longevity health plan (hmo i-snp) illinois - formulario de ......con servicios para los miembros de...

Modelo de Formulario de la Parte D de 2020 (integral)

Longevity Health Plan (HMO I-SNP)

Illinois

Formulario de 2020

Lista de medicamentos cubiertos

LEA ESTA INFORMACIÓN: ESTE DOCUMENTO CONTIENE INFORMACIÓN

SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

HPMS Approved Formulary File Submission ID, 00020282, Version Number 7

Este formulario se actualizó el 5/1/2020. Para más información actualizada u otras preguntas, comuníquese con Servicios para los miembros de Longevity Health Plan (HMO I-SNP) al 888-886-9770 o, para los usuarios de TTY, al 711, en el Horario de atención al público: de 8:00 a. m. a 8:00 p. m., siete días a la semana (excepto el Día de Acción de Gracias y Navidad) del 1 de octubre al 31 de marzo, y de lunes a viernes (excepto los días festivos) del 1 de abril al 30 de septiembre, o visite LongevityHealthPlan.com.

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http://www.LongevityHealthPlan.com

Nuevos medicamentos genéricos. Podemos eliminar inmediatamente un medicamento de marca denuestra Lista de medicamentos si lo reemplazamos con un nuevo medicamento genérico queaparecerá en el mismo nivel de costo compartido o en un nivel de costo compartido más bajo y conlas mismas restricciones o menos. Además, cuando agreguemos el nuevo medicamento genérico,podemos decidir mantener el medicamento de marca en nuestra Lista de medicamentos peroinmediatamente moverlo a un nivel de costo compartido diferente o agregar nuevas restricciones. Siactualmente está tomando ese medicamento de marca, es posible que no le informemos conanticipación antes de realizar ese cambio, pero luego le brindaremos información sobre el(los)cambio(s) específico(s) que realicemos.

o Si realizamos dicho cambio, usted o la persona autorizada a dar recetas pueden solicitarnosque hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. Elaviso que le proporcionamos también incluirá información sobre cómo solicitar una

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Modelo de Formulario de la Parte D de 2020 (integral) Nota para los miembros existentes: Este formulario se ha modificado desde el año pasado. Revise este documento para asegurarse de que aún contenga los medicamentos que toma. Cuando esta lista de medicamentos (formulario) se refiere a “nosotros,” “nos” o “nuestro”, está hablando de Longevity Health Plan (HMO I-SNP). Cuando se refiere a “plan” o “nuestro plan”, está hablando de Longevity Health Plan (HMO I-SNP). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada al 5/1/2020. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la portada y contraportada. Por lo general, debe usar las farmacias de la red para obtener su beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias, y/o los copagos/coseguro pueden cambiar a partir del 1 de enero de 2020 y periódicamente durante el año.

¿Qué es el Formulario de Longevity Health Plan (HMO I-SNP)?

Un formulario es una lista de medicamentos cubiertos seleccionados por Longevity Health Plan (HMO I-SNP) en consulta con un equipo de proveedores del cuidado de la salud, que representa las farmacoterapias que se consideran parte necesaria de un programa de tratamiento de calidad. Longevity Health Plan (HMO I-SNP) generalmente cubrirá los medicamentos que figuran en nuestro formulario, siempre que el. medicamento sea médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red de Longevity Health Plan (HMO I-SNP) y se cumplan otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, revise su Evidencia de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?

La mayoría de los cambios en la cobertura de medicamentos ocurren el 1 de enero, pero podemos agregar o quitar medicamentos de la Lista de medicamentos durante el año, moverlos a diferentes niveles de costo compartido o agregar nuevas restricciones. Debemos seguir las normas de Medicare al hacer estos cambios. Cambios que pueden afectarlo este año: en los siguientes casos, se verá afectado por cambios de cobertura durante el año:

Modelo de Formulario de la Parte D de 2020 (integral) excepción, y también puede encontrar información en la siguiente sección titulada “¿Cómo solicito una excepción al Formulario de Longevity Health Plan (HMO I-SNP)?”

Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos (Foodand Drug Administration, FDA) considera que un medicamento de nuestro formulario no es seguro osi el fabricante del medicamento lo retira del mercado, retiraremos inmediatamente el medicamentode nuestro formulario e informaremos a los miembros que toman dicho medicamento.

Otros cambios. Es posible que hagamos otros cambios que afecten a los miembros que actualmentetoman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevoen el mercado para reemplazar un medicamento de marca actualmente incluido en el formulario oagregar nuevas restricciones al medicamento de marca o moverlo a un nivel diferente de costocompartido. O podemos hacer cambios de acuerdo con las nuevas pautas clínicas. Si retiramosmedicamentos de nuestro formulario, [o] agregamos una autorización previa, límites de cantidad y/orestricciones de terapia escalonada de un medicamento, debemos notificar dicho cambio a losmiembros afectados al menos 30 días antes de que dicho cambio se haga efectivo o, en el momentoen que el miembro solicite que le resurtan el medicamento, momento en el que el miembro recibiráun suministro del medicamento por 30 días.

o Si realizamos estos u otros cambios, usted o la persona autorizada a dar recetas puedensolicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca parausted. El aviso que le proporcionamos también incluirá información sobre cómo solicitar unaexcepción, y también puede encontrar información en la siguiente sección titulada “¿Cómosolicito una excepción al Formulario de Longevity Health Plan (HMO I-SNP)?”

Cambios que no le afectarán si actualmente está tomando el medicamento. Por lo general, si está tomando un medicamento de nuestro formulario de 2020 que estaba cubierto al inicio del año, no descontinuaremos ni reduciremos la cobertura del medicamento durante el año 2020 de cobertura, a menos que se haya descrito anteriormente. Esto significa que estos medicamentos seguirán disponibles con el mismo costo compartido y sin nuevas restricciones para los miembros que los tomen durante el resto del año de cobertura. El formulario adjunto está actualizado al 5/1/2020. Para obtener información actualizada sobre los medicamentos que cubre Longevity Health Plan (HMO I-SNP), comuníquese con nosotros. Nuestra información de contacto figura en la portada y contraportada.

¿Cómo utilizo el Formulario?

Existen dos maneras de encontrar su medicamento dentro del formulario:

Afección médica

El formulario comienza en la página 9. Los medicamentos en este formulario están agrupados encategorías basadas en el tipo de afección médica para los que se utilizan. Por ejemplo, los medicamentos para tratar una afección cardíaca están enumerados en la categoría Agentes cardiovasculares (Cardiovascular Agents). Si usted sabe para qué se usa su medicamento, busque el

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Modelo de Formulario de la Parte D de 2020 (integral) nombre de la categoría en la lista que empieza en la página 9. Luego busque su medicamentobajo el nombre de la categoría correspondiente.

Lista en orden alfabético

Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la página 118. El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos se enumeran en el Índice. Busque en el Índice y encuentre su medicamento. Al lado de su medicamento verá el número de página en la que puede encontrar información de cobertura. Vaya a la página que se enumera en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

Longevity Health Plan (HMO I-SNP) cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico es aquel aprobado por la FDA porque tiene el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos son más económicos que los medicamentos de marca.

¿Existe alguna restricción en mi cobertura?

Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir:

Autorización previa: Longevity Health Plan (HMO I-SNP) requiere que usted [o su médico]obtenga una autorización previa para determinados medicamentos. Esto significa que necesita laaprobación antes de obtener sus medicamentos con receta. Si no obtiene la aprobación, LongevityHealth Plan (HMO I-SNP) podría no cubrir el medicamento.

Límites de cantidad: Para ciertos medicamentos, Longevity Health Plan (HMO I-SNP) limita lacantidad del medicamento que Longevity Health Plan (HMO I-SNP) cubrirá. Por ejemplo, LongevityHealth Plan (HMO I-SNP) proporciona 120 unidades por receta para sulfato de morfina encomprimidos de liberación prolongada de 15mg. Esto puede ser adicional a un suministro estándarde un mes o tres meses.

Terapia escalonada: En algunos casos, Longevity Health Plan (HMO I-SNP) requiere que ustedprimero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otromedicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan suafección médica, es posible que Longevity Health Plan (HMO I-SNP) no cubra el medicamento B amenos que pruebe el medicamento A primero. Si el medicamento A no es efectivo para usted,entonces Longevity Health Plan (HMO I-SNP) cubrirá el medicamento B.

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Modelo de Formulario de la Parte D de 2020 (integral) Usted puede averiguar si su medicamento tiene requisitos o límites adicionales consultando el formulario que empieza en la página 9. También puede obtener más información sobre las restricciones que se aplican adeterminados medicamentos cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra autorización previa y las restricciones de terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la portada y contraportada.

Puede solicitar una excepción a Longevity Health Plan (HMO I-SNP) para estas restricciones o límites, o solicitar una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción para el formulario de Longevity Health Plan (HMO I-SNP)?” en la página 5 para obtener información sobre cómo solicitar una excepción.

¿Qué puedo hacer si mi medicamento no está en el Formulario?

Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con el Servicio para los miembros y consultar si su medicamento está cubierto. Para obtener más información, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la portada y contraportada.]

Si le informan que Longevity Health Plan (HMO I-SNP) no cubre su medicamento, tiene dos opciones:

Puede solicitar al Servicio para los miembros una lista de medicamentos similares que estén cubiertospor Longevity Health Plan (HMO I-SNP). Cuando reciba la lista, muéstresela a su médico y pídaleque le recete un medicamento similar que esté cubierto por Longevity Health Plan (HMO I-SNP).

Puede solicitar una excepción a Longevity Health Plan (HMO I-SNP) para cubrir su medicamento.Consulte lo que se describe a continuación para obtener información sobre cómo solicitar unaexcepción.

¿Cómo solicito una excepción al Formulario de Longevity Health Plan (HMO I-SNP)?

Puede solicitar que Longevity Health Plan (HMO I-SNP) haga una excepción a nuestras normas de cobertura. Existen varios tipos de excepciones que puede solicitarnos.

[Puede solicitarnos que cubramos un medicamento aunque no esté en nuestro formulario. Si seaprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted nopodrá solicitarnos que le suministremos dicho medicamento a un nivel de costo compartido inferior.]

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Puede solicitar que no apliquemos las restricciones o limitaciones de cobertura de su medicamento.Por ejemplo, para ciertos medicamentos, Longevity Health Plan (HMO I-SNP) limita la cantidad delmedicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitar queeximamos el límite y que cubramos más.

Por lo general, Longevity Health Plan (HMO I-SNP) aprobará su solicitud de una excepción únicamente si los medicamentos alternativos incluidos en el formulario del plan, [el medicamento de costo compartido más bajo] o las restricciones de utilización adicional no son favorables para tratar su afección y/o harán que padezca efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para un formulario. Al

solicitar un formulario, deberá enviar una declaración de la persona autorizada a dar recetas o su

médico justificando su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las 72 horas después de obtener la declaración en la que la persona autorizada a dar recetas realiza la justificación. Puede solicitar una excepción acelerada (rápida) si usted o su médico cree que su salud corre un riesgo grave al esperar hasta 72 horas por una decisión. Si se le otorga la solicitud de aceleración, debemos darle una respuesta dentro de las 24 horas luego de recibir la declaración justificatoria de su médico o de otra persona autorizada a dar recetas.

¿Qué debo hacer antes de poder hablar con mi médico para cambiar mis medicamentos

o solicitar una excepción?

Como miembro nuevo o que continúa en nuestro plan, podría estar tomando medicamentos que no están incluidos en nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte antes de que pueda obtener su medicamento con receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que cubrimos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción correcto para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en los que usted es miembro de nuestro plan.

Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal de 31 días. Si su receta está indicada para menos días, permitiremos que los resurtidos le proporcionen un suministro máximo de 31 días de medicamentos. Luego de su primer suministro para 31 días, no pagaremos estos medicamentos, aunque sea miembro del plan por menos de 90 días.

Si usted es residente de un centro de cuidado a largo plazo y necesita un medicamento que no está en nuestro formulario, o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días para ese medicamento mientras solicita una excepción al formulario.

Le proporcionaremos un suministro de transición de una sola vez para 31 días por medicamento, el cual cubrirá un suministro temporal si usted tiene un cambio en sus medicamentos debido a un cambio en el nivel de atención. Un cambio de nivel de atención puede incluir:

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Modelo de Formulario de la Parte D de 2020 (integral) • Entrar o salir de un centro de Atención a largo plazo (Long Term Care, LTC)• Haber sido dado de alta de un hospital o de un hogar• Terminar una hospitalización en un centro de atención de enfermería especializada de la Parte A deMedicare• Renunciar a la condición de Hospicio y volver a los beneficios estándar de Medicare• Terminar una hospitalización en un LTC y regresar a su hogar

Para obtener más información

Para obtener información más detallada sobre su cobertura de medicamentos con receta de Longevity Health Plan (HMO I-SNP), consulte su Evidencia de cobertura y otros materiales del plan. Si tiene alguna pregunta sobre Longevity Health Plan (HMO I-SNP), comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la portada y contraportada. Si tiene preguntas generales sobre la cobertura de medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

Formulario de Longevity Health Plan (HMO I-SNP)

El siguiente formulario proporciona información de cobertura sobre los medicamentos cubiertos por Longevity Health Plan (HMO I-SNP). Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 118.

La primera columna del cuadro enumera el nombre del medicamento. Los medicamentos de marca figuran en letra mayúscula (por ej., VYVANSE 10MG CAP) y los medicamentos genéricos aparecen en letra minúscula y cursiva (p. ej., atomoxetine 100mg cap).

La información en la columna Requisitos/Límites le indica si Longevity Health Plan (HMO I-SNP) tiene algún requisito especial para la cobertura de su medicamento. Primer surtido limitado a un suministro de un mes (First Fill, FF): Es posible que pueda recibir un

suministro de más de 1 mes de la mayoría de los medicamentos de su Formulario. Los medicamentosque se indican con “FF” se limitan a un suministro de 1 mes tanto para Pedidos por correo comoMinoristas solo en su primer surtido. Después del primer surtido, se dispondría de un suministroextendido para el día.

Distribución limitada (Limited Distribution, LD): El símbolo [LD] junto al nombre de unmedicamento indica que la Administración de Alimentos y Medicamentos ha señalado que elmedicamento está restringido a ciertas farmacias. Estos medicamentos solo se pueden obtener enfarmacias designadas como especializadas y capaces de manejarlos apropiadamente.

Suministro no extendido para el día (Non-Extended Day Supply, NDS): Es posible que pueda recibirun suministro de más de 1 mes de la mayoría de los medicamentos de su Formulario a través de un

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http://www.medicare.gov

Modelo de Formulario de la Parte D de 2020 (integral) pedido por correo a un costo compartido reducido. Los medicamentos que se indican con “NDS” se limitan a un suministro de 1 mes tanto para Pedidos por correo como Minoristas.

Autorización previa (Prior Authorization, PA): Navitus MedicareRx (PDP) requiere que usted [o sumédico] obtenga una autorización previa para determinados medicamentos. Esto significa quenecesita obtener aprobación del Plan antes de obtener sus medicamentos con receta. Si no obtiene laaprobación, el Plan podría no cubrir el medicamento.

Restricción por autorización previa de la Parte B vs. la Determinación de la Parte D (PriorAuthorization for Part B vs Part D Determination, PA_BvD): Este medicamento puede ser elegiblepara pago según la Parte B o la Parte D de Medicare. Usted (o su médico) debe obtener autorizaciónprevia del Plan para determinar que este medicamento está cubierto por la Parte D de Medicare antesde obtener su medicamento con receta para este. Es posible que el Plan no cubra este medicamentosin una aprobación previa.

Restricción de autorización previa solo para medicamentos nuevos (Prior Authorization for NewStarts Only, PA_NSO): Si este medicamento es nuevo para el miembro, usted (o su médico) debeobtener autorización previa del Plan antes de obtener su medicamento con receta para este. Es posibleque el Plan no cubra este medicamento sin una aprobación previa.

Límites de cantidad (Quantity Limits, QL): Para ciertos medicamentos, el Plan limita la cantidad delmedicamento que cubrirá. Esto podría incluir una limitación por surtido, diaria, mensual o anual.

Terapia escalonada (Step Therapy, ST): En algunos casos, el Plan requiere que usted primero pruebeciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento paraesa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, esposible que el Plan no cubra el medicamento B a menos que pruebe el medicamento A primero. Si elmedicamento A no es efectivo para usted, entonces el Plan cubrirá el medicamento B.

Terapia escalonada solo para medicamentos nuevos (Step Therapy for New Starts Only, ST_NSO):Si este medicamento es nuevo para el miembro, se le requiere que primero pruebe ciertosmedicamentos para tratar su afección médica antes de que cubramos otro medicamento para esaafección.

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Nombre del Medicamento Nivel deMedicamento

Requisitos/Límites

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAMPHETAMINES

amphetamine/dextroamphetamine 10mg ER cap 1amphetamine/dextroamphetamine 10mg tab 1amphetamine/dextroamphetamine 12.5mg tab 1amphetamine/dextroamphetamine 15mg ER cap 1amphetamine/dextroamphetamine 15mg tab 1amphetamine/dextroamphetamine 20mg ER cap 1amphetamine/dextroamphetamine 20mg tab 1amphetamine/dextroamphetamine 25mg ER cap 1amphetamine/dextroamphetamine 30mg ER cap 1amphetamine/dextroamphetamine 30mg tab 1amphetamine/dextroamphetamine 5mg ER cap 1amphetamine/dextroamphetamine 5mg tab 1amphetamine/dextroamphetamine 7.5mg tab 1dextroamphetamine sulfate 10mg er cap 1dextroamphetamine sulfate 10mg tab 1dextroamphetamine sulfate 15mg er cap 1dextroamphetamine sulfate 5mg er cap 1dextroamphetamine sulfate 5mg tab 1

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTSatomoxetine 100mg cap 1 QL=60 EA/30 Díasatomoxetine 10mg cap 1 QL=60 EA/30 Díasatomoxetine 18mg cap 1 QL=60 EA/30 Díasatomoxetine 25mg cap 1 QL=60 EA/30 Díasatomoxetine 40mg cap 1 QL=60 EA/30 Díasatomoxetine 60mg cap 1 QL=60 EA/30 Díasatomoxetine 80mg cap 1 QL=60 EA/30 Díasguanfacine 1mg er tab 1guanfacine 2mg er tab 1guanfacine 3mg er tab 1guanfacine 4mg er tab 1

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)SUNOSI 150MG TAB 1 NDS PA QL=30 EA/30 DíasSUNOSI 75MG TAB 1 NDS PA QL=30 EA/30 Días

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTSWAKIX 17.8MG TAB 1 NDS PA QL=60 EA/30 DíasWAKIX 4.45MG TAB 1 NDS PA QL=60 EA/30 Días

STIMULANTS - MISC.armodafinil 150mg tab 1 PA QL=30 EA/30 Días

Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones encontrados enesta tabla consultando el principio de esta tabla.

9


Requisitos/Límites

armodafinil 200mg tab 1 PA QL=30 EA/30 Díasarmodafinil 250mg tab 1 PA QL=30 EA/30 Díasarmodafinil 50mg tab 1 PA QL=30 EA/30 DíasBX RATING - METHYLPHENIDATE 18MG SR TAB 1BX RATING - METHYLPHENIDATE 27MG SR TAB 1BX RATING - METHYLPHENIDATE 36MG SR TAB 1BX RATING - METHYLPHENIDATE 54MG SR TAB 1dexmethylphenidate 10mg er cap 1dexmethylphenidate 10mg tab 1dexmethylphenidate 15mg er cap 1dexmethylphenidate 2.5mg tab 1dexmethylphenidate 20mg er cap 1dexmethylphenidate 25mg er cap 1dexmethylphenidate 30mg er cap 1dexmethylphenidate 35mg er cap 1dexmethylphenidate 40mg er cap 1dexmethylphenidate 5mg er cap 1dexmethylphenidate 5mg tab 1metadate 20mg er tab 1methylphenidate 10mg cr cap 1methylphenidate 10mg er tab 1methylphenidate 10mg la cap 1methylphenidate 10mg tab 1methylphenidate 18mg sr tab 1methylphenidate 1mg/ml oral soln 1methylphenidate 20mg cr cap 1methylphenidate 20mg er tab 1methylphenidate 20mg la cap 1methylphenidate 20mg tab 1methylphenidate 27mg sr tab 1methylphenidate 2mg/ml oral soln 1methylphenidate 30mg cr cap 1methylphenidate 30mg la cap 1methylphenidate 36mg sr tab 1methylphenidate 40mg cr cap 1methylphenidate 40mg la cap 1methylphenidate 50mg cr cap 1methylphenidate 54mg sr tab 1methylphenidate 5mg tab 1methylphenidate 60mg cr cap 1


10


Requisitos/Límites

modafinil 100mg tab 1 PA QL=60 EA/30 Díasmodafinil 200mg tab 1 PA QL=60 EA/30 Días

AMINOGLYCOSIDESAMINOGLYCOSIDES

amikacin 250mg/ml inj 1ARIKAYCE 70.3MG/ML INH SOLN 1 NDS PA QL=252 ML/30 DíasGENTAMICIN SULFATE 0.8MG/ML INJ 1gentamicin sulfate 1.2mg/ml inj 1GENTAMICIN SULFATE 1.6MG/ML INJ 1GENTAMICIN SULFATE 1MG/ML INJ 1gentamicin sulfate 40mg/ml inj 1neomycin sulfate 500mg tab 1paromomycin 250mg cap 1STREPTOMYCIN 100MG INJ 1TOBI PODHALER KIT 28MG PACK 1 NDS PATOBRAMYCIN 10MG/ML INJ 1tobramycin 40mg/ml inj 1tobramycin 60mg/ml inh soln 1 NDS PA

ANALGESICS - ANTI-INFLAMMATORYANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA 10MG/0.1ML SYRINGE 1 NDS PAHUMIRA 10MG/0.2ML SYRINGE 1 NDS PAHUMIRA 20MG/0.2ML SYRINGE 1 NDS PAHUMIRA 20MG/0.4ML SYRINGE 1 NDS PAHUMIRA 40MG/0.4ML PEN INJECTOR 1 NDS PAHUMIRA 40MG/0.4ML SYRINGE 1 NDS PAHUMIRA 40MG/0.8ML AUTO-INJECTOR 1 NDS PAHUMIRA 40MG/0.8ML SYRINGE 1 NDS PAHUMIRA PEDIATRIC CROHN'S STARTER PACK (3)80MG/0.8ML INJ

1 NDS PA

HUMIRA PEDIATRIC CROHN'S STARTER PACKSYRINGE (2) 40MG/0.4ML 80MG/0.8ML

1 NDS PA

HUMIRA PEN - CROHN'S STARTER PACK40MG/0.8ML INJ

1 NDS PA

HUMIRA PEN - CROHN'S STARTER PACK80MG/0.8ML INJ

1 NDS PA

HUMIRA PEN - PSORIASIS STARTER PACK40MG/0.8ML INJ

1 NDS PA

HUMIRA PEN - PSORIASIS STARTER PACK80MG/0.8ML INJ

1 NDS PA

SIMPONI 100MG/ML AUTO-INJECTOR 1 NDS PA


11


Requisitos/Límites

SIMPONI 100MG/ML INJ 1 NDS PASIMPONI 50MG/0.5ML AUTO-INJECTOR 1 NDS PASIMPONI 50MG/0.5ML SYRINGE 1 NDS PA

ANTIRHEUMATIC - ENZYME INHIBITORSOLUMIANT 1MG TAB 1 PAOLUMIANT 2MG TAB 1 PARINVOQ 15MG ER TAB 1 NDS PAXELJANZ 10MG TAB 1 NDS PAXELJANZ 5MG TAB 1 NDS PA

GOLD COMPOUNDSRIDAURA 3MG CAP 1

INTERLEUKIN-1 BLOCKERSARCALYST 220MG INJ 1 NDS PA

INTERLEUKIN-6 RECEPTOR INHIBITORSACTEMRA 162MG/0.9ML AUTO-INJECTOR 1 NDS PAACTEMRA 162MG/0.9ML SYRINGE 1 NDS PAKEVZARA 150MG/1.14ML PF INJ 1 NDS PAKEVZARA 200MG/1.14ML PF INJ 1 NDS PA

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)celecoxib 100mg cap 1 QL=60 EA/30 Díascelecoxib 200mg cap 1 QL=60 EA/30 Díascelecoxib 400mg cap 1 QL=60 EA/30 Díascelecoxib 50mg cap 1 QL=60 EA/30 Díasdiclofenac potassium 50mg tab 1diclofenac sodium 100mg er tab 1diclofenac sodium 25mg dr tab 1diclofenac sodium 50mg dr tab 1diclofenac sodium 50mg/misoprostol 0.2mg tab 1diclofenac sodium 75mg dr tab 1diclofenac sodium 75mg/misoprostol 0.2mg tab 1etodolac 200mg cap 1etodolac 300mg cap 1etodolac 400mg er tab 1etodolac 400mg tab 1etodolac 500mg er tab 1etodolac 500mg tab 1etodolac 600mg er tab 1flurbiprofen 100mg tab 1ibu 600mg tab 1ibu 800mg tab 1


12


Requisitos/Límites

ibuprofen 20mg/ml susp 1ibuprofen 400mg tab 1ibuprofen 600mg tab 1ibuprofen 800mg tab 1INDOCIN 50MG RECTAL SUPP 1KETOPROFEN 25MG CAP 1ketorolac tromethamine 10mg tab 1 QL=20 EA/5 Díasmeloxicam 15mg tab 1meloxicam 7.5mg tab 1nabumetone 500mg tab 1nabumetone 750mg tab 1naproxen 250mg tab 1naproxen 375mg dr tab 1naproxen 375mg tab 1naproxen 500mg dr tab 1naproxen 500mg tab 1naproxen sodium 275mg tab 1naproxen sodium 550mg tab 1oxaprozin 600mg tab 1piroxicam 10mg cap 1piroxicam 20mg cap 1sulindac 150mg tab 1sulindac 200mg tab 1

PHOSPHODIESTERASE 4 (PDE4) INHIBITORSOTEZLA 28-DAY STARTER PACK 1 NDS PAOTEZLA 30MG TAB 1 NDS PA

PYRIMIDINE SYNTHESIS INHIBITORSleflunomide 10mg tab 1leflunomide 20mg tab 1

SELECTIVE COSTIMULATION MODULATORSORENCIA 125MG/ML AUTO-INJECTOR 1 NDS PAORENCIA 125MG/ML SYRINGE 1 NDS PAORENCIA 50MG/0.4ML SYRINGE 1 NDS PAORENCIA 87.5MG/0.7ML SYRINGE 1 NDS PA

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTSENBREL 25MG INJ 1 NDS PAENBREL 25MG/0.5ML SYRINGE 1 NDS PAENBREL 50MG/ML CARTRIDGE 1 NDS PAENBREL 50MG/ML SURECLICK INJ 1 NDS PAENBREL 50MG/ML SYRINGE 1 NDS PA


13


Requisitos/Límites

ANALGESICS - NONNARCOTICSALICYLATES

diflunisal 500mg tab 1ANALGESICS - OPIOID

OPIOID AGONISTScodeine sulfate 30mg tab 1 QL=240 EA/30 Díascodeine sulfate 60mg tab 1 QL=180 EA/30 Díasduramorph 0.5mg/ml inj 1 PA BvDduramorph 1mg/ml inj 1 PA BvDfentanyl 0.012mg/hr patch 1 QL=10 EA/30 Díasfentanyl 0.025mg/hr patch 1 QL=10 EA/30 Díasfentanyl 0.05mg/hr patch 1 QL=10 EA/30 Díasfentanyl 0.075mg/hr patch 1 QL=10 EA/30 DíasFENTANYL 0.1MG BUCCAL TAB 1 PA QL=120 EA/30 Díasfentanyl 0.1mg/hr patch 1 QL=10 EA/30 DíasFENTANYL 0.2MG BUCCAL TAB 1 PA QL=120 EA/30 Díasfentanyl 0.2mg lozenge 1 PA QL=120 EA/30 DíasFENTANYL 0.4MG BUCCAL TAB 1 PA QL=120 EA/30 Díasfentanyl 0.4mg lozenge 1 PA QL=120 EA/30 DíasFENTANYL 0.6MG BUCCAL TAB 1 PA QL=120 EA/30 Díasfentanyl 0.6mg lozenge 1 PA QL=120 EA/30 DíasFENTANYL 0.8MG BUCCAL TAB 1 PA QL=120 EA/30 Díasfentanyl 0.8mg lozenge 1 PA QL=120 EA/30 Díasfentanyl 1.2mg lozenge 1 PA QL=120 EA/30 Díasfentanyl 1.6mg lozenge 1 PA QL=120 EA/30 DíasFENTORA 100MCG BUCCAL TAB 1 PA QL=120 EA/30 DíasFENTORA 200MCG BUCCAL TAB 1 PA QL=120 EA/30 DíasFENTORA 400MCG BUCCAL TAB 1 PA QL=120 EA/30 DíasFENTORA 600MCG BUCCAL TAB 1 PA QL=120 EA/30 DíasFENTORA 800MCG BUCCAL TAB 1 PA QL=120 EA/30 Díashydromorphone 10mg/ml (1ml) inj 1hydromorphone 10mg/ml (5ml) inj 1hydromorphone 1mg/ml oral soln 1 QL=2400 ML/30 Díashydromorphone 2mg tab 1 QL=450 EA/30 Díashydromorphone 4mg tab 1 QL=240 EA/30 Díashydromorphone 8mg tab 1 QL=120 EA/30 DíasHYSINGLA 100MG ER TAB 1 QL=30 EA/30 DíasHYSINGLA 120MG ER TAB 1 QL=30 EA/30 DíasHYSINGLA 20MG ER TAB 1 QL=30 EA/30 DíasHYSINGLA 30MG ER TAB 1 QL=30 EA/30 Días


14


Requisitos/Límites

HYSINGLA 40MG ER TAB 1 QL=30 EA/30 DíasHYSINGLA 60MG ER TAB 1 QL=30 EA/30 DíasHYSINGLA 80MG ER TAB 1 QL=30 EA/30 Díasmethadone 10mg tab 1 QL=360 EA/30 Díasmethadone 5mg tab 1 QL=360 EA/30 Díasmorphine sulfate 100mg er tab 1 QL=120 EA/30 Díasmorphine sulfate 15mg er tab 1 QL=120 EA/30 Díasmorphine sulfate 15mg tab 1 QL=180 EA/30 Díasmorphine sulfate 200mg er tab 1 QL=120 EA/30 Díasmorphine sulfate 20mg/ml oral soln 1 QL=180 ML/30 Díasmorphine sulfate 2mg/ml oral soln 1 QL=1800 ML/30 Díasmorphine sulfate 30mg er tab 1 QL=120 EA/30 Díasmorphine sulfate 30mg tab 1 QL=180 EA/30 Díasmorphine sulfate 4mg/ml oral soln 1 QL=900 ML/30 Díasmorphine sulfate 60mg er tab 1 QL=120 EA/30 DíasNUCYNTA 100MG ER TAB 1 QL=60 EA/30 DíasNUCYNTA 150MG ER TAB 1 QL=60 EA/30 DíasNUCYNTA 200MG ER TAB 1 QL=60 EA/30 DíasNUCYNTA 250MG ER TAB 1 QL=60 EA/30 DíasNUCYNTA 50MG ER TAB 1 QL=60 EA/30 Díasoxycodone 10mg tab 1 QL=180 EA/30 Díasoxycodone 15mg tab 1 QL=180 EA/30 Díasoxycodone 1mg/ml oral soln 1 QL=5400 ML/30 Díasoxycodone 20mg tab 1 QL=180 EA/30 Díasoxycodone 20mg/ml oral soln 1 QL=270 ML/30 Díasoxycodone 30mg tab 1 QL=180 EA/30 Díasoxycodone 5mg cap 1 QL=360 EA/30 Díasoxycodone 5mg tab 1 QL=360 EA/30 Díasoxymorphone 10mg tab 1 QL=360 EA/30 Díasoxymorphone 5mg tab 1 QL=360 EA/30 Díastramadol 100mg er tab 1 QL=60 EA/30 Díastramadol 100mg er tab (matrix delivery) 1 QL=60 EA/30 Díastramadol 200mg er tab 1 QL=60 EA/30 Díastramadol 200mg er tab (matrix delivery) 1 QL=60 EA/30 Díastramadol 300mg er tab 1 QL=60 EA/30 Díastramadol 300mg er tab (matrix delivery) 1 QL=60 EA/30 Díastramadol 50mg tab 1 QL=240 EA/30 DíasXTAMPZA 13.5MG ER CAP 1 QL=120 EA/30 DíasXTAMPZA 18MG ER CAP 1 QL=120 EA/30 DíasXTAMPZA 27MG ER CAP 1 QL=120 EA/30 Días


15


Requisitos/Límites

XTAMPZA 36MG ER CAP 1 QL=120 EA/30 DíasXTAMPZA 9MG ER CAP 1 QL=120 EA/30 Días

OPIOID COMBINATIONSacetaminophen 21.7mg/ml/hydrocodone bitartrate0.5mg/ml oral soln

1 QL=5400 ML/30 Días

acetaminophen 24mg/ml/codeine phosphate 2.4mg/mloral soln

1 QL=4980 ML/30 Días

acetaminophen 300mg/codeine phosphate 15mg tab 1 QL=390 EA/30 Díasacetaminophen 300mg/codeine phosphate 30mg tab 1 QL=390 EA/30 Díasacetaminophen 300mg/codeine phosphate 60mg tab 1 QL=390 EA/30 Díasacetaminophen 300mg/hydrocodone bitartrate 10mg tab 1 QL=390 EA/30 Díasacetaminophen 300mg/hydrocodone bitartrate 5mg tab 1 QL=390 EA/30 Díasacetaminophen 300mg/hydrocodone bitartrate 7.5mgtab

1 QL=390 EA/30 Días

acetaminophen 325mg/hydrocodone bitartrate 10mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/hydrocodone bitartrate 5mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/hydrocodone bitartrate 7.5mgtab

1 QL=360 EA/30 Días

acetaminophen 325mg/oxycodone 10mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/oxycodone 2.5mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/oxycodone 5mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/oxycodone 7.5mg tab 1 QL=360 EA/30 Díasacetaminophen 325mg/tramadol 37.5mg tab 1 QL=360 EA/30 Díasaspirin 325mg/oxycodone 4.84mg tab 1 QL=360 EA/30 Díasendocet 10-325mg tab 1 QL=360 EA/30 Díasendocet 5-325mg tab 1 QL=360 EA/30 Díasendocet 7.5-325mg tab 1 QL=360 EA/30 Díashydrocodone 10mg/ibuprofen 200mg tab 1 QL=480 EA/30 Díashydrocodone 5mg/ibuprofen 200mg tab 1 QL=480 EA/30 Díashydrocodone bitartrate 7.5mg/ibuprofen 200mg tab 1 QL=480 EA/30 DíasIBUPROFEN 400MG/OXYCODONE 5MG TAB 1 QL=240 EA/30 Díaslorcet 10-325mg tab 1 QL=360 EA/30 Díaslorcet 5-325mg tab 1 QL=360 EA/30 Díaslorcet 7.5-325mg tab 1 QL=360 EA/30 Días

OPIOID PARTIAL AGONISTSbuprenorphine 2mg sl tab 1buprenorphine 2mg/naloxone 0.5mg sl tab 1buprenorphine 8mg sl tab 1buprenorphine 8mg/naloxone 2mg sl tab 1buprenorphine/naloxone 12-3mg strip 1buprenorphine/naloxone 2-0.5mg strip 1


16


Requisitos/Límites

buprenorphine/naloxone 4-1mg strip 1buprenorphine/naloxone 8-2mg strip 1butorphanol tartrate 10mg/ml nasal spray 1 QL=10 ML/30 DíasZUBSOLV 11.4-2.9MG SL TAB 1 QL=60 EA/30 DíasZUBSOLV 1.4-0.36MG SL TAB 1 QL=90 EA/30 DíasZUBSOLV 2.9-0.71MG SL TAB 1 QL=90 EA/30 DíasZUBSOLV 5.7-1.4MG SL TAB 1 QL=90 EA/30 DíasZUBSOLV 8.6-2.1MG SL TAB 1 QL=60 EA/30 Días

ANDROGENS-ANABOLICANABOLIC STEROIDS

ANADROL-50 50MG TAB 1oxandrolone 10mg tab 1oxandrolone 2.5mg tab 1

ANDROGENSANDRODERM 2MG/24HR PATCH 1 PA QL=60 EA/30 DíasANDRODERM 4MG/24HR PATCH 1 PA QL=30 EA/30 Díasdanazol 100mg cap 1danazol 200mg cap 1danazol 50mg cap 1testosterone 1% (25mg) gel 1 PA QL=300 GM/30 Díastestosterone 1% (50mg) gel 1 PA QL=300 GM/30 DíasTESTOSTERONE 1% GEL PUMP 1 PA QL=300 GM/30 Díastestosterone 1.62% (1.25gm) gel 1 PA QL=75 GM/30 Díastestosterone 1.62% (2.5gm) gel 1 PA QL=150 GM/30 Díastestosterone 1.62% gel pump 1 PA QL=150 GM/30 Díastestosterone cypionate (1ml) 200mg/ml inj 1testosterone cypionate 100mg/ml inj 1testosterone cypionate 200mg/ml inj 1testosterone enanthate 200mg/ml inj 1

ANORECTAL AGENTSINTRARECTAL STEROIDS

hydrocortisone 1.67mg/ml enema 1UCERIS 2MG/ACT FOAM 1 PA

RECTAL COMBINATIONShydrocortisone/pramoxine 1-1% rectal cream 1

RECTAL STEROIDSprocto-med 2.5% cream 1procto-pak 1% rectal cream 1proctosol 2.5% cream 1proctozone hc 2.5% cream 1


17


Requisitos/Límites

VASODILATING AGENTSRECTIV 0.4% RECTAL OINTMENT 1 QL=30 GM/30 Días

ANTHELMINTICSANTHELMINTICS

albendazole 200mg tab 1 NDSBENZNIDAZOLE 100MG TAB 1 PABENZNIDAZOLE 12.5MG TAB 1 PAivermectin 3mg tab 1

ANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.

metronidazole 250mg tab 1metronidazole 375mg cap 1metronidazole 500mg tab 1metronidazole 5mg/ml inj 1NEBUPENT 300MG INH SOLN 1 PA BvDPENTAM 300MG INJ 1pentamidine isethionate 300mg inj 1pentamidine isethionate 50mg/ml inh soln 1 PA BvDtinidazole 250mg tab 1tinidazole 500mg tab 1trimethoprim 100mg tab 1XIFAXAN 200MG TAB 1 PA QL=9 EA/3 DíasXIFAXAN 550MG TAB 1 PA QL=60 EA/30 Días

ANTI-INFECTIVE MISC. - COMBINATIONSsulfamethoxazole 400mg/trimethoprim 80mg tab 1sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp 1sulfamethoxazole 800mg/trimethoprim 160mg tab 1

ANTIPROTOZOAL AGENTSALINIA 100MG/5ML SUSP 1 PA QL=150 ML/3 DíasALINIA 500MG TAB 1 PA QL=6 EA/3 Díasatovaquone 150mg/ml susp 1

CARBAPENEMScilastatin 2.5mg/ml/imipenem 2.5mg/ml inj 1cilastatin 5mg/ml/imipenem 5mg/ml inj 1ertapenem 1gm inj 1meropenem 1gm inj 1meropenem 500mg inj 1

CYCLIC LIPOPEPTIDESDAPTOMYCIN 350MG INJ 1 NDSdaptomycin 500mg inj 1 NDS


18


Requisitos/Límites

GLYCOPEPTIDESDALVANCE 500MG INJ 1 NDSFIRVANQ 25MG/ML ORAL SOLN 1FIRVANQ 50MG/ML ORAL SOLN 1vancomycin 100mg/ml inj 1vancomycin 125mg cap 1 QL=120 EA/30 Díasvancomycin 250mg cap 1 QL=120 EA/30 DíasVANCOMYCIN 250MG INJ 1vancomycin 50mg/ml inj 1VANCOMYCIN 50MG/ML ORAL SOLN 1vancomycin 5mg/ml inj 1vancomycin 750mg inj 1

LEPROSTATICSdapsone 100mg tab 1dapsone 25mg tab 1

LINCOSAMIDESclindamycin 12mg/ml inj 1clindamycin 150mg cap 1clindamycin 150mg/ml (2ml) inj 1clindamycin 150mg/ml (4ml) inj 1clindamycin 150mg/ml (6ml) inj 1clindamycin 15mg/ml oral soln 1clindamycin 18mg/ml inj 1clindamycin 300mg cap 1clindamycin 6mg/ml inj 1clindamycin 75mg cap 1

MONOBACTAMSaztreonam 333mg/ml inj 1CAYSTON 75MG INH SOLN 1 NDS PA

OXAZOLIDINONESlinezolid 20mg/ml susp 1 PAlinezolid 2mg/ml inj 1 NDS PAlinezolid 600mg tab 1 PASIVEXTRO 200MG INJ 1 NDS PA QL=6 EA/6 DíasSIVEXTRO 200MG TAB 1 NDS PA QL=6 EA/6 Días

POLYMYXINScolistin 75mg/ml inj 1polymyxin b 250000unit/ml inj 1

ANTIANGINAL AGENTSANTIANGINALS-OTHER


19


Requisitos/Límites

ranolazine 1000mg er tab 1ranolazine 500mg er tab 1

NITRATESisosorbide dinitrate 10mg tab 1isosorbide dinitrate 20mg tab 1ISOSORBIDE DINITRATE 30MG TAB 1isosorbide dinitrate 5mg tab 1isosorbide mononitrate 10mg tab 1isosorbide mononitrate 120mg er tab 1isosorbide mononitrate 20mg tab 1isosorbide mononitrate 30mg er tab 1isosorbide mononitrate 60mg er tab 1minitran 0.1mg/hr patch 1minitran 0.2mg/hr patch 1minitran 0.4mg/hr patch 1minitran 0.6mg/hr patch 1NITRO-BID 2% OINTMENT 1NITRO-DUR 0.3MG/HR PATCH 1NITRO-DUR 0.8MG/HR PATCH 1nitroglycerin 0.1mg/hr patch 1nitroglycerin 0.2mg/hr patch 1nitroglycerin 0.3mg sl tab 1nitroglycerin 0.4mg sl tab 1nitroglycerin 0.4mg/act spray 1nitroglycerin 0.4mg/hr patch 1nitroglycerin 0.6mg sl tab 1nitroglycerin 0.6mg/hr patch 1

ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.

buspirone 10mg tab 1buspirone 15mg tab 1buspirone 30mg tab 1buspirone 5mg tab 1buspirone 7.5mg tab 1hydroxyzine 10mg tab 1hydroxyzine 25mg tab 1hydroxyzine 2mg/ml oral soln 1hydroxyzine 50mg tab 1HYDROXYZINE PAMOATE 100MG CAP 1hydroxyzine pamoate 25mg cap 1


20


Requisitos/Límites

hydroxyzine pamoate 50mg cap 1BENZODIAZEPINES

alprazolam 0.25mg odt 1alprazolam 0.25mg tab 1alprazolam 0.5mg er tab 1alprazolam 0.5mg odt 1alprazolam 0.5mg tab 1alprazolam 1mg er tab 1alprazolam 1mg odt 1alprazolam 1mg tab 1alprazolam 2mg er tab 1alprazolam 2mg odt 1alprazolam 2mg tab 1alprazolam 3mg er tab 1chlordiazepoxide 10mg cap 1chlordiazepoxide 25mg cap 1chlordiazepoxide 5mg cap 1clorazepate dipotassium 15mg tab 1clorazepate dipotassium 3.75mg tab 1clorazepate dipotassium 7.5mg tab 1diazepam 10mg tab 1DIAZEPAM 1MG/ML ORAL SOLN 1diazepam 2mg tab 1diazepam 5mg tab 1diazepam 5mg/ml oral soln 1lorazepam 0.5mg tab 1lorazepam 1mg tab 1lorazepam 2mg tab 1lorazepam 2mg/ml conc 1OXAZEPAM 10MG CAP 1oxazepam 15mg cap 1OXAZEPAM 30MG CAP 1

ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A

disopyramide 100mg cap 1 PAdisopyramide 150mg cap 1 PANORPACE 100MG ER CAP 1 PANORPACE 150MG ER CAP 1 PAquinidine gluconate 324mg er tab 1QUINIDINE SULFATE 200MG TAB 1


21


Requisitos/Límites

QUINIDINE SULFATE 300MG TAB 1ANTIARRHYTHMICS TYPE I-C

flecainide acetate 100mg tab 1flecainide acetate 150mg tab 1flecainide acetate 50mg tab 1propafenone 150mg tab 1propafenone 225mg er cap 1propafenone 225mg tab 1propafenone 300mg tab 1propafenone 325mg er cap 1propafenone 425mg sr cap 1

ANTIARRHYTHMICS TYPE IIIamiodarone 200mg tab 1amiodarone 400mg tab 1dofetilide 125mcg cap 1dofetilide 250mcg cap 1dofetilide 500mcg cap 1MULTAQ 400MG TAB 1pacerone 200mg tab 1pacerone 400mg tab 1

ANTIASTHMATIC AND BRONCHODILATOR AGENTSANTI-INFLAMMATORY AGENTS

cromolyn sodium 10mg/ml inh soln 1 PA BvDANTIASTHMATIC - MONOCLONAL ANTIBODIES

DUPIXENT 200MG/ML PF SYRINGE 1 NDS PAFASENRA 30MG/ML AUTO-INJECTOR 1 PAFASENRA 30MG/ML SYRINGE 1 PANUCALA 100MG INJ 1 NDS PANUCALA 100MG/ML AUTO-INJECTOR 1 NDS PANUCALA 100MG/ML SYRINGE 1 NDS PAXOLAIR 150MG INJ 1 NDS PAXOLAIR 150MG/ML PF INJ 1 NDS PAXOLAIR 75MG/0.5ML PF INJ 1 NDS PA

