Lista de medicamentos de Blue Cross Community …...Medicamentos para el corazón y la...

Lista de medicamentos de Blue Cross Community CentennialSM

enero de 2019

NTENNIALCARE

Este documento contiene información sobre los medicamentos incluidos en esta cobertura.Vigente a partir del: 1 de abril de 2020

Lista de medicamentos de Blue Cross Community CentennialSM

abril de 2020

2055891_479350.0420_NM_SP_Medicaid_BCCC Q2_Drug List Formulary Intro_Member_Other Print.indd 1 4/6/20 1:04 PM

Blue Cross Community Centennial

i

¿Qué es la Lista de medicamentos de Blue Cross Community Centennial?La Lista de medicamentos (conocida también como Formulary, en inglés) es una lista que muestra los medicamentos que su seguro de gastos médicos de Blue Cross Community Centennial incluye. Los medicamentos que figuran en la lista tendrán cobertura siempre y cuando usted: • tenga una necesidad médica para usarlos,• surta las órdenes de los medicamentos en una farmacia

que forme parte de la red,• siga las otras normas de su seguro de gastos médicos

de Blue Cross Community Centennial.Para obtener más información acerca de cómo surtir sus órdenes de medicamentos, por favor revise su Manual del asegurado. También puede comunicarse con Atención al Asegurado de Blue Cross and Blue Shield of New Mexico (BCBSNM) al 1-866-689-1523 (TTY/TDD 711).

¿Qué tendré que pagar?En la mayoría de los casos, usted no paga por los medicamentos incluidos. Algunos asegurados tendrán que realizar copagos por los medicamentos con receta según la categoría de elegibilidad.

¿Puede haber cambios en la Lista de medicamentos?Sí, la lista puede cambiar por diversas razones; por ejemplo, cuando un medicamento genérico nuevo y menos costoso se encuentre disponible.Se le informará por escrito cuando se realicen cambios en la lista de medicamentos.

¿Cómo debo usar la Lista de medicamentos?Hay dos formas para encontrar su medicamento en la lista empezando en la página 1.

1. Categoría• La Lista de medicamentos con cobertura que comienza

en la página 1 le brinda información acerca de los medicamentos incluidos por Blue Cross Community Centennial. Si tiene dificultad para encontrar su medicamento en la lista, diríjase al Índice que comienza en el reverso de este manual. – La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (por ejemplo, CIPRO) y los medicamentos genéricos aparecen en letra minúscula cursiva (por ejemplo, ciprofloxacina).

ú La información en la columna “Acciones necesarias, restricciones o límites sobre el uso” le indica si Blue Cross Community Centennial tiene alguna regla para que su medicamento tenga cobertura.

• Los medicamentos se enumeran en categorías o grupos, según el tipo de problema médico que tratan. (Por ejemplo, los medicamentos que se usan para tratar un problema médico cardíaco se incluyen debajo de Medicamentos para el corazón y la circulación).

• Si usted sabe para qué se usa su medicamento, busque el grupo en la Lista de medicamentos. Luego, busque su medicamento bajo ese grupo.

2. Listado alfabético• Busque su medicamento en el índice en la parte

posterior de esta guía.• Junto al nombre de su medicamento, verá el número de

página en donde puede encontrar la información de la cobertura.

¿Qué son los medicamentos genéricos?La Administración de Alimentos y Medicamentos (FDA, en inglés) autoriza la fabricación de un medicamento genérico cuando este tiene el mismo ingrediente activo que el medicamento de marca; sin embargo, con frecuencia es menos costoso.¿Existe algún límite en mi cobertura?

¿La cobertura incluye los medicamentos de venta libre (OTC, en inglés)?Sí, Blue Cross Community Centennial incluye cobertura de ciertos medicamentos de venta libre con una orden válida de medicamento de su profesional de la salud, y puede obtenerlos sin ningún costo. Su farmacia debe recetar y surtir los medicamentos genéricos de venta libre cuando estén disponibles. Estos medicamentos de venta libre se deben surtir en una farmacia que participe en una red de Blue Cross Community Centennial y por cantidades de hasta un suministro de 30 días. Muchos de los medicamentos de venta libre que se encuentran en la Lista de medicamentos tienen una restricción de edad según el tipo de cobertura que tenga.

¿Existe algún límite en mi cobertura?Algunos medicamentos están sujetos a restricciones de edad que se basan en pautas clínicas, del fabricante o de la Administración de Alimentos y Medicamentos (FDA, en inglés). Las restricciones de edad constituyen una medida de seguridad para que los asegurados usen los medicamentos de la manera adecuada. Puede averiguar si su medicamento está sujeto a otras condiciones o límites consultando la lista de medicamentos que comienza en la página 1. La fecha de la última actualización de la lista aparece en la portada.


Lista de medicamentos

ii

En algunos medicamentos con cobertura, los límites o condiciones agregados pueden incluir:• Autorización previa: Usted o su profesional de la salud

necesitarán obtener aprobación de Blue Cross and Blue Shield of New Mexico antes de surtir algunas de las órdenes de sus medicamentos. Los medicamentos que necesitan autorización previa se identifican en la Lista de medicamentos por medio de “PA” en la columna “Acciones necesarias, restricciones o límites sobre el uso”. Si no obtiene aprobación, es posible que Blue Cross Community Centennial no incluya (pague) el medicamento. – ¿Qué sucede si mi medicamento requiere una autorización previa? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de autorización previa (excepción).

ú Puede hablar con su profesional de la salud para decidir si primero debe probar un medicamento diferente de nuestra lista antes de solicitar una excepción.

• Cantidades límite: Para algunos medicamentos, Blue Cross Community Centennial limita la cantidad de un medicamento que tendrá cobertura durante un período (por ejemplo, no más de 60 tabletas durante 30 días). Los medicamentos que tienen cantidad límite se identifican en la Lista de medicamentos por medio de “QL” en la columna “Acciones necesarias, restricciones o límites sobre el uso”. – ¿Qué sucede si mi medicamento no tiene cobertura porque supera la cantidad límite? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la cantidad límite.

ú Puede hablar también con su profesional de la salud para decidir si debe probar primero un medicamento diferente de nuestra lista o una dosis diferente de su medicamento antes de solicitar una excepción.

• Terapia escalonada: En algunos casos, Blue Cross Community Centennial requiere que usted pruebe primero ciertos medicamentos antes de que se pueda cubrir otro medicamento. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su problema médico, es posible que su seguro médico

no incluya en su cobertura el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona, su seguro médico incluirá en su cobertura el medicamento B. Los medicamentos que están sujetos a la terapia escalonada se identifican en la Lista de medicamentos por un “ST” en la columna de “Acciones necesarias, restricciones o límites sobre el uso”. – ¿Qué sucede si mi medicamento no tiene cobertura ya que no he cumplido con la terapia escalonada? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la terapia escalonada.

ú Puede hablar con su profesional de la salud para decidir si debe probar primero un medicamento diferente de nuestra lista que no requiera de una terapia escalonada.

• Cálculo de dosis de equivalentes de morfina (ME, en inglés): La tabla de conversión de equivalencias de morfina es una herramienta que se usa para ayudar a prevenir que los asegurados tomen medicamentos para el dolor (opioides) en exceso. Este método le permite a BCBSNM calcular la dosis diaria total de analgésicos que un asegurado está tomando, independientemente del opioide que se le recete. El límite diario actual de dosificación con equivalentes de morfina (ME) en New Mexico es de 90 miligramos por día. Si está tomando una dosis superior a los 90 miligramos, deberá obtener autorización (aprobación) previa de BCBSNM para que Blue Cross Community Centennial pague por la(s) receta(s). Los medicamentos que tienen equivalentes de morfina se identifican en la lista de medicamentos con las siglas “ME” en la columna “Acciones necesarias, restricciones o límites de uso”.

• Límite para surtir opioides: Todos los opioides están sujetos a un límite de consumo del 90% antes de volver a surtirse. Esto significa que el 90% del medicamento que se surtió originalmente debe utilizarse antes de que se pueda volver a surtir. Si no toma opioides habitualmente, todos los días, se le considera un consumidor reciente de opioides. Los consumidores recientes de opioides están limitados a un suministro de siete días de opioides de liberación inmediata para su primer surtido. Una vez que tengan un historial de consumo de opioides de liberación inmediata, podrá surtir el medicamento por más de siete días. Debe tener un historial de consumo de opioides de liberación inmediata antes de poder surtir opioides de liberación



iii

prolongada. Si no tiene un historial de consumo de opioides de liberación inmediata, necesitará obtener autorización previa de BCBSNM para surtir los de liberación extendida. También necesitará obtener una autorización previa de BCBSNM para poder tomar una benzodiazepina y un opioide al mismo tiempo.

• Programa de surtido diferido de medicamentos oncológicos administrados vía oral: La oncología es el estudio del cáncer. Con los medicamentos oncológicos de administración oral se tratan varios tipos de cáncer. Estos medicamentos son parte importante de muchos planes de tratamiento. Estos medicamentos pueden provocar efectos secundarios que podrían hacer que el médico modifique la dosis o que interrumpa el medicamento por completo. Mientras está en curso el tratamiento, el médico podría realizar cambios al plan de tratamiento hasta que se defina la dosis indicada para usted. Este proceso puede tardar varios meses.

Motivos para la implementación del programa de surtido diferido de medicamentos oncológicos administrados vía oral para pacientes que inician tratamiento por primera vez:

– prevenir expedición de recetas médicas para dosis inadecuadas;

– minimizar el desperdicio de estos medicamentos; – controlar efectos secundarios.

Durante los primeros dos o tres meses del tratamiento, recibirá un surtido de 14 a 15 días del medicamento recetado, dos veces al mes. Después de los primeros dos o tres meses de tratamiento y una vez que se haya definido la dosis adecuada, podría empezar a recibir surtidos de un mes por lo que resta de la terapia. En la lista de medicamentos, cualquier medicamento señalado con las letras “SF” es parte del programa de surtido diferido de medicamentos oncológicos administrados vía oral.

¿Qué sucede si mi medicamento no está incluido en la Lista de medicamentos?Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte si su medicamento tiene cobertura. Si Blue Cross Community Centennial no incluye su medicamento, tiene dos opciones:• Puede hablar con su profesional de la salud para decidir

si primero debe probar un medicamento diferente de nuestra lista antes de solicitar una excepción.

• Si su profesional de la salud considera que otro medicamento no sería adecuado para usted, puede solicitar una autorización previa. “Autorización previa” es pedirle a Blue Cross Community Centennial que haga una excepción y cubra el medicamento para usted. Atención al Asegurado puede ayudarlos a usted y su profesional de la salud a solicitar la excepción.

Encontrará el formulario de excepción para la cobertura de medicamentos con receta en MyPrime.com. Los profesionales de la salud pueden enviar los formularios de solicitud de excepción por estos medios: – fax: 1-877-243-6930; – teléfono: 1-800-285-9426 (TTY/TDD: 711); – sitio web: MyPrime.com o CoverMyMeds.com.

Farmacia de medicamentos especializados (SP, en inglés)Los medicamentos especializados son ciertos medicamentos con receta que se usan para tratar padecimientos complejos y crónicos como el cáncer, la artritis reumatoide y la esclerosis múltiple. Los medicamentos especializados a menudo requieren un manejo especial (como refrigeración durante el envío) y administración (como una inyección o infusión). Los medicamentos especializados requieren de autorización previa antes de que se pueda surtir una receta médica. Se pueden surtir en un suministro hasta de 30 días. Esto debe hacerse por medio de un proveedor de medicamentos especializados que forme parte de la red de Blue Cross Community Centennial. AllianceRx Walgreens Prime es el proveedor de medicamentos especializados preferencial de BCBSNM. La mayoría de estos medicamentos están incluidos en la cobertura para medicamentos y se deben surtir por medio de AllianceRx Walgreens Prime. Los medicamentos especializados incluidos en la cobertura y que no están disponibles en AllianceRx Walgreens Prime se pueden obtener de un proveedor de farmacia de distribución limitada. Estos proveedores son conocidos por los fabricantes farmacéuticos por tener los estándares más altos en experiencia clínica, educación para pacientes, servicio, seguimiento terapéutico y apoyo. Para obtener más información sobre los medicamentos especializados, llame a Atención al Asegurado al 1-866-689-1523 (TTY/TDD 711).

¿Cuáles categorías de medicamentos no tienen cobertura según la Lista de medicamentos de su seguro médico?Las siguientes categorías de medicamentos no tienen cobertura por su seguro de gastos médicos de Blue Cross Community Centennial:• medicamentos para el tratamiento de la anorexia,

pérdida de peso o aumento de peso;• productos químicos a granel;• medicamentos para el mejoramiento cosmético;• agentes para diagnóstico;• implementación del estudio de eficacia de medicamentos

(DESI, en inglés). Estos son medicamentos que no han demostrado ser seguros ni eficaces;

• medicamentos experimentales y de investigación;



iv

• medicamentos para la disfunción eréctil recetados para tratar la impotencia;

• medicamentos para la fertilidad;• medicamentos para anestesia general;• productos opioides contra la tos y el resfrío (se excluyen

para los menores de 18 años);• productos de venta libre que no se incluyan en la lista

de medicamentos de la cobertura;• suministros quirúrgicos/dispositivos médicos.Los asegurados de Blue Cross Community Centennial que tienen doble cobertura bajo Medicare y Medicaid se darán cuenta que la mayoría de sus medicamentos tendrán cobertura de Medicare. Sin embargo, un número limitado de medicamentos tendrá cobertura de Blue Cross Community Centennial.Estos son algunos ejemplos de dichos medicamentos: • medicamentos para aliviar los síntomas de la tos

y el resfrío;• vitaminas y minerales recetados por un médico (por

ejemplo, ácido fólico);• medicamentos de venta libre;• productos de venta libre para dejar de fumar. Para los medicamentos con cobertura de la Parte B de Medicare, los asegurados de Blue Cross Community Centennial que cuentan con Medicare y Medicaid podrían recibir ayuda de Medicaid para cubrir su coaseguro. Sin embargo, algunos medicamentos únicamente tienen cobertura bajo la Parte B de Medicare si un asegurado tiene un problema médico específico o recibió un tratamiento médico específico. En algunos casos, para poder cubrir el coaseguro de un asegurado, será necesario revisar primero sus antecedentes médicos. Los asegurados deben llamar a Atención al Asegurado al 1-866-689-1523 (TTY/TDD: 711) para completar esta determinación de cobertura.

Artículos y monitores de medición continua de la glucosaBCBSNM ha modificado el proceso para proporcionar artículos y monitores de medición continua de la glucosa. Un monitor de medición continua de la glucosa es un aparato que monitoriza los niveles de azúcar en la sangre durante todo el día. Si a causa de esta modificación el proveedor de equipo médico duradero (DME, en inglés) ya no reúne los requisitos para proporcionarle el aparato y los artículos, deberá obtenerlos a través de otro proveedor de la red. En BCBSNM podremos ayudarlo a buscar otro proveedor. Si se ve afectado por esta modificación, habría recibido una notificación que lo ayudaría con este proceso. BCBSNM informó esta modificación a los profesionales que recetan y a los proveedores de equipo médico duradero de los

asegurados que se vieron afectados. Si necesita ayuda para buscar profesionales médicos o proveedores de la red, llame a Atención al Asegurado al 1-866-689-1523 (TTY: 711).

Para obtener más información Para obtener más detalles sobre la cobertura de medicamentos de su seguro de gastos médicos de Blue Cross Community Centennial, por favor lea su Manual del asegurado y otros materiales de la cobertura médica.Si tiene alguna pregunta, por favor llame a Atención al Asegurado de BCBSNM al: 1-866-689-1523, (TTY/TDD 711). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.

Asistencia lingüística para la Lista de medicamentosServicios de interpretación Podemos coordinar que alguien le ayude a comunicarse con nosotros en cualquier idioma. Estos servicios son gratuitos. Si su profesional de la salud no habla su idioma, podemos ofrecerle la ayuda de un intérprete. Por favor llame a Atención al Asegurado al 1-866-689-1523 (TTY/TDD 711).

Problemas auditivos y de la vistaPara nuestros asegurados con problemas auditivos, ofrecemos el servicio de TTY/TDD sin ningún cargo. La línea está abierta las 24 horas del día, los siete días de la semana en el 711.

Otros idiomas y formatosPuede obtener este documento en inglés o hablar con alguien acerca de esta información en otros idiomas sin costo alguno. Llame al 1-866-689-1523 (TTY/TDD: 711). La llamada es gratuita. También puede llamar gratis a Atención al Asegurado, para solicitar esta información en otros formatos diferentes como Braille, letra grande y otros formatos. Llame sin costo al: 1-866-689-1523 (TTY/TDD: 711). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.



v

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (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 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

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

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (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。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).

Blue Cross and Blue Shield of New Mexico cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue Cross and Blue Shield of New Mexico no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Blue Cross and Blue Shield of New Mexico:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que secomuniquen de manera eficaz con nosotros, como los siguientes:

o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos

accesibles, otros formatos). Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como

los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Civil Rights Coordinator.

Si considera que Blue Cross and Blue Shield of New Mexico no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Civil Rights Coordinator está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

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

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Para obtener asistencia y servicios auxiliares, o materiales en formatos alternativos u otros idiomas sin costo, llame al 1-866-689-1523 (TTY/TDD: 711).



vi

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (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 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

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

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (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。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).


Medicamento Intervalo de edad elegidoAbilify (aripiprazole)a

2 mg tablet menores de 6 años5 mg tablet menores de 6 años10 mg tablet menores de 6 años15 mg tablet menores de 6 años20 mg tablet menores de 6 años30 mg tablet menores de 6 añosAbilify Discmelt (aripiprazole)a

15 mg orally disintegrating tablet menores de 6 años10 mg orally disintegrating tablet menores de 6 añosClozaril (clozapine)a

25 mg tablet menores de 18 años50 mg tablet menores de 18 años100 mg tablet menores de 18 años200 mg tablet menores de 18 añosFluphenazinea

25 mg/mL decanoate injection menores de 12 añosGeodon (ziprasidone)a

20 mg capsule menores de 10 años40 mg capsule menores de 10 años60 mg capsule menores de 10 años80 mg capsule menores de 10 añosHaldol (haloperidol)a

0.5 mg tablet menores de 5 años1 mg tablet menores de 5 años2 mg tablet menores de 5 años5 mg tablet menores de 5 años10 mg tablet menores de 5 años20 mg tablet menores de 5 años2 mg/mL oral concentrate menores de 18 años50 mg/mL IM injection menores de 18 años100 mg/mL IM injection menores de 18 añosLoxapinea

5 mg capsule menores de 18 años10 mg capsule menores de 18 años25 mg capsule menores de 18 años50 mg capsule menores de 18 añosPerphenazinea

2 mg tablet menores de 12 años4 mg tablet menores de 12 años8 mg tablet menores de 12 años16 mg tablet menores de 12 añosProchlorperazinea

5 mg tablet menores de 2 años10 mg tablet menores de 2 años25 mg suppository menores de 2 añosRisperdal (risperidone)a

1 mg/mL oral solution menores de 5 años

A continuación, se incluye una lista de medicamentos que requieren autorización previa para un grupo de edad específicopara garantizar un uso adecuado.a = medicamento genérico cubierto y incluido en el programa

Page 1 of 152

0.25 mg tablet menores de 5 años0.5 mg tablet menores de 5 años1 mg tablet menores de 5 años2 mg tablet menores de 5 años3 mg tablet menores de 5 años4 mg tablet menores de 5 añosRisperdal M-Tab (risperidone)a

0.5 mg orally disintegrating tablet menores de 5 años1 mg orally disintegrating tablet menores de 5 años2 mg orally disintegrating tablet menores de 5 años3 mg orally disintegrating tablet menores de 5 años4 mg orally disintegrating tablet menores de 5 añosRisperidone0.25 mg orally disintegrating tablet menores de 5 añosSeroquel (quetiapine)a

25 mg tablet menores de 10 años50 mg tablet menores de 10 años100 mg tablet menores de 10 años200 mg tablet menores de 10 años300 mg tablet menores de 10 años400 mg tablet menores de 10 añosThioridazinea

10 mg tablet menores de 5 años25 mg tablet menores de 5 años50 mg tablet menores de 5 años100 mg tablet menores de 5 añosThiothixenea

1 mg capsule menores de 12 años2 mg capsule menores de 12 años5 mg capsule menores de 12 años10 mg capsule menores de 12 añosTrifluoperazinea

1 mg tablet menores de 6 años2 mg tablet menores de 6 años5 mg tablet menores de 6 años10 mg tablet menores de 6 añosZyprexa (olanzapine)a

2.5 mg tablet menores de 13 años5 mg tablet menores de 13 años7.5 mg tablet menores de 13 años10 mg tablet menores de 13 años15 mg tablet menores de 13 años20 mg tablet menores de 13 añosZyprexa Zydis (olanzapine)a

5 mg orally disintegrating tablet menores de 13 años10 mg orally disintegrating tablet menores de 13 años15 mg orally disintegrating tablet menores de 13 años20 mg orally disintegrating tablet menores de 13 añosMolindone5mg tablets menores de 12 años10mg tablets menores de 12 años25mg tablets menores de 12 años

Page 2 of 152

Atralin™ (tretinoin)0.05% gela de 25 años en adelanteAvita® (tretinoin)0.025% creama de 25 años en adelante0.025% gela de 25 años en adelanteBenzamycin (benzoyl peroxide/erythromycin)5%/3% gela de 25 años en adelantebenzoyl peroxide6% foaming clothsa de 25 años en adelanteCleocin T (clindamycin phosphate)1% gela de 25 años en adelante1% lotiona de 25 años en adelante1% solutiona de 25 años en adelante1% padsa de 25 años en adelanteClindacin - P (clindamycin phosphate)1% Pledets de 25 años en adelante1% Pads de 25 años en adelanteDifferin® (adapalene)0.1% creama de 25 años en adelanteDuac (clindamycin phosphate/benzoyl peroxide)

1.2%/5% gela de 25 años en adelanteerythromycin2% padsa de 25 años en adelante2% solutiona de 25 años en adelanteFinacea (azelaic acid)15% gel de 25 años en adelanteisotretinoin10 mg capsulea de 25 años en adelante20 mg capsulea de 25 años en adelante30 mg capsulea de 25 años en adelante40 mg capsulea de 25 años en adelanteKlaron (sulfacetamide sodium)10% lotiona de 25 años en adelanteMetrocream (metronidazole)0.75% creama de 25 años en adelanteMetrogel (metronidazole)0.75% gela de 25 años en adelanteRetin-A® (tretinoin)0.025% creama de 25 años en adelante0.05% creama de 25 años en adelante0.1% creama de 25 años en adelante0.01% gela de 25 años en adelante0.025% gela de 25 años en adelanteTazorac® (tazarotene)0.05% cream de 25 años en adelante0.1% creama de 25 años en adelante0.05% gel de 25 años en adelante0.1% gel de 25 años en adelanteStrattera (atomoxetine)10mg capsules menores de 6 años y mayores de 18 años18mg capsules menores de 6 años y mayores de 18 años

Page 3 of 152

25mg capsules menores de 6 años y mayores de 18 años40mg capsules menores de 6 años y mayores de 18 años60mg capsules menores de 6 años y mayores de 18 años80mg capsules menores de 6 años y mayores de 18 años100mg capsules menores de 6 años y mayores de 18 añosAdderall (amphetamine/dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años7.5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 años12.5 mg tableta menores de 6 años y mayores de 18 años15 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 años30 mg tableta menores de 6 años y mayores de 18 añosAdderall XR (amphetamine/dextroamphetamine ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años25 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 añosConcerta (methylphenidate osmotic ER)a

18 mg tableta menores de 6 años y mayores de 18 años27 mg tableta menores de 6 años y mayores de 18 años36 mg tableta menores de 6 años y mayores de 18 años54 mg tableta menores de 6 años y mayores de 18 añosmethylphenidate ER18 mg tablet menores de 6 años y mayores de 18 años27 mg tablet menores de 6 años y mayores de 18 años36 mg tablet menores de 6 años y mayores de 18 años54 mg tablet menores de 6 años y mayores de 18 añosDexedrine (dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosDexedrine Spansule (dextroamphetamine ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 añosFocalin (dexmethylphenidate)2.5 mg tableta menores de 6 años y mayores de 18 años5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosFocalin XR (dexmethylphenidate ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 añosMetadate ER (methylphenidate ER)20 mg tableta menores de 6 años y mayores de 18 añosMetadate CD (methylphenidate ER)10 mg capsulea menores de 6 años y mayores de 18 años

Page 4 of 152

20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 años50 mg capsulea menores de 6 años y mayores de 18 años60 mg capsulea menores de 6 años y mayores de 18 añosMethylin (methylphenidate)5 mg/5 mL solutiona menores de 6 años y mayores de 18 años10 mg/5 mL solutiona menores de 6 años y mayores de 18 añosMethylin (methylphenidate)2.5 mg chewable tableta menores de 6 años y mayores de 18 años5 mg chewable tableta menores de 6 años y mayores de 18 años10 mg chewable tableta menores de 6 años y mayores de 18 añosMethylphenidate ER10 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 añosProcentra (dextroamphetamine)5 mg/5 mL oral solutiona menores de 6 años y mayores de 18 años

5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 añosRitalin LA (methylphenidate ER)10 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 añosZenzedi (dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosFlovent Diskus® (fluticasone)50 mcg/actuation de 5 años en adelante100 mcg/actuation de 5 años en adelante250 mcg/actuation de 5 años en adelanteFlovent HFA® (fluticasone)44 mcg/actuation de 5 años en adelante110 mcg/actuation de 5 años en adelante220 mcg/actuation de 5 años en adelanteQvar® Redihaler (beclomethasone)40 mcg/actuation de 12 años en adelante80 mcg/actuation de 12 años en adelanteSymbicort® (budesonide and formoterol fumaratedihydrate)80 mcg – 4.5 mcg/actuation de 12 años en adelante160 mcg – 4.5 mcg/actuation de 12 años en adelanteAcetaminophen/codeine120mg-12mg/5mL solution menores de 18 añosButalbital/acetaminophen/caffeine/codeine50mg/325mg/40mg/30mg capsule menores de 18 añosCodeine sulfate30 mg tablet menores de 18 años60 mg tablet menores de 18 añosFiorinal w/Codeine (butalbital/aspirin/caffeine/codeine)

Ritalin (methylphenidate)

Page 5 of 152

50mg/325mg/40mg/30mg capsule menores de 18 añosTylenol w/Codeine (acetaminophen/codeine)

300mg/15mg tablet menores de 18 años300mg/30mg tablet menores de 18 años300mg/60mg tablet menores de 18 añosUltracet (tramadol/acetaminophen)

37.5mg/325mg tablet menores de 18 añosUltram (tramadol)

50 mg tablet menores de 18 años

Page 6 of 152

2020

1 = Medicamentos genéricos AL = Límite de edad ME90 = Equivalente a la morfina ST = Terapia escalonada2 = Medicamentos de marca PA = Autorización previa QL = Límites de cantidad SP = Medicamento especializado90 = Suministro de 90 díasdisponible al realizar el pedido deenvío por correo

SF = Split Fill

7

Nombre del medicamento

Cuánto le costaráel medicamento de(nivel)

Acciones necesarias,restricciones o límitesen el uso

MEDICAMENTOS ANTIINFECCIOSOSPENICILINASAMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg 2AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg 2amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 1amoxicillin (trihydrate) for susp 250 mg/5ml 1amoxicillin (trihydrate) for susp 400 mg/5ml 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

(Augmentin)1

amoxicillin & k clavulanate for susp 400-57 mg/5ml 1amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin

es-600)1

amoxicillin & k clavulanate tab 250-125 mg 1amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1amoxicillin & k clavulanate tab 875-125 mg 1AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin & k

clavulanate chew tab 200-28.5 mg2

AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin & kclavulanate chew tab 400-57 mg

2

AMPICILLIN – ampicillin cap 500 mg 2dicloxacillin sodium cap 250 mg 1dicloxacillin sodium cap 500 mg 1PENICILLIN V POTASSIUM – penicillin v potassium for soln

125 mg/5ml2

PENICILLIN V POTASSIUM – penicillin v potassium for soln250 mg/5ml

2

penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1

CEFALOSPORINAScefaclor cap 250 mg 1cefaclor cap 500 mg 1cefadroxil cap 500 mg 1

Page 7 of 152

2020


SF = Split Fill

8




cefadroxil for susp 250 mg/5ml 1cefadroxil for susp 500 mg/5ml 1cefadroxil tab 1 gm 1cefdinir cap 300 mg 1cefdinir for susp 125 mg/5ml 1cefdinir for susp 250 mg/5ml 1cefixime for susp 100 mg/5ml (Suprax) 1cefixime for susp 200 mg/5ml (Suprax) 1cefprozil for susp 125 mg/5ml 1cefprozil for susp 250 mg/5ml 1cefprozil tab 250 mg 1cefprozil tab 500 mg 1cefuroxime axetil tab 250 mg 1cefuroxime axetil tab 500 mg 1cephalexin cap 250 mg (Keflex) 1cephalexin cap 500 mg (Keflex) 1cephalexin for susp 125 mg/5ml 1cephalexin for susp 250 mg/5ml 1

MACROLIDOSAZITHROMYCIN – azithromycin powd pack for susp 1 gm 2azithromycin for susp 100 mg/5ml (Zithromax) 1azithromycin for susp 200 mg/5ml (Zithromax) 1azithromycin tab 250 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 500 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 600 mg (Zithromax) 1 QL (60 tablets/180 days)CLARITHROMYCIN – clarithromycin for susp 125 mg/5ml 2CLARITHROMYCIN – clarithromycin for susp 250 mg/5ml 2clarithromycin tab 250 mg 1clarithromycin tab 500 mg 1

TETRACICLINASdemeclocycline hcl tab 150 mg 1demeclocycline hcl tab 300 mg 1doxycycline hyclate cap 50 mg 1doxycycline hyclate cap 100 mg (Vibramycin) 1doxycycline hyclate tab delayed release 50 mg (Doryx) 1 PA

Page 8 of 152

2020


SF = Split Fill

9




doxycycline hyclate tab 20 mg 1doxycycline hyclate tab 100 mg 1doxycycline monohydrate cap 50 mg 1doxycycline monohydrate cap 100 mg 1doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 1doxycycline monohydrate tab 50 mg 1doxycycline monohydrate tab 75 mg 1doxycycline monohydrate tab 100 mg 1minocycline hcl cap 50 mg (Minocin) 1minocycline hcl cap 75 mg 1minocycline hcl cap 100 mg 1

FLUOROQUINOLONASciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 750 mg (base equiv) 1levofloxacin oral soln 25 mg/ml 1levofloxacin tab 250 mg 1levofloxacin tab 500 mg (Levaquin) 1levofloxacin tab 750 mg (Levaquin) 1

AMINOGLICOSIDOSneomycin sulfate tab 500 mg 1PAROMOMYCIN SULFATE – paromomycin sulfate cap 250 mg 2TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml 1 PA, QL (56 units/56

days), SPtobramycin nebu soln 300 mg/5ml (Tobi) 1 PA, QL (56 units/56

days), SP

TUBERCULOSISethambutol hcl tab 100 mg (Myambutol) 1ethambutol hcl tab 400 mg (Myambutol) 1isoniazid tab 100 mg 1 90isoniazid tab 300 mg 1 90PRIFTIN – rifapentine tab 150 mg 2pyrazinamide tab 500 mg 1rifabutin cap 150 mg (Mycobutin) 1rifampin cap 150 mg (Rifadin) 1

Page 9 of 152

2020


SF = Split Fill

10




rifampin cap 300 mg (Rifadin) 1

INFECCIONES MICÓTICASfluconazole for susp 10 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole for susp 40 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole tab 50 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 100 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 150 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 200 mg (Diflucan) 1 QL (30 tablets/30 days)flucytosine cap 250 mg (Ancobon) 1flucytosine cap 500 mg (Ancobon) 1griseofulvin microsize susp 125 mg/5ml 1griseofulvin microsize tab 500 mg 1griseofulvin ultramicrosize tab 125 mg 1griseofulvin ultramicrosize tab 250 mg 1itraconazole cap 100 mg (Sporanox) 1 QL (120

capsules/30 days)NOXAFIL – posaconazole susp 40 mg/ml 2 PAnystatin oral powder 1nystatin tab 500000 unit 1posaconazole tab delayed release 100 mg (Noxafil) 1 PAterbinafine hcl tab 250 mg 1 QL (90 tablets/365 days)voriconazole for susp 40 mg/ml (Vfend) 1 PAvoriconazole tab 50 mg (Vfend) 1 PAvoriconazole tab 200 mg (Vfend) 1 PA

INFECCIONES VIRALESCitomegalovirusvalganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 1valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 1

Hepatitisadefovir dipivoxil tab 10 mg (Hepsera) 1BARACLUDE – entecavir oral soln 0.05 mg/ml 2entecavir tab 0.5 mg (Baraclude) 1entecavir tab 1 mg (Baraclude) 1lamivudine tab 100 mg (hbv) (Epivir hbv) 1MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg 2 PA, SP

Page 10 of 152

2020


SF = Split Fill

11




ribavirin cap 200 mg 1 PA, SPribavirin tab 200 mg 1 PA, SPSOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab

400-100 mg2 PA, SP

Herpesacyclovir cap 200 mg (Zovirax) 1acyclovir susp 200 mg/5ml (Zovirax) 1acyclovir tab 400 mg (Zovirax) 1acyclovir tab 800 mg (Zovirax) 1famciclovir tab 125 mg 1valacyclovir hcl tab 500 mg (Valtrex) 1valacyclovir hcl tab 1 gm (Valtrex) 1

VIH/SIDAabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) 1 QL (960 mls/30 days)abacavir sulfate tab 300 mg (base equiv) (Ziagen) 1 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) 1 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

(Trizivir)1 QL (60 tablets/30 days)

APTIVUS – tipranavir cap 250 mg 2 QL (120capsules/30 days)

APTIVUS – tipranavir oral soln 100 mg/ml 2 QL (4 bottles/30 days)atazanavir sulfate cap 150 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg (base equiv) (Reyataz) 1 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days)ATRIPLA – efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg2 QL (30 tablets/30 days)

BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg

2 QL (30 tablets/30 days)

CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg


COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg


CRIXIVAN – indinavir sulfate cap 200 mg 2 QL (270capsules/30 days)

CRIXIVAN – indinavir sulfate cap 400 mg 2 QL (180capsules/30 days)

DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg


Page 11 of 152

2020


SF = Split Fill

12




DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab200-25 mg


DIDANOSINE – didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)DIDANOSINE – didanosine delayed release capsule 400 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg (Videx ec) 1 QL (30 capsules/30 days)DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg (base

eq)2 QL (30 tablets/30 days)

EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 2 QL (30 tablets/30 days)efavirenz cap 50 mg (Sustiva) 1 QL (90 capsules/30 days)efavirenz cap 200 mg (Sustiva) 1 QL (60 capsules/30 days)efavirenz tab 600 mg (Sustiva) 1 QL (30 tablets/30 days)EMTRIVA – emtricitabine caps 200 mg 2 QL (30 capsules/30 days)EMTRIVA – emtricitabine soln 10 mg/ml 2 QL (720 mls/30 days)EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base

equiv)2 QL (30 tablets/30 days)

fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 1 QL (120 tablets/30 days)FUZEON – enfuvirtide for inj 90 mg 2 QL (1 kit/30 days)GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg2 QL (30 tablets/30 days)

INTELENCE – etravirine tab 25 mg 2 QL (120 tablets/30 days)INTELENCE – etravirine tab 100 mg 2 QL (60 tablets/30 days)INTELENCE – etravirine tab 200 mg 2 QL (60 tablets/30 days)INVIRASE – saquinavir mesylate tab 500 mg 2 QL (120 tablets/30 days)ISENTRESS – raltegravir potassium packet for susp 100 mg

(base equiv)2 QL (60 packets/30 days)

ISENTRESS – raltegravir potassium tab 400 mg (base equiv) 2 QL (60 tablets/30 days)ISENTRESS – raltegravir potassium chew tab 25 mg (base

equiv)2 QL (180 tablets/30 days)

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)


ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) 2 QL (60 tablets/30 days)JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base

eq)2 QL (30 tablets/30 days)

KALETRA – lopinavir-ritonavir tab 100-25 mg 2 QL (180 tablets/30 days)KALETRA – lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml (Epivir) 1 QL (4 bottles/30 days)lamivudine tab 150 mg (Epivir) 1 QL (30 tablets/30 days)lamivudine tab 300 mg (Epivir) 1 QL (30 tablets/30 days)

Page 12 of 152

2020


SF = Split Fill

13




lamivudine-zidovudine tab 150-300 mg (Combivir) 1 QL (60 tablets/30 days)LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 2 QL (8 bottles/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) 1 QL (480 mls/30 days)NEVIRAPINE ER – nevirapine tab er 24hr 100 mg 2 QL (90 tablets/30 days)nevirapine susp 50 mg/5ml (Viramune) 1 QL (1200 mls/30 days)nevirapine tab er 24hr 400 mg (Viramune xr) 1 QL (30 tablets/30 days)nevirapine tab 200 mg (Viramune) 1 QL (60 tablets/30 days)NORVIR – ritonavir oral soln 80 mg/ml 2 QL (2 bottles/30 days)ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab


PIFELTRO – doravirine tab 100 mg 2 QL (30 tablets/30 days)PREZCOBIX – darunavir-cobicistat tab 800-150 mg 2 QL (30 tablets/30 days)PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 2 QL (2 bottles/30 days)PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 2 QL (300 tablets/30 days)PREZISTA – darunavir ethanolate tab 150 mg (base equiv) 2 QL (180 tablets/30 days)PREZISTA – darunavir ethanolate tab 600 mg (base equiv) 2 QL (60 tablets/30 days)PREZISTA – darunavir ethanolate tab 800 mg (base equiv) 2 QL (30 tablets/30 days)REYATAZ – atazanavir sulfate oral powder packet 50 mg (base

equiv)2 QL (240 packets/30 days)

ritonavir tab 100 mg (Norvir) 1 QL (180 tablets/30 days)SELZENTRY – maraviroc tab 150 mg 2 QL (60 tablets/30 days)SELZENTRY – maraviroc tab 300 mg 2 QL (120 tablets/30 days)stavudine cap 15 mg 1 QL (60 capsules/30 days)stavudine cap 20 mg 1 QL (60 capsules/30 days)stavudine cap 30 mg 1 QL (60 capsules/30 days)stavudine cap 40 mg 1 QL (60 capsules/30 days)STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg2 QL (30 tablets/30 days)

SUSTIVA – efavirenz tab 600 mg 2 QL (30 tablets/30 days)SUSTIVA – efavirenz cap 50 mg 2 QL (90 capsules/30 days)SUSTIVA – efavirenz cap 200 mg 2 QL (60 capsules/30 days)SYMFI – efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 2 QL (30 tablets/30 days)SYMFI LO – efavirenz-lamivudine-tenofovir df tab


SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg


Page 13 of 152

2020


SF = Split Fill

14




TEMIXYS – lamivudine-tenofovir disoproxil fumarate tab300-300 mg


tenofovir disoproxil fumarate tab 300 mg (Viread) 1 QL (30 tablets/30 days)TIVICAY – dolutegravir sodium tab 50 mg (base equiv) 2 QL (60 tablets/30 days)TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg 2 QL (30 tablets/30 days)TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg2 QL (30 tablets/30 days)

TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






TYBOST – cobicistat tab 150 mg 2 QL (30 tablets/30 days)VIDEX – didanosine for soln 2 gm 2 QL (1200 mls/30 days)VIRACEPT – nelfinavir mesylate tab 250 mg 2 QL (270 tablets/30 days)VIRACEPT – nelfinavir mesylate tab 625 mg 2 QL (120 tablets/30 days)VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm 2 QL (4 bottles/30 days)VIREAD – tenofovir disoproxil fumarate tab 150 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 200 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 250 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 300 mg 2 QL (30 tablets/30 days)zidovudine cap 100 mg (Retrovir) 1 QL (180

capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir) 1 QL (8 bottles/30 days)zidovudine tab 300 mg 1 QL (60 tablets/30 days)

Influenzaoseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) 1 QL (300 mls/120 days)RELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister2 QL (40 blisters/120 days)

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 QL (30 tablets/90 days)

Page 14 of 152

2020


SF = Split Fill

15




atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 QL (30 tablets/90 days)CHLOROQUINE PHOSPHATE – chloroquine phosphate tab

250 mg2

chloroquine phosphate tab 500 mg 1DARAPRIM – pyrimethamine tab 25 mg 2 PA, QL (90

tablets/30 days)hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1KRINTAFEL – tafenoquine succinate tab 150 mg (base

equivalent)2

MEFLOQUINE HCL – mefloquine hcl tab 250 mg 2primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine

phosphate)1

INFECCIONES PARASITARIASalbendazole tab 200 mg (Albenza) 1BENZNIDAZOLE – benznidazole tab 12.5 mg 2BENZNIDAZOLE – benznidazole tab 100 mg 2ivermectin tab 3 mg (Stromectol) 1praziquantel tab 600 mg (Biltricide) 1

