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Presbyterian Senior Care (HMO) Presbyterian MediCare PPO

Formulario 2015 (Lista de medicamentos cubiertos)

AVISO: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE ALGUNOS DE LOS MEDICAMENTOS QUE ESTE PLAN CUBRE. Formulario aprobado por HPMS; ID 15138, Versión Núm. 9.

Este formulario se actualizó el 28 de julio de 2014. Para obtener información más reciente o si tiene otras preguntas, llame al Servicio al Cliente de Presbyterian Health Plan y Presbyterian Insurance Company, Inc. al (505)923-6060 o al 1-800-797-5343; si es usuario de TTY/TDD, llame al 711 o al 1-800-659-8331, de lunes a domingo, de 8:00 a.m. a 8:00 p.m., o visite www.phs.org/Medicare.

Y00055_MPC081418SPAN_rev1_Accepted_08232014

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Aviso para miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurar que todavía incluye los medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) use los términos “nosotros”, “nos” o “nuestro”, se refiere a Presbyterian Health Plan y Presbyterian Insurance Company, Inc. Cuando use los términos “plan” o “nuestro plan”, eso significa los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO.

Este documento incluye una lista de medicamentos (formulario) para nuestro plan que fue actualizada el 28 de julio de 2014. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y en la contraportada.

En general, usted debe acudir a las farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o los copagos o coaseguros pueden cambiar el 1 de enero de 2016, y de vez en cuando durante el año.

Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO son planes de Medicare Advantage que tienen un contrato con Medicare. La inscripción en los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO depende de la renovación del contrato.

Esta información está disponible en otros idiomas de forma gratuita. Llame al Centro de Servicio al Cliente de Presbyterian al (505) 923-6060 o al 1-800-797-5343 para obtener información adicional. Los usuarios de TTY deben llamar al 711 o al 1-800-659-8331. El horario de atención es de lunes a domingo desde las 8 a.m. hasta las 8 p.m.

Esta información está disponible de manera gratuita en otros idiomas. Llame al Centro de Servicio al Cliente de Presbyterian al (505) 923-6060 o al 1-800-797-5343 para conseguir más información. Los usuarios de TTY deben llamar al 711 o al 1-800-659-8331. El horario de atención es de lunes a domingo, de las 8:00 a.m. a las 8:00 p.m.

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¿Qué es el formulario de los planes Presbyterian Senior Care (HMO) y Presbyterian Medicare PPO? Un formulario es una lista de medicamentos cubiertos seleccionados por los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO en consulta con un equipo de proveedores de atención medica, y representa las terapias con receta que se consideran necesarias en un programa de tratamiento de calidad. Los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO generalmente cubrirán los medicamentos incluidos en el formulario siempre y cuando sean médicamente necesarios, la receta sea surtida en una farmacia participante en la red de los planes Presbyterian Senior Care y Presbyterian MediCare PPO, y se cumplan otras reglas del plan. Para obtener más información acerca de cómo surtir sus recetas, revise la Evidencia de Cobertura.

¿El formulario (lista de medicamentos) puede cambiar? Por lo general, si está tomando un medicamento incluido en el formulario de 2015 que estaba cubierto a principios de año, nosotros no descontinuaremos ni reduciremos la cobertura durante el año de cobertura 2015, excepto cuando salga a la venta un medicamento genérico nuevo y más económico o que se publique nueva información adversa acerca de la seguridad o la eficacia del medicamento. Los demás tipos de cambio en el formulario, como eliminar un medicamento, no afectarán a los miembros que estén actualmente tomando el medicamento. El medicamento seguirá estando disponible con los mismos costos compartidos para los miembros que lo estén tomando durante el resto del año de cobertura. Nosotros consideramos importante que usted cuente con acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando seleccionó nuestro plan, excepto en los casos en que pueda ahorrar dinero adicional o podamos mantener su protección.

Si nosotros eliminamos medicamentos del formulario, o agregamos requisitos de autorización previa, límites en la cantidad y/o restricciones en las terapias por pasos para un medicamento, o si movemos un medicamento a un nivel más alto de costos compartidos, tenemos que informarle el cambio a los miembros afectados al menos 60 días antes de que el cambio entre en vigencia, o cuando el miembro solicite un resurtido del medicamento, y en ese momento el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Medicamentos determina que un medicamento en nuestro formulario no es seguro, o el fabricante lo saca del mercado, nosotros eliminaremos ese medicamento de nuestro formulario inmediatamente y se lo notificaremos a los miembros que lo toman. El formulario adjunto fue actualizado el 28 de julio de 2014. Para obtener información actualizada sobre los medicamentos cubiertos por los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y contraportada. Las actualizaciones mensuales del formulario, como por ejemplo adiciones, eliminaciones, adición de autorización previa, límites en la cantidad y/o restricciones a las terapias por pasos se publicarán en nuestro sitio web en www.phs.org/Medicare. Si el cambio afectara el formulario negativamente y determinamos que lo afecta a usted, se lo notificaremos por escrito.

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¿Cómo uso el formulario? Hay dos modos de buscar un medicamento en el formulario de medicamentos:

Condición médica

El formulario comienza en la página 10. Los medicamentos incluidos en este formulario están agrupados por categoría según la clase de condición médica para la que se usan. Por ejemplo, los medicamentos que se usan para tratar una condición del corazón están incluidos en la categoría "Agentes cardiovasculares." Si usted sabe para qué se usa el medicamento, busque el nombre de la categoría en la lista que comienza en la página 53. Luego, busque su medicamento en esa categoría.

Lista en orden alfabético

Si no está seguro de en cuál categoría buscar, busque el medicamento en el índice que comienza en la página 82. El índice ofrece una lista en orden alfabético de todos los medicamentos incluidos en este documento. El índice incluye los medicamentos de marca y también los genéricos. Busque su medicamento en el índice. Al lado de su medicamento, verá el número de la página en la que puede encontrar la información de cobertura. Vaya a la página indicada en el índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO cubren tanto los medicamentos de marca como los genéricos. Un medicamento genérico es un medicamento aprobado por la FDA porque contiene el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos son más económicos que los medicamentos de marca.

¿Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos podrían tener requisitos adicionales o límites en la cobertura. Los requisitos y límites pueden incluir los siguientes:

• Autorización previa: Los planes Presbyterian Senior Care (HMO) y Presbyterian

MediCare PPO requieren que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesita conseguir la aprobación del Presbyterian Senior Care (HMO) y el Presbyterian MediCare PPO antes de surtir las recetas. Si no obtiene la aprobación, es posible que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO no cubran el medicamento.

• Límites de cantidad: Para ciertos medicamentos, los planes Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO limitan la cantidad del medicamento que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO cubrirán. Por ejemplo, Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO cubren 60 (sesenta) cápsulas por cada receta de duloxetina (Cymbalta). Esto puede ser adicional al suministro estándar de un mes o tres meses.

• Terapia por pasos: En algunos casos, Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO requieren que pruebe ciertos medicamentos primero para tratar su condición médica antes de cubrir otro medicamento para esa condición. Por ejemplo, si tanto el Medicamento A como el Medicamento B sirven para tratar su

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condición médica, es posible que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO no cubran el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no funciona, entonces Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO cubrirán el Medicamento B.

Para averiguar si el medicamento que busca está sujeto a requisitos o límites adicionales, puede consultar el formulario que comienza en la página 10. También puede visitar nuestro sitio web para obtener más información acerca de las restricciones que se les aplican a ciertos medicamentos cubiertos. Nosotros hemos publicado documentos en línea que explican nuestra aprobación previa y las restricciones a la terapia por pasos. También nos puede pedir que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y en la contraportada.

Usted puede pedirles a Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO que hagan una excepción a estas restricciones o límites o puede pedirles una lista de otros medicamentos similares que puedan tratar su condición médica. Consulte la sección “¿Cómo solicito una excepción al formulario de Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO?” en la página 4 para obtener información sobre cómo solicitar una excepción.

¿Qué hago si el medicamento que necesito no está en el formulario? Si su medicamento no está incluido en este formulario (la lista de medicamentos cubiertos), primero debe comunicarse con Servicio al Cliente y preguntar si el medicamento está cubierto. Si necesita más información, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y en la contraportada.

Si le informan que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO no cubren el medicamento, tiene dos opciones:

• Usted puede pedirle a Servicio al Cliente una lista de medicamentos similares que estén cubiertos por Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO.

• Usted puede pedir que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO hagan una excepción y cubran el medicamento. A continuación encontrará la información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al formulario de Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO? Usted puede solicitar que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO hagan una excepción a nuestras reglas de cobertura. Hay varios tipos de excepción que nos puede solicitar.

• Usted puede solicitar que nosotros cubramos el medicamento que necesita aunque no esté en el formulario. Si es aprobado, este medicamento se cubrirá al nivel predeterminado de costo compartido, y usted no podrá pedirnos que proporcionemos el medicamento a un costo menor.

• Usted puede solicitar que nosotros cubramos un medicamento del formulario a un nivel menor de costo compartido si no está en el nivel de especialidades. Si es aprobado, esto reducirá la cantidad que tiene que pagar por el medicamento.

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• Usted puede solicitar que no apliquemos los límites o las restricciones de cobertura en el medicamento. Por ejemplo, Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO limitan la cantidad que cubrirán de ciertos medicamentos. Si el medicamento que necesita tiene un límite de cantidad, usted puede pedirnos que no apliquemos el límite y que cubramos una mayor cantidad.

Por lo general, Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO solamente aprobarán su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones adicionales de uso no serían tan efectivas para tratar su condición y/o pudieran causarle efectos médicos adversos.

Usted debe comunicarse con nosotros para solicitar una decisión inicial de cobertura y obtener una excepción al formulario, al nivel o a las restricciones de uso. Cuando solicite una excepción al formulario de medicamentos, al nivel o a las restricciones de uso, usted debe presentar una declaración de su médico u otra persona autorizada para recetar que respalde su solicitud. Generalmente, nosotros tenemos que tomar una decisión en un plazo de 72 horas después de recibir la declaración de respaldo de quien emitió la receta. Se puede pedir una excepción acelerada (rápida) si usted o su médico creen que la salud suya se podría ver gravemente afectada por esperar hasta 72 horas por una decisión. Si se aprueba la excepción acelerada, nosotros tenemos que tomar una decisión en un plazo máximo de 24 horas después de recibir la declaración de respaldo del médico o de otra persona autorizada para recetar.

¿Qué debo hacer antes de hablar con mi médico sobre cambiar el medicamento o de solicitar una excepción? Como miembro nuevo o que ya estaba inscrito en nuestro plan, es posible que esté tomando medicamentos que no están incluidos en nuestro formulario. O quizás esté tomando un medicamento de nuestro formulario pero su habilidad para conseguirlo es limitada. Por ejemplo, quizás necesite una autorización previa de nosotros antes de poder surtir su receta. Usted debe hablar con su médico para decidir si debería cambiar a un medicamento adecuado que esté cubierto, o solicitar una excepción al formulario para que nosotros cubramos el medicamento que toma. Mientras determina con su médico cuál es el curso de acción adecuado, en ciertos casos nosotros podemos cubrir el medicamento durante los primeros 90 días de su membresía en nuestro plan.

Para cada uno de sus medicamentos que no esté en el formulario, o para los cuales su habilidad para obtenerlos sea limitada, nosotros cubriremos un suministro temporal de 30 días (excepto si usted tiene una receta por menos días) en una farmacia de la red. Después del primer suministro de 30 días, nosotros no pagaremos por esos medicamentos aunque haya sido miembro del plan por menos de 90 días.

Si es residente de un centro de atención a largo plazo, nosotros le permitiremos resurtir la receta hasta que haya recibido un suministro de transición de 91 días, de conformidad con el incremento de entrega (a menos que su receta haya sido para menos días). Nosotros cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días de su membresía en el plan. Si necesita un medicamento que no está en nuestro formulario, o si su habilidad para conseguirlo es limitada, pero ya lleva más de 90 días de membresía en el plan, nosotros cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que la receta haya sido para menos días) mientras usted solicita una excepción al formulario.

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Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO - Política de transición:

Esta política tiene como propósito garantizar que Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO tengan un proceso de transición establecido para manejar las situaciones en las que una persona se presente en una farmacia participante por primera vez con la receta de un medicamento que no está en el formulario o cuando haya un cambio en el nivel de atención de un beneficiario, o cuando el beneficiario no sepa qué cosas cubre Presbyterian o desconozca el proceso de excepción de Presbyterian para proporcionar acceso a los medicamentos de la Parte D que no están cubiertos.

Nosotros hemos establecido las pautas a continuación para manejar lo siguiente:

• La transición de miembros nuevos después del periodo anual de elección • La transición de personas recién elegibles para Medicare desde otra cobertura • Los beneficiarios de Medicare que provienen de otra cobertura • La transición de personas que puedan cambiar de plan de la Parte D de Medicare

después de que comience el año del contrato • Las personas inscritas que residan en centros de atención a largo plazo (LTC) (que

incluyen Cambios en el Nivel de Atención y Surtidos de Emergencia) • En algunos casos, las personas actualmente inscritas que se vean afectadas por

cambios en el formulario de un año de contrato al próximo. La política de transición de Presbyterian se aplica a (a) medicamentos de la Parte D que no están en nuestro formulario y (b) medicamentos de la Parte D que están en el formulario pero que requieren autorización previa o terapia por pasos de conformidad con nuestras reglas establecidas de uso.

La política de transición de Presbyterian incluye las situaciones en las que los miembros quizás no saben qué medicamentos están incluidos en el formulario o no saben con certeza qué está cubierto, o no están familiarizados con el proceso de excepción al formulario. La política de transición de Presbyterian satisface las necesidades inmediatas de nuestros miembros y les da suficiente tiempo para trabajar con quien le recetó el medicamento a fin de cambiar a un medicamento terapéuticamente similar del formulario o completar el proceso de excepción al formulario.

Centro de atención ambulatoria (que no sea de atención a largo plazo):

Durante los primeros 90 días de membresía con Presbyterian, el miembro puede obtener un único suministro temporal de hasta 30 días de un medicamento que no está en el formulario, que incluye los medicamentos de la Parte D que requieran autorización previa o terapia por pasos.

Centro de atención a largo plazo: Durante los primeros 90 días de membresía en Presbyterian, el miembro puede obtener un suministro de transición de hasta 30 días.

Presbyterian cubrirá múltiples suministros de un medicamento de la Parte D que no esté en el formulario, entre ellos los que están en el formulario pero requieren autorización previa o terapia por pasos de conformidad con nuestras reglas de uso, como sea apropiado durante todo el periodo de transición de 90 días.

Si una persona inscrita residente en un LTC ya está fuera del periodo de transición de 90 días, Presbyterian le proporcionará un suministro de emergencia de medicamentos que no están en

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el formulario, que incluyen medicamentos de la Parte D que están el formulario pero requieren autorización previa o terapia por pasos, de acuerdo con nuestras reglas de uso. Este suministro de emergencia será para al menos 31 días de medicamentos, a menos que la receta sea para menos de 31 días. El propósito del suministro de emergencia es asegurar que los miembros reciban sus medicamentos mientras se procesa una excepción.

Cambio en el Nivel de Atención: Es posible que los miembros experimenten cambios no planificados en el nivel de atención, por ejemplo, ser dados de alta o admitidos a un LTC, hospital, hogar de convalecencia, etc. En estas circunstancias, Presbyterian les proporcionará un único suministro temporal debido al cambio en el nivel de atención. Este surtido se autorizará para un suministro máximo de 31 días, a menos que la receta sea para menos de 31 días.

Avisos de transición: Todas las personas inscritas que reciban un suministro temporal de un medicamento de la Parte D que no está en el formulario recibirán un aviso escrito por correo con respecto al suministro de transición y el proceso de transición. Este aviso se enviará en un plazo de tres (3) días útiles después del suministro temporal. El aviso incluirá:

(1) una explicación del suministro de transición que el beneficiario recibió. (2) instrucciones para trabajar con Presbyterian y la persona que le recetó el medicamento

a fin de identificar alternativas terapéuticas adecuadas incluidas en el formulario. (3) una explicación sobre el derecho del beneficiario a solicitar una excepción al

formulario (4) una descripción del proceso de excepción al formulario de medicamentos.

Las solicitudes de excepción al formulario están disponibles para los miembros, los representantes designados y los médicos por correo, fax y correo electrónico, y a través de nuestro sitio web, www.phs.org/Medicare.

Para obtener más información

Para obtener más información detallada sobre la cobertura de medicamentos recetados de Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO, lea detenidamente la Evidencia de Cobertura y los demás materiales del plan.

Si tiene preguntas sobre Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y en la contraportada.

Si tiene preguntas generales sobre la cobertura de medicamentos recetados 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

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Formulario de Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO El formulario de medicamentos que comienza en la página 12 contiene información de cobertura de los medicamentos cubiertos por Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO. Si tiene problemas para encontrar su medicamento en la lista, vaya al Índice en la página 84. La primera columna de la tabla tiene el nombre de los medicamentos. Los medicamentos de marca están escritos en mayúsculas (p. ej., LYRICA), y los medicamentos genéricos están en letra cursiva en minúsculas (p. ej., lisinopril).

La información en la columna Requisitos/Límites indica si Presbyterian Senior Care (HMO) y Presbyterian MediCare PPO tienen requisitos especiales para la cobertura del medicamento.

Explicación de los niveles de medicamentos Los medicamentos recetados están agrupados en uno de cinco niveles - Nivel 1, Nivel 2, Nivel 3, Nivel 4, o Nivel 5. Los medicamentos genéricos están aprobados por la FDA por tener el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. Para saber la cantidad de copago o coaseguro de cada nivel de medicamentos, consulte la Evidencia de Cobertura de 2015.

• Nivel 1 - Genéricos preferidos: Medicamentos genéricos o de marca disponibles al costo más económico de este plan

• Nivel 2 - Genéricos no preferidos: Los medicamentos genéricos o de marca que el plan le ofrece a un costo mayor que los medicamentos genéricos preferidos del Nivel 1.

• Nivel 3 - Marca preferida: Los medicamentos genéricos o de marca que el plan le ofrece a un costo menor que los medicamentos de marca no preferidos del Nivel 4.

• Nivel 4 - De marca, no preferidos: Los medicamentos genéricos o de marca que el plan le ofrece a un costo mayor que los medicamentos de marca preferida del Nivel 3.

• Nivel 5 - Especialidad: Algunos medicamentos inyectables y otros medicamentos de alto costo

¿Cuánto pagaré por los medicamentos cubiertos? La cantidad de dinero que pagará dependerá de:

• El Nivel de su medicamento en el formulario • Su etapa actual de pago de medicamentos - consulte la Evidencia de Cobertura (EOC)

para más información

Si usted califica para recibir ayuda adicional con los costos de los medicamentos, es posible que su costo sea diferente. Consulte su Evidencia de Cobertura (EOC) o llame a Servicio al Cliente para saber cuáles son sus costos.

Explicación de las abreviaturas

B/D Este medicamento recetado podría estar cubierto por la Parte B o la Parte D de Medicare dependiendo de las circunstancias. Usted o su médico debe obtener una autorización antes de surtir la receta de este medicamento. Sin aprobación no podremos cubrir este medicamento. Para hacer la determinación es posible que se necesite presentar información que describa el uso y el entorno en que se usará el medicamento. Si el medicamento se administra en un consultorio médico, se requiere que algunos medicamentos se obtengan mediante el proveedor especializado designado de la red y se entreguen en el centro médico o consultorio médico que usted ha elegido.

Este medicamento recetado se limita a ciertas farmacias.

GC Brecha de cobertura. Nosotros cubrimos estos medicamentos recetados en la brecha de cobertura. Consulte la Evidencia de Cobertura para obtener más información sobre esta cobertura.

LA Disponibilidad limitada. Este medicamento recetado se limita a ciertas farmacias.

PA Autorización previa. Usted o su médico debe obtener una autorización antes de surtir la receta de este medicamento. Sin aprobación previa no podremos cubrir este medicamento.

QL Límite de cantidad. Hay un límite en la cantidad de este medicamento que se cubrirá por cada receta, o en un plazo de tiempo específico.

ST Terapia por pasos. En algunos casos, se requerirá que usted primero pruebe ciertos medicamentos para tratar su condición médica antes de cubrir otro medicamento para esa condición.

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Vaya a la página 9 para ver la descripción de las abreviaturas 10

Nombre del medicamento Nivel del medicamento Requisitos/Límites

Analgésicos Analgesics

butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg

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Nonsteroidal Anti-inflammatory Drugs

CELEBREX CAPSULE 100MG 4 CELEBREX CAPSULE 200MG 4 CELEBREX CAPSULE 400MG 4 CELEBREX CAPSULE 50MG 4 diclofenac potassium tablet 50mg 1 GC diclofenac sodium dr tablet delayed release 25mg 2 GC diclofenac sodium dr tablet delayed release 50mg 2 GC diclofenac sodium dr tablet delayed release 75mg 1 GC diclofenac sodium er tablet extended release 24 hour 100mg

2 GC

etodolac capsule 200mg 2 GC etodolac capsule 300mg 2 GC etodolac tablet 400mg 2 GC etodolac tablet 500mg 2 GC FENOPROFEN CALCIUM TABLET 600MG 3 flurbiprofen tablet 100mg 2 GC flurbiprofen tablet 50mg 2 GC ketoprofen capsule 50mg 2 GC ketoprofen capsule 75mg 2 GC meloxicam tablet 15mg 1 GC meloxicam tablet 7.5mg 1 GC nabumetone tablet 500mg 2 GC nabumetone tablet 750mg 2 GC naproxen dr tablet delayed release 500mg 1 GC naproxen sodium tablet 275mg 1 GC naproxen sodium tablet 550mg 1 GC naproxen suspension 125mg/5ml 2 GC naproxen tablet 250mg 1 GC naproxen tablet 375mg 1 GC naproxen tablet 500mg 1 GC oxaprozin tablet 600mg 2 GC piroxicam capsule 10mg 2 GC piroxicam capsule 20mg 2 GC sulindac tablet 150mg 2 GC sulindac tablet 200mg 2 GC

Opioid Analgesics, Long-acting

fentanyl patch 72 hour 100mcg/hr 2 QL (10 EA per 30 days) GC fentanyl patch 72 hour 12mcg/hr 2 QL (10 EA per 30 days) GC fentanyl patch 72 hour 25mcg/hr 2 QL (10 EA per 30 days) GC fentanyl patch 72 hour 50mcg/hr 2 QL (10 EA per 30 days) GC



fentanyl patch 72 hour 75mcg/hr 2 QL (10 EA per 30 days) GC methadone hcl tablet 10mg 2 QL (120 EA per 30 days) GC methadone hcl tablet 5mg 2 QL (180 EA per 30 days) GC morphine sulfate er capsule extended release 24 hour 120mg

4

morphine sulfate er capsule extended release 24 hour 30mg

4


4


4


4


4

morphine sulfate er tablet extended release 100mg 2 QL (60 EA per 30 days) GC morphine sulfate er tablet extended release 15mg 2 QL (90 EA per 30 days) GC morphine sulfate er tablet extended release 200mg 2 QL (60 EA per 30 days) GC morphine sulfate er tablet extended release 30mg 2 QL (90 EA per 30 days) GC morphine sulfate er tablet extended release 60mg 2 QL (60 EA per 30 days) GC oxymorphone hydrochloride er tablet extended release 12 hour 10mg

4 QL (60 EA per 30 days) ST

oxymorphone hydrochloride er tablet extended release 12 hour 15mg










oxymorphone hydrochloride er tablet extended release 12 hour 7.5mg


tramadol hcl er tablet extended release 24 hour 100mg 2 QL (90 EA per 30 days) GC tramadol hcl er tablet extended release 24 hour 200mg 2 QL (30 EA per 30 days) GC

Opioid Analgesics, Short-acting acetaminophen/codeine #3 tablet 300mg; 30mg 2 QL (180 EA per 30 days) GC acetaminophen/codeine solution 120mg/5ml; 12mg/5ml

2 GC

acetaminophen/codeine tablet 300mg; 15mg 2 QL (180 EA per 30 days) GC acetaminophen/codeine tablet 300mg; 60mg 2 QL (180 EA per 30 days) GC CODEINE SULFATE TABLET 15MG 3 QL (180 EA per 30 days) CODEINE SULFATE TABLET 30MG 3 QL (180 EA per 30 days) CODEINE SULFATE TABLET 60MG 3 QL (180 EA per 30 days) duramorph injection 1mg/ml 4 QL (3600 ML per 30 days)



fentanyl citrate oral transmucosal lollipop 1200mcg 5 QL (4 EA per 1 days) PA fentanyl citrate oral transmucosal lollipop 1600mcg 5 QL (4 EA per 1 days) PA fentanyl citrate oral transmucosal lollipop 400mcg 5 QL (4 EA per 1 days) PA fentanyl citrate oral transmucosal lollipop 600mcg 5 QL (4 EA per 1 days) PA fentanyl citrate oral transmucosal lollipop 800mcg 5 QL (4 EA per 1 days) PA hydrocodone/acetaminophen tablet 325mg; 10mg 2 QL (180 EA per 30 days) GC hydrocodone/acetaminophen tablet 325mg; 5mg 2 QL (180 EA per 30 days) GC hydrocodone/acetaminophen tablet 325mg; 7.5mg 2 QL (180 EA per 30 days) GC hydrocodone/ibuprofen tablet 7.5mg; 200mg 2 QL (180 EA per 30 days) GC hydromorphone hcl injection 500mg/50ml 2 GC hydromorphone hcl tablet 2mg 2 QL (180 EA per 30 days) GC hydromorphone hcl tablet 4mg 2 QL (180 EA per 30 days) GC hydromorphone hcl tablet 8mg 2 QL (90 EA per 30 days) GC MORPHINE SULFATE INJECTION 5MG/ML 3 MORPHINE SULFATE TABLET 15MG 3 QL (180 EA per 30 days) MORPHINE SULFATE TABLET 30MG 3 QL (120 EA per 30 days) nalbuphine hcl injection 10mg/ml 2 GC nalbuphine hcl injection 20mg/ml 2 GC oxycodone hcl tablet 10mg 2 QL (180 EA per 30 days) GC oxycodone hcl tablet 15mg 2 QL (150 EA per 30 days) GC oxycodone hcl tablet 20mg 2 QL (120 EA per 30 days) GC oxycodone hcl tablet 30mg 2 QL (60 EA per 30 days) GC oxycodone hcl tablet 5mg 2 QL (180 EA per 30 days) GC oxycodone/acetaminophen tablet 325mg; 10mg 2 QL (180 EA per 30 days) GC oxycodone/acetaminophen tablet 325mg; 2.5mg 2 QL (180 EA per 30 days) GC oxycodone/acetaminophen tablet 325mg; 5mg 2 QL (180 EA per 30 days) GC oxycodone/acetaminophen tablet 325mg; 7.5mg 2 QL (180 EA per 30 days) GC tramadol hcl tablet 50mg 2 QL (240 EA per 30 days) GC

