Presbyterian Centennial Care
PHP Centennial Care Formulary/Preferred Drug Listing
The Centennial Care Preferred Drug List is subject to change.
This list is in alphabetical order. To find a specific drug, use the search feature available in Adobe Acrobat Reader
(keyboard shortcut: Ctrl+F).
Drug Name
Form
Strength
A-200
GEL
4%; 0.33%
Coverage Details
ABACAVIR
TABS
300MG
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE
TABS
ABILIFY
TABS
300MG; 150MG; QL (60.00 EA per 30 days)
300MG
PA; QL (30.00 EA per 30 days)
2MG
ABILIFY
TABS
20MG
PA; QL (30.00 EA per 30 days)
ABILIFY
SOLN
1MG/ML
PA; QL (750.00 ML per 30 days)
ABILIFY
TABS
10MG
PA; QL (30.00 EA per 30 days)
ABILIFY
TABS
15MG
PA; QL (30.00 EA per 30 days)
ABILIFY
TABS
30MG
PA; QL (30.00 EA per 30 days)
ABILIFY
TABS
5MG
PA; QL (30.00 EA per 30 days)
ABILIFY DISCMELT
TBDP
10MG
PA; QL (30.00 EA per 30 days)
ABILIFY DISCMELT
TBDP
15MG
PA; QL (30.00 EA per 30 days)
ABILIFY MAINTENA
SUSR
300MG
PA
MB; SP
ABILIFY MAINTENA
SUSR
400MG
PA
MB; SP
ABRAXANE
SUSR
900MG; 100MG
ACAMPROSATE CALCIUM DR
TBEC
333MG
ACARBOSE
TABS
25MG
ACARBOSE
TABS
100MG
ACARBOSE
TABS
50MG
ACCU-CHEK ACTIVE STRIPS
STRP
0
QL (200.00 EA per 30 days)
ACCU-CHEK AVIVA
STRP
0
QL (200.00 EA per 30 days)
ACCU-CHEK COMFORT CURVE TEST STRIPS
STRP
0
QL (200.00 EA per 30 days)
ACCU-CHEK COMPACT PLUS
STRP
0
QL (200.00 EA per 30 days)
ACCU-CHEK SMARTVIEW STRIPS
STRP
0
QL (200.00 EA per 30 days)
ACEBUTOLOL HCL
CAPS
200MG
ACEBUTOLOL HCL
CAPS
400MG
ACEPHEN
SUPP
325MG
QL (12.00 EA per 1 days)
OTC
ACEPHEN
SUPP
650MG
QL (6.00 EA per 1 days)
OTC
ACETAMINOPHEN
TABS
500MG
QL (8.00 EA per 1 days)
OTC
OTC
OTC
QL (60.00 EA per 30 days)
MB
PA; QL (180.00 EA per 30 days)
ACETAMINOPHEN
TABS
325MG
QL (12.00 EA per 1 days)
ACETAMINOPHEN EXTRA STRENGTH
LIQD
500MG/15ML
QL (120.00 ML per 1 days)
ACETAMINOPHEN/CODEINE #2
TABS
300MG; 15MG
QL (13.00 EA per 1 days)
ACETAMINOPHEN/CODEINE #3
TABS
300MG; 30MG
QL (13.00 EA per 1 days)
ACETAMINOPHEN/CODEINE #4
TABS
300MG; 60MG
QL (13.00 EA per 1 days)
ACETAZOLAMIDE
TABS
125MG
ACETAZOLAMIDE
TABS
250MG
ACETAZOLAMIDE ER
CP12
500MG
[MPC091374]
Note
OTC
[Centennial Care #363]
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Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
ACETIC ACID
SOLN
2%
Coverage Details
Note
ACETIC ACID/ALUMINUM ACETATE
SOLN
2%; 0
ACETYLCYSTEINE
SOLN
10%
ACETYLCYSTEINE
SOLN
20%
ACITRETIN
CAPS
10MG
PA; QL (60.00 EA per 30 days)
ACITRETIN
CAPS
25MG
PA; QL (60.00 EA per 30 days)
ACITRETIN
CAPS
17.5MG
PA; QL (60.00 EA per 30 days)
ACTEMRA
SOLN
200MG/10ML
PA
MB; SP
ACTEMRA
SOLN
80MG/4ML
PA
MB; SP
MB; SP
SP
ACTEMRA
SOLN
400MG/20ML
PA
ACTEMRA
SOSY
162MG/0.9ML
PA; QL (3.60 ML per 28 days)
ACTIMMUNE
SOLN
ACYCLOVIR
SUSP
2000000UNIT/0.
5ML
200MG/5ML
ACYCLOVIR
CAPS
200MG
ACYCLOVIR
TABS
400MG
ACYCLOVIR
TABS
800MG
ACZONE
GEL
5%
PA
ADAPALENE
CREA
0.1%
AG (max: 39y)
ADAPALENE
GEL
0.1%
AG (max: 39y)
ADCETRIS
SOLR
50MG
PA
ADULT ASPIRIN LOW STRENGTH
TBDP
81MG
AG (min: 45y, max: 78y)
ADVAIR DISKUS
AEPB
ADVAIR DISKUS
AEPB
ADVAIR DISKUS
AEPB
ADVAIR HFA
AERO
ADVAIR HFA
AERO
ADVAIR HFA
AERO
AFINITOR
TABS
500MCG/DOSE;
50MCG/DOSE
250MCG/DOSE;
50MCG/DOSE
100MCG/DOSE;
50MCG/DOSE
230MCG/ACT;
21MCG/ACT
45MCG/ACT;
21MCG/ACT
115MCG/ACT;
21MCG/ACT
10MG
PA; QL (60.00 EA per 30 days)
PA
1 inhaler
30 days
1 inhaler
30 days
1 inhaler
30 days
1 inhaler
30 days
1 inhaler
30 days
1 inhaler
30 days
SP
AFINITOR
TABS
5MG
PA
SP
AFINITOR
TABS
2.5MG
PA
SP
AFINITOR DISPERZ
TBSO
3MG
PA
SP
SP
SP
SP
PA; QL (60.00 EA per 30 days)
PA; QL (60.00 EA per 30 days)
PA; QL (12.00 GM per 30 days)
PA; QL (12.00 GM per 30 days)
PA; QL (12.00 GM per 30 days)
AFINITOR DISPERZ
TBSO
5MG
PA
AFINITOR DISPERZ
TBSO
2MG
PA
A-HYDROCORT
SOLR
100MG
AKNE-MYCIN
OINT
2%
AK-POLY-BAC
OINT
ALBUTEROL SULFATE
NEBU
500UNIT/GM;
10000UNIT/GM
0.083%
ALBUTEROL SULFATE
NEBU
1.25MG/3ML
ALBUTEROL SULFATE
NEBU
0.5%
ALBUTEROL SULFATE
TABS
4MG
ALBUTEROL SULFATE
SYRP
2MG/5ML
ALBUTEROL SULFATE
NEBU
0.63MG/3ML
ALBUTEROL SULFATE
TABS
2MG
ALBUTEROL SULFATE ER
TB12
4MG
ALBUTEROL SULFATE ER
TB12
8MG
[MPC091374]
MB
(60 blisters) per
(60 blisters) per
(60 blisters) per
(12 grams) per
(12 grams) per
(12 grams) per
[Centennial Care #363]
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February 1, 2015
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Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
ALCLOMETASONE DIPROPIONATE
OINT
0.05%
Coverage Details
Note
ALDACTAZIDE
TABS
50MG; 50MG
ALENDRONATE SODIUM
TABS
10MG
ALENDRONATE SODIUM
TABS
40MG
QL (30.00 EA per 30 days)
ALENDRONATE SODIUM
TABS
35MG
QL (4.00 EA per 28 days)
ALENDRONATE SODIUM
TABS
5MG
ALENDRONATE SODIUM
TABS
70MG
ALFERON N
SOLN
5MU/ML
ALIMTA
SOLR
500MG
PA
MB
PA
MB
QL (4.00 EA per 28 days)
MB; SP
ALIMTA
SOLR
100MG
ALKERAN
TABS
2MG
ALLEGRA ALLERGY CHILDRENS
TABS
30MG
OTC
ALLEGRA ALLERGY CHILDRENS
SUSP
30MG/5ML
OTC
ALLERGY RELIEF
TBDP
10MG
OTC
ALLOPURINOL
TABS
100MG
ALLOPURINOL
TABS
300MG
ALORA
PTTW
0.1MG/24HR
QL (8.00 EA per 28 days)
ALORA
PTTW
0.075MG/24HR
QL (8.00 EA per 28 days)
ALORA
PTTW
0.05MG/24HR
QL (8.00 EA per 28 days)
ALORA
PTTW
0.025MG/24HR
QL (8.00 EA per 28 days)
ALOXI
SOLN
0.25MG/5ML
PA; QL (5.00 ML per 5 days)
ALPHAGAN P
SOLN
0.1%
ALPRAZOLAM
TABS
0.5MG
QL (90.00 EA per 30 days)
ALPRAZOLAM
TABS
2MG
QL (135.00 EA per 30 days)
ALPRAZOLAM
TABS
1MG
QL (90.00 EA per 30 days)
ALPRAZOLAM
TABS
0.25MG
QL (90.00 EA per 30 days)
ALPRAZOLAM INTENSOL
CONC
1MG/ML
ALREX
SUSP
0.2%
ALTAVERA
TABS
0.03MG; 0.15MG
ALYACEN 1/35
TABS
35MCG; 1MG
AMANTADINE HCL
CAPS
100MG
AMANTADINE HCL
TABS
100MG
AMANTADINE HCL
SYRP
50MG/5ML
AMILORIDE HCL
TABS
5MG
AMILORIDE/HYDROCHLOROTHIAZIDE
TABS
5MG; 50MG
AMIODARONE HCL
TABS
200MG
AMIODARONE HCL
TABS
400MG
AMITRIPTYLINE HCL
TABS
75MG
AMITRIPTYLINE HCL
TABS
10MG
AMITRIPTYLINE HCL
TABS
25MG
AMITRIPTYLINE HCL
TABS
100MG
AMITRIPTYLINE HCL
TABS
150MG
AMITRIPTYLINE HCL
TABS
50MG
AMLODIPINE BESYLATE
TABS
2.5MG
AMLODIPINE BESYLATE
TABS
5MG
AMLODIPINE BESYLATE
TABS
10MG
AMLODIPINE BESYLATE/BENAZEPRIL HCL
CAPS
10MG; 40MG
AMLODIPINE BESYLATE/BENAZEPRIL HCL
CAPS
5MG; 40MG
[MPC091374]
MB; SP
ST
[Centennial Care #363]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
AMLODIPINE BESYLATE/BENAZEPRIL
HYDROCHLORIDE
AMLODIPINE BESYLATE/BENAZEPRIL
HYDROCHLORIDE
AMLODIPINE BESYLATE/BENAZEPRIL
HYDROCHLORIDE
AMLODIPINE BESYLATE/BENAZEPRIL
HYDROCHLORIDE
AMNESTEEM
CAPS
10MG; 20MG
CAPS
5MG; 10MG
CAPS
5MG; 20MG
CAPS
2.5MG; 10MG
CAPS
10MG
QL (60.00 EA per 30 days)
AMNESTEEM
CAPS
20MG
QL (60.00 EA per 30 days)
AMNESTEEM
CAPS
40MG
QL (60.00 EA per 30 days)
AMOXAPINE
TABS
150MG
AMOXAPINE
TABS
100MG
AMOXAPINE
TABS
25MG
AMOXAPINE
TABS
50MG
AMOXICILLIN
SUSR
200MG/5ML
AMOXICILLIN
SUSR
125MG/5ML
AMOXICILLIN
SUSR
250MG/5ML
AMOXICILLIN
CHEW
125MG
AMOXICILLIN
TABS
875MG
AMOXICILLIN
CHEW
250MG
AMOXICILLIN
SUSR
400MG/5ML
AMOXICILLIN
TABS
500MG
AMOXICILLIN
CAPS
500MG
AMOXICILLIN
CAPS
250MG
AMOXICILLIN/CLAVULANATE POTASSIUM
SUSR
AMOXICILLIN/CLAVULANATE POTASSIUM
TABS
200MG/5ML;
28.5MG/5ML
500MG; 125MG
AMOXICILLIN/CLAVULANATE POTASSIUM
TABS
875MG; 125MG
AMOXICILLIN/CLAVULANATE POTASSIUM
CHEW
200MG; 28.5MG
AMOXICILLIN/CLAVULANATE POTASSIUM
SUSR
AMOXICILLIN/CLAVULANATE POTASSIUM
SUSR
AMOXICILLIN/CLAVULANATE POTASSIUM
CHEW
600MG/5ML;
42.9MG/5ML
600MG/5ML;
42.9MG/5ML
400MG; 57MG
AMOXICILLIN/CLAVULANATE POTASSIUM
TABS
250MG; 125MG
AMOXICILLIN/CLAVULANATE POTASSIUM
SUSR
AMOXICILLIN/CLAVULANATE POTASSIUM
SUSR
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
250MG/5ML;
62.5MG/5ML
400MG/5ML;
57MG/5ML
AG (min: 6y); QL (30.00 EA per 30 days)
1.25MG;
1.25MG;
1.25MG; 1.25MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
AG (min: 6y); QL (90.00 EA per 30 days)
1.25MG;
1.25MG;
1.25MG; 1.25MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
5MG; 5MG;
5MG; 5MG
5MG; 5MG;
5MG; 5MG
2.5MG; 2.5MG;
2.5MG; 2.5MG
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
[MPC091374]
Coverage Details
Note
AG (min: 6y); QL (90.00 EA per 30 days)
AG (min: 6y); QL (30.00 EA per 30 days)
AG (min: 6y); QL (90.00 EA per 30 days)
AG (min: 6y); QL (30.00 EA per 30 days)
6.25MG;
6.25MG;
6.25MG; 6.25MG
[Centennial Care #363]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
7.5MG; 7.5MG;
7.5MG; 7.5MG
AG (min: 6y); QL (60.00 EA per 30 days)
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
AG (min: 6y); QL (90.00 EA per 30 days)
3.75MG;
3.75MG;
3.75MG; 3.75MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
AG (min: 6y); QL (90.00 EA per 30 days)
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
3.125MG;
3.125MG;
3.125MG;
3.125MG
2.5MG; 2.5MG;
2.5MG; 2.5MG
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
7.5MG; 7.5MG;
7.5MG; 7.5MG
AG (min: 6y); QL (30.00 EA per 30 days)
AMPHETAMINE/DEXTROAMPHETAMINE
CP24
AG (min: 6y); QL (30.00 EA per 30 days)
3.75MG;
3.75MG;
3.75MG; 3.75MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABS
AMPICILLIN
CAPS
1.875MG;
1.875MG;
1.875MG;
1.875MG
250MG
AMPICILLIN
SUSR
125MG/5ML
AMPICILLIN
SUSR
250MG/5ML
AMPICILLIN
CAPS
500MG
AMPYRA
TB12
10MG
ANAGRELIDE HYDROCHLORIDE
CAPS
1MG
ANAGRELIDE HYDROCHLORIDE
CAPS
0.5MG
ANASTROZOLE
TABS
1MG
ANDRODERM
PT24
4MG/24HR
PA; QL (30.00 EA per 30 days)
ANDRODERM
PT24
2MG/24HR
PA; QL (60.00 EA per 30 days)
ANDROGEL
GEL
40.5MG/2.5GM
PA; QL (150.00 GM per 30 days)
ANDROGEL
GEL
PA; QL (37.50 GM per 30 days)
ANDROGEL
GEL
20.25MG/1.25G
M
25MG/2.5GM
ANDROGEL
GEL
50MG/5GM
PA; QL (300.00 GM per 30 days)
ANDROGEL PUMP
GEL
1.62%
PA; QL (150.00 GM per 30 days)
ANDROGEL PUMP
GEL
1%
PA; QL (300.00 GM per 30 days)
ANDROXY
TABS
10MG
PA; QL (120.00 EA per 30 days)
ANORO ELLIPTA
AEPB
ST
ANTI-DANDRUFF SHAMPOO
SHAM
62.5MCG/INH;
25MCG/INH
1%
ANTIPYRINE/BENZOCAINE
SOLN
5.4%; 1.4%
ANZEMET
TABS
100MG
PA; QL (4.00 EA per 28 days)
ANZEMET
TABS
50MG
PA; QL (4.00 EA per 28 days)
APOKYN
SOLN
10MG/ML
PA
APRI
TABS
0.15MG; 30MCG
APRISO
CP24
0.375GM
ST; QL (120.00 EA per 30 days)
APTIVUS
CAPS
250MG
QL (120.00 EA per 30 days)
APTIVUS
SOLN
100MG/ML
QL (300.00 ML per 30 days)
ARANELLE
TABS
0; 0
ARANESP ALBUMIN FREE
SOLN
500MCG/ML
PA
ARANESP ALBUMIN FREE
SOLN
100MCG/0.5ML
PA
[MPC091374]
Note
AG (min: 6y); QL (30.00 EA per 30 days)
AG (min: 6y); QL (90.00 EA per 30 days)
PA; QL (60.00 EA per 30 days)
SP
PA; QL (75.00 GM per 30 days)
OTC
5.4%-1.4%
SP
[Centennial Care #363]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
ARANESP ALBUMIN FREE
SOLN
25MCG/ML
PA
ARANESP ALBUMIN FREE
SOLN
300MCG/ML
PA
ARANESP ALBUMIN FREE
SOLN
40MCG/ML
PA
ARANESP ALBUMIN FREE
SOLN
60MCG/ML
PA
ARANESP ALBUMIN FREE
SOLN
100MCG/ML
PA
ARTHRITIS PAIN RELIEF
TBCR
650MG
QL (6.00 EA per 1 days)
ST; QL (180.00 EA per 30 days)
Note
OTC
ASACOL
TBEC
400MG
ASMANEX HFA
AERO
100MCG/ACT
ASMANEX HFA
AERO
200MCG/ACT
ASMANEX TWISTHALER 30 METERED DOSES
AEPB
110MCG/INH
ASMANEX TWISTHALER 60 METERED DOSES
AEPB
220MCG/INH
ASPIRIN
CHEW
81MG
AG (min: 45y, max: 78y)
ASPIRIN EC
TBEC
81MG
AG (min: 45y, max: 78y)
ASPIRIN LOW DOSE
TABS
81MG
AG (min: 45y, max: 78y)
ASSESS PEAK FLOW METER LOW RANGE
DEVI
ATENOLOL
TABS
25MG
ATENOLOL
TABS
50MG
ATENOLOL
TABS
100MG
ATORVASTATIN CALCIUM
TABS
20MG
ST; QL (30.00 EA per 30 days)
ATORVASTATIN CALCIUM
TABS
10MG
ST; QL (30.00 EA per 30 days)
ATORVASTATIN CALCIUM
TABS
40MG
ST; QL (30.00 EA per 30 days)
ATORVASTATIN CALCIUM
TABS
80MG
ST; QL (30.00 EA per 30 days)
ATOVAQUONE
SUSP
750MG/5ML
ATRIPLA
TABS
ATROPINE SULFATE
SOLN
600MG; 200MG; QL (30.00 EA per 30 days)
300MG
1%
ATROPINE SULFATE
OINT
1%
ATROVENT HFA
AERS
17MCG/ACT
AUBAGIO
TABS
14MG
PA; QL (30.00 EA per 30 days)
SP
AUBAGIO
TABS
7MG
PA; QL (30.00 EA per 30 days)
SP
AUGMENTED BETAMETHASONE DIPROPIONATE
CREA
0.05%
AUGMENTED BETAMETHASONE DIPROPIONATE
LOTN
0.05%
AUGMENTED BETAMETHASONE DIPROPIONATE
GEL
0.05%
AUGMENTED BETAMETHASONE DIPROPIONATE
OINT
0.05%
AUVI-Q
SOAJ
0.15MG/0.15ML
AUVI-Q
SOAJ
0.3MG/0.3ML
AVANDAMET
TABS
1000MG; 4MG
ST; QL (60.00 EA per 30 days)
AVANDAMET
TABS
500MG; 2MG
ST; QL (60.00 EA per 30 days)
AVANDAMET
TABS
500MG; 4MG
ST; QL (60.00 EA per 30 days)
AVANDAMET
TABS
1000MG; 2MG
ST; QL (60.00 EA per 30 days)
AVANDIA
TABS
8MG
ST; QL (30.00 EA per 30 days)
AVANDIA
TABS
2MG
ST; QL (60.00 EA per 30 days)
AVANDIA
TABS
4MG
ST; QL (60.00 EA per 30 days)
AVASTIN
SOLN
100MG/4ML
PA
MB
PA
MB
AVASTIN
SOLN
400MG/16ML
AVIANE
TABS
20MCG; 0.1MG
AVODART
CAPS
0.5MG
[MPC091374]
ST; QL (30.00 EA per 30 days)
[Centennial Care #363]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
AVONEX
KIT
30MCG/0.5ML
SP
AVONEX
KIT
30MCG/VIAL
SP
AZATHIOPRINE
TABS
50MG
AZELASTINE HCL
SOLN
137MCG/SPRAY PA
AZITHROMYCIN
SUSR
200MG/5ML
AZITHROMYCIN
SUSR
100MG/5ML
AZITHROMYCIN
TABS
600MG
AZITHROMYCIN
TABS
250MG
AZITHROMYCIN
TABS
500MG
AZOPT
SUSP
1%
AZURETTE
TABS
0; 0
BACITRACIN
OINT
500UNIT/GM
BACITRACIN
OINT
500UNIT/GM
BACITRACIN/POLYMYXIN B
OINT
BACLOFEN
TABS
500UNIT/GM;
10000UNIT/GM
10MG
BACLOFEN
TABS
20MG
BACTROBAN NASAL
OINT
2%
BALSALAZIDE DISODIUM
CAPS
750MG
BALZIVA
TABS
35MCG; 0.4MG
BD INSULIN SYRINGES
MISC
QL (200.00 EA per 30 days)
BD PEN NEEDLES
MISC
QL (200.00 EA per 30 days)
BELEODAQ
SOLR
500MG
BENAZEPRIL HCL
TABS
5MG
BENAZEPRIL HCL
TABS
20MG
BENAZEPRIL HCL
TABS
10MG
BENAZEPRIL HCL
TABS
40MG
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
TABS
5MG; 6.25MG
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
TABS
10MG; 12.5MG
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
TABS
20MG; 12.5MG
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
TABS
20MG; 25MG
BENLYSTA
SOLR
400MG
PA
MB; SP
BENLYSTA
SOLR
120MG
PA
MB; SP
BENZOYL PEROXIDE
GEL
2.5%
OTC
BENZOYL PEROXIDE
GEL
5%
OTC
BENZOYL PEROXIDE
GEL
10%
OTC
BENZOYL PEROXIDE WASH
LIQD
10%
OTC
BENZOYL PEROXIDE WASH
LIQD
5%
OTC
BENZTROPINE MESYLATE
TABS
2MG
BENZTROPINE MESYLATE
TABS
1MG
BENZTROPINE MESYLATE
TABS
0.5MG
BERINERT
KIT
500UNIT
BETAMETHASONE DIPROPIONATE
LOTN
0.05%
BETAMETHASONE DIPROPIONATE
CREA
0.05%
BETAMETHASONE DIPROPIONATE
OINT
0.05%
BETAMETHASONE VALERATE
LOTN
0.1%
BETAMETHASONE VALERATE
CREA
0.1%
BETAMETHASONE VALERATE
OINT
0.1%
BETASEPT SURGICAL SCRUB
LIQD
4%
[MPC091374]
Coverage Details
Note
OTC
PA
SP
OTC
[Centennial Care #363]
7 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
BETAXOLOL HCL
TABS
10MG
BETAXOLOL HCL
TABS
20MG
BETAXOLOL HCL
SOLN
0.5%
BETHANECHOL CHLORIDE
TABS
5MG
BETHANECHOL CHLORIDE
TABS
25MG
BETHANECHOL CHLORIDE
TABS
10MG
BETHANECHOL CHLORIDE
TABS
50MG
BETOPTIC-S
SUSP
0.25%
BICALUTAMIDE
TABS
50MG
BIO-STATIN
CAPS
500000UNIT
BIO-STATIN
CAPS
1000000UNIT
BISOPROLOL FUMARATE
TABS
5MG
BISOPROLOL FUMARATE
TABS
10MG
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE
BIVIGAM
TABS
2.5MG; 6.25MG
TABS
5MG; 6.25MG
TABS
10MG; 6.25MG
SOLN
5GM/50ML
BIVIGAM
SOLN
10GM/100ML
BLEPHAMIDE
SUSP
0.2%; 10%
BLEPHAMIDE S.O.P.
