accepted 2015 - connecture...stanford health care advantage 2016 n.º de id. del formulario:...

http://www.stanfordhealthcareadvantage.org/


s0180039

Typewritten Text

Accepted 2015

http://www.medicare.gov/

En las páginas 8 y 9 de este documento, puede encontrar información sobre el significado de los símbolos y las

abreviaturas que aparecen en esta tabla.

13

Stanford Health Care Advantage 2016

N.º de Id. del Formulario: 16441.000, Versión: 8

Fecha de entrada en vigencia: 1 de enero de 2016

Nombre del medicamento Nivel del

medicamento Requisitos/límites

Analgésicos

Analgésicos, varios

acetaminophen-codeine oral solution 120-

12 mg/5 ml, 300 mg-30 mg /12.5 ml

(Acetaminophen with

Codeine)

2 GC; QL (2700 cada 30

días)

acetaminophen-codeine oral tablet 300-15

mg, 300-30 mg

(Tylenol-Codeine

No.3)

2 GC; QL (360 cada 30

días)

acetaminophen-codeine oral tablet 300-60

mg

(Tylenol-Codeine

No.3)

2 GC; QL (180 cada 30

días)

butalbital-acetaminophen-caff oral tablet

50-325-40 mg

(Esgic) 2 PA-HRM; GC; QL (180

cada 30 días)

CAPITAL WITH CODEINE 4 QL (2700 cada 30 días)

CONZIP 4 QL (30 cada 30 días)

DILAUDID ORAL LIQUID 4 QL (1200 cada 30 días)

DILAUDID ORAL TABLET 2 MG, 4

MG

4 QL (180 cada 30 días)

DILAUDID ORAL TABLET 8 MG 4 QL (240 cada 30 días)

DOLOPHINE ORAL 4 QL (360 cada 30 días)

DURAGESIC TRANSDERMAL PATCH

72 HOUR 100 MCG/HR, 75 MCG/HR

5 PA; QL (10 cada 30 días)

DURAGESIC TRANSDERMAL PATCH

72 HOUR 12 MCG/HR, 25 MCG/HR, 50

MCG/HR


endocet oral tablet 10-325 mg, 5-325 mg,

7.5-325 mg

(Percocet) 2 GC; QL (360 cada 30

días)

ESGIC ORAL TABLET 4 PA-HRM; QL (180 cada

30 días)

EXALGO ER ORAL TABLET

EXTENDED RELEASE 24 HR 12 MG,

16 MG, 8 MG


EXALGO ER ORAL TABLET

EXTENDED RELEASE 24 HR 32 MG


fentanyl (Duragesic) 2 PA; GC; QL (10 cada 30

días)

HYCET 4 QL (2700 cada 30 días)

hydrocodone-acetaminophen oral solution

7.5-325 mg/15 ml

(Hycet) 2 GC; QL (2700 cada 30

días)



14






hydrocodone-acetaminophen oral tablet

10-300 mg, 5-300 mg, 7.5-300 mg

(Norco) 2 (incluye Vicodin,

Vicodin ES y Vicodin

HP); GC; QL (390 cada

30 días)

hydrocodone-acetaminophen oral tablet

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

mg

(Norco) 2 GC; QL (360 cada 30

días)

hydromorphone oral liquid (Dilaudid) 2 GC; QL (1200 cada 30

días)

hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) 2 GC; QL (180 cada 30

días)

hydromorphone oral tablet 8 mg (Dilaudid) 2 GC; QL (240 cada 30

días)

hydromorphone oral tablet extended

release 24 hr 12 mg, 16 mg, 8 mg

(Exalgo) 2 PA; GC; QL (30 cada 30

días)

hydromorphone oral tablet extended

release 24 hr 32 mg

(Exalgo) 2 PA; GC; QL (60 cada 30

días)

KADIAN ORAL

CAPSULE,EXTEND.RELEASE

PELLETS 10 MG, 20 MG, 30 MG, 40

MG, 50 MG, 60 MG, 80 MG

4 ST; QL (60 cada 30 días)

KADIAN ORAL


PELLETS 100 MG


KADIAN ORAL


PELLETS 200 MG

5 ST; QL (120 cada 30

días)

lorcet (hydrocodone) (Norco) 2 GC; QL (360 cada 30

días)

lorcet hd (Norco) 2 GC; QL (360 cada 30

días)

lorcet plus oral tablet 7.5-325 mg (Norco) 2 GC; QL (360 cada 30

días)

LORTAB 10-325 4 QL (360 cada 30 días)

LORTAB 5-325 4 QL (360 cada 30 días)

LORTAB 7.5-325 4 QL (360 cada 30 días)

methadone injection (Methadone HCl) 2 GC

methadone oral solution (Methadone HCl) 2 GC; QL (1800 cada 30

días)



15






methadone oral tablet (Dolophine HCl) 2 GC; QL (360 cada 30

días)

morphine concentrate oral solution (Morphine Sulfate) 2 GC; QL (200 cada 30

días)

morphine intravenous cartridge 10 mg/ml,

2 mg/ml, 4 mg/ml, 8 mg/ml

(Morphine Sulfate) 2 GC

morphine intravenous syringe (Morphine Sulfate) 2 GC

morphine oral capsule, er multiphase 24

hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg

(Avinza) 2 ST; GC; QL (30 cada 30

días)

morphine oral capsule, er multiphase 24

hr 90 mg

(Avinza) 2 ST; GC; QL (60 cada 30

días)

morphine oral capsule,extend.release

pellets 10 mg, 20 mg, 30 mg, 50 mg, 60

mg, 80 mg

(Kadian) 2 ST; GC; QL (60 cada 30

días)

morphine oral capsule,extend.release

pellets 100 mg

(Kadian) 5 ST; QL (60 cada 30 días)

morphine oral solution 10 mg/5 ml (Morphine Sulfate) 2 GC; QL (700 cada 30

días)

morphine oral solution 20 mg/5 ml (Morphine Sulfate) 2 GC; QL (300 cada 30

días)

MORPHINE ORAL TABLET 4 QL (180 cada 30 días)

morphine oral tablet extended release 100

mg, 30 mg, 60 mg

(MS Contin) 2 GC; QL (120 cada 30

días)

morphine oral tablet extended release 15

mg, 200 mg

(MS Contin) 2 GC; QL (180 cada 30

días)

MS CONTIN ORAL TABLET

EXTENDED RELEASE 100 MG, 30 MG,

60 MG


MS CONTIN ORAL TABLET

EXTENDED RELEASE 15 MG, 200 MG


NORCO 4 QL (360 cada 30 días)

oxycodone oral capsule (Oxycodone HCl) 2 GC; QL (180 cada 30

días)

oxycodone oral concentrate (Oxycodone HCl) 2 GC; QL (180 cada 30

días)

oxycodone oral solution (Oxycodone HCl) 2 GC; QL (1300 cada 30

días)

oxycodone oral tablet (Roxicodone) 2 GC; QL (180 cada 30

días)



16






oxycodone oral tablet,oral only,ext.rel.12

hr 10 mg, 20 mg, 40 mg

(Oxycodone HCl) 2 GC; QL (60 cada 30

días)

oxycodone oral tablet,oral only,ext.rel.12

hr 80 mg

(Oxycodone HCl) 5 QL (120 cada 30 días)

oxycodone-acetaminophen oral tablet 10-

325 mg, 2.5-325 mg, 5-325 mg, 7.5-325

mg

(Percocet) 2 GC; QL (360 cada 30

días)

OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15 MG,

20 MG, 30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 80 MG


PERCOCET ORAL TABLET 10-325

MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG


PRIMLEV 4 QL (390 cada 30 días)

roxicet oral solution (Oxycodone

HCl/Acetaminophen)

2 GC; QL (1800 cada 30

días)

ROXICODONE 4 QL (180 cada 30 días)

SUBSYS SUBLINGUAL SPRAY,NON-

AEROSOL 100 MCG/SPRAY, 200

MCG/SPRAY, 400 MCG/SPRAY, 600

MCG/SPRAY, 800 MCG/SPRAY

5 PA; QL (120 cada 30

días)

tramadol oral capsule,er biphase 24 hr

17-83

(Conzip) 2 GC; QL (30 cada 30

días)

tramadol oral capsule,er biphase 24 hr

25-75 100 mg, 200 mg

(Conzip) 2 GC; QL (30 cada 30

días)

tramadol oral tablet (Ultram) 2 GC; QL (240 cada 30

días)

tramadol oral tablet extended release 24

hr 100 mg

(Ultram ER) 2 GC; QL (90 cada 30

días)

tramadol oral tablet extended release 24

hr 200 mg, 300 mg


días)

tramadol oral tablet, er multiphase 24 hr

300 mg


días)

TYLENOL-CODEINE #3 4 QL (360 cada 30 días)

TYLENOL-CODEINE #4 4 QL (180 cada 30 días)

ULTRAM 4 QL (240 cada 30 días)

ULTRAM ER ORAL TABLET





17






ULTRAM ER ORAL TABLET


300 MG


vicodin es oral tablet 7.5-300 mg (Norco) 2 (incluye Vicodin,



30 días)

vicodin hp oral tablet 10-300 mg (Norco) 2 (includes Vicodin,



30 días)

vicodin oral tablet 5-300 mg (Norco) 2 (incluye Vicodin,



30 días)

XARTEMIS XR 3 QL (360 cada 30 días)

XODOL 10/300 4 QL (390 cada 30 días)

XODOL 5/300 4 QL (390 cada 30 días)

XODOL 7.5/300 4 QL (390 cada 30 días)

ZAMICET 4 QL (2700 cada 30 días)

Agentes antiinflamatorios no esteroideos

CELEBREX 4 QL (60 cada 30 días)

celecoxib (Celebrex) 2 GC; QL (60 cada 30

días)

diclofenac sodium oral tablet extended

release 24 hr

(Voltaren-XR) 2 GC

diclofenac sodium oral tablet,delayed

release (dr/ec)

(Diclofenac Sodium) 2 GC

diclofenac sodium topical drops (Pennsaid) 2 GC

diclofenac sodium topical gel (Solaraze) 5

EC-NAPROSYN 4

ibuprofen oral suspension (Ibuprofen) 2 GC

ibuprofen oral tablet 400 mg, 600 mg, 800

mg

(Ibuprofen) 1 GC

INDOCIN ORAL 4 PA-HRM

indomethacin oral capsule 25 mg (Indomethacin) 2 PA-HRM; GC; QL (240

cada 30 días)



18






indomethacin oral capsule 50 mg (Indomethacin) 2 PA-HRM; GC; QL (120

cada 30 días)

indomethacin oral capsule, extended

release

(Indomethacin) 2 PA-HRM; GC; QL (60

cada 30 días)

meloxicam oral suspension (Mobic) 2 GC

meloxicam oral tablet (Mobic) 1 GC

MOBIC 4

nabumetone (Nabumetone) 2 GC

NAPROSYN ORAL TABLET 4

naproxen oral suspension (Naprosyn) 2 GC

naproxen oral tablet (Naprosyn) 1 GC

naproxen oral tablet,delayed release

(dr/ec)

(Ec-Naprosyn) 2 GC

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP

4

SOLARAZE 5

VOLTAREN TOPICAL 3

VOLTAREN-XR 4

Anestésicos

Anestésicos locales

lidocaine hcl injection solution 20 mg/ml

(2 %)

(Xylocaine) 2 PA BvD; (PA para

ESRD solamente); GC

lidocaine hcl mucous membrane gel (Lidocaine HCl) 2 GC

lidocaine hcl mucous membrane jelly in

applicator

(Lidocaine HCl) 2 GC

lidocaine hcl mucous membrane solution (Xylocaine) 2 GC

lidocaine hcl urethral (Lidocaine HCl) 2 GC

lidocaine topical adhesive

patch,medicated

(Lidoderm) 2 PA; GC

lidocaine topical ointment (Lidocaine) 2 PA BvD; (PA para

ESRD solamente); GC

lidocaine viscous (Xylocaine) 2 GC

LIDODERM 4 PA

XYLOCAINE INJECTION SOLUTION

20 MG/ML (2 %)

4

XYLOCAINE MUCOUS MEMBRANE

SOLUTION

4



19






Agentes para el tratamiento contra adicciones y abuso de sustancias

Agentes para el tratamiento contra adicciones y abuso de sustancias

BUNAVAIL BUCCAL FILM 2.1-0.3 MG 4 PA; QL (30 cada 30 días)

BUNAVAIL BUCCAL FILM 4.2-0.7

MG, 6.3-1 MG


buprenorphine hcl sublingual (Subutex) 2 PA; GC; QL (90 cada 30

días)

buprenorphine-naloxone (Buprenorphine

HCl/Naloxone HCl)

2 PA; GC; QL (90 cada 30

días)

CHANTIX 3 QL (168 cada 84 días)

CHANTIX CONTINUING MONTH

BOX


CHANTIX CONTINUING MONTH PAK 3 QL (56 cada 28 días)

CHANTIX STARTING MONTH BOX 3 QL (53 cada 28 días)

SUBOXONE SUBLINGUAL FILM 12-3

MG


SUBOXONE SUBLINGUAL FILM 2-0.5

MG, 4-1 MG, 8-2 MG


ZUBSOLV 3 PA; QL (90 cada 30 días)

Agentes ansiolíticos

Benzodiazepinas

ALPRAZOLAM INTENSOL 4 QL (300 cada 30 días)

alprazolam oral tablet (Xanax) 2 GC; QL (120 cada 30

días)

alprazolam oral tablet extended release 24

hr 0.5 mg, 1 mg, 2 mg

(Xanax XR) 2 GC; QL (120 cada 30

días)

alprazolam oral tablet extended release 24

hr 3 mg

(Xanax XR) 2 GC; QL (90 cada 30

días)

alprazolam oral tablet,disintegrating (Alprazolam) 2 GC; QL (120 cada 30

días)

ATIVAN ORAL 4 QL (90 cada 30 días)

clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 2 GC; QL (90 cada 30

días)

clonazepam oral tablet 2 mg (Klonopin) 2 GC; QL (300 cada 30

días)

clonazepam oral tablet,disintegrating

0.125 mg, 0.25 mg, 0.5 mg, 1 mg

(Clonazepam) 2 GC; QL (90 cada 30

días)



20






clonazepam oral tablet,disintegrating 2

mg

(Clonazepam) 2 GC; QL (300 cada 30

días)

KLONOPIN ORAL TABLET 0.5 MG, 1

MG


KLONOPIN ORAL TABLET 2 MG 4 QL (300 cada 30 días)

lorazepam intensol (Ativan) 2 GC; QL (150 cada 30

días)

lorazepam oral tablet (Ativan) 2 GC; QL (90 cada 30

días)

XANAX 4 QL (120 cada 30 días)

XANAX XR ORAL TABLET

EXTENDED RELEASE 24 HR 0.5 MG, 1

MG, 2 MG


XANAX XR ORAL TABLET



Antibacteriales

Aminoglucósidos

gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) 2 GC

neomycin (Neomycin Sulfate) 2 GC

TOBI 5 PA BvD

tobramycin in 0.225 % nacl (Tobi) 5 PA BvD

Antibacterianos, varios

CLEOCIN ORAL 4

clindamycin hcl (Cleocin HCl) 2 GC

clindamycin palmitate hcl (Cleocin Palmitate) 2 GC

clindamycin pediatric (Cleocin Palmitate) 2 GC

FLAGYL 4

FLAGYL ER 4

MACROBID 4 PA-HRM; (med. de alto

riesgo; Se aplica QL a

todos los miembros; PA

requerida para personas

mayores de 65 años con

uso acumulado mayor a

90 días de medicamentos

de nitrofurantoin); QL

(120 cada 30 días)



21






MACRODANTIN 4 PA-HRM; (med. de alto







de nitrofurantoin); QL

(120 cada 30 días)

metronidazole oral (Flagyl) 2 GC

nitrofurantoin macrocrystal oral capsule

100 mg

(Macrodantin/Macro

bid)

2 PA-HRM; GC; QL (120

cada 30 días)

nitrofurantoin macrocrystal oral capsule

50 mg

(Macrodantin/Macro

bid)

2 PA-HRM; (med. de alto







de nitrofurantoin); GC;

QL (120 cada 30 días)

nitrofurantoin monohyd/m-cryst (Macrobid) 2 PA-HRM; (med. de alto







de nitrofurantoin); GC;


PRIMSOL 4

trimethoprim (Trimethoprim) 2 GC

VANCOCIN 5

vancomycin intravenous recon soln 1,000

mg, 10 gram

(Vancomycin HCl) 2 GC

vancomycin oral capsule (Vancocin HCl) 5

Cefalosporinas

cefadroxil oral capsule (Cefadroxil) 2 GC



22






cefadroxil oral suspension for

reconstitution 250 mg/5 ml, 500 mg/5 ml

(Cefadroxil) 2 GC

cefadroxil oral tablet (Cefadroxil) 2 GC

cefdinir (Cefdinir) 2 GC

cefpodoxime (Cefpodoxime

Proxetil)