Anestésicos Local Anesthetics

lidocaine hcl jelly gel 2% 2 GC lidocaine hcl injection 0.5% 2 GC lidocaine hcl injection 1% 2 GC lidocaine hcl solution 4% 2 GC lidocaine viscous solution 2% 2 GC lidocaine/prilocaine cream 2.5%; 2.5% 2 GC lidocaine ointment 5% 2 GC lidocaine patch 5% 4 QL (90 EA per 30 days) PA

Agentes para tratamiento antiadicción/abuso de sustancias Alcohol Deterrents/Anti-craving

acamprosate calcium dr tablet delayed release 333mg 4 disulfiram tablet 250mg 2 GC disulfiram tablet 500mg 2 GC

Opioid Dependence Treatments buprenorphine hcl/naloxone hcl tablet sublingual 2mg; 0.5mg

4 QL (90 EA per 30 days) PA



buprenorphine hcl/naloxone hcl tablet sublingual 8mg; 2mg

4 QL (90 EA per 30 days) PA

buprenorphine hcl injection 0.3mg/ml 4 buprenorphine hcl tablet sublingual 2mg 4 QL (90 EA per 30 days) PA buprenorphine hcl tablet sublingual 8mg 4 QL (90 EA per 30 days) PA naltrexone hcl tablet 50mg 2 GC

Opioid Reversal Agents naloxone hcl injection 1mg/ml 2 GC

Smoking Cessation Agents buproban tablet extended release 12 hour 150mg 2 GC CHANTIX STARTING MONTH PAK TABLET 0 4 QL (106 EA per 365 days) CHANTIX TABLET 0.5MG 4 QL (360 EA per 365 days) CHANTIX TABLET 1MG 4 QL (360 EA per 365 days) NICOTROL INHALER INHALER 10MG 4 NICOTROL NS SOLUTION 10MG/ML 3 QL (720 ML per 365 days)

Agentes antiinflamatorios Nonsteroidal Anti-inflammatory Drugs

DICLOFENAC SODIUM GEL 3% 5 ibuprofen tablet 400mg 1 GC ibuprofen tablet 600mg 1 GC ibuprofen tablet 800mg 1 GC

Antibacteriales Aminoglycosides

amikacin sulfate injection 500mg/2ml 2 GC AMIKACIN SULFATE INJECTION 50MG/ML 3 gentak ointment 0.3% 2 GC GENTAMICIN SULFATE CREAM 0.1% 3 gentamicin sulfate injection 10mg/ml 2 GC gentamicin sulfate injection 40mg/ml 2 GC GENTAMICIN SULFATE OINTMENT 0.1% 3 gentamicin sulfate ointment 0.3% 2 GC gentamicin sulfate solution 0.3% 2 GC neomycin sulfate tablet 500mg 2 GC paromomycin sulfate capsule 250mg 2 GC STREPTOMYCIN SULFATE INJECTION 1GM 3 tobramycin sulfate injection 10mg/ml 2 GC tobramycin sulfate injection 80mg/2ml 2 GC tobramycin sulfate solution 0.3% 2 GC

Antibacterials, Other alcohol preps pad 2 GC bacitracin/polymyxin b ointment 500unit/gm; 10000unit/gm

2 GC

BACITRACIN OINTMENT 500UNIT/GM 3 BACTROBAN NASAL OINTMENT 2% 4 CHLORAMPHENICOL SODIUM SUCCINATE INJECTION 1GM

3



clindamycin hcl capsule 150mg 2 GC clindamycin hcl capsule 300mg 2 GC clindamycin hcl capsule 75mg 2 GC CLINDAMYCIN PHOSPHATE IN D5W INJECTION 300MG/50ML; 5%

4

CLINDAMYCIN PHOSPHATE IN D5W INJECTION 600MG/50ML; 5%

4

CLINDAMYCIN PHOSPHATE IN D5W INJECTION 900MG/50ML; 5%

4

clindamycin phosphate cream 2% 2 GC colistimethate sodium injection 150mg 2 GC CUBICIN INJECTION 500MG 5 LINCOCIN INJECTION 300MG/ML 4 metronidazole in nacl 0.79% injection 500mg/100ml; 0.79%

2 GC

metronidazole vaginal gel 0.75% 2 GC metronidazole capsule 375mg 4 metronidazole cream 0.75% 2 GC metronidazole gel 0.75% 2 GC metronidazole lotion 0.75% 2 GC metronidazole tablet 250mg 2 GC metronidazole tablet 500mg 2 GC mupirocin ointment 2% 2 GC neomycin/bacitracin/polymyxin ointment 400unit/gm; 5mg/gm; 10000unit/gm

2 GC

neomycin/polymyxin/bacitracin/hydrocortisone ointment 400unit/gm; 1%; 0.5%; 10000unit/gm

2 GC

neomycin/polymyxin/gramicidin solution 0.025mg/ml; 1.75mg/ml; 10000unit/ml

2 GC

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSPENSION 1%; 3.5MG/ML; 10000UNIT/ML

3

nitrofurantoin macrocrystals capsule 100mg 2 PA GC nitrofurantoin macrocrystals capsule 50mg 2 PA GC nitrofurantoin monohydrate capsule 100mg 2 PA GC nitrofurantoin suspension 25mg/5ml 2 PA GC polymyxin b sulfate/trimethoprim sulfate solution 10000unit/ml; 0.1%

2 GC

silver sulfadiazine cream 1% 2 GC SYNERCID INJECTION 350MG; 150MG 5 trimethoprim tablet 100mg 2 GC TYGACIL INJECTION 50MG 4 vancomycin hcl capsule 125mg 4 ST vancomycin hcl capsule 250mg 4 ST vancomycin hcl injection 1000mg 2 GC XIFAXAN TABLET 200MG 4 PA XIFAXAN TABLET 550MG 5 PA



ZYVOX INJECTION 2MG/ML 5 PA ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML

5 PA

ZYVOX TABLET 600MG 5 PA Beta-lactam, Cephalosporins

CEFACLOR ER TABLET EXTENDED RELEASE 12 HOUR 500MG

3

cefaclor capsule 250mg 2 GC cefaclor capsule 500mg 2 GC cefadroxil capsule 500mg 2 GC cefadroxil suspension reconstituted 250mg/5ml 2 GC cefadroxil suspension reconstituted 500mg/5ml 2 GC cefadroxil tablet 1gm 2 GC cefazolin sodium injection 10gm 2 GC cefazolin sodium injection 1gm 2 GC cefazolin sodium injection 500mg 2 GC cefdinir capsule 300mg 2 GC cefdinir suspension reconstituted 125mg/5ml 2 GC cefdinir suspension reconstituted 250mg/5ml 2 GC cefepime injection 1gm 2 GC cefepime injection 2gm 2 GC cefotaxime sodium injection 10gm 2 GC cefotaxime sodium injection 1gm 2 GC cefotaxime sodium injection 2gm 2 GC cefpodoxime proxetil suspension reconstituted 100mg/5ml

2 GC

cefpodoxime proxetil suspension reconstituted 50mg/5ml

2 GC

cefpodoxime proxetil tablet 100mg 2 GC cefpodoxime proxetil tablet 200mg 2 GC cefprozil suspension reconstituted 125mg/5ml 2 GC cefprozil suspension reconstituted 250mg/5ml 2 GC cefprozil tablet 250mg 2 GC cefprozil tablet 500mg 2 GC CEFTIN SUSPENSION RECONSTITUTED 250MG/5ML

3

ceftriaxone sodium injection 10gm 2 GC ceftriaxone sodium injection 250mg 2 GC ceftriaxone sodium injection 500mg 2 GC cefuroxime axetil suspension reconstituted 125mg/5ml

2 GC

cefuroxime axetil tablet 250mg 2 GC cefuroxime axetil tablet 500mg 2 GC cefuroxime sodium injection 1.5gm 2 GC cefuroxime sodium injection 7.5gm 2 GC cefuroxime sodium injection 750mg 2 GC



cephalexin capsule 250mg 2 GC cephalexin capsule 500mg 2 GC cephalexin suspension reconstituted 125mg/5ml 2 GC cephalexin suspension reconstituted 250mg/5ml 2 GC SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML

3

SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML

3

SUPRAX TABLET 400MG 3 TEFLARO INJECTION 400MG 4 TEFLARO INJECTION 600MG 4

Beta-lactam, Other AZTREONAM INJECTION 1GM 4 imipenem/cilastatin injection 250mg; 250mg 2 GC imipenem/cilastatin injection 500mg; 500mg 2 GC INVANZ INJECTION 1GM 4 meropenem injection 500mg 2 GC

Beta-lactam, Penicillins amoxicillin/clavulanate potassium suspension reconstituted 200mg/5ml; 28.5mg/5ml

2 GC

amoxicillin/clavulanate potassium suspension reconstituted 250mg/5ml; 62.5mg/5ml

2 GC

amoxicillin/clavulanate potassium suspension reconstituted 400mg/5ml; 57mg/5ml

2 GC

amoxicillin/clavulanate potassium suspension reconstituted 600mg/5ml; 42.9mg/5ml

2 GC

amoxicillin/clavulanate potassium tablet chewable 200mg; 28.5mg

2 GC

amoxicillin/clavulanate potassium tablet chewable 400mg; 57mg

2 GC

amoxicillin/clavulanate potassium tablet 250mg; 125mg

2 GC


2 GC


2 GC

amoxicillin capsule 250mg 2 GC amoxicillin capsule 500mg 2 GC amoxicillin suspension reconstituted 125mg/5ml 2 GC amoxicillin suspension reconstituted 200mg/5ml 2 GC amoxicillin suspension reconstituted 250mg/5ml 2 GC amoxicillin suspension reconstituted 400mg/5ml 2 GC amoxicillin tablet chewable 125mg 2 GC amoxicillin tablet chewable 250mg 2 GC amoxicillin tablet 500mg 2 GC amoxicillin tablet 875mg 2 GC



ampicillin sodium injection 10gm 2 GC ampicillin sodium injection 1gm 2 GC ampicillin-sulbactam injection 2gm; 1gm 2 GC ampicillin capsule 250mg 2 GC ampicillin capsule 500mg 2 GC AMPICILLIN SUSPENSION RECONSTITUTED 125MG/5ML

3

AMPICILLIN SUSPENSION RECONSTITUTED 250MG/5ML

3

BICILLIN C-R INJECTION 300000UNIT/ML; 300000UNIT/ML

3

BICILLIN C-R INJECTION 900000UNIT/2ML; 300000UNIT/2ML

3

dicloxacillin sodium capsule 250mg 2 GC dicloxacillin sodium capsule 500mg 2 GC nafcillin sodium injection 10gm 4 nafcillin sodium injection 1gm 4 penicillin g potassium injection 5mu 4 penicillin v potassium solution reconstituted 125mg/5ml

2 GC

penicillin v potassium solution reconstituted 250mg/5ml

2 GC

penicillin v potassium tablet 250mg 2 GC penicillin v potassium tablet 500mg 2 GC piperacillin sodium/tazobactam sodium injection 3gm; 0.375gm

4

TIMENTIN INJECTION 0.1GM; 3GM 4 Macrolides

azithromycin injection 500mg 2 GC azithromycin tablet 250mg 2 GC azithromycin tablet 500mg 2 GC azithromycin tablet 600mg 2 GC clarithromycin er tablet extended release 24 hour 500mg

2 GC

clarithromycin suspension reconstituted 125mg/5ml 2 GC clarithromycin suspension reconstituted 250mg/5ml 2 GC clarithromycin tablet 250mg 2 GC clarithromycin tablet 500mg 2 GC DIFICID TABLET 200MG 5 QL (20 EA per 30 days) PA ERY-TAB TABLET DELAYED RELEASE 333MG 4 ERYPED 200 SUSPENSION RECONSTITUTED 200MG/5ML

3

ERYTHROCIN LACTOBIONATE INJECTION 500MG

3

ERYTHROMYCIN BASE TABLET 250MG 3 ERYTHROMYCIN BASE TABLET 500MG 3



erythromycin ointment 5mg/gm 2 GC erythromycin solution 2% 2 GC

Quinolones CILOXAN OINTMENT 0.3% 3 ciprofloxacin hcl solution 0.3% 2 GC ciprofloxacin hcl tablet 100mg 2 GC ciprofloxacin hcl tablet 250mg 2 GC ciprofloxacin hcl tablet 500mg 2 GC ciprofloxacin hcl tablet 750mg 2 GC ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5% 2 GC ciprofloxacin injection 400mg/40ml 2 GC CIPRO SUSPENSION RECONSTITUTED 500MG/5ML

3

CIPRO SUSPENSION RECONSTITUTED 5GM/100ML

3

gatifloxacin solution 0.5% 4 levofloxacin injection 25mg/ml 4 levofloxacin solution 25mg/ml 2 GC levofloxacin tablet 250mg 2 GC levofloxacin tablet 500mg 2 GC levofloxacin tablet 750mg 2 GC ofloxacin solution 0.3% 2 GC ofloxacin solution 0.3% 2 GC ofloxacin tablet 200mg 2 GC ofloxacin tablet 300mg 2 GC ofloxacin tablet 400mg 2 GC VIGAMOX SOLUTION 0.5% 4

Sulfonamides BLEPHAMIDE S.O.P. OINTMENT 0.2%; 10% 3 BLEPHAMIDE SUSPENSION 0.2%; 10% 3 sodium sulfacetamide solution 10% 2 GC SULFACETAMIDE SODIUM OINTMENT 10% 4 SULFADIAZINE TABLET 500MG 3 sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg

2 GC

SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400MG/5ML; 80MG/5ML

3

sulfamethoxazole/trimethoprim suspension 200mg/5ml; 40mg/5ml

2 GC

sulfamethoxazole/trimethoprim tablet 400mg; 80mg 2 GC Tetracyclines

doxycycline hyclate capsule 50mg 2 GC doxycycline hyclate tablet 100mg 2 GC doxycycline hyclate tablet 20mg 2 GC doxycycline monohydrate capsule 100mg 2 GC doxycycline monohydrate capsule 50mg 2 GC



minocycline hcl capsule 100mg 2 GC minocycline hcl capsule 50mg 2 GC minocycline hcl capsule 75mg 2 GC minocycline hcl tablet 100mg 2 GC minocycline hcl tablet 50mg 2 GC minocycline hcl tablet 75mg 2 GC

Anticonvulsivos Anticonvulsants, Other

APTIOM TABLET 200MG 4 ST APTIOM TABLET 400MG 4 ST APTIOM TABLET 600MG 4 ST APTIOM TABLET 800MG 4 ST FYCOMPA TABLET 10MG 4 ST FYCOMPA TABLET 12MG 4 ST FYCOMPA TABLET 2MG 4 ST FYCOMPA TABLET 4MG 4 ST FYCOMPA TABLET 6MG 4 ST FYCOMPA TABLET 8MG 4 ST levetiracetam injection 500mg/5ml 2 GC levetiracetam solution 100mg/ml 2 GC levetiracetam tablet 1000mg 2 GC levetiracetam tablet 250mg 2 GC levetiracetam tablet 500mg 2 GC levetiracetam tablet 750mg 2 GC phenobarbital elixir 20mg/5ml 2 GC phenobarbital tablet 100mg 2 GC phenobarbital tablet 15mg 2 GC phenobarbital tablet 16.2mg 2 GC phenobarbital tablet 30mg 2 GC phenobarbital tablet 32.4mg 2 GC phenobarbital tablet 60mg 2 GC PHENOBARBITAL TABLET 64.8MG 3 PHENOBARBITAL TABLET 97.2MG 3 POTIGA TABLET 200MG 4 PA POTIGA TABLET 300MG 4 PA POTIGA TABLET 400MG 4 PA POTIGA TABLET 50MG 4 PA

Calcium Channel Modifying Agents CELONTIN CAPSULE 300MG 4 ethosuximide capsule 250mg 2 GC ethosuximide solution 250mg/5ml 2 GC LYRICA CAPSULE 100MG 3 ST LYRICA CAPSULE 150MG 3 ST LYRICA CAPSULE 200MG 3 ST LYRICA CAPSULE 225MG 3 ST LYRICA CAPSULE 25MG 3 ST



LYRICA CAPSULE 300MG 3 ST LYRICA CAPSULE 50MG 3 ST LYRICA CAPSULE 75MG 3 ST LYRICA SOLUTION 20MG/ML 3 ST zonisamide capsule 100mg 2 GC zonisamide capsule 25mg 2 GC zonisamide capsule 50mg 2 GC

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam odt tablet dispersible 0.125mg 4 QL (90 EA per 30 days) clonazepam odt tablet dispersible 0.25mg 4 QL (90 EA per 30 days) clonazepam odt tablet dispersible 0.5mg 4 QL (90 EA per 30 days) clonazepam odt tablet dispersible 1mg 4 QL (90 EA per 30 days) clonazepam odt tablet dispersible 2mg 4 clonazepam tablet 0.5mg 2 QL (90 EA per 30 days) GC clonazepam tablet 1mg 2 QL (90 EA per 30 days) GC clonazepam tablet 2mg 2 GC DIAZEPAM GEL 10MG 4 ST DIAZEPAM GEL 2.5MG 4 ST DIAZEPAM GEL 20MG 4 ST divalproex sodium dr tablet delayed release 125mg 2 GC divalproex sodium dr tablet delayed release 250mg 2 GC divalproex sodium dr tablet delayed release 500mg 2 GC divalproex sodium er tablet extended release 24 hour 250mg

2 GC

divalproex sodium er tablet extended release 24 hour 500mg

2 GC

divalproex sodium capsule sprinkle 125mg 2 GC gabapentin capsule 100mg 2 GC gabapentin capsule 300mg 2 GC gabapentin capsule 400mg 2 GC gabapentin solution 250mg/5ml 2 GC gabapentin tablet 600mg 2 GC gabapentin tablet 800mg 2 GC GABITRIL TABLET 12MG 4 GABITRIL TABLET 16MG 4 ONFI SUSPENSION 2.5MG/ML 4 ST ONFI TABLET 10MG 4 QL (60 EA per 30 days) ST ONFI TABLET 20MG 4 QL (60 EA per 30 days) ST ONFI TABLET 5MG 4 QL (60 EA per 30 days) ST primidone tablet 250mg 2 GC primidone tablet 50mg 2 GC SABRIL PACKET 500MG 5 SABRIL TABLET 500MG 5 tiagabine hydrochloride tablet 2mg 2 GC tiagabine hydrochloride tablet 4mg 2 GC



valproate sodium injection 500mg/5ml 2 GC valproic acid capsule 250mg 2 GC valproic acid syrup 250mg/5ml 2 GC

Glutamate Reducing Agents felbamate suspension 600mg/5ml 2 GC felbamate tablet 400mg 2 GC felbamate tablet 600mg 2 GC lamotrigine tablet chewable 25mg 2 GC lamotrigine tablet chewable 5mg 2 GC lamotrigine tablet 100mg 2 GC lamotrigine tablet 150mg 2 GC lamotrigine tablet 200mg 2 GC lamotrigine tablet 25mg 2 GC topiramate capsule sprinkle 15mg 2 GC topiramate capsule sprinkle 25mg 2 GC topiramate tablet 100mg 2 GC topiramate tablet 200mg 2 GC topiramate tablet 25mg 2 GC topiramate tablet 50mg 2 GC

Sodium Channel Agents BANZEL SUSPENSION 40MG/ML 4 ST BANZEL TABLET 200MG 4 ST BANZEL TABLET 400MG 4 ST carbamazepine er capsule extended release 12 hour 100mg

2 GC

carbamazepine er capsule extended release 12 hour 200mg

2 GC

carbamazepine er capsule extended release 12 hour 300mg

2 GC

carbamazepine er tablet extended release 12 hour 200mg

2 GC

carbamazepine er tablet extended release 12 hour 400mg

2 GC

carbamazepine suspension 100mg/5ml 2 GC carbamazepine tablet chewable 100mg 2 GC carbamazepine tablet 200mg 2 GC DILANTIN CAPSULE 30MG 4 fosphenytoin sodium injection 100mg pe/2ml 4 oxcarbazepine suspension 300mg/5ml 2 GC oxcarbazepine tablet 150mg 2 GC oxcarbazepine tablet 300mg 2 GC oxcarbazepine tablet 600mg 2 GC PEGANONE TABLET 250MG 4 phenytoin sodium extended capsule 100mg 2 GC phenytoin sodium extended capsule 200mg 2 GC phenytoin sodium extended capsule 300mg 2 GC



phenytoin sodium injection 50mg/ml 2 GC phenytoin suspension 125mg/5ml 2 GC phenytoin tablet chewable 50mg 2 GC TEGRETOL-XR TABLET EXTENDED RELEASE 12 HOUR 100MG

4

VIMPAT INJECTION 200MG/20ML 4 ST VIMPAT SOLUTION 10MG/ML 4 ST VIMPAT TABLET 100MG 4 QL (60 EA per 30 days) ST VIMPAT TABLET 150MG 4 QL (60 EA per 30 days) ST VIMPAT TABLET 200MG 4 QL (60 EA per 30 days) ST VIMPAT TABLET 50MG 4 QL (60 EA per 30 days) ST

Agentes contra la demencia Antidementia Agents, Other

ergoloid mesylates tablet 1mg 2 GC Cholinesterase Inhibitors

donepezil hcl tablet dispersible 10mg 2 QL (60 EA per 30 days) GC donepezil hcl tablet dispersible 5mg 2 QL (30 EA per 30 days) GC donepezil hcl tablet 10mg 2 QL (60 EA per 30 days) GC donepezil hcl tablet 5mg 2 QL (30 EA per 30 days) GC EXELON PATCH 24 HOUR 13.3MG/24HR 4 EXELON PATCH 24 HOUR 4.6MG/24HR 4 EXELON PATCH 24 HOUR 9.5MG/24HR 4 galantamine hydrobromide capsule extended release 24 hour 16mg

2 GC

galantamine hydrobromide capsule extended release 24 hour 24mg

2 GC

galantamine hydrobromide capsule extended release 24 hour 8mg

2 GC

galantamine hydrobromide solution 4mg/ml 2 GC galantamine hydrobromide tablet 12mg 2 GC galantamine hydrobromide tablet 4mg 2 GC galantamine hydrobromide tablet 8mg 2 GC rivastigmine tartrate capsule 1.5mg 2 QL (60 EA per 30 days) GC rivastigmine tartrate capsule 3mg 2 QL (60 EA per 30 days) GC rivastigmine tartrate capsule 4.5mg 2 QL (60 EA per 30 days) GC rivastigmine tartrate capsule 6mg 2 QL (60 EA per 30 days) GC

N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA XR TITRATION PACK CAPSULE EXTENDED RELEASE 24 HOUR 0

3

NAMENDA XR CAPSULE EXTENDED RELEASE 24 HOUR 14MG

3


3


3




3

Antidepresivos Antidepressants, Other

BRINTELLIX TABLET 10MG 4 QL (30 EA per 30 days) ST BRINTELLIX TABLET 20MG 4 QL (30 EA per 30 days) ST BRINTELLIX TABLET 5MG 4 QL (30 EA per 30 days) ST bupropion hcl sr tablet extended release 12 hour 100mg

2 GC

bupropion hcl sr tablet extended release 12 hour 150mg

2 GC

bupropion hcl sr tablet extended release 12 hour 200mg

2 GC

bupropion hcl xl tablet extended release 24 hour 150mg

2 QL (90 EA per 30 days) GC

bupropion hcl xl tablet extended release 24 hour 300mg

2 GC

bupropion hcl tablet 100mg 1 GC bupropion hcl tablet 75mg 1 GC FORFIVO XL TABLET EXTENDED RELEASE 24 HOUR 450MG

4

MAPROTILINE HCL TABLET 25MG 3 MAPROTILINE HCL TABLET 50MG 3 MAPROTILINE HCL TABLET 75MG 3 mirtazapine odt tablet dispersible 30mg 2 GC mirtazapine odt tablet dispersible 45mg 2 GC mirtazapine tablet dispersible 15mg 2 GC mirtazapine tablet 15mg 2 GC mirtazapine tablet 30mg 2 GC mirtazapine tablet 45mg 2 GC mirtazapine tablet 7.5mg 2 GC NEFAZODONE HCL TABLET 100MG 3 NEFAZODONE HCL TABLET 150MG 3 NEFAZODONE HCL TABLET 200MG 3 NEFAZODONE HCL TABLET 250MG 3 NEFAZODONE HCL TABLET 50MG 3 trazodone hcl tablet 100mg 1 GC trazodone hcl tablet 150mg 1 GC trazodone hcl tablet 300mg 1 GC trazodone hcl tablet 50mg 1 GC

Monoamine Oxidase Inhibitors EMSAM PATCH 24 HOUR 12MG/24HR 4 EMSAM PATCH 24 HOUR 6MG/24HR 4 EMSAM PATCH 24 HOUR 9MG/24HR 4 MARPLAN TABLET 10MG 4 phenelzine sulfate tablet 15mg 2 GC



tranylcypromine sulfate tablet 10mg 2 GC SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

citalopram hydrobromide solution 10mg/5ml 2 QL (600 ML per 30 days) GC citalopram hydrobromide tablet 10mg 1 QL (45 EA per 30 days) GC citalopram hydrobromide tablet 20mg 1 GC citalopram hydrobromide tablet 40mg 1 GC duloxetine hcl capsule delayed release particles 20mg

4 QL (60 EA per 30 days)

duloxetine hcl capsule delayed release particles 30mg


duloxetine hcl capsule delayed release particles 60mg


escitalopram oxalate solution 5mg/5ml 2 GC escitalopram oxalate tablet 10mg 2 QL (45 EA per 30 days) GC escitalopram oxalate tablet 20mg 2 QL (30 EA per 30 days) GC escitalopram oxalate tablet 5mg 2 QL (30 EA per 30 days) GC FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120MG

4 ST

FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20MG

4 ST


4 ST


4 ST

fluoxetine hcl capsule 10mg 1 GC fluoxetine hcl capsule 20mg 1 GC fluoxetine hcl capsule 40mg 1 GC fluoxetine hcl solution 20mg/5ml 2 GC fluoxetine hcl tablet 10mg 1 GC fluoxetine hcl tablet 20mg 1 GC fluvoxamine maleate tablet 100mg 2 GC fluvoxamine maleate tablet 25mg 1 GC fluvoxamine maleate tablet 50mg 1 GC KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 100MG


KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 50MG


paroxetine hcl er tablet extended release 24 hour 12.5mg

2 GC

paroxetine hcl er tablet extended release 24 hour 25mg

2 GC

paroxetine hcl er tablet extended release 24 hour 37.5mg

2 GC

paroxetine hcl tablet 10mg 2 GC



paroxetine hcl tablet 20mg 2 GC paroxetine hcl tablet 30mg 2 GC paroxetine hcl tablet 40mg 2 GC paxil suspension 10mg/5ml 2 GC PRISTIQ TABLET EXTENDED RELEASE 24 HOUR 100MG


PRISTIQ TABLET EXTENDED RELEASE 24 HOUR 50MG


sertraline hcl concentrate 20mg/ml 2 GC sertraline hcl tablet 100mg 1 GC sertraline hcl tablet 25mg 1 GC sertraline hcl tablet 50mg 1 GC venlafaxine hcl er capsule extended release 24 hour 150mg


venlafaxine hcl er capsule extended release 24 hour 37.5mg


venlafaxine hcl er capsule extended release 24 hour 75mg


venlafaxine hcl er tablet extended release 24 hour 150mg




venlafaxine hcl er tablet extended release 24 hour 37.5mg




venlafaxine hcl tablet 100mg 2 GC venlafaxine hcl tablet 25mg 2 GC venlafaxine hcl tablet 37.5mg 2 GC venlafaxine hcl tablet 50mg 2 GC venlafaxine hcl tablet 75mg 2 GC VIIBRYD TABLET 10MG 4 QL (30 EA per 30 days) ST VIIBRYD TABLET 20MG 4 QL (30 EA per 30 days) ST VIIBRYD TABLET 40MG 4 QL (30 EA per 30 days) ST

Tricyclics amitriptyline hcl tablet 100mg 4 ST amitriptyline hcl tablet 10mg 4 ST amitriptyline hcl tablet 150mg 4 ST amitriptyline hcl tablet 25mg 4 ST amitriptyline hcl tablet 50mg 4 ST amitriptyline hcl tablet 75mg 4 ST AMOXAPINE TABLET 100MG 3 AMOXAPINE TABLET 150MG 3 AMOXAPINE TABLET 25MG 3 AMOXAPINE TABLET 50MG 3 clomipramine hcl capsule 25mg 2 GC



clomipramine hcl capsule 50mg 2 GC clomipramine hcl capsule 75mg 2 GC desipramine hcl tablet 100mg 2 GC desipramine hcl tablet 10mg 2 GC desipramine hcl tablet 150mg 2 GC desipramine hcl tablet 25mg 2 GC desipramine hcl tablet 50mg 2 GC desipramine hcl tablet 75mg 2 GC doxepin hcl capsule 100mg 4 ST doxepin hcl capsule 10mg 4 ST doxepin hcl capsule 150mg 4 ST doxepin hcl capsule 25mg 4 ST doxepin hcl capsule 50mg 4 ST doxepin hcl capsule 75mg 4 ST doxepin hcl concentrate 10mg/ml 1 GC imipramine hcl tablet 10mg 4 ST imipramine hcl tablet 25mg 4 ST imipramine hcl tablet 50mg 4 ST nortriptyline hcl capsule 10mg 1 GC nortriptyline hcl capsule 25mg 1 GC nortriptyline hcl capsule 50mg 1 GC nortriptyline hcl capsule 75mg 1 GC NORTRIPTYLINE HCL SOLUTION 10MG/5ML 3 protriptyline hcl tablet 10mg 2 GC protriptyline hcl tablet 5mg 2 GC surmontil capsule 100mg 4 ST surmontil capsule 25mg 4 ST surmontil capsule 50mg 4 ST

Antieméticos Antiemetics, Other

meclizine hcl tablet 25mg 2 GC phenadoz suppository 25mg 2 GC promethazine hcl suppository 12.5mg 2 GC promethazine hcl suppository 25mg 2 GC TRANSDERM-SCOP PATCH 72 HOUR 1.5MG 4 QL (10 EA per 30 days)

Emetogenic Therapy Adjuncts ALOXI INJECTION 0.25MG/5ML 4 PA dronabinol capsule 10mg 4 QL (60 EA per 30 days) PA dronabinol capsule 2.5mg 4 QL (60 EA per 30 days) PA dronabinol capsule 5mg 4 QL (60 EA per 30 days) PA EMEND CAPSULE 0 3 QL (12 EA per 30 days) PA EMEND CAPSULE 40MG 3 PA granisetron hcl injection 0.1mg/ml 4 granisetron hcl injection 1mg/ml 4 granisetron hcl tablet 1mg 2 QL (60 EA per 30 days) ST

B/D GC



ondansetron hcl injection 4mg/2ml 2 GC ondansetron hcl tablet 4mg 2 QL (90 EA per 30 days) B/D

GC ondansetron hcl tablet 8mg 2 QL (90 EA per 30 days) B/D

GC ondansetron odt tablet dispersible 4mg 2 QL (90 EA per 30 days) B/D

GC ondansetron odt tablet dispersible 8mg 2 QL (90 EA per 30 days) B/D

GC Antimicóticos

Antifungals ABELCET INJECTION 5MG/ML 4 AMBISOME INJECTION 50MG 4 AMPHOTEC INJECTION 50MG 4 AMPHOTERICIN B INJECTION 50MG 3 CANCIDAS INJECTION 50MG 5 CANCIDAS INJECTION 70MG 5 ciclopirox nail lacquer solution 8% 2 GC ciclopirox olamine cream 0.77% 2 GC ciclopirox gel 0.77% 2 GC ciclopirox shampoo 1% 2 GC ciclopirox suspension 0.77% 2 GC clotrimazole cream 1% 2 GC clotrimazole troche 10mg 2 GC econazole nitrate cream 1% 2 GC ERAXIS INJECTION 100MG 5 fluconazole in dextrose injection 56mg/ml; 400mg/200ml

2 GC

fluconazole suspension reconstituted 10mg/ml 2 GC fluconazole suspension reconstituted 40mg/ml 2 GC fluconazole tablet 100mg 2 GC fluconazole tablet 150mg 1 GC fluconazole tablet 200mg 2 GC fluconazole tablet 50mg 2 GC flucytosine capsule 250mg 4 flucytosine capsule 500mg 4 griseofulvin microsize suspension 125mg/5ml 2 GC itraconazole capsule 100mg 2 GC ketoconazole cream 2% 2 GC ketoconazole shampoo 2% 2 GC ketoconazole tablet 200mg 2 GC NATACYN SUSPENSION 5% 4 NOXAFIL SUSPENSION 40MG/ML 5 PA NOXAFIL TABLET DELAYED RELEASE 100MG 5 PA nystatin/triamcinolone cream 100000unit/gm; 0.1% 2 GC



nystatin/triamcinolone ointment 100000unit/gm; 0.1%

2 GC

nystatin cream 100000unit/gm 1 GC nystatin ointment 100000unit/gm 1 GC nystatin powder 100000unit/gm 1 GC nystatin suspension 100000unit/ml 2 GC nystatin tablet 500000unit 2 GC SPORANOX SOLUTION 10MG/ML 4 terbinafine hcl tablet 250mg 2 QL (90 EA per 365 days) GC terconazole cream 0.4% 2 GC terconazole cream 0.8% 2 GC terconazole suppository 80mg 2 GC voriconazole injection 200mg 4 PA voriconazole suspension reconstituted 40mg/ml 4 PA voriconazole tablet 200mg 5 QL (60 EA per 30 days) PA

Agentes antigota Antigout Agents

allopurinol tablet 100mg 1 GC allopurinol tablet 300mg 1 GC COLCRYS TABLET 0.6MG 3 probenecid/colchicine tablet 0.5mg; 500mg 2 GC probenecid tablet 500mg 2 GC ULORIC TABLET 40MG 4 QL (30 EA per 30 days) ULORIC TABLET 80MG 4 QL (30 EA per 30 days)

Agentes antimigraña Ergot Alkaloids

CAFERGOT TABLET 100MG; 1MG 3 dihydroergotamine mesylate injection 1mg/ml 2 GC dihydroergotamine mesylate solution 4mg/ml 5 QL (8 ML per 28 days) ERGOMAR TABLET SUBLINGUAL 2MG 4 QL (20 EA per 28 days) MIGRANAL SOLUTION 4MG/ML 5 QL (8 ML per 28 days)

Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl tablet 1mg 2 QL (18 EA per 30 days) GC naratriptan hcl tablet 2.5mg 2 QL (18 EA per 30 days) GC RELPAX TABLET 20MG 4 QL (18 EA per 30 days) ST RELPAX TABLET 40MG 4 QL (18 EA per 30 days) ST rizatriptan benzoate odt tablet dispersible 10mg 4 QL (18 EA per 30 days) rizatriptan benzoate odt tablet dispersible 5mg 4 QL (18 EA per 30 days) rizatriptan benzoate tablet 10mg 4 QL (18 EA per 30 days) rizatriptan benzoate tablet 5mg 4 QL (18 EA per 30 days) sumatriptan succinate injection 4mg/0.5ml 4 QL (2 ML per 30 days) sumatriptan succinate injection 6mg/0.5ml 4 QL (5 ML per 30 days) sumatriptan succinate tablet 100mg 2 QL (18 EA per 30 days) GC sumatriptan succinate tablet 25mg 2 QL (18 EA per 30 days) GC sumatriptan succinate tablet 50mg 2 QL (18 EA per 30 days) GC

Agentes antimiasténicos



Parasympathomimetics guanidine hcl tablet 125mg 4 MESTINON SYRUP 60MG/5ML 3 pyridostigmine bromide tablet 60mg 2 GC

Antimicobacteriales Antimycobacterials, Other

DAPSONE TABLET 100MG 3 DAPSONE TABLET 25MG 3 rifabutin capsule 150mg 5

Antituberculars CAPASTAT SULFATE INJECTION 1GM 4 ethambutol hcl tablet 100mg 2 GC ethambutol hcl tablet 400mg 2 GC ISONIAZID INJECTION 100MG/ML 3 ISONIAZID SYRUP 50MG/5ML 3 isoniazid tablet 100mg 2 GC isoniazid tablet 300mg 2 GC PASER PACKET 4GM 4 PRIFTIN TABLET 150MG 3 pyrazinamide tablet 500mg 2 GC rifampin capsule 150mg 2 GC rifampin capsule 300mg 2 GC rifampin injection 600mg 2 GC RIFATER TABLET 50MG; 300MG; 120MG 4 SEROMYCIN CAPSULE 250MG 4 TRECATOR TABLET 250MG 4

Antineoplásicos Alkylating Agents

CYCLOPHOSPHAMIDE INJECTION 1GM 3 CYCLOPHOSPHAMIDE INJECTION 500MG 3 cyclophosphamide tablet 25mg 4 B/D cyclophosphamide tablet 50mg 4 B/D HEXALEN CAPSULE 50MG 5 PA LEUKERAN TABLET 2MG 3 lomustine capsule 100mg 4 lomustine capsule 10mg 4 lomustine capsule 40mg 4 MATULANE CAPSULE 50MG 5 PA

Antiandrogens bicalutamide tablet 50mg 2 GC flutamide capsule 125mg 2 GC NILANDRON TABLET 150MG 4 XTANDI CAPSULE 40MG 5 QL (120 EA per 30 days) PA

LA ZYTIGA TABLET 250MG 5 PA LA

Antiangiogenic Agents



CAPRELSA TABLET 100MG 5 PA LA CAPRELSA TABLET 300MG 5 PA LA REVLIMID CAPSULE 10MG 5 PA LA REVLIMID CAPSULE 15MG 5 PA LA REVLIMID CAPSULE 2.5MG 5 PA LA REVLIMID CAPSULE 20MG 5 PA LA REVLIMID CAPSULE 25MG 5 PA LA REVLIMID CAPSULE 5MG 5 PA LA THALOMID CAPSULE 100MG 5 PA THALOMID CAPSULE 150MG 5 PA THALOMID CAPSULE 200MG 5 PA THALOMID CAPSULE 50MG 5 PA

Antiestrogens/Modifiers EMCYT CAPSULE 140MG 4 PA FARESTON TABLET 60MG 4 FASLODEX INJECTION 250MG/5ML 5 SOLTAMOX SOLUTION 10MG/5ML 4 tamoxifen citrate tablet 10mg 2 GC tamoxifen citrate tablet 20mg 2 GC

Antimetabolites cladribine injection 1mg/ml 2 GC ELITEK INJECTION 1.5MG 5 hydroxyurea capsule 500mg 2 GC mercaptopurine tablet 50mg 2 GC TABLOID TABLET 40MG 4 PA

Antineoplastics, Other ALIMTA INJECTION 500MG 5 PA amifostine injection 500mg 5 PA azacitidine injection 100mg 5 bleomycin sulfate injection 30unit 2 GC COMETRIQ KIT 0 5 PA COMETRIQ KIT 0 5 PA COMETRIQ KIT 20MG 5 PA decitabine injection 50mg 5 DOCETAXEL INJECTION 80MG/8ML 4 epirubicin hcl injection 50mg/25ml 2 GC ERIVEDGE CAPSULE 150MG 5 PA LA ERWINAZE INJECTION 10000UNIT 5 PA fludarabine phosphate injection 50mg/2ml 2 GC fludarabine phosphate injection 50mg 2 GC GILOTRIF TABLET 20MG 5 PA LA GILOTRIF TABLET 30MG 5 PA LA GILOTRIF TABLET 40MG 5 PA LA ICLUSIG TABLET 15MG 5 QL (60 EA per 30 days) PA ICLUSIG TABLET 45MG 5 QL (30 EA per 30 days) PA JAKAFI TABLET 10MG 5 PA LA



JAKAFI TABLET 15MG 5 PA LA JAKAFI TABLET 20MG 5 PA LA JAKAFI TABLET 25MG 5 PA LA JAKAFI TABLET 5MG 5 PA LA leucovorin calcium injection 100mg 2 GC leucovorin calcium injection 350mg 2 GC leucovorin calcium tablet 25mg 2 GC leucovorin calcium tablet 5mg 2 GC MEKINIST TABLET 0.5MG 5 PA LA MEKINIST TABLET 2MG 5 PA LA MENEST TABLET 0.3MG 3 PA MENEST TABLET 0.625MG 3 PA MENEST TABLET 1.25MG 3 PA MENEST TABLET 2.5MG 3 PA mesna injection 100mg/ml 2 GC MESNEX TABLET 400MG 4 mitoxantrone hcl injection 2mg/ml 2 GC ONCASPAR INJECTION 750UNIT/ML 5 PA POMALYST CAPSULE 1MG 5 QL (21 EA per 28 days) PA

LA POMALYST CAPSULE 2MG 5 QL (21 EA per 28 days) PA



LA SYLATRON INJECTION 296MCG 5 PA SYLATRON INJECTION 444MCG 5 PA SYLATRON INJECTION 888MCG 5 PA SYNRIBO INJECTION 3.5MG 5 PA VELCADE INJECTION 3.5MG 5 ZOLINZA CAPSULE 100MG 5 PA

Aromatase Inhibitors, 3rd Generation anastrozole tablet 1mg 2 GC exemestane tablet 25mg 2 GC letrozole tablet 2.5mg 2 GC

Enzyme Inhibitors etoposide injection 500mg/25ml 2 GC topotecan hcl injection 4mg 2 GC

Molecular Target Inhibitors AFINITOR DISPERZ TABLET SOLUBLE 2MG 5 PA AFINITOR DISPERZ TABLET SOLUBLE 3MG 5 PA AFINITOR DISPERZ TABLET SOLUBLE 5MG 5 PA AFINITOR TABLET 10MG 5 PA AFINITOR TABLET 2.5MG 5 PA AFINITOR TABLET 5MG 5 PA



AFINITOR TABLET 7.5MG 5 PA BOSULIF TABLET 100MG 5 QL (120 EA per 30 days) PA BOSULIF TABLET 500MG 5 QL (30 EA per 30 days) PA GLEEVEC TABLET 100MG 5 PA GLEEVEC TABLET 400MG 5 PA IMBRUVICA CAPSULE 140MG 5 QL (120 EA per 30 days) PA INLYTA TABLET 1MG 5 PA LA INLYTA TABLET 5MG 5 PA LA NEXAVAR TABLET 200MG 5 PA LA SPRYCEL TABLET 100MG 5 PA SPRYCEL TABLET 140MG 5 PA SPRYCEL TABLET 20MG 5 PA SPRYCEL TABLET 50MG 5 PA SPRYCEL TABLET 70MG 5 PA SPRYCEL TABLET 80MG 5 PA STIVARGA TABLET 40MG 5 QL (120 EA per 30 days) PA

LA SUTENT CAPSULE 12.5MG 5 PA SUTENT CAPSULE 25MG 5 PA SUTENT CAPSULE 50MG 5 PA TAFINLAR CAPSULE 50MG 5 PA LA TAFINLAR CAPSULE 75MG 5 PA LA TARCEVA TABLET 100MG 5 PA TARCEVA TABLET 150MG 5 PA TARCEVA TABLET 25MG 5 PA TASIGNA CAPSULE 150MG 5 PA TASIGNA CAPSULE 200MG 5 PA TYKERB TABLET 250MG 5 PA LA VOTRIENT TABLET 200MG 5 PA XALKORI CAPSULE 200MG 5 PA LA XALKORI CAPSULE 250MG 5 PA LA ZELBORAF TABLET 240MG 5 PA LA

Monoclonal Antibodies ADCETRIS INJECTION 50MG 5 PA ARZERRA INJECTION 100MG/5ML 5 PA AVASTIN INJECTION 100MG/4ML 5 PA ERBITUX INJECTION 100MG/50ML 5 KADCYLA INJECTION 100MG 5 PA PERJETA INJECTION 420MG/14ML 5 PA RITUXAN INJECTION 10MG/ML 5 PA YERVOY INJECTION 50MG/10ML 5 PA

Retinoids PANRETIN GEL 0.1% 5 TARGRETIN CAPSULE 75MG 5 PA TARGRETIN GEL 1% 5 PA TRETINOIN CAPSULE 10MG 3



Antiparasitarios Anthelmintics

ALBENZA TABLET 200MG 3 BILTRICIDE TABLET 600MG 3

Antiprotozoals ALINIA TABLET 500MG 4 atovaquone/proguanil hcl tablet 250mg; 100mg 4 atovaquone suspension 750mg/5ml 2 GC chloroquine phosphate tablet 250mg 2 GC chloroquine phosphate tablet 500mg 2 GC COARTEM TABLET 20MG; 120MG 4 QL (24 EA per 30 days) DARAPRIM TABLET 25MG 3 hydroxychloroquine sulfate tablet 200mg 2 GC mefloquine hcl tablet 250mg 2 GC NEBUPENT SOLUTION RECONSTITUTED 300MG 4 B/D PENTAM 300 INJECTION 300MG 4 PRIMAQUINE PHOSPHATE TABLET 26.3MG 3 quinine sulfate capsule 324mg 4 QL (42 EA per 30 days) PA

Pediculicides/Scabicides lindane lotion 1% 2 GC lindane shampoo 1% 2 GC malathion lotion 0.5% 2 GC permethrin cream 5% 2 GC SKLICE LOTION 0.5% 4 ST

Agentes antiparkinsonianos Anticholinergics

benztropine mesylate injection 1mg/ml 2 GC benztropine mesylate tablet 0.5mg 2 GC benztropine mesylate tablet 1mg 2 GC benztropine mesylate tablet 2mg 2 GC trihexyphenidyl hcl elixir 0.4mg/ml 2 GC trihexyphenidyl hcl tablet 2mg 2 GC trihexyphenidyl hcl tablet 5mg 2 GC

Antiparkinson Agents, Other entacapone tablet 200mg 4 TASMAR TABLET 100MG 5

Dopamine Agonists APOKYN INJECTION 10MG/ML 4 PA LA bromocriptine mesylate capsule 5mg 2 GC bromocriptine mesylate tablet 2.5mg 2 GC NEUPRO PATCH 24 HOUR 1MG/24HR 4 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 2MG/24HR 4 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 3MG/24HR 4 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 4MG/24HR 4 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 6MG/24HR 4 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 8MG/24HR 4 QL (30 EA per 30 days)



pramipexole dihydrochloride tablet 0.125mg 2 GC pramipexole dihydrochloride tablet 0.25mg 2 GC pramipexole dihydrochloride tablet 0.5mg 2 GC pramipexole dihydrochloride tablet 0.75mg 2 GC pramipexole dihydrochloride tablet 1.5mg 2 GC pramipexole dihydrochloride tablet 1mg 2 GC ropinirole hcl tablet 0.25mg 2 GC ropinirole hcl tablet 0.5mg 2 GC ropinirole hcl tablet 1mg 2 GC ropinirole hcl tablet 2mg 2 GC ropinirole hcl tablet 3mg 2 GC ropinirole hcl tablet 4mg 2 GC ropinirole hcl tablet 5mg 2 GC

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa er tablet extended release 25mg; 100mg

1 GC

carbidopa/levodopa er tablet extended release 50mg; 200mg

1 GC

carbidopa/levodopa tablet 10mg; 100mg 1 GC carbidopa/levodopa tablet 25mg; 100mg 1 GC carbidopa/levodopa tablet 25mg; 250mg 1 GC STALEVO 100 TABLET 25MG; 200MG; 100MG 4 STALEVO 125 TABLET 31.25MG; 200MG; 125MG 4 STALEVO 150 TABLET 37.5MG; 200MG; 150MG 4 STALEVO 200 TABLET 50MG; 200MG; 200MG 4 STALEVO 50 TABLET 12.5MG; 200MG; 50MG 4 STALEVO 75 TABLET 18.75MG; 200MG; 75MG 4

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TABLET 0.5MG 4 AZILECT TABLET 1MG 4 selegiline hcl capsule 5mg 2 GC selegiline hcl tablet 5mg 2 GC

Antipsicóticos 1st Generation/Typical

CHLORPROMAZINE HCL INJECTION 25MG/ML 3 chlorpromazine hcl tablet 100mg 2 GC chlorpromazine hcl tablet 10mg 2 GC chlorpromazine hcl tablet 200mg 2 GC chlorpromazine hcl tablet 25mg 2 GC chlorpromazine hcl tablet 50mg 2 GC fluphenazine decanoate injection 25mg/ml 2 GC FLUPHENAZINE HCL CONCENTRATE 5MG/ML 3 FLUPHENAZINE HCL ELIXIR 2.5MG/5ML 3 FLUPHENAZINE HCL INJECTION 2.5MG/ML 3 fluphenazine hcl tablet 10mg 2 GC



fluphenazine hcl tablet 1mg 2 GC fluphenazine hcl tablet 2.5mg 2 GC fluphenazine hcl tablet 5mg 2 GC haloperidol decanoate injection 100mg/ml 2 GC haloperidol decanoate injection 50mg/ml 2 GC haloperidol lactate injection 5mg/ml 2 GC haloperidol concentrate 2mg/ml 2 GC haloperidol tablet 0.5mg 2 GC haloperidol tablet 10mg 2 GC haloperidol tablet 1mg 2 GC haloperidol tablet 20mg 2 GC haloperidol tablet 2mg 2 GC haloperidol tablet 5mg 2 GC loxapine succinate capsule 10mg 2 GC loxapine succinate capsule 25mg 2 GC loxapine succinate capsule 50mg 2 GC loxapine succinate capsule 5mg 2 GC ORAP TABLET 1MG 3 ORAP TABLET 2MG 3 perphenazine tablet 16mg 2 GC perphenazine tablet 2mg 2 GC perphenazine tablet 4mg 2 GC perphenazine tablet 8mg 2 GC prochlorperazine edisylate injection 5mg/ml 2 GC prochlorperazine maleate tablet 10mg 2 GC prochlorperazine maleate tablet 5mg 2 GC prochlorperazine suppository 25mg 2 GC thioridazine hcl tablet 100mg 2 GC thioridazine hcl tablet 10mg 2 GC thioridazine hcl tablet 25mg 2 GC thioridazine hcl tablet 50mg 2 GC thiothixene capsule 10mg 2 GC thiothixene capsule 1mg 2 GC thiothixene capsule 2mg 2 GC thiothixene capsule 5mg 2 GC trifluoperazine hcl tablet 10mg 2 GC trifluoperazine hcl tablet 1mg 2 GC trifluoperazine hcl tablet 2mg 2 GC trifluoperazine hcl tablet 5mg 2 GC

2nd Generation/Atypical ABILIFY DISCMELT TABLET DISPERSIBLE 10MG 5 ST ABILIFY DISCMELT TABLET DISPERSIBLE 15MG 5 ST ABILIFY MAINTENA INJECTION 300MG 5 ST ABILIFY INJECTION 9.75MG/1.3ML 4 ST ABILIFY SOLUTION 1MG/ML 4 ST ABILIFY TABLET 10MG 5 QL (30 EA per 30 days) ST



ABILIFY TABLET 15MG 5 QL (30 EA per 30 days) ST ABILIFY TABLET 20MG 5 QL (30 EA per 30 days) ST ABILIFY TABLET 2MG 5 QL (30 EA per 30 days) ST ABILIFY TABLET 30MG 5 QL (30 EA per 30 days) ST ABILIFY TABLET 5MG 5 QL (30 EA per 30 days) ST FANAPT TABLET 10MG 4 ST FANAPT TABLET 12MG 4 ST FANAPT TABLET 1MG 4 ST FANAPT TABLET 2MG 4 ST FANAPT TABLET 4MG 4 ST FANAPT TABLET 6MG 4 ST FANAPT TABLET 8MG 4 ST GEODON INJECTION 20MG 3 INVEGA SUSTENNA INJECTION 117MG/0.75ML 5 ST INVEGA SUSTENNA INJECTION 156MG/ML 5 ST INVEGA SUSTENNA INJECTION 234MG/1.5ML 5 ST INVEGA SUSTENNA INJECTION 39MG/0.25ML 4 ST INVEGA SUSTENNA INJECTION 78MG/0.5ML 4 ST INVEGA TABLET EXTENDED RELEASE 24 HOUR 1.5MG

