plan médico servicios de salud bella vista, inc ... · los medicamentos en la lista de...

Plan Médico Servicios de Salud Bella Vista, Inc. 770 Avenida Hostos

Suite 208 Mayaguez, PR 00682-1538

FORMULARIO DE MEDICAMENTOS CUBIERTOS POR CLASIFICACIÓN TERAPÉUTICA

El Plan Médico Servicios de Salud Bella Vista, Inc. Le presenta la lista de Medicamentos que su cubierta de farmacia utilizará para ofrecerle una amplia selección de opciones de tratamiento costo-efectivas. Su cubierta de farmacia utiliza una Lista de Medicamentos para ayudar a reducir el continuo aumento en los costos de los medicamentos y a la vez ofrecerle una amplia selección de opciones de tratamiento costo-efectivas. Se ofrece también como una alternativa para continuar ofreciendo a nuestros asegurados planes de farmacia más accesibles. La Lista de Medicamentos es una guía de los medicamentos seleccionados por el Comité de Farmacia y Terapéutica de PharmPix, la cual representa los medicamentos necesarios para un tratamiento de alta calidad. Nuestro Comité de Farmacia y Terapéutica está compuesto por médicos, farmacéuticos clínicos y otros profesionales de la salud, quienes se reúnen periódicamente para evaluar y seleccionar aquellos medicamentos que serán incluidos en esta Lista de Medicamentos. Esta selección se hace a base de la seguridad, efectividad y costo de los medicamentos. De ahí la importancia de que su médico y usted seleccionen los medicamentos en la Lista. En las páginas a continuación presentamos la Lista de Medicamentos, con toda la información requerida para facilitarle su lectura e interpretación. Le exhortamos a que evalúe con su médico los medicamentos disponibles en nuestra Lista para tratar su condición. Nuestra Lista contiene un sinnúmero de medicamentos por condición, los cuales incluyen medicamentos genéricos y de marca preferidos, entre otros. Al utilizarla, usted contribuye a mantener los costos del beneficio de farmacia en un nivel razonable, además que sus copagos serán menores.

Ramon Santiago, MBA Director Ejecutivo Plan Médico Servicios de Salud Bella Vista, Inc.

FMCMPD 01-17 ii

INTRODUCCIÓN

Esta es una lista abreviada de medicamentos que contiene los medicamentos cubiertos por su clasificación terapéutica. Presentación de la Lista de Medicamentos

En el ejemplo a continuación se ilustra la información que se provee para los medicamentos incluidos en la Lista de Medicamentos.

Medicamento Genérico (Generic Drug)

Presentación (Dosage Form)

Ejemplos del Nombre Comercial

(Examples of Brand Name)

Nivel (Tier)

Inst

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

Amphetamines

Amphetamine-dextroamphet Er 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg Adderall XR (Oral Capsule) 3 LC

Amphetamine-dextroamphet Er 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Amphetamine-Dextroamphet ER (Oral Capsule) 1 LC

Para cada medicamento incluido en la Lista de Medicamentos aparece su nombre comercial, el nivel y si tiene alguna instrucción especial. ¿Cómo usar la Lista de Medicamentos? La manera más fácil en que usted puede conseguir los medicamentos en la Lista de Medicamentos es buscando el medicamento en el Índice al final de la lista. El Índice provee una lista por orden alfabético de todos los medicamentos incluidos en este documento. Ambos, medicamentos de marca como genéricos están incluidos en el Índice. Busque el Índice y encuentre el medicamento. Al lado del medicamento, usted encontrará el número de la página donde encontrará cómo está cubierto. Verifique la página indicada en el Índice y encuentre el nombre del medicamento en las columnas. ¿Cuánto usted paga por los medicamentos cubiertos?

Los medicamentos en la lista de medicamentos se clasifican por niveles. Estos niveles identifican los diferentes niveles de costo compartido, o sea, lo que usted paga por los medicamentos en la receta. Estos niveles son los siguientes:

Nivel 0 – Medicamentos cubierto al amparo de la ley PPACA Nivel 1 – Medicamentos Genéricos Nivel 2 – Medicamentos Preferidos Nivel 3 – Medicamentos de Marca No Preferido Nivel 4 – Medicamentos Especializados o Biotecnológicos

FMCMPD 01-17 iii

¿Qué son medicamentos genéricos (Nivel 1)?

Un medicamento genérico tiene el mismo ingrediente activo en la fórmula que un medicamento de marca. Los medicamentos genéricos usualmente cuestan menos que un medicamento de marca y están aprobados por la Administración Federal de Drogas y Alimentos (FDA, por sus siglas en inglés).

Los medicamentos genéricos están escritos en letras negrillas en la Lista de Medicamentos (ejemplo, Nabumetone).

Recomendamos que utilice los medicamentos genéricos. Estos son iguales en potencia y dosis y también son aprobados por la FDA.

¿Qué son medicamentos preferidos (Nivel 2)?

Hay ciertos medicamentos de marca que han sido seleccionados por el Comité de Farmacia y Terapéutica como agentes preferidos luego de su evaluación de seguridad, eficacia y costo. Los mismos están identificados a la derecha como Nivel 2. En aquellas clases terapéuticas donde no hay genéricos disponibles, les exhortamos a que utilice como primera alternativa aquellos medicamentos identificados como preferidos.

¿Qué son medicamentos No Preferidos (Nivel 3)?

Un medicamento es clasificado como No Preferido porque existen alternativas en los niveles anteriores con menos efectos secundarios o son más costo- efectivos. Si el asegurado obtiene un medicamento de marca del Nivel 4, tendrá que pagar un costo mayor por el medicamento.

¿Qué son medicamentos Especializados o Biotecnológicos (Nivel 4)?

Algunos medicamentos para condiciones crónicas y de alto riesgo requieren una administración y/o un manejo especial, por su composición compleja. Estos medicamentos se ofrecen a través de las farmacias de la red o del Programa de Medicamentos para Condiciones Especiales, el cual cuenta con una red de farmacias especializadas dedicadas a que estos medicamentos sean despachados y administrados correctamente. Si su beneficio de farmacia no establece un nivel específico para estos productos aplicará el primer nivel indicado en la columna de la tabla de productos especializados.

GUÍAS DE REFERENCIA

Programa de Terapia Escalonada

En algunos casos, requerimos que usted utilice primero un medicamento como terapia para su condición antes de que cubramos otro medicamento para esa condición (Terapia Escalonada). Por ejemplo, si el Medicamento A y el Medicamento B se usan ambos para tratar su condición médica, nosotros requerimos que usted utilice primero el Medicamento A. Si el Medicamento A no funciona para usted, entonces cubriremos el Medicamento B.

FMCMPD 01-17 iv

Medicamentos que requieren preautorización (PA)

Ciertos medicamentos necesitan una preautorización para ser adquiridos por el paciente. Los mismos se han identificado a la derecha con PA (requiere preautorización), en cuyo caso, la farmacia gestiona la preautorización con nuestro centro de llamadas. Los medicamentos que requieren preautorización usualmente son aquellos que presentan efectos adversos, son candidatos al uso inapropiado o están relacionados con un costo elevado.

Aquellos medicamentos que han sido identificados que requieren preautorización deben satisfacer los criterios clínicos establecidos según lo haya determinado el Comité de Farmacia y Terapéutica. Estos criterios clínicos se han desarrollado de acuerdo a la literatura médica actual.

Límites de Cantidad (LC)

Ciertos medicamentos tienen un límite en la cantidad a despacharse. Estas cantidades se establecen de acuerdo a lo sugerido por el manufacturero como la cantidad máxima adecuada que no está asociada a efectos adversos y la cual es efectiva para el tratamiento de una condición.

FMCMPD 01-17 5

LISTA DE MEDICAMENTOS CUBIERTOS POR CLASIFICACIÓN TERAPÉUTICA

LIST OF COVERED DRUGS BY THERAPEUTIC CATEGORY



Ejemplos del Nombre Comercial (Examples of Brand Name)

Nivel (Tier)

Inst

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS (ADHD / Anti-Narcolepsia / Anti-Obesidad / Anoréxicos)

Amphetamines (Amfetaminas)

Amphetamine-dextroamphet Er 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg Adderall XR (Oral) 3 LC

Amphetamine-dextroamphet Er

10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Amphetamine-Dextroamphet ER (Oral) 1 LC

Amphetamine-dextroamphetamine

10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg Adderall (Oral) 3 LC

Amphetamine-dextroamphetamine

10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

Amphetamine-Dextroamphetamine (Oral) 1 LC

Dextroamphetamine Sulfate 10 mg, 5 mg Dexedrine (Oral) 1

Dextroamphetamine Sulfate 10 mg, 5 mg Zenzedi (Oral) 2

Dextroamphetamine Sulfate 10 mg, 5 mg, 5 mg/5ml Dextroamphetamine Sulfate (Oral) 1

Dextroamphetamine Sulfate 2.5 mg, 7.5 mg Zenzedi (Oral) 3

Dextroamphetamine Sulfate 5 mg/5ml ProCentra (Oral) 3

Dextroamphetamine Sulfate Er 10 mg, 15 mg, 5 mg Dexedrine (Oral) 3 LC

Dextroamphetamine Sulfate Er 10 mg, 15 mg, 5 mg

Dextroamphetamine Sulfate ER (Oral) 1 LC

Lisdexamfetamine Dimesylate 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg Vyvanse (Oral) 2 LC

Methamphetamine Hcl 5 mg Desoxyn (Oral) 3 LC

Methamphetamine Hcl 5 mg Methamphetamine HCl (Oral) 1 LC

Analeptics (Analepticos)

Caffeine Citrate 20 mg/ml, 60 mg/3ml Caffeine Citrate (Oral) 1

Caffeine Citrate 60 mg/3ml Cafcit (Intravenous) 4 SP

Caffeine Citrate 60 mg/3ml Caffeine Citrate (Intravenous) 4 SP

Doxapram Hcl 20 mg/ml Dopram (Intravenous) 4 SP

Attention-deficit/hyperactivity Disorder (adhd) Agents (Agentes Para el Deficit De Atencion E Hiperactividad)

Atomoxetine Hcl 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg Strattera (Oral) 2 LC

Clonidine Hcl Er 0.1 mg CloNIDine HCl ER (Oral) 1

Clonidine Hcl Er 0.1 mg Kapvay (Oral) 3

Guanfacine Hcl Er 1 mg, 2 mg, 3 mg, 4 mg GuanFACINE HCl ER (Oral) 1

Guanfacine Hcl Er 1 mg, 2 mg, 3 mg, 4 mg Intuniv (Oral) 3

FMCMPD 01-17 6




Nivel (Tier)

Inst

Stimulants - Misc. (Estimulantes - Misc.)

Armodafinil 150 mg, 200 mg, 250 mg, 50 mg Armodafinil (Oral) 2 LC

Armodafinil 150 mg, 200 mg, 250 mg, 50 mg Nuvigil (Oral) 3 LC

Dexmethylphenidate Hcl 10 mg, 2.5 mg, 5 mg Dexmethylphenidate HCl (Oral) 1 LC

Dexmethylphenidate Hcl 10 mg, 2.5 mg, 5 mg Focalin (Oral) 3 LC

Dexmethylphenidate Hcl Er

10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg Focalin XR (Oral) 3 LC

Dexmethylphenidate Hcl Er 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg

Dexmethylphenidate HCl ER (Oral) 1 LC

Methylphenidate 10 mg/9hr, 15 mg/9hr, 20 mg/9hr, 30 mg/9hr Daytrana (Transdermal) 2 LC

Methylphenidate Hcl 10 mg, 10 mg/5ml, 2.5 mg, 5 mg, 5 mg/5ml Methylin (Oral) 3 LC

Methylphenidate Hcl 10 mg, 10 mg/5ml, 2.5 mg, 20 mg, 5 mg, 5 mg/5ml Methylphenidate HCl (Oral) 1 LC

Methylphenidate Hcl 10 mg, 20 mg, 5 mg Ritalin (Oral) 3 LC

Methylphenidate Hcl Er 10 mg Methylphenidate HCl ER (Oral) 3 LC

Methylphenidate Hcl Er 18 mg, 20 mg, 27 mg, 36 mg, 54 mg Methylphenidate HCl ER (Oral) 1 LC

Methylphenidate Hcl Er 18 mg, 27 mg, 36 mg, 54 mg Concerta (Oral) 3 LC

Methylphenidate Hcl Er 20 mg Metadate ER (Oral) 2 LC

Methylphenidate Hcl Er 25 mg/5ml Quillivant XR (Oral) 3 LC

Methylphenidate Hcl Er (cd) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg Metadate CD (Oral) 3 LC

Methylphenidate Hcl Er (cd) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Methylphenidate HCl ER (CD) (Oral) 1 LC

Methylphenidate Hcl Er (la) 10 mg, 20 mg, 30 mg, 40 mg Ritalin LA (Oral) 3 LC

Methylphenidate Hcl Er (la) 20 mg, 30 mg, 40 mg Methylphenidate HCl ER (LA) (Oral) 1 LC

Modafinil 100 mg, 200 mg Modafinil (Oral) 1 LC

Modafinil 100 mg, 200 mg Provigil (Oral) 3 LC

AMINOGLYCOSIDES (Aminoglicosidos)

Aminoglycosides (Aminoglicosidos)

Amikacin Sulfate 1 gm/4ml, 500 mg/2ml Amikacin Sulfate (Injection) 1

FMCMPD 01-17 7




Nivel (Tier)

Inst

Gentamicin Sulfate 0.3 %, 10 mg/ml, 40 mg/ml Gentamicin Sulfate (Ophthalmic, Injection) 1

Gentamicin Sulfate 10 mg/ml Gentamicin Sulfate (Intravenous) 4 SP

Neomycin Sulfate 500 mg Neomycin Sulfate (Oral) 1

Paromomycin Sulfate 250 mg Paromomycin Sulfate (Oral) 1

Streptomycin Sulfate 1 gm Streptomycin Sulfate (Intramuscular) 3

Tobramycin 28 mg Tobi Podhaler (Inhalation) 4 SP

Tobramycin 300 mg/4ml Bethkis (Inhalation) 4 SP

Tobramycin 300 mg/5ml Tobi (Inhalation) 4 SP

Tobramycin Sulfate

1.2 gm, 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml Tobramycin Sulfate (Injection) 1

ANALGESICS - ANTI-INFLAMMATORY (Analgesicos - Antiinflamatorios)

Anti-tnf-alpha - Monoclonal Antibodies (Anticuerpos Monoclonales - Anti-tnf-alfa)

Adalimumab 10 mg/0.2ml, 20 mg/0.4ml, 40 mg/0.8ml Humira (Subcutaneous) 4

PA SP

Adalimumab 40 mg/0.8ml Humira Pediatric Crohns Start (Subcutaneous) 4

PA SP

Adalimumab 40 mg/0.8ml Humira Pen (Subcutaneous) 4 PA SP

Adalimumab 40 mg/0.8ml Humira Pen-Crohns Starter (Subcutaneous) 4

PA SP

Adalimumab 40 mg/0.8ml Humira Pen-Psoriasis Starter (Subcutaneous) 4

PA SP

Golimumab 100 mg/ml, 50 mg/0.5ml Simponi (Subcutaneous) 4 PA SP

Golimumab 50 mg/4ml Simponi Aria (Intravenous) 4 PA SP

Gold Compounds (Compuestos De Oro)

Auranofin 3 mg Ridaura (Oral) 3

Interleukin-1 Blockers (Bloqueadores De Interleukina 1)

Rilonacept 220 mg Arcalyst (Subcutaneous) 4 SP

Interleukin-1 Receptor Antagonist (il-1ra) (Antagonistas De Receptors De Interleukina 1 (il-1ra))

Anakinra 100 mg/0.67ml Kineret (Subcutaneous) 4 PA SP

Interleukin-1beta Blockers (Bloqueadores Beta De Interleukina 1)

Canakinumab 180 mg Ilaris (Subcutaneous) 4 SP

Interleukin-6 Receptor Inhibitors (Inhibidores De Receptors Interleukina 6)

FMCMPD 01-17 8




Nivel (Tier)

Inst

Tocilizumab

162 mg/0.9ml, 200 mg/10ml, 400 mg/20ml, 80 mg/4ml

Actemra (Subcutaneous, Intravenous) 4

PA SP

Nonsteroidal Anti-inflammatory Agents (nsaids) (Agentes Antiinflamatorios No Esteroidales)

Celecoxib 100 mg, 200 mg, 400 mg, 50 mg CeleBREX (Oral) 3 LC

Celecoxib 100 mg, 200 mg, 400 mg, 50 mg Celecoxib (Oral) 1 LC

Diclofenac Potassium 25 mg Zipsor (Oral) 3

Diclofenac Potassium 50 mg Diclofenac Potassium (Oral) 1

Diclofenac Sodium 0.1 %, 1.5 %, 25 mg, 50 mg, 75 mg

Diclofenac Sodium (Ophthalmic, Transdermal, Oral) 1

Diclofenac Sodium Er 100 mg Diclofenac Sodium ER (Oral) 1

Diclofenac-misoprostol 50-0.2 mg, 75-0.2 mg Arthrotec (Oral) 3

Diclofenac-misoprostol 50-0.2 mg, 75-0.2 mg Diclofenac-Misoprostol (Oral) 1

Etodolac 200 mg, 300 mg, 400 mg, 500 mg Etodolac (Oral) 1

Etodolac Er 400 mg, 500 mg, 600 mg Etodolac ER (Oral) 1

Fenoprofen Calcium 200 mg, 400 mg, 600 mg Fenoprofen Calcium (Oral) 3

Fenoprofen Calcium 400 mg Nalfon (Oral) 3

Flurbiprofen 100 mg, 50 mg Flurbiprofen (Oral) 1

Ibuprofen 100 mg/5ml, 400 mg, 600 mg, 800 mg Ibuprofen (Oral) 1

Ibuprofen-famotidine 800-26.6 mg Duexis (Oral) 3

Ibuprofen-liniment 800 mg Ibuprofen Comfort Pac (Combination) 3

Indomethacin 25 mg, 50 mg Indomethacin (Oral) 1

Indomethacin 25 mg/5ml, 50 mg Indocin (Oral, Rectal) 3

Indomethacin Er 75 mg Indomethacin ER (Oral) 1

Ketoprofen 50 mg, 75 mg Ketoprofen (Oral) 1

Ketoprofen Er 200 mg Ketoprofen ER (Oral) 3

Ketorolac Tromethamine

0.4 %, 0.5 %, 10 mg, 15 mg/ml, 30 mg/ml, 60 mg/2ml

Ketorolac Tromethamine (Ophthalmic, Oral, Injection) 1 LC

Ketorolac Tromethamine 15.75 mg/spray Sprix (Nasal) 3

Meclofenamate Sodium 100 mg, 50 mg Meclofenamate Sodium (Oral) 3

Mefenamic Acid 250 mg Mefenamic Acid (Oral) 1

Mefenamic Acid 250 mg Ponstel (Oral) 3

Meloxicam 15 mg, 7.5 mg Meloxicam (Oral) 1

FMCMPD 01-17 9




Nivel (Tier)

Inst

Meloxicam 15 mg, 7.5 mg Mobic (Oral) 3

Nabumetone 500 mg, 750 mg Nabumetone (Oral) 1

Naproxen 125 mg/5ml, 250 mg, 375 mg, 500 mg Naproxen (Oral) 1

Naproxen 375 mg, 500 mg EC-Naprosyn (Oral) 3

Naproxen 375 mg, 500 mg Naproxen DR (Oral) 2

Naproxen 500 mg Naprosyn (Oral) 3

Naproxen Sodium 275 mg, 550 mg Naproxen Sodium (Oral) 1

Naproxen Sodium 550 mg Anaprox DS (Oral) 3

Naproxen Sodium Er 375 mg, 500 mg Naproxen Sodium ER (Oral) 1

Naproxen Sodium Er 375 mg, 500 mg, 750 mg Naprelan (Oral) 3

Naproxen-esomeprazole 375-20 mg, 500-20 mg Vimovo (Oral) 2

Oxaprozin 600 mg Oxaprozin (Oral) 1

Piroxicam 10 mg, 20 mg Feldene (Oral) 3

Piroxicam 10 mg, 20 mg Piroxicam (Oral) 1

Sulindac 150 mg, 200 mg Sulindac (Oral) 1

Tolmetin Sodium 200 mg, 600 mg Tolmetin Sodium (Oral) 3

Tolmetin Sodium 400 mg Tolmetin Sodium (Oral) 1

Pyrimidine Synthesis Inhibitors (Inhibidores De La Sintesis De Pirimidina)

Leflunomide 10 mg, 20 mg Arava (Oral) 3

Leflunomide 10 mg, 20 mg Leflunomide (Oral) 1

Selective Costimulation Modulators (Moduladores Coestimuladores Selectivos)

Abatacept 125 mg/ml Orencia ClickJect (Subcutaneous) 4

PA SP

Abatacept 125 mg/ml, 250 mg Orencia (Subcutaneous, Intravenous) 4

PA SP

Soluble Tumor Necrosis Factor Receptor Agents (Agentes Del Receptor Para Factor Soluble De Necrosis Tumoral)

Etanercept 25 mg, 25 mg/0.5ml, 50 mg/ml Enbrel (Subcutaneous) 4

PA SP

Etanercept 50 mg/ml Enbrel SureClick (Subcutaneous) 4

PA SP

ANALGESICS - NONNARCOTIC (Analgesicos - No Narcoticos)

Analgesic Combinations (Combinaciones de Analgesicos)

Apap-salicylamide-phenyltolox 300-200-20 mg Duraxin (Oral) 2

Apap-salicylamide-phenyltolox 300-200-20 mg Ed-Flex (Oral) 2

Asa-apap-salicyl-caff 500-250-150 mg Levacet (Oral) 3

Butalbital-acetaminophen 50-300 mg Bupap (Oral) 3

FMCMPD 01-17 10




Nivel (Tier)

Inst

Butalbital-acetaminophen 50-325 mg Butalbital-Acetaminophen (Oral) 1

Butalbital-acetaminophen 50-325 mg Marten-Tab (Oral) 2

Butalbital-apap-caffeine 50-300-40 mg Fioricet (Oral) 3

Butalbital-apap-caffeine 50-300-40 mg, 50-325-40 mg Butalbital-APAP-Caffeine (Oral) 1

Butalbital-apap-caffeine 50-325-40 mg Esgic (Oral) 3

Butalbital-apap-caffeine 50-325-40 mg Margesic (Oral) 2

Butalbital-apap-caffeine 50-325-40 mg Zebutal (Oral) 3

Butalbital-aspirin-caffeine 50-325-40 mg Butalbital-ASA-Caffeine (Oral) 1

Butalbital-aspirin-caffeine 50-325-40 mg Butalbital-Aspirin-Caffeine (Oral) 1

Butalbital-aspirin-caffeine 50-325-40 mg Fiorinal (Oral) 3

Salicylates (Salicilatos)

Aspirin 324 mg Aspirtab (Oral) 0 LC

Aspirin 325 mg Bayer Advanced Aspirin Reg St (Oral) 0 LC

Aspirin 325 mg Bayer Aspirin (Oral) 0 LC

Aspirin 325 mg Bayer Aspirin Regimen (Oral) 0 LC

Aspirin 325 mg EQ Aspirin (Oral) 0 LC

Aspirin 325 mg EQL Aspirin EC (Oral) 0 LC

Aspirin 325 mg EcPirin (Oral) 0 LC

Aspirin 325 mg Ecotrin (Oral) 0 LC

Aspirin 325 mg HM Aspirin EC (Oral) 0 LC

Aspirin 325 mg KLS Aspirin EC (Oral) 0 LC

Aspirin 325 mg MM Aspirin (Oral) 0 LC

Aspirin 325 mg Meijer Aspirin EC (Oral) 0 LC

Aspirin 325 mg Norwich Aspirin (Oral) 0 LC

Aspirin 325 mg QC Aspirin (Oral) 0 LC

Aspirin 325 mg RA Aspirin (Oral) 0 LC

Aspirin 325 mg SB Aspirin EC (Oral) 0 LC

Aspirin 325 mg SM Aspirin (Oral) 0 LC

Aspirin 325 mg SM Aspirin EC (Oral) 0 LC

Aspirin 325 mg TGT Aspirin EC (Oral) 0 LC

Aspirin 325 mg, 81 mg Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg Aspirin EC (Oral) 0 LC

Aspirin 325 mg, 81 mg CVS Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg CVS Aspirin EC (Oral) 0 LC

Aspirin 325 mg, 81 mg GNP Aspirin (Oral) 0 LC

FMCMPD 01-17 11




Nivel (Tier)

Inst

Aspirin 325 mg, 81 mg HM Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg PX Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg PX Enteric Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg RA Aspirin EC (Oral) 0 LC

Aspirin 325 mg, 81 mg SB Aspirin (Oral) 0 LC

Aspirin 325 mg, 81 mg TGT Aspirin (Oral) 0 LC

Aspirin 81 mg Adult Aspirin EC Low Strength (Oral) 0 LC

Aspirin 81 mg Aspir-81 (Oral) 0 LC

Aspirin 81 mg Aspir-Low (Oral) 0 LC

Aspirin 81 mg Aspirin Adult Low Strength (Oral) 0 LC

Aspirin 81 mg Aspirin Childrens (Oral) 0 LC

Aspirin 81 mg Aspirin EC Low Dose (Oral) 0 LC

Aspirin 81 mg Aspirin EC Low Strength (Oral) 0 LC

Aspirin 81 mg Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg Aspirin Low Strength (Oral) 0 LC

Aspirin 81 mg Bayer Aspirin EC Low Dose (Oral) 0 LC

Aspirin 81 mg Bayer Low Dose (Oral) 0 LC

Aspirin 81 mg CVS Aspirin Adult Low Dose (Oral) 0 LC

Aspirin 81 mg CVS Aspirin Adult Low Strength (Oral) 0 LC

Aspirin 81 mg CVS Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg CVS Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg Childrens Aspirin Low Strength (Oral) 0 LC

Aspirin 81 mg EC-81 Aspirin (Oral) 0 LC

Aspirin 81 mg EQ Adult Aspirin Low Strength (Oral) 0 LC

Aspirin 81 mg EQ Aspirin Adult Low Dose (Oral) 0 LC

Aspirin 81 mg EQ Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg EQ Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg EQL Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg Ecotrin Low Strength (Oral) 0 LC

FMCMPD 01-17 12




Nivel (Tier)

Inst

Aspirin 81 mg GNP Adult Aspirin Low Strength (Oral) 0 LC

Aspirin 81 mg GNP Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg GoodSense Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg HM Aspirin EC Low Dose (Oral) 0 LC

Aspirin 81 mg KLS Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg KP Aspirin (Oral) 0 LC

Aspirin 81 mg Miniprin Low Dose (Oral) 0 LC

Aspirin 81 mg QC Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg QC Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg RA Aspirin Adult Low Dose (Oral) 0 LC

Aspirin 81 mg RA Aspirin Adult Low Strength (Oral) 0 LC

Aspirin 81 mg RA Aspirin Childrens (Oral) 0 LC

Aspirin 81 mg RA Aspirin EC Adult Low St (Oral) 0 LC

Aspirin 81 mg RA Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg SB Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg SB Low Dose ASA EC (Oral) 0 LC

Aspirin 81 mg SM Aspirin Adult Low Strength (Oral) 0 LC

Aspirin 81 mg SM Aspirin EC Low Strength (Oral) 0 LC

Aspirin 81 mg SM Childrens Aspirin (Oral) 0 LC

Aspirin 81 mg St Joseph Aspirin (Oral) 0 LC

Aspirin 81 mg TGT Aspirin Low Dose (Oral) 0 LC

Aspirin 81 mg TGT Childrens Aspirin (Oral) 0 LC

Choline & Mag Salicylates 1000 mg Choline & Mag Trisalicylate (Oral) 1

Choline & Mag Salicylates 500 mg/5ml Choline-Mag Trisalicylate (Oral) 1

Diflunisal 500 mg Diflunisal (Oral) 1

Salsalate 500 mg, 750 mg Salsalate (Oral) 1

ANALGESICS - OPIOID (Analgesicos - Opioides)

Opioid Agonists (Agonistas Opioides)

Alfentanil 500 mcg/ml Alfenta (Injection) 3

FMCMPD 01-17 13




Nivel (Tier)

Inst

Alfentanil 500 mcg/ml Alfentanil (Injection) 1

Codeine Sulfate 15 mg, 30 mg, 60 mg Codeine Sulfate (Oral) 3

Fentanyl 100 mcg/hr Duragesic-100 (Transdermal) 3 LC

Fentanyl

100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FentaNYL (Transdermal) 1 LC


Fentanyl 1200 (600 x 2) mcg, 1600 (800 x 2) mcg Subsys (Sublingual) 3




Fentanyl Citrate

100 mcg, 200 mcg, 300 mcg, 400 mcg, 600 mcg, 800 mcg Abstral (Sublingual) 3

Fentanyl Citrate 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg Fentora (Buccal) 2 LC

Fentanyl Citrate 100 mcg/act, 300 mcg/act, 400 mcg/act Lazanda (Nasal) 3

Fentanyl Citrate

1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg FentaNYL Citrate (Buccal) 1 LC

Fentanyl Citrate 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg Actiq (Buccal) 3 LC

Fentanyl Citrate (pf)

100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

FentaNYL Citrate (PF) (Injection) 1

Fentanyl Citrate (pf) 100 mcg/2ml, 250 mcg/5ml Sublimaze (Injection) 3

Hydrocodone Bitartrate 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg Zohydro ER (Oral) 3 LC

Hydromorphone Hcl 1 mg/ml, 2 mg, 4 mg, 4 mg/ml, 8 mg

HYDROmorphone HCl (Oral, Injection) 1

Hydromorphone Hcl 2 mg, 4 mg, 8 mg Dilaudid (Oral) 3

Hydromorphone Hcl 2 mg/ml, 3 mg HYDROmorphone HCl (Injection, Rectal) 3

Hydromorphone Hcl Pf 10 mg/ml, 50 mg/5ml, 500 mg/50ml

HYDROmorphone HCl PF (Injection) 1

Levorphanol Tartrate 2 mg Levorphanol Tartrate (Oral) 3

Meperidine Hcl 10 mg/ml, 50 mg/5ml Meperidine HCl (Injection, Oral) 3

FMCMPD 01-17 14




Nivel (Tier)

Inst

Meperidine Hcl

100 mg, 100 mg/2ml, 100 mg/ml, 25 mg/0.5ml, 25 mg/ml, 50 mg, 50 mg/ml, 75 mg/1.5ml, 75 mg/ml Demerol (Oral, Injection) 3

Meperidine Hcl 100 mg, 100 mg/ml, 25 mg/ml, 50 mg, 50 mg/ml Meperidine HCl (Oral, Injection) 1

Methadone Hcl

10 mg, 10 mg/5ml, 10 mg/ml, 40 mg, 5 mg, 5 mg/5ml Methadone HCl (Oral) 1

Methadone Hcl 10 mg, 5 mg Dolophine (Oral) 3

Methadone Hcl 10 mg/ml Methadone HCl (Injection) 3

Methadone Hcl 10 mg/ml Methadone HCl Intensol (Oral) 2

Methadone Hcl 10 mg/ml Methadose (Oral) 3

Methadone Hcl 10 mg/ml Methadose Sugar-Free (Oral) 3

Methadone Hcl 40 mg Methadose (Oral) 2

Morphine Sulfate

10 mg, 10 mg/0.7ml, 15 mg, 20 mg, 30 mg, 5 mg, 5 mg/ml

Morphine Sulfate (Rectal, Intramuscular, Oral, Injection) 3

Morphine Sulfate 10 mg/5ml, 10 mg/ml, 15 mg/ml, 20 mg/5ml, 8 mg/ml

Morphine Sulfate (Oral, Injection) 1

Morphine Sulfate (concentrate) 100 mg/5ml, 20 mg/ml

Morphine Sulfate (Concentrate) (Oral) 1

Morphine Sulfate (pf) 0.5 mg/ml, 1 mg/ml Duramorph (Injection) 2

Morphine Sulfate (pf) 0.5 mg/ml, 1 mg/ml Morphine Sulfate (PF) (Injection) 1

Morphine Sulfate Er

10 mg, 100 mg, 15 mg, 20 mg, 200 mg, 30 mg, 50 mg, 60 mg, 80 mg Morphine Sulfate ER (Oral) 1 LC

Morphine Sulfate Er

10 mg, 100 mg, 20 mg, 200 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg Kadian (Oral) 3 LC

Morphine Sulfate Er 100 mg, 15 mg, 200 mg, 30 mg, 60 mg MS Contin (Oral) 3 LC

Morphine Sulfate Er Beads 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

Morphine Sulfate ER Beads (Oral) 1 LC

Morphine Sulfate Microinfusion 200 mg/20ml (10 mg/ml) Infumorph 200 (Injection) 3

Morphine Sulfate Microinfusion 500 mg/20ml (25 mg/ml) Infumorph 500 (Injection) 3

Oxycodone Hcl

10 mg, 100 mg/5ml, 15 mg, 20 mg, 30 mg, 5 mg, 5 mg/5ml OxyCODONE HCl (Oral) 1

FMCMPD 01-17 15




Nivel (Tier)

Inst

Oxycodone Hcl 15 mg, 30 mg, 5 mg Roxicodone (Oral) 3

Oxymorphone Hcl 1 mg/ml, 10 mg, 5 mg Opana (Injection, Oral) 3

Oxymorphone Hcl 10 mg, 5 mg Oxymorphone HCl (Oral) 1 LC

Oxymorphone Hcl Er 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg Oxymorphone HCl ER (Oral) 1

Tapentadol Hcl 100 mg, 50 mg, 75 mg Nucynta (Oral) 2

Tapentadol Hcl Er 100 mg, 150 mg, 200 mg, 250 mg, 50 mg Nucynta ER (Oral) 2

Tramadol Hcl 50 mg TraMADol HCl (Oral) 1

Tramadol Hcl 50 mg Ultram (Oral) 3

Tramadol Hcl Er 100 mg, 200 mg, 300 mg ConZip (Oral) 3

Tramadol Hcl Er 100 mg, 200 mg, 300 mg TraMADol HCl ER (Oral) 1

Tramadol Hcl Er 150 mg TraMADol HCl ER (Oral) 3

Tramadol Hcl Er 300 mg Ultram ER (Oral) 3

Tramadol Hcl Er (biphasic) 100 mg, 200 mg, 300 mg TraMADol HCl ER (Biphasic) (Oral) 1

Opioid Combinations (Combinaciones De Opioides)

Acetaminophen-codeine 120-12 mg/5ml Capital/Codeine (Oral) 3

Acetaminophen-codeine 120-12 mg/5ml, 300-15 mg, 300-30 mg, 300-60 mg Acetaminophen-Codeine (Oral) 1

Acetaminophen-codeine 300-15 mg Acetaminophen-Codeine #2 (Oral) 1


Acetaminophen-codeine 300-30 mg Tylenol with Codeine #3 (Oral) 3


Acetaminophen-codeine 300-60 mg Tylenol with Codeine #4 (Oral) 3

Aspirin-caff-dihydrocodeine 356.4-30-16 mg Aspirin-Caff-Dihydrocodeine (Oral) 2

Aspirin-caff-dihydrocodeine 356.4-30-16 mg Synalgos-DC (Oral) 3

Butalbital-apap-caff-cod 50-300-40-30 mg Fioricet/Codeine (Oral) 3

Butalbital-apap-caff-cod 50-300-40-30 mg, 50-325-40-30 mg Butalbital-APAP-Caff-Cod (Oral) 1

Butalbital-asa-caff-codeine 50-325-40-30 mg Ascomp-Codeine (Oral) 2

Butalbital-asa-caff-codeine 50-325-40-30 mg Butalbital-ASA-Caff-Codeine (Oral) 1

Butalbital-asa-caff-codeine 50-325-40-30 mg Fiorinal/Codeine #3 (Oral) 3

Hydrocodone-acetaminophen 10-300 mg Vicodin HP (Oral) 2

FMCMPD 01-17 16




Nivel (Tier)

Inst

Hydrocodone-acetaminophen

10-300 mg, 10-325 mg, 2.5-108 mg/5ml, 5-217 mg/10ml, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg, 7.5

Hydrocodone-Acetaminophen (Oral) 1

Hydrocodone-acetaminophen 10-300 mg, 5-300 mg, 7.5-300 mg Xodol (Oral) 3

Hydrocodone-acetaminophen 10-325 mg Lorcet HD (Oral) 3

Hydrocodone-acetaminophen 10-325 mg, 5-325 mg, 7.5-325 mg Lortab (Oral) 3

Hydrocodone-acetaminophen 10-325 mg, 5-325 mg, 7.5-325 mg Norco (Oral) 3

Hydrocodone-acetaminophen 2.5-325 mg Hydrocodone-Acetaminophen (Oral) 3

Hydrocodone-acetaminophen 5-300 mg Vicodin (Oral) 2

Hydrocodone-acetaminophen 5-325 mg Lorcet (Oral) 3

Hydrocodone-acetaminophen 7.5-300 mg Vicodin ES (Oral) 2

Hydrocodone-acetaminophen 7.5-325 mg Lorcet Plus (Oral) 3

Hydrocodone-acetaminophen 7.5-325 mg/15ml Hycet (Oral) 3

Hydrocodone-ibuprofen 10-200 mg Ibudone (Oral) 3

Hydrocodone-ibuprofen 10-200 mg Reprexain (Oral) 2

Hydrocodone-ibuprofen 10-200 mg, 5-200 mg, 7.5-200 mg Hydrocodone-Ibuprofen (Oral) 1

Hydrocodone-ibuprofen 5-200 mg Ibudone (Oral) 2

Hydrocodone-ibuprofen 5-200 mg Reprexain (Oral) 3

Oxycodone-acetaminophen 10-300 mg, 5-300 mg, 7.5-300 mg Primlev (Oral) 3

Oxycodone-acetaminophen

10-325 mg, 2.5-325 mg, 5-325 mg, 5-325 mg/5ml, 7.5-325 mg

Oxycodone-Acetaminophen (Oral) 1

Oxycodone-acetaminophen 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg Percocet (Oral) 3

Oxycodone-acetaminophen 10-325 mg, 5-325 mg, 7.5-325 mg Endocet (Oral) 2

Oxycodone-aspirin 4.8355-325 mg Oxycodone-Aspirin (Oral) 1

Oxycodone-ibuprofen 5-400 mg Oxycodone-Ibuprofen (Oral) 1 LC

Tramadol-acetaminophen 37.5-325 mg Tramadol-Acetaminophen (Oral) 1

Tramadol-acetaminophen 37.5-325 mg Ultracet (Oral) 3

Opioid Partial Agonists (Agonistas Parciales de Opioides)

FMCMPD 01-17 17




Nivel (Tier)

Inst

Buprenorphine 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr Butrans (Transdermal) 2

Buprenorphine Hcl 0.3 mg/ml Buprenex (Injection) 3

Buprenorphine Hcl 0.3 mg/ml, 2 mg, 8 mg Buprenorphine HCl (Injection, Sublingual) 1

Buprenorphine Hcl-naloxone Hcl

1.4-0.36 mg, 11.4-2.9 mg, 2.9-0.71 mg, 5.7-1.4 mg Zubsolv (Sublingual) 3

Buprenorphine Hcl-naloxone Hcl

12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg Suboxone (Sublingual) 2

Buprenorphine Hcl-naloxone Hcl 2-0.5 mg, 8-2 mg

Buprenorphine HCl-Naloxone HCl (Sublingual) 1

Butorphanol Tartrate 1 mg/ml, 10 mg/ml, 2 mg/ml

Butorphanol Tartrate (Injection, Nasal) 1

Nalbuphine Hcl 10 mg/ml, 20 mg/ml Nalbuphine HCl (Injection) 1

Pentazocine Lactate 30 mg/ml Talwin (Injection) 3

Pentazocine-naloxone 50-0.5 mg Pentazocine-Naloxone HCl (Oral) 1

ANDROGENS-ANABOLIC (Androgenos Anabolicos)

Androgens (Androgenos)

Danazol 100 mg, 200 mg, 50 mg Danazol (Oral) 1

Methyltestosterone 10 mg Android (Oral) 3

Methyltestosterone 10 mg Methitest (Oral) 3

Methyltestosterone 10 mg MethylTESTOSTERone (Oral) 2

Methyltestosterone 10 mg Testred (Oral) 3

Testosterone 10 mg/act (2%) Fortesta (Transdermal) 3

Testosterone 10 mg/act (2%) Testosterone (Transdermal) 3

Testosterone 2 mg/24hr, 4 mg/24hr Androderm (Transdermal) 2

Testosterone 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm (1.62%) AndroGel (Transdermal) 2

Testosterone 20.25 mg/act (1.62%) AndroGel Pump (Transdermal) 2 LC

Testosterone 25 mg/2.5gm (1%), 50 mg/5gm (1%) AndroGel (Transdermal) 3

Testosterone 25 mg/2.5gm (1%), 50 mg/5gm (1%) Testosterone (Transdermal) 2

Testosterone 30 mg/act Axiron (Transdermal) 2

Testosterone Buccal 30 mg Striant Buccal (Miscellaneous) 3

Testosterone Cypionate 100 mg/ml, 200 mg/ml Depo-Testosterone (Intramuscular) 3

Testosterone Cypionate 100 mg/ml, 200 mg/ml Testosterone Cypionate (Intramuscular) 1

FMCMPD 01-17 18




Nivel (Tier)

Inst

Testosterone Cypionate 200 mg/ml Testone CIK (Intramuscular) 3

Testosterone Enanthate 200 mg/ml Delatestryl (Intramuscular) 3

Testosterone Enanthate 200 mg/ml Testosterone Enanthate (Intramuscular) 1

Testosterone Propionate 2 % First-Testosterone (Transdermal) 3

Testosterone Propionate 2 % First-Testosterone MC (Transdermal) 3

ANORECTAL AGENTS (Agentes Anorectales)

Intrarectal Steroids (Esteroides Intrarectales)

Budesonide 2 mg/act, 9 mg Uceris (Rectal, Oral) 3

Hydrocortisone 1 %, 10 mg, 100 mg/60ml, 2.5 %, 20 mg, 5 mg

Hydrocortisone (External, Oral, Rectal) 1

Hydrocortisone 100 mg/60ml Colocort (Rectal) 2

Hydrocortisone 100 mg/60ml Cortenema (Rectal) 3

Hydrocortisone Acetate 10 % Cortifoam (Rectal) 2

Rectal Combinations (Combinaciones Rectales)

Hc-pramox-diet Mng Prod -wipe 2.5-1 % Analpram Advanced (Combination) 3

Hydrocortisone Ace-pramoxine 1-1 % Analpram-HC (Rectal) 3

Hydrocortisone Ace-pramoxine 1-1 % Proctofoam HC (Rectal) 2

Hydrocortisone Ace-pramoxine 1-1 %, 2.5-1 %

Hydrocortisone Ace-Pramoxine (Rectal) 1

Hydrocortisone Ace-pramoxine 1.85-1.15 % ProCort (Rectal) 3

Hydrocortisone Ace-pramoxine 2.5-1 % Analpram HC (Rectal) 3

Hydrocortisone Ace-pramoxine 2.5-1 % Analpram HC Singles (Rectal) 3

Lidocaine-hydrocortisone Ace 2-2 %, 2.8-0.55 % Lidocaine-Hydrocortisone Ace (Rectal) 3

Lidocaine-hydrocortisone Ace 3-0.5 % LidaZone HC (Rectal) 2

Lidocaine-hydrocortisone Ace 3-0.5 %, 3-1 %, 3-2.5 %

Lidocaine-Hydrocortisone Ace (Rectal) 1

Rectal Steroids (Esteroides Rectales)

Hydrocortisone 1 % Procto-Pak (Rectal) 2

Hydrocortisone 1 % Proctocort (Rectal) 3



Hydrocortisone 2.5 % Anusol-HC (Rectal) 3

Hydrocortisone 2.5 % Proctosol HC (Rectal) 2

Hydrocortisone 2.5 % Proctozone-HC (Rectal) 2

FMCMPD 01-17 19




Nivel (Tier)

Inst

Hydrocortisone Acetate 25 mg Anucort-HC (Rectal) 2

Hydrocortisone Acetate 25 mg Anusol-HC (Rectal) 3

Hydrocortisone Acetate 25 mg, 30 mg Hydrocortisone Acetate (Rectal) 1

Hydrocortisone Acetate 30 mg Proctocort (Rectal) 3

ANTHELMINTICS (Antihelminticos)

Anthelmintics (Antihelminticos)

Albendazole 200 mg Albenza (Oral) 3

Ivermectin 3 mg Ivermectin (Oral) 2

Ivermectin 3 mg Stromectol (Oral) 3

Praziquantel 600 mg Biltricide (Oral) 3

ANTI-INFECTIVE AGENTS - MISC. (Agentes Antiinfectivos - Misc.)

Anti-infective Agents - Misc. (Agentes Antiinfectivos - Misc.)