2 GC

cefprozil (Cefprozil) 2 GC

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION

4

CEFTIN ORAL TABLET 250 MG, 500

MG

4

ceftriaxone injection recon soln 1 gram,

10 gram, 250 mg, 500 mg

(Rocephin) 2 GC

cefuroxime axetil oral tablet (Ceftin) 2 GC

cephalexin oral capsule (Keflex) 1 GC

cephalexin oral suspension for

reconstitution

(Cephalexin) 1 GC

cephalexin oral tablet (Cephalexin) 1 GC

KEFLEX ORAL CAPSULE 4

Macrólidos

azithromycin (Zithromax) 2 GC

BIAXIN ORAL SUSPENSION FOR

RECONSTITUTION 250 MG/5 ML

4

BIAXIN ORAL TABLET 4

clarithromycin oral suspension for

reconstitution

(Biaxin) 2 GC

clarithromycin oral tablet (Biaxin) 2 GC

clarithromycin oral tablet extended

release 24 hr

(Clarithromycin) 2 GC

ZITHROMAX 4

ZITHROMAX TRI-PAK 4

ZITHROMAX Z-PAK 4

ZMAX 4

Antibióticos betalactámicos, varios

CAYSTON 5 LA

INVANZ INJECTION 4

Penicilinas



23






amoxicillin oral capsule (Amoxicillin) 1 GC

amoxicillin oral suspension for

reconstitution

(Amoxicillin) 1 GC

amoxicillin oral tablet (Amoxicillin) 1 GC

amoxicillin oral tablet,chewable 125 mg,

250 mg

(Amoxicillin) 1 GC

amoxicillin-pot clavulanate oral

suspension for reconstitution

(Augmentin) 2 GC

amoxicillin-pot clavulanate oral tablet (Augmentin) 2 GC

amoxicillin-pot clavulanate oral tablet

extended release 12 hr

(Augmentin XR) 2 GC

amoxicillin-pot clavulanate oral

tablet,chewable

(Amoxicillin/Potassi

um Clav)

2 GC

ampicillin (Ampicillin

Trihydrate)

1 GC

AUGMENTIN ORAL SUSPENSION

FOR RECONSTITUTION 125-31.25

MG/5 ML

4

dicloxacillin (Dicloxacillin

Sodium)

2 GC

penicillin v potassium (Penicillin V

Potassium)

2 GC

Quinolonas

AVELOX 4

AVELOX ABC PACK 4

CIPRO ORAL TABLET 250 MG, 500

MG

4

ciprofloxacin hcl oral (Cipro) 1 GC

LEVAQUIN ORAL 4

levofloxacin intravenous (Levofloxacin) 2 GC

levofloxacin oral solution (Levaquin) 2 GC

levofloxacin oral tablet (Levaquin) 1 GC

moxifloxacin (Avelox) 2 GC

Sulfonamidas

AZULFIDINE 4

AZULFIDINE EN-TABS 4

BACTRIM 4



24






BACTRIM DS 4

sulfamethoxazole-trimethoprim

intravenous

(Sulfamethoxazole/T

rimethoprim)

2 GC

sulfamethoxazole-trimethoprim oral

suspension

(Sulfamethoxazole/T

rimethoprim)

2 GC

sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 1 GC

sulfasalazine (Azulfidine) 2 GC

sulfazine ec (Azulfidine) 2 GC

Tetraciclinas

ADOXA ORAL CAPSULE 4

doxycycline hyclate oral capsule 100 mg (Adoxa) 2 GC

doxycycline hyclate oral tablet 100 mg, 50

mg

(Avidoxy) 2 GC

doxycycline monohydrate oral capsule (Adoxa) 2 GC

doxycycline monohydrate oral suspension

for reconstitution

(Vibramycin) 2 GC

doxycycline monohydrate oral tablet (Avidoxy) 2 GC

MINOCIN ORAL CAPSULE 100 MG, 50

MG

4

minocycline oral capsule (Minocin) 2 GC

minocycline oral tablet (Minocycline HCl) 2 GC

minocycline oral tablet extended release

24 hr

(Minocycline HCl) 2 GC

ORACEA 4

SOLODYN ORAL TABLET


115 MG, 55 MG, 65 MG, 80 MG

5

VIBRAMYCIN ORAL SUSPENSION

FOR RECONSTITUTION

4

Agentes anticancerígenos

Agentes anticancerígenos

AFINITOR DISPERZ 5 PA NSO; QL (112 cada

28 días)

AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 cada

28 días)

AFINITOR ORAL TABLET 2.5 MG, 5

MG, 7.5 MG

5 PA NSO; QL (28 cada

28 días)



25






anastrozole (Arimidex) 2 GC

ARIMIDEX 4

AROMASIN 4

bicalutamide (Casodex) 2 GC

CASODEX 4

DROXIA 3

ELIGARD SUBCUTANEOUS SYRINGE

22.5 MG (3 MONTH)



30 MG (4 MONTH)



45 MG (6 MONTH)



7.5 MG (1 MONTH)

4

exemestane (Aromasin) 2 GC

FEMARA 4

flutamide (Flutamide) 2 GC

GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 cada

30 días)

GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 cada

30 días)

HYDREA 4

hydroxyurea (Hydrea) 2 GC

INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 cada

30 días)

INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 cada

30 días)

JAKAFI 5 PA NSO; QL (60 cada

30 días)

letrozole (Femara) 2 GC

LEUKERAN 4

leuprolide (Leuprolide Acetate) 2 GC

LUPRON DEPOT 5

LUPRON DEPOT (3 MONTH) 5 QL (1 cada 84 días)



LYSODREN 3

megestrol oral tablet (Megestrol Acetate) 2 GC



26






mercaptopurine (Mercaptopurine) 2 GC

methotrexate sodium (pf) injection

solution

(Methotrexate

Sodium)

2 PA BvD; GC

methotrexate sodium injection (Methotrexate

Sodium)

2 PA BvD; GC

methotrexate sodium oral (Methotrexate

Sodium)

2 PA BvD; ST; GC

NEXAVAR 5 PA NSO; QL (120 cada

30 días)

POMALYST 5 PA NSO; QL (21 cada

28 días)

PURIXAN 5

REVLIMID 5 PA NSO; LA

RHEUMATREX 4 PA BvD; ST

SOLTAMOX 4

SPRYCEL ORAL TABLET 100 MG, 140

MG, 50 MG, 70 MG, 80 MG


30 días)

SPRYCEL ORAL TABLET 20 MG 5 PA NSO; QL (60 cada

30 días)

STIVARGA 5 PA NSO; QL (84 cada

28 días)

SUTENT 5 PA NSO; QL (30 cada

30 días)

tamoxifen (Tamoxifen Citrate) 2 GC

TARCEVA ORAL TABLET 100 MG, 25

MG


30 días)

TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 cada

30 días)

TARGRETIN ORAL 5 PA NSO; QL (420 cada

30 días)

TARGRETIN TOPICAL 5 PA NSO; QL (60 cada

28 días)

TASIGNA 5 PA NSO; QL (112 cada

28 días)

tretinoin (chemotherapy) (Tretinoin) 5 (cápsula: 10mg)

TREXALL 4 PA BvD; ST

TYKERB 5



27






VOTRIENT 5 PA NSO; QL (120 cada

30 días)

XALKORI 5 PA NSO; QL (60 cada

30 días)

XTANDI 5 PA NSO; QL (120 cada

30 días)

ZELBORAF 5 PA NSO; QL (240 cada

30 días)

ZYTIGA 5 PA NSO; QL (120 cada

30 días)

Agentes anticolinérgicos

Antimuscarínicos/antiespasmódicos

atropine injection syringe 0.05 mg/ml, 0.1

mg/ml

(Atropine Sulfate) 2 GC

propantheline (Propantheline

Bromide)

2 GC

Anticonvulsivos

Anticonvulsivos

carbamazepine oral capsule, er

multiphase 12 hr

(Carbatrol) 2 GC

carbamazepine oral suspension 100 mg/5

ml

(Tegretol) 2 GC

carbamazepine oral tablet (Tegretol) 2 GC

carbamazepine oral tablet extended

release 12 hr

(Tegretol XR) 2 GC

carbamazepine oral tablet,chewable (Carbamazepine) 2 GC

CARBATROL 4

DEPAKOTE 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLES 4

DILANTIN 3

DILANTIN EXTENDED 4

divalproex oral capsule, sprinkle (Depakote Sprinkle) 2 GC

divalproex oral tablet extended release 24

hr

(Depakote ER) 2 GC

divalproex oral tablet,delayed release

(dr/ec)

(Depakote) 2 GC



28






epitol (Tegretol) 2 GC

EQUETRO 4

gabapentin oral capsule (Neurontin) 2 GC

gabapentin oral solution 250 mg/5 ml (Neurontin) 2 GC

gabapentin oral tablet 600 mg, 800 mg (Neurontin) 2 GC

GRALISE 4 ST; QL (90 cada 30 días)

GRALISE 30-DAY STARTER PACK 4 ST; QL (78 cada 30 días)

KEPPRA ORAL 4

KEPPRA XR 4

LAMICTAL ODT 4

LAMICTAL ORAL TABLET 4

LAMICTAL ORAL TABLET,

CHEWABLE DISPERSIBLE 25 MG, 5

MG

4

LAMICTAL STARTER (BLUE) KIT 4

LAMICTAL STARTER (GREEN) KIT 4

LAMICTAL STARTER (ORANGE) KIT 4

LAMICTAL XR 4

LAMICTAL XR STARTER (BLUE) 4

LAMICTAL XR STARTER (GREEN) 4

LAMICTAL XR STARTER (ORANGE) 4

lamotrigine oral tablet (Lamictal) 2 GC

lamotrigine oral tablet extended release

24hr

(Lamictal XR) 2 GC

lamotrigine oral tablet, chewable

dispersible

(Lamictal) 2 GC

lamotrigine oral tablet,disintegrating (Lamictal Odt) 2 GC

levetiracetam intravenous (Keppra) 2 GC

levetiracetam oral solution 100 mg/ml (Keppra) 2 GC

levetiracetam oral tablet (Keppra) 2 GC

levetiracetam oral tablet extended release

24 hr

(Keppra XR) 2 GC

LYRICA ORAL CAPSULE 3 QL (90 cada 30 días)

LYRICA ORAL SOLUTION 3 QL (900 cada 30 días)

NEURONTIN 4

PHENYTEK 4

phenytoin sodium extended (Dilantin) 2 GC



29






QUDEXY XR 4

TEGRETOL ORAL SUSPENSION 4

TEGRETOL ORAL TABLET 4

TEGRETOL XR ORAL TABLET


3

TEGRETOL XR ORAL TABLET


400 MG

4

TOPAMAX 4

topiramate oral capsule, sprinkle (Topamax) 2 GC

topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 2 GC

topiramate oral tablet (Topamax) 2 GC

TROKENDI XR 4

Agentes antidemencia

Agentes antidemencia

ARICEPT 4 QL (30 cada 30 días)

donepezil oral tablet (Aricept) 2 GC; QL (30 cada 30

días)

donepezil oral tablet,disintegrating (Donepezil HCl) 2 GC; QL (30 cada 30

días)

NAMENDA ORAL SOLUTION 4 QL (360 cada 30 días)

NAMENDA ORAL TABLET 4 QL (60 cada 30 días)

NAMENDA TITRATION PAK 4 QL (49 cada 28 días)

NAMENDA XR ORAL

CAP,SPRINKLE,ER 24HR DOSE PACK


NAMENDA XR ORAL

CAPSULE,SPRINKLE,ER 24HR


Antidepresivos

Antidepresivos

amitriptyline (Amitriptyline HCl) 2 PA NSO-HRM; GC

buproban (Wellbutrin SR) 2 GC

bupropion hcl oral tablet (Wellbutrin SR) 2 GC

bupropion hcl oral tablet extended release (Wellbutrin SR) 2 GC

bupropion hcl oral tablet extended release

24 hr

(Wellbutrin XL) 2 GC

CELEXA ORAL TABLET 4 QL (30 cada 30 días)



30






citalopram oral solution (Citalopram

Hydrobromide)

2 GC

citalopram oral tablet (Celexa) 1 GC; QL (30 cada 30

días)

CYMBALTA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 20 MG, 60 MG


CYMBALTA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 30 MG


duloxetine oral capsule,delayed

release(dr/ec) 20 mg, 60 mg

(Cymbalta) 2 GC; QL (60 cada 30

días)

duloxetine oral capsule,delayed

release(dr/ec) 30 mg, 40 mg

(Cymbalta) 2 GC; QL (30 cada 30

días)

EFFEXOR XR 4

escitalopram oxalate (Lexapro) 2 GC

fluoxetine oral capsule (Prozac) 1 GC

fluoxetine oral capsule,delayed

release(dr/ec)

(Prozac Weekly) 2 GC

fluoxetine oral solution (Fluoxetine HCl) 2 GC

fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 2 GC

FLUOXETINE ORAL TABLET 60 MG 4

FORFIVO XL 4

IRENKA 4 QL (30 cada 30 días)

LEXAPRO 4

paroxetine hcl oral tablet (Paxil) 2 GC

paroxetine hcl oral tablet extended release

24 hr

(Paxil CR) 2 GC

PAXIL 4

PAXIL CR 4

PROZAC ORAL CAPSULE 4

PROZAC WEEKLY 4

SARAFEM ORAL TABLET 10 MG, 20

MG

4

sertraline oral concentrate (Zoloft) 2 GC

sertraline oral tablet (Zoloft) 1 GC

trazodone (Trazodone HCl) 1 GC



31






venlafaxine oral capsule,extended release

24hr

(Effexor XR) 2 GC

venlafaxine oral tablet (Venlafaxine HCl) 2 GC

venlafaxine oral tablet extended release

24hr 150 mg, 37.5 mg, 75 mg

(Venlafaxine HCl) 2 GC

venlafaxine oral tablet extended release

24hr 225 mg

(Venlafaxine HCl) 3

WELLBUTRIN 4

WELLBUTRIN SR 4

WELLBUTRIN XL 4

ZOLOFT 4

Agentes antidiabéticos

Agentes antidiabéticos, varios

ACTOS 4 QL (30 cada 30 días)

BYDUREON 4 PA; ST; QL (4 cada 28

días)

BYETTA SUBCUTANEOUS PEN

INJECTOR 10 MCG/DOSE(250

MCG/ML) 2.4 ML

4 PA; ST; QL (2.4 cada 28

días)

BYETTA SUBCUTANEOUS PEN

INJECTOR 5 MCG/DOSE (250

MCG/ML) 1.2 ML

4 PA; ST; QL (1.2 cada 28

días)

FORTAMET ORAL TABLET

EXTENDED RELEASE 24HR 1,000 MG


FORTAMET ORAL TABLET

EXTENDED RELEASE 24HR 500 MG


GLUCOPHAGE ORAL TABLET 1,000

MG


GLUCOPHAGE ORAL TABLET 500

MG


GLUCOPHAGE ORAL TABLET 850

MG


GLUCOPHAGE XR ORAL TABLET



GLUCOPHAGE XR ORAL TABLET



GLUMETZA ORAL TABLET,ER

GAST.RETENTION 24 HR 1,000 MG




32






GLUMETZA ORAL TABLET,ER

GAST.RETENTION 24 HR 500 MG


JANUMET 3 QL (60 cada 30 días)

JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 100-1,000 MG, 50-

500 MG


JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR 50-1,000 MG


JANUVIA 3 QL (30 cada 30 días)

metformin oral tablet 1,000 mg (Glucophage) 1 GC; QL (60 cada 30

días)

metformin oral tablet 500 mg (Glucophage) 1 GC; QL (150 cada 30

días)

metformin oral tablet 850 mg (Glucophage) 1 GC; QL (90 cada 30

días)

metformin oral tablet extended release 24

hr 500 mg

(Glucophage XR) 2 GC; QL (120 cada 30

días)

metformin oral tablet extended release 24

hr 750 mg


días)

metformin oral tablet extended release

24hr 1,000 mg


días)

ONGLYZA 4 QL (30 cada 30 días)

pioglitazone (Actos) 2 GC; QL (30 cada 30

días)

RIOMET 4 QL (765 cada 30 días)

TRADJENTA 3 QL (30 cada 30 días)

VICTOZA 3-PAK 3 ST; QL (9 cada 28 días)

Insulinas

HUMALOG KWIKPEN

SUBCUTANEOUS INSULIN PEN 100

UNIT/ML

6 GC; QL (30 cada 28

días)

HUMALOG KWIKPEN

SUBCUTANEOUS INSULIN PEN 200

UNIT/ML (3 ML)


días)

HUMALOG SUBCUTANEOUS

CARTRIDGE


días)


SOLUTION 100 UNIT/ML


días)



33







SOLUTION 100 UNIT/ML (PREFILLED

SYRINGE)


días)

LANTUS 6 GC; QL (40 cada 28

días)

LANTUS SOLOSTAR 6 GC; QL (30 cada 28

días)

NOVOLOG 6 GC; QL (40 cada 28

días)

NOVOLOG FLEXPEN 6 GC; QL (30 cada 28

días)

NOVOLOG PENFILL 6 GC; QL (30 cada 28

días)

TOUJEO SOLOSTAR 6 GC

Sulfonilureas

AMARYL ORAL TABLET 1 MG, 2 MG 4 QL (30 cada 30 días)

AMARYL ORAL TABLET 4 MG 4 QL (60 cada 30 días)

DIABETA ORAL TABLET 1.25 MG 4 PA-HRM; QL (280 cada

30 días)

DIABETA ORAL TABLET 2.5 MG 4 PA-HRM; QL (240 cada

30 días)

