lista de medicamentos de 2018 (lista de medicamentos con … · 2019. 9. 30. · lista de...

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Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage Select (HMO) SM Blue Cross Medicare Advantage Value (HMO) SM Y0096_MRK_MAPDFRM_TMP18_FINAL_TX_HMOf2SPA Accepted 09042017 746601.1118 POR FAVOR, LEA ESTE DOCUMENTO: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN HPMS Approved Formulary File ID: 00018146, Versión 15 Esta lista de medicamentos se actualizó el 11/16/2018. Para obtener información más reciente o si tiene alguna pregunta, comuníquese con Servicio al Cliente de Blue Cross Medicare Advantage SM , al 1-877-774-8592 o, para usuarios de TTY/TDD, al 7-1-1, de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si llama del 15 de febrero al 30 de septiembre durante los fines de semana y días feriados, se usarán tecnologías alternativas (por ejemplo, correo de voz); o bien visite www.getbluetx.com/mapd/druglist.

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Page 1: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

Lista de medicamentos de 2018 (Lista de medicamentos con cobertura)Blue Cross Medicare Advantage Select (HMO)SM Blue Cross Medicare Advantage Value (HMO)SM

Y0096_MRK_MAPDFRM_TMP18_FINAL_TX_HMOf2SPA Accepted 09042017 746601.1118

POR FAVOR, LEA ESTE DOCUMENTO: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

HPMS Approved Formulary File ID: 00018146, Versión 15

Esta lista de medicamentos se actualizó el 11/16/2018. Para obtener información más reciente o si tiene alguna pregunta, comuníquese con Servicio al Cliente de Blue Cross Medicare AdvantageSM, al 1-877-774-8592 o, para usuarios de TTY/TDD, al 7-1-1, de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si llama del 15 de febrero al 30 de septiembre durante los fines de semana y días feriados, se usarán tecnologías alternativas (por ejemplo, correo de voz); o bien visite www.getbluetx.com/mapd/druglist.

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This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592 (TTY/TDD users should call 711). We are open between 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al Cliente al 1-877-774-8592 (los usuarios de TTY/TDD deben llamar al 7-1-1). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y días feriados se usarán tecnologías alternativas (por ejemplo, correo de voz).

POR FAVOR, LEA ESTE DOCUMENTO: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Nota para los asegurados existentes: Esta lista de medicamentos cambió con respecto a la del año pasado. Repase este documento para asegurarse de que todavía incluye los medicamentos que usted recibe.

Cuando esta lista de medicamentos se refiere a “nosotros”, “nos” o “nuestro”, significa GHS Insurance Company (GHS). Cuando se refiere a “el plan” o “nuestro plan”, significa Blue Cross Medicare Advantage.

Este documento incluye una lista de medicamentos para nuestro plan que está vigente desde noviembre de 2018. Para obtener una lista de medicamentos actualizada, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos la lista de medicamentos por última vez, aparece en la portada y en la contraportada.

Generalmente tiene que acudir a farmacias de la red para usar su beneficio de medicamentos con receta. Los beneficios, la lista de medicamentos, la red de farmacias y/o los copagos/coseguros pueden cambiar el 1.º de enero de 2018 y ocasionalmente durante el año.

Blue Cross Medicare Advantage

Lista de medicamentos de 2018 (Lista de medicamentos con cobertura)

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¿Qué es la Lista de medicamentos de Blue Cross Medicare Advantage?Es una Lista de medicamentos con cobertura seleccionados por Blue Cross Medicare Advantage en consulta con un equipo de profesionales de la salud que representa las terapias de medicamentos con receta que se consideran una parte necesaria de un programa de tratamiento de calidad. Blue Cross Medicare Advantage generalmente cubrirá los medicamentos incluidos en nuestra Lista de medicamentos siempre y cuando el medicamento sea necesario desde el punto de vista médico, se surta en una farmacia de la red de Blue Cross Medicare Advantage y se sigan otras reglas del plan. Para obtener más información acerca de cómo surtir sus medicamentos con receta, revise su Evidencia de Cobertura.

¿Puede cambiar la lista de medicamentos?Por lo general, si está recibiendo un medicamento que figura en nuestra lista de medicamentos de 2018 y que estaba cubierto a principio de año, no descontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2018, a menos que empiece a comercializarse un medicamento genérico nuevo y más económico o que se publique información nueva adversa sobre la seguridad o la eficacia del medicamento. Otros tipos de cambios de la lista de medicamentos, como la eliminación de un medicamento de la lista, no afectarán a los asegurados que estén recibiendo dicho medicamento actualmente. El medicamento seguirá disponible al mismo costo compartido para aquellos asegurados que estén recibiéndolo durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo, por el resto del año de cobertura, a los medicamentos de la lista de medicamentos que estaban disponibles cuando usted eligió su plan, excepto para los casos en los que usted puede ahorrar más dinero o nosotros podemos garantizar su seguridad. Si eliminamos medicamentos de nuestra lista, si agregamos autorizaciones previas, cantidades límite y/o restricciones a las terapias escalonadas para un medicamento o si cambiamos un medicamento a un nivel más alto de costos compartidos, tenemos que notificar a los asegurados afectados sobre el cambio al menos 60 días antes de que el cambio entre en vigor, o cuando el asegurado vuelva a surtir el medicamento, en cuyo momento el asegurado recibirá un suministro para 60 días del medicamento. Si la Administración de Medicamentos y Alimentos (FDA, en inglés) considera que un medicamento que figura en nuestra lista de medicamentos no es seguro o si el fabricante del medicamento lo retira del mercado, nosotros eliminaremos el medicamento de nuestra lista de medicamentos inmediatamente y les notificaremos a los asegurados que reciben el medicamento. La lista de medicamentos adjunta está vigente desde el 16 de noviembre de 2018. Para obtener información actualizada sobre los medicamentos cubiertos por Blue Cross Medicare Advantage, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y en la contraportada.

¿Cómo uso la lista de medicamentos? Hay dos maneras de encontrar un medicamento en la lista:

Problema de saludLa Lista de medicamentos comienza en la página 1. Los medicamentos incluidos en esta lista están agrupados por categorías según el tipo de problema de salud que tratan. Por ejemplo, los medicamentos que se usan para tratar una enfermedad cardíaca figuran dentro de la categoría Agentes cardiovasculares. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego, busque el medicamento debajo del nombre de la categoría.

Lista alfabéticaSi no está seguro sobre qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 103. El Índice provee una lista alfabética de todos los medicamentos incluidos en este documento. Se incluyen tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Al lado del medicamento, verá el número de la página en la que puede encontrar información de cobertura. Encuentre la página indicada en el Índice y busque el nombre del medicamento en la primera columna de la lista.

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¿Qué son los medicamentos genéricos?Blue Cross Medicare Advantage cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA y tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

¿Existe alguna restricción sobre mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir lo siguiente:

• Autorización previa: Blue Cross Medicare Advantage requiere que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener la aprobación de Blue Cross Medicare Advantage antes de comprar sus medicamentos recetados. Si no obtiene la aprobación, Blue Cross Medicare Advantage posiblemente no cubra el medicamento.

• Límites que rigen la cantidad: Para ciertos medicamentos, Blue Cross Medicare Advantage limita la cantidad de medicamentos que cubrirá. Por ejemplo, Blue Cross Medicare Advantage provee 30 tabletas por receta médica para alfuzosin ER. Esto puede ser además de un suministro estándar para un mes o tres meses.

• Terapia escalonada: En algunos casos, Blue Cross Medicare Advantage requiere que pruebe ciertos medicamentos para tratar su problema de salud antes de cubrir otro medicamento para ese problema. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su problema de salud, Blue Cross Medicare Advantage podría no cubrir el medicamento B a menos que intente usar el medicamento A primero. Si el medicamento A no funciona para usted, entonces Blue Cross Medicare Advantage cubrirá el medicamento B.

Puede averiguar si su medicamento tiene algún requisito o límite adicionales al consultar la Lista de medicamentos que comienza en la página 1. También puede obtener más información acerca de las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio web. Publicamos documentos en línea que explican nuestras restricciones de autorización previa y terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en la que actualizamos la lista de medicamentos por última vez, aparece en la portada y en la contraportada.

Usted puede solicitar a Blue Cross Medicare Advantage que haga una excepción a estas restricciones o límites, o pedir una lista de otros medicamentos similares que podrían tratar su problema de salud. Consulte la sección “¿Cómo solicito una excepción a la Lista de medicamentos de Blue Cross Medicare Advantage?” que se encuentra en la página iv para obtener información acerca de cómo solicitar una excepción.

¿Qué sucede si mi medicamento no está en la lista de medicamentos?Si su medicamento no está incluido en esta lista de medicamentos cubiertos, primero debe comunicarse con Servicio al Cliente y preguntar si su medicamento está cubierto.

Si descubre que Blue Cross Medicare Advantage no cubre su medicamento, usted tiene dos opciones:

• Puede solicitar a Servicio al Cliente una Lista de medicamentos similares que estén cubiertos por Blue Cross Medicare Advantage. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Blue Cross Medicare Advantage.

• Puede solicitar a Blue Cross Medicare Advantage que haga una excepción y que cubra su medicamento. Consulte a continuación para obtener información sobre cómo solicitar una excepción.

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¿Cómo solicito una excepción a la Lista de medicamentos de Blue Cross Medicare Advantage?Puede solicitar a Blue Cross Medicare Advantage que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos.

• Puede solicitarnos que cubramos un medicamento, incluso si no está en nuestra lista de medicamentos. Si lo aprobamos, este medicamento estará cubierto con un nivel predeterminado de costos compartidos y usted no podrá solicitarnos que brindemos el medicamento a un nivel inferior de costos compartidos.

• Puede solicitarnos que cubramos un medicamento de la lista con un nivel de costos compartidos inferior, si este medicamento no está en el nivel de medicamentos especializados. Si se aprueba, esto reducirá el monto que tiene que pagar por su medicamento.

• Puede solicitarnos que eximamos las restricciones o límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, Blue Cross Medicare Advantage limita la cantidad del medicamento que cubriremos. Si su medicamento tiene una cantidad límite, puede solicitarnos que eximamos el límite y cubramos un monto mayor.

Por lo general, Blue Cross Medicare Advantage solo aprobará su solicitud de excepción si los medicamentos alternativos que están incluidos en la Lista de medicamentos del plan, el medicamento con los costos compartidos más bajos o las restricciones adicionales de uso no fueran tan eficaces para tratar su problema y/o le provocaran efectos médicos adversos.

Debe comunicarse con nosotros para pedirnos una decisión de cobertura inicial de una excepción a las restricciones de la lista de medicamentos, en los niveles o en el uso. Cuando solicite una excepción a las restricciones de la lista de medicamentos, en los niveles o en el uso, debe presentar una declaración de la persona que le receta o del médico que respalde su solicitud. Por lo general, tenemos que tomar nuestra decisión dentro de las 72 horas posteriores a la recepción de la declaración de respaldo de la persona que le receta. Puede solicitar una excepción acelerada (rápida), si usted o su médico consideran que su salud podría perjudicarse seriamente si espera hasta 72 horas por una decisión. Si se acepta su solicitud de excepción acelerada, tenemos que proporcionarle una decisión dentro de las 24 horas después de haber recibido una declaración de respaldo de su médico u otra persona que receta.

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¿Qué hago antes de que pueda hablar con mi médico sobre un cambio en mis medicamentos o solicitar una excepción?Como asegurado nuevo o continuo de nuestro plan, es posible que esté recibiendo medicamentos que no se encuentran en nuestra lista de medicamentos. O bien, quizá usted esté recibiendo un medicamento que está en nuestra lista de medicamentos pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte antes de que pueda comprar su medicamento con receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción a la lista de medicamentos para que le cubramos el medicamento que recibe. Mientras habla con su médico para determinar la medida correcta a tomar, es posible que cubramos su medicamento en ciertos casos durante los primeros 90 días que usted esté asegurado en nuestro plan.Para cada uno de sus medicamentos que no esté en nuestra lista de medicamentos o si su capacidad para obtener medicamentos es limitada, cubriremos un suministro provisional de 30 días (a menos que tenga una receta médica por menos días) cuando acuda a una farmacia de la red. Luego del suministro de 30 días, no pagaremos estos medicamentos, incluso si ha sido un asegurado del plan durante menos de 90 días. Si es residente de un centro de atención médica a largo plazo, le permitiremos volver a surtir su receta médica hasta que le hayamos brindado un suministro de transición durante un máximo de 98 días, en consonancia con el incremento en el despacho (a menos que tenga una receta médica para menos días). Cubriremos más de un surtido de estos medicamentos durante los primeros 90 días que usted esté asegurado en nuestro plan. Si necesita un medicamento que no está incluido en nuestra Lista de medicamentos o si su capacidad para obtener su medicamento es limitada, pero ya han pasado más de los primeros 90 días desde que su plan entró en vigor, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que usted tenga una receta médica por menos días) mientras tramita una excepción a la Lista de medicamentos. Puede experimentar cambios entre un tratamiento y otro. Durante este cambio de nivel de atención, quizá se le receten medicamentos que no estén cubiertos por nuestro plan. Si esto ocurre, usted y su médico tienen que usar los procesos de apelaciones y excepciones de su plan. Sin embargo, cuando se le admite, o se le da de alta, de un centro de atención médica a largo plazo (LTC, en inglés), quizá no tenga acceso a los medicamentos que recibió previamente. Puede volver a surtir su receta al ser admitido o dado de alta para evitar una interrupción en la atención.

Para obtener más informaciónPara obtener información más precisa acerca de la cobertura de medicamentos recetados de Blue Cross Medicare Advantage, repase su Evidencia de Cobertura y los otros materiales del plan.Si tiene preguntas acerca de Blue Cross Medicare Advantage, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos la lista de medicamentos por última vez, aparece en la portada y en la contraportada.Si tiene preguntas generales acerca de la cobertura de medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite http://www.medicare.gov.

Lista de medicamentos de Blue Cross Medicare AdvantageLa siguiente lista de medicamentos brinda información de cobertura sobre los medicamentos cubiertos por Blue Cross Medicare Advantage. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 103.La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo, LANTUS) y los medicamentos genéricos están en minúsculas cursivas (por ejemplo, metformina). La información en la columna de Requisitos/Límites indica si Blue Cross Medicare Advantage tiene algún requisito especial para la cobertura de su medicamento.Todos los medicamentos incluidos en esta lista de medicamentos están disponibles a través del beneficio de entrega a domicilio. Comuníquese con nosotros para obtener más información. Nuestra información de contacto aparece en la portada y en la contraportada.

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CLAVENivel 1 = medicamentos genéricos preferidosNivel 2 = medicamentos genéricosNivel 3 = medicamentos de marca preferidosNivel 4 = medicamentos de marca no preferidosNivel 5 = medicamentos especializados

BD = los medicamentos que pueden estar cubiertos por la Parte B o la Parte D de Medicare, según las circunstancias. Estos medicamentos requieren autorización previa para determinar la cobertura de la Parte B o la Parte D. Es posible que deba proporcionarse información que describa el uso o el lugar donde el medicamento se recibe para determinar la cobertura.PA = autorización previaQL = cantidad límiteST = terapia escalonada* = medicamentos de distribución limitada. Es posible que este medicamento recetado esté disponible únicamente en determinadas farmacias. Para obtener más información, consulte el Directorio de farmacias o llame a Servicio al Cliente al 1-877-774-8592, de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y días feriados se usarán tecnologías alternativas (por ejemplo, correo de voz). Los usuarios de TTY deben llamar al 711.# = medicamentos de alto riesgo (HRM, en inglés). Medicamentos que podrían ser perjudiciales en pacientes de más de 65 años. Nuestra lista de medicamentos incluye cobertura para algunos de estos medicamentos, pero puede encontrar alternativas en los niveles de copago más bajos. Trate el tema con su médico para ver si existen alternativas a estos medicamentos que podrían ser adecuadas para usted.^ = brindamos cobertura adicional de este medicamento recetado en la interrupción en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener más información sobre esta cobertura.

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Montos de copago y coseguro:Nivel 1 – Medicamentos genéricos preferidos: $0/$5Nivel 2 – Medicamentos genéricos: $8/$19Nivel 3 – Medicamentos de marca preferidos: $39/$47Nivel 4 – Medicamentos de marca no preferidos: $95/$100Nivel 5 – Medicamentos especializados: 33%/33%Usted tiene que seguir pagando su prima de la Parte B de Medicare.Esta información no representa una descripción completa de los beneficios. Comuníquese con la aseguradora para obtener más información. Es posible que se apliquen limitaciones, copagos y restricciones. Los beneficios, las primas del seguro, los copagos y/o el coseguro pueden cambiar el 1.° de enero de cada año.La Lista de medicamentos, la red de farmacias y/o la red de profesionales de la salud pueden cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.A continuación, se muestra la clave para las abreviaturas usadas dentro de la lista de medicamentos.

CLAVE

act activación la de acción prolongada

ad adsorbido mcg microgramos

aer, aero aerosol meq miliequivalente

ba, breath act, breath activ activado por inhalación mg miligramos

bau unidades bioequivalentes de alergia ml mililitro

cap cápsulas mu unidades de millón

chew tab tableta masticable nebu núbulas

conc concentrado NF no está en la lista de medicamentos

conj conjugado odt tableta de desintegración oral

cr de liberación controlada oin, oint ungüento

crys cristales op, ophth oftálmico

dr difusión retrasada pak paquete

deter elemento disuasivo pow, powd polvo

ec recubrimiento entérico pf sin conservantes

el, eluanálisis de inmunoabsorción enzimática (enzyme-linked immunosorbent assay)

pfu unidades formadoras de placas

er, extend-release, extended, extended rel, xl, xr

difusión prolongada pref prellenado

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CLAVE (Continuación)

ext extracto recomb recombinante

g, gm gramo sl sublingual

gu genitourinario sol, soln solución

hr hora suppos supositorios

ig inmunoglobulina sus, susp suspensión

ir índice de reactividad sr de liberación lenta

inh, inhal inhalación syr jeringa

inj inyección tab, tabs tableta

im intramuscular td transdermal

iv intravenoso tl translingual

l litro unt unidad

lf unidades de floculación va vaginal

liqd líquido vac vacuna

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Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

1

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Medicamentos analgésicosABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 4 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 4 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 4butorphanol tartrate inj 2 mg/ml 4butorphanol tartrate nasal soln 10 mg/ml 4 QL (87.5 mls/30 days)celecoxib cap 50 mg^ 2 QL (60 capsules/30 days)celecoxib cap 100 mg^ 2 QL (60 capsules/30 days)celecoxib cap 200 mg^ 2 QL (60 capsules/30 days)celecoxib cap 400 mg^ 2 QL (30 capsules/30 days)codeine sulfate tab 15 mg 4 QL (180 tablets/30 days)codeine sulfate tab 30 mg 4 QL (180 tablets/30 days)codeine sulfate tab 60 mg 4 QL (180 tablets/30 days)diclofenac potassium tab 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium gel 1%^ 2 STdiclofenac sodium tab delayed release 25 mg^ 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg^ 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg^ 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg^ 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg^ 2 QL (90 tablets/30 days)etodolac cap 200 mg^ 2 QL (150 capsules/30 days)etodolac cap 300 mg^ 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg^ 2 QL (60 tablets/30 days)

Page 11: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.2

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

etodolac tab er 24hr 600 mg^ 2 QL (30 tablets/30 days)etodolac tab 400 mg^ 2 QL (60 tablets/30 days)etodolac tab 500 mg^ 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 5 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 5 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg^ 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg^ 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 4 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl liqd 1 mg/ml 4 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 10 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml^ 2 QL (4800 mls/30 days)ibuprofen tab 400 mg^ 2 QL (240 tablets/30 days)ibuprofen tab 600 mg^ 2 QL (150 tablets/30 days)ibuprofen tab 800 mg^ 2 QL (120 tablets/30 days)

Page 12: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

3

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 2 mg 4 QL (120 tablets/30 days)meloxicam tab 7.5 mg^ 2 QL (60 tablets/30 days)meloxicam tab 15 mg^ 2 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 4 BDmorphine sulfate inj pf 1 mg/ml 4 BDmorphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab er 15 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 PA, QL (90 tablets/30 days)nabumetone tab 500 mg^ 2 QL (120 tablets/30 days)nabumetone tab 750 mg^ 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg^ 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg^ 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml^ 2 QL (1800 mls/30 days)naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)naproxen tab 250 mg^ 2 QL (180 tablets/30 days)naproxen tab 375 mg^ 2 QL (120 tablets/30 days)naproxen tab 500 mg^ 2 QL (90 tablets/30 days)oxaprozin tab 600 mg^ 2 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)

Page 13: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.4

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg^ 2 QL (60 capsules/30 days)piroxicam cap 20 mg^ 2 QL (30 capsules/30 days)sulindac tab 150 mg^ 2 QL (60 tablets/30 days)sulindac tab 200 mg^ 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg^ 2 QL (240 tablets/30 days)ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 20 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 30 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 40 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 50 mg

4 PA, QL (60 capsules/30 days)

Medicamentos anestésicoslidocaine hcl gel 2%^ 2 PA, QL (150 mls/30 days)lidocaine hcl soln 4%^ 2 PAlidocaine hcl viscous soln 2%^ 2lidocaine oint 5%^ 2 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Agentes contra las adicciones y para tratar el abuso deacamprosate calcium tab delayed release 333 mg^ 2buprenorphine hcl sl tab 2 mg^ 2 PA, QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg^ 2 PA, QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 3 PA, QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 3 PA, QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg^ 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3

Page 14: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

5

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab1 mg

3

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

3

disulfiram tab 250 mg^ 2disulfiram tab 500 mg^ 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 3NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3naloxone hcl inj 0.4 mg/ml 3naloxone hcl inj 4 mg/10ml 3naltrexone hcl tab 50 mg^ 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBLOCADE - buprenorphine extended release soln pref syr

100 mg/0.5ml5

SUBLOCADE - buprenorphine extended release soln pref syr300 mg/1.5ml

5

SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 4 PA, QL (120 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 4 PA, QL (30 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 4 PA, QL (60 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 4 PA, QL (60 films/30 days)VIVITROL - naltrexone for im extended release susp 380 mg 5Medicamentos antibacterialesamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3amoxicillin (trihydrate) cap 250 mg^ 2amoxicillin (trihydrate) cap 500 mg^ 2amoxicillin (trihydrate) for susp 125 mg/5ml^ 2amoxicillin (trihydrate) for susp 200 mg/5ml^ 2amoxicillin (trihydrate) for susp 250 mg/5ml^ 2amoxicillin (trihydrate) for susp 400 mg/5ml^ 2amoxicillin (trihydrate) tab 500 mg^ 2amoxicillin (trihydrate) tab 875 mg^ 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml^ 2amoxicillin & k clavulanate for susp 400-57 mg/5ml^ 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml^ 2amoxicillin & k clavulanate tab 250-125 mg^ 2

Page 15: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.6

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

amoxicillin & k clavulanate tab 500-125 mg^ 2amoxicillin & k clavulanate tab 875-125 mg^ 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg4

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

4

ampicillin & sulbactam sodium for inj 3 (2-1) gm 3ampicillin cap 500 mg^ 2AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg 3ampicillin sodium for inj 500 mg 3ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm 3ampicillin sodium for iv soln 2 gm 3ampicillin sodium for iv soln 10 gm 3AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm3

AVELOX - moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8%inj

4

AZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in

dextrose inj 1 gm/50ml4

AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam indextrose inj 2 gm/50ml

4

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml^ 2azithromycin for susp 200 mg/5ml^ 2azithromycin iv for soln 500 mg 3azithromycin tab 250 mg^ 2azithromycin tab 500 mg^ 2azithromycin tab 600 mg^ 2aztreonam for inj 1 gm 3aztreonam for inj 2 gm 3BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

Page 16: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

7

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

cefaclor cap 250 mg^ 2cefaclor cap 500 mg^ 2cefadroxil cap 500 mg^ 2cefadroxil for susp 250 mg/5ml^ 2cefadroxil for susp 500 mg/5ml^ 2cefadroxil tab 1 gm^ 2CEFAZOLIN SODIUM - cefazolin sodium for inj 20 gm 3cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3cefdinir cap 300 mg^ 2cefdinir for susp 125 mg/5ml^ 2cefdinir for susp 250 mg/5ml^ 2cefepime hcl for inj 1 gm 3cefepime hcl for inj 2 gm 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 4CEFOTAXIME SODIUM - cefotaxime sodium for inj 2 gm 3cefotaxime sodium for inj 1 gm 3cefoxitin sodium for inj 10 gm 3cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml^ 2cefpodoxime proxetil for susp 100 mg/5ml^ 2cefpodoxime proxetil tab 100 mg^ 2cefpodoxime proxetil tab 200 mg^ 2cefprozil for susp 125 mg/5ml^ 2cefprozil for susp 250 mg/5ml^ 2cefprozil tab 250 mg^ 2cefprozil tab 500 mg^ 2ceftazidime for inj 1 gm 3ceftazidime for inj 2 gm 3ceftazidime for inj 6 gm 3ceftazidime for iv soln 1 gm 3ceftazidime for iv soln 2 gm 3CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml4

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

4

Page 17: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.8

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%4

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22%

4

cefuroxime axetil tab 250 mg^ 2cefuroxime axetil tab 500 mg^ 2cefuroxime sodium for inj 750 mg 3cefuroxime sodium for inj 7.5 gm 3cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg^ 2cephalexin cap 500 mg^ 2cephalexin cap 750 mg^ 2cephalexin for susp 125 mg/5ml^ 2cephalexin for susp 250 mg/5ml^ 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)^ 2ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)^ 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab er 24hr 500 mg^ 2ciprofloxacin hcl tab er 24hr 1000 mg^ 2ciprofloxacin hcl tab 250 mg^ 2ciprofloxacin hcl tab 500 mg^ 2ciprofloxacin hcl tab 750 mg^ 2ciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3clarithromycin for susp 125 mg/5ml^ 2clarithromycin for susp 250 mg/5ml^ 2clarithromycin tab er 24hr 500 mg^ 2clarithromycin tab 250 mg^ 2clarithromycin tab 500 mg^ 2clindamycin hcl cap 75 mg^ 2

Page 18: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

9

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

clindamycin hcl cap 150 mg^ 2clindamycin hcl cap 300 mg^ 2clindamycin phosphate gel 1%^ 2clindamycin phosphate in d5w iv soln 300 mg/50ml 3clindamycin phosphate in d5w iv soln 600 mg/50ml 3clindamycin phosphate in d5w iv soln 900 mg/50ml 3clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3clindamycin phosphate lotion 1%^ 2clindamycin phosphate soln 1%^ 2clindamycin phosphate swab 1%^ 2clindamycin phosphate vaginal cream 2%^ 2colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 4demeclocycline hcl tab 300 mg 4dicloxacillin sodium cap 250 mg^ 2dicloxacillin sodium cap 500 mg^ 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj 100 mg 3doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2doxycycline monohydrate cap 50 mg 3doxycycline monohydrate cap 75 mg 3doxycycline monohydrate cap 100 mg 3doxycycline monohydrate cap 150 mg 3doxycycline monohydrate tab 50 mg 3doxycycline monohydrate tab 75 mg 3doxycycline monohydrate tab 100 mg 3doxycycline monohydrate tab 150 mg 3

Page 19: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.10

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ertapenem sodium for inj 1 gm 4ERY-TAB - erythromycin tab delayed release 250 mg 4ERY-TAB - erythromycin tab delayed release 333 mg 4ERY-TAB - erythromycin tab delayed release 500 mg 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for

inj 500 mg3

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml^ 2erythromycin pads 2%^ 2erythromycin soln 2%^ 2erythromycin tab 250 mg 4erythromycin tab 500 mg 4gentamicin in saline inj 0.8 mg/ml 3gentamicin in saline inj 1 mg/ml 3gentamicin in saline inj 1.2 mg/ml 3gentamicin in saline inj 1.6 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3IMPAVIDO - miltefosine cap 50 mg 5INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 3levofloxacin oral soln 25 mg/ml 3levofloxacin tab 250 mg^ 2levofloxacin tab 500 mg^ 2levofloxacin tab 750 mg^ 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%5

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 3linezolid tab 600 mg 4 PAmeropenem iv for soln 500 mg 3

Page 20: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

11

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

meropenem iv for soln 1 gm 4methenamine hippurate tab 1 gm^ 2METRONIDAZOLE - metronidazole in nacl 0.74% iv soln

500 mg/100ml3

metronidazole cap 375 mg^ 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole iv soln 5 mg/ml 3metronidazole tab 250 mg^ 2metronidazole tab 500 mg^ 2metronidazole vaginal gel 0.75%^ 2minocycline hcl cap 50 mg 3minocycline hcl cap 75 mg 3minocycline hcl cap 100 mg 3minocycline hcl tab 50 mg 3minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg 3MOXIFLOXACIN HCL - moxifloxacin hcl iv solution 400 mg/250ml 3moxifloxacin hcl tab 400 mg^ 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 3nafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 3nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg^ 2neomycin-polymyxin b gu irrigation soln^ 2nitrofurantoin macrocrystalline cap 50 mg# 4 PAnitrofurantoin macrocrystalline cap 100 mg# 4 PAnitrofurantoin monohydrate macrocrystalline cap 100 mg# 4 PAnitrofurantoin susp 25 mg/5ml# 4 PAofloxacin tab 400 mg^ 2paromomycin sulfate cap 250 mg 4penicillin g potassium for inj 5000000 unit 3penicillin g potassium for inj 20000000 unit 3PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.12

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 3penicillin v potassium for soln 125 mg/5ml^ 2penicillin v potassium for soln 250 mg/5ml^ 2penicillin v potassium tab 250 mg^ 2penicillin v potassium tab 500 mg^ 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10%^ 2SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml^ 2sulfamethoxazole-trimethoprim tab 400-80 mg^ 2sulfamethoxazole-trimethoprim tab 800-160 mg^ 2SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)4

tobramycin sulfate for inj 1.2 gm 4tobramycin sulfate inj 10 mg/ml 4tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 4tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 4trimethoprim tab 100 mg^ 2TYGACIL - tigecycline for iv soln 50 mg 5vancomycin hcl cap 125 mg 4vancomycin hcl cap 250 mg 4

Page 22: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

13

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

vancomycin hcl for iv soln 500 mg 4vancomycin hcl for iv soln 750 mg 4vancomycin hcl for iv soln 1 gm 4vancomycin hcl for iv soln 5 gm 4vancomycin hcl for iv soln 10 gm 4vancomycin hcl for iv soln 100 gm 4VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose iv

soln 500 mg/100ml-5%4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 750 mg/150ml-5%

