blue cross and blue shield of illinois lista de ...lista de medicamentos vigente al 12/1/2017, fecha...

IL_FHP_RX

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRE ESTE PLAN.

Lista de medicamentos vigente al 12/1/2017, fecha de su publicación. Favor de notificar errores en esta lista de medicamentos a Blue Cross Community Family Health Plan por escrito a [email protected] o por teléfono al 1-877-860-2837 TTY/TDD 7-1-1.

229793.1217

Blue Cross and Blue Shield of Illinois

Lista de medicamentos de 2017 del Plan de salud familiar

Blue Cross and Blue Shield of Illinois 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 Illinois no excluye a las personas ni las trata diferente debido a raza, color, nacionalidad, edad, discapacidad o sexo.

Blue Cross and Blue Shield of Illinois:

• Proporciona servicios y ayuda de forma gratuita a las personas que tengan discapacidades para quepuedan comunicarse de forma eficaz con nosotros, tales como:

○ intérpretes de lenguaje de señas capacitados;○ información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros

formatos).• Proporciona servicios de idiomas gratuitos para las personas cuyo idioma principal no sea el inglés

(English), tales como:○ intérpretes capacitados;○ información escrita en otros idiomas.

Si necesita de estos servicios, comuníquese con el Coordinador de Derechos Civiles.

Si cree que Blue Cross and Blue Shield of Illinois no le proporcionó estos servicios o lo discriminó de alguna manera por motivos de raza, color, país de origen, edad, discapacidad o sexo, puede presentar una inconformidad con: 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 hacerlo en persona, por correo, por fax o correo electrónico. Si necesita ayuda para presentar una inconformidad, el Coordinador de Derechos Civiles está disponible para brindarle ayuda.

También puede presentar una queja por discriminación en la oficina de Derechos Civiles ante el Departamento de Salud y Servicios Humanos de los EE. UU. (HHS, en inglés), electrónicamente a través del Portal de quejas de derechos civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf o por correo o teléfono a:

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)

Los formularios de quejas se encuentran disponibles en http://www.hhs.gov/ocr/office/file/index.html.

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

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Lista de medicam

entos¿Qué es la lista de medicamentos del Blue Cross Community Family Health Plan (el “plan”)?La lista de medicamentos (a veces denominada “formulario”) es una lista que enumera los medicamentos que pueden estar cubiertos por el plan. Para que los medicamentos enumerados estén cubiertos, usted debe cumplir con lo siguiente:

• tener la necesidad médica de obtenerlos;

• abastecer las recetas en una farmacia de la red;

• seguir otras normas del plan.

Para obtener más información sobre cómo abastecer sus recetas, consulte el Manual para miembros.

¿Cuánto tendré que pagar?No debe pagar nada por los medicamentos cubiertos.

¿La lista de medicamentos puede cambiar?Sí, puede cambiar.

La cobertura puede cambiar en los siguientes casos:

• cuando esté disponible un nuevo medicamento genérico;

• cuando nueva información sobre un medicamento demuestra que este no es seguro o que es menos eficaz.

Cuando se realicen cambios en la lista de medicamentos, se lo notificaremos por escrito.

¿Cómo utilizo la lista de medicamentos? Hay dos formas de buscar un medicamento en la lista comenzando en la página 1.

1. Por categoría

• La lista de medicamentos cubiertos que comienza en la página 1 brinda información sobre los medicamentos cubiertos por el Blue Cross Community Family Health Plan. Si tiene dificultades para encontrar el medicamento que busca en la lista, consulte el índice que comienza al final de este cuadernillo.

– En la primera columna del cuadro figura el nombre del medicamento. Los medicamentos de marca aparecen en letra mayúscula (por ejemplo, CIPRO) y los medicamentos genéricos aparecen en letra cursiva minúscula (por ejemplo ciprofloxacin).

– La información que aparecen en la columna “Acciones necesarias, restricciones o límites de uso” indican si Blue Cross Community Family Health Plan tiene alguna norma para cubrir su medicamento.

• Los medicamentos se enumeran en categorías, o grupos, según el tipo de afección que tratan. (Por ejemplo, los medicamentos que se utilizan para tratar enfermedades cardíacas se enumeran en “Agentes cardiovasculares”).

• Si sabe qué afección trata su medicamento, busque ese grupo en la lista.

• Luego, busque el medicamento dentro de ese grupo.

2. Listado en orden alfabético

• Busque su medicamento al final de este cuadernillo.

• Al lado del medicamento verá el número de página donde puede encontrar la información de la cobertura.

¿Qué son los medicamentos genéricos?Los medicamentos genéricos son aprobados por la Administración de Drogas y Alimentos (FDA) por tener el mismo ingrediente activo que el medicamento de marca, pero generalmente cuestan menos. El plan cubre medicamentos de marca y medicamentos genéricos

¿Existe algún límite en mi cobertura?Las condiciones o los límites adicionales que tienen algunos medicamentos cubiertos pueden incluir los siguientes:

• Autorización previa: Es posible que usted o su médico deban obtener aprobación antes

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List

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sde abastecer sus recetas. Si no obtiene la aprobación, es posible que el plan no cubra el medicamento.

• Límites de cantidad: El plan limita la cantidad que cubrirá de algunos medicamentos.

• Terapia escalonada: En algunos casos, el plan requiere que primero pruebe determinados medicamentos antes de cubrir otro medicamento. Por ejemplo, si el medicamento A y el medicamento B tratan su enfermedad, es posible que el plan no cubra el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento A no funciona en su caso, entonces el plan cubrirá el medicamento B.

Puede averiguar si su medicamento tiene alguna condición o límite adicional consultando la lista que comienza en la página 1. Encontrará nuestra información de contacto más abajo, y la fecha en que actualizamos la lista en la portada y contraportada.

¿El plan paga medicamentos de venta libre?Sí, el plan paga algunos medicamentos de venta libre (OTC) si tiene una receta válida de su médico, y puede obtenerlos sin costo alguno. Se deben recetar y entregar medicamentos genéricos cuando estén disponibles. Estos medicamentos deben abastecerse en una farmacia de la red por un suministro de 30 días.

¿Qué sucede si mi medicamento no figura en la lista de medicamentos?Comuníquese con Atención al Cliente y pregunte si el medicamento está cubierto. Si le informan que el plan no cubre su medicamento, tiene dos opciones:

• Hable con su médico para determinar si debe probar primero otro medicamento de nuestra lista antes de solicitar una excepción.

• Pregunte en Atención al Cliente cómo solicitar una excepción para que cubramos su medicamento. Envíe una declaración de su médico para respaldar su solicitud. Debemos tomar una decisión dentro de los 24 horas de la recepción de la declaración de su médico.

Por lo general, solo aprobamos las solicitudes de excepción si otros medicamentos incluidos en nuestra lista, o los limites adicionales de uso, harían que su tratamiento sea menos eficaz o serían perjudiciales para su salud.

¿Qué categorías de medicamentos no están cubiertas en la lista de medicamentos del plan?Las siguientes categorías de medicamentos no están cubiertas por su plan:

– medicamentos para el tratamiento de la anorexia, la pérdida de peso o el aumento de peso;

– productos químicos a granel;

– medicamentos con fines cosméticos;

– agentes de diagnóstico;

– medicamentos clasificados como ineficaces por la Implementación del Estudio de la Eficacia de los Medicamentos (DESI);

– medicamentos experimentales y en investigación;

– medicamentos contra la disfunción eréctil para tratar la impotencia;

– medicamentos para la fertilidad;

– medicamentos anestésicos generales;

– medicamentos de venta libre no incluidos de otra manera en la lista de medicamentos del plan;

– Suministros o equipos médicos quirúrgicos.

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Lista de medicam

entosPara obtener más información Si usted tuviese cualquier pregunta, por favor llame a Atención al Cliente al: 1-877-723-7702 (TTY/TDD 711). Estamos a su disposición las 24 horas del día, los siete (7) días de la semana. La llamada es gratuita.

Asistencia lingüísticaUsted puede obtener este documento en español o hablar con alguien, de forma gratuita, acerca de esta información en otros idiomas. Llame al 1-877-723-7702 (TTY/TDD: 711). La llamada es gratuita. Usted también puede llamar al Atención al Cliente, de forma gratuita, para solicitar esta información en otros formatos alternos tales como en Braille, en letra grande y de otras maneras. Llame sin cargos al: 1-877-723-7702 (TTY/TDD: 711). Estamos a su disposición las 24 horas del día, los siete (7) días de la semana. La llamada es gratuita.

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2017

1 = Medicamentos genéricos AL = Límite de edad ME = Equivalente a la morfina 90 = Suministro de 90 díasdisponible al realizar el pedido deenvío por correo

2 = Medicamentos de marca PA = Autorización previa QL = Límites de cantidad SP = Medicamento especializado3 = Medicamentos de venta libre ST = Terapia escalonada

1

Nombre del medicamento

Cuánto le costaráel medicamento de(nivel)

Acciones necesarias,restricciones o límitesen el uso

MEDICAMENTOS ANTIINFECCIOSOSPENICILINASAMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg $0 (2)AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg $0 (2)amoxicillin (trihydrate) cap 250 mg $0 (1)amoxicillin (trihydrate) cap 500 mg $0 (1)amoxicillin (trihydrate) for susp 125 mg/5ml $0 (1)amoxicillin (trihydrate) for susp 200 mg/5ml $0 (1)amoxicillin (trihydrate) for susp 250 mg/5ml $0 (1)amoxicillin (trihydrate) for susp 400 mg/5ml $0 (1)amoxicillin (trihydrate) tab 875 mg $0 (1)amoxicillin & k clavulanate for susp 200-28.5 mg/5ml $0 (1)amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

(Augmentin)$0 (1)

amoxicillin & k clavulanate for susp 400-57 mg/5ml $0 (1)amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin

es-600)$0 (1)

amoxicillin & k clavulanate tab 250-125 mg $0 (1)amoxicillin & k clavulanate tab 500-125 mg (Augmentin) $0 (1)amoxicillin & k clavulanate tab 875-125 mg (Augmentin) $0 (1)AMPICILLIN – ampicillin cap 500 mg $0 (1)dicloxacillin sodium cap 250 mg $0 (1)dicloxacillin sodium cap 500 mg $0 (1)PENICILLIN V POTASSIUM – penicillin v potassium for soln

125 mg/5ml$0 (1)

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

$0 (1)

penicillin v potassium tab 250 mg $0 (1)penicillin v potassium tab 500 mg $0 (1)

CEFALOSPORINAScefaclor cap 250 mg $0 (1)cefaclor cap 500 mg $0 (1)cefadroxil cap 500 mg $0 (1)cefadroxil for susp 250 mg/5ml $0 (1)cefadroxil for susp 500 mg/5ml $0 (1)cefadroxil tab 1 gm $0 (1)

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cefdinir cap 300 mg $0 (1)cefdinir for susp 125 mg/5ml $0 (1)cefdinir for susp 250 mg/5ml $0 (1)cefprozil for susp 125 mg/5ml $0 (1)cefprozil for susp 250 mg/5ml $0 (1)cefprozil tab 250 mg $0 (1)cefprozil tab 500 mg $0 (1)ceftriaxone sodium for inj 250 mg $0 (1)ceftriaxone sodium for inj 500 mg $0 (1)ceftriaxone sodium for inj 1 gm $0 (1)ceftriaxone sodium for inj 2 gm $0 (1)cefuroxime axetil tab 250 mg $0 (1)cefuroxime axetil tab 500 mg $0 (1)cephalexin cap 250 mg (Keflex) $0 (1)cephalexin cap 500 mg (Keflex) $0 (1)cephalexin for susp 125 mg/5ml $0 (1)cephalexin for susp 250 mg/5ml $0 (1)

MACRÓLIDOSazithromycin for susp 100 mg/5ml (Zithromax) $0 (1)azithromycin for susp 200 mg/5ml (Zithromax) $0 (1)azithromycin tab 250 mg (Zithromax) $0 (1) QL (60 tablets/180 days)azithromycin tab 500 mg (Zithromax) $0 (1) QL (60 tablets/180 days)azithromycin tab 600 mg (Zithromax) $0 (1) QL (60 tablets/180 days)clarithromycin tab 250 mg $0 (1)clarithromycin tab 500 mg (Biaxin) $0 (1)

TETRACICLINASdemeclocycline hcl tab 150 mg $0 (1)doxycycline hyclate cap 50 mg $0 (1)doxycycline hyclate cap 100 mg (Vibramycin) $0 (1)doxycycline hyclate tab 20 mg $0 (1)doxycycline hyclate tab 100 mg $0 (1)doxycycline monohydrate cap 50 mg $0 (1)doxycycline monohydrate cap 100 mg (Monodox) $0 (1)doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) $0 (1)doxycycline monohydrate tab 50 mg $0 (1)

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doxycycline monohydrate tab 75 mg $0 (1)doxycycline monohydrate tab 100 mg $0 (1)minocycline hcl cap 50 mg (Minocin) $0 (1)minocycline hcl cap 75 mg $0 (1)minocycline hcl cap 100 mg (Minocin) $0 (1)minocycline hcl tab 50 mg $0 (1)minocycline hcl tab 75 mg $0 (1)minocycline hcl tab 100 mg $0 (1)

FLUOROQUINOLONASciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) $0 (1)ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

(Cipro)$0 (1)

ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) $0 (1)ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) $0 (1)ciprofloxacin hcl tab 750 mg (base equiv) $0 (1)LEVOFLOXACIN – levofloxacin oral soln 25 mg/ml $0 (2)levofloxacin tab 250 mg (Levaquin) $0 (1)levofloxacin tab 500 mg (Levaquin) $0 (1)levofloxacin tab 750 mg (Levaquin) $0 (1)SULFADIAZINE – sulfadiazine tab 500 mg $0 (1)

AMINOGLUCÓSIDOSneomycin sulfate tab 500 mg $0 (1)paromomycin sulfate cap 250 mg $0 (1)tobramycin nebu soln 300 mg/5ml (Tobi) $0 (1) QL (56 ampules/56

days), SP

TUBERCULOSISethambutol hcl tab 100 mg (Myambutol) $0 (1)ethambutol hcl tab 400 mg (Myambutol) $0 (1)isoniazid tab 100 mg $0 (1) 90isoniazid tab 300 mg $0 (1) 90PRIFTIN – rifapentine tab 150 mg $0 (2)pyrazinamide tab 500 mg $0 (1)rifabutin cap 150 mg (Mycobutin) $0 (1)rifampin cap 150 mg (Rifadin) $0 (1)rifampin cap 300 mg $0 (1)

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INFECCIONES FÚNGICASfluconazole for susp 10 mg/ml (Diflucan) $0 (1)fluconazole for susp 40 mg/ml (Diflucan) $0 (1)fluconazole tab 50 mg (Diflucan) $0 (1)fluconazole tab 100 mg (Diflucan) $0 (1)fluconazole tab 150 mg (Diflucan) $0 (1)fluconazole tab 200 mg (Diflucan) $0 (1)flucytosine cap 250 mg (Ancobon) $0 (1)flucytosine cap 500 mg (Ancobon) $0 (1)griseofulvin microsize susp 125 mg/5ml $0 (1)griseofulvin microsize tab 500 mg $0 (1)griseofulvin ultramicrosize tab 125 mg (Gris-peg) $0 (1)griseofulvin ultramicrosize tab 250 mg (Gris-peg) $0 (1)itraconazole cap 100 mg (Sporanox) $0 (1) QL (120

capsules/30 days)ketoconazole tab 200 mg $0 (1)NOXAFIL – posaconazole tab delayed release 100 mg $0 (2) PA, 90NOXAFIL – posaconazole susp 40 mg/ml $0 (2) PA, 90nystatin tab 500000 unit $0 (1)terbinafine hcl tab 250 mg (Lamisil) $0 (1)voriconazole for susp 40 mg/ml (Vfend) $0 (1) PAvoriconazole tab 50 mg (Vfend) $0 (1) PAvoriconazole tab 200 mg (Vfend) $0 (1) PA

INFECCIONES VIRALESCitomegalovirusvalganciclovir hcl tab 450 mg (base equivalent) (Valcyte) $0 (1) 90

HepatitisBARACLUDE – entecavir oral soln 0.05 mg/ml $0 (2) 90entecavir tab 0.5 mg (Baraclude) $0 (1) 90entecavir tab 1 mg (Baraclude) $0 (1) 90EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg $0 (2) PA, SPlamivudine tab 100 mg (hbv) (Epivir hbv) $0 (1) 90MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg $0 (1) PA, SPribavirin cap 200 mg (Rebetol) $0 (1) SPSOVALDI – sofosbuvir tab 400 mg $0 (2) PA, SP

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ZEPATIER – elbasvir-grazoprevir tab 50-100 mg $0 (2) PA, SP

Herpesacyclovir cap 200 mg (Zovirax) $0 (1)acyclovir susp 200 mg/5ml (Zovirax) $0 (1)acyclovir tab 400 mg (Zovirax) $0 (1)acyclovir tab 800 mg (Zovirax) $0 (1)valacyclovir hcl tab 500 mg (Valtrex) $0 (1)valacyclovir hcl tab 1 gm (Valtrex) $0 (1)

VIH/SIDAabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) $0 (1) QL (960 mls/30 days), 90abacavir sulfate tab 300 mg (base equiv) (Ziagen) $0 (1) QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) $0 (1) QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

(Trizivir)$0 (1) QL (60 tablets/30 days)

APTIVUS – tipranavir cap 250 mg $0 (2) QL (120capsules/30 days)

APTIVUS – tipranavir oral soln 100 mg/ml $0 (2) QL (4 bottles/30 days)ATRIPLA – efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg$0 (2) QL (30 tablets/30 days)

CRIXIVAN – indinavir sulfate cap 200 mg $0 (2) QL (270capsules/30 days)

CRIXIVAN – indinavir sulfate cap 400 mg $0 (2) QL (180capsules/30 days)

DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab200-25 mg

$0 (2) QL (30 tablets/30 days)

didanosine delayed release capsule 125 mg (Videx ec) $0 (1) QL (30 capsules/30 days)didanosine delayed release capsule 200 mg (Videx ec) $0 (1) QL (30 capsules/30 days)didanosine delayed release capsule 250 mg (Videx ec) $0 (1) QL (30 capsules/30 days)didanosine delayed release capsule 400 mg (Videx ec) $0 (1) QL (30 capsules/30 days)EDURANT – rilpivirine hcl tab 25 mg (base equivalent) $0 (2) QL (30 tablets/30 days)EMTRIVA – emtricitabine caps 200 mg $0 (2) QL (30 capsules/30 days)EMTRIVA – emtricitabine soln 10 mg/ml $0 (2) QL (720 mls/30 days)fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) $0 (1) QL (120 tablets/30

days), 90GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg$0 (2) QL (30 tablets/30 days)

INTELENCE – etravirine tab 25 mg $0 (2) QL (120 tablets/30 days)

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INTELENCE – etravirine tab 100 mg $0 (2) QL (60 tablets/30 days)INTELENCE – etravirine tab 200 mg $0 (2) QL (60 tablets/30 days)INVIRASE – saquinavir mesylate cap 200 mg $0 (2) QL (300

capsules/30 days)INVIRASE – saquinavir mesylate tab 500 mg $0 (2) QL (120 tablets/30 days)ISENTRESS – raltegravir potassium packet for susp 100 mg

(base equiv)$0 (2) QL (60 packets/30 days)

ISENTRESS – raltegravir potassium tab 400 mg (base equiv) $0 (2) QL (60 tablets/30 days)ISENTRESS – raltegravir potassium chew tab 25 mg (base

equiv)$0 (2) QL (180 tablets/30 days)

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)


ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days)KALETRA – lopinavir-ritonavir tab 100-25 mg $0 (2) QL (180 tablets/30 days)KALETRA – lopinavir-ritonavir tab 200-50 mg $0 (2) QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml (Epivir) $0 (1) QL (4 bottles/30 days)lamivudine tab 150 mg (Epivir) $0 (1) QL (30 tablets/30 days)lamivudine tab 300 mg (Epivir) $0 (1) QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg (Combivir) $0 (1) QL (60 tablets/30 days)LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) $0 (2) QL (8 bottles/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) $0 (1) QL (480 mls/30 days)nevirapine tab er 24hr 100 mg (Viramune xr) $0 (1) QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg (Viramune xr) $0 (1) QL (30 tablets/30 days)nevirapine tab 200 mg (Viramune) $0 (1) QL (60 tablets/30 days)NORVIR – ritonavir cap 100 mg $0 (2) QL (360

capsules/30 days)NORVIR – ritonavir tab 100 mg $0 (2) QL (360 tablets/30 days)NORVIR – ritonavir oral soln 80 mg/ml $0 (2) QL (2 bottles/30 days)PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) $0 (2) QL (2 bottles/30 days)PREZISTA – darunavir ethanolate tab 75 mg (base equiv) $0 (2) QL (300 tablets/30 days)PREZISTA – darunavir ethanolate tab 150 mg (base equiv) $0 (2) QL (180 tablets/30 days)PREZISTA – darunavir ethanolate tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days)PREZISTA – darunavir ethanolate tab 800 mg (base equiv) $0 (2) QL (30 tablets/30 days)RESCRIPTOR – delavirdine mesylate tab 100 mg $0 (2) QL (90 tablets/30 days)RESCRIPTOR – delavirdine mesylate tab 200 mg $0 (2) QL (180 tablets/30 days)REYATAZ – atazanavir sulfate oral powder packet 50 mg (base

equiv)$0 (2) QL (240 packets/30 days)

2017



7




REYATAZ – atazanavir sulfate cap 150 mg (base equiv) $0 (2) QL (30 capsules/30 days)REYATAZ – atazanavir sulfate cap 200 mg (base equiv) $0 (2) QL (60 capsules/30 days)REYATAZ – atazanavir sulfate cap 300 mg (base equiv) $0 (2) QL (30 capsules/30 days)SELZENTRY – maraviroc tab 25 mg $0 (2) QL (240 tablets/30 days)SELZENTRY – maraviroc tab 75 mg $0 (2) QL (60 tablets/30 days)SELZENTRY – maraviroc tab 300 mg $0 (2) QL (120 tablets/30 days)stavudine cap 15 mg (Zerit) $0 (1) QL (60 capsules/30 days)stavudine cap 20 mg (Zerit) $0 (1) QL (60 capsules/30 days)stavudine cap 30 mg (Zerit) $0 (1) QL (60 capsules/30 days)stavudine cap 40 mg (Zerit) $0 (1) QL (60 capsules/30 days)SUSTIVA – efavirenz tab 600 mg $0 (2) QL (30 tablets/30 days)SUSTIVA – efavirenz cap 50 mg $0 (2) QL (90 tablets/30 days)SUSTIVA – efavirenz cap 200 mg $0 (2) QL (60 tablets/30 days)TIVICAY – dolutegravir sodium tab 10 mg (base equiv) $0 (2) QL (60 tablets/30 days)TIVICAY – dolutegravir sodium tab 25 mg (base equiv) $0 (2) QL (60 tablets/30 days)TIVICAY – dolutegravir sodium tab 50 mg (base equiv) $0 (2) QL (60 tablets/30 days)TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg$0 (2) QL (30 tablets/30 days)

TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






VIDEX – didanosine for soln 2 gm $0 (2) QL (1200 mls/30 days)VIDEX – didanosine for soln 4 gm $0 (2) QL (1200 mls/30 days)VIRACEPT – nelfinavir mesylate tab 250 mg $0 (2) QL (270 tablets/30 days)VIRACEPT – nelfinavir mesylate tab 625 mg $0 (2) QL (120 tablets/30 days)VIRAMUNE – nevirapine susp 50 mg/5ml $0 (2) QL (5 bottles/30 days)VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm $0 (2) QL (4 bottles/30 days)VIREAD – tenofovir disoproxil fumarate tab 150 mg $0 (2) QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 200 mg $0 (2) QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 250 mg $0 (2) QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 300 mg $0 (2) QL (30 tablets/30 days)zidovudine cap 100 mg (Retrovir) $0 (1) QL (180

capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir) $0 (1) QL (8 bottles/30 days)

2017



8




zidovudine tab 300 mg $0 (1) QL (60 tablets/30 days)

Influenzaoseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) $0 (1) QL (40 capsules/120

days)oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120

days)oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120

days)RELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister$0 (2) QL (20 disks/120 days)

TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv) $0 (2) QL (360 mls/120 days)

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg (Malarone) $0 (1)atovaquone-proguanil hcl tab 250-100 mg (Malarone) $0 (1)CHLOROQUINE PHOSPHATE – chloroquine phosphate tab

250 mg$0 (2) 90

chloroquine phosphate tab 500 mg $0 (1) 90DARAPRIM – pyrimethamine tab 25 mg $0 (2)hydroxychloroquine sulfate tab 200 mg (Plaquenil) $0 (1) 90mefloquine hcl tab 250 mg $0 (1) 90PRIMAQUINE PHOSPHATE – primaquine phosphate tab

26.3 mg (15 mg base)$0 (2)

INFECCIONES DE PARÁSITOSALBENZA – albendazole tab 200 mg $0 (2)BILTRICIDE – praziquantel tab 600 mg $0 (2)ivermectin tab 3 mg (Stromectol) $0 (1)

OTROS ANTIINFECCIOSOSatovaquone susp 750 mg/5ml (Mepron) $0 (1)clindamycin hcl cap 75 mg (Cleocin) $0 (1)clindamycin hcl cap 150 mg (Cleocin) $0 (1)clindamycin hcl cap 300 mg (Cleocin) $0 (1)clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr)$0 (1)

dapsone tab 25 mg $0 (1) 90dapsone tab 100 mg $0 (1) 90linezolid for susp 100 mg/5ml (Zyvox) $0 (1) QL (600 mls/180 days)linezolid tab 600 mg (Zyvox) $0 (1) QL (56 tablets/180 days)

2017



9




metronidazole cap 375 mg (Flagyl) $0 (1)metronidazole tab 250 mg (Flagyl) $0 (1)metronidazole tab 500 mg (Flagyl) $0 (1)sulfamethoxazole-trimethoprim susp 200-40 mg/5ml $0 (1)sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) $0 (1)sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) $0 (1)trimethoprim tab 100 mg $0 (1)vancomycin hcl cap 125 mg (Vancocin hcl) $0 (1)vancomycin hcl cap 250 mg (Vancocin hcl) $0 (1)XIFAXAN – rifaximin tab 200 mg $0 (2) PA, QL (9

tablets/30 days)XIFAXAN – rifaximin tab 550 mg $0 (2) PA, QL (60 tablets/30

days), 90ZYVOX – linezolid for susp 100 mg/5ml $0 (2) QL (4 bottles/180 days)

AGENTES DE INMUNIZACIÓNAFLURIA PF 2017-2018 – influenza virus vaccine split pf susp

pref syringe 0.5 ml$0 (2)

AFLURIA QUADRIVALENT 2017 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

$0 (2)

AFLURIA QUADRIVALENT 2017 – influenza virus vaccine splitquadrivalent im inj

$0 (2)

AFLURIA 2017-2018 – influenza virus vaccine split im susp $0 (2)FLUARIX QUADRIVALENT 2017 – influenza virus vac split

quadrivalent susp pref syr 0.5ml$0 (2)

FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cult subuntquad susp pref syr 0.5 ml

$0 (2)

FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-culturedsubunit quadrivalent im susp

$0 (1)

FLULAVAL QUADRIVALENT 201 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

$0 (2)

FLULAVAL QUADRIVALENT 201 – influenza virus vaccine splitquadrivalent im inj

$0 (2)

FLUVIRIN 2017-2018 – influenza vac type a&b surface antigensusp pref syr 0.5 ml

$0 (2)

FLUVIRIN 2017-2018 – influenza virus vaccine types a & bsurface antigen im susp

$0 (2)

FLUZONE HIGH-DOSE PF 2017 – influenza virus vac split high-dose pf susp pref syr 0.5ml

$0 (2) AL

FLUZONE QUADRIVALENT 2017 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

$0 (2)

2017



10




FLUZONE QUADRIVALENT 2017 – influenza virus vaccine splitquadrivalent im inj

$0 (2)

SYNAGIS – palivizumab im soln 50 mg/0.5ml $0 (1) PA, SPSYNAGIS – palivizumab im soln 100 mg/ml $0 (1) PA, SP

MEDICAMENTOS PARA EL CÁNCERACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml

(2000000 unit/0.5ml)$0 (2) PA, QL (12 vials/28

days), SPAFINITOR – everolimus tab 2.5 mg $0 (2) PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 5 mg $0 (2) PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 7.5 mg $0 (2) PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 10 mg $0 (2) PA, QL (30 tablets/30

days), SPAFINITOR DISPERZ – everolimus tab for oral susp 2 mg $0 (2) PA, QL (60 tablets/30



days), SPALKERAN – melphalan tab 2 mg $0 (2) SPanastrozole tab 1 mg (Arimidex) $0 (1) 90bexarotene cap 75 mg (Targretin) $0 (1) PA, SPbicalutamide tab 50 mg (Casodex) $0 (1) SPcapecitabine tab 150 mg (Xeloda) $0 (1) PA, SPcapecitabine tab 500 mg (Xeloda) $0 (1) PA, SPCOTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) $0 (2) PA, QL (63 tablets/28

days), SPCYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg $0 (2) SPCYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg $0 (2) SPCYTARABINE – cytarabine inj 20 mg/ml $0 (2)exemestane tab 25 mg (Aromasin) $0 (1) 90flutamide cap 125 mg $0 (1) SPhydroxyurea cap 500 mg (Hydrea) $0 (1) SPIBRANCE – palbociclib cap 75 mg $0 (2) PA, QL (21 capsules/28

days), SP

2017



11




IBRANCE – palbociclib cap 100 mg $0 (2) PA, QL (21 capsules/28days), SP

IBRANCE – palbociclib cap 125 mg $0 (2) PA, QL (21 capsules/28days), SP

imatinib mesylate tab 100 mg (base equivalent) (Gleevec) $0 (1) PA, QL (90tablets/30), SP

imatinib mesylate tab 400 mg (base equivalent) (Gleevec) $0 (1) PA, QL (60 tablets/30days), SP

KISQALI – ribociclib succinate tab 200 mg (base equiv) $0 (2) PA, QL (63 tablets/28days), SP

KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

$0 (1) PA, QL (91 tablets/28days), SP





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

$0 (2) PA, QL (30 capsules/30days), SP

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


letrozole tab 2.5 mg (Femara) $0 (1) 90LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg $0 (2)LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg $0 (2)leucovorin calcium tab 5 mg $0 (1)leucovorin calcium tab 25 mg $0 (1)LEUKERAN – chlorambucil tab 2 mg $0 (2) SPLYNPARZA – olaparib cap 50 mg $0 (2) PA, QL (480

capsules/30 days), SPmegestrol acetate susp 40 mg/ml $0 (1)megestrol acetate tab 20 mg $0 (1)

2017



12




megestrol acetate tab 40 mg $0 (1)MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base

equivalent)$0 (2) PA, QL (90 tablets/30

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

equivalent)$0 (2) PA, QL (30 tablets/30

days), SPmelphalan tab 2 mg (Alkeran) $0 (1)mercaptopurine tab 50 mg $0 (1) SPMETHOTREXATE SODIUM – methotrexate sodium inj

250 mg/10ml (25 mg/ml)$0 (2)

methotrexate sodium tab 2.5 mg (base equiv) $0 (1)MYLERAN – busulfan tab 2 mg $0 (2) SPNEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) $0 (2) PA, QL (120

tablets/30 days), SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) $0 (2) PA, QL (120



tablets/30 days), SPRYDAPT – midostaurin cap 25 mg $0 (1) PA, QL (240

capsules/30 days)SPRYCEL – dasatinib tab 20 mg $0 (2) PA, QL (60 tablets/30

days), SPSPRYCEL – dasatinib tab 50 mg $0 (2) PA, QL (30 tablets/30





days), SPSTIVARGA – regorafenib tab 40 mg $0 (2) PA, QL (84 tablets/28

days), SPSUTENT – sunitinib malate cap 12.5 mg (base equivalent) $0 (2) PA, QL (90 capsules/30

days), SP

2017



13




SUTENT – sunitinib malate cap 25 mg (base equivalent) $0 (2) PA, QL (30 capsules/30days), SP