4 ST

INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG

4 ST


4 ST


4 ST

LATUDA TABLET 120MG 5 ST LATUDA TABLET 20MG 4 ST LATUDA TABLET 40MG 4 ST LATUDA TABLET 60MG 4 ST LATUDA TABLET 80MG 4 ST olanzapine odt tablet dispersible 10mg 4 QL (30 EA per 30 days) olanzapine odt tablet dispersible 15mg 4 QL (30 EA per 30 days) olanzapine odt tablet dispersible 20mg 4 QL (30 EA per 30 days) olanzapine odt tablet dispersible 5mg 4 QL (30 EA per 30 days) olanzapine injection 10mg 2 GC olanzapine tablet 10mg 2 GC olanzapine tablet 15mg 2 GC olanzapine tablet 2.5mg 2 GC olanzapine tablet 20mg 2 GC olanzapine tablet 5mg 2 GC olanzapine tablet 7.5mg 2 GC quetiapine fumarate tablet 100mg 2 GC quetiapine fumarate tablet 200mg 2 GC quetiapine fumarate tablet 25mg 2 GC quetiapine fumarate tablet 300mg 2 GC



quetiapine fumarate tablet 400mg 2 GC quetiapine fumarate tablet 50mg 2 GC RISPERDAL CONSTA INJECTION 25MG 4 RISPERDAL CONSTA INJECTION 37.5MG 5 RISPERDAL CONSTA INJECTION 50MG 5 risperidone odt tablet dispersible 0.5mg 4 risperidone odt tablet dispersible 1mg 4 risperidone odt tablet dispersible 2mg 4 risperidone odt tablet dispersible 3mg 4 risperidone odt tablet dispersible 4mg 4 risperidone solution 1mg/ml 2 GC risperidone tablet 0.25mg 2 GC risperidone tablet 0.5mg 2 GC risperidone tablet 1mg 2 GC risperidone tablet 2mg 2 GC risperidone tablet 3mg 2 GC risperidone tablet 4mg 2 GC SAPHRIS TABLET SUBLINGUAL 10MG 4 ST SAPHRIS TABLET SUBLINGUAL 5MG 4 ST ziprasidone hcl capsule 20mg 2 GC ziprasidone hcl capsule 40mg 2 GC ziprasidone hcl capsule 60mg 2 GC ziprasidone hcl capsule 80mg 2 GC

Treatment-Resistant clozapine tablet 100mg 2 GC clozapine tablet 200mg 2 GC clozapine tablet 25mg 2 GC clozapine tablet 50mg 2 GC FAZACLO TABLET DISPERSIBLE 100MG 4 FAZACLO TABLET DISPERSIBLE 12.5MG 4 FAZACLO TABLET DISPERSIBLE 150MG 4 FAZACLO TABLET DISPERSIBLE 200MG 4 FAZACLO TABLET DISPERSIBLE 25MG 4 VERSACLOZ SUSPENSION 50MG/ML 4

Agentes antiespasticidad Antispasticity Agents

baclofen tablet 10mg 2 GC baclofen tablet 20mg 2 GC tizanidine hcl tablet 2mg 2 GC tizanidine hcl tablet 4mg 2 GC

Antivirales Anti-cytomegalovirus (CMV) Agents

cidofovir injection 75mg/ml 5 ganciclovir injection 500mg 2 GC VALCYTE SOLUTION RECONSTITUTED 50MG/ML

5



VALCYTE TABLET 450MG 5 Anti-hepatitis B (HBV) Agents

adefovir dipivoxil tablet 10mg 5 BARACLUDE TABLET 0.5MG 3 BARACLUDE TABLET 1MG 5 INTRON-A W/DILUENT INJECTION 10MU 4 INTRON-A INJECTION 6000000UNIT/ML 4 TYZEKA TABLET 600MG 5

Anti-hepatitis C (HCV) Agents INCIVEK TABLET 375MG 5 QL (180 EA per 30 days) PA INFERGEN INJECTION 15MCG/0.5ML 5 moderiba tablet 200mg 2 GC OLYSIO CAPSULE 150MG 5 QL (30 EA per 30 days) PA

LA PEG-INTRON REDIPEN INJECTION 120MCG/0.5ML

5

PEG-INTRON REDIPEN INJECTION 150MCG/0.5ML

5


5


5

PEG-INTRON INJECTION 50MCG/0.5ML 5 PEGASYS PROCLICK INJECTION 135MCG/0.5ML 5 PEGASYS INJECTION 180MCG/0.5ML 5 PEGASYS INJECTION 180MCG/0.5ML 5 ribavirin capsule 200mg 2 GC ribavirin tablet 200mg 2 GC SOVALDI TABLET 400MG 5 QL (30 EA per 30 days) PA

LA VICTRELIS CAPSULE 200MG 5 QL (360 EA per 30 days) PA VIRAZOLE SOLUTION RECONSTITUTED 6GM 5

Anti-HIV Agents, Integrase Inhibitors (INSTI) ISENTRESS TABLET CHEWABLE 100MG 3 ISENTRESS TABLET CHEWABLE 25MG 3 ISENTRESS TABLET 400MG 5 TIVICAY TABLET 50MG 5

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA TABLET 200MG; 25MG; 300MG 5 EDURANT TABLET 25MG 5 INTELENCE TABLET 100MG 5 INTELENCE TABLET 200MG 5 INTELENCE TABLET 25MG 4 nevirapine er tablet extended release 24 hour 400mg

4



NEVIRAPINE SUSPENSION 50MG/5ML 4 nevirapine tablet 200mg 2 GC RESCRIPTOR TABLET 100MG 3 RESCRIPTOR TABLET 200MG 3 STRIBILD TABLET 150MG; 150MG; 200MG; 300MG

5

SUSTIVA CAPSULE 200MG 3 SUSTIVA CAPSULE 50MG 3 SUSTIVA TABLET 600MG 3 VIRAMUNE XR TABLET EXTENDED RELEASE 24 HOUR 100MG

4

VIRAMUNE SUSPENSION 50MG/5ML 4 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sulfate/lamivudine/zidovudine tablet 300mg; 150mg; 300mg

5

abacavir tablet 300mg 2 GC didanosine capsule delayed release 125mg 2 GC didanosine capsule delayed release 200mg 2 GC didanosine capsule delayed release 250mg 2 GC didanosine capsule delayed release 400mg 2 GC EMTRIVA CAPSULE 200MG 4 EMTRIVA SOLUTION 10MG/ML 4 EPIVIR HBV SOLUTION 5MG/ML 3 EPIVIR SOLUTION 10MG/ML 3 EPZICOM TABLET 600MG; 300MG 5 lamivudine/zidovudine tablet 150mg; 300mg 5 LAMIVUDINE TABLET 100MG 3 lamivudine tablet 150mg 2 GC lamivudine tablet 300mg 2 GC RETROVIR IV INFUSION INJECTION 10MG/ML 4 stavudine capsule 15mg 2 GC stavudine capsule 20mg 2 GC stavudine capsule 30mg 2 GC stavudine capsule 40mg 2 GC stavudine solution reconstituted 1mg/ml 2 GC TRUVADA TABLET 200MG; 300MG 5 VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM

3

VIREAD POWDER 40MG/GM 5 VIREAD TABLET 150MG 5 VIREAD TABLET 200MG 5 VIREAD TABLET 250MG 5 VIREAD TABLET 300MG 5 ZIAGEN SOLUTION 20MG/ML 4 zidovudine capsule 100mg 2 GC



zidovudine syrup 50mg/5ml 2 GC zidovudine tablet 300mg 2 GC

Anti-HIV Agents, Other FUZEON INJECTION 90MG 5 SELZENTRY TABLET 150MG 5 SELZENTRY TABLET 300MG 5

Anti-HIV Agents, Protease Inhibitors APTIVUS CAPSULE 250MG 5 APTIVUS SOLUTION 100MG/ML 5 CRIXIVAN CAPSULE 200MG 3 CRIXIVAN CAPSULE 400MG 3 INVIRASE CAPSULE 200MG 4 INVIRASE TABLET 500MG 5 KALETRA SOLUTION 400MG/5ML; 100MG/5ML 5 KALETRA TABLET 100MG; 25MG 4 KALETRA TABLET 200MG; 50MG 5 LEXIVA SUSPENSION 50MG/ML 4 LEXIVA TABLET 700MG 5 NORVIR CAPSULE 100MG 4 NORVIR SOLUTION 80MG/ML 4 NORVIR TABLET 100MG 4 PREZISTA SUSPENSION 100MG/ML 5 PREZISTA TABLET 150MG 4 PREZISTA TABLET 400MG 5 PREZISTA TABLET 600MG 5 PREZISTA TABLET 75MG 4 PREZISTA TABLET 800MG 5 REYATAZ CAPSULE 100MG 4 REYATAZ CAPSULE 150MG 5 REYATAZ CAPSULE 200MG 5 REYATAZ CAPSULE 300MG 5 VIRACEPT TABLET 250MG 5 VIRACEPT TABLET 625MG 5

Anti-influenza Agents amantadine hcl capsule 100mg 2 GC AMANTADINE HCL TABLET 100MG 3 RELENZA DISKHALER AEROSOL POWDER BREATH ACTIVATED 5MG/BLISTER

4

rimantadine hcl tablet 100mg 2 GC TAMIFLU CAPSULE 30MG 4 QL (56 EA per 180 days) TAMIFLU CAPSULE 45MG 4 QL (28 EA per 180 days) TAMIFLU CAPSULE 75MG 4 QL (28 EA per 180 days) TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML

4 QL (360 ML per 180 days)

Antiherpetic Agents acyclovir sodium injection 50mg/ml 2 GC



acyclovir capsule 200mg 2 GC acyclovir ointment 5% 4 QL (30 GM per 30 days) acyclovir suspension 200mg/5ml 2 GC acyclovir tablet 400mg 2 GC acyclovir tablet 800mg 2 GC DENAVIR CREAM 1% 4 QL (1.5 GM per 30 days) famciclovir tablet 125mg 2 GC famciclovir tablet 250mg 2 GC famciclovir tablet 500mg 2 GC trifluridine solution 1% 2 GC valacyclovir hcl tablet 1000mg 4 valacyclovir hcl tablet 500mg 4 ZOVIRAX CREAM 5% 3 QL (5 GM per 30 days)

Antivirals ATRIPLA TABLET 600MG; 200MG; 300MG 5

Ansiolíticos Anxiolytics, Other

buspirone hcl tablet 10mg 2 GC buspirone hcl tablet 15mg 2 GC buspirone hcl tablet 30mg 2 GC buspirone hcl tablet 5mg 2 GC buspirone hcl tablet 7.5mg 2 GC diazepam tablet 5mg 2 QL (120 EA per 30 days) GC

Benzodiazepines alprazolam tablet 0.25mg 2 QL (90 EA per 30 days) GC alprazolam tablet 0.5mg 2 QL (90 EA per 30 days) GC alprazolam tablet 1mg 2 QL (90 EA per 30 days) GC alprazolam tablet 2mg 2 QL (150 EA per 30 days) GC chlordiazepoxide hcl capsule 10mg 2 QL (120 EA per 30 days) GC chlordiazepoxide hcl capsule 25mg 2 QL (120 EA per 30 days) GC chlordiazepoxide hcl capsule 5mg 2 QL (120 EA per 30 days) GC clorazepate dipotassium tablet 15mg 2 QL (180 EA per 30 days) GC clorazepate dipotassium tablet 3.75mg 2 QL (180 EA per 30 days) GC clorazepate dipotassium tablet 7.5mg 2 QL (180 EA per 30 days) GC DIAZEPAM INTENSOL CONCENTRATE 5MG/ML 4 diazepam solution 1mg/ml 4 QL (1200 ML per 30 days) diazepam tablet 10mg 2 QL (120 EA per 30 days) GC diazepam tablet 2mg 2 QL (120 EA per 30 days) GC flurazepam hcl capsule 15mg 2 QL (30 EA per 30 days) GC flurazepam hcl capsule 30mg 2 QL (30 EA per 30 days) GC lorazepam tablet 0.5mg 2 QL (90 EA per 30 days) GC lorazepam tablet 1mg 2 QL (90 EA per 30 days) GC lorazepam tablet 2mg 2 QL (90 EA per 30 days) GC temazepam capsule 15mg 2 QL (30 EA per 30 days) GC temazepam capsule 30mg 2 QL (30 EA per 30 days) GC triazolam tablet 0.125mg 2 QL (60 EA per 30 days) GC



triazolam tablet 0.25mg 2 QL (60 EA per 30 days) GC Agentes contra la bipolaridad

Mood Stabilizers lithium carbonate er tablet extended release 300mg 2 GC lithium carbonate er tablet extended release 450mg 2 GC lithium carbonate capsule 150mg 2 GC lithium carbonate capsule 300mg 2 GC LITHIUM CITRATE SOLUTION 8MEQ/5ML 3

Reguladores de glucosa en la sangre Antidiabetic Agents

acarbose tablet 100mg 2 GC acarbose tablet 25mg 2 GC acarbose tablet 50mg 2 GC AVANDAMET TABLET 1000MG; 2MG 4 QL (60 EA per 30 days) AVANDAMET TABLET 1000MG; 4MG 4 QL (60 EA per 30 days) AVANDAMET TABLET 500MG; 2MG 4 QL (60 EA per 30 days) AVANDAMET TABLET 500MG; 4MG 4 QL (60 EA per 30 days) AVANDIA TABLET 2MG 4 QL (30 EA per 30 days) AVANDIA TABLET 4MG 4 QL (30 EA per 30 days) AVANDIA TABLET 8MG 4 QL (30 EA per 30 days) BYDUREON INJECTION 2MG 4 BYETTA INJECTION 10MCG/0.04ML 3 ST BYETTA INJECTION 5MCG/0.02ML 3 ST CYCLOSET TABLET 0.8MG 4 glimepiride tablet 1mg 1 QL (30 EA per 30 days) GC glimepiride tablet 2mg 1 QL (30 EA per 30 days) GC glimepiride tablet 4mg 1 QL (60 EA per 30 days) GC glipizide er tablet extended release 24 hour 10mg 1 QL (60 EA per 30 days) GC glipizide er tablet extended release 24 hour 2.5mg 1 QL (60 EA per 30 days) GC glipizide er tablet extended release 24 hour 5mg 1 QL (60 EA per 30 days) GC glipizide/metformin hcl tablet 2.5mg; 250mg 1 QL (120 EA per 30 days) GC glipizide/metformin hcl tablet 2.5mg; 500mg 1 QL (120 EA per 30 days) GC glipizide/metformin hcl tablet 5mg; 500mg 1 QL (120 EA per 30 days) GC glipizide tablet 10mg 1 QL (120 EA per 30 days) GC glipizide tablet 5mg 1 QL (60 EA per 30 days) GC JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 100MG


JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 50MG


JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 500MG; 50MG


JANUMET TABLET 1000MG; 50MG 3 QL (60 EA per 30 days) JANUMET TABLET 500MG; 50MG 3 QL (30 EA per 30 days) JANUVIA TABLET 100MG 3 QL (30 EA per 30 days) JANUVIA TABLET 25MG 3 QL (30 EA per 30 days) JANUVIA TABLET 50MG 3 QL (30 EA per 30 days)



metformin hcl er tablet extended release 24 hour 500mg


metformin hcl er tablet extended release 24 hour 750mg


metformin hcl tablet 1000mg 1 QL (60 EA per 30 days) GC metformin hcl tablet 500mg 1 QL (120 EA per 30 days) GC metformin hcl tablet 850mg 1 QL (90 EA per 30 days) GC nateglinide tablet 120mg 2 GC nateglinide tablet 60mg 2 GC PIOGLITAZONE HCL-GLIMEPIRIDE TABLET 2MG; 30MG


PIOGLITAZONE HCL-GLIMEPIRIDE TABLET 4MG; 30MG


pioglitazone hcl/metformin hcl tablet 500mg; 15mg 4 QL (90 EA per 30 days) pioglitazone hcl/metformin hcl tablet 850mg; 15mg 4 QL (90 EA per 30 days) pioglitazone hcl tablet 15mg 2 QL (30 EA per 30 days) GC pioglitazone hcl tablet 30mg 2 QL (30 EA per 30 days) GC pioglitazone hcl tablet 45mg 2 QL (30 EA per 30 days) GC PRANDIMET TABLET 500MG; 1MG 3 QL (150 EA per 30 days) PRANDIMET TABLET 500MG; 2MG 3 QL (150 EA per 30 days) REPAGLINIDE TABLET 0.5MG 3 REPAGLINIDE TABLET 1MG 3 REPAGLINIDE TABLET 2MG 3 SYMLINPEN 120 INJECTION 2700MCG/2.7ML 4 SYMLINPEN 60 INJECTION 1500MCG/1.5ML 4 TOLBUTAMIDE TABLET 500MG 3 TRADJENTA TABLET 5MG 4 QL (30 EA per 30 days) ST VICTOZA INJECTION 18MG/3ML 3 ST

Glycemic Agents CLINIMIX E 4.25%/DEXTROSE 25% INJECTION 880MG/100ML; 489MG/100ML; 33MG/100ML;25GM/100ML; 204MG/100ML; 255MG/100ML;311MG/100ML; 247MG/100ML; 51MG/100ML;170MG/100ML; 702MG/100ML; 238MG/100ML;261MG/100ML; 289MG/100ML; 213MG/100ML;297MG/100ML; 77MG/100ML; 179MG/100ML;77MG/100ML; 17MG/100ML; 247MG/100ML

4

dextrose 10% flex container injection 10% 2 GC DEXTROSE 10%/NACL 0.2% INJECTION 10%;0.2%

3

dextrose 2.5%/sodium chloride 0.45% injection 2.5%; 0.45%

2 GC

dextrose 5%/nacl 0.2% injection 5%; 0.2% 2 GC dextrose 5%/nacl 0.33% injection 5%; 0.33% 2 GC dextrose 5%/nacl 0.45% injection 5%; 0.45% 2 GC dextrose 5%/nacl 0.9% injection 5%; 0.9% 2 GC



dextrose 5% injection 5% 2 GC GLUCAGON EMERGENCY KIT INJECTION 1MG 3 PROGLYCEM SUSPENSION 50MG/ML 4

Insulins HUMALOG MIX 50/50 KWIKPEN INJECTION 50UNIT/ML; 50UNIT/ML


HUMALOG MIX 50/50 INJECTION 50UNIT/ML; 50UNIT/ML


HUMALOG MIX 75/25 KWIKPEN INJECTION 25UNIT/ML; 75UNIT/ML


HUMALOG MIX 75/25 INJECTION 25UNIT/ML; 75UNIT/ML


HUMALOG INJECTION 100UNIT/ML 4 QL (45 ML per 30 days) HUMALOG INJECTION 100UNIT/ML 4 QL (50 ML per 30 days) HUMULIN 70/30 PEN INJECTION 30UNIT/ML; 70UNIT/ML


HUMULIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML


HUMULIN N U-100 PEN INJECTION 100UNIT/ML 4 QL (45 ML per 30 days) HUMULIN N INJECTION 100UNIT/ML 4 QL (50 ML per 30 days) HUMULIN R U-500 (CONCENTRATED) INJECTION 500UNIT/ML

4

HUMULIN R INJECTION 100UNIT/ML 4 QL (50 ML per 30 days) LANTUS SOLOSTAR INJECTION 100UNIT/ML 3 QL (45 ML per 30 days) LANTUS INJECTION 100UNIT/ML 3 QL (50 ML per 30 days) LEVEMIR FLEXPEN INJECTION 100UNIT/ML 3 QL (45 ML per 30 days) LEVEMIR INJECTION 100UNIT/ML 3 QL (50 ML per 30 days) NOVOLIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML


NOVOLIN N INJECTION 100UNIT/ML 3 QL (50 ML per 30 days) NOVOLIN R INJECTION 100UNIT/ML 3 QL (50 ML per 30 days) NOVOLOG MIX 70/30 PREFILLED FLEXPEN INJECTION 30UNIT/ML; 70UNIT/ML


NOVOLOG MIX 70/30 INJECTION 30UNIT/ML; 70UNIT/ML


NOVOLOG PENFILL INJECTION 100UNIT/ML 3 QL (45 ML per 30 days) NOVOLOG INJECTION 100UNIT/ML 3 QL (50 ML per 30 days)

Productos para la sangre/Modificadores/Expansores de volumen

Anticoagulants COUMADIN TABLET 10MG 3 COUMADIN TABLET 1MG 3 COUMADIN TABLET 2.5MG 3 COUMADIN TABLET 2MG 3 COUMADIN TABLET 3MG 3 COUMADIN TABLET 4MG 3 COUMADIN TABLET 5MG 3



COUMADIN TABLET 6MG 3 COUMADIN TABLET 7.5MG 3 enoxaparin sodium injection 100mg/ml 2 GC enoxaparin sodium injection 120mg/0.8ml 2 GC enoxaparin sodium injection 150mg/ml 2 GC enoxaparin sodium injection 30mg/0.3ml 2 GC enoxaparin sodium injection 40mg/0.4ml 2 GC enoxaparin sodium injection 60mg/0.6ml 2 GC enoxaparin sodium injection 80mg/0.8ml 2 GC fondaparinux sodium injection 10mg/0.8ml 4 fondaparinux sodium injection 2.5mg/0.5ml 4 fondaparinux sodium injection 5mg/0.4ml 4 fondaparinux sodium injection 7.5mg/0.6ml 4 FRAGMIN INJECTION 10000UNIT/ML 4 FRAGMIN INJECTION 12500UNIT/0.5ML 4 FRAGMIN INJECTION 15000UNIT/0.6ML 4 FRAGMIN INJECTION 18000UNT/0.72ML 4 FRAGMIN INJECTION 25000UNIT/ML 4 FRAGMIN INJECTION 2500UNIT/0.2ML 4 FRAGMIN INJECTION 5000UNIT/0.2ML 4 FRAGMIN INJECTION 7500UNIT/0.3ML 4 HEPARIN SODIUM/D5W INJECTION 5%; 100UNIT/ML

3

HEPARIN SODIUM/D5W INJECTION 5%; 50UNIT/ML

3

heparin sodium/nacl 0.9% injection 2unit/ml; 0.9% 2 GC heparin sodium injection 10000unit/ml 2 GC heparin sodium injection 1000unit/ml 2 GC heparin sodium injection 20000unit/ml 2 GC heparin sodium injection 5000unit/ml 2 GC PRADAXA CAPSULE 150MG 4 QL (60 EA per 30 days) PA PRADAXA CAPSULE 75MG 4 QL (60 EA per 30 days) PA warfarin sodium tablet 10mg 1 GC warfarin sodium tablet 1mg 1 GC warfarin sodium tablet 2.5mg 1 GC warfarin sodium tablet 2mg 1 GC warfarin sodium tablet 3mg 1 GC warfarin sodium tablet 4mg 1 GC warfarin sodium tablet 5mg 1 GC warfarin sodium tablet 6mg 1 GC warfarin sodium tablet 7.5mg 1 GC XARELTO TABLET 10MG 4

Blood Formation Modifiers anagrelide hydrochloride capsule 0.5mg 2 GC anagrelide hydrochloride capsule 1mg 2 GC LEUKINE INJECTION 250MCG 5 PA



LEUKINE INJECTION 500MCG/ML 5 PA NEULASTA INJECTION 6MG/0.6ML 5 PA NEUMEGA INJECTION 5MG 5 PA NEUPOGEN INJECTION 300MCG/0.5ML 5 PA NEUPOGEN INJECTION 480MCG/0.8ML 5 PA NEUPOGEN INJECTION 480MCG/1.6ML 5 PA PROCRIT INJECTION 10000UNIT/ML 3 PA PROCRIT INJECTION 20000UNIT/ML 5 PA PROCRIT INJECTION 2000UNIT/ML 3 QL (15 ML per 30 days) PA PROCRIT INJECTION 3000UNIT/ML 3 QL (15 ML per 30 days) PA PROCRIT INJECTION 40000UNIT/ML 5 PA PROCRIT INJECTION 4000UNIT/ML 3 QL (15 ML per 30 days) PA PROMACTA TABLET 12.5MG 5 PA PROMACTA TABLET 25MG 5 PA PROMACTA TABLET 50MG 5 PA PROMACTA TABLET 75MG 5 PA

Coagulants aminocaproic acid syrup 25% 2 GC aminocaproic acid tablet 500mg 2 GC tranexamic acid injection 100mg/ml 2 GC tranexamic acid tablet 650mg 4

Platelet Modifying Agents AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR 25MG; 200MG

4

BRILINTA TABLET 90MG 3 PA cilostazol tablet 100mg 2 GC cilostazol tablet 50mg 2 GC clopidogrel tablet 75mg 2 GC dipyridamole tablet 25mg 2 GC dipyridamole tablet 50mg 2 GC dipyridamole tablet 75mg 2 GC EFFIENT TABLET 10MG 4 PA EFFIENT TABLET 5MG 4 PA ticlopidine hcl tablet 250mg 2 GC

Agentes cardiovasculares Alpha-adrenergic Agonists

clonidine hcl patch weekly 0.1mg/24hr 4 clonidine hcl patch weekly 0.2mg/24hr 4 clonidine hcl patch weekly 0.3mg/24hr 4 clonidine hcl tablet 0.1mg 2 GC clonidine hcl tablet 0.2mg 2 GC clonidine hcl tablet 0.3mg 2 GC guanfacine hcl tablet 1mg 2 GC guanfacine hcl tablet 2mg 2 GC midodrine hcl tablet 10mg 2 GC midodrine hcl tablet 2.5mg 2 GC



midodrine hcl tablet 5mg 2 GC Alpha-adrenergic Blocking Agents

doxazosin mesylate tablet 1mg 1 GC prazosin hcl capsule 1mg 1 GC prazosin hcl capsule 2mg 1 GC prazosin hcl capsule 5mg 1 GC

Angiotensin II Receptor Antagonists BENICAR HCT TABLET 12.5MG; 20MG 3 ST BENICAR HCT TABLET 12.5MG; 40MG 3 ST BENICAR HCT TABLET 25MG; 40MG 3 ST BENICAR TABLET 20MG 3 ST BENICAR TABLET 40MG 3 ST BENICAR TABLET 5MG 3 ST candesartan cilexetil tablet 16mg 4 ST candesartan cilexetil tablet 32mg 4 ST candesartan cilexetil tablet 4mg 4 ST candesartan cilexetil tablet 8mg 4 ST DIOVAN TABLET 160MG 4 ST DIOVAN TABLET 320MG 4 ST DIOVAN TABLET 40MG 4 ST DIOVAN TABLET 80MG 4 ST irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg

2 ST GC

irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg

2 ST GC

irbesartan tablet 150mg 2 ST GC irbesartan tablet 300mg 2 ST GC irbesartan tablet 75mg 2 ST GC losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg

2 GC

losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg

2 GC

losartan potassium/hydrochlorothiazide tablet 25mg; 100mg

2 GC

losartan potassium tablet 100mg 2 GC losartan potassium tablet 25mg 2 GC losartan potassium tablet 50mg 2 GC valsartan/hydrochlorothiazide tablet 12.5mg; 160mg 2 ST GC valsartan/hydrochlorothiazide tablet 12.5mg; 320mg 2 ST GC valsartan/hydrochlorothiazide tablet 12.5mg; 80mg 2 ST GC valsartan/hydrochlorothiazide tablet 25mg; 160mg 2 ST GC valsartan/hydrochlorothiazide tablet 25mg; 320mg 2 ST GC

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg

1 GC



benazepril hcl/hydrochlorothiazide tablet 20mg; 12.5mg

1 GC

benazepril hcl/hydrochlorothiazide tablet 20mg; 25mg

1 GC

benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg

1 GC

benazepril hcl tablet 10mg 1 GC benazepril hcl tablet 20mg 1 GC benazepril hcl tablet 40mg 1 GC benazepril hcl tablet 5mg 1 GC captopril/hydrochlorothiazide tablet 25mg; 15mg 1 GC captopril/hydrochlorothiazide tablet 25mg; 25mg 1 GC captopril/hydrochlorothiazide tablet 50mg; 15mg 1 GC captopril/hydrochlorothiazide tablet 50mg; 25mg 1 GC captopril tablet 100mg 1 GC captopril tablet 12.5mg 1 GC captopril tablet 25mg 1 GC captopril tablet 50mg 1 GC enalapril maleate/hydrochlorothiazide tablet 10mg; 25mg

1 GC

enalapril maleate/hydrochlorothiazide tablet 5mg; 12.5mg

1 GC

enalapril maleate tablet 10mg 1 GC enalapril maleate tablet 2.5mg 1 GC enalapril maleate tablet 20mg 1 GC enalapril maleate tablet 5mg 1 GC fosinopril sodium/hydrochlorothiazide tablet 10mg; 12.5mg

1 GC

fosinopril sodium/hydrochlorothiazide tablet 20mg; 12.5mg

1 GC

fosinopril sodium tablet 10mg 1 GC fosinopril sodium tablet 20mg 1 GC fosinopril sodium tablet 40mg 1 GC lisinopril/hydrochlorothiazide tablet 12.5mg; 10mg 1 GC lisinopril/hydrochlorothiazide tablet 12.5mg; 20mg 1 GC lisinopril/hydrochlorothiazide tablet 25mg; 20mg 1 GC lisinopril tablet 10mg 1 GC lisinopril tablet 2.5mg 1 GC lisinopril tablet 20mg 1 GC lisinopril tablet 30mg 1 GC lisinopril tablet 40mg 1 GC lisinopril tablet 5mg 1 GC moexipril hcl tablet 15mg 1 GC moexipril hcl tablet 7.5mg 1 GC moexipril/hydrochlorothiazide tablet 12.5mg; 15mg 1 GC moexipril/hydrochlorothiazide tablet 12.5mg; 7.5mg 1 GC



moexipril/hydrochlorothiazide tablet 25mg; 15mg 1 GC quinapril hcl tablet 10mg 1 GC quinapril hcl tablet 20mg 1 GC quinapril hcl tablet 40mg 1 GC quinapril hcl tablet 5mg 1 GC quinapril/hydrochlorothiazide tablet 12.5mg; 10mg 1 GC quinapril/hydrochlorothiazide tablet 12.5mg; 20mg 1 GC quinapril/hydrochlorothiazide tablet 25mg; 20mg 1 GC ramipril capsule 1.25mg 1 GC ramipril capsule 10mg 1 GC ramipril capsule 2.5mg 1 GC ramipril capsule 5mg 1 GC

Antiarrhythmics amiodarone hcl injection 50mg/ml 2 GC amiodarone hcl tablet 200mg 2 GC amiodarone hcl tablet 400mg 2 GC flecainide acetate tablet 100mg 2 GC flecainide acetate tablet 150mg 2 GC flecainide acetate tablet 50mg 2 GC MEXILETINE HCL CAPSULE 150MG 3 MEXILETINE HCL CAPSULE 200MG 3 MEXILETINE HCL CAPSULE 250MG 3 MULTAQ TABLET 400MG 4 PACERONE TABLET 100MG 4 propafenone hcl tablet 150mg 2 GC propafenone hcl tablet 225mg 2 GC propafenone hcl tablet 300mg 2 GC quinidine gluconate cr tablet extended release 324mg

2 GC

QUINIDINE SULFATE ER TABLET EXTENDED RELEASE 300MG

3

quinidine sulfate tablet 200mg 2 GC quinidine sulfate tablet 300mg 2 GC sotalol hcl (af) tablet 120mg 2 GC sotalol hcl tablet 120mg 2 GC sotalol hcl tablet 160mg 2 GC sotalol hcl tablet 240mg 2 GC sotalol hcl tablet 80mg 2 GC TIKOSYN CAPSULE 125MCG 3 TIKOSYN CAPSULE 250MCG 3 TIKOSYN CAPSULE 500MCG 3

Beta-adrenergic Blocking Agents acebutolol hcl capsule 200mg 2 GC acebutolol hcl capsule 400mg 2 GC atenolol/chlorthalidone tablet 100mg; 25mg 2 GC atenolol/chlorthalidone tablet 50mg; 25mg 2 GC



atenolol tablet 100mg 1 GC atenolol tablet 25mg 1 GC atenolol tablet 50mg 1 GC betaxolol hcl tablet 10mg 2 GC betaxolol hcl tablet 20mg 2 GC bisoprolol fumarate/hydrochlorothiazide tablet 10mg; 6.25mg

1 GC

bisoprolol fumarate/hydrochlorothiazide tablet 2.5mg; 6.25mg

1 GC

bisoprolol fumarate/hydrochlorothiazide tablet 5mg; 6.25mg

1 GC

bisoprolol fumarate tablet 10mg 2 GC bisoprolol fumarate tablet 5mg 2 GC BYSTOLIC TABLET 10MG 4 BYSTOLIC TABLET 2.5MG 4 BYSTOLIC TABLET 20MG 4 BYSTOLIC TABLET 5MG 4 carvedilol tablet 12.5mg 1 GC carvedilol tablet 25mg 1 GC carvedilol tablet 3.125mg 1 GC carvedilol tablet 6.25mg 1 GC labetalol hcl injection 5mg/ml 2 GC labetalol hcl tablet 100mg 2 GC labetalol hcl tablet 200mg 2 GC labetalol hcl tablet 300mg 2 GC metoprolol succinate er tablet extended release 24 hour 100mg

1 GC

metoprolol succinate er tablet extended release 24 hour 200mg

1 GC


1 GC


1 GC

metoprolol tartrate injection 1mg/ml 2 GC metoprolol tartrate tablet 100mg 1 GC metoprolol tartrate tablet 25mg 1 GC metoprolol tartrate tablet 50mg 1 GC metoprolol/hydrochlorothiazide tablet 25mg; 100mg 2 GC metoprolol/hydrochlorothiazide tablet 25mg; 50mg 2 GC METOPROLOL/HYDROCHLOROTHIAZIDE TABLET 50MG; 100MG

3

nadolol tablet 20mg 2 GC nadolol tablet 40mg 2 GC nadolol tablet 80mg 2 GC PINDOLOL TABLET 10MG 3 PINDOLOL TABLET 5MG 3



propranolol hcl er capsule extended release 24 hour 120mg

2 GC


2 GC


2 GC


2 GC

propranolol hcl injection 1mg/ml 2 GC PROPRANOLOL HCL SOLUTION 20MG/5ML 3 PROPRANOLOL HCL SOLUTION 40MG/5ML 3 propranolol hcl tablet 10mg 1 GC propranolol hcl tablet 20mg 1 GC propranolol hcl tablet 40mg 1 GC propranolol hcl tablet 60mg 1 GC propranolol hcl tablet 80mg 1 GC PROPRANOLOL/HYDROCHLOROTHIAZIDE TABLET 25MG; 40MG

3

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABLET 25MG; 80MG

3

TIMOLOL MALEATE TABLET 10MG 3 TIMOLOL MALEATE TABLET 20MG 3 TIMOLOL MALEATE TABLET 5MG 3

Calcium Channel Blocking Agents afeditab cr tablet extended release 24 hour 30mg 2 GC afeditab cr tablet extended release 24 hour 60mg 2 GC amlodipine besylate/benazepril hcl capsule 10mg; 40mg

2 GC

amlodipine besylate/benazepril hcl capsule 5mg; 40mg

2 GC

amlodipine besylate/benazepril hydrochloride capsule 10mg; 20mg

2 GC

amlodipine besylate/benazepril hydrochloride capsule 2.5mg; 10mg

2 GC


2 GC


2 GC

amlodipine besylate tablet 10mg 2 GC amlodipine besylate tablet 2.5mg 2 GC amlodipine besylate tablet 5mg 2 GC diltiazem cd capsule extended release 24 hour 120mg

2 GC

diltiazem cd capsule extended release 24 hour 180mg

2 GC



diltiazem cd capsule extended release 24 hour 240mg

2 GC

diltiazem hcl er capsule extended release 12 hour 120mg

2 GC


2 GC


2 GC


2 GC


2 GC


2 GC


2 GC


2 GC

diltiazem hcl injection 50mg/10ml 2 GC diltiazem hcl tablet 120mg 2 GC diltiazem hcl tablet 30mg 2 GC diltiazem hcl tablet 60mg 2 GC diltiazem hcl tablet 90mg 2 GC felodipine er tablet extended release 24 hour 10mg 2 GC felodipine er tablet extended release 24 hour 2.5mg 2 GC felodipine er tablet extended release 24 hour 5mg 2 GC nicardipine hcl capsule 20mg 2 GC nicardipine hcl capsule 30mg 2 GC nifediac cc tablet extended release 24 hour 90mg 2 GC nifedipine er tablet extended release 24 hour 30mg 2 GC nifedipine er tablet extended release 24 hour 60mg 2 GC nifedipine er tablet extended release 24 hour 90mg 2 GC nimodipine capsule 30mg 2 GC NISOLDIPINE TABLET EXTENDED RELEASE 24 HOUR 20MG

3

NISOLDIPINE TABLET EXTENDED RELEASE 24 HOUR 30MG

3

NISOLDIPINE TABLET EXTENDED RELEASE 24 HOUR 40MG

3

taztia xt capsule extended release 24 hour 120mg 2 GC taztia xt capsule extended release 24 hour 180mg 2 GC taztia xt capsule extended release 24 hour 240mg 2 GC taztia xt capsule extended release 24 hour 300mg 2 GC taztia xt capsule extended release 24 hour 360mg 2 GC verapamil hcl er capsule extended release 24 hour 100mg

2 GC



verapamil hcl er capsule extended release 24 hour 120mg

2 GC


2 GC


2 GC


2 GC


2 GC

verapamil hcl er tablet extended release 120mg 2 GC verapamil hcl er tablet extended release 180mg 2 GC verapamil hcl er tablet extended release 240mg 2 GC verapamil hcl sr capsule extended release 24 hour 360mg

2 GC

verapamil hcl tablet 120mg 2 GC verapamil hcl tablet 40mg 2 GC verapamil hcl tablet 80mg 2 GC

Cardiovascular Agents, Other DEMSER CAPSULE 250MG 5 digoxin solution 0.05mg/ml 1 GC digoxin tablet 125mcg 1 GC digoxin tablet 250mcg 1 GC pentoxifylline er tablet extended release 400mg 2 GC RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000MG

3 ST

RANEXA TABLET EXTENDED RELEASE 12 HOUR 500MG

3 ST

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide tablet 125mg 2 GC acetazolamide tablet 250mg 2 GC

Diuretics, Loop bumetanide injection 0.25mg/ml 2 GC bumetanide tablet 0.5mg 2 GC bumetanide tablet 1mg 2 GC bumetanide tablet 2mg 2 GC EDECRIN TABLET 25MG 3 furosemide injection 10mg/ml 2 GC FUROSEMIDE SOLUTION 8MG/ML 3 furosemide tablet 20mg 1 GC furosemide tablet 40mg 1 GC furosemide tablet 80mg 1 GC SODIUM EDECRIN INJECTION 50MG 3 torsemide tablet 100mg 2 GC torsemide tablet 10mg 2 GC torsemide tablet 20mg 2 GC



torsemide tablet 5mg 2 GC Diuretics, Potassium-sparing

ALDACTAZIDE TABLET 50MG; 50MG 4 amiloride hcl tablet 5mg 2 GC amiloride/hydrochlorothiazide tablet 5mg; 50mg 2 GC DYRENIUM CAPSULE 100MG 3 DYRENIUM CAPSULE 50MG 3 eplerenone tablet 25mg 2 GC eplerenone tablet 50mg 2 GC spironolactone/hydrochlorothiazide tablet 25mg; 25mg

2 GC

spironolactone tablet 100mg 1 GC spironolactone tablet 25mg 1 GC spironolactone tablet 50mg 1 GC triamterene/hydrochlorothiazide capsule 25mg; 37.5mg

2 GC

triamterene/hydrochlorothiazide capsule 25mg; 50mg

2 GC

triamterene/hydrochlorothiazide tablet 25mg; 37.5mg

2 GC

triamterene/hydrochlorothiazide tablet 50mg; 75mg 2 GC Diuretics, Thiazide

candesartan cilexetil/hydrochlorothiazide tablet 16mg; 12.5mg

4 ST

candesartan cilexetil/hydrochlorothiazide tablet 32mg; 12.5mg

4 ST

candesartan cilexetil/hydrochlorothiazide tablet 32mg; 25mg

4 ST

chlorothiazide tablet 250mg 2 GC chlorothiazide tablet 500mg 2 GC chlorthalidone tablet 25mg 2 GC chlorthalidone tablet 50mg 2 GC hydrochlorothiazide capsule 12.5mg 1 GC hydrochlorothiazide tablet 25mg 1 GC hydrochlorothiazide tablet 50mg 1 GC indapamide tablet 1.25mg 2 GC indapamide tablet 2.5mg 2 GC METHYCLOTHIAZIDE TABLET 5MG 3 metolazone tablet 10mg 2 GC metolazone tablet 2.5mg 2 GC metolazone tablet 5mg 2 GC

Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized capsule 134mg 2 GC fenofibrate micronized capsule 200mg 2 GC fenofibrate micronized capsule 67mg 2 GC fenofibrate tablet 160mg 2 GC



fenofibrate tablet 54mg 2 GC gemfibrozil tablet 600mg 2 GC

Dyslipidemics, HMG CoA Reductase Inhibitors ADVICOR TABLET EXTENDED RELEASE 24 HOUR 20MG; 1000MG

3

ADVICOR TABLET EXTENDED RELEASE 24 HOUR 20MG; 500MG

3


3


3

atorvastatin calcium tablet 10mg 2 GC atorvastatin calcium tablet 20mg 2 GC atorvastatin calcium tablet 40mg 2 GC atorvastatin calcium tablet 80mg 2 GC CRESTOR TABLET 40MG 3 lovastatin tablet 10mg 1 GC lovastatin tablet 20mg 1 GC lovastatin tablet 40mg 1 GC pravastatin sodium tablet 10mg 1 GC pravastatin sodium tablet 20mg 1 GC pravastatin sodium tablet 40mg 1 GC pravastatin sodium tablet 80mg 1 GC simvastatin tablet 10mg 1 GC simvastatin tablet 20mg 1 GC simvastatin tablet 40mg 1 GC simvastatin tablet 5mg 1 GC simvastatin tablet 80mg 1 GC

Dyslipidemics, Other cholestyramine light packet 4gm 2 GC cholestyramine light powder 4gm/dose 2 GC cholestyramine packet 4gm 2 GC cholestyramine powder 4gm/dose 2 GC colestipol hcl for oral suspension packet 5gm 2 GC colestipol hcl granules 5gm 2 GC colestipol hcl tablet 1gm 2 GC LOVAZA CAPSULE 375MG; 465MG; 1GM 4 niacin er tablet extended release 1000mg 4 niacin er tablet extended release 500mg 4 niacin er tablet extended release 750mg 4 prevalite packet 4gm 2 GC prevalite powder 4gm/dose 2 GC VASCEPA CAPSULE 1GM 4 QL (120 EA per 30 days) VYTORIN TABLET 10MG; 10MG 3 ST VYTORIN TABLET 10MG; 20MG 3 ST VYTORIN TABLET 10MG; 40MG 3 ST



VYTORIN TABLET 10MG; 80MG 3 ST WELCHOL PACKET 3.75GM 3 WELCHOL TABLET 625MG 3 ZETIA TABLET 10MG 3

Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate er tablet extended release 40mg 2 GC isosorbide dinitrate tablet sublingual 2.5mg 2 GC isosorbide dinitrate tablet 10mg 2 GC isosorbide dinitrate tablet 20mg 2 GC isosorbide dinitrate tablet 30mg 2 GC isosorbide dinitrate tablet 5mg 2 GC isosorbide mononitrate er tablet extended release 24 hour 120mg

2 GC

isosorbide mononitrate er tablet extended release 24 hour 30mg

2 GC

isosorbide mononitrate er tablet extended release 24 hour 60mg

2 GC

isosorbide mononitrate tablet 10mg 2 GC isosorbide mononitrate tablet 20mg 2 GC NITRO-BID OINTMENT 2% 3 nitroglycerin transdermal patch 24 hour 0.1mg/hr 2 GC NITROGLYCERIN INJECTION 5MG/ML 3 nitroglycerin patch 24 hour 0.2mg/hr 2 GC nitroglycerin patch 24 hour 0.4mg/hr 2 GC nitroglycerin patch 24 hour 0.6mg/hr 2 GC nitrostat tablet sublingual 0.3mg 1 GC nitrostat tablet sublingual 0.4mg 1 GC nitrostat tablet sublingual 0.6mg 1 GC

Vasodilators, Direct-acting Arterial hydralazine hcl injection 20mg/ml 2 GC hydralazine hcl tablet 100mg 2 GC hydralazine hcl tablet 10mg 2 GC hydralazine hcl tablet 25mg 2 GC hydralazine hcl tablet 50mg 2 GC minoxidil tablet 10mg 2 GC minoxidil tablet 2.5mg 2 GC

Agentes para el sistema nervioso central Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine/dextroamphetamine capsule extended release 24 hour 1.25mg; 1.25mg; 1.25mg; 1.25mg








amphetamine/dextroamphetamine capsule extended release 24 hour 5mg; 5mg; 5mg; 5mg






amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 1.25mg; 1.25mg










amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg




dextroamphetamine sulfate er capsule extended release 24 hour 10mg

2 GC


2 GC


2 GC

DEXTROAMPHETAMINE SULFATE TABLET 10MG


dextroamphetamine sulfate tablet 5mg 2 QL (180 EA per 30 days) GC VYVANSE CAPSULE 20MG 4 QL (30 EA per 30 days) VYVANSE CAPSULE 30MG 4 QL (30 EA per 30 days) VYVANSE CAPSULE 40MG 4 QL (30 EA per 30 days) VYVANSE CAPSULE 50MG 4 QL (30 EA per 30 days) VYVANSE CAPSULE 60MG 4 QL (30 EA per 30 days) VYVANSE CAPSULE 70MG 4 QL (30 EA per 30 days)

Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines

INTUNIV TABLET EXTENDED RELEASE 24 HOUR 1MG

4


4


4


4

methylphenidate hcl cd capsule extended release 10mg














methylphenidate hcl er tablet extended release 10mg

2 GC


2 GC


2 GC


2 GC


2 GC


2 GC

methylphenidate hcl tablet 10mg 2 QL (90 EA per 30 days) GC methylphenidate hcl tablet 20mg 2 QL (90 EA per 30 days) GC methylphenidate hcl tablet 5mg 2 QL (90 EA per 30 days) GC STRATTERA CAPSULE 100MG 3 STRATTERA CAPSULE 10MG 3 STRATTERA CAPSULE 18MG 3 STRATTERA CAPSULE 25MG 3 STRATTERA CAPSULE 40MG 3 STRATTERA CAPSULE 60MG 3 STRATTERA CAPSULE 80MG 3

Central Nervous System, Other NUEDEXTA CAPSULE 20MG; 10MG 4 riluzole tablet 50mg 2 GC XENAZINE TABLET 12.5MG 5 PA XENAZINE TABLET 25MG 5 PA

Multiple Sclerosis Agents AVONEX PEN INJECTION 30MCG/0.5ML 5 AVONEX INJECTION 30MCG/0.5ML 5 AVONEX INJECTION 30MCG/VIAL 5 COPAXONE INJECTION 20MG/ML 5 EXTAVIA INJECTION 0.3MG 5 PA TYSABRI INJECTION 300MG/15ML 5 PA

Agentes dentales y bucales Dental and Oral Agents



chlorhexidine gluconate oral rinse solution 0.12% 2 GC pilocarpine hydrochloride tablet 5mg 2 GC triamcinolone in orabase paste 0.1% 2 GC

Agentes dermatológicos Dermatological Agents

acitretin capsule 10mg 5 acitretin capsule 17.5mg 5 acitretin capsule 25mg 5 adapalene cream 0.1% 4 adapalene gel 0.1% 4 ammonium lactate lotion 12% 2 GC AZELEX CREAM 20% 3 calcipotriene cream 0.005% 4 calcipotriene solution 0.005% 4 CARAC CREAM 0.5% 3 claravis capsule 10mg 4 claravis capsule 20mg 4 CLARAVIS CAPSULE 30MG 4 claravis capsule 40mg 4 clindamycin phosphate gel 1% 2 GC clindamycin phosphate solution 1% 2 GC clindamycin/benzoyl peroxide gel 5%; 1% 2 GC curity gauze pads 2"x2" pad 2 GC erythromycin/benzoyl peroxide gel 5%; 3% 2 GC FINACEA GEL 15% 3 FLUOROPLEX CREAM 1% 4 fluorouracil cream 5% 4 fluorouracil solution 2% 2 GC fluorouracil solution 5% 2 GC imiquimod cream 5% 4 OXSORALEN ULTRA CAPSULE 10MG 4 OXSORALEN LOTION 1% 4 podofilox solution 0.5% 2 GC PROTOPIC OINTMENT 0.03% 4 QL (100 GM per 60 days) ST PROTOPIC OINTMENT 0.1% 4 QL (120 GM per 60 days) ST PRUDOXIN CREAM 5% 4 REGRANEX GEL 0.01% 3 SANTYL OINTMENT 250UNIT/GM 4 selenium sulfide lotion 2.5% 2 GC TAZORAC CREAM 0.05% 4 TAZORAC CREAM 0.1% 4 TAZORAC GEL 0.05% 4 TAZORAC GEL 0.1% 4 tretinoin cream 0.025% 4 tretinoin cream 0.05% 4 tretinoin cream 0.1% 4



UVADEX INJECTION 20MCG/ML 4 VOLTAREN GEL 1% 4 ST ZONALON CREAM 5% 4

Reemplazo de enzimas/modificadores Enzyme Replacement/Modifiers

ADAGEN INJECTION 250UNIT/ML 5 ALDURAZYME INJECTION 2.9MG/5ML 5 BUPHENYL TABLET 500MG 5 CEREZYME INJECTION 400UNIT 5 CREON CAPSULE DELAYED RELEASE PARTICLES 120000UNIT; 24000UNIT; 76000UNIT

3

CREON CAPSULE DELAYED RELEASE PARTICLES 15000UNIT; 3000UNIT; 9500UNIT

3


3


3

CYSTADANE POWDER 0 5 CYSTAGON CAPSULE 150MG 3 CYSTAGON CAPSULE 50MG 3 ELAPRASE INJECTION 6MG/3ML 5 FABRAZYME INJECTION 35MG 5 KUVAN TABLET SOLUBLE 100MG 5 PA LUMIZYME INJECTION 50MG 5 PA LA NAGLAZYME INJECTION 1MG/ML 5 PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 17500UNIT; 4200UNIT; 10000UNIT

3

PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 43750UNIT; 10500UNIT; 25000UNIT

3


3


3

ZAVESCA CAPSULE 100MG 5 Agentes gastrointestinales

Antispasmodics, Gastrointestinal atropine sulfate injection 0.1mg/ml 2 GC bentyl injection 10mg/ml 2 GC dicyclomine hcl capsule 10mg 2 GC dicyclomine hcl solution 10mg/5ml 2 GC dicyclomine hcl tablet 20mg 2 GC glycopyrrolate injection 4mg/20ml 2 GC glycopyrrolate tablet 1mg 2 GC glycopyrrolate tablet 2mg 2 GC

Gastrointestinal Agents, Other cromolyn sodium concentrate 100mg/5ml 2 GC



DIPHENOXYLATE/ATROPINE LIQUID 0.025MG/5ML; 2.5MG/5ML

3

diphenoxylate/atropine tablet 0.025mg; 2.5mg 2 GC HALFLYTELY BOWEL PREP/FLAVOR PACKS KIT 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM

4

loperamide hcl capsule 2mg 2 GC metoclopramide hcl injection 5mg/ml 2 GC metoclopramide hcl solution 5mg/5ml 2 GC metoclopramide hcl tablet 10mg 2 GC metoclopramide hcl tablet 5mg 2 GC RELISTOR INJECTION 12MG/0.6ML 4 QL (30 EA per 30 days) PA ursodiol capsule 300mg 2 GC ursodiol tablet 250mg 2 GC ursodiol tablet 500mg 2 GC

Histamine2 (H2) Receptor Antagonists cimetidine tablet 200mg 2 GC cimetidine tablet 300mg 2 GC cimetidine tablet 400mg 2 GC cimetidine tablet 800mg 2 GC famotidine injection 20mg/2ml 2 GC famotidine tablet 20mg 2 GC famotidine tablet 40mg 2 GC nizatidine capsule 150mg 2 GC nizatidine capsule 300mg 2 GC nizatidine solution 15mg/ml 2 GC ranitidine hcl capsule 150mg 2 GC ranitidine hcl capsule 300mg 2 GC ranitidine hcl injection 150mg/6ml 2 GC ranitidine hcl syrup 15mg/ml 2 GC ranitidine hcl tablet 150mg 1 GC ranitidine hcl tablet 300mg 1 GC

Irritable Bowel Syndrome Agents AMITIZA CAPSULE 24MCG 4 AMITIZA CAPSULE 8MCG 4 LINZESS CAPSULE 145MCG 4 QL (30 EA per 30 days) PA LINZESS CAPSULE 290MCG 4 QL (30 EA per 30 days) PA LOTRONEX TABLET 0.5MG 3 LOTRONEX TABLET 1MG 3