DIABETA ORAL TABLET 5 MG 4 PA-HRM; QL (120 cada

30 días)

glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 GC; QL (30 cada 30

días)

glimepiride oral tablet 4 mg (Amaryl) 1 GC; QL (60 cada 30

días)

glipizide oral tablet 10 mg (Glucotrol) 1 GC; QL (120 cada 30

días)

glipizide oral tablet 5 mg (Glucotrol) 1 GC; QL (60 cada 30

días)

glipizide oral tablet extended release 24hr

10 mg

(Glucotrol XL) 2 GC; QL (60 cada 30

días)

glipizide oral tablet extended release 24hr

2.5 mg, 5 mg

(Glucotrol XL) 2 GC; QL (30 cada 30

días)

GLUCOTROL ORAL TABLET 10 MG 4 QL (120 cada 30 días)

GLUCOTROL ORAL TABLET 5 MG 4 QL (30 cada 30 días)



34






GLUCOTROL XL ORAL TABLET



GLUCOTROL XL ORAL TABLET

EXTENDED RELEASE 24HR 2.5 MG, 5

MG


glyburide oral tablet 1.25 mg (Glyburide) 2 PA-HRM; GC; QL (280

cada 30 días)

glyburide oral tablet 2.5 mg (Glyburide) 2 PA-HRM; GC; QL (240

cada 30 días)

glyburide oral tablet 5 mg (Glyburide) 2 PA-HRM; GC; QL (120

cada 30 días)

Antimicóticos

Antimicóticos

clotrimazole mucous membrane (Clotrimazole) 2 GC

clotrimazole topical cream (Clotrimazole) 2 GC

clotrimazole topical solution (Lotrimin) 2 GC

clotrimazole-betamethasone topical cream (Lotrisone) 2 GC

clotrimazole-betamethasone topical lotion (Clotrimazole/Betam

ethasone Dip)

2 GC

DIFLUCAN 4

econazole topical (Econazole Nitrate) 2 GC

EXTINA 4

fluconazole (Diflucan) 2 GC

ketoconazole oral (Ketoconazole) 2 GC

ketoconazole topical cream (Ketoconazole) 2 GC

ketoconazole topical shampoo (Nizoral) 2 GC

LAMISIL ORAL 4

LOTRISONE TOPICAL CREAM 4

NIZORAL TOPICAL SHAMPOO 4

nyamyc (Nystatin) 2 GC

nystatin oral suspension (Nystatin) 2 GC

nystatin oral tablet (Nystatin) 2 GC

nystatin topical (Nystatin) 2 GC

nystatin-triamcinolone (Nystatin/Triamcin) 2 GC

nystop (Nystatin) 2 GC

terbinafine hcl oral (Lamisil) 2 GC

Antihistamínicos



35






Antihistamínicos

CLARINEX ORAL SYRUP 4

CLARINEX ORAL TABLET 4

cyproheptadine (Cyproheptadine

HCl)

2 PA-HRM; GC

desloratadine oral tablet (Clarinex) 2 GC

desloratadine oral tablet,disintegrating (Desloratadine) 2 GC

levocetirizine (Xyzal) 2 GC

XYZAL 4

Antiinfecciosos (piel y membrana mucosa)

Antiinfecciosos (piel y membrana mucosa) METROGEL VAGINAL 4

metronidazole vaginal (Metrogel-Vaginal) 2 GC

NUVESSA 4

TERAZOL 3 VAGINAL CREAM 4

TERAZOL 7 4

terconazole vaginal cream (Terazol 7) 2 GC

terconazole vaginal suppository (Terconazole) 2 GC

VANDAZOLE 4

Agentes Antimigrañosos

Agentes Antimigrañosos

ALSUMA 4 QL (4 cada 28 días)

IMITREX ORAL 4 QL (18 cada 28 días)

IMITREX STATDOSE KIT REFILL 4 QL (4 cada 28 días)

IMITREX SUBCUTANEOUS 4 QL (4 cada 28 días)

MAXALT 4 QL (18 cada 28 días)

MAXALT-MLT 4 QL (18 cada 28 días)

RELPAX 4 QL (12 cada 28 días)

rizatriptan oral tablet (Maxalt) 2 GC; QL (18 cada 28

días)

rizatriptan oral tablet,disintegrating (Maxalt Mlt) 2 GC; QL (18 cada 28

días)

sumatriptan succinate oral (Imitrex) 2 GC; QL (18 cada 28

días)

sumatriptan succinate subcutaneous

cartridge 6 mg/0.5 ml

(Imitrex) 2 GC; QL (4 cada 28 días)



36






sumatriptan succinate subcutaneous pen

injector 6 mg/0.5 ml


sumatriptan succinate subcutaneous

solution


SUMAVEL DOSEPRO 4 QL (4 cada 28 días)

Antimicobacterianos

Antimicobacterianos

dapsone (Dapsone) 2 GC

ethambutol (Myambutol) 2 GC

isoniazid injection (Isoniazid) 2 GC

isoniazid oral solution (Isoniazid) 2 GC

isoniazid oral tablet (Isoniazid) 1 GC

MYAMBUTOL ORAL TABLET 400 MG 4

RIFADIN 4

rifampin intravenous (Rifadin) 2 GC

rifampin oral (Rifadin) 2 GC

Agentes antieméticos

Agentes antieméticos

meclizine oral tablet 12.5 mg, 25 mg (Antivert) 2 GC

ondansetron (Zofran Odt) 2 PA BvD; GC

phenadoz rectal suppository 12.5 mg (Phenergan) 2 PA-HRM; GC

PHENERGAN 4 PA-HRM

prochlorcadaazine maleate oral (Compazine) 1 GC

promethazine injection solution 25 mg/ml (Promethazine HCl) 2 PA-HRM; GC

promethazine injection solution 50 mg/ml (Phenergan) 2 PA-HRM; GC

promethazine oral tablet (Promethazine HCl) 2 PA-HRM; GC

promethazine rectal (Phenergan) 2 PA-HRM; GC

promethegan rectal suppository 25 mg, 50

mg

(Phenergan) 2 PA-HRM; GC

TRANSDERM-SCOP 4 QL (10 cada 30 días)

ZOFRAN ODT 5 PA BvD

ZUPLENZ 4 PA BvD

Agentes antiparasitarios

Agentes antiparasitarios

atovaquone-proguanil (Malarone) 2 GC

hydroxychloroquine oral (Plaquenil) 2 GC



37






MALARONE 4

MALARONE PEDIATRIC 4

mefloquine (Mefloquine HCl) 2 GC

PLAQUENIL 4

TINDAMAX ORAL TABLET 500 MG 4

tinidazole (Tindamax) 2 GC

Agentes antiparkinsonianos

Agentes antiparkinsonianos

benztropine injection (Cogentin) 2 PA-HRM; GC

benztropine oral (Benztropine

Mesylate)

2 PA-HRM; GC

carbidopa-levodopa oral tablet (Sinemet 25-100) 2 GC

carbidopa-levodopa oral tablet extended

release

(Sinemet CR) 2 GC

carbidopa-levodopa oral

tablet,disintegrating

(Carbidopa/Levodop

a)

2 GC

COGENTIN 4 PA-HRM

MIRAPEX 4

MIRAPEX ER 4

pramipexole oral tablet (Mirapex) 2 GC

pramipexole oral tablet extended release

24 hr 0.75 mg, 1.5 mg

(Mirapex ER) 2 GC

REQUIP 4

REQUIP XL 4

ropinirole oral tablet (Requip) 2 GC

ropinirole oral tablet extended release 24

hr

(Requip XL) 2 GC

RYTARY 4

SINEMET 4

SINEMET CR 4

Agentes antipsicóticos

Agentes antipsicóticos

ABILIFY DISCMELT ORAL

TABLET,DISINTEGRATING 10 MG




38






ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSION,EXTENDED REL

RECON

5

ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSION,EXTENDED REL

SYRING


ABILIFY ORAL TABLET 10 MG, 15

MG, 20 MG, 30 MG, 5 MG


ABILIFY ORAL TABLET 2 MG 4 QL (60 cada 30 días)

aripiprazole oral tablet 10 mg, 15 mg, 20

mg, 30 mg, 5 mg

(Abilify) 2 GC; QL (30 cada 30

días)

aripiprazole oral tablet 2 mg (Abilify) 2 GC; QL (60 cada 30

días)

clozapine oral tablet 100 mg (Clozaril) 2 GC; QL (270 cada 30

días)

clozapine oral tablet 200 mg (Clozaril) 2 GC; QL (135 cada 30

días)

clozapine oral tablet 25 mg, 50 mg (Clozaril) 2 GC; QL (90 cada 30

días)

clozapine oral tablet,disintegrating (Fazaclo) 2 ST; GC

CLOZARIL ORAL TABLET 100 MG 4 QL (270 cada 30 días)

CLOZARIL ORAL TABLET 25 MG 4 QL (90 cada 30 días)

FAZACLO ORAL

TABLET,DISINTEGRATING 100 MG,

12.5 MG, 25 MG


FAZACLO ORAL


4 ST; QL (180 cada 30

días)

FAZACLO ORAL


4 ST; QL (120 cada 30

días)

GEODON ORAL 4 QL (60 cada 30 días)

haloperidol (Haloperidol) 2 GC

olanzapine intramuscular (Zyprexa) 2 GC; QL (30 cada 30

días)

olanzapine oral tablet (Zyprexa) 2 GC; QL (30 cada 30

días)

olanzapine oral tablet,disintegrating 10

mg, 15 mg, 5 mg

(Zyprexa Zydis) 2 GC; QL (30 cada 30

días)



39






olanzapine oral tablet,disintegrating 20

mg

(Zyprexa Zydis) 2 GC; QL (31 cada 30

días)

quetiapine (Seroquel) 2 GC; QL (90 cada 30

días)

RISPERDAL M-TAB ORAL

TABLET,DISINTEGRATING 0.5 MG, 1

MG, 2 MG


RISPERDAL M-TAB ORAL

TABLET,DISINTEGRATING 3 MG, 4

MG


RISPERDAL ORAL SOLUTION 4 QL (480 cada 30 días)

RISPERDAL ORAL TABLET 4 QL (60 cada 30 días)

risperidone oral solution (Risperdal) 2 GC; QL (480 cada 30

días)

risperidone oral tablet (Risperdal) 2 GC; QL (60 cada 30

días)

risperidone oral tablet,disintegrating 0.25

mg, 0.5 mg, 1 mg, 2 mg

(Risperdal M-Tab) 2 GC; QL (60 cada 30

días)

risperidone oral tablet,disintegrating 3

mg, 4 mg

(Risperdal M-Tab) 2 GC; QL (120 cada 30

días)

SEROQUEL 4 QL (90 cada 30 días)

SEROQUEL XR ORAL TABLET


300 MG, 400 MG, 50 MG


SEROQUEL XR ORAL TABLET



VERSACLOZ 5 ST; QL (540 cada 30

días)

ziprasidone hcl (Geodon) 2 GC; QL (60 cada 30

días)

ZYPREXA 4 QL (30 cada 30 días)

ZYPREXA ZYDIS 4 QL (30 cada 30 días)

Antivirales (sistémicos)

Antirretrovirales

ATRIPLA 5

COMPLERA 5

EPZICOM 5



40






ISENTRESS ORAL POWDER IN

PACKET

3

ISENTRESS ORAL TABLET 5

ISENTRESS ORAL

TABLET,CHEWABLE

3

NORVIR 3

PREZISTA ORAL SUSPENSION 4

PREZISTA ORAL TABLET 150 MG, 75

MG

3

PREZISTA ORAL TABLET 600 MG,

800 MG

5

REYATAZ ORAL CAPSULE 150 MG,

200 MG, 300 MG

5

REYATAZ ORAL POWDER IN

PACKET

5

STRIBILD 5

TRUVADA 5

VIREAD 5

Antivirales, varios

SYNAGIS 5

TAMIFLU 3

Antivirales tópicos

OLYSIO 5 PA; QL (28 cada 28 días)

SOVALDI 5 PA; QL (28 cada 28 días)

Interferones

PEGASYS 5 PA

PEGASYS PROCLICK 5 PA

PEGINTRON 5 PA

PEGINTRON REDIPEN 5 PA

SYLATRON 5 PA NSO; QL (4 cada 28

días)

Nucleosídicos y nucleotídicos

acyclovir oral capsule (Zovirax) 2 GC

acyclovir oral suspension 200 mg/5 ml (Zovirax) 2 GC

acyclovir oral tablet (Zovirax) 2 GC

famciclovir (Famvir) 2 GC

FAMVIR 4



41






valacyclovir (Valtrex) 2 GC

VALTREX 4

ZOVIRAX ORAL CAPSULE 4

ZOVIRAX ORAL SUSPENSION 4

Expansores de volumen/modificadores/productos sanguíneos

Anticoagulantes

COUMADIN ORAL 4

enoxaparin subcutaneous solution (Lovenox) 2 GC; QL (36 cada 30

días)

enoxaparin subcutaneous syringe 100

mg/ml

(Lovenox) 5 QL (36 cada 30 días)


mg/0.8 ml

(Lovenox) 5 QL (27.2 cada 30 días)


mg/ml

(Lovenox) 5 QL (34 cada 30 días)


mg/0.3 ml

(Lovenox) 2 GC; QL (18 cada 30

días)


mg/0.4 ml

(Lovenox) 2 GC; QL (13.6 cada 30

días)


mg/0.6 ml


días)


mg/0.8 ml


días)

jantoven (Coumadin) 1 GC

LOVENOX SUBCUTANEOUS

SOLUTION



SYRINGE 100 MG/ML



SYRINGE 120 MG/0.8 ML, 80 MG/0.8

ML

4 QL (27.2 cada 30 días)


SYRINGE 150 MG/ML



SYRINGE 30 MG/0.3 ML







42









warfarin (Coumadin) 1 GC

XARELTO 3

Modificadores de formación de sangre

EPOGEN INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,

20,000 UNIT/2 ML, 20,000 UNIT/ML,

3,000 UNIT/ML, 4,000 UNIT/ML


NEULASTA SUBCUTANEOUS

SYRINGE

5

NEUPOGEN 5

PROCRIT INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,

20,000 UNIT/2 ML, 3,000 UNIT/ML,

4,000 UNIT/ML



20,000 UNIT/ML



40,000 UNIT/ML


Agentes hematológicos, varios

AGRYLIN 4

anagrelide (Agrylin) 2 GC

CYKLOKAPRON 4

LYSTEDA 4 QL (30 cada 30 días)

tranexamic acid intravenous (Tranexamic Acid) 2 GC

tranexamic acid oral (Lysteda) 2 GC; QL (30 cada 30

días)

Inhibidores de agregación plaquetaria

cilostazol (Pletal) 2 GC

clopidogrel (Plavix) 2 GC

EFFIENT 3 QL (30 cada 30 días)

PLAVIX 4

PLETAL 4

Agentes calóricos

Agentes calóricos

CLINIMIX 5%-D20W(SULFITE-FREE) 4 PA BvD



43






CLINIMIX E 4.25%/D25W SUL FREE 4 PA BvD

CLINIMIX E 5%/D15W SULFIT FREE 4 PA BvD

CLINIMIX E 5%/D20W SULFIT FREE 4 PA BvD

CLINISOL SF 15 % 4 PA BvD

dextrose 10 % in water (d10w)

intravenous parenteral solution

(Dextrose 10 % in

Water)

2 PA BvD; GC

dextrose 5 % in water (d5w) intravenous

parenteral solution

(Dextrose 5 % in

Water)