SUTENT – sunitinib malate cap 37.5 mg (base equivalent) $0 (2) PA, QL (30 capsules/30days), SP

SUTENT – sunitinib malate cap 50 mg (base equivalent) $0 (2) PA, QL (30 capsules/30days), SP

tamoxifen citrate tab 10 mg (base equivalent) $0 (1) 90tamoxifen citrate tab 20 mg (base equivalent) $0 (1) 90TARCEVA – erlotinib hcl tab 25 mg (base equivalent) $0 (2) PA, QL (60 tablets/30

days), SPTARCEVA – erlotinib hcl tab 100 mg (base equivalent) $0 (2) PA, QL (30 tablets/30

days), SPTARCEVA – erlotinib hcl tab 150 mg (base equivalent) $0 (2) PA, QL (30 tablets/30

days), SPTASIGNA – nilotinib hcl cap 150 mg (base equivalent) $0 (2) PA, QL (120

capsules/30 days), SPTASIGNA – nilotinib hcl cap 200 mg (base equivalent) $0 (2) PA, QL (120

capsules/30 days), SPtemozolomide cap 5 mg (Temodar) $0 (1) PA, SPtemozolomide cap 20 mg (Temodar) $0 (1) PA, SPtemozolomide cap 100 mg (Temodar) $0 (1) PA, SPtemozolomide cap 140 mg (Temodar) $0 (1) PA, SPtemozolomide cap 180 mg (Temodar) $0 (1) PA, SPtemozolomide cap 250 mg (Temodar) $0 (1) PA, SPtretinoin cap 10 mg $0 (1) PA, SPVOTRIENT – pazopanib hcl tab 200 mg (base equiv) $0 (2) PA, QL (120

tablets/30 days), SPXALKORI – crizotinib cap 200 mg $0 (2) PA, QL (60 capsules/30

days), SPXALKORI – crizotinib cap 250 mg $0 (2) PA, QL (60 capsules/30

days), SPXTANDI – enzalutamide cap 40 mg $0 (2) PA, QL (120

capsules/30 days), SPZELBORAF – vemurafenib tab 240 mg $0 (2) PA, QL (240

tablets/30 days), SPZYTIGA – abiraterone acetate tab 250 mg $0 (2) PA, QL (120

tablets/30 days), SP

2017



14




ZYTIGA – abiraterone acetate tab 500 mg $0 (2) PA, QL (60 tablets/30days), SP

HORMONAS, DIABETES Y MEDICAMENTOS RELACIONADOSCORTICOSTEROIDESbudesonide delayed release particles cap 3 mg (Entocort ec) $0 (1)CORTISONE ACETATE – cortisone acetate tab 25 mg $0 (2)DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml $0 (2)dexamethasone elixir 0.5 mg/5ml $0 (1)dexamethasone tab 0.5 mg $0 (1)dexamethasone tab 0.75 mg $0 (1)dexamethasone tab 1.5 mg $0 (1)dexamethasone tab 4 mg $0 (1)dexamethasone tab 6 mg $0 (1)fludrocortisone acetate tab 0.1 mg $0 (1) 90hydrocortisone tab 5 mg (Cortef) $0 (1)hydrocortisone tab 10 mg (Cortef) $0 (1)hydrocortisone tab 20 mg (Cortef) $0 (1)methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) $0 (1)methylprednisolone tab 4 mg (Medrol) $0 (1)methylprednisolone tab 8 mg (Medrol) $0 (1)methylprednisolone tab 16 mg (Medrol) $0 (1)methylprednisolone tab 32 mg (Medrol) $0 (1)prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)

(Pediapred)$0 (1)

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) $0 (1)prednisolone syrup 15 mg/5ml (usp solution equivalent) $0 (1)PREDNISONE – prednisone tab 50 mg $0 (2)PREDNISONE – prednisone oral soln 5 mg/5ml $0 (2)prednisone tab 1 mg $0 (1)prednisone tab 2.5 mg $0 (1)prednisone tab 5 mg $0 (1)prednisone tab 10 mg $0 (1)prednisone tab 20 mg $0 (1)

HORMONAS MASCULINASdanazol cap 50 mg $0 (1)

2017



15




danazol cap 100 mg $0 (1)danazol cap 200 mg $0 (1)testosterone cypionate im inj in oil 100 mg/ml (Depo-

testosterone)$0 (1) QL (10 mls/28 days)

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

$0 (1) QL (10 mls/28 days)

testosterone enanthate im inj in oil 200 mg/ml $0 (1) QL (1 vial/28 days)

ESTRÓGENOSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day$0 (2) 90

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

$0 (2) 90

estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) $0 (1) 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) $0 (1) 90estradiol tab 0.5 mg (Estrace) $0 (1) 90estradiol tab 1 mg (Estrace) $0 (1) 90estradiol tab 2 mg (Estrace) $0 (1) 90estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30

days), 90estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30




days), 90estradiol td patch weekly 0.025 mg/24hr (Climara) $0 (1) QL (4 patches/30

days), 90estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)

(Climara)$0 (1) QL (4 patches/30





days), 90

2017



16




ESTROPIPATE – estropipate tab 0.75 mg $0 (2) 90ESTROPIPATE – estropipate tab 1.5 mg $0 (2) 90ESTROPIPATE – estropipate tab 3 mg $0 (2) 90norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg $0 (1) 90PREMPRO – conjugated estrogen-medroxyprogest acetate tab

0.3-1.5 mg$0 (2) 90

PREMPRO – conjugated estrogen-medroxyprogest acetate tab0.45-1.5 mg

$0 (2) 90

PREMPRO – conjugated estrogen-medroxyprogest acetate tab0.625-5 mg

$0 (2) 90

PROGESTINASmedroxyprogesterone acetate tab 2.5 mg (Provera) $0 (1)medroxyprogesterone acetate tab 5 mg (Provera) $0 (1)medroxyprogesterone acetate tab 10 mg (Provera) $0 (1)megestrol acetate susp 625 mg/5ml (Megace es) $0 (1)norethindrone acetate tab 5 mg (Aygestin) $0 (1) 90progesterone im in oil 50 mg/ml $0 (1)progesterone micronized cap 100 mg (Prometrium) $0 (1) 90progesterone micronized cap 200 mg (Prometrium) $0 (1) 90

MÉTODOS ANTICONCEPTIVOSCONDOMS - various $0 (3)desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)

(Mircette)$0 (1) QL (28 tablets/21

days), 90desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) $0 (1) QL (28 tablets/21

days), 90DIAPHRAGMS - various $0 (2)drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) $0 (1) QL (28 tablets/21

days), 90ELLA – ulipristal acetate tab 30 mg $0 (2) QL (3 tablets/365 days)ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg $0 (1) QL (28 tablets/21

days), 90KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mg

total)$0 (2)

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg $0 (1) QL (28 tablets/21days), 90

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg $0 (1) QL (28 tablets/21days), 90

2017



17




levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days)levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg $0 (1) QL (28 tablets/21

days), 90medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera

contrac)$0 (1)

MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) $0 (2)NECON 10/11-28 – norethindrone-eth estradiol tab

0.5-35/1-35 mg-mcg (10/11)$0 (2) QL (28 tablets/21

days), 90NEXPLANON – etonogestrel subdermal implant 68 mg $0 (2)norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin

1/20-21)$0 (1) QL (28 tablets/21

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

(Loestrin 1.5/30-21)$0 (1) QL (28 tablets/21

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

(Loestrin fe 1/20)$0 (1) QL (28 tablets/21

days), 90norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-

cyclen)$0 (1) QL (28 tablets/21

days), 90norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg

(Ortho tri-cyclen lo)$0 (1) QL (28 tablets/21

days), 90norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg

(Ortho tri-cyclen)$0 (1) QL (28 tablets/21

days), 90NUVARING – etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr$0 (2) QL (1 ring/21 days), 90

PARAGARD INTRAUTERINE COP – copper iud $0 (2)PLAN B ONE-STEP – levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days)SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) $0 (2)XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr$0 (2) QL (4 patches/21

days), 90

DIABETESacarbose tab 25 mg (Precose) $0 (1) QL (180 tablets/30

days), 90acarbose tab 50 mg (Precose) $0 (1) QL (180 tablets/30

days), 90acarbose tab 100 mg (Precose) $0 (1) QL (90 tablets/30

days), 90ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) $0 (2) QL (30 tablets/30

days), ST, 90

2017



18




ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) $0 (2) QL (30 tablets/30days), ST, 90

ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) $0 (2) QL (30 tablets/30days), ST, 90

ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab12.5-500 mg

$0 (2) QL (60 tablets/30days), ST, 90

ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab12.5-1000 mg


ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab12.5-15 mg






ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab25-15 mg






glimepiride tab 1 mg (Amaryl) $0 (1) QL (60 tablets/30days), 90



glipizide tab er 24hr 2.5 mg (Glucotrol xl) $0 (1) QL (60 tablets/30days), 90

glipizide tab er 24hr 5 mg (Glucotrol xl) $0 (1) QL (90 tablets/30days), 90

glipizide tab er 24hr 10 mg (Glucotrol xl) $0 (1) QL (60 tablets/30days), 90

glipizide tab 5 mg (Glucotrol) $0 (1) QL (120 tablets/30days), 90

glipizide tab 10 mg (Glucotrol) $0 (1) QL (120 tablets/30days), 90

GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg $0 (2) QL (6 pens/365 days)glyburide micronized tab 1.5 mg (Glynase) $0 (1) QL (120 tablets/30

days), 90

2017



19




glyburide micronized tab 3 mg (Glynase) $0 (1) QL (60 tablets/30days), 90

glyburide micronized tab 6 mg (Glynase) $0 (1) QL (60 tablets/30days), 90

glyburide tab 1.25 mg $0 (1) QL (60 tablets/30days), 90

glyburide tab 2.5 mg $0 (1) QL (60 tablets/30days), 90

glyburide tab 5 mg $0 (1) QL (120 tablets/30days), 90

glyburide-metformin tab 1.25-250 mg $0 (1) QL (120 tablets/30days), 90

glyburide-metformin tab 2.5-500 mg (Glucovance) $0 (1) QL (120 tablets/30days), 90

glyburide-metformin tab 5-500 mg (Glucovance) $0 (1) QL (120 tablets/30days), 90

metformin hcl tab er 24hr 500 mg (Glucophage xr) $0 (1) QL (120 tablets/30days), 90

metformin hcl tab er 24hr 750 mg (Glucophage xr) $0 (1) QL (60 tablets/30days), 90

metformin hcl tab 500 mg (Glucophage) $0 (1) QL (120 tablets/30days), 90



nateglinide tab 60 mg (Starlix) $0 (1) QL (120 tablets/30days), 90

nateglinide tab 120 mg (Starlix) $0 (1) QL (90 tablets/30days), 90

pioglitazone hcl tab 15 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30days), 90



TOLAZAMIDE – tolazamide tab 250 mg $0 (2) QL (90 tablets/30days), 90

2017



20




VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) $0 (2) QL (3 pens/30days), ST, 90

DIABETES - INSULINASInsulinas de acción rápidaHUMALOG – insulin lispro soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90HUMALOG – insulin lispro inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90HUMALOG JUNIOR KWIKPEN – insulin lispro soln pen-injector

100 unit/ml$0 (2) QL (45 mls/30 days), 90

HUMALOG KWIKPEN – insulin lispro soln pen-injector 100 unit/ml

$0 (2) QL (45 mls/30 days), 90

HUMALOG KWIKPEN – insulin lispro soln pen-injector 200 unit/ml

$0 (2) QL (24 mls/30 days), 90

NOVOLOG – insulin aspart inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/

ml$0 (2) QL (45 mls/30 days), 90

NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90

Insulinas de acción cortaHUMULIN R – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90NOVOLIN R – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90

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

unit/ml (50-50)$0 (2) QL (45 mls/30 days), 90

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

$0 (2) QL (45 mls/30 days), 90

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

$0 (2) QL (45 mls/30 days), 90

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

$0 (2) QL (45 mls/30 days), 90

HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp

pen-injector 100 unit/ml$0 (3) QL (45 mls/30 days), 90

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

$0 (3) QL (45 mls/30 days), 90

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

$0 (3) QL (45 mls/30 days), 90

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90NOVOLIN N RELION – insulin nph (human) (isophane) inj 100

unit/ml$0 (3) QL (45 mls/30 days), 90

2017



21




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

$0 (3) QL (45 mls/30 days), 90

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

$0 (3) QL (45 mls/30 days), 90

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

$0 (2) QL (45 mls/30 days), 90

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspartsus pen-inj 100 unit/ml (70-30)

$0 (2) QL (45 mls/30 days), 90

Insulinas basalesBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100

unit/ml$0 (2) QL (45 mls/30 days), 90

REGULACIÓN DE LA TIROIDESlevothyroxine sodium tab 25 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 50 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 75 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 88 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 100 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 112 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 125 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 137 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 150 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 175 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 200 mcg (Synthroid) $0 (1) 90levothyroxine sodium tab 300 mcg (Synthroid) $0 (1) 90liothyronine sodium tab 5 mcg (Cytomel) $0 (1) 90liothyronine sodium tab 25 mcg (Cytomel) $0 (1) 90liothyronine sodium tab 50 mcg (Cytomel) $0 (1) 90methimazole tab 5 mg (Tapazole) $0 (1) 90methimazole tab 10 mg (Tapazole) $0 (1) 90propylthiouracil tab 50 mg $0 (1) 90thyroid tab 30 mg (1/2 grain) (Armour thyroid) $0 (1) 90thyroid tab 60 mg (1 grain) (Armour thyroid) $0 (1) 90thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) $0 (1) 90

HORMONA DEL CRECIMIENTOOMNITROPE – somatropin for inj 5.8 mg $0 (2) PA, SP

OTRAS HORMONAS Y MEDICAMENTOS RELACIONADOS

2017



22




ALENDRONATE SODIUM – alendronate sodium tab 40 mg $0 (2) QL (30 tablets/30 days)alendronate sodium tab 5 mg $0 (1) QL (30 tablets/30

days), 90alendronate sodium tab 10 mg $0 (1) QL (30 tablets/30

days), 90alendronate sodium tab 35 mg $0 (1) QL (4 tablets/28 days), 90alendronate sodium tab 70 mg (Fosamax) $0 (1) QL (4 tablets/28 days), 90cabergoline tab 0.5 mg $0 (1)calcitonin (salmon) nasal soln 200 unit/act $0 (1) 90calcitriol cap 0.25 mcg (Rocaltrol) $0 (1) 90calcitriol cap 0.5 mcg (Rocaltrol) $0 (1) 90calcitriol oral soln 1 mcg/ml (Rocaltrol) $0 (1) 90desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) $0 (1) 90desmopressin acetate nasal spray soln 0.01% (Ddavp) $0 (1) 90desmopressin acetate nasal spray soln 0.01% (refrigerated) $0 (1) 90desmopressin acetate tab 0.1 mg (Ddavp) $0 (1) 90desmopressin acetate tab 0.2 mg (Ddavp) $0 (1) 90levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) $0 (1) 90levocarnitine tab 330 mg (Carnitor) $0 (1) 90METHERGINE – methylergonovine maleate tab 0.2 mg $0 (2)octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30

days), SP, 90octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30

days), SP, 90octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30

days), SP, 90octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30

days), SPoctreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30

days), SPraloxifene hcl tab 60 mg (Evista) $0 (1) 90STIMATE – desmopressin acetate nasal soln 1.5 mg/ml $0 (2) 90TYMLOS – abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml$0 (1) PA, QL (1 pen/30

days), SP, 90

MEDICAMENTOS PARA EL CORAZÓN Y LA CIRCULACIÓNINHIBIDORES DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA (ACE, POR SU SIGLA EN INGLÉS)Y COMBINACIONES

2017



23




benazepril & hydrochlorothiazide tab 5-6.25 mg $0 (1) 90benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) $0 (1) 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) $0 (1) 90benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) $0 (1) 90benazepril hcl tab 5 mg $0 (1) 90benazepril hcl tab 10 mg $0 (1) 90benazepril hcl tab 20 mg (Lotensin) $0 (1) 90benazepril hcl tab 40 mg (Lotensin) $0 (1) 90captopril tab 12.5 mg $0 (1) 90captopril tab 25 mg $0 (1) 90captopril tab 50 mg $0 (1) 90captopril tab 100 mg $0 (1) 90CAPTOPRIL/HYDROCHLOROTHIA – captopril &

hydrochlorothiazide tab 25-15 mg$0 (2) 90

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

$0 (2) 90


$0 (2) 90


$0 (2) 90

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg $0 (1) 90enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) $0 (1) 90enalapril maleate tab 2.5 mg (Vasotec) $0 (1) 90enalapril maleate tab 5 mg (Vasotec) $0 (1) 90enalapril maleate tab 10 mg (Vasotec) $0 (1) 90enalapril maleate tab 20 mg (Vasotec) $0 (1) 90fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg $0 (1) 90fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg $0 (1) 90fosinopril sodium tab 10 mg $0 (1) 90fosinopril sodium tab 20 mg $0 (1) 90fosinopril sodium tab 40 mg $0 (1) 90lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) $0 (1) 90lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) $0 (1) 90lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) $0 (1) 90lisinopril tab 2.5 mg (Zestril) $0 (1) 90lisinopril tab 5 mg (Prinivil) $0 (1) 90

2017



24




lisinopril tab 10 mg (Prinivil) $0 (1) 90lisinopril tab 20 mg (Prinivil) $0 (1) 90lisinopril tab 30 mg (Zestril) $0 (1) 90lisinopril tab 40 mg (Zestril) $0 (1) 90moexipril hcl tab 7.5 mg $0 (1) 90moexipril hcl tab 15 mg $0 (1) 90moexipril-hydrochlorothiazide tab 7.5-12.5 mg $0 (1) 90moexipril-hydrochlorothiazide tab 15-12.5 mg $0 (1) 90moexipril-hydrochlorothiazide tab 15-25 mg $0 (1) 90perindopril erbumine tab 2 mg $0 (1) 90perindopril erbumine tab 4 mg (Aceon) $0 (1) 90perindopril erbumine tab 8 mg (Aceon) $0 (1) 90quinapril hcl tab 5 mg (Accupril) $0 (1) 90quinapril hcl tab 10 mg (Accupril) $0 (1) 90quinapril hcl tab 20 mg (Accupril) $0 (1) 90quinapril hcl tab 40 mg (Accupril) $0 (1) 90quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) $0 (1) 90quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) $0 (1) 90quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) $0 (1) 90ramipril cap 1.25 mg (Altace) $0 (1) 90ramipril cap 2.5 mg (Altace) $0 (1) 90ramipril cap 5 mg (Altace) $0 (1) 90ramipril cap 10 mg (Altace) $0 (1) 90trandolapril tab 1 mg $0 (1) 90trandolapril tab 2 mg (Mavik) $0 (1) 90trandolapril tab 4 mg $0 (1) 90

ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II (ARBS, POR SU SIGLA EN INGLÉS) YCOMBINACIONESirbesartan tab 75 mg (Avapro) $0 (1) QL (30 tablets/30

days), 90irbesartan tab 150 mg (Avapro) $0 (1) QL (30 tablets/30

days), 90irbesartan tab 300 mg (Avapro) $0 (1) QL (30 tablets/30

days), 90irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) $0 (1) QL (30 tablets/30

days), 90

2017



25




irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) $0 (1) QL (30 tablets/30days), 90

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

$0 (1) QL (30 tablets/30days), 90

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

$0 (1) QL (30 tablets/30days), 90

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

$0 (1) QL (30 tablets/30days), 90

losartan potassium tab 25 mg (Cozaar) $0 (1) QL (60 tablets/30days), 90



valsartan tab 40 mg (Diovan) $0 (1) QL (60 tablets/30days), 90




valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) $0 (1) QL (30 tablets/30days), 90


valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) $0 (1) QL (30 tablets/30days), 90


valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) $0 (1) QL (30 tablets/30days), 90

BETA BLOQUEADORES Y COMBINACINESacebutolol hcl cap 200 mg $0 (1) 90acebutolol hcl cap 400 mg $0 (1) 90atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) $0 (1) 90atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) $0 (1) 90atenolol tab 25 mg (Tenormin) $0 (1) 90

2017



26




atenolol tab 50 mg (Tenormin) $0 (1) 90atenolol tab 100 mg (Tenormin) $0 (1) 90betaxolol hcl tab 10 mg $0 (1) 90betaxolol hcl tab 20 mg $0 (1) 90bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) $0 (1) 90bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) $0 (1) 90bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) $0 (1) 90bisoprolol fumarate tab 5 mg $0 (1) 90bisoprolol fumarate tab 10 mg $0 (1) 90carvedilol tab 3.125 mg (Coreg) $0 (1) 90carvedilol tab 6.25 mg (Coreg) $0 (1) 90carvedilol tab 12.5 mg (Coreg) $0 (1) 90carvedilol tab 25 mg (Coreg) $0 (1) 90labetalol hcl tab 100 mg $0 (1) 90labetalol hcl tab 200 mg $0 (1) 90labetalol hcl tab 300 mg $0 (1) 90metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) $0 (1) 90metoprolol & hydrochlorothiazide tab 100-25 mg $0 (1) 90metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) $0 (1) 90metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) $0 (1) 90metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol

xl)$0 (1) 90

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

$0 (1) 90

metoprolol tartrate tab 25 mg $0 (1) 90metoprolol tartrate tab 50 mg (Lopressor) $0 (1) 90metoprolol tartrate tab 100 mg (Lopressor) $0 (1) 90METOPROLOL/HYDROCHLOROTHI – metoprolol &


nadolol tab 20 mg (Corgard) $0 (1) 90nadolol tab 40 mg (Corgard) $0 (1) 90nadolol tab 80 mg (Corgard) $0 (1) 90propranolol hcl tab 10 mg $0 (1) 90propranolol hcl tab 20 mg $0 (1) 90propranolol hcl tab 40 mg $0 (1) 90propranolol hcl tab 60 mg $0 (1) 90

2017



27




propranolol hcl tab 80 mg $0 (1) 90PROPRANOLOL/HYDROCHLOROTH – propranolol &


BLOQUEADORES DE CANAL DE CALCIO Y COMBINACIONESamlodipine besylate tab 2.5 mg (Norvasc) $0 (1) 90amlodipine besylate tab 5 mg (Norvasc) $0 (1) 90amlodipine besylate tab 10 mg (Norvasc) $0 (1) 90amlodipine besylate-benazepril hcl cap 2.5-10 mg $0 (1) 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) $0 (1) 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) $0 (1) 90amlodipine besylate-benazepril hcl cap 5-40 mg $0 (1) 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) $0 (1) 90amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) $0 (1) 90amlodipine besylate-valsartan tab 5-160 mg (Exforge) $0 (1) QL (30 tablets/30

days), 90amlodipine besylate-valsartan tab 5-320 mg (Exforge) $0 (1) QL (30 tablets/30



days), 90diltiazem hcl cap er 12hr 60 mg $0 (1) 90diltiazem hcl cap er 24hr 120 mg $0 (1) 90diltiazem hcl cap er 24hr 180 mg $0 (1) 90diltiazem hcl cap er 24hr 240 mg $0 (1) 90diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) $0 (1) 90diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) $0 (1) 90diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) $0 (1) 90diltiazem hcl coated beads cap er 24hr 300 mg $0 (1) 90diltiazem hcl extended release beads cap er 24hr 120 mg

(Tiazac)$0 (1) 90

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

$0 (1) 90


$0 (1) 90


$0 (1) 90

2017



28





$0 (1) 90


$0 (1) 90

diltiazem hcl tab 30 mg (Cardizem) $0 (1) 90diltiazem hcl tab 60 mg (Cardizem) $0 (1) 90diltiazem hcl tab 90 mg $0 (1) 90diltiazem hcl tab 120 mg (Cardizem) $0 (1) 90felodipine tab er 24hr 2.5 mg $0 (1) 90felodipine tab er 24hr 5 mg $0 (1) 90felodipine tab er 24hr 10 mg $0 (1) 90nifedipine cap 10 mg (Procardia) $0 (1) 90nifedipine tab er 24hr 30 mg (Adalat cc) $0 (1) 90nifedipine tab er 24hr 60 mg (Adalat cc) $0 (1) 90nifedipine tab er 24hr 90 mg (Adalat cc) $0 (1) 90nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) $0 (1) 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) $0 (1) 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) $0 (1) 90verapamil hcl cap er 24hr 100 mg (Verelan pm) $0 (1) 90verapamil hcl cap er 24hr 120 mg (Verelan) $0 (1) 90verapamil hcl cap er 24hr 180 mg (Verelan) $0 (1) 90verapamil hcl cap er 24hr 200 mg (Verelan pm) $0 (1) 90verapamil hcl cap er 24hr 240 mg (Verelan) $0 (1) 90verapamil hcl cap er 24hr 300 mg (Verelan pm) $0 (1) 90verapamil hcl cap er 24hr 360 mg (Verelan) $0 (1) 90verapamil hcl tab er 120 mg (Calan sr) $0 (1) 90verapamil hcl tab er 180 mg (Calan sr) $0 (1) 90verapamil hcl tab er 240 mg (Calan sr) $0 (1) 90verapamil hcl tab 40 mg $0 (1) 90verapamil hcl tab 80 mg (Calan) $0 (1) 90verapamil hcl tab 120 mg (Calan) $0 (1) 90

DOLOR EN EL PECHOISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er 40 mg $0 (2) 90isosorbide dinitrate tab 5 mg (Isordil titradose) $0 (1) 90isosorbide dinitrate tab 10 mg $0 (1) 90isosorbide dinitrate tab 20 mg $0 (1) 90

2017



29




isosorbide dinitrate tab 30 mg $0 (1) 90isosorbide mononitrate tab er 24hr 30 mg $0 (1) 90isosorbide mononitrate tab er 24hr 60 mg $0 (1) 90isosorbide mononitrate tab er 24hr 120 mg $0 (1) 90isosorbide mononitrate tab 10 mg $0 (1) 90isosorbide mononitrate tab 20 mg $0 (1) 90nitroglycerin cap er 2.5 mg $0 (1) 90nitroglycerin cap er 6.5 mg $0 (1) 90nitroglycerin cap er 9 mg $0 (1) 90nitroglycerin sl tab 0.3 mg (Nitrostat) $0 (1) 90nitroglycerin sl tab 0.4 mg (Nitrostat) $0 (1) 90nitroglycerin sl tab 0.6 mg (Nitrostat) $0 (1) 90nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) $0 (1) 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) $0 (1) 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) $0 (1) 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) $0 (1) 90

REDUCCIÓN DEL COLESTEROLatorvastatin calcium tab 10 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30

days), 90atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30



days), 90cholestyramine light powder packets 4 gm $0 (1) 90cholestyramine light powder 4 gm/dose (Questran light) $0 (1) 90cholestyramine powder packets 4 gm (Questran) $0 (1) 90cholestyramine powder 4 gm/dose (Questran) $0 (1) 90choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (60 tablets/30

days), 90choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (30 tablets/30

days), 90colestipol hcl granule packets 5 gm (Colestid flavored) $0 (1) 90colestipol hcl granules 5 gm (Colestid) $0 (1) 90colestipol hcl tab 1 gm (Colestid) $0 (1) 90

2017



30




fenofibrate micronized cap 43 mg $0 (1) QL (60 capsules/30days), 90

fenofibrate micronized cap 67 mg (Lofibra) $0 (1) QL (30 capsules/30days), 90



fenofibrate tab 48 mg (Tricor) $0 (1) QL (60 tablets/30days), 90

fenofibrate tab 54 mg (Lofibra) $0 (1) QL (60 tablets/30days), 90

fenofibrate tab 145 mg (Tricor) $0 (1) QL (30 tablets/30days), 90

fenofibrate tab 160 mg $0 (1) QL (30 tablets/30days), 90

gemfibrozil tab 600 mg (Lopid) $0 (1) QL (60 tablets/30days), 90

lovastatin tab 10 mg $0 (1) QL (60 tablets/30days), 90



PRALUENT – alirocumab subcutaneous soln pen-injector 75 mg/ml

$0 (2) PA, QL (2 pens/28days), SP

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml


pravastatin sodium tab 10 mg $0 (1) QL (45 tablets/30days), 90

pravastatin sodium tab 20 mg (Pravachol) $0 (1) QL (45 tablets/30days), 90



REPATHA – evolocumab subcutaneous soln prefilled syringe140 mg/ml

$0 (2) PA, QL (2 syringes/28days), SP

2017



31




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


rosuvastatin calcium tab 5 mg (Crestor) $0 (1) QL (30 tablets/30days), 90




simvastatin tab 5 mg (Zocor) $0 (1) QL (30 tablets/30days), 90




RETENCIÓN DE LÍQUIDOSacetazolamide cap er 12hr 500 mg (Diamox) $0 (1) 90acetazolamide tab 125 mg $0 (1) 90acetazolamide tab 250 mg $0 (1) 90amiloride & hydrochlorothiazide tab 5-50 mg $0 (1) 90amiloride hcl tab 5 mg $0 (1) 90bumetanide tab 0.5 mg (Bumex) $0 (1) 90bumetanide tab 1 mg (Bumex) $0 (1) 90bumetanide tab 2 mg (Bumex) $0 (1) 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg $0 (2) 90chlorothiazide tab 500 mg $0 (1) 90chlorthalidone tab 25 mg $0 (1) 90chlorthalidone tab 50 mg $0 (1) 90furosemide oral soln 10 mg/ml $0 (1) 90furosemide tab 20 mg (Lasix) $0 (1) 90furosemide tab 40 mg (Lasix) $0 (1) 90furosemide tab 80 mg (Lasix) $0 (1) 90hydrochlorothiazide cap 12.5 mg (Microzide) $0 (1) 90hydrochlorothiazide tab 12.5 mg $0 (1) 90

2017



32




hydrochlorothiazide tab 25 mg $0 (1) 90hydrochlorothiazide tab 50 mg $0 (1) 90indapamide tab 1.25 mg $0 (1) 90indapamide tab 2.5 mg $0 (1) 90metolazone tab 2.5 mg $0 (1) 90metolazone tab 5 mg $0 (1) 90metolazone tab 10 mg $0 (1) 90spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) $0 (1) 90spironolactone tab 25 mg (Aldactone) $0 (1) 90spironolactone tab 50 mg (Aldactone) $0 (1) 90spironolactone tab 100 mg (Aldactone) $0 (1) 90torsemide tab 5 mg $0 (1) 90torsemide tab 10 mg (Demadex) $0 (1) 90torsemide tab 20 mg (Demadex) $0 (1) 90torsemide tab 100 mg $0 (1) 90triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) $0 (1) 90triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) $0 (1) 90triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) $0 (1) 90

RITMO CARDÍACOamiodarone hcl tab 200 mg $0 (1) 90disopyramide phosphate cap 100 mg (Norpace) $0 (1) 90disopyramide phosphate cap 150 mg (Norpace) $0 (1) 90dofetilide cap 125 mcg (0.125 mg) (Tikosyn) $0 (1) 90dofetilide cap 250 mcg (0.25 mg) (Tikosyn) $0 (1) 90dofetilide cap 500 mcg (0.5 mg) (Tikosyn) $0 (1) 90flecainide acetate tab 50 mg $0 (1) 90flecainide acetate tab 100 mg $0 (1) 90flecainide acetate tab 150 mg $0 (1) 90mexiletine hcl cap 150 mg $0 (1) 90mexiletine hcl cap 200 mg $0 (1) 90mexiletine hcl cap 250 mg $0 (1) 90propafenone hcl tab 150 mg $0 (1) 90propafenone hcl tab 225 mg $0 (1) 90propafenone hcl tab 300 mg $0 (1) 90quinidine gluconate tab er 324 mg $0 (1) 90

2017



33




QUINIDINE SULFATE – quinidine sulfate tab 200 mg $0 (2) 90QUINIDINE SULFATE – quinidine sulfate tab 300 mg $0 (2) 90sotalol hcl tab 80 mg (Betapace) $0 (1) 90sotalol hcl tab 120 mg (Betapace) $0 (1) 90sotalol hcl tab 160 mg (Betapace) $0 (1) 90sotalol hcl tab 240 mg $0 (1) 90