OTROS ANTIINFECCIOSOSALINIA – nitazoxanide tab 500 mg 2 QL (6 tablets/30 days)CAYSTON – aztreonam lysine for inhal soln 75 mg (base

equivalent)2 PA, QL (84 boxes/56

days), SPclindamycin hcl cap 75 mg (Cleocin) 1clindamycin hcl cap 150 mg (Cleocin) 1clindamycin hcl cap 300 mg (Cleocin) 1clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr)1

dapsone tab 25 mg 1dapsone tab 100 mg 1FIRVANQ – vancomycin hcl for oral soln 25 mg/ml (base

equivalent)2

FIRVANQ – vancomycin hcl for oral soln 50 mg/ml (baseequivalent)

2

IMPAVIDO – miltefosine cap 50 mg 2linezolid for susp 100 mg/5ml (Zyvox) 1 PA, QL (600

mls/180 days)linezolid tab 600 mg (Zyvox) 1 PA, QL (56

tablets/180 days)

Page 15 of 152

2020


SF = Split Fill

16




metronidazole cap 375 mg (Flagyl) 1metronidazole tab 250 mg (Flagyl) 1metronidazole tab 500 mg (Flagyl) 1SULFADIAZINE – sulfadiazine tab 500 mg 2sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 1trimethoprim tab 100 mg 1vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl) 1vancomycin hcl cap 250 mg (base equivalent) (Vancocin) 1XENLETA – lefamulin acetate tab 600 mg 2XIFAXAN – rifaximin tab 550 mg 2 PA, QL (60

tablets/30 days)ZYVOX – linezolid for susp 100 mg/5ml 2 PA, QL (600

mls/180 days)

IMMUNIZING AGENTSIMMUNIZING AGENTSADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-

mcg/0.5ml2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.25 ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

2

ENGERIX-B – hepatitis b vaccine (recombinant) susp10 mcg/0.5ml

2

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml 2FLUAD 2019-2020 – influenza vac type a&b surface ant adj susp

pref syr 0.5 ml2

FLUARIX QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUBLOK QUADRIVALENT 2019-2020 – influenza vac recombha quad pf soln pref syr 0.5 ml

2

Page 16 of 152

2020


SF = Split Fill

17




FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tiss-cult subunt quad susp pref syr 0.5 ml

2

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tissue-cultured subunit quadrivalent im susp

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj

2

FLUZONE HIGH-DOSE PF 2019-2020 – influenza virus vac splithigh-dose pf susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.25 ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent inj 0.5 ml

2

HEPLISAV-B – hepatitis b vaccine recomb adjuvanted pref syr20 mcg/0.5ml

2

HEPLISAV-B – hepatitis b vaccine recombinant adjuvanted20 mcg/0.5ml

2

IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj 2PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj

25 mcg/0.5ml2

PNEUMOVAX 23/1 DOSE – pneumococcal vaccine polyvalent inj25 mcg/0.5ml

2

PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj 2RABAVERT – rabies vaccine, pcec for inj 2RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml2

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp10 mcg/ml

2


2


2

SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml

2 QL (2 vaccines/1 lifetime)

SYNAGIS – palivizumab im soln 50 mg/0.5ml 2 PA, SPSYNAGIS – palivizumab im soln 100 mg/ml 2 PA, SP

Page 17 of 152

2020


SF = Split Fill

18




ZOSTAVAX – zoster vaccine live for subcutaneous susp 19400unit/0.65ml

2 QL (1 vaccine/1 lifetime)

MEDICAMENTOS CONTRA EL CÁNCERMEDICAMENTOS CONTRA EL CÁNCERabiraterone acetate tab 250 mg (Zytiga) 2 PA, QL (120 tablets/30

days), SF, SPACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml

(2000000 unit/0.5ml)2 PA, QL (12 vials/28

days), SPAFINITOR – everolimus tab 10 mg 2 PA, QL (30 tablets/30

days), SF, SPAFINITOR DISPERZ – everolimus tab for oral susp 2 mg 2 PA, QL (60 tablets/30



days), SF, SPALECENSA – alectinib hcl cap 150 mg (base equivalent) 2 PA, QL (240 capsules/30

days), SF, SPALKERAN – melphalan tab 2 mg 2 SPanastrozole tab 1 mg (Arimidex) 1 90BALVERSA – erdafitinib tab 3 mg 2 PA, QL (84 tablets/28

days), SF, SPBALVERSA – erdafitinib tab 4 mg 2 PA, QL (56 tablets/28

days), SF, SPBALVERSA – erdafitinib tab 5 mg 2 PA, QL (28 tablets/28

days), SF, SPbexarotene cap 75 mg (Targretin) 1 PA, SF, SPbicalutamide tab 50 mg (Casodex) 1BOSULIF – bosutinib tab 100 mg 2 PA, QL (120 tablets/30

days), SF, SPBOSULIF – bosutinib tab 500 mg 2 PA, QL (30 tablets/30

days), SF, SPBRAFTOVI – encorafenib cap 75 mg 2 PA, QL (180

capsules/30 days), SPCABOMETYX – cabozantinib s-malate tab 20 mg (base

equivalent)2 PA, QL (30 tablets/30

days), SF, SPCABOMETYX – cabozantinib s-malate tab 40 mg (base


days), SF, SP

Page 18 of 152

2020


SF = Split Fill

19




CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent)

2 PA, QL (30 tablets/30days), SF, SP

CALQUENCE – acalabrutinib cap 100 mg 2 PA, QL (60 capsules/30days), SP

capecitabine tab 150 mg (Xeloda) 1 PA, SPcapecitabine tab 500 mg (Xeloda) 1 PA, SPCAPRELSA – vandetanib tab 100 mg 2 PA, QL (60 tablets/30

days), SPCAPRELSA – vandetanib tab 300 mg 2 PA, QL (30 tablets/30

days), SPCOMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose)

kit2 PA, QL (1 carton/28

days), SF, SPCOMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg

(100 dose) kit2 PA, QL (1 carton/28

days), SF, SPCOMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg

(140 dose) kit2 PA, QL (1 carton/28

days), SF, SPCOPIKTRA – duvelisib cap 15 mg 2 PA, QL (56 capsules/28

days), SF, SPCOPIKTRA – duvelisib cap 25 mg 2 PA, QL (56 capsules/28

days), SF, SPCOTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) 2 PA, QL (63 tablets/28

days), SPcyclophosphamide cap 25 mg (Cyclophosphamide) 1cyclophosphamide cap 50 mg (Cyclophosphamide) 1DAURISMO – glasdegib maleate tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SF, SPDAURISMO – glasdegib maleate tab 100 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SF, SPELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 2 SPELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg2 SP

ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit30 mg

2 SP

ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit45 mg

2 SP

ERIVEDGE – vismodegib cap 150 mg 2 PA, QL (30 capsules/30days), SP

ERLEADA – apalutamide tab 60 mg 2 PA, QL (120tablets/30 days), SP

Page 19 of 152

2020


SF = Split Fill

20




erlotinib hcl tab 25 mg (base equivalent) (Tarceva) 2 PA, QL (60 tablets/30days), SF, SP



ETOPOSIDE – etoposide cap 50 mg 2 SPeverolimus tab 2.5 mg (Afinitor) 2 PA, QL (30 tablets/30

days), SF, SPeverolimus tab 5 mg (Afinitor) 2 PA, QL (30 tablets/30

days), SF, SPeverolimus tab 7.5 mg (Afinitor) 2 PA, QL (30 tablets/30

days), SF, SPexemestane tab 25 mg (Aromasin) 1 90FARYDAK – panobinostat lactate cap 10 mg (base equivalent) 2 PA, QL (6 capsules/21

days), SPFARYDAK – panobinostat lactate cap 15 mg (base equivalent) 2 PA, QL (6 capsules/21

days), SPFARYDAK – panobinostat lactate cap 20 mg (base equivalent) 2 PA, QL (6 capsules/21

days), SPflutamide cap 125 mg 1GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPGILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPGILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPGLEOSTINE – lomustine cap 10 mg 2 SPGLEOSTINE – lomustine cap 40 mg 2 SPGLEOSTINE – lomustine cap 100 mg 2 SPHYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) 2 PA, SPHYCAMTIN – topotecan hcl cap 1 mg (base equiv) 2 PA, SPhydroxyurea cap 500 mg (Hydrea) 1IBRANCE – palbociclib cap 75 mg 2 PA, QL (21 capsules/28

days), SPIBRANCE – palbociclib cap 100 mg 2 PA, QL (21 capsules/28

days), SP

Page 20 of 152

2020


SF = Split Fill

21




IBRANCE – palbociclib cap 125 mg 2 PA, QL (21 capsules/28days), SP

ICLUSIG – ponatinib hcl tab 15 mg (base equiv) 2 PA, QL (60 tablets/30days), SF, SP

ICLUSIG – ponatinib hcl tab 45 mg (base equiv) 2 PA, QL (30 tablets/30days), SF, SP

imatinib mesylate tab 100 mg (base equivalent) (Gleevec) 1 PA, QL (90 tablets/30days), SF, SP




IMBRUVICA – ibrutinib cap 140 mg 2 PA, QL (60 capsules/30days), SF, SP

INLYTA – axitinib tab 1 mg 2 PA, QL (180 tablets/30days), SF, SP

INLYTA – axitinib tab 5 mg 2 PA, QL (120 tablets/30days), SF, SP

INREBIC – fedratinib hcl cap 100 mg 2 PA, QL (120capsules/30 days), SP

IRESSA – gefitinib tab 250 mg 2 PA, QL (30 tablets/30days), SF, SP

JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30days), SF, SP





KISQALI – ribociclib succinate tab pack 200 mg daily dose 2 PA, QL (21 tablets/28days), SP

KISQALI – ribociclib succinate tab pack 400 mg daily dose(200 mg tab)

2 PA, QL (42 tablets/28days), SP

Page 21 of 152

2020


SF = Split Fill

22




KISQALI – ribociclib succinate tab pack 600 mg daily dose(200 mg tab)


KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk






LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack10 mg (10 mg daily dose)

2 PA, QL (30 capsules/30days), SF, SP

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy pack 4(3) mg (12 mg daily dose)


LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10& 4 mg (14 mg daily dose)


LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10& 4 (2) mg (18 mg daily dose)


LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 10(2) mg (20 mg daily dose)


LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10(2) & 4 mg (24 mg daily dose)


LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy pack4 mg (4 mg daily dose)


LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4(2) mg (8 mg daily dose)


letrozole tab 2.5 mg (Femara) 1 90LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg 2LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg 2leucovorin calcium tab 5 mg 1leucovorin calcium tab 25 mg 1LEUKERAN – chlorambucil tab 2 mg 2 SPLONSURF – trifluridine-tipiracil tab 15-6.14 mg 2 PA, QL (100

tablets/28 days), SPLONSURF – trifluridine-tipiracil tab 20-8.19 mg 2 PA, QL (80 tablets/28

days), SPLORBRENA – lorlatinib tab 25 mg 2 PA, QL (90 tablets/30

days), SF, SPLORBRENA – lorlatinib tab 100 mg 2 PA, QL (30 tablets/30

days), SF, SP

Page 22 of 152

2020


SF = Split Fill

23




LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit3.75 mg

2 PA, SP

LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit7.5 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 11.25 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 22.5 mg

2 PA, SP

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 month) forinj kit 30 mg

2 PA, SP

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 month) forinj kit 45 mg

2 PA, SP

LYNPARZA – olaparib tab 100 mg 2 PA, QL (120 tablets/30days), SF, SP

LYNPARZA – olaparib tab 150 mg 2 PA, QL (120 tablets/30days), SF, SP

LYSODREN – mitotane tab 500 mg 2 PA, SPMATULANE – procarbazine hcl cap 50 mg 2 PA, SPmegestrol acetate susp 40 mg/ml 1megestrol acetate tab 20 mg 1megestrol acetate tab 40 mg 1MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base


days), SPMEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base


days), SPMEKTOVI – binimetinib tab 15 mg 2 PA, QL (180

tablets/30 days), SPmelphalan tab 2 mg (Alkeran) 2 SPmercaptopurine tab 50 mg 1methotrexate sodium tab 2.5 mg (base equiv) 1MYLERAN – busulfan tab 2 mg 2 SPNERLYNX – neratinib maleate tab 40 mg (base equivalent) 2 PA, QL (180 tablets/30

days), SF, SPNEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPNINLARO – ixazomib citrate cap 2.3 mg (base equivalent) 2 PA, QL (3 capsules/28

days), SPNINLARO – ixazomib citrate cap 3 mg (base equivalent) 2 PA, QL (3 capsules/28

days), SP

Page 23 of 152

2020


SF = Split Fill

24




NINLARO – ixazomib citrate cap 4 mg (base equivalent) 2 PA, QL (3 capsules/28days), SP

NUBEQA – darolutamide tab 300 mg 2 PA, QL (120tablets/30 days), SP

PIQRAY 200MG DAILY DOSE – alpelisib tab therapy pack200 mg daily dose

2 PA, QL (1 pack/28days), SF, SP

PIQRAY 250MG DAILY DOSE – alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)

2 PA, QL (1 box/28days), SF, SP

PIQRAY 300MG DAILY DOSE – alpelisib tab pack 300 mg dailydose (2x150 mg tab)

2 PA, QL (1 box/28days), SF, SP

POMALYST – pomalidomide cap 1 mg 2 PA, QL (21 capsules/30days), SP




PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) 2 PA, SPROZLYTREK – entrectinib cap 100 mg 2 PA, QL (30 capsules/30

days), SPROZLYTREK – entrectinib cap 200 mg 2 PA, QL (90 capsules/30

days), SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPRUBRACA – rucaparib camsylate tab 250 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPRUBRACA – rucaparib camsylate tab 300 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPRYDAPT – midostaurin cap 25 mg 2 PA, QL (240

capsules/30 days), SPSPRYCEL – dasatinib tab 20 mg 2 PA, QL (90 tablets/30

days), SF, SPSPRYCEL – dasatinib tab 50 mg 2 PA, QL (30 tablets/30



days), SF, SP

Page 24 of 152

2020


SF = Split Fill

25




SPRYCEL – dasatinib tab 100 mg 2 PA, QL (30 tablets/30days), SF, SP

SPRYCEL – dasatinib tab 140 mg 2 PA, QL (30 tablets/30days), SF, SP

STIVARGA – regorafenib tab 40 mg 2 PA, QL (90 tablets/30days), SP

SUTENT – sunitinib malate cap 12.5 mg (base equivalent) 2 PA, QL (90 capsules/30days), SF, SP

SUTENT – sunitinib malate cap 25 mg (base equivalent) 2 PA, QL (30 capsules/30days), SF, SP

SUTENT – sunitinib malate cap 37.5 mg (base equivalent) 2 PA, QL (30 capsules/30days), SF, SP

SUTENT – sunitinib malate cap 50 mg (base equivalent) 2 PA, QL (30 capsules/30days), SF, SP

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 300 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 600 mcg 2 PA, SPTABLOID – thioguanine tab 40 mg 2 SPTAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTAGRISSO – osimertinib mesylate tab 40 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SF, SPTAGRISSO – osimertinib mesylate tab 80 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SF, SPTALZENNA – talazoparib tosylate cap 0.25 mg (base equivalent) 2 PA, QL (90 capsules/30

days), SF, SPTALZENNA – talazoparib tosylate cap 1 mg (base equivalent) 2 PA, QL (30 capsules/30

days), SF, SPtamoxifen citrate tab 10 mg (base equivalent) 1tamoxifen citrate tab 20 mg (base equivalent) 1TARGRETIN – bexarotene cap 75 mg 1 PA, SF, SPTASIGNA – nilotinib hcl cap 50 mg (base equivalent) 2 PA, QL (120 capsules/30

days), SF, SPTASIGNA – nilotinib hcl cap 150 mg (base equivalent) 2 PA, QL (120 capsules/30

days), SF, SP

Page 25 of 152

2020


SF = Split Fill

26




TASIGNA – nilotinib hcl cap 200 mg (base equivalent) 2 PA, QL (120 capsules/30days), SF, SP

TEMODAR – temozolomide for iv soln 100 mg 2temozolomide cap 5 mg (Temodar) 1 PA, SPtemozolomide cap 20 mg (Temodar) 1 PA, SPtemozolomide cap 100 mg (Temodar) 1 PA, SPtemozolomide cap 140 mg (Temodar) 1 PA, SPtemozolomide cap 180 mg (Temodar) 1 PA, SPtemozolomide cap 250 mg (Temodar) 1 PA, SPTIBSOVO – ivosidenib tab 250 mg 2 PA, QL (60 tablets/30

days), SPtoremifene citrate tab 60 mg (base equivalent) (Fareston) 1 SPtretinoin cap 10 mg 1 PA, SPTURALIO – pexidartinib hcl cap 200 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTYKERB – lapatinib ditosylate tab 250 mg (base equiv) 2 PA, QL (180

tablets/30 days), SPVENCLEXTA – venetoclax tab 10 mg 2 PA, QL (60 tablets/30

days), SPVENCLEXTA – venetoclax tab 50 mg 2 PA, QL (30 tablets/30

days), SPVENCLEXTA – venetoclax tab 100 mg 2 PA, QL (180

tablets/30 days), SPVENCLEXTA STARTING PACK – venetoclax tab therapy starter

pack 10 & 50 & 100 mg2 PA, QL (1 pack/180

days), SPVERZENIO – abemaciclib tab 50 mg 2 PA, QL (60 tablets/30




days), SPVITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (base

equivalent)2 PA, QL (300 mls/30

days), SF, SPVITRAKVI – larotrectinib sulfate cap 25 mg (base equivalent) 2 PA, QL (180 capsules/30

days), SF, SP

Page 26 of 152

2020


SF = Split Fill

27




VITRAKVI – larotrectinib sulfate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30days), SF, SP

VIZIMPRO – dacomitinib tab 15 mg 2 PA, QL (30 tablets/30days), SF, SP



VOTRIENT – pazopanib hcl tab 200 mg (base equiv) 2 PA, QL (120 tablets/30days), SF, SP

XALKORI – crizotinib cap 200 mg 2 PA, QL (60 capsules/30days), SF, SP

XALKORI – crizotinib cap 250 mg 2 PA, QL (60 capsules/30days), SF, SP

XOSPATA – gilteritinib fumarate tablet 40 mg (base equivalent) 2 PA, QL (90 tablets/30days), SP

XPOVIO 100 MG ONCE WEEKLY – selinexor tab therapy pack20 mg (100 mg once weekly)






XPOVIO 80 MG TWICE WEEKLY – selinexor tab therapy pack20 mg (80 mg twice weekly)


XTANDI – enzalutamide cap 40 mg 2 PA, QL (120 capsules/30days), SF, SP

YONSA – abiraterone acetate tab 125 mg 2 PA, QL (120 tablets/30days), SF, SP

ZELBORAF – vemurafenib tab 240 mg 2 PA, QL (240tablets/30 days), SP

ZOLINZA – vorinostat cap 100 mg 2 PA, QL (120 capsules/30days), SF, SP

ZYDELIG – idelalisib tab 100 mg 2 PA, QL (60 tablets/30days), SP

ZYDELIG – idelalisib tab 150 mg 2 PA, QL (60 tablets/30days), SP

ZYKADIA – ceritinib tab 150 mg 2 PA, QL (90 tablets/30days), SF, SP

Page 27 of 152

2020


SF = Split Fill

28




ZYTIGA – abiraterone acetate tab 500 mg 2 PA, QL (60 tablets/30days), SF, SP

HORMONAS, DIABETES Y MEDICAMENTOS RELACIONADOSCORTICOSTEROIDESbudesonide delayed release particles cap 3 mg (Entocort ec) 1CORTISONE ACETATE – cortisone acetate tab 25 mg 2DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml 2dexamethasone elixir 0.5 mg/5ml 1dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 1dexamethasone tab 6 mg 1fludrocortisone acetate tab 0.1 mg 1 90hydrocortisone tab 5 mg (Cortef) 1hydrocortisone tab 10 mg (Cortef) 1hydrocortisone tab 20 mg (Cortef) 1methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1methylprednisolone tab 4 mg (Medrol) 1methylprednisolone tab 8 mg (Medrol) 1methylprednisolone tab 16 mg (Medrol) 1methylprednisolone tab 32 mg (Medrol) 1PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp solution

equivalent)2

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)(Pediapred)

1

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1PREDNISONE – prednisone oral soln 5 mg/5ml 2prednisone tab therapy pack 5 mg (21) 1prednisone tab therapy pack 5 mg (48) 1prednisone tab therapy pack 10 mg (21) 1prednisone tab therapy pack 10 mg (48) 1prednisone tab 1 mg 1prednisone tab 2.5 mg 1prednisone tab 5 mg 1prednisone tab 10 mg 1

Page 28 of 152

2020


SF = Split Fill

29




prednisone tab 20 mg 1prednisone tab 50 mg 1

HORMONAS MASCULINASdanazol cap 50 mg 1 PAdanazol cap 100 mg 1 PAdanazol cap 200 mg 1 PAtestosterone cypionate im inj in oil 100 mg/ml (Depo-

testosterone)1 PA, QL (10 mls/28 days)

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)

1 PA, QL (10 mls/28 days)

testosterone td gel 25 mg/2.5gm (1%) (Androgel) 1 PA, QL (60packets/30 days)

testosterone td gel 50 mg/5gm (1%) (Androgel) 1 PA, QL (60packets/30 days)

testosterone td gel 12.5 mg/act (1%) 1 PA, QL (4 pumpbottles/30 days)

ESTRÓGENOSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day2 90

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day

2 90

estradiol & norethindrone acetate tab 0.5-0.1 mg 1 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 90estradiol tab 0.5 mg (Estrace) 1 90estradiol tab 1 mg (Estrace) 1 90estradiol tab 2 mg (Estrace) 1 90estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 1 QL (8 patches/28

days), 90estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) 1 QL (8 patches/28




days), 90estradiol td patch weekly 0.025 mg/24hr (Climara) 1 QL (4 patches/28

days), 90

Page 29 of 152

2020


SF = Split Fill

30




estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)

1 QL (4 patches/28days), 90

estradiol td patch weekly 0.05 mg/24hr (Climara) 1 QL (4 patches/28days), 90




ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)

2

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg(Femhrt low dose)

1 90

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 1 90

PROGESTINASmedroxyprogesterone acetate tab 2.5 mg (Provera) 1 90medroxyprogesterone acetate tab 5 mg (Provera) 1 90medroxyprogesterone acetate tab 10 mg (Provera) 1 90megestrol acetate susp 625 mg/5ml (Megace es) 1 90norethindrone acetate tab 5 mg (Aygestin) 1 90progesterone micronized cap 100 mg (Prometrium) 1 90progesterone micronized cap 200 mg (Prometrium) 1 90

ANTICONCEPTIVOSdesogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)

(Mircette)1 QL (28 tablets/21

days), 90desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 1 QL (28 tablets/21

days), 90desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1 QL (28 tablets/21

days), 90drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 1 QL (28 tablets/21

days), 90ELLA – ulipristal acetate tab 30 mg 2 QL (3 tablets/365 days)ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1 QL (28 tablets/21

days), 90etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr

(Nuvaring)1 QL (1 ring/21 days), 90

Page 30 of 152

2020


SF = Split Fill

31




KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mgtotal)

2

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)(Loseasonique)

1 QL (28 tablets/21days), 90

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)(Seasonique)


levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1 QL (28 tablets/21days), 90

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1 QL (28 tablets/21days), 90

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 1 QL (28 tablets/21days), 90

LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52 mgtotal)

2

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml(Depo-provera contrac)

1 90

medroxyprogesterone acetate im susp 150 mg/ml (Depo-proveracontrac)

1 90

MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) 2NEXPLANON – etonogestrel subdermal implant 68 mg 2norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 1 QL (28 tablets/21

days), 90norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 1 QL (28 tablets/21

days), 90norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Ortho-novum

1/35)1 QL (28 tablets/21

days), 90norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg

(Generess fe)1 QL (28 tablets/21

days), 90norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg

(Estrostep fe)1 QL (28 tablets/21

days), 90norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin

1/20-21)1 QL (28 tablets/21

days), 90norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg

(Loestrin 1.5/30-21)1 QL (28 tablets/21

days), 90norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg

(Loestrin fe 1/20)1 QL (28 tablets/21

days), 90norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg

(Loestrin fe 1.5/30)1 QL (28 tablets/21

days), 90

Page 31 of 152

2020


SF = Split Fill

32




norethindrone tab 0.35 mg (Ortho micronor) 1 QL (28 tablets/21days), 90

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg(Ortho-novum 7/7/7)


norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 1 QL (28 tablets/21days), 90

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 1 QL (28 tablets/21days), 90

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg(Ortho tri-cyclen lo)


norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 1 QL (28 tablets/21days), 90

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1 QL (28 tablets/21days), 90

PARAGARD INTRAUTERINE COPPER CONTRACEPTIVET380A – copper iud

2

SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) 2XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr2 QL (3 patches/21

days), 90

INFERTILITYCHORIONIC GONADOTROPIN – chorionic gonadotropin for im

inj 10000 unit2 SP

CHORIONIC GONADOTROPIN – chorionic gonadotropin for iminj 10000 unit

2 SP

LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &norethindrone tab 5 mg kit

2 PA, SP

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit

2 PA, SP

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetate for injpediatric kit 7.5 mg

2 PA, SP


2 PA, SP

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetate for injpediatric kit 15 mg

2 PA, SP

LUPRON DEPOT-PED (3-MONTH) – leuprolide acetate (3month) for inj pediatric kit 11.25 mg

2 PA, SP

LUPRON DEPOT-PED (3-MONTH) – leuprolide acetate (3month) for inj pediatric kit 30 mg

2 PA, SP

ORILISSA – elagolix sodium tab 150 mg (base equiv) 2 PA, QL (30tablets/30 days)

Page 32 of 152

2020


SF = Split Fill

33




ORILISSA – elagolix sodium tab 200 mg (base equiv) 2 PA, QL (60tablets/30 days)

SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mcg/act)(base eq)

2

DIABETESacarbose tab 25 mg (Precose) 1 QL (180 tablets/30

days), 90acarbose tab 50 mg (Precose) 1 QL (180 tablets/30

days), 90acarbose tab 100 mg (Precose) 1 QL (90 tablets/30

days), 90ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) 2 QL (30 tablets/30

days), ST, 90ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) 2 QL (30 tablets/30

days), ST, 90ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) 2 QL (30 tablets/30

days), ST, 90ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab

12.5-500 mg2 QL (60 tablets/30

days), ST, 90ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab

12.5-1000 mg2 QL (60 tablets/30

days), ST, 90ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab

12.5-15 mg2 QL (30 tablets/30


12.5-30 mg2 QL (30 tablets/30


12.5-45 mg2 QL (30 tablets/30


25-15 mg2 QL (30 tablets/30





days), ST, 90glimepiride tab 1 mg (Amaryl) 1 QL (60 tablets/30

days), 90glimepiride tab 2 mg (Amaryl) 1 QL (60 tablets/30

days), 90glimepiride tab 4 mg (Amaryl) 1 QL (60 tablets/30

days), 90

Page 33 of 152

2020


SF = Split Fill

34




glipizide tab er 24hr 2.5 mg (Glucotrol xl) 1 QL (60 tablets/30days), 90

glipizide tab er 24hr 5 mg (Glucotrol xl) 1 QL (90 tablets/30days), 90

glipizide tab er 24hr 10 mg (Glucotrol xl) 1 QL (60 tablets/30days), 90

glipizide tab 5 mg (Glucotrol) 1 QL (120 tablets/30days), 90

glipizide tab 10 mg (Glucotrol) 1 QL (120 tablets/30days), 90

glipizide-metformin hcl tab 2.5-250 mg 1 QL (120 tablets/30days), 90

glipizide-metformin hcl tab 2.5-500 mg 1 QL (120 tablets/30days), 90

glipizide-metformin hcl tab 5-500 mg 1 QL (120 tablets/30days), 90

GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 2 QL (6 pens/365 days)glyburide tab 1.25 mg 1 QL (60 tablets/30

days), 90glyburide tab 2.5 mg 1 QL (60 tablets/30

days), 90glyburide tab 5 mg 1 QL (120 tablets/30

days), 90glyburide-metformin tab 1.25-250 mg 1 QL (120 tablets/30

days), 90glyburide-metformin tab 2.5-500 mg 1 QL (120 tablets/30

days), 90glyburide-metformin tab 5-500 mg 1 QL (120 tablets/30

days), 90GVOKE PFS – glucagon subcutaneous soln pref syringe

0.5 mg/0.1ml2 QL (6 syringes/365 days)

GVOKE PFS – glucagon subcutaneous soln pref syringe1 mg/0.2ml

2 QL (6 syringes/365 days)

KORLYM – mifepristone tab 300 mg 2 PA, QL (120tablets/30 days), SP

metformin hcl tab er 24hr 500 mg (Glucophage xr) 1 QL (120 tablets/30days), 90

metformin hcl tab er 24hr 750 mg (Glucophage xr) 1 QL (60 tablets/30days), 90

Page 34 of 152

2020


SF = Split Fill

35




metformin hcl tab 500 mg (Glucophage) 1 QL (120 tablets/30days), 90



nateglinide tab 60 mg (Starlix) 1 QL (120 tablets/30days), 90

nateglinide tab 120 mg (Starlix) 1 QL (90 tablets/30days), 90

pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 QL (30 tablets/30days), 90



PROGLYCEM – diazoxide susp 50 mg/ml 2 90STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg (base

equiv)2 QL (60 tablets/30

days), ST, 90STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg (base

equiv)2 QL (30 tablets/30

days), ST, 90TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml 2 PA, QL (4 pens/28 days)TRULICITY – dulaglutide soln pen-injector 1.5 mg/0.5ml 2 PA, QL (4 pens/28 days)VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PA, QL (3 pens/30 days)

DIABETES - INSULINASInsulinas de acción rápidaADMELOG – insulin lispro inj 100 unit/ml 2 QL (45 mls/30 days), 90ADMELOG SOLOSTAR – insulin lispro soln pen-injector 100

unit/ml (1 unit dial)2 QL (45 mls/30 days), 90

Insulinas de acción breveHUMULIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R FLEXPEN – insulin regular (human) soln pen-

injector 100 unit/ml2 QL (45 mls/30 days), 90

NOVOLIN R FLEXPEN RELION – insulin regular (human) solnpen-injector 100 unit/ml

2 QL (45 mls/30 days), 90

NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90RELION R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90

Page 35 of 152

2020


SF = Split Fill

36




Insulinas de acción intermediaHUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (45 mls/30 days), 90

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)

2 QL (45 mls/30 days), 90

HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 unit/ml(75-25)

2 QL (45 mls/30 days), 90

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)

2 QL (45 mls/30 days), 90

HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp

pen-injector 100 unit/ml2 QL (45 mls/30 days), 90

HUMULIN 70/30 – insulin nph isophane & regular human inj 100unit/ml (70-30)

2 QL (45 mls/30 days), 90

HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN N FLEXPEN – insulin nph (human) (isophane) susp

pen-injector 100 unit/ml2 QL (45 mls/30 days), 90

NOVOLIN N FLEXPEN RELION – insulin nph (human)(isophane) susp pen-injector 100 unit/ml

2 QL (45 mls/30 days), 90

NOVOLIN N RELION – insulin nph (human) (isophane) inj 100unit/ml

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 – insulin nph isophane & regular human inj 100unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp pen-inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 FLEXPEN RELION – insulin nph & regular susppen-inj 100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 RELION – insulin nph isophane & regularhuman inj 100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLOG MIX 70/30 PREFILLED FLEXPEN – insulin aspartprot & aspart sus pen-inj 100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

Insulinas basalesBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100

unit/ml2 QL (45 mls/30 days), 90

REGULACIÓN TIROIDEAlevothyroxine sodium tab 25 mcg (Synthroid) 1 90levothyroxine sodium tab 50 mcg (Synthroid) 1 90

Page 36 of 152

2020


SF = Split Fill

37




levothyroxine sodium tab 75 mcg (Synthroid) 1 90levothyroxine sodium tab 88 mcg (Synthroid) 1 90levothyroxine sodium tab 100 mcg (Synthroid) 1 90levothyroxine sodium tab 112 mcg (Synthroid) 1 90levothyroxine sodium tab 125 mcg (Synthroid) 1 90levothyroxine sodium tab 137 mcg (Synthroid) 1 90levothyroxine sodium tab 150 mcg (Synthroid) 1 90levothyroxine sodium tab 175 mcg (Synthroid) 1 90levothyroxine sodium tab 200 mcg (Synthroid) 1 90levothyroxine sodium tab 300 mcg (Synthroid) 1 90liothyronine sodium tab 5 mcg (Cytomel) 1 90liothyronine sodium tab 25 mcg (Cytomel) 1 90liothyronine sodium tab 50 mcg (Cytomel) 1 90methimazole tab 5 mg (Tapazole) 1 90methimazole tab 10 mg (Tapazole) 1 90propylthiouracil tab 50 mg 1 90thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 90thyroid tab 60 mg (1 grain) (Armour thyroid) 1 90thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 90

GROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) 2 PA, SPOMNITROPE – somatropin for inj 5.8 mg 2 PA, SPSEROSTIM – somatropin (non-refrigerated) for subcutaneous inj

4 mg2 PA, SP

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj5 mg

2 PA, SP

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj6 mg

2 PA, SP

ZORBTIVE – somatropin (non-refrigerated) for subcutaneous inj8.8 mg

2 PA, SP

OTRAS HORMONAS Y MEDICAMENTOS RELACIONADOSACTHAR – corticotropin inj gel 80 unit/ml 2 PA, SPALENDRONATE SODIUM – alendronate sodium tab 5 mg 2 QL (30 tablets/30

days), 90alendronate sodium tab 10 mg 1 QL (30 tablets/30

days), 90alendronate sodium tab 35 mg 1 QL (4 tablets/28 days), 90

Page 37 of 152

2020


SF = Split Fill

38




alendronate sodium tab 70 mg (Fosamax) 1 QL (4 tablets/28 days), 90BUPHENYL – sodium phenylbutyrate tab 500 mg 2 PA, SPcabergoline tab 0.5 mg 1calcitonin (salmon) nasal soln 200 unit/act 1 90calcitriol cap 0.25 mcg (Rocaltrol) 1 90calcitriol cap 0.5 mcg (Rocaltrol) 1 90calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 90CARBAGLU – carglumic acid tab 200 mg 2 PA, SPcinacalcet hcl tab 30 mg (base equiv) (Sensipar) 1 PAcinacalcet hcl tab 60 mg (base equiv) (Sensipar) 1 PAcinacalcet hcl tab 90 mg (base equiv) (Sensipar) 1 PACYSTADANE – betaine powder for oral solution 2 PA, QL (180

grams/30 days)desmopressin acetate nasal spray soln 0.01% (Ddavp) 1desmopressin acetate nasal spray soln 0.01% (refrigerated) 1desmopressin acetate tab 0.1 mg (Ddavp) 1 90desmopressin acetate tab 0.2 mg (Ddavp) 1 90ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 QL (1 tablet/30 days), 90KUVAN – sapropterin dihydrochloride soluble tab 100 mg 2 PA, SPKUVAN – sapropterin dihydrochloride powder packet 100 mg 2 PA, SPKUVAN – sapropterin dihydrochloride powder packet 500 mg 2 PA, SPlevocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 90levocarnitine tab 330 mg (Carnitor) 1 90LUPRON DEPOT-PED (1-MONTH) – leuprolide acetate for inj

pediatric kit 7.5 mg2 PA, SP


2 PA, SP

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetate for injpediatric kit 15 mg

2 PA, SP

methylergonovine maleate tab 0.2 mg 1MYALEPT – metreleptin for subcutaneous inj 11.3 mg 2 PA, SPNITYR – nitisinone tab 2 mg 2 PA, SPNITYR – nitisinone tab 5 mg 2 PA, SPNITYR – nitisinone tab 10 mg 2 PA, SPoctreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) 1 PA, QL (90 mls/30

days), SP

Page 38 of 152

2020


SF = Split Fill

39




octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) 1 PA, QL (90 mls/30days), SP

octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) 1 PA, QL (90 mls/30days), SP

octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) 1 PA, QL (30 vials/30days), SP

raloxifene hcl tab 60 mg (Evista) 1 90RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml 2 PA, SPrisedronate sodium tab delayed release 35 mg (Atelvia) 1 QL (4 tablets/28 days), 90SAMSCA – tolvaptan tab 15 mg 2 PA, QL (30 tablets/365

days), SPSAMSCA – tolvaptan tab 30 mg 2 PA, QL (60 tablets/365

days), SPSIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv) 2 PA, QL (60 mls/30



days), SPSOMAVERT – pegvisomant for inj 10 mg (as protein) 2 PA, QL (30 vials/30





days), SPSTIMATE – desmopressin acetate nasal soln 1.5 mg/ml 2STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml 2 PA, SPTYMLOS – abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml2 PA, QL (1 pen/30

days), SPXURIDEN – uridine triacetate oral granules packet 2 gm 2 SP

MEDICAMENTOS CARDÍACOS Y CIRCULATORIOS

Page 39 of 152

2020


SF = Split Fill

40




INHIBIDORES DE LA ENZIMA CONVERTIDORA DEbenazepril & hydrochlorothiazide tab 5-6.25 mg 1 90benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 90benazepril hcl tab 5 mg 1 90benazepril hcl tab 10 mg (Lotensin) 1 90benazepril hcl tab 20 mg (Lotensin) 1 90benazepril hcl tab 40 mg (Lotensin) 1 90captopril tab 12.5 mg 1 90captopril tab 25 mg 1 90captopril tab 50 mg 1 90captopril tab 100 mg 1 90CAPTOPRIL/HYDROCHLOROTHIAZIDE – captopril &

hydrochlorothiazide tab 25-15 mg2 90

CAPTOPRIL/HYDROCHLOROTHIAZIDE – captopril &hydrochlorothiazide tab 25-25 mg

2 90


2 90


2 90

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 90enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 90enalapril maleate tab 2.5 mg (Vasotec) 1 90enalapril maleate tab 5 mg (Vasotec) 1 90enalapril maleate tab 10 mg (Vasotec) 1 90enalapril maleate tab 20 mg (Vasotec) 1 90fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 90fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 90fosinopril sodium tab 10 mg 1 90fosinopril sodium tab 20 mg 1 90fosinopril sodium tab 40 mg 1 90lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 90lisinopril tab 2.5 mg (Zestril) 1 90

Page 40 of 152

2020


SF = Split Fill

41




lisinopril tab 5 mg (Prinivil) 1 90lisinopril tab 10 mg (Prinivil) 1 90lisinopril tab 20 mg (Prinivil) 1 90lisinopril tab 30 mg (Zestril) 1 90lisinopril tab 40 mg (Zestril) 1 90moexipril hcl tab 7.5 mg 1 90moexipril hcl tab 15 mg 1 90perindopril erbumine tab 2 mg 1 90perindopril erbumine tab 4 mg 1 90perindopril erbumine tab 8 mg 1 90quinapril hcl tab 5 mg (Accupril) 1 90quinapril hcl tab 10 mg (Accupril) 1 90quinapril hcl tab 20 mg (Accupril) 1 90quinapril hcl tab 40 mg (Accupril) 1 90quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) 1 90ramipril cap 1.25 mg (Altace) 1 90ramipril cap 2.5 mg (Altace) 1 90ramipril cap 5 mg (Altace) 1 90ramipril cap 10 mg (Altace) 1 90trandolapril tab 1 mg 1 90trandolapril tab 2 mg 1 90trandolapril tab 4 mg 1 90

ANTAGONISTAS RECEPTORES DE ANGIOTENSINA II (ARA-II) Y COMBINACIONESirbesartan tab 75 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan tab 150 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan tab 300 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 1 QL (30 tablets/30

days), 90irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 QL (30 tablets/30

days), 90

Page 41 of 152

2020


SF = Split Fill

42




losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar)


losartan potassium & hydrochlorothiazide tab 100-12.5 mg(Hyzaar)


losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar)


losartan potassium tab 25 mg (Cozaar) 1 QL (60 tablets/30days), 90



olmesartan medoxomil tab 5 mg (Benicar) 1 QL (60 tablets/30days), 90



olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg(Benicar hct)


olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg(Benicar hct)


olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)


valsartan tab 40 mg (Diovan) 1 QL (60 tablets/30days), 90




valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 QL (30 tablets/30days), 90


valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 1 QL (30 tablets/30days), 90

Page 42 of 152

2020


SF = Split Fill

43





valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 1 QL (30 tablets/30days), 90

BETA BLOQUEADORES Y COMBINACINESacebutolol hcl cap 200 mg 1 90acebutolol hcl cap 400 mg 1 90atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 90atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 90atenolol tab 25 mg (Tenormin) 1 90atenolol tab 50 mg (Tenormin) 1 90atenolol tab 100 mg (Tenormin) 1 90betaxolol hcl tab 10 mg 1 90betaxolol hcl tab 20 mg 1 90bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) 1 90bisoprolol fumarate tab 5 mg 1 90bisoprolol fumarate tab 10 mg 1 90carvedilol tab 3.125 mg (Coreg) 1 90carvedilol tab 6.25 mg (Coreg) 1 90carvedilol tab 12.5 mg (Coreg) 1 90carvedilol tab 25 mg (Coreg) 1 90labetalol hcl tab 100 mg 1 90labetalol hcl tab 200 mg 1 90labetalol hcl tab 300 mg 1 90metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 90metoprolol & hydrochlorothiazide tab 100-25 mg 1 90metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol

xl)1 90

metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprolxl)