OINT
0.2%; 10%
BLINCYTO
SOLR
35MCG
PA
BOSULIF
TABS
100MG
PA; QL (120.00 EA per 30 days)
SP
BOSULIF
TABS
500MG
PA; QL (30.00 EA per 30 days)
SP
BOTOX
SOLR
100UNIT
PA
MB
BRILINTA
TABS
90MG
PA; QL (60.00 EA per 30 days)
BRIMONIDINE TARTRATE
SOLN
0.2%
BRIMONIDINE TARTRATE
SOLN
0.15%
BROMOCRIPTINE MESYLATE
CAPS
5MG
BROMOCRIPTINE MESYLATE
TABS
2.5MG
BRONCHO SALINE
AERS
0.9%
BUDESONIDE
SUSP
0.25MG/2ML
AG (max: 12y); QL (120.00 ML per 30 days)
BUDESONIDE
SUSP
0.5MG/2ML
AG (max: 12y); QL (120.00 ML per 30 days)
BUMETANIDE
TABS
2MG
BUMETANIDE
TABS
0.5MG
BUMETANIDE
TABS
1MG
BUPRENORPHINE HCL
SUBL
2MG
QL (90.00 EA per 30 days)
BUPRENORPHINE HCL
SUBL
8MG
QL (90.00 EA per 30 days)
BUPRENORPHINE HCL/NALOXONE HCL
SUBL
8MG; 2MG
QL (90.00 EA per 30 days)
BUPRENORPHINE HCL/NALOXONE HCL
SUBL
2MG; 0.5MG
QL (90.00 EA per 30 days)
BUPROBAN
TB12
150MG
QL (360.00 EA per 365 days)
BUPROPION HCL
TABS
100MG
QL (135.00 EA per 30 days)
BUPROPION HCL
TABS
75MG
QL (120.00 EA per 30 days)
BUPROPION HCL SR
TB12
150MG
QL (360.00 EA per 365 days)
BUPROPION HCL SR
TB12
200MG
QL (60.00 EA per 30 days)
BUPROPION HCL SR
TB12
150MG
QL (60.00 EA per 30 days)
BUPROPION HCL SR
TB12
100MG
QL (60.00 EA per 30 days)
BUPROPION HCL XL
TB24
300MG
QL (30.00 EA per 30 days);
[MPC091374]
Coverage Details
Note
ST
SP
OTC
[Centennial Care #363]
8 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
BUPROPION HCL XL
TB24
150MG
QL (30.00 EA per 30 days);
BUSPIRONE HCL
TABS
10MG
QL (90.00 EA per 30 days)
BUSPIRONE HCL
TABS
15MG
QL (90.00 EA per 30 days)
BUSPIRONE HCL
TABS
7.5MG
QL (90.00 EA per 30 days)
BUSPIRONE HCL
TABS
5MG
QL (90.00 EA per 30 days)
BUSPIRONE HCL
TABS
30MG
QL (60.00 EA per 30 days)
325MG; 50MG;
40MG
500MG; 50MG;
40MG
325MG; 50MG;
40MG
325MG; 50MG;
40MG; 30MG
QL (180.00 EA per 30 days)
Note
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
TABS
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
TABS
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
CAPS
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEI
NE
CAPS
BUTALBITAL/ASPIRIN/CAFFEINE
CAPS
BUTALBITAL/ASPIRIN/CAFFEINE
TABS
BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE
CAPS
BYETTA
SOPN
5MCG/0.02ML
PA; QL (1.20 ML per 30 days)
1 pen per 30 days
BYETTA
SOPN
10MCG/0.04ML
PA; QL (2.40 ML per 30 days)
1 pen per 30 days
CAFERGOT
TABS
100MG; 1MG
CAFFEINE CITRATE
SOLN
60MG/3ML
CAFFEINE CITRATE
SOLN
20MG/ML
CALCIFEROL
SOLN
8000UNIT/ML
CALCIPOTRIENE
SOLN
0.005%
CALCIPOTRIENE
CREA
0.005%
CALCIPOTRIENE
OINT
0.005%
CALCITONIN-SALMON
SOLN
200UNIT/ACT
CALCITRENE
OINT
0.005%
CALCITRIOL
SOLN
1MCG/ML
CALCITRIOL
CAPS
0.5MCG
CALCITRIOL
CAPS
0.25MCG
CALCIUM ACETATE
CAPS
667MG
CALCIUM/VITAMIN D
TABS
CALCIUM/VITAMIN D
TABS
CALCIUM/VITAMIN D
TABS
CALCIUM/VITAMIN D
TABS
CAMILA
TABS
500MG;
125UNIT
600MG;
200UNIT
600MG;
125UNIT
500MG;
200UNIT
0.35MG
CANASA
SUPP
1000MG
CANDESARTAN CILEXETIL
TABS
8MG
ST; QL (60.00 EA per 30 days)
CANDESARTAN CILEXETIL
TABS
32MG
ST; QL (30.00 EA per 30 days)
CANDESARTAN CILEXETIL
TABS
4MG
ST; QL (60.00 EA per 30 days)
CANDESARTAN CILEXETIL
TABS
16MG
ST; QL (60.00 EA per 30 days)
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE
CAPECITABINE
TABS
32MG; 25MG
ST; QL (30.00 EA per 30 days)
TABS
32MG; 12.5MG
ST; QL (30.00 EA per 30 days)
TABS
16MG; 12.5MG
ST; QL (60.00 EA per 30 days)
TABS
500MG
PA
[MPC091374]
QL (180.00 EA per 30 days)
QL (180.00 EA per 30 days)
QL (180.00 EA per 30 days)
325MG; 50MG;
40MG
325MG; 50MG;
40MG
325MG; 50MG;
40MG; 30MG
OTC
OTC
OTC
OTC
OTC
SP
[Centennial Care #363]
9 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
Note
CAPECITABINE
TABS
150MG
PA
SP
CAPRELSA
TABS
300MG
PA; QL (30.00 EA per 30 days)
SP
CAPRELSA
TABS
100MG
PA; QL (60.00 EA per 30 days)
SP
CAPTOPRIL
TABS
25MG
CAPTOPRIL
TABS
100MG
CAPTOPRIL
TABS
12.5MG
CAPTOPRIL
TABS
50MG
CAPTOPRIL/HYDROCHLOROTHIAZIDE
TABS
25MG; 15MG
CAPTOPRIL/HYDROCHLOROTHIAZIDE
TABS
50MG; 15MG
CAPTOPRIL/HYDROCHLOROTHIAZIDE
TABS
50MG; 25MG
CAPTOPRIL/HYDROCHLOROTHIAZIDE
TABS
25MG; 25MG
CARAFATE
SUSP
1GM/10ML
CARBAMAZEPINE
TABS
200MG
CARBAMAZEPINE
SUSP
100MG/5ML
CARBAMAZEPINE
CHEW
100MG
CARBAMAZEPINE ER
CP12
200MG
CARBAMAZEPINE ER
CP12
300MG
CARBAMAZEPINE ER
CP12
100MG
CARBAMAZEPINE ER
TB12
200MG
CARBAMAZEPINE ER
TB12
400MG
CARBIDOPA/LEVODOPA
TABS
25MG; 100MG
CARBIDOPA/LEVODOPA
TABS
10MG; 100MG
CARBIDOPA/LEVODOPA
TABS
25MG; 250MG
CARBIDOPA/LEVODOPA ER
TBCR
50MG; 200MG
CARBIDOPA/LEVODOPA ER
TBCR
25MG; 100MG
CARBIDOPA/LEVODOPA ODT
TBDP
10MG; 100MG
CARBIDOPA/LEVODOPA ODT
TBDP
25MG; 100MG
CARBIDOPA/LEVODOPA ODT
TBDP
25MG; 250MG
CARIMUNE NANOFILTERED
SOLR
6GM
PA
MB; SP
CARIMUNE NANOFILTERED
SOLR
12GM
PA;
MB; SP
CARIMUNE NANOFILTERED
SOLR
3GM
PA
MB; SP
CARISOPRODOL
TABS
350MG
CARISOPRODOL/ASPIRIN
TABS
325MG; 200MG
CARISOPRODOL/ASPIRIN/CODEINE
TABS
CARTEOLOL HCL
SOLN
325MG; 200MG;
16MG
1%
CARTIA XT
CP24
300MG
CARTIA XT
CP24
120MG
CARTIA XT
CP24
180MG
CARTIA XT
CP24
240MG
CARVEDILOL
TABS
3.125MG
CARVEDILOL
TABS
6.25MG
CARVEDILOL
TABS
12.5MG
CARVEDILOL
TABS
25MG
CAZIANT
TABS
0; 0
CEFACLOR
CAPS
500MG
CEFACLOR
CAPS
250MG
CEFDINIR
CAPS
300MG
CEFDINIR
SUSR
250MG/5ML
[MPC091374]
[Centennial Care #363]
10 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
CEFDINIR
SUSR
125MG/5ML
CEFPODOXIME PROXETIL
TABS
200MG
CEFPODOXIME PROXETIL
TABS
100MG
CEFPODOXIME PROXETIL
SUSR
50MG/5ML
CEFPODOXIME PROXETIL
SUSR
100MG/5ML
CEFPROZIL
TABS
500MG
CEFPROZIL
TABS
250MG
CEFPROZIL
SUSR
125MG/5ML
CEFPROZIL
SUSR
250MG/5ML
CEFUROXIME AXETIL
TABS
500MG
CEFUROXIME AXETIL
SUSR
125MG/5ML
CEFUROXIME AXETIL
TABS
250MG
CELECOXIB
CAPS
50MG
ST; QL (60.00 EA per 30 days)
CELECOXIB
CAPS
200MG
ST; QL (60.00 EA per 30 days)
CELECOXIB
CAPS
400MG
ST; QL (60.00 EA per 30 days)
CELECOXIB
CAPS
100MG
ST; QL (60.00 EA per 30 days)
CEPHALEXIN
CAPS
500MG
CEPHALEXIN
CAPS
250MG
CEPHALEXIN
SUSR
125MG/5ML
CEPHALEXIN
SUSR
250MG/5ML
CESIA
TABS
0; 0
CETIRIZINE HCL
TABS
10MG
OTC
CETIRIZINE HCL
CHEW
10MG
OTC
CETIRIZINE HCL
TABS
5MG
OTC
CETIRIZINE HCL
CHEW
5MG
OTC
CETIRIZINE HCL CHILDRENS ALLERGY
SYRP
1MG/ML
OTC
CHANTIX
TABS
0.5MG
CHANTIX
TABS
1MG
CHANTIX STARTING MONTH PAK
TABS
0
CHEMSTRIP UGK
STRP
0
CHILDRENS IBUPROFEN
SUSP
40MG/ML
OTC
CHILDRENS LORATADINE
SYRP
5MG/5ML
OTC
CHLORDIAZEPOXIDE HCL
CAPS
5MG
QL (120.00 EA per 30 days)
CHLORDIAZEPOXIDE HCL
CAPS
10MG
QL (120.00 EA per 30 days)
CHLORDIAZEPOXIDE HCL
CAPS
25MG
QL (120.00 EA per 30 days)
CHLORHEXIDINE GLUCONATE
SOLN
0.12%
CHLOROQUINE PHOSPHATE
TABS
250MG
CHLOROQUINE PHOSPHATE
TABS
500MG
CHLORPROMAZINE HCL
TABS
25MG
CHLORPROMAZINE HCL
TABS
50MG
CHLORPROMAZINE HCL
TABS
200MG
CHLORPROMAZINE HCL
TABS
100MG
CHLORPROMAZINE HCL
TABS
10MG
CHLORPROPAMIDE
TABS
250MG
CHLORPROPAMIDE
TABS
100MG
CHLORTHALIDONE
TABS
50MG
CHLORTHALIDONE
TABS
25MG
CHLORTHALIDONE
TABS
100MG
CHLORZOXAZONE
TABS
500MG
[MPC091374]
Coverage Details
Note
[Centennial Care #363]
11 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
CHOLESTYRAMINE
POWD
4GM/DOSE
CHOLESTYRAMINE
PACK
4GM
CHOLESTYRAMINE LIGHT
POWD
4GM/DOSE
CHOLESTYRAMINE LIGHT
PACK
4GM
CICLOPIROX
GEL
0.77%
CICLOPIROX
SUSP
0.77%
CICLOPIROX NAIL LACQUER
SOLN
8%
CICLOPIROX OLAMINE
CREA
0.77%
CILOSTAZOL
TABS
100MG
CILOSTAZOL
TABS
50MG
CIMETIDINE
TABS
300MG
CIMETIDINE
TABS
400MG
CIMETIDINE
TABS
800MG
CIMETIDINE
TABS
200MG
CIMETIDINE HCL
SOLN
300MG/5ML
CINRYZE
SOLR
500UNIT
PA
CIPRODEX
SUSP
0.3%; 0.1%
AG (max: 12y); QL (7.50 ML per 30 days)
CIPROFLOXACIN
SUSR
500MG/5ML
CIPROFLOXACIN
SUSR
250MG/5ML
CIPROFLOXACIN HCL
TABS
100MG
CIPROFLOXACIN HCL
TABS
500MG
CIPROFLOXACIN HCL
TABS
750MG
CIPROFLOXACIN HCL
TABS
250MG
CIPROFLOXACIN HCL
SOLN
0.3%
CITALOPRAM HYDROBROMIDE
SOLN
10MG/5ML
QL (600.00 ML per 30 days)
CITALOPRAM HYDROBROMIDE
TABS
40MG
QL (30.00 EA per 30 days)
CITALOPRAM HYDROBROMIDE
TABS
10MG
QL (60.00 EA per 30 days)
CITALOPRAM HYDROBROMIDE
TABS
20MG
QL (60.00 EA per 30 days)
CLARAVIS
CAPS
20MG
QL (60.00 EA per 30 days)
CLARAVIS
CAPS
30MG
QL (60.00 EA per 30 days)
CLARAVIS
CAPS
40MG
QL (60.00 EA per 30 days)
CLARAVIS
CAPS
10MG
QL (60.00 EA per 30 days)
CLARAVIS
CAPS
40MG
QL (60.00 EA per 30 days)
CLARITHROMYCIN
TABS
500MG
QL (28.00 EA per 30 days)
CLARITHROMYCIN
SUSR
125MG/5ML
CLARITHROMYCIN
TABS
250MG
CLARITHROMYCIN
SUSR
250MG/5ML
CLEOCIN
SUPP
100MG
CLINDAMAX
LOTN
1%
CLINDAMAX
GEL
1%
CLINDAMYCIN HCL
CAPS
300MG
CLINDAMYCIN HCL
CAPS
75MG
CLINDAMYCIN HCL
CAPS
150MG
CLINDAMYCIN PALMITATE HCL
SOLR
75MG/5ML
CLINDAMYCIN PHOSPHATE
CREA
2%
CLINDAMYCIN PHOSPHATE
SOLN
1%
CLINDAMYCIN PHOSPHATE
SWAB
1%
CLINDAMYCIN PHOSPHATE
GEL
1%
CLINDAMYCIN PHOSPHATE
LOTN
1%
[MPC091374]
Coverage Details
Note
QL (19.80 ML per 365 days)
SP
QL (28.00 EA per 30 days)
[Centennial Care #363]
12 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
CLINPRO 5000
PSTE
1.1%
CLOBETASOL PROPIONATE
OINT
0.05%
CLOBETASOL PROPIONATE
CREA
0.05%
CLOBETASOL PROPIONATE
GEL
0.05%
CLOBETASOL PROPIONATE
SOLN
0.05%
CLOBETASOL PROPIONATE E
CREA
0.05%
CLOMIPRAMINE HCL
CAPS
50MG
CLOMIPRAMINE HCL
CAPS
75MG
CLOMIPRAMINE HCL
CAPS
25MG
CLONAZEPAM
TABS
0.5MG
QL (90.00 EA per 30 days)
CLONAZEPAM
TABS
1MG
QL (90.00 EA per 30 days)
CLONAZEPAM
TABS
2MG
QL (90.00 EA per 30 days)
CLONAZEPAM ODT
TBDP
2MG
QL (90.00 EA per 30 days)
CLONAZEPAM ODT
TBDP
0.125MG
QL (90.00 EA per 30 days)
CLONAZEPAM ODT
TBDP
0.5MG
QL (90.00 EA per 30 days)
CLONAZEPAM ODT
TBDP
0.25MG
QL (90.00 EA per 30 days)
CLONAZEPAM ODT
TBDP
1MG
QL (90.00 EA per 30 days)
CLONIDINE HCL
TABS
0.2MG
CLONIDINE HCL
TABS
0.3MG
CLONIDINE HCL
TABS
0.1MG
CLOPIDOGREL
TABS
75MG
CLORAZEPATE DIPOTASSIUM
TABS
3.75MG
QL (90.00 EA per 30 days)
CLORAZEPATE DIPOTASSIUM
TABS
7.5MG
QL (90.00 EA per 30 days)
CLORAZEPATE DIPOTASSIUM
TABS
15MG
QL (180.00 EA per 30 days)
CLOTRIMAZOLE
CREA
1%
CLOTRIMAZOLE
TROC
10MG
CLOTRIMAZOLE 3 DAY
CREA
2%
OTC
CLOTRIMAZOLE ANTI-FUNGAL
CREA
1%
OTC
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE
CLOZAPINE
CREA
0.05%; 1%
LOTN
0.05%; 1%
TABS
200MG
QL (135.00 EA per 30 days)
CLOZAPINE
TABS
25MG
QL (60.00 EA per 30 days)
CLOZAPINE
TABS
100MG
QL (270.00 EA per 30 days)
CLOZAPINE
TABS
50MG
QL (60.00 EA per 30 days)
CLOZAPINE ODT
TBDP
25MG
QL (180.00 EA per 30 days)
CLOZAPINE ODT
TBDP
100MG
QL (270.00 EA per 30 days)
CLOZAPINE ODT
TBDP
12.5MG
QL (60.00 EA per 30 days)
CODEINE SULFATE
TABS
15MG
QL (180.00 EA per 30 days)
CODEINE SULFATE
TABS
60MG
QL (180.00 EA per 30 days)
CODEINE SULFATE
TABS
30MG
QL (180.00 EA per 30 days)
COGENTIN
SOLN
1MG/ML
COLCRYS
TABS
0.6MG
COLY-MYCIN S
SUSP
COLYTE-FLAVOR PACKS
SOLR
3MG/ML;
10MG/ML;
3.3MG/ML;
0.5MG/ML
227.1GM;
2.82GM;
6.36GM;
5.53GM; 21.5GM
[MPC091374]
Coverage Details
Note
OTC
[Centennial Care #363]
13 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
COMBIPATCH
PTTW
ST; QL (8.00 EA per 28 days)
COMBIPATCH
PTTW
COMBIVENT RESPIMAT
AERS
COMETRIQ
KIT
0.05MG/DAY;
0.14MG/DAY
0.05MG/DAY;
0.25MG/DAY
100MCG/ACT;
20MCG/ACT
0
COMETRIQ
KIT
0
PA
COMETRIQ
KIT
20MG
PA
COMPLERA
TABS
QL (30.00 EA per 30 days)
SP
COMPRO
SUPP
200MG; 25MG;
300MG
25MG
CONSTULOSE
SOLN
10GM/15ML
COPAXONE
KIT
20MG/ML
QL (30.00 ML per 30 days)
SP
CORMAX SCALP APPLICATION
SOLN
0.05%
CORTAID INTENSIVE THERAPYCOOLING SPRAY
SOLN
1%
CORTISPORIN
CREA
CORTISPORIN
OINT
CREON
CPEP
CREON
CPEP
CREON
CPEP
CREON
CPEP
CREON
CPEP
CRIXIVAN
CAPS
0.5%; 0.5%;
10000UNIT/GM
400UNIT/GM;
1%; 0.5%;
5000UNIT/GM
60000UNIT;
12000UNIT;
38000UNIT
15000UNIT;
3000UNIT;
9500UNIT
30000UNIT;
6000UNIT;
19000UNIT
120000UNIT;
24000UNIT;
76000UNIT
180000UNIT;
36000UNIT;
114000UNIT
400MG
QL (180.00 EA per 30 days)
CRIXIVAN
CAPS
200MG
QL (180.00 EA per 30 days)
CROMOLYN SODIUM
NEBU
20MG/2ML
CROMOLYN SODIUM
SOLN
4%
CROMOLYN SODIUM
AERS
5.2MG/ACT
CRYSELLE-28
TABS
30MCG; 0.3MG
CUPRIMINE
CAPS
250MG
CYCLAFEM 1/35
TABS
35MCG; 1MG
CYCLAFEM 7/7/7
TABS
0; 0
CYCLOBENZAPRINE HCL
TABS
5MG
CYCLOBENZAPRINE HCL
TABS
10MG
CYCLOPHOSPHAMIDE
TABS
25MG
CYCLOPHOSPHAMIDE
TABS
50MG
CYCLOSERINE
CAPS
250MG
CYCLOSERINE
CAPS
250MG
CYCLOSPORINE
CAPS
25MG
CYCLOSPORINE
CAPS
100MG
CYCLOSPORINE MODIFIED
SOLN
100MG/ML
CYCLOSPORINE MODIFIED
CAPS
100MG
CYCLOSPORINE MODIFIED
CAPS
50MG
CYCLOSPORINE MODIFIED
SOLN
100MG/ML
[MPC091374]
Note
ST; QL (8.00 EA per 28 days)
QL (4.00 GM per 30 days)
PA
OTC
OTC
[Centennial Care #363]
14 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
CYCLOSPORINE MODIFIED
CAPS
25MG
CYPROHEPTADINE HCL
TABS
4MG
CYPROHEPTADINE HCL
SYRP
2MG/5ML
CYRAMZA
SOLN
500MG/50ML
PA
CYRAMZA
SOLN
100MG/10ML
PA
CYTOGAM
INJ
50MG/ML
PA
CYTRA-2
SOLN
DALIRESP
TABS
334MG/5ML;
500MG/5ML
500MCG
PA; QL (30.00 EA per 30 days)
DANAZOL
CAPS
200MG
DANAZOL
CAPS
50MG
DANAZOL
CAPS
100MG
DAPSONE
TABS
100MG
DAPSONE
TABS
25MG
DELZICOL
CPDR
400MG
DEPEN TITRATABS
TABS
250MG
DESIPRAMINE HCL
TABS
25MG
DESIPRAMINE HCL
TABS
10MG
DESIPRAMINE HCL
TABS
50MG
DESIPRAMINE HCL
TABS
150MG
DESMOPRESSIN ACETATE
TABS
0.2MG
DESMOPRESSIN ACETATE
SOLN
0.01%
DESMOPRESSIN ACETATE
TABS
0.1MG
DESMOPRESSIN ACETATE
SOLN
0.01%
DESONIDE
OINT
0.05%
DESONIDE
LOTN
0.05%
DESONIDE
CREA
0.05%
DEXAMETHASONE
ELIX
0.5MG/5ML
DEXAMETHASONE
SOLN
0.5MG/5ML
DEXAMETHASONE
TABS
1MG
DEXAMETHASONE
TABS
4MG
DEXAMETHASONE
TABS
2MG
DEXAMETHASONE
TABS
0.5MG
DEXAMETHASONE
TABS
0.75MG
DEXAMETHASONE
TABS
1.5MG
DEXAMETHASONE
TABS
6MG
DEXAMETHASONE INTENSOL
CONC
1MG/ML
DEXAMETHASONE SODIUM PHOSPHATE
SOLN
0.1%
DEXFERRUM
SOLN
50MG/ML
PA
DEXTROAMPHETAMINE SULFATE
TABS
5MG
AG (min: 6y); QL (90.00 EA per 30 days)
DEXTROAMPHETAMINE SULFATE
TABS
10MG
AG (min: 6y); QL (90.00 EA per 30 days)
DEXTROAMPHETAMINE SULFATE ER
CP24
5MG
AG (min: 6y); QL (60.00 EA per 30 days)
DEXTROAMPHETAMINE SULFATE ER
CP24
10MG
AG (min: 6y); QL (60.00 EA per 30 days)
DEXTROAMPHETAMINE SULFATE ER
CP24
15MG
AG (min: 6y); QL (60.00 EA per 30 days)
DIALYVITE