BRONCHODILATORS - ANTICHOLINERGICSATROVENT 17MCG INH 1INCRUSE 62.5MCG INH 1ipratropium bromide 0.02% inh soln 1 PA BvDLONHALA 0.0025% INH SOLN 1 STSPIRIVA 1.25MCG RESPIMAT INH 1 ST QL=4 GM/30 Días

LEUKOTRIENE MODULATORS


22


Requisitos/Límites

montelukast 10mg tab 1montelukast 4mg chew tab 1montelukast 4mg granules 1montelukast 5mg chew tab 1zafirlukast 10mg tab 1zafirlukast 20mg tab 1

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORSDALIRESP 250MCG TAB 1DALIRESP 500MCG TAB 1

STEROID INHALANTSARNUITY 100MCG INH 1 QL=30 EA/30 DíasARNUITY 200MCG INH 1 QL=30 EA/30 DíasARNUITY 50MCG INH 1 QL=30 EA/30 DíasASMANEX 100MCG (120ACT) HFA INH 1 QL=13 GM/30 DíasASMANEX 110MCG (30ACT) INH 1 QL=1 EA/30 DíasASMANEX 200MCG (120ACT) HFA INH 1 QL=13 GM/30 DíasASMANEX 220MCG (120ACT) INH 1 QL=1 EA/30 DíasASMANEX 220MCG (30ACT) INH 1 QL=1 EA/30 DíasASMANEX 220MCG (60ACT) INH 1 QL=1 EA/30 Díasbudesonide 0.125mg/ml inh soln 1 PA BvD QL=120 ML/30 Díasbudesonide 0.25mg/ml inh soln 1 PA BvD QL=120 ML/30 Díasbudesonide 0.5mg/ml inh soln 1 PA BvD QL=120 ML/30 DíasFLOVENT 100MCG DISKUS 1 QL=60 EA/30 DíasFLOVENT 110MCG HFA INH 1 QL=24 GM/30 DíasFLOVENT 220MCG HFA INH 1 QL=24 GM/30 DíasFLOVENT 250MCG DISKUS 1 QL=60 EA/30 DíasFLOVENT 44MCG HFA INH 1 QL=21.20 GM/30 DíasFLOVENT 50MCG DISKUS 1 QL=60 EA/30 Días

SYMPATHOMIMETICSADVAIR 115-21MCG HFA INH 1 QL=12 GM/30 DíasADVAIR 230-21MCG HFA INH 1 QL=12 GM/30 DíasADVAIR 45-21MCG HFA INH 1 QL=12 GM/30 Díasalbuterol 0.21mg/ml (0.63mg/3ml) inh soln 1 PA BvDalbuterol 0.417mg/ml (1.25mg/3ml) inh soln 1 PA BvDalbuterol 0.4mg/ml (2mg/5ml) oral oral soln 1albuterol 0.83mg/ml (0.083%) inh soln 1 PA BvDalbuterol 1mg/ml (0.5%) inh soln 1 PA BvDalbuterol 2mg tab 1ALBUTEROL 4MG ER TAB 1albuterol 4mg tab 1


23


Requisitos/Límites

ALBUTEROL 8MG ER TAB 1ANORO 62.5-25MCG ELLIPTA INH 1 QL=60 EA/30 DíasBREO 100-25MCG ELLIPTA INH 1 QL=60 EA/30 DíasBREO 200-25MCG ELLIPTA INH 1 QL=60 EA/30 DíasCOMBIVENT RESPIMAT 20-100MCG INH 1DULERA 100-5MCG INH 1 QL=13 GM/30 DíasDULERA 200-5MCG INH 1 QL=13 GM/30 Díasfluticasone propionate/salmeterol 100-50mcg/act drypowder inh

1 QL=60 EA/30 Días

fluticasone propionate/salmeterol 250-50mcg/act drypowder inh

1 QL=60 EA/30 Días

fluticasone propionate/salmeterol 500-50mcg/act drypowder inh

1 QL=60 EA/30 Días

FLUTICASONE PROPIONATE/SALMETEROLXINAFOATE 113-14MCG/ACT POWDER INH

1 QL=1 EA/30 Días


1 QL=1 EA/30 Días


1 QL=1 EA/30 Días

ipratropium/albuterol 0.5-2.5mg/3ml inh soln 1 PA BvDlevalbuterol 0.31mg inh soln 1 PA BvDlevalbuterol 0.63mg inh soln 1 PA BvDlevalbuterol 1.25mg inh soln 1 PA BvDlevalbuterol 2.5mg inh soln 1 PA BvDMETAPROTERENOL SULFATE 2MG/ML ORALSOLN

1

SEREVENT 50MCG/DOSE INH 1STIOLTO 2.5-2.5MCG INH 1 QL=4 GM/30 Díasterbutaline sulfate 2.5mg tab 1terbutaline sulfate 5mg tab 1TRELEGY 62.5-25MCG ELLIPTA INH 1 QL=60 EA/30 DíasVENTOLIN 108MCG INH 1 QL=36 GM/30 Díaswixela 100-50mcg inh 1 QL=60 EA/30 Díaswixela 250-50mcg inh 1 QL=60 EA/30 Díaswixela 500-50mcg inh 1 QL=60 EA/30 Días

XANTHINEStheophylline 300mg er tab 1theophylline 400mg er tab 1theophylline 5.33mg/ml oral soln 1theophylline 600mg er tab 1

ANTICOAGULANTS


24


Requisitos/Límites

COUMARIN ANTICOAGULANTSjantoven 10mg tab 1jantoven 1mg tab 1jantoven 2.5mg tab 1jantoven 2mg tab 1jantoven 3mg tab 1jantoven 4mg tab 1jantoven 5mg tab 1jantoven 6mg tab 1jantoven 7.5mg tab 1warfarin sodium 10mg tab 1warfarin sodium 1mg tab 1warfarin sodium 2.5mg tab 1warfarin sodium 2mg tab 1warfarin sodium 3mg tab 1warfarin sodium 4mg tab 1warfarin sodium 5mg tab 1warfarin sodium 6mg tab 1warfarin sodium 7.5mg tab 1

DIRECT FACTOR XA INHIBITORSELIQUIS 2.5MG TAB 1ELIQUIS 30-DAY STARTER PACK 1ELIQUIS 5MG TAB 1XARELTO 10MG TAB 1XARELTO 15MG TAB 1XARELTO 2.5MG TAB 1XARELTO 20MG TAB 1XARELTO STARTER PACK 1

HEPARINS AND HEPARINOID-LIKE AGENTSenoxaparin sodium 100mg/1ml syringe 1 QL=60 ML/30 Díasenoxaparin sodium 120mg/0.8ml syringe 1 QL=48 ML/30 Díasenoxaparin sodium 150mg/1ml syringe 1 QL=60 ML/30 Díasenoxaparin sodium 30mg/0.3ml syringe 1 QL=18 ML/30 Díasenoxaparin sodium 40mg/0.4ml syringe 1 QL=24 ML/30 Díasenoxaparin sodium 60mg/0.6ml syringe 1 QL=36 ML/30 Díasenoxaparin sodium 80mg/0.8ml syringe 1 QL=48 ML/30 Díasfondaparinux sodium 12.5mg/ml (0.4ml) syringe 1fondaparinux sodium 12.5mg/ml (0.6ml) syringe 1fondaparinux sodium 12.5mg/ml (0.8ml) syringe 1fondaparinux sodium 5mg/ml syringe 1


25


Requisitos/Límites

FRAGMIN 10000UNIT/ML SYRINGE 1FRAGMIN 12500UNIT/0.5ML SYRINGE 1FRAGMIN 15000UNIT/0.6ML SYRINGE 1FRAGMIN 18000UNIT/0.72ML SYRINGE 1FRAGMIN 2500UNIT/0.2ML SYRINGE 1FRAGMIN 5000UNIT/0.2ML SYRINGE 1FRAGMIN 7500UNIT/0.3ML SYRINGE 1FRAGMIN 95000UNIT/3.8ML INJ 1heparin sodium porcine 10000unit/ml inj 1 PA BvDheparin sodium porcine 1000unit/ml inj 1 PA BvDheparin sodium porcine 20000unit/ml inj 1 PA BvDheparin sodium porcine 5000unit/ml inj 1 PA BvD

THROMBIN INHIBITORSPRADAXA 110MG CAP 1PRADAXA 150MG CAP 1PRADAXA 75MG CAP 1

ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA 0.5MG/ML SUSP 1 PA NSOFYCOMPA 10MG TAB 1 PA NSOFYCOMPA 12MG TAB 1 PA NSOFYCOMPA 2MG TAB 1 PA NSOFYCOMPA 4MG TAB 1 PA NSOFYCOMPA 6MG TAB 1 PA NSOFYCOMPA 8MG TAB 1 PA NSO

ANTICONVULSANTS - BENZODIAZEPINESclobazam 10mg tab 1clobazam 2.5mg/ml susp 1clobazam 20mg tab 1clonazepam 0.125mg odt 1clonazepam 0.25mg odt 1clonazepam 0.5mg odt 1clonazepam 0.5mg tab 1clonazepam 1mg odt 1clonazepam 1mg tab 1clonazepam 2mg odt 1clonazepam 2mg tab 1DIASTAT 10MG APPLICATOR 1DIASTAT 2.5MG APPLICATOR 1DIASTAT 20MG APPLICATOR 1


26


Requisitos/Límites

DIAZEPAM 2.5MG/0.5ML RECTAL GEL 1DIAZEPAM 20MG/4ML RECTAL GEL 1NAYZILAM 5MG/0.1ML NASAL SPRAY 1SYMPAZAN 10MG STRIP 1 ST_NSOSYMPAZAN 20MG STRIP 1 ST_NSOSYMPAZAN 5MG STRIP 1 ST_NSOVALTOCO 10MG DOSE KIT 10MG/0.1ML PACK 1VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK 1VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK 1VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK 1

ANTICONVULSANTS - MISC.APTIOM 200MG TAB 1 PA NSOAPTIOM 400MG TAB 1 PA NSOAPTIOM 600MG TAB 1 PA NSOAPTIOM 800MG TAB 1 PA NSOBANZEL 200MG TAB 1BANZEL 400MG TAB 1BANZEL 40MG/ML SUSP 1BRIVIACT 100MG TAB 1 PA NSO QL=60 EA/30 DíasBRIVIACT 10MG TAB 1 PA NSO QL=60 EA/30 DíasBRIVIACT 10MG/ML ORAL SOLN 1 PA NSOBRIVIACT 25MG TAB 1 PA NSO QL=60 EA/30 DíasBRIVIACT 50MG TAB 1 PA NSO QL=60 EA/30 DíasBRIVIACT 75MG TAB 1 PA NSO QL=60 EA/30 Díascarbamazepine 100mg chew tab 1carbamazepine 100mg er cap 1carbamazepine 100mg er tab 1carbamazepine 200mg er cap 1carbamazepine 200mg er tab 1carbamazepine 200mg tab 1carbamazepine 20mg/ml susp 1carbamazepine 300mg er cap 1carbamazepine 400mg er tab 1EPIDIOLEX 100MG/ML ORAL SOLN 1 PA NSOepitol 200mg tab 1gabapentin 100mg cap 1gabapentin 300mg cap 1gabapentin 400mg cap 1gabapentin 50mg/ml oral soln 1gabapentin 600mg tab 1


27


Requisitos/Límites

gabapentin 800mg tab 1LAMICTAL XR BLUE KIT 1LAMICTAL XR GREEN KIT 1LAMICTAL XR ORANGE KIT 1lamotrigine 100mg er tab 1lamotrigine 100mg odt 1lamotrigine 100mg tab 1lamotrigine 150mg tab 1lamotrigine 200mg er tab 1lamotrigine 200mg odt 1lamotrigine 200mg tab 1lamotrigine 250mg er tab 1lamotrigine 25mg (35) tab starter pack 1lamotrigine 25mg chew tab 1lamotrigine 25mg er tab 1lamotrigine 25mg odt 1lamotrigine 25mg tab 1lamotrigine 300mg er tab 1lamotrigine 50mg er tab 1lamotrigine 50mg odt 1lamotrigine 5mg chew tab 1lamotrigine tab 25mg (42)/100mg (7) starter pack 1lamotrigine tab 25mg (84)/100mg (14) starter pack 1levetiracetam 1000mg tab 1levetiracetam 100mg/ml oral soln 1levetiracetam 250mg tab 1levetiracetam 500mg er tab 1levetiracetam 500mg tab 1levetiracetam 750mg er tab 1levetiracetam 750mg tab 1oxcarbazepine 150mg tab 1oxcarbazepine 300mg tab 1oxcarbazepine 600mg tab 1oxcarbazepine 60mg/ml susp 1OXTELLAR 150MG XR TAB 1OXTELLAR 300MG XR TAB 1OXTELLAR 600MG XR TAB 1pregabalin 100mg cap 1pregabalin 150mg cap 1pregabalin 200mg cap 1


28


Requisitos/Límites

pregabalin 20mg/ml oral soln 1pregabalin 225mg cap 1pregabalin 25mg cap 1pregabalin 300mg cap 1pregabalin 50mg cap 1pregabalin 75mg cap 1primidone 250mg tab 1primidone 50mg tab 1QUDEXY 100MG XR CAP 1 PA NSOQUDEXY 150MG XR CAP 1 PA NSOQUDEXY 200MG XR CAP 1 PA NSOQUDEXY 25MG XR CAP 1 PA NSOQUDEXY 50MG XR CAP 1 PA NSOroweepra 1000mg tab 1roweepra 500mg er tab 1roweepra 500mg tab 1roweepra 750mg er tab 1roweepra 750mg tab 1SPRITAM 1000MG ODT 1 PA NSOSPRITAM 250MG ODT 1 PA NSOSPRITAM 500MG ODT 1 PA NSOSPRITAM 750MG ODT 1 PA NSOTOPIRAMATE 100MG ER CAP 1 PA NSOtopiramate 100mg tab 1TOPIRAMATE 150MG ER CAP 1 PA NSOtopiramate 15mg cap 1TOPIRAMATE 200MG ER CAP 1 PA NSOtopiramate 200mg tab 1topiramate 25mg cap 1TOPIRAMATE 25MG ER CAP 1 PA NSOtopiramate 25mg tab 1TOPIRAMATE 50MG ER CAP 1 PA NSOtopiramate 50mg tab 1TROKENDI 100MG XR CAP 1 PA NSOTROKENDI 200MG XR CAP 1 PA NSOTROKENDI 25MG XR CAP 1 PA NSOTROKENDI 50MG XR CAP 1 PA NSOVIMPAT 100MG TAB 1 QL=60 EA/30 DíasVIMPAT 10MG/ML ORAL SOLN 1VIMPAT 150MG TAB 1 QL=60 EA/30 Días


29


Requisitos/Límites

VIMPAT 200MG TAB 1 QL=60 EA/30 DíasVIMPAT 50MG TAB 1 QL=60 EA/30 Díaszonisamide 100mg cap 1zonisamide 25mg cap 1zonisamide 50mg cap 1

CARBAMATESfelbamate 120mg/ml susp 1felbamate 400mg tab 1felbamate 600mg tab 1

GABA MODULATORStiagabine 12mg tab 1tiagabine 16mg tab 1tiagabine 2mg tab 1tiagabine 4mg tab 1vigabatrin 500mg tab 1 NDS PA NSOvigabatrin 50mg/ml oral soln 1 NDS PA NSOvigadrone 500mg oral soln 1 NDS PA NSO

HYDANTOINSDILANTIN 30MG ER CAP 1PEGANONE 250MG TAB 1phenytoin 25mg/ml susp 1phenytoin 50mg chew tab 1phenytoin sodium 100mg er cap 1phenytoin sodium 200mg er cap 1phenytoin sodium 300mg er cap 1

SUCCINIMIDESCELONTIN 300MG CAP 1ethosuximide 250mg cap 1ethosuximide 50mg/ml oral soln 1

VALPROIC ACIDdivalproex sodium 125mg dr cap 1divalproex sodium 125mg dr tab 1divalproex sodium 250mg dr tab 1divalproex sodium 250mg er tab 1divalproex sodium 500mg dr tab 1divalproex sodium 500mg er tab 1valproic acid 250mg cap 1valproic acid 50mg/ml oral soln 1

ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)


30


Requisitos/Límites

mirtazapine 15mg odt 1mirtazapine 15mg tab 1mirtazapine 30mg odt 1mirtazapine 30mg tab 1mirtazapine 45mg odt 1mirtazapine 45mg tab 1mirtazapine 7.5mg tab 1

ANTIDEPRESSANTS - MISC.APLENZIN 174MG ER TAB 1 ST_NSOAPLENZIN 348MG ER TAB 1 ST_NSOAPLENZIN 522MG ER TAB 1 ST_NSObupropion 100mg sr tab 1bupropion 100mg tab 1bupropion 150mg sr (12 hr) tab 1bupropion 150mg xl (24 hr) tab 1bupropion 200mg sr tab 1bupropion 300mg xl tab 1bupropion 75mg tab 1MAPROTILINE 25MG TAB 1MAPROTILINE 50MG TAB 1MAPROTILINE 75MG TAB 1

MONOAMINE OXIDASE INHIBITORS (MAOIS)EMSAM 12MG/24HR PATCH 1EMSAM 6MG/24HR PATCH 1EMSAM 9MG/24HR PATCH 1MARPLAN 10MG TAB 1phenelzine 15mg tab 1tranylcypromine 10mg tab 1

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)citalopram 10mg tab 1citalopram 20mg tab 1citalopram 2mg/ml oral soln 1citalopram 40mg tab 1escitalopram 10mg tab 1escitalopram 1mg/ml oral soln 1escitalopram 20mg tab 1escitalopram 5mg tab 1fluoxetine 10mg cap 1fluoxetine 10mg tab 1fluoxetine 20mg cap 1


31


Requisitos/Límites

fluoxetine 20mg tab 1fluoxetine 40mg cap 1fluoxetine 4mg/ml oral soln 1fluvoxamine maleate 100mg er cap 1 ST_NSOfluvoxamine maleate 100mg tab 1fluvoxamine maleate 150mg er cap 1 ST_NSOfluvoxamine maleate 25mg tab 1fluvoxamine maleate 50mg tab 1paroxetine 10mg tab 1 PA NSOparoxetine 12.5mg er tab 1 PA NSOparoxetine 20mg tab 1 PA NSOparoxetine 25mg er tab 1 PA NSOparoxetine 30mg tab 1 PA NSOparoxetine 37.5mg er tab 1 PA NSOparoxetine 40mg tab 1 PA NSOPAXIL 10MG/5ML SUSP 1 PA NSOPEXEVA 10MG TAB 1 PA NSOPEXEVA 20MG TAB 1 PA NSOPEXEVA 30MG TAB 1 PA NSOPEXEVA 40MG TAB 1 PA NSOsertraline 100mg tab 1sertraline 20mg/ml oral soln 1sertraline 25mg tab 1sertraline 50mg tab 1

SEROTONIN MODULATORSNEFAZODONE 100MG TAB 1NEFAZODONE 150MG TAB 1NEFAZODONE 200MG TAB 1NEFAZODONE 250MG TAB 1NEFAZODONE 50MG TAB 1trazodone 100mg tab 1trazodone 150mg tab 1trazodone 300mg tab 1trazodone 50mg tab 1TRINTELLIX 10MG TAB 1 ST_NSO QL=30 EA/30 DíasTRINTELLIX 20MG TAB 1 ST_NSO QL=30 EA/30 DíasTRINTELLIX 5MG TAB 1 ST_NSO QL=30 EA/30 DíasVIIBRYD 10/20MG STARTER PACK 1 ST_NSO QL=30 EA/30 DíasVIIBRYD 10MG TAB 1 ST_NSO QL=30 EA/30 DíasVIIBRYD 20MG TAB 1 ST_NSO QL=30 EA/30 Días


32


Requisitos/Límites

VIIBRYD 40MG TAB 1 ST_NSO QL=30 EA/30 DíasSEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

desvenlafaxine succinate 100mg er tab 1desvenlafaxine succinate 25mg er tab 1desvenlafaxine succinate 50mg er tab 1DRIZALMA 20MG DR CAP 1 ST_NSODRIZALMA 30MG DR CAP 1 ST_NSODRIZALMA 40MG DR CAP 1 ST_NSODRIZALMA 60MG DR CAP 1 ST_NSOduloxetine 20mg dr cap 1duloxetine 30mg dr cap 1duloxetine 40mg dr cap 1 ST_NSO QL=30 EA/30 Díasduloxetine 60mg dr cap 1FETZIMA 120MG ER CAP 1 ST_NSO QL=30 EA/30 DíasFETZIMA 20MG ER CAP 1 ST_NSO QL=30 EA/30 DíasFETZIMA 40MG ER CAP 1 ST_NSO QL=30 EA/30 DíasFETZIMA 80MG ER CAP 1 ST_NSO QL=30 EA/30 DíasFETZIMA PACK 1 ST_NSO QL=30 EA/30 Díasvenlafaxine 100mg tab 1venlafaxine 150mg er cap 1venlafaxine 25mg tab 1venlafaxine 37.5mg er cap 1venlafaxine 37.5mg tab 1venlafaxine 50mg tab 1venlafaxine 75mg er cap 1venlafaxine 75mg tab 1

TRICYCLIC AGENTSamitriptyline 100mg tab 1 PA NSOamitriptyline 10mg tab 1 PA NSOamitriptyline 150mg tab 1 PA NSOamitriptyline 25mg tab 1 PA NSOamitriptyline 50mg tab 1 PA NSOamitriptyline 75mg tab 1 PA NSOAMOXAPINE 100MG TAB 1 PA NSOAMOXAPINE 150MG TAB 1 PA NSOAMOXAPINE 25MG TAB 1 PA NSOAMOXAPINE 50MG TAB 1 PA NSOclomipramine 25mg cap 1 PA NSOclomipramine 50mg cap 1 PA NSOclomipramine 75mg cap 1 PA NSO


33


Requisitos/Límites

desipramine 100mg tab 1 PA NSOdesipramine 10mg tab 1 PA NSOdesipramine 150mg tab 1 PA NSOdesipramine 25mg tab 1 PA NSOdesipramine 50mg tab 1 PA NSOdesipramine 75mg tab 1 PA NSOdoxepin 100mg cap 1 PA NSOdoxepin 10mg cap 1 PA NSOdoxepin 10mg/ml oral soln 1 PA NSOdoxepin 150mg cap 1 PA NSOdoxepin 25mg cap 1 PA NSOdoxepin 50mg cap 1 PA NSOdoxepin 75mg cap 1 PA NSOimipramine 10mg tab 1 PA NSOimipramine 25mg tab 1 PA NSOimipramine 50mg tab 1 PA NSOimipramine pamoate 100mg cap 1 PA NSOimipramine pamoate 125mg cap 1 PA NSOimipramine pamoate 150mg cap 1 PA NSOimipramine pamoate 75mg cap 1 PA NSOnortriptyline 10mg cap 1nortriptyline 25mg cap 1NORTRIPTYLINE 2MG/ML ORAL SOLN 1nortriptyline 50mg cap 1nortriptyline 75mg cap 1protriptyline 10mg tab 1 PA NSOprotriptyline 5mg tab 1 PA NSOtrimipramine 100mg cap 1 PA NSOtrimipramine 25mg cap 1 PA NSOtrimipramine 50mg cap 1 PA NSO

ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS

acarbose 100mg tab 1acarbose 25mg tab 1acarbose 50mg tab 1miglitol 100mg tab 1miglitol 25mg tab 1miglitol 50mg tab 1

ANTIDIABETIC COMBINATIONSglipizide 2.5mg/metformin 250mg tab 1


34


Requisitos/Límites

glipizide 2.5mg/metformin 500mg tab 1glipizide 5mg/metformin 500mg tab 1glyburide 1.25mg/metformin 250mg tab 1glyburide 2.5mg/metformin 500mg tab 1glyburide 5mg/metformin 500mg tab 1GLYXAMBI 10-5MG TAB 1 QL=30 EA/30 DíasGLYXAMBI 25-5MG TAB 1 QL=30 EA/30 DíasJANUMET 100-1000MG XR TAB 1 QL=30 EA/30 DíasJANUMET 50-1000MG TAB 1 QL=60 EA/30 DíasJANUMET 50-1000MG XR TAB 1 QL=60 EA/30 DíasJANUMET 50-500MG TAB 1 QL=60 EA/30 DíasJANUMET 50-500MG XR TAB 1 QL=60 EA/30 DíasJENTADUETO 2.5-1000MG TAB 1 QL=60 EA/30 DíasJENTADUETO 2.5-1000MG XR TAB 1 QL=30 EA/30 DíasJENTADUETO 2.5-500MG TAB 1 QL=60 EA/30 DíasJENTADUETO 2.5-850MG TAB 1 QL=60 EA/30 DíasJENTADUETO 5-1000MG XR TAB 1 QL=30 EA/30 DíasSYNJARDY 12.5-1000MG TAB 1 QL=60 EA/30 DíasSYNJARDY 12.5-500MG TAB 1 QL=60 EA/30 DíasSYNJARDY 5-1000MG TAB 1 QL=60 EA/30 DíasSYNJARDY 5-500MG TAB 1 QL=60 EA/30 DíasSYNJARDY XR 10-1000MG TAB 1 QL=30 EA/30 DíasSYNJARDY XR 12.5-1000MG TAB 1 QL=60 EA/30 DíasSYNJARDY XR 25-1000MG TAB 1 QL=30 EA/30 DíasSYNJARDY XR 5-1000MG TAB 1 QL=60 EA/30 DíasXIGDUO 10-1000MG XR TAB 1 QL=30 EA/30 DíasXIGDUO 10-500MG XR TAB 1 QL=30 EA/30 DíasXIGDUO 2.5-1000MG XR TAB 1 QL=60 EA/30 DíasXIGDUO 5-1000MG XR TAB 1 QL=60 EA/30 DíasXIGDUO 5-500MG XR TAB 1 QL=30 EA/30 DíasXULTOPHY 100UNIT-3.6MG/ML PEN INJ 1 PA QL=15 ML/30 Días

BIGUANIDESmetformin 1000mg tab 1metformin 500mg er tab 1metformin 500mg tab 1metformin 750mg er tab 1metformin 850mg tab 1

DIABETIC OTHERBAQSIMI 3MG/DOSE NASAL POWDER 1 QL=2 EA/7 DíasGLUCAGEN 1MG INJ 1 QL=2 EA/7 Días


35


Requisitos/Límites

GLUCAGON 1MG INJ 1 QL=2 EA/7 DíasGVOKE 0.5MG/0.1ML SYRINGE 1 QL=.20 ML/7 DíasGVOKE 1MG/0.2ML SYRINGE 1 QL=.40 ML/7 DíasKORLYM 300MG TAB 1 NDS PAPROGLYCEM 50MG/ML SUSP 1

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSJANUVIA 100MG TAB 1 QL=30 EA/30 DíasJANUVIA 25MG TAB 1 QL=30 EA/30 DíasJANUVIA 50MG TAB 1 QL=30 EA/30 DíasTRADJENTA 5MG TAB 1 QL=30 EA/30 Días

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)BYDUREON 2.35MG/ML AUTO-INJECTOR 1 QL=3.40 ML/28 DíasBYDUREON 2MG PEN INJ 1 QL=4 EA/28 DíasOZEMPIC 2MG/1.5ML PEN INJ 1 QL=1.50 ML/28 DíasOZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) 1 QL=3 ML/28 DíasRYBELSUS 14MG TAB 1 QL=30 EA/30 DíasRYBELSUS 3MG TAB 1 QL=30 EA/30 DíasRYBELSUS 7MG TAB 1 QL=30 EA/30 DíasVICTOZA 18MG/3ML PEN INJ 1 QL=9 ML/30 Días

INSULINFIASP 100UNIT/ML CARTRIDGE 1FIASP 100UNIT/ML INJ 1 PA BvDFIASP 100UNIT/ML PEN INJ 1HUMULIN R 500UNIT/ML INJ 1 PA BvDHUMULIN R 500UNIT/ML PEN INJ 1LANTUS 100UNIT/ML INJ 1LANTUS 100UNIT/ML SOLOSTAR 1LEVEMIR 100UNIT/ML FLEXTOUCH 1LEVEMIR 100UNIT/ML INJ 1NOVOLIN 100UNIT/ML INJ 1NOVOLIN N 100UNIT/ML INJ 1NOVOLIN R 100UNIT/ML INJ 1NOVOLOG 100UNIT/ML FLEXPEN 1NOVOLOG 100UNIT/ML INJ 1NOVOLOG 100UNIT/ML PENFILL 1NOVOLOG MIX 100UNIT/ML FLEXPEN 1NOVOLOG MIX 100UNIT/ML INJ 1TOUJEO 300UNIT/ML PEN INJ 1TOUJEO MAX 300UNIT/ML PEN INJ (3ML) 1TRESIBA 100UNIT/ML FLEXTOUCH PEN INJ 1


36


Requisitos/Límites

TRESIBA 100UNIT/ML INJ (VIAL) 1TRESIBA 200UNIT/ML FLEXTOUCH PEN INJ 1

INSULIN SENSITIZING AGENTSAVANDIA 2MG TAB 1AVANDIA 4MG TAB 1pioglitazone 15mg tab 1pioglitazone 30mg tab 1pioglitazone 45mg tab 1

MEGLITINIDE ANALOGUESnateglinide 120mg tab 1nateglinide 60mg tab 1repaglinide 0.5mg tab 1repaglinide 1mg tab 1repaglinide 2mg tab 1

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORSFARXIGA 10MG TAB 1 QL=30 EA/30 DíasFARXIGA 5MG TAB 1 QL=30 EA/30 DíasJARDIANCE 10MG TAB 1 QL=30 EA/30 DíasJARDIANCE 25MG TAB 1 QL=30 EA/30 Días

SULFONYLUREASglimepiride 1mg tab 1glimepiride 2mg tab 1glimepiride 4mg tab 1glipizide 10mg er tab 1glipizide 10mg tab 1glipizide 2.5mg er tab 1glipizide 5mg er tab 1glipizide 5mg tab 1

ANTIDIARRHEAL/PROBIOTIC AGENTSANTIPERISTALTIC AGENTS

atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/mloral soln

1

atropine sulfate 0.025mg/diphenoxylate 2.5mg tab 1loperamide 2mg cap 1

ANTIDOTESANTIDOTES - CHELATING AGENTS

CHEMET 100MG CAP 1FERRIPROX 100MG/ML ORAL SOLN 1 NDS PAJADENU 180MG TAB 1 NDSJADENU 90MG TAB 1 NDS


37


Requisitos/Límites

OPIOID ANTAGONISTSVIVITROL 380MG INJ 1 NDS

ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS

deferasirox 125mg tab for oral susp 1 NDSdeferasirox 250mg tab for oral susp 1 NDSdeferasirox 360mg tab 1 NDSdeferasirox 500mg tab for oral susp 1 NDSdeferasirox 90mg tab 1 NDSFERRIPROX 1000MG TAB 1 NDS PAFERRIPROX 500MG TAB 1 NDS PAJADENU 180MG GRANULE PACKET 1 NDSJADENU 360MG GRANULE PACKET 1 NDSJADENU 360MG TAB 1 NDSJADENU 90MG GRANULE PACKET 1 NDS

OPIOID ANTAGONISTSNALOXONE 0.4MG/ML CARTRIDGE 1 QL=2 ML/2 Díasnaloxone 0.4mg/ml inj 1 QL=2 ML/2 DíasNALOXONE 1MG/ML SYRINGE 1 QL=4 ML/2 Díasnaltrexone 50mg tab 1NARCAN 4MG/0.1ML NASAL SPRAY 1

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

granisetron 1mg tab 1 PA BvD QL=60 EA/30 Díasondansetron 0.8mg/ml oral soln 1 PA BvDondansetron 24mg tab 1 PA BvDondansetron 4mg odt 1 PA BvDondansetron 4mg tab 1 PA BvDondansetron 8mg odt 1 PA BvDondansetron 8mg tab 1 PA BvD

ANTIEMETICS - ANTICHOLINERGICmeclizine 12.5mg tab 1meclizine 25mg tab 1scopolamine 0.0139mg/hr patch 1TRANSDERM SCOP 1MG/3DAYS PATCH 1 QL=10 EA/30 Díastrimethobenzamide 300mg cap 1

ANTIEMETICS - MISCELLANEOUSdronabinol 10mg cap 1 PAdronabinol 2.5mg cap 1 PAdronabinol 5mg cap 1 PA


38


Requisitos/Límites

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTSaprepitant 125mg cap 1 PA BvD QL=3 EA/2 Díasaprepitant 125mg/80mg pack 1 PA BvD QL=6 EA/4 Díasaprepitant 40mg cap 1 PA BvD QL=3 EA/2 Díasaprepitant 80mg cap 1 PA BvD QL=6 EA/4 DíasVARUBI 90MG TAB 1 PA BvD QL=4 EA/28 Días

ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)

CASPOFUNGIN ACETATE 50MG INJ 1 NDSCASPOFUNGIN ACETATE 70MG INJ 1 NDSERAXIS 100MG INJ 1ERAXIS 50MG INJ 1MYCAMINE 100MG INJ 1MYCAMINE 50MG INJ 1

ANTIFUNGALSABELCET 5MG/ML INJ 1 PA BvDAMBISOME 50MG INJ 1 PA BvDAMPHOTERICIN B 50MG INJ 1 PA BvDflucytosine 250mg cap 1flucytosine 500mg cap 1griseofulvin 125mg tab 1griseofulvin 250mg tab 1griseofulvin 25mg/ml susp 1griseofulvin 500mg tab 1nystatin 500000unit tab 1terbinafine 250mg tab 1

IMIDAZOLE-RELATED ANTIFUNGALSfluconazole 100mg tab 1fluconazole 10mg/ml susp 1fluconazole 150mg tab 1fluconazole 200mg tab 1fluconazole 2mg/ml (100ml) inj 1fluconazole 2mg/ml inj 1fluconazole 40mg/ml susp 1fluconazole 50mg tab 1itraconazole 100mg cap 1 PAketoconazole 200mg tab 1NOXAFIL 100MG DR TAB 1 NDS PANOXAFIL 40MG/ML SUSP 1 PAposaconazole 100mg dr tab 1 NDS PA


39


Requisitos/Límites

voriconazole 200mg inj 1 PAvoriconazole 200mg tab 1 NDS PAvoriconazole 40mg/ml susp 1 PAvoriconazole 50mg tab 1 NDS PA

ANTIHISTAMINESANTIHISTAMINES - NON-SEDATING

cetirizine 1mg/ml oral soln 1desloratadine 5mg tab 1levocetirizine 0.5mg/ml oral soln 1levocetirizine 5mg tab 1

ANTIHISTAMINES - PHENOTHIAZINESphenadoz 12.5mg rectal supp 1promethazine 1.25mg/ml oral soln 1promethazine 12.5mg rectal supp 1promethazine 12.5mg tab 1promethazine 25mg rectal supp 1promethazine 25mg tab 1promethazine 50mg tab 1promethegan 25mg rectal supp 1promethegan 50mg rectal supp 1

ANTIHYPERLIPIDEMICSANTIHYPERLIPIDEMICS - MISC.

omega-3 acid ethyl esters (usp) 1000mg cap 1VASCEPA 1GM CAP 1 QL=120 EA/30 DíasVASCEPA 500MG CAP 1 QL=120 EA/30 Días

BILE ACID SEQUESTRANTScholestyramine resin 4gm sf powder for oral susp 1cholestyramine resin 66.7mg/ml susp 1colesevelam hcl 3.75gm packet 1colesevelam hcl 625mg tab 1colestipol 1000mg tab 1colestipol 5000mg granules 1prevalite 4gm/dose susp 1

FIBRIC ACID DERIVATIVESfenofibrate 134mg cap 1fenofibrate 145mg tab 1FENOFIBRATE 150MG CAP 1fenofibrate 160mg tab 1fenofibrate 200mg cap 1fenofibrate 48mg tab 1


40


Requisitos/Límites

FENOFIBRATE 50MG CAP 1fenofibrate 54mg tab 1fenofibrate 67mg cap 1fenofibric acid 135mg dr cap 1fenofibric acid 45mg dr cap 1gemfibrozil 600mg tab 1

HMG COA REDUCTASE INHIBITORSatorvastatin 10mg tab 1atorvastatin 20mg tab 1atorvastatin 40mg tab 1atorvastatin 80mg tab 1fluvastatin 20mg cap 1fluvastatin 40mg cap 1fluvastatin 80mg er tab 1lovastatin 10mg tab 1lovastatin 20mg tab 1lovastatin 40mg tab 1pravastatin sodium 10mg tab 1pravastatin sodium 20mg tab 1pravastatin sodium 40mg tab 1pravastatin sodium 80mg tab 1rosuvastatin 10mg tab 1rosuvastatin 20mg tab 1rosuvastatin 40mg tab 1rosuvastatin 5mg tab 1simvastatin 10mg tab 1simvastatin 20mg tab 1simvastatin 40mg tab 1simvastatin 5mg tab 1simvastatin 80mg tab 1

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORSezetimibe 10mg tab 1 QL=30 EA/30 Días

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORSJUXTAPID 10MG CAP 1 NDS PAJUXTAPID 20MG CAP 1 NDS PAJUXTAPID 30MG CAP 1 NDS PAJUXTAPID 40MG CAP 1 NDS PAJUXTAPID 5MG CAP 1 NDS PAJUXTAPID 60MG CAP 1 NDS PA

NICOTINIC ACID DERIVATIVES


41


Requisitos/Límites

niacin 1000mg er tab 1niacin 500mg er tab 1niacin 750mg er tab 1

PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORSPRALUENT 150MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 DíasPRALUENT 75MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 DíasREPATHA 120MG/ML CARTRIDGE 1 PA QL=3.50 ML/28 DíasREPATHA 140MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 DíasREPATHA 140MG/ML SYRINGE 1 PA QL=2 ML/28 Días

ANTIHYPERTENSIVESACE INHIBITORS

benazepril 10mg tab 1benazepril 20mg tab 1benazepril 40mg tab 1benazepril 5mg tab 1captopril 100mg tab 1captopril 12.5mg tab 1captopril 25mg tab 1captopril 50mg tab 1enalapril maleate 10mg tab 1enalapril maleate 2.5mg tab 1enalapril maleate 20mg tab 1enalapril maleate 5mg tab 1fosinopril sodium 10mg tab 1fosinopril sodium 20mg tab 1fosinopril sodium 40mg tab 1lisinopril 10mg tab 1lisinopril 2.5mg tab 1lisinopril 20mg tab 1lisinopril 30mg tab 1lisinopril 40mg tab 1lisinopril 5mg tab 1moexipril 15mg tab 1moexipril 7.5mg tab 1perindopril erbumine 2mg tab 1perindopril erbumine 4mg tab 1perindopril erbumine 8mg tab 1QBRELIS 1MG/ML ORAL SOLN 1 PAquinapril 10mg tab 1quinapril 20mg tab 1


42


Requisitos/Límites

quinapril 40mg tab 1quinapril 5mg tab 1ramipril 1.25mg cap 1ramipril 10mg cap 1ramipril 2.5mg cap 1ramipril 5mg cap 1trandolapril 1mg tab 1trandolapril 2mg tab 1trandolapril 4mg tab 1

AGENTS FOR PHEOCHROMOCYTOMADEMSER 250MG CAP 1 NDSphenoxybenzamine 10mg cap 1

ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 150mg tab 1irbesartan 300mg tab 1irbesartan 75mg tab 1losartan potassium 100mg tab 1losartan potassium 25mg tab 1losartan potassium 50mg tab 1olmesartan medoxomil 20mg tab 1olmesartan medoxomil 40mg tab 1olmesartan medoxomil 5mg tab 1telmisartan 20mg tab 1telmisartan 40mg tab 1telmisartan 80mg tab 1valsartan 160mg tab 1valsartan 320mg tab 1valsartan 40mg tab 1valsartan 80mg tab 1

ANTIADRENERGIC ANTIHYPERTENSIVESclonidine 0.00417mg/hr patch 1clonidine 0.00833mg/hr patch 1clonidine 0.0125mg/hr patch 1clonidine 0.1mg tab 1clonidine 0.2mg tab 1clonidine 0.3mg tab 1doxazosin 1mg tab 1doxazosin 2mg tab 1doxazosin 4mg tab 1doxazosin 8mg tab 1


43


Requisitos/Límites

prazosin 1mg cap 1prazosin 2mg cap 1prazosin 5mg cap 1terazosin 10mg cap 1terazosin 1mg cap 1terazosin 2mg cap 1terazosin 5mg cap 1

ANTIHYPERTENSIVE COMBINATIONSamlodipine 10mg/benazepril 20mg cap 1amlodipine 10mg/benazepril 40mg cap 1amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan160mg tab

1

amlodipine 10mg/hydrochlorothiazide 25mg/valsartan160mg tab

1


1

amlodipine 10mg/olmesartan medoxomil 20mg tab 1amlodipine 10mg/olmesartan medoxomil 40mg tab 1amlodipine 10mg/valsartan 160mg tab 1amlodipine 10mg/valsartan 320mg tab 1amlodipine 2.5mg/benazepril 10mg cap 1amlodipine 5mg/benazepril 10mg cap 1amlodipine 5mg/benazepril 20mg cap 1amlodipine 5mg/benazepril 40mg cap 1amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan160mg tab

1


1

amlodipine 5mg/olmesartan medoxomil 20mg tab 1amlodipine 5mg/olmesartan medoxomil 40mg tab 1amlodipine 5mg/valsartan 160mg tab 1amlodipine 5mg/valsartan 320mg tab 1atenolol 100mg/chlorthalidone 25mg tab 1atenolol 50mg/chlorthalidone 25mg tab 1benazepril 10mg/hydrochlorothiazide 12.5mg tab 1benazepril 20mg/hydrochlorothiazide 12.5mg tab 1benazepril 20mg/hydrochlorothiazide 25mg tab 1benazepril 5mg/hydrochlorothiazide 6.25mg tab 1bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mgtab

1


44


Requisitos/Límites

bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mgtab

1

bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mgtab

1

captopril 25mg/hydrochlorothiazide 15mg tab 1CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE25MG TAB

1

captopril 50mg/hydrochlorothiazide 15mg tab 1CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE25MG TAB

1

enalapril maleate 10mg/hydrochlorothiazide 25mg tab 1enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab 1fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab 1fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab 1hydrochlorothiazide 12.5mg/irbesartan 150mg tab 1hydrochlorothiazide 12.5mg/irbesartan 300mg tab 1hydrochlorothiazide 12.5mg/lisinopril 10mg tab 1hydrochlorothiazide 12.5mg/lisinopril 20mg tab 1hydrochlorothiazide 12.5mg/losartan potassium 100mgtab

1

hydrochlorothiazide 12.5mg/losartan potassium 50mgtab

1

hydrochlorothiazide 12.5mg/olmesartan medoxomil20mg tab

1

hydrochlorothiazide 12.5mg/olmesartan medoxomil40mg tab

1

hydrochlorothiazide 12.5mg/quinapril 10mg tab 1hydrochlorothiazide 12.5mg/quinapril 20mg tab 1hydrochlorothiazide 12.5mg/telmisartan 40mg tab 1hydrochlorothiazide 12.5mg/telmisartan 80mg tab 1hydrochlorothiazide 12.5mg/valsartan 160mg tab 1hydrochlorothiazide 12.5mg/valsartan 320mg tab 1hydrochlorothiazide 12.5mg/valsartan 80mg tab 1hydrochlorothiazide 25mg/lisinopril 20mg tab 1hydrochlorothiazide 25mg/losartan potassium 100mgtab

1

hydrochlorothiazide 25mg/metoprolol tartrate 100mgtab

1

hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab 1hydrochlorothiazide 25mg/olmesartan medoxomil 40mgtab

1


45


Requisitos/Límites

hydrochlorothiazide 25mg/propranolol 40mg tab 1hydrochlorothiazide 25mg/propranolol 80mg tab 1hydrochlorothiazide 25mg/quinapril 20mg tab 1hydrochlorothiazide 25mg/telmisartan 80mg tab 1hydrochlorothiazide 25mg/valsartan 160mg tab 1hydrochlorothiazide 25mg/valsartan 320mg tab 1hydrochlorothiazide 50mg/metoprolol tartrate 100mgtab

1

TRANDOLAPRIL 1MG/VERAPAMIL 240MG ERTAB

1

trandolapril 2mg/verapamil 180mg er tab 1trandolapril 2mg/verapamil 240mg er tab 1trandolapril 4mg/verapamil 240mg er tab 1

DIRECT RENIN INHIBITORSaliskiren 150mg tab 1aliskiren 300mg tab 1

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)eplerenone 25mg tab 1eplerenone 50mg tab 1

VASODILATORShydralazine 100mg tab 1hydralazine 10mg tab 1hydralazine 25mg tab 1hydralazine 50mg tab 1minoxidil 10mg tab 1minoxidil 2.5mg tab 1

ANTIMALARIALSANTIMALARIAL COMBINATIONS

atovaquone 250mg/proguanil 100mg tab 1atovaquone 62.5mg/proguanil 25mg tab 1COARTEM 20-120MG TAB 1