OTROS MEDICAMENTOS RELACIONADOS CON EL CORAZÓNADCIRCA – tadalafil tab 20 mg (pah) $0 (2) PA, QL (60 tablets/30

days), SPclonidine hcl tab 0.1 mg (Catapres) $0 (1) 90clonidine hcl tab 0.2 mg (Catapres) $0 (1) 90clonidine hcl tab 0.3 mg (Catapres) $0 (1) 90clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) $0 (1) 90clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) $0 (1) 90clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) $0 (1) 90DIGOXIN – digoxin oral soln 0.05 mg/ml $0 (2) 90digoxin tab 125 mcg (0.125 mg) (Lanoxin) $0 (1) 90digoxin tab 250 mcg (0.25 mg) (Lanoxin) $0 (1) 90doxazosin mesylate tab 1 mg (Cardura) $0 (1) QL (30 tablets/30

days), 90doxazosin mesylate tab 2 mg (Cardura) $0 (1) QL (30 tablets/30



days), 90ENTRESTO – sacubitril-valsartan tab 24-26 mg $0 (2) PA, QL (60 tablets/30



days), 90EPINEPHRINE HCL – epinephrine inj 30 mg/30ml $0 (1)guanfacine hcl tab 1 mg $0 (1) 90guanfacine hcl tab 2 mg $0 (1) 90hydralazine hcl tab 10 mg $0 (1) 90

2017



34




hydralazine hcl tab 25 mg $0 (1) 90hydralazine hcl tab 50 mg $0 (1) 90hydralazine hcl tab 100 mg $0 (1) 90methyldopa tab 250 mg $0 (1) 90methyldopa tab 500 mg $0 (1) 90midodrine hcl tab 2.5 mg $0 (1)midodrine hcl tab 5 mg $0 (1)midodrine hcl tab 10 mg $0 (1)minoxidil tab 2.5 mg $0 (1) 90minoxidil tab 10 mg $0 (1) 90PAPAVERINE HCL – papaverine hcl inj 30 mg/ml $0 (1)phenoxybenzamine hcl cap 10 mg (Dibenzyline) $0 (1)prazosin hcl cap 1 mg (Minipress) $0 (1) 90prazosin hcl cap 2 mg (Minipress) $0 (1) 90prazosin hcl cap 5 mg (Minipress) $0 (1) 90sildenafil citrate tab 20 mg (Revatio) $0 (1) PA, QL (90 tablets/30

days), SP, 90terazosin hcl cap 1 mg $0 (1) QL (30 capsules/30

days), 90terazosin hcl cap 2 mg $0 (1) QL (30 capsules/30



days), 90TRACLEER – bosentan tab 62.5 mg $0 (2) PA, QL (60 tablets/30

days), SPTRACLEER – bosentan tab 125 mg $0 (2) PA, QL (60 tablets/30

days), SP

EQUIPOS PARA PICADURAS DE ABEJASEPINEPHRINE – epinephrine solution auto-injector

0.15 mg/0.3ml (1:2000)$0 (2) QL (4 pens/1

prescription)EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000)$0 (2) QL (4 pens/1

prescription)

AGENTES RESPIRATORIOSANTIHISTAMÍNICOS

2017



35




carbinoxamine maleate soln 4 mg/5ml $0 (1)carbinoxamine maleate tab 4 mg $0 (1)cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) $0 (1)cetirizine hcl tab 5 mg $0 (3)cetirizine hcl tab 10 mg $0 (3)chlorpheniramine maleate tab 4 mg $0 (3)clemastine fumarate tab 1.34 mg (1 mg base equiv) $0 (3)cyproheptadine hcl syrup 2 mg/5ml $0 (1)cyproheptadine hcl tab 4 mg $0 (1)desloratadine tab 5 mg (Clarinex) $0 (1)diphenhydramine hcl cap 25 mg $0 (3)diphenhydramine hcl cap 50 mg $0 (1)diphenhydramine hcl liquid 12.5 mg/5ml $0 (3)diphenhydramine hcl tab 25 mg $0 (3)fexofenadine hcl susp 30 mg/5ml (6 mg/ml) $0 (3)fexofenadine hcl tab 60 mg $0 (3)fexofenadine hcl tab 180 mg $0 (3)levocetirizine dihydrochloride tab 5 mg $0 (1)loratadine syrup 5 mg/5ml $0 (3)loratadine tab 10 mg $0 (3)promethazine hcl suppos 12.5 mg $0 (1)promethazine hcl suppos 25 mg $0 (1)promethazine hcl syrup 6.25 mg/5ml $0 (1)promethazine hcl tab 12.5 mg $0 (1)promethazine hcl tab 25 mg $0 (1)promethazine hcl tab 50 mg $0 (1)

PRODUCTOS NASALESazelastine hcl nasal spray 0.1% (137 mcg/spray) $0 (1) QL (2 bottles/30 days)FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) $0 (1) QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/act $0 (1) QL (1 inhaler/30 days)phenylephrine hcl tab 10 mg $0 (3)saline nasal spray 0.65% $0 (3)

TOS/RESFRÍO/ALERGIAacetylcysteine inhal soln 10% $0 (1)acetylcysteine inhal soln 20% $0 (1)

2017



36




BROHIST D – brompheniramine & phenylephrine tab 4-10 mg $0 (3)brompheniramine & phenylephrine elixir 1-2.5 mg/5ml $0 (3)dextromethorphan-guaifenesin liquid 10-100 mg/5ml $0 (3)diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml $0 (3)guaifenesin liquid 100 mg/5ml $0 (3)guaifenesin-codeine soln 100-10 mg/5ml $0 (3) MEphenylephrine w/ dm-gg liqd 5-10-200 mg/5ml $0 (3)phenylephrine-guaifenesin tab 10-400 mg $0 (3)PHENYLEPHRINE/GUAIFENESIN – phenylephrine-guaifenesin

liqd 7.5-100 mg/5ml (1.5-20 mg/ml)$0 (2)

promethazine w/ codeine syrup 6.25-10 mg/5ml $0 (1) MERELHIST BP – brompheniramine & phenylephrine tab 4-10 mg $0 (3)RU-HIST D – brompheniramine & phenylephrine tab 4-10 mg $0 (3)sodium chloride soln nebu 0.9% $0 (1)sodium chloride soln nebu 3% $0 (1)sodium chloride soln nebu 7% (Hyper-sal) $0 (1)sodium chloride soln nebu 10% $0 (1)TRIAMINIC NIGHT TIME COLD – diphenhydramine-

phenylephrine syrup 6.25-2.5 mg/5ml$0 (3)

ASMA/ENFERMEDAD PULMONAR OBSTRUCTIVA CRÓNICA (EPOC)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) $0 (1) QL (125 containers/30

days), 90albuterol sulfate soln nebu 0.5% (5 mg/ml) $0 (1) QL (60 mls/30 days), 90albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) $0 (1) QL (125 containers/30

days), 90albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) $0 (1) QL (125 containers/30

days), 90albuterol sulfate syrup 2 mg/5ml $0 (1) 90ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 100 mcg/act$0 (2) QL (30 blisters/30

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

activ 200 mcg/act$0 (2) QL (30 blisters/30

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

17 mcg/act$0 (2) QL (2 inhalers/30

days), 90budesonide inhalation susp 0.25 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30

days), 90

2017



37




budesonide inhalation susp 0.5 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30days), 90

budesonide inhalation susp 1 mg/2ml (Pulmicort) $0 (1) QL (60 mls/30 days), 90COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act$0 (2) QL (2 inhalers/30

days), 90CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml $0 (2) QL (120 containers/30

days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/

blister$0 (2) AL, QL (1 inhaler/30

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

100 mcg/blister$0 (2) AL, QL (1 inhaler/30

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

250 mcg/blister$0 (2) AL, QL (4 inhalers/30

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

act (50/valve)$0 (2) AL, QL (1 inhaler/30

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

act (125/valve)$0 (2) AL, QL (1 inhaler/30

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

act (250/valve)$0 (2) AL, QL (2 inhalers/30

days), 90FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer

powder ba 55-14 mcg/act$0 (2) QL (1 inhaler/30





days), 90ipratropium bromide inhal soln 0.02% $0 (1) QL (150 vials/30

days), 90ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml $0 (1) QL (180 containers/30

days), 90montelukast sodium chew tab 4 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30

days), 90montelukast sodium chew tab 5 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30

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

(Singulair)$0 (1) QL (30 packets/30

days), 90montelukast sodium tab 10 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30

days), 90QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)$0 (2) AL, QL (2 containers/30

days), 90

2017



38




QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)

$0 (2) AL, QL (2 containers/30days), 90

SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)

$0 (2) QL (60 blisters/30days), 90

SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhalcap 18 mcg (base equiv)

$0 (2) QL (30 capsules/30days), 90

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

$0 (2) AL, QL (1 inhaler/30days), 90

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

$0 (2) AL, QL (1 inhaler/30days), 90

terbutaline sulfate tab 2.5 mg $0 (1) 90terbutaline sulfate tab 5 mg $0 (1) 90theophylline soln 80 mg/15ml $0 (1) 90theophylline tab er 12hr 100 mg $0 (1) 90theophylline tab er 12hr 200 mg $0 (1) 90theophylline tab er 12hr 300 mg $0 (1) 90theophylline tab er 12hr 450 mg $0 (1) 90theophylline tab er 24hr 400 mg $0 (1) 90theophylline tab er 24hr 600 mg $0 (1) 90VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act

(90mcg base equiv)$0 (2) QL (3 inhalers/30

days), 90

OTROS MEDICAMENTOS RESPIRATORIOSKALYDECO – ivacaftor tab 150 mg $0 (2) PA, QL (60 tablets/30

days), SPKALYDECO – ivacaftor packet 50 mg $0 (2) PA, QL (56 packets/28

days), SPKALYDECO – ivacaftor packet 75 mg $0 (2) PA, QL (56 packets/28

days), SPPULMOZYME – dornase alfa inhal soln 1 mg/ml $0 (2) SP

MEDICAMENTOS GASTROINTESTINALESLAXANTESbisacodyl tab delayed release 5 mg $0 (3)docusate sodium cap 100 mg $0 (3)docusate sodium cap 250 mg $0 (3)docusate sodium liquid 150 mg/15ml $0 (3)FLEET LIQUID GLYCERIN SUP – glycerin enema adult 5.4 gm/

average delivered dose$0 (3)

2017



39




glycerin suppos 1 gm $0 (3)glycerin suppos 2 gm $0 (3)KONSYL – psyllium powder 60.3% $0 (3)KONSYL – psyllium powder 71.67% $0 (3)KONSYL-D – psyllium powder 52.3% $0 (3)lactulose solution 10 gm/15ml $0 (1) 90magnesium citrate soln $0 (3)METAMUCIL MULTIHEALTH FIB – psyllium powder 55.46% $0 (3)METAMUCIL MULTIHEALTH FIB – psyllium powder 63% $0 (3)METAMUCIL SMOOTH TEXTURE – psyllium powder 63% $0 (3)PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml) $0 (3)peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor

pack)$0 (1)

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) $0 (1)peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-

flavor packs)$0 (1)

polyethylene glycol 3350 oral powder $0 (1)psyllium powder 28.3% $0 (3)psyllium powder 30% $0 (3)psyllium powder 30.9% $0 (3)psyllium powder 48.57% $0 (3)psyllium powder 58.6% $0 (3)psyllium powder 95% $0 (3)sennosides tab 8.6 mg $0 (3)

ANTIDIARREICOSbismuth subsalicylate susp 262 mg/15ml $0 (3)diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) $0 (1)loperamide hcl cap 2 mg $0 (1)loperamide hcl liq 1 mg/5ml (0.2 mg/ml) $0 (3)loperamide hcl tab 2 mg $0 (3)

ANTIÁCIDOSalum & mag hydroxide-simethicone susp 200-200-20 mg/5ml $0 (3)alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml $0 (3)calcium carbonate (antacid) chew tab 500 mg $0 (3)calcium carbonate (antacid) chew tab 750 mg $0 (3)

2017



40




calcium carbonate (antacid) chew tab 1000 mg $0 (3)magnesium oxide tab 400 mg $0 (3)

ÚLCERA/ENFERMEDAD POR REFLUJO GASTROESOFÁGICO (ERGE)cimetidine hcl soln 300 mg/5ml $0 (1) 90cimetidine tab 200 mg $0 (1) 90cimetidine tab 300 mg $0 (1) 90cimetidine tab 400 mg $0 (1) 90cimetidine tab 800 mg $0 (1) 90dicyclomine hcl cap 10 mg (Bentyl) $0 (1) 90dicyclomine hcl oral soln 10 mg/5ml $0 (1) 90dicyclomine hcl tab 20 mg $0 (1) 90famotidine for susp 40 mg/5ml (Pepcid) $0 (1) 90famotidine tab 10 mg $0 (3) 90famotidine tab 20 mg (Pepcid) $0 (1) 90famotidine tab 40 mg (Pepcid) $0 (1) 90glycopyrrolate tab 1 mg (Robinul) $0 (1) 90glycopyrrolate tab 2 mg (Robinul forte) $0 (1) 90hyoscyamine sulfate elixir 0.125 mg/5ml $0 (1) 90hyoscyamine sulfate soln 0.125 mg/ml $0 (1) 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) $0 (1) 90hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) $0 (1) 90hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) $0 (1) 90hyoscyamine sulfate tab 0.125 mg (Levsin) $0 (1) 90lansoprazole cap delayed release 15 mg (Prevacid) $0 (1) QL (60 Capsules/30

days; 120 DaysSupply/365 Days), 90

lansoprazole cap delayed release 30 mg (Prevacid) $0 (1) QL (60 Capsules/30days; 120 Days

Supply/365 Days), 90misoprostol tab 100 mcg (Cytotec) $0 (1) 90misoprostol tab 200 mcg (Cytotec) $0 (1) 90NIZATIDINE – nizatidine oral soln 15 mg/ml $0 (2) 90nizatidine cap 150 mg $0 (1) 90nizatidine cap 300 mg $0 (1) 90

2017



41




omeprazole cap delayed release 20 mg $0 (1) QL (60 Capsules/30days; 120 Days

Supply/365 Days), 90omeprazole cap delayed release 40 mg $0 (1) QL (60 Capsules/30


pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30days; 120 Days

Supply/365 Days), 90pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30


ranitidine hcl syrup 15 mg/ml (75 mg/5ml) $0 (1) 90ranitidine hcl tab 75 mg $0 (3) 90ranitidine hcl tab 150 mg (Zantac) $0 (1) 90ranitidine hcl tab 300 mg (Zantac) $0 (1) 90sucralfate tab 1 gm (Carafate) $0 (1) 90

NAUSEAS Y VÓMITOSfructose-dextrose-phosphoric acid oral soln $0 (3)meclizine hcl tab 12.5 mg $0 (1)meclizine hcl tab 25 mg $0 (1)ondansetron hcl oral soln 4 mg/5ml (Zofran) $0 (1) QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) $0 (1) QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) $0 (1) QL (30 tablets/30 days)ondansetron hcl tab 24 mg $0 (1) QL (1 tablet/30 days)ondansetron orally disintegrating tab 4 mg (Zofran odt) $0 (1) QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg (Zofran odt) $0 (1) QL (30 tablets/30 days)prochlorperazine maleate tab 5 mg (base equivalent) $0 (1) 90prochlorperazine maleate tab 10 mg (base equivalent) $0 (1) 90prochlorperazine suppos 25 mg $0 (1)

ENZIMAS DIGESTIVASCREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000

unit$0 (2) 90

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

$0 (2) 90

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

$0 (2) 90

2017



42





$0 (2) 90


$0 (2) 90

ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit

$0 (2) 90


$0 (2) 90


$0 (2) 90


$0 (2) 90


$0 (2) 90


$0 (2) 90


$0 (2) 90

OTROS MEDICAMENTOS GASTROINTESTINALESbalsalazide disodium cap 750 mg (Colazal) $0 (1)calcium acetate (phosphate binder) cap 667 mg (169 mg ca) $0 (1) 90calcium acetate (phosphate binder) tab 667 mg (Eliphos) $0 (1) 90CANASA – mesalamine suppos 1000 mg $0 (2)cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) $0 (1) 90lactulose (encephalopathy) solution 10 gm/15ml $0 (1) 90MESALAMINE DR – mesalamine tab delayed release 800 mg $0 (2)mesalamine enema 4 gm $0 (1)metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) $0 (1)metoclopramide hcl tab 5 mg (Reglan) $0 (1)metoclopramide hcl tab 10 mg (Reglan) $0 (1) 90simethicone chew tab 80 mg $0 (3)simethicone susp 40 mg/0.6ml $0 (3)sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) $0 (1) 90sulfasalazine tab 500 mg (Azulfidine) $0 (1) 90ursodiol cap 300 mg (Actigall) $0 (1) 90ursodiol tab 250 mg (Urso 250) $0 (1) 90ursodiol tab 500 mg (Urso forte) $0 (1) 90

MEDICAMENTOS GENITOURINARIOS

2017



43




INFECCIONES DEL TRACTO URINARIOnitrofurantoin macrocrystalline cap 25 mg (Macrodantin) $0 (1)nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) $0 (1)nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) $0 (1)nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid)$0 (1)

nitrofurantoin susp 25 mg/5ml (Furadantin) $0 (1)

ESPASMOS DEL TRACTO URINARIObethanechol chloride tab 5 mg (Urecholine) $0 (1)bethanechol chloride tab 10 mg (Urecholine) $0 (1)bethanechol chloride tab 25 mg (Urecholine) $0 (1)bethanechol chloride tab 50 mg (Urecholine) $0 (1)oxybutynin chloride syrup 5 mg/5ml $0 (1) QL (600 mls/30 days), 90oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) $0 (1) QL (30 tablets/30

days), 90oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) $0 (1) QL (60 tablets/30

days), 90oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) $0 (1) QL (60 tablets/30

days), 90oxybutynin chloride tab 5 mg $0 (1) QL (120 tablets/30

days), 90

PRODUCTOS VAGINALESclindamycin phosphate vaginal cream 2% (Cleocin) $0 (1)clotrimazole vaginal cream 2% $0 (3)estradiol vaginal tab 10 mcg (Vagifem) $0 (1) 90metronidazole vaginal gel 0.75% (Metrogel-vaginal) $0 (1)miconazole nitrate vaginal cream 2% $0 (3)terconazole vaginal cream 0.4% (Terazol 7) $0 (1)terconazole vaginal cream 0.8% $0 (1)terconazole vaginal suppos 80 mg $0 (1)tioconazole vaginal oint 6.5% $0 (3)

OTROS MEDICAMENTOS GENITOURINARIOSalfuzosin hcl tab er 24hr 10 mg (Uroxatral) $0 (1) QL (30 tablets/30

days), 90finasteride tab 5 mg (Proscar) $0 (1) QL (30 tablets/30

days), 90

2017



44




phenazopyridine hcl tab 100 mg (Pyridium) $0 (1)phenazopyridine hcl tab 200 mg (Pyridium) $0 (1)pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml $0 (1)potassium citrate & citric acid powder pack 3300-1002 mg $0 (1)potassium citrate & citric acid soln 1100-334 mg/5ml $0 (1)potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) $0 (1)potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) $0 (1)potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) $0 (1)sodium chloride irrigation soln 0.9% $0 (1)sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution

modi)$0 (1)

tamsulosin hcl cap 0.4 mg (Flomax) $0 (1) QL (60 capsules/30days), 90

MEDICAMENTOS DEL SISTEMA NERVIOSO CENTRALANSIEDADalprazolam tab 0.25 mg (Xanax) $0 (1) QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) $0 (1) QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) $0 (1) QL (120 tablets/30 days)alprazolam tab 2 mg (Xanax) $0 (1) QL (90 tablets/30 days)buspirone hcl tab 5 mg $0 (1)buspirone hcl tab 10 mg $0 (1)buspirone hcl tab 15 mg $0 (1)buspirone hcl tab 30 mg $0 (1)chlordiazepoxide hcl cap 5 mg $0 (1) QL (120

capsules/30 days)chlordiazepoxide hcl cap 10 mg $0 (1) QL (120

capsules/30 days)chlordiazepoxide hcl cap 25 mg $0 (1) QL (120

capsules/30 days)clorazepate dipotassium tab 3.75 mg $0 (1) QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) $0 (1) QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg $0 (1) QL (120 tablets/30 days)diazepam conc 5 mg/ml $0 (1) QL (240 mls/30 days)diazepam tab 2 mg (Valium) $0 (1) QL (120 tablets/30 days)diazepam tab 5 mg (Valium) $0 (1) QL (120 tablets/30 days)diazepam tab 10 mg (Valium) $0 (1) QL (120 tablets/30 days)

2017



45




HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ml $0 (2)hydroxyzine hcl syrup 10 mg/5ml $0 (1)hydroxyzine hcl tab 10 mg $0 (1)hydroxyzine hcl tab 25 mg $0 (1)hydroxyzine hcl tab 50 mg $0 (1)hydroxyzine pamoate cap 25 mg (Vistaril) $0 (1)hydroxyzine pamoate cap 50 mg (Vistaril) $0 (1)lorazepam conc 2 mg/ml $0 (1) QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) $0 (1) QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) $0 (1) QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) $0 (1) QL (150 tablets/30 days)

DEPRESIÓNamitriptyline hcl tab 10 mg $0 (1) 90amitriptyline hcl tab 25 mg (Elavil) $0 (1) 90amitriptyline hcl tab 50 mg $0 (1) 90amitriptyline hcl tab 75 mg $0 (1) 90amitriptyline hcl tab 100 mg $0 (1) 90amitriptyline hcl tab 150 mg $0 (1) 90bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30

days), 90bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30

days), 90bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30

days), 90bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30

days), 90bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30

days), 90bupropion hcl tab 75 mg $0 (1) QL (60 tablets/30

days), 90bupropion hcl tab 100 mg $0 (1) QL (120 tablets/30

days), 90citalopram hydrobromide oral soln 10 mg/5ml $0 (1) QL (600 mls/30 days), 90citalopram hydrobromide tab 10 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30

days), 90citalopram hydrobromide tab 20 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30

days), 90

2017



46




citalopram hydrobromide tab 40 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30days), 90

doxepin hcl cap 10 mg $0 (1) 90doxepin hcl cap 25 mg $0 (1) 90doxepin hcl cap 50 mg $0 (1) 90doxepin hcl cap 75 mg $0 (1) 90doxepin hcl cap 100 mg $0 (1) 90doxepin hcl cap 150 mg $0 (1) 90doxepin hcl conc 10 mg/ml $0 (1) 90duloxetine hcl enteric coated pellets cap 20 mg (base eq)

(Cymbalta)$0 (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), 90escitalopram oxalate soln 5 mg/5ml (base equiv) $0 (1) QL (600 mls/30 days), 90escitalopram oxalate tab 5 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30

days), 90escitalopram oxalate tab 10 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30

days), 90escitalopram oxalate tab 20 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30

days), 90fluoxetine hcl cap 10 mg (Prozac) $0 (1) QL (30 capsules/30

days), 90fluoxetine hcl cap 20 mg (Prozac) $0 (1) QL (120 capsules/30

days), 90fluoxetine hcl solution 20 mg/5ml $0 (1) QL (600 mls/30 days), 90fluvoxamine maleate tab 25 mg $0 (1) QL (30 tablets/30

days), 90fluvoxamine maleate tab 50 mg $0 (1) QL (30 tablets/30

days), 90fluvoxamine maleate tab 100 mg $0 (1) QL (90 tablets/30

days), 90imipramine hcl tab 10 mg (Tofranil) $0 (1) 90imipramine hcl tab 25 mg (Tofranil) $0 (1) 90imipramine hcl tab 50 mg (Tofranil) $0 (1) 90

2017



47




mirtazapine orally disintegrating tab 15 mg (Remeron soltab) $0 (1) QL (30 tablets/30days), 90



mirtazapine tab 15 mg (Remeron) $0 (1) QL (30 tablets/30days), 90



nortriptyline hcl cap 10 mg (Pamelor) $0 (1) 90nortriptyline hcl cap 25 mg (Pamelor) $0 (1) 90nortriptyline hcl cap 50 mg (Pamelor) $0 (1) 90nortriptyline hcl cap 75 mg (Pamelor) $0 (1) 90paroxetine hcl tab 10 mg (Paxil) $0 (1) QL (30 tablets/30

days), 90paroxetine hcl tab 20 mg (Paxil) $0 (1) QL (30 tablets/30



days), 90sertraline hcl oral conc 20 mg/ml (Zoloft) $0 (1) QL (300 mls/30 days), 90sertraline hcl tab 25 mg (Zoloft) $0 (1) QL (30 tablets/30

days), 90sertraline hcl tab 50 mg (Zoloft) $0 (1) QL (30 tablets/30

days), 90sertraline hcl tab 100 mg (Zoloft) $0 (1) QL (60 tablets/30

days), 90trazodone hcl tab 50 mg $0 (1) 90trazodone hcl tab 100 mg $0 (1) 90trazodone hcl tab 150 mg $0 (1) 90venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor

xr)$0 (1) QL (30 capsules/30

days), 90venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) $0 (1) QL (90 capsules/30

days), 90

2017



48




venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) $0 (1) QL (30 capsules/30days), 90

venlafaxine hcl tab 25 mg $0 (1) QL (90 tablets/30days), 90

venlafaxine hcl tab 37.5 mg $0 (1) QL (90 tablets/30days), 90




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

syringe 300 mg$0 (1) QL (1 syringe/28

days), STABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 400 mg$0 (1) QL (1 syringe/28

days), STABILIFY MAINTENA – aripiprazole im for extended release susp

300 mg$0 (1) QL (1 syringe/28

days), STABILIFY MAINTENA – aripiprazole im for extended release susp

400 mg$0 (1) QL (1 syringe/28

days), STaripiprazole oral solution 1 mg/ml $0 (1) QL (150 mls/30 days), 90aripiprazole tab 2 mg (Abilify) $0 (1) QL (30 tablets/30

days), 90aripiprazole tab 5 mg (Abilify) $0 (1) QL (30 tablets/30





days), 90ARISTADA – aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml$0 (2) QL (1 syringe/28

days), STARISTADA – aripiprazole lauroxil im er susp prefilled syr

662 mg/2.4ml$0 (2) QL (1 syringe/28

days), ST

2017



49




ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml

$0 (2) QL (1 syringe/28days), ST

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml

$0 (2) QL (1 syringe/56days), ST

clozapine orally disintegrating tab 25 mg (Fazaclo) $0 (1) QL (60 tablets/30 days)clozapine orally disintegrating tab 100 mg (Fazaclo) $0 (1) QL (60 tablets/30 days)clozapine tab 25 mg (Clozaril) $0 (1) QL (90 tablets/30 days)clozapine tab 50 mg $0 (1) QL (90 tablets/30 days)clozapine tab 100 mg (Clozaril) $0 (1) QL (270 tablets/30 days)clozapine tab 200 mg $0 (1) QL (120 tablets/30 days)fluphenazine decanoate inj 25 mg/ml $0 (1)FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml $0 (2) 90FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml $0 (2) 90fluphenazine hcl tab 1 mg $0 (1) 90fluphenazine hcl tab 2.5 mg $0 (1) 90fluphenazine hcl tab 5 mg $0 (1) 90fluphenazine hcl tab 10 mg $0 (1) 90haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) $0 (1)haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) $0 (1)haloperidol lactate oral conc 2 mg/ml $0 (1) 90haloperidol tab 0.5 mg $0 (1) 90haloperidol tab 1 mg $0 (1) 90haloperidol tab 2 mg $0 (1) 90haloperidol tab 5 mg $0 (1) 90haloperidol tab 10 mg $0 (1) 90haloperidol tab 20 mg $0 (1) 90INVEGA SUSTENNA – paliperidone palmitate im extended-

release susp 39 mg/0.25ml$0 (2) QL (1 kit/28 days), ST

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 78 mg/0.5ml

$0 (2) QL (1 kit/28 days), ST

INVEGA SUSTENNA – paliperidone palmitate im extend-releasesusp 117 mg/0.75ml

$0 (2) QL (1 kit/28 days), ST

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 156 mg/ml

$0 (2) QL (1 kit/28 days), ST

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 234 mg/1.5ml

$0 (2) QL (1 kit/28 days), ST

2017



50




LATUDA – lurasidone hcl tab 20 mg $0 (2) QL (30 tablets/30days), ST, 90





LITHIUM – lithium oral solution 8 meq/5ml $0 (2) 90lithium carbonate cap 150 mg (Lithium carbonate) $0 (1) 90lithium carbonate cap 300 mg $0 (1) 90lithium carbonate cap 600 mg (Lithium carbonate) $0 (1) 90lithium carbonate tab er 300 mg (Lithobid) $0 (1) 90lithium carbonate tab er 450 mg $0 (1) 90lithium carbonate tab 300 mg $0 (1) 90loxapine succinate cap 5 mg $0 (1) 90loxapine succinate cap 10 mg $0 (1) 90loxapine succinate cap 25 mg $0 (1) 90loxapine succinate cap 50 mg $0 (1) 90olanzapine for im inj 10 mg (Zyprexa) $0 (1) QL (90 vials/30 days), 90olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30

days), 90olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30



days), 90olanzapine tab 2.5 mg (Zyprexa) $0 (1) QL (30 tablets/30

days), 90olanzapine tab 5 mg (Zyprexa) $0 (1) QL (30 tablets/30

days), 90olanzapine tab 7.5 mg (Zyprexa) $0 (1) QL (30 tablets/30

days), 90

2017



51




olanzapine tab 10 mg (Zyprexa) $0 (1) QL (30 tablets/30days), 90



perphenazine tab 2 mg $0 (1) 90perphenazine tab 4 mg $0 (1) 90perphenazine tab 8 mg $0 (1) 90perphenazine tab 16 mg $0 (1) 90quetiapine fumarate tab 25 mg (Seroquel) $0 (1) QL (90 tablets/30

days), 90quetiapine fumarate tab 50 mg (Seroquel) $0 (1) QL (90 tablets/30





days), 90risperidone orally disintegrating tab 0.25 mg $0 (1) QL (60 tablets/30

days), 90risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30

days), 90risperidone orally disintegrating tab 1 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30




days), 90risperidone soln 1 mg/ml (Risperdal) $0 (1) QL (480 mls/30 days), 90risperidone tab 0.25 mg (Risperdal) $0 (1) QL (120 tablets/30

days), 90

2017



52




risperidone tab 0.5 mg (Risperdal) $0 (1) QL (120 tablets/30days), 90

risperidone tab 1 mg (Risperdal) $0 (1) QL (120 tablets/30days), 90




thioridazine hcl tab 10 mg $0 (1) 90thioridazine hcl tab 25 mg $0 (1) 90thioridazine hcl tab 50 mg $0 (1) 90thioridazine hcl tab 100 mg $0 (1) 90thiothixene cap 1 mg $0 (1) 90thiothixene cap 2 mg $0 (1) 90thiothixene cap 5 mg $0 (1) 90thiothixene cap 10 mg $0 (1) 90trifluoperazine hcl tab 1 mg (base equivalent) $0 (1) 90trifluoperazine hcl tab 2 mg (base equivalent) $0 (1) 90trifluoperazine hcl tab 5 mg (base equivalent) $0 (1) 90trifluoperazine hcl tab 10 mg (base equivalent) $0 (1) 90ziprasidone hcl cap 20 mg (Geodon) $0 (1) QL (60 capsules/30

days), 90ziprasidone hcl cap 40 mg (Geodon) $0 (1) QL (60 capsules/30



days), 90

MEDICAMENTOS PARA EL SUEÑOestazolam tab 1 mg $0 (1) QL (30 tablets/30 days)estazolam tab 2 mg $0 (1) QL (30 tablets/30 days)eszopiclone tab 1 mg (Lunesta) $0 (1) QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) $0 (1) QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) $0 (1) QL (30 tablets/30 days)PHENOBARBITAL – phenobarbital tab 15 mg $0 (2) 90

2017



53




PHENOBARBITAL – phenobarbital tab 30 mg $0 (2) 90PHENOBARBITAL – phenobarbital tab 60 mg $0 (2) 90PHENOBARBITAL – phenobarbital tab 100 mg $0 (2) 90phenobarbital elixir 20 mg/5ml $0 (1) 90phenobarbital tab 16.2 mg $0 (1) 90phenobarbital tab 32.4 mg $0 (1) 90phenobarbital tab 64.8 mg $0 (1) 90phenobarbital tab 97.2 mg $0 (1) 90temazepam cap 15 mg (Restoril) $0 (1) QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) $0 (1) QL (30 capsules/30 days)zaleplon cap 5 mg (Sonata) $0 (1) QL (30 capsules/30 days)zaleplon cap 10 mg (Sonata) $0 (1) QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) $0 (1) QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) $0 (1) QL (30 tablets/30 days)