TABS
100MG; 0.3MG;
0.006MG; 1MG;
20MG; 10MG;
10MG; 1.7MG;
1.5MG
DIAZEPAM
TABS
2MG
[MPC091374]
Coverage Details
Note
ST; QL (180.00 EA per 30 days)
MB
QL (120.00 EA per 30 days)
[Centennial Care #363]
15 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
DIAZEPAM
TABS
10MG
QL (120.00 EA per 30 days)
DIAZEPAM
TABS
5MG
QL (120.00 EA per 30 days)
DIAZEPAM
GEL
2.5MG
ST
DIAZEPAM
GEL
10MG
ST
DIAZEPAM
GEL
20MG
ST
DICLOFENAC SODIUM
SOLN
0.1%
DICLOFENAC SODIUM DR
TBEC
50MG
DICLOFENAC SODIUM DR
TBEC
25MG
DICLOFENAC SODIUM DR
TBEC
75MG
DICLOFENAC SODIUM ER
TB24
100MG
DICLOXACILLIN SODIUM
CAPS
250MG
DICLOXACILLIN SODIUM
CAPS
500MG
DICYCLOMINE HCL
SOLN
10MG/5ML
DICYCLOMINE HCL
CAPS
10MG
DICYCLOMINE HCL
TABS
20MG
DIDANOSINE
CPDR
250MG
QL (30.00 EA per 30 days)
DIDANOSINE
CPDR
200MG
QL (30.00 EA per 30 days)
DIDANOSINE
CPDR
125MG
QL (30.00 EA per 30 days)
DIDANOSINE
CPDR
400MG
QL (30.00 EA per 30 days)
DIFICID
TABS
200MG
PA; QL (20.00 EA per 30 days)
DIFLUNISAL
TABS
500MG
DIGOXIN
TABS
125MCG
DIGOXIN
TABS
250MCG
DIGOXIN
SOLN
0.05MG/ML
DILANTIN
CAPS
30MG
DILATRATE SR
CPCR
40MG
DILT-CD
CP24
300MG
DILT-CD
CP24
120MG
DILT-CD
CP24
180MG
DILT-CD
CP24
240MG
DILTIAZEM CD
CP24
240MG
DILTIAZEM CD
CP24
300MG
DILTIAZEM CD
CP24
180MG
DILTIAZEM CD
CP24
120MG
DILTIAZEM HCL
TABS
90MG
DILTIAZEM HCL
SOLN
50MG/10ML
DILTIAZEM HCL
TABS
30MG
DILTIAZEM HCL
TABS
120MG
DILTIAZEM HCL
TABS
60MG
DILTIAZEM HCL ER
CP24
300MG
DILTIAZEM HCL ER
CP24
180MG
DILTIAZEM HCL ER
CP12
60MG
DILTIAZEM HCL ER
CP12
120MG
DILTIAZEM HCL ER
CP24
240MG
DILTIAZEM HCL ER
CP24
120MG
DILTIAZEM HCL ER
CP24
180MG
DILTIAZEM HCL ER
CP24
240MG
DILTIAZEM HCL ER
CP24
360MG
DILTIAZEM HCL ER
CP24
120MG
[MPC091374]
Note
[Centennial Care #363]
16 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
DILTIAZEM HCL ER
CP24
180MG
DILTIAZEM HCL ER
CP24
420MG
DILTIAZEM HCL ER
CP24
240MG
DILTIAZEM HCL ER
CP24
300MG
DILTIAZEM HCL ER
CP24
120MG
DILTIAZEM HCL ER
CP12
90MG
DILTZAC
CP24
180MG
DILTZAC
CP24
240MG
DILTZAC
CP24
120MG
DILTZAC
CP24
300MG
DILTZAC
CP24
360MG
DIOCTO
SYRP
60MG/15ML
DIPHENOXYLATE/ATROPINE
LIQD
DIPYRIDAMOLE
TABS
0.025MG/5ML;
2.5MG/5ML
25MG
DIPYRIDAMOLE
TABS
50MG
DIPYRIDAMOLE
TABS
75MG
DISOPYRAMIDE PHOSPHATE
CAPS
100MG
DISOPYRAMIDE PHOSPHATE
CAPS
150MG
DISULFIRAM
TABS
250MG
DIVALPROEX SODIUM
CPSP
125MG
DIVALPROEX SODIUM DR
TBEC
500MG
DIVALPROEX SODIUM DR
TBEC
125MG
DIVALPROEX SODIUM DR
TBEC
250MG
DIVALPROEX SODIUM ER
TB24
500MG
DIVALPROEX SODIUM ER
TB24
250MG
DOCUSATE SODIUM
TABS
100MG
OTC
DOCUSATE SODIUM
CAPS
100MG
OTC
DOCUSATE SODIUM
CAPS
250MG
OTC
DOLGIC PLUS
TABS
QL (180.00 EA per 30 days)
DONEPEZIL HCL
TABS
750MG; 50MG;
40MG
10MG
DONEPEZIL HCL
TBDP
5MG
QL (30.00 EA per 30 days)
DONEPEZIL HCL
TBDP
10MG
QL (30.00 EA per 30 days)
DONEPEZIL HCL
TABS
5MG
QL (30.00 EA per 30 days)
DORZOLAMIDE HCL
SOLN
2%
DOXAZOSIN MESYLATE
TABS
4MG
DOXAZOSIN MESYLATE
TABS
1MG
DOXAZOSIN MESYLATE
TABS
2MG
DOXAZOSIN MESYLATE
TABS
8MG
DOXEPIN HCL
CONC
10MG/ML
DOXEPIN HCL
CAPS
150MG
DOXEPIN HCL
CAPS
100MG
DOXEPIN HCL
CAPS
10MG
DOXEPIN HCL
CAPS
25MG
DOXEPIN HCL
CAPS
50MG
DOXEPIN HCL
CAPS
75MG
DOXERCALCIFEROL
CAPS
1MCG
[MPC091374]
Coverage Details
Note
OTC
QL (30.00 EA per 30 days)
5 mg and 10 mg tablets;
mg and 10 mg ODT
5 mg and 10 mg tablets;
mg and 10 mg ODT
5 mg and 10 mg tablets;
mg and 10 mg ODT
5 mg and 10 mg tablets;
mg and 10 mg ODT
[Centennial Care #363]
17 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
5
5
5
5
Drug Name
Form
Strength
DOXERCALCIFEROL
CAPS
2.5MCG
Coverage Details
DOXERCALCIFEROL
CAPS
0.5MCG
DOXYCYCLINE HYCLATE
CAPS
50MG
DOXYCYCLINE HYCLATE
CAPS
100MG
DOXYCYCLINE HYCLATE
TABS
20MG
DOXYCYCLINE HYCLATE
TABS
100MG
DROSPIRENONE/ETHINYL ESTRADIOL
TABS
3MG; 0.03MG
DULERA
AERO
ST; QL (13.00 GM per 30 days)
DULERA
AERO
DULOXETINE HCL
CPEP
5MCG/ACT;
100MCG/ACT
5MCG/ACT;
200MCG/ACT
20MG
DULOXETINE HCL
CPEP
30MG
PA; QL (60.00 EA per 30 days)
DULOXETINE HCL
CPEP
60MG
PA; QL (30.00 EA per 30 days)
DUTOPROL
TB24
12.5MG; 100MG
DUTOPROL
TB24
12.5MG; 25MG
DUTOPROL
TB24
12.5MG; 50MG
DYRENIUM
CAPS
50MG
DYRENIUM
CAPS
0; 100MG
E.E.S. 400
TABS
400MG
E.E.S. GRANULES
SUSR
200MG/5ML
ECONAZOLE NITRATE
CREA
1%
EDECRIN
TABS
25MG
EDURANT
TABS
25MG
EFFERVESCENT POTASSIUM
TBEF
2GM; 2.5GM
EFFIENT
TABS
5MG
PA; QL (30.00 EA per 30 days)
EFFIENT
TABS
10MG
PA; QL (30.00 EA per 30 days)
ELIDEL
CREA
1%
PA
ELIGARD
KIT
45MG
ELIGARD
KIT
7.5MG
ELIGARD
KIT
22.5MG
ELIGARD
KIT
30MG
ELIXOPHYLLIN
ELIX
80MG/15ML
EMCYT
CAPS
140MG
PA
EMEND
CAPS
80MG
PA; QL (2.00 EA per dispensing)
EMEND
SOLR
150MG
PA; QL (4.00 EA per 30 days)
QL (60.00 EA per 30 days)
ST; QL (13.00 GM per 30 days)
PA; QL (60.00 EA per 30 days)
EMEND
CAPS
40MG
PA; QL (1.00 EA per dispensing)
EMEND
CAPS
125MG
PA; QL (1.00 EA per dispensing)
EMEND
CAPS
0
PA; QL (1.00 EA per dispensing)
EMOQUETTE
TABS
0.15MG; 30MCG
EMSAM
PT24
6MG/24HR
PA; QL (30.00 EA per 30 days)
EMSAM
PT24
9MG/24HR
PA; QL (30.00 EA per 30 days)
EMSAM
PT24
12MG/24HR
PA; QL (30.00 EA per 30 days)
EMTRIVA
CAPS
200MG
QL (30.00 EA per 30 days)
EMTRIVA
SOLN
10MG/ML
QL (720.00 ML per 30 days)
ENALAPRIL MALEATE
TABS
10MG
ENALAPRIL MALEATE
TABS
20MG
ENALAPRIL MALEATE
TABS
2.5MG
ENALAPRIL MALEATE
TABS
5MG
[MPC091374]
Note
SP
MB
[Centennial Care #363]
18 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE
TABS
10MG; 25MG
Coverage Details
Note
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE
TABS
5MG; 12.5MG
ENBREL
KIT
25MG
PA
SP
SP
ENBREL
SOSY
50MG/ML
PA
ENDOCET
TABS
325MG; 7.5MG
QL (12.00 EA per 1 days)
ENDOCET
TABS
325MG; 10MG
QL (12.00 EA per 1 days)
ENDOCET
TABS
325MG; 5MG
QL (12.00 EA per 1 days)
ENOXAPARIN SODIUM
SOLN
100MG/ML
QL (30.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
40MG/0.4ML
QL (12.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
60MG/0.6ML
QL (18.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
30MG/0.3ML
QL (9.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
120MG/0.8ML
QL (24.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
300MG/3ML
QL (90.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
80MG/0.8ML
QL (24.00 ML per 90 days)
ENOXAPARIN SODIUM
SOLN
150MG/ML
QL (30.00 ML per 90 days)
ENPRESSE-28
TABS
0; 0
ENSKYCE
TABS
0.15MG; 30MCG
ENTACAPONE
TABS
200MG
EPANED
SOLR
1MG/ML
AG (max: 8y); QL (150.00 ML per 30 days)
EPIVIR
SOLN
10MG/ML
QL (900.00 ML per 30 days)
EPIVIR HBV
SOLN
5MG/ML
EPOGEN
SOLN
10000UNIT/ML
PA
EPOGEN
SOLN
20000UNIT/ML
PA
EPOGEN
SOLN
2000UNIT/ML
PA
EPOGEN
SOLN
4000UNIT/ML
PA
EPOGEN
SOLN
3000UNIT/ML
PA
EPZICOM
TABS
600MG; 300MG
QL (30.00 EA per 30 days)
ERGOLOID MESYLATES
TABS
1MG
ERIVEDGE
CAPS
150MG
ERRIN
TABS
0.35MG
ERWINAZE
SOLR
10000UNIT
ERYPED 200
SUSR
200MG/5ML
ERYPED 400
SUSR
400MG/5ML
ERY-TAB
TBEC
333MG
ERY-TAB
TBEC
250MG
ERY-TAB
TBEC
500MG
ERYTHROCIN STEARATE
TABS
250MG
ERYTHROMYCIN
OINT
5MG/GM
ERYTHROMYCIN
GEL
2%
ERYTHROMYCIN
SOLN
2%
ERYTHROMYCIN BASE
TABS
250MG
ERYTHROMYCIN BASE
TABS
500MG
ERYTHROMYCIN ETHYLSUCCINATE
TABS
400MG
ERYTHROMYCIN/BENZOYL PEROXIDE
GEL
5%; 3%
ERYTHROMYCIN/SULFISOXAZOLE
SUSR
ESCITALOPRAM OXALATE
SOLN
200MG/5ML;
600MG/5ML
5MG/5ML
QL (600.00 ML per 30 days)
ESCITALOPRAM OXALATE
TABS
5MG
QL (30.00 EA per 30 days)
[MPC091374]
PA; QL (30.00 EA per 30 days)
SP
PA
[Centennial Care #363]
19 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
ESCITALOPRAM OXALATE
TABS
20MG
QL (30.00 EA per 30 days)
ESCITALOPRAM OXALATE
TABS
10MG
QL (45.00 EA per 30 days)
ESTRACE
CREA
0.1MG/GM
ESTRADIOL
PTWK
0.075MG/24HR
ESTRADIOL
TABS
2MG
ESTRADIOL
PTWK
0.025MG/24HR
ESTRADIOL
PTWK
0.05MG/24HR
ESTRADIOL
PTWK
0.06MG/24HR
ESTRADIOL
TABS
0.5MG
ESTRADIOL
PTWK
0.1MG/24HR
ESTRADIOL
PTWK
37.5MCG/24HR
ESTRADIOL
TABS
1MG
ESTRADIOL/NORETHINDRONE ACETATE
TABS
1MG; 0.5MG
ESTRADIOL/NORETHINDRONE ACETATE
TABS
0.5MG; 0.1MG
ESTROPIPATE
TABS
0.75MG
ESTROPIPATE
TABS
1.5MG
ESTROPIPATE
TABS
3MG
ESZOPICLONE
TABS
3MG
PA; QL (30.00 EA per 30 days)
ESZOPICLONE
TABS
2MG
PA; QL (30.00 EA per 30 days)
ESZOPICLONE
TABS
1MG
PA; QL (30.00 EA per 30 days)
ETHAMBUTOL HCL
TABS
400MG
ETHAMBUTOL HCL
TABS
100MG
ETHOSUXIMIDE
CAPS
250MG
ETHOSUXIMIDE
SOLN
250MG/5ML
ETHYOL
SOLR
500MG
ETODOLAC
CAPS
200MG
ETODOLAC
TABS
500MG
ETODOLAC
TABS
400MG
ETODOLAC
CAPS
300MG
ETODOLAC ER
TB24
500MG
ETODOLAC ER
TB24
600MG
ETODOLAC ER
TB24
400MG
ETOPOSIDE
CAPS
50MG
EUFLEXXA
SOSY
Note
PA
MB
20MG/2ML
PA
MB; SP
PA
SP
PA; QL (30.00 EA per 30 days)
SP
EXTAVIA
KIT
0.3MG
FAMCICLOVIR
TABS
125MG
FAMCICLOVIR
TABS
250MG
FAMCICLOVIR
TABS
500MG
FAMOTIDINE
TABS
20MG
FAMOTIDINE
TABS
40MG
FAMOTIDINE
SUSR
40MG/5ML
FARESTON
TABS
60MG
FELODIPINE ER
TB24
2.5MG
FELODIPINE ER
TB24
5MG
FELODIPINE ER
TB24
10MG
FENOFIBRATE
TABS
160MG
54 mg and 160 mg tablets
FENOFIBRATE
TABS
54MG
54 mg and 160 mg tablets
FENOFIBRATE MICRONIZED
CAPS
200MG
67 mg, 134 mg, and 200
mg capsules
[MPC091374]
[Centennial Care #363]
20 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
FENOFIBRATE MICRONIZED
CAPS
67MG
Coverage Details
Note
75MCG/HR
ST; QL (10.00 EA per 30 days)
67 mg, 134 mg, and 200
mg
capsules
67 mg,
134 mg, and 200
mg capsules
FENOFIBRATE MICRONIZED
CAPS
134MG
FENTANYL
PT72
FENTANYL
FENTANYL
PT72
100MCG/HR
ST; QL (10.00 EA per 30 days)
PT72
50MCG/HR
ST; QL (10.00 EA per 30 days)
FENTANYL
PT72
25MCG/HR
ST; QL (10.00 EA per 30 days)
FENTANYL
PT72
12MCG/HR
ST; QL (10.00 EA per 30 days)
FERAHEME
SOLN
510MG/17ML
PA
FEROSUL
ELIX
220MG/5ML
AG (min: 6m, max: 12m)
FERRLECIT
SOLN
12.5MG/ML
PA
FERROUS GLUCONATE
TABS
324MG
OTC
FERROUS GLUCONATE
TABS
325MG
OTC
FERROUS GLUCONATE
TABS
240MG
OTC
FERROUS SULFATE
SYRP
300MG/5ML
FEVERALL
SUPP
325MG
OTC
FEVERALL
SUPP
120MG
OTC
FEVERALL INFANTS
SUPP
80MG
OTC
FEXOFENADINE HCL
TABS
180MG
OTC
FEXOFENADINE HCL
TABS
60MG
OTC
FINACEA
GEL
15%
FINASTERIDE
TABS
5MG
FIRAZYR
SOLN
30MG/3ML
PA
FLEBOGAMMA DIF
SOLN
10%
PA;
FLEBOGAMMA DIF
SOLN
0.5GM/10ML
PA
FLEBOGAMMA DIF
SOLN
5%
PA
SP
FLEBOGAMMA DIF
SOLN
5%
PA
SP
FLECAINIDE ACETATE
TABS
50MG
FLECAINIDE ACETATE
TABS
150MG
FLECAINIDE ACETATE
TABS
100MG
FLOVENT DISKUS
AEPB
50MCG/BLIST
FLOVENT HFA
AERO
44MCG/ACT
FLOVENT HFA
AERO
110MCG/ACT
FLOVENT HFA
AERO
220MCG/ACT
FLUBLOK 2013-2014
SOLN
0
FLUBLOK 2013-2014
SOLN
0
FLUCONAZOLE
SUSR
10MG/ML
FLUCONAZOLE
SUSR
40MG/ML
FLUCONAZOLE
TABS
50MG
FLUCONAZOLE
TABS
100MG
FLUCONAZOLE
TABS
150MG
FLUCONAZOLE
TABS
200MG
FLUDROCORTISONE ACETATE
TABS
0.1MG
FLUNISOLIDE
SOLN
0.025%
ST
FLUNISOLIDE
SOLN
29MCG/ACT
ST
FLUOCINOLONE ACETONIDE
OIL
0.01%
FLUOCINOLONE ACETONIDE
CREA
0.025%
FLUOCINOLONE ACETONIDE
CREA
0.01%
FLUOCINOLONE ACETONIDE
SOLN
0.01%
FLUOCINOLONE ACETONIDE
OINT
0.025%
[MPC091374]
MB
MB
AG (min: 6m, max: 12m)
SP
[Centennial Care #363]
21 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
FLUOCINOLONE ACETONIDE BODY
OIL
0.01%
FLUOCINOLONE ACETONIDE SCALP
OIL
0.01%
FLUOCINONIDE
SOLN
0.05%
FLUOCINONIDE
GEL
0.05%
FLUOCINONIDE
OINT
0.05%
FLUOCINONIDE
CREA
0.05%
FLUORABON
SOLN
0.55MG/0.6ML
FLUOROMETHOLONE
SUSP
0.1%
FLUOROURACIL
SOLN
5%
FLUOROURACIL
SOLN
2%
FLUOROURACIL
CREA
5%
FLUOXETINE HCL
TABS
10MG
QL (30.00 EA per 30 days)
FLUOXETINE HCL
CAPS
40MG
QL (30.00 EA per 30 days)
FLUOXETINE HCL
CAPS
20MG
QL (120.00 EA per 30 days)
FLUOXETINE HCL
CAPS
10MG
QL (30.00 EA per 30 days)
FLUOXETINE HCL
SOLN
20MG/5ML
QL (600.00 ML per 30 days)
FLUPHENAZINE HCL
ELIX
2.5MG/5ML
FLUPHENAZINE HCL
TABS
10MG
FLUPHENAZINE HCL
TABS
1MG
FLUPHENAZINE HCL
TABS
5MG
FLUPHENAZINE HCL
CONC
5MG/ML
FLUPHENAZINE HCL
TABS
2.5MG
FLUPHENAZINE HCL
SOLN
2.5MG/ML
FLURA-DROPS
SOLN
0.125MG/DROP
AG (max: 6y)
FLURA-DROPS
SOLN
0.25MG/DROP
AG (max: 6y)
FLURBIPROFEN
TABS
50MG
FLURBIPROFEN
TABS
100MG
FLUTAMIDE
CAPS
125MG
FLUTICASONE PROPIONATE
SUSP
50MCG/ACT
FLUTICASONE PROPIONATE
CREA
0.05%
FLUTICASONE PROPIONATE
OINT
0.005%
FLUVOXAMINE MALEATE
TABS
50MG
ST; QL (45.00 EA per 30 days)
FLUVOXAMINE MALEATE
TABS
100MG
ST; QL (90.00 EA per 30 days)
FLUVOXAMINE MALEATE
TABS
25MG
ST; QL (30.00 EA per 30 days)
FML
OINT
0.1%
FML FORTE
SUSP
0.25%
FOLIC ACID
TABS
800MCG
FOLIC ACID
TABS
1MG
FOLIC ACID
TABS
400MCG
FONDAPARINUX SODIUM
SOLN
5MG/0.4ML
PA
FONDAPARINUX SODIUM
SOLN
10MG/0.8ML
PA
FONDAPARINUX SODIUM
SOLN
2.5MG/0.5ML
PA
FONDAPARINUX SODIUM
SOLN
7.5MG/0.6ML
PA
FORADIL AEROLIZER
CAPS
12MCG
FORTEO
SOLN
600MCG/2.4ML
PA
PA; QL (120.00 GM per 30 days)
FORTESTA
GEL
10MG/ACT
FOSINOPRIL SODIUM
TABS
10MG
FOSINOPRIL SODIUM
TABS
40MG
[MPC091374]
Coverage Details
Note
AG (max: 6y)
ST
SP
[Centennial Care #363]
22 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
FOSINOPRIL SODIUM
TABS
20MG
Coverage Details
Note
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE
TABS
20MG; 12.5MG
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE
TABS
10MG; 12.5MG
FRAGMIN
SOLN
2500UNIT/0.2ML PA; QL (30.00 ML per 30 days)
FRAGMIN
SOLN
5000UNIT/0.2ML PA; QL (30.00 ML per 30 days)
FRAGMIN
SOLN
FRAGMIN
SOLN
FRAGMIN
SOLN
12500UNIT/0.5M PA; QL (30.00 ML per 30 days)
L
18000UNT/0.72 PA; QL (30.00 ML per 30 days)
ML
10000UNIT/ML PA; QL (30.00 ML per 30 days)
FRAGMIN
SOLN
FRAGMIN
SOLN
15000UNIT/0.6M PA; QL (30.00 ML per 30 days)
L
7500UNIT/0.3ML PA; QL (30.00 ML per 30 days)
FUROSEMIDE
TABS
20MG
FUROSEMIDE
SOLN
10MG/ML
FUROSEMIDE
TABS
40MG
FUROSEMIDE
TABS
80MG
FUROSEMIDE
SOLN
8MG/ML
FUZEON
KIT
90MG
GABAPENTIN
CAPS
400MG
GABAPENTIN
SOLN
250MG/5ML
GABAPENTIN
CAPS
100MG
GABAPENTIN
TABS
600MG
GABAPENTIN
TABS
800MG
GABAPENTIN
CAPS
300MG
GALANTAMINE HYDROBROMIDE
TABS
8MG
GALANTAMINE HYDROBROMIDE
SOLN
4MG/ML
GALANTAMINE HYDROBROMIDE
CP24
8MG
GALANTAMINE HYDROBROMIDE
CP24
16MG
GALANTAMINE HYDROBROMIDE
CP24
24MG
GALANTAMINE HYDROBROMIDE
TABS
12MG
GALANTAMINE HYDROBROMIDE
TABS
4MG
GAMASTAN S/D
INJ
0
PA
SP
GAMMAGARD LIQUID
SOLN
0
PA
SP
GAMMAGARD S/D
SOLR
10GM
PA
SP
SP
QL (60.00 EA per 30 days)