ANTIMALARIALSCHLOROQUINE PHOSPHATE 250MG TAB 1chloroquine phosphate 500mg tab 1DARAPRIM 25MG TAB 1 NDS QL=90 EA/30 Díashydroxychloroquine sulfate 200mg tab 1KRINTAFEL 150MG TAB 1MEFLOQUINE 250MG TAB 1PRIMAQUINE PHOSPHATE 26.3MG TAB 1quinine sulfate 324mg cap 1


46


Requisitos/Límites

ANTIMYASTHENIC/CHOLINERGIC AGENTSANTIMYASTHENIC/CHOLINERGIC AGENTS

GUANIDINE 125MG TAB 1pyridostigmine bromide 180mg er tab 1pyridostigmine bromide 60mg tab 1RUZURGI 10MG TAB 1 NDS PA

ANTIMYCOBACTERIAL AGENTSANTI TB COMBINATIONS

RIFAMATE 150-300MG CAP 1RIFATER 50-120-300MG TAB 1

ANTIMYCOBACTERIAL AGENTSethambutol 100mg tab 1ethambutol 400mg tab 1isoniazid 100mg tab 1ISONIAZID 10MG/ML ORAL SOLN 1isoniazid 300mg tab 1PASER D/R 4GM GRANULES 1PRIFTIN 150MG TAB 1pyrazinamide 500mg tab 1rifabutin 150mg cap 1rifampin 150mg cap 1rifampin 300mg cap 1rifampin 60mg/ml inj 1SIRTURO 100MG TAB 1 NDS PATRECATOR 250MG TAB 1

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS

CYCLOPHOSPHAMIDE 25MG CAP 1 PA BvDCYCLOPHOSPHAMIDE 50MG CAP 1 PA BvDGLEOSTINE 100MG CAP 1GLEOSTINE 10MG CAP 1GLEOSTINE 40MG CAP 1LEUKERAN 2MG TAB 1

ANTIMETABOLITESmercaptopurine 50mg tab 1methotrexate 2.5mg tab 1methotrexate 250mg/10ml inj 1methotrexate 50mg/2ml inj 1PURIXAN 2000MG/100ML SUSP 1TABLOID 40MG TAB 1


47


Requisitos/Límites

TREXALL 10MG TAB 1TREXALL 15MG TAB 1TREXALL 5MG TAB 1TREXALL 7.5MG TAB 1XATMEP 2.5MG/ML ORAL SOLN 1 PA

ANTINEOPLASTIC - BCL-2 INHIBITORSVENCLEXTA 10/100/50MG STARTING PACK 1 NDS PA NSOVENCLEXTA 100MG TAB 1 NDS PA NSOVENCLEXTA 10MG TAB 1 PA NSOVENCLEXTA 50MG TAB 1 PA NSO

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORSDAURISMO 100MG TAB 1 NDS PA NSODAURISMO 25MG TAB 1 NDS PA NSOERIVEDGE 150MG CAP 1 NDS PA NSOODOMZO 200MG CAP 1 NDS PA NSO

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTSabiraterone 250mg tab 1 NDS QL=120 EA/30 Díasanastrozole 1mg tab 1bicalutamide 50mg tab 1DEPO-PROVERA 400MG/ML INJ 1ELIGARD 22.5MG SYRINGE 1ELIGARD 30MG SYRINGE 1ELIGARD 45MG SYRINGE 1ELIGARD 7.5MG SYRINGE 1EMCYT 140MG CAP 1ERLEADA 60MG TAB 1 NDS PA NSO QL=120 EA/30 Díasexemestane 25mg tab 1FIRMAGON 120MG INJ 1 PA NSOFIRMAGON 80MG INJ 1 PA NSOflutamide 125mg cap 1letrozole 2.5mg tab 1leuprolide acetate 5mg/ml inj 1LUPRON 11.25MG (1.5ML) SYRINGE 1LUPRON 22.5MG SYRINGE 1LUPRON 3.75MG SYRINGE 1LUPRON 30MG SYRINGE 1LUPRON 45MG SYRINGE 1LUPRON 7.5MG SYRINGE 1LYSODREN 500MG TAB 1megestrol acetate 20mg tab 1 PA NSO


48


Requisitos/Límites

megestrol acetate 40mg tab 1 PA NSOmegestrol acetate 40mg/ml susp 1 PAnilutamide 150mg tab 1NUBEQA 300MG TAB 1 NDS PA NSO QL=120 EA/30 DíasSOLTAMOX 10MG/5ML ORAL SOLN 1 PA NSOtamoxifen 10mg tab 1tamoxifen 20mg tab 1toremifene 60mg tab 1TRELSTAR 11.25MG INJ 1TRELSTAR 22.5MG INJ 1TRELSTAR 3.75MG INJ 1XTANDI 40MG CAP 1 NDS PA NSO QL=120 EA/30 Días

ANTINEOPLASTIC - IMMUNOMODULATORSPOMALYST 1MG CAP 1 NDS PA NSOPOMALYST 2MG CAP 1 NDS PA NSOPOMALYST 3MG CAP 1 NDS PA NSOPOMALYST 4MG CAP 1 NDS PA NSO

ANTINEOPLASTIC - XPO1 INHIBITORSXPOVIO 100MG ONCE WEEKLY PACK 1 NDS PA NSOXPOVIO 60MG ONCE WEEKLY PACK 1 NDS PA NSOXPOVIO 80MG ONCE WEEKLY PACK 1 NDS PA NSOXPOVIO 80MG TWICE WEEKLY PACK 1 NDS PA NSO

ANTINEOPLASTIC COMBINATIONSKISQALI/FEMARA TAB CO-PACK 200MG 1 NDS PA NSO QL=49 EA/28 DíasKISQALI/FEMARA TAB CO-PACK 400MG 1 NDS PA NSO QL=70 EA/28 DíasKISQALI/FEMARA TAB CO-PACK 600MG 1 NDS PA NSO QL=91 EA/28 DíasLONSURF 15-6.14MG TAB 1 NDS PA NSOLONSURF 20-8.19MG TAB 1 NDS PA NSO

ANTINEOPLASTIC ENZYME INHIBITORSAFINITOR 10MG TAB 1 NDS PA NSO QL=30 EA/30 DíasAFINITOR 2.5MG TAB 1 NDS PA NSO QL=30 EA/30 DíasAFINITOR 2MG SUSP 1 NDS PA NSOAFINITOR 3MG SUSP 1 NDS PA NSOAFINITOR 5MG SUSP 1 NDS PA NSOAFINITOR 5MG TAB 1 NDS PA NSO QL=30 EA/30 DíasAFINITOR 7.5MG TAB 1 NDS PA NSO QL=30 EA/30 DíasALECENSA 150MG CAP 1 NDS PA NSO QL=240 EA/30 DíasALUNBRIG 180MG TAB 1 NDS PA NSO QL=30 EA/30 DíasALUNBRIG 30MG TAB 1 NDS PA NSO QL=120 EA/30 DíasALUNBRIG 90MG TAB 1 NDS PA NSO QL=30 EA/30 Días


49


Requisitos/Límites

ALUNBRIG TAB STARTER PACK 1 NDS PA NSO QL=30 EA/30 DíasAYVAKIT 100MG TAB 1 NDS PA NSO QL=30 EA/30 DíasAYVAKIT 200MG TAB 1 NDS PA NSO QL=30 EA/30 DíasAYVAKIT 300MG TAB 1 NDS PA NSO QL=30 EA/30 DíasBALVERSA 3MG TAB 1 NDS PA NSO QL=60 EA/30 DíasBALVERSA 4MG TAB 1 NDS PA NSO QL=60 EA/30 DíasBALVERSA 5MG TAB 1 NDS PA NSO QL=30 EA/30 DíasBOSULIF 100MG TAB 1 NDS PA NSOBOSULIF 400MG TAB 1 NDS PA NSOBOSULIF 500MG TAB 1 NDS PA NSOBRAFTOVI 75MG CAP 1 NDS PA NSO QL=180 EA/30 DíasBRUKINSA 80MG CAP 1 NDS PA NSO QL=120 EA/30 DíasCABOMETYX 20MG TAB 1 NDS PA NSOCABOMETYX 40MG TAB 1 NDS PA NSOCABOMETYX 60MG TAB 1 NDS PA NSOCALQUENCE 100MG CAP 1 NDS PA NSO QL=60 EA/30 DíasCAPRELSA 100MG TAB 1 NDS PA NSO QL=60 EA/30 DíasCAPRELSA 300MG TAB 1 NDS PA NSO QL=30 EA/30 DíasCOMETRIQ 100MG DAILY DOSE CARTON PACK 1 NDS PA NSOCOMETRIQ 140MG DAILY DOSE CARTON PACK 1 NDS PA NSOCOMETRIQ 60MG DAILY DOSE CARTON PACK 1 NDS PA NSOCOPIKTRA 15MG CAP 1 NDS PA NSO QL=60 EA/30 DíasCOPIKTRA 25MG CAP 1 NDS PA NSO QL=60 EA/30 DíasCOTELLIC 20MG TAB 1 NDS PA NSO QL=63 EA/28 Díaserlotinib 100mg tab 1 NDS PA NSOerlotinib 150mg tab 1 NDS PA NSOerlotinib 25mg tab 1 NDS PA NSOeverolimus 2.5mg tab 1 NDS PA NSO QL=30 EA/30 Díaseverolimus 5mg tab 1 NDS PA NSO QL=30 EA/30 Díaseverolimus 7.5mg tab 1 NDS PA NSO QL=30 EA/30 DíasFARYDAK 10MG CAP 1 NDS PA NSOFARYDAK 20MG CAP 1 NDS PA NSOGILOTRIF 20MG TAB 1 NDS PA NSO QL=30 EA/30 DíasGILOTRIF 30MG TAB 1 NDS PA NSO QL=30 EA/30 DíasGILOTRIF 40MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIBRANCE 100MG CAP 1 NDS PA NSO QL=21 EA/28 DíasIBRANCE 125MG CAP 1 NDS PA NSO QL=21 EA/28 DíasIBRANCE 75MG CAP 1 NDS PA NSO QL=21 EA/28 DíasICLUSIG 15MG TAB 1 NDS PA NSO QL=60 EA/30 DíasICLUSIG 45MG TAB 1 NDS PA NSO QL=30 EA/30 Días


50


Requisitos/Límites

IDHIFA 100MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIDHIFA 50MG TAB 1 NDS PA NSO QL=30 EA/30 Díasimatinib 100mg tab 1imatinib 400mg tab 1IMBRUVICA 140MG CAP 1 NDS PA NSO QL=90 EA/30 DíasIMBRUVICA 140MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIMBRUVICA 280MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIMBRUVICA 420MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIMBRUVICA 560MG TAB 1 NDS PA NSO QL=30 EA/30 DíasIMBRUVICA 70MG CAP 1 NDS PA NSO QL=30 EA/30 DíasINLYTA 1MG TAB 1 NDS PA NSOINLYTA 5MG TAB 1 NDS PA NSOINREBIC 100MG CAP 1 NDS PA NSO QL=120 EA/30 DíasIRESSA 250MG TAB 1 NDS PA NSOJAKAFI 10MG TAB 1 NDS PA NSO QL=60 EA/30 DíasJAKAFI 15MG TAB 1 NDS PA NSO QL=60 EA/30 DíasJAKAFI 20MG TAB 1 NDS PA NSO QL=60 EA/30 DíasJAKAFI 25MG TAB 1 NDS PA NSO QL=60 EA/30 DíasJAKAFI 5MG TAB 1 NDS PA NSO QL=60 EA/30 DíasKISQALI 200MG DAILY DOSE PACK 1 NDS PA NSO QL=21 EA/28 DíasKISQALI 400MG DAILY DOSE PACK 1 NDS PA NSO QL=42 EA/28 DíasKISQALI 600MG DAILY DOSE PACK 1 NDS PA NSO QL=63 EA/28 DíasLENVIMA (10) 10MG PACK 1 NDS PA NSOLENVIMA (12) 4MG PACK 1 NDS PA NSOLENVIMA (14) PACK 1 NDS PA NSOLENVIMA (18) PACK 1 NDS PA NSOLENVIMA (20) 10MG PACK 1 NDS PA NSOLENVIMA (24) PACK 1 NDS PA NSOLENVIMA (4) 4MG PACK 1 NDS PA NSOLENVIMA (8) 4MG PACK 1 NDS PA NSOLORBRENA 100MG TAB 1 NDS PA NSO QL=30 EA/30 DíasLORBRENA 25MG TAB 1 NDS PA NSO QL=90 EA/30 DíasLYNPARZA 100MG TAB 1 NDS PA NSO QL=120 EA/30 DíasLYNPARZA 150MG TAB 1 NDS PA NSO QL=120 EA/30 DíasMEKINIST 0.5MG TAB 1 NDS PA NSO QL=90 EA/30 DíasMEKINIST 2MG TAB 1 NDS PA NSO QL=30 EA/30 DíasMEKTOVI 15MG TAB 1 NDS PA NSO QL=180 EA/30 DíasNERLYNX 40MG TAB 1 NDS PA NSONEXAVAR 200MG TAB 1 NDS PA NSONINLARO 2.3MG CAP 1 NDS PA NSO


51


Requisitos/Límites

NINLARO 3MG CAP 1 NDS PA NSONINLARO 4MG CAP 1 NDS PA NSOPIQRAY 200MG DAILY DOSE PACK 1 NDS PA NSO QL=30 EA/30 DíasPIQRAY 250MG DAILY DOSE PACK 1 NDS PA NSO QL=60 EA/30 DíasPIQRAY 300MG DAILY DOSE 150MG PACK 1 NDS PA NSO QL=60 EA/30 DíasROZLYTREK 100MG CAP 1 NDS PA NSO QL=30 EA/30 DíasROZLYTREK 200MG CAP 1 NDS PA NSO QL=90 EA/30 DíasRUBRACA 200MG TAB 1 NDS PA NSO QL=120 EA/30 DíasRUBRACA 250MG TAB 1 NDS PA NSO QL=120 EA/30 DíasRUBRACA 300MG TAB 1 NDS PA NSO QL=120 EA/30 DíasRYDAPT 25MG CAP 1 NDS PA NSOSPRYCEL 100MG TAB 1 NDS PA NSOSPRYCEL 140MG TAB 1 NDS PA NSOSPRYCEL 20MG TAB 1 NDS PA NSOSPRYCEL 50MG TAB 1 NDS PA NSOSPRYCEL 70MG TAB 1 NDS PA NSOSPRYCEL 80MG TAB 1 NDS PA NSOSTIVARGA 40MG TAB 1 NDS PA NSO QL=120 EA/30 DíasSUTENT 12.5MG CAP 1 NDS PA NSOSUTENT 25MG CAP 1 NDS PA NSOSUTENT 37.5MG CAP 1 NDS PA NSOSUTENT 50MG CAP 1 NDS PA NSOTAFINLAR 50MG CAP 1 NDS PA NSO QL=120 EA/30 DíasTAFINLAR 75MG CAP 1 NDS PA NSO QL=120 EA/30 DíasTAGRISSO 40MG TAB 1 NDS PA NSOTAGRISSO 80MG TAB 1 NDS PA NSOTALZENNA 0.25MG CAP 1 NDS PA NSO QL=90 EA/30 DíasTALZENNA 1MG CAP 1 NDS PA NSO QL=30 EA/30 DíasTASIGNA 150MG CAP 1 NDS PA NSOTASIGNA 200MG CAP 1 NDS PA NSOTASIGNA 50MG CAP 1 NDS PA NSOTAZVERIK 200MG TAB 1 NDS PA NSO QL=240 EA/30 DíasTIBSOVO 250MG TAB 1 NDS PA NSO QL=60 EA/30 DíasTURALIO 200MG CAP 1 NDS PA NSO QL=120 EA/30 DíasTYKERB 250MG TAB 1 NDS PA NSOVERZENIO 100MG TAB 1 NDS PA NSO QL=56 EA/28 DíasVERZENIO 150MG TAB 1 NDS PA NSO QL=56 EA/28 DíasVERZENIO 200MG TAB 1 NDS PA NSO QL=56 EA/28 DíasVERZENIO 50MG TAB 1 NDS PA NSO QL=56 EA/28 DíasVITRAKVI 100MG CAP 1 NDS PA NSO


52


Requisitos/Límites

VITRAKVI 20MG/ML ORAL SOLN 1 NDS PA NSOVITRAKVI 25MG CAP 1 NDS PA NSOVIZIMPRO 15MG TAB 1 NDS PA NSO QL=30 EA/30 DíasVIZIMPRO 30MG TAB 1 NDS PA NSO QL=30 EA/30 DíasVIZIMPRO 45MG TAB 1 NDS PA NSO QL=30 EA/30 DíasVOTRIENT 200MG TAB 1 NDS PA NSOXALKORI 200MG CAP 1 NDS PA NSO QL=60 EA/30 DíasXALKORI 250MG CAP 1 NDS PA NSO QL=60 EA/30 DíasXOSPATA 40MG TAB 1 NDS PA NSOZEJULA 100MG CAP 1 NDS PA NSO QL=90 EA/30 DíasZELBORAF 240MG TAB 1 NDS PA NSO QL=240 EA/30 DíasZOLINZA 100MG CAP 1 NDS PA NSOZYDELIG 100MG TAB 1 NDS PA NSO QL=60 EA/30 DíasZYDELIG 150MG TAB 1 NDS PA NSO QL=60 EA/30 DíasZYKADIA 150MG TAB 1 NDS PA NSO QL=150 EA/30 Días

ANTINEOPLASTICS MISC.ACTIMMUNE 2000000UNIT/0.5ML INJ 1 NDS PA NSObexarotene 75mg cap 1 NDS PA NSOhydroxyurea 500mg cap 1INTRON A 10MU INJ 1INTRON A 18MU INJ 1 NDSINTRON A 25MU INJ 1INTRON A 50MU INJ 1 NDSINTRON A 6000000UNIT/ML INJ 1MATULANE 50MG CAP 1 NDSSYLATRON 200MCG INJ 1 NDS PA NSOSYLATRON 300MCG INJ 1 NDS PA NSOSYNRIBO 3.5MG INJ 1 NDStretinoin 10mg cap 1

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSLEUCOVORIN 10MG TAB 1LEUCOVORIN 15MG TAB 1leucovorin 25mg tab 1leucovorin 5mg tab 1MESNEX 400MG TAB 1

ANTIPARKINSON AGENTSANTIPARKINSON DOPAMINERGICS

amantadine 100mg cap 1amantadine 10mg/ml oral soln 1bromocriptine 2.5mg tab 1


53


Requisitos/Límites

bromocriptine 5mg cap 1carbidopa 10mg/levodopa 100mg odt 1carbidopa 10mg/levodopa 100mg tab 1CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB

1

CARBIDOPA 18.75MG/ENTACAPONE 200MG/LEVODOPA 75MG TAB

1

CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB

1

carbidopa 25mg/levodopa 100mg er tab 1carbidopa 25mg/levodopa 100mg odt 1carbidopa 25mg/levodopa 100mg tab 1carbidopa 25mg/levodopa 250mg odt 1CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB

1


1


1

carbidopa 50mg/levodopa 200mg er tab 1NEUPRO 1MG/24HR PATCH 1NEUPRO 2MG/24HR PATCH 1NEUPRO 3MG/24HR PATCH 1NEUPRO 4MG/24HR PATCH 1NEUPRO 6MG/24HR PATCH 1NEUPRO 8MG/24HR PATCH 1pramipexole 0.125mg tab 1pramipexole 0.25mg tab 1pramipexole 0.375mg er tab 1pramipexole 0.5mg tab 1pramipexole 0.75mg er tab 1pramipexole 0.75mg tab 1pramipexole 1.5mg er tab 1pramipexole 1.5mg tab 1pramipexole 1mg tab 1pramipexole 2.25mg er tab 1pramipexole 3.75mg er tab 1pramipexole 3mg er tab 1pramipexole 4.5mg er tab 1ropinirole 0.25mg tab 1ropinirole 0.5mg tab 1


54


Requisitos/Límites

ropinirole 12mg er tab 1ropinirole 2mg er tab 1ropinirole 3mg tab 1ropinirole 4mg er tab 1ropinirole 4mg tab 1ropinirole 5mg tab 1ropinirole 6mg er tab 1ropinirole 8mg er tab 1

ANTIPARKINSON AND RELATED THERAPY AGENTSANTIPARKINSON ADJUVANTS

carbidopa 25mg tab 1ANTIPARKINSON ANTICHOLINERGICS

benztropine mesylate 0.5mg tab 1benztropine mesylate 1mg tab 1benztropine mesylate 2mg tab 1trihexyphenidyl 0.4mg/ml oral soln 1trihexyphenidyl 2mg tab 1trihexyphenidyl 5mg tab 1

ANTIPARKINSON COMT INHIBITORSentacapone 200mg tab 1tolcapone 100mg tab 1

ANTIPARKINSON DOPAMINERGICSamantadine 100mg tab 1APOKYN 10MG/ML CARTRIDGE 1 NDScarbidopa 25mg/levodopa 250mg tab 1ropinirole 1mg tab 1ropinirole 2mg tab 1

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORSrasagiline 0.5mg tab 1rasagiline 1mg tab 1selegiline 5mg cap 1selegiline 5mg tab 1

ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

lithium carbonate 150mg cap 1lithium carbonate 300mg cap 1lithium carbonate 300mg er tab 1lithium carbonate 300mg tab 1lithium carbonate 450mg er tab 1lithium carbonate 600mg cap 1


55


Requisitos/Límites

lithium citrate 60mg/ml oral soln 1ANTIPSYCHOTICS - MISC.

EQUETRO 100MG ER CAP 1EQUETRO 200MG ER CAP 1EQUETRO 300MG ER CAP 1GEODON 20MG INJ 1LATUDA 120MG TAB 1 ST_NSO QL=30 EA/30 DíasLATUDA 20MG TAB 1 ST_NSO QL=30 EA/30 DíasLATUDA 40MG TAB 1 ST_NSO QL=30 EA/30 DíasLATUDA 60MG TAB 1 ST_NSO QL=30 EA/30 DíasLATUDA 80MG TAB 1 ST_NSO QL=30 EA/30 DíasNUPLAZID 10MG TAB 1 PA NSO QL=30 EA/30 DíasNUPLAZID 34MG CAP 1 PA NSO QL=30 EA/30 DíasVRAYLAR 1.5/3MG MIXED PACK 1 PA NSO QL=30 EA/30 DíasVRAYLAR 1.5MG CAP 1 PA NSO QL=30 EA/30 DíasVRAYLAR 3MG CAP 1 PA NSO QL=30 EA/30 DíasVRAYLAR 4.5MG CAP 1 PA NSO QL=30 EA/30 DíasVRAYLAR 6MG CAP 1 PA NSO QL=30 EA/30 Díasziprasidone 20mg cap 1ziprasidone 40mg cap 1ziprasidone 60mg cap 1ziprasidone 80mg cap 1

BENZISOXAZOLESFANAPT 10MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 12MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 1MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 2MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 4MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 6MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT 8MG TAB 1 PA NSO QL=60 EA/30 DíasFANAPT TITRATION PACK 1 PA NSO QL=60 EA/30 DíasINVEGA 117MG/0.75ML SYRINGE 1 PA NSOINVEGA 156MG/ML SYRINGE 1 PA NSOINVEGA 234MG/1.5ML SYRINGE 1 PA NSOINVEGA 273MG/0.875ML SYRINGE 1 PA NSOINVEGA 39MG/0.25ML SYRINGE 1 PA NSOINVEGA 410MG/1.315ML SYRINGE 1 PA NSOINVEGA 546MG/1.75ML SYRINGE 1 PA NSOINVEGA 78MG/0.5ML SYRINGE 1 PA NSOINVEGA 819MG/2.625ML SYRINGE 1 PA NSO


56


Requisitos/Límites

paliperidone 1.5mg er tab 1 PA NSO QL=30 EA/30 Díaspaliperidone 3mg er tab 1 PA NSO QL=30 EA/30 Díaspaliperidone 6mg er tab 1 PA NSO QL=60 EA/30 Díaspaliperidone 9mg er tab 1 PA NSO QL=30 EA/30 DíasPERSERIS 120MG SYRINGE 1 NDS PA NSOPERSERIS 90MG SYRINGE 1 NDS PA NSORISPERDAL 12.5MG INJ 1 PA NSORISPERDAL 25MG INJ 1 PA NSORISPERDAL 37.5MG INJ 1 PA NSORISPERDAL 50MG INJ 1 PA NSOrisperidone 0.25mg odt 1risperidone 0.25mg tab 1risperidone 0.5mg odt 1risperidone 0.5mg tab 1risperidone 1mg odt 1risperidone 1mg tab 1risperidone 1mg/ml oral soln 1risperidone 2mg odt 1risperidone 2mg tab 1risperidone 3mg odt 1risperidone 3mg tab 1risperidone 4mg odt 1risperidone 4mg tab 1

BUTYROPHENONEShaloperidol 0.5mg tab 1haloperidol 10mg tab 1haloperidol 1mg tab 1haloperidol 20mg tab 1haloperidol 2mg tab 1haloperidol 2mg/ml oral soln 1haloperidol 5mg tab 1haloperidol 5mg/ml inj 1haloperidol decanoate 100mg/ml inj 1haloperidol decanoate 500mg/5ml inj 1haloperidol decanoate 50mg/ml inj 1

DIBENZAPINESclozapine 100mg odt 1clozapine 100mg tab 1clozapine 12.5mg odt 1CLOZAPINE 150MG ODT 1


57


Requisitos/Límites

CLOZAPINE 200MG ODT 1clozapine 200mg tab 1clozapine 25mg odt 1clozapine 25mg tab 1clozapine 50mg tab 1loxapine 10mg cap 1loxapine 25mg cap 1loxapine 50mg cap 1loxapine 5mg cap 1olanzapine 10mg inj 1olanzapine 10mg odt 1olanzapine 10mg tab 1olanzapine 15mg odt 1olanzapine 15mg tab 1olanzapine 2.5mg tab 1olanzapine 20mg odt 1olanzapine 20mg tab 1olanzapine 5mg odt 1olanzapine 5mg tab 1olanzapine 7.5mg tab 1quetiapine 100mg tab 1quetiapine 150mg xr tab 1quetiapine 200mg tab 1quetiapine 200mg xr tab 1quetiapine 25mg tab 1quetiapine 300mg tab 1quetiapine 300mg xr tab 1quetiapine 400mg tab 1quetiapine 400mg xr tab 1quetiapine 50mg tab 1quetiapine 50mg xr tab 1SAPHRIS 10MG SL TAB 1 PA NSO QL=60 EA/30 DíasSAPHRIS 2.5MG SL TAB 1 PA NSO QL=60 EA/30 DíasSAPHRIS 5MG SL TAB 1 PA NSO QL=60 EA/30 DíasSECUADO 3.8MG/24HR PATCH 1 PA NSO QL=30 EA/30 DíasSECUADO 5.7MG/24HR PATCH 1 PA NSO QL=30 EA/30 DíasSECUADO 7.6MG/24HR PATCH 1 PA NSO QL=30 EA/30 DíasVERSACLOZ 50MG/ML SUSP 1ZYPREXA 210MG INJ 1

DIHYDROINDOLONES


58


Requisitos/Límites

MOLINDONE 10MG TAB 1MOLINDONE 25MG TAB 1MOLINDONE 5MG TAB 1

PHENOTHIAZINESchlorpromazine 100mg tab 1chlorpromazine 10mg tab 1chlorpromazine 200mg tab 1chlorpromazine 25mg tab 1chlorpromazine 50mg tab 1compro 25mg rectal supp 1FLUPHENAZINE 0.5MG/ML ORAL SOLN 1fluphenazine 10mg tab 1fluphenazine 1mg tab 1fluphenazine 2.5mg tab 1FLUPHENAZINE 2.5MG/ML INJ 1fluphenazine 5mg tab 1FLUPHENAZINE 5MG/ML ORAL SOLN 1fluphenazine decanoate 25mg/ml inj 1perphenazine 16mg tab 1perphenazine 2mg tab 1perphenazine 4mg tab 1perphenazine 8mg tab 1prochlorperazine 10mg tab 1prochlorperazine 25mg rectal supp 1prochlorperazine 5mg tab 1thioridazine 100mg tab 1thioridazine 10mg tab 1thioridazine 25mg tab 1thioridazine 50mg tab 1trifluoperazine 10mg tab 1trifluoperazine 1mg tab 1trifluoperazine 2mg tab 1trifluoperazine 5mg tab 1

QUINOLINONE DERIVATIVESABILIFY 300MG MAINTENA INJ 1 NDS PA NSOABILIFY 300MG MAINTENA PF SYRINGE 1 NDS PA NSOABILIFY 400MG MAINTENA INJ 1 NDS PA NSOABILIFY 400MG MAINTENA PF SYRINGE 1 NDS PA NSOaripiprazole 10mg odt 1 PA NSO QL=60 EA/30 Díasaripiprazole 10mg tab 1


59


Requisitos/Límites

aripiprazole 15mg odt 1 PA NSO QL=60 EA/30 Díasaripiprazole 15mg tab 1aripiprazole 1mg/ml oral soln 1 PA NSOaripiprazole 20mg tab 1aripiprazole 2mg tab 1aripiprazole 30mg tab 1aripiprazole 5mg tab 1ARISTADA 1064MG/3.9ML SYRINGE 1 PA NSOARISTADA 441MG/1.6ML SYRINGE 1 NDS PA NSOARISTADA 662MG/2.4ML SYRINGE 1 NDS PA NSOARISTADA 675MG/2.4ML SYRINGE 1 NDS PA NSOARISTADA 882MG/3.2ML SYRINGE 1 PA NSOREXULTI 0.25MG TAB 1 PA NSO QL=30 EA/30 DíasREXULTI 0.5MG TAB 1 PA NSO QL=30 EA/30 DíasREXULTI 1MG TAB 1 PA NSO QL=30 EA/30 DíasREXULTI 2MG TAB 1 PA NSO QL=30 EA/30 DíasREXULTI 3MG TAB 1 PA NSO QL=30 EA/30 DíasREXULTI 4MG TAB 1 PA NSO QL=30 EA/30 Días

THIOXANTHENESthiothixene 10mg cap 1thiothixene 1mg cap 1thiothixene 2mg cap 1thiothixene 5mg cap 1

ANTIVIRALSANTIRETROVIRALS

abacavir 20mg/ml oral soln 1abacavir 300mg tab 1abacavir 300mg/lamivudine 150mg/zidovudine 300mgtab

1

abacavir 600mg/lamivudine 300mg tab 1 NDSAPTIVUS 100MG/ML ORAL SOLN 1 NDSAPTIVUS 250MG CAP 1 NDSatazanavir 150mg cap 1atazanavir 200mg cap 1atazanavir 300mg cap 1ATRIPLA 600-200-300MG TAB 1 NDSBIKTARVY 50-200-25MG TAB 1 NDSCIMDUO 300-300MG TAB 1 NDSCOMPLERA 200-25-300MG TAB 1 NDSCRIXIVAN 200MG CAP 1


60


Requisitos/Límites

CRIXIVAN 400MG CAP 1DELSTRIGO 100-300-300MG TAB 1 NDSDESCOVY 200-25MG TAB 1 NDSdidanosine 200mg dr cap 1didanosine 250mg dr cap 1didanosine 400mg dr cap 1DOVATO 50-300MG TAB 1 NDSEDURANT 25MG TAB 1 NDSefavirenz 200mg cap 1efavirenz 50mg cap 1efavirenz 600mg cap 1EMTRIVA 10MG/ML ORAL SOLN 1EMTRIVA 200MG CAP 1EVOTAZ 300-150MG TAB 1 NDSfosamprenavir 700mg tab 1 NDSFUZEON 90MG INJ 1 NDSGENVOYA 150-150-200-10MG TAB 1 NDSINTELENCE 100MG TAB 1 NDSINTELENCE 200MG TAB 1 NDSINTELENCE 25MG TAB 1INVIRASE 500MG TAB 1 NDSISENTRESS 100MG CHEW TAB 1 NDSISENTRESS 100MG SUSP 1ISENTRESS 25MG CHEW TAB 1ISENTRESS 400MG TAB 1 NDSISENTRESS 600MG TAB 1 NDSJULUCA 50-25MG TAB 1 NDSKALETRA 100-25MG TAB 1KALETRA 200-50MG TAB 1 NDSlamivudine 10mg/ml oral soln 1lamivudine 150mg tab 1lamivudine 150mg/zidovudine 300mg tab 1lamivudine 300mg tab 1LEXIVA 50MG/ML SUSP 1lopinavir 80mg/ml/ritonavir 20mg/ml oral solution 1 NDSnevirapine 100mg er tab 1nevirapine 10mg/ml oral susp 1nevirapine 200mg tab 1nevirapine 400mg er tab 1NORVIR 100MG POWDER PACKET 1


61


Requisitos/Límites

NORVIR 80MG/ML ORAL SOLN 1ODEFSEY 200-25-25MG TAB 1 NDSPIFELTRO 100MG TAB 1 NDSPREZCOBIX 800-150MG TAB 1 NDSPREZISTA 100MG/ML SUSP 1PREZISTA 150MG TAB 1PREZISTA 600MG TAB 1 NDSPREZISTA 75MG TAB 1PREZISTA 800MG TAB 1 NDSRESCRIPTOR 200MG TAB 1REYATAZ 50MG ORAL POWDER 1 NDSritonavir 100mg tab 1SELZENTRY 150MG TAB 1 NDSSELZENTRY 20MG/ML ORAL SOLN 1 NDSSELZENTRY 25MG TAB 1SELZENTRY 300MG TAB 1 NDSSELZENTRY 75MG TAB 1 NDSstavudine 15mg cap 1stavudine 20mg cap 1stavudine 30mg cap 1stavudine 40mg cap 1STRIBILD 150-150-200-300MG TAB 1 NDSSYMFI 600-300-300MG TAB 1SYMFI LO 400-300-300MG TAB 1SYMTUZA 800-150-200-10MG TAB 1 NDStenofovir disoproxil fumarate 300mg tab 1 NDSTIVICAY 10MG TAB 1TIVICAY 25MG TAB 1TIVICAY 50MG TAB 1 NDSTRIUMEQ 600-50-300MG TAB 1 NDSTRUVADA 100-150MG TAB 1 NDSTRUVADA 133-200MG TAB 1 NDSTRUVADA 167-250MG TAB 1 NDSTRUVADA 200-300MG TAB 1 NDSTYBOST 150MG TAB 1VIDEX 125MG DR CAP 1VIDEX 2GM ORAL SOLN 1VIRACEPT 250MG TAB 1 NDSVIRACEPT 625MG TAB 1 NDSVIREAD 150MG TAB 1 NDS


62


Requisitos/Límites

VIREAD 200MG TAB 1 NDSVIREAD 250MG TAB 1 NDSVIREAD 40MG/GM ORAL POWDER 1zidovudine 100mg cap 1zidovudine 10mg/ml oral soln 1zidovudine 300mg tab 1

CMV AGENTSPREVYMIS 240MG TAB 1 NDS PA QL=30 EA/30 DíasPREVYMIS 480MG TAB 1 NDS PA QL=30 EA/30 Díasvalganciclovir 450mg tab 1 NDSvalganciclovir 50mg/ml oral soln 1 NDS

HEPATITIS AGENTSadefovir dipivoxil 10mg tab 1entecavir 0.5mg tab 1entecavir 1mg tab 1EPIVIR HBV 5MG/ML ORAL SOLN 1lamivudine 100mg tab 1MAVYRET 100-40MG TAB 1 NDS PA QL=90 EA/30 DíasPEGASYS 180MCG/0.5ML AUTO-INJECTOR 1 NDSPEGASYS 180MCG/0.5ML SYRINGE 1 NDSPEGASYS 180MCG/ML INJ 1 NDSribavirin 200mg cap 1ribavirin 200mg tab 1SOFOSBUVIR/VELPATASVIR 400-100MG TAB 1 NDS PA QL=30 EA/30 DíasVEMLIDY 25MG TAB 1 NDSVOSEVI 400-100-100MG TAB 1 NDS PA QL=30 EA/30 Días

HERPES AGENTSacyclovir 200mg cap 1acyclovir 400mg tab 1acyclovir 40mg/ml susp 1acyclovir 50mg/ml inj 1 PA BvDacyclovir 800mg tab 1famciclovir 125mg tab 1famciclovir 250mg tab 1famciclovir 500mg tab 1valacyclovir 1000mg tab 1valacyclovir 500mg tab 1

INFLUENZA AGENTSoseltamivir 30mg cap 1 QL=84 EA/180 Díasoseltamivir 45mg cap 1 QL=42 EA/180 Días


63


Requisitos/Límites

oseltamivir 6mg/ml oral susp 1 QL=540 ML/180 Díasoseltamivir 75mg cap 1 QL=42 EA/180 DíasRELENZA 5MG/BLISTER INH 1 QL=120 EA/30 Díasrimantadine 100mg tab 1XOFLUZA 20MG THERAPY PACK 1 QL=2 EA/30 DíasXOFLUZA 40MG THERAPY PACK 1 QL=2 EA/30 Días

ASSORTED CLASSESIMMUNOSUPPRESSIVE AGENTS

AZASAN 100MG TAB 1 PA BvDAZASAN 75MG TAB 1 PA BvDazathioprine 50mg tab 1 PA BvDcyclosporine 100mg cap 1 PA BvDcyclosporine 25mg cap 1 PA BvDcyclosporine modified 100mg cap 1 PA BvDcyclosporine modified 25mg cap 1 PA BvDgengraf 100mg cap 1 PA BvDgengraf 100mg/ml oral soln 1 PA BvDgengraf 25mg cap 1 PA BvDmycophenolate mofetil 200mg/ml susp 1 PA BvDmycophenolate mofetil 250mg cap 1 PA BvDmycophenolate mofetil 500mg tab 1 PA BvDmycophenolic acid 180mg dr tab 1 PA BvDmycophenolic acid 360mg dr tab 1 PA BvDSANDIMMUNE 100MG/ML ORAL SOLN 1 PA BvDsirolimus 0.5mg tab 1 PA BvDsirolimus 1mg tab 1 PA BvDsirolimus 2mg tab 1 PA BvDtacrolimus 0.5mg cap 1 PA BvDtacrolimus 1mg cap 1 PA BvDtacrolimus 5mg cap 1 PA BvD

POTASSIUM REMOVING RESINSkionex 250mg/ml susp 1sodium polystyrene sulfonate 15gm oral susp 1sodium polystyrene sulfonate 250mg/ml susp 1sps 250mg/ml oral susp 1

BETA BLOCKERSALPHA-BETA BLOCKERS

carvedilol 12.5mg tab 1carvedilol 25mg tab 1carvedilol 3.125mg tab 1


64


Requisitos/Límites

carvedilol 6.25mg tab 1labetalol 100mg tab 1labetalol 200mg tab 1labetalol 300mg tab 1

BETA BLOCKERS CARDIO-SELECTIVEacebutolol 200mg cap 1acebutolol 400mg cap 1atenolol 100mg tab 1atenolol 25mg tab 1atenolol 50mg tab 1betaxolol 10mg tab 1betaxolol 20mg tab 1bisoprolol fumarate 10mg tab 1bisoprolol fumarate 5mg tab 1BYSTOLIC 10MG TAB 1BYSTOLIC 2.5MG TAB 1BYSTOLIC 20MG TAB 1BYSTOLIC 5MG TAB 1metoprolol succinate 100mg er tab 1metoprolol succinate 200mg er tab 1metoprolol succinate 25mg er tab 1metoprolol succinate 50mg er tab 1metoprolol tartrate 100mg tab 1metoprolol tartrate 25mg tab 1metoprolol tartrate 50mg tab 1

BETA BLOCKERS NON-SELECTIVEnadolol 20mg tab 1nadolol 40mg tab 1nadolol 80mg tab 1pindolol 10mg tab 1pindolol 5mg tab 1propranolol 10mg tab 1propranolol 120mg er cap 1propranolol 160mg er cap 1propranolol 20mg tab 1propranolol 40mg tab 1PROPRANOLOL 4MG/ML ORAL SOLN 1propranolol 60mg er cap 1propranolol 60mg tab 1propranolol 80mg er cap 1


65


Requisitos/Límites

propranolol 80mg tab 1PROPRANOLOL 8MG/ML ORAL SOLN 1sorine 120mg tab 1sorine 160mg tab 1sorine 240mg tab 1sorine 80mg tab 1sotalol 120mg tab 1sotalol 160mg tab 1sotalol 240mg tab 1sotalol 80mg tab 1sotalol af 120mg tab 1timolol 10mg tab 1timolol 20mg tab 1timolol 5mg tab 1

CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS

amlodipine 10mg tab 1amlodipine 2.5mg tab 1amlodipine 5mg tab 1cartia 120mg er cap 1cartia 180mg er cap 1cartia 240mg er cap 1cartia 300mg er cap 1dilt 120mg xr cap 1dilt 180mg xr cap 1dilt 240mg xr cap 1diltiazem 120mg er (12 hr) cap 1diltiazem 120mg er (24 hr) cap 1diltiazem 120mg tab 1diltiazem 180mg er cap 1diltiazem 240mg er cap 1diltiazem 300mg er cap 1diltiazem 30mg tab 1diltiazem 360mg er cap 1diltiazem 420mg er cap 1diltiazem 60mg er cap 1diltiazem 60mg tab 1diltiazem 90mg er cap 1diltiazem 90mg tab 1felodipine 10mg er tab 1


66


Requisitos/Límites

felodipine 2.5mg er tab 1felodipine 5mg er tab 1isradipine 2.5mg cap 1isradipine 5mg cap 1matzim 180mg er tab 1matzim 240mg er tab 1matzim 300mg er tab 1matzim 360mg er tab 1matzim 420mg er tab 1nicardipine 20mg cap 1nicardipine 30mg cap 1nifedipine 30mg er tab 1nifedipine 30mg osmotic er tab 1nifedipine 60mg er tab 1nifedipine 60mg osmotic er tab 1nifedipine 90mg er tab 1nifedipine 90mg osmotic er tab 1nimodipine 30mg cap 1nisoldipine 17mg er tab 1nisoldipine 20mg er tab 1NISOLDIPINE 25.5MG ER TAB 1nisoldipine 30mg er tab 1nisoldipine 34mg er tab 1nisoldipine 40mg er tab 1nisoldipine 8.5mg er tab 1taztia 120mg er cap 1taztia 180mg er cap 1taztia 240mg er cap 1taztia 300mg er cap 1taztia 360mg er cap 1tiadylt 120mg er cap 1tiadylt 180mg er cap 1tiadylt 240mg er cap 1tiadylt 300mg er cap 1tiadylt 360mg er cap 1tiadylt 420mg er cap 1verapamil 100mg er cap 1verapamil 120mg er cap 1verapamil 120mg er tab 1verapamil 120mg tab 1


67


Requisitos/Límites

verapamil 180mg er cap 1verapamil 180mg er tab 1verapamil 200mg er cap 1verapamil 240mg er cap 1verapamil 240mg er tab 1verapamil 300mg er cap 1VERAPAMIL 360MG SR CAP 1verapamil 40mg tab 1verapamil 80mg tab 1

CARDIOTONICSCARDIAC GLYCOSIDES

digitek 0.125mg tab 1digitek 0.25mg tab 1digox 0.125mg tab 1digox 0.25mg tab 1digoxin 0.05mg/ml oral soln 1digoxin 0.125mg tab 1digoxin 0.25mg tab 1

CARDIOVASCULAR AGENTS - MISC.CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

amlodipine 10mg/atorvastatin 10mg tab 1amlodipine 10mg/atorvastatin 20mg tab 1amlodipine 10mg/atorvastatin 40mg tab 1amlodipine 10mg/atorvastatin 80mg tab 1amlodipine 2.5mg/atorvastatin 10mg tab 1amlodipine 2.5mg/atorvastatin 20mg tab 1amlodipine 2.5mg/atorvastatin 40mg tab 1amlodipine 5mg/atorvastatin 10mg tab 1amlodipine 5mg/atorvastatin 20mg tab 1amlodipine 5mg/atorvastatin 40mg tab 1amlodipine 5mg/atorvastatin 80mg tab 1BIDIL 20-37.5MG TAB 1ENTRESTO 24-26MG TAB 1 QL=60 EA/30 DíasENTRESTO 49-51MG TAB 1 QL=60 EA/30 DíasENTRESTO 97-103MG TAB 1 QL=60 EA/30 Días

PROSTAGLANDIN VASODILATORSORENITRAM 0.125MG ER TAB 1 NDS PAORENITRAM 0.25MG ER TAB 1 NDS PAORENITRAM 1MG ER TAB 1 NDS PAORENITRAM 2.5MG ER TAB 1 NDS PA


68


Requisitos/Límites

ORENITRAM 5MG ER TAB 1 NDS PAVENTAVIS 10MCG/ML INH SOLN 1 NDS PAVENTAVIS 20MCG/ML INH SOLN 1 NDS PA

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTSambrisentan 10mg tab 1 NDS PA QL=30 EA/30 Díasambrisentan 5mg tab 1 NDS PA QL=30 EA/30 Díasbosentan 125mg tab 1 NDS PA QL=60 EA/30 Díasbosentan 62.5mg tab 1 NDS PA QL=60 EA/30 DíasOPSUMIT 10MG TAB 1 NDS PA QL=30 EA/30 DíasTRACLEER 32MG TAB FOR ORAL SUSP 1 NDS PA QL=120 EA/30 Días

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORSalyq 20mg tab 1 PAsildenafil 20mg tab 1 PAtadalafil 20mg tab(PAH) 1 PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONISTUPTRAVI 1000MCG TAB 1 NDS PAUPTRAVI 1200MCG TAB 1 NDS PAUPTRAVI 1400MCG TAB 1 NDS PAUPTRAVI 1600MCG TAB 1 NDS PAUPTRAVI 200MCG TAB 1 NDS PAUPTRAVI 400MCG TAB 1 NDS PAUPTRAVI 600MCG TAB 1 NDS PAUPTRAVI 800MCG TAB 1 NDS PAUPTRAVI TITRATION PACK 1 NDS PA QL=200 EA/28 Días

PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATORADEMPAS 0.5MG TAB 1 NDS PAADEMPAS 1.5MG TAB 1 NDS PAADEMPAS 1MG TAB 1 NDS PAADEMPAS 2.5MG TAB 1 NDS PAADEMPAS 2MG TAB 1 NDS PA

SINUS NODE INHIBITORSCORLANOR 5MG TAB 1 PACORLANOR 5MG/5ML ORAL SOLN 1 PACORLANOR 7.5MG TAB 1 PA

TRANSTHYRETIN STABILIZERSVYNDAMAX 61MG CAP 1 NDS PA QL=30 EA/30 Días

CEPHALOSPORINSCEPHALOSPORIN COMBINATIONS

AVYCAZ 2-0.5GM INJ 1 NDSZERBAXA 1.5GM INJ 1 NDS


69


Requisitos/Límites

CEPHALOSPORINS - 1ST GENERATIONcefadroxil 1000mg tab 1cefadroxil 100mg/ml susp 1cefadroxil 500mg cap 1cefadroxil 50mg/ml susp 1cefazolin 1gm inj 1cefazolin 200mg/ml inj 1cefazolin 500mg inj 1cephalexin 250mg cap 1cephalexin 25mg/ml susp 1cephalexin 500mg cap 1cephalexin 50mg/ml susp 1

CEPHALOSPORINS - 2ND GENERATIONcefaclor 250mg cap 1CEFACLOR 25MG/ML SUSP 1cefaclor 500mg cap 1CEFACLOR 50MG/ML SUSP 1CEFACLOR 75MG/ML SUSP 1cefotetan 1000mg inj 1cefotetan 2000mg inj 1cefoxitin 1000mg inj 1cefoxitin 2000mg inj 1cefoxitin 200mg/ml inj 1cefprozil 250mg tab 1cefprozil 25mg/ml susp 1cefprozil 500mg tab 1cefprozil 50mg/ml susp 1cefuroxime 1.5gm inj 1cefuroxime 250mg tab 1cefuroxime 500mg tab 1cefuroxime 750mg inj 1cefuroxime 95mg/ml inj 1

CEPHALOSPORINS - 3RD GENERATIONcefdinir 25mg/ml susp 1cefdinir 300mg cap 1cefdinir 50mg/ml susp 1cefixime 20mg/ml susp 1cefixime 400mg cap 1cefixime 40mg/ml susp 1cefpodoxime 100mg tab 1


70


Requisitos/Límites

cefpodoxime 10mg/ml susp 1cefpodoxime 200mg tab 1cefpodoxime 20mg/ml susp 1ceftazidime 1000mg inj 1ceftazidime 2000mg inj 1ceftazidime 200mg/ml inj 1ceftriaxone 1000mg inj 1ceftriaxone 100mg/ml inj 1ceftriaxone 2000mg inj 1ceftriaxone 250mg inj 1ceftriaxone 500mg inj 1SUPRAX 400MG CAP 1tazicef 1gm inj 1tazicef 2gm inj 1tazicef 6gm inj 1

CEPHALOSPORINS - 4TH GENERATIONcefepime 1gm inj 1cefepime 2gm inj 1

CEPHALOSPORINS - 5TH GENERATIONTEFLARO 400MG INJ 1 NDSTEFLARO 600MG INJ 1 NDS

CONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORAL

altavera 28 day pack 1alyacen 1/35 28 day pack 1amethia 91 day pack 1amethia lo 91 day pack 1apri 28 day pack 1aranelle 28 pack 1ashlyna 91 day pack 1aubra 28 day pack 1aviane 28 pack 1balziva 28 day pack 1blisovi 21 fe 1.5/30 28 day 1blisovi 24 fe 1/20 28 day pack 1briellyn 28 day pack 1camrese lo 91 day pack 1caziant 28 day pack 1cryselle 28 pack 1cyclafem 1/35 28 day pack 1


71


Requisitos/Límites

cyclafem 7/7/7 28 day pack 1cyred 28 day pack 1desogestrel/ethinyl estradiol 28 day pack 1desogestrel/ethinyl estradiol pack 1drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mgpack

1

drospirenone 3mg/ethinyl estradiol 0.03mg/inertingredients 1mg pack

1

emoquette pack 1enpresse 28 day pack 1enskyce 28 day pack 1estarylla 28 day pack 1ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack

1

ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack

1

ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack

1

ethinyl estradiol 0.025mg/inert/norgestimate0.18mg/0.215mg/0.25mg pack

1

ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack

1

ethinyl estradiol 0.02mg/norethindrone 1mg 21 day pack 1ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack 1ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack

1

ethinyl estradiol 0.035mg/inert/norgestimate0.18mg/0.215mg/0.25mg pack

1

ethinyl estradiol 0.035mg/norgestimate 0.25mg pack 1ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel0.05mg/ 0.075mg pack

1


1

ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28day pack

1

ethinyl estradiol 0.05mg/ethynodiol 1mg/inertingredients 1mg 28 day pack

1

ethinyl estradiol/levonorgestrel 91 day pack 1falmina 28 day pack 1fayosim 91 day pack 1femynor 28 day pack 1


72


Requisitos/Límites

gianvi 28-day pack 1hailey 24 fe 28 day pack 1introvale 91 day pack 1isibloom 28 day pack 1jasmiel 28 day pack 1juleber 28 day pack 1junel 1.5/30 21 day pack 1junel 1/20 21 day pack 1junel fe 1.5/30 28 day pack 1junel fe 1/20 28 day pack 1junel fe 24 1/20 28 day pack 1kaitlib fe 28 day pack 1kariva 28 day pack 1kelnor 1/35 28 day pack 1kelnor 1/50 28 day pack 1kurvelo 28 day pack 1larin 1.5/30 pack 1larin 1/20 pack 1larin fe 1.5/30 pack 1larin fe 1/20 pack 1larissia 28 day pack 1layolis fe 28 pack 1leena 28 day pack 1lessina 28 day pack 1levonest 28 day pack 1levora 0.15/30 28 day pack 1loryna 28 day pack 1low-ogestrel 28 day pack 1lutera 28 day pack 1marlissa 28 day pack 1microgestin 1.5/30 21 day pack 1microgestin 1/20 21 day pack 1microgestin fe 1.5/30 28 day pack 1microgestin fe 1/20 28 day pack 1mili 28 day pack 1NATAZIA 28 DAY PACK 1necon 0.5/35 28 day pack 1nikki 28 day pack 1nortrel 0.5/35 28 day pack 1nortrel 1/35 21 day pack 1


73


Requisitos/Límites

nortrel 1/35 28 day pack 1nortrel 7/7/7 28 day pack 1ocella 28 day pack 1orsythia 28 day pack 1pimtrea pack 1pirmella 1/35 28 day pack 1portia 28 day pack 1previfem 28 day pack 1reclipsen 28 day pack 1rivelsa 91 day pack 1setlakin 91 day pack 1sprintec 28 day pack 1sronyx 28 day pack 1syeda 28 day pack 1tarina 24 fe 1/20 28 day pack 1tarina fe 1/20 28 day pack 1tri-estarylla 28 day pack 1tri-legest 28 day pack 1tri-lo-estarylla 28 day pack 1tri-lo-sprintec 28 day pack 1tri-mili 28 day pack 1tri-previfem 28 day pack 1tri-sprintec 28 day pack 1tri-vylibra 28 day pack 1tri-vylibra lo 28 day pack 1trivora 28 day pack 1velivet 28 day pack 1vienva 28 day pack 1vyfemla 28 day pack 1vylibra 28 day pack 1wymzya fe 28 day pack 1zarah 3-0.03mg pack 1zovia 1/35e 28 day pack 1

COMBINATION CONTRACEPTIVES - TRANSDERMALXULANE 150-35MCG PATCH 1

COMBINATION CONTRACEPTIVES - VAGINALeluryng 0.120-0.015mg/24hr vaginal ring 1etonogestrel-ethinyl estradiol 0.120-0.015mg/24hrvaginal ring

1

NUVARING VAGINAL RING 1


74


Requisitos/Límites

PROGESTIN CONTRACEPTIVES - INJECTABLEmedroxyprogesterone acetate 150mg/ml inj 1medroxyprogesterone acetate 150mg/ml syringe 1

PROGESTIN CONTRACEPTIVES - ORALcamila 28 day 0.35mg pack 1deblitane 28 day 0.35mg pack 1errin 28 day 0.35mg pack 1incassia 28 day 0.35mg pack 1lyza 0.35mg pack 1nora-be 28 day 0.35mg pack 1norethindrone 0.35mg pack 1sharobel 28 day 0.35mg pack 1

CORTICOSTEROIDSGLUCOCORTICOSTEROIDS

budesonide 3mg dr cap 1budesonide 9mg er tab 1 PA QL=30 EA/30 DíasCORTISONE ACETATE 25MG TAB 1dexamethasone 0.1mg/ml oral soln 1dexamethasone 0.5mg tab 1dexamethasone 0.75mg tab 1dexamethasone 1.5mg tab 1DEXAMETHASONE 1MG TAB 1DEXAMETHASONE 1MG/ML ORAL SOLN 1DEXAMETHASONE 2MG TAB 1dexamethasone 4mg tab 1dexamethasone 6mg tab 1hydrocortisone 10mg tab 1hydrocortisone 20mg tab 1hydrocortisone 5mg tab 1MEDROL 2MG TAB 1methylprednisolone 16mg tab 1methylprednisolone 32mg tab 1methylprednisolone 4mg pack 1methylprednisolone 4mg tab 1methylprednisolone 8mg tab 1prednisolone 10mg odt 1prednisolone 15mg odt 1prednisolone 1mg/ml oral soln 1prednisolone 30mg odt 1PREDNISOLONE 3MG/ML ORAL SOLN 1


75


Requisitos/Límites

prednisone 10mg tab 1prednisone 1mg tab 1PREDNISONE 1MG/ML ORAL SOLN 1prednisone 2.5mg tab 1prednisone 20mg tab 1PREDNISONE 50MG TAB 1prednisone 5mg tab 1PREDNISONE 5MG/ML ORAL SOLN 1

MINERALOCORTICOIDSfludrocortisone 0.1mg tab 1

COUGH/COLD/ALLERGYCOUGH/COLD/ALLERGY COMBINATIONS

CLARINEX-D 2.5-120MG ER TAB 1PHENYLEPHRINE 1MG/ML/PROMETHAZINE1.25MG/ML ORAL SOLN

1

MUCOLYTICSacetylcysteine 10% inh soln 1 PA BvDacetylcysteine 20% inh soln 1 PA BvD

DERMATOLOGICALSACNE PRODUCTS

adapalene 0.1% cream 1 PAadapalene 0.1% gel 1 PAadapalene 0.3% gel 1 PAadapalene/benzoyl peroxide 0.1-2.5% gel 1 PAamnesteem 10mg cap 1amnesteem 20mg cap 1amnesteem 40mg cap 1avita 0.025% cream 1 PAavita 0.025% gel 1 PAclaravis 10mg cap 1claravis 20mg cap 1claravis 30mg cap 1claravis 40mg cap 1clindacin 1% pad 1clindamycin 1% foam 1clindamycin 1% gel 1clindamycin 1% lotion 1clindamycin 1% pad 1clindamycin 1% topical soln 1 QL=300 ML/30 Díasclindamycin/benzoyl peroxide 1-5% gel 1


76


Requisitos/Límites

DIFFERIN 0.1% LOTION 1 PAEPIDUO 0.3-2.5% GEL 1 PAery 2% pad 1erythromycin 2% gel 1erythromycin 2% topical soln 1erythromycin/benzoyl peroxide 5-3% gel 1isotretinoin 10mg cap 1isotretinoin 20mg cap 1isotretinoin 30mg cap 1isotretinoin 40mg cap 1myorisan 10mg cap 1myorisan 20mg cap 1myorisan 30mg cap 1myorisan 40mg cap 1sulfacetamide sodium 10% lotion 1tretinoin 0.01% gel 1 PAtretinoin 0.025% cream 1 PAtretinoin 0.025% gel 1 PAtretinoin 0.04% gel 1 PAtretinoin 0.05% cream 1 PAtretinoin 0.05% gel 1 PAtretinoin 0.1% cream 1 PAtretinoin 0.1% gel 1 PAzenatane 10mg cap 1zenatane 20mg cap 1zenatane 30mg cap 1zenatane 40mg cap 1

ANTI-INFLAMMATORY AGENTS - TOPICALdiclofenac sodium 1% gel 1 QL=1000 GM/30 Díasdiclofenac sodium 1.5% topical soln 1 QL=450 ML/30 Días

ANTIBIOTICS - TOPICALgentamicin sulfate 0.1% cream 1gentamicin sulfate 0.1% ointment 1mupirocin 2% ointment 1 QL=220 GM/30 Días

ANTIFUNGALS - TOPICALbetamethasone/clotrimazole 1-0.05% cream 1betamethasone/clotrimazole 1-0.05% lotion 1ciclopirox 0.77% cream 1ciclopirox 0.77% gel 1ciclopirox 0.77% lotion 1


77


Requisitos/Límites

ciclopirox 1% shampoo 1ciclopirox 8% topical soln 1clotrimazole 1% cream 1clotrimazole 1% topical soln 1econazole nitrate 1% cream 1ERTACZO 2% CREAM 1ketoconazole 2% cream 1ketoconazole 2% shampoo 1ketoconazole 20mg/ml foam 1ketodan 2% foam 1naftifine 1% cream 1naftifine 2% cream 1nyamyc 100000unit/gm powder 1nystatin 100000unit/ml cream 1nystatin 100unit/mg ointment 1nystatin 100unit/mg powder 1nystop 100000unit/gm powder 1

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICALdiclofenac sodium 3% gel 1 PA QL=300 GM/30 DíasFLUOROPLEX 1% CREAM 1FLUOROURACIL 0.5% CREAM 1FLUOROURACIL 2% TOPICAL SOLN 1fluorouracil 5% cream 1FLUOROURACIL 5% TOPICAL SOLN 1PANRETIN 0.1% GEL 1 NDSPICATO 0.015% GEL 1 NDS QL=3 EA/10 DíasPICATO 0.05% GEL 1 NDS QL=2 EA/10 DíasTARGRETIN 1% GEL 1 NDS PA NSOTOLAK 4% CREAM 1VALCHLOR 0.016% GEL 1 NDS PA NSO QL=240 GM/30 Días

ANTIPSORIATICSacitretin 10mg cap 1acitretin 17.5mg cap 1acitretin 25mg cap 1calcipotriene 0.005% cream 1 QL=240 GM/30 Díascalcipotriene 0.005% ointment 1 QL=240 GM/30 Díascalcipotriene 0.005% topical soln 1COSENTYX 150MG/ML AUTO-INJECTOR 1 NDS PACOSENTYX 150MG/ML SYRINGE 1 NDS PAmethoxsalen 10mg cap 1


78


Requisitos/Límites

SKYRIZI SYRINGE 150MG DOSE PACK 1 NDS PASTELARA 45MG/0.5ML INJ 1 PASTELARA 45MG/0.5ML SYRINGE 1 PASTELARA 90MG/ML SYRINGE 1 PAtazarotene 1% cream 1TAZORAC 0.05% CREAM 1TAZORAC 0.05% GEL 1TAZORAC 0.1% GEL 1

ANTISEBORRHEIC PRODUCTSselenium sulfide 2.5% lotion/shampoo 1

ANTIVIRALS - TOPICALacyclovir 5% ointment 1DENAVIR 1% CREAM 1

BURN PRODUCTSsilver sulfadiazine 1% cream 1ssd 1% cream 1SULFAMYLON 85MG/GM CREAM 1

CORTICOSTEROIDS - TOPICALala-cort 1% cream 1alclometasone dipropionate 0.05% cream 1alclometasone dipropionate 0.05% ointment 1AMCINONIDE 0.1% CREAM 1 PAAMCINONIDE 0.1% OINTMENT 1 PAbeser 0.05% lotion 1 PAbetamethasone 0.05% aug cream 1BETAMETHASONE 0.05% AUG GEL 1betamethasone 0.05% aug lotion 1betamethasone 0.05% aug ointment 1betamethasone 0.05% cream 1betamethasone 0.05% lotion 1betamethasone 0.05% ointment 1betamethasone 0.1% cream 1betamethasone 0.1% lotion 1betamethasone 0.1% ointment 1betamethasone valerate 0.12% foam 1 PAcalcipotriene/betamethasone 0.005-0.064% ointment 1 QL=420 GM/30 Díasclobetasol propionate 0.05% cream 1clobetasol propionate 0.05% e cream 1clobetasol propionate 0.05% e foam 1 PAclobetasol propionate 0.05% foam 1


79


Requisitos/Límites

clobetasol propionate 0.05% gel 1clobetasol propionate 0.05% lotion 1clobetasol propionate 0.05% ointment 1clobetasol propionate 0.05% shampoo 1clobetasol propionate 0.05% spray 1clobetasol propionate 0.05% topical soln 1 QL=450 ML/30 Díasclodan 0.05% shampoo 1desonide 0.05% cream 1 PAdesonide 0.05% lotion 1 PAdesonide 0.05% ointment 1desoximetasone 0.05% gel 1desoximetasone 0.25% cream 1desoximetasone 0.25% ointment 1fluocinolone acetonide 0.01% cream 1fluocinolone acetonide 0.01% topical soln 1fluocinolone acetonide 0.025% cream 1fluocinolone acetonide 0.025% ointment 1fluocinolone acetonide 0.1mg/ml oil 1fluocinonide 0.05% e cream 1fluocinonide 0.05% gel 1fluocinonide 0.05% ointment 1fluocinonide 0.05% topical soln 1fluticasone propionate 0.005% ointment 1fluticasone propionate 0.05% cream 1fluticasone propionate 0.05% lotion 1 PAhalobetasol propionate 0.05% cream 1halobetasol propionate 0.05% ointment 1hydrocortisone 1% cream 1hydrocortisone 2.5% cream 1hydrocortisone 2.5% lotion 1hydrocortisone 2.5% ointment 1hydrocortisone valerate 0.2% cream 1hydrocortisone valerate 0.2% ointment 1mometasone furoate 0.1% cream 1mometasone furoate 0.1% lotion 1mometasone furoate 0.1% ointment 1PREDNICARBATE 0.1% CREAM 1PREDNICARBATE 0.1% OINTMENT 1tovet 0.05% e foam 1 PAtriamcinolone acetonide 0.025% cream 1


80


Requisitos/Límites

triamcinolone acetonide 0.025% lotion 1triamcinolone acetonide 0.025% ointment 1triamcinolone acetonide 0.1% cream 1triamcinolone acetonide 0.1% lotion 1triamcinolone acetonide 0.1% ointment 1triamcinolone acetonide 0.147mg/ml spray 1triamcinolone acetonide 0.5% cream 1triamcinolone acetonide 0.5% ointment 1triderm 0.1% cream 1

ECZEMA AGENTSDUPIXENT 300MG/2ML PF SYRINGE 1 NDS PA

EMOLLIENTSammonium lactate 12% cream 1ammonium lactate 12% lotion 1

ENZYMES - TOPICALSANTYL 250UNIT/GM OINTMENT 1 QL=90 GM/30 Días

IMMUNOMODULATING AGENTS - TOPICALimiquimod 5% cream 1ZYCLARA 2.5% CREAM 1

IMMUNOSUPPRESSIVE AGENTS - TOPICALpimecrolimus 1% cream 1tacrolimus 0.03% ointment 1 QL=100 GM/30 Díastacrolimus 0.1% ointment 1 QL=100 GM/30 Días

KERATOLYTIC/ANTIMITOTIC AGENTSpodofilox 0.5% topical soln 1

LOCAL ANESTHETICS - TOPICALlidocaine 2% gel 1lidocaine 4% topical soln 1lidocaine 5% ointment 1 PA QL=107 GM/30 Díaslidocaine 5% patch 1 PA QL=90 EA/30 Díaslidocaine/prilocaine 2.5-2.5% cream 1 QL=60 GM/30 Días

ROSACEA AGENTSazelaic acid 15% gel 1FINACEA 15% FOAM 1metronidazole 0.75% cream 1metronidazole 0.75% gel 1metronidazole 0.75% lotion 1metronidazole 1% gel 1

SCABICIDES & PEDICULICIDESlindane 1% shampoo 1


81


Requisitos/Límites

malathion 0.5% lotion 1permethrin 5% cream 1

WOUND CARE PRODUCTSREGRANEX 0.01% GEL 1 NDS QL=30 GM/15 Días

DIGESTIVE AIDSDIGESTIVE ENZYMES

CREON 12000-38000-60000UNIT DR CAP 1CREON 24000-76000-120000UNIT DR CAP 1CREON 3000-9500-15000UNIT DR CAP 1CREON 36000-114000-180000UNIT DR CAP 1CREON 6000-19000-30000UNIT DR CAP 1SUCRAID 8500UNIT/ML ORAL SOLN 1 NDS PAZENPEP 10000-32000-42000UNIT DR CAP 1 STZENPEP 15000-47000-63000UNIT DR CAP 1 STZENPEP 20000-63000-84000UNIT DR CAP 1 STZENPEP 25000-79000-105000UNIT DR CAP 1 STZENPEP 3000-10000-14000UNIT DR CAP 1 STZENPEP 40000-126000-168000UNIT DR CAP 1 STZENPEP 5000-17000-24000UNIT DR CAP 1 ST

DIURETICSCARBONIC ANHYDRASE INHIBITORS

acetazolamide 125mg tab 1acetazolamide 250mg tab 1acetazolamide 500mg er cap 1methazolamide 25mg tab 1methazolamide 50mg tab 1

DIURETIC COMBINATIONSamiloride 5mg/hydrochlorothiazide 50mg tab 1hydrochlorothiazide 25mg/spironolactone 25mg tab 1hydrochlorothiazide 25mg/triamterene 37.5mg cap 1hydrochlorothiazide 25mg/triamterene 37.5mg tab 1hydrochlorothiazide 50mg/triamterene 75mg tab 1

LOOP DIURETICSbumetanide 0.25mg/ml inj 1bumetanide 0.5mg tab 1bumetanide 1mg tab 1bumetanide 2mg tab 1ethacrynic acid 25mg tab 1furosemide 10mg/ml inj 1furosemide 10mg/ml oral soln 1


82


Requisitos/Límites

furosemide 10mg/ml syringe 1furosemide 20mg tab 1furosemide 40mg tab 1furosemide 80mg tab 1FUROSEMIDE 8MG/ML ORAL SOLN 1torsemide 100mg tab 1torsemide 10mg tab 1torsemide 20mg tab 1torsemide 5mg tab 1

POTASSIUM SPARING DIURETICSamiloride 5mg tab 1DYRENIUM 100MG CAP 1DYRENIUM 50MG CAP 1spironolactone 100mg tab 1spironolactone 25mg tab 1spironolactone 50mg tab 1triamterene 100mg cap 1triamterene 50mg cap 1

THIAZIDES AND THIAZIDE-LIKE DIURETICSchlorthalidone 25mg tab 1chlorthalidone 50mg tab 1DIURIL 250MG/5ML SUSP 1hydrochlorothiazide 12.5mg cap 1hydrochlorothiazide 12.5mg tab 1hydrochlorothiazide 25mg tab 1hydrochlorothiazide 50mg tab 1indapamide 1.25mg tab 1indapamide 2.5mg tab 1metolazone 10mg tab 1metolazone 2.5mg tab 1metolazone 5mg tab 1

ENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORS

ALENDRONATE 0.933MG/ML ORAL SOLN 1alendronate 10mg tab 1alendronate 35mg tab 1alendronate 70mg tab 1FORTEO 600MCG/2.4ML PEN INJ 1 NDSibandronate 150mg tab 1 QL=1 EA/30 DíasNATPARA 100MCG CARTRIDGE 1 NDS PA


83


Requisitos/Límites

NATPARA 25MCG CARTRIDGE 1 NDS PANATPARA 50MCG CARTRIDGE 1 NDS PANATPARA 75MCG CARTRIDGE 1 NDS PAPROLIA 60MG/ML SYRINGE 1 PArisedronate sodium 150mg tab 1risedronate sodium 30mg tab 1risedronate sodium 35mg (12) pack 1risedronate sodium 35mg (4) pack 1risedronate sodium 35mg tab 1risedronate sodium 5mg tab 1salmon calcitonin 200unit/act nasal spray 1TYMLOS 2MG/ML PEN INJECTOR 1 NDSXGEVA 120MG/1.7ML INJ 1 NDS PA

GNRH/LHRH ANTAGONISTSORILISSA 150MG TAB 1 PA QL=30 EA/30 DíasORILISSA 200MG TAB 1 PA QL=60 EA/30 Días

GROWTH HORMONE RECEPTOR ANTAGONISTSSOMAVERT 10MG INJ 1 NDS PASOMAVERT 15MG INJ 1 NDS PASOMAVERT 20MG INJ 1 NDS PASOMAVERT 25MG INJ 1 NDS PASOMAVERT 30MG INJ 1 NDS PA

GROWTH HORMONESGENOTROPIN 0.2MG SYRINGE 1 NDS PAGENOTROPIN 0.4MG SYRINGE 1 NDS PAGENOTROPIN 0.6MG SYRINGE 1 NDS PAGENOTROPIN 0.8MG SYRINGE 1 NDS PAGENOTROPIN 1.2MG SYRINGE 1 NDS PAGENOTROPIN 1.4MG SYRINGE 1 NDS PAGENOTROPIN 1.6MG SYRINGE 1 NDS PAGENOTROPIN 1.8MG SYRINGE 1 NDS PAGENOTROPIN 12MG CARTRIDGE 1 NDS PAGENOTROPIN 1MG SYRINGE 1 NDS PAGENOTROPIN 2MG SYRINGE 1 NDS PAGENOTROPIN 5MG CARTRIDGE 1 NDS PA

HORMONE RECEPTOR MODULATORSOSPHENA 60MG TAB 1 PAraloxifene 60mg tab 1

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)INCRELEX 40MG/4ML INJ 1 NDS PA


84


Requisitos/Límites

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTSLUPANETA PACK 1-MONTH PACK 1 NDSLUPANETA PACK 3-MONTH PACK 1SYNAREL 2MG/ML NASAL SPRAY 1 NDS

METABOLIC MODIFIERScalcitriol 0.00025mg cap 1 PA BvDcalcitriol 0.0005mg cap 1 PA BvDcalcitriol 0.001mg/ml oral soln 1 PA BvDCARBAGLU 200MG SUSP 1 PAcinacalcet 30mg tab 1 PA BvDcinacalcet 60mg tab 1 PA BvDcinacalcet 90mg tab 1 PA BvDdoxercalciferol 0.0005mg cap 1 PA BvDdoxercalciferol 0.001mg cap 1 PA BvDdoxercalciferol 0.0025mg cap 1 PA BvDGALAFOLD 123MG CAP 1 NDS PA QL=15 EA/30 DíasKUVAN 100MG POWDER FOR ORAL SOLN 1 NDS PAKUVAN 100MG TAB 1 NDS PAKUVAN 500MG POWDER FOR ORAL SOLN 1 NDS PAlevocarnitine 100mg/ml oral soln 1 PA BvDlevocarnitine 330mg tab 1 PA BvDORFADIN 10MG CAP 1 NDS PAORFADIN 20MG CAP 1 NDS PAORFADIN 2MG CAP 1 NDS PAORFADIN 4MG/ML SUSP 1 NDS PAORFADIN 5MG CAP 1 NDS PAPALYNZIQ 10MG/0.5ML SYRINGE 1 NDS PAPALYNZIQ 2.5MG/0.5ML SYRINGE 1 NDS PAPALYNZIQ 20MG/ML SYRINGE 1 NDS PAparicalcitol 0.001mg cap 1 PA BvDparicalcitol 0.002mg cap 1 PA BvDparicalcitol 0.004mg cap 1 PA BvDRAVICTI 1.1GM/ML ORAL SOLN 1 NDS PAsodium phenylbutyrate 0.94mg/mg oral powder 1

POSTERIOR PITUITARY HORMONESdesmopressin acetate 0.01% nasal spray 1desmopressin acetate 0.1mg tab 1desmopressin acetate 0.2mg tab 1STIMATE 1.5MG/ML NASAL SPRAY 1

PROLACTIN INHIBITORS


85


Requisitos/Límites

cabergoline 0.5mg tab 1SOMATOSTATIC AGENTS

octreotide 0.05mg/ml inj 1octreotide 0.1mg/ml inj 1octreotide 0.2mg/ml inj 1octreotide 0.5mg/ml inj 1octreotide 1mg/ml inj 1SIGNIFOR 0.3MG/ML INJ 1 NDS PA QL=60 ML/30 DíasSIGNIFOR 0.6MG/ML INJ 1 NDS PA QL=60 ML/30 DíasSIGNIFOR 0.9MG/ML INJ 1 NDS PA QL=60 ML/30 DíasSOMATULINE 120MG/0.5ML SYRINGE 1 NDSSOMATULINE 60MG/0.2ML SYRINGE 1 NDSSOMATULINE 90MG/0.3ML SYRINGE 1 NDS

VASOPRESSIN RECEPTOR ANTAGONISTSJYNARQUE 15MG TAB 1 NDS PA QL=120 EA/30 DíasJYNARQUE 30MG TAB 1 NDS PA QL=120 EA/30 DíasJYNARQUE 45/15 THERAPY PACK 1 NDS PA QL=60 EA/30 DíasJYNARQUE 60/30 THERAPY PACK 1 NDS PA QL=60 EA/30 DíasJYNARQUE 90/30 THERAPY PACK 1 NDS PA QL=60 EA/30 Días

ESTROGENSESTROGEN COMBINATIONS

amabelz 0.5/0.1mg 28 day pack 1amabelz 1/0.5mg 28 day pack 1COMBIPATCH 0.05-0.14MG PATCH 1COMBIPATCH 0.05-0.25MG PATCH 1estradiol 0.5mg/norethindrone acetate 0.1mg pack 1estradiol 1mg/norethindrone acetate 0.5mg pack 1ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mgtab

1

ethinyl estradiol 0.005mg/norethindrone acetate 1mg tab 1fyavolv 0.5mg-2.5mcg tab 1fyavolv 1mg-5mcg tab 1jinteli tab 1lopreeza 1/0.5mg 28 day pack 1mimvey pack 1PREMPHASE 28 DAY PACK 1PREMPRO 0.3/1.5MG 28 DAY PACK 1PREMPRO 0.45/1.5 28 DAY PACK 1PREMPRO 0.625/2.5MG 28 DAY PACK 1PREMPRO 0.625/5MG 28 DAY PACK 1


86


Requisitos/Límites

ESTROGENSdotti 0.025mg/24hr patch 1dotti 0.0375mg/24hr patch 1dotti 0.05mg/24hr patch 1dotti 0.075mg/24hr patch 1dotti 0.1mg/24hr patch 1estradiol 0.00104mg/hr twice weekly patch 1estradiol 0.00104mg/hr weekly patch 1estradiol 0.00156mg/hr twice weekly patch 1estradiol 0.00156mg/hr weekly patch 1estradiol 0.00208mg/hr twice weekly patch 1estradiol 0.00208mg/hr weekly patch 1estradiol 0.0025mg/hr weekly patch 1estradiol 0.00312mg/hr weekly patch 1estradiol 0.00313mg/hr twice weekly patch 1estradiol 0.00417mg/hr twice weekly patch 1estradiol 0.00417mg/hr weekly patch 1estradiol 0.5mg tab 1estradiol 1mg tab 1estradiol 20mg/ml inj 1estradiol 2mg tab 1estradiol 40mg/ml inj 1PREMARIN 0.3MG TAB 1PREMARIN 0.45MG TAB 1PREMARIN 0.625MG TAB 1PREMARIN 0.9MG TAB 1PREMARIN 1.25MG TAB 1

FLUOROQUINOLONESFLUOROQUINOLONES

BAXDELA 400MG TAB 1 PA QL=60 EA/30 Díasciprofloxacin 250mg tab 1ciprofloxacin 2mg/ml inj 1ciprofloxacin 500mg tab 1ciprofloxacin 750mg tab 1levofloxacin 250mg tab 1levofloxacin 25mg/ml inj 1levofloxacin 25mg/ml oral soln 1levofloxacin 500mg tab 1levofloxacin 5mg/ml (150ml) inj 1levofloxacin 5mg/ml inj 1


87


Requisitos/Límites

levofloxacin 750mg tab 1moxifloxacin 1.6mg/ml inj 1moxifloxacin 400mg tab 1ofloxacin 400mg tab 1

GASTROINTESTINAL AGENTS - MISC.BILE ACID SYNTHESIS DISORDER AGENTS

CHOLBAM 250MG CAP 1 NDS PACHOLBAM 50MG CAP 1 NDS PA

FARNESOID X RECEPTOR (FXR) AGONISTSOCALIVA 10MG TAB 1 NDS PA QL=30 EA/30 DíasOCALIVA 5MG TAB 1 NDS PA QL=30 EA/30 Días

GALLSTONE SOLUBILIZING AGENTSCHENODAL 250MG TAB 1 NDSursodiol 250mg tab 1ursodiol 300mg cap 1ursodiol 500mg tab 1

GASTROINTESTINAL ANTIALLERGY AGENTScromolyn sodium 20mg/ml oral soln 1

GASTROINTESTINAL STIMULANTSmetoclopramide 10mg tab 1metoclopramide 1mg/ml oral soln 1metoclopramide 5mg tab 1

INFLAMMATORY BOWEL AGENTSAPRISO 0.375GM ER CAP 1balsalazide disodium 750mg cap 1CIMZIA 200MG INJ 1 NDS PACIMZIA 200MG/ML SYRINGE 1 NDS PADIPENTUM 250MG CAP 1mesalamine 1.2gm tab 1mesalamine 1000mg rectal supp 1mesalamine 375mg er cap 1mesalamine 400mg dr cap 1mesalamine 66.7mg/ml enema 1mesalamine 800mg dr tab 1sulfasalazine 500mg dr tab 1sulfasalazine 500mg tab 1

INTESTINAL ACIDIFIERSenulose 10gm/15ml oral soln 1generlac 10gm/15ml oral soln 1

IRRITABLE BOWEL SYNDROME (IBS) AGENTS


88


Requisitos/Límites

alosetron 0.5mg tab 1alosetron 1mg tab 1LINZESS 145MCG CAP 1 PALINZESS 290MCG CAP 1 PALINZESS 72MCG CAP 1 PA

PERIPHERAL OPIOID RECEPTOR ANTAGONISTSMOVANTIK 12.5MG TAB 1 PAMOVANTIK 25MG TAB 1 PARELISTOR 12MG/0.6ML INJ 1 PARELISTOR 12MG/0.6ML SYRINGE 1 PARELISTOR 8MG/0.4ML SYRINGE 1 PASYMPROIC 0.2MG TAB 1 PA

PHOSPHATE BINDER AGENTSAURYXIA 210MG TAB 1 PAcalcium acetate 667mg cap 1calcium acetate 667mg tab 1FOSRENOL 1000MG ORAL POWDER 1FOSRENOL 750MG ORAL POWDER 1lanthanum carbonate 1000mg chew tab 1lanthanum carbonate 500mg chew tab 1lanthanum carbonate 750mg chew tab 1PHOSLYRA 667MG/5ML ORAL SOLN 1sevelamer carbonate 2400mg oral susp 1sevelamer carbonate 800mg oral susp 1sevelamer carbonate 800mg tab 1

SHORT BOWEL SYNDROME (SBS) AGENTSGATTEX 5MG INJ 1 NDS PA

GENITOURINARY AGENTS - MISCELLANEOUSALKALINIZERS

potassium citrate 10meq er tab 1potassium citrate 15 meq er tab 1potassium citrate 5 meq er tab 1

CYSTINOSIS AGENTSCYSTAGON 150MG CAP 1CYSTAGON 50MG CAP 1

GENITOURINARY IRRIGANTSsodium chloride 0.9% soln 1

INTERSTITIAL CYSTITIS AGENTSELMIRON 100MG CAP 1

PROSTATIC HYPERTROPHY AGENTS


89


Requisitos/Límites

alfuzosin 10mg er tab 1dutasteride 0.5mg cap 1dutasteride 0.5mg/tamsulosin 0.4mg cap 1finasteride 5mg tab 1silodosin 4mg cap 1silodosin 8mg cap 1tamsulosin 0.4mg cap 1

URINARY STONE AGENTSLITHOSTAT 250MG TAB 1THIOLA 100MG DR TAB 1THIOLA 100MG TAB 1THIOLA 300MG DR TAB 1

GOUT AGENTSGOUT AGENT COMBINATIONS

colchicine 0.5mg/probenecid 500mg tab 1GOUT AGENTS

allopurinol 100mg tab 1allopurinol 300mg tab 1COLCHICINE 0.6MG CAP 1COLCHICINE 0.6MG TAB 1febuxostat 40mg tab 1 STfebuxostat 80mg tab 1 STMITIGARE 0.6MG CAP 1

URICOSURICSprobenecid 500mg tab 1

HEMATOLOGICAL AGENTS - MISC.BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant 10mg/ml syringe 1 NDS PACOMPLEMENT INHIBITORS

BERINERT 500UNIT INJ 1 NDS PACINRYZE 500UNIT INJ 1 NDS PAHAEGARDA 2000UNT INJ 1 NDS PAHAEGARDA 3000UNT INJ 1 NDS PARUCONEST 2100UNIT INJ 1 NDS PA

HEMATAOLOGIC - TYROSINE KINASE INHIBITORSTAVALISSE 100MG TAB 1 NDS PA QL=60 EA/30 DíasTAVALISSE 150MG TAB 1 NDS PA QL=60 EA/30 Días

HEMATORHEOLOGIC AGENTSpentoxifylline 400mg er tab 1

PLASMA KALLIKREIN INHIBITORS


90


Requisitos/Límites

TAKHZYRO 300MG/2ML INJ 1 NDS PA QL=4 ML/28 DíasPLATELET AGGREGATION INHIBITORS

anagrelide 0.5mg cap 1anagrelide 1mg cap 1aspirin 25mg/dipyridamole 200mg cap 1BRILINTA 60MG TAB 1BRILINTA 90MG TAB 1cilostazol 100mg tab 1cilostazol 50mg tab 1clopidogrel 75mg tab 1prasugrel 10mg tab 1prasugrel 5mg tab 1

HEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASE

CERDELGA 84MG CAP 1 NDS PA QL=60 EA/30 Díasmiglustat 100mg cap 1 NDS PA

AGENTS FOR SICKLE CELL ANEMIADROXIA 200MG CAP 1DROXIA 300MG CAP 1DROXIA 400MG CAP 1ENDARI 5000MG POWDER FOR ORAL SOLN 1 NDS PA QL=180 EA/30 Días

HEMATOPOIETIC GROWTH FACTORSARANESP 100MCG/0.5ML SYRINGE 1 PA BvD STARANESP 100MCG/ML INJ 1 PA BvD STARANESP 10MCG/0.4ML SYRINGE 1 PA BvD STARANESP 150MCG/0.3ML SYRINGE 1 PA BvD STARANESP 200MCG/0.4ML SYRINGE 1 PA BvD STARANESP 200MCG/ML INJ 1 PA BvD STARANESP 25MCG/0.42ML SYRINGE 1 PA BvD STARANESP 25MCG/ML INJ 1 PA BvD STARANESP 300MCG/0.6ML SYRINGE 1 PA BvD STARANESP 300MCG/ML INJ 1 PA BvD STARANESP 40MCG/0.4ML SYRINGE 1 PA BvD STARANESP 40MCG/ML INJ 1 PA BvD STARANESP 500MCG/ML SYRINGE 1 PA BvD STARANESP 60MCG/0.3ML SYRINGE 1 PA BvD STARANESP 60MCG/ML INJ 1 PA BvD STDOPTELET 20MG TAB 1 NDS PA QL=60 EA/30 DíasDOPTELET 40MG DAILY DOSE PACK 1 NDS PA QL=10 EA/5 DíasDOPTELET 60MG DAILY DOSE PACK 1 NDS PA QL=15 EA/5 Días


91


Requisitos/Límites

FULPHILA 6/0.6ML SYRINGE 1 NDSLEUKINE 250MCG INJ 1 NDS PAMULPLETA 3MG TAB 1 NDS PA QL=7 EA/7 DíasNIVESTYM 300MCG/0.5ML PF INJ 1 NDSNIVESTYM 300MCG/1ML INJ 1 NDSNIVESTYM 480MCG/0.8ML PF INJ 1 NDSNIVESTYM 480MCG/1.6ML INJ 1 NDSPROMACTA 12.5MG POWDER FOR ORAL SUSP 1 NDS PAPROMACTA 12.5MG TAB 1 NDS PAPROMACTA 25MG TAB 1 NDS PAPROMACTA 50MG TAB 1 NDS PAPROMACTA 75MG TAB 1 NDS PARETACRIT 10000UNIT/ML INJ 1 PA BvDRETACRIT 2000UNIT/ML INJ 1 PA BvDRETACRIT 3000UNIT/ML INJ 1 PA BvDRETACRIT 40000UNIT/ML INJ 1 PA BvDRETACRIT 4000UNIT/ML INJ 1 PA BvDUDENYCA 6MG/0.6ML SYRINGE 1 NDSZARXIO 300MCG/0.5ML SYRINGE 1 NDSZARXIO 480MCG/0.8ML SYRINGE 1 NDSZIEXTENZO 6MG/0.6ML SYRINGE 1 NDS

HEMOSTATICSHEMOSTATICS - SYSTEMIC

tranexamic acid 650mg tab 1HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

BARBITURATE HYPNOTICSphenobarbital 100mg tab 1phenobarbital 15mg tab 1phenobarbital 16.2mg tab 1phenobarbital 30mg tab 1phenobarbital 32.4mg tab 1phenobarbital 4mg/ml oral soln 1phenobarbital 60mg tab 1phenobarbital 64.8mg tab 1phenobarbital 97.2mg tab 1

NON-BARBITURATE HYPNOTICSestazolam 1mg tab 1estazolam 2mg tab 1eszopiclone 1mg tab 1 QL=30 EA/30 Díaseszopiclone 2mg tab 1 QL=30 EA/30 Días


92


Requisitos/Límites

eszopiclone 3mg tab 1 QL=30 EA/30 DíasFLURAZEPAM 15MG CAP 1FLURAZEPAM 30MG CAP 1temazepam 15mg cap 1temazepam 22.5mg cap 1temazepam 30mg cap 1temazepam 7.5mg cap 1triazolam 0.125mg tab 1triazolam 0.25mg tab 1zaleplon 10mg cap 1 QL=30 EA/30 Díaszaleplon 5mg cap 1 QL=30 EA/30 Díaszolpidem tartrate 10mg tab 1 QL=30 EA/30 Díaszolpidem tartrate 5mg tab 1 QL=60 EA/30 Días

SELECTIVE MELATONIN RECEPTOR AGONISTSHETLIOZ 20MG CAP 1 NDS PA QL=30 EA/30 Díasramelteon 8mg tab 1 QL=30 EA/30 Días

LAXATIVESLAXATIVE COMBINATIONS

CLENPIQ POWDER 1gavilyte-c oral soln 1gavilyte-g powder for oral soln 1gavilyte-n powder for oral soln 1peg 3350/electrolyte oral soln 1peg 3350/kcl/sodium bicarbonate/sodium chloridepowder for oral soln

1

trilyte powder for oral soln 1LAXATIVES - MISCELLANEOUS

constulose 10gm/15ml oral soln 1lactulose 667mg/ml oral soln 1

MACROLIDESAZITHROMYCIN

azithromycin 20mg/ml susp 1azithromycin 250mg pack 1azithromycin 250mg tab 1azithromycin 2mg/ml inj 1azithromycin 40mg/ml susp 1azithromycin 500mg (3) tab pack 1azithromycin 500mg tab 1azithromycin 600mg tab 1

CLARITHROMYCIN


93


Requisitos/Límites

clarithromycin 250mg tab 1CLARITHROMYCIN 25MG/ML SUSP 1clarithromycin 500mg er tab 1clarithromycin 500mg tab 1CLARITHROMYCIN 50MG/ML SUSP 1

ERYTHROMYCINSERYTHROCIN LACTOBIONATE 500MG INJ 1erythromycin 250mg dr cap 1erythromycin 250mg tab 1erythromycin 500mg tab 1erythromycin ethylsuccinate 40mg/ml susp 1erythromycin ethylsuccinate 80mg/ml oral susp 1

MEDICAL DEVICESPARENTERAL THERAPY SUPPLIES

INSULIN SYRINGE (DISP) U-100 1/2ML 1MEDICAL DEVICES AND SUPPLIES

BANDAGES-DRESSINGS-TAPEGAUZE PAD 1

MISC. DEVICESISOPROPYL ALCOHOL 0.7ML/ML PAD 1

PARENTERAL THERAPY SUPPLIESINSULIN PEN NEEDLE 1INSULIN SYRINGE (DISP) U-100 0.3ML 1INSULIN SYRINGE (DISP) U-100 1ML 1INSULIN SYRINGE MIS 1ML/29G 1

MIGRAINE PRODUCTSMIGRAINE PRODUCTS

DIHYDROERGOTAMINE MESYLATE 0.5MG/ACTNASAL SPRAY

1 QL=16 ML/30 Días

MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIESAIMOVIG 140MG/ML AUTO-INJECTOR 1 PAAIMOVIG 70MG/ML AUTO-INJECTOR 1 PAEMGALITY 100MG/ML SYRINGE 1 PAEMGALITY 120MG/ML AUTO-INJECTOR 1 PAEMGALITY 120MG/ML SYRINGE 1 PA

