GuildNet Gold · Si no sabe en qué categoría buscar, debe buscar su medicamento en el índice que comienza en ... Cuando reciba la lista, muéstresela a su médico y pídale que

2018 Formulario

GuildNet Gold Medicare Advantage Prescription Drug Plan

Este vademécum se actualizó el 7/31/17. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con GuildNet Gold, llamando al 1-800-815-0000 o, para los usuarios de TTY 711, 8am a 8pm de lunes a domingo, o visite www.guildnetny.org.H6864_GN595Sp_2018 Formulary _Accepted

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VADEMÉCUM DEL PLAN HMO-SNP DE GUILDNET GOLD PARA EL 2018

VADEMÉCUM PARA EL PLAN HMO-SNP DE GUILDNET GOLD PARA EL 2018 (Lista de medicamentos cubiertos)POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN

GuildNet Gold 2018 FID 18107, Versión número 9

Nota dirigida a los miembros activos: Este vademécum ha cambiado desde el año pasado. Revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma.

Cuando en esta lista de medicamentos (vademécum) se dice “nosotros” o “nuestro”, se está haciendo referencia a GuildNet. Cuando se dice “el plan” o “nuestro plan”, se refiere a GuildNet Gold.

Este documento incluye la lista de medicamentos (vademécum) de nuestro plan, actualizada al 31 de julio del 2018. Para obtener un vademécum actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en la portada y en la contraportada.

Por lo general, usted debe acudir a las farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, vademécum, red de farmacias y copagos o coaseguro pueden cambiar el 1 de enero del 2018 y algunas veces durante el año.

GuildNet Gold es un plan de Organización para el Mantenimiento de la Salud (Health Maintenance Organization, HMO) y para Necesidades Especiales (Special Needs Plans, SNP) del estado de Nueva York que cuenta con un contrato con Medicare y Medicaid. La inscripción en GuildNet Gold depende de la renovación del contrato.

Usted debe continuar pagando la prima de la Parte B de su Medicare. Si usted tiene cobertura total de Medicaid, el plan estatal de Medicaid paga la prima de Medicare Parte B por usted.

La información suministrada sobre los beneficios es un resumen, no una descripción completa de los mismos. Para obtener más información, comuníquese con el plan.

Pueden aplicar ciertas limitaciones, copagos y restricciones.

El vademécum y la red de farmacias pueden cambiar en cualquier momento. Usted recibirá una notificación sobre estos cambios cuando sea necesario.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro servicio de Atención al Cliente llamando al 1-800-815-0000, de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al 711, de 8 a.m. a 8 p.m., de lunes a domingo, para obtener información adicional.

Esta información está disponible en otros idiomas de forma gratuita. Por favor, llame a Servicios al Miembro. Por favor, llame a Servicios para Miembros al 1-800-815-0000 para obtener información adicional. (Los usuarios de TTY deben llamar al 711). Se atiende de lunes a domingo de 8 a.m. a 8 p.m. Servicios al Miembro cuenta con servicios de interpretación gratuitos disponibles para personas que no hablan inglés.

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VADEMÉCUM DEL PLAN HMO-SNP DE GUILDNET GOLD PARA EL 2018VADEMÉCUM DEL PLAN HMO-SNP DE GUILDNET GOLD PARA EL 2018

¿Qué es el vademécum de GuildNet Gold?Un vademécum es una lista de medicamentos cubiertos seleccionados por GuildNet Gold después de consultar a un equipo de proveedores de atención médica, el cual representa las terapias recetadas que se consideran necesarias para llevar a cabo un programa de tratamiento de calidad. Por lo general, GuildNet Gold cubre los medicamentos listados en nuestro vademécum siempre y cuando el medicamento sea necesario en términos médicos, los medicamentos recetados se despachen en farmacias de la red GuildNet Gold y se sigan otras normas del plan. Para obtener más información sobre cómo surtir sus medicamentos recetados, revise su Evidencia de cobertura.

¿El vademécum (listado de medicamentos) puede cambiar?Por lo general, si usted está tomando un medicamento incluido en nuestro vademécum del 2018 y que estaba bajo cobertura al comienzo del año, no suspenderemos ni reduciremos la cobertura de ese medicamento durante el año de cobertura 2018, excepto cuando esté disponible un medicamento genérico nuevo y menos costoso o cuando se publique información desfavorable sobre la seguridad o eficacia de un medicamento. Otro tipo de cambio en el vademécum, como la eliminación de un medicamento de nuestro vademécum, no afectará a los miembros que estén tomando el medicamento en la actualidad. Seguirá estando disponible al mismo costo compartido para aquellos miembros que lo estén tomando por el resto del año de la cobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año de la cobertura a los medicamentos del vademécum que estaban disponibles cuando usted escogió nuestro plan, excepto en los casos en los que pueda ahorrar dinero adicional o que podamos garantizar su seguridad.

Si retiramos medicamentos de nuestro vademécum o agregamos autorización previa, límites de cantidades o restricciones a las terapias escalonadas de un medicamento, estamos obligados a notificarles a los miembros afectados sobre el cambio al menos 60 días antes de que el cambio entre en vigencia o en el momento en que el miembro solicite un resurtido del medicamento recetado, cuando el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Fármacos (Food and Drug Administration, FDA) considera que un medicamento de nuestro vademécum no es seguro o si el fabricante del medicamento lo retira del mercado, lo retiraremos de inmediato de nuestro vademécum y les avisaremos a los miembros que lo usan. El vademécum adjunto está actualizado al 31 de julio de 2017. Para obtener información actualizada acerca de los medicamentos cubiertos por GuildNet Gold, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y en la contraportada. En caso de que se realice algún cambio en el vademécum a mitad de año que no sea por mantenimiento, se anexará a una lista completa de cambios realizados en el vademécum desde su impresión. La lista de cambios se incluye en el folleto del vademécum que se envía por correo a los miembros nuevos con el paquete de bienvenida. Los miembros activos pueden revisar el vademécum actualizado a través de nuestro sitio web www.guildnetny.org. El vademécum publicado en nuestra página web se actualiza cada mes. Los miembros también pueden solicitar la lista de cambios llamando a Atención al Cliente. Nuestra información de contacto aparece en la portada y en la contraportada.

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¿Cómo utilizo el vademécum? Hay dos maneras de encontrar su medicamento dentro del vademécum:

EnfermedadEl vademécum comienza en la página 1. Los medicamentos en este vademécum están agrupados en categorías según el tipo de enfermedad para la que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca están listados bajo la categoría “Cardiovascular-Hipertensivo/Lípidos”. Si usted sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página número 1. Luego busque su medicamento bajo el nombre de la categoría.

Listado en orden alfabéticoSi no sabe en qué categoría buscar, debe buscar su medicamento en el índice que comienza en la página 76. El índice contiene una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos están listados en este Índice. Busque en el índice y encuentre su medicamento. Al lado de su medicamento, verá el número de la página donde puede encontrar la información sobre la cobertura. Vaya a la página listada en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?GuildNet Gold cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico es aquel que contiene los mismos ingredientes activos que el medicamento de marca y tiene la aprobación de la FDA. Por lo general, los medicamentos genéricos cuestan menos que los de marca.

¿Existe alguna restricción en mi cobertura?Algunos medicamentos cubiertos podrían tener requisitos adicionales o límites de cobertura. Estos requisitos o límites podrían incluir:

• Autorización previa: Nuestro plan requiere que usted o su médico obtengan autorización previapara algunos medicamentos. Esto significa que deberá recibir la aprobación de nuestro plan antesde surtir sus recetas. Si no recibe aprobación, puede que nuestro plan no cubra el medicamento.

• Límites de cantidad: Para algunos medicamentos, nuestro plan limita la cantidad delmedicamento que cubriremos. Por ejemplo, nuestro proporciona 30 tabletas por receta paraJanuvia. Esto podría ser adicional a un suministro estándar para uno o tres meses.

• Terapia escalonada: En algunos casos, nuestro plan requiere que primero pruebe algunosmedicamentos para tratar su enfermedad, antes de que cubramos otro medicamento para esaenfermedad. Por ejemplo, si el medicamento A y el B tratan su enfermedad, puede que nuestroplan no cubra el medicamento B, a menos que usted pruebe el A primero. Si el medicamento Ano es adecuado para usted, entonces cubriremos el B.


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Puede saber si su medicamento tiene límites o requisitos adicionales al buscar en el vademécum que comienza en la página 1. También puede obtener más información acerca de las restricciones que aplican a ciertos medicamentos cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra restricción de autorización previa o restricción de terapia escalonada o restricciones de autorizaciones previas y terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en la portada y en la contraportada.

Puede pedirle a GuildNet Gold que haga una excepción en cuanto a estas restricciones o límites, o pedirle una lista de otros medicamentos similares que puedan servir para tratar su enfermedad. Consulte la sección “¿Cómo solicito una excepción para el vademécum de GuildNet Gold?” en la página iv para información acerca de cómo solicitar una excepción.

¿Qué son los medicamentos de venta libre (OTC)?Los medicamentos de venta libre (Over The Counter, OTC) son aquellos que se venden sin receta médica y que, por lo general, no están cubiertos por el Plan de Medicamentos Recetados de Medicare. GuildNet Gold cubre ciertos medicamentos OTC. Los ejemplos de medicamentos de venta libre cubiertos son: aspirina, paracetamol, Advil, antiácidos, medicamentos para resfriados y alergias, cremas antibióticas, laxantes, parches y chicles de nicotina y vitaminas. GuildNet Gold proporcionará estos medicamentos OTC de forma gratuita. El monto que GuildNet Gold pagará por estos medicamentos OTC no contará en los costos totales de los medicamentos de su Parte D (es decir, el monto que usted paga no cuenta para la diferencia de cobertura).

¿Qué ocurre si mi medicamento no está en el vademécum?Si su medicamento no está incluido en este vademécum (lista de medicamentos cubiertos), primero debe contactar a Servicios al Miembro y preguntar si cubrimos su medicamento.

En caso de que GuildNet Gold no cubra su medicamento, usted tiene dos opciones:

• Puede pedirle a Servicios al Miembro una lista de medicamentos similares que estén cubiertospor GuildNet Gold. Cuando reciba la lista, muéstresela a su médico y pídale que le recete unmedicamento similar que esté cubierto por GuildNet Gold.

• Puede pedirle a GuildNet Gold que haga una excepción y cubra su medicamento. Revise másabajo para obtener información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al vademécum de GuildNet Gold?Puede solicitar a GuildNet Gold que haga una excepción en cuanto a nuestras normas de cobertura. Existen varios tipos de excepciones que nos puede solicitar.

• Puede pedirnos que cubramos un medicamento, incluso si este no está en nuestro vademécum.De aprobarse, este medicamento será cubierto a un nivel predeterminado de costo compartido yno podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartidomás bajo.

• Puede solicitarnos que no apliquemos las restricciones o límites de cobertura sobre sumedicamento. Por ejemplo, para ciertos medicamentos, GuildNet Gold limita la cantidad delmedicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnosque no apliquemos el límite y cubramos una cantidad mayor.

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Por lo general, GuildNet Gold solo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el vademécum del plan (el medicamento de menor costo compartido) o las restricciones de uso adicionales no son tan efectivas para tratar su enfermedad o le causarán un efecto médico adverso.

Usted debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción o restricción de uso en el vademécum. Cuando solicita una excepción del vademécum o de las restricciones de uso debe enviar una declaración por parte de su médico que apoye su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las primeras 72 horas de haber recibido la declaración de apoyo de su médico. Usted puede solicitar una excepción expedita (rápida) si usted o su médico creen que su salud puede verse gravemente afectada si tiene que esperar hasta 72 horas por una decisión. Si se le concede esta solicitud expedita, debemos notificarle sobre la decisión a más tardar 24 horas después de haber recibido la declaración de apoyo de su médico u otra persona que haya emitido la receta.

¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción?Como miembro nuevo o regular de nuestro plan, podría estar tomando medicamentos que no estén dentro de nuestro vademécum. O podría estar tomando un medicamento que está en nuestro vademécum, pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte antes de que pueda surtir su receta. Es recomendable que hable con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción al vademécum para que cubramos el medicamento que usted toma. Mientras habla con su médico para determinar qué debe hacer, podríamos cubrir su medicamento en casos determinados durante los primeros 90 días en los que usted es miembro de nuestro plan.

Por cada uno de sus medicamentos que no estén en nuestro vademécum o si su capacidad para obtenerlos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta escrita por menos días) cuando acuda a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días.

Si es residente de un centro de cuidados a largo plazo, le permitiremos resurtir su receta hasta que le hayamos proporcionado un suministro de transición de 98 días, consecuente con el incremento del surtido (a menos que tenga una receta escrita por menos días). Cubriremos más de un resurtido de estos medicamentos durante sus primeros 90 días como miembro de nuestro plan. Si necesita un medicamento que no está en nuestro vademécum o si su capacidad para obtenerlo es limitada, pero tiene más de 90 días como miembro de nuestro plan, cubriremos un suministro de emergencia de 31 días para ese medicamento (a menos que tenga una receta escrita por menos días) mientras tramita una excepción al vademécum.

Si es miembro actual de nuestro plan y experimenta un cambio en el nivel de atención, como una admisión o alta médica en un centro de cuidados a largo plazo, tendrá permitido un resurtido “anticipado” de sus medicamentos, según sea necesario, para ayudarle en la transición a su nuevo nivel de atención.


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Para más informaciónPara obtener más información sobre la cobertura de medicamentos recetados de GuildNet Gold, revise su Evidencia de Cobertura y otros materiales del plan.

Si tiene preguntas sobre GuildNet Gold, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, 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.

Vademécum de GuildNet GoldEl vademécum que comienza en la página 1 proporciona información acerca de los medicamentos cubiertos por GuildNet Gold. Si tiene dificultades para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 78.

La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (p. ej., SYNTHROID) y los genéricos aparecen en minúscula y cursiva (p. ej., levothyroxine).

La información en la columna de Requisitos/Límites indica si GuildNet Gold tiene algún requisito especial para la cobertura de su medicamento.

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A continuación, encontrará una lista de las abreviaturas que pueden aparecer en las siguientes páginas en la columna de Requisitos/Límites, la cual indica si hay algún requisito especial para la cobertura de su medicamento.

Lista de abreviacionesB/D PA: Este medicamento recetado puede estar cubierto por Medicare Parte B o D, dependiendo de las circunstancias. Puede ser necesario presentar información que describa el uso y entorno del medicamento para tomar la decisión.

Disponibilidad limitada (Limited Availability, LA): Disponibilidad limitada. Este medicamento recetado puede estar disponible solo en algunas farmacias. Para obtener más información, por favor llame a Atención al Cliente al 1-877-344-7364, de lunes a domingo de 8:00 a.m. a 8:00 p.m., (los usuarios de TTY deben llamar al 711).

Pedido por correo (Mail-Order, MO): Medicamento pedido por correo. Este medicamento recetado está disponible a través de nuestro servicio de pedido por correo, así como también a través de nuestra red de farmacias minoristas. Considere usar el servicio de pedido por correo para sus medicamentos a largo plazo (de mantenimiento, como los medicamentos para la hipertensión). La red de farmacias minoristas puede ser más adecuada para las recetas a corto plazo (como antibióticos).

AUTORIZACIÓN PREVIA (PRIOR AUTORIZATION, PA): Autorización previa. El plan requiere que usted o su médico obtenga autorización previa para algunos medicamentos. Esto significa que deberá recibir la aprobación antes de surtir sus recetas. Si no recibe aprobación, puede que no cubramos el medicamento.

Límite de cantidad (Quantity Limit, QL): Límite de cantidad. Para ciertos medicamentos, el plan limita la cantidad que cubriremos.

Terapia por pasos (Step Therapy, ST): Terapia por pasos. En algunos casos, el plan requiere que primero pruebe algunos medicamentos para tratar su enfermedad, antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el B tratan su enfermedad, puede que no cubramos el medicamento B a menos que usted pruebe el A primero. Si el medicamento A no es adecuado para usted, entonces cubriremos el B.

Nationwide Emergency Department Sample (NEDS): Suministro de días no extendidos Para algunos medicamentos, el plan limita el suministro de los días que cubriremos durante todo un mes.

Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página vii.

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Nombre del medicamento Nivel del

medicamento

Requisitos/Límites

ANTIINFECCIOSOS

AGENTES ANTIMICÓTICOS

ABELCET INTRAVENOUS SUSPENSION 4 B/D PA; MO

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

4 B/D PA; MO

amphotericin b injection recon soln 2 B/D PA; MO

CANCIDAS INTRAVENOUS RECON SOLN 5 B/D PA; MO

clotrimazole mucous membrane troche 2 MO

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml

2 B/D PA; MO

fluconazole in nacl (iso-osm) intravenous


2 B/D PA

fluconazole oral suspension for reconstitution 2 MO

fluconazole oral tablet 2 MO

flucytosine oral capsule 2 MO

griseofulvin microsize oral suspension 2 MO

griseofulvin microsize oral tablet 2 MO

griseofulvin ultramicrosize oral tablet 2 MO

itraconazole oral capsule 2 MO; QL (120 per 30 days)

ketoconazole oral tablet 2 MO

NOXAFIL ORAL SUSPENSION 5 MO

nystatin oral suspension 2 MO

nystatin oral tablet 2 MO

terbinafine hcl oral tablet 2 MO; QL (90 per 365 days)

voriconazole intravenous solution 2 B/D PA; MO

voriconazole oral suspension for reconstitution 5 MO

voriconazole oral tablet 200 mg 5 MO

voriconazole oral tablet 50 mg 2 MO

ANTIVIRALES

abacavir oral tablet 2 MO; QL (60 per 30 days)

abacavir-lamivudine oral tablet 5 MO; QL (30 per 30 days)

abacavir-lamivudine-zidovudine oral tablet 5 MO; QL (60 per 30 days)

acyclovir oral capsule 2 MO

acyclovir oral suspension 200 mg/5 ml 2 MO

acyclovir oral tablet 2 MO


2


medicamento

Requisitos/Límites

acyclovir sodium intravenous solution 2 B/D PA; MO

adefovir oral tablet 5 MO

amantadine hcl oral capsule 2 MO

amantadine hcl oral solution 2 MO

amantadine hcl oral tablet 2 MO

APTIVUS ORAL CAPSULE 3 MO; QL (120 per 30 days)

APTIVUS ORAL SOLUTION 3 QL (285 per 28 days)

ATRIPLA ORAL TABLET 5 MO; QL (30 per 30 days)

BARACLUDE ORAL SOLUTION 3 MO

cidofovir intravenous solution 3 B/D PA; MO

COMPLERA ORAL TABLET 5 MO; QL (30 per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG 3 MO; QL (270 per 30 days)

CRIXIVAN ORAL CAPSULE 400 MG 3 MO; QL (180 per 30 days)

DESCOVY ORAL TABLET 5 MO; QL (30 per 30 days)

didanosine oral capsule,delayed release(dr/ec)

125 mg

2 QL (30 per 30 days)

didanosine oral capsule,delayed release(dr/ec)

200 mg, 250 mg, 400 mg

2 MO; QL (30 per 30 days)

EDURANT ORAL TABLET 4 MO; QL (30 per 30 days)

EMTRIVA ORAL CAPSULE 3 MO; QL (30 per 30 days)

EMTRIVA ORAL SOLUTION 3 MO; QL (680 per 28 days)

entecavir oral tablet 5 MO; QL (30 per 30 days)

EPCLUSA ORAL TABLET 5 PA; MO; QL (28 per 28 days)

EPIVIR HBV ORAL SOLUTION 4 MO

EVOTAZ ORAL TABLET 5 MO; QL (30 per 30 days)

famciclovir oral tablet 125 mg 2 MO; QL (21 per 10 days)



FUZEON SUBCUTANEOUS RECON SOLN 5 MO; QL (60 per 30 days)

ganciclovir sodium intravenous recon soln 2 B/D PA; MO

GENVOYA ORAL TABLET 5 MO; QL (30 per 30 days)

HARVONI ORAL TABLET 5 PA; MO; QL (28 per 28 days); NEDS

INTELENCE ORAL TABLET 100 MG 3 MO; QL (60 per 30 days)


3


medicamento

Requisitos/Límites



INVIRASE ORAL CAPSULE 5 MO; QL (300 per 30 days)

INVIRASE ORAL TABLET 5 MO; QL (120 per 30 days)

ISENTRESS ORAL POWDER IN PACKET 3 MO; QL (180 per 30 days)

ISENTRESS ORAL TABLET 3 MO; QL (60 per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 3 MO; QL (180 per 30 days)

KALETRA ORAL SOLUTION 5 MO; QL (480 per 30 days)

KALETRA ORAL TABLET 100-25 MG 3 MO; QL (300 per 30 days)

KALETRA ORAL TABLET 200-50 MG 5 MO; QL (120 per 30 days)

lamivudine oral solution 2 MO; QL (900 per 30 days)

lamivudine oral tablet 100 mg, 300 mg 2 MO; QL (30 per 30 days)

lamivudine oral tablet 150 mg 2 MO; QL (60 per 30 days)

lamivudine-zidovudine oral tablet 4 MO; QL (60 per 30 days)

LEXIVA ORAL SUSPENSION 3 MO; QL (1575 per 28 days)

LEXIVA ORAL TABLET 3 MO; QL (120 per 30 days)

nevirapine oral suspension 2 MO; QL (1200 per 30 days)

nevirapine oral tablet 2 MO; QL (60 per 30 days)

nevirapine oral tablet extended release 24 hr 100

mg


nevirapine oral tablet extended release 24 hr 400

mg


NORVIR ORAL CAPSULE 3 MO; QL (360 per 30 days)

NORVIR ORAL SOLUTION 3 MO; QL (480 per 30 days)

NORVIR ORAL TABLET 3 MO; QL (360 per 30 days)

ODEFSEY ORAL TABLET 5 MO; QL (30 per 30 days)

oseltamivir oral capsule 30 mg 2 MO; QL (84 per 180 days)

oseltamivir oral capsule 45 mg, 75 mg 2 MO; QL (42 per 180 days)

PREZCOBIX ORAL TABLET 5 MO; QL (30 per 30 days)

PREZISTA ORAL SUSPENSION 5 MO; QL (400 per 30 days)

PREZISTA ORAL TABLET 150 MG 3 MO; QL (180 per 30 days)





4


medicamento

Requisitos/Límites

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE


RESCRIPTOR ORAL TABLET 3 MO; QL (180 per 30 days)

RESCRIPTOR ORAL TABLET, DISPERSIBLE 3 MO; QL (270 per 30 days)

RETROVIR INTRAVENOUS SOLUTION 3 MO

REYATAZ ORAL CAPSULE 150 MG, 200 MG 3 MO; QL (60 per 30 days)

REYATAZ ORAL CAPSULE 300 MG 3 MO; QL (30 per 30 days)

REYATAZ ORAL POWDER IN PACKET 3 MO; QL (180 per 30 days)

ribavirin oral capsule 2 PA; MO

ribavirin oral tablet 200 mg 2 PA; MO

rimantadine oral tablet 2 MO

SELZENTRY ORAL TABLET 150 MG 5 MO; QL (60 per 30 days)




SOVALDI ORAL TABLET 5 PA; MO; QL (30 per 30 days); NEDS

stavudine oral capsule 2 MO; QL (60 per 30 days)

STRIBILD ORAL TABLET 5 MO; QL (30 per 30 days)

SUSTIVA ORAL CAPSULE 200 MG 3 MO; QL (60 per 30 days)

SUSTIVA ORAL CAPSULE 50 MG 3 MO; QL (90 per 30 days)

SUSTIVA ORAL TABLET 3 MO; QL (30 per 30 days)

SYNAGIS INTRAMUSCULAR SOLUTION 50

MG/0.5 ML

5 PA; MO; LA

TIVICAY ORAL TABLET 10 MG 4 MO; QL (60 per 30 days)

TIVICAY ORAL TABLET 25 MG, 50 MG 5 MO; QL (60 per 30 days)

TRIUMEQ ORAL TABLET 5 MO; QL (30 per 30 days)

TRUVADA ORAL TABLET 5 MO; QL (30 per 30 days)

TYBOST ORAL TABLET 3 MO; QL (30 per 30 days)

valacyclovir oral tablet 2 MO; QL (30 per 30 days)

valganciclovir oral recon soln 5 MO

valganciclovir oral tablet 5 MO

VIDEX 2 GRAM PEDIATRIC ORAL RECON

SOLN

3 MO

VIRACEPT ORAL TABLET 250 MG 3 MO; QL (270 per 30 days)


5


medicamento

Requisitos/Límites

VIRACEPT ORAL TABLET 625 MG 3 MO; QL (120 per 30 days)

VIREAD ORAL POWDER 3 MO; QL (240 per 30 days)

VIREAD ORAL TABLET 3 MO; QL (30 per 30 days)

ZERIT ORAL RECON SOLN 4 MO

ZIAGEN ORAL SOLUTION 3 MO; QL (960 per 30 days)

zidovudine oral capsule 2 MO; QL (180 per 30 days)

zidovudine oral syrup 2 MO; QL (1680 per 28 days)

zidovudine oral tablet 2 MO; QL (60 per 30 days)

