sulfadiazine
2
sulfamethoxazole/tri
1
methoprim ds
4
methoprim inj
1
methoprim susp
1
methoprim tabs
TETRACYCLINES
demeclocycline hcl
2
doxycycline caps
2
75mg
doxycycline hyclate
1
caps
doxycycline hyclate
4
inj
doxycycline hyclate
1
tabs 100mg
doxycycline hyclate
2
tabs 20mg
doxycycline
2
monohydrate
doxycycline susr
2
minocycline hcl
2
morgidox 1x100mg
1
caps
morgidox 2x100mg
1
caps
tetracycline hcl
1
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
APTIOM TABS
4 QL(30/30)
200MG, 400MG,
ST
800MG
35
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
APTIOM TABS
4 QL(60/30)
ONFI SUSP
3 QL(480/30)
TEGRETOL-XR
4
600MG
ST
ONFI TABS 10MG
3 QL(60/30)
TB12 200MG,
FYCOMPA
4 ST
ONFI TABS 20MG
3 QL(120/30)
400MG
levetiracetam er
2
primidone
2
TEGRETOL-XR
3
levetiracetam inj
4
SABRIL PACK
5 PA
TB12 100MG
levetiracetam oral
2
QL(200/30)
VIMPAT INJ
4 QL(1200/30)
soln
SABRIL TABS
5 PA
ST
levetiracetam tabs
2
QL(180/30)
VIMPAT ORAL
3 QL(1200/30)
phenobarbital
2
tiagabine
2 QL(240/30)
SOLN
ST
POTIGA
3 PA
hydrochloride tabs
ST
VIMPAT TABS
3 QL(60/30)
QL(90/30)
2mg
ST
tiagabine
2 QL(420/30)
CALCIUM CHANNEL MODIFYING
ANTIDEMENTIA AGENTS
hydrochloride tabs
ST
AGENTS
ANTIDEMENTIA AGENTS, OTHER
4mg
CELONTIN
3
ergoloid mesylates
2 PA
valproate
sodium
4
ethosuximide
2
CHOLINESTERASE INHIBITORS
valproic acid
2
LYRICA CAPS
3 QL(60/30)
donepezil hcl tabs
2 QL(30/30)
GLUTAMATE REDUCING AGENTS
225MG, 25MG,
23mg, 5mg
300MG
felbamate
2
donepezil hcl tabs
2 QL(60/30)
LYRICA CAPS
3 QL(90/30)
lamotrigine
2
10mg
100MG, 150MG,
lamotrigine er
2
donepezil hcl tbdp
2 QL(30/30)
200MG, 50MG,
topiragen
2
5mg
75MG
topiramate
2
donepezil hcl tbdp
2 QL(60/30)
LYRICA ORAL
3 QL(900/30)
SODIUM CHANNEL AGENTS
10mg
SOLN
BANZEL SUSP
5 PA
EXELON PT24
3 QL(30/30)
zonisamide
2
BANZEL TABS
5 PA
galantamine
2 QL(60/30)
GAMMA-AMINOBUTYRIC ACID
400MG
galantamine
2 QL(30/30)
(GABA) AUGMENTING AGENTS
BANZEL TABS
4 PA
hydrobromide cp24
clonazepam odt
2 QL(90/30)
200MG
galantamine
2 QL(200/30)
tbdp 0.125mg,
carbamazepine
2
hydrobromide oral
0.25mg, 0.5mg,
carbamazepine er
2
soln
1mg
dilantin caps 30mg
2
galantamine
2 QL(60/30)
clonazepam odt
2 QL(300/30)
DILANTIN CAPS
4
hydrobromide tabs
tbdp 2mg
100MG
rivastigmine tartrate
2 QL(60/30)
clonazepam tabs
2 QL(90/30)
DILANTIN
4
N-METHYL-D-ASPARTATE (NMDA)
0.5mg, 1mg
INFATABS
RECEPTOR ANTAGONIST
clonazepam tabs
2 QL(300/30)
epitol
2
NAMENDA ORAL
3 QL(300/30)
2mg
fosphenytoin
4
SOLN
DIAZEPAM GEL
3
sodium
NAMENDA XR
3 QL(30/30)
divalproex sodium
2
oxcarbazepine
2
NAMENDA XR
3 QL(28/28)
divalproex sodium
2
PEGANONE
3
TITRATION PACK
dr
phenytoin
2
ANTIDEPRESSANTS
divalproex sodium
2
phenytoin infatabs
2
ANTIDEPRESSANTS, OTHER
er
phenytoin sodium
4
BRINTELLIX
4 QL(30/30)
gabapentin
2
phenytoin sodium
2
ST
GABITRIL TABS
3 QL(90/30)
extended
bupropion hcl
2
16MG
ST
TEGRETOL TABS
4
bupropion hcl er
2 QL(60/30)
GABITRIL TABS
3 QL(120/30)
tb12 100mg, 200mg
12MG
ST
36
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
bupropion hcl er
2 QL(90/30)
tb12 150mg
bupropion hcl sr
2 QL(60/30)
tb12 100mg, 200mg
bupropion hcl sr
2 QL(90/30)
tb12 150mg
bupropion hcl xl
2 QL(30/30)
tb24 300mg
bupropion hcl xl
2 QL(90/30)
tb24 150mg
maprotiline hcl
2
mirtazapine
2 QL(30/30)
mirtazapine odt
2 QL(30/30)
nefazodone hcl
2 QL(60/30)
trazodone hcl tabs
2
300mg
trazodone hcl tabs
1
100mg, 150mg,
50mg
MONOAMINE OXIDASE INHIBITORS
EMSAM
3
MARPLAN
4
phenelzine sulfate
2
tranylcypromine
2
sulfate
SSRIS/SNRIS (SELECTIVE
SEROTONIN REUPTAKE
INHIBITORS/SEROTONIN AND
NOREPINEPHRINE REUPTAKE
INHIBITOR
citalopram
1 QL(600/30)
hydrobromide oral
soln
citalopram
1 QL(30/30)
hydrobromide tabs
40mg
citalopram
1 QL(60/30)
hydrobromide tabs
10mg, 20mg
duloxetine hcl cpep
2 QL(60/30)
20mg, 60mg
duloxetine hcl cpep
2 QL(90/30)
30mg
escitalopram
2 QL(600/30)
oxalate oral soln
escitalopram
oxalate tabs
FETZIMA
venlafaxine hcl er
cp24 150mg,
37.5mg
venlafaxine hcl er
cp24 75mg
venlafaxine hcl er
tb24 150mg,
37.5mg
venlafaxine hcl er
tb24 75mg
VIIBRYD
FETZIMA
TITRATION PACK
fluoxetine dr
fluoxetine hcl caps
fluoxetine hcl oral
soln
fluoxetine hcl tabs
10mg, 20mg
fluvoxamine
maleate
fluvoxamine
maleate er cp24
150mg
fluvoxamine
maleate er cp24
100mg
olanzapine/fluoxetin
e
paroxetine hcl er
tb24 12.5mg
paroxetine hcl er
tb24 37.5mg
paroxetine hcl er
tb24 25mg
paroxetine hcl tabs
30mg, 40mg
paroxetine hcl tabs
10mg
paroxetine hcl tabs
20mg
PAXIL SUSP
PRISTIQ
sertraline hcl conc
sertraline hcl tabs
25mg
sertraline hcl tabs
100mg
sertraline hcl tabs
50mg
venlafaxine hcl
2 QL(60/30)
4 QL(30/30)
ST
4 QL(28/28)
ST
2
2
2
2
2
2 QL(60/30)
2 QL(90/30)
2 QL(30/30)
2 QL(30/30)
2 QL(60/30)
2 QL(90/30)
2 QL(60/30)
1 QL(30/30)
1 QL(60/30)
3 QL(900/30)
4 QL(30/30)
ST
2 QL(300/30)
2 QL(30/30)
2 QL(60/30)
2 QL(90/30)
2 QL(120/30)
2 QL(30/30)
2 QL(90/30)
2 QL(30/30)
2 QL(90/30)
4 QL(30/30)
ST
TRICYCLICS
amitriptyline hcl
2 PA
tabs 150mg
amitriptyline hcl
1 PA
tabs 100mg, 10mg,
25mg, 50mg, 75mg
amoxapine
2
clomipramine hcl
2 PA
desipramine hcl
2
doxepin hcl
2 PA
imipramine hcl
2 PA
imipramine
2 PA
pamoate
nortriptyline hcl
1
caps
nortriptyline hcl oral
2
soln
perphenazine/amitri
2 PA
ptyline
protriptyline hcl
2
SURMONTIL
4 PA
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl tabs
2
phenadoz
2 PA
promethazine hcl
2 PA
plain
promethazine hcl
2 PA
supp 12.5mg, 25mg
promethegan
2 PA
TRANSDERM3 QL(12/36)
SCOP
EMETOGENIC THERAPY ADJUNCTS
37
Drug Name
dronabinol
EMEND CAPS
40MG
EMEND CAPS
125MG
EMEND CAPS
80MG
EMEND CAPS
granisetron hcl inj
0.1mg/ml, 1mg/ml
granisetron hcl tabs
ondansetron hcl inj
4mg/2ml
ondansetron hcl
oral soln
ondansetron hcl
tabs 24mg
ondansetron hcl
tabs 4mg, 8mg
ondansetron odt
Tier
fluconazole tabs
2 PA
100mg, 200mg,
QL(90/30)
50mg
3 B/D PA
fluconazole tabs
QL(2/30)
150mg
3 B/D PA
FLUCYTOSINE
QL(4/30)
griseofulvin
3 B/D PA
microsize
QL(8/30)
griseofulvin
3 B/D PA
ultramicrosize
QL(12/30)
itraconazole
4 B/D PA
2 B/D PA
QL(60/30)
4
2 B/D PA
2 B/D PA
QL(5/30)
2 B/D PA
QL(90/30)
2 B/D PA
QL(90/30)
ANTIFUNGALS
ANTIFUNGALS
ABELCET
5 PA
AMBISOME
4 PA
AMPHOTEC INJ
4 PA
50MG
amphotericin b
4 PA
CANCIDAS
5 PA
ciclopirox nail
2
lacquer
ciclopirox olamine
2
ciclopirox sham
2
ciclopirox susp
2
clotrimazole
2
external crea
clotrimazole
2
external soln
clotrimazole troc
2
econazole nitrate
2
fluconazole in
4
dextrose
fluconazole in nacl
4
fluconazole susr
2
Drug Reqs/Limits
Tier
Tier
2
ULORIC
3 ST
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
1 QL(8/30)
cafergot
2
dihydroergotamine
2
5
mesylate inj
2
migergot
2
SEROTONIN (5-HT) 1B/1D RECEPTOR
2
AGONISTS
naratriptan hcl
2 QL(9/30)
2 PA