Aztreonam 1 gm, 2 gm Azactam (Injection) 3

Aztreonam 1 gm, 2 gm Aztreonam (Injection) 1

Aztreonam In Dextrose 1 gm, 2 gm Azactam in Dextrose (Intravenous) 4 SP

Aztreonam Lysine 75 mg Cayston (Inhalation) 4 SP

Bacitracin 50000 unit BACiiM (Intramuscular) 2

Bacitracin 50000 unit Bacitracin (Intramuscular) 1

Colistimethate Sodium 150 mg Colistimethate Sodium (Injection) 1

Colistimethate Sodium 150 mg Coly-Mycin M (Injection) 3

Metronidazole 0.75 %, 1 %, 250 mg, 375 mg, 500 mg

MetroNIDAZOLE (Vaginal, External, Oral) 1

Metronidazole 250 mg, 375 mg, 500 mg Flagyl (Oral) 3

Metronidazole In Nacl 5-0.79 mg/ml-%, 500-0.79 mg/100ml-%

MetroNIDAZOLE in NaCl (Intravenous) 4 SP

Metronidazole In Nacl 500-0.74 mg/100ml-% Metro (Intravenous) 4 SP

Oritavancin Diphosphate 400 mg Orbactiv (Intravenous) 4 SP

Pentamidine Isethionate 300 mg Nebupent (Inhalation) 3

Pentamidine Isethionate 300 mg Pentam (Injection) 4 SP

Rifaximin 200 mg, 550 mg Xifaxan (Oral) 2

Telavancin Hcl 750 mg Vibativ (Intravenous) 4 SP

Tinidazole 250 mg, 500 mg Tinidazole (Oral) 1

Tinidazole 500 mg Tindamax (Oral) 3

Trimethoprim 100 mg Trimethoprim (Oral) 1

Trimethoprim Hcl 50 mg/5ml Primsol (Oral) 3

Vancomycin Hcl 125 mg, 250 mg Vancocin HCl (Oral) 3

FMCMPD 01-17 20




Nivel (Tier)

Inst

Vancomycin Hcl 125 mg, 250 mg Vancomycin HCl (Oral) 1

Anti-infective Misc. - Combinations (Antiinfectivos Misc. - Combinaciones)

Sulfamethoxazole-trimethoprim

200-40 mg/5ml, 400-80 mg, 800-160 mg

Sulfamethoxazole-Trimethoprim (Oral) 1

Sulfamethoxazole-trimethoprim 400-80 mg Bactrim (Oral) 3

Sulfamethoxazole-trimethoprim 400-80 mg/5ml Sulfamethoxazole-Trimethoprim (Intravenous) 4 SP

Sulfamethoxazole-trimethoprim 800-160 mg Bactrim DS (Oral) 3

Antiprotozoal Agents (Agentes Antiprotozoarios)

Atovaquone 750 mg/5ml Atovaquone (Oral) 1

Atovaquone 750 mg/5ml Mepron (Oral) 3

Nitazoxanide 100 mg/5ml, 500 mg Alinia (Oral) 3

Trimetrexate Glucuronate 25 mg Neutrexin (Intravenous) 4 SP

Carbapenems (Carbapenems)

Ertapenem Sodium 1 gm INVanz (Injection) 3

Meropenem 1 gm, 500 mg Meropenem (Intravenous) 4 SP

Meropenem 1 gm, 500 mg Merrem (Intravenous) 4 SP

Cyclic Lipopeptides (Ciclopeptidas Ciclicas)

Daptomycin 500 mg Cubicin (Intravenous) 4 SP

Daptomycin 500 mg DAPTOmycin (Intravenous) 4 SP

Glycylcyclines (Glicilciclinas)

Tigecycline 50 mg Tygacil (Intravenous) 4 SP

Leprostatics (Leprostaticos)

Dapsone 100 mg, 25 mg Dapsone (Oral) 3

Lincosamides (Lincosamidas)

Clindamycin Hcl 150 mg, 300 mg, 75 mg Cleocin (Oral) 3

Clindamycin Hcl 150 mg, 300 mg, 75 mg Clindamycin HCl (Oral) 1

Clindamycin Palmitate Hcl 75 mg/5ml Cleocin (Oral) 3

Clindamycin Palmitate Hcl 75 mg/5ml Clindamycin Palmitate HCl (Oral) 1

Clindamycin Phosphate

2 %, 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

Clindamycin Phosphate (Vaginal, Injection) 1

Clindamycin Phosphate 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml Cleocin Phosphate (Injection) 3

Lincomycin Hcl 300 mg/ml Lincocin (Injection) 3

Lincomycin Hcl 300 mg/ml Lincomycin HCl (Injection) 2

Oxazolidinones (Oazolidinonas)

Linezolid 100 mg/5ml Linezolid (Oral) 1

FMCMPD 01-17 21




Nivel (Tier)

Inst

Linezolid 100 mg/5ml, 600 mg Zyvox (Oral) 3

Linezolid 200 mg/100ml, 600 mg/300ml Zyvox (Intravenous) 4

PA SP

Linezolid 600 mg Linezolid (Oral) 2

Linezolid 600 mg/300ml Linezolid (Intravenous) 4 PA SP

Linezolid In Sodium Chloride 600-0.9 mg/300ml-% Linezolid in Sodium Chloride (Intravenous) 4

PA SP

Polymyxins (Polimixinas)

Polymyxin B Sulfate 500000 unit Polymyxin B Sulfate (Injection) 1

Streptogramins (Estreptograminas)

Quinupristin-dalfopristin 150-350 mg Synercid (Intravenous) 4 SP

ANTIANGINAL AGENTS (Agentes Antianginales)

Antianginals-other (Antianginales-Otros)

Ranolazine Er 1000 mg, 500 mg Ranexa (Oral) 2

Nitrates (Nitratos)

Isosorbide Dinitrate 10 mg, 20 mg, 30 mg, 5 mg Isosorbide Dinitrate (Oral) 1

Isosorbide Dinitrate 40 mg, 5 mg Isordil Titradose (Oral) 3

Isosorbide Dinitrate Er 40 mg Dilatrate-SR (Oral) 3

Isosorbide Dinitrate Er 40 mg Isosorbide Dinitrate ER (Oral) 1

Isosorbide Mononitrate 10 mg, 20 mg Isosorbide Mononitrate (Oral) 1

Isosorbide Mononitrate Er 120 mg, 30 mg, 60 mg Isosorbide Mononitrate ER (Oral) 1

Nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Minitran (Transdermal) 2

Nitroglycerin

0.1 mg/hr, 0.2 mg/hr, 0.3 mg/hr, 0.4 mg/hr, 0.6 mg/hr, 0.8 mg/hr Nitro-Dur (Transdermal) 3

Nitroglycerin

0.1 mg/hr, 0.2 mg/hr, 0.3 mg, 0.4 mg, 0.4 mg/hr, 0.6 mg, 0.6 mg/hr

Nitroglycerin (Transdermal, Sublingual) 1

Nitroglycerin 0.3 mg, 0.4 mg, 0.6 mg Nitrostat (Sublingual) 3

Nitroglycerin 2 % Nitro-Bid (Transdermal) 3

Nitroglycerin 5 mg/ml Nitroglycerin (Intravenous) 4 SP

Nitroglycerin Er 2.5 mg, 6.5 mg, 9 mg Nitro-Time (Oral) 2

Nitroglycerin Er 2.5 mg, 6.5 mg, 9 mg Nitroglycerin ER (Oral) 1

Nitroglycerin In D5w

100-5 mcg/ml-%, 200-5 mcg/ml-%, 400-5 mcg/ml-%

Nitroglycerin in D5W (Intravenous) 4 SP

ANTIANXIETY AGENTS (Agentes Contra La Ansiedad)

FMCMPD 01-17 22




Nivel (Tier)

Inst

Antianxiety Agents - Misc. (Agentes Contra La Ansiedad - Misc.)

Buspirone Hcl 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg BusPIRone HCl (Oral) 1

Droperidol 2.5 mg/ml Droperidol (Injection) 1

Hydroxyzine Hcl 10 mg, 10 mg/5ml, 25 mg, 50 mg HydrOXYzine HCl (Oral) 1

Hydroxyzine Pamoate 100 mg HydrOXYzine Pamoate (Oral) 3

Hydroxyzine Pamoate 25 mg, 50 mg HydrOXYzine Pamoate (Oral) 1

Hydroxyzine Pamoate 25 mg, 50 mg Vistaril (Oral) 3

Meprobamate 200 mg, 400 mg Meprobamate (Oral) 1

Benzodiazepines (Benzodiazepinas)

Alprazolam 0.25 mg, 0.5 mg, 1 mg, 2 mg ALPRAZolam (Oral) 1

Alprazolam 0.25 mg, 0.5 mg, 1 mg, 2 mg Xanax (Oral) 3

Alprazolam 1 mg/ml ALPRAZolam Intensol (Oral) 3

Alprazolam Er 0.5 mg, 1 mg, 2 mg, 3 mg ALPRAZolam ER (Oral) 1

Alprazolam Er 0.5 mg, 1 mg, 2 mg, 3 mg ALPRAZolam XR (Oral) 2

Alprazolam Er 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR (Oral) 3

Chlordiazepoxide Hcl 10 mg, 25 mg, 5 mg ChlordiazePOXIDE HCl (Oral) 1

Clorazepate Dipotassium 15 mg, 3.75 mg, 7.5 mg Clorazepate Dipotassium (Oral) 1

Clorazepate Dipotassium 7.5 mg Tranxene-T (Oral) 3

Diazepam 1 mg/ml, 10 mg, 2.5 mg, 20 mg, 5 mg/ml

Diazepam (Oral, Rectal, Injection) 2

Diazepam 10 mg, 2 mg, 5 mg Diazepam (Oral) 1

Diazepam 10 mg, 2 mg, 5 mg Valium (Oral) 3

Diazepam 10 mg/2ml DiazePAM (Intramuscular) 2

Diazepam 5 mg/ml Diazepam (Oral) 3

Diazepam 5 mg/ml Diazepam Intensol (Oral) 3

Lorazepam 0.5 mg, 1 mg, 2 mg, 2 mg/ml, 4 mg/ml Ativan (Oral, Injection) 3

Lorazepam 0.5 mg, 1 mg, 2 mg, 2 mg/ml, 4 mg/ml LORazepam (Oral, Injection) 1

Lorazepam 2 mg/ml LORazepam Intensol (Oral) 3

Oxazepam 10 mg, 15 mg, 30 mg Oxazepam (Oral) 1

ANTIARRHYTHMICS (Antiarritmicos)

Antiarrhythmics Type I-a (Antiarritmicos Tipo I-A)

Disopyramide Phosphate 100 mg, 150 mg Disopyramide Phosphate (Oral) 1

FMCMPD 01-17 23




Nivel (Tier)

Inst

Disopyramide Phosphate 100 mg, 150 mg Norpace (Oral) 3

Disopyramide Phosphate Er 100 mg, 150 mg Norpace CR (Oral) 3

Procainamide Hcl 100 mg/ml, 500 mg/ml Procainamide HCl (Injection) 3

Quinidine Gluconate 80 mg/ml QuiNIDine Gluconate (Injection) 3

Quinidine Gluconate Er 324 mg QuiNIDine Gluconate ER (Oral) 1

Quinidine Sulfate 200 mg, 300 mg QuiNIDine Sulfate (Oral) 1

Antiarrhythmics Type I-b (Antiarritmicos Tipo I-B)

Mexiletine Hcl 150 mg, 200 mg, 250 mg Mexiletine HCl (Oral) 1

Antiarrhythmics Type I-c (Antiarritmicos Tipo I-C)

Flecainide Acetate 100 mg, 150 mg, 50 mg Flecainide Acetate (Oral) 1

Propafenone Hcl 150 mg, 225 mg, 300 mg Propafenone HCl (Oral) 1

Propafenone Hcl Er 225 mg, 325 mg, 425 mg Propafenone HCl ER (Oral) 1

Propafenone Hcl Er 225 mg, 325 mg, 425 mg Rythmol SR (Oral) 3

Antiarrhythmics Type Iii (Antiarritmicos Tipo III)

Amiodarone Hcl 100 mg, 200 mg, 400 mg Amiodarone HCl (Oral) 1

Amiodarone Hcl 100 mg, 200 mg, 400 mg Pacerone (Oral) 2

Amiodarone Hcl 200 mg Cordarone (Oral) 3

Dofetilide 125 mcg, 250 mcg, 500 mcg Dofetilide (Oral) 2

Dofetilide 125 mcg, 250 mcg, 500 mcg Tikosyn (Oral) 3

Dronedarone Hcl 400 mg Multaq (Oral) 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS (Agentes Antiasmaticos Y Broncodilatadores)

Anti-inflammatory Agents (Agentes Antiinflamatorios)

Cromolyn Sodium 20 mg/2ml, 4 % Cromolyn Sodium (Inhalation, Ophthalmic) 1

Antiasthmatic - Monoclonal Antibodies (Anticuerpos Antiasmaticos Monoclonales)

Mepolizumab 100 mg Nucala (Subcutaneous) 4 PA SP

Reslizumab 100 mg/10ml Cinqair (Intravenous) 4 PA SP

Bronchodilators - Anticholinergics (Broncodilatadores - Anticolinergicos)

Aclidinium Bromide 400 mcg/act Tudorza Pressair (Inhalation) 2

Ipratropium Bromide 0.02 %, 0.03 %, 0.06 % Ipratropium Bromide (Inhalation, Nasal) 1

Ipratropium Bromide Hfa 17 mcg/act Atrovent HFA (Inhalation) 3 LC

Tiotropium Bromide Monohydrate 1.25 mcg/act Spiriva Respimat (Inhalation) 3 LC

Tiotropium Bromide Monohydrate 18 mcg Spiriva HandiHaler (Inhalation) 2 LC

FMCMPD 01-17 24




Nivel (Tier)

Inst

Tiotropium Bromide Monohydrate 2.5 mcg/act Spiriva Respimat (Inhalation) 2 LC

Leukotriene Modulators (Moduladores Leucotrienos)

Montelukast Sodium 10 mg, 4 mg, 5 mg Montelukast Sodium (Oral) 1

Montelukast Sodium 10 mg, 4 mg, 5 mg Singulair (Oral) 3

Zafirlukast 10 mg, 20 mg Zafirlukast (Oral) 1

Zileuton 600 mg Zyflo (Oral) 3

Zileuton Er 600 mg Zyflo CR (Oral) 3

Selective Phosphodiesterase 4 (pde4) Inhibitors (Inhibidores Selectivos De La Fosfodiesterasa (Pde4))

Roflumilast 500 mcg Daliresp (Oral) 2 PA

Steroid Inhalants (Inhalantes Esteroidales)

Beclomethasone Dipropionate 40 mcg/act, 80 mcg/act Qvar (Inhalation) 2 LC

Budesonide 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml, 3 mg Budesonide (Inhalation, Oral) 1 LC

Budesonide 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml Pulmicort (Inhalation) 3 LC

Budesonide 180 mcg/act, 90 mcg/act Pulmicort Flexhaler (Inhalation) 2

Ciclesonide 160 mcg/act, 80 mcg/act Alvesco (Inhalation) 3 LC

Fluticasone Propionate (inhal) 100 mcg/blist, 250 mcg/blist, 50 mcg/blist Flovent Diskus (Inhalation) 3 LC

Fluticasone Propionate Hfa 110 mcg/act, 220 mcg/act, 44 mcg/act Flovent HFA (Inhalation) 3 LC

Mometasone Furoate 110 mcg/inh Asmanex 7 Metered Doses (Inhalation) 2 LC

Mometasone Furoate 110 mcg/inh, 220 mcg/inh Asmanex 30 Metered Doses (Inhalation) 2 LC




Sympathomimetics (Simpatomimeticos)

Albuterol Sulfate

(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml, 2 mg, 2 mg/5ml, 4 mg

Albuterol Sulfate (Inhalation, Oral) 1

Albuterol Sulfate 108 (90 base) mcg/act ProAir RespiClick (Inhalation) 3 LC

Albuterol Sulfate Er 4 mg, 8 mg Albuterol Sulfate ER (Oral) 1

Albuterol Sulfate Er 4 mg, 8 mg VoSpire ER (Oral) 3

FMCMPD 01-17 25




Nivel (Tier)

Inst

Albuterol Sulfate Hfa 108 (90 base) mcg/act ProAir HFA (Inhalation) 2 LC

Albuterol Sulfate Hfa 108 (90 base) mcg/act Proventil HFA (Inhalation) 3 LC

Albuterol Sulfate Hfa 108 (90 base) mcg/act Ventolin HFA (Inhalation) 2

Arformoterol Tartrate 15 mcg/2ml Brovana (Inhalation) 3 LC

Budesonide-formoterol Fumarate

160-4.5 mcg/act, 80-4.5 mcg/act Symbicort (Inhalation) 2 LC

Epinephrine Hcl 1 mg/ml EPINEPHrine HCl (Injection) 1

Fluticasone Furoate-vilanterol 100-25 mcg/inh, 200-25 mcg/inh Breo Ellipta (Inhalation) 3 LC

Fluticasone-salmeterol

100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose Advair Diskus (Inhalation) 3 LC

Fluticasone-salmeterol 115-21 mcg/act, 230-21 mcg/act, 45-21 mcg/act Advair HFA (Inhalation) 3 LC

Formoterol Fumarate 20 mcg/2ml Perforomist (Inhalation) 2 LC

Indacaterol Maleate 75 mcg Arcapta Neohaler (Inhalation) 3

Ipratropium-albuterol 0.5-2.5 (3) mg/3ml Ipratropium-Albuterol (Inhalation) 1

Ipratropium-albuterol 20-100 mcg/act Combivent Respimat (Inhalation) 2

Isoproterenol Hcl 0.2 mg/ml Isuprel (Injection) 3

Levalbuterol Hcl

0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml Levalbuterol HCl (Inhalation) 1

Levalbuterol Tartrate 45 mcg/act Xopenex HFA (Inhalation) 3 LC

Metaproterenol Sulfate 10 mg, 10 mg/5ml, 20 mg Metaproterenol Sulfate (Oral) 3

Mometasone Furo-formoterol Fum

100-5 mcg/act, 200-5 mcg/act Dulera (Inhalation) 2

Salmeterol Xinafoate 50 mcg/dose Serevent Diskus (Inhalation) 2 LC

Terbutaline Sulfate 2.5 mg, 5 mg Terbutaline Sulfate (Oral) 1

Umeclidinium-vilanterol 62.5-25 mcg/inh Anoro Ellipta (Inhalation) 3 LC

Xanthines (Xantinas)

Aminophylline 25 mg/ml Aminophylline (Intravenous) 4 SP

Theophylline 80 mg/15ml Elixophyllin (Oral) 3

Theophylline 80 mg/15ml Theophylline (Oral) 1

Theophylline Er 100 mg, 200 mg, 300 mg Theochron (Oral) 2

Theophylline Er 100 mg, 200 mg, 300 mg, 400 mg Theo-24 (Oral) 3

Theophylline Er 100 mg, 200 mg, 300 mg, 400 mg, 450 mg, 600 mg Theophylline ER (Oral) 1

FMCMPD 01-17 26




Nivel (Tier)

Inst

Theophylline In D5w 0.8-5 mg/ml-% Theophylline in D5W (Intravenous) 4 SP

ANTICOAGULANTS (Anticoagulantes)

Coumarin Anticoagulants (Anticoagulantes De Cumarina)

Warfarin Sodium

1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Coumadin (Oral) 3

Warfarin Sodium

1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Jantoven (Oral) 2

Warfarin Sodium

1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Warfarin Sodium (Oral) 1

Direct Factor Xa Inhibitors (Inhibidores De Factor Directo XA)

Apixaban 2.5 mg, 5 mg Eliquis (Oral) 3 LC

Rivaroxaban 10 mg, 15 mg, 20 mg Xarelto (Oral) 2 LC

Rivaroxaban 15 & 20 mg Xarelto Starter Pack (Oral) 2 LC

Heparins And Heparinoid-like Agents (Heparinas y Agentes Similares a Heparinoides)

Dalteparin Sodium

10000 unit/ml, 12500 unit/0.5ml, 15000 unit/0.6ml, 18000 unt/0.72ml, 2500 unit/0.2ml, 5000 unit/0.2ml Fragmin (Subcutaneous) 2

PA SP

Dalteparin Sodium 7500 unit/0.3ml, 95000 unit/3.8ml Fragmin (Subcutaneous) 4

PA SP

Enoxaparin Sodium

100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Enoxaparin Sodium (Subcutaneous) 1 PA

Enoxaparin Sodium

100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml Lovenox (Subcutaneous) 3 PA

Enoxaparin Sodium 300 mg/3ml Enoxaparin Sodium (Injection) 1 PA SP

Enoxaparin Sodium 300 mg/3ml Lovenox (Injection) 3 PA SP

Fondaparinux Sodium 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml Arixtra (Subcutaneous) 3

PA SP

Fondaparinux Sodium 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Fondaparinux Sodium (Subcutaneous) 1

PA SP

FMCMPD 01-17 27




Nivel (Tier)

Inst

Thrombin Inhibitors (Inhibidores de Trombina)

Dabigatran Etexilate Mesylate 110 mg, 150 mg, 75 mg Pradaxa (Oral) 2 LC

ANTICONVULSANTS (Anticonvulsivos)

Anticonvulsants - Benzodiazepines (Anticonvulsivos - Benzodiacepinas)

Clobazam 10 mg, 2.5 mg/ml, 20 mg Onfi (Oral) 3

Clonazepam 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg ClonazePAM (Oral) 1

Clonazepam 0.5 mg, 1 mg, 2 mg KlonoPIN (Oral) 3

Diazepam 1 mg/ml, 10 mg, 2.5 mg, 20 mg, 5 mg/ml

Diazepam (Oral, Rectal, Injection) 2

Diazepam 10 mg, 20 mg Diastat AcuDial (Rectal) 3

Diazepam 2.5 mg Diastat Pediatric (Rectal) 3

Anticonvulsants - Misc. (Anticonvulsivos - Misc.)

Carbamazepine 100 mg, 100 mg/5ml, 200 mg CarBAMazepine (Oral) 1

Carbamazepine 100 mg/5ml, 200 mg TEGretol (Oral) 3

Carbamazepine 200 mg Epitol (Oral) 2

Carbamazepine Er 100 mg, 200 mg, 300 mg Carbatrol (Oral) 3

Carbamazepine Er 100 mg, 200 mg, 300 mg, 400 mg CarBAMazepine ER (Oral) 1

Carbamazepine Er 100 mg, 200 mg, 400 mg TEGretol-XR (Oral) 3

Eslicarbazepine Acetate 200 mg, 400 mg, 600 mg, 800 mg Aptiom (Oral) 3

Ezogabine 200 mg, 300 mg, 400 mg, 50 mg Potiga (Oral) 3

Gabapentin

100 mg, 250 mg/5ml, 300 mg, 400 mg, 600 mg, 800 mg Gabapentin (Oral) 1

Gabapentin

100 mg, 250 mg/5ml, 300 mg, 400 mg, 600 mg, 800 mg Neurontin (Oral) 3

Lacosamide 10 mg/ml, 100 mg, 150 mg, 200 mg, 50 mg Vimpat (Oral) 2

Lacosamide 200 mg/20ml Vimpat (Intravenous) 4 SP

Lamotrigine 100 mg, 150 mg, 200 mg, 25 mg, 5 mg LaMICtal (Oral) 3

Lamotrigine

100 mg, 150 mg, 200 mg, 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 25 mg, 5 mg, 50 (42)-100(14) mg LamoTRIgine (Oral) 1

FMCMPD 01-17 28




Nivel (Tier)

Inst

Lamotrigine

100 mg, 200 mg, 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 25 mg, 50 (42)-100(14) mg, 50 mg LaMICtal ODT (Oral) 3

Lamotrigine 100 mg, 200 mg, 25 mg, 50 mg LamoTRIgine (Oral) 2

Lamotrigine 25 (35) mg, 25 (42)-100 (7) mg, 25 (84)-100(14) mg LaMICtal Starter (Oral) 3

Lamotrigine Er

100 mg, 200 mg, 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 25 mg, 250 mg, 300 mg, 50 & 100 & 200 mg, 50 mg LaMICtal XR (Oral) 3

Lamotrigine Er 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg LamoTRIgine ER (Oral) 1

Levetiracetam 100 mg/ml, 1000 mg, 250 mg, 500 mg, 750 mg Keppra (Oral) 3

Levetiracetam 100 mg/ml, 1000 mg, 250 mg, 500 mg, 750 mg LevETIRAcetam (Oral) 1

Levetiracetam 500 mg/5ml Keppra (Intravenous) 4 SP

Levetiracetam 500 mg/5ml LevETIRAcetam (Intravenous) 4 SP

Levetiracetam Er 500 mg, 750 mg Keppra XR (Oral) 3

Levetiracetam Er 500 mg, 750 mg LevETIRAcetam ER (Oral) 1

Levetiracetam In Nacl 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

Levetiracetam in NaCl (Intravenous) 4 SP

Oxcarbazepine 150 mg, 300 mg, 300 mg/5ml, 600 mg OXcarbazepine (Oral) 1

Oxcarbazepine 150 mg, 300 mg, 300 mg/5ml, 600 mg Trileptal (Oral) 3

Oxcarbazepine Er 150 mg, 300 mg, 600 mg Oxtellar XR (Oral) 3

Pregabalin

100 mg, 150 mg, 20 mg/ml, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg Lyrica (Oral) 2

Primidone 250 mg, 50 mg Mysoline (Oral) 3

Primidone 250 mg, 50 mg Primidone (Oral) 1

Rufinamide 200 mg, 40 mg/ml, 400 mg Banzel (Oral) 3

Topiramate 100 mg, 15 mg, 200 mg, 25 mg, 50 mg Topiramate (Oral) 1

Topiramate 100 mg, 200 mg, 25 mg, 50 mg Topamax (Oral) 3

Topiramate 15 mg, 25 mg Topamax Sprinkle (Oral) 3

FMCMPD 01-17 29




Nivel (Tier)

Inst

Topiramate Er 100 mg, 200 mg, 25 mg, 50 mg Trokendi XR (Oral) 3

Zonisamide 100 mg, 25 mg Zonegran (Oral) 3

Zonisamide 100 mg, 25 mg, 50 mg Zonisamide (Oral) 1

Carbamates (Carbamatos)

Felbamate 400 mg, 600 mg, 600 mg/5ml Felbamate (Oral) 1

Felbamate 400 mg, 600 mg, 600 mg/5ml Felbatol (Oral) 3

Gaba Modulators (Moduladores Gaba)

Tiagabine Hcl 12 mg, 16 mg, 2 mg, 4 mg Gabitril (Oral) 3

Tiagabine Hcl 2 mg, 4 mg TiaGABine HCl (Oral) 1

Vigabatrin 500 mg Sabril (Oral) 4 SP

Hydantoins (Hidantoinas)

Ethotoin 250 mg Peganone (Oral) 3

Fosphenytoin Sodium 100 mg pe/2ml, 500 mg pe/10ml Cerebyx (Injection) 3

Fosphenytoin Sodium 100 mg pe/2ml, 500 mg pe/10ml Fosphenytoin Sodium (Injection) 1

Phenytoin 125 mg/5ml Dilantin (Oral) 3

Phenytoin 125 mg/5ml, 50 mg Phenytoin (Oral) 1

Phenytoin 50 mg Dilantin Infatabs (Oral) 3

Phenytoin 50 mg Phenytoin Infatabs (Oral) 2

Phenytoin Sodium 50 mg/ml Phenytoin Sodium (Injection) 1

Phenytoin Sodium Extended 100 mg Phenytoin Sodium Extended (Oral) 1

Phenytoin Sodium Extended 100 mg, 30 mg Dilantin (Oral) 3

Phenytoin Sodium Extended 200 mg, 300 mg Phenytek (Oral) 3

Succinimides (Succinimidas)

Ethosuximide 250 mg, 250 mg/5ml Ethosuximide (Oral) 1

Ethosuximide 250 mg, 250 mg/5ml Zarontin (Oral) 3

Methsuximide 300 mg Celontin (Oral) 3

Valproic Acid (Acido Valproico)

Divalproex Sodium 125 mg Depakote Sprinkles (Oral) 3

Divalproex Sodium 125 mg, 250 mg, 500 mg Depakote (Oral) 3

Divalproex Sodium 125 mg, 250 mg, 500 mg Divalproex Sodium (Oral) 1

Divalproex Sodium Er 250 mg, 500 mg Depakote ER (Oral) 3

Divalproex Sodium Er 250 mg, 500 mg Divalproex Sodium ER (Oral) 1

Valproate Sodium 100 mg/ml Depacon (Intravenous) 4 SP

FMCMPD 01-17 30




Nivel (Tier)

Inst

Valproate Sodium 100 mg/ml, 500 mg/5ml Valproate Sodium (Intravenous) 4 SP

Valproate Sodium 250 mg/5ml Depakene (Oral) 3

Valproate Sodium 250 mg/5ml Valproate Sodium (Oral) 1

Valproate Sodium 250 mg/5ml Valproic Acid (Oral) 1

Valproic Acid 250 mg Depakene (Oral) 3

Valproic Acid 250 mg Valproic Acid (Oral) 1

ANTIDEPRESSANTS (Antidepresivos)

Alpha-2 Receptor Antagonists (tetracyclics) (Antagonistas De Receptores Alfa-2 (Tetraciclicos))

Mirtazapine 15 mg, 30 mg, 45 mg Remeron (Oral) 3

Mirtazapine 15 mg, 30 mg, 45 mg Remeron SolTab (Oral) 3

Mirtazapine 15 mg, 30 mg, 45 mg, 7.5 mg Mirtazapine (Oral) 1

Antidepressants - Misc. (Antidepresivos - Misc.)

Bupropion Hbr Er 174 mg, 348 mg, 522 mg Aplenzin (Oral) 3 LC

Bupropion Hcl 100 mg, 75 mg BuPROPion HCl (Oral) 1

Bupropion Hcl Er (sr) 100 mg, 150 mg, 200 mg BuPROPion HCl ER (SR) (Oral) 1 LC

Bupropion Hcl Er (sr) 100 mg, 150 mg, 200 mg Wellbutrin SR (Oral) 3 LC

Bupropion Hcl Er (xl) 150 mg, 300 mg BuPROPion HCl ER (XL) (Oral) 1 LC

Bupropion Hcl Er (xl) 150 mg, 300 mg Wellbutrin XL (Oral) 3 LC

Bupropion Hcl Er (xl) 450 mg Forfivo XL (Oral) 3 LC

Maprotiline Hcl 25 mg, 50 mg, 75 mg Maprotiline HCl (Oral) 3

Monoamine Oxidase Inhibitors (maois) (Inhibidores De Monoamina Oxidasa (IMAO))

Isocarboxazid 10 mg Marplan (Oral) 3

Phenelzine Sulfate 15 mg Nardil (Oral) 3

Phenelzine Sulfate 15 mg Phenelzine Sulfate (Oral) 1

Selegiline 12 mg/24hr, 6 mg/24hr, 9 mg/24hr Emsam (Transdermal) 3

Tranylcypromine Sulfate 10 mg Parnate (Oral) 3

Tranylcypromine Sulfate 10 mg Tranylcypromine Sulfate (Oral) 1

Selective Serotonin Reuptake Inhibitors (ssris) (Inhibidores Selectivos de la Recaptación de Serotonina (SSRIs ))

Citalopram Hydrobromide 10 mg, 10 mg/5ml, 20 mg, 40 mg Citalopram Hydrobromide (Oral) 1 LC

Citalopram Hydrobromide 10 mg, 20 mg, 40 mg CeleXA (Oral) 3 LC

Escitalopram Oxalate 10 mg, 20 mg, 5 mg, 5 mg/5ml Escitalopram Oxalate (Oral) 1 LC

FMCMPD 01-17 31




Nivel (Tier)

Inst

Escitalopram Oxalate 10 mg, 20 mg, 5 mg, 5 mg/5ml Lexapro (Oral) 3 LC

Fluoxetine Hcl 10 mg, 20 mg, 20 mg/5ml, 40 mg, 90 mg FLUoxetine HCl (Oral) 1 LC

Fluoxetine Hcl 10 mg, 20 mg, 40 mg PROzac (Oral) 3 LC

Fluoxetine Hcl 60 mg FLUoxetine HCl (Oral) 3

Fluoxetine Hcl 90 mg PROzac Weekly (Oral) 3 LC

Fluvoxamine Maleate 100 mg, 25 mg, 50 mg FluvoxaMINE Maleate (Oral) 1 LC

Fluvoxamine Maleate Er 100 mg, 150 mg FluvoxaMINE Maleate ER (Oral) 1 LC

Paroxetine Hcl 10 mg, 10 mg/5ml, 20 mg, 30 mg, 40 mg Paxil (Oral) 3 LC

Paroxetine Hcl 10 mg, 20 mg, 30 mg, 40 mg PARoxetine HCl (Oral) 1 LC

Paroxetine Hcl Er 12.5 mg, 25 mg, 37.5 mg PARoxetine HCl ER (Oral) 1 LC

Paroxetine Hcl Er 12.5 mg, 25 mg, 37.5 mg Paxil CR (Oral) 3 LC

Paroxetine Mesylate 10 mg, 20 mg, 30 mg, 40 mg Pexeva (Oral) 3 LC

Sertraline Hcl 100 mg, 20 mg/ml, 25 mg, 50 mg Sertraline HCl (Oral) 1 LC

Sertraline Hcl 100 mg, 20 mg/ml, 25 mg, 50 mg Zoloft (Oral) 3 LC

Serotonin Modulators (Moduladores De Serotonina)

Nefazodone Hcl 100 mg, 150 mg, 200 mg, 50 mg Nefazodone HCl (Oral) 3

Nefazodone Hcl 250 mg Nefazodone HCl (Oral) 1

Trazodone Hcl 100 mg, 150 mg, 300 mg, 50 mg TraZODone HCl (Oral) 1

Vilazodone Hcl 10 & 20 mg Viibryd Starter Pack (Oral) 2 LC

Vilazodone Hcl 10 mg, 20 mg, 40 mg Viibryd (Oral) 2 LC

Serotonin-norepinephrine Reuptake Inhibitors (snris) (Inhibidores Selectivos de la Recaptacion de Serotonina y Norepine)

Desvenlafaxine Er 100 mg, 50 mg Desvenlafaxine ER (Oral) 3 LC

Desvenlafaxine Succinate Er 100 mg, 25 mg, 50 mg Pristiq (Oral) 2 LC

Duloxetine Hcl 20 mg, 30 mg, 60 mg Cymbalta (Oral) 3 LC

Duloxetine Hcl 20 mg, 30 mg, 60 mg DULoxetine HCl (Oral) 1 LC

Venlafaxine Hcl 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg Venlafaxine HCl (Oral) 1 LC

Venlafaxine Hcl Er 150 mg, 37.5 mg, 75 mg Effexor XR (Oral) 3 LC

Venlafaxine Hcl Er 150 mg, 37.5 mg, 75 mg Venlafaxine HCl ER (Oral) 1 LC

FMCMPD 01-17 32




Nivel (Tier)

Inst

Venlafaxine Hcl Er 225 mg Venlafaxine HCl ER (Oral) 3 LC

Tricyclic Agents (Agentes Triciclicos)

Amitriptyline Hcl 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg Amitriptyline HCl (Oral) 1

Amoxapine 100 mg, 150 mg, 25 mg, 50 mg Amoxapine (Oral) 3

Clomipramine Hcl 25 mg, 50 mg, 75 mg Anafranil (Oral) 3

Clomipramine Hcl 25 mg, 50 mg, 75 mg ClomiPRAMINE HCl (Oral) 1

Desipramine Hcl 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg Desipramine HCl (Oral) 1

Doxepin Hcl 10 mg, 10 mg/ml, 100 mg, 150 mg, 25 mg, 50 mg Doxepin HCl (Oral) 1

Doxepin Hcl 75 mg Doxepin HCl (Oral) 3

Imipramine Hcl 10 mg, 25 mg, 50 mg Imipramine HCl (Oral) 1

Imipramine Hcl 10 mg, 25 mg, 50 mg Tofranil (Oral) 3

Imipramine Pamoate 100 mg, 125 mg, 150 mg, 75 mg Imipramine Pamoate (Oral) 1

Nortriptyline Hcl 10 mg, 25 mg, 50 mg, 75 mg Nortriptyline HCl (Oral) 1

Nortriptyline Hcl 10 mg, 25 mg, 50 mg, 75 mg Pamelor (Oral) 3

Nortriptyline Hcl 10 mg/5ml Nortriptyline HCl (Oral) 3

Protriptyline Hcl 10 mg, 5 mg Protriptyline HCl (Oral) 1

Trimipramine Maleate 100 mg, 25 mg, 50 mg Surmontil (Oral) 3

ANTIDIABETICS (Antidiabeticos)

Alpha-glucosidase Inhibitors (Inhibidores De Alfa-Glocosidasa)

Acarbose 100 mg, 25 mg, 50 mg Acarbose (Oral) 1

Acarbose 100 mg, 25 mg, 50 mg Precose (Oral) 3

Miglitol 100 mg, 25 mg, 50 mg Glyset (Oral) 3

Miglitol 100 mg, 25 mg, 50 mg Miglitol (Oral) 1

Antidiabetic - Amylin Analogs (Antidiabeticos - Analogos de Amilina)

Pramlintide Acetate 1500 mcg/1.5ml SymlinPen 60 (Subcutaneous) 2

Pramlintide Acetate 2700 mcg/2.7ml SymlinPen 120 (Subcutaneous) 2

Antidiabetic Combinations (Combinaciones Contra La Diabetes)

Alogliptin-metformin Hcl 12.5-1000 mg, 12.5-500 mg Kazano (Oral) 3

Alogliptin-pioglitazone

12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg Oseni (Oral) 3

FMCMPD 01-17 33




Nivel (Tier)

Inst

Dapagliflozin-metformin Hcl Er 10-1000 mg, 10-500 mg, 5-1000 mg, 5-500 mg Xigduo XR (Oral) 3 LC

Empagliflozin-linagliptin 10-5 mg, 25-5 mg Glyxambi (Oral) 3 LC

Empagliflozin-metformin Hcl 12.5-1000 mg, 12.5-500 mg, 5-1000 mg, 5-500 mg Synjardy (Oral) 3 LC

Glipizide-metformin Hcl 2.5-250 mg, 2.5-500 mg, 5-500 mg

GlipiZIDE-MetFORMIN HCl (Oral) 1

Glyburide-metformin 1.25-250 mg, 2.5-500 mg, 5-500 mg GlyBURIDE-MetFORMIN (Oral) 1

Glyburide-metformin 2.5-500 mg, 5-500 mg Glucovance (Oral) 3

Linagliptin-metformin Hcl 2.5-1000 mg, 2.5-500 mg, 2.5-850 mg Jentadueto (Oral) 3

Linagliptin-metformin Hcl Er 2.5-1000 mg, 5-1000 mg Jentadueto XR (Oral) 3

Pioglitazone Hcl-glimepiride 30-2 mg, 30-4 mg Duetact (Oral) 3

Pioglitazone Hcl-glimepiride 30-2 mg, 30-4 mg Pioglitazone HCl-Glimepiride (Oral) 1

Pioglitazone Hcl-metformin Er 15-1000 mg, 30-1000 mg Actoplus met XR (Oral) 3

Pioglitazone Hcl-metformin Hcl 15-500 mg, 15-850 mg Actoplus Met (Oral) 3

Pioglitazone Hcl-metformin Hcl 15-500 mg, 15-850 mg

Pioglitazone HCl-Metformin HCl (Oral) 1

Repaglinide-metformin Hcl 1-500 mg, 2-500 mg Repaglinide-Metformin HCl (Oral) 1

Saxagliptin-metformin Er 2.5-1000 mg, 5-1000 mg, 5-500 mg Kombiglyze XR (Oral) 2

Sitagliptin-metformin Hcl 50-1000 mg, 50-500 mg Janumet (Oral) 2

Sitagliptin-metformin Hcl Er 100-1000 mg, 50-1000 mg, 50-500 mg Janumet XR (Oral) 2

Biguanides (Biguanidas)

Metformin Hcl 1000 mg, 500 mg, 850 mg Glucophage (Oral) 3

Metformin Hcl 1000 mg, 500 mg, 850 mg MetFORMIN HCl (Oral) 1

Metformin Hcl 500 mg/5ml Riomet (Oral) 2

Metformin Hcl Er 500 mg, 750 mg Glucophage XR (Oral) 3

Metformin Hcl Er 500 mg, 750 mg MetFORMIN HCl ER (Oral) 1

Metformin Hcl Er (mod) 1000 mg, 500 mg Glumetza (Oral) 3

Metformin Hcl Er (mod) 1000 mg, 500 mg MetFORMIN HCl ER (MOD) (Oral) 2

Metformin Hcl Er (osm) 1000 mg, 500 mg Fortamet (Oral) 3

Metformin Hcl Er (osm) 1000 mg, 500 mg MetFORMIN HCl ER (OSM) (Oral) 1

Diabetic Other (Diabetes - Otros)

FMCMPD 01-17 34




Nivel (Tier)

Inst

Diazoxide 50 mg/ml Proglycem (Oral) 3

Glucagon (rdna) 1 mg Glucagon Emergency (Injection) 2 LC

Glucagon Hcl (rdna) 1 mg GlucaGen HypoKit (Injection) 3 LC

Mifepristone 300 mg Korlym (Oral) 4 SP

Dipeptidyl Peptidase-4 (dpp-4) Inhibitors (Inhibidores De Dipeptidil Peptidasa-4 (DPP-4))

Alogliptin Benzoate 12.5 mg, 25 mg, 6.25 mg Nesina (Oral) 3

Linagliptin 5 mg Tradjenta (Oral) 3

Saxagliptin Hcl 2.5 mg, 5 mg Onglyza (Oral) 2

Sitagliptin Phosphate 100 mg, 25 mg, 50 mg Januvia (Oral) 2

Dopamine Receptor Agonists - Antidiabetic (Agonistas Receptores de Dopamina - Antidiabeticos)

Bromocriptine Mesylate 0.8 mg Cycloset (Oral) 3

Incretin Mimetic Agents (glp-1 Receptor Agonists) (Agentes Miméticos de Incretina (Agonistas del Receptor GLP-1))

Dulaglutide 0.75 mg/0.5ml, 1.5 mg/0.5ml Trulicity (Subcutaneous) 3

Exenatide 10 mcg/0.04ml Byetta 10 MCG Pen (Subcutaneous) 2

Exenatide 5 mcg/0.02ml Byetta 5 MCG Pen (Subcutaneous) 2

Exenatide Er 2 mg Bydureon (Subcutaneous) 2

Liraglutide 18 mg/3ml Victoza (Subcutaneous) 3 LC

Insulin (Insulina)

Insulin Aspart 100 unit/ml NovoLOG (Subcutaneous) 3

Insulin Aspart 100 unit/ml NovoLOG FlexPen (Subcutaneous) 3

Insulin Aspart 100 unit/ml NovoLOG PenFill (Subcutaneous) 3

Insulin Aspart Prot & Aspart (70-30) 100 unit/ml NovoLOG Mix 70/30 (Subcutaneous) 3

Insulin Aspart Prot & Aspart (70-30) 100 unit/ml NovoLOG Mix 70/30 FlexPen (Subcutaneous) 3

Insulin Degludec 100 unit/ml, 200 unit/ml Tresiba FlexTouch (Subcutaneous) 3 PA

Insulin Detemir 100 unit/ml Levemir (Subcutaneous) 2

Insulin Detemir 100 unit/ml Levemir FlexTouch (Subcutaneous) 2

Insulin Glargine 100 unit/ml Lantus (Subcutaneous) 2

Insulin Glargine 100 unit/ml Lantus SoloStar (Subcutaneous) 2

FMCMPD 01-17 35




Nivel (Tier)

Inst

Insulin Glargine 300 unit/ml Toujeo SoloStar (Subcutaneous) 3

Insulin Glulisine 100 unit/ml Apidra (Injection) 3

Insulin Glulisine 100 unit/ml Apidra SoloStar (Subcutaneous) 3

Insulin Lispro 100 unit/ml HumaLOG (Subcutaneous) 2

Insulin Lispro 100 unit/ml HumaLOG KwikPen (Subcutaneous) 2

Insulin Lispro Prot & Lispro (50-50) 100 unit/ml HumaLOG Mix 50/50 (Subcutaneous) 2

Insulin Lispro Prot & Lispro (50-50) 100 unit/ml HumaLOG Mix 50/50 KwikPen (Subcutaneous) 2

Insulin Lispro Prot & Lispro (75-25) 100 unit/ml HumaLOG Mix 75/25 (Subcutaneous) 2

Insulin Lispro Prot & Lispro (75-25) 100 unit/ml HumaLOG Mix 75/25 KwikPen (Subcutaneous) 2

Insulin Nph (human) (isophane) 100 unit/ml HumuLIN N (Subcutaneous) 2

Insulin Nph (human) (isophane) 100 unit/ml HumuLIN N KwikPen (Subcutaneous) 2

Insulin Nph (human) (isophane) 100 unit/ml NovoLIN N (Subcutaneous) 3

Insulin Nph (human) (isophane) 100 unit/ml NovoLIN N ReliOn (Subcutaneous) 3

Insulin Nph Isophane & Regular (70-30) 100 unit/ml HumuLIN 70/30 (Subcutaneous) 2

Insulin Nph Isophane & Regular (70-30) 100 unit/ml HumuLIN 70/30 KwikPen (Subcutaneous) 2

Insulin Nph Isophane & Regular (70-30) 100 unit/ml NovoLIN 70/30 (Subcutaneous) 3

Insulin Nph Isophane & Regular (70-30) 100 unit/ml NovoLIN 70/30 ReliOn (Subcutaneous) 3

Insulin Regular Human 100 unit/ml HumuLIN R (Injection) 2

Insulin Regular Human 100 unit/ml NovoLIN R (Injection) 3

Insulin Regular Human 100 unit/ml NovoLIN R ReliOn (Injection) 3

Insulin Regular Human (conc) 500 unit/ml

HumuLIN R U-500 (CONCENTRATED) (Subcutaneous) 2

Insulin Regular Human (conc) 500 unit/ml HumuLIN R U-500 KwikPen (Subcutaneous) 2

Insulin Sensitizing Agents (Agentes Sensibilizadores De Insulina)

Pioglitazone Hcl 15 mg, 30 mg, 45 mg Actos (Oral) 3

Pioglitazone Hcl 15 mg, 30 mg, 45 mg Pioglitazone HCl (Oral) 1

FMCMPD 01-17 36




Nivel (Tier)

Inst

Rosiglitazone Maleate 2 mg, 4 mg Avandia (Oral) 3

Meglitinide Analogues (Analogos De Meglitinida)

Nateglinide 120 mg, 60 mg Nateglinide (Oral) 1

Nateglinide 120 mg, 60 mg Starlix (Oral) 3

Repaglinide 0.5 mg, 1 mg, 2 mg Prandin (Oral) 3

Repaglinide 0.5 mg, 1 mg, 2 mg Repaglinide (Oral) 1

Sodium-glucose Co-transporter 2 (sglt2) Inhibitors (Inhibidores de SGLT2)

Canagliflozin 100 mg, 300 mg Invokana (Oral) 3 LC

Dapagliflozin Propanediol 10 mg, 5 mg Farxiga (Oral) 3 LC

Empagliflozin 10 mg, 25 mg Jardiance (Oral) 3 LC

Sulfonylureas (Sulfonilureas)

Chlorpropamide 100 mg, 250 mg ChlorproPAMIDE (Oral) 3

Glimepiride 1 mg, 2 mg, 4 mg Amaryl (Oral) 3

Glimepiride 1 mg, 2 mg, 4 mg Glimepiride (Oral) 1

Glipizide 10 mg, 5 mg GlipiZIDE (Oral) 1

Glipizide 10 mg, 5 mg Glucotrol (Oral) 3

Glipizide Er 10 mg, 2.5 mg, 5 mg GlipiZIDE ER (Oral) 1

Glipizide Er 10 mg, 2.5 mg, 5 mg GlipiZIDE XL (Oral) 2

Glipizide Er 10 mg, 2.5 mg, 5 mg Glucotrol XL (Oral) 3

Glyburide 1.25 mg, 2.5 mg, 5 mg GlyBURIDE (Oral) 1

Glyburide Micronized 1.5 mg, 3 mg, 6 mg GlyBURIDE Micronized (Oral) 1

Glyburide Micronized 1.5 mg, 3 mg, 6 mg Glynase (Oral) 3

Tolazamide 250 mg TOLAZamide (Oral) 1

Tolazamide 500 mg TOLAZamide (Oral) 3

Tolbutamide 500 mg TOLBUTamide (Oral) 3

ANTIDIARRHEALS (Antidiarreicos)

Antiperistaltic Agents (Agentes Antiperistalticos)

Diphenoxylate-atropine 2.5-0.025 mg Diphenoxylate-Atropine (Oral) 1

Diphenoxylate-atropine 2.5-0.025 mg Lofene (Oral) 2

Diphenoxylate-atropine 2.5-0.025 mg Lomotil (Oral) 3

Diphenoxylate-atropine 2.5-0.025 mg/5ml Diphenoxylate-Atropine (Oral) 3

Loperamide Hcl 2 mg Loperamide HCl (Oral) 1

ANTIDOTES AND SPECIFIC ANTAGONISTS (Antidotos y Antagonistas Especificos)

Antidotes - Chelating Agents (Antidotos - Agentes Quelantes)

Deferasirox 125 mg, 250 mg, 500 mg Exjade (Oral) 4 PA SP

Succimer 100 mg Chemet (Oral) 3

Antidotes And Specific Antagonists (Antidotos y Antagonistas Especificos)

FMCMPD 01-17 37




Nivel (Tier)

Inst

Uridine Triacetate 10 gm Vistogard (Oral) 4 PA SP

Opioid Antagonists (Antagonistas Opioides)

Naloxone Hcl 0.4 mg/0.4ml Evzio (Injection) 3

Naloxone Hcl 0.4 mg/ml, 2 mg/2ml Naloxone HCl (Injection) 1

Naltrexone 380 mg Vivitrol (Intramuscular) 4 SP

Naltrexone Hcl 50 mg Naltrexone HCl (Oral) 1

ANTIEMETICS (Antiemeticos)

5-ht3 Receptor Antagonists (Antagonistas De Receptores 5-Ht3)

Granisetron 3.1 mg/24hr Sancuso (Transdermal) 2 LC

Granisetron Hcl 1 mg Granisetron HCl (Oral) 1 LC

Ondansetron 4 mg, 8 mg Ondansetron (Oral) 1 LC

Ondansetron 4 mg, 8 mg Zuplenz (Oral) 3

Ondansetron Hcl 24 mg, 4 mg, 4 mg/2ml, 4 mg/5ml, 40 mg/20ml, 8 mg

Ondansetron HCl (Oral, Injection) 1 LC

Ondansetron Hcl 8 mg Zofran (Oral) 3 LC

Antiemetics - Anticholinergic (Antiemeticos - Anticolinergicos)

Meclizine Hcl 12.5 mg, 25 mg Meclizine HCl (Oral) 1

Scopolamine 1 mg/3days Transderm-Scop (1.5 MG) (Transdermal) 3

Trimethobenzamide Hcl 100 mg/ml, 300 mg Tigan (Intramuscular, Oral) 3

Trimethobenzamide Hcl 300 mg Trimethobenzamide HCl (Oral) 1

Antiemetics - Miscellaneous (Antiemeticos - Miscelaneos)

Dronabinol 10 mg, 2.5 mg, 5 mg Dronabinol (Oral) 1

Dronabinol 10 mg, 2.5 mg, 5 mg Marinol (Oral) 3

Nabilone 1 mg Cesamet (Oral) 3

Substance P/neurokinin 1 (nk1) Receptor Antagonists (Antagonistas del Receptor de NK1)

Aprepitant 125 mg, 40 mg, 80 mg Emend (Oral) 3 LC

Aprepitant Oral 80 & 125 mg Emend (Miscellaneous) 3 LC

Fosaprepitant Dimeglumine 150 mg Emend (Intravenous) 4 SP

ANTIFUNGALS (Antifungales)

Antifungal - Glucan Synthesis Inhibitors (echinocandins) (Antifungales- Inhibidores De La Sintesis De Glucano (equinocandin)

Anidulafungin 100 mg, 50 mg Eraxis (Intravenous) 4 SP

Caspofungin Acetate 50 mg, 70 mg Cancidas (Intravenous) 4 SP

Micafungin Sodium 100 mg, 50 mg Mycamine (Intravenous) 4 SP

Antifungals (Antifungales)

Amphotericin B 50 mg Amphotericin B (Injection) 3

Flucytosine 250 mg Ancobon (Oral) 3

FMCMPD 01-17 38




Nivel (Tier)

Inst

Flucytosine 250 mg, 500 mg Flucytosine (Oral) 1

Flucytosine 500 mg Ancobon (Oral) 4 SP

Griseofulvin Microsize 125 mg/5ml, 500 mg Griseofulvin Microsize (Oral) 1

Griseofulvin Ultramicrosize 125 mg, 250 mg Gris-PEG (Oral) 3

Griseofulvin Ultramicrosize 125 mg, 250 mg Griseofulvin Ultramicrosize (Oral) 1

Nystatin 100000 unit/gm, 100000 unit/ml, 500000 unit

Nystatin (External, Mouth/Throat, Oral) 1

Nystatin 1000000 unit, 500000 unit Bio-Statin (Oral) 3

Terbinafine Hcl 250 mg LamISIL (Oral) 3

Terbinafine Hcl 250 mg Terbinafine HCl (Oral) 1

Imidazole-related Antifungals (Antifungales Relacionados al Imidazole)

Fluconazole 10 mg/ml, 100 mg, 150 mg, 200 mg, 40 mg/ml, 50 mg Diflucan (Oral) 3

Fluconazole 10 mg/ml, 100 mg, 150 mg, 200 mg, 40 mg/ml, 50 mg Fluconazole (Oral) 1

Fluconazole In Dextrose 200 mg/100ml, 400 mg/200ml

Fluconazole in Dextrose (Intravenous) 4 SP

Fluconazole In Sodium Chloride

100-0.9 mg/50ml-%, 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

Fluconazole in Sodium Chloride (Intravenous) 4 SP

Isavuconazonium Sulfate 186 mg, 372 mg Cresemba (Oral, Intravenous) 4 PA SP

Itraconazole 10 mg/ml, 100 mg Sporanox (Oral) 3

Itraconazole 100 mg Itraconazole (Oral) 1

Itraconazole 100 mg Sporanox Pulsepak (Oral) 3

Itraconazole 200 mg Onmel (Oral) 3

Ketoconazole 200 mg Ketoconazole (Oral) 1 PA

Posaconazole 100 mg, 40 mg/ml Noxafil (Oral) 3

Voriconazole 200 mg Vfend IV (Intravenous) 4 SP

Voriconazole 200 mg Voriconazole (Intravenous) 4 SP

Voriconazole 200 mg, 40 mg/ml, 50 mg Vfend (Oral) 3

Voriconazole 200 mg, 40 mg/ml, 50 mg Voriconazole (Oral) 1

ANTIHISTAMINES (Antihistaminicos)

Antihistamines - Alkylamines (Antihistaminicos - Alquilaminas)

Brompheniramine Tannate 12 mg Brompheniramine Tannate (Oral) 3

Antihistamines - Ethanolamines (Antihistaminicos - Etanolaminas)

Carbinoxamine Maleate 4 mg Arbinoxa (Oral) 2

Carbinoxamine Maleate 4 mg Carbinoxamine Maleate (Oral) 1

FMCMPD 01-17 39




Nivel (Tier)

Inst

Clemastine Fumarate 2.68 mg Clemastine Fumarate (Oral) 1

Diphenhydramine Hcl 12.5 mg/5ml, 25 mg, 50 mg, 50 mg/ml

DiphenhydrAMINE HCl (Oral, Injection) 1

Antihistamines - Non-sedating (Antihistaminicos - No sedantes)

Cetirizine Hcl 1 mg/ml Cetirizine HCl (Oral) 1

Desloratadine 0.5 mg/ml Clarinex (Oral) 2

Desloratadine 2.5 mg, 5 mg Desloratadine (Oral) 1

Desloratadine 5 mg Clarinex (Oral) 3

Levocetirizine Dihydrochloride 2.5 mg/5ml, 5 mg

Levocetirizine Dihydrochloride (Oral) 1

Levocetirizine Dihydrochloride 2.5 mg/5ml, 5 mg Xyzal (Oral) 3

Antihistamines - Phenothiazines (Antihistaminicos - Fenotiazinas)

Promethazine Hcl 12.5 mg, 25 mg Phenadoz (Rectal) 2

Promethazine Hcl 12.5 mg, 25 mg Promethegan (Rectal) 2

Promethazine Hcl

12.5 mg, 25 mg, 25 mg/ml, 50 mg, 50 mg/ml, 6.25 mg/5ml

Promethazine HCl (Oral, Injection) 1

Promethazine Hcl 25 mg/ml, 50 mg/ml Phenergan (Injection) 3

Promethazine Hcl 50 mg Promethegan (Rectal) 3

Antihistamines - Piperidines (Antihistaminicos - Piperidinas)

Cyproheptadine Hcl 2 mg/5ml, 4 mg Cyproheptadine HCl (Oral) 1

ANTIHYPERLIPIDEMICS (Antihiperlipidemicos)

Antihyperlipidemics - Combinations (Combinaciones De Antihiperlipidemicos)

Ezetimibe-simvastatin 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg Vytorin (Oral) 2

LC TE

Antihyperlipidemics - Misc. (Antihiperlipidemicos - Misc.)