2 GC

INTRALIPID INTRAVENOUS

EMULSION 20 %, 30 %

4 PA BvD

NUTRILIPID 4 PA BvD

PROSOL 20 % 4 PA BvD

TRAVASOL 10 % 4 PA BvD

TROPHAMINE 10 % 4 PA BvD

Agentes cardiovasculares

Agentes alfa-adrenérgicos

CARDURA 4

CARDURA XL 4

CATAPRES 4

clonidine hcl oral tablet (Catapres) 1 GC

doxazosin (Cardura) 2 GC

guanfacine oral tablet (Tenex) 2 PA-HRM; GC

TENEX 4 PA-HRM

Antagonistas del receptor de la angiotensina II

AVAPRO 4 ST

COZAAR 4

DIOVAN 4 ST

DIOVAN HCT 4 ST

HYZAAR 4

irbesartan (Avapro) 2 GC

losartan (Cozaar) 1 GC

losartan-hydrochlorothiazide (Hyzaar) 2 GC

valsartan (Diovan) 2 GC

valsartan-hydrochlorothiazide (Diovan HCT) 2 GC

Inhibidores de la enzima convertidora de angiotensina

ALTACE 4



44






benazepril (Lotensin) 1 GC

enalapril maleate (Vasotec) 1 GC

EPANED 4

lisinopril (Zestril) 1 GC

lisinopril-hydrochlorothiazide (Zestoretic) 1 GC

LOTENSIN ORAL TABLET 20 MG, 40

MG

4

PRINIVIL ORAL TABLET 10 MG, 20

MG, 5 MG

4

ramipril (Altace) 2 GC

VASOTEC 4

ZESTORETIC 4

ZESTRIL 4

Agentes antiarrítmicos

amiodarone intravenous solution (Amiodarone HCl) 2 GC

amiodarone oral tablet 200 mg, 400 mg (Cordarone) 2 GC

flecainide (Tambocor) 2 GC

pacerone oral tablet 100 mg, 200 mg, 400

mg

(Cordarone) 2 GC

propafenone oral capsule,extended release

12 hr

(Rythmol SR) 2 GC

propafenone oral tablet (Rythmol) 2 GC

RYTHMOL ORAL TABLET 150 MG,

225 MG

4

RYTHMOL SR 4

Agentes bloqueadores de beta-adrenérgicos

atenolol (Tenormin) 1 GC

carvedilol (Coreg) 1 GC

COREG 4

INDERAL LA 4

INNOPRAN XL 4

labetalol intravenous solution (Labetalol HCl) 2 GC

labetalol oral (Trandate) 2 GC

LOPRESSOR INTRAVENOUS 4

LOPRESSOR ORAL TABLET 100 MG 4

metoprolol succinate (Toprol XL) 2 GC

metoprolol tartrate intravenous solution (Lopressor) 2 GC



45






metoprolol tartrate oral (Lopressor) 1 GC

propranolol intravenous (Propranolol HCl) 2 GC

propranolol oral capsule,extended release

24 hr

(Inderal LA) 2 GC

propranolol oral solution (Propranolol HCl) 2 GC

propranolol oral tablet (Propranolol HCl) 2 GC

TENORMIN 4

TOPROL XL 4

Agentes bloqueadores de los canales de calcio

CALAN 4

CALAN SR 4

CARDIZEM CD 4

CARDIZEM LA 4

CARDIZEM ORAL TABLET 120 MG,

30 MG, 60 MG

4

cartia xt (Cardizem CD) 2 GC

diltiazem hcl intravenous (Cardizem CD) 2 GC

diltiazem hcl oral capsule, extended

release 180 mg, 360 mg, 420 mg

(Cardizem CD) 2 GC

diltiazem hcl oral capsule,extended

release 12 hr

(Cardizem CD) 2 GC

diltiazem hcl oral capsule,extended

release 24hr

(Cardizem CD) 2 GC

diltiazem hcl oral tablet (Cardizem CD) 1 GC

dilt-xr (Cardizem CD) 2 GC

matzim la (Cardizem CD) 2 GC

taztia xt (Cardizem CD) 2 GC

TIAZAC 4

verapamil intravenous solution (Verapamil HCl) 2 GC

verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 2 GC

verapamil oral capsule,ext rel. pellets 24

hr

(Verelan) 2 GC

verapamil oral tablet (Calan SR) 1 GC

verapamil oral tablet extended release (Calan SR) 2 GC

VERELAN 4

VERELAN PM 4



46






Agentes cardiovasculares, varios

digitek oral tablet 125 mcg (Lanoxin) 2 PA-HRM; (med. de alto

riesgo para pacientes

mayores de 65 años y

con una dosis mayor a

125 mcg por día); GC;


digitek oral tablet 250 mcg (Lanoxin) 2 PA-HRM; GC; QL (30

cada 30 días)

digox (Lanoxin) 2 PA-HRM; (med. de alto






digoxin injection (Digoxin) 2 PA-HRM; GC

DIGOXIN ORAL SOLUTION 50

MCG/ML

3 PA-HRM; QL (300 cada

30 días)

digoxin oral tablet (Lanoxin) 2 PA-HRM; (med. de alto






hydralazine (Hydralazine HCl) 2 GC

LANOXIN INJECTION 4 PA-HRM

LANOXIN ORAL 4 PA-HRM; (med. de alto




125 mcg por día); QL

(30 cada 30 días)

Dihidropiridina

ADALAT CC 4

afeditab cr (Adalat CC) 2 GC

amlodipine (Norvasc) 1 GC

amlodipine-benazepril (Lotrel) 2 GC

LOTREL 4



47






nifedical xl (Procardia XL) 2 GC

nifedipine oral capsule (Procardia) 2 PA-HRM; GC

nifedipine oral tablet extended release

24hr 30 mg

(Adalat CC) 2 GC

nifedipine oral tablet extended release

24hr 60 mg, 90 mg

(Procardia XL) 2 GC

nifedipine oral tablet extended release 30

mg

(Adalat CC) 2 GC

NORVASC 4

PROCARDIA 4 PA-HRM

PROCARDIA XL 4

Diuréticos

chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 1 GC

DYAZIDE 4

furosemide injection (Furosemide) 2 GC

furosemide oral solution 10 mg/ml, 40

mg/5 ml

(Furosemide) 2 GC

furosemide oral tablet (Lasix) 1 GC

hydrochlorothiazide oral capsule (Microzide) 1 GC

hydrochlorothiazide oral tablet (Hydrochlorothiazide

)

1 GC

LASIX 4

MAXZIDE 4

MAXZIDE-25MG 4

MICROZIDE 4

triamterene-hydrochlorothiazid oral

capsule

(Dyazide) 2 GC

triamterene-hydrochlorothiazid oral tablet (Maxzide-25 Mg) 2 GC

Dislipidémicos

ALTOPREV 4

atorvastatin (Lipitor) 2 GC

CRESTOR 3 ST

fenofibrate oral capsule (Lipofen) 2 GC

fenofibrate oral tablet 160 mg, 54 mg (Fenoglide) 2 GC

FENOGLIDE 4

gemfibrozil oral (Lopid) 2 GC

LIPITOR 4



48






LIPOFEN 4

LOFIBRA ORAL TABLET 4

LOPID 4

lovastatin (Mevacor) 1 GC

PRAVACHOL 4

pravastatin (Pravachol) 1 GC

simvastatin (Zocor) 1 GC; QL (30 cada 30

días)

ZOCOR 4 QL (30 cada 30 días)

Inhibidores del sistema renina-angiotensina-aldosterona

ALDACTAZIDE 4

ALDACTONE 4

spironolactone (Aldactone) 2 GC

spironolacton-hydrochlorothiaz (Aldactazide) 2 GC

Vasodilatadores

isosorbide mononitrate oral tablet (Isosorbide

Mononitrate)

2 GC

isosorbide mononitrate oral tablet

extended release 24 hr

(Imdur) 2 GC

minitran transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.6 mg/hr

(Nitro-Dur) 2 GC; QL (30 cada 30

días)

minitran transdermal patch 24 hour 0.4

mg/hr


días)

NITRO-BID 3

NITRO-DUR 4

nitroglycerin intravenous (Nitroglycerin) 2 GC

nitroglycerin transdermal patch 24 hour

0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr


días)

nitroglycerin transdermal patch 24 hour

0.4 mg/hr


días)

nitroglycerin translingual spray,non-

aerosol

(Nitrolingual) 2 GC

NITROLINGUAL 4

NITROMIST 4

NITROSTAT 3



49






Agentes del sistema nervioso central

Agentes del sistema nervioso central ADDERALL ORAL TABLET 20 MG, 5

MG, 7.5 MG

4

ADDERALL XR ORAL

CAPSULE,EXTENDED RELEASE

24HR 10 MG, 15 MG, 5 MG


ADDERALL XR ORAL

CAPSULE,EXTENDED RELEASE

24HR 20 MG, 25 MG, 30 MG


amphetamine salt combo (Adderall) 2 GC; QL (60 cada 30

días)

CONCERTA ORAL TABLET

EXTENDED RELEASE 24HR 18 MG, 27

MG, 54 MG


CONCERTA ORAL TABLET



dexmethylphenidate oral capsule,er

biphasic 50-50

(Focalin XR) 2 GC; QL (30 cada 30

días)

dexmethylphenidate oral tablet (Focalin) 2 GC; QL (60 cada 30

días)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15

mg, 5 mg

(Adderall XR) 2 GC; QL (30 cada 30

días)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 20 mg, 25

mg, 30 mg

(Adderall XR) 2 GC; QL (60 cada 30

días)

FOCALIN 4 QL (60 cada 30 días)

FOCALIN XR 4 QL (30 cada 30 días)

lithium carbonate oral capsule (Lithium Carbonate) 2 GC

lithium carbonate oral tablet (Lithobid) 2 GC

lithium carbonate oral tablet extended

release

(Lithobid) 2 GC

LITHOBID 4

METADATE CD ORAL CAPSULE, ER

BIPHASIC 30-70 10 MG, 20 MG, 40 MG,

50 MG, 60 MG




50






METADATE CD ORAL CAPSULE, ER

BIPHASIC 30-70 30 MG


metadate er (Methylphenidate

HCl)


METHYLIN ORAL SOLUTION 4 QL (900 cada 30 días)

METHYLIN ORAL

TABLET,CHEWABLE 10 MG


METHYLIN ORAL

TABLET,CHEWABLE 2.5 MG, 5 MG


methylphenidate oral capsule, er biphasic

30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg

(Metadate Cd) 2 GC; QL (30 cada 30

días)

methylphenidate oral capsule, er biphasic

30-70 30 mg


días)

methylphenidate oral capsule,er biphasic

50-50 20 mg, 40 mg


días)

methylphenidate oral capsule,er biphasic

50-50 30 mg


días)

methylphenidate oral solution (Methylin) 2 GC; QL (900 cada 30

días)

methylphenidate oral tablet (Ritalin) 2 GC; QL (90 cada 30

días)

methylphenidate oral tablet extended

release

(Methylphenidate

HCl)


días)


release 24hr 18 mg, 27 mg, 54 mg

(Concerta) 2 GC; QL (30 cada 30

días)


release 24hr 36 mg

(Concerta) 2 GC; QL (60 cada 30

días)

methylphenidate oral tablet,chewable 10

mg

(Methylin) 2 GC; QL (180 cada 30

días)

methylphenidate oral tablet,chewable 2.5

mg, 5 mg

(Methylin) 2 GC; QL (90 cada 30

días)

QUILLIVANT XR 3

RITALIN 4 QL (90 cada 30 días)

RITALIN LA ORAL CAPSULE,ER

BIPHASIC 50-50 10 MG, 20 MG, 40 MG,

60 MG


RITALIN LA ORAL CAPSULE,ER

BIPHASIC 50-50 30 MG




51






VYVANSE 4 PA; QL (30 cada 30 días)

Anticonceptivos

Anticonceptivos

AMETHYST 4

apri (Desogen) 2 GC

aubra (Amethyst) 2 GC

aviane (Amethyst) 2 GC

CYCLESSA (28) 4

delyla (28) (Amethyst) 2 GC

DESOGEN 4

drospirenone-ethinyl estradiol (Yaz) 2 GC

emoquette (Desogen) 2 GC

enpresse (Amethyst) 2 GC

falmina (28) (Amethyst) 2 GC

gianvi (28) (Yaz) 2 GC

gildess 24 fe (Loestrin Fe) 2 GC

introvale (Levonorgestrel-

Ethin Estradiol)


días)

junel fe 1.5/30 (28) (Loestrin Fe) 2 GC

junel fe 1/20 (28) (Loestrin Fe) 2 GC

junel fe 24 (Loestrin Fe) 2 GC

larin fe (Loestrin Fe) 2 GC

lessina (Amethyst) 2 GC

levonest (28) (Amethyst) 2 GC

levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg, 90-20 mcg

(Amethyst) 2 GC

levonorgestrel-ethinyl estrad oral tablet

0.15-0.03 mg

(Amethyst) 2 GC; QL (91 cada 84

días)

levonorgestrel-ethinyl estrad oral

tablets,dose pack,3 month

(Amethyst) 2 GC; QL (91 cada 84

días)

levora-28 (Amethyst) 2 GC

LO LOESTRIN FE 4

LOESTRIN FE 1.5/30 (28-DAY) 4

LOESTRIN FE 1/20 (28-DAY) 4

lomedia 24 fe (Loestrin Fe) 2 GC

loryna (28) (Yaz) 2 GC

lutera (28) (Amethyst) 2 GC



52






marlissa (Amethyst) 2 GC

microgestin fe 1.5/30 (28) (Loestrin Fe) 2 GC

microgestin fe 1/20 (28) (Loestrin Fe) 2 GC

MINASTRIN 24 FE 4

mononessa (28) (Ortho Tri-Cyclen) 2 GC

nikki (28) (Yaz) 2 GC

norethindrone-e.estradiol-iron oral tablet

1 mg-20 mcg (24)/75 mg (4)

(Loestrin Fe) 2 GC

ocella (Yaz) 2 GC

orsythia (Amethyst) 2 GC

ORTHO TRI-CYCLEN (28) 4

ORTHO TRI-CYCLEN LO (28) 4

ORTHO-CEPT (28) 4

ORTHO-CYCLEN (28) 4

portia (Amethyst) 2 GC

previfem (Ortho Tri-Cyclen) 2 GC

quasense (Levonorgestrel-

Ethin Estradiol)


días)

reclipsen (28) (Desogen) 2 GC

sprintec (28) (Ortho Tri-Cyclen) 2 GC

sronyx (Amethyst) 2 GC

tarina fe (Loestrin Fe) 2 GC

tri-legest fe (Loestrin Fe) 2 GC

trinessa (28) (Ortho Tri-Cyclen) 2 GC

tri-previfem (28) (Ortho Tri-Cyclen) 2 GC

tri-sprintec (28) (Ortho Tri-Cyclen) 2 GC

trivora (28) (Amethyst) 2 GC

velivet triphasic regimen (28) (Desogen) 2 GC

vestura (28) (Yaz) 2 GC

YASMIN (28) 4

YAZ (28) 4

Agentes orales y dentales

Agentes orales y dentales

chlorhexidine gluconate mucous

membrane

(Peridex) 2 GC

periogard (Peridex) 2 GC



53






triamcinolone acetonide dental (Triamcinolone

Acetonide)

2 GC

Agentes dermatológicos

Agentes dermatológicos, otros

ABSORICA 4

acyclovir topical (Zovirax) 2 GC; QL (30 cada 30

días)

ALDARA 4 PA NSO; QL (24 cada

30 días)

ammonium lactate topical (Lac-Hydrin) 2 GC

amnesteem (Isotretinoin) 2 GC

AZELEX 4

calcipotriene topical cream (Dovonex) 2 GC

calcipotriene topical ointment (Calcipotriene) 2 GC

calcipotriene topical solution (Calcipotriene) 2 GC

CARAC 5

claravis (Isotretinoin) 2 GC

DOVONEX TOPICAL CREAM 4

EFUDEX TOPICAL CREAM 4

FINACEA TOPICAL GEL 4

fluorouracil topical cream (Carac) 2 GC

fluorouracil topical solution (Fluorouracil) 2 GC

imiquimod (Aldara) 2 PA NSO; GC; QL (24

cada 30 días)

myorisan (Isotretinoin) 2 GC

SORILUX 4

zenatane (Isotretinoin) 2 GC

ZOVIRAX TOPICAL CREAM 3 QL (15 cada 30 días)

ZOVIRAX TOPICAL OINTMENT 4 QL (30 cada 30 días)

ZYCLARA TOPICAL CREAM IN

METERED-DOSE PUMP 2.5 %


28 días)


METERED-DOSE PUMP 3.75 %

4 PA NSO


PACKET

4 PA NSO

Antibacterianos dermatológicos

ACANYA 4



54






BACTROBAN TOPICAL OINTMENT 4

BENZACLIN 4

BENZACLIN PUMP 4

CLEOCIN T 4

CLINDACIN P 4

CLINDACIN PAC 4

CLINDAGEL 4

clindamycin phosphate topical foam (Evoclin) 2 GC

clindamycin phosphate topical gel (Cleocin T) 2 GC

clindamycin phosphate topical lotion (Cleocin T) 2 GC

clindamycin phosphate topical solution (Cleocin T) 2 GC

clindamycin phosphate topical swab (Cleocin T) 2 GC

clindamycin-benzoyl peroxide topical gel

1-5 %

(Duac) 2 GC

EVOCLIN 4

METROCREAM 4

METROGEL TOPICAL GEL 1 % 4

METROLOTION 4

metronidazole topical cream (Metrocream) 2 GC

metronidazole topical gel (Metrogel) 2 GC

metronidazole topical lotion (Metrolotion) 2 GC

mupirocin (Bactroban) 2 GC

neuac (Duac) 2 GC

NORITATE 4

ONEXTON 4

SILVADENE 4

silver sulfadiazine (Silvadene) 2 GC

ssd (Silvadene) 2 GC

Agentes antiinflamatorios dermatológicos

ala-cort topical cream (Anusol-HC) 2 GC

ala-scalp (Scalacort) 2 GC

ANUSOL-HC RECTAL CREAM 4

betamethasone dipropionate (Betamethasone

Dipropionate)

2 GC

betamethasone, augmented topical gel (Betamethasone

Dipropionate)

2 GC

clobetasol topical cream (Temovate) 2 GC



55






clobetasol topical foam (Olux) 2 GC

clobetasol topical gel (Clobetasol

Propionate)

2 GC

clobetasol topical lotion (Clobex) 2 GC

clobetasol topical ointment (Temovate) 2 GC

clobetasol topical shampoo (Clobex) 2 GC

clobetasol topical solution (Clobetasol

Propionate)

2 GC

clobetasol topical spray,non-aerosol (Clobex) 2 GC

clobetasol-emollient topical cream (Temovate) 2 GC

CLOBEX 4

CLODAN 4

colocort (Cortenema) 2 GC

cormax topical solution (Clobetasol

Propionate)