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 1 gm/200ml-5%

4

ZINACEF - cefuroxime in sterile water inj 1.5 gm/50ml 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

Medicamentos anticonvulsantesAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg^ 2carbamazepine cap er 12hr 200 mg^ 2carbamazepine cap er 12hr 300 mg^ 2carbamazepine chew tab 100 mg^ 2carbamazepine susp 100 mg/5ml^ 2carbamazepine tab er 12hr 100 mg^ 2

Page 23: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.14

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

carbamazepine tab er 12hr 200 mg^ 2carbamazepine tab er 12hr 400 mg^ 2carbamazepine tab 200 mg^ 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg^ 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg^ 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system2.5 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 3divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2ethosuximide cap 250 mg^ 2ethosuximide soln 250 mg/5ml^ 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 3felbamate tab 600 mg 3fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg^ 2 QL (1080 capsules/30 days)

Page 24: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

15

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

gabapentin cap 300 mg^ 2 QL (360 capsules/30 days)gabapentin cap 400 mg^ 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml^ 2 QL (2160 mls/30 days)gabapentin tab 600 mg^ 2 QL (180 tablets/30 days)gabapentin tab 800 mg^ 2 QL (135 tablets/30 days)GABITRIL - tiagabine hcl tab 12 mg 4GABITRIL - tiagabine hcl tab 16 mg 4lamotrigine tab chewable dispersible 5 mg^ 2lamotrigine tab chewable dispersible 25 mg^ 2lamotrigine tab 25 mg^ 2lamotrigine tab 100 mg^ 2lamotrigine tab 150 mg^ 2lamotrigine tab 200 mg^ 2levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml^ 2levetiracetam tab 250 mg^ 2levetiracetam tab 500 mg^ 2levetiracetam tab 750 mg^ 2levetiracetam tab 1000 mg^ 2LYRICA - pregabalin cap 25 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 50 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 75 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 100 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 150 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 200 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 225 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin cap 300 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)ONFI - clobazam suspension 2.5 mg/ml 5 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 5 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 5 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4oxcarbazepine tab 150 mg^ 2oxcarbazepine tab 300 mg^ 2oxcarbazepine tab 600 mg^ 2

Page 25: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.16

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/

ml#4 PA

phenobarbital tab 15 mg# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 30 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 60 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenobarbital tab 100 mg# 4 PAphenytoin chew tab 50 mg^ 2phenytoin sodium extended cap 100 mg^ 2phenytoin sodium extended cap 200 mg^ 2phenytoin sodium extended cap 300 mg^ 2phenytoin susp 125 mg/5ml^ 2primidone tab 50 mg^ 2primidone tab 250 mg^ 2SABRIL - vigabatrin powd pack 500 mg* 4SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 5SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 3tiagabine hcl tab 12 mg 3tiagabine hcl tab 16 mg 3topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 2topiramate tab 50 mg^ 2topiramate tab 100 mg^ 2topiramate tab 200 mg^ 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml^ 2

Page 26: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

17

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

valproic acid cap 250 mg^ 2vigabatrin powd pack 500 mg* 4VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg^ 2zonisamide cap 50 mg^ 2zonisamide cap 100 mg^ 2Agentes contra la demenciadonepezil hydrochloride orally disintegrating tab 5 mg^ 2donepezil hydrochloride orally disintegrating tab 10 mg^ 2donepezil hydrochloride tab 5 mg^ 2donepezil hydrochloride tab 10 mg^ 2donepezil hydrochloride tab 23 mg^ 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3 PAGALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg^ 2galantamine hydrobromide cap er 24hr 16 mg^ 2galantamine hydrobromide cap er 24hr 24 mg^ 2galantamine hydrobromide tab 4 mg^ 2galantamine hydrobromide tab 8 mg^ 2galantamine hydrobromide tab 12 mg^ 2memantine hcl oral solution 2 mg/ml^ 2 PAmemantine hcl tab 5 mg^ 2 PAmemantine hcl tab 10 mg^ 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak^ 2 PArivastigmine tartrate cap 1.5 mg^ 2rivastigmine tartrate cap 3 mg^ 2rivastigmine tartrate cap 4.5 mg^ 2rivastigmine tartrate cap 6 mg^ 2rivastigmine td patch 24hr 4.6 mg/24hr^ 2rivastigmine td patch 24hr 9.5 mg/24hr^ 2rivastigmine td patch 24hr 13.3 mg/24hr^ 2

Page 27: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.18

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Medicamentos antidepresivosamitriptyline hcl tab 10 mg# 4 PAamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg# 4 PAAMOXAPINE - amoxapine tab 50 mg# 4 PAAMOXAPINE - amoxapine tab 100 mg# 4 PAAMOXAPINE - amoxapine tab 150 mg# 4 PAbupropion hcl tab er 12hr 100 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg^ 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg^ 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml^ 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg^ 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PAdesipramine hcl tab 10 mg# 4 PAdesipramine hcl tab 25 mg# 4 PAdesipramine hcl tab 50 mg# 4 PAdesipramine hcl tab 75 mg# 4 PAdesipramine hcl tab 100 mg# 4 PAdesipramine hcl tab 150 mg# 4 PAdesvenlafaxine succinate tab er 24hr 25 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg^ 2 QL (30 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

19

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

doxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 3 PAduloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml^ 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20

& 40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg^ 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg^ 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg^ 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg^ 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml^ 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg^ 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg^ 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg^ 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4 PAimipramine hcl tab 25 mg# 4 PAimipramine hcl tab 50 mg# 4 PAMAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg^ 2 QL (30 tablets/30 days)

Page 29: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.20

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

mirtazapine orally disintegrating tab 45 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 15 mg^ 1 QL (45 tablets/30 days)mirtazapine tab 30 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 45 mg^ 1 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 4NEFAZODONE HCL - nefazodone hcl tab 150 mg 4nefazodone hcl tab 50 mg^ 2nefazodone hcl tab 250 mg^ 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 4nortriptyline hcl cap 10 mg# 3 PAnortriptyline hcl cap 25 mg# 3 PAnortriptyline hcl cap 50 mg# 3 PAnortriptyline hcl cap 75 mg# 3 PAnortriptyline hcl soln 10 mg/5ml# 4 PAparoxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)phenelzine sulfate tab 15 mg^ 2protriptyline hcl tab 5 mg# 4 PAprotriptyline hcl tab 10 mg# 4 PAsertraline hcl oral concentrate for solution 20 mg/ml^ 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg^ 2trazodone hcl tab 100 mg^ 2trazodone hcl tab 150 mg^ 2trazodone hcl tab 300 mg^ 2trimipramine maleate cap 25 mg# 4 PAtrimipramine maleate cap 50 mg# 4 PAtrimipramine maleate cap 100 mg# 4 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)

Page 30: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

21

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

venlafaxine hcl cap er 24hr 37.5 mg^ 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg^ 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg^ 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg 3 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 3 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg 3 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg^ 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

Medicamentos antieméticosALOXI - palonosetron hcl iv soln 0.25 mg/5ml 4aprepitant capsule therapy pack 80 & 125 mg^ 2 BDaprepitant capsule 40 mg^ 2 BDaprepitant capsule 80 mg^ 2 BDaprepitant capsule 125 mg^ 2 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 3 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 3 PAchlorpromazine hcl tab 100 mg 3 PAchlorpromazine hcl tab 200 mg 3 PAdronabinol cap 2.5 mg 4 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3granisetron hcl tab 1 mg^ 2 BDmeclizine hcl tab 12.5 mg# 4ondansetron hcl inj 4 mg/2ml (2 mg/ml) 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.22

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml^ 2 BDondansetron hcl tab 4 mg^ 2 BDondansetron hcl tab 8 mg^ 2 BDondansetron hcl tab 24 mg^ 2 BDondansetron orally disintegrating tab 4 mg^ 2 BDondansetron orally disintegrating tab 8 mg^ 2 BDpalonosetron hcl iv soln 0.25 mg/5ml 4PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

pref syr 0.25 mg/5ml5

PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln0.25 mg/2ml

4

perphenazine tab 2 mg^ 2 PAperphenazine tab 4 mg^ 2 PAperphenazine tab 8 mg^ 2 PAperphenazine tab 16 mg^ 2 PAprochlorperazine edisylate inj 5 mg/ml 4prochlorperazine maleate tab 5 mg^ 2prochlorperazine maleate tab 10 mg^ 2prochlorperazine suppos 25 mg^ 2promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAMedicamentos antimicóticosAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for inj 50 mg 3 BDCANCIDAS - caspofungin acetate for iv soln 50 mg 5CANCIDAS - caspofungin acetate for iv soln 70 mg 5caspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77%^ 2ciclopirox olamine cream 0.77%^ 2ciclopirox olamine susp 0.77%^ 2ciclopirox shampoo 1%^ 2ciclopirox solution 8%^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

23

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

clotrimazole cream 1%^ 2clotrimazole troche 10 mg^ 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1%^ 2fluconazole for susp 10 mg/ml^ 2fluconazole for susp 40 mg/ml^ 2fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg^ 2fluconazole tab 100 mg^ 2fluconazole tab 150 mg^ 2fluconazole tab 200 mg^ 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml^ 2griseofulvin ultramicrosize tab 125 mg^ 2griseofulvin ultramicrosize tab 250 mg^ 2itraconazole cap 100 mg 4ketoconazole cream 2%^ 2ketoconazole shampoo 2%^ 2ketoconazole tab 200 mg^ 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm^ 2nystatin oint 100000 unit/gm^ 2nystatin susp 100000 unit/ml^ 2nystatin tab 500000 unit^ 2nystatin topical powder 100000 unit/gm^ 2terbinafine hcl tab 250 mg^ 2terconazole vaginal cream 0.4%^ 2terconazole vaginal cream 0.8%^ 2terconazole vaginal suppos 80 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.24

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAgentes contra la gotaallopurinol sodium for inj 500 mg^ 2allopurinol tab 100 mg^ 1allopurinol tab 300 mg^ 1colchicine w/ probenecid tab 0.5-500 mg^ 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg^ 2ULORIC - febuxostat tab 40 mg 3 STULORIC - febuxostat tab 80 mg 3 STAgentes contra las migrañasMIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg^ 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg^ 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 4sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg^ 2 QL (18 tablets/30 days)Agentes antimiasténicosGUANIDINE HCL - guanidine hcl tab 125 mg 4MESTINON - pyridostigmine bromide syrup 60 mg/5ml 5pyridostigmine bromide tab er 180 mg^ 2pyridostigmine bromide tab 60 mg^ 2

Page 34: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

25

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Medicamentos antimicobacterialesCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4CYCLOSERINE - cycloserine cap 250 mg 5dapsone tab 25 mg^ 2dapsone tab 100 mg^ 2ethambutol hcl tab 100 mg^ 2ethambutol hcl tab 400 mg^ 2ISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg^ 2isoniazid tab 300 mg^ 2PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg^ 2rifabutin cap 150 mg 4rifampin cap 150 mg^ 2rifampin cap 300 mg^ 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg 5TRECATOR - ethionamide tab 250 mg 4Medicamentos antineoplásicosABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5AFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5ALIMTA - pemetrexed disodium for iv soln 500 mg 5ALIQOPA - copanlisib hcl for iv soln 60 mg 5ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg 5 PA, QL (180 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg^ 2ARRANON - nelarabine iv soln 5 mg/ml 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.26

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ARSENIC TRIOXIDE - arsenic trioxide inj 10 mg/10ml (1 mg/ml) 4ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5ARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/

ml)5

BELEODAQ - belinostat for iv inj 500 mg* 5BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5bexarotene cap 75 mg 5 PAbicalutamide tab 50 mg^ 2BICNU - carmustine for inj 100 mg 4bleomycin sulfate for inj 15 unit 3 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BDBOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 50 mg 5 PA, QL (180 capsules/30 days)BRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5

Page 36: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

27

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100dose) kit*

5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 PA, QL (112 capsules/28 days)

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*

5 PA, QL (84 capsules/28 days)

COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COSMEGEN - dactinomycin for inj 0.5 mg 5COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 4 BDcyclophosphamide cap 50 mg 4 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5CYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5CYTARABINE - cytarabine inj 20 mg/ml 3 BDcytarabine inj pf 20 mg/ml 3 BDcytarabine inj pf 100 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5DARZALEX - daratumumab iv soln 400 mg/20ml* 5daunorubicin hcl iv soln 20 mg/4ml 3DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml3

decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 20 mg/ml 5DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml 5DOCETAXEL - docetaxel soln for iv infusion 80 mg/8ml 5DOCETAXEL - docetaxel soln for iv infusion 160 mg/16ml 5DOCETAXEL - docetaxel soln for iv infusion 200 mg/20ml 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.28

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5docetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg 4 BDdoxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 3 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BDELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 4EMPLICITI - elotuzumab for iv soln 300 mg 5EMPLICITI - elotuzumab for iv soln 400 mg 5epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 4epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 4ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5ERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg 5 PA, QL (120 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000

unit5

ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3EVOMELA - melphalan hcl for inj 50 mg* 5exemestane tab 25 mg 4FARESTON - toremifene citrate tab 60 mg 5FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5fludarabine phosphate for inj 50 mg 3fludarabine phosphate inj 25 mg/ml 3fluorouracil iv soln 500 mg/10ml (50 mg/ml)^ 2 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml)^ 2 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml)^ 2 BD

Page 38: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

29

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

fluorouracil iv soln 5 gm/100ml (50 mg/ml)^ 2 BDflutamide cap 125 mg^ 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5FOLOTYN - pralatrexate iv inj 40 mg/2ml 5GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml

(25 mg/ml)5

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 3gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 3gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 3GILOTRIF - afatinib dimaleate tab 20 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 4HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5HERCEPTIN - trastuzumab for iv soln 150 mg* 5HERCEPTIN - trastuzumab for iv soln 440 mg* 5HEXALEN - altretamine cap 50 mg 5 PAhydroxyurea cap 500 mg 3IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 4ifosfamide iv inj 3 gm/60ml (50 mg/ml) 4

Page 39: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.30

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5IMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5IMLYGIC - talimogene laherparepvec intralesional inj 1000000

unit/ml*4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml*

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX - romidepsin for iv inj 10 mg 5ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5IXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5KISQALI - ribociclib succinate tab 200 mg 5 PA, QL (63 tablets/28 days)KISQALI FEMARA 200 DOSE - ribociclib tab 200 mg & letrozole

tab 2.5 mg therapy pack5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

Page 40: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

31

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

KISQALI FEMARA 600 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KYPROLIS - carfilzomib for inj 10 mg 5KYPROLIS - carfilzomib for inj 30 mg 5KYPROLIS - carfilzomib for inj 60 mg 5LARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*

5 PA, QL (30 capsules/30 days)

LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*

5 PA, QL (90 capsules/30 days)

LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*

5 PA, QL (60 capsules/30 days)

LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*

5 PA, QL (90 capsules/30 days)

LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*

5 PA, QL (60 capsules/30 days)

LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) & 4 mg*

5 PA, QL (90 capsules/30 days)

LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg^ 2LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium tab 5 mg 3leucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 4LONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LYNPARZA - olaparib cap 50 mg* 5 PA, QL (480 capsules/30 days)LYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.32

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml(0.16 mg/ml)

5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg^ 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 4mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 4mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MUSTARGEN - mechlorethamine hcl for inj 10 mg 4MYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5NERLYNX - neratinib maleate tab 40 mg 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5OPDIVO - nivolumab iv soln 40 mg/4ml* 5OPDIVO - nivolumab iv soln 100 mg/10ml* 5OPDIVO - nivolumab iv soln 240 mg/24ml* 5oxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

33

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5

POMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5POTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5PROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml

5 PA

RUBRACA - rucaparib camsylate tab 200 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 4SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.34

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5TABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)tamoxifen citrate tab 10 mg^ 2tamoxifen citrate tab 20 mg^ 2TARCEVA - erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5TEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 5topotecan hcl inj 4 mg/4ml (for infusion) 5TORISEL - temsirolimus soln for iv infusion 25 mg/ml 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 5VALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5VECTIBIX - panitumumab iv soln 400 mg/20ml 5VELCADE - bortezomib for inj 3.5 mg 5VENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

35

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

VENCLEXTA - venetoclax tab 50 mg* 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (120 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 4 BDvincristine sulfate iv soln 1 mg/ml^ 2 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5XALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5YERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5YONDELIS - trabectedin for inj 1 mg 5YONSA - abiraterone acetate tab 125 mg* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5ZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (150 capsules/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 5 PA, QL (120 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)Medicamentos antiparasitariosalbendazole tab 200 mg 5ALBENZA - albendazole tab 200 mg 5ALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5

Page 45: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.36

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

atovaquone-proguanil hcl tab 62.5-25 mg^ 2atovaquone-proguanil hcl tab 250-100 mg^ 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4BILTRICIDE - praziquantel tab 600 mg 4CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg^2

chloroquine phosphate tab 500 mg^ 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg^ 2ivermectin tab 3 mg^ 2LINDANE - lindane shampoo 1% 3malathion lotion 0.5% 3mefloquine hcl tab 250 mg^ 2NEBUPENT - pentamidine isethionate for nebulization soln

300 mg4 BD

PENTAM 300 - pentamidine isethionate for soln 300 mg 4 BDpermethrin cream 5%^ 2praziquantel tab 600 mg 4PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26.3 mg 4Agentes contra la enfermedad de Parkinsonamantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2amantadine hcl tab 100 mg^ 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg^ 2bromocriptine mesylate tab 2.5 mg 3carbidopa & levodopa orally disintegrating tab 10-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-250 mg^ 2carbidopa & levodopa tab er 25-100 mg^ 2carbidopa & levodopa tab er 50-200 mg^ 2carbidopa & levodopa tab 10-100 mg^ 2carbidopa & levodopa tab 25-100 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

37

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

carbidopa & levodopa tab 25-250 mg^ 2carbidopa tab 25 mg 5CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 31.25-125-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 37.5-150-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

3

entacapone tab 200 mg 3NEUPRO - rotigotine td patch 24hr 1 mg/24hr 3NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3pramipexole dihydrochloride tab 0.125 mg^ 2pramipexole dihydrochloride tab 0.25 mg^ 2pramipexole dihydrochloride tab 0.5 mg^ 2pramipexole dihydrochloride tab 0.75 mg^ 2pramipexole dihydrochloride tab 1 mg^ 2pramipexole dihydrochloride tab 1.5 mg^ 2rasagiline mesylate tab 0.5 mg^ 2rasagiline mesylate tab 1 mg^ 2ropinirole hydrochloride tab 0.25 mg^ 2ropinirole hydrochloride tab 0.5 mg^ 2ropinirole hydrochloride tab 1 mg^ 2ropinirole hydrochloride tab 2 mg^ 2ropinirole hydrochloride tab 3 mg^ 2ropinirole hydrochloride tab 4 mg^ 2ropinirole hydrochloride tab 5 mg^ 2selegiline hcl cap 5 mg^ 2selegiline hcl tab 5 mg^ 2tolcapone tab 100 mg 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.38

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Medicamentos antipsicóticosADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 4 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 3 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg 3 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 3 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 3 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 3 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 3 PA, QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 PA, QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 PA, QL (1 syringe/28 days)

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

5 PA, QL (1 syringe/28 days)

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

5 PA, QL (1 syringe/56 days)

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

5 PA, QL (1 syringe/42 days)

clozapine orally disintegrating tab 12.5 mg 4 PA, QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 4 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 4 PA, QL (270 tablets/30 days)clozapine tab 25 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 50 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 100 mg^ 2 PA, QL (270 tablets/30 days)clozapine tab 200 mg^ 2 PA, QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 3 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

39

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg^ 2 PAfluphenazine hcl tab 2.5 mg^ 2 PAfluphenazine hcl tab 5 mg^ 2 PAfluphenazine hcl tab 10 mg^ 2 PAGEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PAhaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml^ 2 PAhaloperidol tab 0.5 mg^ 2 PAhaloperidol tab 1 mg^ 2 PAhaloperidol tab 2 mg^ 2 PAhaloperidol tab 5 mg^ 2 PAhaloperidol tab 10 mg^ 2 PAhaloperidol tab 20 mg^ 2 PAINVEGA SUSTENNA - paliperidone palmitate im extend-release

susp 117 mg/0.75ml5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 39 mg/0.25ml

4 PA, QL (1 kit/28 days)

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

5 PA, QL (1 kit/28 days)

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

5 PA, QL (1 kit/28 days)

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

5 PA, QL (1 kit/28 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp273 mg/0.875ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp410 mg/1.315ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp546 mg/1.75ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp819 mg/2.625ml

5 PA, QL (1 kit/90 days)

LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg^ 2 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.40

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

loxapine succinate cap 10 mg^ 2 PAloxapine succinate cap 25 mg^ 2 PAloxapine succinate cap 50 mg^ 2 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)NUPLAZID - pimavanserin tartrate tab 17 mg* 5 PA, QL (60 tablets/30 days)olanzapine for im inj 10 mg 4 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)pimozide tab 1 mg^ 2pimozide tab 2 mg^ 2quetiapine fumarate tab er 24hr 50 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 3 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab 25 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

41

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml^ 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg^ 2 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg^ 2 PAthiothixene cap 2 mg^ 2 PAthiothixene cap 5 mg^ 2 PAthiothixene cap 10 mg^ 2 PAtrifluoperazine hcl tab 1 mg^ 2 PAtrifluoperazine hcl tab 2 mg^ 2 PAtrifluoperazine hcl tab 5 mg^ 2 PAtrifluoperazine hcl tab 10 mg^ 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.42

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg^ 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg^ 2 PA, QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg

5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

Agentes antiespasmódicosbaclofen tab 10 mg^ 1baclofen tab 20 mg^ 1dantrolene sodium cap 25 mg^ 2dantrolene sodium cap 50 mg^ 2dantrolene sodium cap 100 mg^ 2tizanidine hcl cap 2 mg^ 2tizanidine hcl cap 4 mg^ 2tizanidine hcl cap 6 mg^ 2tizanidine hcl tab 2 mg^ 1tizanidine hcl tab 4 mg^ 1Medicamentos antiviralesabacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg^ 2acyclovir oint 5% 4acyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg^ 2acyclovir tab 800 mg^ 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

43

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ATRIPLA - efavirenz-emtricitabine-tenofovir df tab600-200-300 mg

5 QL (30 tablets/30 days)

BARACLUDE - entecavir oral soln 0.05 mg/ml 4BIKTARVY - bictegravir-emtricitabine-tenofovir af tab

50-200-25 mg5 QL (30 tablets/30 days)

cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab

300-300 mg5 QL (30 tablets/30 days)

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

5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DAKLINZA - daclatasvir dihydrochloride tab 30 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 60 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 90 mg 5 PADELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg5 QL (30 tablets/30 days)

DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 3 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 3 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (60 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 4entecavir tab 1 mg 4EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg^ 2famciclovir tab 250 mg^ 2famciclovir tab 500 mg^ 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.44

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ganciclovir sodium for inj 500 mg 3 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 4 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate cap 200 mg 5 QL (300 capsules/30 days)INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 5 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml^ 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg^ 2 QL (60 tablets/30 days)lamivudine tab 300 mg^ 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 4 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PAnevirapine susp 50 mg/5ml 3 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg^ 2 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

45

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

NORVIR - ritonavir cap 100 mg 4 QL (360 capsules/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)NORVIR - ritonavir tab 100 mg 4 QL (360 tablets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg^ 2oseltamivir phosphate cap 45 mg^ 2oseltamivir phosphate cap 75 mg^ 2oseltamivir phosphate for susp 6 mg/ml^ 2PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 100 mg 4 QL (360 tablets/30 days)RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 5RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5ribavirin cap 200 mg^ 2ribavirin tab 200 mg^ 2rimantadine hydrochloride tab 100 mg^ 2ritonavir tab 100 mg 3 QL (360 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.46

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg^ 2 QL (60 capsules/30 days)stavudine cap 20 mg^ 2 QL (60 capsules/30 days)stavudine cap 30 mg^ 2 QL (60 capsules/30 days)stavudine cap 40 mg^ 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg5 QL (30 tablets/30 days)

SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)SUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)SUSTIVA - efavirenz tab 600 mg 5 QL (30 tablets/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab

800-150-200-10 mg5 QL (30 tablets/30 days)

TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg 5 PAtenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab167-250 mg

5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab200-300 mg

5 QL (30 tablets/30 days)

TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

47

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

valacyclovir hcl tab 500 mg^ 2valacyclovir hcl tab 1 gm^ 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak

12.5-75-50 & 250 mg5 PA

VIEKIRA XR - dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAZERIT - stavudine for oral soln 1 mg/ml 4 QL (2400 mls/30 days)ZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)zidovudine cap 100 mg^ 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml^ 2 QL (1920 mls/30 days)zidovudine tab 300 mg^ 2 QL (60 tablets/30 days)Medicamentos ansiolíticosalprazolam tab 0.25 mg 4 QL (120 tablets/30 days)alprazolam tab 0.5 mg 4 QL (120 tablets/30 days)alprazolam tab 1 mg 4 QL (120 tablets/30 days)alprazolam tab 2 mg 4 QL (150 tablets/30 days)buspirone hcl tab 5 mg^ 2buspirone hcl tab 7.5 mg^ 2buspirone hcl tab 10 mg^ 2buspirone hcl tab 15 mg^ 2buspirone hcl tab 30 mg^ 2clonazepam orally disintegrating tab 0.125 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg^ 2 PA, QL (90 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.48

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

clonazepam orally disintegrating tab 0.5 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg^ 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 1 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 2 mg^ 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg^ 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg^ 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg^ 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml^ 2 PA, QL (240 mls/30 days)diazepam tab 2 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg^ 2 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAlorazepam tab 0.5 mg^ 2 PA, QL (120 tablets/30 days)lorazepam tab 1 mg^ 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg^ 2 PA, QL (150 tablets/30 days)Agentes bipolaresLITHIUM - lithium oral solution 8 meq/5ml 4lithium carbonate cap 150 mg^ 2lithium carbonate cap 300 mg^ 2lithium carbonate cap 600 mg^ 2lithium carbonate tab er 300 mg^ 2lithium carbonate tab er 450 mg^ 2lithium carbonate tab 300 mg^ 2Reguladores de la glucosa en sangreacarbose tab 25 mg^ 2 QL (360 tablets/30 days)acarbose tab 50 mg^ 2 QL (180 tablets/30 days)acarbose tab 100 mg^ 2 QL (90 tablets/30 days)ALCOHOL SWABS 3ASSURE ID INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X

1/2"3

ASSURE ID INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" 3ASSURE ID SAFETY PEN NEEDLES 31G X 5 MM (3/16") 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

49

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

BYDUREON - exenatide for inj extended release susp 2 mg 3 QL (4 vials/28 days)BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days)

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days)

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X

1/2"3

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE1ML/29GX1/2"

3

GAUZE PADS 2" X 2" 3glimepiride tab 1 mg^ 1 QL (240 tablets/30 days)glimepiride tab 2 mg^ 1 QL (120 tablets/30 days)glimepiride tab 4 mg^ 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg^ 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg^ 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg^ 1 QL (60 tablets/30 days)glipizide tab 5 mg^ 1 QL (240 tablets/30 days)glipizide tab 10 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg^ 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg^ 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg^ 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 4GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 4HUMALOG - insulin lispro inj 100 unit/ml^ 2 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml^ 2 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector

100 unit/ml^2 QL (20 pens/30 days)

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

2 QL (20 pens/30 days)

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

2 QL (20 pens/30 days)

HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100unit/ml (50-50)^

2 QL (6 vials/30 days)

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

2 QL (20 pens/30 days)

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

2 QL (6 vials/30 days)

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

2 QL (20 pens/30 days)

HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml^ 2 QL (60 mls/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.50

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

HUMULIN N KWIKPEN - insulin nph (human) (isophane) susppen-injector 100 unit/ml^

2 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml^ 2 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml^2 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml^

2 QL (20 pens/30 days)

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

2 QL (60 mls/30 days)

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

2 QL (20 pens/30 days)

INJECTION DEVICE FOR INSULIN 3INSULIN PEN NEEDLE 29 G X 10 MM 3INSULIN PEN NEEDLE 29 G X 12.7 MM 3INSULIN PEN NEEDLE 29 G X 5 MM (3/16") 3INSULIN PEN NEEDLE 29 G X 8 MM (5/16") 3INSULIN PEN NEEDLE 30 G X 5 MM (3/16") 3INSULIN PEN NEEDLE 30 G X 8 MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 31 G X 4 MM (1/6") 3INSULIN PEN NEEDLE 32 G X 5 MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33 G X 4 MM (5/32") 3INSULIN PEN NEEDLE 33 G X 5 MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33 G X 6 MM (1/4") 3INSULIN PEN NEEDLE 33 G X 8 MM (1/3" OR 5/16") 3INSULIN SYRINGE (DISP) U-100 0.3 ML 3INSULIN SYRINGE (DISP) U-100 1 ML 3INSULIN SYRINGE (DISP) U-100 1/2 ML 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 28 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 G 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1" 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 G 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 1/4" (6 MM) 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 3/16" (5 MM) 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X 1/4" (6 MM) 3INSULIN SYRINGE/NEEDLE U-100 1 ML 25 X 1" 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

51

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

INSULIN SYRINGE/NEEDLE U-100 1 ML 25 X 5/8" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 26 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X 5/8" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 G 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 3/16" (5 MM) 3INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 1/4" (6 MM) 3INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2" 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 G 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 G 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 3/8" 3INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 2 ML 27.5 X 5/8" 3INSULIN SYRINGE/NEEDLE U-40 1 ML 25 X 5/8" 3INSULIN SYRINGE/NEEDLE U-500 0.5 ML 31G X 6MM (15/64") 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr

50-500 mg3 QL (120 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg

3 QL (60 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr150-500 mg

3 QL (60 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr150-1000 mg

3 QL (60 tablets/30 days)

INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.52

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr5-1000 mg

4 QL (30 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr2.5-1000 mg

3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr5-500 mg

3 QL (30 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr5-1000 mg

3 QL (30 tablets/30 days)

LANTUS - insulin glargine inj 100 unit/ml^ 2 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/

ml^2 QL (20 pens/30 days)