HIPERACTIVIDAD/NARCOLEPSIAamphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) $0 (1) AL, QL (30

capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)$0 (1) AL, QL (30


xr)$0 (1) AL, QL (30


xr)$0 (1) AL, QL (30


xr)$0 (1) AL, QL (30


xr)$0 (1) AL, QL (30

capsules/30 days)amphetamine-dextroamphetamine tab 5 mg (Adderall) $0 (1) AL, QL (60

tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg (Adderall) $0 (1) AL, QL (60

tablets/30 days)amphetamine-dextroamphetamine tab 10 mg (Adderall) $0 (1) AL, QL (60

tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg (Adderall) $0 (1) AL, QL (60

tablets/30 days)amphetamine-dextroamphetamine tab 15 mg (Adderall) $0 (1) AL, QL (60

tablets/30 days)

2017



54




amphetamine-dextroamphetamine tab 20 mg (Adderall) $0 (1) AL, QL (90tablets/30 days)

amphetamine-dextroamphetamine tab 30 mg (Adderall) $0 (1) AL, QL (60tablets/30 days)

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) $0 (1)dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) $0 (1) AL, QL (30

capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) $0 (1) AL, QL (30





capsules/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin) $0 (1) AL, QL (60

tablets/30 days)dexmethylphenidate hcl tab 5 mg (Focalin) $0 (1) AL, QL (60

tablets/30 days)dexmethylphenidate hcl tab 10 mg (Focalin) $0 (1) AL, QL (60

tablets/30 days)guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days)methylphenidate hcl cap er 10 mg (cd) $0 (1) AL, QL (30

capsules/30 days)methylphenidate hcl cap er 20 mg (cd) $0 (1) AL, QL (30




capsules/30 days)

2017



55




methylphenidate hcl cap er 60 mg (cd) $0 (1) AL, QL (30capsules/30 days)

methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) $0 (1) AL, QL (30capsules/30 days)



METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr18 mg

$0 (2) AL, QL (30tablets/30 days)







methylphenidate hcl tab er osmotic release (osm) 18 mg(Concerta)








methylphenidate hcl tab er 10 mg $0 (1) AL, QL (90tablets/30 days)

methylphenidate hcl tab 5 mg (Ritalin) $0 (1) AL, QL (90tablets/30 days)



modafinil tab 100 mg (Provigil) $0 (1) PA, QL (30tablets/30 days)

modafinil tab 200 mg (Provigil) $0 (1) PA, QL (30tablets/30 days)

ESCLEROSIS MÚLTIPLEAMPYRA – dalfampridine tab er 12hr 10 mg $0 (2) PA, QL (60 tablets/30

days), SP

2017



56




AUBAGIO – teriflunomide tab 7 mg $0 (2) PA, QL (30 tablets/30days), SP

AUBAGIO – teriflunomide tab 14 mg $0 (2) PA, QL (30 tablets/30days), SP

AVONEX – interferon beta-1a im prefilled syringe kit30 mcg/0.5ml

$0 (2) PA, QL (1 kit/28days), SP

AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6mu)/vial)

$0 (2) PA, QL (4 vials/28days), SP

AVONEX PEN – interferon beta-1a im auto-injector kit30 mcg/0.5ml

$0 (2) PA, QL (1 kit/28days), SP

EXTAVIA – interferon beta-1b for inj kit 0.3 mg $0 (2) PA, QL (14 vials/28days), SP

glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) $0 (1) PA, QL (30 syringes/30days), SP

OTROS MEDICAMENTOS DEL SISTEMA NERVIOSO CENTRALacamprosate calcium tab delayed release 333 mg $0 (1) 90bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) $0 (1) QL (180 days/365 days)CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) $0 (2) QL (180 days/365 days)CHANTIX – varenicline tartrate tab 1 mg (base equiv) $0 (2) QL (180 days/365 days)CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg

(base equiv)$0 (2) QL (180 days/365 days)

CHANTIX STARTING MONTH PA – varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

$0 (2) QL (180 days/365 days)

disulfiram tab 250 mg (Antabuse) $0 (1) 90disulfiram tab 500 mg (Antabuse) $0 (1) 90donepezil hydrochloride orally disintegrating tab 5 mg $0 (1) QL (30 tablets/30

days), 90donepezil hydrochloride orally disintegrating tab 10 mg $0 (1) QL (30 tablets/30

days), 90donepezil hydrochloride tab 5 mg (Aricept) $0 (1) QL (30 tablets/30

days), 90donepezil hydrochloride tab 10 mg (Aricept) $0 (1) QL (30 tablets/30

days), 90naltrexone hcl tab 50 mg $0 (1)nicotine polacrilex gum 2 mg $0 (3) QL (180 days/365 days)nicotine polacrilex gum 4 mg $0 (3) QL (180 days/365 days)nicotine td patch 24hr 7 mg/24hr $0 (3) QL (180 days/365 days)nicotine td patch 24hr 14 mg/24hr $0 (3) QL (180 days/365 days)

2017



57




nicotine td patch 24hr 21 mg/24hr $0 (3) QL (180 days/365 days)pimozide tab 1 mg (Orap) $0 (1) 90pimozide tab 2 mg (Orap) $0 (1) 90VIVITROL – naltrexone for im extended release susp 380 mg $0 (2) SPXYREM – sodium oxybate oral solution 500 mg/ml $0 (2) PA, QL (3 bottles/30

days), SP

MEDICAMENTOS PARA ALIVIAR EL DOLORMEDICAMENTOS NO ESTUPEFACIENTESacetaminophen cap 500 mg $0 (3)acetaminophen chew tab 80 mg $0 (3)acetaminophen chew tab 160 mg $0 (3)acetaminophen disintegrating tab 80 mg $0 (3)acetaminophen liquid 160 mg/5ml $0 (3)acetaminophen soln 160 mg/5ml $0 (3)acetaminophen suppos 120 mg $0 (3)acetaminophen susp 80 mg/0.8ml $0 (3)acetaminophen susp 160 mg/5ml $0 (3)acetaminophen tab 325 mg $0 (3)acetaminophen tab 500 mg $0 (3)aspirin chew tab 81 mg $0 (3) 90aspirin tab delayed release 81 mg $0 (3) 90aspirin tab delayed release 325 mg $0 (3) 90aspirin tab 325 mg $0 (3) 90butalbital-acetaminophen tab 50-325 mg $0 (1) QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) $0 (1) QL (180

capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg $0 (1) QL (180

capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) $0 (1) QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) $0 (1) QL (180

capsules/30 days)salsalate tab 500 mg $0 (1) 90salsalate tab 750 mg $0 (1) 90

MEDICAMENTOS ESTUPEFACIENTESacetaminophen w/ codeine soln 120-12 mg/5ml $0 (1) ME, QL (2700

mls/30 days)

2017



58




acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) $0 (1) ME, QL (360tablets/30 days)

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) $0 (1) ME, QL (360tablets/30 days)

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) $0 (1) ME, QL (180tablets/30 days)

ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg

$0 (2) ME, QL (300capsules/30 days)

BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3 mg(base equiv)

$0 (2) QL (60 films/30 days)

BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7 mg(base equiv)

$0 (2) QL (60 films/30 days)

BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 mg (baseequiv)

$0 (2) QL (60 films/30 days)

buprenorphine hcl sl tab 2 mg (base equiv) $0 (1) QL (15 tablets/90 days)buprenorphine hcl sl tab 8 mg (base equiv) $0 (1) QL (15 tablets/90 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) $0 (1) QL (60 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) $0 (1) QL (60 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg $0 (1) ME, QL (180

capsules/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/

codeine #3)$0 (1) ME, QL (180

capsules/30 days)codeine sulfate tab 15 mg (Codeine sulfate) $0 (1) ME, QL (180

tablets/30 days)codeine sulfate tab 30 mg (Codeine sulfate) $0 (1) ME, QL (180

tablets/30 days)codeine sulfate tab 60 mg (Codeine sulfate) $0 (1) ME, QL (180

tablets/30 days)fentanyl td patch 72hr 12 mcg/hr (Duragesic) $0 (1) ME, QL (15

patches/30 days)fentanyl td patch 72hr 25 mcg/hr (Duragesic) $0 (1) ME, QL (15




patches/30 days)

2017



59




hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) $0 (1) ME, QL (3600mls/30 days)

hydrocodone-acetaminophen tab 2.5-325 mg $0 (1) ME, QL (360tablets/30 days)

hydrocodone-acetaminophen tab 10-325 mg (Norco) $0 (1) ME, QL (180tablets/30 days)

hydrocodone-acetaminophen tab 5-325 mg (Norco) $0 (1) ME, QL (360tablets/30 days)

hydrocodone-acetaminophen tab 7.5-325 mg (Norco) $0 (1) ME, QL (180tablets/30 days)

hydromorphone hcl liqd 1 mg/ml (Dilaudid) $0 (1) ME, QL (1440mls/30 days)

hydromorphone hcl tab 2 mg (Dilaudid) $0 (1) ME, QL (180tablets/30 days)



meperidine hcl tab 50 mg $0 (1) ME, QL (240tablets/30 days)

meperidine hcl tab 100 mg (Demerol) $0 (1) ME, QL (240tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 15 mg $0 (2) ME, QL (240tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 30 mg $0 (2) ME, QL (180tablets/30 days)

MORPHINE SULFATE – morphine sulfate suppos 5 mg $0 (2) MEMORPHINE SULFATE – morphine sulfate suppos 10 mg $0 (2) MEMORPHINE SULFATE – morphine sulfate suppos 20 mg $0 (2) MEMORPHINE SULFATE – morphine sulfate suppos 30 mg $0 (2) MEmorphine sulfate oral soln 10 mg/5ml $0 (1) ME, QL (2700

mls/30 days)morphine sulfate oral soln 20 mg/5ml $0 (1) ME, QL (1350

mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270

mls/30 days)oxycodone hcl conc 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270

mls/30 days)

2017



60




oxycodone hcl soln 5 mg/5ml $0 (1) ME, QL (5400mls/30 days)

oxycodone hcl tab 5 mg (Roxicodone) $0 (1) ME, QL (360tablets/30 days)

oxycodone hcl tab 10 mg $0 (1) ME, QL (180tablets/30 days)


oxycodone hcl tab 20 mg $0 (1) ME, QL (180tablets/30 days)


oxycodone w/ acetaminophen tab 5-325 mg (Percocet) $0 (1) ME, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) $0 (1) ME, QL (240tablets/30 days)

oxycodone w/ acetaminophen tab 10-325 mg (Percocet) $0 (1) ME, QL (180tablets/30 days)

oxycodone-aspirin tab 4.8355-325 mg $0 (1) ME, QL (360tablets/30 days)

OXYCODONE/ACETAMINOPHEN – oxycodone w/acetaminophen soln 5-325 mg/5ml

$0 (2) ME, QL (1800mls/30 days)

PROBUPHINE IMPLANT KIT – buprenorphine hcl subdermalimplant 74.2 mg (base equiv)

$0 (2)

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg(base equiv)

$0 (2) QL (60 films/30 days)

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg(base equiv)

$0 (2) QL (60 films/30 days)


$0 (2) QL (60 films/30 days)


$0 (2) QL (60 films/30 days)

tramadol hcl tab 50 mg (Ultram) $0 (1) ME, QL (240tablets/30 days)

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg(base eq)






2017



61








ARTRITIS REUMATOIDEA Y OSTEOARTRITIScelecoxib cap 50 mg (Celebrex) $0 (1) AL, QL (60 capsules/30

days), ST, 90celecoxib cap 100 mg (Celebrex) $0 (1) AL, QL (60 capsules/30



days), ST, 90diclofenac potassium tab 50 mg $0 (1) QL (120 tablets/30

days), 90diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days)diclofenac sodium tab delayed release 50 mg $0 (1) QL (120 tablets/30

days), 90diclofenac sodium tab delayed release 75 mg $0 (1) QL (60 tablets/30

days), 90diclofenac sodium tab er 24hr 100 mg $0 (1) QL (60 tablets/30

days), 90ENBREL – etanercept for subcutaneous inj 25 mg $0 (2) PA, QL (8 vials/28

days), SP, 90ENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml$0 (2) PA, QL (8 syringes/28

days), SP, 90ENBREL – etanercept subcutaneous soln prefilled syringe

50 mg/ml$0 (2) PA, QL (4 syringes/28

days), SP, 90ENBREL SURECLICK – etanercept subcutaneous solution auto-

injector 50 mg/ml$0 (2) PA, QL (4 syringes/28

days), SP, 90flurbiprofen tab 50 mg $0 (1) QL (180 tablets/30

days), 90flurbiprofen tab 100 mg $0 (1) QL (90 tablets/30

days), 90HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml $0 (2) PA, QL (2 syringes/28

days), SPHUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml $0 (2) PA, QL (2 syringes/28

days), SP

2017



62




HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml $0 (2) PA, QL (2 syringes/28days), SP

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringekit 40 mg/0.8ml


HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml $0 (2) PA, QL (2 pens/180days), SP

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit40 mg/0.8ml


HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit40 mg/0.8ml


ibuprofen cap 200 mg $0 (3) 90ibuprofen susp 100 mg/5ml $0 (1) QL (1000 mls/30 days)ibuprofen tab 200 mg $0 (3) 90ibuprofen tab 400 mg $0 (1) QL (120 tablets/30

days), 90ibuprofen tab 600 mg $0 (1) QL (150 tablets/30

days), 90ibuprofen tab 800 mg $0 (1) QL (120 tablets/30

days), 90indomethacin cap er 75 mg $0 (1) QL (60 capsules/30

days), 90indomethacin cap 25 mg $0 (1) QL (90 capsules/30

days), 90indomethacin cap 50 mg $0 (1) QL (60 capsules/30

days), 90ketoprofen cap 50 mg $0 (1) QL (180 capsules/30

days), 90ketoprofen cap 75 mg $0 (1) QL (120 capsules/30

days), 90ketorolac tromethamine tab 10 mg $0 (1) QL (20 tablets/30 days)leflunomide tab 10 mg (Arava) $0 (1) 90leflunomide tab 20 mg (Arava) $0 (1) 90meloxicam tab 7.5 mg (Mobic) $0 (1) QL (60 tablets/30

days), 90meloxicam tab 15 mg (Mobic) $0 (1) QL (30 tablets/30

days), 90nabumetone tab 500 mg $0 (1) QL (120 tablets/30

days), 90

2017



63




nabumetone tab 750 mg $0 (1) QL (60 tablets/30days), 90

naproxen sodium tab 220 mg $0 (3) 90naproxen sodium tab 275 mg $0 (1) QL (150 tablets/30

days), 90naproxen sodium tab 550 mg (Anaprox ds) $0 (1) QL (90 tablets/30

days), 90naproxen tab ec 375 mg (Ec-naprosyn) $0 (1) QL (120 tablets/30

days), 90naproxen tab ec 500 mg (Ec-naprosyn) $0 (1) QL (90 tablets/30

days), 90naproxen tab 250 mg $0 (1) QL (150 tablets/30

days), 90naproxen tab 375 mg $0 (1) QL (120 tablets/30

days), 90naproxen tab 500 mg (Naprosyn) $0 (1) QL (90 tablets/30

days), 90piroxicam cap 10 mg (Feldene) $0 (1) QL (60 capsules/30

days), 90piroxicam cap 20 mg (Feldene) $0 (1) QL (30 capsules/30

days), 90sulindac tab 150 mg $0 (1) QL (60 tablets/30

days), 90sulindac tab 200 mg $0 (1) QL (60 tablets/30

days), 90

MIGRAÑASrizatriptan benzoate oral disintegrating tab 5 mg (base eq)

(Maxalt-mlt)$0 (1) QL (18 tablets/30 days)

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)(Maxalt-mlt)


rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days)sumatriptan succinate inj 6 mg/0.5ml (Imitrex) $0 (1) QL (12 vials/30 days)sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex

statdose ref)$0 (1) QL (6 packages/30 days)

sumatriptan succinate tab 25 mg (Imitrex) $0 (1) QL (18 tablets/30 days)sumatriptan succinate tab 50 mg (Imitrex) $0 (1) QL (18 tablets/30 days)sumatriptan succinate tab 100 mg (Imitrex) $0 (1) QL (18 tablets/30 days)

2017



64




GOTAallopurinol tab 100 mg (Zyloprim) $0 (1) 90allopurinol tab 300 mg (Zyloprim) $0 (1) 90colchicine w/ probenecid tab 0.5-500 mg $0 (1) 90probenecid tab 500 mg $0 (1) 90

MEDICAMENTOS NEUROMUSCULARESCONVULSIONEScarbamazepine chew tab 100 mg $0 (1) 90carbamazepine susp 100 mg/5ml (Tegretol) $0 (1) 90carbamazepine tab er 12hr 100 mg (Tegretol-xr) $0 (1) 90carbamazepine tab er 12hr 200 mg (Tegretol-xr) $0 (1) 90carbamazepine tab er 12hr 400 mg (Tegretol-xr) $0 (1) 90carbamazepine tab 200 mg (Tegretol) $0 (1) 90clonazepam orally disintegrating tab 0.125 mg $0 (1) QL (90 tablets/30

days), 90clonazepam orally disintegrating tab 0.25 mg $0 (1) QL (90 tablets/30

days), 90clonazepam orally disintegrating tab 0.5 mg $0 (1) QL (90 tablets/30

days), 90clonazepam orally disintegrating tab 1 mg $0 (1) QL (90 tablets/30

days), 90clonazepam orally disintegrating tab 2 mg $0 (1) QL (60 tablets/30

days), 90clonazepam tab 0.5 mg (Klonopin) $0 (1) QL (90 tablets/30

days), 90clonazepam tab 1 mg (Klonopin) $0 (1) QL (90 tablets/30

days), 90clonazepam tab 2 mg (Klonopin) $0 (1) QL (60 tablets/30

days), 90DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system

2.5 mg$0 (2) QL (2 packs/30 days)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system10 mg

$0 (2) QL (2 packs/30 days)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system20 mg

$0 (2) QL (2 packs/30 days)

DILANTIN – phenytoin sodium extended cap 30 mg $0 (2) 90divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)$0 (1) 90

2017



65




divalproex sodium tab delayed release 125 mg (Depakote) $0 (1) 90divalproex sodium tab delayed release 250 mg (Depakote) $0 (1) 90divalproex sodium tab delayed release 500 mg (Depakote) $0 (1) 90divalproex sodium tab er 24 hr 250 mg (Depakote er) $0 (1) 90divalproex sodium tab er 24 hr 500 mg (Depakote er) $0 (1) 90ethosuximide cap 250 mg (Zarontin) $0 (1) 90ethosuximide soln 250 mg/5ml (Zarontin) $0 (1) 90gabapentin cap 100 mg (Neurontin) $0 (1) QL (720 capsules/30

days), 90gabapentin cap 300 mg (Neurontin) $0 (1) QL (240 capsules/30

days), 90gabapentin cap 400 mg (Neurontin) $0 (1) QL (180 capsules/30

days), 90gabapentin oral soln 250 mg/5ml (Neurontin) $0 (1) QL (1500 mls/30

days), 90gabapentin tab 600 mg (Neurontin) $0 (1) QL (120 tablets/30

days), 90gabapentin tab 800 mg (Neurontin) $0 (1) QL (90 tablets/30

days), 90lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) $0 (1) 90lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)$0 (1) 90

lamotrigine tab 25 mg (Lamictal) $0 (1) 90lamotrigine tab 100 mg (Lamictal) $0 (1) 90lamotrigine tab 150 mg (Lamictal) $0 (1) 90lamotrigine tab 200 mg (Lamictal) $0 (1) 90levetiracetam oral soln 100 mg/ml (Keppra) $0 (1) 90levetiracetam tab er 24hr 500 mg (Keppra xr) $0 (1) 90levetiracetam tab er 24hr 750 mg (Keppra xr) $0 (1) 90levetiracetam tab 250 mg (Keppra) $0 (1) 90levetiracetam tab 500 mg (Keppra) $0 (1) 90levetiracetam tab 750 mg (Keppra) $0 (1) 90levetiracetam tab 1000 mg (Keppra) $0 (1) 90oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) $0 (1) 90oxcarbazepine tab 150 mg (Trileptal) $0 (1) 90oxcarbazepine tab 300 mg (Trileptal) $0 (1) 90

2017



66




oxcarbazepine tab 600 mg (Trileptal) $0 (1) 90phenytoin chew tab 50 mg (Dilantin infatabs) $0 (1) 90phenytoin sodium extended cap 100 mg (Dilantin) $0 (1) 90phenytoin sodium extended cap 200 mg (Phenytek) $0 (1) 90phenytoin sodium extended cap 300 mg (Phenytek) $0 (1) 90phenytoin susp 125 mg/5ml (Dilantin-125) $0 (1) 90primidone tab 50 mg (Mysoline) $0 (1) 90primidone tab 250 mg (Mysoline) $0 (1) 90topiramate sprinkle cap 15 mg (Topamax sprinkle) $0 (1) 90topiramate sprinkle cap 25 mg (Topamax sprinkle) $0 (1) 90topiramate tab 25 mg (Topamax) $0 (1) 90topiramate tab 50 mg (Topamax) $0 (1) 90topiramate tab 100 mg (Topamax) $0 (1) 90topiramate tab 200 mg (Topamax) $0 (1) 90valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) $0 (1) 90valproic acid cap 250 mg (Depakene) $0 (1) 90zonisamide cap 25 mg (Zonegran) $0 (1) 90zonisamide cap 50 mg $0 (1) 90zonisamide cap 100 mg (Zonegran) $0 (1) 90

ENFERMEDAD DE PARKINSONamantadine hcl cap 100 mg $0 (1) 90amantadine hcl syrup 50 mg/5ml $0 (1) 90benztropine mesylate tab 0.5 mg $0 (1) 90benztropine mesylate tab 1 mg $0 (1) 90benztropine mesylate tab 2 mg $0 (1) 90bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) $0 (1) 90carbidopa & levodopa tab er 25-100 mg (Sinemet cr) $0 (1) 90carbidopa & levodopa tab er 50-200 mg (Sinemet cr) $0 (1) 90carbidopa & levodopa tab 10-100 mg (Sinemet) $0 (1) 90carbidopa & levodopa tab 25-100 mg (Sinemet) $0 (1) 90carbidopa & levodopa tab 25-250 mg (Sinemet) $0 (1) 90carbidopa tab 25 mg (Lodosyn) $0 (1) 90entacapone tab 200 mg (Comtan) $0 (1) 90pramipexole dihydrochloride tab 0.125 mg (Mirapex) $0 (1) 90pramipexole dihydrochloride tab 0.25 mg (Mirapex) $0 (1) 90

2017



67




pramipexole dihydrochloride tab 0.5 mg (Mirapex) $0 (1) 90pramipexole dihydrochloride tab 0.75 mg (Mirapex) $0 (1) 90pramipexole dihydrochloride tab 1 mg (Mirapex) $0 (1) 90pramipexole dihydrochloride tab 1.5 mg (Mirapex) $0 (1) 90ropinirole hydrochloride tab 0.25 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 0.5 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 1 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 2 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 3 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 4 mg (Requip) $0 (1) 90ropinirole hydrochloride tab 5 mg (Requip) $0 (1) 90selegiline hcl cap 5 mg (Eldepryl) $0 (1) 90selegiline hcl tab 5 mg $0 (1) 90trihexyphenidyl hcl elixir 0.4 mg/ml $0 (1) 90trihexyphenidyl hcl tab 2 mg $0 (1) 90trihexyphenidyl hcl tab 5 mg $0 (1) 90

RELAJANTES MUSCULARESbaclofen tab 10 mg $0 (1) 90baclofen tab 20 mg $0 (1) 90chlorzoxazone tab 500 mg (Parafon forte dsc) $0 (1)cyclobenzaprine hcl tab 5 mg $0 (1)cyclobenzaprine hcl tab 10 mg $0 (1)dantrolene sodium cap 25 mg (Dantrium) $0 (1)dantrolene sodium cap 50 mg (Dantrium) $0 (1)dantrolene sodium cap 100 mg $0 (1)methocarbamol tab 500 mg (Robaxin) $0 (1)methocarbamol tab 750 mg (Robaxin-750) $0 (1)orphenadrine citrate tab er 12hr 100 mg $0 (1)tizanidine hcl tab 2 mg (base equivalent) $0 (1) QL (180 tablets/30

days), 90tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) $0 (1) QL (180 tablets/30

days), 90

OTROS MEDICAMENTOS NEUROMUSCULARESBOTOX – onabotulinumtoxina for inj 100 unit $0 (1) PApyridostigmine bromide tab 60 mg (Mestinon) $0 (1)

2017



68




riluzole tab 50 mg (Rilutek) $0 (1) 90

SUPLEMENTOSVITAMINASascorbic acid tab 500 mg $0 (3)cholecalciferol cap 1000 unit $0 (3)cholecalciferol cap 2000 unit $0 (3)cholecalciferol cap 5000 unit $0 (3)cholecalciferol cap 10000 unit $0 (3)cholecalciferol cap 50000 unit $0 (3)cholecalciferol oral liquid 400 unit/ml $0 (3)cholecalciferol tab 400 unit $0 (3)cholecalciferol tab 1000 unit $0 (3)cholecalciferol tab 2000 unit $0 (3)cholecalciferol tab 50000 unit $0 (3)cyanocobalamin inj 1000 mcg/ml $0 (1)cyanocobalamin tab er 1000 mcg $0 (3)cyanocobalamin tab 100 mcg $0 (3)cyanocobalamin tab 250 mcg $0 (3)cyanocobalamin tab 500 mcg $0 (3)cyanocobalamin tab 1000 mcg $0 (3)DECARA – cholecalciferol cap 25000 unit $0 (3)ergocalciferol cap 50000 unit $0 (1) 90folic acid tab 400 mcg $0 (3)folic acid tab 800 mcg $0 (3) 90folic acid tab 1 mg $0 (1) 90folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg $0 (1)folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) $0 (1)folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg $0 (1)iron combination cap $0 (1)iron polysacch complex-vit b12-fa cap 150-0.025-1 mg $0 (1)iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg

(Hematron-af)$0 (1)

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite150)

$0 (1)

MEPHYTON – phytonadione tab 5 mg $0 (2)niacin cap er 250 mg $0 (3)

2017



69




niacin cap er 500 mg $0 (3)niacin tab er 250 mg $0 (3)niacin tab er 500 mg $0 (3)niacin tab er 750 mg $0 (3)niacin tab 100 mg $0 (3)niacin tab 500 mg $0 (3)NIACIN TR – niacin tab er 1000 mg $0 (3)thiamine hcl tab 50 mg $0 (3)thiamine hcl tab 100 mg $0 (3)

MULTIVITAMINASb-complex w/ c & folic acid cap 1 mg (Nephrocaps) $0 (1)b-complex w/ c & folic acid tab $0 (1)b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) $0 (1)b-complex w/ c & folic acid tab 5 mg $0 (1)EQ MULTIVITAMINS ADULT GU – multiple vitamins w/ minerals

chew tab$0 (3)

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acidtab 5 mg

$0 (2)

multiple vitamin tab $0 (3)multiple vitamins w/ iron tab $0 (3)multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) $0 (1)multiple vitamins w/ minerals cap $0 (1)multiple vitamins w/ minerals tab (Strovite forte) $0 (1)pediatric multiple vitamin w/ c & fa chew tab $0 (3)pediatric multiple vitamin w/ minerals & c drops 45 mg/ml $0 (3)PRENATAL VITAMINS - various $0 (2)PRESERVISION AREDS 2 + MU – multiple vitamins w/ minerals

cap$0 (3)

TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400unit-35 mg/ml

$0 (3)

MINERALES Y ELECTROLITOScalcium carbonate tab 1250 mg (500 mg elemental ca) $0 (3)calcium carbonate-cholecalciferol tab 500 mg-200 unit $0 (3)calcium carbonate-cholecalciferol tab 600 mg-400 unit $0 (3)calcium carbonate-vitamin d tab 250 mg-125 unit $0 (3)calcium carbonate-vitamin d tab 500 mg-200 unit $0 (3)

2017



70




calcium carbonate-vitamin d tab 600 mg-400 unit $0 (3)calcium citrate tab 950 mg (200 mg elemental ca) $0 (3)fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap

(Tandem plus)$0 (1)

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg $0 (1)fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg $0 (1)ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg $0 (1)ferrous fumarate-folic acid tab 324-1 mg $0 (1)ferrous sulfate tab ec 325 mg (65 mg fe equivalent) $0 (3)ferrous sulfate tab 325 mg (65 mg elemental fe) $0 (3)K-PHOS – potassium phosphate monobasic tab 500 mg $0 (2) 90magnesium oxide tab 400 mg (241.3 mg elemental mg) $0 (1)oral electrolyte solution $0 (3)pot bicarbonate & chloride effer tab 25 meq $0 (1) 90pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral)$0 (1) 90

potassium bicarbonate effer tab 25 meq $0 (1) 90POTASSIUM CHLORIDE – potassium chloride oral soln 20% (40

meq/15ml)$0 (2) 90

potassium chloride cap er 8 meq (Micro-k) $0 (1) 90potassium chloride cap er 10 meq (Micro-k) $0 (1) 90POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq

(600 mg)$0 (2) 90

potassium chloride microencapsulated crys er tab 10 meq $0 (1) 90potassium chloride microencapsulated crys er tab 20 meq $0 (1) 90potassium chloride oral soln 10% (20 meq/15ml) $0 (1) 90potassium chloride powder packet 20 meq $0 (1) 90potassium chloride tab er 8 meq (600 mg) $0 (1) 90potassium chloride tab er 10 meq (K-tab) $0 (1) 90SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg

naf)$0 (2) 90

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) $0 (1) 90sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) $0 (1) 90sodium fluoride chew tab 1 mg f (from 2.2 mg naf) $0 (1) 90sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) $0 (1) 90sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) $0 (1) 90

OTROS SUPLEMENTOS

2017



71




FALESSA – levomefolate glucosamine tab 1 mg (folateequivalent)

$0 (2)

FISH OIL ULTRA – omega-3 fatty acids cap 1400 mg $0 (3)OCEAN BLUE MINICAPS OMEGA – omega-3 fatty acids cap

350 mg$0 (3)

OMEGA POWER – omega-3 fatty acids cap 1050 mg $0 (3)OMEGA-3 – omega-3 fatty acids cap 1400 mg $0 (3)OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg $0 (3)OMEGA-3 2100 – omega-3 fatty acids cap 1050 mg $0 (3)omega-3 fatty acids cap 500 mg $0 (3)omega-3 fatty acids cap 435 mg $0 (3)omega-3 fatty acids cap 1000 mg $0 (3)omega-3 fatty acids cap 1200 mg $0 (3)omega-3 fatty acids cap delayed release 1000 mg $0 (3)omega-3 fatty acids cap delayed release 1200 mg $0 (3)PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap delayed

release 332.5 mg$0 (3)

MEDICAMENTOS MODIFICADORES DE SANGREADVATE – antihemophilic factor rahf-pfm for inj 250 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 500 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1000 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1500 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 2000 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 3000 unit $0 (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 4000 unit $0 (2) PA, SPADYNOVATE – antihemophilic factor recomb pegylated for inj

250 unit$0 (2) PA, SP

ADYNOVATE – antihemophilic factor recomb pegylated for inj500 unit

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

2017



72




ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf(human) for inj 250 unit

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

ALPHANINE SD – coagulation factor ix for inj 500 unit $0 (2) PA, SPALPHANINE SD – coagulation factor ix for inj 1000 unit $0 (2) PA, SPALPHANINE SD – coagulation factor ix for inj 1500 unit $0 (2) PA, SPanagrelide hcl cap 0.5 mg (Agrylin) $0 (1) 90anagrelide hcl cap 1 mg $0 (1) 90ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml$0 (2) PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 500 mcg/ml