2 QL(12/30)
QL(120/30)
2 QL(12/30)
ketoconazole
2
odt
NAFTIN
3
SUMATRIPTAN
3 QL(12/30)
NATACYN
3
sumatriptan
2 QL(4/30)
NOXAFIL SUSP
5 PA
succinate inj
QL(600/30)
4mg/0.5ml
NOXAFIL TBEC
5 PA
sumatriptan
2 QL(8/30)
QL(93/30)
succinate inj
nyamyc
2
4mg/0.5ml,
nystatin crea
2
6mg/0.5ml
nystatin oint
2
sumatriptan
2 QL(4/30)
nystatin powd
2
succinate refill inj
100000unit/gm
6mg/0.5ml
nystatin susp
2
sumatriptan
2 QL(8/30)
nystatin tabs
2
succinate refill inj
nystatin/triamcinolo
2
4mg/0.5ml
ne
sumatriptan
2 QL(9/30)
nystop
2
succinate tabs
pedi-dri
2
ANTIMYASTHENIC AGENTS
SPORANOX ORAL
3 PA
PARASYMPATHOMIMETICS
SOLN
GUANIDINE HCL
3
TERAZOL 3 CREA
4
MESTINON
3
TERAZOL 7
4
terbinafine hcl tabs
1 QL(180/365) TIMESPAN
pyridostigmine
2
terconazole
2
bromide
voriconazole inj
4 PA
regonol
4
voriconazole susr
5 PA
ANTIMYCOBACTERIALS
voriconazole tabs
5 PA
ANTIMYCOBACTERIALS,
OTHER
XOLEGEL
3
dapsone
2
zazole supp
2
rifabutin
2
ANTIGOUT AGENTS
ANTITUBERCULARS
ANTIGOUT AGENTS
CAPASTAT
4
allopurinol
1
SULFATE
COLCRYS
3
cycloserine
2
probenecid
2
ethambutol
hcl
2
probenecid/colchici
2
isoniazid inj
4
ne
38
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
isoniazid syrp
2
isoniazid tabs
2
100mg
isoniazid tabs
1
300mg
PASER
3
PRIFTIN
3
pyrazinamide
2
rifampin caps
2
rifampin inj
4
RIFATER
3
SIRTURO
4 PA
TRECATOR
3
ANTINEOPLASTICS
ALKYLATING AGENTS
BICNU
4 B/D PA
BUSULFEX
5 B/D PA
CYCLOPHOSPHA
3 B/D PA
MIDE CAPS
cyclophosphamide
4 B/D PA
inj
cyclophosphamide
2 B/D PA
tabs
dacarbazine
4 B/D PA
HEXALEN
5
ifosfamide inj 1gm,
4 B/D PA
3gm
ifosfamide/mesna
5 B/D PA
LEUKERAN
3
LOMUSTINE
3
MATULANE
5
melphalan
5 B/D PA
hydrochloride
MUSTARGEN
4 B/D PA
TEMODAR INJ
5 B/D PA
TREANDA
5 B/D PA
VALCHLOR
5 PA
ZANOSAR
4 B/D PA
ANTIANDROGENS
bicalutamide
2
flutamide
2
NILANDRON
5
XTANDI
5 PA
QL(120/30)
ZYTIGA
5 PA
QL(120/30)
ANTIANGIOGENIC AGENTS
CAPRELSA
5 PA
REVLIMID
5 PA
QL(28/28)
THALOMID CAPS
5 PA
150MG, 200MG,
QL(60/30)
50MG
THALOMID CAPS
5 PA
100MG
QL(90/30)
ANTIESTROGENS/MODIFIERS
EMCYT
3
FARESTON
5
FASLODEX
5 B/D PA
SOLTAMOX
3
tamoxifen citrate
2
ANTIMETABOLITES
adrucil inj
4 B/D PA
2.5gm/50ml
cladribine
4 B/D PA
CLOLAR
4 B/D PA
cytarabine
4 B/D PA
cytarabine aqueous
4 B/D PA
DROXIA
3
ELITEK
5 B/D PA
fluorouracil inj
4 B/D PA
2.5gm/50ml
FOLOTYN
5 B/D PA
gemcitabine
4 B/D PA
gemcitabine hcl
5 B/D PA
hydroxyurea
2
mercaptopurine
2
TABLOID
3
ANTINEOPLASTICS
KYPROLIS
5 PA QL(6/28)
ZALTRAP
5 PA
ANTINEOPLASTICS, OTHER
ABRAXANE
5 B/D PA
adriamycin
2 B/D PA
ALIMTA INJ 500MG
5 B/D PA
amifostine
5 B/D PA
ARRANON
4
AZACITIDINE
5 B/D PA
bleomycin sulfate
4 B/D PA
calcium folinate
4
carboplatin
4 B/D PA
cisplatin inj
100mg/100ml
COMETRIQ
COSMEGEN
daunorubicin hcl
DAUNOXOME
decitabine
dexrazoxane inj
250mg
DOCEFREZ
docetaxel inj
140mg/7ml,
20mg/ml,
80mg/4ml,
80mg/8ml
doxorubicin hcl inj
2mg/ml
DOXORUBICIN
HCL LIPOSOME
ELLENCE INJ
200MG/100ML
epirubicin hcl inj
50mg/25ml
epirubicin hcl inj
200mg/100ml
ERIVEDGE
ERWINAZE
fludarabine
phosphate
FUSILEV
HALAVEN
ICLUSIG
idarubicin hcl inj
10mg/10ml
irinotecan inj
100mg/5ml
ISTODAX
IXEMPRA KIT
JAKAFI
4 B/D PA
5
5
4
5
5
4
PA
B/D PA
B/D PA
B/D PA
B/D PA
5 B/D PA
5 B/D PA
2 B/D PA
5 B/D PA
4 B/D PA
4 B/D PA
5 B/D PA
5 PA
QL(30/30)
5 B/D PA
4 B/D PA
5
5 PA
5 PA
5 B/D PA
4 B/D PA
5 PA
5 B/D PA
5 PA
QL(60/30)
5 B/D PA
4
JEVTANA
leucovorin calcium
inj 100mg, 350mg,
500mg, 50mg
leucovorin calcium
2
tabs
39
Drug Name
LIPODOX
LIPODOX 50
MEKINIST
MENEST
mesna
MESNEX TABS
mitomycin
MITOXANTRONE
HCL
ONCASPAR
oxaliplatin inj
100mg/20ml
paclitaxel inj
300mg/50ml
PICATO
POMALYST
Drug
Tier
5
5
5
3
2
5
4
3
Reqs/Limits Drug Name
B/D PA
B/D PA
PA
PA
B/D PA
B/D PA
B/D PA
5 B/D PA
5 B/D PA
4 B/D PA
4 ST
5 PA
QL(21/28)
5 B/D PA
5 PA
5 PA
5 B/D PA
4 B/D PA
5 B/D PA
4 B/D PA
PROLEUKIN
SYLATRON
SYNRIBO
TAXOTERE
TRISENOX
VELCADE
vinblastine sulfate
inj 1mg/ml
vincasar pfs
4 B/D PA
vincristine sulfate
4 B/D PA
vinorelbine tartrate
4 B/D PA
ZINECARD INJ
4 B/D PA
250MG
ZOLINZA
5 QL(120/30)
AROMATASE INHIBITORS, 3RD
GENERATION
anastrozole
2 QL(30/30)
exemestane
2
letrozole
2 QL(30/30)
ENZYME INHIBITORS
ETOPOPHOS
4 B/D PA
ETOPOSIDE INJ
3 B/D PA
TOPOSAR
3 B/D PA
topotecan hcl inj
5
4mg
MOLECULAR TARGET INHIBITORS
AFINITOR
5 PA
QL(30/30)
AFINITOR
5 PA
DISPERZ
QL(60/30)
Drug Reqs/Limits
Tier
Tier
BOSULIF
5 PA
ANTHELMINTICS
GILOTRIF
5 PA
ALBENZA
3
QL(30/30)
STROMECTOL
3
GLEEVEC
5 PA
ANTIPROTOZOALS
QL(60/30)
ALINIA
3
IMBRUVICA
5 PA
ATOVAQUONE
5
QL(120/30)
atovaquone/progua
2
INLYTA TABS 5MG
5 PA
nil hcl
QL(120/30)
chloroquine
2
INLYTA TABS 1MG
5 PA
phosphate
QL(240/30)
COARTEM
3
NEXAVAR
5 PA
DARAPRIM
3
SPRYCEL
5 PA
hydroxychloroquine
2
STIVARGA
5 PA
sulfate
QL(84/21)
mefloquine hcl
2
SUTENT CAPS
5 PA
NEBUPENT
3 B/D PA
12.5MG, 25MG,
NEUTREXIN
5
50MG
PENTAM 300
3
TAFINLAR
5 PA
PRIMAQUINE
3
TARCEVA
5 PA
PHOSPHATE
TASIGNA
5 PA
quinine sulfate
1
TYKERB
5 PA
PEDICULICIDES/SCABICIDES
VOTRIENT
5 PA
acticin
2
QL(120/30)
lindane
2
XALKORI
5 PA
malathion
2
QL(60/30)
permethrin crea
2
ZELBORAF
5 PA
ANTIPARKINSON AGENTS
QL(240/30)
ANTICHOLINERGICS
ZYKADIA
5 PA
benztropine
4 PA
MONOCLONAL ANTIBODIES
mesylate inj
ARZERRA
5 B/D PA
benztropine
1 PA
AVASTIN INJ
5 B/D PA
mesylate tabs 2mg
100MG/4ML
benztropine
2 PA
ERBITUX
5 B/D PA
mesylate tabs
GAZYVA
5 PA
0.5mg, 1mg
HERCEPTIN
5 B/D PA
trihexyphenidyl hcl
2 PA
KADCYLA
5 PA
elix
PERJETA
5 PA
trihexyphenidyl hcl
2 PA
RITUXAN
5 PA
tabs 5mg
VECTIBIX INJ
3 B/D PA
trihexyphenidyl hcl
1 PA
100MG/5ML
tabs 2mg
YERVOY
5 B/D PA
ANTIPARKINSON AGENTS, OTHER
RETINOIDS
entacapone
2
PANRETIN
5
TASMAR
5
TARGRETIN
5
DOPAMINE
AGONISTS
TRETINOIN CAPS
5
APOKYN
5 PA
ANTIPARASITICS
QL(60/30)
40
Nombre del
Nivel del
Requ./
bromocriptine
mesylate
NEUPRO
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
2
haloperidol tabs
1
INVEGA
4 QL(0.5/28)
0.5mg, 1mg, 2mg,
SUSTENNA INJ
4 PA
5mg
78MG/0.5ML
QL(30/30)
haloperidol tabs
2
INVEGA
5 QL(0.75/28)
pramipexole
2 QL(90/30)
10mg, 20mg
SUSTENNA INJ
dihydrochloride
loxapine
2
117MG/0.75ML
ropinirole hcl
2
loxapine succinate
2
INVEGA
5 QL(1/28)
3
SUSTENNA INJ
DOPAMINE PRECURSORS/L- AMINO ORAP
2
156MG/ML
ACID DECARBOXYLASE INHIBITORS perphenazine
prochlorperazine
2
INVEGA
5 QL(1.5/28)
carbidopa
2
prochlorperazine
4
SUSTENNA
INJ
carbidopa/levodopa
2
edisylate
234MG/1.5ML
carbidopa/levodopa
2
prochlorperazine
1
INVEGA TB24 9MG
5 QL(30/30)
er
maleate
tabs
10mg
ST
carbidopa/levodopa
2
prochlorperazine
2
INVEGA TB24
4 QL(30/30)
odt
maleate
tabs
5mg
1.5MG,
3MG
ST
CARBIDOPA/LEVO
3
thioridazine hcl
2 PA
INVEGA TB24 6MG
4 QL(60/30)
DOPA/ENTACAPO
thiothixene
caps
2
ST
NE
10mg, 1mg, 5mg
LATUDA TABS
4 QL(30/30)
MONOAMINE OXIDASE B (MAO-B)
