2018 formulario - castiarx asp compre… · el formulario, aparece en las cubiertas delantera y...

2018 Formulario (Lista de medicamentos cubiertos))

FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS

MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Aspire Health Value (HMO) | Aspire Health Advantage (HMO)

Aspire Health Group Plus (HMO-POS) | Aspire Health Plus (HMO-POS)

H8764_SP_2018CompFormulary_0817_ CMS Accepted

http://www.aspirehealthplan.org/

Contents

¿Qué es el Formulario del Aspire Health Advantage Value, Aspire Health Advantage, Aspire Health Advantage Group Plus (HMO-POS) o Aspire Health Advantage Plus? .... 3

¿Puede cambiar el Formulario (lista de medicamentos)? ............................................... 3

¿Cómo se utiliza el Formulario? ...................................................................................... 4

¿Qué son medicamentos genéricos? .............................................................................. 4

¿Hay restricciones en mi cobertura? ............................................................................... 5

¿Cómo se solicita una excepción al Formulario de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus? ........................................... 6

¿Qué hago antes de poder hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? ............................................................................................... 8

Para mayor información .................................................................................................. 9

Formulario de Aspire Health Advantage Value, Aspire Health Advantage, Aspire Health Advantage Group Plus, o Aspire Health Advantage Plus ................................................ 9

Índice de Medicamentos ............................................................................................... 99

Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Examine este documento para asegurarse de que aún contiene lo medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) se refiere a “nosotros,” “nos,” o “nuestro,” quiere decir Aspire Health Advantage Value (HMO), Aspire Health Advantage (HMO) o Aspire Health Advantage Plus (HMO-POS). Cuando se refiere a “plan” o “nuestro plan,” quiere decir Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus.

Este documento incluye lista de medicamentos (formulario) para nuestro plan que está al día el 10/23/2018. Para el formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las cubiertas delantera y trasera.

Generalmente, debe utilizar farmacias de red para utilizar su beneficio de medicamentos de receta. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1 de enero de 2018, y de vez en cuando durante el año.

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¿Qué es el Formulario del Aspire Health Advantage Value, Aspire Health Advantage, Aspire Health Advantage Group Plus (HMO-POS) o Aspire Health Advantage Plus?

Un formulario es una lista de medicamentos cubiertos seleccionados por Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus consultando con un equipo de proveedores de atención médica, que representa las terapias de receta que se cree son parte necesaria de un programa de tratamiento de calidad. Generalmente, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus cubrirá los medicamentos enumerados en nuestro formulario siempre que el medicamento sea necesario por motivos médicos, la receta se surta en una farmacia de la red de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus y se sigan otras reglas del plan. Para mayor información acerca de cómo surtir sus recetas, examine su Evidencia de Cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?

Generalmente, si está tomando un medicamento de nuestro formulario de 2018 que estaba cubierto al principio del año, no eliminaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2018 excepto cuando un medicamento genérico nuevo y menos caro esté disponible o cuando se divulgue nueva información adversa acerca de la seguridad o eficacia de un medicamento. Otros tipos de cambios al formulario, tales como quitar un medicamento del mismo, no afectarán a los miembros que estén tomando el medicamento actualmente. Seguirá estando disponible al mismo costo compartido para los miembros que lo tomen durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que pueda ahorrar más dinero o podamos garantizar su seguridad.

Si quitamos medicamentos de nuestro formulario o añadimos, después de obtener autorización, límites de cantidades y/o restricciones de terapia en pasos que afecten a un medicamento o trasladamos un medicamento a un nivel más alto de costo compartido, debemos notificar a los miembros afectados del cambio al menos 60 días antes de que entre en vigor, o en el momento en que el miembro solicite que se le repita la receta del medicamento, cuando el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Medicamentos considera que

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uno de los medicamentos de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está al día el 10/23/2018. Para obtener información actualizada acerca de los medicamentos cubiertos por Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus, póngase en contacto con nosotros. Nuestra información de contacto aparece en las cubiertas delantera y trasera.

En el evento de que haya cambios al formulario durante el año del plan que no son de mantenimiento, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus puede hacer cambios y enviárselos por correo. También puede ir a nuestra página en la Internet para revisar los cambios.

¿Cómo se utiliza el Formulario?

Hay dos maneras de encontrar su medicamento en el formulario:

Condición Médica

El formulario empieza en la página 11. Los medicamentos de este formulario están agrupados en categorías según el tipo de condición médica para el tratamiento de la cual se utilizan. Por ejemplo, los medicamentos que se utilizan para tratar una condición cardiaca se enumeran bajo la categoría, “CARDIOVASCULAR”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 11. Después, busque su medicamento bajo el nombre de la categoría.

Lista Alfabética

Si no está seguro de la categoría bajo la cual buscar, debe buscar su medicamento en el Índice que empieza en la página 99. El Índice da una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se enumeran en el Índice. Mire en el Índice para encontrar su medicamento. Al lado de su medicamento verá el número de la página donde puede encontrar información de cobertura. Vaya a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son medicamentos genéricos?

Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage

Plus cubre tanto medicamentos de marca como los medicamentos genéricos. Un

medicamento genérico está aprobado por la Administración de Alimentos y

Medicamentos (FDA) indicando que tiene el mismo ingrediente activo que el

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medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos

que los medicamentos de marca.

¿Hay restricciones en mi cobertura?

Es posible que algunos medicamentos cubiertos tengan requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir:

1. Autorización Previa: Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus requiere que usted o su médico obtenga autorización previa para ciertos medicamentos. Esto quiere decir que necesitará obtener la aprobación de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus antes de surtir sus recetas. Si no obtiene aprobación, es posible que, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus no cubra el medicamento.

2. Límites de Cantidad: Para ciertos medicamentos, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus limita la cantidad de medicamento que cubrirá Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus. Por ejemplo, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus proporciona 60 capsules por receta para celecoxib. Esto puede ser además de un suministro estándar de un mes o tres meses.

3. Terapia en Pasos: En algunos casos, Aspire Health Advantage Value, Aspire

Health Advantage o Aspire Health Advantage Plus requiere que pruebe primero ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan su condición médica, es posible que, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus no cubra el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no le va bien, Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus cubrirá entonces el Medicamento B.

Puede averiguar si su medicamento tiene requisitos o límites adicionales mirando en el formulario que empieza en la página 11. También puede obtener más información acerca de las restricciones aplicadas a medicamentos específicos cubiertos visitando nuestro sitio Web Hemos publicado documentos en línea que explican la autorización previa y las restricciones de terapias escalonadas.También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera.

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Puede pedirle a Aspire Health Advantage Value, Aspire Health Advantage o Aspire

Health Advantage Plus que haga una excepción a estas restricciones a límites, o

pedirle una lista de otros medicamentos parecidos que puedan tratar su condición

médica. Vea la sección, “¿Cómo se solicita una excepción al Formulario de Aspire

Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus?”

en la página 6 para ver información acerca de la manera de solicitar una excepción.

¿Qué pasa si mi medicamento no está en el Formulario?

Si su medicamento no está incluido en este formulario (lista de medicamentos

cubiertos), lo primero que debe hacer es ponerse en contacto con Servicios de

Miembros y preguntar si está cubierto su medicamento.

Si averigua que Aspire Health Advantage Value, Aspire Health Advantage o Aspire

Health Advantage Plus no cubre su medicamento, tiene dos opciones:

1. Puede pedirle a Servicios de Miembros una lista de medicamentos parecidos

que estén cubiertos por Aspire Health Advantage Value, Aspire Health

Advantage o Aspire Health Advantage Plus Cuando reciba la lista, enséñesela a

su médico y pídale que le recete un medicamento parecido que esté cubierto por

Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health

Advantage Plus.

2. Le puede pedir a Aspire Health Advantage Value, Aspire Health Advantage o

Aspire Health Advantage Plus que haga una excepción y cubra su medicamento.

Vea la información que aparece a continuación para ver cómo solicitar una

excepción.

¿Cómo se solicita una excepción al Formulario de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus?

Le puede pedir a Aspire Health Advantage Value, Aspire Health Advantage o Aspire

Health Advantage Plus que haga una excepción a nuestras reglas de cobertura. Hay

varios tipos de excepciones que puede pedirnos que hagamos.

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1. Puede pedirnos que cubramos un medicamento aún si no está en nuestro

formulario. Si se aprueba, este medicamento se cubrirá a un nivel

predeterminado de costo compartido, y usted no podría pedirnos que

proporcionemos el medicamento a un nivel más bajo de costo compartido.

2. Puede pedirnos que cubramos un medicamento del formulario a un nivel más

bajo de costo compartido [si este medicamento no está en el nivel de

especialidad. Si se aprueba, esto reduciría la cantidad que debe pagar usted por

su medicamento.

3. Puede pedirnos que demos una exención para las restricciones o límites de

cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, Aspire

Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage

Plus limita la cantidad de medicamento que cubrimos. Si su medicamento tiene

un límite de cantidad, pude pedirnos que otorguemos una exención para el límite

y que cubramos una cantidad mayor.

Generalmente, Aspire Health Advantage Value, Aspire Health Advantage o Aspire

Health Advantage Plus solamente aprobará su solicitud de excepción si los

medicamentos de alternativa incluidos en el formulario del plan, el medicamento de

costo compartido más bajo o las restricciones de utilización adicionales no serían tan

efectivas en el tratamiento de su condición y/o harían que usted tuviera efectos

médicos adversos.

Debe ponerse en contacto con nosotros para pedirnos una decisión de cobertura inicial

para una excepción al formulario, o de las restricciones de utilización. Cuando solicite

una excepción al formulario, insert if plan has multiple tiers o de restricciones de

utilización, debe presentar una declaración de su recetador o médico apoyando

su solicitud. Generalmente, tenemos que tomar una decisión dentro de las 72 horas

siguientes a recibir la declaración de apoyo de su recetador. Puede solicitar una

excepción acelerada (rápida) si usted o su médico cree que su salud podría verse

severamente dañada si espora 72 horas para recibir una decisión. Si su solicitud de

acelerar se concede, debemos darle una decisión no más de 24 horas después de

recibir una declaración de apoyo de su médico u otro recetador.

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¿Qué hago antes de poder hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción?

Como miembro nuevo de o si continua en nuestro plan, puede que esté tomando medicamentos que no estén en nuestro formulario. O puede que esté tomando un medicamento que esté en el formulario poro su habilidad de obtenerlo sea limitada. Por ejemplo, puede que necesite autorización previa nuestra antes de poder surtir su receta. Debe hablar con su médico para decidir si debería cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el rumbo correcto que seguir, puede que cubramos su medicamento en ciertos casos durante los primeros 90 días que sea miembro de nuestro plan. Para cada uno de sus medicamentos que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta que indique un número de días menor) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aún si ha sido miembro del plan menos de 90 días. Si es residente de una clínica de cuidado de largo plazo, pormitiremos que repita su receta hasta que le hayamos provisto un suministro de transición de 91 días, consistente con el incremento de suministro (a menos que tenga una receta que indique un número menor de días). Cubriremos más de una repetición de estos medicamentos durante los primeros 90 días que sea miembro de nuestro plan. Si necesita un medicamento que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, poro ya han pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta que indique un número menor de días) mientras tramita una excepción al formulario.

Excepciones son disponibles para beneficiarios que han exporimentado un cambio en el nivel de cuidado que están recibiendo cual les requiere que cambien de una facilidad o centro de tratamiento a otro. Ejemplos de situaciones en cual los beneficiarios serian elegibles una vez para la excepción de suministro, una vez, cuando estén fuera del día efectivo de tres meses del programa de la Parte D son como lo siguiente:

1. El beneficiario es dado de alta del hospital y es proveído una lista de dado de

alta de medicamentos basado en el formulario del hospital

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2. Los beneficiarios que terminan su estadía de Medicare Parte A en un

establecimiento de cuidado medico continuo (donde los pagos incluyen todos los

cobros de la farmacia) y necesita volver a su formulario del plan de la Parte D

3. Los beneficiarios que dan por vencido el Estado de Hospicio para volver a los

beneficios normales de la Parte A y la Parte B de Medicare

4. Los beneficiarios que son dados de alta de Hospitales Psiquiátricos Crónicos

con regímenes de medicamento que son altamente individualizados

Para mayor información

Para obtener información más detallada acerca de su cobertura de medicamentos de receta de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus examine su Evidencia de Cobertura y otros materiales del plan.

Si tiene preguntas acerca de Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera. Si tiene preguntas generales acerca de la cobertura de medicamentos de receta de

Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día / 7

días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite

http://www.medicare.gov.

Formulario de Aspire Health Advantage Value, Aspire Health Advantage, Aspire Health Advantage Group Plus, o Aspire Health Advantage Plus

El formulario empieza en la página 11 proporciona información de cobertura acerca de los medicamentos cubiertos por Aspire Health Advantage Value, Aspire Health Advantage, Aspire Health Advantage Group Plus, o Aspire Health Advantage Plus. Si tiene dificultades para encontrar su medicamento en la lista, vaya al Índice que empieza en la página 99.

La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en letras mayúsculas (por ejemplo, HUMIRA) y los medicamentos genéricos aparecen en cursiva minúscula (por ejemplo, celecoxib). La segunda columna indica el nivel de la droga.

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La información de la columna de Requisitos/Límites le dice si Aspire Health Advantage Value, Aspire Health Advantage o Aspire Health Advantage Plus tiene algún requisito especial para la cobertura de su medicamento.

Los medicamentos recetados están agrupados en uno de cinco niveles. Humana cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (FDA) por tener el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

Nivel 1 - Genéricos preferidos: Medicamentos genéricos que están disponibles al costo compartido más bajo para el plan Nivel 2 - Genéricos: Medicamentos genéricos o de marca que el plan le ofrece a un costo mayor que los medicamentos genéricos preferidos del Nivel 1 Nivel 3 - De marca preferidos: Medicamentos genéricos o de marca que el plan le ofrece a un costo menor que los medicamentos de marca no preferidos del Nivel 4 Nivel 4 - De marca no preferidos: Medicamentos genéricos o de marca que el plan le ofrece a un costo mayor que los medicamentos de marca preferidos del Nivel 3 Nivel 5 - Especializados: Algunos medicamentos inyectables y otros de alto costo La cantidad de dinero que usted paga depende de: 1. El nivel en que se encuentra su medicamento 2. Si usted compra el medicamento en una farmacia de la red. 3. La etapa del beneficio en que se encuentra para el pago de medicamentos. Por

favor, lea su Evidencia de Cobertura (EOC) para más información

Estas cantidades de costo compartido se caracterizan por la fase inicial de cobertura de la prestación y están sujetos a las limitaciones de cobertura de la Parte D que se describen en la Evidencia de cobertura. Esta información no es una descripción completa de los beneficios .Comunicarse con el plan para obtener más información.

Usted puede encontrar información sobre el significado de las abreviaciones utilizadas en esta tabla al principio y al final de la lista de los medicamentos.

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La siguiente tabla describe las abreviaciones utilizadas en el listado de medicamentos.

ABREVIACION SIGNIFICADO DE LA ABREVIACION

LA Esta receta puede estar disponible sólo en ciertas farmacias. Para obtener

más información, por favor llame al 1-800-546-5677- 24 horas al día,

siete días a la semana. TTY/TDD los usuarios deben llamar al 1-866-

706-4757.

QL Cantidad límitada. Siga las especificaciones de cantidad límitada por día

PA Este medicamento requiere autorización previa. Para obtener una

excepción por favor llame al 1-800-546-5677 - 24 horas al día, siete días

a la semana. TTY/TDD los usuarios deben llamar al 1-866-706-4757

NEW PA Este medicamento require una autorización previa solo cuando se utiliza

por primera vez. Para obtener una excepción favor de contactarnos al 1-

800-546-5677 - 24 horas al día-siete días a la semana. Para usuarios

TTY/TDD pueden comunicarse al 1-866-706-4757.

B/D PA Este medicamento puede ser cubierto bajo Medicare Parte B o D,

dependiendo de las circunstancias. Puede necesitar presentar

información que describe el uso y la creación de fármacos para hacer la

determinación.

ST Requiere tratamiento escalonado.

FFF Este medicamento es parte del primer llenado gratis del programa y se

proporcionará a cero costo compartido cuando se selecciona este

medicamento sobre la versión de marca de medicamentos seleccionados.

Lista de medicamentos

Nombre de Medicamentos Nivel Requisitos/Limites

ANALGESICS Analgesics

acetaminophen w/ codeine soln 120-12 mg/5ml 2 QL 4500 POR 30 DIAS

acetaminophen w/ codeine tab 300-15 mg 2 QL 400 POR 30 DIAS



butalbital-acetaminophen tab 50-325 mg 4 QL 180 POR 30 DIAS; PA

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30

mg 2 QL 360 POR 30 DIAS; PA

butalbital-acetaminophen-caffeine cap 50-325-40 mg 4 QL 120 POR 30 DIAS; PA

butalbital-acetaminophen-caffeine tab 50-325-40 mg 4 QL 120 POR 30 DIAS; PA

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg 2 QL 180 POR 30 DIAS; PA

butalbital-aspirin-caffeine cap 50-325-40 mg 4 QL 180 POR 30 DIAS; PA

diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 ergotamine w/ caffeine tab 1-100 mg 2


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Nombre de Medicamentos Nivel Requisitos/Limites hydrocodo Usted puede encontrar información

sobre el significado de las abreviaciones

utilizadas en esta tabla al principio y al final de

la lista de los medicamentos.

ne-acetaminophen soln 7.5-325 mg/15ml 2 QL 3600 POR 30 DIAS

hydrocodone-acetaminophen tab 10-300 mg 2 QL 120 POR 30 DIAS




hydrocodone-acetaminophen tab 7.5-300 mg 2 QL 120 POR 30 DIAS

hydrocodone-acetaminophen tab 7.5-325 mg 2 QL 360 POR 30 DIAS

hydrocodone-ibuprofen tab 7.5-200 mg 2 QL 480 POR 30 DIAS

oxycodone w/ acetaminophen tab 10-325 mg 2 QL 360 POR 30 DIAS

oxycodone w/ acetaminophen tab 2.5-325 mg 2 QL 120 POR 30 DIAS

oxycodone w/ acetaminophen tab 5-325 mg 2 QL 360 POR 30 DIAS

oxycodone w/ acetaminophen tab 7.5-325 mg 2 QL 360 POR 30 DIAS

oxycodone-aspirin tab 4.8355-325 mg 2 QL 360 POR 30 DIAS

oxycodone-ibuprofen tab 5-400 mg 2 QL 120 POR 30 DIAS

tramadol-acetaminophen tab 37.5-325 mg 2 QL 240 POR 30 DIAS

Nonsteroidal Anti-inflammatory Drugs

diclofenac sodium gel 1% 2 diclofenac sodium soln 1.5% 2 oxaprozin tab 600 mg 4 Opioid Analgesics, Long-acting

buprenorphine hcl inj 0.3 mg/ml (base equiv) 3 fentanyl td patch 72hr 100 mcg/hr 2 QL 20 POR 30 DIAS

fentanyl td patch 72hr 12 mcg/hr 2 QL 20 POR 30 DIAS




HYSINGLA ER TAB100 MG 3 QL 30 POR 30 DIAS







levorphanol tartrate tab 2 mg 2 QL 240 POR 30 DIAS

METHADONE INJ10MG/ML 4

QL 120 POR 30 DIAS;

B/D PA

methadone hcl soln 10 mg/5ml 2 QL 600 POR 30 DIAS

methadone hcl soln 5 mg/5ml 2 QL 1200 POR 30 DIAS

methadone hcl tab 10 mg 2 QL 180 POR 30 DIAS

methadone hcl tab 5 mg 2 QL 180 POR 30 DIAS


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Nombre de Medicamentos Nivel Requisitos/Limites morphine sulfate beads cap sr 24hr 120 mg 2 QL 60 POR 30 DIAS

morphine sulfate beads cap sr 24hr 30 mg 2 QL 60 POR 30 DIAS





morphine sulfate cap sr 24hr 10 mg 2 QL 60 POR 30 DIAS







morphine sulfate oral soln 20 mg/5ml 2 QL 900 POR 30 DIAS

morphine sulfate tab cr 100 mg 2 QL 120 POR 30 DIAS





MORPHINE SULINJ10MG/ML 2 B/D PA




OXYCONTIN TAB10MG CR 3 QL 90 POR 30 DIAS; ST







Opioid Analgesics, Short-acting

butorphanol tartrate nasal soln 10 mg/ml 2 QL 10 POR 30 DIAS

fentanyl citrate lozenge on a handle 1200 mcg 5 QL 120 POR 30 DIAS; PA






hydromorphone hcl tab 2 mg 2 QL 120 POR 30 DIAS



morphine sulfate inj pf 0.5 mg/ml 4

QL 180 POR 30 DIAS;

B/D PA


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morphine sulfate inj pf 1 mg/ml 4

QL 180 POR 30 DIAS;

B/D PA

morphine sulfate oral soln 10 mg/5ml 2 QL 1800 POR 30 DIAS

morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 2 QL 180 POR 30 DIAS

morphine sulfate tab 15 mg 2 QL 180 POR 30 DIAS

morphine sulfate tab 30 mg 2 QL 180 POR 30 DIAS

nalbuphine hcl inj 10 mg/ml 4

QL 120 POR 30 DIAS;

B/D PA

nalbuphine hcl inj 20 mg/ml 4

QL 120 POR 30 DIAS;

B/D PA

oxycodone hcl cap 5 mg 2 QL 120 POR 30 DIAS

oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2 QL 120 POR 30 DIAS

oxycodone hcl tab 10 mg 2 QL 120 POR 30 DIAS





tramadol hcl tab 50 mg 2 QL 240 POR 30 DIAS

ANESTHETICS Local Anesthetics

lidocaine hcl gel 2% 2 lidocaine hcl local preservative free (pf) inj 0.5% 4 B/D PA

lidocaine hcl soln 4% 2 lidocaine hcl viscous soln 2% 2 lidocaine oint 5% 2 lidocaine patch 5% 2 PA

lidocaine-prilocaine cream 2.5-2.5% 2 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving

acamprosate calcium tab delayed release 333 mg 2 disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naltrexone hcl tab 50 mg 2 Opioid Dependence Treatments

buprenorphine hcl sl tab 2 mg (base equiv) 2 QL 120 POR 30 DIAS

buprenorphine hcl sl tab 8 mg (base equiv) 2 QL 120 POR 30 DIAS

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base

equiv) 2 QL 120 POR 30 DIAS

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base


SUBOXONE MIS12-3MG 4 QL 120 POR 30 DIAS

SUBOXONE MIS2-0.5MG 4 QL 90 POR 30 DIAS

SUBOXONE MIS4-1MG 4 QL 120 POR 30 DIAS


15

Nombre de Medicamentos Nivel Requisitos/Limites SUBOXONE MIS8-2MG 4 QL 90 POR 30 DIAS

VIVITROL INJ380MG 5 PA

Opioid Reversal Agents

naloxone hcl soln prefilled syringe 2 mg/2ml 3 NARCAN SPR 3

Smoking Cessation Agents

bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2 QL 90 POR 30 DIAS

CHANTIX PAK0.5& 1MG 3 QL 60 POR 30 DIAS

CHANTIX PAK1MG 3 CHANTIX TAB0.5MG 3 QL 60 POR 30 DIAS

CHANTIX TAB1MG 3 QL 60 POR 30 DIAS

NICOTROL NS SPR10MG/ML 4 QL 40 POR 30 DIAS

ANTIBACTERIALS Aminoglycosides

GENTAMICIN OIN0.1% 2 gentamicin sulfate cream 0.1% 2 gentamicin sulfate inj 40 mg/ml 2 B/D PA

gentamicin sulfate iv soln 10 mg/ml 2 B/D PA

gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 1 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 2 B/D PA

TOBRADEX OIN0.3-0.1% 4 tobramycin ophth soln 0.3% 2 tobramycin sulfate inj 10 mg/ml (base equivalent) 4 B/D PA

tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base

equiv) 4 B/D PA

Antibacterials

colistimethate sodium for inj 150 mg 4 B/D PA

neomycin-polymyxin b gu irrigation soln 2 SYNERCID INJ500MG 5 B/D PA

Antibacterials, Other

acetic acid otic soln 2% 2 bacitracin intramuscular for soln 50000 unit 4 bacitracin ophth oint 500 unit/gm 2 chloramphenicol sodium succinate for iv inj 1 gm 4 B/D PA

clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 2 clindamycin hcl cap 75 mg 2 clindamycin phosphate gel 1% 2 clindamycin phosphate in d5w iv soln 300 mg/50ml 4 clindamycin phosphate in d5w iv soln 600 mg/50ml 4


16

Nombre de Medicamentos Nivel Requisitos/Limites clindamycin phosphate in d5w iv soln 900 mg/50ml 4 clindamycin phosphate inj 600 mg/4ml 4 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 clindamycin phosphate vaginal cream 2% 2 daptomycin for iv soln 500 mg 2 B/D PA

linezolid for susp 100 mg/5ml 5 PA

linezolid iv soln 600 mg/300ml (2 mg/ml) 5 PA

linezolid tab 600 mg 5 QL 28 POR 14 DIAS; PA

methenamine hippurate tab 1 gm 2 metronidazole cap 375 mg 3 metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole in nacl 0.79% iv soln 500 mg/100ml 2 metronidazole lotion 0.75% 2 metronidazole tab 250 mg 2 metronidazole tab 500 mg 1 metronidazole vaginal gel 0.75% 2 mupirocin calcium cream 2% 2 mupirocin oint 2% 2 nitrofurantoin macrocrystalline cap 100 mg 2 PA

nitrofurantoin macrocrystalline cap 50 mg 4 PA

nitrofurantoin susp 25 mg/5ml 2 PA

SULFAMYLON CRE85MG/GM 4 TIGECYCLINE INJ50MG 2 PA

trimethoprim tab 100 mg 2 TYGACIL INJ50MG 5 PA

vancomycin hcl cap 125 mg 5 QL 40 POR 30 DIAS; PA

vancomycin hcl cap 250 mg 5 QL 80 POR 30 DIAS; PA

vancomycin hcl for inj 10 gm 4 PA

vancomycin hcl for inj 1000 mg 4 PA

vancomycin hcl for inj 500 mg 4 PA

Beta-lactam, Cephalosporins

cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 cefaclor monohydrate tab sr 12hr 500 mg 2 cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 4 B/D PA

cefazolin sodium for inj 10 gm 4 B/D PA

cefazolin sodium for inj 500 mg 4 B/D PA


17

Nombre de Medicamentos Nivel Requisitos/Limites cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefepime hcl for inj 1 gm 4 B/D PA

cefepime hcl for inj 2 gm 4 B/D PA

cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefoxitin sodium for inj 10 gm 4 B/D PA

cefoxitin sodium for iv soln 1 gm 4 B/D PA

cefoxitin sodium for iv soln 2 gm 4 B/D PA

cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 ceftriaxone sodium for inj 10 gm 4 ceftriaxone sodium for inj 250 mg 4 B/D PA

ceftriaxone sodium for inj 500 mg 4 B/D PA

ceftriaxone sodium for iv soln 1 gm 4 ceftriaxone sodium for iv soln 2 gm 4 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 1.5 gm 4 B/D PA

cefuroxime sodium for inj 7.5 gm 4 B/D PA

cefuroxime sodium for inj 750 mg 4 B/D PA

cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 SUPRAX CAP400MG 4 TEFLARO INJ400MG 5 B/D PA

TEFLARO INJ600MG 5 B/D PA

Beta-lactam, Other

AZACTAM/DEX INJ2GM 4 PA

aztreonam for inj 1 gm 4 CAYSTON INH75MG 5 LA


18

Nombre de Medicamentos Nivel Requisitos/Limites imipenem-cilastatin intravenous for soln 250 mg 2 imipenem-cilastatin intravenous for soln 500 mg 2 INVANZ INJ1GM 4 meropenem iv for soln 500 mg 2 B/D PA

meropenem iv for soln 1 gm 2 B/D PA

Beta-lactam, Penicillins

AMOX/K CLAV CHW200MG 2 amoxicillin & k clavulanate chew tab 400-57 mg 2 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 2 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 2 amoxicillin & k clavulanate for susp 400-57 mg/5ml 2 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 2 amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 2 amoxicillin (trihydrate) cap 250 mg 2 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp 125 mg/5ml 2 amoxicillin (trihydrate) for susp 200 mg/5ml 2 amoxicillin (trihydrate) for susp 250 mg/5ml 2 amoxicillin (trihydrate) for susp 400 mg/5ml 2 amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm 4 B/D PA

ampicillin & sulbactam sodium for inj 3 (2-1) gm 4 B/D PA

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm 4 B/D PA

ampicillin cap 250 mg 1 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 4 B/D PA

ampicillin sodium for inj 125 mg 4 B/D PA

ampicillin sodium for iv soln 10 gm 4 B/D PA

BICILLIN C-RINJ1200000 4 BICILLIN C-RINJ900/300 4 BICILLIN L-AINJ1200000 4 BICILLIN L-AINJ2400000 4 BICILLIN L-AINJ600000 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 4 B/D PA


19

Nombre de Medicamentos Nivel Requisitos/Limites nafcillin sodium for inj 10 gm 5 B/D PA

PENICILL GK/INJDEX 2MU 2 PENICILL GK/INJDEX 3MU 2 penicillin g potassium for inj 5000000 unit 4 B/D PA

penicillin g procaine intramuscular susp 600000 unit/ml 4 penicillin g sodium for inj 5000000 unit 4 B/D PA

penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2 penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj 3.375 gm (3-

0.375 gm) 2 B/D PA

piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm) 2 B/D PA

piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5

gm) 2 B/D PA

ZOSYN SOL2-0.25GM 4 PA

ZOSYN SOL3-0.375G 4 PA

Macrolides

AZASITE SOL1% 4 azithromycin for susp 100 mg/5ml 2 QL 30 POR 5 DIAS

azithromycin for susp 200 mg/5ml 2 QL 90 POR 5 DIAS

azithromycin iv for soln 500 mg 4 B/D PA

azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 QL 6 POR 5 DIAS

azithromycin tab 500 mg 2 QL 6 POR 5 DIAS

azithromycin tab 600 mg 2 QL 30 POR 30 DIAS

clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab sr 24hr 500 mg 2 DIFICID TAB200MG 5 PA

ERYTHROCIN INJ500MG 4 B/D PA

ERYTHROM ETHTAB400MG 2 erythromycin ethylsuccinate tab 400 mg 2 erythromycin gel 2% 2 erythromycin ophth oint 5 mg/gm 2 erythromycin pads 2% 2 erythromycin soln 2% 2 erythromycin stearate tab 250 mg 4 erythromycin tab 250 mg 4 erythromycin tab 500 mg 4 erythromycin tab delayed release 250 mg 4


20

Nombre de Medicamentos Nivel Requisitos/Limites erythromycin tab delayed release 333 mg 4 erythromycin tab delayed release 500 mg 4 ZMAX SUS2GM 4 QL 60 POR 30 DIAS

Quinolones

AVELOX INJ 4 B/D PA

CILOXAN OIN0.3% OP 4 ciprofloxacin 200 mg/100ml in d5w 4 ciprofloxacin hcl ophth soln 0.3% 2 ciprofloxacin hcl tab 100 mg (base equiv) 4 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 4 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000

mg(base eq) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg

(base eq) 2 levofloxacin in d5w iv soln 500 mg/100ml 4 B/D PA

levofloxacin ophth soln 0.5% 4 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 QL 14 POR 14 DIAS

levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 QL 14 POR 14 DIAS

MOXEZA SOL0.5% 3 moxifloxacin hcl tab 400 mg (base equiv) 4 moxifloxacin sol0.5% 2

ofloxacin ophth soln 0.3% 2 ofloxacin otic soln 0.3% 2 ofloxacin tab 300 mg 2 ofloxacin tab 400 mg 2 VIGAMOX DRO0.5% 3 Sulfonamides

silver sulfadiazine cream 1% 2 SULFACET SODOIN10% OP 2 sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium ophth soln 10% 2 sulfadiazine tab 500 mg 2 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 4 B/D PA

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2 sulfamethoxazole-trimethoprim tab 400-80 mg 2 sulfamethoxazole-trimethoprim tab 800-160 mg 1 Tetracyclines

demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2


21

Nombre de Medicamentos Nivel Requisitos/Limites doxycycline hyclate cap 100 mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate for inj 100 mg 4 doxycycline hyclate tab 100 mg 2 doxycycline monohydrate cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 ANTICONVULSANTS Anticonvulsants, Other

BRIVIACT INJ50MG/5ML 5 BRIVIACT SOL10MG/ML 5 QL 600 POR 30 DIAS

BRIVIACT TAB100MG 5 QL 60 POR 30 DIAS





levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 1000 mg 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab sr 24hr 500 mg 2 QL 180 POR 30 DIAS

levetiracetam tab sr 24hr 750 mg 2 QL 120 POR 30 DIAS

SPRITAM TAB1000MG 4 QL 90 POR 30 DIAS




Calcium Channel Modifying Agents

CELONTIN CAP300MG 4 ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 LYRICA CAP100MG 3 QL 180 POR 30 DIAS

zonisamide cap 100 mg 2 zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam orally disintegrating tab 0.5 mg 2 QL 1200 POR 30 DIAS

clonazepam orally disintegrating tab 1 mg 2 QL 600 POR 30 DIAS

clonazepam tab 1 mg 2 QL 600 POR 30 DIAS

DIASTAT ACDLGEL12.5-20 4 QL 40 POR 30 DIAS

DIASTAT ACDLGEL5-10MG 4 QL 30 POR 30 DIAS


22

Nombre de Medicamentos Nivel Requisitos/Limites DIASTAT PED GEL2.5M GEL 4 QL 30 POR 30 DIAS

diazepam conc 5 mg/ml 2 QL 240 POR 30 DIAS

diazepam oral soln 1 mg/ml 2 QL 1200 POR 30 DIAS

diazepam tab 10 mg 2 QL 180 POR 30 DIAS



gabapentin cap 100 mg 2 QL 360 POR 30 DIAS



gabapentin oral soln 250 mg/5ml 2 QL 2160 POR 30 DIAS

gabapentin tab 600 mg 2 QL 180 POR 30 DIAS

gabapentin tab 800 mg 2 QL 120 POR 30 DIAS

GABITRIL TAB12MG 4 GABITRIL TAB16MG 5 ONFI SUS2.5MG/ML 5 QL 480 POR 30 DIAS

ONFI TAB10MG 5 QL 60 POR 30 DIAS

ONFI TAB20MG 5 QL 60 POR 30 DIAS

PHENOBARB TAB100MG 2 QL 90 POR 30 DIAS




phenobarbital elixir 20 mg/5ml 2 QL 1500 POR 30 DIAS

phenobarbital tab 16.2 mg 2 QL 360 POR 30 DIAS




primidone tab 250 mg 2 primidone tab 50 mg 2 SABRIL POW500MG 5 LA; QL 180 POR 30 DIAS

SABRIL TAB500MG 5 LA; QL 180 POR 30 DIAS

tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 tiagabine hcl tab 12 mg 4

tiagabine hcl tab 16 mg 4

valproate sodium inj 100 mg/ml 4 vigabatrin pak500mg 5 LA; QL 180 POR 30 DIAS

Glutamate Reducing Agents

felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 FYCOMPA SUS0.5MG/ML 5 QL 720 POR 30 DIAS

FYCOMPA TAB10MG 4 QL 30 POR 30 DIAS




23

Nombre de Medicamentos Nivel Requisitos/Limites FYCOMPA TAB4MG 4 QL 90 POR 30 DIAS



lamotrigine kitstart 35 4



lamotrigine orally disintegrating tab 100 mg 2 topiramate sprinkle cap 25 mg 2 Sodium Channel Agents

APTIOM TAB200MG 5 QL 180 POR 30 DIAS




BANZEL SUS40MG/ML 5 QL 2400 POR 30 DIAS

BANZEL TAB200MG 5 QL 240 POR 30 DIAS

BANZEL TAB400MG 5 QL 240 POR 30 DIAS

carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 400 mg 2 DILANTIN CAP30MG 3 EQUETRO CAP300MG 4 QL 180 POR 30 DIAS

fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 4 B/D PA

oxcarbazepine susp 300 mg/5ml (60 mg/ml) 2 oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 OXTELLAR XR TAB150MG 4 QL 480 POR 30 DIAS

OXTELLAR XR TAB300MG 4 QL 240 POR 30 DIAS

OXTELLAR XR TAB600MG 4 QL 120 POR 30 DIAS

PEGANONE TAB250MG 4 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 4 B/D PA

phenytoin susp 125 mg/5ml 2 VIMPAT INJ200MG/20 5 QL 1200 POR 30 DIAS

VIMPAT SOL10MG/ML 5 QL 1200 POR 30 DIAS

VIMPAT TAB100MG 5 QL 60 POR 30 DIAS




ANTIDEMENTIA AGENTS


24

Nombre de Medicamentos Nivel Requisitos/Limites Antidementia Agents, Other

ergoloid mesylates tab 1 mg 2 Cholinesterase Inhibitors

donepezil hydrochloride orally disintegrating tab 10 mg 4 QL 30 POR 30 DIAS

donepezil hydrochloride orally disintegrating tab 5 mg 4 QL 30 POR 30 DIAS

donepezil hydrochloride tab 10 mg 1 QL 30 POR 30 DIAS

donepezil hydrochloride tab 5 mg 2 QL 30 POR 30 DIAS

galantamine hydrobromide cap sr 24hr 16 mg 4 QL 30 POR 30 DIAS



galantamine hydrobromide oral soln 4 mg/ml 4 QL 180 POR 30 DIAS

galantamine hydrobromide tab 12 mg 4 QL 60 POR 30 DIAS



rivastigmine tartrate cap 1.5 mg 4 QL 60 POR 30 DIAS

rivastigmine tartrate cap 3 mg 4 QL 60 POR 30 DIAS

rivastigmine tartrate cap 4.5 mg 4 QL 60 POR 30 DIAS

rivastigmine tartrate cap 6 mg 4 QL 60 POR 30 DIAS

rivastigmine td patch 24hr 13.3 mg/24hr 2 QL 30 POR 30 DIAS



N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hccap14mg er 2 QL 30 POR 30 DIAS




memantine hcl oral solution 2 mg/ml 2 QL 360 POR 30 DIAS

memantine hcl tab 10 mg 2 QL 60 POR 30 DIAS

memantine hcl tab 5 mg 2 QL 60 POR 30 DIAS

memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 4 QL 60 POR 30 DIAS

ANTIDEPRESSANTS Antidepressants

olanzapine-fluoxetine hcl cap 12-25 mg 4 QL 30 POR 30 DIAS





perphenazine-amitriptyline tab 2-10 mg 4 perphenazine-amitriptyline tab 2-25 mg 4 perphenazine-amitriptyline tab 4-10 mg 4 perphenazine-amitriptyline tab 4-25 mg 4 perphenazine-amitriptyline tab 4-50 mg 4 Antidepressants, Other


25

Nombre de Medicamentos Nivel Requisitos/Limites ABILIFY MAININJ400MG 5

aripiprazolesol1mg/ml 2

ARISTADA INJ1064MG 5 QL 3.9 POR 56 DIAS

bupropion hcl tab 100 mg 2 QL 120 POR 30 DIAS

bupropion hcl tab 75 mg 1 QL 180 POR 30 DIAS

bupropion hcl tab sr 12hr 100 mg 2 QL 60 POR 30 DIAS





mirtazapine orally disintegrating tab 15 mg 2 QL 30 POR 30 DIAS



mirtazapine tab 15 mg 2 QL 30 POR 30 DIAS



mirtazapine tab 7.5 mg 2 QL 30 POR 30 DIAS

QUETIAPINE TAB300MG ER 2 QL 60 POR 30 DIAS


quetiapine fumarate tab 300 mg 2 QL 90 POR 30 DIAS


SEROQUEL XR TAB300MG 3 QL 60 POR 30 DIAS


Monoamine Oxidase Inhibitors

EMSAM DIS12MG/24H 5 QL 30 POR 30 DIAS

EMSAM DIS6MG/24HR 5 QL 30 POR 30 DIAS

EMSAM DIS9MG/24HR 5 QL 30 POR 30 DIAS

MARPLAN TAB10MG 4 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine

Reuptake Inhibitors)

citalopram hydrobromide oral soln 10 mg/5ml 2 QL 600 POR 30 DIAS

citalopram hydrobromide tab 10 mg (base equiv) 2 QL 30 POR 30 DIAS; FFF



DESVENLAFAX TAB100MG ER 4 QL 120 POR 30 DIAS

DESVENLAFAX TAB50MG ER 4 QL 240 POR 30 DIAS

desvenlafaxine succinate tab sr 24hr 100 mg (base


desvenlafaxine succinate tab sr 24hr 25 mg (base equiv) 2 QL 240 POR 30 DIAS

desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) 2 QL 240 POR 30 DIAS

duloxetine hcl enteric coated pellets cap 40 mg 2 QL 90 POR 30 DIAS

FETZIMA CAP120MG 4 QL 30 POR 30 DIAS


26

Nombre de Medicamentos Nivel Requisitos/Limites FETZIMA CAP20MG 4 QL 180 POR 30 DIAS



FETZIMA CAPTITRATIO 4 QL 28 POR 28 DIAS

fluoxetine hcl cap 10 mg 2 QL 30 POR 30 DIAS



fluoxetine hcl cap delayed release 90 mg 1 QL 5 POR 30 DIAS

fluoxetine hcl solution 20 mg/5ml 2 QL 600 POR 30 DIAS

fluoxetine hcl tab 10 mg 1 QL 30 POR 30 DIAS

fluoxetine hcl tab 20 mg 1 QL 120 POR 30 DIAS

fluvoxamine maleate tab 100 mg 2 QL 90 POR 30 DIAS



KHEDEZLA TAB100MG ER 4 QL 120 POR 30 DIAS

KHEDEZLA TAB50MG ER 4 QL 240 POR 30 DIAS

maprotiline hcl tab 25 mg 2 QL 270 POR 30 DIAS

maprotiline hcl tab 50 mg 2 QL 135 POR 30 DIAS

maprotiline hcl tab 75 mg 2 nefazodone hcl tab 100 mg 2 QL 180 POR 30 DIAS

nefazodone hcl tab 150 mg 2 QL 120 POR 30 DIAS




trazodone hcl tab 100 mg 2 trazodone hcl tab 150 mg 2 trazodone hcl tab 300 mg 2 trazodone hcl tab 50 mg 2 TRINTELLIX TAB10MG 4 QL 60 POR 30 DIAS

TRINTELLIX TAB20MG 4 QL 30 POR 30 DIAS

TRINTELLIX TAB5MG 4 QL 120 POR 30 DIAS

venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 2 QL 60 POR 30 DIAS; FFF

venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 2 QL 90 POR 30 DIAS; FFF

venlafaxine hcl tab 100 mg 2 QL 90 POR 30 DIAS


venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 4 QL 90 POR 30 DIAS

VIIBRYD KITSTARTER 4 VIIBRYD TAB10MG 4 QL 120 POR 30 DIAS

VIIBRYD TAB20MG 4 QL 60 POR 30 DIAS

VIIBRYD TAB40MG 4 QL 30 POR 30 DIAS

Tricyclics

amitriptyline hcl tab 10 mg 2 amitriptyline hcl tab 100 mg 2 amitriptyline hcl tab 150 mg 2


27

Nombre de Medicamentos Nivel Requisitos/Limites amitriptyline hcl tab 25 mg 2 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 2 amitriptyline hcl tab 75 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 clomipramine hcl cap 25 mg 2 clomipramine hcl cap 50 mg 2 clomipramine hcl cap 75 mg 2 desipramine hcl tab 10 mg 2 desipramine hcl tab 100 mg 2 desipramine hcl tab 150 mg 2 desipramine hcl tab 25 mg 2 desipramine hcl tab 50 mg 2 desipramine hcl tab 75 mg 2 doxepin hcl cap 25 mg 2 imipramine hcl tab 10 mg 2 imipramine hcl tab 25 mg 2 imipramine hcl tab 50 mg 2 nortriptyline hcl cap 10 mg 2 nortriptyline hcl cap 25 mg 2 nortriptyline hcl cap 50 mg 2 nortriptyline hcl cap 75 mg 2 nortriptyline hcl soln 10 mg/5ml 2 protriptyline hcl tab 10 mg 2 protriptyline hcl tab 5 mg 2 trimipramine maleate cap 100 mg 2 trimipramine maleate cap 25 mg 2 trimipramine maleate cap 50 mg 2 ANTIEMETICS Antiemetics, Other

chlorpromazine hcl inj 50 mg/2ml 4 meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 1 prochlorperazine suppos 25 mg 2 Emetogenic Therapy Adjuncts

aprepitant capsule 125 mg 2

QL 30 POR 30 DIAS; B/D

PA



PA



PA


28


aprepitant capsule therapy pack 80 & 125 mg 2


PA

dronabinol cap 2.5 mg 4

QL 120 POR 30 DIAS;

B/D PA

dronabinol cap 5 mg 4

QL 120 POR 30 DIAS;

B/D PA

EMEND SUS125MG 4 B/D PA

granisetron hcl tab 1 mg 4


PA

ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 B/D PA

ondansetron hcl oral soln 4 mg/5ml 2

QL 450 POR 30 DIAS;

B/D PA

ondansetron hcl tab 24 mg 2


PA



PA



PA

ondansetron orally disintegrating tab 4 mg 2 B/D PA

ondansetron orally disintegrating tab 8 mg 2 B/D PA

SYNDROS SOL5MG/ML 5 B/D PA

ANTIFUNGALS Antifungals

ABELCET INJ5MG/ML 5 PA

AMBISOME INJ50MG 5 B/D PA

amphotericin b for inj 50 mg 4 PA

CANCIDAS INJ50MG 5 B/D PA

CANCIDAS INJ70MG 5 B/D PA

CASPOFUNGIN INJ50MG 5 B/D PA

CASPOFUNGIN INJ70MG 5 B/D PA

ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base equiv) 2 ciclopirox olamine susp 0.77% (base equiv) 2 ciclopirox shampoo 1% 2 ciclopirox solution 8% 2 clotrimazole cream 1% 2 clotrimazole soln 1% 2 clotrimazole troche 10 mg 2 econazole nitrate cream 1% 4 ERAXIS INJ100MG 5 PA

fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 4 fluconazole tab 100 mg 2


29

Nombre de Medicamentos Nivel Requisitos/Limites fluconazole tab 150 mg 1 fluconazole tab 200 mg 2 fluconazole tab 50 mg 2 flucytosine cap 250 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 griseofulvin ultramicrosize tab 250 mg 2 itraconazole cap 100 mg 2 ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 ketoconazole tab 200 mg 2 miconazole nitrate vaginal suppos 200 mg 2 QL 3 POR 3 DIAS