1 90

metoprolol tartrate tab 25 mg 1 90metoprolol tartrate tab 50 mg (Lopressor) 1 90

Page 43 of 152

2020


SF = Split Fill

44




metoprolol tartrate tab 100 mg (Lopressor) 1 90METOPROLOL/HYDROCHLOROTHIAZIDE – metoprolol &


nadolol tab 20 mg (Corgard) 1 90nadolol tab 40 mg (Corgard) 1 90nadolol tab 80 mg (Corgard) 1 90pindolol tab 5 mg 1 90PROPRANOLOL HCL – propranolol hcl oral soln 20 mg/5ml 2 90PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml 2 90propranolol hcl cap er 24hr 60 mg (Inderal la) 1 90propranolol hcl cap er 24hr 80 mg (Inderal la) 1 90propranolol hcl cap er 24hr 120 mg (Inderal la) 1 90propranolol hcl cap er 24hr 160 mg (Inderal la) 1 90propranolol hcl tab 10 mg 1 90propranolol hcl tab 20 mg 1 90propranolol hcl tab 40 mg 1 90propranolol hcl tab 60 mg 1 90propranolol hcl tab 80 mg 1 90PROPRANOLOL/HYDROCHLOROTHIAZIDE – propranolol &


PROPRANOLOL/HYDROCHLOROTHIAZIDE – propranolol &hydrochlorothiazide tab 80-25 mg

2 90

BLOQUEADORES DE LOS CANALES DE CALCIO Y COMBINACIONESamlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 10 mg (base equivalent) (Norvasc) 1 90amlodipine besylate-benazepril hcl cap 2.5-10 mg 1 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-40 mg 1 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 1 90DILT-XR – diltiazem hcl cap er 24hr 120 mg 2 90DILT-XR – diltiazem hcl cap er 24hr 180 mg 2 90DILT-XR – diltiazem hcl cap er 24hr 240 mg 2 90diltiazem hcl cap er 12hr 60 mg 1 90

Page 44 of 152

2020


SF = Split Fill

45




diltiazem hcl cap er 12hr 90 mg 1 90diltiazem hcl cap er 12hr 120 mg 1 90diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 300 mg (Cardizem cd) 1 90diltiazem hcl extended release beads cap er 24hr 120 mg

(Tiazac)1 90

diltiazem hcl extended release beads cap er 24hr 180 mg(Tiazac)

1 90


1 90


1 90


1 90


1 90

diltiazem hcl tab 30 mg (Cardizem) 1 90diltiazem hcl tab 60 mg (Cardizem) 1 90diltiazem hcl tab 90 mg 1 90diltiazem hcl tab 120 mg (Cardizem) 1 90ENTRESTO – sacubitril-valsartan tab 24-26 mg 2 PA, QL (180

tablets/30 days), 90ENTRESTO – sacubitril-valsartan tab 49-51 mg 2 PA, QL (60 tablets/30

days), 90ENTRESTO – sacubitril-valsartan tab 97-103 mg 2 PA, QL (60 tablets/30

days), 90felodipine tab er 24hr 2.5 mg 1 90felodipine tab er 24hr 5 mg 1 90felodipine tab er 24hr 10 mg 1 90isradipine cap 2.5 mg 1 90isradipine cap 5 mg 1 90nicardipine hcl cap 20 mg 1 90nifedipine cap 10 mg (Procardia) 1 90nifedipine cap 20 mg 1 90nifedipine tab er 24hr 30 mg (Adalat cc) 1 90nifedipine tab er 24hr 60 mg (Adalat cc) 1 90

Page 45 of 152

2020


SF = Split Fill

46




nifedipine tab er 24hr 90 mg (Adalat cc) 1 90nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 1 90nimodipine cap 30 mg 1 90trandolapril-verapamil hcl tab er 2-180 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 2-240 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 4-240 mg (Tarka) 1 90TRANDOLAPRIL/VERAPAMIL HCL ER – trandolapril-verapamil

hcl tab er 1-240 mg2 90

verapamil hcl cap er 24hr 120 mg (Verelan) 1 90verapamil hcl cap er 24hr 180 mg (Verelan) 1 90verapamil hcl cap er 24hr 240 mg (Verelan) 1 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100 mg 2 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300 mg 2 90VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg 2 90verapamil hcl tab er 120 mg (Calan sr) 1 90verapamil hcl tab er 180 mg (Calan sr) 1 90verapamil hcl tab er 240 mg (Calan sr) 1 90verapamil hcl tab 40 mg 1 90verapamil hcl tab 80 mg 1 90verapamil hcl tab 120 mg (Calan) 1 90VERAPAMIL HYDROCHLORIDE ER – verapamil hcl cap er 24hr

200 mg2 90

DOLOR TORÁCICOisosorbide mononitrate tab er 24hr 30 mg 1 90isosorbide mononitrate tab er 24hr 60 mg 1 90isosorbide mononitrate tab er 24hr 120 mg 1 90isosorbide mononitrate tab 10 mg 1 90isosorbide mononitrate tab 20 mg 1 90NITRO-TIME – nitroglycerin cap er 2.5 mg 2 90NITRO-TIME – nitroglycerin cap er 6.5 mg 2 90NITRO-TIME – nitroglycerin cap er 9 mg 2 90nitroglycerin sl tab 0.3 mg (Nitrostat) 1nitroglycerin sl tab 0.4 mg (Nitrostat) 1nitroglycerin sl tab 0.6 mg (Nitrostat) 1

Page 46 of 152

2020


SF = Split Fill

47




nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 90

REDUCTORES DEL COLESTEROLatorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30

days), 90atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30



days), 90cholestyramine light powder packets 4 gm 1 90cholestyramine light powder 4 gm/dose (Questran light) 1 90cholestyramine powder packets 4 gm (Questran) 1 90cholestyramine powder 4 gm/dose (Questran) 1 90choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 1 QL (60 capsules/30

days), 90colestipol hcl granule packets 5 gm (Colestid flavored) 1 90colestipol hcl granules 5 gm (Colestid flavored) 1 90colestipol hcl tab 1 gm (Colestid) 1 90fenofibrate micronized cap 43 mg 1 QL (60 capsules/30

days), 90fenofibrate micronized cap 67 mg 1 QL (30 capsules/30



days), 90fenofibrate tab 48 mg (Tricor) 1 QL (60 tablets/30

days), 90fenofibrate tab 54 mg 1 QL (60 tablets/30

days), 90fenofibrate tab 145 mg (Tricor) 1 QL (30 tablets/30

days), 90

Page 47 of 152

2020


SF = Split Fill

48




fenofibrate tab 160 mg 1 QL (30 tablets/30days), 90

fluvastatin sodium tab er 24 hr 80 mg (base equivalent) (Lescolxl)


gemfibrozil tab 600 mg (Lopid) 1 QL (60 tablets/30days), 90

JUXTAPID – lomitapide mesylate cap 5 mg (base equiv) 2 PA, QL (30 capsules/30days), SP






lovastatin tab 10 mg 1 QL (60 tablets/30days), 90



pravastatin sodium tab 10 mg 1 QL (45 tablets/30days), 90

pravastatin sodium tab 20 mg (Pravachol) 1 QL (45 tablets/30days), 90

pravastatin sodium tab 40 mg (Pravachol) 1 QL (45 tablets/30days), 90

pravastatin sodium tab 80 mg 1 QL (30 tablets/30days), 90

REPATHA – evolocumab subcutaneous soln prefilled syringe140 mg/ml

2 PA, QL (2 syringes/28days), SP

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml

2 PA, QL (1 syringe/30days), SP

REPATHA SURECLICK – evolocumab subcutaneous soln auto-injector 140 mg/ml


Page 48 of 152

2020


SF = Split Fill

49




rosuvastatin calcium tab 5 mg (Crestor) 1 QL (30 tablets/30days), 90




simvastatin tab 5 mg 1 QL (30 tablets/30days), 90

simvastatin tab 10 mg (Zocor) 1 QL (30 tablets/30days), 90




RETENCIÓN DE LÍQUIDOS (EDEMA)acetazolamide cap er 12hr 500 mg 1 90acetazolamide tab 125 mg 1 90acetazolamide tab 250 mg 1 90amiloride & hydrochlorothiazide tab 5-50 mg 1 90amiloride hcl tab 5 mg 1 90bumetanide tab 0.5 mg (Bumex) 1 90bumetanide tab 1 mg (Bumex) 1 90bumetanide tab 2 mg (Bumex) 1 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg 2 90CHLOROTHIAZIDE – chlorothiazide tab 500 mg 2 90chlorthalidone tab 25 mg 1 90chlorthalidone tab 50 mg 1 90furosemide oral soln 10 mg/ml 1 90furosemide tab 20 mg (Lasix) 1 90furosemide tab 40 mg (Lasix) 1 90furosemide tab 80 mg (Lasix) 1 90hydrochlorothiazide cap 12.5 mg 1 90hydrochlorothiazide tab 12.5 mg 1 90

Page 49 of 152

2020


SF = Split Fill

50




hydrochlorothiazide tab 25 mg 1 90hydrochlorothiazide tab 50 mg 1 90indapamide tab 1.25 mg 1 90indapamide tab 2.5 mg 1 90metolazone tab 2.5 mg 1 90metolazone tab 5 mg 1 90metolazone tab 10 mg 1 90spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 1 90spironolactone tab 25 mg (Aldactone) 1 90spironolactone tab 50 mg (Aldactone) 1 90spironolactone tab 100 mg (Aldactone) 1 90torsemide tab 5 mg 1 90torsemide tab 10 mg 1 90torsemide tab 20 mg 1 90torsemide tab 100 mg 1 90triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 90triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 90triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 90

RITMO CARDÍACOamiodarone hcl tab 200 mg 1 90disopyramide phosphate cap 100 mg (Norpace) 1 90disopyramide phosphate cap 150 mg (Norpace) 1 90dofetilide cap 125 mcg (0.125 mg) (Tikosyn) 1dofetilide cap 250 mcg (0.25 mg) (Tikosyn) 1dofetilide cap 500 mcg (0.5 mg) (Tikosyn) 1flecainide acetate tab 50 mg 1 90flecainide acetate tab 100 mg 1 90flecainide acetate tab 150 mg 1 90propafenone hcl tab 150 mg 1 90propafenone hcl tab 225 mg 1 90propafenone hcl tab 300 mg 1 90quinidine gluconate tab er 324 mg 1 90QUINIDINE SULFATE – quinidine sulfate tab 200 mg 2 90QUINIDINE SULFATE – quinidine sulfate tab 300 mg 2 90sotalol hcl (afib/afl) tab 80 mg (Betapace af) 1 90

Page 50 of 152

2020


SF = Split Fill

51




sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 90sotalol hcl tab 80 mg (Betapace) 1 90sotalol hcl tab 120 mg (Betapace) 1 90sotalol hcl tab 160 mg (Betapace) 1 90sotalol hcl tab 240 mg 1 90

OTROS MEDICAMENTOS RELACIONADOS AL CORAZÓNADEMPAS – riociguat tab 0.5 mg 2 PA, QL (90 tablets/30

days), SPADEMPAS – riociguat tab 1 mg 2 PA, QL (90 tablets/30

days), SPADEMPAS – riociguat tab 1.5 mg 2 PA, QL (90 tablets/30

days), SPADEMPAS – riociguat tab 2 mg 2 PA, QL (90 tablets/30

days), SPADEMPAS – riociguat tab 2.5 mg 2 PA, QL (90 tablets/30

days), SPambrisentan tab 5 mg (Letairis) 2 PA, QL (30 tablets/30

days), SPambrisentan tab 10 mg (Letairis) 2 PA, QL (30 tablets/30

days), SPbosentan tab 62.5 mg (Tracleer) 2 PA, QL (60 tablets/30

days), SPbosentan tab 125 mg (Tracleer) 2 PA, QL (60 tablets/30

days), SPclonidine hcl tab 0.1 mg (Catapres) 1 90clonidine hcl tab 0.2 mg (Catapres) 1 90clonidine hcl tab 0.3 mg (Catapres) 1 90clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1) 1clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1DIGOXIN – digoxin oral soln 0.05 mg/ml 2 90digoxin oral soln 0.05 mg/ml (Digoxin) 1 90digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 90digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 90doxazosin mesylate tab 1 mg (Cardura) 1 QL (30 tablets/30

days), 90

Page 51 of 152

2020


SF = Split Fill

52




doxazosin mesylate tab 2 mg (Cardura) 1 QL (30 tablets/30days), 90



guanfacine hcl tab 1 mg 1 90guanfacine hcl tab 2 mg 1 90hydralazine hcl tab 10 mg 1 90hydralazine hcl tab 25 mg 1 90hydralazine hcl tab 50 mg 1 90hydralazine hcl tab 100 mg 1 90methyldopa tab 250 mg 1 90methyldopa tab 500 mg 1 90midodrine hcl tab 2.5 mg 1midodrine hcl tab 5 mg 1midodrine hcl tab 10 mg 1minoxidil tab 2.5 mg 1 90minoxidil tab 10 mg 1 90ORENITRAM – treprostinil diolamine tab er 0.125 mg (base

equiv)2 PA, QL (300

tablets/30 days), SPORENITRAM – treprostinil diolamine tab er 0.25 mg (base equiv) 2 PA, QL (300

tablets/30 days), SPORENITRAM – treprostinil diolamine tab er 1 mg (base equiv) 2 PA, QL (300

tablets/30 days), SPORENITRAM – treprostinil diolamine tab er 2.5 mg (base equiv) 2 PA, QL (300

tablets/30 days), SPphenoxybenzamine hcl cap 10 mg (Dibenzyline) 1prazosin hcl cap 1 mg (Minipress) 1 90prazosin hcl cap 2 mg (Minipress) 1 90prazosin hcl cap 5 mg (Minipress) 1 90sildenafil citrate for suspension 10 mg/ml (Revatio) 2 PA, QL (2 bottles/30

days), SPsildenafil citrate tab 20 mg (Revatio) 1 PA, QL (90 tablets/30

days), SPsildenafil citrate tab 20 mg (Revatio) 1 PA, QL (90 tablets/30

days), SP

Page 52 of 152

2020


SF = Split Fill

53




tadalafil tab 20 mg (pah) (Adcirca) 2 PA, QL (60 tablets/30days), SP

terazosin hcl cap 1 mg (base equivalent) 1 QL (30 capsules/30days), 90




TRACLEER – bosentan tab for oral susp 32 mg 2 PA, QL (120tablets/30 days), SP

TYVASO – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2mls/28 days), SP

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2mls/28 days), SP

TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (1 kit/180days), SP

UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60)

2 PA, QL (200tablets/180 days), SP

UPTRAVI – selexipag tab 200 mcg 2 PA, QL (60 tablets/30days), SP

UPTRAVI – selexipag tab 200 mcg 2 PA, QL (140tablets/180 days), SP

UPTRAVI – selexipag tab 200 mcg 2 SPUPTRAVI – selexipag tab 400 mcg 2 PA, QL (60 tablets/30

days), SPUPTRAVI – selexipag tab 600 mcg 2 PA, QL (60 tablets/30






days), SP

Page 53 of 152

2020


SF = Split Fill

54




VYNDAQEL – tafamidis meglumine (cardiac) cap 20 mg 2 PA, QL (120capsules/30 days), SP

ANAFILAXIAepinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)

(Epipen-jr 2-pak)1 QL (4 pens/1

prescription)epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen

2-pak)1 QL (4 pens/1

prescription)

AGENTES RESPIRATORIOSANTIHISTAMINASCARBINOXAMINE MALEATE – carbinoxamine maleate soln

4 mg/5ml2

carbinoxamine maleate tab 4 mg 1cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1cyproheptadine hcl syrup 2 mg/5ml 1cyproheptadine hcl tab 4 mg 1desloratadine tab 5 mg (Clarinex) 1diphenhydramine hcl cap 50 mg 1levocetirizine dihydrochloride tab 5 mg 1promethazine hcl suppos 12.5 mg 1promethazine hcl suppos 25 mg 1promethazine hcl syrup 6.25 mg/5ml 1promethazine hcl tab 12.5 mg 1promethazine hcl tab 25 mg 1promethazine hcl tab 50 mg 1

PRODUCTOS NASALESazelastine hcl nasal spray 0.1% (137 mcg/spray) 1 QL (2 bottles/30 days)FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/act 1 QL (1 bottle/30 days)ipratropium bromide nasal soln 0.03% (21 mcg/spray) 1 QL (2 bottles/30 days), 90ipratropium bromide nasal soln 0.06% (42 mcg/spray) 1 QL (3 bottles/30 days), 90triamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 QL (1 bottle/30 days)

TOS/RESFRÍO/ALERGIAacetylcysteine inhal soln 10% 1acetylcysteine inhal soln 20% 1promethazine w/ codeine syrup 6.25-10 mg/5ml 1 ME90

Page 54 of 152

2020


SF = Split Fill

55




sodium chloride soln nebu 0.9% 1sodium chloride soln nebu 3% 1sodium chloride soln nebu 7% (Hyper-sal) 1sodium chloride soln nebu 10% 1

ASMA/ENFERMEDAD PULMONAR OBSTRUCTIVA CRÓNICA (EPOC)ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 4 mg 2 90ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 8 mg 2 90ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero

108 mcg/act (90mcg base equiv)2 QL (3 inhalers/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 QL (125containers/30 days)

albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 QL (60 mls/30 days)albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 QL (125

containers/30 days)albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 QL (125

containers/30 days)albuterol sulfate syrup 2 mg/5ml 1albuterol sulfate tab 2 mg 1albuterol sulfate tab 4 mg 1ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 50 mcg/act2 QL (30 blisters/30

days), 90ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath


days), 90ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath


days), 90ATROVENT HFA – ipratropium bromide hfa inhal aerosol

17 mcg/act2 QL (2 inhalers/30

days), 90BEVESPI AEROSPHERE – glycopyrrolate-formoterol fumarate

aerosol 9-4.8 mcg/act2 QL (1 inhaler/30

days), 90budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 QL (2 packages/30

days), 90budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 1 QL (2 packages/30

days), 90budesonide inhalation susp 1 mg/2ml (Pulmicort) 1 QL (60 mls/30 days), 90COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act2 QL (2 inhalers/30

days), 90cromolyn sodium soln nebu 20 mg/2ml 1 QL (240 mls/30 days), 90

Page 55 of 152

2020


SF = Split Fill

56




dyphylline-guaifenesin liqd 100-100 mg/5ml 1FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/

blister2 AL, QL (1 inhaler/30

days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba

100 mcg/blister2 AL, QL (1 inhaler/30

days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba

250 mcg/blister2 AL, QL (4 inhalers/30

days), 90FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/

act (50/valve)2 AL, QL (1 inhaler/30

days), 90FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/

act (125/valve)2 AL, QL (1 inhaler/30

days), 90FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/

act (250/valve)2 AL, QL (2 inhalers/30

days), 90FLUTICASONE PROPIONATE/SALMETEROL – fluticasone-

salmeterol aer powder ba 55-14 mcg/act2 QL (1 inhaler/30





days), 90INCRUSE ELLIPTA – umeclidinium br aero powd breath act

62.5 mcg/inh (base eq)2 QL (30 blisters/30

days), 90ipratropium bromide inhal soln 0.02% 1 QL (125 cartridges/30

days), 90ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 1 QL (180 containers/30

days), 90montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 QL (30 tablets/30

days), 90montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 QL (30 tablets/30

days), 90montelukast sodium oral granules packet 4 mg (base equiv)

(Singulair)1 QL (30 packets/30

days), 90montelukast sodium tab 10 mg (base equiv) (Singulair) 1 QL (30 tablets/30

days), 90QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 40 mcg/act2 AL, QL (1 inhaler/30

days), 90QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 80 mcg/act2 AL, QL (2 inhalers/30

days), 90STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln

2.5 mcg/act (base equiv)2 QL (1 inhaler/30

days), 90

Page 56 of 152

2020


SF = Split Fill

57




SYMBICORT – budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act

2 AL, QL (1 inhaler/30days), 90

SYMBICORT – budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act

2 AL, QL (1 inhaler/30days), 90

terbutaline sulfate tab 2.5 mg 1 90terbutaline sulfate tab 5 mg 1 90THEOPHYLLINE ER – theophylline tab er 12hr 300 mg 2 90THEOPHYLLINE ER – theophylline tab er 12hr 450 mg 2 90theophylline soln 80 mg/15ml 1 90theophylline tab er 24hr 400 mg 1 90theophylline tab er 24hr 600 mg 1 90

OTHER RESPIRATORY DRUGSESBRIET – pirfenidone cap 267 mg 2 PA, QL (180

capsules/30 days), SPKALYDECO – ivacaftor tab 150 mg 2 PA, QL (60 tablets/30

days), SPKALYDECO – ivacaftor packet 25 mg 2 PA, QL (60 packets/30



days), SPOFEV – nintedanib esylate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30

days), SPOFEV – nintedanib esylate cap 150 mg (base equivalent) 2 PA, QL (60 capsules/30

days), SPORKAMBI – lumacaftor-ivacaftor tab 100-125 mg 2 PA, QL (120

tablets/30 days), SPORKAMBI – lumacaftor-ivacaftor tab 200-125 mg 2 PA, QL (120

tablets/30 days), SPORKAMBI – lumacaftor-ivacaftor granules packet 100-125 mg 2 PA, QL (60 packets/30

days), SPORKAMBI – lumacaftor-ivacaftor granules packet 150-188 mg 2 PA, QL (60 packets/30

days), SPPULMOZYME – dornase alfa inhal soln 1 mg/ml 2 PA, SPSYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab

tbpk2 PA, QL (60 tablets/30

days), SP

Page 57 of 152

2020


SF = Split Fill

58




SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


TRIKAFTA – elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor150 mg tbpk


MEDICAMENTOS GENITOURINARIOSLAXANTESbisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 1GAVILYTE-C – peg 3350-kcl-na bicarb-nacl-na sulfate for soln

240 gm2

lactulose solution 10 gm/15ml 1 90peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor

pack)1

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1

ANTIDIARRHEALSdiphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1loperamide hcl cap 2 mg 1

ÚLCERA/ENFERMEDAD POR REFLUJO GASTROESOFÁGICO (ERGE)CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml 2 90dicyclomine hcl cap 10 mg 1dicyclomine hcl oral soln 10 mg/5ml 1dicyclomine hcl tab 20 mg 1famotidine for susp 40 mg/5ml 1 90famotidine tab 20 mg (Pepcid) 1 90famotidine tab 40 mg (Pepcid) 1 90glycopyrrolate tab 1 mg 1glycopyrrolate tab 2 mg 1hyoscyamine sulfate elixir 0.125 mg/5ml 1 90hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl) 1 90hyoscyamine sulfate soln 0.125 mg/ml 1 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) 1 90hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) 1 90hyoscyamine sulfate tab 0.125 mg (Levsin) 1 90lansoprazole cap delayed release 15 mg (Prevacid) 1 QL (120 days

supply/365 days)lansoprazole cap delayed release 30 mg (Prevacid) 1 QL (120 days

supply/365 days)

Page 58 of 152

2020


SF = Split Fill

59




METHSCOPOLAMINE BROMIDE – methscopolamine bromidetab 2.5 mg

2

misoprostol tab 100 mcg (Cytotec) 1 90misoprostol tab 200 mcg (Cytotec) 1 90nizatidine cap 150 mg 1 90nizatidine cap 300 mg 1 90omeprazole cap delayed release 10 mg 1 QL (120 days

supply/365 days)omeprazole cap delayed release 20 mg 1 QL (120 days

supply/365 days)omeprazole cap delayed release 40 mg 1 QL (120 days

supply/365 days)pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 QL (120 days

supply/365 days)pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 QL (120 days

supply/365 days)rabeprazole sodium ec tab 20 mg (Aciphex) 1 QL (120 days

supply/365 days)ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 90ranitidine hcl tab 150 mg 1 90ranitidine hcl tab 300 mg 1 90sucralfate tab 1 gm (Carafate) 1 90

NÁUSEA Y VÓMITOSaprepitant capsule 40 mg (Emend) 1 QL (2 capsules/30 days)aprepitant capsule 80 mg (Emend) 1 QL (6 capsules/30 days)aprepitant capsule 125 mg (Emend) 1 QL (3 capsules/30 days)meclizine hcl tab 12.5 mg 1meclizine hcl tab 25 mg 1ONDANSETRON HCL – ondansetron hcl tab 24 mg 2 QL (1 tablet/30 days)ondansetron hcl oral soln 4 mg/5ml 1 QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron orally disintegrating tab 4 mg 1 QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg 1 QL (30 tablets/30 days)trimethobenzamide hcl cap 300 mg (Tigan) 1

ENZIMAS DIGESTIVAS -

Page 59 of 152

2020


SF = Split Fill

60




CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000unit

2 90

CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000unit

2 90

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit

2 90


2 90


2 90

SUCRAID – sacrosidase soln 8500 unit/ml 2 PA, QL (1 box/28days), SP

OTROS MEDICAMENTOS GASTROINTESTINALESalosetron hcl tab 0.5 mg (base equiv) (Lotronex) 1 PA, QL (60

tablets/30 days)alosetron hcl tab 1 mg (base equiv) (Lotronex) 1 PA, QL (60

tablets/30 days)balsalazide disodium cap 750 mg (Colazal) 1calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 1 90calcium acetate (phosphate binder) tab 667 mg 1 90CHENODAL – chenodiol tab 250 mg 2 PA, SPCHOLBAM – cholic acid cap 50 mg 2 SPCHOLBAM – cholic acid cap 250 mg 2 SPCIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml 2 PA, QL (2 kits/28

days), SPCIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml 2 PA, QL (1 kit/180

days), SPGATTEX – teduglutide (rdna) for inj kit 5 mg 2 PA, SPlactulose (encephalopathy) solution 10 gm/15ml 1 90lanthanum carbonate chew tab 500 mg (elemental) (Fosrenol) 1 90lanthanum carbonate chew tab 750 mg (elemental) (Fosrenol) 1 90lanthanum carbonate chew tab 1000 mg (elemental) (Fosrenol) 1 90mesalamine cap er 24hr 0.375 gm (Apriso) 1 90mesalamine enema 4 gm 1mesalamine suppos 1000 mg (Canasa) 1mesalamine tab delayed release 800 mg (Asacol hd) 1metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 1metoclopramide hcl tab 5 mg (base equivalent) (Reglan) 1

Page 60 of 152

2020


SF = Split Fill

61




metoclopramide hcl tab 10 mg (base equivalent) (Reglan) 1OCALIVA – obeticholic acid tab 5 mg 2 PA, QL (30 tablets/30

days), SPOCALIVA – obeticholic acid tab 10 mg 2 PA, QL (30 tablets/30

days), SPsevelamer carbonate packet 0.8 gm (Renvela) 1 90sevelamer carbonate packet 2.4 gm (Renvela) 1 90sevelamer carbonate tab 800 mg (Renvela) 1 90sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1 90sulfasalazine tab 500 mg (Azulfidine) 1 90ursodiol cap 300 mg (Actigall) 1 90ursodiol tab 250 mg (Urso 250) 1 90ursodiol tab 500 mg (Urso forte) 1 90

GENITOURINARY DRUGSINFECCIONES DEL TRACTO URINARIOnitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid)1

ESPASMOS EN EL TRACTO URINARIObethanechol chloride tab 5 mg (Urecholine) 1bethanechol chloride tab 10 mg (Urecholine) 1bethanechol chloride tab 25 mg (Urecholine) 1bethanechol chloride tab 50 mg (Urecholine) 1darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)

(Enablex)1 QL (30 tablets/30

days), 90darifenacin hydrobromide tab er 24hr 15 mg (base equiv)

(Enablex)1 QL (30 tablets/30

days), 90oxybutynin chloride syrup 5 mg/5ml 1 QL (600 mls/30 days), 90oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 QL (30 tablets/30

days), 90oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 QL (60 tablets/30

days), 90oxybutynin chloride tab er 24hr 15 mg 1 QL (60 tablets/30

days), 90

Page 61 of 152

2020


SF = Split Fill

62




oxybutynin chloride tab 5 mg 1 QL (120 tablets/30days), 90

tolterodine tartrate tab 2 mg (Detrol) 1 QL (60 tablets/30days), 90

trospium chloride cap er 24hr 60 mg 1 QL (30 capsules/30days), 90

trospium chloride tab 20 mg 1 QL (60 tablets/30days), 90

PRODUCTOS VAGINALESclindamycin phosphate vaginal cream 2% (Cleocin) 1estradiol vaginal cream 0.1 mg/gm (Estrace) 1estradiol vaginal tab 10 mcg (Vagifem) 1 90metronidazole vaginal gel 0.75% 1TERCONAZOLE – terconazole vaginal cream 0.8% 2terconazole vaginal cream 0.4% 1terconazole vaginal suppos 80 mg 1

OTROS MEDICAMENTOS GENITOURINARIOSalfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 QL (30 tablets/30

days), 90CYSTAGON – cysteamine bitartrate cap 50 mg 2 PA, SPCYSTAGON – cysteamine bitartrate cap 150 mg 2 PA, SPdutasteride cap 0.5 mg (Avodart) 1 QL (30 capsules/30

days), 90dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 1 QL (30 capsules/30

days), 90finasteride tab 5 mg (Proscar) 1 QL (30 tablets/30

days), 90phenazopyridine hcl tab 100 mg (Pyridium) 1phenazopyridine hcl tab 200 mg (Pyridium) 1pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1potassium citrate & citric acid powder pack 3300-1002 mg 1potassium citrate & citric acid soln 1100-334 mg/5ml 1potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 1potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 1sodium chloride irrigation soln 0.9% 1

Page 62 of 152

2020


SF = Split Fill

63




sodium citrate & citric acid soln 500-334 mg/5ml 1tamsulosin hcl cap 0.4 mg (Flomax) 1 QL (60 capsules/30

days), 90

MEDICAMENTOS PARA EL SISTEMA NERVIOSO CENTRALANSIEDADALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml 2 QL (180 mls/30 days)alprazolam tab er 24hr 0.5 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 1 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 2 mg (Xanax xr) 1 QL (90 tablets/30 days)alprazolam tab er 24hr 3 mg (Xanax xr) 1 QL (60 tablets/30 days)alprazolam tab 0.25 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 2 mg (Xanax) 1 QL (90 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1chlordiazepoxide hcl cap 5 mg 1 QL (120

capsules/30 days)chlordiazepoxide hcl cap 10 mg 1 QL (120

capsules/30 days)chlordiazepoxide hcl cap 25 mg 1 QL (120

capsules/30 days)clorazepate dipotassium tab 3.75 mg 1 QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 1 QL (120 tablets/30 days)DIAZEPAM – diazepam oral soln 1 mg/ml 2 QL (1200 mls/30 days)diazepam conc 5 mg/ml 1 QL (240 mls/30 days)diazepam tab 2 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 5 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 10 mg (Valium) 1 QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml 1hydroxyzine hcl tab 10 mg 1hydroxyzine hcl tab 25 mg 1hydroxyzine hcl tab 50 mg 1

Page 63 of 152

2020


SF = Split Fill

64




hydroxyzine pamoate cap 25 mg (Vistaril) 1hydroxyzine pamoate cap 50 mg (Vistaril) 1lorazepam conc 2 mg/ml 1 QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) 1 QL (150 tablets/30 days)

DEPRESIÓNamitriptyline hcl tab 10 mg 1 90amitriptyline hcl tab 25 mg 1 90amitriptyline hcl tab 50 mg 1 90amitriptyline hcl tab 75 mg 1 90amitriptyline hcl tab 100 mg 1 90amitriptyline hcl tab 150 mg 1 90APLENZIN – bupropion hbr tab er 24hr 174 mg 2 PA, QL (30 tablets/30

days), 90APLENZIN – bupropion hbr tab er 24hr 348 mg 2 PA, QL (30 tablets/30

days), 90APLENZIN – bupropion hbr tab er 24hr 522 mg 2 PA, QL (30 tablets/30

days), 90bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 QL (60 tablets/30



days), 90bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) 1 QL (30 tablets/30

days), 90bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) 1 QL (30 tablets/30

days), 90bupropion hcl tab 75 mg 1 QL (60 tablets/30

days), 90bupropion hcl tab 100 mg 1 QL (120 tablets/30

days), 90BUPROPION HYDROCHLORIDE ER – bupropion hcl tab er 24hr

450 mg2 PA, QL (30 tablets/30

days), 90citalopram hydrobromide oral soln 10 mg/5ml 1 QL (600 mls/30 days), 90

Page 64 of 152

2020


SF = Split Fill

65




citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 QL (30 tablets/30days), 90



desipramine hcl tab 10 mg (Norpramin) 1 90desipramine hcl tab 25 mg (Norpramin) 1 90desipramine hcl tab 50 mg 1 90desipramine hcl tab 75 mg 1 90desipramine hcl tab 100 mg 1 90desipramine hcl tab 150 mg 1 90DOXEPIN HCL – doxepin hcl cap 150 mg 2 90doxepin hcl cap 10 mg 1 90doxepin hcl cap 25 mg 1 90doxepin hcl cap 50 mg 1 90doxepin hcl cap 75 mg 1 90doxepin hcl cap 100 mg 1 90doxepin hcl conc 10 mg/ml 1 90duloxetine hcl enteric coated pellets cap 20 mg (base eq)

(Cymbalta)1 QL (60 capsules/30

days), 90duloxetine hcl enteric coated pellets cap 30 mg (base eq)


days), 90duloxetine hcl enteric coated pellets cap 60 mg (base eq)


days), 90EMSAM – selegiline td patch 24hr 6 mg/24hr 2 PA, 90EMSAM – selegiline td patch 24hr 9 mg/24hr 2 PA, 90EMSAM – selegiline td patch 24hr 12 mg/24hr 2 PA, 90escitalopram oxalate soln 5 mg/5ml (base equiv) 1 QL (600 mls/30 days), 90escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base

equivalent)2 PA, QL (30 capsules/30

days), 90

Page 65 of 152

2020


SF = Split Fill

66




FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent)

2 PA, QL (30 capsules/30days), 90





FETZIMA TITRATION PACK – levomilnacipran hcl cap er 24hr20 & 40 mg therapy pack

2 PA, QL (28capsules/180 days)

fluoxetine hcl cap 10 mg (Prozac) 1 QL (30 capsules/30days), 90



fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days), 90fluoxetine hcl tab 10 mg 1 QL (30 tablets/30

days), 90fluoxetine hcl tab 20 mg 1 QL (120 tablets/30

days), 90fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30



days), 90FORFIVO XL – bupropion hcl tab er 24hr 450 mg 2 PA, QL (30 tablets/30

days), 90imipramine hcl tab 10 mg (Tofranil) 1 90imipramine hcl tab 25 mg (Tofranil) 1 90imipramine hcl tab 50 mg (Tofranil) 1 90MAPROTILINE HCL – maprotiline hcl tab 25 mg 2 PA, QL (90 tablets/30

days), 90MAPROTILINE HCL – maprotiline hcl tab 50 mg 2 PA, QL (90 tablets/30

days), 90MAPROTILINE HCL – maprotiline hcl tab 75 mg 2 PA, QL (90 tablets/30

days), 90MARPLAN – isocarboxazid tab 10 mg 2 PA, 90

Page 66 of 152

2020


SF = Split Fill

67




mirtazapine tab 15 mg (Remeron) 1 QL (30 tablets/30days), 90

mirtazapine tab 30 mg (Remeron) 1 QL (30 tablets/30days), 90

mirtazapine tab 45 mg 1 QL (30 tablets/30days), 90

nortriptyline hcl cap 10 mg (Pamelor) 1 90nortriptyline hcl cap 25 mg (Pamelor) 1 90nortriptyline hcl cap 50 mg (Pamelor) 1 90nortriptyline hcl cap 75 mg (Pamelor) 1 90paroxetine hcl tab 10 mg (Paxil) 1 QL (30 tablets/30

days), 90paroxetine hcl tab 20 mg (Paxil) 1 QL (30 tablets/30



days), 90PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) 2 PA, QL (900

mls/30 days), 90PEXEVA – paroxetine mesylate tab 10 mg (base equiv) 2 PA, QL (30 tablets/30

days), 90PEXEVA – paroxetine mesylate tab 20 mg (base equiv) 2 PA, QL (30 tablets/30



days), 90sertraline hcl oral concentrate for solution 20 mg/ml 1 QL (300 mls/30 days), 90sertraline hcl tab 25 mg (Zoloft) 1 QL (30 tablets/30

days), 90sertraline hcl tab 50 mg (Zoloft) 1 QL (30 tablets/30

days), 90sertraline hcl tab 100 mg (Zoloft) 1 QL (60 tablets/30

days), 90trazodone hcl tab 50 mg 1 90trazodone hcl tab 100 mg 1 90trazodone hcl tab 150 mg 1 90

Page 67 of 152

2020


SF = Split Fill

68




venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexorxr)

1 QL (30 capsules/30days), 90

venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) 1 QL (90 capsules/30days), 90

venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) 1 QL (30 capsules/30days), 90

venlafaxine hcl tab 25 mg (base equivalent) 1 QL (90 tablets/30days), 90

venlafaxine hcl tab 37.5 mg (base equivalent) 1 QL (90 tablets/30days), 90




VIIBRYD – vilazodone hcl tab 10 mg 2 PA, QL (30 tablets/30days), 90



VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7)& 20 (23) mg

2 PA, QL (30tablets/180 days)

TRASTORNOS PSICÓTICOS Y BIPOLARESABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 300 mg2 PA, QL (1

syringe/28 days)ABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 400 mg2 PA, QL (1

syringe/28 days)ABILIFY MAINTENA – aripiprazole im for extended release susp

300 mg2 PA, QL (1

syringe/28 days)ABILIFY MAINTENA – aripiprazole im for extended release susp

400 mg2 PA, QL (1

syringe/28 days)ADASUVE – loxapine aerosol powder breath activated 10 mg 2 PAaripiprazole oral solution 1 mg/ml 1 PA, QL (150

mls/30 days), 90aripiprazole orally disintegrating tab 10 mg 1 AL, QL (30 tablets/30

days), 90

Page 68 of 152

2020


SF = Split Fill

69




aripiprazole orally disintegrating tab 15 mg 1 AL, QL (30 tablets/30days), 90

aripiprazole tab 2 mg (Abilify) 1 AL, QL (30 tablets/30days), 90






ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml

2 PA, QL (1syringe/28 days)







ARISTADA INITIO – aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml

2 PA, QL (1 kit/180 days)

CHLORPROMAZINE HCL – chlorpromazine hcl inj 25 mg/ml 2 PACHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml 2 PAchlorpromazine hcl tab 10 mg 1 PA, 90chlorpromazine hcl tab 25 mg 1 PA, 90chlorpromazine hcl tab 50 mg 1 PA, 90chlorpromazine hcl tab 100 mg 1 PA, 90chlorpromazine hcl tab 200 mg 1 PA, 90CLOZAPINE ODT – clozapine orally disintegrating tab 12.5 mg 2 PA, QL (60

tablets/30 days)CLOZAPINE ODT – clozapine orally disintegrating tab 150 mg 2 PA, QL (60

tablets/30 days)CLOZAPINE ODT – clozapine orally disintegrating tab 200 mg 2 PA, QL (120

tablets/30 days)

Page 69 of 152

2020


SF = Split Fill

70




clozapine orally disintegrating tab 25 mg (Fazaclo) 1 PA, QL (60tablets/30 days)

clozapine orally disintegrating tab 100 mg (Fazaclo) 1 PA, QL (60tablets/30 days)

clozapine tab 25 mg (Clozaril) 1 AL, QL (90tablets/30 days)

clozapine tab 50 mg (Clozapine) 1 AL, QL (90tablets/30 days)

clozapine tab 100 mg (Clozaril) 1 AL, QL (270tablets/30 days)

clozapine tab 200 mg (Clozapine) 1 AL, QL (120tablets/30 days)

EQUETRO – carbamazepine (antipsychotic) cap er 12hr 100 mg 2 PA, 90EQUETRO – carbamazepine (antipsychotic) cap er 12hr 200 mg 2 PA, 90EQUETRO – carbamazepine (antipsychotic) cap er 12hr 300 mg 2 PA, 90FANAPT – iloperidone tab 1 mg 2 PA, QL (60 tablets/30

days), 90FANAPT – iloperidone tab 2 mg 2 PA, QL (60 tablets/30






days), 90FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg &

4 mg & 6 mg titration pak2 PA, QL (8

tablets/180 days)FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml 2 PA, 90FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl tab 1 mg 2 90FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg 2 90FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg 2 90FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg 2 90

Page 70 of 152

2020


SF = Split Fill

71




FLUPHENAZINE HYDROCHLORIDE – fluphenazine hcl elixir2.5 mg/5ml

2 PA, 90

GEODON – ziprasidone mesylate for inj 20 mg (base equivalent) 2 PA, QL (60 vials/30 days)haloperidol lactate oral conc 2 mg/ml 1 AL, 90haloperidol tab 0.5 mg 1 AL, 90haloperidol tab 1 mg 1 AL, 90haloperidol tab 2 mg 1 AL, 90haloperidol tab 5 mg 1 AL, 90haloperidol tab 10 mg 1 AL, 90haloperidol tab 20 mg 1 AL, 90INVEGA – paliperidone tab er 24hr 1.5 mg 2 PA, QL (30 tablets/30

days), 90INVEGA – paliperidone tab er 24hr 3 mg 2 PA, QL (30 tablets/30



days), 90INVEGA SUSTENNA – paliperidone palmitate er susp pref syr

39 mg/0.25ml2 PA, QL (1 kit/28 days)