thiothixene
caps
1
120MG,
20MG,
ST
INHIBITORS
2mg
40MG,
60MG
AZILECT
3
trifluoperazine hcl
2
LATUDA TABS
4 QL(60/30)
selegiline hcl
2
80MG
ST
2ND GENERATION/ATYPICAL
ANTIPSYCHOTICS
olanzapine inj
4
ABILIFY
5 QL(60/30)
1ST GENERATION/TYPICAL
olanzapine
odt
2 QL(30/30)
DISCMELT
ST
chlorpromazine hcl
4
olanzapine tabs
2 QL(30/30)
ABILIFY INJ
4 ST
inj
quetiapine
fumarate
2 QL(90/30)
ABILIFY
5 QL(1.5/30)
chlorpromazine hcl
2
RISPERDAL
4
MAINTENA INJ
tabs
CONSTA INJ
300MG
compazine supp
2
12.5MG, 25MG
ABILIFY
5 QL(2/30)
compro
2
RISPERDAL
5
MAINTENA INJ
fluphenazine
4
CONSTA
INJ
400MG
decanoate
37.5MG, 50MG
ABILIFY ORAL
4 QL(900/30)
fluphenazine hcl
2
risperidone m-tab
2 QL(90/30)
SOLN
ST
conc
tbdp 0.5mg, 1mg,
ABILIFY TABS
5 QL(30/30)
fluphenazine hcl
2
2mg, 3mg
ST
elix
risperidone m-tab
2 QL(120/30)
FANAPT TABS
5 QL(60/30)
fluphenazine hcl inj
4
tbdp 4mg
10MG,
12MG,
ST
fluphenazine hcl
1
risperidone odt tbdp
2 QL(90/30)
6MG, 8MG
tabs 1mg
0.25mg, 0.5mg,
FANAPT TABS
4 QL(60/30)
fluphenazine hcl
2
1mg, 2mg, 3mg
1MG, 2MG, 4MG
ST
tabs 10mg, 2.5mg,
risperidone odt tbdp
2 QL(120/30)
FANAPT
4 QL(16/30)
5mg
4mg
TITRATION PACK
ST
haloperidol conc
2
risperidone oral
2 QL(360/30)
GEODON
INJ
4
QL(60/30)
haloperidol
4
soln
INVEGA
4 QL(0.25/28)
decanoate
SUSTENNA
INJ
haloperidol lactate
4
39MG/0.25ML
41
Drug Name
Drug Reqs/Limits
Tier
Tier
risperidone tabs
2 QL(90/30)
MODERIBA 800
5 PA
0.25mg, 0.5mg,
DOSE PACK
1mg, 2mg, 3mg
MODERIBA MISC
5 PA
risperidone tabs
2 QL(120/30)
moderiba tabs
2 PA
4mg
OLYSIO
5 PA
SAPHRIS
3 QL(60/30)
QL(30/30)
ST
PEG-INTRON
5 PA
ziprasidone hcl
2 QL(60/30)
PEG-INTRON
5 PA
ZYPREXA
5
REDIPEN
RELPREVV
PEG-INTRON
5 PA
REDIPEN
PAK
4
TREATMENT-RESISTANT
REBETOL ORAL
4 PA
clozapine
2
SOLN
CLOZAPINE ODT
3
ribasphere caps
2 PA
FAZACLO
4 ST
RIBASPHERE
5 PA
VERSACLOZ
5
RIBAPAK
ANTISPASTICITY AGENTS
RIBASPHERE
5 PA
ANTISPASTICITY AGENTS
TABS
600MG
baclofen tabs 10mg
1
ribasphere tabs
2 PA
baclofen tabs 20mg
2
200mg
dantrolene sodium
2
RIBASPHERE
4 PA
tizanidine hcl tabs
2
TABS
400MG
ANTIVIRALS
RIBATAB
5 PA
ANTI-CYTOMEGALOVIRUS (CMV)
ribavirin
2 PA
AGENTS
SOVALDI
5 PA
cidofovir
5
QL(30/30)
foscarnet sodium
4
VICTRELIS
5 PA
ganciclovir
4 B/D PA
QL(360/30)
VALCYTE
5
VIRAZOLE
5 B/D PA
ZIRGAN
3 ST
ANTI-HIV AGENTS, INTEGRASE
ANTI-HEPATITIS B (HBV) AGENTS
INHIBITORS (INSTI)
ADEFOVIR
5 QL(30/30)
ISENTRESS
3 QL(360/30)
DIPIVOXIL
CHEW 25MG
BARACLUDE
3
ISENTRESS
5 QL(180/30)
ORAL SOLN
CHEW 100MG
BARACLUDE
5
ISENTRESS PACK
3
TABS
ISENTRESS TABS
5 QL(60/30)
INTRON-A
5
TIVICAY
5 QL(60/30)
INTRON-A
5
ANTI-HIV AGENTS, NONW/DILUENT INJ
NUCLEOSIDE REVERSE
10MU, 18MU
TRANSCRIPTASE INHIBITORS
TYZEKA
5 PA
(NNRTI)
ANTI-HEPATITIS C (HCV) AGENTS
COMPLERA
5
INCIVEK
5 PA
EDURANT
3
QL(180/30)
INTELENCE TABS
5 QL(60/30)
MODERIBA 1200
5 PA
200MG
DOSE PACK
INTELENCE TABS
5 QL(120/30)
Drug Name
Drug Reqs/Limits
Tier
INTELENCE TABS
4 QL(180/30)
25MG
nevirapine er
2
NEVIRAPINE
3
SUSP
nevirapine tabs
2
RESCRIPTOR
3
STRIBILD
5
SUSTIVA
3
VIRAMUNE XR
3
TB24 100MG
ANTI-HIV AGENTS, NUCLEOSIDE
AND NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS (NRTI)
abacavir
2
abacavir
5
sulfate/lamivudine/z
idovudine
didanosine
2
EMTRIVA
3
EPIVIR HBV ORAL
3
SOLN
EPIVIR ORAL
3
SOLN
EPZICOM
5
lamivudine
2
lamivudine/zidovudi
5
ne
RETROVIR IV
4
INFUSION
stavudine
2
TRUVADA
5
VIDEX PEDIATRIC
3
VIREAD
5
ZIAGEN ORAL
3
SOLN
zidovudine
2
ANTI-HIV AGENTS, OTHER
ATRIPLA
5
FUZEON
5 QL(60/30)
SELZENTRY TABS
5 QL(60/30)
150MG
SELZENTRY TABS
5 QL(120/30)
300MG
ANTI-HIV AGENTS, PROTEASE
INHIBITORS
APTIVUS
5
100MG
42
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
CRIXIVAN
3
INVIRASE
5
KALETRA ORAL
5
SOLN
KALETRA TABS
5
200MG; 50MG
KALETRA TABS
4
100MG; 25MG
LEXIVA SUSP
4
LEXIVA TABS
5
NORVIR
3
PREZISTA SUSP
5 QL(400/30)
PREZISTA TABS
5 QL(30/30)
800MG
PREZISTA TABS
5 QL(60/30)
600MG
PREZISTA TABS
4 QL(180/30)
150MG
PREZISTA TABS
4 QL(360/30)
75MG
REYATAZ
5
VIRACEPT
5
ANTI-INFLUENZA AGENTS
amantadine hcl
2
rimantadine hcl
2
TAMIFLU CAPS
3 QL(56/365)
75MG
TAMIFLU CAPS
3 QL(60/365)
45MG
TAMIFLU CAPS
3 QL(120/365)
30MG
TAMIFLU SUSR
3 QL(700/365)
ANTIHERPETIC AGENTS
acyclovir
2
acyclovir sodium inj
4
1000mg, 50mg/ml
DENAVIR
3
famciclovir
2 QL(21/7)
trifluridine
2
valacyclovir hcl tabs
2 QL(30/30)
1000mg
valacyclovir hcl tabs
2 QL(60/30)
500mg
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl tabs
1
10mg, 5mg
buspirone hcl tabs
2
15mg, 30mg, 7.5mg
BENZODIAZEPINES
alprazolam odt tbdp
2 QL(90/30)
0.25mg, 0.5mg
alprazolam odt tbdp
2 QL(120/30)
1mg
alprazolam odt tbdp
2 QL(150/30)
2mg
alprazolam tabs
2 QL(90/30)
0.25mg, 0.5mg
alprazolam tabs
2 QL(120/30)
1mg
alprazolam tabs
2 QL(150/30)
2mg
clorazepate
2 QL(90/30)
dipotassium tabs
3.75mg, 7.5mg
clorazepate
2 QL(120/30)
dipotassium tabs
15mg
diazepam oral soln
2 QL(1200/30)
diazepam tabs
2 QL(120/30)
lorazepam conc
2 QL(120/30)
lorazepam inj
4
2mg/ml, 4mg/ml
lorazepam tabs
2 QL(120/30)
oxazepam
2 QL(120/30)
temazepam
2 QL(90/365)
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate
1
caps 300mg
lithium carbonate
2
caps 150mg,
600mg
lithium carbonate er
2
lithium carbonate
2
tabs
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose
2 QL(90/30)
BYDUREON
3 QL(2.6/28)
BYETTA
3 QL(2.4/30)
glimepiride tabs
1 QL(30/30)
1mg, 2mg
glimepiride tabs
1 QL(60/30)
4mg
glipizide
1
glipizide er
1
glipizide/metformin
1
hcl
glyburide/metformin
2 PA
hcl
GLYSET
3
JANUMET
3 QL(60/30)
JANUMET XR
3 QL(30/30)
TB24 1000MG;
100MG
JANUMET XR
3 QL(60/30)
TB24 1000MG;
50MG, 500MG;
50MG
JANUVIA
3 QL(30/30)
JENTADUETO
3 QL(60/30)
metformin hcl
1
metformin hcl er
1
tb24 500mg, 750mg
nateglinide
2 QL(90/30)
pioglitazone hcl
2 QL(30/30)
pioglitazone hcl2 QL(30/30)
glimepiride
pioglitazone
2 QL(90/30)
hcl/metformin hcl
repaglinide
2
RIOMET
3
TRADJENTA
3 QL(30/30)
GLYCEMIC AGENTS
clinimix
4 B/D PA
4.25%/dextrose
20%
CLINIMIX
4 B/D PA
5%/DEXTROSE
15%
CLINIMIX
4 B/D PA
5%/DEXTROSE
20%
CLINIMIX E
3 B/D PA
4.25%/DEXTROSE
25%
43
Drug Name
Drug Reqs/Limits
Tier
Tier
dextrose 10%/nacl
4 B/D PA
potassium chloride
4 B/D PA
0.45%
0.15% d5w/nacl
dextrose 10% flex
4 B/D PA
0.45%
container
potassium chloride
4 B/D PA
dextrose 10%/nacl
4 B/D PA
0.22% d5w/nacl
0.2%
0.45%
dextrose 2.5%/nacl
4 B/D PA
potassium chloride
4 B/D PA
0.45%
0.224%/d5w/nacl
dextrose
4 B/D PA
0.45%
2.5%/sodium
PROGLYCEM
3
chloride 0.45%
INSULINS
dextrose 5%
4 B/D PA
HUMALOG
3
dextrose 5%/nacl
4 B/D PA
HUMALOG
3
0.2%
KWIKPEN
dextrose 5%/nacl
4 B/D PA
HUMALOG MIX
3
0.225%
50/50
dextrose 5%/nacl
4 B/D PA
HUMALOG MIX
3
0.33%
50/50 KWIKPEN
dextrose 5%/nacl
4 B/D PA
HUMALOG MIX
3
0.45%
75/25
dextrose 5%/nacl