Icosapent Ethyl 1 gm Vascepa (Oral) 3

Omega-3-acid Ethyl Esters 1 gm Lovaza (Oral) 3

Omega-3-acid Ethyl Esters 1 gm Omega-3-acid Ethyl Esters (Oral) 1

Bile Acid Sequestrants (Secuestrantes Del Acido Biliar)

Cholestyramine 4 gm, 4 gm/dose Cholestyramine (Oral) 1

Cholestyramine 4 gm, 4 gm/dose Questran (Oral) 3

Cholestyramine Light 4 gm, 4 gm/dose Cholestyramine Light (Oral) 1

Cholestyramine Light 4 gm, 4 gm/dose Prevalite (Oral) 2

Cholestyramine Light 4 gm/dose Questran Light (Oral) 3

Colesevelam Hcl 3.75 gm, 625 mg Welchol (Oral) 2

Colestipol Hcl 1 gm, 5 gm Colestid (Oral) 3

Colestipol Hcl 1 gm, 5 gm Colestipol HCl (Oral) 1

FMCMPD 01-17 40




Nivel (Tier)

Inst

Colestipol Hcl 5 gm Colestid Flavored (Oral) 3

Fibric Acid Derivatives (Derivados De Acido Fibrico)

Choline Fenofibrate 135 mg, 45 mg Fenofibric Acid (Oral) 1

Choline Fenofibrate 135 mg, 45 mg Trilipix (Oral) 3

Fenofibrate 120 mg, 40 mg Fenoglide (Oral) 2

Fenofibrate 145 mg, 160 mg, 48 mg, 54 mg Fenofibrate (Oral) 1

Fenofibrate 145 mg, 48 mg Tricor (Oral) 3

Fenofibrate 150 mg, 50 mg Fenofibrate (Oral) 2

Fenofibrate 150 mg, 50 mg Lipofen (Oral) 2

Fenofibrate 160 mg, 54 mg Lofibra (Oral) 3

Fenofibrate Micronized 130 mg, 134 mg, 200 mg, 43 mg, 67 mg Fenofibrate Micronized (Oral) 1

Fenofibrate Micronized 134 mg, 200 mg, 67 mg Lofibra (Oral) 3

Fenofibric Acid 105 mg, 35 mg Fenofibric Acid (Oral) 2

Fenofibric Acid 105 mg, 35 mg Fibricor (Oral) 3

Gemfibrozil 600 mg Gemfibrozil (Oral) 1

Gemfibrozil 600 mg Lopid (Oral) 3

Hmg Coa Reductase Inhibitors (Inhibidores De La Reductasa Hng Coa)

Atorvastatin Calcium 10 mg, 20 mg, 40 mg, 80 mg Atorvastatin Calcium (Oral) 1 LC

Atorvastatin Calcium 10 mg, 20 mg, 40 mg, 80 mg Lipitor (Oral) 3

LC TE

Fluvastatin Sodium 20 mg, 40 mg Fluvastatin Sodium (Oral) 1 LC TE

Fluvastatin Sodium Er 80 mg Fluvastatin Sodium ER (Oral) 2 LC

Fluvastatin Sodium Er 80 mg Lescol XL (Oral) 3 LC TE

Lovastatin 10 mg, 20 mg, 40 mg Lovastatin (Oral) 1 LC

Lovastatin 40 mg Mevacor (Oral) 3 LC TE

Lovastatin Er 20 mg, 40 mg, 60 mg Altoprev (Oral) 3 LC TE

Pitavastatin Calcium 1 mg, 2 mg, 4 mg Livalo (Oral) 3 LC TE

Pravastatin Sodium 10 mg, 20 mg, 40 mg, 80 mg Pravastatin Sodium (Oral) 1 LC

Pravastatin Sodium 20 mg, 40 mg, 80 mg Pravachol (Oral) 3 LC TE

Rosuvastatin Calcium 10 mg, 20 mg, 40 mg, 5 mg Crestor (Oral) 3 LC

Rosuvastatin Calcium 10 mg, 20 mg, 40 mg, 5 mg Rosuvastatin Calcium (Oral) 1 LC

FMCMPD 01-17 41




Nivel (Tier)

Inst

Simvastatin 10 mg, 20 mg, 40 mg, 5 mg, 80 mg Simvastatin (Oral) 1 LC

Simvastatin 10 mg, 20 mg, 40 mg, 5 mg, 80 mg Zocor (Oral) 3

LC TE

Intestinal Cholesterol Absorption Inhibitors (Inhibidores De La Absorcion Intestinal Del Colesterol)

Ezetimibe 10 mg Zetia (Oral) 2 LC

Microsomal Triglyceride Transfer Protein (mtp) Inhibitors (Inhibidores De La Proteina De Transferencia Microsomal Trigliceri)

Lomitapide Mesylate 10 mg, 20 mg, 5 mg Juxtapid (Oral) 3 SP

Lomitapide Mesylate 30 mg, 40 mg, 60 mg Juxtapid (Oral) 4 SP

Nicotinic Acid Derivatives (Derivados De Acido De Nicotina)

Niacin (antihyperlipidemic) 500 mg Niacor (Oral) 3

Niacin Er (antihyperlipidemic) 1000 mg, 500 mg, 750 mg Niacin ER (Antihyperlipidemic) (Oral) 1

Niacin Er (antihyperlipidemic) 1000 mg, 500 mg, 750 mg Niaspan (Oral) 3

ANTIHYPERTENSIVES (Antihipertensivos)

Ace Inhibitors (Inhibidores ACE)

Benazepril Hcl 10 mg, 20 mg, 40 mg Lotensin (Oral) 3

Benazepril Hcl 10 mg, 20 mg, 40 mg, 5 mg Benazepril HCl (Oral) 1

Captopril 100 mg, 12.5 mg, 25 mg, 50 mg Captopril (Oral) 1

Enalapril Maleate 1 mg/ml Epaned (Oral) 3

Enalapril Maleate 10 mg, 2.5 mg, 20 mg, 5 mg Enalapril Maleate (Oral) 1

Enalapril Maleate 10 mg, 2.5 mg, 20 mg, 5 mg Vasotec (Oral) 3

Fosinopril Sodium 10 mg, 20 mg, 40 mg Fosinopril Sodium (Oral) 1

Lisinopril 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg Lisinopril (Oral) 1

Lisinopril 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg Zestril (Oral) 3

Lisinopril 10 mg, 20 mg, 5 mg Prinivil (Oral) 3

Moexipril Hcl 15 mg, 7.5 mg Moexipril HCl (Oral) 1

Perindopril Erbumine 2 mg, 4 mg, 8 mg Perindopril Erbumine (Oral) 1

Perindopril Erbumine 4 mg, 8 mg Aceon (Oral) 3

Quinapril Hcl 10 mg, 20 mg, 40 mg, 5 mg Accupril (Oral) 3

Quinapril Hcl 10 mg, 20 mg, 40 mg, 5 mg Quinapril HCl (Oral) 1

Ramipril 1.25 mg, 10 mg, 2.5 mg, 5 mg Altace (Oral) 3

FMCMPD 01-17 42




Nivel (Tier)

Inst

Ramipril 1.25 mg, 10 mg, 2.5 mg, 5 mg Ramipril (Oral) 1

Trandolapril 1 mg, 2 mg, 4 mg Mavik (Oral) 3

Trandolapril 1 mg, 2 mg, 4 mg Trandolapril (Oral) 1

Agents For Pheochromocytoma (Agentes para Feocromocitoma)

Metyrosine 250 mg Demser (Oral) 3

Phenoxybenzamine Hcl 10 mg Dibenzyline (Oral) 3

Phenoxybenzamine Hcl 10 mg Phenoxybenzamine HCl (Oral) 2

Angiotensin Ii Receptor Antagonists (Antagonistas Para Receptores De Angiotensina II)

Azilsartan Medoxomil 40 mg, 80 mg Edarbi (Oral) 3 LC

Candesartan Cilexetil 16 mg, 32 mg, 4 mg, 8 mg Atacand (Oral) 3 LC

Candesartan Cilexetil 16 mg, 32 mg, 4 mg, 8 mg Candesartan Cilexetil (Oral) 1 LC

Eprosartan Mesylate 600 mg Eprosartan Mesylate (Oral) 1 LC

Irbesartan 150 mg, 300 mg, 75 mg Avapro (Oral) 3 LC

Irbesartan 150 mg, 300 mg, 75 mg Irbesartan (Oral) 1 LC

Losartan Potassium 100 mg, 25 mg, 50 mg Cozaar (Oral) 3 LC

Losartan Potassium 100 mg, 25 mg, 50 mg Losartan Potassium (Oral) 1 LC

Olmesartan Medoxomil 20 mg, 40 mg, 5 mg Benicar (Oral) 3 LC

Olmesartan Medoxomil 20 mg, 40 mg, 5 mg Olmesartan Medoxomil (Oral) 1 LC

Telmisartan 20 mg, 40 mg, 80 mg Micardis (Oral) 3 LC

Telmisartan 20 mg, 40 mg, 80 mg Telmisartan (Oral) 1 LC

Valsartan 160 mg, 320 mg, 40 mg, 80 mg Diovan (Oral) 3 LC

Valsartan 160 mg, 320 mg, 40 mg, 80 mg Valsartan (Oral) 1 LC

Antiadrenergic Antihypertensives (Antihipertensivos Antiadrenergicos)

Clonidine Hcl

0.1 mg, 0.1 mg/24hr, 0.2 mg, 0.2 mg/24hr, 0.3 mg, 0.3 mg/24hr

CloNIDine HCl (Oral, Transdermal) 1

Clonidine Hcl 0.1 mg, 0.2 mg, 0.3 mg Catapres (Oral) 3

Clonidine Hcl 0.1 mg/24hr Catapres-TTS-1 (Transdermal) 3



Doxazosin Mesylate 1 mg, 2 mg, 4 mg, 8 mg Cardura (Oral) 3

Doxazosin Mesylate 1 mg, 2 mg, 4 mg, 8 mg Doxazosin Mesylate (Oral) 1

Guanfacine Hcl 1 mg, 2 mg GuanFACINE HCl (Oral) 1

Guanfacine Hcl 1 mg, 2 mg Tenex (Oral) 3

Methyldopa 250 mg, 500 mg Methyldopa (Oral) 1

Prazosin Hcl 1 mg, 2 mg, 5 mg Minipress (Oral) 3

FMCMPD 01-17 43




Nivel (Tier)

Inst

Prazosin Hcl 1 mg, 2 mg, 5 mg Prazosin HCl (Oral) 1

Terazosin Hcl 1 mg, 10 mg, 2 mg, 5 mg Terazosin HCl (Oral) 1

Antihypertensive Combinations (Combinaciones de Antihipertensivos)

Aliskiren-hydrochlorothiazide 150-12.5 mg, 150-25 mg, 300-12.5 mg, 300-25 mg Tekturna HCT (Oral) 2

Amlodipine Besy-benazepril Hcl

10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

Amlodipine Besy-Benazepril HCl (Oral) 1

Amlodipine Besy-benazepril Hcl 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg Lotrel (Oral) 3

Amlodipine Besylate-valsartan 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

Amlodipine Besylate-Valsartan (Oral) 2 LC

Amlodipine Besylate-valsartan 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg Exforge (Oral) 3 LC

Amlodipine-olmesartan 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg Amlodipine-Olmesartan (Oral) 1 LC

Amlodipine-olmesartan 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg Azor (Oral) 3 LC

Amlodipine-valsartan-hctz

10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Amlodipine-Valsartan-HCTZ (Oral) 2 LC

Amlodipine-valsartan-hctz

10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg Exforge HCT (Oral) 3 LC

Atenolol-chlorthalidone 100-25 mg Tenoretic 100 (Oral) 3

Atenolol-chlorthalidone 100-25 mg, 50-25 mg Atenolol-Chlorthalidone (Oral) 1

Atenolol-chlorthalidone 50-25 mg Tenoretic 50 (Oral) 3

Azilsartan-chlorthalidone 40-12.5 mg, 40-25 mg Edarbyclor (Oral) 3 LC

Benazepril-hydrochlorothiazide

10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

Benazepril-Hydrochlorothiazide (Oral) 1

Benazepril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg Lotensin HCT (Oral) 3

Bisoprolol-hydrochlorothiazide

10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

Bisoprolol-Hydrochlorothiazide (Oral) 1

Bisoprolol-hydrochlorothiazide 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg Ziac (Oral) 3

Candesartan Cilexetil-hctz 16-12.5 mg, 32-12.5 mg, 32-25 mg Atacand HCT (Oral) 3 LC

Candesartan Cilexetil-hctz 16-12.5 mg, 32-12.5 mg, 32-25 mg

Candesartan Cilexetil-HCTZ (Oral) 1 LC

FMCMPD 01-17 44




Nivel (Tier)

Inst

Captopril-hydrochlorothiazide 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

Captopril-Hydrochlorothiazide (Oral) 3

Clonidine-chlorthalidone 0.1-15 mg, 0.2-15 mg, 0.3-15 mg Clorpres (Oral) 3

Enalapril-hydrochlorothiazide 10-25 mg Vaseretic (Oral) 3

Enalapril-hydrochlorothiazide 10-25 mg, 5-12.5 mg Enalapril-Hydrochlorothiazide (Oral) 1

Fosinopril Sodium-hctz 10-12.5 mg, 20-12.5 mg Fosinopril Sodium-HCTZ (Oral) 1

Irbesartan-hydrochlorothiazide 150-12.5 mg, 300-12.5 mg Avalide (Oral) 3 LC

Irbesartan-hydrochlorothiazide 150-12.5 mg, 300-12.5 mg

Irbesartan-Hydrochlorothiazide (Oral) 1 LC

Lisinopril-hydrochlorothiazide

10-12.5 mg, 20-12.5 mg, 20-25 mg

Lisinopril-Hydrochlorothiazide (Oral) 1

Lisinopril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg Zestoretic (Oral) 3

Losartan Potassium-hctz 100-12.5 mg, 100-25 mg, 50-12.5 mg Hyzaar (Oral) 3 LC

Losartan Potassium-hctz 100-12.5 mg, 100-25 mg, 50-12.5 mg

Losartan Potassium-HCTZ (Oral) 1 LC

Methyldopa-hydrochlorothiazide 250-15 mg, 250-25 mg Methyldopa-Hydrochlorothiazide (Oral) 3

Metoprolol-hctz Er 100-12.5 mg, 25-12.5 mg, 50-12.5 mg Dutoprol (Oral) 3

Metoprolol-hydrochlorothiazide

100-25 mg, 100-50 mg, 50-25 mg

Metoprolol-Hydrochlorothiazide (Oral) 1

Metoprolol-hydrochlorothiazide 50-25 mg Lopressor HCT (Oral) 3

Moexipril-hydrochlorothiazide

15-12.5 mg, 15-25 mg, 7.5-12.5 mg

Moexipril-Hydrochlorothiazide (Oral) 1

Nadolol-bendroflumethiazide 40-5 mg, 80-5 mg Corzide (Oral) 3

Nadolol-bendroflumethiazide 40-5 mg, 80-5 mg Nadolol-Bendroflumethiazide (Oral) 1

Olmesartan Medoxomil-hctz 20-12.5 mg, 40-12.5 mg, 40-25 mg Benicar HCT (Oral) 3 LC

Olmesartan Medoxomil-hctz 20-12.5 mg, 40-12.5 mg, 40-25 mg

Olmesartan Medoxomil-HCTZ (Oral) 1 LC

Olmesartan-amlodipine-hctz

20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg

Olmesartan-Amlodipine-HCTZ (Oral) 1

FMCMPD 01-17 45




Nivel (Tier)

Inst

Olmesartan-amlodipine-hctz

20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg Tribenzor (Oral) 3

Propranolol-hctz 40-25 mg, 80-25 mg Propranolol-HCTZ (Oral) 3

Quinapril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg Accuretic (Oral) 3

Quinapril-hydrochlorothiazide

10-12.5 mg, 20-12.5 mg, 20-25 mg

Quinapril-Hydrochlorothiazide (Oral) 1

Telmisartan-amlodipine 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg Telmisartan-Amlodipine (Oral) 1 LC

Telmisartan-amlodipine 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg Twynsta (Oral) 3 LC

Telmisartan-hctz 40-12.5 mg, 80-12.5 mg, 80-25 mg Micardis HCT (Oral) 3 LC

Telmisartan-hctz 40-12.5 mg, 80-12.5 mg, 80-25 mg Telmisartan-HCTZ (Oral) 1 LC

Trandolapril-verapamil Hcl Er 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg Tarka (Oral) 3

Trandolapril-verapamil Hcl Er 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg

Trandolapril-Verapamil HCl ER (Oral) 1

Valsartan-hydrochlorothiazide

160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Diovan HCT (Oral) 3 LC

Valsartan-hydrochlorothiazide

160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Valsartan-Hydrochlorothiazide (Oral) 1 LC

Antihypertensives - Misc. (Antihipertensivos - Misc.)

Mecamylamine Hcl 2.5 mg Vecamyl (Oral) 3 SP

Direct Renin Inhibitors (Inhibidores Directos De La Renina)

Aliskiren Fumarate 150 mg, 300 mg Tekturna (Oral) 2

Selective Aldosterone Receptor Antagonists (saras) (Antagonistas Selectivos del Receptor de Aldosterona (SARAS))

Eplerenone 25 mg, 50 mg Eplerenone (Oral) 1

Eplerenone 25 mg, 50 mg Inspra (Oral) 3

Vasodilators (Vasodilatadores)

Hydralazine Hcl 10 mg, 100 mg, 20 mg/ml, 25 mg, 50 mg

HydrALAZINE HCl (Oral, Injection) 1

Minoxidil 10 mg, 2.5 mg Minoxidil (Oral) 1

ANTIMALARIALS (Antimalariales)

Antimalarial Combinations (Combinaciones contra la Malaria)

FMCMPD 01-17 46




Nivel (Tier)

Inst

Artemether-lumefantrine 20-120 mg Coartem (Oral) 3

Atovaquone-proguanil Hcl 250-100 mg Atovaquone-Proguanil HCl (Oral) 1

Atovaquone-proguanil Hcl 250-100 mg, 62.5-25 mg Malarone (Oral) 3

Atovaquone-proguanil Hcl 62.5-25 mg Atovaquone-Proguanil HCl (Oral) 2

Antimalarials (Antimalariales)

Chloroquine Phosphate 250 mg, 500 mg Chloroquine Phosphate (Oral) 1

Hydroxychloroquine Sulfate 200 mg Hydroxychloroquine Sulfate (Oral) 1

Hydroxychloroquine Sulfate 200 mg Plaquenil (Oral) 3

Mefloquine Hcl 250 mg Mefloquine HCl (Oral) 1

Primaquine Phosphate 26.3 mg Primaquine Phosphate (Oral) 3

Pyrimethamine 25 mg Daraprim (Oral) 4 PA SP

Quinine Sulfate 324 mg Qualaquin (Oral) 3

Quinine Sulfate 324 mg QuiNINE Sulfate (Oral) 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS (Agentes Antimiastenia/Colinergicos)

Antimyasthenic/cholinergic Agents (Agentes Antimiastenia/Colinergicos)

Edrophonium Chloride 10 mg/ml Enlon (Injection) 3

Guanidine Hcl 125 mg Guanidine HCl (Oral) 3

Pyridostigmine Bromide 10 mg/2ml Regonol (Intravenous) 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES (Antineoplasicos Y Terapias Adyuvantes)

Alkylating Agents (Agentes Alquilantes)

Altretamine 50 mg Hexalen (Oral) 4 SP

Busulfan 2 mg Myleran (Oral) 3

Chlorambucil 2 mg Leukeran (Oral) 3

Cyclophosphamide 25 mg, 50 mg Cyclophosphamide (Oral) 3

Melphalan 2 mg Alkeran (Oral) 3

Temozolomide 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg Temodar (Oral) 4 SP

Temozolomide 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg Temozolomide (Oral) 4 SP

Antimetabolites (Antimetabolitos)

Capecitabine 150 mg, 500 mg Capecitabine (Oral) 4 SP

Capecitabine 150 mg, 500 mg Xeloda (Oral) 4 SP

Mercaptopurine 2000 mg/100ml Purixan (Oral) 3

Mercaptopurine 50 mg Mercaptopurine (Oral) 1

Methotrexate Sodium 10 mg, 15 mg, 5 mg, 7.5 mg Trexall (Oral) 3

FMCMPD 01-17 47




Nivel (Tier)

Inst

Methotrexate Sodium 2.5 mg Methotrexate (Oral) 1

Thioguanine 40 mg Tabloid (Oral) 3

Antineoplastic - Hedgehog Pathway Inhibitors (Antineoplásicos - Inhibidores del Trayecto de "Hedgehog")

Vismodegib 150 mg Erivedge (Oral) 4 SP

Antineoplastic - Hormonal And Related Agents (Antineoplasticos - Agentes Hormonales Y Relacionados)

Abiraterone Acetate 250 mg Zytiga (Oral) 3 PA SP

Anastrozole 1 mg Anastrozole (Oral) 1

Anastrozole 1 mg Arimidex (Oral) 3

Bicalutamide 50 mg Bicalutamide (Oral) 1

Bicalutamide 50 mg Casodex (Oral) 3

Enzalutamide 40 mg Xtandi (Oral) 4 SP

Estramustine Phosphate Sodium 140 mg Emcyt (Oral) 3

Exemestane 25 mg Aromasin (Oral) 3

Exemestane 25 mg Exemestane (Oral) 1

Flutamide 125 mg Flutamide (Oral) 1

Hydroxyprogesterone Caproate 1.25 gm/5ml Hydroxyprogesterone Caproate (Intramuscular) 2 SP

Letrozole 2.5 mg Femara (Oral) 3

Letrozole 2.5 mg Letrozole (Oral) 1

Megestrol Acetate 20 mg, 40 mg, 40 mg/ml, 400 mg/10ml Megestrol Acetate (Oral) 1

Megestrol Acetate 40 mg/ml Megace (Oral) 3

Mitotane 500 mg Lysodren (Oral) 4 SP

Nilutamide 150 mg Nilandron (Oral) 3

Nilutamide 150 mg Nilutamide (Oral) 2

Tamoxifen Citrate 10 mg, 20 mg Tamoxifen Citrate (Oral) 0

Tamoxifen Citrate 10 mg/5ml Soltamox (Oral) 3

Toremifene Citrate 60 mg Fareston (Oral) 3

Antineoplastic - Immunomodulators (Antineoplastico - Inmunomoduladores)

Pomalidomide 1 mg, 2 mg, 3 mg, 4 mg Pomalyst (Oral) 3 PA SP

Antineoplastic Combinations (Antineoplastico - Combinaciones)

Trifluridine-tipiracil 15-6.14 mg, 20-8.19 mg Lonsurf (Oral) 4 PA SP

Antineoplastic Enzyme Inhibitors (Inhibidores De Las Enzimas Antineoplasticas)

Afatinib Dimaleate 20 mg, 30 mg, 40 mg Gilotrif (Oral) 4 SP

Alectinib Hcl 150 mg Alecensa (Oral) 4 PA SP

FMCMPD 01-17 48




Nivel (Tier)

Inst

Axitinib 1 mg, 5 mg Inlyta (Oral) 4 SP

Bosutinib 100 mg, 500 mg Bosulif (Oral) 4 SP

Cabozantinib S-malate 1 x 80 & 1 x 20 mg Cometriq (100 mg Daily Dose) (Oral) 4 SP

Cabozantinib S-malate 1 x 80 & 3 x 20 mg Cometriq (140 mg Daily Dose) (Oral) 4 SP

Cabozantinib S-malate 20 mg Cometriq (60 mg Daily Dose) (Oral) 4 SP

Cabozantinib S-malate 20 mg, 40 mg, 60 mg Cabometyx (Oral) 4 PA SP

Ceritinib 150 mg Zykadia (Oral) 4 SP

Crizotinib 200 mg, 250 mg Xalkori (Oral) 4 SP

Dasatinib 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg Sprycel (Oral) 4 SP

Erlotinib Hcl 100 mg, 150 mg, 25 mg Tarceva (Oral) 4 SP

Everolimus 10 mg, 2.5 mg, 5 mg, 7.5 mg Afinitor (Oral) 4 SP

Everolimus 2 mg, 3 mg, 5 mg Afinitor Disperz (Oral) 4 SP

Ibrutinib 140 mg Imbruvica (Oral) 4 PA SP

Idelalisib 100 mg, 150 mg Zydelig (Oral) 4 SP

Imatinib Mesylate 100 mg, 400 mg Gleevec (Oral) 4 SP

Imatinib Mesylate 100 mg, 400 mg Imatinib Mesylate (Oral) 4 SP

Lenvatinib 10 Mg Daily Dose 10 mg Lenvima 10 MG Daily Dose (Oral) 4

PA SP

Lenvatinib 14 Mg Daily Dose 10 & 4 mg Lenvima 14 MG Daily Dose (Oral) 4

PA SP

Lenvatinib 18 Mg Daily Dose 10 & 4 (2) mg Lenvima 18 MG Daily Dose (Oral) 4

PA SP

Lenvatinib 20 Mg Daily Dose 10 (2) mg Lenvima 20 MG Daily Dose (Oral) 4

PA SP

Lenvatinib 24 Mg Daily Dose 10 (2) & 4 mg Lenvima 24 MG Daily Dose (Oral) 4

PA SP

Lenvatinib 8 Mg Daily Dose 4 (2) mg Lenvima 8 MG Daily Dose (Oral) 4 PA SP

Nilotinib Hcl 150 mg, 200 mg Tasigna (Oral) 4 SP

Olaparib 50 mg Lynparza (Oral) 4 PA SP

Osimertinib Mesylate 40 mg, 80 mg Tagrisso (Oral) 4 PA SP

FMCMPD 01-17 49




Nivel (Tier)

Inst

Palbociclib 100 mg, 125 mg, 75 mg Ibrance (Oral) 4 PA SP

Panobinostat Lactate 10 mg, 15 mg, 20 mg Farydak (Oral) 4 PA SP

Ponatinib Hcl 15 mg, 45 mg Iclusig (Oral) 4 SP

Regorafenib 40 mg Stivarga (Oral) 4 SP

Ruxolitinib Phosphate 10 mg, 15 mg, 20 mg, 25 mg, 5 mg Jakafi (Oral) 4

PA SP

Sorafenib Tosylate 200 mg NexAVAR (Oral) 4 SP

Sunitinib Malate 12.5 mg, 25 mg, 37.5 mg, 50 mg Sutent (Oral) 4 SP

Vandetanib 100 mg, 300 mg Caprelsa (Oral) 4 SP

Vemurafenib 240 mg Zelboraf (Oral) 4 SP

Vorinostat 100 mg Zolinza (Oral) 4 SP

Antineoplastics Misc. (Antineoplasicos Misc.)

Bexarotene 75 mg Bexarotene (Oral) 4 SP

Bexarotene 75 mg Targretin (Oral) 4 SP

Hydroxyurea 500 mg Hydrea (Oral) 3

Hydroxyurea 500 mg Hydroxyurea (Oral) 1

Procarbazine Hcl 50 mg Matulane (Oral) 4 SP

Tretinoin 10 mg Tretinoin (Oral) 1 SP

Chemotherapy Rescue/antidote Agents (Agentes para el Rescate/Antídoto de Quimioterapia)

Leucovorin Calcium 10 mg, 15 mg Leucovorin Calcium (Oral) 3

Leucovorin Calcium 25 mg, 5 mg Leucovorin Calcium (Oral) 1

Mesna 400 mg Mesnex (Oral) 4 SP

Mitotic Inhibitors (Inhibidores Mitoticos)

Etoposide 50 mg Etoposide (Oral) 3

ANTIPARKINSON AGENTS (Agentes Antiparkinson)

Antiparkinson Adjuvants (Adyuvantes Antiparkinson)

Carbidopa 25 mg Carbidopa (Oral) 1

Carbidopa 25 mg Lodosyn (Oral) 3

Antiparkinson Anticholinergics (Anticolinergicos Antiparkinson)

Benztropine Mesylate 0.5 mg, 1 mg, 1 mg/ml, 2 mg

Benztropine Mesylate (Oral, Injection) 1

Benztropine Mesylate 1 mg/ml Cogentin (Injection) 3

Trihexyphenidyl Hcl 0.4 mg/ml, 2 mg, 5 mg Trihexyphenidyl HCl (Oral) 1

Antiparkinson Comt Inhibitors (Inhibidores de COMT - Antiparkinson)

Entacapone 200 mg Comtan (Oral) 3

Entacapone 200 mg Entacapone (Oral) 1

FMCMPD 01-17 50




Nivel (Tier)

Inst

Tolcapone 100 mg Tasmar (Oral) 3

Tolcapone 100 mg Tolcapone (Oral) 2

Antiparkinson Dopaminergics (Dopaminergicos Antiparkinson)

Amantadine Hcl 100 mg Amantadine HCl (Oral) 3

Apomorphine Hcl 10 mg/ml Apokyn (Subcutaneous) 4 SP

Bromocriptine Mesylate 2.5 mg Parlodel (Oral) 3

Bromocriptine Mesylate 2.5 mg, 5 mg Bromocriptine Mesylate (Oral) 1

Carbidopa-levodopa 10-100 mg, 25-100 mg, 25-250 mg Carbidopa-Levodopa (Oral) 1

Carbidopa-levodopa 10-100 mg, 25-100 mg, 25-250 mg Sinemet (Oral) 3

Carbidopa-levodopa Er 25-100 mg, 50-200 mg Sinemet CR (Oral) 3

Carbidopa-levodopa Er 50-200 mg Carbidopa-Levodopa ER (Oral) 1

Carbidopa-levodopa-entacapone 12.5-50-200 mg Stalevo 50 (Oral) 3

Carbidopa-levodopa-entacapone

12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

Carbidopa-Levodopa-Entacapone (Oral) 2


Carbidopa-levodopa-entacapone 25-100-200 mg Stalevo 100 (Oral) 3



Carbidopa-levodopa-entacapone 50-200-200 mg Stalevo 200 (Oral) 3

Pramipexole Dihydrochloride 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg Mirapex (Oral) 3

Pramipexole Dihydrochloride 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

Pramipexole Dihydrochloride (Oral) 1

Pramipexole Dihydrochloride Er

0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg Mirapex ER (Oral) 3

Pramipexole Dihydrochloride Er

0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

Pramipexole Dihydrochloride ER (Oral) 1

FMCMPD 01-17 51




Nivel (Tier)

Inst

Ropinirole Hcl 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg ROPINIRole HCl (Oral) 1

Ropinirole Hcl 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg Requip (Oral) 3

Ropinirole Hcl Er 12 mg, 2 mg, 4 mg, 6 mg, 8 mg ROPINIRole HCl ER (Oral) 1

Ropinirole Hcl Er 12 mg, 2 mg, 4 mg, 6 mg, 8 mg Requip XL (Oral) 3

Rotigotine

1 mg/24hr, 2 mg/24hr, 3 mg/24hr, 4 mg/24hr, 6 mg/24hr, 8 mg/24hr Neupro (Transdermal) 3

Antiparkinson Monoamine Oxidase Inhibitors (Inhibidores de Monoamino-oxidasa - Antiparkinson)

Rasagiline Mesylate 0.5 mg, 1 mg Azilect (Oral) 2

Selegiline Hcl 1.25 mg Zelapar (Oral) 3

Selegiline Hcl 5 mg Eldepryl (Oral) 3

Selegiline Hcl 5 mg Selegiline HCl (Oral) 1

ANTIPSYCHOTICS/ANTIMANIC AGENTS (Agentes Antipsicoticos/Antimaniaticos)

Antimanic Agents (Agentes Antimaniacos)

Lithium 8 meq/5ml Lithium (Oral) 3

Lithium Carbonate 150 mg, 300 mg, 600 mg Lithium Carbonate (Oral) 1

Lithium Carbonate Er 300 mg Lithobid (Oral) 3

Lithium Carbonate Er 300 mg, 450 mg Lithium Carbonate ER (Oral) 1

Antipsychotics - Misc. (Antipsicoticos - Misc.)

Carbamazepine Er (antipsych) 100 mg, 200 mg, 300 mg Equetro (Oral) 3

Lurasidone Hcl 120 mg, 20 mg, 40 mg, 60 mg, 80 mg Latuda (Oral) 2 LC

Ziprasidone Hcl 20 mg, 40 mg, 60 mg, 80 mg Geodon (Oral) 3

Ziprasidone Hcl 20 mg, 40 mg, 60 mg, 80 mg Ziprasidone HCl (Oral) 1

Ziprasidone Mesylate 20 mg Geodon (Intramuscular) 3 LC

Benzisoxazoles (Benzoisoxazoles)

Iloperidone 1 mg, 10 mg, 12 mg, 2 mg, 4 mg, 6 mg, 8 mg Fanapt (Oral) 3 LC

Iloperidone Oral 1 & 2 & 4 & 6 mg Fanapt Titration Pack (Miscellaneous) 3

Paliperidone Er 1.5 mg, 3 mg, 6 mg, 9 mg Invega (Oral) 3

Paliperidone Er 1.5 mg, 3 mg, 6 mg, 9 mg Paliperidone ER (Oral) 2

FMCMPD 01-17 52




Nivel (Tier)

Inst

Paliperidone Palmitate

117 mg/0.75ml, 156 mg/ml, 234 mg/1.5ml, 39 mg/0.25ml, 78 mg/0.5ml Invega Sustenna (Intramuscular) 4 SP

Risperidone 0.25 mg, 0.5 mg, 1 mg, 1 mg/ml, 2 mg, 3 mg, 4 mg RisperDAL (Oral) 3

Risperidone 0.25 mg, 0.5 mg, 1 mg, 1 mg/ml, 2 mg, 3 mg, 4 mg RisperiDONE (Oral) 1

Risperidone 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg RisperDAL M-TAB (Oral) 3 LC

Risperidone 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg RisperiDONE M-TAB (Oral) 2 LC

Risperidone Microspheres 12.5 mg, 25 mg, 37.5 mg, 50 mg

RisperDAL Consta (Intramuscular) 3

Butyrophenones (Butiroferonas)

Haloperidol 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg Haloperidol (Oral) 1

Haloperidol Decanoate 100 mg/ml, 50 mg/ml Haldol Decanoate (Intramuscular) 3

Haloperidol Decanoate 100 mg/ml, 50 mg/ml Haloperidol Decanoate (Intramuscular) 1

Haloperidol Lactate 2 mg/ml, 5 mg/ml Haloperidol Lactate (Oral, Injection) 1

Haloperidol Lactate 5 mg/ml Haldol (Injection) 3

Dibenzapines (Dibenzapinas)

Asenapine Maleate 10 mg, 2.5 mg, 5 mg Saphris (Sublingual) 3 LC

Clozapine 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg CloZAPine (Oral) 2 LC

Clozapine 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FazaClo (Oral) 3 LC

Clozapine 100 mg, 200 mg, 25 mg, 50 mg CloZAPine (Oral) 1 LC

Clozapine 100 mg, 25 mg Clozaril (Oral) 3 LC

Loxapine 10 mg Adasuve (Inhalation) 4 PA SP

Loxapine Succinate 10 mg, 25 mg, 5 mg, 50 mg Loxapine Succinate (Oral) 1

Olanzapine 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

OLANZapine (Intramuscular, Oral) 1

Olanzapine 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg ZyPREXA (Intramuscular, Oral) 3

Olanzapine 10 mg, 15 mg, 20 mg, 5 mg ZyPREXA Zydis (Oral) 3 LC

FMCMPD 01-17 53




Nivel (Tier)

Inst

Olanzapine Pamoate 210 mg, 300 mg, 405 mg ZyPREXA Relprevv (Intramuscular) 3

Quetiapine Fumarate 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg QUEtiapine Fumarate (Oral) 1 LC

Quetiapine Fumarate 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg SEROquel (Oral) 3 LC

Quetiapine Fumarate Er 150 mg, 200 mg, 300 mg, 400 mg, 50 mg SEROquel XR (Oral) 2 LC

Phenothiazines (Fenotiazinas)

Chlorpromazine Hcl 10 mg, 100 mg, 200 mg, 25 mg, 50 mg ChlorproMAZINE HCl (Oral) 1

Chlorpromazine Hcl 25 mg/ml ChlorproMAZINE HCl (Injection) 3

Fluphenazine Decanoate 25 mg/ml FluPHENAZine Decanoate (Injection) 3

Fluphenazine Hcl 1 mg, 10 mg, 2.5 mg, 5 mg FluPHENAZine HCl (Oral) 1

Fluphenazine Hcl 2.5 mg/5ml, 2.5 mg/ml, 5 mg/ml

FluPHENAZine HCl (Oral, Injection) 3

Perphenazine 16 mg, 2 mg, 4 mg, 8 mg Perphenazine (Oral) 1

Prochlorperazine 25 mg Compro (Rectal) 2

Prochlorperazine 25 mg Prochlorperazine (Rectal) 1

Prochlorperazine Edisylate 5 mg/ml Prochlorperazine Edisylate (Injection) 3

Prochlorperazine Maleate 10 mg, 5 mg Prochlorperazine Maleate (Oral) 1

Thioridazine Hcl 10 mg, 100 mg, 25 mg, 50 mg Thioridazine HCl (Oral) 1

Trifluoperazine Hcl 1 mg, 10 mg, 2 mg, 5 mg Trifluoperazine HCl (Oral) 1

Quinolinone Derivatives (Derivados De La Quinolona)

Aripiprazole 1 mg/ml, 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg ARIPiprazole (Oral) 2 LC

Aripiprazole 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg Abilify (Oral) 3 LC

Aripiprazole 300 mg, 400 mg Abilify Maintena (Intramuscular) 2

Thioxanthenes (Tioxantenos)

Thiothixene 1 mg, 10 mg, 2 mg, 5 mg Thiothixene (Oral) 1

ANTIVIRALS (Antivirales)

Herpes Agents (Agentes Para El Herpes)

Acyclovir 200 mg, 200 mg/5ml, 400 mg, 5 %, 800 mg Acyclovir (Oral, External) 1

FMCMPD 01-17 54




Nivel (Tier)

Inst

Acyclovir 200 mg, 200 mg/5ml, 400 mg, 5 %, 800 mg Zovirax (Oral, External) 3

Acyclovir 50 mg Sitavig (Buccal) 3

Acyclovir Sodium 50 mg/ml Acyclovir Sodium (Intravenous) 4 SP

Famciclovir 125 mg, 250 mg, 500 mg Famciclovir (Oral) 1

Famciclovir 125 mg, 250 mg, 500 mg Famvir (Oral) 3

Valacyclovir Hcl 1 gm, 500 mg ValACYclovir HCl (Oral) 1

Valacyclovir Hcl 1 gm, 500 mg Valtrex (Oral) 3

Influenza Agents (Agentes para la Influenza)

Oseltamivir Phosphate 30 mg, 45 mg, 75 mg Oseltamivir Phosphate (Oral) 1

Oseltamivir Phosphate 30 mg, 45 mg, 75 mg Tamiflu (Oral) 3 LC

Oseltamivir Phosphate 6 mg/ml Tamiflu (Oral) 2 LC

Rimantadine Hcl 100 mg Flumadine (Oral) 3

Rimantadine Hcl 100 mg Rimantadine HCl (Oral) 1

Zanamivir 5 mg/blister Relenza Diskhaler (Inhalation) 3 LC

Respiratory Syncytial Virus (rsv) Agents (Agentes Para El Virus Respiratorio Sincital (rsv))

Ribavirin 6 gm Virazole (Inhalation) 3

ASSORTED CLASSES (Clases Diversas)

Chelating Agents (Agentes Quelantes)

Penicillamine 250 mg Cuprimine (Oral) 4 PA SP

Penicillamine 250 mg Depen Titratabs (Oral) 3

Trientine Hcl 250 mg Syprine (Oral) 3

Immunomodulators (Inmunomoduladores)

Lenalidomide 10 mg, 15 mg, 2.5 mg, 20 mg, 25 mg, 5 mg Revlimid (Oral) 4

PA SP

Thalidomide 100 mg, 150 mg, 200 mg, 50 mg Thalomid (Oral) 4

PA SP

Potassium Removing Agents (Agentes Removedores de Potasio)

Sodium Polystyrene Sulfonate Kayexalate (Oral) 3

Sodium Polystyrene Sulfonate , 15 gm/60ml Kionex (Oral) 2

Sodium Polystyrene Sulfonate

, 15 gm/60ml, 30 gm/120ml, 50 gm/200ml

Sodium Polystyrene Sulfonate (Oral, Rectal) 1

Sodium Polystyrene Sulfonate 15 gm/60ml SPS (Oral) 3

BETA BLOCKERS (Bloqueadores Beta)

Alpha-beta Blockers (Bloqueadores Alfa-Beta)

Carvedilol 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Carvedilol (Oral) 1

FMCMPD 01-17 55




Nivel (Tier)