LEVEMIR - insulin detemir inj 100 unit/ml^ 2 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100

unit/ml^2 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg^ 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg^ 1 QL (60 tablets/30 days)metformin hcl tab 500 mg^ 1 QL (150 tablets/30 days)metformin hcl tab 850 mg^ 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg^ 1 QL (75 tablets/30 days)MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29GX1/2"3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"

3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"

3

nateglinide tab 60 mg^ 2 QL (180 tablets/30 days)nateglinide tab 120 mg^ 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

53

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)

3 QL (1 pen/28 days)

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days)pioglitazone hcl tab 15 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg^ 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg^ 2 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 3repaglinide tab 0.5 mg^ 2 QL (960 tablets/30 days)repaglinide tab 1 mg^ 2 QL (480 tablets/30 days)repaglinide tab 2 mg^ 2 QL (240 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)3

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

3

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr

5-1000 mg3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg

3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg

3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg

3 QL (30 tablets/30 days)

TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 5/16" 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.54

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

TECHLITE PEN NEEDLES 29G X 10 MM 3TECHLITE PEN NEEDLES 29G X 12 MM 3TECHLITE PEN NEEDLES 31G X 5MM 3TECHLITE PEN NEEDLES/31G X 6 MM 3TECHLITE PEN NEEDLES/31G X 8MM 3TECHLITE PEN NEEDLES/32G X 4MM 3TECHLITE PEN NEEDLES/32G X 6MM 3TECHLITE PEN NEEDLES/32G X 8MM 3TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300

unit/ml^2 QL (60 mls/30 days)

TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml^

2 QL (60 mls/30 days)

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml^2 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml^

2 QL (20 pens/30 days)

TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 3TRUEPLUS PEN NEEDLES 29GX12MM 3TRUEPLUS PEN NEEDLES 31GX5MM 3TRUEPLUS PEN NEEDLES 31GX6MM 3TRUEPLUS PEN NEEDLES 31GX8MM 3TRUEPLUS PEN NEEDLES 32GX4MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 3TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 4 QL (4 pens/28 days)TRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 4 QL (4 pens/28 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

55

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" 3ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 3VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 3VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days)Hemoderivados/Modificadores de la sangre/ Expansores delanagrelide hcl cap 0.5 mg^ 2anagrelide hcl cap 1 mg^ 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml4 PA

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

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 40 mcg/0.4ml

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 60 mcg/0.3ml

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 100 mcg/0.5ml

5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 150 mcg/0.3ml

5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 200 mcg/0.4ml

5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilledsyringe 300 mcg/0.6ml

5 PA

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

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg^ 2azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 1cilostazol tab 100 mg^ 1clopidogrel bisulfate tab 75 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.56

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 3EFFIENT - prasugrel hcl tab 10 mg 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (120 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (120 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 4 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

57

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3heparin sodium (porcine) 40 unit/ml in d5w 4LEUKINE - sargramostim lyophilized for inj 250 mcg 5MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

NEUPOGEN - filgrastim inj 300 mcg/ml 5NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml 5NEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml

(600 mcg/ml)5

PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg^ 2prasugrel hcl tab 10 mg^ 2PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 3tranexamic acid tab 650 mg 3warfarin sodium tab 1 mg^ 2warfarin sodium tab 2 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.58

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

warfarin sodium tab 2.5 mg^ 2warfarin sodium tab 3 mg^ 2warfarin sodium tab 4 mg^ 2warfarin sodium tab 5 mg^ 2warfarin sodium tab 6 mg^ 2warfarin sodium tab 7.5 mg^ 2warfarin sodium tab 10 mg^ 2XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Agentes cardiovascularesacebutolol hcl cap 200 mg^ 2acebutolol hcl cap 400 mg^ 2acetazolamide cap er 12hr 500 mg^ 2acetazolamide tab 125 mg 3acetazolamide tab 250 mg^ 2amiloride & hydrochlorothiazide tab 5-50 mg^ 2amiloride hcl tab 5 mg^ 2amiodarone hcl tab 200 mg^ 2amiodarone hcl tab 400 mg^ 2amlodipine besylate tab 2.5 mg^ 1amlodipine besylate tab 5 mg^ 1amlodipine besylate tab 10 mg^ 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-10 mg 3amlodipine besylate-atorvastatin calcium tab 5-20 mg 3amlodipine besylate-atorvastatin calcium tab 5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-80 mg 3amlodipine besylate-atorvastatin calcium tab 10-10 mg 3amlodipine besylate-atorvastatin calcium tab 10-20 mg 3amlodipine besylate-atorvastatin calcium tab 10-40 mg 3amlodipine besylate-atorvastatin calcium tab 10-80 mg 3amlodipine besylate-benazepril hcl cap 2.5-10 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

59

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

amlodipine besylate-benazepril hcl cap 5-10 mg^ 2amlodipine besylate-benazepril hcl cap 5-20 mg^ 2amlodipine besylate-benazepril hcl cap 5-40 mg^ 2amlodipine besylate-benazepril hcl cap 10-20 mg^ 2amlodipine besylate-benazepril hcl cap 10-40 mg^ 2amlodipine besylate-valsartan tab 5-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg^ 2 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg^ 2atenolol & chlorthalidone tab 100-25 mg^ 2atenolol tab 25 mg^ 1atenolol tab 50 mg^ 1atenolol tab 100 mg^ 1atorvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg^ 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg^ 2benazepril & hydrochlorothiazide tab 10-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-25 mg^ 2benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1betaxolol hcl tab 10 mg^ 2betaxolol hcl tab 20 mg^ 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg^ 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg^ 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg^ 2bisoprolol fumarate tab 5 mg^ 2bisoprolol fumarate tab 10 mg^ 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg^ 2bumetanide tab 1 mg^ 2bumetanide tab 2 mg^ 2candesartan cilexetil tab 4 mg^ 2 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.60

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

candesartan cilexetil tab 8 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg^ 2 QL (30 tablets/30 days)captopril tab 12.5 mg^ 2captopril tab 25 mg^ 2captopril tab 50 mg^ 2captopril tab 100 mg^ 2carvedilol tab 3.125 mg^ 1carvedilol tab 6.25 mg^ 1carvedilol tab 12.5 mg^ 1carvedilol tab 25 mg^ 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 4chlorothiazide tab 500 mg^ 2chlorthalidone tab 25 mg^ 2chlorthalidone tab 50 mg^ 2cholestyramine light powder packets 4 gm^ 2cholestyramine light powder 4 gm/dose^ 2cholestyramine powder packets 4 gm^ 2cholestyramine powder 4 gm/dose^ 2choline fenofibrate cap dr 45 mg^ 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg^ 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg^ 2clonidine hcl tab 0.2 mg^ 2clonidine hcl tab 0.3 mg^ 2clonidine td patch weekly 0.1 mg/24hr^ 2clonidine td patch weekly 0.2 mg/24hr^ 2clonidine td patch weekly 0.3 mg/24hr^ 2colesevelam hcl packet for susp 3.75 gm 4colesevelam hcl tab 625 mg 4colestipol hcl granule packets 5 gm^ 2colestipol hcl granules 5 gm^ 2colestipol hcl tab 1 gm^ 2CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)DEMSER - metyrosine cap 250 mg 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

61

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

DIGOXIN - digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)#^ 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg^ 2diltiazem hcl cap er 12hr 90 mg^ 2diltiazem hcl cap er 12hr 120 mg^ 2diltiazem hcl cap er 24hr 120 mg^ 2diltiazem hcl cap er 24hr 180 mg^ 2diltiazem hcl cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 120 mg^ 2diltiazem hcl coated beads cap er 24hr 180 mg^ 2diltiazem hcl coated beads cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 300 mg^ 2diltiazem hcl coated beads cap er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 180 mg^ 2diltiazem hcl coated beads tab er 24hr 240 mg^ 2diltiazem hcl coated beads tab er 24hr 300 mg^ 2diltiazem hcl coated beads tab er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 420 mg^ 2diltiazem hcl extended release beads cap er 24hr 120 mg^ 2diltiazem hcl extended release beads cap er 24hr 180 mg^ 2diltiazem hcl extended release beads cap er 24hr 240 mg^ 2diltiazem hcl extended release beads cap er 24hr 300 mg^ 2diltiazem hcl extended release beads cap er 24hr 360 mg^ 2diltiazem hcl extended release beads cap er 24hr 420 mg^ 2diltiazem hcl tab 30 mg^ 2diltiazem hcl tab 60 mg^ 2diltiazem hcl tab 90 mg^ 2diltiazem hcl tab 120 mg^ 2dofetilide cap 125 mcg (0.125 mg) 4dofetilide cap 250 mcg (0.25 mg) 4dofetilide cap 500 mcg (0.5 mg) 4doxazosin mesylate tab 1 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg^ 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg^ 1enalapril maleate & hydrochlorothiazide tab 10-25 mg^ 1

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.62

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

enalapril maleate tab 2.5 mg^ 1enalapril maleate tab 5 mg^ 1enalapril maleate tab 10 mg^ 1enalapril maleate tab 20 mg^ 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 PA, QL (60 tablets/30 days)eplerenone tab 25 mg^ 2eplerenone tab 50 mg^ 2ezetimibe tab 10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg^ 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg^ 2felodipine tab er 24hr 5 mg^ 2felodipine tab er 24hr 10 mg^ 2fenofibrate micronized cap 67 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg^ 2 QL (30 capsules/30 days)fenofibrate tab 48 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 54 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 145 mg^ 2 QL (30 tablets/30 days)fenofibrate tab 160 mg^ 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg^ 2flecainide acetate tab 100 mg^ 2flecainide acetate tab 150 mg^ 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg^ 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg^ 2fosinopril sodium tab 10 mg^ 1fosinopril sodium tab 20 mg^ 1fosinopril sodium tab 40 mg^ 1furosemide inj 10 mg/ml 3furosemide oral soln 10 mg/ml^ 2furosemide tab 20 mg^ 2furosemide tab 40 mg^ 2furosemide tab 80 mg^ 2gemfibrozil tab 600 mg^ 2 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

63

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

hydralazine hcl tab 10 mg^ 2hydralazine hcl tab 25 mg^ 2hydralazine hcl tab 50 mg^ 2hydralazine hcl tab 100 mg^ 2hydrochlorothiazide cap 12.5 mg^ 2hydrochlorothiazide tab 12.5 mg^ 2hydrochlorothiazide tab 25 mg^ 2hydrochlorothiazide tab 50 mg^ 2indapamide tab 1.25 mg^ 2indapamide tab 2.5 mg^ 2irbesartan tab 75 mg^ 1 QL (30 tablets/30 days)irbesartan tab 150 mg^ 1 QL (30 tablets/30 days)irbesartan tab 300 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg^ 1 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg^ 2isosorbide dinitrate tab 10 mg^ 2isosorbide dinitrate tab 20 mg^ 2isosorbide dinitrate tab 30 mg^ 2isosorbide mononitrate tab er 24hr 30 mg^ 2isosorbide mononitrate tab er 24hr 60 mg^ 2isosorbide mononitrate tab er 24hr 120 mg^ 2isosorbide mononitrate tab 10 mg^ 2isosorbide mononitrate tab 20 mg^ 2isradipine cap 2.5 mg^ 2isradipine cap 5 mg^ 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAKYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/

ml*5 PA

labetalol hcl tab 100 mg^ 2labetalol hcl tab 200 mg^ 2labetalol hcl tab 300 mg^ 2LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml 4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.64

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

lisinopril & hydrochlorothiazide tab 10-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-25 mg^ 1lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg^ 1 QL (30 tablets/30 days)losartan potassium tab 25 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 50 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 100 mg^ 1 QL (30 tablets/30 days)lovastatin tab 10 mg^ 1 QL (60 tablets/30 days)lovastatin tab 20 mg^ 1 QL (60 tablets/30 days)lovastatin tab 40 mg^ 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 3metolazone tab 2.5 mg^ 2metolazone tab 5 mg^ 2metolazone tab 10 mg^ 2metoprolol & hydrochlorothiazide tab 50-25 mg^ 2metoprolol & hydrochlorothiazide tab 100-25 mg^ 2metoprolol succinate tab er 24hr 25 mg^ 2metoprolol succinate tab er 24hr 50 mg^ 2metoprolol succinate tab er 24hr 100 mg^ 2metoprolol succinate tab er 24hr 200 mg^ 2metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1mexiletine hcl cap 150 mg^ 2mexiletine hcl cap 200 mg^ 2mexiletine hcl cap 250 mg^ 2midodrine hcl tab 2.5 mg^ 2midodrine hcl tab 5 mg^ 2midodrine hcl tab 10 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

65

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

minoxidil tab 2.5 mg^ 2minoxidil tab 10 mg^ 2moexipril hcl tab 7.5 mg^ 2moexipril hcl tab 15 mg^ 2moexipril-hydrochlorothiazide tab 7.5-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-25 mg^ 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg^ 2nadolol tab 40 mg^ 2nadolol tab 80 mg^ 2niacin tab er 500 mg^ 2 QL (30 tablets/30 days)niacin tab er 750 mg^ 2 QL (60 tablets/30 days)niacin tab er 1000 mg^ 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg^ 2nicardipine hcl cap 30 mg^ 2nifedipine tab er 24hr 30 mg^ 2nifedipine tab er 24hr 60 mg^ 2nifedipine tab er 24hr 90 mg^ 2nifedipine tab er 24hr osmotic release 30 mg^ 2nifedipine tab er 24hr osmotic release 60 mg^ 2nifedipine tab er 24hr osmotic release 90 mg^ 2nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 4nisoldipine tab er 24hr 8.5 mg^ 2nisoldipine tab er 24hr 17 mg^ 2nisoldipine tab er 24hr 34 mg^ 2NITRO-BID - nitroglycerin oint 2% 3nitroglycerin sl tab 0.3 mg^ 2nitroglycerin sl tab 0.4 mg^ 2nitroglycerin sl tab 0.6 mg^ 2nitroglycerin td patch 24hr 0.1 mg/hr^ 2nitroglycerin td patch 24hr 0.2 mg/hr^ 2nitroglycerin td patch 24hr 0.4 mg/hr^ 2nitroglycerin td patch 24hr 0.6 mg/hr^ 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 4NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.66

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

NORTHERA - droxidopa cap 300 mg* 5 PAolmesartan medoxomil tab 5 mg^ 2 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil tab 40 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg^ 2 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg^ 2 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm^ 2pentoxifylline tab er 400 mg^ 2perindopril erbumine tab 2 mg^ 2perindopril erbumine tab 4 mg^ 2perindopril erbumine tab 8 mg^ 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg^ 2pindolol tab 10 mg^ 2PRALUENT - alirocumab subcutaneous soln pen-injector 75 mg/

ml*5 PA, QL (2 pens/28 days)

PRALUENT - alirocumab subcutaneous soln pen-injector 150 mg/ml*

5 PA, QL (2 pens/28 days)

pravastatin sodium tab 10 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg^ 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2propafenone hcl cap er 12hr 225 mg 4propafenone hcl cap er 12hr 325 mg 4propafenone hcl cap er 12hr 425 mg 4propafenone hcl tab 150 mg^ 2propafenone hcl tab 225 mg^ 2propafenone hcl tab 300 mg^ 2propranolol hcl cap er 24hr 60 mg^ 2propranolol hcl cap er 24hr 80 mg^ 2propranolol hcl cap er 24hr 120 mg^ 2propranolol hcl cap er 24hr 160 mg^ 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg^ 1

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

67

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

propranolol hcl tab 20 mg^ 1propranolol hcl tab 40 mg^ 1propranolol hcl tab 60 mg^ 1propranolol hcl tab 80 mg^ 1quinapril hcl tab 5 mg^ 1quinapril hcl tab 10 mg^ 1quinapril hcl tab 20 mg^ 1quinapril hcl tab 40 mg^ 1quinapril-hydrochlorothiazide tab 10-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-25 mg^ 2quinidine gluconate tab er 324 mg^ 2QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg^ 1ramipril cap 2.5 mg^ 1ramipril cap 5 mg^ 1ramipril cap 10 mg^ 1RANEXA - ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)RANEXA - ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml5 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

5 PA, QL (1 system/30 days)

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

5 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg^ 2 QL (30 tablets/30 days)simvastatin tab 5 mg^ 1 QL (45 tablets/30 days)simvastatin tab 10 mg^ 1 QL (45 tablets/30 days)simvastatin tab 20 mg^ 1 QL (60 tablets/30 days)simvastatin tab 40 mg^ 1 QL (45 tablets/30 days)simvastatin tab 80 mg^ 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg^ 2sotalol hcl (afib/afl) tab 120 mg^ 2sotalol hcl (afib/afl) tab 160 mg^ 2sotalol hcl tab 80 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.68

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

sotalol hcl tab 120 mg^ 2sotalol hcl tab 160 mg^ 2sotalol hcl tab 240 mg^ 2spironolactone & hydrochlorothiazide tab 25-25 mg^ 2spironolactone tab 25 mg^ 2spironolactone tab 50 mg^ 2spironolactone tab 100 mg^ 2TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg^ 2 QL (30 tablets/30 days)telmisartan tab 40 mg^ 2 QL (30 tablets/30 days)telmisartan tab 80 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg^ 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg^ 2 QL (90 capsules/30 days)terazosin hcl cap 2 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 2 QL (60 capsules/30 days)TIMOLOL MALEATE - timolol maleate tab 5 mg 3TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3torsemide tab 5 mg^ 2torsemide tab 10 mg^ 2torsemide tab 20 mg^ 2torsemide tab 100 mg^ 2trandolapril tab 1 mg^ 1trandolapril tab 2 mg^ 1trandolapril tab 4 mg^ 1triamterene & hydrochlorothiazide cap 37.5-25 mg^ 2triamterene & hydrochlorothiazide tab 37.5-25 mg^ 2triamterene & hydrochlorothiazide tab 75-50 mg^ 2valsartan tab 40 mg^ 2 QL (60 tablets/30 days)valsartan tab 80 mg^ 2 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

69

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

valsartan tab 160 mg^ 2 QL (60 tablets/30 days)valsartan tab 320 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg^ 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3verapamil hcl cap er 24hr 100 mg^ 2verapamil hcl cap er 24hr 120 mg^ 2verapamil hcl cap er 24hr 180 mg^ 2verapamil hcl cap er 24hr 200 mg^ 2verapamil hcl cap er 24hr 240 mg^ 2verapamil hcl cap er 24hr 300 mg^ 2verapamil hcl cap er 24hr 360 mg^ 2verapamil hcl tab er 120 mg^ 2verapamil hcl tab er 180 mg^ 2verapamil hcl tab er 240 mg^ 2verapamil hcl tab 40 mg^ 2verapamil hcl tab 80 mg^ 2verapamil hcl tab 120 mg^ 2WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4Agentes del sistema nervioso centralamphetamine-dextroamphetamine cap er 24hr 5 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.70

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

AMPYRA - dalfampridine tab er 12hr 10 mg* 5 PAatomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 4 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 4 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 4 QL (30 capsules/30 days)AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/

vial)5 PA, QL (1 kit/28 days)

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit

30 mcg/0.5ml5 PA, QL (1 kit/28 days)

BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/syringes/30 days)

clonidine hcl tab er 12hr 0.1 mg^ 2 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dalfampridine tab er 12hr 10 mg* 5 PAdexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)methylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3

PLEGRIDY - peginterferon beta-1a soln pen-injector125 mcg/0.5ml

5 PA, QL (2 syringes/28 days)

PLEGRIDY - peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml

5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

71

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

riluzole tab 50 mg 4TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg* 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg* 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAAgentes dentales y oraleschlorhexidine gluconate soln 0.12%^ 2KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg^ 2pilocarpine hcl tab 7.5 mg^ 2triamcinolone acetonide dental paste 0.1%^ 2Agentes dermatológicosacitretin cap 10 mg 4acitretin cap 17.5 mg 4acitretin cap 25 mg 4alclometasone dipropionate cream 0.05%^ 2alclometasone dipropionate oint 0.05%^ 2AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3%^ 2betamethasone dipropionate augmented cream 0.05%^ 2betamethasone dipropionate augmented gel 0.05%^ 2betamethasone dipropionate augmented lotion 0.05%^ 2betamethasone dipropionate augmented oint 0.05%^ 2betamethasone dipropionate cream 0.05%^ 2betamethasone dipropionate lotion 0.05%^ 2betamethasone dipropionate oint 0.05%^ 2betamethasone valerate cream 0.1%^ 2betamethasone valerate lotion 0.1%^ 2betamethasone valerate oint 0.1%^ 2calcipotriene cream 0.005% 3calcipotriene oint 0.005% 3calcipotriene soln 0.005% (50 mcg/ml) 3CARAC - fluorouracil cream 0.5% 5clindamycin phosphate-benzoyl peroxide gel 1-5%^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.72

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

clobetasol propionate cream 0.05% 3clobetasol propionate emollient base cream 0.05% 3clobetasol propionate gel 0.05% 3clobetasol propionate oint 0.05% 3clobetasol propionate soln 0.05% 3clotrimazole w/ betamethasone cream 1-0.05%^ 2clotrimazole w/ betamethasone lotion 1-0.05%^ 2desonide cream 0.05%^ 2desonide lotion 0.05%^ 2desonide oint 0.05%^ 2desoximetasone cream 0.05%^ 2desoximetasone cream 0.25%^ 2desoximetasone gel 0.05%^ 2desoximetasone oint 0.25%^ 2diclofenac sodium gel 3% 5diflorasone diacetate oint 0.05% 4ELIDEL - pimecrolimus cream 1% 4 PAFINACEA - azelaic acid foam 15% 4FINACEA - azelaic acid gel 15% 4fluocinolone acetonide cream 0.01%^ 2fluocinonide cream 0.05%^ 2fluocinonide emulsified base cream 0.05%^ 2fluocinonide gel 0.05%^ 2fluocinonide oint 0.05%^ 2fluocinonide soln 0.05%^ 2fluorouracil cream 5% 3fluorouracil soln 2%^ 2fluorouracil soln 5%^ 2fluticasone propionate cream 0.05%^ 2fluticasone propionate oint 0.005%^ 2gentamicin sulfate cream 0.1%^ 2gentamicin sulfate oint 0.1%^ 2halobetasol propionate cream 0.05%^ 2halobetasol propionate oint 0.05%^ 2hydrocortisone butyrate cream 0.1%^ 2hydrocortisone butyrate hydrophilic lipo base cream 0.1%^ 2hydrocortisone butyrate oint 0.1%^ 2hydrocortisone butyrate soln 0.1%^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

73

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

hydrocortisone cream 1%^ 2hydrocortisone cream 2.5%^ 2hydrocortisone lotion 2.5%^ 2hydrocortisone oint 1%^ 2hydrocortisone oint 2.5%^ 2hydrocortisone valerate cream 0.2%^ 2hydrocortisone valerate oint 0.2%^ 2imiquimod cream 5%^ 2 PAisotretinoin cap 10 mg 3isotretinoin cap 20 mg 3isotretinoin cap 30 mg 3isotretinoin cap 40 mg 3lactic acid (ammonium lactate) cream 12%^ 2lactic acid (ammonium lactate) lotion 12%^ 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75%^ 2metronidazole gel 0.75%^ 2metronidazole gel 1%^ 2metronidazole lotion 0.75%^ 2mometasone furoate cream 0.1%^ 2mometasone furoate oint 0.1%^ 2mometasone furoate solution 0.1% (lotion)^ 2mupirocin oint 2%^ 2nystatin-triamcinolone cream 100000-0.1 unit/gm-%^ 2nystatin-triamcinolone oint 100000-0.1 unit/gm-%^ 2ORACEA - doxycycline cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)podofilox soln 0.5%^ 2prednicarbate cream 0.1%^ 2prednicarbate oint 0.1%^ 2REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5%^ 2silver sulfadiazine cream 1% 4SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03%^ 2 PAtacrolimus oint 0.1%^ 2 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.74

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

tazarotene cream 0.1% 4TAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025%^ 2tretinoin cream 0.05%^ 2tretinoin cream 0.1%^ 2tretinoin gel 0.01%^ 2tretinoin gel 0.025%^ 2triamcinolone acetonide cream 0.025%^ 2triamcinolone acetonide cream 0.1%^ 2triamcinolone acetonide cream 0.5%^ 2triamcinolone acetonide lotion 0.025%^ 2triamcinolone acetonide lotion 0.1%^ 2triamcinolone acetonide oint 0.025%^ 2triamcinolone acetonide oint 0.1%^ 2triamcinolone acetonide oint 0.5%^ 2Electrolitos/Minerales/Metales/Vitaminasamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDcalcium acetate cap 667 mg^ 2calcium acetate tab 667 mg^ 2CARBAGLU - carglumic acid tab 200 mg 5CHEMET - succimer cap 100 mg 4dextrose inj 5% 4dextrose inj 10% 4dextrose 5% in lactated ringers 4dextrose 2.5% w/ sodium chloride 0.45% 4dextrose 5% w/ sodium chloride 0.2% 4dextrose 5% w/ sodium chloride 0.33% 4dextrose 5% w/ sodium chloride 0.45% 4dextrose 5% w/ sodium chloride 0.9% 4EXJADE - deferasirox tab for oral susp 125 mg* 5EXJADE - deferasirox tab for oral susp 250 mg* 5EXJADE - deferasirox tab for oral susp 500 mg* 5fat emulsion iv soln 20% 4 BDfomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate chew tab 500 mg 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

75

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

FOSRENOL - lanthanum carbonate chew tab 750 mg 5FOSRENOL - lanthanum carbonate chew tab 1000 mg 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5HEPATAMINE - amino acid infusion 8% 4 BDJADENU - deferasirox tab 90 mg 5JADENU - deferasirox tab 180 mg 5JADENU - deferasirox tab 360 mg 5JADENU SPRINKLE - deferasirox granules packet 90 mg 5JADENU SPRINKLE - deferasirox granules packet 180 mg 5JADENU SPRINKLE - deferasirox granules packet 360 mg 5kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 4kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 4kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 4lactated ringer's solution 4lanthanum carbonate chew tab 500 mg 5lanthanum carbonate chew tab 750 mg 5lanthanum carbonate chew tab 1000 mg 5levocarnitine oral soln 1 gm/10ml (10%)^ 2levocarnitine tab 330 mg^ 2magnesium sulfate inj 50% 3NORMOSOL-M IN D5W - electrolyte-m in d5w soln 4PHOSLYRA - calcium acetate oral soln 667 mg/5ml 4potassium chloride cap er 8 meq^ 2potassium chloride cap er 10 meq^ 2potassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq^ 2potassium chloride microencapsulated crys er tab 20 meq^ 2potassium chloride oral soln 10% (20 meq/15ml)^ 2potassium chloride tab er 8 meq (600 mg) 3potassium chloride tab er 10 meq 3potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 4POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.76

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

4

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 40 meq/l (0.3%) in d5w lactated ringers

4

potassium citrate tab er 5 meq (540 mg)^ 2potassium citrate tab er 10 meq (1080 mg)^ 2potassium citrate tab er 15 meq (1620 mg)^ 2RENVELA - sevelamer carbonate tab 800 mg 5SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5sevelamer carbonate packet 2.4 gm 5sevelamer carbonate tab 800 mg 5sodium chloride inj 0.45% 4sodium chloride irrigation soln 0.9%^ 2sodium chloride iv soln 0.9% 4sodium polystyrene sulfonate oral susp 15 gm/60ml^ 2sodium polystyrene sulfonate powder^ 2sodium polystyrene sulfonate rectal susp 30 gm/120ml^ 2SYPRINE - trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)water for irrigation, sterile irrigation soln 4Agentes gastrointestinalesalosetron hcl tab 0.5 mg 4alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5cimetidine hcl soln 300 mg/5ml^ 2cimetidine tab 200 mg^ 2cimetidine tab 300 mg^ 2cimetidine tab 400 mg^ 2cimetidine tab 800 mg^ 2cromolyn sodium oral conc 100 mg/5ml^ 2dicyclomine hcl tab 20 mg# 3 PAesomeprazole magnesium cap delayed release 20 mg^ 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg^ 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

77

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

esomeprazole sodium for intravenous soln 40 mg 3famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg^ 2famotidine tab 40 mg^ 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg^ 2glycopyrrolate tab 2 mg^ 2lactulose (encephalopathy) solution 10 gm/15ml^ 2lactulose solution 10 gm/15ml^ 2lansoprazole cap delayed release 15 mg^ 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg^ 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg^ 2methscopolamine bromide tab 2.5 mg^ 2methscopolamine bromide tab 5 mg^ 2metoclopramide hcl inj 5 mg/ml 4metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 4metoclopramide hcl tab 5 mg^ 2metoclopramide hcl tab 10 mg^ 2misoprostol tab 100 mcg^ 2misoprostol tab 200 mcg^ 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 20 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 40 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 2.5 mg

4 QL (30 packets/30 days)

nizatidine cap 150 mg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.78

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

nizatidine cap 300 mg^ 2omeprazole cap delayed release 10 mg^ 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg^ 2 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg^ 2 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg^ 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg^ 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg^ 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm^ 2polyethylene glycol 3350 oral packet^ 2polyethylene glycol 3350 oral powder^ 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg3

ranitidine hcl cap 150 mg^ 2ranitidine hcl cap 300 mg^ 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml)^ 2ranitidine hcl tab 150 mg^ 2ranitidine hcl tab 300 mg^ 2RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/

ml)5 PA

RELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm^ 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg 3ursodiol tab 250 mg 3ursodiol tab 500 mg 3XIFAXAN - rifaximin tab 550 mg 5Trastorno genético o enzimático:ADAGEN - pegademase bovine inj 250 unit/ml* 5ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

BUPHENYL - sodium phenylbutyrate tab 500 mg 5CEREZYME - imiglucerase for inj 400 unit* 5CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000

unit3

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

3

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

79

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4CYSTAGON - cysteamine bitartrate cap 150 mg* 4ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml)* 5ELELYSO - taliglucerase alfa for inj 200 unit* 5FABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

sodium phenylbutyrate oral powder 3 gm/teaspoonful 5sodium phenylbutyrate tab 500 mg 5STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.80

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150

unit4

VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300unit

4

VPRIV - velaglucerase alfa for inj 400 unit 5ZAVESCA - miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-32000-42000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-47000-63000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-63000-84000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap25000-79000-105000 unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

Agentes genitourinariosalfuzosin hcl tab er 24hr 10 mg^ 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg^ 2bethanechol chloride tab 10 mg^ 2bethanechol chloride tab 25 mg^ 2bethanechol chloride tab 50 mg^ 2DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg^ 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg^ 2 QL (30 capsules/30 days)finasteride tab 5 mg^ 2 QL (30 tablets/30 days)methylergonovine maleate tab 0.2 mg 5oxybutynin chloride syrup 5 mg/5ml^ 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg^ 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg^ 2 QL (120 tablets/30 days)RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