4 B/D PA
HUMALOG MIX
3
0.9%
75/25 KWIKPEN
dextrose
4 B/D PA
HUMULIN 70/30
3
5%/sodium chloride
HUMULIN 70/30
3
0.2%
KWIKPEN
dextrose
4 B/D PA
HUMULIN 70/30
3
5%/sodium chloride
PEN
0.45%
HUMULIN N
3
GLUCAGEN
4
HUMULIN N
3
HYPOKIT
KWIKPEN
kcl
4 B/D PA
HUMULIN N U-100
3
0.075%/d5w/nacl
PEN
0.45%
HUMULIN R
3
kcl 0.15%/d5w/ nacl
4 B/D PA
HUMULIN R U-500
3
0.3%
(CONCENTRATED
kcl 0.15%/d5w/lr
4 B/D PA
)
kcl 0.15%/d5w/nacl
4 B/D PA
LANTUS
3
0.2%
LANTUS
3
kcl 0.15%/d5w/nacl
4 B/D PA
SOLOSTAR
0.45%
LEVEMIR
3
kcl 0.15%/d5w/nacl
4 B/D PA
LEVEMIR
3
0.9%
FLEXPEN
kcl 0.3%/d5w/nacl
4 B/D PA
BLOOD
0.45%
PRODUCTS/MODIFIERS/VOLUME
normosol-r in d5w
4 B/D PA
EXPANDERS
potassium chloride
4 B/D PA
ANTICOAGULANTS
0.15% d5w/nacl
COUMADIN
4
0.33%
Drug Reqs/Limits
Tier
ELIQUIS
3 PA
QL(60/30)
enoxaparin sodium
5 QL(24/30)
inj 120mg/0.8ml
enoxaparin sodium
5 QL(30/30)
inj 100mg/ml,
150mg/ml
enoxaparin sodium
4 QL(9/30)
inj 30mg/0.3ml
enoxaparin sodium
4 QL(12/30)
inj 40mg/0.4ml
enoxaparin sodium
4 QL(18/30)
inj 60mg/0.6ml
enoxaparin sodium
4 QL(24/30)
inj 80mg/0.8ml
enoxaparin sodium
4 QL(90/30)
inj 300mg/3ml
fondaparinux
4 QL(15/30)
sodium inj
2.5mg/0.5ml
fondaparinux
5 QL(12/30)
sodium inj
5mg/0.4ml
fondaparinux
5 QL(18/30)
sodium inj
7.5mg/0.6ml
fondaparinux
5 QL(24/30)
sodium inj
10mg/0.8ml
heparin sodium inj
4
10000unit/ml,
1000unit/ml,
20000unit/ml,
2000unit/ml,
2500unit/ml,
5000unit/ml
heparin sodium/d5w
4
heparin sodium/nacl
4
0.9%
jantoven
1
PRADAXA
3 PA
QL(60/30)
warfarin sodium
1
XARELTO TABS
3 PA
10MG, 20MG
QL(30/30)
XARELTO TABS
3 PA
15MG
QL(60/30)
BLOOD FORMATION MODIFIERS
44
Drug Name
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
anagrelide
hydrochloride
ARANESP
ALBUMIN FREE
INJ
25MCG/0.42ML,
25MCG/ML,
40MCG/0.4ML,
40MCG/ML,
60MCG/0.3ML,
60MCG/ML
ARANESP
ALBUMIN FREE
INJ
100MCG/0.5ML,
100MCG/ML,
150MCG/0.3ML,
200MCG/0.4ML,
200MCG/ML,
300MCG/0.6ML,
300MCG/ML,
500MCG/ML
LEUKINE
NEULASTA
NEUMEGA
NEUPOGEN INJ
300MCG/0.5ML,
480MCG/0.8ML,
480MCG/1.6ML
PROCRIT INJ
20000UNIT/ML,
40000UNIT/ML
PROCRIT INJ
10000UNIT/ML,
2000UNIT/ML,
3000UNIT/ML,
4000UNIT/ML
PROMACTA
cilostazol
2
clopidogrel tabs
2 QL(1/30)
300mg
clopidogrel tabs
2 QL(30/30)
75mg
dipyridamole tabs
2 PA
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl er
2
clonidine hcl ptwk
2 QL(4/28)
0.1mg/24hr,
0.2mg/24hr
clonidine hcl ptwk
2 QL(8/28)
0.3mg/24hr
clonidine hcl tabs
2
0.3mg
clonidine hcl tabs
1
0.1mg, 0.2mg
methyldopate hcl
2 PA
midodrine hcl
2
ALPHA-ADRENERGIC BLOCKING
AGENTS
DIBENZYLINE
3
prazosin hcl
1
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
AVALIDE
4
BENICAR
3 QL(30/30)
ST
BENICAR HCT
3 QL(30/30)
ST
candesartan
2
cilexetil
COZAAR TABS
4 QL(30/30)
100MG
COZAAR TABS
4 QL(60/30)
25MG, 50MG
HYZAAR TABS
4 QL(30/30)
12.5MG; 100MG,
25MG; 100MG
HYZAAR TABS
4 QL(60/30)
12.5MG; 50MG
irbesartan
1
irbesartan/hydrochl
1
orothiazide
losartan potassium
1 QL(30/30)
tabs 100mg
losartan potassium
1 QL(60/30)
tabs 50mg
losartan potassium
1 QL(90/30)
tabs 25mg
losartan
1 QL(30/30)
potassium/hydrochl
orothiazide tabs
12.5mg; 100mg,
25mg; 100mg
losartan
1 QL(60/30)
potassium/hydrochl
orothiazide tabs
12.5mg; 50mg
telmisartan
2 QL(30/30)
telmisartan/amlodipi
2 QL(30/30)
ne
telmisartan/hydrochl
2 QL(30/30)
oroth
telmisartan/hydrochl
2 QL(30/30)
orothiazide
valsartan/hydrochlo
2
rothiazide
ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITORS
ACCUPRIL
4
ACCURETIC
4
ACEON
4
ALTACE
4
benazepril hcl
1
benazepril
2
hcl/hydrochlorothiaz
ide
captopril
1
captopril/hydrochlor
2
othiazide
enalapril maleate
1
enalapril
1
maleate/hydrochlor
othiazide
fosinopril sodium
2
fosinopril
2
sodium/hydrochloro
thiazide
lisinopril
1
2
4 PA
5 PA
5
5
5
5
PA
PA
PA
PA
5 PA
4 PA
5 PA
QL(30/30)
COAGULANTS
tranexamic acid inj
2 PA
tranexamic acid
2
tabs
PLATELET MODIFYING AGENTS
AGGRENOX
4 QL(60/30)
BRILINTA
4 QL(60/30)
45
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
lisinopril/hydrochlor
1
betaxolol hcl
2
diltiazem hcl er
2
othiazide
bisoprolol fumarate
2
cp12
LOTENSIN
4
bisoprolol
1
diltiazem hcl er
2
LOTENSIN HCT
4
fumarate/hydrochlor
cp24
MAVIK
4
othiazide
diltiazem hcl inj
4
moexipril hcl
2
carvedilol
1
100mg, 25mg/5ml,
moexipril/hydrochlor
2
COREG CR
4
50mg/10ml
othiazide
labetalol hcl inj
4
diltiazem hcl tabs
1
perindopril
1
labetalol hcl tabs
2
EXFORGE
3
erbumine
metoprolol
2
EXFORGE HCT
3
PRINIVIL
4
succinate er
felodipine er
2
quinapril hcl
1
metoprolol tartrate
4
isradipine
2
quinapril/hydrochlor
2
inj
matzim la
2
othiazide
metoprolol tartrate
1
nicardipine hcl caps
2
ramipril
1
tabs
nicardipine hcl inj
4
trandolapril
2
metoprolol/hydrochl
2
nifediac cc tb24
2
UNIRETIC
4
orothiazide
30mg, 60mg
UNIVASC
4
nadolol tabs 80mg
2
nifedical xl
2
VASERETIC
4
nadolol tabs 20mg,
1
nifedipine er
2
VASOTEC TABS
4
40mg
nimodipine
2
10MG, 2.5MG,
nadolol/bendroflum
2
nisoldipine
2
20MG
ethiazide
nisoldipine er
2
ZESTORETIC
4
pindolol
1
taztia xt
2
ZESTRIL
4
propranolol hcl er
2
verapamil hcl er
2
propranolol hcl inj
4
verapamil hcl inj
4
ANTIARRHYTHMICS
propranolol hcl oral
2
verapamil hcl tabs
1
amiodarone hcl inj
4
soln
120mg,
80mg
50mg/ml
propranolol hcl tabs
2
verapamil hcl tabs
2
amiodarone hcl
2
60mg
40mg
tabs
propranolol hcl tabs
1
CARDIOVASCULAR AGENTS, OTHER
flecainide acetate
2
10mg,
20mg,
40mg,
lidocaine hcl inj
4
AMTURNIDE
3 ST
80mg
10mg/ml
DEMSER
5
propranolol/hydroch
2
mexiletine hcl
2
digox tabs 125mcg
1 QL(30/30)
lorothiazide
MULTAQ
3 QL(60/30)
digox tabs 250mcg
1 PA
timolol maleate tabs
2
pacerone
2
digoxin inj
4 PA
CALCIUM CHANNEL BLOCKING
propafenone hcl
2
digoxin tabs
1 QL(30/30)
AGENTS
propafenone hcl er
2
125mcg
quinidine sulfate
2
afeditab cr
2
digoxin tabs
1 PA
sorine
2
amlodipine besylate
1
250mcg
sotalol hcl
2
amlodipine
2
LANOXIN
4 PA
sotalol hcl (af)
2
besylate/benazepril
PEDIATRIC
TIKOSYN
3
hcl
LANOXIN TABS
4 QL(30/30)
amlodipine
2
125MCG
BETA-ADRENERGIC BLOCKING
besylate/benazepril
LANOXIN TABS
4 PA
AGENTS
hydrochloride
250MCG
acebutolol hcl
2
cartia
xt
2
pentoxifylline er
2
atenolol
1
dilt-xr
2
RANEXA TB12
3 QL(60/30)
atenolol/chlorthalido
1
diltiazem
cd
2
1000MG
ST
ne
46
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
RANEXA TB12
3 QL(120/30)
500MG
ST
TEKAMLO
3 ST
TEKTURNA
3 ST
TEKTURNA HCT
3 ST
DIURETICS, CARBONIC ANHYDRASE
INHIBITORS
acetazolamide
2
acetazolamide
4
sodium
DIURETICS, LOOP
bumetanide inj
4
bumetanide tabs
1
0.5mg, 1mg
bumetanide tabs
2
2mg
EDECRIN
3
furosemide inj
4
furosemide oral
2
soln
furosemide tabs
1
SODIUM EDECRIN
4
torsemide tabs
2
DIURETICS, POTASSIUM-SPARING
amiloride hcl
2
amiloride/hydrochlo
1
rothiazide
spironolactone tabs
1
25mg