INVEGA SUSTENNA – paliperidone palmitate er susp pref syr78 mg/0.5ml




INVEGA SUSTENNA – paliperidone palmitate er susp pref syr156 mg/ml




INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml








LATUDA – lurasidone hcl tab 20 mg 2 PA, QL (30 tablets/30days), 90

Page 71 of 152

2020


SF = Split Fill

72








LITHIUM – lithium oral solution 8 meq/5ml 2 PA, 90lithium carbonate cap 150 mg (Lithium carbonate) 1 90lithium carbonate cap 300 mg 1 90lithium carbonate cap 600 mg (Lithium carbonate) 1 90lithium carbonate tab er 300 mg (Lithobid) 1 90lithium carbonate tab er 450 mg 1 90lithium carbonate tab 300 mg 1 90loxapine succinate cap 5 mg 1 AL, 90loxapine succinate cap 10 mg 1 AL, 90loxapine succinate cap 25 mg 1 AL, 90loxapine succinate cap 50 mg 1 AL, 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg 2 AL, 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg 2 AL, 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg 2 AL, 90olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30

days), 90olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30



days), 90olanzapine tab 2.5 mg (Zyprexa) 1 AL, QL (30 tablets/30

days), 90olanzapine tab 5 mg (Zyprexa) 1 AL, QL (30 tablets/30

days), 90olanzapine tab 7.5 mg (Zyprexa) 1 AL, QL (30 tablets/30

days), 90

Page 72 of 152

2020


SF = Split Fill

73




olanzapine tab 10 mg (Zyprexa) 1 AL, QL (30 tablets/30days), 90



paliperidone tab er 24hr 1.5 mg (Invega) 1 PA, QL (30 tablets/30days), 90

paliperidone tab er 24hr 3 mg (Invega) 1 PA, QL (30 tablets/30days), 90



perphenazine tab 2 mg 1 AL, 90perphenazine tab 4 mg 1 AL, 90perphenazine tab 8 mg 1 AL, 90perphenazine tab 16 mg 1 AL, 90prochlorperazine maleate tab 5 mg (base equivalent) 1 AL, 90prochlorperazine maleate tab 10 mg (base equivalent) 1 AL, 90prochlorperazine suppos 25 mg 1 ALquetiapine fumarate tab er 24hr 50 mg (Seroquel xr) 1 PA, QL (60 tablets/30

days), 90quetiapine fumarate tab er 24hr 150 mg (Seroquel xr) 1 PA, QL (30 tablets/30




days), 90quetiapine fumarate tab 25 mg (Seroquel) 1 AL, QL (90 tablets/30



days), 90

Page 73 of 152

2020


SF = Split Fill

74




quetiapine fumarate tab 200 mg (Seroquel) 1 AL, QL (90 tablets/30days), 90



REXULTI – brexpiprazole tab 0.25 mg 2 PA, QL (30 tablets/30days), 90

REXULTI – brexpiprazole tab 0.5 mg 2 PA, QL (30 tablets/30days), 90

REXULTI – brexpiprazole tab 1 mg 2 PA, QL (30 tablets/30days), 90




RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 12.5 mg

2 PA, QL (2 vials/28 days)

RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 25 mg


RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 37.5 mg


RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 50 mg


RISPERIDONE ODT – risperidone orally disintegrating tab0.25 mg

2 AL, QL (60 tablets/30days), 90

risperidone orally disintegrating tab 0.5 mg 1 AL, QL (60 tablets/30days), 90

risperidone orally disintegrating tab 1 mg 1 AL, QL (60 tablets/30days), 90



risperidone orally disintegrating tab 4 mg 1 AL, QL (120tablets/30 days), 90

risperidone soln 1 mg/ml (Risperdal) 1 AL, QL (480mls/30 days), 90

Page 74 of 152

2020


SF = Split Fill

75




risperidone tab 0.25 mg 1 AL, QL (120tablets/30 days), 90

risperidone tab 0.5 mg (Risperdal) 1 AL, QL (120tablets/30 days), 90

risperidone tab 1 mg (Risperdal) 1 AL, QL (120tablets/30 days), 90


risperidone tab 3 mg (Risperdal) 1 AL, QL (60 tablets/30days), 90


SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv) 2 PA, QL (60 tablets/30days), 90

SAPHRIS – asenapine maleate sl tab 5 mg (base equiv) 2 PA, QL (60 tablets/30days), 90

SAPHRIS – asenapine maleate sl tab 10 mg (base equiv) 2 PA, QL (60 tablets/30days), 90

thiothixene cap 1 mg 1 AL, 90thiothixene cap 2 mg 1 AL, 90thiothixene cap 5 mg 1 AL, 90thiothixene cap 10 mg 1 AL, 90trifluoperazine hcl tab 1 mg (base equivalent) 1 AL, 90trifluoperazine hcl tab 2 mg (base equivalent) 1 AL, 90trifluoperazine hcl tab 5 mg (base equivalent) 1 AL, 90trifluoperazine hcl tab 10 mg (base equivalent) 1 AL, 90VERSACLOZ – clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)ziprasidone hcl cap 20 mg (Geodon) 1 AL, QL (60 capsules/30

days), 90ziprasidone hcl cap 40 mg (Geodon) 1 AL, QL (60 capsules/30



days), 90ZYPREXA RELPREVV – olanzapine pamoate for extended rel im

susp 210 mg (base eq)2 PA, QL (2 vials/28 days)

Page 75 of 152

2020


SF = Split Fill

76




ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 300 mg (base eq)


ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 405 mg (base eq)

2 PA, QL (1 vial/28 days)

SOMNÍFEROSDORAL – quazepam tab 15 mg 2 QL (30 tablets/30 days)estazolam tab 1 mg 1 QL (30 tablets/30 days)estazolam tab 2 mg 1 QL (30 tablets/30 days)eszopiclone tab 1 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) 1 QL (30 tablets/30 days)phenobarbital elixir 20 mg/5ml 1 90phenobarbital tab 15 mg 1 90phenobarbital tab 16.2 mg 1 90phenobarbital tab 30 mg 1 90phenobarbital tab 32.4 mg 1 90phenobarbital tab 60 mg 1 90phenobarbital tab 64.8 mg 1 90phenobarbital tab 97.2 mg 1 90phenobarbital tab 100 mg 1 90QUAZEPAM – quazepam tab 15 mg 2 QL (30 tablets/30 days)temazepam cap 15 mg (Restoril) 1 QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) 1 QL (30 capsules/30 days)zaleplon cap 5 mg 1 QL (30 capsules/30 days)zaleplon cap 10 mg 1 QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) 1 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) 1 QL (30 tablets/30 days)

HIPERACTIVIDAD/NARCOLEPSIAamphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) 1 AL, QL (30

capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)1 AL, QL (30


xr)1 AL, QL (30


xr)1 AL, QL (30

capsules/30 days)

Page 76 of 152

2020


SF = Split Fill

77




amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderallxr)

1 AL, QL (30capsules/30 days)

amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderallxr)

1 AL, QL (30capsules/30 days)

amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 AL, QL (60tablets/30 days)

amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 1 AL, QL (60tablets/30 days)


amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 1 AL, QL (60tablets/30 days)




armodafinil tab 50 mg (Nuvigil) 1 PA, QL (30 tablets/30days), 90




atomoxetine hcl cap 10 mg (base equiv) (Strattera) 1 AL, QL (60capsules/30 days)






Page 77 of 152

2020


SF = Split Fill

78





caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 1clonidine hcl tab er 12hr 0.1 mg (Kapvay) 1 QL (120 tablets/30

days), 90dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) 1 AL, QL (30

capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) 1 AL, QL (30







capsules/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 AL, QL (60

tablets/30 days)dexmethylphenidate hcl tab 5 mg (Focalin) 1 AL, QL (60

tablets/30 days)dexmethylphenidate hcl tab 10 mg (Focalin) 1 AL, QL (60

tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine) 1 AL, QL (90

capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine) 1 AL, QL (120

capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine) 1 AL, QL (120

capsules/30 days)dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 AL, QL (1800

mls/30 days)dextroamphetamine sulfate tab 5 mg 1 AL, QL (90

tablets/30 days)dextroamphetamine sulfate tab 10 mg 1 AL, QL (180

tablets/30 days)

Page 78 of 152

2020


SF = Split Fill

79




guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)methylphenidate hcl cap er 10 mg (cd) 1 AL, QL (30

capsules/30 days)methylphenidate hcl cap er 20 mg (cd) 1 AL, QL (30





capsules/30 days)methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin la) 1 AL, QL (30




capsules/30 days)methylphenidate hcl chew tab 2.5 mg 1 AL, QL (90

tablets/30 days)methylphenidate hcl chew tab 5 mg 1 AL, QL (90

tablets/30 days)methylphenidate hcl chew tab 10 mg 1 AL, QL (180

tablets/30 days)methylphenidate hcl soln 5 mg/5ml (Methylin) 1 AL, QL (450 mls/30 days)methylphenidate hcl soln 10 mg/5ml (Methylin) 1 AL, QL (900 mls/30 days)methylphenidate hcl tab er osmotic release (osm) 18 mg

(Concerta)1 AL, QL (30

tablets/30 days)methylphenidate hcl tab er osmotic release (osm) 27 mg


tablets/30 days)methylphenidate hcl tab er osmotic release (osm) 36 mg


tablets/30 days)

Page 79 of 152

2020


SF = Split Fill

80




methylphenidate hcl tab er osmotic release (osm) 54 mg(Concerta)

1 AL, QL (30tablets/30 days)

methylphenidate hcl tab er 10 mg 1 AL, QL (90tablets/30 days)

methylphenidate hcl tab er 20 mg 1 AL, QL (90tablets/30 days)

methylphenidate hcl tab er 24hr 27 mg 1 AL, QL (30tablets/30 days)



methylphenidate hcl tab 5 mg (Ritalin) 1 AL, QL (90tablets/30 days)



METHYLPHENIDATE HYDROCHLORIDE ER – methylphenidatehcl tab er 24hr 18 mg

2 AL, QL (30tablets/30 days)

modafinil tab 100 mg (Provigil) 1 PA, QL (30 tablets/30days), 90

modafinil tab 200 mg (Provigil) 1 PA, QL (30 tablets/30days), 90

MULTIPLE SCLEROSISAUBAGIO – teriflunomide tab 7 mg 2 PA, QL (30 tablets/30

days), SPAUBAGIO – teriflunomide tab 14 mg 2 PA, QL (30 tablets/30

days), SPAVONEX – interferon beta-1a im prefilled syringe kit

30 mcg/0.5ml2 PA, QL (1 kit/28

days), SPAVONEX PEN – interferon beta-1a im auto-injector kit

30 mcg/0.5ml2 PA, QL (1 kit/28

days), SPEXTAVIA – interferon beta-1b for inj kit 0.3 mg 2 PA, QL (14 vials/28

days), SPglatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) 1 PA, QL (12 syringes/28

days), SP

OTROS MEDICAMENTOS PARA EL SISTEMA NERVIOSO CENTRAL

Page 80 of 152

2020


SF = Split Fill

81




acamprosate calcium tab delayed release 333 mg 1 90bupropion hcl (smoking deterrent) tab er 12hr 150 mg 1 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) 2 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 1 mg (base equiv) 2 QL (180 days/365 days)CHANTIX CONTINUING MONTH PAK – varenicline tartrate tab

1 mg (base equiv)2 QL (180 days/365 days)

CHANTIX STARTING MONTH PAK – varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

2 QL (180 days/365 days)

CHLORDIAZEPOXIDE/AMITRIPTYLINE – chlordiazepoxide-amitriptyline tab 5-12.5 mg


CHLORDIAZEPOXIDE/AMITRIPTYLINE – chlordiazepoxide-amitriptyline tab 10-25 mg


disulfiram tab 250 mg (Antabuse) 1 90disulfiram tab 500 mg (Antabuse) 1 90donepezil hydrochloride orally disintegrating tab 5 mg 1 QL (30 tablets/30

days), 90donepezil hydrochloride orally disintegrating tab 10 mg 1 QL (30 tablets/30

days), 90donepezil hydrochloride tab 5 mg (Aricept) 1 QL (30 tablets/30

days), 90donepezil hydrochloride tab 10 mg (Aricept) 1 QL (30 tablets/30

days), 90GALANTAMINE HYDROBROMIDE – galantamine hydrobromide

oral soln 4 mg/ml2 QL (200 mls/30 days), 90

galantamine hydrobromide cap er 24hr 8 mg (Razadyne er) 1 QL (30 capsules/30days), 90



galantamine hydrobromide tab 4 mg (Razadyne) 1 QL (60 tablets/30days), 90



memantine hcl oral solution 2 mg/ml 1 QL (360 mls/30 days), 90memantine hcl tab 5 mg (Namenda) 1 QL (60 tablets/30

days), 90

Page 81 of 152

2020


SF = Split Fill

82




memantine hcl tab 10 mg (Namenda) 1 QL (60 tablets/30days), 90

NICOTROL INHALER – nicotine inhaler system 10 mg (4 mgdelivered)

2 QL (180 days/365 days)

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 2 QL (180 days/365 days)PERPHENAZINE/AMITRIPTYLINE – perphenazine-amitriptyline

tab 2-10 mg2 PA, 90

PERPHENAZINE/AMITRIPTYLINE – perphenazine-amitriptylinetab 2-25 mg

2 PA, 90


2 PA, 90


2 PA, 90


2 PA, 90

PIMOZIDE – pimozide tab 1 mg 2 90PIMOZIDE – pimozide tab 2 mg 2 90rivastigmine tartrate cap 4.5 mg (base equivalent) 1 QL (60 capsules/30

days), 90

ANALGÉSICOSMEDICAMENTOS NO NARCÓTICOSbutalbital-acetaminophen tab 50-325 mg 1 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 1 QL (180

capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 QL (180

capsules/30 days)

MEDICAMENTOS NARCÓTICOSacetaminophen w/ codeine soln 120-12 mg/5ml 1 AL, ME90, QL (2700

mls/30 days)acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 AL, ME90, QL (180

tablets/30 days)ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE –

acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg2 ME90, QL (300

capsules/30 days)

Page 82 of 152

2020


SF = Split Fill

83




buprenorphine hcl sl tab 2 mg (base equiv) 1 ME90, QL (90tablets/30 days)

buprenorphine hcl sl tab 8 mg (base equiv) 1 ME90, QL (90tablets/30 days)

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)(Suboxone)

1 ME90, QL (90films/30 days)

buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)(Suboxone)






buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 ME90, QL (90tablets/30 days)

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 ME90, QL (90tablets/30 days)

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 1 AL, ME90, QL (180capsules/30 days)

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)

1 AL, ME90, QL (180capsules/30 days)

butorphanol tartrate nasal soln 10 mg/ml 1 ME90, QL (2bottles/30 days)

codeine sulfate tab 30 mg (Codeine sulfate) 1 AL, ME90, QL (180tablets/30 days)

fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 ME90, PA, QL (15patches/30 days)





hydrocodone-acetaminophen soln 7.5-325 mg/15ml 1 ME90, QL (2700mls/30 days)

hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 ME90, QL (180tablets/30 days)

Page 83 of 152

2020


SF = Split Fill

84




hydrocodone-acetaminophen tab 7.5-300 mg 1 ME90, QL (180tablets/30 days)

hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 ME90, QL (240tablets/30 days)

hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 ME90, QL (180tablets/30 days)

hydrocodone-acetaminophen tab 10-300 mg 1 ME90, QL (180tablets/30 days)

hydrocodone-ibuprofen tab 5-200 mg 1 ME90, QL (150tablets/30 days)

hydrocodone-ibuprofen tab 7.5-200 mg 1 ME90, QL (150tablets/30 days)

hydromorphone hcl liqd 1 mg/ml (Dilaudid) 1 ME90, QL (1440mls/30 days)

hydromorphone hcl tab 2 mg (Dilaudid) 1 ME90, QL (180tablets/30 days)



methadone hcl conc 10 mg/ml (Methadose) 1 ME90, QL (90mls/30 days)

methadone hcl soln 5 mg/5ml (Methadone hcl) 1 ME90, QL (900mls/30 days)

methadone hcl soln 10 mg/5ml (Methadone hcl) 1 ME90, QL (450mls/30 days)

methadone hcl tab for oral susp 40 mg 1 ME90, QL (90tablets/30 days)

methadone hcl tab 5 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

methadone hcl tab 10 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 15 mg 2 ME90, QL (240tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 30 mg 2 ME90, QL (180tablets/30 days)

MORPHINE SULFATE – morphine sulfate suppos 5 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 10 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 20 mg 2 ME90

Page 84 of 152

2020


SF = Split Fill

85




MORPHINE SULFATE – morphine sulfate suppos 30 mg 2 ME90morphine sulfate cap er 24hr 100 mg (Kadian) 1 ME90, PA, QL (60

capsules/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

60 mg2 ME90, PA, QL (30


75 mg2 ME90, PA, QL (30


120 mg2 ME90, PA, QL (30

capsules/30 days)morphine sulfate oral soln 10 mg/5ml 1 ME90, QL (2700

mls/30 days)morphine sulfate oral soln 20 mg/5ml 1 ME90, QL (1350

mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 1 ME90, QL (270

mls/30 days)morphine sulfate tab er 15 mg (Ms contin) 1 ME90, PA, QL (90

tablets/30 days)morphine sulfate tab er 30 mg (Ms contin) 1 ME90, PA, QL (90




tablets/30 days)morphine sulfate tab 15 mg (Morphine sulfate) 1 ME90, QL (240

tablets/30 days)morphine sulfate tab 30 mg (Morphine sulfate) 1 ME90, QL (180

tablets/30 days)oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 ME90, QL (270

mls/30 days)oxycodone hcl soln 5 mg/5ml 1 ME90, QL (5400

mls/30 days)oxycodone hcl tab 5 mg (Roxicodone) 1 ME90, QL (360

tablets/30 days)oxycodone hcl tab 10 mg 1 ME90, QL (180

tablets/30 days)oxycodone hcl tab 15 mg (Roxicodone) 1 ME90, QL (180

tablets/30 days)

Page 85 of 152

2020


SF = Split Fill

86




oxycodone hcl tab 20 mg 1 ME90, QL (180tablets/30 days)

oxycodone hcl tab 30 mg (Roxicodone) 1 ME90, QL (180tablets/30 days)

oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 1 ME90, QL (240tablets/30 days)

oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 ME90, QL (180tablets/30 days)

OXYCODONE/ASPIRIN – oxycodone-aspirin tab 4.8355-325 mg 2 ME90, QL (360tablets/30 days)

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg

2 ME90, QL (120tablets/30 days)

oxymorphone hcl tab 5 mg (Opana) 1 ME90, QL (180tablets/30 days)

oxymorphone hcl tab 10 mg (Opana) 1 ME90, QL (180tablets/30 days)

OXYMORPHONE HYDROCHLORIDE ER – oxymorphone hcltab er 12hr 5 mg

2 ME90, PA, QL (60tablets/30 days)

OXYMORPHONE HYDROCHLORIDE ER – oxymorphone hcltab er 12hr 7.5 mg












SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg(base equiv)


SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg(base equiv)


Page 86 of 152

2020


SF = Split Fill

87








tramadol hcl tab 50 mg (Ultram) 1 AL, ME90, QL (240tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 AL, ME90, QL (240tablets/30 days)

REUMATISMO Y OSTEOARTRITISARCALYST – rilonacept for inj 220 mg 2 PA, QL (4 vials/28

days), SPcelecoxib cap 50 mg (Celebrex) 1 QL (60 capsules/30

days), 90celecoxib cap 100 mg (Celebrex) 1 QL (60 capsules/30



days), 90diclofenac potassium tab 50 mg 1 QL (120 tablets/30

days), 90diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30

days), 90diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30

days), 90diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30

days), 90ENBREL – etanercept for subcutaneous inj 25 mg 2 PA, QL (8 vials/28

days), SPENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml2 PA, QL (4 syringes/28

days), SPENBREL – etanercept subcutaneous soln prefilled syringe

50 mg/ml2 PA, QL (4 syringes/28

days), SPENBREL MINI – etanercept subcutaneous solution cartridge

50 mg/ml2 PA, QL (4 cartridges/28

days), SPENBREL SURECLICK – etanercept subcutaneous solution auto-

injector 50 mg/ml2 PA, QL (4 syringes/28

days), SPflurbiprofen tab 50 mg 1 QL (180 tablets/30

days), 90

Page 87 of 152

2020


SF = Split Fill

88




flurbiprofen tab 100 mg 1 QL (90 tablets/30days), 90

HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml 2 PA, QL (2 syringes/28days), SP






HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK –adalimumab prefilled syringe kit 80 mg/0.8ml


HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK –adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml


HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml 2 PA, QL (2 pens/28days), SP

HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml 2 PA, QL (2 pens/28days), SP

HUMIRA PEN-CD/UC/HS STARTER – adalimumab pen-injectorkit 40 mg/0.8ml

2 PA, QL (6 pens/180days), SP

HUMIRA PEN-CD/UC/HS STARTER – adalimumab pen-injectorkit 80 mg/0.8ml

2 PA, QL (1 kit/180days), SP

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit40 mg/0.8ml

2 PA, QL (4 pens/28days), SP

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

2 PA, QL (1 kit/180days), SP

ibuprofen susp 100 mg/5ml 1 QL (1000 mls/30 days)ibuprofen tab 400 mg 1 QL (120 tablets/30

days), 90ibuprofen tab 600 mg 1 QL (150 tablets/30

days), 90ibuprofen tab 800 mg 1 QL (120 tablets/30

days), 90indomethacin cap er 75 mg 1 QL (60 capsules/30

days), 90

Page 88 of 152

2020


SF = Split Fill

89




indomethacin cap 25 mg 1 QL (90 capsules/30days), 90

indomethacin cap 50 mg 1 QL (60 capsules/30days), 90

ketorolac tromethamine tab 10 mg 1 QL (20 tablets/30 days)KINERET – anakinra subcutaneous soln prefilled syringe


days), SPKINERET – anakinra subcutaneous soln prefilled syringe


days), SPleflunomide tab 10 mg (Arava) 1 90leflunomide tab 20 mg (Arava) 1 90meloxicam tab 7.5 mg (Mobic) 1 QL (60 tablets/30

days), 90meloxicam tab 15 mg (Mobic) 1 QL (30 tablets/30

days), 90nabumetone tab 500 mg 1 QL (120 tablets/30

days), 90nabumetone tab 750 mg 1 QL (60 tablets/30

days), 90naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 QL (120 tablets/30

days), 90naproxen sodium tab 275 mg 1 QL (150 tablets/30

days), 90naproxen sodium tab 550 mg 1 QL (90 tablets/30

days), 90naproxen susp 125 mg/5ml (Naprosyn) 1 PA, QL (1800

mls/30 days), 90naproxen tab ec 375 mg (Ec-naprosyn) 1 QL (120 tablets/30

days), 90naproxen tab ec 500 mg (Ec-naproxen) 1 QL (90 tablets/30

days), 90naproxen tab 250 mg 1 QL (150 tablets/30



days), 90OLUMIANT – baricitinib tab 1 mg 2 PA, QL (30 tablets/30

days), SP

Page 89 of 152

2020


SF = Split Fill

90




OLUMIANT – baricitinib tab 2 mg 2 PA, QL (30 tablets/30days), SP

ORENCIA – abatacept subcutaneous soln prefilled syringe125 mg/ml


ORENCIA CLICKJECT – abatacept subcutaneous soln auto-injector 125 mg/ml


OTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg &30 mg


OTEZLA – apremilast tab 30 mg 2 PA, QL (60 tablets/30days), SP

piroxicam cap 10 mg (Feldene) 1 QL (60 capsules/30days), 90

piroxicam cap 20 mg (Feldene) 1 QL (30 capsules/30days), 90

SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml


SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ml


SIMPONI – golimumab subcutaneous soln prefilled syringe50 mg/0.5ml


SIMPONI – golimumab subcutaneous soln prefilled syringe100 mg/ml


sulindac tab 150 mg 1 QL (60 tablets/30days), 90

sulindac tab 200 mg 1 QL (60 tablets/30days), 90

XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30days), SP

XELJANZ – tofacitinib citrate tab 10 mg (base equivalent) 2 PA, QL (224tablets/365 days), SP

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent)


XELJANZ XR – tofacitinib citrate tab er 24hr 22 mg (baseequivalent)

2 PA, QL (112tablets/365 days), SP

DOLOR DE CABEZA/MIGRAÑASalmotriptan malate tab 6.25 mg 1 QL (18 tablets/30 days)almotriptan malate tab 12.5 mg 1 QL (18 tablets/30 days)frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 1 QL (18 tablets/30 days)

Page 90 of 152

2020


SF = Split Fill

91




IMITREX – sumatriptan nasal spray 5 mg/act 2 QL (12 units/30 days)IMITREX – sumatriptan nasal spray 20 mg/act 2 QL (12 units/30 days)rizatriptan benzoate oral disintegrating tab 5 mg (base eq) 1 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg (base eq)

(Maxalt-mlt)1 QL (18 tablets/30 days)

rizatriptan benzoate tab 5 mg (base equivalent) 1 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act (Imitrex) 1 QL (12 units/30 days)sumatriptan nasal spray 20 mg/act (Imitrex) 1 QL (12 units/30 days)SUMATRIPTAN SUCCINATE – sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml2 QL (12 doses/30 days)

sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex

statdose sys)1 QL (12 doses/30 days)

sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrexstatdose sys)

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrexstatdose ref)

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrexstatdose ref)

1 QL (6 packages/30 days)

sumatriptan succinate tab 25 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg (Imitrex) 1 QL (18 tablets/30 days)

GOTAallopurinol tab 100 mg (Zyloprim) 1 90allopurinol tab 300 mg (Zyloprim) 1 90colchicine w/ probenecid tab 0.5-500 mg 1 90MITIGARE – colchicine cap 0.6 mg 2probenecid tab 500 mg 1 90

MEDICAMENTOS NEUROMUSCULARESCONVULSIONESAPTIOM – eslicarbazepine acetate tab 200 mg 2 90APTIOM – eslicarbazepine acetate tab 400 mg 2 90APTIOM – eslicarbazepine acetate tab 600 mg 2 90APTIOM – eslicarbazepine acetate tab 800 mg 2 90carbamazepine cap er 12hr 100 mg (Carbatrol) 1 90carbamazepine cap er 12hr 200 mg (Carbatrol) 1 90

Page 91 of 152

2020


SF = Split Fill

92




carbamazepine cap er 12hr 300 mg (Carbatrol) 1 90carbamazepine chew tab 100 mg 1 90carbamazepine susp 100 mg/5ml (Tegretol) 1 90carbamazepine tab er 12hr 100 mg (Tegretol-xr) 1 90carbamazepine tab er 12hr 200 mg (Tegretol-xr) 1 90carbamazepine tab er 12hr 400 mg (Tegretol-xr) 1 90carbamazepine tab 200 mg (Tegretol) 1 90clonazepam orally disintegrating tab 0.125 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 1 QL (60 tablets/30 days)clonazepam tab 0.5 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 1 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 2 mg (Klonopin) 1 QL (60 tablets/30 days)DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system

2.5 mg2 QL (2 packs/30 days)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system10 mg

2 QL (2 packs/30 days)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system20 mg

2 QL (2 packs/30 days)

DILANTIN – phenytoin sodium extended cap 30 mg 2 90divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)1 90

divalproex sodium tab delayed release 125 mg (Depakote) 1 90divalproex sodium tab delayed release 250 mg (Depakote) 1 90divalproex sodium tab delayed release 500 mg (Depakote) 1 90divalproex sodium tab er 24 hr 250 mg (Depakote er) 1 90divalproex sodium tab er 24 hr 500 mg (Depakote er) 1 90ethosuximide cap 250 mg (Zarontin) 1 90ethosuximide soln 250 mg/5ml (Zarontin) 1 90felbamate susp 600 mg/5ml (Felbatol) 1 90felbamate tab 400 mg (Felbatol) 1 90felbamate tab 600 mg (Felbatol) 1 90gabapentin cap 100 mg (Neurontin) 1 QL (720 capsules/30

days), 90

Page 92 of 152

2020


SF = Split Fill

93




gabapentin cap 300 mg (Neurontin) 1 QL (240 capsules/30days), 90

gabapentin cap 400 mg (Neurontin) 1 QL (180 capsules/30days), 90

gabapentin oral soln 250 mg/5ml (Neurontin) 1 QL (1500 mls/30days), 90

gabapentin tab 600 mg (Neurontin) 1 QL (120 tablets/30days), 90

gabapentin tab 800 mg (Neurontin) 1 QL (90 tablets/30days), 90

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 mg (7)titration kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) &100 mg(7) kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) &200 mg(7) kit

2 PA

lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 90lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)1 90

lamotrigine tab er 24hr 25 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 50 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 100 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 200 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 250 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 300 mg (Lamictal xr) 1 90lamotrigine tab 25 mg (Lamictal) 1 90lamotrigine tab 100 mg (Lamictal) 1 90lamotrigine tab 150 mg (Lamictal) 1 90lamotrigine tab 200 mg (Lamictal) 1 90lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak) 1 PAlamotrigine tab 25 mg (42) & 100 mg (7) starter kit (Lamictal

starter/not)1 PA

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit (Lamictalstarter/tak)

1 PA

levetiracetam oral soln 100 mg/ml (Keppra) 1 90levetiracetam tab er 24hr 500 mg (Keppra xr) 1 90levetiracetam tab er 24hr 750 mg (Keppra xr) 1 90levetiracetam tab 250 mg (Keppra) 1 90

Page 93 of 152

2020


SF = Split Fill

94




levetiracetam tab 500 mg (Keppra) 1 90levetiracetam tab 750 mg (Keppra) 1 90levetiracetam tab 1000 mg (Keppra) 1 90NAYZILAM – midazolam nasal spray soln 5 mg/0.1 ml 2 QL (10 sprays/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1 90oxcarbazepine tab 150 mg (Trileptal) 1 90oxcarbazepine tab 300 mg (Trileptal) 1 90oxcarbazepine tab 600 mg (Trileptal) 1 90OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg 2 PA, 90OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg 2 PA, 90OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg 2 PA, 90phenytoin chew tab 50 mg (Dilantin infatabs) 1 90phenytoin sodium extended cap 100 mg (Dilantin) 1 90phenytoin sodium extended cap 200 mg (Phenytek) 1 90phenytoin sodium extended cap 300 mg (Phenytek) 1 90phenytoin susp 125 mg/5ml (Dilantin-125) 1 90pregabalin cap 25 mg (Lyrica) 1 QL (90 capsules/30

days), ST, 90pregabalin cap 50 mg (Lyrica) 1 QL (90 capsules/30







days), ST, 90primidone tab 50 mg (Mysoline) 1 90primidone tab 250 mg (Mysoline) 1 90tiagabine hcl tab 2 mg (Gabitril) 1 90tiagabine hcl tab 4 mg (Gabitril) 1 90

Page 94 of 152

2020


SF = Split Fill

95




topiramate sprinkle cap 15 mg (Topamax sprinkle) 1 90topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 90topiramate tab 25 mg (Topamax) 1 90topiramate tab 50 mg (Topamax) 1 90topiramate tab 100 mg (Topamax) 1 90topiramate tab 200 mg (Topamax) 1 90valproate sodium oral soln 250 mg/5ml (base equiv) 1 90valproic acid cap 250 mg 1 90vigabatrin powd pack 500 mg (Sabril) 1 PA, QL (180

packets/30 days), SPvigabatrin tab 500 mg (Sabril) 2 PA, QL (180

tablets/30 days), SPzonisamide cap 25 mg (Zonegran) 1 90zonisamide cap 50 mg 1 90zonisamide cap 100 mg (Zonegran) 1 90

ENFERMEDAD DE PARKINSONamantadine hcl cap 100 mg 1 90amantadine hcl syrup 50 mg/5ml 1 90benztropine mesylate tab 0.5 mg 1 90benztropine mesylate tab 1 mg 1 90benztropine mesylate tab 2 mg 1 90bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel) 1 90bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1 90carbidopa & levodopa orally disintegrating tab 10-100 mg 1carbidopa & levodopa orally disintegrating tab 25-100 mg 1carbidopa & levodopa orally disintegrating tab 25-250 mg 1carbidopa & levodopa tab er 25-100 mg (Sinemet cr) 1carbidopa & levodopa tab er 50-200 mg (Sinemet cr) 1carbidopa & levodopa tab 10-100 mg (Sinemet) 1carbidopa & levodopa tab 25-100 mg (Sinemet) 1carbidopa & levodopa tab 25-250 mg (Sinemet) 1carbidopa tab 25 mg (Lodosyn) 1entacapone tab 200 mg (Comtan) 1 90pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er) 1pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1

Page 95 of 152

2020


SF = Split Fill

96




pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1pramipexole dihydrochloride tab 1 mg (Mirapex) 1pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1ropinirole hydrochloride tab 0.25 mg 1ropinirole hydrochloride tab 0.5 mg 1ropinirole hydrochloride tab 1 mg 1ropinirole hydrochloride tab 2 mg 1ropinirole hydrochloride tab 3 mg 1ropinirole hydrochloride tab 4 mg 1ropinirole hydrochloride tab 5 mg 1SELEGILINE HCL – selegiline hcl tab 5 mg 2selegiline hcl cap 5 mg 1tolcapone tab 100 mg (Tasmar) 1 90trihexyphenidyl hcl elixir 0.4 mg/ml 1 90trihexyphenidyl hcl tab 2 mg 1 90trihexyphenidyl hcl tab 5 mg 1 90

RELAJANTES MUSCULARESbaclofen tab 10 mg 1baclofen tab 20 mg 1chlorzoxazone tab 500 mg 1cyclobenzaprine hcl tab 5 mg 1cyclobenzaprine hcl tab 10 mg 1dantrolene sodium cap 25 mg (Dantrium) 1dantrolene sodium cap 50 mg (Dantrium) 1dantrolene sodium cap 100 mg 1methocarbamol tab 500 mg 1methocarbamol tab 750 mg (Robaxin-750) 1orphenadrine citrate tab er 12hr 100 mg 1tizanidine hcl tab 2 mg (base equivalent) 1 QL (180 tablets/30 days)tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 QL (180 tablets/30 days)

OTROS MEDICAMENTOS NEUROMUSCULARESpyridostigmine bromide tab 60 mg (Mestinon) 1riluzole tab 50 mg (Rilutek) 1

Page 96 of 152

2020


SF = Split Fill

97




SUPLEMENTOSVITAMINAScholecalciferol cap 125 mcg (5000 unit) 1ergocalciferol cap 1.25 mg (50000 unit) (Drisdol) 1phytonadione tab 5 mg (Mephyton) 1

COMPLEJO MULTIVITAMÍNICOb-complex w/ c & folic acid cap 1 mg 1b-complex w/ c & folic acid tab 1b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1b-complex w/ c & folic acid tab 5 mg 1CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

CORVITA – multiple vitamins w/ minerals & fa tab 1.25 mg 2CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acidtab 5 mg

2

GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2GOODSENSE PRENATAL VITAMINS – prenatal vit w/ fe

fumarate-fa tab 28-0.8 mg2

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2multiple vitamins w/ minerals cap 1multiple vitamins w/ minerals tab (Strovite forte) 1NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2pediatric multiple vitamin w/ minerals & c drops 45 mg/ml 1pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1PNV FOLIC ACID + IRON MULTIVITAMIN – prenatal vit w/ fe

fumarate-fa tab 27-1 mg2

PNV PRENATAL PLUS MULTIVITAMIN – prenatal vit w/ fefumarate-fa tab 27-1 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.25 mg

2

Page 97 of 152

2020


SF = Split Fill

98




POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.5 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab1 mg

2

PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

2

PRENATAL – prenatal multivitamins & minerals w/iron & fa tab0.8 mg

2

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2PRENATAL AND IRON – prenatal multivitamins & minerals w/

iron & fa tab 0.8 mg2

PRENATAL FORTE – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg

2

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap27-0.8-228 mg

2

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 1PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab

27-0.8 mg2

PRENATAL VITAMIN & MINERAL – prenatal vit w/ fe fumarate-fatab 28-0.8 mg

2

PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS PLUS LOW IRON – prenatal vit w/ fefumarate-fa tab 27-1 mg

2

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2

Page 98 of 152

2020


SF = Split Fill

99




RA PRENATAL FORMULA/FOLIC ACID – prenatal vit w/ fefumarate-fa tab 28-0.8 mg

2

RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

speciality vitamin product tab 1TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 2VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2

MINERALES Y ELECTROLITOSEFFERVESCENT POTASSIUM/CHLORIDE – pot bicarbonate &

chloride effer tab 25 meq2

K-PHOS – potassium phosphate monobasic tab 500 mg 2pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral)1

potassium bicarbonate effer tab 25 meq 1potassium chloride cap er 8 meq 1potassium chloride cap er 10 meq 1POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq

(600 mg)2

potassium chloride microencapsulated crys er tab 10 meq 1potassium chloride microencapsulated crys er tab 20 meq 1potassium chloride oral soln 10% (20 meq/15ml) 1potassium chloride oral soln 20% (40 meq/15ml) 1potassium chloride tab er 8 meq (600 mg) 1potassium chloride tab er 10 meq (K-tab) 1SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg

naf)2

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mgnaf)

2

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) 1sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) 1sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 1

Page 99 of 152

2020


SF = Split Fill

100




sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) 1

OTHER SUPPLEMENTSacetylcysteine cap 600 mg 1amino acids cap 1FOLBIC – folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg 2WESTAB MAX – folic acid-pyridoxine-cyanocobalamin tab

2.5-25-2 mg2

MEDICAMENTOS MODIFICADORES DE LA SANGREMEDICAMENTOS MODIFICADORES DE LA SANGREADVATE – antihemophilic factor rahf-pfm for inj 250 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 500 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1000 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1500 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 2000 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 3000 unit 2 PA, SPADVATE – antihemophilic factor rahf-pfm for inj 4000 unit 2 PA, SPADYNOVATE – antihemophilic factor recomb pegylated for inj

250 unit2 PA, SP

ADYNOVATE – antihemophilic factor recomb pegylated for inj500 unit

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf(human) for inj 250 unit

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

Page 100 of 152

2020


SF = Split Fill

101





2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

ALPHANINE SD – coagulation factor ix for inj 500 unit 2 PA, SPALPHANINE SD – coagulation factor ix for inj 500 unit 2 PA, SPALPHANINE SD – coagulation factor ix for inj 1000 unit 2 PA, SPALPHANINE SD – coagulation factor ix for inj 1000 unit 2 PA, SPALPHANINE SD – coagulation factor ix for inj 1500 unit 2 PA, SPALPHANINE SD – coagulation factor ix for inj 1500 unit 2 PA, SPanagrelide hcl cap 0.5 mg (Agrylin) 1anagrelide hcl cap 1 mg 1ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 500 mcg/ml

2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

2 PA, SP


2 PA, SP

Page 101 of 152

2020


SF = Split Fill

102





2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 250 unit 2 PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 500 unit 2 PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 1000

unit2 PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 2000unit

2 PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 3000unit

2 PA, SP

BERINERT – c1 esterase inhibitor (human) for iv inj kit 500 unit 2 PA, QL (10 vials/30days), SP

BRILINTA – ticagrelor tab 60 mg 2 PA, QL (60tablets/30 days)

BRILINTA – ticagrelor tab 90 mg 2 PA, QL (60tablets/30 days)

CERDELGA – eliglustat tartrate cap 84 mg (base equivalent) 2 PA, QL (60 capsules/30days), SP

cilostazol tab 50 mg 1cilostazol tab 100 mg 1clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1clopidogrel bisulfate tab 300 mg (base equiv) 1COAGADEX – coagulation factor x (human) for inj 250 unit 2 PA, SPCOAGADEX – coagulation factor x (human) for inj 500 unit 2 PA, SPcyanocobalamin inj 1000 mcg/ml 1dipyridamole tab 25 mg 1dipyridamole tab 50 mg 1dipyridamole tab 75 mg 1DROXIA – hydroxyurea cap 200 mg 2DROXIA – hydroxyurea cap 300 mg 2DROXIA – hydroxyurea cap 400 mg 2ELIQUIS – apixaban tab 2.5 mg 2 PA, QL (60

tablets/30 days)

Page 102 of 152

2020


SF = Split Fill

103




ELIQUIS – apixaban tab 5 mg 2 PA, QL (74tablets/30 days)

ELIQUIS STARTER PACK – apixaban tab 5 mg 2 PA, QL (74tablets/180 days)

enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 QL (30 syringes/365days)




enoxaparin sodium inj 100 mg/ml (Lovenox) 1 QL (30 syringes/365days)


enoxaparin sodium inj 150 mg/ml (Lovenox) 1 QL (30 syringes/365days)

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap 1fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg 1ferrous fumarate-folic acid tab 324-1 mg 1folic acid tab 1 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 2 PA, SPHAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj

2000 unit2 PA, QL (16 vials/28

days), SPHAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj

3000 unit2 PA, QL (8 vials/28

days), SPHEMOFIL M – antihemophilic factor (human) for inj 250 unit 2 PA, SPHEMOFIL M – antihemophilic factor (human) for inj 500 unit 2 PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1000 unit 2 PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1700 unit 2 PA, SP