Laxatives constulose solution 10gm/15ml 2 GC enulose solution 10gm/15ml 2 GC gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm

2 GC

gavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm

2 GC



gavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm

2 GC

generlac solution 10gm/15ml 2 GC GOLYTELY SOLUTION RECONSTITUTED 227.1GM; 2.82GM; 6.36GM; 5.53GM; 21.5GM

3

KRISTALOSE PACKET 10GM 4 KRISTALOSE PACKET 20GM 4 lactulose solution 10gm/15ml 2 GC polyethylene glycol 3350 powder 0 2 GC trilyte solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm

2 GC

Protectants CARAFATE SUSPENSION 1GM/10ML 4 misoprostol tablet 100mcg 2 GC misoprostol tablet 200mcg 2 GC sucralfate tablet 1gm 2 GC

Proton Pump Inhibitors dexilant capsule delayed release 30mg 4 ST dexilant capsule delayed release 60mg 4 ST lansoprazole capsule delayed release 15mg 2 GC lansoprazole capsule delayed release 30mg 2 GC omeprazole capsule delayed release 10mg 2 QL (60 EA per 30 days) GC omeprazole capsule delayed release 20mg 2 QL (60 EA per 30 days) GC omeprazole capsule delayed release 40mg 2 QL (60 EA per 30 days) GC pantoprazole sodium injection 40mg 2 GC pantoprazole sodium tablet delayed release 20mg 2 QL (60 EA per 30 days) GC pantoprazole sodium tablet delayed release 40mg 2 QL (60 EA per 30 days) GC rabeprazole sodium tablet delayed release 20mg 4 QL (60 EA per 30 days) ST

Agentes genitourinarios Antispasmodics, Urinary

flavoxate hcl tablet 100mg 2 GC oxybutynin chloride er tablet extended release 24 hour 10mg

2 GC

oxybutynin chloride er tablet extended release 24 hour 15mg

2 GC

oxybutynin chloride er tablet extended release 24 hour 5mg

2 GC

oxybutynin chloride syrup 5mg/5ml 2 GC oxybutynin chloride tablet 5mg 2 GC tolterodine tartrate er capsule extended release 24 hour 2mg

4 ST

tolterodine tartrate er capsule extended release 24 hour 4mg

4 ST

tolterodine tartrate tablet 1mg 2 GC tolterodine tartrate tablet 2mg 2 GC trospium chloride tablet 20mg 2 GC



VESICARE TABLET 10MG 3 VESICARE TABLET 5MG 3

Benign Prostatic Hypertrophy Agents AVODART CAPSULE 0.5MG 3 ST doxazosin mesylate tablet 2mg 1 GC doxazosin mesylate tablet 4mg 1 GC doxazosin mesylate tablet 8mg 1 GC finasteride tablet 5mg 2 GC tamsulosin hcl capsule 0.4mg 2 GC terazosin hcl capsule 10mg 1 GC terazosin hcl capsule 1mg 1 GC terazosin hcl capsule 2mg 1 GC terazosin hcl capsule 5mg 1 GC

Genitourinary Agents, Other bethanechol chloride tablet 10mg 2 GC bethanechol chloride tablet 25mg 2 GC bethanechol chloride tablet 50mg 2 GC bethanechol chloride tablet 5mg 2 GC ELMIRON CAPSULE 100MG 4

Phosphate Binders calcium acetate capsule 667mg 2 GC RENVELA PACKET 0.8GM 3 RENVELA PACKET 2.4GM 3 RENVELA TABLET 800MG 3

Agentes hormonales, estimulantes/reemplazo/modificadores (adrenales)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

alclometasone dipropionate cream 0.05% 2 GC alclometasone dipropionate ointment 0.05% 2 GC amcinonide cream 0.1% 4 AMCINONIDE OINTMENT 0.1% 4 augmented betamethasone dipropionate cream 0.05%

2 GC

augmented betamethasone dipropionate gel 0.05% 2 GC augmented betamethasone dipropionate lotion 0.05%

2 GC

augmented betamethasone dipropionate ointment 0.05%

2 GC

betamethasone dipropionate cream 0.05% 2 GC betamethasone dipropionate lotion 0.05% 2 GC betamethasone dipropionate ointment 0.05% 2 GC betamethasone valerate cream 0.1% 2 GC betamethasone valerate lotion 0.1% 2 GC betamethasone valerate ointment 0.1% 2 GC budesonide capsule extended release 24 hour 3mg 5



clobetasol propionate e cream 0.05% 2 GC clobetasol propionate cream 0.05% 2 GC clobetasol propionate gel 0.05% 2 GC clobetasol propionate ointment 0.05% 2 GC clobetasol propionate solution 0.05% 2 GC clotrimazole/betamethasone dipropionate cream 0.05%; 1%

4

clotrimazole/betamethasone dipropionate lotion 0.05%; 1%

4

CORTISONE ACETATE TABLET 25MG 3 desonide cream 0.05% 2 GC desonide lotion 0.05% 2 GC desonide ointment 0.05% 2 GC desoximetasone cream 0.05% 4 desoximetasone cream 0.25% 4 desoximetasone gel 0.05% 4 desoximetasone ointment 0.25% 4 DEXAMETHASONE INTENSOL CONCENTRATE 1MG/ML

3

dexamethasone sodium phosphate injection 10mg/ml

2 GC

dexamethasone sodium phosphate injection 120mg/30ml

2 GC

dexamethasone elixir 0.5mg/5ml 2 GC dexamethasone tablet 0.5mg 2 GC dexamethasone tablet 0.75mg 2 GC dexamethasone tablet 1.5mg 2 GC DEXAMETHASONE TABLET 1MG 3 DEXAMETHASONE TABLET 2MG 3 dexamethasone tablet 4mg 2 GC dexamethasone tablet 6mg 2 GC DIFLORASONE DIACETATE CREAM 0.05% 3 diflorasone diacetate ointment 0.05% 2 GC fludrocortisone acetate tablet 0.1mg 2 GC fluocinolone acetonide body oil 0.01% 2 GC fluocinolone acetonide scalp oil 0.01% 2 GC fluocinolone acetonide cream 0.01% 2 GC fluocinolone acetonide cream 0.025% 2 GC fluocinolone acetonide oil 0.01% 2 GC fluocinolone acetonide ointment 0.025% 2 GC fluocinolone acetonide solution 0.01% 4 fluocinonide-e cream 0.05% 2 GC fluocinonide cream 0.05% 2 GC fluocinonide gel 0.05% 2 GC fluocinonide ointment 0.05% 2 GC fluocinonide solution 0.05% 2 GC



fluticasone propionate cream 0.05% 2 GC fluticasone propionate ointment 0.005% 2 GC halobetasol propionate cream 0.05% 2 GC halobetasol propionate ointment 0.05% 2 GC hydrocortisone butyrate cream 0.1% 2 GC hydrocortisone butyrate ointment 0.1% 2 GC hydrocortisone butyrate solution 0.1% 2 GC hydrocortisone valerate cream 0.2% 2 GC hydrocortisone valerate ointment 0.2% 4 hydrocortisone cream 1% 2 GC hydrocortisone cream 2.5% 2 GC hydrocortisone enema 100mg/60ml 2 GC hydrocortisone lotion 2.5% 2 GC hydrocortisone ointment 1% 2 GC hydrocortisone ointment 2.5% 2 GC hydrocortisone tablet 10mg 2 GC hydrocortisone tablet 20mg 2 GC hydrocortisone tablet 5mg 2 GC methylprednisolone dose pack tablet 4mg 2 GC methylprednisolone sodiumsuccinate injection 1gm 2 GC methylprednisolone tablet 16mg 2 GC methylprednisolone tablet 32mg 2 GC methylprednisolone tablet 4mg 2 GC methylprednisolone tablet 8mg 2 GC mometasone furoate cream 0.1% 2 GC mometasone furoate ointment 0.1% 2 GC mometasone furoate solution 0.1% 2 GC prednisolone sodium phosphate solution 15mg/5ml 2 GC prednisolone sodium phosphate solution 5mg/5ml 2 GC PREDNISONE INTENSOL CONCENTRATE 5MG/ML

3

prednisone tablet 10mg 2 GC prednisone tablet 1mg 2 GC prednisone tablet 2.5mg 2 GC prednisone tablet 20mg 2 GC PREDNISONE TABLET 50MG 3 prednisone tablet 5mg 2 GC procto-pak cream 1% 2 GC proctozone-hc cream 2.5% 2 GC SOLU-MEDROL INJECTION 2GM 4 triamcinolone acetonide cream 0.025% 2 GC triamcinolone acetonide cream 0.1% 2 GC triamcinolone acetonide cream 0.5% 2 GC triamcinolone acetonide lotion 0.025% 2 GC triamcinolone acetonide lotion 0.1% 2 GC triamcinolone acetonide ointment 0.025% 2 GC



triamcinolone acetonide ointment 0.1% 2 GC TRIAMCINOLONE ACETONIDE OINTMENT 0.5% 3 TRIANEX OINTMENT 0.05% 4 u-cort cream 1%; 10% 2 GC

Agentes hormonales, estimulantes/reemplazo/modificadores (pituitaria)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate injection 4mcg/ml 2 GC desmopressin acetate solution 0.01% 2 GC desmopressin acetate solution 0.01% 2 GC desmopressin acetate tablet 0.1mg 2 GC desmopressin acetate tablet 0.2mg 2 GC INCRELEX INJECTION 40MG/4ML 5 PA LA OMNITROPE INJECTION 10MG/1.5ML 5 PA LA OMNITROPE INJECTION 5.8MG 5 PA LA OMNITROPE INJECTION 5MG/1.5ML 5 PA LA

Agentes hormonales, estimulantes/reemplazo/modificadores (hormonas sexuales/modificadores)

Anabolic Steroids ANADROL-50 TABLET 50MG 5 oxandrolone tablet 10mg 2 GC oxandrolone tablet 2.5mg 2 GC

Androgens ANDRODERM PATCH 24 HOUR 2MG/24HR 4 QL (30 EA per 30 days) PA ANDRODERM PATCH 24 HOUR 4MG/24HR 4 QL (30 EA per 30 days) PA ANDROGEL PUMP GEL 1% 3 QL (300 GM per 30 days) PA ANDROGEL PUMP GEL 1.62% 3 QL (150 GM per 30 days) PA ANDROGEL GEL 20.25MG/1.25GM 3 QL (30 GM per 30 days) PA ANDROGEL GEL 25MG/2.5GM 3 QL (300 GM per 30 days) PA ANDROGEL GEL 40.5MG/2.5GM 3 QL (60 GM per 30 days) PA ANDROGEL GEL 50MG/5GM 3 QL (300 GM per 30 days) PA ANDROXY TABLET 10MG 4 danazol capsule 100mg 2 GC danazol capsule 200mg 2 GC danazol capsule 50mg 2 GC FORTESTA GEL 10MG/ACT 4 QL (120 GM per 30 days) PA testosterone cypionate injection 100mg/ml 2 PA GC testosterone cypionate injection 200mg/ml 2 PA GC testosterone enanthate injection 200mg/ml 2 PA GC

Estrogens ALORA PATCH BIWEEKLY 0.025MG/24HR 4 PA ALORA PATCH BIWEEKLY 0.05MG/24HR 4 PA ALORA PATCH BIWEEKLY 0.075MG/24HR 4 PA ALORA PATCH BIWEEKLY 0.1MG/24HR 4 PA amethia lo tablet 0; 0 2 GC



amethia tablet 0; 0 2 GC AMETHYST TABLET 20MCG; 90MCG 3 apri tablet 0.15mg; 30mcg 2 GC aviane tablet 20mcg; 0.1mg 2 GC balziva tablet 35mcg; 0.4mg 2 GC BEYAZ TABLET 3MG; 0.02MG; 0.451MG 4 briellyn tablet 35mcg; 0.4mg 2 GC camrese lo tablet 0; 0 2 GC CENESTIN TABLET 0.3MG 4 PA CENESTIN TABLET 0.45MG 4 PA CENESTIN TABLET 0.625MG 4 PA CENESTIN TABLET 0.9MG 4 PA CENESTIN TABLET 1.25MG 4 PA COMBIPATCH PATCH BIWEEKLY 0.05MG/DAY; 0.14MG/DAY

4 PA

COMBIPATCH PATCH BIWEEKLY 0.05MG/DAY; 0.25MG/DAY

4 PA

cyclafem 1/35 tablet 35mcg; 1mg 2 GC cyclafem 7/7/7 tablet 0; 0 2 GC DIVIGEL GEL 1MG/GM 3 PA drospirenone/ethinyl estradiol tablet 3mg; 0.03mg 2 GC ESTRACE CREAM 0.1MG/GM 3 estradiol/norethindrone acetate tablet 0.5mg; 0.1mg 2 PA GC estradiol/norethindrone acetate tablet 1mg; 0.5mg 2 PA GC estradiol patch weekly 0.025mg/24hr 2 PA GC estradiol patch weekly 0.05mg/24hr 2 PA GC estradiol patch weekly 0.06mg/24hr 2 PA GC estradiol patch weekly 0.075mg/24hr 2 PA GC estradiol patch weekly 0.1mg/24hr 2 PA GC estradiol patch weekly 37.5mcg/24hr 2 PA GC estradiol tablet 0.5mg 2 PA GC estradiol tablet 1mg 2 PA GC estradiol tablet 2mg 2 PA GC ESTRASORB EMULSION 4.35MG/1.74GM 4 PA ESTRING RING 2MG 4 estropipate tablet 0.75mg 2 PA GC estropipate tablet 1.5mg 2 PA GC estropipate tablet 3mg 2 PA GC EVAMIST SOLUTION 1.53MG/SPRAY 4 PA FEMHRT LOW DOSE TABLET 2.5MCG; 0.5MG 3 FEMRING RING 0.05MG/24HR 4 FEMRING RING 0.1MG/24HR 4 gianvi tablet 3mg; 0.02mg 2 GC gildagia tablet 35mcg; 0.4mg 2 GC JINTELI TABLET 5MCG; 1MG 3 kariva tablet 0; 0 2 GC



larin 1/20 tablet 20mcg; 1mg 2 GC larin fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 2 GC larin fe 1/20 tablet 20mcg; 75mg; 1mg 2 GC leena tablet 0; 0 2 GC lessina tablet 20mcg; 0.1mg 2 GC levonest tablet 0; 0 2 GC levonorgestrel/ethinyl estradiol tablet 0.03mg; 0.15mg

2 GC

LO LOESTRIN FE TABLET 10MCG; 75MG; 1MG 4 LOESTRIN 24 FE TABLET 20MCG; 75MG; 1MG 4 lomedia 24 fe tablet 20mcg; 75mg; 1mg 4 low-ogestrel tablet 30mcg; 0.3mg 2 GC marlissa tablet 0.03mg; 0.15mg 2 GC microgestin 1.5/30 tablet 30mcg; 1.5mg 2 GC microgestin 1/20 tablet 20mcg; 1mg 2 GC microgestin fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 2 GC microgestin fe tablet 20mcg; 75mg; 1mg 2 GC mononessa tablet 35mcg; 0.25mg 2 GC NATAZIA TABLET 0; 0 4 PA necon 1/35 tablet 35mcg; 1mg 2 GC NECON 1/50-28 TABLET 50MCG; 1MG 3 NECON 10/11-28 TABLET 35MCG; 0 4 necon 7/7/7 tablet 0; 0 2 GC nortrel 0.5/35 (28) tablet 35mcg; 0.5mg 2 GC NUVARING RING 0.015MG/24HR; 0.12MG/24HR 4 ocella tablet 3mg; 0.03mg 2 GC OGESTREL TABLET 50MCG; 0.5MG 4 ORTHO TRI-CYCLEN LO TABLET 0; 0 4 pimtrea tablet 0; 0 2 GC pirmella 1/35 tablet 35mcg; 1mg 2 GC portia-28 tablet 0.03mg; 0.15mg 2 GC PREFEST TABLET 0; 0 3 PA PREMARIN CREAM 0.625MG/GM 3 PREMARIN INJECTION 25MG 3 PREMARIN TABLET 0.3MG 3 PA PREMARIN TABLET 0.45MG 3 PA PREMARIN TABLET 0.625MG 3 PA PREMARIN TABLET 0.9MG 3 PA PREMARIN TABLET 1.25MG 3 PA PREMPHASE TABLET 0.625MG; 5MG 3 PA PREMPRO TABLET 0.3MG; 1.5MG 3 PA PREMPRO TABLET 0.45MG; 1.5MG 3 PA PREMPRO TABLET 0.625MG; 2.5MG 3 PA PREMPRO TABLET 0.625MG; 5MG 3 PA quasense tablet 0.03mg; 0.15mg 2 GC SAFYRAL TABLET 3MG; 0.03MG; 0.451MG 4



tri-legest fe tablet 0; 75mg; 1mg 2 GC trinessa tablet 0; 0 2 GC trivora-28 tablet 0; 0 2 GC VAGIFEM TABLET 10MCG 3 velivet tablet 0; 0 2 GC vestura tablet 3mg; 0.02mg 2 GC VIVELLE-DOT PATCH BIWEEKLY 0.025MG/24HR 4 PA VIVELLE-DOT PATCH BIWEEKLY 0.0375MG/24HR

4 PA

VIVELLE-DOT PATCH BIWEEKLY 0.05MG/24HR 4 PA VIVELLE-DOT PATCH BIWEEKLY 0.075MG/24HR 4 PA VIVELLE-DOT PATCH BIWEEKLY 0.1MG/24HR 4 PA vyfemla tablet 35mcg; 0.4mg 2 GC xulane patch weekly 35mcg/24hr; 150mcg/24hr 4 zenchent tablet 35mcg; 0.4mg 2 GC zovia 1/35e tablet 35mcg; 1mg 2 GC ZOVIA 1/50E TABLET 50MCG; 1MG 4

Progesterone Agonists/Antagonists ELLA TABLET 30MG 3

Progestins camila tablet 0.35mg 2 GC jolivette tablet 0.35mg 2 GC lyza tablet 0.35mg 2 GC medroxyprogesterone acetate injection 150mg/ml 2 GC medroxyprogesterone acetate tablet 10mg 2 GC medroxyprogesterone acetate tablet 2.5mg 2 GC medroxyprogesterone acetate tablet 5mg 2 GC MEGACE ES SUSPENSION 625MG/5ML 3 PA megestrol acetate suspension 40mg/ml 2 PA GC megestrol acetate tablet 20mg 2 GC megestrol acetate tablet 40mg 2 GC nora-be tablet 0.35mg 2 GC norethindrone acetate tablet 5mg 2 GC norethindrone tablet 0.35mg 2 GC progesterone capsule 100mg 2 GC progesterone capsule 200mg 2 GC

Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride tablet 60mg 2 GC

Agentes hormonales, estimulantes/reemplazo/modificadores (tiroides)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tablet 100mcg 1 GC levothyroxine sodium tablet 112mcg 1 GC levothyroxine sodium tablet 125mcg 1 GC levothyroxine sodium tablet 137mcg 1 GC



levothyroxine sodium tablet 150mcg 1 GC levothyroxine sodium tablet 175mcg 1 GC levothyroxine sodium tablet 200mcg 1 GC levothyroxine sodium tablet 25mcg 1 GC levothyroxine sodium tablet 300mcg 1 GC levothyroxine sodium tablet 50mcg 1 GC levothyroxine sodium tablet 75mcg 1 GC levothyroxine sodium tablet 88mcg 1 GC levoxyl tablet 100mcg 1 GC levoxyl tablet 112mcg 1 GC levoxyl tablet 125mcg 1 GC levoxyl tablet 137mcg 1 GC levoxyl tablet 150mcg 1 GC levoxyl tablet 175mcg 1 GC levoxyl tablet 200mcg 1 GC levoxyl tablet 25mcg 1 GC levoxyl tablet 50mcg 1 GC levoxyl tablet 75mcg 1 GC levoxyl tablet 88mcg 1 GC liothyronine sodium tablet 25mcg 2 GC liothyronine sodium tablet 50mcg 2 GC liothyronine sodium tablet 5mcg 2 GC SYNTHROID TABLET 100MCG 4 SYNTHROID TABLET 112MCG 4 SYNTHROID TABLET 125MCG 4 SYNTHROID TABLET 137MCG 4 SYNTHROID TABLET 150MCG 4 SYNTHROID TABLET 175MCG 4 SYNTHROID TABLET 200MCG 4 SYNTHROID TABLET 25MCG 4 SYNTHROID TABLET 300MCG 4 SYNTHROID TABLET 50MCG 4 SYNTHROID TABLET 75MCG 4 SYNTHROID TABLET 88MCG 4

Agentes hormonales, supresores (adrenales) Hormonal Agents, Suppressant (Adrenal)

LYSODREN TABLET 500MG 3 Agentes hormonales, supresores (paratiroides)

Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABLET 30MG 3 SENSIPAR TABLET 60MG 3 SENSIPAR TABLET 90MG 3

Agentes hormonales, supresores (pituitaria) Hormonal Agents, Suppressant (Pituitary)

cabergoline tablet 0.5mg 2 GC ELIGARD INJECTION 22.5MG 4



ELIGARD INJECTION 30MG 4 ELIGARD INJECTION 45MG 4 ELIGARD INJECTION 7.5MG 3 FIRMAGON INJECTION 120MG 4 FIRMAGON INJECTION 80MG 4 leuprolide acetate injection 1mg/0.2ml 2 GC LUPRON DEPOT-PED INJECTION 11.25MG 5 LUPRON DEPOT-PED INJECTION 15MG 5 LUPRON DEPOT INJECTION 11.25MG 5 LUPRON DEPOT INJECTION 22.5MG 5 LUPRON DEPOT INJECTION 3.75MG 5 LUPRON DEPOT INJECTION 30MG 5 LUPRON DEPOT INJECTION 45MG 5 LUPRON DEPOT INJECTION 7.5MG 5 octreotide acetate injection 1000mcg/ml 5 octreotide acetate injection 100mcg/ml 2 GC octreotide acetate injection 200mcg/ml 2 GC octreotide acetate injection 500mcg/ml 5 octreotide acetate injection 50mcg/ml 2 GC SOMATULINE DEPOT INJECTION 120MG/0.5ML 5 PA SOMATULINE DEPOT INJECTION 60MG/0.2ML 5 PA SOMATULINE DEPOT INJECTION 90MG/0.3ML 5 PA SOMAVERT INJECTION 10MG 5 SOMAVERT INJECTION 15MG 5 SOMAVERT INJECTION 20MG 5 SYNAREL SOLUTION 2MG/ML 5 PA

Agentes hormonales, supresores (tiroides) Antithyroid Agents

methimazole tablet 10mg 2 GC methimazole tablet 5mg 2 GC propylthiouracil tablet 50mg 2 GC

Agentes inmunológicos Angioedema (HAE) Agents

CINRYZE INJECTION 500UNIT 5 PA FIRAZYR INJECTION 30MG/3ML 5 PA LA

Immune Suppressants azathioprine tablet 50mg 2 B/D GC CELLCEPT INTRAVENOUS INJECTION 500MG 4 B/D CELLCEPT SUSPENSION RECONSTITUTED 200MG/ML

5 B/D

cyclosporine modified capsule 100mg 2 B/D GC cyclosporine modified capsule 25mg 2 B/D GC CYCLOSPORINE MODIFIED CAPSULE 50MG 4 B/D cyclosporine modified solution 100mg/ml 2 B/D GC cyclosporine capsule 100mg 2 B/D GC cyclosporine capsule 25mg 2 B/D GC



cyclosporine injection 50mg/ml 2 B/D GC ENBREL SURECLICK INJECTION 50MG/ML 5 PA ENBREL INJECTION 25MG/0.5ML 5 PA ENBREL INJECTION 25MG 5 PA ENBREL INJECTION 50MG/ML 5 PA gengraf capsule 100mg 2 B/D GC gengraf capsule 25mg 2 B/D GC HUMIRA INJECTION 20MG/0.4ML 5 PA HUMIRA INJECTION 40MG/0.8ML 5 PA KINERET INJECTION 100MG/0.67ML 5 PA methotrexate sodium injection 1gm/40ml 2 GC METHOTREXATE SODIUM INJECTION 1GM 3 methotrexate sodium injection 25mg/ml 2 GC methotrexate tablet 2.5mg 1 GC mycophenolate mofetil capsule 250mg 2 B/D GC mycophenolate mofetil tablet 500mg 2 B/D GC mycophenolic acid dr tablet delayed release 180mg 4 B/D mycophenolic acid dr tablet delayed release 360mg 5 B/D ORENCIA INJECTION 125MG/ML 5 PA PROGRAF INJECTION 5MG/ML 4 B/D RAPAMUNE SOLUTION 1MG/ML 4 B/D RAPAMUNE TABLET 1MG 4 B/D RAPAMUNE TABLET 2MG 5 B/D REMICADE INJECTION 100MG 5 PA SANDIMMUNE SOLUTION 100MG/ML 4 B/D sirolimus tablet 0.5mg 4 B/D tacrolimus capsule 0.5mg 2 B/D GC tacrolimus capsule 1mg 2 B/D GC tacrolimus capsule 5mg 2 B/D GC ZORTRESS TABLET 0.25MG 4 QL (60 EA per 30 days) B/D ZORTRESS TABLET 0.5MG 5 QL (60 EA per 30 days) B/D ZORTRESS TABLET 0.75MG 5 QL (60 EA per 30 days) B/D

Immunizing Agents, Passive GAMASTAN S/D INJECTION 0 3 B/D GAMUNEX-C INJECTION 1GM/10ML 4 PA HIZENTRA INJECTION 1GM/5ML 5 PA THYMOGLOBULIN INJECTION 25MG 5

Immunomodulators ACTIMMUNE INJECTION 2000000UNIT/0.5ML 5 ARCALYST INJECTION 220MG 5 PA ILARIS INJECTION 180MG 5 PA LA leflunomide tablet 10mg 2 GC leflunomide tablet 20mg 2 GC RIDAURA CAPSULE 3MG 4 SYNAGIS INJECTION 50MG/0.5ML 5

Vaccines



ACTHIB INJECTION 0 3 ADACEL INJECTION 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML

3

BCG VACCINE INJECTION 0 3 BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML

3

BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML

3

CERVARIX INJECTION 0 3 COMVAX INJECTION 7.5MCG/0.5ML; 5MCG/0.5ML

3

DAPTACEL INJECTION 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML

3

DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC INJECTION 25LFU/0.5ML; 5LFU/0.5ML