NATACYN SUS5% OP 4 NOXAFIL SUS40MG/ML 5 QL 630 POR 30 DIAS

NOXAFIL TAB100MG 5 nystatin cream 100000 unit/gm 2 nystatin oint 100000 unit/gm 2 nystatin susp 100000 unit/ml 2 nystatin tab 500000 unit 2 nystatin topical powder 100000 unit/gm 2 nystatin-triamcinolone cream 100000-0.1 unit/gm-% 4 nystatin-triamcinolone oint 100000-0.1 unit/gm-% 4 terbinafine hcl tab 250 mg 2 QL 30 POR 30 DIAS

terconazole vaginal cream 0.4% 2 terconazole vaginal cream 0.8% 2 terconazole vaginal suppos 80 mg 2 voriconazole for inj 200 mg 4 PA

voriconazole for susp 40 mg/ml 5 PA

voriconazole tab 200 mg 5 QL 60 POR 30 DIAS; PA

voriconazole tab 50 mg 5 QL 120 POR 30 DIAS; PA

ANTIGOUT AGENTS Antigout Agents

allopurinol sodium for inj 500 mg 5 B/D PA

allopurinol tab 300 mg 2 colchicine w/ probenecid tab 0.5-500 mg 2 COLCRYS TAB0.6MG 4 QL 120 POR 30 DIAS

probenecid tab 500 mg 2 ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs

celecoxib cap 100 mg 2 QL 60 POR 30 DIAS



30

Nombre de Medicamentos Nivel Requisitos/Limites celecoxib cap 400 mg 2 QL 60 POR 30 DIAS


diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 mg 2 diclofenac sodium tab delayed release 50 mg 2 diclofenac sodium tab delayed release 75 mg 2 diclofenac sodium tab sr 24hr 100 mg 2 diflunisal tab 500 mg 2 etodolac cap 200 mg 4 etodolac cap 300 mg 4 fenoprofen calcium tab 600 mg 2 FLECTOR DIS1.3% 4 QL 60 POR 30 DIAS; PA

flurbiprofen tab 100 mg 2 flurbiprofen tab 50 mg 2 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 2 FFF

ibu tab 600 mg 2

ibu tab 800 mg 2

ibuprofen tab 600 mg 2 FFF

ibuprofen tab 800 mg 2 FFF

meloxicam tab 15 mg 2 QL 30 POR 30 DIAS; FFF

meloxicam tab 7.5 mg 2 QL 30 POR 30 DIAS; FFF

nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen sodium tab 275 mg 4 naproxen sodium tab 550 mg 4 naproxen susp 125 mg/5ml 4 naproxen tab 250 mg 2 naproxen tab 375 mg 2 naproxen tab 500 mg 2 naproxen tab ec 375 mg 4 naproxen tab ec 500 mg 4 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 ANTIMIGRAINE AGENTS Antimigraine Agents

ergotamine w/ caffeine suppos 2-100 mg 4 Ergot Alkaloids

dihydroergotamine mesylate inj 1 mg/ml 3 DIHYDROERGOTSPR4MG/ML 5 QL 16 POR 30 DIAS

ergotamine w/ caffeine tab 1-100 mg 1


31

Nombre de Medicamentos Nivel Requisitos/Limites Prophylactic

divalproex sodium tab delayed release 125 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 5 mg 2 topiramate sprinkle cap 15 mg 2 topiramate tab 100 mg 2 QL 480 POR 30 DIAS

topiramate tab 200 mg 2 QL 240 POR 30 DIAS



Serotonin (5-HT) 1b/1d Receptor Agonists

naratriptan hcl tab 1 mg (base equiv) 2 QL 9 POR 30 DIAS

naratriptan hcl tab 2.5 mg (base equiv) 2 QL 9 POR 30 DIAS

sumatriptan succinate inj 6 mg/0.5ml 4 QL 6 POR 30 DIAS

sumatriptan succinate tab 100 mg 2 QL 12 POR 30 DIAS



ANTIMYASTHENIC AGENTS Parasympathomimetics

GUANIDINE TAB125MG 4 MESTINON SYP60MG/5ML 4 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab cr 180 mg 2 ANTIMYCOBACTERIALS Antimycobacterials

aminosalicylic acid cr granules packet 4 gm 2 RIFAMATE CAP 4 Antimycobacterials, Other

dapsone tab 100 mg 2 dapsone tab 25 mg 2 rifabutin cap 150 mg 4 Antituberculars

CAPASTAT SULINJ1GM 4 B/D PA

ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 4 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PRIFTIN TAB150MG 4 pyrazinamide tab 500 mg 2 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 4 B/D PA


32

Nombre de Medicamentos Nivel Requisitos/Limites RIFATER TAB 5 SIRTURO TAB100MG 5 TRECATOR TAB250MG 4 ANTINEOPLASTICS Alkylating Agents

busulfan inj 6 mg/ml 5 B/D PA

CYCLOPHOSPH CAP25MG 4 B/D PA

CYCLOPHOSPH CAP50MG 4 B/D PA

GLEOSTINE CAP100MG 4 GLEOSTINE CAP10MG 4 GLEOSTINE CAP40MG 4 GLEOSTINE CAP5MG 4 HEXALEN CAP50MG 5 ifosfamide for inj 1 gm 4 LEUKERAN TAB2MG 3 MATULANE CAP50MG 5 LA

melphalan hcl for inj 50 mg (base equiv) 4 MUSTARGEN INJ10MG 5 TREANDA INJ25MG 5

TREANDA INJ100MG 5 VALCHLOR GEL0.016% 5 YONDELIS INJ1MG 5 LA; B/D PA

Antiandrogens

bicalutamide tab 50 mg 2 QL 30 POR 30 DIAS

ERLEADA TAB60MG 5 QL 120 POR 30 DIAS

flutamide cap 125 mg 2 nilutamide tab 150 mg 2 QL 30 POR 30 DIAS

XTANDI CAP40MG 5 LA; QL 120 POR 30 DIAS

YONSA TAB125MG 5 QL 120 POR 30 DIAS

ZYTIGA TAB250MG 5 LA; QL 120 POR 30 DIAS

ZYTIGA TAB500MG 5 LA; QL 60 POR 30 DIAS

Antiangiogenic Agents

POMALYST CAP1MG 5 LA; QL 120 POR 30 DIAS




REVLIMID CAP10MG 5 LA; QL 60 POR 30 DIAS


REVLIMID CAP2.5MG 5 LA; QL 30 POR 30 DIAS




THALOMID CAP100MG 5 QL 30 POR 30 DIAS


33

Nombre de Medicamentos Nivel Requisitos/Limites THALOMID CAP150MG 5 QL 60 POR 30 DIAS



Antiestrogens/Modifiers

EMCYT CAP140MG 5 FARESTON TAB60MG 5 QL 30 POR 30 DIAS

SOLTAMOX SOL10MG/5ML 5 tamoxifen citrate tab 10 mg (base equivalent) 2 tamoxifen citrate tab 20 mg (base equivalent) 2 Antimetabolites

DROXIA CAP200MG 4 DROXIA CAP300MG 4 DROXIA CAP400MG 4 hydroxyurea cap 500 mg 2 PURIXAN SUS20MG/ML 5 LA

TABLOID TAB40MG 5 Antineoplastics

ABRAXANE INJ100MG 5 ALIMTA INJ100MG 5 B/D PA

ALIMTA INJ500MG 5 B/D PA

ARRANON INJ5MG/ML 5 B/D PA

AVASTIN INJ 5 LA; B/D PA

AVASTIN INJ400/16ML 5 LA; B/D PA

BICNU INJ100MG 5 bleomycin sulfate for inj 30 unit 4 B/D PA

BORTEZOMIB INJ3.5MG 5 B/D PA

carboplatin iv soln 150 mg/15ml 4 cisplatin inj 100 mg/100ml (1 mg/ml) 4 B/D PA

clofarabine iv soln 1 mg/ml 5 COSMEGEN INJ0.5MG 5 dacarbazine for inj 200 mg 4 DARZALEX SOL100MG/5M 5 LA; B/D PA

dactinomycininj0.5mg 5 B/D PA

daunorubicin hcl inj 5 mg/ml (base equiv) 4 dexrazoxane for inj 250 mg 4 DOCETAXEL INJ80MG/4ML 5 DOCETAXEL INJ80MG/8ML 5 doxorubicin hcl inj 2 mg/ml 4 doxorubicin hcl inj 2 mg/ml 4 B/D PA

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 2 B/D PA

epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2 B/D PA

ERBITUX INJ100MG 5 FASLODEX INJ250MG 5 FOLOTYN INJ40MG/2ML 5


34

Nombre de Medicamentos Nivel Requisitos/Limites HALAVEN INJ1MG/2ML 5 B/D PA

HERCEPTIN INJ440MG 5 LA; B/D PA

hydroxyprogesterone caproate im in oil 1.25 gm/5ml 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 4 B/D PA

IMFINZI INJ120/2.4 5 B/D PA

IMFINZI INJ500/10 5 B/D PA

irinotecan hcl inj 100 mg/5ml (20 mg/ml) 4 KADCYLA INJ100MG 5 LA

KADCYLA INJ160MG 5 LA

KEYTRUDA INJ100MG/4M 5 B/D PA

KEYTRUDA SOL50MG 5 B/D PA

KISQALI 200 PAKFEMARA 5 QL 49 POR 28 DIAS



levoleucovorinj50mg 5 B/D PA

mitomycin for iv soln 20 mg 4 mitomycin for iv soln 40 mg 4 mitomycin for iv soln 5 mg 4 NIPENT INJ10MG 5 oxaliplatin inj100mg 4

oxaliplatin iv soln 100 mg/20ml 4 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 4 PERJETA INJ420/14ML 5 LA; B/D PA

PROLEUKIN INJ22MU 5 B/D PA

SYNRIBO INJ3.5MG 5 B/D PA

thiotepa for inj 15 mg 5 B/D PA

TRISENOX SOL10MG/10M 5 B/D PA

TRISENOX SOL12MG/6ML 5 B/D PA

VECTIBIX INJ100MG 5 VERZENIO TAB100MG 5 QL 112 POR 28 DIAS

VERZENIO TAB150MG 5 QL 56 POR 28 DIAS



vinblastine sulfate inj 1 mg/ml 4 B/D PA

vincristine sulfate iv soln 1 mg/ml 4 B/D PA

vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base

equiv) 4 VYXEOS INJ44-100MG 5 B/D PA

ZALTRAP INJ100/4ML 5 B/D PA

ZANOSAR INJ1GM 5 B/D PA

Antineoplastics, Other

cladribine iv soln 10 mg/10ml (1 mg/ml) 5 B/D PA

CLOLAR INJ1MG/ML 5 cytarabine inj 20 mg/ml 4 B/D PA


35

Nombre de Medicamentos Nivel Requisitos/Limites cytarabine inj pf 100 mg/ml 4 B/D PA

decitabine for inj 50 mg 5 B/D PA

ERWINAZE INJ10000UNT 5 B/D PA

fludarabine phosphate for inj 50 mg 4 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 4 B/D PA

gemcitabine hcl for inj 1 gm 5 B/D PA

ISTODAX OVR INJ10MG 5 B/D PA

KYPROLIS SOL30MG 5 LA; B/D PA

KYPROLIS SOL60MG 5 LA; B/D PA

leucovorin calcium for inj 100 mg 4 B/D PA

leucovorin calcium for inj 350 mg 4 B/D PA

leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 2 leucovorin calcium tab 25 mg 2 leucovorin calcium tab 5 mg 2 LONSURF TAB15-6.14 5 QL 110 POR 28 DIAS

LONSURF TAB20-8.19 5 QL 80 POR 28 DIAS

mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 4 B/D PA

NINLARO CAP2.3MG 5 QL 3 POR 28 DIAS

NINLARO CAP3MG 5 QL 3 POR 28 DIAS

NINLARO CAP4MG 5 QL 3 POR 28 DIAS

RUBRACA TAB200MG 5 LA; QL 180 POR 30 DIAS



VELCADE INJ3.5MG 5 B/D PA

ZOLINZA CAP100MG 5 QL 120 POR 30 DIAS

Aromatase Inhibitors, 3rd Generation

anastrozole tab 1 mg 2 QL 30 POR 30 DIAS

exemestane tab 25 mg 2 QL 60 POR 30 DIAS

letrozole tab 2.5 mg 2 QL 30 POR 30 DIAS

Enzyme Inhibitors

ETOPOPHOS INJ100MG 5 B/D PA

etoposide inj 1 gm/50ml (20 mg/ml) 4 B/D PA

etoposide inj 500 mg/25ml (20 mg/ml) 3 B/D PA

topotecan hcl for inj 4 mg 5 Molecular Target Inhibitors

AFINITOR TAB10MG 5 QL 60 POR 30 DIAS

AFINITOR TAB2.5MG 5 QL 60 POR 30 DIAS

AFINITOR TAB5MG 5 QL 60 POR 30 DIAS

AFINITOR TAB7.5MG 5 QL 60 POR 30 DIAS

AFINITOR DISTAB2MG 5 QL 150 POR 30 DIAS



ALECENSA CAP150MG 5 LA; QL 240 POR 30 DIAS


36

Nombre de Medicamentos Nivel Requisitos/Limites ALIQOPA INJ60MG 5 B/D PA

ALUNBRIG PAK 5 QL 30 POR 30 DIAS

ALUNBRIG TAB30MG 5 QL 180 POR 30 DIAS



BELEODAQ INJ500MG 5 B/D PA

BOSULIF TAB100MG 5 QL 120 POR 30 DIAS



CABOMETYX TAB20MG 5 LA; QL 120 POR 30 DIAS



CALQUENCE CAP100MG 5 LA; QL 60 POR 30 DIAS

CAPRELSA TAB100MG 5 LA; QL 60 POR 30 DIAS

CAPRELSA TAB300MG 5 LA; QL 30 POR 30 DIAS

COMETRIQ KIT100MG 5 LA; QL 56 POR 28 DIAS



COTELLIC TAB20MG 5 LA; QL 63 POR 28 DIAS

CYRAMZA INJ100/10ML 5 LA; B/D PA

CYRAMZA INJ500/50ML 5 LA; B/D PA

ERIVEDGE CAP150MG 5 LA; QL 30 POR 30 DIAS

FARYDAK CAP10MG 5 LA



GILOTRIF TAB20MG 5 LA; QL 30 POR 30 DIAS



IBRANCE CAP100MG 5 LA; QL 30 POR 30 DIAS



ICLUSIG TAB15MG 5 LA; QL 90 POR 30 DIAS

ICLUSIG TAB45MG 5 LA

IDHIFA TAB100MG 5 QL 30 POR 30 DIAS

IDHIFA TAB50MG 5 QL 60 POR 30 DIAS

imatinib mesylate tab 100 mg (base equivalent) 5 QL 90 POR 30 DIAS

imatinib mesylate tab 400 mg (base equivalent) 5 QL 60 POR 30 DIAS

IMBRUVICA CAP140MG 5 LA; QL 120 POR 30 DIAS

IMBRUVICA CAP70MG 5 LA; QL 240 POR 30 DIAS

IMBRUVICA TAB140MG 5 LA; QL 120 POR 30 DIAS




INLYTA TAB1MG 5 LA; QL 240 POR 30 DIAS


37

Nombre de Medicamentos Nivel Requisitos/Limites INLYTA TAB5MG 5 LA; QL 120 POR 30 DIAS

IRESSA TAB250MG 5 LA; QL 30 POR 30 DIAS

JAKAFI TAB10MG 5 LA; QL 60 POR 30 DIAS





JEVTANA INJ60/1.5ML 5 B/D PA

KISQALI TAB200DOSE 5 QL 21 POR 28 DIAS



LENVIMA CAP10 MG 5 LA






LYNPARZA CAP50MG 5 LA; QL 480 POR 30 DIAS

LYNPARZA TAB100MG 5 QL 180 POR 30 DIAS

LYNPARZA TAB150MG 5 QL 120 POR 30 DIAS

MEKINIST TAB0.5MG 5 QL 120 POR 30 DIAS

MEKINIST TAB2MG 5 QL 30 POR 30 DIAS

NERLYNX TAB40MG 5 QL 180 POR 30 DIAS

NEXAVAR TAB200MG 5 LA; QL 120 POR 30 DIAS

ODOMZO CAP200MG 5 QL 30 POR 30 DIAS

RYDAPT CAP25MG 5 QL 224 POR 28 DIAS

SPRYCEL TAB100MG 5 QL 30 POR 30 DIAS






STIVARGA TAB40MG 5 LA; QL 84 POR 28 DIAS

SUTENT CAP12.5MG 5 QL 90 POR 30 DIAS

SUTENT CAP25MG 5 QL 30 POR 30 DIAS

SUTENT CAP37.5MG 5 QL 30 POR 30 DIAS

SUTENT CAP50MG 5 QL 30 POR 30 DIAS

TAFINLAR CAP50MG 5 QL 180 POR 30 DIAS

TAFINLAR CAP75MG 5 QL 120 POR 30 DIAS

TAGRISSO TAB40MG 5 LA; QL 60 POR 30 DIAS

TAGRISSO TAB80MG 5 LA; QL 30 POR 30 DIAS

TARCEVA TAB100MG 5 LA; QL 30 POR 30 DIAS




38

Nombre de Medicamentos Nivel Requisitos/Limites TASIGNA CAP50MG 5 QL 480 POR 30 DIAS

TASIGNA CAP150MG 5 QL 120 POR 30 DIAS

TASIGNA CAP200MG 5 QL 120 POR 30 DIAS

TYKERB TAB250MG 5 LA; QL 180 POR 30 DIAS

VENCLEXTA TAB100MG 5 LA; QL 112 POR 28 DIAS

VENCLEXTA TAB10MG 4

LA; QL 1120 POR 28

DIAS

VENCLEXTA TAB50MG 4 LA; QL 224 POR 28 DIAS

VENCLEXTA TABSTART PK 5 LA; QL 42 POR 28 DIAS

VOTRIENT TAB200MG 5 QL 120 POR 30 DIAS

XALKORI CAP200MG 5 LA; QL 60 POR 30 DIAS

XALKORI CAP250MG 5 LA; QL 60 POR 30 DIAS

ZEJULA CAP100MG 5 QL 90 POR 30 DIAS

ZELBORAF TAB240MG 5 LA; QL 240 POR 30 DIAS

ZYDELIG TAB100MG 5 LA; QL 90 POR 30 DIAS

ZYDELIG TAB150MG 5 LA; QL 60 POR 30 DIAS

ZYKADIA CAP150MG 5 LA; QL 150 POR 30 DIAS

Monoclonal Antibody/Antibody-Drug Conjugate

BAVENCIO INJ20MG/ML 5 LA; B/D PA

EMPLICITI INJ300MG 5 B/D PA

EMPLICITI INJ400MG 5 B/D PA

LARTRUVO INJ190MG/19ML 5 LA; B/D PA

LARTRUVO INJ10MG/ML 5 LA; B/D PA

MYLOTARG INJ4.5MG 5 B/D PA

OPDIVO INJ40MG/4ML 5 B/D PA

OPDIVO INJ100MG/10ML 5 B/D PA

RITUXAN INJ500MG 5 LA; B/D PA

RITUXAN INJ100MG 5 LA; B/D PA

TECENTRIQ INJ1200/20 5 LA; B/D PA

YERVOY INJ50MG 5 LA; B/D PA

Retinoids

bexarotene cap 75 mg 5 PANRETIN GEL0.1% 5 TARGRETIN GEL1% 5 QL 60 POR 30 DIAS

tretinoin cap 10 mg 5 Treatment Adjuncts

allopurinol tab 100 mg 1 ELITEK INJ1.5MG 5 B/D PA

ELITEK INJ7.5MG 5 B/D PA

mesna inj 100 mg/ml 4 PA

MESNEX TAB400MG 5 ANTIPARASITICS Antihelminthics


39

Nombre de Medicamentos Nivel Requisitos/Limites ALBENZA TAB200MG 5 BILTRICIDE TAB600MG 4 ivermectin tab 3 mg 2 Antiprotozoals

ALINIA SUS100/5ML 4 QL 180 POR 3 DIAS

ALINIA TAB500MG 5 atovaquone susp 750 mg/5ml 5 PA

atovaquone-proguanil hcl tab 250-100 mg 2 chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 COARTEM TAB20-120MG 4 DARAPRIM TAB25MG 5 hydroxychloroquine sulfate tab 200 mg 2 mefloquine hcl tab 250 mg 2 NEBUPENT INH300MG 4 PA

PENTAM 300 INJ300MG 4 PA

primaquine phosphate tab 26.3 mg (15 mg base) 4 quinine sulfate cap 324 mg 2 Pediculicides/Scabicides

lindane shampoo 1% 2 malathion lotion 0.5% 2 permethrin cream 5% 2 ANTIPARKINSON AGENTS Anticholinergics

benztropine mesylate inj 1 mg/ml 4 benztropine mesylate tab 0.5 mg 2 PA

benztropine mesylate tab 1 mg 2 PA

benztropine mesylate tab 2 mg 2 PA

diphenhydramine hcl inj 50 mg/ml 4 B/D PA

trihexyphenidyl hcl elixir 0.4 mg/ml 2 PA

trihexyphenidyl hcl tab 2 mg 2 PA

trihexyphenidyl hcl tab 5 mg 2 PA

Antiparkinson Agents, Other

amantadine hcl syrup 50 mg/5ml 4 tolcapone tab 100 mg 5 Dopamine Agonists

APOKYN INJ10MG/ML 5 LA; PA

NEUPRO DIS1MG/24HR 4 QL 30 POR 30 DIAS







40

Nombre de Medicamentos Nivel Requisitos/Limites pramipexole dihydrochloride tab 0.125 mg 2 QL 90 POR 30 DIAS

pramipexole dihydrochloride tab 0.25 mg 2 QL 90 POR 30 DIAS



pramipexole dihydrochloride tab 1 mg 2 QL 90 POR 30 DIAS


ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 ropinirole hydrochloride tab sr 24hr 12 mg (base

equivalent) 2 ropinirole hydrochloride tab sr 24hr 2 mg (base




equivalent) 2 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors

carbidopa & levodopa orally disintegrating tab 10-100

mg 2 carbidopa & levodopa orally disintegrating tab 25-100

mg 2 carbidopa & levodopa orally disintegrating tab 25-250

mg 1 carbidopa & levodopa tab 10-100 mg 2 carbidopa & levodopa tab 25-100 mg 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa & levodopa tab cr 25-100 mg 2 carbidopa & levodopa tab cr 50-200 mg 2 carbidopa tab 25 mg 2 Monoamine Oxidase B (MAO-B) Inhibitors

rasagiline mesylate tab 0.5 mg (base equiv) 2 rasagiline mesylate tab 1 mg (base equiv) 2 selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 ANTIPSYCHOTICS 1st Generation/Typical

chlorpromazine hcl tab 10 mg 2


41

Nombre de Medicamentos Nivel Requisitos/Limites chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 fluphenazine decanoate inj 25 mg/ml 4 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 4 fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 10 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 haloperidol decanoate im soln 100 mg/ml 4

haloperidol decanoate im soln 50 mg/ml 4 B/D PA

haloperidol lactate inj 5 mg/ml 4 haloperidol lactate oral conc 2 mg/ml 2 haloperidol tab 0.5 mg 2 haloperidol tab 1 mg 2 haloperidol tab 10 mg 2 haloperidol tab 2 mg 2 haloperidol tab 20 mg 2 haloperidol tab 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 5 mg 2 loxapine succinate cap 50 mg 2 perphenazine tab 16 mg 2 perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 pimozide tab 1 mg 4 pimozide tab 2 mg 4 prochlorperazine edisylate inj 5 mg/ml 4 prochlorperazine maleate tab 10 mg (base equivalent) 2 prochlorperazine maleate tab 5 mg (base equivalent) 2 thioridazine hcl tab 10 mg 2 thioridazine hcl tab 100 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thiothixene cap 1 mg 2 thiothixene cap 10 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 trifluoperazine hcl tab 1 mg 2


42

Nombre de Medicamentos Nivel Requisitos/Limites trifluoperazine hcl tab 10 mg 2 trifluoperazine hcl tab 2 mg 2 trifluoperazine hcl tab 5 mg 2 2nd Generation/Atypical

ABILIFY MAININJ300MG 5 QL 2 POR 28 DIAS

aripiprazole orally disintegrating tab 10 mg 5 QL 90 POR 30 DIAS

aripiprazole orally disintegrating tab 15 mg 5 QL 60 POR 30 DIAS

aripiprazole tab 15 mg 2 QL 60 POR 30 DIAS



ARISTADA INJ441MG/1. 5 QL 1.6 POR 28 DIAS

ARISTADA INJ662MG/2 5 QL 2.4 POR 28 DIAS

FANAPT PAK 4 QL 60 POR 30 DIAS

FANAPT TAB10MG 5 QL 90 POR 30 DIAS







INVEGA SUST INJ117/0.75 5 QL 2 POR 28 DIAS

INVEGA SUST INJ156MG/ML 5 QL 2 POR 28 DIAS



INVEGA SUST INJ78/0.5ML 5 QL 2 POR 28 DIAS

INVEGA TRINZINJ273MG 5 INVEGA TRINZINJ410MG 5 INVEGA TRINZINJ546MG 5 INVEGA TRINZINJ819MG 5 LATUDA TAB120MG 5 QL 30 POR 30 DIAS

LATUDA TAB20MG 5 QL 120 POR 30 DIAS




NUPLAZID TAB17MG 5 LA; QL 60 POR 30 DIAS

olanzapine orally disintegrating tab 10 mg 2 QL 60 POR 30 DIAS


olanzapine tab 2.5 mg 2

QL 240 POR 30 DIAS;

FFF

olanzapine tab 7.5 mg 2 QL 90 POR 30 DIAS; FFF

paliperidone tab sr 24hr 1.5 mg 5 QL 240 POR 30 DIAS

paliperidone tab sr 24hr 3 mg 5 QL 120 POR 30 DIAS




43

Nombre de Medicamentos Nivel Requisitos/Limites QUETIAPINE TAB200MG ER 2 QL 30 POR 30 DIAS



REXULTI TAB0.25MG 5 QL 480 POR 30 DIAS

REXULTI TAB0.5MG 5 QL 240 POR 30 DIAS

REXULTI TAB1MG 5 QL 120 POR 30 DIAS




risperidone orally disintegrating tab 2 mg 4 QL 240 POR 30 DIAS



risperidone soln 1 mg/ml 2 QL 480 POR 30 DIAS

risperidone tab 0.5 mg 2

QL 960 POR 30 DIAS;

FFF

risperidone tab 1 mg 1

QL 480 POR 30 DIAS;

FFF


QL 240 POR 30 DIAS;

FFF


QL 120 POR 30 DIAS;

FFF

SAPHRIS SUB2.5MG 5 QL 240 POR 30 DIAS


VRAYLAR CAP1.5-3MG 4 VRAYLAR CAP1.5MG 5 VRAYLAR CAP3MG 5 VRAYLAR CAP4.5MG 5 VRAYLAR CAP6MG 5 ziprasidone hcl cap 80 mg 2 QL 60 POR 30 DIAS

Treatment-Resistant

CLOZAPINE TAB12.5/ODT 2 QL 90 POR 30 DIAS

CLOZAPINE TAB150/ODT 2 QL 180 POR 30 DIAS

CLOZAPINE TAB200/ODT 5 QL 120 POR 30 DIAS

clozapine orally disintegrating tab 100 mg 2 QL 270 POR 30 DIAS

clozapine orally disintegrating tab 25 mg 2 QL 270 POR 30 DIAS

clozapine tab 100 mg 1 QL 120 POR 30 DIAS




FAZACLO TAB12.5 ODT 4 QL 90 POR 30 DIAS

FAZACLO TAB150 ODT 5 QL 180 POR 30 DIAS

FAZACLO TAB200 ODT 5 QL 120 POR 30 DIAS

VERSACLOZ SUS50MG/ML 5 QL 540 POR 30 DIAS

ANTISPASTICITY AGENTS


44

Nombre de Medicamentos Nivel Requisitos/Limites Antispasticity Agents

baclofen tab 5 mg 2

baclofen tab 10 mg 2 baclofen tab 20 mg 2 dantrolene sodium cap 100 mg 2 dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 tizanidine hcl cap 2 mg (base equivalent) 4 tizanidine hcl cap 4 mg (base equivalent) 4 tizanidine hcl cap 6 mg (base equivalent) 4 tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2 ANTIVIRALS Anti-cytomegalovirus (CMV) Agents

cidofovir iv inj 75 mg/ml 2 ganciclovir sodium for inj 500 mg 4 B/D PA

valganciclovir hcl for soln 50 mg/ml (base equiv) 2 valganciclovir hcl tab 450 mg (base equivalent) 5 ZIRGAN GEL0.15% 4 Anti-hepatitis B (HBV) Agents

adefovir dipivoxil tab 10 mg 5 BARACLUDE SOL.05MG/ML 5 QL 600 POR 30 DIAS; PA

entecavir tab 0.5 mg 5 QL 30 POR 30 DIAS; PA

entecavir tab 1 mg 5 QL 30 POR 30 DIAS; PA

EPIVIR HBV SOL5MG/ML 4 INTRON A INJ10MU 5 LA

INTRON A INJ18MU 5 LA


lamivudine tab 100 mg (hbv) 2 VIREAD POW40MG/GM 5 QL 240 POR 30 DIAS

VIREAD TAB150MG 5 QL 30 POR 30 DIAS




Anti-hepatitis C (HCV) Agents, Other



PEGASYS INJ 5 QL 2 POR 28 DIAS; PA

PEGASYS INJ180MCG/M 5 QL 4 POR 28 DIAS

PEGASYS INJPROCLICK 5 PEGASYS INJPROCLICK 5 QL 2 POR 28 DIAS; PA

REBETOL SOL40MG/ML 5 ribavirin cap 200 mg 4


45

Nombre de Medicamentos Nivel Requisitos/Limites ribavirin cap 200 mg 2 ribavirin tab 200 mg 4 ribavirin tab 200 mg 2 ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 5 ribavirin tab 400 mg 5 ribavirin tab 400 mg 4 ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 ribavirin tab 600 mg 5 SYLATRON KIT200MCG 5 QL 5 POR 28 DIAS

SYLATRON KIT300MCG 5 QL 5 POR 28 DIAS

SYLATRON KIT600MCG 5 QL 5 POR 28 DIAS

Anti-hepatitis C (HCV) Direct Acting Agents

HARVONI TAB90-400MG 5 QL 28 POR 28 DIAS; PA

OLYSIO CAP150MG 5 QL 30 POR 30 DIAS; PA

SOVALDI TAB400MG 5 QL 30 POR 30 DIAS; PA

TECHNIVIE TAB 5 QL 56 POR 28 DIAS; PA

VIEKIRA PAK TAB 5 QL 112 POR 28 DIAS; PA

VIEKIRA XR TAB 5 QL 84 POR 28 DIAS; PA

Antiherpetic Agents

acyclovir cap 200 mg 2 acyclovir oint 5% 2 QL 30 POR 30 DIAS

acyclovir sodium iv soln 50 mg/ml 4 B/D PA

acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 DENAVIR CRE1% 5 QL 5 POR 28 DIAS

famciclovir tab 125 mg 2 QL 60 POR 30 DIAS



trifluridine ophth soln 1% 2 valacyclovir hcl tab 1 gm 2 QL 30 POR 1 DIAS

valacyclovir hcl tab 500 mg 2 QL 30 POR 1 DIAS

ZOVIRAX CRE5% 5 QL 10 POR 30 DIAS

Anti-HIV Agents, Integrase Inhibitors (INSTI)

GENVOYA TAB 5 QL 30 POR 30 DIAS

ISENTRESS CHW100MG 5 QL 180 POR 30 DIAS

ISENTRESS CHW25MG 4 QL 720 POR 30 DIAS

ISENTRESS HDTAB600MG 5 QL 60 POR 30 DIAS

ISENTRESS POW100MG 5 QL 300 POR 30 DIAS

ISENTRESS TAB400MG 5 QL 120 POR 30 DIAS

STRIBILD TAB 5 QL 30 POR 30 DIAS

TIVICAY TAB10MG 4 QL 30 POR 30 DIAS




46

Nombre de Medicamentos Nivel Requisitos/Limites Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

ATRIPLA TAB 5 QL 30 POR 30 DIAS

COMPLERA TAB 5 QL 30 POR 30 DIAS

EDURANT TAB25MG 5 QL 30 POR 30 DIAS

efavirenz cap50mg 2 QL 360 POR 30 DIAS

efavirenz cap200mg 2 QL 120 POR 30 DIAS

efavirenz tab600mg 5 QL 30 POR 30 DIAS

INTELENCE TAB100MG 5 QL 120 POR 30 DIAS



NEVIRAPINE SUS50MG/5ML 4 nevirapine tab 200 mg 2 QL 60 POR 30 DIAS

nevirapine tab sr 24hr 100 mg 2 QL 120 POR 30 DIAS

nevirapine tab sr 24hr 400 mg 2 QL 30 POR 30 DIAS

ODEFSEY TAB 5 QL 30 POR 30 DIAS

RESCRIPTOR TAB100 MG 4 QL 360 POR 30 DIAS

RESCRIPTOR TAB200MG 4 QL 180 POR 30 DIAS

SUSTIVA CAP200MG 5 QL 120 POR 30 DIAS

SUSTIVA CAP50MG 4 QL 360 POR 30 DIAS

SUSTIVA TAB600MG 5 QL 30 POR 30 DIAS

VIRAMUNE SUS50MG/5ML 4 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sol20mg/ml 2 QL 960 POR 30 DIAS

abacavir sulfate tab 300 mg (base equiv) 2 QL 60 POR 30 DIAS

abacavir sulfate-lamivudine-zidovudine tab 300-150-

300 mg 5 QL 60 POR 30 DIAS

BIKTARVY TAB 5 QL 30 POR 30 DIAS

CIMDUO TAB300-300 5 QL 30 POR 30 DIAS

didanosine delayed release capsule 125 mg 2 QL 90 POR 30 DIAS




EMTRIVA CAP200MG 4 QL 30 POR 30 DIAS

EMTRIVA SOL10MG/ML 4 QL 850 POR 30 DIAS

JULUCA TAB50-25MG 5 QL 30 POR 30 DIAS

lamivudine oral soln 10 mg/ml 2 QL 900 POR 30 DIAS

lamivudine tab 150 mg 2 QL 60 POR 30 DIAS

lamivudine tab 300 mg 2 QL 30 POR 30 DIAS

lamivudine-zidovudine tab 150-300 mg 2 QL 60 POR 30 DIAS

RETROVIR INJ10MG/ML 4 stavudine cap 15 mg 2 QL 120 POR 30 DIAS

stavudine cap 20 mg 2 QL 120 POR 30 DIAS




47

Nombre de Medicamentos Nivel Requisitos/Limites SYMFI TAB 5 QL 30 POR 30 DIAS

SYMFI LO TAB 5 QL 30 POR 30 DIAS

TRUVADA TAB100-150 5 QL 60 POR 30 DIAS




VIDEX EC CAP125MG 4 QL 90 POR 30 DIAS

VIDEX SOL2GM 4 QL 1200 POR 30 DIAS

ZERIT SOL1MG/ML 5 QL 2400 POR 30 DIAS

ZIAGEN SOL20MG/ML 3 QL 960 POR 30 DIAS

zidovudine cap 100 mg 2 QL 180 POR 30 DIAS

zidovudine syrup 10 mg/ml 2 QL 1920 POR 30 DIAS

zidovudine tab 300 mg 2 QL 60 POR 30 DIAS

Anti-HIV Agents, Other

abacavir sulfate-lamivudine tab 600-300 mg 2 QL 30 POR 30 DIAS

DESCOVY TAB200/25 5 QL 30 POR 30 DIAS

FUZEON INJ90MG 5 QL 60 POR 30 DIAS

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 2 QL 480 POR 30 DIAS

SELZENTRY TAB150MG 5 QL 120 POR 30 DIAS




TYBOST TAB150MG 4 QL 30 POR 30 DIAS

Anti-HIV Agents, Protease Inhibitors

APTIVUS CAP250MG 5 QL 120 POR 30 DIAS

APTIVUS SOL 5 QL 300 POR 30 DIAS

atazanavir cap150mg 5 QL 60 POR 30 DIAS



CRIXIVAN CAP200MG 4 QL 360 POR 30 DIAS

CRIXIVAN CAP400MG 4 QL 180 POR 30 DIAS

EVOTAZ TAB300-150 5 QL 30 POR 30 DIAS

fosamprenavitab700mg 2 QL 120 POR 30 DIAS

INVIRASE CAP200MG 5 QL 300 POR 30 DIAS

INVIRASE TAB500MG 5 QL 120 POR 30 DIAS

KALETRA TAB100-25MG 4 QL 300 POR 30 DIAS

KALETRA TAB200-50MG 5 QL 120 POR 30 DIAS

LEXIVA SUS50MG/ML 4 QL 1800 POR 30 DIAS

NORVIR CAP100MG 4 QL 360 POR 30 DIAS

NORVIR POW100MG 4 QL 360 POR 30 DIAS

NORVIR SOL80MG/ML 4 QL 480 POR 30 DIAS

NORVIR TAB100MG 4 QL 360 POR 30 DIAS

PREZCOBIX TAB800-150 5 QL 30 POR 30 DIAS

PREZISTA SUS100MG/ML 5 QL 400 POR 30 DIAS


48

Nombre de Medicamentos Nivel Requisitos/Limites PREZISTA TAB150MG 5 QL 180 POR 30 DIAS

PREZISTA TAB600MG 5 QL 60 POR 30 DIAS



REYATAZ CAP150MG 5 QL 60 POR 30 DIAS



REYATAZ POW50MG 5 QL 240 POR 30 DIAS

ritonavir tab100mg 4 QL 360 POR 30 DIAS

VIRACEPT TAB250MG 5 QL 300 POR 30 DIAS

VIRACEPT TAB625MG 5 QL 120 POR 30 DIAS

Anti-influenza Agents

amantadine hcl cap 100 mg 2 amantadine hcl tab 100 mg 2 oseltamivir sus6mg/ml 2

RELENZA MISDISKHALE 3 QL 60 POR 180 DIAS

rimantadine hydrochloride tab 100 mg 2 Antivirals

oseltamivir phosphate cap 30 mg (base equiv) 2 oseltamivir phosphate cap 45 mg (base equiv) 2 oseltamivir phosphate cap 75 mg (base equiv) 2 TRIUMEQ TAB 5 QL 30 POR 30 DIAS

ANXIOLYTICS Anxiolytics, Other

buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2 buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 doxepin hcl cap 10 mg 2 doxepin hcl cap 100 mg 2 doxepin hcl cap 150 mg 1 doxepin hcl cap 50 mg 2 doxepin hcl cap 75 mg 2 doxepin hcl conc 10 mg/ml 2 hydroxyzine hcl im soln 25 mg/ml 4 B/D PA

hydroxyzine hcl im soln 50 mg/ml 4 PA

hydroxyzine hcl tab 25 mg 1 PA

hydroxyzine hcl tab 50 mg 4 PA

meprobamate tab 200 mg 2 PA

meprobamate tab 400 mg 2 PA

Benzodiazepines

alprazolam conc 1 mg/ml 2


49

Nombre de Medicamentos Nivel Requisitos/Limites alprazolam orally disintegrating tab 0.25 mg 2 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 QL 150 POR 30 DIAS

alprazolam tab 0.25 mg 2 QL 90 POR 30 DIAS

alprazolam tab 0.5 mg 2 QL 90 POR 30 DIAS

alprazolam tab 1 mg 2 QL 90 POR 30 DIAS

alprazolam tab 2 mg 2 QL 150 POR 30 DIAS

alprazolam tab sr 24hr 0.5 mg 2 QL 120 POR 30 DIAS

alprazolam tab sr 24hr 1 mg 2 QL 120 POR 30 DIAS



chlordiazepoxide hcl cap 10 mg 2 chlordiazepoxide hcl cap 25 mg 2 chlordiazepoxide hcl cap 5 mg 2 clonazepam orally disintegrating tab 0.125 mg 2 QL 4800 POR 30 DIAS

clonazepam orally disintegrating tab 0.25 mg 2 QL 2400 POR 30 DIAS

clonazepam orally disintegrating tab 2 mg 2 QL 300 POR 30 DIAS

clonazepam tab 0.5 mg 2 QL 1200 POR 30 DIAS

clonazepam tab 2 mg 2 QL 300 POR 30 DIAS

clorazepate dipotassium tab 15 mg 2 QL 180 POR 30 DIAS

clorazepate dipotassium tab 3.75 mg 2 QL 720 POR 30 DIAS

clorazepate dipotassium tab 7.5 mg 2 QL 360 POR 30 DIAS

lorazepam conc 2 mg/ml 2 lorazepam tab 0.5 mg 2 QL 600 POR 30 DIAS

lorazepam tab 1 mg 2 QL 300 POR 30 DIAS

lorazepam tab 2 mg 2 QL 150 POR 30 DIAS

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine

Reuptake Inhibitors)

escitalopram oxalate soln 5 mg/5ml (base equiv) 2 QL 620 POR 30 DIAS

escitalopram oxalate tab 10 mg (base equiv) 2 QL 60 POR 30 DIAS



paroxetine hcl tab 10 mg 2 QL 90 POR 30 DIAS; FFF




paroxetine hcl tab sr 24hr 12.5 mg 2 QL 150 POR 30 DIAS

paroxetine hcl tab sr 24hr 25 mg 2 QL 90 POR 30 DIAS

paroxetine hcl tab sr 24hr 37.5 mg 2 QL 60 POR 30 DIAS

PAXIL SUS10MG/5ML 4 QL 900 POR 30 DIAS

sertraline hcl oral conc 20 mg/ml 2 QL 300 POR 30 DIAS

sertraline hcl tab 100 mg 2 QL 60 POR 30 DIAS

sertraline hcl tab 25 mg 2 QL 240 POR 30 DIAS


50

Nombre de Medicamentos Nivel Requisitos/Limites sertraline hcl tab 50 mg 1 QL 120 POR 30 DIAS

venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 2

QL 180 POR 30 DIAS;

FFF


venlafaxine hcl tab 37.5 mg 2 QL 180 POR 30 DIAS




venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) 4 QL 180 POR 30 DIAS

BIPOLAR AGENTS Bipolar Agents, Other

ABILIFY MAININJ300MG 5 QL 2 POR 28 DIAS

ABILIFY MAININJ400MG 5 aripiprazole tab 10 mg 2 QL 90 POR 30 DIAS



ARISTADA INJ882MG/3 5 QL 3.2 POR 28 DIAS

GEODON INJ20MG 4

olanzapine for im inj 10 mg 4


PA



olanzapine tab 10 mg 2 QL 60 POR 30 DIAS; FFF



olanzapine tab 5 mg 2

QL 120 POR 30 DIAS;

FFF




quetiapine fumarate tab sr 24hr 400 mg 2 QL 60 POR 30 DIAS

RISPERDAL INJ12.5MG 4


PA

RISPERDAL INJ25MG 5


PA

RISPERDAL INJ37.5MG 5


PA

RISPERDAL INJ50MG 5 B/D PA

risperidone orally disintegrating tab 0.25 mg 4 QL 1920 POR 30 DIAS

risperidone orally disintegrating tab 0.5 mg 4 QL 960 POR 30 DIAS


risperidone tab 0.25 mg 2

QL 1920 POR 30 DIAS;

FFF


51



QL 180 POR 30 DIAS;

FFF

SAPHRIS SUB10MG 5 QL 60 POR 30 DIAS

SAPHRIS SUB5MG 5 QL 120 POR 30 DIAS


ziprasidone hcl cap 20 mg 2 QL 240 POR 30 DIAS



Mood Stabilizers

carbamazepine cap sr 12hr 100 mg 2 carbamazepine cap sr 12hr 200 mg 2 carbamazepine cap sr 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab sr 12hr 200 mg 2 divalproex sodium cap delayed release sprinkle 125 mg 2 divalproex sodium tab delayed release 250 mg 2 divalproex sodium tab delayed release 500 mg 2 divalproex sodium tab sr 24 hr 250 mg 2 divalproex sodium tab sr 24 hr 500 mg 2 EQUETRO CAP100MG 4 QL 480 POR 30 DIAS

EQUETRO CAP200MG 4 QL 240 POR 30 DIAS

lamotrigine orally disintegrating tab 200 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab 25 mg 2 lamotrigine tab chewable dispersible 25 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab sr 24hr 100 mg 2 lamotrigine tab sr 24hr 200 mg 2 lamotrigine tab sr 24hr 25 mg 2 lamotrigine tab sr 24hr 250 mg 2 lamotrigine tab sr 24hr 300 mg 2 lamotrigine tab sr 24hr 50 mg 2 LITHIUM SOL8MEQ/5ML 4 lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 2 lithium carbonate cap 600 mg 2 lithium carbonate tab 300 mg 2 lithium carbonate tab cr 300 mg 2 lithium carbonate tab cr 450 mg 2 valproate sodium oral soln 250 mg/5ml (base equiv) 2 valproic acid cap 250 mg 2


52


BLOOD GLUCOSE REGULATORS Antidiabetic Agents

acarbose tab 100 mg 2 QL 90 POR 30 DIAS



BYDUREON INJ2MG 3 QL 4.5 POR 30 DIAS

BYDUREON INJBCISE 3 QL 3.4 POR 28 DIAS

BYDUREON PENINJ2MG 3 QL 4 POR 28 DIAS

BYETTA INJ10MCG 3 QL 2.4 POR 30 DIAS

BYETTA INJ5MCG 3 QL 2.4 POR 30 DIAS

chlorpropamide tab 100 mg 2 QL 120 POR 30 DIAS; PA

chlorpropamide tab 250 mg 1 QL 90 POR 30 DIAS; PA

CYCLOSET TAB0.8MG 4 QL 180 POR 30 DIAS

FARXIGA TAB10MG 3 FARXIGA TAB5MG 3 glimepiride tab 1 mg 1 QL 60 POR 30 DIAS

glimepiride tab 2 mg 1 QL 60 POR 30 DIAS

glimepiride tab 4 mg 1 QL 60 POR 30 DIAS

glipizide tab 10 mg 1 QL 120 POR 30 DIAS

glipizide tab 5 mg 1 QL 240 POR 30 DIAS

glipizide tab sr 24hr 10 mg 2 QL 60 POR 30 DIAS

glipizide tab sr 24hr 2.5 mg 2 QL 240 POR 30 DIAS

glipizide tab sr 24hr 5 mg 2 QL 120 POR 30 DIAS

JANUVIA TAB100MG 3 QL 30 POR 30 DIAS



JARDIANCE TAB10MG 3 QL 30 POR 30 DIAS

JARDIANCE TAB25MG 3 QL 30 POR 30 DIAS

metformin hcl tab 1000 mg 1 QL 90 POR 30 DIAS



metformin hcl tab sr 24hr 500 mg 1 QL 120 POR 30 DIAS

metformin hcl tab sr 24hr 750 mg 2 QL 90 POR 30 DIAS

nateglinide tab 120 mg 4 QL 90 POR 30 DIAS

nateglinide tab 60 mg 4 QL 90 POR 30 DIAS

ONGLYZA TAB2.5MG 4 QL 30 POR 30 DIAS

ONGLYZA TAB5MG 4 QL 30 POR 30 DIAS

OZEMPIC INJ2/1.5ML 3 QL 3 POR 28 DIAS

OZEMPIC INJ2/1.5ML 3 QL 1.5 POR 28 DIAS

pioglitazone hcl tab 15 mg (base equiv) 2 QL 30 POR 30 DIAS



QTERN TAB10MG/5MG 3 QL 30 POR 30 DIAS


53

Nombre de Medicamentos Nivel Requisitos/Limites SYMLINPEN 60INJ1000MCG 4 QL 10.8 POR 30 DIAS