Page 103 of 152

2020


SF = Split Fill

104




HUMATE-P – antihemophilic factor/vwf (human) for inj 250-600unit

2 PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200unit

2 PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit

2 PA, SP

icatibant acetate inj 30 mg/3ml (base equivalent) (Firazyr) 2 PA, QL (6 syringes/30days), SP

iron combination cap 1iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg

(Hematron-af)1

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite150)

1

IXINITY – coagulation factor ix (recombinant) for inj 250 unit 2 PA, SPIXINITY – coagulation factor ix (recombinant) for inj 500 unit 2 PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1000 unit 2 PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1500 unit 2 PA, SPIXINITY – coagulation factor ix (recombinant) for inj 2000 unit 2 PA, SPIXINITY – coagulation factor ix (recombinant) for inj 3000 unit 2 PA, SPKOATE – antihemophilic factor (human) for inj 250 unit 2 PA, SPKOATE – antihemophilic factor (human) for inj 500 unit 2 PA, SPKOATE – antihemophilic factor (human) for inj 1000 unit 2 PA, SPKOATE-DVI – antihemophilic factor (human) for inj 250 unit 2 PA, SPKOATE-DVI – antihemophilic factor (human) for inj 500 unit 2 PA, SPKOATE-DVI – antihemophilic factor (human) for inj 1000 unit 2 PA, SPKOGENATE FS – antihemophilic factor (recombinant) for inj kit

250 unit2 PA, SP

KOGENATE FS – antihemophilic factor (recombinant) for inj kit500 unit

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

miglustat cap 100 mg (Zavesca) 1 PA, QL (90 capsules/30days), SP

MONONINE – coagulation factor ix for inj 1000 unit 2 PA, SP

Page 104 of 152

2020


SF = Split Fill

105




NIVESTYM – filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 2 PA, SPNIVESTYM – filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 2 PA, SPNIVESTYM – filgrastim-aafi inj 300 mcg/ml 2 PA, SPNIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 2 PA, SPpentoxifylline tab er 400 mg 1PROFILNINE – factor ix complex for inj 500 unit 2 PA, SPPROFILNINE – factor ix complex for inj 1000 unit 2 PA, SPPROFILNINE – factor ix complex for inj 1500 unit 2 PA, SPPROFILNINE SD – factor ix complex for inj 500 unit 2 PA, SPPROFILNINE SD – factor ix complex for inj 1000 unit 2 PA, SPPROFILNINE SD – factor ix complex for inj 1500 unit 2 PA, SPPROMACTA – eltrombopag olamine powder pack for susp

12.5 mg (base eq)2 PA, QL (30 packets/30

days), SPPROMACTA – eltrombopag olamine tab 12.5 mg (base equiv) 2 PA, QL (30 tablets/30

days), SPPROMACTA – eltrombopag olamine tab 25 mg (base equiv) 2 PA, QL (30 tablets/30



days), SPRECOMBINATE – antihemophilic factor (recombinant) for inj

220-400 unit2 PA, SP

RECOMBINATE – antihemophilic factor (recombinant) for inj401-800 unit

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

RETACRIT – epoetin alfa-epbx inj 2000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 3000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 4000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 10000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 40000 unit/ml 2 PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 250 unit 2 PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 500 unit 2 PA, SP

Page 105 of 152

2020


SF = Split Fill

106




RIXUBIS – coagulation factor ix (recombinant) for inj 1000 unit 2 PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 2000 unit 2 PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 3000 unit 2 PA, SPRUCONEST – c1 esterase inhibitor (recombinant) for iv inj 2100

unit2 PA, QL (8 vials/30

days), SPRUCONEST – c1 esterase inhibitor (recombinant) for iv inj 2100

unit2 PA, QL (8 vials/30

days), SPtranexamic acid tab 650 mg (Lysteda) 1VONVENDI – von willebrand factor (recombinant) for inj 650 unit 2 PA, SPVONVENDI – von willebrand factor (recombinant) for inj 1300

unit2 PA, SP

warfarin sodium tab 1 mg (Coumadin) 1warfarin sodium tab 2 mg (Coumadin) 1warfarin sodium tab 2.5 mg (Coumadin) 1warfarin sodium tab 3 mg (Coumadin) 1warfarin sodium tab 4 mg (Coumadin) 1warfarin sodium tab 5 mg (Coumadin) 1warfarin sodium tab 6 mg (Coumadin) 1warfarin sodium tab 7.5 mg (Coumadin) 1warfarin sodium tab 10 mg (Coumadin) 1WILATE – antihemophilic factor/vwf (human) for inj 500-500 unit

kit2 PA, SP

WILATE – antihemophilic factor/vwf (human) for inj 1000-1000unit kit

2 PA, SP

XARELTO – rivaroxaban tab 2.5 mg 2 QL (60 tablets/30 days)XARELTO – rivaroxaban tab 10 mg 2 PA, QL (35

tablets/365 days)XARELTO – rivaroxaban tab 15 mg 2 PA, QL (60

tablets/30 days)XARELTO – rivaroxaban tab 20 mg 2 PA, QL (30

tablets/30 days)XARELTO STARTER PACK – rivaroxaban tab starter therapy

pack 15 mg & 20 mg2 PA, QL (51

tablets/30 days)XYNTHA – antihemophilic factor recombinant paf for inj kit 250

unit2 PA, SP

XYNTHA – antihemophilic factor recombinant paf for inj kit 500unit

2 PA, SP

Page 106 of 152

2020


SF = Split Fill

107





2 PA, SP


2 PA, SP

XYNTHA SOLOFUSE – antihemophilic factor recombinant paf forinj kit 250 unit

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

MEDICAMENTOS TÓPICOSOJOSAntinfecciosoBACITRACIN – bacitracin ophth oint 500 unit/gm 2bacitracin-polymyxin b ophth oint 1ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan) 1erythromycin ophth oint 5 mg/gm 1GENTAK – gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 1moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox) 1NATACYN – natamycin ophth susp 5% 2neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1NEOMYCIN/POLYMYXIN/GRAMICIDIN – neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml2

ofloxacin ophth soln 0.3% (Ocuflox) 1polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

(Polytrim)1

sulfacetamide sodium ophth soln 10% (Bleph-10) 1tobramycin ophth soln 0.3% (Tobrex) 1TRIFLURIDINE – trifluridine ophth soln 1% 2

Productos esteroides y combinacionesbacitracin-polymyxin-neomycin-hc ophth oint 1% 1DEXAMETHASONE SODIUM PHOSPHATE – dexamethasone

sodium phosphate ophth soln 0.1%2

fluorometholone ophth susp 0.1% (Fml liquifilm) 1

Page 107 of 152

2020


SF = Split Fill

108




neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) 1neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) 1PREDNISOLONE ACETATE – prednisolone acetate ophth susp

1%2

PREDNISOLONE SODIUM PHOSPHATE – prednisolone sodiumphosphate ophth soln 1%

2

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUMPHOSPHATE – sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%

2

Glaucomaapraclonidine hcl ophth soln 0.5% (base equivalent) 1betaxolol hcl ophth soln 0.5% 1brimonidine tartrate ophth soln 0.2% 1CARTEOLOL HCL – carteolol hcl ophth soln 1% 2dorzolamide hcl ophth soln 2% (Trusopt) 1dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

(Cosopt)1

latanoprost ophth soln 0.005% (Xalatan) 1 QL (1 bottle/30 days)LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.5% 2pilocarpine hcl ophth soln 1% (Isopto carpine) 1pilocarpine hcl ophth soln 2% (Isopto carpine) 1pilocarpine hcl ophth soln 4% (Isopto carpine) 1timolol maleate ophth soln 0.25% (Timoptic) 1timolol maleate ophth soln 0.5% (Timoptic) 1

Otros productos oftálmicosATROPINE SULFATE – atropine sulfate ophth oint 1% 2ATROPINE SULFATE – atropine sulfate ophth soln 1% 2azelastine hcl ophth soln 0.05% 1cromolyn sodium ophth soln 4% 1cyclopentolate hcl ophth soln 0.5% (Cyclogyl) 1cyclopentolate hcl ophth soln 1% (Cyclogyl) 1cyclopentolate hcl ophth soln 2% (Cyclogyl) 1CYSTARAN – cysteamine hcl ophth soln 0.44% (base

equivalent)2 PA, QL (4 bottles/30

days), SPdiclofenac sodium ophth soln 0.1% 1epinastine hcl ophth soln 0.05% 1

Page 108 of 152

2020


SF = Split Fill

109




FLURBIPROFEN SODIUM – flurbiprofen sodium ophth soln0.03%

2

homatropine hbr ophth soln 5% 1ISOPTO ATROPINE – atropine sulfate ophth soln 1% 2ketorolac tromethamine ophth soln 0.4% (Acular ls) 1ketorolac tromethamine ophth soln 0.5% (Acular) 1olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol) 1phenylephrine hcl ophth soln 2.5% 1proparacaine hcl ophth soln 0.5% (Alcaine) 1tetracaine hcl ophth soln 0.5% 1

OÍDOacetic acid otic soln 2% 1hydrocortisone w/ acetic acid otic soln 1-2% 1neomycin-polymyxin-hc otic soln 1% 1neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 1ofloxacin otic soln 0.3% (Floxin otic) 1

BOCA Y GARGANTA (local)chlorhexidine gluconate soln 0.12% (Peridex) 1clotrimazole troche 10 mg 1lidocaine hcl viscous soln 2% 1nystatin susp 100000 unit/ml 1pilocarpine hcl tab 5 mg (Salagen) 1pilocarpine hcl tab 7.5 mg (Salagen) 1PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 2PREVIDENT RINSE – sodium fluoride rinse 0.2% 2PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1%

(0.5% f)2

sodium fluoride cream 1.1% (Prevident 5000 plus) 1sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1sodium fluoride paste 1.1% (Prevident 5000 boost) 1sodium fluoride rinse 0.2% (Prevident rinse) 1sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000

sensi)1

stannous fluoride gel 0.4% 1triamcinolone acetonide dental paste 0.1% 1

AGENTES ANORRECTALES

Page 109 of 152

2020


SF = Split Fill

110




hydrocortisone enema 100 mg/60ml (Cortenema) 1hydrocortisone rectal cream 1% (Proctocort) 1hydrocortisone rectal cream 2.5% (Anusol-hc) 1

AFECCIONES DE LA PIEL/PRODUCTOSAcnéadapalene cream 0.1% (Differin) 1 ALazelaic acid gel 15% (Finacea) 1 ALbenzoyl peroxide cloth 6% 1 ALbenzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 ALclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)1 AL

clindamycin phosphate gel 1% (Cleocin-t) 1 ALclindamycin phosphate lotion 1% (Cleocin-t) 1 ALclindamycin phosphate soln 1% 1 ALclindamycin phosphate swab 1% 1 ALERY – erythromycin pads 2% 2 ALerythromycin soln 2% 1 ALisotretinoin cap 10 mg 1 ALisotretinoin cap 20 mg 1 ALisotretinoin cap 30 mg 1 ALisotretinoin cap 40 mg 1 ALmetronidazole cream 0.75% (Metrocream) 1 ALmetronidazole gel 0.75% 1 ALsulfacetamide sodium lotion 10% (acne) (Klaron) 1 ALtazarotene cream 0.1% (Tazorac) 1 ALTAZORAC – tazarotene cream 0.05% 2 ALTAZORAC – tazarotene gel 0.05% 2 ALTAZORAC – tazarotene gel 0.1% 2 ALtretinoin cream 0.025% (Retin-a) 1 ALtretinoin cream 0.05% (Retin-a) 1 ALtretinoin cream 0.1% (Retin-a) 1 ALtretinoin gel 0.01% (Retin-a) 1 ALtretinoin gel 0.025% (Retin-a) 1 ALtretinoin gel 0.05% (Atralin) 1 AL

Antinfecciosos

Page 110 of 152

2020


SF = Split Fill

111




acyclovir oint 5% (Zovirax) 1ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1ciclopirox olamine susp 0.77% (base equiv) (Loprox) 1ciclopirox solution 8% (Penlac Nail Lacquer) 1 PA, QL (6.6 mls/30 days)clotrimazole cream 1% 1clotrimazole soln 1% 1clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 1gentamicin sulfate cream 0.1% 1gentamicin sulfate oint 0.1% 1ketoconazole cream 2% 1ketoconazole shampoo 2% (Nizoral) 1mupirocin oint 2% 1naftifine hcl cream 2% (Naftin) 1nystatin cream 100000 unit/gm 1nystatin oint 100000 unit/gm 1nystatin topical powder 100000 unit/gm 1oxiconazole nitrate cream 1% (Oxistat) 1salicylic acid cream 6% 1salicylic acid cream 6% & cleanser liqd kit 1salicylic acid film forming liquid 27.5% (Virasal) 1salicylic acid foam 6% (Salvax) 1salicylic acid gel 6% (Keralyt) 1salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) 1salicylic acid shampoo 6% (Salex) 1silver sulfadiazine cream 1% (Silvadene) 1

Corticosteroidesalclometasone dipropionate cream 0.05% 1alclometasone dipropionate oint 0.05% 1AUGMENTED BETAMETHASONE DIPROPIONATE –

betamethasone dipropionate augmented gel 0.05%2 QL (180 grams/90 days)

betamethasone dipropionate augmented cream 0.05%(Diprolene af)

1 QL (180 grams/90 days)

betamethasone dipropionate augmented lotion 0.05% 1 QL (180 mls/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 QL (180 grams/90 days)betamethasone dipropionate cream 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate lotion 0.05% 1 QL (180 mls/90 days)

Page 111 of 152

2020


SF = Split Fill

112




betamethasone dipropionate oint 0.05% 1 QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent) 1betamethasone valerate lotion 0.1% (base equivalent) 1betamethasone valerate oint 0.1% (base equivalent) 1clobetasol propionate emollient base cream 0.05% 1clobetasol propionate soln 0.05% 1 QL (180 mls/90 days)desonide cream 0.05% (Desowen) 1desonide oint 0.05% 1desoximetasone cream 0.05% (Topicort) 1 QL (180 grams/90 days)desoximetasone cream 0.25% (Topicort) 1 QL (180 grams/90 days)desoximetasone gel 0.05% (Topicort) 1 QL (180 grams/90 days)fluocinolone acetonide cream 0.01% 1fluocinolone acetonide cream 0.025% (Synalar) 1fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs

sca)1

fluocinolone acetonide oint 0.025% (Synalar) 1fluocinolone acetonide soln 0.01% (Synalar) 1fluocinonide cream 0.05% 1 QL (180 grams/90 days)fluocinonide emulsified base cream 0.05% 1 QL (180 grams/90 days)fluocinonide gel 0.05% 1 QL (180 grams/90 days)fluocinonide oint 0.05% 1 QL (180 grams/90 days)fluocinonide soln 0.05% 1 QL (180 mls/90 days)flurandrenolide cream 0.05% (Cordran) 1fluticasone propionate cream 0.05% 1fluticasone propionate oint 0.005% 1halobetasol propionate cream 0.05% 1 QL (180 grams/90 days)halobetasol propionate oint 0.05% 1 QL (180 grams/90 days)hydrocortisone butyrate oint 0.1% 1hydrocortisone butyrate soln 0.1% (Locoid) 1hydrocortisone cream 1% 1hydrocortisone cream 2.5% 1hydrocortisone lotion 2.5% 1hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1hydrocortisone valerate cream 0.2% 1

Page 112 of 152

2020


SF = Split Fill

113




hydrocortisone valerate oint 0.2% 1mometasone furoate cream 0.1% (Elocon) 1mometasone furoate oint 0.1% 1 QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion) 1PREDNICARBATE – prednicarbate cream 0.1% 2PREDNICARBATE – prednicarbate oint 0.1% 2triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1triamcinolone acetonide cream 0.025% 1triamcinolone acetonide cream 0.1% 1triamcinolone acetonide cream 0.5% 1 QL (180 grams/90 days)triamcinolone acetonide lotion 0.025% 1triamcinolone acetonide lotion 0.1% 1triamcinolone acetonide oint 0.025% 1triamcinolone acetonide oint 0.1% 1

Otros productos para la pielacitretin cap 10 mg (Soriatane) 1acitretin cap 17.5 mg 1acitretin cap 25 mg (Soriatane) 1calcipotriene cream 0.005% (Dovonex) 1calcipotriene oint 0.005% 1calcipotriene soln 0.005% (50 mcg/ml) 1CEM-UREA – urea soln 45% 2CERAMAX – dermatological products misc - cream 2COSENTYX – secukinumab subcutaneous soln prefilled syringe

150 mg/ml2 PA, QL (1 syringe/28

days), SPCOSENTYX – secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)2 PA, QL (2 syringes/28

days), SPCOSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml2 PA, QL (1 syringe/28

days), SPCOSENTYX SENSOREADY PEN – secukinumab subcutaneous

auto-inj 150 mg/ml (300 mg dose)2 PA, QL (2 syringes/28

days), SPCUTTER BACKWOODS – diethyltoluamide (deet) aerosol 2CUTTER SKINSATIONS – diethyltoluamide (deet) liquid 2diclofenac sodium gel 1% (Voltaren) 1 QL (200 grams/30 days)FLUOROURACIL – fluorouracil soln 2% 2FLUOROURACIL – fluorouracil soln 5% 2

Page 113 of 152

2020


SF = Split Fill

114




fluorouracil cream 5% (Efudex) 1 QL (240 grams/180 days)imiquimod cream 5% (Aldara) 1 QL (48 packets/180 days)lidocaine hcl gel 2% 1 PA, QL (120

grams/30 days)LIDOCAINE HCL JELLY – lidocaine hcl urethral/mucosal gel 2% 2 PA, QL (120

grams/30 days)lidocaine hcl soln 4% 1 PA, QL (120

grams/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 1 PA, QL (120

grams/30 days)lidocaine patch 5% (Lidoderm) 1 PA, QL (90

patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 1 PA, QL (30

grams/60 days)malathion lotion 0.5% (Ovide) 1methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1NATRAPEL 12-HOUR TICK & INSECT REPELLENT

CONTINUOUS SPRAY – picaridin aerosol2

OFF ACTIVE – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS DRY – diethyltoluamide (deet) aerosol 2OFF SMOOTH & DRY – diethyltoluamide (deet) aerosol 2permethrin cream 5% (Elimite) 1podofilox soln 0.5% 1REPEL SPORTSMEN – diethyltoluamide (deet) aerosol 2REPEL SPORTSMEN MAX – diethyltoluamide (deet) aerosol 2SAWYER PREMIUM INSECT REPELLENT – picaridin liquid 2selenium sulfide lotion 2.5% 1selenium sulfide shampoo 2.25% 1STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 2 PA, QL (1 syringe/84

days), SPSTELARA – ustekinumab soln prefilled syringe 90 mg/ml 2 PA, QL (1 syringe/56

days), SPtacrolimus oint 0.03% (Protopic) 1 QL (60 days

supply/120 days), STtacrolimus oint 0.1% (Protopic) 1 QL (60 days

supply/120 days), ST

Page 114 of 152

2020


SF = Split Fill

115




TALTZ – ixekizumab subcutaneous soln auto-injector 80 mg/ml 2 PA, QL (1 syringe/28days), SP

TALTZ – ixekizumab subcutaneous soln prefilled syringe 80 mg/ml


TARGRETIN – bexarotene gel 1% 2 SPVALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) 2 PA, SP

CATEGORÍAS VARIASSUMINISTROS PARA DIABÉTICOSBlood Glucose Monitors, Test Strips, and Monitor Calibration LiquidsONETOUCH ULTRA BLUE – glucose blood test strip 2 QL (102 strips/30

days w/o insulinor 153 strips/30

days w/ insulin), STONETOUCH ULTRA CONTROL – blood glucose calibration -

liquid2

ONETOUCH ULTRA MINI – blood glucose monitoring kit w/device

2 QL (2 systems/365 days)

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO CONTROL SOLUTION HIGH –

blood glucose calibration - liquid - high2

ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORINGSYSTEM – blood glucose monitoring kit w/ device


ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORINGSYSTEM – blood glucose monitoring kit w/ device


ONETOUCH VERIO MID CONTROL SOLUTION –blood glucose calibration - liquid

2

ONETOUCH VERIO TEST STRIPS – glucose blood test strip 2 QL (102 strips/30days w/o insulinor 153 strips/30

days w/ insulin), ST

Other Diabetic SuppliesINSULIN PEN NEEDLES - TECHLITE AND TRUEPLUS

PRODUCTS2 QL (200 insulin pen

needles/30 days)INSULIN SYRINGES - TECHLITE AND TRUEPLUS

PRODUCTS2 QL (200

syringes/30 days)ONETOUCH DELICA LANCING DEVICE – lancet devices 2ONETOUCH DELICA PLUS LANCING DEVICE – lancet devices 2ONETOUCH SURESOFT LANCING DEVICE – lancets misc. 2 QL (200 units/30 days)

Page 115 of 152

2020


SF = Split Fill

116




MEDICAMENTOS VARIOSazathioprine tab 50 mg (Imuran) 1CHEMET – succimer cap 100 mg 2cyclosporine cap 25 mg (Sandimmune) 1cyclosporine cap 100 mg (Sandimmune) 1cyclosporine modified cap 25 mg (Neoral) 1cyclosporine modified cap 50 mg 1cyclosporine modified cap 100 mg (Neoral) 1cyclosporine modified oral soln 100 mg/ml (Neoral) 1deferasirox tab for oral susp 125 mg (Exjade) 2 PA, QL (30 tablets/30

days), SPdeferasirox tab for oral susp 250 mg (Exjade) 2 PA, QL (30 tablets/30

days), SPdeferasirox tab for oral susp 500 mg (Exjade) 2 PA, QL (90 tablets/30

days), SPDEPEN TITRATABS – penicillamine tab 250 mg 2 PA, SPFERRIPROX – deferiprone oral soln 100 mg/ml 2 PA, QL (2700

mls/30 days), SPFERRIPROX – deferiprone tab 500 mg 2 PA, QL (540

tablets/30 days), SPFERRIPROX – deferiprone tab 1000 mg 2 PA, QL (270

tablets/30 days), SPirrigation solution, physiological 1lactated ringer's for irrigation 1mycophenolate mofetil cap 250 mg (Cellcept) 1mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1mycophenolate mofetil tab 500 mg (Cellcept) 1mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

(Myfortic)1

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)(Myfortic)

1

naltrexone hcl tab 50 mg 1NARCAN – naloxone hcl nasal spray 4 mg/0.1ml 2penicillamine cap 250 mg (Cuprimine) 2 PA, SPpenicillamine tab 250 mg (Depen titratabs) 2 PA, SPREVLIMID – lenalidomide caps 2.5 mg 2 PA, QL (30 capsules/30

days), SP

Page 116 of 152

2020


SF = Split Fill

117




REVLIMID – lenalidomide cap 5 mg 2 PA, QL (30 capsules/30days), SP





ringer's solution for irrigation 1sirolimus tab 0.5 mg (Rapamune) 1sirolimus tab 1 mg (Rapamune) 1sirolimus tab 2 mg (Rapamune) 1sodium polystyrene sulfonate oral susp 15 gm/60ml 1sodium polystyrene sulfonate powder 1sodium polystyrene sulfonate rectal susp 30 gm/120ml 1tacrolimus cap 0.5 mg (Prograf) 1tacrolimus cap 1 mg (Prograf) 1tacrolimus cap 5 mg (Prograf) 1THALOMID – thalidomide cap 50 mg 2 PA, QL (30 capsules/30

days), SPTHALOMID – thalidomide cap 100 mg 2 PA, QL (30 capsules/30



days), SPtrientine hcl cap 250 mg (Syprine) 1 PA, QL (240

capsules/30 days), SPVIVITROL – naltrexone for im extended release susp 380 mg 2 QL (1 vial/28 days), SPwater for irrigation, sterile irrigation soln 1ZORTRESS – everolimus tab 0.25 mg 2ZORTRESS – everolimus tab 0.5 mg 2ZORTRESS – everolimus tab 0.75 mg 2ZORTRESS – everolimus tab 1 mg 2

Page 117 of 152

2020

118

INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg(Epzicom).......................................................................... 11

abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)....................................................................... 11

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)...... 11abacavir sulfate tab 300 mg (base equiv) (Ziagen)...........11ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................68

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................68

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................68

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................68

abiraterone acetate tab 250 mg (Zytiga)...........................18acamprosate calcium tab delayed release 333 mg...........81acarbose tab 25 mg (Precose)..........................................33acarbose tab 50 mg (Precose)..........................................33acarbose tab 100 mg (Precose)........................................33acebutolol hcl cap 200 mg.................................................43acebutolol hcl cap 400 mg.................................................43ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE –acetaminophen-caffeine-dihydrocodeine cap320.5-30-16 mg................................................................ 82

acetaminophen w/ codeine soln 120-12 mg/5ml...............82acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................82

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 82

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 82

acetazolamide cap er 12hr 500 mg...................................49acetazolamide tab 125 mg................................................ 49acetazolamide tab 250 mg................................................ 49acetic acid otic soln 2%...................................................109acetylcysteine cap 600 mg.............................................. 100acetylcysteine inhal soln 10%............................................54acetylcysteine inhal soln 20%............................................54acitretin cap 17.5 mg....................................................... 113acitretin cap 10 mg (Soriatane)....................................... 113acitretin cap 25 mg (Soriatane)....................................... 113ACTHAR – corticotropin inj gel 80 unit/ml.........................37ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................18

acyclovir cap 200 mg (Zovirax)......................................... 11acyclovir oint 5% (Zovirax).............................................. 111acyclovir susp 200 mg/5ml (Zovirax).................................11acyclovir tab 400 mg (Zovirax).......................................... 11acyclovir tab 800 mg (Zovirax).......................................... 11ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml..........................................................................16

adapalene cream 0.1% (Differin).....................................110

ADASUVE – loxapine aerosol powder breath activated 10mg......................................................................................68

adefovir dipivoxil tab 10 mg (Hepsera)..............................10ADEMPAS – riociguat tab 0.5 mg..................................... 51ADEMPAS – riociguat tab 1 mg........................................ 51ADEMPAS – riociguat tab 1.5 mg..................................... 51ADEMPAS – riociguat tab 2 mg........................................ 51ADEMPAS – riociguat tab 2.5 mg..................................... 51ADMELOG – insulin lispro inj 100 unit/ml......................... 35ADMELOG SOLOSTAR – insulin lispro soln pen-injector100 unit/ml (1 unit dial).................................................... 35

ADVATE – antihemophilic factor rahf-pfm for inj 250unit...................................................................................100







ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 250 unit................................................................ 100



ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 1000 unit.............................................................. 100




AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................18



AFINITOR – everolimus tab 10 mg................................... 18AFLURIA QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................16

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 16

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

albendazole tab 200 mg (Albenza)....................................15ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg.................................................................................. 55

Page 118 of 152

2020

119

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg.................................................................................. 55

ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero108 mcg/act (90mcg base equiv).................................... 55

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............55albuterol sulfate soln nebu 0.5% (5 mg/ml).......................55albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......55albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......55albuterol sulfate syrup 2 mg/5ml....................................... 55albuterol sulfate tab 2 mg..................................................55albuterol sulfate tab 4 mg..................................................55alclometasone dipropionate cream 0.05%...................... 111alclometasone dipropionate oint 0.05%.......................... 111ALECENSA – alectinib hcl cap 150 mg (baseequivalent).........................................................................18

ALENDRONATE SODIUM – alendronate sodium tab 5mg......................................................................................37

alendronate sodium tab 10 mg..........................................37alendronate sodium tab 35 mg..........................................37alendronate sodium tab 70 mg (Fosamax)....................... 38alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................62ALINIA – nitazoxanide tab 500 mg....................................15ALKERAN – melphalan tab 2 mg......................................18allopurinol tab 100 mg (Zyloprim)......................................91allopurinol tab 300 mg (Zyloprim)......................................91almotriptan malate tab 6.25 mg.........................................90almotriptan malate tab 12.5 mg.........................................90ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 33

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 33

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 33



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 33



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................33

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................33

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................33

alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 60alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 60ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 250 unit...........................................100

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 500 unit...........................................100

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 1000 unit.........................................101



ALPHANINE SD – coagulation factor ix for inj 500unit...................................................................................101



ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml.......................................................................................63

alprazolam tab er 24hr 0.5 mg (Xanax xr)........................ 63alprazolam tab er 24hr 1 mg (Xanax xr)........................... 63alprazolam tab er 24hr 2 mg (Xanax xr)........................... 63alprazolam tab er 24hr 3 mg (Xanax xr)........................... 63alprazolam tab 0.25 mg (Xanax)....................................... 63alprazolam tab 0.5 mg (Xanax)......................................... 63alprazolam tab 1 mg (Xanax)............................................ 63alprazolam tab 2 mg (Xanax)............................................ 63amantadine hcl cap 100 mg.............................................. 95amantadine hcl syrup 50 mg/5ml...................................... 95ambrisentan tab 5 mg (Letairis).........................................51ambrisentan tab 10 mg (Letairis).......................................51amiloride & hydrochlorothiazide tab 5-50 mg....................49amiloride hcl tab 5 mg....................................................... 49amino acids cap............................................................... 100amiodarone hcl tab 200 mg...............................................50amitriptyline hcl tab 10 mg.................................................64amitriptyline hcl tab 25 mg.................................................64amitriptyline hcl tab 50 mg.................................................64amitriptyline hcl tab 75 mg.................................................64amitriptyline hcl tab 100 mg...............................................64amitriptyline hcl tab 150 mg...............................................64amlodipine besylate-benazepril hcl cap 2.5-10 mg...........44amlodipine besylate-benazepril hcl cap 5-40 mg..............44amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 44

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 44



amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................44

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................44

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................44

AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin& k clavulanate chew tab 200-28.5 mg............................. 7

AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin& k clavulanate chew tab 400-57 mg................................ 7

Page 119 of 152

2020

120

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 7amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 7amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................7

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)............................................................ 7

amoxicillin & k clavulanate tab 250-125 mg........................7amoxicillin & k clavulanate tab 875-125 mg........................7amoxicillin & k clavulanate tab 500-125 mg(Augmentin).........................................................................7

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................7

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................7

amoxicillin (trihydrate) cap 250 mg......................................7amoxicillin (trihydrate) cap 500 mg......................................7amoxicillin (trihydrate) for susp 125 mg/5ml........................7amoxicillin (trihydrate) for susp 200 mg/5ml........................7amoxicillin (trihydrate) for susp 250 mg/5ml........................7amoxicillin (trihydrate) for susp 400 mg/5ml........................7amoxicillin (trihydrate) tab 875 mg...................................... 7amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 76

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................... 76





amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................77

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................77


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................77




AMPICILLIN – ampicillin cap 500 mg..................................7anagrelide hcl cap 1 mg.................................................. 101anagrelide hcl cap 0.5 mg (Agrylin).................................101anastrozole tab 1 mg (Arimidex)....................................... 18APLENZIN – bupropion hbr tab er 24hr 174 mg...............64APLENZIN – bupropion hbr tab er 24hr 348 mg...............64APLENZIN – bupropion hbr tab er 24hr 522 mg...............64apraclonidine hcl ophth soln 0.5% (base equivalent)......108aprepitant capsule 40 mg (Emend)................................... 59

aprepitant capsule 80 mg (Emend)................................... 59aprepitant capsule 125 mg (Emend)................................. 59APTIOM – eslicarbazepine acetate tab 200 mg................91APTIOM – eslicarbazepine acetate tab 400 mg................91APTIOM – eslicarbazepine acetate tab 600 mg................91APTIOM – eslicarbazepine acetate tab 800 mg................91APTIVUS – tipranavir cap 250 mg.................................... 11APTIVUS – tipranavir oral soln 100 mg/ml....................... 11ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml.............................................................................101

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml.............................................................................101

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml.............................................................................102

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml..................................................................... 102



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml.......................................101

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.....................................101







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml.......................................... 101

ARCALYST – rilonacept for inj 220 mg.............................87aripiprazole orally disintegrating tab 10 mg.......................68aripiprazole orally disintegrating tab 15 mg.......................69aripiprazole oral solution 1 mg/ml......................................68aripiprazole tab 2 mg (Abilify)............................................69aripiprazole tab 5 mg (Abilify)............................................69aripiprazole tab 10 mg (Abilify)..........................................69aripiprazole tab 15 mg (Abilify)..........................................69aripiprazole tab 20 mg (Abilify)..........................................69aripiprazole tab 30 mg (Abilify)..........................................69ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................69

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................69

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................69

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................69

Page 120 of 152

2020

121

ARISTADA INITIO – aripiprazole lauroxil im er suspprefilled syr 675 mg/2.4ml................................................69

armodafinil tab 50 mg (Nuvigil)..........................................77armodafinil tab 150 mg (Nuvigil)........................................77armodafinil tab 200 mg (Nuvigil)........................................77armodafinil tab 250 mg (Nuvigil)........................................77ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 50 mcg/act....................................................55

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................55

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................55

atazanavir sulfate cap 150 mg (base equiv) (Reyataz).....11atazanavir sulfate cap 200 mg (base equiv) (Reyataz).....11atazanavir sulfate cap 300 mg (base equiv) (Reyataz).....11atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......43atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 43

atenolol tab 25 mg (Tenormin).......................................... 43atenolol tab 50 mg (Tenormin).......................................... 43atenolol tab 100 mg (Tenormin)........................................ 43atomoxetine hcl cap 10 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 18 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 25 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 40 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 60 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 80 mg (base equiv) (Strattera)......... 77atomoxetine hcl cap 100 mg (base equiv) (Strattera)....... 78atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 47

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 47



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...... 14atovaquone-proguanil hcl tab 250-100 mg (Malarone)..... 15ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg............................................................... 11

ATROPINE SULFATE – atropine sulfate ophth oint1%................................................................................... 108

ATROPINE SULFATE – atropine sulfate ophth soln1%................................................................................... 108

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 55

AUBAGIO – teriflunomide tab 7 mg.................................. 80AUBAGIO – teriflunomide tab 14 mg................................ 80AUGMENTED BETAMETHASONE DIPROPIONATE –betamethasone dipropionate augmented gel 0.05%.....111

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................80

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................80

azathioprine tab 50 mg (Imuran)..................................... 116azelaic acid gel 15% (Finacea)....................................... 110

azelastine hcl nasal spray 0.1% (137 mcg/spray).............54azelastine hcl ophth soln 0.05%......................................108AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................8

azithromycin for susp 100 mg/5ml (Zithromax)...................8azithromycin for susp 200 mg/5ml (Zithromax)...................8azithromycin tab 250 mg (Zithromax)..................................8azithromycin tab 500 mg (Zithromax)..................................8azithromycin tab 600 mg (Zithromax)..................................8

BBACITRACIN – bacitracin ophth oint 500 unit/gm.......... 107bacitracin-polymyxin b ophth oint.................................... 107bacitracin-polymyxin-neomycin-hc ophth oint 1%........... 107baclofen tab 10 mg............................................................ 96baclofen tab 20 mg............................................................ 96balsalazide disodium cap 750 mg (Colazal)......................60BALVERSA – erdafitinib tab 3 mg.....................................18BALVERSA – erdafitinib tab 4 mg.....................................18BALVERSA – erdafitinib tab 5 mg.....................................18BARACLUDE – entecavir oral soln 0.05 mg/ml................ 10BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 36

b-complex w/ c & folic acid cap 1 mg................................97b-complex w/ c & folic acid tab..........................................97b-complex w/ c & folic acid tab 5 mg................................ 97b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......97benazepril & hydrochlorothiazide tab 5-6.25 mg...............40benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................40

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................40

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................40

benazepril hcl tab 5 mg..................................................... 40benazepril hcl tab 10 mg (Lotensin)..................................40benazepril hcl tab 20 mg (Lotensin)..................................40benazepril hcl tab 40 mg (Lotensin)..................................40BENEFIX – coagulation factor ix (recombinant) for inj kit250 unit........................................................................... 102

BENEFIX – coagulation factor ix (recombinant) for inj kit500 unit........................................................................... 102

BENEFIX – coagulation factor ix (recombinant) for inj kit1000 unit......................................................................... 102



BENZNIDAZOLE – benznidazole tab 12.5 mg................. 15BENZNIDAZOLE – benznidazole tab 100 mg.................. 15benzoyl peroxide cloth 6%...............................................110benzoyl peroxide-erythromycin gel 5-3%(Benzamycin).................................................................. 110

benztropine mesylate tab 0.5 mg...................................... 95benztropine mesylate tab 1 mg......................................... 95benztropine mesylate tab 2 mg......................................... 95

Page 121 of 152

2020

122

BERINERT – c1 esterase inhibitor (human) for iv inj kit500 unit........................................................................... 102

betamethasone dipropionate augmented cream 0.05%(Diprolene af)..................................................................111

betamethasone dipropionate augmented lotion0.05%.............................................................................. 111

betamethasone dipropionate augmented oint 0.05%(Diprolene)...................................................................... 111

betamethasone dipropionate cream 0.05%.....................111betamethasone dipropionate lotion 0.05%......................111betamethasone dipropionate oint 0.05%.........................112betamethasone valerate cream 0.1% (baseequivalent).......................................................................112

betamethasone valerate lotion 0.1% (baseequivalent).......................................................................112

betamethasone valerate oint 0.1% (base equivalent).....112betaxolol hcl ophth soln 0.5%..........................................108betaxolol hcl tab 10 mg..................................................... 43betaxolol hcl tab 20 mg..................................................... 43bethanechol chloride tab 5 mg (Urecholine)..................... 61bethanechol chloride tab 10 mg (Urecholine)................... 61bethanechol chloride tab 25 mg (Urecholine)................... 61bethanechol chloride tab 50 mg (Urecholine)................... 61BEVESPI AEROSPHERE – glycopyrrolate-formoterolfumarate aerosol 9-4.8 mcg/act.......................................55

bexarotene cap 75 mg (Targretin)..................................... 18bicalutamide tab 50 mg (Casodex)....................................18BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg................................................................... 11

bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for solnkit....................................................................................... 58

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 43

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......43bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 43

bisoprolol fumarate tab 5 mg.............................................43bisoprolol fumarate tab 10 mg...........................................43BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml.......................................................................16

bosentan tab 62.5 mg (Tracleer)....................................... 51bosentan tab 125 mg (Tracleer)........................................ 51BOSULIF – bosutinib tab 100 mg..................................... 18BOSULIF – bosutinib tab 500 mg..................................... 18BRAFTOVI – encorafenib cap 75 mg................................18BRILINTA – ticagrelor tab 60 mg.................................... 102BRILINTA – ticagrelor tab 90 mg.................................... 102brimonidine tartrate ophth soln 0.2%...............................108bromocriptine mesylate cap 5 mg (base equivalent)(Parlodel)...........................................................................95

bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................95

budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................28

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 55budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 55

budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 55bumetanide tab 0.5 mg (Bumex).......................................49bumetanide tab 1 mg (Bumex)..........................................49bumetanide tab 2 mg (Bumex)..........................................49BUPHENYL – sodium phenylbutyrate tab 500 mg............38buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv) (Suboxone)............................................................ 83

buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv) (Suboxone)............................................................ 83



buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................83

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................83

buprenorphine hcl sl tab 2 mg (base equiv)......................83buprenorphine hcl sl tab 8 mg (base equiv)......................83bupropion hcl (smoking deterrent) tab er 12hr 150 mg.....81bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............64bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............64bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............64bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 64bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 64bupropion hcl tab 75 mg....................................................64bupropion hcl tab 100 mg..................................................64BUPROPION HYDROCHLORIDE ER – bupropion hcl taber 24hr 450 mg.................................................................64

buspirone hcl tab 5 mg...................................................... 63buspirone hcl tab 10 mg....................................................63buspirone hcl tab 15 mg....................................................63buspirone hcl tab 30 mg....................................................63butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 82

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 82

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................83

butalbital-acetaminophen tab 50-325 mg..........................82butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....82butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................83

butorphanol tartrate nasal soln 10 mg/ml..........................83

Ccabergoline tab 0.5 mg...................................................... 38CABOMETYX – cabozantinib s-malate tab 20 mg (baseequivalent).........................................................................18

CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent).........................................................................18

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent).........................................................................19

caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................78

calcipotriene cream 0.005% (Dovonex).......................... 113

Page 122 of 152

2020

123

calcipotriene oint 0.005%.................................................113calcipotriene soln 0.005% (50 mcg/ml)........................... 113calcitonin (salmon) nasal soln 200 unit/act....................... 38calcitriol cap 0.25 mcg (Rocaltrol)..................................... 38calcitriol cap 0.5 mcg (Rocaltrol)....................................... 38calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 38calcium acetate (phosphate binder) cap 667 mg (169 mgca)......................................................................................60

calcium acetate (phosphate binder) tab 667 mg...............60CALQUENCE – acalabrutinib cap 100 mg........................19capecitabine tab 150 mg (Xeloda).....................................19capecitabine tab 500 mg (Xeloda).....................................19CAPRELSA – vandetanib tab 100 mg.............................. 19CAPRELSA – vandetanib tab 300 mg.............................. 19CAPTOPRIL/HYDROCHLOROTHIAZIDE – captopril &hydrochlorothiazide tab 25-15 mg................................... 40