Inst

Carvedilol 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Coreg (Oral) 3

Carvedilol Phosphate Er 10 mg, 20 mg, 40 mg, 80 mg Coreg CR (Oral) 2

Labetalol Hcl 100 mg, 200 mg, 300 mg Labetalol HCl (Oral) 1

Beta Blockers Cardio-selective (Bloqueadores Beta Cardioselectivos)

Acebutolol Hcl 200 mg, 400 mg Acebutolol HCl (Oral) 1

Acebutolol Hcl 200 mg, 400 mg Sectral (Oral) 3

Atenolol 100 mg, 25 mg, 50 mg Atenolol (Oral) 1

Atenolol 100 mg, 25 mg, 50 mg Tenormin (Oral) 3

Betaxolol Hcl 0.5 %, 10 mg, 20 mg Betaxolol HCl (Ophthalmic, Oral) 1

Betaxolol Hcl 10 mg, 20 mg Kerlone (Oral) 3

Bisoprolol Fumarate 10 mg Zebeta (Oral) 3

Bisoprolol Fumarate 10 mg, 5 mg Bisoprolol Fumarate (Oral) 1

Metoprolol Succinate Er 100 mg, 200 mg, 25 mg, 50 mg Metoprolol Succinate ER (Oral) 1

Metoprolol Succinate Er 100 mg, 200 mg, 25 mg, 50 mg Toprol XL (Oral) 3

Metoprolol Tartrate 100 mg, 25 mg, 50 mg Metoprolol Tartrate (Oral) 1

Metoprolol Tartrate 100 mg, 50 mg Lopressor (Oral) 3

Metoprolol Tartrate 37.5 mg, 75 mg Metoprolol Tartrate (Oral) 3

Nebivolol Hcl 10 mg, 2.5 mg, 20 mg, 5 mg Bystolic (Oral) 2

Beta Blockers Non-selective (Bloqueadores Beta No Selectivos)

Nadolol 20 mg, 40 mg, 80 mg Corgard (Oral) 3

Nadolol 20 mg, 40 mg, 80 mg Nadolol (Oral) 1

Pindolol 10 mg, 5 mg Pindolol (Oral) 3

Propranolol Hcl 10 mg, 20 mg, 40 mg, 60 mg, 80 mg Propranolol HCl (Oral) 1

Propranolol Hcl 20 mg/5ml, 40 mg/5ml Propranolol HCl (Oral) 3

Propranolol Hcl 4.28 mg/ml Hemangeol (Oral) 2

Propranolol Hcl Er 120 mg, 160 mg, 60 mg, 80 mg Inderal LA (Oral) 3

Propranolol Hcl Er 120 mg, 160 mg, 60 mg, 80 mg Propranolol HCl ER (Oral) 1

Sotalol Hcl 120 mg, 160 mg, 240 mg, 80 mg Sorine (Oral) 2

Sotalol Hcl 120 mg, 160 mg, 240 mg, 80 mg Sotalol HCl (Oral) 1

FMCMPD 01-17 56




Nivel (Tier)

Inst

Sotalol Hcl 120 mg, 160 mg, 80 mg Betapace (Oral) 3

Sotalol Hcl Af 120 mg, 160 mg, 80 mg Betapace AF (Oral) 3

Sotalol Hcl Af 120 mg, 160 mg, 80 mg Sotalol HCl (AF) (Oral) 1

Timolol Maleate 10 mg, 20 mg, 5 mg Timolol Maleate (Oral) 3

CALCIUM CHANNEL BLOCKERS (Bloqueadores De Canal De Calcio)

Calcium Channel Blockers (Bloqueadores De Canal De Calcio)

Amlodipine Besylate 10 mg, 2.5 mg, 5 mg AmLODIPine Besylate (Oral) 1

Amlodipine Besylate 10 mg, 2.5 mg, 5 mg Norvasc (Oral) 3

Diltiazem Hcl 120 mg, 25 mg/5ml, 30 mg, 60 mg, 90 mg

Diltiazem HCl (Oral, Intravenous) 1

Diltiazem Hcl 120 mg, 30 mg, 60 mg Cardizem (Oral) 3

Diltiazem Hcl Er 120 mg, 180 mg, 240 mg Dilt-XR (Oral) 2

Diltiazem Hcl Er 120 mg, 180 mg, 240 mg, 60 mg, 90 mg Diltiazem HCl ER (Oral) 1

Diltiazem Hcl Er Beads 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Diltiazem HCl ER Beads (Oral) 1

Diltiazem Hcl Er Beads 120 mg, 180 mg, 240 mg, 300 mg, 360 mg Taztia XT (Oral) 2

Diltiazem Hcl Er Coated Beads 120 mg, 180 mg, 240 mg, 360 mg Cardizem CD (Oral) 3

Diltiazem Hcl Er Coated Beads 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Cardizem LA (Oral) 3

Diltiazem Hcl Er Coated Beads 120 mg, 180 mg, 240 mg, 300 mg Cartia XT (Oral) 2

Diltiazem Hcl Er Coated Beads

120 mg, 180 mg, 240 mg, 300 mg DiltiaZEM CD (Oral) 1

Diltiazem Hcl Er Coated Beads

120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Diltiazem HCl ER Coated Beads (Oral) 1

Diltiazem Hcl Er Coated Beads 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Matzim LA (Oral) 2

Felodipine Er 10 mg, 2.5 mg, 5 mg Felodipine ER (Oral) 1

Isradipine 2.5 mg, 5 mg Isradipine (Oral) 3

Nicardipine Hcl 20 mg, 30 mg NiCARdipine HCl (Oral) 1

Nifedipine 10 mg Procardia (Oral) 3

Nifedipine 10 mg, 20 mg NIFEdipine (Oral) 1

Nifedipine Er 30 mg Nifediac CC (Oral) 2

Nifedipine Er 30 mg, 60 mg Afeditab CR (Oral) 2

Nifedipine Er 30 mg, 60 mg, 90 mg Adalat CC (Oral) 3

Nifedipine Er 30 mg, 60 mg, 90 mg NIFEdipine ER (Oral) 1

FMCMPD 01-17 57




Nivel (Tier)

Inst

Nifedipine Er Osmotic Release 30 mg, 60 mg Nifedical XL (Oral) 2

Nifedipine Er Osmotic Release 30 mg, 60 mg, 90 mg

NIFEdipine ER Osmotic Release (Oral) 1

Nifedipine Er Osmotic Release 30 mg, 60 mg, 90 mg Procardia XL (Oral) 3

Nimodipine 30 mg NiMODipine (Oral) 1

Nimodipine 60 mg/20ml Nymalize (Oral) 3

Nisoldipine Er 17 mg, 34 mg, 8.5 mg Nisoldipine ER (Oral) 1

Nisoldipine Er 17 mg, 34 mg, 8.5 mg Sular (Oral) 3

Nisoldipine Er 20 mg, 25.5 mg, 30 mg, 40 mg Nisoldipine ER (Oral) 3

Verapamil Hcl 120 mg, 80 mg Calan (Oral) 3

Verapamil Hcl 120 mg, 80 mg Verapamil HCl (Oral) 1

Verapamil Hcl 40 mg Verapamil HCl (Oral) 3

Verapamil Hcl Er

100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg Verapamil HCl ER (Oral) 1

Verapamil Hcl Er 100 mg, 200 mg, 300 mg Verelan PM (Oral) 3

Verapamil Hcl Er 120 mg, 180 mg, 240 mg Calan SR (Oral) 3

Verapamil Hcl Er 120 mg, 180 mg, 240 mg, 360 mg Verelan (Oral) 3

CARDIOTONICS (Cardiotonicos)

Cardiac Glycosides (Glucosidos Cardiacos)

Digoxin 0.05 mg/ml Digoxin (Oral) 3

Digoxin 0.1 mg/ml Lanoxin Pediatric (Injection) 3

Digoxin

0.25 mg/ml, 125 mcg, 187.5 mcg, 250 mcg, 62.5 mcg Lanoxin (Injection, Oral) 3

Digoxin 0.25 mg/ml, 125 mcg, 250 mcg Digoxin (Injection, Oral) 1

Digoxin 125 mcg, 250 mcg Digitek (Oral) 1

Digoxin 125 mcg, 250 mcg Digox (Oral) 1

CARDIOVASCULAR AGENTS - MISC. (Agentes Cardiovasculares - Misc.)

Cardiovascular Agents Misc. - Combinations (Agentes Cardiovasculares - Misc. - Combinaciones)

Amlodipine-atorvastatin

10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg Amlodipine-Atorvastatin (Oral) 1

Sacubitril-valsartan 24-26 mg, 49-51 mg, 97-103 mg Entresto (Oral) 3 PA

Prostaglandin Vasodilators (Vasodilatadores De Prostaglandina)

FMCMPD 01-17 58




Nivel (Tier)

Inst

Epoprostenol Sodium 0.5 mg, 1.5 mg Epoprostenol Sodium (Intravenous) 4 SP

Epoprostenol Sodium 0.5 mg, 1.5 mg Flolan (Intravenous) 4 SP

Epoprostenol Sodium 0.5 mg, 1.5 mg Veletri (Intravenous) 4 SP

Iloprost 10 mcg/ml, 20 mcg/ml Ventavis (Inhalation) 4 SP

Treprostinil 0.6 mg/ml Tyvaso (Inhalation) 4 SP

Treprostinil 0.6 mg/ml Tyvaso Refill (Inhalation) 4 SP

Treprostinil 0.6 mg/ml Tyvaso Starter (Inhalation) 4 SP

Treprostinil Diolamine Er 0.125 mg, 0.25 mg, 1 mg, 2.5 mg Orenitram (Oral) 4 SP

Treprostinil Sodium 1 mg/ml, 10 mg/ml, 2.5 mg/ml, 5 mg/ml Remodulin (Injection) 4 SP

Pulmonary Hypertension - Endothelin Receptor Antagonists (Hipertension Pulmonar - Antagonistas de receptores de endotelina)

Ambrisentan 10 mg, 5 mg Letairis (Oral) 4 PA SP

Bosentan 125 mg, 62.5 mg Tracleer (Oral) 4 PA SP

Pulmonary Hypertension - Phosphodiesterase Inhibitors (Hipertension Pulmonar - Inhibidores de la fosfodiesterasa)

Sildenafil Citrate 20 mg Revatio (Oral) 4 PA SP

Sildenafil Citrate 20 mg Sildenafil Citrate (Oral) 1 PA

Tadalafil (pah) 20 mg Adcirca (Oral) 4 PA SP

Pulmonary Hypertension - Sol Guanylate Cyclase Stimulator (Hipertension Pulmonar - Estimulador de ciclasa Sol Guanylate)

Riociguat 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg Adempas (Oral) 4

PA SP

Sinus Node Inhibitor (Inhibidor del Nodo Sinusal)

Ivabradine Hcl 5 mg, 7.5 mg Corlanor (Oral) 3 PA

CEPHALOSPORINS (Cefalosporinas)

Cephalosporins - 1st Generation (Cefalosporinas de 1ra Generacion)

Cefadroxil 1 gm, 250 mg/5ml, 500 mg, 500 mg/5ml Cefadroxil (Oral) 1

Cefazolin Sodium 1 gm, 10 gm, 20 gm CeFAZolin Sodium (Injection) 1

Cephalexin 125 mg/5ml, 250 mg, 250 mg/5ml, 500 mg, 750 mg Cephalexin (Oral) 1

Cephalexin 250 mg, 500 mg Cephalexin (Oral) 3

Cephalosporins - 2nd Generation (Cefalosporinas de 2da Generacion)

FMCMPD 01-17 59




Nivel (Tier)

Inst

Cefaclor 125 mg/5ml, 250 mg/5ml, 375 mg/5ml Cefaclor (Oral) 3

Cefaclor 250 mg, 500 mg Cefaclor (Oral) 1

Cefaclor Er 500 mg Cefaclor ER (Oral) 3

Cefotetan Disodium 1 gm, 2 gm CefoTEtan Disodium (Injection) 3

Cefoxitin Sodium 10 gm CefOXitin Sodium (Injection) 1

Cefprozil 125 mg/5ml, 250 mg, 250 mg/5ml, 500 mg Cefprozil (Oral) 1

Cefuroxime Axetil 125 mg/5ml, 250 mg, 250 mg/5ml, 500 mg Ceftin (Oral) 3

Cefuroxime Axetil 250 mg, 500 mg Cefuroxime Axetil (Oral) 1

Cefuroxime Sodium 1.5 gm, 7.5 gm, 750 mg Cefuroxime Sodium (Injection) 1

Cefuroxime Sodium 225 gm, 75 gm Cefuroxime Sodium (Injection) 3

Cephalosporins - 3rd Generation (Cefalosporinas de 3ra Generacion)

Cefdinir 125 mg/5ml, 250 mg/5ml, 300 mg Cefdinir (Oral) 1

Cefditoren Pivoxil 200 mg, 400 mg Cefditoren Pivoxil (Oral) 2

Cefixime

100 mg, 100 mg/5ml, 200 mg, 200 mg/5ml, 400 mg, 500 mg/5ml Suprax (Oral) 3

Cefixime 100 mg/5ml, 200 mg/5ml Cefixime (Oral) 2

Cefotaxime Sodium 1 gm, 10 gm, 2 gm, 500 mg Cefotaxime Sodium (Injection) 1

Cefotaxime Sodium 10 gm, 2 gm, 500 mg Claforan (Injection) 3

Cefpodoxime Proxetil 100 mg, 100 mg/5ml, 200 mg, 50 mg/5ml Cefpodoxime Proxetil (Oral) 1

Ceftazidime 1 gm, 2 gm, 6 gm CefTAZidime (Injection) 1

Ceftibuten 180 mg/5ml, 400 mg Cedax (Oral) 3

Ceftriaxone Sodium 1 gm Rocephin (Injection) 3

Ceftriaxone Sodium 1 gm, 2 gm, 250 mg, 500 mg CefTRIAXone Sodium (Injection) 1

Cephalosporins - 4th Generation (Cefalosporinas de 4ta Generacion)

Cefepime Hcl 1 gm, 2 gm Cefepime HCl (Injection) 1

Cefepime Hcl 1 gm, 2 gm Maxipime (Injection) 3

CONTRACEPTIVES (Contraceptivos)

Combination Contraceptives - Oral (Combinaciones Anticonceptivas Orales)

Desogest-eth Estrad Triphasic 0.1/0.125/0.15 -0.025 mg Caziant (Oral) 0

Desogest-eth Estrad Triphasic 0.1/0.125/0.15 -0.025 mg Cesia (Oral) 0

Desogest-eth Estrad Triphasic 0.1/0.125/0.15 -0.025 mg Velivet (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Azurette (Oral) 0

FMCMPD 01-17 60




Nivel (Tier)

Inst

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Bekyree (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg

Desogestrel-Ethinyl Estradiol (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Kariva (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Kimidess (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Pimtrea (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-0.02/0.01 mg (21/5) Viorele (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Apri (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Cyred (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Emoquette (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Enskyce (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Juleber (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Reclipsen (Oral) 0

Desogestrel-ethinyl Estradiol 0.15-30 mg-mcg Solia (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.02 mg Gianvi (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.02 mg Loryna (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.02 mg Nikki (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.02 mg Vestura (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.02 mg, 3-0.03 mg Drospirenone-Ethinyl Estradiol (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.03 mg Ocella (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.03 mg Syeda (Oral) 0

Drospirenone-ethinyl Estradiol 3-0.03 mg Zarah (Oral) 0

Ethynodiol Diac-eth Estradiol 1-35 mg-mcg Kelnor 1/35 (Oral) 0

Ethynodiol Diac-eth Estradiol 1-35 mg-mcg Zovia 1/35E (28) (Oral) 0

Levonorg-eth Estrad Triphasic Enpresse-28 (Oral) 0

Levonorg-eth Estrad Triphasic Levonest (Oral) 0

Levonorg-eth Estrad Triphasic Levonorg-Eth Estrad Triphasic (Oral) 0

Levonorg-eth Estrad Triphasic Myzilra (Oral) 0

Levonorg-eth Estrad Triphasic Trivora (28) (Oral) 0

Levonorgest-eth Estrad 91-day 0.1-0.02 & 0.01 mg Amethia Lo (Oral) 0

Levonorgest-eth Estrad 91-day 0.1-0.02 & 0.01 mg Camrese Lo (Oral) 0

Levonorgest-eth Estrad 91-day

0.1-0.02 & 0.01 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg

Levonorgest-Eth Estrad 91-Day (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 &0.01 mg Amethia (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 &0.01 mg Ashlyna (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 &0.01 mg Camrese (Oral) 0

FMCMPD 01-17 61




Nivel (Tier)

Inst

Levonorgest-eth Estrad 91-day 0.15-0.03 &0.01 mg Daysee (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 mg Introvale (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 mg Jolessa (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 mg Quasense (Oral) 0

Levonorgest-eth Estrad 91-day 0.15-0.03 mg Setlakin (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Aubra (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Aviane (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Delyla (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Falmina (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Larissia (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Lessina (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Lutera (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Orsythia (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Sronyx (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg Vienva (Oral) 0

Levonorgestrel-ethinyl Estrad 0.1-20 mg-mcg, 0.15-30 mg-mcg, 90-20 mcg

Levonorgestrel-Ethinyl Estrad (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Altavera (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Chateal (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Kurvelo (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Levora 0.15/30 (28) (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Marlissa (Oral) 0

Levonorgestrel-ethinyl Estrad 0.15-30 mg-mcg Portia-28 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Blisovi FE 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Gildess FE 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Junel FE 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Larin Fe 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Microgestin 24 Fe (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Microgestin FE 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg Tarina FE 1/20 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg(24) Blisovi 24 Fe (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg(24) Junel Fe 24 (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg(24) Larin 24 FE (Oral) 0

Norethin Ace-eth Estrad-fe 1-20 mg-mcg, 1-20 mg-mcg(24)

Norethin Ace-Eth Estrad-FE (Oral) 0

Norethin Ace-eth Estrad-fe 1.5-30 mg-mcg Blisovi Fe 1.5/30 (Oral) 0

Norethin Ace-eth Estrad-fe 1.5-30 mg-mcg Gildess FE 1.5/30 (Oral) 0

Norethin Ace-eth Estrad-fe 1.5-30 mg-mcg Junel FE 1.5/30 (Oral) 0

Norethin Ace-eth Estrad-fe 1.5-30 mg-mcg Larin Fe 1.5/30 (Oral) 0

FMCMPD 01-17 62




Nivel (Tier)

Inst

Norethin Ace-eth Estrad-fe 1.5-30 mg-mcg Microgestin FE 1.5/30 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Alyacen 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Cyclafem 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Dasetta 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Necon 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Nortrel 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/0.75/1-35 mg-mcg Pirmella 7/7/7 (Oral) 0

Norethin-eth Estrad Triphasic 0.5/1/0.5-35 mg-mcg Aranelle (Oral) 0

Norethin-eth Estrad Triphasic 0.5/1/0.5-35 mg-mcg Leena (Oral) 0

Norethin-eth Estradiol-fe 0.4-35 mg-mcg Wymzya Fe (Oral) 0

Norethin-eth Estradiol-fe 0.4-35 mg-mcg Zenchent FE (Oral) 0

Norethin-eth Estradiol-fe 0.4-35 mg-mcg, 0.8-25 mg-mcg Norethin-Eth Estradiol-Fe (Oral) 0

Norethin-eth Estradiol-fe 0.8-25 mg-mcg Kaitlib Fe (Oral) 0

Norethin-eth Estradiol-fe 0.8-25 mg-mcg Layolis FE (Oral) 0

Norethindron-ethinyl Estrad-fe 1-20/1-30/1-35 mg-mcg Tilia Fe (Oral) 0

Norethindron-ethinyl Estrad-fe 1-20/1-30/1-35 mg-mcg Tri-Legest Fe (Oral) 0

Norethindrone Acet-ethinyl Est 1-20 mg-mcg Junel 1/20 (Oral) 0

Norethindrone Acet-ethinyl Est 1-20 mg-mcg Larin 1/20 (Oral) 0

Norethindrone Acet-ethinyl Est 1-20 mg-mcg Microgestin 1/20 (Oral) 0

Norethindrone Acet-ethinyl Est 1-20 mg-mcg Norethindrone Acet-Ethinyl Est (Oral) 0

Norethindrone Acet-ethinyl Est 1.5-30 mg-mcg Junel 1.5/30 (Oral) 0

Norethindrone Acet-ethinyl Est 1.5-30 mg-mcg Larin 1.5/30 (Oral) 0

Norethindrone Acet-ethinyl Est 1.5-30 mg-mcg Microgestin 1.5/30 (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Balziva (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Briellyn (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Gildagia (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Philith (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Vyfemla (Oral) 0

Norethindrone-eth Estradiol 0.4-35 mg-mcg Zenchent (Oral) 0

Norethindrone-eth Estradiol 0.5-35 mg-mcg Necon 0.5/35 (28) (Oral) 0

Norethindrone-eth Estradiol 0.5-35 mg-mcg Nortrel 0.5/35 (28) (Oral) 0

Norethindrone-eth Estradiol 0.5-35 mg-mcg Wera (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Alyacen 1/35 (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Cyclafem 1/35 (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Dasetta 1/35 (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Necon 1/35 (28) (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Nortrel 1/35 (21) (Oral) 0

FMCMPD 01-17 63




Nivel (Tier)

Inst

Norethindrone-eth Estradiol 1-35 mg-mcg Nortrel 1/35 (28) (Oral) 0

Norethindrone-eth Estradiol 1-35 mg-mcg Pirmella 1/35 (Oral) 0

Norgestim-eth Estrad Triphasic

0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg

Norgestim-Eth Estrad Triphasic (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-25 mcg Tri-Lo-Estarylla (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-25 mcg Tri-Lo-Marzia (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-25 mcg Tri-Lo-Sprintec (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-25 mcg TriNessa Lo (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-35 mcg Tri-Estarylla (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-35 mcg Tri-Linyah (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-35 mcg Tri-Previfem (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-35 mcg Tri-Sprintec (Oral) 0

Norgestim-eth Estrad Triphasic 0.18/0.215/0.25 mg-35 mcg TriNessa (28) (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg Estarylla (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg Mono-Linyah (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg MonoNessa (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg Norgestimate-Eth Estradiol (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg Previfem (Oral) 0

Norgestimate-eth Estradiol 0.25-35 mg-mcg Sprintec 28 (Oral) 0

Norgestrel-ethinyl Estradiol 0.3-30 mg-mcg Cryselle-28 (Oral) 0

Norgestrel-ethinyl Estradiol 0.3-30 mg-mcg Elinest (Oral) 0

Norgestrel-ethinyl Estradiol 0.3-30 mg-mcg Low-Ogestrel (Oral) 0

Combination Contraceptives - Transdermal (Combinaciones Anticonceptivas Transdermales)

Norelgestromin-eth Estradiol 150-35 mcg/24hr Xulane (Transdermal) 0

Combination Contraceptives - Vaginal (Combinaciones Anticonceptivas Vaginales)

Etonogestrel-ethinyl Estradiol 0.12-0.015 mg/24hr NuvaRing (Vaginal) 0 LC

Emergency Contraceptives (Contraceptivos de Emergencia)

Levonorgestrel 1.5 mg Levonorgestrel (Oral) 0

Levonorgestrel 1.5 mg My Way (Oral) 0

Levonorgestrel 1.5 mg Next Choice One Dose (Oral) 0

Progestin Contraceptives - Injectable (Anticonceptivos Inyectables De Progestina)

Medroxyprogesterone Acetate 150 mg/ml MedroxyPROGESTERone Acetate (Intramuscular) 0 LC

Progestin Contraceptives - Oral (Contraceptivos Orales de Progestina)

Norethindrone 0.35 mg Camila (Oral) 0

Norethindrone 0.35 mg Deblitane (Oral) 0

Norethindrone 0.35 mg Errin (Oral) 0

FMCMPD 01-17 64




Nivel (Tier)

Inst

Norethindrone 0.35 mg Heather (Oral) 0

Norethindrone 0.35 mg Jencycla (Oral) 0

Norethindrone 0.35 mg Jolivette (Oral) 0

Norethindrone 0.35 mg Lyza (Oral) 0

Norethindrone 0.35 mg Nora-BE (Oral) 0

Norethindrone 0.35 mg Norethindrone (Oral) 0

Norethindrone 0.35 mg Norlyroc (Oral) 0

Norethindrone 0.35 mg Sharobel (Oral) 0

CORTICOSTEROIDS (Corticosteroides)

Glucocorticosteroids (Glucocorticosteroides)

Betamethasone Sod Phos & Acet 6 (3-3) mg/ml

Betamethasone Sod Phos & Acet (Injection) 1

Betamethasone Sod Phos & Acet 6 (3-3) mg/ml Celestone Soluspan (Injection) 3

Budesonide 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml, 3 mg Budesonide (Inhalation, Oral) 1

Budesonide 2 mg/act, 9 mg Uceris (Rectal, Oral) 3

Budesonide 3 mg Entocort EC (Oral) 3

Cortisone Acetate 25 mg Cortisone Acetate (Oral) 3

Dexamethasone 0.5 mg, 0.5 mg/5ml, 0.75 mg, 1.5 mg, 4 mg, 6 mg Dexamethasone (Oral) 1

Dexamethasone 0.5 mg/5ml, 1 mg, 2 mg Dexamethasone (Oral) 3

Dexamethasone 1 mg/ml Dexamethasone Intensol (Oral) 3

Dexamethasone 1.5 mg (21) DexPak 6 Day (Oral) 3



Dexamethasone Sod Phosphate Pf 10 mg/ml

Dexamethasone Sod Phosphate PF (Injection) 3

Dexamethasone Sodium Phosphate

0.1 %, 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml

Dexamethasone Sodium Phosphate (Ophthalmic, Injection) 1



Hydrocortisone 10 mg, 20 mg, 5 mg Cortef (Oral) 3

Hydrocortisone Na Succinate Pf 100 mg, 1000 mg, 250 mg, 500 mg Solu-CORTEF (Injection) 3

Methylprednisolone 16 mg, 2 mg, 32 mg, 4 mg, 8 mg Medrol (Oral) 3

Methylprednisolone 16 mg, 32 mg, 4 mg, 8 mg MethylPREDNISolone (Oral) 1

FMCMPD 01-17 65




Nivel (Tier)

Inst

Methylprednisolone Acetate 20 mg/ml, 40 mg/ml, 80 mg/ml Depo-Medrol (Injection) 3

Methylprednisolone Acetate 40 mg/ml, 80 mg/ml MethylPREDNISolone Acetate (Injection) 1

Methylprednisolone Sodium Succ

1000 mg, 125 mg, 2 gm, 40 mg, 500 mg Solu-MEDROL (Injection) 3

Methylprednisolone Sodium Succ 1000 mg, 125 mg, 40 mg

MethylPREDNISolone Sodium Succ (Injection) 1

Prednisolone 15 mg/5ml PrednisoLONE (Oral) 1

Prednisolone 5 mg Millipred (Oral) 3

Prednisolone 5 mg (21), 5 mg (48) Millipred DP (Oral) 3

Prednisolone 5 mg (48) Millipred DP 12-Day (Oral) 3

Prednisolone Sodium Phosphate 1 %, 25 mg/5ml

PrednisoLONE Sodium Phosphate (Ophthalmic, Oral) 3

Prednisolone Sodium Phosphate 10 mg, 15 mg, 30 mg Orapred ODT (Oral) 3

Prednisolone Sodium Phosphate 10 mg, 15 mg, 30 mg

PrednisoLONE Sodium Phosphate (Oral) 2

Prednisolone Sodium Phosphate 10 mg/5ml Millipred (Oral) 3

Prednisolone Sodium Phosphate

15 mg/5ml, 6.7 (5 base) mg/5ml

PrednisoLONE Sodium Phosphate (Oral) 1

Prednisolone Sodium Phosphate 20 mg/5ml Veripred 20 (Oral) 3

Prednisolone Sodium Phosphate 6.7 (5 base) mg/5ml Pediapred (Oral) 3

Prednisone 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg PredniSONE (Oral) 1

Prednisone

10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48), 5 mg/5ml, 50 mg PredniSONE (Oral) 3

Prednisone 20 mg Deltasone (Oral) 1

Prednisone 5 mg/ml PredniSONE Intensol (Oral) 3

Triamcinolone Acetonide 0.147 mg/gm, 10 mg/ml, 40 mg/ml Kenalog (External, Injection) 3

Mineralocorticoids (Mineralocorticoides)

Fludrocortisone Acetate 0.1 mg Fludrocortisone Acetate (Oral) 1

COUGH/COLD/ALLERGY (Tos/Catarro/Alergia)

Cough/cold/allergy Combinations (Combinaciones Para Tos/Catarro/Alergia)

Codeine Polt-chlorphen Polt Er 14.7-2.8 mg/5ml Tuzistra XR (Oral) 3

FMCMPD 01-17 66




Nivel (Tier)

Inst

Mucolytics (Mucoliticos)

Acetylcysteine 10 %, 20 % Acetylcysteine (Inhalation) 1

DERMATOLOGICALS (Dermatologicos)

Agents For External Genital And Perianal Warts (Agentes Para Verrugas Externas Genitales y Perianales)

Sinecatechins 15 % Veregen (External) 3

Anti-inflammatory Agents - Topical (Agentes Antiinflamatorios - Topicos)

Diclofenac Epolamine 1.3 % Flector (Transdermal) 2



Diclofenac Sodium 1 % Diclofenac Sodium (Transdermal) 2

Diclofenac Sodium 1 % Voltaren (Transdermal) 3

Ketoprofen-ketamine-lidocaine 5-5-2 % LidoProfen (External) 3

Naproxen 15 % NaPro (External) 3

Antibiotics - Topical (Antibioticos Topicos)

Bacit-poly-neo Hc 1 % Cortisporin (External) 3

Gentamicin Sulfate 0.1 % Gentamicin Sulfate (External) 3

Mupirocin 2 % Bactroban (External) 3

Mupirocin 2 % Centany (External) 3

Mupirocin 2 % Centany AT (External) 3

Mupirocin 2 % Mupirocin (External) 1

Mupirocin Calcium 2 % Mupirocin Calcium (External) 1

Neo-fluocinolone & Emollient 0.5-0.025 % Neo-Synalar (External) 3

Neomycin-fluocinolone 0.5-0.025 % Neo-Synalar (External) 3

Neomycin-polymyxin-hc 3.5-10000-0.5, 3.5-10000-1 Cortisporin (External, Otic) 3

Retapamulin 1 % Altabax (External) 3

Antifungals - Topical (Antifungales - Topicos)

Butenafine Hcl 1 % Mentax (External) 3

Ciclopirox 0.77 %, 1 %, 8 % Ciclopirox (External) 1

Ciclopirox 1 % Loprox (External) 3

Ciclopirox 8 % Ciclodan (External) 2

Ciclopirox 8 % Ciclodan Solution (External) 3

Ciclopirox 8 % Ciclopirox Treatment (External) 2

Ciclopirox 8 % Penlac (External) 3

Ciclopirox Olamine 0.77 % Ciclodan (External) 2

Ciclopirox Olamine 0.77 % Ciclopirox Olamine (External) 1

Ciclopirox Olamine 0.77 % Loprox (External) 3

Ciclopirox Olamine-cleanser 0.77 % (susp) Loprox (External) 3

FMCMPD 01-17 67




Nivel (Tier)

Inst

Clioquinol-hc 3-0.5 % Ala-Quin (External) 3

Clotrimazole 1 %, 10 mg Clotrimazole (External, Mouth/Throat) 1

Clotrimazole-betamethasone 1-0.05 % Clotrimazole-Betamethasone (External) 1

Clotrimazole-betamethasone 1-0.05 % Lotrisone (External) 3

Econazole Nitrate 1 % Econazole Nitrate (External) 1

Haloprogin 1 % Halotin (External) 3

Iodoquinol-hc 1-1 % Dermazene (External) 2

Iodoquinol-hc 1-1 % Hydrocortisone-Iodoquinol (External) 1

Iodoquinol-hc-aloe Polysacch 1-2-1 % Alcortin A (External) 3

Iodoquinol-hydrocortisone-aloe 1-1.9 %

Iodoquinol-Hydrocortisone-Aloe (External) 1

Iodoquinol-hydrocortisone-aloe 1-1.9 % Vytone (External) 3

Ketoconazole 2 % Extina (External) 3

Ketoconazole 2 % Ketoconazole (External) 1

Ketoconazole 2 % Ketodan (External) 2

Ketoconazole 2 % Nizoral (External) 3

Ketoconazole 2 % Xolegel (External) 3

Ketoconazole & Pyrithione Zinc 2 & 1 % Xolegel Duo/Head & Shoulders (External) 3

Ketoconazole & Pyrithione Zinc 2 & 1 % Xolegel Duo/Xolex (External) 3

Ketoconazole-cleanser 2 % Ketodan (External) 3

Ketoconazole-hydrocortisone 2 & 1 % Xolegel CorePak (External) 3

Naftifine Hcl 1 %, 2 % Naftifine HCl (External) 1

Naftifine Hcl 1 %, 2 % Naftin (External) 2

Naftifine Hcl 2 % Naftin (External) 3



Nystatin-triamcinolone 100000-0.1 unit/gm-% Nystatin-Triamcinolone (External) 1

Oxiconazole Nitrate 1 % Oxiconazole Nitrate (External) 2

Oxiconazole Nitrate 1 % Oxistat (External) 3

Sertaconazole Nitrate 2 % Ertaczo (External) 3

Sod Thiosulfate-salicylic Acd 25-1 % Exoderm (External) 2

Sulconazole Nitrate 1 % Exelderm (External) 2

Antineoplastic Or Premalignant Lesion Agents - Topical (Agentes Tópicos - Antineoplásicos o Lesiones Pre-malignas)

FMCMPD 01-17 68




Nivel (Tier)

Inst

Diclofenac Sodium 3 % Solaraze (Transdermal) 3

Fluorouracil 0.5 % Carac (External) 3

Fluorouracil 1 % Fluoroplex (External) 3

Fluorouracil 2 %, 5 % Fluorouracil (External) 1

Fluorouracil 5 % Efudex (External) 3

Mechlorethamine Hcl 0.016 % Valchlor (External) 4 SP

Antipruritics - Topical (Antipruriginosos Topicos)

Doxepin Hcl 5 % Doxepin HCl (External) 2

Doxepin Hcl 5 % Prudoxin (External) 3

Doxepin Hcl 5 % Zonalon (External) 3

Antipsoriatics (Antisoriasicos)

Acitretin 10 mg, 17.5 mg, 25 mg Acitretin (Oral) 1

Acitretin 10 mg, 17.5 mg, 25 mg Soriatane (Oral) 3

Calcipotriene 0.005 % Calcipotriene (External) 1

Calcipotriene 0.005 % Calcitrene (External) 2

Calcipotriene 0.005 % Dovonex (External) 3

Calcipotriene 0.005 % Sorilux (External) 3

Calcitriol 3 mcg/gm Calcitriol (External) 2

Calcitriol 3 mcg/gm Vectical (External) 3

Methoxsalen 10 mg Methoxsalen (Oral) 4 SP

Methoxsalen Rapid 10 mg Methoxsalen Rapid (Oral) 1

Methoxsalen Rapid 10 mg Oxsoralen Ultra (Oral) 3

Secukinumab 150 mg/ml Cosentyx (Subcutaneous) 4 PA SP

Secukinumab 150 mg/ml Cosentyx Sensoready Pen (Subcutaneous) 4

PA SP

Tazarotene 0.05 %, 0.1 % Tazorac (External) 2

Ustekinumab 45 mg/0.5ml, 90 mg/ml Stelara (Subcutaneous) 4 PA SP

Antiseborrheic Products (Productos Antiseborreicos)

Antiseborrheic Products, Misc. Loutrex (External) 3

Selenium Sulf-pyrithione-urea 2.25 % Selenium Sulfide (External) 1

Selenium Sulfide 2.25 % Tersi (External) 3

Selenium Sulfide 2.5 % Selenium Sulfide (External) 1

Sulfacetamide Sodium 10 % Ovace Plus Wash (External) 3

Sulfacetamide Sodium 10 % Ovace Wash (External) 3

Sulfacetamide Sodium 10 % Seb-Prev Wash (External) 2

FMCMPD 01-17 69




Nivel (Tier)

Inst

Sulfacetamide Sodium 10 % Sodium Sulfacetamide (External) 1

Sulfacetamide Sodium 10 %, 10 % (cleans) Sulfacetamide Sodium (Ophthalmic, External) 1

Sulfacetamide Sodium 10 %, 9.8 % Ovace Plus (External) 3

Antivirals - Topical (Antivirales - Topicos)

Acyclovir 200 mg, 200 mg/5ml, 400 mg, 5 %, 800 mg Acyclovir (Oral, External) 1

Acyclovir 200 mg, 200 mg/5ml, 400 mg, 5 %, 800 mg Zovirax (Oral, External) 3

Acyclovir 5 % Zovirax (External) 2

Acyclovir-hydrocortisone 5-1 % Xerese (External) 3

Penciclovir 1 % Denavir (External) 3

Corticosteroids - Topical (Corticosteroides Topicos)

Alclometasone Dipropionate 0.05 % Aclovate (External) 3

Alclometasone Dipropionate 0.05 % Alclometasone Dipropionate (External) 1

Amcinonide 0.1 % Amcinonide (External) 1

Betamethasone Dipropionate 0.05 % Betamethasone Dipropionate (External) 1

Betamethasone Dipropionate Aug 0.05 % AlphaTrex (External) 2

Betamethasone Dipropionate Aug 0.05 %

Betamethasone Dipropionate Aug (External) 1

Betamethasone Dipropionate Aug 0.05 % Diprolene (External) 3

Betamethasone Dipropionate Aug 0.05 % Diprolene AF (External) 3

Betamethasone Valerate 0.1 %, 0.12 % Betamethasone Valerate (External) 1

Betamethasone Valerate 0.12 % Luxiq (External) 3

Calcipotriene-betameth Diprop 0.005-0.064 %

Calcipotriene-Betameth Diprop (External) 1

Calcipotriene-betameth Diprop 0.005-0.064 % Taclonex (External) 2

Clobetasol Prop & Cleanser 0.05 % Clodan (External) 3

Clobetasol Prop Emollient Base 0.05 % Clobetasol Propionate E (External) 2

Clobetasol Prop Emollient Base 0.05 % Temovate E (External) 3

FMCMPD 01-17 70




Nivel (Tier)

Inst

Clobetasol Propionate 0.05 % Clobetasol Propionate (External) 1

Clobetasol Propionate 0.05 % Clobex (External) 3

Clobetasol Propionate 0.05 % Clobex Spray (External) 3

Clobetasol Propionate 0.05 % Clodan (External) 1

Clobetasol Propionate 0.05 % Cormax Scalp Application (External) 2

Clobetasol Propionate 0.05 % Olux (External) 3

Clobetasol Propionate 0.05 % Temovate (External) 3

Clobetasol Propionate Emulsion 0.05 %

Clobetasol Propionate Emulsion (External) 1

Clobetasol Propionate Emulsion 0.05 % Olux-E (External) 3

Clocortolone Pivalate 0.1 % Cloderm (External) 2

Clocortolone Pivalate 0.1 % Cloderm Pump (External) 2

Desonide 0.05 % DesOwen (External) 3

Desonide 0.05 % Desonate (External) 3

Desonide 0.05 % Desonide (External) 1

Desonide 0.05 % LoKara (External) 2

Desonide 0.05 % Verdeso (External) 3

Desoximetasone 0.05 % Desoximetasone (External) 3

Desoximetasone 0.05 %, 0.25 % Topicort (External) 3

Desoximetasone 0.25 % Topicort Spray (External) 3

Diflorasone Diacet Emoll Base 0.05 % ApexiCon E (External) 3

Diflorasone Diacetate 0.05 % Diflorasone Diacetate (External) 1

Fluocinolone & Cleanser 0.01 % Synalar TS (External) 3

Fluocinolone Acetonide 0.01 % Capex (External) 3

Fluocinolone Acetonide 0.01 %, 0.025 % Fluocinolone Acetonide (Otic, External) 1

Fluocinolone Acetonide 0.01 %, 0.025 % Synalar (External) 3

Fluocinolone Acetonide Body 0.01 % Derma-Smoothe/FS Body (External) 3

Fluocinolone Acetonide Body 0.01 % Fluocinolone Acetonide Body (External) 2

Fluocinolone Acetonide Scalp 0.01 % Derma-Smoothe/FS Scalp (External) 3

Fluocinolone Acetonide Scalp 0.01 % Fluocinolone Acetonide Scalp (External) 2

FMCMPD 01-17 71




Nivel (Tier)

Inst

Fluocinolone Cream & Emollient 0.025 % Synalar (Cream) (External) 3

Fluocinolone Oint & Emollient 0.025 % Synalar (Ointment) (External) 3

Fluocinonide 0.05 %, 0.1 % Fluocinonide (External) 1

Fluocinonide 0.1 % Vanos (External) 3

Fluocinonide Emulsified Base 0.05 % Fluocinonide-E (External) 1

Flurandrenolide 0.05 % Flurandrenolide (External) 2

Flurandrenolide 0.05 %, 4 mcg/sqcm Cordran (External) 3

Fluticasone Propionate 0.005 %, 0.05 %, 50 mcg/act

Fluticasone Propionate (External, Nasal) 1

Fluticasone Propionate 0.05 % Cutivate (External) 3

Halcinonide 0.1 % Halog (External) 3

Halobetasol Cr & Lactic Ac Cr 0.05 & 10 % Ultravate X (Cream) (External) 3

Halobetasol Oint &lactic Ac Cr 0.05 & 10 % Ultravate X (Ointment) (External) 3

Halobetasol Propionate 0.05 % Halobetasol Propionate (External) 1

Halobetasol Propionate 0.05 % Ultravate (External) 3

Halobetasol-ammonium Lactate 0.05 & 12 % Halac (External) 2

Hc & Sal Acid-sulfur & Shampoo 2 & 2-2 % Scalacort DK (External) 3

Hc-pramoxine-chloroxylenol 10-10-1 mg/ml Cortane-B (External) 3

Hydrocortisone 1 % Ala-Cort (External) 2

Hydrocortisone 1 % Hydrocortisone in Absorbase (External) 1



Hydrocortisone 10 % First-Hydrocortisone (External) 3

Hydrocortisone 2 % Ala Scalp (External) 3

Hydrocortisone 2 % Scalacort (External) 2

Hydrocortisone 2.5 % Texacort (External) 3

Hydrocortisone Acetate 2 % NuCort (External) 3

Hydrocortisone Butyr Lipo Base 0.1 % Hydrocortisone Butyr Lipo Base (External) 2

Hydrocortisone Butyr Lipo Base 0.1 % Locoid Lipocream (External) 3

Hydrocortisone Butyrate 0.1 % Hydrocortisone Butyrate (External) 1

FMCMPD 01-17 72




Nivel (Tier)

Inst

Hydrocortisone Butyrate 0.1 % Locoid (External) 3

Hydrocortisone Probutate 0.1 % Pandel (External) 3

Hydrocortisone Valerate 0.2 % Hydrocortisone Valerate (External) 1

Hydrocortisone Valerate 0.2 % Westcort (External) 3

Mometasone Furoate 0.1 % Elocon (External) 3

Mometasone Furoate 0.1 % Mometasone Furoate (External) 1

Pramoxine-hc 1-1 % Epifoam (External) 3

Pramoxine-hc 1-1 %, 1-2.5 % Pramosone (External) 2

Pramoxine-hc 2.5-1 % Hydrocortisone Ace-Pramoxine (External) 1

Pramoxine-hc Emollient Base 1-2.5 % Pramosone E (External) 3

Prednicarbate 0.1 % Dermatop (External) 3

Prednicarbate 0.1 % Prednicarbate (External) 1

Triamcinolone Acetonide 0.025 %, 0.1 %, 0.5 %, 55 mcg/act

Triamcinolone Acetonide (External, Mouth/Throat, Nasal) 1

Triamcinolone Acetonide 0.05 % Trianex (External) 3

Triamcinolone Acetonide 0.1 % Triderm (External) 2

Triamcinolone Acetonide 0.147 mg/gm Triamcinolone Acetonide (External) 2

Triamcinolone Acetonide 0.147 mg/gm, 10 mg/ml, 40 mg/ml Kenalog (External, Injection) 3

Triamcinolone Acetonide 0.5 % Triamcinolone Acetonide (External) 3

Emollients (Emolientes)

Ammonium Lactate 10 % Lactic Acid (External) 1

Ammonium Lactate 12 % Ammonium Lactate (External) 1

Ammonium Lactate 12 % Lac-Hydrin (External) 3

Enzymes - Topical (Enzimas Topicas)

Collagenase 250 unit/gm Santyl (External) 3

Trypsin-castor Oil-peru Balsam 650-72.5-0.1 mg/0.82ml TBC (External) 2

Immunomodulating Agents - Topical (Agentes Inmunomodulares - Topicos)

Imiquimod 2.5 %, 3.75 % Zyclara Pump (External) 3

Imiquimod 3.75 % Zyclara (External) 3

Imiquimod 5 % Aldara (External) 3

Imiquimod 5 % Imiquimod (External) 1

Immunosuppressive Agents - Topical (Agentes Inmunosupresores - Topicos)

FMCMPD 01-17 73




Nivel (Tier)

Inst

Pimecrolimus 1 % Elidel (External) 2

Tacrolimus 0.03 %, 0.1 % Protopic (External) 3

Tacrolimus 0.03 %, 0.1 % Tacrolimus (External) 1

Keratolytic/antimitotic Agents (Agentes Keratoliticos / Antimitoticos)

Podofilox 0.5 % Condylox (External) 2

Podofilox 0.5 % Podofilox (External) 1

Local Anesthetics - Topical (Anestesia Local - Topica)

Lidocaine 5 % Lidocaine (External) 1

Lidocaine 5 % Lidoderm (External) 3

Lidocaine 5 % Premium Lidocaine (External) 1

Lidocaine Hcl 2 % Glydo (External) 1

Lidocaine Hcl 2 %, 3 %, 4 % Lidocaine HCl (External, Mouth/Throat) 1

Lidocaine Hcl 3 % LidoRx (External) 3

Lidocaine Hcl 3 % Lidocaine HCl (External) 3

Lidocaine Hcl 4 % Xylocaine (External) 3

Lidocaine-prilocaine 2.5-2.5 % LP Lite Pak (External) 3

Lidocaine-prilocaine 2.5-2.5 % Lidocaine-Prilocaine (External) 1

Rosacea Agents (Agentes Rosacea)

Azelaic Acid 15 % Finacea (External) 2

Brimonidine Tartrate 0.33 % Mirvaso (External) 3

Doxycycline 40 mg Oracea (Oral) 2

Metronidazole 0.75 % MetroCream (External) 3

Metronidazole 0.75 % MetroLotion (External) 3

Metronidazole 0.75 % Rosadan (External) 2



Metronidazole 1 % Metrogel (External) 3

Metronidazole 1 % Noritate (External) 3

Metronidazole-cleanser 0.75 % (cream), 0.75 % (gel) Rosadan (External) 3

Scabicides & Pediculicides (Escabicidas y Pediculicidas)

Benzyl Alcohol 5 % Ulesfia (External) 2

Crotamiton 10 % Eurax (External) 3

Ivermectin 0.5 % Sklice (External) 3

Lindane 1 % Lindane (External) 1

Malathion 0.5 % Malathion (External) 1

Malathion 0.5 % Ovide (External) 3

Permethrin 5 % Elimite (External) 3

FMCMPD 01-17 74




Nivel (Tier)

Inst

Permethrin 5 % Permethrin (External) 1

Spinosad 0.9 % Natroba (External) 3

Spinosad 0.9 % Spinosad (External) 2

Wound Care Products (Productos Para Curar Heridas)

Becaplermin 0.01 % Regranex (External) 3

DIAGNOSTIC PRODUCTS (Productos Para Diagnosticos)

Diagnostic Drugs (Medicamentos para Diagnosticas)

Glucagon Hcl Rdna (diagnostic) 1 mg GlucaGen Diagnostic (Injection) 3

DIGESTIVE AIDS (Digestivos)

Digestive Enzymes (Enzimas Digestivas)

Pancrelipase (lip-prot-amyl)

10000 unit, 15000 unit, 20000 unit, 25000 unit, 3000-10000 unit, 5000 unit Zenpep (Oral) 2

Pancrelipase (lip-prot-amyl) 10440 unit, 20880 unit Viokace (Oral) 3


10500 unit, 16800 unit, 21000 unit, 2600 unit, 4200 unit Pancreaze (Oral) 3


12000 unit, 24000 unit, 3000-9500 unit, 36000 unit, 6000 unit Creon (Oral) 2

Pancrelipase (lip-prot-amyl) 16000 unit, 4000 unit, 8000 unit Pertzye (Oral) 3

DIURETICS (Diureticos)

Carbonic Anhydrase Inhibitors (Inhibidores De la anhidrasa carbonica)

Acetazolamide 125 mg AcetaZOLAMIDE (Oral) 3

Acetazolamide 250 mg AcetaZOLAMIDE (Oral) 1

Acetazolamide Er 500 mg AcetaZOLAMIDE ER (Oral) 1

Acetazolamide Er 500 mg Diamox Sequels (Oral) 3

Dichlorphenamide 50 mg Keveyis (Oral) 4 PA SP

Methazolamide 25 mg, 50 mg Methazolamide (Oral) 1

Methazolamide 25 mg, 50 mg Neptazane (Oral) 3

Diuretic Combinations (Combinaciones Diureticas)

Amiloride-hydrochlorothiazide 5-50 mg

Amiloride-Hydrochlorothiazide (Oral) 1

Spironolactone-hctz 25-25 mg Spironolactone-HCTZ (Oral) 1

Spironolactone-hctz 25-25 mg, 50-50 mg Aldactazide (Oral) 3

Triamterene-hctz 37.5-25 mg Dyazide (Oral) 3

Triamterene-hctz 37.5-25 mg Maxzide-25 (Oral) 3

FMCMPD 01-17 75




Nivel (Tier)

Inst

Triamterene-hctz 37.5-25 mg, 75-50 mg Triamterene-HCTZ (Oral) 1

Triamterene-hctz 75-50 mg Maxzide (Oral) 3

Loop Diuretics (Diureticos de Asa)

Bumetanide 0.5 mg, 1 mg, 2 mg Bumetanide (Oral) 1

Ethacrynic Acid 25 mg Edecrin (Oral) 3

Ethacrynic Acid 25 mg Ethacrynic Acid (Oral) 1

Furosemide 10 mg/ml, 20 mg, 40 mg, 80 mg Furosemide (Injection, Oral) 1

Furosemide 20 mg, 40 mg, 80 mg Lasix (Oral) 3

Furosemide 8 mg/ml Furosemide (Oral) 3

Torsemide 10 mg, 100 mg, 20 mg, 5 mg Torsemide (Oral) 1

Torsemide 10 mg, 20 mg Demadex (Oral) 3

Potassium Sparing Diuretics (Diuréticos Conservadores de Potasio)

Amiloride Hcl 5 mg AMILoride HCl (Oral) 1

Spironolactone 100 mg, 25 mg, 50 mg Aldactone (Oral) 3

Spironolactone 100 mg, 25 mg, 50 mg Spironolactone (Oral) 1

Triamterene 100 mg, 50 mg Dyrenium (Oral) 3

Thiazides And Thiazide-like Diuretics (Diureticos de Tiazidas/Parecidos a Tiazidas)

Chlorothiazide 250 mg, 500 mg Chlorothiazide (Oral) 1

Chlorothiazide 250 mg/5ml Diuril (Oral) 3

Chlorthalidone 100 mg, 25 mg, 50 mg Chlorthalidone (Oral) 3

Hydrochlorothiazide 12.5 mg Microzide (Oral) 3

Hydrochlorothiazide 12.5 mg, 25 mg, 50 mg Hydrochlorothiazide (Oral) 1

Indapamide 1.25 mg, 2.5 mg Indapamide (Oral) 1

Methyclothiazide 5 mg Methyclothiazide (Oral) 3

Metolazone 10 mg, 2.5 mg, 5 mg Metolazone (Oral) 1

ENDOCRINE AND METABOLIC AGENTS - MISC. (Agentes Endocrinos Y Metabolicos - Misc.)