2 GC

DESONATE 4

desonide topical cream (Desowen) 2 GC

desonide topical lotion (Desowen) 2 GC

desonide topical ointment (Desonide) 2 GC

ELOCON 4

fluocinonide topical cream (Vanos) 2 GC

fluocinonide topical gel (Fluocinonide) 2 GC

fluocinonide topical ointment (Fluocinonide) 2 GC

fluocinonide topical solution (Fluocinonide) 2 GC

fluocinonide-e (Vanos) 2 GC

hydrocortisone rectal enema (Cortenema) 2 GC

hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 2 GC

hydrocortisone topical lotion 2.5 % (Scalacort) 2 GC

hydrocortisone topical ointment 1 %, 2.5

%

(Hydrocortisone) 2 GC

KENALOG TOPICAL 4

mometasone (Elocon) 2 GC

OLUX 4

procto-pak (Anusol-HC) 2 GC

proctosol hc (Hydrocortisone) 2 GC

proctozone-hc (Hydrocortisone) 2 GC

TEMOVATE TOPICAL CREAM 4



56






TEMOVATE TOPICAL OINTMENT 4

triamcinolone acetonide topical aerosol (Kenalog) 2 GC

triamcinolone acetonide topical cream (Triamcinolone

Acetonide)

2 GC

triamcinolone acetonide topical lotion (Triamcinolone

Acetonide)

2 GC

triamcinolone acetonide topical ointment

0.025 %, 0.1 %, 0.5 %

(Triamcinolone

Acetonide)

2 GC

trianex (Triamcinolone

Acetonide)

2 GC

triderm topical cream (Triamcinolone

Acetonide)

2 GC

VANOS 5

Retinoides dermatológicos

adapalene topical cream (Differin) 2 GC

adapalene topical gel (Differin) 2 GC

ATRALIN 4 PA

avita (Retin-A) 2 PA; GC

DIFFERIN TOPICAL CREAM 4

DIFFERIN TOPICAL GEL 4

DIFFERIN TOPICAL LOTION 4

RETIN-A 4 PA

tretinoin topical (Retin-A) 2 PA; GC

Escabicidas y pediculicidas

malathion (Ovide) 2 GC

OVIDE 4

permethrin topical cream (Elimite) 2 GC

Dispositivos

Dispositivos

BD INSULIN SYRINGE ULTRA-FINE

SYRINGE 1 ML 31 X 5/16", 1/2 ML 31 X

5/16"

2 GC

INSULIN SYRINGE-NEEDLE U-100

SYRINGE 1 ML 29 X 1/2", 1/2 ML 28

2 GC

Reemplazos/modificadores enzimáticos

Reemplazos/modificadores enzimáticos



57






CREON 3

KUVAN ORAL POWDER IN PACKET

500 MG

5

KUVAN ORAL TABLET,SOLUBLE 5

ORFADIN 5

PANCREAZE 4

PERTZYE 4

PULMOZYME 5 PA BvD

SUCRAID 5

ULTRESA 4

VIOKACE 4

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-34,000 -

55,000 UNIT, 15,000-51,000 -82,000

UNIT, 20,000-68,000 -109,000 UNIT,

25,000-85,000- 136,000 UNIT, 3,000-

10,000- 16,000 UNIT, 40,000-136,000-

218,000 UNIT

3

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 5,000-17,000 -27,000

UNIT

4

Agentes para garganta, nariz, oídos y ojos

Agentes para garganta, nariz, oídos y ojos, varios

ASTEPRO NASAL SPRAY,NON-

AEROSOL


atropine ophthalmic drops (Isopto Atropine) 2 GC

ATROVENT NASAL SPRAY,NON-

AEROSOL 0.03 %


ATROVENT NASAL SPRAY,NON-

AEROSOL 0.06 %


azelastine nasal (Astepro) 2 GC; QL (30 cada 25

días)

azelastine ophthalmic (Azelastine HCl) 2 GC

cromolyn ophthalmic (Cromolyn Sodium) 2 GC

ipratropium bromide nasal spray,non-

aerosol 0.03 %

(Atrovent) 2 GC; QL (30 cada 28

días)

ipratropium bromide nasal spray,non-

aerosol 0.06 %

(Atrovent) 2 GC; QL (15 cada 10

días)



58






olopatadine (Patanase) 2 GC; QL (30.5 cada 30

días)

PATADAY 4 ST

PATANASE 4 QL (30.5 cada 30 días)

PATANOL 4 ST

PAZEO 4 ST

Agentes antiinfecciosos para garganta, nariz, oídos y ojos

CIPRODEX 3

CORTISPORIN OTIC SOLUTION 4

erythromycin ophthalmic (Ilotycin) 2 GC

GARAMYCIN OPHTHALMIC DROPS 4

gentak ophthalmic ointment (Garamycin) 2 GC

gentamicin ophthalmic (Garamycin) 2 GC

ILOTYCIN 4

MAXITROL 4

MOXEZA 3

neomycin-polymyxin b-dexameth (Maxitrol) 2 GC

neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxi

n B Sulf/HC)

2 GC

neomycin-polymyxin-hc otic

drops,suspension

(Neomycin/Polymyxi

n B Sulf/HC)

2 GC

neomycin-polymyxin-hc otic solution (Cortisporin) 2 GC

OCUFLOX 4

ofloxacin ophthalmic (Ocuflox) 2 GC

ofloxacin otic (Ocuflox) 2 GC

TOBRADEX 4

TOBRADEX ST 3

tobramycin-dexamethasone (Tobradex) 2 GC

VIGAMOX 3

Agentes antiinflamatorios para garganta, nariz, oídos y ojos

ACULAR 4

ACULAR LS 4

ALREX 3 ST

fluticasone nasal (Fluticasone

Propionate)


días)

ketorolac ophthalmic (Acular LS) 2 GC

LOTEMAX 3



59






NASONEX 4 QL (34 cada 28 días)

OMNIPRED 4

PRED FORTE 4

PRED MILD 4

prednisolone acetate (Pred Forte) 2 GC

RESTASIS 3 QL (60 cada 30 días)

triamcinolone acetonide nasal (Triamcinolone

Acetonide)

2 GC; QL (16.5 cada 30

días)

Agentes gastrointestinales

Agentes antiulcerosos y supresores del ácido

esomeprazole magnesium oral

capsule,delayed release(dr/ec) 20 mg

(Nexium) 2 ST; GC

famotidine (pf) (Famotidine) 2 GC

famotidine intravenous (Famotidine) 2 GC

famotidine oral suspension (Pepcid) 2 (Producto con receta

solamente); GC

famotidine oral tablet 20 mg, 40 mg (Pepcid) 1 (Producto con receta

solamente); GC

NEXIUM 4 ST

NEXIUM PACKET 4 ST

omeprazole oral capsule,delayed

release(dr/ec)

(Prilosec) 2 GC

pantoprazole oral (Protonix) 2 GC

PEPCID ORAL SUSPENSION 4 (Producto con receta

solamente)

PEPCID ORAL TABLET 20 MG 4 (Producto con receta

solamente)

PRILOSEC ORAL

CAPSULE,DELAYED

RELEASE(DR/EC)

4 (Producto con receta

solamente)

PROTONIX 4

ranitidine hcl injection (Zantac) 2 (Producto con receta

solamente); GC

ranitidine hcl oral capsule (Ranitidine HCl) 2 (Producto con receta

solamente); GC

ranitidine hcl oral syrup (Ranitidine HCl) 2 (Producto con receta

solamente); GC



60






ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) 1 (Producto con receta

solamente); GC

ZANTAC INJECTION 4

ZANTAC ORAL TABLET 4 (Producto con receta

solamente)

Agentes gastrointestinales, otros

ACTIGALL 4

BENTYL INTRAMUSCULAR 4

BENTYL ORAL CAPSULE 4

BENTYL ORAL TABLET 4

constulose (Lactulose) 2 GC

dicyclomine oral capsule (Bentyl) 2 GC

dicyclomine oral solution (Dicyclomine HCl) 2 GC

dicyclomine oral tablet (Bentyl) 2 GC

diphenoxylate-atropine oral liquid (Diphenoxylate

HCl/Atropine)

2 GC

diphenoxylate-atropine oral tablet (Lomotil) 2 GC

enulose (Lactulose) 2 GC

generlac (Lactulose) 2 GC

KRISTALOSE 4

lactulose oral solution 10 gram/15 ml (Lactulose) 2 GC

LOMOTIL 4

loperamide oral capsule (Loperamide HCl) 2 GC

metoclopramide hcl injection solution (Metoclopramide

HCl)

2 GC

metoclopramide hcl oral solution (Metoclopramide

HCl)

2 GC

metoclopramide hcl oral tablet (Reglan) 1 GC

metoclopramide hcl oral

tablet,disintegrating

(Metozolv Odt) 2 GC

METOZOLV ODT ORAL


4

REGLAN ORAL 4

URSO 250 4

URSO FORTE 4

ursodiol oral capsule (Actigall) 2 GC

ursodiol oral tablet (Urso) 2 GC



61






Laxantes

COLYTE WITH FLAVOR PACKS 4

gavilyte-c (Golytely) 2 GC

gavilyte-g (Golytely) 2 GC

GOLYTELY 4

peg 3350-electrolytes oral recon soln 236-

22.74-6.74 -5.86 gram

(Golytely) 2 GC

SUPREP BOWEL PREP KIT 4

Quelantes de fosfato

calcium acetate oral capsule (Phoslo) 2 GC

eliphos (Calcium Acetate) 2 GC

PHOSLO 4

PHOSLYRA 4

RENVELA 3

Agentes genitourinarios

Antiespasmódicos, urinarios

DETROL 4

DETROL LA 4

DITROPAN XL 4

GELNIQUE TRANSDERMAL GEL IN

PACKET


oxybutynin chloride oral syrup (Oxybutynin

Chloride)

2 GC

oxybutynin chloride oral tablet (Oxybutynin

Chloride)

2 GC

oxybutynin chloride oral tablet extended

release 24hr

(Ditropan XL) 2 GC

tolterodine oral capsule,extended release

24hr

(Detrol LA) 2 GC

tolterodine oral tablet (Detrol) 2 GC

VESICARE 3

Agentes genitourinarios, varios

FLOMAX 4

tamsulosin (Flomax) 2 GC

terazosin (Terazosin HCl) 1 GC

Antagonistas de metales pesados



62






Antagonistas de metales pesados

CUPRIMINE 5

DEPEN TITRATABS 5

EXJADE ORAL TABLET,

DISPERSIBLE 125 MG

4

EXJADE ORAL TABLET,

DISPERSIBLE 250 MG, 500 MG

5

JADENU 5

Agentes hormonales, estimulantes/reemplazos/modificadores

Andrógenos

ANDRODERM 3 PA; QL (30 cada 30 días)

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 1.25 GRAM/

ACTUATION (1 %)

4 PA; QL (300 cada 30

días)


METERED-DOSE PUMP 20.25 MG/1.25

GRAM (1.62 %)

3 PA; QL (150 cada 30

días)


PACKET 1 % (25 MG/2.5GRAM), 1 %

(50 MG/5 GRAM)

4 PA; QL (300 cada 30

días)


PACKET 1.62 % (20.25 MG/1.25

GRAM), 1.62 % (40.5 MG/2.5 GRAM)

3 PA; QL (150 cada 30

días)

AXIRON 3 PA; QL (180 cada 28

días)

DEPO-TESTOSTERONE 4 PA

FORTESTA 4 PA; QL (120 cada 30

días)

NATESTO 4 PA

STRIANT 4 PA; QL (60 cada 30 días)

TESTIM 4 PA; QL (300 cada 30

días)

testosterone cypionate (Depo-Testosterone) 2 PA; GC

testosterone transdermal gel in metered-

dose pump 1.25 gram/ actuation (1 %)

(Androgel) 2 PA; GC; QL (300 cada

30 días)

testosterone transdermal gel in metered-

dose pump 10 mg/0.5 gram /actuation


30 días)



63






testosterone transdermal gel in packet 1 %

(25 mg/2.5gram)


30 días)

testosterone transdermal gel in packet 1 %

(50 mg/5 gram)

(Testim) 2 PA; GC; QL (300 cada

30 días)

VOGELXO TRANSDERMAL GEL 4 PA; QL (300 cada 30

días)

VOGELXO TRANSDERMAL GEL IN

METERED-DOSE PUMP

4 PA; QL (300 cada 30

días)

Estrógenos y antiestrógenos

ALORA 4 PA-HRM; QL (8 cada 28

días)

CLIMARA 4 PA-HRM; QL (4 cada 28

días)

DIVIGEL TRANSDERMAL GEL IN

PACKET 0.5 MG (0.1 %), 1 MG (0.1 %)

4 PA-HRM; QL (30 cada

30 días)

ELESTRIN 4 PA-HRM

ESTRACE ORAL 4 PA-HRM

ESTRACE VAGINAL 3

estradiol oral (Estrace) 2 PA-HRM; GC

estradiol transdermal patch semiweekly (Vivelle-Dot) 2 PA-HRM; GC; QL (8

cada 28 días)

estradiol transdermal patch weekly (Climara) 2 PA-HRM; GC; QL (4

cada 28 días)

ESTRING 4 QL (1 cada 84 días)

EVAMIST 4 PA-HRM; QL (8.1 cada

25 días)

EVISTA 4

MENOSTAR 4 PA-HRM; QL (4 cada 28

días)

MINIVELLE 4 PA-HRM; QL (8 cada 28

días)

PREMARIN INJECTION 3

PREMARIN ORAL 3 PA-HRM

PREMARIN VAGINAL 3

PREMPHASE 3 PA-HRM

PREMPRO 3 PA-HRM

raloxifene (Evista) 2 GC

VAGIFEM 3 QL (18 cada 28 días)



64






VIVELLE-DOT 4 PA-HRM; QL (8 cada 28

días)

Glucocorticoides/mineralocorticoides

DEXAMETHASONE INTENSOL 4

dexamethasone oral elixir (Dexamethasone) 2 PA BvD; GC

dexamethasone oral tablet (Dexamethasone) 1 PA BvD; GC

DEXPAK 13 DAY 4

MEDROL 4 PA BvD

MEDROL (PAK) 4 PA BvD

methylprednisolone (Medrol) 2 PA BvD; GC

MILLIPRED ORAL SOLUTION 4

ORAPRED ODT ORAL


4 PA BvD

ORAPRED ODT ORAL

TABLET,DISINTEGRATING 15 MG, 30

MG

4

prednisolone sodium phosphate oral

solution 15 mg/5 ml, 25 mg/5 ml (5

mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

(Pediapred) 2 PA BvD; GC


tablet,disintegrating 10 mg

(Orapred Odt) 2 PA BvD; GC


tablet,disintegrating 15 mg, 30 mg

(Orapred Odt) 2 GC

PREDNISONE INTENSOL 3 PA BvD

prednisone oral solution (Prednisone) 2 PA BvD; GC

prednisone oral tablet (Prednisone) 1 PA BvD; GC

RAYOS 4 PA BvD

VERIPRED 20 4 PA BvD

Pituitaria

CHORIONIC GONADOTROPIN,

HUMAN

4

DDAVP INJECTION 4

DDAVP NASAL SOLUTION 4

DDAVP ORAL 4

desmopressin injection (Desmopressin

Acetate)

2 GC



65






desmopressin nasal solution (DDAVP) 2 GC; QL (15 cada 30

días)

desmopressin nasal spray,non-aerosol (Desmopressin

Acetate)


días)

desmopressin oral (DDAVP) 2 GC

GENOTROPIN 5 PA

GENOTROPIN MINIQUICK

SUBCUTANEOUS SYRINGE 0.2

MG/0.25 ML

4 PA

GENOTROPIN MINIQUICK

SUBCUTANEOUS SYRINGE 0.4

MG/0.25 ML, 0.6 MG/0.25 ML, 0.8

MG/0.25 ML, 1 MG/0.25 ML, 1.2

MG/0.25 ML, 1.4 MG/0.25 ML, 1.6

MG/0.25 ML, 1.8 MG/0.25 ML, 2

MG/0.25 ML

5 PA

HUMATROPE 5 PA

NORDITROPIN FLEXPRO 5 PA

NORDITROPIN NORDIFLEX 5 PA

NOVAREL 4

NUTROPIN AQ NUSPIN 5 PA

NUTROPIN AQ SUBCUTANEOUS

CARTRIDGE

5 PA

OMNITROPE 5 PA

PREGNYL 4

SAIZEN 5 PA

SAIZEN CLICK.EASY 5 PA

SEROSTIM SUBCUTANEOUS RECON

SOLN 4 MG, 5 MG, 6 MG

5 PA

STIMATE 4

ZOMACTON 5 PA

ZORBTIVE 5 PA

Progestinas

CRINONE VAGINAL GEL 4 % 4

DEPO-PROVERA INTRAMUSCULAR

SOLUTION


DEPO-PROVERA INTRAMUSCULAR

SUSPENSION




66






DEPO-SUBQ PROVERA 104 4 QL (1 cada 84 días)

medroxyprogesterone intramuscular

suspension

(Depo-Provera) 2 GC; QL (1 cada 84 días)

medroxyprogesterone oral (Provera) 2 GC

progesterone micronized (Prometrium) 2 GC

PROMETRIUM 4

PROVERA 4

Agentes tiroideos y antitiroideos

CYTOMEL 4

levothyroxine intravenous recon soln 100

mcg

(Levothyroxine

Sodium)