GAMMAGARD S/D
SOLR
5GM
PA
GAMMAGARD S/D
SOLR
2.5GM
PA
SP
GAMMAGARD S/D IGA LESS THAN 1MCG/ML
SOLR
5GM
PA
SP
GAMMAGARD S/D IGA LESS THAN 1MCG/ML
SOLR
10GM
PA
SP
GAMMAPLEX
SOLN
2.5GM/50ML
PA
SP
SP
GAMMAPLEX
SOLN
5GM/100ML
PA
GAMMAPLEX
SOLN
10GM/200ML
PA
SP
GAMUNEX
SOLN
10%
PA
SP
SP
SP
GAMUNEX-C
SOLN
1GM/10ML
PA
GAMUNEX-C
SOLN
10GM/100ML
PA
GAMUNEX-C
SOLN
20GM/200ML
PA;
SP
SP
GAMUNEX-C
SOLN
2.5GM/25ML
PA
GAMUNEX-C
SOLN
5GM/50ML
PA
[MPC091374]
(SP)
[Centennial Care #363]
23 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
GARAMYCIN
OINT
0.3%
GAZYVA
SOLN
1000MG/40ML
GEMFIBROZIL
TABS
600MG
GENGRAF
SOLN
100MG/ML
GENGRAF
CAPS
25MG
GENGRAF
CAPS
100MG
GENTAK
OINT
0.3%
GENTAMICIN SULFATE
SOLN
0.3%
GENTAMICIN SULFATE
OINT
0.1%
GENTAMICIN SULFATE
CREA
0.1%
GILDESS 1.5/30
TABS
30MCG; 1.5MG
GILDESS 1/20
TABS
20MCG; 1MG
GILDESS FE 1.5/30
TABS
GILDESS FE 1/20
TABS
GILOTRIF
TABS
30MCG; 75MG;
1.5MG
20MCG; 75MG;
1MG
30MG
PA
GILOTRIF
TABS
40MG
PA
GILOTRIF
TABS
20MG
PA
GLEEVEC
TABS
100MG
PA
SP
GLEEVEC
TABS
400MG
PA
SP
GLIMEPIRIDE
TABS
2MG
GLIMEPIRIDE
TABS
4MG
GLIMEPIRIDE
TABS
1MG
GLIPIZIDE
TABS
5MG
GLIPIZIDE
TABS
10MG
GLIPIZIDE ER
TB24
2.5MG
GLIPIZIDE ER
TB24
5MG
GLIPIZIDE ER
TB24
10MG
GLIPIZIDE/METFORMIN HCL
TABS
2.5MG; 500MG
GLIPIZIDE/METFORMIN HCL
TABS
5MG; 500MG
GLIPIZIDE/METFORMIN HCL
TABS
2.5MG; 250MG
GLUCAGEN
SOLR
1MG
GLUCAGON EMERGENCY KIT
KIT
1MG
GLYBURIDE
TABS
5MG
GLYBURIDE
TABS
1.25MG
GLYBURIDE
TABS
2.5MG
GLYBURIDE/METFORMIN HCL
TABS
2.5MG; 500MG
ST; QL (60.00 EA per 30 days)
GLYBURIDE/METFORMIN HCL
TABS
5MG; 500MG
ST; QL (120.00 EA per 30 days)
GLYBURIDE/METFORMIN HCL
TABS
1.25MG; 250MG ST; QL (60.00 EA per 30 days)
GLYCOPYRROLATE
SOLN
0.4MG/2ML
GLYCOPYRROLATE
TABS
2MG
GLYCOPYRROLATE
SOLN
0.2MG/ML
GLYCOPYRROLATE
SOLN
1MG/5ML
GLYCOPYRROLATE
SOLN
4MG/20ML
GLYCOPYRROLATE
TABS
1MG
GOLYTELY
SOLR
227.1GM;
2.82GM;
6.36GM;
5.53GM; 21.5GM
[MPC091374]
Coverage Details
Note
PA
QL (120.00 EA per 30 days)
QL (120.00 EA per 30 days)
[Centennial Care #363]
24 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
GRANISETRON HCL
SOLN
0.1MG/ML
GRANISETRON HCL
TABS
1MG
GRANISETRON HCL
SOLN
1MG/ML
GRANIX
SOSY
300MCG/0.5ML
PA
GRANIX
SOSY
300MCG/0.5ML
PA
GRANIX
SOSY
480MCG/0.8ML
PA
GRANIX
SOSY
480MCG/0.8ML
PA
GRIFULVIN V
TABS
500MG
GRISEOFULVIN MICROSIZE
SUSP
125MG/5ML
GRISEOFULVIN ULTRAMICROSIZE
TABS
250MG
GRISEOFULVIN ULTRAMICROSIZE
TABS
125MG
GUANFACINE HCL
TABS
2MG
GUANFACINE HCL
TABS
1MG
HALOPERIDOL
TABS
1MG
HALOPERIDOL
TABS
5MG
HALOPERIDOL
TABS
2MG
HALOPERIDOL
TABS
0.5MG
HALOPERIDOL
TABS
10MG
HALOPERIDOL DECANOATE
SOLN
50MG/ML
HALOPERIDOL DECANOATE
SOLN
100MG/ML
HEATHER
TABS
0.35MG
HECORIA
CAPS
0.5MG
HECORIA
CAPS
5MG
HECORIA
CAPS
1MG
HEPAGAM B
SOLN
0
HEPARIN LOCK FLUSH
SOLN
100UNIT/ML
HEPARIN LOCK FLUSH
SOLN
1UNIT/ML
HEPARIN LOCK FLUSH
SOLN
2UNIT/ML
HEPARIN SODIUM
SOLN
1000UNIT/ML
HEPARIN SODIUM
SOLN
10000UNIT/ML
HEPARIN SODIUM
SOLN
2500UNIT/ML
HEPARIN SODIUM
SOLN
2000UNIT/ML
HEPARIN SODIUM
SOLN
5000UNIT/ML
HEPARIN SODIUM LOCK FLUSH
KIT
HEPARIN SODIUM LOCK FLUSH
KIT
HEPARIN SODIUM LOCK FLUSH
SOLN
10UNIT/ML;
0.9%
100UNIT/ML;
0.9%
10UNIT/ML
HEPARIN SODIUM/D5W
SOLN
HEPARIN SODIUM/D5W
SOLN
5%;
100UNIT/ML
5%; 50UNIT/ML
HEPARIN SODIUM/D5W
SOLN
5%; 40UNIT/ML
HEPARIN SODIUM/NACL 0.45%
SOLN
HEPARIN SODIUM/NACL 0.45%
SOLN
HEPARIN SODIUM/SODIUM CHLORIDE 0.9%
PREMIX
HEXALEN
SOLN
100UNIT/ML;
0.45%
50UNIT/ML;
0.45%
2UNIT/ML; 0.9%
CAPS
50MG
PA
SP
PA
SP
HIZENTRA
SOLN
1GM/5ML
HOMATROPAIRE
SOLN
5%
[MPC091374]
Coverage Details
Note
MB
ST; QL (20.00 EA per 30 days)
MB
PA
[Centennial Care #363]
25 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
Note
HUMIRA
KIT
20MG/0.4ML
PA
SP
HUMIRA
KIT
40MG/0.8ML
PA
SP
HYCAMTIN
CAPS
1MG
PA
SP
HYCAMTIN
CAPS
0.25MG
PA
SP
HYDRALAZINE HCL
TABS
50MG
HYDRALAZINE HCL
TABS
100MG
HYDRALAZINE HCL
TABS
10MG
HYDRALAZINE HCL
TABS
25MG
HYDROCHLOROTHIAZIDE
TABS
50MG
HYDROCHLOROTHIAZIDE
CAPS
12.5MG
HYDROCHLOROTHIAZIDE
TABS
25MG
HYDROCODONE BITARTRATE/ACETAMINOPHEN
TABS
750MG; 10MG
QL (5.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
500MG; 5MG
QL (8.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
750MG; 7.5MG
QL (5.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
650MG; 10MG
QL (6.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
325MG; 5MG
QL (12.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
650MG; 7.5MG
QL (6.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
325MG; 10MG
QL (12.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
325MG; 7.5MG
QL (12.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
500MG; 10MG
QL (8.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
SOLN
HYDROCODONE/ACETAMINOPHEN
TABS
500MG/15ML;
7.5MG/15ML
660MG; 10MG
QL (6.00 EA per 1 days)
HYDROCODONE/ACETAMINOPHEN
TABS
500MG; 7.5MG
QL (8.00 EA per 1 days)
HYDROCODONE/IBUPROFEN
TABS
7.5MG; 200MG
QL (5.00 EA per 1 days)
HYDROCORTISONE
TABS
5MG
HYDROCORTISONE
TABS
10MG
HYDROCORTISONE
TABS
20MG
HYDROCORTISONE
OINT
2.5%
HYDROCORTISONE
ENEM
100MG/60ML
HYDROCORTISONE
CREA
0.5%
HYDROCORTISONE
CREA
1%
HYDROCORTISONE
OINT
1%
HYDROCORTISONE
LOTN
2.5%
HYDROCORTISONE
CREA
2.5%
HYDROCORTISONE
OINT
0.5%
HYDROCORTISONE VALERATE
CREA
0.2%
HYDROCORTISONE VALERATE
OINT
0.2%
HYDROCORTISONE/ACETIC ACID
SOLN
2%; 1%
HYDROGESIC
CAPS
500MG; 5MG
QL (8.00 EA per 1 days)
HYDROMORPHONE HCL
LIQD
1MG/ML
QL (50.00 ML per 1 days)
HYDROMORPHONE HCL
TABS
2MG
QL (6.00 EA per 1 days)
HYDROMORPHONE HCL
TABS
4MG
QL (6.00 EA per 1 days)
HYDROMORPHONE HCL
TABS
8MG
QL (6.00 EA per 1 days)
HYDROXYCHLOROQUINE SULFATE
TABS
200MG
HYDROXYUREA
CAPS
500MG
HYDROXYZINE HCL
SYRP
10MG/5ML
HYDROXYZINE HCL
TABS
50MG
HYDROXYZINE HCL
TABS
10MG
[MPC091374]
OTC
OTC
[Centennial Care #363]
26 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
HYDROXYZINE HCL
TABS
25MG
Coverage Details
Note
HYDROXYZINE PAMOATE
CAPS
25MG
HYDROXYZINE PAMOATE
CAPS
50MG
HYDROXYZINE PAMOATE
CAPS
100MG
HYOSCYAMINE SULFATE
TABS
0.125MG
HYOSCYAMINE SULFATE
SOLN
0.125MG/ML
HYOSCYAMINE SULFATE
SUBL
0.125MG
HYOSCYAMINE SULFATE
ELIX
0.125MG/5ML
HYOSCYAMINE SULFATE ER
TB12
0.375MG
IBANDRONATE SODIUM
TABS
150MG
IBUPROFEN
TABS
400MG
IBUPROFEN
TABS
800MG
IBUPROFEN
SUSP
100MG/5ML
IBUPROFEN
TABS
200MG
IBUPROFEN
TABS
600MG
IBUPROFEN JUNIOR STRENGTH
CHEW
100MG
IMBRUVICA
CAPS
140MG
IMIPRAMINE HCL
TABS
10MG
IMIPRAMINE HCL
TABS
25MG
IMIPRAMINE HCL
TABS
50MG
IMIQUIMOD
CREA
5%
QL (12.00 EA per 28 days);
INCIVEK
TABS
375MG
PA; QL (180.00 EA per 30 days)
SP
INCRELEX
SOLN
40MG/4ML
PA
SP
INDAPAMIDE
TABS
1.25MG
INDAPAMIDE
TABS
2.5MG
INDOCIN
SUSP
25MG/5ML
INDOCIN
SUPP
50MG
INDOMETHACIN
CAPS
25MG
INDOMETHACIN
CAPS
50MG
INDOMETHACIN ER
CPCR
75MG
INFED
SOLN
50MG/ML
PA
MB
INJECTAFER
SOLN
750MG/15ML
PA
MB
INLYTA
TABS
5MG
PA; QL (4.00 EA per 1 days)
SP
SP
ST; QL (1.00 EA per 28 days)
OTC
OTC
PA; QL (120.00 EA per 30 days)
25 mg/5 mL oral
suspension and 50 mg
25 mg/5 mL oral
suspension and 50 mg
INLYTA
TABS
1MG
PA; QL (4.00 EA per 1 days)
INTELENCE
TABS
100MG
QL (60.00 EA per 30 days)
SP
INTELENCE
TABS
25MG
QL (60.00 EA per 30 days)
SP
INTELENCE
TABS
200MG
QL (60.00 EA per 30 days)
SP
INTRON-A
SOLN
10MU/ML
SP
INTRON-A
SOLN
SP
INTRON-A W/DILUENT
SOLR
6000000UNIT/M
L
18MU
INTRON-A W/DILUENT
SOLR
50MU
SP
INTRON-A W/DILUENT
SOLR
10MU
SP
SP
INVIRASE
CAPS
200MG
QL (300.00 EA per 30 days);
INVIRASE
TABS
500MG
QL (120.00 EA per 30 days)
IPRATROPIUM BROMIDE
SOLN
0.06%
IPRATROPIUM BROMIDE
SOLN
0.02%
IPRATROPIUM BROMIDE
SOLN
0.03%
0.5 mg/2.5 mL nebulizer
solution
0.03% and 0.06% nasal
solution
[MPC091374]
[Centennial Care #363]
27 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE
SOLN
IRBESARTAN
TABS
2.5MG/3ML;
0.5MG/3ML
75MG
ST; QL (30.00 EA per 30 days)
IRBESARTAN
TABS
300MG
ST; QL (30.00 EA per 30 days)
IRBESARTAN
TABS
150MG
ST; QL (30.00 EA per 30 days)
IRBESARTAN/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 300MG ST; QL (30.00 EA per 30 days)
IRON
TABS
256MG
Note
OTC
ISENTRESS
CHEW
25MG
QL (120.00 EA per 30 days)
ISENTRESS
CHEW
100MG
QL (60.00 EA per 30 days)
ISENTRESS
PACK
100MG
QL (60.00 EA per 30 days)
ISENTRESS
TABS
400MG
QL (60.00 EA per 30 days)
ISONIAZID
TABS
300MG
ISONIAZID
TABS
100MG
ISONIAZID
SYRP
50MG/5ML
ISOPTO CARBACHOL
SOLN
3%
ISOPTO CARBACHOL
SOLN
1.5%
ISOPTO HOMATROPINE
SOLN
2%
ISOPTO HYOSCINE
SOLN
0.25%
ISOSORBIDE DINITRATE
SUBL
2.5MG
ISOSORBIDE DINITRATE
TABS
10MG
ISOSORBIDE DINITRATE
TABS
20MG
ISOSORBIDE DINITRATE
TABS
30MG
ISOSORBIDE DINITRATE
TABS
5MG
ISOSORBIDE DINITRATE ER
TBCR
40MG
ISOSORBIDE MONONITRATE
TABS
20MG
ISOSORBIDE MONONITRATE
TABS
10MG
ISOSORBIDE MONONITRATE ER
TB24
60MG
ISOSORBIDE MONONITRATE ER
TB24
30MG
ISOSORBIDE MONONITRATE ER
TB24
120MG
JAKAFI
TABS
5MG
PA; QL (60.00 EA per 30 days)
SP
JAKAFI
TABS
25MG
PA; QL (60.00 EA per 30 days)
SP
JAKAFI
TABS
10MG
PA; QL (60.00 EA per 30 days)
SP
JAKAFI
TABS
15MG
PA; QL (60.00 EA per 30 days)
SP
JAKAFI
TABS
20MG
PA; QL (60.00 EA per 30 days)
SP
JANTOVEN
TABS
1MG
JANTOVEN
TABS
2.5MG
JANTOVEN
TABS
6MG
JANTOVEN
TABS
2MG
JANTOVEN
TABS
4MG
JANTOVEN
TABS
7.5MG
JANTOVEN
TABS
10MG
JANTOVEN
TABS
3MG
JANTOVEN
TABS
5MG
JANUMET
TABS
500MG; 50MG
ST; QL (60.00 EA per 30 days)
JANUMET
TABS
1000MG; 50MG
ST; QL (60.00 EA per 30 days)
JANUMET XR
TB24
500MG; 50MG
ST; QL (60.00 EA per 30 days)
JANUMET XR
TB24
1000MG; 100MG ST; QL (30.00 EA per 30 days)
JANUMET XR
TB24
1000MG; 50MG
[MPC091374]
ST; QL (60.00 EA per 30 days)
[Centennial Care #363]
28 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
JANUVIA
TABS
50MG
ST; QL (30.00 EA per 30 days)
JANUVIA
TABS
25MG
ST; QL (30.00 EA per 30 days)
JANUVIA
TABS
100MG
ST; QL (30.00 EA per 30 days)
JINTELI
TABS
5MCG; 1MG
JOLIVETTE
TABS
0.35MG
JR STRENGTH NON-ASPIRIN
TBDP
160MG
JUNEL 1.5/30
TABS
30MCG; 1.5MG
JUNEL 1/20
TABS
20MCG; 1MG
JUNEL FE 1.5/30
TABS
JUNEL FE 1/20
TABS
KADCYLA
SOLR
30MCG; 75MG;
1.5MG
20MCG; 75MG;
1MG
160MG
PA
MB
MB
OTC
KADCYLA
SOLR
100MG
PA
KADIAN
CP24
200MG
ST; QL (60.00 EA per 30 days)
KADIAN
CP24
10MG
ST; QL (60.00 EA per 30 days)
KALBITOR
SOLN
10MG/ML
PA
KALETRA
TABS
100MG; 25MG
QL (60.00 EA per 30 days)
KALETRA
SOLN
QL (300.00 ML per 30 days)
KALETRA
TABS
400MG/5ML;
100MG/5ML
200MG; 50MG
KARIVA
TABS
0; 0
K-BICARB
CAPS
99MG
KELNOR 1/35
TABS
35MCG; 1MG
KETOCONAZOLE
TABS
200MG
KETOCONAZOLE
SHAM
2%
KETOCONAZOLE
CREA
2%
KETOPROFEN
CAPS
50MG
KETOPROFEN
CAPS
75MG
KETOPROFEN ER
CP24
200MG
KETOROLAC TROMETHAMINE
SOLN
0.4%
KETOROLAC TROMETHAMINE
SOLN
0.5%
KETOTIFEN FUMARATE
SOLN
0.025%
KEYTRUDA
SOLR
50MG
KIONEX
SUSP
15GM/60ML
KIONEX
POWD
0
KLOR-CON
PACK
20MEQ
KLOR-CON 10
TBCR
10MEQ
KLOR-CON 25
PACK
25MEQ
KLOR-CON 8
TBCR
8MEQ
KLOR-CON M10
TBCR
10MEQ
KLOR-CON M15
TBCR
15MEQ
KLOR-CON M20
TBCR
20MEQ
KLOR-CON/EF
TBEF
25MEQ
KURVELO
TABS
0.03MG; 0.15MG
KYPROLIS
SOLR
60MG
LABETALOL HCL
TABS
200MG
LABETALOL HCL
TABS
300MG
LABETALOL HCL
TABS
100MG
LACTULOSE
SOLN
10GM/15ML
[MPC091374]
Note
SP
QL (120.00 EA per 30 days)
OTC
OTC
PA
PA
MB
[Centennial Care #363]
29 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
LACTULOSE
SOLN
10GM/15ML
Coverage Details
LAMICTAL
CHEW
2MG
LAMIVUDINE
TABS
150MG
LAMIVUDINE
TABS
100MG
LAMIVUDINE
TABS
300MG
QL (30.00 EA per 30 days)
LAMIVUDINE/ZIDOVUDINE
TABS
150MG; 300MG
QL (60.00 EA per 30 days)
LAMOTRIGINE
TABS
100MG
QL (60.00 EA per 30 days)
LAMOTRIGINE
TABS
200MG
QL (60.00 EA per 30 days)
LAMOTRIGINE
CHEW
25MG
LAMOTRIGINE
CHEW
5MG
LAMOTRIGINE
TABS
25MG
QL (120.00 EA per 30 days)
LAMOTRIGINE
TABS
150MG
QL (60.00 EA per 30 days)
LANACORT 10
CREA
1%
LANSOPRAZOLE
CPDR
15MG
ST; QL (60.00 EA per 30 days)
LANSOPRAZOLE
CPDR
30MG
ST; QL (60.00 EA per 30 days)
LANTUS
SOLN
100UNIT/ML
QL (50.00 ML per 30 days)
LANTUS SOLOSTAR
SOPN
100UNIT/ML
QL (45.00 ML per 30 days)
LARIN FE 1.5/30
TABS
LARIN FE 1/20
TABS
LATANOPROST
SOLN
30MCG; 75MG;
1.5MG
20MCG; 75MG;
1MG
0.005%
LEENA
TABS
0; 0
LEFLUNOMIDE
TABS
10MG
LEFLUNOMIDE
TABS
20MG
LESSINA
TABS
20MCG; 0.1MG
LETAIRIS
TABS
5MG
PA; QL (30.00 EA per 30 days)
SP
PA; QL (30.00 EA per 30 days)
SP
PA
SP
2 mg chewable tablet
QL (60.00 EA per 30 days)
OTC
LETAIRIS
TABS
10MG
LETROZOLE
TABS
2.5MG
LEUCOVORIN CALCIUM
TABS
15MG
LEUCOVORIN CALCIUM
TABS
25MG
LEUCOVORIN CALCIUM
TABS
5MG
LEUCOVORIN CALCIUM
TABS
10MG
LEUKERAN
TABS
2MG
LEUPROLIDE ACETATE
KIT
1MG/0.2ML
LEVEMIR
SOLN
100UNIT/ML
QL (50.00 ML per 30 days)
LEVEMIR FLEXPEN
SOPN
100UNIT/ML
QL (45.00 ML per 30 days)
LEVEMIR FLEXTOUCH
SOPN
100UNIT/ML
QL (45.00 ML per 30 days)
LEVETIRACETAM
SOLN
100MG/ML
LEVETIRACETAM
TABS
1000MG
LEVETIRACETAM
TABS
250MG
LEVETIRACETAM
TABS
500MG
LEVETIRACETAM
TABS
750MG
LEVOBUNOLOL HCL
SOLN
0.5%
LEVOBUNOLOL HCL
SOLN
0.25%
LEVOFLOXACIN
TABS
500MG
LEVOFLOXACIN
TABS
750MG
LEVOFLOXACIN
SOLN
25MG/ML
LEVOFLOXACIN
TABS
250MG
LEVONORGESTREL
TABS
0.75MG
[MPC091374]
Note
QL (6.00 EA per 365 days)
[Centennial Care #363]
30 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
LEVORA 0.15/30-28
TABS
30MCG; 0.15MG
LEVOTHROID
TABS
88MCG
LEVOTHROID
TABS
137MCG
LEVOTHROID
TABS
125MCG
LEVOTHROID
TABS
300MCG
LEVOTHROID
TABS
175MCG
LEVOTHROID
TABS
200MCG
LEVOTHYROXINE SODIUM
TABS
137MCG
LEVOTHYROXINE SODIUM
TABS
75MCG
LEVOTHYROXINE SODIUM
TABS
88MCG
LEVOTHYROXINE SODIUM
TABS
25MCG
LEVOTHYROXINE SODIUM
TABS
150MCG
LEVOTHYROXINE SODIUM
TABS
200MCG
LEVOTHYROXINE SODIUM
TABS
50MCG
LEVOTHYROXINE SODIUM
TABS
100MCG
LEVOTHYROXINE SODIUM
TABS
112MCG
LEVOTHYROXINE SODIUM
TABS
300MCG
LEVOTHYROXINE SODIUM
TABS
125MCG
LEVOTHYROXINE SODIUM
TABS
175MCG
LEVOXYL
TABS
88MCG
LEVOXYL
TABS
125MCG
LEVOXYL
TABS
150MCG
LEVOXYL
TABS
200MCG
LEVOXYL
TABS
75MCG
LEVOXYL
TABS
112MCG
LEVOXYL
TABS
175MCG
LEVOXYL
TABS
100MCG
LEVOXYL
TABS
25MCG
LEVOXYL
TABS
50MCG
LEVOXYL
TABS
137MCG
LEXIVA
SUSP
50MG/ML
QL (1680.00 ML per 30 days)
