Formulario - ArchCare AA Spanish... · Formulario, aparece en las páginas de la portada y la...

Este documento incluye una lista de medicamentos cubiertos en nuestro formulario a fecha

1 de mayo de 2019. Puede encontrar información sobre lo que significan los símbolos y

abreviaturas de esta tabla en la página 7.

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2019 Formulario

(Lista de medicamentos cubiertos)

Este vademécum se actualizó el 1 de mayo de 2019. Para obtener

información más reciente o si tiene otras preguntas, póngase en

contacto con ArchCare Advantage HMO Special Needs Plan

Member Services llamando al 1-888-816-7977 o, para los usuarios de

TTY, 711, las 24 horas al día / 7 días a la semana, o visite

www.ArchCareAdvantage.org.

H1777_2019 FormularySP_C

FormularyFormularySP_C_Accepted




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ArchCare Advantage HMO Special Needs Plan

Formulario para 2019

Lista de medicamentos cubiertos

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN

ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Formulario: 00019298, Versión: 10

Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado.

Revise este documento para asegurarse de que aún contiene los medicamentos que toma.

Cuando esta Lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”, hace

referencia a Catholic Special Needs Plan, LLC. Cuando dice “plan” o “nuestro plan”, hace

referencia a ArchCare Advantage HMO Special Needs Plan.

Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual está

en vigencia desde el 1 de mayo de 2019. Para obtener un formulario actualizado, comuníquese

con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del

Formulario, aparece en las páginas de la portada y la portada posterior.

Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con

receta. Los beneficios, el formulario, la red de farmacias o los copagos/el coseguro pueden

cambiar el 1 de enero de 2019 y periódicamente durante el año.

¿Qué es el Formulario de ArchCare Advantage HMO Special Needs Plan?

Un Formulario es una lista de medicamentos cubiertos seleccionados por ArchCare Advantage

HMO Special Needs Plan con la colaboración de un equipo de proveedores de atención médica,

que representa los tratamientos con receta que se considera que son parte necesaria de un

programa de tratamiento de calidad. Normalmente, ArchCare Advantage HMO Special Needs

Plan cubrirá los medicamentos incluidos en el formulario, siempre que el medicamento sea

médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red de

ArchCare Advantage HMO Special Needs Plan y se cumpla con otras normas del plan. Para

obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia

de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?

En general, si usted toma un medicamento de nuestro Formulario para 2019 que estaba cubierto al

comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento

durante el año de cobertura 2019, excepto cuando esté disponible un nuevo medicamento genérico

de menor costo, cuando se dé a conocer nueva información acerca de la seguridad o eficacia del

medicamento, o el medicamento sea retirado del mercado. (Consulte los puntos a continuación

para obtener más información sobre cambios que afectan a los miembros que actualmente toman el

medicamento). Otros tipos de cambios en el Formulario, por ejemplo, la eliminación de un




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medicamento, no afectarán a los miembros que estén actualmente tomando el medicamento. Por

el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos

miembros que estén tomándolo. A continuación se incluyen cambios en la Lista de medicamentos

que también afectarán a los miembros que actualmente toman un medicamento:

Nuevos medicamentos genéricos. Podemos eliminar inmediatamente un medicamento de

marca de nuestra Lista de medicamentos si lo reemplazamos con un nuevo medicamento

genérico que aparecerá en el mismo nivel de costo compartido o en un nivel de costo

compartido más bajo y con las mismas restricciones o menos. Además, cuando agreguemos

el nuevo medicamento genérico, podemos decidir mantener el medicamento de marca en

nuestra Lista de medicamentos pero inmediatamente moverlo a un nivel de costo

compartido diferente o agregar nuevas restricciones. Si actualmente está tomando ese

medicamento de marca, quizás no le informemos con antelación antes de que realicemos el

cambio, pero más adelante le proporcionaremos información sobre los cambios específicos

que hemos realizado.

o Si realizamos un cambio, usted o la persona autorizada a dar recetas pueden

solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de

marca para usted. El aviso que le proporcionaremos también incluirá información

sobre los pasos que puede tomar para solicitar una excepción, y usted también

puede encontrar información en la sección a continuación titulada “¿Cómo puedo

solicitar que se haga una excepción al Formulario de ArchCare Advantage?”

Medicamentos retirados del mercado. Si la Administración de Drogas y Alimentos

considera que un medicamento de nuestro Formulario es inseguro o el fabricante del

medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de

nuestro Formulario y les notificaremos a los miembros que toman el medicamento en

cuestión.

Otros cambios. Podemos hacer otros cambios que afectan a los miembros que actualmente

toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no

es nuevo en el mercado para reemplazar un medicamento de marca que actualmente se

encuentre en el Formulario o agregar nuevas restricciones al medicamento de marca o

moverlo a un nivel de costo compartido diferente. O bien, podemos hacer cambios en

función de las nuevas pautas clínicas. Si retiramos medicamentos de nuestro Formulario, o

agregamos autorizaciones previas, restricciones de límite de cantidad o de tratamiento

escalonado en un medicamento, debemos notificarles a los miembros afectados por el

cambio al menos 30 días antes de que entre en vigencia dicho cambio, o cuando el

miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un

suministro del medicamento para 30 días.

El Formulario adjunto está vigente a partir del 1 de mayo de 2019. Para recibir información

actualizada sobre los medicamentos cubiertos por ArchCare Advantage, comuníquese con

nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada

posterior. Visite nuestro sitio web en www.ArchCareAdvantage.org o llame a nuestro número de

Servicios para Afiliados al 1-888-816-7977, las 24 horas, los siete días de la semana. Los usuarios

de TTY/TDD deben llamar al 711. Le notificaremos por correo en el caso de que se produzcan

cambios de mitad de año que no sean de mantenimiento en el formulario.




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¿Cómo utilizo el Formulario?

Hay dos formas para encontrar su medicamento dentro del Formulario:

Afección médica

El Formulario comienza en la página 11. Los medicamentos de este Formulario están

agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea.

Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran dentro

de la categoría “Cardiovascular”. Si sabe para qué se utiliza su medicamento, busque el

nombre de la categoría en la lista que empieza. Luego, busque su medicamento debajo del

nombre de la categoría.

Listado alfabético

Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que

comienza en la página 105. El Índice proporciona una lista alfabética de todos los

medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de

marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su

medicamento, verá el número de página donde puede encontrar información acerca de la

cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento

en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

ArchCare Advantage HMO Special Needs Plan cubre tanto los medicamentos de marca como

los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y

Alimentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el

medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de

marca.

¿Hay alguna restricción en mi cobertura?

Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos

requisitos y límites pueden incluir:

Autorización previa: ArchCare Advantage HMO Special Needs Plan exige que usted o su

médico obtenga una autorización previa para determinados medicamentos. Esto significa

que necesitará contar con la aprobación de ArchCare Advantage HMO Special Needs Plan

antes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible

que ArchCare Advantage HMO Special Needs Plan no cubra el medicamento.

Límites de cantidad: para ciertos medicamentos, ArchCare Advantage HMO Special

Needs Plan limita la cantidad del medicamento que cubrirá. Por ejemplo, ArchCare

Advantage HMO Special Needs Plan proporciona 30 por receta para Vesicare. Esto puede

ser complementario a un suministro estándar para un mes o tres meses.

Tratamiento escalonado: en algunos casos, ArchCare Advantage HMO Special Needs

Plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección

médica antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el

medicamento A y el medicamento B tratan su afección médica, es posible que ArchCare




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Advantage HMO Special Needs Plan no cubra el medicamento B a menos que usted

pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces

ArchCare Advantage HMO Special Needs Plan cubrirá el medicamento B.

Para averiguar si su medicamento tiene requisitos o límites adicionales, consulte el Formulario que

empieza en la página 7. También puede obtener más información sobre las restricciones que se

aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado en línea que

explica(n) nuestra(s) restricción de autorización previa restricción de tratamiento escalonado

restricciones de autorización previa y tratamiento escalonado. También puede pedirnos que le

enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización

del Formulario, aparece en las páginas de la portada y la portada posterior.

Puede pedirle a ArchCare Advantage HMO Special Needs Plan que haga una excepción a estas

restricciones o límites, o puede solicitarle una lista de otros medicamentos similares que puedan

tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al Formulario de

ArchCare Advantage HMO Special Needs Plan?” en la página 5 para obtener información acerca

de cómo solicitar una excepción.

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

Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos

cubiertos), primero debe comunicarse con Servicios para los miembros y preguntar si su

medicamento está cubierto.

Si resulta que ArchCare Advantage HMO Special Needs Plan no cubre el medicamento que toma,

tiene dos alternativas:

Puede pedir a Servicios para los miembros una lista de medicamentos similares que estén

cubiertos por ArchCare Advantage HMO Special Needs Plan. Cuando reciba la lista,

muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto

por ArchCare Advantage HMO Special Needs Plan.

Puede solicitar que ArchCare Advantage HMO Special Needs Plan haga una excepción y

cubra su medicamento. Consulte a continuación para obtener información sobre cómo

solicitar una excepción.

¿Cómo puedo solicitar que se haga una excepción al Formulario de ArchCare

Advantage HMO Special Needs Plan?

Puede solicitarle a ArchCare Advantage HMO Special Needs Plan que haga una excepción a

nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario.

Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido

predeterminado, y usted no podrá pedirnos que le brindemos el medicamento a un nivel de

costo compartido menor.

Puede pedirnos que no apliquemos restricciones o límites de cobertura para su

medicamento. Por ejemplo, para ciertos medicamentos, ArchCare Advantage HMO




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Special Needs Plan limita la cantidad del medicamento que cubriremos. Si su

medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al

límite y cubramos una cantidad mayor.

Por lo general, ArchCare Advantage HMO Special Needs Plan solo aprobará su pedido de

excepción si los medicamentos alternativos incluidos en el Formulario del plan, el medicamento de

menor costo compartido o las restricciones de uso adicionales no fueran tan efectivos para tratar su

afección o pudieran causarle efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión inicial de cobertura para una

excepción al Formulario, o a la restricción de uso. Cuando solicita una excepción al

Formulario, o a la restricción de uso, debe presentar una declaración de su médico o de la

persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una

decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su

solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada

(rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría

perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos

comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la

declaración de respaldo de su médico o de otra persona autorizada a dar recetas.

¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los

medicamentos que tomo o la solicitud de una excepción?

Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos

que no están incluidos en el Formulario. También es posible que esté tomando un medicamento

incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede

necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe

consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que

nosotros cubramos o solicitar una excepción al formulario para que le cubramos el medicamento

que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso,

podemos cubrir su medicamento, en ciertos casos, durante los primeros 90 días en que usted sea

miembro de nuestro plan.

Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para

conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su

receta está indicada para menos días, permitiremos que realice resurtidos por un máximo de hasta

30 días del medicamento. Después del primer suministro para 30 días, no seguiremos pagando

estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.

Si es residente de un centro de atención a largo plazo y necesita un medicamento que no está en el

Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los

primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del

medicamento para 31 días mientras solicita la excepción al formulario.




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Si experimenta un cambio en el nivel de atención, cubriremos un suministro de transición de sus

medicamentos. Un cambio de nivel de atención se produce cuando usted recibe el alta de un

hospital o hay un cambio de destino o procedencia a un centro de atención a largo plazo. En estas

circunstancias, le proporcionaremos un suministro de emergencia de medicamentos que no forman

parte del formulario (incluidos los medicamentos de la Parte D que no están en nuestro formulario,

pero requieren autorización previa o terapia en pasos en virtud de nuestras reglas de

administración de utilización). Este suministro de emergencia será para un suministro de 31 días, o

menos si su receta es por menos días. El suministro de emergencia es para asegurar que usted

reciba los medicamentos mientras que se ha solicitado una excepción.

Para obtener más información

Para obtener información más detallada sobre la cobertura para medicamentos con receta de

ArchCare Advantage, consulte la Evidencia de cobertura y otra documentación del plan.

Si tiene alguna pregunta sobre ArchCare Advantage HMO Special Needs Plan, comuníquese con

nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del

Formulario, aparece en las páginas de la portada y la portada posterior.

Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame

a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas, los 7 días de la semana. Los

usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

Formulario de ArchCare Advantage HMO Special Needs Plan

El formulario resumido a continuación/que comienza en la siguiente página proporciona

información acerca de la cobertura de los medicamentos cubiertos por ArchCare Advantage HMO

Special Needs Plan. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista,

consulte el Índice que comienza en la página 105.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de

marca están en letra mayúscula (por ejemplo, COUMADIN), y los medicamentos genéricos están

en letra minúscula y cursiva (por ejemplo, warfarin).

La información incluida en la columna de Requisitos/límites indica si ArchCare Advantage HMO

Special Needs Plan tiene algún requisito especial para la cobertura del medicamento.

GUÍA DE LAS ABREVIATURAS

PA – Se requiere autorización previa. Esto significa que usted o su médico debe obtener nuestra

aprobación antes de completar sus prescripciones para ciertos medicamentos. Si no consigue la

autorización, es posible que no cubramos los medicamentos.

QL – Corresponden límites de cantidad. Para algunos medicamentos, ponemos un límite a la

cantidad que cubrirá el plan.

B/D – El plan determinará si este medicamento quedará cubierto por la Parte B o Parte D de

Medicare, basándose en el motivo por el cual el doctor le haya prescrito este medicamento.




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LA – Acceso limitado: el medicamento sólo está disponible en un número limitado de farmacias

especializadas.

NM – No disponible en nuestras farmacias de pedidos por correo. No todos los medicamentos

están disponibles en el pedido por correo, por favor consulte con el servicio al cliente si tiene

cualquier pregunta.

ST – Terapia en etapas. En algunos casos, ArchCare Advantage requiere que primero pruebe con

ciertos medicamentos para tratar su enfermedad antes de cubrir otro medicamento para dicha

enfermedad.

Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Servicio al

Miembro, al 1-888-816-7977 (teléfono de texto (TTY: 711), las 24 horas del día, los 7 días de la

semana. ArchCare Advantage HMO SNP es un plan de Cuidado Coordinado con un contrato

Medicare. La inscripción en ArchCare Advantage depende de la renovación del contrato. Este plan

está disponible para cualquier persona con Medicare que se encuentra con el nivel de centro de

enfermería especializada (SNF) de la atención. Esta información está disponible gratuitamente en

otros idiomas. Llame a nuestro Servicio al Miembro, al 1-888-816-7977 (teléfono de texto (TTY:

711), las 24 horas del día, los 7 días de la semana.

El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.




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Discrimination is Against the Law

ArchCare complies with applicable Federal civil rights laws and does not discriminate on the basis

of race, color, national origin, age, disability, or sex. ArchCare does not exclude people or treat

them differently because of race, color, national origin, age, disability, or sex.

ArchCare

Provides free aids and services to people with disabilities to communicate effectively with

us, such as:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic

formats, other formats)

Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, contact Victor Fama at (917) 484-5055, TTY 711.

If you believe that ArchCare has failed to provide these services listed above or discriminated in

another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance

with: Victor Fama, (917) 484-5055, TTY 711, or email [email protected]. You can

file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Victor Fama

at (917) 484-5055, TTY 711, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint

Portal, available at https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available on-line at http://www.hhs.gov/civil-rights/filing-a-

complaint/complaint-process/index.html

ATTENTION: If you speak English, language assistance services, free of charge, are available to

you. Call 1-800-373-3177 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-800-373-3177 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-373-3177 (TTY:

711)。

https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf

http://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html

http://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html




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CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số

1-800-373-3177 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-

373-3177 (청각 장애인용 서비스: 711)으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong

sa wika nang walang bayad. Tumawag sa 1-800-373-3177 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги

перевода. Звоните 1-800-373-3177 (телетайп: 711).

3177-373-800-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

(711:YTT)الصم والبكم هاتف رقم

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele

1-800-373-3177 (TTY: 711).

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés

gratuitement. Appelez le 1-800-373-3177 (ATS: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń

pod numer 1-800-373-3177 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para

1-800-373-3177 (TTY: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero 1-800-373-3177 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-373-3177 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。（1-800-373-

3177 (TTY: 711).まで、お電話にてご連絡ください。

شما رای گان ب صورت رای ی ب ان یالت زب سھ ید، ت ن گو می ک ت ف سی گ ار ان ف ھ زب ر ب وجھ: اگ ت

ف یم دشاب .اب.(TTY: 711) 3177-373-800-1 سامت دیریگب.




11

ArchCare Advantage HMO Special Needs Plan

Formulario: Efectivo 1 de mayo de 2019

Nombre del Medicamento Nivel de Medicamento

Requisitos/Límites

ANALGESICS

GOUT

allopurinol tab 1

colchicine w/ probenecid 1

COLCRYS 1 QL (120 tabs / 30 days)

MITIGARE 1 QL (60 caps / 30 days)

probenecid 1

ULORIC 1 ST

NSAIDS

celecoxib CAPS 50mg 1 QL (240 caps / 30 days)




diclofenac potassium 1 QL (120 tabs / 30 days)

diclofenac sodium TB24; TBEC 1

diflunisal 1

etodolac 1

flurbiprofen TABS 1

ibu tab 600mg 1

ibu tab 800mg 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg 1




12

Nombre del Medicamento Nivel de

Medicamento

Requisitos/Límites

meloxicam TABS 1

nabumetone TABS 1

naproxen TABS 1

naproxen dr 1

naproxen sodium TABS 275mg, 550mg 1

piroxicam CAPS 1

sulindac TABS 1

OPIOID ANALGESICS

acetaminophen w/ codeine 300-15mg 1 QL (400 tabs / 30 days)



acetaminophen w/ codeine soln 1 QL (2700 mL / 30 days)

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

1

nalbuphine hcl SOLN 1

tramadol hcl tab 50 mg 1 QL (240 tabs / 30 days)

tramadol-acetaminophen 1 QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII

endocet 2.5-325mg 1 QL (360 tabs / 30 days)

endocet 5-325mg 1 QL (360 tabs / 30 days)

endocet 7.5-325mg 1 QL (240 tabs / 30 days)

endocet 10-325mg 1 QL (180 tabs / 30 days)

fentanyl citrate LPOP 1 QL (120 lozenges / 30 days), PA




13


Medicamento

Requisitos/Límites

fentanyl patch 12 mcg/hr 1 QL (10 patches / 30

days), PA

fentanyl patch 25 mcg/hr 1 QL (10 patches / 30

days), PA

fentanyl patch 50 mcg/hr 1 QL (10 patches / 30 days), PA



FENTORA 1 QL (120 tabs / 30 days), PA

hydroco/apap tab 5-325mg 1 QL (240 tabs / 30 days)

hydroco/apap tab 7.5-325 1 QL (180 tabs / 30 days)

hydroco/apap tab 10-325mg 1 QL (180 tabs / 30 days)

hydrocodone-acetaminophen 7.5-325

mg/15ml

1 QL (2700 mL / 30 days)

hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (150 tabs / 30 days)

hydromorphone hcl LIQD 1 QL (600 mL / 30 days)

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

1 B/D

hydromorphone hcl TABS 1 QL (180 tabs / 30 days)

HYSINGLA ER 1 QL (30 tabs / 30 days), PA

lorcet hd tab 10-325mg 1 QL (180 tabs / 30 days)

lorcet plus tab 7.5-325 1 QL (180 tabs / 30 days)

lorcet tab 5-325mg 1 QL (240 tabs / 30 days)

methadone hcl SOLN 5mg/5ml, 10mg/5ml 1 QL (450 mL / 30 days),

PA




14


Medicamento

Requisitos/Límites

methadone hcl 5mg 1 QL (90 tabs / 30 days), PA

methadone hcl 10mg 1 QL (90 tabs / 30 days), PA

methadone hcl intensol 1 QL (90 mL / 30 days), PA

morphine ext-rel tab 15mg, 30mg, 60mg,

100mg

1 QL (90 tabs / 30 days), PA

morphine ext-rel tab 200mg 1 QL (60 tabs / 30 days), PA

morphine sul inj 1mg/ml 1 B/D

MORPHINE SUL INJ 4MG/ML 1 B/D

morphine sul inj 10mg/ml 1 B/D

MORPHINE SULFATE SOLN 2mg/ml,

4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml

1 B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

1 B/D

morphine sulfate TABS 15mg 1 QL (180 tabs / 30 days)

morphine sulfate TABS 30mg 1 QL (90 tabs / 30 days)

morphine sulfate oral soln 10mg/5ml 1 QL (900 mL / 30 days)



NUCYNTA ER 50mg, 100mg, 200mg, 250mg

1 QL (60 tabs / 30 days), PA

NUCYNTA ER 150mg 1 QL (90 tabs / 30 days), PA

oxycodone hcl CAPS 1 QL (180 caps / 30 days)

oxycodone hcl CONC 1 QL (180 mL / 30 days)

oxycodone hcl SOLN 1 QL (900 mL / 30 days)




15


Medicamento

Requisitos/Límites

oxycodone hcl TABS 1 QL (180 tabs / 30 days)

oxycodone w/ acetaminophen 2.5-325mg 1 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 5-325mg 1 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 7.5-325mg 1 QL (240 tabs / 30 days)

oxycodone w/ acetaminophen 10-325mg 1 QL (180 tabs / 30 days)

ANESTHETICS

LOCAL ANESTHETICS

lidocaine hcl (local anesth.) 1 B/D

lidocaine inj 0.5% 1 B/D

lidocaine inj 1% 1 B/D

lidocaine inj 1.5% preservative free (pf) 1 B/D

ANTI-INFECTIVES

ANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN 1

gentamicin in saline 1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

SULFADIAZINE TABS 1

tobramycin NEBU 1 NM, PA

tobramycin inj 1.2 gm/30ml 1

tobramycin inj 1.2gm 1

tobramycin inj 10mg/ml 1




16


Medicamento

Requisitos/Límites

tobramycin inj 40mg/ml 1

tobramycin inj 80mg/2ml 1

ANTI-INFECTIVES - MISCELLANEOUS

albendazole TABS 1

ALINIA 1

atovaquone SUSP 1

AZACTAM IN ISO-OSMOTIC DE 1

AZACTAM/DEX INJ 1

aztreonam 1

CAYSTON 1 NM, LA, PA

clindamycin cap 75mg 1

clindamycin cap 300 mg 1

clindamycin hcl cap 150 mg 1

clindamycin phosphate in d5w 1

CLINDAMYCIN PHOSPHATE IN NACL 1

clindamycin phosphate inj 1

clindamycin soln 75mg/5ml 1

colistimethate sodium SOLR 1

dapsone TABS 1

DAPTOMYCIN 350mg 1

daptomycin 500mg 1

EMVERM 1

ertapenem sodium 1




17


Medicamento

Requisitos/Límites

imipenem-cilastatin 1

ivermectin TABS 1

linezolid in sodium chloride 1

linezolid inj 1

linezolid susp 1

linezolid tab 600mg 1

meropenem 1

methenamine hippurate 1

metronidazole TABS 1

metronidazole in nacl 1

NEBUPENT 1 B/D

nitrofurantoin macrocrystal 50mg, 100mg 1 PA; PA applies if 70 years and older after a 90 day

supply in a calendar year

nitrofurantoin monohyd macro 1 PA; PA applies if 70 years and older after a 90 day supply in a calendar year