2 GC

levothyroxine oral (Synthroid) 1 GC

LEVOXYL ORAL TABLET 100 MCG,

112 MCG, 125 MCG, 137 MCG, 150

MCG, 175 MCG, 200 MCG, 25 MCG, 50

MCG, 75 MCG, 88 MCG

4

liothyronine intravenous (Triostat) 2 GC

liothyronine oral (Cytomel) 2 GC

SYNTHROID 4

TIROSINT 4

TRIOSTAT 4

UNITHROID ORAL TABLET 100 MCG,

112 MCG, 125 MCG, 150 MCG, 175

MCG, 200 MCG, 25 MCG, 300 MCG, 50

MCG, 75 MCG, 88 MCG

4

Agentes inmunitarios

Agentes inmunitarios

ARAVA 4

ASTAGRAF XL 4 PA BvD

AZASAN 4 PA BvD

azathioprine (Imuran) 2 PA BvD; GC

CELLCEPT ORAL CAPSULE 4 PA BvD

CELLCEPT ORAL SUSPENSION FOR

RECONSTITUTION

5 PA BvD

CELLCEPT ORAL TABLET 5 PA BvD

cyclosporine modified (Neoral) 2 PA BvD; GC

ENBREL 5 PA



67






ENBREL SURECLICK 5 PA

gengraf (Neoral) 2 PA BvD; GC

HUMIRA 5 PA

HUMIRA CROHN'S DIS START PCK 5 PA

HUMIRA PEN 5 PA

IMURAN 4 PA BvD

leflunomide (Arava) 2 GC

mycophenolate mofetil oral capsule (Cellcept) 2 PA BvD; GC

mycophenolate mofetil oral suspension for

reconstitution

(Cellcept) 5 PA BvD

mycophenolate mofetil oral tablet (Cellcept) 2 PA BvD; GC

mycophenolate sodium (Myfortic) 2 PA BvD; GC

MYFORTIC 4 PA BvD

NEORAL 4 PA BvD

PROGRAF 4 PA BvD

tacrolimus oral (Prograf) 2 PA BvD; GC

Vacunas

ADACEL(TDAP

ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION

3

BOOSTRIX TDAP 3

ENGERIX-B (PF) 3 PA BvD; QL (3 cada 365

días)

ENGERIX-B PEDIATRIC (PF) 3 PA BvD; QL (3 cada 365

días)

GARDASIL (PF) 3 QL (1.5 cada 365 días)

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML

3

HAVRIX (PF) INTRAMUSCULAR

SYRINGE 720 ELISA UNIT/0.5 ML

3

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF) 3

RECOMBIVAX HB (PF)

INTRAMUSCULAR SUSPENSION 10

MCG/ML, 40 MCG/ML

3 PA BvD; QL (3 cada 365

días)

RECOMBIVAX HB (PF)

INTRAMUSCULAR SYRINGE

3 PA BvD; QL (3 cada 365

días)



68






TWINRIX (PF) INTRAMUSCULAR

SUSPENSION

3

TYPHIM VI INTRAMUSCULAR

SOLUTION

3

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML

3

VAQTA (PF) INTRAMUSCULAR

SYRINGE

3

ZOSTAVAX (PF) 3 QL (1 cada 365 días)

Agentes para la enfermedad inflamatoria intestinal

Agentes para la enfermedad inflamatoria intestinal APRISO 3

ASACOL HD 3

budesonide oral (Entocort EC) 5

CANASA 4

DELZICOL 3

ENTOCORT EC 5

LIALDA 4 ST

mesalamine rectal (Sfrowasa) 2 GC

mesalamine with cleansing wipe (Sfrowasa) 2 GC

PENTASA 4 ST

SFROWASA 4

UCERIS ORAL 5 ST

UCERIS RECTAL 4

Soluciones de irrigación

Soluciones de irrigación

sodium chloride irrigation (Sodium Chloride

Irrig Solution)

2 GC

water for irrigation, sterile (Water For

Irrigation,Sterile)

2 GC

Agentes para las osteopatías metabólicas

Agentes para las osteopatías metabólicas

ACTONEL ORAL TABLET 150 MG 4 QL (1 cada 28 días)

ACTONEL ORAL TABLET 30 MG, 5

MG


ACTONEL ORAL TABLET 35 MG 3 QL (4 cada 28 días)



69






alendronate oral solution (Alendronate

Sodium)

2 GC; QL (300 cada 28

días)

alendronate oral tablet 10 mg, 40 mg, 5

mg

(Fosamax) 1 GC

alendronate oral tablet 35 mg, 70 mg (Fosamax) 1 GC; QL (4 cada 28 días)

ATELVIA 4 QL (4 cada 28 días)

BINOSTO 4 QL (4 cada 28 días)

BONIVA INTRAVENOUS 4 PA BvD; (PA para

ESRD solamente); QL (3

cada 84 días)

BONIVA ORAL 4 QL (1 cada 28 días)

calcitriol intravenous solution 1 mcg/ml (Calcitriol) 2 PA BvD; (PA para

ESRD solamente); GC

calcitriol oral (Rocaltrol) 2 PA BvD; (PA para

ESRD solamente); GC

FOSAMAX ORAL TABLET 70 MG 4

ibandronate intravenous solution (Ibandronate

Sodium)

2 PA BvD; (PA para

ESRD solamente); GC;


ibandronate oral (Boniva) 2 GC; QL (1 cada 28 días)

risedronate oral tablet 150 mg (Actonel) 2 GC; QL (1 cada 28 días)

risedronate oral tablet 30 mg, 5 mg (Actonel) 2 GC; QL (30 cada 28

días)

risedronate oral tablet,delayed release

(dr/ec)

(Atelvia) 2 GC; QL (4 cada 28 días)

ROCALTROL ORAL CAPSULE 0.25

MCG

4 PA BvD

ROCALTROL ORAL CAPSULE 0.5

MCG

4 PA BvD; (PA para

ESRD solamente)

ROCALTROL ORAL SOLUTION 4 PA BvD; (PA para

ESRD solamente)

Agentes terapéuticos varios

Agentes terapéuticos varios

allopurinol (Zyloprim) 2 GC

AVODART 4

AVONEX (WITH ALBUMIN) 5 ST

AVONEX INTRAMUSCULAR PEN

INJECTOR KIT

5 ST



70






AVONEX INTRAMUSCULAR

SYRINGE KIT

5 ST

buspirone (Buspirone HCl) 2 GC

colchicine oral capsule (Mitigare) 2 GC

colchicine oral tablet (Colcrys) 2 GC

COLCRYS 4

COPAXONE SUBCUTANEOUS

SYRINGE

5

ELMIRON 4

finasteride oral tablet 5 mg (Proscar) 2 GC

glatopa (Copaxone) 5

GLUCAGEN HYPOKIT 3

GLUCAGON EMERGENCY KIT

(HUMAN)

4

hydroxyzine hcl intramuscular (Hydroxyzine HCl) 2 PA-HRM; GC

hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) 2 PA-HRM; GC

hydroxyzine hcl oral tablet (Hydroxyzine HCl) 2 PA-HRM; GC

hydroxyzine pamoate (Vistaril) 2 PA-HRM; GC

leucovorin calcium injection recon soln

100 mg, 200 mg, 350 mg

(Leucovorin

Calcium)

2 GC

leucovorin calcium oral (Leucovorin

Calcium)

2 GC

MESTINON ORAL 4

MESTINON TIMESPAN 4

PROSCAR 4

pyridostigmine bromide oral tablet (Mestinon) 2 GC

REBIF (WITH ALBUMIN) 5

REBIF REBIDOSE 5

REBIF TITRATION PACK 5

SENSIPAR ORAL TABLET 30 MG 3

SENSIPAR ORAL TABLET 60 MG, 90

MG

5

TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG




71






TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG (14)- 240

MG (46), 240 MG


ULORIC 3 ST; QL (30 cada 30 días)

VISTARIL 4 PA-HRM

ZYLOPRIM 4

Agentes oftálmicos

Agentes antiglaucoma

ALPHAGAN P OPHTHALMIC DROPS

0.1 %

3

ALPHAGAN P OPHTHALMIC DROPS

0.15 %

4

brimonidine (Alphagan P) 2 (gotas: 0.15%, 0.20%);

GC

COSOPT 4

dorzolamide-timolol (Cosopt) 2 GC

ISTALOL 4

latanoprost (Xalatan) 2 GC

LUMIGAN OPHTHALMIC DROPS 0.01

%


timolol maleate ophthalmic drops (Timolol Maleate) 2 GC

timolol maleate ophthalmic gel forming

solution

(Timoptic-Xe) 2 GC

TIMOPTIC-XE 4

TRAVATAN Z 3 QL (2.5 cada 25 días)

XALATAN 4 QL (2.5 cada 25 días)

Preparaciones de reemplazo

Preparaciones de reemplazo

d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45

% NaCl)

2 GC

dextrose 5 %-lactated ringers (Dextrose 5%-

Lactated Ringers)

2 GC

klor-con 10 (Potassium Chloride) 2 GC

KLOR-CON 8 4

klor-con m10 (Potassium Chloride) 2 GC




72







K-TAB 4

LACTATED RINGERS INTRAVENOUS 4

magnesium sulfate injection (Magnesium Sulfate) 2 GC

potassium chlorid-d5-0.45%nacl (Potassium

Chloride/D5-

0.45nacl)

2 GC

potassium chloride intravenous piggyback

10 meq/100 ml, 10 meq/50 ml, 20 meq/100

ml, 20 meq/50 ml, 40 meq/100 ml

(Potassium Chloride) 2 GC

potassium chloride intravenous solution (Potassium Chloride) 2 GC

potassium chloride oral capsule, extended

release

(Micro-K) 2 GC

potassium chloride oral liquid (Potassium Chloride) 2 GC

potassium chloride oral tablet extended

release 10 meq, 8 meq

(K-Tab ER) 2 GC

potassium chloride oral tablet,er

particles/crystals 10 meq

(K-Tab ER) 2 GC

potassium chloride oral tablet,er

particles/crystals 20 meq

(Potassium Chloride) 2 GC

potassium citrate (Urocit-K) 2 GC

sodium chloride 0.45 % intravenous

parenteral solution

(Sodium Chloride

0.45 %)

2 GC

sodium chloride 0.9 % intravenous

parenteral solution

(0.9 % Sodium

Chloride)

2 GC

sodium chloride intravenous parenteral

solution 2.5 meq/ml

(Sodium Chloride) 2 GC

UROCIT-K 10 4

UROCIT-K 15 4

UROCIT-K 5 4

Agentes de las vías respiratorias

Antiinflamatorios, corticoesteroides inhalados

ADVAIR DISKUS 3 QL (60 cada 30 días)

ADVAIR HFA 3 QL (12 cada 28 días)

FLOVENT DISKUS INHALATION

BLISTER WITH DEVICE 100

MCG/ACTUATION, 50

MCG/ACTUATION




73






FLOVENT DISKUS INHALATION

BLISTER WITH DEVICE 250

MCG/ACTUATION


FLOVENT HFA INHALATION HFA

AEROSOL INHALER 110

MCG/ACTUATION



AEROSOL INHALER 220

MCG/ACTUATION



AEROSOL INHALER 44

MCG/ACTUATION


QVAR 3 QL (17.4 cada 25 días)

Antileucotrienos

ACCOLATE 4

montelukast (Singulair) 2 GC

SINGULAIR 4

zafirlukast (Accolate) 2 GC

Broncodilatadores

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,

2.5 mg /3 ml (0.083 %), 5 mg/ml

(Albuterol Sulfate) 2 PA BvD; GC

albuterol sulfate oral syrup (Albuterol Sulfate) 2 GC

albuterol sulfate oral tablet (Albuterol Sulfate) 2 GC

albuterol sulfate oral tablet extended

release 12 hr

(Vospire ER) 2 GC

ATROVENT HFA 3 QL (25.8 cada 28 días)

COMBIVENT RESPIMAT 3 QL (8 cada 30 días)

PROAIR HFA 3 QL (17 cada 25 días)

PROAIR RESPICLICK 3 QL (2 cada 30 días)

PROVENTIL HFA 4 QL (13.4 cada 25 días)

SPIRIVA RESPIMAT 3 QL (4 cada 30 días)

SPIRIVA WITH HANDIHALER 3 QL (30 cada 30 días)

VENTOLIN HFA 3 QL (36 cada 25 días)

VOSPIRE ER 4

Agentes de las vías respiratorias, otros

DALIRESP 3 QL (30 cada 30 días)



74






XOLAIR 5 PA

Miorrelajantes

Miorrelajantes

AMRIX 4 PA-HRM

baclofen (Baclofen) 2 GC

cyclobenzaprine oral tablet (Fexmid) 2 PA-HRM; GC

FEXMID 4 PA-HRM

methocarbamol oral (Robaxin) 2 PA-HRM; GC

Agentes para el trastorno del sueño

Agentes para el trastorno del sueño

AMBIEN 4 PA-HRM; (med. de alto






90 días con cualquier

medicamento hipnótico

de no benzodiacepina);


AMBIEN CR 4 PA-HRM; (med. de alto












75






EDLUAR 4 PA-HRM; (med. de alto










eszopiclone (Lunesta) 2 PA-HRM; GC; QL (30

cada 30 días)

INTERMEZZO 4 PA-HRM; (med. de alto










LUNESTA 4 PA-HRM; (med. de alto










modafinil (Provigil) 2 PA; GC; QL (60 cada 30

días)

PROVIGIL 4 PA; QL (60 cada 30 días)



76






zolpidem oral tablet (Ambien) 2 PA-HRM; (med. de alto









GC; QL (30 cada

30 días)

zolpidem oral tablet,ext release multiphase (Ambien CR) 2 PA-HRM; (med. de alto









GC; QL (30 cada

30 días)

ZOLPIMIST 4 PA-HRM; (med. de alto









QL (7.7 cada 30 días)

Agentes vasodilatadores

Agentes vasodilatadores

ADCIRCA 5 PA; QL (60 cada 30 días)

CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; QL (30 cada 30 días)

REVATIO INTRAVENOUS 5 PA; QL (37.5 cada 1 día)

REVATIO ORAL SUSPENSION FOR

RECONSTITUTION

5 PA; QL (224 cada 30

días)



77






REVATIO ORAL TABLET 5 PA; QL (90 cada 30 días)

sildenafil intravenous (Revatio) 5 PA; QL (37.5 cada 1 día)

sildenafil oral (Revatio) 2 PA; GC; QL (90 cada 30

días)

TRACLEER 5 PA; LA; QL (60 cada 30

días)

Vitaminas y minerales

Vitaminas y minerales

multivitamin with fluoride (Pedi M.Vit No.17

with Fluoride)

2 GC

prenatal plus (calcium carb) (Pnv with

Ca,No.72/Iron/Fa)

3 (Todas las vitaminas

prenatales con receta

cubiertas)

prenatal vitamins low iron (Pnv with

Ca,No.72/Iron/Fa)

3 (Todas las vitaminas

prenatales con receta

cubiertas)

sodium fluoride oral tablet (Pedi M.Vit No.17

with Fluoride)

2 GC

I-1




A ABILIFY ................................ 37

ABILIFY DISCMELT ........... 36

ABILIFY MAINTENA .......... 37

ABSORICA ............................ 52

ACANYA ............................... 52

ACCOLATE........................... 72

acetaminophen-codeine .......... 12

ACTIGALL ............................ 59

ACTONEL ............................. 67

ACTOS ................................... 30

ACULAR ............................... 57

ACULAR LS .......................... 57

acyclovir ........................... 39, 52

ADACEL(TDAP

ADOLESN/ADULT)(PF) .. 66

ADALAT CC ......................... 45

adapalene ................................ 55

ADCIRCA .............................. 75

ADDERALL .......................... 48

ADDERALL XR .................... 48

ADOXA ................................. 23

ADVAIR DISKUS ................. 71

ADVAIR HFA ....................... 71

afeditab cr ............................... 45

AFINITOR ............................. 23

AFINITOR DISPERZ ............ 23

AGRYLIN .............................. 41

ala-cort .................................... 53

ala-scalp .................................. 53

albuterol sulfate ...................... 72

ALDACTAZIDE .................... 47

ALDACTONE ....................... 47

ALDARA ............................... 52

alendronate ............................. 68

allopurinol .............................. 68

ALORA .................................. 62

ALPHAGAN P ....................... 70

alprazolam ............................. 18

ALPRAZOLAM INTENSOL 18

ALREX .................................. 57

ALSUMA .............................. 34

ALTACE ............................... 42

ALTOPREV .......................... 46

AMARYL .............................. 32

AMBIEN ............................... 73

AMBIEN CR ......................... 73

AMETHYST ......................... 50

amiodarone ............................ 43

amitriptyline........................... 28

amlodipine ............................. 45

amlodipine-benazepril ........... 45

ammonium lactate .................. 52

amnesteem ............................. 52

amoxicillin ....................... 21, 22

amoxicillin-pot clavulanate ... 22

amphetamine salt combo ....... 48

ampicillin ............................... 22

AMRIX .................................. 73

anagrelide ............................... 41

anastrozole ............................. 24

ANDRODERM ..................... 61

ANDROGEL ......................... 61

ANUSOL-HC ........................ 53

apri ......................................... 50

APRISO ................................. 67

ARAVA ................................. 65

ARICEPT............................... 28

ARIMIDEX ........................... 24

aripiprazole ............................ 37

AROMASIN .......................... 24

ASACOL HD ........................ 67

ASTAGRAF XL .................... 65

ASTEPRO ............................. 56

ATELVIA .............................. 68

atenolol .................................. 43

ATIVAN ................................ 18

atorvastatin ............................. 46

atovaquone-proguanil ............ 35

ATRALIN .............................. 55

ATRIPLA ............................... 38

atropine ............................ 26, 56

ATROVENT .......................... 56

ATROVENT HFA ................. 72

aubra ....................................... 50

AUGMENTIN ....................... 22

AVAPRO ............................... 42

AVELOX ............................... 22

AVELOX ABC PACK .......... 22

aviane ..................................... 50

avita ........................................ 55

AVODART ............................ 68

AVONEX ......................... 68, 69

AVONEX (WITH ALBUMIN)