CAPTOPRIL/HYDROCHLOROTHIAZIDE – captopril &hydrochlorothiazide tab 25-25 mg................................... 40



captopril tab 12.5 mg......................................................... 40captopril tab 25 mg............................................................ 40captopril tab 50 mg............................................................ 40captopril tab 100 mg.......................................................... 40CARBAGLU – carglumic acid tab 200 mg........................ 38carbamazepine cap er 12hr 100 mg (Carbatrol)............... 91carbamazepine cap er 12hr 200 mg (Carbatrol)............... 91carbamazepine cap er 12hr 300 mg (Carbatrol)............... 92carbamazepine chew tab 100 mg..................................... 92carbamazepine susp 100 mg/5ml (Tegretol).....................92carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............92carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............92carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............92carbamazepine tab 200 mg (Tegretol).............................. 92carbidopa & levodopa orally disintegrating tab 10-100mg......................................................................................95

carbidopa & levodopa orally disintegrating tab 25-100mg......................................................................................95

carbidopa & levodopa orally disintegrating tab 25-250mg......................................................................................95

carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 95carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 95carbidopa & levodopa tab 10-100 mg (Sinemet)...............95carbidopa & levodopa tab 25-100 mg (Sinemet)...............95carbidopa & levodopa tab 25-250 mg (Sinemet)...............95carbidopa tab 25 mg (Lodosyn).........................................95CARBINOXAMINE MALEATE – carbinoxamine maleatesoln 4 mg/5ml................................................................... 54

carbinoxamine maleate tab 4 mg...................................... 54CARTEOLOL HCL – carteolol hcl ophth soln 1%........... 108carvedilol tab 3.125 mg (Coreg)........................................43carvedilol tab 6.25 mg (Coreg)..........................................43carvedilol tab 12.5 mg (Coreg)..........................................43carvedilol tab 25 mg (Coreg).............................................43

CAYSTON – aztreonam lysine for inhal soln 75 mg (baseequivalent).........................................................................15

cefaclor cap 250 mg............................................................ 7cefaclor cap 500 mg............................................................ 7cefadroxil cap 500 mg..........................................................7cefadroxil for susp 250 mg/5ml........................................... 8cefadroxil for susp 500 mg/5ml........................................... 8cefadroxil tab 1 gm.............................................................. 8cefdinir cap 300 mg............................................................. 8cefdinir for susp 125 mg/5ml............................................... 8cefdinir for susp 250 mg/5ml............................................... 8cefixime for susp 100 mg/5ml (Suprax)...............................8cefixime for susp 200 mg/5ml (Suprax)...............................8cefprozil for susp 125 mg/5ml............................................. 8cefprozil for susp 250 mg/5ml............................................. 8cefprozil tab 250 mg............................................................ 8cefprozil tab 500 mg............................................................ 8cefuroxime axetil tab 250 mg.............................................. 8cefuroxime axetil tab 500 mg.............................................. 8celecoxib cap 50 mg (Celebrex)........................................87celecoxib cap 100 mg (Celebrex)......................................87celecoxib cap 200 mg (Celebrex)......................................87celecoxib cap 400 mg (Celebrex)......................................87CEM-UREA – urea soln 45%.......................................... 113cephalexin cap 250 mg (Keflex)..........................................8cephalexin cap 500 mg (Keflex)..........................................8cephalexin for susp 125 mg/5ml..........................................8cephalexin for susp 250 mg/5ml..........................................8CERAMAX – dermatological products misc - cream.......113CERDELGA – eliglustat tartrate cap 84 mg (baseequivalent).......................................................................102

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................54CHANTIX CONTINUING MONTH PAK – vareniclinetartrate tab 1 mg (base equiv)......................................... 81

CHANTIX STARTING MONTH PAK – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 81

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................81

CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 81CHEMET – succimer cap 100 mg...................................116CHENODAL – chenodiol tab 250 mg................................60CHLORDIAZEPOXIDE/AMITRIPTYLINE –chlordiazepoxide-amitriptyline tab 5-12.5 mg..................81

CHLORDIAZEPOXIDE/AMITRIPTYLINE –chlordiazepoxide-amitriptyline tab 10-25 mg...................81

chlordiazepoxide hcl cap 5 mg..........................................63chlordiazepoxide hcl cap 10 mg........................................63chlordiazepoxide hcl cap 25 mg........................................63chlorhexidine gluconate soln 0.12% (Peridex)................ 109CHLOROQUINE PHOSPHATE – chloroquine phosphatetab 250 mg....................................................................... 15

chloroquine phosphate tab 500 mg...................................15CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 49CHLOROTHIAZIDE – chlorothiazide tab 500 mg............. 49CHLORPROMAZINE HCL – chlorpromazine hcl inj 25mg/ml.................................................................................69

Page 123 of 152

2020

124

CHLORPROMAZINE HCL – chlorpromazine hcl inj 50mg/2ml...............................................................................69

chlorpromazine hcl tab 10 mg........................................... 69chlorpromazine hcl tab 25 mg........................................... 69chlorpromazine hcl tab 50 mg........................................... 69chlorpromazine hcl tab 100 mg......................................... 69chlorpromazine hcl tab 200 mg......................................... 69chlorthalidone tab 25 mg................................................... 49chlorthalidone tab 50 mg................................................... 49chlorzoxazone tab 500 mg................................................ 96CHOLBAM – cholic acid cap 50 mg..................................60CHOLBAM – cholic acid cap 250 mg................................60cholecalciferol cap 125 mcg (5000 unit)............................97cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................47

cholestyramine light powder packets 4 gm....................... 47cholestyramine powder 4 gm/dose (Questran)................. 47cholestyramine powder packets 4 gm (Questran).............47choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................47

CHORIONIC GONADOTROPIN – chorionic gonadotropinfor im inj 10000 unit......................................................... 32

ciclopirox olamine cream 0.77% (base equiv)(Loprox)...........................................................................111

ciclopirox olamine susp 0.77% (base equiv)(Loprox)...........................................................................111

ciclopirox solution 8% (Penlac Nail Lacquer)..................111cilostazol tab 50 mg.........................................................102cilostazol tab 100 mg.......................................................102CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg.......................................................................11

CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml........58CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml...........60CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200mg/ml.................................................................................60

cinacalcet hcl tab 30 mg (base equiv) (Sensipar)............. 38cinacalcet hcl tab 60 mg (base equiv) (Sensipar)............. 38cinacalcet hcl tab 90 mg (base equiv) (Sensipar)............. 38ciprofloxacin hcl ophth soln 0.3% (base equivalent)(Ciloxan)..........................................................................107

ciprofloxacin hcl tab 750 mg (base equiv)...........................9ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............9ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............9citalopram hydrobromide oral soln 10 mg/5ml.................. 64citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................65

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................65

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................65

CLARITHROMYCIN – clarithromycin for susp 125mg/5ml.................................................................................8

CLARITHROMYCIN – clarithromycin for susp 250mg/5ml.................................................................................8

clarithromycin tab 250 mg................................................... 8clarithromycin tab 500 mg................................................... 8

CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................97

clindamycin hcl cap 75 mg (Cleocin).................................15clindamycin hcl cap 150 mg (Cleocin)...............................15clindamycin hcl cap 300 mg (Cleocin)...............................15clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr)........................................................ 15

clindamycin phosphate gel 1% (Cleocin-t)...................... 110clindamycin phosphate lotion 1% (Cleocin-t).................. 110clindamycin phosphate soln 1%...................................... 110clindamycin phosphate swab 1%.................................... 110clindamycin phosphate vaginal cream 2% (Cleocin).........62clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................. 110

clobetasol propionate emollient base cream 0.05%........112clobetasol propionate soln 0.05%................................... 112clonazepam orally disintegrating tab 0.125 mg.................92clonazepam orally disintegrating tab 0.25 mg...................92clonazepam orally disintegrating tab 0.5 mg.....................92clonazepam orally disintegrating tab 1 mg........................92clonazepam orally disintegrating tab 2 mg........................92clonazepam tab 0.5 mg (Klonopin)....................................92clonazepam tab 1 mg (Klonopin).......................................92clonazepam tab 2 mg (Klonopin).......................................92clonidine hcl tab er 12hr 0.1 mg (Kapvay)........................ 78clonidine hcl tab 0.1 mg (Catapres).................................. 51clonidine hcl tab 0.2 mg (Catapres).................................. 51clonidine hcl tab 0.3 mg (Catapres).................................. 51clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 51

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 51

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 51

clopidogrel bisulfate tab 300 mg (base equiv).................102clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)......102clorazepate dipotassium tab 3.75 mg................................63clorazepate dipotassium tab 15 mg...................................63clorazepate dipotassium tab 7.5 mg (Tranxene t).............63clotrimazole cream 1%.....................................................111clotrimazole soln 1%........................................................111clotrimazole troche 10 mg............................................... 109clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)....................................................................... 111

CLOZAPINE ODT – clozapine orally disintegrating tab12.5 mg.............................................................................69

CLOZAPINE ODT – clozapine orally disintegrating tab150 mg..............................................................................69

CLOZAPINE ODT – clozapine orally disintegrating tab200 mg..............................................................................69

clozapine orally disintegrating tab 25 mg (Fazaclo)..........70clozapine orally disintegrating tab 100 mg (Fazaclo)........70clozapine tab 50 mg (Clozapine).......................................70clozapine tab 200 mg (Clozapine).....................................70clozapine tab 25 mg (Clozaril)...........................................70clozapine tab 100 mg (Clozaril).........................................70

Page 124 of 152

2020

125

COAGADEX – coagulation factor x (human) for inj 250unit...................................................................................102

COAGADEX – coagulation factor x (human) for inj 500unit...................................................................................102

codeine sulfate tab 30 mg (Codeine sulfate).................... 83colchicine w/ probenecid tab 0.5-500 mg..........................91colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 47

colestipol hcl granules 5 gm (Colestid flavored)................47colestipol hcl tab 1 gm (Colestid)...................................... 47COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................29

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................29

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................55

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit......................................................................19

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit............................................................. 19

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit............................................................. 19

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg................................................................. 11

COPIKTRA – duvelisib cap 15 mg....................................19COPIKTRA – duvelisib cap 25 mg....................................19CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................28

CORVITA – multiple vitamins w/ minerals & fa tab 1.25mg......................................................................................97

COSENTYX – secukinumab subcutaneous pref syr 150mg/ml (300 mg dose).....................................................113

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml..........................................................113

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous auto-inj 150 mg/ml (300 mg dose)......... 113

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml..................113

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................19

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 60

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 60

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 60

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 60

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 60

CRIXIVAN – indinavir sulfate cap 200 mg.........................11CRIXIVAN – indinavir sulfate cap 400 mg.........................11cromolyn sodium ophth soln 4%..................................... 108cromolyn sodium soln nebu 20 mg/2ml.............................55CUTTER BACKWOODS – diethyltoluamide (deet)aerosol.............................................................................113

CUTTER SKINSATIONS – diethyltoluamide (deet)liquid................................................................................ 113

CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................97

cyanocobalamin inj 1000 mcg/ml.................................... 102cyclobenzaprine hcl tab 5 mg............................................96cyclobenzaprine hcl tab 10 mg..........................................96cyclopentolate hcl ophth soln 0.5% (Cyclogyl)................108cyclopentolate hcl ophth soln 1% (Cyclogyl)...................108cyclopentolate hcl ophth soln 2% (Cyclogyl)...................108cyclophosphamide cap 25 mg (Cyclophosphamide).........19cyclophosphamide cap 50 mg (Cyclophosphamide).........19cyclosporine cap 25 mg (Sandimmune)..........................116cyclosporine cap 100 mg (Sandimmune)........................116cyclosporine modified cap 50 mg....................................116cyclosporine modified cap 25 mg (Neoral)......................116cyclosporine modified cap 100 mg (Neoral)....................116cyclosporine modified oral soln 100 mg/ml (Neoral)....... 116cyproheptadine hcl syrup 2 mg/5ml...................................54cyproheptadine hcl tab 4 mg............................................. 54CYSTADANE – betaine powder for oral solution.............. 38CYSTAGON – cysteamine bitartrate cap 50 mg............... 62CYSTAGON – cysteamine bitartrate cap 150 mg............. 62CYSTARAN – cysteamine hcl ophth soln 0.44% (baseequivalent).......................................................................108

Ddanazol cap 50 mg............................................................ 29danazol cap 100 mg.......................................................... 29danazol cap 200 mg.......................................................... 29dantrolene sodium cap 100 mg.........................................96dantrolene sodium cap 25 mg (Dantrium).........................96dantrolene sodium cap 50 mg (Dantrium).........................96dapsone tab 25 mg............................................................15dapsone tab 100 mg..........................................................15DARAPRIM – pyrimethamine tab 25 mg...........................15darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)(Enablex)...........................................................................61

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)...........................................................................61

DAURISMO – glasdegib maleate tab 25 mg (baseequivalent).........................................................................19

DAURISMO – glasdegib maleate tab 100 mg (baseequivalent).........................................................................19

deferasirox tab for oral susp 125 mg (Exjade)................ 116deferasirox tab for oral susp 250 mg (Exjade)................ 116deferasirox tab for oral susp 500 mg (Exjade)................ 116DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg............................................................... 11

demeclocycline hcl tab 150 mg........................................... 8demeclocycline hcl tab 300 mg........................................... 8DEPEN TITRATABS – penicillamine tab 250 mg............116DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................. 12

desipramine hcl tab 50 mg................................................ 65desipramine hcl tab 75 mg................................................ 65

Page 125 of 152

2020

126

desipramine hcl tab 100 mg.............................................. 65desipramine hcl tab 150 mg.............................................. 65desipramine hcl tab 10 mg (Norpramin)............................65desipramine hcl tab 25 mg (Norpramin)............................65desloratadine tab 5 mg (Clarinex)..................................... 54desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................38

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 38

desmopressin acetate tab 0.1 mg (Ddavp)....................... 38desmopressin acetate tab 0.2 mg (Ddavp)....................... 38desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette)........................................................... 30

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg........................ 30

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg......... 30desonide cream 0.05% (Desowen)................................. 112desonide oint 0.05%........................................................ 112desoximetasone cream 0.05% (Topicort)........................112desoximetasone cream 0.25% (Topicort)........................112desoximetasone gel 0.05% (Topicort)............................. 112DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................28

dexamethasone elixir 0.5 mg/5ml......................................28DEXAMETHASONE SODIUM PHOSPHATE –dexamethasone sodium phosphate ophth soln0.1%................................................................................ 107

dexamethasone tab 0.5 mg............................................... 28dexamethasone tab 0.75 mg.............................................28dexamethasone tab 1.5 mg............................................... 28dexamethasone tab 4 mg.................................................. 28dexamethasone tab 6 mg.................................................. 28dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 78

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 78







dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 78dexmethylphenidate hcl tab 5 mg (Focalin)...................... 78dexmethylphenidate hcl tab 10 mg (Focalin).................... 78dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 78

dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine)....................................................................... 78

dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine)....................................................................... 78

dextroamphetamine sulfate oral solution 5 mg/5ml(Procentra)........................................................................ 78

dextroamphetamine sulfate tab 5 mg................................78dextroamphetamine sulfate tab 10 mg..............................78diazepam conc 5 mg/ml.....................................................63DIAZEPAM – diazepam oral soln 1 mg/ml........................63DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 2.5 mg.................................................................. 92

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 10 mg................................................................... 92

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 20 mg................................................................... 92

diazepam tab 2 mg (Valium)..............................................63diazepam tab 5 mg (Valium)..............................................63diazepam tab 10 mg (Valium)............................................63diclofenac potassium tab 50 mg........................................87diclofenac sodium gel 1% (Voltaren)...............................113diclofenac sodium ophth soln 0.1%.................................108diclofenac sodium tab delayed release 50 mg..................87diclofenac sodium tab delayed release 75 mg..................87diclofenac sodium tab er 24hr 100 mg..............................87dicloxacillin sodium cap 250 mg..........................................7dicloxacillin sodium cap 500 mg..........................................7dicyclomine hcl cap 10 mg................................................ 58dicyclomine hcl oral soln 10 mg/5ml................................. 58dicyclomine hcl tab 20 mg.................................................58didanosine delayed release capsule 250 mg (Videxec)......................................................................................12

DIDANOSINE – didanosine delayed release capsule 200mg......................................................................................12

DIDANOSINE – didanosine delayed release capsule 400mg......................................................................................12

DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 51digoxin oral soln 0.05 mg/ml (Digoxin)..............................51digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 51digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 51DILANTIN – phenytoin sodium extended cap 30 mg........92diltiazem hcl cap er 12hr 60 mg........................................44diltiazem hcl cap er 12hr 90 mg........................................45diltiazem hcl cap er 12hr 120 mg......................................45diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................45

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................45



diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 45



Page 126 of 152

2020

127




diltiazem hcl tab 90 mg......................................................45diltiazem hcl tab 30 mg (Cardizem)...................................45diltiazem hcl tab 60 mg (Cardizem)...................................45diltiazem hcl tab 120 mg (Cardizem).................................45DILT-XR – diltiazem hcl cap er 24hr 120 mg.................... 44DILT-XR – diltiazem hcl cap er 24hr 180 mg.................... 44DILT-XR – diltiazem hcl cap er 24hr 240 mg.................... 44diphenhydramine hcl cap 50 mg....................................... 54diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 58dipyridamole tab 25 mg................................................... 102dipyridamole tab 50 mg................................................... 102dipyridamole tab 75 mg................................................... 102disopyramide phosphate cap 100 mg (Norpace).............. 50disopyramide phosphate cap 150 mg (Norpace).............. 50disulfiram tab 250 mg (Antabuse)..................................... 81disulfiram tab 500 mg (Antabuse)..................................... 81divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................92

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 92



divalproex sodium tab er 24 hr 250 mg (Depakote er)......92divalproex sodium tab er 24 hr 500 mg (Depakote er)......92dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................50dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................50dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................50donepezil hydrochloride orally disintegrating tab 5 mg..... 81donepezil hydrochloride orally disintegrating tab 10mg......................................................................................81

donepezil hydrochloride tab 5 mg (Aricept).......................81donepezil hydrochloride tab 10 mg (Aricept).....................81DORAL – quazepam tab 15 mg........................................76dorzolamide hcl ophth soln 2% (Trusopt)........................108dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)..................................................................... 108

DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg(base eq)...........................................................................12

doxazosin mesylate tab 1 mg (Cardura)........................... 51doxazosin mesylate tab 2 mg (Cardura)........................... 52doxazosin mesylate tab 4 mg (Cardura)........................... 52doxazosin mesylate tab 8 mg (Cardura)........................... 52doxepin hcl cap 10 mg...................................................... 65doxepin hcl cap 25 mg...................................................... 65doxepin hcl cap 50 mg...................................................... 65doxepin hcl cap 75 mg...................................................... 65doxepin hcl cap 100 mg.................................................... 65doxepin hcl conc 10 mg/ml................................................65

DOXEPIN HCL – doxepin hcl cap 150 mg........................65doxycycline hyclate cap 50 mg............................................8doxycycline hyclate cap 100 mg (Vibramycin).................... 8doxycycline hyclate tab delayed release 50 mg (Doryx).....8doxycycline hyclate tab 20 mg............................................ 9doxycycline hyclate tab 100 mg.......................................... 9doxycycline monohydrate cap 50 mg..................................9doxycycline monohydrate cap 100 mg................................9doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 9

doxycycline monohydrate tab 50 mg...................................9doxycycline monohydrate tab 75 mg...................................9doxycycline monohydrate tab 100 mg.................................9drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)..................................................................................... 30

DROXIA – hydroxyurea cap 200 mg...............................102DROXIA – hydroxyurea cap 300 mg...............................102DROXIA – hydroxyurea cap 400 mg...............................102duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................65

duloxetine hcl enteric coated pellets cap 30 mg (base eq)(Cymbalta).........................................................................65

duloxetine hcl enteric coated pellets cap 60 mg (base eq)(Cymbalta).........................................................................65

dutasteride cap 0.5 mg (Avodart)...................................... 62dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............62dyphylline-guaifenesin liqd 100-100 mg/5ml..................... 56

EEDURANT – rilpivirine hcl tab 25 mg (baseequivalent).........................................................................12

efavirenz cap 50 mg (Sustiva)...........................................12efavirenz cap 200 mg (Sustiva).........................................12efavirenz tab 600 mg (Sustiva)..........................................12EFFERVESCENT POTASSIUM/CHLORIDE – potbicarbonate & chloride effer tab 25 meq......................... 99

ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5mg......................................................................................19

ELIGARD – leuprolide acetate (3 month) forsubcutaneous inj kit 22.5mg............................................ 19

ELIGARD – leuprolide acetate (4 month) forsubcutaneous inj kit 30 mg.............................................. 19

ELIGARD – leuprolide acetate (6 month) forsubcutaneous inj kit 45 mg.............................................. 19

ELIQUIS – apixaban tab 2.5 mg..................................... 102ELIQUIS – apixaban tab 5 mg........................................ 103ELIQUIS STARTER PACK – apixaban tab 5 mg............ 103ELLA – ulipristal acetate tab 30 mg.................................. 30EMSAM – selegiline td patch 24hr 6 mg/24hr...................65EMSAM – selegiline td patch 24hr 9 mg/24hr...................65EMSAM – selegiline td patch 24hr 12 mg/24hr.................65EMTRIVA – emtricitabine caps 200 mg............................ 12EMTRIVA – emtricitabine soln 10 mg/ml...........................12enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................40

Page 127 of 152

2020

128

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 40

enalapril maleate tab 2.5 mg (Vasotec).............................40enalapril maleate tab 5 mg (Vasotec)............................... 40enalapril maleate tab 10 mg (Vasotec)............................. 40enalapril maleate tab 20 mg (Vasotec)............................. 40ENBREL – etanercept for subcutaneous inj 25 mg...........87ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 87

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 87

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................87

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................87

ENGERIX-B – hepatitis b vaccine (recombinant) 10mcg/0.5ml..........................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml.......................................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10mcg/0.5ml..........................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20mcg/ml...............................................................................16

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............... 103enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............... 103enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............... 103enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............... 103enoxaparin sodium inj 100 mg/ml (Lovenox).................. 103enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............. 103enoxaparin sodium inj 150 mg/ml (Lovenox).................. 103entacapone tab 200 mg (Comtan).....................................95entecavir tab 0.5 mg (Baraclude)...................................... 10entecavir tab 1 mg (Baraclude)......................................... 10ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 45ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 45ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 45epinastine hcl ophth soln 0.05%......................................108epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)(Epipen-jr 2-pak)...............................................................54

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(Epipen 2-pak).................................................................. 54

EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................97

EQUETRO – carbamazepine (antipsychotic) cap er 12hr100 mg..............................................................................70



ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)............. 97ERIVEDGE – vismodegib cap 150 mg..............................19ERLEADA – apalutamide tab 60 mg.................................19erlotinib hcl tab 25 mg (base equivalent) (Tarceva).......... 20erlotinib hcl tab 100 mg (base equivalent) (Tarceva)........ 20erlotinib hcl tab 150 mg (base equivalent) (Tarceva)........ 20ERY – erythromycin pads 2%......................................... 110

erythromycin ophth oint 5 mg/gm....................................107erythromycin soln 2%.......................................................110ESBRIET – pirfenidone cap 267 mg................................. 57escitalopram oxalate soln 5 mg/5ml (base equiv).............65escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....65escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................65

escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................65

estazolam tab 1 mg........................................................... 76estazolam tab 2 mg........................................................... 76estradiol & norethindrone acetate tab 0.5-0.1 mg.............29estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................29

estradiol tab 0.5 mg (Estrace)........................................... 29estradiol tab 1 mg (Estrace).............................................. 29estradiol tab 2 mg (Estrace).............................................. 29estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 29

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 29




estradiol td patch weekly 0.025 mg/24hr (Climara)...........29estradiol td patch weekly 0.05 mg/24hr (Climara).............30estradiol td patch weekly 0.06 mg/24hr (Climara).............30estradiol td patch weekly 0.075 mg/24hr (Climara)...........30estradiol td patch weekly 0.1 mg/24hr (Climara)...............30estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................30

estradiol vaginal cream 0.1 mg/gm (Estrace)....................62estradiol vaginal tab 10 mcg (Vagifem).............................62ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gmmetered-dose pump)........................................................ 30

eszopiclone tab 1 mg (Lunesta)........................................ 76eszopiclone tab 2 mg (Lunesta)........................................ 76eszopiclone tab 3 mg (Lunesta)........................................ 76ethambutol hcl tab 100 mg (Myambutol).............................9ethambutol hcl tab 400 mg (Myambutol).............................9ethosuximide cap 250 mg (Zarontin).................................92ethosuximide soln 250 mg/5ml (Zarontin)......................... 92ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg....................................................................................30

etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr(Nuvaring)......................................................................... 30

ETOPOSIDE – etoposide cap 50 mg................................20everolimus tab 2.5 mg (Afinitor)........................................ 20everolimus tab 5 mg (Afinitor)........................................... 20everolimus tab 7.5 mg (Afinitor)........................................ 20EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)...................................................................... 12

exemestane tab 25 mg (Aromasin)................................... 20

Page 128 of 152

2020

129

EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................80

Ffamciclovir tab 125 mg.......................................................11famotidine for susp 40 mg/5ml.......................................... 58famotidine tab 20 mg (Pepcid).......................................... 58famotidine tab 40 mg (Pepcid).......................................... 58FANAPT – iloperidone tab 1 mg........................................70FANAPT – iloperidone tab 2 mg........................................70FANAPT – iloperidone tab 4 mg........................................70FANAPT – iloperidone tab 6 mg........................................70FANAPT – iloperidone tab 8 mg........................................70FANAPT – iloperidone tab 10 mg......................................70FANAPT – iloperidone tab 12 mg......................................70FANAPT TITRATION PACK – iloperidone tab 1 mg & 2mg & 4 mg & 6 mg titration pak...................................... 70

FARYDAK – panobinostat lactate cap 10 mg (baseequivalent).........................................................................20



fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg....................................................................................103

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg....................................................................................103

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cucap...................................................................................103

felbamate susp 600 mg/5ml (Felbatol)..............................92felbamate tab 400 mg (Felbatol)....................................... 92felbamate tab 600 mg (Felbatol)....................................... 92felodipine tab er 24hr 2.5 mg............................................ 45felodipine tab er 24hr 5 mg............................................... 45felodipine tab er 24hr 10 mg............................................. 45fenofibrate micronized cap 43 mg..................................... 47fenofibrate micronized cap 67 mg..................................... 47fenofibrate micronized cap 134 mg................................... 47fenofibrate micronized cap 200 mg................................... 47fenofibrate tab 54 mg.........................................................47fenofibrate tab 160 mg.......................................................48fenofibrate tab 48 mg (Tricor)............................................ 47fenofibrate tab 145 mg (Tricor).......................................... 47fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................83fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................83fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................83fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................83fentanyl td patch 72hr 100 mcg/hr (Duragesic).................83FERRIPROX – deferiprone oral soln 100 mg/ml.............116FERRIPROX – deferiprone tab 500 mg..........................116FERRIPROX – deferiprone tab 1000 mg........................116ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg....................................................................................103

ferrous fumarate-folic acid tab 324-1 mg........................ 103FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (baseequivalent).........................................................................65

FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent).........................................................................66



FETZIMA TITRATION PACK – levomilnacipran hcl cap er24hr 20 & 40 mg therapy pack........................................66

finasteride tab 5 mg (Proscar)...........................................62FIRVANQ – vancomycin hcl for oral soln 25 mg/ml (baseequivalent).........................................................................15

FIRVANQ – vancomycin hcl for oral soln 50 mg/ml (baseequivalent).........................................................................15

flecainide acetate tab 50 mg............................................. 50flecainide acetate tab 100 mg........................................... 50flecainide acetate tab 150 mg........................................... 50FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 56

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 56

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 56

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 56

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 56

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 56

FLUAD 2019-2020 – influenza vac type a&b surface antadj susp pref syr 0.5 ml................................................... 16

FLUARIX QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

FLUBLOK QUADRIVALENT 2019-2020 – influenza vacrecomb ha quad pf soln pref syr 0.5 ml...........................16

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactiss-cult subunt quad susp pref syr 0.5 ml.......................17

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactissue-cultured subunit quadrivalent im susp.................. 17

fluconazole for susp 10 mg/ml (Diflucan)..........................10fluconazole for susp 40 mg/ml (Diflucan)..........................10fluconazole tab 50 mg (Diflucan).......................................10fluconazole tab 100 mg (Diflucan).....................................10fluconazole tab 150 mg (Diflucan).....................................10fluconazole tab 200 mg (Diflucan).....................................10flucytosine cap 250 mg (Ancobon)....................................10flucytosine cap 500 mg (Ancobon)....................................10fludrocortisone acetate tab 0.1 mg....................................28FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................17

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 17

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................54

fluocinolone acetonide cream 0.01%.............................. 112fluocinolone acetonide cream 0.025% (Synalar).............112

Page 129 of 152

2020

130

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca).............................................................. 112

fluocinolone acetonide oint 0.025% (Synalar).................112fluocinolone acetonide soln 0.01% (Synalar).................. 112fluocinonide cream 0.05%............................................... 112fluocinonide emulsified base cream 0.05%.....................112fluocinonide gel 0.05%.....................................................112fluocinonide oint 0.05%....................................................112fluocinonide soln 0.05%...................................................112fluorometholone ophth susp 0.1% (Fml liquifilm)............ 107fluorouracil cream 5% (Efudex)....................................... 114FLUOROURACIL – fluorouracil soln 2%.........................113FLUOROURACIL – fluorouracil soln 5%.........................113fluoxetine hcl cap 10 mg (Prozac).....................................66fluoxetine hcl cap 20 mg (Prozac).....................................66fluoxetine hcl cap 40 mg (Prozac).....................................66fluoxetine hcl solution 20 mg/5ml...................................... 66fluoxetine hcl tab 10 mg.................................................... 66fluoxetine hcl tab 20 mg.................................................... 66FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml.......................................................................................70

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................70

FLUPHENAZINE HCL – fluphenazine hcl tab 1 mg..........70FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg.......70FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg..........70FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg........70FLUPHENAZINE HYDROCHLORIDE – fluphenazine hclelixir 2.5 mg/5ml............................................................... 71

flurandrenolide cream 0.05% (Cordran)..........................112FLURBIPROFEN SODIUM – flurbiprofen sodium ophthsoln 0.03%...................................................................... 109

flurbiprofen tab 50 mg........................................................87flurbiprofen tab 100 mg......................................................88flutamide cap 125 mg........................................................ 20FLUTICASONE PROPIONATE/SALMETEROL –fluticasone-salmeterol aer powder ba 55-14 mcg/act......56

FLUTICASONE PROPIONATE/SALMETEROL –fluticasone-salmeterol aer powder ba 113-14 mcg/act......................................................................................56

FLUTICASONE PROPIONATE/SALMETEROL –fluticasone-salmeterol aer powder ba 232-14 mcg/act......................................................................................56

fluticasone propionate cream 0.05%............................... 112fluticasone propionate nasal susp 50 mcg/act.................. 54fluticasone propionate oint 0.005%................................. 112fluvastatin sodium tab er 24 hr 80 mg (base equivalent)(Lescol xl)..........................................................................48

fluvoxamine maleate tab 25 mg........................................ 66fluvoxamine maleate tab 50 mg........................................ 66fluvoxamine maleate tab 100 mg...................................... 66FLUZONE HIGH-DOSE PF 2019-2020 – influenza virusvac split high-dose pf susp pref syr 0.5ml....................... 17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent inj 0.5 ml.................................17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 17

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................97

FOLBIC – folic acid-pyridoxine-cyanocobalamin tab2.5-25-2 mg.................................................................... 100

folic acid tab 1 mg........................................................... 103folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg........103folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...........103folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx).................................................................................... 103

FORFIVO XL – bupropion hcl tab er 24hr 450 mg............66fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)..............................................................................12

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................40

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................40

fosinopril sodium tab 10 mg.............................................. 40fosinopril sodium tab 20 mg.............................................. 40fosinopril sodium tab 40 mg.............................................. 40frovatriptan succinate tab 2.5 mg (base equivalent)(Frova)...............................................................................90

FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml......................................................................... 103

furosemide oral soln 10 mg/ml.......................................... 49furosemide tab 20 mg (Lasix)............................................49furosemide tab 40 mg (Lasix)............................................49furosemide tab 80 mg (Lasix)............................................49FUZEON – enfuvirtide for inj 90 mg..................................12

Ggabapentin cap 100 mg (Neurontin)..................................92gabapentin cap 300 mg (Neurontin)..................................93gabapentin cap 400 mg (Neurontin)..................................93gabapentin oral soln 250 mg/5ml (Neurontin)...................93gabapentin tab 600 mg (Neurontin)...................................93gabapentin tab 800 mg (Neurontin)...................................93galantamine hydrobromide cap er 24hr 8 mg (Razadyneer)...................................................................................... 81

galantamine hydrobromide cap er 24hr 16 mg (Razadyneer)...................................................................................... 81

galantamine hydrobromide cap er 24hr 24 mg (Razadyneer)...................................................................................... 81

GALANTAMINE HYDROBROMIDE – galantaminehydrobromide oral soln 4 mg/ml...................................... 81

galantamine hydrobromide tab 4 mg (Razadyne).............81galantamine hydrobromide tab 8 mg (Razadyne).............81galantamine hydrobromide tab 12 mg (Razadyne)...........81GATTEX – teduglutide (rdna) for inj kit 5 mg.................... 60GAVILYTE-C – peg 3350-kcl-na bicarb-nacl-na sulfate forsoln 240 gm......................................................................58

Page 130 of 152

2020

131

gemfibrozil tab 600 mg (Lopid)..........................................48GENTAK – gentamicin sulfate ophth oint 0.3%...............107gentamicin sulfate cream 0.1%....................................... 111gentamicin sulfate oint 0.1%............................................111gentamicin sulfate ophth soln 0.3%.................................107GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg..........................................................12

GEODON – ziprasidone mesylate for inj 20 mg (baseequivalent).........................................................................71

GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent).........................................................................20



glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 80

GLEOSTINE – lomustine cap 10 mg................................ 20GLEOSTINE – lomustine cap 40 mg................................ 20GLEOSTINE – lomustine cap 100 mg.............................. 20glimepiride tab 1 mg (Amaryl)........................................... 33glimepiride tab 2 mg (Amaryl)........................................... 33glimepiride tab 4 mg (Amaryl)........................................... 33glipizide-metformin hcl tab 2.5-250 mg............................. 34glipizide-metformin hcl tab 2.5-500 mg............................. 34glipizide-metformin hcl tab 5-500 mg................................ 34glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 34glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 34glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 34glipizide tab 5 mg (Glucotrol).............................................34glipizide tab 10 mg (Glucotrol)...........................................34GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................34

glyburide-metformin tab 1.25-250 mg............................... 34glyburide-metformin tab 2.5-500 mg................................. 34glyburide-metformin tab 5-500 mg.....................................34glyburide tab 1.25 mg........................................................ 34glyburide tab 2.5 mg.......................................................... 34glyburide tab 5 mg............................................................. 34glycopyrrolate tab 1 mg..................................................... 58glycopyrrolate tab 2 mg..................................................... 58GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................97

GOODSENSE PRENATAL VITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 97

griseofulvin microsize susp 125 mg/5ml........................... 10griseofulvin microsize tab 500 mg.....................................10griseofulvin ultramicrosize tab 125 mg..............................10griseofulvin ultramicrosize tab 250 mg..............................10guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....79guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....79guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....79guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....79guanfacine hcl tab 1 mg.................................................... 52guanfacine hcl tab 2 mg.................................................... 52

GVOKE PFS – glucagon subcutaneous soln pref syringe0.5 mg/0.1ml..................................................................... 34

GVOKE PFS – glucagon subcutaneous soln pref syringe1 mg/0.2ml........................................................................ 34

HHAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit............................................ 103

HAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit............................................ 103

halobetasol propionate cream 0.05%..............................112halobetasol propionate oint 0.05%.................................. 112haloperidol lactate oral conc 2 mg/ml................................71haloperidol tab 0.5 mg....................................................... 71haloperidol tab 1 mg.......................................................... 71haloperidol tab 2 mg.......................................................... 71haloperidol tab 5 mg.......................................................... 71haloperidol tab 10 mg........................................................ 71haloperidol tab 20 mg........................................................ 71HEMOFIL M – antihemophilic factor (human) for inj 250unit...................................................................................103

HEMOFIL M – antihemophilic factor (human) for inj 500unit...................................................................................103



HEPLISAV-B – hepatitis b vaccine recomb adjuvantedpref syr 20 mcg/0.5ml...................................................... 17

HEPLISAV-B – hepatitis b vaccine recombinantadjuvanted 20 mcg/0.5ml.................................................17

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................97

homatropine hbr ophth soln 5%...................................... 109HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................36

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 36

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 36

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 36

HUMATE-P – antihemophilic factor/vwf (human) for inj250-600 unit....................................................................104

HUMATE-P – antihemophilic factor/vwf (human) for inj500-1200 unit..................................................................104

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit................................................................104

HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................88




Page 131 of 152

2020

132



HUMIRA PEDIATRIC CROHNS DISEASE STARTERPACK – adalimumab prefilled syringe kit 80mg/0.8ml............................................................................88

HUMIRA PEDIATRIC CROHNS DISEASE STARTERPACK – adalimumab prefilled syringe kit 80 mg/0.8ml &40 mg/0.4ml...................................................................... 88

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................88

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................88

HUMIRA PEN-CD/UC/HS STARTER – adalimumab pen-injector kit 40 mg/0.8ml....................................................88

HUMIRA PEN-CD/UC/HS STARTER – adalimumab pen-injector kit 80 mg/0.8ml....................................................88

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 40 mg/0.8ml....................................................88

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml........................... 88

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 36

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................36

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................36

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................36

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 35HYCAMTIN – topotecan hcl cap 0.25 mg (baseequiv).................................................................................20

HYCAMTIN – topotecan hcl cap 1 mg (base equiv)......... 20hydralazine hcl tab 10 mg................................................. 52hydralazine hcl tab 25 mg................................................. 52hydralazine hcl tab 50 mg................................................. 52hydralazine hcl tab 100 mg............................................... 52hydrochlorothiazide cap 12.5 mg.......................................49hydrochlorothiazide tab 12.5 mg....................................... 49hydrochlorothiazide tab 25 mg.......................................... 50hydrochlorothiazide tab 50 mg.......................................... 50hydrocodone-acetaminophen soln 7.5-325 mg/15ml........83hydrocodone-acetaminophen tab 7.5-300 mg...................84hydrocodone-acetaminophen tab 10-300 mg....................84hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 84hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 84hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 83hydrocodone-ibuprofen tab 7.5-200 mg............................ 84hydrocodone-ibuprofen tab 5-200 mg............................... 84hydrocortisone butyrate oint 0.1%...................................112hydrocortisone butyrate soln 0.1% (Locoid)....................112hydrocortisone cream 1%................................................ 112hydrocortisone cream 2.5%............................................. 112hydrocortisone enema 100 mg/60ml (Cortenema)..........110hydrocortisone lotion 2.5%.............................................. 112

hydrocortisone oint 1%.................................................... 112hydrocortisone oint 2.5%................................................. 112hydrocortisone rectal cream 2.5% (Anusol-hc)............... 110hydrocortisone rectal cream 1% (Proctocort)..................110hydrocortisone tab 5 mg (Cortef).......................................28hydrocortisone tab 10 mg (Cortef).....................................28hydrocortisone tab 20 mg (Cortef).....................................28hydrocortisone valerate cream 0.2%...............................112hydrocortisone valerate oint 0.2%................................... 113hydrocortisone w/ acetic acid otic soln 1-2%.................. 109hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................84hydromorphone hcl tab 2 mg (Dilaudid)............................84hydromorphone hcl tab 4 mg (Dilaudid)............................84hydromorphone hcl tab 8 mg (Dilaudid)............................84hydroxychloroquine sulfate tab 200 mg (Plaquenil).......... 15hydroxyurea cap 500 mg (Hydrea)....................................20hydroxyzine hcl syrup 10 mg/5ml......................................63hydroxyzine hcl tab 10 mg.................................................63hydroxyzine hcl tab 25 mg.................................................63hydroxyzine hcl tab 50 mg.................................................63hydroxyzine pamoate cap 25 mg (Vistaril)........................ 64hydroxyzine pamoate cap 50 mg (Vistaril)........................ 64hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 58hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)...............58hyoscyamine sulfate soln 0.125 mg/ml............................. 58hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........58hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 58hyoscyamine sulfate tab 0.125 mg (Levsin)......................58

Iibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................38

IBRANCE – palbociclib cap 75 mg....................................20IBRANCE – palbociclib cap 100 mg..................................20IBRANCE – palbociclib cap 125 mg..................................21ibuprofen susp 100 mg/5ml............................................... 88ibuprofen tab 400 mg.........................................................88ibuprofen tab 600 mg.........................................................88ibuprofen tab 800 mg.........................................................88icatibant acetate inj 30 mg/3ml (base equivalent)(Firazyr)...........................................................................104

ICLUSIG – ponatinib hcl tab 15 mg (base equiv)..............21ICLUSIG – ponatinib hcl tab 45 mg (base equiv)..............21imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................21

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................21

IMBRUVICA – ibrutinib cap 140 mg..................................21imipramine hcl tab 10 mg (Tofranil)...................................66imipramine hcl tab 25 mg (Tofranil)...................................66imipramine hcl tab 50 mg (Tofranil)...................................66imiquimod cream 5% (Aldara)......................................... 114IMITREX – sumatriptan nasal spray 5 mg/act...................91IMITREX – sumatriptan nasal spray 20 mg/act.................91IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdcinj....................................................................................... 17