$0 (2) PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

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$0 (2) PA, SP


$0 (2) PA, SP

aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox) $0 (1) 90BEBULIN – factor ix complex for inj 200-1200 unit $0 (2) PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 250 unit $0 (2) PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 500 unit $0 (2) PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 1000

unit$0 (2) PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 2000unit

$0 (2) PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 3000unit

$0 (2) PA, SP

BRILINTA – ticagrelor tab 60 mg $0 (2) PA, QL (60 tablets/30days), 90

BRILINTA – ticagrelor tab 90 mg $0 (2) PA, QL (60 tablets/30days), 90

cilostazol tab 50 mg $0 (1) 90cilostazol tab 100 mg $0 (1) 90clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) $0 (1) 90clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) $0 (1)COAGADEX – coagulation factor x (human) for inj 250 unit $0 (2) PA, SPCOAGADEX – coagulation factor x (human) for inj 500 unit $0 (2) PA, SPdipyridamole tab 25 mg $0 (1) 90dipyridamole tab 50 mg $0 (1) 90dipyridamole tab 75 mg $0 (1) 90ELIQUIS – apixaban tab 2.5 mg $0 (2) PA, QL (60 tablets/30

days), 90ELIQUIS – apixaban tab 5 mg $0 (2) PA, QL (120

tablets/30 days), 90enoxaparin sodium inj 30 mg/0.3ml (Lovenox) $0 (1) QL (30 syringes/365

days)enoxaparin sodium inj 40 mg/0.4ml (Lovenox) $0 (1) QL (30 syringes/365

days)enoxaparin sodium inj 60 mg/0.6ml (Lovenox) $0 (1) QL (30 syringes/365

days)

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enoxaparin sodium inj 80 mg/0.8ml (Lovenox) $0 (1) QL (30 syringes/365days)

enoxaparin sodium inj 100 mg/ml (Lovenox) $0 (1) QL (30 syringes/365days)

enoxaparin sodium inj 120 mg/0.8ml (Lovenox) $0 (1) QL (30 syringes/365days)

enoxaparin sodium inj 150 mg/ml (Lovenox) $0 (1) QL (30 syringes/365days)

enoxaparin sodium inj 300 mg/3ml (Lovenox) $0 (1) QL (30 vials/365 days)FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) $0 (2) PA, QL (6 syringes/30

days), SPHELIXATE FS – antihemophilic factor (recombinant) for inj kit

250 unit$0 (1) PA, SP

HELIXATE FS – antihemophilic factor (recombinant) for inj kit500 unit

$0 (1) PA, SP


$0 (1) PA, SP


$0 (1) PA, SP


$0 (2) PA, SP

HEMOFIL M – antihemophilic factor (human) for inj 250 unit $0 (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 500 unit $0 (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1700 unit $0 (2) PA, SPHUMATE-P – antihemophilic factor/vwf (human) for inj 250-600

unit$0 (2) PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200unit

$0 (2) PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit

$0 (2) PA, SP

IXINITY – coagulation factor ix (recombinant) for inj 500 unit $0 (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1000 unit $0 (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1500 unit $0 (2) PA, SPKOATE – antihemophilic factor (human) for inj 250 unit $0 (2) PA, SPKOATE – antihemophilic factor (human) for inj 500 unit $0 (2) PA, SPKOATE – antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SPKOATE-DVI – antihemophilic factor (human) for inj 250 unit $0 (2) PA, SPKOATE-DVI – antihemophilic factor (human) for inj 500 unit $0 (2) PA, SP

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KOATE-DVI – antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SPKOGENATE FS – antihemophilic factor (recombinant) for inj kit

250 unit$0 (1) PA, SP

KOGENATE FS – antihemophilic factor (recombinant) for inj kit500 unit

$0 (1) PA, SP


$0 (1) PA, SP


$0 (1) PA, SP


$0 (2) PA, SP

KOGENATE FS BIO-SET – antihemophilic factor (recombinant)for inj kit 250 unit

$0 (1) PA, SP


$0 (1) PA, SP


$0 (1) PA, SP


$0 (1) PA, SP


$0 (2) PA, SP

LMD 10% DEXTROSE 5% – dextran 40 inj 10% in d5w $0 (2)MONOCLATE-P – antihemophilic factor (human) for inj kit 1000

unit$0 (2) PA, SP

MONOCLATE-P – antihemophilic factor (human) for inj kit 1500unit

$0 (2) PA, SP

MONONINE – coagulation factor ix for inj 1000 unit $0 (2) PA, SPNEUPOGEN – filgrastim soln prefilled syringe 300 mcg/0.5ml $0 (2) SPNEUPOGEN – filgrastim soln prefilled syringe 480 mcg/0.8ml

(600 mcg/ml)$0 (2) SP

NEUPOGEN – filgrastim inj 300 mcg/ml $0 (2) SPNEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) $0 (2) SPpentoxifylline tab er 400 mg $0 (1) 90PROFILNINE – factor ix complex for inj 500 unit $0 (2) PA, SPPROFILNINE – factor ix complex for inj 1000 unit $0 (2) PA, SPPROFILNINE – factor ix complex for inj 1500 unit $0 (2) PA, SPPROFILNINE SD – factor ix complex for inj 500 unit $0 (2) PA, SPPROFILNINE SD – factor ix complex for inj 1000 unit $0 (2) PA, SPPROFILNINE SD – factor ix complex for inj 1500 unit $0 (2) PA, SP

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RECOMBINATE – antihemophilic factor (recombinant) for inj220-400 unit

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

RIXUBIS – coagulation factor ix (recombinant) for inj 250 unit $0 (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 500 unit $0 (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 1000 unit $0 (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 2000 unit $0 (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 3000 unit $0 (2) PA, SPtranexamic acid tab 650 mg (Lysteda) $0 (1)warfarin sodium tab 1 mg (Coumadin) $0 (1) 90warfarin sodium tab 2 mg (Coumadin) $0 (1) 90warfarin sodium tab 2.5 mg (Coumadin) $0 (1) 90warfarin sodium tab 3 mg (Coumadin) $0 (1) 90warfarin sodium tab 4 mg (Coumadin) $0 (1) 90warfarin sodium tab 5 mg (Coumadin) $0 (1) 90warfarin sodium tab 6 mg (Coumadin) $0 (1) 90warfarin sodium tab 7.5 mg (Coumadin) $0 (1) 90warfarin sodium tab 10 mg (Coumadin) $0 (1) 90XARELTO – rivaroxaban tab 10 mg $0 (2) QL (35 tablets/365

days), 90XARELTO – rivaroxaban tab 15 mg $0 (2) PA, QL (60 tablets/30

days), 90XARELTO – rivaroxaban tab 20 mg $0 (2) PA, QL (30 tablets/30

days), 90XARELTO STARTER PACK – rivaroxaban tab starter therapy

pack 15 mg & 20 mg$0 (2) PA, QL (51

tablets/30 days)XYNTHA – antihemophilic factor recombinant paf for inj kit 250

unit$0 (2) PA, SP

XYNTHA – antihemophilic factor recombinant paf for inj kit 500unit

$0 (2) PA, SP


$0 (2) PA, SP

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$0 (2) PA, SP

XYNTHA SOLOFUSE – antihemophilic factor recombinant paf forinj kit 250 unit

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml $0 (2) SPZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml $0 (2) SP

MEDICAMENTOS TÓPICOSOJOAntinfecciososBACITRACIN – bacitracin ophth oint 500 unit/gm $0 (2)bacitracin-polymyxin b ophth oint $0 (1)ciprofloxacin hcl ophth soln 0.3% (Ciloxan) $0 (1)erythromycin ophth oint 5 mg/gm $0 (1)GENTAK – gentamicin sulfate ophth oint 0.3% $0 (1)gentamicin sulfate ophth soln 0.3% $0 (1)levofloxacin ophth soln 0.5% $0 (1)NATACYN – natamycin ophth susp 5% $0 (2)neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin $0 (1)neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/

ml (Neosporin)$0 (1)

ofloxacin ophth soln 0.3% (Ocuflox) $0 (1)polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

(Polytrim)$0 (1)

sulfacetamide sodium ophth soln 10% (Bleph-10) $0 (1)tobramycin ophth soln 0.3% (Tobrex) $0 (1)trifluridine ophth soln 1% (Viroptic) $0 (1)

Esteroides y productos de combinaciónbacitracin-polymyxin-neomycin-hc ophth oint 1% $0 (1)DEXAMETHASONE SODIUM PHOS – dexamethasone sodium

phosphate ophth soln 0.1%$0 (2)

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fluorometholone ophth susp 0.1% (Fml liquifilm) $0 (1)neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) $0 (1)neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) $0 (1)prednisolone acetate ophth susp 1% (Pred forte) $0 (1)PREDNISOLONE SODIUM PHOSP – prednisolone sodium

phosphate ophth soln 1%$0 (2)

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% $0 (1)tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) $0 (1)

GlaucomaALPHAGAN P – brimonidine tartrate ophth soln 0.1% $0 (2) 90apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) $0 (1)betaxolol hcl ophth soln 0.5% $0 (1) 90brimonidine tartrate ophth soln 0.2% $0 (1) 90carteolol hcl ophth soln 1% $0 (1) 90dorzolamide hcl ophth soln 2% (Trusopt) $0 (1) 90dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

(Cosopt)$0 (1) 90

latanoprost ophth soln 0.005% (Xalatan) $0 (1) QL (1 bottle/30 days), 90levobunolol hcl ophth soln 0.5% (Betagan) $0 (1) 90pilocarpine hcl ophth soln 1% (Isopto carpine) $0 (1) 90pilocarpine hcl ophth soln 2% (Isopto carpine) $0 (1) 90pilocarpine hcl ophth soln 4% (Isopto carpine) $0 (1) 90timolol maleate ophth soln 0.25% (Timoptic) $0 (1) 90timolol maleate ophth soln 0.5% (Timoptic) $0 (1) 90

Otros productos ocularesartificial tear ophth solution $0 (3)ATROPINE SULFATE – atropine sulfate ophth soln 1% $0 (2) 90ATROPINE SULFATE – atropine sulfate ophth oint 1% $0 (2) 90azelastine hcl ophth soln 0.05% $0 (1)cromolyn sodium ophth soln 4% $0 (1)cyclopentolate hcl ophth soln 0.5% (Cyclogyl) $0 (1) 90cyclopentolate hcl ophth soln 1% (Cyclogyl) $0 (1) 90cyclopentolate hcl ophth soln 2% (Cyclogyl) $0 (1) 90diclofenac sodium ophth soln 0.1% $0 (1)ketorolac tromethamine ophth soln 0.4% (Acular ls) $0 (1)

2017



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ketorolac tromethamine ophth soln 0.5% (Acular) $0 (1)ketotifen fumarate ophth soln 0.025% (base equiv) $0 (3)proparacaine hcl ophth soln 0.5% $0 (1)tetracaine hcl ophth soln 0.5% $0 (1)tetrahydroz-dextran-peg-povidone ophth soln 0.05-0.1-1-1% $0 (3)

OÍDOacetic acid otic soln 2% $0 (1)carbamide peroxide 6.5% otic soln $0 (3)hydrocortisone w/ acetic acid otic soln 1-2% $0 (1)neomycin-polymyxin-hc otic soln 1% $0 (1)neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% $0 (1)ofloxacin otic soln 0.3% (Floxin otic) $0 (1)

BOCA Y GARGANTA (local)chlorhexidine gluconate soln 0.12% (Peridex) $0 (1)clotrimazole troche 10 mg $0 (1)lidocaine hcl viscous soln 2% $0 (1)nystatin susp 100000 unit/ml $0 (1)pilocarpine hcl tab 5 mg (Salagen) $0 (1) 90pilocarpine hcl tab 7.5 mg (Salagen) $0 (1) 90sodium fluoride cream 1.1% (Prevident 5000 plus) $0 (1) 90sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) $0 (1) 90sodium fluoride rinse 0.2% $0 (1) 90triamcinolone acetonide dental paste 0.1% $0 (1)

AGENTES ANORRECTALEShydrocortisone enema 100 mg/60ml (Cortenema) $0 (1)hydrocortisone rectal cream 1% (Proctocort) $0 (1)hydrocortisone rectal cream 2.5% (Anusol-hc) $0 (1)

CONDICIONES/PRODUCTOS DE LA PIELAcnébenzoyl peroxide liq 10% $0 (1) ALbenzoyl peroxide lotion 6% $0 (1) ALclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)$0 (1) AL

clindamycin phosphate gel 1% (Cleocin-t) $0 (1) ALclindamycin phosphate lotion 1% (Cleocin-t) $0 (1) AL

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clindamycin phosphate soln 1% (Cleocin-t) $0 (1) ALclindamycin phosphate swab 1% (Cleocin-t) $0 (1) ALDIFFERIN – adapalene gel 0.1% $0 (3) ALerythromycin gel 2% (Erygel) $0 (1) ALerythromycin pads 2% $0 (1) ALerythromycin soln 2% $0 (1) ALisotretinoin cap 10 mg $0 (1) ALisotretinoin cap 20 mg $0 (1) ALmetronidazole cream 0.75% (Metrocream) $0 (1) ALmetronidazole gel 0.75% $0 (1) ALmetronidazole gel 1% (Metrogel) $0 (1) ALsulfacetamide sodium w/ sulfur emulsion 10-1% $0 (1) ALsulfacetamide sodium w/ sulfur emulsion 10-5% $0 (1) ALtazarotene cream 0.1% (Tazorac) $0 (1) ALTAZORAC – tazarotene gel 0.05% $0 (2) ALTAZORAC – tazarotene gel 0.1% $0 (2) ALtretinoin cream 0.025% (Retin-a) $0 (1) ALtretinoin cream 0.05% (Retin-a) $0 (1) ALtretinoin cream 0.1% (Retin-a) $0 (1) ALtretinoin gel 0.01% (Retin-a) $0 (1) ALtretinoin gel 0.025% (Retin-a) $0 (1) AL

Antinfecciososbacitracin oint 500 unit/gm $0 (3)bacitracin zinc oint 500 unit/gm $0 (3)bacitracin-polymyxin b oint $0 (3)ciclopirox olamine cream 0.77% (base equiv) (Loprox) $0 (1)clotrimazole cream 1% $0 (1)clotrimazole soln 1% $0 (1)clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) $0 (1)diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days)econazole nitrate cream 1% $0 (1)GENTAMICIN SULFATE – gentamicin sulfate oint 0.1% $0 (2)gentamicin sulfate cream 0.1% $0 (1)ketoconazole cream 2% $0 (1)ketoconazole shampoo 2% (Nizoral) $0 (1)

2017



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miconazole nitrate aerosol pow 2% $0 (3)miconazole nitrate cream 2% $0 (3)mupirocin oint 2% $0 (1)neomycin-bacitracin-polymyxin oint $0 (3)nystatin cream 100000 unit/gm $0 (1)nystatin oint 100000 unit/gm $0 (1)nystatin topical powder 100000 unit/gm $0 (1)silver sulfadiazine cream 1% (Silvadene) $0 (1)tolnaftate aerosol 1% $0 (3)

Corticosteroidesalclometasone dipropionate cream 0.05% $0 (1)alclometasone dipropionate oint 0.05% $0 (1)betamethasone dipropionate augmented cream 0.05%

(Diprolene af)$0 (1)

betamethasone dipropionate augmented gel 0.05% $0 (1)betamethasone dipropionate augmented lotion 0.05% (Diprolene) $0 (1)betamethasone dipropionate augmented oint 0.05% (Diprolene) $0 (1)betamethasone dipropionate cream 0.05% $0 (1)betamethasone dipropionate lotion 0.05% $0 (1)betamethasone dipropionate oint 0.05% $0 (1)betamethasone valerate cream 0.1% (base equivalent) $0 (1)betamethasone valerate lotion 0.1% (base equivalent) $0 (1)betamethasone valerate oint 0.1% (base equivalent) $0 (1)clobetasol propionate cream 0.05% (Temovate) $0 (1)clobetasol propionate emollient base cream 0.05% $0 (1)clobetasol propionate gel 0.05% (Temovate) $0 (1)clobetasol propionate oint 0.05% (Temovate) $0 (1)clobetasol propionate soln 0.05% (Temovate) $0 (1)desoximetasone cream 0.25% (Topicort) $0 (1)fluocinolone acetonide cream 0.01% $0 (1)fluocinolone acetonide cream 0.025% (Synalar) $0 (1)fluocinolone acetonide oint 0.025% (Synalar) $0 (1)fluocinolone acetonide soln 0.01% (Synalar) $0 (1)fluocinonide cream 0.05% $0 (1)fluocinonide emulsified base cream 0.05% $0 (1)

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fluocinonide gel 0.05% $0 (1)fluocinonide oint 0.05% $0 (1)fluocinonide soln 0.05% $0 (1)fluticasone propionate cream 0.05% (Cutivate) $0 (1)fluticasone propionate oint 0.005% $0 (1)halobetasol propionate cream 0.05% (Ultravate) $0 (1)halobetasol propionate oint 0.05% (Ultravate) $0 (1)hydrocortisone butyrate oint 0.1% (Locoid) $0 (1)hydrocortisone cream 0.5% $0 (3)hydrocortisone cream 1% $0 (1)hydrocortisone cream 2.5% $0 (1)hydrocortisone lotion 2.5% $0 (1)hydrocortisone oint 0.5% $0 (3)hydrocortisone oint 1% $0 (1)hydrocortisone oint 2.5% $0 (1)hydrocortisone valerate cream 0.2% $0 (1)hydrocortisone valerate oint 0.2% (Westcort) $0 (1)mometasone furoate cream 0.1% (Elocon) $0 (1)mometasone furoate oint 0.1% (Elocon) $0 (1)mometasone furoate solution 0.1% (lotion) $0 (1)prednicarbate cream 0.1% (Dermatop) $0 (1)prednicarbate oint 0.1% (Dermatop) $0 (1)triamcinolone acetonide cream 0.025% $0 (1)triamcinolone acetonide cream 0.1% $0 (1)triamcinolone acetonide cream 0.5% $0 (1)triamcinolone acetonide lotion 0.025% $0 (1)triamcinolone acetonide lotion 0.1% $0 (1)triamcinolone acetonide oint 0.025% $0 (1)triamcinolone acetonide oint 0.1% $0 (1)

Otros productos para la pielcalcipotriene cream 0.005% (Dovonex) $0 (1)calcipotriene oint 0.005% $0 (1)calcipotriene soln 0.005% (50 mcg/ml) $0 (1)ELIDEL – pimecrolimus cream 1% $0 (2) STfluorouracil cream 5% (Efudex) $0 (1) QL (240 grams/180 days)

2017



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imiquimod cream 5% (Aldara) $0 (1) QL (48 packs/180 days)lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) $0 (3)lidocaine hcl cream 3% $0 (1) QL (120 grams/30 days)lidocaine hcl gel 2% $0 (1) QL (120 grams/30 days)lidocaine hcl soln 4% (Xylocaine) $0 (1) QL (120 grams/30 days)lidocaine oint 5% $0 (1) PA, QL (120

grams/30 days)lidocaine patch 5% (Lidoderm) $0 (1) PA, QL (120

patches/30 days)lidocaine-prilocaine cream kit 2.5-2.5% $0 (1)lidocaine-prilocaine cream 2.5-2.5% $0 (1)methoxsalen rapid cap 10 mg (Oxsoralen ultra) $0 (1)permethrin cream 5% (Elimite) $0 (1)permethrin creme rinse 1% $0 (3)podofilox soln 0.5% $0 (1)QC CALAMINE – calamine lotion $0 (3)selenium sulfide lotion 2.5% $0 (1)tacrolimus oint 0.03% (Protopic) $0 (1) STtacrolimus oint 0.1% (Protopic) $0 (1) STVALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) $0 (2) SPvitamins a & d oint $0 (3)zinc oxide oint 20% $0 (3)zinc oxide oint 10% $0 (3)ZYCLARA – imiquimod cream 3.75% $0 (2) PA, QL (56

packets/180 days)ZYCLARA PUMP – imiquimod cream 2.5% $0 (2) PA, QL (15

grams/180 days)ZYCLARA PUMP – imiquimod cream 3.75% $0 (2) PA, QL (15

grams/180 days)

CATEGORÍAS MISCELÁNEAS (incluyen los suministros y los dispositivos)SUMINISTROS PARA LA DIABETESGLUCOSE METERS - BAYER ASCENCIA $0 (3)TEST STRIPS - BAYER ASCENCIA $0 (3) QL (204 strips/30

days), ST, 90ALCOHOL PREP PADS, SWABS - various $0 (3) QL (200 swabs/30

days), 90

2017



84




INSULIN PEN NEEDLES - TECHLITE and TRUEPLUS $0 (3) QL (200 insulin penneedles/30 days), 90

INSULIN SYRINGES - TRUEPLUS $0 (3) QL (200 syringes/30days), 90

LANCETS - BAYER ASCENCIA $0 (3) QL (200 units/30days), 90

INHALADOR RESPIRATORIO-DISPOSITIVOS DE ASISTENCIARESPIRATORY THERAPY SUPPLIES - various $0 (3)SPACER/AEROSOL - HOLDING CHAMBERS - various $0 (2)

MEDICAMENTOS MISCELÁNEOSazathioprine tab 50 mg (Imuran) $0 (1) 90CHEMET – succimer cap 100 mg $0 (2)cyclosporine cap 25 mg (Sandimmune) $0 (1) 90cyclosporine cap 100 mg (Sandimmune) $0 (1) 90CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg $0 (2) 90cyclosporine modified cap 25 mg (Neoral) $0 (1) 90cyclosporine modified cap 50 mg (Cyclosporine modifie) $0 (1) 90cyclosporine modified cap 100 mg (Neoral) $0 (1) 90cyclosporine modified oral soln 100 mg/ml (Neoral) $0 (1) 90DEPEN TITRATABS – penicillamine tab 250 mg $0 (2) SPirrigation solution, physiological $0 (1)lactated ringer's for irrigation $0 (1)mycophenolate mofetil cap 250 mg (Cellcept) $0 (1) 90mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) $0 (1) 90mycophenolate mofetil tab 500 mg (Cellcept) $0 (1) 90mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

(Myfortic)$0 (1) 90

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)(Myfortic)

$0 (1) 90

NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml $0 (2)NALOXONE HCL – naloxone hcl soln prefilled syringe 2 mg/2ml $0 (2)NARCAN – naloxone hcl nasal spray 4 mg/0.1ml $0 (2)REVLIMID – lenalidomide caps 2.5 mg $0 (2) PA, QL (30 capsules/30

days), SPREVLIMID – lenalidomide cap 5 mg $0 (2) PA, QL (30 capsules/30

days), SP

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85




REVLIMID – lenalidomide cap 10 mg $0 (2) PA, QL (30 capsules/30days), SP




ringer's solution for irrigation $0 (1)sirolimus tab 0.5 mg (Rapamune) $0 (1) 90sirolimus tab 1 mg (Rapamune) $0 (1) 90sirolimus tab 2 mg (Rapamune) $0 (1) 90sodium polystyrene sulfonate oral susp 15 gm/60ml $0 (1)sodium polystyrene sulfonate powder $0 (1)sodium polystyrene sulfonate rectal susp 30 gm/120ml $0 (1)tacrolimus cap 0.5 mg (Prograf) $0 (1) 90tacrolimus cap 1 mg (Prograf) $0 (1) 90tacrolimus cap 5 mg (Prograf) $0 (1) 90THALOMID – thalidomide cap 50 mg $0 (2) PA, QL (30 capsules/30

days), SPTHALOMID – thalidomide cap 100 mg $0 (2) PA, QL (30 capsules/30

days), SPTHALOMID – thalidomide cap 150 mg $0 (2) PA, QL (60 capsules/30

days), SPwater for irrigation, sterile irrigation soln $0 (1)ZORTRESS – everolimus tab 0.25 mg $0 (2) 90ZORTRESS – everolimus tab 0.5 mg $0 (2) 90ZORTRESS – everolimus tab 0.75 mg $0 (2) 90

2017

86

INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg (Epzicom)..... 5abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)......................................................................... 5

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)........ 5abacavir sulfate tab 300 mg (base equiv) (Ziagen).............5ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................48

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................48

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................48

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................48

acamprosate calcium tab delayed release 333 mg...........56acarbose tab 25 mg (Precose)..........................................17acarbose tab 50 mg (Precose)..........................................17acarbose tab 100 mg (Precose)........................................17acebutolol hcl cap 200 mg.................................................25acebutolol hcl cap 400 mg.................................................25ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg................. 58

acetaminophen cap 500 mg.............................................. 57acetaminophen chew tab 80 mg....................................... 57acetaminophen chew tab 160 mg..................................... 57acetaminophen disintegrating tab 80 mg.......................... 57acetaminophen liquid 160 mg/5ml.....................................57acetaminophen soln 160 mg/5ml.......................................57acetaminophen suppos 120 mg........................................ 57acetaminophen susp 80 mg/0.8ml.....................................57acetaminophen susp 160 mg/5ml......................................57acetaminophen tab 325 mg............................................... 57acetaminophen tab 500 mg............................................... 57acetaminophen w/ codeine soln 120-12 mg/5ml...............57acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................58

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 58

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 58

acetazolamide cap er 12hr 500 mg (Diamox)................... 31acetazolamide tab 125 mg................................................ 31acetazolamide tab 250 mg................................................ 31acetic acid otic soln 2%..................................................... 79acetylcysteine inhal soln 10%............................................35acetylcysteine inhal soln 20%............................................35ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................10

acyclovir cap 200 mg (Zovirax)........................................... 5acyclovir susp 200 mg/5ml (Zovirax)...................................5acyclovir tab 400 mg (Zovirax)............................................ 5acyclovir tab 800 mg (Zovirax)............................................ 5ADCIRCA – tadalafil tab 20 mg (pah)............................... 33

ADVATE – antihemophilic factor rahf-pfm for inj 250unit.....................................................................................71







ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 250 unit.................................................................. 71



ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 1000 unit................................................................ 71




AEROCHAMBER MINI AEROSOL....................................84AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................10

AFINITOR DISPERZ – everolimus tab for oral susp 3mg......................................................................................10

AFINITOR DISPERZ – everolimus tab for oral susp 5mg......................................................................................10

AFINITOR – everolimus tab 2.5 mg.................................. 10AFINITOR – everolimus tab 5 mg..................................... 10AFINITOR – everolimus tab 7.5 mg.................................. 10AFINITOR – everolimus tab 10 mg................................... 10AFLURIA 2017-2018 – influenza virus vaccine split imsusp..................................................................................... 9

AFLURIA PF 2017-2018 – influenza virus vaccine split pfsusp pref syringe 0.5 ml.................................................... 9

AFLURIA QUADRIVALENT 2017 – influenza virusvaccine split quadrivalent im inj.........................................9

AFLURIA QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

ALBENZA – albendazole tab 200 mg................................. 8albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............36albuterol sulfate soln nebu 0.5% (5 mg/ml).......................36albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......36albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......36albuterol sulfate syrup 2 mg/5ml....................................... 36alclometasone dipropionate cream 0.05%........................ 81alclometasone dipropionate oint 0.05%............................ 81ALCOHOL PREP PADS, SWABS - various...................... 83

2017

87

ALENDRONATE SODIUM – alendronate sodium tab 40mg......................................................................................22

alendronate sodium tab 5 mg............................................22alendronate sodium tab 10 mg..........................................22alendronate sodium tab 35 mg..........................................22alendronate sodium tab 70 mg (Fosamax)....................... 22alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................43ALKERAN – melphalan tab 2 mg......................................10allopurinol tab 100 mg (Zyloprim)......................................64allopurinol tab 300 mg (Zyloprim)......................................64ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 18

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 18

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 18



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 18



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................17

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................18

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................18

ALPHAGAN P – brimonidine tartrate ophth soln 0.1%..... 78ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 250 unit.............................................72

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 500 unit.............................................72

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 1000 unit...........................................72



ALPHANINE SD – coagulation factor ix for inj 500unit.....................................................................................72



alprazolam tab 0.25 mg (Xanax)....................................... 44alprazolam tab 0.5 mg (Xanax)......................................... 44alprazolam tab 1 mg (Xanax)............................................ 44alprazolam tab 2 mg (Xanax)............................................ 44alum & mag hydroxide-simethicone susp 200-200-20mg/5ml...............................................................................39

alum & mag hydroxide-simethicone susp 400-400-40mg/5ml...............................................................................39

amantadine hcl cap 100 mg.............................................. 66amantadine hcl syrup 50 mg/5ml...................................... 66amiloride & hydrochlorothiazide tab 5-50 mg....................31amiloride hcl tab 5 mg....................................................... 31amiodarone hcl tab 200 mg...............................................32amitriptyline hcl tab 10 mg.................................................45amitriptyline hcl tab 50 mg.................................................45amitriptyline hcl tab 75 mg.................................................45amitriptyline hcl tab 100 mg...............................................45amitriptyline hcl tab 150 mg...............................................45amitriptyline hcl tab 25 mg (Elavil).................................... 45amlodipine besylate-benazepril hcl cap 2.5-10 mg...........27amlodipine besylate-benazepril hcl cap 5-40 mg..............27amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 27

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 27



amlodipine besylate tab 2.5 mg (Norvasc)........................27amlodipine besylate tab 5 mg (Norvasc)...........................27amlodipine besylate tab 10 mg (Norvasc).........................27amlodipine besylate-valsartan tab 5-160 mg(Exforge)............................................................................27

amlodipine besylate-valsartan tab 5-320 mg(Exforge)............................................................................27



amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 1amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................1

amoxicillin & 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).........................................................................1

amoxicillin & k clavulanate tab 875-125 mg(Augmentin).........................................................................1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................1

amoxicillin (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...................................... 1

2017

88

amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 53






amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................53

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................53


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................53




AMPICILLIN – ampicillin cap 500 mg..................................1AMPYRA – dalfampridine tab er 12hr 10 mg....................55anagrelide hcl cap 1 mg.................................................... 72anagrelide hcl cap 0.5 mg (Agrylin)...................................72anastrozole tab 1 mg (Arimidex)....................................... 10apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................... 78

APTIVUS – tipranavir cap 250 mg...................................... 5APTIVUS – tipranavir oral soln 100 mg/ml......................... 5ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml...............................................................................72

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml...............................................................................72

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml...............................................................................72

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml....................................................................... 72



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml......................................... 72

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.......................................72







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml............................................ 72

aripiprazole oral solution 1 mg/ml......................................48aripiprazole tab 2 mg (Abilify)............................................48aripiprazole tab 5 mg (Abilify)............................................48aripiprazole tab 10 mg (Abilify)..........................................48aripiprazole tab 15 mg (Abilify)..........................................48aripiprazole tab 20 mg (Abilify)..........................................48aripiprazole tab 30 mg (Abilify)..........................................48ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................48

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................48

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................49

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................49

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................36

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................36

artificial tear ophth solution................................................78ascorbic acid tab 500 mg.................................................. 68aspirin chew tab 81 mg..................................................... 57aspirin-dipyridamole cap er 12hr 25-200 mg(Aggrenox)........................................................................ 73

aspirin tab delayed release 81 mg.................................... 57aspirin tab delayed release 325 mg.................................. 57aspirin tab 325 mg............................................................. 57atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......25atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 25

atenolol tab 25 mg (Tenormin).......................................... 25atenolol tab 50 mg (Tenormin).......................................... 26atenolol tab 100 mg (Tenormin)........................................ 26atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 29

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 29



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)........ 8atovaquone-proguanil hcl tab 250-100 mg (Malarone)....... 8atovaquone susp 750 mg/5ml (Mepron)............................. 8ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg................................................................. 5

2017

89

ATROPINE SULFATE – atropine sulfate ophth oint1%..................................................................................... 78

ATROPINE SULFATE – atropine sulfate ophth soln1%..................................................................................... 78

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 36

AUBAGIO – teriflunomide tab 7 mg.................................. 56AUBAGIO – teriflunomide tab 14 mg................................ 56AVONEX – interferon beta-1a for im inj kit 30mcg(33mcg(6.6 mu)/vial).........................................................56

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................56

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................56

azathioprine tab 50 mg (Imuran)....................................... 84azelastine hcl nasal spray 0.1% (137 mcg/spray).............35azelastine hcl ophth soln 0.05%........................................78azithromycin for susp 100 mg/5ml (Zithromax)...................2azithromycin for susp 200 mg/5ml (Zithromax)...................2azithromycin tab 250 mg (Zithromax)..................................2azithromycin tab 500 mg (Zithromax)..................................2azithromycin tab 600 mg (Zithromax)..................................2