81

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

tamsulosin hcl cap 0.4 mg^ 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg^ 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg^ 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg^ 2 QL (30 capsules/30 days)trospium chloride tab 20 mg^ 2 QL (60 tablets/30 days)Agentes hormonales, estimulantes/sustitutos/modificadoresCORTISONE ACETATE - cortisone acetate tab 25 mg 4DEXAMETHASONE - dexamethasone tab 1 mg^ 2DEXAMETHASONE - dexamethasone tab 2 mg^ 2dexamethasone elixir 0.5 mg/5ml^ 2dexamethasone sodium phosphate inj 4 mg/ml 3dexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab 0.5 mg^ 2dexamethasone tab 0.75 mg^ 2dexamethasone tab 1.5 mg^ 2dexamethasone tab 4 mg^ 2dexamethasone tab 6 mg^ 2fludrocortisone acetate tab 0.1 mg^ 2H.P. ACTHAR - corticotropin inj gel 80 unit/ml* 5 PAhydrocortisone tab 5 mg^ 2hydrocortisone tab 10 mg^ 2hydrocortisone tab 20 mg^ 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21)^ 2methylprednisolone tab 4 mg^ 2methylprednisolone tab 8 mg^ 2methylprednisolone tab 16 mg^ 2methylprednisolone tab 32 mg^ 2prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)^ 2prednisolone sod phosphate oral soln 15 mg/5ml^ 2prednisolone syrup 15 mg/5ml^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.82

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

PREDNISONE - prednisone oral soln 5 mg/5ml 3PREDNISONE - prednisone tab therapy pack 5 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 5 mg (48)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (48)^ 2PREDNISONE - prednisone tab 50 mg 3prednisone tab 1 mg^ 2prednisone tab 2.5 mg^ 2prednisone tab 5 mg^ 2prednisone tab 10 mg^ 2prednisone tab 20 mg^ 2Agentes hormonales, estimulantes/sustitutos/modificadoreschorionic gonadotropin for im inj 10000

unit(chorionic gonadotropin, pregnyl)4 PA

DDAVP - desmopressin acetate nasal soln 0.01% (refrigerated) 4desmopressin acetate inj 4 mcg/ml 4desmopressin acetate tab 0.1 mg^ 2desmopressin acetate tab 0.2 mg^ 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 4 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PASTIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Agentes hormonales, estimulantes/sustitutos/modificadoresANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump

bottles/30 days)danazol cap 50 mg 3 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 3 PADEPO-PROVERA - medroxyprogesterone acetate im susp

400 mg/ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

83

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg^ 2desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg^ 2drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg^ 2drospirenone-ethinyl estradiol tab 3-0.02 mg^ 2drospirenone-ethinyl estradiol tab 3-0.03 mg^ 2ELLA - ulipristal acetate tab 30 mg 3ESTRACE - estradiol vaginal cream 0.1 mg/gm 4estradiol & norethindrone acetate tab 0.5-0.1 mg# 4 PAestradiol & norethindrone acetate tab 1-0.5 mg# 4 PAestradiol tab 0.5 mg# 4 PAestradiol tab 1 mg# 4 PAestradiol tab 2 mg# 4 PAestradiol vaginal cream 0.1 mg/gm 3estradiol vaginal tab 10 mcg^ 2ESTROPIPATE - estropipate tab 0.75 mg# 4 PAethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg^ 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg^ 2HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)^ 2levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)^ 2levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg^ 2levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg^ 2levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg^ 2levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg^ 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 4medroxyprogesterone acetate im susp 150 mg/ml 4medroxyprogesterone acetate tab 2.5 mg^ 2medroxyprogesterone acetate tab 5 mg^ 2medroxyprogesterone acetate tab 10 mg^ 2megestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAmethyltestosterone cap 10 mg 4 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.84

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

norethindrone & ethinyl estradiol tab 1 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg^ 2norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg^ 2norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg^ 2norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)^ 2norethindrone acetate tab 5 mg^ 2norethindrone tab 0.35 mg^ 2norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg^ 2norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg^ 2norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg^ 2norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg^ 2norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg^ 2norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg^ 2oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4 PA

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

4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-2.5 mg#

4 PA

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

4 PA

progesterone micronized cap 100 mg 3progesterone micronized cap 200 mg 3raloxifene hcl tab 60 mg^ 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 25 mg/2.5gm (1%)^ 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%)^ 2 PA, QL (60 packets/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

85

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

testosterone td gel 12.5 mg/act (1%)^ 2 PA, QL (4 pumpbottles/30 days)

testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump

bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump

bottles/30 days)Agentes hormonales, estimulantes/sustitutos/modificadores)levothyroxine sodium tab 25 mcg^ 2levothyroxine sodium tab 50 mcg^ 2levothyroxine sodium tab 75 mcg^ 2levothyroxine sodium tab 88 mcg^ 2levothyroxine sodium tab 100 mcg^ 2levothyroxine sodium tab 112 mcg^ 2levothyroxine sodium tab 125 mcg^ 2levothyroxine sodium tab 137 mcg^ 2levothyroxine sodium tab 150 mcg^ 2levothyroxine sodium tab 175 mcg^ 2levothyroxine sodium tab 200 mcg^ 2levothyroxine sodium tab 300 mcg^ 2liothyronine sodium tab 5 mcg^ 2liothyronine sodium tab 25 mcg^ 2liothyronine sodium tab 50 mcg^ 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Agentes hormonales, supresores (suprarrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.86

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Agentes hormonales, supresores (pituitarios)cabergoline tab 0.5 mg^ 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

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

4

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

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 3LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

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

5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 11.25 mg

5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

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

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

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

5

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

5

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

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 4 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 4 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PA

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

87

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

SIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5Agentes hormonales, supresores (tiroides)methimazole tab 5 mg^ 2methimazole tab 10 mg^ 2propylthiouracil tab 50 mg^ 2Agentes inmunológicosACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 4ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg^ 2 BDBCG VACCINE - bcg vaccine inj 4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.88

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

4

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

4

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous soln prefilled syringe

150 mg/ml5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml

5 PA

cyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 3 BDcyclosporine iv soln 50 mg/ml 3 BDcyclosporine modified cap 25 mg^ 2 BDcyclosporine modified cap 50 mg^ 2 BDcyclosporine modified cap 100 mg^ 2 BDcyclosporine modified oral soln 100 mg/ml 3 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5

lf/0.5ml4

DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml

4

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml

5 PA

ENBREL MINI - etanercept subcutaneous solution cartridge50 mg/ml

5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

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

4 BD

ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDFIRAZYR - icatibant acetate inj 30 mg/3ml* 5 PA, QL (6 syringes/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

89

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 1 gm/10ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 10 gm/100ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 20 gm/200ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 30 gm/300ml

5 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln 5 gm 5 BD, PAGAMMAGARD S/D - immune globulin (human) iv for soln 10 gm 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln10 gm/100ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln20 gm/200ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln40 gm/400ml

5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacim susp

4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.90

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

HIBERIX - haemophilus b polysaccharide conjugate vac for inj10 mcg

4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 4 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10

lf/0.5ml4

IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg^ 2leflunomide tab 20 mg^ 2M-M-R II - measles, mumps & rubella virus vaccines for inj 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac forinj

4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

91

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

METHOTREXATE SODIUM - methotrexate sodium inj250 mg/10ml (25 mg/ml)^

2

methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)^ 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)^ 2methotrexate sodium inj 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium tab 2.5 mg 3mycophenolate mofetil cap 250 mg^ 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg^ 2 BDmycophenolate mofetil tab 500 mg^ 2 BDmycophenolate sodium tab dr 180 mg^ 2 BDmycophenolate sodium tab dr 360 mg^ 2 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector 125 mg/ml

5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg

5 PA

OTEZLA - apremilast tab 30 mg 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 4PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

4

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp4

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

4

RABAVERT - rabies vaccine, pcec for inj 4 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.92

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

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

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

REMICADE - infliximab for iv inj 100 mg 5 PARENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5ROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml4 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 3 BDsirolimus tab 2 mg 5 BDSTAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 3 BDtacrolimus cap 1 mg 3 BDtacrolimus cap 5 mg 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 4TETANUS/DIPHTHERIA TOXOIDS ADSORBED - tetanus-

diphtheria toxoids (td) inj 2-2 lf/0.5ml3

THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg(lymphocyte ig)

5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

4

TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml

4

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

93

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj25 mcg/0.5ml

4

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

XATMEP - methotrexate oral soln 2.5 mg/ml 5 BDXOLAIR - omalizumab for inj 150 mg* 5 PAYF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml4 QL (1 vaccine/lifetime)

Agentes para tratar la enfermedad inflamatoria intestinalAPRISO - mesalamine cap er 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3balsalazide disodium cap 750 mg^ 2budesonide delayed release particles cap 3 mg 5CANASA - mesalamine suppos 1000 mg 5DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml^ 2hydrocortisone rectal cream 1%^ 2hydrocortisone rectal cream 2.5%^ 2LIALDA - mesalamine tab delayed release 1.2 gm 4mesalamine enema 4 gm^ 2mesalamine rectal enema 4 gm & cleanser wipe kit^ 2mesalamine tab delayed release 800 mg 3mesalamine tab delayed release 1.2 gm 3PENTASA - mesalamine cap er 250 mg 4PENTASA - mesalamine cap er 500 mg 4sulfasalazine tab delayed release 500 mg^ 2sulfasalazine tab 500 mg^ 2Agentes para tratar la enfermedad ósea metabólicaalendronate sodium tab 5 mg^ 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg^ 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg^ 1 QL (4 tablets/28 days)

Page 103: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.94

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

alendronate sodium tab 70 mg^ 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act^ 2calcitriol cap 0.25 mcg^ 2calcitriol cap 0.5 mcg^ 2calcitriol inj 1 mcg/ml 4calcitriol oral soln 1 mcg/ml 3ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 4ibandronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 4NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge75 mcg*

5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge100 mcg*

5 PA, QL (2 cartridges/28 days)

paricalcitol cap 1 mcg 4paricalcitol cap 2 mcg 4paricalcitol cap 4 mcg 4paricalcitol iv soln 2 mcg/ml 4paricalcitol iv soln 5 mcg/ml 4PROLIA - denosumab inj 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)SENSIPAR - cinacalcet hcl tab 30 mg 5 PASENSIPAR - cinacalcet hcl tab 60 mg 5 PASENSIPAR - cinacalcet hcl tab 90 mg 5 PAXGEVA - denosumab inj 120 mg/1.7ml 5zoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4ZOMETA - zoledronic acid iv soln 4 mg/100ml 5

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

95

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

Agentes oftálmicosALPHAGAN P - brimonidine tartrate ophth soln 0.1% 4azelastine hcl ophth soln 0.05%^ 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint^ 2bacitracin-polymyxin-neomycin-hc ophth oint 1%^ 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5%^ 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03%^ 2brimonidine tartrate ophth soln 0.15%^ 2brimonidine tartrate ophth soln 0.2%^ 2bromfenac sodium ophth soln 0.09% (once-daily)^ 2carteolol hcl ophth soln 1%^ 2ciprofloxacin hcl ophth soln 0.3%^ 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4%^ 2CYSTARAN - cysteamine hcl ophth soln 0.44% 5DEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1%^ 2dorzolamide hcl ophth soln 2%^ 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml^ 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05%^ 2erythromycin ophth oint 5 mg/gm^ 2fluorometholone ophth susp 0.1% 4flurbiprofen sodium ophth soln 0.03%^ 2gentamicin sulfate ophth oint 0.3%^ 2gentamicin sulfate ophth soln 0.3%^ 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4%^ 2ketorolac tromethamine ophth soln 0.5%^ 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005%^ 2

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.96

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

levobunolol hcl ophth soln 0.5%^ 2LOTEMAX - loteprednol etabonate ophth gel 0.5% 3LOTEMAX - loteprednol etabonate ophth oint 0.5% 3LOTEMAX - loteprednol etabonate ophth susp 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5%^ 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin^ 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/

ml^2

neomycin-polymyxin-dexamethasone ophth oint 0.1%^ 2neomycin-polymyxin-dexamethasone ophth susp 0.1%^ 2ofloxacin ophth soln 0.3%^ 2olopatadine hcl ophth soln 0.1%^ 2olopatadine hcl ophth soln 0.2%^ 2PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 4pilocarpine hcl ophth soln 2% 4pilocarpine hcl ophth soln 4% 4polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%^ 2prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp

1-0.2%3

sulfacetamide sodium ophth soln 10%^ 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%^ 2timolol maleate ophth gel forming soln 0.25%^ 2timolol maleate ophth gel forming soln 0.5%^ 2timolol maleate ophth soln 0.25%^ 2timolol maleate ophth soln 0.5%^ 2timolol maleate ophth soln 0.5% (once-daily) 3TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3%^ 2tobramycin-dexamethasone ophth susp 0.3-0.1%^ 2

Page 106: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

97

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1%^ 2VIGAMOX - moxifloxacin hcl ophth soln 0.5% 3Agentes óticosacetic acid otic soln 2%^ 2ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in

aluminum acetate otic soln4

CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01%^ 2hydrocortisone w/ acetic acid otic soln 1-2%^ 2neomycin-polymyxin-hc otic soln 1%^ 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%^ 2ofloxacin otic soln 0.3%^ 2Agentes para el tracto respiratorio/pulmonaracetylcysteine inhal soln 10%^ 2 BDacetylcysteine inhal soln 20%^ 2 BDADCIRCA - tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/

act3 QL (1 canister/30 days)

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act

3 QL (1 canister/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)^ 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml)^ 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml^ 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml^ 2 BDalbuterol sulfate syrup 2 mg/5ml^ 2albuterol sulfate tab er 12hr 4 mg 4albuterol sulfate tab er 12hr 8 mg 4

Page 107: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.98

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

albuterol sulfate tab 2 mg 4albuterol sulfate tab 4 mg 4ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 100 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 200 mcg/act

3 QL (30 blisters/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 14 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 30 METERED DOSES - mometasonefuroate inhal powd 110 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 30 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 60 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 7 METERED DOSES - mometasonefuroate inhal powd 110 mcg/inh

3 QL (1 canister/30 days)

ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray)^ 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray)^ 2 QL (2 bottles/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 3 BDbudesonide inhalation susp 0.5 mg/2ml 3 BDbudesonide inhalation susp 1 mg/2ml 3 BDcaffeine citrate oral soln 60 mg/3ml^ 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BD

Page 108: Lista de medicamentos de 2018 (Lista de medicamentos con … · 2019. 9. 30. · Lista de medicamentos de 2018 (Lista de medicamentos con cobertura) Blue Cross Medicare Advantage

2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.

99

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

DALIRESP - roflumilast tab 250 mcg 4DALIRESP - roflumilast tab 500 mcg 4diphenhydramine hcl inj 50 mg/ml 3DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act

4 QL (1 canister/30 days)

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

3

EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000) (authorized generic for EpiPen 2-Pak)

3

EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)

3

EPIPEN-JR 2-PAK - epinephrine solution auto-injector0.15 mg/0.3ml (1:2000)

3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister

3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)

3 QL (1 canister/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)

3 QL (1 canister/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)

3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act^ 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act^2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act^

2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act^

2 QL (1 inhaler/30 days)

INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh

3 QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02%^ 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray)^ 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray)^ 2 QL (3 bottles/30 days)

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2018

Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.100

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg^ 1mometasone furoate nasal susp 50 mcg/act^ 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg^ 2montelukast sodium chew tab 5 mg^ 2montelukast sodium oral granules packet 4 mg^ 2montelukast sodium tab 10 mg^ 2OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6%^ 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh

aer 40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inhaer 80 mcg/act

3 QL (2 canisters/30 days)

REMODULIN - treprostinil sodium inj 1 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 2.5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 10 mg/ml* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg^ 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act

3 QL (1 inhaler/30 days)

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101

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act

3 QL (1 inhaler/30 days)

STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act

3 QL (1 canister/30 days)

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

3 QL (1 canister/30 days)

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

3 QL (1 canister/30 days)

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

5 PA, QL (60 tablets/30 days)

tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg^ 2terbutaline sulfate tab 5 mg^ 2theophylline tab er 12hr 100 mg^ 2theophylline tab er 12hr 200 mg^ 2theophylline tab er 12hr 300 mg^ 2theophylline tab er 12hr 450 mg^ 2theophylline tab er 24hr 400 mg^ 2theophylline tab er 24hr 600 mg^ 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

triamcinolone acetonide nasal aerosol suspension 55 mcg/act^ 2 QL (1 bottle/30 days)UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg

(60)*5 PA, QL (1 pack (200

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)

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Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en estatabla al inicio de este documento.102

Nombre del medicamentoNivel delmedicamento Requisitos/Límites

zafirlukast tab 10 mg^ 2zafirlukast tab 20 mg^ 2Relajantes de los músculos esqueléticoscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PAAgentes para tratar los trastornos del sueñoarmodafinil tab 50 mg 4 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 4 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 4 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 4 PA, QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 4 PA, QL (30 tablets/30 days)modafinil tab 200 mg 4 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4 PAzaleplon cap 10 mg# 4 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA

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ÍNDICE

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................42abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................42abacavir sulfate soln 20 mg/ml.................................. 42abacavir sulfate tab 300 mg.......................................42ABRAXANE...................................................................25ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 48acarbose tab 25 mg.................................................... 48acarbose tab 50 mg.................................................... 48acebutolol hcl cap 200 mg..........................................58acebutolol hcl cap 400 mg..........................................58acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................58acetazolamide tab 125 mg......................................... 58acetazolamide tab 250 mg......................................... 58ACETIC ACID/ALUMINUM ACETATE...................... 97acetic acid otic soln 2%.............................................. 97acetylcysteine inhal soln 10%.................................... 97acetylcysteine inhal soln 20%.................................... 97acitretin cap 10 mg......................................................71acitretin cap 17.5 mg...................................................71acitretin cap 25 mg......................................................71ACTHIB..........................................................................87ACTIMMUNE................................................................ 87acyclovir cap 200 mg.................................................. 42acyclovir oint 5%..........................................................42acyclovir sodium iv soln 50 mg/ml.............................42acyclovir susp 200 mg/5ml......................................... 42acyclovir tab 400 mg................................................... 42acyclovir tab 800 mg................................................... 42ADACEL........................................................................ 87ADAGEN........................................................................78ADASUVE..................................................................... 38

ADCIRCA...................................................................... 97adefovir dipivoxil tab 10 mg........................................42ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADVAIR DISKUS..........................................................97ADVAIR DISKUS..........................................................97ADVAIR DISKUS..........................................................97ADVAIR HFA.................................................................97ADVAIR HFA.................................................................97ADVAIR HFA.................................................................97AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR DISPERZ................................................... 25AFINITOR DISPERZ................................................... 25AFINITOR DISPERZ................................................... 25albendazole tab 200 mg............................................. 35ALBENZA...................................................................... 35albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................97albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................97albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 97albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 97albuterol sulfate syrup 2 mg/5ml................................97albuterol sulfate tab 2 mg...........................................98albuterol sulfate tab 4 mg...........................................98albuterol sulfate tab er 12hr 4 mg..............................97albuterol sulfate tab er 12hr 8 mg..............................97alclometasone dipropionate cream

0.05%..........................................................................71alclometasone dipropionate oint

0.05%..........................................................................71ALCOHOL SWABS......................................................48ALDURAZYME............................................................. 78ALECENSA................................................................... 25alendronate sodium tab 10 mg.................................. 93alendronate sodium tab 35 mg.................................. 93alendronate sodium tab 5 mg.................................... 93alendronate sodium tab 70 mg.................................. 94alfuzosin hcl tab er 24hr 10 mg................................. 80ALIMTA.......................................................................... 25ALIMTA.......................................................................... 25ALINIA............................................................................35ALINIA............................................................................35ALIQOPA....................................................................... 25

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allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24alosetron hcl tab 0.5 mg............................................. 76alosetron hcl tab 1 mg................................................ 76ALOXI.............................................................................21ALPHAGAN P...............................................................95alprazolam tab 0.25 mg.............................................. 47alprazolam tab 0.5 mg................................................ 47alprazolam tab 1 mg....................................................47alprazolam tab 2 mg....................................................47ALUNBRIG....................................................................25ALUNBRIG....................................................................25ALUNBRIG....................................................................25ALUNBRIG....................................................................25amantadine hcl cap 100 mg.......................................36amantadine hcl syrup 50 mg/5ml...............................36amantadine hcl tab 100 mg........................................36AMBISOME...................................................................22amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................5amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................5amiloride & hydrochlorothiazide tab 5-50

mg................................................................................58amiloride hcl tab 5 mg.................................................58amino acid infusion 15%.............................................74amino acid infusion 6%...............................................74amiodarone hcl tab 200 mg........................................58amiodarone hcl tab 400 mg........................................58AMITIZA.........................................................................76AMITIZA.........................................................................76amitriptyline hcl tab 100 mg....................................... 18amitriptyline hcl tab 10 mg..........................................18amitriptyline hcl tab 150 mg....................................... 18amitriptyline hcl tab 25 mg..........................................18amitriptyline hcl tab 50 mg..........................................18amitriptyline hcl tab 75 mg..........................................18amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 10-20

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 10-40

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 10-80

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 2.5-10

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 2.5-20

mg................................................................................58amlodipine besylate-atorvastatin calcium tab 2.5-40

mg................................................................................58

amlodipine besylate-atorvastatin calcium tab 5-10mg................................................................................58

amlodipine besylate-atorvastatin calcium tab 5-20mg................................................................................58

amlodipine besylate-atorvastatin calcium tab 5-40mg................................................................................58

amlodipine besylate-atorvastatin calcium tab 5-80mg................................................................................58

amlodipine besylate-benazepril hcl cap 10-20mg................................................................................59

amlodipine besylate-benazepril hcl cap 10-40mg................................................................................59

amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................58

amlodipine besylate-benazepril hcl cap 5-10mg................................................................................59

amlodipine besylate-benazepril hcl cap 5-20mg................................................................................59

amlodipine besylate-benazepril hcl cap 5-40mg................................................................................59

amlodipine besylate tab 10 mg..................................58amlodipine besylate tab 2.5 mg.................................58amlodipine besylate tab 5 mg.................................... 58amlodipine besylate-valsartan tab 10-160

mg................................................................................59amlodipine besylate-valsartan tab 10-320

mg................................................................................59amlodipine besylate-valsartan tab 5-160

mg................................................................................59amlodipine besylate-valsartan tab 5-320

mg................................................................................59AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6amoxicillin (trihydrate) cap 250 mg..............................5amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 200

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 250

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 400

mg/5ml.......................................................................... 5amoxicillin (trihydrate) tab 500 mg...............................5amoxicillin (trihydrate) tab 875 mg...............................5

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amoxicillin & k clavulanate for susp 200-28.5mg/5ml.......................................................................... 5

amoxicillin & k clavulanate for susp 400-57mg/5ml.......................................................................... 5

amoxicillin & k clavulanate for susp 600-42.9mg/5ml.......................................................................... 5

amoxicillin & k clavulanate tab 250-125mg..................................................................................5

amoxicillin & k clavulanate tab 500-125mg..................................................................................6

amoxicillin & k clavulanate tab 875-125mg..................................................................................6

amphetamine-dextroamphetamine cap er 24hr 10mg................................................................................69

amphetamine-dextroamphetamine cap er 24hr 15mg................................................................................69

amphetamine-dextroamphetamine cap er 24hr 20mg................................................................................69

amphetamine-dextroamphetamine cap er 24hr 25mg................................................................................69

amphetamine-dextroamphetamine cap er 24hr 30mg................................................................................69

amphetamine-dextroamphetamine cap er 24hr 5mg................................................................................69

amphetamine-dextroamphetamine tab 10mg................................................................................69

amphetamine-dextroamphetamine tab 12.5mg................................................................................69

amphetamine-dextroamphetamine tab 15mg................................................................................69

amphetamine-dextroamphetamine tab 20mg................................................................................69

amphetamine-dextroamphetamine tab 30mg................................................................................69

amphetamine-dextroamphetamine tab 5mg................................................................................69

amphetamine-dextroamphetamine tab 7.5mg................................................................................69

AMPHOTERICIN B......................................................22ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6ampicillin cap 500 mg....................................................6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPICILLIN-SULBACTAM........................................... 6AMPYRA........................................................................70ANADROL-50............................................................... 82

anagrelide hcl cap 0.5 mg.......................................... 55anagrelide hcl cap 1 mg............................................. 55anastrozole tab 1 mg...................................................25ANDRODERM.............................................................. 82ANDRODERM.............................................................. 82ANDROGEL.................................................................. 82ANDROGEL.................................................................. 82ANDROGEL PUMP..................................................... 82ANORO ELLIPTA.........................................................98APOKYN........................................................................36aprepitant capsule 125 mg.........................................21aprepitant capsule 40 mg........................................... 21aprepitant capsule 80 mg........................................... 21aprepitant capsule therapy pack 80 & 125

mg................................................................................21APRISO......................................................................... 93APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 42APTIVUS....................................................................... 42ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARANESP ALBUMIN FREE.......................................55ARCALYST....................................................................87aripiprazole orally disintegrating tab 10

mg................................................................................38aripiprazole orally disintegrating tab 15

mg................................................................................38aripiprazole oral solution 1 mg/ml..............................38aripiprazole tab 10 mg................................................ 38aripiprazole tab 15 mg................................................ 38aripiprazole tab 20 mg................................................ 38aripiprazole tab 2 mg...................................................38aripiprazole tab 30 mg................................................ 38aripiprazole tab 5 mg...................................................38ARISTADA.....................................................................38ARISTADA.....................................................................38ARISTADA.....................................................................38

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ARISTADA.....................................................................38ARISTADA INITIO........................................................38armodafinil tab 150 mg............................................. 102armodafinil tab 200 mg............................................. 102armodafinil tab 250 mg............................................. 102armodafinil tab 50 mg............................................... 102ARNUITY ELLIPTA......................................................98ARNUITY ELLIPTA......................................................98ARNUITY ELLIPTA......................................................98ARRANON.................................................................... 25ARSENIC TRIOXIDE...................................................26ARZERRA..................................................................... 26ARZERRA..................................................................... 26ASACOL HD.................................................................93ASMANEX HFA............................................................98ASMANEX HFA............................................................98ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 98ASMANEX TWISTHALER 14 METERED

DOSES....................................................................... 98ASMANEX TWISTHALER 30 METERED

DOSES....................................................................... 98ASMANEX TWISTHALER 30 METERED

DOSES....................................................................... 98ASMANEX TWISTHALER 60 METERED

DOSES....................................................................... 98ASMANEX TWISTHALER 7 METERED

DOSES....................................................................... 98aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................55ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"......................................... 48ASSURE ID INSULIN SAFETY SYRINGE/

U-100/1ML/29G X 1/2".............................................48ASSURE ID SAFETY PEN NEEDLES 31G X 5 MM

(3/16")......................................................................... 48atazanavir sulfate cap 150 mg...................................42atazanavir sulfate cap 200 mg...................................42atazanavir sulfate cap 300 mg...................................42atenolol & chlorthalidone tab 100-25

mg................................................................................59atenolol & chlorthalidone tab 50-25 mg.................... 59atenolol tab 100 mg.....................................................59atenolol tab 25 mg.......................................................59atenolol tab 50 mg.......................................................59ATGAM.......................................................................... 87atomoxetine hcl cap 100 mg...................................... 70atomoxetine hcl cap 10 mg........................................ 70atomoxetine hcl cap 18 mg........................................ 70atomoxetine hcl cap 25 mg........................................ 70atomoxetine hcl cap 40 mg........................................ 70atomoxetine hcl cap 60 mg........................................ 70

atomoxetine hcl cap 80 mg........................................ 70atorvastatin calcium tab 10 mg.................................. 59atorvastatin calcium tab 20 mg.................................. 59atorvastatin calcium tab 40 mg.................................. 59atorvastatin calcium tab 80 mg.................................. 59atovaquone-proguanil hcl tab 250-100

mg................................................................................36atovaquone-proguanil hcl tab 62.5-25

mg................................................................................36atovaquone susp 750 mg/5ml....................................35ATRIPLA........................................................................ 43ATROVENT HFA..........................................................98AVASTIN........................................................................26AVASTIN........................................................................26AVELOX...........................................................................6AVONEX........................................................................ 70AVONEX........................................................................ 70AVONEX PEN.............................................................. 70azacitidine for inj 100 mg............................................55AZACTAM........................................................................6AZACTAM........................................................................6AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZASAN........................................................................ 87AZASAN........................................................................ 87AZATHIOPRINE........................................................... 87azathioprine tab 50 mg............................................... 87azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................98azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................98azelastine hcl ophth soln 0.05%................................ 95AZELEX......................................................................... 71AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT........................................................................... 95aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN................................................................ 95bacitracin-polymyxin b ophth oint.............................. 95bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................... 95baclofen tab 10 mg......................................................42

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baclofen tab 20 mg......................................................42balsalazide disodium cap 750 mg............................. 93BANZEL.........................................................................13BANZEL.........................................................................13BANZEL.........................................................................13BARACLUDE................................................................ 43BAVENCIO.................................................................... 26BCG VACCINE.............................................................87BELEODAQ.................................................................. 26benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................59benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................59benazepril & hydrochlorothiazide tab 20-25

mg................................................................................59benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................59benazepril hcl tab 10 mg............................................ 59benazepril hcl tab 20 mg............................................ 59benazepril hcl tab 40 mg............................................ 59benazepril hcl tab 5 mg.............................................. 59BENDEKA..................................................................... 26BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88BENZNIDAZOLE..........................................................36BENZNIDAZOLE..........................................................36benzoyl peroxide-erythromycin gel

5-3%............................................................................71benztropine mesylate tab 0.5 mg.............................. 36benztropine mesylate tab 1 mg..................................36benztropine mesylate tab 2 mg..................................36BESIVANCE..................................................................95BESPONSA.................................................................. 26betamethasone dipropionate augmented cream

0.05%..........................................................................71betamethasone dipropionate augmented gel

0.05%..........................................................................71betamethasone dipropionate augmented lotion

0.05%..........................................................................71betamethasone dipropionate augmented oint

0.05%..........................................................................71betamethasone dipropionate cream

0.05%..........................................................................71betamethasone dipropionate lotion

0.05%..........................................................................71betamethasone dipropionate oint