PENTAM 300 1

pentamidine isethionate 1

praziquantel TABS 1

SIVEXTRO 1

sulfamethoxazole-trimethop ds 1

sulfamethoxazole-trimethoprim inj 1

sulfamethoxazole-trimethoprim susp 1




18


Medicamento

Requisitos/Límites

sulfamethoxazole-trimethoprim tab 400-

80mg

1

SYNERCID 1

tigecycline 1

trimethoprim TABS 1

vancomycin hcl CAPS 1

vancomycin hcl SOLR 1gm, 5gm, 10gm,

500mg, 750mg

1

VANCOMYCIN IN NACL 1

ANTIFUNGALS

ABELCET 1 B/D

AMBISOME 1 B/D

amphotericin b SOLR 1 B/D

caspofungin acetate 1

fluconazole SUSR; TABS 1

fluconazole in dextrose 1

fluconazole inj nacl 200 1

fluconazole inj nacl 400 1

flucytosine CAPS 1

griseofulvin microsize 1

griseofulvin ultramicrosize 1

itraconazole CAPS 1 PA

ketoconazole TABS 1 PA

MYCAMINE 1




19


Medicamento

Requisitos/Límites

NOXAFIL SUSP 1 QL (630 mL / 30 days)

NOXAFIL TBEC 1 QL (93 tabs / 30 days)

nystatin TABS 1

terbinafine hcl TABS 1 QL (90 tabs / year)

voriconazole SOLR; SUSR; TABS 1

ANTIMALARIALS

atovaquone-proguanil hcl 1

chloroquine phosphate TABS 1

COARTEM 1

mefloquine hcl 1

primaquine phosphate 26.3mg 1

PRIMAQUINE PHOSPHATE 26.3mg 1

quinine sulfate CAPS 1 PA

ANTIRETROVIRAL AGENTS

abacavir sulfate 1 NM

APTIVUS 1 NM

atazanavir sulfate 1 NM

CRIXIVAN 1 NM

didanosine 1 NM

EDURANT 1 NM

efavirenz 1 NM

EMTRIVA 1 NM

fosamprenavir tab 700 mg 1 NM

FUZEON 1 NM




20


Medicamento

Requisitos/Límites

INTELENCE 1 NM

INVIRASE 1 NM

ISENTRESS 1 NM

ISENTRESS HD 1 NM

lamivudine 1 NM

LEXIVA SUSP 1 NM

nevirapine susp 50 mg/5ml 1 NM

nevirapine tab 100mg er 1 NM

nevirapine tab 200mg 1 NM

nevirapine tab 400mg er 1 NM

NORVIR PACK 1 NM

NORVIR SOLN 1 NM

PIFELTRO 1 NM

PREZISTA SUSP 1 QL (400 mL / 30 days), NM

PREZISTA TABS 75mg 1 QL (480 tabs / 30 days), NM




RESCRIPTOR 1 NM

REYATAZ PACK 1 NM




21


Medicamento

Requisitos/Límites

ritonavir 1 NM

SELZENTRY 1 NM

stavudine 1 NM

tenofovir disoproxil fumarate 1 NM

TIVICAY 1 NM

TROGARZO 1 NM, LA

TYBOST 1 NM

VIDEX EC 125mg 1 NM

VIDEX PEDIATRIC 1 NM

VIRACEPT 1 NM

VIRAMUNE SUSP 1 NM

VIREAD POWD 1 NM

VIREAD TABS 150mg, 200mg, 250mg 1 NM

zidovudine cap 100mg 1 NM

zidovudine syp 50mg/5ml 1 NM

zidovudine tab 300mg 1 NM

ANTIRETROVIRAL COMBINATION AGENTS

abacavir sulfate-lamivudine 1 NM

abacavir sulfate-lamivudine-zidovudine 1 NM

ATRIPLA 1 NM

BIKTARVY 1 NM

CIMDUO 1 NM

COMPLERA 1 NM




22


Medicamento

Requisitos/Límites

DELSTRIGO 1 NM

DESCOVY 1 NM

EVOTAZ 1 NM

GENVOYA 1 NM

JULUCA 1 NM

KALETRA TAB 100-25MG 1 NM

KALETRA TAB 200-50MG 1 NM

lamivudine-zidovudine 1 NM

lopinavir-ritonavir 1 NM

ODEFSEY 1 NM

PREZCOBIX 1 NM

STRIBILD 1 NM

SYMFI 1 NM

SYMFI LO 1 NM

SYMTUZA 1 NM

TRIUMEQ 1 NM

TRUVADA TAB 100-150 1 QL (60 tabs / 30 days),

NM


NM


NM


NM




23


Medicamento

Requisitos/Límites

ANTITUBERCULAR AGENTS

cycloserine CAPS 1

ethambutol hcl TABS 1

isoniazid TABS 1

isoniazid syp 50mg/5ml 1

PASER D/R 1

PRIFTIN 1

pyrazinamide TABS 1

rifabutin 1

rifampin CAPS; SOLR 1

RIFATER 1

SIRTURO 1 LA, PA

TRECATOR 1

ANTIVIRALS

acyclovir CAPS; SUSP; TABS 1

acyclovir sodium 1 B/D

adefovir dipivoxil 1 NM

BARACLUDE SOLN 1 NM

entecavir 1 NM

EPCLUSA 1 NM, PA

EPIVIR HBV SOLN 1 NM

famciclovir 1

ganciclovir sodium 1 B/D

HARVONI 1 NM, PA




24


Medicamento

Requisitos/Límites

lamivudine (hbv) 1 NM

MAVYRET 1 NM, PA

oseltamivir phosphate CAPS 30mg 1 QL (168 caps / year)

oseltamivir phosphate CAPS 45mg, 75mg 1 QL (84 caps / year)

oseltamivir phosphate SUSR 1 QL (1080 mL / year)

PEGASYS 1 NM, PA

PEGASYS PROCLICK 1 NM, PA

REBETOL SOLN 1 NM

RELENZA DISKHALER 1 QL (6 inhalers / year)

ribasphere CAPS 1 NM

ribasphere TABS 200mg, 600mg 1 NM

RIBASPHERE TABS 400mg 1 NM

ribavirin cap 200mg 1 NM

ribavirin tab 200mg 1 NM

rimantadine hydrochloride 1

valacyclovir hcl TABS 1

valganciclovir hcl 1

VEMLIDY 1 NM

VOSEVI 1 NM, PA

ZEPATIER 1 NM, PA

CEPHALOSPORINS

cefaclor 1

CEFACLOR ER TAB 500MG 1




25


Medicamento

Requisitos/Límites

cefadroxil 1

CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 1

cefazolin inj 1

cefazolin sodium SOLR 1gm, 20gm 1

CEFAZOLIN SODIUM 1 GM/50ML 1

cefdinir 1

cefepime for inj 1

cefixime 1

cefotaxime sodium 1

cefoxitin for inj 1

cefpodoxime proxetil 1

cefprozil 1

ceftazidime SOLR 1

CEFTAZIDIME/DEXTROSE 1

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1

cefuroxime axetil 1

cefuroxime sodium 1

cephalexin CAPS 250mg, 500mg 1

cephalexin SUSR 1

SUPRAX CAPS 1

SUPRAX CHEW 1

SUPRAX SUSR 500mg/5ml 1




26


Medicamento

Requisitos/Límites

tazicef SOLR 1

TEFLARO 1

ERYTHROMYCINS/MACROLIDES

azithromycin PACK; SOLR; SUSR; TABS 1

clarithromycin TABS 1

clarithromycin er 1

clarithromycin for susp 1

DIFICID 1

e.e.s. 400 1

ery-tab 1

ERYTHROCIN LACTOBIONATE 1

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate TABS 1

FLUOROQUINOLONES

ciprofloxacin SUSR 1

ciprofloxacin hcl tab 1

ciprofloxacin in d5w 1

levofloxacin TABS 1

levofloxacin in d5w 1

levofloxacin inj 25mg/ml 1

levofloxacin oral soln 25 mg/ml 1

moxifloxacin hcl TABS 1




27


Medicamento

Requisitos/Límites

PENICILLINS

amoxicillin 1

amoxicillin & pot clavulanate 1

ampicillin & sulbactam sodium 1

ampicillin cap 500mg 1

ampicillin inj 1

ampicillin sodium 1

BICILLIN L-A 1

dicloxacillin sodium 1

nafcillin sodium for inj 1

NAFCILLIN SODIUM FOR INJ 10GM 1

oxacillin sodium 1

PENICILLIN G POT IN DEXTROSE 2MU 1

PENICILLIN G POT IN DEXTROSE 3MU 1

PENICILLIN G PROCAINE 1

penicillin g sodium 1

penicillin v potassium 1

penicilln gk inj 5mu 1

penicilln gk inj 20mu 1

pfizerpen-g inj 5mu 1

pfizerpen-g inj 20mu 1

piper/tazoba inj 2-0.25gm 1





28


Medicamento

Requisitos/Límites


PIPER/TAZOBA INJ 12-1.5GM 1


TETRACYCLINES

doxy 100 1

doxycycline (monohydrate) CAPS 50mg, 100mg

1

doxycycline (monohydrate) TABS 1

doxycycline hyclate CAPS; SOLR 1

doxycycline hyclate 20 mg 1

doxycycline hyclate 100 mg 1

minocycline hcl CAPS 1

mondoxyne nl cap 100mg 1

morgidox cap 1x50mg 1

tetracycline hcl CAPS 1

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS

BENDEKA 1 B/D, NM

cyclophosphamide CAPS; SOLR 1 B/D

dacarbazine 100mg 1 B/D

EMCYT 1

GLEOSTINE 1

IFEX INJ 3GM 1 B/D

ifosfamide inj 1gm/20ml 1 B/D

IFOSFAMIDE INJ 3GM 1 B/D




29


Medicamento

Requisitos/Límites

ifosfamide inj 3gm/60ml 1 B/D

LEUKERAN 1

ANTHRACYCLINES

adriamycin SOLN 1 B/D

doxorubicin hcl 1 B/D

doxorubicin hcl liposomal 1 B/D

epirubicin hcl 1 B/D

ANTIBIOTICS

bleomycin sulfate 1 B/D

mitomycin SOLR 1 B/D

ANTIMETABOLITES

adrucil 1 B/D

adrucil inj 1 B/D

ALIMTA 1 B/D

azacitidine 1 B/D, NM

cytarabine 20mg/ml 1 B/D

fluorouracil SOLN 1 B/D

gemcitabine inj soln 1 B/D

gemcitabine inj solr 1 B/D

mercaptopurine TABS 1

methotrexate sodium inj 1 B/D

PURIXAN 1 NM

TABLOID 1




30


Medicamento

Requisitos/Límites

ANTIMITOTIC, TAXOIDS

ABRAXANE 1 B/D

docetaxel CONC 20mg/ml, 80mg/4ml 1 B/D

DOCETAXEL CONC 80mg/4ml,

160mg/8ml, 200mg/10ml

1 B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D

paclitaxel 1 B/D

TAXOTERE 80mg/4ml 1 B/D

ANTIMITOTIC, VINCA ALKALOIDS

vinblastine sulfate 1 B/D

vincasar pfs 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERS

AVASTIN 1 NM, LA, PA

BORTEZOMIB 1 NM, PA

DAURISMO 1 NM, LA, PA

ERIVEDGE 1 NM, LA, PA

FARYDAK 1 NM, LA, PA

HERCEPTIN 1 NM, PA

IBRANCE 1 NM, LA, PA

IDHIFA 1 NM, LA, PA

KADCYLA 1 B/D, NM




31


Medicamento

Requisitos/Límites

KEYTRUDA 1 NM, PA

KISQALI 1 NM, PA

KISQALI FEMARA 200 DOSE 1 NM, PA



LYNPARZA 1 NM, LA, PA

MYLOTARG 1 NM, LA, PA

NINLARO 1 NM, PA

ODOMZO 1 NM, LA, PA

RITUXAN 1 NM, LA, PA

RITUXAN HYCELA 1 NM, LA, PA

RUBRACA 1 NM, LA, PA

TALZENNA 1 NM, LA, PA

TECENTRIQ 1 NM, LA, PA

TIBSOVO 1 NM, LA, PA

VELCADE 1 NM, PA

VENCLEXTA 1 NM, LA, PA

VENCLEXTA STARTING PACK 1 NM, LA, PA

VERZENIO 1 NM, LA, PA

ZEJULA 1 NM, LA, PA

ZOLINZA 1 NM, PA

HORMONAL ANTINEOPLASTIC AGENTS

abiraterone acetate 1 NM, PA




32


Medicamento

Requisitos/Límites

anastrozole TABS 1

bicalutamide 1

DEPO-PROVERA INJ 400/ML 1 B/D

ERLEADA 1 NM, LA, PA

exemestane 1

FASLODEX 1 B/D

flutamide 1

letrozole TABS 1

leuprolide inj 1mg/0.2 1 NM, PA

LUPRON DEPOT (1-MONTH) 3.75mg 1 NM, PA

LUPRON DEPOT INJ 11.25MG (3-MONTH) 1 NM, PA

LYSODREN 1

megestrol ac sus 40mg/ml 1

megestrol ac tab 20mg 1

megestrol ac tab 40mg 1

megestrol sus 625mg/5ml 1 PA

nilutamide 1

SOLTAMOX 1

tamoxifen citrate TABS 1

toremifene citrate 1

TRELSTAR DEP INJ 3.75MG 1 NM, PA

TRELSTAR LA INJ 11.25MG 1 NM, PA

XTANDI 1 NM, LA, PA




33


Medicamento

Requisitos/Límites

ZYTIGA 500mg 1 NM, LA, PA

IMMUNOMODULATORS

POMALYST 1 NM, LA, PA

REVLIMID 1 QL (28 caps / 28 days),

NM, LA, PA

THALOMID 50mg, 100mg 1 QL (30 caps / 30 days), NM, PA

THALOMID 150mg, 200mg 1 QL (60 caps / 30 days), NM, PA

KINASE INHIBITORS

AFINITOR 1 QL (30 tabs / 30 days),

NM, PA

AFINITOR DISPERZ 2mg 1 QL (150 tabs / 30 days),

NM, PA


NM, PA


NM, PA

ALECENSA 1 NM, LA, PA

ALUNBRIG 1 NM, LA, PA

BOSULIF 1 NM, PA

BRAFTOVI 1 NM, LA, PA

CABOMETYX 1 QL (30 tabs / 30 days),

NM, LA, PA

CALQUENCE 1 NM, LA, PA

CAPRELSA 1 NM, LA, PA

COMETRIQ 1 NM, LA, PA

COPIKTRA 1 NM, LA, PA




34


Medicamento

Requisitos/Límites

COTELLIC 1 NM, LA, PA

GILOTRIF TAB 20MG 1 NM, LA, PA



ICLUSIG 1 NM, LA, PA

imatinib mesylate 100mg 1 QL (90 tabs / 30 days), NM, PA

imatinib mesylate 400mg 1 QL (60 tabs / 30 days), NM, PA

IMBRUVICA 1 NM, LA, PA

INLYTA 1mg 1 QL (180 tabs / 30 days), NM, LA, PA

INLYTA 5mg 1 QL (120 tabs / 30 days), NM, LA, PA

IRESSA 1 NM, LA, PA

JAKAFI 1 QL (60 tabs / 30 days),

NM, LA, PA

LENVIMA 4 MG DAILY DOSE 1 NM, LA, PA



LENVIMA 12MG DAILY DOSE 1 NM, LA, PA








35


Medicamento

Requisitos/Límites

LORBRENA 1 NM, LA, PA

MEKINIST 1 NM, LA, PA

MEKTOVI 1 NM, LA, PA

NERLYNX 1 NM, LA, PA

NEXAVAR 1 NM, LA, PA

RYDAPT 1 NM, PA

SPRYCEL 1 NM, PA

STIVARGA 1 NM, LA, PA

SUTENT 1 NM, PA

TAFINLAR 1 NM, LA, PA

TAGRISSO 1 NM, LA, PA

TARCEVA 25mg 1 QL (90 tabs / 30 days), NM, LA, PA

TARCEVA 100mg, 150mg 1 QL (30 tabs / 30 days),

NM, LA, PA

TASIGNA 1 NM, PA

TYKERB 1 NM, LA, PA

VITRAKVI 1 NM, LA, PA

VIZIMPRO 1 NM, LA, PA

VOTRIENT 1 NM, LA, PA

XALKORI 1 NM, LA, PA

XOSPATA 1 NM, LA, PA

ZELBORAF 1 NM, LA, PA

ZYDELIG 1 NM, LA, PA




36


Medicamento

Requisitos/Límites

ZYKADIA 1 NM, LA, PA

MISCELLANEOUS

bexarotene 1 NM, PA

hydroxyurea CAPS 1

LONSURF 1 NM, PA

MATULANE 1 LA

SYLATRON KIT 200MCG 1 NM, PA



SYNRIBO 1 NM, PA

tretinoin (chemotherapy) 1

PLATINUM-BASED AGENTS

carboplatin 1 B/D

cisplatin 1 B/D

oxaliplatin inj 50mg 1 B/D

oxaliplatin inj 50mg/10ml 1 B/D

oxaliplatin inj 100mg 1 B/D

oxaliplatin inj 100mg/20ml 1 B/D

PROTECTIVE AGENTS

dexrazoxane hcl 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

MESNEX TABS 1




37


Medicamento

Requisitos/Límites

TOPOISOMERASE INHIBITORS

etoposide SOLN 1 B/D

irinotecan hcl 1 B/D

toposar 1 B/D

topotecan hcl 1 B/D

TOPOTECAN INJ 4MG/4ML 1 B/D

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS

amlodipine besylate-benazepril hcl cap 2.5-

10 mg

1

amlodipine besylate-benazepril hcl cap 5-

10 mg

1


20 mg

1


40 mg

1


20 mg

1


40 mg

1

benazepril & hydrochlorothiazide 1

captopril & hydrochlorothiazide 1

enalapril maleate & hydrochlorothiazide 1

fosinopril sodium & hydrochlorothiazide 1

lisinopril & hydrochlorothiazide 1

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide 1




38


Medicamento

Requisitos/Límites

ACE INHIBITORS

benazepril hcl TABS 1

captopril TABS 1

enalapril maleate TABS 1

fosinopril sodium 1

lisinopril TABS 1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1

ramipril 1

trandolapril 1

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone 1

spironolactone TABS 1

ALPHA BLOCKERS

doxazosin mesylate TABS 1

prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

amlodipine besylate-olmesartan medoxomil 1

amlodipine besylate-valsartan tab 1

amlodipine-valsartan-hydrochlorothiazide tab

1

candesartan cilexetil-hydrochlorothiazide 1

ENTRESTO 1




39


Medicamento

Requisitos/Límites

irbesartan-hydrochlorothiazide 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil-amlodipine-hydrochlorothiazide

1

olmesartan medoxomil-hydrochlorothiazide 1

telmisartan-amlodipine 1

telmisartan-hydrochlorothiazide 1

valsartan-hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 1

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

olmesartan medoxomil TABS 1

telmisartan 1

valsartan 1

ANTIARRHYTHMICS

amiodarone hcl soln 1

amiodarone tab 100mg 1



disopyramide phosphate 1

dofetilide 1 NM

flecainide acetate 1




40


Medicamento

Requisitos/Límites

mexiletine hcl 1

MULTAQ 1

NORPACE CR 1

pacerone 1

propafenone hcl 1

propafenone hcl 12hr 1

quinidine gluconate 1

quinidine sulfate 1

sorine 1

sotalol hcl 1

sotalol hcl (afib/afl) 1

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS

atorvastatin calcium TABS 1

lovastatin 1

pravastatin sodium 1

rosuvastatin calcium 1 QL (30 tabs / 30 days)

simvastatin TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin TABS 80mg 1 QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS

cholestyramine 1

cholestyramine light 1

colesevelam hcl 1

colestipol hcl gran 1




41


Medicamento

Requisitos/Límites

colestipol hcl pack 1

colestipol hcl tabs 1

ezetimibe 1

ezetimibe-simvastatin 1

fenofibrate TABS 48mg, 54mg, 145mg,

160mg

1

fenofibrate micronized 67mg, 134mg,

200mg

1

gemfibrozil TABS 1

JUXTAPID 1 NM, LA, PA

KYNAMRO 1 PA

niacin er (antihyperlipidemic) 500mg 1 QL (90 tabs / 30 days)

niacin er (antihyperlipidemic) 750mg,

1000mg

1

niacor 1

PRALUENT 1 PA

prevalite 1

VASCEPA 1

BETA-BLOCKER/DIURETIC COMBINATIONS

atenolol & chlorthalidone 1

bisoprolol & hydrochlorothiazide 1

metoprolol & hydrochlorothiazide 1

propranolol & hydrochlorothiazide 1

BETA-BLOCKERS

acebutolol hcl CAPS 1




42


Medicamento

Requisitos/Límites

atenolol TABS 1

betaxolol hcl 1

bisoprolol fumarate 1

BYSTOLIC 2.5mg, 5mg, 10mg 1 QL (30 tabs / 30 days)