BBACITRACIN – bacitracin ophth oint 500 unit/gm............ 77bacitracin oint 500 unit/gm.................................................80bacitracin-polymyxin b oint................................................ 80bacitracin-polymyxin b ophth oint...................................... 77bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 77bacitracin zinc oint 500 unit/gm.........................................80baclofen tab 10 mg............................................................ 67baclofen tab 20 mg............................................................ 67balsalazide disodium cap 750 mg (Colazal)......................42BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 21

BAYER CONTOUR BLOOD GLUCO................................ 83BAYER MICROLET LANCETS..........................................84b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 69b-complex w/ c & folic acid tab..........................................69b-complex w/ c & folic acid tab 5 mg................................ 69b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......69BEBULIN – factor ix complex for inj 200-1200 unit...........73benazepril & hydrochlorothiazide tab 5-6.25 mg...............23benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................23

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................23

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................23

benazepril hcl tab 5 mg..................................................... 23benazepril hcl tab 10 mg................................................... 23benazepril hcl tab 20 mg (Lotensin)..................................23benazepril hcl tab 40 mg (Lotensin)..................................23BENEFIX – coagulation factor ix (recombinant) for inj kit250 unit............................................................................. 73

BENEFIX – coagulation factor ix (recombinant) for inj kit500 unit............................................................................. 73

BENEFIX – coagulation factor ix (recombinant) for inj kit1000 unit........................................................................... 73



benzoyl peroxide liq 10%...................................................79benzoyl peroxide lotion 6%................................................79benztropine mesylate tab 0.5 mg...................................... 66benztropine mesylate tab 1 mg......................................... 66benztropine mesylate tab 2 mg......................................... 66betamethasone dipropionate augmented cream 0.05%(Diprolene af)....................................................................81

betamethasone dipropionate augmented gel 0.05%.........81betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 81

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 81

betamethasone dipropionate cream 0.05%.......................81betamethasone dipropionate lotion 0.05%........................81betamethasone dipropionate oint 0.05%...........................81betamethasone valerate cream 0.1% (baseequivalent).........................................................................81

betamethasone valerate lotion 0.1% (baseequivalent).........................................................................81

betamethasone valerate oint 0.1% (base equivalent).......81betaxolol hcl ophth soln 0.5%............................................78betaxolol hcl tab 10 mg..................................................... 26betaxolol hcl tab 20 mg..................................................... 26bethanechol chloride tab 5 mg (Urecholine)..................... 43bethanechol chloride tab 10 mg (Urecholine)................... 43bethanechol chloride tab 25 mg (Urecholine)................... 43bethanechol chloride tab 50 mg (Urecholine)................... 43bexarotene cap 75 mg (Targretin)..................................... 10bicalutamide tab 50 mg (Casodex)....................................10BILTRICIDE – praziquantel tab 600 mg.............................. 8bisacodyl tab delayed release 5 mg..................................38bismuth subsalicylate susp 262 mg/15ml..........................39bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 26

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......26bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 26

bisoprolol fumarate tab 5 mg.............................................26bisoprolol fumarate tab 10 mg...........................................26BOTOX – onabotulinumtoxina for inj 100 unit...................67BRILINTA – ticagrelor tab 60 mg...................................... 73BRILINTA – ticagrelor tab 90 mg...................................... 73brimonidine tartrate ophth soln 0.2%.................................78BROHIST D – brompheniramine & phenylephrine tab 4-10mg......................................................................................36

bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................66

brompheniramine & phenylephrine elixir 1-2.5 mg/5ml.....36

2017

90

budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................14

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 36budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 37budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 37bumetanide tab 0.5 mg (Bumex).......................................31bumetanide tab 1 mg (Bumex)..........................................31bumetanide tab 2 mg (Bumex)..........................................31BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3mg (base equiv)................................................................58

BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7mg (base equiv)................................................................58

BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1mg (base equiv)................................................................58

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................58

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................58

buprenorphine hcl sl tab 2 mg (base equiv)......................58buprenorphine hcl sl tab 8 mg (base equiv)......................58bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 56

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............45bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............45bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............45bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 45bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 45bupropion hcl tab 75 mg....................................................45bupropion hcl tab 100 mg..................................................45buspirone hcl tab 5 mg...................................................... 44buspirone hcl tab 10 mg....................................................44buspirone hcl tab 15 mg....................................................44buspirone hcl tab 30 mg....................................................44butalbital-acetaminophen-caffeine cap 50-325-40 mg......57butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 57

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 57

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................58

butalbital-acetaminophen tab 50-325 mg..........................57butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....57butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................58

Ccabergoline tab 0.5 mg...................................................... 22caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................54

calcipotriene cream 0.005% (Dovonex)............................ 82calcipotriene oint 0.005%...................................................82calcipotriene soln 0.005% (50 mcg/ml)............................. 82calcitonin (salmon) nasal soln 200 unit/act....................... 22calcitriol cap 0.25 mcg (Rocaltrol)..................................... 22calcitriol cap 0.5 mcg (Rocaltrol)....................................... 22calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 22

calcium acetate (phosphate binder) cap 667 mg (169 mgca)......................................................................................42

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................ 42

calcium carbonate (antacid) chew tab 500 mg..................39calcium carbonate (antacid) chew tab 750 mg..................39calcium carbonate (antacid) chew tab 1000 mg................40calcium carbonate-cholecalciferol tab 500 mg-200unit.....................................................................................69

calcium carbonate-cholecalciferol tab 600 mg-400unit.....................................................................................69

calcium carbonate tab 1250 mg (500 mg elementalca)......................................................................................69

calcium carbonate-vitamin d tab 250 mg-125 unit............ 69calcium carbonate-vitamin d tab 500 mg-200 unit............ 69calcium carbonate-vitamin d tab 600 mg-400 unit............ 70calcium citrate tab 950 mg (200 mg elemental ca)........... 70CANASA – mesalamine suppos 1000 mg........................ 42capecitabine tab 150 mg (Xeloda).....................................10capecitabine tab 500 mg (Xeloda).....................................10CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg................................... 23

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg................................... 23



captopril tab 12.5 mg......................................................... 23captopril tab 25 mg............................................................ 23captopril tab 50 mg............................................................ 23captopril tab 100 mg.......................................................... 23carbamazepine chew tab 100 mg..................................... 64carbamazepine susp 100 mg/5ml (Tegretol).....................64carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............64carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............64carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............64carbamazepine tab 200 mg (Tegretol).............................. 64carbamide peroxide 6.5% otic soln................................... 79carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 66carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 66carbidopa & levodopa tab 10-100 mg (Sinemet)...............66carbidopa & levodopa tab 25-100 mg (Sinemet)...............66carbidopa & levodopa tab 25-250 mg (Sinemet)...............66carbidopa tab 25 mg (Lodosyn).........................................66carbinoxamine maleate soln 4 mg/5ml..............................35carbinoxamine maleate tab 4 mg...................................... 35carteolol hcl ophth soln 1%............................................... 78carvedilol tab 3.125 mg (Coreg)........................................26carvedilol tab 6.25 mg (Coreg)..........................................26carvedilol tab 12.5 mg (Coreg)..........................................26carvedilol tab 25 mg (Coreg).............................................26cefaclor cap 250 mg............................................................ 1cefaclor cap 500 mg............................................................ 1cefadroxil cap 500 mg..........................................................1cefadroxil for susp 250 mg/5ml........................................... 1

2017

91

cefadroxil for susp 500 mg/5ml........................................... 1cefadroxil tab 1 gm.............................................................. 1cefdinir cap 300 mg............................................................. 2cefdinir for susp 125 mg/5ml............................................... 2cefdinir for susp 250 mg/5ml............................................... 2cefprozil for susp 125 mg/5ml............................................. 2cefprozil for susp 250 mg/5ml............................................. 2cefprozil tab 250 mg............................................................ 2cefprozil tab 500 mg............................................................ 2ceftriaxone sodium for inj 1 gm........................................... 2ceftriaxone sodium for inj 2 gm........................................... 2ceftriaxone sodium for inj 250 mg....................................... 2ceftriaxone sodium for inj 500 mg....................................... 2cefuroxime axetil tab 250 mg.............................................. 2cefuroxime axetil tab 500 mg.............................................. 2celecoxib cap 50 mg (Celebrex)........................................61celecoxib cap 100 mg (Celebrex)......................................61celecoxib cap 200 mg (Celebrex)......................................61celecoxib cap 400 mg (Celebrex)......................................61cephalexin cap 250 mg (Keflex)..........................................2cephalexin cap 500 mg (Keflex)..........................................2cephalexin for susp 125 mg/5ml..........................................2cephalexin for susp 250 mg/5ml..........................................2cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................35cetirizine hcl tab 5 mg........................................................35cetirizine hcl tab 10 mg......................................................35CHANTIX CONTINUING MONTH – varenicline tartratetab 1 mg (base equiv)......................................................56

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 56

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................56

CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 56CHEMET – succimer cap 100 mg.....................................84chlordiazepoxide hcl cap 5 mg..........................................44chlordiazepoxide hcl cap 10 mg........................................44chlordiazepoxide hcl cap 25 mg........................................44chlorhexidine gluconate soln 0.12% (Peridex).................. 79CHLOROQUINE PHOSPHATE – chloroquine phosphatetab 250 mg..........................................................................8

chloroquine phosphate tab 500 mg.....................................8CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 31chlorothiazide tab 500 mg................................................. 31chlorpheniramine maleate tab 4 mg..................................35chlorthalidone tab 25 mg................................................... 31chlorthalidone tab 50 mg................................................... 31chlorzoxazone tab 500 mg (Parafon forte dsc)................. 67cholecalciferol cap 1000 unit............................................. 68cholecalciferol cap 2000 unit............................................. 68cholecalciferol cap 5000 unit............................................. 68cholecalciferol cap 10000 unit........................................... 68cholecalciferol cap 50000 unit........................................... 68cholecalciferol oral liquid 400 unit/ml.................................68cholecalciferol tab 400 unit................................................ 68cholecalciferol tab 1000 unit.............................................. 68cholecalciferol tab 2000 unit.............................................. 68

cholecalciferol tab 50000 unit............................................68cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................29

cholestyramine light powder packets 4 gm....................... 29cholestyramine powder 4 gm/dose (Questran)................. 29cholestyramine powder packets 4 gm (Questran).............29choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................29

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)(Trilipix)..............................................................................29

ciclopirox olamine cream 0.77% (base equiv)(Loprox).............................................................................80

cilostazol tab 50 mg...........................................................73cilostazol tab 100 mg.........................................................73cimetidine hcl soln 300 mg/5ml......................................... 40cimetidine tab 200 mg........................................................40cimetidine tab 300 mg........................................................40cimetidine tab 400 mg........................................................40cimetidine tab 800 mg........................................................40ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)(Cipro)..................................................................................3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)...............................................................3

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...................... 77ciprofloxacin hcl tab 750 mg (base equiv)...........................3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............3ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............3citalopram hydrobromide oral soln 10 mg/5ml.................. 45citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................45

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................45

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................46

clarithromycin tab 250 mg................................................... 2clarithromycin tab 500 mg (Biaxin)......................................2clemastine fumarate tab 1.34 mg (1 mg base equiv)........35clindamycin hcl cap 75 mg (Cleocin)...................................8clindamycin hcl cap 150 mg (Cleocin).................................8clindamycin hcl cap 300 mg (Cleocin).................................8clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr).......................................................... 8

clindamycin phosphate gel 1% (Cleocin-t)........................ 79clindamycin phosphate lotion 1% (Cleocin-t).................... 79clindamycin phosphate soln 1% (Cleocin-t)...................... 80clindamycin phosphate swab 1% (Cleocin-t).................... 80clindamycin phosphate vaginal cream 2% (Cleocin).........43clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................... 79

clobetasol propionate cream 0.05% (Temovate)...............81clobetasol propionate emollient base cream 0.05%..........81clobetasol propionate gel 0.05% (Temovate)....................81clobetasol propionate oint 0.05% (Temovate)...................81clobetasol propionate soln 0.05% (Temovate).................. 81clonazepam orally disintegrating tab 0.125 mg.................64clonazepam orally disintegrating tab 0.25 mg...................64

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clonazepam orally disintegrating tab 0.5 mg.....................64clonazepam orally disintegrating tab 1 mg........................64clonazepam orally disintegrating tab 2 mg........................64clonazepam tab 0.5 mg (Klonopin)....................................64clonazepam tab 1 mg (Klonopin).......................................64clonazepam tab 2 mg (Klonopin).......................................64clonidine hcl tab 0.1 mg (Catapres).................................. 33clonidine hcl tab 0.2 mg (Catapres).................................. 33clonidine hcl tab 0.3 mg (Catapres).................................. 33clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 33

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 33

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 33

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........73clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......73clorazepate dipotassium tab 3.75 mg................................44clorazepate dipotassium tab 15 mg...................................44clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 44clotrimazole cream 1%.......................................................80clotrimazole soln 1%.......................................................... 80clotrimazole troche 10 mg................................................. 79clotrimazole vaginal cream 2%..........................................43clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................... 80

clozapine orally disintegrating tab 25 mg (Fazaclo)..........49clozapine orally disintegrating tab 100 mg (Fazaclo)........49clozapine tab 50 mg...........................................................49clozapine tab 200 mg.........................................................49clozapine tab 25 mg (Clozaril)...........................................49clozapine tab 100 mg (Clozaril).........................................49COAGADEX – coagulation factor x (human) for inj 250unit.....................................................................................73

COAGADEX – coagulation factor x (human) for inj 500unit.....................................................................................73

codeine sulfate tab 15 mg (Codeine sulfate).................... 58codeine sulfate tab 30 mg (Codeine sulfate).................... 58codeine sulfate tab 60 mg (Codeine sulfate).................... 58colchicine w/ probenecid tab 0.5-500 mg..........................64colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 29

colestipol hcl granules 5 gm (Colestid)............................. 29colestipol hcl tab 1 gm (Colestid)...................................... 29COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................15

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................15

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................37

CONDOMS......................................................................... 16CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................14

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................10

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 41

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 41

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 41

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 42

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 42

CRIXIVAN – indinavir sulfate cap 200 mg...........................5CRIXIVAN – indinavir sulfate cap 400 mg...........................5CROMOLYN SODIUM – cromolyn sodium soln nebu 20mg/2ml...............................................................................37

cromolyn sodium ophth soln 4%....................................... 78cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)..... 42cyanocobalamin inj 1000 mcg/ml...................................... 68cyanocobalamin tab er 1000 mcg..................................... 68cyanocobalamin tab 100 mcg............................................68cyanocobalamin tab 250 mcg............................................68cyanocobalamin tab 500 mcg............................................68cyanocobalamin tab 1000 mcg..........................................68cyclobenzaprine hcl tab 5 mg............................................67cyclobenzaprine hcl tab 10 mg..........................................67cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..................78cyclopentolate hcl ophth soln 1% (Cyclogyl).....................78cyclopentolate hcl ophth soln 2% (Cyclogyl).....................78CYCLOPHOSPHAMIDE – cyclophosphamide cap 25mg......................................................................................10

CYCLOPHOSPHAMIDE – cyclophosphamide cap 50mg......................................................................................10

cyclosporine cap 25 mg (Sandimmune)............................84cyclosporine cap 100 mg (Sandimmune)..........................84cyclosporine modified cap 50 mg (Cyclosporinemodifie)..............................................................................84

cyclosporine modified cap 25 mg (Neoral)........................84cyclosporine modified cap 100 mg (Neoral)......................84CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg................................................................................ 84

cyclosporine modified oral soln 100 mg/ml (Neoral)......... 84cyproheptadine hcl syrup 2 mg/5ml...................................35cyproheptadine hcl tab 4 mg............................................. 35CYTARABINE – cytarabine inj 20 mg/ml.......................... 10

Ddanazol cap 50 mg............................................................ 14danazol cap 100 mg.......................................................... 15danazol cap 200 mg.......................................................... 15dantrolene sodium cap 100 mg.........................................67dantrolene sodium cap 25 mg (Dantrium).........................67dantrolene sodium cap 50 mg (Dantrium).........................67dapsone tab 25 mg..............................................................8dapsone tab 100 mg............................................................8DARAPRIM – pyrimethamine tab 25 mg.............................8DECARA – cholecalciferol cap 25000 unit........................68demeclocycline hcl tab 150 mg........................................... 2

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DEPEN TITRATABS – penicillamine tab 250 mg..............84DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................... 5

desloratadine tab 5 mg (Clarinex)..................................... 35desmopressin acetate nasal soln 0.01% (refrigerated)(Ddavp)..............................................................................22

desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................22

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 22

desmopressin acetate tab 0.1 mg (Ddavp)....................... 22desmopressin acetate tab 0.2 mg (Ddavp)....................... 22desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette)........................................................... 16

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 16

desoximetasone cream 0.25% (Topicort)..........................81DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................14

dexamethasone elixir 0.5 mg/5ml......................................14DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................ 77

dexamethasone tab 0.5 mg............................................... 14dexamethasone tab 0.75 mg.............................................14dexamethasone tab 1.5 mg............................................... 14dexamethasone tab 4 mg.................................................. 14dexamethasone tab 6 mg.................................................. 14dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 54

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 54





dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 54dexmethylphenidate hcl tab 5 mg (Focalin)...................... 54dexmethylphenidate hcl tab 10 mg (Focalin).................... 54dextromethorphan-guaifenesin liquid 10-100 mg/5ml.......36diazepam conc 5 mg/ml.....................................................44DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 2.5 mg.................................................................. 64

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 10 mg................................................................... 64

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 20 mg................................................................... 64

diazepam tab 2 mg (Valium)..............................................44diazepam tab 5 mg (Valium)..............................................44diazepam tab 10 mg (Valium)............................................44diclofenac potassium tab 50 mg........................................61diclofenac sodium gel 1% (Voltaren)............................61,80diclofenac sodium ophth soln 0.1%...................................78

diclofenac sodium tab delayed release 50 mg..................61diclofenac sodium tab delayed release 75 mg..................61diclofenac sodium tab er 24hr 100 mg..............................61dicloxacillin sodium cap 250 mg..........................................1dicloxacillin sodium cap 500 mg..........................................1dicyclomine hcl cap 10 mg (Bentyl)...................................40dicyclomine hcl oral soln 10 mg/5ml................................. 40dicyclomine hcl tab 20 mg.................................................40didanosine delayed release capsule 125 mg (Videx ec).....5didanosine delayed release capsule 200 mg (Videx ec).....5didanosine delayed release capsule 250 mg (Videx ec).....5didanosine delayed release capsule 400 mg (Videx ec).....5DIFFERIN – adapalene gel 0.1%......................................80DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 33digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 33digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 33DILANTIN – phenytoin sodium extended cap 30 mg........64diltiazem hcl cap er 12hr 60 mg........................................27diltiazem hcl cap er 24hr 120 mg......................................27diltiazem hcl cap er 24hr 180 mg......................................27diltiazem hcl cap er 24hr 240 mg......................................27diltiazem hcl coated beads cap er 24hr 300 mg............... 27diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................27

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................27

diltiazem hcl coated beads cap er 24hr 240 mg (Cardizemcd)......................................................................................27

diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 27






diltiazem hcl tab 90 mg......................................................28diltiazem hcl tab 30 mg (Cardizem)...................................28diltiazem hcl tab 60 mg (Cardizem)...................................28diltiazem hcl tab 120 mg (Cardizem).................................28diphenhydramine hcl cap 25 mg....................................... 35diphenhydramine hcl cap 50 mg....................................... 35diphenhydramine hcl liquid 12.5 mg/5ml...........................35diphenhydramine hcl tab 25 mg........................................ 35diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml....... 36diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 39dipyridamole tab 25 mg..................................................... 73dipyridamole tab 50 mg..................................................... 73dipyridamole tab 75 mg..................................................... 73disopyramide phosphate cap 100 mg (Norpace).............. 32disopyramide phosphate cap 150 mg (Norpace).............. 32disulfiram tab 250 mg (Antabuse)..................................... 56

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disulfiram tab 500 mg (Antabuse)..................................... 56divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................64

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 65



divalproex sodium tab er 24 hr 250 mg (Depakote er)......65divalproex sodium tab er 24 hr 500 mg (Depakote er)......65docusate sodium cap 100 mg........................................... 38docusate sodium cap 250 mg........................................... 38docusate sodium liquid 150 mg/15ml................................38dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................32dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................32dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................32donepezil hydrochloride orally disintegrating tab 5 mg..... 56donepezil hydrochloride orally disintegrating tab 10mg......................................................................................56

donepezil hydrochloride tab 5 mg (Aricept).......................56donepezil hydrochloride tab 10 mg (Aricept).....................56dorzolamide hcl ophth soln 2% (Trusopt)..........................78dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)....................................................................... 78

doxazosin mesylate tab 1 mg (Cardura)........................... 33doxazosin mesylate tab 2 mg (Cardura)........................... 33doxazosin mesylate tab 4 mg (Cardura)........................... 33doxazosin mesylate tab 8 mg (Cardura)........................... 33doxepin hcl cap 10 mg...................................................... 46doxepin hcl cap 25 mg...................................................... 46doxepin hcl cap 50 mg...................................................... 46doxepin hcl cap 75 mg...................................................... 46doxepin hcl cap 100 mg.................................................... 46doxepin hcl cap 150 mg.................................................... 46doxepin hcl conc 10 mg/ml................................................46doxycycline hyclate cap 50 mg............................................2doxycycline hyclate cap 100 mg (Vibramycin).................... 2doxycycline hyclate tab 20 mg............................................ 2doxycycline hyclate tab 100 mg.......................................... 2doxycycline monohydrate cap 50 mg..................................2doxycycline monohydrate cap 100 mg (Monodox)..............2doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 2

doxycycline monohydrate tab 50 mg...................................2doxycycline monohydrate tab 75 mg...................................3doxycycline monohydrate tab 100 mg.................................3drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)..................................................................................... 16

duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................46



Eeconazole nitrate cream 1%.............................................. 80EDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 5ELIDEL – pimecrolimus cream 1%....................................82ELIQUIS – apixaban tab 2.5 mg....................................... 73ELIQUIS – apixaban tab 5 mg.......................................... 73ELLA – ulipristal acetate tab 30 mg.................................. 16EMTRIVA – emtricitabine caps 200 mg.............................. 5EMTRIVA – emtricitabine soln 10 mg/ml.............................5enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................23

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 23

enalapril maleate tab 2.5 mg (Vasotec).............................23enalapril maleate tab 5 mg (Vasotec)............................... 23enalapril maleate tab 10 mg (Vasotec)............................. 23enalapril maleate tab 20 mg (Vasotec)............................. 23ENBREL – etanercept for subcutaneous inj 25 mg...........61ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 61

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 61

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................61

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 73enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 73enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 73enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 74enoxaparin sodium inj 100 mg/ml (Lovenox).................... 74enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 74enoxaparin sodium inj 150 mg/ml (Lovenox).................... 74enoxaparin sodium inj 300 mg/3ml (Lovenox).................. 74entacapone tab 200 mg (Comtan).....................................66entecavir tab 0.5 mg (Baraclude)........................................ 4entecavir tab 1 mg (Baraclude)........................................... 4ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 33ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 33ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 33EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg.......... 4EPINEPHRINE – epinephrine solution auto-injector 0.15mg/0.3ml (1:2000)............................................................ 34

EPINEPHRINE – epinephrine solution auto-injector 0.3mg/0.3ml (1:1000)............................................................ 34

EPINEPHRINE HCL – epinephrine inj 30 mg/30ml.......... 33EQ MULTIVITAMINS ADULT GU – multiple vitamins w/minerals chew tab............................................................ 69

ergocalciferol cap 50000 unit.............................................68erythromycin gel 2% (Erygel)............................................ 80erythromycin ophth oint 5 mg/gm......................................77erythromycin pads 2%....................................................... 80erythromycin soln 2%.........................................................80escitalopram oxalate soln 5 mg/5ml (base equiv).............46escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....46escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................46

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escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................46

estazolam tab 1 mg........................................................... 52estazolam tab 2 mg........................................................... 52estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)...........................................................................15

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................15

estradiol tab 0.5 mg (Estrace)........................................... 15estradiol tab 1 mg (Estrace).............................................. 15estradiol tab 2 mg (Estrace).............................................. 15estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 15

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 15




estradiol td patch weekly 0.025 mg/24hr (Climara)...........15estradiol td patch weekly 0.05 mg/24hr (Climara).............15estradiol td patch weekly 0.06 mg/24hr (Climara).............15estradiol td patch weekly 0.075 mg/24hr (Climara)...........15estradiol td patch weekly 0.1 mg/24hr (Climara)...............15estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................15

estradiol vaginal tab 10 mcg (Vagifem).............................43ESTROPIPATE – estropipate tab 0.75 mg........................16ESTROPIPATE – estropipate tab 1.5 mg..........................16ESTROPIPATE – estropipate tab 3 mg.............................16eszopiclone tab 1 mg (Lunesta)........................................ 52eszopiclone tab 2 mg (Lunesta)........................................ 52eszopiclone tab 3 mg (Lunesta)........................................ 52ethambutol hcl tab 100 mg (Myambutol).............................3ethambutol hcl tab 400 mg (Myambutol).............................3ethosuximide cap 250 mg (Zarontin).................................65ethosuximide soln 250 mg/5ml (Zarontin)......................... 65ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg....................................................................................16

exemestane tab 25 mg (Aromasin)................................... 10EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................56

FFALESSA – levomefolate glucosamine tab 1 mg (folateequivalent).........................................................................71

famotidine for susp 40 mg/5ml (Pepcid)............................40famotidine tab 10 mg......................................................... 40famotidine tab 20 mg (Pepcid).......................................... 40famotidine tab 40 mg (Pepcid).......................................... 40fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg......................................................................................70

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg......................................................................................70

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)...................................................................70

felodipine tab er 24hr 2.5 mg............................................ 28felodipine tab er 24hr 5 mg............................................... 28felodipine tab er 24hr 10 mg............................................. 28fenofibrate micronized cap 43 mg..................................... 30fenofibrate micronized cap 67 mg (Lofibra).......................30fenofibrate micronized cap 134 mg (Lofibra).....................30fenofibrate micronized cap 200 mg (Lofibra).....................30fenofibrate tab 160 mg.......................................................30fenofibrate tab 54 mg (Lofibra)..........................................30fenofibrate tab 48 mg (Tricor)............................................ 30fenofibrate tab 145 mg (Tricor).......................................... 30fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................58fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................58fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................58fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................58fentanyl td patch 72hr 100 mcg/hr (Duragesic).................58ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg......................................................................................70

ferrous fumarate-folic acid tab 324-1 mg.......................... 70ferrous sulfate tab ec 325 mg (65 mg fe equivalent).........70ferrous sulfate tab 325 mg (65 mg elemental fe).............. 70fexofenadine hcl susp 30 mg/5ml (6 mg/ml)..................... 35fexofenadine hcl tab 60 mg............................................... 35fexofenadine hcl tab 180 mg............................................. 35finasteride tab 5 mg (Proscar)...........................................43FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent).........................................................................74

FISH OIL ULTRA – omega-3 fatty acids cap 1400 mg..... 71flecainide acetate tab 50 mg............................................. 32flecainide acetate tab 100 mg........................................... 32flecainide acetate tab 150 mg........................................... 32FLEET LIQUID GLYCERIN SUP – glycerin enema adult5.4 gm/average delivered dose....................................... 38

FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 37

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 37

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 37

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 37

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 37

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 37

FLUARIX QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cultsubunt quad susp pref syr 0.5 ml...................................... 9

FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-cultured subunit quadrivalent im susp............................... 9

fluconazole for susp 10 mg/ml (Diflucan)............................4fluconazole for susp 40 mg/ml (Diflucan)............................4fluconazole tab 50 mg (Diflucan).........................................4

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96

fluconazole tab 100 mg (Diflucan).......................................4fluconazole tab 150 mg (Diflucan).......................................4fluconazole tab 200 mg (Diflucan).......................................4flucytosine cap 250 mg (Ancobon)......................................4flucytosine cap 500 mg (Ancobon)......................................4fludrocortisone acetate tab 0.1 mg....................................14FLULAVAL QUADRIVALENT 201 – influenza virusvaccine split quadrivalent im inj.........................................9

FLULAVAL QUADRIVALENT 201 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................35

fluocinolone acetonide cream 0.01%................................ 81fluocinolone acetonide cream 0.025% (Synalar)...............81fluocinolone acetonide oint 0.025% (Synalar)...................81fluocinolone acetonide soln 0.01% (Synalar).................... 81fluocinonide cream 0.05%................................................. 81fluocinonide emulsified base cream 0.05%.......................81fluocinonide gel 0.05%.......................................................82fluocinonide oint 0.05%......................................................82fluocinonide soln 0.05%.....................................................82fluorometholone ophth susp 0.1% (Fml liquifilm).............. 78fluorouracil cream 5% (Efudex)......................................... 82fluoxetine hcl cap 10 mg (Prozac).....................................46fluoxetine hcl cap 20 mg (Prozac).....................................46fluoxetine hcl solution 20 mg/5ml...................................... 46fluphenazine decanoate inj 25 mg/ml................................49FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml...............................................................................49

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................49

fluphenazine hcl tab 1 mg................................................. 49fluphenazine hcl tab 2.5 mg.............................................. 49fluphenazine hcl tab 5 mg................................................. 49fluphenazine hcl tab 10 mg............................................... 49flurbiprofen tab 50 mg........................................................61flurbiprofen tab 100 mg......................................................61flutamide cap 125 mg........................................................ 10FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act........................ 37

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act...................... 37

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act...................... 37

fluticasone propionate cream 0.05% (Cutivate)................ 82fluticasone propionate nasal susp 50 mcg/act.................. 35fluticasone propionate oint 0.005%................................... 82FLUVIRIN 2017-2018 – influenza vac type a&b surfaceantigen susp pref syr 0.5 ml.............................................. 9

FLUVIRIN 2017-2018 – influenza virus vaccine types a &b surface antigen im susp..................................................9

fluvoxamine maleate tab 25 mg........................................ 46fluvoxamine maleate tab 50 mg........................................ 46fluvoxamine maleate tab 100 mg...................................... 46FLUZONE HIGH-DOSE PF 2017 – influenza virus vacsplit high-dose pf susp pref syr 0.5ml................................9

FLUZONE QUADRIVALENT 2017 – influenza virusvaccine split quadrivalent im inj.......................................10

FLUZONE QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................69

folic acid tab 400 mcg........................................................68folic acid tab 800 mcg........................................................68folic acid tab 1 mg............................................................. 68folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........68folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............68folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx)...................................................................................... 68

fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)................................................................................5

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................23

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................23

fosinopril sodium tab 10 mg.............................................. 23fosinopril sodium tab 20 mg.............................................. 23fosinopril sodium tab 40 mg.............................................. 23fructose-dextrose-phosphoric acid oral soln......................41furosemide oral soln 10 mg/ml.......................................... 31furosemide tab 20 mg (Lasix)............................................31furosemide tab 40 mg (Lasix)............................................31furosemide tab 80 mg (Lasix)............................................31