Page 132 of 152

2020

133

IMPAVIDO – miltefosine cap 50 mg.................................. 15INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........37INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq).............................................. 56

indapamide tab 1.25 mg.................................................... 50indapamide tab 2.5 mg...................................................... 50indomethacin cap er 75 mg...............................................88indomethacin cap 25 mg................................................... 89indomethacin cap 50 mg................................................... 89INLYTA – axitinib tab 1 mg................................................21INLYTA – axitinib tab 5 mg................................................21INREBIC – fedratinib hcl cap 100 mg............................... 21INSULIN PEN NEEDLES - TECHLITE AND TRUEPLUSPRODUCTS....................................................................115

INSULIN SYRINGES - TECHLITE AND TRUEPLUSPRODUCTS....................................................................115

INTELENCE – etravirine tab 25 mg.................................. 12INTELENCE – etravirine tab 100 mg................................ 12INTELENCE – etravirine tab 200 mg................................ 12INVEGA – paliperidone tab er 24hr 1.5 mg...................... 71INVEGA – paliperidone tab er 24hr 3 mg......................... 71INVEGA – paliperidone tab er 24hr 6 mg......................... 71INVEGA – paliperidone tab er 24hr 9 mg......................... 71INVEGA SUSTENNA – paliperidone palmitate er susppref syr 39 mg/0.25ml...................................................... 71

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 78 mg/0.5ml........................................................ 71

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 117 mg/0.75ml.................................................... 71

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 156 mg/ml........................................................... 71

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 234 mg/1.5ml...................................................... 71

INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml................................................................71


INVEGA TRINZA – paliperidone palmitate er susp pref syr546 mg/1.75ml..................................................................71


INVIRASE – saquinavir mesylate tab 500 mg...................12ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 56ipratropium bromide inhal soln 0.02%...............................56ipratropium bromide nasal soln 0.03% (21 mcg/spray).....54ipratropium bromide nasal soln 0.06% (42 mcg/spray).....54irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 41

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 41

irbesartan tab 75 mg (Avapro)...........................................41irbesartan tab 150 mg (Avapro).........................................41irbesartan tab 300 mg (Avapro).........................................41IRESSA – gefitinib tab 250 mg..........................................21iron combination cap........................................................104

iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)..................................................................104

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)...................................................................104

iron polysacch complex-vit b12-fa cap 150-0.025-1mg....................................................................................104

irrigation solution, physiological.......................................116ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)................................................................12

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv).................................................................................12

isoniazid tab 100 mg............................................................9isoniazid tab 300 mg............................................................9ISOPTO ATROPINE – atropine sulfate ophth soln1%................................................................................... 109

isosorbide mononitrate tab er 24hr 30 mg........................ 46isosorbide mononitrate tab er 24hr 60 mg........................ 46isosorbide mononitrate tab er 24hr 120 mg...................... 46isosorbide mononitrate tab 10 mg.....................................46isosorbide mononitrate tab 20 mg.....................................46isotretinoin cap 10 mg..................................................... 110isotretinoin cap 20 mg..................................................... 110isotretinoin cap 30 mg..................................................... 110isotretinoin cap 40 mg..................................................... 110isradipine cap 2.5 mg.........................................................45isradipine cap 5 mg............................................................45itraconazole cap 100 mg (Sporanox)................................ 10ivermectin tab 3 mg (Stromectol)...................................... 15IXINITY – coagulation factor ix (recombinant) for inj 250unit...................................................................................104

IXINITY – coagulation factor ix (recombinant) for inj 500unit...................................................................................104





JJAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent).........................................................................21

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent).........................................................................21



Page 133 of 152

2020

134


JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq)...........................................................................12

JUXTAPID – lomitapide mesylate cap 5 mg (baseequiv).................................................................................48






KKALETRA – lopinavir-ritonavir tab 100-25 mg.................. 12KALETRA – lopinavir-ritonavir tab 200-50 mg.................. 12KALYDECO – ivacaftor packet 25 mg...............................57KALYDECO – ivacaftor packet 50 mg...............................57KALYDECO – ivacaftor packet 75 mg...............................57KALYDECO – ivacaftor tab 150 mg.................................. 57ketoconazole cream 2%...................................................111ketoconazole shampoo 2% (Nizoral)...............................111ketorolac tromethamine ophth soln 0.5% (Acular).......... 109ketorolac tromethamine ophth soln 0.4% (Acular ls).......109ketorolac tromethamine tab 10 mg....................................89KINERET – anakinra subcutaneous soln prefilled syringe100 mg/0.67ml..................................................................89

KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk..............................22



KISQALI – ribociclib succinate tab pack 200 mg dailydose...................................................................................21

KISQALI – ribociclib succinate tab pack 400 mg dailydose (200 mg tab)............................................................21

KISQALI – ribociclib succinate tab pack 600 mg dailydose (200 mg tab)............................................................22

KOATE – antihemophilic factor (human) for inj 250unit...................................................................................104



KOATE-DVI – antihemophilic factor (human) for inj 250unit...................................................................................104



KOGENATE FS – antihemophilic factor (recombinant) forinj kit 250 unit................................................................. 104

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 500 unit................................................................. 104

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 1000 unit............................................................... 104



KORLYM – mifepristone tab 300 mg.................................34K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................99

KP PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 97

KRINTAFEL – tafenoquine succinate tab 150 mg (baseequivalent).........................................................................15

KUVAN – sapropterin dihydrochloride powder packet 100mg......................................................................................38

KUVAN – sapropterin dihydrochloride powder packet 500mg......................................................................................38

KUVAN – sapropterin dihydrochloride soluble tab 100mg......................................................................................38

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 31

Llabetalol hcl tab 100 mg.................................................... 43labetalol hcl tab 200 mg.................................................... 43labetalol hcl tab 300 mg.................................................... 43lactated ringer's for irrigation........................................... 116lactulose (encephalopathy) solution 10 gm/15ml.............. 60lactulose solution 10 gm/15ml........................................... 58LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit.........................................................93

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit....................................................93

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50mg (7) titration kit............................................................. 93

lamivudine oral soln 10 mg/ml (Epivir).............................. 12lamivudine tab 150 mg (Epivir)..........................................12lamivudine tab 300 mg (Epivir)..........................................12lamivudine tab 100 mg (hbv) (Epivir hbv)......................... 10lamivudine-zidovudine tab 150-300 mg (Combivir)...........13lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................93

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................93

lamotrigine tab er 24hr 25 mg (Lamictal xr)...................... 93lamotrigine tab er 24hr 50 mg (Lamictal xr)...................... 93lamotrigine tab er 24hr 100 mg (Lamictal xr).................... 93lamotrigine tab er 24hr 200 mg (Lamictal xr).................... 93lamotrigine tab er 24hr 250 mg (Lamictal xr).................... 93lamotrigine tab er 24hr 300 mg (Lamictal xr).................... 93lamotrigine tab 25 mg (42) & 100 mg (7) starter kit(Lamictal starter/not).........................................................93

Page 134 of 152

2020

135

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit(Lamictal starter/tak).........................................................93

lamotrigine tab 25 mg (Lamictal).......................................93lamotrigine tab 100 mg (Lamictal).....................................93lamotrigine tab 150 mg (Lamictal).....................................93lamotrigine tab 200 mg (Lamictal).....................................93lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak).....................................................................................93

lansoprazole cap delayed release 15 mg (Prevacid)........ 58lansoprazole cap delayed release 30 mg (Prevacid)........ 58lanthanum carbonate chew tab 500 mg (elemental)(Fosrenol)..........................................................................60

lanthanum carbonate chew tab 750 mg (elemental)(Fosrenol)..........................................................................60

lanthanum carbonate chew tab 1000 mg (elemental)(Fosrenol)..........................................................................60

latanoprost ophth soln 0.005% (Xalatan)........................ 108LATUDA – lurasidone hcl tab 20 mg.................................71LATUDA – lurasidone hcl tab 40 mg.................................72LATUDA – lurasidone hcl tab 60 mg.................................72LATUDA – lurasidone hcl tab 80 mg.................................72LATUDA – lurasidone hcl tab 120 mg...............................72leflunomide tab 10 mg (Arava).......................................... 89leflunomide tab 20 mg (Arava).......................................... 89LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 22

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................22

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................22

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................22

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapypack 4 (3) mg (12 mg daily dose)................................... 22

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 22

LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapypack 4 mg (4 mg daily dose)...........................................22

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 22

letrozole tab 2.5 mg (Femara)...........................................22LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................22

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg......................................................................................22

leucovorin calcium tab 5 mg..............................................22leucovorin calcium tab 25 mg............................................22LEUKERAN – chlorambucil tab 2 mg................................22levetiracetam oral soln 100 mg/ml (Keppra)..................... 93levetiracetam tab er 24hr 500 mg (Keppra xr).................. 93levetiracetam tab er 24hr 750 mg (Keppra xr).................. 93levetiracetam tab 250 mg (Keppra)...................................93levetiracetam tab 500 mg (Keppra)...................................94levetiracetam tab 750 mg (Keppra)...................................94levetiracetam tab 1000 mg (Keppra).................................94

LEVOBUNOLOL HCL – levobunolol hcl ophth soln0.5%................................................................................ 108

levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........38levocarnitine tab 330 mg (Carnitor)...................................38levocetirizine dihydrochloride tab 5 mg............................. 54levofloxacin oral soln 25 mg/ml........................................... 9levofloxacin tab 250 mg.......................................................9levofloxacin tab 500 mg (Levaquin).....................................9levofloxacin tab 750 mg (Levaquin).....................................9levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg....... 31levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg..... 31levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg..................................31

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)............................................... 31

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)...................................................31

levothyroxine sodium tab 25 mcg (Synthroid)...................36levothyroxine sodium tab 50 mcg (Synthroid)...................36levothyroxine sodium tab 75 mcg (Synthroid)...................37levothyroxine sodium tab 88 mcg (Synthroid)...................37levothyroxine sodium tab 100 mcg (Synthroid).................37levothyroxine sodium tab 112 mcg (Synthroid)................. 37levothyroxine sodium tab 125 mcg (Synthroid).................37levothyroxine sodium tab 137 mcg (Synthroid).................37levothyroxine sodium tab 150 mcg (Synthroid).................37levothyroxine sodium tab 175 mcg (Synthroid).................37levothyroxine sodium tab 200 mcg (Synthroid).................37levothyroxine sodium tab 300 mcg (Synthroid).................37LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv).................................................................................13

lidocaine hcl gel 2%.........................................................114LIDOCAINE HCL JELLY – lidocaine hcl urethral/mucosalgel 2%.............................................................................114

lidocaine hcl soln 4%....................................................... 114lidocaine hcl urethral/mucosal gel prefilled syringe2%................................................................................... 114

lidocaine hcl viscous soln 2%..........................................109lidocaine patch 5% (Lidoderm)........................................114lidocaine-prilocaine cream 2.5-2.5%............................... 114LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52mg total)............................................................................31

linezolid for susp 100 mg/5ml (Zyvox)...............................15linezolid tab 600 mg (Zyvox)............................................. 15liothyronine sodium tab 5 mcg (Cytomel)..........................37liothyronine sodium tab 25 mcg (Cytomel)........................37liothyronine sodium tab 50 mcg (Cytomel)........................37lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 40

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 40

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 40

lisinopril tab 5 mg (Prinivil)................................................ 41lisinopril tab 10 mg (Prinivil).............................................. 41lisinopril tab 20 mg (Prinivil).............................................. 41

Page 135 of 152

2020

136

lisinopril tab 2.5 mg (Zestril).............................................. 40lisinopril tab 30 mg (Zestril)............................................... 41lisinopril tab 40 mg (Zestril)............................................... 41lithium carbonate cap 300 mg........................................... 72lithium carbonate cap 150 mg (Lithium carbonate)...........72lithium carbonate cap 600 mg (Lithium carbonate)...........72lithium carbonate tab er 450 mg........................................72lithium carbonate tab er 300 mg (Lithobid)....................... 72lithium carbonate tab 300 mg............................................72LITHIUM – lithium oral solution 8 meq/5ml....................... 72LONSURF – trifluridine-tipiracil tab 15-6.14 mg................22LONSURF – trifluridine-tipiracil tab 20-8.19 mg................22loperamide hcl cap 2 mg................................................... 58lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra).............................................................................13

lorazepam conc 2 mg/ml................................................... 64lorazepam tab 0.5 mg (Ativan).......................................... 64lorazepam tab 1 mg (Ativan)............................................. 64lorazepam tab 2 mg (Ativan)............................................. 64LORBRENA – lorlatinib tab 25 mg....................................22LORBRENA – lorlatinib tab 100 mg..................................22losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................42

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 42

losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar).............................................................................42

losartan potassium tab 25 mg (Cozaar)............................42losartan potassium tab 50 mg (Cozaar)............................42losartan potassium tab 100 mg (Cozaar)..........................42lovastatin tab 10 mg...........................................................48lovastatin tab 20 mg...........................................................48lovastatin tab 40 mg...........................................................48loxapine succinate cap 5 mg.............................................72loxapine succinate cap 10 mg...........................................72loxapine succinate cap 25 mg...........................................72loxapine succinate cap 50 mg...........................................72LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &norethindrone tab 5 mg kit...............................................32

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit...............................................32

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 3.75 mg........................................................................23

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 7.5 mg..........................................................................23

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 11.25 mg............................................... 23

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 22.5 mg.................................................23

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4month) for inj kit 30 mg....................................................23

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6month) for inj kit 45 mg....................................................23

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetatefor inj pediatric kit 7.5 mg........................................... 32,38

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetatefor inj pediatric kit 11.25 mg........................................32,38

LUPRON DEPOT-PED (1-MONTH) – leuprolide acetatefor inj pediatric kit 15 mg............................................ 32,38

LUPRON DEPOT-PED (3-MONTH) – leuprolide acetate(3 month) for inj pediatric kit 11.25 mg............................ 32

LUPRON DEPOT-PED (3-MONTH) – leuprolide acetate(3 month) for inj pediatric kit 30 mg.................................32

LYNPARZA – olaparib tab 100 mg....................................23LYNPARZA – olaparib tab 150 mg....................................23LYSODREN – mitotane tab 500 mg..................................23

Mmalathion lotion 0.5% (Ovide)......................................... 114MAPROTILINE HCL – maprotiline hcl tab 25 mg............. 66MAPROTILINE HCL – maprotiline hcl tab 50 mg............. 66MAPROTILINE HCL – maprotiline hcl tab 75 mg............. 66MARPLAN – isocarboxazid tab 10 mg..............................66MATULANE – procarbazine hcl cap 50 mg.......................23MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg....... 10meclizine hcl tab 12.5 mg..................................................59meclizine hcl tab 25 mg.....................................................59medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)............................................................... 31

medroxyprogesterone acetate im susp prefilled syr 150mg/ml (Depo-provera contrac)......................................... 31

medroxyprogesterone acetate tab 2.5 mg (Provera)........ 30medroxyprogesterone acetate tab 5 mg (Provera)........... 30medroxyprogesterone acetate tab 10 mg (Provera)......... 30MEFLOQUINE HCL – mefloquine hcl tab 250 mg............15megestrol acetate susp 40 mg/ml..................................... 23megestrol acetate susp 625 mg/5ml (Megace es)............ 30megestrol acetate tab 20 mg.............................................23megestrol acetate tab 40 mg.............................................23MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 23

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................23

MEKTOVI – binimetinib tab 15 mg....................................23meloxicam tab 7.5 mg (Mobic).......................................... 89meloxicam tab 15 mg (Mobic)........................................... 89melphalan tab 2 mg (Alkeran)........................................... 23memantine hcl oral solution 2 mg/ml.................................81memantine hcl tab 5 mg (Namenda).................................81memantine hcl tab 10 mg (Namenda)...............................82mercaptopurine tab 50 mg.................................................23mesalamine cap er 24hr 0.375 gm (Apriso)......................60mesalamine enema 4 gm.................................................. 60mesalamine suppos 1000 mg (Canasa)........................... 60mesalamine tab delayed release 800 mg (Asacol hd)...... 60metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 34metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 34metformin hcl tab 500 mg (Glucophage)...........................35metformin hcl tab 850 mg (Glucophage)...........................35metformin hcl tab 1000 mg (Glucophage).........................35methadone hcl conc 10 mg/ml (Methadose).....................84

Page 136 of 152

2020

137

methadone hcl soln 5 mg/5ml (Methadone hcl)................ 84methadone hcl soln 10 mg/5ml (Methadone hcl).............. 84methadone hcl tab for oral susp 40 mg............................ 84methadone hcl tab 5 mg (Dolophine)................................84methadone hcl tab 10 mg (Dolophine)..............................84methimazole tab 5 mg (Tapazole)..................................... 37methimazole tab 10 mg (Tapazole)................................... 37methocarbamol tab 500 mg...............................................96methocarbamol tab 750 mg (Robaxin-750).......................96methotrexate sodium tab 2.5 mg (base equiv)..................23methoxsalen rapid cap 10 mg (Oxsoralen ultra)............. 114METHSCOPOLAMINE BROMIDE – methscopolaminebromide tab 2.5 mg..........................................................59

methyldopa tab 250 mg..................................................... 52methyldopa tab 500 mg..................................................... 52methylergonovine maleate tab 0.2 mg.............................. 38methylphenidate hcl cap er 24hr 10 mg (la) (Ritalinla).......................................................................................79

methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................79



methylphenidate hcl cap er 10 mg (cd).............................79methylphenidate hcl cap er 20 mg (cd).............................79methylphenidate hcl cap er 30 mg (cd).............................79methylphenidate hcl cap er 40 mg (cd).............................79methylphenidate hcl cap er 50 mg (cd).............................79methylphenidate hcl cap er 60 mg (cd).............................79methylphenidate hcl chew tab 2.5 mg...............................79methylphenidate hcl chew tab 5 mg..................................79methylphenidate hcl chew tab 10 mg................................79methylphenidate hcl soln 5 mg/5ml (Methylin)..................79methylphenidate hcl soln 10 mg/5ml (Methylin)................79methylphenidate hcl tab er 24hr 27 mg.............................80methylphenidate hcl tab er 24hr 36 mg.............................80methylphenidate hcl tab er 24hr 54 mg.............................80methylphenidate hcl tab er 10 mg.....................................80methylphenidate hcl tab er 20 mg.....................................80methylphenidate hcl tab er osmotic release (osm) 18 mg(Concerta)......................................................................... 79

methylphenidate hcl tab er osmotic release (osm) 27 mg(Concerta)......................................................................... 79



methylphenidate hcl tab 5 mg (Ritalin)..............................80methylphenidate hcl tab 10 mg (Ritalin)............................80methylphenidate hcl tab 20 mg (Ritalin)............................80METHYLPHENIDATE HYDROCHLORIDE ER –methylphenidate hcl tab er 24hr 18 mg...........................80

methylprednisolone tab 4 mg (Medrol)..............................28methylprednisolone tab 8 mg (Medrol)..............................28methylprednisolone tab 16 mg (Medrol)............................28

methylprednisolone tab 32 mg (Medrol)............................28methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................28

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................60

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................60

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................61

metolazone tab 2.5 mg...................................................... 50metolazone tab 5 mg......................................................... 50metolazone tab 10 mg....................................................... 50METOPROLOL/HYDROCHLOROTHIAZIDE – metoprolol& hydrochlorothiazide tab 100-50 mg..............................44

metoprolol & hydrochlorothiazide tab 100-25 mg..............43metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................43

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 43




metoprolol tartrate tab 25 mg............................................ 43metoprolol tartrate tab 50 mg (Lopressor).........................43metoprolol tartrate tab 100 mg (Lopressor).......................44metronidazole cap 375 mg (Flagyl)...................................16metronidazole cream 0.75% (Metrocream).....................110metronidazole gel 0.75%................................................. 110metronidazole tab 250 mg (Flagyl)....................................16metronidazole tab 500 mg (Flagyl)....................................16metronidazole vaginal gel 0.75%.......................................62midodrine hcl tab 2.5 mg...................................................52midodrine hcl tab 5 mg...................................................... 52midodrine hcl tab 10 mg....................................................52miglustat cap 100 mg (Zavesca)..................................... 104minocycline hcl cap 75 mg.................................................. 9minocycline hcl cap 100 mg................................................ 9minocycline hcl cap 50 mg (Minocin).................................. 9minoxidil tab 2.5 mg...........................................................52minoxidil tab 10 mg............................................................52MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................31

mirtazapine tab 45 mg....................................................... 67mirtazapine tab 15 mg (Remeron).....................................67mirtazapine tab 30 mg (Remeron).....................................67misoprostol tab 100 mcg (Cytotec)....................................59misoprostol tab 200 mcg (Cytotec)....................................59MITIGARE – colchicine cap 0.6 mg.................................. 91M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................97

modafinil tab 100 mg (Provigil)..........................................80modafinil tab 200 mg (Provigil)..........................................80moexipril hcl tab 7.5 mg.................................................... 41

Page 137 of 152

2020

138

moexipril hcl tab 15 mg..................................................... 41MOLINDONE HYDROCHLORIDE – molindone hcl tab 5mg......................................................................................72

MOLINDONE HYDROCHLORIDE – molindone hcl tab 10mg......................................................................................72

MOLINDONE HYDROCHLORIDE – molindone hcl tab 25mg......................................................................................72

mometasone furoate cream 0.1% (Elocon).....................113mometasone furoate oint 0.1%........................................113mometasone furoate solution 0.1% (lotion).....................113MONONINE – coagulation factor ix for inj 1000 unit.......104montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................56

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................56

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 56

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................56

morphine sulfate cap er 24hr 100 mg (Kadian).................85MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 60 mg...................................................................85

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 75 mg...................................................................85

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 120 mg.................................................................85

MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................84




MORPHINE SULFATE – morphine sulfate tab 15 mg...... 84MORPHINE SULFATE – morphine sulfate tab 30 mg...... 84morphine sulfate oral soln 10 mg/5ml............................... 85morphine sulfate oral soln 20 mg/5ml............................... 85morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........85morphine sulfate tab er 15 mg (Ms contin)....................... 85morphine sulfate tab er 30 mg (Ms contin)....................... 85morphine sulfate tab er 60 mg (Ms contin)....................... 85morphine sulfate tab er 100 mg (Ms contin)..................... 85morphine sulfate tab er 200 mg (Ms contin)..................... 85morphine sulfate tab 15 mg (Morphine sulfate).................85morphine sulfate tab 30 mg (Morphine sulfate).................85moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)........................................................................107

multiple vitamins w/ minerals cap......................................97multiple vitamins w/ minerals tab (Strovite forte)...............97MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................97

mupirocin oint 2%............................................................ 111M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 97MYALEPT – metreleptin for subcutaneous inj 11.3 mg.....38mycophenolate mofetil cap 250 mg (Cellcept)................116

mycophenolate mofetil for oral susp 200 mg/ml(Cellcept).........................................................................116

mycophenolate mofetil tab 500 mg (Cellcept).................116mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)..............................................................116

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)..............................................................116

MYLERAN – busulfan tab 2 mg........................................ 23

Nnabumetone tab 500 mg....................................................89nabumetone tab 750 mg....................................................89nadolol tab 20 mg (Corgard)............................................. 44nadolol tab 40 mg (Corgard)............................................. 44nadolol tab 80 mg (Corgard)............................................. 44naftifine hcl cream 2% (Naftin)........................................ 111naltrexone hcl tab 50 mg.................................................116naproxen sodium tab er 24hr 375 mg (base equiv)(Naprelan)......................................................................... 89

naproxen sodium tab 275 mg............................................89naproxen sodium tab 550 mg............................................89naproxen susp 125 mg/5ml (Naprosyn)............................ 89naproxen tab ec 375 mg (Ec-naprosyn)............................89naproxen tab ec 500 mg (Ec-naproxen)............................89naproxen tab 250 mg.........................................................89naproxen tab 375 mg.........................................................89naproxen tab 500 mg.........................................................89NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...........116NATACYN – natamycin ophth susp 5%.......................... 107nateglinide tab 60 mg (Starlix)...........................................35nateglinide tab 120 mg (Starlix).........................................35NATRAPEL 12-HOUR TICK & INSECT REPELLENTCONTINUOUS SPRAY – picaridin aerosol................... 114

NAYZILAM – midazolam nasal spray soln 5 mg/0.1ml.......................................................................................94

NEOMYCIN/POLYMYXIN/GRAMICIDIN – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.....................................................................................107

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin.............................................................................. 107

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)......................................................................... 108

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)......................................................................... 108

neomycin-polymyxin-hc otic soln 1%.............................. 109neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.............................................................................. 109

neomycin sulfate tab 500 mg.............................................. 9NERLYNX – neratinib maleate tab 40 mg (baseequivalent).........................................................................23

NEVIRAPINE ER – nevirapine tab er 24hr 100 mg.......... 13nevirapine susp 50 mg/5ml (Viramune).............................13nevirapine tab er 24hr 400 mg (Viramune xr)................... 13nevirapine tab 200 mg (Viramune)....................................13NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................23

Page 138 of 152

2020

139

NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................31

nicardipine hcl cap 20 mg..................................................45NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered)....................................................................82

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................ 82

nifedipine cap 20 mg..........................................................45nifedipine cap 10 mg (Procardia)...................................... 45nifedipine tab er 24hr 30 mg (Adalat cc)...........................45nifedipine tab er 24hr 60 mg (Adalat cc)...........................45nifedipine tab er 24hr 90 mg (Adalat cc)...........................46nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................46

nifedipine tab er 24hr osmotic release 60 mg (Procardiaxl).......................................................................................46

nifedipine tab er 24hr osmotic release 90 mg (Procardiaxl).......................................................................................46

nimodipine cap 30 mg........................................................46NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent).........................................................................23

NINLARO – ixazomib citrate cap 3 mg (baseequivalent).........................................................................23

NINLARO – ixazomib citrate cap 4 mg (baseequivalent).........................................................................24

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................61



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 61

nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 46nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 46nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 46nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 47nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 47nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 47nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 47NITRO-TIME – nitroglycerin cap er 2.5 mg.......................46NITRO-TIME – nitroglycerin cap er 6.5 mg.......................46NITRO-TIME – nitroglycerin cap er 9 mg..........................46NITYR – nitisinone tab 2 mg............................................. 38NITYR – nitisinone tab 5 mg............................................. 38NITYR – nitisinone tab 10 mg........................................... 38NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................97

NIVESTYM – filgrastim-aafi inj 300 mcg/ml.................... 105NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml)....................................................................................105

NIVESTYM – filgrastim-aafi soln prefilled syringe 300mcg/0.5ml........................................................................105

NIVESTYM – filgrastim-aafi soln prefilled syringe 480mcg/0.8ml........................................................................105

nizatidine cap 150 mg........................................................59

nizatidine cap 300 mg........................................................59norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25mcg (Generess fe)............................................................31

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg........31norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg........31norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Ortho-novum 1/35)......................................................................31

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20).............................................................. 31

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)...................................................31

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21)............................................................. 31

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21).......................................................... 31

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................30

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................... 30

norethindrone acetate tab 5 mg (Aygestin).......................30norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)............................................................31

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg....................................................................................32

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7).................................................32

norethindrone tab 0.35 mg (Ortho micronor).....................32norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg.......32norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg............................................................................. 32

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)............................................ 32

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg..............32nortriptyline hcl cap 10 mg (Pamelor)............................... 67nortriptyline hcl cap 25 mg (Pamelor)............................... 67nortriptyline hcl cap 50 mg (Pamelor)............................... 67nortriptyline hcl cap 75 mg (Pamelor)............................... 67NORVIR – ritonavir oral soln 80 mg/ml.............................13NOVOLIN 70/30 FLEXPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................36

NOVOLIN 70/30 FLEXPEN RELION – insulin nph &regular susp pen-inj 100 unit/ml (70-30)..........................36

NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 36

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 36

NOVOLIN N FLEXPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................36

NOVOLIN N FLEXPEN RELION – insulin nph (human)(isophane) susp pen-injector 100 unit/ml.........................36

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................36

NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 36

NOVOLIN R FLEXPEN – insulin regular (human) solnpen-injector 100 unit/ml....................................................35

Page 139 of 152

2020

140

NOVOLIN R FLEXPEN RELION – insulin regular (human)soln pen-injector 100 unit/ml............................................35

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 35NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................35

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 36

NOVOLOG MIX 70/30 PREFILLED FLEXPEN – insulinaspart prot & aspart sus pen-inj 100 unit/ml (70-30)....... 36

NOXAFIL – posaconazole susp 40 mg/ml........................ 10NUBEQA – darolutamide tab 300 mg............................... 24nystatin cream 100000 unit/gm....................................... 111nystatin oint 100000 unit/gm............................................111nystatin oral powder...........................................................10nystatin susp 100000 unit/ml...........................................109nystatin tab 500000 unit.................................................... 10nystatin topical powder 100000 unit/gm..........................111

OOCALIVA – obeticholic acid tab 5 mg............................... 61OCALIVA – obeticholic acid tab 10 mg............................. 61octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin).....................................................................39

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)(Sandostatin).....................................................................39

octreotide acetate inj 500 mcg/ml (0.5 mg/ml)(Sandostatin).....................................................................39

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg................................................................... 13

OFEV – nintedanib esylate cap 100 mg (baseequivalent).........................................................................57

OFEV – nintedanib esylate cap 150 mg (baseequivalent).........................................................................57

OFF ACTIVE – diethyltoluamide (deet) aerosol..............114OFF DEEP WOODS – diethyltoluamide (deet)aerosol.............................................................................114

OFF DEEP WOODS DRY – diethyltoluamide (deet)aerosol.............................................................................114

OFF SMOOTH & DRY – diethyltoluamide (deet)aerosol.............................................................................114

ofloxacin ophth soln 0.3% (Ocuflox)................................107ofloxacin otic soln 0.3% (Floxin otic)...............................109olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 72

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 72



olanzapine tab 2.5 mg (Zyprexa).......................................72olanzapine tab 5 mg (Zyprexa)..........................................72olanzapine tab 7.5 mg (Zyprexa).......................................72olanzapine tab 10 mg (Zyprexa)........................................73olanzapine tab 15 mg (Zyprexa)........................................73olanzapine tab 20 mg (Zyprexa)........................................73

olmesartan medoxomil-hydrochlorothiazide tab 20-12.5mg (Benicar hct)...............................................................42

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5mg (Benicar hct)...............................................................42

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)..................................................................... 42

olmesartan medoxomil tab 5 mg (Benicar)....................... 42olmesartan medoxomil tab 20 mg (Benicar)..................... 42olmesartan medoxomil tab 40 mg (Benicar)..................... 42olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)..........................................................................109

OLUMIANT – baricitinib tab 1 mg..................................... 89OLUMIANT – baricitinib tab 2 mg..................................... 90omeprazole cap delayed release 10 mg........................... 59omeprazole cap delayed release 20 mg........................... 59omeprazole cap delayed release 40 mg........................... 59OMNITROPE – somatropin for inj 5.8 mg.........................37ONDANSETRON HCL – ondansetron hcl tab 24 mg....... 59ondansetron hcl oral soln 4 mg/5ml.................................. 59ondansetron hcl tab 4 mg (Zofran)....................................59ondansetron hcl tab 8 mg (Zofran)....................................59ondansetron orally disintegrating tab 4 mg....................... 59ondansetron orally disintegrating tab 8 mg....................... 59ONETOUCH DELICA LANCING DEVICE – lancetdevices............................................................................ 115

ONETOUCH DELICA PLUS LANCING DEVICE – lancetdevices............................................................................ 115

ONETOUCH SURESOFT LANCING DEVICE – lancetsmisc................................................................................. 115

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/device.............................................................................. 115

ONETOUCH ULTRA BLUE – glucose blood teststrip..................................................................................115

ONETOUCH ULTRA CONTROL – blood glucosecalibration - liquid........................................................... 115

ONETOUCH ULTRA MINI – blood glucose monitoring kitw/ device.........................................................................115

ONETOUCH VERIO – blood glucose monitoring kit w/device.............................................................................. 115

ONETOUCH VERIO CONTROL SOLUTION HIGH –blood glucose calibration - liquid - high......................... 115

ONETOUCH VERIO FLEX BLOOD GLUCOSEMONITORING SYSTEM – blood glucose monitoring kitw/ device.........................................................................115

ONETOUCH VERIO IQ BLOOD GLUCOSEMONITORING SYSTEM – blood glucose monitoring kitw/ device.........................................................................115

ONETOUCH VERIO MID CONTROL SOLUTION – bloodglucose calibration - liquid............................................. 115

ONETOUCH VERIO TEST STRIPS – glucose blood teststrip..................................................................................115

ORENCIA – abatacept subcutaneous soln prefilledsyringe 125 mg/ml............................................................90

ORENCIA CLICKJECT – abatacept subcutaneous solnauto-injector 125 mg/ml....................................................90

Page 140 of 152

2020

141

ORENITRAM – treprostinil diolamine tab er 0.125 mg(base equiv)...................................................................... 52

ORENITRAM – treprostinil diolamine tab er 0.25 mg (baseequiv).................................................................................52

ORENITRAM – treprostinil diolamine tab er 1 mg (baseequiv).................................................................................52

ORENITRAM – treprostinil diolamine tab er 2.5 mg (baseequiv).................................................................................52

ORILISSA – elagolix sodium tab 150 mg (base equiv).....32ORILISSA – elagolix sodium tab 200 mg (base equiv).....33ORKAMBI – lumacaftor-ivacaftor granules packet 100-125mg......................................................................................57

ORKAMBI – lumacaftor-ivacaftor granules packet 150-188mg......................................................................................57

ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg............57ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg............57orphenadrine citrate tab er 12hr 100 mg...........................96oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................14

oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu).............................................................................14

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu).............................................................................14

oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................14

OTEZLA – apremilast tab 30 mg.......................................90OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg......................................................................90

oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 94

oxcarbazepine tab 150 mg (Trileptal)................................94oxcarbazepine tab 300 mg (Trileptal)................................94oxcarbazepine tab 600 mg (Trileptal)................................94oxiconazole nitrate cream 1% (Oxistat).......................... 111OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg.......94OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg.......94OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg.......94oxybutynin chloride syrup 5 mg/5ml..................................61oxybutynin chloride tab er 24hr 15 mg..............................61oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 61oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 61oxybutynin chloride tab 5 mg.............................................62OXYCODONE/ASPIRIN – oxycodone-aspirin tab4.8355-325 mg..................................................................86

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg...........................................................................86

oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 85oxycodone hcl soln 5 mg/5ml............................................85oxycodone hcl tab 10 mg.................................................. 85oxycodone hcl tab 20 mg.................................................. 86oxycodone hcl tab 5 mg (Roxicodone)..............................85oxycodone hcl tab 15 mg (Roxicodone)............................85oxycodone hcl tab 30 mg (Roxicodone)............................86oxycodone w/ acetaminophen tab 2.5-325 mg(Percocet)..........................................................................86

oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................86

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................86

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................86

oxymorphone hcl tab 5 mg (Opana)..................................86oxymorphone hcl tab 10 mg (Opana)................................86OXYMORPHONE HYDROCHLORIDE ER –oxymorphone hcl tab er 12hr 5 mg................................. 86

OXYMORPHONE HYDROCHLORIDE ER –oxymorphone hcl tab er 12hr 7.5 mg.............................. 86

OXYMORPHONE HYDROCHLORIDE ER –oxymorphone hcl tab er 12hr 10 mg............................... 86





Ppaliperidone tab er 24hr 1.5 mg (Invega)..........................73paliperidone tab er 24hr 3 mg (Invega).............................73paliperidone tab er 24hr 6 mg (Invega).............................73paliperidone tab er 24hr 9 mg (Invega).............................73pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................59

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................59

PARAGARD INTRAUTERINE COPPERCONTRACEPTIVE T380A – copper iud..........................32

PAROMOMYCIN SULFATE – paromomycin sulfate cap250 mg................................................................................ 9

paroxetine hcl tab 10 mg (Paxil)........................................67paroxetine hcl tab 20 mg (Paxil)........................................67paroxetine hcl tab 30 mg (Paxil)........................................67paroxetine hcl tab 40 mg (Paxil)........................................67PAXIL – paroxetine hcl oral susp 10 mg/5ml (baseequiv).................................................................................67

pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................97

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml............97peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................58

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 58

penicillamine cap 250 mg (Cuprimine)............................116penicillamine tab 250 mg (Depen titratabs).....................116PENICILLIN V POTASSIUM – penicillin v potassium forsoln 125 mg/5ml.................................................................7

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 250 mg/5ml.................................................................7

penicillin v potassium tab 250 mg....................................... 7

Page 141 of 152

2020

142

penicillin v potassium tab 500 mg....................................... 7pentoxifylline tab er 400 mg............................................ 105perindopril erbumine tab 2 mg...........................................41perindopril erbumine tab 4 mg...........................................41perindopril erbumine tab 8 mg...........................................41permethrin cream 5% (Elimite)........................................114PERPHENAZINE/AMITRIPTYLINE – perphenazine-amitriptyline tab 2-10 mg................................................. 82

PERPHENAZINE/AMITRIPTYLINE – perphenazine-amitriptyline tab 2-25 mg................................................. 82




perphenazine tab 2 mg......................................................73perphenazine tab 4 mg......................................................73perphenazine tab 8 mg......................................................73perphenazine tab 16 mg....................................................73PEXEVA – paroxetine mesylate tab 10 mg (baseequiv).................................................................................67

PEXEVA – paroxetine mesylate tab 20 mg (baseequiv).................................................................................67



phenazopyridine hcl tab 100 mg (Pyridium)......................62phenazopyridine hcl tab 200 mg (Pyridium)......................62phenobarbital elixir 20 mg/5ml...........................................76phenobarbital tab 15 mg....................................................76phenobarbital tab 16.2 mg.................................................76phenobarbital tab 30 mg....................................................76phenobarbital tab 32.4 mg.................................................76phenobarbital tab 60 mg....................................................76phenobarbital tab 64.8 mg.................................................76phenobarbital tab 97.2 mg.................................................76phenobarbital tab 100 mg..................................................76phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............52phenylephrine hcl ophth soln 2.5%................................. 109phenytoin chew tab 50 mg (Dilantin infatabs)................... 94phenytoin sodium extended cap 100 mg (Dilantin)...........94phenytoin sodium extended cap 200 mg (Phenytek)........94phenytoin sodium extended cap 300 mg (Phenytek)........94phenytoin susp 125 mg/5ml (Dilantin-125)........................94phytonadione tab 5 mg (Mephyton)...................................97PIFELTRO – doravirine tab 100 mg.................................. 13pilocarpine hcl ophth soln 1% (Isopto carpine)............... 108pilocarpine hcl ophth soln 2% (Isopto carpine)............... 108pilocarpine hcl ophth soln 4% (Isopto carpine)............... 108pilocarpine hcl tab 5 mg (Salagen)..................................109pilocarpine hcl tab 7.5 mg (Salagen)...............................109PIMOZIDE – pimozide tab 1 mg....................................... 82PIMOZIDE – pimozide tab 2 mg....................................... 82pindolol tab 5 mg............................................................... 44

pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 35pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 35pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 35PIQRAY 250MG DAILY DOSE – alpelisib tab pack 250mg daily dose (200 mg & 50 mg tabs)............................ 24

PIQRAY 300MG DAILY DOSE – alpelisib tab pack 300mg daily dose (2x150 mg tab).........................................24

PIQRAY 200MG DAILY DOSE – alpelisib tab therapypack 200 mg daily dose...................................................24

piroxicam cap 10 mg (Feldene).........................................90piroxicam cap 20 mg (Feldene).........................................90PNEUMOVAX 23/1 DOSE – pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml............................................. 17

PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj25 mcg/0.5ml.................................................................... 17

PNV FOLIC ACID + IRON MULTIVITAMIN – prenatal vitw/ fe fumarate-fa tab 27-1 mg......................................... 97

PNV PRENATAL PLUS MULTIVITAMIN – prenatal vit w/fe fumarate-fa tab 27-1 mg.............................................. 97

podofilox soln 0.5%..........................................................114polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim).........................................................................107

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.25 mg.............................................................97

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.5 mg...............................................................98

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 1 mg..................................................................98

POMALYST – pomalidomide cap 1 mg.............................24POMALYST – pomalidomide cap 2 mg.............................24POMALYST – pomalidomide cap 3 mg.............................24POMALYST – pomalidomide cap 4 mg.............................24posaconazole tab delayed release 100 mg (Noxafil)........ 10pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......62potassium bicarbonate effer tab 25 meq...........................99potassium chloride cap er 8 meq...................................... 99potassium chloride cap er 10 meq.................................... 99POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................99

potassium chloride microencapsulated crys er tab 10meq....................................................................................99

potassium chloride microencapsulated crys er tab 20meq....................................................................................99

potassium chloride oral soln 10% (20 meq/15ml)............. 99potassium chloride oral soln 20% (40 meq/15ml)............. 99potassium chloride tab er 10 meq (K-tab).........................99potassium chloride tab er 8 meq (600 mg)....................... 99potassium citrate & citric acid powder pack 3300-1002mg......................................................................................62

potassium citrate & citric acid soln 1100-334 mg/5ml....... 62potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........62potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 62

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 62

Page 142 of 152

2020

143

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................99

pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapexer)...................................................................................... 95