LEXIVA
TABS
700MG
QL (120.00 EA per 30 days)
LICIDE
AERO
0.5%
LIDOCAINE
OINT
5%
LIDOCAINE
PTCH
5%
LIDOCAINE
CREA
3%
LIDOCAINE HCL/HYDROCORTISONE ACETATE
CREA
0.5%; 3%
LIDOCAINE VISCOUS
SOLN
2%
LIDOCAINE/PRILOCAINE
CREA
2.5%; 2.5%
LINDANE
SHAM
1%
LINDANE
LOTN
1%
LINZESS
CAPS
145MCG
PA; QL (30.00 EA per 30 days)
LINZESS
CAPS
290MCG
PA; QL (30.00 EA per 30 days)
LIOTHYRONINE SODIUM
TABS
5MCG
LIOTHYRONINE SODIUM
TABS
25MCG
LIOTHYRONINE SODIUM
TABS
50MCG
LISINOPRIL
TABS
2.5MG
LISINOPRIL
TABS
5MG
[MPC091374]
Coverage Details
Note
OTC
PA; QL (30.00 EA per 30 days)
[Centennial Care #363]
31 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
LISINOPRIL
TABS
40MG
Coverage Details
Note
LISINOPRIL
TABS
10MG
LISINOPRIL
TABS
20MG
LISINOPRIL
TABS
30MG
LISINOPRIL/HYDROCHLOROTHIAZIDE
TABS
25MG; 20MG
LISINOPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 20MG
LISINOPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 10MG
LITHIUM
SOLN
8MEQ/5ML
LITHIUM CARBONATE
CAPS
300MG
LITHIUM CARBONATE
CAPS
600MG
LITHIUM CARBONATE
TABS
300MG
LITHIUM CARBONATE
CAPS
150MG
LITHIUM CARBONATE ER
TBCR
450MG
LITHIUM CARBONATE ER
TBCR
300MG
LOKARA
LOTN
0.05%
LOMUSTINE
CAPS
40MG
PA
SP
LOMUSTINE
CAPS
100MG
PA
SP
LOMUSTINE
CAPS
10MG
PA
SP
LORATADINE
TABS
10MG
LORAZEPAM
TABS
2MG
QL (90.00 EA per 30 days)
LORAZEPAM
TABS
0.5MG
QL (90.00 EA per 30 days)
LORAZEPAM
TABS
1MG
QL (90.00 EA per 30 days)
LORAZEPAM
CONC
2MG/ML
LOSARTAN POTASSIUM
TABS
50MG
LOSARTAN POTASSIUM
TABS
25MG
LOSARTAN POTASSIUM
TABS
100MG
OTC
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS
12.5MG; 100MG
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS
25MG; 100MG
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS
12.5MG; 50MG
LOTEMAX
SUSP
0.5%
ST
LOTEMAX
GEL
0.5%
ST
LOTRONEX
TABS
0.5MG
LOTRONEX
TABS
1MG
LOVASTATIN
TABS
20MG
LOVASTATIN
TABS
10MG
LOVASTATIN
TABS
40MG
LOW-OGESTREL
TABS
30MCG; 0.3MG
LOXAPINE SUCCINATE
CAPS
50MG
LOXAPINE SUCCINATE
CAPS
5MG
LOXAPINE SUCCINATE
CAPS
10MG
LOXAPINE SUCCINATE
CAPS
25MG
LOZI-FLUR
LOZG
1MG
LUMIGAN
SOLN
0.01%
LUMIGAN
SOLN
0.03%
LUPRON DEPOT-PED
KIT
7.5MG
LUPRON DEPOT-PED
KIT
11.25MG
LUPRON DEPOT-PED
KIT
15MG
[MPC091374]
AG (max: 6y)
[Centennial Care #363]
32 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
LUTERA
TABS
20MCG; 0.1MG
LYNPARZA
CAPS
50MG
PA
LYRICA
CAPS
75MG
PA; QL (90.00 EA per 30 days)
LYRICA
CAPS
100MG
PA; QL (90.00 EA per 30 days)
LYRICA
CAPS
225MG
PA; QL (60.00 EA per 30 days)
LYRICA
CAPS
25MG
PA; QL (90.00 EA per 30 days)
LYRICA
CAPS
50MG
PA; QL (90.00 EA per 30 days)
LYRICA
CAPS
300MG
PA; QL (60.00 EA per 30 days)
LYRICA
CAPS
150MG
PA; QL (90.00 EA per 30 days)
LYRICA
CAPS
200MG
PA; QL (90.00 EA per 30 days)
LYSODREN
TABS
500MG
MACRODANTIN
CAPS
25MG
MAPROTILINE HCL
TABS
25MG
MAPROTILINE HCL
TABS
50MG
MAPROTILINE HCL
TABS
75MG
MARLISSA
TABS
0.03MG; 0.15MG
MARQIBO
SUSP
5MG/31ML
PA
MB
MATULANE
CAPS
50MG
PA
SP
MCT OIL
OIL
0
OTC
MEDROL
TABS
2MG
2 mg tablets
MEDROXYPROGESTERONE ACETATE
TABS
10MG
MEDROXYPROGESTERONE ACETATE
TABS
5MG
MEDROXYPROGESTERONE ACETATE
SUSP
150MG/ML
MEDROXYPROGESTERONE ACETATE
TABS
2.5MG
MEGACE ES
SUSP
625MG/5ML
MEGESTROL ACETATE
TABS
40MG
MEGESTROL ACETATE
TABS
20MG
MEGESTROL ACETATE
SUSP
40MG/ML
MEKINIST
TABS
0.5MG
PA; QL (90.00 EA per 30 days)
SP
MEKINIST
TABS
2MG
PA; QL (30.00 EA per 30 days)
SP
MELOXICAM
SUSP
7.5MG/5ML
MELOXICAM
TABS
7.5MG
MELOXICAM
TABS
15MG
MENEST
TABS
1.25MG
MENEST
TABS
2.5MG
MENEST
TABS
0.3MG
MENEST
TABS
0.625MG
MEPERIDINE HCL
TABS
50MG
QL (180.00 EA per 30 days)
MEPERIDINE HCL
TABS
100MG
QL (180.00 EA per 30 days)
MEPERIDINE HCL
SOLN
50MG/5ML
QL (1200.00 ML per 30 days)
MEPHYTON
TABS
5MG
MEPROBAMATE
TABS
400MG
MEPROBAMATE
TABS
200MG
MERCAPTOPURINE
TABS
50MG
MESALAMINE
ENEM
4GM
MESTINON
SYRP
60MG/5ML
METAPROTERENOL SULFATE
SYRP
10MG/5ML
METAPROTERENOL SULFATE
TABS
10MG
[MPC091374]
Coverage Details
Note
25 mg capsules
PA
[Centennial Care #363]
33 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
METAPROTERENOL SULFATE
TABS
20MG
METFORMIN HCL
TABS
1000MG
METFORMIN HCL
TABS
850MG
METFORMIN HCL
TABS
500MG
METFORMIN HCL ER
TB24
500MG
METFORMIN HCL ER
TB24
750MG
METHADONE HCL
TABS
5MG
PA; QL (180.00 EA per 30 days)
METHADONE HCL
TABS
10MG
PA; QL (180.00 EA per 30 days)
METHADONE HCL
SOLN
10MG/5ML
PA; QL (900.00 ML per 30 days)
METHADONE HCL
SOLN
5MG/5ML
PA; QL (900.00 ML per 30 days)
METHAZOLAMIDE
TABS
50MG
METHAZOLAMIDE
TABS
25MG
METHENAMINE HIPPURATE
TABS
1GM
METHENAMINE MANDELATE
TABS
1GM
METHENAMINE MANDELATE
TABS
0.5GM
METHIMAZOLE
TABS
10MG
METHIMAZOLE
TABS
5MG
METHOCARBAMOL
TABS
500MG
METHOCARBAMOL
TABS
750MG
METHOTREXATE
TABS
2.5MG
METHOTREXATE SODIUM
SOLN
50MG/2ML
METHOTREXATE SODIUM
SOLR
1GM
METHOTREXATE SODIUM
SOLN
25MG/ML
METHYLDOPA
TABS
500MG
METHYLDOPA
TABS
250MG
METHYLERGONOVINE MALEATE
TABS
0.2MG
METHYLPHENIDATE HCL
TABS
10MG
AG (min: 6y); QL (90.00 EA per 30 days)
METHYLPHENIDATE HCL
TABS
5MG
AG (min: 6y); QL (90.00 EA per 30 days)
METHYLPHENIDATE HCL
TABS
20MG
AG (min: 6y); QL (90.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
10MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
20MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
30MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
40MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
50MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL CD
CPCR
60MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
54MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
36MG
AG (min: 6y); QL (60.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
18MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
27MG
AG (min: 6y); QL (30.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
10MG
AG (min: 6y); QL (60.00 EA per 30 days)
METHYLPHENIDATE HCL ER
TBCR
20MG
AG (min: 6y); QL (90.00 EA per 30 days)
METHYLPREDNISOLONE
TABS
16MG
METHYLPREDNISOLONE
TABS
4MG
METHYLPREDNISOLONE
TABS
8MG
METHYLPREDNISOLONE DOSE PACK
TABS
4MG
METOCLOPRAMIDE HCL
TABS
10MG
METOCLOPRAMIDE HCL
TABS
5MG
METOCLOPRAMIDE HCL
SOLN
5MG/5ML
METOLAZONE
TABS
5MG
[MPC091374]
Coverage Details
Note
[Centennial Care #363]
34 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
METOLAZONE
TABS
10MG
METOLAZONE
TABS
2.5MG
METOPROLOL SUCCINATE ER
TB24
25MG
METOPROLOL SUCCINATE ER
TB24
100MG
METOPROLOL SUCCINATE ER
TB24
50MG
METOPROLOL SUCCINATE ER
TB24
200MG
METOPROLOL TARTRATE
TABS
100MG
METOPROLOL TARTRATE
TABS
50MG
METOPROLOL TARTRATE
TABS
25MG
METOPROLOL/HYDROCHLOROTHIAZIDE
TABS
25MG; 50MG
METOPROLOL/HYDROCHLOROTHIAZIDE
TABS
25MG; 100MG
METOPROLOL/HYDROCHLOROTHIAZIDE
TABS
50MG; 100MG
METRONIDAZOLE
TABS
500MG
METRONIDAZOLE
TABS
250MG
METRONIDAZOLE
GEL
0.75%
METRONIDAZOLE
CREA
0.75%
METRONIDAZOLE
LOTN
0.75%
METRONIDAZOLE VAGINAL
GEL
0.75%
MEXILETINE HCL
CAPS
250MG
MEXILETINE HCL
CAPS
200MG
MEXILETINE HCL
CAPS
150MG
MICROGESTIN 1.5/30
TABS
30MCG; 1.5MG
MICROGESTIN 1/20
TABS
20MCG; 1MG
MICROGESTIN FE
TABS
MICROGESTIN FE 1.5/30
TABS
MICRONEFRIN
NEBU
20MCG; 75MG;
1MG
30MCG; 75MG;
1.5MG
2.25%
MIDODRINE HCL
TABS
2.5MG
MIDODRINE HCL
TABS
10MG
MIDODRINE HCL
TABS
5MG
MILLIPRED
TABS
5MG
MILLIPRED DP
TABS
5MG
MIMVEY
TABS
1MG; 0.5MG
MINOCYCLINE HCL
CAPS
50MG
MINOCYCLINE HCL
CAPS
75MG
MINOCYCLINE HCL
CAPS
100MG
MINOXIDIL
TABS
2.5MG
MINOXIDIL
TABS
10MG
MIRENA
IUD
20MCG/24HR
Coverage Details
OTC
MB
MIRTAZAPINE
TABS
30MG
QL (30.00 EA per 30 days)
MIRTAZAPINE
TBDP
15MG
QL (30.00 EA per 30 days)
MIRTAZAPINE
TABS
15MG
QL (30.00 EA per 30 days)
MIRTAZAPINE
TABS
45MG
QL (30.00 EA per 30 days)
MIRTAZAPINE
TABS
7.5MG
QL (30.00 EA per 30 days)
MIRTAZAPINE ODT
TBDP
45MG
PA; QL (30.00 EA per 30 days)
MIRTAZAPINE ODT
TBDP
30MG
PA; QL (30.00 EA per 30 days)
MISOPROSTOL
TABS
100MCG
MISOPROSTOL
TABS
200MCG
MOEXIPRIL HCL
TABS
15MG
[MPC091374]
Note
[Centennial Care #363]
35 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
MOEXIPRIL HCL
TABS
7.5MG
MOEXIPRIL/HYDROCHLOROTHIAZIDE
TABS
25MG; 15MG
MOEXIPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 7.5MG
MOEXIPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 15MG
MOMETASONE FUROATE
OINT
0.1%
MOMETASONE FUROATE
CREA
0.1%
MOMETASONE FUROATE
SOLN
0.1%
MONONESSA
TABS
35MCG; 0.25MG
MONTELUKAST SODIUM
TABS
10MG
QL (30.00 EA per 30 days)
MONTELUKAST SODIUM
CHEW
5MG
QL (30.00 EA per 30 days)
MONTELUKAST SODIUM
CHEW
4MG
QL (30.00 EA per 30 days)
MORPHINE SULFATE
SOLN
20MG/5ML
QL (900.00 ML per 30 days)
MORPHINE SULFATE
TABS
30MG
QL (180.00 EA per 30 days)
MORPHINE SULFATE
TABS
15MG
QL (180.00 EA per 30 days)
MORPHINE SULFATE
SOLN
20MG/ML
QL (180.00 ML per 30 days)
MORPHINE SULFATE
SOLN
10MG/5ML
QL (900.00 ML per 30 days)
MORPHINE SULFATE ER
CP24
60MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
TBCR
30MG
QL (90.00 EA per 30 days)
MORPHINE SULFATE ER
TBCR
60MG
QL (90.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
20MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
50MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
60MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
100MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
TBCR
15MG
QL (90.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
30MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
45MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
30MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
80MG
ST; QL (60.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
90MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
120MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
CP24
75MG
PA; QL (30.00 EA per 30 days)
MORPHINE SULFATE ER
TBCR
100MG
QL (180.00 EA per 30 days);
MORPHINE SULFATE ER
TBCR
200MG
QL (90.00 EA per 30 days);
MOTRIN IB
TABS
200MG
MULTAQ
TABS
400MG
MULTI-VIT/FLUORIDE
SOLN
35MG/ML;
400UNIT/ML;
2MCG/ML;
8MG/ML;
0.4MG/ML;
0.6MG/ML;
0.5MG/ML;
0.5MG/ML;
5UNIT/ML;
1500UNIT/ML
[MPC091374]
Coverage Details
Note
OTC
PA; QL (60.00 EA per 30 days)
[Centennial Care #363]
36 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
MULTI-VIT/FLUORIDE
SOLN
MULTI-VIT/IRON/FLUORIDE
SOLN
MULTIVITAMINS/FLUORIDE
CHEW
35MG/ML;
400UNIT/ML;
2MCG/ML;
8MG/ML;
0.4MG/ML;
0.6MG/ML;
0.25MG/ML;
0.5MG/ML;
5UNIT/ML;
1500UNIT/ML
35MG/ML;
400UNIT/ML;
10MG/ML;
8MG/ML;
0.4MG/ML;
0.6MG/ML;
0.25MG/ML;
0.5MG/ML;
5UNIT/ML;
1500UNIT/ML
60MG;
400UNIT;
4.5MCG;
0.3MG; 13.5MG;
1.05MG; 1.2MG;
0.25MG;
1.05MG;
15UNIT;
2500UNIT
MULTIVITAMINS/FLUORIDE
CHEW
60MG;
400UNIT;
4.5MCG;
0.3MG; 13.5MG;
1.05MG; 1.2MG;
0.5MG; 1.05MG;
15UNIT;
2500UNIT
MULTIVITAMINS/FLUORIDE
CHEW
60MG;
400UNIT;
4.5MCG;
0.3MG; 13.5MG;
1.05MG; 1.2MG;
1MG; 1.05MG;
15UNIT;
2500UNIT
MUPIROCIN
OINT
2%
MYCOPHENOLATE MOFETIL
CAPS
250MG
MYCOPHENOLATE MOFETIL
TABS
500MG
MYCOPHENOLATE MOFETIL
SUSR
200MG/ML
MYLERAN
TABS
2MG
[MPC091374]
Coverage Details
Note
PA
SP
[Centennial Care #363]
37 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
MYNATAL
CAPS
120MG; 30MCG;
300MG; 25MCG;
2MG; 12MCG;
400UNIT;
65MG; 1MG;
25MG; 5MG;
25MCG; 20MG;
10MG; 150MCG;
10MG; 3.4MG;
3MG; 30UNIT;
5000UNIT;
25MG
NABUMETONE
TABS
750MG
NABUMETONE
TABS
500MG
NADOLOL
TABS
40MG
NADOLOL
TABS
80MG
NADOLOL
TABS
20MG
NALTREXONE HCL
TABS
50MG
NAMENDA
TABS
5MG
ST; QL (60.00 EA per 30 days)
NAMENDA
TABS
10MG
ST; QL (60.00 EA per 30 days)
NAMENDA XR
CP24
7MG
ST; QL (30.00 EA per 30 days)
NAMENDA XR
CP24
28MG
ST; QL (30.00 EA per 30 days)
NAMENDA XR
CP24
21MG
ST; QL (30.00 EA per 30 days)
NAMENDA XR
CP24
14MG
ST; QL (30.00 EA per 30 days)
NAPHCON-A
SOLN
0.025%; 0.3%
NAPROXEN
TABS
375MG
NAPROXEN
TABS
500MG
NAPROXEN
SUSP
125MG/5ML
NAPROXEN
TABS
250MG
NAPROXEN DR
TBEC
375MG
NAPROXEN DR
TBEC
500MG
NAPROXEN SODIUM
TABS
275MG
NAPROXEN SODIUM
TABS
550MG
NARATRIPTAN HCL
TABS
1MG
ST; QL (18.00 EA per 30 days)
NARATRIPTAN HCL
TABS
2.5MG
ST; QL (18.00 EA per 30 days)
NASACORT ALLERGY 24HR
AERO
55MCG/ACT
NASACORT ALLERGY 24HR
AERO
55MCG/ACT
NATEGLINIDE
TABS
120MG
NATEGLINIDE
TABS
60MG
NEBUPENT
SOLR
300MG
NECON 0.5/35-28
TABS
35MCG; 0.5MG
NECON 1/35
TABS
35MCG; 1MG
NECON 1/50-28
TABS
50MCG; 1MG
NECON 7/7/7
TABS
0; 0
NEOMYCIN SULFATE
TABS
500MG
NEOMYCIN/BACITRACIN/POLYMYXIN
OINT
NEOMYCIN/POLYMYXIN B SULFATES
SOLN
400UNIT/GM;
5MG/GM;
10000UNIT/GM
40MG/ML;
200000UNIT/ML
[MPC091374]
Coverage Details
Note
OTC
[Centennial Care #363]
38 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCOR OINT
TISONE
Strength
Coverage Details
Note
400UNIT/GM;
1%; 0.5%;
10000UNIT/GM
0.1%;
3.5MG/GM;
10000UNIT/GM
0.1%;
3.5MG/ML;
10000UNIT/ML
0.025MG/ML;
1.75MG/ML;
10000UNIT/ML
1%; 3.5MG/ML;
10000UNIT/ML
NEOMYCIN/POLYMYXIN/DEXAMETHASONE
OINT
NEOMYCIN/POLYMYXIN/DEXAMETHASONE
SUSP
NEOMYCIN/POLYMYXIN/GRAMICIDIN
SOLN
NEOMYCIN/POLYMYXIN/HYDROCORTISONE
SUSP
NEOMYCIN/POLYMYXIN/HYDROCORTISONE
SUSP
1%; 3.5MG/ML;
10000UNIT/ML
NEOMYCIN/POLYMYXIN/HYDROCORTISONE
SOLN
1%; 3.5MG/ML;
10000UNIT/ML
NEPHRONEX
TABS
60MG; 300MCG;
0.01MCG; 1MG;
20MG; 10MG;
10MG; 1.7MG;
1.5MG
NEULASTA
SOLN
6MG/0.6ML
PA
SP
NEUMEGA
SOLR
5MG
PA
SP
NEUPOGEN
SOLN
300MCG/ML
PA
NEUPOGEN
SOLN
480MCG/0.8ML
PA
NEUTREXIN
SOLR
25MG
NEVIRAPINE
SUSP
50MG/5ML
QL (1200.00 ML per 30 days)
NEVIRAPINE
TABS
200MG
QL (30.00 EA per 30 days)
NEVIRAPINE ER
TB24
400MG
QL (30.00 EA per 30 days)
NEXAVAR
TABS
200MG
PA; QL (120.00 EA per 30 days)
NEXPLANON
IMPL
68MG
NEXT CHOICE
TABS
0.75MG
NIACIN
TABS
50MG
OTC
NIACIN
TABS
100MG
OTC
NIACIN
TABS
250MG
OTC
NIACIN ER
TBCR
1000MG
NIACIN ER
TBCR
750MG
NIACIN ER
TBCR
500MG
NIACIN ER
CPCR
250MG
OTC
NIACIN ER
CPCR
500MG
OTC
NIACIN SR
TBCR
250MG
OTC
NIACIN TR
TBCR
750MG
OTC
NIACIN TR
TBCR
500MG
OTC
NIACIN TR
TBCR
1000MG
OTC
NIACOR
TABS
500MG
NIFEDIAC CC
TB24
60MG
NIFEDIAC CC
TB24
30MG
NIFEDICAL XL
TB24
60MG
NIFEDICAL XL
TB24
30MG
NIFEDIPINE
CAPS
10MG
NIFEDIPINE
CAPS
20MG