Ggabapentin cap 100 mg (Neurontin)..................................65gabapentin cap 300 mg (Neurontin)..................................65gabapentin cap 400 mg (Neurontin)..................................65gabapentin oral soln 250 mg/5ml (Neurontin)...................65gabapentin tab 600 mg (Neurontin)...................................65gabapentin tab 800 mg (Neurontin)...................................65gemfibrozil tab 600 mg (Lopid)..........................................30GENTAK – gentamicin sulfate ophth oint 0.3%.................77gentamicin sulfate cream 0.1%......................................... 80GENTAMICIN SULFATE – gentamicin sulfate oint0.1%.................................................................................. 80

gentamicin sulfate ophth soln 0.3%...................................77GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg............................................................ 5

glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 56

glimepiride tab 1 mg (Amaryl)........................................... 18glimepiride tab 2 mg (Amaryl)........................................... 18glimepiride tab 4 mg (Amaryl)........................................... 18glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 18glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 18glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 18glipizide tab 5 mg (Glucotrol).............................................18glipizide tab 10 mg (Glucotrol)...........................................18GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................18

glyburide-metformin tab 1.25-250 mg............................... 19

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glyburide-metformin tab 2.5-500 mg (Glucovance)...........19glyburide-metformin tab 5-500 mg (Glucovance)..............19glyburide micronized tab 1.5 mg (Glynase).......................18glyburide micronized tab 3 mg (Glynase)..........................19glyburide micronized tab 6 mg (Glynase)..........................19glyburide tab 1.25 mg........................................................ 19glyburide tab 2.5 mg.......................................................... 19glyburide tab 5 mg............................................................. 19glycerin suppos 1 gm.........................................................39glycerin suppos 2 gm.........................................................39glycopyrrolate tab 1 mg (Robinul)..................................... 40glycopyrrolate tab 2 mg (Robinul forte).............................40griseofulvin microsize susp 125 mg/5ml..............................4griseofulvin microsize tab 500 mg.......................................4griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............4griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............4guaifenesin-codeine soln 100-10 mg/5ml..........................36guaifenesin liquid 100 mg/5ml...........................................36guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....54guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....54guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....54guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....54guanfacine hcl tab 1 mg.................................................... 33guanfacine hcl tab 2 mg.................................................... 33

Hhalobetasol propionate cream 0.05% (Ultravate)..............82halobetasol propionate oint 0.05% (Ultravate).................. 82haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................49

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................49

haloperidol lactate oral conc 2 mg/ml................................49haloperidol tab 0.5 mg....................................................... 49haloperidol tab 1 mg.......................................................... 49haloperidol tab 2 mg.......................................................... 49haloperidol tab 5 mg.......................................................... 49haloperidol tab 10 mg........................................................ 49haloperidol tab 20 mg........................................................ 49HELIXATE FS – antihemophilic factor (recombinant) for injkit 250 unit........................................................................ 74

HELIXATE FS – antihemophilic factor (recombinant) for injkit 500 unit........................................................................ 74

HELIXATE FS – antihemophilic factor (recombinant) for injkit 1000 unit...................................................................... 74



HEMOFIL M – antihemophilic factor (human) for inj 250unit.....................................................................................74




HUMALOG – insulin lispro inj 100 unit/ml.........................20HUMALOG – insulin lispro soln cartridge 100 unit/ml.......20HUMALOG JUNIOR KWIKPEN – insulin lispro soln pen-injector 100 unit/ml........................................................... 20

HUMALOG KWIKPEN – insulin lispro soln pen-injector100 unit/ml........................................................................ 20

HUMALOG KWIKPEN – insulin lispro soln pen-injector200 unit/ml........................................................................ 20

HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................20

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 20

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 20

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 20

HUMATE-P – antihemophilic factor/vwf (human) for inj250-600 unit......................................................................74

HUMATE-P – antihemophilic factor/vwf (human) for inj500-1200 unit....................................................................74

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit..................................................................74

HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml............................................................................61



HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml....................................................62

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................62

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml....................................................62

HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml....................................................62

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 20

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................20

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................20

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................20

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 20hydralazine hcl tab 10 mg................................................. 33hydralazine hcl tab 25 mg................................................. 34hydralazine hcl tab 50 mg................................................. 34hydralazine hcl tab 100 mg............................................... 34hydrochlorothiazide cap 12.5 mg (Microzide)................... 31hydrochlorothiazide tab 12.5 mg....................................... 31hydrochlorothiazide tab 25 mg.......................................... 32hydrochlorothiazide tab 50 mg.......................................... 32

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hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)...............................................................................59

hydrocodone-acetaminophen tab 2.5-325 mg...................59hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 59hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 59hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 59hydrocortisone butyrate oint 0.1% (Locoid).......................82hydrocortisone cream 0.5%............................................... 82hydrocortisone cream 1%.................................................. 82hydrocortisone cream 2.5%............................................... 82hydrocortisone enema 100 mg/60ml (Cortenema)............79hydrocortisone lotion 2.5%................................................ 82hydrocortisone oint 0.5%................................................... 82hydrocortisone oint 1%...................................................... 82hydrocortisone oint 2.5%................................................... 82hydrocortisone rectal cream 2.5% (Anusol-hc)................. 79hydrocortisone rectal cream 1% (Proctocort)....................79hydrocortisone tab 5 mg (Cortef).......................................14hydrocortisone tab 10 mg (Cortef).....................................14hydrocortisone tab 20 mg (Cortef).....................................14hydrocortisone valerate cream 0.2%.................................82hydrocortisone valerate oint 0.2% (Westcort)................... 82hydrocortisone w/ acetic acid otic soln 1-2%.................... 79hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................59hydromorphone hcl tab 2 mg (Dilaudid)............................59hydromorphone hcl tab 4 mg (Dilaudid)............................59hydromorphone hcl tab 8 mg (Dilaudid)............................59hydroxychloroquine sulfate tab 200 mg (Plaquenil)............ 8hydroxyurea cap 500 mg (Hydrea)....................................10HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ml.......................................................................................45

hydroxyzine hcl syrup 10 mg/5ml......................................45hydroxyzine hcl tab 10 mg.................................................45hydroxyzine hcl tab 25 mg.................................................45hydroxyzine hcl tab 50 mg.................................................45hydroxyzine pamoate cap 25 mg (Vistaril)........................ 45hydroxyzine pamoate cap 50 mg (Vistaril)........................ 45hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 40hyoscyamine sulfate soln 0.125 mg/ml............................. 40hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........40hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 40hyoscyamine sulfate tab 0.125 mg (Levsin)......................40hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)...............40

IIBRANCE – palbociclib cap 75 mg....................................10IBRANCE – palbociclib cap 100 mg..................................11IBRANCE – palbociclib cap 125 mg..................................11ibuprofen cap 200 mg........................................................62ibuprofen susp 100 mg/5ml............................................... 62ibuprofen tab 200 mg.........................................................62ibuprofen tab 400 mg.........................................................62ibuprofen tab 600 mg.........................................................62ibuprofen tab 800 mg.........................................................62imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................11

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................11

imipramine hcl tab 10 mg (Tofranil)...................................46imipramine hcl tab 25 mg (Tofranil)...................................46imipramine hcl tab 50 mg (Tofranil)...................................46imiquimod cream 5% (Aldara)........................................... 83indapamide tab 1.25 mg.................................................... 32indapamide tab 2.5 mg...................................................... 32indomethacin cap er 75 mg...............................................62indomethacin cap 25 mg................................................... 62indomethacin cap 50 mg................................................... 62INSULIN SYRINGE/0.5ML/30G.........................................84INTELENCE – etravirine tab 25 mg.................................... 5INTELENCE – etravirine tab 100 mg.................................. 6INTELENCE – etravirine tab 200 mg.................................. 6INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 39 mg/0.25ml............................. 49

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 78 mg/0.5ml............................... 49

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 156 mg/ml...................................49

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 234 mg/1.5ml............................. 49

INVEGA SUSTENNA – paliperidone palmitate im extend-release susp 117 mg/0.75ml............................................49

INVIRASE – saquinavir mesylate cap 200 mg....................6INVIRASE – saquinavir mesylate tab 500 mg.....................6ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 37ipratropium bromide inhal soln 0.02%...............................37irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 24

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 25

irbesartan tab 75 mg (Avapro)...........................................24irbesartan tab 150 mg (Avapro).........................................24irbesartan tab 300 mg (Avapro).........................................24iron combination cap..........................................................68iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)....................................................................68

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)..................................................................... 68

iron polysacch complex-vit b12-fa cap 150-0.025-1mg......................................................................................68

irrigation solution, physiological.........................................84ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)..................................................................6

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)...................................................................................6

isoniazid tab 100 mg............................................................3isoniazid tab 300 mg............................................................3

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ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er40 mg................................................................................ 28

isosorbide dinitrate tab 10 mg........................................... 28isosorbide dinitrate tab 20 mg........................................... 28isosorbide dinitrate tab 30 mg........................................... 29isosorbide dinitrate tab 5 mg (Isordil titradose)................. 28isosorbide mononitrate tab er 24hr 30 mg........................ 29isosorbide mononitrate tab er 24hr 60 mg........................ 29isosorbide mononitrate tab er 24hr 120 mg...................... 29isosorbide mononitrate tab 10 mg.....................................29isosorbide mononitrate tab 20 mg.....................................29isotretinoin cap 10 mg........................................................80isotretinoin cap 20 mg........................................................80itraconazole cap 100 mg (Sporanox).................................. 4ivermectin tab 3 mg (Stromectol)........................................ 8IXINITY – coagulation factor ix (recombinant) for inj 500unit.....................................................................................74

IXINITY – coagulation factor ix (recombinant) for inj 1000unit.....................................................................................74

IXINITY – coagulation factor ix (recombinant) for inj 1500unit.....................................................................................74

J

KKALETRA – lopinavir-ritonavir tab 100-25 mg.................... 6KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 6KALYDECO – ivacaftor packet 50 mg...............................38KALYDECO – ivacaftor packet 75 mg...............................38KALYDECO – ivacaftor tab 150 mg.................................. 38ketoconazole cream 2%.....................................................80ketoconazole shampoo 2% (Nizoral).................................80ketoconazole tab 200 mg.................................................... 4ketoprofen cap 50 mg........................................................62ketoprofen cap 75 mg........................................................62ketorolac tromethamine ophth soln 0.5% (Acular)............ 79ketorolac tromethamine ophth soln 0.4% (Acular ls).........78ketorolac tromethamine tab 10 mg....................................62ketotifen fumarate ophth soln 0.025% (base equiv)..........79KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 11

KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 11

KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 11

KISQALI – ribociclib succinate tab 200 mg (baseequiv).................................................................................11

KOATE – antihemophilic factor (human) for inj 250unit.....................................................................................74



KOATE-DVI – antihemophilic factor (human) for inj 250unit.....................................................................................74



KOGENATE FS – antihemophilic factor (recombinant) forinj kit 250 unit................................................................... 75

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 500 unit................................................................... 75

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 1000 unit................................................................. 75



KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 250 unit...................................... 75

KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 500 unit...................................... 75

KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 1000 unit.................................... 75



KONSYL-D – psyllium powder 52.3%...............................39KONSYL – psyllium powder 60.3%...................................39KONSYL – psyllium powder 71.67%.................................39K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................70

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 16

Llabetalol hcl tab 100 mg.................................................... 26labetalol hcl tab 200 mg.................................................... 26labetalol hcl tab 300 mg.................................................... 26lactated ringer's for irrigation............................................. 84lactic acid (ammonium lactate) lotion 12% (Lac-hydrin)............................................................................... 83

lactulose (encephalopathy) solution 10 gm/15ml.............. 42lactulose solution 10 gm/15ml........................................... 39lamivudine oral soln 10 mg/ml (Epivir)................................ 6lamivudine tab 150 mg (Epivir)............................................6lamivudine tab 300 mg (Epivir)............................................6lamivudine tab 100 mg (hbv) (Epivir hbv)........................... 4lamivudine-zidovudine tab 150-300 mg (Combivir).............6lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................65

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................65

lamotrigine tab 25 mg (Lamictal).......................................65lamotrigine tab 100 mg (Lamictal).....................................65lamotrigine tab 150 mg (Lamictal).....................................65lamotrigine tab 200 mg (Lamictal).....................................65lansoprazole cap delayed release 15 mg (Prevacid)........ 40lansoprazole cap delayed release 30 mg (Prevacid)........ 40

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latanoprost ophth soln 0.005% (Xalatan).......................... 78LATUDA – lurasidone hcl tab 20 mg.................................50LATUDA – lurasidone hcl tab 40 mg.................................50LATUDA – lurasidone hcl tab 60 mg.................................50LATUDA – lurasidone hcl tab 80 mg.................................50LATUDA – lurasidone hcl tab 120 mg...............................50leflunomide tab 10 mg (Arava).......................................... 62leflunomide tab 20 mg (Arava).......................................... 62LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 11

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................11

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................11

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................11

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 11

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 11

letrozole tab 2.5 mg (Femara)...........................................11LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................11

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg......................................................................................11

leucovorin calcium tab 5 mg..............................................11leucovorin calcium tab 25 mg............................................11LEUKERAN – chlorambucil tab 2 mg................................11levetiracetam oral soln 100 mg/ml (Keppra)..................... 65levetiracetam tab er 24hr 500 mg (Keppra xr).................. 65levetiracetam tab er 24hr 750 mg (Keppra xr).................. 65levetiracetam tab 250 mg (Keppra)...................................65levetiracetam tab 500 mg (Keppra)...................................65levetiracetam tab 750 mg (Keppra)...................................65levetiracetam tab 1000 mg (Keppra).................................65levobunolol hcl ophth soln 0.5% (Betagan).......................78levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........22levocarnitine tab 330 mg (Carnitor)...................................22levocetirizine dihydrochloride tab 5 mg............................. 35LEVOFLOXACIN – levofloxacin oral soln 25 mg/ml........... 3levofloxacin ophth soln 0.5%.............................................77levofloxacin tab 250 mg (Levaquin).....................................3levofloxacin tab 500 mg (Levaquin).....................................3levofloxacin tab 750 mg (Levaquin).....................................3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg....... 16levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg..... 16levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg..................................17

levonorgestrel tab 1.5 mg.................................................. 17levothyroxine sodium tab 25 mcg (Synthroid)...................21levothyroxine sodium tab 50 mcg (Synthroid)...................21levothyroxine sodium tab 75 mcg (Synthroid)...................21levothyroxine sodium tab 88 mcg (Synthroid)...................21levothyroxine sodium tab 100 mcg (Synthroid).................21levothyroxine sodium tab 112 mcg (Synthroid)................. 21levothyroxine sodium tab 125 mcg (Synthroid).................21

levothyroxine sodium tab 137 mcg (Synthroid).................21levothyroxine sodium tab 150 mcg (Synthroid).................21levothyroxine sodium tab 175 mcg (Synthroid).................21levothyroxine sodium tab 200 mcg (Synthroid).................21levothyroxine sodium tab 300 mcg (Synthroid).................21LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv)...................................................................................6

lidocaine hcl cream 3%......................................................83lidocaine hcl gel 2%...........................................................83lidocaine hcl soln 4% (Xylocaine)......................................83lidocaine hcl viscous soln 2%............................................79lidocaine oint 5%................................................................83lidocaine patch 5% (Lidoderm)..........................................83lidocaine-prilocaine cream 2.5-2.5%................................. 83lidocaine-prilocaine cream kit 2.5-2.5%.............................83linezolid for susp 100 mg/5ml (Zyvox).................................8linezolid tab 600 mg (Zyvox)............................................... 8liothyronine sodium tab 5 mcg (Cytomel)..........................21liothyronine sodium tab 25 mcg (Cytomel)........................21liothyronine sodium tab 50 mcg (Cytomel)........................21lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 23

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 23

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 23

lisinopril tab 5 mg (Prinivil)................................................ 23lisinopril tab 10 mg (Prinivil).............................................. 24lisinopril tab 20 mg (Prinivil).............................................. 24lisinopril tab 2.5 mg (Zestril).............................................. 23lisinopril tab 30 mg (Zestril)............................................... 24lisinopril tab 40 mg (Zestril)............................................... 24lithium carbonate cap 300 mg........................................... 50lithium carbonate cap 150 mg (Lithium carbonate)...........50lithium carbonate cap 600 mg (Lithium carbonate)...........50lithium carbonate tab er 450 mg........................................50lithium carbonate tab er 300 mg (Lithobid)....................... 50lithium carbonate tab 300 mg............................................50LITHIUM – lithium oral solution 8 meq/5ml....................... 50LMD 10% DEXTROSE 5% – dextran 40 inj 10% ind5w....................................................................................75

loperamide hcl cap 2 mg................................................... 39loperamide hcl liq 1 mg/5ml (0.2 mg/ml)........................... 39loperamide hcl tab 2 mg....................................................39lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................6

loratadine syrup 5 mg/5ml................................................. 35loratadine tab 10 mg..........................................................35lorazepam conc 2 mg/ml................................................... 45lorazepam tab 0.5 mg (Ativan).......................................... 45lorazepam tab 1 mg (Ativan)............................................. 45lorazepam tab 2 mg (Ativan)............................................. 45losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................25

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 25

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

losartan potassium tab 25 mg (Cozaar)............................25losartan potassium tab 50 mg (Cozaar)............................25losartan potassium tab 100 mg (Cozaar)..........................25lovastatin tab 10 mg...........................................................30lovastatin tab 20 mg...........................................................30lovastatin tab 40 mg...........................................................30loxapine succinate cap 5 mg.............................................50loxapine succinate cap 10 mg...........................................50loxapine succinate cap 25 mg...........................................50loxapine succinate cap 50 mg...........................................50LYNPARZA – olaparib cap 50 mg..................................... 11

Mmagnesium citrate soln......................................................39magnesium oxide tab 400 mg........................................... 40magnesium oxide tab 400 mg (241.3 mg elementalmg).................................................................................... 70

MASK VORTEX/CHILD/FROG..........................................84MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg......... 4meclizine hcl tab 12.5 mg..................................................41meclizine hcl tab 25 mg.....................................................41medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)............................................................... 17

medroxyprogesterone acetate tab 2.5 mg (Provera)........ 16medroxyprogesterone acetate tab 5 mg (Provera)........... 16medroxyprogesterone acetate tab 10 mg (Provera)......... 16mefloquine hcl tab 250 mg.................................................. 8megestrol acetate susp 40 mg/ml..................................... 11megestrol acetate susp 625 mg/5ml (Megace es)............ 16megestrol acetate tab 20 mg.............................................11megestrol acetate tab 40 mg.............................................12MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 12

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................12

meloxicam tab 7.5 mg (Mobic).......................................... 62meloxicam tab 15 mg (Mobic)........................................... 62melphalan tab 2 mg (Alkeran)........................................... 12meperidine hcl tab 50 mg..................................................59meperidine hcl tab 100 mg (Demerol)...............................59MEPHYTON – phytonadione tab 5 mg............................. 68mercaptopurine tab 50 mg.................................................12MESALAMINE DR – mesalamine tab delayed release 800mg......................................................................................42

mesalamine enema 4 gm.................................................. 42METAMUCIL MULTIHEALTH FIB – psyllium powder55.46%.............................................................................. 39

METAMUCIL MULTIHEALTH FIB – psyllium powder63%................................................................................... 39

METAMUCIL SMOOTH TEXTURE – psyllium powder63%................................................................................... 39

metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 19metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 19metformin hcl tab 500 mg (Glucophage)...........................19

metformin hcl tab 850 mg (Glucophage)...........................19metformin hcl tab 1000 mg (Glucophage).........................19METHERGINE – methylergonovine maleate tab 0.2mg......................................................................................22

methimazole tab 5 mg (Tapazole)..................................... 21methimazole tab 10 mg (Tapazole)................................... 21methocarbamol tab 750 mg (Robaxin-750).......................67methocarbamol tab 500 mg (Robaxin)..............................67METHOTREXATE SODIUM – methotrexate sodium inj250 mg/10ml (25 mg/ml)..................................................12

methotrexate sodium tab 2.5 mg (base equiv)..................12methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 83methyldopa tab 250 mg..................................................... 34methyldopa tab 500 mg..................................................... 34methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................55

methylphenidate hcl cap er 24hr 30 mg (la) (Ritalinla).......................................................................................55

methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla).......................................................................................55

methylphenidate hcl cap er 10 mg (cd).............................54methylphenidate hcl cap er 20 mg (cd).............................54methylphenidate hcl cap er 30 mg (cd).............................54methylphenidate hcl cap er 40 mg (cd).............................54methylphenidate hcl cap er 50 mg (cd).............................54methylphenidate hcl cap er 60 mg (cd).............................55METHYLPHENIDATE HCL ER – methylphenidate hcl taber 24hr 18 mg...................................................................55

METHYLPHENIDATE HCL ER – methylphenidate hcl taber 24hr 27 mg...................................................................55



methylphenidate hcl tab er 10 mg.....................................55methylphenidate hcl tab er osmotic release (osm) 18 mg(Concerta)......................................................................... 55

methylphenidate hcl tab er osmotic release (osm) 27 mg(Concerta)......................................................................... 55



methylphenidate hcl tab 5 mg (Ritalin)..............................55methylphenidate hcl tab 10 mg (Ritalin)............................55methylphenidate hcl tab 20 mg (Ritalin)............................55methylprednisolone tab 4 mg (Medrol)..............................14methylprednisolone tab 8 mg (Medrol)..............................14methylprednisolone tab 16 mg (Medrol)............................14methylprednisolone tab 32 mg (Medrol)............................14methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................14

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)............. 42metoclopramide hcl tab 5 mg (Reglan)............................. 42metoclopramide hcl tab 10 mg (Reglan)........................... 42metolazone tab 2.5 mg...................................................... 32

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102

metolazone tab 5 mg......................................................... 32metolazone tab 10 mg....................................................... 32METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg................................. 26

metoprolol & hydrochlorothiazide tab 100-25 mg..............26metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................26

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 26




metoprolol tartrate tab 25 mg............................................ 26metoprolol tartrate tab 50 mg (Lopressor).........................26metoprolol tartrate tab 100 mg (Lopressor).......................26metronidazole cap 375 mg (Flagyl).....................................9metronidazole cream 0.75% (Metrocream).......................80metronidazole gel 0.75%................................................... 80metronidazole gel 1% (Metrogel).......................................80metronidazole tab 250 mg (Flagyl)......................................9metronidazole tab 500 mg (Flagyl)......................................9metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 43mexiletine hcl cap 150 mg.................................................32mexiletine hcl cap 200 mg.................................................32mexiletine hcl cap 250 mg.................................................32miconazole nitrate aerosol pow 2%...................................81miconazole nitrate cream 2%............................................ 81miconazole nitrate vaginal cream 2%................................43midodrine hcl tab 2.5 mg...................................................34midodrine hcl tab 5 mg...................................................... 34midodrine hcl tab 10 mg....................................................34minocycline hcl cap 75 mg.................................................. 3minocycline hcl cap 50 mg (Minocin).................................. 3minocycline hcl cap 100 mg (Minocin)................................ 3minocycline hcl tab 50 mg...................................................3minocycline hcl tab 75 mg...................................................3minocycline hcl tab 100 mg.................................................3minoxidil tab 2.5 mg...........................................................34minoxidil tab 10 mg............................................................34MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................17

mirtazapine orally disintegrating tab 15 mg (Remeronsoltab)................................................................................47



mirtazapine tab 15 mg (Remeron).....................................47mirtazapine tab 30 mg (Remeron).....................................47mirtazapine tab 45 mg (Remeron).....................................47misoprostol tab 100 mcg (Cytotec)....................................40misoprostol tab 200 mcg (Cytotec)....................................40modafinil tab 100 mg (Provigil)..........................................55

modafinil tab 200 mg (Provigil)..........................................55moexipril hcl tab 7.5 mg.................................................... 24moexipril hcl tab 15 mg..................................................... 24moexipril-hydrochlorothiazide tab 7.5-12.5 mg................. 24moexipril-hydrochlorothiazide tab 15-12.5 mg.................. 24moexipril-hydrochlorothiazide tab 15-25 mg..................... 24mometasone furoate cream 0.1% (Elocon).......................82mometasone furoate oint 0.1% (Elocon)...........................82mometasone furoate solution 0.1% (lotion).......................82MONOCLATE-P – antihemophilic factor (human) for inj kit1000 unit........................................................................... 75

MONOCLATE-P – antihemophilic factor (human) for inj kit1500 unit........................................................................... 75

MONONINE – coagulation factor ix for inj 1000 unit.........75montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................37

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................37

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 37

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................37

MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................59




MORPHINE SULFATE – morphine sulfate tab 15 mg...... 59MORPHINE SULFATE – morphine sulfate tab 30 mg...... 59morphine sulfate oral soln 10 mg/5ml............................... 59morphine sulfate oral soln 20 mg/5ml............................... 59morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........59multiple vitamins w/ iron tab.............................................. 69multiple vitamins w/ minerals & fa tab 1.25 mg(Corvite).............................................................................69

multiple vitamins w/ minerals cap......................................69multiple vitamins w/ minerals tab (Strovite forte)...............69multiple vitamin tab............................................................ 69mupirocin oint 2%...............................................................81mycophenolate mofetil cap 250 mg (Cellcept)..................84mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................84

mycophenolate mofetil tab 500 mg (Cellcept)...................84mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)................................................................84

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)................................................................84

MYLERAN – busulfan tab 2 mg........................................ 12

Nnabumetone tab 500 mg....................................................62nabumetone tab 750 mg....................................................63nadolol tab 20 mg (Corgard)............................................. 26

2017

103

nadolol tab 40 mg (Corgard)............................................. 26nadolol tab 80 mg (Corgard)............................................. 26NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml.......................................................................................84

NALOXONE HCL – naloxone hcl soln prefilled syringe 2mg/2ml...............................................................................84

naltrexone hcl tab 50 mg...................................................56naproxen sodium tab 220 mg............................................63naproxen sodium tab 275 mg............................................63naproxen sodium tab 550 mg (Anaprox ds)......................63naproxen tab ec 375 mg (Ec-naprosyn)............................63naproxen tab ec 500 mg (Ec-naprosyn)............................63naproxen tab 250 mg.........................................................63naproxen tab 375 mg.........................................................63naproxen tab 500 mg (Naprosyn)......................................63NARCAN – naloxone hcl nasal spray 4 mg/0.1ml.............84NATACYN – natamycin ophth susp 5%............................ 77nateglinide tab 60 mg (Starlix)...........................................19nateglinide tab 120 mg (Starlix).........................................19NECON 10/11-28 – norethindrone-eth estradiol tab0.5-35/1-35 mg-mcg (10/11).............................................17

neomycin-bacitracin-polymyxin oint...................................81neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin................................................................................ 77

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)......................................................77

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................... 78

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)........................................................................... 78

neomycin-polymyxin-hc otic soln 1%................................ 79neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%................................................................................ 79

neomycin sulfate tab 500 mg.............................................. 3NEUPOGEN – filgrastim inj 300 mcg/ml...........................75NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml)......................................................................................75

NEUPOGEN – filgrastim soln prefilled syringe 300mcg/0.5ml..........................................................................75

NEUPOGEN – filgrastim soln prefilled syringe 480mcg/0.8ml (600 mcg/ml)...................................................75

nevirapine tab er 24hr 100 mg (Viramune xr)..................... 6nevirapine tab er 24hr 400 mg (Viramune xr)..................... 6nevirapine tab 200 mg (Viramune)......................................6NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................12

NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................17

niacin cap er 250 mg......................................................... 68niacin cap er 500 mg......................................................... 69niacin tab er 250 mg..........................................................69niacin tab er 500 mg..........................................................69niacin tab er 750 mg..........................................................69niacin tab 100 mg.............................................................. 69niacin tab 500 mg.............................................................. 69NIACIN TR – niacin tab er 1000 mg................................. 69

nicotine polacrilex gum 2 mg.............................................56nicotine polacrilex gum 4 mg.............................................56nicotine td patch 24hr 7 mg/24hr.......................................56nicotine td patch 24hr 14 mg/24hr.....................................56nicotine td patch 24hr 21 mg/24hr.....................................57nifedipine cap 10 mg (Procardia)...................................... 28nifedipine tab er 24hr 30 mg (Adalat cc)...........................28nifedipine tab er 24hr 60 mg (Adalat cc)...........................28nifedipine tab er 24hr 90 mg (Adalat cc)...........................28nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................28

nifedipine tab er 24hr osmotic release 60 mg (Procardiaxl).......................................................................................28

nifedipine tab er 24hr osmotic release 90 mg (Procardiaxl).......................................................................................28

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................43



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 43

nitrofurantoin susp 25 mg/5ml (Furadantin)...................... 43nitroglycerin cap er 2.5 mg................................................29nitroglycerin cap er 6.5 mg................................................29nitroglycerin cap er 9 mg...................................................29nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 29nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 29nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 29nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 29nizatidine cap 150 mg........................................................40nizatidine cap 300 mg........................................................40NIZATIDINE – nizatidine oral soln 15 mg/ml.....................40norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20).............................................................. 17

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21)............................................................. 17

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21).......................................................... 17

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................16

norethindrone acetate tab 5 mg (Aygestin).......................16norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen)................................................................... 17

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)................................................ 17

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)............................................ 17

nortriptyline hcl cap 10 mg (Pamelor)............................... 47nortriptyline hcl cap 25 mg (Pamelor)............................... 47nortriptyline hcl cap 50 mg (Pamelor)............................... 47nortriptyline hcl cap 75 mg (Pamelor)............................... 47

2017

104

NORVIR – ritonavir cap 100 mg..........................................6NORVIR – ritonavir oral soln 80 mg/ml...............................6NORVIR – ritonavir tab 100 mg.......................................... 6NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 21

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 21

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................20

NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 20

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 20NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................20

NOVOLOG FLEXPEN – insulin aspart soln pen-injector100 unit/ml........................................................................ 20

NOVOLOG – insulin aspart inj 100 unit/ml....................... 20NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 21

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30).............................21

NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml................................................................................20

NOXAFIL – posaconazole susp 40 mg/ml.......................... 4NOXAFIL – posaconazole tab delayed release 100 mg..... 4NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr........................................................ 17

nystatin cream 100000 unit/gm......................................... 81nystatin oint 100000 unit/gm..............................................81nystatin susp 100000 unit/ml.............................................79nystatin tab 500000 unit...................................................... 4nystatin topical powder 100000 unit/gm............................81

OOCEAN BLUE MINICAPS OMEGA – omega-3 fatty acidscap 350 mg.......................................................................71

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin).....................................................................22




octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin).....................................................................22

ofloxacin ophth soln 0.3% (Ocuflox)..................................77ofloxacin otic soln 0.3% (Floxin otic).................................79olanzapine for im inj 10 mg (Zyprexa)...............................50olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 50

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 50



olanzapine tab 2.5 mg (Zyprexa).......................................50olanzapine tab 5 mg (Zyprexa)..........................................50olanzapine tab 7.5 mg (Zyprexa).......................................50olanzapine tab 10 mg (Zyprexa)........................................51olanzapine tab 15 mg (Zyprexa)........................................51olanzapine tab 20 mg (Zyprexa)........................................51omega-3 fatty acids cap delayed release 1000 mg...........71omega-3 fatty acids cap delayed release 1200 mg...........71omega-3 fatty acids cap 500 mg.......................................71omega-3 fatty acids cap 435 mg.......................................71omega-3 fatty acids cap 1000 mg.....................................71omega-3 fatty acids cap 1200 mg.....................................71OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg..... 71OMEGA-3 – omega-3 fatty acids cap 1400 mg................ 71OMEGA-3 2100 – omega-3 fatty acids cap 1050 mg....... 71OMEGA POWER – omega-3 fatty acids cap 1050 mg..... 71omeprazole cap delayed release 20 mg........................... 41omeprazole cap delayed release 40 mg........................... 41OMNIFLEX DIAPHRAGM..................................................16OMNITROPE – somatropin for inj 5.8 mg.........................21ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 41ondansetron hcl tab 24 mg................................................41ondansetron hcl tab 4 mg (Zofran)....................................41ondansetron hcl tab 8 mg (Zofran)....................................41ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................... 41

ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................... 41

oral electrolyte solution...................................................... 70orphenadrine citrate tab er 12hr 100 mg...........................67oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu)...............................................................................8

oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu)...............................................................................8

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu)...............................................................................8

oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 65

oxcarbazepine tab 150 mg (Trileptal)................................65oxcarbazepine tab 300 mg (Trileptal)................................65oxcarbazepine tab 600 mg (Trileptal)................................66oxybutynin chloride syrup 5 mg/5ml..................................43oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 43oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 43oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)......... 43oxybutynin chloride tab 5 mg.............................................43OXYCODONE/ACETAMINOPHEN – oxycodone w/acetaminophen soln 5-325 mg/5ml..................................60

oxycodone-aspirin tab 4.8355-325 mg.............................. 60oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 59oxycodone hcl soln 5 mg/5ml............................................60oxycodone hcl tab 10 mg.................................................. 60oxycodone hcl tab 20 mg.................................................. 60oxycodone hcl tab 5 mg (Roxicodone)..............................60

2017

105

oxycodone hcl tab 15 mg (Roxicodone)............................60oxycodone hcl tab 30 mg (Roxicodone)............................60oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................60