CEFALOSPORINAS

cefaclor oral capsule 2 MO

cefaclor oral tablet extended release 12 hr 2 MO

cefadroxil oral capsule 2 MO

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

2 MO

cefadroxil oral tablet 2 MO

cefazolin injection recon soln 1 gram, 500 mg 2 B/D PA; MO

cefazolin injection recon soln 10 gram 2 B/D PA

cefdinir oral capsule 2 MO

cefdinir oral suspension for reconstitution 2 MO

cefepime injection recon soln 2 B/D PA; MO

cefixime oral suspension for reconstitution 2 MO

cefotaxime injection recon soln 1 gram, 2 gram,

500 mg

2

cefotetan injection recon soln 2

cefoxitin intravenous recon soln 1 gram, 2 gram 2 B/D PA; MO

cefoxitin intravenous recon soln 10 gram 2 B/D PA

cefpodoxime oral suspension for reconstitution 2 MO

cefpodoxime oral tablet 2 MO

cefprozil oral suspension for reconstitution 2 MO

cefprozil oral tablet 2 MO

ceftazidime injection recon soln 1 gram, 2 gram 2 MO

ceftazidime injection recon soln 6 gram 2

ceftriaxone injection recon soln 10 gram 2 B/D PA

ceftriaxone injection recon soln 250 mg, 500 mg 2 B/D PA; MO

ceftriaxone intravenous recon soln 2 B/D PA; MO


6


medicamento

Requisitos/Límites

cefuroxime axetil oral tablet 2 MO

cefuroxime sodium injection recon soln 750 mg 2 B/D PA; MO

cefuroxime sodium intravenous recon soln 1.5

gram

2 B/D PA; MO

cefuroxime sodium intravenous recon soln 7.5

gram

2 B/D PA

cephalexin oral capsule 1 MO

cephalexin oral suspension for reconstitution 1 MO

cephalexin oral tablet 1 MO

SUPRAX ORAL CAPSULE 4 MO

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5 ML

4

SUPRAX ORAL TABLET,CHEWABLE 4 MO

TEFLARO INTRAVENOUS RECON SOLN 4 B/D PA; MO

ERITROMICINAS/OTROS MACRÓLIDOS

azithromycin intravenous recon soln 2 B/D PA; MO

azithromycin oral packet 2 MO

azithromycin oral suspension for reconstitution 2 MO

azithromycin oral tablet 2 MO

clarithromycin oral suspension for reconstitution 2 MO

clarithromycin oral tablet 2 MO

clarithromycin oral tablet extended release 24 hr 2 MO

e.e.s. 400 oral tablet 2 MO

ERYPED 200 ORAL SUSPENSION FOR

RECONSTITUTION

3 MO

erythrocin (as stearate) oral tablet 250 mg 2 MO

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

3 B/D PA; MO; NEDS

erythromycin ethylsuccinate oral suspension for

reconstitution

2 MO

erythromycin ethylsuccinate oral tablet 2 MO

erythromycin oral capsule,delayed release(dr/ec) 2 MO

erythromycin oral tablet 2 MO

ANTIINFECCIOSOS DIVERSOS


7


medicamento

Requisitos/Límites

ALBENZA ORAL TABLET 4 MO

amikacin injection solution 500 mg/2 ml 2 B/D PA; MO

atovaquone oral suspension 5 MO

atovaquone-proguanil oral tablet 2 MO

aztreonam injection recon soln 1 gram 2 MO

baciim intramuscular recon soln 2

bacitracin intramuscular recon soln 2 MO

CAPASTAT INJECTION RECON SOLN 4 B/D PA

CAYSTON INHALATION SOLUTION FOR

NEBULIZATION

5 MO; LA; QL (84 per 28 days)

chloramphenicol sod succinate intravenous recon

soln

2 B/D PA

chloroquine phosphate oral tablet 2 MO

clindamycin hcl oral capsule 2 MO

clindamycin pediatric oral recon soln 2 MO

clindamycin phosphate injection solution 2 B/D PA; MO

clindamycin phosphate intravenous solution 600

mg/4 ml

2 B/D PA; MO

COARTEM ORAL TABLET 4 MO

colistin (colistimethate na) injection recon soln 4 B/D PA; MO

CUBICIN INTRAVENOUS RECON SOLN 5 MO

dapsone oral tablet 4 MO

daptomycin intravenous recon soln 5 MO

DARAPRIM ORAL TABLET 5 PA; MO; NEDS

ethambutol oral tablet 2 MO

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 80 mg/50 ml

2 MO



2



4

gentamicin injection solution 40 mg/ml 2 B/D PA; MO

hydroxychloroquine oral tablet 1 MO

imipenem-cilastatin intravenous recon soln 2 B/D PA; MO

isoniazid injection solution 2

isoniazid oral solution 2 MO


8


medicamento

Requisitos/Límites

isoniazid oral tablet 2 MO

ivermectin oral tablet 2 MO

linezolid intravenous parenteral solution 5 PA

linezolid oral suspension for reconstitution 4 PA; MO

linezolid oral tablet 5 PA; MO

mefloquine oral tablet 2 MO

meropenem intravenous recon soln 500 mg 2 B/D PA; MO

metronidazole in nacl (iso-osm) intravenous

piggyback

2 MO

metronidazole oral capsule 2 MO

metronidazole oral tablet 2 MO

NEBUPENT INHALATION RECON SOLN 4 B/D PA; MO

neomycin oral tablet 2 MO

paromomycin oral capsule 2 MO

PASER ORAL GRANULES DR FOR SUSP IN

PACKET

4 MO

PENTAM INJECTION RECON SOLN 4 B/D PA; MO

polymyxin b sulfate injection recon soln 2 MO

PRIFTIN ORAL TABLET 4 MO

PRIMAQUINE ORAL TABLET 4 MO

pyrazinamide oral tablet 2 MO

quinine sulfate oral capsule 2 PA; MO

rifabutin oral capsule 2 MO

rifampin intravenous recon soln 2 B/D PA; MO

rifampin oral capsule 2 MO

SIRTURO ORAL TABLET 5 MO; LA

STREPTOMYCIN INTRAMUSCULAR RECON

SOLN

4 B/D PA; MO

SYNERCID INTRAVENOUS RECON SOLN 4 B/D PA

tinidazole oral tablet 2 MO

TOBI PODHALER INHALATION CAPSULE,

W/INHALATION DEVICE


tobramycin in 0.225 % nacl inhalation solution for

nebulization

5 B/D PA; MO


9


medicamento

Requisitos/Límites

tobramycin sulfate injection solution 2 B/D PA; MO

TRECATOR ORAL TABLET 4 MO

TYGACIL INTRAVENOUS RECON SOLN 4 MO

XIFAXAN ORAL TABLET 550 MG 5 MO

PENICILINAS

amoxicillin oral capsule 1 MO

amoxicillin oral suspension for reconstitution 1 MO

amoxicillin oral tablet 1 MO

amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO

amoxicillin-pot clavulanate oral suspension for

reconstitution

2 MO

amoxicillin-pot clavulanate oral tablet 2 MO

amoxicillin-pot clavulanate oral tablet extended

release 12 hr

2 MO

amoxicillin-pot clavulanate oral tablet,chewable 2 MO

ampicillin oral capsule 2 MO

ampicillin oral suspension for reconstitution 2 MO

ampicillin sodium injection recon soln 1 gram, 10

gram, 125 mg

2 B/D PA; MO

ampicillin-sulbactam injection recon soln 1.5

gram, 3 gram

2 B/D PA; MO

ampicillin-sulbactam injection recon soln 15 gram 2 B/D PA

BICILLIN C-R INTRAMUSCULAR SYRINGE 4 MO

BICILLIN L-A INTRAMUSCULAR SYRINGE 4 MO

dicloxacillin oral capsule 2 MO

nafcillin injection recon soln 1 gram 2 B/D PA; MO

nafcillin injection recon soln 10 gram 5 B/D PA; MO

oxacillin in dextrose (iso-osm) intravenous

piggyback 1 gram/50 ml

2

oxacillin in dextrose (iso-osm) intravenous

piggyback 2 gram/50 ml

5 MO

oxacillin injection recon soln 10 gram 5

oxacillin injection recon soln 2 gram 2 MO

penicillin g potassium injection recon soln 5

million unit

2 B/D PA; MO

penicillin g procaine intramuscular syringe 1.2

million unit/2 ml

2 MO


10


medicamento

Requisitos/Límites

penicillin g sodium injection recon soln 2 B/D PA; MO

penicillin v potassium oral recon soln 2 MO

penicillin v potassium oral tablet 2 MO

piperacillin-tazobactam intravenous recon soln

3.375 gram, 4.5 gram, 40.5 gram

2 B/D PA; MO

QUINOLONAS

AVELOX IN NACL (ISO-OSM)

INTRAVENOUS PIGGYBACK

4 B/D PA; MO

ciprofloxacin (mixture) oral tablet, er multiphase

24 hr

2 MO

ciprofloxacin hcl oral tablet 2 MO

ciprofloxacin lactate intravenous solution 400

mg/40 ml

2 B/D PA

ciprofloxacin oral suspension,microcapsule recon 2

levofloxacin in d5w intravenous piggyback 500

mg/100 ml, 750 mg/150 ml

2 MO

levofloxacin intravenous solution 2 B/D PA; MO

levofloxacin oral solution 2 MO

levofloxacin oral tablet 2 MO

moxifloxacin oral tablet 2 MO

ofloxacin oral tablet 300 mg 2

ofloxacin oral tablet 400 mg 2 MO

SULFAMIDA/AGENTES RELACIONADOS

sulfadiazine oral tablet 2 MO

sulfamethoxazole-trimethoprim intravenous

solution

2 B/D PA; MO

sulfamethoxazole-trimethoprim oral suspension 2 MO

sulfamethoxazole-trimethoprim oral tablet 2 MO

TETRACICLINAS

demeclocycline oral tablet 2 MO

doxy-100 intravenous recon soln 2 MO; NEDS

doxycycline hyclate oral capsule 2 MO

doxycycline hyclate oral tablet 100 mg, 20 mg 2 MO

doxycycline hyclate oral tablet,delayed release

(dr/ec)

2 MO


11


medicamento

Requisitos/Límites

doxycycline monohydrate oral capsule 2 MO

doxycycline monohydrate oral tablet 2 MO

minocycline oral capsule 2 MO

minocycline oral tablet 2 MO

minocycline oral tablet extended release 24 hr 2 MO

morgidox oral capsule 50 mg 2

ORACEA ORAL CAPSULE,IR - DELAY

REL,BIPHASE

4 MO

tetracycline oral capsule 2 MO

AGENTES DEL TRACTO URINARIO

methenamine hippurate oral tablet 2 MO

nitrofurantoin macrocrystal oral capsule 2 MO

nitrofurantoin monohyd/m-cryst oral capsule 2 MO

trimethoprim oral tablet 2 MO

VANCOMICINA

vancomycin intravenous recon soln 1,000 mg, 10

gram, 500 mg

2 B/D PA; MO

vancomycin oral capsule 5 MO

MEDICAMENTOS ANTINEOPLÁSICOS/INMUNOSUPRESORES

AGENTES ADICIONALES

dexrazoxane hcl intravenous recon soln 250 mg 2 B/D PA

ELITEK INTRAVENOUS RECON SOLN 5 B/D PA; MO

leucovorin calcium injection recon soln 100 mg,

350 mg

2 B/D PA; MO

leucovorin calcium oral tablet 2 MO

levoleucovorin intravenous solution 4 B/D PA

mesna intravenous solution 2 B/D PA; MO

MESNEX ORAL TABLET 5 MO

XGEVA SUBCUTANEOUS SOLUTION 5 B/D PA; MO

MEDICAMENTOS ANTINEOPLÁSICOS/INMUNOSUPRESORES

ABRAXANE INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

4 B/D PA; MO

adriamycin intravenous solution 20 mg/10 ml 2 B/D PA

adrucil intravenous solution 500 mg/10 ml 2 B/D PA; MO


12


medicamento

Requisitos/Límites

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION

5 PA; MO; NEDS

AFINITOR ORAL TABLET 5 PA; MO; NEDS

ALECENSA ORAL CAPSULE 5 PA; MO

ALIMTA INTRAVENOUS RECON SOLN 500

MG

5 B/D PA; MO

ALUNBRIG ORAL TABLET 5 PA; MO; QL (180 per 30 days);

NEDS

anastrozole oral tablet 2 MO; QL (30 per 30 days)

ASTAGRAF XL ORAL CAPSULE,EXTENDED

RELEASE 24HR

4 B/D PA; MO

AVASTIN INTRAVENOUS SOLUTION 5 B/D PA; MO

azacitidine injection recon soln 5 MO

AZASAN ORAL TABLET 3 B/D PA; MO

azathioprine oral tablet 2 B/D PA; MO

azathioprine sodium injection recon soln 2 B/D PA

BAVENCIO INTRAVENOUS SOLUTION 5 PA; MO; NEDS

BELEODAQ INTRAVENOUS RECON SOLN 5 B/D PA; MO

bexarotene oral capsule 5 PA; MO

bicalutamide oral tablet 2 MO; QL (30 per 30 days)

BICNU INTRAVENOUS RECON SOLN 3 B/D PA; MO

bleomycin injection recon soln 30 unit 2 B/D PA; MO

BOSULIF ORAL TABLET 5 PA; MO; NEDS

BUSULFEX INTRAVENOUS SOLUTION 3 B/D PA

CABOMETYX ORAL TABLET 5 PA; MO; LA

CAPRELSA ORAL TABLET 100 MG 5 MO; LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG 5 MO; LA; QL (30 per 30 days)

carboplatin intravenous solution 2 B/D PA; MO

CELLCEPT INTRAVENOUS RECON SOLN 4 B/D PA; MO

CELLCEPT ORAL SUSPENSION FOR

RECONSTITUTION

4 B/D PA; MO

cisplatin intravenous solution 2 B/D PA; MO

cladribine intravenous solution 2 B/D PA; MO

clofarabine intravenous solution 5 B/D PA


13


medicamento

Requisitos/Límites

COMETRIQ ORAL CAPSULE 5 PA; MO

COTELLIC ORAL TABLET 5 PA; MO; LA

CYCLOPHOSPHAMIDE ORAL CAPSULE 4 B/D PA; MO

cyclosporine intravenous solution 2 B/D PA

cyclosporine modified oral capsule 2 B/D PA; MO

cyclosporine modified oral solution 2 B/D PA; MO

cyclosporine oral capsule 2 B/D PA; MO

CYRAMZA INTRAVENOUS SOLUTION 5 PA; MO

cytarabine injection solution 2 B/D PA; MO

dacarbazine intravenous recon soln 200 mg 2 B/D PA; MO

DARZALEX INTRAVENOUS SOLUTION 3 PA; MO; LA

daunorubicin intravenous solution 2 B/D PA

decitabine intravenous recon soln 5 B/D PA; MO

doxorubicin intravenous solution 50 mg/25 ml 2 B/D PA; MO

doxorubicin, peg-liposomal intravenous

suspension

5 B/D PA; MO

DROXIA ORAL CAPSULE 3 MO

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE

3 PA; MO


SYRINGE

3 PA; MO


SYRINGE

3 PA; MO

ELIGARD SUBCUTANEOUS SYRINGE 3 PA; MO

EMCYT ORAL CAPSULE 3 MO

EMPLICITI INTRAVENOUS RECON SOLN 5 PA; MO

ENVARSUS XR ORAL TABLET EXTENDED

RELEASE 24 HR

4 B/D PA; MO

epirubicin intravenous solution 200 mg/100 ml 4 B/D PA; MO

ERIVEDGE ORAL CAPSULE 3 PA; MO

ERWINAZE INJECTION RECON SOLN 5 PA; MO

etoposide intravenous solution 2 B/D PA; MO

exemestane oral tablet 2 MO

FARESTON ORAL TABLET 3 MO; QL (30 per 30 days)

FARYDAK ORAL CAPSULE 5 PA; MO

FASLODEX INTRAMUSCULAR SYRINGE 5 B/D PA; MO


14


medicamento

Requisitos/Límites

fludarabine intravenous recon soln 4 B/D PA; MO

fluorouracil intravenous solution 2.5 gram/50 ml 2 B/D PA; MO

flutamide oral capsule 2 MO

gemcitabine intravenous recon soln 1 gram 5 B/D PA; MO

gengraf oral capsule 2 B/D PA; MO

gengraf oral solution 2 B/D PA; MO

GILOTRIF ORAL TABLET 5 PA; MO

GLEOSTINE ORAL CAPSULE 4 MO

HERCEPTIN INTRAVENOUS RECON SOLN

440 MG

5 B/D PA; MO

HEXALEN ORAL CAPSULE 5 MO

hydroxyurea oral capsule 2 MO

IBRANCE ORAL CAPSULE 5 PA; MO; QL (21 per 28 days)

ICLUSIG ORAL TABLET 15 MG 5 PA

ICLUSIG ORAL TABLET 45 MG 5 PA; MO

idarubicin intravenous solution 2 B/D PA

ifosfamide intravenous recon soln 1 gram 2 B/D PA; MO

imatinib oral tablet 100 mg 5 PA; MO

imatinib oral tablet 400 mg 5 PA; MO; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 5 PA; MO

IMFINZI INTRAVENOUS SOLUTION 5 PA; MO; LA

INLYTA ORAL TABLET 4 PA; MO

IRESSA ORAL TABLET 5 PA; MO

irinotecan intravenous solution 100 mg/5 ml 2 B/D PA; MO

ISTODAX INTRAVENOUS RECON SOLN 5 B/D PA; MO

JAKAFI ORAL TABLET 10 MG, 15 MG, 20

MG, 5 MG

5 PA; MO

JAKAFI ORAL TABLET 25 MG 5 PA; MO; QL (60 per 30 days)

KADCYLA INTRAVENOUS RECON SOLN 100

MG

5 PA; MO; NEDS

KEYTRUDA INTRAVENOUS RECON SOLN 5 PA; MO

KEYTRUDA INTRAVENOUS SOLUTION 5 PA; MO

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; MO; QL (49 per 30 days); NEDS


15


medicamento

Requisitos/Límites


400 MG/DAY(200 MG X 2)-2.5 MG



600 MG/DAY(200 MG X 3)-2.5 MG


KISQALI ORAL TABLET 200 MG/DAY (200

MG X 1)



MG X 2)



MG X 3)


KYPROLIS INTRAVENOUS RECON SOLN 5 PA; MO

LARTRUVO INTRAVENOUS SOLUTION 5 PA; MO; LA

LENVIMA ORAL CAPSULE 5 PA; MO

letrozole oral tablet 2 MO; QL (30 per 30 days)

LEUKERAN ORAL TABLET 3 MO

leuprolide subcutaneous kit 2 PA; MO

LONSURF ORAL TABLET 5 PA; MO

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT

5 PA; MO



5 PA; MO



5 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG

3 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 7.5 MG

5 PA; MO

LUPRON DEPOT-PED INTRAMUSCULAR KIT

11.25 MG, 15 MG

5 PA; MO

LYNPARZA ORAL CAPSULE 5 PA; MO

LYSODREN ORAL TABLET 3 MO

MATULANE ORAL CAPSULE 5 MO

megestrol oral suspension 400 mg/10 ml (40

mg/ml), 625 mg/5 ml

4 PA; MO

megestrol oral tablet 2 PA; MO

MEKINIST ORAL TABLET 5 PA; MO

melphalan hcl intravenous recon soln 2 B/D PA

mercaptopurine oral tablet 2 MO


16


medicamento

Requisitos/Límites

methotrexate sodium (pf) injection recon soln 2 B/D PA

methotrexate sodium (pf) injection solution 2 B/D PA; MO

methotrexate sodium oral tablet 1 B/D PA; MO

mitomycin intravenous recon soln 2 B/D PA; MO

mitoxantrone intravenous concentrate 2 B/D PA; MO

MUSTARGEN INJECTION RECON SOLN 3 B/D PA; MO

mycophenolate mofetil hcl intravenous recon soln 4 B/D PA

mycophenolate mofetil oral capsule 2 B/D PA; MO

mycophenolate mofetil oral suspension for

reconstitution

2 B/D PA; MO

mycophenolate mofetil oral tablet 2 B/D PA; MO

mycophenolate sodium oral tablet,delayed release

(dr/ec)

2 B/D PA; MO

NEORAL ORAL CAPSULE 4 B/D PA; MO

NEORAL ORAL SOLUTION 4 B/D PA; MO

NEXAVAR ORAL TABLET 5 PA; MO; LA

nilutamide oral tablet 2 MO; QL (30 per 30 days)

NINLARO ORAL CAPSULE 5 PA; MO

NULOJIX INTRAVENOUS RECON SOLN 5 B/D PA; MO

octreotide acetate injection solution 1,000 mcg/ml,

500 mcg/ml

5 PA; MO

octreotide acetate injection solution 100 mcg/ml,

200 mcg/ml, 50 mcg/ml

2 PA; MO

ODOMZO ORAL CAPSULE 5 PA; MO; LA

OPDIVO INTRAVENOUS SOLUTION 40 MG/4

ML

5 PA; MO

oxaliplatin intravenous solution 100 mg/20 ml 4 B/D PA; MO

paclitaxel intravenous concentrate 2 B/D PA; MO

PERJETA INTRAVENOUS SOLUTION 5 PA; MO

POMALYST ORAL CAPSULE 5 PA; MO; LA

PURIXAN ORAL SUSPENSION 4 MO

RAPAMUNE ORAL SOLUTION 3 B/D PA; MO

RAPAMUNE ORAL TABLET 4 B/D PA; MO

REVLIMID ORAL CAPSULE 5 PA; MO; LA


17


medicamento

Requisitos/Límites

RITUXAN INTRAVENOUS CONCENTRATE 5 PA; MO

RUBRACA ORAL TABLET 200 MG, 300 MG 5 PA; MO; LA; QL (120 per 30 days)

RYDAPT ORAL CAPSULE 5 PA; MO; NEDS

SANDIMMUNE ORAL CAPSULE 4 B/D PA; MO

SANDIMMUNE ORAL SOLUTION 4 B/D PA; MO

SIGNIFOR SUBCUTANEOUS SOLUTION 5 PA; MO

SIMULECT INTRAVENOUS RECON SOLN 20

MG

3 B/D PA; MO

sirolimus oral tablet 2 B/D PA; MO

SOLTAMOX ORAL SOLUTION 4 MO

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE

5 B/D PA; MO

SPRYCEL ORAL TABLET 100 MG, 140 MG, 80

MG


SPRYCEL ORAL TABLET 20 MG, 50 MG 5 PA; MO; NEDS

SPRYCEL ORAL TABLET 70 MG 5 PA; MO; QL (60 per 30 days); NEDS

STIVARGA ORAL TABLET 5 PA; MO

SUTENT ORAL CAPSULE 5 PA; MO

SYNRIBO SUBCUTANEOUS RECON SOLN 5 B/D PA; MO

TABLOID ORAL TABLET 3 MO

tacrolimus oral capsule 0.5 mg, 1 mg 2 B/D PA; MO

tacrolimus oral capsule 5 mg 4 B/D PA; MO

TAFINLAR ORAL CAPSULE 5 PA; MO; NEDS

TAGRISSO ORAL TABLET 5 PA; MO; LA

tamoxifen oral tablet 2 MO

TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA; MO; NEDS

TARCEVA ORAL TABLET 150 MG 5 PA; MO; QL (30 per 30 days); NEDS

TARGRETIN TOPICAL GEL 5 MO; QL (60 per 30 days)

TASIGNA ORAL CAPSULE 5 PA; MO

TECENTRIQ INTRAVENOUS SOLUTION 5 PA; MO; LA

THALOMID ORAL CAPSULE 5 PA; MO

thiotepa injection recon soln 5 PA; MO

toposar intravenous solution 2 B/D PA; MO

topotecan intravenous recon soln 5 B/D PA


18


medicamento

Requisitos/Límites

TREANDA INTRAVENOUS RECON SOLN 100

MG

5 B/D PA; MO

TRELSTAR INTRAMUSCULAR SYRINGE

11.25 MG/2 ML, 3.75 MG/2 ML

3 B/D PA; MO

TRELSTAR INTRAMUSCULAR SYRINGE 22.5

MG/2 ML

5 B/D PA; MO

tretinoin (chemotherapy) oral capsule 5 MO

TRISENOX INTRAVENOUS SOLUTION 3 B/D PA; MO

TYKERB ORAL TABLET 5 PA; MO; LA; NEDS

VELCADE INJECTION RECON SOLN 5 B/D PA; MO

VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 PA; MO; LA

VENCLEXTA ORAL TABLET 100 MG 5 PA; MO; LA

VENCLEXTA STARTING PACK ORAL

TABLETS,DOSE PACK

5 PA; MO; LA

vinblastine intravenous solution 2 B/D PA; MO

vincasar pfs intravenous solution 1 mg/ml 2 B/D PA

vincristine intravenous solution 1 mg/ml 2 B/D PA; MO

vinorelbine intravenous solution 50 mg/5 ml 2 B/D PA; MO

VOTRIENT ORAL TABLET 5 PA; MO; NEDS

XALKORI ORAL CAPSULE 5 PA; MO

XERMELO ORAL TABLET 5 PA; MO; QL (84 per 28 days); NEDS

XTANDI ORAL CAPSULE 5 PA; MO; QL (120 per 30 days)

YERVOY INTRAVENOUS SOLUTION 50

MG/10 ML (5 MG/ML)