[MPC091374]
MB
SP
MB
QL (6.00 EA per 365 days)
[Centennial Care #363]
39 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
NIFEDIPINE ER
TB24
90MG
NIFEDIPINE ER
TB24
90MG
NIFEDIPINE ER
TB24
60MG
NIFEDIPINE ER
TB24
60MG
NIFEDIPINE ER
TB24
90MG
NIFEDIPINE ER
TB24
30MG
NIFEDIPINE ER
TB24
30MG
NIMODIPINE
CAPS
30MG
NISOLDIPINE
TB24
20MG
NISOLDIPINE
TB24
40MG
NISOLDIPINE
TB24
30MG
NITRO-BID
OINT
2%
NITRO-DUR
PT24
0.3MG/HR
NITRO-DUR
PT24
0.8MG/HR
NITROFURANTOIN
SUSP
25MG/5ML
NITROFURANTOIN MACROCRYSTALS
CAPS
100MG
NITROFURANTOIN MACROCRYSTALS
CAPS
50MG
NITROFURANTOIN MONOHYDRATE
CAPS
100MG
NITROGLYCERIN ER
CPCR
6.5MG
NITROGLYCERIN ER
CPCR
9MG
NITROGLYCERIN TRANSDERMAL
PT24
0.1MG/HR
NITROGLYCERIN TRANSDERMAL
PT24
0.4MG/HR
NITROGLYCERIN TRANSDERMAL
PT24
0.2MG/HR
NITROGLYCERIN TRANSDERMAL
PT24
0.6MG/HR
NITROSTAT
SUBL
0.3MG
NITROSTAT
SUBL
0.6MG
NITROSTAT
SUBL
0.4MG
NON-ASPIRIN INFANT
SUSP
80MG/0.8ML
NORA-BE
TABS
0.35MG
NORETHINDRONE
TABS
0.35MG
NORETHINDRONE ACETATE
TABS
5MG
NORGESTIMATE/ETHINYL ESTRADIOL
TABS
35MCG; 0.25MG
NORGESTIMATE/ETHINYL ESTRADIOL
TABS
0; 0
NORPACE CR
CP12
150MG
NORPACE CR
CP12
100MG
NORTREL 0.5/35 (28)
TABS
35MCG; 0.5MG
NORTREL 1/35
TABS
35MCG; 1MG
NORTREL 7/7/7
TABS
0; 0
NORTRIPTYLINE HCL
CAPS
75MG
NORTRIPTYLINE HCL
CAPS
10MG
NORTRIPTYLINE HCL
CAPS
25MG
NORTRIPTYLINE HCL
CAPS
50MG
NORVIR
CAPS
100MG
QL (360.00 EA per 30 days);
NORVIR
TABS
100MG
QL (360.00 EA per 30 days);
NORVIR
SOLN
80MG/ML
QL (450.00 ML per 30 days);
NOVACORT
GEL
1%; 2%; 1%
NOVOFINE 32GX6MM PEN NEEDLES
MISC
NOVOLIN 70/30
SUSP
[MPC091374]
30UNIT/ML;
70UNIT/ML
Coverage Details
Note
(OTC)
QL (50.00 ML per 30 days);
[Centennial Care #363]
40 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
NOVOLIN N
SUSP
100UNIT/ML
QL (50.00 ML per 30 days);
NOVOLIN R
SOLN
100UNIT/ML
QL (50.00 ML per 30 days);
NOVOLOG
SOLN
100UNIT/ML
QL (50.00 ML per 30 days);
NOVOLOG FLEXPEN
SOPN
100UNIT/ML
QL (45.00 ML per 30 days);
NOVOLOG MIX 70/30
SUSP
QL (50.00 ML per 30 days);
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
SUPN
NOVOLOG PENFILL
SOCT
30UNIT/ML;
70UNIT/ML
30UNIT/ML;
70UNIT/ML
100UNIT/ML
NOVOTWIST 32GX5MM PEN NEEDLES
MISC
NP THYROID 30
TABS
30MG
NP THYROID 60
TABS
60MG
NP THYROID 90
TABS
90MG
NUVIGIL
TABS
200MG
PA; QL (30.00 EA per 30 days);
NUVIGIL
TABS
150MG
PA; QL (30.00 EA per 30 days);
NUVIGIL
TABS
50MG
PA; QL (30.00 EA per 30 days);
NUVIGIL
TABS
250MG
PA; QL (30.00 EA per 30 days);
NYAMYC
POWD
100000UNIT/GM
NYSTATIN
SUSP
100000UNIT/ML
NYSTATIN
TABS
500000UNIT
NYSTATIN
OINT
100000UNIT/GM
NYSTATIN
CREA
100000UNIT/GM
NYSTATIN
POWD
100000UNIT/GM
NYSTATIN/TRIAMCINOLONE
CREA
NYSTATIN/TRIAMCINOLONE
OINT
NYSTOP
POWD
100000UNIT/GM
; 0.1%
100000UNIT/GM
; 0.1%
100000UNIT/GM
OCELLA
TABS
3MG; 0.03MG
OCTAGAM
SOLN
10GM/100ML
PA
OCTAGAM
SOLN
1GM/20ML
PA
OCTAGAM
SOLN
10GM/200ML
PA
OCTAGAM
SOLN
25GM/500ML
PA
OCTAGAM
SOLN
2GM/20ML
PA
OCTAGAM
SOLN
5GM/100ML
PA
OCTAGAM
SOLN
5GM/50ML
PA
OCTAGAM
SOLN
2.5GM/50ML
PA
OCTAGAM
SOLN
20GM/200ML
PA
OFLOXACIN
SOLN
0.3%
OFLOXACIN
SOLN
0.3%
OLANZAPINE
TABS
7.5MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE
TABS
10MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE
TABS
20MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE
TABS
2.5MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE
TABS
5MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE
TABS
15MG
AG (min: 6y); QL (30.00 EA per 30 days)
OLANZAPINE ODT
TBDP
15MG
AG; QL (30.00 EA per 30 days)
OLANZAPINE ODT
TBDP
10MG
AG; QL (30.00 EA per 30 days)
OLANZAPINE ODT
TBDP
5MG
AG (min: 6y); QL (30.00 EA per 30 days)
[MPC091374]
Note
QL (45.00 ML per 30 days);
QL (45.00 ML per 30 days);
[Centennial Care #363]
41 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
OLANZAPINE ODT
TBDP
20MG
AG; QL (30.00 EA per 30 days)
OMEPRAZOLE
CPDR
10MG
OMEPRAZOLE
CPDR
20MG
OMEPRAZOLE
CPDR
40MG
OMNITROPE
SOLR
5.8MG
PA
ONDANSETRON HCL
TABS
8MG
QL (90.00 EA per 30 days);
ONDANSETRON HCL
TABS
4MG
QL (90.00 EA per 30 days);
ONDANSETRON ODT
TBDP
4MG
QL (90.00 EA per 30 days);
ONDANSETRON ODT
TBDP
8MG
QL (90.00 EA per 30 days);
OPCON-A
SOLN
0.027%; 0.315%
OPDIVO
SOLN
100MG/10ML
PA
OPDIVO
SOLN
40MG/4ML
PA
ORACIT
SOLN
ORALONE
PSTE
640MG/5ML;
490MG/5ML
0.1%
QL (5.00 GM per 30 days)
ORENCIA
SOSY
125MG/ML
PA;
(SP)
ORENCIA
SOLR
250MG
PA;
(SP)
ORSYTHIA
TABS
20MCG; 0.1MG
ORTHO-EST
TABS
0.75MG
OXAPROZIN
TABS
600MG
OXCARBAZEPINE
TABS
150MG
OXCARBAZEPINE
TABS
300MG
OXCARBAZEPINE
TABS
600MG
OXYBUTYNIN CHLORIDE
TABS
5MG
OXYBUTYNIN CHLORIDE
SYRP
5MG/5ML
OXYBUTYNIN CHLORIDE ER
TB24
15MG
OXYBUTYNIN CHLORIDE ER
TB24
5MG
OXYBUTYNIN CHLORIDE ER
TB24
10MG
OXYCODONE HCL
TABS
30MG
QL (180.00 EA per 30 days);
OXYCODONE HCL
TABS
5MG
QL (180.00 EA per 30 days);
OXYCODONE HCL
TABS
15MG
QL (180.00 EA per 30 days);
OXYCODONE HCL
TABS
20MG
QL (180.00 EA per 30 days);
OXYCODONE HCL
SOLN
5MG/5ML
QL (2700.00 ML per 30 days)
OXYCODONE HCL
CONC
100MG/5ML
QL (180.00 ML per 30 days);
OXYCODONE/ACETAMINOPHEN
TABS
500MG; 7.5MG
QL (8.00 EA per 1 days);
OXYCODONE/ACETAMINOPHEN
TABS
500MG; 7.5MG
OXYCODONE/ACETAMINOPHEN
TABS
650MG; 10MG
OXYCODONE/ACETAMINOPHEN
TABS
650MG; 10MG
OXYCODONE/ACETAMINOPHEN
TABS
325MG; 7.5MG
QL (12.00 EA per 1 days);
OXYCODONE/ACETAMINOPHEN
TABS
325MG; 10MG
QL (12.00 EA per 1 days);
OXYCODONE/ACETAMINOPHEN
TABS
325MG; 5MG
QL (8.00 EA per 1 days);
OXYCODONE/ACETAMINOPHEN
CAPS
500MG; 5MG
QL (8.00 EA per 1 days);
OXYCODONE/ASPIRIN
TABS
OXYMORPHONE HYDROCHLORIDE ER
TB12
325MG;
4.835MG
5MG
ST; QL (60.00 EA per 30 days);
OXYMORPHONE HYDROCHLORIDE ER
TB12
40MG
ST; QL (60.00 EA per 30 days);
OXYMORPHONE HYDROCHLORIDE ER
TB12
10MG
ST; QL (60.00 EA per 30 days);
OXYMORPHONE HYDROCHLORIDE ER
TB12
20MG
ST; QL (60.00 EA per 30 days);
OXYMORPHONE HYDROCHLORIDE ER
TB12
7.5MG
ST; QL (60.00 EA per 30 days);
[MPC091374]
Note
(SP)
QL (6.00 EA per 1 days);
[Centennial Care #363]
42 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
OXYMORPHONE HYDROCHLORIDE ER
TB12
15MG
ST; QL (60.00 EA per 30 days);
OXYMORPHONE HYDROCHLORIDE ER
TB12
30MG
ST; QL (60.00 EA per 30 days);
OXYTROL FOR WOMEN
PTTW
3.9MG/24HR
QL (8.00 EA per 30 days);
OYSTER SHELL CALCIUM + VITAMIN D
TABS
OYSTER SHELL CALCIUM/VITAMIN D
TABS
OYSTER SHELL CALCIUM/VITAMIN D
TABS
OTC
OYSTER SHELL CALCIUM/VITAMIN D
TABS
PACERONE
TABS
200UNIT;
500MG
250UNIT;
250MG
250MG;
125UNIT; 0
250MG;
125UNIT
100MG
PAIN & FEVER CHILDRENS
CHEW
80MG
(OTC)
PANCREAZE
CPEP
PANCREAZE
CPEP
PANCREAZE
CPEP
PANCREAZE
CPEP
PANOXYL WASH
LIQD
61000UNIT;
21000UNIT;
37000UNIT
43750UNIT;
10500UNIT;
25000UNIT
70000UNIT;
16800UNIT;
40000UNIT
17500UNIT;
4200UNIT;
10000UNIT
10%
PANTOPRAZOLE SODIUM
TBEC
40MG
QL (60.00 EA per 30 days);
PANTOPRAZOLE SODIUM
TBEC
20MG
QL (60.00 EA per 30 days);
PAROXETINE HCL
TABS
40MG
QL (45.00 EA per 30 days);
PAROXETINE HCL
TABS
10MG
QL (30.00 EA per 30 days);
PAROXETINE HCL
TABS
20MG
QL (30.00 EA per 30 days);
PAROXETINE HCL
TABS
30MG
QL (30.00 EA per 30 days);
PAROXETINE HCL ER
TB24
12.5MG
ST;
PAROXETINE HCL ER
TB24
25MG
ST;
PASER
PACK
4GM
PAXIL
SUSP
10MG/5ML
PEDI-DRI
POWD
100000UNIT/GM
PEG 3350/ELECTROLYTES
SOLR
QL (8000.00 ML per 30 days);
PEG-3350/ELECTROLYTES
SOLR
PEGASYS
SOLN
240GM;
2.98GM;
6.72GM;
5.84GM;
22.72GM
236GM;
2.97GM;
6.74GM;
5.86GM;
22.74GM
180MCG/ML
PA;
(SP)
PEGASYS
KIT
180MCG/0.5ML
PA;
(SP)
PEG-INTRON
KIT
50MCG/0.5ML
PA;
(SP)
PEG-INTRON
KIT
120MCG/0.5ML
PA;
(SP)
(SP)
(SP)
OTC
OTC
OTC
(OTC)
QL (900.00 ML per 30 days);
QL (8000.00 ML per 30 days);
PEG-INTRON REDIPEN PAK 4
KIT
150MCG/0.5ML
PA;
PEG-INTRON REDIPEN PAK 4
KIT
80MCG/0.5ML
PA;
PENICILLIN V POTASSIUM
TABS
500MG
PENICILLIN V POTASSIUM
SOLR
250MG/5ML
PENICILLIN V POTASSIUM
TABS
250MG
PENICILLIN V POTASSIUM
SOLR
125MG/5ML
[MPC091374]
Note
[Centennial Care #363]
43 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
PENTAM 300
SOLR
300MG
PENTASA
CPCR
250MG
ST;
PENTASA
CPCR
500MG
ST;
PENTOXIFYLLINE ER
TBCR
400MG
PERIOGARD
SOLN
0.12%
PERJETA
SOLN
420MG/14ML
PERMETHRIN
CREA
5%
PERMETHRIN
LOTN
1%
PERPHENAZINE
TABS
4MG
PERPHENAZINE
TABS
8MG
PERPHENAZINE
TABS
16MG
PERPHENAZINE
TABS
2MG
PERPHENAZINE/AMITRIPTYLINE
TABS
25MG; 2MG
PERPHENAZINE/AMITRIPTYLINE
TABS
10MG; 4MG
PERPHENAZINE/AMITRIPTYLINE
TABS
50MG; 4MG
PERPHENAZINE/AMITRIPTYLINE
TABS
10MG; 2MG
PERPHENAZINE/AMITRIPTYLINE
TABS
25MG; 4MG
PHENAZOPYRIDINE HCL
TABS
200MG
PHENAZOPYRIDINE HCL
TABS
100MG
PHENELZINE SULFATE
TABS
15MG
PHENOBARBITAL
TABS
15MG
PHENOBARBITAL
TABS
32.4MG
PHENOBARBITAL
TABS
64.8MG
PHENOBARBITAL
TABS
97.2MG
PHENOBARBITAL
TABS
60MG
PHENOBARBITAL
ELIX
20MG/5ML
PHENOBARBITAL
TABS
100MG
PHENOBARBITAL
TABS
16.2MG
PHENOBARBITAL
TABS
30MG
PHENYLEPHRINE HCL
SOLN
10%
PHENYTOIN
CHEW
50MG
PHENYTOIN
SUSP
125MG/5ML
PHENYTOIN SODIUM EXTENDED
CAPS
200MG
PHENYTOIN SODIUM EXTENDED
CAPS
300MG
PHENYTOIN SODIUM EXTENDED
CAPS
100MG
PHILITH
TABS
35MCG; 0.4MG
PHOS-FLUR
GEL
1.1%
PHOSLYRA
SOLN
667MG/5ML
PHOSPHA 250 NEUTRAL
TABS
PHOSPHOLINE IODIDE
SOLR
155MG; 852MG;
130MG
0.125%
PILOCARPINE HCL
TABS
7.5MG
PILOCARPINE HCL
SOLN
1%
PILOCARPINE HCL
SOLN
2%
PILOCARPINE HCL
SOLN
4%
PILOCARPINE HYDROCHLORIDE
TABS
5MG
PINDOLOL
TABS
5MG
PINDOLOL
TABS
10MG
PIN-X
CHEW
720.5MG
[MPC091374]
Coverage Details
PA;
Note
(SP)
(OTC)
QL (90.00 EA per 30 days);
QL (90.00 EA per 30 days);
QL (12.00 EA per 30 days)
(OTC)
[Centennial Care #363]
44 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
Note
PIN-X
SUSP
50MG/ML
QL (60.00 ML per 30 days)
(OTC)
PIOGLITAZONE HCL
TABS
45MG
ST; QL (30.00 EA per 30 days)
PIOGLITAZONE HCL
TABS
30MG
ST; QL (30.00 EA per 30 days)
PIOGLITAZONE HCL
TABS
15MG
ST; QL (30.00 EA per 30 days)
PIOGLITAZONE HCL/METFORMIN HCL
TABS
500MG; 15MG
ST
PIOGLITAZONE HCL/METFORMIN HCL
TABS
850MG; 15MG
ST
PIOGLITAZONE HCL-GLIMEPIRIDE
TABS
4MG; 30MG
ST
PIOGLITAZONE HCL-GLIMEPIRIDE
TABS
2MG; 30MG
ST
PIRMELLA 1/35
TABS
35MCG; 1MG
PIRMELLA 7/7/7
TABS
0; 0
PIROXICAM
CAPS
20MG
PIROXICAM
CAPS
10MG
PODOFILOX
SOLN
0.5%
POLYCIN B
OINT
POLYETHYLENE GLYCOL 3350
POWD
500UNIT/GM;
10000UNIT/GM
0
POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN
POMALYST
CAPS
10000UNIT/ML;
0.1%
PA; QL (21.00 EA per 28 days)
2MG
POMALYST
CAPS
4MG
PA; QL (21.00 EA per 28 days)
(SP)
POMALYST
CAPS
1MG
PA; QL (21.00 EA per 28 days)
(SP)
POMALYST
CAPS
3MG
PA; QL (21.00 EA per 28 days)
(SP)
PORTIA-28
TABS
0.03MG; 0.15MG
POTASSIUM CHLORIDE
LIQD
10%
POTASSIUM CHLORIDE
LIQD
20%
POTASSIUM CHLORIDE ER
CPCR
8MEQ
POTASSIUM CHLORIDE ER
TBCR
20MEQ
POTASSIUM CHLORIDE ER
TBCR
10MEQ
POTASSIUM CHLORIDE ER
TBCR
8MEQ
POTASSIUM CHLORIDE ER
TBCR
10MEQ
POTASSIUM CHLORIDE ER
CPCR
10MEQ
POTASSIUM CITRATE ER
TBCR
540MG
POTASSIUM CITRATE ER
TBCR
1080MG
POTIGA
TABS
50MG
PA; QL (90.00 EA per 30 days)
POTIGA
TABS
200MG
PA; QL (90.00 EA per 30 days)
POTIGA
TABS
400MG
PA; QL (90.00 EA per 30 days)
POTIGA
TABS
300MG
PA; QL (90.00 EA per 30 days)
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
0.75MG
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
0.125MG
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
0.25MG
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
1MG
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
1.5MG
PRAMIPEXOLE DIHYDROCHLORIDE
TABS
0.5MG
PRANDIMET
TABS
500MG; 2MG
ST;
PRANDIMET
TABS
500MG; 1MG
ST;
PRAVASTATIN SODIUM
TABS
10MG
PRAVASTATIN SODIUM
TABS
20MG
PRAVASTATIN SODIUM
TABS
40MG
PRAVASTATIN SODIUM
TABS
80MG
[MPC091374]
(SP)
[Centennial Care #363]
45 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
PRAZOSIN HCL
CAPS
1MG
PRAZOSIN HCL
CAPS
2MG
PRAZOSIN HCL
CAPS
5MG
PRECISION XTRA
STRP
0
PRED MILD
SUSP
0.12%
PREDNISOLONE
SOLN
15MG/5ML
PREDNISOLONE ACETATE
SUSP
1%
PREDNISOLONE SODIUM PHOSPHATE
SOLN
1%
PREDNISOLONE SODIUM PHOSPHATE
SOLN
15MG/5ML
PREDNISOLONE SODIUM PHOSPHATE
SOLN
5MG/5ML
PREDNISONE
SOLN
5MG/5ML
PREDNISONE
TABS
10MG
PREDNISONE
TABS
20MG
PREDNISONE
TABS
5MG
PREDNISONE
TABS
2.5MG
PREDNISONE
TABS
10MG
PREDNISONE
TABS
5MG
PREDNISONE
TABS
1MG
PREDNISONE
TABS
50MG
PREFEST
TABS
0; 0
PREMARIN
TABS
0.9MG
PREMARIN
TABS
0.3MG
PREMARIN
CREA
0.625MG/GM
PREMARIN
TABS
0.45MG
PREMARIN
TABS
0.625MG
PREMARIN
TABS
1.25MG
PREMPHASE
TABS
0.625MG; 5MG
PREMPRO
TABS
0.3MG; 1.5MG
PREMPRO
TABS
0.625MG; 5MG
PREMPRO
TABS
0.45MG; 1.5MG
PREVACID SOLUTAB
TBDP
15MG
PA
PREVACID SOLUTAB
TBDP
30MG
PA
PREVALITE
POWD
4GM/DOSE
PREVIFEM
TABS
35MCG; 0.25MG
PREZISTA
TABS
800MG
QL (30.00 EA per 30 days)
PREZISTA
TABS
400MG
QL (60.00 EA per 30 days);
PREZISTA
TABS
150MG
QL (60.00 EA per 30 days);
PREZISTA
SUSP
100MG/ML
QL (360.00 ML per 30 days)
PREZISTA
TABS
600MG
QL (60.00 EA per 30 days);
PREZISTA
TABS
75MG
QL (60.00 EA per 30 days);
PRIMAQUINE PHOSPHATE
TABS
26.3MG
PRIMIDONE
TABS
250MG
PRIMIDONE
TABS
50MG
PRIVIGEN
SOLN
20GM/200ML
PA;
PRIVIGEN
SOLN
10GM/100ML
PA;
PRIVIGEN
SOLN
5GM/50ML
PA;
PROBENECID
TABS
500MG
PROBENECID/COLCHICINE
TABS
0.5MG; 500MG
[MPC091374]
Coverage Details
Note
[Centennial Care #363]
46 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
PROCHLORPERAZINE
SUPP
25MG
Coverage Details
Note
PROCHLORPERAZINE EDISYLATE
SOLN
5MG/ML
PROCHLORPERAZINE MALEATE
TABS
5MG
PROCHLORPERAZINE MALEATE
TABS
10MG
PROCRIT
SOLN
3000UNIT/ML
PA;
(SP)
PROCRIT
SOLN
10000UNIT/ML
PA;
(SP)
(SP)
PROCRIT
SOLN
4000UNIT/ML
PA;
PROCRIT
SOLN
2000UNIT/ML
PA;
(SP)
PROCRIT
SOLN
20000UNIT/ML
PA;
(SP)
PA;
(SP)
PA;
(SP)
PA
(MB)
PROCRIT
SOLN
40000UNIT/ML
PROCTOCREAM HC
CREA
2.5%
PROCTOSOL HC
CREA
2.5%
PROGESTERONE
CAPS
200MG
PROGESTERONE
CAPS
100MG
PROLIA
SOLN
60MG/ML
PROMETHAZINE HCL
SUPP
12.5MG
PROMETHAZINE HCL
TABS
12.5MG
PROMETHAZINE HCL
SUPP
25MG
PROMETHAZINE HCL
TABS
25MG
PROMETHAZINE HCL
TABS
50MG
PROMETHAZINE HCL PLAIN
SYRP
6.25MG/5ML
PROMETHEGAN
SUPP
50MG
PROPAFENONE HCL
TABS
300MG
