EXHIBIT 10.12
THIS NOTE IS SUBJECT TO THE SUBORDINATION AGREEMENT, DATED MARCH 29, 2002, BY
AND AMONG APS HEALTHCARE BETHESDA, INC., CC HOLDINGS, LLC, INNOVATIVE RESOURCE
GROUP, LLC, CAPITALSOURCE FINANCE LLC AND CANPARTNERS INVESTMENTS IV, LLC, UNDER
WHICH THIS NOTE AND APS HEALTHCARE BETHESDA, INC.'S OBLIGATIONS HEREUNDER ARE
SUBORDINATED IN THE MANNER SET FORTH THEREIN TO THE PRIOR INDEFEASIBLE PAYMENT
OF CERTAIN OBLIGATIONS OWING BY APS HEALTHCARE BETHESDA, INC. TO THE HOLDERS OF
SENIOR INDEBTEDNESS AS DEFINED THEREIN.
$10,000,000
Milwaukee, Wisconsin
March 29, 2002
SUBORDINATED PROMISSORY NOTE
APS Healthcare Bethesda, Inc., an Iowa corporation ("Payor"), for value
received, promises to pay to the order of CC Holdings, LLC, a Wisconsin limited
liability company ("Payee"), the principal sum of Ten Million Dollars
($10,000,000.00), with interest as herein provided, payable in three equal
annual installments of interest on the first (1st), second (2nd) and third (3rd)
anniversaries of the date of issuance of this Note indicated above, plus one
installment of principal and interest on June 30, 2005; PROVIDED HOWEVER, in the
event of a closing of a Qualified IPO (as defined below in Section 10), then all
amounts due hereunder shall become immediately due and payable on the third
(3rd) business day after the closing of such Qualified IPO (subject to the terms
of the Subordination Agreement). Payment of interest due shall be made annually
on each anniversary date (or the first business day thereafter, if the
anniversary date falls on a day on which banks in Milwaukee, Wisconsin are
authorized or required to be closed) while any principal balance is outstanding.
All amounts due shall be paid and delivered to Payee at its corporate offices,
00000 Xxxxxxxxx Xxxx, Xxxxx 000, Xxxxxxxx, Xxxxxxxxx 00000, or to such other
address as Payee shall from time to time direct Payor in writing. Payments shall
be made in lawful money of the United States of America and shall be credited
only when received in available funds by Payee. Payment by check shall
constitute payment only when the amount paid has been collected.
1. INTEREST. Interest shall accrue on the unpaid principal amount
hereof at the rate which is three and one-half percent (3.5%) per annum above
the per annum rate of interest announced from time to time by Bank of America,
N.A. or its successor as its "prime" rate, such rate of interest under this Note
changing when and as such prime rate changes. Such rate of interest shall be
calculated on the basis of a three hundred sixty-five (365) day year and the
number of days elapsed in any period.
2. PREPAYMENT. Payor may prepay all or any portion of the principal
amount of this Note at any time AND from time to time, without premium or
penalty.
1
3. DEFAULT. The entire unpaid principal amount of this Note and all
accrued and unpaid interest thereon shall immediately be due and payable if any
of the following events occur (each, an "Event of Default"):
(a) Payor shall fail to pay when due any amount due under this Note.
(b) There shall occur with respect to Payor, any direct or indirect
parent corporation of Payor (each a "Parent"), or Innovative
Resource Group, LLC, a Wisconsin limited liability company
("IRG"), any "Insolvency Event" as defined below in Section 10.
(c) Payor, any Parent or IRG shall take any steps, including any
action by the board of directors or shareholders of Payor, such
Parent or IRG to such end: (i) to dissolve or liquidate its
business, or (ii) to merge with or into or to consolidate with or
into any other corporation or entity except a merger of IRG into
any Parent or into Payor (and such Parent or Payor is the
surviving entity) or any merger of a Parent into another Parent,
or (iii) to sell, lease, transfer or otherwise dispose of all or
substantially all of its property, assets or business, or (iv) to
sell all or any substantial portion of the stock or other equity
interests in IRG, Payor or any Parent, other than as a result of
a Qualifying IPO.
(d) Any transaction shall be consummated the result of which is that
any "person" (as such term is used in Section 13(d)(3) of the
Securities Exchange Act of 1934 and the regulations promulgated
thereunder (the "Exchange Act")) becomes the "beneficial owner"
(as such term is defined in Rule 13d-3 and Rule 13d-5 under the
Exchange Act, except that a person shall be deemed to have
"beneficial ownership" of all securities that such person has the
right to acquire, whether such right is currently exercisable or
is exercisable only upon the occurrence of a subsequent
condition), directly or indirectly of more than 50% of the voting
stock of APS Healthcare, Inc., a Delaware corporation ("APS
Healthcare") (measured by voting power rather than number of
shares), other than as a result of a Qualifying IPO.
(e) Any representation or warranty under Section 3 of the Purchase
and Sale Agreement (defined below) related to this Note as an
"Ancillary Instrument" (as defined in the Purchase and Sale
Agreement), shall be untrue in any material respect when made,
including on the date hereof and on the Closing Date (as defined
in the Purchase and Sale Agreement).
4. DEFAULT INTEREST RATE. Upon the occurrence and from the date of
an Event of Default, all sums due under this Note shall bear interest at a rate
which is two percent (2%) per annum in excess of the rate that would otherwise
be applicable to the outstanding principal balance hereof.
2
5. WAIVERS. Payor waives demand for payment, notice of nonpayment,
presentment, notice of dishonor, protest and notice of payment. If Payor fails
to make any payment or payments required by this Note to be made by it, Payor
shall pay all the costs of collection (including reasonable attorneys' fees)
thereupon incurred by Payee. Failure by Payee to assert any right contained in
this Note, or any delay in asserting any such right, shall not constitute a
waiver of such right.
6. ACKNOWLEDGEMENT OF BUSINESS PURPOSES; CHOICE OF LAW. Payor hereby
represents and warrants to Payee that this Note has been entered into by Payor
solely for business purposes and that Payor is not entitled to the benefits of
any usury or similar provisions of law. This Note shall be governed by and
construed in accordance with the laws of the State of Wisconsin, without
reference to principles of conflict of laws.
7. MISCELLANEOUS. If any provision of this Note is held to be void
or unenforceable, such provision at the option of Payee shall be deemed omitted
and this Note, with such provision omitted, shall remain in full force and
effect. All notices, requests, demands and other communications required or
permitted to be given under this Note shall be in writing and shall be deemed
duly given when given in accordance with Section 11.9 of the Purchase and Sale
Agreement. Payee may freely transfer and assign all or any part of its interests
under this Note as long as prior to any such transfer or assignment the assignee
executes and delivers to the Senior Lenders an agreement satisfactory to Senior
Lenders that the assignee takes this Note subject to the terms and provisions of
the Subordination Agreements. Payor may not assign its obligations under this
Note. This Note may not be modified, amended, waived, extended, changed,
discharged or terminated orally or by any act or failure to act on the part of
Payor or Payee, but only by an agreement in writing signed by the party against
whom enforcement of any modification, amendment, waiver, extension, change,
discharge or termination is sought. This Note, the Subordination Agreement and
the Purchase and Sale Agreement contain the entire agreement between Payor and
Payee with respect to the subject matter hereof, superseding all previous
communications and negotiations, and no representation, undertaking, promise or
condition concerning the subject matter hereof shall be binding upon Payee
unless clearly expressed in this Note or the Purchase and Sale Agreement. The
provisions of this Note shall inure to the benefit of Payee and its successors
and assigns and shall be binding upon Payor its successors.