SEROTONIN AGONISTSeletriptan 20mg tab 1 QL=18 EA/30 Díaseletriptan 40mg tab 1 QL=18 EA/30 Díasnaratriptan 1mg tab 1 QL=18 EA/30 Díasnaratriptan 2.5mg tab 1 QL=18 EA/30 Días


94


Requisitos/Límites

rizatriptan 10mg odt 1 QL=36 EA/60 Díasrizatriptan 10mg tab 1 QL=36 EA/60 Díasrizatriptan 5mg odt 1 QL=36 EA/60 Díasrizatriptan 5mg tab 1 QL=36 EA/60 Díassumatriptan 100mg tab 1 QL=18 EA/30 Díassumatriptan 12mg/ml auto-injector 1 QL=5 ML/30 Díassumatriptan 12mg/ml inj 1 QL=5 ML/30 DíasSUMATRIPTAN 12MG/ML SYRINGE 1 QL=5 ML/30 Díassumatriptan 20mg/act nasal spray 1 QL=12 EA/30 Díassumatriptan 25mg tab 1 QL=18 EA/30 Díassumatriptan 4mg cartridge 1 QL=5 ML/30 Díassumatriptan 50mg tab 1 QL=18 EA/30 Díassumatriptan 5mg/act nasal spray 1 QL=12 EA/30 Díassumatriptan 6mg cartridge 1 QL=5 ML/30 Díassumatriptan 8mg/ml auto-injector 1 QL=5 ML/30 Díaszolmitriptan 2.5mg odt 1 QL=18 EA/30 Díaszolmitriptan 2.5mg tab 1 QL=18 EA/30 Díaszolmitriptan 5mg odt 1 QL=18 EA/30 Díaszolmitriptan 5mg tab 1 QL=18 EA/30 DíasZOMIG 2.5MG NASAL SPRAY 1 QL=16 EA/30 DíasZOMIG 5MG NASAL SPRAY 1 QL=12 EA/30 Días

MINERALS & ELECTROLYTESELECTROLYTE MIXTURES

GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342MEQ/ML INJ

1 PA BvD


1 PA BvD


1

glucose 50 mg/ml/potassium chloride 0.04meq/ml/sodium chloride 4.5mg/ml inj

1

glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml inj

1

glucose 50mg/ml/potassium chloride 0.02 meq/ml inj 1glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.0342 meq/ml inj

1


1

glucose 50mg/ml/potassium chloride 0.02meq/ml/sodiumchloride 4.5mg/ml inj

1


95


Requisitos/Límites


1

GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04MEQ/ML INJ

1

GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ

1

glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj 1GLUCOSE 50MG/ML/SODIUM CHLORIDE 0.0385MEQ/ML INJ

1

glucose 50mg/ml/sodium chloride 4.5mg/ml inj 1glucose 50mg/ml/sodium chloride 9mg/ml inj 1ISOLYTE P INJ 1ISOLYTE S INJ 1KCL/D5W/LR INJ 0.15% 1NORMOSOL-M INJ 1NORMOSOL-R IN 5% DEXTROSE INJ 1NORMOSOL-R INJ 1PLASMA-LYTE 148 INJ 1PLASMALYTE A INJ 1potassium chloride 0.02 meq/ml/sodium chloride 0.0769meq/ml inj

1

potassium chloride 0.02 meq/ml/sodium chloride 0.154meq/ml inj

1

potassium chloride 0.04 meq/ml/sodium chloride 0.154meq/ml inj

1

TPN ELECTROLYTES INJ 1 PA BvDMAGNESIUM

magnesium sulfate 50% inj 1magnesium sulfate 50% syringe 1

POTASSIUMK-TAB 20MEQ ER TAB 1K-TAB 8MEQ ER TAB 1klor-con 10meq er micro tab 1klor-con 10meq er tab 1KLOR-CON 15MEQ ER TAB 1klor-con 20meq er micro tab 1klor-con 20meq powder 1klor-con 8meq er tab 1potassium chloride 0.1 meq/ml inj 1potassium chloride 0.2meq/ml inj 1potassium chloride 0.4meq/ml inj 1


96


Requisitos/Límites

potassium chloride 10% oral soln 1potassium chloride 10meq er cap 1potassium chloride 10meq er micro tab 1potassium chloride 10meq er tab 1potassium chloride 20% oral soln 1potassium chloride 20meq er micro tab 1POTASSIUM CHLORIDE 20MEQ ER TAB 1potassium chloride 20meq powder for oral soln 1potassium chloride 2meq/ml inj 1potassium chloride 40meq/20ml inj 1potassium chloride 8 meq er cap 1potassium chloride 8 meq er tab 1

SODIUMsodium chloride 0.45% inj 1sodium chloride 0.9% inj 1sodium chloride 3% inj 1sodium chloride 5% inj 1

MISCELLANEOUS THERAPEUTIC CLASSESCHELATING AGENTS

DEPEN 250MG TAB 1penicillamine 250mg tab 1trientine 250mg tab 1 PA

IMMUNOMODULATORSREVLIMID 10MG CAP 1 NDS PA NSO QL=30 EA/30 DíasREVLIMID 15MG CAP 1 NDS PA NSO QL=30 EA/30 DíasREVLIMID 2.5MG CAP 1 NDS PA NSO QL=30 EA/30 DíasREVLIMID 20MG CAP 1 NDS PA NSO QL=30 EA/30 DíasREVLIMID 25MG CAP 1 NDS PA NSO QL=30 EA/30 DíasREVLIMID 5MG CAP 1 NDS PA NSO QL=30 EA/30 DíasTHALOMID 100MG CAP 1 NDS PA NSOTHALOMID 150MG CAP 1 NDS PA NSOTHALOMID 200MG CAP 1 NDS PA NSOTHALOMID 50MG CAP 1 NDS PA NSO

IMMUNOSUPPRESSIVE AGENTSASTAGRAF 0.5MG XL CAP 1 PA BvDASTAGRAF 1MG XL CAP 1 PA BvDASTAGRAF 5MG XL CAP 1 PA BvDcyclosporine modified 100mg/ml oral soln 1 PA BvDCYCLOSPORINE MODIFIED 50MG CAP 1 PA BvDENVARSUS 0.75MG ER TAB 1 PA BvD


97


Requisitos/Límites

ENVARSUS 1MG ER TAB 1 PA BvDENVARSUS 4MG ER TAB 1 PA BvDPROGRAF 0.2MG GRANULES PACKET 1 PA BvDPROGRAF 1MG GRANULES PACKET 1 PA BvDsirolimus 1mg/ml oral soln 1 PA BvDZORTRESS 0.25MG TAB 1 PA BvDZORTRESS 0.5MG TAB 1 PA BvDZORTRESS 0.75MG TAB 1 PA BvDZORTRESS 1MG TAB 1 PA BvD

POTASSIUM REMOVING AGENTSLOKELMA 10GM PACKET 1 PALOKELMA 5GM PACKET 1 PAVELTASSA 16.8GM POWDER FOR ORAL SUSP 1 PAVELTASSA 25.2GM POWDER FOR ORAL SUSP 1 PAVELTASSA 8.4GM POWDER FOR ORAL SUSP 1 PA

SYSTEMIC LUPUS ERYTHEMATOSUS AGENTSBENLYSTA 200MG/ML AUTO-INJECTOR 1 NDS PA QL=4 ML/28 DíasBENLYSTA 200MG/ML SYRINGE 1 NDS PA QL=4 ML/28 Días

MOUTH/THROAT/DENTAL AGENTSANESTHETICS TOPICAL ORAL

lidocaine 2% topical soln 1ANTI-INFECTIVES - THROAT

clotrimazole 10mg lozenge 1nystatin 100000unit/ml susp 1

ANTISEPTICS - MOUTH/THROATchlorhexidine gluconate 0.12% mouthwash 1

STEROIDS - MOUTH/THROATtriamcinolone acetonide 0.1% paste 1

THROAT PRODUCTS - MISC.cevimeline 30mg cap 1pilocarpine 5mg tab 1pilocarpine 7.5mg tab 1

MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS

baclofen 10mg tab 1baclofen 20mg tab 1carisoprodol 350mg tab 1CHLORZOXAZONE 500MG TAB 1cyclobenzaprine 10mg tab 1cyclobenzaprine 5mg tab 1


98


Requisitos/Límites

cyclobenzaprine 7.5mg tab 1METAXALONE 400MG TAB 1metaxalone 800mg tab 1methocarbamol 500mg tab 1methocarbamol 750mg tab 1orphenadrine citrate 100mg er tab 1tizanidine 2mg cap 1tizanidine 2mg tab 1tizanidine 4mg cap 1tizanidine 4mg tab 1tizanidine 6mg cap 1

DIRECT MUSCLE RELAXANTSdantrolene sodium 100mg cap 1dantrolene sodium 25mg cap 1dantrolene sodium 50mg cap 1

NASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGY

azelastine 0.1% (137mcg) nasal inhaler 1azelastine 0.15% (205.5mcg) nasal inhaler 1olopatadine 0.6% nasal inhaler 1

NASAL ANTICHOLINERGICSipratropium bromide 0.03% nasal inhaler 1ipratropium bromide 0.06% nasal inhaler 1

NASAL STEROIDSFLUNISOLIDE 25MCG NASAL INHALER 1 QL=50 ML/30 Díasfluticasone propionate 50mcg nasal inhaler 1 QL=32 GM/30 Días

NEUROMUSCULAR AGENTSALS AGENTS

riluzole 50mg tab 1NUTRIENTS

CARBOHYDRATESglucose 10% inj 1 PA BvDglucose 100mg/ml inj 1

LIPIDSintralipid 200mg/ml inj 1 PA BvDnutrilipid 20% iv soln 1 PA BvD

PROTEINSAMINOSYN II 10% INJ 1 PA BvDAMINOSYN-PF 10% SULFITE-FREE INJ 1 PA BvDAMINOSYN-PF 7% INJ 1 PA BvD


99


Requisitos/Límites

CLINIMIX 4.25/10 INJ 1 PA BvDCLINIMIX 4.25/5 INJ 1 PA BvDCLINIMIX 5/15 INJ 1 PA BvDCLINIMIX 5/20 INJ 1 PA BvDCLINIMIX E 2.75/5 INJ 1 PA BvDCLINIMIX E 4.25/10 INJ 1 PA BvDCLINIMIX E 4.25/5 INJ 1 PA BvDCLINIMIX E 5/15 INJ 1 PA BvDCLINIMIX E 5/20 INJ 1 PA BvDclinisol 15% inj 1 PA BvDFREAMINE 6.9% INJ 1 PA BvDHEPATAMINE 8% INJ 1 PA BvDNEPHRAMINE 5.4% INJ 1 PA BvDplenamine 15% inj 1 PA BvDPREMASOL 10% INJ 1 PA BvDPROCALAMINE 3% INJ 1 PA BvDPROSOL 20% INJ 1 PA BvDTRAVASOL 10% INJ 1 PA BvDTROPHAMINE 10% INJ 1 PA BvD

OPHTHALMIC AGENTSARTIFICIAL TEARS AND LUBRICANTS

LACRISERT 5MG IMPLANT 1BETA-BLOCKERS - OPHTHALMIC

betaxolol 0.5% ophth soln 1BETIMOL 0.25% OPHTH SOLN 1BETIMOL 0.5% OPHTH SOLN 1BETOPTIC S 0.25% OPHTH SUSP 1CARTEOLOL 1% OPHTH SOLN 1COMBIGAN 0.2-0.5% OPHTH SOLN 1dorzolamide 20mg/ml/timolol 5mg/ml ophth soln 1dorzolamide/timolol 22.3-6.8mg/ml ophth soln(preservative-free)

1

levobunolol 0.5% ophth soln 1TIMOLOL 0.25% OPHTH GEL 1timolol 0.25% ophth soln 1TIMOLOL 0.5% OPHTH GEL 1timolol 0.5% ophth soln 1timolol 5mg/ml ophth 24hr ophth soln 1TIMOPTIC-XE 0.25% OPHTH GEL 1TIMOPTIC-XE 0.5% OPHTH GEL 1


100


Requisitos/Límites

CYCLOPLEGIC MYDRIATICSATROPINE SULFATE 1% OPHTH SOLN 1

MIOTICSPHOSPHOLINE IODIDE 0.125% OPHTH SOLN 1pilocarpine 1% ophth soln 1pilocarpine 2% ophth soln 1pilocarpine 4% ophth soln 1

OPHTHALMIC ADRENERGIC AGENTSALPHAGAN P 0.1% OPHTH SOLN 1apraclonidine 0.5% ophth soln 1brimonidine tartrate 0.15% ophth soln 1brimonidine tartrate 0.2% ophth soln 1IOPIDINE 1% OPHTH SOLN 1SIMBRINZA 1-0.2% OPHTH SUSP 1

OPHTHALMIC ANTI-INFECTIVESAZASITE 1% OPHTH SOLN 1BACITRACIN 0.5UNIT/MG OPHTH OINTMENT 1bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophthointment

1

ciprofloxacin 0.3% ophth soln 1erythromycin 0.005mg/mg ophth ointment 1gatifloxacin 0.5% ophth soln 1GENTAK 0.3% OPHTH OINTMENT 1gentamicin sulfate 0.3% ophth soln 1GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN

1

levofloxacin 0.5% ophth soln 1moxifloxacin 0.5% ophth soln 1NATACYN 5% OPHTH SUSP 1neomycin/bacitracin/polymyxin ophth ointment5(3.5)mg-400unit-10000unit

1

ofloxacin 0.3% ophth soln 1polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophthsoln

1

SULFACETAMIDE SODIUM 10% OPHTHOINTMENT

1

sulfacetamide sodium 10% ophth soln 1tobramycin 0.3% ophth soln 1TRIFLURIDINE 1% SOLN 1ZIRGAN 0.15% OPHTH GEL 1

OPHTHALMIC IMMUNOMODULATORS


101


Requisitos/Límites

RESTASIS 0.05% OPHTH SUSP 1OPHTHALMIC LOCAL ANESTHETICS

proparacaine 0.5% ophth soln 1OPHTHALMIC NERVE GROWTH FACTORS

OXERVATE 0.002% OPHTH SOLN 1 NDS PA QL=112 ML/365 DíasOPHTHALMIC STEROIDS

ALREX 0.2% OPHTH SUSP 1BLEPHAMIDE 10-0.2% OPHTH SUSP 1DEXAMETHASONE 0.1% OPHTH SOLN 1dexamethasone/neomycin/polymyxin b 0.1% ophthointment

1

dexamethasone/neomycin/polymyxin b 0.1% ophth susp 1dexamethasone/tobramycin 0.3-0.1% ophth susp 1DUREZOL 0.05% OPHTH SUSP 1fluorometholone 0.1% ophth susp 1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxinb 10000unit/ml ophth susp

1

LOTEMAX 0.5% OPHTH GEL 1LOTEMAX 0.5% OPHTH OINTMENT 1loteprednol etabonate 0.5% ophth susp 1MAXIDEX 0.1% OPHTH SUSP 1neomycin/polymyxin/bacitracin/hydrocortisone ophthointmentment 1%

1

PRED MILD 0.12% OPHTH SUSP 1PRED-G 0.3-1% OPHTH SUSP 1PREDNISOLONE 1% OPHTH SOLN 1PREDNISOLONE ACETATE 1% OPHTH SUSP 1PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTHSOLN

1

TOBRADEX 0.3-0.1% OPHTH OINTMENT 1ZYLET 0.5-0.3% OPHTH SUSP 1

OPHTHALMICS - MISC.ALOCRIL 2% OPHTH SOLN 1ALOMIDE 0.1% OPHTH SOLN 1azelastine 0.05% ophth soln 1AZOPT 1% OPHTH SUSP 1BROMFENAC 0.09% OPHTH SOLN 1cromolyn sodium 4% ophth soln 1CYSTARAN 0.44% OPHTH SOLN 1 NDS PA QL=60 ML/30 Díasdiclofenac sodium 0.1% ophth soln 1


102


Requisitos/Límites

dorzolamide 2% ophth soln 1epinastine 0.05% ophth soln 1flurbiprofen sodium 0.03% ophth soln 1ILEVRO 0.3% OPHTH SUSP 1ketorolac tromethamine 0.4% ophth soln 1ketorolac tromethamine 0.5% ophth soln 1NEVANAC 0.1% OPHTH SUSP 1olopatadine 1mg/ml ophth soln 1olopatadine 2% ophth soln 1

PROSTAGLANDINS - OPHTHALMICbimatoprost 0.03% ophth soln 1 QL=5 ML/30 Díaslatanoprost 0.005% ophth soln 1 QL=5 ML/30 DíasLUMIGAN 0.01% OPHTH SOLN 1 QL=5 ML/30 DíasTRAVATAN Z 0.004% OPHTH SOLN 1 QL=5 ML/30 Díastravoprost 0.004% ophth soln 1 QL=5 ML/30 Días

OTIC AGENTSOTIC AGENTS - MISCELLANEOUS

acetic acid 2% otic soln 1OTIC ANTI-INFECTIVES

CETRAXAL 0.2% OTIC SOLN 1CIPROFLOXACIN 0.2% OTIC SOLN 1ofloxacin 0.3% otic soln 1

OTIC COMBINATIONSCIPRODEX 0.3-0.1% OTIC SUSP 1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxinb 10000unit/ml otic soln

1

hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxinb 10000unit/ml otic susp

1

OTIC STEROIDSacetic acid/hydrocortisone 1-2% otic soln 1fluocinolone acetonide 0.01% otic oil 1fluocinolone acetonide 0.01% otic soln 1

PASSIVE IMMUNIZING AND TREATMENT AGENTSIMMUNE SERUMS

BIVIGAM 5GM/50ML INJ 1 NDS PAFLEBOGAMMA 10% INJ 1 NDS PAGAMMAGARD 10GM INJ 1 NDS PAGAMMAGARD 2.5GM/25ML INJ 1 NDS PAGAMMAGARD 5GM INJ 1 NDS PAGAMMAKED 1GM/10ML INJ 1 NDS PA


103


Requisitos/Límites

GAMMAPLEX 10GM/100ML INJ 1 NDS PAGAMMAPLEX 10GM/200ML INJ 1 NDS PAGAMMAPLEX 20GM/200ML INJ 1 NDS PAGAMMAPLEX 5GM/50ML INJ 1 NDS PAGAMUNEX 1GM/10ML INJ 1 NDS PAOCTAGAM 25GM/500ML INJ 1 NDS PAOCTAGAM 2GM/20ML INJ 1 NDS PAPANZYGA 10GM/100ML IV SOLN 1 NDS PAPANZYGA 1GM/10ML IV SOLN 1 NDS PAPANZYGA 2.5GM/25ML IV SOLN 1 NDS PAPANZYGA 20GM/200ML IV SOLN 1 NDS PAPANZYGA 30GM/300ML IV SOLN 1 NDS PAPANZYGA 5GM/50ML IV SOLN 1 NDS PAPRIVIGEN 20GM/200ML INJ 1 NDS PAVARIZIG 124.8/1.2ML INJ 1 NDS

PENICILLINSAMINOPENICILLINS

amoxicillin 125mg chew tab 1amoxicillin 250mg cap 1AMOXICILLIN 250MG CHEW TAB 1amoxicillin 25mg/ml susp 1amoxicillin 40mg/ml susp 1amoxicillin 500mg cap 1amoxicillin 500mg tab 1amoxicillin 50mg/ml susp 1amoxicillin 80mg/ml susp 1amoxicillin 875mg tab 1ampicillin 100mg/ml inj 1AMPICILLIN 125MG/ML INJ 1ampicillin 250mg/ml inj 1AMPICILLIN 500MG CAP 1

NATURAL PENICILLINSBICILLIN L-A 1200000UNIT/2ML SYRINGE 1BICILLIN L-A 2400000UNIT/4ML SYRINGE 1BICILLIN L-A 600000UNIT/ML SYRINGE 1penicillin g potassium 1000000unit/ml inj 1PENICILLIN G POTASSIUM 40000UNIT/ML INJ 1PENICILLIN G POTASSIUM 60000UNIT/ML INJ 1PENICILLIN G PROCAINE 600000UNIT/MLSYRINGE

1


104


Requisitos/Límites

PENICILLIN G SODIUM 100000UNIT/ML INJ 1penicillin v potassium 250mg tab 1PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN 1penicillin v potassium 500mg tab 1PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN 1

PENICILLIN COMBINATIONSamoxicillin 120mg/ml/clavulanate 8.58mg/ml susp 1AMOXICILLIN 200MG/CLAVULANATE 28.5MGCHEW TAB

1

amoxicillin 250mg/clavulanate 125mg tab 1AMOXICILLIN 400MG/CLAVULANATE 57MGCHEW TAB

1

amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp 1amoxicillin 500mg/clavulanate 125mg tab 1amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp 1amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp 1amoxicillin 875mg/clavulanate 125mg tab 1ampicillin 20mg/ml/sulbactam 10mg/ml inj 1ampicillin 250mg/ml/sulbactam 125mg/ml inj 1BICILLIN 300000-300000UNIT/ML SYRINGE 1BICILLIN 450000-150000UNIT/ML SYRINGE 1piperacillin 2000mg/tazobactam 250mg inj 1piperacillin 200mg/ml/tazobactam 25mg/ml inj 1piperacillin 3000mg/tazobactam 375mg inj 1piperacillin 4000mg/tazobactam 500mg inj 1ZOSYN 40-5MG/ML INJ 1ZOSYN 60-7.5MG/ML INJ 1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin 250mg cap 1dicloxacillin 500mg cap 1nafcillin 100mg/ml inj 1nafcillin 1gm inj 1nafcillin 2gm inj 1oxacillin 100mg/ml inj 1oxacillin 1gm inj 1oxacillin 2000mg inj 1OXACILLIN 20MG/ML INJ 1OXACILLIN 40MG/ML INJ 1

PROGESTINSPROGESTINS


105


Requisitos/Límites

medroxyprogesterone acetate 10mg tab 1medroxyprogesterone acetate 2.5mg tab 1medroxyprogesterone acetate 5mg tab 1megestrol acetate 125mg/ml susp 1 PAnorethindrone acetate 5mg tab 1progesterone 100mg cap 1progesterone 200mg cap 1

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calcium 333mg dr tab 1disulfiram 250mg tab 1disulfiram 500mg tab 1

ANTI-CATAPLECTIC AGENTSXYREM 500MG/ML ORAL SOLN 1 NDS PA QL=540 ML/30 Días

ANTIDEMENTIA AGENTSdonepezil 10mg odt 1 QL=30 EA/30 Díasdonepezil 10mg tab 1donepezil 23mg tab 1 ST QL=30 EA/30 Díasdonepezil 5mg odt 1 QL=30 EA/30 Díasdonepezil 5mg tab 1galantamine 12mg tab 1galantamine 4mg tab 1galantamine 8mg tab 1galantamine hydrobromide 16mg er cap 1galantamine hydrobromide 24mg er cap 1GALANTAMINE HYDROBROMIDE 4MG/ML ORALSOLN

1

galantamine hydrobromide 8mg er cap 1memantine 10mg tab 1memantine 10mg/memantine 5mg pack 1memantine 14mg er cap 1memantine 21mg er cap 1memantine 28mg er cap 1memantine 2mg/ml oral soln 1memantine 5mg tab 1memantine 7mg er cap 1rivastigmine 1.5mg cap 1rivastigmine 13.3mg/24hr patch 1rivastigmine 3mg cap 1rivastigmine 4.5mg cap 1


106


Requisitos/Límites

rivastigmine 4.6mg/24hr patch 1rivastigmine 6mg cap 1rivastigmine 9.5mg/24hr patch 1

COMBINATION PSYCHOTHERAPEUTICSAMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB 1AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB 1amitriptyline 12.5mg/chlordiazepoxide 5mg tab 1amitriptyline 25mg/chlordiazepoxide 10mg tab 1AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB 1AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB 1AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB 1fluoxetine 25mg/olanzapine 12mg cap 1fluoxetine 25mg/olanzapine 3mg cap 1fluoxetine 25mg/olanzapine 6mg cap 1fluoxetine 50mg/olanzapine 12mg cap 1fluoxetine 50mg/olanzapine 6mg cap 1

FIBROMYALGIA AGENTSSAVELLA 100MG TAB 1 QL=60 EA/30 DíasSAVELLA 12.5MG TAB 1 QL=60 EA/30 DíasSAVELLA 25MG TAB 1 QL=60 EA/30 DíasSAVELLA 4-WEEK TITRATION PACK 1SAVELLA 50MG TAB 1 QL=60 EA/30 Días

MOVEMENT DISORDER DRUG THERAPYAUSTEDO 12MG TAB 1 NDS PAAUSTEDO 6MG TAB 1 NDS PAAUSTEDO 9MG TAB 1 NDS PAINGREZZA 40MG CAP 1 NDS PAINGREZZA 80MG CAP 1 NDS PAtetrabenazine 12.5mg tab 1 NDS PAtetrabenazine 25mg tab 1 NDS PA

MULTIPLE SCLEROSIS AGENTSAUBAGIO 14MG TAB 1 NDSAUBAGIO 7MG TAB 1 NDSAVONEX 30MCG/0.5ML AUTO-INJECTOR 1 NDSAVONEX 30MCG/0.5ML SYRINGE 1 NDSdalfampridine 10mg er tab 1 PA QL=60 EA/30 DíasEXTAVIA 0.3MG INJ 1 NDSGILENYA 0.5MG CAP 1 NDSglatiramer 20mg/ml syringe 1 NDSglatiramer 40mg/ml syringe 1 NDS


107


Requisitos/Límites

glatopa 20mg/ml syringe 1 NDSglatopa 40mg/ml syringe 1 NDSMAYZENT 0.25MG TAB 1 NDSMAYZENT 2MG TAB 1 NDSPLEGRIDY 125MCG/0.5ML AUTO-INJECTOR 1 NDSPLEGRIDY 125MCG/0.5ML SYRINGE 1 NDSPLEGRIDY PEN STARTER PACK 1 NDSPLEGRIDY STARTER PACK 1 NDSREBIF 22MCG/0.5ML AUTO-INJECTOR 1 NDSREBIF 22MCG/0.5ML SYRINGE 1 NDSREBIF 44MCG/0.5ML AUTO-INJECTOR 1 NDSREBIF 44MCG/0.5ML SYRINGE 1 NDSREBIF REBIDOSE PACK 1 NDSREBIF TITRATION PACK 1 NDSTECFIDERA 120MG DR CAP 1 NDSTECFIDERA 240MG DR CAP 1 NDSTECFIDERA 30-DAY STARTER PACK 1 NDS

PSEUDOBULBAR AFFECT (PBA) AGENTSNUEDEXTA 20-10MG CAP 1 PA QL=60 EA/30 Días

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.ERGOLOID MESYLATES 1MG TAB 1PIMOZIDE 1MG TAB 1PIMOZIDE 2MG TAB 1

SMOKING DETERRENTSbupropion 150mg sr tab 1CHANTIX 0.5MG TAB 1CHANTIX 1MG TAB 1CHANTIX CONTINUING MONTHS OF THERAPY1MG PACK

1

CHANTIX FIRST MONTH OF THERAPY PACK 1NICOTROL 10MG INHALER 1NICOTROL 10MG/ML NASAL INHALER 1

TRANSTHYRETIN AMYLOIDOSIS AGENTSTEGSEDI 189MG/ML SYRINGE 1 NDS PA QL=6 ML/28 Días

RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST 500MG INJ 1 NDSGLASSIA 1000MG/50ML INJ 1 NDSPROLASTIN 1000MG INJ 1 NDSZEMAIRA 1000MG INJ 1 NDS


108


Requisitos/Límites

CYSTIC FIBROSIS AGENTSKALYDECO 150MG TAB 1 NDS PA QL=60 EA/30 DíasKALYDECO 25MG GRANULES 1 NDS PA QL=60 EA/30 DíasKALYDECO 50MG GRANULES PACKET 1 NDS PA QL=60 EA/30 DíasKALYDECO 75MG GRANULES PACKET 1 NDS PA QL=60 EA/30 DíasORKAMBI 100-125MG GRANULES PACKET 1 NDS PA QL=60 EA/30 DíasORKAMBI 100-125MG TAB 1 NDS PA QL=120 EA/30 DíasORKAMBI 188-150MG GRANULES PACKET 1 NDS PA QL=60 EA/30 DíasORKAMBI 200-125MG TAB 1 NDS PA QL=120 EA/30 DíasPULMOZYME 1MG/ML INH SOLN 1 NDS PA BvDSYMDEKO 50-75MG/75MG PACK 1 NDS PA QL=60 EA/30 DíasSYMDEKO TAB 4-WEEK PACK 1 NDS PA QL=60 EA/30 Días

PULMONARY FIBROSIS AGENTSESBRIET 267MG CAP 1 NDS PAESBRIET 267MG TAB 1 NDS PAESBRIET 801MG TAB 1 NDS PAOFEV 100MG CAP 1 NDS PAOFEV 150MG CAP 1 NDS PA

SULFONAMIDESSULFONAMIDES

SULFADIAZINE 500MG TAB 1TETRACYCLINES

AMINOMETHYLCYCLINESNUZYRA 150MG TAB 1 NDS PA QL=30 EA/14 Días

GLYCYLCYCLINESTIGECYCLINE 50MG INJ 1 NDS

TETRACYCLINESdemeclocycline 150mg tab 1demeclocycline 300mg tab 1doxy 100mg inj 1doxycycline hyclate 100mg cap 1doxycycline hyclate 100mg tab 1doxycycline hyclate 20mg tab 1doxycycline hyclate 50mg cap 1doxycycline monohydrate 100mg cap 1doxycycline monohydrate 100mg tab 1doxycycline monohydrate 50mg cap 1doxycycline monohydrate 50mg tab 1doxycycline monohydrate 5mg/ml susp 1doxycycline monohydrate 75mg tab 1


109


Requisitos/Límites

minocycline 100mg cap 1minocycline 100mg tab 1minocycline 50mg cap 1minocycline 50mg tab 1minocycline 75mg cap 1minocycline 75mg tab 1mondoxyne 100mg cap 1tetracycline 250mg cap 1tetracycline 500mg cap 1

THYROID AGENTSANTITHYROID AGENTS

methimazole 10mg tab 1methimazole 5mg tab 1propylthiouracil 50mg tab 1

THYROID HORMONESeuthyrox 100mcg tab 1euthyrox 112mcg tab 1euthyrox 125mcg tab 1euthyrox 137mcg tab 1euthyrox 150mcg tab 1euthyrox 175mcg tab 1euthyrox 200mcg tab 1euthyrox 25mcg tab 1euthyrox 50mcg tab 1euthyrox 75mcg tab 1euthyrox 88mcg tab 1levo-t 100mcg tab 1levo-t 112mcg tab 1levo-t 125mcg tab 1levo-t 137mcg tab 1levo-t 150mcg tab 1levo-t 175mcg tab 1levo-t 200mcg tab 1levo-t 25mcg tab 1levo-t 300mcg tab 1levo-t 50mcg tab 1levo-t 75mcg tab 1levo-t 88mcg tab 1levothyroxine sodium 100mcg tab 1levothyroxine sodium 112mcg tab 1


110


Requisitos/Límites

levothyroxine sodium 125mcg tab 1levothyroxine sodium 137mcg tab 1levothyroxine sodium 150mcg tab 1levothyroxine sodium 175mcg tab 1levothyroxine sodium 200mcg tab 1levothyroxine sodium 25mcg tab 1levothyroxine sodium 300mcg tab 1levothyroxine sodium 50mcg tab 1levothyroxine sodium 75mcg tab 1levothyroxine sodium 88mcg tab 1levoxyl 100mcg tab 1levoxyl 112mcg tab 1levoxyl 125mcg tab 1levoxyl 137mcg tab 1levoxyl 150mcg tab 1levoxyl 175mcg tab 1levoxyl 200mcg tab 1levoxyl 25mcg tab 1levoxyl 50mcg tab 1levoxyl 75mcg tab 1levoxyl 88mcg tab 1liothyronine sodium 0.005mg tab 1liothyronine sodium 0.025mg tab 1liothyronine sodium 0.05mg tab 1SYNTHROID 100MCG TAB 1SYNTHROID 112MCG TAB 1SYNTHROID 125MCG TAB 1SYNTHROID 137MCG TAB 1SYNTHROID 150MCG TAB 1SYNTHROID 175MCG TAB 1SYNTHROID 200MCG TAB 1SYNTHROID 25MCG TAB 1SYNTHROID 300MCG TAB 1SYNTHROID 50MCG TAB 1SYNTHROID 75MCG TAB 1SYNTHROID 88MCG TAB 1unithroid 100mcg tab 1unithroid 112mcg tab 1unithroid 125mcg tab 1unithroid 150mcg tab 1


111


Requisitos/Límites

unithroid 175mcg tab 1unithroid 200mcg tab 1unithroid 25mcg tab 1unithroid 300mcg tab 1unithroid 50mcg tab 1unithroid 75mcg tab 1unithroid 88mcg tab 1

TOXOIDSTOXOID COMBINATIONS

ADACEL INJ 1ADACEL SYRINGE 1BOOSTRIX INJ 1BOOSTRIX SYRINGE 1DAPTACEL INJ 1DIPHTHERIA/TETANUS TOXOID INJ 1 PA BvDINFANRIX INJ 1KINRIX INJ 1KINRIX PF INJ 1PEDIARIX INJ 1QUADRACEL INJ 1TENIVAC SYRINGE 1 PA BvDTETANUS/DIPHTHERIA TOXOID INJ 1 PA BvD

ULCER DRUGSH-2 ANTAGONISTS

cimetidine 200mg tab 1cimetidine 300mg tab 1cimetidine 400mg tab 1cimetidine 800mg tab 1famotidine 20mg tab 1famotidine 40mg tab 1famotidine 8mg/ml susp 1nizatidine 150mg cap 1nizatidine 300mg cap 1ranitidine 150mg cap 1ranitidine 15mg/ml oral soln 1ranitidine 300mg cap 1

MISC. ANTI-ULCERsucralfate 1000mg tab 1

PROTON PUMP INHIBITORSesomeprazole 20mg dr cap 1


112


Requisitos/Límites

lansoprazole 15mg dr cap 1lansoprazole 30mg dr cap 1NEXIUM 10MG SUSP 1NEXIUM 2.5MG SUSP 1NEXIUM 20MG SUSP 1NEXIUM 40MG SUSP 1NEXIUM 5MG SUSP 1omeprazole 10mg dr cap 1omeprazole 20mg dr cap 1pantoprazole 20mg dr tab 1pantoprazole 40mg dr tab 1rabeprazole sodium 20mg dr tab 1

ULCER DRUGS - PROSTAGLANDINSmisoprostol 0.1mg tab 1misoprostol 0.2mg tab 1

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICSANTISPASMODICS

dicyclomine 10mg cap 1dicyclomine 20mg tab 1dicyclomine 2mg/ml oral soln 1glycopyrrolate 1mg tab 1glycopyrrolate 2mg tab 1methscopolamine 2.5mg tab 1methscopolamine 5mg tab 1

H-2 ANTAGONISTSCIMETIDINE 60MG/ML ORAL SOLN 1NIZATIDINE 15MG/ML ORAL SOLN 1ranitidine 150mg tab 1ranitidine 300mg tab 1

MISC. ANTI-ULCERsucralfate 100mg/ml susp 1

PROTON PUMP INHIBITORSesomeprazole 40mg dr cap 1omeprazole 40mg dr cap 1

ULCER THERAPY COMBINATIONSamoxicillin 500mg/clarithromycin 500mg/lansoprazole30mg pack

1

PYLERA 140-125-125MG CAP 1URINARY ANTI-INFECTIVESURINARY ANTI-INFECTIVES


113


Requisitos/Límites

methenamine hippurate 1000mg tab 1MONUROL 3000MG ORAL SOLN 1nitrofurantoin 5mg/ml susp 1nitrofurantoin macro 100mg cap 1nitrofurantoin macro 25mg cap 1nitrofurantoin macro 25mg/nitrofurantoin mono 75mgcap

1

nitrofurantoin macro 50mg cap 1URINARY ANTISPASMODICS

URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)oxybutynin chloride 10mg er tab 1oxybutynin chloride 15mg er tab 1oxybutynin chloride 1mg/ml oral soln 1oxybutynin chloride 5mg er tab 1oxybutynin chloride 5mg tab 1solifenacin succinate 10mg tab 1solifenacin succinate 5mg tab 1tolterodine tartrate 1mg tab 1tolterodine tartrate 2mg er cap 1tolterodine tartrate 2mg tab 1tolterodine tartrate 4mg er cap 1trospium chloride 20mg tab 1trospium chloride 60mg er cap 1

URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTSMYRBETRIQ 25MG ER TAB 1MYRBETRIQ 50MG ER TAB 1

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTSbethanechol chloride 10mg tab 1bethanechol chloride 25mg tab 1bethanechol chloride 50mg tab 1bethanechol chloride 5mg tab 1

URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTSflavoxate 100mg tab 1

VACCINESBACTERIAL VACCINES

ACTHIB INJ 1BCG LIVE TICE STRAIN 50MG/ML INJ 1BEXSERO SYRINGE 1HIBERIX INJ 1MENACTRA INJ 1


114


Requisitos/Límites

MENVEO INJ 1PEDVAXHIB 7.5MCG/0.5ML INJ 1TRUMENBA SYRINGE 1TYPHIM VI 25MCG/0.5ML INJ 1TYPHIM VI 25MCG/0.5ML SYRINGE 1

VIRAL VACCINESENGERIX-B 10MCG/0.5ML SYRINGE 1 PA BvDENGERIX-B 20MCG/ML SYRINGE 1 PA BvDGARDASIL 9 INJ 1GARDASIL 9 SYRINGE 1HAVRIX 1440UNIT INJ 1HAVRIX 1440UNIT SYRINGE 1HAVRIX 720UNIT INJ 1HAVRIX 720UNIT SYRINGE 1IMOVAX 2.5UNIT/ML INJ 1 PA BvDIPOL INJ 1IXIARO SYRINGE 1M-M-R II INJ 1PROQUAD INJ 1RABAVERT 2.5UNIT/ML INJ 1 PA BvDRECOMBIVAX 10MCG/ML SYRINGE 1 PA BvDRECOMBIVAX 40MCG/ML INJ 1 PA BvDRECOMBIVAX 5MCG/0.5ML SYRINGE 1 PA BvDRECOMBIVAX HB 10MCG/ML INJ 1 PA BvDROTARIX SUSP 1ROTATEQ SUSP 1SHINGRIX INJ 1TWINRIX 720UNIT SYRINGE 1VAQTA 25UNIT/0.5ML SYRINGE 1VAQTA 50UNIT/0.5ML INJ 1VAQTA 50UNIT/1ML INJ 1VAQTA 50UNIT/ML SYRINGE 1VARIVAX 1350PFU/0.5ML INJ 1YF-VAX 4000UNIT/ML INJ 1ZOSTAVAX 19400UNIT/0.65ML INJ 1

VAGINAL PRODUCTSVAGINAL ANTI-INFECTIVES

clindamycin 2% vaginal cream 1metronidazole 0.75% vaginal gel 1terconazole 0.4% vaginal cream 1


115


Requisitos/Límites

TERCONAZOLE 0.8% VAGINAL CREAM 1terconazole 80mg vaginal supp 1vandazole 0.75% vaginal gel 1

VAGINAL ESTROGENSestradiol 0.1mg/ml vaginal cream 1ESTRING 2MG VAGINAL RING 1 STPREMARIN 0.625MG/GM VAGINAL CREAM 1

VAGINAL PROGESTINSCRINONE 4% VAGINAL GEL 1 PACRINONE 8% VAGINAL GEL 1 PA

VASOPRESSORSANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE 0.15MG/0.3ML AUTO-INJECTOR 1 QL=2 EA/15 Díasepinephrine 0.3mg/0.3ml auto-injector 1 QL=2 EA/15 DíasSYMJEPI 0.15MG/0.3ML SYRINGE 1 QL=2 EA/15 DíasSYMJEPI 0.3MG/0.3ML SYRINGE 1 QL=2 EA/15 Días

NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTSNORTHERA 100MG CAP 1 NDS PANORTHERA 200MG CAP 1 NDS PANORTHERA 300MG CAP 1 NDS PA

VASOPRESSORSmidodrine 10mg tab 1midodrine 2.5mg tab 1midodrine 5mg tab 1


116

Índice

Aabacavir 20mg/ml oral soln 60abacavir 300mg tab 60abacavir 300mg/lamivudine150mg/zidovudine 300mgtab

60

abacavir 600mg/lamivudine300mg tab

60

ABELCET 5MG/ML INJ 39ABILIFY 300MGMAINTENA INJ

59

ABILIFY 300MGMAINTENA PF SYRINGE

59

ABILIFY 400MGMAINTENA INJ

59

ABILIFY 400MGMAINTENA PF SYRINGE

59

abiraterone 250mg tab 48acamprosate calcium 333mgdr tab

106

acarbose 100mg tab 34acarbose 25mg tab 34acarbose 50mg tab 34acebutolol 200mg cap 65acebutolol 400mg cap 65acetaminophen 21.7mg/ml/hydrocodone bitartrate0.5mg/ml oral soln

16

acetaminophen 24mg/ml/codeine phosphate 2.4mg/mloral soln

16

acetaminophen 300mg/codeine phosphate 15mg tab

16


16


16

acetaminophen 300mg/hydrocodone bitartrate10mg tab

16

acetaminophen 300mg/hydrocodone bitartrate 5mgtab

16

acetaminophen 300mg/hydrocodone bitartrate7.5mg tab

16

acetaminophen 325mg/hydrocodone bitartrate10mg tab

16

acetaminophen 325mg/hydrocodone bitartrate 5mgtab

16

acetaminophen 325mg/hydrocodone bitartrate7.5mg tab

16

acetaminophen 325mg/oxycodone 10mg tab

16

acetaminophen 325mg/oxycodone 2.5mg tab

16

acetaminophen 325mg/oxycodone 5mg tab

16

acetaminophen 325mg/oxycodone 7.5mg tab

16

acetaminophen 325mg/tramadol 37.5mg tab

16

acetazolamide 125mg tab 82acetazolamide 250mg tab 82acetazolamide 500mg er cap 82acetic acid 2% otic soln 103acetic acid/hydrocortisone1-2% otic soln

103

acetylcysteine 10% inh soln 76acetylcysteine 20% inh soln 76acitretin 10mg cap 78acitretin 17.5mg cap 78acitretin 25mg cap 78ACTEMRA 162MG/0.9MLAUTO-INJECTOR

12

ACTEMRA 162MG/0.9MLSYRINGE

12

ACTHIB INJ 114ACTIMMUNE2000000UNIT/0.5ML INJ

53

acyclovir 200mg cap 63acyclovir 400mg tab 63acyclovir 40mg/ml susp 63acyclovir 5% ointment 79acyclovir 50mg/ml inj 63acyclovir 800mg tab 63

ADACEL INJ 112ADACEL SYRINGE 112adapalene 0.1% cream 76adapalene 0.1% gel 76adapalene 0.3% gel 76adapalene/benzoyl peroxide0.1-2.5% gel

76

adefovir dipivoxil 10mg tab 63ADEMPAS 0.5MG TAB 69ADEMPAS 1.5MG TAB 69ADEMPAS 1MG TAB 69ADEMPAS 2.5MG TAB 69ADEMPAS 2MG TAB 69ADVAIR 115-21MCG HFAINH

23

ADVAIR 230-21MCG HFAINH

23

ADVAIR 45-21MCG HFAINH

23

AFINITOR 10MG TAB 49AFINITOR 2.5MG TAB 49AFINITOR 2MG SUSP 49AFINITOR 3MG SUSP 49AFINITOR 5MG SUSP 49AFINITOR 5MG TAB 49AFINITOR 7.5MG TAB 49AIMOVIG 140MG/MLAUTO-INJECTOR

94

AIMOVIG 70MG/MLAUTO-INJECTOR

94

ala-cort 1% cream 79albendazole 200mg tab 18albuterol 0.21mg/ml(0.63mg/3ml) inh soln

23

albuterol 0.417mg/ml(1.25mg/3ml) inh soln

23

albuterol 0.4mg/ml(2mg/5ml) oral oral soln

23

albuterol 0.83mg/ml(0.083%) inh soln

23

albuterol 1mg/ml (0.5%) inhsoln

23

albuterol 2mg tab 23ALBUTEROL 4MG ERTAB

23

albuterol 4mg tab 23

Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones encontrados enesta tabla consultando el principio de esta tabla

117

Índice

ALBUTEROL 8MG ERTAB

24

alclometasone dipropionate0.05% cream

79

alclometasone dipropionate0.05% ointment

79

ALECENSA 150MG CAP 49ALENDRONATE0.933MG/ML ORAL SOLN

83

alendronate 10mg tab 83alendronate 35mg tab 83alendronate 70mg tab 83alfuzosin 10mg er tab 90ALINIA 100MG/5MLSUSP

18

ALINIA 500MG TAB 18aliskiren 150mg tab 46aliskiren 300mg tab 46allopurinol 100mg tab 90allopurinol 300mg tab 90ALOCRIL 2% OPHTHSOLN

102

ALOMIDE 0.1% OPHTHSOLN

102

alosetron 0.5mg tab 89alosetron 1mg tab 89ALPHAGAN P 0.1%OPHTH SOLN

101

alprazolam 0.25mg odt 21alprazolam 0.25mg tab 21alprazolam 0.5mg er tab 21alprazolam 0.5mg odt 21alprazolam 0.5mg tab 21alprazolam 1mg er tab 21alprazolam 1mg odt 21alprazolam 1mg tab 21alprazolam 2mg er tab 21alprazolam 2mg odt 21alprazolam 2mg tab 21alprazolam 3mg er tab 21ALREX 0.2% OPHTHSUSP