Bone Density Regulators (Reguladores De La Densidad Osea)

Alendronate Sodium 10 mg, 35 mg, 5 mg, 70 mg Alendronate Sodium (Oral) 1

Alendronate Sodium 40 mg, 70 mg/75ml Alendronate Sodium (Oral) 3

Alendronate Sodium 70 mg Binosto (Oral) 3 TE

Alendronate Sodium 70 mg Fosamax (Oral) 3 TE

Alendronate-cholecalciferol 70-2800 mg-unit, 70-5600 mg-unit Fosamax Plus D (Oral) 3

LC TE

Calcitonin (salmon) 200 unit/act Calcitonin (Salmon) (Nasal) 1

Calcitonin (salmon) 200 unit/act, 200 unit/ml Miacalcin (Nasal, Injection) 3

Denosumab 120 mg/1.7ml Xgeva (Subcutaneous) 4 PA SP

FMCMPD 01-17 76




Nivel (Tier)

Inst

Denosumab 60 mg/ml Prolia (Subcutaneous) 4

LC PA SP

Etidronate Disodium 200 mg, 400 mg Etidronate Disodium (Oral) 3

Ibandronate Sodium 150 mg Boniva (Oral) 3 LC TE

Ibandronate Sodium 150 mg Ibandronate Sodium (Oral) 1 LC

Ibandronate Sodium 3 mg/3ml Boniva (Intravenous) 4 SP

Ibandronate Sodium 3 mg/3ml Ibandronate Sodium (Intravenous) 4 SP

Pamidronate Disodium 30 mg, 30 mg/10ml, 6 mg/ml, 90 mg, 90 mg/10ml

Pamidronate Disodium (Intravenous) 4 SP

Risedronate Sodium 150 mg, 30 mg, 35 mg, 5 mg Actonel (Oral) 3

LC TE

Risedronate Sodium 150 mg, 30 mg, 35 mg, 5 mg Risedronate Sodium (Oral) 1 LC

Risedronate Sodium 35 mg Atelvia (Oral) 3 LC TE

Risedronate Sodium 35 mg Risedronate Sodium (Oral) 2 LC

Zoledronic Acid 4 mg, 4 mg/100ml, 4 mg/5ml, 5 mg/100ml Zoledronic Acid (Intravenous) 4 SP

Zoledronic Acid 4 mg/100ml, 4 mg/5ml Zometa (Intravenous) 4 SP

Zoledronic Acid 5 mg/100ml Reclast (Intravenous) 4 SP

Hormone Receptor Modulators (Moduladores de Receptores Hormonales)

Ospemifene 60 mg Osphena (Oral) 3

Raloxifene Hcl 60 mg Evista (Oral) 3

Raloxifene Hcl 60 mg Raloxifene HCl (Oral) 0 Lhrh/gnrh Agonist Analog Pituitary Suppressants (Supresores De Agonistas Analogos Lhrh/gnrh De La Pituitaria)

Leuprolide Acetate 11.25 mg, 15 mg, 7.5 mg Lupron Depot-Ped (Intramuscular) 4

PA SP

Leuprolide Acetate (3 Month) 11.25 mg (ped), 30 mg (ped)

Lupron Depot-Ped (Intramuscular) 4

PA SP

Nafarelin Acetate 2 mg/ml Synarel (Nasal) 3

Metabolic Modifiers (Modificadores Metabolicos)

Agalsidase Beta 35 mg, 5 mg Fabrazyme (Intravenous) 4 SP

Alglucosidase Alfa 50 mg Lumizyme (Intravenous) 4 SP

Asfotase Alfa

18 mg/0.45ml, 28 mg/0.7ml, 40 mg/ml, 80 mg/0.8ml Strensiq (Subcutaneous) 4

PA SP

FMCMPD 01-17 77




Nivel (Tier)

Inst

Calcitriol 0.25 mcg, 0.5 mcg, 1 mcg/ml Calcitriol (Oral) 1

Calcitriol 0.25 mcg, 0.5 mcg, 1 mcg/ml Rocaltrol (Oral) 3

Calcitriol 1 mcg/ml Calcitriol (Intravenous) 4 SP

Carglumic Acid 200 mg Carbaglu (Oral) 3

Cinacalcet Hcl 30 mg, 60 mg, 90 mg Sensipar (Oral) 3

Doxercalciferol 0.5 mcg, 1 mcg, 2.5 mcg Hectorol (Oral) 3

Doxercalciferol 0.5 mcg, 1 mcg, 2.5 mcg, 4 mcg/2ml

Doxercalciferol (Oral, Intravenous) 1

Doxercalciferol 2 mcg/ml, 4 mcg/2ml Hectorol (Intravenous) 4 SP

Elosulfase Alfa 5 mg/5ml Vimizim (Intravenous) 4 SP

Galsulfase 1 mg/ml Naglazyme (Intravenous) 4 SP

Glycerol Phenylbutyrate 1.1 gm/ml Ravicti (Oral) 3

Idursulfase 6 mg/3ml Elaprase (Intravenous) 4 SP

Laronidase 2.9 mg/5ml Aldurazyme (Intravenous) 4 SP

Levocarnitine 1 gm/10ml Carnitor SF (Oral) 3

Levocarnitine 1 gm/10ml, 330 mg Carnitor (Oral) 3

Levocarnitine 1 gm/10ml, 330 mg LevOCARNitine (Oral) 1

Levocarnitine 200 mg/ml Carnitor (Intravenous) 4 SP

Levocarnitine 200 mg/ml LevOCARNitine (Intravenous) 4 SP

Metreleptin 11.3 mg Myalept (Subcutaneous) 4 SP

Nitisinone 10 mg, 2 mg, 20 mg, 4 mg/ml, 5 mg Orfadin (Oral) 4 SP

Paricalcitol 1 mcg, 2 mcg Zemplar (Oral) 3

Paricalcitol 1 mcg, 2 mcg, 4 mcg Paricalcitol (Oral) 1

Paricalcitol 2 mcg/ml, 5 mcg/ml Zemplar (Intravenous) 4 SP

Sapropterin Dihydrochloride 100 mg, 500 mg Kuvan (Oral) 4 SP

Sebelipase Alfa 20 mg/10ml Kanuma (Intravenous) 4 PA SP

Sodium Phenylbutyrate 3 gm/tsp, 500 mg Buphenyl (Oral) 4 SP

Uridine Triacetate 2 gm Xuriden (Oral) 4 PA SP

Prolactin Inhibitors (Inhibidores De Prolactina)

Cabergoline 0.5 mg Cabergoline (Oral) 1

Somatostatic Agents (Agentes Somatostaticos)

Lanreotide Acetate 120 mg/0.5ml, 60 mg/0.2ml, 90 mg/0.3ml

Somatuline Depot (Subcutaneous) 4 SP

Octreotide Acetate 10 mg, 20 mg SandoSTATIN LAR Depot (Intramuscular) 4

PA SP

FMCMPD 01-17 78




Nivel (Tier)

Inst

Octreotide Acetate

100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml Octreotide Acetate (Injection) 1

Octreotide Acetate

100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SandoSTATIN (Injection) 4 SP

Pasireotide Diaspartate 0.3 mg/ml, 0.6 mg/ml, 0.9 mg/ml Signifor (Subcutaneous) 4 SP

Vasopressin Receptor Antagonists (Antagonistas De Receptores De Vasopresina)

Tolvaptan 15 mg, 30 mg Samsca (Oral) 4 LC SP

ESTROGENS (Estrogenos)

Estrogen Combinations (Combinaciones de Estrogenos)

Conj Estrog-medroxyprogest Ace

0.3-1.5 mg, 0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg Prempro (Oral) 2

Conj Estrog-medroxyprogest Ace 0.625-5 mg Premphase (Oral) 2

Conj Estrogens-bazedoxifene 0.45-20 mg Duavee (Oral) 3

Drospirenone-estradiol 0.25-0.5 mg, 0.5-1 mg Angeliq (Oral) 3

Est Estrogens-methyltest 0.625-1.25 mg Est Estrogens-Methyltest HS (Oral) 2

Est Estrogens-methyltest 1.25-2.5 mg Est Estrogens-Methyltest (Oral) 1

Est Estrogens-methyltest 1.25-2.5 mg Est Estrogens-Methyltest DS (Oral) 2

Estradiol-levonorgestrel 0.045-0.015 mg/day Climara Pro (Transdermal) 2

Estradiol-norethindrone Acet 0.05-0.14 mg/day, 0.05-0.25 mg/day CombiPatch (Transdermal) 2

Estradiol-norethindrone Acet 0.5-0.1 mg Mimvey Lo (Oral) 2

Estradiol-norethindrone Acet 0.5-0.1 mg, 1-0.5 mg Activella (Oral) 3

Estradiol-norethindrone Acet 0.5-0.1 mg, 1-0.5 mg Amabelz (Oral) 1

Estradiol-norethindrone Acet 0.5-0.1 mg, 1-0.5 mg Estradiol-Norethindrone Acet (Oral) 1

Estradiol-norethindrone Acet 1-0.5 mg Mimvey (Oral) 2

Estradiol-norgestimate 1/1-0.09 mg (15/15) Prefest (Oral) 3

Norethindrone-eth Estradiol 0.5-2.5 mg-mcg Femhrt Low Dose (Oral) 3

Norethindrone-eth Estradiol 0.5-2.5 mg-mcg, 1-5 mg-mcg Fyavolv (Oral) 1

FMCMPD 01-17 79




Nivel (Tier)

Inst

Norethindrone-eth Estradiol 0.5-2.5 mg-mcg, 1-5 mg-mcg

Norethindrone-Eth Estradiol (Oral) 2

Norethindrone-eth Estradiol 1-5 mg-mcg Jinteli (Oral) 3

Estrogens (Estrogenos)

Esterified Estrogens 0.3 mg, 0.625 mg, 1.25 mg, 2.5 mg Menest (Oral) 3

Estradiol

0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr Climara (Transdermal) 3

Estradiol

0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr, 0.5 mg, 1 mg Estradiol (Transdermal, Oral) 1

Estradiol

0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr Vivelle-Dot (Transdermal) 2

Estradiol

0.025 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr Alora (Transdermal) 3

Estradiol

0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr Minivelle (Transdermal) 3

Estradiol 0.25 mg/0.25gm, 0.5 mg/0.5gm, 1 mg/gm Divigel (Transdermal) 2

Estradiol 0.5 mg, 1 mg, 2 mg Estrace (Oral) 3

Estradiol 0.52 mg/0.87 gm (0.06%) Elestrin (Transdermal) 3

Estradiol 0.75 mg/1.25 gm (0.06%) Estrogel (Transdermal) 3

Estradiol 1.53 mg/spray Evamist (Transdermal) 2

Estradiol 14 mcg/24hr Menostar (Transdermal) 3

Estradiol Cypionate 5 mg/ml Depo-Estradiol (Intramuscular) 3

Estradiol Valerate 10 mg/ml, 20 mg/ml, 40 mg/ml Delestrogen (Intramuscular) 3

Estradiol Valerate 20 mg/ml, 40 mg/ml Estradiol Valerate (Intramuscular) 1

Estrogens Conj Synthetic B 0.3 mg Enjuvia (Oral) 2

Estrogens Conjugated 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg, 25 mg Premarin (Oral, Injection) 2

Estropipate 0.75 mg, 1.5 mg Estropipate (Oral) 1

FMCMPD 01-17 80




Nivel (Tier)

Inst

Estropipate 3 mg Estropipate (Oral) 3

FLUOROQUINOLONES (Fluoroquinolonas)

Fluoroquinolones (Fluoroquinolonas)

Ciprofloxacin 200 mg/20ml, 250 mg/5ml (5%), 500 mg/5ml (10%) Ciprofloxacin (Intravenous, Oral) 1

Ciprofloxacin 250 mg/5ml (5%), 500 mg/5ml (10%) Cipro (Oral) 3

Ciprofloxacin 400 mg/40ml Ciprofloxacin (Intravenous) 4 SP

Ciprofloxacin Hcl 0.3 %, 100 mg, 250 mg, 500 mg, 750 mg

Ciprofloxacin HCl (Ophthalmic, Oral) 1

Ciprofloxacin Hcl 250 mg, 500 mg Cipro (Oral) 3

Ciprofloxacin In D5w 200 mg/100ml, 400 mg/200ml

Ciprofloxacin in D5W (Intravenous) 1

Ciprofloxacin In D5w 400 mg/200ml Cipro in D5W (Intravenous) 4 SP

Ciprofloxacin-ciproflox Hcl Er 1000 mg, 500 mg Cipro XR (Oral) 3

Ciprofloxacin-ciproflox Hcl Er 1000 mg, 500 mg Ciprofloxacin-Ciproflox HCl ER (Oral) 1

Gemifloxacin Mesylate 320 mg Factive (Oral) 3

Levofloxacin 0.5 %, 25 mg/ml, 250 mg, 500 mg, 750 mg Levofloxacin (Ophthalmic, Oral) 1

Levofloxacin 25 mg/ml Levofloxacin (Intravenous) 4 SP

Levofloxacin 250 mg, 500 mg, 750 mg Levaquin (Oral) 3

Levofloxacin In D5w 250 mg/50ml, 500 mg/100ml, 750 mg/150ml

Levofloxacin in D5W (Intravenous) 4 SP

Moxifloxacin Hcl 400 mg Avelox (Oral) 3

Moxifloxacin Hcl 400 mg Avelox ABC Pack (Oral) 2

Moxifloxacin Hcl 400 mg Moxifloxacin HCl (Oral) 1

Moxifloxacin Hcl In Nacl 400 mg/250ml Avelox (Intravenous) 4 SP

Ofloxacin 0.3 %, 400 mg Ofloxacin (Ophthalmic, Oral) 1

GASTROINTESTINAL AGENTS - MISC. (Agentes Gastrointestinales - Misc.)

Bile Acid Synthesis Disorder Agents (Agentes Para El Desorden De La Sintesis Del Acido Biliar)

Cholic Acid 250 mg, 50 mg Cholbam (Oral) 4 PA SP

Farnesoid X Receptor (fxr) Agonists (Agentes del Receptor de Farnesoido X (fxr))

Obeticholic Acid 10 mg, 5 mg Ocaliva (Oral) 4 PA SP

Gallstone Solubilizing Agents (Agentes Solubilizantes De Calculos Biliares)

Ursodiol 250 mg Urso 250 (Oral) 3

Ursodiol 250 mg, 300 mg, 500 mg Ursodiol (Oral) 1

Ursodiol 300 mg Actigall (Oral) 3

FMCMPD 01-17 81




Nivel (Tier)

Inst

Ursodiol 500 mg Urso Forte (Oral) 3

Gastrointestinal Chloride Channel Activators (Activadores Del Canal De Cloro Gastrointestinal)

Lubiprostone 24 mcg, 8 mcg Amitiza (Oral) 2

Gastrointestinal Stimulants (Estimulantes Gastrointestinales)

Metoclopramide Hcl 10 mg Metoclopramide HCl (Oral) 3

Metoclopramide Hcl 10 mg, 10 mg/10ml, 5 mg, 5 mg/5ml, 5 mg/ml

Metoclopramide HCl (Oral, Injection) 1

Metoclopramide Hcl 10 mg, 5 mg Reglan (Oral) 3

Metoclopramide Hcl 5 mg Metoclopramide HCl (Oral) 2

Inflammatory Bowel Agents (Agentes para el sindrome de intestino inflamado)

Balsalazide Disodium 1.1 gm Giazo (Oral) 3

Balsalazide Disodium 750 mg Balsalazide Disodium (Oral) 1

Balsalazide Disodium 750 mg Colazal (Oral) 3

Certolizumab Pegol 2 x 200 mg Cimzia (Subcutaneous) 4 PA SP

Certolizumab Pegol 2 x 200 mg/ml Cimzia Prefilled (Subcutaneous) 4 PA SP

Certolizumab Pegol 6 x 200 mg/ml Cimzia Starter Kit (Subcutaneous) 4

PA SP

Infliximab 100 mg Remicade (Intravenous) 4 PA SP

Infliximab-dyyb 100 mg Inflectra (Intravenous) 4 PA SP

Mesalamine 1.2 gm Lialda (Oral) 2

Mesalamine 1000 mg Canasa (Rectal) 2

Mesalamine 4 gm Mesalamine (Rectal) 1

Mesalamine 4 gm/60ml SfRowasa (Rectal) 3

Mesalamine 400 mg Delzicol (Oral) 3

Mesalamine 800 mg Asacol HD (Oral) 2

Mesalamine Er 0.375 gm Apriso (Oral) 2

Mesalamine Er 250 mg, 500 mg Pentasa (Oral) 3

Mesalamine-cleanser 4 gm Mesalamine-Cleanser (Rectal) 1

Mesalamine-cleanser 4 gm Rowasa (Rectal) 3

Olsalazine Sodium 250 mg Dipentum (Oral) 3

Sulfasalazine 500 mg Azulfidine (Oral) 3

Sulfasalazine 500 mg Azulfidine EN-tabs (Oral) 3

Sulfasalazine 500 mg SulfaSALAzine (Oral) 1

Sulfasalazine 500 mg Sulfazine (Oral) 2

Vedolizumab 300 mg Entyvio (Intravenous) 4 PA SP

FMCMPD 01-17 82




Nivel (Tier)

Inst

Intestinal Acidifiers (Acidificadores Intestinales)

Lactulose Encephalopathy 10 gm/15ml Enulose (Oral) 2

Lactulose Encephalopathy 10 gm/15ml Generlac (Oral) 2

Lactulose Encephalopathy 10 gm/15ml Lactulose Encephalopathy (Oral) 1

Irritable Bowel Syndrome (ibs) Agents (Agentes para el sindrome de intestino irritable)

Alosetron Hcl 0.5 mg, 1 mg Alosetron HCl (Oral) 1

Alosetron Hcl 0.5 mg, 1 mg Lotronex (Oral) 3

Eluxadoline 100 mg, 75 mg Viberzi (Oral) 3

Linaclotide 145 mcg, 290 mcg Linzess (Oral) 2

Peripheral Opioid Receptor Antagonists (iAntagonistas De Receptores Opiodes Periferales)

Alvimopan 12 mg Entereg (Oral) 3

Methylnaltrexone Bromide 12 mg/0.6ml, 150 mg, 8 mg/0.4ml Relistor (Subcutaneous, Oral) 3

Phosphate Binder Agents (Agentes Aglutinantes de Fosfato)

Calcium Acetate 667 mg Calcium Acetate (Oral) 1

Calcium Acetate 667 mg Calcium Acetate (Phos Binder) (Oral) 1

Calcium Acetate 667 mg PhosLo (Oral) 3

Calcium Acetate (phos Binder) 667 mg

Calcium Acetate (Phos Binder) (Oral) 1

Calcium Acetate (phos Binder) 667 mg Eliphos (Oral) 3

Calcium Acetate (phos Binder) 667 mg/5ml Phoslyra (Oral) 3

Lanthanum Carbonate 1000 mg, 500 mg, 750 mg Fosrenol (Oral) 2

Sevelamer Carbonate 0.8 gm, 2.4 gm, 800 mg Renvela (Oral) 2

Sevelamer Hcl 400 mg, 800 mg Renagel (Oral) 3

GENITOURINARY AGENTS - MISCELLANEOUS (Agentes Genitourinarios - Misc.)

Alkalinizers (Alkalinizadores)

Pot & Sod Cit-cit Ac 550-500-334 mg/5ml Tricitrates (Oral) 3

Pot & Sod Cit-cit Ac 550-500-334 mg/5ml Virtrate-3 (Oral) 3

Potassium Citrate-citric Acid 1100-334 mg/5ml Potassium Citrate-Citric Acid (Oral) 3

Potassium Citrate-citric Acid 1100-334 mg/5ml Virtrate-K (Oral) 3

Potassium Citrate-citric Acid 3300-1002 mg Cytra K Crystals (Oral) 2

Potassium Citrate-citric Acid 3300-1002 mg Potassium Citrate-Citric Acid (Oral) 1

Potassium Citrate-citric Acid 3300-1002 mg Taron-Crystals (Oral) 2

Sod Citrate-citric Acid 334-500 mg/5ml Citric Acid-Sodium Citrate (Oral) 1

FMCMPD 01-17 83




Nivel (Tier)

Inst

Sod Citrate-citric Acid 490-640 mg/5ml Oracit (Oral) 3

Sod Citrate-citric Acid 500-334 mg/5ml Shohls Modified (Oral) 3

Sod Citrate-citric Acid 500-334 mg/5ml Virtrate-2 (Oral) 2

Cystinosis Agents (Agentes Para La Cistinosis)

Cysteamine Bitartrate 150 mg, 50 mg Cystagon (Oral) 4 SP

Cysteamine Bitartrate 25 mg, 75 mg Procysbi (Oral) 4 SP

Interstitial Cystitis Agents (Agentes para la Cistitis Intersticial)

Pentosan Polysulfate Sodium 100 mg Elmiron (Oral) 3

Prostatic Hypertrophy Agents (Agentes Para La Hipertrofia Prostatica)

Alfuzosin Hcl Er 10 mg Alfuzosin HCl ER (Oral) 1

Alfuzosin Hcl Er 10 mg Uroxatral (Oral) 3

Doxazosin Mesylate Er 4 mg, 8 mg Cardura XL (Oral) 3

Dutasteride 0.5 mg Avodart (Oral) 3

Dutasteride 0.5 mg Dutasteride (Oral) 2

Dutasteride-tamsulosin Hcl 0.5-0.4 mg Dutasteride-Tamsulosin HCl (Oral) 2

Dutasteride-tamsulosin Hcl 0.5-0.4 mg Jalyn (Oral) 3

Finasteride 5 mg Finasteride (Oral) 1

Finasteride 5 mg Proscar (Oral) 3

Silodosin 4 mg, 8 mg Rapaflo (Oral) 2

Tamsulosin Hcl 0.4 mg Flomax (Oral) 3

Tamsulosin Hcl 0.4 mg Tamsulosin HCl (Oral) 1

GOUT AGENTS (Agentes para la Gota)

Gout Agent Combinations (Combinaciones de Agentes Para La Gota)

Colchicine-probenecid 0.5-500 mg Colchicine-Probenecid (Oral) 1

Gout Agents (Agentes para la Gota)

Allopurinol 100 mg, 300 mg Allopurinol (Oral) 1

Allopurinol 100 mg, 300 mg Zyloprim (Oral) 3

Colchicine 0.6 mg Colcrys (Oral) 2

Colchicine 0.6 mg Mitigare (Oral) 3

Febuxostat 40 mg, 80 mg Uloric (Oral) 2

Uricosurics (Uricosuricos)

Probenecid 500 mg Probenecid (Oral) 1

HEMATOLOGICAL AGENTS - MISC. (Agentes Hematologicos - Misc.)

Antihemophilic Products (Productos Antihemofilicos)

Antihemophilic Factor 1000 unit, 1500 unit Monoclate-P (Intravenous) 4 PA SP

Antihemophilic Factor 1000 unit, 1700 unit, 250 unit, 500 unit Hemofil M (Intravenous) 4

PA SP

FMCMPD 01-17 84




Nivel (Tier)

Inst

Antihemophilic Factor 1000 unit, 250 unit, 500 unit Koate-DVI (Intravenous) 4

PA SP

Antihemophilic Factor (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit Helixate FS (Intravenous) 4

PA SP

Antihemophilic Factor (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit Kogenate FS (Intravenous) 4

PA SP

Antihemophilic Factor (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit

Kogenate FS Bio-Set (Intravenous) 4

PA SP

Antihemophilic Factor (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit Kovaltry (Intravenous) 4

PA SP

Antihemophilic Factor (recomb)

1241-1800 unit, 1801-2400 unit, 220-400 unit, 401-800 unit, 801-1240 unit Recombinate (Intravenous) 4

PA SP

Antihemophilic Factor Rahf-paf 1000 unit, 2000 unit, 250 unit, 500 unit Xyntha (Intravenous) 4

PA SP

Antihemophilic Factor Rahf-paf 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit Xyntha Solofuse (Intravenous) 4

PA SP

Antihemophilic Factor Rahf-pfm

1000 unit, 1500 unit, 2000 unit, 250 unit, 3000 unit, 4000 unit, 500 unit Advate (Intravenous) 4

PA SP

Antihemophilic Factor Rpfviii 500 unit Obizur (Intravenous) 4 SP

Antihemophilic Factor-vwf 1000 unit, 1500 unit, 250 unit, 500 unit

Alphanate/VWF Complex/Human (Intravenous) 4

PA SP

Antihemophilic Factor-vwf 1000-2400 unit, 250-600 unit, 500-1200 unit Humate-P (Intravenous) 4

PA SP

Antiinhibitor Coagulant Cmplx Feiba (Intravenous) 4 PA SP

Coagulation Factor Ix 1000 unit Mononine (Intravenous) 4 PA SP

Coagulation Factor Ix 1000 unit, 1500 unit, 500 unit AlphaNine SD (Intravenous) 4

PA SP

Coagulation Factor Ix (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit BeneFIX (Intravenous) 4

PA SP

Coagulation Factor Ix (recomb) 1000 unit, 2000 unit, 250 unit, 3000 unit, 500 unit Rixubis (Intravenous) 4

PA SP

Coagulation Factor Ix (rfixfc) 1000 unit, 2000 unit, 3000 unit, 500 unit Alprolix (Intravenous) 4

PA SP

Coagulation Factor Viia Recomb 1 mg, 2 mg, 5 mg, 8 mg NovoSeven RT (Intravenous) 4

PA SP

Coagulation Factor X (human) 250 unit, 500 unit Coagadex (Intravenous) 4 PA SP

FMCMPD 01-17 85




Nivel (Tier)

Inst

Factor Ix Complex 1000 unit, 1500 unit, 500 unit Profilnine SD (Intravenous) 4

PA SP

Factor Ix Complex 200-1200 unit Bebulin (Intravenous) 4 PA SP

Factor Xiii Concentrate Human 1000-1600 unit Corifact (Intravenous) 4 PA SP

Fibrinogen Concentrate (human) RiaSTAP (Intravenous) 4

PA SP

Prothrombin Complex Conc Human 500 unit Kcentra (Intravenous) 4

PA SP

Hematorheologic Agents (Agentes Hematoreológicos)

Pentoxifylline Er 400 mg Pentoxifylline ER (Oral) 1

Platelet Aggregation Inhibitors (Inhibidores De Agregacion De Plaquetas)

Anagrelide Hcl 0.5 mg Agrylin (Oral) 3

Anagrelide Hcl 0.5 mg, 1 mg Anagrelide HCl (Oral) 1

Aspirin-dipyridamole Er 25-200 mg Aggrenox (Oral) 2

Cilostazol 100 mg, 50 mg Cilostazol (Oral) 1

Clopidogrel Bisulfate 300 mg, 75 mg Clopidogrel Bisulfate (Oral) 1

Clopidogrel Bisulfate 300 mg, 75 mg Plavix (Oral) 3

Dipyridamole 25 mg, 50 mg, 75 mg Dipyridamole (Oral) 1

Prasugrel Hcl 10 mg, 5 mg Effient (Oral) 2

Ticagrelor 60 mg, 90 mg Brilinta (Oral) 2

Vorapaxar Sulfate 2.08 mg Zontivity (Oral) 3 LC

HEMATOPOIETIC AGENTS (Agentes Hematopoyeticos)

Agents For Gaucher Disease (Agentes para la enfermedad de Gaucher)

Eliglustat Tartrate 84 mg Cerdelga (Oral) 4 SP

Imiglucerase 400 unit Cerezyme (Intravenous) 4 SP

Taliglucerase Alfa 200 unit Elelyso (Intravenous) 4 SP

Velaglucerase Alfa 400 unit Vpriv (Intravenous) 4 SP

Folic Acid/folates (Acido Folico / Folatos)

Folic Acid 400 mcg GNP Folic Acid (Oral) 0 LC

Folic Acid 400 mcg HM Folic Acid (Oral) 0 LC

Folic Acid 400 mcg PX Folic Acid (Oral) 0 LC

Folic Acid 400 mcg SM Folic Acid (Oral) 0 LC

Folic Acid 400 mcg YL Folic Acid (Oral) 0 LC

Folic Acid 400 mcg, 800 mcg Folic Acid (Oral) 0 LC

Folic Acid 400 mcg, 800 mcg RA Folic Acid (Oral) 0 LC

Folic Acid 800 mcg CVS Folic Acid (Oral) 0 LC

Folic Acid 800 mcg FA-8 (Oral) 0 LC

Folic Acid 800 mcg KP Folic Acid (Oral) 0 LC

FMCMPD 01-17 86




Nivel (Tier)

Inst

Hematopoietic Growth Factors (Factores Hematopoyeticos de Crecimiento)

Darbepoetin Alfa

10 mcg/0.4ml, 100 mcg/0.5ml, 100 mcg/ml, 150 mcg/0.3ml, 200 mcg/0.4ml, 200 mcg/ml, 25 mcg/0.42ml, 25

Aranesp (Albumin Free) (Injection) 4

PA SP

Eltrombopag Olamine 12.5 mg Promacta (Oral) 4 PA SP

Epoetin Alfa

10000 unit/ml, 2000 unit/ml, 20000 unit/ml, 3000 unit/ml, 4000 unit/ml Epogen (Injection) 4

PA SP

Epoetin Alfa

10000 unit/ml, 2000 unit/ml, 20000 unit/ml, 3000 unit/ml, 4000 unit/ml, 40000 unit/ml Procrit (Injection) 4

PA SP

Filgrastim

300 mcg/0.5ml, 300 mcg/ml, 480 mcg/0.8ml, 480 mcg/1.6ml Neupogen (Injection) 4

PA SP

Filgrastim-sndz 300 mcg/0.5ml, 480 mcg/0.8ml Zarxio (Injection) 4

PA SP

Pegfilgrastim 6 mg/0.6ml Neulasta (Subcutaneous) 4 PA SP

Romiplostim 250 mcg, 500 mcg Nplate (Subcutaneous) 4 PA SP

Sargramostim 250 mcg Leukine (Intravenous) 4 PA SP

Iron (Hierro)

Ferrous Sulfate 220 (44 fe) mg/5ml FeroSul (Oral) 0 LC

Ferrous Sulfate

220 (44 fe) mg/5ml, 300 (60 fe) mg/5ml, 75 (15 fe) mg/ml Ferrous Sulfate (Oral) 0

Ferrous Sulfate 5 mg/20ml Spatone pur-Absorb Iron (Oral) 0 LC

Ferrous Sulfate 75 (15 fe) mg/ml BProtected Pedia Iron (Oral) 0

Ferrous Sulfate 75 (15 fe) mg/ml Fer-In-Sol (Oral) 0

Ferrous Sulfate 75 (15 fe) mg/ml Fer-Iron (Oral) 0 LC

Ferrous Sulfate 75 (15 fe) mg/ml Iron Supplement Childrens (Oral) 0

HEMOSTATICS (Hemostaticos)

Hemostatics - Systemic (Hemostaticos - Sistemicos)

Tranexamic Acid 650 mg Lysteda (Oral) 3

Tranexamic Acid 650 mg Tranexamic Acid (Oral) 1

FMCMPD 01-17 87




Nivel (Tier)

Inst

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS (Hipnoticos/Sendates/Agentes Para Problemas de Sueño)

Barbiturate Hypnotics (Hipnoticos Barbituricos)

Amobarbital Sodium 500 mg Amytal Sodium (Injection) 3

Butabarbital Sodium 30 mg Butisol Sodium (Oral) 3

Pentobarbital Sodium 50 mg/ml Nembutal (Injection) 3

Phenobarbital 100 mg, 15 mg, 30 mg, 60 mg, 64.8 mg, 97.2 mg PHENobarbital (Oral) 3

Phenobarbital 16.2 mg, 20 mg/5ml, 32.4 mg PHENobarbital (Oral) 1

Phenobarbital Sodium 130 mg/ml PHENobarbital Sodium (Injection) 1

Phenobarbital Sodium 65 mg/ml PHENobarbital Sodium (Injection) 3

Secobarbital Sodium 100 mg Seconal (Oral) 3

Hypnotics - Tricyclic Agents (Hipnoticos - Agentes Triciclicos)

Doxepin Hcl 3 mg, 6 mg Silenor (Oral) 2

Non-barbiturate Hypnotics (Hipnoticos No Barbituricos)

Estazolam 1 mg, 2 mg Estazolam (Oral) 1

Eszopiclone 1 mg, 2 mg, 3 mg Eszopiclone (Oral) 1 LC

Eszopiclone 1 mg, 2 mg, 3 mg Lunesta (Oral) 3 LC

Flurazepam Hcl 15 mg, 30 mg Flurazepam HCl (Oral) 1

Midazolam Hcl

10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 2 mg/ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml Midazolam HCl (Injection, Oral) 1

Quazepam 15 mg Doral (Oral) 3

Quazepam 15 mg Quazepam (Oral) 2

Temazepam 15 mg, 22.5 mg, 30 mg, 7.5 mg Restoril (Oral) 3

Temazepam 15 mg, 22.5 mg, 30 mg, 7.5 mg Temazepam (Oral) 1

Triazolam 0.125 mg, 0.25 mg Triazolam (Oral) 1

Triazolam 0.25 mg Halcion (Oral) 3

Zaleplon 10 mg, 5 mg Sonata (Oral) 3 LC

Zaleplon 10 mg, 5 mg Zaleplon (Oral) 1 LC

Zolpidem Tartrate 1.75 mg, 3.5 mg Intermezzo (Sublingual) 3

Zolpidem Tartrate 1.75 mg, 3.5 mg Zolpidem Tartrate (Sublingual) 2

Zolpidem Tartrate 10 mg, 5 mg Ambien (Oral) 3 LC

FMCMPD 01-17 88




Nivel (Tier)

Inst

Zolpidem Tartrate 10 mg, 5 mg Edluar (Sublingual) 3 LC

Zolpidem Tartrate 10 mg, 5 mg Zolpidem Tartrate (Oral) 1 LC

Zolpidem Tartrate 5 mg/act Zolpimist (Oral) 3 LC

Zolpidem Tartrate Er 12.5 mg, 6.25 mg Ambien CR (Oral) 3 LC

Zolpidem Tartrate Er 12.5 mg, 6.25 mg Zolpidem Tartrate ER (Oral) 1 LC

Orexin Receptor Antagonists (Antagonistas De Receptores De Orexina)

Suvorexant 10 mg, 15 mg, 20 mg, 5 mg Belsomra (Oral) 3

Selective Melatonin Receptor Agonists (Agonistas Selectivos De Receptores De Melatonina)

Ramelteon 8 mg Rozerem (Oral) 3 LC

Tasimelteon 20 mg Hetlioz (Oral) 3 PA SP

LAXATIVES (Laxantes)

Laxative Combinations (Combinaciones Laxantes)

Na Sulfate-k Sulfate-mg Sulf Suprep Bowel Prep (Oral) 2

Peg 3350-kcl-na Bicarb-nacl 420 gm GaviLyte-N with Flavor Pack (Oral) 2

Peg 3350-kcl-na Bicarb-nacl 420 gm Nulytely with Flavor Packs (Oral) 3

Peg 3350-kcl-na Bicarb-nacl 420 gm PEG 3350-KCl-Na Bicarb-NaCl (Oral) 1

Peg 3350-kcl-na Bicarb-nacl 420 gm TriLyte (Oral) 2

Peg 3350-kcl-nabcb-nacl-nasulf 227.1 gm, 236 gm Golytely (Oral) 3

Peg 3350-kcl-nabcb-nacl-nasulf 236 gm GaviLyte-G (Oral) 2

Peg 3350-kcl-nabcb-nacl-nasulf 236 gm PEG-3350/Electrolytes (Oral) 1

Peg 3350-kcl-nabcb-nacl-nasulf 240 gm Colyte with Flavor Packs (Oral) 3

Peg 3350-kcl-nabcb-nacl-nasulf 240 gm GaviLyte-C (Oral) 2

Peg 3350-kcl-nabcb-nacl-nasulf 240 gm PEG 3350/Electrolytes (Oral) 1

Peg-kcl-nacl-nasulf-na Asc-c 100 gm MoviPrep (Oral) 3

Sod Picosulfate-mag Ox-cit Acd 10-3.5-12 mg-gm-gm Prepopik (Oral) 3

Laxatives - Miscellaneous (Laxantes - Miscelaneos)

Lactulose 10 gm, 20 gm Kristalose (Oral) 3

Lactulose 10 gm/15ml Constulose (Oral) 2

Lactulose 10 gm/15ml, 20 gm/30ml Lactulose (Oral) 1

FMCMPD 01-17 89




Nivel (Tier)

Inst

Polyethylene Glycol 3350 PEGyLAX (Oral) 2

Polyethylene Glycol 3350 Polyethylene Glycol 3350 (Oral) 1

MACROLIDES (Macrolidos)

Azithromycin (Acitromicina)

Azithromycin 1 gm Azithromycin (Oral) 2

Azithromycin

1 gm, 100 mg/5ml, 200 mg/5ml, 250 mg, 500 mg, 600 mg Zithromax (Oral) 3

Azithromycin 100 mg/5ml, 200 mg/5ml, 250 mg, 500 mg, 600 mg Azithromycin (Oral) 1

Azithromycin 2 gm Zmax (Oral) 3

Azithromycin 250 mg Zithromax Z-Pak (Oral) 3

Azithromycin 500 mg Azithromycin (Intravenous) 4 SP

Azithromycin 500 mg Zithromax (Intravenous) 4 SP

Azithromycin 500 mg Zithromax Tri-Pak (Oral) 3

Clarithromycin (Claritromicina)

Clarithromycin 125 mg/5ml, 250 mg, 250 mg/5ml, 500 mg Clarithromycin (Oral) 1

Clarithromycin 250 mg, 250 mg/5ml, 500 mg Biaxin (Oral) 3

Clarithromycin Er 500 mg Clarithromycin ER (Oral) 1

Erythromycins (Eritromicinas)

Erythromycin Base 250 mg Erythromycin Base (Oral) 1

Erythromycin Base 250 mg, 333 mg, 500 mg Ery-Tab (Oral) 3

Erythromycin Base 250 mg, 500 mg Erythromycin Base (Oral) 3

Erythromycin Base Coated 333 mg, 500 mg PCE (Oral) 3

Erythromycin Ethylsuccinate 200 mg/5ml E.E.S. Granules (Oral) 3

Erythromycin Ethylsuccinate 200 mg/5ml EryPed 200 (Oral) 3

Erythromycin Ethylsuccinate 200 mg/5ml Erythromycin Ethylsuccinate (Oral) 1

Erythromycin Ethylsuccinate 400 mg E.E.S. 400 (Oral) 3

Erythromycin Ethylsuccinate 400 mg Erythromycin Ethylsuccinate (Oral) 3

Erythromycin Ethylsuccinate 400 mg/5ml EryPed 400 (Oral) 3

Erythromycin Stearate 250 mg Erythrocin Stearate (Oral) 3

Fidaxomicin (Fidaxomicina)

Fidaxomicin 200 mg Dificid (Oral) 3

MEDICAL DEVICES AND SUPPLIES (Equipo Medico Y Suplidos)

FMCMPD 01-17 90




Nivel (Tier)

Inst

Contraceptives (Contraceptivos)

Condoms - Female FC Female Condom (Miscellaneous) 0

Condoms - Female FC2 Female Condom (Miscellaneous) 0

Diaphragm Coil Spring 100 mm Ortho Diaphragm Coil (Vaginal) 0

Diaphragm Flat Spring 65 mm Ortho Diaphragm Flat (Vaginal) 0

Diaphragm Wide Seal 2 % Wide-Seal Diaphragm 65 (Vaginal) 0



Diabetic Supplies (Diabetes - Suplidos)

Lancets Advocate Lancets 30G (Miscellaneous) 2

Lancets Advocate Safety Lancets 26G (Miscellaneous) 2

Lancets In Touch Sterile Lancets 30G (Miscellaneous) 2

Parenteral Therapy Supplies (Suplidos Para Terapia Parenteral)

Insulin Pen Needle 29g x 12.7mm Advocate Insulin Pen Needles (Miscellaneous) 2

Insulin Syringe-needle U-100

27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2"

Monoject Insulin Syringe (Miscellaneous) 2


28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Monoject Ultra Comfort Syringe (Miscellaneous) 2


29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/

Magellan Insulin Safety Syr (Miscellaneous) 2

Insulin Syringe-needle U-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

UltiCare Insulin Safety Syr (Miscellaneous) 2

Insulin Syringe-needle U-100 29g x 1/2" 1 ml Assure ID Insulin Safety Syr (Miscellaneous) 2

FMCMPD 01-17 91




Nivel (Tier)

Inst


29g x 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml

Easy Touch FlipLock Insulin Sy (Miscellaneous) 2

Insulin Syringe-needle U-100 31g x 1/4" 0.3 ml Sure Comfort Insulin Syringe (Miscellaneous) 2

Insulin Syringe-needle U-100 31g x 15/64" 0.3 ml BD Insulin Syringe Ultrafine (Miscellaneous) 2

Insulin Syringe-needle U-40 25g x 5/8" 1 ml BD Insulin Syringe U-40 (Miscellaneous) 2

Insulin Syringes (disposable) u-100 0.3 ml, u-100 0.5 ml, u-100 1 ml

Kmart Valu Insulin Syringe 30G (Miscellaneous) 2

Insulin Syringes (disposable) u-100 0.5 ml, u-100 1 ml Kmart Valu Insulin Syringe 29G (Miscellaneous) 2

Insulin Syringes (disposable) u-100 1 ml BD Insulin Syringe (Miscellaneous) 2

Insulin Syringes (disposable) u-100 1 ml Monoject Insulin Syringe (Miscellaneous) 2

MIGRAINE PRODUCTS (Productos Para La Migraña)

Migraine Combinations (Combinaciones Para La Migraña)

Ergotamine-caffeine 1-100 mg Cafergot (Oral) 3

Ergotamine-caffeine 2-100 mg Migergot (Rectal) 3

Isometheptene-caffeine-apap 65-20-325 mg Isometheptene-Caffeine-APAP (Oral) 3

Isometheptene-dichloral-apap 325-65-100 mg Nodolor (Oral) 2

Isometheptene-dichloral-apap 65-100-325 mg Isometheptene-Dichloral-APAP (Oral) 2

Sumatriptan-naproxen Sodium 10-60 mg, 85-500 mg Treximet (Oral) 2 LC

Migraine Products (Productos Para La Migraña)

Dihydroergotamine Mesylate 1 mg/ml D.H.E. 45 (Injection) 3

Dihydroergotamine Mesylate 1 mg/ml Dihydroergotamine Mesylate (Injection) 1

Dihydroergotamine Mesylate 4 mg/ml Dihydroergotamine Mesylate (Nasal) 2 LC

Dihydroergotamine Mesylate 4 mg/ml Migranal (Nasal) 2 LC

Ergotamine Tartrate 2 mg Ergomar (Sublingual) 3

Migraine Products - Nsaids (Productos Para La Migraña - Nsaids)

Diclofenac Potassium 50 mg Cambia (Oral) 3

Serotonin Agonists (Agonistas De Serotonina)

Almotriptan Malate 12.5 mg, 6.25 mg Almotriptan Malate (Oral) 2 LC

Almotriptan Malate 12.5 mg, 6.25 mg Axert (Oral) 3 LC

FMCMPD 01-17 92




Nivel (Tier)

Inst

Eletriptan Hydrobromide 20 mg, 40 mg Relpax (Oral) 2 LC

Frovatriptan Succinate 2.5 mg Frova (Oral) 3 LC

Frovatriptan Succinate 2.5 mg Frovatriptan Succinate (Oral) 2 LC

Naratriptan Hcl 1 mg, 2.5 mg Amerge (Oral) 3 LC

Naratriptan Hcl 1 mg, 2.5 mg Naratriptan HCl (Oral) 1 LC

Rizatriptan Benzoate 10 mg, 5 mg Maxalt (Oral) 3 LC

Rizatriptan Benzoate 10 mg, 5 mg Maxalt-MLT (Oral) 3 LC

Rizatriptan Benzoate 10 mg, 5 mg Rizatriptan Benzoate (Oral) 1 LC

Sumatriptan 20 mg/act, 5 mg/act Imitrex (Nasal) 3 LC

Sumatriptan 20 mg/act, 5 mg/act SUMAtriptan (Nasal) 2 LC

Sumatriptan Succinate 100 mg, 25 mg, 50 mg, 6 mg/0.5ml Imitrex (Oral, Subcutaneous) 3 LC

Sumatriptan Succinate 100 mg, 25 mg, 50 mg, 6 mg/0.5ml

SUMAtriptan Succinate (Oral, Subcutaneous) 1 LC

Sumatriptan Succinate 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose Refill (Subcutaneous) 3 LC

Sumatriptan Succinate 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose System (Subcutaneous) 3 LC

Sumatriptan Succinate 4 mg/0.5ml, 6 mg/0.5ml SUMAtriptan Succinate Refill (Subcutaneous) 1 LC

Sumatriptan Succinate 4 mg/0.5ml, 6 mg/0.5ml Sumavel DosePro (Subcutaneous) 2 LC

Zolmitriptan 2.5 mg, 5 mg ZOLMitriptan (Oral) 1 LC

Zolmitriptan 2.5 mg, 5 mg Zomig (Nasal) 3 LC

Zolmitriptan 2.5 mg, 5 mg Zomig ZMT (Oral) 3 LC

MINERALS & ELECTROLYTES (Minerales y Electrolitos)

Fluoride (Fluoruro)

Sodium Fluoride 0.275 (0.125 f) mg/drop Fluor-a-day (Oral) 0

Sodium Fluoride 0.275 (0.125 f) mg/drop Karidium (Oral) 0

Sodium Fluoride 0.275 (0.125 f) mg/drop NaFrinse Drops (Oral) 0

Sodium Fluoride

0.275 (0.125 f) mg/drop, 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Fluoritab (Oral) 0

Sodium Fluoride 0.275 (0.125 f) mg/drop, 0.55 (0.25 f) mg/drop Flura-Drops (Oral) 0

Sodium Fluoride 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent (Oral) 0

Sodium Fluoride

0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 1.1 (0.5 f) mg/ml, 2.2 (1 f) mg Sodium Fluoride (Oral) 0

FMCMPD 01-17 93




Nivel (Tier)

Inst

Sodium Fluoride 0.55 (0.25 f) mg/0.6ml Fluorabon (Oral) 0

Sodium Fluoride 1.1 (0.5 f) mg, 1.1 (0.5 f) mg/ml, 2.2 (1 f) mg Luride (Oral) 0

Sodium Fluoride 2.2 (1 f) mg Lozi-Flur (Mouth/Throat) 0

Sodium Fluoride 2.2 (1 f) mg NaFrinse (Oral) 0

Sodium (Sodio)

Sodium Chloride Flush 0.9 % Monoject Flush Syringe (Intravenous) 2

Sodium Chloride Flush 0.9 % Monoject Sodium Chloride Flush (Intravenous) 2

Sodium Chloride Flush 0.9 % Saline Flush (Intravenous) 1

Sodium Chloride Flush 0.9 % Sodium Chloride Flush (Intravenous) 1

MOUTH/THROAT/DENTAL AGENTS (Agentes Para La Boca/Garganta/Dentales)

Anesthetics Topical Oral (Anestesicos Orales Topicos)

Benzocaine 20 % Topex Topical Anesthetic (Mouth/Throat) 2

Lidocaine Hcl 2 % Lidocaine Viscous (Mouth/Throat) 1

Lidocaine Hcl 2 %, 3 %, 4 % Lidocaine HCl (External, Mouth/Throat) 1

Anti-infectives - Throat (Antiinfectivos Garganta)

Clotrimazole 1 %, 10 mg Clotrimazole (External, Mouth/Throat) 1



Antiseptics - Mouth/throat (Antisepticos - Boca y Garganta)

Chlorhexidine Gluconate 0.12 % Chlorhexidine Gluconate (Mouth/Throat) 1

Chlorhexidine Gluconate 0.12 % Peridex (Mouth/Throat) 3

Chlorhexidine Gluconate 0.12 % Periogard (Mouth/Throat) 2

Sulfuric Acid-sulf Phenolics 30-50 % Debacterol (Mouth/Throat) 3

Dental Products (Productos Dentales)

Sodium Fluoride 0.05 % NaFrinse Daily/Neutral (Mouth/Throat) 3

Sodium Fluoride 0.2 % CaviRinse (Mouth/Throat) 2

Sodium Fluoride 0.2 % NaFrinse Weekly (Mouth/Throat) 3

Sodium Fluoride 0.2 % Neutral Sodium Fluoride (Mouth/Throat) 2

FMCMPD 01-17 94




Nivel (Tier)

Inst

Sodium Fluoride 0.2 % PreviDent (Mouth/Throat) 3

Sodium Fluoride-phosphoric Acd 1 mg/5ml

NaFrinse Daily Acidulated (Mouth/Throat) 3

Stannous Fluoride 0.63 % Gel-Kam Oral Care Rinse (Mouth/Throat) 3

Periodontal Products (Productos Periodontales)

Minocycline Hcl Dental 1 mg Arestin Dental (Miscellaneous) 3

Steroids - Mouth/throat (Esteroides - Boca/Garganta)


Triamcinolone Acetonide (External, Mouth/Throat, Nasal) 1

Triamcinolone Acetonide 0.1 % Oralone (Mouth/Throat) 2

Throat Products - Misc. (Productos Para La Garganta - Misc.)