8. PURCHASE AND SALE AGREEMENT. This Note is issued under and
pursuant to the terms of that certain Purchase and Sale Agreement, dated as of
March 29, 2002, among Payee (and certain of its affiliates) and Payor (the
"Purchase and Sale Agreement"), and reference is made to the Purchase and Sale
Agreement for a more complete statement of certain of the rights and obligations
of Payor and Payee with respect to the acquisition by Payor of the membership
interests held by Payee in IRG.
9. SUBORDINATION. This Note is subject to the terms and provisions
of the Subordination Agreement under which, among other things, this Note and
the Payor's obligations hereunder are subordinated in the manner set forth
therein to the prior indefeasible payment of certain obligations owing by Payor
to the holders of Senior Indebtedness as defined therein.
3
10. DEFINITIONS. As used in this Note, the term:
"CANPARTNERS" means CanPartners Investments IV, LLC, a California limited
liability company.
"CAPITALSOURCE" means CapitalSource Finance LLC, a Delaware limited
liability company.
"CAPITALSOURCE CREDIT AGREEMENT" means the Amended and Restated Credit
Agreement (Term Loan) dated as of July 23, 2001 between APS Healthcare Holdings
and CapitalSource, as amended, restated, supplemented or otherwise modified from
time to time.
"INSOLVENCY EVENT" means the occurrence of any of the following: any
receivership, conservatorship, general meeting of creditors, insolvency or
bankruptcy proceeding, assignment for the benefit of creditors, or any
proceeding or action by or against Payor, any Parent or IRG for any relief under
any bankruptcy or insolvency law or other laws relating to the relief of
debtors, readjustment of indebtedness, reorganizations, dissolution,
liquidation, compositions or extensions, or the appointment of any receiver,
intervenor or conservator of or trustee, or similar officer for, Payor, any
Parent or IRG or any substantial part of its properties or assets, including,
without limitation, proceedings under the United States Bankruptcy Code, or
under federal, state or local statutes, laws, rules and regulations, all whether
now or hereafter in effect, or Payor, any Parent or IRG shall be or become
insolvent, or shall admit in writing its inability to pay its debts as they come
do.
"Senior Lenders" means CapitalSource and CanPartners, and their respective
successors and assigns.
"SUBORDINATION AGREEMENT" means that certain Subordination Agreement dated
March 29, 2002 by and among CapitalSource, CanPartners, IRG, Payee and Payor, as
may be amended, modified or restated from time to time.
"QUALIFIED IPO" means an underwritten public offering, pursuant to an
effective registration statement under the Securities Act of 1933, as amended
and under other applicable securities laws and regulations covering the offer
and sale of capital stock, by APS Healthcare, Inc., a Delaware corporation,
which generates a minimum of $30,000,000 of gross proceeds, and as to which
offering CapitalSource has not, prior to effectiveness of such offering,
indicated CapitalSource's reasonable objection.
11. CONSENT TO JURISDICTION; WAIVER OF JURY TRIAL. PAYOR HEREBY
CONSENTS TO THE JURISDICTION OF ANY STATE OR FEDERAL COURT SITUATED IN THE STATE
OF WISCONSIN AND WAIVES ANY OBJECTION BASED ON LACK OF PERSONAL JURISDICTION,
IMPROPER VENUE OR FORUM NON CONVENIENS, WITH REGARD TO ANY ACTIONS, CLAIMS,
DISPUTES OR PROCEEDINGS RELATING TO THIS NOTE. PAYOR WAIVES PERSONAL SERVICE OF
ANY AND ALL PROCESS, AND CONSENTS TO ALL SUCH SERVICE OF PROCESS MADE BY MAIL OR
BY MESSENGER TO THE ADDRESS SPECIFIED IN THE PURCHASE AND SALE AGREEMENT. PAYOR
HEREBY WAIVES ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY ACTION
4
OR PROCEEDING RELATING TO THIS NOTE. PAYOR REPRESENTS THAT THIS WAIVER IS
KNOWINGLY, WILLINGLY AND VOLUNTARILY GIVEN.
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
5
IN WITNESS WHEREOF, Payor has caused this Note to be executed by its
duly authorized officer on and as of the day first above written.
APS Healthcare Bethesda, Inc.
By: /s/ Xxxx X. Xxxxxx
------------------------
Xxxx X. Xxxxxx
------------------------
Print Name
President
------------------------
Title
0
XXXXXXXXXXXXXXXX XX XXXXXXX XX SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
ADDENDUM 1
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
# Class Restriction Product by category Comments
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
1 AD000 ANTIDOTES/DETERRENTS/POISON CONTROL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
2 AD100 ALCOHOL DETERRENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
3 AD100 PA DISULFRAM ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
4
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
5 AD400 ANTIDOTES/DETERRENTS/POISON CONTROL EXCHANGE RESINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
6 AD400 SODIUM POLYSTYRENE SULFONATE PWDR
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
7 AD400 SODIUM POLYSTYRENE SULFONATE RTL SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
8 AD400 SODIUM POLYSTYRENE SULFONATE SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
9
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
10 AH000 ANTIHISTAMINES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
11 AH100 PROMETHAZINE HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
12 AH100 PROMETHAZINE HCL RTL SUPP Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
13 AH109 DIPHENHYDRAMINE 50MG
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
14 AH500 HYDROXYZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
15 AH900 CETTRIZINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
16
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
17 AH900 ONE OF THE FOLLOWING NON-SEDATING ANTIHISTAMINES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
18 FEXOFENADINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
19 LORATADINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
20
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
21 AM000 ANTIMICROBIALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
22 AM050 ANTIMICROBIALS, PENICILLINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
23 AM051 PA PENICILLIN G BENZATHINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
24 AM051 PA PENICILLIN G PROCAINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
25 AM051 PENICILLIN VK ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
26 AM052 AMOXICILLIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
27 AM052 AMOXICILLIN/CLAVULANATE K ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
28 AM052 AMPICILLIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
29 AM100 CEPHALOSPORINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
30 AM101 ONE OF THE FOLLOWING FIRST GENERATION CEPHALOSPORINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
31 CEPHALEXIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
32 CEPHRADINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
33 CEFADROXIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
34
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
35 AM102 ONE OF THE FOLLOWING SECOND GENERATION CEPHALOSPORINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
36 CEPHACLOR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
37 CEFPODOXIME PROXETIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
38 CEFUROXIME AXETIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
39 LORACARBEF
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
40
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
41 AM103 THIRD GENERATION CEPHALOSPORIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
42 AM103 CEFIXIME ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
43
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
44 AM200 ERYTHROMYCIN/MACROLIDES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
45 AM200 AZITHROMYCIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
46 AM200 CLARITHROMYCIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
47 AM200 ERYTHROMYCIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
48 AM200 ERYTHROMYCIN/SULFA
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
49
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
50 AM250 TETRACYCLINES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
51 AM250 DEMECLOCYCLINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
52
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
53 AM250 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
54 DOXYCYCLINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
55 MINOCYCLINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
56 TETRACYCLINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
57
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
58 AM300 AMINOCLYCOSIDES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
59 AM300 SC STREPTOMYCIN SULFATE INJ
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
60 PA TOBRAMYCIN INH
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
61 AM350 LINCOMYCINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
62 AM350 CLINDAMYCIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
63 AM350 CLINDAMYCIN PALMITATE ORAL SOLH
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
64
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
65 AM500 ANTITUBERCULARS
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
66 AM500 SC CAPREOMYCIN INJ
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
67 AM500 SC CYCLOSERINE ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
68 AM500 SC ETHAMBUTOL HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
(TUBERCULOSIS) Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
69 AM500 SC ETHIONAMIDE ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
70 AM500 SC ISONIAZID ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
71 AM500 SC ISONIAZID/RIFAMPIN ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
72 AM500 SC PYRAZINAMIDE ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
73 AM500 SC RIFABUTIN ORAL
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
74 AM500 SC RIFABUTIN
(TUBERCULOSIS)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
75
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
76 AM600 NITROFURANS ANTIMICROBIALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
77 AM600 NITROFURANTOIN MACROCRYSTAL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
78
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
79 AM650 SULFONAMIDE/RELATED ANTIMICROBIALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
80 AM650 SULFADIAZINE ORAL OR TRIPLE SULFA
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
81 AM650 SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
82
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
83 AM700 ANTIFUNGALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
84 AM700 FLUCONAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
85 AM700 GRISEOFULVIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
86 AM700 PA ITRACONAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
87 AM700 PA KETOCONAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