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................60

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................60

Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................41

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................41

PAPAVERINE HCL – papaverine hcl inj 30 mg/ml............34PARAGARD INTRAUTERINE COP – copper iud............. 17paromomycin sulfate cap 250 mg....................................... 3paroxetine hcl tab 10 mg (Paxil)........................................47paroxetine hcl tab 20 mg (Paxil)........................................47paroxetine hcl tab 30 mg (Paxil)........................................47paroxetine hcl tab 40 mg (Paxil)........................................47PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml)........39pediatric multiple vitamin w/ c & fa chew tab.................... 69pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................69

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).........................................................39

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................39

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 39

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 125 mg/5ml.................................................................1

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 250 mg/5ml.................................................................1

penicillin v potassium tab 250 mg....................................... 1penicillin v potassium tab 500 mg....................................... 1pentoxifylline tab er 400 mg.............................................. 75perindopril erbumine tab 2 mg...........................................24perindopril erbumine tab 4 mg (Aceon).............................24perindopril erbumine tab 8 mg (Aceon).............................24permethrin cream 5% (Elimite)..........................................83permethrin creme rinse 1%............................................... 83perphenazine tab 2 mg......................................................51perphenazine tab 4 mg......................................................51perphenazine tab 8 mg......................................................51perphenazine tab 16 mg....................................................51phenazopyridine hcl tab 100 mg (Pyridium)......................44phenazopyridine hcl tab 200 mg (Pyridium)......................44phenobarbital elixir 20 mg/5ml...........................................53PHENOBARBITAL – phenobarbital tab 15 mg................. 52PHENOBARBITAL – phenobarbital tab 30 mg................. 53PHENOBARBITAL – phenobarbital tab 60 mg................. 53PHENOBARBITAL – phenobarbital tab 100 mg............... 53phenobarbital tab 16.2 mg.................................................53phenobarbital tab 32.4 mg.................................................53

phenobarbital tab 64.8 mg.................................................53phenobarbital tab 97.2 mg.................................................53phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............34PHENYLEPHRINE/GUAIFENESIN – phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)............. 36

phenylephrine-guaifenesin tab 10-400 mg........................36phenylephrine hcl tab 10 mg............................................. 35phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml.................36phenytoin chew tab 50 mg (Dilantin infatabs)................... 66phenytoin sodium extended cap 100 mg (Dilantin)...........66phenytoin sodium extended cap 200 mg (Phenytek)........66phenytoin sodium extended cap 300 mg (Phenytek)........66phenytoin susp 125 mg/5ml (Dilantin-125)........................66pilocarpine hcl ophth soln 1% (Isopto carpine)................. 78pilocarpine hcl ophth soln 2% (Isopto carpine)................. 78pilocarpine hcl ophth soln 4% (Isopto carpine)................. 78pilocarpine hcl tab 5 mg (Salagen)....................................79pilocarpine hcl tab 7.5 mg (Salagen).................................79pimozide tab 1 mg (Orap)..................................................57pimozide tab 2 mg (Orap)..................................................57pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 19pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 19pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 19piroxicam cap 10 mg (Feldene).........................................63piroxicam cap 20 mg (Feldene).........................................63PLAN B ONE-STEP – levonorgestrel tab 1.5 mg............. 17PNV TABS 29-1................................................................. 69podofilox soln 0.5%............................................................83polyethylene glycol 3350 oral powder............................... 39polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim)...........................................................................77

pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......44potassium bicarbonate effer tab 25 meq...........................70potassium chloride cap er 8 meq (Micro-k).......................70potassium chloride cap er 10 meq (Micro-k).....................70POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................70

potassium chloride microencapsulated crys er tab 10meq....................................................................................70

potassium chloride microencapsulated crys er tab 20meq....................................................................................70

potassium chloride oral soln 10% (20 meq/15ml)............. 70POTASSIUM CHLORIDE – potassium chloride oral soln20% (40 meq/15ml)..........................................................70

potassium chloride powder packet 20 meq.......................70potassium chloride tab er 10 meq (K-tab).........................70potassium chloride tab er 8 meq (600 mg)....................... 70potassium citrate & citric acid powder pack 3300-1002mg......................................................................................44

potassium citrate & citric acid soln 1100-334 mg/5ml....... 44potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........44potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 44

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 44

pot bicarbonate & chloride effer tab 25 meq.....................70

2017

106

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................70

PRALUENT – alirocumab subcutaneous soln pen-injector75 mg/ml........................................................................... 30

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml......................................................................... 30

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......66pramipexole dihydrochloride tab 0.25 mg (Mirapex).........66pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........67pramipexole dihydrochloride tab 0.75 mg (Mirapex).........67pramipexole dihydrochloride tab 1 mg (Mirapex)..............67pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........67pravastatin sodium tab 10 mg........................................... 30pravastatin sodium tab 20 mg (Pravachol)........................30pravastatin sodium tab 40 mg (Pravachol)........................30pravastatin sodium tab 80 mg (Pravachol)........................30prazosin hcl cap 1 mg (Minipress).................................... 34prazosin hcl cap 2 mg (Minipress).................................... 34prazosin hcl cap 5 mg (Minipress).................................... 34prednicarbate cream 0.1% (Dermatop)............................. 82prednicarbate oint 0.1% (Dermatop)................................. 82prednisolone acetate ophth susp 1% (Pred forte).............78PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%................................... 78

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................14

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................14

prednisolone syrup 15 mg/5ml (usp solutionequivalent).........................................................................14

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 14PREDNISONE – prednisone tab 50 mg............................14prednisone tab 1 mg..........................................................14prednisone tab 2.5 mg.......................................................14prednisone tab 5 mg..........................................................14prednisone tab 10 mg........................................................14prednisone tab 20 mg........................................................14PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg.....................................................16

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg...................................................16

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg....................................................16

PRESERVISION AREDS 2 + MU – multiple vitamins w/minerals cap..................................................................... 69

PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)...................................................................................6

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)...................................................................................6




PRIFTIN – rifapentine tab 150 mg...................................... 3

PRIMAQUINE PHOSPHATE – primaquine phosphate tab26.3 mg (15 mg base)....................................................... 8

primidone tab 50 mg (Mysoline)........................................66primidone tab 250 mg (Mysoline)......................................66probenecid tab 500 mg......................................................64PROBUPHINE IMPLANT KIT – buprenorphine hclsubdermal implant 74.2 mg (base equiv)........................ 60

prochlorperazine maleate tab 5 mg (base equivalent)......41prochlorperazine maleate tab 10 mg (baseequivalent).........................................................................41

prochlorperazine suppos 25 mg........................................ 41PROFILNINE – factor ix complex for inj 500 unit..............75PROFILNINE – factor ix complex for inj 1000 unit............75PROFILNINE – factor ix complex for inj 1500 unit............75PROFILNINE SD – factor ix complex for inj 500 unit........75PROFILNINE SD – factor ix complex for inj 1000 unit......75PROFILNINE SD – factor ix complex for inj 1500 unit......75progesterone im in oil 50 mg/ml........................................16progesterone micronized cap 100 mg (Prometrium).........16progesterone micronized cap 200 mg (Prometrium).........16promethazine hcl suppos 12.5 mg.................................... 35promethazine hcl suppos 25 mg....................................... 35promethazine hcl syrup 6.25 mg/5ml................................ 35promethazine hcl tab 12.5 mg...........................................35promethazine hcl tab 25 mg..............................................35promethazine hcl tab 50 mg..............................................35promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 36PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids capdelayed release 332.5 mg............................................... 71

propafenone hcl tab 150 mg..............................................32propafenone hcl tab 225 mg..............................................32propafenone hcl tab 300 mg..............................................32proparacaine hcl ophth soln 0.5%.....................................79PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg................................... 27

propranolol hcl tab 10 mg..................................................26propranolol hcl tab 20 mg..................................................26propranolol hcl tab 40 mg..................................................26propranolol hcl tab 60 mg..................................................26propranolol hcl tab 80 mg..................................................27propylthiouracil tab 50 mg................................................. 21psyllium powder 28.3%......................................................39psyllium powder 30%......................................................... 39psyllium powder 30.9%......................................................39psyllium powder 48.57%....................................................39psyllium powder 58.6%......................................................39psyllium powder 95%......................................................... 39PULMOZYME – dornase alfa inhal soln 1 mg/ml..............38pyrazinamide tab 500 mg.................................................... 3pyridostigmine bromide tab 60 mg (Mestinon)..................67

QQC CALAMINE – calamine lotion......................................83quetiapine fumarate tab 25 mg (Seroquel)........................51quetiapine fumarate tab 50 mg (Seroquel)........................51quetiapine fumarate tab 100 mg (Seroquel)......................51

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107

quetiapine fumarate tab 200 mg (Seroquel)......................51quetiapine fumarate tab 300 mg (Seroquel)......................51quetiapine fumarate tab 400 mg (Seroquel)......................51quinapril hcl tab 5 mg (Accupril)........................................24quinapril hcl tab 10 mg (Accupril)......................................24quinapril hcl tab 20 mg (Accupril)......................................24quinapril hcl tab 40 mg (Accupril)......................................24quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 24

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 24

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 24

quinidine gluconate tab er 324 mg....................................32QUINIDINE SULFATE – quinidine sulfate tab 200 mg......33QUINIDINE SULFATE – quinidine sulfate tab 300 mg......33QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).................................................................... 37

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve).................................................................. 38

Rraloxifene hcl tab 60 mg (Evista).......................................22ramipril cap 1.25 mg (Altace)............................................ 24ramipril cap 2.5 mg (Altace).............................................. 24ramipril cap 5 mg (Altace)................................................. 24ramipril cap 10 mg (Altace)............................................... 24ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 41ranitidine hcl tab 75 mg..................................................... 41ranitidine hcl tab 150 mg (Zantac).....................................41ranitidine hcl tab 300 mg (Zantac).....................................41RECOMBINATE – antihemophilic factor (recombinant) forinj 220-400 unit.................................................................76

RECOMBINATE – antihemophilic factor (recombinant) forinj 401-800 unit.................................................................76

RECOMBINATE – antihemophilic factor (recombinant) forinj 801-1240 unit...............................................................76

RECOMBINATE – antihemophilic factor (recombinant) forinj 1241-1800 unit.............................................................76

RECOMBINATE – antihemophilic factor (recombinant) forinj 1801-2400 unit.............................................................76

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister......................................................... 8

RELHIST BP – brompheniramine & phenylephrine tab4-10 mg.............................................................................36

REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................30

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................31

RESCRIPTOR – delavirdine mesylate tab 100 mg.............6RESCRIPTOR – delavirdine mesylate tab 200 mg.............6REVLIMID – lenalidomide cap 5 mg................................. 84REVLIMID – lenalidomide cap 10 mg............................... 85REVLIMID – lenalidomide cap 15 mg............................... 85REVLIMID – lenalidomide cap 20 mg............................... 85REVLIMID – lenalidomide cap 25 mg............................... 85

REVLIMID – lenalidomide caps 2.5 mg............................ 84REYATAZ – atazanavir sulfate cap 150 mg (baseequiv)...................................................................................7

REYATAZ – atazanavir sulfate cap 200 mg (baseequiv)...................................................................................7

REYATAZ – atazanavir sulfate cap 300 mg (baseequiv)...................................................................................7

REYATAZ – atazanavir sulfate oral powder packet 50 mg(base equiv)........................................................................ 6

ribavirin cap 200 mg (Rebetol)............................................ 4rifabutin cap 150 mg (Mycobutin)........................................3rifampin cap 300 mg............................................................ 3rifampin cap 150 mg (Rifadin)............................................. 3riluzole tab 50 mg (Rilutek)................................................68ringer's solution for irrigation..............................................85risperidone orally disintegrating tab 0.25 mg.................... 51risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).................................................................................... 51

risperidone orally disintegrating tab 1 mg (Risperdal m-tab).................................................................................... 51




risperidone soln 1 mg/ml (Risperdal).................................51risperidone tab 0.25 mg (Risperdal)..................................51risperidone tab 0.5 mg (Risperdal)....................................52risperidone tab 1 mg (Risperdal).......................................52risperidone tab 2 mg (Risperdal).......................................52risperidone tab 3 mg (Risperdal).......................................52risperidone tab 4 mg (Risperdal).......................................52RIXUBIS – coagulation factor ix (recombinant) for inj 250unit.....................................................................................76

RIXUBIS – coagulation factor ix (recombinant) for inj 500unit.....................................................................................76




rizatriptan benzoate oral disintegrating tab 5 mg (base eq)(Maxalt-mlt)....................................................................... 63

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................63

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)............................................................................. 63

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 63

ropinirole hydrochloride tab 0.25 mg (Requip)..................67ropinirole hydrochloride tab 0.5 mg (Requip)....................67ropinirole hydrochloride tab 1 mg (Requip).......................67ropinirole hydrochloride tab 2 mg (Requip).......................67ropinirole hydrochloride tab 3 mg (Requip).......................67

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108

ropinirole hydrochloride tab 4 mg (Requip).......................67ropinirole hydrochloride tab 5 mg (Requip).......................67rosuvastatin calcium tab 5 mg (Crestor)........................... 31rosuvastatin calcium tab 10 mg (Crestor)......................... 31rosuvastatin calcium tab 20 mg (Crestor)......................... 31rosuvastatin calcium tab 40 mg (Crestor)......................... 31RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................12

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................12

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................12

RU-HIST D – brompheniramine & phenylephrine tab 4-10mg......................................................................................36

RYDAPT – midostaurin cap 25 mg................................... 12

Ssaline nasal spray 0.65%...................................................35salsalate tab 500 mg..........................................................57salsalate tab 750 mg..........................................................57selegiline hcl cap 5 mg (Eldepryl)..................................... 67selegiline hcl tab 5 mg.......................................................67selenium sulfide lotion 2.5%.............................................. 83SELZENTRY – maraviroc tab 25 mg.................................. 7SELZENTRY – maraviroc tab 75 mg.................................. 7SELZENTRY – maraviroc tab 300 mg................................ 7sennosides tab 8.6 mg...................................................... 39SEREVENT DISKUS – salmeterol xinafoate aer pow ba50 mcg/dose (base equiv)............................................... 38

sertraline hcl oral conc 20 mg/ml (Zoloft)..........................47sertraline hcl tab 25 mg (Zoloft)........................................ 47sertraline hcl tab 50 mg (Zoloft)........................................ 47sertraline hcl tab 100 mg (Zoloft)...................................... 47sildenafil citrate tab 20 mg (Revatio).................................34silver sulfadiazine cream 1% (Silvadene)......................... 81simethicone chew tab 80 mg.............................................42simethicone susp 40 mg/0.6ml..........................................42simvastatin tab 5 mg (Zocor).............................................31simvastatin tab 10 mg (Zocor)...........................................31simvastatin tab 20 mg (Zocor)...........................................31simvastatin tab 40 mg (Zocor)...........................................31sirolimus tab 0.5 mg (Rapamune)..................................... 85sirolimus tab 1 mg (Rapamune)........................................ 85sirolimus tab 2 mg (Rapamune)........................................ 85SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total)............................................................................17

sodium chloride irrigation soln 0.9%..................................44sodium chloride soln nebu 0.9%....................................... 36sodium chloride soln nebu 3%.......................................... 36sodium chloride soln nebu 10%........................................ 36sodium chloride soln nebu 7% (Hyper-sal)....................... 36sodium citrate & citric acid soln 500-334 mg/5ml (Shohlssolution modi)................................................................... 44

sodium fluoride chew tab 0.25 mg f (from 0.55 mgnaf).................................................................................... 70

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)........70

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)...........70sodium fluoride cream 1.1% (Prevident 5000 plus).......... 79sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......79sodium fluoride rinse 0.2%................................................ 79SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)....................................................................... 70

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................... 70

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)......70sodium polystyrene sulfonate oral susp 15 gm/60ml........ 85sodium polystyrene sulfonate powder............................... 85sodium polystyrene sulfonate rectal susp 30gm/120ml...........................................................................85

sotalol hcl tab 240 mg....................................................... 33sotalol hcl tab 80 mg (Betapace).......................................33sotalol hcl tab 120 mg (Betapace).....................................33sotalol hcl tab 160 mg (Betapace).....................................33SOVALDI – sofosbuvir tab 400 mg..................................... 4SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (base equiv).................. 38

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 32

spironolactone tab 25 mg (Aldactone)...............................32spironolactone tab 50 mg (Aldactone)...............................32spironolactone tab 100 mg (Aldactone)............................ 32SPRYCEL – dasatinib tab 20 mg...................................... 12SPRYCEL – dasatinib tab 50 mg...................................... 12SPRYCEL – dasatinib tab 70 mg...................................... 12SPRYCEL – dasatinib tab 80 mg...................................... 12SPRYCEL – dasatinib tab 100 mg.................................... 12SPRYCEL – dasatinib tab 140 mg.................................... 12stavudine cap 15 mg (Zerit).................................................7stavudine cap 20 mg (Zerit).................................................7stavudine cap 30 mg (Zerit).................................................7stavudine cap 40 mg (Zerit).................................................7STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................22

STIVARGA – regorafenib tab 40 mg................................. 12SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................60

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................60

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................60

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................60

sucralfate tab 1 gm (Carafate)...........................................41sulfacetamide sodium ophth soln 10% (Bleph-10)............77sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%................................................................. 78

sulfacetamide sodium w/ sulfur emulsion 10-1%.............. 80sulfacetamide sodium w/ sulfur emulsion 10-5%.............. 80SULFADIAZINE – sulfadiazine tab 500 mg.........................3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml......... 9sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)..............................................................................9

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109

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)........................................................................................9

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................42

sulfasalazine tab 500 mg (Azulfidine)................................42sulindac tab 150 mg...........................................................63sulindac tab 200 mg...........................................................63sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................63sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 63

sumatriptan succinate tab 25 mg (Imitrex)........................63sumatriptan succinate tab 50 mg (Imitrex)........................63sumatriptan succinate tab 100 mg (Imitrex)......................63SUSTIVA – efavirenz cap 50 mg.........................................7SUSTIVA – efavirenz cap 200 mg.......................................7SUSTIVA – efavirenz tab 600 mg....................................... 7SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................12

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................13

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................13

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................13

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................38

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................38

SYNAGIS – palivizumab im soln 50 mg/0.5ml..................10SYNAGIS – palivizumab im soln 100 mg/ml.....................10

Ttacrolimus cap 0.5 mg (Prograf)........................................85tacrolimus cap 1 mg (Prograf)...........................................85tacrolimus cap 5 mg (Prograf)...........................................85tacrolimus oint 0.03% (Protopic)........................................83tacrolimus oint 0.1% (Protopic)..........................................83TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (baseequiv)...................................................................................8

tamoxifen citrate tab 10 mg (base equivalent).................. 13tamoxifen citrate tab 20 mg (base equivalent).................. 13tamsulosin hcl cap 0.4 mg (Flomax)................................. 44TARCEVA – erlotinib hcl tab 25 mg (base equivalent)......13TARCEVA – erlotinib hcl tab 100 mg (baseequivalent).........................................................................13

TARCEVA – erlotinib hcl tab 150 mg (baseequivalent).........................................................................13

TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................13

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................13

tazarotene cream 0.1% (Tazorac)..................................... 80TAZORAC – tazarotene gel 0.05%................................... 80TAZORAC – tazarotene gel 0.1%..................................... 80TECHLITE PEN NEEDLES 29G....................................... 84temazepam cap 15 mg (Restoril)...................................... 53

temazepam cap 30 mg (Restoril)...................................... 53temozolomide cap 5 mg (Temodar)...................................13temozolomide cap 20 mg (Temodar).................................13temozolomide cap 100 mg (Temodar)...............................13temozolomide cap 140 mg (Temodar)...............................13temozolomide cap 180 mg (Temodar)...............................13temozolomide cap 250 mg (Temodar)...............................13terazosin hcl cap 1 mg...................................................... 34terazosin hcl cap 2 mg...................................................... 34terazosin hcl cap 5 mg...................................................... 34terazosin hcl cap 10 mg.................................................... 34terbinafine hcl tab 250 mg (Lamisil).................................... 4terbutaline sulfate tab 2.5 mg............................................38terbutaline sulfate tab 5 mg...............................................38terconazole vaginal cream 0.8%....................................... 43terconazole vaginal cream 0.4% (Terazol 7).....................43terconazole vaginal suppos 80 mg....................................43testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)..................................................................... 15

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)..................................................................... 15

testosterone enanthate im inj in oil 200 mg/ml..................15tetracaine hcl ophth soln 0.5%.......................................... 79tetrahydroz-dextran-peg-povidone ophth soln0.05-0.1-1-1%................................................................... 79

THALOMID – thalidomide cap 50 mg............................... 85THALOMID – thalidomide cap 100 mg............................. 85THALOMID – thalidomide cap 150 mg............................. 85theophylline soln 80 mg/15ml............................................38theophylline tab er 12hr 100 mg........................................38theophylline tab er 12hr 200 mg........................................38theophylline tab er 12hr 300 mg........................................38theophylline tab er 12hr 450 mg........................................38theophylline tab er 24hr 400 mg........................................38theophylline tab er 24hr 600 mg........................................38thiamine hcl tab 50 mg...................................................... 69thiamine hcl tab 100 mg.................................................... 69thioridazine hcl tab 10 mg................................................. 52thioridazine hcl tab 25 mg................................................. 52thioridazine hcl tab 50 mg................................................. 52thioridazine hcl tab 100 mg............................................... 52thiothixene cap 1 mg..........................................................52thiothixene cap 2 mg..........................................................52thiothixene cap 5 mg..........................................................52thiothixene cap 10 mg........................................................52thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................21thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............21thyroid tab 60 mg (1 grain) (Armour thyroid).....................21timolol maleate ophth soln 0.25% (Timoptic).................... 78timolol maleate ophth soln 0.5% (Timoptic)...................... 78tioconazole vaginal oint 6.5%............................................43TIVICAY – dolutegravir sodium tab 10 mg (base equiv)..... 7TIVICAY – dolutegravir sodium tab 25 mg (base equiv)..... 7TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 7tizanidine hcl tab 2 mg (base equivalent)..........................67tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........67

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110

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex)......................................................................... 78

tobramycin nebu soln 300 mg/5ml (Tobi)............................ 3tobramycin ophth soln 0.3% (Tobrex)................................77TOLAZAMIDE – tolazamide tab 250 mg...........................19tolnaftate aerosol 1%......................................................... 81topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 66topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 66topiramate tab 25 mg (Topamax)...................................... 66topiramate tab 50 mg (Topamax)...................................... 66topiramate tab 100 mg (Topamax).................................... 66topiramate tab 200 mg (Topamax).................................... 66torsemide tab 5 mg............................................................32torsemide tab 100 mg........................................................32torsemide tab 10 mg (Demadex).......................................32torsemide tab 20 mg (Demadex).......................................32TRACLEER – bosentan tab 62.5 mg................................ 34TRACLEER – bosentan tab 125 mg................................. 34tramadol hcl tab 50 mg (Ultram)........................................60trandolapril tab 1 mg..........................................................24trandolapril tab 4 mg..........................................................24trandolapril tab 2 mg (Mavik).............................................24tranexamic acid tab 650 mg (Lysteda).............................. 76trazodone hcl tab 50 mg....................................................47trazodone hcl tab 100 mg..................................................47trazodone hcl tab 150 mg..................................................47tretinoin cap 10 mg............................................................ 13tretinoin cream 0.025% (Retin-a).......................................80tretinoin cream 0.05% (Retin-a).........................................80tretinoin cream 0.1% (Retin-a)...........................................80tretinoin gel 0.01% (Retin-a)..............................................80tretinoin gel 0.025% (Retin-a)............................................80triamcinolone acetonide cream 0.025%............................ 82triamcinolone acetonide cream 0.1%................................ 82triamcinolone acetonide cream 0.5%................................ 82triamcinolone acetonide dental paste 0.1%...................... 79triamcinolone acetonide lotion 0.025%..............................82triamcinolone acetonide lotion 0.1%..................................82triamcinolone acetonide oint 0.025%................................ 82triamcinolone acetonide oint 0.1%.....................................82TRIAMINIC NIGHT TIME COLD – diphenhydramine-phenylephrine syrup 6.25-2.5 mg/5ml............................. 36

triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................32

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 32

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................32

trifluoperazine hcl tab 1 mg (base equivalent).................. 52trifluoperazine hcl tab 2 mg (base equivalent).................. 52trifluoperazine hcl tab 5 mg (base equivalent).................. 52trifluoperazine hcl tab 10 mg (base equivalent)................ 52trifluridine ophth soln 1% (Viroptic)....................................77trihexyphenidyl hcl elixir 0.4 mg/ml....................................67trihexyphenidyl hcl tab 2 mg..............................................67trihexyphenidyl hcl tab 5 mg..............................................67

trimethoprim tab 100 mg......................................................9TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400unit-35 mg/ml....................................................................69

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg.................................................................. 7




TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml.............................................................. 22

Uursodiol cap 300 mg (Actigall)...........................................42ursodiol tab 250 mg (Urso 250).........................................42ursodiol tab 500 mg (Urso forte)....................................... 42

Vvalacyclovir hcl tab 1 gm (Valtrex).......................................5valacyclovir hcl tab 500 mg (Valtrex)...................................5VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent).........................................................................83

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 4

valproate sodium oral soln 250 mg/5ml (base equiv)(Depakene)....................................................................... 66

valproic acid cap 250 mg (Depakene)...............................66valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................25

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................25

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................25

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................25

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................25

valsartan tab 40 mg (Diovan)............................................ 25valsartan tab 80 mg (Diovan)............................................ 25valsartan tab 160 mg (Diovan).......................................... 25valsartan tab 320 mg (Diovan).......................................... 25vancomycin hcl cap 125 mg (Vancocin hcl)........................9vancomycin hcl cap 250 mg (Vancocin hcl)........................9venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 47

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 47

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 48

venlafaxine hcl tab 25 mg..................................................48venlafaxine hcl tab 37.5 mg...............................................48venlafaxine hcl tab 50 mg..................................................48venlafaxine hcl tab 75 mg..................................................48venlafaxine hcl tab 100 mg................................................48

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VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv)..........................................................38

verapamil hcl cap er 24hr 120 mg (Verelan).....................28verapamil hcl cap er 24hr 180 mg (Verelan).....................28verapamil hcl cap er 24hr 240 mg (Verelan).....................28verapamil hcl cap er 24hr 360 mg (Verelan).....................28verapamil hcl cap er 24hr 100 mg (Verelan pm)...............28verapamil hcl cap er 24hr 200 mg (Verelan pm)...............28verapamil hcl cap er 24hr 300 mg (Verelan pm)...............28verapamil hcl tab er 120 mg (Calan sr).............................28verapamil hcl tab er 180 mg (Calan sr).............................28verapamil hcl tab er 240 mg (Calan sr).............................28verapamil hcl tab 40 mg.................................................... 28verapamil hcl tab 80 mg (Calan)....................................... 28verapamil hcl tab 120 mg (Calan)..................................... 28VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................20

VIDEX – didanosine for soln 2 gm......................................7VIDEX – didanosine for soln 4 gm......................................7VIRACEPT – nelfinavir mesylate tab 250 mg..................... 7VIRACEPT – nelfinavir mesylate tab 625 mg..................... 7VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 7VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm..................................................................................7

VIREAD – tenofovir disoproxil fumarate tab 150 mg...........7VIREAD – tenofovir disoproxil fumarate tab 200 mg...........7VIREAD – tenofovir disoproxil fumarate tab 250 mg...........7VIREAD – tenofovir disoproxil fumarate tab 300 mg...........7vitamins a & d oint............................................................. 83VIVITROL – naltrexone for im extended release susp 380mg......................................................................................57

voriconazole for susp 40 mg/ml (Vfend)..............................4voriconazole tab 50 mg (Vfend).......................................... 4voriconazole tab 200 mg (Vfend)........................................ 4VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......13

Wwarfarin sodium tab 1 mg (Coumadin)..............................76warfarin sodium tab 2 mg (Coumadin)..............................76warfarin sodium tab 2.5 mg (Coumadin)...........................76warfarin sodium tab 3 mg (Coumadin)..............................76warfarin sodium tab 4 mg (Coumadin)..............................76warfarin sodium tab 5 mg (Coumadin)..............................76warfarin sodium tab 6 mg (Coumadin)..............................76warfarin sodium tab 7.5 mg (Coumadin)...........................76warfarin sodium tab 10 mg (Coumadin)............................76water for irrigation, sterile irrigation soln........................... 85

XXALKORI – crizotinib cap 200 mg.....................................13XALKORI – crizotinib cap 250 mg.....................................13XARELTO – rivaroxaban tab 10 mg..................................76XARELTO – rivaroxaban tab 15 mg..................................76XARELTO – rivaroxaban tab 20 mg..................................76XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg.......................................... 76

XIFAXAN – rifaximin tab 200 mg.........................................9XIFAXAN – rifaximin tab 550 mg.........................................9XTANDI – enzalutamide cap 40 mg.................................. 13XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 17

XYNTHA – antihemophilic factor recombinant paf for inj kit250 unit............................................................................. 76

XYNTHA – antihemophilic factor recombinant paf for inj kit500 unit............................................................................. 76

XYNTHA – antihemophilic factor recombinant paf for inj kit1000 unit........................................................................... 76

XYNTHA – antihemophilic factor recombinant paf for inj kit2000 unit........................................................................... 77

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 250 unit.................................. 77

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 500 unit.................................. 77

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 1000 unit................................ 77



XYREM – sodium oxybate oral solution 500 mg/ml..........57

Y

Zzaleplon cap 5 mg (Sonata).............................................. 53zaleplon cap 10 mg (Sonata)............................................ 53ZARXIO – filgrastim-sndz soln prefilled syringe 300mcg/0.5ml..........................................................................77

ZARXIO – filgrastim-sndz soln prefilled syringe 480mcg/0.8ml..........................................................................77

ZELBORAF – vemurafenib tab 240 mg............................ 13ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit.................................................... 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-27000 unit.................................................... 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-34000-55000 unit.................................................. 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap15000-51000-82000 unit.................................................. 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap20000-68000-109000 unit................................................ 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-85000-136000 unit................................................ 42

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit.............................................. 42

ZEPATIER – elbasvir-grazoprevir tab 50-100 mg............... 5zidovudine cap 100 mg (Retrovir)....................................... 7zidovudine syrup 10 mg/ml (Retrovir)..................................7zidovudine tab 300 mg.........................................................8zinc oxide oint 10%............................................................83zinc oxide oint 20%............................................................83ziprasidone hcl cap 20 mg (Geodon)................................ 52ziprasidone hcl cap 40 mg (Geodon)................................ 52

2017

112

ziprasidone hcl cap 60 mg (Geodon)................................ 52ziprasidone hcl cap 80 mg (Geodon)................................ 52zolpidem tartrate tab 5 mg (Ambien).................................53zolpidem tartrate tab 10 mg (Ambien)...............................53zonisamide cap 50 mg.......................................................66zonisamide cap 25 mg (Zonegran)....................................66zonisamide cap 100 mg (Zonegran)..................................66ZORTRESS – everolimus tab 0.25 mg............................. 85ZORTRESS – everolimus tab 0.5 mg............................... 85ZORTRESS – everolimus tab 0.75 mg............................. 85ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab1.4-0.36 mg (base eq)......................................................60

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab2.9-0.71 mg (base eq)......................................................60

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4mg (base eq).................................................................... 60

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1mg (base eq).................................................................... 61

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab11.4-2.9 mg (base eq)......................................................61

ZYCLARA – imiquimod cream 3.75%............................... 83ZYCLARA PUMP – imiquimod cream 2.5%......................83ZYCLARA PUMP – imiquimod cream 3.75%....................83ZYTIGA – abiraterone acetate tab 250 mg....................... 13ZYTIGA – abiraterone acetate tab 500 mg....................... 14ZYVOX – linezolid for susp 100 mg/5ml............................. 9

Este formulario fue actualizado el 12/1/2017.

Blue Cross Community Family Health Plan es proporcionado por Blue Cross and Blue Shield of Illinois, una división de Health Care Service Corporation, una compañía mutua de reserva legal (HCSC), un licenciatario independiente de Blue Cross and Blue Shield Association.

blue cross and blue shield of illinois lista de ...lista de medicamentos vigente al 12/1/2017, fecha...

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