BYSTOLIC 20mg 1 QL (60 tabs / 30 days)

carvedilol 1

labetalol hcl TABS 1

metoprolol succinate 1

metoprolol tartrate SOCT 1

metoprolol tartrate SOLN 1

metoprolol tartrate TABS 25mg, 50mg, 100mg

1

nadolol TABS 1

pindolol 1

propranolol cap er 1

propranolol hcl TABS 1

propranolol oral sol 1

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKERS

amlodipine besylate TABS 1

cartia xt 1

dilt-xr cap 1

diltiazem cap 180mg cd 1





43


Medicamento

Requisitos/Límites


diltiazem cap er/12hr 1

diltiazem hcl TABS 1

diltiazem hcl cap sr 24hr 1

diltiazem hcl coated beads cap sr 24hr 1

diltiazem hcl extended release beads cap sr

1

diltiazem inj 1

felodipine 1

isradipine 1

nicardipine hcl CAPS 1

nifedipine TB24 1

nifedipine er 1

nimodipine CAPS 1

NYMALIZE 1

taztia xt 1

verapamil cap er 1

verapamil hcl SOLN; TABS; TBCR 1

verapamil tab er 1

DIGITALIS GLYCOSIDES

digitek .25mg 1 PA; PA if 70 years and

older

digitek .125mg 1 QL (30 tabs / 30 days)

digox 125mcg 1 QL (30 tabs / 30 days)




44


Medicamento

Requisitos/Límites

digox 250mcg 1 PA; PA if 70 years and

older

digoxin TABS 125mcg 1 QL (30 tabs / 30 days)

digoxin TABS 250mcg 1 PA; PA if 70 years and older

digoxin inj 1

digoxin sol 50mcg/ml 1 PA; PA if 70 years and older

DIRECT RENIN INHIBITORS/COMBINATIONS

TEKTURNA 1

TEKTURNA HCT 1

DIURETICS

acetazolamide CP12; TABS 1

amiloride & hydrochlorothiazide 1

amiloride hcl TABS 1

bumetanide inj 0.25/ml 1

bumetanide tab 1

chlorothiazide tabs 1

chlorthalidone 1

furosemide SOLN; TABS 1

furosemide inj 1

hydrochlorothiazide CAPS; TABS 1

indapamide 1

methazolamide TABS 1

methyclothiazide 1




45


Medicamento

Requisitos/Límites

metolazone 1

spironolactone & hydrochlorothiazide 1

torsemide tabs 1

triamterene & hydrochlorothiazide cap

37.5-25 mg

1

triamterene & hydrochlorothiazide tabs 1

MISCELLANEOUS

clonidine hcl TABS 1

clonidine hcl ptwk 1

CORLANOR 1

DEMSER 1 PA

hydralazine hcl SOLN; TABS 1

midodrine hcl 1

minoxidil TABS 1

NORTHERA 1 NM, LA, PA

RANEXA 1

ranolazine 1

NITRATES

isosorb mononitrate tab 1

isosorbide dinitrate 1

isosorbide dinitrate er 1

isosorbide mononitrate er 1

minitran 1

NITRO-BID 1




46


Medicamento

Requisitos/Límites

NITRO-DUR DIS 0.3MG/HR 1

NITRO-DUR DIS 0.8MG/HR 1

nitroglycerin SOLN .4mg/spray 1

nitroglycerin SUBL 1

nitroglycerin td patch 1

PULMONARY ARTERIAL HYPERTENSION

ADEMPAS 1 QL (90 tabs / 30 days),

NM, LA, PA

LETAIRIS 1 QL (30 tabs / 30 days),

NM, LA, PA

OPSUMIT 1 QL (30 tabs / 30 days),

NM, LA, PA

REMODULIN 1 NM, LA, PA

sildenafil citrate tab 20 mg (pulmonary hypertension)

1 QL (90 tabs / 30 days), NM, PA

TRACLEER TABS 62.5mg 1 QL (120 tabs / 30 days), NM, LA, PA

TRACLEER TABS 125mg 1 QL (60 tabs / 30 days), NM, LA, PA

VENTAVIS 1 NM, PA

CENTRAL NERVOUS SYSTEM

ANTIANXIETY

alprazolam tab 0.5mg 1 QL (150 tabs / 30 days)

alprazolam tab 0.25mg 1 QL (150 tabs / 30 days)

alprazolam tab 1mg 1 QL (150 tabs / 30 days)

alprazolam tab 2 mg 1 QL (150 tabs / 30 days)

buspirone hcl TABS 1




47


Medicamento

Requisitos/Límites

fluvoxamine maleate TABS 1

lorazepam SOLN 1

lorazepam TABS 1 QL (150 tabs / 30 days)

lorazepam intensol 1 QL (150 mL / 30 days)

ANTICONVULSANTS

APTIOM 200mg 1 QL (180 tabs / 30 days)

APTIOM 400mg 1 QL (90 tabs / 30 days)

APTIOM 600mg, 800mg 1 QL (60 tabs / 30 days)

BANZEL SUS 40MG/ML 1 PA

BANZEL TAB 200MG 1 PA

BANZEL TAB 400MG 1 PA

BRIVIACT INJ 50MG/5ML 1 PA

BRIVIACT SOL 10MG/ML 1 PA

BRIVIACT TAB 10MG 1 PA





carbamazepine CHEW; CP12; SUSP; TABS; TB12

1

CELONTIN 1

clobazam 1 PA

clonazepam TABS 2mg 1 QL (300 tabs / 30 days)

clonazepam TABS .5mg, 1mg 1 QL (90 tabs / 30 days)




48


Medicamento

Requisitos/Límites

clonazepam TBDP 2mg 1 QL (300 tabs / 30 days)

clonazepam TBDP .125mg, .25mg, .5mg, 1mg

1 QL (90 tabs / 30 days)

clorazepate dipotassium 1 QL (180 tabs / 30 days), PA; PA if 65 years and

older

DIASTAT ACUDIAL 1

DIASTAT PEDIATRIC 1

diazepam TABS 1 QL (120 tabs / 30 days), PA; PA if 65 years and older

diazepam gel 1

diazepam inj 1

diazepam intensol 1 QL (240 mL / 30 days), PA; PA if 65 years and older

diazepam oral soln 1 mg/ml 1 QL (1200 mL / 30 days), PA; PA if 65 years and

older

DILANTIN CAP 30MG 1

DILANTIN CAP 100MG 1

DILANTIN CHEW TAB 50MG 1

DILANTIN-125 SUSP 1

divalproex sodium CSDR; TB24; TBEC 1

EPIDIOLEX 1 QL (600 mL / 30 days), NM, LA, PA

epitol 1

ethosuximide CAPS; SOLN 1




49


Medicamento

Requisitos/Límites

felbamate 1

FYCOMPA SUSP 1 QL (720 mL / 30 days), PA

FYCOMPA TABS 2mg, 4mg, 6mg 1 QL (60 tabs / 30 days), PA

FYCOMPA TABS 8mg, 10mg, 12mg 1 QL (30 tabs / 30 days), PA

gabapentin CAPS 100mg 1 QL (1080 caps / 30 days)



gabapentin SOLN 1 QL (2160 mL / 30 days)

gabapentin TABS 600mg 1 QL (180 tabs / 30 days)

gabapentin TABS 800mg 1 QL (120 tabs / 30 days)

lamotrigine CHEW; TABS; TB24 1

levetiracetam SOLN; TABS; TB24 1

levetiracetam in sodium chloride 1

levetiracetam oral soln 100 mg/ml 1

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg

1 QL (120 caps / 30 days)

LYRICA CAPS 200mg 1 QL (90 caps / 30 days)

LYRICA CAPS 225mg, 300mg 1 QL (60 caps / 30 days)

LYRICA SOLN 1 QL (946 mL / 30 days)

oxcarbazepine 1

PEGANONE 1

phenobarbital ELIX; TABS 1 PA; PA if 70 years and older




50


Medicamento

Requisitos/Límites

PHENOBARBITAL SODIUM SOLN 65mg/ml 1 PA; PA if 70 years and

older

phenobarbital sodium SOLN 130mg/ml 1 PA; PA if 70 years and

older

PHENYTEK 1

phenytoin CHEW; SUSP 1

phenytoin sodium extended 1

phenytoin sodium inj 50mg/ml 1

primidone TABS 1

roweepra 1

roweepra xr 1

SPRITAM 1

subvenite tab 1

SYMPAZAN 1 PA

tiagabine hcl 1

topiramate CPSP; TABS 1

valproate sodium SOLN 1

valproate sodium oral soln 1

valproic acid CAPS 1

vigabatrin powd pack 500mg 1 QL (180 packets / 30

days), NM, LA, PA

vigabatrin tab 500mg 1 QL (180 tabs / 30 days),

NM, LA, PA

vigadrone 1 QL (180 packets / 30

days), NM, LA, PA




51


Medicamento

Requisitos/Límites

VIMPAT 50mg 1 QL (120 tabs / 30 days)

VIMPAT 100mg, 150mg, 200mg 1 QL (60 tabs / 30 days)

VIMPAT INJ 200MG/20ML 1

VIMPAT SOL 10MG/ML 1 QL (1200 mL / 30 days)

zonisamide CAPS 1

ANTIDEMENTIA

donepezil hydrochloride TABS 5mg 1 QL (30 tabs / 30 days)

donepezil hydrochloride TABS 10mg 1

donepezil hydrochloride TBDP 5mg 1 QL (30 tabs / 30 days)

donepezil hydrochloride TBDP 10mg 1

galantamine hydrobromide SOLN 1

galantamine hydrobromide TABS 1 QL (60 tabs / 30 days)

galantamine hydrobromide er 1 QL (30 caps / 30 days)

memantine hcl cp24 1 PA; PA if < 30 yrs

memantine soln 1 PA; PA if < 30 yrs

memantine tabs 1 PA; PA if < 30 yrs

memantine titration pak 1 PA; PA if < 30 yrs

NAMZARIC 1

rivastigmine tartrate 1.5mg, 3mg 1 QL (90 caps / 30 days)

rivastigmine tartrate 4.5mg, 6mg 1 QL (60 caps / 30 days)

rivastigmine td patch 24hr 4.6 mg/24hr 1 QL (30 patches / 30 days)






52


Medicamento

Requisitos/Límites

ANTIDEPRESSANTS

amitriptyline hcl TABS 1

amoxapine 1

bupropion hcl TABS 1

bupropion hcl TB12 1

bupropion hcl TB24 150mg, 300mg 1

citalopram hydrobromide 1

clomipramine hcl CAPS 1 PA

desipramine hcl TABS 1

desvenlafaxine succinate 1 QL (30 tabs / 30 days), PA

doxepin hcl CAPS; CONC 1

duloxetine hcl CPEP 20mg 1 QL (180 caps / 30 days)



EMSAM 1 QL (30 patches / 30

days), PA

escitalopram oxalate 1

FETZIMA 20mg 1 QL (180 caps / 30 days),

PA

FETZIMA 40mg 1 QL (90 caps / 30 days),

PA

FETZIMA 80mg, 120mg 1 QL (30 caps / 30 days), PA

FETZIMA TITRATION PACK 1 PA

fluoxetine cap 10mg 1




53


Medicamento

Requisitos/Límites



fluoxetine hcl SOLN 1

imipramine hcl TABS 1

maprotiline hcl 1

MARPLAN TAB 10MG 1 QL (180 tabs / 30 days)

mirtazapine TABS; TBDP 1

nefazodone hcl 1

nortriptyline hcl CAPS; SOLN 1

paroxetine hcl tabs 1

PAXIL SUSP 1 QL (900 mL / 30 days)

phenelzine sulfate TABS 1

protriptyline hcl 1

sertraline hcl CONC; TABS 1

tranylcypromine sulfate 1

trazodone hcl TABS 50mg, 100mg, 150mg 1

trimipramine maleate CAPS 25mg 1 QL (240 caps / 30 days)



TRINTELLIX 5mg 1 QL (120 tabs / 30 days)



venlafaxine hcl CP24; TABS 1




54


Medicamento

Requisitos/Límites

VIIBRYD STARTER PACK 1

VIIBRYD TAB 1 QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS

amantadine hcl CAPS 1 QL (120 caps / 30 days)

amantadine hcl SYRP; TABS 1

APOKYN 1 QL (20 cartridges / 30 days), NM, LA, PA

benztropine mesylate inj 1

benztropine mesylate tab 0.5mg 1 PA; PA if 70 years and

older

benztropine mesylate tab 1mg 1 PA; PA if 70 years and

older

benztropine mesylate tab 2mg 1 PA; PA if 70 years and

older

bromocriptine mesylate CAPS; TABS 1

carbidopa-levodopa 1

carbidopa/levodopa/entacapone 1

entacapone 1

NEUPRO 1

pramipexole tab 0.5mg 1





pramipexole tab 1mg 1




55


Medicamento

Requisitos/Límites

rasagiline mesylate TABS 1

ropinirole tab 0.5mg 1

ropinirole tab 0.25mg 1

ropinirole tab 1mg 1





selegiline hcl CAPS; TABS 1

trihexyphenidyl hcl 1 PA; PA if 70 years and older

ANTIPSYCHOTICS

ABILIFY MAINTENA 1 QL (1 injection / 28 days)

aripiprazole odt 1 QL (60 tabs / 30 days)

aripiprazole oral solution 1 mg/ml 1 QL (900 mL / 30 days)

aripiprazole tab 1 QL (30 tabs / 30 days)

ARISTADA 441mg/1.6ml, 662mg/2.4ml,

882mg/3.2ml

1 QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml 1 QL (1 injection / 56 days)

ARISTADA INITIO 1

chlorpromazine hcl TABS 1

CHLORPROMAZINE INJ 1

clozapine odt 12.5mg, 25mg 1 PA

clozapine odt 100mg 1 QL (270 tabs / 30 days),

PA




56


Medicamento

Requisitos/Límites


PA


PA

clozapine tab 25mg 1

clozapine tab 50mg 1

clozapine tab 100mg 1 QL (270 tabs / 30 days)

clozapine tab 200mg 1 QL (135 tabs / 30 days)

FANAPT 1 QL (60 tabs / 30 days)

FANAPT TITRATION PACK 1

fluphenazine decanoate SOLN 1

fluphenazine hcl 1

GEODON SOLR 1 QL (6 mL / 3 days)

haloperidol TABS 1

haloperidol conc 2mg/ml 1

haloperidol decanoate SOLN 1

haloperidol lactate inj 5mg/ml 1

INVEGA SUST INJ 39 MG/0.25 ML 1 QL (1 injection / 28 days)



INVEGA SUST INJ 156MG/ML 1 QL (1 injection / 28 days)


INVEGA TRINZA 1 QL (1 injection / 90 days)

LATUDA 20mg, 60mg, 80mg 1 QL (60 tabs / 30 days)




57


Medicamento

Requisitos/Límites

LATUDA 40mg, 120mg 1 QL (30 tabs / 30 days)

loxapine succinate 1

molindone hcl 1

NUPLAZID CAPS 1 QL (30 caps / 30 days),

NM, LA, PA

NUPLAZID TABS 10MG 1 QL (30 tabs / 30 days),

NM, LA, PA

NUPLAZID TABS 17MG 1 QL (60 tabs / 30 days),

NM, LA, PA

olanzapine SOLR 1 QL (3 vials / 1 day)

olanzapine TABS 2.5mg 1 QL (240 tabs / 30 days)

olanzapine TABS 5mg 1 QL (120 tabs / 30 days)

olanzapine TABS 7.5mg, 15mg, 20mg 1 QL (30 tabs / 30 days)

olanzapine TABS 10mg 1 QL (60 tabs / 30 days)

olanzapine TBDP 5mg, 15mg, 20mg 1 QL (30 tabs / 30 days)

olanzapine TBDP 10mg 1 QL (60 tabs / 30 days)

paliperidone 1.5mg, 3mg, 9mg 1 QL (30 tabs / 30 days)

paliperidone 6mg 1 QL (60 tabs / 30 days)

perphenazine TABS 1

PERSERIS 1 QL (1 injection / 30 days)

pimozide 1

quetiapine fumarate TABS 1

quetiapine fumarate TB24 50mg, 300mg,

400mg


quetiapine fumarate TB24 150mg, 200mg 1 QL (30 tabs / 30 days)




58


Medicamento

Requisitos/Límites

REXULTI 1mg 1 QL (90 tabs / 30 days)

REXULTI 2mg 1 QL (60 tabs / 30 days)

REXULTI 3mg, 4mg 1 QL (30 tabs / 30 days)

REXULTI .5mg 1 QL (180 tabs / 30 days)

REXULTI .25mg 1 QL (360 tabs / 30 days)

RISPERDAL INJ 12.5MG 1 QL (2 injections / 28 days)

RISPERDAL INJ 25MG 1 QL (2 injections / 28 days)

RISPERDAL INJ 37.5MG 1 QL (2 injections / 28 days)

RISPERDAL INJ 50MG 1 QL (2 injections / 28 days)

risperidone SOLN 1 QL (240 mL / 30 days)

risperidone TABS 1

risperidone TBDP .5mg 1 QL (90 tabs / 30 days)

risperidone TBDP .25mg, 1mg, 2mg, 3mg, 4mg


SAPHRIS 2.5mg 1 QL (240 tabs / 30 days)

SAPHRIS 5mg 1 QL (120 tabs / 30 days)

SAPHRIS 10mg 1 QL (60 tabs / 30 days)

thioridazine hcl TABS 1

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 1 QL (600 mL / 30 days), PA




59


Medicamento

Requisitos/Límites

VRAYLAR 1.5mg 1 QL (60 caps / 30 days),

PA

VRAYLAR 3mg, 4.5mg, 6mg 1 QL (30 caps / 30 days),

PA

VRAYLAR THERAPY PACK 1 PA

ziprasidone hcl 1 QL (60 caps / 30 days)

ZYPREXA RELPREVV 300mg 1 QL (2 vials / 28 days), PA

ZYPREXA RELPREVV 405mg 1 QL (1 vial / 28 days), PA

ZYPREXA RELPREVV INJ 210MG 1 QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine cap sr

24hr 5 mg



24hr 10 mg



24hr 15 mg



24hr 20 mg


amphetamine-dextroamphetamine cap sr 24hr 25 mg


amphetamine-dextroamphetamine cap sr 24hr 30 mg


amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg







60


Medicamento

Requisitos/Límites

amphetamine-dextroamphetamine tab

12.5 mg


amphetamine-dextroamphetamine tab 15

mg






atomoxetine hcl 10mg, 18mg, 25mg 1 QL (120 caps / 30 days)

atomoxetine hcl 40mg 1 QL (60 caps / 30 days)

atomoxetine hcl 60mg, 80mg, 100mg 1 QL (30 caps / 30 days)

dexmethylphenidate hcl TABS 2.5mg, 5mg 1 QL (120 tabs / 30 days)

dexmethylphenidate hcl TABS 10mg 1 QL (60 tabs / 30 days)

guanfacine er (adhd) 1 PA; PA if 70 years and older

metadate er tab 20mg 1 QL (90 tabs / 30 days)

methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 30 days)

methylphenidate hcl TABS 20mg 1 QL (90 tabs / 30 days)

methylphenidate hcl oral soln 5mg/5ml 1 QL (1800 mL / 30 days)

methylphenidate hcl oral soln 10mg/5ml 1 QL (900 mL / 30 days)

methylphenidate tab 10mg er 1 QL (90 tabs / 30 days)

methylphenidate tab 20mg er 1 QL (90 tabs / 30 days)

HYPNOTICS

eszopiclone 1 QL (30 tabs / 30 days),

PA; PA applies if 70 years and older after a 90 day supply in a calendar year




61


Medicamento

Requisitos/Límites

HETLIOZ 1 NM, LA, PA

SILENOR 3mg 1 QL (60 tabs / 30 days)

SILENOR 6mg 1 QL (30 tabs / 30 days)

temazepam 7.5mg 1 QL (30 caps / 30 days),

PA; PA applies if 65 years and older after a 90 day supply in a calendar year

temazepam 15mg 1 QL (60 caps / 30 days), PA; PA applies if 65 years

and older after a 90 day supply in a calendar year

zaleplon 1 QL (60 caps / 30 days), PA; PA applies if 70 years


zolpidem tartrate TABS 1 QL (30 tabs / 30 days), PA; PA applies if 70 years


MIGRAINE

AIMOVIG 1 QL (1 pen / 30 days), PA

dihydroergotamine mesylate inj 1 mg/ml 1

dihydroergotamine mesylate nasal 1 QL (8 mL / 30 days)

eletriptan hydrobromide 1 QL (12 tabs / 30 days)

EMGALITY SOAJ 1 QL (2 pens / 30 days), PA

EMGALITY SOSY 1 QL (2 syringes / 30 days),

PA

ergotamine w/ caffeine TABS 1

naratriptan hcl 1 QL (12 tabs / 30 days)

rizatriptan benzoate 1 QL (18 tabs / 30 days)




62


Medicamento

Requisitos/Límites

rizatriptan benzoate odt 1 QL (18 tabs / 30 days)

sumatriptan SOLN 5mg/act 1 QL (24 inhalers / 30 days)

sumatriptan SOLN 20mg/act 1 QL (12 inhalers / 30 days)

sumatriptan inj 4mg/0.5ml 1 QL (18 injections / 30

days)

sumatriptan inj 6mg/0.5ml 1 QL (12 injections / 30

days)

sumatriptan succinate TABS 1 QL (12 tabs / 30 days)

zolmitriptan TABS 1 QL (12 tabs / 30 days)

zolmitriptan odt 1 QL (12 tabs / 30 days)

MISCELLANEOUS

AUSTEDO 6mg 1 QL (60 tabs / 30 days), NM, LA, PA

AUSTEDO 9mg, 12mg 1 QL (120 tabs / 30 days), NM, LA, PA

lithium carbonate CAPS; TABS 1

lithium carbonate er 1

LITHIUM SOLN 8MEQ/5ML 1

LYRICA CR 82.5mg, 165mg 1 QL (90 tabs / 30 days), PA

LYRICA CR 330mg 1 QL (60 tabs / 30 days), PA

NUEDEXTA 1 QL (60 caps / 30 days), PA

pyridostigmine tab 60mg 1

riluzole 1

tetrabenazine 12.5mg 1 QL (240 tabs / 30 days),

NM, PA




63


Medicamento

Requisitos/Límites

tetrabenazine 25mg 1 QL (120 tabs / 30 days),

NM, PA

MULTIPLE SCLEROSIS AGENTS

BETASERON 1 QL (14 syringes / 28 days), NM, PA

dalfampridine 1 NM, PA

GILENYA 1 QL (28 caps / 28 days),

NM, PA

glatiramer acetate 20mg/ml 1 QL (30 syringes / 30

days), NM, PA

glatiramer acetate 40mg/ml 1 QL (12 syringes / 28

days), NM, PA

glatopa 20mg/ml 1 QL (30 syringes / 30 days), NM, PA

glatopa 40mg/ml 1 QL (12 syringes / 28 days), NM, PA

MUSCULOSKELETAL THERAPY AGENTS

baclofen TABS 10mg, 20mg 1

carisoprodol TABS 350mg 1 QL (120 tabs / 30 days),

PA; PA if 70 years and older

cyclobenzaprine hcl TABS 5mg, 10mg 1 PA; PA if 70 years and older

dantrolene sodium CAPS 1

methocarbamol TABS 1 PA; PA if 70 years and

older

tizanidine hcl TABS 1

NARCOLEPSY/CATAPLEXY

armodafinil 50mg 1 QL (90 tabs / 30 days), PA

armodafinil 150mg, 200mg, 250mg 1 QL (30 tabs / 30 days), PA




64


Medicamento

Requisitos/Límites

XYREM 1 QL (540 mL / 30 days),

NM, LA, PA

PSYCHOTHERAPEUTIC-MISC

acamprosate calcium 1

buprenorphine hcl SUBL 1 QL (90 tabs / 30 days), PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