0.05%..........................................................................71betamethasone valerate cream 0.1%....................... 71betamethasone valerate lotion 0.1%.........................71betamethasone valerate oint 0.1%............................71

BETASERON................................................................ 70betaxolol hcl ophth soln 0.5%.................................... 95betaxolol hcl tab 10 mg...............................................59betaxolol hcl tab 20 mg...............................................59bethanechol chloride tab 10 mg.................................80bethanechol chloride tab 25 mg.................................80bethanechol chloride tab 50 mg.................................80bethanechol chloride tab 5 mg...................................80BETOPTIC-S.................................................................95BEVYXXA......................................................................55BEVYXXA......................................................................55bexarotene cap 75 mg................................................ 26BEXSERO..................................................................... 88bicalutamide tab 50 mg...............................................26BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICNU............................................................................26BIKTARVY..................................................................... 43BILTRICIDE...................................................................36bimatoprost ophth soln 0.03%................................... 95bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................59bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................59bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................59bisoprolol fumarate tab 10 mg................................... 59bisoprolol fumarate tab 5 mg..................................... 59bleomycin sulfate for inj 15 unit................................. 26bleomycin sulfate for inj 30 unit................................. 26BLINCYTO.....................................................................26BOOSTRIX....................................................................88BOSULIF....................................................................... 26BOSULIF....................................................................... 26BOSULIF....................................................................... 26BRAFTOVI.....................................................................26BRAFTOVI.....................................................................26BREO ELLIPTA............................................................ 98BREO ELLIPTA............................................................ 98BRILINTA.......................................................................55BRILINTA.......................................................................55brimonidine tartrate ophth soln 0.15%...................... 95brimonidine tartrate ophth soln 0.2%........................ 95BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13

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bromfenac sodium ophth soln 0.09% (once-daily)............................................................................95

bromocriptine mesylate cap 5 mg..............................36bromocriptine mesylate tab 2.5 mg........................... 36budesonide delayed release particles cap 3

mg................................................................................93budesonide inhalation susp 0.25

mg/2ml........................................................................ 98budesonide inhalation susp 0.5

mg/2ml........................................................................ 98budesonide inhalation susp 1 mg/2ml.......................98bumetanide inj 0.25 mg/ml......................................... 59bumetanide tab 0.5 mg............................................... 59bumetanide tab 1 mg.................................................. 59bumetanide tab 2 mg.................................................. 59BUPHENYL...................................................................78buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................4buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................4buprenorphine hcl sl tab 2 mg......................................4buprenorphine hcl sl tab 8 mg......................................4bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................4bupropion hcl tab 100 mg...........................................18bupropion hcl tab 75 mg.............................................18bupropion hcl tab er 12hr 100 mg............................. 18bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 18bupropion hcl tab er 24hr 150 mg............................. 18bupropion hcl tab er 24hr 300 mg............................. 18buspirone hcl tab 10 mg............................................. 47buspirone hcl tab 15 mg............................................. 47buspirone hcl tab 30 mg............................................. 47buspirone hcl tab 5 mg............................................... 47buspirone hcl tab 7.5 mg............................................ 47busulfan inj 6 mg/ml.................................................... 26butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON..................................................................49

BYDUREON BCISE.....................................................49BYDUREON PEN........................................................ 49Ccabergoline tab 0.5 mg............................................... 86CABOMETYX............................................................... 26CABOMETYX............................................................... 26CABOMETYX............................................................... 26caffeine citrate oral soln 60 mg/3ml...........................98calcipotriene cream 0.005%.......................................71calcipotriene oint 0.005%............................................71calcipotriene soln 0.005% (50 mcg/ml).....................71calcitonin (salmon) nasal soln 200 unit/

act................................................................................94calcitriol cap 0.25 mcg................................................ 94calcitriol cap 0.5 mcg...................................................94calcitriol inj 1 mcg/ml...................................................94calcitriol oral soln 1 mcg/ml........................................94calcium acetate cap 667 mg...................................... 74calcium acetate tab 667 mg....................................... 74CALQUENCE................................................................26CANASA........................................................................93CANCIDAS....................................................................22CANCIDAS....................................................................22candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................60candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................60candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................60candesartan cilexetil tab 16 mg................................. 60candesartan cilexetil tab 32 mg................................. 60candesartan cilexetil tab 4 mg................................... 59candesartan cilexetil tab 8 mg................................... 60CAPASTAT SULFATE..................................................25CAPRELSA................................................................... 26CAPRELSA................................................................... 26captopril tab 100 mg....................................................60captopril tab 12.5 mg...................................................60captopril tab 25 mg......................................................60captopril tab 50 mg......................................................60CARAC.......................................................................... 71CARBAGLU.................................................................. 74carbamazepine cap er 12hr 100 mg......................... 13carbamazepine cap er 12hr 200 mg......................... 13carbamazepine cap er 12hr 300 mg......................... 13carbamazepine chew tab 100 mg..............................13carbamazepine susp 100 mg/5ml..............................13carbamazepine tab 200 mg........................................14carbamazepine tab er 12hr 100 mg.......................... 13carbamazepine tab er 12hr 200 mg.......................... 14carbamazepine tab er 12hr 400 mg.......................... 14

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CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................37

carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................36

carbidopa & levodopa orally disintegrating tab25-100 mg..................................................................36

carbidopa & levodopa orally disintegrating tab25-250 mg..................................................................36

carbidopa & levodopa tab 10-100 mg....................... 36carbidopa & levodopa tab 25-100 mg....................... 36carbidopa & levodopa tab 25-250 mg....................... 37carbidopa & levodopa tab er 25-100

mg................................................................................36carbidopa & levodopa tab er 50-200

mg................................................................................36carbidopa tab 25 mg................................................... 37carboplatin iv soln 150 mg/15ml................................ 26carboplatin iv soln 450 mg/45ml................................ 26carboplatin iv soln 50 mg/5ml.................................... 26carboplatin iv soln 600 mg/60ml................................ 26carmustine for inj 100 mg...........................................26carteolol hcl ophth soln 1%........................................ 95carvedilol tab 12.5 mg.................................................60carvedilol tab 25 mg....................................................60carvedilol tab 3.125 mg...............................................60carvedilol tab 6.25 mg.................................................60caspofungin acetate for iv soln 50 mg...................... 22caspofungin acetate for iv soln 70 mg...................... 22cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7CEFAZOLIN SODIUM................................................... 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7cefepime hcl for inj 1 gm.............................................. 7

cefepime hcl for inj 2 gm.............................................. 7CEFOTAXIME SODIUM................................................7CEFOTAXIME SODIUM................................................7cefotaxime sodium for inj 1 gm.................................... 7cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................7cefprozil tab 500 mg......................................................7ceftazidime for inj 1 gm.................................................7ceftazidime for inj 2 gm.................................................7ceftazidime for inj 6 gm.................................................7ceftazidime for iv soln 1 gm..........................................7ceftazidime for iv soln 2 gm..........................................7CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 8cefuroxime axetil tab 500 mg....................................... 8cefuroxime sodium for inj 7.5 gm.................................8cefuroxime sodium for inj 750 mg................................8cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 78CHANTIX......................................................................... 4

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CHANTIX......................................................................... 4CHANTIX CONTINUING MONTH

PACK.............................................................................5CHANTIX STARTING MONTH PACK.........................5CHEMET........................................................................74CHENODAL.................................................................. 76CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlorhexidine gluconate soln 0.12%..........................71CHLOROQUINE PHOSPHATE................................. 36chloroquine phosphate tab 500 mg...........................36CHLOROTHIAZIDE..................................................... 60chlorothiazide tab 500 mg.......................................... 60CHLORPROMAZINE HCL..........................................21CHLORPROMAZINE HCL..........................................21chlorpromazine hcl tab 100 mg..................................21chlorpromazine hcl tab 10 mg....................................21chlorpromazine hcl tab 200 mg..................................21chlorpromazine hcl tab 25 mg....................................21chlorpromazine hcl tab 50 mg....................................21chlorthalidone tab 25 mg............................................ 60chlorthalidone tab 50 mg............................................ 60cholestyramine light powder 4 gm/

dose............................................................................ 60cholestyramine light powder packets 4

gm................................................................................60cholestyramine powder 4 gm/dose............................60cholestyramine powder packets 4 gm.......................60choline fenofibrate cap dr 135 mg............................. 60choline fenofibrate cap dr 45 mg............................... 60chorionic gonadotropin for im inj 10000 unit(chorionic

gonadotropin, pregnyl)............................................. 82ciclopirox gel 0.77%.................................................... 22ciclopirox olamine cream 0.77%................................22ciclopirox olamine susp 0.77%...................................22ciclopirox shampoo 1%............................................... 22ciclopirox solution 8%..................................................22cidofovir iv inj 75 mg/ml.............................................. 43cilostazol tab 100 mg.................................................. 55cilostazol tab 50 mg.................................................... 55CIMDUO........................................................................ 43cimetidine hcl soln 300 mg/5ml..................................76cimetidine tab 200 mg.................................................76cimetidine tab 300 mg.................................................76cimetidine tab 400 mg.................................................76cimetidine tab 800 mg.................................................76CINRYZE.......................................................................88CIPRODEX....................................................................97ciprofloxacin 200 mg/100ml in d5w............................. 8ciprofloxacin 400 mg/200ml in d5w............................. 8ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).....................................................................8

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml).....................................................................8

CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%.............................. 95ciprofloxacin hcl tab 250 mg.........................................8ciprofloxacin hcl tab 500 mg.........................................8ciprofloxacin hcl tab 750 mg.........................................8ciprofloxacin hcl tab er 24hr 1000 mg......................... 8ciprofloxacin hcl tab er 24hr 500 mg........................... 8CISPLATIN.................................................................... 26cisplatin inj 100 mg/100ml (1 mg/ml).........................26cisplatin inj 50 mg/50ml (1 mg/ml).............................26citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 18citalopram hydrobromide tab 10 mg..........................18citalopram hydrobromide tab 20 mg..........................18citalopram hydrobromide tab 40 mg..........................18cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................26clarithromycin for susp 125 mg/5ml.............................8clarithromycin for susp 250 mg/5ml.............................8clarithromycin tab 250 mg............................................ 8clarithromycin tab 500 mg............................................ 8clarithromycin tab er 24hr 500 mg...............................8CLEMASTINE FUMARATE........................................ 98clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 8clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................71clindamycin phosphate gel 1%.................................... 9clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 9clindamycin phosphate inj 300 mg/2ml....................... 9clindamycin phosphate inj 600 mg/4ml....................... 9clindamycin phosphate inj 900 mg/6ml....................... 9clindamycin phosphate inj 9 gm/60ml......................... 9clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 9clindamycin phosphate iv soln 600

mg/4ml.......................................................................... 9clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 9clindamycin phosphate lotion 1%................................ 9clindamycin phosphate soln 1%...................................9clindamycin phosphate swab 1%.................................9clindamycin phosphate vaginal cream

2%..................................................................................9

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clobazam suspension 2.5 mg/ml............................... 14clobazam tab 10 mg....................................................14clobazam tab 20 mg....................................................14clobetasol propionate cream 0.05%..........................72clobetasol propionate emollient base cream

0.05%..........................................................................72clobetasol propionate gel 0.05%................................72clobetasol propionate oint 0.05%.............................. 72clobetasol propionate soln 0.05%..............................72clofarabine iv soln 1 mg/ml.........................................26clomipramine hcl cap 25 mg...................................... 18clomipramine hcl cap 50 mg...................................... 18clomipramine hcl cap 75 mg...................................... 18clonazepam orally disintegrating tab 0.125

mg................................................................................47clonazepam orally disintegrating tab 0.25

mg................................................................................47clonazepam orally disintegrating tab 0.5

mg................................................................................48clonazepam orally disintegrating tab 1

mg................................................................................48clonazepam orally disintegrating tab 2

mg................................................................................48clonazepam tab 0.5 mg.............................................. 48clonazepam tab 1 mg..................................................48clonazepam tab 2 mg..................................................48clonidine hcl tab 0.1 mg..............................................60clonidine hcl tab 0.2 mg..............................................60clonidine hcl tab 0.3 mg..............................................60clonidine hcl tab er 12hr 0.1 mg................................ 70clonidine td patch weekly 0.1 mg/24hr......................60clonidine td patch weekly 0.2 mg/24hr......................60clonidine td patch weekly 0.3 mg/24hr......................60clopidogrel bisulfate tab 75 mg..................................55clorazepate dipotassium tab 15 mg...........................48clorazepate dipotassium tab 3.75 mg....................... 48clorazepate dipotassium tab 7.5 mg......................... 48clotrimazole cream 1%................................................23clotrimazole troche 10 mg.......................................... 23clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 72clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 72clozapine orally disintegrating tab 100

mg................................................................................38clozapine orally disintegrating tab 12.5

mg................................................................................38clozapine orally disintegrating tab 25

mg................................................................................38clozapine tab 100 mg..................................................38clozapine tab 200 mg..................................................38clozapine tab 25 mg....................................................38

clozapine tab 50 mg....................................................38COARTEM.....................................................................36codeine sulfate tab 15 mg............................................ 1codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24COLCRYS..................................................................... 24colesevelam hcl packet for susp 3.75

gm................................................................................60colesevelam hcl tab 625 mg.......................................60colestipol hcl granule packets 5 gm.......................... 60colestipol hcl granules 5 gm.......................................60colestipol hcl tab 1 gm................................................ 60colistimethate sod for inj 150 mg................................. 9COMBIGAN...................................................................95COMBIVENT RESPIMAT........................................... 98COMETRIQ...................................................................27COMETRIQ...................................................................27COMETRIQ...................................................................27COMPLERA.................................................................. 43COPAXONE.................................................................. 70COPIKTRA....................................................................27COPIKTRA....................................................................27CORLANOR..................................................................60CORLANOR..................................................................60CORTISONE ACETATE..............................................81COSENTYX.................................................................. 88COSENTYX SENSOREADY PEN............................ 88COSMEGEN................................................................. 27COTELLIC.....................................................................27COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56COUMADIN...................................................................56CREON..........................................................................78CREON..........................................................................78CREON..........................................................................79CREON..........................................................................79CREON..........................................................................79CRESEMBA.................................................................. 23CRESEMBA.................................................................. 23CRIXIVAN......................................................................43CRIXIVAN......................................................................43cromolyn sodium ophth soln 4%................................95cromolyn sodium oral conc 100

mg/5ml........................................................................ 76

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cromolyn sodium soln nebu 20 mg/2ml.................... 98cyclobenzaprine hcl tab 10 mg................................ 102cyclobenzaprine hcl tab 5 mg.................................. 102cyclobenzaprine hcl tab 7.5 mg...............................102cyclophosphamide cap 25 mg................................... 27cyclophosphamide cap 50 mg................................... 27cyclophosphamide for inj 1 gm.................................. 27cyclophosphamide for inj 2 gm.................................. 27cyclophosphamide for inj 500 mg..............................27CYCLOSERINE............................................................25CYCLOSET...................................................................49cyclosporine cap 100 mg............................................88cyclosporine cap 25 mg..............................................88cyclosporine iv soln 50 mg/ml....................................88cyclosporine modified cap 100 mg............................ 88cyclosporine modified cap 25 mg.............................. 88cyclosporine modified cap 50 mg.............................. 88cyclosporine modified oral soln 100 mg/

ml.................................................................................88CYRAMZA.....................................................................27CYRAMZA.....................................................................27CYSTADANE................................................................ 79CYSTAGON.................................................................. 79CYSTAGON.................................................................. 79CYSTARAN...................................................................95CYTARABINE............................................................... 27cytarabine inj pf 100 mg/ml........................................ 27cytarabine inj pf 20 mg/ml.......................................... 27DDACARBAZINE............................................................ 27dacarbazine for inj 200 mg.........................................27dactinomycin for inj 0.5 mg........................................ 27DAKLINZA.....................................................................43DAKLINZA.....................................................................43DAKLINZA.....................................................................43dalfampridine tab er 12hr 10 mg................................70DALIRESP.....................................................................99DALIRESP.....................................................................99DALVANCE......................................................................9danazol cap 100 mg....................................................82danazol cap 200 mg....................................................82danazol cap 50 mg......................................................82dantrolene sodium cap 100 mg................................. 42dantrolene sodium cap 25 mg....................................42dantrolene sodium cap 50 mg....................................42dapsone tab 100 mg................................................... 25dapsone tab 25 mg......................................................25DAPTACEL....................................................................88daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 36DARZALEX................................................................... 27

DARZALEX................................................................... 27daunorubicin hcl iv soln 20 mg/4ml........................... 27DAUNORUBICIN HYDROCHLORIDE......................27DDAVP...........................................................................82decitabine for inj 50 mg.............................................. 27DELSTRIGO................................................................. 43DELZICOL.....................................................................93demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 60DENAVIR.......................................................................43DEPEN TITRATABS.................................................... 80DEPO-PROVERA........................................................ 82DESCOVY.....................................................................43desipramine hcl tab 100 mg.......................................18desipramine hcl tab 10 mg......................................... 18desipramine hcl tab 150 mg.......................................18desipramine hcl tab 25 mg......................................... 18desipramine hcl tab 50 mg......................................... 18desipramine hcl tab 75 mg......................................... 18desmopressin acetate inj 4 mcg/ml...........................82desmopressin acetate tab 0.1 mg............................. 82desmopressin acetate tab 0.2 mg............................. 82desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 82desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................83

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................83

desonide cream 0.05%............................................... 72desonide lotion 0.05%.................................................72desonide oint 0.05%....................................................72desoximetasone cream 0.05%...................................72desoximetasone cream 0.25%...................................72desoximetasone gel 0.05%........................................ 72desoximetasone oint 0.25%....................................... 72desvenlafaxine succinate tab er 24hr 100

mg................................................................................18desvenlafaxine succinate tab er 24hr 25

mg................................................................................18desvenlafaxine succinate tab er 24hr 50

mg................................................................................18DEXAMETHASONE.................................................... 81DEXAMETHASONE.................................................... 81dexamethasone elixir 0.5 mg/5ml..............................81DEXAMETHASONE SODIUM

PHOSPHATE.............................................................95dexamethasone sodium phosphate inj 120

mg/30ml......................................................................81dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 81

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dexamethasone sodium phosphate inj 4 mg/ml.................................................................................81

dexamethasone tab 0.5 mg........................................81dexamethasone tab 0.75 mg......................................81dexamethasone tab 1.5 mg........................................81dexamethasone tab 4 mg...........................................81dexamethasone tab 6 mg...........................................81dexmethylphenidate hcl tab 10 mg............................70dexmethylphenidate hcl tab 2.5 mg...........................70dexmethylphenidate hcl tab 5 mg..............................70dexrazoxane for inj 250 mg........................................27dexrazoxane for inj 500 mg........................................27dextroamphetamine sulfate cap er 24hr 10

mg................................................................................70dextroamphetamine sulfate cap er 24hr 15

mg................................................................................70dextroamphetamine sulfate cap er 24hr 5

mg................................................................................70dextroamphetamine sulfate tab 10 mg......................70dextroamphetamine sulfate tab 5 mg........................70dextrose 2.5% w/ sodium chloride

0.45%..........................................................................74dextrose 5% in lactated ringers................................. 74dextrose 5% w/ sodium chloride 0.2%...................... 74dextrose 5% w/ sodium chloride

0.33%..........................................................................74dextrose 5% w/ sodium chloride

0.45%..........................................................................74dextrose 5% w/ sodium chloride 0.9%...................... 74dextrose inj 10%.......................................................... 74dextrose inj 5%.............................................................74DIASTAT ACUDIAL......................................................14DIASTAT ACUDIAL......................................................14DIASTAT PEDIATRIC..................................................14DIAZEPAM.................................................................... 48diazepam conc 5 mg/ml..............................................48DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................48diazepam tab 2 mg......................................................48diazepam tab 5 mg......................................................48diclofenac potassium tab 50 mg.................................. 1diclofenac sodium gel 1%.............................................1diclofenac sodium gel 3%...........................................72diclofenac sodium ophth soln 0.1%...........................95diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1

diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl tab 20 mg..........................................76didanosine delayed release capsule 200

mg................................................................................43didanosine delayed release capsule 250

mg................................................................................43didanosine delayed release capsule 400

mg................................................................................43DIFICID............................................................................ 9diflorasone diacetate oint 0.05%................................72DIGOXIN........................................................................61digoxin tab 125 mcg (0.125 mg)................................61digoxin tab 250 mcg (0.25 mg).................................. 61DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 61diltiazem hcl cap er 12hr 60 mg.................................61diltiazem hcl cap er 12hr 90 mg.................................61diltiazem hcl cap er 24hr 120 mg.............................. 61diltiazem hcl cap er 24hr 180 mg.............................. 61diltiazem hcl cap er 24hr 240 mg.............................. 61diltiazem hcl coated beads cap er 24hr 120

mg................................................................................61diltiazem hcl coated beads cap er 24hr 180

mg................................................................................61diltiazem hcl coated beads cap er 24hr 240

mg................................................................................61diltiazem hcl coated beads cap er 24hr 300

mg................................................................................61diltiazem hcl coated beads cap er 24hr 360

mg................................................................................61diltiazem hcl coated beads tab er 24hr 180

mg................................................................................61diltiazem hcl coated beads tab er 24hr 240

mg................................................................................61diltiazem hcl coated beads tab er 24hr 300

mg................................................................................61diltiazem hcl coated beads tab er 24hr 360

mg................................................................................61diltiazem hcl coated beads tab er 24hr 420

mg................................................................................61diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 61diltiazem hcl extended release beads cap er 24hr

180 mg....................................................................... 61diltiazem hcl extended release beads cap er 24hr

240 mg....................................................................... 61

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diltiazem hcl extended release beads cap er 24hr300 mg....................................................................... 61

diltiazem hcl extended release beads cap er 24hr360 mg....................................................................... 61

diltiazem hcl extended release beads cap er 24hr420 mg....................................................................... 61

diltiazem hcl tab 120 mg.............................................61diltiazem hcl tab 30 mg...............................................61diltiazem hcl tab 60 mg...............................................61diltiazem hcl tab 90 mg...............................................61DIPENTUM....................................................................93diphenhydramine hcl inj 50 mg/ml.............................99DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................88dipyridamole tab 25 mg.............................................. 56dipyridamole tab 50 mg.............................................. 56dipyridamole tab 75 mg.............................................. 56disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium tab delayed release 125

mg................................................................................14divalproex sodium tab delayed release 250

mg................................................................................14divalproex sodium tab delayed release 500

mg................................................................................14divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................14DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27docetaxel for inj conc 20 mg/ml................................. 28docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................28docetaxel soln for iv infusion 160

mg/16ml......................................................................28docetaxel soln for iv infusion 20

mg/2ml........................................................................ 28docetaxel soln for iv infusion 80

mg/8ml........................................................................ 28dofetilide cap 125 mcg (0.125 mg)............................61dofetilide cap 250 mcg (0.25 mg).............................. 61dofetilide cap 500 mcg (0.5 mg)................................ 61donepezil hydrochloride orally disintegrating tab 10

mg................................................................................17

donepezil hydrochloride orally disintegrating tab 5mg................................................................................17

donepezil hydrochloride tab 10 mg........................... 17donepezil hydrochloride tab 23 mg........................... 17donepezil hydrochloride tab 5 mg..............................17dorzolamide hcl ophth soln 2%..................................95dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml.......................................................................... 95doxazosin mesylate tab 1 mg.................................... 61doxazosin mesylate tab 2 mg.................................... 61doxazosin mesylate tab 4 mg.................................... 61doxazosin mesylate tab 8 mg.................................... 61doxepin hcl cap 100 mg..............................................19doxepin hcl cap 10 mg................................................18doxepin hcl cap 150 mg..............................................19doxepin hcl cap 25 mg................................................18doxepin hcl cap 50 mg................................................18doxepin hcl cap 75 mg................................................18doxepin hcl conc 10 mg/ml.........................................19doxorubicin hcl for inj 10 mg...................................... 28doxorubicin hcl for inj 50 mg...................................... 28doxorubicin hcl inj 2 mg/ml.........................................28doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................28doxycycline hyclate cap 100 mg..................................9doxycycline hyclate cap 50 mg.................................... 9doxycycline hyclate for inj 100 mg...............................9doxycycline hyclate tab 100 mg...................................9doxycycline hyclate tab 20 mg.....................................9doxycycline monohydrate cap 100 mg........................9doxycycline monohydrate cap 150 mg........................9doxycycline monohydrate cap 50 mg..........................9doxycycline monohydrate cap 75 mg..........................9doxycycline monohydrate tab 100 mg.........................9doxycycline monohydrate tab 150 mg.........................9doxycycline monohydrate tab 50 mg...........................9doxycycline monohydrate tab 75 mg...........................9dronabinol cap 10 mg................................................. 21dronabinol cap 2.5 mg................................................ 21dronabinol cap 5 mg....................................................21drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................83drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................83drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................83drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................83DULERA........................................................................ 99DULERA........................................................................ 99duloxetine hcl enteric coated pellets cap 20

mg................................................................................19

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duloxetine hcl enteric coated pellets cap 30mg................................................................................19

duloxetine hcl enteric coated pellets cap 60mg................................................................................19

DUPIXENT.................................................................... 88DUREZOL..................................................................... 95dutasteride cap 0.5 mg............................................... 80dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................80EEASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/0.5ML/29G X 1/2"......................................... 49EASY TOUCH SHEATHLOCK SAFETY INSULIN

SYRINGE 1ML/29GX1/2"........................................ 49econazole nitrate cream 1%.......................................23EDURANT..................................................................... 43efavirenz cap 200 mg..................................................43efavirenz cap 50 mg....................................................43efavirenz tab 600 mg...................................................43EFFIENT........................................................................56EFFIENT........................................................................56EGRIFTA....................................................................... 82EGRIFTA....................................................................... 82ELAPRASE................................................................... 79ELELYSO.......................................................................79ELIDEL...........................................................................72ELIGARD.......................................................................86ELIGARD.......................................................................86ELIGARD.......................................................................86ELIGARD.......................................................................86ELIQUIS.........................................................................56ELIQUIS.........................................................................56ELIQUIS STARTER PACK......................................... 56ELITEK...........................................................................28ELITEK...........................................................................28ELLA...............................................................................83EMCYT.......................................................................... 28EMEND..........................................................................21EMPLICITI.....................................................................28EMPLICITI.....................................................................28EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................43EMTRIVA.......................................................................43enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................61enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................61enalapril maleate tab 10 mg.......................................62enalapril maleate tab 2.5 mg......................................62enalapril maleate tab 20 mg.......................................62

enalapril maleate tab 5 mg.........................................62ENBREL........................................................................ 88ENBREL........................................................................ 88ENBREL........................................................................ 88ENBREL MINI...............................................................88ENBREL SURECLICK................................................ 88ENGERIX-B.................................................................. 88ENGERIX-B.................................................................. 88enoxaparin sodium inj 100 mg/ml..............................56enoxaparin sodium inj 120 mg/0.8ml........................ 56enoxaparin sodium inj 150 mg/ml..............................56enoxaparin sodium inj 300 mg/3ml............................56enoxaparin sodium inj 30 mg/0.3ml...........................56enoxaparin sodium inj 40 mg/0.4ml...........................56enoxaparin sodium inj 60 mg/0.6ml...........................56enoxaparin sodium inj 80 mg/0.8ml...........................56entacapone tab 200 mg..............................................37entecavir tab 0.5 mg....................................................43entecavir tab 1 mg.......................................................43ENTRESTO...................................................................62ENTRESTO...................................................................62ENTRESTO...................................................................62EPCLUSA......................................................................43epinastine hcl ophth soln 0.05%................................95EPINEPHRINE............................................................. 99EPINEPHRINE............................................................. 99EPIPEN 2-PAK............................................................. 99EPIPEN-JR 2-PAK....................................................... 99epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................28epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................28EPIVIR HBV..................................................................43eplerenone tab 25 mg.................................................62eplerenone tab 50 mg.................................................62EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56EPOGEN....................................................................... 56ERBITUX....................................................................... 28ERBITUX....................................................................... 28ERGOLOID MESYLATES...........................................17ERIVEDGE....................................................................28ERLEADA......................................................................28ertapenem sodium for inj 1 gm.................................. 10ERWINAZE................................................................... 28ERYPED 400................................................................10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERYTHROCIN LACTOBIONATE...............................10

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ERYTHROCIN STEARATE........................................ 10erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm.............................. 95erythromycin pads 2%.................................................10erythromycin soln 2%..................................................10erythromycin tab 250 mg............................................ 10erythromycin tab 500 mg............................................ 10ESBRIET....................................................................... 99ESBRIET....................................................................... 99ESBRIET....................................................................... 99escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 5 mg...................................19esomeprazole magnesium cap delayed release 20

mg................................................................................76esomeprazole magnesium cap delayed release 40

mg................................................................................76ESOMEPRAZOLE SODIUM...................................... 76esomeprazole sodium for intravenous soln 40

mg................................................................................77ESTRACE......................................................................83estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................83estradiol & norethindrone acetate tab 1-0.5

mg................................................................................83estradiol tab 0.5 mg.....................................................83estradiol tab 1 mg........................................................83estradiol tab 2 mg........................................................83estradiol vaginal cream 0.1 mg/gm........................... 83estradiol vaginal tab 10 mcg...................................... 83ESTROPIPATE............................................................. 83ethambutol hcl tab 100 mg.........................................25ethambutol hcl tab 400 mg.........................................25ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................83ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................83ETIDRONATE DISODIUM..........................................94ETIDRONATE DISODIUM..........................................94etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 28etoposide inj 100 mg/5ml (20 mg/ml)........................28

etoposide inj 1 gm/50ml (20 mg/ml).......................... 28etoposide inj 500 mg/25ml (20 mg/ml)......................28EVOMELA..................................................................... 28EVOTAZ.........................................................................43exemestane tab 25 mg............................................... 28EXJADE.........................................................................74EXJADE.........................................................................74EXJADE.........................................................................74ezetimibe-simvastatin tab 10-10 mg..........................62ezetimibe-simvastatin tab 10-20 mg..........................62ezetimibe-simvastatin tab 10-40 mg..........................62ezetimibe-simvastatin tab 10-80 mg..........................62ezetimibe tab 10 mg....................................................62FFABRAZYME................................................................ 79FABRAZYME................................................................ 79famciclovir tab 125 mg................................................43famciclovir tab 250 mg................................................43famciclovir tab 500 mg................................................43famotidine inj 200 mg/20ml........................................ 77famotidine inj 20 mg/2ml.............................................77famotidine inj 40 mg/4ml.............................................77famotidine tab 20 mg...................................................77famotidine tab 40 mg...................................................77FANAPT.........................................................................38FANAPT.........................................................................38FANAPT.........................................................................38FANAPT.........................................................................38FANAPT.........................................................................38FANAPT.........................................................................38FANAPT.........................................................................38FANAPT TITRATION PACK....................................... 38FARESTON...................................................................28FARYDAK......................................................................28FARYDAK......................................................................28FARYDAK......................................................................28FASLODEX................................................................... 28fat emulsion iv soln 20%.............................................74felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 62felodipine tab er 24hr 2.5 mg..................................... 62felodipine tab er 24hr 5 mg........................................ 62fenofibrate micronized cap 134 mg........................... 62fenofibrate micronized cap 200 mg........................... 62fenofibrate micronized cap 67 mg............................. 62fenofibrate tab 145 mg................................................62fenofibrate tab 160 mg................................................62fenofibrate tab 48 mg.................................................. 62fenofibrate tab 54 mg.................................................. 62