102

altavera 28 day pack 71ALUNBRIG 180MG TAB 49ALUNBRIG 30MG TAB 49ALUNBRIG 90MG TAB 49

ALUNBRIG TABSTARTER PACK

50

alyacen 1/35 28 day pack 71alyq 20mg tab 69amabelz 0.5/0.1mg 28 daypack

86

amabelz 1/0.5mg 28 daypack

86

amantadine 100mg cap 53amantadine 100mg tab 55amantadine 10mg/ml oralsoln

53

AMBISOME 50MG INJ 39ambrisentan 10mg tab 69ambrisentan 5mg tab 69AMCINONIDE 0.1%CREAM

79

AMCINONIDE 0.1%OINTMENT

79

amethia 91 day pack 71amethia lo 91 day pack 71amikacin 250mg/ml inj 11amiloride 5mg tab 83amiloride 5mg/hydrochlorothiazide 50mgtab

82

AMINOSYN II 10% INJ 99AMINOSYN-PF 10%SULFITE-FREE INJ

99

AMINOSYN-PF 7% INJ 99amiodarone 200mg tab 22amiodarone 400mg tab 22amitriptyline 100mg tab 33amitriptyline 10mg tab 33AMITRIPTYLINE 10MG/PERPHENAZINE 2MGTAB

107

AMITRIPTYLINE 10MG/PERPHENAZINE 4MGTAB

107

amitriptyline 12.5mg/chlordiazepoxide 5mg tab

107

amitriptyline 150mg tab 33amitriptyline 25mg tab 33amitriptyline 25mg/chlordiazepoxide 10mg tab

107


107


107

amitriptyline 50mg tab 33AMITRIPTYLINE 50MG/PERPHENAZINE 4MGTAB

107

amitriptyline 75mg tab 33amlodipine 10mg tab 66amlodipine 10mg/atorvastatin 10mg tab

68

amlodipine 10mg/atorvastatin 20mg tab

68


68


68

amlodipine 10mg/benazepril20mg cap

44


44

amlodipine 10mg/hydrochlorothiazide12.5mg/valsartan 160mgtab

44

amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab

44


44

amlodipine 10mg/olmesartan medoxomil20mg tab

44

amlodipine 10mg/olmesartan medoxomil40mg tab

44

amlodipine 10mg/valsartan160mg tab

44


44

amlodipine 2.5mg tab 66


118

Índice

amlodipine 2.5mg/atorvastatin 10mg tab

68


68


68

amlodipine 2.5mg/benazepril 10mg cap

44

amlodipine 5mg tab 66amlodipine 5mg/atorvastatin 10mg tab

68


68


68


68


44


44


44

amlodipine 5mg/hydrochlorothiazide12.5mg/valsartan 160mgtab

44


44

amlodipine 5mg/olmesartanmedoxomil 20mg tab

44

amlodipine 5mg/olmesartanmedoxomil 40mg tab

44


44


44

ammonium lactate 12%cream

81

ammonium lactate 12%lotion

81

amnesteem 10mg cap 76amnesteem 20mg cap 76amnesteem 40mg cap 76

AMOXAPINE 100MGTAB

33

AMOXAPINE 150MGTAB

33

AMOXAPINE 25MG TAB 33AMOXAPINE 50MG TAB 33amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp

105

amoxicillin 125mg chew tab104AMOXICILLIN 200MG/CLAVULANATE 28.5MGCHEW TAB

105

amoxicillin 250mg cap 104AMOXICILLIN 250MGCHEW TAB

104

amoxicillin 250mg/clavulanate 125mg tab

105

amoxicillin 25mg/ml susp 104AMOXICILLIN 400MG/CLAVULANATE 57MGCHEW TAB

105

amoxicillin 40mg/ml susp 104amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp

105

amoxicillin 500mg cap 104amoxicillin 500mg tab 104amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack

113

amoxicillin 500mg/clavulanate 125mg tab

105


105


105

amoxicillin 875mg tab 104amoxicillin 875mg/clavulanate 125mg tab

105

amphetamine/dextroamphetamine 10mgER cap

9

amphetamine/dextroamphetamine 10mgtab

9

amphetamine/dextroamphetamine 12.5mgtab

9


9


9


9


9


9


9


9

amphetamine/dextroamphetamine 5mg ERcap

9

amphetamine/dextroamphetamine 5mg tab

9

amphetamine/dextroamphetamine 7.5mgtab

9

AMPHOTERICIN B 50MGINJ

39

ampicillin 100mg/ml inj 104AMPICILLIN 125MG/MLINJ

104

ampicillin 20mg/ml/sulbactam 10mg/ml inj

105

ampicillin 250mg/ml inj 104ampicillin 250mg/ml/sulbactam 125mg/ml inj

105

AMPICILLIN 500MG CAP104ANADROL-50 50MG TAB 17anagrelide 0.5mg cap 91anagrelide 1mg cap 91


119

Índice

anastrozole 1mg tab 48ANDRODERM 2MG/24HRPATCH

17

ANDRODERM 4MG/24HRPATCH

17

ANORO 62.5-25MCGELLIPTA INH

24

APLENZIN 174MG ERTAB

31


31


31

APOKYN 10MG/MLCARTRIDGE

55

apraclonidine 0.5% ophthsoln

101

aprepitant 125mg cap 39aprepitant 125mg/80mgpack

39

aprepitant 40mg cap 39aprepitant 80mg cap 39apri 28 day pack 71APRISO 0.375GM ER CAP 88APTIOM 200MG TAB 27APTIOM 400MG TAB 27APTIOM 600MG TAB 27APTIOM 800MG TAB 27APTIVUS 100MG/MLORAL SOLN

60

APTIVUS 250MG CAP 60ARALAST 500MG INJ 108aranelle 28 pack 71ARANESP100MCG/0.5ML SYRINGE

91

ARANESP 100MCG/MLINJ

91

ARANESP 10MCG/0.4MLSYRINGE

91

ARANESP150MCG/0.3ML SYRINGE

91


91


91


91

ARANESP 25MCG/MLINJ

91


91


91


91

ARANESP 40MCG/MLINJ

91

ARANESP 500MCG/MLSYRINGE

91


91

ARANESP 60MCG/MLINJ

91

ARCALYST 220MG INJ 12ARIKAYCE 70.3MG/MLINH SOLN

11

aripiprazole 10mg odt 59aripiprazole 10mg tab 59aripiprazole 15mg odt 60aripiprazole 15mg tab 60aripiprazole 1mg/ml oralsoln

60

aripiprazole 20mg tab 60aripiprazole 2mg tab 60aripiprazole 30mg tab 60aripiprazole 5mg tab 60ARISTADA1064MG/3.9ML SYRINGE

60

ARISTADA 441MG/1.6MLSYRINGE

60


60


60


60

armodafinil 150mg tab 9armodafinil 200mg tab 10armodafinil 250mg tab 10armodafinil 50mg tab 10ARNUITY 100MCG INH 23

ARNUITY 200MCG INH 23ARNUITY 50MCG INH 23ashlyna 91 day pack 71ASMANEX 100MCG(120ACT) HFA INH

23

ASMANEX 110MCG(30ACT) INH

23

ASMANEX 200MCG(120ACT) HFA INH

23


23


23


23

aspirin 25mg/dipyridamole200mg cap

91

aspirin 325mg/oxycodone4.84mg tab

16

ASTAGRAF 0.5MG XLCAP

97

ASTAGRAF 1MG XL CAP 97ASTAGRAF 5MG XL CAP 97atazanavir 150mg cap 60atazanavir 200mg cap 60atazanavir 300mg cap 60atenolol 100mg tab 65atenolol 100mg/chlorthalidone 25mg tab

44

atenolol 25mg tab 65atenolol 50mg tab 65atenolol 50mg/chlorthalidone 25mg tab

44

atomoxetine 100mg cap 9atomoxetine 10mg cap 9atomoxetine 18mg cap 9atomoxetine 25mg cap 9atomoxetine 40mg cap 9atomoxetine 60mg cap 9atomoxetine 80mg cap 9atorvastatin 10mg tab 41atorvastatin 20mg tab 41atorvastatin 40mg tab 41atorvastatin 80mg tab 41atovaquone 150mg/ml susp 18


120

Índice

atovaquone 250mg/proguanil 100mg tab

46

atovaquone 62.5mg/proguanil 25mg tab

46

ATRIPLA 600-200-300MGTAB

60

atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/mloral soln

37

atropine sulfate 0.025mg/diphenoxylate 2.5mg tab

37

ATROPINE SULFATE 1%OPHTH SOLN

101

ATROVENT 17MCG INH 22AUBAGIO 14MG TAB 107AUBAGIO 7MG TAB 107aubra 28 day pack 71AURYXIA 210MG TAB 89AUSTEDO 12MG TAB 107AUSTEDO 6MG TAB 107AUSTEDO 9MG TAB 107AVANDIA 2MG TAB 37AVANDIA 4MG TAB 37aviane 28 pack 71avita 0.025% cream 76avita 0.025% gel 76AVONEX 30MCG/0.5MLAUTO-INJECTOR

107

AVONEX 30MCG/0.5MLSYRINGE

107

AVYCAZ 2-0.5GM INJ 69AYVAKIT 100MG TAB 50AYVAKIT 200MG TAB 50AYVAKIT 300MG TAB 50AZASAN 100MG TAB 64AZASAN 75MG TAB 64AZASITE 1% OPHTHSOLN

101

azathioprine 50mg tab 64azelaic acid 15% gel 81azelastine 0.05% ophth soln102azelastine 0.1% (137mcg)nasal inhaler

99

azelastine 0.15%(205.5mcg) nasal inhaler

99

azithromycin 20mg/ml susp 93

azithromycin 250mg pack 93azithromycin 250mg tab 93azithromycin 2mg/ml inj 93azithromycin 40mg/ml susp 93azithromycin 500mg (3) tabpack

93

azithromycin 500mg tab 93azithromycin 600mg tab 93AZOPT 1% OPHTH SUSP 102aztreonam 333mg/ml inj 19

BBACITRACIN 0.5UNIT/MG OPHTH OINTMENT

101

bacitracin 0.5unit/mg/polymyxin b 10unit/mgophth ointment

101

baclofen 10mg tab 98baclofen 20mg tab 98balsalazide disodium 750mgcap

88

BALVERSA 3MG TAB 50BALVERSA 4MG TAB 50BALVERSA 5MG TAB 50balziva 28 day pack 71BANZEL 200MG TAB 27BANZEL 400MG TAB 27BANZEL 40MG/ML SUSP 27BAQSIMI 3MG/DOSENASAL POWDER

35

BAXDELA 400MG TAB 87BCG LIVE TICE STRAIN50MG/ML INJ

114

benazepril 10mg tab 42benazepril 10mg/hydrochlorothiazide 12.5mgtab

44

benazepril 20mg tab 42benazepril 20mg/hydrochlorothiazide 12.5mgtab

44

benazepril 20mg/hydrochlorothiazide 25mgtab

44

benazepril 40mg tab 42benazepril 5mg tab 42

benazepril 5mg/hydrochlorothiazide 6.25mgtab

44

BENLYSTA 200MG/MLAUTO-INJECTOR

98

BENLYSTA 200MG/MLSYRINGE

98

BENZNIDAZOLE 100MGTAB

18

BENZNIDAZOLE 12.5MGTAB

18

benztropine mesylate 0.5mgtab

55

benztropine mesylate 1mgtab

55

benztropine mesylate 2mgtab

55

BERINERT 500UNIT INJ 90beser 0.05% lotion 79betamethasone 0.05% augcream

79

BETAMETHASONE0.05% AUG GEL

79

betamethasone 0.05% auglotion

79

betamethasone 0.05% augointment

79

betamethasone 0.05%cream

79

betamethasone 0.05% lotion 79betamethasone 0.05%ointment

79

betamethasone 0.1% cream 79betamethasone 0.1% lotion 79betamethasone 0.1%ointment

79

betamethasone valerate0.12% foam

79

betamethasone/clotrimazole1-0.05% cream

77

betamethasone/clotrimazole1-0.05% lotion

77

betaxolol 0.5% ophth soln 100betaxolol 10mg tab 65betaxolol 20mg tab 65


121

Índice

bethanechol chloride 10mgtab

114


114


114


114

BETIMOL 0.25% OPHTHSOLN

100

BETIMOL 0.5% OPHTHSOLN

100

BETOPTIC S 0.25%OPHTH SUSP

100

bexarotene 75mg cap 53BEXSERO SYRINGE 114bicalutamide 50mg tab 48BICILLIN300000-300000UNIT/MLSYRINGE

105

BICILLIN450000-150000UNIT/MLSYRINGE

105

BICILLIN L-A1200000UNIT/2MLSYRINGE

104

BICILLIN L-A2400000UNIT/4MLSYRINGE

104

BICILLIN L-A600000UNIT/MLSYRINGE

104

BIDIL 20-37.5MG TAB 68BIKTARVY 50-200-25MGTAB

60

bimatoprost 0.03% ophthsoln

103

bisoprolol fumarate 10mgtab

65


44

bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mgtab

45

bisoprolol fumarate 5mg tab 65


45

BIVIGAM 5GM/50ML INJ 103BLEPHAMIDE 10-0.2%OPHTH SUSP

102

blisovi 21 fe 1.5/30 28 day 71blisovi 24 fe 1/20 28 daypack

71

BOOSTRIX INJ 112BOOSTRIX SYRINGE 112bosentan 125mg tab 69bosentan 62.5mg tab 69BOSULIF 100MG TAB 50BOSULIF 400MG TAB 50BOSULIF 500MG TAB 50BRAFTOVI 75MG CAP 50BREO 100-25MCGELLIPTA INH

24

BREO 200-25MCGELLIPTA INH

24

briellyn 28 day pack 71BRILINTA 60MG TAB 91BRILINTA 90MG TAB 91brimonidine tartrate 0.15%ophth soln

101

brimonidine tartrate 0.2%ophth soln

101

BRIVIACT 100MG TAB 27BRIVIACT 10MG TAB 27BRIVIACT 10MG/MLORAL SOLN

27

BRIVIACT 25MG TAB 27BRIVIACT 50MG TAB 27BRIVIACT 75MG TAB 27BROMFENAC 0.09%OPHTH SOLN

102

bromocriptine 2.5mg tab 53bromocriptine 5mg cap 54BRUKINSA 80MG CAP 50budesonide 0.125mg/ml inhsoln

23

budesonide 0.25mg/ml inhsoln

23

budesonide 0.5mg/ml inhsoln

23

budesonide 3mg dr cap 75budesonide 9mg er tab 75bumetanide 0.25mg/ml inj 82bumetanide 0.5mg tab 82bumetanide 1mg tab 82bumetanide 2mg tab 82buprenorphine 2mg sl tab 16buprenorphine 2mg/naloxone 0.5mg sl tab

16

buprenorphine 8mg sl tab 16buprenorphine 8mg/naloxone 2mg sl tab

16

buprenorphine/naloxone12-3mg strip

16

buprenorphine/naloxone2-0.5mg strip

16


17


17

bupropion 100mg sr tab 31bupropion 100mg tab 31bupropion 150mg sr (12 hr)tab

31

bupropion 150mg sr tab 108bupropion 150mg xl (24 hr)tab

31

bupropion 200mg sr tab 31bupropion 300mg xl tab 31bupropion 75mg tab 31buspirone 10mg tab 20buspirone 15mg tab 20buspirone 30mg tab 20buspirone 5mg tab 20buspirone 7.5mg tab 20butorphanol tartrate 10mg/ml nasal spray

17

BX RATING -METHYLPHENIDATE18MG SR TAB

10


10


10


122

Índice


10

BYDUREON 2.35MG/MLAUTO-INJECTOR

36

BYDUREON 2MG PENINJ

36

BYSTOLIC 10MG TAB 65BYSTOLIC 2.5MG TAB 65BYSTOLIC 20MG TAB 65BYSTOLIC 5MG TAB 65

Ccabergoline 0.5mg tab 86CABOMETYX 20MG TAB 50CABOMETYX 40MG TAB 50CABOMETYX 60MG TAB 50calcipotriene 0.005% cream 78calcipotriene 0.005%ointment

78

calcipotriene 0.005%topical soln

78

calcipotriene/betamethasone0.005-0.064% ointment

79

calcitriol 0.00025mg cap 85calcitriol 0.0005mg cap 85calcitriol 0.001mg/ml oralsoln

85

calcium acetate 667mg cap 89calcium acetate 667mg tab 89CALQUENCE 100MGCAP

50

camila 28 day 0.35mg pack 75camrese lo 91 day pack 71CAPRELSA 100MG TAB 50CAPRELSA 300MG TAB 50captopril 100mg tab 42captopril 12.5mg tab 42captopril 25mg tab 42captopril 25mg/hydrochlorothiazide 15mgtab

45

CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE25MG TAB

45

captopril 50mg tab 42captopril 50mg/hydrochlorothiazide 15mgtab

45

CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE25MG TAB

45

CARBAGLU 200MG SUSP 85carbamazepine 100mg chewtab

27

carbamazepine 100mg ercap

27

carbamazepine 100mg ertab

27


27


27

carbamazepine 200mg tab 27carbamazepine 20mg/mlsusp

27


27


27

carbidopa 10mg/levodopa100mg odt

54

carbidopa 10mg/levodopa100mg tab

54


54


54

carbidopa 25mg tab 55CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB

54

carbidopa 25mg/levodopa100mg er tab

54


54


54


54


55


54


54


54

carbidopa 50mg/levodopa200mg er tab

54

carisoprodol 350mg tab 98CARTEOLOL 1% OPHTHSOLN

100

cartia 120mg er cap 66cartia 180mg er cap 66cartia 240mg er cap 66cartia 300mg er cap 66carvedilol 12.5mg tab 64carvedilol 25mg tab 64carvedilol 3.125mg tab 64carvedilol 6.25mg tab 65CASPOFUNGINACETATE 50MG INJ

39

CASPOFUNGINACETATE 70MG INJ

39

CAYSTON 75MG INHSOLN

19

caziant 28 day pack 71cefaclor 250mg cap 70CEFACLOR 25MG/MLSUSP

70

cefaclor 500mg cap 70CEFACLOR 50MG/MLSUSP

70

CEFACLOR 75MG/MLSUSP

70

cefadroxil 1000mg tab 70cefadroxil 100mg/ml susp 70cefadroxil 500mg cap 70cefadroxil 50mg/ml susp 70cefazolin 1gm inj 70


123

Índice

cefazolin 200mg/ml inj 70cefazolin 500mg inj 70cefdinir 25mg/ml susp 70cefdinir 300mg cap 70cefdinir 50mg/ml susp 70cefepime 1gm inj 71cefepime 2gm inj 71cefixime 20mg/ml susp 70cefixime 400mg cap 70cefixime 40mg/ml susp 70cefotetan 1000mg inj 70cefotetan 2000mg inj 70cefoxitin 1000mg inj 70cefoxitin 2000mg inj 70cefoxitin 200mg/ml inj 70cefpodoxime 100mg tab 70cefpodoxime 10mg/ml susp 71cefpodoxime 200mg tab 71cefpodoxime 20mg/ml susp 71cefprozil 250mg tab 70cefprozil 25mg/ml susp 70cefprozil 500mg tab 70cefprozil 50mg/ml susp 70ceftazidime 1000mg inj 71ceftazidime 2000mg inj 71ceftazidime 200mg/ml inj 71ceftriaxone 1000mg inj 71ceftriaxone 100mg/ml inj 71ceftriaxone 2000mg inj 71ceftriaxone 250mg inj 71ceftriaxone 500mg inj 71cefuroxime 1.5gm inj 70cefuroxime 250mg tab 70cefuroxime 500mg tab 70cefuroxime 750mg inj 70cefuroxime 95mg/ml inj 70celecoxib 100mg cap 12celecoxib 200mg cap 12celecoxib 400mg cap 12celecoxib 50mg cap 12CELONTIN 300MG CAP 30cephalexin 250mg cap 70cephalexin 25mg/ml susp 70cephalexin 500mg cap 70cephalexin 50mg/ml susp 70CERDELGA 84MG CAP 91

cetirizine 1mg/ml oral soln 40CETRAXAL 0.2% OTICSOLN

103

cevimeline 30mg cap 98CHANTIX 0.5MG TAB 108CHANTIX 1MG TAB 108CHANTIX CONTINUINGMONTHS OF THERAPY1MG PACK

108

CHANTIX FIRST MONTHOF THERAPY PACK

108

CHEMET 100MG CAP 37CHENODAL 250MG TAB 88chlordiazepoxide 10mg cap 21chlordiazepoxide 25mg cap 21chlordiazepoxide 5mg cap 21chlorhexidine gluconate0.12% mouthwash

98

CHLOROQUINEPHOSPHATE 250MG TAB

46

chloroquine phosphate500mg tab

46

chlorpromazine 100mg tab 59chlorpromazine 10mg tab 59chlorpromazine 200mg tab 59chlorpromazine 25mg tab 59chlorpromazine 50mg tab 59chlorthalidone 25mg tab 83chlorthalidone 50mg tab 83CHLORZOXAZONE500MG TAB

98

CHOLBAM 250MG CAP 88CHOLBAM 50MG CAP 88cholestyramine resin 4gm sfpowder for oral susp

40

cholestyramine resin66.7mg/ml susp

40

ciclopirox 0.77% cream 77ciclopirox 0.77% gel 77ciclopirox 0.77% lotion 77ciclopirox 1% shampoo 78ciclopirox 8% topical soln 78cilastatin 2.5mg/ml/imipenem 2.5mg/ml inj

18

cilastatin 5mg/ml/imipenem5mg/ml inj

18

cilostazol 100mg tab 91cilostazol 50mg tab 91CIMDUO 300-300MG TAB 60cimetidine 200mg tab 112cimetidine 300mg tab 112cimetidine 400mg tab 112CIMETIDINE 60MG/MLORAL SOLN

113

cimetidine 800mg tab 112CIMZIA 200MG INJ 88CIMZIA 200MG/MLSYRINGE

88

cinacalcet 30mg tab 85cinacalcet 60mg tab 85cinacalcet 90mg tab 85CINRYZE 500UNIT INJ 90CIPRODEX 0.3-0.1% OTICSUSP

103

CIPROFLOXACIN 0.2%OTIC SOLN

103

ciprofloxacin 0.3% ophthsoln

101

ciprofloxacin 250mg tab 87ciprofloxacin 2mg/ml inj 87ciprofloxacin 500mg tab 87ciprofloxacin 750mg tab 87citalopram 10mg tab 31citalopram 20mg tab 31citalopram 2mg/ml oral soln 31citalopram 40mg tab 31claravis 10mg cap 76claravis 20mg cap 76claravis 30mg cap 76claravis 40mg cap 76CLARINEX-D 2.5-120MGER TAB

76

clarithromycin 250mg tab 94CLARITHROMYCIN25MG/ML SUSP

94

clarithromycin 500mg er tab 94clarithromycin 500mg tab 94CLARITHROMYCIN50MG/ML SUSP

94

CLENPIQ POWDER 93clindacin 1% pad 76clindamycin 1% foam 76


124

Índice

clindamycin 1% gel 76clindamycin 1% lotion 76clindamycin 1% pad 76clindamycin 1% topical soln 76clindamycin 12mg/ml inj 19clindamycin 150mg cap 19clindamycin 150mg/ml(2ml) inj

19

clindamycin 150mg/ml(4ml) inj

19

clindamycin 150mg/ml(6ml) inj

19

clindamycin 15mg/ml oralsoln

19

clindamycin 18mg/ml inj 19clindamycin 2% vaginalcream

115

clindamycin 300mg cap 19clindamycin 6mg/ml inj 19clindamycin 75mg cap 19clindamycin/benzoylperoxide 1-5% gel

76

CLINIMIX 4.25/10 INJ 100CLINIMIX 4.25/5 INJ 100CLINIMIX 5/15 INJ 100CLINIMIX 5/20 INJ 100CLINIMIX E 2.75/5 INJ 100CLINIMIX E 4.25/10 INJ 100CLINIMIX E 4.25/5 INJ 100CLINIMIX E 5/15 INJ 100CLINIMIX E 5/20 INJ 100clinisol 15% inj 100clobazam 10mg tab 26clobazam 2.5mg/ml susp 26clobazam 20mg tab 26clobetasol propionate0.05% cream

79

clobetasol propionate0.05% e cream

79

clobetasol propionate0.05% e foam

79

clobetasol propionate0.05% foam

79

clobetasol propionate0.05% gel

80

clobetasol propionate0.05% lotion

80

clobetasol propionate0.05% ointment

80

clobetasol propionate0.05% shampoo

80

clobetasol propionate0.05% spray

80

clobetasol propionate0.05% topical soln

80

clodan 0.05% shampoo 80clomipramine 25mg cap 33clomipramine 50mg cap 33clomipramine 75mg cap 33clonazepam 0.125mg odt 26clonazepam 0.25mg odt 26clonazepam 0.5mg odt 26clonazepam 0.5mg tab 26clonazepam 1mg odt 26clonazepam 1mg tab 26clonazepam 2mg odt 26clonazepam 2mg tab 26clonidine 0.00417mg/hrpatch

43

clonidine 0.00833mg/hrpatch

43

clonidine 0.0125mg/hrpatch

43

clonidine 0.1mg tab 43clonidine 0.2mg tab 43clonidine 0.3mg tab 43clopidogrel 75mg tab 91clorazepate dipotassium15mg tab

21

clorazepate dipotassium3.75mg tab

21

clorazepate dipotassium7.5mg tab

21

clotrimazole 1% cream 78clotrimazole 1% topical soln 78clotrimazole 10mg lozenge 98clozapine 100mg odt 57clozapine 100mg tab 57clozapine 12.5mg odt 57CLOZAPINE 150MG ODT 57CLOZAPINE 200MG ODT 58

clozapine 200mg tab 58clozapine 25mg odt 58clozapine 25mg tab 58clozapine 50mg tab 58COARTEM 20-120MGTAB

46

codeine sulfate 30mg tab 14codeine sulfate 60mg tab 14colchicine 0.5mg/probenecid 500mg tab

90

COLCHICINE 0.6MG CAP 90COLCHICINE 0.6MG TAB 90colesevelam hcl 3.75gmpacket

40

colesevelam hcl 625mg tab 40colestipol 1000mg tab 40colestipol 5000mg granules 40colistin 75mg/ml inj 19COMBIGAN 0.2-0.5%OPHTH SOLN

100

COMBIPATCH0.05-0.14MG PATCH

86

COMBIPATCH0.05-0.25MG PATCH

86

COMBIVENT RESPIMAT20-100MCG INH

24

COMETRIQ 100MGDAILY DOSE CARTONPACK

50

COMETRIQ 140MGDAILY DOSE CARTONPACK

50

COMETRIQ 60MG DAILYDOSE CARTON PACK

50

COMPLERA200-25-300MG TAB

60

compro 25mg rectal supp 59constulose 10gm/15ml oralsoln

93

COPIKTRA 15MG CAP 50COPIKTRA 25MG CAP 50CORLANOR 5MG TAB 69CORLANOR 5MG/5MLORAL SOLN

69

CORLANOR 7.5MG TAB 69


125

Índice

CORTISONE ACETATE25MG TAB

75

COSENTYX 150MG/MLAUTO-INJECTOR

78

COSENTYX 150MG/MLSYRINGE

78

COTELLIC 20MG TAB 50CREON12000-38000-60000UNITDR CAP

82

CREON24000-76000-120000UNITDR CAP

82

CREON3000-9500-15000UNIT DRCAP

82


82


82

CRINONE 4% VAGINALGEL

116

CRINONE 8% VAGINALGEL

116

CRIXIVAN 200MG CAP 60CRIXIVAN 400MG CAP 61cromolyn sodium 10mg/mlinh soln

22

cromolyn sodium 20mg/mloral soln

88

cromolyn sodium 4% ophthsoln

102

cryselle 28 pack 71cyclafem 1/35 28 day pack 71cyclafem 7/7/7 28 day pack 72cyclobenzaprine 10mg tab 98cyclobenzaprine 5mg tab 98cyclobenzaprine 7.5mg tab 99CYCLOPHOSPHAMIDE25MG CAP

47

CYCLOPHOSPHAMIDE50MG CAP

47

cyclosporine 100mg cap 64cyclosporine 25mg cap 64

cyclosporine modified100mg cap

64

cyclosporine modified100mg/ml oral soln

97

cyclosporine modified 25mgcap

64

CYCLOSPORINEMODIFIED 50MG CAP

97

cyred 28 day pack 72CYSTAGON 150MG CAP 89CYSTAGON 50MG CAP 89CYSTARAN 0.44%OPHTH SOLN

102

Ddalfampridine 10mg er tab 107DALIRESP 250MCG TAB 23DALIRESP 500MCG TAB 23DALVANCE 500MG INJ 19danazol 100mg cap 17danazol 200mg cap 17danazol 50mg cap 17dantrolene sodium 100mgcap

99

dantrolene sodium 25mgcap

99

dantrolene sodium 50mgcap

99

dapsone 100mg tab 19dapsone 25mg tab 19DAPTACEL INJ 112DAPTOMYCIN 350MGINJ

18

daptomycin 500mg inj 18DARAPRIM 25MG TAB 46DAURISMO 100MG TAB 48DAURISMO 25MG TAB 48deblitane 28 day 0.35mgpack

75

deferasirox 125mg tab fororal susp

38

deferasirox 250mg tab fororal susp

38

deferasirox 360mg tab 38deferasirox 500mg tab fororal susp

38

deferasirox 90mg tab 38DELSTRIGO100-300-300MG TAB

61

demeclocycline 150mg tab 109demeclocycline 300mg tab 109DEMSER 250MG CAP 43DENAVIR 1% CREAM 79DEPEN 250MG TAB 97DEPO-PROVERA 400MG/ML INJ

48

DESCOVY 200-25MGTAB

61

desipramine 100mg tab 34desipramine 10mg tab 34desipramine 150mg tab 34desipramine 25mg tab 34desipramine 50mg tab 34desipramine 75mg tab 34desloratadine 5mg tab 40desmopressin acetate 0.01%nasal spray

85

desmopressin acetate 0.1mgtab

85

desmopressin acetate 0.2mgtab

85

desogestrel/ethinyl estradiol28 day pack

72

desogestrel/ethinyl estradiolpack

72

desonide 0.05% cream 80desonide 0.05% lotion 80desonide 0.05% ointment 80desoximetasone 0.05% gel 80desoximetasone 0.25%cream

80

desoximetasone 0.25%ointment

80

desvenlafaxine succinate100mg er tab

33


33


33

DEXAMETHASONE 0.1%OPHTH SOLN

102


126

Índice

dexamethasone 0.1mg/mloral soln

75

dexamethasone 0.5mg tab 75dexamethasone 0.75mg tab 75dexamethasone 1.5mg tab 75DEXAMETHASONE 1MGTAB

75

DEXAMETHASONE1MG/ML ORAL SOLN

75

DEXAMETHASONE 2MGTAB

75

dexamethasone 4mg tab 75dexamethasone 6mg tab 75dexamethasone/neomycin/polymyxin b 0.1% ophthointment

102

dexamethasone/neomycin/polymyxin b 0.1% ophthsusp

102

dexamethasone/tobramycin0.3-0.1% ophth susp

102

dexmethylphenidate 10mger cap

10

dexmethylphenidate 10mgtab

10


10

dexmethylphenidate 2.5mgtab

10


10


10


10


10


10

dexmethylphenidate 5mg ercap

10

dexmethylphenidate 5mg tab 10dextroamphetamine sulfate10mg er cap

9

dextroamphetamine sulfate10mg tab

9

dextroamphetamine sulfate15mg er cap

9

dextroamphetamine sulfate5mg er cap

9

dextroamphetamine sulfate5mg tab

9

DIASTAT 10MGAPPLICATOR

26

DIASTAT 2.5MGAPPLICATOR

26

DIASTAT 20MGAPPLICATOR

26

diazepam 10mg tab 21DIAZEPAM 1MG/MLORAL SOLN

21

DIAZEPAM 2.5MG/0.5MLRECTAL GEL

27

DIAZEPAM 20MG/4MLRECTAL GEL

27

diazepam 2mg tab 21diazepam 5mg tab 21diazepam 5mg/ml oral soln 21diclofenac potassium 50mgtab

12

diclofenac sodium 0.1%ophth soln

102

diclofenac sodium 1% gel 77diclofenac sodium 1.5%topical soln

77

diclofenac sodium 100mg ertab

12

diclofenac sodium 25mg drtab

12

diclofenac sodium 3% gel 78diclofenac sodium 50mg drtab

12

diclofenac sodium 50mg/misoprostol 0.2mg tab

12

diclofenac sodium 75mg drtab

12

diclofenac sodium 75mg/misoprostol 0.2mg tab

12

dicloxacillin 250mg cap 105dicloxacillin 500mg cap 105dicyclomine 10mg cap 113dicyclomine 20mg tab 113

dicyclomine 2mg/ml oralsoln

113

didanosine 200mg dr cap 61didanosine 250mg dr cap 61didanosine 400mg dr cap 61DIFFERIN 0.1% LOTION 77diflunisal 500mg tab 14digitek 0.125mg tab 68digitek 0.25mg tab 68digox 0.125mg tab 68digox 0.25mg tab 68digoxin 0.05mg/ml oral soln 68digoxin 0.125mg tab 68digoxin 0.25mg tab 68DIHYDROERGOTAMINEMESYLATE 0.5MG/ACTNASAL SPRAY

94

DILANTIN 30MG ER CAP 30dilt 120mg xr cap 66dilt 180mg xr cap 66dilt 240mg xr cap 66diltiazem 120mg er (12 hr)cap

66

diltiazem 120mg er (24 hr)cap

66

diltiazem 120mg tab 66diltiazem 180mg er cap 66diltiazem 240mg er cap 66diltiazem 300mg er cap 66diltiazem 30mg tab 66diltiazem 360mg er cap 66diltiazem 420mg er cap 66diltiazem 60mg er cap 66diltiazem 60mg tab 66diltiazem 90mg er cap 66diltiazem 90mg tab 66DIPENTUM 250MG CAP 88DIPHTHERIA/TETANUSTOXOID INJ

112

disopyramide 100mg cap 21disopyramide 150mg cap 21disulfiram 250mg tab 106disulfiram 500mg tab 106DIURIL 250MG/5MLSUSP

83


127

Índice

divalproex sodium 125mg drcap

30

divalproex sodium 125mg drtab

30


30

divalproex sodium 250mg ertab

30


30

divalproex sodium 500mg ertab

30

dofetilide 125mcg cap 22dofetilide 250mcg cap 22dofetilide 500mcg cap 22donepezil 10mg odt 106donepezil 10mg tab 106donepezil 23mg tab 106donepezil 5mg odt 106donepezil 5mg tab 106DOPTELET 20MG TAB 91DOPTELET 40MG DAILYDOSE PACK

91

DOPTELET 60MG DAILYDOSE PACK

91

dorzolamide 2% ophth soln 103dorzolamide 20mg/ml/timolol 5mg/ml ophth soln

100

dorzolamide/timolol22.3-6.8mg/ml ophth soln(preservative-free)

100

dotti 0.025mg/24hr patch 87dotti 0.0375mg/24hr patch 87dotti 0.05mg/24hr patch 87dotti 0.075mg/24hr patch 87dotti 0.1mg/24hr patch 87DOVATO 50-300MG TAB 61doxazosin 1mg tab 43doxazosin 2mg tab 43doxazosin 4mg tab 43doxazosin 8mg tab 43doxepin 100mg cap 34doxepin 10mg cap 34doxepin 10mg/ml oral soln 34doxepin 150mg cap 34doxepin 25mg cap 34

doxepin 50mg cap 34doxepin 75mg cap 34doxercalciferol 0.0005mgcap

85

doxercalciferol 0.001mg cap 85doxercalciferol 0.0025mgcap

85

doxy 100mg inj 109doxycycline hyclate 100mgcap

109

doxycycline hyclate 100mgtab

109

doxycycline hyclate 20mgtab

109

doxycycline hyclate 50mgcap

109

doxycycline monohydrate100mg cap

109

doxycycline monohydrate100mg tab

109

doxycycline monohydrate50mg cap

109


109

doxycycline monohydrate5mg/ml susp

109


109

DRIZALMA 20MG DRCAP

33

DRIZALMA 30MG DRCAP

33

DRIZALMA 40MG DRCAP

33

DRIZALMA 60MG DRCAP

33

dronabinol 10mg cap 38dronabinol 2.5mg cap 38dronabinol 5mg cap 38drospirenone 3mg/ethinylestradiol 0.02mg/inert 1 mgpack

72

drospirenone 3mg/ethinylestradiol 0.03mg/inertingredients 1mg pack

72

DROXIA 200MG CAP 91

DROXIA 300MG CAP 91DROXIA 400MG CAP 91DULERA 100-5MCG INH 24DULERA 200-5MCG INH 24duloxetine 20mg dr cap 33duloxetine 30mg dr cap 33duloxetine 40mg dr cap 33duloxetine 60mg dr cap 33DUPIXENT 200MG/ML PFSYRINGE

22

DUPIXENT 300MG/2MLPF SYRINGE

81

duramorph 0.5mg/ml inj 14duramorph 1mg/ml inj 14DUREZOL 0.05% OPHTHSUSP

102

dutasteride 0.5mg cap 90dutasteride 0.5mg/tamsulosin 0.4mg cap

90

DYRENIUM 100MG CAP 83DYRENIUM 50MG CAP 83

Eeconazole nitrate 1% cream 78EDURANT 25MG TAB 61efavirenz 200mg cap 61efavirenz 50mg cap 61efavirenz 600mg cap 61eletriptan 20mg tab 94eletriptan 40mg tab 94ELIGARD 22.5MGSYRINGE

48

ELIGARD 30MGSYRINGE

48

ELIGARD 45MGSYRINGE

48

ELIGARD 7.5MGSYRINGE

48

ELIQUIS 2.5MG TAB 25ELIQUIS 30-DAYSTARTER PACK

25

ELIQUIS 5MG TAB 25ELMIRON 100MG CAP 89eluryng0.120-0.015mg/24hr vaginalring

74


128

Índice

EMCYT 140MG CAP 48EMGALITY 100MG/MLSYRINGE

94

EMGALITY 120MG/MLAUTO-INJECTOR

94

EMGALITY 120MG/MLSYRINGE

94

emoquette pack 72EMSAM 12MG/24HRPATCH

31

EMSAM 6MG/24HRPATCH

31

EMSAM 9MG/24HRPATCH

31

EMTRIVA 10MG/MLORAL SOLN

61

EMTRIVA 200MG CAP 61enalapril maleate 10mg tab 42enalapril maleate 10mg/hydrochlorothiazide 25mgtab

45

enalapril maleate 2.5mg tab 42enalapril maleate 20mg tab 42enalapril maleate 5mg tab 42enalapril maleate 5mg/hydrochlorothiazide 12.5mgtab

45

ENBREL 25MG INJ 13ENBREL 25MG/0.5MLSYRINGE

13

ENBREL 50MG/MLCARTRIDGE

13

ENBREL 50MG/MLSURECLICK INJ

13

ENBREL 50MG/MLSYRINGE

13

ENDARI 5000MGPOWDER FOR ORALSOLN

91

endocet 10-325mg tab 16endocet 5-325mg tab 16endocet 7.5-325mg tab 16ENGERIX-B10MCG/0.5ML SYRINGE

115

ENGERIX-B 20MCG/MLSYRINGE

115

enoxaparin sodium100mg/1ml syringe

25

enoxaparin sodium120mg/0.8ml syringe

25

enoxaparin sodium150mg/1ml syringe

25


25


25


25


25

enpresse 28 day pack 72enskyce 28 day pack 72entacapone 200mg tab 55entecavir 0.5mg tab 63entecavir 1mg tab 63ENTRESTO 24-26MG TAB 68ENTRESTO 49-51MG TAB 68ENTRESTO 97-103MGTAB

68

enulose 10gm/15ml oralsoln

88

ENVARSUS 0.75MG ERTAB

97

ENVARSUS 1MG ER TAB 98ENVARSUS 4MG ER TAB 98EPIDIOLEX 100MG/MLORAL SOLN

27

EPIDUO 0.3-2.5% GEL 77epinastine 0.05% ophth soln103EPINEPHRINE0.15MG/0.3ML AUTO-INJECTOR

116

epinephrine 0.3mg/0.3mlauto-injector

116

epitol 200mg tab 27EPIVIR HBV 5MG/MLORAL SOLN

63

eplerenone 25mg tab 46eplerenone 50mg tab 46EQUETRO 100MG ERCAP

56

EQUETRO 200MG ERCAP

56

EQUETRO 300MG ERCAP

56

ERAXIS 100MG INJ 39ERAXIS 50MG INJ 39ERGOLOID MESYLATES1MG TAB

108

ERIVEDGE 150MG CAP 48ERLEADA 60MG TAB 48erlotinib 100mg tab 50erlotinib 150mg tab 50erlotinib 25mg tab 50errin 28 day 0.35mg pack 75ERTACZO 2% CREAM 78ertapenem 1gm inj 18ery 2% pad 77ERYTHROCINLACTOBIONATE 500MGINJ

94

erythromycin 0.005mg/mgophth ointment

101

erythromycin 2% gel 77erythromycin 2% topicalsoln

77

erythromycin 250mg dr cap 94erythromycin 250mg tab 94erythromycin 500mg tab 94erythromycin ethylsuccinate40mg/ml susp

94

erythromycin ethylsuccinate80mg/ml oral susp

94

erythromycin/benzoylperoxide 5-3% gel

77

ESBRIET 267MG CAP 109ESBRIET 267MG TAB 109ESBRIET 801MG TAB 109escitalopram 10mg tab 31escitalopram 1mg/ml oralsoln

31

escitalopram 20mg tab 31escitalopram 5mg tab 31esomeprazole 20mg dr cap 112esomeprazole 40mg dr cap 113estarylla 28 day pack 72estazolam 1mg tab 92


129

Índice

estazolam 2mg tab 92estradiol 0.00104mg/hrtwice weekly patch

87

estradiol 0.00104mg/hrweekly patch

87

estradiol 0.00156mg/hrtwice weekly patch

87


87


87


87


87


87


87


87


87

estradiol 0.1mg/ml vaginalcream

116

estradiol 0.5mg tab 87estradiol 0.5mg/norethindrone acetate 0.1mgpack

86

estradiol 1mg tab 87estradiol 1mg/norethindroneacetate 0.5mg pack

86

estradiol 20mg/ml inj 87estradiol 2mg tab 87estradiol 40mg/ml inj 87ESTRING 2MG VAGINALRING

116

eszopiclone 1mg tab 92eszopiclone 2mg tab 92eszopiclone 3mg tab 93ethacrynic acid 25mg tab 82ethambutol 100mg tab 47ethambutol 400mg tab 47ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mgtab

86

ethinyl estradiol 0.005mg/norethindrone acetate 1mgtab

86

ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 daypack

72

ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack

72


72

ethinyl estradiol 0.025mg/inert/norgestimate0.18mg/0.215mg/0.25mgpack

72


72

ethinyl estradiol 0.02mg/norethindrone 1mg 21 daypack

72

ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack

72


72

ethinyl estradiol 0.035mg/inert/norgestimate0.18mg/0.215mg/0.25mgpack

72

ethinyl estradiol 0.035mg/norgestimate 0.25mg pack

72

ethinyl estradiol0.03mg/0.04mg /inert/levonorgestrel 0.05mg/0.075mg pack

72


72

ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab28 day pack

72

ethinyl estradiol 0.05mg/ethynodiol 1mg/inertingredients 1mg 28 day pack

72

ethinyl estradiol/levonorgestrel 91 day pack

72

ethosuximide 250mg cap 30ethosuximide 50mg/ml oralsoln

30

etodolac 200mg cap 12etodolac 300mg cap 12etodolac 400mg er tab 12etodolac 400mg tab 12etodolac 500mg er tab 12etodolac 500mg tab 12etodolac 600mg er tab 12etonogestrel-ethinyl estradiol0.120-0.015mg/24hr vaginalring

74

euthyrox 100mcg tab 110euthyrox 112mcg tab 110euthyrox 125mcg tab 110euthyrox 137mcg tab 110euthyrox 150mcg tab 110euthyrox 175mcg tab 110euthyrox 200mcg tab 110euthyrox 25mcg tab 110euthyrox 50mcg tab 110euthyrox 75mcg tab 110euthyrox 88mcg tab 110everolimus 2.5mg tab 50everolimus 5mg tab 50everolimus 7.5mg tab 50EVOTAZ 300-150MG TAB 61exemestane 25mg tab 48EXTAVIA 0.3MG INJ 107ezetimibe 10mg tab 41

Ffalmina 28 day pack 72famciclovir 125mg tab 63famciclovir 250mg tab 63famciclovir 500mg tab 63famotidine 20mg tab 112famotidine 40mg tab 112famotidine 8mg/ml susp 112


130

Índice

FANAPT 10MG TAB 56FANAPT 12MG TAB 56FANAPT 1MG TAB 56FANAPT 2MG TAB 56FANAPT 4MG TAB 56FANAPT 6MG TAB 56FANAPT 8MG TAB 56FANAPT TITRATIONPACK