88 AM700 NYSTATIN SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
89 AM700 PA TERBINAFINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
90 AM700 CLOTRIMAZOLE XXXXXX
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
91
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
92 AM800 ANTIVIRALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
93 AM800 SC(HIV) ABACAVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
94 AM800 SC(HIV) ACYCLOVIR ORAL PA for herpes related infections
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
95 AM800 SC(HIV) AMANTADINE HCL ORAL Refer to Non-Bioequivalent Formulatory, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
96 AM800 SC(HIV) CIDOFOVIR INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
97 AM800 SC(HIV) DELAVIRDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
98 AM800 SC(HIV) DIDANOSINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
99 AM800 SC(HIV) EFAVIRENZ ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
100 AM800 SC(HIV) FAMCICLOVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
101 AM800 SC(HIV) FOSCARNET SODIUM INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
102 AM800 SC(HIV) GANCICLOVIR INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
103 AM800 SC(HIV) GANCICLOVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
104 AM800 SC(HIV) LAMIVUDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
105 AM800 SC(HIV) LAMIVUDINE/ZIDOVUDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
106 AM800 SC(HIV) NEVIRAPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
107 AM800 SC(HIV) RIMANTADINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
108 AM800 SC(HIV) STAVUDINE (44T) ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
109 AM800 SC(HIV) VALACYCLOVIR ORAL PA for herpes related infections
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
110 AM800 SC(HIV) VIDARABINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
111 AM800 SC(HIV) ZALCITABINE (JJC) ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
112 AM800 SC(HIV) ZIDOVUDINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
113 AM800 SC(HIV) ZIDOVUDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
114 AM800 THE FOLLOWING PROTEASE INHIBITORS ARE COVERED ONLY
THROUGH PASET (PUERTO RICO DEPARTMENT OF HEALTH)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
115 AMPRENAVIR
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
116 INDINAVIR SO4 ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
117 NELFINAVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
118 RITONAVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
119 SAQUINAVIR ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
120
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
121 AM800 PA PALIVIZUMAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
122
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
123 AM900 ANTI-INFECTIVES, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
124 AM900 CIRPOFLOXACIN HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
125
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
126 AM900 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
127 OFLOXACIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
128 LEVOFLOXACIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
129 LOMEFLOXACIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
130
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
131 AM900 SC(LEPROSY) CLOFAZIMINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
132 AM900 SC(LEPROSY) DAPSONE ORAL
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
133 AM900 METRONIDAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
134 AM900 PA VANCOMYCIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
135
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
136 AN000 ANTINEOPLASTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
137 AN100 SC(CANCER) BUSULFAN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
138 AN100 SC(CANCER) BUSULFAN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
139 AN100 SC(CANCER) CARMUSTINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
140 AN100 SC(CANCER) CHLORAMBUCIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
141 AN100 SC(CANCER) CYCLOPHOSPHAMIDE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
142 AN100 SC(CANCER) CYCLOPHOSPHAMIDE ORAL PA for systemic herpes [ILLEGIBLE]
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
143 AN100 SC(CANCER) IFOSFAMIDE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
144 AN100 SC(CANCER) IFOSFAMIDE/MESNA INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
145 AN100 SC(CANCER) LOMUSTINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
146 AN100 SC(CANCER) MECHLORETHAMINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
147 AN100 SC(CANCER) MELPHALAN HCL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
148 AN100 SC(CANCER) MELPHALAN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
149 AN100 SC(CANCER) THIOTEPA INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
150 AN100 SC(CANCER) URACIL MUSTARD ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
151 AN200 SC(CANCER) BLEOMYCIN SO4 INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
152 AN200 SC(CANCER) DACTINOMYCIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
153 AN200 SC(CANCER) DAUNORUBICIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
154 AN200 SC(CANCER) DOXORUBICIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
155 AN200 SC(CANCER) IDARUBICIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
156 AN200 SC(CANCER) MITOMYCIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
157 AN200 SC(CANCER) PLICAMYCIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
158 AN200 SC(CANCER) STREPTOZOCIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
159 AN300 SC(CANCER) CLADRIBINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
160 AN300 SC(CANCER) CYTARABINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
161 AN300 SC(CANCER) FLUDARABINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
162 AN300 SC(CANCER) FLUOROURACIL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
163 AN300 SC(CANCER) HYDROXYUREA ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
164 AN300 SC(CANCER) MERCAPTOPURINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
165 AN300 SC(CANCER) METHOTREXATENA INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
166 AN300 SC(CANCER) METHOTREXATENA ORAL PA for rheumatoid arthritis
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
167 AN300 SC(CANCER) THIOGUANINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
168 AN400 SC(CANCER) LEVAMISOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
169 AN500 SC(CANCER), PA GOSERELIN ACETATE IMPLANT SYRINGE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
170 AN500 SC(CANCER), PA LEUPROLIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
171 AN500 SC(CANCER) TAMOXIFEN CITRATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
172 AN500 SC(CANCER) TESTOLACTONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
173 AN700 SC(CANCER), PA DEXRAZOXANE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
174 AN900 SC(CANCER) ASPARAGINASE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
175 AN900 SC(CANCER) BCQTICE VACCINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
176 AN900 SC(CANCER) CARBOPLATIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
177 AN900 SC(CANCER) CISPLATIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
178 AN900 SC(CANCER) DACARBAZINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
179 AN900 SC(CANCER) ESTRAMUSTINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
180 AN900 SC(CANCER) ETOPOSIDE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
181 AN900 SC(CANCER) ETOPOSIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
182 AN900 SC(CANCER), PA GEMCITABINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
183 AN900 SC(CANCER), PA IRINOTECAN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
184 AN900 SC(CANCER) MITOTANE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
185 AN900 SC(CANCER) MITOXANTRONE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
186 AN900 SC(CANCER) PACLITAXEL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
187 AN900 SC(CANCER), PA PENTOSTATIN/MANHITOL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
188 AN900 SC(CANCER) PROCARBAZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
189 AN900 SC(CANCER) TENIPOSIDE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
190 AN900 SC(CANCER) VINBLASTINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
191 AN900 SC(CANCER) VINCRISTINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
192 AN900 SC(CANCER) VINORELBINE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
193 AN900 SC(CANCER), PA ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
194 FLUTAMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
195 NILUTAMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
196 BICALUTAMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
197
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
198
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
199 AP000 ANTIPARASITICS
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
200 AP101 HYDROXYCHLOROQUINE SULFATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
201 AP101 PRIMAQUINE PHOSPHATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
202 AP101 PYRIMETHAMINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
203 AP101 CHLOROQUINE SULFATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
204 AP101 QUININE SULFATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
205 AP101 IODOQUINOL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
206 AP101 QUINACRINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
207 AP101 MEFLOQUINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
208 AP101 SC(HIV) SULFADOXIME/PYRIMETHAMINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
209 AP109 SC(HIV) ATOVAQUONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
210 AP109 SC(HIV) PENTAMIDINE ISETHIONATE +C 106 SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
211 AP109 FURAZOLIDONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
212 AP200 ALBENDAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
213 AP200 MEBENDAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
214 AP200 THIABENDAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
215 AP300 LINDANE CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
216 AP300 LINDANE LOTION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
217 AP300 LINDANE SHAMPOO
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
218
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
219 AU000 AUTONOMIC MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
220 AU300 METOCLOPRAMIDE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
221 AU300 NEOSTIGMINE BROMIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
222 AU300 PYRIDOSTIGMINE BROMIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
223 AU300 MENZTROPINE MESYLATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