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fentanyl citrate lozenge on a handle 1200mcg................................................................................2

fentanyl citrate lozenge on a handle 1600mcg................................................................................2

fentanyl citrate lozenge on a handle 200mcg................................................................................2

fentanyl citrate lozenge on a handle 400mcg................................................................................2

fentanyl citrate lozenge on a handle 600mcg................................................................................2

fentanyl citrate lozenge on a handle 800mcg................................................................................2

fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 37.5 mcg/hr..............................2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 62.5 mcg/hr..............................2fentanyl td patch 72hr 75 mcg/hr................................. 2fentanyl td patch 72hr 87.5 mcg/hr..............................2FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA TITRATION PACK......................................19FINACEA....................................................................... 72FINACEA....................................................................... 72finasteride tab 5 mg.....................................................80FIRAZYR....................................................................... 88FIRMAGON...................................................................86FIRMAGON...................................................................86flecainide acetate tab 100 mg....................................62flecainide acetate tab 150 mg....................................62flecainide acetate tab 50 mg...................................... 62FLOVENT DISKUS......................................................99FLOVENT DISKUS......................................................99FLOVENT DISKUS......................................................99FLOVENT HFA.............................................................99FLOVENT HFA.............................................................99FLOVENT HFA.............................................................99fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................23fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................23

fluconazole tab 200 mg...............................................23fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 23flucytosine cap 500 mg............................................... 23fludarabine phosphate for inj 50 mg..........................28fludarabine phosphate inj 25 mg/ml.......................... 28fludrocortisone acetate tab 0.1 mg............................ 81fluocinolone acetonide (otic) oil 0.01%..................... 97fluocinolone acetonide cream 0.01%........................ 72fluocinonide cream 0.05%.......................................... 72fluocinonide emulsified base cream

0.05%..........................................................................72fluocinonide gel 0.05%................................................72fluocinonide oint 0.05%...............................................72fluocinonide soln 0.05%..............................................72fluorometholone ophth susp 0.1%.............................95fluorouracil cream 5%................................................. 72fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................28fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................28fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................28fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................29fluorouracil soln 2%..................................................... 72fluorouracil soln 5%..................................................... 72FLUOXETINE DR........................................................ 19fluoxetine hcl cap 10 mg.............................................19fluoxetine hcl cap 20 mg.............................................19fluoxetine hcl cap 40 mg.............................................19fluoxetine hcl solution 20 mg/5ml.............................. 19fluoxetine hcl tab 10 mg..............................................19fluoxetine hcl tab 20 mg..............................................19fluphenazine decanoate inj 25 mg/ml........................38FLUPHENAZINE HCL.................................................38FLUPHENAZINE HCL.................................................38FLUPHENAZINE HCL.................................................39fluphenazine hcl tab 10 mg........................................ 39fluphenazine hcl tab 1 mg.......................................... 39fluphenazine hcl tab 2.5 mg....................................... 39fluphenazine hcl tab 5 mg.......................................... 39flurbiprofen sodium ophth soln 0.03%.......................95flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................29FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 99FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 99FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 99

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fluticasone propionate cream 0.05%.........................72fluticasone propionate nasal susp 50 mcg/

act................................................................................99fluticasone propionate oint 0.005%........................... 72fluvoxamine maleate tab 100 mg...............................19fluvoxamine maleate tab 25 mg.................................19fluvoxamine maleate tab 50 mg.................................19FOLOTYN......................................................................29FOLOTYN......................................................................29fomepizole inj 1 gm/ml (for iv infusion)......................74fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................56fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................56fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................56fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................56FORTEO........................................................................94fosamprenavir calcium tab 700 mg........................... 43fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................62fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................62fosinopril sodium tab 10 mg....................................... 62fosinopril sodium tab 20 mg....................................... 62fosinopril sodium tab 40 mg....................................... 62fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................14FOSRENOL.................................................................. 74FOSRENOL.................................................................. 75FOSRENOL.................................................................. 75FOSRENOL.................................................................. 75FOSRENOL.................................................................. 75furosemide inj 10 mg/ml..............................................62furosemide oral soln 10 mg/ml...................................62furosemide tab 20 mg................................................. 62furosemide tab 40 mg................................................. 62furosemide tab 80 mg................................................. 62FUZEON........................................................................43FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14Ggabapentin cap 100 mg.............................................. 14gabapentin cap 300 mg.............................................. 15gabapentin cap 400 mg.............................................. 15

gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg............................................... 15gabapentin tab 800 mg............................................... 15GABITRIL...................................................................... 15GABITRIL...................................................................... 15GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

mg................................................................................17galantamine hydrobromide cap er 24hr 24

mg................................................................................17galantamine hydrobromide cap er 24hr 8

mg................................................................................17galantamine hydrobromide tab 12 mg...................... 17galantamine hydrobromide tab 4 mg.........................17galantamine hydrobromide tab 8 mg.........................17GAMMAGARD LIQUID............................................... 89GAMMAGARD LIQUID............................................... 89GAMMAGARD LIQUID............................................... 89GAMMAGARD LIQUID............................................... 89GAMMAGARD LIQUID............................................... 89GAMMAGARD LIQUID............................................... 89GAMMAGARD S/D......................................................89GAMMAGARD S/D......................................................89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89ganciclovir sodium for inj 500 mg.............................. 44GARDASIL 9.................................................................89GARDASIL 9.................................................................89GATTEX.........................................................................77GAUZE PADS 2" X 2".................................................49GAZYVA.........................................................................29gemcitabine hcl for inj 1 gm....................................... 29gemcitabine hcl for inj 200 mg...................................29gemcitabine hcl for inj 2 gm....................................... 29gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................29gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................29gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................29gemfibrozil tab 600 mg............................................... 62gentamicin in saline inj 0.8 mg/ml............................. 10

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gentamicin in saline inj 1.2 mg/ml............................. 10gentamicin in saline inj 1.6 mg/ml............................. 10gentamicin in saline inj 1 mg/ml.................................10gentamicin sulfate cream 0.1%..................................72gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate oint 0.1%...................................... 72gentamicin sulfate ophth oint 0.3%........................... 95gentamicin sulfate ophth soln 0.3%...........................95GENVOYA.....................................................................44GEODON.......................................................................39GILOTRIF......................................................................29GILOTRIF......................................................................29GILOTRIF......................................................................29glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................70glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................70GLEOSTINE..................................................................29GLEOSTINE..................................................................29GLEOSTINE..................................................................29glimepiride tab 1 mg....................................................49glimepiride tab 2 mg....................................................49glimepiride tab 4 mg....................................................49glipizide-metformin hcl tab 2.5-250 mg.....................49glipizide-metformin hcl tab 2.5-500 mg.....................49glipizide-metformin hcl tab 5-500 mg........................ 49glipizide tab 10 mg...................................................... 49glipizide tab 5 mg.........................................................49glipizide tab er 24hr 10 mg.........................................49glipizide tab er 24hr 2.5 mg........................................49glipizide tab er 24hr 5 mg...........................................49GLUCAGEN HYPOKIT............................................... 49GLUCAGON EMERGENCY KIT............................... 49glycopyrrolate tab 1 mg.............................................. 77glycopyrrolate tab 2 mg.............................................. 77granisetron hcl inj 1 mg/ml......................................... 21granisetron hcl inj 4 mg/4ml (1 mg/ml)......................21granisetron hcl tab 1 mg.............................................21GRANIX......................................................................... 56GRANIX......................................................................... 56griseofulvin microsize susp 125

mg/5ml........................................................................ 23griseofulvin ultramicrosize tab 125 mg......................23griseofulvin ultramicrosize tab 250 mg......................23GUANIDINE HCL.........................................................24HH.P. ACTHAR............................................................... 81HAEGARDA.................................................................. 89HAEGARDA.................................................................. 89HALAVEN...................................................................... 29

halobetasol propionate cream 0.05%........................72halobetasol propionate oint 0.05%............................ 72haloperidol decanoate im soln 100 mg/

ml.................................................................................39haloperidol decanoate im soln 50 mg/

ml.................................................................................39haloperidol lactate inj 5 mg/ml................................... 39haloperidol lactate oral conc 2 mg/ml........................39haloperidol tab 0.5 mg................................................ 39haloperidol tab 10 mg................................................. 39haloperidol tab 1 mg....................................................39haloperidol tab 20 mg................................................. 39haloperidol tab 2 mg....................................................39haloperidol tab 5 mg....................................................39HARVONI...................................................................... 44HAVRIX..........................................................................89HAVRIX..........................................................................89heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................57heparin sodium (porcine) inj 10000 unit/

ml.................................................................................57heparin sodium (porcine) inj 1000 unit/

ml.................................................................................56heparin sodium (porcine) inj 20000 unit/

ml.................................................................................57heparin sodium (porcine) inj 5000 unit/

ml.................................................................................56heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................57HEPATAMINE............................................................... 75HERCEPTIN................................................................. 29HERCEPTIN................................................................. 29HETLIOZ..................................................................... 102HEXALEN......................................................................29HIBERIX........................................................................ 90HUMALOG.................................................................... 49HUMALOG.................................................................... 49HUMALOG JUNIOR KWIKPEN.................................49HUMALOG KWIKPEN.................................................49HUMALOG KWIKPEN.................................................49HUMALOG MIX 50/50.................................................49HUMALOG MIX 50/50 KWIKPEN............................. 49HUMALOG MIX 75/25.................................................49HUMALOG MIX 75/25 KWIKPEN............................. 49HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................90

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HUMIRA PEDIATRIC CROHNS DISEASESTARTER PACK.......................................................90

HUMIRA PEDIATRIC CROHNS DISEASESTARTER PACK.......................................................90

HUMIRA PEN............................................................... 90HUMIRA PEN............................................................... 90HUMIRA PEN-CD/UC/HS STARTER........................90HUMIRA PEN-CD/UC/HS STARTER........................90HUMIRA PEN-PS/UV STARTER...............................90HUMIRA PEN-PS/UV STARTER...............................90HUMULIN 70/30...........................................................50HUMULIN 70/30 KWIKPEN....................................... 50HUMULIN N..................................................................49HUMULIN N KWIKPEN.............................................. 50HUMULIN R..................................................................50HUMULIN R U-500 (CONCENTRATE).....................50HUMULIN R U-500 KWIKPEN...................................50hydralazine hcl tab 100 mg........................................ 63hydralazine hcl tab 10 mg.......................................... 63hydralazine hcl tab 25 mg.......................................... 63hydralazine hcl tab 50 mg.......................................... 63hydrochlorothiazide cap 12.5 mg...............................63hydrochlorothiazide tab 12.5 mg................................63hydrochlorothiazide tab 25 mg...................................63hydrochlorothiazide tab 50 mg...................................63hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325

mg..................................................................................2hydrocodone-acetaminophen tab 5-300

mg..................................................................................2hydrocodone-acetaminophen tab 5-325

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 72hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................72hydrocortisone butyrate oint 0.1%.............................72hydrocortisone butyrate soln 0.1%............................ 72hydrocortisone cream 1%...........................................73hydrocortisone cream 2.5%........................................73hydrocortisone enema 100 mg/60ml.........................93hydrocortisone lotion 2.5%......................................... 73hydrocortisone oint 1%............................................... 73

hydrocortisone oint 2.5%............................................ 73hydrocortisone rectal cream 1%................................ 93hydrocortisone rectal cream 2.5%.............................93hydrocortisone tab 10 mg...........................................81hydrocortisone tab 20 mg...........................................81hydrocortisone tab 5 mg............................................. 81hydrocortisone valerate cream 0.2%.........................73hydrocortisone valerate oint 0.2%............................. 73hydrocortisone w/ acetic acid otic soln

1-2%............................................................................97hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 36HYDROXYPROGESTERONE

CAPROATE................................................................83hydroxyurea cap 500 mg............................................ 29hydroxyzine hcl syrup 10 mg/5ml.............................. 48hydroxyzine hcl tab 10 mg..........................................48hydroxyzine hcl tab 25 mg..........................................48hydroxyzine hcl tab 50 mg..........................................48Iibandronate sodium iv soln 3 mg/3ml........................94ibandronate sodium tab 150 mg................................ 94IBRANCE.......................................................................29IBRANCE.......................................................................29IBRANCE.......................................................................29ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen tab 400 mg.................................................... 2ibuprofen tab 600 mg.................................................... 2ibuprofen tab 800 mg.................................................... 2ICLUSIG........................................................................ 29ICLUSIG........................................................................ 29idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................29idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................29idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................29IDHIFA............................................................................29IDHIFA............................................................................29IFEX............................................................................... 29IFOSFAMIDE................................................................ 29ifosfamide for inj 1 gm.................................................29ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 29ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 29ILARIS............................................................................90ILEVRO..........................................................................95imatinib mesylate tab 100 mg.................................... 30

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imatinib mesylate tab 400 mg.................................... 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMBRUVICA.................................................................. 30IMFINZI..........................................................................30IMFINZI..........................................................................30imipenem-cilastatin intravenous for soln 250

mg................................................................................10imipenem-cilastatin intravenous for soln 500

mg................................................................................10imipramine hcl tab 10 mg........................................... 19imipramine hcl tab 25 mg........................................... 19imipramine hcl tab 50 mg........................................... 19imiquimod cream 5%...................................................73IMLYGIC........................................................................ 30IMLYGIC........................................................................ 30IMOVAX RABIES (H.D.C.V.)...................................... 90IMPAVIDO..................................................................... 10INCRELEX.................................................................... 82INCRUSE ELLIPTA..................................................... 99indapamide tab 1.25 mg............................................. 63indapamide tab 2.5 mg............................................... 63INFANRIX......................................................................90INJECTION DEVICE FOR INSULIN......................... 50INLYTA...........................................................................30INLYTA...........................................................................30INSULIN PEN NEEDLE 29 G X 10

MM.............................................................................. 50INSULIN PEN NEEDLE 29 G X 12.7

MM.............................................................................. 50INSULIN PEN NEEDLE 29 G X 5 MM

(3/16")......................................................................... 50INSULIN PEN NEEDLE 29 G X 8 MM

(5/16")......................................................................... 50INSULIN PEN NEEDLE 30 G X 5 MM

(3/16")......................................................................... 50INSULIN PEN NEEDLE 30 G X 8 MM (1/3" OR

5/16")...........................................................................50INSULIN PEN NEEDLE 31 G X 4 MM

(1/6")........................................................................... 50INSULIN PEN NEEDLE 32 G X 5 MM (1/5" OR

3/16")...........................................................................50INSULIN PEN NEEDLE 33 G X 4 MM

(5/32")......................................................................... 50INSULIN PEN NEEDLE 33 G X 5 MM (1/5" OR

3/16")...........................................................................50INSULIN PEN NEEDLE 33 G X 6 MM

(1/4")........................................................................... 50

INSULIN PEN NEEDLE 33 G X 8 MM (1/3" OR5/16")...........................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 28 X1/2".............................................................................. 50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29G..................................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X1"................................................................................. 50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30G..................................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X1/2".............................................................................. 50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X15/64"..........................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X1/4" (6 MM)................................................................ 50

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X15/64"..........................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X15/64"..........................................................................50

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X3/16" (5 MM)..............................................................50

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 31 X1/4" (6 MM)................................................................ 50

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X1/2".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X5/16"............................................................................51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29G..................................................................................51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X5/16"............................................................................51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30G..................................................................................51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X3/8".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 25 X1"................................................................................. 50

INSULIN SYRINGE/NEEDLE U-100 1 ML 25 X5/8".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 26 X1/2".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X1/2".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 27 X5/8".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X5/16"............................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X5/16"............................................................................51

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INSULIN SYRINGE/NEEDLE U-100 1 ML 30G..................................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X1/2".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X3/16" (5 MM)..............................................................51

INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X1/4" (6 MM)................................................................ 51

INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X15/64"..........................................................................51

INSULIN SYRINGE/NEEDLE U-100 2 ML 27.5 X5/8".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-40 1 ML 25 X5/8".............................................................................. 51

INSULIN SYRINGE/NEEDLE U-500 0.5 ML 31G X6MM (15/64").............................................................51

INSULIN SYRINGE (DISP) U-100 0.3ML................................................................................50

INSULIN SYRINGE (DISP) U-100 1/2ML................................................................................50

INSULIN SYRINGE (DISP) U-100 1ML................................................................................50

INTELENCE.................................................................. 44INTELENCE.................................................................. 44INTELENCE.................................................................. 44INTRON A.....................................................................44INTRON A.....................................................................44INTRON A.....................................................................44INTRON A.....................................................................44INTRON A.....................................................................44INTRON A W/DILUENT..............................................44INTRON A W/DILUENT..............................................44INTRON A W/DILUENT..............................................44INVANZ.......................................................................... 10INVANZ.......................................................................... 10INVEGA SUSTENNA.................................................. 39INVEGA SUSTENNA.................................................. 39INVEGA SUSTENNA.................................................. 39INVEGA SUSTENNA.................................................. 39INVEGA SUSTENNA.................................................. 39INVEGA TRINZA..........................................................39INVEGA TRINZA..........................................................39INVEGA TRINZA..........................................................39INVEGA TRINZA..........................................................39INVIRASE......................................................................44INVIRASE......................................................................44INVOKAMET.................................................................51INVOKAMET.................................................................51INVOKAMET.................................................................51INVOKAMET.................................................................51

INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKANA....................................................................51INVOKANA....................................................................51IPOL INACTIVATED IPV.............................................90ipratropium bromide inhal soln 0.02%.......................99ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................99ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................99irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................63irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................63irbesartan tab 150 mg.................................................63irbesartan tab 300 mg.................................................63irbesartan tab 75 mg................................................... 63IRESSA..........................................................................30IRINOTECAN................................................................30irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................30irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 30ISENTRESS..................................................................44ISENTRESS..................................................................44ISENTRESS..................................................................44ISENTRESS..................................................................44ISENTRESS HD...........................................................44ISONIAZID.................................................................... 25isoniazid tab 100 mg................................................... 25isoniazid tab 300 mg................................................... 25isosorbide dinitrate tab 10 mg....................................63isosorbide dinitrate tab 20 mg....................................63isosorbide dinitrate tab 30 mg....................................63isosorbide dinitrate tab 5 mg......................................63isosorbide mononitrate tab 10 mg............................. 63isosorbide mononitrate tab 20 mg............................. 63isosorbide mononitrate tab er 24hr 120

mg................................................................................63isosorbide mononitrate tab er 24hr 30

mg................................................................................63isosorbide mononitrate tab er 24hr 60

mg................................................................................63isotretinoin cap 10 mg.................................................73isotretinoin cap 20 mg.................................................73isotretinoin cap 30 mg.................................................73isotretinoin cap 40 mg.................................................73isradipine cap 2.5 mg..................................................63isradipine cap 5 mg..................................................... 63ISTALOL........................................................................ 95ISTODAX.......................................................................30

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ISTODAX (OVERFILL)................................................30itraconazole cap 100 mg............................................ 23ivermectin tab 3 mg.....................................................36IXEMPRA KIT...............................................................30IXEMPRA KIT...............................................................30IXIARO...........................................................................90JJADENU........................................................................ 75JADENU........................................................................ 75JADENU........................................................................ 75JADENU SPRINKLE................................................... 75JADENU SPRINKLE................................................... 75JADENU SPRINKLE................................................... 75JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JANUMET......................................................................51JANUMET......................................................................51JANUMET XR...............................................................51JANUMET XR...............................................................52JANUMET XR...............................................................52JANUVIA........................................................................52JANUVIA........................................................................52JANUVIA........................................................................52JARDIANCE..................................................................52JARDIANCE..................................................................52JENTADUETO.............................................................. 52JENTADUETO.............................................................. 52JENTADUETO.............................................................. 52JENTADUETO XR....................................................... 52JENTADUETO XR....................................................... 52JEVTANA.......................................................................30JULUCA.........................................................................44JUXTAPID..................................................................... 63JUXTAPID..................................................................... 63JUXTAPID..................................................................... 63JUXTAPID..................................................................... 63JUXTAPID..................................................................... 63JUXTAPID..................................................................... 63KKADCYLA......................................................................30KADCYLA......................................................................30KALETRA...................................................................... 44KALETRA...................................................................... 44KALYDECO.................................................................100KALYDECO.................................................................100KALYDECO.................................................................100kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%inj................................................................................. 75

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33%inj................................................................................. 75

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45%inj................................................................................. 75

kcl 20 meq/l (0.15%) in nacl 0.45% inj......................75kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45%

inj................................................................................. 75KEPIVANCE..................................................................71ketoconazole cream 2%..............................................23ketoconazole shampoo 2%........................................ 23ketoconazole tab 200 mg........................................... 23ketorolac tromethamine ophth soln

0.4%............................................................................95ketorolac tromethamine ophth soln

0.5%............................................................................95KEYTRUDA...................................................................30KINERET....................................................................... 90KINRIX........................................................................... 90KISQALI.........................................................................30KISQALI FEMARA 200 DOSE...................................30KISQALI FEMARA 400 DOSE...................................30KISQALI FEMARA 600 DOSE...................................31KOMBIGLYZE XR........................................................52KOMBIGLYZE XR........................................................52KOMBIGLYZE XR........................................................52KORLYM........................................................................85KUVAN...........................................................................79KUVAN...........................................................................79KUVAN...........................................................................79KYNAMRO.................................................................... 63KYPROLIS.................................................................... 31KYPROLIS.................................................................... 31KYPROLIS.................................................................... 31Llabetalol hcl tab 100 mg..............................................63labetalol hcl tab 200 mg..............................................63labetalol hcl tab 300 mg..............................................63LACRISERT.................................................................. 95lactated ringer's solution............................................. 75lactic acid (ammonium lactate) cream

12%............................................................................. 73lactic acid (ammonium lactate) lotion

12%............................................................................. 73lactulose (encephalopathy) solution 10

gm/15ml......................................................................77lactulose solution 10 gm/15ml....................................77lamivudine oral soln 10 mg/ml................................... 44

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lamivudine tab 100 mg (hbv)......................................44lamivudine tab 150 mg................................................44lamivudine tab 300 mg................................................44lamivudine-zidovudine tab 150-300 mg.................... 44lamotrigine tab 100 mg............................................... 15lamotrigine tab 150 mg............................................... 15lamotrigine tab 200 mg............................................... 15lamotrigine tab 25 mg................................................. 15lamotrigine tab chewable dispersible 25

mg................................................................................15lamotrigine tab chewable dispersible 5

mg................................................................................15lansoprazole cap delayed release 15

mg................................................................................77lansoprazole cap delayed release 30

mg................................................................................77lanthanum carbonate chew tab 1000

mg................................................................................75lanthanum carbonate chew tab 500

mg................................................................................75lanthanum carbonate chew tab 750

mg................................................................................75LANTUS.........................................................................52LANTUS SOLOSTAR..................................................52LARTRUVO...................................................................31LARTRUVO...................................................................31latanoprost ophth soln 0.005%.................................. 95LATUDA.........................................................................39LATUDA.........................................................................39LATUDA.........................................................................39LATUDA.........................................................................39LATUDA.........................................................................39LAZANDA........................................................................ 3LAZANDA........................................................................ 3LAZANDA........................................................................ 3leflunomide tab 10 mg.................................................90leflunomide tab 20 mg.................................................90LENVIMA 10 MG DAILY DOSE.................................31LENVIMA 12MG DAILY DOSE..................................31LENVIMA 14 MG DAILY DOSE.................................31LENVIMA 18 MG DAILY DOSE.................................31LENVIMA 20 MG DAILY DOSE.................................31LENVIMA 24 MG DAILY DOSE.................................31LENVIMA 4 MG DAILY DOSE...................................31LENVIMA 8 MG DAILY DOSE...................................31LETAIRIS.....................................................................100LETAIRIS.....................................................................100letrozole tab 2.5 mg.....................................................31LEUCOVORIN CALCIUM...........................................31LEUCOVORIN CALCIUM...........................................31leucovorin calcium for inj 100 mg.............................. 31leucovorin calcium for inj 200 mg.............................. 31

leucovorin calcium for inj 350 mg.............................. 31leucovorin calcium for inj 500 mg.............................. 31leucovorin calcium for inj 50 mg................................ 31leucovorin calcium tab 25 mg.................................... 31leucovorin calcium tab 5 mg.......................................31LEUKERAN...................................................................31LEUKINE....................................................................... 57leuprolide acetate inj kit 5 mg/ml............................... 86LEVEMIR.......................................................................52LEVEMIR FLEXTOUCH..............................................52levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................15levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levobunolol hcl ophth soln 0.5%................................ 96levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 75levocarnitine tab 330 mg............................................ 75levocetirizine dihydrochloride tab 5

mg............................................................................. 100levofloxacin in d5w iv soln 250

mg/50ml......................................................................10levofloxacin in d5w iv soln 500

mg/100ml....................................................................10levofloxacin in d5w iv soln 750

mg/150ml....................................................................10levofloxacin iv soln 25 mg/ml..................................... 10levofloxacin oral soln 25 mg/ml..................................10levofloxacin tab 250 mg..............................................10levofloxacin tab 500 mg..............................................10levofloxacin tab 750 mg..............................................10levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 83levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................83levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................83levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................83levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................83levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................83

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levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7)...................................................................83

LEVORPHANOL TARTRATE....................................... 3levothyroxine sodium tab 100 mcg............................85levothyroxine sodium tab 112 mcg............................ 85levothyroxine sodium tab 125 mcg............................85levothyroxine sodium tab 137 mcg............................85levothyroxine sodium tab 150 mcg............................85levothyroxine sodium tab 175 mcg............................85levothyroxine sodium tab 200 mcg............................85levothyroxine sodium tab 25 mcg..............................85levothyroxine sodium tab 300 mcg............................85levothyroxine sodium tab 50 mcg..............................85levothyroxine sodium tab 75 mcg..............................85levothyroxine sodium tab 88 mcg..............................85LEXIVA...........................................................................44LEXIVA...........................................................................44LIALDA...........................................................................93LIDOCAINE HCL..........................................................63lidocaine hcl gel 2%.......................................................4lidocaine hcl soln 4%.....................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4LINDANE....................................................................... 36LINEZOLID....................................................................10linezolid for susp 100 mg/5ml.................................... 10linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................10linezolid tab 600 mg.................................................... 10LINZESS........................................................................77LINZESS........................................................................77LINZESS........................................................................77liothyronine sodium tab 25 mcg.................................85liothyronine sodium tab 50 mcg.................................85liothyronine sodium tab 5 mcg................................... 85lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................64lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................64lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................64lisinopril tab 10 mg...................................................... 64lisinopril tab 2.5 mg..................................................... 64lisinopril tab 20 mg...................................................... 64lisinopril tab 30 mg...................................................... 64lisinopril tab 40 mg...................................................... 64lisinopril tab 5 mg.........................................................64LITHIUM........................................................................ 48lithium carbonate cap 150 mg....................................48lithium carbonate cap 300 mg....................................48

lithium carbonate cap 600 mg....................................48lithium carbonate tab 300 mg.....................................48lithium carbonate tab er 300 mg................................48lithium carbonate tab er 450 mg................................48LONSURF..................................................................... 31LONSURF..................................................................... 31loperamide hcl cap 2 mg............................................ 77lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................44lorazepam tab 0.5 mg................................................. 48lorazepam tab 1 mg.................................................... 48lorazepam tab 2 mg.................................................... 48losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 64losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................64losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................64losartan potassium tab 100 mg..................................64losartan potassium tab 25 mg....................................64losartan potassium tab 50 mg....................................64LOTEMAX..................................................................... 96LOTEMAX..................................................................... 96LOTEMAX..................................................................... 96lovastatin tab 10 mg....................................................64lovastatin tab 20 mg....................................................64lovastatin tab 40 mg....................................................64loxapine succinate cap 10 mg....................................40loxapine succinate cap 25 mg....................................40loxapine succinate cap 50 mg....................................40loxapine succinate cap 5 mg......................................39LUMIGAN...................................................................... 96LUMIZYME....................................................................79LUPRON DEPOT (1-MONTH)...................................86LUPRON DEPOT (1-MONTH)...................................86LUPRON DEPOT (3-MONTH)...................................86LUPRON DEPOT (3-MONTH)...................................86LUPRON DEPOT (4-MONTH)...................................86LUPRON DEPOT (6-MONTH)...................................86LUPRON DEPOT-PED (1-MONTH)..........................86LUPRON DEPOT-PED (1-MONTH)..........................86LUPRON DEPOT-PED (1-MONTH)..........................86LUPRON DEPOT-PED (3-MONTH)..........................86LUPRON DEPOT-PED (3-MONTH)..........................86LYNPARZA....................................................................31LYNPARZA....................................................................31LYNPARZA....................................................................31LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15