SYMLNPEN 120INJ1000MCG 4 QL 10.8 POR 30 DIAS

tolazamide tab 250 mg 4 tolazamide tab 500 mg 4 tolbutamide tab 500 mg 4 TRULICITY INJ0.75/0.5 3 TRULICITY INJ1.5/0.5 3 VICTOZA INJ18MG/3ML 3 WELCHOL PAK3.75GM 4 WELCHOL TAB625MG 4 Blood Glucose Regulators

glipizide-metformin hcl tab 2.5-250 mg 2 QL 240 POR 30 DIAS

glipizide-metformin hcl tab 2.5-500 mg 2 QL 120 POR 30 DIAS

glipizide-metformin hcl tab 5-500 mg 2 QL 120 POR 30 DIAS

JANUMET TAB50-1000 3 QL 60 POR 30 DIAS

JANUMET TAB50-500MG 3 QL 60 POR 30 DIAS

JANUMET XR TAB100-1000 3 QL 60 POR 30 DIAS

JANUMET XR TAB50-1000 3 QL 60 POR 30 DIAS

JANUMET XR TAB50-500MG 3 QL 60 POR 30 DIAS

pioglitazone hcl-glimepiride tab 30-2 mg 2 QL 90 POR 30 DIAS

pioglitazone hcl-glimepiride tab 30-4 mg 2 QL 90 POR 30 DIAS

pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL 90 POR 30 DIAS

pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL 90 POR 30 DIAS

XIGDUO XR TAB10-1000 3 QL 30 POR 30 DIAS

XIGDUO XR TAB10-500MG 3 QL 30 POR 30 DIAS



Glycemic Agents

GLUCAGEN INJHYPOKIT 4 QL 30 POR 30 DIAS

GLUCAGON KIT1MG 3 QL 2 POR 30 DIAS

KORLYM TAB300MG 5

LA; QL 120 POR 30

DIAS; PA

PROGLYCEM SUS50MG/ML 5 Insulins

ADMELOG INJ100U/ML 2 QL 30 POR 30 DIAS

ADMELOG SOLOINJ100U/ML 2 QL 30 POR 30 DIAS

APIDRA INJSOLOSTAR 4 QL 30 POR 30 DIAS

APIDRA INJU-100 4 QL 30 POR 30 DIAS

BASAGLAR INJ100UNIT 2 QL 30 POR 30 DIAS

HUMALOG INJ100/ML 3 QL 30 POR 30 DIAS

HUMALOG JR INJ100/ML 3 QL 30 POR 30 DIAS

HUMALOG KWIKINJ100/ML 3 QL 30 POR 30 DIAS

HUMALOG KWIKINJ200/ML 3 QL 30 POR 30 DIAS

HUMALOG MIX INJ50/50 3 QL 30 POR 30 DIAS


54

Nombre de Medicamentos Nivel Requisitos/Limites HUMALOG MIX INJ50/50KWP 3 QL 30 POR 30 DIAS

HUMALOG MIX INJ75/25KWP 3 QL 30 POR 30 DIAS

HUMALOG MIX SUS75/25 3 QL 30 POR 30 DIAS

HUMULIN INJ70/30 3 QL 30 POR 30 DIAS

HUMULIN INJ70/30KWP 3 QL 30 POR 30 DIAS

HUMULIN N INJU-100 3 QL 30 POR 30 DIAS

HUMULIN N INJU-100KWP 3 QL 30 POR 30 DIAS

HUMULIN R INJU-100 3 QL 30 POR 30 DIAS

HUMULIN R INJU-500 3 QL 30 POR 30 DIAS

LANTUS INJ100/ML 3 QL 30 POR 30 DIAS

LANTUS INJSOLOSTAR 3 QL 30 POR 30 DIAS

LEVEMIR INJ 3 QL 30 POR 30 DIAS

LEVEMIR INJFLEXTOUC 3 QL 30 POR 30 DIAS

NOVOLIN INJ70/30 4 QL 30 POR 30 DIAS

NOVOLIN N INJU-100 4 QL 30 POR 30 DIAS

NOVOLIN R INJU-100 4 QL 30 POR 30 DIAS

NOVOLOG INJ100/ML 4 QL 30 POR 30 DIAS

NOVOLOG INJFLEXPEN 4 QL 30 POR 30 DIAS

NOVOLOG INJPENFILL 4 QL 30 POR 30 DIAS

NOVOLOG MIX INJ70/30 4 QL 30 POR 30 DIAS

NOVOLOG MIX INJFLEXPEN 4 QL 30 POR 30 DIAS

TOUJEO SOLO INJ300IU/ML 3 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS Anticoagulants

COUMADIN TAB10MG 3 COUMADIN TAB1MG 3 COUMADIN TAB2.5MG 3 COUMADIN TAB2MG 3 COUMADIN TAB3MG 3 COUMADIN TAB4MG 3 COUMADIN TAB5MG 3 COUMADIN TAB6MG 3 COUMADIN TAB7.5MG 3 ELIQUIS ST PTAB5MG 3

ELIQUIS TAB2.5MG 3 ELIQUIS TAB5MG 3 enoxaparin sodium inj 100 mg/ml 4 QL 28 POR 30 DIAS

enoxaparin sodium inj 120 mg/0.8ml 4 QL 22.4 POR 30 DIAS

enoxaparin sodium inj 150 mg/ml 4 QL 28 POR 30 DIAS


enoxaparin sodium inj 300 mg/3ml 4 QL 84 POR 30 DIAS




55

Nombre de Medicamentos Nivel Requisitos/Limites enoxaparin sodium inj 80 mg/0.8ml 4 QL 22.4 POR 30 DIAS

fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL 24 POR 30 DIAS

fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL 15 POR 30 DIAS

fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL 12 POR 30 DIAS

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL 18 POR 30 DIAS

FRAGMIN INJ10000/ML 5 QL 20 POR 30 DIAS; PA

FRAGMIN INJ12500UNT 5 QL 20 POR 30 DIAS; PA



FRAGMIN INJ2500/0.2 4 QL 20 POR 30 DIAS; PA

FRAGMIN INJ5000/0.2 4 QL 20 POR 30 DIAS; PA

HEP SOD/D5W INJ25000UNT 4 B/D PA

heparin sodium (porcine) 40 unit/ml in d5w 4 B/D PA

heparin sodium (porcine) 50 unit/ml in d5w 4 B/D PA

heparin sodium (porcine) inj 1000 unit/ml 4 B/D PA




PRADAXA CAP110MG 3 PRADAXA CAP150MG 3 QL 60 POR 30 DIAS

PRADAXA CAP75MG 3 QL 60 POR 30 DIAS

warfarin sodium tab 1 mg 1 warfarin sodium tab 10 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 XARELTO TAB10MG 4 QL 30 POR 30 DIAS

XARELTO TAB15MG 4 QL 30 POR 30 DIAS

XARELTO TAB20MG 4 QL 30 POR 30 DIAS

XARELTO STARTAB15/20MG 4 QL 51 POR 30 DIAS

Blood Formation Modifiers

anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 ARANESP INJ100MCG 5 QL 2 POR 28 DIAS; PA

ARANESP INJ100MCG 5 QL 4 POR 28 DIAS; PA

ARANESP INJ150MCG 5 QL 1.2 POR 28 DIAS; PA



ARANESP INJ25MCG 4

QL 1.68 POR 28 DIAS;

PA


56

Nombre de Medicamentos Nivel Requisitos/Limites ARANESP INJ25MCG 4 QL 4 POR 28 DIAS; PA








azacitidine for inj 100 mg 5 B/D PA

EPOGEN INJ10000/ML 4 PA

EPOGEN INJ2000/ML 4 QL 12 POR 28 DIAS; PA

EPOGEN INJ20000/ML 5 PA



LEUKINE INJ250MCG 5 PA

MOZOBIL INJ 5 B/D PA

NEULASTA INJ6MG/0.6M 5 QL 2 POR 30 DIAS; PA

NEUPOGEN INJ300/0.5 5 PA

NEUPOGEN INJ300MCG 5 PA

NEUPOGEN INJ480/0.8 5 PA

NEUPOGEN INJ480MCG 5 PA

PROCRIT INJ10000/ML 4 PA

PROCRIT INJ2000/ML 4 QL 12 POR 28 DIAS; PA

PROCRIT INJ20000/ML 5 PA




PROMACTA TAB12.5MG 5

LA; QL 90 POR 30 DIAS;

PA

PROMACTA TAB25MG 5


PA

PROMACTA TAB50MG 5


PA

PROMACTA TAB75MG 5 LA; QL 90 POR 30 DIAS

ZARXIO INJ300/0.5 5 B/D PA

ZARXIO INJ480/0.8 5 B/D PA

Hemostasis Agents

tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 4 B/D PA

tranexamic acid tab 650 mg 2 Platelet Modifying Agents

aspirin-dipyridamole cap sr 12hr 25-200 mg 2 QL 60 POR 30 DIAS

BRILINTA TAB60MG 3 QL 60 POR 30 DIAS

BRILINTA TAB90MG 3 QL 60 POR 30 DIAS

cilostazol tab 100 mg 2


57

Nombre de Medicamentos Nivel Requisitos/Limites cilostazol tab 50 mg 2 clopidogrel bisulfate tab 300 mg (base equiv) 2 QL 30 POR 30 DIAS

clopidogrel bisulfate tab 75 mg (base equiv) 1 QL 30 POR 30 DIAS

EFFIENT TAB10MG 3 QL 30 POR 30 DIAS

EFFIENT TAB5MG 3 QL 30 POR 30 DIAS

prasugrel tab10mg 2 QL 30 POR 30 DIAS

prasugrel tab5mg 2 QL 30 POR 30 DIAS

CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists

clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 2 clonidine hcl td patch weekly 0.1 mg/24hr 4 QL 4 POR 28 DIAS

clonidine hcl td patch weekly 0.2 mg/24hr 4 QL 4 POR 28 DIAS

clonidine hcl td patch weekly 0.3 mg/24hr 4 QL 4 POR 28 DIAS

guanfacine hcl tab 1 mg 2 PA

guanfacine hcl tab sr 24hr 1 mg (base equiv) 2 PA




methyldopa tab 250 mg 2 PA

methyldopa tab 500 mg 2 PA

methyldopate hcl inj 250 mg/5ml 4 B/D PA

midodrine hcl tab 10 mg 2 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2

NORTHERA CAP100MG 5


PA

NORTHERA CAP200MG 5


PA

NORTHERA CAP300MG 5


PA

Alpha-adrenergic Blocking Agents

phenoxybenzamine hcl cap 10 mg 5 terazosin hcl cap 5 mg 2 QL 30 POR 30 DIAS

Angiotensin II Receptor Antagonists

eprosartan mesylate tab 600 mg 2 QL 30 POR 30 DIAS

irbesartan tab 150 mg 2 QL 30 POR 30 DIAS



losartan potassium tab 100 mg 2 QL 30 POR 30 DIAS; FFF



olmesa medoxtab20mg 2 QL 30 POR 30 DIAS


58

Nombre de Medicamentos Nivel Requisitos/Limites olmesa medoxtab40mg 2 QL 30 POR 30 DIAS

olmesa medoxtab5mg 2 QL 30 POR 30 DIAS

telmisartan tab 20 mg 2 QL 30 POR 30 DIAS



valsartan tab 160 mg 1 QL 60 POR 30 DIAS




Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 benazepril hcl tab 5 mg 1 captopril tab 100 mg 1 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 2.5 mg 1 enalapril maleate tab 20 mg 1 enalapril maleate tab 5 mg 1 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2 fosinopril sodium tab 40 mg 2 lisinopril tab 10 mg 1 lisinopril tab 2.5 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 lisinopril tab 5 mg 1 moexipril hcl tab 15 mg 2 moexipril hcl tab 7.5 mg 2 perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2 quinapril hcl tab 40 mg 2 quinapril hcl tab 5 mg 2 ramipril cap 1.25 mg 2 QL 30 POR 30 DIAS

ramipril cap 10 mg 2 QL 60 POR 30 DIAS

ramipril cap 2.5 mg 2 QL 30 POR 30 DIAS

ramipril cap 5 mg 2 QL 30 POR 30 DIAS


59

Nombre de Medicamentos Nivel Requisitos/Limites trandolapril tab 1 mg 2 QL 30 POR 30 DIAS

trandolapril tab 2 mg 2 QL 30 POR 30 DIAS

trandolapril tab 4 mg 2 QL 60 POR 30 DIAS

Antiarrhythmics

amiodarone hcl inj 150 mg/3ml (50 mg/ml) 4 B/D PA

amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 disopyramide phosphate cap 100 mg 2 PA

disopyramide phosphate cap 150 mg 2 PA

dofetilide cap 125 mcg (0.125 mg) 4 dofetilide cap 250 mcg (0.25 mg) 4 dofetilide cap 500 mcg (0.5 mg) 4 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 flecainide acetate tab 50 mg 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 procainamide hcl inj 100 mg/ml 4 B/D PA

procainamide hcl inj 500 mg/ml 4 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 1 propafenone hcl tab 300 mg 2 QUINIDINE GLINJ80MG/ML 4 quinidine gluconate tab cr 324 mg 4 quinidine sulfate tab 200 mg 2 quinidine sulfate tab 300 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 sotalol hcl tab 80 mg 2 Beta-adrenergic Blocking Agents

acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 100 mg 1 atenolol tab 25 mg 1 atenolol tab 50 mg 1 betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 10 mg 2 bisoprolol fumarate tab 5 mg 2 carvedilol cap10mg er 2


60

Nombre de Medicamentos Nivel Requisitos/Limites carvedilol cap20mg er 2

carvedilol cap40mg er 2

carvedilol cap80mg er 2

carvedilol tab 12.5 mg 1 FFF

carvedilol tab 25 mg 1 FFF



labetalol hcl iv soln 5 mg/ml 4 B/D PA

labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) 2 QL 30 POR 30 DIAS

metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) 2 QL 60 POR 30 DIAS



metoprolol tartrate iv soln 5 mg/5ml 4 B/D PA

metoprolol tartrate iv soln cart inj 5 mg/5ml (1 mg/ml) 4 B/D PA

metoprolol tartrate tab 100 mg 1 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 10 mg 2 pindolol tab 5 mg 2 propranolol hcl cap sr 24hr 120 mg 2 propranolol hcl cap sr 24hr 160 mg 2 propranolol hcl cap sr 24hr 60 mg 2 propranolol hcl cap sr 24hr 80 mg 2 propranolol hcl inj 1 mg/ml 4 B/D PA

propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 2 propranolol hcl tab 20 mg 2 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 2 propranolol hcl tab 80 mg 2 timolol maleate tab 20 mg 2 Calcium Channel Blocking Agents

amlodipine besylate tab 10 mg 2 QL 30 POR 30 DIAS

amlodipine besylate tab 2.5 mg 1 QL 30 POR 30 DIAS

amlodipine besylate tab 5 mg 1 QL 30 POR 30 DIAS

diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 12hr 60 mg 2


61

Nombre de Medicamentos Nivel Requisitos/Limites diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr 120 mg 2 diltiazem hcl coated beads cap sr 24hr 180 mg 2 diltiazem hcl coated beads cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr 240 mg 1 diltiazem hcl coated beads cap sr 24hr 300 mg 2 diltiazem hcl extended release beads cap sr 24hr 120 mg 2 diltiazem hcl extended release beads cap sr 24hr 180 mg 2 diltiazem hcl extended release beads cap sr 24hr 240 mg 2 diltiazem hcl extended release beads cap sr 24hr 300 mg 2 diltiazem hcl extended release beads cap sr 24hr 360 mg 2 diltiazem hcl extended release beads cap sr 24hr 420 mg 2 diltiazem hcl iv for soln 100 mg 4 B/D PA

diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) 4 B/D PA

diltiazem hcl tab 120 mg 2 diltiazem hcl tab 30 mg 2 diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 felodipine tab sr 24hr 10 mg 2 felodipine tab sr 24hr 2.5 mg 2 felodipine tab sr 24hr 5 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 4 nifedipine tab sr 24hr 30 mg 2 nifedipine tab sr 24hr 60 mg 2 nifedipine tab sr 24hr 90 mg 2 nifedipine tab sr 24hr osmotic release 30 mg 2 nifedipine tab sr 24hr osmotic release 60 mg 2 nifedipine tab sr 24hr osmotic release 90 mg 2 nimodipine cap 30 mg 4 nisoldipine tab sr 24hr 17 mg 2 nisoldipine tab sr 24hr 20 mg 2 nisoldipine tab sr 24hr 25.5 mg 2 nisoldipine tab sr 24hr 30 mg 2 nisoldipine tab sr 24hr 34 mg 2 nisoldipine tab sr 24hr 40 mg 2 nisoldipine tab sr 24hr 8.5 mg 2 verapamil hcl cap sr 24hr 100 mg 2


62

Nombre de Medicamentos Nivel Requisitos/Limites verapamil hcl cap sr 24hr 120 mg 2 verapamil hcl cap sr 24hr 180 mg 2 verapamil hcl cap sr 24hr 200 mg 2 verapamil hcl cap sr 24hr 240 mg 2 verapamil hcl cap sr 24hr 300 mg 2 verapamil hcl iv soln 2.5 mg/ml 4 B/D PA

verapamil hcl tab 120 mg 1 verapamil hcl tab 40 mg 2 verapamil hcl tab 80 mg 2 verapamil hcl tab cr 180 mg 2 verapamil hcl tab cr 240 mg 2 Cardiovascular Agents

amiloride & hydrochlorothiazide tab 5-50 mg 1 amlodipine besylate-atorvastatin calcium tab 10-10 mg 2 QL 30 POR 30 DIAS

amlodipine besylate-atorvastatin calcium tab 10-20 mg 2 QL 30 POR 30 DIAS



amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 2 QL 30 POR 30 DIAS







amlodipine besylate-benazepril hcl cap 10-20 mg 2 QL 30 POR 30 DIAS


amlodipine besylate-benazepril hcl cap 2.5-10 mg 2 QL 30 POR 30 DIAS




amlodipine besylate-valsartan tab 10-160 mg 2 QL 30 POR 30 DIAS




amlodipine-valsartan-hydrochlorothiazide tab 10-160-

12.5 mg 2 QL 30 POR 30 DIAS






12.5 mg 2 QL 30 POR 30 DIAS

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25

mg 2 QL 30 POR 30 DIAS


63

Nombre de Medicamentos Nivel Requisitos/Limites atenolol & chlorthalidone tab 100-25 mg 1 atenolol & chlorthalidone tab 50-25 mg 1 benazepril & hydrochlorothiazide tab 10-12.5 mg 1 benazepril & hydrochlorothiazide tab 20-12.5 mg 1 benazepril & hydrochlorothiazide tab 20-25 mg 1 benazepril & hydrochlorothiazide tab 5-6.25 mg 1 bisoprolol & hydrochlorothiazide tab 10-6.25 mg 2 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 2 bisoprolol & hydrochlorothiazide tab 5-6.25 mg 2 candesartan cilexetil-hydrochlorothiazide tab 16-12.5


candesartan cilexetil-hydrochlorothiazide tab 32-12.5


candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 4 QL 30 POR 30 DIAS

captopril & hydrochlorothiazide tab 25-15 mg 2 captopril & hydrochlorothiazide tab 25-25 mg 2 captopril & hydrochlorothiazide tab 50-15 mg 1 captopril & hydrochlorothiazide tab 50-25 mg 2 DEMSER CAP250MG 5 enalapril maleate & hydrochlorothiazide tab 10-25 mg 1 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 ezetim/simvatab10-10mg 2 QL 30 POR 30 DIAS

ezetim/simvatab10-20mg 2 QL 30 POR 30 DIAS



fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg 2 fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg 2 irbesartan-hydrochlorothiazide tab 150-12.5 mg 4 QL 30 POR 30 DIAS

irbesartan-hydrochlorothiazide tab 300-12.5 mg 4 QL 30 POR 30 DIAS

lisinopril & hydrochlorothiazide tab 10-12.5 mg 1 lisinopril & hydrochlorothiazide tab 20-12.5 mg 1 lisinopril & hydrochlorothiazide tab 20-25 mg 1 losartan potassium & hydrochlorothiazide tab 100-12.5

mg 1 QL 30 POR 30 DIAS; FFF

losartan potassium & hydrochlorothiazide tab 100-25


losartan potassium & hydrochlorothiazide tab 50-12.5


methyldopa & hydrochlorothiazide tab 250-15 mg 2 PA

methyldopa & hydrochlorothiazide tab 250-25 mg 2 PA

metoprolol & hydrochlorothiazide tab 100-25 mg 2 metoprolol & hydrochlorothiazide tab 100-50 mg 2


64

Nombre de Medicamentos Nivel Requisitos/Limites metoprolol & hydrochlorothiazide tab 50-25 mg 2 moexipril-hydrochlorothiazide tab 15-12.5 mg 2 moexipril-hydrochlorothiazide tab 15-25 mg 2 moexipril-hydrochlorothiazide tab 7.5-12.5 mg 2 nadolol & bendroflumethiazide tab 40-5 mg 2 nadolol & bendroflumethiazide tab 80-5 mg 2 propranolol & hydrochlorothiazide tab 40-25 mg 1 propranolol & hydrochlorothiazide tab 80-25 mg 1 quinapril-hydrochlorothiazide tab 10-12.5 mg 2 quinapril-hydrochlorothiazide tab 20-12.5 mg 2 quinapril-hydrochlorothiazide tab 20-25 mg 2 spironolactone & hydrochlorothiazide tab 25-25 mg 1 TEKTURNA HCTTAB150-12.5 3 QL 30 POR 30 DIAS

TEKTURNA HCTTAB150-25MG 3 QL 30 POR 30 DIAS

TEKTURNA HCTTAB300-12.5 3 QL 30 POR 30 DIAS

TEKTURNA HCTTAB300-25MG 3 QL 30 POR 30 DIAS

telmisartan-amlodipine tab 40-10 mg 2 QL 30 POR 30 DIAS




telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL 30 POR 30 DIAS

telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL 30 POR 30 DIAS

telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL 30 POR 30 DIAS

triamterene & hydrochlorothiazide cap 37.5-25 mg 2 triamterene & hydrochlorothiazide tab 37.5-25 mg 2 triamterene & hydrochlorothiazide tab 75-50 mg 2 valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL 30 POR 30 DIAS

valsartan-hydrochlorothiazide tab 160-25 mg 2 QL 30 POR 30 DIAS

valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL 30 POR 30 DIAS

valsartan-hydrochlorothiazide tab 320-25 mg 2 QL 30 POR 30 DIAS

valsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL 30 POR 30 DIAS

Cardiovascular Agents, Other

CORLANOR TAB5MG 4 CORLANOR TAB7.5MG 4 DIGOXIN SOL50MCG/ML 4 digox tab 125 mcg 2

digox tab 250 mcg 2

digoxin inj 0.25 mg/ml 4 B/D PA

digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 1 PA

digoxin tab 250 mcg (0.25 mg) 2 PA

ENTRESTO TAB24-26MG 3 QL 60 POR 30 DIAS




65

Nombre de Medicamentos Nivel Requisitos/Limites pentoxifylline tab cr 400 mg 2 RANEXA TAB1000MG 3 QL 120 POR 30 DIAS

RANEXA TAB500MG 3 QL 120 POR 30 DIAS

TEKTURNA TAB150MG 3 QL 30 POR 30 DIAS

TEKTURNA TAB300MG 3 QL 30 POR 30 DIAS

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide sodium for inj 500 mg 4 KEVEYIS TAB50MG 5 QL 120 POR 30 DIAS

Diuretics, Loop

bumetanide inj 0.25 mg/ml 4 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 furosemide inj 10 mg/ml 4 B/D PA

furosemide oral soln 10 mg/ml 1 furosemide oral soln 8 mg/ml 1 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 torsemide tab 10 mg 2 torsemide tab 100 mg 2 torsemide tab 20 mg 2 torsemide tab 5 mg 2 Diuretics, Potassium-sparing

amiloride hcl tab 5 mg 2 eplerenone tab 25 mg 4 eplerenone tab 50 mg 4 spironolactone tab 100 mg 2 spironolactone tab 25 mg 2 spironolactone tab 50 mg 2 Diuretics, Thiazide

chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 1 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 2 indapamide tab 2.5 mg 2 methyclothiazide tab 5 mg 2 metolazone tab 10 mg 2


66

Nombre de Medicamentos Nivel Requisitos/Limites metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized cap 134 mg 2 QL 30 POR 30 DIAS



fenofibrate tab 145 mg 1 QL 30 POR 30 DIAS




gemfibrozil tab 600 mg 1 Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium tab 10 mg (base equivalent) 1 QL 30 POR 30 DIAS; FFF




fluvastatin sodium cap 20 mg 2 QL 60 POR 30 DIAS

fluvastatin sodium cap 40 mg 2 QL 60 POR 30 DIAS

lovastatin tab 10 mg 2 QL 30 POR 30 DIAS



pravastatin sodium tab 10 mg 1 QL 30 POR 30 DIAS




rosuvastatin calcium tab 10 mg 2 QL 30 POR 30 DIAS




simvastatin tab 10 mg 1 QL 30 POR 30 DIAS; FFF





Dyslipidemics, Other

cholestyramine light powder 4 gm/dose 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 ezetimibe tab 10 mg 2 QL 30 POR 30 DIAS

JUXTAPID CAP10MG 5

LA; QL 180 POR 30

DIAS; PA


67


JUXTAPID CAP20MG 5


PA

JUXTAPID CAP5MG 5

LA; QL 360 POR 30

DIAS; PA

KYNAMRO INJ200MG/ML 5


PA

niacin (antihyperlipidemic) tab 500 mg 2 niacin er tab1000mg 1

niacin er tab500mg 1

niacin er tab750mg 1

omega-3-acid ethyl esters cap 1 gm 2 PRALUENT INJ150MG/ML 5 QL 2 POR 28 DIAS; PA

PRALUENT INJ75MG/ML 5 QL 2 POR 28 DIAS; PA

REPATHA INJ140MG/ML 5 QL 3 POR 28 DIAS; PA

REPATHA PUSHINJ420/3.5 5 QL 3.5 POR 28 DIAS; PA

REPATHA SUREINJ140MG/ML 5 QL 3 POR 28 DIAS; PA

Vasodilators, Direct-acting Arterial

hydralazine hcl inj 20 mg/ml 4 B/D PA

hydralazine hcl tab 10 mg 1 hydralazine hcl tab 100 mg 1 hydralazine hcl tab 25 mg 1 hydralazine hcl tab 50 mg 1 minoxidil tab 10 mg 2 minoxidil tab 2.5 mg 2 Vasodilators, Direct-acting Arterial/Venous

isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab cr 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab sr 24hr 120 mg 2 isosorbide mononitrate tab sr 24hr 30 mg 2 isosorbide mononitrate tab sr 24hr 60 mg 1 NITRO-DUR DIS0.3MG/HR 4 NITRO-DUR DIS0.8MG/HR 4 nitroglycerin iv soln 5 mg/ml 4 B/D PA

nitroglycerin oint 2% 2 nitroglycerin sl tab 0.3 mg 1 nitroglycerin sl tab 0.4 mg 1 nitroglycerin sl tab 0.6 mg 1 nitroglycerin td patch 24hr 0.1 mg/hr 2 QL 30 POR 30 DIAS

nitroglycerin td patch 24hr 0.2 mg/hr 2 QL 30 POR 30 DIAS


68

Nombre de Medicamentos Nivel Requisitos/Limites nitroglycerin td patch 24hr 0.4 mg/hr 2 QL 30 POR 30 DIAS



nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 4 NITROMIST AER400MCG 3 CENTRAL NERVOUS SYSTEM AGENTS Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine-dextroamphetamine tab 10 mg 2 QL 60 POR 30 DIAS

amphetamine-dextroamphetamine tab 12.5 mg 2 QL 60 POR 30 DIAS





amphetamine-dextroamphetamine tab 7.5 mg 2 QL 90 POR 30 DIAS

dextroamphetamine sulfate tab 10 mg 2 QL 180 POR 30 DIAS

dextroamphetamine sulfate tab 5 mg 2 QL 90 POR 30 DIAS

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine hcl cap 10 mg (base equiv) 2 QL 60 POR 30 DIAS







dexmethylphenidate hcl tab 10 mg 4 QL 90 POR 30 DIAS

dexmethylphenidate hcl tab 2.5 mg 4 QL 90 POR 30 DIAS

dexmethylphenidate hcl tab 5 mg 4 QL 90 POR 30 DIAS

guanfacine hcl tab 2 mg 2 PA

methylphenidate hcl cap cr 30 mg (cd) 2 QL 60 POR 30 DIAS

methylphenidate hcl tab 10 mg 2 QL 90 POR 30 DIAS



methylphenidate hcl tab cr 20 mg 2 QL 90 POR 30 DIAS

methylphenidate hcl tab sr 24hr 27 mg 2 STRATTERA CAP100MG 4 QL 60 POR 30 DIAS

STRATTERA CAP10MG 4 QL 60 POR 30 DIAS






Central Nervous System, Other

NUEDEXTA CAP20-10MG 4 QL 60 POR 30 DIAS


69

Nombre de Medicamentos Nivel Requisitos/Limites riluzole tab 50 mg 2 PA

tetrabenazine tab 12.5 mg 5

LA; QL 240 POR 30

DIAS; PA

tetrabenazine tab 25 mg 5

LA; QL 120 POR 30

DIAS; PA

Fibromyalgia Agents




LYRICA CAP150MG 3 QL 120 POR 30 DIAS







LYRICA SOL20MG/ML 3 QL 900 POR 30 DIAS

Multiple Sclerosis Agents

AMPYRA TAB10MG 5 LA; PA

AVONEX KIT30MCG 5 QL 4 POR 28 DIAS; PA

AVONEX PEN KIT30MCG 5 QL 4 POR 28 DIAS; PA

AVONEX PREFLKIT30MCG 5 QL 4 POR 28 DIAS; PA

BETASERON INJ0.3MG 5 QL 15 POR 30 DIAS; PA

EXTAVIA INJ0.3MG 5 QL 15 POR 30 DIAS; PA

GILENYA CAP0.5MG 5 QL 30 POR 30 DIAS; PA

glatiramer acetate soln prefilled syringe 20 mg/ml 5 QL 30 POR 30 DIAS

glatiramer acetate soln prefilled syringe 40 mg/ml 5 QL 12 POR 30 DIAS

glatopa 40 mg/ml 5 QL 12 POR 30 DIAS

PLEGRIDY INJ 5


PA

PLEGRIDY INJPEN 5 LA

PLEGRIDY INJSTARTER 5


PA

PLEGRIDY PENINJSTARTER 5


PA

REBIF INJ22/0.5 5 QL 12 POR 30 DIAS; PA

REBIF INJ44/0.5 5 QL 12 POR 30 DIAS; PA

REBIF TITRTNINJPACK 5 QL 6 POR 30 DIAS; PA

TECFIDERA CAP120MG 5 LA; PA

TECFIDERA CAP240MG 5 LA; PA

TECFIDERA MISSTARTER 5 LA; PA

TYSABRI INJ300/15ML 5 LA; PA

ZINBRYTA INJ150MG/ML 5


PA


70


DENTAL AND ORAL AGENTS Dental and Oral Agents

cevimeline hcl cap 30 mg 2 chlorhexidine gluconate soln 0.12% 2 doxycycline hyclate tab 20 mg 2 KEPIVANCE INJ6.25MG 5 B/D PA

pilocarpine hcl tab 5 mg 2 pilocarpine hcl tab 7.5 mg 2 triamcinolone acetonide dental paste 0.1% 2 DERMATOLOGICAL AGENTS Dermatological Agents

acitretin cap 10 mg 5 acitretin cap 17.5 mg 5 acitretin cap 25 mg 5 adapalene cream 0.1% 4 PA

adapalene gel 0.1% 4 PA

adapalene/ben pgel0.1-2.5% 2

benzoyl PORoxide-erythromycin gel 5-3% 2 calcipotriene oint 0.005% 2 CALCITRIOL OIN3MCG/GM 4 clotrimazole w/ betamethasone cream 1-0.05% 2 clotrimazole w/ betamethasone lotion 1-0.05% 4 COSENTYX INJ150MG/ML 5 LA; PA

COSENTYX PENINJ150MG/ML 5 LA; PA

diclofenac sodium (actinic keratoses) gel 3% 5 QL 100 POR 30 DIAS

fluorouracil cream 5% 2 fluorouracil soln 2% 4 fluorouracil soln 5% 4 imiquimod cream 5% 2 isotretinoin cap 10 mg 2 isotretinoin cap 20 mg 2 isotretinoin cap 30 mg 2 isotretinoin cap 30 mg 5 isotretinoin cap 40 mg 2 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 12% 2 methoxsalen rapid cap 10 mg 5 ORACEA CAP40MG 4 podofilox soln 0.5% 2 SANTYL OIN250/GM 4 QL 30 POR 30 DIAS

selenium sulfide lotion 2.5% 2 tacrolimus oint 0.03% 2 QL 30 POR 30 DIAS

tacrolimus oint 0.1% 2 QL 30 POR 30 DIAS


71

Nombre de Medicamentos Nivel Requisitos/Limites tazarotene cre0.1% 2

TAZORAC CRE0.05% 4 TOLAK CRE4% 4 tretinoin cream 0.025% 2 QL 45 POR 30 DIAS

tretinoin cream 0.05% 2 QL 45 POR 30 DIAS

tretinoin cream 0.1% 2 QL 45 POR 30 DIAS

tretinoin gel 0.01% 2 QL 45 POR 30 DIAS

tretinoin gel 0.025% 2 QL 45 POR 30 DIAS

VECTICAL OIN3MCG/GM 4 DIABETES SUPPLIES Diabetes Supplies GAUZE PADS & DRESSINGS - PADS 2 X 2 3 INSULIN PEN NEEDLE 3 INSULIN SYRINGE (DISP) U-100 0.3 ML 2 INSULIN SYRINGE (DISP) U-100 1 ML 2 INSULIN SYRINGE (DISP) U-100 1/2 ML 2 ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED

PAD 3 NEEDLES, INSULIN DISP., SAFETY 2 ELECTROLYTES/MINERALS/METALS/VITAMINS Electrolyte/Mineral /Metal Modifiers

CHEMET CAP100MG 4 DEPEN TITRA TAB250MG 5 EXJADE TAB125MG 5 LA; PA

EXJADE TAB250MG 5 LA; PA

EXJADE TAB500MG 5 LA; PA

FERRIPROX TAB500MG 5 LA; PA

sodium polystyrene sulfonate oral susp 15 gm/60ml 2 SYPRINE CAP250MG 5 Electrolyte/Mineral Replacement

AMINOSYN II INJ10% 4 B/D PA

AMINOSYN II INJ7% 4 B/D PA

AMINOSYN II INJ8.5% 4 B/D PA

AMINOSYN-HBCINJ7% 4 B/D PA

AMINOSYN-PF INJ10% 4 B/D PA

AMINOSYN-PF INJ7% 4 B/D PA

CARBAGLU TAB200MG 5 LA; PA

D10W/NACL INJ0.2% 4 B/D PA



dextrose 2.5% w/ sodium chloride 0.45% 4 B/D PA

dextrose 5% in lactated ringers 4 B/D PA

dextrose 5% w/ sodium chloride 0.2% 4 B/D PA


72

Nombre de Medicamentos Nivel Requisitos/Limites dextrose 5% w/ sodium chloride 0.33% 4 B/D PA



dextrose inj 10% 4 B/D PA

dextrose inj 5% 4 B/D PA

fat emulsion iv soln 20% 4 B/D PA

kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4 B/D PA





kcl 20 meq/l (0.15%) in nacl 0.45% inj 4 B/D PA




lactated ringer's solution 4 B/D PA

magnesium sulfate inj 50% 4 B/D PA

PHYSIOLYTE SOL 2 PHYSIOSOL SOLIRRIGAT 2 POT CHL/D5W INJ40MEQ/L 4 B/D PA

POT CHLORIDETAB20MEQ ER 2 potassium chloride 20 meq/l (0.15%) in d5w lactated

ringers 4 B/D PA

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 4 B/D PA

potassium chloride cap cr 10 meq 2 potassium chloride cap cr 8 meq 2 potassium chloride inj 10 meq/100ml 4 B/D PA

potassium chloride inj 2 meq/ml 4 B/D PA

potassium chloride inj 20 meq/100ml 4 B/D PA

potassium chloride inj 40 meq/100ml 4 B/D PA

potassium chloride microencapsulated crys cr tab 10

meq 2 potassium chloride microencapsulated crys cr tab 15

meq 2 potassium chloride microencapsulated crys cr tab 20

meq 2 potassium chloride oral soln 10% (20 meq/15ml) 2 potassium chloride oral soln 20% (40 meq/15ml) 2 potassium chloride tab cr 10 meq 1 potassium chloride tab cr 10 meq 2 potassium chloride tab cr 8 meq (600 mg) 2 potassium citrate tab cr 10 meq (1080 mg) 2 potassium citrate tab cr 15 meq (1620 mg) 2 potassium citrate tab cr 5 meq (540 mg) 2


73

Nombre de Medicamentos Nivel Requisitos/Limites sodium chloride inj 0.45% 4 B/D PA

sodium chloride inj 2.5 meq/ml (14.6%) 4 B/D PA

sodium chloride inj 3% 4 B/D PA

sodium chloride inj 5% 4 B/D PA

sodium chloride irrigation soln 0.9% 4 sodium chloride iv soln 0.9% 4 B/D PA

TPN ELECTROLINJ 4 B/D PA

TRAVASOL INJ10% 4 B/D PA

TROPHAMINE INJ10% 4 B/D PA

Electrolytes/Minerals/Metals/Vitamins

AMINOSYN INJ8.5/LYTE 4 B/D PA

AMINOSYN II INJ8.5/LYTE 4 B/D PA

fomepizole inj 1 gm/ml (for iv infusion) 2 lactated ringer's for irrigation 4 levocarnitine oral soln 1 gm/10ml (10%) 2 levocarnitine tab 330 mg 2 ringer's solution for irrigation 4 GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal

dicyclomine hcl cap 10 mg 2 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 1 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 scopolamine dis1mg/3day 2 QL 24 POR 30 DIAS

TRANSDERM-SCDIS1MG 4 QL 24 POR 30 DIAS

Gastrointestinal Agents

CREON CAP3000UNIT 3 CREON CAP36000UNT 3 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2 peg 3350-kcl-sod bicarb-nacl for soln 420 gm 2 ZENPEP CAP25000UNT 4 ZENPEP CAP3000UNIT 4 Gastrointestinal Agents, Other

cromolyn sodium oral conc 100 mg/5ml 4 GATTEX KIT5MG 5 LA

loperamide hcl cap 2 mg 2 metoclopramide hcl inj 5 mg/ml 4 B/D PA

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2 metoclopramide hcl tab 10 mg 2


74

Nombre de Medicamentos Nivel Requisitos/Limites metoclopramide hcl tab 5 mg 2 NUTROPIN AQ INJ20MG/2ML 5 LA; PA

RELISTOR INJ12/0.6ML 5 PA

RELISTOR INJ8/0.4ML 5 RELISTOR TAB150MG 4 PA

SEROSTIM INJ4MG 5 PA



SYMPROIC TAB0.2MG 4 QL 30 POR 30 DIAS

ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2 ZOMACTON INJ5MG 4 PA

ZORBTIVE INJ8.8MG 5 PA

Histamine2 (H2) Receptor Antagonists

cimetidine hcl soln 300 mg/5ml 4 cimetidine tab 200 mg 4 cimetidine tab 300 mg 4 cimetidine tab 400 mg 4 cimetidine tab 800 mg 4 famotidine for susp 40 mg/5ml 4 famotidine in nacl 0.9% iv soln 20 mg/50ml 4 B/D PA

famotidine inj 20 mg/2ml 4 B/D PA

famotidine tab 20 mg 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 4 nizatidine cap 300 mg 4 nizatidine oral soln 15 mg/ml 4 ranitidine hcl cap 150 mg 1 ranitidine hcl cap 300 mg 4 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 4 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 ranitidine hcl tab 150 mg 2 ranitidine hcl tab 300 mg 2 Irritable Bowel Syndrome Agents

alosetron hcl tab 0.5 mg (base equiv) 5 QL 60 POR 30 DIAS

alosetron hcl tab 1 mg (base equiv) 5 QL 60 POR 30 DIAS

AMITIZA CAP24MCG 3 QL 60 POR 30 DIAS

AMITIZA CAP8MCG 3 QL 60 POR 30 DIAS

LINZESS CAP145MCG 4 QL 30 POR 30 DIAS



VIBERZI TAB100MG 5 QL 60 POR 30 DIAS

VIBERZI TAB75MG 5 QL 60 POR 30 DIAS


75

Nombre de Medicamentos Nivel Requisitos/Limites XERMELO TAB250MG 5 LA; QL 84 POR 28 DIAS

Laxatives

lactulose (encephalopathy) solution 10 gm/15ml 2 lactulose solution 10 gm/15ml 2 polyethylene glycol 3350 oral powder 2 Protectants

sucralfate tab 1 gm 2 Proton Pump Inhibitors

esomeprazole sodium for intravenous soln 20 mg (base

equiv) 2 B/D PA

esomeprazole sodium for intravenous soln 40 mg (base

equiv) 4 B/D PA

lansoprazole cap delayed release 15 mg 4 QL 30 POR 30 DIAS

lansoprazole cap delayed release 30 mg 4 QL 30 POR 30 DIAS

omeprazole cap delayed release 10 mg 1 QL 60 POR 30 DIAS; FFF



pantoprazole sodium ec tab 20 mg (base equiv) 2 QL 30 POR 30 DIAS

pantoprazole sodium ec tab 40 mg (base equiv) 1 QL 30 POR 30 DIAS

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS,

TREATMENT Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN INJ250/ML 5 LA; PA

ALDURAZYME INJ2.9MG/5M 5 PA

ARALAST NP INJ500MG 5 LA; NEW PA

CEREZYME INJ400UNIT 5 PA

CREON CAP12000UNT 3 CREON CAP24000UNT 3 CREON CAP6000UNIT 3 CYSTADANE POW 5 LA

CYSTAGON CAP150MG 4 LA

CYSTAGON CAP50MG 4 LA

CYSTARAN SOL0.44% 5 LA

ELAPRASE INJ6MG/3ML 5 PA

FABRAZYME INJ35MG 5 PA

KUVAN TAB100MG 5 LA; PA

miglustat cap100mg 5 LA

NAGLAZYME INJ1MG/ML 5 LA; PA

PALYNZIQ INJ10/0.5ML 5 QL 14 POR 28 DIAS; PA

PALYNZIQ INJ2.5/0.5ML 5 QL 4 POR 28 DIAS; PA

PALYNZIQ INJ20/ML 5 QL 56 POR 28 DIAS; PA

PROLASTIN-C INJ1000MG 5 LA; PA


76


RAVICTI LIQ1.1GM/ML 5

LA; QL 525 POR 30

DIAS; PA

VPRIV INJ400UNIT 5 PA

ZAVESCA CAP100MG 5 LA

ZEMAIRA INJ1000MG 5 LA; PA

ZENPEP CAP10000UNT 4 ZENPEP CAP15000UNT 4 ZENPEP CAP20000UNT 4 ZENPEP CAP5000UNIT 4 GENITOURINARY AGENTS Antispasmodics, Urinary

darifenacin hydrobromide tab sr 24hr 15 mg (base


darifenacin hydrobromide tab sr 24hr 7.5 mg (base


flavoxate hcl tab 100 mg 4 MYRBETRIQ TAB25MG 4 QL 30 POR 30 DIAS

MYRBETRIQ TAB50MG 4 QL 30 POR 30 DIAS

oxybutynin chloride syrup 5 mg/5ml 2 QL 600 POR 30 DIAS

oxybutynin chloride tab 5 mg 1 QL 120 POR 30 DIAS

oxybutynin chloride tab sr 24hr 10 mg 2 QL 90 POR 30 DIAS



tolterodine tartrate cap sr 24hr 2 mg 2 QL 30 POR 30 DIAS

tolterodine tartrate cap sr 24hr 4 mg 2 QL 30 POR 30 DIAS

tolterodine tartrate tab 1 mg 2 QL 60 POR 30 DIAS

tolterodine tartrate tab 2 mg 2 QL 60 POR 30 DIAS

TOVIAZ TAB4MG 3 QL 30 POR 30 DIAS

TOVIAZ TAB8MG 3 QL 30 POR 30 DIAS

Benign Prostatic Hypertrophy Agents

alfuzosin hcl tab sr 24hr 10 mg 2 QL 30 POR 30 DIAS

doxazosin mesylate tab 1 mg 2 QL 30 POR 30 DIAS




dutasteride cap 0.5 mg 2 QL 30 POR 30 DIAS

finasteride tab 5 mg 1 QL 30 POR 30 DIAS; FFF

prazosin hcl cap 1 mg 1 prazosin hcl cap 2 mg 1 prazosin hcl cap 5 mg 1 tamsulosin hcl cap 0.4 mg 1 QL 60 POR 30 DIAS; FFF

terazosin hcl cap 1 mg 2 QL 30 POR 30 DIAS




77

Nombre de Medicamentos Nivel Requisitos/Limites Genitourinary Agents, Other

bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 5 mg 2 bethanechol chloride tab 50 mg 2 ELMIRON CAP100MG 4 QL 90 POR 30 DIAS

Phosphate Binders

calcium acetate (phosphate binder) cap 667 mg (169 mg

ca) 2 lanthanum chw1000mg 2

lanthanum chw750mg 2

lanthanum chw500mg 2

PHOSLYRA SOL 4 RENAGEL TAB400MG 4 RENAGEL TAB800MG 5 RENVELA PAK0.8GM 5 QL 180 POR 30 DIAS

RENVELA PAK2.4GM 5 QL 90 POR 30 DIAS

RENVELA TAB800MG 5 QL 270 POR 30 DIAS

sevelamer carbonate packet 0.8 gm 2 QL 270 POR 30 DIAS

sevelamer carbonate packet 2.4 gm 2 QL 90 POR 30 DIAS

sevelamer tab800mg 2 QL 270 POR 30 DIAS

HORMONAL AGENTS, PARATHYROID Hormonal Agents, Parathyroid

NATPARA INJ100MCG 5


PA

NATPARA INJ25MCG 5


PA

NATPARA INJ50MCG 5


PA

NATPARA INJ75MCG 5


PA

SENSIPAR TAB30MG 4


PA

SENSIPAR TAB60MG 3


PA

SENSIPAR TAB90MG 3

QL 120 POR 30 DIAS;

B/D PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING

(ADRENAL) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 amcinonide cream 0.1% 2