spironolactone tabs
2
100mg, 50mg
spironolactone/hydr
2
ochlorothiazide
triamterene/hydroch
2
lorothiazide caps
25mg; 50mg
triamterene/hydroch
1
lorothiazide caps
25mg; 37.5mg
triamterene/hydroch
1
lorothiazide tabs
DIURETICS, THIAZIDE
candesartan
2
cilexetil/hydrochloro
thiazide
chlorothiazide
2
chlorothiazide
4
sodium
chlorthalidone tabs
1
25mg, 50mg
hydrochlorothiazide
1
caps
hydrochlorothiazide
1
tabs 25mg, 50mg
hydrochlorothiazide
2
tabs 12.5mg
indapamide
1
metolazone
2
DYSLIPIDEMICS, FIBRIC ACID
DERIVATIVES
fenofibrate caps
2
130mg, 43mg
fenofibrate
2
micronized
fenofibrate tabs
2
fenofibric acid dr
2
gemfibrozil
2
LIPOFEN
3
DYSLIPIDEMICS, HMG COA
REDUCTASE INHIBITORS
atorvastatin calcium
2 QL(30/30)
CRESTOR
3 QL(30/30)
fluvastatin caps
2 QL(30/30)
20mg
fluvastatin caps
2 QL(60/30)
40mg
lovastatin tabs
2 QL(60/30)
40mg
lovastatin tabs
1 QL(90/30)
10mg, 20mg
pravastatin sodium
1 QL(30/30)
tabs 80mg
pravastatin sodium
1 QL(60/30)
tabs 40mg
pravastatin sodium
1 QL(90/30)
tabs 10mg, 20mg
simvastatin tabs
1 QL(30/30)
20mg, 40mg, 80mg
simvastatin tabs
1 QL(90/30)
10mg, 5mg
DYSLIPIDEMICS, OTHER
cholestyramine
2
cholestyramine light
2
colestipol hcl
2
niacin er tbcr
2 QL(30/30)
500mg
niacin er tbcr
2 QL(60/30)
1000mg, 750mg
niacor
2
omega-3-acid ethyl
2 QL(120/30)
esters
prevalite
2
WELCHOL
4
ZETIA
3 QL(30/30)
VASODILATORS, DIRECT-ACTING
ARTERIAL
hydralazine hcl inj
4
hydralazine hcl tabs
2
minoxidil tabs
2
VASODILATORS, DIRECT-ACTING
ARTERIAL/VENOUS
isoditrate er
2
2
2
er
isosorbide
2
mononitrate
isosorbide
2
mononitrate er
minitran
2
nitroglycerin inj
4
nitroglycerin lingual
2
translingual soln
nitroglycerin pt24
2
nitroglycerin
2
transdermal
NITROSTAT
3
CENTRAL NERVOUS SYSTEM
AGENTS
ATTENTION DEFICIT HYPERACTIVITY
DISORDER AGENTS,
AMPHETAMINES
amphetamine/dextr
2 QL(60/30)
oamphetamine
cp24
amphetamine/dextr
2 QL(90/30)
oamphetamine tabs
47
Drug Name
Drug Reqs/Limits
Tier
Tier
dextroamphetamine
2 QL(90/30)
REBIF REBIDOSE
5 PA QL(6/28)
sulfate er cp24
REBIF REBIDOSE
5 PA
10mg, 5mg
TITRATION PACK
QL(4.2/28)
dextroamphetamine
2 QL(120/30)
REBIF TITRATION
5 PA
sulfate er cp24
PACK
QL(4.2/28)
15mg
TYSABRI
5 PA
dextroamphetamine
2 QL(1800/30)
DENTAL AND ORAL AGENTS
sulfate oral soln
DENTAL AND ORAL AGENTS
dextroamphetamine
2 QL(90/30)
chlorhexidine
1
sulfate tabs 5mg
gluconate oral rinse
dextroamphetamine
2 QL(180/30)
oralone
2
sulfate tabs 10mg
periogard
1
procentra
2 QL(1800/30) pilocarpine hcl tabs
2
ATTENTION DEFICIT HYPERACTIVITY pilocarpine
2
DISORDER AGENTS, NONhydrochloride
AMPHETAMINES
triamcinolone
2
dexmethylphenidate
2 QL(60/30)
acetonide pste
hcl
triamcinolone in
2
metadate er
2 QL(90/30)
orabase
methylphenidate hcl
2 QL(90/30)
DERMATOLOGICAL AGENTS
methylphenidate hcl
2 QL(90/30)
DERMATOLOGICAL AGENTS
er tbcr 20mg
acitretin
5 PA
methylphenidate hcl
2 QL(180/30)
ammonium lactate
2
er tbcr 10mg
amnesteem
2
methylphenidate hcl
2 QL(90/30)
calcipotriene crea
2
sr
calcipotriene
2
STRATTERA
3
external soln
CENTRAL NERVOUS SYSTEM,
calcipotriene oint
2 QL(120/30)
OTHER
calcitrene
2 QL(120/30)
butalbital/acetamino
2 PA
CALCITRIOL OINT
3
phen/caffeine/codei
QL(180/30)
CARAC
3
ne caps 325mg;
claravis
2
50mg; 40mg; 30mg
clindacin etz
2
NUEDEXTA
3 PA
pledgets
riluzole
4
clindacin-p
2
XENAZINE TABS
5 PA
clindamycin
2
12.5MG
QL(90/30)
phosphate external
XENAZINE TABS
5 PA
soln
25MG
QL(120/30)
clindamycin
2
MULTIPLE SCLEROSIS AGENTS
phosphate gel
AMPYRA
5 PA
clindamycin
2
QL(60/30)
phosphate lotn
AVONEX
5 PA QL(4/28) clindamycin
2
AVONEX PEN
5 PA QL(4/28) phosphate swab
COPAXONE INJ
5 QL(30/30)
curity gauze pads
2
20MG/ML
2"x2"
REBIF
5 PA QL(6/28) ELIDEL
3
Drug Reqs/Limits
Tier
erythromycin/benzo
2
yl peroxide
FLUOROPLEX
3
fluorouracil crea
2
fluorouracil external
2
soln
imiquimod
2
laclotion
2
methoxsalen
5
myorisan
2
podofilox
2
PROTOPIC
3
PRUDOXIN
3
REGRANEX
5 PA
SANTYL
3
selenium sulfide
1
lotn
sulfacetamide
2
sodium susp
TAZORAC CREA
3 QL(120/30)
TAZORAC GEL
3 QL(100/30)
tretinoin crea
2 PA
QL(45/30)
tretinoin gel
2 PA
QL(45/30)
tretinoin
2 PA
microsphere
QL(50/30)
tretinoin
2 PA
microsphere pump
QL(50/30)
gel 0.04%
UVADEX
4 B/D PA
VECTICAL
3
VOLTAREN
3 QL(1000/30)
ST
zenatane
2
ZONALON
3
ZYCLARA
5
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
ADAGEN
5 PA
ALDURAZYME
5 PA
BUPHENYL TABS
5
CEREZYME INJ
5 B/D PA
400UNIT
CREON
3
CYSTADANE
5
CYSTAGON
3
ELAPRASE
5 PA
48
Drug Name
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
FABRAZYME
5 B/D PA
KUVAN
5 PA
LUMIZYME
5 PA
NAGLAZYME
5 PA
ORFADIN
5
PANCRELIPASE
3
SODIUM
5
PHENYLBUTYRAT
E
VPRIV
5 PA
ZAVESCA
5
ZENPEP
3
GASTROINTESTINAL AGENTS
ANTISPASMODICS,
GASTROINTESTINAL
atropine sulfate inj
4
0.05mg/ml,
0.1mg/ml
dicyclomine hcl
1
caps
dicyclomine hcl oral
2
soln
dicyclomine hcl tabs
1
glycopyrrolate inj
4
4mg/20ml
glycopyrrolate tabs
2
methscopolamine
2
bromide
propantheline
2
bromide
GASTROINTESTINAL AGENTS,
OTHER
cromolyn sodium
2
conc
diphenoxylate/atropi
2
ne
lofene
2
lonox
2
loperamide hcl caps
2
metoclopramide hcl
4
inj
metoclopramide hcl
1
oral soln
metoclopramide hcl
1
tabs 10mg
metoclopramide hcl
2
tabs 5mg
OSMOPREP
4
RELISTOR INJ
4 PA
8MG/0.4ML
QL(12/30)
RELISTOR INJ VIAL 4 PA
12MG/0.6ML
QL(18/30)
RELISTOR INJ KIT
4 PA
12MG/0.6ML
QL(28/28)
ursodiol
2
HISTAMINE2 (H2) RECEPTOR
ANTAGONISTS
cimetidine
2
cimetidine hcl
2
famotidine inj
4
20mg/2ml
famotidine
4
premixed
famotidine tabs
1
20mg
famotidine tabs
2
40mg
nizatidine caps
2
ranitidine hcl caps
2
ranitidine hcl inj
4
150mg/6ml
ranitidine hcl syrp
2
ranitidine hcl tabs
1
IRRITABLE BOWEL SYNDROME
AGENTS
AMITIZA
3 QL(60/30)
LOTRONEX
5 PA
QL(60/30)
LAXATIVES
constulose
1
enulose
1
gavilyte-c
2
gavilyte-n/flavor
2
pack
generlac
1
lactulose
1
MOVIPREP
4
peg
2
3350/electrolytes
peg-3350/nacl/na
2
bicarbonate/kcl
polyethylene glycol
2
3350 powd
trilyte
2
PROTECTANTS
CARAFATE SUSP
3
misoprostol
2
sucralfate
2
PROTON PUMP INHIBITORS
ESOMEPRAZOLE
4
SODIUM
lansoprazole
2 QL(60/30)
omeprazole cpdr
2 QL(60/30)
pantoprazole
2 QL(60/30)
sodium tbec
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl
2
oxybutynin chloride
1
oxybutynin chloride
2 QL(30/30)
er tb24 5mg
oxybutynin chloride
2 QL(60/30)
er tb24 10mg, 15mg
tolterodine tartrate
1
VESICARE
3 QL(30/30)
BENIGN PROSTATIC HYPERTROPHY
AGENTS
AVODART
3
doxazosin mesylate
1 QL(30/30)
tabs 1mg, 2mg,
4mg
doxazosin mesylate
1 QL(60/30)
tabs 8mg
finasteride tabs
2 QL(30/30)
5mg
JALYN
3
RAPAFLO
4 QL(30/30)
tamsulosin hcl
2
terazosin hcl caps
1 QL(30/30)
1mg, 5mg
terazosin hcl caps
1 QL(60/30)
10mg, 2mg
GENITOURINARY AGENTS, OTHER
bethanechol
2
chloride
ELMIRON
3
PHOSPHATE BINDERS