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LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYSODREN...................................................................85Mmagnesium sulfate inj 50%........................................ 75malathion lotion 0.5%..................................................36MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MARPLAN..................................................................... 19MARQIBO......................................................................32MATULANE...................................................................32MAVYRET..................................................................... 44meclizine hcl tab 12.5 mg...........................................21medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................83medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 83medroxyprogesterone acetate tab 10

mg................................................................................83medroxyprogesterone acetate tab 2.5

mg................................................................................83medroxyprogesterone acetate tab 5

mg................................................................................83mefloquine hcl tab 250 mg......................................... 36megestrol acetate susp 40 mg/ml..............................83megestrol acetate tab 20 mg..................................... 83megestrol acetate tab 40 mg..................................... 83MEKINIST......................................................................32MEKINIST......................................................................32MEKTOVI.......................................................................32meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 32memantine hcl oral solution 2 mg/ml.........................17memantine hcl tab 10 mg...........................................17memantine hcl tab 5 mg............................................. 17memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................17MENACTRA.................................................................. 90MENVEO....................................................................... 90mercaptopurine tab 50 mg......................................... 32meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 10mesalamine enema 4 gm........................................... 93mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 93mesalamine tab delayed release 1.2

gm................................................................................93

mesalamine tab delayed release 800mg................................................................................93

mesna inj 100 mg/ml...................................................32MESNEX........................................................................32MESTINON................................................................... 24metformin hcl tab 1000 mg.........................................52metformin hcl tab 500 mg...........................................52metformin hcl tab 850 mg...........................................52metformin hcl tab er 24hr 500 mg............................. 52metformin hcl tab er 24hr 750 mg............................. 52methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 64methazolamide tab 50 mg.......................................... 64methenamine hippurate tab 1 gm..............................11methimazole tab 10 mg.............................................. 87methimazole tab 5 mg.................................................87methocarbamol tab 500 mg..................................... 102methocarbamol tab 750 mg..................................... 102METHOTREXATE SODIUM.......................................91methotrexate sodium for inj 1 gm.............................. 91methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................91methotrexate sodium inj pf 1000 mg/40ml (25 mg/

ml)................................................................................91methotrexate sodium inj pf 250 mg/10ml (25 mg/

ml)................................................................................91methotrexate sodium inj pf 50 mg/2ml (25 mg/

ml)................................................................................91methotrexate sodium tab 2.5 mg............................... 91methoxsalen rapid cap 10 mg....................................73methscopolamine bromide tab 2.5 mg......................77methscopolamine bromide tab 5 mg......................... 77methylergonovine maleate tab 0.2 mg......................80methylphenidate hcl tab 10 mg..................................70methylphenidate hcl tab 20 mg..................................70methylphenidate hcl tab 5 mg....................................70methylphenidate hcl tab er 20 mg............................. 70methylprednisolone sod succ for inj 1000

mg................................................................................81methylprednisolone sod succ for inj 125

mg................................................................................81methylprednisolone sod succ for inj 40

mg................................................................................81methylprednisolone tab 16 mg...................................81methylprednisolone tab 32 mg...................................81methylprednisolone tab 4 mg.....................................81methylprednisolone tab 8 mg.....................................81methylprednisolone tab therapy pack 4 mg

(21)..............................................................................81methyltestosterone cap 10 mg...................................83metoclopramide hcl inj 5 mg/ml................................. 77

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metoclopramide hcl soln 5 mg/5ml (10mg/10ml).....................................................................77

metoclopramide hcl tab 10 mg...................................77metoclopramide hcl tab 5 mg.....................................77metolazone tab 10 mg................................................ 64metolazone tab 2.5 mg............................................... 64metolazone tab 5 mg...................................................64metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................64metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................64metoprolol succinate tab er 24hr 100

mg................................................................................64metoprolol succinate tab er 24hr 200

mg................................................................................64metoprolol succinate tab er 24hr 25

mg................................................................................64metoprolol succinate tab er 24hr 50

mg................................................................................64metoprolol tartrate tab 100 mg...................................64metoprolol tartrate tab 25 mg.....................................64metoprolol tartrate tab 50 mg.....................................64METRONIDAZOLE...................................................... 11metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................73metronidazole gel 0.75%............................................ 73metronidazole gel 1%..................................................73metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole iv soln 5 mg/ml................................... 11metronidazole lotion 0.75%........................................ 73metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%...............................11mexiletine hcl cap 150 mg..........................................64mexiletine hcl cap 200 mg..........................................64mexiletine hcl cap 250 mg..........................................64MIACALCIN...................................................................94midodrine hcl tab 10 mg............................................. 64midodrine hcl tab 2.5 mg............................................ 64midodrine hcl tab 5 mg............................................... 64MIGERGOT...................................................................24miglustat cap 100 mg..................................................79MIGRANAL....................................................................24minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg......................................... 11minocycline hcl cap 75 mg......................................... 11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 65minoxidil tab 2.5 mg.................................................... 65

mirtazapine orally disintegrating tab 15mg................................................................................19

mirtazapine orally disintegrating tab 30mg................................................................................19

mirtazapine orally disintegrating tab 45mg................................................................................20

mirtazapine tab 15 mg................................................ 20mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 20misoprostol tab 100 mcg............................................ 77misoprostol tab 200 mcg............................................ 77mitomycin for iv soln 20 mg....................................... 32mitomycin for iv soln 40 mg....................................... 32mitomycin for iv soln 5 mg..........................................32mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................32mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................32mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................32M-M-R II........................................................................ 90modafinil tab 100 mg.................................................102modafinil tab 200 mg.................................................102moexipril hcl tab 15 mg...............................................65moexipril hcl tab 7.5 mg..............................................65moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................65moexipril-hydrochlorothiazide tab 15-25

mg................................................................................65moexipril-hydrochlorothiazide tab 7.5-12.5

mg................................................................................65mometasone furoate cream 0.1%............................. 73mometasone furoate nasal susp 50 mcg/

act..............................................................................100mometasone furoate oint 0.1%..................................73mometasone furoate solution 0.1%

(lotion).........................................................................73MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29GX1/2".......................................52MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.5ML/29G X 1/2".................................... 52MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/1ML/29G X 1/2"........................................52montelukast sodium chew tab 4 mg........................100montelukast sodium chew tab 5 mg........................100montelukast sodium oral granules packet 4

mg............................................................................. 100montelukast sodium tab 10 mg................................100MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3morphine sulfate inj pf 0.5 mg/ml.................................3

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morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 77MOXEZA........................................................................96MOXIFLOXACIN HCL................................................. 11moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................11moxifloxacin hcl ophth soln 0.5%.............................. 96moxifloxacin hcl tab 400 mg.......................................11MOZOBIL...................................................................... 57MULTAQ........................................................................ 65mupirocin oint 2%........................................................ 73MUSTARGEN............................................................... 32MYALEPT...................................................................... 77MYCAMINE...................................................................23MYCAMINE...................................................................23mycophenolate mofetil cap 250 mg...........................91mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................91mycophenolate mofetil hcl for iv soln 500

mg................................................................................91mycophenolate mofetil tab 500 mg........................... 91mycophenolate sodium tab dr 180 mg......................91mycophenolate sodium tab dr 360 mg......................91MYLOTARG.................................................................. 32Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................65nadolol tab 40 mg........................................................65nadolol tab 80 mg........................................................65NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11nafcillin sodium for iv soln 10 gm.............................. 11NAGLAZYME................................................................79NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5

naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................24naratriptan hcl tab 2.5 mg...........................................24NARCAN..........................................................................5NATACYN......................................................................96nateglinide tab 120 mg............................................... 52nateglinide tab 60 mg..................................................52NATPARA...................................................................... 94NATPARA...................................................................... 94NATPARA...................................................................... 94NATPARA...................................................................... 94NEBUPENT...................................................................36NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20NEFAZODONE HYDROCHLORIDE.........................20neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................96neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml............................. 96neomycin-polymyxin b gu irrigation

soln..............................................................................11neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................96neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................96neomycin-polymyxin-hc otic soln 1%........................ 97neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 97neomycin sulfate tab 500 mg.....................................11NERLYNX......................................................................32NEULASTA....................................................................57NEULASTA ONPRO KIT............................................ 57NEUPOGEN..................................................................57NEUPOGEN..................................................................57NEUPOGEN..................................................................57NEUPOGEN..................................................................57NEUPRO....................................................................... 37NEUPRO....................................................................... 37NEUPRO....................................................................... 37NEUPRO....................................................................... 37NEUPRO....................................................................... 37NEUPRO....................................................................... 37nevirapine susp 50 mg/5ml........................................ 44

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nevirapine tab 200 mg................................................ 44nevirapine tab er 24hr 100 mg...................................44nevirapine tab er 24hr 400 mg...................................44NEXAVAR......................................................................32NEXIUM.........................................................................77NEXIUM.........................................................................77NEXIUM.........................................................................77NEXIUM.........................................................................77NEXIUM.........................................................................77niacin tab er 1000 mg................................................. 65niacin tab er 500 mg................................................... 65niacin tab er 750 mg................................................... 65nicardipine hcl cap 20 mg...........................................65nicardipine hcl cap 30 mg...........................................65NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab er 24hr 30 mg...................................... 65nifedipine tab er 24hr 60 mg...................................... 65nifedipine tab er 24hr 90 mg...................................... 65nifedipine tab er 24hr osmotic release 30

mg................................................................................65nifedipine tab er 24hr osmotic release 60

mg................................................................................65nifedipine tab er 24hr osmotic release 90

mg................................................................................65nilutamide tab 150 mg.................................................32nimodipine cap 30 mg.................................................65NINLARO.......................................................................32NINLARO.......................................................................32NINLARO.......................................................................32NIPENT..........................................................................32NISOLDIPINE ER........................................................ 65nisoldipine tab er 24hr 17 mg.................................... 65nisoldipine tab er 24hr 34 mg.................................... 65nisoldipine tab er 24hr 8.5 mg................................... 65NITRO-BID....................................................................65nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................11nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11nitroglycerin sl tab 0.3 mg.......................................... 65nitroglycerin sl tab 0.4 mg.......................................... 65nitroglycerin sl tab 0.6 mg.......................................... 65nitroglycerin td patch 24hr 0.1 mg/hr.........................65nitroglycerin td patch 24hr 0.2 mg/hr.........................65nitroglycerin td patch 24hr 0.4 mg/hr.........................65nitroglycerin td patch 24hr 0.6 mg/hr.........................65nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................65

nizatidine cap 150 mg.................................................77nizatidine cap 300 mg.................................................78norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................84norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................84norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................83norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................83norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................84norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................84norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................84norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................84norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................84norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................84norethindrone acetate tab 5 mg.................................84norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................84norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................84norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................84norethindrone tab 0.35 mg......................................... 84norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................84norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................84norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................84norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................84NORMOSOL-M IN D5W............................................. 75NORTHERA.................................................................. 65NORTHERA.................................................................. 65NORTHERA.................................................................. 66nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 20nortriptyline hcl soln 10 mg/5ml................................. 20NORVIR.........................................................................45NORVIR.........................................................................45NORVIR.........................................................................45NORVIR.........................................................................45NOXAFIL....................................................................... 23

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NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NUEDEXTA...................................................................70NULOJIX........................................................................91NUPLAZID.....................................................................40NUPLAZID.....................................................................40NUPLAZID.....................................................................40nystatin cream 100000 unit/gm..................................23nystatin oint 100000 unit/gm...................................... 23nystatin susp 100000 unit/ml......................................23nystatin tab 500000 unit..............................................23nystatin topical powder 100000 unit/

gm................................................................................23nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................73nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................73OOCALIVA....................................................................... 79OCALIVA....................................................................... 79octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................86octreotide acetate inj 100 mcg/ml (0.1 mg/

ml)................................................................................86octreotide acetate inj 200 mcg/ml (0.2 mg/

ml)................................................................................86octreotide acetate inj 500 mcg/ml (0.5 mg/

ml)................................................................................86octreotide acetate inj 50 mcg/ml (0.05 mg/

ml)................................................................................86ODEFSEY..................................................................... 45ODOMZO...................................................................... 32OFEV........................................................................... 100OFEV........................................................................... 100ofloxacin ophth soln 0.3%...........................................96ofloxacin otic soln 0.3%.............................................. 97ofloxacin tab 400 mg...................................................11olanzapine for im inj 10 mg........................................ 40olanzapine orally disintegrating tab 10

mg................................................................................40olanzapine orally disintegrating tab 15

mg................................................................................40olanzapine orally disintegrating tab 20

mg................................................................................40olanzapine orally disintegrating tab 5

mg................................................................................40olanzapine tab 10 mg..................................................40olanzapine tab 15 mg..................................................40olanzapine tab 2.5 mg.................................................40olanzapine tab 20 mg..................................................40olanzapine tab 5 mg....................................................40

olanzapine tab 7.5 mg.................................................40olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................66olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................66olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................66olmesartan medoxomil tab 20 mg............................. 66olmesartan medoxomil tab 40 mg............................. 66olmesartan medoxomil tab 5 mg............................... 66olopatadine hcl nasal soln 0.6%..............................100olopatadine hcl ophth soln 0.1%................................96olopatadine hcl ophth soln 0.2%................................96omega-3-acid ethyl esters cap 1 gm.........................66omeprazole cap delayed release 10

mg................................................................................78omeprazole cap delayed release 20

mg................................................................................78omeprazole cap delayed release 40

mg................................................................................78OMNITROPE................................................................ 82OMNITROPE................................................................ 82OMNITROPE................................................................ 82ONCASPAR.................................................................. 32ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................21ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22ondansetron orally disintegrating tab 8

mg................................................................................22ONFI...............................................................................15ONFI...............................................................................15ONFI...............................................................................15ONGLYZA......................................................................52ONGLYZA......................................................................52ONIVYDE...................................................................... 32OPDIVO.........................................................................32OPDIVO.........................................................................32OPDIVO.........................................................................32OPSUMIT....................................................................100ORACEA........................................................................73ORALAIR.....................................................................100ORENCIA...................................................................... 91ORENCIA...................................................................... 91ORENCIA...................................................................... 91ORENCIA...................................................................... 91

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ORENCIA CLICKJECT............................................... 91ORFADIN.......................................................................79ORFADIN.......................................................................79ORFADIN.......................................................................79ORFADIN.......................................................................79ORFADIN.......................................................................79ORKAMBI....................................................................100ORKAMBI....................................................................100ORKAMBI....................................................................100ORKAMBI....................................................................100oseltamivir phosphate cap 30 mg..............................45oseltamivir phosphate cap 45 mg..............................45oseltamivir phosphate cap 75 mg..............................45oseltamivir phosphate for susp 6 mg/

ml.................................................................................45OTEZLA.........................................................................91OTEZLA.........................................................................91oxaliplatin for iv inj 100 mg.........................................32oxaliplatin for iv inj 50 mg...........................................32oxaliplatin iv soln 100 mg/20ml..................................32oxaliplatin iv soln 50 mg/10ml....................................32oxandrolone tab 10 mg............................................... 84oxandrolone tab 2.5 mg..............................................84oxaprozin tab 600 mg....................................................3oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................15oxcarbazepine tab 150 mg.........................................15oxcarbazepine tab 300 mg.........................................15oxcarbazepine tab 600 mg.........................................15oxybutynin chloride syrup 5 mg/5ml..........................80oxybutynin chloride tab 5 mg..................................... 80oxybutynin chloride tab er 24hr 10 mg......................80oxybutynin chloride tab er 24hr 15 mg......................80oxybutynin chloride tab er 24hr 5 mg........................80oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................3oxycodone hcl tab 20 mg..............................................3oxycodone hcl tab 30 mg..............................................3oxycodone hcl tab 5 mg................................................3oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................3oxycodone w/ acetaminophen tab 5-325

mg..................................................................................3oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4OZEMPIC...................................................................... 53OZEMPIC...................................................................... 53

Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................32paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................32paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................32paliperidone tab er 24hr 1.5 mg.................................40paliperidone tab er 24hr 3 mg....................................40paliperidone tab er 24hr 6 mg....................................40paliperidone tab er 24hr 9 mg....................................40palonosetron hcl iv soln 0.25 mg/5ml........................22PALONOSETRON

HYDROCHLORIDE.................................................. 22PALONOSETRON

HYDROCHLORIDE.................................................. 22PALYNZIQ..................................................................... 79PALYNZIQ..................................................................... 79PALYNZIQ..................................................................... 79PANRETIN.....................................................................33pantoprazole sodium ec tab 20 mg........................... 78pantoprazole sodium ec tab 40 mg........................... 78pantoprazole sodium for iv soln 40 mg..................... 78paricalcitol cap 1 mcg................................................. 94paricalcitol cap 2 mcg................................................. 94paricalcitol cap 4 mcg................................................. 94paricalcitol iv soln 2 mcg/ml....................................... 94paricalcitol iv soln 5 mcg/ml....................................... 94paromomycin sulfate cap 250 mg..............................11paroxetine hcl tab 10 mg............................................ 20paroxetine hcl tab 20 mg............................................ 20paroxetine hcl tab 30 mg............................................ 20paroxetine hcl tab 40 mg............................................ 20PASER........................................................................... 25PAXIL............................................................................. 20PAZEO........................................................................... 96PEDIARIX......................................................................91PEDVAX HIB................................................................ 91peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................78peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................78peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................78PEGANONE..................................................................16PEGASYS..................................................................... 45PEGASYS..................................................................... 45PEGASYS PROCLICK................................................45PEGASYS PROCLICK................................................45penicillin g potassium for inj 20000000

unit...............................................................................11

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penicillin g potassium for inj 5000000unit...............................................................................11

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 11

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 11

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 12

PENICILLIN G SODIUM............................................. 12penicillin v potassium for soln 125

mg/5ml........................................................................ 12penicillin v potassium for soln 250

mg/5ml........................................................................ 12penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL....................................................................91PENTAM 300................................................................36PENTASA...................................................................... 93PENTASA...................................................................... 93pentoxifylline tab er 400 mg....................................... 66perindopril erbumine tab 2 mg................................... 66perindopril erbumine tab 4 mg................................... 66perindopril erbumine tab 8 mg................................... 66PERJETA.......................................................................33permethrin cream 5%..................................................36perphenazine tab 16 mg.............................................22perphenazine tab 2 mg............................................... 22perphenazine tab 4 mg............................................... 22perphenazine tab 8 mg............................................... 22phenelzine sulfate tab 15 mg.....................................20phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 100 mg...........................................16phenobarbital tab 15 mg.............................................16phenobarbital tab 16.2 mg..........................................16phenobarbital tab 30 mg.............................................16phenobarbital tab 32.4 mg..........................................16phenobarbital tab 60 mg.............................................16phenobarbital tab 64.8 mg..........................................16phenobarbital tab 97.2 mg..........................................16phenoxybenzamine hcl cap 10 mg............................66phenytoin chew tab 50 mg......................................... 16phenytoin sodium extended cap 100

mg................................................................................16phenytoin sodium extended cap 200

mg................................................................................16phenytoin sodium extended cap 300

mg................................................................................16phenytoin susp 125 mg/5ml....................................... 16PHOSLYRA...................................................................75PHOSPHOLINE IODIDE.............................................96

PICATO..........................................................................73PICATO..........................................................................73PIFELTRO..................................................................... 45pilocarpine hcl ophth soln 1%.................................... 96pilocarpine hcl ophth soln 2%.................................... 96pilocarpine hcl ophth soln 4%.................................... 96pilocarpine hcl tab 5 mg..............................................71pilocarpine hcl tab 7.5 mg.......................................... 71pimozide tab 1 mg....................................................... 40pimozide tab 2 mg....................................................... 40pindolol tab 10 mg....................................................... 66pindolol tab 5 mg......................................................... 66pioglitazone hcl-glimepiride tab 30-2

mg................................................................................53pioglitazone hcl-glimepiride tab 30-4

mg................................................................................53pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................53pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................53pioglitazone hcl tab 15 mg..........................................53pioglitazone hcl tab 30 mg..........................................53pioglitazone hcl tab 45 mg..........................................53piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12piroxicam cap 10 mg..................................................... 4piroxicam cap 20 mg..................................................... 4PLEGRIDY.................................................................... 70PLEGRIDY.................................................................... 70PLEGRIDY STARTER PACK..................................... 70PLEGRIDY STARTER PACK..................................... 71podofilox soln 0.5%..................................................... 73polyethylene glycol 3350 oral packet........................ 78polyethylene glycol 3350 oral powder.......................78polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 96POMALYST...................................................................33POMALYST...................................................................33POMALYST...................................................................33POMALYST...................................................................33PORTRAZZA................................................................ 33POTASSIUM CHLORIDE/DEXTROSE.....................75POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................76POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................76potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 75

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potassium chloride cap er 10 meq............................ 75potassium chloride cap er 8 meq...............................75potassium chloride inj 2 meq/ml................................ 75potassium chloride microencapsulated crys er tab 10

meq............................................................................. 75potassium chloride microencapsulated crys er tab 20

meq............................................................................. 75potassium chloride oral soln 10% (20

meq/15ml).................................................................. 75potassium chloride tab er 10 meq............................. 75potassium chloride tab er 8 meq (600

mg).............................................................................. 75potassium citrate tab er 10 meq (1080

mg).............................................................................. 76potassium citrate tab er 15 meq (1620

mg).............................................................................. 76potassium citrate tab er 5 meq (540

mg).............................................................................. 76POTELIGEO................................................................. 33PRADAXA..................................................................... 57PRADAXA..................................................................... 57PRADAXA..................................................................... 57PRALUENT................................................................... 66PRALUENT................................................................... 66pramipexole dihydrochloride tab 0.125

mg................................................................................37pramipexole dihydrochloride tab 0.25

mg................................................................................37pramipexole dihydrochloride tab 0.5

mg................................................................................37pramipexole dihydrochloride tab 0.75

mg................................................................................37pramipexole dihydrochloride tab 1.5

mg................................................................................37pramipexole dihydrochloride tab 1 mg...................... 37prasugrel hcl tab 10 mg..............................................57prasugrel hcl tab 5 mg................................................ 57pravastatin sodium tab 10 mg....................................66pravastatin sodium tab 20 mg....................................66pravastatin sodium tab 40 mg....................................66pravastatin sodium tab 80 mg....................................66praziquantel tab 600 mg............................................. 36prazosin hcl cap 1 mg.................................................66prazosin hcl cap 2 mg.................................................66prazosin hcl cap 5 mg.................................................66prednicarbate cream 0.1%......................................... 73prednicarbate oint 0.1%..............................................73prednisolone acetate ophth susp 1%........................96prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 81prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................81

prednisolone syrup 15 mg/5ml...................................81PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82prednisone tab 10 mg................................................. 82prednisone tab 1 mg................................................... 82prednisone tab 2.5 mg................................................ 82prednisone tab 20 mg................................................. 82prednisone tab 5 mg................................................... 82PREMARIN................................................................... 84PREMPHASE............................................................... 84PREMPRO.................................................................... 84PREMPRO.................................................................... 84PREMPRO.................................................................... 84PREMPRO.................................................................... 84PREZCOBIX................................................................. 45PREZISTA..................................................................... 45PREZISTA..................................................................... 45PREZISTA..................................................................... 45PREZISTA..................................................................... 45PREZISTA..................................................................... 45PRIFTIN.........................................................................25PRIMAQUINE PHOSPHATE......................................36primidone tab 250 mg................................................. 16primidone tab 50 mg................................................... 16PROAIR HFA..............................................................100PROAIR RESPICLICK..............................................100probenecid tab 500 mg............................................... 24prochlorperazine edisylate inj 5 mg/ml......................22prochlorperazine maleate tab 10 mg.........................22prochlorperazine maleate tab 5 mg...........................22prochlorperazine suppos 25 mg................................ 22PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57PROCRIT...................................................................... 57progesterone micronized cap 100 mg.......................84progesterone micronized cap 200 mg.......................84PROGLYCEM............................................................... 53PROGRAF.....................................................................91PROLASTIN-C..............................................................79PROLASTIN-C..............................................................79PROLENSA...................................................................96PROLEUKIN................................................................. 33PROLIA..........................................................................94PROMACTA.................................................................. 57PROMACTA.................................................................. 57

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PROMACTA.................................................................. 57PROMACTA.................................................................. 57promethazine hcl suppos 12.5 mg............................ 22promethazine hcl suppos 25 mg................................22promethazine hcl syrup 6.25 mg/5ml........................ 22promethazine hcl tab 12.5 mg....................................22promethazine hcl tab 25 mg.......................................22promethazine hcl tab 50 mg.......................................22propafenone hcl cap er 12hr 225 mg........................ 66propafenone hcl cap er 12hr 325 mg........................ 66propafenone hcl cap er 12hr 425 mg........................ 66propafenone hcl tab 150 mg...................................... 66propafenone hcl tab 225 mg...................................... 66propafenone hcl tab 300 mg...................................... 66propranolol hcl cap er 24hr 120 mg.......................... 66propranolol hcl cap er 24hr 160 mg.......................... 66propranolol hcl cap er 24hr 60 mg.............................66propranolol hcl cap er 24hr 80 mg.............................66propranolol hcl inj 1 mg/ml......................................... 66propranolol hcl tab 10 mg...........................................66propranolol hcl tab 20 mg...........................................67propranolol hcl tab 40 mg...........................................67propranolol hcl tab 60 mg...........................................67propranolol hcl tab 80 mg...........................................67propylthiouracil tab 50 mg.......................................... 87PROQUAD.................................................................... 91protriptyline hcl tab 10 mg.......................................... 20protriptyline hcl tab 5 mg............................................ 20PULMOZYME.............................................................100PURIXAN.......................................................................33PYLERA.........................................................................78pyrazinamide tab 500 mg........................................... 25pyridostigmine bromide tab 60 mg............................ 24pyridostigmine bromide tab er 180 mg......................24QQUADRACEL................................................................91quetiapine fumarate tab 100 mg................................40quetiapine fumarate tab 200 mg................................40quetiapine fumarate tab 25 mg..................................40quetiapine fumarate tab 300 mg................................40quetiapine fumarate tab 400 mg................................40quetiapine fumarate tab 50 mg..................................40quetiapine fumarate tab er 24hr 150

mg................................................................................40quetiapine fumarate tab er 24hr 200

mg................................................................................40quetiapine fumarate tab er 24hr 300

mg................................................................................40quetiapine fumarate tab er 24hr 400

mg................................................................................40quetiapine fumarate tab er 24hr 50 mg.....................40

quinapril hcl tab 10 mg............................................... 67quinapril hcl tab 20 mg............................................... 67quinapril hcl tab 40 mg............................................... 67quinapril hcl tab 5 mg..................................................67quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................67quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................67quinapril-hydrochlorothiazide tab 20-25

mg................................................................................67quinidine gluconate tab er 324 mg............................ 67QUINIDINE SULFATE................................................. 67QUINIDINE SULFATE................................................. 67QVAR REDIHALER................................................... 100QVAR REDIHALER................................................... 100RRABAVERT................................................................... 91raloxifene hcl tab 60 mg............................................. 84ramipril cap 1.25 mg....................................................67ramipril cap 10 mg.......................................................67ramipril cap 2.5 mg......................................................67ramipril cap 5 mg.........................................................67RANEXA........................................................................67RANEXA........................................................................67ranitidine hcl cap 150 mg........................................... 78ranitidine hcl cap 300 mg........................................... 78ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................78ranitidine hcl tab 150 mg............................................ 78ranitidine hcl tab 300 mg............................................ 78RAPAFLO...................................................................... 80RAPAFLO...................................................................... 80RAPAMUNE.................................................................. 91rasagiline mesylate tab 0.5 mg.................................. 37rasagiline mesylate tab 1 mg..................................... 37REBETOL......................................................................45RECOMBIVAX HB....................................................... 91RECOMBIVAX HB....................................................... 92RECOMBIVAX HB....................................................... 92REGRANEX.................................................................. 73RELENZA DISKHALER.............................................. 45RELISTOR.....................................................................78RELISTOR.....................................................................78RELISTOR.....................................................................78REMICADE................................................................... 92REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100RENFLEXIS.................................................................. 92RENVELA......................................................................76

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repaglinide tab 0.5 mg................................................ 53repaglinide tab 1 mg....................................................53repaglinide tab 2 mg....................................................53REPATHA...................................................................... 67REPATHA PUSHTRONEX SYSTEM........................67REPATHA SURECLICK.............................................. 67RESCRIPTOR.............................................................. 45RESCRIPTOR.............................................................. 45RESTASIS.....................................................................96RESTASIS MULTIDOSE.............................................96RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETACRIT.....................................................................57RETROVIR IV INFUSION...........................................45REVLIMID......................................................................33REVLIMID......................................................................33REVLIMID......................................................................33REVLIMID......................................................................33REVLIMID......................................................................33REVLIMID......................................................................33REXULTI........................................................................40REXULTI........................................................................40REXULTI........................................................................40REXULTI........................................................................40REXULTI........................................................................41REXULTI........................................................................41REYATAZ.......................................................................45REYATAZ.......................................................................45REYATAZ.......................................................................45REYATAZ.......................................................................45RIBASPHERE...............................................................45RIBASPHERE...............................................................45RIBASPHERE RIBAPAK.............................................45RIBASPHERE RIBAPAK.............................................45ribavirin cap 200 mg....................................................45ribavirin for inhal soln 6 gm......................................100ribavirin tab 200 mg.....................................................45RIDAURA...................................................................... 92rifabutin cap 150 mg....................................................25rifampin cap 150 mg....................................................25rifampin cap 300 mg....................................................25rifampin for inj 600 mg................................................ 25riluzole tab 50 mg........................................................ 71rimantadine hydrochloride tab 100 mg......................45risedronate sodium tab 150 mg................................. 94risedronate sodium tab 30 mg................................... 94risedronate sodium tab 35 mg................................... 94risedronate sodium tab 5 mg..................................... 94risedronate sodium tab delayed release 35

mg................................................................................94

RISPERDAL CONSTA................................................ 41RISPERDAL CONSTA................................................ 41RISPERDAL CONSTA................................................ 41RISPERDAL CONSTA................................................ 41risperidone orally disintegrating tab 0.25

mg................................................................................41risperidone orally disintegrating tab 0.5

mg................................................................................41risperidone orally disintegrating tab 1

mg................................................................................41risperidone orally disintegrating tab 2

mg................................................................................41risperidone orally disintegrating tab 3

mg................................................................................41risperidone orally disintegrating tab 4

mg................................................................................41risperidone soln 1 mg/ml............................................ 41risperidone tab 0.25 mg..............................................41risperidone tab 0.5 mg................................................ 41risperidone tab 1 mg................................................... 41risperidone tab 2 mg................................................... 41risperidone tab 3 mg................................................... 41risperidone tab 4 mg................................................... 41ritonavir tab 100 mg.................................................... 45RITUXAN.......................................................................33RITUXAN.......................................................................33RITUXAN HYCELA......................................................33RITUXAN HYCELA......................................................33rivastigmine tartrate cap 1.5 mg................................ 17rivastigmine tartrate cap 3 mg....................................17rivastigmine tartrate cap 4.5 mg................................ 17rivastigmine tartrate cap 6 mg....................................17rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 17rivastigmine td patch 24hr 4.6 mg/24hr.....................17rivastigmine td patch 24hr 9.5 mg/24hr.....................17rizatriptan benzoate oral disintegrating tab 10

mg................................................................................24rizatriptan benzoate oral disintegrating tab 5

mg................................................................................24rizatriptan benzoate tab 10 mg.................................. 24rizatriptan benzoate tab 5 mg.................................... 24ropinirole hydrochloride tab 0.25 mg.........................37ropinirole hydrochloride tab 0.5 mg...........................37ropinirole hydrochloride tab 1 mg.............................. 37ropinirole hydrochloride tab 2 mg.............................. 37ropinirole hydrochloride tab 3 mg.............................. 37ropinirole hydrochloride tab 4 mg.............................. 37ropinirole hydrochloride tab 5 mg.............................. 37rosuvastatin calcium tab 10 mg................................. 67rosuvastatin calcium tab 20 mg................................. 67rosuvastatin calcium tab 40 mg................................. 67