1 QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg






buprenorphine hcl-naloxone hcl sl 1 QL (90 tabs / 30 days)

bupropion hcl (smoking deterrent) 1

CHANTIX 1 PA

CHANTIX CONTINUING MONTH 1 PA

CHANTIX STARTER PACK 1 PA

disulfiram TABS 1

naloxone inj 0.4mg/ml 1

naloxone inj 1mg/ml 1

naltrexone hcl TABS 1

NARCAN 1

NICOTROL INHALER 1

NICOTROL NS 1

SUBOXONE MIS 2-0.5MG 1 QL (90 films / 30 days)




65


Medicamento

Requisitos/Límites

SUBOXONE MIS 4-1MG 1 QL (90 films / 30 days)



VIVITROL 1

ENDOCRINE AND METABOLIC

ANDROGENS

ANADROL-50 1 PA

ANDRODERM 1 QL (30 patches / 30 days), PA

oxandrolone tab 2.5mg 1 PA

oxandrolone tab 10mg 1 PA

testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

1 QL (300 grams / 30 days), PA

testosterone cypionate SOLN 100mg/ml,

200mg/ml

1 PA

testosterone enanthate SOLN 1 PA

ANTIDIABETICS, INJECTABLE

ALCOHOL SWABS 1

BASAGLAR KWIKPEN 1

BD ULTRAFINE INSULIN SYRINGE 1

BD ULTRAFINE/NANO PEN NEEDLES 1

BYDUREON BCISE 1 QL (4 pens / 28 days)

BYDUREON INJ 1 QL (4 vials / 28 days)

BYDUREON PEN 1 QL (4 pens / 28 days)

BYETTA 1 QL (1 pen / 30 days)

FIASP 1




66


Medicamento

Requisitos/Límites

FIASP FLEXTOUCH 1

GAUZE PADS 2" X 2" 1

HUMULIN R INJ U-500 1 B/D

HUMULIN R U-500 KWIKPEN 1

INSULIN PEN NEEDLE 1

INSULIN SAFETY NEEDLES 1

INSULIN SYRINGE 1

LEVEMIR 1

LEVEMIR FLEXTOUCH 1

NOVOLIN 70/30 1 (brand RELION not covered)

NOVOLIN 70/30 FLEXPEN 1 (brand RELION not covered)

NOVOLIN N 1 (brand RELION not covered)

NOVOLIN R 1 (brand RELION not covered)

NOVOLOG 1

NOVOLOG 70/30 FLEXPEN 1

NOVOLOG FLEXPEN 1

NOVOLOG MIX 70/30 1

NOVOLOG PENFILL 1

OZEMPIC INJ 0.25 OR 0.5MG/DOSE 1 QL (1 pen / 28 days)

OZEMPIC INJ 1MG/DOSE 1 QL (2 pens / 28 days)

SOLIQUA 100/33 1 QL (10 pens / 30 days)




67


Medicamento

Requisitos/Límites

TRESIBA FLEXTOUCH 1

TRESIBA INJ 1

TRULICITY 1 QL (4 pens / 28 days)

VICTOZA 1 QL (3 pens / 30 days)

XULTOPHY 100/3.6 1 QL (5 pens / 30 days)

ANTIDIABETICS, ORAL

acarbose 1

FARXIGA 5mg 1 QL (60 tabs / 30 days)

FARXIGA 10mg 1 QL (30 tabs / 30 days)

glimepiride 1mg 1 QL (240 tabs / 30 days)



glip/metform tab 2.5-250mg 1 QL (240 tabs / 30 days)

glip/metform tab 2.5-500mg 1 QL (120 tabs / 30 days)

glip/metform tab 5-500mg 1 QL (120 tabs / 30 days)

glipizide TABS 5mg 1 QL (240 tabs / 30 days)

glipizide TABS 10mg 1 QL (120 tabs / 30 days)

glipizide TB24 2.5mg 1 QL (240 tabs / 30 days)

glipizide TB24 5mg 1 QL (120 tabs / 30 days)

glipizide TB24 10mg 1 QL (60 tabs / 30 days)

glipizide xl 2.5mg 1 QL (240 tabs / 30 days)

glipizide xl 5mg 1 QL (120 tabs / 30 days)

glipizide xl 10mg 1 QL (60 tabs / 30 days)




68


Medicamento

Requisitos/Límites

glyburide TABS 1.25mg 1 QL (480 tabs / 30 days),


glyburide TABS 2.5mg 1 QL (240 tabs / 30 days), PA; PA if 70 years and

older

glyburide TABS 5mg 1 QL (120 tabs / 30 days),


glyburide micronized 1.5mg 1 QL (240 tabs / 30 days), PA; PA if 70 years and

older

glyburide micronized 3mg 1 QL (120 tabs / 30 days),


glyburide micronized 6mg 1 QL (60 tabs / 30 days), PA; PA if 70 years and

older

glyburide-metformin tab 1.25-250 mg 1 QL (240 tabs / 30 days),


glyburide-metformin tab 2.5-500 mg 1 QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 5-500mg 1 QL (120 tabs / 30 days),


JANUMET 1 QL (60 tabs / 30 days)

JANUMET XR TAB 50-500MG 1 QL (60 tabs / 30 days)

JANUMET XR TAB 50-1000 1 QL (60 tabs / 30 days)

JANUMET XR TAB 100-1000 1 QL (30 tabs / 30 days)

JANUVIA 1 QL (30 tabs / 30 days)




69


Medicamento

Requisitos/Límites

JARDIANCE 10mg 1 QL (60 tabs / 30 days)

JARDIANCE 25mg 1 QL (30 tabs / 30 days)

JENTADUETO 1 QL (60 tabs / 30 days)

JENTADUETO TAB XR 2.5-1000 MG 1 QL (60 tabs / 30 days)

JENTADUETO TAB XR 5-1000 MG 1 QL (30 tabs / 30 days)

metformin er 500mg 1 QL (120 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin er 750mg 1 QL (60 tabs / 30 days); (generic of GLUCOPHAGE

XR)

metformin hcl TABS 500mg 1 QL (150 tabs / 30 days)



nateglinide 1 QL (90 tabs / 30 days)

pioglitazone hcl 1 QL (30 tabs / 30 days)

repaglinide 2mg 1 QL (240 tabs / 30 days)

repaglinide .5mg, 1mg 1 QL (120 tabs / 30 days)

SYNJARDY TAB 5-500MG 1 QL (120 tabs / 30 days)

SYNJARDY TAB 5-1000MG 1 QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-500MG 1 QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-1000MG 1 QL (60 tabs / 30 days)

SYNJARDY XR TAB 5-1000MG 1 QL (60 tabs / 30 days)


SYNJARDY XR TAB 12.5-1000MG 1 QL (60 tabs / 30 days)




70


Medicamento

Requisitos/Límites


TRADJENTA 1 QL (30 tabs / 30 days)

XIGDUO XR TAB 2.5-1000MG 1 QL (60 tabs / 30 days)

XIGDUO XR TAB 5-500MG 1 QL (60 tabs / 30 days)




BISPHOSPHONATES

alendronate sodium 1

ibandronate sodium TABS 1 B/D

PAMIDRONATE DISODIUM 6mg/ml 1 B/D

pamidronate disodium 30mg/10ml,

90mg/10ml

1 B/D

pamidronate inj 30mg 1 B/D

pamidronate inj 90mg 1 B/D

risedronate sodium TABS 5mg, 35mg, 150mg

1

risedronate sodium TBEC 1

zoledronic acid inj 5mg/100ml 1 B/D, NM

zoledronic inj 4mg/5ml 1 B/D, NM

CALCIUM RECEPTOR AGONISTS

cinacalcet hcl 30mg, 90mg 1 B/D, QL (120 tabs / 30

days), NM

cinacalcet hcl 60mg 1 B/D, QL (60 tabs / 30

days), NM




71


Medicamento

Requisitos/Límites

SENSIPAR 30mg, 90mg 1 B/D, QL (120 tabs / 30

days), NM

SENSIPAR 60mg 1 B/D, QL (60 tabs / 30

days), NM

CHELATING AGENTS

CHEMET 1

DEPEN TITRATABS 1

JADENU 1 NM, LA, PA

JADENU SPRINKLE 1 NM, LA, PA

kionex sus 15gm/60ml 1

sodium polystyrene sulfonate powder 1

sodium polystyrene sulfonate susp 1

sps susp 15gm/60ml 1

trientine hcl 1 PA

ENDOMETRIOSIS

danazol CAPS 1

SYNAREL 1

ENZYME REPLACEMENTS

ADAGEN 1 NM, LA, PA

ALDURAZYME 1 NM, LA, PA

CARBAGLU 1 NM, LA, PA

CERDELGA 1 NM, PA

CEREZYME 1 NM, LA, PA

CYSTADANE 1 NM, LA

CYSTAGON 1 NM, LA, PA




72


Medicamento

Requisitos/Límites

FABRAZYME 1 NM, LA, PA

KUVAN 1 NM, LA, PA

levocarnitine (metabolic modifiers) 1 B/D

LUMIZYME 1 NM, LA, PA

miglustat 1 NM, PA

NAGLAZYME 1 NM, LA, PA

NITYR 1 NM, LA, PA

ORFADIN 1 NM, LA, PA

sodium phenylbutyrate 1 NM, PA

ESTROGENS

DELESTROGEN 10mg/ml 1

estradiol PTWK; TABS 1

estradiol vaginal cream 1

estradiol vaginal tab 1

estradiol valerate inj 1

fyavolv 1

jinteli 1

norethindrone acetate-ethinyl estradiol 1

yuvafem vaginal tablet 10 mcg 1

GLUCOCORTICOIDS

cortisone acetate TABS 1

DEXAMETHASONE CONC 1

dexamethasone ELIX; SOLN; TABS 1

dexamethasone sodium phosphate 1




73


Medicamento

Requisitos/Límites

fludrocortisone acetate TABS 1

hydrocortisone TABS 1

methylpr ss inj 1 B/D

methylpred pak 4mg 1

methylpred tab 4mg 1 B/D




methylprednisolone acetate 1 B/D

pred sod pho sol 5mg/5ml 1 B/D

prednisolone sodium phosphate SOLN 15mg/5ml

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

PREDNISONE CON 5MG/ML 1 B/D

prednisone pak 5mg 1

prednisone pak 10mg 1

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D







74


Medicamento

Requisitos/Límites


SOLU-CORTEF 1

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT 1

GLUCAGON EMERGENCY KIT 1

PROGLYCEM SUS 50MG/ML 1

MISCELLANEOUS

cabergoline 1

calcitonin (salmon) 1 B/D

FORTEO 1 NM, PA

GENOTROPIN 1 NM, PA

GENOTROPIN MINIQUICK 1 NM, PA

INCRELEX 1 NM, LA, PA

KORLYM 1 NM, LA, PA

LUPRON DEP-PED INJ 7.5MG 1 NM, PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH) 1 NM, PA

LUPRON DEPOT-PED (1-MONTH 1 NM, PA

LUPRON DEPOT-PED (3-MONTH 1 NM, PA

NATPARA 1 NM, PA

octreotide acetate 1 NM, PA

PROLIA 1 QL (1 injection / 180 days), NM

raloxifene tab 60mg 1

SIGNIFOR 1 NM, LA, PA




75


Medicamento

Requisitos/Límites

SOMATULINE DEPOT 1 NM, PA

SOMAVERT 1 NM, LA, PA

TYMLOS 1 NM, PA

XGEVA 1 NM, PA

PHOSPHATE BINDER AGENTS

AURYXIA 1 QL (360 tabs / 30 days), PA

calcium acetate (phosphate binder) CAPS 1 QL (360 caps / 30 days)

calcium acetate (phosphate binder) TABS 1 QL (360 tabs / 30 days)

sevelamer carbonate PACK 2.4gm 1 QL (180 packets / 30

days)

sevelamer carbonate PACK .8gm 1 QL (540 packets / 30 days)

sevelamer carbonate TABS 1 QL (540 tabs / 30 days)

PROGESTINS

medroxyprogesterone acetate tab 1

norethindrone acetate TABS 1

THYROID AGENTS

levo-t 1

levothyroxine sodium TABS 1

levoxyl 1

liothyronine sodium TABS 1

methimazole TABS 1

propylthiouracil TABS 1

SYNTHROID 1

unithroid 1




76


Medicamento

Requisitos/Límites

VASOPRESSINS

desmopressin acetate spray 1

desmopressin acetate spray refrigerated 1

desmopressin acetate tabs 1

desmopressin inj 4mcg/ml 1

STIMATE 1 NM

GASTROINTESTINAL

ANTIEMETICS

aprepitant 1 B/D

aprepitant pak 80mg & 125mg 1 B/D

compro supp 1

dronabinol 1 B/D, QL (60 caps / 30 days)

EMEND SUSR 1 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

meclizine hcl TABS 1

metoclopramide hcl SOLN; TABS 1

metoclopramide hcl inj 1

ondansetron hcl TABS 1 B/D

ondansetron hcl inj 1

ondansetron hcl oral soln 1 B/D

ondansetron odt 1 B/D

prochlorperazine inj 1

prochlorperazine maleate TABS 1




77


Medicamento

Requisitos/Límites

prochlorperazine supp 1

promethazine hcl SYRP; TABS 1 PA; PA if 70 years and older

promethazine hcl inj 1 PA; PA if 70 years and older

scopolamine patch 1 QL (10 patches / 30 days), PA; PA if 70 years

and older

TRANSDERM-SCOP 1 QL (10 patches / 30

days), PA; PA if 70 years and older

ANTISPASMODICS

dicyclomine hcl cap 10mg 1

dicyclomine hcl soln 10mg/5ml 1

dicyclomine hcl tab 20mg 1

glycopyrrolate tab 1mg 1

glycopyrrolate tab 2mg 1

H2-RECEPTOR ANTAGONISTS

famotidine SUSR 1

famotidine TABS 20mg, 40mg 1

famotidine in nacl 1

famotidine inj 1

ranitidine hcl TABS 150mg, 300mg 1

ranitidine hcl inj 1

ranitidine inj 1

ranitidine syrup 1




78


Medicamento

Requisitos/Límites

INFLAMMATORY BOWEL DISEASE

APRISO 1 QL (120 caps / 30 days)

balsalazide disodium 1

budesonide ec 1

colocort 1

DELZICOL 1

hydrocortisone (enema) 1

mesalamine ENEM 1

mesalamine SUPP 1

mesalamine TBEC 800mg 1

mesalamine w/ cleanser 1

sulfasalazine TABS 1

sulfasalazine ec 1

LAXATIVES

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n/flavor pack 1

generlac 1

GOLYTELY 1

lactulose SOLN 1

lactulose (encephalopathy) 1

MOVIPREP 1




79


Medicamento

Requisitos/Límites

NULYTELY/FLAVOR PACKS 1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

peg 3350/electrolytes 1

SUPREP BOWEL PREP KIT 1

trilyte 1

MISCELLANEOUS

alosetron hcl 1 PA

AMITIZA CAP 8MCG 1 QL (180 caps / 30 days)

AMITIZA CAP 24MCG 1 QL (60 caps / 30 days)

cromolyn sodium (mastocytosis) 1

diphenoxylate w/ atropine 1

GATTEX 1 NM, LA, PA

LINZESS 1 QL (30 caps / 30 days)

loperamide hcl CAPS 1

misoprostol TABS 1

MOVANTIK 12.5mg 1 QL (60 tabs / 30 days)

MOVANTIK 25mg 1 QL (30 tabs / 30 days)

RELISTOR SOLN 1 PA

sucralfate TABS 1

SYMPROIC 1

ursodiol CAPS; TABS 1




80


Medicamento

Requisitos/Límites

XIFAXAN 550mg 1 PA

PANCREATIC ENZYMES

CREON 1

ZENPEP 1

PROTON PUMP INHIBITORS

DEXILANT 1 QL (30 caps / 30 days)

esomeprazole magnesium 1 QL (30 caps / 30 days)

esomeprazole sodium inj 1

lansoprazole CPDR 1 QL (30 caps / 30 days)

omeprazole cap 10mg 1



pantoprazole sodium SOLR 1

pantoprazole sodium tbec 1

rabeprazole sodium 1 QL (30 tabs / 30 days)

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl 1 QL (30 tabs / 30 days)

dutasteride CAPS 1 QL (30 caps / 30 days)

dutasteride-tamsulosin hcl 1 QL (30 caps / 30 days)

finasteride TABS 5mg 1

tamsulosin hcl 1

MISCELLANEOUS

bethanechol chloride TABS 1

potassium citrate (alkalinizer) er tabs 1




81


Medicamento

Requisitos/Límites

URINARY ANTISPASMODICS

MYRBETRIQ 25mg 1 QL (60 tabs / 30 days)

MYRBETRIQ 50mg 1 QL (30 tabs / 30 days)

oxybutynin chloride SYRP 1

oxybutynin chloride TABS 1

oxybutynin chloride TB24 5mg 1 QL (30 tabs / 30 days)

oxybutynin chloride TB24 10mg, 15mg 1 QL (60 tabs / 30 days)

tolterodine tartrate CP24 1 QL (30 caps / 30 days),

ST

tolterodine tartrate TABS 1 ST

TOVIAZ 1 QL (30 tabs / 30 days)

trospium chloride TABS 1 QL (60 tabs / 30 days)

VESICARE 1 QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES

clindamycin phosphate vaginal 1

metronidazole vaginal 1

terconazole vaginal 1

vandazole 1

HEMATOLOGIC

ANTICOAGULANTS

COUMADIN 1

ELIQUIS 1

ELIQUIS STARTER PACK 1

enoxaparin sodium 1

fondaparinux sodium 1




82


Medicamento

Requisitos/Límites

heparin sod (porcine) in d5w 1

heparin sod inj 1000/ml 1 B/D




HEPARIN SODIUM/NACL 0.45% 1

jantoven 1

PRADAXA 1

warfarin sodium 1

XARELTO 1

XARELTO STARTER PACK 1

HEMATOPOIETIC GROWTH FACTORS

GRANIX 1 NM, PA

NEUPOGEN 1 NM, PA

PROCRIT 1 NM, PA

MISCELLANEOUS

anagrelide hcl 1

BERINERT 1 QL (24 boxes / 30 days),

NM, LA, PA

cilostazol 1

DROXIA 1

ENDARI 1 NM, LA, PA

FIRAZYR 1 QL (9 syringes / 30 days), NM, PA




83


Medicamento

Requisitos/Límites

HAEGARDA 2000unit 1 QL (30 vials / 30 days),

NM, LA, PA

HAEGARDA 3000unit 1 QL (20 vials / 30 days),

NM, LA, PA

pentoxifylline TBCR 1

PROMACTA PACK 1 QL (360 packets / 30 days), NM, LA, PA

PROMACTA TABS 12.5mg 1 QL (360 tabs / 30 days), NM, LA, PA

PROMACTA TABS 25mg 1 QL (180 tabs / 30 days), NM, LA, PA



tranexamic acid SOLN; TABS 1

PLATELET AGGREGATION INHIBITORS

aspirin-dipyridamole 1

BRILINTA 1

clopidogrel tab 75mg 1

prasugrel hcl 1

ZONTIVITY 1

IMMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)

HUMIRA 10mg/0.1ml, 20mg/0.2ml 1 QL (2 injections / 28 days), NM, PA

HUMIRA 40mg/0.4ml 1 QL (6 injections / 28 days), NM, PA




84


Medicamento

Requisitos/Límites

HUMIRA INJ 10MG/0.2ML 1 QL (2 syringes / 28 days),

NM, PA

HUMIRA KIT 20MG/0.4ML 1 QL (2 syringes / 28 days),

NM, PA

HUMIRA KIT 40MG/0.8ML 1 QL (6 syringes / 28 days), NM, PA

HUMIRA PEDIATRIC CROHNS DISEASE 1 NM, PA

HUMIRA PEN 1 QL (6 pens / 28 days), NM, PA

HUMIRA PEN CD/UC/HS STARTER 1 NM, PA

HUMIRA PEN INJ CD/UC/HS STARTER 1 NM, PA

HUMIRA PEN INJ PS/UV STARTER 1 NM, PA

HUMIRA PEN-PS/UV STARTER 1 NM, PA

hydroxychloroquine sulfate 1

leflunomide TABS 1

methotrexate sodium tabs 1

REMICADE 1 NM, PA

XATMEP 1 B/D

XELJANZ 1 QL (60 tabs / 30 days), NM, PA

XELJANZ XR 1 QL (30 tabs / 30 days),

NM, PA

IMMUNOGLOBULINS

BIVIGAM 1 NM, PA

CARIMUNE NANOFILTERED 1 NM, PA

FLEBOGAMMA DIF 1 NM, PA




85


Medicamento

Requisitos/Límites

GAMASTAN S/D 1 B/D, NM

GAMMAGARD LIQUID 1 NM, PA

GAMMAGARD S/D 1 NM, PA

GAMMAKED 1 NM, PA

GAMMAPLEX 1 NM, PA

GAMMAPLEX 10GM/100ML 1 NM, PA

GAMUNEX-C 1 NM, PA

OCTAGAM 1 NM, PA

PANZYGA 1 NM, PA

PRIVIGEN 1 NM, PA

IMMUNOMODULATORS

ACTIMMUNE 1 NM, LA, PA

ARCALYST 1 NM, PA

INTRON-A INJ 10MU 1 B/D, NM




IMMUNOSUPPRESSANTS

azathioprine TABS 1 B/D

BENLYSTA 1 NM, PA

cyclosporine CAPS; SOLN 1 B/D, NM

cyclosporine modified (for microemulsion) 1 B/D, NM

gengraf 1 B/D, NM

mycophenolate mofetil CAPS; SUSR; TABS 1 B/D, NM




86


Medicamento

Requisitos/Límites

mycophenolate sodium tbec 1 B/D, NM

NULOJIX 1 B/D, NM

RAPAMUNE SOLN 1 B/D, NM

SANDIMMUNE SOLN 100mg/ml 1 B/D, NM

sirolimus SOLN; TABS 1 B/D, NM

tacrolimus CAPS 1 B/D, NM

ZORTRESS TAB 0.5MG 1 B/D, NM



ZORTRESS TAB 1MG 1 B/D, NM

VACCINES

ACTHIB 1

ADACEL 1

BCG VACCINE 1

BEXSERO 1

BOOSTRIX 1

DAPTACEL 1

DIPHTHERIA/TETANUS TOXOID 1 B/D

ENGERIX-B SUSP 1 B/D

GARDASIL 9 1

HAVRIX 1

HIBERIX 1

IMOVAX RABIES (H.D.C.V.) 1 B/D




87


Medicamento

Requisitos/Límites

INFANRIX 1

IPOL INACTIVATED IPV 1

IXIARO 1

KINRIX 1

M-M-R II 1

MENACTRA 1

MENVEO 1

PEDIARIX 1

PEDVAX HIB 1

PENTACEL 1

PROQUAD 1

QUADRACEL 1

RABAVERT 1 B/D

RECOMBIVAX HB 1 B/D

ROTARIX 1

ROTATEQ 1

SHINGRIX 1 QL (2 vials per lifetime)