78

Nombre de Medicamentos Nivel Requisitos/Limites amcinonide lotion 0.1% 2 amcinonide oint 0.1% 2 betamethasone dipropionate augmented cream 0.05% 2 betamethasone dipropionate augmented gel 0.05% 2 betamethasone dipropionate augmented lotion 0.05% 2 betamethasone dipropionate augmented oint 0.05% 2 betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 2 betamethasone valerate aerosol foam 0.12% 2 betamethasone valerate cream 0.1% 2 betamethasone valerate lotion 0.1% 2 betamethasone valerate oint 0.1% 2 CAPEX SHA0.01% 4 desonide lotion 0.05% 2 desonide lotion 0.05% 4 desonide oint 0.05% 4 desoximetasone cream 0.05% 2 desoximetasone cream 0.05% 4 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.25% 2 dexamethasone sodium phosphate inj 120 mg/30ml 4 diflorasone diacetate cream 0.05% 4 diflorasone diacetate oint 0.05% 4 fludrocortisone acetate tab 0.1 mg 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluocinolone acetonide soln 0.01% 2 fluocinonide cream 0.1% 4 fluocinonide emulsified base cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate lotion 0.05% 2 fluticasone propionate oint 0.005% 2 halobetasol propionate cream 0.05% 4 halobetasol propionate oint 0.05% 4 HALOG CRE0.1% 4 HALOG OIN0.1% 4 hydrocortisone cream 1% 2 hydrocortisone cream 2.5% 2


79

Nombre de Medicamentos Nivel Requisitos/Limites hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 hydrocortisone rectal cream 2.5% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 prednicarbate oint 0.1% 4 prednisolone sod phos orally disintegr tab 10 mg (base

eq) 2 prednisolone sod phos orally disintegr tab 15 mg (base

eq) 2 prednisolone sod phos orally disintegr tab 30 mg (base

eq) 2 prednisone conc 5 mg/ml 2 prednisone tab 2.5 mg 2 prednisone tab 20 mg 2 prednisone tab 5 mg 2 prednisone tab therapy pack 10 mg (21) 2 prednisone tab therapy pack 10 mg (48) 2 prednisone tab therapy pack 5 mg (21) 2 prednisone tab therapy pack 5 mg (48) 2 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide cream 0.1% 2 triamcinolone acetonide cream 0.5% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide oint 0.025% 2 triamcinolone acetonide oint 0.1% 2 triamcinolone acetonide oint 0.5% 2 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING

(PITUITARY) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate inj 4 mcg/ml 4 B/D PA

desmopressin acetate nasal spray soln 0.01%

(refrigerated) 2 desmopressin acetate tab 0.1 mg 2 desmopressin acetate tab 0.2 mg 2 GENOTROPIN INJ0.2MG 4 PA

GENOTROPIN INJ0.4MG 5 PA



80

Nombre de Medicamentos Nivel Requisitos/Limites GENOTROPIN INJ0.8MG 5 PA





GENOTROPIN INJ12MG 5 PA




HUMATROPE INJ12MG 5 PA




INCRELEX INJ40MG/4ML 5 LA; PA

NORDITROPIN INJ10/1.5ML 5 PA



NUTROPIN AQ INJ10MG/2ML 5 LA; PA

NUTROPIN AQ INJNUSPIN 5 5 LA; PA

OMNITROPE INJ10/1.5ML 5 PA

OMNITROPE INJ5.8MG 5 PA

OMNITROPE INJ5/1.5ML 5 PA

SAIZEN INJ5MG 5 PA

SAIZEN INJ8.8MG 5 PA

STIMATE SOL1.5MG/ML 4 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING

(PROSTAGLANDINS) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING

(SEX HORMONES/MODIFIERS) Anabolic Steroids

ANADROL-50 TAB50MG 5 oxandrolone tab 10 mg 5 QL 60 POR 30 DIAS

oxandrolone tab 2.5 mg 2 QL 120 POR 30 DIAS

Androgens

ANDROGEL GEL1.62% 3 ANDROGEL GEL1.62% 3 QL 300 POR 30 DIAS

AXIRON SOL30MG/ACT 3 danazol cap 100 mg 2 danazol cap 200 mg 2 danazol cap 50 mg 2


81

Nombre de Medicamentos Nivel Requisitos/Limites testosterone cypionate im inj in oil 100 mg/ml 2 B/D PA

testosterone cypionate im inj in oil 200 mg/ml 2 B/D PA

testosterone enanthate im inj in oil 200 mg/ml 4 B/D PA

testosteronesol30mg/act 2

testosterone td gel 12.5 mg/act (1%) 2 testosterone td gel 25 mg/2.5gm (1%) 2 testosterone td gel 50 mg/5gm (1%) 2 QL 300 POR 30 DIAS

Estrogens

ALORA DIS0.025MG 4 QL 8 POR 28 DIAS; PA




esterified estrogens tab 0.3 mg 2 PA



estradiol tab 0.5 mg 2 PA

estradiol tab 1 mg 2 PA

estradiol tab 2 mg 2 PA

estradiol td patch twice weekly 0.025 mg/24hr 2 QL 8 POR 28 DIAS; PA





estradiol vaginal cream 0.1 mg/gm 2 estradiol vaginal tab 10 mcg 2 ESTRING MIS2MG 4 QL 1 POR 90 DIAS

estropipate tab 0.75 mg 2 PA

estropipate tab 1.5 mg 2 PA

estropipate tab 3 mg 2 PA

INTRAROSA SUP6.5MG 4

MINIVELLE DIS0.025 MG 4 QL 8 POR 28 DIAS; PA

MINIVELLE DIS0.05MG 4 QL 8 POR 28 DIAS; PA



PREMARIN INJ25MG 4 B/D PA

PREMARIN TAB0.3MG 3 PREMARIN TAB0.45MG 3 PREMARIN TAB0.625MG 3 PREMARIN TAB0.9MG 3 PREMARIN TAB1.25MG 3 PREMARIN VAGCRE0.625MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5) 2


82

Nombre de Medicamentos Nivel Requisitos/Limites desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-

0.025mg-mg 2 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2 drospirenone-ethinyl estradiol tab 3-0.03 mg 2 estradiol & norethindrone acetate tab 0.5-0.1 mg 2 PA

estradiol & norethindrone acetate tab 1-0.5 mg 2 PA

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg 2 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg 2 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-

0.03 mg 2 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 2 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-

30mg-mcg 2 norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr 2 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 2 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 2 norethindrone & ethinyl estradiol tab 1 mg-35 mcg 2 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 2 norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg 2 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg 2 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30

mcg 2 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg

(24) 2 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 2 PA

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg 2 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-

mcg 2 norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg

(10/11) 2 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-

mcg 2 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 2 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35

mg-mcg 2 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 2 norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg 2


83

Nombre de Medicamentos Nivel Requisitos/Limites NUVARING MIS 4 PREFEST TAB 3 PA

PREMPHASE TAB 3 PREMPRO TAB.625-2.5 3 PREMPRO TAB0.3-1.5 3 PREMPRO TAB0.45-1.5 3 PREMPRO TAB0.625-5 3 Progestins

DEPO-PROVERAINJ400/ML 4 medroxyprogesterone acetate im susp 150 mg/ml 4 QL 1 POR 90 DIAS

medroxyprogesterone acetate tab 10 mg 2 medroxyprogesterone acetate tab 2.5 mg 2 medroxyprogesterone acetate tab 5 mg 2 megestrol acetate susp 40 mg/ml 2 megestrol acetate susp 625 mg/5ml 2 PA

megestrol acetate tab 20 mg 2 megestrol acetate tab 40 mg 2 norethindrone acetate tab 5 mg 2 norethindrone tab 0.35 mg 2 progesterone micronized cap 100 mg 4 progesterone micronized cap 200 mg 4 Selective Estrogen Receptor Modifying Agents

DUAVEE TAB0.45-20 3 QL 30 POR 30 DIAS

raloxifene hcl tab 60 mg 2 QL 30 POR 30 DIAS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING

(THYROID) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 300 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 LEVOXYL TAB100MCG 3 LEVOXYL TAB112MCG 3 LEVOXYL TAB125MCG 3


84

Nombre de Medicamentos Nivel Requisitos/Limites LEVOXYL TAB137MCG 3 LEVOXYL TAB150MCG 3 LEVOXYL TAB175MCG 3 LEVOXYL TAB200MCG 3 LEVOXYL TAB25MCG 3 LEVOXYL TAB50MCG 3 LEVOXYL TAB75MCG 3 LEVOXYL TAB88MCG 3 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 50 mcg 2 SYNTHROID TAB100MCG 3 SYNTHROID TAB112MCG 3 SYNTHROID TAB125MCG 3 SYNTHROID TAB137MCG 3 SYNTHROID TAB150MCG 3 SYNTHROID TAB175MCG 3 SYNTHROID TAB200MCG 3 SYNTHROID TAB25MCG 3 SYNTHROID TAB300MCG 3 SYNTHROID TAB50MCG 3 SYNTHROID TAB75MCG 3 SYNTHROID TAB88MCG 3 HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Adrenal)

LYSODREN TAB500MG 5 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary)

bromocriptine mesylate cap 5 mg (base equivalent) 2 bromocriptine mesylate tab 2.5 mg (base equivalent) 2 cabergoline tab 0.5 mg 2 FIRMAGON INJ120MG 5 FIRMAGON INJ80MG 4 leuprolide acetate inj kit 5 mg/ml 5 LUPR DEP-PEDINJ11.25MG 5 PA

LUPR DEP-PEDINJ15MG 5 PA

LUPRON DEPOTINJ11.25MG 5 LUPRON DEPOTINJ22.5MG 5 LUPRON DEPOTINJ3.75MG 5 QL 1 POR 28 DIAS

LUPRON DEPOTINJ30MG 5 LUPRON DEPOTINJ45MG 5 B/D PA

LUPRON DEPOTINJ7.5MG 5 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 PA


85

Nombre de Medicamentos Nivel Requisitos/Limites octreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PA

octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 PA



SANDOSTATIN KITLAR 10MG 5 PA



SIGNIFOR INJ0.3MG/ML 5 LA; PA



SOMATULINE INJ120/.5ML 5 SOMATULINE INJ60/0.2ML 5 SOMATULINE INJ90/0.3ML 5 SOMAVERT INJ10MG 5 LA; PA

SOMAVERT INJ15MG 5 LA; PA




SYNAREL SOL2MG/ML 5 PA

TRELSTAR MIXINJ11.25MG 5 TRELSTAR MIXINJ22.5MG 5 QL 1 POR 168 DIAS

TRELSTAR MIXINJ3.75MG 5 HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents

methimazole tab 10 mg 2 methimazole tab 5 mg 2 propylthiouracil tab 50 mg 2 IMMUNOLOGICAL AGENTS Angioedema Agents

CINRYZE SOL500 UNIT 5 LA; B/D PA

FIRAZYR INJ30MG/3ML 5 QL 18 POR 30 DIAS; PA

Immune Suppressants

ASTAGRAF XL CAP0.5MG 4 B/D PA

ASTAGRAF XL CAP1MG 4 B/D PA

ASTAGRAF XL CAP5MG 5 B/D PA

azathioprine sodium for inj 100 mg 5 B/D PA

azathioprine tab 100 mg 2 B/D PA



cyclosporine cap 100 mg 2 B/D PA

cyclosporine cap 25 mg 2 B/D PA

cyclosporine iv soln 50 mg/ml 4 B/D PA

cyclosporine modified cap 100 mg 2 B/D PA


86

Nombre de Medicamentos Nivel Requisitos/Limites cyclosporine modified cap 25 mg 2 B/D PA

cyclosporine modified cap 50 mg 2 B/D PA

cyclosporine modified oral soln 100 mg/ml 2 B/D PA

ELIDEL CRE1% 4 QL 30 POR 30 DIAS; PA

ENBREL INJ25/0.5ML 5

QL 8 POR 28 DIAS; PA;

ST

ENBREL INJ25MG 5


ST

ENBREL INJ50MG/ML 5


ST

ENBREL SRCLKINJ50MG/ML 5


ST

ENVARSUS XR TAB0.75MG 4 B/D PA

ENVARSUS XR TAB1MG 4 B/D PA

ENVARSUS XR TAB4MG 5 B/D PA

HUMIRA INJ10MG/0.1 5 QL 6 POR 28 DIAS; PA




HUMIRA KIT20MG/0.4 5 QL 8 POR 28 DIAS; PA

HUMIRA KIT40MG/0.8 5 QL 8 POR 28 DIAS; PA

HUMIRA PEDIAINJCROHNS 5


PA



PA



PA

HUMIRA PEN INJ40MG/0.4 5 QL 8 POR 28 DIAS; PA

HUMIRA PEN INJ40MG/0.8 5 QL 8 POR 28 DIAS; PA

HUMIRA PEN INJCROHNS 5 QL 8 POR 28 DIAS; PA

HUMIRA PEN INJPSORIASI 5 QL 8 POR 28 DIAS; PA

HUMIRA PEN KITCD/UC/HS 5 QL 3 POR 28 DIAS; PA

HUMIRA PEN KITPS/UV 5 QL 3 POR 28 DIAS; PA

INFLECTRA INJ100MG 5 PA

KINERET INJ 5 QL 28 POR 28 DIAS; PA

mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 4 B/D PA

methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 4 B/D PA

methotrexate sodium inj pf 250 mg/10ml 4 B/D PA

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 4 B/D PA

methotrexate sodium tab 10 mg (base equiv) 2 methotrexate sodium tab 15 mg (base equiv) 2 methotrexate sodium tab 2.5 mg (base equiv) 2 methotrexate sodium tab 5 mg (base equiv) 2


87

Nombre de Medicamentos Nivel Requisitos/Limites methotrexate sodium tab 7.5 mg (base equiv) 2 mycophenolate mofetil cap 250 mg 2 B/D PA

mycophenolate mofetil for oral susp 200 mg/ml 5 B/D PA

mycophenolate mofetil hcl for iv soln 500 mg (base

equiv) 4 B/D PA

mycophenolate mofetil tab 500 mg 2 B/D PA

mycophenolate sodium tab dr 180 mg (mycophenolic

acid equiv) 4 B/D PA

mycophenolate sodium tab dr 360 mg (mycophenolic

acid equiv) 4 B/D PA

ORENCIA INJ125MG/ML 5 QL 4 POR 28 DIAS

ORENCIA INJ250MG 5 ST; PA

ORENCIA INJ50/0.4 5 ST; PA

ORENCIA INJ87.5/0.7 5 ST; PA

ORENCIA CLCKINJ125MG/ML 5


ST

OTREXUP INJ10MG 4 OTREXUP INJ12.5/0.4 4 OTREXUP INJ15MG 4 OTREXUP INJ17.5/0.4 4 OTREXUP INJ20MG 4 OTREXUP INJ22.5/0.4 4 OTREXUP INJ25MG 4 PROGRAF INJ5MG/ML 4 B/D PA

RAPAMUNE SOL1MG/ML 5 B/D PA

RASUVO INJ20MG 4 REMICADE INJ100MG 5 PA

SANDIMMUNE SOL100MG/ML 4 B/D PA

SIMPONI INJ100MG/ML 5

SIMPONI INJ50/0.5ML 5


ST

SIMPONI INJ50/0.5ML 5 SIMPONI ARIASOL50MG/4ML 5 SIMULECT INJ20MG 5 B/D PA

sirolimus tab 0.5 mg 4 B/D PA

sirolimus tab 1 mg 4 B/D PA

sirolimus tab 2 mg 5 B/D PA

tacrolimus cap 0.5 mg 2 B/D PA

tacrolimus cap 1 mg 2 B/D PA

tacrolimus cap 5 mg 4 B/D PA

TORISEL SOL25MG/ML 5 XATMEP SOL2.5MG/ML 5

XELJANZ TAB5MG 5 XELJANZ TAB10MG 5


88

Nombre de Medicamentos Nivel Requisitos/Limites XELJANZ XR TAB11MG 5

ZORTRESS TAB0.25MG 5


PA

ZORTRESS TAB0.5MG 5


PA

ZORTRESS TAB0.75MG 5


PA

Immunizing Agents, Passive

ATGAM INJ250MG 5 THYMOGLOBULNINJ25MG 5 PA

Immunological Agents

SYNAGIS INJ50MG 5 LA; PA

ZINPLAVA SOL25MG/ML 5 PA

Immunomodulators

ACTIMMUNE INJ2MU/0.5 5 LA; B/D PA

ARCALYST INJ220MG 5 LA; PA

BENLYSTA INJ120MG 5 LA; PA

BENLYSTA INJ400MG 5 LA; PA

ILARIS INJ150MG 5 LA

ILARIS INJ180MG 5 LA; B/D PA

leflunomide tab 10 mg 2 QL 30 POR 30 DIAS

leflunomide tab 20 mg 2 QL 30 POR 30 DIAS

NULOJIX INJ250MG 5 B/D PA

OTEZLA TAB10/20/30 5 LA; QL 60 POR 30 DIAS

OTEZLA TAB30MG 5 LA; QL 60 POR 30 DIAS

RIDAURA CAP3MG 5 Vaccines

ACTHIB INJ 4 ADACEL INJ 4 BCG VACCINE INJ 4 BEXSERO INJ 4 BIVIGAM INJ10% 4 PA

BOOSTRIX INJ 4 CARIMUNE NF INJ6GM 5 PA

DAPTACEL INJ 4 DIP/TET PED INJ25-5LFU 4 ENGERIX-B INJ10/0.5ML 4 B/D PA

ENGERIX-B INJ20MCG/ML 4 B/D PA

FLEBOGAMMA INJDIF 10% 4 PA

GAMASTAN S/DINJ 3 PA

GAMMAGARD INJ2.5GM/25 5 PA

GAMMAGARD SDINJ10GM HU 5 PA

GAMMAGARD SDINJ5GM HU 5 PA

GAMMAKED INJ1GM/10ML 4 PA


89

Nombre de Medicamentos Nivel Requisitos/Limites GAMMAPLEX INJ5% 4 PA

GAMUNEX-C INJ1GM/10ML 4 PA

GARDASIL 9 INJ 4 PA

HAVRIX INJ1440UNIT 4 HAVRIX INJ720UNIT 4 HIBERIX SOL10MCG 4 HYPERRAB S/DINJ150/ML 5 IMOGAM RABIEINJ150/ML 4 IMOVAX RABIEINJ2.5/ML 4 INFANRIX INJ 4 IPOL INJINACTIVE 4 IXIARO INJ 4 KINRIX INJ 4 MENACTRA INJ 4 MENOMUNE INJA/C/Y/W 4 MENVEO INJ 4 M-M-R II INJ 4 OCTAGAM INJ1GM 4 PA

OCTAGAM INJ2GM/20ML 4 PA

PEDIARIX INJ0.5ML 4 PEDVAX HIB INJ 4 PRIVIGEN INJ20GRAMS 4 PA

PROQUAD INJ 4 QUADRACEL INJ 4 RABAVERT INJ 4 RECOMBIVA HBINJ10MCG/ML 4 B/D PA

RECOMBIVA HBINJ5MCG/0.5 4 B/D PA

RECOMBIVA-HBINJ40MCG/ML 4 B/D PA

ROTARIX SUS 4 ROTATEQ SOL 4 SHINGRIX INJ50MCG 3

TENIVAC INJ5-2LF 4 TET/DIP TOX INJ2-2 LF 3 TRUMENBA INJ 4 TWINRIX INJ 4 TYPHIM VI INJ 4 VAQTA INJ25/0.5ML 4 VAQTA INJ50UNT/ML 4 VARIVAX INJ 4 YF-VAX INJ 4 ZOSTAVAX INJ 3 INFLAMMATORY BOWEL DISEASE AGENTS Aminosalicylates


90

Nombre de Medicamentos Nivel Requisitos/Limites *mesalamine rectal enema 4 gm & cleanser wipe kit** 2 balsalazide disodium cap 750 mg 2 CANASA SUP1000MG 5 DIPENTUM CAP250MG 5 MESALAMINE TAB800MG DR 4 mesalamine tab1.2gm 4

PENTASA CAP250MG CR 4 PENTASA CAP500MG CR 5 Glucocorticoids

budesonide delayed release particles cap 3 mg 5 cortisone acetate tab 25 mg 2 dexamethasone conc 1 mg/ml 1 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 2 dexamethasone tab 0.75 mg 2 dexamethasone tab 1 mg 2 dexamethasone tab 1.5 mg 2 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 2 dexamethasone tab 6 mg 2 hydrocortisone enema 100 mg/60ml 2 hydrocortisone rectal cream 1% 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 hydrocortisone tab 5 mg 2 methylprednisolone acetate inj susp 40 mg/ml 4 B/D PA

methylprednisolone acetate inj susp 80 mg/ml 4 B/D PA

methylprednisolone sodium succinate for inj 125 mg 4 B/D PA

methylprednisolone sodium succinate for inj 40 mg 4 B/D PA

methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab 4 mg 1 methylprednisolone tab 8 mg 2 methylprednisolone tab therapy pack 4 mg (21) 1 prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base) 2 prednisolone sod phosphate oral soln 10 mg/5ml (base

equiv) 2 prednisolone sod phosphate oral soln 15 mg/5ml (base

equiv) 2 prednisolone sod phosphate oral soln 20 mg/5ml (base

equiv) 2 prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2


91

Nombre de Medicamentos Nivel Requisitos/Limites prednisone tab 10 mg 2 prednisone tab 50 mg 2 Sulfonamides

sulfasalazine tab 500 mg 2 sulfasalazine tab delayed release 500 mg 2 METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents

alendronate sodium tab 10 mg 2

QL 120 POR 30 DIAS;

FFF

alendronate sodium tab 35 mg 2 QL 5 POR 30 DIAS; FFF


alendronate sodium tab 5 mg 2

QL 240 POR 30 DIAS;

FFF


calcitonin (salmon) nasal soln 200 unit/act 2 calcitriol cap 0.25 mcg 2 calcitriol cap 0.5 mcg 2 calcitriol inj 1 mcg/ml 4 B/D PA

calcitriol oral soln 1 mcg/ml 2 doxercalciferol cap 0.5 mcg 4 doxercalciferol cap 1 mcg 5 doxercalciferol cap 2.5 mcg 5 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 4 B/D PA

etidronate disodium tab 200 mg 4 etidronate disodium tab 400 mg 4 FORTEO SOL600/2.4 5 QL 3 POR 28 DIAS; PA

ibandronate sodium iv soln 3 mg/3ml (base equivalent) 4


PA

ibandronate sodium tab 150 mg (base equivalent) 4 QL 1 POR 30 DIAS

MIACALCIN INJ200/ML 4 PA

pamidronate disodium iv soln 3 mg/ml 4 B/D PA



paricalcitol iv soln 5 mcg/ml 2 B/D PA

PROLIA SOL60MG/ML 4 QL 2 POR 365 DIAS

risedronate sodium tab 150 mg 4 QL 5 POR 30 DIAS




XGEVA INJ 5 QL 1.7 POR 28 DIAS

zoledronic acid inj conc for iv infusion 4 mg/5ml 4 B/D PA

zoledronic acid iv soln 5 mg/100ml 4 B/D PA

OPHTHALMIC AGENTS


92

Nombre de Medicamentos Nivel Requisitos/Limites Ophthalmic Agents

bacitracin-polymyxin b ophth oint 2 bacitracin-polymyxin-neomycin-hc ophth oint 1% 2 BLEPHAMIDE SUSOP 4 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml 2 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-

10000unt op oin 2 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-

unt-mg/ml 2 neomycin-polymyxin-dexamethasone ophth oint 0.1% 2 neomycin-polymyxin-dexamethasone ophth susp 0.1% 2 neomycin-polymyxin-hc ophth susp 2 polymyxin b-trimethoprim ophth soln 10000 unit/ml-

0.1% 2 PRED-G SUSOP 4 PRED-G S.O.POINOP 4 proparacaine hcl ophth soln 0.5% 2 sulfacetamide sodium-prednisolone ophth oint 10-0.2% 2 sulfacetamide sodium-prednisolone ophth soln 10-

0.23(0.25)% 2 tobramycin-dexamethasone ophth susp 0.3-0.1% 2 Ophthalmic Agents, Other

LACRISERT MIS5MG OP 4 RESTASIS EMU0.05% 3 QL 60 POR 30 DIAS

Ophthalmic Anti-allergy Agents

azelastine hcl ophth soln 0.05% 2 cromolyn sodium ophth soln 4% 2 olopatadine hcl ophth soln 0.1% (base equivalent) 4 FFF

olopatadine hcl ophth soln 0.2% 2

PATADAY SOL0.2% 3 PAZEO DRO0.7% 3 Ophthalmic Antiglaucoma Agents

acetazolamide cap sr 12hr 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 ALPHAGAN P SOL0.1% 3 apraclonidine hcl ophth soln 0.5% (base equivalent) 2 AZOPT SUS1% OP 3 betaxolol hcl ophth soln 0.5% 2 brimonidine tartrate ophth soln 0.15% 2 FFF

brimonidine tartrate ophth soln 0.2% 2 FFF

carteolol hcl ophth soln 1% 2 dorzolamide hcl ophth soln 2% 2 FFF


93

Nombre de Medicamentos Nivel Requisitos/Limites IOPIDINE SOL1% OP 4 levobunolol hcl ophth soln 0.5% 2 methazolamide tab 25 mg 2 methazolamide tab 50 mg 2 metipranolol ophth soln 0.3% 2 PHOSPHOLINE SOL0.125%OP 4 timolol maleate ophth gel forming soln 0.25% 2 timolol maleate ophth gel forming soln 0.5% 2 timolol maleate ophth soln 0.25% 2 timolol maleate ophth soln 0.5% 1 Ophthalmic Anti-inflammatories

ALREX SUS0.2% 4 bromfenac sodium ophth soln 0.09% (base equivalent) 4 dexamethasone sodium phosphate ophth soln 0.1% 2 diclofenac sodium ophth soln 0.1% 4 DUREZOL EMU0.05% 3 FLAREX SUS0.1% OP 4 flurbiprofen sodium ophth soln 0.03% 2 FML OIN0.1% OP 4 FML FORTE SUS0.25% OP 4 ILEVRO DRO0.3% OP 3 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 LOTEMAX GEL0.5% 3 LOTEMAX OIN0.5% 3 LOTEMAX SUS0.5% 3 MAXIDEX SUS0.1% OP 4 NEVANAC SUS0.1% 3 PRED MILD SUS0.12% OP 4 prednisolone sodium phosphate ophth soln 1% 2 prednisolone sus1%op 2

Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost ophth soln 0.03% 2 latanoprost ophth soln 0.005% 1 QL 5 POR 30 DIAS; FFF

LUMIGAN SOL0.01% 3 QL 7.5 POR 30 DIAS

TRAVATAN Z DRO0.004% 3 OTIC AGENTS Otic Agents

CIPRODEX SUS0.3-0.1% 3 fluocinolone acetonide (otic) oil 0.01% 2 fluocinolone acetonide oil 0.01% (body oil) 2 hydrocortisone w/ acetic acid otic soln 1-2% 2 neomycin-polymyxin-hc otic soln 1% 2


94

Nombre de Medicamentos Nivel Requisitos/Limites neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1% 2 RESPIRATORY TRACT/PULMONARY AGENTS Antihistamines

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL 30 POR 30 DIAS; FFF

azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 4 QL 60 POR 30 DIAS; FFF

carbinoxamine maleate soln 4 mg/5ml 2 PA

carbinoxamine maleate tab 4 mg 2 PA

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 2 clemastine fumarate tab 2.68 mg 2 PA

cyproheptadine hcl syrup 2 mg/5ml 2 PA

cyproheptadine hcl tab 4 mg 2 PA

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5

mg/ml) 2 levocetirizine dihydrochloride tab 5 mg 2 QL 30 POR 30 DIAS

olopatadine hcl nasal soln 0.6% 4 promethazine hcl syrup 6.25 mg/5ml 1 PA

promethazine hcl tab 12.5 mg 2 PA

promethazine hcl tab 25 mg 2 PA

promethazine hcl tab 50 mg 2 PA

Anti-inflammatories, Inhaled Corticosteroids

ASMANEX 120 AER220MCG 4 QL 2 POR 30 DIAS




BECONASE AQ SUS0.042% 4 QL 50 POR 30 DIAS

budesonide inhalation susp 1 mg/2ml 2 B/D PA

budesonide nasal susp 32 mcg/act 2 QL 17.2 POR 30 DIAS

flunisolide nasal soln 25 mcg/act (0.025%) 2 QL 50 POR 30 DIAS

fluticasone propionate nasal susp 50 mcg/act 2 mometasone furoate nasal susp 50 mcg/act 2 QL 34 POR 30 DIAS

PULMICORT INH180MCG 3 QL 2 POR 30 DIAS

PULMICORT INH90MCG 3 QL 2 POR 30 DIAS

QVAR AER40MCG 3 QL 34.8 POR 30 DIAS

QVAR AER80MCG 3 QVAR REDIHALAER 40MG 3 QL 10.6 POR 30 DIAS

QVAR REDIHALAER 80MG 3 QL 21.20 POR 30 DIAS

Antileukotrienes

montelukast sodium chew tab 4 mg (base equiv) 2 QL 30 POR 30 DIAS

montelukast sodium chew tab 5 mg (base equiv) 2 QL 30 POR 30 DIAS

montelukast sodium oral granules packet 4 mg (base


montelukast sodium tab 10 mg (base equiv) 1 QL 30 POR 30 DIAS

zafirlukast tab 10 mg 2 QL 60 POR 30 DIAS


95

Nombre de Medicamentos Nivel Requisitos/Limites zafirlukast tab 20 mg 2 QL 60 POR 30 DIAS

zileuton er tab600mg 5 QL 120 POR 30 DIAS

ZYFLO TAB600MG 5 Bronchodilators, Anticholinergic

ATROVENT HFAAER17MCG 4 QL 25.8 POR 30 DIAS

INCRUSE ELPTINH62.5MCG 4 QL 30 POR 30 DIAS

ipratropium bromide inhal soln 0.02% 2 B/D PA

ipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL 30 POR 30 DIAS

ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL 30 POR 30 DIAS

SPIRIVA AER1.25MCG 3 SPIRIVA CAPHANDIHLR 3 QL 90 POR 30 DIAS

SPIRIVA SPR2.5MCG 3 TUDORZA PRESAER400/ACT 3 Bronchodilators, Sympathomimetic

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2

QL 360 POR 30 DIAS;

B/D PA

albuterol sulfate soln nebu 0.5% (5 mg/ml) 2


PA

albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 2

QL 360 POR 30 DIAS;

B/D PA

albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 2

QL 360 POR 30 DIAS;

B/D PA

albuterol sulfate syrup 2 mg/5ml 2 albuterol sulfate tab 2 mg 4 albuterol sulfate tab 4 mg 4 albuterol sulfate tab sr 12hr 4 mg 2 albuterol sulfate tab sr 12hr 8 mg 2 ARCAPTA CAP75MCG 3 QL 30 POR 30 DIAS

EPINEPHRINE INJ0.15MG 4 QL 2 POR 30 DIAS




EPIPEN 2-PAKINJ0.3MG 4 QL 2 POR 30 DIAS

EPIPEN-JR INJ2-PAK 4 QL 2 POR 30 DIAS

metaproterenol sulfate syrup 10 mg/5ml 2 metaproterenol sulfate tab 10 mg 2 metaproterenol sulfate tab 20 mg 2 PROAIR HFA AER 2 QL 17 POR 30 DIAS

PROAIR RESPIAER 3 QL 2 POR 30 DIAS

PROVENTIL AERHFA 3 QL 13.4 POR 30 DIAS

SEREVENT DISAER50MCG 3 QL 60 POR 30 DIAS

terbutaline sulfate inj 1 mg/ml 4 terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2


96

Nombre de Medicamentos Nivel Requisitos/Limites VENTOLIN HFAAER 4 QL 36 POR 30 DIAS

Cystic Fibrosis Agents

KALYDECO PAK50MG 5 QL 60 POR 30 DIAS; PA

KALYDECO PAK75MG 5 QL 60 POR 30 DIAS; PA

KALYDECO TAB150MG 5 QL 60 POR 30 DIAS; PA

ORKAMBI TAB100-125 5

LA; QL 112 POR 28

DIAS; PA

ORKAMBI TAB200-125 5

LA; QL 112 POR 28

DIAS; PA

TOBI PODHALRCAP28MG 5 LA

tobramycin nebu soln 300 mg/5ml 5 PA

Mast Cell Stabilizers

cromolyn sodium soln nebu 20 mg/2ml 2

QL 240 POR 30 DIAS;

B/D PA

Phosphodiesterase Inhibitors, Airways Disease

DALIRESP TAB250MCG 4 QL 30 POR 30 DIAS

DALIRESP TAB500MCG 4 QL 30 POR 30 DIAS

theophylline tab sr 12hr 100 mg 2 theophylline tab sr 12hr 200 mg 2 theophylline tab sr 12hr 300 mg 2 theophylline tab sr 24hr 400 mg 2 theophylline tab sr 24hr 600 mg 2 Pulmonary Antihypertensives

ADEMPAS TAB0.5MG 5


PA

ADEMPAS TAB1.5MG 5


PA

ADEMPAS TAB1MG 5


PA

ADEMPAS TAB2.5MG 5


PA

ADEMPAS TAB2MG 5


PA

LETAIRIS TAB10MG 5


PA

LETAIRIS TAB5MG 5


PA

OPSUMIT TAB10MG 5


PA

ORENITRAM TAB0.125MG 4 LA; PA


ORENITRAM TAB1MG 5 LA; PA


ORENITRAM TAB5MG 5 LA; PA


97

Nombre de Medicamentos Nivel Requisitos/Limites REMODULIN INJ1MG/ML 5 LA; PA

REMODULIN INJ2.5MG/ML 5 LA; PA

REMODULIN INJ5MG/ML 5 LA; PA

sildenafil citrate tab 20 mg 2 QL 90 POR 30 DIAS; PA

UPTRAVI TAB1000MCG 5


PA



PA



PA



PA

UPTRAVI TAB200/800 5

LA; QL 140 POR 60

DIAS; PA

UPTRAVI TAB200MCG 5


PA

UPTRAVI TAB400MCG 5


PA

UPTRAVI TAB600MCG 5


PA

UPTRAVI TAB800MCG 5


PA

Pulmonary Fibrosis Agents

ESBRIET CAP267MG 5

LA; QL 270 POR 30

DIAS; PA

ESBRIET TAB267MG 5

LA; QL 270 POR 30

DIAS; PA

ESBRIET TAB801MG 5


PA

OFEV CAP100MG 5


PA

OFEV CAP150MG 5


PA

Respiratory Tract Agents, Other

acetylcysteine inhal soln 10% 2 B/D PA

acetylcysteine inhal soln 20% 2 B/D PA

ADVAIR DISKUAER100/50 4 QL 60 POR 30 DIAS



ADVAIR HFA AER115/21 4 QL 12 POR 30 DIAS



ANORO ELLIPTAER62.5-25 3 QL 60 POR 30 DIAS

BREO ELLIPTAINH100-25 4 QL 60 POR 30 DIAS


98

Nombre de Medicamentos Nivel Requisitos/Limites BREO ELLIPTAINH200-25 4 QL 60 POR 30 DIAS

DULERA AER100-5MCG 3 QL 13 POR 30 DIAS

DULERA AER200-5MCG 3 QL 13 POR 30 DIAS

FLUTICASONE INHSALMETER 2 QL 1 POR 30 DIAS

SYMBICORT AER160-4.5 3 QL 10.2 POR 30 DIAS

SYMBICORT AER80-4.5 3 TRELEGY AERELLIPTA 4 QL 60 POR 30 DIAS

Respiratory Tract/Pulmonary Agents

COMBIVENT AER20-100 4 QL 4 POR 20 DIAS

PULMOZYME SOL1MG/ML 5 PA

STIOLTO AER2.5-2.5 3 XOLAIR SOL150MG 5 LA; PA

SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants

cyclobenzaprine hcl tab 10 mg 4 PA

cyclobenzaprine hcl tab 5 mg 2 PA

cyclobenzaprine hcl tab 7.5 mg 2 PA

metaxalone tab 800 mg 2 PA

SLEEP DISORDER AGENTS GABA Receptor Modulators

eszopiclone tab 1 mg 2 QL 30 POR 30 DIAS; PA



temazepam cap 15 mg 2 QL 30 POR 30 DIAS

temazepam cap 30 mg 2 QL 30 POR 30 DIAS

zaleplon cap 10 mg 2 QL 60 POR 30 DIAS; PA

zaleplon cap 5 mg 2 QL 30 POR 30 DIAS; PA

zolpidem tartrate tab 10 mg 2 QL 30 POR 30 DIAS; PA

zolpidem tartrate tab 5 mg 2 QL 30 POR 30 DIAS; PA

Sleep Disorders, Other

HETLIOZ CAP20MG 5


PA

modafinil tab 100 mg 2 QL 60 POR 30 DIAS; PA

modafinil tab 200 mg 2 QL 60 POR 30 DIAS; PA

ROZEREM TAB8MG 4 QL 30 POR 30 DIAS

XYREM SOL500MG/ML 5

LA; QL 540 POR 30

DIAS; PA

99

Índice de Medicamentos

1st Generation/Typical .................................. 40 2nd Generation/Atypical ............................... 42 abacavir sol20mg/ml ........................................ 46 abacavir sulfate tab 300 mg (base equiv) ........ 46 abacavir sulfate-lamivudine tab 600-300 mg .. 47 abacavir sulfate-lamivudine-zidovudine tab 300-

150-300 mg .................................................. 46 ABELCET INJ5MG/ML ............................. 28 ABILIFY MAININJ300MG ...................... 42, 50 ABILIFY MAININJ400MG ............................ 25 ABILIFY MAININJ400MG ............................ 50 ABRAXANE INJ100MG ............................. 33 acamprosate calcium tab delayed release 333

mg ................................................................. 14 acarbose tab 100 mg ........................................ 52 acarbose tab 25 mg .......................................... 52 acarbose tab 50 mg .......................................... 52 acebutolol hcl cap 200 mg ............................... 59 acebutolol hcl cap 400 mg ............................... 59 acetaminophen w/ codeine soln 120-12 mg/5ml

..................................................................... 11 acetaminophen w/ codeine tab 300-15 mg ....... 11 acetaminophen w/ codeine tab 300-30 mg ....... 11 acetaminophen w/ codeine tab 300-60 mg ....... 11 acetazolamide cap sr 12hr 500 mg .................. 92 acetazolamide sodium for inj 500 mg .............. 65 acetazolamide tab 125 mg ............................... 92 acetazolamide tab 250 mg ............................... 92 acetic acid otic soln 2% ................................... 15 acetylcysteine inhal soln 10% .......................... 97 acetylcysteine inhal soln 20% .......................... 97 acitretin cap 10 mg .......................................... 70 acitretin cap 17.5 mg ....................................... 70 acitretin cap 25 mg .......................................... 70 ACTHIB INJ ............................................... 88 ACTIMMUNE INJ2MU/0.5 .......................... 88 acyclovir cap 200 mg ....................................... 45 acyclovir oint 5% ............................................. 45 acyclovir sodium iv soln 50 mg/ml ................... 45 acyclovir susp 200 mg/5ml ............................... 45

acyclovir tab 400 mg ....................................... 45 acyclovir tab 800 mg ....................................... 45 ADACEL INJ ............................................. 88 ADAGEN INJ250/ML................................ 75 adapalene cream 0.1% .................................... 70 adapalene gel 0.1% ......................................... 70 adapalene/ben pgel0.1-2.5% ........................... 70 adefovir dipivoxil tab 10 mg ............................ 44 ADEMPAS TAB0.5MG .............................. 96 ADEMPAS TAB1.5MG .............................. 96 ADEMPAS TAB1MG ................................. 96 ADEMPAS TAB2.5MG .............................. 96 ADEMPAS TAB2MG ................................. 96 ADMELOG INJ100U/ML............................... 53 ADMELOG SOLOINJ100U/ML .................... 53 ADVAIR DISKUAER100/50 ......................... 97 ADVAIR DISKUAER250/50 ......................... 97 ADVAIR DISKUAER500/50 ......................... 97 ADVAIR HFA AER115/21 ............................. 97 ADVAIR HFA AER230/21 ............................. 97 ADVAIR HFA AER45/21 ............................... 97 AFINITOR TAB10MG ................................ 35 AFINITOR TAB2.5MG ............................... 35 AFINITOR TAB5MG .................................. 35 AFINITOR TAB7.5MG ............................... 35 AFINITOR DISTAB2MG ............................... 35 AFINITOR DISTAB3MG ............................... 35 AFINITOR DISTAB5MG ............................... 35 ALBENZA TAB200MG ............................. 39 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)

..................................................................... 95 albuterol sulfate soln nebu 0.5% (5 mg/ml) ..... 95 albuterol sulfate soln nebu 0.63 mg/3ml (base

equiv) ........................................................... 95 albuterol sulfate soln nebu 1.25 mg/3ml (base

equiv) ........................................................... 95 albuterol sulfate syrup 2 mg/5ml ..................... 95 albuterol sulfate tab 2 mg ................................ 95 albuterol sulfate tab 4 mg ................................ 95 albuterol sulfate tab sr 12hr 4 mg ................... 95

100

albuterol sulfate tab sr 12hr 8 mg .................... 95 alclometasone dipropionate cream 0.05% ....... 77 alclometasone dipropionate oint 0.05% .......... 77 Alcohol Deterrents/Anti-craving .................. 14 ALDURAZYME INJ2.9MG/5M .................... 75 ALECENSA CAP150MG ............................ 35 alendronate sodium tab 10 mg ......................... 91 alendronate sodium tab 35 mg ......................... 91 alendronate sodium tab 40 mg ......................... 91 alendronate sodium tab 5 mg ........................... 91 alendronate sodium tab 70 mg ......................... 91 alfuzosin hcl tab sr 24hr 10 mg ........................ 76 ALIMTA INJ100MG .................................. 33 ALIMTA INJ500MG .................................. 33 ALINIA SUS100/5ML ............................... 39 ALINIA TAB500MG ................................. 39 ALIQOPA INJ60MG ....................................... 36 Alkylating Agents ........................................... 32 allopurinol sodium for inj 500 mg ................... 29 allopurinol tab 100 mg ..................................... 38 allopurinol tab 300 mg ..................................... 29 ALORA DIS0.025MG ............................... 81 ALORA DIS0.05MG ................................. 81 ALORA DIS0.075MG ............................... 81 ALORA DIS0.1MG ................................... 81 alosetron hcl tab 0.5 mg (base equiv) .............. 74 alosetron hcl tab 1 mg (base equiv) ................. 74 Alpha-adrenergic Agonists ............................ 57 Alpha-adrenergic Blocking Agents............... 57 ALPHAGAN P SOL0.1% .............................. 92 alprazolam conc 1 mg/ml ................................. 48 alprazolam orally disintegrating tab 0.25 mg . 49 alprazolam orally disintegrating tab 0.5 mg ... 49 alprazolam orally disintegrating tab 1 mg ...... 49 alprazolam orally disintegrating tab 2 mg ...... 49 alprazolam tab 0.25 mg ................................... 49 alprazolam tab 0.5 mg ..................................... 49 alprazolam tab 1 mg ........................................ 49 alprazolam tab 2 mg ........................................ 49 alprazolam tab sr 24hr 0.5 mg ......................... 49 alprazolam tab sr 24hr 1 mg ............................ 49 alprazolam tab sr 24hr 2 mg ............................ 49 alprazolam tab sr 24hr 3 mg ............................ 49 ALREX SUS0.2% ...................................... 93 ALUNBRIG TAB180MG ............................ 36 ALUNBRIG TAB30MG .............................. 36 ALUNBRIG TAB90MG .............................. 36 ALUNBRIG PAK ........................................... 36

amantadine hcl cap 100 mg ............................. 48 amantadine hcl syrup 50 mg/5ml ..................... 39 amantadine hcl tab 100 mg.............................. 48 AMBISOME INJ50MG ............................... 28 amcinonide cream 0.1% .................................. 77 amcinonide lotion 0.1% ................................... 78 amcinonide oint 0.1% ...................................... 78 amiloride & hydrochlorothiazide tab 5-50 mg 62 amiloride hcl tab 5 mg ..................................... 65 Aminoglycosides ............................................. 15 Aminosalicylates ............................................ 89 aminosalicylic acid cr granules packet 4 gm .. 31 AMINOSYN INJ8.5/LYTE .......................... 73 AMINOSYN II INJ10% .................................. 71 AMINOSYN II INJ7% .................................... 71 AMINOSYN II INJ8.5% ................................. 71 AMINOSYN II INJ8.5/LYTE ......................... 73 AMINOSYN-HBCINJ7% ............................... 71 AMINOSYN-PF INJ10% ................................ 71 AMINOSYN-PF INJ7% .................................. 71 amiodarone hcl inj 150 mg/3ml (50 mg/ml) .... 59 amiodarone hcl tab 100 mg ............................. 59 amiodarone hcl tab 200 mg ............................. 59 amiodarone hcl tab 400 mg ............................. 59 AMITIZA CAP24MCG............................... 74 AMITIZA CAP8MCG ................................ 74 amitriptyline hcl tab 10 mg .............................. 26 amitriptyline hcl tab 100 mg ............................ 26 amitriptyline hcl tab 150 mg ............................ 26 amitriptyline hcl tab 25 mg .............................. 27 amitriptyline hcl tab 50 mg .............................. 27 amitriptyline hcl tab 75 mg .............................. 27 amlodipine besylate tab 10 mg ........................ 60 amlodipine besylate tab 2.5 mg ....................... 60 amlodipine besylate tab 5 mg .......................... 60 amlodipine besylate-atorvastatin calcium tab

10-10 mg ...................................................... 62 amlodipine besylate-atorvastatin calcium tab




2.5-10 mg ..................................................... 62 amlodipine besylate-atorvastatin calcium tab

2.5-20 mg ..................................................... 62

101

amlodipine besylate-atorvastatin calcium tab

2.5-40 mg ..................................................... 62 amlodipine besylate-atorvastatin calcium tab 5-

10 mg ............................................................ 62 amlodipine besylate-atorvastatin calcium tab 5-



80 mg ............................................................ 62 amlodipine besylate-benazepril hcl cap 10-20

mg ................................................................. 62 amlodipine besylate-benazepril hcl cap 10-40

mg ................................................................. 62 amlodipine besylate-benazepril hcl cap 2.5-10

mg ................................................................. 62 amlodipine besylate-benazepril hcl cap 5-10 mg

..................................................................... 62 amlodipine besylate-benazepril hcl cap 5-20 mg

..................................................................... 62 amlodipine besylate-benazepril hcl cap 5-40 mg

..................................................................... 62 amlodipine besylate-valsartan tab 10-160 mg . 62 amlodipine besylate-valsartan tab 10-320 mg . 62 amlodipine besylate-valsartan tab 5-160 mg ... 62 amlodipine besylate-valsartan tab 5-320 mg ... 62 amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg ............................................ 62 amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg ............................................... 62 amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg ............................................... 62 amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg .............................................. 62 amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg ................................................. 62 AMOX/K CLAV CHW200MG ....................... 18 amoxapine tab 100 mg ..................................... 27 amoxapine tab 150 mg ..................................... 27 amoxapine tab 25 mg ....................................... 27 amoxapine tab 50 mg ....................................... 27 amoxicillin & k clavulanate chew tab 400-57 mg

..................................................................... 18 amoxicillin & k clavulanate for susp 200-28.5

mg/5ml ......................................................... 18 amoxicillin & k clavulanate for susp 250-62.5

mg/5ml ......................................................... 18 amoxicillin & k clavulanate for susp 400-57

mg/5ml ......................................................... 18

amoxicillin & k clavulanate for susp 600-42.9

mg/5ml ......................................................... 18 amoxicillin & k clavulanate tab 250-125 mg... 18 amoxicillin & k clavulanate tab 500-125 mg... 18 amoxicillin & k clavulanate tab 875-125 mg... 18 amoxicillin & k clavulanate tab sr 12hr 1000-