49
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
colocort
2
hydrocortisone
2
FOSRENOL
5 ST
cormax
scalp
2
butyrate
(lipophilic)
RENVELA PACK
5 QL(180/30)
application
hydrocortisone crea
1
2.4GM
cortisone acetate
2
1%, 2.5%
RENVELA PACK
3 QL(180/30)
DEPO-MEDROL
4
hydrocortisone in
2
0.8GM
INJ 20MG/ML
absorbase
RENVELA TABS
3 QL(540/30)
desonide lotn
2
hydrocortisone lotn
2
HORMONAL AGENTS,
desonide
oint
2
2.5%
STIMULANT/REPLACEMENT/MODIFYI
desoximetasone
2
hydrocortisone oint
2
NG (ADRENAL)
crea
1%, 2.5%
HORMONAL AGENTS,
desoximetasone
gel
2
hydrocortisone tabs
2
desoximetasone
2
hydrocortisone
2
NG (ADRENAL)
oint
0.25%
valerate
a-hydrocort
4
dexamethasone elix
2
MEDROL TABS
3
a-methapred
4
DEXAMETHASON
3
2MG
ala cort
1
E INTENSOL
methylprednisolone
2
ALA SCALP
3
dexamethasone
4
methylprednisolone
4
alclometasone
2
sodium
phosphate
acetate
dipropionate
inj 10mg/ml,
methylprednisolone
2
alphatrex
2
120mg/30ml
dose
pack
amcinonide
2
dexamethasone
1
methylprednisolone
4
apexicon
2
tabs
0.5mg,
sodiumsuccinate
inj
augmented
2
0.75mg, 4mg
125mg, 40mg
betamethasone
dexamethasone
2
mometasone
2
dipropionate
tabs 1.5mg, 1mg,
furoate
betamethasone
2
2mg,
6mg
prednicarbate oint
2
dipropionate
diflorasone
2
prednisolone
2
betamethasone
2
diacetate
sodium phosphate
valerate
fludrocortisone
2
oral soln
budesonide cp24
2
acetate
PREDNISONE
3
clobetasol
2
fluocinolone
2
INTENSOL
propionate crea
acetonide crea
prednisone oral
2
clobetasol
2
fluocinolone
1
soln
propionate e
acetonide external
prednisone tabs
2
clobetasol
2
soln
50mg
propionate
fluocinolone
2
prednisone tabs
1
emollient crea
acetonide oint
10mg, 1mg, 2.5mg,
clobetasol
2
fluocinonide
2
20mg, 5mg
propionate external
fluocinonide-e
2
procto-pak
2
soln
fluticasone
2
proctosol
hc
2
clobetasol
2
propionate crea
proctozone-hc
2
propionate foam
fluticasone
2
SOLU-CORTEF
INJ
4
clobetasol
2
propionate oint
1000MG, 250MG,
propionate gel
halobetasol
2
500MG
clobetasol
2
propionate
TEXACORT
3
propionate oint
hydrocortisone
2
triamcinolone
1
clotrimazole/betame
2
butyrate
acetonide
crea
thasone
0.1%
dipropionate
50
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
triamcinolone
2
acetonide crea
0.025%, 0.5%
triamcinolone
2
acetonide lotn
triamcinolone
2
acetonide oint
triderm
1
u-cort
2
HORMONAL AGENTS,
NG (PITUITARY)
HORMONAL AGENTS,
NG (PITUITARY)
chorionic
4 PA
gonadotropin
desmopressin
4
acetate inj
desmopressin
2
acetate nasal soln
0.01%
DESMOPRESSIN
3
ACETATE NASAL
SOLN 0.01%
desmopressin
2
acetate tabs
INCRELEX
4 PA
novarel
4 PA
pregnyl w/diluent
4 PA
benzyl alcohol/nacl
SAIZEN
5 PA
SAIZEN
5 PA
CLICK.EASY
STIMATE
3
HORMONAL AGENTS,
NG (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50
5 PA
oxandrolone tabs
2 PA
10mg
QL(60/30)
oxandrolone tabs
2 PA
2.5mg
QL(120/30)
ANDROGENS
ANDROXY
3 PA
danazol
TESTIM
testosterone
cypionate
testosterone
enanthate
Nombre del
Nivel del
Requ./
2
3 PA
4 PA
introvale
2
junel 1.5/30
2
junel 1/20
2
junel fe 1.5/30
2
4 PA
junel fe 1/20
2
kariva
2
kelnor
1/35
2
ESTROGENS
2
ALORA
3 PA QL(8/28) kurvelo
larin
1/20
2
altavera
2
larin fe 1.5/30
2
alyacen 1/35
2
larin
fe
1/20
2
alyacen 7/7/7
2
lessina
2
apri
2
levonest
2
aranelle
2
levonorgestrel/ethin
2
aubra
2
yl estradiol
aviane
2
levora 0.15/30-28
2
azurette
2
low-ogestrel
2
balziva
2
lutera
2
briellyn
2
marlissa
2
caziant
2
MENOSTAR
3 PA QL(4/28)
chateal
2
microgestin
1.5/30
2
cryselle-28
2
microgestin 1/20
2
cyclafem 1/35
2
microgestin
fe
2
cyclafem 7/7/7
2
microgestin fe
2
dasetta 1/35
2
1.5/30
dasetta 7/7/7
2
mimvey
2 PA
DEPO-ESTRADIOL
4
mimvey
lo
2 PA
desogestrel/ethinyl
2
MINIVELLE PTTW
3 PA QL(8/28)
estradiol tabs
0.1MG/24HR
0.15mg; 30mcg
mono-linyah
2
elinest
2
myzilra
2
emoquette
2
necon
0.5/35-28
2
enpresse-28
2
necon 1/35
2
enskyce
2
necon
10/11-28
2
estarylla
2
2
estradiol ptwk
2 PA QL(4/28) necon 7/7/7
norgestimate/ethinyl
2
estradiol tabs
2 PA
estradiol
estradiol valerate
4
nortrel 0.5/35 (28)
2
estradiol/norethindr
2 PA
nortrel
1/35
2
one acetate
nortrel 7/7/7
2
ESTRING
3 QL(1/90)
ogestrel
2
falmina
2
orsythia
2
FEMRING
3
philith
2
gildagia
2
pimtrea
2
gildess 1.5/30
2
pirmella
1/35
2
gildess 1/20
2
pirmella 7/7/7
2
gildess fe 1.5/30
2
portia-28
2
gildess fe 1/20
2
51
Drug Name
Drug Reqs/Limits
Tier
Tier
PREMARIN CREA
3
raloxifene
2 QL(30/30)
PREMARIN INJ
4
hydrochloride
PREMARIN TABS
4 PA
HORMONAL AGENTS,
QL(30/30)
previfem
2
NG (THYROID)
quasense
2
HORMONAL AGENTS,
reclipsen
2
sprintec 28
2
NG (THYROID)
sronyx
2
levothyroxine
1
tilia fe
2
sodium tabs
tri-estarylla
2
LEVOXYL
4
tri-legest fe
2
liothyronine sodium
4
tri-linyah
2
inj
tri-previfem
2
liothyronine sodium
2
tri-sprintec
2
tabs
trivora-28
2
SYNTHROID
4
velivet
2
THYROLAR-1
3
viorele
2
THYROLAR-1/2
3
VIVELLE-DOT
3 PA QL(8/28) THYROLAR-1/4
3
vyfemla
2
THYROLAR-2
3
wera
2
THYROLAR-3
3
zenchent
2
UNITHROID
4
zovia 1/35e
2
UNITHROID
4
zovia 1/50e
2
DIRECT
PROGESTERONE
HORMONAL AGENTS,
AGONISTS/ANTAGONISTS
SUPPRESSANT (ADRENAL)
ELLA
3
HORMONAL AGENTS,
PROGESTINS
SUPPRESSANT (ADRENAL)
camila
2
LYSODREN
3
DEPO-PROVERA
4
HORMONAL AGENTS,
errin
2
SUPPRESSANT (PARATHYROID)
heather
2
HORMONAL AGENTS,
jencycla
2
SUPPRESSANT (PARATHYROID)
lyza
2
SENSIPAR TABS
3 QL(60/30)
MAKENA
5
30MG
medroxyprogestero
4 QL(1/90)
SENSIPAR TABS
5 QL(60/30)
ne acetate inj
60MG
medroxyprogestero
1
SENSIPAR TABS
5 QL(120/30)
ne acetate tabs
90MG
megestrol acetate
2 PA
HORMONAL AGENTS,
norethindrone
2
SUPPRESSANT (PITUITARY)
norethindrone
2
HORMONAL AGENTS,
acetate
SUPPRESSANT (PITUITARY)
progesterone caps
2
cabergoline
2
SELECTIVE ESTROGEN RECEPTOR
ELIGARD INJ
4 PA
MODIFYING AGENTS
30MG
QL(1/120)
Drug Name
ELIGARD INJ
45MG
ELIGARD INJ
7.5MG
ELIGARD INJ
22.5MG
firmagon inj 80mg
FIRMAGON INJ
120MG
leuprolide acetate
Drug Reqs/Limits
Tier
4 PA
QL(1/180)
4 PA QL(1/30)
4 PA QL(1/90)
4 B/D PA
QL(4/28)
5 B/D PA
QL(6/365)
4 PA
QL(30/30)
5 PA QL(1/30)
5 PA QL(1/30)
LUPRON DEPOT
LUPRON DEPOTPED
octreotide acetate
5 PA
inj 1000mcg/ml,
500mcg/ml
octreotide acetate
4 PA
inj 100mcg/ml,
200mcg/ml,
50mcg/ml
SANDOSTATIN
5 PA
LAR DEPOT
SOMATULINE
5 PA
DEPOT
SOMAVERT INJ
5 PA
15MG, 20MG
QL(60/30)
SOMAVERT INJ
5 PA
10MG
QL(90/30)
SYNAREL
5 PA
TRELSTAR DEPOT
5 PA QL(1/28)
TRELSTAR DEPOT
5 PA QL(2/28)
MIXJECT
TRELSTAR LA
5 PA QL(1/84)
TRELSTAR LA
5 PA QL(2/84)
MIXJECT
TRELSTAR
5 PA
MIXJECT
QL(2/168)
HORMONAL AGENTS,
SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole
2
propylthiouracil
2
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
CINRYZE
5 PA
52
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
FIRAZYR
5 PA
IMOVAX RABIES
4
IMMUNIZING AGENTS, PASSIVE
(H.D.C.V.)