PROPAFENONE HCL
TABS
150MG
PROPAFENONE HCL
TABS
225MG
PROPANTHELINE BROMIDE
TABS
15MG
PROPRANOLOL HCL
TABS
80MG
PROPRANOLOL HCL
TABS
60MG
PROPRANOLOL HCL
SOLN
20MG/5ML
PROPRANOLOL HCL
TABS
20MG
PROPRANOLOL HCL
SOLN
40MG/5ML
PROPRANOLOL HCL
TABS
10MG
PROPRANOLOL HCL
TABS
40MG
PROPRANOLOL HCL ER
CP24
60MG
PROPRANOLOL HCL ER
CP24
80MG
PROPRANOLOL HCL ER
CP24
160MG
PROPRANOLOL HCL ER
CP24
120MG
PROPYLTHIOURACIL
TABS
50MG
PROVENGE
SUSP
0
PULMOZYME
SOLN
1MG/ML
PYRAZINAMIDE
TABS
500MG
PYRIDOSTIGMINE BROMIDE
TABS
60MG
Q-PAP
LIQD
160MG/5ML
QL (125.00 ML per 1 days)
OTC
Q-PAP CHILDRENS
SUSP
160MG/5ML
QL (125.00 ML per 1 days);
(OTC)
Q-PAP INFANTS
SOLN
80MG/0.8ML
QUETIAPINE FUMARATE
TABS
25MG
AG (min: 6y); QL (90.00 EA per 30 days)
QUETIAPINE FUMARATE
TABS
200MG
AG (min: 6y); QL (90.00 EA per 30 days)
QUETIAPINE FUMARATE
TABS
300MG
AG (min: 6y); QL (60.00 EA per 30 days)
QUETIAPINE FUMARATE
TABS
400MG
AG (min: 6y); QL (60.00 EA per 30 days)
[MPC091374]
(OTC)
[Centennial Care #363]
47 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
QUETIAPINE FUMARATE
TABS
50MG
AG (min: 6y); QL (90.00 EA per 30 days)
QUETIAPINE FUMARATE
TABS
100MG
AG (min: 6y); QL (90.00 EA per 30 days)
QUINAPRIL HCL
TABS
5MG
QUINAPRIL HCL
TABS
20MG
QUINAPRIL HCL
TABS
40MG
QUINAPRIL HCL
TABS
10MG
QUINAPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 10MG
QUINAPRIL/HYDROCHLOROTHIAZIDE
TABS
25MG; 20MG
QUINAPRIL/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 20MG
QUINIDINE GLUCONATE CR
TBCR
324MG
QUINIDINE SULFATE
TABS
200MG
QUINIDINE SULFATE
TABS
300MG
QVAR
AERS
80MCG/ACT
ST;
QVAR
AERS
40MCG/ACT
ST;
RABEPRAZOLE SODIUM
TBEC
20MG
ST; QL (60.00 EA per 30 days);
RALOXIFENE HYDROCHLORIDE
TABS
60MG
RAMIPRIL
CAPS
2.5MG
RAMIPRIL
CAPS
5MG
RAMIPRIL
CAPS
10MG
RAMIPRIL
CAPS
1.25MG
RANEXA
TB12
1000MG
ST;
RANEXA
TB12
500MG
ST;
RANITIDINE HCL
SYRP
15MG/ML
RANITIDINE HCL
TABS
150MG
RANITIDINE HCL
TABS
300MG
REBIF
SOLN
44MCG/0.5ML
PA;
(SP)
REBIF
SOLN
22MCG/0.5ML
PA;
(SP)
REBIF TITRATION PACK
SOLN
0
PA;
(SP)
RECLIPSEN
TABS
0.15MG; 30MCG
REESES PINWORM MEDICINE
TABS
180MG
QL (48.00 EA per 30 days)
(OTC)
REESES PINWORM MEDICINE
SUSP
144MG/ML
QL (60.00 ML per 30 days)
(OTC)
RELENZA DISKHALER
AEPB
5MG/BLISTER
QL (20.00 EA per 180 days);
REMICADE
SOLR
100MG
PA;
RENAGEL
TABS
400MG
RENAGEL
TABS
800MG
RENAL
CAPS
RENALPREN
CAPS
100MG;
150MCG;
6MCG; 1MG;
20MG; 5MG;
10MG; 1.7MG;
1.5MG
100MG;
150MCG; 5MG;
6MCG; 1MG;
20MG; 10MG;
1.7MG; 1.5MG
RENA-VITE
TABS
[MPC091374]
60MG; 300MCG;
6MCG;
800MCG; 20MG;
10MG; 10MG;
1.7MG; 1.5MG
Note
(MB) (SP)
(OTC)
[Centennial Care #363]
48 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
RENA-VITE RX
TABS
60MG; 300MCG;
10MG; 6MCG;
1MG; 20MG;
10MG; 1.7MG;
1.5MG
Coverage Details
RENO CAPS
CAPS
100MG;
150MCG; 5MG;
6MCG; 1MG;
20MG; 10MG;
1.7MG; 1.5MG
RESCRIPTOR
TABS
200MG
QL (180.00 EA per 30 days);
RESCRIPTOR
TABS
100MG
QL (180.00 EA per 30 days);
Note
(SP)
RESTASIS
EMUL
0.05%
PA; QL (60.00 EA per 30 days);
RETIN-A
GEL
0.025%
AG (min: 40y, max: 40y);
RETIN-A
CREA
0.025%
AG (max: 40y);
REVLIMID
CAPS
5MG
PA;
(SP)
REVLIMID
CAPS
15MG
PA;
(SP)
REVLIMID
CAPS
25MG
PA;
(SP)
REVLIMID
CAPS
10MG
PA;
(SP)
REYATAZ
CAPS
300MG
QL (60.00 EA per 30 days);
REYATAZ
CAPS
200MG
QL (60.00 EA per 30 days);
REYATAZ
CAPS
100MG
QL (60.00 EA per 30 days);
REYATAZ
CAPS
150MG
QL (60.00 EA per 30 days);
RIBASPHERE
CAPS
200MG
RIBAVIRIN
TABS
200MG
RIDAURA
CAPS
3MG
RIFABUTIN
CAPS
150MG
RIFAMPIN
CAPS
150MG
RIFAMPIN
CAPS
300MG
RISPERDAL CONSTA
SUSR
RISPERDAL CONSTA
(SP)
PA;
(SP)
37.5MG
QL (2.00 EA per 30 days);
(MB) (SP)
SUSR
50MG
QL (2.00 EA per 30 days);
(MB) (SP)
RISPERDAL CONSTA
SUSR
25MG
QL (2.00 EA per 30 days);
(MB) (SP)
RISPERDAL CONSTA
SUSR
12.5MG
QL (2.00 EA per 30 days);
(MB) (SP)
RISPERIDONE
TABS
3MG
AG (min: 6y); QL (60.00 EA per 30 days);
RISPERIDONE
SOLN
1MG/ML
AG (min: 6y); QL (480.00 ML per 30 days);
RISPERIDONE
TABS
0.25MG
AG (min: 6y); QL (60.00 EA per 30 days);
RISPERIDONE
TABS
4MG
AG (min: 6y); QL (120.00 EA per 30 days);
RISPERIDONE
TABS
0.5MG
AG (min: 6y); QL (60.00 EA per 30 days);
RISPERIDONE
TABS
2MG
AG (min: 6y); QL (60.00 EA per 30 days);
RISPERIDONE
TABS
1MG
AG (min: 6y); QL (60.00 EA per 30 days);
RISPERIDONE ODT
TBDP
4MG
PA; QL (120.00 EA per 30 days);
RISPERIDONE ODT
TBDP
0.25MG
PA; QL (60.00 EA per 30 days)
RISPERIDONE ODT
TBDP
1MG
PA; QL (60.00 EA per 30 days);
RISPERIDONE ODT
TBDP
2MG
PA; QL (60.00 EA per 30 days);
RISPERIDONE ODT
TBDP
0.5MG
PA; QL (60.00 EA per 30 days);
RISPERIDONE ODT
TBDP
3MG
PA; QL (60.00 EA per 30 days);
RITUXAN
CONC
10MG/ML
PA;
RIZATRIPTAN BENZOATE
TABS
5MG
ST; QL (18.00 EA per 30 days)
RIZATRIPTAN BENZOATE
TABS
10MG
ST; QL (18.00 EA per 30 days)
RIZATRIPTAN BENZOATE ODT
TBDP
10MG
ST; QL (18.00 EA per 30 days)
[MPC091374]
(MB)
[Centennial Care #363]
49 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
RIZATRIPTAN BENZOATE ODT
TBDP
5MG
ST; QL (18.00 EA per 30 days)
ROPINIROLE HCL
TABS
0.5MG
ROPINIROLE HCL
TABS
4MG
ROPINIROLE HCL
TABS
0.25MG
ROPINIROLE HCL
TABS
5MG
ROPINIROLE HCL
TABS
1MG
ROPINIROLE HCL
TABS
3MG
ROPINIROLE HCL
TABS
2MG
ROSANIL CLEANSER
EMUL
10%; 5%
ROXICET
SOLN
QL (60.00 ML per 1 days);
ROXICET
TABS
325MG/5ML;
5MG/5ML
500MG; 5MG
ROZEREM
TABS
8MG
PA; QL (30.00 EA per 30 days);
S.S.S. TONIC
LIQD
SALSALATE
TABS
0.6MG/15ML;
100MG/15ML;
20MG/15ML;
2.4MG/15ML;
5MG/15ML
500MG
SALSALATE
TABS
750MG
SANDIMMUNE
SOLN
100MG/ML
SELEGILINE HCL
TABS
5MG
SELEGILINE HCL
CAPS
5MG
SELENIUM SULFIDE
LOTN
2.5%
SELZENTRY
TABS
300MG
QL (120.00 EA per 30 days)
SELZENTRY
TABS
150MG
QL (120.00 EA per 30 days);
SENNA LAX
TABS
8.6MG
SENSIPAR
TABS
90MG
PA;
SENSIPAR
TABS
60MG
PA;
SENSIPAR
TABS
30MG
PA;
SEREVENT DISKUS
AEPB
50MCG/DOSE
SERTRALINE HCL
TABS
25MG
QL (60.00 EA per 30 days);
SERTRALINE HCL
TABS
50MG
QL (45.00 EA per 30 days);
SERTRALINE HCL
TABS
100MG
QL (60.00 EA per 30 days);
SERTRALINE HCL
CONC
20MG/ML
QL (300.00 ML per 30 days);
SEVELAMER CARBONATE
TABS
800MG
SF
GEL
1.1%
SILDENAFIL CITRATE
TABS
20MG
SILVER SULFADIAZINE
CREA
1%
SIMCOR
TB24
500MG; 20MG
ST;
SIMCOR
TB24
1000MG; 20MG
ST;
SIMCOR
TB24
750MG; 20MG
ST;
SIMVASTATIN
TABS
10MG
SIMVASTATIN
TABS
40MG
SIMVASTATIN
TABS
5MG
SIMVASTATIN
TABS
80MG
SIMVASTATIN
TABS
20MG
SKLICE
LOTN
0.5%
SODIUM CHLORIDE
NEBU
7%
SODIUM CHLORIDE
NEBU
0.9%
[MPC091374]
Note
QL (8.00 EA per 1 days);
(OTC)
(SP)
(OTC)
PA; QL (90.00 EA per 30 days)
ST
[Centennial Care #363]
50 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Strength
Coverage Details
SODIUM FERRIC GLUCONATE COMPLEX/SUCROSE SOLN
Drug Name
Form
12.5MG/ML
PA;
SODIUM FLUORIDE
CHEW
0.25MG
AG (max: 6y);
SODIUM FLUORIDE
CHEW
1MG
AG (max: 6y);
SODIUM FLUORIDE
CHEW
0.5MG
AG (max: 6y);
SODIUM FLUORIDE
SOLN
0.5MG/ML
AG (max: 6y)
SODIUM POLYSTYRENE SULFONATE
POWD
0
SODIUM SULFACETAMIDE/SULFUR
LOTN
10%; 5%
SODIUM SULFACETAMIDE/SULFUR
CREA
10%; 5%
SODIUM SULFACETAMIDE/SULFUR
SUSP
10%; 5%
SOLIA
TABS
0.15MG; 30MCG
SOLIRIS
SOLN
10MG/ML
SOLU-CORTEF
SOLR
100MG
SOLU-CORTEF
SOLR
250MG
SOTALOL HCL
TABS
80MG
SOTALOL HCL
TABS
240MG
SOTALOL HCL
TABS
120MG
SOTALOL HCL
TABS
160MG
SOTALOL HCL (AF)
TABS
120MG
SOTALOL HCL (AF)
TABS
160MG
SOTALOL HCL (AF)
TABS
80MG
SPIRIVA HANDIHALER
CAPS
18MCG
SPIRIVA RESPIMAT
AERS
2.5MCG/ACT
SPIRONOLACTONE
TABS
50MG
SPIRONOLACTONE
TABS
25MG
SPIRONOLACTONE
TABS
100MG
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE
TABS
25MG; 25MG
SPRINTEC 28
TABS
35MCG; 0.25MG
SPRYCEL
TABS
20MG
PA; QL (30.00 EA per 30 days);
(SP)
SPRYCEL
TABS
80MG
PA; QL (30.00 EA per 30 days);
(SP)
SPRYCEL
TABS
70MG
PA; QL (30.00 EA per 30 days);
(SP)
SPRYCEL
TABS
50MG
PA; QL (30.00 EA per 30 days);
(SP)
SPRYCEL
TABS
100MG
PA; QL (30.00 EA per 30 days);
(SP)
SPRYCEL
TABS
140MG
PA; QL (30.00 EA per 30 days);
(SP)
SRONYX
TABS
20MCG; 0.1MG
ST JOSEPH ADULT
CHEW
75MG
AG (min: 45y, max: 78y)
STAVUDINE
CAPS
15MG
QL (60.00 EA per 30 days);
STAVUDINE
CAPS
30MG
QL (60.00 EA per 30 days);
STAVUDINE
SOLR
1MG/ML
QL (2400.00 ML per 30 days);
STAVUDINE
CAPS
20MG
QL (60.00 EA per 30 days);
STAVUDINE
CAPS
40MG
QL (60.00 EA per 30 days);
STIVARGA
TABS
40MG
PA; QL (120.00 EA per 30 days)
STRATTERA
CAPS
10MG
ST; QL (30.00 EA per 30 days);
STRATTERA
CAPS
18MG
ST; QL (30.00 EA per 30 days);
STRATTERA
CAPS
40MG
ST; QL (30.00 EA per 30 days);
STRATTERA
CAPS
60MG
ST; QL (30.00 EA per 30 days);
STRATTERA
CAPS
80MG
ST; QL (30.00 EA per 30 days);
STRATTERA
CAPS
100MG
ST; QL (30.00 EA per 30 days);
[MPC091374]
PA;
Note
(MB) (SP)
(SP)
[Centennial Care #363]
51 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
STRATTERA
CAPS
25MG
ST; QL (30.00 EA per 30 days);
Note
STRIBILD
TABS
150MG; 150MG; QL (30.00 EA per 30 days)
200MG; 300MG
STROVITE PLUS
TABS
500MG;
0.15MG; 25MG;
0.1MG; 3MG;
50MCG; 0.8MG;
27MG; 50MG;
5MG; 100MG;
25MG; 20MG;
20MG;
5000UNIT;
30UNIT; 22.5MG
SUBOXONE
FILM
4MG; 1MG
QL (90.00 EA per 30 days);
SUBOXONE
FILM
8MG; 2MG
QL (90.00 EA per 30 days);
SUBOXONE
FILM
12MG; 3MG
QL (60.00 EA per 30 days);
SUBOXONE
FILM
2MG; 0.5MG
QL (90.00 EA per 30 days);
SUCRALFATE
TABS
1GM
SULFACETAMIDE SODIUM
SOLN
10%
SULFACETAMIDE SODIUM/SULFUR CLEANSER
EMUL
10%; 5%
SULFAMETHOXAZOLE/TRIMETHOPRIM
SUSP
SULFAMETHOXAZOLE/TRIMETHOPRIM
TABS
200MG/5ML;
40MG/5ML
400MG; 80MG
SULFAMETHOXAZOLE/TRIMETHOPRIM DS
TABS
800MG; 160MG
SULFASALAZINE
TBEC
500MG
SULFASALAZINE
TABS
500MG
SULINDAC
TABS
200MG
SULINDAC
TABS
150MG
SUMATRIPTAN
SOLN
20MG/ACT
QL (6.00 EA per 30 days);
SUMATRIPTAN
SOLN
5MG/ACT
QL (6.00 EA per 30 days);
SUMATRIPTAN SUCCINATE
TABS
25MG
QL (18.00 EA per 30 days);
SUMATRIPTAN SUCCINATE
TABS
50MG
QL (18.00 EA per 30 days);
SUMATRIPTAN SUCCINATE
TABS
100MG
QL (18.00 EA per 30 days);
SUMATRIPTAN SUCCINATE
SOAJ
6MG/0.5ML
QL (2.00 ML per 30 days)
SUMATRIPTAN SUCCINATE
SOAJ
4MG/0.5ML
QL (2.00 ML per 30 days)
SUPER B-COMPLEX/VITAMIN C
TABS
180MG; 45MCG;
100MG; 5.5MG;
30MCG;
400MCG; 25MG;
5MG; 20MG;
100MG
SUSTIVA
CAPS
50MG
QL (30.00 EA per 30 days);
SUSTIVA
CAPS
200MG
QL (30.00 EA per 30 days);
SUSTIVA
TABS
600MG
QL (30.00 EA per 30 days);
SUTENT
CAPS
50MG
PA;
(SP)
(SP)
(SP)
(OTC)
SUTENT
CAPS
12.5MG
PA;
SUTENT
CAPS
25MG
PA;
(SP)
SYEDA
TABS
3MG; 0.03MG
SYLATRON
KIT
444MCG
PA;
(SP)
SYLATRON
KIT
888MCG
PA;
(SP)
888MCG
PA;
(SP)
SYLATRON
KIT
[MPC091374]
[Centennial Care #363]
52 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
SYLATRON
KIT
444MCG
PA;
Note
(SP)
(SP)
(SP)
SYLATRON
KIT
296MCG
PA;
SYLATRON
KIT
296MCG
PA;
SYMBICORT
AERO
SYMBICORT
AERO
SYMLINPEN 120
SOPN
ST; QL (6.90 GM per 30 days);
80MCG/ACT;
4.5MCG/ACT
ST; QL (6.00 GM per 30 days);
160MCG/ACT;
4.5MCG/ACT
2700MCG/2.7ML PA;
SYNAGIS
SOLN
50MG/0.5ML
PA;
SYNAGIS
SOLN
100MG/ML
PA;
SYNVISC
SOSY
16MG/2ML
PA; QL (6.00 ML per 180 days);
SYNVISC ONE
SOSY
48MG/6ML
PA; QL (6.00 ML per 180 days);
TABLOID
TABS
40MG
PA;
TACROLIMUS
OINT
0.1%
PA
TACROLIMUS
OINT
0.03%
PA
TACROLIMUS
CAPS
1MG
TACROLIMUS
CAPS
0.5MG
TACROLIMUS
CAPS
5MG
TAFINLAR
CAPS
75MG
PA; QL (120.00 EA per 30 days)
(SP)
TAFINLAR
CAPS
50MG
PA; QL (120.00 EA per 30 days)
(SP)
TAMIFLU
CAPS
45MG
QL (10.00 EA per 180 days);
TAMIFLU
SUSR
6MG/ML
QL (125.00 ML per 180 days)
TAMIFLU
CAPS
75MG
QL (10.00 EA per 180 days);
TAMIFLU
CAPS
30MG
QL (10.00 EA per 180 days);
TAMOXIFEN CITRATE
TABS
20MG
TAMOXIFEN CITRATE
TABS
10MG
TAMSULOSIN HCL
CAPS
0.4MG
TARCEVA
TABS
100MG
PA; QL (60.00 EA per 30 days);
(SP)
TARCEVA
TABS
150MG
PA; QL (60.00 EA per 30 days);
(SP)
TARCEVA
TABS
25MG
PA; QL (60.00 EA per 30 days);
(SP)
TARGRETIN
CAPS
75MG
PA;
(SP)
TARINA FE 1/20
TABS
TASIGNA
CAPS
20MCG; 75MG;
1MG
200MG
PA;
(SP)
TASIGNA
CAPS
150MG
PA;
(SP)
TAZTIA XT
CP24
360MG
TAZTIA XT
CP24
180MG
TAZTIA XT
CP24
120MG
TAZTIA XT
CP24
300MG
TAZTIA XT
CP24
240MG
TEGRETOL-XR
TB12
100MG
TEMAZEPAM
CAPS
15MG
QL (30.00 EA per 30 days);
TEMAZEPAM
CAPS
30MG
QL (30.00 EA per 30 days);
TEMOZOLOMIDE
CAPS
5MG
PA
(SP)
TEMOZOLOMIDE
CAPS
100MG
PA
(SP)
TEMOZOLOMIDE
CAPS
250MG
PA
(SP)
(SP)
(SP)
TEMOZOLOMIDE
CAPS
140MG
PA
TEMOZOLOMIDE
CAPS
20MG
PA
(SP)
TEMOZOLOMIDE
CAPS
180MG
PA
(SP)
TERAZOSIN HCL
CAPS
5MG
[MPC091374]
[Centennial Care #363]
53 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
TERAZOSIN HCL
CAPS
10MG
TERAZOSIN HCL
CAPS
1MG
TERAZOSIN HCL
CAPS
2MG
TERBINAFINE HCL
TABS
250MG
TERBUTALINE SULFATE
TABS
5MG
TERBUTALINE SULFATE
TABS
2.5MG
TERCONAZOLE
CREA
0.4%
TERCONAZOLE
SUPP
80MG
TERCONAZOLE
CREA
0.8%
TESTIM
GEL
1%
PA; QL (60.00 GM per 30 days);
TESTOPEL
PLLT
75MG
PA; QL (6.00 EA per 90 days)
TESTOSTERONE
GEL
10MG/ACT
PA; QL (120.00 GM per 30 days)
TESTOSTERONE
GEL
1%
PA; QL (60.00 GM per 30 days);
TESTOSTERONE CYPIONATE
SOLN
100MG/ML
PA;
TESTOSTERONE CYPIONATE
SOLN
200MG/ML
PA;
TESTOSTERONE ENANTHATE
SOLN
200MG/ML
PA;
TETRACYCLINE HCL
CAPS
500MG
TETRACYCLINE HCL
CAPS
250MG
THALOMID
CAPS
50MG
PA;
THALOMID
CAPS
100MG
PA;
THALOMID
CAPS
150MG
PA;
THALOMID
CAPS
200MG
PA;
THEOPHYLLINE CR
TB12
200MG
THEOPHYLLINE CR
TB12
100MG
THEOPHYLLINE ER
TB24
600MG
THEOPHYLLINE ER
TB12
450MG
THEOPHYLLINE ER
TB24
400MG
THEOPHYLLINE ER
TB12
300MG
THIORIDAZINE HCL
TABS
10MG
THIORIDAZINE HCL
TABS
25MG
THIORIDAZINE HCL
TABS
50MG
THIORIDAZINE HCL
TABS
100MG
THIOTHIXENE
CAPS
1MG
THIOTHIXENE
CAPS
2MG
THIOTHIXENE
CAPS
5MG
THIOTHIXENE
CAPS
10MG
TICLOPIDINE HCL
TABS
250MG
TILIA FE
TABS
0; 75MG; 1MG
TIMOLOL MALEATE
TABS
10MG
TIMOLOL MALEATE
TABS
5MG
TIMOLOL MALEATE
TABS
20MG
TIMOLOL MALEATE
SOLN
0.25%
TIMOLOL MALEATE
SOLN
0.5%
TIMOLOL MALEATE OPHTHALMIC GEL FORMING
SOLG
0.5%
TIMOLOL MALEATE OPHTHALMIC GEL FORMING
SOLG
0.25%
TIVICAY
TABS
50MG
TIZANIDINE HCL
TABS
4MG
TIZANIDINE HCL
TABS
2MG
[MPC091374]
Coverage Details
Note
QL (90.00 EA per 365 days);
PA; QL (30.00 EA per 30 days)
(MB)
(SP)
[Centennial Care #363]
54 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