5 PA; MO

YONDELIS INTRAVENOUS RECON SOLN 5 PA; MO

ZALTRAP INTRAVENOUS SOLUTION 100

MG/4 ML (25 MG/ML)

5 PA; MO

ZEJULA ORAL CAPSULE 5 PA; MO; LA; QL (90 per 30 days);

NEDS

ZELBORAF ORAL TABLET 5 PA; MO; NEDS

ZOLINZA ORAL CAPSULE 5 MO; QL (120 per 30 days)

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG 3 B/D PA; MO

ZORTRESS ORAL TABLET 0.75 MG 5 B/D PA; MO

ZYDELIG ORAL TABLET 5 PA; MO

ZYKADIA ORAL CAPSULE 5 PA; MO; QL (150 per 30 days)


19


medicamento

Requisitos/Límites

ZYTIGA ORAL TABLET 250 MG 5 MO; QL (120 per 30 days); NEDS

MEDICAMENTOS PARA SISTEMA NERVIOSO AUTÓNOMO/CENTRAL,

NEUROLOGÍA/PSIQUIATRÍA

ANTICONVULSIVOS

APTIOM ORAL TABLET 4 PA; MO

BANZEL ORAL SUSPENSION 4 MO

BANZEL ORAL TABLET 4 PA; MO

BRIVIACT INTRAVENOUS SOLUTION 4 PA

BRIVIACT ORAL SOLUTION 5 PA; MO

BRIVIACT ORAL TABLET 5 PA; MO

carbamazepine oral capsule, er multiphase 12 hr 2 MO

carbamazepine oral suspension 100 mg/5 ml 2 MO

carbamazepine oral tablet 1 MO

carbamazepine oral tablet extended release 12 hr 2 MO

carbamazepine oral tablet,chewable 1 MO

CELONTIN ORAL CAPSULE 300 MG 4 MO

clonazepam oral tablet 2 MO

clonazepam oral tablet,disintegrating 2 PA; MO

DIASTAT RECTAL KIT 4 MO

DILANTIN 30 MG ORAL CAPSULE 4 MO

divalproex oral capsule, delayed release sprinkle 2 MO

divalproex oral tablet extended release 24 hr 2 MO

divalproex oral tablet,delayed release (dr/ec) 2 MO

epitol oral tablet 1 MO

ethosuximide oral capsule 2 MO

ethosuximide oral solution 2 MO

felbamate oral suspension 2 MO

felbamate oral tablet 2 MO

fosphenytoin injection solution 100 mg pe/2 ml 2 B/D PA; MO

FYCOMPA ORAL SUSPENSION 4 PA; MO

FYCOMPA ORAL TABLET 4 PA; MO

gabapentin oral capsule 2 MO

gabapentin oral solution 250 mg/5 ml 2 MO

gabapentin oral tablet 600 mg, 800 mg 2 MO


20


medicamento

Requisitos/Límites

GABITRIL ORAL TABLET 12 MG, 16 MG 4 MO

lamotrigine oral tablet 2 MO

lamotrigine oral tablet extended release 24hr 2 MO

lamotrigine oral tablet, chewable dispersible 2 MO

lamotrigine oral tablet,disintegrating 2 MO

levetiracetam in nacl (iso-osm) intravenous

piggyback 1,000 mg/100 ml, 1,500 mg/100 ml

2

levetiracetam in nacl (iso-osm) intravenous


2 MO

levetiracetam intravenous solution 2 B/D PA; MO

levetiracetam oral solution 100 mg/ml 2 MO

levetiracetam oral tablet 2 MO

levetiracetam oral tablet extended release 24 hr 2 MO

LYRICA ORAL CAPSULE 3 MO

LYRICA ORAL SOLUTION 3 MO

ONFI ORAL SUSPENSION 4 PA; MO

ONFI ORAL TABLET 10 MG, 20 MG 4 PA; MO

oxcarbazepine oral suspension 2 MO

oxcarbazepine oral tablet 2 MO

PEGANONE ORAL TABLET 4 MO

phenobarbital oral elixir 2 PA; MO

phenobarbital oral tablet 2 PA; MO

PHENYTEK ORAL CAPSULE 3 MO

phenytoin oral suspension 125 mg/5 ml 2 MO

phenytoin oral tablet,chewable 2 MO

phenytoin sodium extended oral capsule 2 MO

phenytoin sodium intravenous solution 2 B/D PA; MO

primidone oral tablet 2 MO

roweepra oral tablet 1,000 mg, 750 mg 4

roweepra oral tablet 500 mg 4 MO

SABRIL ORAL POWDER IN PACKET 5 PA; MO; LA

SABRIL ORAL TABLET 5 PA; MO; LA

SPRITAM ORAL TABLET FOR SUSPENSION 4 MO


21


medicamento

Requisitos/Límites

tiagabine oral tablet 2 MO

topiramate oral capsule, sprinkle 2 PA; MO

TOPIRAMATE ORAL

CAPSULE,SPRINKLE,ER 24HR

3 PA; MO

topiramate oral tablet 2 PA; MO

valproate sodium intravenous solution 2 B/D PA; MO

valproic acid (as sodium salt) oral solution 250

mg/5 ml

2 MO

valproic acid oral capsule 2 MO

VIMPAT INTRAVENOUS SOLUTION 4 PA

VIMPAT ORAL SOLUTION 4 PA; MO

VIMPAT ORAL TABLET 4 PA; MO

zonisamide oral capsule 2 PA; MO

AGENTES ANTIPARKINSONIANOS

APOKYN SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA

benztropine injection solution 2 B/D PA; MO

benztropine oral tablet 2 PA; MO

bromocriptine oral capsule 2 MO

bromocriptine oral tablet 2 MO

carbidopa oral tablet 2 MO

carbidopa-levodopa oral tablet 2 MO

carbidopa-levodopa oral tablet extended release 2 MO

carbidopa-levodopa oral tablet,disintegrating 2 MO

carbidopa-levodopa-entacapone oral tablet 2 MO

entacapone oral tablet 2 MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 4 PA; MO

pramipexole oral tablet 2 MO

pramipexole oral tablet extended release 24 hr 2 MO

rasagiline oral tablet 4 MO

ropinirole oral tablet 2 MO

ropinirole oral tablet extended release 24 hr 2 MO

selegiline hcl oral capsule 2 MO

selegiline hcl oral tablet 2 MO

tolcapone oral tablet 2 MO

trihexyphenidyl oral elixir 2 PA; MO


22


medicamento

Requisitos/Límites

trihexyphenidyl oral tablet 2 PA; MO

TERAPIA PARA MIGRAÑAS/CEFALEA EN RACIMOS

dihydroergotamine injection solution 2 MO

dihydroergotamine nasal spray,non-aerosol 4 MO

migergot rectal suppository 2 MO

naratriptan oral tablet 2 MO; QL (18 per 28 days)

rizatriptan oral tablet 2 MO; QL (36 per 30 days)

rizatriptan oral tablet,disintegrating 2 MO; QL (36 per 30 days)

sumatriptan nasal spray,non-aerosol 2 MO

sumatriptan succinate oral tablet 2 MO; QL (9 per 30 days)

sumatriptan succinate subcutaneous cartridge 2 MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous pen injector 2 MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous solution 2 MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml


zolmitriptan oral tablet 2 MO; QL (12 per 30 days)

zolmitriptan oral tablet,disintegrating 2 MO; QL (12 per 30 days)

TERAPIA NEUROLÓGICA DIVERSA

AMPYRA ORAL TABLET EXTENDED

RELEASE 12 HR

5 PA; MO; LA; NEDS

AUBAGIO ORAL TABLET 5 PA; MO

donepezil oral tablet 2 MO; QL (30 per 30 days)

donepezil oral tablet,disintegrating 2 MO; QL (30 per 30 days)

galantamine oral solution 2 MO

galantamine oral tablet 2 MO

GILENYA ORAL CAPSULE 5 MO

glatopa subcutaneous syringe 5 PA; MO

KEVEYIS ORAL TABLET 5 PA; MO

memantine oral solution 2 PA; MO

memantine oral tablet 2 PA; MO

MEMANTINE ORAL TABLETS,DOSE PACK 4 PA; MO

NAMENDA XR ORAL CAP,SPRINKLE,ER

24HR DOSE PACK

3 PA; MO


23


medicamento

Requisitos/Límites

NAMENDA XR ORAL

CAPSULE,SPRINKLE,ER 24HR

3 PA; MO

NUEDEXTA ORAL CAPSULE 3 MO

rivastigmine tartrate oral capsule 1.5 mg 2 MO; QL (240 per 30 days)

rivastigmine tartrate oral capsule 3 mg 2 MO; QL (120 per 30 days)

rivastigmine tartrate oral capsule 4.5 mg, 6 mg 2 MO; QL (60 per 30 days)

rivastigmine transdermal patch 24 hour 2 MO; QL (30 per 30 days)

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

5 MO; LA

tetrabenazine oral tablet 5 PA; MO

TYSABRI INTRAVENOUS SOLUTION 5 PA; MO; LA

TERAPIA DE RELAJANTES MUSCULARES/ANTIESPASMÓDICA

baclofen oral tablet 2 MO

cyclobenzaprine oral tablet 2 PA; MO

dantrolene oral capsule 2 MO

meprobamate oral tablet 2 PA; MO

MESTINON ORAL SYRUP 3 MO

metaxalone oral tablet 2 PA; MO

pyridostigmine bromide oral tablet 2 MO

pyridostigmine bromide oral tablet extended

release

2 MO

tizanidine oral capsule 2 MO

tizanidine oral tablet 2 MO

ANALGÉSICOS NARCÓTICOS

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg


acetaminophen-codeine oral tablet 300-60 mg 2 MO; QL (180 per 30 days)

buprenorphine hcl injection solution 2 B/D PA; MO; QL (267 per 30 days)

buprenorphine hcl injection syringe 2 B/D PA; QL (267 per 30 days)

buprenorphine hcl sublingual tablet 2 mg 2 MO; QL (300 per 30 days)

buprenorphine hcl sublingual tablet 8 mg 2 MO; QL (75 per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50-

300-40-30 mg

4 PA; MO; QL (360 per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg


butalbital-acetaminophen oral tablet 50-325 mg 4 MO; QL (360 per 30 days)


24


medicamento

Requisitos/Límites

butalbital-acetaminophen-caff oral capsule 50-

300-40 mg


butalbital-acetaminophen-caff oral capsule 50-

325-40 mg


butalbital-acetaminophen-caff oral tablet 50-325-

40 mg


butalbital-aspirin-caffeine oral capsule 4 PA; MO

codeine sulfate oral tablet 2 MO; QL (180 per 30 days)

duramorph (pf) injection solution 0.5 mg/ml 4 B/D PA; MO; QL (4000 per 30 days)

duramorph (pf) injection solution 1 mg/ml 4 B/D PA; QL (2000 per 30 days)

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325

mg


fentanyl citrate buccal lozenge on a handle 1,200

mcg


fentanyl citrate buccal lozenge on a handle 1,600

mcg


fentanyl citrate buccal lozenge on a handle 200

mcg



mcg



mcg



mcg


fentanyl transdermal patch 72 hour 100 mcg/hr 2 MO; QL (9 per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr, 25

mcg/hr, 50 mcg/hr, 75 mcg/hr


hydrocodone-acetaminophen oral solution 7.5-325

mg/15 ml


hydrocodone-acetaminophen oral tablet 10-300

mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg,

7.5-300 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg, 7.5-200 mg


hydromorphone (pf) injection solution 2 B/D PA; MO; QL (120 per 30 days)

hydromorphone oral liquid 2 MO; QL (1500 per 30 days)

hydromorphone oral tablet 2 MO; QL (180 per 30 days)


25


medicamento

Requisitos/Límites

ibuprofen-oxycodone oral tablet 2 MO; QL (28 per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 200 MG


levorphanol tartrate oral tablet 2 MO; QL (120 per 30 days)

methadone injection solution 2 B/D PA; QL (160 per 30 days)

methadone oral solution 10 mg/5 ml 2 MO; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 2 MO; QL (1200 per 30 days)

methadone oral tablet 10 mg 2 MO; QL (120 per 30 days)

methadone oral tablet 5 mg 2 MO; QL (240 per 30 days)

morphine concentrate oral solution 2 MO; QL (300 per 30 days)

MORPHINE INTRAVENOUS SYRINGE 10

MG/ML

4 B/D PA; QL (200 per 30 days)

MORPHINE INTRAVENOUS SYRINGE 8

MG/ML

4 B/D PA; QL (250 per 30 days)

morphine oral capsule, er multiphase 24 hr 120

mg


morphine oral capsule, er multiphase 24 hr 30 mg,

45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets 2 MO; QL (60 per 30 days)

morphine oral solution 2 MO; QL (900 per 30 days)

morphine oral tablet 2 MO; QL (180 per 30 days)

morphine oral tablet extended release 100 mg 2 MO; QL (60 per 30 days)

morphine oral tablet extended release 15 mg, 30

mg, 60 mg


morphine oral tablet extended release 200 mg 2 MO; QL (30 per 30 days)

oxycodone oral capsule 2 MO; QL (360 per 30 days)

oxycodone oral concentrate 2 MO; QL (180 per 30 days)

oxycodone oral solution 2 MO; QL (1200 per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg 2 MO; QL (180 per 30 days)

oxycodone oral tablet 30 mg 2 MO; QL (134 per 30 days)

oxycodone oral tablet 5 mg 2 MO; QL (360 per 30 days)

oxycodone-acetaminophen oral solution 2 QL (1846 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 2 MO; QL (360 per 30 days)

oxymorphone oral tablet 10 mg 2 MO; QL (200 per 30 days)


26


medicamento

Requisitos/Límites

oxymorphone oral tablet 5 mg 2 MO; QL (180 per 30 days)

oxymorphone oral tablet extended release 12 hr 10

mg, 15 mg, 20 mg, 5 mg, 7.5 mg



mg



mg


zamicet oral solution 2 QL (5550 per 30 days)

ANALGÉSICOS NO NARCÓTICOS

buprenorphine-naloxone sublingual tablet 2 MO; QL (90 per 30 days)

butorphanol tartrate injection solution 1 mg/ml 2 MO; QL (720 per 30 days)

butorphanol tartrate injection solution 2 mg/ml 2 MO; QL (360 per 30 days)

butorphanol tartrate nasal spray,non-aerosol 2 MO; QL (5 per 30 days)

celecoxib oral capsule 2 MO

diclofenac potassium oral tablet 2 MO

diclofenac sodium oral tablet extended release 24

hr

2 MO

diclofenac sodium oral tablet,delayed release

(dr/ec)

2 MO

diclofenac sodium topical drops 4 MO

diclofenac sodium topical gel 1 % 4 MO

diclofenac-misoprostol oral tablet,ir,delayed

release,biphasic

2 MO

diflunisal oral tablet 2 MO

etodolac oral capsule 2 MO

etodolac oral tablet 2 MO

etodolac oral tablet extended release 24 hr 2 MO

fenoprofen oral tablet 2 MO

flurbiprofen oral tablet 2 MO

ibuprofen oral suspension 2 MO

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO

indomethacin oral capsule 2 MO

indomethacin oral capsule, extended release 2 MO

ketoprofen oral capsule 2 MO


27


medicamento

Requisitos/Límites

ketoprofen oral capsule,ext rel. pellets 24 hr 200

mg

2 MO

meclofenamate oral capsule 2 MO

mefenamic acid oral capsule 2 MO

meloxicam oral tablet 1 MO

nabumetone oral tablet 2 MO

nalbuphine injection solution 10 mg/ml 2 B/D PA; MO; QL (200 per 30 days)

nalbuphine injection solution 20 mg/ml 2 B/D PA; MO; QL (100 per 30 days)

naloxone injection solution 2 MO

naloxone injection syringe 1 mg/ml 2 MO

naltrexone oral tablet 2 MO

NAPRELAN CR ORAL TABLET, ER

MULTIPHASE 24 HR 750 MG

4 MO

naproxen oral suspension 2 MO

naproxen oral tablet 250 mg, 375 mg 1 MO

naproxen oral tablet,delayed release (dr/ec) 1 MO

naproxen sodium oral tablet 275 mg, 550 mg 2 MO

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION

4 MO

NUCYNTA ER ORAL TABLET EXTENDED

RELEASE 12 HR

3 MO

NUCYNTA ORAL TABLET 3 MO

oxaprozin oral tablet 2 MO

piroxicam oral capsule 2 MO

SUBOXONE SUBLINGUAL FILM 12-3 MG 4 MO; QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-

1 MG, 8-2 MG


sulindac oral tablet 2 MO

tolmetin oral capsule 2 MO

tolmetin oral tablet 600 mg 2 MO

tramadol oral tablet 2 MO; QL (240 per 30 days)

tramadol oral tablet extended release 24 hr 100

mg, 200 mg


tramadol oral tablet, er multiphase 24 hr 300 mg 2 MO; QL (30 per 30 days)

tramadol-acetaminophen oral tablet 2 MO; QL (240 per 30 days)


28


medicamento

Requisitos/Límites

VIVITROL INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON

4 MO

MEDICAMENTOS PSICOTERAPÉUTICOS

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 300

MG

5 B/D PA; MO

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING

5 MO

alprazolam oral tablet 2 MO

alprazolam oral tablet extended release 24 hr 1

mg, 2 mg, 3 mg

2 PA; MO

alprazolam oral tablet,disintegrating 2 MO

amitriptyline oral tablet 2 PA; MO

amoxapine oral tablet 2 MO

aripiprazole oral tablet 10 mg 4 MO; QL (90 per 30 days)

aripiprazole oral tablet 15 mg, 20 mg 4 MO; QL (60 per 30 days)




aripiprazole oral tablet,disintegrating 10 mg 2 MO; QL (90 per 30 days)

aripiprazole oral tablet,disintegrating 15 mg 2 MO; QL (60 per 30 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED RELEASE

SYRINGE 1,064 MG/3.9 ML

5

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED RELEASE

SYRINGE 441 MG/1.6 ML, 662 MG/2.4 ML, 882

MG/3.2 ML

5 MO

atomoxetine oral capsule 2 MO

BRISDELLE ORAL CAPSULE 4 MO

bupropion hcl oral tablet 2 MO

bupropion hcl oral tablet extended release 12 hr 2 MO

bupropion hcl oral tablet extended release 24 hr 2 MO

buspirone oral tablet 2 MO

chlorpromazine injection solution 2 MO

chlorpromazine oral tablet 2 MO


29


medicamento

Requisitos/Límites

citalopram oral solution 2 MO

citalopram oral tablet 1 MO

clomipramine oral capsule 2 PA; MO

clonidine hcl oral tablet extended release 12 hr 2 MO

clorazepate dipotassium oral tablet 2 PA; MO

clozapine oral tablet 2 MO

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 25 mg

2

CLOZAPINE ORAL

TABLET,DISINTEGRATING 150 MG, 200 MG

4

desipramine oral tablet 2 MO

desvenlafaxine succinate oral tablet extended

release 24 hr

2 MO

dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg

2 MO

dexmethylphenidate oral tablet 2 MO

dextroamphetamine oral capsule, extended release 2 MO

dextroamphetamine oral tablet 2 MO

dextroamphetamine-amphetamine oral

capsule,extended release 24hr

2 MO

dextroamphetamine-amphetamine oral tablet 2 MO

diazepam intensol oral concentrate 2 PA; MO

diazepam oral solution 5 mg/5 ml (1 mg/ml) 2 PA; MO

diazepam oral tablet 2 PA; MO

doxepin oral capsule 2 PA; MO

doxepin oral concentrate 2 PA; MO

duloxetine oral capsule,delayed release(dr/ec) 2 MO

EMSAM TRANSDERMAL PATCH 24 HOUR 4 MO

ergoloid oral tablet 2 PA; MO

escitalopram oxalate oral solution 2 MO

escitalopram oxalate oral tablet 2 MO

eszopiclone oral tablet 2 MO; QL (30 per 30 days)

FANAPT ORAL TABLET 4 MO; QL (60 per 30 days)

FANAPT ORAL TABLETS,DOSE PACK 4 MO; QL (8 per 28 days)

FAZACLO ORAL TABLET,DISINTEGRATING

150 MG, 200 MG

4


30


medicamento

Requisitos/Límites

FETZIMA ORAL CAPSULE,EXT REL 24HR

DOSE PACK


FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR


fluoxetine oral capsule 2 MO

fluoxetine oral capsule,delayed release(dr/ec) 2 MO

fluoxetine oral solution 2 MO

fluoxetine oral tablet 10 mg, 20 mg 2 MO

FLUOXETINE ORAL TABLET 60 MG 4 MO

fluphenazine decanoate injection solution 2 B/D PA; MO

fluphenazine hcl injection solution 2 B/D PA; MO

fluphenazine hcl oral concentrate 2 MO

fluphenazine hcl oral elixir 2 MO

fluphenazine hcl oral tablet 2 MO

fluvoxamine oral capsule,extended release 24hr 2 MO

fluvoxamine oral tablet 2 MO

FORFIVO XL ORAL TABLET EXTENDED

RELEASE 24 HR

4 MO

GEODON INTRAMUSCULAR RECON SOLN 4 B/D PA; MO

guanfacine oral tablet extended release 24 hr 2 MO

guanidine oral tablet 2 MO

haloperidol decanoate intramuscular solution 2 B/D PA; MO

haloperidol lactate injection solution 2 B/D PA; MO

haloperidol lactate oral concentrate 2 MO

haloperidol oral tablet 2 MO

HETLIOZ ORAL CAPSULE 5 PA; MO; QL (30 per 30 days)

imipramine hcl oral tablet 2 PA; MO

imipramine pamoate oral capsule 2 PA; MO

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234

MG/1.5 ML

5 MO

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML

4 MO

INVEGA TRINZA INTRAMUSCULAR

SYRINGE

5 MO


31


medicamento

Requisitos/Límites

KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24HR

4 MO

LATUDA ORAL TABLET 4 MO

lithium carbonate oral capsule 1 MO

lithium carbonate oral tablet 1 MO

lithium carbonate oral tablet extended release 1 MO

lithium citrate oral solution 8 meq/5 ml 2 MO

lorazepam intensol oral concentrate 2 PA; MO

lorazepam oral tablet 2 PA; MO

loxapine succinate oral capsule 2 MO

maprotiline oral tablet 2 MO

MARPLAN ORAL TABLET 4 MO

metadate er oral tablet extended release 2 MO

methamphetamine oral tablet 2 PA; MO

methylphenidate hcl oral capsule, er biphasic 30-

70 10 mg, 50 mg, 60 mg

2 MO

methylphenidate hcl oral capsule,er biphasic 50-

50 20 mg

2 MO

methylphenidate hcl oral solution 2 MO

methylphenidate hcl oral tablet 2 MO

methylphenidate hcl oral tablet extended release 2 MO

methylphenidate hcl oral tablet extended release

24hr 18 mg

2 MO

mirtazapine oral tablet 2 MO

mirtazapine oral tablet,disintegrating 30 mg, 45

mg

2 MO

modafinil oral tablet 2 PA; MO

nefazodone oral tablet 2 MO

nortriptyline oral capsule 2 MO

nortriptyline oral solution 2 MO

NUPLAZID ORAL TABLET 5 PA; MO; QL (60 per 30 days)

olanzapine intramuscular recon soln 2 MO

olanzapine oral tablet 2 MO

olanzapine oral tablet,disintegrating 2 MO

olanzapine-fluoxetine oral capsule 2 MO

oxazepam oral capsule 2 PA; MO


32


medicamento

Requisitos/Límites

paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6

mg


paroxetine hcl oral tablet 1 MO

paroxetine hcl oral tablet extended release 24 hr 2 MO

PAXIL ORAL SUSPENSION 4 MO

perphenazine oral tablet 2 MO

perphenazine-amitriptyline oral tablet 2 PA; MO

phenelzine oral tablet 2 MO

pimozide oral tablet 2 MO

protriptyline oral tablet 2 MO

quetiapine oral tablet 2 MO

quetiapine oral tablet extended release 24 hr 4 MO

REXULTI ORAL TABLET 5 MO

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 12.5 MG/2 ML, 25 MG/2 ML

3 B/D PA; MO

RISPERDAL CONSTA INTRAMUSCULAR

SYRINGE 37.5 MG/2 ML, 50 MG/2 ML

5 B/D PA; MO

risperidone oral solution 2 MO

risperidone oral tablet 2 MO

risperidone oral tablet,disintegrating 2 MO

ROZEREM ORAL TABLET 4 MO; QL (30 per 30 days)

SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 10 MG, 5 MG


SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 2.5 MG

4 MO

sertraline oral concentrate 2 MO

sertraline oral tablet 1 MO

temazepam oral capsule 2 PA; MO

thioridazine oral tablet 2 PA; MO

thiothixene oral capsule 1 MO

tranylcypromine oral tablet 2 MO

trazodone oral tablet 2 MO

trifluoperazine oral tablet 2 MO


33


medicamento

Requisitos/Límites

trimipramine oral capsule 2 PA; MO

TRINTELLIX ORAL TABLET 4 MO

venlafaxine oral capsule,extended release 24hr 2 MO

venlafaxine oral tablet 2 MO

venlafaxine oral tablet extended release 24hr 150

mg, 37.5 mg, 75 mg

2 MO

venlafaxine oral tablet extended release 24hr 225

mg

4 MO

VERSACLOZ ORAL SUSPENSION 5

VIIBRYD ORAL TABLET 3 MO

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)