62.5 mg ........................................................ 18 amoxicillin (trihydrate) cap 250 mg ................ 18 amoxicillin (trihydrate) cap 500 mg ................ 18 amoxicillin (trihydrate) chew tab 125 mg ....... 18 amoxicillin (trihydrate) chew tab 250 mg ....... 18 amoxicillin (trihydrate) for susp 125 mg/5ml .. 18 amoxicillin (trihydrate) for susp 200 mg/5ml .. 18 amoxicillin (trihydrate) for susp 250 mg/5ml .. 18 amoxicillin (trihydrate) for susp 400 mg/5ml .. 18 amoxicillin (trihydrate) tab 500 mg ................. 18 amoxicillin (trihydrate) tab 875 mg ................. 18 amphetamine-dextroamphetamine tab 10 mg .. 68 amphetamine-dextroamphetamine tab 12.5 mg

..................................................................... 68 amphetamine-dextroamphetamine tab 15 mg .. 68 amphetamine-dextroamphetamine tab 20 mg .. 68 amphetamine-dextroamphetamine tab 30 mg .. 68 amphetamine-dextroamphetamine tab 5 mg .... 68 amphetamine-dextroamphetamine tab 7.5 mg . 68 amphotericin b for inj 50 mg ........................... 28 ampicillin & sulbactam sodium for inj 1.5 (1-

0.5) gm ......................................................... 18 ampicillin & sulbactam sodium for inj 3 (2-1)

gm ................................................................ 18 ampicillin & sulbactam sodium for iv soln 15

(10-5) gm ..................................................... 18 ampicillin cap 250 mg ..................................... 18 ampicillin cap 500 mg ..................................... 18 ampicillin for susp 125 mg/5ml ....................... 18 ampicillin for susp 250 mg/5ml ....................... 18 ampicillin sodium for inj 1 gm ......................... 18 ampicillin sodium for inj 125 mg ..................... 18 ampicillin sodium for iv soln 10 gm ................ 18 AMPYRA TAB10MG ................................ 69 Anabolic Steroids ........................................... 80 ANADROL-50 TAB50MG ............................ 80 anagrelide hcl cap 0.5 mg ............................... 55 anagrelide hcl cap 1 mg .................................. 55 Analgesics ....................................................... 11 ANALGESICS ............................................... 11 anastrozole tab 1 mg ........................................ 35 ANDROGEL GEL1.62% ............................. 80

102

Androgens ....................................................... 80 ANESTHETICS ............................................. 14 Angioedema Agents ...................................... 85 Angiotensin II Receptor Antagonists ........... 57 Angiotensin-converting Enzyme (ACE)

Inhibitors .................................................... 58 ANORO ELLIPTAER62.5-25 ......................... 97 ANTI-ADDICTION/SUBSTANCE ABUSE

TREATMENT AGENTS .......................... 14 Antiandrogens ................................................ 32 Antiangiogenic Agents ................................... 32 Antiarrhythmics ............................................. 59 Antibacterials ................................................. 15 ANTIBACTERIALS ...................................... 15 Antibacterials, Other ..................................... 15 Anticholinergics.............................................. 39 Anticoagulants ................................................ 54 ANTICONVULSANTS ................................. 21 Anticonvulsants, Other .................................. 21 Anti-cytomegalovirus (CMV) Agents ........... 44 ANTIDEMENTIA AGENTS ........................ 23 Antidementia Agents, Other ......................... 24 Antidepressants .............................................. 24 ANTIDEPRESSANTS ................................... 24 Antidepressants, Other .................................. 24 Antidiabetic Agents ........................................ 52 ANTIEMETICS ............................................. 27 Antiemetics, Other ......................................... 27 Antiestrogens/Modifiers ................................ 33 Antifungals ..................................................... 28 ANTIFUNGALS ............................................ 28 Antigout Agents .............................................. 29 ANTIGOUT AGENTS .................................. 29 Antihelminthics .............................................. 38 Anti-hepatitis B (HBV) Agents ..................... 44 Anti-hepatitis C (HCV) Agents, Other ......... 44 Anti-hepatitis C (HCV) Direct Acting Agents

..................................................................... 45 Antiherpetic Agents ....................................... 45 Antihistamines ................................................ 94 Anti-HIV Agents, Integrase Inhibitors

(INSTI) ........................................................ 45 Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors (NNRTI) ........... 46 Anti-HIV Agents, Nucleoside and Nucleotide

Reverse Transcriptase Inhibitors (NRTI) 46 Anti-HIV Agents, Other ................................ 47 Anti-HIV Agents, Protease Inhibitors .......... 47

Anti-inflammatories, Inhaled Corticosteroids

..................................................................... 94 ANTI-INFLAMMATORY AGENTS .......... 29 Anti-influenza Agents .................................... 48 Antileukotrienes ............................................. 94 Antimetabolites .............................................. 33 Antimigraine Agents ...................................... 30 ANTIMIGRAINE AGENTS......................... 30 ANTIMYASTHENIC AGENTS .................. 31 Antimycobacterials ........................................ 31 ANTIMYCOBACTERIALS ......................... 31 Antimycobacterials, Other ............................ 31 Antineoplastics ......................................... 33, 34 ANTINEOPLASTICS ................................... 32 Antineoplastics, Other ................................... 34 ANTIPARASITICS ....................................... 38 ANTIPARKINSON AGENTS ...................... 39 Antiparkinson Agents, Other ....................... 39 Antiprotozoals ................................................ 39 ANTIPSYCHOTICS ..................................... 40 Antispasmodics, Gastrointestinal ................. 73 Antispasmodics, Urinary ............................... 76 Antispasticity Agents ..................................... 44 ANTISPASTICITY AGENTS ...................... 43 Antithyroid Agents ........................................ 85 Antituberculars .............................................. 31 Antivirals ........................................................ 48 ANTIVIRALS ................................................ 44 ANXIOLYTICS ............................................. 48 Anxiolytics, Other .......................................... 48 APIDRA INJSOLOSTAR .......................... 53 APIDRA INJU-100 .................................... 53 APOKYN INJ10MG/ML ........................... 39 apraclonidine hcl ophth soln 0.5% (base

equivalent) ................................................... 92 aprepitant capsule 125 mg............................... 27 aprepitant capsule 40 mg................................. 27 aprepitant capsule 80 mg................................. 27 aprepitant capsule therapy pack 80 & 125 mg 28 APTIOM TAB200MG ............................... 23 APTIOM TAB400MG ............................... 23 APTIOM TAB600MG ............................... 23 APTIOM TAB800MG ............................... 23 APTIVUS CAP250MG ............................... 47 APTIVUS SOL ............................................ 47 ARALAST NP INJ500MG............................. 75 ARANESP INJ100MCG ............................. 55 ARANESP INJ150MCG ............................. 55

103

ARANESP INJ200MCG ............................. 55 ARANESP INJ25MCG ......................... 55, 56 ARANESP INJ300MCG ............................. 56 ARANESP INJ40MCG ............................... 56 ARANESP INJ500MCG ............................. 56 ARANESP INJ60MCG ............................... 56 ARCALYST INJ220MG .............................. 88 ARCAPTA CAP75MCG ............................. 95 aripiprazole orally disintegrating tab 10 mg ... 42 aripiprazole orally disintegrating tab 15 mg ... 42 aripiprazole tab 10 mg ..................................... 50 aripiprazole tab 15 mg ..................................... 42 aripiprazole tab 2 mg ....................................... 42 aripiprazole tab 20 mg ..................................... 42 aripiprazole tab 30 mg ..................................... 50 aripiprazole tab 5 mg ....................................... 50 aripiprazolesol1mg/ml ..................................... 25 ARISTADA INJ1064MG ............................. 25 ARISTADA INJ441MG/1. ........................... 42 ARISTADA INJ662MG/2 ............................ 42 ARISTADA INJ882MG/3 ............................ 50 Aromatase Inhibitors, 3rd Generation ......... 35 ARRANON INJ5MG/ML ........................... 33 ASMANEX 120 AER220MCG ....................... 94 ASMANEX 30 AER110MCG ........................ 94 ASMANEX 30 AER220MCG ........................ 94 ASMANEX 60 AER220MCG ........................ 94 aspirin-dipyridamole cap sr 12hr 25-200 mg .. 56 ASTAGRAF XL CAP0.5MG .......................... 85 ASTAGRAF XL CAP1MG ............................. 85 ASTAGRAF XL CAP5MG ............................. 85 atazanavir cap150mg ....................................... 47 atazanavir cap200mg ....................................... 47 atazanavir cap300mg ....................................... 47 atenolol & chlorthalidone tab 100-25 mg ........ 63 atenolol & chlorthalidone tab 50-25 mg .......... 63 atenolol tab 100 mg ......................................... 59 atenolol tab 25 mg ........................................... 59 atenolol tab 50 mg ........................................... 59 ATGAM INJ250MG .................................. 88 atomoxetine hcl cap 10 mg (base equiv) .......... 68 atomoxetine hcl cap 100 mg (base equiv) ........ 68 atomoxetine hcl cap 18 mg (base equiv) .......... 68 atomoxetine hcl cap 25 mg (base equiv) .......... 68 atomoxetine hcl cap 40 mg (base equiv) .......... 68 atomoxetine hcl cap 60 mg (base equiv) .......... 68 atomoxetine hcl cap 80 mg (base equiv) .......... 68

atorvastatin calcium tab 10 mg (base

equivalent) ................................................... 66 atorvastatin calcium tab 20 mg (base



equivalent) ................................................... 66 atovaquone susp 750 mg/5ml........................... 39 atovaquone-proguanil hcl tab 250-100 mg ..... 39 ATRIPLA TAB ........................................... 46 ATROVENT HFAAER17MCG ...................... 95 Attention Deficit Hyperactivity Disorder

Agents, Amphetamines .............................. 68 Attention Deficit Hyperactivity Disorder

Agents, Non-amphetamines ...................... 68 AVASTIN INJ ............................................. 33 AVASTIN INJ400/16ML ............................ 33 AVELOX INJ ............................................. 20 AVONEX KIT30MCG ............................... 69 AVONEX PEN KIT30MCG .......................... 69 AVONEX PREFLKIT30MCG ........................ 69 AXIRON SOL30MG/ACT ......................... 80 azacitidine for inj 100 mg ................................ 56 AZACTAM/DEX INJ2GM ............................. 17 AZASITE SOL1% ....................................... 19 azathioprine sodium for inj 100 mg ................. 85 azathioprine tab 100 mg .................................. 85 azathioprine tab 50 mg .................................... 85 azathioprine tab 75 mg .................................... 85 azelastine hcl nasal spray 0.1% (137 mcg/spray)

..................................................................... 94 azelastine hcl nasal spray 0.15% (205.5

mcg/spray) ................................................... 94 azelastine hcl ophth soln 0.05% ...................... 92 azithromycin for susp 100 mg/5ml ................... 19 azithromycin for susp 200 mg/5ml ................... 19 azithromycin iv for soln 500 mg ...................... 19 azithromycin powd pack for susp 1 gm ............ 19 azithromycin tab 250 mg ................................. 19 azithromycin tab 500 mg ................................. 19 azithromycin tab 600 mg ................................. 19 AZOPT SUS1% OP ................................... 92 aztreonam for inj 1 gm ..................................... 17 bacitracin intramuscular for soln 50000 unit .. 15 bacitracin ophth oint 500 unit/gm ................... 15 bacitracin-polymyxin b ophth oint ................... 92

104

bacitracin-polymyxin-neomycin-hc ophth oint

1% ................................................................ 92 baclofen tab 10 mg ........................................... 44 baclofen tab 20 mg ........................................... 44 baclofen tab 5 mg ............................................. 44 balsalazide disodium cap 750 mg .................... 90 BANZEL SUS40MG/ML ........................... 23 BANZEL TAB200MG ............................... 23 BANZEL TAB400MG ............................... 23 BARACLUDE SOL.05MG/ML .................... 44 BASAGLAR INJ100UNIT .............................. 53 BAVENCIO INJ20MG/ML .......................... 38 BCG VACCINE INJ ........................................ 88 BECONASE AQ SUS0.042% ......................... 94 BELEODAQ INJ500MG .............................. 36 benazepril & hydrochlorothiazide tab 10-12.5

mg ................................................................. 63 benazepril & hydrochlorothiazide tab 20-12.5

mg ................................................................. 63 benazepril & hydrochlorothiazide tab 20-25 mg

..................................................................... 63 benazepril & hydrochlorothiazide tab 5-6.25 mg

..................................................................... 63 benazepril hcl tab 10 mg .................................. 58 benazepril hcl tab 20 mg .................................. 58 benazepril hcl tab 40 mg .................................. 58 benazepril hcl tab 5 mg .................................... 58 Benign Prostatic Hypertrophy Agents ......... 76 BENLYSTA INJ120MG .............................. 88 BENLYSTA INJ400MG .............................. 88 Benzodiazepines ............................................. 48 benztropine mesylate inj 1 mg/ml..................... 39 benztropine mesylate tab 0.5 mg ...................... 39 benztropine mesylate tab 1 mg ......................... 39 benztropine mesylate tab 2 mg ......................... 39 Beta-adrenergic Blocking Agents ................. 59 Beta-lactam, Cephalosporins ........................ 16 Beta-lactam, Other ......................................... 17 Beta-lactam, Penicillins ................................. 18 betamethasone dipropionate augmented cream

0.05% ........................................................... 78 betamethasone dipropionate augmented gel

0.05% ........................................................... 78 betamethasone dipropionate augmented lotion

0.05% ........................................................... 78 betamethasone dipropionate augmented oint

0.05% ........................................................... 78 betamethasone dipropionate cream 0.05% ...... 78

betamethasone dipropionate lotion 0.05% ...... 78 betamethasone dipropionate oint 0.05% ......... 78 betamethasone valerate aerosol foam 0.12% .. 78 betamethasone valerate cream 0.1% ............... 78 betamethasone valerate lotion 0.1% ................ 78 betamethasone valerate oint 0.1% ................... 78 BETASERON INJ0.3MG.............................. 69 betaxolol hcl ophth soln 0.5% ......................... 92 betaxolol hcl tab 10 mg ................................... 59 betaxolol hcl tab 20 mg ................................... 59 bethanechol chloride tab 10 mg ...................... 77 bethanechol chloride tab 25 mg ...................... 77 bethanechol chloride tab 5 mg ........................ 77 bethanechol chloride tab 50 mg ...................... 77 bexarotene cap 75 mg ...................................... 38 BEXSERO INJ ............................................ 88 bicalutamide tab 50 mg ................................... 32 BICILLIN C-RINJ1200000 ............................. 18 BICILLIN C-RINJ900/300 .............................. 18 BICILLIN L-AINJ1200000 ............................. 18 BICILLIN L-AINJ2400000 ............................. 18 BICILLIN L-AINJ600000 ............................... 18 BICNU INJ100MG .................................... 33 BIKTARVY TAB ............................................ 46 BILTRICIDE TAB600MG ............................. 39 bimatoprost ophth soln 0.03% ......................... 93 BIPOLAR AGENTS ...................................... 50 Bipolar Agents, Other ................................... 50 bisoprolol & hydrochlorothiazide tab 10-6.25

mg ................................................................ 63 bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg ................................................................ 63 bisoprolol & hydrochlorothiazide tab 5-6.25 mg

..................................................................... 63 bisoprolol fumarate tab 10 mg ........................ 59 bisoprolol fumarate tab 5 mg .......................... 59 BIVIGAM INJ10% ...................................... 88 bleomycin sulfate for inj 30 unit ...................... 33 BLEPHAMIDE SUSOP ................................. 92 Blood Formation Modifiers .......................... 55 Blood Glucose Regulators ............................. 53 BLOOD GLUCOSE REGULATORS ......... 52 BLOOD

PRODUCTS/MODIFIERS/VOLUME

EXPANDERS ............................................. 54 BOOSTRIX INJ ........................................... 88 BORTEZOMIB INJ3.5MG ............................. 33 BOSULIF TAB100MG ............................... 36

105

BOSULIF TAB400MG ............................... 36 BOSULIF TAB500MG ............................... 36 BREO ELLIPTAINH100-25 ........................... 97 BREO ELLIPTAINH200-25 ........................... 98 BRILINTA TAB60MG ................................ 56 BRILINTA TAB90MG ................................ 56 brimonidine tartrate ophth soln 0.15% ............ 92 brimonidine tartrate ophth soln 0.2% .............. 92 BRIVIACT INJ50MG/5ML ......................... 21 BRIVIACT SOL10MG/ML .......................... 21 BRIVIACT TAB100MG .............................. 21 BRIVIACT TAB10MG ................................ 21 BRIVIACT TAB25MG ................................ 21 BRIVIACT TAB50MG ................................ 21 BRIVIACT TAB75MG ................................ 21 bromfenac sodium ophth soln 0.09% (base

equivalent).................................................... 93 bromocriptine mesylate cap 5 mg (base

equivalent).................................................... 84 bromocriptine mesylate tab 2.5 mg (base

equivalent).................................................... 84 Bronchodilators, Anticholinergic ................. 95 Bronchodilators, Sympathomimetic ............. 95 budesonide delayed release particles cap 3 mg

..................................................................... 90 budesonide inhalation susp 1 mg/2ml .............. 94 budesonide nasal susp 32 mcg/act ................... 94 bumetanide inj 0.25 mg/ml ............................... 65 bumetanide tab 0.5 mg ..................................... 65 bumetanide tab 1 mg ........................................ 65 bumetanide tab 2 mg ........................................ 65 buprenorphine hcl inj 0.3 mg/ml (base equiv) . 12 buprenorphine hcl sl tab 2 mg (base equiv) ..... 14 buprenorphine hcl sl tab 8 mg (base equiv) ..... 14 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg

(base equiv) .................................................. 14 buprenorphine hcl-naloxone hcl sl tab 8-2 mg

(base equiv) .................................................. 14 bupropion hcl (smoking deterrent) tab sr 12hr

150 mg .......................................................... 15 bupropion hcl tab 100 mg ................................ 25 bupropion hcl tab 75 mg .................................. 25 bupropion hcl tab sr 12hr 100 mg ................... 25 bupropion hcl tab sr 12hr 150 mg ................... 25 bupropion hcl tab sr 12hr 200 mg ................... 25 bupropion hcl tab sr 24hr 150 mg ................... 25 bupropion hcl tab sr 24hr 300 mg ................... 25 buspirone hcl tab 10 mg ................................... 48

buspirone hcl tab 15 mg .................................. 48 buspirone hcl tab 30 mg .................................. 48 buspirone hcl tab 5 mg .................................... 48 buspirone hcl tab 7.5 mg ................................. 48 busulfan inj 6 mg/ml ........................................ 32 butalbital-acetaminophen tab 50-325 mg ........ 11 butalbital-acetaminophen-caff w/ cod cap 50-

325-40-30 mg ............................................... 11 butalbital-acetaminophen-caffeine cap 50-325-

40 mg ........................................................... 11 butalbital-acetaminophen-caffeine tab 50-325-

40 mg ........................................................... 11 butalbital-aspirin-caff w/ codeine cap 50-325-

40-30 mg ...................................................... 11 butalbital-aspirin-caffeine cap 50-325-40 mg . 11 butorphanol tartrate nasal soln 10 mg/ml ....... 13 BYDUREON INJ2MG ................................. 52 BYDUREON INJBCISE ................................. 52 BYDUREON PENINJ2MG ............................ 52 BYETTA INJ10MCG ................................. 52 BYETTA INJ5MCG ................................... 52 cabergoline tab 0.5 mg .................................... 84 CABOMETYX TAB20MG........................... 36 CABOMETYX TAB40MG........................... 36 CABOMETYX TAB60MG........................... 36 calcipotriene oint 0.005% ................................ 70 calcitonin (salmon) nasal soln 200 unit/act ..... 91 CALCITRIOL OIN3MCG/GM ...................... 70 calcitriol cap 0.25 mcg .................................... 91 calcitriol cap 0.5 mcg ...................................... 91 calcitriol inj 1 mcg/ml ...................................... 91 calcitriol oral soln 1 mcg/ml............................ 91 calcium acetate (phosphate binder) cap 667 mg

(169 mg ca) .................................................. 77 Calcium Channel Blocking Agents............... 60 Calcium Channel Modifying Agents ............ 21 CALQUENCE CAP100MG ............................ 36 CANASA SUP1000MG ............................. 90 CANCIDAS INJ50MG ................................. 28 CANCIDAS INJ70MG ................................. 28 candesartan cilexetil-hydrochlorothiazide tab

16-12.5 mg ................................................... 63 candesartan cilexetil-hydrochlorothiazide tab

32-12.5 mg ................................................... 63 candesartan cilexetil-hydrochlorothiazide tab

32-25 mg ...................................................... 63 CAPASTAT SULINJ1GM .............................. 31 CAPEX SHA0.01% ................................... 78

106

CAPRELSA TAB100MG ............................. 36 CAPRELSA TAB300MG ............................. 36 captopril & hydrochlorothiazide tab 25-15 mg

..................................................................... 63 captopril & hydrochlorothiazide tab 25-25 mg



..................................................................... 63 captopril tab 100 mg ........................................ 58 captopril tab 12.5 mg ....................................... 58 captopril tab 25 mg .......................................... 58 captopril tab 50 mg .......................................... 58 CARBAGLU TAB200MG ........................... 71 carbamazepine cap sr 12hr 100 mg ................. 51 carbamazepine cap sr 12hr 200 mg ................. 51 carbamazepine cap sr 12hr 300 mg ................. 51 carbamazepine chew tab 100 mg ..................... 51 carbamazepine susp 100 mg/5ml ..................... 51 carbamazepine tab 200 mg .............................. 23 carbamazepine tab sr 12hr 100 mg .................. 23 carbamazepine tab sr 12hr 200 mg .................. 51 carbamazepine tab sr 12hr 400 mg .................. 23 carbidopa & levodopa orally disintegrating tab

10-100 mg .................................................... 40 carbidopa & levodopa orally disintegrating tab

25-100 mg .................................................... 40 carbidopa & levodopa orally disintegrating tab

25-250 mg .................................................... 40 carbidopa & levodopa tab 10-100 mg ............. 40 carbidopa & levodopa tab 25-100 mg ............. 40 carbidopa & levodopa tab 25-250 mg ............. 40 carbidopa & levodopa tab cr 25-100 mg ......... 40 carbidopa & levodopa tab cr 50-200 mg ......... 40 carbidopa tab 25 mg ........................................ 40 carbinoxamine maleate soln 4 mg/5ml ............ 94 carbinoxamine maleate tab 4 mg ..................... 94 carboplatin iv soln 150 mg/15ml ..................... 33 Cardiovascular Agents ............................ 62, 64 CARDIOVASCULAR AGENTS .................. 57 Cardiovascular Agents, Other ...................... 64 CARIMUNE NF INJ6GM ............................... 88 carteolol hcl ophth soln 1% ............................. 92 carvedilol cap10mg er ..................................... 59 carvedilol cap20mg er ..................................... 60 carvedilol cap40mg er ..................................... 60 carvedilol cap80mg er ..................................... 60

carvedilol tab 12.5 mg ..................................... 60 carvedilol tab 25 mg ........................................ 60 carvedilol tab 3.125 mg ................................... 60 carvedilol tab 6.25 mg ..................................... 60 CASPOFUNGIN INJ50MG ............................ 28 CASPOFUNGIN INJ70MG ............................ 28 CAYSTON INH75MG ................................ 17 cefaclor cap 250 mg ........................................ 16 cefaclor cap 500 mg ........................................ 16 cefaclor monohydrate tab sr 12hr 500 mg ...... 16 cefadroxil cap 500 mg ..................................... 16 cefadroxil for susp 250 mg/5ml ....................... 16 cefadroxil for susp 500 mg/5ml ....................... 16 cefadroxil tab 1 gm .......................................... 16 cefazolin sodium for inj 1 gm........................... 16 cefazolin sodium for inj 10 gm......................... 16 cefazolin sodium for inj 500 mg....................... 16 cefdinir cap 300 mg ......................................... 17 cefdinir for susp 125 mg/5ml ........................... 17 cefdinir for susp 250 mg/5ml ........................... 17 cefepime hcl for inj 1 gm ................................. 17 cefepime hcl for inj 2 gm ................................. 17 cefixime for susp 100 mg/5ml .......................... 17 cefixime for susp 200 mg/5ml .......................... 17 cefoxitin sodium for inj 10 gm ......................... 17 cefoxitin sodium for iv soln 1 gm ..................... 17 cefoxitin sodium for iv soln 2 gm ..................... 17 cefpodoxime proxetil for susp 100 mg/5ml ...... 17 cefpodoxime proxetil for susp 50 mg/5ml ........ 17 cefpodoxime proxetil tab 100 mg ..................... 17 cefpodoxime proxetil tab 200 mg ..................... 17 cefprozil for susp 125 mg/5ml.......................... 17 cefprozil for susp 250 mg/5ml.......................... 17 cefprozil tab 250 mg ........................................ 17 cefprozil tab 500 mg ........................................ 17 ceftazidime for inj 1 gm ................................... 17 ceftazidime for inj 2 gm ................................... 17 ceftazidime for inj 6 gm ................................... 17 ceftriaxone sodium for inj 10 gm ..................... 17 ceftriaxone sodium for inj 250 mg ................... 17 ceftriaxone sodium for inj 500 mg ................... 17 ceftriaxone sodium for iv soln 1 gm ................. 17 ceftriaxone sodium for iv soln 2 gm ................. 17 cefuroxime axetil tab 250 mg ........................... 17 cefuroxime axetil tab 500 mg ........................... 17 cefuroxime sodium for inj 1.5 gm .................... 17 cefuroxime sodium for inj 7.5 gm .................... 17 cefuroxime sodium for inj 750 mg ................... 17

107

celecoxib cap 100 mg ....................................... 29 celecoxib cap 200 mg ....................................... 29 celecoxib cap 400 mg ....................................... 30 celecoxib cap 50 mg ......................................... 30 CELONTIN CAP300MG ............................. 21 CENTRAL NERVOUS SYSTEM AGENTS

..................................................................... 68 Central Nervous System, Other .................... 68 cephalexin cap 250 mg ..................................... 17 cephalexin cap 500 mg ..................................... 17 cephalexin for susp 125 mg/5ml....................... 17 cephalexin for susp 250 mg/5ml....................... 17 cephalexin tab 250 mg ..................................... 17 cephalexin tab 500 mg ..................................... 17 CEREZYME INJ400UNIT ........................... 75 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ..... 94 cevimeline hcl cap 30 mg ................................. 70 CHANTIX PAK0.5& 1MG ......................... 15 CHANTIX PAK1MG .................................. 15 CHANTIX TAB0.5MG ............................... 15 CHANTIX TAB1MG .................................. 15 CHEMET CAP100MG ............................... 71 chloramphenicol sodium succinate for iv inj 1

gm ................................................................. 15 chlordiazepoxide hcl cap 10 mg....................... 49 chlordiazepoxide hcl cap 25 mg....................... 49 chlordiazepoxide hcl cap 5 mg......................... 49 chlorhexidine gluconate soln 0.12% ................ 70 chloroquine phosphate tab 250 mg .................. 39 chloroquine phosphate tab 500 mg .................. 39 chlorothiazide sodium for inj 500 mg .............. 65 chlorothiazide tab 250 mg ............................... 65 chlorothiazide tab 500 mg ............................... 65 chlorpromazine hcl inj 50 mg/2ml ................... 27 chlorpromazine hcl tab 10 mg ......................... 40 chlorpromazine hcl tab 100 mg ....................... 41 chlorpromazine hcl tab 200 mg ....................... 41 chlorpromazine hcl tab 25 mg ......................... 41 chlorpromazine hcl tab 50 mg ......................... 41 chlorpropamide tab 100 mg ............................. 52 chlorpropamide tab 250 mg ............................. 52 chlorthalidone tab 25 mg ................................. 65 chlorthalidone tab 50 mg ................................. 65 cholestyramine light powder 4 gm/dose ........... 66 cholestyramine powder 4 gm/dose ................... 66 cholestyramine powder packets 4 gm .............. 66 Cholinesterase Inhibitors .............................. 24 ciclopirox gel 0.77% ........................................ 28

ciclopirox olamine cream 0.77% (base equiv) 28 ciclopirox olamine susp 0.77% (base equiv) ... 28 ciclopirox shampoo 1% ................................... 28 ciclopirox solution 8% ..................................... 28 cidofovir iv inj 75 mg/ml .................................. 44 cilostazol tab 100 mg ....................................... 56 cilostazol tab 50 mg ......................................... 57 CILOXAN OIN0.3% OP ............................. 20 CIMDUO TAB300-300 ................................... 46 cimetidine hcl soln 300 mg/5ml ....................... 74 cimetidine tab 200 mg ...................................... 74 cimetidine tab 300 mg ...................................... 74 cimetidine tab 400 mg ...................................... 74 cimetidine tab 800 mg ...................................... 74 CINRYZE SOL500 UNIT ........................... 85 CIPRODEX SUS0.3-0.1% ........................... 93 ciprofloxacin 200 mg/100ml in d5w ................ 20 ciprofloxacin hcl ophth soln 0.3% ................... 20 ciprofloxacin hcl tab 100 mg (base equiv)....... 20 ciprofloxacin hcl tab 250 mg (base equiv)....... 20 ciprofloxacin hcl tab 500 mg (base equiv)....... 20 ciprofloxacin hcl tab 750 mg (base equiv)....... 20 ciprofloxacin iv soln 400 mg/40ml (1%) ......... 20 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000

mg(base eq).................................................. 20 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500

mg (base eq) ................................................. 20 cisplatin inj 100 mg/100ml (1 mg/ml) .............. 33 citalopram hydrobromide oral soln 10 mg/5ml

..................................................................... 25 citalopram hydrobromide tab 10 mg (base

equiv) ........................................................... 25 citalopram hydrobromide tab 20 mg (base

equiv) ........................................................... 25 citalopram hydrobromide tab 40 mg (base

equiv) ........................................................... 25 cladribine iv soln 10 mg/10ml (1 mg/ml) ......... 34 clarithromycin for susp 125 mg/5ml ................ 19 clarithromycin for susp 250 mg/5ml ................ 19 clarithromycin tab 250 mg............................... 19 clarithromycin tab 500 mg............................... 19 clarithromycin tab sr 24hr 500 mg .................. 19 clemastine fumarate tab 2.68 mg ..................... 94 clindamycin hcl cap 150 mg ............................ 15 clindamycin hcl cap 300 mg ............................ 15 clindamycin hcl cap 75 mg .............................. 15 clindamycin phosphate gel 1% ........................ 15

108

clindamycin phosphate in d5w iv soln 300

mg/50ml ....................................................... 15 clindamycin phosphate in d5w iv soln 600

mg/50ml ....................................................... 15 clindamycin phosphate in d5w iv soln 900

mg/50ml ....................................................... 16 clindamycin phosphate inj 600 mg/4ml ........... 16 clindamycin phosphate lotion 1% .................... 16 clindamycin phosphate soln 1% ....................... 16 clindamycin phosphate swab 1% ..................... 16 clindamycin phosphate vaginal cream 2% ...... 16 clofarabine iv soln 1 mg/ml .............................. 33 CLOLAR INJ1MG/ML .............................. 34 clomipramine hcl cap 25 mg ............................ 27 clomipramine hcl cap 50 mg ............................ 27 clomipramine hcl cap 75 mg ............................ 27 clonazepam orally disintegrating tab 0.125 mg

..................................................................... 49 clonazepam orally disintegrating tab 0.25 mg . 49 clonazepam orally disintegrating tab 0.5 mg ... 21 clonazepam orally disintegrating tab 1 mg ...... 21 clonazepam orally disintegrating tab 2 mg ...... 49 clonazepam tab 0.5 mg .................................... 49 clonazepam tab 1 mg ....................................... 21 clonazepam tab 2 mg ....................................... 49 clonidine hcl tab 0.1 mg ................................... 57 clonidine hcl tab 0.2 mg ................................... 57 clonidine hcl tab 0.3 mg ................................... 57 clonidine hcl td patch weekly 0.1 mg/24hr ...... 57 clonidine hcl td patch weekly 0.2 mg/24hr ...... 57 clonidine hcl td patch weekly 0.3 mg/24hr ...... 57 clopidogrel bisulfate tab 300 mg (base equiv) . 57 clopidogrel bisulfate tab 75 mg (base equiv) ... 57 clorazepate dipotassium tab 15 mg .................. 49 clorazepate dipotassium tab 3.75 mg ............... 49 clorazepate dipotassium tab 7.5 mg ................. 49 clotrimazole cream 1% .................................... 28 clotrimazole soln 1% ........................................ 28 clotrimazole troche 10 mg ............................... 28 clotrimazole w/ betamethasone cream 1-0.05%

..................................................................... 70 clotrimazole w/ betamethasone lotion 1-0.05%

..................................................................... 70 CLOZAPINE TAB12.5/ODT ........................ 43 CLOZAPINE TAB150/ODT ......................... 43 CLOZAPINE TAB200/ODT ......................... 43 clozapine orally disintegrating tab 100 mg ..... 43 clozapine orally disintegrating tab 25 mg ....... 43

clozapine tab 100 mg ....................................... 43 clozapine tab 200 mg ....................................... 43 clozapine tab 25 mg ......................................... 43 clozapine tab 50 mg ......................................... 43 COARTEM TAB20-120MG ....................... 39 colchicine w/ probenecid tab 0.5-500 mg ........ 29 COLCRYS TAB0.6MG .............................. 29 colestipol hcl granules 5 gm ............................ 66 colestipol hcl tab 1 gm ..................................... 66 colistimethate sodium for inj 150 mg ............... 15 COMBIVENT AER20-100 ........................... 98 COMETRIQ KIT100MG ............................. 36 COMETRIQ KIT140MG ............................. 36 COMETRIQ KIT60MG ............................... 36 COMPLERA TAB ....................................... 46 CORLANOR TAB5MG ............................... 64 CORLANOR TAB7.5MG ............................ 64 cortisone acetate tab 25 mg ............................. 90 COSENTYX INJ150MG/ML ....................... 70 COSENTYX PENINJ150MG/ML .................. 70 COSMEGEN INJ0.5MG .............................. 33 COTELLIC TAB20MG................................ 36 COUMADIN TAB10MG ............................. 54 COUMADIN TAB1MG ............................... 54 COUMADIN TAB2.5MG ............................ 54 COUMADIN TAB2MG ............................... 54 COUMADIN TAB3MG ............................... 54 COUMADIN TAB4MG ............................... 54 COUMADIN TAB5MG ............................... 54 COUMADIN TAB6MG ............................... 54 COUMADIN TAB7.5MG ............................ 54 CREON CAP12000UNT ........................... 75 CREON CAP24000UNT ........................... 75 CREON CAP3000UNIT ........................... 73 CREON CAP36000UNT ........................... 73 CREON CAP6000UNIT ........................... 75 CRIXIVAN CAP200MG.............................. 47 CRIXIVAN CAP400MG.............................. 47 cromolyn sodium ophth soln 4%...................... 92 cromolyn sodium oral conc 100 mg/5ml ......... 73 cromolyn sodium soln nebu 20 mg/2ml ........... 96 cyclobenzaprine hcl tab 10 mg ........................ 98 cyclobenzaprine hcl tab 5 mg .......................... 98 cyclobenzaprine hcl tab 7.5 mg ....................... 98 CYCLOPHOSPH CAP25MG ......................... 32 CYCLOPHOSPH CAP50MG ......................... 32 CYCLOSET TAB0.8MG ............................. 52 cyclosporine cap 100 mg ................................. 85

109

cyclosporine cap 25 mg ................................... 85 cyclosporine iv soln 50 mg/ml .......................... 85 cyclosporine modified cap 100 mg ................... 85 cyclosporine modified cap 25 mg..................... 86 cyclosporine modified cap 50 mg..................... 86 cyclosporine modified oral soln 100 mg/ml ..... 86 cyproheptadine hcl syrup 2 mg/5ml ................. 94 cyproheptadine hcl tab 4 mg ............................ 94 CYRAMZA INJ100/10ML .......................... 36 CYRAMZA INJ500/50ML .......................... 36 CYSTADANE POW ..................................... 75 CYSTAGON CAP150MG ............................ 75 CYSTAGON CAP50MG .............................. 75 CYSTARAN SOL0.44% .............................. 75 Cystic Fibrosis Agents ................................... 96 cytarabine inj 20 mg/ml ................................... 34 cytarabine inj pf 100 mg/ml ............................. 35 D10W/NACL INJ0.2% .................................. 71 D10W/NACL INJ0.45% ................................ 71 D5W/NACL INJ0.225% ............................... 71 dacarbazine for inj 200 mg .............................. 33 dactinomycininj0.5mg ...................................... 33 DALIRESP TAB250MCG ........................... 96 DALIRESP TAB500MCG ........................... 96 danazol cap 100 mg ......................................... 80 danazol cap 200 mg ......................................... 80 danazol cap 50 mg ........................................... 80 dantrolene sodium cap 100 mg ........................ 44 dantrolene sodium cap 25 mg .......................... 44 dantrolene sodium cap 50 mg .......................... 44 dapsone tab 100 mg ......................................... 31 dapsone tab 25 mg ........................................... 31 DAPTACEL INJ ........................................... 88 daptomycin for iv soln 500 mg ......................... 16 DARAPRIM TAB25MG .............................. 39 darifenacin hydrobromide tab sr 24hr 15 mg

(base equiv) .................................................. 76 darifenacin hydrobromide tab sr 24hr 7.5 mg

(base equiv) .................................................. 76 DARZALEX SOL100MG/5M ..................... 33 daunorubicin hcl inj 5 mg/ml (base equiv) ...... 33 decitabine for inj 50 mg ................................... 35 demeclocycline hcl tab 150 mg ........................ 20 demeclocycline hcl tab 300 mg ........................ 20 DEMSER CAP250MG ............................... 63 DENAVIR CRE1% ..................................... 45 Dental and Oral Agents ................................. 70 DENTAL AND ORAL AGENTS ................. 70

DEPEN TITRA TAB250MG .......................... 71 DEPO-PROVERAINJ400/ML ........................ 83 Dermatological Agents .................................. 70 DERMATOLOGICAL AGENTS ................ 70 DESCOVY TAB200/25 .............................. 47 desipramine hcl tab 10 mg ............................... 27 desipramine hcl tab 100 mg ............................. 27 desipramine hcl tab 150 mg ............................. 27 desipramine hcl tab 25 mg ............................... 27 desipramine hcl tab 50 mg ............................... 27 desipramine hcl tab 75 mg ............................... 27 desmopressin acetate inj 4 mcg/ml .................. 79 desmopressin acetate nasal spray soln 0.01%

(refrigerated) ............................................... 79 desmopressin acetate tab 0.1 mg ..................... 79 desmopressin acetate tab 0.2 mg ..................... 79 desogest-eth estrad & eth estrad tab 0.15-

0.02/0.01 mg(21/5) ...................................... 81 desogest-ethin est tab 0.1-0.025/0.125-

0.025/0.15-0.025mg-mg ............................... 82 desogestrel & ethinyl estradiol tab 0.15 mg-30

mcg .............................................................. 82 desonide lotion 0.05% ..................................... 78 desonide oint 0.05% ........................................ 78 desoximetasone cream 0.05% .......................... 78 desoximetasone cream 0.25% .......................... 78 desoximetasone gel 0.05% ............................... 78 desoximetasone oint 0.25% ............................. 78 DESVENLAFAX TAB100MG ER ................. 25 DESVENLAFAX TAB50MG ER ................... 25 desvenlafaxine succinate tab sr 24hr 100 mg

(base equiv).................................................. 25 desvenlafaxine succinate tab sr 24hr 25 mg

(base equiv).................................................. 25 desvenlafaxine succinate tab sr 24hr 50 mg

(base equiv).................................................. 25 dexamethasone conc 1 mg/ml .......................... 90 dexamethasone elixir 0.5 mg/5ml .................... 90 dexamethasone sodium phosphate inj 120

mg/30ml ....................................................... 78 dexamethasone sodium phosphate ophth soln

0.1% ............................................................. 93 dexamethasone tab 0.5 mg ............................... 90 dexamethasone tab 0.75 mg ............................. 90 dexamethasone tab 1 mg .................................. 90 dexamethasone tab 1.5 mg ............................... 90 dexamethasone tab 2 mg .................................. 90 dexamethasone tab 4 mg .................................. 90

110

dexamethasone tab 6 mg .................................. 90 dexmethylphenidate hcl tab 10 mg ................... 68 dexmethylphenidate hcl tab 2.5 mg .................. 68 dexmethylphenidate hcl tab 5 mg ..................... 68 dexrazoxane for inj 250 mg .............................. 33 dextroamphetamine sulfate tab 10 mg ............. 68 dextroamphetamine sulfate tab 5 mg ............... 68 dextrose 2.5% w/ sodium chloride 0.45% ........ 71 dextrose 5% in lactated ringers ....................... 71 dextrose 5% w/ sodium chloride 0.2% ............. 71 dextrose 5% w/ sodium chloride 0.33% ........... 72 dextrose 5% w/ sodium chloride 0.45% ........... 72 dextrose 5% w/ sodium chloride 0.9% ............. 72 dextrose inj 10% .............................................. 72 dextrose inj 5% ................................................ 72 Diabetes Supplies ........................................... 71 DIABETES SUPPLIES ................................. 71 DIASTAT ACDLGEL12.5-20......................... 21 DIASTAT ACDLGEL5-10MG ....................... 21 DIASTAT PED GEL2.5M GEL ...................... 22 diazepam conc 5 mg/ml .................................... 22 diazepam oral soln 1 mg/ml ............................. 22 diazepam tab 10 mg ......................................... 22 diazepam tab 2 mg ........................................... 22 diazepam tab 5 mg ........................................... 22 diclofenac potassium tab 50 mg ....................... 30 diclofenac sodium (actinic keratoses) gel 3% .. 70 diclofenac sodium gel 1% ................................ 12 diclofenac sodium ophth soln 0.1% ................. 93 diclofenac sodium soln 1.5% ........................... 12 diclofenac sodium tab delayed release 25 mg.. 30 diclofenac sodium tab delayed release 50 mg.. 30 diclofenac sodium tab delayed release 75 mg.. 30 diclofenac sodium tab sr 24hr 100 mg ............. 30 diclofenac w/ misoprostol tab delayed release

50-0.2 mg ..................................................... 11 diclofenac w/ misoprostol tab delayed release

75-0.2 mg ..................................................... 11 dicloxacillin sodium cap 250 mg ..................... 18 dicloxacillin sodium cap 500 mg ..................... 18 dicyclomine hcl cap 10 mg ............................... 73 dicyclomine hcl oral soln 10 mg/5ml ............... 73 dicyclomine hcl tab 20 mg ............................... 73 didanosine delayed release capsule 125 mg .... 46 didanosine delayed release capsule 200 mg .... 46 didanosine delayed release capsule 250 mg .... 46 didanosine delayed release capsule 400 mg .... 46 DIFICID TAB200MG ................................. 19

diflorasone diacetate cream 0.05% ................. 78 diflorasone diacetate oint 0.05% ..................... 78 diflunisal tab 500 mg ....................................... 30 digox tab 125 mcg ............................................ 64 digox tab 250 mcg ............................................ 64 DIGOXIN SOL50MCG/ML ....................... 64 digoxin inj 0.25 mg/ml ..................................... 64 digoxin tab 125 mcg (0.125 mg) ...................... 64 digoxin tab 250 mcg (0.25 mg) ........................ 64 dihydroergotamine mesylate inj 1 mg/ml ........ 30 DIHYDROERGOTSPR4MG/ML ................... 30 DILANTIN CAP30MG ................................ 23 diltiazem hcl cap sr 12hr 120 mg .................... 60 diltiazem hcl cap sr 12hr 60 mg ...................... 60 diltiazem hcl cap sr 12hr 90 mg ...................... 61 diltiazem hcl cap sr 24hr 120 mg .................... 61 diltiazem hcl cap sr 24hr 180 mg .................... 61 diltiazem hcl cap sr 24hr 240 mg .................... 61 diltiazem hcl coated beads cap sr 24hr 120 mg

..................................................................... 61 diltiazem hcl coated beads cap sr 24hr 180 mg



..................................................................... 61 diltiazem hcl extended release beads cap sr 24hr

120 mg ......................................................... 61 diltiazem hcl extended release beads cap sr 24hr





420 mg ......................................................... 61 diltiazem hcl iv for soln 100 mg ....................... 61 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ..... 61 diltiazem hcl tab 120 mg .................................. 61 diltiazem hcl tab 30 mg .................................... 61 diltiazem hcl tab 60 mg .................................... 61 diltiazem hcl tab 90 mg .................................... 61 DIP/TET PED INJ25-5LFU ............................ 88 DIPENTUM CAP250MG ............................ 90 diphenhydramine hcl inj 50 mg/ml .................. 39 disopyramide phosphate cap 100 mg .............. 59

111

disopyramide phosphate cap 150 mg ............... 59 disulfiram tab 250 mg ...................................... 14 disulfiram tab 500 mg ...................................... 14 Diuretics, Carbonic Anhydrase Inhibitors .. 65 Diuretics, Loop ............................................... 65 Diuretics, Potassium-sparing ........................ 65 Diuretics, Thiazide ......................................... 65 divalproex sodium cap delayed release sprinkle

125 mg .......................................................... 51 divalproex sodium tab delayed release 125 mg

..................................................................... 31 divalproex sodium tab delayed release 250 mg

..................................................................... 51 divalproex sodium tab delayed release 500 mg

..................................................................... 51 divalproex sodium tab sr 24 hr 250 mg ........... 51 divalproex sodium tab sr 24 hr 500 mg ........... 51 DOCETAXEL INJ80MG/4ML ..................... 33 DOCETAXEL INJ80MG/8ML ..................... 33 dofetilide cap 125 mcg (0.125 mg)................... 59 dofetilide cap 250 mcg (0.25 mg)..................... 59 dofetilide cap 500 mcg (0.5 mg)....................... 59 donepezil hydrochloride orally disintegrating

tab 10 mg ..................................................... 24 donepezil hydrochloride orally disintegrating

tab 5 mg ....................................................... 24 donepezil hydrochloride tab 10 mg .................. 24 donepezil hydrochloride tab 5 mg .................... 24 Dopamine Agonists ........................................ 39 Dopamine Precursors/ L-Amino Acid