56

FARXIGA 10MG TAB 37FARXIGA 5MG TAB 37FARYDAK 10MG CAP 50FARYDAK 20MG CAP 50FASENRA 30MG/MLAUTO-INJECTOR

22

FASENRA 30MG/MLSYRINGE

22

fayosim 91 day pack 72febuxostat 40mg tab 90febuxostat 80mg tab 90felbamate 120mg/ml susp 30felbamate 400mg tab 30felbamate 600mg tab 30felodipine 10mg er tab 66felodipine 2.5mg er tab 67felodipine 5mg er tab 67femynor 28 day pack 72fenofibrate 134mg cap 40fenofibrate 145mg tab 40FENOFIBRATE 150MGCAP

40

fenofibrate 160mg tab 40fenofibrate 200mg cap 40fenofibrate 48mg tab 40FENOFIBRATE 50MGCAP

41

fenofibrate 54mg tab 41fenofibrate 67mg cap 41fenofibric acid 135mg drcap

41

fenofibric acid 45mg dr cap 41fentanyl 0.012mg/hr patch 14fentanyl 0.025mg/hr patch 14fentanyl 0.05mg/hr patch 14fentanyl 0.075mg/hr patch 14

FENTANYL 0.1MGBUCCAL TAB

14

fentanyl 0.1mg/hr patch 14FENTANYL 0.2MGBUCCAL TAB

14

fentanyl 0.2mg lozenge 14FENTANYL 0.4MGBUCCAL TAB

14


14


14

fentanyl 0.8mg lozenge 14fentanyl 1.2mg lozenge 14fentanyl 1.6mg lozenge 14FENTORA 100MCGBUCCAL TAB

14

FENTORA 200MCGBUCCAL TAB

14


14


14


14

FERRIPROX 1000MGTAB

38

FERRIPROX 100MG/MLORAL SOLN

37

FERRIPROX 500MG TAB 38FETZIMA 120MG ER CAP 33FETZIMA 20MG ER CAP 33FETZIMA 40MG ER CAP 33FETZIMA 80MG ER CAP 33FETZIMA PACK 33FIASP 100UNIT/MLCARTRIDGE

36

FIASP 100UNIT/ML INJ 36FIASP 100UNIT/ML PENINJ

36

FINACEA 15% FOAM 81finasteride 5mg tab 90FIRMAGON 120MG INJ 48FIRMAGON 80MG INJ 48

FIRVANQ 25MG/MLORAL SOLN

19

FIRVANQ 50MG/MLORAL SOLN

19

flavoxate 100mg tab 114FLEBOGAMMA 10% INJ 103flecainide acetate 100mgtab

22

flecainide acetate 150mgtab

22

flecainide acetate 50mg tab 22FLOVENT 100MCGDISKUS

23

FLOVENT 110MCG HFAINH

23


23

FLOVENT 250MCGDISKUS

23


23

FLOVENT 50MCGDISKUS

23

fluconazole 100mg tab 39fluconazole 10mg/ml susp 39fluconazole 150mg tab 39fluconazole 200mg tab 39fluconazole 2mg/ml (100ml)inj

39

fluconazole 2mg/ml inj 39fluconazole 40mg/ml susp 39fluconazole 50mg tab 39flucytosine 250mg cap 39flucytosine 500mg cap 39fludrocortisone 0.1mg tab 76FLUNISOLIDE 25MCGNASAL INHALER

99

fluocinolone acetonide0.01% cream

80

fluocinolone acetonide0.01% otic oil

103

fluocinolone acetonide0.01% otic soln

103

fluocinolone acetonide0.01% topical soln

80


131

Índice

fluocinolone acetonide0.025% cream

80

fluocinolone acetonide0.025% ointment

80

fluocinolone acetonide0.1mg/ml oil

80

fluocinonide 0.05% e cream 80fluocinonide 0.05% gel 80fluocinonide 0.05%ointment

80

fluocinonide 0.05% topicalsoln

80

fluorometholone 0.1% ophthsusp

102

FLUOROPLEX 1%CREAM

78

FLUOROURACIL 0.5%CREAM

78

FLUOROURACIL 2%TOPICAL SOLN

78

fluorouracil 5% cream 78FLUOROURACIL 5%TOPICAL SOLN

78

fluoxetine 10mg cap 31fluoxetine 10mg tab 31fluoxetine 20mg cap 31fluoxetine 20mg tab 32fluoxetine 25mg/olanzapine12mg cap

107

fluoxetine 25mg/olanzapine3mg cap

107


107

fluoxetine 40mg cap 32fluoxetine 4mg/ml oral soln 32fluoxetine 50mg/olanzapine12mg cap

107


107

FLUPHENAZINE 0.5MG/ML ORAL SOLN

59

fluphenazine 10mg tab 59fluphenazine 1mg tab 59fluphenazine 2.5mg tab 59FLUPHENAZINE 2.5MG/ML INJ

59

fluphenazine 5mg tab 59FLUPHENAZINE 5MG/ML ORAL SOLN

59

fluphenazine decanoate25mg/ml inj

59

FLURAZEPAM 15MGCAP

93

FLURAZEPAM 30MGCAP

93

flurbiprofen 100mg tab 12flurbiprofen sodium 0.03%ophth soln

103

flutamide 125mg cap 48fluticasone propionate0.005% ointment

80

fluticasone propionate0.05% cream

80

fluticasone propionate0.05% lotion

80

fluticasone propionate50mcg nasal inhaler

99

fluticasone propionate/salmeterol 100-50mcg/actdry powder inh

24


24


24

FLUTICASONEPROPIONATE/SALMETEROLXINAFOATE 113-14MCG/ACT POWDER INH

24


24


24

fluvastatin 20mg cap 41

fluvastatin 40mg cap 41fluvastatin 80mg er tab 41fluvoxamine maleate 100mger cap

32

fluvoxamine maleate 100mgtab

32

fluvoxamine maleate 150mger cap

32


32


32

fondaparinux sodium12.5mg/ml (0.4ml) syringe

25


25


25

fondaparinux sodium 5mg/ml syringe

25

FORTEO 600MCG/2.4MLPEN INJ

83

fosamprenavir 700mg tab 61fosinopril sodium 10mg tab 42fosinopril sodium 10mg/hydrochlorothiazide 12.5mgtab

45

fosinopril sodium 20mg tab 42fosinopril sodium 20mg/hydrochlorothiazide 12.5mgtab

45

fosinopril sodium 40mg tab 42FOSRENOL 1000MGORAL POWDER

89

FOSRENOL 750MG ORALPOWDER

89

FRAGMIN 10000UNIT/ML SYRINGE

26

FRAGMIN12500UNIT/0.5MLSYRINGE

26


26


132

Índice


26


26


26


26

FRAGMIN95000UNIT/3.8ML INJ

26

FREAMINE 6.9% INJ 100FULPHILA 6/0.6MLSYRINGE

92

furosemide 10mg/ml inj 82furosemide 10mg/ml oralsoln

82

furosemide 10mg/ml syringe 83furosemide 20mg tab 83furosemide 40mg tab 83furosemide 80mg tab 83FUROSEMIDE 8MG/MLORAL SOLN

83

FUZEON 90MG INJ 61fyavolv 0.5mg-2.5mcg tab 86fyavolv 1mg-5mcg tab 86FYCOMPA 0.5MG/MLSUSP

26

FYCOMPA 10MG TAB 26FYCOMPA 12MG TAB 26FYCOMPA 2MG TAB 26FYCOMPA 4MG TAB 26FYCOMPA 6MG TAB 26FYCOMPA 8MG TAB 26

Ggabapentin 100mg cap 27gabapentin 300mg cap 27gabapentin 400mg cap 27gabapentin 50mg/ml oralsoln

27

gabapentin 600mg tab 27gabapentin 800mg tab 28

GALAFOLD 123MG CAP 85galantamine 12mg tab 106galantamine 4mg tab 106galantamine 8mg tab 106galantamine hydrobromide16mg er cap

106

galantamine hydrobromide24mg er cap

106

GALANTAMINEHYDROBROMIDE 4MG/ML ORAL SOLN

106

galantamine hydrobromide8mg er cap

106

GAMMAGARD 10GM INJ103GAMMAGARD2.5GM/25ML INJ

103

GAMMAGARD 5GM INJ 103GAMMAKED 1GM/10MLINJ

103

GAMMAPLEX10GM/100ML INJ

104


104


104


104

GAMUNEX 1GM/10MLINJ

104

GARDASIL 9 INJ 115GARDASIL 9 SYRINGE 115gatifloxacin 0.5% ophthsoln

101

GATTEX 5MG INJ 89GAUZE PAD 94gavilyte-c oral soln 93gavilyte-g powder for oralsoln

93

gavilyte-n powder for oralsoln

93

gemfibrozil 600mg tab 41generlac 10gm/15ml oralsoln

88

gengraf 100mg cap 64gengraf 100mg/ml oral soln 64gengraf 25mg cap 64

GENOTROPIN 0.2MGSYRINGE

84


84


84


84


84


84


84


84

GENOTROPIN 12MGCARTRIDGE

84

GENOTROPIN 1MGSYRINGE

84

GENOTROPIN 2MGSYRINGE

84

GENOTROPIN 5MGCARTRIDGE

84

GENTAK 0.3% OPHTHOINTMENT

101

gentamicin sulfate 0.1%cream

77

gentamicin sulfate 0.1%ointment

77

gentamicin sulfate 0.3%ophth soln

101

GENTAMICIN SULFATE0.8MG/ML INJ

11

gentamicin sulfate 1.2mg/mlinj

11

GENTAMICIN SULFATE1.6MG/ML INJ

11

GENTAMICIN SULFATE1MG/ML INJ

11

gentamicin sulfate 40mg/mlinj

11

GENVOYA150-150-200-10MG TAB

61

GEODON 20MG INJ 56gianvi 28-day pack 73


133

Índice

GILENYA 0.5MG CAP 107GILOTRIF 20MG TAB 50GILOTRIF 30MG TAB 50GILOTRIF 40MG TAB 50GLASSIA 1000MG/50MLINJ

108

glatiramer 20mg/ml syringe 107glatiramer 40mg/ml syringe 107glatopa 20mg/ml syringe 108glatopa 40mg/ml syringe 108GLEOSTINE 100MG CAP 47GLEOSTINE 10MG CAP 47GLEOSTINE 40MG CAP 47glimepiride 1mg tab 37glimepiride 2mg tab 37glimepiride 4mg tab 37glipizide 10mg er tab 37glipizide 10mg tab 37glipizide 2.5mg er tab 37glipizide 2.5mg/metformin250mg tab

34

glipizide 2.5mg/metformin500mg tab

35

glipizide 5mg er tab 37glipizide 5mg tab 37glipizide 5mg/metformin500mg tab

35

GLUCAGEN 1MG INJ 35GLUCAGON 1MG INJ 36glucose 10% inj 99glucose 100mg/ml inj 99GLUCOSE 100MG/ML/SODIUM CHLORIDE0.0342 MEQ/ML INJ

95

GLUCOSE 100MG/ML/SODIUM CHLORIDE0.0769 MEQ/ML INJ

95


95

glucose 50 mg/ml/potassiumchloride 0.04meq/ml/sodiumchloride 4.5mg/ml inj

95

glucose 50mg/ml/potassiumchloride 0.01 meq/ml/

95

sodium chloride 0.0769meq/ml injglucose 50mg/ml/potassiumchloride 0.02 meq/ml inj

95

glucose 50mg/ml/potassiumchloride 0.02 meq/ml/sodium chloride 0.0342meq/ml inj

95

glucose 50mg/ml/potassiumchloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj

95

glucose 50mg/ml/potassiumchloride 0.02meq/ml/sodiumchloride 4.5mg/ml inj

95

glucose 50mg/ml/potassiumchloride 0.03 meq/ml/sodium chloride 0.0769meq/ml inj

96

GLUCOSE 50MG/ML/POTASSIUM CHLORIDE0.04 MEQ/ML INJ

96

GLUCOSE 50MG/ML/POTASSIUM CHLORIDE0.04 MEQ/ML/SODIUMCHLORIDE 0.154 MEQ/ML INJ

96

glucose 50mg/ml/sodiumchloride 0.0342 meq/ml inj

96


96

glucose 50mg/ml/sodiumchloride 4.5mg/ml inj

96

glucose 50mg/ml/sodiumchloride 9mg/ml inj

96

glyburide 1.25mg/metformin250mg tab

35

glyburide 2.5mg/metformin500mg tab

35

glyburide 5mg/metformin500mg tab

35

glycopyrrolate 1mg tab 113glycopyrrolate 2mg tab 113GLYXAMBI 10-5MG TAB 35GLYXAMBI 25-5MG TAB 35

GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B10000UNIT/ML OPHTHSOLN

101

granisetron 1mg tab 38griseofulvin 125mg tab 39griseofulvin 250mg tab 39griseofulvin 25mg/ml susp 39griseofulvin 500mg tab 39guanfacine 1mg er tab 9guanfacine 2mg er tab 9guanfacine 3mg er tab 9guanfacine 4mg er tab 9GUANIDINE 125MG TAB 47GVOKE 0.5MG/0.1MLSYRINGE

36

GVOKE 1MG/0.2MLSYRINGE

36

HHAEGARDA 2000UNTINJ

90

HAEGARDA 3000UNTINJ

90

hailey 24 fe 28 day pack 73halobetasol propionate0.05% cream

80

halobetasol propionate0.05% ointment

80

haloperidol 0.5mg tab 57haloperidol 10mg tab 57haloperidol 1mg tab 57haloperidol 20mg tab 57haloperidol 2mg tab 57haloperidol 2mg/ml oralsoln

57

haloperidol 5mg tab 57haloperidol 5mg/ml inj 57haloperidol decanoate100mg/ml inj

57

haloperidol decanoate500mg/5ml inj

57

haloperidol decanoate50mg/ml inj

57

HAVRIX 1440UNIT INJ 115


134

Índice

HAVRIX 1440UNITSYRINGE

115

HAVRIX 720UNIT INJ 115HAVRIX 720UNITSYRINGE

115

heparin sodium porcine10000unit/ml inj

26


26


26


26

HEPATAMINE 8% INJ 100HETLIOZ 20MG CAP 93HIBERIX INJ 114HUMIRA 10MG/0.1MLSYRINGE

11

HUMIRA 10MG/0.2MLSYRINGE

11


11


11

HUMIRA 40MG/0.4MLPEN INJECTOR

11


11

HUMIRA 40MG/0.8MLAUTO-INJECTOR

11


11

HUMIRA PEDIATRICCROHN'S STARTERPACK (3) 80MG/0.8MLINJ

11

HUMIRA PEDIATRICCROHN'S STARTERPACK SYRINGE(2) 40MG/0.4ML80MG/0.8ML

11

HUMIRA PEN - CROHN'SSTARTER PACK40MG/0.8ML INJ

11

HUMIRA PEN - CROHN'SSTARTER PACK80MG/0.8ML INJ

11

HUMIRA PEN -PSORIASIS STARTERPACK 40MG/0.8ML INJ

11

HUMIRA PEN -PSORIASIS STARTERPACK 80MG/0.8ML INJ

11

HUMULIN R 500UNIT/ML INJ

36

HUMULIN R 500UNIT/ML PEN INJ

36

hydralazine 100mg tab 46hydralazine 10mg tab 46hydralazine 25mg tab 46hydralazine 50mg tab 46hydrochlorothiazide 12.5mgcap

83

hydrochlorothiazide 12.5mgtab

83

hydrochlorothiazide12.5mg/irbesartan 150mgtab

45

hydrochlorothiazide12.5mg/irbesartan 300mgtab

45

hydrochlorothiazide12.5mg/lisinopril 10mg tab

45

hydrochlorothiazide12.5mg/lisinopril 20mg tab

45

hydrochlorothiazide12.5mg/losartan potassium100mg tab

45

hydrochlorothiazide12.5mg/losartan potassium50mg tab

45

hydrochlorothiazide12.5mg/olmesartanmedoxomil 20mg tab

45

hydrochlorothiazide12.5mg/olmesartanmedoxomil 40mg tab

45

hydrochlorothiazide12.5mg/quinapril 10mg tab

45

hydrochlorothiazide12.5mg/quinapril 20mg tab

45

hydrochlorothiazide12.5mg/telmisartan 40mgtab

45

hydrochlorothiazide12.5mg/telmisartan 80mgtab

45

hydrochlorothiazide12.5mg/valsartan 160mgtab

45

hydrochlorothiazide12.5mg/valsartan 320mgtab

45

hydrochlorothiazide12.5mg/valsartan 80mg tab

45

hydrochlorothiazide 25mgtab

83

hydrochlorothiazide 25mg/lisinopril 20mg tab

45

hydrochlorothiazide 25mg/losartan potassium 100mgtab

45


45


45

hydrochlorothiazide 25mg/olmesartan medoxomil40mg tab

45

hydrochlorothiazide 25mg/propranolol 40mg tab

46

hydrochlorothiazide 25mg/propranolol 80mg tab

46

hydrochlorothiazide 25mg/quinapril 20mg tab

46

hydrochlorothiazide 25mg/spironolactone 25mg tab

82

hydrochlorothiazide 25mg/telmisartan 80mg tab

46

hydrochlorothiazide 25mg/triamterene 37.5mg cap

82

hydrochlorothiazide 25mg/triamterene 37.5mg tab

82


135

Índice

hydrochlorothiazide 25mg/valsartan 160mg tab

46

hydrochlorothiazide 25mg/valsartan 320mg tab

46

hydrochlorothiazide 50mgtab

83


46

hydrochlorothiazide 50mg/triamterene 75mg tab

82

hydrocodone 10mg/ibuprofen 200mg tab

16

hydrocodone 5mg/ibuprofen200mg tab

16

hydrocodone bitartrate7.5mg/ibuprofen 200mg tab

16

hydrocortisone 1% cream 80hydrocortisone 1.67mg/mlenema

17

hydrocortisone 10mg tab 75hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/mlophth susp

102

hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/mlotic soln

103

hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/mlotic susp

103

hydrocortisone 2.5% cream 80hydrocortisone 2.5% lotion 80hydrocortisone 2.5%ointment

80

hydrocortisone 20mg tab 75hydrocortisone 5mg tab 75hydrocortisone valerate0.2% cream

80

hydrocortisone valerate0.2% ointment

80

hydrocortisone/pramoxine1-1% rectal cream

17

hydromorphone 10mg/ml(1ml) inj

14

hydromorphone 10mg/ml(5ml) inj

14

hydromorphone 1mg/ml oralsoln

14

hydromorphone 2mg tab 14hydromorphone 4mg tab 14hydromorphone 8mg tab 14hydroxychloroquine sulfate200mg tab

46

hydroxyurea 500mg cap 53hydroxyzine 10mg tab 20hydroxyzine 25mg tab 20hydroxyzine 2mg/ml oralsoln

20

hydroxyzine 50mg tab 20HYDROXYZINEPAMOATE 100MG CAP

20

hydroxyzine pamoate 25mgcap

20

hydroxyzine pamoate 50mgcap

21

HYSINGLA 100MG ERTAB

14

HYSINGLA 120MG ERTAB

14

HYSINGLA 20MG ERTAB

14

HYSINGLA 30MG ERTAB

14

HYSINGLA 40MG ERTAB

15

HYSINGLA 60MG ERTAB

15

HYSINGLA 80MG ERTAB

15

Iibandronate 150mg tab 83IBRANCE 100MG CAP 50IBRANCE 125MG CAP 50IBRANCE 75MG CAP 50ibu 600mg tab 12ibu 800mg tab 12ibuprofen 20mg/ml susp 13

ibuprofen 400mg tab 13IBUPROFEN 400MG/OXYCODONE 5MG TAB

16

ibuprofen 600mg tab 13ibuprofen 800mg tab 13icatibant 10mg/ml syringe 90ICLUSIG 15MG TAB 50ICLUSIG 45MG TAB 50IDHIFA 100MG TAB 51IDHIFA 50MG TAB 51ILEVRO 0.3% OPHTHSUSP

103

imatinib 100mg tab 51imatinib 400mg tab 51IMBRUVICA 140MG CAP 51IMBRUVICA 140MG TAB 51IMBRUVICA 280MG TAB 51IMBRUVICA 420MG TAB 51IMBRUVICA 560MG TAB 51IMBRUVICA 70MG CAP 51imipramine 10mg tab 34imipramine 25mg tab 34imipramine 50mg tab 34imipramine pamoate 100mgcap

34

imipramine pamoate 125mgcap

34


34


34

imiquimod 5% cream 81IMOVAX 2.5UNIT/ML INJ115incassia 28 day 0.35mgpack

75

INCRELEX 40MG/4MLINJ

84

INCRUSE 62.5MCG INH 22indapamide 1.25mg tab 83indapamide 2.5mg tab 83INDOCIN 50MG RECTALSUPP

13

INFANRIX INJ 112INGREZZA 40MG CAP 107INGREZZA 80MG CAP 107INLYTA 1MG TAB 51


136

Índice

INLYTA 5MG TAB 51INREBIC 100MG CAP 51INSULIN PEN NEEDLE 94INSULIN SYRINGE(DISP) U-100 0.3ML

94

INSULIN SYRINGE(DISP) U-100 1/2ML

94

INSULIN SYRINGE(DISP) U-100 1ML

94

INSULIN SYRINGE MIS1ML/29G

94

INTELENCE 100MG TAB 61INTELENCE 200MG TAB 61INTELENCE 25MG TAB 61intralipid 200mg/ml inj 99INTRON A 10MU INJ 53INTRON A 18MU INJ 53INTRON A 25MU INJ 53INTRON A 50MU INJ 53INTRON A 6000000UNIT/ML INJ

53

introvale 91 day pack 73INVEGA 117MG/0.75MLSYRINGE

56

INVEGA 156MG/MLSYRINGE

56

INVEGA 234MG/1.5MLSYRINGE

56


56


56


56


56


56


56

INVIRASE 500MG TAB 61IOPIDINE 1% OPHTHSOLN

101

IPOL INJ 115ipratropium bromide 0.02%inh soln

22

ipratropium bromide 0.03%nasal inhaler

99

ipratropium bromide 0.06%nasal inhaler

99

ipratropium/albuterol0.5-2.5mg/3ml inh soln

24

irbesartan 150mg tab 43irbesartan 300mg tab 43irbesartan 75mg tab 43IRESSA 250MG TAB 51ISENTRESS 100MGCHEW TAB

61

ISENTRESS 100MG SUSP 61ISENTRESS 25MG CHEWTAB

61

ISENTRESS 400MG TAB 61ISENTRESS 600MG TAB 61isibloom 28 day pack 73ISOLYTE P INJ 96ISOLYTE S INJ 96isoniazid 100mg tab 47ISONIAZID 10MG/MLORAL SOLN

47

isoniazid 300mg tab 47ISOPROPYL ALCOHOL0.7ML/ML PAD

94

isosorbide dinitrate 10mgtab

20

isosorbide dinitrate 20mgtab

20

ISOSORBIDE DINITRATE30MG TAB

20

isosorbide dinitrate 5mg tab 20isosorbide mononitrate10mg tab

20

isosorbide mononitrate120mg er tab

20

isosorbide mononitrate20mg tab

20


20


20

isotretinoin 10mg cap 77isotretinoin 20mg cap 77isotretinoin 30mg cap 77

isotretinoin 40mg cap 77isradipine 2.5mg cap 67isradipine 5mg cap 67itraconazole 100mg cap 39ivermectin 3mg tab 18IXIARO SYRINGE 115

JJADENU 180MGGRANULE PACKET

38

JADENU 180MG TAB 37JADENU 360MGGRANULE PACKET

38

JADENU 360MG TAB 38JADENU 90MGGRANULE PACKET

38

JADENU 90MG TAB 37JAKAFI 10MG TAB 51JAKAFI 15MG TAB 51JAKAFI 20MG TAB 51JAKAFI 25MG TAB 51JAKAFI 5MG TAB 51jantoven 10mg tab 25jantoven 1mg tab 25jantoven 2.5mg tab 25jantoven 2mg tab 25jantoven 3mg tab 25jantoven 4mg tab 25jantoven 5mg tab 25jantoven 6mg tab 25jantoven 7.5mg tab 25JANUMET 100-1000MGXR TAB

35

JANUMET 50-1000MGTAB

35

JANUMET 50-1000MG XRTAB

35

JANUMET 50-500MGTAB

35

JANUMET 50-500MG XRTAB

35

JANUVIA 100MG TAB 36JANUVIA 25MG TAB 36JANUVIA 50MG TAB 36JARDIANCE 10MG TAB 37JARDIANCE 25MG TAB 37


137

Índice

jasmiel 28 day pack 73JENTADUETO2.5-1000MG TAB

35

JENTADUETO2.5-1000MG XR TAB

35

JENTADUETO 2.5-500MGTAB

35

JENTADUETO 2.5-850MGTAB

35

JENTADUETO 5-1000MGXR TAB

35

jinteli tab 86juleber 28 day pack 73JULUCA 50-25MG TAB 61junel 1.5/30 21 day pack 73junel 1/20 21 day pack 73junel fe 1.5/30 28 day pack 73junel fe 1/20 28 day pack 73junel fe 24 1/20 28 day pack 73JUXTAPID 10MG CAP 41JUXTAPID 20MG CAP 41JUXTAPID 30MG CAP 41JUXTAPID 40MG CAP 41JUXTAPID 5MG CAP 41JUXTAPID 60MG CAP 41JYNARQUE 15MG TAB 86JYNARQUE 30MG TAB 86JYNARQUE 45/15THERAPY PACK

86

JYNARQUE 60/30THERAPY PACK

86

JYNARQUE 90/30THERAPY PACK

86

KK-TAB 20MEQ ER TAB 96K-TAB 8MEQ ER TAB 96kaitlib fe 28 day pack 73KALETRA 100-25MGTAB

61

KALETRA 200-50MGTAB

61

KALYDECO 150MG TAB 109KALYDECO 25MGGRANULES

109

KALYDECO 50MGGRANULES PACKET

109

KALYDECO 75MGGRANULES PACKET

109

kariva 28 day pack 73KCL/D5W/LR INJ 0.15% 96kelnor 1/35 28 day pack 73kelnor 1/50 28 day pack 73ketoconazole 2% cream 78ketoconazole 2% shampoo 78ketoconazole 200mg tab 39ketoconazole 20mg/ml foam 78ketodan 2% foam 78KETOPROFEN 25MGCAP

13

ketorolac tromethamine0.4% ophth soln

103

ketorolac tromethamine0.5% ophth soln

103

ketorolac tromethamine10mg tab

13

KEVZARA150MG/1.14ML PF INJ

12

KEVZARA200MG/1.14ML PF INJ

12

KINRIX INJ 112KINRIX PF INJ 112kionex 250mg/ml susp 64KISQALI 200MG DAILYDOSE PACK

51

KISQALI 400MG DAILYDOSE PACK

51

KISQALI 600MG DAILYDOSE PACK

51

KISQALI/FEMARA TABCO-PACK 200MG

49


49


49

klor-con 10meq er micro tab 96klor-con 10meq er tab 96KLOR-CON 15MEQ ERTAB

96

klor-con 20meq er micro tab 96klor-con 20meq powder 96

klor-con 8meq er tab 96KORLYM 300MG TAB 36KRINTAFEL 150MG TAB 46kurvelo 28 day pack 73KUVAN 100MG POWDERFOR ORAL SOLN

85

KUVAN 100MG TAB 85KUVAN 500MG POWDERFOR ORAL SOLN

85

Llabetalol 100mg tab 65labetalol 200mg tab 65labetalol 300mg tab 65LACRISERT 5MGIMPLANT

100

lactulose 667mg/ml oralsoln

93

LAMICTAL XR BLUE KIT 28LAMICTAL XR GREENKIT

28

LAMICTAL XR ORANGEKIT

28

lamivudine 100mg tab 63lamivudine 10mg/ml oralsoln

61

lamivudine 150mg tab 61lamivudine 150mg/zidovudine 300mg tab

61

lamivudine 300mg tab 61lamotrigine 100mg er tab 28lamotrigine 100mg odt 28lamotrigine 100mg tab 28lamotrigine 150mg tab 28lamotrigine 200mg er tab 28lamotrigine 200mg odt 28lamotrigine 200mg tab 28lamotrigine 250mg er tab 28lamotrigine 25mg (35) tabstarter pack

28

lamotrigine 25mg chew tab 28lamotrigine 25mg er tab 28lamotrigine 25mg odt 28lamotrigine 25mg tab 28lamotrigine 300mg er tab 28lamotrigine 50mg er tab 28


138

Índice

lamotrigine 50mg odt 28lamotrigine 5mg chew tab 28lamotrigine tab 25mg(42)/100mg (7) starter pack

28

lamotrigine tab 25mg(84)/100mg (14) starterpack

28

lansoprazole 15mg dr cap 113lansoprazole 30mg dr cap 113lanthanum carbonate1000mg chew tab

89

lanthanum carbonate500mg chew tab

89

lanthanum carbonate750mg chew tab

89

LANTUS 100UNIT/MLINJ

36

LANTUS 100UNIT/MLSOLOSTAR

36

larin 1.5/30 pack 73larin 1/20 pack 73larin fe 1.5/30 pack 73larin fe 1/20 pack 73larissia 28 day pack 73latanoprost 0.005% ophthsoln

103

LATUDA 120MG TAB 56LATUDA 20MG TAB 56LATUDA 40MG TAB 56LATUDA 60MG TAB 56LATUDA 80MG TAB 56layolis fe 28 pack 73leena 28 day pack 73leflunomide 10mg tab 13leflunomide 20mg tab 13LENVIMA (10) 10MGPACK

51

LENVIMA (12) 4MGPACK

51

LENVIMA (14) PACK 51LENVIMA (18) PACK 51LENVIMA (20) 10MGPACK

51

LENVIMA (24) PACK 51LENVIMA (4) 4MG PACK 51LENVIMA (8) 4MG PACK 51

lessina 28 day pack 73letrozole 2.5mg tab 48LEUCOVORIN 10MGTAB

53

LEUCOVORIN 15MGTAB

53

leucovorin 25mg tab 53leucovorin 5mg tab 53LEUKERAN 2MG TAB 47LEUKINE 250MCG INJ 92leuprolide acetate 5mg/mlinj

48

levalbuterol 0.31mg inh soln 24levalbuterol 0.63mg inh soln 24levalbuterol 1.25mg inh soln 24levalbuterol 2.5mg inh soln 24LEVEMIR 100UNIT/MLFLEXTOUCH

36

LEVEMIR 100UNIT/MLINJ

36

levetiracetam 1000mg tab 28levetiracetam 100mg/mloral soln

28

levetiracetam 250mg tab 28levetiracetam 500mg er tab 28levetiracetam 500mg tab 28levetiracetam 750mg er tab 28levetiracetam 750mg tab 28levo-t 100mcg tab 110levo-t 112mcg tab 110levo-t 125mcg tab 110levo-t 137mcg tab 110levo-t 150mcg tab 110levo-t 175mcg tab 110levo-t 200mcg tab 110levo-t 25mcg tab 110levo-t 300mcg tab 110levo-t 50mcg tab 110levo-t 75mcg tab 110levo-t 88mcg tab 110levobunolol 0.5% ophth soln100levocarnitine 100mg/ml oralsoln

85

levocarnitine 330mg tab 85levocetirizine 0.5mg/ml oralsoln

40

levocetirizine 5mg tab 40levofloxacin 0.5% ophthsoln

101

levofloxacin 250mg tab 87levofloxacin 25mg/ml inj 87levofloxacin 25mg/ml oralsoln

87

levofloxacin 500mg tab 87levofloxacin 5mg/ml(150ml) inj

87

levofloxacin 5mg/ml inj 87levofloxacin 750mg tab 88levonest 28 day pack 73levora 0.15/30 28 day pack 73levothyroxine sodium100mcg tab

110

levothyroxine sodium112mcg tab

110


111


111


111


111


111

levothyroxine sodium 25mcgtab

111


111


111


111


111

levoxyl 100mcg tab 111levoxyl 112mcg tab 111levoxyl 125mcg tab 111levoxyl 137mcg tab 111levoxyl 150mcg tab 111levoxyl 175mcg tab 111levoxyl 200mcg tab 111levoxyl 25mcg tab 111


139

Índice

levoxyl 50mcg tab 111levoxyl 75mcg tab 111levoxyl 88mcg tab 111LEXIVA 50MG/ML SUSP 61lidocaine 2% gel 81lidocaine 2% topical soln 98lidocaine 4% topical soln 81lidocaine 5% ointment 81lidocaine 5% patch 81lidocaine/prilocaine2.5-2.5% cream

81

lindane 1% shampoo 81linezolid 20mg/ml susp 19linezolid 2mg/ml inj 19linezolid 600mg tab 19LINZESS 145MCG CAP 89LINZESS 290MCG CAP 89LINZESS 72MCG CAP 89liothyronine sodium0.005mg tab

111

liothyronine sodium0.025mg tab

111

liothyronine sodium 0.05mgtab

111

lisinopril 10mg tab 42lisinopril 2.5mg tab 42lisinopril 20mg tab 42lisinopril 30mg tab 42lisinopril 40mg tab 42lisinopril 5mg tab 42lithium carbonate 150mgcap

55

lithium carbonate 300mgcap

55

lithium carbonate 300mg ertab

55

lithium carbonate 300mgtab

55

lithium carbonate 450mg ertab

55

lithium carbonate 600mgcap

55

lithium citrate 60mg/ml oralsoln

56

LITHOSTAT 250MG TAB 90

LOKELMA 10GMPACKET

98

LOKELMA 5GM PACKET 98LONHALA 0.0025% INHSOLN

22

LONSURF 15-6.14MGTAB

49

LONSURF 20-8.19MGTAB

49

loperamide 2mg cap 37lopinavir 80mg/ml/ritonavir20mg/ml oral solution

61

lopreeza 1/0.5mg 28 daypack

86

lorazepam 0.5mg tab 21lorazepam 1mg tab 21lorazepam 2mg tab 21lorazepam 2mg/ml conc 21LORBRENA 100MG TAB 51LORBRENA 25MG TAB 51lorcet 10-325mg tab 16lorcet 5-325mg tab 16lorcet 7.5-325mg tab 16loryna 28 day pack 73losartan potassium 100mgtab

43

losartan potassium 25mgtab

43

losartan potassium 50mgtab

43

LOTEMAX 0.5% OPHTHGEL

102

LOTEMAX 0.5% OPHTHOINTMENT

102

loteprednol etabonate 0.5%ophth susp

102

lovastatin 10mg tab 41lovastatin 20mg tab 41lovastatin 40mg tab 41low-ogestrel 28 day pack 73loxapine 10mg cap 58loxapine 25mg cap 58loxapine 50mg cap 58loxapine 5mg cap 58LUMIGAN 0.01% OPHTHSOLN

103

LUPANETA PACK 1-MONTH PACK

85

LUPANETA PACK 3-MONTH PACK

85

LUPRON 11.25MG(1.5ML) SYRINGE

48

LUPRON 22.5MGSYRINGE

48

LUPRON 3.75MGSYRINGE

48

LUPRON 30MG SYRINGE 48LUPRON 45MG SYRINGE 48LUPRON 7.5MGSYRINGE

48

lutera 28 day pack 73LYNPARZA 100MG TAB 51LYNPARZA 150MG TAB 51LYSODREN 500MG TAB 48lyza 0.35mg pack 75

MM-M-R II INJ 115magnesium sulfate 50% inj 96magnesium sulfate 50%syringe

96

malathion 0.5% lotion 82MAPROTILINE 25MGTAB

31

MAPROTILINE 50MGTAB

31

MAPROTILINE 75MGTAB

31

marlissa 28 day pack 73MARPLAN 10MG TAB 31MATULANE 50MG CAP 53matzim 180mg er tab 67matzim 240mg er tab 67matzim 300mg er tab 67matzim 360mg er tab 67matzim 420mg er tab 67MAVYRET 100-40MGTAB

63

MAXIDEX 0.1% OPHTHSUSP

102

MAYZENT 0.25MG TAB 108MAYZENT 2MG TAB 108


140

Índice

meclizine 12.5mg tab 38meclizine 25mg tab 38MEDROL 2MG TAB 75medroxyprogesteroneacetate 10mg tab

106

medroxyprogesteroneacetate 150mg/ml inj

75

medroxyprogesteroneacetate 150mg/ml syringe

75

medroxyprogesteroneacetate 2.5mg tab

106

medroxyprogesteroneacetate 5mg tab

106

MEFLOQUINE 250MGTAB

46

megestrol acetate 125mg/mlsusp

106

megestrol acetate 20mg tab 48megestrol acetate 40mg tab 49megestrol acetate 40mg/mlsusp

49

MEKINIST 0.5MG TAB 51MEKINIST 2MG TAB 51MEKTOVI 15MG TAB 51meloxicam 15mg tab 13meloxicam 7.5mg tab 13memantine 10mg tab 106memantine 10mg/memantine5mg pack

106

memantine 14mg er cap 106memantine 21mg er cap 106memantine 28mg er cap 106memantine 2mg/ml oral soln106memantine 5mg tab 106memantine 7mg er cap 106MENACTRA INJ 114MENVEO INJ 115mercaptopurine 50mg tab 47meropenem 1gm inj 18meropenem 500mg inj 18mesalamine 1.2gm tab 88mesalamine 1000mg rectalsupp

88

mesalamine 375mg er cap 88mesalamine 400mg dr cap 88

mesalamine 66.7mg/mlenema

88

mesalamine 800mg dr tab 88MESNEX 400MG TAB 53metadate 20mg er tab 10METAPROTERENOLSULFATE 2MG/ML ORALSOLN

24

METAXALONE 400MGTAB

99

metaxalone 800mg tab 99metformin 1000mg tab 35metformin 500mg er tab 35metformin 500mg tab 35metformin 750mg er tab 35metformin 850mg tab 35methadone 10mg tab 15methadone 5mg tab 15methazolamide 25mg tab 82methazolamide 50mg tab 82methenamine hippurate1000mg tab

114

methimazole 10mg tab 110methimazole 5mg tab 110methocarbamol 500mg tab 99methocarbamol 750mg tab 99methotrexate 2.5mg tab 47methotrexate 250mg/10mlinj

47

methotrexate 50mg/2ml inj 47methoxsalen 10mg cap 78methscopolamine 2.5mg tab113methscopolamine 5mg tab 113methylphenidate 10mg crcap

10

methylphenidate 10mg ertab

10

methylphenidate 10mg lacap

10

methylphenidate 10mg tab 10methylphenidate 18mg srtab

10

methylphenidate 1mg/mloral soln

10

methylphenidate 20mg crcap

10

methylphenidate 20mg ertab

10


10

methylphenidate 20mg tab 10methylphenidate 27mg srtab

10

methylphenidate 2mg/mloral soln

10


10


10

methylphenidate 36mg srtab

10


10


10


10

methylphenidate 54mg srtab

10

methylphenidate 5mg tab 10methylphenidate 60mg crcap

10

methylprednisolone 16mgtab

75

methylprednisolone 32mgtab

75

methylprednisolone 4mgpack

75

methylprednisolone 4mg tab 75methylprednisolone 8mg tab 75metoclopramide 10mg tab 88metoclopramide 1mg/mloral soln

88

metoclopramide 5mg tab 88metolazone 10mg tab 83metolazone 2.5mg tab 83metolazone 5mg tab 83metoprolol succinate 100mger tab

65

metoprolol succinate 200mger tab

65


141

Índice


65


65

metoprolol tartrate 100mgtab

65


65


65

metronidazole 0.75% cream 81metronidazole 0.75% gel 81metronidazole 0.75% lotion 81metronidazole 0.75%vaginal gel

115

metronidazole 1% gel 81metronidazole 250mg tab 18metronidazole 375mg cap 18metronidazole 500mg tab 18metronidazole 5mg/ml inj 18microgestin 1.5/30 21 daypack

73

microgestin 1/20 21 daypack

73

microgestin fe 1.5/30 28 daypack

73

microgestin fe 1/20 28 daypack

73

midodrine 10mg tab 116midodrine 2.5mg tab 116midodrine 5mg tab 116miglitol 100mg tab 34miglitol 25mg tab 34miglitol 50mg tab 34miglustat 100mg cap 91mili 28 day pack 73mimvey pack 86minitran 0.1mg/hr patch 20minitran 0.2mg/hr patch 20minitran 0.4mg/hr patch 20minitran 0.6mg/hr patch 20minocycline 100mg cap 110minocycline 100mg tab 110minocycline 50mg cap 110minocycline 50mg tab 110minocycline 75mg cap 110

minocycline 75mg tab 110minoxidil 10mg tab 46minoxidil 2.5mg tab 46mirtazapine 15mg odt 31mirtazapine 15mg tab 31mirtazapine 30mg odt 31mirtazapine 30mg tab 31mirtazapine 45mg odt 31mirtazapine 45mg tab 31mirtazapine 7.5mg tab 31misoprostol 0.1mg tab 113misoprostol 0.2mg tab 113MITIGARE 0.6MG CAP 90modafinil 100mg tab 11modafinil 200mg tab 11moexipril 15mg tab 42moexipril 7.5mg tab 42MOLINDONE 10MG TAB 59MOLINDONE 25MG TAB 59MOLINDONE 5MG TAB 59mometasone furoate 0.1%cream

80

mometasone furoate 0.1%lotion

80

mometasone furoate 0.1%ointment

80

mondoxyne 100mg cap 110montelukast 10mg tab 23montelukast 4mg chew tab 23montelukast 4mg granules 23montelukast 5mg chew tab 23MONUROL 3000MGORAL SOLN

114

morphine sulfate 100mg ertab

15


15

morphine sulfate 15mg tab 15morphine sulfate 200mg ertab

15

morphine sulfate 20mg/mloral soln

15

morphine sulfate 2mg/mloral soln

15


15

morphine sulfate 30mg tab 15morphine sulfate 4mg/mloral soln

15


15

MOVANTIK 12.5MG TAB 89MOVANTIK 25MG TAB 89moxifloxacin 0.5% ophthsoln

101

moxifloxacin 1.6mg/ml inj 88moxifloxacin 400mg tab 88MULPLETA 3MG TAB 92MULTAQ 400MG TAB 22mupirocin 2% ointment 77MYCAMINE 100MG INJ 39MYCAMINE 50MG INJ 39mycophenolate mofetil200mg/ml susp

64

mycophenolate mofetil250mg cap

64

mycophenolate mofetil500mg tab

64

mycophenolic acid 180mgdr tab

64

mycophenolic acid 360mgdr tab

64

myorisan 10mg cap 77myorisan 20mg cap 77myorisan 30mg cap 77myorisan 40mg cap 77MYRBETRIQ 25MG ERTAB

114

MYRBETRIQ 50MG ERTAB

114

Nnabumetone 500mg tab 13nabumetone 750mg tab 13nadolol 20mg tab 65nadolol 40mg tab 65nadolol 80mg tab 65nafcillin 100mg/ml inj 105nafcillin 1gm inj 105nafcillin 2gm inj 105naftifine 1% cream 78naftifine 2% cream 78


142

Índice

NALOXONE 0.4MG/MLCARTRIDGE

38

naloxone 0.4mg/ml inj 38NALOXONE 1MG/MLSYRINGE

38

naltrexone 50mg tab 38naproxen 250mg tab 13naproxen 375mg dr tab 13naproxen 375mg tab 13naproxen 500mg dr tab 13naproxen 500mg tab 13naproxen sodium 275mg tab 13naproxen sodium 550mg tab 13naratriptan 1mg tab 94naratriptan 2.5mg tab 94NARCAN 4MG/0.1MLNASAL SPRAY

38

NATACYN 5% OPHTHSUSP

101

NATAZIA 28 DAY PACK 73nateglinide 120mg tab 37nateglinide 60mg tab 37NATPARA 100MCGCARTRIDGE

83

NATPARA 25MCGCARTRIDGE

84


84


84

NAYZILAM 5MG/0.1MLNASAL SPRAY

27

NEBUPENT 300MG INHSOLN

18

necon 0.5/35 28 day pack 73NEFAZODONE 100MGTAB

32

NEFAZODONE 150MGTAB

32

NEFAZODONE 200MGTAB

32

NEFAZODONE 250MGTAB

32

NEFAZODONE 50MGTAB

32

neomycin sulfate 500mg tab 11

neomycin/bacitracin/polymyxin ophth ointment5(3.5)mg-400unit-10000unit

101

neomycin/polymyxin/bacitracin/hydrocortisoneophth ointmentment 1%

102

NEPHRAMINE 5.4% INJ 100NERLYNX 40MG TAB 51NEUPRO 1MG/24HRPATCH

54

NEUPRO 2MG/24HRPATCH

54


54


54


54


54

NEVANAC 0.1% OPHTHSUSP

103

nevirapine 100mg er tab 61nevirapine 10mg/ml oralsusp

61

nevirapine 200mg tab 61nevirapine 400mg er tab 61NEXAVAR 200MG TAB 51NEXIUM 10MG SUSP 113NEXIUM 2.5MG SUSP 113NEXIUM 20MG SUSP 113NEXIUM 40MG SUSP 113NEXIUM 5MG SUSP 113niacin 1000mg er tab 42niacin 500mg er tab 42niacin 750mg er tab 42nicardipine 20mg cap 67nicardipine 30mg cap 67NICOTROL 10MGINHALER

108

NICOTROL 10MG/MLNASAL INHALER

108

nifedipine 30mg er tab 67nifedipine 30mg osmotic ertab

67

nifedipine 60mg er tab 67

nifedipine 60mg osmotic ertab

67

nifedipine 90mg er tab 67nifedipine 90mg osmotic ertab

67

nikki 28 day pack 73nilutamide 150mg tab 49nimodipine 30mg cap 67NINLARO 2.3MG CAP 51NINLARO 3MG CAP 52NINLARO 4MG CAP 52nisoldipine 17mg er tab 67nisoldipine 20mg er tab 67NISOLDIPINE 25.5MG ERTAB

67

nisoldipine 30mg er tab 67nisoldipine 34mg er tab 67nisoldipine 40mg er tab 67nisoldipine 8.5mg er tab 67NITRO-BID 2%OINTMENT