IMMUNE SUPPRESSANTS
ATGAM
4 B/D PA
INFANRIX
4
ASTAGRAF XL
4 B/D PA
BIVIGAM
4 B/D PA
IPOL
4
AZASAN
3 B/D PA
FLEBOGAMMA DIF
4 B/D PA
INACTIVATED
IPV
azathioprine
2 B/D PA
gamastan s/d
4 B/D PA
IXIARO
4
CELLCEPT
4 B/D PA
GAMMAGARD
4 B/D PA
M-M-R
II
4
INTRAVENOUS
LIQUID
W/DILUENT 10
CELLCEPT SUSR
3 B/D PA
GAMMAKED
4 B/D PA
DOSE
cyclosporine caps
2 B/D PA
GAMMAPLEX INJ
4 B/D PA
MENACTRA
4
cyclosporine inj
4 B/D PA
10GM/200ML,
MENOMUNE4
cyclosporine
2 B/D PA
2.5GM/50ML,
A/C/Y/W-135
modified
5GM/100ML
MENVEO
4
ENBREL
5 PA QL(8/28) GAMUNEX-C
4 B/D PA
PEDVAX
HIB
4
ENBREL
5 PA QL(8/28) OCTAGAM INJ
4 B/D PA
PROQUAD
4
SURECLICK
10GM/200ML,
RABAVERT
4
gengraf
2 B/D PA
2.5GM/50ML,
RECOMBIVAX HB
4 B/D PA
hecoria
2 B/D PA
5GM/100ML
INJ
10MCG/ML,
HUMIRA INJ
5 PA QL(2/28) PRIVIGEN INJ
4 B/D PA
40MCG/ML
20MG/0.4ML
10GM/100ML,
ROTARIX
3
HUMIRA INJ
5 PA QL(6/28) 20GM/200ML,
ROTATEQ
3
40MG/0.8ML
5GM/50ML
tenivac
4
HUMIRA PEN
5 PA QL(6/28) THYMOGLOBULIN
3 B/D PA
tetanus
toxoid
4
HUMIRA PEN5 PA QL(6/28)
IMMUNOMODULATORS
adsorbed
CROHNS
ACTIMMUNE
5 PA
tetanus/diphtheria
4
DISEASESTARTE
ARCALYST
5 PA
toxoids-adsorbed
R
ILARIS
5 PA
adult
methotrexate
2
leflunomide
2 QL(30/30)
TWINRIX
4
methotrexate
4
PROVENGE
5 B/D PA
TYPHIM
VI
4
sodium
RIDAURA
5
VAQTA
4
mycophenolate
2 B/D PA
SIMULECT
5 B/D PA
VARIVAX
4
mofetil
SYNAGIS INJ
5 PA
yf-vax
4
mycophenolic acid
2 B/D PA
50MG/0.5ML
ZOSTAVAX
4
dr
VACCINES
INFLAMMATORY
BOWEL
DISEASE
NULOJIX
5 PA
ACTHIB
4
AGENTS
PROGRAF INJ
4 B/D PA
ADACEL
4
RAPAMUNE ORAL
3 B/D PA
AMINOSALICYLATES
BOOSTRIX
4
SOLN
APRISO
3
CERVARIX
4
RAPAMUNE TABS
3 B/D PA
balsalazide
2
COMVAX
4
1MG, 2MG
disodium
DAPTACEL
4
REMICADE
5 PA
DELZICOL
3
DIPHTHERIA/TETA
4
sirolimus
2 B/D PA
mesalamine
2
NUS TOXOIDS
tacrolimus
2 B/D PA
SULFONAMIDES
ADSORBED
TORISEL
3 B/D PA
sulfasalazine
tabs
2
PEDIATRIC
ZORTRESS TABS
4 B/D PA
sulfazine
2
ENGERIX-B
4 B/D PA
0.25MG
sulfazine
ec
2
GARDASIL
4
ZORTRESS TABS
5 B/D PA
HAVRIX
4
METABOLIC BONE DISEASE AGENTS
0.5MG, 0.75MG
53
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
2 QL(200/30)
METABOLIC BONE DISEASE AGENTS novofine 30gx8mm
OPHTHALMIC ANTInovofine
31
2
QL(200/30)
INFLAMMATORIES
ACTONEL TABS
3 QL(4/28)
novofine 32gx6mm
2 QL(200/30)
35MG
bromfenac
2
novofine
autocover
2
QL(200/30)
ACTONEL TABS
3 QL(30/30)
dexamethasone
2
30gx8mm
30MG, 5MG
sodium phosphate
novotwist 30gx8mm
2 QL(200/30)
alendronate sodium
1 QL(4/28)
ophthalmic soln
novotwist 32gx5mm
2 QL(200/30)
tabs 35mg, 70mg
diclofenac sodium
2
physiolyte
4
B/D
PA
alendronate sodium
2 QL(30/30)
ophthalmic soln
physiosol irrigation
4
tabs 10mg, 40mg,
DUREZOL
3
ringers irrigation
4
5mg
FLUOROMETHOL
3
sodium
chloride
4
calcitonin-salmon
2 QL(3.7/30)
ONE
0.9%
calcitriol caps
2
flurbiprofen sodium
2
sterile
water
4
calcitriol inj
4 B/D PA
ketorolac
2
irrigation
calcitriol oral soln
2
tromethamine
tis-u-sol
4
doxercalciferol caps
2
ophthalmic soln
VORAXAZE
5
doxercalciferol inj
4 B/D PA
neomycin/polymyxi
2
OPHTHALMIC
AGENTS
etidronate disodium
2
n/dexamethasone
FORTEO
5 PA
OPHTHALMIC PROSTAGLANDIN
poly-dex
2
QL(2.4/28)
AND PROSTAMIDE ANALOGS
PRED MILD
3
ibandronate sodium
2 QL(1/28)
PRED-G
3
COMBIGAN
3
tabs
PRED-G
S.O.P.
3
latanoprost
2 QL(5/30)
MIACALCIN INJ
4
3
TRAVATAN Z
3 QL(5/30) ST PREDNISOLONE
pamidronate
4 B/D PA
ACETATE
OPHTHALMIC AGENTS, OTHER
disodium inj
prednisolone
1
LACRISERT
3
30mg/10ml,
sodium
phosphate
mydral
2
6mg/ml, 90mg/10ml
ophthalmic soln
naphazoline hcl
2
paricalcitol
2
TOBRADEX OINT
3
neo-polycin
2
PROLIA
4 QL(1/180)
tobramycin/dexame
2
neomycin/polymyxi
2
ST
thasone
n/bacitracin zinc
risedronate sodium
2 QL(1/28)
OPHTHALMIC ANTIGLAUCOMA
parcaine
2
XGEVA
5 PA
AGENTS
polycin
2
zoledronic acid inj
5 B/D PA
acetazolamide er
2
proparacaine hcl
2
4mg/5ml
apraclonidine
2
RESTASIS
3 QL(64/30)
zoledronic acid inj
4 B/D PA
AZOPT
3 ST
trimethoprim
2
5mg/100ml
betaxolol hcl
2
sulfate/polymyxin b
ZOMETA INJ
5 B/D PA
brimonidine
tartrate
2
sulfate
4MG/100ML
ophthalmic soln
tropicamide
2
MISCELLANEOUS THERAPEUTIC
0.2%
OPHTHALMIC ANTI-ALLERGY
AGENTS
BRIMONIDINE
3
AGENTS
TARTRATE
ALOCRIL
3
AGENTS
OPHTHALMIC
azelastine hcl
2
SOLN 0.15%
fomepizole
5
ophthalmic soln
carteolol hcl
2
lactated ringers
4
cromolyn sodium
2
dorzolamide
hcl
2
irrigation
ophthalmic soln
dorzolamide
2
levocarnitine inj
4 B/D PA
epinastine hcl
2
hcl/timolol maleate
levocarnitine oral
2
PATADAY
3
soln
PATANOL
3
levocarnitine tabs
2
54
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
LEVOBUNOLOL
3
HCL OPHTHALMIC
SOLN 0.25%
levobunolol hcl
1
ophthalmic soln
0.5%
methazolamide
2
metipranolol
2
PHOSPHOLINE
4
IODIDE
PILOCARPINE
3
HCL OPHTHALMIC
SOLN
timolol maleate
1
ophthalmic soln
OTIC AGENTS
OTIC AGENTS
acetasol hc
2
acetic acid
2
COLY-MYCIN S
3
CORTISPORIN-TC
3
fluocinolone
2
acetonide oil
hydrocortisone/aceti
2
c acid
neomycin/polymyxi
2
n/hc
neomycin/polymyxi
2
n/hydrocortisone
RESPIRATORY TRACT/PULMONARY
AGENTS
ANTI-INFLAMMATORIES, INHALED
CORTICOSTEROIDS
budesonide susp
2 QL(17.2/30)
32mcg/act
budesonide susp
2 B/D PA
0.25mg/2ml,
QL(120/30)
0.5mg/2ml
DULERA
3 QL(13/30)
FLOVENT DISKUS
3 QL(120/30)
AEPB
250MCG/BLIST,
50MCG/BLIST
FLOVENT DISKUS
3 QL(180/30)
AEPB
100MCG/BLIST
FLOVENT HFA
3 QL(22/30)
AERO 44MCG/ACT
FLOVENT HFA
3 QL(24/30)
AERO
110MCG/ACT,
220MCG/ACT
flunisolide
1
fluticasone
2 QL(16/30)
propionate susp
QVAR
3 QL(18/30)
SYMBICORT
3 QL(11/30)
AERO
160MCG/ACT;
4.5MCG/ACT
SYMBICORT
3 QL(14/30)
AERO
80MCG/ACT;
4.5MCG/ACT
triamcinolone
2 QL(16.5/30)
acetonide inha
ANTIHISTAMINES
azelastine hcl nasal
2 QL(60/30)
soln
desloratadine
2 QL(30/30)
desloratadine odt
2 QL(30/30)
diphenhydramine
4
hcl inj
levocetirizine
2 QL(300/30)
dihydrochloride oral
soln
levocetirizine
2 QL(30/30)
dihydrochloride tabs
promethazine hcl inj
4 PA
promethazine hcl
2 PA
syrp
promethazine hcl
2 PA
tabs 12.5mg, 50mg
promethazine hcl
1 PA
tabs 25mg
ANTILEUKOTRIENES
montelukast sodium
2 QL(30/30)
zafirlukast
2
BRONCHODILATORS,
ANTICHOLINERGIC
ATROVENT HFA
3 QL(26/30)
Nombre del
Nivel del
Requ./
COMBIVENT
3 QL(8/30)
RESPIMAT
ipratropium bromide
2 B/D PA
inhalation soln
QL(300/30)
ipratropium bromide
2 QL(30/30)
nasal soln 0.06%
ipratropium bromide
2 QL(60/30)
nasal soln 0.03%
ipratropium
2 B/D PA
bromide/albuterol
QL(540/30)
sulfate
SPIRIVA
3 QL(30/30)
HANDIHALER
BRONCHODILATORS,
SYMPATHOMIMETIC
albuterol sulfate er
2
albuterol sulfate
2 B/D PA
nebu 0.63mg/3ml,
QL(375/30)
1.25mg/3ml
albuterol sulfate
1 B/D PA
nebu 0.5%
QL(360/30)
albuterol sulfate
1 B/D PA
nebu 0.083%
QL(375/30)
albuterol sulfate
1
syrp
albuterol sulfate
1
tabs
EPINEPHRINE
4
HCL INJ 0.1MG/ML
epinephrine hcl inj
4
1mg/ml
EPIPEN 2-PAK
3 QL(2/30)
EPIPEN-JR 2-PAK
3 QL(2/30)
FORADIL
3 QL(60/30)
AEROLIZER
metaproterenol
2
sulfate
PERFOROMIST
3 B/D PA
QL(120/30)
PROAIR HFA
3 QL(17/30)
SEREVENT
3 QL(60/30)
DISKUS
terbutaline sulfate
4
inj
terbutaline sulfate
2
tabs
VENTOLIN HFA
4 QL(36/30)
55
Drug Name
Drug Reqs/Limits
Tier
Tier
orphenadrine citrate
2 PA
CYSTIC FIBROSIS AGENTS
er
PULMOZYME
5 B/D PA
SLEEP DISORDER AGENTS
TOBI PODHALER
5 QL(1568/36
5)
GABA RECEPTOR MODULATORS
tobramycin
4 B/D PA
zaleplon
2 QL(90/365)
MAST CELL STABILIZERS
zolpidem tartrate
2 PA
QL(90/365)
cromolyn sodium
2 B/D PA
nebu
SLEEP DISORDERS, OTHER
PHOSPHODIESTERASE INHIBITORS, MODAFINIL TABS
4 PA
AIRWAYS DISEASE
100MG
QL(30/30)
modafinil tabs
5 PA
aminophylline
4
200mg
QL(60/30)
DALIRESP
3 PA
ROZEREM
3
QL(30/30)
QL(30/30)
SILENOR
3 QL(30/30)
THEO-24
4
XYREM
5 PA
theochron
2
QL(540/30)
theophylline cr
2
2
THERAPEUTIC
200mg, 300mg,
NUTRIENTS/MINERALS/ELECTROLYT
450mg
ES
2
ELECTROLYTE/MINERAL MODIFIERS
PULMONARY ANTIHYPERTENSIVES CHEMET
3
LETAIRIS
5 PA
CUPRIMINE
5
QL(30/30)
DEPEN
3
REMODULIN
5 B/D PA
TITRATABS