Decarboxylase Inhibitors ........................... 40 dorzolamide hcl ophth soln 2% ........................ 92 dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml ............................................. 92 doxazosin mesylate tab 1 mg ............................ 76 doxazosin mesylate tab 2 mg ............................ 76 doxazosin mesylate tab 4 mg ............................ 76 doxazosin mesylate tab 8 mg ............................ 76 doxepin hcl cap 10 mg ..................................... 48 doxepin hcl cap 100 mg ................................... 48 doxepin hcl cap 150 mg ................................... 48 doxepin hcl cap 25 mg ..................................... 27 doxepin hcl cap 50 mg ..................................... 48 doxepin hcl cap 75 mg ..................................... 48 doxepin hcl conc 10 mg/ml .............................. 48 doxercalciferol cap 0.5 mcg ............................. 91 doxercalciferol cap 1 mcg ................................ 91 doxercalciferol cap 2.5 mcg ............................. 91

doxercalciferol inj 4 mcg/2ml (2 mcg/ml)........ 91 doxorubicin hcl inj 2 mg/ml ............................. 33 doxorubicin hcl liposomal inj (for iv infusion) 2

mg/ml ........................................................... 33 doxycycline hyclate cap 100 mg ...................... 21 doxycycline hyclate cap 50 mg ........................ 21 doxycycline hyclate for inj 100 mg .................. 21 doxycycline hyclate tab 100 mg ....................... 21 doxycycline hyclate tab 20 mg ......................... 70 doxycycline monohydrate cap 75 mg ............... 21 dronabinol cap 2.5 mg ..................................... 28 dronabinol cap 5 mg ........................................ 28 drospirenone-ethinyl estradiol tab 3-0.03 mg . 82 DROXIA CAP200MG ............................... 33 DROXIA CAP300MG ............................... 33 DROXIA CAP400MG ............................... 33 DUAVEE TAB0.45-20............................... 83 DULERA AER100-5MCG ......................... 98 DULERA AER200-5MCG ......................... 98 duloxetine hcl enteric coated pellets cap 20 mg

..................................................................... 69 duloxetine hcl enteric coated pellets cap 30 mg



..................................................................... 69 DUREZOL EMU0.05% .............................. 93 dutasteride cap 0.5 mg ..................................... 76 Dyslipidemics, Fibric Acid Derivatives ........ 66 Dyslipidemics, HMG CoA Reductase

Inhibitors .................................................... 66 Dyslipidemics, Other ..................................... 66 econazole nitrate cream 1% ............................ 28 EDURANT TAB25MG ............................... 46 efavirenz cap200mg ......................................... 46 efavirenz cap50mg ........................................... 46 efavirenz tab600mg .......................................... 46 EFFIENT TAB10MG .................................. 57 EFFIENT TAB5MG .................................... 57 ELAPRASE INJ6MG/3ML .......................... 75 Electrolyte/Mineral /Metal Modifiers .......... 71 Electrolyte/Mineral Replacement ................. 71 Electrolytes/Minerals/Metals/Vitamins ....... 73 ELECTROLYTES/MINERALS/METALS/V

ITAMINS .................................................... 71 ELIDEL CRE1% ........................................ 86 ELIQUIS TAB2.5MG ................................. 54

112

ELIQUIS TAB5MG ..................................... 54 ELIQUIS ST PTAB5MG ................................ 54 ELITEK INJ1.5MG .................................... 38 ELITEK INJ7.5MG .................................... 38 ELMIRON CAP100MG .............................. 77 EMCYT CAP140MG ................................ 33 EMEND SUS125MG ................................. 28 Emetogenic Therapy Adjuncts ..................... 27 EMPLICITI INJ300MG ................................. 38 EMPLICITI INJ400MG ................................. 38 EMSAM DIS12MG/24H ........................... 25 EMSAM DIS6MG/24HR .......................... 25 EMSAM DIS9MG/24HR .......................... 25 EMTRIVA CAP200MG .............................. 46 EMTRIVA SOL10MG/ML ......................... 46 enalapril maleate & hydrochlorothiazide tab 10-

25 mg ............................................................ 63 enalapril maleate & hydrochlorothiazide tab 5-

12.5 mg ......................................................... 63 enalapril maleate tab 10 mg ............................ 58 enalapril maleate tab 2.5 mg ........................... 58 enalapril maleate tab 20 mg ............................ 58 enalapril maleate tab 5 mg .............................. 58 ENBREL INJ25/0.5ML .............................. 86 ENBREL INJ25MG .................................... 86 ENBREL INJ50MG/ML ............................. 86 ENBREL SRCLKINJ50MG/ML ..................... 86 ENGERIX-B INJ10/0.5ML ........................... 88 ENGERIX-B INJ20MCG/ML ....................... 88 enoxaparin sodium inj 100 mg/ml .................... 54 enoxaparin sodium inj 120 mg/0.8ml ............... 54 enoxaparin sodium inj 150 mg/ml .................... 54 enoxaparin sodium inj 30 mg/0.3ml ................. 54 enoxaparin sodium inj 300 mg/3ml .................. 54 enoxaparin sodium inj 40 mg/0.4ml ................. 54 enoxaparin sodium inj 60 mg/0.6ml ................. 54 enoxaparin sodium inj 80 mg/0.8ml ................. 55 entecavir tab 0.5 mg ......................................... 44 entecavir tab 1 mg ............................................ 44 ENTRESTO TAB24-26MG ......................... 64 ENTRESTO TAB49-51MG ......................... 64 ENTRESTO TAB97-103MG ....................... 64 ENVARSUS XR TAB0.75MG ....................... 86 ENVARSUS XR TAB1MG ............................ 86 ENVARSUS XR TAB4MG ............................ 86 Enzyme Inhibitors .......................................... 35 EPINEPHRINE INJ0.15MG ............................ 95 EPINEPHRINE INJ0.3MG .............................. 95

EPIPEN 2-PAKINJ0.3MG .............................. 95 EPIPEN-JR INJ2-PAK .................................. 95 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)

..................................................................... 33 EPIVIR HBV SOL5MG/ML .......................... 44 eplerenone tab 25 mg ...................................... 65 eplerenone tab 50 mg ...................................... 65 EPOGEN INJ10000/ML ............................. 56 EPOGEN INJ2000/ML ............................... 56 EPOGEN INJ20000/ML ............................. 56 EPOGEN INJ3000/ML ............................... 56 EPOGEN INJ4000/ML ............................... 56 eprosartan mesylate tab 600 mg ...................... 57 EQUETRO CAP100MG ............................. 51 EQUETRO CAP200MG ............................. 51 EQUETRO CAP300MG ............................. 23 ERAXIS INJ100MG ................................... 28 ERBITUX INJ100MG ................................. 33 ergoloid mesylates tab 1 mg ............................ 24 Ergot Alkaloids .............................................. 30 ergotamine w/ caffeine suppos 2-100 mg ........ 30 ergotamine w/ caffeine tab 1-100 mg ........ 11, 30 ERIVEDGE CAP150MG ............................. 36 ERLEADA TAB60MG ................................... 32 ERWINAZE INJ10000UNT ........................ 35 ERYTHROCIN INJ500MG ........................... 19 ERYTHROM ETHTAB400MG ...................... 19 erythromycin ethylsuccinate tab 400 mg ......... 19 erythromycin gel 2% ........................................ 19 erythromycin ophth oint 5 mg/gm .................... 19 erythromycin pads 2% ..................................... 19 erythromycin soln 2% ...................................... 19 erythromycin stearate tab 250 mg ................... 19 erythromycin tab 250 mg ................................. 19 erythromycin tab 500 mg ................................. 19 erythromycin tab delayed release 250 mg ....... 19 erythromycin tab delayed release 333 mg ....... 20 erythromycin tab delayed release 500 mg ....... 20 ESBRIET CAP267MG ................................ 97 ESBRIET TAB267MG ................................ 97 ESBRIET TAB801MG ................................ 97 escitalopram oxalate soln 5 mg/5ml (base equiv)

..................................................................... 49 escitalopram oxalate tab 10 mg (base equiv) .. 49 escitalopram oxalate tab 20 mg (base equiv) .. 49 escitalopram oxalate tab 5 mg (base equiv) .... 49 esomeprazole sodium for intravenous soln 20

mg (base equiv) ............................................ 75

113

esomeprazole sodium for intravenous soln 40

mg (base equiv) ............................................ 75 esterified estrogens tab 0.3 mg ........................ 81 esterified estrogens tab 0.625 mg .................... 81 esterified estrogens tab 1.25 mg ...................... 81 estradiol & norethindrone acetate tab 0.5-0.1

mg ................................................................. 82 estradiol & norethindrone acetate tab 1-0.5 mg

..................................................................... 82 estradiol tab 0.5 mg ......................................... 81 estradiol tab 1 mg ............................................ 81 estradiol tab 2 mg ............................................ 81 estradiol td patch twice weekly 0.025 mg/24hr 81 estradiol td patch twice weekly 0.0375 mg/24hr

..................................................................... 81 estradiol td patch twice weekly 0.05 mg/24hr .. 81 estradiol td patch twice weekly 0.075 mg/24hr 81 estradiol td patch twice weekly 0.1 mg/24hr .... 81 estradiol vaginal cream 0.1 mg/gm .................. 81 estradiol vaginal tab 10 mcg ............................ 81 ESTRING MIS2MG .................................... 81 Estrogens ......................................................... 81 estropipate tab 0.75 mg .................................... 81 estropipate tab 1.5 mg ...................................... 81 estropipate tab 3 mg ......................................... 81 eszopiclone tab 1 mg ........................................ 98 eszopiclone tab 2 mg ........................................ 98 eszopiclone tab 3 mg ........................................ 98 ethambutol hcl tab 100 mg ............................... 31 ethambutol hcl tab 400 mg ............................... 31 ethosuximide cap 250 mg ................................. 21 ethosuximide soln 250 mg/5ml ......................... 21 ethynodiol diacetate & ethinyl estradiol tab 1

mg-35 mcg .................................................... 82 ethynodiol diacetate & ethinyl estradiol tab 1

mg-50 mcg .................................................... 82 etidronate disodium tab 200 mg ...................... 91 etidronate disodium tab 400 mg ...................... 91 etodolac cap 200 mg ........................................ 30 etodolac cap 300 mg ........................................ 30 ETOPOPHOS INJ100MG ............................. 35 etoposide inj 1 gm/50ml (20 mg/ml) ................ 35 etoposide inj 500 mg/25ml (20 mg/ml) ............ 35 EVOTAZ TAB300-150 .............................. 47 exemestane tab 25 mg ...................................... 35 EXJADE TAB125MG ................................ 71 EXJADE TAB250MG ................................ 71 EXJADE TAB500MG ................................ 71

EXTAVIA INJ0.3MG ................................. 69 ezetim/simvatab10-10mg ................................. 63 ezetim/simvatab10-20mg ................................. 63 ezetim/simvatab10-40mg ................................. 63 ezetim/simvatab10-80mg ................................. 63 ezetimibe tab 10 mg ......................................... 66 FABRAZYME INJ35MG ............................. 75 famciclovir tab 125 mg .................................... 45 famciclovir tab 250 mg .................................... 45 famciclovir tab 500 mg .................................... 45 famotidine for susp 40 mg/5ml ........................ 74 famotidine in nacl 0.9% iv soln 20 mg/50ml ... 74 famotidine inj 20 mg/2ml ................................. 74 famotidine tab 20 mg ....................................... 74 famotidine tab 40 mg ....................................... 74 FANAPT PAK ............................................ 42 FANAPT TAB10MG ................................. 42 FANAPT TAB12MG ................................. 42 FANAPT TAB1MG ................................... 42 FANAPT TAB2MG ................................... 42 FANAPT TAB4MG ................................... 42 FANAPT TAB6MG ................................... 42 FANAPT TAB8MG ................................... 42 FARESTON TAB60MG .............................. 33 FARXIGA TAB10MG ................................ 52 FARXIGA TAB5MG .................................. 52 FARYDAK CAP10MG ............................... 36 FARYDAK CAP15MG ............................... 36 FARYDAK CAP20MG ............................... 36 FASLODEX INJ250MG .............................. 33 fat emulsion iv soln 20% .................................. 72 FAZACLO TAB12.5 ODT .......................... 43 FAZACLO TAB150 ODT ........................... 43 FAZACLO TAB200 ODT ........................... 43 felbamate susp 600 mg/5ml ............................. 22 felbamate tab 400 mg ...................................... 22 felbamate tab 600 mg ...................................... 22 felodipine tab sr 24hr 10 mg ............................ 61 felodipine tab sr 24hr 2.5 mg ........................... 61 felodipine tab sr 24hr 5 mg .............................. 61 fenofibrate micronized cap 134 mg ................. 66 fenofibrate micronized cap 200 mg ................. 66 fenofibrate micronized cap 67 mg ................... 66 fenofibrate tab 145 mg ..................................... 66 fenofibrate tab 160 mg ..................................... 66 fenofibrate tab 48 mg ....................................... 66 fenofibrate tab 54 mg ....................................... 66 fenoprofen calcium tab 600 mg ....................... 30

114

fentanyl citrate lozenge on a handle 1200 mcg 13 fentanyl citrate lozenge on a handle 1600 mcg 13 fentanyl citrate lozenge on a handle 200 mcg .. 13 fentanyl citrate lozenge on a handle 400 mcg .. 13 fentanyl citrate lozenge on a handle 600 mcg .. 13 fentanyl citrate lozenge on a handle 800 mcg .. 13 fentanyl td patch 72hr 100 mcg/hr ................... 12 fentanyl td patch 72hr 12 mcg/hr ..................... 12 fentanyl td patch 72hr 25 mcg/hr ..................... 12 fentanyl td patch 72hr 50 mcg/hr ..................... 12 fentanyl td patch 72hr 75 mcg/hr ..................... 12 FERRIPROX TAB500MG ............................ 71 FETZIMA CAP120MG ............................... 25 FETZIMA CAP20MG ................................. 26 FETZIMA CAP40MG ................................. 26 FETZIMA CAP80MG ................................. 26 FETZIMA CAPTITRATIO ......................... 26 Fibromyalgia Agents ...................................... 69 finasteride tab 5 mg ......................................... 76 FIRAZYR INJ30MG/3ML .......................... 85 FIRMAGON INJ120MG .............................. 84 FIRMAGON INJ80MG ................................ 84 FLAREX SUS0.1% OP .............................. 93 flavoxate hcl tab 100 mg .................................. 76 FLEBOGAMMA INJDIF 10% ....................... 88 flecainide acetate tab 100 mg .......................... 59 flecainide acetate tab 150 mg .......................... 59 flecainide acetate tab 50 mg ............................ 59 FLECTOR DIS1.3% .................................... 30 fluconazole for susp 10 mg/ml ......................... 28 fluconazole for susp 40 mg/ml ......................... 28 fluconazole in nacl 0.9% inj 400 mg/200ml ..... 28 fluconazole tab 100 mg .................................... 28 fluconazole tab 150 mg .................................... 29 fluconazole tab 200 mg .................................... 29 fluconazole tab 50 mg ...................................... 29 flucytosine cap 250 mg ..................................... 29 flucytosine cap 500 mg ..................................... 29 fludarabine phosphate for inj 50 mg ................ 35 fludrocortisone acetate tab 0.1 mg .................. 78 flunisolide nasal soln 25 mcg/act (0.025%) ..... 94 fluocinolone acetonide (otic) oil 0.01% ........... 93 fluocinolone acetonide cream 0.01% ............... 78 fluocinolone acetonide cream 0.025% ............. 78 fluocinolone acetonide oil 0.01% (body oil) .... 93 fluocinolone acetonide oint 0.025%................. 78 fluocinolone acetonide soln 0.01% .................. 78 fluocinonide cream 0.1% ................................. 78

fluocinonide emulsified base cream 0.05% ..... 78 fluocinonide gel 0.05% .................................... 78 fluocinonide oint 0.05% ................................... 78 fluocinonide soln 0.05% .................................. 78 fluorouracil cream 5% ..................................... 70 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ......... 35 fluorouracil soln 2% ........................................ 70 fluorouracil soln 5% ........................................ 70 fluoxetine hcl cap 10 mg .................................. 26 fluoxetine hcl cap 20 mg .................................. 26 fluoxetine hcl cap 40 mg .................................. 26 fluoxetine hcl cap delayed release 90 mg ........ 26 fluoxetine hcl solution 20 mg/5ml .................... 26 fluoxetine hcl tab 10 mg ................................... 26 fluoxetine hcl tab 20 mg ................................... 26 fluphenazine decanoate inj 25 mg/ml .............. 41 fluphenazine hcl elixir 2.5 mg/5ml ................... 41 fluphenazine hcl inj 2.5 mg/ml ......................... 41 fluphenazine hcl oral conc 5 mg/ml ................. 41 fluphenazine hcl tab 1 mg ................................ 41 fluphenazine hcl tab 10 mg .............................. 41 fluphenazine hcl tab 2.5 mg ............................. 41 fluphenazine hcl tab 5 mg ................................ 41 flurbiprofen sodium ophth soln 0.03% ............ 93 flurbiprofen tab 100 mg ................................... 30 flurbiprofen tab 50 mg ..................................... 30 flutamide cap 125 mg ...................................... 32 FLUTICASONE INHSALMETER ................. 98 fluticasone propionate cream 0.05% ............... 78 fluticasone propionate lotion 0.05%................ 78 fluticasone propionate nasal susp 50 mcg/act . 94 fluticasone propionate oint 0.005% ................. 78 fluvastatin sodium cap 20 mg .......................... 66 fluvastatin sodium cap 40 mg .......................... 66 fluvoxamine maleate tab 100 mg ..................... 26 fluvoxamine maleate tab 25 mg ....................... 26 fluvoxamine maleate tab 50 mg ....................... 26 FML OIN0.1% OP .................................. 93 FML FORTE SUS0.25% OP ......................... 93 FOLOTYN INJ40MG/2ML ........................ 33 fomepizole inj 1 gm/ml (for iv infusion) ........... 73 fondaparinux sodium subcutaneous inj 10

mg/0.8ml ...................................................... 55 fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml ...................................................... 55 fondaparinux sodium subcutaneous inj 5

mg/0.4ml ...................................................... 55

115

fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml ...................................................... 55 FORTEO SOL600/2.4 ................................ 91 fosamprenavitab700mg .................................... 47 fosinopril sodium & hydrochlorothiazide tab 10-

12.5 mg ......................................................... 63 fosinopril sodium & hydrochlorothiazide tab 20-

12.5 mg ......................................................... 63 fosinopril sodium tab 10 mg ............................ 58 fosinopril sodium tab 20 mg ............................ 58 fosinopril sodium tab 40 mg ............................ 58 fosphenytoin sodium inj 100 mg/2ml (phenytoin

equiv) ........................................................... 23 FRAGMIN INJ10000/ML ........................... 55 FRAGMIN INJ12500UNT .......................... 55 FRAGMIN INJ15000UNT .......................... 55 FRAGMIN INJ18000UNT .......................... 55 FRAGMIN INJ2500/0.2 .............................. 55 FRAGMIN INJ5000/0.2 .............................. 55 furosemide inj 10 mg/ml ................................... 65 furosemide oral soln 10 mg/ml......................... 65 furosemide oral soln 8 mg/ml .......................... 65 furosemide tab 20 mg ....................................... 65 furosemide tab 40 mg ....................................... 65 furosemide tab 80 mg ....................................... 65 FUZEON INJ90MG .................................... 47 FYCOMPA SUS0.5MG/ML ....................... 22 FYCOMPA TAB10MG ............................... 22 FYCOMPA TAB12MG ............................... 22 FYCOMPA TAB2MG ................................. 22 FYCOMPA TAB4MG ................................. 23 FYCOMPA TAB6MG ................................. 23 FYCOMPA TAB8MG ................................. 23 GABA Receptor Modulators......................... 98 gabapentin cap 100 mg .................................... 22 gabapentin cap 300 mg .................................... 22 gabapentin cap 400 mg .................................... 22 gabapentin oral soln 250 mg/5ml .................... 22 gabapentin tab 600 mg ..................................... 22 gabapentin tab 800 mg ..................................... 22 GABITRIL TAB12MG ................................ 22 GABITRIL TAB16MG ................................ 22 galantamine hydrobromide cap sr 24hr 16 mg 24 galantamine hydrobromide cap sr 24hr 24 mg 24 galantamine hydrobromide cap sr 24hr 8 mg .. 24 galantamine hydrobromide oral soln 4 mg/ml . 24 galantamine hydrobromide tab 12 mg ............. 24 galantamine hydrobromide tab 4 mg ............... 24

galantamine hydrobromide tab 8 mg ............... 24 GAMASTAN S/DINJ ...................................... 88 Gamma-aminobutyric Acid (GABA)

Augmenting Agents ................................... 21 GAMMAGARD INJ2.5GM/25 ..................... 88 GAMMAGARD SDINJ10GM HU ................. 88 GAMMAGARD SDINJ5GM HU ................... 88 GAMMAKED INJ1GM/10ML .................... 88 GAMMAPLEX INJ5% ................................. 89 GAMUNEX-C INJ1GM/10ML ..................... 89 ganciclovir sodium for inj 500 mg ................... 44 GARDASIL 9 INJ .......................................... 89 Gastrointestinal Agents ................................. 73 GASTROINTESTINAL AGENTS .............. 73 Gastrointestinal Agents, Other ..................... 73 GATTEX KIT5MG .................................... 73 GAUZE PADS & DRESSINGS - PADS 2 X 2

..................................................................... 71 gemcitabine hcl for inj 1 gm ............................ 35 gemfibrozil tab 600 mg .................................... 66 Genetic or Enzyme Disorder

Replacement, Modifiers, Treatment ........ 75 GENETIC OR ENZYME DISORDER

REPLACEMENT, MODIFIERS,

TREATMENT ....................................... 75 GENITOURINARY AGENTS ..................... 76 Genitourinary Agents, Other ........................ 77 GENOTROPIN INJ0.2MG............................. 79 GENOTROPIN INJ0.4MG............................. 79 GENOTROPIN INJ0.6MG............................. 79 GENOTROPIN INJ0.8MG............................. 80 GENOTROPIN INJ1.2MG............................. 80 GENOTROPIN INJ1.4MG............................. 80 GENOTROPIN INJ1.6MG............................. 80 GENOTROPIN INJ1.8MG............................. 80 GENOTROPIN INJ12MG.............................. 80 GENOTROPIN INJ1MG................................ 80 GENOTROPIN INJ2MG................................ 80 GENOTROPIN INJ5MG................................ 80 GENTAMICIN OIN0.1%............................... 15 gentamicin sulfate cream 0.1% ........................ 15 gentamicin sulfate inj 40 mg/ml ....................... 15 gentamicin sulfate iv soln 10 mg/ml ................ 15 gentamicin sulfate ophth oint 0.3% ................. 15 gentamicin sulfate ophth soln 0.3% ................. 15 GENVOYA TAB ........................................ 45 GEODON INJ20MG .................................. 50 GILENYA CAP0.5MG ............................... 69

116

GILOTRIF TAB20MG ................................. 36 GILOTRIF TAB30MG ................................. 36 GILOTRIF TAB40MG ................................. 36 glatiramer acetate soln prefilled syringe 20

mg/ml ........................................................... 69 glatiramer acetate soln prefilled syringe 40

mg/ml ........................................................... 69 glatopa 40 mg/ml ............................................. 69 GLEOSTINE CAP100MG ............................ 32 GLEOSTINE CAP10MG .............................. 32 GLEOSTINE CAP40MG .............................. 32 GLEOSTINE CAP5MG ................................ 32 glimepiride tab 1 mg ........................................ 52 glimepiride tab 2 mg ........................................ 52 glimepiride tab 4 mg ........................................ 52 glipizide tab 10 mg ........................................... 52 glipizide tab 5 mg ............................................. 52 glipizide tab sr 24hr 10 mg .............................. 52 glipizide tab sr 24hr 2.5 mg ............................. 52 glipizide tab sr 24hr 5 mg ................................ 52 glipizide-metformin hcl tab 2.5-250 mg ........... 53 glipizide-metformin hcl tab 2.5-500 mg ........... 53 glipizide-metformin hcl tab 5-500 mg .............. 53 GLUCAGEN INJHYPOKIT ........................ 53 GLUCAGON KIT1MG ................................ 53 Glucocorticoids ............................................... 90 Glutamate Reducing Agents ......................... 22 Glycemic Agents ............................................. 53 glycopyrrolate tab 1 mg ................................... 73 glycopyrrolate tab 2 mg ................................... 73 granisetron hcl tab 1 mg .................................. 28 griseofulvin microsize susp 125 mg/5ml .......... 29 griseofulvin microsize tab 500 mg ................... 29 griseofulvin ultramicrosize tab 125 mg ........... 29 griseofulvin ultramicrosize tab 250 mg ........... 29 guanfacine hcl tab 1 mg ................................... 57 guanfacine hcl tab 2 mg ................................... 68 guanfacine hcl tab sr 24hr 1 mg (base equiv) .. 57 guanfacine hcl tab sr 24hr 2 mg (base equiv) .. 57 guanfacine hcl tab sr 24hr 3 mg (base equiv) .. 57 guanfacine hcl tab sr 24hr 4 mg (base equiv) .. 57 GUANIDINE TAB125MG ............................ 31 HALAVEN INJ1MG/2ML .......................... 34 halobetasol propionate cream 0.05% .............. 78 halobetasol propionate oint 0.05% .................. 78 HALOG CRE0.1% .................................... 78 HALOG OIN0.1% ..................................... 78 haloperidol decanoate im soln 100 mg/ml ....... 41

haloperidol decanoate im soln 50 mg/ml ......... 41 haloperidol lactate inj 5 mg/ml........................ 41 haloperidol lactate oral conc 2 mg/ml ............. 41 haloperidol tab 0.5 mg ..................................... 41 haloperidol tab 1 mg ........................................ 41 haloperidol tab 10 mg ...................................... 41 haloperidol tab 2 mg ........................................ 41 haloperidol tab 20 mg ...................................... 41 haloperidol tab 5 mg ........................................ 41 HARVONI TAB90-400MG ........................ 45 HAVRIX INJ1440UNIT ............................ 89 HAVRIX INJ720UNIT .............................. 89 Hemostasis Agents ......................................... 56 HEP SOD/D5W INJ25000UNT ...................... 55 heparin sodium (porcine) 40 unit/ml in d5w ... 55 heparin sodium (porcine) 50 unit/ml in d5w ... 55 heparin sodium (porcine) inj 1000 unit/ml ...... 55 heparin sodium (porcine) inj 10000 unit/ml .... 55 heparin sodium (porcine) inj 20000 unit/ml .... 55 heparin sodium (porcine) inj 5000 unit/ml ...... 55 HERCEPTIN INJ440MG .............................. 34 HETLIOZ CAP20MG ................................. 98 HEXALEN CAP50MG ............................... 32 HIBERIX SOL10MCG ............................... 89 Histamine2 (H2) Receptor Antagonists ....... 74 Hormonal Agents, Parathyroid .................... 77 HORMONAL AGENTS, PARATHYROID 77 Hormonal Agents,

Stimulant/Replacement/Modifying

(Adrenal)..................................................... 77 HORMONAL AGENTS,

STIMULANT/REPLACEMENT/MODIFY

ING (ADRENAL) ...................................... 77 Hormonal Agents,


(Pituitary) ................................................... 79 HORMONAL AGENTS,


ING (PITUITARY) .................................... 79 Hormonal Agents,


(Prostaglandins) ......................................... 80 HORMONAL AGENTS,


ING (PROSTAGLANDINS) ..................... 80 Hormonal Agents,

Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers) ................................ 81

117

HORMONAL AGENTS,


ING (SEX HORMONES/MODIFIERS) .. 80 Hormonal Agents,


(Thyroid) ..................................................... 83 HORMONAL AGENTS,


ING (THYROID) ....................................... 83 Hormonal Agents, Suppressant (Adrenal) ... 84 HORMONAL AGENTS, SUPPRESSANT

(ADRENAL) ............................................... 84 Hormonal Agents, Suppressant (Pituitary) . 84 HORMONAL AGENTS, SUPPRESSANT

(PITUITARY) ............................................ 84 HORMONAL AGENTS, SUPPRESSANT

(THYROID) ................................................ 85 HUMALOG INJ100/ML ............................. 53 HUMALOG JR INJ100/ML ........................... 53 HUMALOG KWIKINJ100/ML ...................... 53 HUMALOG KWIKINJ200/ML ...................... 53 HUMALOG MIX INJ50/50 ............................ 53 HUMALOG MIX INJ50/50KWP .................... 54 HUMALOG MIX INJ75/25KWP .................... 54 HUMALOG MIX SUS75/25 ........................... 54 HUMATROPE INJ12MG ............................. 80 HUMATROPE INJ24MG ............................. 80 HUMATROPE INJ5MG ............................... 80 HUMATROPE INJ6MG ............................... 80 HUMIRA INJ10MG/0.1 ............................. 86 HUMIRA INJ10MG/0.2 ............................. 86 HUMIRA INJ20MG/0.2 ............................. 86 HUMIRA INJ40MG/0.4 ............................. 86 HUMIRA KIT20MG/0.4 ............................ 86 HUMIRA KIT40MG/0.8 ............................ 86 HUMIRA PEDIAINJCROHNS ....................... 86 HUMIRA PEN INJ40MG/0.4 ........................ 86 HUMIRA PEN INJ40MG/0.8 ........................ 86 HUMIRA PEN INJCROHNS ......................... 86 HUMIRA PEN INJPSORIASI ....................... 86 HUMIRA PEN KITCD/UC/HS ...................... 86 HUMIRA PEN KITPS/UV ............................. 86 HUMULIN INJ70/30 ................................... 54 HUMULIN INJ70/30KWP .......................... 54 HUMULIN N INJU-100 ................................ 54 HUMULIN N INJU-100KWP ....................... 54 HUMULIN R INJU-100 ................................ 54 HUMULIN R INJU-500 ................................ 54

hydralazine hcl inj 20 mg/ml ........................... 67 hydralazine hcl tab 10 mg................................ 67 hydralazine hcl tab 100 mg.............................. 67 hydralazine hcl tab 25 mg................................ 67 hydralazine hcl tab 50 mg................................ 67 hydrochlorothiazide cap 12.5 mg .................... 65 hydrochlorothiazide tab 12.5 mg ..................... 65 hydrochlorothiazide tab 25 mg ........................ 65 hydrochlorothiazide tab 50 mg ........................ 65 hydrocodone-acetaminophen tab 10-300 mg .. 12 hydrocodone-acetaminophen tab 10-325 mg .. 12 hydrocodone-acetaminophen tab 5-300 mg .... 12 hydrocodone-acetaminophen tab 5-325 mg .... 12 hydrocodone-acetaminophen tab 7.5-300 mg . 12 hydrocodone-acetaminophen tab 7.5-325 mg . 12 hydrocodone-ibuprofen tab 7.5-200 mg .......... 12 hydrocortisone cream 1% ................................ 78 hydrocortisone cream 2.5% ............................. 78 hydrocortisone enema 100 mg/60ml ................ 90 hydrocortisone lotion 2.5% ............................. 79 hydrocortisone oint 1% ................................... 79 hydrocortisone oint 2.5%................................. 79 hydrocortisone rectal cream 1% ..................... 90 hydrocortisone rectal cream 2.5% .................. 79 hydrocortisone tab 10 mg ................................ 90 hydrocortisone tab 20 mg ................................ 90 hydrocortisone tab 5 mg .................................. 90 hydrocortisone valerate cream 0.2% ............... 79 hydrocortisone valerate oint 0.2% .................. 79 hydrocortisone w/ acetic acid otic soln 1-2% .. 93 hydromorphone hcl tab 2 mg ........................... 13 hydromorphone hcl tab 4 mg ........................... 13 hydromorphone hcl tab 8 mg ........................... 13 hydroxychloroquine sulfate tab 200 mg .......... 39 hydroxyprogesterone caproate im in oil 1.25

gm/5ml ......................................................... 34 hydroxyurea cap 500 mg ................................. 33 hydroxyzine hcl im soln 25 mg/ml ................... 48 hydroxyzine hcl im soln 50 mg/ml ................... 48 hydroxyzine hcl tab 25 mg ............................... 48 hydroxyzine hcl tab 50 mg ............................... 48 HYPERRAB S/DINJ150/ML .......................... 89 HYSINGLA ER TAB100 MG ........................ 12 HYSINGLA ER TAB120 MG ........................ 12 HYSINGLA ER TAB20 MG .......................... 12 HYSINGLA ER TAB30 MG .......................... 12 HYSINGLA ER TAB40 MG .......................... 12 HYSINGLA ER TAB60 MG .......................... 12

118

HYSINGLA ER TAB80 MG ........................... 12 ibandronate sodium iv soln 3 mg/3ml (base

equivalent).................................................... 91 ibandronate sodium tab 150 mg (base

equivalent).................................................... 91 IBRANCE CAP100MG ............................... 36 IBRANCE CAP125MG ............................... 36 IBRANCE CAP75MG ................................. 36 ibu tab 600 mg ................................................. 30 ibu tab 800 mg ................................................. 30 ibuprofen susp 100 mg/5ml .............................. 30 ibuprofen tab 400 mg ....................................... 30 ibuprofen tab 600 mg ....................................... 30 ibuprofen tab 800 mg ....................................... 30 ICLUSIG TAB15MG .................................. 36 ICLUSIG TAB45MG .................................. 36 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ..... 34 IDHIFA TAB100MG ....................................... 36 IDHIFA TAB50MG ......................................... 36 ifosfamide for inj 1 gm ..................................... 32 ILARIS INJ150MG .................................... 88 ILARIS INJ180MG .................................... 88 ILEVRO DRO0.3% OP .............................. 93 imatinib mesylate tab 100 mg (base equivalent)

..................................................................... 36 imatinib mesylate tab 400 mg (base equivalent)

..................................................................... 36 IMBRUVICA CAP140MG ........................... 36 IMBRUVICA CAP70MG ............................. 36 IMBRUVICA TAB140MG ........................... 36 IMBRUVICA TAB280MG ........................... 36 IMBRUVICA TAB420MG ........................... 36 IMBRUVICA TAB560MG ........................... 36 IMFINZI INJ120/2.4 .................................... 34 IMFINZI INJ500/10 ..................................... 34 imipenem-cilastatin intravenous for soln 250 mg

..................................................................... 18 imipenem-cilastatin intravenous for soln 500 mg

..................................................................... 18 imipramine hcl tab 10 mg ................................ 27 imipramine hcl tab 25 mg ................................ 27 imipramine hcl tab 50 mg ................................ 27 imiquimod cream 5% ....................................... 70 Immune Suppressants ................................... 85 Immunizing Agents, Passive ......................... 88 Immunological Agents ................................... 88 IMMUNOLOGICAL AGENTS ................... 85 Immunomodulators ....................................... 88

IMOGAM RABIEINJ150/ML ........................ 89 IMOVAX RABIEINJ2.5/ML .......................... 89 INCRELEX INJ40MG/4ML ........................ 80 INCRUSE ELPTINH62.5MCG ...................... 95 indapamide tab 1.25 mg .................................. 65 indapamide tab 2.5 mg .................................... 65 INFANRIX INJ ............................................ 89 INFLAMMATORY BOWEL DISEASE

AGENTS ..................................................... 89 INFLECTRA INJ100MG .............................. 86 INLYTA TAB1MG .................................... 36 INLYTA TAB5MG .................................... 37 INSULIN PEN NEEDLE ................................ 71 INSULIN SYRINGE (DISP) U-100 0.3 ML .. 71 INSULIN SYRINGE (DISP) U-100 1 ML ..... 71 INSULIN SYRINGE (DISP) U-100 1/2 ML .. 71 Insulins ............................................................ 53 INTELENCE TAB100MG ............................ 46 INTELENCE TAB200MG ............................ 46 INTELENCE TAB25MG .............................. 46 INTRAROSA SUP6.5MG ............................... 81 INTRON A INJ10MU .................................. 44 INTRON A INJ18MU .................................. 44 INTRON A INJ25MU .................................. 44 INTRON A INJ50MU .................................. 44 INVANZ INJ1GM ...................................... 18 INVEGA SUST INJ117/0.75 .......................... 42 INVEGA SUST INJ156MG/ML ..................... 42 INVEGA SUST INJ234/1.5 ............................ 42 INVEGA SUST INJ39/0.25 ............................ 42 INVEGA SUST INJ78/0.5ML ........................ 42 INVEGA TRINZINJ273MG ........................... 42 INVEGA TRINZINJ410MG ........................... 42 INVEGA TRINZINJ546MG ........................... 42 INVEGA TRINZINJ819MG ........................... 42 INVIRASE CAP200MG .............................. 47 INVIRASE TAB500MG .............................. 47 IOPIDINE SOL1% OP ................................. 93 IPOL INJINACTIVE ................................ 89 ipratropium bromide inhal soln 0.02% ........... 95 ipratropium bromide nasal soln 0.03% (21

mcg/spray) ................................................... 95 ipratropium bromide nasal soln 0.06% (42

mcg/spray) ................................................... 95 irbesartan tab 150 mg ...................................... 57 irbesartan tab 300 mg ...................................... 57 irbesartan tab 75 mg ........................................ 57

119

irbesartan-hydrochlorothiazide tab 150-12.5 mg

..................................................................... 63 irbesartan-hydrochlorothiazide tab 300-12.5 mg

..................................................................... 63 IRESSA TAB250MG ................................. 37 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ....... 34 Irritable Bowel Syndrome Agents ................ 74 ISENTRESS CHW100MG ............................ 45 ISENTRESS CHW25MG .............................. 45 ISENTRESS HDTAB600MG ....................... 45 ISENTRESS POW100MG ............................ 45 ISENTRESS TAB400MG ............................. 45 isoniazid inj 100 mg/ml .................................... 31 isoniazid syrup 50 mg/5ml ............................... 31 isoniazid tab 100 mg ........................................ 31 isoniazid tab 300 mg ........................................ 31 ISOPROPYL ALCOHOL 0.7 ML/ML

MEDICATED PAD ..................................... 71 isosorbide dinitrate tab 10 mg ......................... 67 isosorbide dinitrate tab 20 mg ......................... 67 isosorbide dinitrate tab 30 mg ......................... 67 isosorbide dinitrate tab 5 mg ........................... 67 isosorbide dinitrate tab cr 40 mg ..................... 67 isosorbide mononitrate tab 10 mg ................... 67 isosorbide mononitrate tab 20 mg ................... 67 isosorbide mononitrate tab sr 24hr 120 mg ..... 67 isosorbide mononitrate tab sr 24hr 30 mg ....... 67 isosorbide mononitrate tab sr 24hr 60 mg ....... 67 isotretinoin cap 10 mg ..................................... 70 isotretinoin cap 20 mg ..................................... 70 isotretinoin cap 30 mg ..................................... 70 isotretinoin cap 40 mg ..................................... 70 isradipine cap 2.5 mg ....................................... 61 isradipine cap 5 mg .......................................... 61 ISTODAX OVR INJ10MG ............................. 35 itraconazole cap 100 mg .................................. 29 ivermectin tab 3 mg .......................................... 39 IXIARO INJ ................................................ 89 JAKAFI TAB10MG ................................... 37 JAKAFI TAB15MG ................................... 37 JAKAFI TAB20MG ................................... 37 JAKAFI TAB25MG ................................... 37 JAKAFI TAB5MG ..................................... 37 JANUMET TAB50-1000 ............................. 53 JANUMET TAB50-500MG ........................ 53 JANUMET XR TAB100-1000 ....................... 53 JANUMET XR TAB50-1000 ......................... 53 JANUMET XR TAB50-500MG ..................... 53

JANUVIA TAB100MG............................... 52 JANUVIA TAB25MG ................................ 52 JANUVIA TAB50MG ................................ 52 JARDIANCE TAB10MG .............................. 52 JARDIANCE TAB25MG .............................. 52 JEVTANA INJ60/1.5ML ............................ 37 JULUCA TAB50-25MG ................................. 46 JUXTAPID CAP10MG ................................ 66 JUXTAPID CAP20MG ................................ 67 JUXTAPID CAP5MG .................................. 67 KADCYLA INJ100MG............................... 34 KADCYLA INJ160MG............................... 34 KALETRA TAB100-25MG ........................ 47 KALETRA TAB200-50MG ........................ 47 KALYDECO PAK50MG ............................. 96 KALYDECO PAK75MG ............................. 96 KALYDECO TAB150MG ........................... 96 kcl 10 meq/l (0.075%) in dextrose 5% & nacl

0.45% inj ...................................................... 72 kcl 20 meq/l (0.15%) in dextrose 5% & nacl

0.2% inj ........................................................ 72 kcl 20 meq/l (0.15%) in dextrose 5% & nacl



0.9% inj ........................................................ 72 kcl 20 meq/l (0.15%) in nacl 0.45% inj ........... 72 kcl 30 meq/l (0.224%) in dextrose 5% & nacl


0.45% inj ...................................................... 72 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9%

inj ................................................................. 72 KEPIVANCE INJ6.25MG ............................ 70 ketoconazole cream 2% ................................... 29 ketoconazole shampoo 2% ............................... 29 ketoconazole tab 200 mg ................................. 29 ketorolac tromethamine ophth soln 0.4% ........ 93 ketorolac tromethamine ophth soln 0.5% ........ 93 KEVEYIS TAB50MG ................................. 65 KEYTRUDA INJ100MG/4M ...................... 34 KEYTRUDA SOL50MG ............................. 34 KHEDEZLA TAB100MG ER ..................... 26 KHEDEZLA TAB50MG ER ....................... 26 KINERET INJ ............................................. 86 KINRIX INJ ............................................... 89 KISQALI TAB200DOSE ............................ 37

120

KISQALI TAB400DOSE ............................ 37 KISQALI TAB600DOSE ............................ 37 KISQALI 200 PAKFEMARA ......................... 34 KISQALI 400 PAKFEMARA ......................... 34 KISQALI 600 PAKFEMARA ......................... 34 KORLYM TAB300MG .............................. 53 KUVAN TAB100MG ................................ 75 KYNAMRO INJ200MG/ML ....................... 67 KYPROLIS SOL30MG ................................ 35 KYPROLIS SOL60MG ................................ 35 labetalol hcl iv soln 5 mg/ml ............................ 60 labetalol hcl tab 100 mg .................................. 60 labetalol hcl tab 200 mg .................................. 60 labetalol hcl tab 300 mg .................................. 60 LACRISERT MIS5MG OP ........................... 92 lactated ringer's for irrigation ......................... 73 lactated ringer's solution ................................. 72 lactic acid (ammonium lactate) cream 12% .... 70 lactic acid (ammonium lactate) lotion 12% ..... 70 lactulose (encephalopathy) solution 10 gm/15ml

..................................................................... 75 lactulose solution 10 gm/15ml ......................... 75 lamivudine oral soln 10 mg/ml......................... 46 lamivudine tab 100 mg (hbv) ........................... 44 lamivudine tab 150 mg ..................................... 46 lamivudine tab 300 mg ..................................... 46 lamivudine-zidovudine tab 150-300 mg ........... 46 lamotrigine kitstart 35 ...................................... 23 lamotrigine kitstart 49 ...................................... 23 lamotrigine kitstart 98 ...................................... 23 lamotrigine orally disintegrating tab 100 mg .. 23 lamotrigine orally disintegrating tab 200 mg .. 51 lamotrigine tab 100 mg .................................... 51 lamotrigine tab 150 mg .................................... 51 lamotrigine tab 200 mg .................................... 51 lamotrigine tab 25 mg ...................................... 51 lamotrigine tab chewable dispersible 25 mg ... 51 lamotrigine tab chewable dispersible 5 mg ..... 51 lamotrigine tab sr 24hr 100 mg ....................... 51 lamotrigine tab sr 24hr 200 mg ....................... 51 lamotrigine tab sr 24hr 25 mg ......................... 51 lamotrigine tab sr 24hr 250 mg ....................... 51 lamotrigine tab sr 24hr 300 mg ....................... 51 lamotrigine tab sr 24hr 50 mg ......................... 51 lansoprazole cap delayed release 15 mg ......... 75 lansoprazole cap delayed release 30 mg ......... 75 lanthanum chw1000mg .................................... 77 lanthanum chw500mg ...................................... 77

lanthanum chw750mg ...................................... 77 LANTUS INJ100/ML ................................. 54 LANTUS INJSOLOSTAR ......................... 54 LARTRUVO INJ10MG/ML ........................ 38 LARTRUVO INJ190MG/19ML .................. 38 latanoprost ophth soln 0.005% ........................ 93 LATUDA TAB120MG .............................. 42 LATUDA TAB20MG ................................ 42 LATUDA TAB40MG ................................ 42 LATUDA TAB60MG ................................ 42 LATUDA TAB80MG ................................ 42 Laxatives ......................................................... 75 leflunomide tab 10 mg ..................................... 88 leflunomide tab 20 mg ..................................... 88 LENVIMA CAP10 MG ............................... 37 LENVIMA CAP14 MG ............................... 37 LENVIMA CAP18 MG ............................... 37 LENVIMA CAP20 MG ............................... 37 LENVIMA CAP24 MG ............................... 37 LENVIMA CAP8 MG ................................. 37 LETAIRIS TAB10MG ................................. 96 LETAIRIS TAB5MG ................................... 96 letrozole tab 2.5 mg ......................................... 35 leucovorin calcium for inj 100 mg ................... 35 leucovorin calcium for inj 350 mg ................... 35 leucovorin calcium tab 10 mg.......................... 35 leucovorin calcium tab 15 mg.......................... 35 leucovorin calcium tab 25 mg.......................... 35 leucovorin calcium tab 5 mg............................ 35 LEUKERAN TAB2MG ............................... 32 LEUKINE INJ250MCG .............................. 56 leuprolide acetate inj kit 5 mg/ml .................... 84 LEVEMIR INJ ............................................. 54 LEVEMIR INJFLEXTOUC ........................ 54 levetiracetam inj 500 mg/5ml (100 mg/ml) ...... 21 levetiracetam oral soln 100 mg/ml .................. 21 levetiracetam tab 1000 mg............................... 21 levetiracetam tab 250 mg................................. 21 levetiracetam tab 500 mg................................. 21 levetiracetam tab 750 mg................................. 21 levetiracetam tab sr 24hr 500 mg .................... 21 levetiracetam tab sr 24hr 750 mg .................... 21 levobunolol hcl ophth soln 0.5% ..................... 93 levocarnitine oral soln 1 gm/10ml (10%) ........ 73 levocarnitine tab 330 mg ................................. 73 levocetirizine dihydrochloride soln 2.5 mg/5ml

(0.5 mg/ml)................................................... 94 levocetirizine dihydrochloride tab 5 mg .......... 94

121

levofloxacin in d5w iv soln 500 mg/100ml ....... 20 levofloxacin ophth soln 0.5% ........................... 20 levofloxacin oral soln 25 mg/ml ....................... 20 levofloxacin tab 250 mg ................................... 20 levofloxacin tab 500 mg ................................... 20 levofloxacin tab 750 mg ................................... 20 levoleucovorinj50mg ........................................ 34 levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg ................................................ 82 levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg ............................................................... 82 levonorgestrel & ethinyl estradiol tab 0.15 mg-

30 mcg .......................................................... 82 levonorgestrel-eth estra tab 0.05-30/0.075-