TDVAX 1 B/D

TENIVAC 1 B/D

TRUMENBA 1

TWINRIX INJ 1

TYPHIM VI 1

VAQTA 1




88


Medicamento

Requisitos/Límites

VARIVAX 1

YF-VAX 1

ZOSTAVAX 1 QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES

klor-con 8 1

klor-con 10 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con pak 20meq 1

klor-con spr cap 8meq 1

klor-con spr cap 10meq 1

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml,

40gm/1000ml

1

magnesium sulfate SOLN 2gm/50ml,

4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

1

MAGNESIUM SULFATE IN D5W 1

magnesium sulfate in dextrose 1

magnesium sulfate inj 50% 1

potassium chloride CPCR 1

potassium chloride PACK 1

potassium chloride SOLN 10%, 20% 1

potassium chloride TBCR 1




89


Medicamento

Requisitos/Límites

potassium chloride microencapsulated

crystals er

1

potassium chloride tab cr 10 meq 1

sodium chloride SOLN 2.5meq/ml 1

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

1

tpn electrolytes 1 B/D

IV NUTRITION

AMINOSYN 1 B/D

AMINOSYN 7%/ELECTROLYTES 1 B/D

aminosyn 8.5%/electrolyte 1 B/D

aminosyn ii 8.5%/electrol 1 B/D

AMINOSYN II INJ 8.5% 1 B/D

AMINOSYN II INJ 10% 1 B/D

AMINOSYN M 1 B/D

AMINOSYN-HBC 1 B/D

AMINOSYN-PF 7% 1 B/D

AMINOSYN-PF INJ 10% 1 B/D

AMINOSYN-RF 1 B/D

CLINIMIX 4.25%/DEXTROSE 5% 1 B/D

CLINIMIX 4.25%/DEXTROSE 25% 1 B/D

CLINIMIX 5%/DEXTROSE 15% 1 B/D






90


Medicamento

Requisitos/Límites

CLINIMIX INJ 4.25/D10 1 B/D

FREAMINE HBC 6.9% 1 B/D

FREAMINE III 1 B/D

hepatamine 1 B/D

INTRALIPID 30% 1 B/D

intralipid inj 20% 1 B/D

NEPHRAMINE 1 B/D

nutrilipid inj 20% 1 B/D

premasol 6% 1 B/D

PREMASOL 10% 1 B/D

PROCALAMINE 1 B/D

PROSOL 1 B/D

TRAVASOL 1 B/D

TROPHAMINE INJ 10% 1 B/D

IV REPLACEMENT SOLUTIONS

dextrose 2.5%/nacl 0.45% 1

dextrose 5% 1

DEXTROSE 5% /ELECTROLYTE 1

dextrose 5%/nacl 0.2% 1

DEXTROSE 5%/NACL 0.3% 1







91


Medicamento

Requisitos/Límites


dextrose 5%/potassium chl 1

dextrose 10% flex contain 1

DEXTROSE 10%/NACL 0.2% 1


dextrose 50% 1

dextrose in lactated ringers 1

dextrose inj 70% 1

IONOSOL-MB/DEXTROSE 5% 1

ISOLYTE P 1

ISOLYTE S 1

kcl0.15%/d5w/nacl0.2% 1

KCL 0.3%/D5W/NACL 0.9% 1

kcl 0.3%/d5w/nacl 0.45% 1

kcl 0.15%/d5w/nacl 0.9% 1

KCL 0.15%/D5W/NACL 0.225% 1

kcl 0.075%/d5w/nacl 0.45% 1

kcl/d5w inj 0.3% 1

kcl/d5w/nacl inj 0.22%/0.45% 1

kcl/d5w/nacl inj .15/.33% 1

kcl/d5w/nacl inj .15/.45% 1

kcl/nacl inj 0.3-0.9 1

kcl/nacl inj 0.15%-0.9% 1




92


Medicamento

Requisitos/Límites

lactated ringer's 1

NORMOSOL-M IN D5W 1

NORMOSOL-R 1

NORMOSOL-R IN D5W 1

PLASMA-LYTE A 1

PLASMA-LYTE-148 1

pot chloride inj 2meq/ml 1

potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml,

20meq/100ml, 40meq/100ml

1

potassium chloride in nacl 1

sodium chloride SOLN 3%, 5% 1

sodium chloride 0.45% 1

sodium chloride inj 0.9% 1

VITAMINS

calcitriol CAPS 1 B/D

calcitriol inj 1 B/D

calcitriol oral soln 1 mcg/ml 1 B/D

M-NATAL PLUS 1

paricalcitol CAPS 1 B/D

PNV FOLIC ACID + IRON MUL 1

PRENATAL 1

PRENATAL PLUS 1

PRENATAL PLUS LOW IRON 1




93


Medicamento

Requisitos/Límites

RAYALDEE 1

TRICARE 1

OPHTHALMIC

ANTI-INFECTIVE/ANTI-INFLAMMATORY

bacitracin-poly-neomycin-hc 1

BLEPHAMIDE OINT 1

neomycin-polymy-dexameth 1

neomycin-polymyxin-hc (ophth) 1

sulfacetamide sod-prednisolone 1

TOBRADEX OINT 1

TOBRADEX ST 1

tobramycin-dexamethasone 1

ZYLET 1

ANTI-INFECTIVES

AZASITE 1

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 1

CILOXAN OINT 1

ciprofloxacin hcl (ophth) 1

erythromycin (ophth) 1

gatifloxacin (ophth) 1

gentak 1

gentamicin sulfate soln (ophth) 1




94


Medicamento

Requisitos/Límites

MOXEZA 1

moxifloxacin hcl (ophth) 1

NATACYN 1

neomycin-bacitracin zn-polymyxin 1

neomycin-polymyxin-gramicidin 1

ofloxacin (ophth) 1

polymyxin b-trimethoprim 1

sulfacetamide sodium (ophth) 1

tobramycin (ophth) 1

trifluridine 1

ZIRGAN 1

ANTI-INFLAMMATORIES

ALREX 1

bromfenac sodium (ophth) 1

BROMSITE 1

dexamethasone sodium phosphate (ophth) 1

diclofenac sodium (ophth) 1

DUREZOL 1

fluorometholone 1

flurbiprofen sodium 1

ILEVRO 1

ketorolac tromethamine (ophth) 1

LOTEMAX 1




95


Medicamento

Requisitos/Límites

prednisolone acetate (ophth) 1

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

1

PROLENSA 1

ANTIALLERGICS

azelastine drop 0.05% 1

BEPREVE 1

cromolyn sodium (ophth) 1

LASTACAFT 1

olopatadine hcl 0.2% 1

PAZEO 1

ANTIGLAUCOMA

ALPHAGAN P SOL 0.1% 1

AZOPT 1

betaxolol hcl (ophth) 1

BETOPTIC-S 1

brimonidine sol 0.2% 1

brimonidine sol 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 1

dorzolamide hcl 1

dorzolamide hcl-timolol maleate 1

latanoprost SOLN 1

levobunolol hcl 1




96


Medicamento

Requisitos/Límites

LUMIGAN 1

PHOSPHOLINE IODIDE 1

pilocarpine hcl SOLN 1

RHOPRESSA 1

SIMBRINZA 1

timolol maleate (ophth) soln 1

timolol maleate gel 1

timolol maleate ophth soln 0.5% (once-daily)

1

TRAVATAN Z 1

MISCELLANEOUS

CYSTARAN 1 NM, LA, PA

proparacaine hcl SOLN 1

RESTASIS 1 QL (60 single use vials /

30 days)

RESTASIS MULTIDOSE 1 QL (1 bottle / 30 days)

RESPIRATORY

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA 1 QL (60 blisters / 30 days)

BEVESPI AEROSPHERE 1 QL (1 inhaler / 30 days)

COMBIVENT RESPIMAT 1 QL (2 inhalers / 30 days)

ipratropium-albuterol nebu 1 B/D

TRELEGY ELLIPTA 1 QL (60 blisters / 30 days)

ANTICHOLINERGICS

ATROVENT HFA 1 QL (2 inhalers / 30 days)




97


Medicamento

Requisitos/Límites

INCRUSE ELLIPTA 1 QL (30 blisters / 30 days)

ipratropium bromide SOLN 1 B/D

ipratropium bromide (nasal) 1

ANTIHISTAMINES

azelastine spr 0.1% 1

azelastine spr 0.15% 1

cetirizine syrup 1

cyproheptadine hcl SYRP; TABS 1 PA; PA if 70 years and

older

diphenhydramine hcl inj 50mg/ml 1

hydroxyzine hcl SYRP; TABS 1 PA; PA if 70 years and older

hydroxyzine hcl inj 1 PA; PA if 70 years and older

hydroxyzine pamoate CAPS 25mg, 50mg 1 PA; PA if 70 years and older

levocetirizine dihydrochloride 1

BETA AGONISTS

albuterol sulfate AERS 108mcg/act 1 QL (2 inhalers / 30 days); (generic of Proair HFA)

albuterol sulfate AERS 108mcg/act 1 QL (2 inhalers / 30 days); (generic of Ventolin HFA)

albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP 1

albuterol sulfate TABS 1

albuterol sulfate TB12 1

levalbuterol hcl NEBU 1 B/D




98


Medicamento

Requisitos/Límites

levalbuterol hcl soln nebu conc 1.25

mg/0.5ml

1 B/D

levalbuterol tartrate hfa 1 QL (2 inhalers / 30 days)

SEREVENT DISKUS 1 QL (60 inhalations / 30 days)

terbutaline sulfate TABS 1

VENTOLIN HFA 1 QL (2 inhalers / 30 days)

LEUKOTRIENE MODULATORS

montelukast sodium CHEW; PACK; TABS 1

zafirlukast 1

MAST CELL STABILIZERS

cromolyn sod neb 20mg/2ml 1 B/D

MISCELLANEOUS

acetylcysteine SOLN 10%, 20% 1 B/D

ARALAST NP 1 NM, LA, PA

DALIRESP 1

epinephrine (anaphylaxis) .15mg/0.15ml,

.3mg/0.3ml

1 (generic of Adrenaclick)

ESBRIET 1 NM, PA

KALYDECO 1 NM, PA

OFEV 1 NM, PA

ORKAMBI 1 NM, PA

PROLASTIN-C 1 NM, LA, PA

PULMOZYME 1 NM, PA

SYMDEKO 1 NM, LA, PA

THEO-24 1




99


Medicamento

Requisitos/Límites

theophylline 1

XOLAIR 1 NM, LA, PA

ZEMAIRA 1 NM, LA, PA

NASAL STEROIDS

flunisolide (nasal) 1 QL (3 bottles / 30 days)

fluticasone propionate (nasal) 1 QL (1 bottle / 30 days)

STEROID INHALANTS

ARNUITY ELLIPTA 1 QL (30 inhalations / 30 days)

budesonide (inhalation) .25mg/2ml, .5mg/2ml

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

1 QL (120 inhalations / 30 days)

FLOVENT DISKUS 250mcg/blist 1 QL (240 inhalations / 30 days)

FLOVENT HFA 1 QL (2 inhalers / 30 days)

PULMICORT FLEXHALER 1 QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS

ADVAIR DISKUS 1 QL (60 inhalations / 30 days)

ADVAIR HFA 1 QL (1 inhaler / 30 days)

BREO ELLIPTA 1 QL (60 blisters / 30 days)

SYMBICORT 1 QL (1 inhaler / 30 days)

TOPICAL

DERMATOLOGY, ACNE

amnesteem 1 PA

avita 1 PA




100


Medicamento

Requisitos/Límites

benzoyl peroxide-erythromycin 1

claravis 1 PA

clindacin-p 1

clindamycin phosphate (topical) GEL;

LOTN; SOLN; SWAB

1

ery pad 2% 1

erythromycin (acne aid) 1

isotretinoin CAPS 1 PA

myorisan 1 PA

sulfacetamide sodium (acne) 1

tretinoin CREA 1 PA

tretinoin GEL .01%, .025% 1 PA

zenatane 1 PA

DERMATOLOGY, ANTIBIOTICS

gentamicin sulfate (topical) 1

mupirocin OINT 1

silver sulfadiazine CREA 1

ssd 1

SULFAMYLON CREA 1

DERMATOLOGY, ANTIFUNGALS

ciclopirox CREA; GEL; SUSP 1

ciclopirox shampoo 1% 1

clotrimazole (topical) 1

clotrimazole w/ betamethasone CREA 1




101


Medicamento

Requisitos/Límites

ketoconazole cream 1

nyamyc 1

nystatin (topical) 1

nystop 1

DERMATOLOGY, ANTIPSORIATICS

acitretin 1 PA

calcipotriene CREA; OINT 1 QL (120 gm / 30 days),

PA

calcipotriene SOLN 1 QL (120 mL / 30 days),

PA

calcitrene 1 QL (120 gm / 30 days),

PA

tazarotene CREA 1 PA

TAZORAC CREA .05% 1 PA

DERMATOLOGY, ANTISEBORRHEICS

ketoconazole shampoo 1

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS

ala-cort 1

alclometasone dipropionate 1

betamethasone dipropionate (topical) 1

betamethasone dipropionate augmented 1

betamethasone valerate CREA; LOTN;

OINT

1

ENSTILAR 1 PA

fluocinolone acetonide CREA; OIL; OINT; SOLN

1




102


Medicamento

Requisitos/Límites

fluocinolone acetonide oil body 1

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate CREA; OINT 1

halobetasol propionate CREA; OINT 1

hydrocortisone (topical) CREA 1

hydrocortisone (topical) LOTN 1

hydrocortisone (topical) OINT 2.5% 1

hydrocortisone butyrate cream 0.1% 1

hydrocortisone butyrate oint 0.1% 1

hydrocortisone valerate 1

mometasone furoate CREA; OINT; SOLN 1

TEXACORT SOLN 2.5% 1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

DERMATOLOGY, LOCAL ANESTHETICS

glydo 1 QL (30 mL / 30 days), PA

lidocaine PTCH 1 QL (3 patches / 1 day), PA

lidocaine hcl GEL 1 QL (30 mL / 30 days), PA

lidocaine hcl SOLN 4% 1 QL (50 mL / 30 days), PA

lidocaine oint 5% 1 QL (50 grams / 30 days), PA




103


Medicamento

Requisitos/Límites

lidocaine-prilocaine 1 QL (30 grams / 30 days),

PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

ammonium lactate CREA; LOTN 1

diclofenac sodium (topical) 1% gel 1 PA

fluorouracil (topical) CREA 5% 1

fluorouracil (topical) SOLN 1

imiquimod CREA 5% 1

metronidazole (topical) CREA; LOTN 1

metronidazole gel 0.75% 1

PANRETIN 1

PICATO .05% 1 QL (2 tubes / 30 days)

PICATO .015% 1 QL (3 tubes / 30 days)

podofilox SOLN 1

procto-med hc 1

procto-pak 1

proctosol hc cre 2.5% 1

proctozone-hc 1

rosadan cre 0.75% 1

tacrolimus (topical) 1

TARGRETIN GEL 1 NM, PA

VALCHLOR 1 NM, LA, PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES

malathion 1




104


Medicamento

Requisitos/Límites

permethrin cre 5% 1

DERMATOLOGY, WOUND CARE AGENTS

acetic acid .25% 1

REGRANEX 1 PA

SANTYL 1

sodium chlor sol 0.9% irr 1

water for irrigation, sterile 1

MOUTH/THROAT/DENTAL AGENTS

cevimeline hcl 1

chlorhexidine gluconate (mouth-throat) 1

clotrimazole LOZG 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

paroex sol 0.12% 1

periogard 1

pilocarpine hcl (oral) 1

triamcinolone acetonide (mouth) 1

OTIC

acetic acid (otic) 1

CIPRODEX 1

flac 1

fluocinolone acetonide (otic) 1

neomycin-polymyxin-hc (otic) 1

ofloxacin (otic) 1




105

Índice de medicamentos

A abacavir sulfate .............................. 19

abacavir sulfate-lamivudine .............. 21

abacavir sulfate-lamivudine-zidovudine..................................................... 21

ABELCET ........................................ 18 ABILIFY MAINTENA .......................... 55

abiraterone acetate ......................... 31 ABRAXANE ..................................... 30

acamprosate calcium ....................... 64 acarbose ........................................ 67

acebutolol hcl ................................. 41 acetaminophen w/ codeine 300-15mg12

acetaminophen w/ codeine 300-30mg12 acetaminophen w/ codeine 300-60mg12

acetaminophen w/ codeine soln ........ 12 acetazolamide ................................. 44

acetic acid .................................... 104

acetic acid (otic) ........................... 104 acetylcysteine ................................. 98

acitretin ....................................... 101 ACTHIB .......................................... 86

ACTIMMUNE ................................... 85 acyclovir ........................................ 23

acyclovir sodium ............................. 23 ADACEL ......................................... 86

ADAGEN ......................................... 71 adefovir dipivoxil ............................. 23

ADEMPAS ....................................... 46 adriamycin ..................................... 29

adrucil ........................................... 29 adrucil inj ....................................... 29

ADVAIR DISKUS .............................. 99

ADVAIR HFA ................................... 99 AFINITOR ....................................... 33

AFINITOR DISPERZ ......................... 33 AIMOVIG ........................................ 61

ala-cort ........................................ 101 albendazole .................................... 16

albuterol sulfate .............................. 97 alclometasone dipropionate ............ 101

ALCOHOL SWABS ............................ 65

ALDURAZYME ................................. 71 ALECENSA ...................................... 33

alendronate sodium ......................... 70 alfuzosin hcl ................................... 80

ALIMTA .......................................... 29 ALINIA ........................................... 16

allopurinol tab................................. 11 alosetron hcl ................................... 79

ALPHAGAN P SOL 0.1%.................... 95 alprazolam tab 0.25mg .................... 46

alprazolam tab 0.5mg ...................... 46 alprazolam tab 1mg ......................... 46

alprazolam tab 2 mg ........................ 46 ALREX ........................................... 94

ALUNBRIG ...................................... 33

amantadine hcl ............................... 54 AMBISOME ..................................... 18

amikacin sulfate .............................. 15 amiloride & hydrochlorothiazide ........ 44

amiloride hcl ................................... 44 AMINOSYN ..................................... 89

AMINOSYN 7%/ELECTROLYTES ......... 89 aminosyn 8.5%/electrolyte ............... 89

aminosyn ii 8.5%/electrol ................. 89 AMINOSYN II INJ 10% ..................... 89

AMINOSYN II INJ 8.5% .................... 89 AMINOSYN M .................................. 89

AMINOSYN-HBC .............................. 89 AMINOSYN-PF 7% ........................... 89

AMINOSYN-PF INJ 10% .................... 89

AMINOSYN-RF ................................ 89 amiodarone hcl soln ........................ 39

amiodarone tab 100mg .................... 39 amiodarone tab 200mg .................... 39

amiodarone tab 400mg .................... 39 AMITIZA CAP 24MCG ....................... 79




106

AMITIZA CAP 8MCG ......................... 79

amitriptyline hcl .............................. 52 amlodipine besylate ......................... 42

amlodipine besylate-benazepril hcl cap 10-20 mg ....................................... 37

amlodipine besylate-benazepril hcl cap 10-40 mg ....................................... 37

amlodipine besylate-benazepril hcl cap 2.5-10 mg ...................................... 37

amlodipine besylate-benazepril hcl cap 5-10 mg ......................................... 37



amlodipine besylate-olmesartan

medoxomil ..................................... 38 amlodipine besylate-valsartan tab ..... 38

amlodipine-valsartan-hydrochlorothiazide tab .................... 38

ammonium lactate ........................ 103 amnesteem .................................... 99

amoxapine ..................................... 52 amoxicillin ...................................... 27

amoxicillin & pot clavulanate ............ 27 amphetamine-dextroamphetamine cap

sr 24hr 10 mg................................. 59 amphetamine-dextroamphetamine cap

sr 24hr 15 mg................................. 59 amphetamine-dextroamphetamine cap

sr 24hr 20 mg................................. 59

amphetamine-dextroamphetamine cap sr 24hr 25 mg................................. 59

amphetamine-dextroamphetamine cap sr 24hr 30 mg................................. 59

amphetamine-dextroamphetamine cap sr 24hr 5 mg .................................. 59

amphetamine-dextroamphetamine tab 10 mg ............................................ 59

amphetamine-dextroamphetamine tab 12.5 mg ......................................... 60

amphetamine-dextroamphetamine tab

15 mg ............................................ 60



amphetamine-dextroamphetamine tab 5 mg ............................................. 59

amphetamine-dextroamphetamine tab 7.5 mg ........................................... 59

amphotericin b ................................ 18 ampicillin & sulbactam sodium .......... 27

ampicillin cap 500mg ....................... 27 ampicillin inj ................................... 27

ampicillin sodium ............................ 27 ANADROL-50 .................................. 65

anagrelide hcl ................................. 82

anastrozole .................................... 32 ANDRODERM .................................. 65