............................................ 68

AXIRON ................................ 61

AZASAN ............................... 65

azathioprine ............................ 65

azelastine ................................ 56

AZELEX ................................ 52

azithromycin .......................... 21

AZULFIDINE ........................ 22

AZULFIDINE EN-TABS ...... 22

B baclofen .................................. 73

BACTRIM ............................. 22

BACTRIM DS ....................... 23

BACTROBAN ....................... 53

BD INSULIN SYRINGE

ULTRA-FINE .................... 55

benazepril ............................... 43

BENTYL ................................ 59

BENZACLIN ......................... 53

BENZACLIN PUMP ............. 53

ÍNDICE

I-2




benztropine ............................. 36

betamethasone dipropionate ... 53

betamethasone, augmented..... 53

BIAXIN .................................. 21

bicalutamide ........................... 24

BINOSTO............................... 68

BONIVA ................................ 68

BOOSTRIX TDAP ................ 66

brimonidine ............................ 70

budesonide .............................. 67

BUNAVAIL ........................... 18

buprenorphine hcl ................... 18

buprenorphine-naloxone......... 18

buproban ................................. 28

bupropion hcl.......................... 28

buspirone ................................ 69

butalbital-acetaminophen-caff 12

BYDUREON .......................... 30

BYETTA ................................ 30

C CALAN .................................. 44

CALAN SR ............................ 44

calcipotriene ........................... 52

calcitriol .................................. 68

calcium acetate ....................... 60

CANASA ............................... 67

CAPITAL WITH CODEINE . 12

CARAC .................................. 52

carbamazepine ........................ 26

CARBATROL ........................ 26

carbidopa-levodopa ................ 36

CARDIZEM ........................... 44

CARDIZEM CD .................... 44

CARDIZEM LA ..................... 44

CARDURA ............................ 42

CARDURA XL ...................... 42

cartia xt ................................... 44

carvedilol ................................ 43

CASODEX ............................. 24

CATAPRES ........................... 42

CAYSTON ............................. 21

cefadroxil .......................... 20, 21

cefdinir ................................... 21

cefpodoxime .......................... 21

cefprozil ................................. 21

CEFTIN ................................. 21

ceftriaxone ............................. 21

cefuroxime axetil ................... 21

CELEBREX........................... 16

celecoxib ................................ 16

CELEXA ............................... 28

CELLCEPT ........................... 65

cephalexin .............................. 21

CHANTIX ............................. 18

CHANTIX CONTINUING

MONTH BOX ................... 18

CHANTIX CONTINUING

MONTH PAK.................... 18

CHANTIX STARTING

MONTH BOX ................... 18

chlorhexidine gluconate ......... 51

chlorthalidone ........................ 46

CHORIONIC

GONADOTROPIN,

HUMAN ............................ 63

CIALIS .................................. 75

cilostazol ................................ 41

CIPRO ................................... 22

CIPRODEX ........................... 57

ciprofloxacin hcl .................... 22

citalopram .............................. 29

claravis ................................... 52

CLARINEX ..................... 33, 34

clarithromycin ........................ 21

CLEOCIN .............................. 19

CLEOCIN T .......................... 53

CLIMARA ............................. 62

CLINDACIN P ...................... 53

CLINDACIN PAC ................ 53

CLINDAGEL ........................ 53

clindamycin hcl...................... 19

clindamycin palmitate hcl ...... 19

clindamycin pediatric ............ 19

clindamycin phosphate .......... 53

clindamycin-benzoyl peroxide

............................................ 53

CLINIMIX 5%-

D20W(SULFITE-FREE) ... 41

CLINIMIX E 4.25%/D25W

SUL FREE ......................... 42

CLINIMIX E 5%/D15W

SULFIT FREE ................... 42

CLINIMIX E 5%/D20W

SULFIT FREE ................... 42

CLINISOL SF 15 %............... 42

clobetasol ......................... 53, 54

clobetasol-emollient ............... 54

CLOBEX................................ 54

CLODAN ............................... 54

clonazepam ...................... 18, 19

clonidine hcl ........................... 42

clopidogrel ............................. 41

clotrimazole............................ 33

clotrimazole-betamethasone .. 33

clozapine ................................ 37

CLOZARIL ............................ 37

COGENTIN ........................... 36

colchicine ............................... 69

COLCRYS ............................. 69

colocort .................................. 54

COLYTE WITH FLAVOR

PACKS ............................... 60

COMBIVENT RESPIMAT ... 72

COMPLERA .......................... 38

CONCERTA .......................... 48

constulose ............................... 59

CONZIP ................................. 12

COPAXONE .......................... 69

COREG .................................. 43

cormax.................................... 54

CORTISPORIN ..................... 57

COSOPT ................................ 70

COUMADIN.......................... 40

COZAAR ............................... 42

CREON ............................ 55, 56

CRESTOR.............................. 46

I-3




CRINONE .............................. 64

cromolyn................................. 56

CUPRIMINE .................... 60, 61

CYCLESSA (28) .................... 50

cyclobenzaprine ...................... 73

cyclosporine modified ............ 65

CYKLOKAPRON .................. 41

CYMBALTA ......................... 29

cyproheptadine ....................... 34

CYTOMEL............................. 65

D d5 %-0.45 % sodium chloride 70

DALIRESP ............................. 72

dapsone ................................... 35

DDAVP .................................. 63

delyla (28) .............................. 50

DELZICOL ............................ 67

DEPAKOTE ........................... 26

DEPAKOTE ER ..................... 26

DEPAKOTE SPRINKLES .... 26

DEPEN TITRATABS ............ 61

DEPO-PROVERA ................. 64

DEPO-SUBQ PROVERA 104

............................................ 65

DEPO-TESTOSTERONE ...... 61

desloratadine........................... 34

desmopressin .................... 63, 64

DESOGEN ............................. 50

DESONATE ........................... 54

desonide .................................. 54

DETROL ................................ 60

DETROL LA .......................... 60

dexamethasone ....................... 63

DEXAMETHASONE

INTENSOL ........................ 63

dexmethylphenidate ............... 48

DEXPAK 13 DAY ................. 63

dextroamphetamine-

amphetamine ...................... 48

dextrose 10 % in water (d10w)

............................................ 42

dextrose 5 % in water (d5w) .. 42

dextrose 5 %-lactated ringers 70

DIABETA .............................. 32

diclofenac sodium .................. 16

dicloxacillin ........................... 22

dicyclomine ........................... 59

DIFFERIN ............................. 55

DIFLUCAN ........................... 33

digitek .................................... 45

digox ...................................... 45

digoxin ................................... 45

DIGOXIN .............................. 45

DILANTIN ............................ 26

DILANTIN EXTENDED ...... 26

DILAUDID ............................ 12

diltiazem hcl .......................... 44

dilt-xr ..................................... 44

DIOVAN ............................... 42

DIOVAN HCT ...................... 42

diphenoxylate-atropine .......... 59

DITROPAN XL ..................... 60

divalproex .............................. 26

DIVIGEL ............................... 62

DOLOPHINE ........................ 12

donepezil ................................ 28

dorzolamide-timolol .............. 70

DOVONEX ........................... 52

doxazosin ............................... 42

doxycycline hyclate ............... 23

doxycycline monohydrate ...... 23

drospirenone-ethinyl estradiol 50

DROXIA ................................ 24

duloxetine .............................. 29

DURAGESIC ........................ 12

DYAZIDE ............................. 46

E EC-NAPROSYN ................... 16

econazole ............................... 33

EDLUAR ............................... 74

EFFEXOR XR ....................... 29

EFFIENT ............................... 41

EFUDEX ............................... 52

ELESTRIN ............................ 62

ELIGARD .............................. 24

eliphos .................................... 60

ELMIRON ............................. 69

ELOCON ............................... 54

emoquette ............................... 50

enalapril maleate .................... 43

ENBREL ................................ 65

ENBREL SURECLICK ......... 66

endocet ................................... 12

ENGERIX-B (PF) .................. 66

ENGERIX-B PEDIATRIC (PF)

............................................ 66

enoxaparin .............................. 40

enpresse .................................. 50

ENTOCORT EC .................... 67

enulose ................................... 59

EPANED ................................ 43

epitol ...................................... 27

EPOGEN ................................ 41

EPZICOM .............................. 38

EQUETRO ............................. 27

erythromycin .......................... 57

escitalopram oxalate............... 29

ESGIC .................................... 12

esomeprazole magnesium ...... 58

ESTRACE .............................. 62

estradiol .................................. 62

ESTRING ............................... 62

eszopiclone ............................. 74

ethambutol.............................. 35

EVAMIST .............................. 62

EVISTA ................................. 62

EVOCLIN .............................. 53

EXALGO ER ......................... 12

exemestane ............................. 24

EXJADE ................................ 61

EXTINA ................................. 33

F falmina (28) ............................ 50

famciclovir ............................. 39

famotidine .............................. 58

famotidine (pf) ....................... 58

I-4




FAMVIR ................................ 39

FAZACLO ............................. 37

FEMARA ............................... 24

fenofibrate .............................. 46

FENOGLIDE ......................... 46

fentanyl ................................... 12

FEXMID................................. 73

FINACEA............................... 52

finasteride ............................... 69

FLAGYL ................................ 19

FLAGYL ER .......................... 19

flecainide ................................ 43

FLOMAX ............................... 60

FLOVENT DISKUS ........ 71, 72

FLOVENT HFA ..................... 72

fluconazole ............................. 33

fluocinonide ............................ 54

fluocinonide-e......................... 54

fluorouracil ............................. 52

fluoxetine ................................ 29

FLUOXETINE ....................... 29

flutamide................................. 24

fluticasone .............................. 57

FOCALIN............................... 48

FOCALIN XR ........................ 48

FORFIVO XL ........................ 29

FORTAMET .......................... 30

FORTESTA ............................ 61

FOSAMAX ............................ 68

furosemide .............................. 46

G gabapentin .............................. 27

GARAMYCIN ....................... 57

GARDASIL (PF).................... 66

gavilyte-c ................................ 60

gavilyte-g ................................ 60

GELNIQUE ............................ 60

gemfibrozil ............................. 46

generlac .................................. 59

gengraf .................................... 66

GENOTROPIN ...................... 64

GENOTROPIN MINIQUICK 64

gentak..................................... 57

gentamicin ....................... 19, 57

GEODON .............................. 37

gianvi (28).............................. 50

gildess 24 fe ........................... 50

glatopa ................................... 69

GLEEVEC ............................. 24

glimepiride ............................. 32

glipizide ................................. 32

GLUCAGEN HYPOKIT ....... 69

GLUCAGON EMERGENCY

KIT (HUMAN) .................. 69

GLUCOPHAGE .................... 30

GLUCOPHAGE XR.............. 30

GLUCOTROL ....................... 32

GLUCOTROL XL ................. 33

GLUMETZA ................... 30, 31

glyburide ................................ 33

GOLYTELY .......................... 60

GRALISE .............................. 27

GRALISE 30-DAY STARTER

PACK................................. 27

guanfacine .............................. 42

H haloperidol ............................. 37

HAVRIX (PF)........................ 66

HUMALOG ..................... 31, 32

HUMALOG KWIKPEN ....... 31

HUMATROPE ...................... 64

HUMIRA ............................... 66

HUMIRA CROHN'S DIS

START PCK ...................... 66

HUMIRA PEN ...................... 66

HYCET .................................. 12

hydralazine ............................. 45

HYDREA............................... 24

hydrochlorothiazide ............... 46

hydrocodone-acetaminophen 12,

13

hydrocortisone ....................... 54

hydromorphone ...................... 13

hydroxychloroquine ............... 35

hydroxyurea ........................... 24

hydroxyzine hcl ...................... 69

hydroxyzine pamoate ............. 69

HYZAAR ............................... 42

I ibandronate ............................. 68

ibuprofen ................................ 16

ILOTYCIN ............................. 57

imiquimod .............................. 52

IMITREX ............................... 34

IMITREX STATDOSE KIT

REFILL .............................. 34

IMURAN ............................... 66

INDERAL LA ........................ 43

INDOCIN ............................... 16

indomethacin .................... 16, 17

INLYTA ................................. 24

INNOPRAN XL..................... 43

INSULIN SYRINGE-NEEDLE

U-100 ................................. 55

INTERMEZZO ...................... 74

INTRALIPID ......................... 42

introvale ................................. 50

INVANZ ................................ 21

ipratropium bromide .............. 56

irbesartan ................................ 42

IRENKA ................................ 29

ISENTRESS ........................... 39

isoniazid ................................. 35

isosorbide mononitrate ........... 47

ISTALOL ............................... 70

J JADENU ................................ 61

JAKAFI .................................. 24

jantoven .................................. 40

JANUMET ............................. 31

JANUMET XR ...................... 31

JANUVIA .............................. 31

junel fe 1.5/30 (28) ................. 50

junel fe 1/20 (28) .................... 50

junel fe 24 .............................. 50

I-5




K KADIAN ................................ 13

KEFLEX................................. 21

KENALOG............................. 54

KEPPRA................................. 27

KEPPRA XR .......................... 27

ketoconazole ........................... 33

ketorolac ................................. 57

KLONOPIN ........................... 19

klor-con 10 ............................. 70

KLOR-CON 8 ........................ 70

klor-con m10 .......................... 70

klor-con m15 .......................... 70

klor-con m20 .......................... 71

KRISTALOSE ....................... 59

K-TAB .................................... 71

KUVAN ................................. 56

L labetalol .................................. 43

LACTATED RINGERS ......... 71

lactulose .................................. 59

LAMICTAL ........................... 27

LAMICTAL ODT .................. 27

LAMICTAL STARTER

(BLUE) KIT ....................... 27

LAMICTAL STARTER

(GREEN) KIT .................... 27

LAMICTAL STARTER

(ORANGE) KIT ................. 27

LAMICTAL XR ..................... 27

LAMICTAL XR STARTER

(BLUE) ............................... 27

LAMICTAL XR STARTER

(GREEN) ............................ 27

LAMICTAL XR STARTER

(ORANGE)......................... 27

LAMISIL ................................ 33

lamotrigine ............................. 27

LANOXIN .............................. 45

LANTUS ................................ 32

LANTUS SOLOSTAR .......... 32

larin fe .................................... 50

LASIX ................................... 46

latanoprost ............................. 70

leflunomide ............................ 66

lessina .................................... 50

letrozole ................................. 24

leucovorin calcium ................ 69

LEUKERAN .......................... 24

leuprolide ............................... 24

LEVAQUIN........................... 22

levetiracetam .......................... 27

levocetirizine ......................... 34

levofloxacin ........................... 22

levonest (28) .......................... 50

levonorgestrel-ethinyl estrad . 50

levora-28 ................................ 50

levothyroxine ......................... 65

LEVOXYL ............................ 65

LEXAPRO ............................. 29

LIALDA ................................ 67

lidocaine................................. 17

lidocaine hcl ........................... 17

lidocaine viscous.................... 17

LIDODERM .......................... 17

liothyronine ............................ 65

LIPITOR ................................ 46

LIPOFEN ............................... 47

lisinopril ................................. 43

lisinopril-hydrochlorothiazide 43

lithium carbonate ................... 48

LITHOBID ............................ 48

LO LOESTRIN FE ................ 50

LOESTRIN FE 1.5/30 (28-

DAY) ................................. 50

LOESTRIN FE 1/20 (28-DAY)

........................................... 50

LOFIBRA .............................. 47

lomedia 24 fe ......................... 50

LOMOTIL ............................. 59

loperamide ............................. 59

LOPID ................................... 47

LOPRESSOR......................... 43

lorazepam ............................... 19

lorazepam intensol ................. 19

lorcet (hydrocodone) .............. 13

lorcet hd ................................. 13

lorcet plus ............................... 13

LORTAB 10-325 ................... 13

LORTAB 5-325 ..................... 13

LORTAB 7.5-325 .................. 13

loryna (28) .............................. 50

losartan ................................... 42

losartan-hydrochlorothiazide . 42

LOTEMAX ............................ 57

LOTENSIN ............................ 43

LOTREL ................................ 45

LOTRISONE ......................... 33

lovastatin ................................ 47

LOVENOX ...................... 40, 41

LUMIGAN ............................. 70

LUNESTA ............................. 74

LUPRON DEPOT .................. 24

LUPRON DEPOT (3 MONTH)