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......95pramipexole dihydrochloride tab 0.25 mg (Mirapex).........96pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........96pramipexole dihydrochloride tab 0.75 mg (Mirapex).........96pramipexole dihydrochloride tab 1 mg (Mirapex)..............96pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........96pravastatin sodium tab 10 mg........................................... 48pravastatin sodium tab 80 mg........................................... 48pravastatin sodium tab 20 mg (Pravachol)........................48pravastatin sodium tab 40 mg (Pravachol)........................48praziquantel tab 600 mg (Biltricide)...................................15prazosin hcl cap 1 mg (Minipress).................................... 52prazosin hcl cap 2 mg (Minipress).................................... 52prazosin hcl cap 5 mg (Minipress).................................... 52PREDNICARBATE – prednicarbate cream 0.1%............113PREDNICARBATE – prednicarbate oint 0.1%................113PREDNISOLONE ACETATE – prednisolone acetateophth susp 1%................................................................108

PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)...........................................................28

PREDNISOLONE SODIUM PHOSPHATE – prednisolonesodium phosphate ophth soln 1%................................. 108

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................28

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................28

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 28prednisone tab 1 mg..........................................................28prednisone tab 2.5 mg.......................................................28prednisone tab 5 mg..........................................................28prednisone tab 10 mg........................................................28prednisone tab 20 mg........................................................29prednisone tab 50 mg........................................................29prednisone tab therapy pack 5 mg (21)............................ 28prednisone tab therapy pack 5 mg (48)............................ 28prednisone tab therapy pack 10 mg (21).......................... 28prednisone tab therapy pack 10 mg (48).......................... 28pregabalin cap 25 mg (Lyrica)...........................................94pregabalin cap 50 mg (Lyrica)...........................................94pregabalin cap 75 mg (Lyrica)...........................................94pregabalin cap 100 mg (Lyrica).........................................94pregabalin cap 150 mg (Lyrica).........................................94pregabalin cap 200 mg (Lyrica).........................................94pregabalin cap 225 mg (Lyrica).........................................94pregabalin cap 300 mg (Lyrica).........................................94PRENATAL AND IRON – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................98

PRE-NATAL FORMULA – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................98

PRENATAL FORTE – prenatal multivitamins & mineralsw/iron & fa tab 0.8 mg..................................................... 98

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 98

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 27-0.8-228 mg........................................... 98

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................98

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 98

PRENATAL – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg.................................................................... 98

PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab29-1 mg.............................................................................98

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................98

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8mg......................................................................................98

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................98

PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................98

PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................98

PRENATAL VITAMIN & MINERAL – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 98

PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................98

PRENATAL VITAMINS PLUS LOW IRON – prenatal vit w/fe fumarate-fa tab 27-1 mg.............................................. 98

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................98

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg..................... 98PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................98

PREVIDENT 5000 DRY MOUTH – sodium fluoride gel1.1% (0.5% f)..................................................................109

PREVIDENT FLUORIDE – sodium fluoride gel 1.1%(0.5% f)........................................................................... 109

PREVIDENT RINSE – sodium fluoride rinse 0.2%......... 109PREVNAR 13 – pneumococcal 13-valent conjugatevaccine inj......................................................................... 17

PREZCOBIX – darunavir-cobicistat tab 800-150 mg........13PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv).................................................................................13

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv).................................................................................13




PRIFTIN – rifapentine tab 150 mg...................................... 9primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate)................................................... 15

primidone tab 50 mg (Mysoline)........................................94primidone tab 250 mg (Mysoline)......................................94

Page 143 of 152

2020

144

probenecid tab 500 mg......................................................91prochlorperazine maleate tab 5 mg (base equivalent)......73prochlorperazine maleate tab 10 mg (baseequivalent).........................................................................73

prochlorperazine suppos 25 mg........................................ 73PROFILNINE – factor ix complex for inj 500 unit............105PROFILNINE – factor ix complex for inj 1000 unit..........105PROFILNINE – factor ix complex for inj 1500 unit..........105PROFILNINE SD – factor ix complex for inj 500 unit......105PROFILNINE SD – factor ix complex for inj 1000unit...................................................................................105

PROFILNINE SD – factor ix complex for inj 1500unit...................................................................................105

progesterone micronized cap 100 mg (Prometrium).........30progesterone micronized cap 200 mg (Prometrium).........30PROGLYCEM – diazoxide susp 50 mg/ml........................35PROMACTA – eltrombopag olamine powder pack forsusp 12.5 mg (base eq).................................................105

PROMACTA – eltrombopag olamine tab 12.5 mg (baseequiv)...............................................................................105

PROMACTA – eltrombopag olamine tab 25 mg (baseequiv)...............................................................................105



promethazine hcl suppos 12.5 mg.................................... 54promethazine hcl suppos 25 mg....................................... 54promethazine hcl syrup 6.25 mg/5ml................................ 54promethazine hcl tab 12.5 mg...........................................54promethazine hcl tab 25 mg..............................................54promethazine hcl tab 50 mg..............................................54promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 54propafenone hcl tab 150 mg..............................................50propafenone hcl tab 225 mg..............................................50propafenone hcl tab 300 mg..............................................50proparacaine hcl ophth soln 0.5% (Alcaine)....................109PROPRANOLOL/HYDROCHLOROTHIAZIDE –propranolol & hydrochlorothiazide tab 40-25 mg.............44

PROPRANOLOL/HYDROCHLOROTHIAZIDE –propranolol & hydrochlorothiazide tab 80-25 mg.............44

propranolol hcl cap er 24hr 60 mg (Inderal la)..................44propranolol hcl cap er 24hr 80 mg (Inderal la)..................44propranolol hcl cap er 24hr 120 mg (Inderal la)................44propranolol hcl cap er 24hr 160 mg (Inderal la)................44PROPRANOLOL HCL – propranolol hcl oral soln 20mg/5ml...............................................................................44

PROPRANOLOL HCL – propranolol hcl oral soln 40mg/5ml...............................................................................44

propranolol hcl tab 10 mg..................................................44propranolol hcl tab 20 mg..................................................44propranolol hcl tab 40 mg..................................................44propranolol hcl tab 60 mg..................................................44propranolol hcl tab 80 mg..................................................44propylthiouracil tab 50 mg................................................. 37PULMOZYME – dornase alfa inhal soln 1 mg/ml..............57

PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)......................................................................................24

PX PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 98

pyrazinamide tab 500 mg.................................................... 9pyridostigmine bromide tab 60 mg (Mestinon)..................96

QQC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................98

QUAZEPAM – quazepam tab 15 mg................................ 76quetiapine fumarate tab er 24hr 50 mg (Seroquel xr)....... 73quetiapine fumarate tab er 24hr 150 mg (Seroquel xr)..... 73quetiapine fumarate tab er 24hr 200 mg (Seroquel xr)..... 73quetiapine fumarate tab er 24hr 300 mg (Seroquel xr)..... 73quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)..... 73quetiapine fumarate tab 25 mg (Seroquel)........................73quetiapine fumarate tab 50 mg (Seroquel)........................73quetiapine fumarate tab 100 mg (Seroquel)......................73quetiapine fumarate tab 200 mg (Seroquel)......................74quetiapine fumarate tab 300 mg (Seroquel)......................74quetiapine fumarate tab 400 mg (Seroquel)......................74quinapril hcl tab 5 mg (Accupril)........................................41quinapril hcl tab 10 mg (Accupril)......................................41quinapril hcl tab 20 mg (Accupril)......................................41quinapril hcl tab 40 mg (Accupril)......................................41quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 41

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 41

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 41

quinidine gluconate tab er 324 mg....................................50QUINIDINE SULFATE – quinidine sulfate tab 200 mg......50QUINIDINE SULFATE – quinidine sulfate tab 300 mg......50QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act..................................................... 56

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act..................................................... 56

RRABAVERT – rabies vaccine, pcec for inj.........................17rabeprazole sodium ec tab 20 mg (Aciphex).................... 59raloxifene hcl tab 60 mg (Evista).......................................39ramipril cap 1.25 mg (Altace)............................................ 41ramipril cap 2.5 mg (Altace).............................................. 41ramipril cap 5 mg (Altace)................................................. 41ramipril cap 10 mg (Altace)............................................... 41ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 59ranitidine hcl tab 150 mg................................................... 59ranitidine hcl tab 300 mg................................................... 59RA PRENATAL FORMULA/FOLIC ACID – prenatal vit w/fe fumarate-fa tab 28-0.8 mg........................................... 99

RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................98

RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml......... 39

Page 144 of 152

2020

145

RECOMBINATE – antihemophilic factor (recombinant) forinj 220-400 unit...............................................................105

RECOMBINATE – antihemophilic factor (recombinant) forinj 401-800 unit...............................................................105

RECOMBINATE – antihemophilic factor (recombinant) forinj 801-1240 unit.............................................................105

RECOMBINATE – antihemophilic factor (recombinant) forinj 1241-1800 unit...........................................................105

RECOMBINATE – antihemophilic factor (recombinant) forinj 1801-2400 unit...........................................................105

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml............................................................. 17

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 10 mcg/ml................................................................ 17

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 40 mcg/ml................................................................ 17

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister....................................................... 14

RELION R – insulin regular (human) inj 100 unit/ml......... 35REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................48

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml.........48

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................48

REPEL SPORTSMEN – diethyltoluamide (deet)aerosol.............................................................................114

REPEL SPORTSMEN MAX – diethyltoluamide (deet)aerosol.............................................................................114

RETACRIT – epoetin alfa-epbx inj 2000 unit/ml..............105RETACRIT – epoetin alfa-epbx inj 3000 unit/ml..............105RETACRIT – epoetin alfa-epbx inj 4000 unit/ml..............105RETACRIT – epoetin alfa-epbx inj 10000 unit/ml............105RETACRIT – epoetin alfa-epbx inj 40000 unit/ml............105REVLIMID – lenalidomide cap 5 mg............................... 117REVLIMID – lenalidomide cap 10 mg............................. 117REVLIMID – lenalidomide cap 15 mg............................. 117REVLIMID – lenalidomide cap 20 mg............................. 117REVLIMID – lenalidomide cap 25 mg............................. 117REVLIMID – lenalidomide caps 2.5 mg.......................... 116REXULTI – brexpiprazole tab 0.25 mg..............................74REXULTI – brexpiprazole tab 0.5 mg................................74REXULTI – brexpiprazole tab 1 mg...................................74REXULTI – brexpiprazole tab 2 mg...................................74REXULTI – brexpiprazole tab 3 mg...................................74REXULTI – brexpiprazole tab 4 mg...................................74REYATAZ – atazanavir sulfate oral powder packet 50 mg(base equiv)...................................................................... 13

ribavirin cap 200 mg.......................................................... 11ribavirin tab 200 mg........................................................... 11rifabutin cap 150 mg (Mycobutin)........................................9rifampin cap 150 mg (Rifadin)............................................. 9rifampin cap 300 mg (Rifadin)........................................... 10RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 99

riluzole tab 50 mg (Rilutek)................................................96

ringer's solution for irrigation............................................117risedronate sodium tab delayed release 35 mg(Atelvia)............................................................................. 39

RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 12.5 mg.............................................. 74

RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 25 mg................................................. 74

RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 37.5 mg.............................................. 74

RISPERDAL CONSTA – risperidone microspheres for imextended rel susp 50 mg................................................. 74

RISPERIDONE ODT – risperidone orally disintegratingtab 0.25 mg...................................................................... 74

risperidone orally disintegrating tab 0.5 mg...................... 74risperidone orally disintegrating tab 1 mg......................... 74risperidone orally disintegrating tab 2 mg......................... 74risperidone orally disintegrating tab 3 mg......................... 74risperidone orally disintegrating tab 4 mg......................... 74risperidone soln 1 mg/ml (Risperdal).................................74risperidone tab 0.25 mg.....................................................75risperidone tab 0.5 mg (Risperdal)....................................75risperidone tab 1 mg (Risperdal).......................................75risperidone tab 2 mg (Risperdal).......................................75risperidone tab 3 mg (Risperdal).......................................75risperidone tab 4 mg (Risperdal).......................................75ritonavir tab 100 mg (Norvir)..............................................13rivastigmine tartrate cap 4.5 mg (base equivalent)........... 82RIXUBIS – coagulation factor ix (recombinant) for inj 250unit...................................................................................105

RIXUBIS – coagulation factor ix (recombinant) for inj 500unit...................................................................................105




rizatriptan benzoate oral disintegrating tab 5 mg (baseeq)..................................................................................... 91

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................91

rizatriptan benzoate tab 5 mg (base equivalent)...............91rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 91

ropinirole hydrochloride tab 0.25 mg.................................96ropinirole hydrochloride tab 0.5 mg...................................96ropinirole hydrochloride tab 1 mg......................................96ropinirole hydrochloride tab 2 mg......................................96ropinirole hydrochloride tab 3 mg......................................96ropinirole hydrochloride tab 4 mg......................................96ropinirole hydrochloride tab 5 mg......................................96rosuvastatin calcium tab 5 mg (Crestor)........................... 49rosuvastatin calcium tab 10 mg (Crestor)......................... 49rosuvastatin calcium tab 20 mg (Crestor)......................... 49rosuvastatin calcium tab 40 mg (Crestor)......................... 49ROZLYTREK – entrectinib cap 100 mg............................ 24

Page 145 of 152

2020

146

ROZLYTREK – entrectinib cap 200 mg............................ 24RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................24

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................24

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................24

RUCONEST – c1 esterase inhibitor (recombinant) for ivinj 2100 unit.................................................................... 106

RYDAPT – midostaurin cap 25 mg................................... 24

Ssalicylic acid cream 6%................................................... 111salicylic acid cream 6% & cleanser liqd kit......................111salicylic acid film forming liquid 27.5% (Virasal)..............111salicylic acid foam 6% (Salvax).......................................111salicylic acid gel 6% (Keralyt)..........................................111salicylic acid lotion 6% & cleanser liqd kit (Salexlotion)...............................................................................111

salicylic acid shampoo 6% (Salex)..................................111SAMSCA – tolvaptan tab 15 mg....................................... 39SAMSCA – tolvaptan tab 30 mg....................................... 39SAPHRIS – asenapine maleate sl tab 2.5 mg (baseequiv).................................................................................75

SAPHRIS – asenapine maleate sl tab 5 mg (baseequiv).................................................................................75

SAPHRIS – asenapine maleate sl tab 10 mg (baseequiv).................................................................................75

SAWYER PREMIUM INSECT REPELLENT – picaridinliquid................................................................................ 114

selegiline hcl cap 5 mg...................................................... 96SELEGILINE HCL – selegiline hcl tab 5 mg..................... 96selenium sulfide lotion 2.5%............................................114selenium sulfide shampoo 2.25%....................................114SELZENTRY – maraviroc tab 150 mg.............................. 13SELZENTRY – maraviroc tab 300 mg.............................. 13SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1mg......................................................................................99

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................99

SEROSTIM – somatropin (non-refrigerated) forsubcutaneous inj 4 mg.....................................................37



sertraline hcl oral concentrate for solution 20 mg/ml.........67sertraline hcl tab 25 mg (Zoloft)........................................ 67sertraline hcl tab 50 mg (Zoloft)........................................ 67sertraline hcl tab 100 mg (Zoloft)...................................... 67sevelamer carbonate packet 0.8 gm (Renvela)................ 61sevelamer carbonate packet 2.4 gm (Renvela)................ 61sevelamer carbonate tab 800 mg (Renvela).....................61SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml.................................................................... 17

SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (baseequiv).................................................................................39



sildenafil citrate for suspension 10 mg/ml (Revatio)..........52sildenafil citrate tab 20 mg (Revatio).................................52silver sulfadiazine cream 1% (Silvadene)....................... 111SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml...................................................................... 90

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml......................................................................... 90

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml.........................................................90

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml............................................................90

simvastatin tab 5 mg..........................................................49simvastatin tab 10 mg (Zocor)...........................................49simvastatin tab 20 mg (Zocor)...........................................49simvastatin tab 40 mg (Zocor)...........................................49simvastatin tab 80 mg (Zocor)...........................................49sirolimus tab 0.5 mg (Rapamune)................................... 117sirolimus tab 1 mg (Rapamune)...................................... 117sirolimus tab 2 mg (Rapamune)...................................... 117SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total)............................................................................32

SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fatab 28-0.8 mg................................................................... 99

sodium chloride irrigation soln 0.9%..................................62sodium chloride soln nebu 0.9%....................................... 55sodium chloride soln nebu 3%.......................................... 55sodium chloride soln nebu 10%........................................ 55sodium chloride soln nebu 7% (Hyper-sal)....................... 55sodium citrate & citric acid soln 500-334 mg/5ml..............63sodium fluoride chew tab 0.25 mg f (from 0.55 mgnaf).................................................................................... 99

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)........99sodium fluoride chew tab 1 mg f (from 2.2 mg naf)...........99sodium fluoride cream 1.1% (Prevident 5000 plus)........ 109sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride)........................................................................... 109

sodium fluoride paste 1.1% (Prevident 5000 boost)....... 109sodium fluoride-potassium nitrate paste 1.1-5% (Prevident5000 sensi)..................................................................... 109

sodium fluoride rinse 0.2% (Prevident rinse).................. 109SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)....................................................................... 99

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)....................................................................... 99

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................. 100

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/mlnaf).................................................................................. 100

sodium polystyrene sulfonate oral susp 15 gm/60ml...... 117sodium polystyrene sulfonate powder............................. 117

Page 146 of 152

2020

147

sodium polystyrene sulfonate rectal susp 30gm/120ml........................................................................ 117

SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvirtab 400-100 mg................................................................ 11

SOMAVERT – pegvisomant for inj 10 mg (as protein)......39SOMAVERT – pegvisomant for inj 15 mg (as protein)......39SOMAVERT – pegvisomant for inj 20 mg (as protein)......39SOMAVERT – pegvisomant for inj 25 mg (as protein)......39SOMAVERT – pegvisomant for inj 30 mg (as protein)......39sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 50sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 51sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 51sotalol hcl tab 240 mg....................................................... 51sotalol hcl tab 80 mg (Betapace).......................................51sotalol hcl tab 120 mg (Betapace).....................................51sotalol hcl tab 160 mg (Betapace).....................................51speciality vitamin product tab............................................ 99spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 50

spironolactone tab 25 mg (Aldactone)...............................50spironolactone tab 50 mg (Aldactone)...............................50spironolactone tab 100 mg (Aldactone)............................ 50SPRYCEL – dasatinib tab 20 mg...................................... 24SPRYCEL – dasatinib tab 50 mg...................................... 24SPRYCEL – dasatinib tab 70 mg...................................... 24SPRYCEL – dasatinib tab 80 mg...................................... 24SPRYCEL – dasatinib tab 100 mg.................................... 25SPRYCEL – dasatinib tab 140 mg.................................... 25stannous fluoride gel 0.4%.............................................. 109stavudine cap 15 mg..........................................................13stavudine cap 20 mg..........................................................13stavudine cap 30 mg..........................................................13stavudine cap 40 mg..........................................................13STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg(base equiv)...................................................................... 35

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg(base equiv)...................................................................... 35

STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml......................................................................... 114

STELARA – ustekinumab soln prefilled syringe 90 mg/ml.....................................................................................114

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................39

STIVARGA – regorafenib tab 40 mg................................. 25STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml......................................................................... 39

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................39

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml.......................................................................................39

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................39

STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg........................................................13

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................. 56

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................86

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................86

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................87

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................87

SUCRAID – sacrosidase soln 8500 unit/ml.......................60sucralfate tab 1 gm (Carafate)...........................................59SULFACETAMIDE SODIUM/PREDNISOLONE SODIUMPHOSPHATE – sulfacetamide sodium-prednisoloneophth soln 10-0.23(0.25)%.............................................108

sulfacetamide sodium lotion 10% (acne) (Klaron)...........110sulfacetamide sodium ophth soln 10% (Bleph-10)..........107SULFADIAZINE – sulfadiazine tab 500 mg.......................16sulfamethoxazole-trimethoprim susp 200-40 mg/5ml....... 16sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................16

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)......................................................................................16

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................61

sulfasalazine tab 500 mg (Azulfidine)................................61sulindac tab 150 mg...........................................................90sulindac tab 200 mg...........................................................90sumatriptan nasal spray 5 mg/act (Imitrex).......................91sumatriptan nasal spray 20 mg/act (Imitrex).....................91sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................91sumatriptan succinate solution auto-injector 4 mg/0.5ml(Imitrex statdose sys)....................................................... 91

sumatriptan succinate solution auto-injector 6 mg/0.5ml(Imitrex statdose sys)....................................................... 91

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)........................................................ 91

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 91

SUMATRIPTAN SUCCINATE – sumatriptan succinatesolution prefilled syringe 6 mg/0.5ml............................... 91

sumatriptan succinate tab 25 mg (Imitrex)........................91sumatriptan succinate tab 50 mg (Imitrex)........................91sumatriptan succinate tab 100 mg (Imitrex)......................91SUSTIVA – efavirenz cap 50 mg.......................................13SUSTIVA – efavirenz cap 200 mg.....................................13SUSTIVA – efavirenz tab 600 mg..................................... 13SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................25

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................25

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................25

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................25

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg.....25SYLATRON – peginterferon alfa-2b for inj kit 300 mcg.....25SYLATRON – peginterferon alfa-2b for inj kit 600 mcg.....25

Page 147 of 152

2020

148

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................57

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................57

SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75mg tab tbpk.......................................................................57

SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk............................................................... 58

SYMFI – efavirenz-lamivudine-tenofovir df tab600-300-300 mg............................................................... 13

SYMFI LO – efavirenz-lamivudine-tenofovir df tab400-300-300 mg............................................................... 13

SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg..........................................................13

SYNAGIS – palivizumab im soln 50 mg/0.5ml..................17SYNAGIS – palivizumab im soln 100 mg/ml.....................17SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)........................................................... 33

TTABLOID – thioguanine tab 40 mg................................... 25tacrolimus cap 0.5 mg (Prograf)......................................117tacrolimus cap 1 mg (Prograf).........................................117tacrolimus cap 5 mg (Prograf).........................................117tacrolimus oint 0.03% (Protopic)......................................114tacrolimus oint 0.1% (Protopic)........................................114tadalafil tab 20 mg (pah) (Adcirca)....................................53TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent).........................................................................25

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent).........................................................................25

TAGRISSO – osimertinib mesylate tab 40 mg (baseequivalent).........................................................................25

TAGRISSO – osimertinib mesylate tab 80 mg (baseequivalent).........................................................................25

TALTZ – ixekizumab subcutaneous soln auto-injector 80mg/ml...............................................................................115

TALTZ – ixekizumab subcutaneous soln prefilled syringe80 mg/ml......................................................................... 115

TALZENNA – talazoparib tosylate cap 0.25 mg (baseequivalent).........................................................................25

TALZENNA – talazoparib tosylate cap 1 mg (baseequivalent).........................................................................25

tamoxifen citrate tab 10 mg (base equivalent).................. 25tamoxifen citrate tab 20 mg (base equivalent).................. 25tamsulosin hcl cap 0.4 mg (Flomax)................................. 63TARGRETIN – bexarotene cap 75 mg..............................25TARGRETIN – bexarotene gel 1%..................................115TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 25TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................25

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................26

tazarotene cream 0.1% (Tazorac)................................... 110TAZORAC – tazarotene cream 0.05%............................ 110TAZORAC – tazarotene gel 0.05%................................. 110

TAZORAC – tazarotene gel 0.1%................................... 110temazepam cap 15 mg (Restoril)...................................... 76temazepam cap 30 mg (Restoril)...................................... 76TEMIXYS – lamivudine-tenofovir disoproxil fumarate tab300-300 mg.......................................................................14

TEMODAR – temozolomide for iv soln 100 mg................ 26temozolomide cap 5 mg (Temodar)...................................26temozolomide cap 20 mg (Temodar).................................26temozolomide cap 100 mg (Temodar)...............................26temozolomide cap 140 mg (Temodar)...............................26temozolomide cap 180 mg (Temodar)...............................26temozolomide cap 250 mg (Temodar)...............................26tenofovir disoproxil fumarate tab 300 mg (Viread)............ 14terazosin hcl cap 1 mg (base equivalent)......................... 53terazosin hcl cap 2 mg (base equivalent)......................... 53terazosin hcl cap 5 mg (base equivalent)......................... 53terazosin hcl cap 10 mg (base equivalent)....................... 53terbinafine hcl tab 250 mg.................................................10terbutaline sulfate tab 2.5 mg............................................57terbutaline sulfate tab 5 mg...............................................57TERCONAZOLE – terconazole vaginal cream 0.8%........62terconazole vaginal cream 0.4%....................................... 62terconazole vaginal suppos 80 mg....................................62testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)..................................................................... 29

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)..................................................................... 29

testosterone td gel 12.5 mg/act (1%)................................ 29testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 29testosterone td gel 50 mg/5gm (1%) (Androgel)............... 29tetracaine hcl ophth soln 0.5%........................................ 109THALOMID – thalidomide cap 50 mg............................. 117THALOMID – thalidomide cap 100 mg........................... 117THALOMID – thalidomide cap 150 mg........................... 117THALOMID – thalidomide cap 200 mg........................... 117THEOPHYLLINE ER – theophylline tab er 12hr 300mg......................................................................................57

THEOPHYLLINE ER – theophylline tab er 12hr 450mg......................................................................................57

theophylline soln 80 mg/15ml............................................57theophylline tab er 24hr 400 mg........................................57theophylline tab er 24hr 600 mg........................................57thiothixene cap 1 mg..........................................................75thiothixene cap 2 mg..........................................................75thiothixene cap 5 mg..........................................................75thiothixene cap 10 mg........................................................75thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................37thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............37thyroid tab 60 mg (1 grain) (Armour thyroid).....................37tiagabine hcl tab 2 mg (Gabitril)........................................ 94tiagabine hcl tab 4 mg (Gabitril)........................................ 94TIBSOVO – ivosidenib tab 250 mg................................... 26timolol maleate ophth soln 0.25% (Timoptic).................. 108timolol maleate ophth soln 0.5% (Timoptic).................... 108TIVICAY – dolutegravir sodium tab 50 mg (baseequiv).................................................................................14

Page 148 of 152

2020

149

tizanidine hcl tab 2 mg (base equivalent)..........................96tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........96tobramycin nebu soln 300 mg/5ml (Tobi)............................ 9tobramycin ophth soln 0.3% (Tobrex)..............................107TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml.......... 9tolcapone tab 100 mg (Tasmar)........................................ 96tolterodine tartrate tab 2 mg (Detrol).................................62topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 95topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 95topiramate tab 25 mg (Topamax)...................................... 95topiramate tab 50 mg (Topamax)...................................... 95topiramate tab 100 mg (Topamax).................................... 95topiramate tab 200 mg (Topamax).................................... 95toremifene citrate tab 60 mg (base equivalent)(Fareston)..........................................................................26

torsemide tab 5 mg............................................................50torsemide tab 10 mg..........................................................50torsemide tab 20 mg..........................................................50torsemide tab 100 mg........................................................50TRACLEER – bosentan tab for oral susp 32 mg.............. 53tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 87tramadol hcl tab 50 mg (Ultram)........................................87TRANDOLAPRIL/VERAPAMIL HCL ER – trandolapril-verapamil hcl tab er 1-240 mg.........................................46

trandolapril tab 1 mg..........................................................41trandolapril tab 2 mg..........................................................41trandolapril tab 4 mg..........................................................41trandolapril-verapamil hcl tab er 2-180 mg (Tarka)........... 46trandolapril-verapamil hcl tab er 2-240 mg (Tarka)........... 46trandolapril-verapamil hcl tab er 4-240 mg (Tarka)........... 46tranexamic acid tab 650 mg (Lysteda)............................ 106trazodone hcl tab 50 mg....................................................67trazodone hcl tab 100 mg..................................................67trazodone hcl tab 150 mg..................................................67tretinoin cap 10 mg............................................................ 26tretinoin cream 0.025% (Retin-a).....................................110tretinoin cream 0.05% (Retin-a).......................................110tretinoin cream 0.1% (Retin-a).........................................110tretinoin gel 0.05% (Atralin)............................................. 110tretinoin gel 0.01% (Retin-a)............................................110tretinoin gel 0.025% (Retin-a)..........................................110triamcinolone acetonide aerosol soln 0.147 mg/gm(Kenalog).........................................................................113

triamcinolone acetonide cream 0.025%.......................... 113triamcinolone acetonide cream 0.1%.............................. 113triamcinolone acetonide cream 0.5%.............................. 113triamcinolone acetonide dental paste 0.1%.................... 109triamcinolone acetonide lotion 0.025%............................113triamcinolone acetonide lotion 0.1%................................113triamcinolone acetonide nasal aerosol suspension 55mcg/act..............................................................................54

triamcinolone acetonide oint 0.025%.............................. 113triamcinolone acetonide oint 0.1%.................................. 113triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................50

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 50

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................50

TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg.....99trientine hcl cap 250 mg (Syprine).................................. 117trifluoperazine hcl tab 1 mg (base equivalent).................. 75trifluoperazine hcl tab 2 mg (base equivalent).................. 75trifluoperazine hcl tab 5 mg (base equivalent).................. 75trifluoperazine hcl tab 10 mg (base equivalent)................ 75TRIFLURIDINE – trifluridine ophth soln 1%....................107trihexyphenidyl hcl elixir 0.4 mg/ml....................................96trihexyphenidyl hcl tab 2 mg..............................................96trihexyphenidyl hcl tab 5 mg..............................................96TRIKAFTA – elexacaf-tezacaf-ivacaf 100-50-75 mg&ivacaftor 150 mg tbpk.................................................... 58

trimethobenzamide hcl cap 300 mg (Tigan)......................59trimethoprim tab 100 mg....................................................16TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................99

TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg................................................................. 14

trospium chloride cap er 24hr 60 mg................................ 62trospium chloride tab 20 mg..............................................62TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................35

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................35

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................ 14




TURALIO – pexidartinib hcl cap 200 mg (baseequivalent).........................................................................26

TYBOST – cobicistat tab 150 mg......................................14TYKERB – lapatinib ditosylate tab 250 mg (baseequiv).................................................................................26

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml.............................................................. 39

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml.......................................................................................53

TYVASO STARTER – treprostinil inhalation solution 0.6mg/ml.................................................................................53

TYVASO – treprostinil inhalation solution 0.6 mg/ml.........53

UUPTRAVI – selexipag tab 200 mcg...................................53UPTRAVI – selexipag tab 400 mcg...................................53UPTRAVI – selexipag tab 600 mcg...................................53UPTRAVI – selexipag tab 800 mcg...................................53UPTRAVI – selexipag tab 1000 mcg.................................53UPTRAVI – selexipag tab 1200 mcg.................................53

Page 149 of 152

2020

150

UPTRAVI – selexipag tab 1400 mcg.................................53UPTRAVI – selexipag tab 1600 mcg.................................53UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60).................................................................... 53

ursodiol cap 300 mg (Actigall)...........................................61ursodiol tab 250 mg (Urso 250).........................................61ursodiol tab 500 mg (Urso forte)....................................... 61

Vvalacyclovir hcl tab 1 gm (Valtrex).....................................11valacyclovir hcl tab 500 mg (Valtrex).................................11VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent).......................................................................115

valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte)............................................................................ 10

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte)............................................................................ 10

valproate sodium oral soln 250 mg/5ml (base equiv)........95valproic acid cap 250 mg...................................................95valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................42

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................42

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................42

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................43

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................43

valsartan tab 40 mg (Diovan)............................................ 42valsartan tab 80 mg (Diovan)............................................ 42valsartan tab 160 mg (Diovan).......................................... 42valsartan tab 320 mg (Diovan).......................................... 42vancomycin hcl cap 250 mg (base equivalent)(Vancocin)......................................................................... 16

vancomycin hcl cap 125 mg (base equivalent) (Vancocinhcl).....................................................................................16

VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg....................................... 26

VENCLEXTA – venetoclax tab 10 mg...............................26VENCLEXTA – venetoclax tab 50 mg...............................26VENCLEXTA – venetoclax tab 100 mg.............................26venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 68

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 68

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 68

venlafaxine hcl tab 25 mg (base equivalent).....................68venlafaxine hcl tab 37.5 mg (base equivalent)..................68venlafaxine hcl tab 50 mg (base equivalent).....................68venlafaxine hcl tab 75 mg (base equivalent).....................68venlafaxine hcl tab 100 mg (base equivalent)...................68verapamil hcl cap er 24hr 120 mg (Verelan).....................46verapamil hcl cap er 24hr 180 mg (Verelan).....................46verapamil hcl cap er 24hr 240 mg (Verelan).....................46

VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100mg......................................................................................46

VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300mg......................................................................................46

VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360mg......................................................................................46

verapamil hcl tab er 120 mg (Calan sr).............................46verapamil hcl tab er 180 mg (Calan sr).............................46verapamil hcl tab er 240 mg (Calan sr).............................46verapamil hcl tab 40 mg.................................................... 46verapamil hcl tab 80 mg.................................................... 46verapamil hcl tab 120 mg (Calan)..................................... 46VERAPAMIL HYDROCHLORIDE ER – verapamil hcl caper 24hr 200 mg.................................................................46

VERSACLOZ – clozapine susp 50 mg/ml.........................75VERZENIO – abemaciclib tab 50 mg................................26VERZENIO – abemaciclib tab 100 mg..............................26VERZENIO – abemaciclib tab 150 mg..............................26VERZENIO – abemaciclib tab 200 mg..............................26VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................35

VIDEX – didanosine for soln 2 gm....................................14vigabatrin powd pack 500 mg (Sabril)...............................95vigabatrin tab 500 mg (Sabril)........................................... 95VIIBRYD STARTER PACK – vilazodone hcl tab starter kit10 (7) & 20 (23) mg......................................................... 68

VIIBRYD – vilazodone hcl tab 10 mg................................68VIIBRYD – vilazodone hcl tab 20 mg................................68VIIBRYD – vilazodone hcl tab 40 mg................................68VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1mg......................................................................................99

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................99

VIRACEPT – nelfinavir mesylate tab 250 mg................... 14VIRACEPT – nelfinavir mesylate tab 625 mg................... 14VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm............................................................................... 14

VIREAD – tenofovir disoproxil fumarate tab 150 mg.........14VIREAD – tenofovir disoproxil fumarate tab 200 mg.........14VIREAD – tenofovir disoproxil fumarate tab 250 mg.........14VIREAD – tenofovir disoproxil fumarate tab 300 mg.........14VITRAKVI – larotrectinib sulfate cap 25 mg (baseequivalent).........................................................................26

VITRAKVI – larotrectinib sulfate cap 100 mg (baseequivalent).........................................................................27

VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (baseequivalent).........................................................................26

VIVITROL – naltrexone for im extended release susp 380mg....................................................................................117

VIZIMPRO – dacomitinib tab 15 mg..................................27VIZIMPRO – dacomitinib tab 30 mg..................................27VIZIMPRO – dacomitinib tab 45 mg..................................27VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................99

VONVENDI – von willebrand factor (recombinant) for inj650 unit........................................................................... 106

Page 150 of 152

2020

151

VONVENDI – von willebrand factor (recombinant) for inj1300 unit......................................................................... 106

voriconazole for susp 40 mg/ml (Vfend)............................10voriconazole tab 50 mg (Vfend)........................................ 10voriconazole tab 200 mg (Vfend)...................................... 10VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......27VYNDAQEL – tafamidis meglumine (cardiac) cap 20mg......................................................................................54

Wwarfarin sodium tab 1 mg (Coumadin)............................106warfarin sodium tab 2 mg (Coumadin)............................106warfarin sodium tab 2.5 mg (Coumadin).........................106warfarin sodium tab 3 mg (Coumadin)............................106warfarin sodium tab 4 mg (Coumadin)............................106warfarin sodium tab 5 mg (Coumadin)............................106warfarin sodium tab 6 mg (Coumadin)............................106warfarin sodium tab 7.5 mg (Coumadin).........................106warfarin sodium tab 10 mg (Coumadin)..........................106water for irrigation, sterile irrigation soln......................... 117WESTAB MAX – folic acid-pyridoxine-cyanocobalamin tab2.5-25-2 mg.................................................................... 100

WILATE – antihemophilic factor/vwf (human) for inj500-500 unit kit...............................................................106

WILATE – antihemophilic factor/vwf (human) for inj1000-1000 unit kit...........................................................106

XXALKORI – crizotinib cap 200 mg.....................................27XALKORI – crizotinib cap 250 mg.....................................27XARELTO – rivaroxaban tab 2.5 mg...............................106XARELTO – rivaroxaban tab 10 mg................................106XARELTO – rivaroxaban tab 15 mg................................106XARELTO – rivaroxaban tab 20 mg................................106XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg........................................ 106

XELJANZ – tofacitinib citrate tab 5 mg (baseequivalent).........................................................................90

XELJANZ – tofacitinib citrate tab 10 mg (baseequivalent).........................................................................90

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent).........................................................................90

XELJANZ XR – tofacitinib citrate tab er 24hr 22 mg (baseequivalent).........................................................................90

XENLETA – lefamulin acetate tab 600 mg........................16XIFAXAN – rifaximin tab 550 mg.......................................16XOSPATA – gilteritinib fumarate tablet 40 mg (baseequivalent).........................................................................27

XPOVIO 100 MG ONCE WEEKLY – selinexor tab therapypack 20 mg (100 mg once weekly)................................. 27

XPOVIO 60 MG ONCE WEEKLY – selinexor tab therapypack 20 mg (60 mg once weekly)................................... 27

XPOVIO 80 MG ONCE WEEKLY – selinexor tab therapypack 20 mg (80 mg once weekly)................................... 27

XPOVIO 80 MG TWICE WEEKLY – selinexor tab therapypack 20 mg (80 mg twice weekly)................................... 27

XTANDI – enzalutamide cap 40 mg.................................. 27

XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 32

XURIDEN – uridine triacetate oral granules packet 2gm......................................................................................39

XYNTHA – antihemophilic factor recombinant paf for inj kit250 unit........................................................................... 106

XYNTHA – antihemophilic factor recombinant paf for inj kit500 unit........................................................................... 106

XYNTHA – antihemophilic factor recombinant paf for inj kit1000 unit......................................................................... 107

XYNTHA – antihemophilic factor recombinant paf for inj kit2000 unit......................................................................... 107

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 250 unit................................ 107

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 500 unit................................ 107

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 1000 unit.............................. 107



YYONSA – abiraterone acetate tab 125 mg....................... 27

Zzaleplon cap 5 mg..............................................................76zaleplon cap 10 mg............................................................76ZELBORAF – vemurafenib tab 240 mg............................ 27zidovudine cap 100 mg (Retrovir)..................................... 14zidovudine syrup 10 mg/ml (Retrovir)................................14zidovudine tab 300 mg...................................................... 14ziprasidone hcl cap 20 mg (Geodon)................................ 75ziprasidone hcl cap 40 mg (Geodon)................................ 75ziprasidone hcl cap 60 mg (Geodon)................................ 75ziprasidone hcl cap 80 mg (Geodon)................................ 75ZOLINZA – vorinostat cap 100 mg....................................27zolpidem tartrate tab 5 mg (Ambien).................................76zolpidem tartrate tab 10 mg (Ambien)...............................76zonisamide cap 50 mg.......................................................95zonisamide cap 25 mg (Zonegran)....................................95zonisamide cap 100 mg (Zonegran)..................................95ZORBTIVE – somatropin (non-refrigerated) forsubcutaneous inj 8.8 mg..................................................37

ZORTRESS – everolimus tab 0.25 mg........................... 117ZORTRESS – everolimus tab 0.5 mg............................. 117ZORTRESS – everolimus tab 0.75 mg........................... 117ZORTRESS – everolimus tab 1 mg................................ 117ZOSTAVAX – zoster vaccine live for subcutaneous susp19400 unit/0.65ml............................................................. 18

ZYDELIG – idelalisib tab 100 mg......................................27ZYDELIG – idelalisib tab 150 mg......................................27ZYKADIA – ceritinib tab 150 mg....................................... 27ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 210 mg (base eq)..........................75

Page 151 of 152

2020

152

ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 300 mg (base eq)..........................76

ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 405 mg (base eq)..........................76

ZYTIGA – abiraterone acetate tab 500 mg....................... 28ZYVOX – linezolid for susp 100 mg/5ml........................... 16

Page 152 of 152

Prime Therapeutics LLC ofrece el sitio digital MyPrime.com.Prime Therapeutics tiene interés de propiedad en AllianceRx Walgreens Prime, una farmacia central especializada con servicio de entrega a domicilio. BCBSNM tiene contrato con Prime Therapeutics para proporcionar servicios de administración de beneficios farmacéuticos y otros servicios relacionados. Tanto BCBSNM como varias entidades Blue Cross and Blue Shield independientes tienen interés de propiedad en Prime Therapeutics.CoverMyMeds es una marca registrada de CoverMyMeds LLC, un proveedor enteramente responsable por los productos y servicios que ofrece. BCBSNM no recomienda, ni avala, ni garantiza ninguno de los productos o servicios disponibles a través de los proveedores mencionados en este documento. Comuníquese directamente con el (los) proveedor(es) en caso de tener preguntas en relación con los productos o servicios que ofrece(n). Esos servicios reciben financiamiento parcial del estado de Nuevo México.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 479350.0420


Lista de medicamentos de Blue Cross Community …...Medicamentos para el corazón y la...

Documents

Transcript of Lista de medicamentos de Blue Cross Community …...Medicamentos para el corazón y la...