224 AU300 DICYCLOMINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
225 AU300 PROPANTHELINE BR ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
226
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
227 AU350 TRIHEXYPHENDYL HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
228 AU900 BROMOCRIPTINE MESYLATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
229
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
230 BL000 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
231 BL100 PA DALTEPARIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
232 BL100 PA ENOXAPARIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
233 BL100 WARFARIN NA ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
234 BL400 PA EPEOTIN ALFA RECOMBINANT INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
235 BL400 PA FILGASTIM INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
236 BL400 PA SARGRAMOSTIM INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
237 BL600 PA ANTHEMOPHILIC FACTOR, HUMAN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
238 BL600 PA FACTOR IX COMPLEX, HUMAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
239 BL700 PA TICLOPIDINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
240 BL700 PA DIPYRIDAMOLE/ASPIRIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
241 BL700 PA CLOPIDROGEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
242 BL900 PENTOXIPHYLLINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
243
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
244 CN000 CENTRAL NERVOUS SYSTEM AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
245 CN101 OPIOID ANALGESICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
246 CN101 CODEINE SO4 ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
247 CN101 CODEINE/ACETAMINOPHEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
248 CN101 PA FENTANYL PATCH
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
249 CN101 HYDROCODONE/ACETAMINOPHEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
250 CN101 MEPERIDINE HCL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
251 CN101 PA(ASSMCA) METHADONE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
252 CN101 MORPHINE SO4 ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
253 CN101 MORPHINE SO4 RTL SUPP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
254 CN101 OXYCODONE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
255 CN101 OXYCODONE HCL/ACETAMINOPHEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
256 CN101 PROPOXYPHENE/ACETAMINOPHEN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
257 CN103 APAP/BUTALBITAL/CAFN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
258 CN105 CAFFEINE/ERGOTAMINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
259
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
260 CN105 ANTIMIGRAINE AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
261 CN105 ONE OF THE FOLLOWING TRIPRANES:
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
262 NARATRIPTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
263 RIZATRIPTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
264 SUMATRIPTAN SUCCINATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
265 ZOLMITRIPTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
266
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
267 CN300 SEDATIVES/HYPNOTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
268 CN301 BARBITURIC ACID DERIVATIVE SEDATIVE HYPNOTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
269 CN301 PHENOBARBITAL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
270
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
271 CN302 BENZODIAZEPINE DERIVATIVE SEDATIVE HYPNOTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
272 CN302 ALPRAZOLAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
273 CN302 AHLORDIAZEMOXIDE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
274 CN302 DIAZEPAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
275 CN302 FLURAZEPAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
276 CN302 LORAZEPAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
277 CN302 PA MIDAZOLAM HCL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
278 CN302 OXAZEPAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
279 CN302 TEMAZEPAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
280
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
281 CN309 SEDATIVES/HYPNOTICS OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
282 CN309 PA BUSPIRONE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
283 CN309 CHLORAL HYDRATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
284
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
285 CN400 ANTICONVULSANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
286 CN400 CARBAMAZEPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
287 CN400 CLONAZEPAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
288 CN400 DIVALPROEX NA ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
289 CN400 ETHOSUXIMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
290 CN400 GABAPENTIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
291
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
292 CN400 LAMOTRIGINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
293 CN400 PHENYTOIN ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
294 CN400 PRIMIDONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
295 CN400 VALPROIC ACID ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
296
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
297 CN500 ANTIPARKINSON AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
298 CN500 CARBIDOPA/LEVODOPA SA TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
299 CN500 CARBIDOPA/LEVODOPA ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
300 CN500 PA PRAMIPEXOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
301 CN500 SELEGILINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
302
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
303 CN600 ANTIDEPRESSANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
304 CN601 TRICYCLIC ANTIDEPRESSANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
305 CN601 AMITRIPTYILINE HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
306 CN601 CLOMIPRAMINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
307 CN601 DESIPRAMINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
308 CN601 DOXEPIN HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
309 CN601 IMIPRAMINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
310 CN601 NORTRIPTYLINE HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
311
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
312 CN609 ANTIDEPRESSANTS OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
313 CN609 PA BUPROPION HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
314 CN609 PA THREE OF THE FOLLOWING THIRD GENERATION
ANTIDEPRESSANTS WITH PRIOR AUTHORIZATION:
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
315 CITALOPRAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
316 FLUOXETINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
317 NEFAZODONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
318 PAROXETINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
319 SERTRALINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
320 TRAZODONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
321 VENLAFAXINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
322
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
323 CN700 ANTIPSYCHOTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
324 CN701 PHENOTHLAZINES/RELATED ANTIPSYCHOTICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
325 CN701 CHLORPROMAZINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
326 CN701 CHLORPROMAZINE SUPP RTL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
327 CN701 FLUPHENAZINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
328 CN701 FLUPHENAZINE DECAONATE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
329 CN701 PERPHENAZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
330 CN701 THIORIDAZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
331 CN701 THIOTHIXENE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
332 CN701 TRIFLUOPERAZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
333
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
334 CN709 ANTIPSYCHOTICS OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
335 CN709 PA CLOZAPINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
336 CN709 HALOPERIDOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
337 CN709 HALOPERIDOL DECAONATE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
338 CN709 PA OLANZAPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
339 CN709 PA RISPERIDONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
340
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
341 CN750 LITHIUM SALTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
342 CN750 LITHIUM CARBONATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
343 CN750 LITHIUM CITRATE SYRUP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
344
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
345 CN800 CNS STIMULANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
346 CN802 AMPHETAMINE-LIKE STIMULANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
347 CN802 METHYLPHENIDATE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
348
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
349 CN900 CNS MEDICATIONS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
350 CN900 PA DONEPEZIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
351 CN900 ERGOLOID MESYLATES ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
352 CN900 PA TACRINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
353
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
354 CV000 CARDIOVASCULAR MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
355 CV050 DIGITALIS GLYCOSIDES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
356 CV050 DIGOXIN ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
357
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
358 CV100 BETA-BLOCKERS/RELATED
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
359 CV100 ATENOLOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
360 CV100 CARVEDILOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
361 CV100 METOPROLOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
362 CV100 PROPRANOLOL HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
363
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
364 CV150 ALPHA-BLOCKERS/RELATED: ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
365 DOXAZOSIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
366 TERAZOSIN HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
367
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
368 CV200 CALCIUM CHANNEL BLOCKERS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
369 CV200 DILTIAZEM HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
370 CV200 VERAPAMIL HCL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
371