40/0.125-30mg-mcg ..................................... 82 levorphanol tartrate tab 2 mg .......................... 12 levothyroxine sodium tab 100 mcg ................... 83 levothyroxine sodium tab 112 mcg ................... 83 levothyroxine sodium tab 125 mcg ................... 83 levothyroxine sodium tab 137 mcg ................... 83 levothyroxine sodium tab 150 mcg ................... 83 levothyroxine sodium tab 175 mcg ................... 83 levothyroxine sodium tab 200 mcg ................... 83 levothyroxine sodium tab 25 mcg ..................... 83 levothyroxine sodium tab 300 mcg ................... 83 levothyroxine sodium tab 50 mcg ..................... 83 levothyroxine sodium tab 75 mcg ..................... 83 levothyroxine sodium tab 88 mcg ..................... 83 LEVOXYL TAB100MCG ........................... 83 LEVOXYL TAB112MCG ........................... 83 LEVOXYL TAB125MCG ........................... 83 LEVOXYL TAB137MCG ........................... 84 LEVOXYL TAB150MCG ........................... 84 LEVOXYL TAB175MCG ........................... 84 LEVOXYL TAB200MCG ........................... 84 LEVOXYL TAB25MCG ............................. 84 LEVOXYL TAB50MCG ............................. 84 LEVOXYL TAB75MCG ............................. 84 LEVOXYL TAB88MCG ............................. 84 LEXIVA SUS50MG/ML ............................ 47 lidocaine hcl gel 2% ......................................... 14 lidocaine hcl local preservative free (pf) inj

0.5% ............................................................. 14 lidocaine hcl soln 4% ....................................... 14 lidocaine hcl viscous soln 2% .......................... 14 lidocaine oint 5% ............................................. 14 lidocaine patch 5% .......................................... 14 lidocaine-prilocaine cream 2.5-2.5% .............. 14

lindane shampoo 1% ....................................... 39 linezolid for susp 100 mg/5ml .......................... 16 linezolid iv soln 600 mg/300ml (2 mg/ml) ....... 16 linezolid tab 600 mg ........................................ 16 LINZESS CAP145MCG ............................. 74 LINZESS CAP290MCG ............................. 74 LINZESS CAP72MCG ............................... 74 liothyronine sodium tab 25 mcg ...................... 84 liothyronine sodium tab 5 mcg ........................ 84 liothyronine sodium tab 50 mcg ...................... 84 lisinopril & hydrochlorothiazide tab 10-12.5 mg

..................................................................... 63 lisinopril & hydrochlorothiazide tab 20-12.5 mg

..................................................................... 63 lisinopril & hydrochlorothiazide tab 20-25 mg

..................................................................... 63 lisinopril tab 10 mg .......................................... 58 lisinopril tab 2.5 mg ......................................... 58 lisinopril tab 20 mg .......................................... 58 lisinopril tab 30 mg .......................................... 58 lisinopril tab 40 mg .......................................... 58 lisinopril tab 5 mg ............................................ 58 LITHIUM SOL8MEQ/5ML ........................ 51 lithium carbonate cap 150 mg ......................... 51 lithium carbonate cap 300 mg ......................... 51 lithium carbonate cap 600 mg ......................... 51 lithium carbonate tab 300 mg .......................... 51 lithium carbonate tab cr 300 mg ..................... 51 lithium carbonate tab cr 450 mg ..................... 51 Local Anesthetics ........................................... 14 LONSURF TAB15-6.14 .............................. 35 LONSURF TAB20-8.19 .............................. 35 loperamide hcl cap 2 mg.................................. 73 lopinavir-ritonavir soln 400-100 mg/5ml (80-20

mg/ml) .......................................................... 47 lorazepam conc 2 mg/ml .................................. 49 lorazepam tab 0.5 mg ...................................... 49 lorazepam tab 1 mg ......................................... 49 lorazepam tab 2 mg ......................................... 49 losartan potassium & hydrochlorothiazide tab

100-12.5 mg ................................................. 63 losartan potassium & hydrochlorothiazide tab

100-25 mg .................................................... 63 losartan potassium & hydrochlorothiazide tab

50-12.5 mg ................................................... 63 losartan potassium tab 100 mg ........................ 57 losartan potassium tab 25 mg .......................... 57 losartan potassium tab 50 mg .......................... 57

122

LOTEMAX GEL0.5% ................................. 93 LOTEMAX OIN0.5% .................................. 93 LOTEMAX SUS0.5% ................................. 93 lovastatin tab 10 mg ......................................... 66 lovastatin tab 20 mg ......................................... 66 lovastatin tab 40 mg ......................................... 66 loxapine succinate cap 10 mg .......................... 41 loxapine succinate cap 25 mg .......................... 41 loxapine succinate cap 5 mg ............................ 41 loxapine succinate cap 50 mg .......................... 41 LUMIGAN SOL0.01% ................................ 93 LUPR DEP-PEDINJ11.25MG ......................... 84 LUPR DEP-PEDINJ15MG .............................. 84 LUPRON DEPOTINJ11.25MG ...................... 84 LUPRON DEPOTINJ22.5MG ........................ 84 LUPRON DEPOTINJ3.75MG ........................ 84 LUPRON DEPOTINJ30MG ........................... 84 LUPRON DEPOTINJ45MG ........................... 84 LUPRON DEPOTINJ7.5MG .......................... 84 LYNPARZA CAP50MG .............................. 37 LYNPARZA TAB100MG .............................. 37 LYNPARZA TAB150MG .............................. 37 LYRICA CAP100MG ................................ 21 LYRICA CAP150MG ................................ 69 LYRICA CAP200MG ................................ 69 LYRICA CAP225MG ................................ 69 LYRICA CAP25MG .................................. 69 LYRICA CAP300MG ................................ 69 LYRICA CAP50MG .................................. 69 LYRICA CAP75MG .................................. 69 LYRICA SOL20MG/ML ............................ 69 LYSODREN TAB500MG ............................ 84 Macrolides ...................................................... 19 magnesium sulfate inj 50% .............................. 72 malathion lotion 0.5% ...................................... 39 maprotiline hcl tab 25 mg ................................ 26 maprotiline hcl tab 50 mg ................................ 26 maprotiline hcl tab 75 mg ................................ 26 MARPLAN TAB10MG ............................... 25 Mast Cell Stabilizers ...................................... 96 MATULANE CAP50MG ............................. 32 MAXIDEX SUS0.1% OP ............................ 93 meclizine hcl tab 12.5 mg ................................. 27 meclizine hcl tab 25 mg .................................... 27 medroxyprogesterone acetate im susp 150 mg/ml

..................................................................... 83 medroxyprogesterone acetate tab 10 mg ......... 83 medroxyprogesterone acetate tab 2.5 mg ........ 83

medroxyprogesterone acetate tab 5 mg ........... 83 mefloquine hcl tab 250 mg ............................... 39 megestrol acetate susp 40 mg/ml ..................... 83 megestrol acetate susp 625 mg/5ml ................. 83 megestrol acetate tab 20 mg ............................ 83 megestrol acetate tab 40 mg ............................ 83 MEKINIST TAB0.5MG ............................... 37 MEKINIST TAB2MG .................................. 37 meloxicam tab 15 mg ....................................... 30 meloxicam tab 7.5 mg ...................................... 30 melphalan hcl for inj 50 mg (base equiv) ........ 32 memantine hccap14mg er ................................ 24 memantine hccap21mg er ................................ 24 memantine hccap28mg er ................................ 24 memantine hccap7mg er .................................. 24 memantine hcl oral solution 2 mg/ml .............. 24 memantine hcl tab 10 mg ................................. 24 memantine hcl tab 5 mg ................................... 24 memantine hcl tab 5 mg (28) & 10 mg (21)

titration pak ................................................. 24 MENACTRA INJ ......................................... 89 MENOMUNE INJA/C/Y/W ........................ 89 MENVEO INJ ............................................ 89 meprobamate tab 200 mg ................................ 48 meprobamate tab 400 mg ................................ 48 mercaptopurine tab 50 mg ............................... 86 meropenem iv for soln 1 gm............................. 18 meropenem iv for soln 500 mg......................... 18 MESALAMINE TAB800MG DR .................. 90 mesalamine tab1.2gm ...................................... 90 mesna inj 100 mg/ml ........................................ 38 MESNEX TAB400MG .............................. 38 MESTINON SYP60MG/5ML ...................... 31 Metabolic Bone Disease Agents .................... 91 METABOLIC BONE DISEASE AGENTS . 91 metaproterenol sulfate syrup 10 mg/5ml ......... 95 metaproterenol sulfate tab 10 mg .................... 95 metaproterenol sulfate tab 20 mg .................... 95 metaxalone tab 800 mg .................................... 98 metformin hcl tab 1000 mg .............................. 52 metformin hcl tab 500 mg ................................ 52 metformin hcl tab 850 mg ................................ 52 metformin hcl tab sr 24hr 500 mg ................... 52 metformin hcl tab sr 24hr 750 mg ................... 52 METHADONE INJ10MG/ML ...................... 12 methadone hcl soln 10 mg/5ml ........................ 12 methadone hcl soln 5 mg/5ml .......................... 12 methadone hcl tab 10 mg ................................. 12

123

methadone hcl tab 5 mg ................................... 12 methazolamide tab 25 mg ................................ 93 methazolamide tab 50 mg ................................ 93 methenamine hippurate tab 1 gm ..................... 16 methimazole tab 10 mg .................................... 85 methimazole tab 5 mg ...................................... 85 methotrexate sodium for inj 1 gm .................... 86 methotrexate sodium inj pf 1000 mg/40ml (25

mg/ml) .......................................................... 86 methotrexate sodium inj pf 250 mg/10ml ......... 86 methotrexate sodium inj pf 50 mg/2ml (25

mg/ml) .......................................................... 86 methotrexate sodium tab 10 mg (base equiv) ... 86 methotrexate sodium tab 15 mg (base equiv) ... 86 methotrexate sodium tab 2.5 mg (base equiv) .. 86 methotrexate sodium tab 5 mg (base equiv) ..... 86 methotrexate sodium tab 7.5 mg (base equiv) .. 87 methoxsalen rapid cap 10 mg .......................... 70 methscopolamine bromide tab 2.5 mg ............. 73 methscopolamine bromide tab 5 mg ................ 73 methyclothiazide tab 5 mg ............................... 65 methyldopa & hydrochlorothiazide tab 250-15

mg ................................................................. 63 methyldopa & hydrochlorothiazide tab 250-25

mg ................................................................. 63 methyldopa tab 250 mg .................................... 57 methyldopa tab 500 mg .................................... 57 methyldopate hcl inj 250 mg/5ml ..................... 57 methylphenidate hcl cap cr 30 mg (cd) ............ 68 methylphenidate hcl tab 10 mg ........................ 68 methylphenidate hcl tab 20 mg ........................ 68 methylphenidate hcl tab 5 mg .......................... 68 methylphenidate hcl tab cr 20 mg .................... 68 methylphenidate hcl tab sr 24hr 27 mg ............ 68 methylprednisolone acetate inj susp 40 mg/ml 90 methylprednisolone acetate inj susp 80 mg/ml 90 methylprednisolone sodium succinate for inj 125

mg ................................................................. 90 methylprednisolone sodium succinate for inj 40

mg ................................................................. 90 methylprednisolone tab 16 mg ......................... 90 methylprednisolone tab 32 mg ......................... 90 methylprednisolone tab 4 mg ........................... 90 methylprednisolone tab 8 mg ........................... 90 methylprednisolone tab therapy pack 4 mg (21)

..................................................................... 90 metipranolol ophth soln 0.3% .......................... 93 metoclopramide hcl inj 5 mg/ml....................... 73

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)

..................................................................... 73 metoclopramide hcl tab 10 mg ........................ 73 metoclopramide hcl tab 5 mg .......................... 74 metolazone tab 10 mg ...................................... 65 metolazone tab 2.5 mg ..................................... 66 metolazone tab 5 mg ........................................ 66 metoprolol & hydrochlorothiazide tab 100-25

mg ................................................................ 63 metoprolol & hydrochlorothiazide tab 100-50

mg ................................................................ 63 metoprolol & hydrochlorothiazide tab 50-25 mg

..................................................................... 64 metoprolol succinate tab sr 24hr 100 mg

(tartrate equiv) ............................................. 60 metoprolol succinate tab sr 24hr 200 mg

(tartrate equiv) ............................................. 60 metoprolol succinate tab sr 24hr 25 mg (tartrate

equiv) ........................................................... 60 metoprolol succinate tab sr 24hr 50 mg (tartrate

equiv) ........................................................... 60 metoprolol tartrate iv soln 5 mg/5ml ............... 60 metoprolol tartrate iv soln cart inj 5 mg/5ml (1

mg/ml) .......................................................... 60 metoprolol tartrate tab 100 mg........................ 60 metoprolol tartrate tab 25 mg.......................... 60 metoprolol tartrate tab 50 mg.......................... 60 metronidazole cap 375 mg ............................... 16 metronidazole cream 0.75% ............................ 16 metronidazole gel 0.75% ................................. 16 metronidazole in nacl 0.79% iv soln 500

mg/100ml ..................................................... 16 metronidazole lotion 0.75% ............................. 16 metronidazole tab 250 mg ............................... 16 metronidazole tab 500 mg ............................... 16 metronidazole vaginal gel 0.75% .................... 16 mexiletine hcl cap 150 mg ............................... 59 mexiletine hcl cap 200 mg ............................... 59 mexiletine hcl cap 250 mg ............................... 59 MIACALCIN INJ200/ML ............................. 91 miconazole nitrate vaginal suppos 200 mg ..... 29 midodrine hcl tab 10 mg .................................. 57 midodrine hcl tab 2.5 mg ................................. 57 midodrine hcl tab 5 mg .................................... 57 miglustat cap100mg ......................................... 75 MINIVELLE DIS0.025 MG .......................... 81 MINIVELLE DIS0.05MG ............................. 81 MINIVELLE DIS0.075MG ........................... 81

124

MINIVELLE DIS0.1MG ............................... 81 minocycline hcl cap 100 mg ............................. 21 minocycline hcl cap 50 mg ............................... 21 minocycline hcl cap 75 mg ............................... 21 minoxidil tab 10 mg ......................................... 67 minoxidil tab 2.5 mg ........................................ 67 mirtazapine orally disintegrating tab 15 mg .... 25 mirtazapine orally disintegrating tab 30 mg .... 25 mirtazapine orally disintegrating tab 45 mg .... 25 mirtazapine tab 15 mg ..................................... 25 mirtazapine tab 30 mg ..................................... 25 mirtazapine tab 45 mg ..................................... 25 mirtazapine tab 7.5 mg .................................... 25 misoprostol tab 100 mcg .................................. 80 misoprostol tab 200 mcg .................................. 80 mitomycin for iv soln 20 mg ............................. 34 mitomycin for iv soln 40 mg ............................. 34 mitomycin for iv soln 5 mg ............................... 34 mitoxantrone hcl inj conc 25 mg/12.5ml (2

mg/ml) .......................................................... 35 M-M-R II INJ ................................................ 89 modafinil tab 100 mg ....................................... 98 modafinil tab 200 mg ....................................... 98 moexipril hcl tab 15 mg ................................... 58 moexipril hcl tab 7.5 mg .................................. 58 moexipril-hydrochlorothiazide tab 15-12.5 mg64 moexipril-hydrochlorothiazide tab 15-25 mg .. 64 moexipril-hydrochlorothiazide tab 7.5-12.5 mg

..................................................................... 64 Molecular Target Inhibitors ......................... 35 mometasone furoate cream 0.1% ..................... 79 mometasone furoate nasal susp 50 mcg/act ..... 94 mometasone furoate oint 0.1%......................... 79 mometasone furoate solution 0.1% (lotion) ..... 79 Monoamine Oxidase B (MAO-B) Inhibitors40 Monoamine Oxidase Inhibitors .................... 25 Monoclonal Antibody/Antibody-Drug

Conjugate .................................................... 38 montelukast sodium chew tab 4 mg (base equiv)

..................................................................... 94 montelukast sodium chew tab 5 mg (base equiv)

..................................................................... 94 montelukast sodium oral granules packet 4 mg

(base equiv) .................................................. 94 montelukast sodium tab 10 mg (base equiv) .... 94 Mood Stabilizers............................................. 51 morphine sulfate beads cap sr 24hr 120 mg .... 13 morphine sulfate beads cap sr 24hr 30 mg ...... 13

morphine sulfate beads cap sr 24hr 45 mg ...... 13 morphine sulfate beads cap sr 24hr 60 mg ...... 13 morphine sulfate beads cap sr 24hr 75 mg ...... 13 morphine sulfate beads cap sr 24hr 90 mg ...... 13 morphine sulfate cap sr 24hr 10 mg ................ 13 morphine sulfate cap sr 24hr 100 mg .............. 13 morphine sulfate cap sr 24hr 20 mg ................ 13 morphine sulfate cap sr 24hr 30 mg ................ 13 morphine sulfate cap sr 24hr 50 mg ................ 13 morphine sulfate cap sr 24hr 60 mg ................ 13 morphine sulfate cap sr 24hr 80 mg ................ 13 morphine sulfate inj pf 0.5 mg/ml .................... 13 morphine sulfate inj pf 1 mg/ml ....................... 14 morphine sulfate oral soln 10 mg/5ml ............. 14 morphine sulfate oral soln 100 mg/5ml (20

mg/ml) .......................................................... 14 morphine sulfate oral soln 20 mg/5ml ............. 13 morphine sulfate tab 15 mg ............................. 14 morphine sulfate tab 30 mg ............................. 14 morphine sulfate tab cr 100 mg ....................... 13 morphine sulfate tab cr 15 mg ......................... 13 morphine sulfate tab cr 200 mg ....................... 13 morphine sulfate tab cr 30 mg ......................... 13 morphine sulfate tab cr 60 mg ......................... 13 MORPHINE SULINJ10MG/ML ..................... 13 MORPHINE SULINJ2MG/ML....................... 13 MORPHINE SULINJ4MG/ML....................... 13 MORPHINE SULINJ8MG/ML....................... 13 MOXEZA SOL0.5% .................................. 20 moxifloxacin hcl tab 400 mg (base equiv) ....... 20 moxifloxacin sol0.5%mg .................................. 20 MOZOBIL INJ ............................................ 56 Multiple Sclerosis Agents .............................. 69 mupirocin calcium cream 2% .......................... 16 mupirocin oint 2% ........................................... 16 MUSTARGEN INJ10MG ............................. 32 mycophenolate mofetil cap 250 mg ................. 87 mycophenolate mofetil for oral susp 200 mg/ml

..................................................................... 87 mycophenolate mofetil hcl for iv soln 500 mg

(base equiv).................................................. 87 mycophenolate mofetil tab 500 mg .................. 87 mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) ........................... 87 mycophenolate sodium tab dr 360 mg

(mycophenolic acid equiv) ........................... 87 MYLOTARG INJ4.5MG ................................ 38 MYRBETRIQ TAB25MG ............................ 76

125

MYRBETRIQ TAB50MG ............................. 76 nabumetone tab 500 mg ................................... 30 nabumetone tab 750 mg ................................... 30 nadolol & bendroflumethiazide tab 40-5 mg ... 64 nadolol & bendroflumethiazide tab 80-5 mg ... 64 nadolol tab 20 mg ............................................ 60 nadolol tab 40 mg ............................................ 60 nadolol tab 80 mg ............................................ 60 nafcillin sodium for inj 1 gm ............................ 18 nafcillin sodium for inj 10 gm .......................... 19 NAGLAZYME INJ1MG/ML ........................ 75 nalbuphine hcl inj 10 mg/ml............................. 14 nalbuphine hcl inj 20 mg/ml............................. 14 naloxone hcl soln prefilled syringe 2 mg/2ml .. 15 naltrexone hcl tab 50 mg .................................. 14 naproxen sodium tab 275 mg ........................... 30 naproxen sodium tab 550 mg ........................... 30 naproxen susp 125 mg/5ml .............................. 30 naproxen tab 250 mg ....................................... 30 naproxen tab 375 mg ....................................... 30 naproxen tab 500 mg ....................................... 30 naproxen tab ec 375 mg ................................... 30 naproxen tab ec 500 mg ................................... 30 naratriptan hcl tab 1 mg (base equiv) .............. 31 naratriptan hcl tab 2.5 mg (base equiv) ........... 31 NARCAN SPR................................................. 15 NATACYN SUS5% OP .............................. 29 nateglinide tab 120 mg ..................................... 52 nateglinide tab 60 mg ....................................... 52 NATPARA INJ100MCG ............................. 77 NATPARA INJ25MCG ............................... 77 NATPARA INJ50MCG ............................... 77 NATPARA INJ75MCG ............................... 77 NEBUPENT INH300MG ............................. 39 NEEDLES, INSULIN DISP., SAFETY .......... 71 nefazodone hcl tab 100 mg .............................. 26 nefazodone hcl tab 150 mg .............................. 26 nefazodone hcl tab 200 mg .............................. 26 nefazodone hcl tab 250 mg .............................. 26 nefazodone hcl tab 50 mg ................................ 26 neomycin sulfate tab 500 mg ............................ 15 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-

10000unt op oin ........................................... 92 neomycin-polymy-gramicid op sol 1.75-10000-

0.025mg-unt-mg/ml ...................................... 92 neomycin-polymyxin b gu irrigation soln ........ 15 neomycin-polymyxin-dexamethasone ophth oint

0.1% ............................................................. 92

neomycin-polymyxin-dexamethasone ophth susp

0.1% ............................................................. 92 neomycin-polymyxin-hc ophth susp ................. 92 neomycin-polymyxin-hc otic soln 1% .............. 93 neomycin-polymyxin-hc otic susp 3.5 mg/ml-

10000 unit/ml-1% ........................................ 94 NERLYNX TAB40MG ................................... 37 NEULASTA INJ6MG/0.6M ........................ 56 NEUPOGEN INJ300/0.5 .............................. 56 NEUPOGEN INJ300MCG ........................... 56 NEUPOGEN INJ480/0.8 .............................. 56 NEUPOGEN INJ480MCG ........................... 56 NEUPRO DIS1MG/24HR .......................... 39 NEUPRO DIS2MG/24HR .......................... 39 NEUPRO DIS3MG/24HR .......................... 39 NEUPRO DIS4MG/24HR .......................... 39 NEUPRO DIS6MG/24HR .......................... 39 NEUPRO DIS8MG/24HR .......................... 39 NEVANAC SUS0.1% ................................. 93 NEVIRAPINE SUS50MG/5ML .................... 46 nevirapine tab 200 mg ..................................... 46 nevirapine tab sr 24hr 100 mg......................... 46 nevirapine tab sr 24hr 400 mg......................... 46 NEXAVAR TAB200MG ............................ 37 niacin (antihyperlipidemic) tab 500 mg .......... 67 niacin er tab1000mg ........................................ 67 niacin er tab500mg .......................................... 67 niacin er tab750mg .......................................... 67 nicardipine hcl cap 20 mg ............................... 61 nicardipine hcl cap 30 mg ............................... 61 nicardipine hcl iv soln 2.5 mg/ml .................... 61 NICOTROL NS SPR10MG/ML ..................... 15 nifedipine tab sr 24hr 30 mg ............................ 61 nifedipine tab sr 24hr 60 mg ............................ 61 nifedipine tab sr 24hr 90 mg ............................ 61 nifedipine tab sr 24hr osmotic release 30 mg .. 61 nifedipine tab sr 24hr osmotic release 60 mg .. 61 nifedipine tab sr 24hr osmotic release 90 mg .. 61 nilutamide tab 150 mg ..................................... 32 nimodipine cap 30 mg ...................................... 61 NINLARO CAP2.3MG ............................... 35 NINLARO CAP3MG .................................. 35 NINLARO CAP4MG .................................. 35 NIPENT INJ10MG ..................................... 34 nisoldipine tab sr 24hr 17 mg .......................... 61 nisoldipine tab sr 24hr 20 mg .......................... 61 nisoldipine tab sr 24hr 25.5 mg ....................... 61 nisoldipine tab sr 24hr 30 mg .......................... 61

126

nisoldipine tab sr 24hr 34 mg .......................... 61 nisoldipine tab sr 24hr 40 mg .......................... 61 nisoldipine tab sr 24hr 8.5 mg ......................... 61 NITRO-DUR DIS0.3MG/HR ........................ 67 NITRO-DUR DIS0.8MG/HR ........................ 67 nitrofurantoin macrocrystalline cap 100 mg ... 16 nitrofurantoin macrocrystalline cap 50 mg ..... 16 nitrofurantoin susp 25 mg/5ml ......................... 16 nitroglycerin iv soln 5 mg/ml ........................... 67 nitroglycerin oint 2% ....................................... 67 nitroglycerin sl tab 0.3 mg ............................... 67 nitroglycerin sl tab 0.4 mg ............................... 67 nitroglycerin sl tab 0.6 mg ............................... 67 nitroglycerin td patch 24hr 0.1 mg/hr .............. 67 nitroglycerin td patch 24hr 0.2 mg/hr .............. 67 nitroglycerin td patch 24hr 0.4 mg/hr .............. 68 nitroglycerin td patch 24hr 0.6 mg/hr .............. 68 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray).................................................... 68 NITROMIST AER400MCG .......................... 68 nizatidine cap 150 mg ...................................... 74 nizatidine cap 300 mg ...................................... 74 nizatidine oral soln 15 mg/ml .......................... 74 N-methyl-D-aspartate (NMDA) Receptor

Antagonist ................................................... 24 Nonsteroidal Anti-inflammatory Drugs . 12, 29 NORDITROPIN INJ10/1.5ML ........................ 80 NORDITROPIN INJ15/1.5ML ........................ 80 NORDITROPIN INJ5/1.5ML .......................... 80 norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr ...................................................... 82 norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg ............................................................... 82 norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg ............................................................... 82 norethindrone & ethinyl estradiol tab 1 mg-35

mcg ............................................................... 82 norethindrone ace & ethinyl estradiol tab 1 mg-

20 mcg .......................................................... 82 norethindrone ace & ethinyl estradiol tab 1.5

mg-30 mcg .................................................... 82 norethindrone ace & ethinyl estradiol-fe tab 1

mg-20 mcg .................................................... 82 norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg .................................................... 82 norethindrone ace-ethinyl estradiol-fe tab 1 mg-

20 mcg (24) .................................................. 82 norethindrone acetate tab 5 mg ....................... 83

norethindrone acetate-ethinyl estradiol tab 1

mg-5 mcg ..................................................... 82 norethindrone ac-ethinyl estrad-fe tab 1-20/1-

30/1-35 mg-mcg ........................................... 82 norethindrone tab 0.35 mg .............................. 83 norethindrone-eth estradiol tab 0.5-35/0.75-

35/1-35 mg-mcg ........................................... 82 norethindrone-eth estradiol tab 0.5-35/1-35 mg-

mcg (10/11) .................................................. 82 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-

35 mg-mcg ................................................... 82 norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg .............................................................. 82 norgestimate-eth estrad tab 0.18-35/0.215-

35/0.25-35 mg-mcg ...................................... 82 norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg .............................................................. 82 norgestrel & ethinyl estradiol tab 0.5 mg-50

mcg .............................................................. 82 NORTHERA CAP100MG ........................... 57 NORTHERA CAP200MG ........................... 57 NORTHERA CAP300MG ........................... 57 nortriptyline hcl cap 10 mg.............................. 27 nortriptyline hcl cap 25 mg.............................. 27 nortriptyline hcl cap 50 mg.............................. 27 nortriptyline hcl cap 75 mg.............................. 27 nortriptyline hcl soln 10 mg/5ml...................... 27 NORVIR CAP100MG ................................ 47 NORVIR POW100MG ............................... 47 NORVIR SOL80MG/ML ........................... 47 NORVIR TAB100MG ............................... 47 NOVOLIN INJ70/30 ................................... 54 NOVOLIN N INJU-100 ................................ 54 NOVOLIN R INJU-100 ................................ 54 NOVOLOG INJ100/ML .............................. 54 NOVOLOG INJFLEXPEN ......................... 54 NOVOLOG INJPENFILL ........................... 54 NOVOLOG MIX INJ70/30 ............................. 54 NOVOLOG MIX INJFLEXPEN .................... 54 NOXAFIL SUS40MG/ML .......................... 29 NOXAFIL TAB100MG .............................. 29 NUEDEXTA CAP20-10MG ........................ 68 NULOJIX INJ250MG ................................. 88 NUPLAZID TAB17MG ............................... 42 NUTROPIN AQ INJ10MG/2ML .................... 80 NUTROPIN AQ INJ20MG/2ML .................... 74 NUTROPIN AQ INJNUSPIN 5 ...................... 80 NUVARING MIS ......................................... 83

127

nystatin cream 100000 unit/gm ........................ 29 nystatin oint 100000 unit/gm ........................... 29 nystatin susp 100000 unit/ml ........................... 29 nystatin tab 500000 unit ................................... 29 nystatin topical powder 100000 unit/gm .......... 29 nystatin-triamcinolone cream 100000-0.1

unit/gm-% ..................................................... 29 nystatin-triamcinolone oint 100000-0.1 unit/gm-

% .................................................................. 29 OCTAGAM INJ1GM .................................. 89 OCTAGAM INJ2GM/20ML ....................... 89 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 84 octreotide acetate inj 1000 mcg/ml (1 mg/ml) . 85 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 85 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 85 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) 85 ODEFSEY TAB........................................... 46 ODOMZO CAP200MG .............................. 37 OFEV CAP100MG ................................... 97 OFEV CAP150MG ................................... 97 ofloxacin ophth soln 0.3% ................................ 20 ofloxacin otic soln 0.3% ................................... 20 ofloxacin tab 300 mg ........................................ 20 ofloxacin tab 400 mg ........................................ 20 olanzapine for im inj 10 mg ............................. 50 olanzapine orally disintegrating tab 10 mg ..... 42 olanzapine orally disintegrating tab 15 mg ..... 42 olanzapine orally disintegrating tab 20 mg ..... 50 olanzapine orally disintegrating tab 5 mg ....... 50 olanzapine tab 10 mg ....................................... 50 olanzapine tab 15 mg ....................................... 50 olanzapine tab 2.5 mg ...................................... 42 olanzapine tab 20 mg ....................................... 50 olanzapine tab 5 mg ......................................... 50 olanzapine tab 7.5 mg ...................................... 42 olanzapine-fluoxetine hcl cap 12-25 mg .......... 24 olanzapine-fluoxetine hcl cap 12-50 mg .......... 24 olanzapine-fluoxetine hcl cap 3-25 mg ............ 24 olanzapine-fluoxetine hcl cap 6-25 mg ............ 24 olanzapine-fluoxetine hcl cap 6-50 mg ............ 24 olmesa medoxtab20mg ..................................... 57 olmesa medoxtab40mg ..................................... 58 olmesa medoxtab5mg ....................................... 58 olopatadine hcl nasal soln 0.6% ...................... 94 olopatadine hcl ophth soln 0.1% (base

equivalent).................................................... 92 olopatadine hcl ophth soln 0.2%...................... 92 OLYSIO CAP150MG ................................. 45

omega-3-acid ethyl esters cap 1 gm ................ 67 omeprazole cap delayed release 10 mg ........... 75 omeprazole cap delayed release 20 mg ........... 75 omeprazole cap delayed release 40 mg ........... 75 OMNITROPE INJ10/1.5ML ......................... 80 OMNITROPE INJ5.8MG .............................. 80 OMNITROPE INJ5/1.5ML ........................... 80 ondansetron hcl inj 4 mg/2ml (2 mg/ml) .......... 28 ondansetron hcl oral soln 4 mg/5ml ................ 28 ondansetron hcl tab 24 mg .............................. 28 ondansetron hcl tab 4 mg ................................ 28 ondansetron hcl tab 8 mg ................................ 28 ondansetron orally disintegrating tab 4 mg .... 28 ondansetron orally disintegrating tab 8 mg .... 28 ONFI SUS2.5MG/ML .............................. 22 ONFI TAB10MG ..................................... 22 ONFI TAB20MG ..................................... 22 ONGLYZA TAB2.5MG.............................. 52 ONGLYZA TAB5MG ................................ 52 OPDIVO INJ100MG/10ML ....................... 38 OPDIVO INJ40MG/4ML ........................... 38 Ophthalmic Agents ........................................ 92 OPHTHALMIC AGENTS ............................ 91 Ophthalmic Agents, Other ............................ 92 Ophthalmic Anti-allergy Agents .................. 92 Ophthalmic Antiglaucoma Agents ............... 92 Ophthalmic Anti-inflammatories ................. 93 Ophthalmic Prostaglandin and Prostamide

Analogs ....................................................... 93 Opioid Analgesics, Long-acting .................... 12 Opioid Analgesics, Short-acting ................... 13 Opioid Dependence Treatments ................... 14 Opioid Reversal Agents ................................. 15 OPSUMIT TAB10MG ................................ 96 ORACEA CAP40MG ................................. 70 ORENCIA INJ125MG/ML ......................... 87 ORENCIA INJ250MG ................................ 87 ORENCIA INJ50/0.4 ................................... 87 ORENCIA INJ87.5/0.7 ................................ 87 ORENCIA CLCKINJ125MG/ML................... 87 ORENITRAM TAB0.125MG ....................... 96 ORENITRAM TAB0.25MG ......................... 96 ORENITRAM TAB1MG .............................. 96 ORENITRAM TAB2.5MG ........................... 96 ORENITRAM TAB5MG .............................. 96 ORKAMBI TAB100-125 ............................ 96 ORKAMBI TAB200-125 ............................ 96 oseltamivir phosphate cap 30 mg (base equiv) 48

128

oseltamivir phosphate cap 45 mg (base equiv) 48 oseltamivir phosphate cap 75 mg (base equiv) 48 oseltamivir sus6mg/ml ..................................... 48 OTEZLA TAB10/20/30 .............................. 88 OTEZLA TAB30MG .................................. 88 Otic Agents ..................................................... 93 OTIC AGENTS .............................................. 93 OTREXUP INJ10MG .................................. 87 OTREXUP INJ12.5/0.4 ............................... 87 OTREXUP INJ15MG .................................. 87 OTREXUP INJ17.5/0.4 ............................... 87 OTREXUP INJ20MG .................................. 87 OTREXUP INJ22.5/0.4 ............................... 87 OTREXUP INJ25MG .................................. 87 oxaliplatin inj100mg ........................................ 34 oxaliplatin iv soln 100 mg/20ml ....................... 34 oxandrolone tab 10 mg .................................... 80 oxandrolone tab 2.5 mg ................................... 80 oxaprozin tab 600 mg ....................................... 12 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .... 23 oxcarbazepine tab 150 mg ............................... 23 oxcarbazepine tab 300 mg ............................... 23 oxcarbazepine tab 600 mg ............................... 23 OXTELLAR XR TAB150MG ........................ 23 OXTELLAR XR TAB300MG ........................ 23 OXTELLAR XR TAB600MG ........................ 23 oxybutynin chloride syrup 5 mg/5ml ................ 76 oxybutynin chloride tab 5 mg ........................... 76 oxybutynin chloride tab sr 24hr 10 mg ............ 76 oxybutynin chloride tab sr 24hr 15 mg ............ 76 oxybutynin chloride tab sr 24hr 5 mg .............. 76 oxycodone hcl cap 5 mg ................................... 14 oxycodone hcl conc 100 mg/5ml (20 mg/ml) ... 14 oxycodone hcl tab 10 mg .................................. 14 oxycodone hcl tab 15 mg .................................. 14 oxycodone hcl tab 20 mg .................................. 14 oxycodone hcl tab 30 mg .................................. 14 oxycodone hcl tab 5 mg .................................... 14 oxycodone w/ acetaminophen tab 10-325 mg .. 12 oxycodone w/ acetaminophen tab 2.5-325 mg . 12 oxycodone w/ acetaminophen tab 5-325 mg .... 12 oxycodone w/ acetaminophen tab 7.5-325 mg . 12 oxycodone-aspirin tab 4.8355-325 mg............. 12 oxycodone-ibuprofen tab 5-400 mg ................. 12 OXYCONTIN TAB10MG CR ...................... 13 OXYCONTIN TAB15MG CR ...................... 13 OXYCONTIN TAB20MG CR ...................... 13 OXYCONTIN TAB30MG CR ...................... 13

OXYCONTIN TAB40MG CR ...................... 13 OXYCONTIN TAB60MG CR ...................... 13 OXYCONTIN TAB80MG CR ...................... 13 OZEMPIC INJ2/1.5ML ................................... 52 paclitaxel iv conc 300 mg/50ml (6 mg/ml)....... 34 paliperidone tab sr 24hr 1.5 mg ...................... 42 paliperidone tab sr 24hr 3 mg ......................... 42 paliperidone tab sr 24hr 6 mg ......................... 42 paliperidone tab sr 24hr 9 mg ......................... 42 PALYNZIQ INJ10/0.5ML .............................. 75 PALYNZIQ INJ2.5/0.5ML ............................. 75 PALYNZIQ INJ20/ML ................................... 75 pamidronate disodium iv soln 3 mg/ml ............ 91 pamidronate disodium iv soln 6 mg/ml ............ 91 pamidronate disodium iv soln 9 mg/ml ............ 91 PANRETIN GEL0.1% ................................. 38 pantoprazole sodium ec tab 20 mg (base equiv)

..................................................................... 75 pantoprazole sodium ec tab 40 mg (base equiv)

..................................................................... 75 Parasympathomimetics ................................. 31 paricalcitol iv soln 5 mcg/ml ........................... 91 paromomycin sulfate cap 250 mg .................... 15 paroxetine hcl tab 10 mg ................................. 49 paroxetine hcl tab 20 mg ................................. 49 paroxetine hcl tab 30 mg ................................. 49 paroxetine hcl tab 40 mg ................................. 49 paroxetine hcl tab sr 24hr 12.5 mg .................. 49 paroxetine hcl tab sr 24hr 25 mg ..................... 49 paroxetine hcl tab sr 24hr 37.5 mg .................. 49 PATADAY SOL0.2% ................................. 92 PAXIL SUS10MG/5ML ............................ 49 PAZEO DRO0.7% ..................................... 92 PEDIARIX INJ0.5ML .................................. 89 Pediculicides/Scabicides ................................ 39 PEDVAX HIB INJ ......................................... 89 peg 3350-kcl-na bicarb-nacl-na sulfate for soln

236 gm ......................................................... 73 peg 3350-kcl-na bicarb-nacl-na sulfate for soln

240 gm ......................................................... 73 peg 3350-kcl-sod bicarb-nacl for soln 420 gm 73 PEGANONE TAB250MG ........................... 23 PEGASYS INJ ............................................. 44 PEGASYS INJ180MCG/M ......................... 44 PEGASYS INJPROCLICK ......................... 44 PENICILL GK/INJDEX 2MU ........................ 19 PENICILL GK/INJDEX 3MU ........................ 19 penicillin g potassium for inj 5000000 unit ..... 19

129

penicillin g procaine intramuscular susp 600000

unit/ml .......................................................... 19 penicillin g sodium for inj 5000000 unit .......... 19 penicillin v potassium for soln 125 mg/5ml ..... 19 penicillin v potassium for soln 250 mg/5ml ..... 19 penicillin v potassium tab 250 mg.................... 19 penicillin v potassium tab 500 mg.................... 19 PENTAM 300 INJ300MG .............................. 39 PENTASA CAP250MG CR ........................ 90 PENTASA CAP500MG CR ........................ 90 pentoxifylline tab cr 400 mg ............................ 65 perindopril erbumine tab 2 mg ........................ 58 perindopril erbumine tab 4 mg ........................ 58 perindopril erbumine tab 8 mg ........................ 58 PERJETA INJ420/14ML ............................. 34 permethrin cream 5% ...................................... 39 perphenazine tab 16 mg ................................... 41 perphenazine tab 2 mg ..................................... 41 perphenazine tab 4 mg ..................................... 41 perphenazine tab 8 mg ..................................... 41 perphenazine-amitriptyline tab 2-10 mg .......... 24 perphenazine-amitriptyline tab 2-25 mg .......... 24 perphenazine-amitriptyline tab 4-10 mg .......... 24 perphenazine-amitriptyline tab 4-25 mg .......... 24 perphenazine-amitriptyline tab 4-50 mg .......... 24 phenelzine sulfate tab 15 mg ............................ 25 PHENOBARB TAB100MG .......................... 22 PHENOBARB TAB15MG ............................ 22 PHENOBARB TAB30MG ............................ 22 PHENOBARB TAB60MG ............................ 22 phenobarbital elixir 20 mg/5ml ....................... 22 phenobarbital tab 16.2 mg ............................... 22 phenobarbital tab 32.4 mg ............................... 22 phenobarbital tab 64.8 mg ............................... 22 phenobarbital tab 97.2 mg ............................... 22 phenoxybenzamine hcl cap 10 mg .................... 57 phenytoin chew tab 50 mg ................................ 23 phenytoin sodium extended cap 100 mg .......... 23 phenytoin sodium extended cap 200 mg .......... 23 phenytoin sodium extended cap 300 mg .......... 23 phenytoin sodium inj 50 mg/ml ........................ 23 phenytoin susp 125 mg/5ml .............................. 23 PHOSLYRA SOL ......................................... 77 Phosphate Binders ......................................... 77 Phosphodiesterase Inhibitors, Airways

Disease ......................................................... 96 PHOSPHOLINE SOL0.125%OP .................... 93 PHYSIOLYTE SOL ....................................... 72

PHYSIOSOL SOLIRRIGAT......................... 72 pilocarpine hcl tab 5 mg .................................. 70 pilocarpine hcl tab 7.5 mg ............................... 70 pimozide tab 1 mg ............................................ 41 pimozide tab 2 mg ............................................ 41 pindolol tab 10 mg ........................................... 60 pindolol tab 5 mg ............................................. 60 pioglitazone hcl tab 15 mg (base equiv) .......... 52 pioglitazone hcl tab 30 mg (base equiv) .......... 52 pioglitazone hcl tab 45 mg (base equiv) .......... 52 pioglitazone hcl-glimepiride tab 30-2 mg ........ 53 pioglitazone hcl-glimepiride tab 30-4 mg ........ 53 pioglitazone hcl-metformin hcl tab 15-500 mg 53 pioglitazone hcl-metformin hcl tab 15-850 mg 53 piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm) ................................................ 19 piperacillin sod-tazobactam sod for inj 4.5 gm

(4-0.5 gm) .................................................... 19 piperacillin sod-tazobactam sod for inj 40.5 gm

(36-4.5 gm) .................................................. 19 piroxicam cap 10 mg ....................................... 30 piroxicam cap 20 mg ....................................... 30 Platelet Modifying Agents ............................. 56 PLEGRIDY INJ ............................................ 69 PLEGRIDY INJPEN .................................... 69 PLEGRIDY INJSTARTER ............................. 69 PLEGRIDY PENINJSTARTER ..................... 69 podofilox soln 0.5% ......................................... 70 polyethylene glycol 3350 oral powder ............. 75 polymyxin b-trimethoprim ophth soln 10000

unit/ml-0.1% ................................................ 92 POMALYST CAP1MG ............................... 32 POMALYST CAP2MG ............................... 32 POMALYST CAP3MG ............................... 32 POMALYST CAP4MG ............................... 32 POT CHL/D5W INJ40MEQ/L ........................ 72 POT CHLORIDETAB20MEQ ER .................. 72 potassium chloride 20 meq/l (0.15%) in d5w

lactated ringers ............................................ 72 potassium chloride 20 meq/l (0.15%) in dextrose

5% inj ........................................................... 72 potassium chloride cap cr 10 meq ................... 72 potassium chloride cap cr 8 meq ..................... 72 potassium chloride inj 10 meq/100ml .............. 72 potassium chloride inj 2 meq/ml ...................... 72 potassium chloride inj 20 meq/100ml .............. 72 potassium chloride inj 40 meq/100ml .............. 72

130

potassium chloride microencapsulated crys cr

tab 10 meq .................................................... 72 potassium chloride microencapsulated crys cr

tab 15 meq .................................................... 72 potassium chloride microencapsulated crys cr

tab 20 meq .................................................... 72 potassium chloride oral soln 10% (20

meq/15ml) .................................................... 72 potassium chloride oral soln 20% (40

meq/15ml) .................................................... 72 potassium chloride tab cr 10 meq .................... 72 potassium chloride tab cr 8 meq (600 mg) ...... 72 potassium citrate tab cr 10 meq (1080 mg) ..... 72 potassium citrate tab cr 15 meq (1620 mg) ..... 72 potassium citrate tab cr 5 meq (540 mg) ......... 72 PRADAXA CAP110MG ............................. 55 PRADAXA CAP150MG ............................. 55 PRADAXA CAP75MG ............................... 55 PRALUENT INJ150MG/ML ....................... 67 PRALUENT INJ75MG/ML ......................... 67 pramipexole dihydrochloride tab 0.125 mg ..... 40 pramipexole dihydrochloride tab 0.25 mg ....... 40 pramipexole dihydrochloride tab 0.5 mg ......... 40 pramipexole dihydrochloride tab 0.75 mg ....... 40 pramipexole dihydrochloride tab 1 mg ............ 40 pramipexole dihydrochloride tab 1.5 mg ......... 40 prasugrel tab10mg ........................................... 57 prasugrel tab5mg ............................................. 57 pravastatin sodium tab 10 mg .......................... 66 pravastatin sodium tab 20 mg .......................... 66 pravastatin sodium tab 40 mg .......................... 66 pravastatin sodium tab 80 mg .......................... 66 prazosin hcl cap 1 mg ...................................... 76 prazosin hcl cap 2 mg ...................................... 76 prazosin hcl cap 5 mg ...................................... 76 PRED MILD SUS0.12% OP ......................... 93 PRED-G SUSOP ......................................... 92 PRED-G S.O.POINOP ..................................... 92 prednicarbate oint 0.1% .................................. 79 prednisolone sod phos orally disintegr tab 10

mg (base eq) ................................................. 79 prednisolone sod phos orally disintegr tab 15

mg (base eq) ................................................. 79 prednisolone sod phos orally disintegr tab 30

mg (base eq) ................................................. 79 prednisolone sod phosph oral soln 6.7 mg/5ml

(5 mg/5ml base)............................................ 90

prednisolone sod phosphate oral soln 10 mg/5ml

(base equiv).................................................. 90 prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv).................................................. 90 prednisolone sod phosphate oral soln 20 mg/5ml

(base equiv).................................................. 90 prednisolone sodium phosphate ophth soln 1%

..................................................................... 93 prednisolone sus1%op ..................................... 93 prednisone conc 5 mg/ml ................................. 79 prednisone oral soln 5 mg/5ml ........................ 90 prednisone tab 1 mg ........................................ 90 prednisone tab 10 mg ...................................... 91 prednisone tab 2.5 mg ..................................... 79 prednisone tab 20 mg ...................................... 79 prednisone tab 5 mg ........................................ 79 prednisone tab 50 mg ...................................... 91 prednisone tab therapy pack 10 mg (21) ......... 79 prednisone tab therapy pack 10 mg (48) ......... 79 prednisone tab therapy pack 5 mg (21) ........... 79 prednisone tab therapy pack 5 mg (48) ........... 79 PREFEST TAB ............................................ 83 PREMARIN INJ25MG ................................ 81 PREMARIN TAB0.3MG ............................. 81 PREMARIN TAB0.45MG ........................... 81 PREMARIN TAB0.625MG ......................... 81 PREMARIN TAB0.9MG ............................. 81 PREMARIN TAB1.25MG ........................... 81 PREMARIN VAGCRE0.625MG .................... 81 PREMPHASE TAB ....................................... 83 PREMPRO TAB.625-2.5 ............................ 83 PREMPRO TAB0.3-1.5 .............................. 83 PREMPRO TAB0.45-1.5 ............................ 83 PREMPRO TAB0.625-5 ............................. 83 PREZCOBIX TAB800-150 ........................... 47 PREZISTA SUS100MG/ML ........................ 47 PREZISTA TAB150MG .............................. 48 PREZISTA TAB600MG .............................. 48 PREZISTA TAB75MG ................................ 48 PREZISTA TAB800MG .............................. 48 PRIFTIN TAB150MG ................................. 31 primaquine phosphate tab 26.3 mg (15 mg base)