VRAYLAR ORAL CAPSULE 1.5 MG 5 MO; QL (120 per 30 days)

VRAYLAR ORAL CAPSULE 3 MG 5 MO; QL (60 per 30 days)

VRAYLAR ORAL CAPSULE 4.5 MG 5 MO; QL (40 per 30 days)

VRAYLAR ORAL CAPSULE 6 MG 5 MO; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK 4 MO; QL (7 per 30 days)

XYREM ORAL SOLUTION 5 MO; LA

ziprasidone hcl oral capsule 2 MO

zolpidem oral tablet 2 MO; QL (90 per 365 days)

zolpidem oral tablet,ext release multiphase 2 MO; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 210

MG

4 B/D PA

CARDIOVASCULAR, HIPERTENSIÓN/LÍPIDOS

AGENTES ANTIARRÍTMICOS

amiodarone intravenous solution 2 B/D PA; MO

amiodarone oral tablet 200 mg, 400 mg 2 MO

dofetilide oral capsule 2 MO

flecainide oral tablet 2 MO

mexiletine oral capsule 2 MO

MULTAQ ORAL TABLET 3 MO; QL (60 per 30 days)

pacerone oral tablet 100 mg, 200 mg, 400 mg 2 MO

procainamide injection solution 100 mg/ml 2 MO

procainamide injection solution 500 mg/ml 2


34


medicamento

Requisitos/Límites

propafenone oral capsule,extended release 12 hr 2 MO

propafenone oral tablet 2 MO

quinidine gluconate injection solution 2 MO

quinidine gluconate oral tablet extended release 2 MO

quinidine sulfate oral tablet 2 MO

sorine oral tablet 120 mg, 160 mg, 80 mg 2 MO

sorine oral tablet 240 mg 2

sotalol af oral tablet 120 mg 2 MO

sotalol oral tablet 160 mg, 240 mg, 80 mg 2 MO

TERAPIA ANTIHIPERTENSIVA

acebutolol oral capsule 2 MO

afeditab cr oral tablet extended release 2 MO

amiloride oral tablet 2 MO

amiloride-hydrochlorothiazide oral tablet 1 MO

amlodipine oral tablet 1 MO

amlodipine-benazepril oral capsule 1 MO

amlodipine-olmesartan oral tablet 2 MO

amlodipine-valsartan oral tablet 2 MO

amlodipine-valsartan-hydrochlorothiazide oral

tablet

2 MO

atenolol oral tablet 1 MO

atenolol-chlorthalidone oral tablet 1 MO

benazepril oral tablet 1 MO; QL (60 per 30 days)

benazepril-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

betaxolol oral tablet 2 MO

bisoprolol fumarate oral tablet 2 MO

bisoprolol-hydrochlorothiazide oral tablet 2 MO

bumetanide injection solution 2 MO

bumetanide oral tablet 2 MO

BYSTOLIC ORAL TABLET 3 MO

candesartan oral tablet 2 MO

candesartan-hydrochlorothiazide oral tablet 2 MO

captopril oral tablet 1 MO


35


medicamento

Requisitos/Límites

captopril-hydrochlorothiazide oral tablet 2 MO

cartia xt oral capsule,extended release 24hr 2 MO

carvedilol oral tablet 1 MO

chlorothiazide oral tablet 1 MO

chlorothiazide sodium intravenous recon soln 2 MO

chlorthalidone oral tablet 25 mg, 50 mg 2 MO

clonidine hcl oral tablet 1 MO

clonidine transdermal patch weekly 2 MO

COREG CR ORAL CAPSULE, ER

MULTIPHASE 24 HR

4 ST; MO

DEMSER ORAL CAPSULE 5 PA; MO

diltiazem hcl intravenous recon soln 2 B/D PA

diltiazem hcl intravenous solution 2 B/D PA

diltiazem hcl oral capsule, extended release 180

mg, 360 mg, 420 mg

2 MO

diltiazem hcl oral capsule,extended release 12 hr 2 MO

diltiazem hcl oral capsule,extended release 24hr

120 mg, 240 mg, 300 mg

2 MO

diltiazem hcl oral tablet 2 MO

dilt-xr oral capsule,ext release degradable 2 MO

doxazosin oral tablet 1 MO

enalapril maleate oral tablet 1 MO

enalapril-hydrochlorothiazide oral tablet 1 MO

eplerenone oral tablet 2 MO

eprosartan oral tablet 2 MO

felodipine oral tablet extended release 24 hr 1 MO

fosinopril oral tablet 1 MO; QL (60 per 30 days)

fosinopril-hydrochlorothiazide oral tablet 1 MO; QL (120 per 30 days)

furosemide injection syringe 2 B/D PA; MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1 MO

furosemide oral tablet 1 MO

hydralazine injection solution 2 B/D PA; MO

hydralazine oral tablet 2 MO

hydrochlorothiazide oral capsule 1 MO


36


medicamento

Requisitos/Límites

hydrochlorothiazide oral tablet 1 MO

indapamide oral tablet 1 MO

irbesartan oral tablet 1 MO

irbesartan-hydrochlorothiazide oral tablet 1 MO

isradipine oral capsule 2 MO

labetalol intravenous solution 2 B/D PA; MO

labetalol oral tablet 2 MO

lisinopril oral tablet 1 MO; QL (60 per 30 days)

lisinopril-hydrochlorothiazide oral tablet 1 MO; QL (60 per 30 days)

losartan oral tablet 100 mg 1 MO; QL (45 per 30 days)

losartan oral tablet 25 mg, 50 mg 1 MO; QL (60 per 30 days)

losartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

matzim la oral tablet extended release 24 hr 2 MO

methyclothiazide oral tablet 2 MO

methyldopa-hydrochlorothiazide oral tablet 2 PA; MO

metolazone oral tablet 2 MO

metoprolol succinate oral tablet extended release

24 hr

2 MO

metoprolol tartrate intravenous solution 1 B/D PA; MO; NEDS

metoprolol tartrate intravenous syringe 1 B/D PA; NEDS

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

1 MO

metoprolol tartrate-hydrochlorothiazide oral

tablet

2 MO

minoxidil oral tablet 2 MO

moexipril oral tablet 2 MO

moexipril-hydrochlorothiazide oral tablet 2 MO

nadolol oral tablet 2 MO

nadolol-bendroflumethiazide oral tablet 2 MO

nicardipine intravenous solution 2 MO

nicardipine oral capsule 2 MO

nifedipine oral tablet extended release 2 MO

nifedipine oral tablet extended release 24hr 2 MO

nimodipine oral capsule 1 MO


37


medicamento

Requisitos/Límites

olmesartan oral tablet 2 MO; QL (30 per 30 days)

olmesartan-amlodipine- hydrochlorothiazide oral

tablet

2 MO

olmesartan-hydrochlorothiazide oral tablet 2 MO; QL (30 per 30 days)

perindopril erbumine oral tablet 2 MO

phenoxybenzamine oral capsule 5 PA; MO

pindolol oral tablet 2 MO

prazosin oral capsule 2 MO

propranolol intravenous solution 2 B/D PA

propranolol oral capsule,extended release 24 hr 2 MO

propranolol oral solution 2 MO

propranolol oral tablet 2 MO

propranolol-hydrochlorothiazide oral tablet 2 MO

quinapril oral tablet 1 MO

quinapril-hydrochlorothiazide oral tablet 1 MO

ramipril oral capsule 1 MO

REMODULIN INJECTION SOLUTION 5 B/D PA; MO; LA

spironolactone oral tablet 2 MO

spironolactone-hydrochlorothiazide oral tablet 2 MO

taztia xt oral capsule, extended release 2 MO

TEKTURNA HCT ORAL TABLET 3 MO

TEKTURNA ORAL TABLET 3 MO

telmisartan oral tablet 2 MO

telmisartan-hydrochlorothiazide oral tablet 2 MO

terazosin oral capsule 1 MO

timolol maleate oral tablet 2 MO

torsemide oral tablet 2 MO

trandolapril oral tablet 2 MO

trandolapril-verapamil oral tablet, ir - er, biphasic

24hr

2 MO

triamterene-hydrochlorothiazide oral capsule 2 MO

triamterene-hydrochlorothiazide oral tablet 2 MO

UPTRAVI ORAL TABLET 5 PA; MO; LA; QL (60 per 30 days)

UPTRAVI ORAL TABLETS,DOSE PACK 5 PA; MO; LA

valsartan oral tablet 160 mg, 40 mg, 80 mg 1 MO; QL (60 per 30 days)


38


medicamento

Requisitos/Límites

valsartan oral tablet 320 mg 1 MO; QL (30 per 30 days)

valsartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

verapamil intravenous solution 1 B/D PA; MO

verapamil oral capsule, 24 hr er pellet ct 2 MO

verapamil oral capsule,ext rel. pellets 24 hr 2 MO

verapamil oral tablet 1 MO

verapamil oral tablet extended release 2 MO

GLUCÓSIDOS CARDÍACOS

digitek oral tablet 1 PA; MO

digoxin injection solution 2 PA; MO

digoxin oral solution 50 mcg/ml 2 PA; MO

digoxin oral tablet 1 PA; MO

LANOXIN ORAL TABLET 4 MO

TERAPIA DE COAGULACIÓN

aspirin-dipyridamole oral capsule, er multiphase

12 hr

2 MO

BRILINTA ORAL TABLET 3 MO

cilostazol oral tablet 2 MO

clopidogrel oral tablet 300 mg 2 MO; QL (1 per 30 days)

clopidogrel oral tablet 75 mg 2 MO

COUMADIN ORAL TABLET 3 MO

EFFIENT ORAL TABLET 3 MO

ELIQUIS ORAL TABLET 3 MO

enoxaparin subcutaneous solution 4 MO; QL (180 per 30 days); NEDS

enoxaparin subcutaneous syringe 100 mg/ml, 150

mg/ml

4 MO; QL (60 per 30 days); NEDS

enoxaparin subcutaneous syringe 120 mg/0.8 ml,

80 mg/0.8 ml

4 MO; QL (48 per 30 days); NEDS

enoxaparin subcutaneous syringe 30 mg/0.3 ml 4 MO; QL (18 per 30 days); NEDS



fondaparinux subcutaneous syringe 10 mg/0.8 ml 5 MO; QL (24 per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 4 MO; QL (15 per 30 days)

fondaparinux subcutaneous syringe 5 mg/0.4 ml 5 MO; QL (12 per 30 days)


39


medicamento

Requisitos/Límites

fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 5 MO; QL (18 per 30 days)

FRAGMIN SUBCUTANEOUS SOLUTION 4 MO; QL (30 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 10,000

ANTI-XA UNIT/ML



ANTI-XA UNIT/0.5 ML



ANTI-XA UNIT/0.6 ML



ANTI-XA UNIT/0.72 ML

5 MO; QL (21.6 per 30 days)


ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA

UNIT/0.2 ML



ANTI-XA UNIT/0.3 ML


heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml (40

unit/ml)

2 B/D PA

heparin (porcine) in 5 % dex intravenous

parenteral solution 25,000 unit/250 ml(100

unit/ml), 25,000 unit/500 ml (50 unit/ml)

2 B/D PA; MO

heparin (porcine) injection solution 2 B/D PA; MO

jantoven oral tablet 3 MO

pentoxifylline oral tablet extended release 2 MO

PRADAXA ORAL CAPSULE 4 MO

PROMACTA ORAL TABLET 5 PA; MO; LA

tranexamic acid intravenous solution 2 B/D PA; MO

warfarin oral tablet 1 MO

AGENTES QUE REDUCEN EL COLESTEROL/LÍPIDOS

amlodipine-atorvastatin oral tablet 2 MO; QL (30 per 30 days)

atorvastatin oral tablet 1 MO; QL (45 per 30 days)

cholestyramine (with sugar) oral powder 2 MO

cholestyramine light oral powder 2 MO

colestipol oral granules 2 MO

colestipol oral tablet 2 MO

ezetimibe oral tablet 2 MO; QL (30 per 30 days)

ezetimibe-simvastatin oral tablet 2 MO


40


medicamento

Requisitos/Límites

fenofibrate micronized oral capsule 2 MO

fenofibrate nanocrystallized oral tablet 2 MO

fenofibrate oral tablet 160 mg, 54 mg 2 MO

fenofibric acid (choline) oral capsule,delayed

release(dr/ec)

2 MO

fenofibric acid oral tablet 2 MO

fluvastatin oral capsule 2 MO

fluvastatin oral tablet extended release 24 hr 2 MO

gemfibrozil oral tablet 1 MO

JUXTAPID ORAL CAPSULE 5 PA; MO; LA

KYNAMRO SUBCUTANEOUS SYRINGE 5 PA; MO

lovastatin oral tablet 10 mg, 20 mg 1 MO; QL (45 per 30 days)

lovastatin oral tablet 40 mg 1 MO; QL (60 per 30 days)

niacin oral tablet extended release 24 hr 2 MO

omega-3 acid ethyl esters oral capsule 2 MO

PRALUENT SUBCUTANEOUS PEN

INJECTOR 150 MG/ML


PRALUENT SUBCUTANEOUS PEN

INJECTOR 75 MG/ML


pravastatin oral tablet 1 MO; QL (45 per 30 days)

prevalite oral powder 2 MO

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR

5 PA; MO; QL (3.5 per 28 days)

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR


REPATHA SUBCUTANEOUS SYRINGE 5 PA; MO; QL (3 per 28 days)

rosuvastatin oral tablet 2 MO; QL (30 per 30 days)

simvastatin oral tablet 1 MO; QL (30 per 30 days)

WELCHOL ORAL POWDER IN PACKET 3 MO

WELCHOL ORAL TABLET 3 MO

AGENTES CARDIOVASCULARES DIVERSOS

CORLANOR ORAL TABLET 4 PA; MO

ENTRESTO ORAL TABLET 3 MO

RANEXA ORAL TABLET EXTENDED

RELEASE 12 HR



41


medicamento

Requisitos/Límites

VECAMYL ORAL TABLET 4

NITRATOS

ISORDIL ORAL TABLET 3 MO

isosorbide dinitrate oral tablet 2 MO

isosorbide dinitrate oral tablet extended release 2 MO

isosorbide mononitrate oral tablet 1 MO

isosorbide mononitrate oral tablet extended

release 24 hr

1 MO

nitro-bid transdermal ointment 2 MO

nitroglycerin intravenous solution 2 B/D PA

nitroglycerin sublingual tablet 2 MO

nitroglycerin transdermal patch 24 hour 2 MO

nitroglycerin translingual spray,non-aerosol 2 MO

TERAPIA DERMATOLÓGICA/TÓPICOS

ANTIPSORIÁSICO/ANTISEBORREICO

acitretin oral capsule 10 mg 4 MO

acitretin oral capsule 17.5 mg, 25 mg 5 MO; NEDS

calcipotriene scalp solution 2 MO

calcipotriene topical cream 2 MO

calcipotriene topical ointment 2 MO

calcipotriene-betamethasone topical ointment 4 MO

calcitriol topical ointment 2 MO

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE

5 ST; MO

COSENTYX PEN (2 PENS) SUBCUTANEOUS

INJECTOR

5 ST; MO

selenium sulfide topical lotion 2 MO

TERAPIA DE QUEMADOS

silver sulfadiazine topical cream 2 MO

ssd topical cream 2 MO

DERMATOLÓGICOS DIVERSOS

ammonium lactate topical cream 2 MO

ammonium lactate topical lotion 2 MO

CARAC TOPICAL CREAM 3 MO

diclofenac sodium topical gel 3 % 5 PA; MO


42


medicamento

Requisitos/Límites

ELIDEL TOPICAL CREAM 4 ST; MO

FLUOROURACIL TOPICAL CREAM 0.5 % 4 MO

fluorouracil topical cream 5 % 2 MO

fluorouracil topical solution 2 MO

imiquimod topical cream in packet 2 MO

methoxsalen oral capsule,liqd-filled,rapid rel 2 MO

PANRETIN TOPICAL GEL 5 MO

podofilox topical solution 2 MO

REGRANEX TOPICAL GEL 5 MO; QL (30 per 30 days)

tacrolimus topical ointment 4 MO

VALCHLOR TOPICAL GEL 5 MO

ZYCLARA TOPICAL CREAM IN METERED-

DOSE PUMP 2.5 %

4 MO

ZYCLARA TOPICAL CREAM IN PACKET 4 MO

TRATAMIENTO PARA EL ACNÉ

adapalene topical cream 2 PA; MO

adapalene topical gel 2 PA; MO

claravis oral capsule 4 MO

clindamycin phosphate topical foam 2 MO

clindamycin phosphate topical gel 2 MO

clindamycin phosphate topical lotion 2 MO

clindamycin phosphate topical solution 2 MO

clindamycin phosphate topical swab 2 MO

clindamycin-benzoyl peroxide topical gel 2 MO

ery pads topical swab 2 MO

erythromycin with ethanol topical gel 2 MO

erythromycin with ethanol topical solution 2 MO

erythromycin-benzoyl peroxide topical gel 2 MO

metronidazole topical cream 2 MO

metronidazole topical gel 2 MO

metronidazole topical lotion 2 MO

tazarotene topical cream 4 MO

tretinoin microspheres topical gel 2 PA; MO


43


medicamento

Requisitos/Límites

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 2 PA; MO

tretinoin topical gel 0.01 %, 0.025 % 2 PA; MO

ANESTÉSICOS TÓPICOS

lidocaine (pf) injection solution 10 mg/ml (1 %), 5

mg/ml (0.5 %)

2 B/D PA; MO

lidocaine hcl injection solution 20 mg/ml (2 %) 2 B/D PA; MO

lidocaine hcl mucous membrane jelly 2 MO

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

2 MO

lidocaine topical adhesive patch,medicated 2 PA; MO

lidocaine topical ointment 2 MO

lidocaine viscous mucous membrane solution 2 MO

lidocaine-prilocaine topical cream 2 MO

ANTIBACTERIALES TÓPICOS

gentamicin topical cream 2 MO

gentamicin topical ointment 2 MO

mupirocin calcium topical cream 2 MO

mupirocin topical ointment 2 MO

sulfacetamide sodium (acne) topical suspension 2 MO

SULFAMYLON TOPICAL CREAM 4 MO

ANTIMICÓTICOS TÓPICOS

ciclopirox topical cream 2 MO

ciclopirox topical gel 2 MO

ciclopirox topical shampoo 2 MO

ciclopirox topical solution 2 MO

ciclopirox topical suspension 2 MO

clotrimazole topical cream 2 MO

clotrimazole-betamethasone topical cream 2 MO

clotrimazole-betamethasone topical lotion 2 MO

econazole topical cream 2 MO

ketoconazole topical cream 2 MO

ketoconazole topical foam 2 MO

ketoconazole topical shampoo 2 MO

nyamyc topical powder 2 MO

nystatin topical cream 2 MO


44


medicamento

Requisitos/Límites

nystatin topical ointment 2 MO

nystatin topical powder 2 MO

nystatin-triamcinolone topical cream 2 MO

nystatin-triamcinolone topical ointment 2 MO

nystop topical powder 2 MO

ANTIVIRALES TÓPICOS

acyclovir topical ointment 2 MO

DENAVIR TOPICAL CREAM 3 MO

CORTICOSTEROIDES TÓPICOS

ala-cort topical cream 2 MO

alclometasone topical cream 2 MO

alclometasone topical ointment 2 MO

amcinonide topical cream 2 MO

amcinonide topical lotion 2 MO

amcinonide topical ointment 2 MO

betamethasone dipropionate topical cream 2 MO

betamethasone dipropionate topical lotion 2 MO

betamethasone dipropionate topical ointment 2 MO

betamethasone valerate topical cream 2 MO

betamethasone valerate topical foam 2 MO

betamethasone valerate topical lotion 2 MO

betamethasone valerate topical ointment 2 MO

betamethasone, augmented topical cream 2 MO

betamethasone, augmented topical gel 2 MO

betamethasone, augmented topical lotion 2 MO

cormax scalp solution 2

desoximetasone topical cream 2 MO

desoximetasone topical gel 2 MO

desoximetasone topical ointment 2 MO

diflorasone topical cream 2 MO

diflorasone topical ointment 2 MO

fluocinolone topical oil 2 MO

fluocinolone topical ointment 2 MO


45


medicamento

Requisitos/Límites

fluocinolone topical solution 2 MO

fluticasone topical cream 2 MO

fluticasone topical lotion 2 MO

fluticasone topical ointment 2 MO

hydrocortisone butyrate topical ointment 2 MO

hydrocortisone butyrate topical solution 2 MO

hydrocortisone butyr-emollient topical cream 2 MO

hydrocortisone topical cream 1 %, 2.5 % 2 MO

hydrocortisone topical lotion 2.5 % 2 MO

hydrocortisone topical ointment 1 %, 2.5 % 2 MO

hydrocortisone valerate topical cream 2 MO

hydrocortisone valerate topical ointment 2 MO

mometasone topical cream 2 MO

mometasone topical ointment 2 MO

mometasone topical solution 2 MO

prednicarbate topical ointment 2 MO

triamcinolone acetonide topical aerosol 2 MO

triamcinolone acetonide topical cream 2 MO

triamcinolone acetonide topical lotion 2 MO

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

2 MO

trianex topical ointment 2 MO

triderm topical cream 2 MO

ENZIMAS TÓPICAS

SANTYL TOPICAL OINTMENT 3 MO

ESCABICIDAS Y PEDICULICIDAS TÓPICOS

lindane topical shampoo 2 MO

malathion topical lotion 2 MO

permethrin topical cream 2 MO

DIAGNÓSTICOS/AGENTES DIVERSOS

SOLUCIONES DE IRRIGACIÓN

lactated ringers irrigation solution 2 MO

neomycin-polymyxin b gu irrigation solution 2 MO

AGENTES DIVERSOS


46


medicamento

Requisitos/Límites

acamprosate oral tablet,delayed release (dr/ec) 2 MO

ADAGEN INTRAMUSCULAR SOLUTION 5 B/D PA; MO

alendronate oral tablet 40 mg 1 MO; QL (30 per 30 days)

anagrelide oral capsule 2 MO

ARALAST NP INTRAVENOUS RECON SOLN

500 MG

5 B/D PA; MO; LA

AURYXIA ORAL TABLET 5 MO

cevimeline oral capsule 2 MO

CHEMET ORAL CAPSULE 3 MO

CLINIMIX 4.25%/D5W SULFITE FREE

INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

CLINIMIX E 2.75%/D10W SULFITE FREE


4 B/D PA



4 B/D PA

d10 %-0.45 % sodium chloride intravenous

parenteral solution

2

d2.5 %-0.45 % sodium chloride intravenous

parenteral solution

2 B/D PA

d5 % and 0.9 % sodium chloride intravenous

parenteral solution

2 B/D PA; MO

d5 %-0.45 % sodium chloride intravenous

parenteral solution

2 B/D PA; MO

dextrose 10 % and 0.2 % nacl intravenous

parenteral solution

2 B/D PA

dextrose 10 % in water (d10w) intravenous

parenteral solution

2 B/D PA; MO

dextrose 5 % in water (d5w) intravenous

parenteral solution

2 B/D PA; MO

dextrose 5 %-lactated ringers intravenous

parenteral solution

2 B/D PA; MO

dextrose 5%-0.2 % sod chloride intravenous

parenteral solution

2 B/D PA

dextrose 5%-0.3 % sod.chloride intravenous

parenteral solution

2 B/D PA

dextrose with sodium chloride intravenous

parenteral solution

2 B/D PA


47


medicamento

Requisitos/Límites

disulfiram oral tablet 2 MO

etidronate disodium oral tablet 2 MO

EXJADE ORAL TABLET, DISPERSIBLE 125

MG

4 MO; LA

EXJADE ORAL TABLET, DISPERSIBLE 250

MG, 500 MG

5 MO; LA

FERRIPROX ORAL TABLET 5 PA; MO

FOSRENOL ORAL POWDER IN PACKET 3 MO

FOSRENOL ORAL TABLET,CHEWABLE 500

MG, 750 MG

3 MO

INCRELEX SUBCUTANEOUS SOLUTION 5 B/D PA; MO; LA

kionex oral powder 4 MO

levocarnitine (with sugar) oral solution 2 B/D PA; MO

levocarnitine oral tablet 2 B/D PA; MO

midodrine oral tablet 2 MO

NORTHERA ORAL CAPSULE 5 PA; MO

pilocarpine hcl oral tablet 2 MO

RAVICTI ORAL LIQUID 5 PA; MO

RENVELA ORAL POWDER IN PACKET 3 MO

RENVELA ORAL TABLET 3 MO

riluzole oral tablet 2 MO

risedronate oral tablet 30 mg 2 MO

sodium chloride 0.9 % intravenous parenteral

solution

2 MO

sodium chloride irrigation solution 2 MO

sodium polystyrene (sorb free) oral suspension 2 MO

sps (with sorbitol) oral suspension 2 MO

SYPRINE ORAL CAPSULE 3 MO

zoledronic acid-mannitol-water intravenous

piggyback

2 PA; MO

DISUASORIOS DEL TABACO

bupropion hcl (smoking deter) oral tablet extended

release 12 hr

2 MO

CHANTIX CONTINUING MONTH BOX ORAL

TABLET

4 MO

CHANTIX ORAL TABLET 4 MO


48


medicamento

Requisitos/Límites

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK

4 MO

NICOTROL INHALATION CARTRIDGE 3 MO

NICOTROL NS NASAL SPRAY,NON-

AEROSOL

3 MO

MEDICAMENTOS PARA OÍDOS, NARIZ Y GARGANTA

AGENTES DIVERSOS

azelastine nasal spray, aerosol 2 MO; QL (60 per 30 days)

azelastine nasal spray,non-aerosol 2 MO; QL (60 per 30 days)

chlorhexidine gluconate mucous membrane

mouthwash

2 MO

ipratropium bromide nasal spray,non-aerosol 0.03

%


ipratropium bromide nasal spray,non-aerosol 0.06

%


olopatadine nasal spray,non-aerosol 4 MO; QL (30.5 per 30 days)

periogard mucous membrane mouthwash 2 MO

triamcinolone acetonide dental paste 2 MO

PREPARACIONES ÓTICAS DIVERSAS

acetasol hc otic drops 2 MO

acetic acid otic solution 2 MO

fluocinolone acetonide oil otic drops 2 MO

hydrocortisone-acetic acid otic drops 2 MO

ofloxacin otic drops 2 MO

ESTEROIDES ÓTICOS/ANTIBIÓTICOS

CIPRODEX OTIC DROPS,SUSPENSION 4 MO

neomycin-polymyxin-hc otic drops,suspension 2 MO

neomycin-polymyxin-hc otic solution 2 MO

ENDOCRINO/DIABETES

HORMONAS SUPRARRENALES

ACTHAR H.P. INJECTION GEL 5 PA; MO

cortisone oral tablet 2 MO

dexamethasone intensol oral drops 2 MO

dexamethasone oral elixir 2 MO


49


medicamento

Requisitos/Límites

dexamethasone oral tablet 2 MO

dexamethasone sodium phosphate injection

solution

2 B/D PA; MO

fludrocortisone oral tablet 2 MO

hydrocortisone oral tablet 2 MO

KENALOG INJECTION SUSPENSION 4 MO

methylprednisolone acetate injection suspension 2 B/D PA; MO

methylprednisolone oral tablet 2 MO

methylprednisolone oral tablets,dose pack 2 MO

methylprednisolone sodium succ injection recon

soln 125 mg, 40 mg

2 B/D PA; MO

methylprednisolone sodium succ intravenous

recon soln

2 B/D PA; MO

millipred oral tablet 2 MO

prednisolone sodium phosphate oral solution 10

mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4

mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7

mg/5 ml)