Artificial Saliva Aquoral (Mouth/Throat) 3

Artificial Saliva Caphosol (Mouth/Throat) 3

Artificial Saliva NeutraSal (Mouth/Throat) 3

Artificial Saliva Numoisyn (Mouth/Throat) 3

Cevimeline Hcl 30 mg Cevimeline HCl (Oral) 1

Cevimeline Hcl 30 mg Evoxac (Oral) 3

Oral Wound Care Products MuGard (Mouth/Throat) 3

Oral Wound Care Products Mucotrol (Mouth/Throat) 3

Oral Wound Care Products OraMagicRx (Mouth/Throat) 3

Oral Wound Care Products SaliCept (Mouth/Throat) 3

Oral Wound Care Products Pump Episil (Mouth/Throat) 3

Pilocarpine Hcl 1 %, 2 %, 4 %, 5 mg, 7.5 mg

Pilocarpine HCl (Ophthalmic, Oral) 1

Pilocarpine Hcl 5 mg, 7.5 mg Salagen (Oral) 3

Povidone-nahyaluron-glycyrrhet Gelclair (Mouth/Throat) 3

MULTIVITAMINS (Multivitaminas)

Ped Multi Vitamins W/fl & Fe (Multi Vitaminas Ped con FL y FE)

Ped Multivitamins-fl-iron 0.25-6 mg/ml Escavite LQ (Oral) 3

Prenatal Vitamins (Vitaminas Prenatales)

Prenat Fepoly-fehempo-fa-dha 22-6-1-200 mg PreferaOB One (Oral) 2

Prenat Fepoly-fehempo-fa-dha 22-6-1-200 mg VP-HEME One (Oral) 3

Prenat Fepoly-fehempo-fa-omega Oral 28-6-1 & 203 mg

HemeNatal OB + DHA Oral (Miscellaneous) 3

Prenat Mv-min-methylfolate-fa 0.6-0.4 mg Prenate (Oral) 3

Prenat Vit-fe Gly Cys-fa-omega EnBrace HR (Oral) 3

FMCMPD 01-17 95




Nivel (Tier)

Inst

Prenat Vit-fepoly-methylfol-fa 29-0.6-0.4 mg Select-OB (Oral) 3

Prenat W/o A Fecbnfeglu-fa& B6 Oral 20-1 & 25 (2) mg

CitraNatal B-Calm Oral (Miscellaneous) 3

Prenat W/o A Vit-fefum-fepo-fa 130-92.4-1 mg Concept OB (Oral) 3

Prenat W/o A Vit-fefum-fepo-fa 130-92.4-1 mg Folivane-OB (Oral) 3

Prenat W/o A Vit-fefum-fepo-fa 162-115.2-1 mg PureFe OB Plus (Oral) 3

Prenat W/o A Vit-fefum-fepo-fa 20-20-1.25 mg Provida OB (Oral) 3

Prenat W/o A-fe Fum-fa-omega 3 28-1-250 mg Calcium PNV (Oral) 3

Prenat W/o A-fe Fum-fa-omega 3 28-1-250 mg Natelle ONE (Oral) 3

Prenat W/o A-fe Poly Cmplx-fa 60-1 mg Marnatal-F (Oral) 3

Prenat W/o A-fe-fa-ca-omega Oral 32-1-200 mg

Nestabs ABC Oral (Miscellaneous) 3

Prenat W/o A-fe-methf-fa-omega 28-0.6-0.4-340 mg PNV-Omega (Oral) 3

Prenat W/o A-fe-methf-fa-omega 28-0.6-0.4-340 mg Virt-PN Plus (Oral) 3

Prenat W/o A-fe-methf-fa-omega 28-0.6-0.4-340 mg Zatean-Pn Plus (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 27-0.6-0.4-300 mg PNV-DHA (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 27-0.6-0.4-300 mg Rulavite DHA (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 27-0.6-0.4-300 mg Virt-PN DHA (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 27-0.6-0.4-300 mg Zatean-Pn DHA (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 28-0.6-0.4-300 mg Prenate DHA (Oral) 3

Prenat W/o A-fe-methfol-fa-dha 30-0.6-0.4-200 mg VitaMedMD One Rx/Quatrefolic (Oral) 3

Prenat W/o A-fe-methfol-fa-dha Oral 30-0.6-0.4 &300 mg

VitaMedMD Plus Rx/Quatrefolic Oral (Miscellaneous) 3

Prenat W/o A-fecb-fegl-dss-fa 27-1 mg CitraNatal Rx (Oral) 3

Prenat W/o A-fecbgl-dss-fa-dha Oral 27-1 & 250 mg

CitraNatal DHA Oral (Miscellaneous) 3


PNV OB+DHA Oral (Miscellaneous) 3


CitraNatal Assure Oral (Miscellaneous) 3


Focalgin CA Oral (Miscellaneous) 3


CitraNatal 90 DHA Oral (Miscellaneous) 3

FMCMPD 01-17 96




Nivel (Tier)

Inst


Focalgin 90 DHA Oral (Miscellaneous) 3

Prenat W/o A-fecbn-dss-fa-dha 27-1-250 mg Zatean-CH (Oral) 3

Prenat W/o A-fecbn-dss-fa-dha 28-1-250 mg Macnatal CN DHA (Oral) 3

Prenat W/o A-fecbn-dss-fa-dha 28-1-250 mg Prenaissance Plus (Oral) 3

Prenat W/o A-fecbn-dss-fa-dha 29-1-265 mg Infanate Balance (Oral) 3

Prenat W/o A-fecbn-dss-fa-dha 30-1-260 mg Prenaissance Balance (Oral) 3

Prenat W/o A-fecbn-dss-fa-dha 30-1-260 mg VP-CH-PNV (Oral) 3

Prenat W/o A-fecbn-meth-fa-dha 27.5-1-200 mg OB Complete Gold (Oral) 3

Prenat W/o A-fecbn-meth-fa-dha 31-0.6-0.4-200 mg TriStart DHA (Oral) 3

Prenat W/o A-fefum-fa&fish Oil Oral 27-1 mg

TriCare Prenatal Compleat Oral (Miscellaneous) 3

Prenat W/oa-fefum-methf-omegas 27-1.13 mg Neevo DHA (Oral) 2

Prenat-b2-b6-b12-d3-fa 1.4 mg Prena1 (Oral) 3

Prenat-b2-b6-b12-d3-fa 1.4 mg VitaMedMD RediChew Rx (Oral) 3

Prenat-fe Bisgly-fa-w/o Vit A 32-1 mg Nestabs (Oral) 3

Prenat-fe Bisgly-fa-w/o Vit A 32-1 mg Newgen (Oral) 3

Prenat-fe Poly-methfol-fa-dha 29-0.6-0.4-200 mg Vitafol Ultra (Oral) 3

Prenat-fe-methyl-dss-dha W/o A 38-1-225 mg Folet One (Oral) 3

Prenat-fe-methyl-dss-dha W/o A 38-1-225 mg Obstetrix One (Oral) 3

Prenat-feasp-meth-fa-dha W/o A 10-0.6-0.4-200 mg Prenate Pixie (Oral) 3

Prenat-feasp-meth-fa-dha W/o A 18-0.6-0.4-300 mg Prenate DHA (Oral) 3

Prenat-feasp-meth-fa-dha W/o A 18-0.6-0.4-300 mg Prenate Essential (Oral) 3

Prenat-febis-fepro-fa-ca-omega Oral 29-1-200 & 250 mg

Complete Natal DHA Oral (Miscellaneous) 3


PR Natal 400 Oral (Miscellaneous) 3


Triveen-Duo DHA Oral (Miscellaneous) 3

Prenat-febis-fepro-fa-ca-omega Oral 29-1-200 & 400 mg (dr)

PR Natal 400 ec Oral (Miscellaneous) 3

FMCMPD 01-17 97




Nivel (Tier)

Inst


PR Natal 430 Oral (Miscellaneous) 3

Prenat-febis-fepro-fa-ca-omega Oral 29-1-200 & 430 mg (dr)

PR Natal 430 ec Oral (Miscellaneous) 3

Prenat-fecbn-feas-fa-dss-omega 20-7-1 mg UltimateCare ONE NF (Oral) 3

Prenat-fecbn-feasp-meth-fa-dha 18-0.6-0.4-350 mg Prenate Mini (Oral) 3

Prenat-fecbn-feaspgl-fa-fish 50-1-476 mg OB Complete One (Oral) 3

Prenat-fecbn-feaspgl-fa-omega 30-10-1-200 mg OB Complete/DHA (Oral) 3

Prenat-fecbn-feaspgl-fa-omega 35-5-1-200 mg OB Complete Petite (Oral) 3

Prenat-fecbn-febisg-fa-fishoil 35-5-1.2 mg PNV-Total (Oral) 3

Prenat-fechel-fa-dha W/o Vit A Oral 30-1.4 & 300 mg VitaTrue Oral (Miscellaneous) 3

Prenat-fefum-doc-fa-dha W/o A 29-1.25-350 mg Extra-Virt Plus DHA (Oral) 3

Prenat-fefum-doc-fa-dha W/o A 29-1.25-350 mg Nexa Plus (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 26-1.2-300 mg Triveen-PRx RNF (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 26-1.2-300 mg VirtPrex (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 27-1.25-300 mg Folcal DHA (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 27-1.25-300 mg PNV-DHA+Docusate (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 27-1.25-300 mg VemaVite-PRx 2 (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 29-1.25-325 mg Prenaissance (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 29-1.25-325 mg TL-Select (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 29-1.25-325 mg Virt-Select (Oral) 3

Prenat-fefum-dss-fa-dha W/o A 30-1.2-265 mg Taron-Prex (Oral) 3

Prenat-fefum-fepo-fa-dha W/o A 16-16-1.25-110 mg Provida DHA (Oral) 3

Prenat-fefum-fepo-fa-omega 3 53.5-38-1 mg Concept DHA (Oral) 3

Prenat-fefum-fepo-fa-omega 3 53.5-38-1 mg Dothelle DHA (Oral) 3

FMCMPD 01-17 98




Nivel (Tier)

Inst

Prenat-fefum-fepo-fa-omega 3 53.5-38-1 mg Taron-C DHA (Oral) 3

Prenat-fefum-fepo-fa-omega 3 53.5-38-1 mg Virt-C DHA (Oral) 3

Prenat-fepoly-fered-fa-omega 3 Oral 25-1 & 267 mg

Duet DHA Balanced Oral (Miscellaneous) 3


Duet DHA 400 Oral (Miscellaneous) 3


Prenaissance Harmony DHA Oral (Miscellaneous) 3


Bal-Care DHA Oral (Miscellaneous) 3


Vena-Bal DHA Oral (Miscellaneous) 3

Prenat-fepoly-metf-fa-dha-dss 90-1-200 & 50 mg Vitafol FE+ (Oral) 3

Prenat-fepyro-mfol W/o A & Dha 4.5-1 & 150 mg TriCare Prenatal (Oral) 3

Prenat-w/oa-fe Bisgly-fa-omega Oral 32-1 mg

Nestabs DHA Oral (Miscellaneous) 3

Prenat-w/oa-fe Bisgly-fa-omega Oral 32-1 mg

Tri-Tabs DHA Oral (Miscellaneous) 3

Prenatal Ca-b6-b12-fa-ginger 1 mg Prenate AM (Oral) 3

Prenatal Calcium-b6-fa-ginger 1.2 mg Prenaissance Next (Oral) 3

Prenatal Calcium-b6-fa-ginger 1.2 mg VP-GGR-B6 Prenatal (Oral) 3

Prenatal Multivit-min-fe-fa Mynatal (Oral) 3

Prenatal Mv-min-fe Fum-fa-dha Oral 65-1 & 250 mg

Vitafol-OB+DHA Oral (Miscellaneous) 3

Prenatal Vit W/ Fe Bisg-fa 29-1 mg Vinate II (Oral) 3

Prenatal Vit W/fe-methylfol-fa 26-0.6-0.4 mg Prenate Elite (Oral) 3

Prenatal Vit W/fe-methylfol-fa 27-0.5-0.5 mg TL Folate (Oral) 3

Prenatal Vit W/fe-methylfol-fa 27-0.6-0.4 mg Virt-PN (Oral) 3

Prenatal Vit-docusate-iron-fa Vita-Pren (Oral) 3

Prenatal Vit-dss-fe Cbn-fa Inatal GT (Oral) 3

Prenatal Vit-dss-fe Cbn-fa Mynatal Advance (Oral) 3

Prenatal Vit-dss-fe Cbn-fa iNatal Advance (Oral) 3

Prenatal Vit-dss-fe Cbn-fa iNatal Ultra (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 29-1 mg Atabex EC (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 29-1 mg Obstetrix EC (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 90-1 mg Mynatal (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 90-1 mg TriAdvance (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 90-1 mg Trinatal GT (Oral) 3

FMCMPD 01-17 99




Nivel (Tier)

Inst

Prenatal Vit-dss-fe Cbn-fa 90-1 mg Virt-Advance (Oral) 3

Prenatal Vit-dss-fe Cbn-fa 90-1 mg Virt-Vite GT (Oral) 3

Prenatal Vit-dss-fe Fum-fa , 29-1 mg Prenatal 19 (Oral) 3

Prenatal Vit-dss-fe Fum-fa 29-1 mg PNV Fe Fum/Docusate/Folic Acid (Oral) 2

Prenatal Vit-dss-fe Fum-fa 29-1 mg Se-Natal 19 (Oral) 3

Prenatal Vit-dss-fe Fum-fa 29-1 mg Thrivite 19 (Oral) 3

Prenatal Vit-dss-fe Fum-fa Er Mynate 90 Plus (Oral) 3

Prenatal Vit-fe Fum-fa-omega 28-1-200 mg C-Nate DHA (Oral) 3

Prenatal Vit-fe Fum-fa-omega 28-1-200 mg Relnate DHA (Oral) 3

Prenatal Vit-fe Fum-fa-omega 28-1-200 mg Virt-Nate DHA (Oral) 3

Prenatal Vit-fe Fum-fa-omega 28-1-200 mg Viva DHA (Oral) 3

Prenatal Vit-fe Fum-fa-omega 28-1-215.8 mg VP-PNV-DHA (Oral) 3

Prenatal Vit-fe Fum-fe Bisg-fa 28-1 mg NataChew (Oral) 3

Prenatal Vit-fe Fumarate-fa Co-Natal FA (Oral) 3

Prenatal Vit-fe Fumarate-fa M-Vit (Oral) 3

Prenatal Vit-fe Fumarate-fa Mynatal Plus (Oral) 3

Prenatal Vit-fe Fumarate-fa Mynatal-Z (Oral) 3

Prenatal Vit-fe Fumarate-fa Natalvit (Oral) 3

Prenatal Vit-fe Fumarate-fa O-Cal Prenatal (Oral) 3

Prenatal Vit-fe Fumarate-fa TriCare (Oral) 3

Prenatal Vit-fe Fumarate-fa Trinate (Oral) 3

Prenatal Vit-fe Fumarate-fa Vitafol-OB (Oral) 3

Prenatal Vit-fe Fumarate-fa , 29-1 mg Prenatal 19 (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg Niva-Plus (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg O-Cal FA (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg PNV Folic Acid + Iron (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg PNV Prenatal Plus Multivitamin (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg Prenatal (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg Prenatal Low Iron (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg Prenatal Vitamin Plus Low Iron (Oral) 3

Prenatal Vit-fe Fumarate-fa 27-1 mg Vol-Plus (Oral) 3

Prenatal Vit-fe Fumarate-fa 28-1 mg Virt Nate (Oral) 3

Prenatal Vit-fe Fumarate-fa 28-1 mg Vol-Nate (Oral) 3

Prenatal Vit-fe Fumarate-fa 29-1 mg CompleteNate (Oral) 3

Prenatal Vit-fe Fumarate-fa 29-1 mg PreTAB (Oral) 3

Prenatal Vit-fe Fumarate-fa 29-1 mg Se-Natal 19 (Oral) 3

FMCMPD 01-17 100




Nivel (Tier)

Inst

Prenatal Vit-fe Fumarate-fa 60-1 mg Trinatal Rx 1 (Oral) 3

Prenatal Vit-fe Fumarate-fa 60-1 mg Vinate One (Oral) 3

Prenatal Vit-fe Phos-fa-omega 3.33-0.333-34.8 mg Vitafol Gummies (Oral) 3

Prenatal Vit-fe Psac Cmplx-fa 29-1 mg Select-OB (Oral) 3

Prenatal Vit-fepoly-fa-dha 29-1-200 mg Vitafol-One (Oral) 3

Prenatal Vit-fepoly-fa-dha Oral 29-1 & 250 mg Select-OB+DHA Oral (Miscellaneous) 3

Prenatal Vit-fepoly-fehempo-fa 28-6-1 mg HemeNatal OB (Oral) 3

Prenatal Vit-fepoly-fehempo-fa 34-1 mg Prefera OB (Oral) 3

Prenatal Vit-iron Carbonyl-fa 29-1 mg PNV Tabs 29-1 (Oral) 3

Prenatal Vit-iron Carbonyl-fa 29-1 mg Prenatabs Rx (Oral) 3

Prenatal Vit-iron Carbonyl-fa 29-1 mg Prenatal Plus Iron (Oral) 3

Prenatal Vit-iron Carbonyl-fa 29-1 mg Thrivite Rx (Oral) 3

Prenatal Vit-iron Carbonyl-fa 29-1 mg Vol-Tab Rx (Oral) 3

Prenatal Vit-iron Carbonyl-fa 50-1.25 mg Elite-OB (Oral) 3

Prenatal Vit-iron Carbonyl-fa 50-1.25 mg OB Complete (Oral) 3

Prenatal Vit-sel-fe Fum-fa 27-1 mg Vinate M (Oral) 3

Prenatal W/o A Vit-fe Fum-fa 106.5-1 mg PNV-VP-U (Oral) 3

Prenatal W/o A Vit-fe Fum-fa 106.5-1 mg Prenatal-U (Oral) 3

Prenatal W/o A Vit-fe Fum-fa 29-1 mg PreNata (Oral) 3

Prenatal W/o Vit A-fecbn-fa-b6 Oral 20-1 & 25 (2) mg Taron-Bc Oral (Miscellaneous) 3

Prenatal-fe Asparto Gly-fa 20-1 mg Prenate Star (Oral) 3

Prenatal-fe Cbn-dss-fa-dha 15-25-0.5-50 mg PreQue 10 (Oral) 3

Prenatal-fe Cbn-fa-dha W/o A 20-1-320 mg Active OB (Oral) 3

Prenatal-fe Cbn-fe Asp Gly-fa 30-20-1 mg OB Complete Premier (Oral) 3

Prenatal-fe Pyroph-methf W/o A 4.5-1 mg TriCare Prenatal (Oral) 3

Prenatal-fe-methylfol-fa-dha 27-1.13-0.4 mg Levomefolate DHA (Oral) 3

Prenatal-feaspgly-methylfol-fa 20-0.6-0.4 mg Prenate Elite (Oral) 3

Prenatal-fecbn-fa-dss-omega 3 Oral 29-1 & 387 mg

Obstetrix DHA Oral (Miscellaneous) 3

Prenatal-fecbn-feaspgl-fa-omeg 27-1 mg Folcaps Omega 3 (Oral) 3

Prenatal-fecbn-feaspgl-fa-omeg 27-1 mg UltimateCare ONE (Oral) 3

Prenatal-fecbn-feaspgl-fa-omeg 27-1 mg Virt-Care One (Oral) 3

Prenatal-fefum-fa-dss-fish Oil 27-1-500 mg TL-Care DHA (Oral) 3

FMCMPD 01-17 101




Nivel (Tier)

Inst

Prenatal-fefum-fa-dss-fish Oil 27-1-500 mg TriCare Prenatal DHA ONE (Oral) 3

MUSCULOSKELETAL THERAPY AGENTS (Agentes Para Terapia Musculoesqueletal)

Central Muscle Relaxants (Relajantes Del Sistema Muscular)

Baclofen 10 mg, 20 mg Baclofen (Oral) 1

Carisoprodol 250 mg Carisoprodol (Oral) 2

Carisoprodol 250 mg, 350 mg Soma (Oral) 3

Carisoprodol 350 mg Carisoprodol (Oral) 1

Chlorzoxazone 375 mg, 750 mg Lorzone (Oral) 3

Chlorzoxazone 500 mg Chlorzoxazone (Oral) 1

Chlorzoxazone 500 mg Parafon Forte DSC (Oral) 3

Cyclobenzaprine Hcl 10 mg, 5 mg, 7.5 mg Cyclobenzaprine HCl (Oral) 1

Cyclobenzaprine Hcl Er 15 mg, 30 mg Amrix (Oral) 3

Cyclobenzaprine Hcl-liniment 10 mg Cyclobenzaprine Comfort Pac (Combination) 3

Metaxalone 400 mg Metaxalone (Oral) 3

Metaxalone 800 mg Metaxalone (Oral) 1

Metaxalone 800 mg Skelaxin (Oral) 3

Methocarbamol 1000 mg/10ml Methocarbamol (Injection) 2

Methocarbamol 1000 mg/10ml, 500 mg Robaxin (Injection, Oral) 3

Methocarbamol 500 mg, 750 mg Methocarbamol (Oral) 1

Methocarbamol 750 mg Robaxin-750 (Oral) 3

Orphenadrine Citrate 30 mg/ml Orphenadrine Citrate (Injection) 1

Orphenadrine Citrate Er 100 mg Orphenadrine Citrate ER (Oral) 1

Tizanidine Hcl 2 mg, 4 mg, 6 mg TiZANidine HCl (Oral) 1

Tizanidine Hcl 2 mg, 4 mg, 6 mg Zanaflex (Oral) 3

Direct Muscle Relaxants (Relajantes Musculares Directos)

Dantrolene Sodium 100 mg, 25 mg, 50 mg Dantrolene Sodium (Oral) 1

Dantrolene Sodium 25 mg, 50 mg Dantrium (Oral) 3

Muscle Relaxant Combinations (Combinaciones De Relajantes Musculares)

Carisoprodol-aspirin 200-325 mg Carisoprodol-Aspirin (Oral) 1

Carisoprodol-aspirin-codeine 200-325-16 mg Carisoprodol-Aspirin-Codeine (Oral) 1

NASAL AGENTS - SYSTEMIC AND TOPICAL (Agentes Nasales - Sistemicos y Topicos)

Nasal Agent Combinations (Combinaciones De Agentes Nasales)

Azelastine-fluticasone 137-50 mcg/act Dymista (Nasal) 2

Nasal Anti-infectives (Antiinfectivos Nasales)

Mupirocin Calcium 2 % Bactroban (Nasal) 3

Nasal Antiallergy (Antialergicos Nasales)

FMCMPD 01-17 102




Nivel (Tier)

Inst

Azelastine Hcl 0.05 %, 0.1 % Azelastine HCl (Ophthalmic, Nasal) 1

Azelastine Hcl 0.15 % Astepro (Nasal) 3

Azelastine Hcl 0.15 % Azelastine HCl (Nasal) 2

Olopatadine Hcl 0.6 % Olopatadine HCl (Nasal) 1

Olopatadine Hcl 0.6 % Patanase (Nasal) 3

Nasal Anticholinergics (Anticolinergicos Nasales)

Ipratropium Bromide 0.02 %, 0.03 %, 0.06 % Ipratropium Bromide (Inhalation, Nasal) 1

Nasal Steroids (Esteroides Nasales)

Beclomethasone Diprop Monohyd 42 mcg/spray Beconase AQ (Nasal) 3

LC TE

Beclomethasone Dipropionate 40 mcg/act Qnasl Childrens (Nasal) 2 TE

Beclomethasone Dipropionate 80 mcg/act Qnasl (Nasal) 2 TE

Budesonide 32 mcg/act Budesonide (Nasal) 2 LC TE

Budesonide 32 mcg/act Rhinocort Aqua (Nasal) 3 LC TE

Ciclesonide 37 mcg/act Zetonna (Nasal) 3 LC TE

Ciclesonide 50 mcg/act Omnaris (Nasal) 3 LC TE

Flunisolide 25 mcg/act (0.025%) Flunisolide (Nasal) 1 LC TE

Fluticasone Furoate 27.5 mcg/spray Veramyst (Nasal) 3 LC TE

Fluticasone Propionate 0.005 %, 0.05 %, 50 mcg/act

Fluticasone Propionate (External, Nasal) 1 LC

Mometasone Furoate 50 mcg/act Mometasone Furoate (Nasal) 2 LC TE

Mometasone Furoate 50 mcg/act Nasonex (Nasal) 3 LC TE


Triamcinolone Acetonide (External, Mouth/Throat, Nasal) 1 TE

Sympathomimetic Decongestants (Descongestionantes Simpatomimeticos)

Epinephrine Hcl (nasal) 0.1 % Adrenalin (Nasal) 3

Tetrahydrozoline Hcl 0.05 % Tyzine (Nasal) 3

NEUROMUSCULAR AGENTS (Agentes Neuromusculares)

Als Agents (Agentes ALS)

Riluzole 50 mg Rilutek (Oral) 3

Riluzole 50 mg Riluzole (Oral) 1

FMCMPD 01-17 103




Nivel (Tier)

Inst

OPHTHALMIC AGENTS (Agentes Oftalmicos)

Artificial Tears And Lubricants (Lagrimas Artificiales y Lubricantes)

Artificial Tear Insert 5 mg Lacrisert (Ophthalmic) 3

Polyvinyl Alcohol 1.4 % Polyvinyl Alcohol (Ophthalmic) 1

Beta-blockers - Ophthalmic (Bloqueadores Beta - Oftalmicos)

Betaxolol Hcl 0.25 % Betoptic-S (Ophthalmic) 3

Betaxolol Hcl 0.5 %, 10 mg, 20 mg Betaxolol HCl (Ophthalmic, Oral) 1

Brimonidine Tartrate-timolol 0.2-0.5 % Combigan (Ophthalmic) 2

Carteolol Hcl 1 % Carteolol HCl (Ophthalmic) 1

Dorzolamide Hcl-timolol Mal 22.3-6.8 mg/ml Cosopt (Ophthalmic) 3

Dorzolamide Hcl-timolol Mal 22.3-6.8 mg/ml Dorzolamide HCl-Timolol Mal (Ophthalmic) 1

Dorzolamide Hcl-timolol Mal Pf 22.3-6.8 mg/ml Cosopt PF (Ophthalmic) 3

Levobunolol Hcl 0.5 % Betagan (Ophthalmic) 3

Levobunolol Hcl 0.5 % Levobunolol HCl (Ophthalmic) 1

Metipranolol 0.3 % Metipranolol (Ophthalmic) 1

Timolol Hemihydrate 0.25 %, 0.5 % Betimol (Ophthalmic) 3

Timolol Maleate 0.25 %, 0.5 % Timolol Maleate (Ophthalmic) 1

Timolol Maleate 0.25 %, 0.5 % Timoptic (Ophthalmic) 3

Timolol Maleate 0.25 %, 0.5 % Timoptic-XE (Ophthalmic) 3

Timolol Maleate 0.5 % Istalol (Ophthalmic) 3

Timolol Maleate Pf 0.25 %, 0.5 % Timoptic Ocudose (Ophthalmic) 3

Cycloplegic Mydriatics (Midriáticos Ciclopléjicos)

Atropine Sulfate 0.05 mg/ml, 0.8 mg/ml, 1 % Atropine Sulfate (Injection, Ophthalmic) 3

Cyclopentolate Hcl 0.5 %, 1 %, 2 % Cyclogyl (Ophthalmic) 3

Cyclopentolate Hcl 1 %, 2 % Cyclopentolate HCl (Ophthalmic) 1

Cyclopentolate-phenylephrine 0.2-1 % Cyclomydril (Ophthalmic) 3

Homatropine Hbr 5 % Homatropaire (Ophthalmic) 2

Homatropine Hbr 5 % Homatropine HBr (Ophthalmic) 1

Homatropine Hbr 5 % Isopto Homatropine (Ophthalmic) 3

Tropicamide 0.5 %, 1 % Tropicamide (Ophthalmic) 1

Tropicamide 1 % Mydriacyl (Ophthalmic) 3

Miotics (Mioticos)

FMCMPD 01-17 104




Nivel (Tier)

Inst

Echothiophate Iodide 0.125 % Phospholine Iodide (Ophthalmic) 3

Pilocarpine Hcl 1 %, 2 %, 4 % Isopto Carpine (Ophthalmic) 3

Pilocarpine Hcl 1 %, 2 %, 4 %, 5 mg, 7.5 mg

Pilocarpine HCl (Ophthalmic, Oral) 1

Ophthalmic Adrenergic Agents (Agentes Adrenergicos Oftalmicos)

Apraclonidine Hcl 0.5 % Apraclonidine HCl (Ophthalmic) 1

Apraclonidine Hcl 0.5 %, 1 % Iopidine (Ophthalmic) 3

Brimonidine Tartrate 0.1 % Alphagan P (Ophthalmic) 2

Brimonidine Tartrate 0.15 % Alphagan P (Ophthalmic) 3

Brimonidine Tartrate 0.15 %, 0.2 % Brimonidine Tartrate (Ophthalmic) 1

Brinzolamide-brimonidine 1-0.2 % Simbrinza (Ophthalmic) 3

Ophthalmic Anti-infectives (Antiinfectivos Oftalmicos)

Azithromycin 1 % AzaSite (Ophthalmic) 3

Bacitracin 500 unit/gm Bacitracin (Ophthalmic) 3

Bacitracin-polymyxin B 500-10000 unit/gm AK-Poly-Bac (Ophthalmic) 2

Bacitracin-polymyxin B 500-10000 unit/gm Bacitracin-Polymyxin B (Ophthalmic) 1

Bacitracin-polymyxin B 500-10000 unit/gm Polycin (Ophthalmic) 2

Besifloxacin Hcl 0.6 % Besivance (Ophthalmic) 2

Ciprofloxacin Hcl 0.3 % Ciloxan (Ophthalmic) 3

Ciprofloxacin Hcl 0.3 %, 100 mg, 250 mg, 500 mg, 750 mg

Ciprofloxacin HCl (Ophthalmic, Oral) 1

Erythromycin 5 mg/gm Erythromycin (Ophthalmic) 1

Erythromycin 5 mg/gm Ilotycin (Ophthalmic) 2

Ganciclovir 0.15 % Zirgan (Ophthalmic) 3

Gatifloxacin 0.5 % Gatifloxacin (Ophthalmic) 1

Gatifloxacin 0.5 % Zymaxid (Ophthalmic) 2

Gentamicin Sulfate 0.3 % Gentak (Ophthalmic) 2

Gentamicin Sulfate 0.3 %, 10 mg/ml, 40 mg/ml Gentamicin Sulfate (Ophthalmic, Injection) 1

Levofloxacin 0.5 %, 25 mg/ml, 250 mg, 500 mg, 750 mg Levofloxacin (Ophthalmic, Oral) 1

Mitomycin 0.2 mg Mitosol (Ophthalmic) 3

Moxifloxacin Hcl 0.5 % Vigamox (Ophthalmic) 2

Moxifloxacin Hcl (2x Day) 0.5 % Moxeza (Ophthalmic) 2

Natamycin 5 % Natacyn (Ophthalmic) 3

FMCMPD 01-17 105




Nivel (Tier)

Inst

Neomycin-bacitracin Zn-polymyx 3.5-400-10000 Neo-Polycin (Ophthalmic) 2

Neomycin-bacitracin Zn-polymyx 5-400-10000

Neomycin-Bacitracin Zn-Polymyx (Ophthalmic) 1

Ofloxacin 0.3 % Ocuflox (Ophthalmic) 3

Ofloxacin 0.3 %, 400 mg Ofloxacin (Ophthalmic, Oral) 1

Polymyxin B-trimethoprim 10000-0.1 unit/ml-% Polymyxin B-Trimethoprim (Ophthalmic) 1

Polymyxin B-trimethoprim 10000-0.1 unit/ml-% Polytrim (Ophthalmic) 3

Povidone-iodine 5 % Betadine (Ophthalmic) 3

Sulfacetamide Sodium 10 % Bleph-10 (Ophthalmic) 3

Sulfacetamide Sodium 10 % Sulfacetamide Sodium (Ophthalmic) 3

Sulfacetamide Sodium 10 %, 10 % (cleans) Sulfacetamide Sodium (Ophthalmic, External) 1

Tobramycin 0.3 % Tobramycin (Ophthalmic) 1

Tobramycin 0.3 % Tobrex (Ophthalmic) 3

Trifluridine 1 % Trifluridine (Ophthalmic) 1

Trifluridine 1 % Viroptic (Ophthalmic) 3

Ophthalmic Decongestants (Descongestionantes Oftamilcos)

Phenylephrine Hcl 10 %, 2.5 % Altafrin (Ophthalmic) 2

Phenylephrine Hcl 10 %, 2.5 % Phenylephrine HCl (Ophthalmic) 1

Ophthalmic Immunomodulators (Inmunomoduladores Oftalmicos)

Cyclosporine 0.05 % Restasis (Ophthalmic) 2 PA

Ophthalmic Local Anesthetics (Anestesia Local Oftalmica)

Lidocaine Hcl 3.5 % Akten (Ophthalmic) 3

Proparacaine Hcl 0.5 % Alcaine (Ophthalmic) 3

Proparacaine Hcl 0.5 % Proparacaine HCl (Ophthalmic) 1

Tetracaine Hcl 0.5 % Altacaine (Ophthalmic) 2

Tetracaine Hcl 0.5 % Tetcaine (Ophthalmic) 2

Tetracaine Hcl 0.5 % TetraVisc (Ophthalmic) 2

Tetracaine Hcl 0.5 % TetraVisc Forte (Ophthalmic) 2

Tetracaine Hcl 0.5 % Tetracaine HCl (Ophthalmic) 1

Ophthalmic Steroids (Esteroides Oftalmicos)

Bacitracin-polymyx-neo-hc 1 % Bacitra-Neomycin-Polymyxin-HC (Ophthalmic) 1

Bacitracin-polymyx-neo-hc 1 % Neo-Polycin HC (Ophthalmic) 2

FMCMPD 01-17 106




Nivel (Tier)

Inst

Dexamethasone 0.1 % Maxidex (Ophthalmic) 3

Dexamethasone Sodium Phosphate

0.1 %, 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml

Dexamethasone Sodium Phosphate (Ophthalmic, Injection) 1

Difluprednate 0.05 % Durezol (Ophthalmic) 2

Fluorometholone 0.1 % FML (Ophthalmic) 3

Fluorometholone 0.1 % FML Liquifilm (Ophthalmic) 3

Fluorometholone 0.1 % Fluorometholone (Ophthalmic) 1

Fluorometholone 0.25 % FML Forte (Ophthalmic) 3

Fluorometholone Acetate 0.1 % Flarex (Ophthalmic) 3

Gentamicin-prednisolone Acet 0.3-0.6 % Pred-G S.O.P. (Ophthalmic) 3

Gentamicin-prednisolone Acet 0.3-1 % Pred-G (Ophthalmic) 3

Loteprednol Etabonate 0.2 % Alrex (Ophthalmic) 2

Loteprednol Etabonate 0.5 % Lotemax (Ophthalmic) 2

Loteprednol-tobramycin 0.5-0.3 % Zylet (Ophthalmic) 2

Neomycin-polymyxin-dexameth 0.1 %, 3.5-10000-0.1

Neomycin-Polymyxin-Dexameth (Ophthalmic) 1

Neomycin-polymyxin-dexameth 3.5-10000-0.1 Maxitrol (Ophthalmic) 3

Neomycin-polymyxin-hc 3.5-10000-1 Neomycin-Polymyxin-HC (Ophthalmic) 3

Prednisolone Acetate 0.12 % Pred Mild (Ophthalmic) 3

Prednisolone Acetate 1 % Omnipred (Ophthalmic) 3

Prednisolone Acetate 1 % Pred Forte (Ophthalmic) 3

Prednisolone Acetate 1 % PrednisoLONE Acetate (Ophthalmic) 1

Prednisolone Sodium Phosphate 1 %, 25 mg/5ml

PrednisoLONE Sodium Phosphate (Ophthalmic, Oral) 3

Sulfacetamide-prednisolone 10-0.2 % Blephamide (Ophthalmic) 3

Sulfacetamide-prednisolone 10-0.2 % Blephamide S.O.P. (Ophthalmic) 3

Sulfacetamide-prednisolone 10-0.23 % Sulfacetamide-Prednisolone (Ophthalmic) 1

Tobramycin-dexamethasone 0.3-0.05 % TobraDex ST (Ophthalmic) 2

Tobramycin-dexamethasone 0.3-0.1 % TobraDex (Ophthalmic) 2

Tobramycin-dexamethasone 0.3-0.1 % Tobramycin-Dexamethasone (Ophthalmic) 1

Ophthalmics - Misc. (Oftalmicos - Misc.)

Alcaftadine 0.25 % Lastacaft (Ophthalmic) 3

FMCMPD 01-17 107




Nivel (Tier)

Inst

Azelastine Hcl 0.05 %, 0.1 % Azelastine HCl (Ophthalmic, Nasal) 1

Bepotastine Besilate 1.5 % Bepreve (Ophthalmic) 3

Brinzolamide 1 % Azopt (Ophthalmic) 2

Bromfenac Sodium 0.07 % Prolensa (Ophthalmic) 3

Bromfenac Sodium 0.09 % Bromfenac Sodium (Ophthalmic) 3

Bromfenac Sodium (once-daily) 0.09 % Bromfenac Sodium (Once-Daily) (Ophthalmic) 3

Cromolyn Sodium 20 mg/2ml, 4 % Cromolyn Sodium (Inhalation, Ophthalmic) 1

Cysteamine Hcl 0.44 % Cystaran (Ophthalmic) 4 SP



Dorzolamide Hcl 2 % Dorzolamide HCl (Ophthalmic) 1

Dorzolamide Hcl 2 % Trusopt (Ophthalmic) 3

Emedastine Difumarate 0.05 % Emadine (Ophthalmic) 3

Epinastine Hcl 0.05 % Elestat (Ophthalmic) 3

Epinastine Hcl 0.05 % Epinastine HCl (Ophthalmic) 1

Flurbiprofen Sodium 0.03 % Flurbiprofen Sodium (Ophthalmic) 1

Flurbiprofen Sodium 0.03 % Ocufen (Ophthalmic) 3

Ketorolac Tromethamine 0.4 % Acular LS (Ophthalmic) 3

Ketorolac Tromethamine

0.4 %, 0.5 %, 10 mg, 15 mg/ml, 30 mg/ml, 60 mg/2ml

Ketorolac Tromethamine (Ophthalmic, Oral, Injection) 1

Ketorolac Tromethamine 0.45 % Acuvail (Ophthalmic) 3

Ketorolac Tromethamine 0.5 % Acular (Ophthalmic) 3

Ketotifen Fumarate 0.025 % Ketotifen Fumarate (Ophthalmic) 1

Lodoxamide Tromethamine 0.1 % Alomide (Ophthalmic) 3

Nedocromil Sodium 2 % Alocril (Ophthalmic) 3

Nepafenac 0.1 % Nevanac (Ophthalmic) 3

Nepafenac 0.3 % Ilevro (Ophthalmic) 3

Olopatadine Hcl 0.1 % Olopatadine HCl (Ophthalmic) 2

Olopatadine Hcl 0.1 % Patanol (Ophthalmic) 3

Olopatadine Hcl 0.2 % Pataday (Ophthalmic) 2

Prostaglandins - Ophthalmic (Prostaglandinas Oftalmicas)

Bimatoprost 0.01 % Lumigan (Ophthalmic) 2

FMCMPD 01-17 108




Nivel (Tier)

Inst

Latanoprost 0.005 % Latanoprost (Ophthalmic) 1

Latanoprost 0.005 % Xalatan (Ophthalmic) 3

Tafluprost 0.0015 % Zioptan (Ophthalmic) 3

Travoprost (bak Free) 0.004 % Travatan Z (Ophthalmic) 2

Unoprostone Isopropyl 0.15 % Rescula (Ophthalmic) 3

OTIC AGENTS (Agentes Oticos)

Otic Agents - Miscellaneous (Agentes Oticos - Misc.)