TOBI PODHALER
CAPS
28MG
QL (224.00 EA per 28 days)
TOBRAMYCIN
NEBU
300MG/5ML
TOBRAMYCIN SULFATE
SOLN
0.3%
TOLAZAMIDE
TABS
250MG
TOLAZAMIDE
TABS
500MG
TOLTERODINE TARTRATE
TABS
2MG
ST
TOLTERODINE TARTRATE
TABS
1MG
ST
TOLTERODINE TARTRATE ER
CP24
4MG
ST; QL (30.00 EA per 30 days);
TOLTERODINE TARTRATE ER
CP24
2MG
ST; QL (30.00 EA per 30 days);
TOPIRAMATE
TABS
50MG
TOPIRAMATE
CPSP
15MG
TOPIRAMATE
CPSP
25MG
TOPIRAMATE
TABS
25MG
TOPIRAMATE
TABS
100MG
TOPIRAMATE
TABS
200MG
TRAMADOL HCL
TABS
50MG
QL (240.00 EA per 30 days);
TRANEXAMIC ACID
TABS
650MG
QL (30.00 EA per 30 days);
TRANYLCYPROMINE SULFATE
TABS
10MG
TRAZODONE HCL
TABS
50MG
TRAZODONE HCL
TABS
150MG
TRAZODONE HCL
TABS
100MG
TRAZODONE HCL
TABS
300MG
TRETINOIN
CREA
0.05%
AG (max: 40y);
TRETINOIN
GEL
0.01%
AG (min: 40y, max: 40y);
TRETINOIN
CREA
0.1%
AG (max: 40y);
TREXALL
TABS
5MG
TRIAMCINOLONE ACETONIDE
LOTN
0.025%
TRIAMCINOLONE ACETONIDE
OINT
0.1%
TRIAMCINOLONE ACETONIDE
CREA
0.025%
TRIAMCINOLONE ACETONIDE
CREA
0.5%
TRIAMCINOLONE ACETONIDE
OINT
0.025%
TRIAMCINOLONE ACETONIDE
OINT
0.5%
TRIAMCINOLONE ACETONIDE
CREA
0.1%
TRIAMCINOLONE ACETONIDE
LOTN
0.1%
TRIAMCINOLONE IN ORABASE
PSTE
0.1%
TRIAMTERENE/HYDROCHLOROTHIAZIDE
CAPS
25MG; 37.5MG
TRIAMTERENE/HYDROCHLOROTHIAZIDE
TABS
25MG; 37.5MG
TRIAMTERENE/HYDROCHLOROTHIAZIDE
TABS
50MG; 75MG
TRIANEX
OINT
0.05%
TRIAZOLAM
TABS
0.125MG
QL (60.00 EA per 30 days);
TRIAZOLAM
TABS
0.25MG
QL (60.00 EA per 30 days);
TRIFLUOPERAZINE HCL
TABS
10MG
TRIFLUOPERAZINE HCL
TABS
1MG
TRIFLUOPERAZINE HCL
TABS
2MG
TRIFLUOPERAZINE HCL
TABS
5MG
TRIFLURIDINE
SOLN
1%
TRIHEXYPHENIDYL HCL
ELIX
0.4MG/ML
TRIHEXYPHENIDYL HCL
TABS
2MG
TRIHEXYPHENIDYL HCL
TABS
5MG
[MPC091374]
Note
QL (5.00 GM per 30 days);
[Centennial Care #363]
55 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
TRI-LEGEST FE
TABS
0; 75MG; 1MG
TRI-LINYAH
TABS
0; 0
TRIMETHOBENZAMIDE HCL
CAPS
300MG
TRIMETHOPRIM
TABS
100MG
TRINESSA
TABS
0; 0
TRIPHROCAPS
CAPS
100MG;
150MCG; 5MG;
6MCG; 1MG;
20MG; 10MG;
1.7MG; 1.5MG
TRI-PREVIFEM
TABS
0; 0
TRI-SPRINTEC
TABS
0; 0
TRIUMEQ
TABS
TRIVORA-28
TABS
600MG; 50MG;
300MG
0; 0
TROPICAMIDE
SOLN
1%
TROPICAMIDE
SOLN
0.5%
TROSPIUM CHLORIDE
TABS
20MG
ST;
TROSPIUM CHLORIDE ER
CP24
60MG
ST; QL (30.00 EA per 30 days)
TRUVADA
TABS
200MG; 300MG
TUDORZA PRESSAIR
AEPB
400MCG/ACT
TYBOST
TABS
150MG
QL (30.00 EA per 30 days)
TYKERB
TABS
250MG
PA; QL (180.00 EA per 30 days);
TYSABRI
CONC
300MG/15ML
PA;
ULORIC
TABS
80MG
PA; QL (30.00 EA per 30 days);
ULORIC
TABS
40MG
PA; QL (30.00 EA per 30 days);
UNITHROID
TABS
25MCG
UNITHROID
TABS
112MCG
UNITHROID
TABS
125MCG
UNITHROID
TABS
175MCG
UNITHROID
TABS
137MCG
UNITHROID
TABS
100MCG
UNITHROID
TABS
150MCG
UNITHROID
TABS
50MCG
UNITHROID
TABS
75MCG
UNITHROID
TABS
88MCG
UNITHROID
TABS
200MCG
UNITHROID
TABS
300MCG
UROCIT-K 15
TBCR
15MEQ
URSODIOL
TABS
500MG
URSODIOL
TABS
250MG
URSODIOL
CAPS
300MG
VAGIFEM
TABS
10MCG
QL (18.00 EA per 365 days);
VAGIFEM
TABS
10MCG
QL (8.00 EA per 28 days);
VALCYTE
SOLR
50MG/ML
PA;
VALGANCICLOVIR
TABS
450MG
PA; QL (60.00 EA per 30 days)
VALPROIC ACID
CAPS
250MG
VALPROIC ACID
SYRP
250MG/5ML
VALSARTAN/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 160MG ST
VALSARTAN/HYDROCHLOROTHIAZIDE
TABS
25MG; 320MG
[MPC091374]
Coverage Details
Note
QL (30.00 EA per 30 days)
(SP)
(MB) (SP)
ST
[Centennial Care #363]
56 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
VALSARTAN/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 80MG
ST
VALSARTAN/HYDROCHLOROTHIAZIDE
TABS
25MG; 160MG
ST
VALSARTAN/HYDROCHLOROTHIAZIDE
TABS
12.5MG; 320MG ST
VANCOMYCIN HCL
CAPS
125MG
PA
VANCOMYCIN HCL
CAPS
250MG
PA
VANCOMYCIN HCL
SOLR
500MG
VELIVET
TABS
0; 0
VENLAFAXINE HCL
TABS
50MG
QL (90.00 EA per 30 days);
VENLAFAXINE HCL
TABS
25MG
QL (90.00 EA per 30 days);
VENLAFAXINE HCL
TABS
37.5MG
QL (90.00 EA per 30 days);
VENLAFAXINE HCL
TABS
100MG
QL (90.00 EA per 30 days);
VENLAFAXINE HCL
TABS
75MG
QL (90.00 EA per 30 days);
VENLAFAXINE HCL ER
CP24
37.5MG
QL (60.00 EA per 30 days);
VENLAFAXINE HCL ER
CP24
150MG
QL (60.00 EA per 30 days);
VENLAFAXINE HCL ER
CP24
75MG
QL (90.00 EA per 30 days);
VENOFER
SOLN
20MG/ML
PA;
VENTOLIN HFA
AERS
108MCG/ACT
VERAPAMIL HCL
TABS
40MG
VERAPAMIL HCL
TABS
120MG
VERAPAMIL HCL
TABS
80MG
VERAPAMIL HCL ER
TBCR
180MG
VERAPAMIL HCL ER
TBCR
240MG
VERAPAMIL HCL ER
CP24
100MG
VERAPAMIL HCL ER
CP24
200MG
VERAPAMIL HCL ER
TBCR
120MG
VERAPAMIL HCL ER
CP24
180MG
VERAPAMIL HCL ER
CP24
240MG
VERAPAMIL HCL ER
CP24
120MG
VERAPAMIL HCL ER
CP24
300MG
VERAPAMIL HCL SR
CP24
360MG
VFEND
SUSR
40MG/ML
VIBRAMYCIN
SUSR
25MG/5ML
VICTOZA
SOPN
18MG/3ML
PA; QL (3.00 ML per 30 days);
VICTRELIS
CAPS
200MG
PA; QL (360.00 EA per 30 days);
(SP)
(SP)
(MB)
PA;
VIDEX PEDIATRIC
SOLR
4GM
QL (1200.00 ML per 30 days);
VIDEX PEDIATRIC
SOLR
2GM
QL (1200.00 ML per 30 days);
VIIBRYD
TABS
10MG
PA; QL (30.00 EA per 30 days);
VIIBRYD
TABS
20MG
PA; QL (30.00 EA per 30 days);
VIIBRYD
TABS
40MG
PA; QL (30.00 EA per 30 days);
VIRACEPT
TABS
250MG
QL (120.00 EA per 30 days);
VIRACEPT
TABS
625MG
QL (120.00 EA per 30 days);
VIREAD
POWD
40MG/GM
VIREAD
TABS
200MG
VIREAD
TABS
250MG
QL (30.00 EA per 30 days)
VIREAD
TABS
300MG
QL (30.00 EA per 30 days);
VIREAD
TABS
150MG
QL (30.00 EA per 30 days)
VITAMIN D
CAPS
50000UNIT
VIVELLE-DOT
PTTW
0.0375MG/24HR QL (8.00 EA per 28 days);
[MPC091374]
Note
(SP)
[Centennial Care #363]
57 of 61
February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
Drug Name
Form
Strength
Coverage Details
VIVELLE-DOT
PTTW
0.05MG/24HR
QL (8.00 EA per 28 days);
VIVELLE-DOT
PTTW
0.075MG/24HR
QL (8.00 EA per 28 days);
VIVELLE-DOT
PTTW
0.1MG/24HR
QL (8.00 EA per 28 days);
VIVELLE-DOT
PTTW
0.025MG/24HR
QL (8.00 EA per 28 days);
VIVITROL
SUSR
380MG
PA; QL (1.00 EA per 30 days);
VOL-CARE RX
TABS
60MG; 300MCG;
10MG; 6MCG;
1MG; 20MG;
10MG; 1.7MG;
1.5MG
VORICONAZOLE
TABS
50MG
PA; QL (60.00 EA per 30 days);
VORICONAZOLE
TABS
200MG
PA; QL (60.00 EA per 30 days);
VOTRIENT
TABS
200MG
PA; QL (120.00 EA per 30 days);
VYFEMLA
TABS
35MCG; 0.4MG
VYTORIN
TABS
10MG; 40MG
ST;
VYTORIN
TABS
10MG; 80MG
ST;
VYTORIN
TABS
10MG; 20MG
ST;
VYTORIN
TABS
10MG; 10MG
ST;
VYVANSE
CAPS
30MG
PA; AG (min: 6y); QL (30.00 EA per 30 days);
VYVANSE
CAPS
50MG
PA; AG (min: 6y); QL (30.00 EA per 30 days);
VYVANSE
CAPS
60MG
PA; AG (min: 6y); QL (30.00 EA per 30 days);
VYVANSE
CAPS
40MG
PA; AG (min: 6y); QL (30.00 EA per 30 days);
VYVANSE
CAPS
70MG
PA; AG (min: 6y); QL (30.00 EA per 30 days);
VYVANSE
CAPS
20MG
ST; AG (min: 6y); QL (30.00 EA per 30 days);
WARFARIN SODIUM
TABS
4MG
WARFARIN SODIUM
TABS
1MG
WARFARIN SODIUM
TABS
2.5MG
WARFARIN SODIUM
TABS
10MG
WARFARIN SODIUM
TABS
3MG
WARFARIN SODIUM
TABS
5MG
WARFARIN SODIUM
TABS
7.5MG
WARFARIN SODIUM
TABS
2MG
WARFARIN SODIUM
TABS
6MG
WELCHOL
TABS
625MG
WELCHOL
PACK
3.75GM
WESTHROID
TABS
260MG
WESTHROID
TABS
97.5MG
WESTHROID
TABS
325MG
XALKORI
CAPS
200MG
PA; QL (60.00 EA per 30 days);
(SP)
(SP)
XALKORI
CAPS
250MG
PA; QL (60.00 EA per 30 days);
XARELTO
TABS
10MG
QL (35.00 EA per 365 days)
XELJANZ
TABS
5MG
PA; QL (60.00 EA per 30 days);
XGEVA
SOLN
120MG/1.7ML
PA;
XIFAXAN
TABS
550MG
PA;
XIFAXAN
TABS
200MG
PA;
XOLAIR
SOLR
150MG
PA;
XTANDI
CAPS
40MG
PA; QL (120.00 EA per 30 days)
XYREM
SOLN
500MG/ML
YERVOY
SOLN
50MG/10ML
[MPC091374]
PA;
Note
(SP)
(SP)
(SP)
(SP)
(SP)
(SP)
(MB)
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Drug Name
Form
Strength
Coverage Details
Note
YERVOY
SOLN
200MG/40ML
PA;
(MB)
ZAFIRLUKAST
TABS
10MG
ZAFIRLUKAST
TABS
20MG
ZALEPLON
CAPS
5MG
QL (60.00 EA per 30 days);
ZALEPLON
CAPS
10MG
QL (60.00 EA per 30 days);
ZALTRAP
SOLN
100MG/4ML
PA
(MB) (SP)
PA
(MB) (SP)
ZALTRAP
SOLN
200MG/8ML
ZARAH
TABS
3MG; 0.03MG
ZELBORAF
TABS
240MG
ZENCHENT
TABS
35MCG; 0.4MG
ZETIA
TABS
10MG
ZIAGEN
SOLN
20MG/ML
QL (900.00 ML per 30 days);
ZIDOVUDINE
CAPS
100MG
QL (60.00 EA per 30 days);
ZIDOVUDINE
TABS
300MG
QL (60.00 EA per 30 days);
ZIDOVUDINE
SYRP
50MG/5ML
ZIPRASIDONE HCL
CAPS
20MG
AG (min: 6y); QL (60.00 EA per 30 days)
ZIPRASIDONE HCL
CAPS
80MG
AG (min: 6y); QL (60.00 EA per 30 days)
ZIPRASIDONE HCL
CAPS
40MG
AG (min: 6y); QL (60.00 EA per 30 days)
ZIPRASIDONE HCL
CAPS
60MG
AG (min: 6y); QL (60.00 EA per 30 days)
ZOLADEX
IMPL
3.6MG
ZOLADEX
IMPL
10.8MG
ZOLEDRONIC ACID
SOLN
5MG/100ML
PA
(MB)
ZOLEDRONIC ACID
CONC
4MG/5ML
PA
(MB)
ZOLINZA
CAPS
100MG
PA; QL (120.00 EA per 30 days);
ZOLPIDEM TARTRATE
TABS
5MG
QL (30.00 EA per 30 days);
ZOLPIDEM TARTRATE
TABS
10MG
QL (30.00 EA per 30 days);
ZOLPIDEM TARTRATE ER
TBCR
6.25MG
PA; QL (30.00 EA per 30 days);
ZOLPIDEM TARTRATE ER
TBCR
12.5MG
PA; QL (30.00 EA per 30 days);
ZONISAMIDE
CAPS
50MG
ZONISAMIDE
CAPS
25MG
ZONISAMIDE
CAPS
100MG
ZORTRESS
TABS
0.75MG
PA
ZORTRESS
TABS
0.5MG
PA
ZORTRESS
TABS
0.25MG
PA
ZOSTAVAX
SOLR
ZOVIA 1/35E
TABS
19400UNT/0.65 AG (min: 60y);
ML
35MCG; 1MG
ZOVIA 1/50E
TABS
50MCG; 1MG
ZOVIRAX
CREA
5%
ZOVIRAX
OINT
5%
QL (30.00 GM per 30 days);
ZYDELIG
TABS
100MG
PA; QL (60.00 EA per 30 days)
ZYDELIG
TABS
150MG
PA; QL (60.00 EA per 30 days)
ZYKADIA
CAPS
150MG
PA; QL (150.00 EA per 30 days);
ZYTIGA
TABS
250MG
PA; QL (120.00 EA per 30 days);
ZYVOX
TABS
600MG
PA;
ZYVOX
SUSR
100MG/5ML
PA;
PA; QL (240.00 EA per 30 days);
(SP)
(SP)
(SP)
Please see following page for disclaimer and explanation of terms.
[MPC091374]
[Centennial Care #363]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
DISCLAIMER
The Centennial Care Preferred Drug List (also called a formulary) may change at any
time. Please visit our website for the most up-to-date list: www.phs.org/centennialcare.
You can also contact the Presbyterian Customer Service Center 7 days a week, 24
hours a day.
Phone: (505) 923-5200/Toll-free: 1-888-977-2333
TTY: 1-800-659-8331
Email: [email protected]
Phone (Navajo/Diné): (505) 923-5157/Toll-free (Navajo/Diné): 1-888-806-8793
This is not a full list. It does not give a promise of coverage (payment by your
insurance). Also, coverage for some drugs listed may be only for certain dosage forms
and/or strengths. You may switch from a brand-name drug to a generic drug only when
the generic drug is the same dosage and/or strength as the brand-name drug. Drugs
that are not in the formulary will not be covered unless you have tried all of the
formulary drugs first and your doctor has written that they do not work.
Explanation of Terms:
1. Age Limit (AG) – The member must be a certain age for the drug to be covered.
2. Medical Drugs (MED) – Drugs you get through the medical benefit. Medical
Drugs are drugs that a healthcare provider gives you in an office or facility. These
drugs may be given as a shot or IV (put into your veins). They may also be taken
by mouth, inhaled, or any other way the provider sees fit. You may have to get
them from a specialty pharmacy vendor. Some Medical Drugs may need Prior
Authorization before you can get them. (See #3 below.) “Given in the office”
means the drug can be given in all outpatient settings. This includes doctor’s
offices, emergency rooms, urgent care clinics, outpatient surgery centers, or any
other type of outpatient setting. For a full list of Medical Drugs and to find out
which need Prior Authorization, please see the Presbyterian Pharmacy website:
www.phs.org/centennialcare.
3. Prior Authorization (PA) – You or your doctor must get permission (an OK)
from Presbyterian Centennial Care before you fill your drug prescription. If you
don’t get Prior Authorization, Presbyterian Centennial Care may not pay for the
drug. You or your doctor can ask for permission by fax, phone, or email.
4. Quantity Limit (QL) – A limit to the amount of drug Presbyterian Centennial
Care will pay for in a period of time.
5. Specialty (SP) – Specialty drugs are high-cost (more than $600 for a 30-day
supply), injectable, infused (put into your veins), oral (taken by mouth), or inhaled
(breathed in) drugs. They often must have special care and supervision.
Specialty drugs have a special delivery process. You usually get them from a
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Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.
specialty pharmacy vendor. Specialty drugs are self-administered. This means
that the member can give it to himself or a caregiver or family member can give it
to him. Even if you have Prior Authorization (permission) for a non-formulary
drug, there still may be rules for specialty pharmacy.
6. Step Edit (ST) – You must first try certain drugs to treat a medical health
problem before a different drug will be covered for the same health problem. For
example, if Drug A and Drug B both treat your medical health problem,
Presbyterian Centennial Care may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, the plan may then cover Drug B.
7. Pharmacy Exception – Permission to use a drug that is not on the Presbyterian
Centennial Care Formulary. You may get an Exception to use a non-formulary
drug if you have any allergy or bad reaction to all of the formulary drugs or if the
formulary drugs do not work.
8. Over-the-Counter (OTC) – You must have a doctor’s prescription for these
drugs to be covered. Note: Listed OTC drugs for Alternative Benefit Package
recipients are covered only for members age 19 and 20.
[MPC091374]
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February 1, 2015
Services are funded in part under contract with the State of New Mexico.
Presbyterian exists to improve the health of the patients, members, and communities we serve.

Sample Evaluation of Medicine for the Year 2014-15

Formulary List 2015

CHLORELLA GENERAL COMPOSITION

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Laboratory

A nnounced A nnounced