3

ENGERIX-B INJECTION 10MCG/0.5ML 3 B/D ENGERIX-B INJECTION 10MCG/0.5ML 3 B/D ENGERIX-B INJECTION 20MCG/ML 3 B/D GARDASIL INJECTION 0 3 HAVRIX INJECTION 1440ELU/ML 3 HAVRIX INJECTION 720ELU/0.5ML 3 IMOVAX RABIES (H.D.C.V.) INJECTION 2.5UNIT/ML

3

INFANRIX INJECTION 58MCG/0.5ML; 25LFU/0.5ML; 10LFU/0.5ML

3

IPOL INACTIVATED IPV INJECTION 0 3 IXIARO INJECTION 0 3 M-M-R II W/DILUENT 10 DOSE INJECTION 0; 0; 0 3 MENACTRA INJECTION 0 3 MENOMUNE-A/C/Y/W-135 INJECTION 0 3 MENVEO INJECTION 0 3 PEDVAX HIB INJECTION 0 3 PROQUAD INJECTION 0; 0; 0; 0 3 RABAVERT INJECTION 0 3 RECOMBIVAX HB INJECTION 10MCG/ML 3 B/D RECOMBIVAX HB INJECTION 40MCG/ML 3 B/D ROTARIX SUSPENSION RECONSTITUTED 0 3 ROTATEQ SOLUTION 0 3 TETANUS TOXOID ADSORBED INJECTION 5LFU 3 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT INJECTION 2LF/0.5ML; 2LF/0.5ML

3

TWINRIX INJECTION 720ELU/ML; 20MCG/ML 3 TYPHIM VI INJECTION 25MCG/0.5ML 3 VAQTA INJECTION 25UNIT/0.5ML 3 VARIVAX INJECTION 1350PFU/0.5ML 3 YF-VAX INJECTION 0 3



ZOSTAVAX INJECTION 19400UNT/0.65ML 3 Agentes para enfermedad inflamatoria intestinal

Aminosalicylates APRISO CAPSULE EXTENDED RELEASE 24 HOUR 0.375GM


balsalazide disodium capsule 750mg 2 GC CANASA SUPPOSITORY 1000MG 3 DELZICOL CAPSULE DELAYED RELEASE 400MG 4 QL (180 EA per 30 days) ST DIPENTUM CAPSULE 250MG 5 mesalamine kit 4gm 2 GC PENTASA CAPSULE EXTENDED RELEASE 250MG


PENTASA CAPSULE EXTENDED RELEASE 500MG


Sulfonamides sulfasalazine tablet delayed release 500mg 2 GC sulfasalazine tablet 500mg 2 GC sulfazine ec tablet delayed release 500mg 2 GC

Agentes para enfermedades óseas metabólicas Metabolic Bone Disease Agents

ACTONEL TABLET 150MG 4 ACTONEL TABLET 30MG 4 ACTONEL TABLET 35MG 4 ACTONEL TABLET 5MG 4 alendronate sodium tablet 10mg 2 GC alendronate sodium tablet 35mg 1 GC alendronate sodium tablet 40mg 2 GC alendronate sodium tablet 5mg 2 GC alendronate sodium tablet 70mg 1 GC ATELVIA TABLET DELAYED RELEASE 35MG 4 calcitonin-salmon solution 200unit/act 4 calcitriol capsule 0.25mcg 2 GC calcitriol capsule 0.5mcg 2 GC calcitriol injection 1mcg/ml 2 GC calcitriol solution 1mcg/ml 2 GC doxercalciferol capsule 0.5mcg 4 doxercalciferol capsule 1mcg 4 doxercalciferol capsule 2.5mcg 4 doxercalciferol injection 4mcg/2ml 4 ETIDRONATE DISODIUM TABLET 200MG 3 etidronate disodium tablet 400mg 2 GC FORTEO INJECTION 600MCG/2.4ML 5 PA ibandronate sodium tablet 150mg 4 MIACALCIN INJECTION 200UNIT/ML 4 paricalcitol capsule 1mcg 4 paricalcitol capsule 2mcg 4



paricalcitol capsule 4mcg 4 PROLIA INJECTION 60MG/ML 4 PA XGEVA INJECTION 120MG/1.7ML 5 PA ZEMPLAR INJECTION 2MCG/ML 4 ZEMPLAR INJECTION 5MCG/ML 4 zoledronic acid injection 4mg/5ml 5 PA zoledronic acid injection 5mg/100ml 4 PA

Agentes terapéuticos misceláneos Miscellaneous Therapeutic Agents

bd insulin syringe safetyglide/1ml/29g x 1/2" miscellaneous

2 GC

bd insulin syringe ultrafine/0.3ml/31g x 5/16" miscellaneous

2 GC

bd insulin syringe ultrafine/0.5ml/30g x 1/2" miscellaneous

2 GC

bd insulin syringe ultrafine/1ml/31g x 5/16" miscellaneous

2 GC

novofine pen needle miscellaneous 2 GC intralipid injection 2.25%; 20% 2 B/D GC lactated ringers irrigation solution 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l

2 GC

ORFADIN CAPSULE 10MG 5 PA ORFADIN CAPSULE 2MG 5 PA ORFADIN CAPSULE 5MG 5 PA sodium chloride 0.9% solution 0.9% 2 GC

Agentes oftalmológicos Ophthalmic Prostaglandin and Prostamide Analogs

COMBIGAN SOLUTION 0.2%; 0.5% 4 latanoprost solution 0.005% 2 GC LUMIGAN SOLUTION 0.01% 4 TRAVATAN Z SOLUTION 0.004% 3

Ophthalmic Agents, Other LACRISERT INSERT 5MG 3 NAPHAZOLINE HCL SOLUTION 0.1% 3 RESTASIS EMULSION 0.05% 4

Ophthalmic Anti-allergy Agents ALOCRIL SOLUTION 2% 3 azelastine hcl solution 0.05% 2 GC cromolyn sodium solution 4% 2 GC epinastine hcl solution 0.05% 2 GC PATADAY SOLUTION 0.2% 3 PATANOL SOLUTION 0.1% 3

Ophthalmic Anti-inflammatories ALOMIDE SOLUTION 0.1% 3 ALREX SUSPENSION 0.2% 3 diclofenac sodium solution 0.1% 2 GC



fluorometholone suspension 0.1% 2 GC flurbiprofen sodium solution 0.03% 2 GC FML FORTE SUSPENSION 0.25% 3 FML OINTMENT 0.1% 3 ketorolac tromethamine solution 0.4% 2 GC ketorolac tromethamine solution 0.5% 2 GC LOTEMAX GEL 0.5% 4 LOTEMAX SUSPENSION 0.5% 4 neomycin/polymyxin/dexamethasone ointment 0.1%; 3.5mg/gm; 10000unit/gm

2 GC

neomycin/polymyxin/dexamethasone suspension 0.1%; 3.5mg/ml; 10000unit/ml

2 GC

prednisolone acetate suspension 1% 2 GC PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1%

3

TOBRADEX OINTMENT 0.1%; 0.3% 3 tobramycin/dexamethasone suspension 0.1%; 0.3% 2 GC

Ophthalmic Antiglaucoma Agents ALPHAGAN P SOLUTION 0.1% 3 apraclonidine solution 0.5% 2 GC AZOPT SUSPENSION 1% 3 betaxolol hcl solution 0.5% 2 GC BETOPTIC-S SUSPENSION 0.25% 3 brimonidine tartrate solution 0.15% 2 GC brimonidine tartrate solution 0.2% 2 GC carteolol hcl solution 1% 2 GC dorzolamide hcl/timolol maleate solution 22.3mg/ml; 6.8mg/ml

2 GC

dorzolamide hcl solution 2% 2 GC LEVOBUNOLOL HCL SOLUTION 0.25% 3 levobunolol hcl solution 0.5% 2 GC methazolamide tablet 25mg 2 GC methazolamide tablet 50mg 2 GC metipranolol solution 0.3% 2 GC PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED 0.125%

3

SIMBRINZA SUSPENSION 0.2%; 1% 4 timolol maleate solution 0.25% 2 GC timolol maleate solution 0.5% 2 GC

Agentes óticos Otic Agents

hydrocortisone/acetic acid solution 2%; 1% 2 GC neomycin/polymyxin/hc solution 1%; 3.5mg/ml; 10000unit/ml

2 GC

neomycin/polymyxin/hydrocortisone suspension 1%; 3.5mg/ml; 10000unit/ml

2 GC



Agentes para el tracto respiratorio/pulmones Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 100MCG/DOSE; 50MCG/DOSE

4 ST


4 ST


4 ST

ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT

4 ST


4 ST


4 ST

ASMANEX 120 METERED DOSES AEROSOL POWDER BREATH ACTIVATED 220MCG/INH

4


4


4

budesonide suspension 0.25mg/2ml 2 B/D GC budesonide suspension 0.5mg/2ml 2 B/D GC DULERA AEROSOL 5MCG/ACT; 100MCG/ACT 3 ST DULERA AEROSOL 5MCG/ACT; 200MCG/ACT 3 ST FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 100MCG/BLIST

3

FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 250MCG/BLIST

3

FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50MCG/BLIST

3

FLOVENT HFA AEROSOL 110MCG/ACT 3 FLOVENT HFA AEROSOL 220MCG/ACT 3 FLOVENT HFA AEROSOL 44MCG/ACT 3 flunisolide solution 0.025% 2 GC flunisolide solution 29mcg/act 2 GC fluticasone propionate suspension 50mcg/act 2 GC NASONEX SUSPENSION 50MCG/ACT 4 PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 180MCG/ACT

4

PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90MCG/ACT

4

PULMICORT SUSPENSION 1MG/2ML 4 B/D QVAR AEROSOL SOLUTION 40MCG/ACT 4 QVAR AEROSOL SOLUTION 80MCG/ACT 4 RHINOCORT AQUA SUSPENSION 32MCG/ACT 4



SYMBICORT AEROSOL 160MCG/ACT; 4.5MCG/ACT

3 ST

SYMBICORT AEROSOL 80MCG/ACT; 4.5MCG/ACT

3 ST

Antihistamines azelastine hcl solution 137mcg/spray 2 GC cetirizine hcl syrup 1mg/ml 2 GC cyproheptadine hcl syrup 2mg/5ml 2 GC cyproheptadine hcl tablet 4mg 2 GC diphenhydramine hcl injection 50mg/ml 2 GC levocetirizine dihydrochloride tablet 5mg 2 GC promethazine hcl injection 25mg/ml 2 GC promethazine hcl injection 50mg/ml 2 GC promethazine hcl syrup 6.25mg/5ml 2 GC promethazine hcl tablet 12.5mg 2 GC promethazine hcl tablet 25mg 2 GC promethazine hcl tablet 50mg 2 GC

Antileukotrienes montelukast sodium tablet chewable 4mg 2 QL (30 EA per 30 days) GC montelukast sodium tablet chewable 5mg 2 QL (30 EA per 30 days) GC montelukast sodium tablet 10mg 2 QL (30 EA per 30 days) GC zafirlukast tablet 10mg 2 GC zafirlukast tablet 20mg 2 GC ZYFLO CR TABLET EXTENDED RELEASE 12 HOUR 600MG


Bronchodilators, Anticholinergic ATROVENT HFA AEROSOL SOLUTION 17MCG/ACT

3

COMBIVENT RESPIMAT AEROSOL SOLUTION 100MCG/ACT; 20MCG/ACT

4 QL (8 GM per 30 days)

ipratropium bromide/albuterol sulfate solution 2.5mg/3ml; 0.5mg/3ml

2 B/D GC

ipratropium bromide solution 0.02% 2 B/D GC ipratropium bromide solution 0.03% 2 GC ipratropium bromide solution 0.06% 2 GC SPIRIVA HANDIHALER CAPSULE 18MCG 3 TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400MCG/ACT

3

Bronchodilators, Sympathomimetic albuterol sulfate er tablet extended release 12 hour 4mg

2 GC

albuterol sulfate er tablet extended release 12 hour 8mg

2 GC

albuterol sulfate nebulization solution 0.083% 2 B/D GC albuterol sulfate nebulization solution 0.5% 2 B/D GC albuterol sulfate nebulization solution 0.63mg/3ml 2 B/D GC



albuterol sulfate nebulization solution 1.25mg/3ml 2 B/D GC albuterol sulfate syrup 2mg/5ml 2 GC albuterol sulfate tablet 2mg 2 GC albuterol sulfate tablet 4mg 2 GC AUVI-Q INJECTION 0.15MG/0.15ML 3 AUVI-Q INJECTION 0.3MG/0.3ML 3 FORADIL AEROLIZER CAPSULE 12MCG 3 metaproterenol sulfate syrup 10mg/5ml 2 GC METAPROTERENOL SULFATE TABLET 10MG 3 METAPROTERENOL SULFATE TABLET 20MG 3 PROAIR HFA AEROSOL SOLUTION 108MCG/ACT 4 PROVENTIL HFA AEROSOL SOLUTION 108MCG/ACT

4

SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50MCG/DOSE

3

terbutaline sulfate injection 1mg/ml 2 GC terbutaline sulfate tablet 2.5mg 2 GC terbutaline sulfate tablet 5mg 2 GC VENTOLIN HFA AEROSOL SOLUTION 108MCG/ACT

3

Cystic Fibrosis Agents PULMOZYME SOLUTION 1MG/ML 5 B/D TOBI PODHALER CAPSULE 28MG 5 QL (224 EA per 28 days) tobramycin nebulization solution 300mg/5ml 5 B/D

Mast Cell Stabilizers cromolyn sodium nebulization solution 20mg/2ml 2 B/D GC

Phosphodiesterase Inhibitors, Airways Disease aminophylline injection 25mg/ml 2 GC DALIRESP TABLET 500MCG 3 PA ELIXOPHYLLIN ELIXIR 80MG/15ML 4 theophylline cr tablet extended release 12 hour 100mg

2 GC

theophylline cr tablet extended release 12 hour 200mg

2 GC

theophylline er tablet extended release 12 hour 300mg

2 GC

theophylline er tablet extended release 12 hour 450mg

2 GC

Pulmonary Antihypertensives ADCIRCA TABLET 20MG 5 QL (60 EA per 30 days) PA LETAIRIS TABLET 10MG 5 LETAIRIS TABLET 5MG 5 REMODULIN INJECTION 10MG/ML 5 B/D REMODULIN INJECTION 1MG/ML 5 B/D REMODULIN INJECTION 2.5MG/ML 5 B/D REMODULIN INJECTION 5MG/ML 5 B/D



sildenafil tablet 20mg 2 QL (90 EA per 30 days) PA GC

TRACLEER TABLET 125MG 5 LA TRACLEER TABLET 62.5MG 5 LA

Respiratory Tract Agents, Other acetylcysteine solution 10% 2 B/D GC acetylcysteine solution 20% 2 B/D GC PROLASTIN-C INJECTION 1000MG 5 TYZINE PEDIATRIC NASAL DROPS SOLUTION 0.05%

4

TYZINE SOLUTION 0.1% 4 XOLAIR INJECTION 150MG 5 PA LA

Relajantes musculoesqueléticos Skeletal Muscle Relaxants

chlorzoxazone tablet 500mg 2 GC cyclobenzaprine hcl tablet 10mg 2 QL (90 EA per 30 days) PA

GC cyclobenzaprine hcl tablet 5mg 2 QL (90 EA per 30 days) PA

GC cyclobenzaprine hcl tablet 7.5mg 2 QL (90 EA per 30 days) PA

GC orphenadrine citrate er tablet extended release 12 hour 100mg

2 GC

Agentes del trastorno del sueño GABA Receptor Modulators

eszopiclone tablet 1mg 2 QL (180 EA per 365 days) PA GC



zaleplon capsule 10mg 2 QL (90 EA per 365 days) GC zaleplon capsule 5mg 2 QL (90 EA per 365 days) GC zolpidem tartrate er tablet extended release 12.5mg 2 QL (90 EA per 365 days) GC zolpidem tartrate er tablet extended release 6.25mg 2 QL (90 EA per 365 days) GC zolpidem tartrate tablet 10mg 2 QL (90 EA per 365 days) GC zolpidem tartrate tablet 5mg 2 QL (90 EA per 365 days) GC

Sleep Disorders, Other NUVIGIL TABLET 150MG 3 QL (30 EA per 30 days) PA NUVIGIL TABLET 200MG 3 QL (30 EA per 30 days) PA NUVIGIL TABLET 250MG 3 QL (30 EA per 30 days) PA NUVIGIL TABLET 50MG 3 QL (30 EA per 30 days) PA ROZEREM TABLET 8MG 3 QL (30 EA per 30 days) XYREM SOLUTION 500MG/ML 5 LA

Nutrientes terapéuticos/minerales/electrolitos Electrolyte/Mineral Modifiers



CUPRIMINE CAPSULE 250MG 3 EXJADE TABLET SOLUBLE 125MG 4 EXJADE TABLET SOLUBLE 250MG 5 EXJADE TABLET SOLUBLE 500MG 5 sodium polystyrene sulfonate suspension 15gm/60ml

2 GC

SYPRINE CAPSULE 250MG 4 Electrolyte/Mineral Replacement

AMINOSYN II INJECTION 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML

3 B/D

klor-con 10 tablet extended release 10meq 2 GC klor-con 8 tablet extended release 8meq 2 GC klor-con m20 tablet extended release 20meq 2 GC lactated ringers dextrose 5% viaflex injection 2.7meq/l; 109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l

2 GC

lactated ringers viaflex injection 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l

2 GC

MOZOBIL INJECTION 24MG/1.2ML 5 QL (8 ML per 30 days) PA potassium chloride er capsule extended release 10meq

2 GC

potassium chloride er tablet extended release 10meq

2 GC

potassium chloride er tablet extended release 20meq

2 GC

potassium chloride sr tablet extended release 8meq 2 GC potassium chloride injection 0.4meq/ml 2 GC potassium chloride injection 10meq/100ml 2 GC potassium citrate tablet extended release 1080mg 2 GC potassium citrate tablet extended release 540mg 2 GC sodium chloride injection 2.5meq/ml 2 GC sodium chloride injection 3% 2 GC sodium chloride injection 5% 2 GC tpn electrolytes injection 29.5meq/20ml; 4.5meq/20ml; 35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml

2 GC

Vitamins PRENATABS OBN TABLET 120MG; 200MG; 400UNIT; 8MCG; 1MG; 29MG; 20MG; 150MCG; 3MG; 3MG; 3MG; 30UNIT; 15MG

3

82

Nombre del medicamento Página #

ALINIA 33 allopurinol 28 ALOCRIL 75 ALOMIDE 75

ALORA 66 ALOXI 26

ALPHAGAN P 76 alprazolam 41

ALREX 75 amantadine hcl 40

AMBISOME 27 amcinonide 63

amethia 67 amethia lo 66

AMETHYST 67 amifostine 30

amikacin sulfate 13 amiloride hcl 54

amiloride/hydrochlorothiazide 54 aminocaproic acid 46

aminophylline 79 AMINOSYN II 81

amiodarone hcl 49 AMITIZA 61

amitriptyline hcl 25 amlodipine besylate 51

amlodipine besylate/benazepril hcl 51 amlodipine besylate/benazepril

hydrochloride 51

ammonium lactate 59 AMOXAPINE 25

amoxicillin 16 amoxicillin/clavulanate potassium 16

amphetamine/dextroamphetamine 56 AMPHOTEC 27

AMPHOTERICIN B 27 ampicillin 17

ampicillin sodium 17 ampicillin-sulbactam 17

ANADROL-50 66 anagrelide hydrochloride 45

anastrozole 31 ANDRODERM 66

ANDROGEL 66

Índice Nombre del medicamento Página

# abacavir 39 abacavir

sulfate/lamivudine/zidovudine 39

ABELCET 27 ABILIFY 35

ABILIFY DISCMELT 35 ABILIFY MAINTENA 35

acamprosate calcium dr 12 acarbose 42

acebutolol hcl 49 acetaminophen/codeine 11

acetaminophen/codeine #3 11 acetazolamide 53 acetylcysteine 80

acitretin 59 ACTHIB 73

ACTIMMUNE 72 ACTONEL 74

acyclovir 41 acyclovir sodium 40

ADACEL 73 ADAGEN 60

adapalene 59 ADCETRIS 32 ADCIRCA 79

adefovir dipivoxil 38 ADVAIR DISKUS 77

ADVAIR HFA 77 ADVICOR 55 afeditab cr 51 AFINITOR 31

AFINITOR DISPERZ 31 AGGRENOX 46

ALBENZA 33 albuterol sulfate 78

albuterol sulfate er 78 alclometasone dipropionate 63

alcohol preps 13 ALDACTAZIDE 54 ALDURAZYME 60

alendronate sodium 74 ALIMTA 30

83


BACTROBAN NASAL 13 balsalazide disodium 74

balziva 67 BANZEL 21

BARACLUDE 38 BCG VACCINE 73

bd insulin syringe safetyglide/1ml/29g x 1/2"

75

bd insulin syringe ultrafine/0.3ml/31g x 5/16"

75

bd insulin syringe ultrafine/0.5ml/30g x 1/2"

75

bd insulin syringe ultrafine/1ml/31g x 5/16"

75

Novofine needle 75 benazepril hcl 48

benazepril hcl/hydrochlorothiazide 47 BENICAR 47

BENICAR HCT 47 bentyl 60

benztropine mesylate 33 betamethasone dipropionate 63

betamethasone valerate 63 betaxolol hcl 50 betaxolol hcl 76

bethanechol chloride 63 BETOPTIC-S 76

BEYAZ 67 bicalutamide 29

BICILLIN C-R 17 BILTRICIDE 33

bisoprolol fumarate 50 bisoprolol

fumarate/hydrochlorothiazide 50

bleomycin sulfate 30 BLEPHAMIDE 18

BLEPHAMIDE S.O.P. 18 BOOSTRIX 73

BOSULIF 32 briellyn 67

BRILINTA 46 brimonidine tartrate 76

BRINTELLIX 23 bromocriptine mesylate 33

budesonide 63


ANDROGEL PUMP 66 ANDROXY 66

APOKYN 33 apraclonidine 76

apri 67 APRISO 74 APTIOM 19

APTIVUS 40 ARCALYST 72 ARZERRA 32

ASMANEX 120 METERED DOSES 77 ASMANEX 30 METERED DOSES 77 ASMANEX 60 METERED DOSES 77

ATELVIA 74 atenolol 50

atenolol/chlorthalidone 49 atorvastatin calcium 55

atovaquone 33 atovaquone/proguanil hcl 33

ATRIPLA 41 atropine sulfate 60

ATROVENT HFA 78 augmented betamethasone

dipropionate 63

AUVI-Q 79 AVANDAMET 42

AVANDIA 42 AVASTIN 32

aviane 67 AVODART 63

AVONEX 58 AVONEX PEN 58

azacitidine 30 azathioprine 71

azelastine hcl 75 azelastine hcl 78

AZELEX 59 AZILECT 34

azithromycin 17 AZOPT 76

AZTREONAM 16 BACITRACIN 13

bacitracin/polymyxin b 13 baclofen 37

84


cefepime 15 cefotaxime sodium 15

cefpodoxime proxetil 15 cefprozil 15 CEFTIN 15

ceftriaxone sodium 15 cefuroxime axetil 15

cefuroxime sodium 15 CELEBREX 10 CELLCEPT 71

CELLCEPT INTRAVENOUS 71 CELONTIN 19 CENESTIN 67 cephalexin 16

CEREZYME 60 CERVARIX 73

cetirizine hcl 78 CHANTIX 13

CHANTIX STARTING MONTH PAK 13 CHLORAMPHENICOL SODIUM

SUCCINATE 13

chlordiazepoxide hcl 41 chlorhexidine gluconate oral rinse 59

chloroquine phosphate 33 chlorothiazide 54

CHLORPROMAZINE HCL 34 chlorthalidone 54 chlorzoxazone 80 cholestyramine 55

cholestyramine light 55 ciclopirox 27

ciclopirox nail lacquer 27 ciclopirox olamine 27

cidofovir 37 cilostazol 46

CILOXAN 18 cimetidine 61 CINRYZE 71

CIPRO 18 ciprofloxacin 18

ciprofloxacin hcl 18 ciprofloxacin i.v.-in d5w 18

citalopram hydrobromide 24 cladribine 30


budesonide 77 bumetanide 53 BUPHENYL 60

buprenorphine hcl 13 buprenorphine hcl/naloxone hcl 12

buproban 13 bupropion hcl 23

bupropion hcl sr 23 bupropion hcl xl 23

buspirone hcl 41 butalbital/acetaminophen/caffeine 10

BYDUREON 42 BYETTA 42

BYSTOLIC 50 cabergoline 70

CAFERGOT 28 calcipotriene 59

calcitonin-salmon 74 calcitriol 74

calcium acetate 63 camila 69

camrese lo 67 CANASA 74

CANCIDAS 27 candesartan cilexetil 47

candesartan cilexetil/hydrochlorothiazide

54

CAPASTAT SULFATE 29 CAPRELSA 30

captopril 48 captopril/hydrochlorothiazide 48

CARAC 59 CARAFATE 62

carbamazepine 21 carbamazepine er 21

carbidopa/levodopa 34 carbidopa/levodopa er 34

carteolol hcl 76 carvedilol 50

cefaclor 15 CEFACLOR ER 15

cefadroxil 15 cefazolin sodium 15

cefdinir 15

85


CUPRIMINE 81 curity gauze pads 2"x2" 59

cyclafem 1/35 67 cyclafem 7/7/7 67

cyclobenzaprine hcl 80 CYCLOPHOSPHAMIDE 29

CYCLOSET 42 cyclosporine 71

cyclosporine modified 71 cyproheptadine hcl 78

CYSTADANE 60 CYSTAGON 60

DALIRESP 79 danazol 66

DAPSONE 29 DAPTACEL 73 DARAPRIM 33

decitabine 30 DELZICOL 74

DEMSER 53 DENAVIR 41

desipramine hcl 26 desmopressin acetate 66

desonide 64 desoximetasone 64 dexamethasone 64

DEXAMETHASONE INTENSOL 64 dexamethasone sodium phosphate 64

dexilant 62 DEXTROAMPHETAMINE SULFATE 57

dextroamphetamine sulfate er 57 dextrose 10% flex container 43

DEXTROSE 10%/NACL 0.2% 43 dextrose 2.5%/sodium chloride 0.45% 43

dextrose 5% 44 dextrose 5%/nacl 0.2% 43

dextrose 5%/nacl 0.33% 43 dextrose 5%/nacl 0.45% 43 dextrose 5%/nacl 0.9% 43

DIAZEPAM 20 diazepam 41 diazepam 41

DIAZEPAM INTENSOL 41 diclofenac potassium 10


claravis 59 clarithromycin 17

clarithromycin er 17 clindamycin hcl 14

clindamycin phosphate 14 clindamycin phosphate 59

CLINDAMYCIN PHOSPHATE IN D5W

14

clindamycin/benzoyl peroxide 59 CLINIMIX E 4.25%/DEXTROSE 25% 43

clobetasol propionate 64 clobetasol propionate e 64

clomipramine hcl 25 clonazepam 20

clonazepam odt 20 clonidine hcl 46

clopidogrel 46 clorazepate dipotassium 41

clotrimazole 27 clotrimazole/betamethasone

dipropionate 64

clozapine 37 COARTEM 33

CODEINE SULFATE 11 COLCRYS 28

colestipol hcl 55 colestipol hcl for oral suspension 55

colistimethate sodium 14 COMBIGAN 75

COMBIPATCH 67 COMBIVENT RESPIMAT 78

COMETRIQ 30 COMPLERA 38

COMVAX 73 constulose 61

COPAXONE 58 CORTISONE ACETATE 64

COUMADIN 44 CREON 60

CRESTOR 55 CRIXIVAN 40

cromolyn sodium 60 cromolyn sodium 75 cromolyn sodium 79

CUBICIN 14

86


EDECRIN 53 EDURANT 38

EFFIENT 46 ELAPRASE 60

ELIGARD 70 ELITEK 30

ELIXOPHYLLIN 79 ELLA 69

ELMIRON 63 EMCYT 30 EMEND 26 EMSAM 23

EMTRIVA 39 enalapril maleate 48

enalapril maleate/hydrochlorothiazide 48 ENBREL 72

ENBREL SURECLICK 72 ENGERIX-B 73

enoxaparin sodium 45 entacapone 33

enulose 61 epinastine hcl 75 epirubicin hcl 30

EPIVIR 39 EPIVIR HBV 39

eplerenone 54 EPZICOM 39

ERAXIS 27 ERBITUX 32

ergoloid mesylates 22 ERGOMAR 28 ERIVEDGE 30 ERWINAZE 30

ERYPED 200 17 ERY-TAB 17

ERYTHROCIN LACTOBIONATE 17 erythromycin 18

ERYTHROMYCIN BASE 17 erythromycin/benzoyl peroxide 59

escitalopram oxalate 24 ESTRACE 67

estradiol 67 estradiol/norethindrone acetate 67

ESTRASORB 67


DICLOFENAC SODIUM 13 diclofenac sodium 75

diclofenac sodium dr 10 diclofenac sodium er 10

dicloxacillin sodium 17 dicyclomine hcl 60

didanosine 39 DIFICID 17

DIFLORASONE DIACETATE 64 digoxin 53

dihydroergotamine mesylate 28 DILANTIN 21

diltiazem cd 51 diltiazem hcl 52

diltiazem hcl er 52 DIOVAN 47

DIPENTUM 74 diphenhydramine hcl 78

DIPHENOXYLATE/ATROPINE 61 DIPHTHERIA/TETANUS TOXOIDS

ADSORBED PEDIATRIC 73

dipyridamole 46 disulfiram 12

divalproex sodium 20 divalproex sodium dr 20 divalproex sodium er 20

DIVIGEL 67 DOCETAXEL 30 donepezil hcl 22

dorzolamide hcl 76 dorzolamide hcl/timolol maleate 76

doxazosin mesylate 47 doxazosin mesylate 63

doxepin hcl 26 doxercalciferol 74

doxycycline hyclate 18 doxycycline monohydrate 18

dronabinol 26 drospirenone/ethinyl estradiol 67

DULERA 77 duloxetine hcl 24

duramorph 11 DYRENIUM 54

econazole nitrate 27

87


fluocinolone acetonide 64 fluocinolone acetonide body 64 fluocinolone acetonide scalp 64