2 MO

prednisolone sodium phosphate oral

tablet,disintegrating

2 MO

prednisone intensol oral concentrate 2 MO

prednisone oral solution 2 MO

prednisone oral tablet 1 MO

prednisone oral tablets,dose pack 1 MO

SOLU-CORTEF (PF) INJECTION RECON

SOLN 100 MG/2 ML, 250 MG/2 ML

3 B/D PA; MO

veripred 20 oral solution 2 MO

AGENTES ANTITIROIDEOS

methimazole oral tablet 10 mg, 5 mg 2 MO

propylthiouracil oral tablet 2 MO

TERAPIA PARA LA DIABETES

acarbose oral tablet 2 MO

ACTOPLUS MET XR ORAL TABLET, ER

MULTIPHASE 24 HR 15-1,000 MG

4 ST; MO; QL (60 per 30 days)

ACTOPLUS MET XR ORAL TABLET, ER

MULTIPHASE 24 HR 30-1,000 MG

4 ST; MO; QL (30 per 30 days)

alcohol pads topical pads, medicated 3 MO


50


medicamento

Requisitos/Límites

BYDUREON SUBCUTANEOUS PEN

INJECTOR

3 MO

BYDUREON SUBCUTANEOUS

SUSPENSION,EXTENDED REL RECON

3 MO

CYCLOSET ORAL TABLET 4 ST; MO

FARXIGA ORAL TABLET 3 MO; QL (30 per 30 days)

GAUZE PADS 2 X 2 3 MO

glimepiride oral tablet 1 MO

glipizide oral tablet 1 MO

glipizide oral tablet extended release 24hr 1 MO

glipizide-metformin oral tablet 2.5-250 mg, 2.5-

500 mg


glipizide-metformin oral tablet 5-500 mg 2 MO; QL (120 per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON

SOLN

3 MO

GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION KIT

3 MO

glyburide micronized oral tablet 2 ST; MO

glyburide oral tablet 2 ST; MO

glyburide-metformin oral tablet 2 ST; MO

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

INSULIN PEN

3 MO

HUMULIN 70/30 SUBCUTANEOUS

SUSPENSION

3 MO

HUMULIN N KWIKPEN SUBCUTANEOUS

INSULIN PEN

3 MO

HUMULIN N SUBCUTANEOUS SUSPENSION 3 MO

HUMULIN R U-100 INJECTION SOLUTION 3 MO

HUMULIN R U-500 (CONC) KWIKPEN

SUBCUTANEOUS INSULIN PEN

3 MO

HUMULIN R U-500 (CONCENTRATED)

SUBCUTANEOUS SOLUTION

3 MO

INSULIN PEN NEEDLE 3 MO

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1

ML, 1/2 ML

3 MO

JANUMET ORAL TABLET 3 MO; QL (60 per 30 days)


51


medicamento

Requisitos/Límites

JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR


JANUVIA ORAL TABLET 3 MO; QL (30 per 30 days)

JARDIANCE ORAL TABLET 3 MO

KOMBIGLYZE XR ORAL TABLET, ER

MULTIPHASE 24 HR


LEVEMIR FLEXTOUCH SUBCUTANEOUS

INSULIN PEN

3 MO

LEVEMIR SUBCUTANEOUS SOLUTION 3 MO

metformin oral tablet 1 MO

metformin oral tablet extended release 24 hr 500

mg


metformin oral tablet extended release 24 hr 750

mg


nateglinide oral tablet 2 MO

NEEDLES, INSULIN DISP.,SAFETY 3 MO

NOVOLIN 70/30 SUBCUTANEOUS

SUSPENSION

3 MO

NOVOLIN N SUBCUTANEOUS SUSPENSION 3 MO

NOVOLIN R INJECTION SOLUTION 3 MO

NOVOLOG FLEXPEN SUBCUTANEOUS

INSULIN PEN

3 MO

NOVOLOG MIX 70-30 FLEXPEN


3 MO

NOVOLOG MIX 70-30 SUBCUTANEOUS

SOLUTION

3 MO

NOVOLOG PENFILL SUBCUTANEOUS

CARTRIDGE

3 MO

NOVOLOG SUBCUTANEOUS SOLUTION 3 MO

ONGLYZA ORAL TABLET 3 MO; QL (30 per 30 days)

pioglitazone oral tablet 2 MO

pioglitazone-glimepiride oral tablet 2 MO; QL (30 per 30 days)

pioglitazone-metformin oral tablet 2 MO; QL (90 per 30 days)

PROGLYCEM ORAL SUSPENSION 4 MO

repaglinide oral tablet 0.5 mg 1 MO; QL (930 per 30 days)

repaglinide oral tablet 1 mg 1 MO; QL (480 per 30 days)

repaglinide oral tablet 2 mg 1 MO; QL (240 per 30 days)


52


medicamento

Requisitos/Límites

repaglinide-metformin oral tablet 2 MO

SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR

3 MO

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR

3 MO

SYNJARDY ORAL TABLET 3 MO; QL (60 per 30 days)

tolazamide oral tablet 2 MO

tolbutamide oral tablet 1 MO

TRESIBA FLEXTOUCH U-100


3 MO

TRESIBA FLEXTOUCH U-200


3 MO

VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR

3 MO

XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-

500 MG


XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG


HORMONAS DIVERSAS

ALDURAZYME INTRAVENOUS SOLUTION 5 B/D PA; MO

ANADROL-50 ORAL TABLET 4 PA; MO

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25 GRAM

(1.62 %)

3 MO

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62

% (40.5 MG/2.5 GRAM)

3 MO

cabergoline oral tablet 2 MO; QL (20 per 30 days)

calcitonin (salmon) nasal spray,non-aerosol 2 MO

calcitriol intravenous solution 1 mcg/ml 2 B/D PA; MO

calcitriol oral capsule 2 B/D PA; MO

calcitriol oral solution 2 B/D PA; MO

CEREZYME INTRAVENOUS RECON SOLN

400 UNIT

5 B/D PA; MO

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR RECON SOLN

4 PA; MO


53


medicamento

Requisitos/Límites

danazol oral capsule 2 MO

desmopressin injection solution 2 MO

desmopressin nasal solution 2

desmopressin nasal spray,non-aerosol 2 MO

desmopressin oral tablet 2 MO

ELAPRASE INTRAVENOUS SOLUTION 5 B/D PA; MO

ELELYSO INTRAVENOUS RECON SOLN 5 B/D PA; MO

FABRAZYME INTRAVENOUS RECON SOLN

35 MG

5 PA; MO

KORLYM ORAL TABLET 5 PA; MO

KUVAN ORAL TABLET,SOLUBLE 5 PA; MO

methyltestosterone oral capsule 2 MO

MIACALCIN INJECTION SOLUTION 3 B/D PA; MO

NAGLAZYME INTRAVENOUS SOLUTION 5 B/D PA; MO; LA

NATPARA SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA

NOVAREL INTRAMUSCULAR RECON SOLN 4 PA; MO

oxandrolone oral tablet 10 mg 5 MO

oxandrolone oral tablet 2.5 mg 2 MO

pamidronate intravenous solution 2 B/D PA; MO

paricalcitol oral capsule 2 B/D PA; MO

PREGNYL INTRAMUSCULAR RECON SOLN 4 PA; MO

SAMSCA ORAL TABLET 15 MG 5 PA; MO; QL (30 per 30 days); NEDS

SAMSCA ORAL TABLET 30 MG 5 PA; MO; QL (60 per 30 days); NEDS

SENSIPAR ORAL TABLET 30 MG 3 MO; QL (60 per 30 days)



SOMAVERT SUBCUTANEOUS RECON SOLN 5 B/D PA; MO

SYNAREL NASAL SPRAY,NON-AEROSOL 3 MO

testosterone cypionate intramuscular oil 2 B/D PA; MO

testosterone enanthate intramuscular oil 2 B/D PA; MO

VPRIV INTRAVENOUS RECON SOLN 5 B/D PA; MO

ZAVESCA ORAL CAPSULE 5 MO; LA

ZEMPLAR INTRAVENOUS SOLUTION 3 B/D PA; MO

zoledronic acid intravenous solution 2 B/D PA; MO


54


medicamento

Requisitos/Límites

ZOMETA INTRAVENOUS PIGGYBACK 5 B/D PA; MO

HORMONAS TIROIDEAS

LEVOTHYROXINE INTRAVENOUS RECON

SOLN 100 MCG

3 MO

levothyroxine oral tablet 1 MO

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

4 MO

liothyronine intravenous solution 2 MO

liothyronine oral tablet 2 MO

SYNTHROID ORAL TABLET 4 MO

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

1 MO

GASTROENTEROLOGÍA

ANTIDIARREICOS/ANTIESPASMÓDICOS

atropine injection syringe 0.05 mg/ml 2

dicyclomine oral capsule 2 MO

dicyclomine oral solution 2 MO

dicyclomine oral tablet 2 MO

glycopyrrolate injection solution 2 MO

glycopyrrolate oral tablet 2 MO

loperamide oral capsule 2 MO

methscopolamine oral tablet 2 MO

AGENTES GASTROINTESTINALES DIVERSOS

alosetron oral tablet 5 PA; MO; QL (60 per 30 days)

AMITIZA ORAL CAPSULE 3 MO; QL (60 per 30 days)

aprepitant oral capsule 4 B/D PA; MO

aprepitant oral capsule,dose pack 4 B/D PA; MO

APRISO ORAL CAPSULE,EXTENDED

RELEASE 24HR

3 MO

balsalazide oral capsule 2 MO

budesonide oral capsule,delayed,extend.release 5 MO

CANASA RECTAL SUPPOSITORY 3 MO


55


medicamento

Requisitos/Límites

CHOLBAM ORAL CAPSULE 5 PA; MO

CIMZIA POWDER FOR RECONST

SUBCUTANEOUS KIT

5 B/D PA; ST; MO

CIMZIA SUBCUTANEOUS SYRINGE KIT 5 ST; MO

compro rectal suppository 2 MO

constulose oral solution 2 MO

CREON ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

4 MO

cromolyn oral concentrate 2 MO

CYSTADANE ORAL POWDER 5 MO

DELZICOL ORAL CAPSULE (WITH DEL REL

TABLETS)

4 MO

DIPENTUM ORAL CAPSULE 4 MO

dronabinol oral capsule 4 B/D PA; MO

EMEND ORAL SUSPENSION FOR

RECONSTITUTION

4 B/D PA

enulose oral solution 2 MO

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 PA; MO

gavilyte-c oral recon soln 2 MO

gavilyte-g oral recon soln 2 MO

gavilyte-n oral recon soln 2 MO

generlac oral solution 2 MO

granisetron (pf) intravenous solution 100 mcg/ml 2 B/D PA; MO

granisetron hcl intravenous solution 2 B/D PA; MO

granisetron hcl oral tablet 2 B/D PA; MO

hydrocortisone rectal enema 2 MO

lactulose oral solution 10 gram/15 ml 2 MO

LIALDA ORAL TABLET,DELAYED RELEASE

(DR/EC)

3 MO

LINZESS ORAL CAPSULE 3 MO; QL (30 per 30 days)

meclizine oral tablet 12.5 mg, 25 mg 2 MO

mesalamine with cleansing wipe rectal enema kit 2 MO

metoclopramide hcl injection solution 2 B/D PA; MO

metoclopramide hcl oral solution 2 MO

metoclopramide hcl oral tablet 1 MO

MOVANTIK ORAL TABLET 3 MO


56


medicamento

Requisitos/Límites

MOVIPREP ORAL POWDER IN PACKET 3 MO

ondansetron hcl (pf) injection solution 2 B/D PA; MO

ondansetron hcl (pf) injection syringe 2 B/D PA; MO

ondansetron hcl oral solution 2 B/D PA; MO

ondansetron hcl oral tablet 24 mg 2 B/D PA

ondansetron hcl oral tablet 4 mg, 8 mg 2 B/D PA; MO

ondansetron oral tablet,disintegrating 2 B/D PA; MO

PANCREAZE ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT,

16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850

UNIT, 21,000-54,700- 83,900 UNIT, 4,200-

14,200- 24,600 UNIT

4 MO

peg 3350-electrolytes oral recon soln 236-22.74-

6.74 -5.86 gram

1 MO

peg-electrolyte oral recon soln 1

PENTASA ORAL CAPSULE, EXTENDED

RELEASE

4 MO

polyethylene glycol 3350 oral powder 2 MO

prochlorperazine edisylate injection solution 10

mg/2 ml (5 mg/ml)

2 MO

prochlorperazine maleate oral tablet 1 MO

prochlorperazine rectal suppository 2 MO

procto-pak topical cream with perineal applicator 2 MO

proctosol hc topical cream with perineal

applicator

2 MO

proctozone-hc topical cream with perineal

applicator

2 MO

RELISTOR SUBCUTANEOUS SOLUTION 5 MO

RELISTOR SUBCUTANEOUS SYRINGE 5 MO

REMICADE INTRAVENOUS RECON SOLN 5 PA; MO

SANCUSO TRANSDERMAL PATCH WEEKLY 3 B/D PA; MO; QL (2 per 15 days)

sulfasalazine oral tablet 2 MO

sulfasalazine oral tablet,delayed release (dr/ec) 2 MO

TRANSDERM-SCOP TRANSDERMAL PATCH

3 DAY


trilyte with flavor packets oral recon soln 2 MO


57


medicamento

Requisitos/Límites

ursodiol oral capsule 2 MO

ursodiol oral tablet 2 MO

VARUBI ORAL TABLET 4 B/D PA; MO

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

3 MO

TERAPIA DE ÚLCERA

amoxicil-clarithromy-lansopraz oral combo pack 2 MO

CARAFATE ORAL SUSPENSION 3 MO

cimetidine hcl oral solution 2 MO

cimetidine oral tablet 2 MO

DEXILANT ORAL CAPSULE,BIPHASE

DELAYED RELEASE

3 MO

esomeprazole sodium intravenous recon soln 2 B/D PA

famotidine (pf) intravenous solution 2 B/D PA; MO

famotidine (pf)-nacl (iso-osm) intravenous

piggyback

2 B/D PA; MO

famotidine oral suspension 2 MO

famotidine oral tablet 20 mg, 40 mg 1 MO

lansoprazole oral capsule,delayed release(dr/ec) 2 MO

misoprostol oral tablet 2 MO

nizatidine oral capsule 2 MO

nizatidine oral solution 2 MO

omeprazole oral capsule,delayed release(dr/ec) 2 MO

pantoprazole oral tablet,delayed release (dr/ec) 2 MO

ranitidine hcl oral capsule 2 MO

ranitidine hcl oral syrup 2 MO

ranitidine hcl oral tablet 150 mg, 300 mg 2 MO

sucralfate oral tablet 2 MO

INMUNOLOGÍA, VACUNAS/BIOTECNOLOGÍA

MEDICAMENTOS DE BIOTECNOLOGÍA

ACTIMMUNE SUBCUTANEOUS SOLUTION 5 PA; MO

ARCALYST SUBCUTANEOUS RECON SOLN 5 PA; MO

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT



58


medicamento

Requisitos/Límites

AVONEX INTRAMUSCULAR PEN INJECTOR

KIT


AVONEX INTRAMUSCULAR SYRINGE KIT 5 PA; MO; QL (4 per 28 days)

EGRIFTA SUBCUTANEOUS RECON SOLN 1

MG

5 PA; MO

EXTAVIA SUBCUTANEOUS KIT 5 PA; MO; QL (15 per 30 days)

ILARIS (PF) SUBCUTANEOUS RECON SOLN 5 PA; MO; LA

INTRON A INJECTION RECON SOLN 10

MILLION UNIT (1 ML), 50 MILLION UNIT (1

ML)

5 B/D PA; MO

INTRON A INJECTION RECON SOLN 18

MILLION UNIT (1 ML)

4 B/D PA; MO

INTRON A INJECTION SOLUTION 6

MILLION UNIT/ML

5 B/D PA; MO

LEUKINE INJECTION RECON SOLN 5 PA; MO

MOZOBIL SUBCUTANEOUS SOLUTION 5 B/D PA; MO

NEUPOGEN INJECTION SOLUTION 5 PA; MO

NEUPOGEN INJECTION SYRINGE 5 PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR

5 PA; MO

PEGASYS SUBCUTANEOUS SOLUTION 5 PA; MO; QL (4 per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE 5 PA; MO; QL (2 per 28 days)

PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML



UNIT/ML



UNIT/ML


PROLEUKIN INTRAVENOUS RECON SOLN 5 B/D PA; MO

REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE


REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; MO; QL (4.2 per 180 days)


59


medicamento

Requisitos/Límites

REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE


SYLATRON SUBCUTANEOUS KIT 5 PA; MO

VACUNAS/INMUNOLÓGICOS DIVERSOS

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN

3 MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION

3 MO

BCG VACCINE, LIVE (PF) PERCUTANEOUS

SUSPENSION FOR RECONSTITUTION

4 B/D PA; MO

BEXSERO INTRAMUSCULAR SYRINGE 4 MO

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION

3 MO

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE

3 MO

DAPTACEL (DTAP PEDIATRIC) (PF)


3 MO

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

3 B/D PA; MO

ENGERIX-B PEDIATRIC (PF)


3 B/D PA; MO

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE

3 B/D PA; MO

fomepizole intravenous solution 2 B/D PA; MO

GAMMAGARD LIQUID INJECTION

SOLUTION

5 PA; MO

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN

5 B/D PA; MO

GAMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %)

3 PA; MO

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION

3 MO

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE

3 MO

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML

3 MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT/0.5 ML

3


60


medicamento

Requisitos/Límites

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN

3 MO

HYPERRAB S/D (PF) INTRAMUSCULAR

SOLUTION

4

IMOGAM RABIES-HT (PF)

INTRAMUSCULAR SOLUTION

4 MO

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN

4 MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION

3 MO

IPOL INJECTION SUSPENSION 3 MO

IXIARO (PF) INTRAMUSCULAR SYRINGE 3 MO

KINRIX (PF) INTRAMUSCULAR

SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE 3 MO

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

3 MO

MENOMUNE - A/C/Y/W-135 (PF)

SUBCUTANEOUS RECON SOLN

3 MO

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT

3 MO

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN

3 MO

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 3 MO

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION

3 MO

PROQUAD (PF) SUBCUTANEOUS


3 MO

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION

3

RABAVERT (PF) INTRAMUSCULAR


3 MO

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML

3 B/D PA; MO


SYRINGE 10 MCG/ML

3 B/D PA; MO


SYRINGE 5 MCG/0.5 ML

3 B/D PA


61


medicamento

Requisitos/Límites

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION

4

ROTATEQ VACCINE ORAL SOLUTION 3 MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE 4 MO

TETANUS,DIPHTHERIA TOX PED(PF)


4 MO

TETANUS-DIPHTHERIA TOXOIDS-TD


4 B/D PA; MO

TRUMENBA INTRAMUSCULAR SYRINGE 3 MO

TWINRIX (PF) INTRAMUSCULAR

SUSPENSION

3 B/D PA; MO

TYPHIM VI INTRAMUSCULAR SOLUTION 3

TYPHIM VI INTRAMUSCULAR SYRINGE 3 MO

VAQTA (PF) INTRAMUSCULAR SYRINGE 3 MO

VARIVAX (PF) SUBCUTANEOUS


3 MO

VARIZIG INTRAMUSCULAR SOLUTION 4 MO

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION

3 MO

ZOSTAVAX (PF) SUBCUTANEOUS



MUSCULOESQUELÉTICO/REUMATOLOGÍA

TERAPIA DE GOTA

allopurinol oral tablet 1 MO

allopurinol sodium intravenous recon soln 2 B/D PA

COLCRYS ORAL TABLET 3 MO

probenecid oral tablet 2 MO

probenecid-colchicine oral tablet 2 MO

ULORIC ORAL TABLET 3 MO

TERAPIA DE OSTEOPOROSIS

alendronate oral solution 1 MO; QL (375 per 30 days)

alendronate oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg 1 MO; QL (5 per 30 days)

FORTEO SUBCUTANEOUS PEN INJECTOR 5 MO; QL (2.4 per 28 days)

ibandronate oral tablet 2 MO; QL (1 per 30 days)

PROLIA SUBCUTANEOUS SYRINGE 4 PA; MO


62


medicamento

Requisitos/Límites

raloxifene oral tablet 2 MO

risedronate oral tablet 2 MO

risedronate oral tablet,delayed release (dr/ec) 2 MO

OTROS REUMATOLÓGICOS

ACTEMRA INTRAVENOUS SOLUTION 5 B/D PA; ST; MO

BENLYSTA INTRAVENOUS RECON SOLN 4 B/D PA; MO

CUPRIMINE ORAL CAPSULE 5 MO

DEPEN TITRATABS ORAL TABLET 4 PA; MO

ENBREL SUBCUTANEOUS RECON SOLN 5 MO; QL (8 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5ML (0.51)


ENBREL SUBCUTANEOUS SYRINGE 50

MG/ML (0.98 ML)


ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR


HUMIRA PEDIATRIC CROHN'S START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML


HUMIRA PEDIATRIC CROHN'S START

SUBCUTANEOUS SYRINGE KIT 40 MG/0.8

ML (6 PACK)


HUMIRA PEN CROHN'S-UC-HS START

SUBCUTANEOUS INJECTOR KIT


HUMIRA PEN PSORIASIS-UVEITIS

SUBCUTANEOUS INJECTOR KIT


HUMIRA PEN SUBCUTANEOUS INJECTOR

KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT 10

MG/0.2 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 20

MG/0.4 ML, 40 MG/0.8 ML


leflunomide oral tablet 2 MO; QL (30 per 30 days)

SAVELLA ORAL TABLET 3 MO; QL (60 per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK 3 MO; QL (60 per 30 days)

XELJANZ ORAL TABLET 5 ST; MO

XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HR

5 ST; MO


63


medicamento

Requisitos/Límites

OBSTETRICIA/GINECOLOGÍA

ESTRÓGENOS/PROGESTERONA

camila oral tablet 2 MO

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY

4 MO

CRINONE VAGINAL GEL 4 PA; MO

DEPO-PROVERA INTRAMUSCULAR

SOLUTION

3 B/D PA; MO

DEPO-SUBQ PROVERA 104

SUBCUTANEOUS SYRINGE

4 MO

errin oral tablet 2 MO

ESTRACE VAGINAL CREAM 4 MO

estradiol oral tablet 2 PA; MO

estradiol transdermal patch semiweekly 2 MO

estradiol transdermal patch weekly 2 MO

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

2 MO

hydroxyprogesterone caproate intramuscular oil 4 PA; MO

jinteli oral tablet 4 MO

jolivette oral tablet 2 MO

lyza oral tablet 2 MO

medroxyprogesterone intramuscular suspension 2 MO; QL (1 per 90 days)

medroxyprogesterone oral tablet 2 MO

norethindrone (contraceptive) oral tablet 2 MO

norethindrone acetate oral tablet 2 MO

PREMARIN INJECTION RECON SOLN 4 B/D PA; MO

PREMARIN VAGINAL CREAM 4 MO

progesterone micronized oral capsule 2 MO

OBSTÉTRICOS/GINECOLÓGICOS DIVERSOS

CLEOCIN VAGINAL SUPPOSITORY 4 MO

clindamycin phosphate vaginal cream 2 MO

metronidazole vaginal gel 2 MO

miconazole-3 vaginal suppository 2 MO; QL (3 per 3 days)