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
372 CV200 TWO OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
373 AMLODIPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
374 FELODIPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
375 ISRADIPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
376 NICARDIPINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
377 NIFEDIPINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
378
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
379 CV250 ANTIANGINALS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
380 CV250 ISOSORBIDE DINITRATE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
381 CV250 NITROGLYCERINE PATCH
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
382 CV250 NITROGLYCERIN TOP OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
383 CV250 NITROGLYCERIN SL TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
384
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
385 CV300 ANTIARRHYTHMICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
386 CV300 PA AMIODARONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
387 CV300 PROCAINAMIDE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
388 CV300 QUINIDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
389 CV300 PA FLECAINIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
390 CV300 PA MEXILITINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
391 CV300 PA MORICIZINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
392 CV300 PA PROPAFENONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
393 CV300 PA TOCAINIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
394 CV300 PA ENCAINIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
395
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
396 CV350 ANTILIPEMIC AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
397 CV350 ONE OF THE FOLLOWING TWO
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
398 COLESTIPOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
399 CHOLESTYRAMINE RESIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
400
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
401 CV350 GEMFRBROZIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
402 CV350 NIACIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
403
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
404 CV350 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
405 CV350 ATORVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
406 CERIVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
407 FLUVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
408 LOVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
409 PRAVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
410 SIMVASTATIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
411
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
412 CV400 ANTIHYPERTENSIVE COMBINATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
413 ANTIHYPERTENSIVES, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
414 CV450 PA CLONIDINE PATCH
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
415 CV450 CLONIDINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
416 CV450 HYDRALAZINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
417 CV450 METHYLDOPA ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
418 CV450 MONOXIDIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
419
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
420 CV700 DIURETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
421 CV701 THIAZIDES/RELATED DIURETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
422 CV701 METOLAZONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
423 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
424 CV701 CHLORTHALIDONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
425 CV701 HYDROCHLOROTHIAZIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
426 CV701 CHLOROTHIAZIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
427 CV701 METHICHLOTHIAZIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
428
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
429 CV702 LOOP DIURETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
430 CV702 FUROSEMIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
431
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
432 CV703 CARBONIC ANHYDRASE INHIBITORS DIURETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
433 CV703 ACETAZOLAMIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
434
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
435 CV704 POTASSIUM SPARING/COMBINATION DIURETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
436 CV704 HYDROCHLOROTHYAZIDE/TRIAMTERENE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
437 CV704 SPIRONOLACTONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
438
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
439 CV800 ACE INHIBITORS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
440 CV800 CAPTOPRIL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
441
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
442 CV800 TWO OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
443 ENALAPRIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
444 FOSINOPRIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
445 LISINOPRIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
446 QUINAPRIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
447 RAMIPRIL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
448
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
449 CV805 ANGIOTENSIN II INHIBITORS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
450 CV805 PA ONE OF THE FOLLOWING WITH PRIOR AUTHORIZATION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
451 CANDESARTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
452 IRBESARTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
453 LOSARTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
454 TELMISARTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
455 VALSARTAN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
456
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
457 DE000 DERMATOLOGICAL AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
458 DE101 ANTIBACTERIAL TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
459 DE101 GENTAMICIN SULFATE CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
460 DE101 METRONIDAZOLE TOP GEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
461 DE101 PA MUPIROCIN OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
462 DE101 SILVER SULFADIAZINE CREAM Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
463
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
464 DE102 ANTIFUNGAL TOPICAL (ONLY LEGEND DOSAGE FORMS ARE
COVERED)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
465 DE102 CLOTRIMAZOLE 1% LOTION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
466 DE102 CLOTRIMAZOLE 1% TOP CREAM Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
467 DE102 CLOTRIMAZOLE 1% TOP SOLN
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
468 DE102 KETOCONAZOLE 2% CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
469 DE102 MICONAZOLE NITRATE 2% TOP PWDR
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
470 DE102 MICONAZOLE NITRATE 2% TOP TINCTURE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
471 DE102 NYSTATIN 1000 COUNT AGM TOP OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
472 DE102 TERBINAFINE HCL 1% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
473
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
474 DE200 ANTI-INFLAMMATORY, TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
475 DE200 ONE OF THE FOLLOWING LOWEST POTENCY AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
476 MEXAMETHASONE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
477 HYDROCORTISONE 2%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
478 METHYLPREDNISOLONE 0.25-1.0% OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
479
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
480 DE200 ONE OF THE FOLLOWING LOW POTENCY AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
481 BETAMETHASONE VALERATE 0.01%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
482 CLOCORTOLONE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
483 DESONIDE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
484 FLUOCINOLONE ACETONIDE 0.01%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
485 FLURANDRENOLIDE 0.025%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
486 TRIAMCINOLONE ACETONIDE 0.025%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
487
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
488 DE200 ONE OF THE FOLLOWING INTERMEDIATE POTENCY AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
489 BETAMETHASONE BENZOATE 0.025%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
490 BETAMETHASONE VALERATE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
491 DESOXIMETHASONE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
492 FLUOCINOLONE ACETONIDE 0.025%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
493 FLURANDRENOLIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
494 FLUTICASONE PROPIONATE 0.005-0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
495 HALCINONIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
496 HYDROCORTISONE VALERATE 0.2%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
497 MOMETASONE FUROATE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
498 TRIAMCINOLONE ACETONIDE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
499
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
500 DE200 ONE OF THE FOLLOWING HIGH POTENCY AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
501 AMCINONIDE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
502 BETAMETHSONE DIPROPIONATE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
503 DESOXIMETHASONE 0.25%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
504 DIFLORASONE DIACETATE 0.05% Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
505 FLUOCINOLONE 0.2%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
506 FLUOCINONIDE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
507 HALCINONIDE 0.1%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
508 TRIAMCINOLONE ACETONIDE 0.5%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
509
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
510 DE200 ONE OF THE FOLLOWING HIGHEST POTENCY AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
511 BETAMETHASONE DIPROPIONATE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
512 PA CLOBETASOL DIPROPIONATE 0.05% Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
513 DIFLORASONE DIACETATE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
514 HALOBETASOL PROPIONATE 0.05%
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
515
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
516 DE400 SOAPS/SHAMPOOS/SOAP-FREE CLEANSERS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
517 DE400 SELENIUM SULFIDE 2.5% SHAMPOO
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
518
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