ANORO ELLIPTA .............................. 96 APOKYN ......................................... 54

aprepitant ...................................... 76 aprepitant pak 80mg & 125mg .......... 76

APRISO .......................................... 78 APTIOM .......................................... 47

APTIVUS ........................................ 19 ARALAST NP ................................... 98

ARCALYST ...................................... 85 aripiprazole odt ............................... 55

aripiprazole oral solution 1 mg/ml ..... 55 aripiprazole tab ............................... 55

ARISTADA ...................................... 55

ARISTADA INITIO............................ 55 armodafinil ..................................... 63

ARNUITY ELLIPTA ............................ 99 aspirin-dipyridamole ........................ 83

atazanavir sulfate ............................ 19 atenolol ......................................... 42

atenolol & chlorthalidone .................. 41 atomoxetine hcl .............................. 60

atorvastatin calcium ........................ 40 atovaquone .................................... 16

atovaquone-proguanil hcl ................. 19




107

ATRIPLA ......................................... 21

ATROVENT HFA ............................... 96 AURYXIA ........................................ 75

AUSTEDO ....................................... 62 AVASTIN ........................................ 30

avita .............................................. 99 azacitidine ...................................... 29

AZACTAM IN ISO-OSMOTIC DE ......... 16 AZACTAM/DEX INJ .......................... 16

AZASITE ........................................ 93 azathioprine ................................... 85

azelastine drop 0.05% ..................... 95 azelastine spr 0.1% ......................... 97

azelastine spr 0.15% ....................... 97 azithromycin ................................... 26

AZOPT ........................................... 95

aztreonam ...................................... 16 B bacitracin (ophthalmic) .................... 93 bacitracin-polymyxin b (ophth) ......... 93

bacitracin-poly-neomycin-hc ............. 93 baclofen ......................................... 63

balsalazide disodium ........................ 78 BANZEL SUS 40MG/ML .................... 47

BANZEL TAB 200MG ........................ 47 BANZEL TAB 400MG ........................ 47

BARACLUDE ................................... 23 BASAGLAR KWIKPEN ....................... 65

BCG VACCINE ................................. 86 BD ULTRAFINE INSULIN SYRINGE ..... 65

BD ULTRAFINE/NANO PEN NEEDLES .. 65

benazepril & hydrochlorothiazide ....... 37 benazepril hcl ................................. 38

BENDEKA ....................................... 28 BENLYSTA ...................................... 85

benzoyl peroxide-erythromycin ....... 100 benztropine mesylate inj .................. 54

benztropine mesylate tab 0.5mg ....... 54 benztropine mesylate tab 1mg .......... 54

benztropine mesylate tab 2mg .......... 54 BEPREVE ........................................ 95

BERINERT ...................................... 82

BESIVANCE .................................... 93

betamethasone dipropionate (topical)................................................... 101

betamethasone dipropionate augmented ................................... 101

betamethasone valerate ................. 101 BETASERON ................................... 63

betaxolol hcl ................................... 42 betaxolol hcl (ophth) ....................... 95

bethanechol chloride ........................ 80 BETOPTIC-S ................................... 95

BEVESPI AEROSPHERE ..................... 96 bexarotene ..................................... 36

BEXSERO ....................................... 86 bicalutamide ................................... 32

BICILLIN L-A .................................. 27

BIKTARVY ...................................... 21 bisoprolol & hydrochlorothiazide ........ 41

bisoprolol fumarate ......................... 42 BIVIGAM ........................................ 84

bleomycin sulfate ............................ 29 BLEPHAMIDE .................................. 93

BOOSTRIX ...................................... 86 BORTEZOMIB.................................. 30

BOSULIF ........................................ 33 BRAFTOVI ...................................... 33

BREO ELLIPTA ................................ 99 BRILINTA ....................................... 83

brimonidine sol 0.15% ..................... 95 brimonidine sol 0.2% ....................... 95

BRIVIACT INJ 50MG/5ML ................. 47

BRIVIACT SOL 10MG/ML .................. 47 BRIVIACT TAB 100MG ...................... 47

BRIVIACT TAB 10MG ....................... 47 BRIVIACT TAB 25MG ....................... 47

BRIVIACT TAB 50MG ....................... 47 BRIVIACT TAB 75MG ....................... 47

bromfenac sodium (ophth) ............... 94 bromocriptine mesylate .................... 54

BROMSITE ...................................... 94 budesonide (inhalation) ................... 99

budesonide ec................................. 78




108

bumetanide inj 0.25/ml .................... 44

bumetanide tab............................... 44 buprenorphine hcl ........................... 64

buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........................... 64

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg .......................... 64

buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................. 64

buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................. 64

buprenorphine hcl-naloxone hcl sl ..... 64 bupropion hcl .................................. 52

bupropion hcl (smoking deterrent) .... 64 buspirone hcl .................................. 46

butorphanol tartrate ........................ 12

BYDUREON BCISE ........................... 65 BYDUREON INJ ............................... 65

BYDUREON PEN .............................. 65 BYETTA .......................................... 65

BYSTOLIC ...................................... 42 C cabergoline .................................... 74 CABOMETYX ................................... 33

calcipotriene ................................. 101 calcitonin (salmon) .......................... 74

calcitrene ..................................... 101 calcitriol ......................................... 92

calcitriol inj .................................... 92 calcitriol oral soln 1 mcg/ml .............. 92

calcium acetate (phosphate binder) ... 75

CALQUENCE ................................... 33 candesartan cilexetil ........................ 39

candesartan cilexetil-hydrochlorothiazide ......................... 38

CAPRELSA ...................................... 33 captopril ........................................ 38

captopril & hydrochlorothiazide ......... 37 CARBAGLU ..................................... 71

carbamazepine ............................... 47 carbidopa/levodopa/entacapone ........ 54

carbidopa-levodopa ......................... 54

carboplatin ..................................... 36

CARIMUNE NANOFILTERED ............... 84 carisoprodol .................................... 63

carteolol hcl (ophth) ........................ 95 cartia xt ......................................... 42

carvedilol ....................................... 42 caspofungin acetate ......................... 18

CAYSTON ....................................... 16 cefaclor .......................................... 24

CEFACLOR ER TAB 500MG ................ 24 cefadroxil ....................................... 25

CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ................................................ 25

cefazolin inj .................................... 25 cefazolin sodium ............................. 25

CEFAZOLIN SODIUM 1 GM/50ML ....... 25

cefdinir .......................................... 25 cefepime for inj ............................... 25

cefixime ......................................... 25 cefotaxime sodium .......................... 25

cefoxitin for inj ............................... 25 cefpodoxime proxetil ....................... 25

cefprozil ......................................... 25 ceftazidime ..................................... 25

CEFTAZIDIME/DEXTROSE ................. 25 ceftriaxone sodium .......................... 25

cefuroxime axetil ............................ 25 cefuroxime sodium .......................... 25

celecoxib ........................................ 11 CELONTIN ...................................... 47

cephalexin ...................................... 25

CERDELGA ..................................... 71 CEREZYME ..................................... 71

cetirizine syrup ............................... 97 cevimeline hcl ............................... 104

CHANTIX ........................................ 64 CHANTIX CONTINUING MONTH ......... 64

CHANTIX STARTER PACK ................. 64 CHEMET ......................................... 71

chlorhexidine gluconate (mouth-throat)................................................... 104

chloroquine phosphate ..................... 19




109

chlorothiazide tabs .......................... 44

chlorpromazine hcl .......................... 55 CHLORPROMAZINE INJ .................... 55

chlorthalidone ................................. 44 cholestyramine ............................... 40

cholestyramine light ........................ 40 ciclopirox ..................................... 100

ciclopirox shampoo 1% .................. 100 cilostazol ........................................ 82

CILOXAN ........................................ 93 CIMDUO ......................................... 21

cinacalcet hcl .................................. 70 CIPRODEX .................................... 104

ciprofloxacin ................................... 26 ciprofloxacin hcl (ophth) ................... 93

ciprofloxacin hcl tab ......................... 26

ciprofloxacin in d5w ......................... 26 cisplatin ......................................... 36

citalopram hydrobromide ................. 52 claravis ........................................ 100

clarithromycin ................................. 26 clarithromycin er ............................. 26

clarithromycin for susp .................... 26 clindacin-p ................................... 100

clindamycin cap 300 mg ................... 16 clindamycin cap 75mg ..................... 16

clindamycin hcl cap 150 mg .............. 16 clindamycin phosphate (topical) ...... 100

clindamycin phosphate in d5w .......... 16 CLINDAMYCIN PHOSPHATE IN NACL .. 16

clindamycin phosphate inj ................ 16

clindamycin phosphate vaginal .......... 81 clindamycin soln 75mg/5ml .............. 16

CLINIMIX 4.25%/DEXTROSE 25% ..... 89 CLINIMIX 4.25%/DEXTROSE 5% ....... 89

CLINIMIX 5%/DEXTROSE 15% ......... 89 CLINIMIX 5%/DEXTROSE 20% ......... 89

CLINIMIX 5%/DEXTROSE 25% ......... 89 CLINIMIX INJ 4.25/D10 ................... 90

clobazam ....................................... 47 clomipramine hcl ............................. 52

clonazepam .............................. 47, 48

clonidine hcl ................................... 45

clonidine hcl ptwk ............................ 45 clopidogrel tab 75mg ....................... 83

clorazepate dipotassium ................... 48 clotrimazole .................................. 104

clotrimazole (topical) ..................... 100 clotrimazole w/ betamethasone ....... 100

clozapine odt ............................ 55, 56 clozapine tab 100mg ....................... 56

clozapine tab 200mg ....................... 56 clozapine tab 25mg ......................... 56

clozapine tab 50mg ......................... 56 COARTEM ....................................... 19

colchicine w/ probenecid .................. 11 COLCRYS ....................................... 11

colesevelam hcl .............................. 40

colestipol hcl gran ........................... 40 colestipol hcl pack ........................... 41

colestipol hcl tabs ............................ 41 colistimethate sodium ...................... 16

colocort.......................................... 78 COMBIGAN ..................................... 95

COMBIVENT RESPIMAT .................... 96 COMETRIQ ..................................... 33

COMPLERA ..................................... 21 compro supp .................................. 76

constulose ...................................... 78 COPIKTRA ...................................... 33

CORLANOR ..................................... 45 cortisone acetate ............................. 72

COTELLIC ....................................... 34

COUMADIN ..................................... 81 CREON ........................................... 80

CRIXIVAN....................................... 19 cromolyn sod neb 20mg/2ml ............ 98

cromolyn sodium (mastocytosis) ....... 79 cromolyn sodium (ophth) ................. 95

cyclobenzaprine hcl ......................... 63 cyclophosphamide ........................... 28

cycloserine ..................................... 23 cyclosporine ................................... 85

cyclosporine modified (for




110

microemulsion) ............................... 85

cyproheptadine hcl .......................... 97 CYSTADANE ................................... 71

CYSTAGON ..................................... 71 CYSTARAN ..................................... 96

cytarabine ...................................... 29 D dacarbazine .................................... 28 dalfampridine ................................. 63

DALIRESP ...................................... 98 danazol .......................................... 71

dantrolene sodium .......................... 63 dapsone ......................................... 16

DAPTACEL ...................................... 86 daptomycin .................................... 16

DAPTOMYCIN .................................. 16

DAURISMO ..................................... 30 DELESTROGEN ................................ 72

DELSTRIGO .................................... 22 DELZICOL ...................................... 78

DEMSER ......................................... 45 DEPEN TITRATABS .......................... 71

DEPO-PROVERA INJ 400/ML ............. 32 DESCOVY ....................................... 22

desipramine hcl............................... 52 desmopressin acetate spray ............. 76

desmopressin acetate spray refrigerated..................................................... 76

desmopressin acetate tabs ............... 76 desmopressin inj 4mcg/ml ............... 76

desvenlafaxine succinate .................. 52

dexamethasone .............................. 72 DEXAMETHASONE ........................... 72

dexamethasone sodium phosphate .... 72 dexamethasone sodium phosphate

(ophth) .......................................... 94 DEXILANT ...................................... 80

dexmethylphenidate hcl ................... 60 dexrazoxane hcl .............................. 36

dextrose 10% flex contain ................ 91 DEXTROSE 10%/NACL 0.2% ............ 91

dextrose 10%/nacl 0.45% ................ 91

dextrose 2.5%/nacl 0.45% ............... 90

dextrose 5% ................................... 90 DEXTROSE 5% /ELECTROLYTE .......... 90

dextrose 5%/nacl 0.2% ................... 90 dextrose 5%/nacl 0.225% ................ 91

DEXTROSE 5%/NACL 0.3% .............. 90 dextrose 5%/nacl 0.33%.................. 90

dextrose 5%/nacl 0.45%.................. 90 dextrose 5%/nacl 0.9% ................... 90

dextrose 5%/potassium chl .............. 91 dextrose 50% ................................. 91

dextrose in lactated ringers .............. 91 dextrose inj 70% ............................ 91

DIASTAT ACUDIAL .......................... 48 DIASTAT PEDIATRIC ........................ 48

diazepam ....................................... 48

diazepam gel .................................. 48 diazepam inj ................................... 48

diazepam intensol ........................... 48 diazepam oral soln 1 mg/ml ............. 48

diclofenac potassium ....................... 11 diclofenac sodium ............................ 11

diclofenac sodium (ophth) ................ 94 diclofenac sodium (topical) 1% gel .. 103

dicloxacillin sodium ......................... 27 dicyclomine hcl cap 10mg ................ 77

dicyclomine hcl soln 10mg/5ml ......... 77 dicyclomine hcl tab 20mg ................. 77

didanosine ...................................... 19 DIFICID ......................................... 26

diflunisal ........................................ 11

digitek ........................................... 43 digox ....................................... 43, 44

digoxin .......................................... 44 digoxin inj ...................................... 44

digoxin sol 50mcg/ml ...................... 44 dihydroergotamine mesylate inj 1

mg/ml ........................................... 61 dihydroergotamine mesylate nasal .... 61

DILANTIN CAP 100MG ..................... 48 DILANTIN CAP 30MG ....................... 48

DILANTIN CHEW TAB 50MG .............. 48




111

DILANTIN-125 SUSP ........................ 48

diltiazem cap 180mg cd ................... 42 diltiazem cap 240mg cd ................... 42

diltiazem cap 360mg cd ................... 43 diltiazem cap er/12hr ....................... 43

diltiazem hcl ................................... 43 diltiazem hcl cap sr 24hr .................. 43

diltiazem hcl coated beads cap sr 24hr..................................................... 43

diltiazem hcl extended release beads cap sr ............................................ 43

diltiazem inj ................................... 43 dilt-xr cap ...................................... 42

diphenhydramine hcl inj 50mg/ml ..... 97 diphenoxylate w/ atropine ................ 79

DIPHTHERIA/TETANUS TOXOID ........ 86

disopyramide phosphate .................. 39 disulfiram ....................................... 64

divalproex sodium ........................... 48 docetaxel ....................................... 30

DOCETAXEL .................................... 30 dofetilide ........................................ 39

donepezil hydrochloride ................... 51 dorzolamide hcl ............................... 95

dorzolamide hcl-timolol maleate ........ 95 doxazosin mesylate ......................... 38

doxepin hcl ..................................... 52 doxorubicin hcl ............................... 29

doxorubicin hcl liposomal ................. 29 doxy 100 ........................................ 28

doxycycline (monohydrate) .............. 28

doxycycline hyclate ......................... 28 doxycycline hyclate 100 mg .............. 28

doxycycline hyclate 20 mg ............... 28 dronabinol ...................................... 76

DROXIA ......................................... 82 duloxetine hcl ................................. 52

DUREZOL ....................................... 94 dutasteride ..................................... 80

dutasteride-tamsulosin hcl ............... 80 E e.e.s. 400 ...................................... 26

EDURANT ....................................... 19

efavirenz ........................................ 19 eletriptan hydrobromide ................... 61

ELIQUIS ......................................... 81 ELIQUIS STARTER PACK ................... 81

EMCYT ........................................... 28 EMEND .......................................... 76

EMGALITY ...................................... 61 EMSAM .......................................... 52

EMTRIVA ........................................ 19 EMVERM ........................................ 16

enalapril maleate ............................ 38 enalapril maleate & hydrochlorothiazide

..................................................... 37 ENDARI .......................................... 82

endocet 10-325mg .......................... 12

endocet 2.5-325mg ......................... 12 endocet 5-325mg ............................ 12

endocet 7.5-325mg ......................... 12 ENGERIX-B ..................................... 86

enoxaparin sodium .......................... 81 ENSTILAR..................................... 101

entacapone .................................... 54 entecavir ........................................ 23

ENTRESTO ..................................... 38 enulose .......................................... 78

EPCLUSA ........................................ 23 EPIDIOLEX ..................................... 48

epinephrine (anaphylaxis) ................ 98 epirubicin hcl .................................. 29

epitol ............................................. 48

EPIVIR HBV .................................... 23 eplerenone ..................................... 38

eprosartan mesylate ........................ 39 ergotamine w/ caffeine .................... 61

ERIVEDGE ...................................... 30 ERLEADA ........................................ 32

ertapenem sodium .......................... 16 ery pad 2% .................................. 100

ery-tab .......................................... 26 ERYTHROCIN LACTOBIONATE ........... 26

erythrocin stearate .......................... 26




112

erythromycin (acne aid) ................. 100

erythromycin (ophth) ...................... 93 erythromycin base........................... 26

erythromycin cap 250mg ec ............. 26 erythromycin ethylsuccinate ............. 26

ESBRIET ........................................ 98 escitalopram oxalate ........................ 52

esomeprazole magnesium ................ 80 esomeprazole sodium inj .................. 80

estradiol......................................... 72 estradiol vaginal cream .................... 72

estradiol vaginal tab ........................ 72 estradiol valerate inj ........................ 72

eszopiclone .................................... 60 ethambutol hcl ................................ 23

ethosuximide .................................. 48

etodolac ......................................... 11 etoposide ....................................... 37

EVOTAZ ......................................... 22 exemestane .................................... 32

ezetimibe ....................................... 41 ezetimibe-simvastatin ...................... 41

F FABRAZYME .................................... 72

famciclovir ..................................... 23 famotidine ...................................... 77

famotidine in nacl ............................ 77 famotidine inj ................................. 77

FANAPT .......................................... 56 FANAPT TITRATION PACK ................. 56

FARXIGA ........................................ 67

FARYDAK ....................................... 30 FASLODEX ...................................... 32

felbamate ....................................... 49 felodipine ....................................... 43

fenofibrate ..................................... 41 fenofibrate micronized ..................... 41

fentanyl citrate ............................... 12 fentanyl patch 100 mcg/hr ............... 13

fentanyl patch 12 mcg/hr ................. 13 fentanyl patch 25 mcg/hr ................. 13

fentanyl patch 50 mcg/hr ................. 13

fentanyl patch 75 mcg/hr ................. 13

FENTORA ....................................... 13 FETZIMA ........................................ 52

FETZIMA TITRATION PACK ............... 52 FIASP ............................................ 65

FIASP FLEXTOUCH ........................... 66 finasteride ...................................... 80

FIRAZYR ........................................ 82 flac .............................................. 104

FLEBOGAMMA DIF ........................... 84 flecainide acetate ............................ 39

FLOVENT DISKUS ............................ 99 FLOVENT HFA ................................. 99

fluconazole ..................................... 18 fluconazole in dextrose .................... 18

fluconazole inj nacl 200 .................... 18

fluconazole inj nacl 400 .................... 18 flucytosine...................................... 18

fludrocortisone acetate .................... 73 flunisolide (nasal) ............................ 99

fluocinolone acetonide ................... 101 fluocinolone acetonide (otic) ........... 104

fluocinolone acetonide oil body ....... 102 fluocinonide .................................. 102

fluocinonide emulsified base ........... 102 fluorometholone .............................. 94

fluorouracil ..................................... 29 fluorouracil (topical) ...................... 103

fluoxetine cap 10mg ........................ 52 fluoxetine cap 20mg ........................ 53

fluoxetine cap 40mg ........................ 53

fluoxetine hcl .................................. 53 fluphenazine decanoate ................... 56

fluphenazine hcl .............................. 56 flurbiprofen .................................... 11

flurbiprofen sodium ......................... 94 flutamide ....................................... 32

fluticasone propionate .................... 102 fluticasone propionate (nasal) ........... 99

fluvoxamine maleate ....................... 47 fondaparinux sodium ....................... 81

FORTEO ......................................... 74




113

fosamprenavir tab 700 mg ............... 19

fosinopril sodium ............................. 38 fosinopril sodium & hydrochlorothiazide

..................................................... 37 FREAMINE HBC 6.9% ....................... 90

FREAMINE III.................................. 90 furosemide ..................................... 44

furosemide inj................................. 44 FUZEON ......................................... 19

fyavolv .......................................... 72 FYCOMPA ....................................... 49

G gabapentin ..................................... 49

galantamine hydrobromide ............... 51 galantamine hydrobromide er ........... 51

GAMASTAN S/D .............................. 85

GAMMAGARD LIQUID ....................... 85 GAMMAGARD S/D ........................... 85

GAMMAKED .................................... 85 GAMMAPLEX ................................... 85

GAMMAPLEX 10GM/100ML ................ 85 GAMUNEX-C ................................... 85

ganciclovir sodium ........................... 23 GARDASIL 9 ................................... 86

gatifloxacin (ophth) ......................... 93 GATTEX ......................................... 79

GAUZE PADS 2 ............................... 66 gavilyte-c ....................................... 78

gavilyte-g ....................................... 78 gavilyte-n/flavor pack ...................... 78

gemcitabine inj soln ........................ 29

gemcitabine inj solr ......................... 29 gemfibrozil ..................................... 41

generlac ......................................... 78 gengraf .......................................... 85

GENOTROPIN .................................. 74 GENOTROPIN MINIQUICK ................. 74

gentak ........................................... 93 gentamicin in saline ......................... 15

gentamicin sulfate ........................... 15 gentamicin sulfate (topical) ............ 100

gentamicin sulfate soln (ophth) ......... 93

GENVOYA ....................................... 22

GEODON ........................................ 56 GILENYA ........................................ 63

GILOTRIF TAB 20MG ........................ 34 GILOTRIF TAB 30MG ........................ 34

GILOTRIF TAB 40MG ........................ 34 glatiramer acetate 20mg/ml ............. 63

glatiramer acetate 40mg/ml ............. 63 glatopa .......................................... 63