..................................................................... 39 primidone tab 250 mg ...................................... 22 primidone tab 50 mg ........................................ 22 PRIVIGEN INJ20GRAMS ........................... 89 PROAIR HFA AER ........................................ 95 PROAIR RESPIAER ....................................... 95

131

probenecid tab 500 mg ..................................... 29 procainamide hcl inj 100 mg/ml ...................... 59 procainamide hcl inj 500 mg/ml ...................... 59 prochlorperazine edisylate inj 5 mg/ml ........... 41 prochlorperazine maleate tab 10 mg (base

equivalent).................................................... 41 prochlorperazine maleate tab 5 mg (base

equivalent).................................................... 41 prochlorperazine suppos 25 mg ....................... 27 PROCRIT INJ10000/ML ............................. 56 PROCRIT INJ2000/ML ............................... 56 PROCRIT INJ20000/ML ............................. 56 PROCRIT INJ3000/ML ............................... 56 PROCRIT INJ4000/ML ............................... 56 PROCRIT INJ40000/ML ............................. 56 progesterone micronized cap 100 mg .............. 83 progesterone micronized cap 200 mg .............. 83 Progestins ........................................................ 83 PROGLYCEM SUS50MG/ML ..................... 53 PROGRAF INJ5MG/ML ............................. 87 PROLASTIN-C INJ1000MG .......................... 75 PROLEUKIN INJ22MU ................................ 34 PROLIA SOL60MG/ML ............................ 91 PROMACTA TAB12.5MG .......................... 56 PROMACTA TAB25MG ............................. 56 PROMACTA TAB50MG ............................. 56 PROMACTA TAB75MG ............................. 56 promethazine hcl syrup 6.25 mg/5ml ............... 94 promethazine hcl tab 12.5 mg .......................... 94 promethazine hcl tab 25 mg ............................. 94 promethazine hcl tab 50 mg ............................. 94 propafenone hcl tab 150 mg ............................ 59 propafenone hcl tab 225 mg ............................ 59 propafenone hcl tab 300 mg ............................ 59 proparacaine hcl ophth soln 0.5% ................... 92 Prophylactic .................................................... 31 propranolol & hydrochlorothiazide tab 40-25

mg ................................................................. 64 propranolol & hydrochlorothiazide tab 80-25

mg ................................................................. 64 propranolol hcl cap sr 24hr 120 mg ................ 60 propranolol hcl cap sr 24hr 160 mg ................ 60 propranolol hcl cap sr 24hr 60 mg .................. 60 propranolol hcl cap sr 24hr 80 mg .................. 60 propranolol hcl inj 1 mg/ml ............................. 60 propranolol hcl oral soln 20 mg/5ml ............... 60 propranolol hcl oral soln 40 mg/5ml ............... 60 propranolol hcl tab 10 mg ............................... 60

propranolol hcl tab 20 mg ............................... 60 propranolol hcl tab 40 mg ............................... 60 propranolol hcl tab 60 mg ............................... 60 propranolol hcl tab 80 mg ............................... 60 propylthiouracil tab 50 mg .............................. 85 PROQUAD INJ ........................................... 89 Protectants ...................................................... 75 Proton Pump Inhibitors ................................ 75 protriptyline hcl tab 10 mg .............................. 27 protriptyline hcl tab 5 mg ................................ 27 PROVENTIL AERHFA ................................ 95 PULMICORT INH180MCG ......................... 94 PULMICORT INH90MCG ........................... 94 Pulmonary Antihypertensives ...................... 96 Pulmonary Fibrosis Agents ........................... 97 PULMOZYME SOL1MG/ML ...................... 98 PURIXAN SUS20MG/ML .......................... 33 pyrazinamide tab 500 mg ................................ 31 pyridostigmine bromide tab 60 mg .................. 31 pyridostigmine bromide tab cr 180 mg ............ 31 QTERN TAB10MG/5MG ............................... 52 QUADRACEL INJ ........................................ 89 QUETIAPINE TAB150MG ER ..................... 50 QUETIAPINE TAB200MG ER ..................... 43 QUETIAPINE TAB300MG ER ..................... 25 QUETIAPINE TAB50MG ER ....................... 25 quetiapine fumarate tab 100 mg ...................... 50 quetiapine fumarate tab 200 mg ...................... 50 quetiapine fumarate tab 25 mg ........................ 43 quetiapine fumarate tab 300 mg ...................... 25 quetiapine fumarate tab 400 mg ...................... 25 quetiapine fumarate tab 50 mg ........................ 43 quetiapine fumarate tab sr 24hr 400 mg ......... 50 quinapril hcl tab 10 mg ................................... 58 quinapril hcl tab 20 mg ................................... 58 quinapril hcl tab 40 mg ................................... 58 quinapril hcl tab 5 mg ..................................... 58 quinapril-hydrochlorothiazide tab 10-12.5 mg 64 quinapril-hydrochlorothiazide tab 20-12.5 mg 64 quinapril-hydrochlorothiazide tab 20-25 mg .. 64 QUINIDINE GLINJ80MG/ML ....................... 59 quinidine gluconate tab cr 324 mg .................. 59 quinidine sulfate tab 200 mg............................ 59 quinidine sulfate tab 300 mg............................ 59 quinine sulfate cap 324 mg .............................. 39 Quinolones ...................................................... 20 QVAR AER40MCG ................................. 94 QVAR AER80MCG ................................. 94

132

QVAR REDIHALAER 40MG ........................ 94 QVAR REDIHALAER 80MG ........................ 94 RABAVERT INJ .......................................... 89 raloxifene hcl tab 60 mg .................................. 83 ramipril cap 1.25 mg ........................................ 58 ramipril cap 10 mg ........................................... 58 ramipril cap 2.5 mg .......................................... 58 ramipril cap 5 mg............................................. 58 RANEXA TAB1000MG ............................ 65 RANEXA TAB500MG .............................. 65 ranitidine hcl cap 150 mg ................................ 74 ranitidine hcl cap 300 mg ................................ 74 ranitidine hcl inj 50 mg/2ml (25 mg/ml) .......... 74 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ..... 74 ranitidine hcl tab 150 mg ................................. 74 ranitidine hcl tab 300 mg ................................. 74 RAPAMUNE SOL1MG/ML ........................ 87 rasagiline mesylate tab 0.5 mg (base equiv) .... 40 rasagiline mesylate tab 1 mg (base equiv) ....... 40 RASUVO INJ20MG ................................... 87 RAVICTI LIQ1.1GM/ML ........................... 76 REBETOL SOL40MG/ML ......................... 44 REBIF INJ22/0.5 ....................................... 69 REBIF INJ44/0.5 ....................................... 69 REBIF TITRTNINJPACK ............................... 69 RECOMBIVA HBINJ10MCG/ML ................. 89 RECOMBIVA HBINJ5MCG/0.5 .................... 89 RECOMBIVA-HBINJ40MCG/ML ................. 89 RELENZA MISDISKHALE ....................... 48 RELISTOR INJ12/0.6ML ............................. 74 RELISTOR INJ8/0.4ML ............................... 74 RELISTOR TAB150MG .............................. 74 REMICADE INJ100MG .............................. 87 REMODULIN INJ1MG/ML ......................... 97 REMODULIN INJ2.5MG/ML ...................... 97 REMODULIN INJ5MG/ML ......................... 97 RENAGEL TAB400MG ............................. 77 RENAGEL TAB800MG ............................. 77 RENVELA PAK0.8GM .............................. 77 RENVELA PAK2.4GM .............................. 77 RENVELA TAB800MG ............................. 77 REPATHA INJ140MG/ML ......................... 67 REPATHA PUSHINJ420/3.5 .......................... 67 REPATHA SUREINJ140MG/ML ................... 67 RESCRIPTOR TAB100 MG .......................... 46 RESCRIPTOR TAB200MG ........................... 46 Respiratory Tract Agents, Other .................. 97 Respiratory Tract/Pulmonary Agents .......... 98

RESPIRATORY TRACT/PULMONARY

AGENTS ..................................................... 94 RESTASIS EMU0.05% ................................ 92 Retinoids ......................................................... 38 RETROVIR INJ10MG/ML .......................... 46 REVLIMID CAP10MG ............................... 32 REVLIMID CAP15MG ............................... 32 REVLIMID CAP2.5MG............................... 32 REVLIMID CAP20MG ............................... 32 REVLIMID CAP25MG ............................... 32 REVLIMID CAP5MG ................................. 32 REXULTI TAB0.25MG .............................. 43 REXULTI TAB0.5MG ................................ 43 REXULTI TAB1MG ................................... 43 REXULTI TAB2MG ................................... 43 REXULTI TAB3MG ................................... 43 REXULTI TAB4MG ................................... 43 REYATAZ CAP150MG ............................. 48 REYATAZ CAP200MG ............................. 48 REYATAZ CAP300MG ............................. 48 REYATAZ POW50MG .............................. 48 ribavirin cap 200 mg ................................. 44, 45 ribavirin tab 200 mg ........................................ 45 ribavirin tab 200 mg & ribavirin tab 400 mg

dose pack ..................................................... 45 ribavirin tab 400 mg ........................................ 45 ribavirin tab 400 mg & ribavirin tab 600 mg

dose pack ..................................................... 45 ribavirin tab 600 mg ........................................ 45 RIDAURA CAP3MG .................................. 88 rifabutin cap 150 mg ........................................ 31 RIFAMATE CAP ......................................... 31 rifampin cap 150 mg ........................................ 31 rifampin cap 300 mg ........................................ 31 rifampin for inj 600 mg .................................... 31 RIFATER TAB ............................................ 32 riluzole tab 50 mg ............................................ 69 rimantadine hydrochloride tab 100 mg ........... 48 risedronate sodium tab 150 mg ....................... 91 risedronate sodium tab 30 mg ......................... 91 risedronate sodium tab 35 mg ......................... 91 risedronate sodium tab 5 mg ........................... 91 RISPERDAL INJ12.5MG ............................. 50 RISPERDAL INJ25MG ................................ 50 RISPERDAL INJ37.5MG ............................. 50 RISPERDAL INJ50MG ................................ 50 risperidone orally disintegrating tab 0.25 mg . 50 risperidone orally disintegrating tab 0.5 mg ... 50

133

risperidone orally disintegrating tab 1 mg ...... 50 risperidone orally disintegrating tab 2 mg ...... 43 risperidone orally disintegrating tab 3 mg ...... 43 risperidone orally disintegrating tab 4 mg ...... 43 risperidone soln 1 mg/ml ................................. 43 risperidone tab 0.25 mg ................................... 50 risperidone tab 0.5 mg ..................................... 43 risperidone tab 1 mg ........................................ 43 risperidone tab 2 mg ........................................ 43 risperidone tab 3 mg ........................................ 51 risperidone tab 4 mg ........................................ 43 ritonavir tab100mg .......................................... 48 RITUXAN INJ100MG ................................ 38 RITUXAN INJ500MG ................................ 38 rivastigmine tartrate cap 1.5 mg ...................... 24 rivastigmine tartrate cap 3 mg ......................... 24 rivastigmine tartrate cap 4.5 mg ...................... 24 rivastigmine tartrate cap 6 mg ......................... 24 rivastigmine td patch 24hr 13.3 mg/24hr ......... 24 rivastigmine td patch 24hr 4.6 mg/24hr ........... 24 rivastigmine td patch 24hr 9.5 mg/24hr ........... 24 ropinirole hydrochloride tab 0.25 mg .............. 40 ropinirole hydrochloride tab 0.5 mg ................ 40 ropinirole hydrochloride tab 1 mg ................... 40 ropinirole hydrochloride tab 2 mg ................... 40 ropinirole hydrochloride tab 3 mg ................... 40 ropinirole hydrochloride tab 4 mg ................... 40 ropinirole hydrochloride tab 5 mg ................... 40 ropinirole hydrochloride tab sr 24hr 12 mg

(base equivalent) .......................................... 40 ropinirole hydrochloride tab sr 24hr 2 mg (base

equivalent).................................................... 40 ropinirole hydrochloride tab sr 24hr 4 mg (base



equivalent).................................................... 40 rosuvastatin calcium tab 10 mg ....................... 66 rosuvastatin calcium tab 20 mg ....................... 66 rosuvastatin calcium tab 40 mg ....................... 66 rosuvastatin calcium tab 5 mg ......................... 66 ROTARIX SUS ........................................... 89 ROTATEQ SOL .......................................... 89 ROZEREM TAB8MG ................................. 98 RUBRACA TAB200MG ............................. 35 RUBRACA TAB250MG ............................. 35 RUBRACA TAB300MG ............................. 35

RYDAPT CAP25MG ................................. 37 SABRIL POW500MG ................................ 22 SABRIL TAB500MG ................................. 22 SAIZEN INJ5MG ....................................... 80 SAIZEN INJ8.8MG .................................... 80 SANDIMMUNE SOL100MG/ML ................. 87 SANDOSTATIN KITLAR 10MG .................. 85 SANDOSTATIN KITLAR 20MG .................. 85 SANDOSTATIN KITLAR 30MG .................. 85 SANTYL OIN250/GM ............................... 70 SAPHRIS SUB10MG .................................. 51 SAPHRIS SUB2.5MG ................................. 43 SAPHRIS SUB5MG .................................... 51 scopolamine dis1mg/3day ................................ 73 Selective Estrogen Receptor Modifying

Agents ......................................................... 83 selegiline hcl cap 5 mg .................................... 40 selegiline hcl tab 5 mg ..................................... 40 selenium sulfide lotion 2.5% ............................ 70 SELZENTRY TAB150MG ........................... 47 SELZENTRY TAB25MG ............................. 47 SELZENTRY TAB300MG ........................... 47 SELZENTRY TAB75MG ............................. 47 SENSIPAR TAB30MG ................................ 77 SENSIPAR TAB60MG ................................ 77 SENSIPAR TAB90MG ................................ 77 SEREVENT DISAER50MCG ........................ 95 SEROQUEL XR TAB150MG ........................ 51 SEROQUEL XR TAB200MG ........................ 43 SEROQUEL XR TAB300MG ........................ 25 SEROQUEL XR TAB50MG .......................... 25 SEROSTIM INJ4MG ................................... 74 SEROSTIM INJ5MG ................................... 74 SEROSTIM INJ6MG ................................... 74 Serotonin (5-HT) 1b/1d Receptor Agonists . 31 sertraline hcl oral conc 20 mg/ml .................... 49 sertraline hcl tab 100 mg ................................. 49 sertraline hcl tab 25 mg ................................... 49 sertraline hcl tab 50 mg ................................... 50 sevelamer carbonate packet 0.8 gm ................. 77 sevelamer carbonate packet 2.4 gm ................. 77 sevelamer tab800mg ........................................ 77 SHINGRIX INJ50MCG .................................. 89 SIGNIFOR INJ0.3MG/ML........................... 85 SIGNIFOR INJ0.6MG/ML........................... 85 SIGNIFOR INJ0.9MG/ML........................... 85 sildenafil citrate tab 20 mg .............................. 97 silver sulfadiazine cream 1% ........................... 20

134

SIMPONI INJ100MG/ML ........................... 87 SIMPONI INJ50/0.5ML .............................. 87 SIMPONI ARIASOL50MG/4ML ................... 87 SIMULECT INJ20MG ................................. 87 simvastatin tab 10 mg ...................................... 66 simvastatin tab 20 mg ...................................... 66 simvastatin tab 40 mg ...................................... 66 simvastatin tab 5 mg ........................................ 66 simvastatin tab 80 mg ...................................... 66 sirolimus tab 0.5 mg ......................................... 87 sirolimus tab 1 mg ............................................ 87 sirolimus tab 2 mg ............................................ 87 SIRTURO TAB100MG ............................... 32 Skeletal Muscle Relaxants ............................. 98 SKELETAL MUSCLE RELAXANTS ........ 98 SLEEP DISORDER AGENTS ..................... 98 Sleep Disorders, Other ................................... 98 Smoking Cessation Agents ............................ 15 Sodium Channel Agents ................................ 23 sodium chloride inj 0.45% ............................... 73 sodium chloride inj 2.5 meq/ml (14.6%) .......... 73 sodium chloride inj 3% .................................... 73 sodium chloride inj 5% .................................... 73 sodium chloride irrigation soln 0.9% .............. 73 sodium chloride iv soln 0.9% ........................... 73 sodium polystyrene sulfonate oral susp 15

gm/60ml ....................................................... 71 SOLTAMOX SOL10MG/5ML .................... 33 SOMATULINE INJ120/.5ML ........................ 85 SOMATULINE INJ60/0.2ML ........................ 85 SOMATULINE INJ90/0.3ML ........................ 85 SOMAVERT INJ10MG ............................... 85 SOMAVERT INJ15MG ............................... 85 SOMAVERT INJ20MG ............................... 85 SOMAVERT INJ25MG ............................... 85 SOMAVERT INJ30MG ............................... 85 sotalol hcl (afib/afl) tab 120 mg ....................... 59 sotalol hcl tab 120 mg ...................................... 59 sotalol hcl tab 160 mg ...................................... 59 sotalol hcl tab 240 mg ...................................... 59 sotalol hcl tab 80 mg ........................................ 59 SOVALDI TAB400MG ............................... 45 SPIRIVA AER1.25MCG ............................. 95 SPIRIVA CAPHANDIHLR ........................ 95 SPIRIVA SPR2.5MCG ................................ 95 spironolactone & hydrochlorothiazide tab 25-25

mg ................................................................. 64 spironolactone tab 100 mg ............................... 65

spironolactone tab 25 mg ................................ 65 spironolactone tab 50 mg ................................ 65 SPRITAM TAB1000MG............................. 21 SPRITAM TAB250MG .............................. 21 SPRITAM TAB500MG .............................. 21 SPRITAM TAB750MG .............................. 21 SPRYCEL TAB100MG .............................. 37 SPRYCEL TAB140MG .............................. 37 SPRYCEL TAB20MG ................................ 37 SPRYCEL TAB50MG ................................ 37 SPRYCEL TAB70MG ................................ 37 SPRYCEL TAB80MG ................................ 37 SSRIs/SNRIs (Selective Serotonin Reuptake

Inhibitors/Serotonin Norepinephrine

Reuptake Inhibitors) ........................... 25, 49 stavudine cap 15 mg ........................................ 46 stavudine cap 20 mg ........................................ 46 stavudine cap 30 mg ........................................ 46 stavudine cap 40 mg ........................................ 46 STIMATE SOL1.5MG/ML ......................... 80 STIOLTO AER2.5-2.5 ................................ 98 STIVARGA TAB40MG ............................... 37 STRATTERA CAP100MG ........................... 68 STRATTERA CAP10MG ............................. 68 STRATTERA CAP18MG ............................. 68 STRATTERA CAP25MG ............................. 68 STRATTERA CAP40MG ............................. 68 STRATTERA CAP60MG ............................. 68 STRATTERA CAP80MG ............................. 68 streptomycin sulfate for inj 1 gm ..................... 15 STRIBILD TAB ........................................... 45 SUBOXONE MIS12-3MG ........................... 14 SUBOXONE MIS2-0.5MG .......................... 14 SUBOXONE MIS4-1MG ............................. 14 SUBOXONE MIS8-2MG ............................. 15 sucralfate tab 1 gm .......................................... 75 SULFACET SODOIN10% OP........................ 20 sulfacetamide sodium lotion 10% (acne) ......... 20 sulfacetamide sodium ophth soln 10% ............ 20 sulfacetamide sodium-prednisolone ophth oint

10-0.2%........................................................ 92 sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)% ............................................ 92 sulfadiazine tab 500 mg ................................... 20 sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml ......................................................... 20 sulfamethoxazole-trimethoprim susp 200-40

mg/5ml ......................................................... 20

135

sulfamethoxazole-trimethoprim tab 400-80 mg

..................................................................... 20 sulfamethoxazole-trimethoprim tab 800-160 mg

..................................................................... 20 SULFAMYLON CRE85MG/GM................... 16 sulfasalazine tab 500 mg .................................. 91 sulfasalazine tab delayed release 500 mg ........ 91 Sulfonamides ............................................ 20, 91 sulindac tab 150 mg ......................................... 30 sulindac tab 200 mg ......................................... 30 sumatriptan succinate inj 6 mg/0.5ml .............. 31 sumatriptan succinate tab 100 mg ................... 31 sumatriptan succinate tab 25 mg ..................... 31 sumatriptan succinate tab 50 mg ..................... 31 SUPRAX CAP400MG ................................ 17 SUSTIVA CAP200MG ............................... 46 SUSTIVA CAP50MG ................................. 46 SUSTIVA TAB600MG ............................... 46 SUTENT CAP12.5MG ............................... 37 SUTENT CAP25MG .................................. 37 SUTENT CAP37.5MG ............................... 37 SUTENT CAP50MG .................................. 37 SYLATRON KIT200MCG .......................... 45 SYLATRON KIT300MCG .......................... 45 SYLATRON KIT600MCG .......................... 45 SYMBICORT AER160-4.5 ........................... 98 SYMBICORT AER80-4.5 ............................. 98 SYMFI LO TAB .............................................. 47 SYMFI TAB .................................................... 47 SYMLINPEN 60INJ1000MCG ....................... 53 SYMLNPEN 120INJ1000MCG ...................... 53 SYMPROIC TAB0.2MG ................................. 74 SYNAGIS INJ50MG ................................... 88 SYNAREL SOL2MG/ML ........................... 85 SYNDROS SOL5MG/ML ............................... 28 SYNERCID INJ500MG ............................... 15 SYNRIBO INJ3.5MG .................................. 34 SYNTHROID TAB100MCG ........................ 84 SYNTHROID TAB112MCG ........................ 84 SYNTHROID TAB125MCG ........................ 84 SYNTHROID TAB137MCG ........................ 84 SYNTHROID TAB150MCG ........................ 84 SYNTHROID TAB175MCG ........................ 84 SYNTHROID TAB200MCG ........................ 84 SYNTHROID TAB25MCG .......................... 84 SYNTHROID TAB300MCG ........................ 84 SYNTHROID TAB50MCG .......................... 84 SYNTHROID TAB75MCG .......................... 84

SYNTHROID TAB88MCG .......................... 84 SYPRINE CAP250MG ............................... 71 TABLOID TAB40MG ................................ 33 tacrolimus cap 0.5 mg ..................................... 87 tacrolimus cap 1 mg ........................................ 87 tacrolimus cap 5 mg ........................................ 87 tacrolimus oint 0.03% ...................................... 70 tacrolimus oint 0.1% ........................................ 70 TAFINLAR CAP50MG ............................... 37 TAFINLAR CAP75MG ............................... 37 TAGRISSO TAB40MG ............................... 37 TAGRISSO TAB80MG ............................... 37 tamoxifen citrate tab 10 mg (base equivalent). 33 tamoxifen citrate tab 20 mg (base equivalent). 33 tamsulosin hcl cap 0.4 mg ............................... 76 TARCEVA TAB100MG ............................. 37 TARCEVA TAB150MG ............................. 37 TARCEVA TAB25MG ............................... 37 TARGRETIN GEL1% .................................. 38 TASIGNA CAP150MG............................... 38 TASIGNA CAP200MG............................... 38 TASIGNA CAP50MG ................................ 38 tazarotene cre0.1% .......................................... 71 TAZORAC CRE0.05% ............................... 71 TECENTRIQ INJ1200/20 ............................. 38 TECFIDERA CAP120MG ............................ 69 TECFIDERA CAP240MG ............................ 69 TECFIDERA MISSTARTER ....................... 69 TECHNIVIE TAB ......................................... 45 TEFLARO INJ400MG ................................ 17 TEFLARO INJ600MG ................................ 17 TEKTURNA TAB150MG ........................... 65 TEKTURNA TAB300MG ........................... 65 TEKTURNA HCTTAB150-12.5 .................... 64 TEKTURNA HCTTAB150-25MG ................. 64 TEKTURNA HCTTAB300-12.5 .................... 64 TEKTURNA HCTTAB300-25MG ................. 64 telmisartan tab 20 mg ...................................... 58 telmisartan tab 40 mg ...................................... 58 telmisartan tab 80 mg ...................................... 58 telmisartan-amlodipine tab 40-10 mg ............. 64 telmisartan-amlodipine tab 40-5 mg ............... 64 telmisartan-amlodipine tab 80-10 mg ............. 64 telmisartan-amlodipine tab 80-5 mg ............... 64 telmisartan-hydrochlorothiazide tab 40-12.5 mg

..................................................................... 64 telmisartan-hydrochlorothiazide tab 80-12.5 mg

..................................................................... 64

136

telmisartan-hydrochlorothiazide tab 80-25 mg64 temazepam cap 15 mg ...................................... 98 temazepam cap 30 mg ...................................... 98 TENIVAC INJ5-2LF ................................... 89 terazosin hcl cap 1 mg ..................................... 76 terazosin hcl cap 10 mg ................................... 76 terazosin hcl cap 2 mg ..................................... 76 terazosin hcl cap 5 mg ..................................... 57 terbinafine hcl tab 250 mg ............................... 29 terbutaline sulfate inj 1 mg/ml ......................... 95 terbutaline sulfate tab 2.5 mg .......................... 95 terbutaline sulfate tab 5 mg ............................. 95 terconazole vaginal cream 0.4% ...................... 29 terconazole vaginal cream 0.8% ...................... 29 terconazole vaginal suppos 80 mg ................... 29 testosterone cypionate im inj in oil 100 mg/ml 81 testosterone cypionate im inj in oil 200 mg/ml 81 testosterone enanthate im inj in oil 200 mg/ml 81 testosterone td gel 12.5 mg/act (1%) ............... 81 testosterone td gel 25 mg/2.5gm (1%) ............. 81 testosterone td gel 50 mg/5gm (1%) ................ 81 testosteronesol30mg/act ................................... 81 TET/DIP TOX INJ2-2 LF ................................ 89 tetrabenazine tab 12.5 mg ................................ 69 tetrabenazine tab 25 mg ................................... 69 Tetracyclines ................................................... 20 THALOMID CAP100MG ............................ 32 THALOMID CAP150MG ............................ 33 THALOMID CAP200MG ............................ 33 THALOMID CAP50MG .............................. 33 theophylline tab sr 12hr 100 mg ...................... 96 theophylline tab sr 12hr 200 mg ...................... 96 theophylline tab sr 12hr 300 mg ...................... 96 theophylline tab sr 24hr 400 mg ...................... 96 theophylline tab sr 24hr 600 mg ...................... 96 thioridazine hcl tab 10 mg ............................... 41 thioridazine hcl tab 100 mg ............................. 41 thioridazine hcl tab 25 mg ............................... 41 thioridazine hcl tab 50 mg ............................... 41 thiotepa for inj 15 mg ....................................... 34 thiothixene cap 1 mg ........................................ 41 thiothixene cap 10 mg ...................................... 41 thiothixene cap 2 mg ........................................ 41 thiothixene cap 5 mg ........................................ 41 THYMOGLOBULNINJ25MG ........................ 88 tiagabine hcl tab 12 mg .................................... 22 tiagabine hcl tab 16 mg .................................... 22 tiagabine hcl tab 2 mg ...................................... 22

tiagabine hcl tab 4 mg ..................................... 22 TIGECYCLINE INJ50MG .............................. 16 timolol maleate ophth gel forming soln 0.25% 93 timolol maleate ophth gel forming soln 0.5% .. 93 timolol maleate ophth soln 0.25% ................... 93 timolol maleate ophth soln 0.5% ..................... 93 timolol maleate tab 10 mg ............................... 31 timolol maleate tab 20 mg ............................... 60 timolol maleate tab 5 mg ................................. 31 TIVICAY TAB10MG ................................. 45 TIVICAY TAB25MG ................................. 45 TIVICAY TAB50MG ................................. 45 tizanidine hcl cap 2 mg (base equivalent) ....... 44 tizanidine hcl cap 4 mg (base equivalent) ....... 44 tizanidine hcl cap 6 mg (base equivalent) ....... 44 tizanidine hcl tab 2 mg (base equivalent) ........ 44 tizanidine hcl tab 4 mg (base equivalent) ........ 44 TOBI PODHALRCAP28MG .......................... 96 TOBRADEX OIN0.3-0.1% .......................... 15 tobramycin nebu soln 300 mg/5ml ................... 96 tobramycin ophth soln 0.3% ............................ 15 tobramycin sulfate inj 10 mg/ml (base

equivalent) ................................................... 15 tobramycin sulfate inj 80 mg/2ml (40 mg/ml)

(base equiv).................................................. 15 tobramycin-dexamethasone ophth susp 0.3-0.1%

..................................................................... 92 TOLAK CRE4% ........................................ 71 tolazamide tab 250 mg ..................................... 53 tolazamide tab 500 mg ..................................... 53 tolbutamide tab 500 mg ................................... 53 tolcapone tab 100 mg ...................................... 39 tolterodine tartrate cap sr 24hr 2 mg .............. 76 tolterodine tartrate cap sr 24hr 4 mg .............. 76 tolterodine tartrate tab 1 mg............................ 76 tolterodine tartrate tab 2 mg............................ 76 topiramate sprinkle cap 15 mg ........................ 31 topiramate sprinkle cap 25 mg ........................ 23 topiramate tab 100 mg ..................................... 31 topiramate tab 200 mg ..................................... 31 topiramate tab 25 mg ....................................... 31 topiramate tab 50 mg ....................................... 31 topotecan hcl for inj 4 mg ................................ 35 TORISEL SOL25MG/ML ........................... 87 torsemide tab 10 mg ........................................ 65 torsemide tab 100 mg ...................................... 65 torsemide tab 20 mg ........................................ 65 torsemide tab 5 mg .......................................... 65

137

TOUJEO SOLO INJ300IU/ML ....................... 54 TOVIAZ TAB4MG .................................... 76 TOVIAZ TAB8MG .................................... 76 TPN ELECTROLINJ ....................................... 73 tramadol hcl tab 50 mg .................................... 14 tramadol-acetaminophen tab 37.5-325 mg ...... 12 trandolapril tab 1 mg ....................................... 59 trandolapril tab 2 mg ....................................... 59 trandolapril tab 4 mg ....................................... 59 tranexamic acid iv soln 1000 mg/10ml (100

mg/ml) .......................................................... 56 tranexamic acid tab 650 mg ............................. 56 TRANSDERM-SCDIS1MG ............................ 73 tranylcypromine sulfate tab 10 mg................... 25 TRAVASOL INJ10% ................................... 73 TRAVATAN Z DRO0.004% ......................... 93 trazodone hcl tab 100 mg ................................. 26 trazodone hcl tab 150 mg ................................. 26 trazodone hcl tab 300 mg ................................. 26 trazodone hcl tab 50 mg ................................... 26 TREANDA INJ100MG ............................... 32 TREANDA INJ25MG ................................. 32 Treatment Adjuncts ....................................... 38 Treatment-Resistant ...................................... 43 TRECATOR TAB250MG ............................ 32 TRELEGY AERELLIPTA .............................. 98 TRELSTAR MIXINJ11.25MG ....................... 85 TRELSTAR MIXINJ22.5MG ......................... 85 TRELSTAR MIXINJ3.75MG ......................... 85 tretinoin cap 10 mg .......................................... 38 tretinoin cream 0.025% ................................... 71 tretinoin cream 0.05% ..................................... 71 tretinoin cream 0.1% ....................................... 71 tretinoin gel 0.01% ........................................... 71 tretinoin gel 0.025% ......................................... 71 triamcinolone acetonide cream 0.025% .......... 79 triamcinolone acetonide cream 0.1% .............. 79 triamcinolone acetonide cream 0.5% .............. 79 triamcinolone acetonide dental paste 0.1% ..... 70 triamcinolone acetonide lotion 0.025% ........... 79 triamcinolone acetonide lotion 0.1% ............... 79 triamcinolone acetonide oint 0.025% .............. 79 triamcinolone acetonide oint 0.1% .................. 79 triamcinolone acetonide oint 0.5% .................. 79 triamterene & hydrochlorothiazide cap 37.5-25

mg ................................................................. 64 triamterene & hydrochlorothiazide tab 37.5-25

mg ................................................................. 64

triamterene & hydrochlorothiazide tab 75-50

mg ................................................................ 64 Tricyclics......................................................... 26 trifluoperazine hcl tab 1 mg ............................. 41 trifluoperazine hcl tab 10 mg ........................... 42 trifluoperazine hcl tab 2 mg ............................. 42 trifluoperazine hcl tab 5 mg ............................. 42 trifluridine ophth soln 1% ................................ 45 trihexyphenidyl hcl elixir 0.4 mg/ml ................ 39 trihexyphenidyl hcl tab 2 mg............................ 39 trihexyphenidyl hcl tab 5 mg............................ 39 trimethoprim tab 100 mg ................................. 16 trimipramine maleate cap 100 mg ................... 27 trimipramine maleate cap 25 mg ..................... 27 trimipramine maleate cap 50 mg ..................... 27 TRINTELLIX TAB10MG.............................. 26 TRINTELLIX TAB20MG.............................. 26 TRINTELLIX TAB5MG................................ 26 TRISENOX SOL10MG/10M ....................... 34 TRISENOX SOL12MG/6ML ...................... 34 TRIUMEQ TAB .......................................... 48 TROPHAMINE INJ10% ................................ 73 TRULICITY INJ0.75/0.5 .............................. 53 TRULICITY INJ1.5/0.5 ................................ 53 TRUMENBA INJ ......................................... 89 TRUVADA TAB100-150 ........................... 47 TRUVADA TAB133-200 ........................... 47 TRUVADA TAB167-250 ........................... 47 TRUVADA TAB200-300 ........................... 47 TUDORZA PRESAER400/ACT..................... 95 TWINRIX INJ ............................................. 89 TYBOST TAB150MG ............................... 47 TYGACIL INJ50MG .................................. 16 TYKERB TAB250MG ............................... 38 TYPHIM VI INJ ............................................ 89 TYSABRI INJ300/15ML ............................ 69 UPTRAVI TAB1000MCG .......................... 97 UPTRAVI TAB1200MCG .......................... 97 UPTRAVI TAB1400MCG .......................... 97 UPTRAVI TAB1600MCG .......................... 97 UPTRAVI TAB200/800 .............................. 97 UPTRAVI TAB200MCG ............................ 97 UPTRAVI TAB400MCG ............................ 97 UPTRAVI TAB600MCG ............................ 97 UPTRAVI TAB800MCG ............................ 97 ursodiol cap 300 mg ........................................ 74 ursodiol tab 250 mg ......................................... 74 ursodiol tab 500 mg ......................................... 74

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Vaccines .......................................................... 88 valacyclovir hcl tab 1 gm ................................. 45 valacyclovir hcl tab 500 mg ............................. 45 VALCHLOR GEL0.016% ............................ 32 valganciclovir hcl for soln 50 mg/ml (base

equiv) ........................................................... 44 valganciclovir hcl tab 450 mg (base equivalent)

..................................................................... 44 valproate sodium inj 100 mg/ml....................... 22 valproate sodium oral soln 250 mg/5ml (base

equiv) ........................................................... 51 valproic acid cap 250 mg ................................. 51 valsartan tab 160 mg ....................................... 58 valsartan tab 320 mg ....................................... 58 valsartan tab 40 mg ......................................... 58 valsartan tab 80 mg ......................................... 58 valsartan-hydrochlorothiazide tab 160-12.5 mg

..................................................................... 64 valsartan-hydrochlorothiazide tab 160-25 mg 64 valsartan-hydrochlorothiazide tab 320-12.5 mg

..................................................................... 64 valsartan-hydrochlorothiazide tab 320-25 mg 64 valsartan-hydrochlorothiazide tab 80-12.5 mg 64 vancomycin hcl cap 125 mg ............................. 16 vancomycin hcl cap 250 mg ............................. 16 vancomycin hcl for inj 10 gm ........................... 16 vancomycin hcl for inj 1000 mg ....................... 16 vancomycin hcl for inj 500 mg ......................... 16 VAQTA INJ25/0.5ML ............................... 89 VAQTA INJ50UNT/ML ........................... 89 VARIVAX INJ ............................................ 89 Vasodilators, Direct-acting Arterial ............. 67 Vasodilators, Direct-acting Arterial/Venous

..................................................................... 67 VECTIBIX INJ100MG ................................. 34 VECTICAL OIN3MCG/GM ........................ 71 VELCADE INJ3.5MG ................................. 35 VENCLEXTA TAB100MG .......................... 38 VENCLEXTA TAB10MG ............................ 38 VENCLEXTA TAB50MG ............................ 38 VENCLEXTA TABSTART PK .................... 38 venlafaxine hcl cap sr 24hr 150 mg (base

equivalent).................................................... 26 venlafaxine hcl cap sr 24hr 37.5 mg (base

equivalent).................................................... 50 venlafaxine hcl cap sr 24hr 75 mg (base

equivalent).................................................... 26 venlafaxine hcl tab 100 mg .............................. 26

venlafaxine hcl tab 25 mg ................................ 50 venlafaxine hcl tab 37.5 mg ............................. 50 venlafaxine hcl tab 50 mg ................................ 50 venlafaxine hcl tab 75 mg ................................ 26 venlafaxine hcl tab sr 24hr 150 mg (base

equivalent) ................................................... 50 venlafaxine hcl tab sr 24hr 225 mg (base

equivalent) ................................................... 50 venlafaxine hcl tab sr 24hr 37.5 mg (base

equivalent) ................................................... 50 venlafaxine hcl tab sr 24hr 75 mg (base

equivalent) ................................................... 26 VENTOLIN HFAAER .................................... 96 verapamil hcl cap sr 24hr 100 mg ................... 61 verapamil hcl cap sr 24hr 120 mg ................... 62 verapamil hcl cap sr 24hr 180 mg ................... 62 verapamil hcl cap sr 24hr 200 mg ................... 62 verapamil hcl cap sr 24hr 240 mg ................... 62 verapamil hcl cap sr 24hr 300 mg ................... 62 verapamil hcl iv soln 2.5 mg/ml ....................... 62 verapamil hcl tab 120 mg ................................ 62 verapamil hcl tab 40 mg .................................. 62 verapamil hcl tab 80 mg .................................. 62 verapamil hcl tab cr 180 mg ............................ 62 verapamil hcl tab cr 240 mg ............................ 62 VERSACLOZ SUS50MG/ML ...................... 43 VERZENIO TAB100MG ................................ 34 VERZENIO TAB150MG ................................ 34 VERZENIO TAB200MG ................................ 34 VERZENIO TAB50MG .................................. 34 VIBERZI TAB100MG ................................ 74 VIBERZI TAB75MG .................................. 74 VICTOZA INJ18MG/3ML ......................... 53 VIDEX SOL2GM ...................................... 47 VIDEX EC CAP125MG ................................. 47 VIEKIRA PAK TAB ....................................... 45 VIEKIRA XR TAB ........................................ 45 vigabatrin pak500mg ....................................... 22 VIGAMOX DRO0.5% ................................ 20 VIIBRYD KITSTARTER ........................... 26 VIIBRYD TAB10MG ................................. 26 VIIBRYD TAB20MG ................................. 26 VIIBRYD TAB40MG ................................. 26 VIMPAT INJ200MG/20 ............................. 23 VIMPAT SOL10MG/ML ........................... 23 VIMPAT TAB100MG ............................... 23 VIMPAT TAB150MG ............................... 23 VIMPAT TAB200MG ............................... 23

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VIMPAT TAB50MG .................................. 23 vinblastine sulfate inj 1 mg/ml ......................... 34 vincristine sulfate iv soln 1 mg/ml.................... 34 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml)

(base equiv) .................................................. 34 VIRACEPT TAB250MG .............................. 48 VIRACEPT TAB625MG .............................. 48 VIRAMUNE SUS50MG/5ML ..................... 46 VIREAD POW40MG/GM .......................... 44 VIREAD TAB150MG ................................ 44 VIREAD TAB200MG ................................ 44 VIREAD TAB250MG ................................ 44 VIREAD TAB300MG ................................ 44 VIVITROL INJ380MG ................................ 15 voriconazole for inj 200 mg ............................. 29 voriconazole for susp 40 mg/ml ....................... 29 voriconazole tab 200 mg .................................. 29 voriconazole tab 50 mg .................................... 29 VOTRIENT TAB200MG ............................. 38 VPRIV INJ400UNIT ................................. 76 VRAYLAR CAP1.5-3MG ........................... 43 VRAYLAR CAP1.5MG .............................. 43 VRAYLAR CAP3MG ................................. 43 VRAYLAR CAP4.5MG .............................. 43 VRAYLAR CAP6MG ................................. 43 VYXEOS INJ44-100MG ................................. 34 warfarin sodium tab 1 mg ................................ 55 warfarin sodium tab 10 mg .............................. 55 warfarin sodium tab 2 mg ................................ 55 warfarin sodium tab 2.5 mg ............................. 55 warfarin sodium tab 3 mg ................................ 55 warfarin sodium tab 4 mg ................................ 55 warfarin sodium tab 5 mg ................................ 55 warfarin sodium tab 6 mg ................................ 55 warfarin sodium tab 7.5 mg ............................. 55 WELCHOL PAK3.75GM ............................ 53 WELCHOL TAB625MG ............................. 53 XALKORI CAP200MG .............................. 38 XALKORI CAP250MG .............................. 38 XARELTO TAB10MG ............................... 55 XARELTO TAB15MG ............................... 55 XARELTO TAB20MG ............................... 55 XARELTO STARTAB15/20MG .................... 55 XATMEP SOL2.5MG/ML .............................. 87 XELJANZ TAB10MG ................................. 87 XELJANZ TAB5MG ................................... 87 XELJANZ XR TAB11MG ............................. 88 XERMELO TAB250MG ............................. 75

XGEVA INJ .............................................. 91 XIGDUO XR TAB10-1000 ........................... 53 XIGDUO XR TAB10-500MG ...................... 53 XIGDUO XR TAB5-1000MG ...................... 53 XIGDUO XR TAB5-500MG ........................ 53 XOLAIR SOL150MG ................................ 98 XTANDI CAP40MG .................................. 32 XYREM SOL500MG/ML ......................... 98 YERVOY INJ50MG .................................. 38 YF-VAX INJ .............................................. 89 YONDELIS INJ1MG ................................... 32 YONSA TAB125MG ...................................... 32 zafirlukast tab 10 mg ....................................... 94 zafirlukast tab 20 mg ....................................... 95 zaleplon cap 10 mg .......................................... 98 zaleplon cap 5 mg ............................................ 98 ZALTRAP INJ100/4ML ............................. 34 ZANOSAR INJ1GM ................................... 34 ZARXIO INJ300/0.5 .................................. 56 ZARXIO INJ480/0.8 .................................. 56 ZAVESCA CAP100MG .............................. 76 ZEJULA CAP100MG ................................ 38 ZELBORAF TAB240MG ............................ 38 ZEMAIRA INJ1000MG .............................. 76 ZENPEP CAP10000UNT ........................... 76 ZENPEP CAP15000UNT ........................... 76 ZENPEP CAP20000UNT ........................... 76 ZENPEP CAP25000UNT ........................... 73 ZENPEP CAP3000UNIT ........................... 73 ZENPEP CAP5000UNIT ........................... 76 ZERIT SOL1MG/ML ................................ 47 ZIAGEN SOL20MG/ML ........................... 47 zidovudine cap 100 mg .................................... 47 zidovudine syrup 10 mg/ml .............................. 47 zidovudine tab 300 mg ..................................... 47 zileuton er tab600mg ....................................... 95 ZINBRYTA INJ150MG/ML ........................ 69 ZINPLAVA SOL25MG/ML ........................ 88 ziprasidone hcl cap 20 mg ............................... 51 ziprasidone hcl cap 40 mg ............................... 51 ziprasidone hcl cap 60 mg ............................... 51 ziprasidone hcl cap 80 mg ............................... 43 ZIRGAN GEL0.15% .................................. 44 ZMAX SUS2GM ...................................... 20 zoledronic acid inj conc for iv infusion 4 mg/5ml

..................................................................... 91 zoledronic acid iv soln 5 mg/100ml ................. 91 ZOLINZA CAP100MG ............................... 35

140

zolpidem tartrate tab 10 mg ............................. 98 zolpidem tartrate tab 5 mg ............................... 98 ZOMACTON INJ5MG ................................. 74 zonisamide cap 100 mg .................................... 21 zonisamide cap 25 mg ...................................... 21 zonisamide cap 50 mg ...................................... 21 ZORBTIVE INJ8.8MG ................................. 74 ZORTRESS TAB0.25MG ............................ 88 ZORTRESS TAB0.5MG .............................. 88 ZORTRESS TAB0.75MG ............................ 88

ZOSTAVAX INJ .......................................... 89 ZOSYN SOL2-0.25GM ............................. 19 ZOSYN SOL3-0.375G .............................. 19 ZOVIRAX CRE5% ..................................... 45 ZYDELIG TAB100MG............................... 38 ZYDELIG TAB150MG............................... 38 ZYFLO TAB600MG ................................. 95 ZYKADIA CAP150MG .............................. 38 ZYTIGA TAB250MG ................................ 32 ZYTIGA TAB500MG ................................ 32

141

Este vademécum se actualizó el 10/23/2018. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con Aspire Health Advantage Value (HMO), Aspire Health Advantage (HMO) o Aspire Health Advantage Plus (HMO-POS) llamando al 1-866-632-7958 o, para los usuarios de TTY, 1-866-706-4757,24 horas al dia, siete días a la semana, o visite www.aspirehealthplan.org. Aspire Health Plan Inc es una Organización para el Mantenimiento de la Salud aprobada por Medicare con un contrato Medicare Advantage y de medicamentos recetados con el gobierno federal. La inscripción en Aspire Health Plan depende de la renovación del contrato. This information is available for free in other languages. Please call our customer service number at toll free (855)570-1600 or TTY users call 711. We are open 8:00am - 8:00pm PST Monday through Friday (except certain holidías) from February 15 through September 30 and 8:00am - 8:00pm PST seven días a week for the poriod of October 1 through February 14. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de atención al cliente en (855) 570-1600 or Usuarios de TTY deben llamar al 711. Estamos abiertas de 8:00 am - 8:00 pm PST de lunes a viernes (excepto ciertos días festivos) del 15 de febrero al 30 de septiembre y las 8:00 am - 8:00 pm PST siete días a la semana para el poríodo del 1 de octubre al 14 de febrero.

El Formulario puede cambiar en cualquier momento. Recibira un aviso cuando sea

necesario.

Aspire Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Aspire Health Plan no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. Aspire Health Plan:

• Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes:

○ Intérpretes de lenguaje de señas capacitados. ○ Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

○ Intérpretes capacitados. ○ Información escrita en otros idiomas.

http://www.aspirehealthplan.org/

142

Si necesita recibir estos servicios, comuníquese con Aspire Health Plan Grievance Coordinator. Si considera que Aspire Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Grievance Coordinator, Aspire Health Plan, 10 Ragsdale Dr. Suite 101, Monterey, CA 93940, phone: (855) 570-1600, TTY: 711, fax: (831) 657-0703, email: [email protected]. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Aspire Health Plan Grievance Coordinator está a su disposición para brindársela. También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

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