Acetic Acid 2 % Acetic Acid (Otic) 1

Acetic Acid-aluminum Acetate 2 % Acetic Acid-Aluminum Acetate (Otic) 3

Otic Anti-infectives (Antiinfectivos Oticos)

Ciprofloxacin Hcl 0.2 % Cetraxal (Otic) 3

Ciprofloxacin Hcl 0.2 % Ciprofloxacin HCl (Otic) 2

Otic Combinations (Combinaciones Oticas)

Ciprofloxacin-dexamethasone 0.3-0.1 % Ciprodex (Otic) 2

Ciprofloxacin-hydrocortisone 0.2-1 % Cipro HC (Otic) 3

Neomycin-polymyxin-hc 1 %, 3.5-10000-1 Neomycin-Polymyxin-HC (Otic) 1

Neomycin-polymyxin-hc 3.5-10000-0.5, 3.5-10000-1 Cortisporin (External, Otic) 3

Pramoxine-chloroxylenol 1-0.1 % PramOtic (Otic) 3

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Cortane-B (Otic) 3

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Cortic-ND (Otic) 2

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Cyotic (Otic) 2

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Exotic-HC (Otic) 2

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Oticin HC NR (Otic) 3

Pramoxine-hc-chloroxylenol 10-10-1 mg/ml Otomax-HC (Otic) 2

Pramoxine-hc-chloroxylenol Aq 10-10-1 mg/ml Cortane-B Aqueous (Otic) 3

Otic Steroids (Esteroides Oticos)

Fluocinolone Acetonide 0.01 % DermOtic (Otic) 3

Fluocinolone Acetonide 0.01 %, 0.025 % Fluocinolone Acetonide (Otic, External) 1

Hydrocortisone-acetic Acid 1-2 % Hydrocortisone-Acetic Acid (Otic) 1

Hydrocortisone-acetic Acid 2-1 % Acetasol HC (Otic) 2

PENICILLINS (Penicilinas)

Aminopenicillins (Aminopenicilinas)

Amoxicillin 125 mg, 250 mg Amoxicillin (Oral) 3

Amoxicillin

125 mg/5ml, 200 mg/5ml, 250 mg, 250 mg/5ml, 400 mg/5ml, 500 mg, 875 mg Amoxicillin (Oral) 1

FMCMPD 01-17 109




Nivel (Tier)

Inst

Ampicillin 125 mg/5ml, 250 mg/5ml Ampicillin (Oral) 3

Ampicillin 250 mg, 500 mg Ampicillin (Oral) 1

Ampicillin Sodium 1 gm, 10 gm, 2 gm, 250 mg, 500 mg Ampicillin Sodium (Injection) 1

Ampicillin Sodium 125 mg Ampicillin Sodium (Injection) 3

Natural Penicillins (Penicilinas Naturales)

Penicillin G Benzathine 1200000 unit/2ml, 2400000 unit/4ml, 600000 unit/ml Bicillin L-A (Intramuscular) 3

Penicillin V Potassium 125 mg/5ml, 250 mg, 250 mg/5ml, 500 mg Penicillin V Potassium (Oral) 1

Penicillin Combinations (Combinaciones De Penicilina)

Amoxicillin-pot Clavulanate

200-28.5 mg, 200-28.5 mg/5ml, 250-125 mg, 250-62.5 mg/5ml, 400-57 mg, 400-57 mg/5ml, 500-125 mg, 600-

Amoxicillin-Pot Clavulanate (Oral) 1

Penicillin G Benzathine & Proc 1200000 unit/2ml Bicillin C-R (Intramuscular) 3

Penicillin G Benzathine & Proc 900000-300000 unit/2ml Bicillin C-R 900/300 (Intramuscular) 3

Penicillinase-resistant Penicillins (Penicilinas Resistentes a la Penicilinasa)

Dicloxacillin Sodium 250 mg, 500 mg Dicloxacillin Sodium (Oral) 1

Nafcillin Sodium 1 gm, 10 gm, 2 gm Nafcillin Sodium (Injection) 1

Nafcillin Sodium 2 gm Nafcillin Sodium (Intravenous) 4 SP

Oxacillin Sodium 1 gm, 10 gm, 2 gm Oxacillin Sodium (Injection) 1

PROGESTINS (Progestinas)

Progestins (Progestinas)

Hydroxyprogesterone Caproate 250 mg/ml Makena (Intramuscular) 4 SP

Medroxyprogesterone Acetate 10 mg, 2.5 mg, 5 mg

MedroxyPROGESTERone Acetate (Oral) 1

Megestrol Acetate 625 mg/5ml Megace ES (Oral) 3

Megestrol Acetate 625 mg/5ml Megestrol Acetate (Oral) 2

Norethindrone Acetate 5 mg Aygestin (Oral) 3

Norethindrone Acetate 5 mg Norethindrone Acetate (Oral) 1

Progesterone 50 mg/ml Progesterone (Intramuscular) 1

Progesterone Micronized 100 mg, 200 mg Progesterone Micronized (Oral) 1

Progesterone Micronized 100 mg, 200 mg Prometrium (Oral) 3

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. (Agentes Psicoterapeuticos y Neurologicos - Misc.)

FMCMPD 01-17 110




Nivel (Tier)

Inst

Anti-cataplectic Agents (Agentes Anti- cataplejicos)

Sodium Oxybate 500 mg/ml Xyrem (Oral) 4 SP

Antidementia Agents (Agentes Contra La Demencia)

Donepezil Hcl 10 mg, 23 mg, 5 mg Aricept (Oral) 3

Donepezil Hcl 10 mg, 23 mg, 5 mg Donepezil HCl (Oral) 1

Galantamine Hydrobromide 12 mg, 4 mg, 4 mg/ml, 8 mg

Galantamine Hydrobromide (Oral) 1

Galantamine Hydrobromide 12 mg, 4 mg, 8 mg Razadyne (Oral) 3

Galantamine Hydrobromide Er 16 mg, 24 mg, 8 mg

Galantamine Hydrobromide ER (Oral) 1

Galantamine Hydrobromide Er 16 mg, 24 mg, 8 mg Razadyne ER (Oral) 3

Memantine Hcl 10 mg, 10 mg/5ml, 5 mg Namenda (Oral) 3

Memantine Hcl 10 mg, 5 (28)-10 (21) mg, 5 mg Memantine HCl (Oral) 1

Memantine Hcl 2 mg/ml Memantine HCl (Oral) 2

Memantine Hcl 5 (28)-10 (21) mg Namenda Titration Pak (Oral) 3

Memantine Hcl Er 14 mg, 21 mg, 28 mg, 7 mg Namenda XR (Oral) 2

Memantine Hcl Er 7 & 14 & 21 &28 mg Namenda XR Titration Pack (Oral) 2

Rivastigmine 13.3 mg/24hr Exelon (Transdermal) 2

Rivastigmine 4.6 mg/24hr, 9.5 mg/24hr Exelon (Transdermal) 3

Rivastigmine 4.6 mg/24hr, 9.5 mg/24hr Rivastigmine (Transdermal) 2

Rivastigmine Tartrate 1.5 mg, 3 mg, 4.5 mg, 6 mg Rivastigmine Tartrate (Oral) 1

Combination Psychotherapeutics (Combinaciones Psicoterapeuticas)

Chlordiazepoxide-amitriptyline 10-25 mg, 5-12.5 mg Chlordiazepoxide-Amitriptyline (Oral) 3

Olanzapine-fluoxetine Hcl 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

OLANZapine-FLUoxetine HCl (Oral) 1 LC

Olanzapine-fluoxetine Hcl 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg Symbyax (Oral) 3 LC

Perphenazine-amitriptyline 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

Perphenazine-Amitriptyline (Oral) 3

Fibromyalgia Agents (Agentes Para Fibromialgia)

Milnacipran Hcl 100 mg, 12.5 mg, 25 mg, 50 mg Savella (Oral) 2

Milnacipran Hcl Oral 12.5 & 25 & 50 mg Savella Titration Pack Oral (Miscellaneous) 2

Movement Disorder Drug Therapy (Terapia para Desórdenes del Movimiento)

Tetrabenazine 12.5 mg, 25 mg Tetrabenazine (Oral) 4 SP

FMCMPD 01-17 111




Nivel (Tier)

Inst

Tetrabenazine 12.5 mg, 25 mg Xenazine (Oral) 4 SP

Multiple Sclerosis Agents (Agentes Para La Esclerosis Multiple)

Alemtuzumab 12 mg/1.2ml Lemtrada (Intravenous) 4 PA SP

Daclizumab 150 mg/ml Zinbryta (Subcutaneous) 4 PA SP

Dalfampridine Er 10 mg Ampyra (Oral) 4 PA SP

Dimethyl Fumarate 120 mg, 240 mg Tecfidera (Oral) 4 PA SP

Dimethyl Fumarate Oral 120 & 240 mg Tecfidera Oral (Miscellaneous) 4 PA SP

Fingolimod Hcl 0.5 mg Gilenya (Oral) 4 PA SP

Glatiramer Acetate 20 mg/ml Copaxone (Subcutaneous) 4 PA SP

Glatiramer Acetate 20 mg/ml Glatopa (Subcutaneous) 4 PA SP

Interferon Beta-1a 22 mcg/0.5ml, 44 mcg/0.5ml Rebif (Subcutaneous) 4

PA SP

Interferon Beta-1a 22 mcg/0.5ml, 44 mcg/0.5ml Rebif Rebidose (Subcutaneous) 4

PA SP

Interferon Beta-1a 30 mcg Avonex (Intramuscular) 4 PA SP

Interferon Beta-1a 30 mcg/0.5ml Avonex Pen (Intramuscular) 4 PA SP

Interferon Beta-1a 30 mcg/0.5ml Avonex Prefilled (Intramuscular) 4 PA SP

Interferon Beta-1a 6x8.8 & 6x22 mcg Rebif Rebidose Titration Pack (Subcutaneous) 4

PA SP

Interferon Beta-1a 6x8.8 & 6x22 mcg Rebif Titration Pack (Subcutaneous) 4

PA SP

Interferon Beta-1b 0.3 mg Betaseron (Subcutaneous) 4 PA SP

Natalizumab 300 mg/15ml Tysabri (Intravenous) 4 PA SP

Teriflunomide 14 mg, 7 mg Aubagio (Oral) 4 PA SP

Postherpetic Neuralgia (phn) Agents (Agentes para la Neuralgia Post-herpética (PHN))

Gabapentin (once-daily) 300 mg, 600 mg Gralise (Oral) 3

Gabapentin (once-daily) Oral 300 & 600 mg Gralise Starter Oral (Miscellaneous) 3

Premenstrual Dysphoric Disorder (pmdd) Agents (Agentes para el Trastorno Disfórico Premenstrual (PMDD))

FMCMPD 01-17 112




Nivel (Tier)

Inst

Fluoxetine Hcl (pmdd) 10 mg, 20 mg FLUoxetine HCl (PMDD) (Oral) 1 LC

Fluoxetine Hcl (pmdd) 10 mg, 20 mg Sarafem (Oral) 3 LC

Pseudobulbar Affect (pba) Agents (Agentes Afecccion Pseudobulbar (pba))

Dextromethorphan-quinidine 20-10 mg Nuedexta (Oral) 2

Psychotherapeutic And Neurological Agents - Misc. (Agentes Psicoterapeuticos y Neurologicos - Misc.)

Ergoloid Mesylates 1 mg Ergoloid Mesylates (Oral) 3

Pimozide 1 mg, 2 mg Orap (Oral) 3

Pimozide 1 mg, 2 mg Pimozide (Oral) 2

Restless Leg Syndrome (rls) Agents (Agentes Para El Sindrome De La Pierna Inquieta)

Gabapentin Enacarbil Er 300 mg, 600 mg Horizant (Oral) 3

Smoking Deterrents (Disuasivos de Fumar)

Bupropion Hcl Er (smoking Det) 150 mg

BuPROPion HCl ER (Smoking Det) (Oral) 1

Bupropion Hcl Er (smoking Det) 150 mg Zyban (Oral) 3

Nicotine 10 mg Nicotrol (Inhalation) 2

Nicotine 10 mg/ml Nicotrol NS (Nasal) 2

Varenicline Tartrate 0.5 mg, 1 mg Chantix (Oral) 2

Varenicline Tartrate 1 mg Chantix Continuing Month Pak (Oral) 2

Varenicline Tartrate Oral 0.5 mg x 11 & 1 mg x 42 Chantix Starting Month Pak (Miscellaneous) 2

Vasomotor Symptom Agents (Agentes Para El Sindrome Vasomotor)

Paroxetine Mesylate 7.5 mg Brisdelle (Oral) 3 LC

RESPIRATORY AGENTS - MISC. (Agentes Respiratorios - Misc.)

Alpha-proteinase Inhibitor (human) (Inhibidores de Alfa-Proteinasa (humana))

Alpha1-proteinase Inhibitor 1000 mg Prolastin-C (Intravenous) 4 PA SP

Alpha1-proteinase Inhibitor 1000 mg Zemaira (Intravenous) 4 PA SP

Alpha1-proteinase Inhibitor 1000 mg, 500 mg Aralast NP (Intravenous) 4 PA SP

Alpha1-proteinase Inhibitor 1000 mg/50ml Glassia (Intravenous) 4 PA SP

Pulmonary Fibrosis Agents (Agentes Para La Fibrosis Pulmonar)

Nintedanib Esylate 100 mg, 150 mg Ofev (Oral) 4 SP

Pirfenidone 267 mg Esbriet (Oral) 4 SP

SULFONAMIDES (Sulfonamidas)

Sulfonamides (Sulfonamidas)

Sulfadiazine 500 mg SulfADIAZINE (Oral) 3

FMCMPD 01-17 113




Nivel (Tier)

Inst

TETRACYCLINES (Tetraciclinas)

Tetracyclines (Tetraciclinas)

Demeclocycline Hcl 150 mg, 300 mg Demeclocycline HCl (Oral) 1

Doxycycline Calcium 50 mg/5ml Vibramycin (Oral) 3

Doxycycline Hyclate 100 mg Doxy 100 (Intravenous) 4 SP

Doxycycline Hyclate 100 mg Doxycycline Hyclate (Intravenous) 4 SP

Doxycycline Hyclate 100 mg Vibramycin (Oral) 3

Doxycycline Hyclate 100 mg, 150 mg, 20 mg, 50 mg, 75 mg Doxycycline Hyclate (Oral) 1

Doxycycline Hyclate 120 mg Doryx MPC (Oral) 3

Doxycycline Hyclate 200 mg Doryx (Oral) 3

Doxycycline Hyclate 200 mg, 50 mg Doxycycline Hyclate (Oral) 2

Doxycycline Monohydrate 100 mg, 150 mg, 25 mg/5ml, 50 mg, 75 mg Doxycycline Monohydrate (Oral) 1

Doxycycline Monohydrate 100 mg, 50 mg Adoxa (Oral) 3

Doxycycline Monohydrate 25 mg/5ml Vibramycin (Oral) 3

Doxycycline Monohydrate 75 mg Monodox (Oral) 3

Minocycline Hcl 100 mg Minocin (Intravenous) 4 SP

Minocycline Hcl 100 mg, 50 mg, 75 mg Minocin (Oral) 3

Minocycline Hcl 100 mg, 50 mg, 75 mg Minocycline HCl (Oral) 1

Minocycline Hcl Er 135 mg, 45 mg, 90 mg Minocycline HCl ER (Oral) 1

Tetracycline Hcl 250 mg, 500 mg Tetracycline HCl (Oral) 3

THYROID AGENTS (Agentes Para La Tiroides)

Antithyroid Agents (Agentes Antitiroideo)

Methimazole 10 mg, 5 mg Methimazole (Oral) 1

Methimazole 10 mg, 5 mg Tapazole (Oral) 3

Propylthiouracil 50 mg Propylthiouracil (Oral) 1

Thyroid Hormones (Hormonas Para La Tiroides)

Levothyroxine Sodium

100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 8 Levo-T (Oral) 1


100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 8 Levothyroxine Sodium (Oral) 1

FMCMPD 01-17 114




Nivel (Tier)

Inst


100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg Levoxyl (Oral) 1


100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 8 Synthroid (Oral) 2


100 mcg, 112 mcg, 125 mcg, 13 mcg, 137 mcg, 150 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg Tirosint (Oral) 3


100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 8 Unithroid (Oral) 2


100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg Unithroid Direct (Oral) 2

Levothyroxine Sodium 100 mcg, 200 mcg, 500 mcg

Levothyroxine Sodium (Intravenous) 4 SP

Liothyronine Sodium 10 mcg/ml Liothyronine Sodium (Intravenous) 4 SP

Liothyronine Sodium 10 mcg/ml Triostat (Intravenous) 4 SP

Liothyronine Sodium 25 mcg, 5 mcg, 50 mcg Cytomel (Oral) 3 PA

Liothyronine Sodium 25 mcg, 5 mcg, 50 mcg Liothyronine Sodium (Oral) 1 PA

Liotrix (t3-t4) 120 (25-100) mg (mcg) Thyrolar-2 (Oral) 3

Liotrix (t3-t4) 15 (3.1-12.5) mg (mcg) Thyrolar-1/4 (Oral) 3

Liotrix (t3-t4) 180 (37.5-150) mg (mcg) Thyrolar-3 (Oral) 3

Liotrix (t3-t4) 30 (6.25-25) mg (mcg) Thyrolar-1/2 (Oral) 3

Liotrix (t3-t4) 60 (12.5-50) mg (mcg) Thyrolar-1 (Oral) 3

Thyroid

120 mg, 15 mg, 180 mg, 240 mg, 30 mg, 300 mg, 60 mg, 90 mg Armour Thyroid (Oral) 3

Thyroid 15 mg, 30 mg, 60 mg, 90 mg NP Thyroid (Oral) 1

ULCER DRUGS (Medicamentos Para La Ulcera)

FMCMPD 01-17 115




Nivel (Tier)

Inst

Antispasmodics (Antiespasmodicos)

Atropine Sulfate 0.05 mg/ml, 0.8 mg/ml, 1 % Atropine Sulfate (Injection, Ophthalmic) 3

Atropine Sulfate 0.1 mg/ml, 0.4 mg/ml, 1 %, 1 mg/ml

Atropine Sulfate (Injection, Ophthalmic) 1

Atropine Sulfate

0.25 mg/0.3ml, 0.5 mg/0.7ml, 1 mg/0.7ml, 2 mg/0.7ml AtroPen (Intramuscular) 3

Dicyclomine Hcl 10 mg, 10 mg/ml, 20 mg Bentyl (Oral, Intramuscular) 3

Dicyclomine Hcl 10 mg, 20 mg Dicyclomine HCl (Oral) 1

Dicyclomine Hcl 10 mg/5ml Dicyclomine HCl (Oral) 3

Dicyclomine Hcl 10 mg/ml Dicyclomine HCl (Intramuscular) 2

Glycopyrrolate

0.2 mg/ml, 0.4 mg/2ml, 1 mg, 1 mg/5ml, 2 mg, 4 mg/20ml Glycopyrrolate (Injection, Oral) 1

Glycopyrrolate 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml Robinul (Injection) 3

Glycopyrrolate 1 mg/5ml Cuvposa (Oral) 3

Methscopolamine Bromide 2.5 mg Pamine (Oral) 3

Methscopolamine Bromide 2.5 mg, 5 mg Methscopolamine Bromide (Oral) 1

Methscopolamine Bromide 5 mg Pamine Forte (Oral) 3

Misc. Anti-ulcer (Medicamentos Para La Ulcera - Misc.)

Sucralfate 1 gm Sucralfate (Oral) 1

Sucralfate 1 gm, 1 gm/10ml Carafate (Oral) 3

Proton Pump Inhibitors (Inhibidores De Bomba De Protones)

Dexlansoprazole 30 mg, 60 mg Dexilant (Oral) 3 LC TE

Esomeprazole Magnesium 10 mg, 2.5 mg, 20 mg, 40 mg, 5 mg NexIUM (Oral) 2 LC

Esomeprazole Magnesium 20 mg, 40 mg Esomeprazole Magnesium (Oral) 1

LC TE

Esomeprazole Magnesium 20 mg, 40 mg NexIUM (Oral) 3 LC TE

Lansoprazole 15 mg, 30 mg Lansoprazole (Oral) 1 LC

Lansoprazole 15 mg, 30 mg Prevacid (Oral) 3 LC TE

Lansoprazole 15 mg, 30 mg Prevacid SoluTab (Oral) 3 LC TE

Lansoprazole 3 mg/ml First-Lansoprazole (Oral) 3

FMCMPD 01-17 116




Nivel (Tier)

Inst

Omeprazole 10 mg, 20 mg, 40 mg Omeprazole (Oral) 1 LC

Omeprazole 10 mg, 20 mg, 40 mg PriLOSEC (Oral) 3 LC TE

Omeprazole 2 mg/ml First-Omeprazole (Oral) 3

Omeprazole 2 mg/ml Omeprazole+Syrspend SF Alka (Oral) 3

Omeprazole Magnesium 10 mg, 2.5 mg PriLOSEC (Oral) 3 LC

Pantoprazole Sodium 20 mg, 40 mg Pantoprazole Sodium (Oral) 1 LC

Pantoprazole Sodium 20 mg, 40 mg Protonix (Oral) 3 LC TE

Rabeprazole Sodium 10 mg, 5 mg AcipHex Sprinkle (Oral) 3 LC

Rabeprazole Sodium 20 mg Aciphex (Oral) 3 LC TE

Rabeprazole Sodium 20 mg RABEprazole Sodium (Oral) 1 LC

Ulcer Drugs - Prostaglandins (Medicamentos Para La Ulcera - Protaglandinas)

Misoprostol 100 mcg, 200 mcg Cytotec (Oral) 3

Misoprostol 100 mcg, 200 mcg Misoprostol (Oral) 1

Ulcer Therapy Combinations (Combinaciones Para Terapia de Ulcera)

Amoxicill-clarithro-lansopraz Oral

Amoxicill-Clarithro-Lansopraz Oral (Miscellaneous) 1

Amoxicill-clarithro-lansopraz Oral Prevpac Oral (Miscellaneous) 3

Amoxicill-clarithro-omeprazole Oral 500-500-20 mg

Omeclamox-Pak Oral (Miscellaneous) 3

Bis Subcit-metronid-tetracyc 140-125-125 mg Pylera (Oral) 2

Omeprazole-sodium Bicarbonate

20-1100 mg, 20-1680 mg, 40-1100 mg Zegerid (Oral) 3

LC TE

Omeprazole-sodium Bicarbonate 20-1100 mg, 40-1100 mg

Omeprazole-Sodium Bicarbonate (Oral) 1 LC

Omeprazole-sodium Bicarbonate 20-1680 mg, 40-1680 mg

Omeprazole-Sodium Bicarbonate (Oral) 2

LC TE

URINARY ANTI-INFECTIVES (Antinfectivos Urinarios)

Urinary Anti-infective Combinations (Combinaciones De Antiinfectivos Urinarios)

Meth-hyo-m Bl-benz Acd-ph Sal 81.6 mg Hyophen (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal Uretron D/S (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal Urin DS (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 118 mg Uribel (Oral) 3

Meth-hyo-m Bl-na Phos-ph Sal 118 mg Uro-MP (Oral) 3

Meth-hyo-m Bl-na Phos-ph Sal 120 mg Urimar-T (Oral) 3

FMCMPD 01-17 117




Nivel (Tier)

Inst

Meth-hyo-m Bl-na Phos-ph Sal 120 mg Ustell (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 120 mg Uticap (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 81 mg Urelle (Oral) 3

Meth-hyo-m Bl-na Phos-ph Sal 81.6 mg Phosphasal (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 81.6 mg Ur N-C (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 81.6 mg Utira-C (Oral) 2

Meth-hyo-m Bl-na Phos-ph Sal 81.6 mg Utrona-C (Oral) 2

Methen-hyosc-meth Blue-na Phos 120 mg UTA (Oral) 2

Methen-hyosc-meth Blue-na Phos 81.6 mg Urogesic-Blue (Oral) 3

Methen-hyosc-meth Blue-na Phos 81.6 mg Uryl (Oral) 2

Urinary Anti-infectives (Antinfectivos Urinarios)

Fosfomycin Tromethamine 3 gm Monurol (Oral) 3

Methenamine Hippurate 1 gm Hiprex (Oral) 3

Methenamine Hippurate 1 gm Methenamine Hippurate (Oral) 1

Methenamine Mandelate 0.5 gm Methenamine Mandelate (Oral) 3

Methenamine Mandelate 1 gm Methenamine Mandelate (Oral) 1

Nitrofurantoin 25 mg/5ml Nitrofurantoin (Oral) 1

Nitrofurantoin Macrocrystal 100 mg, 25 mg, 50 mg Macrodantin (Oral) 3

Nitrofurantoin Macrocrystal 100 mg, 25 mg, 50 mg Nitrofurantoin Macrocrystal (Oral) 1

Nitrofurantoin Monohyd Macro 100 mg Macrobid (Oral) 3

Nitrofurantoin Monohyd Macro 100 mg

Nitrofurantoin Monohyd Macro (Oral) 1

URINARY ANTISPASMODICS (Antiespasmodicos Urinarios)

Urinary Antispasmodic - Antimuscarinics (anticholinergic) (Antiespasmódicos Urinarios - Antimuscarinicos (Anticolinergicos))

Darifenacin Hydrobromide Er 15 mg, 7.5 mg Darifenacin Hydrobromide ER (Oral) 2

Darifenacin Hydrobromide Er 15 mg, 7.5 mg Enablex (Oral) 3

Fesoterodine Fumarate Er 4 mg, 8 mg Toviaz (Oral) 2

Oxybutynin 3.9 mg/24hr Oxytrol (Transdermal) 2 LC

Oxybutynin Chloride 10 % Gelnique (Transdermal) 2

Oxybutynin Chloride 5 mg, 5 mg/5ml Oxybutynin Chloride (Oral) 1

Oxybutynin Chloride Er 10 mg, 15 mg, 5 mg Ditropan XL (Oral) 3

Oxybutynin Chloride Er 10 mg, 15 mg, 5 mg Oxybutynin Chloride ER (Oral) 1

Solifenacin Succinate 10 mg, 5 mg VESIcare (Oral) 2

FMCMPD 01-17 118




Nivel (Tier)

Inst

Tolterodine Tartrate 1 mg, 2 mg Detrol (Oral) 3

Tolterodine Tartrate 1 mg, 2 mg Tolterodine Tartrate (Oral) 1

Tolterodine Tartrate Er 2 mg, 4 mg Detrol LA (Oral) 3

Tolterodine Tartrate Er 2 mg, 4 mg Tolterodine Tartrate ER (Oral) 1

Trospium Chloride 20 mg Trospium Chloride (Oral) 1

Trospium Chloride Er 60 mg Trospium Chloride ER (Oral) 1

Urinary Antispasmodics - Cholinergic Agonists (Antiespasmodicos Urinarios Agonistas Colinergicos)

Bethanechol Chloride 10 mg, 25 mg, 5 mg, 50 mg Bethanechol Chloride (Oral) 1

Bethanechol Chloride 10 mg, 25 mg, 5 mg, 50 mg Urecholine (Oral) 3 Urinary Antispasmodics - Direct Muscle Relaxants (Antiespasmodicos Urinarios - Relajantes Musculares Directos)

Flavoxate Hcl 100 mg FlavoxATE HCl (Oral) 1

VAGINAL PRODUCTS (Productos Vaginales)

Miscellaneous Vaginal Products (Productos Vaginales Miscelaneos)

Acetic Acid-oxyquinoline 0.9-0.025 % Fem pH (Vaginal) 3

Acetic Acid-oxyquinoline 0.9-0.025 % Relagard (Vaginal) 3

Vaginal Anti-infectives (Antiinfectivos Vaginales)

Butoconazole Nitrate (1 Dose) 2 % Gynazole-1 (Vaginal) 3

Clindamycin Phosphate 100 mg, 2 % Cleocin (Vaginal) 3

Clindamycin Phosphate

2 %, 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml

Clindamycin Phosphate (Vaginal, Injection) 1

Clindamycin Phosphate (1 Dose) 2 % Clindesse (Vaginal) 3

Metronidazole 0.75 % MetroGel-Vaginal (Vaginal) 3

Metronidazole 0.75 % Vandazole (Vaginal) 2



Miconazole Nitrate 200 mg Miconazole 3 (Vaginal) 3

Sulfanilamide 15 % AVC (Vaginal) 3

Terconazole 0.4 % Terazol 7 (Vaginal) 3

Terconazole 0.4 %, 0.8 %, 80 mg Terconazole (Vaginal) 1

Terconazole 0.8 %, 80 mg Zazole (Vaginal) 2

Vaginal Estrogens (Estrogenos Vaginales)

Estradiol 0.1 mg/gm Estrace (Vaginal) 2

Estradiol 10 mcg Vagifem (Vaginal) 3

Estradiol 10 mcg Yuvafem (Vaginal) 1

Estradiol 2 mg Estring (Vaginal) 3 LC

Estradiol Acetate 0.05 mg/24hr, 0.1 mg/24hr Femring (Vaginal) 3 LC

FMCMPD 01-17 119




Nivel (Tier)

Inst

Estrogens, Conjugated 0.625 mg/gm Premarin (Vaginal) 2

Vaginal Progestins (Progestinas Vaginales)

Progesterone 100 mg Endometrin (Vaginal) 3

Progesterone 100 mg First-Progesterone VGS 100 (Vaginal) 3


Progesterone 4 %, 8 % Crinone (Vaginal) 2 PA


VASOPRESSORS (Vasopresores)

Anaphylaxis Therapy Agents (Agentes para Terapia de Anafilaxis)

Epinephrine 0.15 mg/0.15ml, 0.3 mg/0.3ml Adrenaclick (Injection) 3

Epinephrine 0.15 mg/0.15ml, 0.3 mg/0.3ml EPINEPHrine (Injection) 2

Epinephrine 0.15 mg/0.3ml EpiPen Jr 2-Pak (Injection) 2

Epinephrine 0.3 mg/0.3ml EpiPen 2-Pak (Injection) 2

Epinephrine 1 mg/ml Adrenalin (Injection) 3 Neurogenic Orthostatic Hypotension (noh) - Agents (Agentes Para Hypotension Neurogenica Ortostatica (noh))

Droxidopa 100 mg, 200 mg, 300 mg Northera (Oral) 4 SP

VITAMINS (Vitaminas)

Oil Soluble Vitamins (Vitaminas Solubles En Aceite)

Ergocalciferol 50000 unit Vitamin D (Ergocalciferol) (Oral) 0

FMCMPD 01-17 120

INDICE

A

Abatacept .......................................................................9

Abiraterone Acetate ...................................................... 47

Acarbose ....................................................................... 32

Acebutolol Hcl ............................................................... 55

Acetaminophen-codeine ............................................... 15

Acetazolamide .............................................................. 74

Acetazolamide Er .......................................................... 74

Acetic Acid .......................................................... 108, 118

Acetic Acid-aluminum Acetate .................................... 108

Acetic Acid-oxyquinoline ............................................. 118

Acetylcysteine ............................................................... 66

Acitretin ........................................................................ 68

Aclidinium Bromide ....................................................... 23

Acyclovir ........................................................... 53, 54, 69

Acyclovir Sodium ........................................................... 54

Acyclovir-hydrocortisone............................................... 69

Adalimumab....................................................................7

Afatinib Dimaleate ........................................................ 47

Agalsidase Beta ............................................................. 76

Albendazole .................................................................. 19

Albuterol Sulfate ..................................................... 24, 25

Albuterol Sulfate Er ....................................................... 24

Albuterol Sulfate Hfa ..................................................... 25

Alcaftadine .................................................................. 106

Alclometasone Dipropionate ......................................... 69

Alectinib Hcl .................................................................. 47

Alemtuzumab.............................................................. 111

Alendronate Sodium ..................................................... 75

Alendronate-cholecalciferol .......................................... 75

Alfentanil ................................................................ 12, 13

Alfuzosin Hcl Er ............................................................. 83

Alglucosidase Alfa ......................................................... 76

Aliskiren Fumarate ........................................................ 45

Aliskiren-hydrochlorothiazide ........................................ 43

Allopurinol .................................................................... 83

Almotriptan Malate ....................................................... 91

Alogliptin Benzoate ....................................................... 34

Alogliptin-metformin Hcl............................................... 32

Alogliptin-pioglitazone .................................................. 32

Alosetron Hcl ................................................................ 82

Alpha1-proteinase Inhibitor ........................................ 112

Alprazolam ................................................................... 22

Alprazolam Er ............................................................... 22

Altretamine .................................................................. 46

Alvimopan .................................................................... 82

Amantadine Hcl ............................................................ 50

Ambrisentan ................................................................. 58

Amcinonide .................................................................. 69

Amikacin Sulfate ............................................................. 6

Amiloride Hcl ................................................................ 75

Amiloride-hydrochlorothiazide ..................................... 74

Aminophylline............................................................... 25

Amiodarone Hcl ............................................................ 23

Amitriptyline Hcl ........................................................... 32

Amlodipine Besy-benazepril Hcl .................................... 43

Amlodipine Besylate ............................................... 43, 56

Amlodipine Besylate-valsartan ...................................... 43

Amlodipine-atorvastatin ............................................... 57

Amlodipine-olmesartan ................................................ 43

Amlodipine-valsartan-hctz ............................................ 43

Ammonium Lactate ...................................................... 72

Amobarbital Sodium ..................................................... 87

Amoxapine ................................................................... 32

Amoxicill-clarithro-lansopraz Oral ............................... 116

Amoxicill-clarithro-omeprazole Oral............................ 116

Amoxicillin .......................................................... 108, 109

Amoxicillin-pot Clavulanate......................................... 109

Amphetamine-dextroamphet Er ................................. ii, 5

Amphetamine-dextroamphetamine ................................ 5

Amphotericin B ............................................................. 37

Ampicillin .................................................................... 109

Ampicillin Sodium ....................................................... 109

Anagrelide Hcl .............................................................. 85

Anakinra ......................................................................... 7

FMCMPD 01-17 121

Anastrozole ................................................................... 47

Anidulafungin ................................................................ 37

Antihemophilic Factor ............................................. 83, 84

Antihemophilic Factor (recomb) .................................... 84

Antihemophilic Factor Rahf-paf ..................................... 84

Antihemophilic Factor Rahf-pfm .................................... 84

Antihemophilic Factor Rpfviii......................................... 84

Antihemophilic Factor-vwf ............................................ 84

Antiinhibitor Coagulant Cmplx ....................................... 84

Antiseborrheic Products, Misc. ...................................... 68

Apap-salicylamide-phenyltolox........................................9

Apixaban ....................................................................... 26

Apomorphine Hcl .......................................................... 50

Apraclonidine Hcl ........................................................ 104

Aprepitant..................................................................... 37

Aprepitant Oral ............................................................. 37

Arformoterol Tartrate ................................................... 25

Aripiprazole................................................................... 53

Armodafinil .....................................................................6

Artemether-lumefantrine .............................................. 46

Artificial Saliva ............................................................... 94

Artificial Tear Insert ..................................................... 103

Asa-apap-salicyl-caff........................................................9

Asenapine Maleate ....................................................... 52

Asfotase Alfa ................................................................. 76

Aspirin ......................................10, 11, 12, 15, 16, 85, 101

Aspirin-caff-dihydrocodeine .......................................... 15

Aspirin-dipyridamole Er ................................................. 85

Atenolol .................................................................. 43, 55

Atenolol-chlorthalidone ................................................ 43

Atomoxetine Hcl .............................................................5

Atorvastatin Calcium ..................................................... 40

Atovaquone ............................................................ 20, 46

Atovaquone-proguanil Hcl ............................................. 46

Atropine Sulfate .................................................. 103, 115

Auranofin ........................................................................7

Axitinib.......................................................................... 48

Azelaic Acid ................................................................... 73

Azelastine Hcl ...................................................... 102, 107

Azelastine-fluticasone ................................................. 101

Azilsartan Medoxomil.................................................... 42

Azilsartan-chlorthalidone .............................................. 43

Azithromycin ........................................................ 89, 104

Aztreonam .................................................................... 19

Aztreonam In Dextrose ................................................. 19

Aztreonam Lysine ......................................................... 19

B

Bacit-poly-neo Hc.......................................................... 66

Bacitracin ....................................................... 19, 104, 105

Bacitracin-polymyxin B................................................ 104

Bacitracin-polymyx-neo-hc.......................................... 105

Baclofen ..................................................................... 101

Balsalazide Disodium .................................................... 81

Becaplermin ................................................................. 74

Beclomethasone Diprop Monohyd .............................. 102

Beclomethasone Dipropionate .............................. 24, 102

Benazepril Hcl ............................................................... 41

Benazepril-hydrochlorothiazide .................................... 43

Benzocaine ................................................................... 93

Benztropine Mesylate ................................................... 49

Benzyl Alcohol .............................................................. 73

Bepotastine Besilate ................................................... 107

Besifloxacin Hcl ........................................................... 104

Betamethasone Dipropionate ....................................... 69

Betamethasone Dipropionate Aug ................................ 69

Betamethasone Sod Phos & Acet .................................. 64

Betamethasone Valerate .............................................. 69

Betaxolol Hcl ......................................................... 55, 103

Bethanechol Chloride.................................................. 118

Bexarotene ................................................................... 49

Bicalutamide ................................................................. 47

Bimatoprost ................................................................ 107

Bis Subcit-metronid-tetracyc ....................................... 116

Bisoprolol Fumarate...................................................... 55

Bisoprolol-hydrochlorothiazide ..................................... 43

Bosentan ...................................................................... 58

Bosutinib ...................................................................... 48

Brimonidine Tartrate ..................................... 73, 103, 104

Brimonidine Tartrate-timolol ...................................... 103

Brinzolamide ....................................................... 104, 107

Brinzolamide-brimonidine .......................................... 104

Bromfenac Sodium ..................................................... 107

FMCMPD 01-17 122

Bromfenac Sodium (once-daily)................................... 107

Bromocriptine Mesylate .......................................... 34, 50

Brompheniramine Tannate ........................................... 38

Budesonide .......................................... 18, 24, 25, 64, 102

Budesonide-formoterol Fumarate ................................. 25

Bumetanide .................................................................. 75

Buprenorphine .............................................................. 17

Buprenorphine Hcl ........................................................ 17

Buprenorphine Hcl-naloxone Hcl ................................... 17

Bupropion Hbr Er .......................................................... 30

Bupropion Hcl ....................................................... 30, 112

Bupropion Hcl Er (smoking Det) ................................... 112

Bupropion Hcl Er (sr) ..................................................... 30

Bupropion Hcl Er (xl) ..................................................... 30

Buspirone Hcl ................................................................ 22

Busulfan ........................................................................ 46

Butabarbital Sodium ..................................................... 87

Butalbital-acetaminophen ......................................... 9, 10

Butalbital-apap-caff-cod ................................................ 15

Butalbital-apap-caffeine ................................................ 10

Butalbital-asa-caff-codeine ............................................ 15

Butalbital-aspirin-caffeine ............................................. 10

Butenafine Hcl............................................................... 66

Butoconazole Nitrate (1 Dose) ..................................... 118

Butorphanol Tartrate .................................................... 17

C

Cabergoline ................................................................... 77

Cabozantinib S-malate .................................................. 48

Caffeine Citrate ...............................................................5

Calcipotriene ........................................................... 68, 69

Calcipotriene-betameth Diprop ..................................... 69

Calcitonin (salmon) ....................................................... 75

Calcitriol .................................................................. 68, 77

Calcium Acetate ............................................................ 82

Calcium Acetate (phos Binder) ...................................... 82

Canagliflozin .................................................................. 36

Canakinumab ..................................................................7

Candesartan Cilexetil ............................................... 42, 43

Candesartan Cilexetil-hctz ............................................. 43

Capecitabine ................................................................. 46

Captopril ................................................................. 41, 44

Captopril-hydrochlorothiazide ...................................... 44

Carbamazepine ....................................................... 27, 51

Carbamazepine Er ................................................... 27, 51

Carbamazepine Er (antipsych) ....................................... 51

Carbidopa ............................................................... 49, 50

Carbidopa-levodopa ..................................................... 50

Carbidopa-levodopa Er ................................................. 50

Carbidopa-levodopa-entacapone .................................. 50

Carbinoxamine Maleate ................................................ 38

Carglumic Acid .............................................................. 77

Carisoprodol ............................................................... 101

Carisoprodol-aspirin.................................................... 101

Carisoprodol-aspirin-codeine ...................................... 101

Carteolol Hcl ............................................................... 103

Carvedilol ............................................................... 54, 55

Carvedilol Phosphate Er ................................................ 55

Caspofungin Acetate ..................................................... 37

Cefaclor ........................................................................ 59

Cefaclor Er .................................................................... 59

Cefadroxil ..................................................................... 58

Cefazolin Sodium .......................................................... 58

Cefdinir ......................................................................... 59

Cefditoren Pivoxil .......................................................... 59

Cefepime Hcl ................................................................ 59

Cefixime ....................................................................... 59

Cefotaxime Sodium ....................................................... 59

Cefotetan Disodium ...................................................... 59

Cefoxitin Sodium........................................................... 59

Cefpodoxime Proxetil.................................................... 59

Cefprozil ....................................................................... 59

Ceftazidime................................................................... 59

Ceftibuten..................................................................... 59

Ceftriaxone Sodium ...................................................... 59

Cefuroxime Axetil ......................................................... 59

Cefuroxime Sodium ...................................................... 59

Celecoxib ........................................................................ 8

Cephalexin .................................................................... 58

Ceritinib ........................................................................ 48

Certolizumab Pegol ....................................................... 81

Cetirizine Hcl ................................................................. 39

Cevimeline Hcl .............................................................. 94

FMCMPD 01-17 123

Chlorambucil ................................................................. 46

Chlordiazepoxide Hcl ..................................................... 22

Chlordiazepoxide-amitriptyline ................................... 110

Chlorhexidine Gluconate ............................................... 93

Chloroquine Phosphate ................................................. 46

Chlorothiazide ............................................................... 75

Chlorpromazine Hcl ....................................................... 53

Chlorpropamide ............................................................ 36

Chlorthalidone ........................................................ 43, 75

Chlorzoxazone ............................................................. 101

Cholestyramine ............................................................. 39

Cholestyramine Light..................................................... 39

Cholic Acid .................................................................... 80

Choline & Mag Salicylates ............................................. 12

Choline Fenofibrate ....................................................... 40

Ciclesonide ............................................................ 24, 102

Ciclopirox ...................................................................... 66

Ciclopirox Olamine ........................................................ 66

Ciclopirox Olamine-cleanser .......................................... 66

Cilostazol ...................................................................... 85

Cinacalcet Hcl ................................................................ 77

Ciprofloxacin ................................................. 80, 104, 108

Ciprofloxacin Hcl ........................................... 80, 104, 108

Ciprofloxacin In D5w ..................................................... 80

Ciprofloxacin-ciproflox Hcl Er ........................................ 80

Ciprofloxacin-dexamethasone ..................................... 108

Ciprofloxacin-hydrocortisone ...................................... 108

Citalopram Hydrobromide ............................................. 30

Clarithromycin .............................................................. 89

Clarithromycin Er .......................................................... 89

Clemastine Fumarate .................................................... 39

Clindamycin Hcl ............................................................. 20

Clindamycin Palmitate Hcl ............................................. 20

Clindamycin Phosphate ......................................... 20, 118

Clindamycin Phosphate (1 Dose) ................................. 118

Clioquinol-hc ................................................................. 67

Clobazam ...................................................................... 27

Clobetasol Prop & Cleanser ........................................... 69

Clobetasol Prop Emollient Base ..................................... 69

Clobetasol Propionate ............................................. 69, 70

Clobetasol Propionate Emulsion .................................... 70

Clocortolone Pivalate .................................................... 70

Clomipramine Hcl ......................................................... 32

Clonazepam .................................................................. 27

Clonidine Hcl ............................................................. 5, 42

Clonidine Hcl Er............................................................... 5

Clonidine-chlorthalidone............................................... 44

Clopidogrel Bisulfate ..................................................... 85

Clorazepate Dipotassium .............................................. 22

Clotrimazole ........................................................... 67, 93

Clotrimazole-betamethasone ........................................ 67

Clozapine ...................................................................... 52

Coagulation Factor Ix .................................................... 84

Coagulation Factor Ix (recomb) ..................................... 84

Coagulation Factor Ix (rfixfc) ......................................... 84

Coagulation Factor Viia Recomb.................................... 84

Coagulation Factor X (human) ....................................... 84

Codeine Polt-chlorphen Polt Er ..................................... 65

Codeine Sulfate............................................................. 13

Colchicine ..................................................................... 83

Colchicine-probenecid .................................................. 83

Colesevelam Hcl ............................................................ 39

Colestipol Hcl .......................................................... 39, 40

Colistimethate Sodium .................................................. 19

Collagenase .................................................................. 72

Condoms - Female ........................................................ 90

Conj Estrogens-bazedoxifene ........................................ 78

Conj Estrog-medroxyprogest Ace .................................. 78

Cortisone Acetate ......................................................... 64

Crizotinib ...................................................................... 48

Cromolyn Sodium ................................................. 23, 107

Crotamiton ................................................................... 73

Cyclobenzaprine Hcl .................................................... 101

Cyclobenzaprine Hcl Er................................................ 101

Cyclobenzaprine Hcl-liniment...................................... 101

Cyclopentolate Hcl ...................................................... 103

Cyclopentolate-phenylephrine .................................... 103

Cyclophosphamide ....................................................... 46

Cyclosporine ............................................................... 105

Cyproheptadine Hcl ...................................................... 39

Cysteamine Bitartrate ................................................... 83

Cysteamine Hcl ........................................................... 107

FMCMPD 01-17 124

D

Dabigatran Etexilate Mesylate ....................................... 27

Daclizumab ................................................................. 111

Dalfampridine Er ......................................................... 111

Dalteparin Sodium ........................................................ 26

Danazol ......................................................................... 17

Dantrolene Sodium ..................................................... 101

Dapagliflozin Propanediol .............................................. 36

Dapagliflozin-metformin Hcl Er ...................................... 33

Dapsone ........................................................................ 20

Daptomycin................................................................... 20

Darbepoetin Alfa ........................................................... 86

Darifenacin Hydrobromide Er ...................................... 117

Dasatinib ....................................................................... 48

Deferasirox ................................................................... 36

Demeclocycline Hcl ..................................................... 113

Denosumab ............................................................. 75, 76

Desipramine Hcl ............................................................ 32

Desloratadine ................................................................ 39

Desogest-eth Estrad Triphasic ....................................... 59

Desogestrel-ethinyl Estradiol ................................... 59, 60

Desonide ....................................................................... 70

Desoximetasone............................................................ 70

Desvenlafaxine Er .......................................................... 31

Desvenlafaxine Succinate Er .......................................... 31

Dexamethasone .................................................... 64, 106

Dexamethasone Sod Phosphate Pf ................................ 64

Dexamethasone Sodium Phosphate ...................... 64, 106

Dexlansoprazole .......................................................... 115

Dexmethylphenidate Hcl .................................................6

Dexmethylphenidate Hcl Er .............................................6

Dextroamphetamine Sulfate ...........................................5

Dextroamphetamine Sulfate Er .......................................5

Dextromethorphan-quinidine ...................................... 112

Diaphragm Coil Spring ................................................... 90

Diaphragm Flat Spring ................................................... 90

Diaphragm Wide Seal .................................................... 90

Diazepam ................................................................ 22, 27

Diazoxide ...................................................................... 34

Dichlorphenamide ......................................................... 74

Diclofenac Epolamine .................................................... 66

Diclofenac Potassium ................................................ 8, 91

Diclofenac Sodium ....................................... 8, 66, 68, 107

Diclofenac Sodium Er ...................................................... 8

Diclofenac-misoprostol ................................................... 8

Dicloxacillin Sodium .................................................... 109

Dicyclomine Hcl .......................................................... 115

Diflorasone Diacet Emoll Base ....................................... 70

Diflorasone Diacetate ................................................... 70

Diflunisal ....................................................................... 12

Difluprednate ............................................................. 106

Digoxin ......................................................................... 57

Dihydroergotamine Mesylate........................................ 91

Diltiazem Hcl ................................................................. 56

Diltiazem Hcl Er ............................................................. 56

Diltiazem Hcl Er Beads .................................................. 56

Diltiazem Hcl Er Coated Beads....................................... 56

Dimethyl Fumarate ..................................................... 111

Dimethyl Fumarate Oral .............................................. 111

Diphenhydramine Hcl ................................................... 39

Diphenoxylate-atropine ................................................ 36

Dipyridamole ................................................................ 85

Disopyramide Phosphate ........................................ 22, 23

Disopyramide Phosphate Er .......................................... 23

Divalproex Sodium ........................................................ 29

Divalproex Sodium Er .................................................... 29

Dofetilide ...................................................................... 23

Donepezil Hcl .............................................................. 110

Dorzolamide Hcl ................................................. 103, 107

Dorzolamide Hcl-timolol Mal ...................................... 103

Dorzolamide Hcl-timolol Mal Pf .................................. 103

Doxapram Hcl ................................................................. 5

Doxazosin Mesylate ................................................ 42, 83

Doxazosin Mesylate Er .................................................. 83

Doxepin Hcl .......................................................32, 68, 87

Doxercalciferol .............................................................. 77

Doxycycline ........................................................... 73, 113

Doxycycline Calcium ................................................... 113

Doxycycline Hyclate .................................................... 113

Doxycycline Monohydrate .......................................... 113

Dronabinol .................................................................... 37

Dronedarone Hcl........................................................... 23

Droperidol .................................................................... 22