519 DE600 ANTINEOPLASTICS, TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
520 DE600 SC(CANCER) FLUOROURACIL 2% TOP SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
521 DE600 SC(CANCER) FLUOROURACIL 5% CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
522 DE600 SC(CANCER) FLUOROURACIL 5% TOP SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
523
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
524 DE750 ANTIACNE AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
525 DE750 ANTIACNE AGENTS, SYSTEMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
526 DE751 PA ISOTRETINOIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
527
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
528 DE752 ANTIACNE AGENTS, TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
529 DE752 CLINDAMYCIN PHOSPHATE 1% TOP SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
530 DE752 ERYTHROMYCIN 2% TOP GEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
531 DE752 ERYTHROMYCIN 2% TOP SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
532 DE752 METRONIDAZOLE 0.75% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
533 DE752 PA TRETINOIN 0.025% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
534 DE752 PA TRETINOIN 0.025% TOP GEL
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
535 DE752 PA TRETINOIN 0.05% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
536 DE752 PA TRETINOIN 0.1% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
537
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
538 DE800 ANTIPSORIATICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
539 DE801 ANTIPSORIATICS, SYSTEMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
540 DE801 PA ACITRETIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
541 DE801 PA METHOXSALEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
542
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
543 DE802 ANTIPSORIATICS, TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
544 DE802 PA ANTHRALIN 0.1% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
545 DE802 PA ANTHRALIN 0.25% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
546 DE802 PA ANTHRALIN 0.5% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
547 DE802 PA ANTHRALIN 1% TOP CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
548 DE802 PA [ILLEGIBLE] OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
549
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
550 GA000 GASTROINTESTINAL MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
551 GA300 ANTIULCER AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
552 GA301 HISTAMINE-2 RECEPTOR ANTAGONISTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
553 GA301 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
554 CIMETIDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
555 FAMOTIDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
556 NIZATIDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
557 RANTIDINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
558
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
559 GA302 PROTECTANTS, ULCER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
560 GA302 SUCRALFATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
561
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
562 GA309 ANTIULCER AGENTS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
563 GA309 MISOPROSTOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
564
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
565 GA400 ANTIDIARRHEAL AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
566 GA400 ATROPINE SO4 /DIPHENOXYLATE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
567 GA400 LOPERAMIDE 2MG HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
568 GA400 PA OCTREOTIDE ACETATE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
569
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
570 GA500 DIGESTANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
571 GA500 PANCREATIC ENZYMES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
572
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
573 GA609 PROCHLORPERAZINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
574
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
575 GA700 ANTIMETICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
576 GA700 SC(CANCER) ONE OF THE FOLLOWING 5HT3 AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
577 DOLASETRON
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
578 GRANISETRON
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
579 ONDANSETRON
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
580
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
581 XXXX
XXXXXXXXXX
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
582 GA700 METOCLOPRAMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
583 GA700 TRIMETHOBENZAMIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
584
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
585 GA900 GASTRIC MEDICATIONS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
586 GA900 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
587 LANSOPRAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
588 OMEPRAZOLE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
589 PANTOPRAZOLE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
590 RABEPRAZOLE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
591
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
592 GA900 OLSALAZINE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
593 GA900 MESALAMINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
594 GA900 SULFASALAZINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
595 GA900 PA ORSCONOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
596
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
597 GU000 GENITOURINARY MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
598 GU100 ANALGESICS, URINARY
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
599 GU100 PHENAZOPYRIDINE HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
600
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
601 GU200 ATROPINE+HYOSCYAMINE+METHYLENE BLUE+PHENYLSALICYLATE+
BENZOIC ACID
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
602 GU201 ANTISPASMODICS, URINARY
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
603 GU201 OXYBUTYNIN CHLORIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
604
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
605 GU300 ANTI-INFECTIVES, VAGINAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
606 GU300 CLINDAMYCIN PHOSPHATE VAG CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
607 GU300 METRONIDAZOLE VAG GEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
608 GU300 TRIPLE SULFA VAG CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
609 GU300 TRIPLE SULFA VAG TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
610 GU302 CLOTRIMAZOLE VAG TAB 500MG
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
611 GU302 TERCONAZOLE VAG CREAM AND SUPP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
612 GU400 TERBUTALINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
613
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
614 GU500 ESTROGENS, VAGINAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
615 GU500 ESTROGENS CONJUGATED VAG CREAM Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
616
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
617 HS000 HORMONES/SYNTHETICS/MODIFIERS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
618 HS051 DEXAMETHASONE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
619 HS051 HYDROCORTISONE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
620 HS051 METHYLPREDNISOLONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
621 HS051 PREDNISOLONE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
622 HS051 PREDNISONE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
623 HS052 FLUOROCORTISONE ACETATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
624
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
625 HS100 ANDROGENS/ANABOLICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
626 HS100 PA NANDROLONE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
627 HS100 PA METHYLTESTOSTERONE Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
628 HS100 PA TESTOSTERONE INJ (IN OIL)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
629
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
630 HS200 CONTRACEPTIVES, SYSTEMIC (FOR THERAPEUTIC USE ONLY) Contraceptives are covered by [ILLEGIBLE] Women
and Children Program, Puerto Rico Department of
Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
631 HS200 PA DESOGESTRELO, 15/ETHINYL ESTRADOL 30 TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
632 HS200 PA ETHINYL ESTRADIOL 30MCG/NORGESTREL 0.3MG TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
633 HS200 PA ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB 21
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
634 HS200 PA ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB 23
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
635 HS200 PA XXXXXXXXX 00XXX/XXXXXXXXXXXXX 0XX TAB 21
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
636 HS200 PA XXXXXXXXX 00XXX/XXXXXXXXXXXXX 0XX TAB 23
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
637 HS200 PA NORGESTREL 0.075 TAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
638 HS200 PA TRIPHASIC ORAL CONTRACEPTIVE/ORTHO-NOVUM 7/7/7/
BASED 21
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
639 HS200 PA TRIPHASIC ORAL CONTRACEPTIVE/ORTHO-NOVUM 7/7/7/
BASED 23
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
640
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
641 HS300 ESTROGENS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
642 HS300 DIETHYLSTIBSTROL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
643 HS300 ESTROGENS CONJUGATED INJ Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
644 HS300 ESTROGENS CONJUGATED ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
645 ESTROGENS CONJUGATED/MEDROXYPROGESTERONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
646
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
647 HS500 BLOOD GLUCOSE REGULATION AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
648 HS501 INSULIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
649 HS501 INSULIN HUMAN 50/50 (NPH/REG) INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
650 HS501 INSULIN HUMAN 70/30 (NPH/REG) INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
651 HS501 INSULIN HUMAN LENTE 100u/ML INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
652 HS501 INSULIN HUMAN NPH 100U/ML INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
653 HS501 INSULIN HUMAN REGULAR 100U/ML INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
654 HS501 INSULIN HUMAN ULTRALENTE 100U/ML INJ (OTC) Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
655
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
656 HS502 HYPOGLYCEMIC AGENTS, ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
657 HS502 METFORMIN HCL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
658