GLEOSTINE .................................... 28 glimepiride ..................................... 67

glip/metform tab 2.5-250mg ............ 67 glip/metform tab 2.5-500mg ............ 67

glip/metform tab 5-500mg ............... 67 glipizide ......................................... 67

glipizide xl ...................................... 67

GLUCAGEN HYPOKIT........................ 74 GLUCAGON EMERGENCY KIT ............ 74

glyburide ........................................ 68 glyburide micronized ....................... 68

glyburide-metformin tab 1.25-250 mg..................................................... 68

glyburide-metformin tab 2.5-500 mg . 68 glyburide-metformin tab 5-500mg ..... 68

glycopyrrolate tab 1mg .................... 77 glycopyrrolate tab 2mg .................... 77

glydo ........................................... 102 GOLYTELY ...................................... 78

granisetron hcl ................................ 76 GRANIX ......................................... 82

griseofulvin microsize ...................... 18

griseofulvin ultramicrosize ................ 18 guanfacine er (adhd) ....................... 60

H HAEGARDA ..................................... 83

halobetasol propionate ................... 102 haloperidol ..................................... 56

haloperidol conc 2mg/ml .................. 56 haloperidol decanoate ...................... 56

haloperidol lactate inj 5mg/ml .......... 56 HARVONI ....................................... 23

HAVRIX .......................................... 86




114

heparin sod (porcine) in d5w ............ 82

heparin sod inj 1000/ml ................... 82 heparin sod inj 10000/ml ................. 82

heparin sod inj 20000/ml ................. 82 heparin sod inj 5000/ml ................... 82

HEPARIN SODIUM/NACL 0.45% ........ 82 hepatamine .................................... 90

HERCEPTIN .................................... 30 HETLIOZ ........................................ 61

HIBERIX ......................................... 86 HUMIRA ......................................... 83

HUMIRA INJ 10MG/0.2ML ................. 84 HUMIRA KIT 20MG/0.4ML ................. 84

HUMIRA KIT 40MG/0.8ML ................. 84 HUMIRA PEDIATRIC CROHNS DISEASE

..................................................... 84

HUMIRA PEN ................................... 84 HUMIRA PEN CD/UC/HS STARTER ..... 84

HUMIRA PEN INJ CD/UC/HS STARTER 84 HUMIRA PEN INJ PS/UV STARTER...... 84

HUMIRA PEN-PS/UV STARTER ........... 84 HUMULIN R INJ U-500 ..................... 66

HUMULIN R U-500 KWIKPEN ............ 66 hydralazine hcl................................ 45

hydrochlorothiazide ......................... 44 hydroco/apap tab 10-325mg ............ 13

hydroco/apap tab 5-325mg .............. 13 hydroco/apap tab 7.5-325 ................ 13

hydrocodone-acetaminophen 7.5-325 mg/15ml ........................................ 13

hydrocodone-ibuprofen tab 7.5-200 mg

..................................................... 13 hydrocortisone ................................ 73

hydrocortisone (enema) ................... 78 hydrocortisone (topical) ................. 102

hydrocortisone butyrate cream 0.1%................................................... 102

hydrocortisone butyrate oint 0.1% .. 102 hydrocortisone valerate ................. 102

hydromorphone hcl ......................... 13 hydroxychloroquine sulfate ............... 84

hydroxyurea ................................... 36

hydroxyzine hcl ............................... 97

hydroxyzine hcl inj .......................... 97 hydroxyzine pamoate ...................... 97

HYSINGLA ER ................................. 13 I ibandronate sodium ......................... 70 IBRANCE ........................................ 30

ibu tab 600mg ................................ 11 ibu tab 800mg ................................ 11

ibuprofen ....................................... 11 ICLUSIG ......................................... 34

IDHIFA .......................................... 30 IFEX INJ 3GM ................................. 28

ifosfamide inj 1gm/20ml .................. 28 IFOSFAMIDE INJ 3GM ...................... 28

ifosfamide inj 3gm/60ml .................. 29

ILEVRO .......................................... 94 imatinib mesylate ............................ 34

IMBRUVICA .................................... 34 imipenem-cilastatin ......................... 17

imipramine hcl ................................ 53 imiquimod .................................... 103

IMOVAX RABIES (H.D.C.V.) .............. 86 INCRELEX ...................................... 74

INCRUSE ELLIPTA ........................... 97 indapamide .................................... 44

INFANRIX ....................................... 87 INLYTA .......................................... 34

INSULIN PEN NEEDLE ...................... 66 INSULIN SAFETY NEEDLES ............... 66

INSULIN SYRINGE ........................... 66

INTELENCE ..................................... 20 INTRALIPID 30%............................. 90

intralipid inj 20% ............................ 90 INTRON-A INJ 10MU ........................ 85

INTRON-A INJ 18MU ........................ 85 INTRON-A INJ 25MU ........................ 85

INTRON-A INJ 50MU ........................ 85 INVEGA SUST INJ 117 MG/0.75 ML ... 56

INVEGA SUST INJ 156MG/ML ............ 56 INVEGA SUST INJ 234 MG/1.5 ML ..... 56

INVEGA SUST INJ 39 MG/0.25 ML ..... 56




115

INVEGA SUST INJ 78 MG/0.5 ML ....... 56

INVEGA TRINZA .............................. 56 INVIRASE ....................................... 20

IONOSOL-MB/DEXTROSE 5% ........... 91 IPOL INACTIVATED IPV .................... 87

ipratropium bromide ........................ 97 ipratropium bromide (nasal) ............. 97

ipratropium-albuterol nebu ............... 96 irbesartan ...................................... 39

irbesartan-hydrochlorothiazide .......... 39 IRESSA .......................................... 34

irinotecan hcl .................................. 37 ISENTRESS .................................... 20

ISENTRESS HD ............................... 20 ISOLYTE P ...................................... 91

ISOLYTE S ...................................... 91

isoniazid ........................................ 23 isoniazid syp 50mg/5ml ................... 23

isosorb mononitrate tab ................... 45 isosorbide dinitrate .......................... 45

isosorbide dinitrate er ...................... 45 isosorbide mononitrate er ................. 45

isotretinoin ................................... 100 isradipine ....................................... 43

itraconazole .................................... 18 ivermectin ...................................... 17

IXIARO .......................................... 87 J JADENU ......................................... 71 JADENU SPRINKLE .......................... 71

JAKAFI ........................................... 34

jantoven ........................................ 82 JANUMET ....................................... 68

JANUMET XR TAB 100-1000.............. 68 JANUMET XR TAB 50-1000 ............... 68

JANUMET XR TAB 50-500MG ............. 68 JANUVIA ........................................ 68

JARDIANCE .................................... 69 JENTADUETO .................................. 69

JENTADUETO TAB XR 2.5-1000 MG ... 69 JENTADUETO TAB XR 5-1000 MG ...... 69

jinteli ............................................. 72

JULUCA .......................................... 22

JUXTAPID ....................................... 41 K KADCYLA ....................................... 30 KALETRA TAB 100-25MG .................. 22

KALETRA TAB 200-50MG .................. 22 KALYDECO ..................................... 98

kcl 0.075%/d5w/nacl 0.45% ............ 91 KCL 0.15%/D5W/NACL 0.225% ........ 91

kcl 0.15%/d5w/nacl 0.9% ................ 91 kcl 0.3%/d5w/nacl 0.45% ................ 91

KCL 0.3%/D5W/NACL 0.9% ............. 91 kcl/d5w inj 0.3% ............................. 91

kcl/d5w/nacl inj .15/.33% ................ 91 kcl/d5w/nacl inj .15/.45% ................ 91

kcl/d5w/nacl inj 0.22%/0.45% ......... 91

kcl/nacl inj 0.15%-0.9% .................. 91 kcl/nacl inj 0.3-0.9 .......................... 91

kcl0.15%/d5w/nacl0.2% .................. 91 ketoconazole .................................. 18

ketoconazole cream ....................... 101 ketoconazole shampoo ................... 101

ketorolac tromethamine (ophth) ....... 94 KEYTRUDA ..................................... 31

KINRIX .......................................... 87 kionex sus 15gm/60ml ..................... 71

KISQALI ......................................... 31 KISQALI FEMARA 200 DOSE ............. 31

KISQALI FEMARA 400 DOSE ............. 31 KISQALI FEMARA 600 DOSE ............. 31

klor-con 10 ..................................... 88

klor-con 8 ...................................... 88 klor-con m10 .................................. 88

klor-con m15 .................................. 88 klor-con m20 .................................. 88

klor-con pak 20meq ........................ 88 klor-con spr cap 10meq ................... 88

klor-con spr cap 8meq ..................... 88 KORLYM ......................................... 74

KUVAN ........................................... 72 KYNAMRO ...................................... 41




116

L labetalol hcl .................................... 42 lactated ringer's .............................. 92

lactulose ........................................ 78 lactulose (encephalopathy) ............... 78

lamivudine ..................................... 20 lamivudine (hbv) ............................. 24

lamivudine-zidovudine ..................... 22 lamotrigine ..................................... 49

lansoprazole ................................... 80 LASTACAFT .................................... 95

latanoprost ..................................... 95 LATUDA ................................... 56, 57

leflunomide .................................... 84 LENVIMA 10 MG DAILY DOSE ........... 34

LENVIMA 12MG DAILY DOSE ............ 34

LENVIMA 14 MG DAILY DOSE ........... 34 LENVIMA 18 MG DAILY DOSE ........... 34

LENVIMA 20 MG DAILY DOSE ........... 34 LENVIMA 24 MG DAILY DOSE ........... 34

LENVIMA 4 MG DAILY DOSE ............. 34 LENVIMA 8 MG DAILY DOSE ............. 34

LETAIRIS ....................................... 46 letrozole ......................................... 32

leucovorin calcium ........................... 36 LEUKERAN ...................................... 29

leuprolide inj 1mg/0.2 ..................... 32 levalbuterol hcl ............................... 97

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ....................................... 98

levalbuterol tartrate hfa ................... 98

LEVEMIR ........................................ 66 LEVEMIR FLEXTOUCH ...................... 66

levetiracetam.................................. 49 levetiracetam in sodium chloride ....... 49

levetiracetam oral soln 100 mg/ml .... 49 levobunolol hcl ................................ 95

levocarnitine (metabolic modifiers) .... 72 levocetirizine dihydrochloride ............ 97

levofloxacin .................................... 26 levofloxacin in d5w .......................... 26

levofloxacin inj 25mg/ml .................. 26

levofloxacin oral soln 25 mg/ml......... 26

levo-t ............................................ 75 levothyroxine sodium ....................... 75

levoxyl ........................................... 75 LEXIVA .......................................... 20

lidocaine ...................................... 102 lidocaine hcl ................................. 102

lidocaine hcl (local anesth.) .............. 15 lidocaine hcl (mouth-throat) ........... 104

lidocaine inj 0.5% ........................... 15 lidocaine inj 1% .............................. 15

lidocaine inj 1.5% preservative free (pf)..................................................... 15

lidocaine oint 5% .......................... 102 lidocaine-prilocaine ........................ 103

linezolid in sodium chloride ............... 17

linezolid inj ..................................... 17 linezolid susp .................................. 17

linezolid tab 600mg ......................... 17 LINZESS ........................................ 79

liothyronine sodium ......................... 75 lisinopril ......................................... 38

lisinopril & hydrochlorothiazide.......... 37 lithium carbonate ............................ 62

lithium carbonate er ........................ 62 LITHIUM SOLN 8MEQ/5ML ................ 62

LONSURF ....................................... 36 loperamide hcl ................................ 79

lopinavir-ritonavir ............................ 22 lorazepam ...................................... 47

lorazepam intensol .......................... 47

LORBRENA ..................................... 35 lorcet hd tab 10-325mg ................... 13

lorcet plus tab 7.5-325 .................... 13 lorcet tab 5-325mg ......................... 13

losartan potassium .......................... 39 losartan-hydrochlorothiazide ............. 39

LOTEMAX ....................................... 94 lovastatin ....................................... 40

loxapine succinate ........................... 57 LUMIGAN ....................................... 96

LUMIZYME ...................................... 72




117

LUPRON DEPOT (1-MONTH) .............. 32

LUPRON DEPOT INJ 11.25MG (3-MONTH) ......................................... 32

LUPRON DEPOT-PED (1-MONTH ........ 74 LUPRON DEPOT-PED (3-MONTH ........ 74

LUPRON DEP-PED INJ 11.25MG (3-MONTH) ......................................... 74

LUPRON DEP-PED INJ 7.5MG ............ 74 LYNPARZA ...................................... 31

LYRICA .......................................... 49 LYRICA CR ..................................... 62

LYSODREN ..................................... 32 M magnesium sulfate .......................... 88 MAGNESIUM SULFATE ..................... 88

MAGNESIUM SULFATE IN D5W .......... 88

magnesium sulfate in dextrose ......... 88 magnesium sulfate inj 50% .............. 88

malathion ..................................... 103 maprotiline hcl ................................ 53

MARPLAN TAB 10MG ........................ 53 MATULANE ..................................... 36

MAVYRET ....................................... 24 meclizine hcl ................................... 76

medroxyprogesterone acetate tab ..... 75 mefloquine hcl ................................ 19

megestrol ac sus 40mg/ml ............... 32 megestrol ac tab 20mg .................... 32

megestrol ac tab 40mg .................... 32 megestrol sus 625mg/5ml ................ 32

MEKINIST ...................................... 35

MEKTOVI........................................ 35 meloxicam ..................................... 12

memantine hcl cp24 ........................ 51 memantine soln .............................. 51

memantine tabs .............................. 51 memantine titration pak ................... 51

MENACTRA ..................................... 87 MENVEO ........................................ 87

mercaptopurine .............................. 29 meropenem .................................... 17

mesalamine .................................... 78

mesalamine w/ cleanser ................... 78

MESNEX ......................................... 36 metadate er tab 20mg ..................... 60

metformin er .................................. 69 metformin hcl ................................. 69

methadone hcl ................................ 13 methadone hcl 10mg ....................... 14

methadone hcl 5mg ......................... 14 methadone hcl intensol .................... 14

methazolamide ............................... 44 methenamine hippurate ................... 17

methimazole ................................... 75 methocarbamol ............................... 63

methotrexate sodium inj .................. 29 methotrexate sodium tabs ................ 84

methyclothiazide ............................. 44

methylphenidate hcl ........................ 60 methylphenidate hcl oral soln ........... 60

methylphenidate tab 10mg er ........... 60 methylphenidate tab 20mg er ........... 60

methylpr ss inj ................................ 73 methylpred pak 4mg ....................... 73

methylpred tab 16mg ...................... 73 methylpred tab 32mg ...................... 73

methylpred tab 4mg ........................ 73 methylpred tab 8mg ........................ 73

methylprednisolone acetate .............. 73 metoclopramide hcl ......................... 76

metoclopramide hcl inj ..................... 76 metolazone .................................... 45

metoprolol & hydrochlorothiazide ...... 41

metoprolol succinate ........................ 42 metoprolol tartrate .......................... 42

metronidazole ................................. 17 metronidazole (topical) .................. 103

metronidazole gel 0.75% ............... 103 metronidazole in nacl ....................... 17

metronidazole vaginal ...................... 81 mexiletine hcl ................................. 40

midodrine hcl .................................. 45 miglustat ....................................... 72

minitran ......................................... 45




118

minocycline hcl ............................... 28

minoxidil ........................................ 45 mirtazapine .................................... 53

misoprostol .................................... 79 MITIGARE ...................................... 11

mitomycin ...................................... 29 M-M-R II ........................................ 87

M-NATAL PLUS ................................ 92 moexipril hcl ................................... 38

moexipril-hydrochlorothiazide ........... 37 molindone hcl ................................. 57

mometasone furoate ..................... 102 mondoxyne nl cap 100mg ................ 28

montelukast sodium ........................ 98 morgidox cap 1x50mg ..................... 28

morphine ext-rel tab ........................ 14

morphine sul inj 10mg/ml ................ 14 morphine sul inj 1mg/ml .................. 14

MORPHINE SUL INJ 4MG/ML ............. 14 morphine sulfate ............................. 14

MORPHINE SULFATE ........................ 14 morphine sulfate oral soln 100mg/5ml

..................................................... 14 morphine sulfate oral soln 10mg/5ml . 14

morphine sulfate oral soln 20mg/5ml . 14 MOVANTIK ..................................... 79

MOVIPREP ...................................... 78 MOXEZA......................................... 94

moxifloxacin hcl .............................. 26 moxifloxacin hcl (ophth) ................... 94

MULTAQ ......................................... 40

mupirocin ..................................... 100 MYCAMINE ..................................... 18

mycophenolate mofetil ..................... 85 mycophenolate sodium tbec ............. 86

MYLOTARG ..................................... 31 myorisan ...................................... 100

MYRBETRIQ .................................... 81 N nabumetone ................................... 12 nadolol .......................................... 42

nafcillin sodium for inj...................... 27

NAFCILLIN SODIUM FOR INJ 10GM .... 27

NAGLAZYME ................................... 72 nalbuphine hcl ................................ 12

naloxone inj 0.4mg/ml ..................... 64 naloxone inj 1mg/ml ........................ 64

naltrexone hcl ................................. 64 NAMZARIC ..................................... 51

naproxen ....................................... 12 naproxen dr .................................... 12

naproxen sodium ............................ 12 naratriptan hcl ................................ 61

NARCAN ......................................... 64 NATACYN ....................................... 94

nateglinide ..................................... 69 NATPARA ....................................... 74

NEBUPENT...................................... 17

nefazodone hcl ................................ 53 neomycin sulfate ............................. 15

neomycin-bacitracin zn-polymyxin ..... 94 neomycin-polymy-dexameth............. 93

neomycin-polymyxin-gramicidin ........ 94 neomycin-polymyxin-hc (ophth)........ 93

neomycin-polymyxin-hc (otic) ......... 104 NEPHRAMINE .................................. 90

NERLYNX........................................ 35 NEUPOGEN ..................................... 82

NEUPRO ......................................... 54 nevirapine susp 50 mg/5ml .............. 20

nevirapine tab 100mg er .................. 20 nevirapine tab 200mg ...................... 20

nevirapine tab 400mg er .................. 20

NEXAVAR ....................................... 35 niacin er (antihyperlipidemic) ........... 41

niacor ............................................ 41 nicardipine hcl ................................ 43

NICOTROL INHALER ........................ 64 NICOTROL NS ................................. 64

nifedipine ....................................... 43 nifedipine er ................................... 43

nilutamide ...................................... 32 nimodipine ..................................... 43

NINLARO ........................................ 31




119

NITRO-BID ..................................... 45

NITRO-DUR DIS 0.3MG/HR ............... 46 NITRO-DUR DIS 0.8MG/HR ............... 46

nitrofurantoin macrocrystal .............. 17 nitrofurantoin monohyd macro .......... 17

nitroglycerin ................................... 46 nitroglycerin td patch ....................... 46

NITYR ............................................ 72 norethindrone acetate ...................... 75

norethindrone acetate-ethinyl estradiol..................................................... 72

NORMOSOL-M IN D5W ..................... 92 NORMOSOL-R ................................. 92

NORMOSOL-R IN D5W ..................... 92 NORPACE CR .................................. 40

NORTHERA ..................................... 45

nortriptyline hcl .............................. 53 NORVIR PACK ................................. 20

NORVIR SOLN ................................. 20 NOVOLIN 70/30 .............................. 66

NOVOLIN 70/30 FLEXPEN ................. 66 NOVOLIN N .................................... 66

NOVOLIN R .................................... 66 NOVOLOG ...................................... 66

NOVOLOG 70/30 FLEXPEN ................ 66 NOVOLOG FLEXPEN ......................... 66

NOVOLOG MIX 70/30 ....................... 66 NOVOLOG PENFILL .......................... 66

NOXAFIL ........................................ 19 NUCYNTA ER .................................. 14

NUEDEXTA ..................................... 62

NULOJIX ........................................ 86 NULYTELY/FLAVOR PACKS ................ 79

NUPLAZID CAPS .............................. 57 NUPLAZID TABS 10MG ..................... 57

NUPLAZID TABS 17MG ..................... 57 nutrilipid inj 20% ............................ 90

nyamyc ........................................ 101 NYMALIZE ...................................... 43

nystatin ......................................... 19 nystatin (mouth-throat) ................. 104

nystatin (topical) ........................... 101

nystop ......................................... 101

O OCTAGAM ...................................... 85

octreotide acetate ........................... 74 ODEFSEY ....................................... 22

ODOMZO ........................................ 31 OFEV ............................................. 98

ofloxacin (ophth) ............................. 94 ofloxacin (otic) .............................. 104

olanzapine ...................................... 57 olmesartan medoxomil ..................... 39

olmesartan medoxomil-amlodipine-hydrochlorothiazide ......................... 39

olmesartan medoxomil-hydrochlorothiazide ......................... 39

olopatadine hcl 0.2% ....................... 95

omeprazole cap 10mg ...................... 80 omeprazole cap 20mg ...................... 80

omeprazole cap 40mg ...................... 80 ondansetron hcl .............................. 76

ondansetron hcl inj .......................... 76 ondansetron hcl oral soln ................. 76

ondansetron odt .............................. 76 OPSUMIT ....................................... 46

ORFADIN........................................ 72 ORKAMBI ....................................... 98

oseltamivir phosphate ...................... 24 oxacillin sodium .............................. 27

oxaliplatin inj 100mg ....................... 36 oxaliplatin inj 100mg/20ml ............... 36

oxaliplatin inj 50mg ......................... 36

oxaliplatin inj 50mg/10ml ................. 36 oxandrolone tab 10mg ..................... 65

oxandrolone tab 2.5mg .................... 65 oxcarbazepine ................................ 49

oxybutynin chloride ......................... 81 oxycodone hcl ........................... 14, 15

oxycodone w/ acetaminophen 10-325mg ........................................... 15

oxycodone w/ acetaminophen 2.5-325mg ........................................... 15

oxycodone w/ acetaminophen 5-325mg




120

..................................................... 15

oxycodone w/ acetaminophen 7.5-325mg ........................................... 15

OZEMPIC INJ 0.25 OR 0.5MG/DOSE .. 66 OZEMPIC INJ 1MG/DOSE .................. 66

P pacerone ........................................ 40

paclitaxel ....................................... 30 paliperidone ................................... 57

pamidronate disodium ..................... 70 PAMIDRONATE DISODIUM ................ 70

pamidronate inj 30mg ..................... 70 pamidronate inj 90mg ..................... 70