sildenafil
2 PA
EXJADE
5
QL(90/30)
kionex
2
TRACLEER
5 PA
SAMSCA TABS
5 PA
QL(60/30)
30MG
QL(60/30)
SAMSCA
TABS
5
PA
RESPIRATORY TRACT AGENTS,
15MG
QL(90/30)
OTHER
sodium
bicarbonate
4
acetylcysteine
2 B/D PA
inj 7.5%, 8.4%
inhalation soln
sodium lactate
4 B/D PA
ARALAST NP INJ
5 B/D PA
sodium polystyrene
2
1000MG
sulfonate powd
PROLASTIN-C
5 B/D PA
sodium polystyrene
2
TYZINE
3
sulfonate susp
TYZINE
3
15gm/60ml
PEDIATRIC NASAL
sps
2
DROPS
SYPRINE
5
XOLAIR
5 PA
ELECTROLYTE/MINERAL
ZEMAIRA
5 B/D PA
REPLACEMENT
SKELETAL MUSCLE RELAXANTS
AMINO ACIDS
4 B/D PA
SKELETAL MUSCLE RELAXANTS
AMINOSYN
4 B/D PA
chlorzoxazone
2 PA
AMINOSYN
4 B/D PA
cyclobenzaprine hcl
2 PA
7%/ELECTROLYTE
tabs 10mg, 5mg
S
Drug Name
AMINOSYN
8.5%/ELECTROLY
TES
AMINOSYN II
AMINOSYN II
8.5%/ELECTROLY
TES
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-HF
AMINOSYN-PF
AMINOSYN-PF 7%
calcium acetate
caps
calcium acetate
tabs 667mg
CARBAGLU
CLINIMIX
2.75%/DEXTROSE
5%
clinimix
4.25%/dextrose
10%
clinimix
4.25%/dextrose
25%
CLINIMIX
4.25%/DEXTROSE
5%
CLINIMIX
5%/DEXTROSE
25%
clinisol sf 15%
dextrose 5%
/electrolyte #48
viaflex
dextrose
5%/potassium
chloride 0.15%
fluoride chew
0.25mg, 1.1mg,
2.2mg
fluoritab chew
FREAMINE III
FREAMINE III 3%
hepatamine
HEPATASOL
Drug Reqs/Limits
Tier
4 B/D PA
4 B/D PA
4 B/D PA
4
4
4
4
4
2
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
2
5
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
1
1
4
4
4
4
B/D PA
B/D PA
B/D PA
B/D PA
56
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
Nombre del
Nivel del
Requ./
isolyte-m/dextrose
5%
k-vescent pack
klor-con
klor-con m10
klor-con m20
lactated ringers
dextrose 5% viaflex
lactated ringers inj
3meq/l; 109meq/l;
28meq/l; 4meq/l;
130meq/l
lactated ringers
viaflex
ludent
magnesium sulfate
inj 50%
MOZOBIL
nafrinse
normosol-m in d5w
NORMOSOL-R
PHOSLYRA
potassium chloride
0.15%/d5w
potassium chloride
0.15%/nacl 0.9%
POTASSIUM
CHLORIDE 0.3%/
NACL 0.9%
potassium chloride
0.3%/d5w
potassium chloride
0.3%/nacl
0.9%/viaflex
potassium chloride
cr
potassium chloride
er cpcr
POTASSIUM
CHLORIDE ER
TBCR 10MEQ
potassium chloride
er tbcr 10meq,
20meq
potassium chloride
inj 10meq/100ml,
20meq/100ml,
2meq/ml,
40meq/100ml
potassium chloride
liqd
potassium chloride
pack
POTASSIUM
CHLORIDE SR
POTASSIUM
CITRATE
PREMASOL INJ
52MEQ/L;
1760MG/100ML;
880MG/100ML;
34MEQ/L;
1760MG/100ML;
372MG/100ML;
406MG/100ML;
526MG/100ML;
492MG/100ML;
492MG/100ML;
526MG/100ML;
356MG/100ML;
356MG/100ML;
390MG/100ML;
34MG/100ML;
152MG/100ML
premasol inj
56meq/l;
320mg/100ml;
730mg/100ml;
190mg/100ml;
3meq/l;
20mg/100ml;
300mg/100ml;
220mg/100ml;
290mg/100ml;
490mg/100ml;
840mg/100ml;
490mg/100ml;
200mg/100ml;
290mg/100ml;
410mg/100ml;
230mg/100ml;
5meq/l;
15mg/100ml;
250mg/100ml;
120mg/100ml;
140mg/100ml;
470mg/100ml
PROCALAMINE
PROSOL
ringers injection
sodium chloride
0.45% viaflex
sodium chloride inj
0.9%, 2.5meq/ml,
3%, 5%
sodium fluoride
chew 0.25mg,
0.5mg, 1mg, 2.2mg
sodium fluoride tabs
tpn electrolytes
TRAVASOL
4 B/D PA
2
2
1
1
4
4
4
1
4 B/D PA
5 QL(9.6/30)
1
4 B/D PA
4 B/D PA
4
4
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
1
2
4 B/D PA
2
2
3
3
4 B/D PA
4 B/D PA
4 B/D PA
4 B/D PA
4
4 B/D PA
4 B/D PA
1
1
4 B/D PA
4 B/D PA
3
1
57
Drug Name
Tier
TROPHAMINE INJ
4 B/D PA
97MEQ/L;
0.54GM/100ML;
1.2GM/100ML;
0.32GM/100ML; 0;
0; 0.5GM/100ML;
0.36GM/100ML;
0.48GM/100ML;
0.82GM/100ML;
1.4GM/100ML;
1.2GM/100ML;
0.34GM/100ML;
0.48GM/100ML;
0.68GM/100ML;
0.38GM/100ML;
5MEQ/L;
0.025GM/100ML;
0.42GM/100ML;
0.2GM/100ML;
0.24GM/100ML;
0.78GM/100ML
THERAPEUTIC
NUTRIENTS/MINERALS/ELECTROLYT
ES
intralipid inj 2.25%;
4 B/D PA
20%
liposyn iii inj 2.5%;
4 B/D PA
30%
VITAMINS
OB COMPLETE
3
400
OB
3
COMPLETE/DHA
PRENATABS OBN
3
Tier
Drug Reqs/Limits
Tier
58
Nombre del
Nivel del
Requ./
Needles And Syringes
AGENTS
AGENTS
bd insulin syringe
2 QL(200/30)
safetyglide/1ml/29g
x 1/2"
bd insulin syringe
2 QL(200/30)
ultrafine/0.3ml/31g
x 5/16"
bd insulin syringe
2 QL(200/30)
ultrafine/0.5ml/30g
x 1/2"
bd insulin syringe
2 QL(200/30)
ultrafine/1ml/31g x
5/16"
bd insulin syringe
2 QL(200/30)
ultrafine/u100/0.3ml/31g x
15/64"
bd insulin syringe
2 QL(200/30)
ultrafine/u100/0.5ml/31g x
15/64"
bd insulin syringe
2 QL(200/30)
ultrafine/u100/1ml/31g x
15/64"
bd pen
2 QL(200/30)
needle/mini/ultrafine
/31g x 3/16"
bd pen
2 QL(200/30)
needle/nano/ultra
fine/32g x 4mm
bd pen
2 QL(200/30)
needle/ultrafine/29g
x 12.7mm
monoject insulin
2 QL(200/30)
syringe/detach
needle/1ml/27g x
1/2"
monoject insulin
2 QL(200/30)
syringe/safety/perm
needle/0.3ml/29g x
1/2"
Nombre del
Nivel del
Requ./
monoject insulin
syringe/u100/0.5ml/30g x
5/16"
monoject insulin
syringe/u100/1ml/30g x 5/16"
monoject ultra
comfort insulin
syringe/0.3ml/30g x
5/16"
monoject ultra
comfort insulin
syringe/0.5ml/28g x
1/2"
monoject ultra
comfort insulin
syringe/0.5ml/29g x
1/2"
monoject ultra
comfort insulin
syringe/1ml/28g x
1/2"
ulticare insulin
1/2"
ulticare insulin
5/16"
ulticare insulin
syringe/u100/1ml/30g x 1/2"
Nombre del
Nivel del
Requ./
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
2 QL(200/30)
59
www.cignahealthspring.com
This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring Rx
Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m., local time, 7 days a week. (From February 15 – September 30,
Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST, customer service agents available. Messaging
service used weekends after hours). Or visit www.cignahealthspring.com. Esta lista de medicamentos se actualizó en agosto de 2014.
Para información más reciente u otras preguntas, favor de contactar al Departamento de servicio al cliente de Cigna-HealthSpring Rx,
al 1-800-222-6700 o, para los usuarios de TTY, 711, de 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de
septiembre, de lunes a viernes, de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros
representantes de servicio al cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio
de contestadora automática). O visite www.cignahealthspring.com. This information is available for free in other languages. Please
call our Customer Service number at 1-800-222-6700 for additional information (TTY users should call 711), 8 a.m. – 8 p.m., local time,
7 days a week. (From February 15 – September 30, Monday – Friday 8 a.m. – 8 p.m. local time, Saturday and Sunday 10 a.m. – 6 p.m., EST,
customer service agents available. Messaging service used weekends after hours). Customer Service also has free language interpreter
services available for non‑English speakers. Esta información está disponible de forma gratuita en otros idiomas. Favor de ponerse
en contacto con nuestro Departamento de servicio al cliente al 1-800-222-6700 para información adicional. (Los usuarios de TTY
deben llamar al 711). De 8 a.m. a 8 p.m., hora local, 7 días de la semana. (Del 15 de febrero al 30 de septiembre, de lunes a viernes,
de 8 a.m. a 8 p.m. hora local; y los sábados y domingos, de 10 a.m. a 6 p.m., Hora del este, nuestros representantes de servicio al
cliente estás disponibles. Si llama los fines de semana, o fuera del horario de servicio, entrará el servicio de contestadora automática).
El Departamento de servicio al cliente también tiene servicios gratuitos de intérprete de idiomas para las personas que no hablan inglés.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna
Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation,
incluyendo Cigna Health and Life Insurance Company. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de
Cigna Intellectual Property, Inc. © 2014 Cigna

CIGNA-HEALTHSPRING® COMPREHENSIVE DRUG LIST

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