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
659 HS502 PA ONE OF THE FOLLOWING INHIBITORS OF [ILLEGIBLE] WITH
PRIOR AUTHORIZATION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
660 ACARBOSE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
661 MIGLITOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
662
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
663 HS502 TWO OF THE FOLLOWING SECOND GENERATION SULFONILUREAS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
664 HS502 GLIPIZIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
665 XX000 XXXXXXXXX ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
666
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
667 HS502 ONE OF THE FOLLOWING TIAZOLIDINEDIONES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
668 PIOGLITAZONE
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
669 ROSIGLITAZONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
670
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
671 HS508 GLUCAGON FOR INJECTION (EMERGENCY KIT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
672 HS701 PA HUMAN GROWTH HORMONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
673
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
674 HS702 POSTERIOR PITUITARY
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
675 HS702 PA DESMOPRESSIN ACETATE NASAL SOLN Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
676
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
677 HS800 PROGESTINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
678 HS800 MEDROXYPROGESTERONE ACETATE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
679 HS800 MEGESTROL ACETATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
680
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
681 HS850 THYROID MODIFIERS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
682 HS851 THYROID SUPPLEMENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
683 HS851 LEVOTHYROXINE NA ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
684
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
685 HS852 ANTITHYROID AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
686 HS852 METHINAZOLE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
687 HS852 PROPYLTIDOURACIL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
688
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
689 HS900 HORMONES/SYNTHETICS/MODIFIERS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
690 HS900 SC(CANCER) ETIDRONATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
691 HS900 PA FINASTERIDE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
692 HS900 PA ALENDRONATE SODIUM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
693
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
694 IM000 IMMUNOLOGICAL AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
695 IM500 PA PALIVIZUMAB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
696 IM600 SC(RENAL AZATHIOPRINE INJ
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
697 IM600 SC(RENAL AZATHIOPRINE ORAL PA [ILLEGIBLE] Disorder
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
698 IM600 SC(RENAL CYCLOSPORINE INJ
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
699 IM600 SC(RENAL CYCLOSPORINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
TRANSPLANT) Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
700 IM600 SC(RENAL MUROMONAB-CDJ INJ
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
701 IM600 SC(RENAL MYCOPHENOLATE MOFETIL ORAL
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
702 IM600 SC(RENAL RAPAMYCIN ORAL
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
703 IM600 SC(RENAL TACROLIMUS INJ
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
704 IM600 SC(RENAL TACROLIMUS ORAL
TRANSPLANT)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
705
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
706 IM700 IMMUNE STIMULANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
707 IM700 SC(CANCER) ALDESLEUKIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
708 IM700 SC(CANCER) INTERFERON ALFA INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
709 IM700 PA INTERFERON BETA-IA INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
710 IM700 PA INTERFERON ALPHA-IB INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
712 IM900 IMMUNOLOGICAL AGENTS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
713 IM900 CROMOLYN SODIUM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
714 IM900 PA GLATIRAMER ACETATE INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
715 IM900 PA INTERFERON BETA-IB INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
716 [ILLEGIBLE] [ILLEGIBLE]
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
717
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
718 MS000 MUSCULOSKELETAL MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
719 MS100 ANTIRHEUMATICS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
720 MS101 SALICYLATES, ANTIRHEUMATIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
721 MS101 ONE OF THE FOLLOWING NON ACETILATED SALICYLATES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
722 CHOLINE SALICYLATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
723 MAGNESIUM CHOLINE SALICYLATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
724 DIFUNISAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
725 MAGNESIUM SALICYLATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
726 SALSALATE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
727 SODIUM SALICYLATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
728
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
729 MS102 NONSALICYLATE NSUD
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
730 MS102 FOUR OF THE FOLLOWING NONSALICYLATE NSUD (AT LEAST ONE
FROM EACH SUB CATEGORY)
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
731 DICLOFENAC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
732 ETODOLAC ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
733 FENOPROFEN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
734 FLURBIPROFEN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
735 IBUPROFEN ORAL
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
736 INDOMETHACIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
737 KETOPROFEN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
738 NABUMETONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
739 NAPROXEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
740 OXAPROZIN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
741 PROXICAM ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
742 SULINDAC ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
743 TOLMETIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
744
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
745 MS104 PA PENICILLAMINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
746
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
747 MS104 GOLD COMPOUNDS, ANTIRHEUMATIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
748 MS106 PA AURANOFIN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
749 MS106 PA AUROTHIOGLUCOSE SUSP INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
750
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
751 MS109 ANTIRHEUMATICS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
752 MS109 COM-2 INHIBITORS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
753 PA CELECOXIB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
754 PA ROFECOXIB
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
755
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
756 MS200 SKELETAL MUSCLE RELAXANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
757 MS200 BACLOFEN ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
758 MS200 CARISOPROCOL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
759 MS200 CHLOROXAZONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
760 MS200 CYCLOBENZAPRINE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
761 MS200 PA DANTROLENE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
762
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
763 MS400 ANTIGOUT AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
764 MS400 ALLOPURINOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
765 MS400 COLCHICINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
766 MS400 PROBENECID ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
767
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
768 NT000 NASAL AND THROAT AGENTS, TOPICAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
769 NT200 ANTI-INFLAMMATORIES, NASAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
770 NT200 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
771 BECLOMETHASONE DIPROPIONATE Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
772 BUDENOSIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
773 DEXAMETHASONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
774 FLUNISOLIDE Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
775 FLUTICASONE PROPIONATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
776 MOMETASONE FUROATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
777 TRIANICINOLONE ACETONIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
778
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
779 NT900 NASAL AND THROAL AGENTS, TOPICAL, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
780 NT900 CLOTRIMAZOLE XXXXXX
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
781 NT900 CORMOLYN SODIUM NASAL INHL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
782
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
783 OP000 OPHTHALMIC AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
784 OP100 ANTIGLAUCOMA AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
785 OP101 BETA-BLOCKERS TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
786 OP101 BETAXOLOL 0.25% SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
787 OP101 BETAXOLOL 0.5% SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
788 OP101 LEVOBUNOLOL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
789 OP101 TIMOLOL OPH GEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
790 OP101 TIMOLOL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
791
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
792 OP102 ABOTICS TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
793 OP102 PILOCARPINE OPH GEL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
794 OP102 PILOCARPINE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
795
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
796 OP103 ADRENERGICS TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
797 OP103 DIPIVEFRIN HCL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
798 OP103 EPINEPHRINE HCL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
799
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
800 OP109 ANTI GLAUCOMA, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
801 OP109 PA DORZOLAMIDE HCL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
802 OP109 PA LATANOPROST OPH SOLN
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
803