NUVARING VAGINAL RING 4 MO

terconazole vaginal cream 2 MO


64


medicamento

Requisitos/Límites

terconazole vaginal suppository 2 MO

tranexamic acid oral tablet 2 MO

vandazole vaginal gel 2 MO

ANTICONCEPTIVOS ORALES/AGENTES RELACIONADOS

alyacen 1/35 (28) oral tablet 2 MO

amethia lo oral tablets,dose pack,3 month 2 MO

amethia oral tablets,dose pack,3 month 2 MO

apri oral tablet 2 MO

aranelle (28) oral tablet 2 MO

ashlyna oral tablets,dose pack,3 month 2 MO

aubra oral tablet 2 MO

aviane oral tablet 2 MO

balziva (28) oral tablet 2 MO

blisovi 24 fe oral tablet 2 MO

blisovi fe 1.5/30 (28) oral tablet 2 MO

blisovi fe 1/20 (28) oral tablet 2 MO

briellyn oral tablet 2 MO

camrese lo oral tablets,dose pack,3 month 2 MO

caziant (28) oral tablet 2 MO

cryselle (28) oral tablet 2 MO

cyclafem 1/35 (28) oral tablet 2 MO

cyclafem 7/7/7 (28) oral tablet 2 MO

desog-e.estradiol/e.estradiol oral tablet 2 MO

drospirenone-e.estradiol-lm.fa oral tablet 2 MO

drospirenone-ethinyl estradiol oral tablet 2 MO

emoquette oral tablet 2 MO

enpresse oral tablet 2 MO

falmina (28) oral tablet 2 MO

gianvi (28) oral tablet 2 MO

introvale oral tablets,dose pack,3 month 2 MO

junel 1.5/30 (21) oral tablet 2 MO

junel 1/20 (21) oral tablet 2 MO

junel fe 1.5/30 (28) oral tablet 2 MO


65


medicamento

Requisitos/Límites

junel fe 1/20 (28) oral tablet 2 MO

junel fe 24 oral tablet 2 MO

kariva (28) oral tablet 2 MO

kelnor 1/35 (28) oral tablet 2 MO

kimidess (28) oral tablet 2 MO

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

2 MO

larissia oral tablet 2 MO

layolis fe oral tablet,chewable 2 MO

lessina oral tablet 2 MO

levonest (28) oral tablet 2 MO

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 90-20 mcg

2 MO

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

2 MO

levonorg-eth estrad triphasic oral tablet 2 MO

levora-28 oral tablet 2 MO

loryna (28) oral tablet 2 MO

low-ogestrel (28) oral tablet 2 MO

lutera (28) oral tablet 2 MO

marlissa oral tablet 2 MO

microgestin 1.5/30 (21) oral tablet 2 MO

microgestin 1/20 (21) oral tablet 2 MO

microgestin fe 1.5/30 (28) oral tablet 2 MO

microgestin fe 1/20 (28) oral tablet 2 MO

mononessa (28) oral tablet 2 MO

necon 0.5/35 (28) oral tablet 2 MO

necon 1/50 (28) oral tablet 2 MO

necon 10/11 (28) oral tablet 2

necon 7/7/7 (28) oral tablet 2 MO

nikki (28) oral tablet 2 MO

noreth-ethinyl estradiol-iron oral tablet,chewable

0.4mg-35mcg(21) and 75 mg (7)

2

noreth-ethinyl estradiol-iron oral tablet,chewable

0.8mg-25mcg(24) and 75 mg (4)

2 MO


66


medicamento

Requisitos/Límites

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-

35 mcg (28)

2 MO

nortrel 0.5/35 (28) oral tablet 2 MO

nortrel 1/35 (21) oral tablet 2 MO

nortrel 1/35 (28) oral tablet 2 MO

nortrel 7/7/7 (28) oral tablet 2 MO

ocella oral tablet 2 MO

ogestrel (28) oral tablet 2 MO

orsythia oral tablet 2 MO

pimtrea (28) oral tablet 2 MO

pirmella oral tablet 1-35 mg-mcg 2 MO

portia oral tablet 2 MO

previfem oral tablet 2 MO

quasense oral tablets,dose pack,3 month 2 MO

reclipsen (28) oral tablet 2 MO

sprintec (28) oral tablet 2 MO

sronyx oral tablet 2 MO

tri-legest fe oral tablet 2 MO

trinessa (28) oral tablet 2 MO

tri-previfem (28) oral tablet 2 MO

tri-sprintec (28) oral tablet 2 MO

trivora (28) oral tablet 2 MO

velivet triphasic regimen (28) oral tablet 2 MO

vestura (28) oral tablet 2 MO

wymzya fe oral tablet,chewable 2 MO

zarah oral tablet 2 MO

zenchent (28) oral tablet 2 MO

zenchent fe oral tablet,chewable 2 MO

zovia 1/35e (28) oral tablet 2 MO

zovia 1/50e (28) oral tablet 2 MO

OFTALMOLOGÍA

ANTIBIÓTICOS


67


medicamento

Requisitos/Límites

AZASITE OPHTHALMIC DROPS 3 MO

bacitracin ophthalmic ointment 2 MO

bacitracin-polymyxin b ophthalmic ointment 2 MO

CILOXAN OPHTHALMIC OINTMENT 4 MO

ciprofloxacin hcl ophthalmic drops 2 MO

erythromycin ophthalmic ointment 2 MO

gatifloxacin ophthalmic drops 2 MO

gentak ophthalmic ointment 1 MO

gentamicin ophthalmic drops 1 MO

levofloxacin ophthalmic drops 2 MO

NATACYN OPHTHALMIC

DROPS,SUSPENSION

3 MO

neomycin-bacitracin-polymyxin ophthalmic

ointment

2 MO

neomycin-polymyxin-gramicidin ophthalmic drops 2 MO

ofloxacin ophthalmic drops 2 MO

polymyxin b sulf-trimethoprim ophthalmic drops 1 MO

tobramycin ophthalmic drops 1 MO

TOBREX OPHTHALMIC OINTMENT 3 MO

VIGAMOX OPHTHALMIC DROPS 3 MO

ANTIVIRALES

trifluridine ophthalmic drops 2 MO

ZIRGAN OPHTHALMIC GEL 4 MO

BETABLOQUEADORES

betaxolol ophthalmic drops 2 MO

BETIMOL OPHTHALMIC DROPS 4 MO

carteolol ophthalmic drops 1 MO

levobunolol ophthalmic drops 0.5 % 1 MO

metipranolol ophthalmic drops 2

timolol maleate ophthalmic drops 1 MO

timolol maleate ophthalmic gel forming solution 2 MO

MIÓTICOS INHIBIDORES DE COLINESTERASA

PHOSPHOLINE IODIDE OPHTHALMIC

DROPS

3 MO

MIÓTICOS DE ACCIÓN DIRECTA


68


medicamento

Requisitos/Límites

pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 2 MO

OFTALMOLÓGICOS DIVERSOS

azelastine ophthalmic drops 2 MO

cromolyn ophthalmic drops 2 MO

CYSTARAN OPHTHALMIC DROPS 4 MO

epinastine ophthalmic drops 2 MO

LASTACAFT OPHTHALMIC DROPS 3 MO

olopatadine ophthalmic drops 0.1 % 4 MO

olopatadine ophthalmic drops 0.2 % 2 MO

PAZEO OPHTHALMIC DROPS 3 MO

RESTASIS OPHTHALMIC DROPPERETTE 3 MO; QL (60 per 30 days)

AGENTES ANTIINFLAMATORIOS NO ESTEROIDEOS

bromfenac ophthalmic drops 2 MO

diclofenac sodium ophthalmic drops 2 MO

flurbiprofen sodium ophthalmic drops 2 MO

ILEVRO OPHTHALMIC DROPS,SUSPENSION 3 MO

ketorolac ophthalmic drops 2 MO

MEDICAMENTOS ORALES PARA El GLAUCOMA

acetazolamide oral capsule, extended release 2 MO

acetazolamide oral tablet 2 MO

acetazolamide sodium injection recon soln 2 MO

methazolamide oral tablet 2 MO

OTROS MEDICAMENTOS PARA EL GLAUCOMA

COMBIGAN OPHTHALMIC DROPS 3 MO

dorzolamide ophthalmic drops 2 MO

dorzolamide-timolol ophthalmic drops 2 MO

latanoprost ophthalmic drops 2 MO

LUMIGAN OPHTHALMIC DROPS 0.01 % 3 MO; QL (2.5 per 30 days)

TRAVATAN Z OPHTHALMIC DROPS 3 MO; QL (2.5 per 30 days)

COMBINACIONES ESTEROIDE-ANTIBIÓTICO

neomycin-bacitracin-poly-hc ophthalmic ointment 2 MO

neomycin-polymyxin b-dexameth ophthalmic

drops,suspension

1 MO


69


medicamento

Requisitos/Límites

neomycin-polymyxin b-dexameth ophthalmic

ointment

1 MO

neomycin-polymyxin-hc ophthalmic

drops,suspension

2 MO

TOBRADEX ST OPHTHALMIC

DROPS,SUSPENSION

3 MO

tobramycin-dexamethasone ophthalmic

drops,suspension

2 MO

ESTEROIDES

dexamethasone sodium phosphate ophthalmic

drops

2 MO

DUREZOL OPHTHALMIC DROPS 3 MO

fluorometholone ophthalmic drops,suspension 2 MO

FML S.O.P. OPHTHALMIC OINTMENT 3 MO

prednisolone acetate ophthalmic drops,suspension 2 MO

prednisolone sodium phosphate ophthalmic drops 2 MO

COMBINACIONES ESTEROIDE-SULFONAMIDA

BLEPHAMIDE S.O.P. OPHTHALMIC

OINTMENT

3 MO

sulfacetamide-prednisolone ophthalmic drops 2 MO

SULFONAMIDAS

sulfacetamide sodium ophthalmic drops 1 MO

sulfacetamide sodium ophthalmic ointment 2 MO

SIMPATICOMIMÉTICOS

ALPHAGAN P OPHTHALMIC DROPS 0.1 % 3 MO

apraclonidine ophthalmic drops 2 MO

brimonidine ophthalmic drops 2 MO

RESPIRATORIO Y ALERGIA

AGENTES ANTIHISTAMÍNICOS/ANTIALÉRGICOS

cetirizine oral solution 1 mg/ml 2 MO

clemastine oral tablet 2.68 mg 2 PA; MO

cyproheptadine oral syrup 2 PA; MO

cyproheptadine oral tablet 2 PA; MO

desloratadine oral tablet 2 MO

desloratadine oral tablet,disintegrating 2 MO

diphenhydramine hcl injection solution 50 mg/ml 2 B/D PA; MO


70


medicamento

Requisitos/Límites

EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.3 ML, 0.3 MG/0.3 ML


EPIPEN 2-PAK INJECTION AUTO-INJECTOR 3 MO; QL (4 per 2 days)

EPIPEN JR 2-PAK INJECTION AUTO-

INJECTOR


hydroxyzine hcl intramuscular solution 2 B/D PA; MO

hydroxyzine hcl oral solution 10 mg/5 ml 4 MO

hydroxyzine hcl oral tablet 4 MO

levocetirizine oral solution 2 MO

levocetirizine oral tablet 2 MO; QL (30 per 30 days)

promethazine oral tablet 2 PA; MO

AGENTES PULMONARES

acetylcysteine solution 2 B/D PA; MO

ADCIRCA ORAL TABLET 5 PA; MO; QL (60 per 30 days)

ADEMPAS ORAL TABLET 5 PA; MO; LA

ADVAIR DISKUS INHALATION BLISTER

WITH DEVICE


ADVAIR HFA AEROSOL INHALER 3 MO; QL (24 per 30 days)

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3

ml (0.083 %)

2 B/D PA; MO; QL (360 per 30 days)

albuterol sulfate inhalation solution for

nebulization 5 mg/ml


albuterol sulfate oral syrup 2 MO

albuterol sulfate oral tablet 2 MO

albuterol sulfate oral tablet extended release 12 hr 2 MO

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE

3 MO

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE

3 MO

ASMANEX HFA AEROSOL INHALER 3 MO; QL (26 per 30 days)

ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED 110

MCG (30 DOSES), 220 MCG (120 DOSES), 220

MCG (30 DOSES), 220 MCG (60 DOSES)


ATROVENT HFA AEROSOL INHALER 3 MO; QL (26 per 30 days)


71


medicamento

Requisitos/Límites

BEVESPI AEROSPHERE HFA AEROSOL

INHALER

3 MO

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE

3 MO

budesonide inhalation suspension for nebulization

0.25 mg/2 ml, 0.5 mg/2 ml


budesonide inhalation suspension for nebulization

1 mg/2 ml

2 B/D PA; MO

budesonide nasal spray,non-aerosol 2 MO

CINRYZE INTRAVENOUS RECON SOLN 5 PA; MO

COMBIVENT RESPIMAT INHALATION MIST 3 MO; QL (8 per 30 days)

cromolyn inhalation solution for nebulization 2 B/D PA; MO; QL (240 per 30 days)

DALIRESP ORAL TABLET 4 MO

ESBRIET ORAL CAPSULE 5 PA; MO

ESBRIET ORAL TABLET 5 PA; MO; NEDS

FIRAZYR SUBCUTANEOUS SYRINGE 5 PA; MO

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 50

MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA AEROSOL INHALER 110

MCG/ACTUATION



MCG/ACTUATION



MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)


fluticasone nasal spray,suspension 2 MO; QL (16 per 30 days)

ipratropium bromide inhalation solution 2 B/D PA; MO; QL (315 per 30 days)

ipratropium-albuterol inhalation solution for

nebulization


KALYDECO ORAL GRANULES IN PACKET 5 PA; MO; QL (60 per 30 days)

KALYDECO ORAL TABLET 5 PA; MO; QL (60 per 30 days)

LETAIRIS ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days)

levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 0.63 mg/3 ml

2 B/D PA; MO


72


medicamento

Requisitos/Límites

levalbuterol hcl inhalation solution for

nebulization 1.25 mg/0.5 ml, 1.25 mg/3 ml


metaproterenol oral syrup 2 MO

metaproterenol oral tablet 2 MO

mometasone nasal spray,non-aerosol 4 MO; QL (51 per 30 days)

montelukast oral granules in packet 2 MO

montelukast oral tablet 2 MO

montelukast oral tablet,chewable 2 MO

OFEV ORAL CAPSULE 5 PA; MO; QL (60 per 30 days)

OPSUMIT ORAL TABLET 5 PA; MO; LA

ORKAMBI ORAL TABLET 5 PA; MO

PERFOROMIST INHALATION SOLUTION

FOR NEBULIZATION


PULMOZYME INHALATION SOLUTION 5 B/D PA; MO

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE


sildenafil oral tablet 2 PA; MO; QL (90 per 30 days)

SYMBICORT HFA AEROSOL INHALER 3 MO; QL (20 per 30 days)

terbutaline oral tablet 2 MO

terbutaline subcutaneous solution 2 MO

theophylline oral solution 2 MO

theophylline oral tablet extended release 12 hr 100

mg, 200 mg, 300 mg

2 MO

theophylline oral tablet extended release 24 hr 2 MO

triamcinolone acetonide nasal spray, aerosol 2 MO; QL (17 per 30 days)

TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH ACTIVATED

3 MO

VENTOLIN HFA AEROSOL INHALER 3 MO; QL (54 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN 5 PA; MO; LA; QL (6 per 28 days)

zafirlukast oral tablet 2 MO

UROLÓGICOS

ANTICOLINÉRGICOS/ANTIESPASMÓDICOS

darifenacin oral tablet extended release 24 hr 2 MO

flavoxate oral tablet 2 MO


73


medicamento

Requisitos/Límites

GELNIQUE TRANSDERMAL GEL IN PACKET 3 ST; MO

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HR

3 MO

oxybutynin chloride oral syrup 2 MO

oxybutynin chloride oral tablet 2 MO

oxybutynin chloride oral tablet extended release

24hr

2 MO

tolterodine oral capsule,extended release 24hr 2 MO

tolterodine oral tablet 2 MO

trospium oral capsule,extended release 24hr 2 MO

trospium oral tablet 2 MO

VESICARE ORAL TABLET 3 MO

TERAPIA DE HIPERPLASIA BENIGNA DE PRÓSTATA (BENIGN PROSTATIC

HYPERPLASIA, HBP)

alfuzosin oral tablet extended release 24 hr 2 MO

dutasteride oral capsule 2 MO

dutasteride-tamsulosin oral capsule, er multiphase

24 hr

2 MO

finasteride oral tablet 5 mg 2 MO

tamsulosin oral capsule,extended release 24hr 2 MO

ESTIMULANTES COLINÉRGICOS

bethanechol chloride oral tablet 2 MO

UROLÓGICOS DIVERSOS

CIALIS ORAL TABLET 2.5 MG, 5 MG 4 PA; MO; QL (30 per 30 days)

CYSTAGON ORAL CAPSULE 3 MO; LA

ELMIRON ORAL CAPSULE 4 MO

potassium citrate oral tablet extended release 2 MO

VITAMINAS, HEMATÍNICOS / ELECTRÓLITOS

ELECTRÓLITOS

calcium acetate oral capsule 2 MO

calcium acetate oral tablet 667 mg 2 MO

eliphos oral tablet 2 MO

klor-con 10 oral tablet extended release 2 MO

klor-con 8 oral tablet extended release 2 MO

klor-con m15 oral tablet,er particles/crystals 2 MO


74


medicamento

Requisitos/Límites

klor-con m20 oral tablet,er particles/crystals 2 MO

klor-con sprinkle oral capsule, extended release 2 MO

k-tab oral tablet extended release 8 meq 2 MO

lactated ringers intravenous parenteral solution 2 MO

magnesium sulfate injection solution 2 B/D PA; MO

magnesium sulfate injection syringe 2 B/D PA

NORMOSOL-R IN 5 % DEXTROSE


4 B/D PA

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

2 B/D PA

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 20 meq/l

2 B/D PA; MO

potassium chloride in 0.9%nacl intravenous

parenteral solution 20 meq/l, 40 meq/l

2 B/D PA

potassium chloride in 5 % dex intravenous

parenteral solution 20 meq/l, 40 meq/l

2 B/D PA

potassium chloride in lr-d5 intravenous parenteral

solution 20 meq/l

2 B/D PA; MO

potassium chloride intravenous piggyback 10

meq/100 ml

2 MO

potassium chloride intravenous piggyback 20

meq/100 ml, 40 meq/100 ml

2

potassium chloride intravenous solution 2 % 2

potassium chloride intravenous solution 2 meq/ml 2 MO

potassium chloride oral capsule, extended release 2 MO

potassium chloride oral liquid 2 MO

potassium chloride oral tablet extended release 8

meq

2 MO

potassium chloride oral tablet,er particles/crystals 2 MO

potassium chloride-0.45 % nacl intravenous

parenteral solution

2

potassium chloride-d5-0.2%nacl intravenous


2 B/D PA; MO



2 B/D PA



2 B/D PA; MO


75


medicamento

Requisitos/Límites



2 B/D PA

ringer's intravenous parenteral solution 2 B/D PA

sodium chloride 0.45 % intravenous parenteral

solution

2 MO

sodium chloride 3 % intravenous parenteral

solution

2 MO

sodium chloride 5 % intravenous parenteral

solution

2

sodium chloride intravenous parenteral solution

2.5 meq/ml

2 MO

sodium lactate intravenous solution 2

PRODUCTOS DE NUTRICIÓN DIVERSOS

amino acids 15 % intravenous parenteral solution 2 B/D PA

AMINOSYN 8.5 %-ELECTROLYTES


4 B/D PA

AMINOSYN II 10 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA


PARENTERAL SOLUTION

4 B/D PA


PARENTERAL SOLUTION

4 B/D PA

AMINOSYN II 8.5 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

AMINOSYN II 8.5 %-ELECTROLYTES


4 B/D PA

AMINOSYN-HBC 7% INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

AMINOSYN-PF 10 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

AMINOSYN-PF 7 % SULFITE-FREE


4 B/D PA

AMINOSYN-RF 5.2 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

CLINIMIX 5%/D15W SULFITE FREE


4 B/D PA

CLINIMIX 5%/D25W SULFITE FREE


4 B/D PA


76


medicamento

Requisitos/Límites



4 B/D PA



4 B/D PA

CLINIMIX 4.25%-D20W SULFITE FREE


4 B/D PA

CLINIMIX 4.25%-D25W SULFITE FREE


4 B/D PA

CLINIMIX 5%-D20W SULFITE FREE


4 B/D PA



4 B/D PA



4 B/D PA



4 B/D PA

CLINIMIX E 5%/D15W SULFITE FREE


4 B/D PA



4 B/D PA



4 B/D PA

HEPATAMINE 8% INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

intralipid intravenous emulsion 20 % 4 B/D PA

INTRALIPID INTRAVENOUS EMULSION 30

%

4 B/D PA

IONOSOL-MB IN D5W INTRAVENOUS

PARENTERAL SOLUTION

4

ISOLYTE-P IN 5 % DEXTROSE


4

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

4

NEPHRAMINE 5.4 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

NORMOSOL-M IN 5 % DEXTROSE


4 B/D PA


77


medicamento

Requisitos/Límites

NORMOSOL-R PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

PLASMA-LYTE 148 INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

PLASMA-LYTE A INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

premasol 10 % intravenous parenteral solution 4 B/D PA; MO

PREMASOL 6 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

PROCALAMINE 3% INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL

SOLUTION

4 B/D PA; MO

travasol 10 % intravenous parenteral solution 4 B/D PA; MO

TROPHAMINE 10 % INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA; MO

TROPHAMINE 6% INTRAVENOUS

PARENTERAL SOLUTION

4 B/D PA


78

Índice

A abacavir .................................. 1

abacavir-lamivudine ............... 1

abacavir-lamivudine-

zidovudine .......................... 1

ABELCET .............................. 1

ABILIFY MAINTENA ........ 28

ABRAXANE ........................ 11

acamprosate .......................... 46

acarbose ................................ 49

acebutolol ............................. 34

acetaminophen-codeine ........ 23

acetasol hc ............................ 48

acetazolamide ....................... 68

acetazolamide sodium .......... 68

acetic acid ............................. 48

acetylcysteine ....................... 70

acitretin ................................. 41

ACTEMRA .......................... 62

ACTHAR H.P. ..................... 48

ACTHIB (PF) ....................... 59

ACTIMMUNE ..................... 57

ACTOPLUS MET XR ......... 49

acyclovir ........................... 1, 44

acyclovir sodium .................... 2

ADACEL(TDAP

ADOLESN/ADULT)(PF) 59

ADAGEN ............................. 46

adapalene .............................. 42

ADCIRCA ............................ 70

adefovir................................... 2

ADEMPAS ........................... 70

adriamycin ............................ 11

adrucil ................................... 11

ADVAIR DISKUS ............... 70

ADVAIR HFA ..................... 70

afeditab cr ............................. 34

AFINITOR ........................... 12

AFINITOR DISPERZ .......... 12

ala-cort .................................. 44

ALBENZA ............................. 7

albuterol sulfate .................... 70

alclometasone ....................... 44

alcohol pads .......................... 49

ALDURAZYME .................. 52

ALECENSA ......................... 12

alendronate ..................... 46, 61

alfuzosin ............................... 73

ALIMTA .............................. 12

allopurinol ............................ 61

allopurinol sodium ................ 61

alosetron ............................... 54

ALPHAGAN P ..................... 69

alprazolam ............................ 28

ALUNBRIG ......................... 12

alyacen 1/35 (28) .................. 64

amantadine hcl ........................ 2

AMBISOME .......................... 1

amcinonide ........................... 44

amethia ................................. 64

amethia lo ............................. 64

amikacin ................................. 7

amiloride ............................... 34

amiloride-hydrochlorothiazide

.......................................... 34

amino acids 15 % ................. 75

AMINOSYN 8.5 %-

ELECTROLYTES............ 75

AMINOSYN II 10 % ........... 75

AMINOSYN II 15 % ........... 75

AMINOSYN II 7 % ............. 75

AMINOSYN II 8.5 % .......... 75

AMINOSYN II 8.5 %-

ELECTROLYTES............ 75

AMINOSYN-HBC 7%......... 75

AMINOSYN-PF 10 % ......... 75

AMINOSYN-PF 7 %

SULFITE-FREE ............... 75

AMINOSYN-RF 5.2 % ........ 75

amiodarone ........................... 33

AMITIZA ............................. 54

amitriptyline ......................... 28

amlodipine ............................ 34

amlodipine-atorvastatin ........ 39

amlodipine-benazepril .......... 34

amlodipine-olmesartan ......... 34

amlodipine-valsartan ............ 34

amlodipine-valsartan-

hydrochlorothiazide .......... 34

ammonium lactate ................ 41

amoxapine ............................ 28

amoxicil-clarithromy-lansopraz

.......................................... 57

amoxicillin .............................. 9

amoxicillin-pot clavulanate .... 9

amphotericin b ........................ 1

ampicillin ................................ 9

ampicillin sodium ................... 9

ampicillin-sulbactam .............. 9

AMPYRA ............................. 22

ANADROL-50 ..................... 52

anagrelide ............................. 46

anastrozole ............................ 12

ANDROGEL ........................ 52

ANORO ELLIPTA ............... 70

APOKYN ............................. 21

apraclonidine ........................ 69

aprepitant .............................. 54

apri ........................................ 64

APRISO ................................ 54

APTIOM ............................... 19

APTIVUS ............................... 2

ARALAST NP ...................... 46

aranelle (28) .......................... 64

ARCALYST ......................... 57

aripiprazole ........................... 28

ARISTADA .......................... 28

ARNUITY ELLIPTA ........... 70

ashlyna .................................. 64

ASMANEX HFA ................. 70

ASMANEX TWISTHALER 70

aspirin-dipyridamole ............. 38

ASTAGRAF XL ................... 12

atenolol ................................. 34

atenolol-chlorthalidone ......... 34

atomoxetine .......................... 28

atorvastatin ........................... 39

atovaquone .............................. 7

atovaquone-proguanil ............. 7

ATRIPLA ............................... 2

atropine ................................. 54

ATROVENT HFA ................ 70

AUBAGIO ............................ 22

aubra ..................................... 64

AURYXIA ............................ 46

AVASTIN ............................. 12

AVELOX IN NACL (ISO-

OSM) ................................ 10

aviane .................................... 64

AVONEX ............................. 58

AVONEX (WITH ALBUMIN)