fluocinonide 64 fluocinonide-e 64

fluorometholone 76 FLUOROPLEX 59

fluorouracil 59 fluoxetine hcl 24

fluphenazine decanoate 34 FLUPHENAZINE HCL 34

flurazepam hcl 41 flurbiprofen 10

flurbiprofen sodium 76 flutamide 29

fluticasone propionate 65 fluticasone propionate 77

fluvoxamine maleate 24 FML 76

FML FORTE 76 fondaparinux sodium 45

FORADIL AEROLIZER 79 FORFIVO XL 23

FORTEO 74 FORTESTA 66

fosinopril sodium 48 fosinopril sodium/hydrochlorothiazide 48

fosphenytoin sodium 21 FRAGMIN 45

furosemide 53 FUZEON 40

FYCOMPA 19 gabapentin 20 GABITRIL 20

galantamine hydrobromide 22 GAMASTAN S/D 72

GAMUNEX-C 72 ganciclovir 37

GARDASIL 73 gatifloxacin 18

gavilyte-c 61 gavilyte-g 61

gavilyte-n/flavor pack 62 gemfibrozil 55


ESTRING 67 estropipate 67

eszopiclone 80 ethambutol hcl 29

ethosuximide 19 ETIDRONATE DISODIUM 74

etodolac 10 etoposide 31 EVAMIST 67 EXELON 22

exemestane 31 EXJADE 81

EXTAVIA 58 FABRAZYME 60

famciclovir 41 famotidine 61

FANAPT 36 FARESTON 30 FASLODEX 30

FAZACLO 37 felbamate 21

felodipine er 52 FEMHRT LOW DOSE 67

FEMRING 67 fenofibrate 54

fenofibrate micronized 54 FENOPROFEN CALCIUM 10

fentanyl 10 fentanyl citrate oral transmucosal 12

FETZIMA 24 FINACEA 59 finasteride 63 FIRAZYR 71

FIRMAGON 71 flavoxate hcl 62

flecainide acetate 49 FLOVENT DISKUS 77

FLOVENT HFA 77 fluconazole 27

fluconazole in dextrose 27 flucytosine 27

fludarabine phosphate 30 fludrocortisone acetate 64

flunisolide 77

88


hydralazine hcl 56 hydrochlorothiazide 54

hydrocodone/acetaminophen 12 hydrocodone/ibuprofen 12

hydrocortisone 65 hydrocortisone butyrate 65 hydrocortisone valerate 65

hydrocortisone/acetic acid 76 hydromorphone hcl 12

hydroxychloroquine sulfate 33 hydroxyurea 30

ibandronate sodium 74 ibuprofen 13 ICLUSIG 30

ILARIS 72 IMBRUVICA 32

imipenem/cilastatin 16 imipramine hcl 26

imiquimod 59 IMOVAX RABIES (H.D.C.V.) 73

INCIVEK 38 INCRELEX 66 indapamide 54 INFANRIX 73

INFERGEN 38 INLYTA 32

INTELENCE 38 intralipid 75

INTRON-A 38 INTRON-A W/DILUENT 38

INTUNIV 57 INVANZ 16 INVEGA 36

INVEGA SUSTENNA 36 INVIRASE 40

IPOL INACTIVATED IPV 73 ipratropium bromide 78

ipratropium bromide/albuterol sulfate 78 irbesartan 47

irbesartan/hydrochlorothiazide 47 ISENTRESS 38

ISONIAZID 29 isosorbide dinitrate 56

isosorbide dinitrate er 56


generlac 62 gengraf 72 gentak 13

GENTAMICIN SULFATE 13 GEODON 36

gianvi 67 gildagia 67

GILOTRIF 30 GLEEVEC 32 glimepiride 42

glipizide 42 glipizide er 42

glipizide/metformin hcl 42 GLUCAGON EMERGENCY KIT 44

glycopyrrolate 60 GOLYTELY 62

granisetron hcl 26 griseofulvin microsize 27

guanfacine hcl 46 guanidine hcl 29

HALFLYTELY BOWEL PREP/FLAVOR PACKS

61

halobetasol propionate 65 haloperidol 35

haloperidol decanoate 35 haloperidol lactate 35

HAVRIX 73 heparin sodium 45

HEPARIN SODIUM/D5W 45 heparin sodium/nacl 0.9% 45

HEXALEN 29 HIZENTRA 72 HUMALOG 44

HUMALOG MIX 50/50 44 HUMALOG MIX 50/50 KWIKPEN 44

HUMALOG MIX 75/25 44 HUMALOG MIX 75/25 KWIKPEN 44

HUMIRA 72 HUMULIN 70/30 44

HUMULIN 70/30 PEN 44 HUMULIN N 44

HUMULIN N U-100 PEN 44 HUMULIN R 44

HUMULIN R U-500 (CONCENTRATED)

44

89


letrozole 31 leucovorin calcium 31

LEUKERAN 29 LEUKINE 45

leuprolide acetate 71 LEVEMIR 44

LEVEMIR FLEXPEN 44 levetiracetam 19

LEVOBUNOLOL HCL 76 levocetirizine dihydrochloride 78

levofloxacin 18 levonest 68

levonorgestrel/ethinyl estradiol 68 levothyroxine sodium 69

levoxyl 70 LEXIVA 40

lidocaine 12 lidocaine hcl 12

lidocaine hcl jelly 12 lidocaine viscous 12

lidocaine/prilocaine 12 LINCOCIN 14

lindane 33 LINZESS 61

liothyronine sodium 70 lisinopril 48

lisinopril/hydrochlorothiazide 48 lithium carbonate 42

lithium carbonate er 42 LITHIUM CITRATE 42 LO LOESTRIN FE 68 LOESTRIN 24 FE 68

lomedia 24 fe 68 lomustine 29

loperamide hcl 61 lorazepam 41

losartan potassium 47 losartan

potassium/hydrochlorothiazide 47

LOTEMAX 76 LOTRONEX 61

lovastatin 55 LOVAZA 55

low-ogestrel 68


isosorbide mononitrate 56 isosorbide mononitrate er 56

itraconazole 27 IXIARO 73 JAKAFI 30

JANUMET 42 JANUMET XR 42

JANUVIA 42 JINTELI 67 jolivette 69

KADCYLA 32 KALETRA 40

kariva 67 ketoconazole 27

ketoprofen 10 ketorolac tromethamine 76

KHEDEZLA 24 KINERET 72

klor-con 10 81 klor-con 8 81

klor-con m20 81 KRISTALOSE 62

KUVAN 60 labetalol hcl 50

LACRISERT 75 lactated ringers dextrose 5% viaflex 81

lactated ringers irrigation 75 lactated ringers viaflex 81

lactulose 62 LAMIVUDINE 39

lamivudine/zidovudine 39 lamotrigine 21

lansoprazole 62 LANTUS 44

LANTUS SOLOSTAR 44 larin 1/20 68

larin fe 1.5/30 68 larin fe 1/20 68 latanoprost 75

LATUDA 36 leena 68

leflunomide 72 lessina 68

LETAIRIS 79

90


methylprednisolone sodiumsuccinate 65 metipranolol 76

metoclopramide hcl 61 metolazone 54

metoprolol succinate er 50 metoprolol tartrate 50

metoprolol/hydrochlorothiazide 50 metronidazole 14

metronidazole in nacl 0.79% 14 metronidazole vaginal 14

MEXILETINE HCL 49 MIACALCIN 74

microgestin 1.5/30 68 microgestin 1/20 68

microgestin fe 68 microgestin fe 1.5/30 68

midodrine hcl 46 MIGRANAL 28

minocycline hcl 19 minoxidil 56

mirtazapine 23 mirtazapine odt 23

misoprostol 62 mitoxantrone hcl 31

M-M-R II W/DILUENT 10 DOSE 73 moderiba 38

moexipril hcl 48 moexipril/hydrochlorothiazide 48

mometasone furoate 65 mononessa 68

montelukast sodium 78 MORPHINE SULFATE 12

morphine sulfate er 11 MOZOBIL 81 MULTAQ 49 mupirocin 14

mycophenolate mofetil 72 mycophenolic acid dr 72

nabumetone 10 nadolol 50

nafcillin sodium 17 NAGLAZYME 60

nalbuphine hcl 12 naloxone hcl 13


loxapine succinate 35 LUMIGAN 75

LUMIZYME 60 LUPRON DEPOT 71

LUPRON DEPOT-PED 71 LYRICA 19

LYSODREN 70 lyza 69

malathion 33 MAPROTILINE HCL 23

marlissa 68 MARPLAN 23

MATULANE 29 meclizine hcl 26

medroxyprogesterone acetate 69 mefloquine hcl 33 MEGACE ES 69

megestrol acetate 69 MEKINIST 31 meloxicam 10

MENACTRA 73 MENEST 31

MENOMUNE-A/C/Y/W-135 73 MENVEO 73

mercaptopurine 30 meropenem 16 mesalamine 74

mesna 31 MESNEX 31

MESTINON 29 metaproterenol sulfate 79

metformin hcl 43 metformin hcl er 43

methadone hcl 11 methazolamide 76

methimazole 71 methotrexate 72

methotrexate sodium 72 METHYCLOTHIAZIDE 54

methylphenidate hcl 58 methylphenidate hcl cd 57 methylphenidate hcl er 58

methylprednisolone 65 methylprednisolone dose pack 65

91


nitrofurantoin 14 nitrofurantoin macrocrystals 14 nitrofurantoin monohydrate 14

NITROGLYCERIN 56 nitroglycerin transdermal 56

nitrostat 56 nizatidine 61

nora-be 69 norethindrone 69

norethindrone acetate 69 nortrel 0.5/35 (28) 68

novofine pen needle miscellaneous 75 nortriptyline hcl 26

NORVIR 40 NOVOLIN 70/30 44

NOVOLIN N 44 NOVOLIN R 44 NOVOLOG 44

NOVOLOG MIX 70/30 44 NOVOLOG MIX 70/30 PREFILLED

FLEXPEN 44

NOVOLOG PENFILL 44 NOXAFIL 27

NUEDEXTA 58 NUVARING 68

NUVIGIL 80 nystatin 28

nystatin/triamcinolone 27 ocella 68

octreotide acetate 71 ofloxacin 18

OGESTREL 68 olanzapine 36

olanzapine odt 36 OLYSIO 38

omeprazole 62 OMNITROPE 66 ONCASPAR 31

ondansetron hcl 27 ondansetron odt 27

ONFI 20 ORAP 35

ORENCIA 72 ORFADIN 75


naltrexone hcl 13 NAMENDA XR 22

NAMENDA XR TITRATION PACK 22 NAPHAZOLINE HCL 75

naproxen 10 naproxen dr 10

naproxen sodium 10 naratriptan hcl 28

NASONEX 77 NATACYN 27

NATAZIA 68 nateglinide 43

NEBUPENT 33 necon 1/35 68

NECON 1/50-28 68 NECON 10/11-28 68

necon 7/7/7 68 NEFAZODONE HCL 23

neomycin sulfate 13 neomycin/bacitracin/polymyxin 14

neomycin/polymyxin/bacitracin/hydro cortisone

14

neomycin/polymyxin/dexamethasone 76 neomycin/polymyxin/gramicidin 14

neomycin/polymyxin/hc 76 NEOMYCIN/POLYMYXIN/HYDROC

ORTISONE 14

neomycin/polymyxin/hydrocortisone 76 NEULASTA 46 NEUMEGA 46

NEUPOGEN 46 NEUPRO 33

NEVIRAPINE 39 nevirapine er 38

NEXAVAR 32 niacin er 55

nicardipine hcl 52 NICOTROL INHALER 13

NICOTROL NS 13 nifediac cc 52

nifedipine er 52 NILANDRON 29

nimodipine 52 NISOLDIPINE 52

NITRO-BID 56

92


orphenadrine citrate er 80 ORTHO TRI-CYCLEN LO 68

oxandrolone 66 oxaprozin 10

oxcarbazepine 21 OXSORALEN 59

OXSORALEN ULTRA 59 oxybutynin chloride 62

oxybutynin chloride er 62 oxycodone hcl 12

oxycodone/acetaminophen 12 oxymorphone hydrochloride er 11

PACERONE 49 PANCREAZE 60

PANRETIN 32 pantoprazole sodium 62

paricalcitol 74 paromomycin sulfate 13

paroxetine hcl 24 paroxetine hcl er 24

PASER 29 PATADAY 75 PATANOL 75

paxil 25 PEDVAX HIB 73 PEGANONE 21

PEGASYS 38 PEGASYS PROCLICK 38

PEG-INTRON 38 PEG-INTRON REDIPEN 38

penicillin g potassium 17 penicillin v potassium 17

PENTAM 300 33 PENTASA 74

pentoxifylline er 53 PERJETA 32 permethrin 33

perphenazine 35 phenadoz 26

phenelzine sulfate 23 phenobarbital 19

phenytoin 22 phenytoin sodium 22

phenytoin sodium extended 21


PHOSPHOLINE IODIDE 76 pilocarpine hydrochloride 59

pimtrea 68 PINDOLOL 50

pioglitazone hcl 43 pioglitazone hcl/metformin hcl 43

PIOGLITAZONE HCL-GLIMEPIRIDE 43 piperacillin sodium/tazobactam

sodium 17

pirmella 1/35 68 piroxicam 10 podofilox 59

polyethylene glycol 3350 62 polymyxin b sulfate/trimethoprim

sulfate 14

POMALYST 31 portia-28 68

potassium chloride 81 potassium chloride er 81 potassium chloride sr 81

potassium citrate 81 POTIGA 19

PRADAXA 45 pramipexole dihydrochloride 34

PRANDIMET 43 pravastatin sodium 55

prazosin hcl 47 prednisolone acetate 76

prednisolone sodium phosphate 65 PREDNISOLONE SODIUM

PHOSPHATE 76

prednisone 65 PREDNISONE INTENSOL 65

PREFEST 68 PREMARIN 68

PREMPHASE 68 PREMPRO 68

PRENATABS OBN 81 prevalite 55

PREZISTA 40 PRIFTIN 29

PRIMAQUINE PHOSPHATE 33 primidone 20 PRISTIQ 25

PROAIR HFA 79

93


ramipril 49 RANEXA 53

ranitidine hcl 61 RAPAMUNE 72

RECOMBIVAX HB 73 REGRANEX 59

RELENZA DISKHALER 40 RELISTOR 61

RELPAX 28 REMICADE 72

REMODULIN 79 RENVELA 63

REPAGLINIDE 43 RESCRIPTOR 39

RESTASIS 75 RETROVIR IV INFUSION 39

REVLIMID 30 REYATAZ 40

RHINOCORT AQUA 77 ribavirin 38

RIDAURA 72 rifabutin 29 rifampin 29

RIFATER 29 riluzole 58

rimantadine hcl 40 RISPERDAL CONSTA 37

risperidone 37 risperidone odt 37

RITUXAN 32 rivastigmine tartrate 22 rizatriptan benzoate 28

rizatriptan benzoate odt 28 ropinirole hcl 34

ROTARIX 73 ROTATEQ 73 ROZEREM 80

SABRIL 20 SAFYRAL 68

SANDIMMUNE 72 SANTYL 59

SAPHRIS 37 selegiline hcl 34

selenium sulfide 59


probenecid 28 probenecid/colchicine 28

prochlorperazine 35 prochlorperazine edisylate 35 prochlorperazine maleate 35

PROCRIT 46 procto-pak 65

proctozone-hc 65 progesterone 69

PROGLYCEM 44 PROGRAF 72

PROLASTIN-C 80 PROLIA 75

PROMACTA 46 promethazine hcl 26 promethazine hcl 78 propafenone hcl 49

propranolol hcl 51 propranolol hcl er 51

PROPRANOLOL/HYDROCHLOROT HIAZIDE

51

propylthiouracil 71 PROQUAD 73 PROTOPIC 59

protriptyline hcl 26 PROVENTIL HFA 79

PRUDOXIN 59 PULMICORT 77

PULMICORT FLEXHALER 77 PULMOZYME 79 pyrazinamide 29

pyridostigmine bromide 29 quasense 68

quetiapine fumarate 36 quinapril hcl 49

quinapril/hydrochlorothiazide 49 quinidine gluconate cr 49

quinidine sulfate 49 QUINIDINE SULFATE ER 49

quinine sulfate 33 QVAR 77

RABAVERT 73 rabeprazole sodium 62

raloxifene hydrochloride 69

94


sulfamethoxazole/trimethoprim ds 18 sulfasalazine 74 sulfazine ec 74

sulindac 10 sumatriptan succinate 28

SUPRAX 16 surmontil 26 SUSTIVA 39 SUTENT 32

SYLATRON 31 SYMBICORT 78

SYMLINPEN 120 43 SYMLINPEN 60 43

SYNAGIS 72 SYNAREL 71

SYNERCID 14 SYNRIBO 31

SYNTHROID 70 SYPRINE 81 TABLOID 30

tacrolimus 72 TAFINLAR 32 TAMIFLU 40

tamoxifen citrate 30 tamsulosin hcl 63

TARCEVA 32 TARGRETIN 32

TASIGNA 32 TASMAR 33

TAZORAC 59 taztia xt 52

TEFLARO 16 TEGRETOL-XR 22

temazepam 41 terazosin hcl 63

terbinafine hcl 28 terbutaline sulfate 79

terconazole 28 testosterone cypionate 66 testosterone enanthate 66

TETANUS TOXOID ADSORBED 73 TETANUS/DIPHTHERIA TOXOIDS-

ADSORBED ADULT 73

THALOMID 30


SELZENTRY 40 SENSIPAR 70

SEREVENT DISKUS 79 SEROMYCIN 29 sertraline hcl 25

sildenafil 80 silver sulfadiazine 14

SIMBRINZA 76 simvastatin 55

sirolimus 72 SKLICE 33

sodium chloride 81 sodium chloride 0.9% 75

SODIUM EDECRIN 53 sodium polystyrene sulfonate 81

sodium sulfacetamide 18 SOLTAMOX 30

SOLU-MEDROL 65 SOMATULINE DEPOT 71

SOMAVERT 71 sotalol hcl 49

sotalol hcl (af) 49 SOVALDI 38

SPIRIVA HANDIHALER 78 spironolactone 54

spironolactone/hydrochlorothiazide 54 SPORANOX 28

SPRYCEL 32 STALEVO 100 34 STALEVO 125 34 STALEVO 150 34 STALEVO 200 34

STALEVO 50 34 STALEVO 75 34

stavudine 39 STIVARGA 32

STRATTERA 58 STREPTOMYCIN SULFATE 13

STRIBILD 39 sucralfate 62

SULFACETAMIDE SODIUM 18 SULFADIAZINE 18

SULFAMETHOXAZOLE/TRIMETHO PRIM

18

95


trihexyphenidyl hcl 33 tri-legest fe 69

trilyte 62 trimethoprim 14

trinessa 69 trivora-28 69

trospium chloride 62 TRUVADA 39

TUDORZA PRESSAIR 78 TWINRIX 73 TYGACIL 14 TYKERB 32

TYPHIM VI 73 TYSABRI 58 TYZEKA 38 TYZINE 80

TYZINE PEDIATRIC NASAL DROPS 80 u-cort 66

ULORIC 28 ursodiol 61

UVADEX 60 VAGIFEM 69

valacyclovir hcl 41 VALCYTE 37

valproate sodium 21 valproic acid 21

valsartan/hydrochlorothiazide 47 vancomycin hcl 14

VAQTA 73 VARIVAX 73

VASCEPA 55 VELCADE 31

velivet 69 venlafaxine hcl 25

venlafaxine hcl er 25 VENTOLIN HFA 79

verapamil hcl 53 verapamil hcl er 52 verapamil hcl sr 53

VERSACLOZ 37 VESICARE 63

vestura 69 VICTOZA 43

VICTRELIS 38


theophylline cr 79 theophylline er 79 thioridazine hcl 35

thiothixene 35 THYMOGLOBULIN 72

tiagabine hydrochloride 20 ticlopidine hcl 46

TIKOSYN 49 TIMENTIN 17

TIMOLOL MALEATE 51 timolol maleate 76

TIVICAY 38 tizanidine hcl 37

TOBI PODHALER 79 TOBRADEX 76

tobramycin 79 tobramycin sulfate 13

tobramycin/dexamethasone 76 TOLBUTAMIDE 43

tolterodine tartrate 62 tolterodine tartrate er 62

topiramate 21 topotecan hcl 31

torsemide 53 tpn electrolytes 81

TRACLEER 80 TRADJENTA 43 tramadol hcl 12

tramadol hcl er 11 tranexamic acid 46

TRANSDERM-SCOP 26 tranylcypromine sulfate 24

TRAVATAN Z 75 trazodone hcl 23 TRECATOR 29 TRETINOIN 32

tretinoin 59 triamcinolone acetonide 65

triamcinolone in orabase 59 triamterene/hydrochlorothiazide 54

TRIANEX 66 triazolam 41

trifluoperazine hcl 35 trifluridine 41

96


zonisamide 20 ZORTRESS 72 ZOSTAVAX 74 zovia 1/35e 69

ZOVIA 1/50E 69 ZOVIRAX 41

ZYFLO CR 78 ZYTIGA 29 ZYVOX 15


VIDEX PEDIATRIC 39 VIGAMOX 18

VIIBRYD 25 VIMPAT 22

VIRACEPT 40 VIRAMUNE 39

VIRAMUNE XR 39 VIRAZOLE 38

VIREAD 39 VIVELLE-DOT 69

VOLTAREN 60 voriconazole 28

VOTRIENT 32 vyfemla 69

VYTORIN 55 VYVANSE 57

warfarin sodium 45 WELCHOL 56

XALKORI 32 XARELTO 45

XENAZINE 58 XGEVA 75

XIFAXAN 14 XOLAIR 80 XTANDI 29

xulane 69 XYREM 80

YERVOY 32 YF-VAX 73

zafirlukast 78 zaleplon 80

ZAVESCA 60 ZELBORAF 32

ZEMPLAR 75 zenchent 69

ZETIA 56 ZIAGEN 39

zidovudine 39 ziprasidone hcl 37 zoledronic acid 75

ZOLINZA 31 zolpidem tartrate 80

zolpidem tartrate er 80 ZONALON 60

Presbyterian Senior Care (HMO) Presbyterian MediCare PPO

Este formulario se actualizó el 28 de julio de 2014. Para obtener información más reciente o si tiene otras preguntas, llame al Servicio al Cliente de Presbyterian Health Plan y Presbyterian Insurance Company, Inc. al (505)923-6060 o al 1-800-797-5343; si es usuario de TTY/TDD, llame al 711 o al 1-800-659-8331, de lunes a domingo, de 8:00 a.m. a 8:00 p.m., o visite www.phs.org/Medicare.

Presbyterian existe para mejorar la salud de los pacientes, sus miembros y las comunidades a las que brindamos servicio.

www.phs.org/Medicare

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