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
804 OP200 ANTI-INFECTIVE, TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
805 OP201 ANTI-BACTERIALS, TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
806 OP201 BACITRACIN OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
807 OP201 CHLORAMPHENICOL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
808 OP201 ERYTHTOMYCIN OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
809 OP201 GENTAMICIN SO4 OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
810 OP201 GENTAMICIN SO4 OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
811 OP201 SULFACETAMIDE NA OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
812 OP201 SULFACETAMIDE NA OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
813 OP201 TOBRAMYCIN OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
814
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
815 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
816 OP201 PA CIPROFLOXACIN HCL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
817 OP201 PA OFLOXACIN OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
818
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
819 OP203 PA TRIFLURIDINE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
820 OP203 PA VIDARABINE OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
821 OP209 BACITRACIN/NEOMYCIN/POLYMYXIN OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
822
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
823 OP300 ANTI-INFLAMMATORIES, TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
824 ONE OF THE FOLLOWING
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
825 OP300 DICLOFENAC NA OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
826 OP300 FLURBIPROFEN NA OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
827 OP300 KETOROLAC TROMETHAMINE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
828
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
829 OP300 PREDNISOLONE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
830 OP300 PREDNISOLONE OPH SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
831 OP350 DEXAMETHASONE/TOBRAMYCIN OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
832 OP350 DEXAMETHASONE/TOBRAMYCIN OPH SUSP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
833
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
834 OP600 MIDRIATICS/CYCLOPEGICS, TOPICAL OPHTHALMIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
835 OP600 ATROPINE SULFATE OPH OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
836 OP600 ATROPINE SULFATE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
837
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
838 OP900 OPHTHALMICS, OTHER
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
839 OP900 PA APRACLONIDINE HCL OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
840 OP900 PA BRIMONIDINE TARTRATE OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
841 OP900 CROMOLYN NA OPH SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
842
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
843 OR900 LIDOCAINE HYDROCHLORIDE TOPICAL SOLUTION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
844 OR900 HYDROCORTISONE ACETATE DENTAL PASTE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
845 OR900 CHLORHEXIDINE GLUCONATE ORAL RINSE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
846
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
847 OT000 OTIC AGENTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
848 OT109 ACETIC ACID OTIC SOLUTION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
849 OT109 ACETIC ACID/ALUMINUM ACETATE OTIC SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
850 OT250 ACETIC ACID/HC/OTIC SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
851 OT250 HC/NEOMYCIN/POLYMYXIN OTIC
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
852 OT900 PA OFLOXACIN OTIC SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
853
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
854 RE000 RESPIRATORY TRACT MEDICATIONS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
855 RE100 ANTIASTHMA/BRONCHODILATORS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
856 RE101 ANTI-INFLAMMATORIES, INHALATION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
857 RE101 TWO OF THE FOLLOWING INHALED CORTICOSTEROIDS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
858 BECLOMETHASONE DIPROPIONATE Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
859 DEXAMETHASONE SODIUM PHOSPHATE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
860 FLUNISOLIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
861 TRIAMCINOLONE ACETONIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
862 BUDENOSIDE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
863 FLUTICASONE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
864
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
865 RE102 BRONCHODILATORS, SYMPATHOMMETIC, INHALATION
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
866 RE102 ALBUTEROL INHL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
867 RE102 ALBUTEROL INHL SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
868 RE102 PA SALMETEROL ORAL INHL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
869
------------------------------------------------------------------------------------------------------------------------------------
ADMINISTRATACION DE SEGUROS DE SALUD
FORMULARIO MEDULAR DE MEDICAMENTOS
REQUEST FOR PROPOSAL FOR PHARMACY BENEFIT MANAGEMENT FOR REQUIRED PERSONS
UNDER THE PRHLA
AUGUST 3,2001
------------------------------------------------------------------------------------------------------------------------------------
870 RE103 BRONCHOLDILATORS SYMPATHOMEDTIC, ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
871 RE103 ALBUTERAL ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
872 RE103 TERBUTALINE Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
873 RE104 THEOPHYLLINE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
874 RE105 IPRATROPIUM BROMIDE INHL SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
875 RE105 IPRATROPIUM BROMIDE ORAL SOLN
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
876
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
877 RE108 ANTIASTHMA ANTILEUKOTRIENES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
878 RE108 MONTELUKAST
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
879 RE108 ZAFIRLUKAST
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
880
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
881 RE300 ANTITUSSIVEXPECTORANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
882 RE301 OPIOID CONTAINING ANTITUSSIVEXPECTORANTS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
883 RE301 CODEINE/GUA IFENESIN SYRUP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
884
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
885 RS100 RECTAL LOCAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
886 RS100 ANTI-INFLAMMATORIES, RECTAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
887 RS100 HYDROCORTISONE ACETATE RTL FOAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
888 RS100 HYDROCORTISONE ENEMA Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
889 RS100 MESALAMINE ENEMA
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
890 RS100 MESALAMINE RTL SUPP
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
891
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
892 RS202 HEMORRHOIDAL PREPARATIONS WITH STEROID
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
893 RS202 HEMORRHOIDAL/HC RTL OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
894 RS202 HEMORRHOIDAL/PRAMOXINE RTL CREAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
895 RS202 HEMORRHOIDAL/PRAMOXINE RTL FOAM
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
896 RS202 HEMORRHOIDAL/PRAMOXINE RTL OINT
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
897
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
898 TN000 THERAPEUTIC NUTRIENTS/MINERAL/ELECTROLYTES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
899 TN401 IRON INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
900 TN403 POTASSIUM CHLORIDE ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
901 TN700 PA LEVOCARNITTINA
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
902
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
903 VT100 VITAMINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
904 VT102 SC(CANCER) LEUCOVARIN CALCIUM INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
905 VT102 SC(CANCER) LEUCOVARIN CALCIUM ORAL Refer to Non-Bioequivalent Formulary, Puerto
Rico Department of Health
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
906 VT110 CYANOCOBALAMIN INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
907 VT120 FOLIC ACID ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
908 VT501 SC(DYALISIS) CALCIFEDIOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
909 VT502 SC(DYALISIS) CALCIFEDIOL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
910 VT503 SC(DYALISIS) DIHYDROTACHYSTEROL ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
911 VT504 SC(DYALISIS) ERGOCALCIFERAL INJ
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
912 VT504 SC(DYALISIS) VITAMIN D ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
913 VT702 PHYTONADIONE ORAL
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
914 VT702 PRENATAL VITAMINS
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
915
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
916 XA000 PROSTHECTICS/SUPPLIES/DEVICES
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
917 XA854 INSULIN SYRINGE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
918 XA854 INSULIN SYRINGE LOW DOSE
---- --------- -------------- ------------------------------------------------------ -----------------------------------------------
919
====================================================================================================================================
----------------------------- ------------------------------------------------------ -----------------------------------------------
PA = PRE AUTHORITATION
----------------------------- ------------------------------------------------------ -----------------------------------------------
SC = SPECIAL COVERAGE
----------------------------- ------------------------------------------------------ -----------------------------------------------
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE]
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY (ASSMCA)
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY (ASSMCA)
----------------------------- ------------------------------------------------------ -----------------------------------------------
[ILLEGIBLE] NEW DRUG(S) IN FORMULARY (ASSMCA)
----------------------------- ------------------------------------------------------ -----------------------------------------------
* La inclusion de estea nedica [ILLEGIBLE]
----------------------------- ------------------------------------------------------ -----------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