.......................................... 57

azacitidine ............................. 12

AZASAN .............................. 12

AZASITE ............................. 67

azathioprine .......................... 12

azathioprine sodium .............. 12


79

azelastine ........................ 48, 68

azithromycin ........................... 6

aztreonam ............................... 7

B baciim ..................................... 7

bacitracin .......................... 7, 67

bacitracin-polymyxin b ........ 67

baclofen ................................ 23

balsalazide ............................ 54

balziva (28) ........................... 64

BANZEL .............................. 19

BARACLUDE ....................... 2

BAVENCIO ......................... 12

BCG VACCINE, LIVE (PF) 59

BELEODAQ ........................ 12

benazepril ............................. 34

benazepril-hydrochlorothiazide

.......................................... 34

BENLYSTA ......................... 62

benztropine ........................... 21

betamethasone dipropionate . 44

betamethasone valerate ........ 44

betamethasone, augmented... 44

betaxolol ......................... 34, 67

bethanechol chloride ............ 73

BETIMOL ............................ 67

BEVESPI AEROSPHERE ... 71

bexarotene ............................ 12

BEXSERO ............................ 59

bicalutamide ......................... 12

BICILLIN C-R ....................... 9

BICILLIN L-A ....................... 9

BICNU ................................. 12

bisoprolol fumarate .............. 34

bisoprolol-hydrochlorothiazide

.......................................... 34

bleomycin ............................. 12

BLEPHAMIDE S.O.P. ......... 69

blisovi 24 fe .......................... 64

blisovi fe 1.5/30 (28) ............ 64

blisovi fe 1/20 (28) ............... 64

BOOSTRIX TDAP .............. 59

BOSULIF ............................. 12

BREO ELLIPTA .................. 71

briellyn ................................. 64

BRILINTA ........................... 38

brimonidine .......................... 69

BRISDELLE ........................ 28

BRIVIACT ........................... 19

bromfenac ............................. 68

bromocriptine ....................... 21

budesonide ...................... 54, 71

bumetanide ........................... 34

buprenorphine hcl ................. 23

buprenorphine-naloxone ....... 26

bupropion hcl ........................ 28

bupropion hcl (smoking deter)

.......................................... 47

buspirone .............................. 28

BUSULFEX ......................... 12

butalbital-acetaminop-caf-cod

.......................................... 23

butalbital-acetaminophen ..... 23

butalbital-acetaminophen-caff

.......................................... 24

butalbital-aspirin-caffeine .... 24

butorphanol tartrate .............. 26

BYDUREON ........................ 50

BYSTOLIC .......................... 34

C cabergoline ........................... 52

CABOMETYX ..................... 12

calcipotriene ......................... 41

calcipotriene-betamethasone 41

calcitonin (salmon) ............... 52

calcitriol .......................... 41, 52

calcium acetate ..................... 73

camila ................................... 63

camrese lo ............................. 64

CANASA.............................. 54

CANCIDAS............................ 1

candesartan ........................... 34

candesartan-


CAPASTAT ........................... 7

CAPRELSA.......................... 12

captopril ................................ 34

captopril-hydrochlorothiazide

.......................................... 35

CARAC ................................ 41

CARAFATE ......................... 57

carbamazepine ...................... 19

carbidopa .............................. 21

carbidopa-levodopa .............. 21

carbidopa-levodopa-

entacapone ........................ 21

carboplatin ............................ 12

carteolol ................................ 67

cartia xt ................................. 35

carvedilol .............................. 35

CAYSTON ............................. 7

caziant (28) ........................... 64

cefaclor ................................... 5

cefadroxil ................................ 5

cefazolin ................................. 5

cefdinir .................................... 5

cefepime ................................. 5

cefixime .................................. 5

cefotaxime .............................. 5

cefotetan ................................. 5

cefoxitin .................................. 5

cefpodoxime ........................... 5

cefprozil .................................. 5

ceftazidime ............................. 5

ceftriaxone .............................. 5

cefuroxime axetil .................... 6

cefuroxime sodium ................. 6

celecoxib ............................... 26

CELLCEPT .......................... 12

CELLCEPT INTRAVENOUS

.......................................... 12

CELONTIN .......................... 19

cephalexin ............................... 6

CEREZYME ......................... 52

cetirizine ............................... 69

cevimeline ............................. 46

CHANTIX ............................ 47

CHANTIX CONTINUING

MONTH BOX .................. 47

CHANTIX STARTING

MONTH BOX .................. 48

CHEMET .............................. 46

chloramphenicol sod succinate

............................................ 7

chlorhexidine gluconate ........ 48

chloroquine phosphate ............ 7

chlorothiazide ....................... 35

chlorothiazide sodium .......... 35

chlorpromazine ..................... 28

chlorthalidone ....................... 35

CHOLBAM .......................... 55

cholestyramine (with sugar) . 39

cholestyramine light ............. 39

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 52

CIALIS ................................. 73

ciclopirox .............................. 43

cidofovir ................................. 2

cilostazol ............................... 38

CILOXAN ............................ 67

cimetidine ............................. 57

cimetidine hcl ....................... 57


80

CIMZIA ................................ 55

CIMZIA POWDER FOR

RECONST ........................ 55

CINRYZE............................. 71

CIPRODEX .......................... 48

ciprofloxacin......................... 10

ciprofloxacin (mixture) ........ 10

ciprofloxacin hcl ............. 10, 67

ciprofloxacin lactate ............. 10

cisplatin ................................ 12

citalopram ............................. 29

cladribine .............................. 12

claravis ................................. 42

clarithromycin ........................ 6

clemastine ............................. 69

CLEOCIN............................. 63

clindamycin hcl ...................... 7

clindamycin pediatric ............. 7

clindamycin phosphate .... 7, 42,

63

clindamycin-benzoyl peroxide

.......................................... 42

CLINIMIX 5%/D15W

SULFITE FREE ............... 75

CLINIMIX 5%/D25W

SULFITE-FREE ............... 75

CLINIMIX 2.75%/D5W

SULFITE FREE ............... 76

CLINIMIX 4.25%/D10W

SULFITE FREE ............... 76

CLINIMIX 4.25%/D5W

SULFITE FREE ............... 46

CLINIMIX 4.25%-D20W

SULFITE-FREE ............... 76

CLINIMIX 4.25%-D25W

SULFITE-FREE ............... 76

CLINIMIX 5%-D20W

SULFITE-FREE ............... 76

CLINIMIX E 2.75%/D10W

SULFITE FREE ............... 46


SULFITE FREE ............... 46


SULFITE FREE ............... 76


SULFITE FREE ............... 76


SULFITE FREE ............... 76

CLINIMIX E 5%/D15W

SULFITE FREE ............... 76

CLINIMIX E 5%/D20W

SULFITE FREE ............... 76

CLINIMIX E 5%/D25W

SULFITE FREE ............... 76

clofarabine ............................ 12

clomipramine ........................ 29

clonazepam ........................... 19

clonidine ............................... 35

clonidine hcl ................... 29, 35

clopidogrel ............................ 38

clorazepate dipotassium ....... 29

clotrimazole ...................... 1, 43

clotrimazole-betamethasone . 43

clozapine ............................... 29

CLOZAPINE ........................ 29

COARTEM ............................ 7

codeine sulfate ...................... 24

COLCRYS............................ 61

colestipol .............................. 39

colistin (colistimethate na) ..... 7

COMBIGAN ........................ 68

COMBIPATCH .................... 63

COMBIVENT RESPIMAT . 71

COMETRIQ ......................... 13

COMPLERA .......................... 2

compro .................................. 55

constulose ............................. 55

COREG CR .......................... 35

CORLANOR ........................ 40

cormax .................................. 44

cortisone ............................... 48

COSENTYX (2 SYRINGES)

.......................................... 41

COSENTYX PEN (2 PENS) 41

COTELLIC ........................... 13

COUMADIN ........................ 38

CREON ................................ 55

CRINONE ............................ 63

CRIXIVAN ............................ 2

cromolyn ................... 55, 68, 71

cryselle (28) .......................... 64

CUBICIN................................ 7

CUPRIMINE ........................ 62

cyclafem 1/35 (28)................ 64

cyclafem 7/7/7 (28) .............. 64

cyclobenzaprine .................... 23

CYCLOPHOSPHAMIDE .... 13

CYCLOSET ......................... 50

cyclosporine.......................... 13

cyclosporine modified .......... 13

cyproheptadine ..................... 69

CYRAMZA .......................... 13

CYSTADANE ...................... 55

CYSTAGON ........................ 73

CYSTARAN ......................... 68

cytarabine ............................. 13

D d10 %-0.45 % sodium chloride

.......................................... 46

d2.5 %-0.45 % sodium

chloride ............................. 46

d5 % and 0.9 % sodium

chloride ............................. 46

d5 %-0.45 % sodium chloride

.......................................... 46

dacarbazine ........................... 13

DALIRESP ........................... 71

danazol .................................. 53

dantrolene ............................. 23

dapsone ................................... 7

DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 59

daptomycin ............................. 7

DARAPRIM ........................... 7

darifenacin ............................ 72

DARZALEX ......................... 13

daunorubicin ......................... 13

decitabine .............................. 13

DELZICOL ........................... 55

demeclocycline ..................... 10

DEMSER .............................. 35

DENAVIR ............................ 44

DEPEN TITRATABS .......... 62

DEPO-PROVERA ................ 63

DEPO-SUBQ PROVERA 104

.......................................... 63

DESCOVY ............................. 2

desipramine ........................... 29

desloratadine ......................... 69

desmopressin ........................ 53

desog-e.estradiol/e.estradiol . 64

desoximetasone ..................... 44

desvenlafaxine succinate ...... 29

dexamethasone ............... 48, 49

dexamethasone intensol ........ 48

dexamethasone sodium

phosphate .................... 49, 69

DEXILANT .......................... 57

dexmethylphenidate .............. 29

dexrazoxane hcl .................... 11

dextroamphetamine .............. 29


81

dextroamphetamine-

amphetamine .................... 29

dextrose 10 % and 0.2 % nacl

.......................................... 46

dextrose 10 % in water (d10w)

.......................................... 46

dextrose 5 % in water (d5w) 46

dextrose 5 %-lactated ringers46

dextrose 5%-0.2 % sod

chloride ............................. 46

dextrose 5%-0.3 %

sod.chloride ...................... 46

dextrose with sodium chloride

.......................................... 46

DIASTAT ............................. 19

diazepam............................... 29

diazepam intensol ................. 29

diclofenac potassium ............ 26

diclofenac sodium .... 26, 41, 68

diclofenac-misoprostol ......... 26

dicloxacillin ............................ 9

dicyclomine .......................... 54

didanosine............................... 2

diflorasone ............................ 44

diflunisal ............................... 26

digitek ................................... 38

digoxin .................................. 38

dihydroergotamine ............... 22

DILANTIN 30 MG .............. 19

diltiazem hcl ......................... 35

dilt-xr .................................... 35

DIPENTUM ......................... 55

diphenhydramine hcl ............ 69

disulfiram ............................. 47

divalproex ............................. 19

dofetilide............................... 33

donepezil .............................. 22

dorzolamide .......................... 68

dorzolamide-timolol ............. 68

doxazosin .............................. 35

doxepin ................................. 29

doxorubicin........................... 13

doxorubicin, peg-liposomal .. 13

doxy-100............................... 10

doxycycline hyclate .............. 10

doxycycline monohydrate .... 11

dronabinol............................. 55

drospirenone-e.estradiol-lm.fa

.......................................... 64

drospirenone-ethinyl estradiol

.......................................... 64

DROXIA .............................. 13

duloxetine ............................. 29

duramorph (pf) ..................... 24

DUREZOL ........................... 69

dutasteride ............................ 73

dutasteride-tamsulosin .......... 73

E e.e.s. 400 ................................. 6

econazole .............................. 43

EDURANT ............................. 2

EFFIENT .............................. 38

EGRIFTA ............................. 58

ELAPRASE .......................... 53

ELELYSO ............................ 53

ELIDEL ................................ 42

ELIGARD ............................ 13

ELIGARD (3 MONTH) ....... 13



eliphos .................................. 73

ELIQUIS .............................. 38

ELITEK ................................ 11

ELMIRON ............................ 73

EMCYT ................................ 13

EMEND ................................ 55

emoquette ............................. 64

EMPLICITI .......................... 13

EMSAM ............................... 29

EMTRIVA .............................. 2

enalapril maleate................... 35

enalapril-hydrochlorothiazide

.......................................... 35

ENBREL .............................. 62

ENBREL SURECLICK ....... 62

endocet.................................. 24

ENGERIX-B (PF) ................ 59

ENGERIX-B PEDIATRIC

(PF) ................................... 59

enoxaparin ............................ 38

enpresse ................................ 64

entacapone ............................ 21

entecavir ................................. 2

ENTRESTO.......................... 40

enulose .................................. 55

ENVARSUS XR .................. 13

EPCLUSA .............................. 2

epinastine .............................. 68

EPINEPHRINE .................... 70

EPIPEN 2-PAK .................... 70

EPIPEN JR 2-PAK ............... 70

epirubicin .............................. 13

epitol ..................................... 19

EPIVIR HBV .......................... 2

eplerenone ............................. 35

eprosartan ............................. 35

ergoloid ................................. 29

ERIVEDGE .......................... 13

errin ....................................... 63

ERWINAZE ......................... 13

ery pads ................................. 42

ERYPED 200 .......................... 6

ERYTHROCIN ...................... 6

erythrocin (as stearate) ........... 6

erythromycin ..................... 6, 67

erythromycin ethylsuccinate ... 6

erythromycin with ethanol .... 42

erythromycin-benzoyl peroxide

.......................................... 42

ESBRIET .............................. 71

escitalopram oxalate ............. 29

esomeprazole sodium ........... 57

ESTRACE ............................ 63

estradiol ................................ 63

estradiol valerate ................... 63

eszopiclone ........................... 29

ethambutol .............................. 7

ethosuximide ......................... 19

etidronate disodium .............. 47

etodolac ................................. 26

etoposide ............................... 13

EVOTAZ ................................ 2

exemestane ........................... 13

EXJADE ............................... 47

EXTAVIA ............................ 58

ezetimibe ............................... 39

ezetimibe-simvastatin ........... 39

F FABRAZYME ..................... 53

falmina (28) .......................... 64

famciclovir .............................. 2

famotidine ............................. 57

famotidine (pf) ...................... 57

famotidine (pf)-nacl (iso-osm)

.......................................... 57

FANAPT ............................... 29

FARESTON ......................... 13

FARXIGA ............................ 50

FARYDAK ........................... 13

FASLODEX ......................... 13

FAZACLO ............................ 29

felbamate .............................. 19

felodipine .............................. 35


82

fenofibrate ............................ 40

fenofibrate micronized ......... 40

fenofibrate nanocrystallized . 40

fenofibric acid ...................... 40

fenofibric acid (choline) ....... 40

fenoprofen ............................ 26

fentanyl ................................. 24

fentanyl citrate ...................... 24

FERRIPROX ........................ 47

FETZIMA............................. 30

finasteride ............................. 73

FIRAZYR ............................. 71

flavoxate ............................... 72

flecainide .............................. 33

FLOVENT DISKUS ............ 71

FLOVENT HFA ................... 71

fluconazole ............................. 1

fluconazole in nacl (iso-osm) . 1

flucytosine .............................. 1

fludarabine ............................ 14

fludrocortisone ..................... 49

flunisolide ............................. 71

fluocinolone .................... 44, 45

fluocinolone acetonide oil .... 48

fluorometholone ................... 69

fluorouracil ..................... 14, 42

FLUOROURACIL ............... 42

fluoxetine .............................. 30

FLUOXETINE ..................... 30

fluphenazine decanoate ........ 30

fluphenazine hcl ................... 30

flurbiprofen........................... 26

flurbiprofen sodium .............. 68

flutamide............................... 14

fluticasone ...................... 45, 71

fluvastatin ............................. 40

fluvoxamine .......................... 30

FML S.O.P. .......................... 69

fomepizole ............................ 59

fondaparinux................... 38, 39

FORFIVO XL ...................... 30

FORTEO .............................. 61

fosinopril .............................. 35

fosinopril-hydrochlorothiazide

.......................................... 35

fosphenytoin ......................... 19

FOSRENOL ......................... 47

FRAGMIN ........................... 39

furosemide ............................ 35

FUZEON ................................ 2

FYCOMPA .......................... 19

G gabapentin ............................ 19

GABITRIL ........................... 20

galantamine .......................... 22

GAMMAGARD LIQUID .... 59

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 59

GAMUNEX-C...................... 59

ganciclovir sodium ................. 2

GARDASIL 9 (PF) ............... 59

gatifloxacin ........................... 67

GATTEX 30-VIAL .............. 55

GAUZE PAD ....................... 50

gavilyte-c .............................. 55

gavilyte-g .............................. 55

gavilyte-n .............................. 55

GELNIQUE .......................... 73

gemcitabine .......................... 14

gemfibrozil ........................... 40

generlac ................................ 55

gengraf .................................. 14

gentak ................................... 67

gentamicin .................. 7, 43, 67

gentamicin in nacl (iso-osm) .. 7

GENVOYA ............................ 2

GEODON ............................. 30

gianvi (28) ............................ 64

GILENYA ............................ 22

GILOTRIF ............................ 14

glatopa .................................. 22

GLEOSTINE ........................ 14

glimepiride............................ 50

glipizide ................................ 50

glipizide-metformin .............. 50

GLUCAGEN HYPOKIT ..... 50

GLUCAGON EMERGENCY

KIT (HUMAN)................. 50

glyburide ............................... 50

glyburide micronized ............ 50

glyburide-metformin ............ 50

glycopyrrolate ....................... 54

granisetron (pf) ..................... 55

granisetron hcl ...................... 55

griseofulvin microsize ............ 1

griseofulvin ultramicrosize ..... 1

guanfacine ............................ 30

guanidine .............................. 30

H haloperidol ............................ 30

haloperidol decanoate ........... 30

haloperidol lactate ................ 30

HARVONI .............................. 2

HAVRIX (PF) ...................... 59

heparin (porcine) .................. 39

heparin (porcine) in 5 % dex 39

HEPATAMINE 8% .............. 76

HERCEPTIN ........................ 14

HETLIOZ ............................. 30

HEXALEN ........................... 14

HIBERIX (PF) ...................... 60

HUMIRA .............................. 62

HUMIRA PEDIATRIC

CROHN'S START............ 62

HUMIRA PEN ..................... 62

HUMIRA PEN CROHN'S-

UC-HS START ................ 62

HUMIRA PEN PSORIASIS-

UVEITIS ........................... 62

HUMULIN 70/30 ................. 50

HUMULIN 70/30 KWIKPEN

.......................................... 50

HUMULIN N ....................... 50

HUMULIN N KWIKPEN .... 50

HUMULIN R U-100 ............ 50

HUMULIN R U-500 (CONC)

KWIKPEN ........................ 50

HUMULIN R U-500

(CONCENTRATED) ....... 50

hydralazine ........................... 35

hydrochlorothiazide ........ 35, 36

hydrocodone-acetaminophen 24

hydrocodone-ibuprofen ........ 24

hydrocortisone .......... 45, 49, 55

hydrocortisone butyrate ........ 45

hydrocortisone butyr-emollient

.......................................... 45

hydrocortisone valerate ........ 45

hydrocortisone-acetic acid .... 48

hydromorphone ..................... 24

hydromorphone (pf) .............. 24

hydroxychloroquine ................ 7

hydroxyprogesterone caproate

.......................................... 63

hydroxyurea .......................... 14

hydroxyzine hcl .................... 70

HYPERRAB S/D (PF) ......... 60

I ibandronate ........................... 61

IBRANCE ............................. 14

ibuprofen ............................... 26

ibuprofen-oxycodone ............ 25

ICLUSIG .............................. 14


83

idarubicin .............................. 14

ifosfamide ............................. 14

ILARIS (PF) ......................... 58

ILEVRO ............................... 68

imatinib................................. 14

IMBRUVICA ....................... 14

IMFINZI ............................... 14

imipenem-cilastatin ................ 7

imipramine hcl...................... 30

imipramine pamoate ............. 30

imiquimod ............................ 42

IMOGAM RABIES-HT (PF)

.......................................... 60

IMOVAX RABIES VACCINE

(PF) ................................... 60

INCRELEX .......................... 47

indapamide ........................... 36

indomethacin ........................ 26

INFANRIX (DTAP) (PF)..... 60

INLYTA ............................... 14

INSULIN PEN NEEDLE ..... 50

INSULIN SYRINGE (DISP)

U-100 ................................ 50

INTELENCE ...................... 2, 3

intralipid ............................... 76

INTRALIPID ....................... 76

INTRON A ........................... 58

introvale ................................ 64

INVEGA SUSTENNA ......... 30

INVEGA TRINZA ............... 30

INVIRASE ............................. 3

IONOSOL-MB IN D5W ...... 76

IPOL ..................................... 60

ipratropium bromide ....... 48, 71

ipratropium-albuterol ........... 71

irbesartan .............................. 36

irbesartan-hydrochlorothiazide

.......................................... 36

IRESSA ................................ 14

irinotecan .............................. 14

ISENTRESS ........................... 3

ISOLYTE-P IN 5 %

DEXTROSE ..................... 76

ISOLYTE-S .......................... 76

isoniazid ............................. 7, 8

ISORDIL .............................. 41

isosorbide dinitrate ............... 41

isosorbide mononitrate ......... 41

isradipine .............................. 36

ISTODAX ............................ 14

itraconazole ............................ 1

ivermectin ............................... 8

IXIARO (PF) ........................ 60

J JAKAFI ................................ 14

jantoven ................................ 39

JANUMET ........................... 50

JANUMET XR ..................... 51

JANUVIA ............................. 51

JARDIANCE ........................ 51

jinteli ..................................... 63

jolivette ................................. 63

junel 1.5/30 (21) ................... 64

junel 1/20 (21) ...................... 64

junel fe 1.5/30 (28) ............... 64

junel fe 1/20 (28) .................. 65

junel fe 24 ............................. 65

JUXTAPID ........................... 40

K KADCYLA .......................... 14

KADIAN .............................. 25

KALETRA ............................. 3

KALYDECO ........................ 71

kariva (28) ............................ 65

kelnor 1/35 (28) .................... 65

KENALOG ........................... 49

ketoconazole ..................... 1, 43

ketoprofen ....................... 26, 27

ketorolac ............................... 68

KEVEYIS ............................. 22

KEYTRUDA ........................ 14

KHEDEZLA ......................... 31

kimidess (28) ........................ 65

KINRIX (PF) ........................ 60

kionex ................................... 47

KISQALI .............................. 15

KISQALI FEMARA CO-

PACK ......................... 14, 15

klor-con 10 ........................... 73

klor-con 8 ............................. 73

klor-con m15 ........................ 73

klor-con m20 ........................ 74

klor-con sprinkle................... 74

KOMBIGLYZE XR ............. 51

KORLYM ............................. 53

k-tab ...................................... 74

KUVAN................................ 53

KYNAMRO ......................... 40

KYPROLIS .......................... 15

L l norgest/e.estradiol-e.estrad . 65

labetalol ................................ 36

lactated ringers ................ 45, 74

lactulose ................................ 55

lamivudine .............................. 3

lamivudine-zidovudine ........... 3

lamotrigine ............................ 20

LANOXIN ............................ 38

lansoprazole .......................... 57

larissia ................................... 65

LARTRUVO ........................ 15

LASTACAFT ....................... 68

latanoprost ............................ 68

LATUDA .............................. 31

layolis fe ............................... 65

leflunomide ........................... 62

LENVIMA ............................ 15

lessina ................................... 65

LETAIRIS ............................ 71

letrozole ................................ 15

leucovorin calcium ............... 11

LEUKERAN ......................... 15

LEUKINE ............................. 58

leuprolide .............................. 15

levalbuterol hcl ............... 71, 72

LEVEMIR ............................ 51

LEVEMIR FLEXTOUCH .... 51

levetiracetam ......................... 20

levetiracetam in nacl (iso-osm)