............................................ 24


............................................ 24


............................................ 24

lutera (28) ............................... 50

LYRICA ................................. 27

LYSODREN .......................... 24

LYSTEDA ............................. 41

M MACROBID .......................... 19

MACRODANTIN.................. 20

magnesium sulfate ................. 71

MALARONE ......................... 36

MALARONE PEDIATRIC ... 36

malathion................................ 55

marlissa .................................. 51

matzim la ................................ 44

MAXALT .............................. 34

MAXALT-MLT ..................... 34

MAXITROL .......................... 57

MAXZIDE ............................. 46

I-6




MAXZIDE-25MG .................. 46

meclizine ................................ 35

MEDROL ............................... 63

MEDROL (PAK) ................... 63

medroxyprogesterone ............. 65

mefloquine .............................. 36

megestrol ................................ 24

meloxicam .............................. 17

MENACTRA (PF) ................. 66

MENOSTAR .......................... 62

MENVEO A-C-Y-W-135-DIP

(PF) ..................................... 66

mercaptopurine ....................... 25

mesalamine ............................. 67

mesalamine with cleansing wipe

............................................ 67

MESTINON ........................... 69

MESTINON TIMESPAN ...... 69

METADATE CD ............. 48, 49

metadate er ............................. 49

metformin ............................... 31

methadone ........................ 13, 14

methocarbamol ....................... 73

methotrexate sodium .............. 25

methotrexate sodium (pf) ....... 25

METHYLIN ........................... 49

methylphenidate ..................... 49

methylprednisolone ................ 63

metoclopramide hcl ................ 59

metoprolol succinate .............. 43

metoprolol tartrate ............ 43, 44

METOZOLV ODT ................. 59

METROCREAM .................... 53

METROGEL .......................... 53

METROGEL VAGINAL ....... 34

METROLOTION ................... 53

metronidazole ............. 20, 34, 53

microgestin fe 1.5/30 (28) ...... 51

microgestin fe 1/20 (28) ......... 51

MICROZIDE .......................... 46

MILLIPRED........................... 63

MINASTRIN 24 FE ............... 51

minitran .................................. 47

MINIVELLE ......................... 62

MINOCIN .............................. 23

minocycline ........................... 23

MIRAPEX ............................. 36

MIRAPEX ER ....................... 36

MOBIC .................................. 17

modafinil ................................ 74

mometasone ........................... 54

mononessa (28) ...................... 51

montelukast ............................ 72

morphine ................................ 14

MORPHINE .......................... 14

morphine concentrate ............ 14

MOXEZA .............................. 57

moxifloxacin .......................... 22

MS CONTIN ......................... 14

multivitamin with fluoride ..... 76

mupirocin ............................... 53

MYAMBUTOL ..................... 35

mycophenolate mofetil .......... 66

mycophenolate sodium .......... 66

MYFORTIC........................... 66

myorisan ................................ 52

N nabumetone ............................ 17

NAMENDA ........................... 28

NAMENDA TITRATION PAK

........................................... 28

NAMENDA XR .................... 28

NAPROSYN .......................... 17

naproxen ................................ 17

NASONEX ............................ 58

NATESTO ............................. 61

neomycin ............................... 19

neomycin-polymyxin b-

dexameth ............................ 57

neomycin-polymyxin-hc ........ 57

NEORAL ............................... 66

neuac ...................................... 53

NEULASTA .......................... 41

NEUPOGEN .......................... 41

NEURONTIN ........................ 27

NEXAVAR ............................ 25

NEXIUM................................ 58

NEXIUM PACKET ............... 58

nifedical xl ............................. 46

nifedipine ............................... 46

nikki (28) ................................ 51

NITRO-BID ........................... 47

NITRO-DUR.......................... 47

nitrofurantoin macrocrystal .... 20

nitrofurantoin monohyd/m-cryst

............................................ 20

nitroglycerin ........................... 47

NITROLINGUAL.................. 47

NITROMIST .......................... 47

NITROSTAT ......................... 47

NIZORAL .............................. 33

NORCO.................................. 14

NORDITROPIN FLEXPRO .. 64

NORDITROPIN NORDIFLEX

............................................ 64

norethindrone-e.estradiol-iron 51

NORITATE............................ 53

NORVASC ............................ 46

NORVIR ................................ 39

NOVAREL ............................ 64

NOVOLOG ............................ 32

NOVOLOG FLEXPEN ......... 32

NOVOLOG PENFILL ........... 32

NUTRILIPID ......................... 42

NUTROPIN AQ..................... 64

NUTROPIN AQ NUSPIN ..... 64

NUVESSA ............................. 34

nyamyc ................................... 33

nystatin ................................... 33

nystatin-triamcinolone ........... 33

nystop ..................................... 33

O ocella ...................................... 51

OCUFLOX ............................. 57

ofloxacin ................................ 57

olanzapine ........................ 37, 38

I-7




olopatadine ............................. 57

OLUX ..................................... 54

OLYSIO ................................. 39

omeprazole ............................. 58

OMNIPRED ........................... 58

OMNITROPE......................... 64

ondansetron ............................ 35

ONEXTON............................. 53

ONGLYZA............................. 31

ORACEA ............................... 23

ORAPRED ODT .................... 63

ORFADIN .............................. 56

orsythia ................................... 51

ORTHO TRI-CYCLEN (28) .. 51

ORTHO TRI-CYCLEN LO (28)

............................................ 51

ORTHO-CEPT (28) ............... 51

ORTHO-CYCLEN (28) ......... 51

OVIDE ................................... 55

oxybutynin chloride................ 60

oxycodone ........................ 14, 15

oxycodone-acetaminophen ..... 15

OXYCONTIN ........................ 15

P pacerone ................................. 43

PANCREAZE ........................ 56

pantoprazole ........................... 58

paroxetine hcl ......................... 29

PATADAY ............................. 57

PATANASE ........................... 57

PATANOL ............................. 57

PAXIL .................................... 29

PAXIL CR .............................. 29

PAZEO ................................... 57

peg 3350-electrolytes ............. 60

PEGASYS .............................. 39

PEGASYS PROCLICK ......... 39

PEGINTRON ......................... 39

PEGINTRON REDIPEN ....... 39

penicillin v potassium............. 22

PENNSAID ............................ 17

PENTASA .............................. 67

PEPCID ................................. 58

PERCOCET ........................... 15

periogard ................................ 51

permethrin .............................. 55

PERTZYE .............................. 56

phenadoz ................................ 35

PHENERGAN ....................... 35

PHENYTEK .......................... 27

phenytoin sodium extended ... 27

PHOSLO ................................ 60

PHOSLYRA .......................... 60

pioglitazone ........................... 31

PLAQUENIL ......................... 36

PLAVIX................................. 41

PLETAL ................................ 41

POMALYST .......................... 25

portia ...................................... 51

potassium chlorid-d5-0.45%nacl

........................................... 71

potassium chloride ................. 71

potassium citrate .................... 71

pramipexole ........................... 36

PRAVACHOL ....................... 47

pravastatin .............................. 47

PRED FORTE ....................... 58

PRED MILD .......................... 58

prednisolone acetate .............. 58

prednisolone sodium phosphate

........................................... 63

prednisone .............................. 63

PREDNISONE INTENSOL .. 63

PREGNYL ............................. 64

PREMARIN........................... 62

PREMPHASE ........................ 62

PREMPRO............................. 62

prenatal plus (calcium carb) .. 76

prenatal vitamins low iron ..... 76

previfem ................................. 51

PREZISTA............................. 39

PRILOSEC ............................ 58

PRIMLEV .............................. 15

PRIMSOL .............................. 20

PRINIVIL .............................. 43

PROAIR HFA ........................ 72

PROAIR RESPICLICK ......... 72

PROCARDIA ........................ 46

PROCARDIA XL .................. 46

prochlorperazine maleate ....... 35

PROCRIT ............................... 41

procto-pak .............................. 54

proctosol hc ............................ 54

proctozone-hc ......................... 54

progesterone micronized ........ 65

PROGRAF ............................. 66

promethazine .......................... 35

promethegan ........................... 35

PROMETRIUM ..................... 65

propafenone............................ 43

propantheline.......................... 26

propranolol ............................. 44

PROSCAR ............................. 69

PROSOL 20 % ....................... 42

PROTONIX ........................... 58

PROVENTIL HFA ................ 72

PROVERA ............................. 65

PROVIGIL ............................. 74

PROZAC ................................ 29

PROZAC WEEKLY .............. 29

PULMOZYME ...................... 56

PURIXAN .............................. 25

pyridostigmine bromide ......... 69

Q quasense ................................. 51

QUDEXY XR ........................ 28

quetiapine ............................... 38

QUILLIVANT XR................. 49

QVAR .................................... 72

R raloxifene ............................... 62

ramipril ................................... 43

ranitidine hcl .................... 58, 59

RAYOS .................................. 63

REBIF (WITH ALBUMIN) .. 69

REBIF REBIDOSE ................ 69

I-8




REBIF TITRATION PACK .. 69

reclipsen (28) .......................... 51

RECOMBIVAX HB (PF) ...... 66

REGLAN ................................ 59

RELPAX ................................ 34

RENVELA ............................. 60

REQUIP ................................. 36

REQUIP XL ........................... 36

RESTASIS ............................. 58

RETIN-A ................................ 55

REVATIO ........................ 75, 76

REVLIMID ............................ 25

REYATAZ ............................. 39

RHEUMATREX .................... 25

RIFADIN ................................ 35

rifampin .................................. 35

RIOMET................................. 31

risedronate .............................. 68

RISPERDAL .......................... 38

RISPERDAL M-TAB ............ 38

risperidone .............................. 38

RITALIN ................................ 49

RITALIN LA.......................... 49

rizatriptan ............................... 34

ROCALTROL ........................ 68

ropinirole ................................ 36

roxicet ..................................... 15

ROXICODONE ..................... 15

RYTARY ............................... 36

RYTHMOL ............................ 43

RYTHMOL SR ...................... 43

S SAIZEN .................................. 64

SAIZEN CLICK.EASY ......... 64

SARAFEM ............................. 29

SENSIPAR ............................. 69

SEROQUEL ........................... 38

SEROQUEL XR .................... 38

SEROSTIM ............................ 64

sertraline ................................. 29

SFROWASA .......................... 67

sildenafil ................................. 76

SILVADENE ......................... 53

silver sulfadiazine .................. 53

simvastatin ............................. 47

SINEMET .............................. 36

SINEMET CR........................ 36

SINGULAIR .......................... 72

sodium chloride ............... 67, 71

sodium chloride 0.45 % ......... 71

sodium chloride 0.9 % ........... 71

sodium fluoride ...................... 76

SOLARAZE .......................... 17

SOLODYN ............................ 23

SOLTAMOX ......................... 25

SORILUX .............................. 52

SOVALDI .............................. 39

SPIRIVA RESPIMAT ........... 72

SPIRIVA WITH

HANDIHALER ................. 72

spironolactone ........................ 47

spironolacton-hydrochlorothiaz

........................................... 47

sprintec (28) ........................... 51

SPRYCEL .............................. 25

sronyx .................................... 51

ssd .......................................... 53

STIMATE .............................. 64

STIVARGA ........................... 25

STRIANT .............................. 61

STRIBILD ............................. 39

SUBOXONE ......................... 18

SUBSYS ................................ 15

SUCRAID .............................. 56

sulfamethoxazole-trimethoprim

........................................... 23

sulfasalazine ........................... 23

sulfazine ec ............................ 23

sumatriptan succinate ...... 34, 35

SUMAVEL DOSEPRO ......... 35

SUPREP BOWEL PREP KIT 60

SUTENT ................................ 25

SYLATRON .......................... 39

SYNAGIS .............................. 39

SYNTHROID ........................ 65

T tacrolimus ............................... 66

TAMIFLU .............................. 39

tamoxifen ............................... 25

tamsulosin .............................. 60

TARCEVA ............................. 25

TARGRETIN ......................... 25

tarina fe .................................. 51

TASIGNA .............................. 25

taztia xt ................................... 44

TECFIDERA.................... 69, 70

TEGRETOL ........................... 28

TEGRETOL XR .................... 28

TEMOVATE.................... 54, 55

TENEX .................................. 42

TENORMIN .......................... 44

TERAZOL 3 .......................... 34

TERAZOL 7 .......................... 34

terazosin ................................. 60

terbinafine hcl ........................ 33

terconazole ............................. 34

TESTIM ................................. 61

testosterone ...................... 61, 62

testosterone cypionate ............ 61

TIAZAC ................................. 44

timolol maleate....................... 70

TIMOPTIC-XE ...................... 70

TINDAMAX .......................... 36

tinidazole ................................ 36

TIROSINT ............................. 65

TOBI ...................................... 19

TOBRADEX .......................... 57

TOBRADEX ST .................... 57

tobramycin in 0.225 % nacl ... 19

tobramycin-dexamethasone ... 57

tolterodine .............................. 60

TOPAMAX ............................ 28

topiramate .............................. 28

TOPROL XL .......................... 44

TOUJEO SOLOSTAR ........... 32

TRACLEER ........................... 76

I-9




TRADJENTA ......................... 31

tramadol .................................. 15

tranexamic acid ...................... 41

TRANSDERM-SCOP ............ 35

TRAVASOL 10 % ................. 42

TRAVATAN Z ...................... 70

trazodone ................................ 29

tretinoin .................................. 55

tretinoin (chemotherapy) ........ 25

TREXALL .............................. 25

triamcinolone acetonide .. 52, 55,

58

triamterene-hydrochlorothiazid

............................................ 46

trianex ..................................... 55

triderm .................................... 55

tri-legest fe.............................. 51

trimethoprim ........................... 20

trinessa (28) ............................ 51

TRIOSTAT............................. 65

tri-previfem (28) ..................... 51

tri-sprintec (28) ....................... 51

trivora (28).............................. 51

TROKENDI XR ..................... 28

TROPHAMINE 10 % ............ 42

TRUVADA ............................ 39

TWINRIX (PF) ...................... 67

TYKERB ................................ 25

TYLENOL-CODEINE #3...... 15

TYLENOL-CODEINE #4...... 15

TYPHIM VI ........................... 67

U UCERIS .................................. 67

ULORIC ................................. 70

ULTRAM ............................... 15

ULTRAM ER ................... 15, 16

ULTRESA .............................. 56

UNITHROID .......................... 65

UROCIT-K 10 ........................ 71

UROCIT-K 15 ........................ 71

UROCIT-K 5 .......................... 71

URSO 250 .............................. 59

URSO FORTE ....................... 59

ursodiol .................................. 59

V VAGIFEM ............................. 62

valacyclovir ........................... 40

valsartan ................................. 42

valsartan-hydrochlorothiazide 42

VALTREX............................. 40

VANCOCIN .......................... 20

vancomycin ............................ 20

VANDAZOLE....................... 34

VANOS ................................. 55

VAQTA (PF) ......................... 67

VASOTEC ............................. 43

velivet triphasic regimen (28) 51

venlafaxine ............................. 30

VENTOLIN HFA .................. 72

verapamil ............................... 44

VERELAN............................. 44

VERELAN PM ...................... 44

VERIPRED 20 ....................... 63

VERSACLOZ ........................ 38

VESICARE ............................ 60

vestura (28) ............................ 51

VIBRAMYCIN ..................... 23

vicodin ................................... 16

vicodin es ............................... 16

vicodin hp .............................. 16

VICTOZA 3-PAK ................. 31

VIGAMOX ............................ 57

VIOKACE ............................. 56

VIREAD ................................ 39

VISTARIL ............................. 70

VIVELLE-DOT ..................... 63

VOGELXO ............................ 62

VOLTAREN .......................... 17

VOLTAREN-XR ................... 17

VOSPIRE ER ........................ 72

VOTRIENT ........................... 26

VYVANSE ............................ 50

W warfarin .................................. 41

water for irrigation, sterile ..... 67

WELLBUTRIN...................... 30

WELLBUTRIN SR ................ 30

WELLBUTRIN XL ............... 30

X XALATAN ............................ 70

XALKORI.............................. 26

XANAX ................................. 19

XANAX XR........................... 19

XARELTO ............................. 41

XARTEMIS XR..................... 16

XODOL 10/300 ..................... 16

XODOL 5/300 ....................... 16

XODOL 7.5/300 .................... 16

XOLAIR ................................ 73

XTANDI ................................ 26

XYLOCAINE ........................ 17

XYZAL .................................. 34

Y YASMIN (28) ........................ 51

YAZ (28) ................................ 51

Z zafirlukast ............................... 72

ZAMICET .............................. 16

ZANTAC ............................... 59

ZELBORAF ........................... 26

zenatane.................................. 52

ZENPEP ................................. 56

ZESTORETIC........................ 43

ZESTRIL................................ 43

ziprasidone hcl ....................... 38

ZITHROMAX........................ 21

ZITHROMAX TRI-PAK ....... 21

ZITHROMAX Z-PAK ........... 21

ZMAX .................................... 21

ZOCOR .................................. 47

ZOFRAN ODT ...................... 35

ZOLOFT ................................ 30

zolpidem ................................. 75

ZOLPIMIST ........................... 75

ZOMACTON ......................... 64

ZORBTIVE ............................ 64

I-10




ZOSTAVAX (PF) .................. 67

ZOVIRAX ........................ 40, 52

ZUBSOLV ............................. 18

ZUPLENZ ............................. 35

ZYCLARA ............................ 52

ZYLOPRIM ........................... 70

ZYPREXA ............................. 38

ZYPREXA ZYDIS ................ 38

ZYTIGA ................................. 26



s0180039

Typewritten Text

Accepted 2015

accepted 2015 - connecture...stanford health care advantage 2016 n.º de id. del formulario:...

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