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rosuvastatin calcium tab 5 mg................................... 67ROTARIX.......................................................................92ROTATEQ......................................................................92RUBRACA.....................................................................33RUBRACA.....................................................................33RUBRACA.....................................................................33RYDAPT........................................................................ 33SSABRIL.......................................................................... 16SABRIL.......................................................................... 16SAMSCA........................................................................76SAMSCA........................................................................76SANDIMMUNE............................................................. 92SANTYL.........................................................................73SAPHRIS.......................................................................41SAPHRIS.......................................................................41SAPHRIS.......................................................................41selegiline hcl cap 5 mg............................................... 37selegiline hcl tab 5 mg................................................ 37selenium sulfide lotion 2.5%.......................................73SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SELZENTRY.................................................................46SENSIPAR.....................................................................94SENSIPAR.....................................................................94SENSIPAR.....................................................................94SEREVENT DISKUS.................................................100sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................20sertraline hcl tab 100 mg............................................ 20sertraline hcl tab 25 mg.............................................. 20sertraline hcl tab 50 mg.............................................. 20sevelamer carbonate packet 0.8 gm......................... 76sevelamer carbonate packet 2.4 gm......................... 76sevelamer carbonate tab 800 mg..............................76SHINGRIX..................................................................... 92SIGNIFOR..................................................................... 86SIGNIFOR..................................................................... 86SIGNIFOR..................................................................... 86SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87sildenafil citrate tab 20 mg....................................... 100SILENOR.....................................................................102SILENOR.....................................................................102silver sulfadiazine cream 1%......................................73SIMBRINZA...................................................................96SIMULECT.................................................................... 92

SIMULECT.................................................................... 92simvastatin tab 10 mg.................................................67simvastatin tab 20 mg.................................................67simvastatin tab 40 mg.................................................67simvastatin tab 5 mg................................................... 67simvastatin tab 80 mg.................................................67sirolimus tab 0.5 mg.................................................... 92sirolimus tab 1 mg....................................................... 92sirolimus tab 2 mg....................................................... 92SIRTURO.......................................................................25SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12sodium chloride inj 0.45%...........................................76sodium chloride irrigation soln 0.9%......................... 76sodium chloride iv soln 0.9%..................................... 76sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................79sodium phenylbutyrate tab 500 mg........................... 79sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................76sodium polystyrene sulfonate powder.......................76sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................76SOLTAMOX...................................................................33SOMATULINE DEPOT................................................87SOMATULINE DEPOT................................................87SOMATULINE DEPOT................................................87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 87SOOLANTRA................................................................73sotalol hcl (afib/afl) tab 120 mg..................................67sotalol hcl (afib/afl) tab 160 mg..................................67sotalol hcl (afib/afl) tab 80 mg....................................67sotalol hcl tab 120 mg.................................................68sotalol hcl tab 160 mg.................................................68sotalol hcl tab 240 mg.................................................68sotalol hcl tab 80 mg...................................................67SOVALDI....................................................................... 46SPIRIVA HANDIHALER............................................100SPIRIVA RESPIMAT................................................. 100SPIRIVA RESPIMAT................................................. 101spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................68spironolactone tab 100 mg.........................................68spironolactone tab 25 mg........................................... 68spironolactone tab 50 mg........................................... 68SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16

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SPRITAM.......................................................................16SPRYCEL......................................................................33SPRYCEL......................................................................33SPRYCEL......................................................................33SPRYCEL......................................................................33SPRYCEL......................................................................33SPRYCEL......................................................................33STAMARIL.....................................................................92stavudine cap 15 mg...................................................46stavudine cap 20 mg...................................................46stavudine cap 30 mg...................................................46stavudine cap 40 mg...................................................46STELARA...................................................................... 92STELARA...................................................................... 92STELARA...................................................................... 92STELARA...................................................................... 92STIMATE....................................................................... 82STIOLTO RESPIMAT................................................ 101STIVARGA.....................................................................33STRENSIQ....................................................................79STRENSIQ....................................................................79STRENSIQ....................................................................80STRENSIQ....................................................................80STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 46SUBLOCADE.................................................................. 5SUBLOCADE.................................................................. 5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5sucralfate tab 1 gm......................................................78sulfacetamide sodium lotion 10%.............................. 12sulfacetamide sodium ophth soln 10%..................... 96sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................96SULFADIAZINE............................................................ 12sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................12sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................12sulfasalazine tab 500 mg............................................93sulfasalazine tab delayed release 500

mg................................................................................93sulindac tab 150 mg...................................................... 4sulindac tab 200 mg...................................................... 4sumatriptan nasal spray 20 mg/act........................... 24sumatriptan nasal spray 5 mg/act..............................24

sumatriptan succinate inj 6 mg/0.5ml........................24sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................24sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................24sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................24sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................24sumatriptan succinate tab 100 mg............................ 24sumatriptan succinate tab 25 mg...............................24sumatriptan succinate tab 50 mg...............................24SUPRAX........................................................................12SUPRAX........................................................................12SUPRAX........................................................................12SUPREP BOWEL PREP KIT.....................................78SUSTIVA........................................................................46SUSTIVA........................................................................46SUSTIVA........................................................................46SUTENT........................................................................ 33SUTENT........................................................................ 33SUTENT........................................................................ 33SUTENT........................................................................ 33SYLATRON................................................................... 46SYLATRON................................................................... 46SYLATRON................................................................... 46SYLVANT.......................................................................92SYLVANT.......................................................................92SYMBICORT...............................................................101SYMBICORT...............................................................101SYMDEKO.................................................................. 101SYMFI............................................................................ 46SYMFI LO..................................................................... 46SYMLINPEN 120......................................................... 53SYMLINPEN 60............................................................53SYMTUZA..................................................................... 46SYNAGIS.......................................................................92SYNAGIS.......................................................................92SYNAREL......................................................................87SYNERCID....................................................................12SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNRIBO...................................................................... 34SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85

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SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYNTHROID.................................................................85SYPRINE.......................................................................76TTABLOID........................................................................34tacrolimus cap 0.5 mg.................................................92tacrolimus cap 1 mg....................................................92tacrolimus cap 5 mg....................................................92tacrolimus oint 0.03%..................................................73tacrolimus oint 0.1%.................................................... 73tadalafil tab 20 mg (pah)...........................................101TAFINLAR..................................................................... 34TAFINLAR..................................................................... 34TAGRISSO.................................................................... 34TAGRISSO.................................................................... 34TAMIFLU........................................................................46tamoxifen citrate tab 10 mg........................................34tamoxifen citrate tab 20 mg........................................34tamsulosin hcl cap 0.4 mg..........................................81TARCEVA...................................................................... 34TARCEVA...................................................................... 34TARCEVA...................................................................... 34TARGRETIN..................................................................34TASIGNA....................................................................... 34TASIGNA....................................................................... 34TASIGNA....................................................................... 34tazarotene cream 0.1%...............................................74TAZORAC......................................................................74TAZORAC......................................................................74TAZORAC......................................................................74TECENTRIQ................................................................. 34TECFIDERA..................................................................71TECFIDERA..................................................................71TECFIDERA STARTER PACK...................................71TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X

1/2".............................................................................. 53TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X

5/16"............................................................................53TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X

5/16"............................................................................53TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X

1/2".............................................................................. 53TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X

1/2".............................................................................. 53

TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X5/16"............................................................................53

TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X5/16"............................................................................53

TECHLITE INSULIN SYRINGE U-100/1ML/29G X1/2".............................................................................. 53

TECHLITE INSULIN SYRINGE U-100/1ML/30G X5/16"............................................................................53

TECHLITE INSULIN SYRINGE U-100/1ML/31G X5/16"............................................................................53

TECHLITE PEN NEEDLES/31G X 6MM.............................................................................. 54

TECHLITE PEN NEEDLES/31G X8MM............................................................................ 54

TECHLITE PEN NEEDLES/32G X4MM............................................................................ 54

TECHLITE PEN NEEDLES/32G X6MM............................................................................ 54

TECHLITE PEN NEEDLES/32G X8MM............................................................................ 54

TECHLITE PEN NEEDLES 29G X 10MM.............................................................................. 54

TECHLITE PEN NEEDLES 29G X 12MM.............................................................................. 54

TECHLITE PEN NEEDLES 31G X5MM............................................................................ 54

TECHNIVIE................................................................... 46TEFLARO......................................................................12TEFLARO......................................................................12TEKTURNA...................................................................68TEKTURNA...................................................................68TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68TEKTURNA HCT......................................................... 68telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................68telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................68telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................68telmisartan tab 20 mg................................................. 68telmisartan tab 40 mg................................................. 68telmisartan tab 80 mg................................................. 68temazepam cap 15 mg............................................. 102temazepam cap 30 mg............................................. 102TEMODAR.................................................................... 34temsirolimus soln for iv infusion 25 mg/

ml.................................................................................34TENCON..........................................................................4TENIVAC....................................................................... 92

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tenofovir disoproxil fumarate tab 300mg................................................................................46

terazosin hcl cap 10 mg..............................................68terazosin hcl cap 1 mg................................................68terazosin hcl cap 2 mg................................................68terazosin hcl cap 5 mg................................................68terbinafine hcl tab 250 mg..........................................23terbutaline sulfate tab 2.5 mg.................................. 101terbutaline sulfate tab 5 mg......................................101terconazole vaginal cream 0.4%................................23terconazole vaginal cream 0.8%................................23terconazole vaginal suppos 80 mg............................23testosterone cypionate im inj in oil 100 mg/

ml.................................................................................84testosterone cypionate im inj in oil 200 mg/

ml.................................................................................84testosterone enanthate im inj in oil 200 mg/

ml.................................................................................84testosterone td gel 12.5 mg/act (1%)........................ 85testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 85testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 85testosterone td gel 25 mg/2.5gm (1%)......................84testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 85testosterone td gel 50 mg/5gm (1%).........................84testosterone td soln 30 mg/act...................................85TETANUS/DIPHTHERIA TOXOIDS

ADSORBED...............................................................92tetrabenazine tab 12.5 mg..........................................71tetrabenazine tab 25 mg.............................................71tetracycline hcl cap 250 mg........................................12tetracycline hcl cap 500 mg........................................12THALOMID....................................................................34THALOMID....................................................................34THALOMID....................................................................34THALOMID....................................................................34theophylline tab er 12hr 100 mg..............................101theophylline tab er 12hr 200 mg..............................101theophylline tab er 12hr 300 mg..............................101theophylline tab er 12hr 450 mg..............................101theophylline tab er 24hr 400 mg..............................101theophylline tab er 24hr 600 mg..............................101thioridazine hcl tab 100 mg........................................ 41thioridazine hcl tab 10 mg.......................................... 41thioridazine hcl tab 25 mg.......................................... 41thioridazine hcl tab 50 mg.......................................... 41thiotepa for inj 15 mg.................................................. 34thiothixene cap 10 mg.................................................41thiothixene cap 1 mg...................................................41thiothixene cap 2 mg...................................................41

thiothixene cap 5 mg...................................................41THYMOGLOBULIN......................................................92tiagabine hcl tab 12 mg.............................................. 16tiagabine hcl tab 16 mg.............................................. 16tiagabine hcl tab 2 mg.................................................16tiagabine hcl tab 4 mg.................................................16TIBSOVO.......................................................................34tigecycline for iv soln 50 mg.......................................12TIMOLOL MALEATE................................................... 68TIMOLOL MALEATE................................................... 68TIMOLOL MALEATE................................................... 68timolol maleate ophth gel forming soln

0.25%..........................................................................96timolol maleate ophth gel forming soln

0.5%............................................................................96timolol maleate ophth soln 0.25%..............................96timolol maleate ophth soln 0.5%................................96timolol maleate ophth soln 0.5% (once-

daily)............................................................................96TIVICAY......................................................................... 46TIVICAY......................................................................... 46TIVICAY......................................................................... 46tizanidine hcl cap 2 mg............................................... 42tizanidine hcl cap 4 mg............................................... 42tizanidine hcl cap 6 mg............................................... 42tizanidine hcl tab 2 mg................................................42tizanidine hcl tab 4 mg................................................42TOBRADEX...................................................................96tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 96tobramycin nebu soln 300 mg/5ml.......................... 101tobramycin ophth soln 0.3%.......................................96TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................12tobramycin sulfate inj 10 mg/ml................................. 12tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................12tolcapone tab 100 mg................................................. 37TOLMETIN SODIUM..................................................... 4tolterodine tartrate cap er 24hr 2 mg.........................81tolterodine tartrate cap er 24hr 4 mg.........................81tolterodine tartrate tab 1 mg.......................................81tolterodine tartrate tab 2 mg.......................................81topiramate sprinkle cap 15 mg...................................16topiramate sprinkle cap 25 mg...................................16topiramate tab 100 mg................................................16topiramate tab 200 mg................................................16topiramate tab 25 mg.................................................. 16topiramate tab 50 mg.................................................. 16topotecan hcl for inj 4 mg........................................... 34

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topotecan hcl inj 4 mg/4ml (forinfusion)...................................................................... 34

TORISEL....................................................................... 34torsemide tab 100 mg................................................. 68torsemide tab 10 mg................................................... 68torsemide tab 20 mg................................................... 68torsemide tab 5 mg......................................................68TOUJEO MAX SOLOSTAR........................................54TOUJEO SOLOSTAR..................................................54TOVIAZ.......................................................................... 81TOVIAZ.......................................................................... 81TRACLEER.................................................................101TRACLEER.................................................................101TRACLEER.................................................................101TRADJENTA................................................................. 54tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4trandolapril tab 1 mg................................................... 68trandolapril tab 2 mg................................................... 68trandolapril tab 4 mg................................................... 68tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................57tranexamic acid tab 650 mg.......................................57tranylcypromine sulfate tab 10 mg............................ 20TRAVATAN Z................................................................ 97trazodone hcl tab 100 mg...........................................20trazodone hcl tab 150 mg...........................................20trazodone hcl tab 300 mg...........................................20trazodone hcl tab 50 mg.............................................20TREANDA..................................................................... 34TREANDA..................................................................... 34TRECATOR...................................................................25TRELEGY ELLIPTA...................................................101TRELSTAR....................................................................87TRELSTAR....................................................................87TRELSTAR MIXJECT..................................................87TRELSTAR MIXJECT..................................................87TRELSTAR MIXJECT..................................................87TRESIBA FLEXTOUCH.............................................. 54TRESIBA FLEXTOUCH.............................................. 54tretinoin cap 10 mg......................................................34tretinoin cream 0.025%............................................... 74tretinoin cream 0.05%................................................. 74tretinoin cream 0.1%................................................... 74tretinoin gel 0.01%.......................................................74tretinoin gel 0.025%.....................................................74triamcinolone acetonide cream

0.025%........................................................................74triamcinolone acetonide cream 0.1%........................74triamcinolone acetonide cream 0.5%........................74

triamcinolone acetonide dental paste0.1%............................................................................71

triamcinolone acetonide lotion 0.025%..................... 74triamcinolone acetonide lotion 0.1%..........................74triamcinolone acetonide nasal aerosol suspension

55 mcg/act............................................................... 101triamcinolone acetonide oint 0.025%........................ 74triamcinolone acetonide oint 0.1%.............................74triamcinolone acetonide oint 0.5%.............................74triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................68triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................68triamterene & hydrochlorothiazide tab 75-50

mg................................................................................68trientine hcl cap 250 mg............................................. 76trifluoperazine hcl tab 10 mg......................................41trifluoperazine hcl tab 1 mg........................................41trifluoperazine hcl tab 2 mg........................................41trifluoperazine hcl tab 5 mg........................................41trifluridine ophth soln 1%............................................ 97trimethoprim tab 100 mg.............................................12trimipramine maleate cap 100 mg............................. 20trimipramine maleate cap 25 mg............................... 20trimipramine maleate cap 50 mg............................... 20TRINTELLIX..................................................................20TRINTELLIX..................................................................20TRINTELLIX..................................................................20TRISENOX....................................................................34TRIUMEQ......................................................................46TROGARZO..................................................................46trospium chloride cap er 24hr 60 mg.........................81trospium chloride tab 20 mg.......................................81TRUEPLUS 5-BEVEL PEN NEEDLES

31GX5MM.................................................................. 54TRUEPLUS 5-BEVEL PEN NEEDLES

31GX6MM.................................................................. 54TRUEPLUS 5-BEVEL PEN NEEDLES

31GX8MM.................................................................. 54TRUEPLUS 5-BEVEL PEN NEEDLES

32GX4MM.................................................................. 54TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G

X 1/2"..........................................................................54TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G

X 5/16"........................................................................54TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G

X 5/16"........................................................................54TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G

X 1/2"..........................................................................54TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G

X 1/2"..........................................................................54

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TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30GX 5/16"........................................................................54

TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31GX 5/16"........................................................................54

TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X1/2".............................................................................. 54

TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2".............................................................................. 54

TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16"............................................................................54

TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16"............................................................................54

TRUEPLUS PEN NEEDLES29GX12MM................................................................54

TRUEPLUS PEN NEEDLES31GX5MM.................................................................. 54

TRUEPLUS PEN NEEDLES31GX6MM.................................................................. 54

TRUEPLUS PEN NEEDLES31GX8MM.................................................................. 54

TRUEPLUS PEN NEEDLES32GX4MM.................................................................. 54

TRULICITY....................................................................54TRULICITY....................................................................54TRUMENBA.................................................................. 92TRUVADA......................................................................46TRUVADA......................................................................46TRUVADA......................................................................46TRUVADA......................................................................46TWINRIX........................................................................92TYBOST........................................................................ 46TYGACIL....................................................................... 12TYKERB........................................................................ 34TYPHIM VI.................................................................... 93TYSABRI....................................................................... 71UULORIC......................................................................... 24ULORIC......................................................................... 24ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G

X 1/2"..........................................................................55ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X

1/2".............................................................................. 55UNITUXIN......................................................................34UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101

ursodiol cap 300 mg....................................................78ursodiol tab 250 mg.....................................................78ursodiol tab 500 mg.....................................................78Vvalacyclovir hcl tab 1 gm............................................ 47valacyclovir hcl tab 500 mg........................................47VALCHLOR................................................................... 34valganciclovir hcl for soln 50 mg/ml.......................... 47valganciclovir hcl tab 450 mg.....................................47valproate sodium inj 100 mg/ml.................................16valproate sodium oral soln 250 mg/5ml.................... 16valproic acid cap 250 mg............................................17valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................69valsartan-hydrochlorothiazide tab 160-25

mg................................................................................69valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................69valsartan-hydrochlorothiazide tab 320-25

mg................................................................................69valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................69valsartan tab 160 mg...................................................69valsartan tab 320 mg...................................................69valsartan tab 40 mg.....................................................68valsartan tab 80 mg.....................................................68vancomycin hcl cap 125 mg.......................................12vancomycin hcl cap 250 mg.......................................12vancomycin hcl for iv soln 100 gm............................ 13vancomycin hcl for iv soln 10 gm.............................. 13vancomycin hcl for iv soln 1 gm.................................13vancomycin hcl for iv soln 500 mg............................ 13vancomycin hcl for iv soln 5 gm.................................13vancomycin hcl for iv soln 750 mg............................ 13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANISHPOINT INSULIN SYRINGE/0.5ML/30G X

1/2".............................................................................. 55VAQTA........................................................................... 93VAQTA........................................................................... 93VARIVAX........................................................................93VASCEPA...................................................................... 69VASCEPA...................................................................... 69VECTIBIX...................................................................... 34VECTIBIX...................................................................... 34VELCADE......................................................................34VENCLEXTA.................................................................34VENCLEXTA.................................................................35VENCLEXTA.................................................................35VENCLEXTA STARTING PACK................................ 35

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venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 75 mg...........................................21venlafaxine hcl tab er 24hr 150 mg........................... 21venlafaxine hcl tab er 24hr 37.5 mg..........................21venlafaxine hcl tab er 24hr 75 mg............................. 21VENTAVIS................................................................... 101VENTAVIS................................................................... 101VENTOLIN HFA......................................................... 101verapamil hcl cap er 24hr 100 mg.............................69verapamil hcl cap er 24hr 120 mg.............................69verapamil hcl cap er 24hr 180 mg.............................69verapamil hcl cap er 24hr 200 mg.............................69verapamil hcl cap er 24hr 240 mg.............................69verapamil hcl cap er 24hr 300 mg.............................69verapamil hcl cap er 24hr 360 mg.............................69verapamil hcl tab 120 mg........................................... 69verapamil hcl tab 40 mg............................................. 69verapamil hcl tab 80 mg............................................. 69verapamil hcl tab er 120 mg.......................................69verapamil hcl tab er 180 mg.......................................69verapamil hcl tab er 240 mg.......................................69VERSACLOZ................................................................ 41VERZENIO....................................................................35VERZENIO....................................................................35VERZENIO....................................................................35VERZENIO....................................................................35VICTOZA....................................................................... 55VIDEX............................................................................ 47VIDEX............................................................................ 47VIDEX EC..................................................................... 47VIEKIRA PAK................................................................47VIEKIRA XR..................................................................47vigabatrin powd pack 500 mg.................................... 17VIGAMOX......................................................................97VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD STARTER PACK......................................... 21VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VINBLASTINE SULFATE............................................35vincristine sulfate iv soln 1 mg/ml..............................35

vinorelbine tartrate inj 10 mg/ml.................................35vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................35VIOKACE.......................................................................80VIOKACE.......................................................................80VIRACEPT.................................................................... 47VIRACEPT.................................................................... 47VIRAMUNE................................................................... 47VIREAD..........................................................................47VIREAD..........................................................................47VIREAD..........................................................................47VIREAD..........................................................................47VIREAD..........................................................................47VIVITROL........................................................................ 5voriconazole for inj 200 mg........................................ 24voriconazole for susp 40 mg/ml.................................24voriconazole tab 200 mg............................................ 24voriconazole tab 50 mg...............................................24VOSEVI..........................................................................47VOTRIENT.................................................................... 35VPRIV............................................................................ 80VRAYLAR...................................................................... 41VRAYLAR...................................................................... 41VRAYLAR...................................................................... 41VRAYLAR...................................................................... 42VYXEOS........................................................................35Wwarfarin sodium tab 10 mg.........................................58warfarin sodium tab 1 mg...........................................57warfarin sodium tab 2.5 mg........................................58warfarin sodium tab 2 mg...........................................57warfarin sodium tab 3 mg...........................................58warfarin sodium tab 4 mg...........................................58warfarin sodium tab 5 mg...........................................58warfarin sodium tab 6 mg...........................................58warfarin sodium tab 7.5 mg........................................58water for irrigation, sterile irrigation

soln..............................................................................76WELCHOL.....................................................................69WELCHOL.....................................................................69XXALKORI....................................................................... 35XALKORI....................................................................... 35XARELTO...................................................................... 58XARELTO...................................................................... 58XARELTO...................................................................... 58XARELTO STARTER PACK.......................................58XATMEP........................................................................ 93XGEVA...........................................................................94XIFAXAN........................................................................78XOLAIR..........................................................................93

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XOPENEX HFA..........................................................101XTANDI.......................................................................... 35XYREM........................................................................102YYERVOY........................................................................35YERVOY........................................................................35YF-VAX.......................................................................... 93YONDELIS.................................................................... 35YONSA.......................................................................... 35Zzafirlukast tab 10 mg.................................................102zafirlukast tab 20 mg.................................................102zaleplon cap 10 mg...................................................102zaleplon cap 5 mg..................................................... 102ZALTRAP.......................................................................35ZALTRAP.......................................................................35ZANOSAR..................................................................... 35ZAVESCA...................................................................... 80ZEJULA..........................................................................35ZELBORAF................................................................... 35ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZENPEP........................................................................ 80ZEPATIER..................................................................... 47ZERIT.............................................................................47ZIAGEN..........................................................................47zidovudine cap 100 mg...............................................47zidovudine syrup 10 mg/ml.........................................47zidovudine tab 300 mg................................................47ZINACEF....................................................................... 13ziprasidone hcl cap 20 mg..........................................42ziprasidone hcl cap 40 mg..........................................42ziprasidone hcl cap 60 mg..........................................42ziprasidone hcl cap 80 mg..........................................42ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 94zoledronic acid iv soln 5 mg/100ml........................... 94ZOLINZA........................................................................35zolpidem tartrate tab 10 mg..................................... 102zolpidem tartrate tab 5 mg....................................... 102ZOMETA........................................................................ 94

zonisamide cap 100 mg..............................................17zonisamide cap 25 mg................................................17zonisamide cap 50 mg................................................17ZONTIVITY....................................................................58ZORTRESS...................................................................93ZORTRESS...................................................................93ZORTRESS...................................................................93ZORTRESS...................................................................93ZOSTAVAX....................................................................93ZOSYN...........................................................................13ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 35ZYDELIG....................................................................... 35ZYKADIA....................................................................... 35ZYPREXA RELPREVV............................................... 42ZYPREXA RELPREVV............................................... 42ZYPREXA RELPREVV............................................... 42ZYTIGA..........................................................................35ZYTIGA..........................................................................35

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Blue Cross and Blue Shield of Texas 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 Texas no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Blue Cross and Blue Shield of Texas:

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

○ Intérpretes de lenguaje de señas capacitados.

○ Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

○ Intérpretes capacitados.

○ Información escrita en otros idiomas.

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

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

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

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

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

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

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

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Y0096_MRK_TX_NDNOTICE17SPA Accepted 09042016 732442.0916

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ATT NTION If you peak Engli h, language a i tance ervice , free of charge, are avai able to youCall

Ca l <1-877 -8592> ( Y <7 >)

Llam <1-8 7- 4-8592> (TT < 11>)

Gọi < -877-774-8592 ( TY: <711>)

注意 如果您使用繁體中文 您可 免費獲得語言援助服務。請致電 < -877 774-8592

해 주십 오

م) ل ص و ف م >ر 1>)

TTY <711

walang baya Tumawag sa <1-877 4 8592> (T Y <711>)

Ap e e e < -877 74 8592> ( TS <71 >)

<1-877 774-8592> ( Yري تماس بگ

TY <7 1>)

Zadzw ń po nu r < -8 7- -8592> (T < >

注 如果您 用 體 文

주 국 하 경우 언어 지 이 하 수 습 다 8 7 774 92TT

غ ف دخ ن ا ملا وغل ةدعا تت ة ا ل كل ر اج تا م ل

ВНИ А И Е и в говори е а р сс ом е т а ст п ы беспл ны луги пе ево аЗв ните < 877-774-85

رادربخ لوب ودر پآ رگا بز وک پآ و ،ںیہ ے م یک ن خ یک د ام یرک لاک ںیہ بیتسد ںیم تفم <1-877-7 >)

HÚ Ý u ạn nó T ếng V ệt, c ác d ch vụ hỗ trợ n ôn ng miễn phí dGọi s <1-877-7 4 8592> TTY <

ATT NZ ONE: In caso la lingua pa lata s a l’ital ano sono disponib l servizi di as is enza ling istica g atu ti

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.Call 1-877-774-8592 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al 1-877-774-8592 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số1-877-774-8592 (TTY: 711).

注意:如果您使用繁體中文, 您可以免費獲得語言援助服務。請致電 1-877-774-8592 (TTY: 711) 。

주의: 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다.

1-877-774-8592 (TTY: 711) 번으로전화해주십시오.

8592-774-877-1رقم ل تصا .نبالمجاك فر لتتواة يعدة اللغوات المسان خدمفإ، ةيبلعرة اغحدث اللتتت نا كإذ :ظحومل

.( 711:كمبواللصم اف تهام قر)

و کپ آو ت ، ہي ے تولبو ارد پ آ ر اگ :بردارخ ں میت مفت ادمخاں ں ريکل کا۔ ں ہی ب استيدی کد مدی کن زب

با .باشدمی همفراما ی شبران گايت رارصوه بنی بات زلايتسه، يدنی کگو متگفرسی فان باه زباگر :جهوت

ລິ

(TTY: 711). 1-877-774-8592يديرگبس مات.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: 1-877-774-8592 (TTY: 711).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-877-774-8592(TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-774-8592 (телетайп: 711).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ້າພາສາ ລາວ, ການບໍ ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ໂດຍບ່ໍ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-877-774-8592 (TTY: 711).

1-877-774-8592

.(TTY: 711)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-774-8592 (TTY: 711).

ATTENTION Si vous parlez français des services d’aide linguistique vous sont proposés gratuitement.Appelez le 1-877-774-8592 (ATS: 711).

ध्यान दें: यदद आप दहिं े े ललए मफ्त म भाषा सहायता सेवाएिंदी बोलत हैं तो आपक ु ें उपलब्ध हैं। 1-877-774-8592 (TTY: 711) पर कॉल करें।

注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-877-774-8592 (TTY: 711).まで、お電話にてご連絡ください。

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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-774-8592 (TTY: 711). We are open between 8:00 a.m. and 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-774-8592 (TTY: 7-1-1). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y días feriados se usarán tecnologías alternativas (por ejemplo, correo de voz).

Blue Cross and Blue Shield of Texas, que se refiere a GHS Insurance Company (GHS), licenciataria independiente de Blue Cross and Blue Shield Association, ofrece las coberturas HMO y HMO-POS. GHS es una organización Medicare Advantage con un contrato con Medicare. La inscripción en los planes de GHS depende de la renovación del contrato.

Esta lista de medicamentos se actualizó el 11/16/2018. Para obtener información más reciente o si tiene alguna pregunta, comuníquese con Servicio al Cliente de Blue Cross Medicare Advantage, al 1-877-774-8592 o, para usuarios de TTY/TDD, al 7-1-1, de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si llama del 15 de febrero al 30 de septiembre durante los fines de semana y días feriados, se usarán tecnologías alternativas (por ejemplo, correo de voz); o bien visite www.getbluetx.com/mapd/druglist.