.......................................... 20

levobunolol ........................... 67

levocarnitine ......................... 47

levocarnitine (with sugar) ..... 47

levocetirizine ........................ 70

levofloxacin .................... 10, 67

levofloxacin in d5w .............. 10

levoleucovorin ...................... 11

levonest (28) ......................... 65

levonorgestrel-ethinyl estrad 65

levonorg-eth estrad triphasic 65

levora-28 ............................... 65

levorphanol tartrate ............... 25

levothyroxine ........................ 54

LEVOTHYROXINE ............ 54

levoxyl .................................. 54

LEXIVA ................................. 3

LIALDA ............................... 55

lidocaine ............................... 43

lidocaine (pf) ........................ 43

lidocaine hcl .......................... 43

lidocaine viscous .................. 43

lidocaine-prilocaine .............. 43

lindane .................................. 45


84

linezolid .................................. 8

LINZESS .............................. 55

liothyronine .......................... 54

lisinopril ............................... 36

lisinopril-hydrochlorothiazide

.......................................... 36

lithium carbonate .................. 31

lithium citrate ....................... 31

LONSURF ............................ 15

loperamide ............................ 54

lorazepam ............................. 31

lorazepam intensol................ 31

loryna (28) ............................ 65

losartan ................................. 36

losartan-hydrochlorothiazide 36

lovastatin .............................. 40

low-ogestrel (28) .................. 65

loxapine succinate ................ 31

LUMIGAN ........................... 68

LUPRON DEPOT ................ 15

LUPRON DEPOT (3

MONTH) .......................... 15

LUPRON DEPOT (4

MONTH) .......................... 15

LUPRON DEPOT (6

MONTH) .......................... 15

LUPRON DEPOT-PED ....... 15

lutera (28) ............................. 65

LYNPARZA......................... 15

LYRICA ............................... 20

LYSODREN......................... 15

lyza ....................................... 63

M magnesium sulfate ................ 74

malathion .............................. 45

maprotiline ........................... 31

marlissa................................. 65

MARPLAN .......................... 31

MATULANE ....................... 15

matzim la .............................. 36

meclizine .............................. 55

meclofenamate ..................... 27

medroxyprogesterone ........... 63

mefenamic acid .................... 27

mefloquine .............................. 8

megestrol .............................. 15

MEKINIST ........................... 15

meloxicam ............................ 27

melphalan hcl ....................... 15

memantine ............................ 22

MEMANTINE ..................... 22

MENACTRA (PF) ............... 60

MENOMUNE - A/C/Y/W-135

(PF) ................................... 60

MENVEO A-C-Y-W-135-DIP

(PF) ................................... 60

meprobamate ........................ 23

mercaptopurine ..................... 15

meropenem ............................. 8

mesalamine with cleansing

wipe .................................. 55

mesna .................................... 11

MESNEX.............................. 11

MESTINON ......................... 23

metadate er ........................... 31

metaproterenol ...................... 72

metaxalone............................ 23

metformin ............................. 51

methadone ............................ 25

methamphetamine ................ 31

methazolamide...................... 68

methenamine hippurate ........ 11

methimazole ......................... 49

methotrexate sodium ............ 16

methotrexate sodium (pf) ..... 16

methoxsalen .......................... 42

methscopolamine .................. 54

methyclothiazide .................. 36

methyldopa-


methylphenidate hcl ............. 31

methylprednisolone .............. 49

methylprednisolone acetate .. 49

methylprednisolone sodium

succ ................................... 49

methyltestosterone ................ 53

metipranolol.......................... 67

metoclopramide hcl .............. 55

metolazone............................ 36

metoprolol succinate............. 36

metoprolol tartrate ................ 36

metoprolol tartrate-


metronidazole ............. 8, 42, 63

metronidazole in nacl (iso-

osm) .................................... 8

mexiletine ............................. 33

MIACALCIN ....................... 53

miconazole-3 ........................ 63

microgestin 1.5/30 (21) ........ 65

microgestin 1/20 (21) ........... 65

microgestin fe 1.5/30 (28) .... 65

microgestin fe 1/20 (28) ....... 65

midodrine .............................. 47

migergot ................................ 22

millipred ............................... 49

minocycline .......................... 11

minoxidil ............................... 36

mirtazapine ........................... 31

misoprostol ........................... 57

mitomycin ............................. 16

mitoxantrone ......................... 16

M-M-R II (PF) ...................... 60

modafinil ............................... 31

moexipril ............................... 36

moexipril-hydrochlorothiazide

.......................................... 36

mometasone .................... 45, 72

mononessa (28) ..................... 65

montelukast ........................... 72

morgidox ............................... 11

morphine ............................... 25

MORPHINE ......................... 25

morphine concentrate ........... 25

MOVANTIK ........................ 55

MOVIPREP .......................... 56

moxifloxacin ......................... 10

MOZOBIL ............................ 58

MULTAQ ............................. 33

mupirocin .............................. 43

mupirocin calcium ................ 43

MUSTARGEN ..................... 16

mycophenolate mofetil ......... 16

mycophenolate mofetil hcl ... 16

mycophenolate sodium ......... 16

MYRBETRIQ ....................... 73

N nabumetone ........................... 27

nadolol .................................. 36

nadolol-bendroflumethiazide 36

nafcillin ................................... 9

NAGLAZYME ..................... 53

nalbuphine ............................ 27

naloxone ............................... 27

naltrexone ............................. 27

NAMENDA XR ............. 22, 23

NAPRELAN CR .................. 27

naproxen ............................... 27

naproxen sodium .................. 27

naratriptan ............................. 22

NARCAN ............................. 27

NATACYN ........................... 67

nateglinide ............................ 51


85

NATPARA ........................... 53

NEBUPENT ........................... 8

necon 0.5/35 (28).................. 65

necon 1/50 (28)..................... 65

necon 10/11 (28)................... 65

necon 7/7/7 (28) ................... 65

NEEDLES, INSULIN

DISP.,SAFETY ................ 51

nefazodone ........................... 31

neomycin ................................ 8

neomycin-bacitracin-poly-hc 68

neomycin-bacitracin-

polymyxin......................... 67

neomycin-polymyxin b gu ... 45

neomycin-polymyxin b-

dexameth .................... 68, 69

neomycin-polymyxin-

gramicidin......................... 67

neomycin-polymyxin-hc 48, 69

NEORAL .............................. 16

NEPHRAMINE 5.4 % ......... 76

NEUPOGEN ........................ 58

NEUPRO .............................. 21

nevirapine ............................... 3

NEXAVAR .......................... 16

niacin .................................... 40

nicardipine ............................ 36

NICOTROL .......................... 48

NICOTROL NS.................... 48

nifedipine .............................. 36

nikki (28) .............................. 65

nilutamide ............................. 16

nimodipine ............................ 36

NINLARO ............................ 16

nitro-bid ................................ 41

nitrofurantoin macrocrystal .. 11

nitrofurantoin monohyd/m-

cryst .................................. 11

nitroglycerin ......................... 41

nizatidine .............................. 57

NORDITROPIN FLEXPRO 58

noreth-ethinyl estradiol-iron . 65

norethindrone (contraceptive)

.......................................... 63

norethindrone acetate ........... 63

norgestimate-ethinyl estradiol

.......................................... 66

NORMOSOL-M IN 5 %

DEXTROSE ..................... 76

NORMOSOL-R IN 5 %

DEXTROSE ..................... 74

NORMOSOL-R PH 7.4 ....... 77

NORTHERA ........................ 47

nortrel 0.5/35 (28)................. 66

nortrel 1/35 (21).................... 66

nortrel 1/35 (28).................... 66

nortrel 7/7/7 (28) .................. 66

nortriptyline .......................... 31

NORVIR ................................. 3

NOVAREL ........................... 53

NOVOLIN 70/30 .................. 51

NOVOLIN N ........................ 51

NOVOLIN R ........................ 51

NOVOLOG .......................... 51

NOVOLOG FLEXPEN ........ 51

NOVOLOG MIX 70-30 ....... 51

NOVOLOG MIX 70-30

FLEXPEN ........................ 51

NOVOLOG PENFILL ......... 51

NOXAFIL .............................. 1

NUCYNTA .......................... 27

NUCYNTA ER .................... 27

NUEDEXTA ........................ 23

NULOJIX ............................. 16

NUPLAZID .......................... 31

NUVARING ......................... 63

nyamyc ................................. 43

nystatin ....................... 1, 43, 44

nystatin-triamcinolone .......... 44

nystop ................................... 44

O ocella .................................... 66

octreotide acetate .................. 16

ODEFSEY .............................. 3

ODOMZO ............................ 16

OFEV.................................... 72

ofloxacin ................... 10, 48, 67

ogestrel (28) .......................... 66

olanzapine ............................. 31

olanzapine-fluoxetine ........... 31

olmesartan ............................ 37

olmesartan-amlodipine-


olmesartan-


olopatadine ..................... 48, 68

omega-3 acid ethyl esters ..... 40

omeprazole ........................... 57

ondansetron .......................... 56

ondansetron hcl..................... 56

ondansetron hcl (pf).............. 56

ONFI ..................................... 20

ONGLYZA ........................... 51

OPDIVO ............................... 16

OPSUMIT ............................. 72

ORACEA .............................. 11

ORKAMBI ........................... 72

orsythia ................................. 66

oseltamivir .............................. 3

oxacillin .................................. 9

oxacillin in dextrose(iso-osm) 9

oxaliplatin ............................. 16

oxandrolone .......................... 53

oxaprozin .............................. 27

oxazepam .............................. 31

oxcarbazepine ....................... 20

oxybutynin chloride .............. 73

oxycodone ............................. 25

oxycodone-acetaminophen ... 25

oxycodone-aspirin ................ 25

oxymorphone .................. 25, 26

P pacerone ................................ 33

paclitaxel ............................... 16

paliperidone .......................... 32

pamidronate .......................... 53

PANCREAZE ....................... 56

PANRETIN .......................... 42

pantoprazole ......................... 57

paricalcitol ............................ 53

paromomycin .......................... 8

paroxetine hcl ....................... 32

PASER .................................... 8

PAXIL .................................. 32

PAZEO ................................. 68

PEDIARIX (PF) ................... 60

PEDVAX HIB (PF) .............. 60

peg 3350-electrolytes ............ 56

PEGANONE ......................... 20

PEGASYS ............................ 58

peg-electrolyte soln .............. 56

penicillin g potassium ............. 9

penicillin g procaine ............... 9

penicillin g sodium ............... 10

penicillin v potassium ........... 10

PENTAM ................................ 8

PENTASA ............................ 56

pentoxifylline ........................ 39

PERFOROMIST ................... 72

perindopril erbumine ............ 37

periogard ............................... 48

PERJETA ............................. 16

permethrin ............................. 45


86

perphenazine......................... 32

perphenazine-amitriptyline... 32

phenelzine............................. 32

phenobarbital ........................ 20

phenoxybenzamine ............... 37

PHENYTEK ......................... 20

phenytoin .............................. 20

phenytoin sodium ................. 20

phenytoin sodium extended .. 20

PHOSPHOLINE IODIDE .... 67

pilocarpine hcl ................ 47, 68

pimozide ............................... 32

pimtrea (28) .......................... 66

pindolol................................. 37

pioglitazone .......................... 51

pioglitazone-glimepiride ...... 51

pioglitazone-metformin ........ 51

piperacillin-tazobactam ........ 10

pirmella................................. 66

piroxicam .............................. 27

PLASMA-LYTE 148 ........... 77

PLASMA-LYTE A .............. 77

podofilox .............................. 42

polyethylene glycol 3350 ..... 56

polymyxin b sulfate ................ 8

polymyxin b sulf-trimethoprim

.......................................... 67

POMALYST ........................ 16

portia..................................... 66

potassium chlorid-d5-

0.45%nacl ......................... 74

potassium chloride................ 74

potassium chloride in 0.9%nacl

.......................................... 74

potassium chloride in 5 % dex

.......................................... 74

potassium chloride in lr-d5 ... 74

potassium chloride-0.45 % nacl

.......................................... 74

potassium chloride-d5-

0.2%nacl ........................... 74


0.3%nacl ........................... 74


0.9%nacl ..................... 74, 75

potassium citrate ................... 73

PRADAXA........................... 39

PRALUENT PEN ................ 40

pramipexole .......................... 21

pravastatin ............................ 40

prazosin ................................ 37

prednicarbate ........................ 45

prednisolone acetate ............. 69

prednisolone sodium phosphate

.................................... 49, 69

prednisone ............................ 49

prednisone intensol ............... 49

PREGNYL............................ 53

PREMARIN ......................... 63

premasol 10 % ...................... 77

PREMASOL 6 % ................. 77

prevalite ................................ 40

previfem................................ 66

PREZCOBIX .......................... 3

PREZISTA ............................. 3

PRIFTIN ................................. 8

PRIMAQUINE ....................... 8

primidone.............................. 20

probenecid ............................ 61

probenecid-colchicine .......... 61

procainamide ........................ 33

PROCALAMINE 3% ........... 77

prochlorperazine ................... 56

prochlorperazine edisylate .... 56

prochlorperazine maleate oral

.......................................... 56

PROCRIT ............................. 58

procto-pak ............................. 56

proctosol hc .......................... 56

proctozone-hc ....................... 56

progesterone micronized ...... 63

PROGLYCEM ..................... 51

PROLEUKIN ....................... 58

PROLIA................................ 61

PROMACTA ........................ 39

promethazine ........................ 70

propafenone .......................... 34

propranolol ........................... 37

propranolol-


propylthiouracil .................... 49

PROQUAD (PF)................... 60

PROSOL 20 % ..................... 77

protriptyline .......................... 32

PULMOZYME ..................... 72

PURIXAN ............................ 16

pyrazinamide .......................... 8

pyridostigmine bromide ....... 23

Q QUADRACEL (PF) ............. 60

quasense................................ 66

quetiapine ............................. 32

quinapril ................................ 37

quinapril-hydrochlorothiazide

.......................................... 37

quinidine gluconate .............. 34

quinidine sulfate ................... 34

quinine sulfate ........................ 8

R RABAVERT (PF) ................ 60

raloxifene .............................. 62

ramipril ................................. 37

RANEXA ............................. 40

ranitidine hcl ......................... 57

RAPAMUNE ........................ 16

rasagiline ............................... 21

RAVICTI .............................. 47

REBIF (WITH ALBUMIN) . 58

REBIF REBIDOSE .............. 58

REBIF TITRATION PACK . 59

reclipsen (28) ........................ 66

RECOMBIVAX HB (PF) ..... 60

REGRANEX ........................ 42

RELENZA DISKHALER ...... 4

RELISTOR ........................... 56

REMICADE ......................... 56

REMODULIN ...................... 37

RENVELA ........................... 47

repaglinide ............................ 51

repaglinide-metformin .......... 52

REPATHA PUSHTRONEX 40

REPATHA SURECLICK .... 40

REPATHA SYRINGE ......... 40

RESCRIPTOR ........................ 4

RESTASIS ............................ 68

RETROVIR ............................ 4

REVLIMID ........................... 16

REXULTI ............................. 32

REYATAZ ............................. 4

ribavirin .................................. 4

rifabutin .................................. 8

rifampin .................................. 8

riluzole .................................. 47

rimantadine ............................. 4

ringer's .................................. 75

risedronate ...................... 47, 62

RISPERDAL CONSTA ....... 32

risperidone ............................ 32

RITUXAN ............................ 17

rivastigmine .......................... 23

rivastigmine tartrate .............. 23

rizatriptan .............................. 22

ropinirole .............................. 21


87

rosuvastatin........................... 40

ROTARIX ............................ 61

ROTATEQ VACCINE ........ 61

roweepra ............................... 20

ROZEREM ........................... 32

RUBRACA........................... 17

RYDAPT .............................. 17

S SABRIL ................................ 20

SAMSCA ............................. 53

SANCUSO ........................... 56

SANDIMMUNE .................. 17

SANTYL .............................. 45

SAPHRIS (BLACK

CHERRY) ........................ 32

SAVELLA ............................ 62

selegiline hcl ......................... 21

selenium sulfide.................... 41

SELZENTRY ......................... 4

SENSIPAR ........................... 53

SEREVENT DISKUS .......... 72

sertraline ............................... 32

SIGNIFOR ........................... 17

sildenafil ............................... 72

silver sulfadiazine ................. 41

SIMULECT .......................... 17

simvastatin ............................ 40

sirolimus ............................... 17

SIRTURO ............................... 8

sodium chloride .............. 47, 75

sodium chloride 0.45 % ........ 75

sodium chloride 0.9 % .......... 47

sodium chloride 3 % ............. 75

sodium chloride 5 % ............. 75

sodium lactate intravenous ... 75

sodium polystyrene (sorb free)

.......................................... 47

SOLTAMOX ........................ 17

SOLU-CORTEF (PF) ........... 49

SOMATULINE DEPOT ...... 17

SOMAVERT ........................ 53

sorine .................................... 34

sotalol ................................... 34

sotalol af ............................... 34

SOVALDI .............................. 4

spironolactone ...................... 37

spironolactone-


sprintec (28).......................... 66

SPRITAM............................. 20

SPRYCEL ............................ 17

sps (with sorbitol) ................. 47

sronyx ................................... 66

ssd ......................................... 41

stavudine ................................. 4

STIVARGA .......................... 17

STREPTOMYCIN ................. 8

STRIBILD .............................. 4

SUBOXONE ........................ 27

sucralfate .............................. 57

sulfacetamide sodium ........... 69

sulfacetamide sodium (acne) 43

sulfacetamide-prednisolone .. 69

sulfadiazine ........................... 10

sulfamethoxazole-trimethoprim

.......................................... 10

SULFAMYLON ................... 43

sulfasalazine ......................... 56

sulindac ................................. 27

sumatriptan ........................... 22

sumatriptan succinate ........... 22

SUPRAX ................................ 6

SUSTIVA ............................... 4

SUTENT ............................... 17

SYLATRON ......................... 59

SYMBICORT ....................... 72

SYMLINPEN 120 ................ 52

SYMLINPEN 60 .................. 52

SYNAGIS ............................... 4

SYNAREL............................ 53

SYNERCID ............................ 8

SYNJARDY ......................... 52

SYNRIBO ............................ 17

SYNTHROID ....................... 54

SYPRINE ............................. 47

T TABLOID ............................ 17

tacrolimus ....................... 17, 42

TAFINLAR .......................... 17

TAGRISSO .......................... 17

tamoxifen .............................. 17

tamsulosin ............................. 73

TARCEVA ........................... 17

TARGRETIN ....................... 17

TASIGNA ............................ 17

tazarotene.............................. 42

taztia xt ................................. 37

TECENTRIQ ........................ 17

TECFIDERA ........................ 23

TEFLARO .............................. 6

TEKTURNA ........................ 37

TEKTURNA HCT ............... 37

telmisartan ............................ 37

telmisartan-


temazepam ............................ 32

TENIVAC (PF) .................... 61

terazosin ................................ 37

terbinafine hcl ......................... 1

terbutaline ............................. 72

terconazole ...................... 63, 64

testosterone cypionate .......... 53

testosterone enanthate ........... 53

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 61

TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 61

tetrabenazine ......................... 23

tetracycline ........................... 11

THALOMID ......................... 17

theophylline .......................... 72

thioridazine ........................... 32

thiotepa ................................. 17

thiothixene ............................ 32

tiagabine ............................... 21

timolol maleate ............... 37, 67

tinidazole ................................ 8

TIVICAY ................................ 4

tizanidine .............................. 23

TOBI PODHALER ................ 8

TOBRADEX ST ................... 69

tobramycin ............................ 67

tobramycin in 0.225 % nacl .... 8

tobramycin sulfate .................. 9

tobramycin-dexamethasone .. 69

TOBREX .............................. 67

tolazamide ............................. 52

tolbutamide ........................... 52

tolcapone ............................... 21

tolmetin ................................. 27

tolterodine ............................. 73

topiramate ............................. 21

TOPIRAMATE .................... 21

toposar .................................. 17

topotecan ............................... 17

torsemide .............................. 37

tramadol ................................ 27

tramadol-acetaminophen ...... 27

trandolapril ........................... 37

trandolapril-verapamil .......... 37

tranexamic acid ............... 39, 64

TRANSDERM-SCOP .......... 56

tranylcypromine .................... 32


88

travasol 10 % ........................ 77

TRAVATAN Z .................... 68

trazodone .............................. 32

TREANDA ........................... 18

TRECATOR ........................... 9

TRELSTAR .......................... 18

TRESIBA FLEXTOUCH U-

100 .................................... 52

TRESIBA FLEXTOUCH U-

200 .................................... 52

tretinoin (chemotherapy) ...... 18

tretinoin microspheres .......... 42

tretinoin topical .................... 43

triamcinolone acetonide 45, 48,

72

triamterene-


trianex ................................... 45

triderm .................................. 45

trifluoperazine ...................... 32

trifluridine............................. 67

trihexyphenidyl............... 21, 22

tri-legest fe............................ 66

trilyte with flavor packets ..... 56

trimethoprim ......................... 11

trimipramine ......................... 33

trinessa (28) .......................... 66

TRINTELLIX....................... 33

tri-previfem (28) ................... 66

TRISENOX .......................... 18

tri-sprintec (28) ..................... 66

TRIUMEQ .............................. 4

trivora (28)............................ 66

TROPHAMINE 10 % .......... 77

TROPHAMINE 6% ............. 77

trospium ................................ 73

TRUMENBA ....................... 61

TRUVADA ............................ 4

TUDORZA PRESSAIR ....... 72

TWINRIX (PF) .................... 61

TYBOST ................................ 4

TYGACIL .............................. 9

TYKERB .............................. 18

TYPHIM VI ......................... 61

TYSABRI ............................. 23

U ULORIC ............................... 61

unithroid ............................... 54

UPTRAVI............................. 37

ursodiol ................................. 57

V valacyclovir ............................ 4

VALCHLOR ........................ 42

valganciclovir ......................... 4

valproate sodium .................. 21

valproic acid ......................... 21

valproic acid (as sodium salt)

.......................................... 21

valsartan.......................... 37, 38

valsartan-hydrochlorothiazide

.......................................... 38

vancomycin .......................... 11

vandazole .............................. 64

VAQTA (PF) ........................ 61

VARIVAX (PF) ................... 61

VARIZIG.............................. 61

VARUBI ............................... 57

VECAMYL .......................... 41

VELCADE ........................... 18

velivet triphasic regimen (28)

.......................................... 66

VENCLEXTA ...................... 18

VENCLEXTA STARTING

PACK ............................... 18

venlafaxine ........................... 33

VENTOLIN HFA ................. 72

verapamil .............................. 38

veripred 20 ............................ 49

VERSACLOZ ...................... 33

VESICARE .......................... 73

vestura (28) ........................... 66

VICTOZA 3-PAK ................ 52

VIDEX 2 GRAM PEDIATRIC

............................................ 4

VIGAMOX ........................... 67

VIIBRYD ............................. 33

VIMPAT ............................... 21

vinblastine ............................ 18

vincasar pfs ........................... 18

vincristine ............................. 18

vinorelbine ............................ 18

VIRACEPT ........................ 4, 5

VIREAD ................................. 5

VIVITROL ........................... 28

voriconazole ........................... 1

VOTRIENT .......................... 18

VPRIV .................................. 53

VRAYLAR ........................... 33

W warfarin ................................ 39

WELCHOL .......................... 40

wymzya fe ............................ 66

X XALKORI ............................ 18

XELJANZ ............................. 62

XELJANZ XR ...................... 62

XERMELO ........................... 18

XGEVA ................................ 11

XIFAXAN .............................. 9

XIGDUO XR ........................ 52

XOLAIR ............................... 72

XTANDI ............................... 18

XYREM ................................ 33

Y YERVOY ............................. 18

YF-VAX (PF) ....................... 61

YONDELIS .......................... 18

Z zafirlukast ............................. 72

ZALTRAP ............................ 18

zamicet .................................. 26

zarah ..................................... 66

ZAVESCA ............................ 53

ZEJULA ............................... 18

ZELBORAF ......................... 18

ZEMPLAR ........................... 53

zenchent (28) ........................ 66

zenchent fe ............................ 66

ZENPEP ............................... 57

ZERIT ..................................... 5

ZIAGEN ................................. 5

zidovudine .............................. 5

ziprasidone hcl ...................... 33

ZIRGAN ............................... 67

zoledronic acid ...................... 53

zoledronic acid-mannitol-water

.......................................... 47

ZOLINZA ............................. 18

zolmitriptan ........................... 22

zolpidem ............................... 33

ZOMETA ............................. 54

zonisamide ............................ 21

ZORTRESS .......................... 18

ZOSTAVAX (PF) ................ 61

zovia 1/35e (28) .................... 66

zovia 1/50e (28) .................... 66

ZYCLARA ........................... 42

ZYDELIG ............................. 18

ZYKADIA ............................ 18

ZYPREXA RELPREVV ...... 33

ZYTIGA ............................... 19


89

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