PANRETIN .................................... 103 pantoprazole sodium ....................... 80

pantoprazole sodium tbec ................ 80

PANZYGA ....................................... 85 paricalcitol ...................................... 92

paroex sol 0.12% .......................... 104 paromomycin sulfate ....................... 15

paroxetine hcl tabs .......................... 53 PASER D/R ..................................... 23

PAXIL ............................................ 53 PAZEO ........................................... 95

PEDIARIX ....................................... 87 PEDVAX HIB ................................... 87

peg 3350/electrolytes ...................... 79 peg 3350-kcl-sod bicarb-sod chloride-

sod sulfate ..................................... 79 peg 3350-potassium chloride-sod

bicarbonate-sod chloride .................. 79

PEGANONE ..................................... 49 PEGASYS........................................ 24

PEGASYS PROCLICK ........................ 24 PENICILLIN G POT IN DEXTROSE 2MU

..................................................... 27 PENICILLIN G POT IN DEXTROSE 3MU

..................................................... 27 PENICILLIN G PROCAINE .................. 27

penicillin g sodium ........................... 27 penicillin v potassium ...................... 27

penicilln gk inj 20mu ....................... 27

penicilln gk inj 5mu ......................... 27

PENTACEL ...................................... 87 PENTAM 300 ................................... 17

pentamidine isethionate ................... 17 pentoxifylline .................................. 83

perindopril erbumine ....................... 38 periogard ..................................... 104

permethrin cre 5% ........................ 104 perphenazine .................................. 57

PERSERIS ...................................... 57 pfizerpen-g inj 20mu ....................... 27

pfizerpen-g inj 5mu ......................... 27 phenelzine sulfate ........................... 53

phenobarbital ................................. 49 phenobarbital sodium ...................... 50

PHENOBARBITAL SODIUM ................ 50

PHENYTEK ...................................... 50 phenytoin ....................................... 50

phenytoin sodium extended .............. 50 phenytoin sodium inj 50mg/ml ......... 50

PHOSPHOLINE IODIDE ..................... 96 PICATO ........................................ 103

PIFELTRO ....................................... 20 pilocarpine hcl ................................ 96

pilocarpine hcl (oral) ...................... 104 pimozide ........................................ 57

pindolol .......................................... 42 pioglitazone hcl ............................... 69

PIPER/TAZOBA INJ 12-1.5GM ........... 28 piper/tazoba inj 2-0.25gm ................ 27

piper/tazoba inj 3-0.375gm .............. 27

piper/tazoba inj 36-4.5gm ................ 28 piper/tazoba inj 4-0.5gm ................. 28

piroxicam ....................................... 12 PLASMA-LYTE A .............................. 92

PLASMA-LYTE-148 ........................... 92 PNV FOLIC ACID + IRON MUL ........... 92

podofilox ...................................... 103 polymyxin b-trimethoprim ................ 94

POMALYST ...................................... 33 pot chloride inj 2meq/ml .................. 92

potassium chloride .................... 88, 92




121

potassium chloride in nacl ................ 92

potassium chloride microencapsulated crystals er ...................................... 89

potassium chloride tab cr 10 meq ...... 89 potassium citrate (alkalinizer) er tabs 80

PRADAXA ....................................... 82 PRALUENT ...................................... 41

pramipexole tab 0.125mg ................ 54 pramipexole tab 0.25mg .................. 54

pramipexole tab 0.5mg .................... 54 pramipexole tab 0.75mg .................. 54

pramipexole tab 1.5mg .................... 54 pramipexole tab 1mg ....................... 54

prasugrel hcl .................................. 83 pravastatin sodium .......................... 40

praziquantel ................................... 17

prazosin hcl .................................... 38 pred sod pho sol 5mg/5ml ................ 73

prednisolone acetate (ophth) ............ 95 prednisolone sodium phosphate ........ 73

PREDNISOLONE SODIUM PHOSPHATE (OPHTH) ........................................ 95

prednisolone sol 15mg/5ml .............. 73 prednisolone sol 25mg/5ml .............. 73

PREDNISONE CON 5MG/ML .............. 73 prednisone pak 10mg ...................... 73

prednisone pak 5mg ........................ 73 prednisone sol 5mg/5ml ................... 73

prednisone tab 10mg ....................... 73 prednisone tab 1mg......................... 73

prednisone tab 2.5mg ...................... 73

prednisone tab 20mg ....................... 73 prednisone tab 50mg ....................... 74

prednisone tab 5mg......................... 73 PREMASOL 10% .............................. 90

premasol 6% .................................. 90 PRENATAL ...................................... 92

PRENATAL PLUS .............................. 92 PRENATAL PLUS LOW IRON .............. 92

prevalite ........................................ 41 PREZCOBIX .................................... 22

PREZISTA ....................................... 20

PRIFTIN ......................................... 23

primaquine phosphate ..................... 19 PRIMAQUINE PHOSPHATE ................ 19

primidone ....................................... 50 PRIVIGEN ....................................... 85

probenecid ..................................... 11 PROCALAMINE ................................ 90

prochlorperazine inj ......................... 76 prochlorperazine maleate ................. 76

prochlorperazine supp ...................... 77 PROCRIT ........................................ 82

procto-med hc .............................. 103 procto-pak ................................... 103

proctosol hc cre 2.5% .................... 103 proctozone-hc ............................... 103

PROGLYCEM SUS 50MG/ML .............. 74

PROLASTIN-C ................................. 98 PROLENSA ...................................... 95

PROLIA .......................................... 74 PROMACTA ..................................... 83

promethazine hcl ............................ 77 promethazine hcl inj ........................ 77

propafenone hcl .............................. 40 propafenone hcl 12hr ....................... 40

proparacaine hcl ............................. 96 propranolol & hydrochlorothiazide ..... 41

propranolol cap er ........................... 42 propranolol hcl ................................ 42

propranolol oral sol.......................... 42 propylthiouracil ............................... 75

PROQUAD ...................................... 87

PROSOL ......................................... 90 protriptyline hcl............................... 53

PULMICORT FLEXHALER ................... 99 PULMOZYME ................................... 98

PURIXAN ........................................ 29 pyrazinamide .................................. 23

pyridostigmine tab 60mg ................. 62 Q QUADRACEL ................................... 87 quetiapine fumarate ........................ 57

quinapril hcl ................................... 38




122

quinapril-hydrochlorothiazide ............ 37

quinidine gluconate ......................... 40 quinidine sulfate ............................. 40

quinine sulfate ................................ 19 R RABAVERT ...................................... 87 rabeprazole sodium ......................... 80

raloxifene tab 60mg ........................ 74 ramipril .......................................... 38

RANEXA ......................................... 45 ranitidine hcl .................................. 77

ranitidine hcl inj .............................. 77 ranitidine inj ................................... 77

ranitidine syrup ............................... 77 ranolazine ...................................... 45

RAPAMUNE ..................................... 86

rasagiline mesylate.......................... 55 RAYALDEE ...................................... 93

REBETOL SOLN ............................... 24 RECOMBIVAX HB ............................. 87

REGRANEX ................................... 104 RELENZA DISKHALER ...................... 24

RELISTOR ...................................... 79 REMICADE ...................................... 84

REMODULIN ................................... 46 repaglinide ..................................... 69

RESCRIPTOR .................................. 20 RESTASIS ...................................... 96

RESTASIS MULTIDOSE ..................... 96 REVLIMID ....................................... 33

REXULTI ........................................ 58

REYATAZ ........................................ 20 RHOPRESSA ................................... 96

ribasphere ...................................... 24 RIBASPHERE................................... 24

ribavirin cap 200mg ......................... 24 ribavirin tab 200mg ......................... 24

rifabutin ......................................... 23 rifampin ......................................... 23

RIFATER......................................... 23 riluzole .......................................... 62

rimantadine hydrochloride ................ 24

risedronate sodium .......................... 70

RISPERDAL INJ 12.5MG ................... 58 RISPERDAL INJ 25MG ...................... 58

RISPERDAL INJ 37.5MG ................... 58 RISPERDAL INJ 50MG ...................... 58

risperidone ..................................... 58 ritonavir ......................................... 21

RITUXAN ........................................ 31 RITUXAN HYCELA ............................ 31

rivastigmine tartrate ........................ 51 rivastigmine td patch 24hr 13.3

mg/24hr ........................................ 51 rivastigmine td patch 24hr 4.6 mg/24hr

..................................................... 51 rivastigmine td patch 24hr 9.5 mg/24hr

..................................................... 51

rizatriptan benzoate ........................ 61 rizatriptan benzoate odt ................... 62

ropinirole tab 0.25mg ...................... 55 ropinirole tab 0.5mg ........................ 55

ropinirole tab 1mg ........................... 55 ropinirole tab 2mg ........................... 55

ropinirole tab 3mg ........................... 55 ropinirole tab 4mg ........................... 55

ropinirole tab 5mg ........................... 55 rosadan cre 0.75% ........................ 103

rosuvastatin calcium ........................ 40 ROTARIX ........................................ 87

ROTATEQ ....................................... 87 roweepra ....................................... 50

roweepra xr .................................... 50

RUBRACA ....................................... 31 RYDAPT ......................................... 35

S SANDIMMUNE ................................. 86

SANTYL ........................................ 104 SAPHRIS ........................................ 58

scopolamine patch ........................... 77 selegiline hcl ................................... 55

selenium sulfide ............................ 101 SELZENTRY .................................... 21

SENSIPAR ...................................... 71




123

SEREVENT DISKUS .......................... 98

sertraline hcl .................................. 53 sevelamer carbonate ....................... 75

SHINGRIX ...................................... 87 SIGNIFOR ...................................... 74

sildenafil citrate tab 20 mg (pulmonary hypertension) ................................. 46

SILENOR ........................................ 61 silver sulfadiazine .......................... 100

SIMBRINZA .................................... 96 simvastatin .................................... 40

sirolimus ........................................ 86 SIRTURO ........................................ 23

SIVEXTRO ...................................... 17 sodium chlor sol 0.9% irr ............... 104

sodium chloride ........................ 89, 92

sodium chloride 0.45% .................... 92 sodium chloride inj 0.9%.................. 92

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ..................................... 89

sodium phenylbutyrate .................... 72 sodium polystyrene sulfonate powder 71

sodium polystyrene sulfonate susp .... 71 SOLIQUA 100/33............................. 66

SOLTAMOX ..................................... 32 SOLU-CORTEF ................................ 74

SOMATULINE DEPOT ....................... 75 SOMAVERT ..................................... 75

sorine ............................................ 40 sotalol hcl ...................................... 40

sotalol hcl (afib/afl) ......................... 40

spironolactone ................................ 38 spironolactone & hydrochlorothiazide . 45

SPRITAM ........................................ 50 SPRYCEL ........................................ 35

sps susp 15gm/60ml ....................... 71 ssd .............................................. 100

stavudine ....................................... 21 STIMATE ........................................ 76

STIVARGA ...................................... 35 streptomycin sulfate ........................ 15

STRIBILD ....................................... 22

SUBOXONE MIS 12-3MG .................. 65

SUBOXONE MIS 2-0.5MG ................. 64 SUBOXONE MIS 4-1MG .................... 65

SUBOXONE MIS 8-2MG .................... 65 subvenite tab .................................. 50

sucralfate ....................................... 79 sulfacetamide sodium (acne) .......... 100

sulfacetamide sodium (ophth) ........... 94 sulfacetamide sod-prednisolone ........ 93

SULFADIAZINE ............................... 15 sulfamethoxazole-trimethop ds ......... 17

sulfamethoxazole-trimethoprim inj .... 17 sulfamethoxazole-trimethoprim susp . 17

sulfamethoxazole-trimethoprim tab 400-80mg ...................................... 18

SULFAMYLON ................................ 100

sulfasalazine ................................... 78 sulfasalazine ec ............................... 78

sulindac ......................................... 12 sumatriptan .................................... 62

sumatriptan inj 4mg/0.5ml ............... 62 sumatriptan inj 6mg/0.5ml ............... 62

sumatriptan succinate ...................... 62 SUPRAX ......................................... 25

SUPREP BOWEL PREP KIT ................. 79 SUTENT ......................................... 35

SYLATRON KIT 200MCG ................... 36 SYLATRON KIT 300MCG ................... 36

SYLATRON KIT 600MCG ................... 36 SYMBICORT .................................... 99

SYMDEKO ....................................... 98

SYMFI ............................................ 22 SYMFI LO ....................................... 22

SYMPAZAN ..................................... 50 SYMPROIC ...................................... 79

SYMTUZA ....................................... 22 SYNAREL ........................................ 71

SYNERCID ...................................... 18 SYNJARDY TAB 12.5-1000MG ........... 69

SYNJARDY TAB 12.5-500MG ............. 69 SYNJARDY TAB 5-1000MG ................ 69

SYNJARDY TAB 5-500MG .................. 69




124

SYNJARDY XR TAB 10-1000MG ......... 69

SYNJARDY XR TAB 12.5-1000MG ...... 69 SYNJARDY XR TAB 25-1000MG ......... 70

SYNJARDY XR TAB 5-1000MG ........... 69 SYNRIBO ........................................ 36

SYNTHROID .................................... 75 T TABLOID ........................................ 29 tacrolimus ...................................... 86

tacrolimus (topical) ....................... 103 TAFINLAR ....................................... 35

TAGRISSO ...................................... 35 TALZENNA ...................................... 31

tamoxifen citrate ............................. 32 tamsulosin hcl ................................ 80

TARCEVA ....................................... 35

TARGRETIN .................................. 103 TASIGNA ........................................ 35

TAXOTERE ...................................... 30 tazarotene .................................... 101

tazicef ........................................... 26 TAZORAC ..................................... 101

taztia xt ......................................... 43 TDVAX ........................................... 87

TECENTRIQ .................................... 31 TEFLARO ........................................ 26

TEKTURNA ..................................... 44 TEKTURNA HCT ............................... 44

telmisartan ..................................... 39 telmisartan-amlodipine .................... 39

telmisartan-hydrochlorothiazide ........ 39

temazepam .................................... 61 TENIVAC ........................................ 87

tenofovir disoproxil fumarate ............ 21 terazosin hcl ................................... 38

terbinafine hcl ................................. 19 terbutaline sulfate ........................... 98

terconazole vaginal ......................... 81 testosterone ................................... 65

testosterone cypionate ..................... 65 testosterone enanthate .................... 65

tetrabenazine ........................... 62, 63

tetracycline hcl ............................... 28

TEXACORT SOLN 2.5% .................. 102 THALOMID ..................................... 33

THEO-24 ........................................ 98 theophylline ................................... 99

thioridazine hcl ............................... 58 thiothixene ..................................... 58

tiagabine hcl ................................... 50 TIBSOVO ........................................ 31

tigecycline ...................................... 18 timolol maleate ............................... 42

timolol maleate (ophth) soln ............. 96 timolol maleate gel .......................... 96

timolol maleate ophth soln 0.5% (once-daily) ............................................. 96

TIVICAY ......................................... 21

tizanidine hcl .................................. 63 TOBRADEX ..................................... 93

TOBRADEX ST ................................ 93 tobramycin ..................................... 15

tobramycin (ophth) ......................... 94 tobramycin inj 1.2 gm/30ml ............. 15

tobramycin inj 1.2gm ...................... 15 tobramycin inj 10mg/ml ................... 15

tobramycin inj 40mg/ml ................... 16 tobramycin inj 80mg/2ml ................. 16

tobramycin-dexamethasone ............. 93 tolterodine tartrate .......................... 81

topiramate ..................................... 50 toposar .......................................... 37

topotecan hcl .................................. 37

TOPOTECAN INJ 4MG/4ML ................ 37 toremifene citrate ........................... 32

torsemide tabs ................................ 45 TOVIAZ .......................................... 81

tpn electrolytes ............................... 89 TRACLEER ...................................... 46

TRADJENTA .................................... 70 tramadol hcl tab 50 mg .................... 12

tramadol-acetaminophen ................. 12 trandolapril..................................... 38

tranexamic acid .............................. 83




125

TRANSDERM-SCOP .......................... 77

tranylcypromine sulfate.................... 53 TRAVASOL ...................................... 90

TRAVATAN Z ................................... 96 trazodone hcl .................................. 53

TRECATOR ..................................... 23 TRELEGY ELLIPTA ............................ 96

TRELSTAR DEP INJ 3.75MG .............. 32 TRELSTAR LA INJ 11.25MG ............... 32

TRESIBA FLEXTOUCH....................... 67 TRESIBA INJ ................................... 67

tretinoin ....................................... 100 tretinoin (chemotherapy) ................. 36

triamcinolone acetonide (mouth) ..... 104 triamcinolone acetonide (topical)..... 102

triamterene & hydrochlorothiazide cap

37.5-25 mg .................................... 45 triamterene & hydrochlorothiazide tabs

..................................................... 45 TRICARE ........................................ 93

trientine hcl .................................... 71 trifluoperazine hcl ........................... 58

trifluridine ...................................... 94 trihexyphenidyl hcl .......................... 55

trilyte ............................................ 79 trimethoprim .................................. 18

trimipramine maleate ...................... 53 TRINTELLIX .................................... 53

TRIUMEQ ....................................... 22 TROGARZO ..................................... 21

TROPHAMINE INJ 10% ..................... 90

trospium chloride ............................ 81 TRULICITY ...................................... 67

TRUMENBA ..................................... 87 TRUVADA TAB 100-150 .................... 22

TRUVADA TAB 133-200 .................... 22 TRUVADA TAB 167-250 .................... 22

TRUVADA TAB 200-300 .................... 22 TWINRIX INJ .................................. 87

TYBOST ......................................... 21 TYKERB .......................................... 35

TYMLOS ......................................... 75

TYPHIM VI ...................................... 87

U ULORIC .......................................... 11

unithroid ........................................ 75 ursodiol ......................................... 79

V valacyclovir hcl ............................... 24

VALCHLOR ................................... 103 valganciclovir hcl ............................. 24

valproate sodium ............................ 50 valproate sodium oral soln ............... 50

valproic acid ................................... 50 valsartan ........................................ 39

valsartan-hydrochlorothiazide ........... 39 vancomycin hcl ............................... 18

VANCOMYCIN IN NACL ..................... 18

vandazole ...................................... 81 VAQTA ........................................... 87

VARIVAX ........................................ 88 VASCEPA ........................................ 41

VELCADE ........................................ 31 VEMLIDY ........................................ 24

VENCLEXTA .................................... 31 VENCLEXTA STARTING PACK ............ 31

venlafaxine hcl ................................ 53 VENTAVIS ...................................... 46

VENTOLIN HFA ................................ 98 verapamil cap er ............................. 43

verapamil hcl .................................. 43 verapamil tab er ............................. 43

VERSACLOZ .................................... 58

VERZENIO ...................................... 31 VESICARE ...................................... 81

VICTOZA ........................................ 67 VIDEX EC ....................................... 21

VIDEX PEDIATRIC ........................... 21 vigabatrin powd pack 500mg ............ 50

vigabatrin tab 500mg ...................... 50 vigadrone ....................................... 50

VIIBRYD STARTER PACK .................. 54 VIIBRYD TAB .................................. 54

VIMPAT .......................................... 51




126

VIMPAT INJ 200MG/20ML ................. 51

VIMPAT SOL 10MG/ML ..................... 51 vinblastine sulfate ........................... 30

vincasar pfs .................................... 30 vincristine sulfate ............................ 30

vinorelbine tartrate .......................... 30 VIRACEPT ....................................... 21

VIRAMUNE ..................................... 21 VIREAD .......................................... 21

VITRAKVI ....................................... 35 VIVITROL ....................................... 65

VIZIMPRO ...................................... 35 voriconazole ................................... 19

VOSEVI .......................................... 24 VOTRIENT ...................................... 35

VRAYLAR ........................................ 59

VRAYLAR THERAPY PACK .................. 59 W warfarin sodium .............................. 82 water for irrigation, sterile ............. 104

X XALKORI ........................................ 35

XARELTO ........................................ 82 XARELTO STARTER PACK ................. 82

XATMEP ......................................... 84 XELJANZ ........................................ 84

XELJANZ XR ................................... 84 XGEVA ........................................... 75

XIFAXAN ........................................ 80 XIGDUO XR TAB 10-1000MG ............ 70

XIGDUO XR TAB 10-500MG .............. 70

XIGDUO XR TAB 2.5-1000MG ........... 70 XIGDUO XR TAB 5-1000MG .............. 70

XIGDUO XR TAB 5-500MG ................ 70 XOLAIR .......................................... 99

XOSPATA ....................................... 35 XTANDI .......................................... 32

XULTOPHY 100/3.6 .......................... 67

XYREM ........................................... 64

Y YF-VAX .......................................... 88

yuvafem vaginal tablet 10 mcg ......... 72 Z zafirlukast ...................................... 98 zaleplon ......................................... 61

ZEJULA .......................................... 31 ZELBORAF ...................................... 35

ZEMAIRA ........................................ 99 zenatane ...................................... 100

ZENPEP .......................................... 80 ZEPATIER ....................................... 24

zidovudine cap 100mg ..................... 21 zidovudine syp 50mg/5ml ................ 21

zidovudine tab 300mg ..................... 21

ziprasidone hcl ................................ 59 ZIRGAN ......................................... 94

zoledronic acid inj 5mg/100ml .......... 70 zoledronic inj 4mg/5ml .................... 70

ZOLINZA ........................................ 31 zolmitriptan .................................... 62

zolmitriptan odt .............................. 62 zolpidem tartrate ............................ 61

zonisamide ..................................... 51 ZONTIVITY ..................................... 83

ZORTRESS TAB 0.25MG ................... 86 ZORTRESS TAB 0.5MG ..................... 86

ZORTRESS TAB 0.75MG ................... 86 ZORTRESS TAB 1MG ........................ 86

ZOSTAVAX ..................................... 88

ZYDELIG ........................................ 35 ZYKADIA ........................................ 36

ZYLET ............................................ 93 ZYPREXA RELPREVV ........................ 59

ZYPREXA RELPREVV INJ 210MG ........ 59 ZYTIGA .......................................... 33




127




128

Este vademécum se actualizó el 1 de mayo de 2019. Para obtener

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contacto con ArchCare Advantage HMO Special Needs Plan

Member Services llamando al 1-888-816-7977 o, para los usuarios de

TTY, 711, las 24 horas al día / 7 días a la semana, o visite

www.ArchCareAdvantage.org.

Formulario - ArchCare AA Spanish... · Formulario, aparece en las páginas de la portada y la...

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Transcript of Formulario - ArchCare AA Spanish... · Formulario, aparece en las páginas de la portada y la...