FMCMPD 01-17 125

Drospirenone-estradiol ................................................. 78

Drospirenone-ethinyl Estradiol ...................................... 60

Droxidopa ................................................................... 119

Dulaglutide ................................................................... 34

Duloxetine Hcl ............................................................... 31

Dutasteride ................................................................... 83

Dutasteride-tamsulosin Hcl ........................................... 83

E

Echothiophate Iodide .................................................. 104

Econazole Nitrate .......................................................... 67

Edrophonium Chloride .................................................. 46

Eletriptan Hydrobromide............................................... 92

Eliglustat Tartrate .......................................................... 85

Elosulfase Alfa ............................................................... 77

Eltrombopag Olamine ................................................... 86

Eluxadoline ................................................................... 82

Emedastine Difumarate ............................................... 107

Empagliflozin........................................................... 33, 36

Empagliflozin-linagliptin ................................................ 33

Empagliflozin-metformin Hcl ......................................... 33

Enalapril Maleate .......................................................... 41

Enalapril-hydrochlorothiazide ....................................... 44

Enoxaparin Sodium ....................................................... 26

Entacapone ............................................................. 49, 50

Enzalutamide ................................................................ 47

Epinastine Hcl ............................................................. 107

Epinephrine................................................... 25, 102, 119

Epinephrine Hcl ..................................................... 25, 102

Epinephrine Hcl (nasal)................................................ 102

Eplerenone ................................................................... 45

Epoetin Alfa .................................................................. 86

Epoprostenol Sodium .................................................... 58

Eprosartan Mesylate ..................................................... 42

Ergocalciferol .............................................................. 119

Ergoloid Mesylates ...................................................... 112

Ergotamine Tartrate ...................................................... 91

Ergotamine-caffeine ...................................................... 91

Erlotinib Hcl .................................................................. 48

Ertapenem Sodium........................................................ 20

Erythromycin ........................................................ 89, 104

Erythromycin Base ........................................................ 89

Erythromycin Base Coated ............................................ 89

Erythromycin Ethylsuccinate ......................................... 89

Erythromycin Stearate .................................................. 89

Escitalopram Oxalate .............................................. 30, 31

Eslicarbazepine Acetate ................................................ 27

Esomeprazole Magnesium .......................................... 115

Est Estrogens-methyltest .............................................. 78

Estazolam ..................................................................... 87

Esterified Estrogens ...................................................... 79

Estradiol .........................................60, 62, 63, 78, 79, 118

Estradiol Acetate......................................................... 118

Estradiol Cypionate ....................................................... 79

Estradiol Valerate ......................................................... 79

Estradiol-levonorgestrel ................................................ 78

Estradiol-norethindrone Acet ........................................ 78

Estradiol-norgestimate ................................................. 78

Estramustine Phosphate Sodium ................................... 47

Estrogens Conj Synthetic B ............................................ 79

Estrogens Conjugated ................................................... 79

Estrogens, Conjugated ................................................ 119

Estropipate ............................................................. 79, 80

Eszopiclone ................................................................... 87

Etanercept ...................................................................... 9

Ethacrynic Acid ............................................................. 75

Ethosuximide ................................................................ 29

Ethotoin ........................................................................ 29

Ethynodiol Diac-eth Estradiol ........................................ 60

Etidronate Disodium ..................................................... 76

Etodolac ......................................................................... 8

Etodolac Er ..................................................................... 8

Etonogestrel-ethinyl Estradiol ....................................... 63

Etoposide...................................................................... 49

Everolimus .................................................................... 48

Exemestane .................................................................. 47

Exenatide ...................................................................... 34

Exenatide Er.................................................................. 34

Ezetimibe ................................................................ 39, 41

Ezetimibe-simvastatin ................................................... 39

Ezogabine ..................................................................... 27

FMCMPD 01-17 126

F

Factor Ix Complex .......................................................... 85

Factor Xiii Concentrate Human ...................................... 85

Famciclovir .................................................................... 54

Febuxostat .................................................................... 83

Felbamate ..................................................................... 29

Felodipine Er ................................................................. 56

Fenofibrate ................................................................... 40

Fenofibrate Micronized ................................................. 40

Fenofibric Acid .............................................................. 40

Fenoprofen Calcium ........................................................8

Fentanyl ........................................................................ 13

Fentanyl Citrate............................................................. 13

Fentanyl Citrate (pf) ...................................................... 13

Ferrous Sulfate .............................................................. 86

Fesoterodine Fumarate Er ........................................... 117

Fibrinogen Concentrate (human) ................................... 85

Fidaxomicin ................................................................... 89

Filgrastim ...................................................................... 86

Filgrastim-sndz .............................................................. 86

Finasteride .................................................................... 83

Fingolimod Hcl ............................................................ 111

Flavoxate Hcl ............................................................... 118

Flecainide Acetate ......................................................... 23

Fluconazole ................................................................... 38

Fluconazole In Dextrose ................................................ 38

Fluconazole In Sodium Chloride..................................... 38

Flucytosine .............................................................. 37, 38

Fludrocortisone Acetate ................................................ 65

Flunisolide ................................................................... 102

Fluocinolone & Cleanser ................................................ 70

Fluocinolone Acetonide ......................................... 70, 108

Fluocinolone Acetonide Body ........................................ 70

Fluocinolone Acetonide Scalp ........................................ 70

Fluocinolone Cream & Emollient ................................... 71

Fluocinolone Oint & Emollient ....................................... 71

Fluocinonide ................................................................. 71

Fluocinonide Emulsified Base ........................................ 71

Fluorometholone ........................................................ 106

Fluorometholone Acetate ........................................... 106

Fluorouracil ................................................................... 68

Fluoxetine Hcl ....................................................... 31, 112

Fluoxetine Hcl (pmdd) ................................................. 112

Fluphenazine Decanoate ............................................... 53

Fluphenazine Hcl........................................................... 53

Flurandrenolide ............................................................ 71

Flurazepam Hcl ............................................................. 87

Flurbiprofen ............................................................ 8, 107

Flurbiprofen Sodium ................................................... 107

Flutamide ..................................................................... 47

Fluticasone Furoate .............................................. 25, 102

Fluticasone Furoate-vilanterol ...................................... 25

Fluticasone Propionate .................................... 24, 71, 102

Fluticasone Propionate (inhal) ...................................... 24

Fluticasone Propionate Hfa ........................................... 24

Fluticasone-salmeterol .................................................. 25

Fluvastatin Sodium ....................................................... 40

Fluvastatin Sodium Er ................................................... 40

Fluvoxamine Maleate.................................................... 31

Fluvoxamine Maleate Er ............................................... 31

Folic Acid ................................................................ 85, 99

Fondaparinux Sodium ................................................... 26

Formoterol Fumarate.................................................... 25

Fosaprepitant Dimeglumine .......................................... 37

Fosfomycin Tromethamine ......................................... 117

Fosinopril Sodium ................................................... 41, 44

Fosinopril Sodium-hctz.................................................. 44

Fosphenytoin Sodium ................................................... 29

Frovatriptan Succinate .................................................. 92

Furosemide ................................................................... 75

G

Gabapentin .................................................... 27, 111, 112

Gabapentin (once-daily) .............................................. 111

Gabapentin (once-daily) Oral ...................................... 111

Gabapentin Enacarbil Er .............................................. 112

Galantamine Hydrobromide........................................ 110

Galantamine Hydrobromide Er ................................... 110

Galsulfase ..................................................................... 77

Ganciclovir .................................................................. 104

Gatifloxacin................................................................. 104

Gemfibrozil ................................................................... 40

FMCMPD 01-17 127

Gemifloxacin Mesylate .................................................. 80

Gentamicin Sulfate ............................................ 7, 66, 104

Gentamicin-prednisolone Acet .................................... 106

Glatiramer Acetate ...................................................... 111

Glimepiride ............................................................. 33, 36

Glipizide .................................................................. 33, 36

Glipizide Er .................................................................... 36

Glipizide-metformin Hcl ................................................ 33

Glucagon (rdna) ............................................................ 34

Glucagon Hcl (rdna) ....................................................... 34

Glucagon Hcl Rdna (diagnostic) ..................................... 74

Glyburide ................................................................ 33, 36

Glyburide Micronized .................................................... 36

Glyburide-metformin .................................................... 33

Glycerol Phenylbutyrate ................................................ 77

Glycopyrrolate ............................................................ 115

Golimumab .....................................................................7

Granisetron ................................................................... 37

Granisetron Hcl ............................................................. 37

Griseofulvin Microsize ................................................... 38

Griseofulvin Ultramicrosize ........................................... 38

Guanfacine Hcl .......................................................... 5, 42

Guanfacine Hcl Er ............................................................5

Guanidine Hcl ................................................................ 46

H

Halcinonide ................................................................... 71

Halobetasol Cr & Lactic Ac Cr ........................................ 71

Halobetasol Oint &lactic Ac Cr ....................................... 71

Halobetasol Propionate ................................................. 71

Halobetasol-ammonium Lactate.................................... 71

Haloperidol ................................................................... 52

Haloperidol Decanoate .................................................. 52

Haloperidol Lactate ....................................................... 52

Haloprogin .................................................................... 67

Hc & Sal Acid-sulfur & Shampoo .................................... 71

Hc-pramox-diet Mng Prod -wipe ................................... 18

Hc-pramoxine-chloroxylenol ......................................... 71

Homatropine Hbr ........................................................ 103

Hydralazine Hcl ............................................................. 45

Hydrochlorothiazide ............................... 43, 44, 45, 74, 75

Hydrocodone Bitartrate ................................................ 13

Hydrocodone-acetaminophen ................................ 15, 16

Hydrocodone-ibuprofen ............................................... 16

Hydrocortisone ......................... 18, 19, 64, 67, 71, 72, 108

Hydrocortisone Ace-pramoxine..................................... 18

Hydrocortisone Acetate .....................................18, 19, 71

Hydrocortisone Butyr Lipo Base .................................... 71

Hydrocortisone Butyrate ......................................... 71, 72

Hydrocortisone Na Succinate Pf .................................... 64

Hydrocortisone Probutate ............................................ 72

Hydrocortisone Valerate ............................................... 72

Hydrocortisone-acetic Acid ......................................... 108

Hydromorphone Hcl ..................................................... 13

Hydromorphone Hcl Pf ................................................. 13

Hydroxychloroquine Sulfate .......................................... 46

Hydroxyprogesterone Caproate ............................ 47, 109

Hydroxyurea ................................................................. 49

Hydroxyzine Hcl ............................................................ 22

Hydroxyzine Pamoate ................................................... 22

I

Ibandronate Sodium ..................................................... 76

Ibrutinib ........................................................................ 48

Ibuprofen.................................................................. 8, 16

Ibuprofen-famotidine ..................................................... 8

Ibuprofen-liniment.......................................................... 8

Icosapent Ethyl ............................................................. 39

Idelalisib ....................................................................... 48

Idursulfase .................................................................... 77

Iloperidone ................................................................... 51

Iloperidone Oral ............................................................ 51

Iloprost ......................................................................... 58

Imatinib Mesylate ......................................................... 48

Imiglucerase ................................................................. 85

Imipramine Hcl ............................................................. 32

Imipramine Pamoate .................................................... 32

Imiquimod .................................................................... 72

Indacaterol Maleate...................................................... 25

Indapamide .................................................................. 75

Indomethacin ................................................................. 8

Indomethacin Er ............................................................. 8

FMCMPD 01-17 128

Infliximab ...................................................................... 81

Infliximab-dyyb ............................................................. 81

Insulin Aspart ................................................................ 34

Insulin Aspart Prot & Aspart .......................................... 34

Insulin Degludec ............................................................ 34

Insulin Detemir.............................................................. 34

Insulin Glargine ....................................................... 34, 35

Insulin Glulisine ............................................................. 35

Insulin Lispro ................................................................. 35

Insulin Lispro Prot & Lispro ............................................ 35

Insulin Nph (human) (isophane) .................................... 35

Insulin Nph Isophane & Regular .................................... 35

Insulin Pen Needle ........................................................ 90

Insulin Regular Human .................................................. 35

Insulin Regular Human (conc) ........................................ 35

Insulin Syringe-needle U-100 ................................... 90, 91

Insulin Syringe-needle U-40 ........................................... 91

Insulin Syringes (disposable) .......................................... 91

Interferon Beta-1a....................................................... 111

Interferon Beta-1b ...................................................... 111

Iodoquinol-hc ................................................................ 67

Iodoquinol-hc-aloe Polysacch ........................................ 67

Iodoquinol-hydrocortisone-aloe .................................... 67

Ipratropium Bromide ............................................ 23, 102

Ipratropium Bromide Hfa .............................................. 23

Ipratropium-albuterol ................................................... 25

Irbesartan ............................................................... 42, 44

Irbesartan-hydrochlorothiazide ..................................... 44

Isavuconazonium Sulfate ............................................... 38

Isocarboxazid ................................................................ 30

Isometheptene-caffeine-apap ....................................... 91

Isometheptene-dichloral-apap ...................................... 91

Isoproterenol Hcl .......................................................... 25

Isosorbide Dinitrate ....................................................... 21

Isosorbide Dinitrate Er................................................... 21

Isosorbide Mononitrate................................................. 21

Isosorbide Mononitrate Er ............................................ 21

Isradipine ...................................................................... 56

Itraconazole .................................................................. 38

Ivabradine Hcl ............................................................... 58

Ivermectin ............................................................... 19, 73

K

Ketoconazole .......................................................... 38, 67

Ketoconazole & Pyrithione Zinc..................................... 67

Ketoconazole-cleanser .................................................. 67

Ketoconazole-hydrocortisone ....................................... 67

Ketoprofen ............................................................... 8, 66

Ketoprofen Er ................................................................. 8

Ketoprofen-ketamine-lidocaine .................................... 66

Ketorolac Tromethamine ........................................ 8, 107

Ketotifen Fumarate ..................................................... 107

L

Labetalol Hcl ................................................................. 55

Lacosamide ................................................................... 27

Lactulose ................................................................ 82, 88

Lactulose Encephalopathy............................................. 82

Lamotrigine ............................................................ 27, 28

Lamotrigine Er .............................................................. 28

Lancets ......................................................................... 90

Lanreotide Acetate ....................................................... 77

Lansoprazole............................................................... 115

Lanthanum Carbonate .................................................. 82

Laronidase .................................................................... 77

Latanoprost ................................................................ 108

Leflunomide.................................................................... 9

Lenalidomide ................................................................ 54

Lenvatinib 10 Mg Daily Dose ......................................... 48





Lenvatinib 8 Mg Daily Dose ........................................... 48

Letrozole....................................................................... 47

Leucovorin Calcium ....................................................... 49

Leuprolide Acetate........................................................ 76

Leuprolide Acetate (3 Month) ....................................... 76

Levalbuterol Hcl ............................................................ 25

Levalbuterol Tartrate .................................................... 25

Levetiracetam ............................................................... 28

Levetiracetam Er ........................................................... 28

FMCMPD 01-17 129

Levetiracetam In Nacl .................................................... 28

Levobunolol Hcl........................................................... 103

Levocarnitine ................................................................ 77

Levocetirizine Dihydrochloride ...................................... 39

Levofloxacin .......................................................... 80, 104

Levofloxacin In D5w ...................................................... 80

Levonorgest-eth Estrad 91-day ................................ 60, 61

Levonorgestrel ........................................................ 61, 63

Levonorgestrel-ethinyl Estrad ........................................ 61

Levonorg-eth Estrad Triphasic ....................................... 60

Levorphanol Tartrate .................................................... 13

Levothyroxine Sodium ......................................... 113, 114

Lidocaine.................................................... 18, 73, 93, 105

Lidocaine Hcl ................................................... 73, 93, 105

Lidocaine-hydrocortisone Ace ....................................... 18

Lidocaine-prilocaine ...................................................... 73

Linaclotide .................................................................... 82

Linagliptin ............................................................... 33, 34

Linagliptin-metformin Hcl .............................................. 33

Linagliptin-metformin Hcl Er .......................................... 33

Lincomycin Hcl .............................................................. 20

Lindane ......................................................................... 73

Linezolid .................................................................. 20, 21

Linezolid In Sodium Chloride ......................................... 21

Liothyronine Sodium ................................................... 114

Liotrix (t3-t4) ............................................................... 114

Liraglutide ..................................................................... 34

Lisdexamfetamine Dimesylate .........................................5

Lisinopril ................................................................. 41, 44

Lisinopril-hydrochlorothiazide ....................................... 44

Lithium .......................................................................... 51

Lithium Carbonate ........................................................ 51

Lithium Carbonate Er .................................................... 51

Lodoxamide Tromethamine ........................................ 107

Lomitapide Mesylate ..................................................... 41

Loperamide Hcl ............................................................. 36

Lorazepam .................................................................... 22

Losartan Potassium ................................................. 42, 44

Losartan Potassium-hctz ............................................... 44

Loteprednol Etabonate ............................................... 106

Loteprednol-tobramycin ............................................. 106

Lovastatin ..................................................................... 40

Lovastatin Er ................................................................. 40

Loxapine ....................................................................... 52

Loxapine Succinate ....................................................... 52

Lubiprostone ................................................................ 81

Lurasidone Hcl .............................................................. 51

M

Malathion ..................................................................... 73

Maprotiline Hcl ............................................................. 30

Mecamylamine Hcl ....................................................... 45

Mechlorethamine Hcl ................................................... 68

Meclizine Hcl ................................................................ 37

Meclofenamate Sodium .................................................. 8

Medroxyprogesterone Acetate ............................. 63, 109

Mefenamic Acid .............................................................. 8

Mefloquine Hcl ............................................................. 46

Megestrol Acetate ................................................ 47, 109

Meloxicam .................................................................. 8, 9

Melphalan .................................................................... 46

Memantine Hcl ........................................................... 110

Memantine Hcl Er ....................................................... 110

Meperidine Hcl ....................................................... 13, 14

Mepolizumab ................................................................ 23

Meprobamate............................................................... 22

Mercaptopurine ............................................................ 46

Meropenem .................................................................. 20

Mesalamine .................................................................. 81

Mesalamine Er .............................................................. 81

Mesalamine-cleanser .................................................... 81

Mesna .......................................................................... 49

Metaproterenol Sulfate ................................................ 25

Metaxalone ................................................................ 101

Metformin Hcl .............................................................. 33

Metformin Hcl Er .......................................................... 33

Metformin Hcl Er (mod) ................................................ 33

Metformin Hcl Er (osm)................................................. 33

Methadone Hcl ............................................................. 14

Methamphetamine Hcl ................................................... 5

Methazolamide ............................................................. 74

Methenamine Hippurate ............................................ 117

Methenamine Mandelate ........................................... 117

FMCMPD 01-17 130

Methen-hyosc-meth Blue-na Phos .............................. 117

Meth-hyo-m Bl-benz Acd-ph Sal .................................. 116

Meth-hyo-m Bl-na Phos-ph Sal ............................ 116, 117

Methimazole ............................................................... 113

Methocarbamol .......................................................... 101

Methotrexate Sodium ............................................. 46, 47

Methoxsalen ................................................................. 68

Methoxsalen Rapid ....................................................... 68

Methscopolamine Bromide ......................................... 115

Methsuximide ............................................................... 29

Methyclothiazide .......................................................... 75

Methyldopa ............................................................ 42, 44

Methyldopa-hydrochlorothiazide .................................. 44

Methylnaltrexone Bromide ........................................... 82

Methylphenidate ............................................................6

Methylphenidate Hcl .......................................................6

Methylphenidate Hcl Er ...................................................6

Methylphenidate Hcl Er (cd) ............................................6

Methylphenidate Hcl Er (la) .............................................6

Methylprednisolone ................................................ 64, 65

Methylprednisolone Acetate ......................................... 65

Methylprednisolone Sodium Succ ................................. 65

Methyltestosterone ...................................................... 17

Metipranolol ............................................................... 103

Metoclopramide Hcl ...................................................... 81

Metolazone ................................................................... 75

Metoprolol Succinate Er ................................................ 55

Metoprolol Tartrate ...................................................... 55

Metoprolol-hctz Er ........................................................ 44

Metoprolol-hydrochlorothiazide ................................... 44

Metreleptin ................................................................... 77

Metronidazole ................................................ 19, 73, 118

Metronidazole In Nacl ................................................... 19

Metronidazole-cleanser ................................................ 73

Metyrosine ................................................................... 42

Mexiletine Hcl ............................................................... 23

Micafungin Sodium ....................................................... 37

Miconazole Nitrate...................................................... 118

Midazolam Hcl .............................................................. 87

Mifepristone ................................................................. 34

Miglitol ......................................................................... 32

Milnacipran Hcl ........................................................... 110

Milnacipran Hcl Oral ................................................... 110

Minocycline Hcl .................................................... 94, 113

Minocycline Hcl Dental ................................................. 94

Minocycline Hcl Er ...................................................... 113

Minoxidil....................................................................... 45

Mirtazapine .................................................................. 30

Misoprostol ............................................................ 8, 116

Mitomycin .................................................................. 104

Mitotane....................................................................... 47

Modafinil ........................................................................ 6

Moexipril Hcl ................................................................ 41

Moexipril-hydrochlorothiazide ...................................... 44

Mometasone Furoate ...................................... 24, 72, 102

Mometasone Furo-formoterol Fum .............................. 25

Montelukast Sodium ..................................................... 24

Morphine Sulfate .......................................................... 14

Morphine Sulfate (concentrate) .................................... 14

Morphine Sulfate (pf).................................................... 14

Morphine Sulfate Er ...................................................... 14

Morphine Sulfate Er Beads ............................................ 14

Morphine Sulfate Microinfusion ................................... 14

Moxifloxacin Hcl ................................................... 80, 104

Moxifloxacin Hcl (2x Day) ............................................ 104

Moxifloxacin Hcl In Nacl ................................................ 80

Mupirocin ............................................................. 66, 101

Mupirocin Calcium ................................................ 66, 101

N

Na Sulfate-k Sulfate-mg Sulf .......................................... 88

Nabilone ....................................................................... 37

Nabumetone.............................................................. iii, 9

Nadolol ................................................................... 44, 55

Nadolol-bendroflumethiazide ....................................... 44

Nafarelin Acetate .......................................................... 76

Nafcillin Sodium .......................................................... 109

Naftifine Hcl .................................................................. 67

Nalbuphine Hcl ............................................................. 17

Naloxone Hcl ................................................................ 37

Naltrexone .................................................................... 37

Naltrexone Hcl .............................................................. 37

Naproxen .................................................................. 9, 66

FMCMPD 01-17 131

Naproxen Sodium............................................................9

Naproxen Sodium Er .......................................................9

Naproxen-esomeprazole .................................................9

Naratriptan Hcl ............................................................. 92

Natalizumab ................................................................ 111

Natamycin ................................................................... 104

Nateglinide ................................................................... 36

Nebivolol Hcl ................................................................. 55

Nedocromil Sodium..................................................... 107

Nefazodone Hcl ............................................................. 31

Neo-fluocinolone & Emollient ....................................... 66

Neomycin Sulfate ............................................................7

Neomycin-bacitracin Zn-polymyx ................................ 105

Neomycin-fluocinolone ................................................. 66

Neomycin-polymyxin-dexameth .................................. 106

Neomycin-polymyxin-hc ................................ 66, 106, 108

Nepafenac................................................................... 107

Niacin (antihyperlipidemic) ........................................... 41

Niacin Er (antihyperlipidemic) ....................................... 41

Nicardipine Hcl .............................................................. 56

Nicotine ...................................................................... 112

Nifedipine ............................................................... 56, 57

Nifedipine Er ........................................................... 56, 57

Nifedipine Er Osmotic Release ....................................... 57

Nilotinib Hcl .................................................................. 48

Nilutamide .................................................................... 47

Nimodipine ................................................................... 57

Nintedanib Esylate ...................................................... 112

Nisoldipine Er ................................................................ 57

Nitazoxanide ................................................................. 20

Nitisinone ..................................................................... 77

Nitrofurantoin ............................................................. 117

Nitrofurantoin Macrocrystal ........................................ 117

Nitrofurantoin Monohyd Macro .................................. 117

Nitroglycerin ................................................................. 21

Nitroglycerin Er ............................................................. 21

Nitroglycerin In D5w ..................................................... 21

Norelgestromin-eth Estradiol ........................................ 63

Norethin Ace-eth Estrad-fe...................................... 61, 62

Norethindrone ............................... 62, 63, 64, 78, 79, 109

Norethindrone Acetate ............................................... 109

Norethindrone Acet-ethinyl Est ..................................... 62

Norethindrone-eth Estradiol ........................ 62, 63, 78, 79

Norethindron-ethinyl Estrad-fe ..................................... 62

Norethin-eth Estrad Triphasic ....................................... 62

Norethin-eth Estradiol-fe .............................................. 62

Norgestimate-eth Estradiol ........................................... 63

Norgestim-eth Estrad Triphasic ..................................... 63

Norgestrel-ethinyl Estradiol .......................................... 63

Nortriptyline Hcl ........................................................... 32

Nystatin .............................................................38, 67, 93

Nystatin-triamcinolone ................................................. 67

O

Obeticholic Acid ............................................................ 80

Octreotide Acetate ................................................. 77, 78

Ofloxacin .............................................................. 80, 105

Olanzapine ....................................................... 52, 53, 110

Olanzapine Pamoate ..................................................... 53

Olanzapine-fluoxetine Hcl ........................................... 110

Olaparib ........................................................................ 48

Olmesartan Medoxomil .......................................... 42, 44

Olmesartan Medoxomil-hctz ......................................... 44

Olmesartan-amlodipine-hctz ................................... 44, 45

Olopatadine Hcl .................................................. 102, 107

Olsalazine Sodium ......................................................... 81

Omega-3-acid Ethyl Esters ............................................ 39

Omeprazole ................................................................ 116

Omeprazole Magnesium ............................................. 116

Omeprazole-sodium Bicarbonate ................................ 116

Ondansetron................................................................. 37

Ondansetron Hcl ........................................................... 37

Oral Wound Care Products............................................ 94

Oral Wound Care Products Pump .................................. 94

Oritavancin Diphosphate .............................................. 19

Orphenadrine Citrate .................................................. 101

Orphenadrine Citrate Er .............................................. 101

Oseltamivir Phosphate .................................................. 54

Osimertinib Mesylate .................................................... 48

Ospemifene .................................................................. 76

Oxacillin Sodium ......................................................... 109

Oxaprozin ....................................................................... 9

Oxazepam ..................................................................... 22

FMCMPD 01-17 132

Oxcarbazepine .............................................................. 28

Oxcarbazepine Er .......................................................... 28

Oxiconazole Nitrate ....................................................... 67

Oxybutynin ................................................................. 117

Oxybutynin Chloride.................................................... 117

Oxybutynin Chloride Er................................................ 117

Oxycodone Hcl ........................................................ 14, 15

Oxycodone-acetaminophen .......................................... 16

Oxycodone-aspirin ........................................................ 16

Oxycodone-ibuprofen ................................................... 16

Oxymorphone Hcl ......................................................... 15

Oxymorphone Hcl Er ..................................................... 15

P

Palbociclib ..................................................................... 49

Paliperidone Er .............................................................. 51

Paliperidone Palmitate .................................................. 52

Pamidronate Disodium .................................................. 76

Pancrelipase (lip-prot-amyl) .......................................... 74

Panobinostat Lactate .................................................... 49

Pantoprazole Sodium .................................................. 116

Paricalcitol .................................................................... 77

Paromomycin Sulfate ......................................................7

Paroxetine Hcl ............................................................... 31

Paroxetine Hcl Er ........................................................... 31

Paroxetine Mesylate ............................................. 31, 112

Pasireotide Diaspartate ................................................. 78

Ped Multivitamins-fl-iron............................................... 94

Peg 3350-kcl-na Bicarb-nacl........................................... 88

Peg 3350-kcl-nabcb-nacl-nasulf ..................................... 88

Pegfilgrastim ................................................................. 86

Peg-kcl-nacl-nasulf-na Asc-c .......................................... 88

Penciclovir .................................................................... 69

Penicillamine ................................................................. 54

Penicillin G Benzathine ................................................ 109

Penicillin G Benzathine & Proc ..................................... 109

Penicillin V Potassium.................................................. 109

Pentamidine Isethionate ............................................... 19

Pentazocine Lactate ...................................................... 17

Pentazocine-naloxone ................................................... 17

Pentobarbital Sodium.................................................... 87

Pentosan Polysulfate Sodium ........................................ 83

Pentoxifylline Er ............................................................ 85

Perindopril Erbumine .................................................... 41

Permethrin ............................................................. 73, 74

Perphenazine ........................................................ 53, 110

Perphenazine-amitriptyline ......................................... 110

Phenelzine Sulfate ........................................................ 30

Phenobarbital ............................................................... 87

Phenobarbital Sodium .................................................. 87

Phenoxybenzamine Hcl ................................................. 42

Phenylephrine Hcl ....................................................... 105

Phenytoin ..................................................................... 29

Phenytoin Sodium ......................................................... 29

Phenytoin Sodium Extended ......................................... 29

Pilocarpine Hcl ...................................................... 94, 104

Pimecrolimus ................................................................ 73

Pimozide ..................................................................... 112

Pindolol ........................................................................ 55

Pioglitazone Hcl ...................................................... 33, 35

Pioglitazone Hcl-glimepiride .......................................... 33

Pioglitazone Hcl-metformin Er ...................................... 33

Pioglitazone Hcl-metformin Hcl ..................................... 33

Pirfenidone ................................................................. 112

Piroxicam ........................................................................ 9

Pitavastatin Calcium...................................................... 40

Podofilox ...................................................................... 73

Polyethylene Glycol 3350 .............................................. 89

Polymyxin B Sulfate ...................................................... 21

Polymyxin B-trimethoprim .......................................... 105

Polyvinyl Alcohol ......................................................... 103

Pomalidomide .............................................................. 47

Ponatinib Hcl ................................................................ 49

Posaconazole ................................................................ 38

Pot & Sod Cit-cit Ac ....................................................... 82

Potassium Citrate-citric Acid ......................................... 82

Povidone-iodine .......................................................... 105

Povidone-nahyaluron-glycyrrhet ................................... 94

Pramipexole Dihydrochloride ........................................ 50

Pramipexole Dihydrochloride Er .................................... 50

Pramlintide Acetate ...................................................... 32

Pramoxine-chloroxylenol ............................................ 108

Pramoxine-hc........................................................ 72, 108

FMCMPD 01-17 133

Pramoxine-hc Emollient Base ........................................ 72

Pramoxine-hc-chloroxylenol ........................................ 108

Pramoxine-hc-chloroxylenol Aq ................................... 108

Prasugrel Hcl ................................................................. 85

Pravastatin Sodium ....................................................... 40

Praziquantel .................................................................. 19

Prazosin Hcl............................................................. 42, 43

Prednicarbate ............................................................... 72

Prednisolone ......................................................... 65, 106

Prednisolone Acetate .................................................. 106

Prednisolone Sodium Phosphate ........................... 65, 106

Prednisone .................................................................... 65

Pregabalin ..................................................................... 28

Prenat Fepoly-fehempo-fa-dha ..................................... 94

Prenat Fepoly-fehempo-fa-omega Oral ......................... 94

Prenat Mv-min-methylfolate-fa ..................................... 94

Prenat Vit-fe Gly Cys-fa-omega ...................................... 94

Prenat Vit-fepoly-methylfol-fa ....................................... 95

Prenat W/o A Fecbnfeglu-fa& B6 Oral ........................... 95

Prenat W/o A Vit-fefum-fepo-fa .................................... 95

Prenat W/o A-fe Fum-fa-omega 3.................................. 95

Prenat W/o A-fe Poly Cmplx-fa ...................................... 95

Prenat W/o A-fecb-fegl-dss-fa ....................................... 95

Prenat W/o A-fecbgl-dss-fa-dha Oral ....................... 95, 96

Prenat W/o A-fecbn-dss-fa-dha ..................................... 96

Prenat W/o A-fecbn-meth-fa-dha .................................. 96

Prenat W/o A-fe-fa-ca-omega Oral ................................ 95

Prenat W/o A-fefum-fa&fish Oil Oral ............................. 96

Prenat W/o A-fe-methf-fa-omega ................................. 95

Prenat W/o A-fe-methfol-fa-dha ................................... 95

Prenat W/o A-fe-methfol-fa-dha Oral ............................ 95

Prenat W/oa-fefum-methf-omegas ............................... 96

Prenatal Ca-b6-b12-fa-ginger ........................................ 98

Prenatal Calcium-b6-fa-ginger ....................................... 98

Prenatal Multivit-min-fe-fa ............................................ 98

Prenatal Mv-min-fe Fum-fa-dha Oral ............................. 98

Prenatal Vit W/ Fe Bisg-fa.............................................. 98

Prenatal Vit W/fe-methylfol-fa ...................................... 98

Prenatal Vit-docusate-iron-fa ........................................ 98

Prenatal Vit-dss-fe Cbn-fa ........................................ 98, 99

Prenatal Vit-dss-fe Fum-fa ............................................. 99

Prenatal Vit-dss-fe Fum-fa Er ......................................... 99

Prenatal Vit-fe Fumarate-fa................................... 99, 100

Prenatal Vit-fe Fum-fa-omega ....................................... 99

Prenatal Vit-fe Fum-fe Bisg-fa ....................................... 99

Prenatal Vit-fe Phos-fa-omega .................................... 100

Prenatal Vit-fe Psac Cmplx-fa ...................................... 100

Prenatal Vit-fepoly-fa-dha ........................................... 100

Prenatal Vit-fepoly-fa-dha Oral ................................... 100

Prenatal Vit-fepoly-fehempo-fa................................... 100

Prenatal Vit-iron Carbonyl-fa ...................................... 100

Prenatal Vit-sel-fe Fum-fa ........................................... 100

Prenatal W/o A Vit-fe Fum-fa ...................................... 100

Prenatal W/o Vit A-fecbn-fa-b6 Oral ........................... 100

Prenatal-fe Asparto Gly-fa ........................................... 100

Prenatal-fe Cbn-dss-fa-dha ......................................... 100

Prenatal-fe Cbn-fa-dha W/o A ..................................... 100

Prenatal-fe Cbn-fe Asp Gly-fa ...................................... 100

Prenatal-fe Pyroph-methf W/o A ................................ 100

Prenatal-feaspgly-methylfol-fa .................................... 100

Prenatal-fecbn-fa-dss-omega 3 Oral ............................ 100

Prenatal-fecbn-feaspgl-fa-omeg .................................. 100

Prenatal-fefum-fa-dss-fish Oil ............................. 100, 101

Prenatal-fe-methylfol-fa-dha ...................................... 100

Prenat-b2-b6-b12-d3-fa ................................................ 96

Prenat-fe Bisgly-fa-w/o Vit A ......................................... 96

Prenat-fe Poly-methfol-fa-dha ...................................... 96

Prenat-feasp-meth-fa-dha W/o A .................................. 96

Prenat-febis-fepro-fa-ca-omega Oral ...................... 96, 97

Prenat-fecbn-feas-fa-dss-omega ................................... 97

Prenat-fecbn-feaspgl-fa-fish .......................................... 97

Prenat-fecbn-feaspgl-fa-omega ..................................... 97

Prenat-fecbn-feasp-meth-fa-dha ................................... 97

Prenat-fecbn-febisg-fa-fishoil ........................................ 97

Prenat-fechel-fa-dha W/o Vit A Oral ............................. 97

Prenat-fefum-doc-fa-dha W/o A ................................... 97

Prenat-fefum-dss-fa-dha W/o A .................................... 97

Prenat-fefum-fepo-fa-dha W/o A .................................. 97

Prenat-fefum-fepo-fa-omega 3 ............................... 97, 98

Prenat-fe-methyl-dss-dha W/o A .................................. 96

Prenat-fepoly-fered-fa-omega 3 Oral ............................ 98

Prenat-fepoly-metf-fa-dha-dss ...................................... 98

Prenat-fepyro-mfol W/o A & Dha .................................. 98

Prenat-w/oa-fe Bisgly-fa-omega Oral ............................ 98

FMCMPD 01-17 134

Primaquine Phosphate .................................................. 46

Primidone ..................................................................... 28

Probenecid .................................................................... 83

Procainamide Hcl .......................................................... 23

Procarbazine Hcl ........................................................... 49

Prochlorperazine ........................................................... 53

Prochlorperazine Edisylate ............................................ 53

Prochlorperazine Maleate ............................................. 53

Progesterone ...................................................... 109, 119

Progesterone Micronized ............................................ 109

Promethazine Hcl .......................................................... 39

Propafenone Hcl ........................................................... 23

Propafenone Hcl Er ....................................................... 23

Proparacaine Hcl ......................................................... 105

Propranolol Hcl ............................................................. 55

Propranolol Hcl Er ......................................................... 55

Propranolol-hctz ........................................................... 45

Propylthiouracil ........................................................... 113

Prothrombin Complex Conc Human .............................. 85

Protriptyline Hcl ............................................................ 32

Pyridostigmine Bromide ................................................ 46

Pyrimethamine ............................................................. 46

Q

Quazepam ..................................................................... 87

Quetiapine Fumarate .................................................... 53

Quetiapine Fumarate Er ................................................ 53

Quinapril Hcl ................................................................. 41

Quinapril-hydrochlorothiazide....................................... 45

Quinidine Gluconate ..................................................... 23

Quinidine Gluconate Er ................................................. 23

Quinidine Sulfate .......................................................... 23

Quinine Sulfate ............................................................. 46

Quinupristin-dalfopristin ............................................... 21

R

Rabeprazole Sodium ................................................... 116

Raloxifene Hcl ............................................................... 76

Ramelteon .................................................................... 88

Ramipril .................................................................. 41, 42

Ranolazine Er ................................................................ 21

Rasagiline Mesylate ...................................................... 51

Regorafenib .................................................................. 49

Repaglinide ............................................................. 33, 36

Repaglinide-metformin Hcl ........................................... 33

Reslizumab ................................................................... 23

Retapamulin ................................................................. 66

Ribavirin ....................................................................... 54

Rifaximin....................................................................... 19

Rilonacept ...................................................................... 7

Riluzole ....................................................................... 102

Rimantadine Hcl ........................................................... 54

Riociguat ....................................................................... 58

Risedronate Sodium ...................................................... 76

Risperidone .................................................................. 52

Risperidone Microspheres ............................................ 52

Rivaroxaban .................................................................. 26

Rivastigmine ............................................................... 110

Rivastigmine Tartrate .................................................. 110

Rizatriptan Benzoate ..................................................... 92

Roflumilast ................................................................... 24

Romiplostim ................................................................. 86

Ropinirole Hcl ............................................................... 51

Ropinirole Hcl Er ........................................................... 51

Rosiglitazone Maleate ................................................... 36

Rosuvastatin Calcium .................................................... 40

Rotigotine ..................................................................... 51

Rufinamide ................................................................... 28

Ruxolitinib Phosphate ................................................... 49

S

Sacubitril-valsartan ....................................................... 57

Salmeterol Xinafoate .................................................... 25

Salsalate ....................................................................... 12

Sapropterin Dihydrochloride ......................................... 77

Sargramostim ............................................................... 86

Saxagliptin Hcl .............................................................. 34

Saxagliptin-metformin Er .............................................. 33

Scopolamine ................................................................. 37

Sebelipase Alfa ............................................................. 77

Secobarbital Sodium ..................................................... 87

FMCMPD 01-17 135

Secukinumab................................................................. 68

Selegiline................................................................. 30, 51

Selegiline Hcl ................................................................. 51

Selenium Sulfide ........................................................... 68

Selenium Sulf-pyrithione-urea ....................................... 68

Sertaconazole Nitrate .................................................... 67

Sertraline Hcl ................................................................ 31

Sevelamer Carbonate .................................................... 82

Sevelamer Hcl ............................................................... 82

Sildenafil Citrate ............................................................ 58

Silodosin ....................................................................... 83

Simvastatin ................................................................... 41

Sinecatechins ................................................................ 66

Sitagliptin Phosphate .................................................... 34

Sitagliptin-metformin Hcl .............................................. 33

Sitagliptin-metformin Hcl Er .......................................... 33

Sod Citrate-citric Acid .............................................. 82, 83

Sod Picosulfate-mag Ox-cit Acd ..................................... 88

Sod Thiosulfate-salicylic Acd .......................................... 67

Sodium Chloride Flush ................................................... 93

Sodium Fluoride ................................................ 92, 93, 94

Sodium Fluoride-phosphoric Acd ................................... 94

Sodium Oxybate .......................................................... 110

Sodium Phenylbutyrate ................................................. 77

Sodium Polystyrene Sulfonate ....................................... 54

Solifenacin Succinate ................................................... 117

Sorafenib Tosylate......................................................... 49

Sotalol Hcl ............................................................... 55, 56

Sotalol Hcl Af ................................................................. 56

Spinosad ....................................................................... 74

Spironolactone ........................................................ 74, 75

Spironolactone-hctz ...................................................... 74

Stannous Fluoride ......................................................... 94

Streptomycin Sulfate .......................................................7

Succimer ....................................................................... 36

Sucralfate .................................................................... 115

Sulconazole Nitrate ....................................................... 67

Sulfacetamide Sodium ..................................... 68, 69, 105

Sulfacetamide-prednisolone ........................................ 106

Sulfadiazine ................................................................. 112

Sulfamethoxazole-trimethoprim ................................... 20

Sulfanilamide .............................................................. 118

Sulfasalazine ................................................................. 81

Sulfuric Acid-sulf Phenolics ........................................... 93

Sulindac .......................................................................... 9

Sumatriptan ............................................................ 91, 92

Sumatriptan Succinate .................................................. 92

Sumatriptan-naproxen Sodium ..................................... 91

Sunitinib Malate ........................................................... 49

Suvorexant ................................................................... 88

T

Tacrolimus .................................................................... 73

Tadalafil (pah) ............................................................... 58

Tafluprost ................................................................... 108

Taliglucerase Alfa .......................................................... 85

Tamoxifen Citrate ......................................................... 47

Tamsulosin Hcl .............................................................. 83

Tapentadol Hcl .............................................................. 15

Tapentadol Hcl Er.......................................................... 15

Tasimelteon .................................................................. 88

Tazarotene ................................................................... 68

Telavancin Hcl ............................................................... 19

Telmisartan ............................................................. 42, 45

Telmisartan-amlodipine ................................................ 45

Telmisartan-hctz ........................................................... 45

Temazepam .................................................................. 87

Temozolomide .............................................................. 46

Terazosin Hcl ................................................................ 43

Terbinafine Hcl ............................................................. 38

Terbutaline Sulfate ....................................................... 25

Terconazole ................................................................ 118

Teriflunomide ............................................................. 111

Testosterone .......................................................... 17, 18

Testosterone Buccal ...................................................... 17

Testosterone Cypionate .......................................... 17, 18

Testosterone Enanthate ................................................ 18

Testosterone Propionate .............................................. 18

Tetrabenazine ..................................................... 110, 111

Tetracaine Hcl ............................................................. 105

Tetracycline Hcl .......................................................... 113

Tetrahydrozoline Hcl ................................................... 102

Thalidomide .................................................................. 54

FMCMPD 01-17 136

Theophylline ........................................................... 25, 26

Theophylline Er ............................................................. 25

Theophylline In D5w...................................................... 26

Thioguanine .................................................................. 47

Thioridazine Hcl ............................................................ 53

Thiothixene ................................................................... 53

Thyroid ............................................................... 113, 114

Tiagabine Hcl................................................................. 29

Ticagrelor ...................................................................... 85

Tigecycline .................................................................... 20

Timolol Hemihydrate................................................... 103

Timolol Maleate .................................................... 56, 103

Timolol Maleate Pf ...................................................... 103

Tinidazole...................................................................... 19

Tiotropium Bromide Monohydrate .......................... 23, 24

Tizanidine Hcl .............................................................. 101

Tobramycin ..................................................... 7, 105, 106

Tobramycin Sulfate .........................................................7

Tobramycin-dexamethasone ....................................... 106

Tocilizumab .....................................................................8

Tolazamide.................................................................... 36

Tolbutamide .................................................................. 36

Tolcapone ..................................................................... 50

Tolmetin Sodium .............................................................9

Tolterodine Tartrate .................................................... 118

Tolterodine Tartrate Er ................................................ 118

Tolvaptan ...................................................................... 78

Topiramate ............................................................. 28, 29

Topiramate Er ............................................................... 29

Toremifene Citrate ........................................................ 47

Torsemide ..................................................................... 75

Tramadol Hcl ................................................................. 15

Tramadol Hcl Er ............................................................. 15

Tramadol Hcl Er (biphasic) ............................................. 15

Tramadol-acetaminophen ............................................. 16

Trandolapril ............................................................ 42, 45

Trandolapril-verapamil Hcl Er ........................................ 45

Tranexamic Acid ............................................................ 86

Tranylcypromine Sulfate ............................................... 30

Travoprost (bak Free) .................................................. 108

Trazodone Hcl ............................................................... 31

Treprostinil ................................................................... 58

Treprostinil Diolamine Er .............................................. 58

Treprostinil Sodium....................................................... 58

Tretinoin ....................................................................... 49

Triamcinolone Acetonide ........................... 65, 72, 94, 102

Triamterene ............................................................ 74, 75

Triamterene-hctz .................................................... 74, 75

Triazolam ...................................................................... 87

Trientine Hcl ................................................................. 54

Trifluoperazine Hcl ........................................................ 53

Trifluridine ............................................................ 47, 105

Trifluridine-tipiracil ....................................................... 47

Trihexyphenidyl Hcl ...................................................... 49

Trimethobenzamide Hcl ................................................ 37

Trimethoprim .................................................. 19, 20, 105

Trimethoprim Hcl .......................................................... 19

Trimetrexate Glucuronate ............................................. 20

Trimipramine Maleate .................................................. 32

Tropicamide ................................................................ 103

Trospium Chloride ...................................................... 118

Trospium Chloride Er .................................................. 118

Trypsin-castor Oil-peru Balsam ..................................... 72

U

Umeclidinium-vilanterol ............................................... 25

Unoprostone Isopropyl ............................................... 108

Uridine Triacetate ................................................... 37, 77

Ursodiol .................................................................. 80, 81

Ustekinumab ................................................................ 68

V

Valacyclovir Hcl ............................................................. 54

Valproate Sodium ................................................... 29, 30

Valproic Acid ........................................................... 29, 30

Valsartan ...........................................................42, 43, 45

Valsartan-hydrochlorothiazide ...................................... 45

Vancomycin Hcl ...................................................... 19, 20

Vandetanib ................................................................... 49

Varenicline Tartrate .................................................... 112

Varenicline Tartrate Oral ............................................. 112

Vedolizumab ................................................................. 81

FMCMPD 01-17 137

Velaglucerase Alfa ......................................................... 85

Vemurafenib ................................................................. 49

Venlafaxine Hcl ....................................................... 31, 32

Venlafaxine Hcl Er ................................................... 31, 32

Verapamil Hcl ................................................................ 57

Verapamil Hcl Er ............................................................ 57

Vigabatrin ..................................................................... 29

Vilazodone Hcl .............................................................. 31

Vismodegib ................................................................... 47

Vorapaxar Sulfate .......................................................... 85

Voriconazole ................................................................. 38

Vorinostat ..................................................................... 49

W

Warfarin Sodium ........................................................... 26

Z

Zafirlukast ..................................................................... 24

Zaleplon ........................................................................ 87

Zanamivir ...................................................................... 54

Zileuton ........................................................................ 24

Zileuton Er .................................................................... 24

Ziprasidone Hcl ............................................................. 51

Ziprasidone Mesylate .................................................... 51

Zoledronic Acid ............................................................. 76

Zolmitriptan .................................................................. 92

Zolpidem Tartrate ................................................... 87, 88

Zolpidem Tartrate Er ..................................................... 88

Zonisamide ................................................................... 29

plan médico servicios de salud bella vista, inc ... · los medicamentos en la lista de...

Documents