20

NITRO-DUR 0.3MG/HRPATCH

20

NITRO-DUR 0.8MG/HRPATCH

20

nitrofurantoin 5mg/ml susp 114nitrofurantoin macro 100mgcap

114

nitrofurantoin macro 25mgcap

114

nitrofurantoin macro 25mg/nitrofurantoin mono 75mgcap

114

nitrofurantoin macro 50mgcap

114

nitroglycerin 0.1mg/hrpatch

20


20

nitroglycerin 0.3mg sl tab 20nitroglycerin 0.4mg sl tab 20nitroglycerin 0.4mg/actspray

20


20

nitroglycerin 0.6mg sl tab 20


143

Índice


20

NIVESTYM300MCG/0.5ML PF INJ

92

NIVESTYM 300MCG/1MLINJ

92

NIVESTYM480MCG/0.8ML PF INJ

92

NIVESTYM480MCG/1.6ML INJ

92

nizatidine 150mg cap 112NIZATIDINE 15MG/MLORAL SOLN

113

nizatidine 300mg cap 112nora-be 28 day 0.35mg pack 75norethindrone 0.35mg pack 75norethindrone acetate 5mgtab

106

NORMOSOL-M INJ 96NORMOSOL-R IN 5%DEXTROSE INJ

96

NORMOSOL-R INJ 96NORPACE 100MG ERCAP

21

NORPACE 150MG ERCAP

21

NORTHERA 100MG CAP 116NORTHERA 200MG CAP 116NORTHERA 300MG CAP 116nortrel 0.5/35 28 day pack 73nortrel 1/35 21 day pack 73nortrel 1/35 28 day pack 74nortrel 7/7/7 28 day pack 74nortriptyline 10mg cap 34nortriptyline 25mg cap 34NORTRIPTYLINE 2MG/ML ORAL SOLN

34

nortriptyline 50mg cap 34nortriptyline 75mg cap 34NORVIR 100MGPOWDER PACKET

61

NORVIR 80MG/ML ORALSOLN

62

NOVOLIN 100UNIT/MLINJ

36

NOVOLIN N 100UNIT/MLINJ

36

NOVOLIN R 100UNIT/MLINJ

36

NOVOLOG 100UNIT/MLFLEXPEN

36

NOVOLOG 100UNIT/MLINJ

36

NOVOLOG 100UNIT/MLPENFILL

36

NOVOLOG MIX100UNIT/ML FLEXPEN

36

NOVOLOG MIX100UNIT/ML INJ

36

NOXAFIL 100MG DRTAB

39

NOXAFIL 40MG/MLSUSP

39

NUBEQA 300MG TAB 49NUCALA 100MG INJ 22NUCALA 100MG/MLAUTO-INJECTOR

22

NUCALA 100MG/MLSYRINGE

22

NUCYNTA 100MG ERTAB

15

NUCYNTA 150MG ERTAB

15

NUCYNTA 200MG ERTAB

15

NUCYNTA 250MG ERTAB

15

NUCYNTA 50MG ER TAB 15NUEDEXTA 20-10MGCAP

108

NUPLAZID 10MG TAB 56NUPLAZID 34MG CAP 56nutrilipid 20% iv soln 99NUVARING VAGINALRING

74

NUZYRA 150MG TAB 109nyamyc 100000unit/gmpowder

78

nystatin 100000unit/mlcream

78

nystatin 100000unit/ml susp 98

nystatin 100unit/mgointment

78

nystatin 100unit/mg powder 78nystatin 500000unit tab 39nystop 100000unit/gmpowder

78

OOCALIVA 10MG TAB 88OCALIVA 5MG TAB 88ocella 28 day pack 74OCTAGAM 25GM/500MLINJ

104

OCTAGAM 2GM/20MLINJ

104

octreotide 0.05mg/ml inj 86octreotide 0.1mg/ml inj 86octreotide 0.2mg/ml inj 86octreotide 0.5mg/ml inj 86octreotide 1mg/ml inj 86ODEFSEY 200-25-25MGTAB

62

ODOMZO 200MG CAP 48OFEV 100MG CAP 109OFEV 150MG CAP 109ofloxacin 0.3% ophth soln 101ofloxacin 0.3% otic soln 103ofloxacin 400mg tab 88olanzapine 10mg inj 58olanzapine 10mg odt 58olanzapine 10mg tab 58olanzapine 15mg odt 58olanzapine 15mg tab 58olanzapine 2.5mg tab 58olanzapine 20mg odt 58olanzapine 20mg tab 58olanzapine 5mg odt 58olanzapine 5mg tab 58olanzapine 7.5mg tab 58olmesartan medoxomil20mg tab

43

olmesartan medoxomil40mg tab

43

olmesartan medoxomil 5mgtab

43


144

Índice

olopatadine 0.6% nasalinhaler

99

olopatadine 1mg/ml ophthsoln

103

olopatadine 2% ophth soln 103OLUMIANT 1MG TAB 12OLUMIANT 2MG TAB 12omega-3 acid ethyl esters(usp) 1000mg cap

40

omeprazole 10mg dr cap 113omeprazole 20mg dr cap 113omeprazole 40mg dr cap 113ondansetron 0.8mg/ml oralsoln

38

ondansetron 24mg tab 38ondansetron 4mg odt 38ondansetron 4mg tab 38ondansetron 8mg odt 38ondansetron 8mg tab 38OPSUMIT 10MG TAB 69ORENCIA 125MG/MLAUTO-INJECTOR

13

ORENCIA 125MG/MLSYRINGE

13

ORENCIA 50MG/0.4MLSYRINGE

13

ORENCIA 87.5MG/0.7MLSYRINGE

13

ORENITRAM 0.125MGER TAB

68

ORENITRAM 0.25MG ERTAB

68

ORENITRAM 1MG ERTAB

68

ORENITRAM 2.5MG ERTAB

68

ORENITRAM 5MG ERTAB

69

ORFADIN 10MG CAP 85ORFADIN 20MG CAP 85ORFADIN 2MG CAP 85ORFADIN 4MG/ML SUSP 85ORFADIN 5MG CAP 85ORILISSA 150MG TAB 84ORILISSA 200MG TAB 84

ORKAMBI 100-125MGGRANULES PACKET

109

ORKAMBI 100-125MGTAB

109

ORKAMBI 188-150MGGRANULES PACKET

109

ORKAMBI 200-125MGTAB

109

orphenadrine citrate 100mger tab

99

orsythia 28 day pack 74oseltamivir 30mg cap 63oseltamivir 45mg cap 63oseltamivir 6mg/ml oralsusp

64

oseltamivir 75mg cap 64OSPHENA 60MG TAB 84OTEZLA 28-DAYSTARTER PACK

13

OTEZLA 30MG TAB 13oxacillin 100mg/ml inj 105oxacillin 1gm inj 105oxacillin 2000mg inj 105OXACILLIN 20MG/MLINJ

105

OXACILLIN 40MG/MLINJ

105

oxandrolone 10mg tab 17oxandrolone 2.5mg tab 17oxaprozin 600mg tab 13OXAZEPAM 10MG CAP 21oxazepam 15mg cap 21OXAZEPAM 30MG CAP 21oxcarbazepine 150mg tab 28oxcarbazepine 300mg tab 28oxcarbazepine 600mg tab 28oxcarbazepine 60mg/mlsusp

28

OXERVATE 0.002%OPHTH SOLN

102

OXTELLAR 150MG XRTAB

28


28


28

oxybutynin chloride 10mg ertab

114


114

oxybutynin chloride 1mg/mloral soln

114


114

oxybutynin chloride 5mg tab114oxycodone 10mg tab 15oxycodone 15mg tab 15oxycodone 1mg/ml oral soln 15oxycodone 20mg tab 15oxycodone 20mg/ml oralsoln

15

oxycodone 30mg tab 15oxycodone 5mg cap 15oxycodone 5mg tab 15oxymorphone 10mg tab 15oxymorphone 5mg tab 15OZEMPIC 2MG/1.5MLPEN INJ

36

OZEMPIC 2MG/1.5MLPEN INJ (1MG DOSE)

36

Ppacerone 200mg tab 22pacerone 400mg tab 22paliperidone 1.5mg er tab 57paliperidone 3mg er tab 57paliperidone 6mg er tab 57paliperidone 9mg er tab 57PALYNZIQ 10MG/0.5MLSYRINGE

85

PALYNZIQ 2.5MG/0.5MLSYRINGE

85

PALYNZIQ 20MG/MLSYRINGE

85

PANRETIN 0.1% GEL 78pantoprazole 20mg dr tab 113pantoprazole 40mg dr tab 113PANZYGA 10GM/100MLIV SOLN

104

PANZYGA 1GM/10ML IVSOLN

104


145

Índice

PANZYGA 2.5GM/25MLIV SOLN

104

PANZYGA 20GM/200MLIV SOLN

104

PANZYGA 30GM/300MLIV SOLN

104

PANZYGA 5GM/50ML IVSOLN

104

paricalcitol 0.001mg cap 85paricalcitol 0.002mg cap 85paricalcitol 0.004mg cap 85paromomycin 250mg cap 11paroxetine 10mg tab 32paroxetine 12.5mg er tab 32paroxetine 20mg tab 32paroxetine 25mg er tab 32paroxetine 30mg tab 32paroxetine 37.5mg er tab 32paroxetine 40mg tab 32PASER D/R 4GMGRANULES

47

PAXIL 10MG/5ML SUSP 32PEDIARIX INJ 112PEDVAXHIB7.5MCG/0.5ML INJ

115

peg 3350/electrolyte oralsoln

93

peg 3350/kcl/sodiumbicarbonate/sodiumchloride powder for oralsoln

93

PEGANONE 250MG TAB 30PEGASYS 180MCG/0.5MLAUTO-INJECTOR

63

PEGASYS 180MCG/0.5MLSYRINGE

63

PEGASYS 180MCG/MLINJ

63

penicillamine 250mg tab 97penicillin g potassium1000000unit/ml inj

104

PENICILLIN GPOTASSIUM 40000UNIT/ML INJ

104

PENICILLIN GPOTASSIUM 60000UNIT/ML INJ

104

PENICILLIN GPROCAINE 600000UNIT/ML SYRINGE

104

PENICILLIN G SODIUM100000UNIT/ML INJ

105

penicillin v potassium250mg tab

105

PENICILLIN VPOTASSIUM 25MG/MLORAL SOLN

105

penicillin v potassium500mg tab

105

PENICILLIN VPOTASSIUM 50MG/MLORAL SOLN

105

PENTAM 300MG INJ 18pentamidine isethionate300mg inj

18

pentamidine isethionate50mg/ml inh soln

18

pentoxifylline 400mg er tab 90perindopril erbumine 2mgtab

42

perindopril erbumine 4mgtab

42

perindopril erbumine 8mgtab

42

permethrin 5% cream 82perphenazine 16mg tab 59perphenazine 2mg tab 59perphenazine 4mg tab 59perphenazine 8mg tab 59PERSERIS 120MGSYRINGE

57

PERSERIS 90MGSYRINGE

57

PEXEVA 10MG TAB 32PEXEVA 20MG TAB 32PEXEVA 30MG TAB 32PEXEVA 40MG TAB 32phenadoz 12.5mg rectalsupp

40

phenelzine 15mg tab 31

phenobarbital 100mg tab 92phenobarbital 15mg tab 92phenobarbital 16.2mg tab 92phenobarbital 30mg tab 92phenobarbital 32.4mg tab 92phenobarbital 4mg/ml oralsoln

92

phenobarbital 60mg tab 92phenobarbital 64.8mg tab 92phenobarbital 97.2mg tab 92phenoxybenzamine 10mgcap

43

PHENYLEPHRINE 1MG/ML/PROMETHAZINE1.25MG/ML ORAL SOLN

76

phenytoin 25mg/ml susp 30phenytoin 50mg chew tab 30phenytoin sodium 100mg ercap

30

phenytoin sodium 200mg ercap

30

phenytoin sodium 300mg ercap

30

PHOSLYRA 667MG/5MLORAL SOLN

89

PHOSPHOLINE IODIDE0.125% OPHTH SOLN

101

PICATO 0.015% GEL 78PICATO 0.05% GEL 78PIFELTRO 100MG TAB 62pilocarpine 1% ophth soln 101pilocarpine 2% ophth soln 101pilocarpine 4% ophth soln 101pilocarpine 5mg tab 98pilocarpine 7.5mg tab 98pimecrolimus 1% cream 81PIMOZIDE 1MG TAB 108PIMOZIDE 2MG TAB 108pimtrea pack 74pindolol 10mg tab 65pindolol 5mg tab 65pioglitazone 15mg tab 37pioglitazone 30mg tab 37pioglitazone 45mg tab 37piperacillin 2000mg/tazobactam 250mg inj

105


146

Índice

piperacillin 200mg/ml/tazobactam 25mg/ml inj

105

piperacillin 3000mg/tazobactam 375mg inj

105

piperacillin 4000mg/tazobactam 500mg inj

105

PIQRAY 200MG DAILYDOSE PACK

52

PIQRAY 250MG DAILYDOSE PACK

52

PIQRAY 300MG DAILYDOSE 150MG PACK

52

pirmella 1/35 28 day pack 74piroxicam 10mg cap 13piroxicam 20mg cap 13PLASMA-LYTE 148 INJ 96PLASMALYTE A INJ 96PLEGRIDY125MCG/0.5ML AUTO-INJECTOR

108

PLEGRIDY125MCG/0.5ML SYRINGE

108

PLEGRIDY PENSTARTER PACK

108

PLEGRIDY STARTERPACK

108

plenamine 15% inj 100podofilox 0.5% topical soln 81polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophthsoln

101

polymyxin b 250000unit/mlinj

19

POMALYST 1MG CAP 49POMALYST 2MG CAP 49POMALYST 3MG CAP 49POMALYST 4MG CAP 49portia 28 day pack 74posaconazole 100mg dr tab 39potassium chloride 0.02meq/ml/sodium chloride0.0769 meq/ml inj

96

potassium chloride 0.02meq/ml/sodium chloride0.154 meq/ml inj

96

potassium chloride 0.04meq/ml/sodium chloride0.154 meq/ml inj

96

potassium chloride 0.1 meq/ml inj

96

potassium chloride 0.2meq/ml inj

96

potassium chloride 0.4meq/ml inj

96

potassium chloride 10%oral soln

97

potassium chloride 10meqer cap

97

potassium chloride 10meqer micro tab

97

potassium chloride 10meqer tab

97

potassium chloride 20%oral soln

97

potassium chloride 20meqer micro tab

97

POTASSIUM CHLORIDE20MEQ ER TAB

97

potassium chloride 20meqpowder for oral soln

97

potassium chloride 2meq/mlinj

97

potassium chloride40meq/20ml inj

97

potassium chloride 8 meq ercap

97

potassium chloride 8 meq ertab

97

potassium citrate 10meq ertab

89

potassium citrate 15 meq ertab

89

potassium citrate 5 meq ertab

89

PRADAXA 110MG CAP 26PRADAXA 150MG CAP 26PRADAXA 75MG CAP 26PRALUENT 150MG/MLAUTO-INJECTOR

42

PRALUENT 75MG/MLAUTO-INJECTOR

42

pramipexole 0.125mg tab 54pramipexole 0.25mg tab 54pramipexole 0.375mg er tab 54pramipexole 0.5mg tab 54pramipexole 0.75mg er tab 54pramipexole 0.75mg tab 54pramipexole 1.5mg er tab 54pramipexole 1.5mg tab 54pramipexole 1mg tab 54pramipexole 2.25mg er tab 54pramipexole 3.75mg er tab 54pramipexole 3mg er tab 54pramipexole 4.5mg er tab 54prasugrel 10mg tab 91prasugrel 5mg tab 91pravastatin sodium 10mgtab

41

pravastatin sodium 20mgtab

41


41


41

prazosin 1mg cap 44prazosin 2mg cap 44prazosin 5mg cap 44PRED MILD 0.12%OPHTH SUSP

102

PRED-G 0.3-1% OPHTHSUSP

102

PREDNICARBATE 0.1%CREAM

80

PREDNICARBATE 0.1%OINTMENT

80

PREDNISOLONE 1%OPHTH SOLN

102

prednisolone 10mg odt 75prednisolone 15mg odt 75prednisolone 1mg/ml oralsoln

75

prednisolone 30mg odt 75PREDNISOLONE 3MG/ML ORAL SOLN

75

PREDNISOLONEACETATE 1% OPHTHSUSP

102


147

Índice

PREDNISOLONESODIUM PHOSPHATE2.5MG/ML/SULFACETAMIDESODIUM 100MG/MLOPHTH SOLN

102

prednisone 10mg tab 76prednisone 1mg tab 76PREDNISONE 1MG/MLORAL SOLN

76

prednisone 2.5mg tab 76prednisone 20mg tab 76PREDNISONE 50MG TAB 76prednisone 5mg tab 76PREDNISONE 5MG/MLORAL SOLN

76

pregabalin 100mg cap 28pregabalin 150mg cap 28pregabalin 200mg cap 28pregabalin 20mg/ml oralsoln

29

pregabalin 225mg cap 29pregabalin 25mg cap 29pregabalin 300mg cap 29pregabalin 50mg cap 29pregabalin 75mg cap 29PREMARIN 0.3MG TAB 87PREMARIN 0.45MG TAB 87PREMARIN 0.625MG TAB 87PREMARIN 0.625MG/GMVAGINAL CREAM

116

PREMARIN 0.9MG TAB 87PREMARIN 1.25MG TAB 87PREMASOL 10% INJ 100PREMPHASE 28 DAYPACK

86

PREMPRO 0.3/1.5MG 28DAY PACK

86

PREMPRO 0.45/1.5 28DAY PACK

86

PREMPRO 0.625/2.5MG28 DAY PACK

86

PREMPRO 0.625/5MG 28DAY PACK

86

prevalite 4gm/dose susp 40previfem 28 day pack 74

PREVYMIS 240MG TAB 63PREVYMIS 480MG TAB 63PREZCOBIX 800-150MGTAB

62

PREZISTA 100MG/MLSUSP

62

PREZISTA 150MG TAB 62PREZISTA 600MG TAB 62PREZISTA 75MG TAB 62PREZISTA 800MG TAB 62PRIFTIN 150MG TAB 47PRIMAQUINEPHOSPHATE 26.3MG TAB

46

primidone 250mg tab 29primidone 50mg tab 29PRIVIGEN 20GM/200MLINJ

104

probenecid 500mg tab 90PROCALAMINE 3% INJ 100prochlorperazine 10mg tab 59prochlorperazine 25mgrectal supp

59

prochlorperazine 5mg tab 59procto-med 2.5% cream 17procto-pak 1% rectal cream 17proctosol 2.5% cream 17proctozone hc 2.5% cream 17progesterone 100mg cap 106progesterone 200mg cap 106PROGLYCEM 50MG/MLSUSP

36

PROGRAF 0.2MGGRANULES PACKET

98

PROGRAF 1MGGRANULES PACKET

98

PROLASTIN 1000MG INJ 108PROLIA 60MG/MLSYRINGE

84

PROMACTA 12.5MGPOWDER FOR ORALSUSP

92

PROMACTA 12.5MG TAB 92PROMACTA 25MG TAB 92PROMACTA 50MG TAB 92PROMACTA 75MG TAB 92

promethazine 1.25mg/mloral soln

40

promethazine 12.5mg rectalsupp

40

promethazine 12.5mg tab 40promethazine 25mg rectalsupp

40

promethazine 25mg tab 40promethazine 50mg tab 40promethegan 25mg rectalsupp

40

promethegan 50mg rectalsupp

40

propafenone 150mg tab 22propafenone 225mg er cap 22propafenone 225mg tab 22propafenone 300mg tab 22propafenone 325mg er cap 22propafenone 425mg sr cap 22proparacaine 0.5% ophthsoln

102

propranolol 10mg tab 65propranolol 120mg er cap 65propranolol 160mg er cap 65propranolol 20mg tab 65propranolol 40mg tab 65PROPRANOLOL 4MG/MLORAL SOLN

65

propranolol 60mg er cap 65propranolol 60mg tab 65propranolol 80mg er cap 65propranolol 80mg tab 66PROPRANOLOL 8MG/MLORAL SOLN

66

propylthiouracil 50mg tab 110PROQUAD INJ 115PROSOL 20% INJ 100protriptyline 10mg tab 34protriptyline 5mg tab 34PULMOZYME 1MG/MLINH SOLN

109

PURIXAN2000MG/100ML SUSP

47

PYLERA 140-125-125MGCAP

113

pyrazinamide 500mg tab 47


148

Índice

pyridostigmine bromide180mg er tab

47

pyridostigmine bromide60mg tab

47

QQBRELIS 1MG/ML ORALSOLN

42

QUADRACEL INJ 112QUDEXY 100MG XR CAP 29QUDEXY 150MG XR CAP 29QUDEXY 200MG XR CAP 29QUDEXY 25MG XR CAP 29QUDEXY 50MG XR CAP 29quetiapine 100mg tab 58quetiapine 150mg xr tab 58quetiapine 200mg tab 58quetiapine 200mg xr tab 58quetiapine 25mg tab 58quetiapine 300mg tab 58quetiapine 300mg xr tab 58quetiapine 400mg tab 58quetiapine 400mg xr tab 58quetiapine 50mg tab 58quetiapine 50mg xr tab 58quinapril 10mg tab 42quinapril 20mg tab 42quinapril 40mg tab 43quinapril 5mg tab 43quinidine gluconate 324mger tab

21

QUINIDINE SULFATE200MG TAB

21

QUINIDINE SULFATE300MG TAB

22

quinine sulfate 324mg cap 46

RRABAVERT 2.5UNIT/MLINJ

115

rabeprazole sodium 20mgdr tab

113

raloxifene 60mg tab 84ramelteon 8mg tab 93ramipril 1.25mg cap 43ramipril 10mg cap 43

ramipril 2.5mg cap 43ramipril 5mg cap 43ranitidine 150mg cap 112ranitidine 150mg tab 113ranitidine 15mg/ml oral soln112ranitidine 300mg cap 112ranitidine 300mg tab 113ranolazine 1000mg er tab 20ranolazine 500mg er tab 20rasagiline 0.5mg tab 55rasagiline 1mg tab 55RAVICTI 1.1GM/MLORAL SOLN

85

REBIF 22MCG/0.5MLAUTO-INJECTOR

108

REBIF 22MCG/0.5MLSYRINGE

108

REBIF 44MCG/0.5MLAUTO-INJECTOR

108

REBIF 44MCG/0.5MLSYRINGE

108

REBIF REBIDOSE PACK 108REBIF TITRATION PACK 108reclipsen 28 day pack 74RECOMBIVAX 10MCG/ML SYRINGE

115

RECOMBIVAX 40MCG/ML INJ

115

RECOMBIVAX5MCG/0.5ML SYRINGE

115

RECOMBIVAX HB10MCG/ML INJ

115

RECTIV 0.4% RECTALOINTMENT

18

REGRANEX 0.01% GEL 82RELENZA 5MG/BLISTERINH

64

RELISTOR 12MG/0.6MLINJ

89

RELISTOR 12MG/0.6MLSYRINGE

89

RELISTOR 8MG/0.4MLSYRINGE

89

repaglinide 0.5mg tab 37repaglinide 1mg tab 37repaglinide 2mg tab 37

REPATHA 120MG/MLCARTRIDGE

42

REPATHA 140MG/MLAUTO-INJECTOR

42

REPATHA 140MG/MLSYRINGE

42

RESCRIPTOR 200MGTAB

62

RESTASIS 0.05% OPHTHSUSP

102

RETACRIT 10000UNIT/ML INJ

92

RETACRIT 2000UNIT/MLINJ

92


92

RETACRIT 40000UNIT/ML INJ

92


92

REVLIMID 10MG CAP 97REVLIMID 15MG CAP 97REVLIMID 2.5MG CAP 97REVLIMID 20MG CAP 97REVLIMID 25MG CAP 97REVLIMID 5MG CAP 97REXULTI 0.25MG TAB 60REXULTI 0.5MG TAB 60REXULTI 1MG TAB 60REXULTI 2MG TAB 60REXULTI 3MG TAB 60REXULTI 4MG TAB 60REYATAZ 50MG ORALPOWDER

62

ribavirin 200mg cap 63ribavirin 200mg tab 63RIDAURA 3MG CAP 12rifabutin 150mg cap 47RIFAMATE 150-300MGCAP

47

rifampin 150mg cap 47rifampin 300mg cap 47rifampin 60mg/ml inj 47RIFATER 50-120-300MGTAB

47

riluzole 50mg tab 99


149

Índice

rimantadine 100mg tab 64RINVOQ 15MG ER TAB 12risedronate sodium 150mgtab

84

risedronate sodium 30mgtab

84

risedronate sodium 35mg(12) pack

84

risedronate sodium 35mg(4) pack

84

risedronate sodium 35mgtab

84

risedronate sodium 5mg tab 84RISPERDAL 12.5MG INJ 57RISPERDAL 25MG INJ 57RISPERDAL 37.5MG INJ 57RISPERDAL 50MG INJ 57risperidone 0.25mg odt 57risperidone 0.25mg tab 57risperidone 0.5mg odt 57risperidone 0.5mg tab 57risperidone 1mg odt 57risperidone 1mg tab 57risperidone 1mg/ml oralsoln

57

risperidone 2mg odt 57risperidone 2mg tab 57risperidone 3mg odt 57risperidone 3mg tab 57risperidone 4mg odt 57risperidone 4mg tab 57ritonavir 100mg tab 62rivastigmine 1.5mg cap 106rivastigmine 13.3mg/24hrpatch

106

rivastigmine 3mg cap 106rivastigmine 4.5mg cap 106rivastigmine 4.6mg/24hrpatch

107

rivastigmine 6mg cap 107rivastigmine 9.5mg/24hrpatch

107

rivelsa 91 day pack 74rizatriptan 10mg odt 95rizatriptan 10mg tab 95rizatriptan 5mg odt 95

rizatriptan 5mg tab 95ropinirole 0.25mg tab 54ropinirole 0.5mg tab 54ropinirole 12mg er tab 55ropinirole 1mg tab 55ropinirole 2mg er tab 55ropinirole 2mg tab 55ropinirole 3mg tab 55ropinirole 4mg er tab 55ropinirole 4mg tab 55ropinirole 5mg tab 55ropinirole 6mg er tab 55ropinirole 8mg er tab 55rosuvastatin 10mg tab 41rosuvastatin 20mg tab 41rosuvastatin 40mg tab 41rosuvastatin 5mg tab 41ROTARIX SUSP 115ROTATEQ SUSP 115roweepra 1000mg tab 29roweepra 500mg er tab 29roweepra 500mg tab 29roweepra 750mg er tab 29roweepra 750mg tab 29ROZLYTREK 100MG CAP 52ROZLYTREK 200MG CAP 52RUBRACA 200MG TAB 52RUBRACA 250MG TAB 52RUBRACA 300MG TAB 52RUCONEST 2100UNITINJ

90

RUZURGI 10MG TAB 47RYBELSUS 14MG TAB 36RYBELSUS 3MG TAB 36RYBELSUS 7MG TAB 36RYDAPT 25MG CAP 52

Ssalmon calcitonin 200unit/act nasal spray

84

SANDIMMUNE 100MG/ML ORAL SOLN

64

SANTYL 250UNIT/GMOINTMENT

81

SAPHRIS 10MG SL TAB 58SAPHRIS 2.5MG SL TAB 58

SAPHRIS 5MG SL TAB 58SAVELLA 100MG TAB 107SAVELLA 12.5MG TAB 107SAVELLA 25MG TAB 107SAVELLA 4-WEEKTITRATION PACK

107

SAVELLA 50MG TAB 107scopolamine 0.0139mg/hrpatch

38

SECUADO 3.8MG/24HRPATCH

58


58


58

selegiline 5mg cap 55selegiline 5mg tab 55selenium sulfide 2.5%lotion/shampoo

79

SELZENTRY 150MG TAB 62SELZENTRY 20MG/MLORAL SOLN

62

SELZENTRY 25MG TAB 62SELZENTRY 300MG TAB 62SELZENTRY 75MG TAB 62SEREVENT 50MCG/DOSEINH

24

sertraline 100mg tab 32sertraline 20mg/ml oral soln 32sertraline 25mg tab 32sertraline 50mg tab 32setlakin 91 day pack 74sevelamer carbonate2400mg oral susp

89

sevelamer carbonate 800mgoral susp

89

sevelamer carbonate 800mgtab

89

sharobel 28 day 0.35mgpack

75

SHINGRIX INJ 115SIGNIFOR 0.3MG/ML INJ 86SIGNIFOR 0.6MG/ML INJ 86SIGNIFOR 0.9MG/ML INJ 86sildenafil 20mg tab 69silodosin 4mg cap 90


150

Índice

silodosin 8mg cap 90silver sulfadiazine 1%cream

79

SIMBRINZA 1-0.2%OPHTH SUSP

101

SIMPONI 100MG/MLAUTO-INJECTOR

11

SIMPONI 100MG/ML INJ 12SIMPONI 50MG/0.5MLAUTO-INJECTOR

12

SIMPONI 50MG/0.5MLSYRINGE

12

simvastatin 10mg tab 41simvastatin 20mg tab 41simvastatin 40mg tab 41simvastatin 5mg tab 41simvastatin 80mg tab 41sirolimus 0.5mg tab 64sirolimus 1mg tab 64sirolimus 1mg/ml oral soln 98sirolimus 2mg tab 64SIRTURO 100MG TAB 47SIVEXTRO 200MG INJ 19SIVEXTRO 200MG TAB 19SKYRIZI SYRINGE150MG DOSE PACK

79

sodium chloride 0.45% inj 97sodium chloride 0.9% inj 97sodium chloride 0.9% soln 89sodium chloride 3% inj 97sodium chloride 5% inj 97sodium phenylbutyrate0.94mg/mg oral powder

85

sodium polystyrenesulfonate 15gm oral susp

64

sodium polystyrenesulfonate 250mg/ml susp

64

SOFOSBUVIR/VELPATASVIR400-100MG TAB

63

solifenacin succinate 10mgtab

114

solifenacin succinate 5mgtab

114

SOLTAMOX 10MG/5MLORAL SOLN

49

SOMATULINE120MG/0.5ML SYRINGE

86


86


86

SOMAVERT 10MG INJ 84SOMAVERT 15MG INJ 84SOMAVERT 20MG INJ 84SOMAVERT 25MG INJ 84SOMAVERT 30MG INJ 84sorine 120mg tab 66sorine 160mg tab 66sorine 240mg tab 66sorine 80mg tab 66sotalol 120mg tab 66sotalol 160mg tab 66sotalol 240mg tab 66sotalol 80mg tab 66sotalol af 120mg tab 66SPIRIVA 1.25MCGRESPIMAT INH

22

spironolactone 100mg tab 83spironolactone 25mg tab 83spironolactone 50mg tab 83sprintec 28 day pack 74SPRITAM 1000MG ODT 29SPRITAM 250MG ODT 29SPRITAM 500MG ODT 29SPRITAM 750MG ODT 29SPRYCEL 100MG TAB 52SPRYCEL 140MG TAB 52SPRYCEL 20MG TAB 52SPRYCEL 50MG TAB 52SPRYCEL 70MG TAB 52SPRYCEL 80MG TAB 52sps 250mg/ml oral susp 64sronyx 28 day pack 74ssd 1% cream 79stavudine 15mg cap 62stavudine 20mg cap 62stavudine 30mg cap 62stavudine 40mg cap 62STELARA 45MG/0.5MLINJ

79

STELARA 45MG/0.5MLSYRINGE

79

STELARA 90MG/MLSYRINGE

79

STIMATE 1.5MG/MLNASAL SPRAY

85

STIOLTO 2.5-2.5MCG INH 24STIVARGA 40MG TAB 52STREPTOMYCIN 100MGINJ

11

STRIBILD150-150-200-300MG TAB

62

SUCRAID 8500UNIT/MLORAL SOLN

82

sucralfate 1000mg tab 112sucralfate 100mg/ml susp 113sulfacetamide sodium 10%lotion

77

SULFACETAMIDESODIUM 10% OPHTHOINTMENT

101

sulfacetamide sodium 10%ophth soln

101

SULFADIAZINE 500MGTAB

109

sulfamethoxazole 400mg/trimethoprim 80mg tab

18

sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp

18

sulfamethoxazole 800mg/trimethoprim 160mg tab

18

SULFAMYLON 85MG/GMCREAM

79

sulfasalazine 500mg dr tab 88sulfasalazine 500mg tab 88sulindac 150mg tab 13sulindac 200mg tab 13sumatriptan 100mg tab 95sumatriptan 12mg/ml auto-injector

95

sumatriptan 12mg/ml inj 95SUMATRIPTAN 12MG/ML SYRINGE

95

sumatriptan 20mg/act nasalspray

95

sumatriptan 25mg tab 95


151

Índice

sumatriptan 4mg cartridge 95sumatriptan 50mg tab 95sumatriptan 5mg/act nasalspray

95

sumatriptan 6mg cartridge 95sumatriptan 8mg/ml auto-injector

95

SUNOSI 150MG TAB 9SUNOSI 75MG TAB 9SUPRAX 400MG CAP 71SUTENT 12.5MG CAP 52SUTENT 25MG CAP 52SUTENT 37.5MG CAP 52SUTENT 50MG CAP 52syeda 28 day pack 74SYLATRON 200MCG INJ 53SYLATRON 300MCG INJ 53SYMDEKO50-75MG/75MG PACK

109

SYMDEKO TAB 4-WEEKPACK

109

SYMFI 600-300-300MGTAB

62

SYMFI LO400-300-300MG TAB

62

SYMJEPI 0.15MG/0.3MLSYRINGE

116

SYMJEPI 0.3MG/0.3MLSYRINGE

116

SYMPAZAN 10MG STRIP 27SYMPAZAN 20MG STRIP 27SYMPAZAN 5MG STRIP 27SYMPROIC 0.2MG TAB 89SYMTUZA800-150-200-10MG TAB

62

SYNAREL 2MG/MLNASAL SPRAY

85

SYNJARDY 12.5-1000MGTAB

35

SYNJARDY 12.5-500MGTAB

35

SYNJARDY 5-1000MGTAB

35

SYNJARDY 5-500MGTAB

35

SYNJARDY XR10-1000MG TAB

35

SYNJARDY XR12.5-1000MG TAB

35


35


35

SYNRIBO 3.5MG INJ 53SYNTHROID 100MCGTAB

111

SYNTHROID 112MCGTAB

111

SYNTHROID 125MCGTAB

111

SYNTHROID 137MCGTAB

111

SYNTHROID 150MCGTAB

111

SYNTHROID 175MCGTAB

111

SYNTHROID 200MCGTAB

111

SYNTHROID 25MCG TAB111SYNTHROID 300MCGTAB

111

SYNTHROID 50MCG TAB111SYNTHROID 75MCG TAB111SYNTHROID 88MCG TAB111

TTABLOID 40MG TAB 47tacrolimus 0.03% ointment 81tacrolimus 0.1% ointment 81tacrolimus 0.5mg cap 64tacrolimus 1mg cap 64tacrolimus 5mg cap 64tadalafil 20mg tab(PAH) 69TAFINLAR 50MG CAP 52TAFINLAR 75MG CAP 52TAGRISSO 40MG TAB 52TAGRISSO 80MG TAB 52TAKHZYRO 300MG/2MLINJ

91

TALZENNA 0.25MG CAP 52TALZENNA 1MG CAP 52

tamoxifen 10mg tab 49tamoxifen 20mg tab 49tamsulosin 0.4mg cap 90TARGRETIN 1% GEL 78tarina 24 fe 1/20 28 daypack

74

tarina fe 1/20 28 day pack 74TASIGNA 150MG CAP 52TASIGNA 200MG CAP 52TASIGNA 50MG CAP 52TAVALISSE 100MG TAB 90TAVALISSE 150MG TAB 90tazarotene 1% cream 79tazicef 1gm inj 71tazicef 2gm inj 71tazicef 6gm inj 71TAZORAC 0.05% CREAM 79TAZORAC 0.05% GEL 79TAZORAC 0.1% GEL 79taztia 120mg er cap 67taztia 180mg er cap 67taztia 240mg er cap 67taztia 300mg er cap 67taztia 360mg er cap 67TAZVERIK 200MG TAB 52TECFIDERA 120MG DRCAP

108

TECFIDERA 240MG DRCAP

108

TECFIDERA 30-DAYSTARTER PACK

108

TEFLARO 400MG INJ 71TEFLARO 600MG INJ 71TEGSEDI 189MG/MLSYRINGE

108

telmisartan 20mg tab 43telmisartan 40mg tab 43telmisartan 80mg tab 43temazepam 15mg cap 93temazepam 22.5mg cap 93temazepam 30mg cap 93temazepam 7.5mg cap 93TENIVAC SYRINGE 112tenofovir disoproxilfumarate 300mg tab

62

terazosin 10mg cap 44


152

Índice

terazosin 1mg cap 44terazosin 2mg cap 44terazosin 5mg cap 44terbinafine 250mg tab 39terbutaline sulfate 2.5mgtab

24

terbutaline sulfate 5mg tab 24terconazole 0.4% vaginalcream

115

TERCONAZOLE 0.8%VAGINAL CREAM

116

terconazole 80mg vaginalsupp

116

testosterone 1% (25mg) gel 17testosterone 1% (50mg) gel 17TESTOSTERONE 1% GELPUMP

17

testosterone 1.62% (1.25gm)gel

17

testosterone 1.62% (2.5gm)gel

17

testosterone 1.62% gelpump

17

testosterone cypionate (1ml)200mg/ml inj

17

testosterone cypionate100mg/ml inj

17

testosterone cypionate200mg/ml inj

17

testosterone enanthate200mg/ml inj

17

TETANUS/DIPHTHERIATOXOID INJ

112

tetrabenazine 12.5mg tab 107tetrabenazine 25mg tab 107tetracycline 250mg cap 110tetracycline 500mg cap 110THALOMID 100MG CAP 97THALOMID 150MG CAP 97THALOMID 200MG CAP 97THALOMID 50MG CAP 97theophylline 300mg er tab 24theophylline 400mg er tab 24theophylline 5.33mg/ml oralsoln

24

theophylline 600mg er tab 24

THIOLA 100MG DR TAB 90THIOLA 100MG TAB 90THIOLA 300MG DR TAB 90thioridazine 100mg tab 59thioridazine 10mg tab 59thioridazine 25mg tab 59thioridazine 50mg tab 59thiothixene 10mg cap 60thiothixene 1mg cap 60thiothixene 2mg cap 60thiothixene 5mg cap 60tiadylt 120mg er cap 67tiadylt 180mg er cap 67tiadylt 240mg er cap 67tiadylt 300mg er cap 67tiadylt 360mg er cap 67tiadylt 420mg er cap 67tiagabine 12mg tab 30tiagabine 16mg tab 30tiagabine 2mg tab 30tiagabine 4mg tab 30TIBSOVO 250MG TAB 52TIGECYCLINE 50MG INJ 109TIMOLOL 0.25% OPHTHGEL

100

timolol 0.25% ophth soln 100TIMOLOL 0.5% OPHTHGEL

100

timolol 0.5% ophth soln 100timolol 10mg tab 66timolol 20mg tab 66timolol 5mg tab 66timolol 5mg/ml ophth 24hrophth soln

100

TIMOPTIC-XE 0.25%OPHTH GEL

100

TIMOPTIC-XE 0.5%OPHTH GEL

100

tinidazole 250mg tab 18tinidazole 500mg tab 18TIVICAY 10MG TAB 62TIVICAY 25MG TAB 62TIVICAY 50MG TAB 62tizanidine 2mg cap 99tizanidine 2mg tab 99tizanidine 4mg cap 99

tizanidine 4mg tab 99tizanidine 6mg cap 99TOBI PODHALER KIT28MG PACK

11

TOBRADEX 0.3-0.1%OPHTH OINTMENT

102

tobramycin 0.3% ophth soln101TOBRAMYCIN 10MG/MLINJ

11

tobramycin 40mg/ml inj 11tobramycin 60mg/ml inhsoln

11

TOLAK 4% CREAM 78tolcapone 100mg tab 55tolterodine tartrate 1mg tab 114tolterodine tartrate 2mg ercap

114

tolterodine tartrate 2mg tab 114tolterodine tartrate 4mg ercap

114

TOPIRAMATE 100MG ERCAP

29

topiramate 100mg tab 29TOPIRAMATE 150MG ERCAP

29

topiramate 15mg cap 29TOPIRAMATE 200MG ERCAP

29

topiramate 200mg tab 29topiramate 25mg cap 29TOPIRAMATE 25MG ERCAP

29

topiramate 25mg tab 29TOPIRAMATE 50MG ERCAP

29

topiramate 50mg tab 29toremifene 60mg tab 49torsemide 100mg tab 83torsemide 10mg tab 83torsemide 20mg tab 83torsemide 5mg tab 83TOUJEO 300UNIT/MLPEN INJ

36

TOUJEO MAX 300UNIT/ML PEN INJ (3ML)

36

tovet 0.05% e foam 80


153

Índice

TPN ELECTROLYTES INJ 96TRACLEER 32MG TABFOR ORAL SUSP

69

TRADJENTA 5MG TAB 36tramadol 100mg er tab 15tramadol 100mg er tab(matrix delivery)

15

tramadol 200mg er tab 15tramadol 200mg er tab(matrix delivery)

15

tramadol 300mg er tab 15tramadol 300mg er tab(matrix delivery)

15

tramadol 50mg tab 15trandolapril 1mg tab 43TRANDOLAPRIL 1MG/VERAPAMIL 240MG ERTAB

46

trandolapril 2mg tab 43trandolapril 2mg/verapamil180mg er tab

46

trandolapril 2mg/verapamil240mg er tab

46

trandolapril 4mg tab 43trandolapril 4mg/verapamil240mg er tab

46

tranexamic acid 650mg tab 92TRANSDERM SCOP1MG/3DAYS PATCH

38

tranylcypromine 10mg tab 31TRAVASOL 10% INJ 100TRAVATAN Z 0.004%OPHTH SOLN

103

travoprost 0.004% ophthsoln

103

trazodone 100mg tab 32trazodone 150mg tab 32trazodone 300mg tab 32trazodone 50mg tab 32TRECATOR 250MG TAB 47TRELEGY 62.5-25MCGELLIPTA INH

24

TRELSTAR 11.25MG INJ 49TRELSTAR 22.5MG INJ 49TRELSTAR 3.75MG INJ 49

TRESIBA 100UNIT/MLFLEXTOUCH PEN INJ

36

TRESIBA 100UNIT/MLINJ (VIAL)

37

TRESIBA 200UNIT/MLFLEXTOUCH PEN INJ

37

tretinoin 0.01% gel 77tretinoin 0.025% cream 77tretinoin 0.025% gel 77tretinoin 0.04% gel 77tretinoin 0.05% cream 77tretinoin 0.05% gel 77tretinoin 0.1% cream 77tretinoin 0.1% gel 77tretinoin 10mg cap 53TREXALL 10MG TAB 48TREXALL 15MG TAB 48TREXALL 5MG TAB 48TREXALL 7.5MG TAB 48tri-estarylla 28 day pack 74tri-legest 28 day pack 74tri-lo-estarylla 28 day pack 74tri-lo-sprintec 28 day pack 74tri-mili 28 day pack 74tri-previfem 28 day pack 74tri-sprintec 28 day pack 74tri-vylibra 28 day pack 74tri-vylibra lo 28 day pack 74triamcinolone acetonide0.025% cream

80

triamcinolone acetonide0.025% lotion

81

triamcinolone acetonide0.025% ointment

81

triamcinolone acetonide0.1% cream

81

triamcinolone acetonide0.1% lotion

81


81

triamcinolone acetonide0.1% paste

98

triamcinolone acetonide0.147mg/ml spray

81

triamcinolone acetonide0.5% cream

81


81

triamterene 100mg cap 83triamterene 50mg cap 83triazolam 0.125mg tab 93triazolam 0.25mg tab 93triderm 0.1% cream 81trientine 250mg tab 97trifluoperazine 10mg tab 59trifluoperazine 1mg tab 59trifluoperazine 2mg tab 59trifluoperazine 5mg tab 59TRIFLURIDINE 1% SOLN101trihexyphenidyl 0.4mg/mloral soln

55

trihexyphenidyl 2mg tab 55trihexyphenidyl 5mg tab 55trilyte powder for oral soln 93trimethobenzamide 300mgcap

38

trimethoprim 100mg tab 18trimipramine 100mg cap 34trimipramine 25mg cap 34trimipramine 50mg cap 34TRINTELLIX 10MG TAB 32TRINTELLIX 20MG TAB 32TRINTELLIX 5MG TAB 32TRIUMEQ 600-50-300MGTAB

62

trivora 28 day pack 74TROKENDI 100MG XRCAP

29

TROKENDI 200MG XRCAP

29

TROKENDI 25MG XRCAP

29

TROKENDI 50MG XRCAP

29

TROPHAMINE 10% INJ 100trospium chloride 20mg tab 114trospium chloride 60mg ercap

114

TRUMENBA SYRINGE 115TRUVADA 100-150MGTAB

62


154

Índice

TRUVADA 133-200MGTAB

62


62


62

TURALIO 200MG CAP 52TWINRIX 720UNITSYRINGE

115

TYBOST 150MG TAB 62TYKERB 250MG TAB 52TYMLOS 2MG/ML PENINJECTOR

84

TYPHIM VI25MCG/0.5ML INJ

115

TYPHIM VI25MCG/0.5ML SYRINGE

115

UUCERIS 2MG/ACT FOAM 17UDENYCA 6MG/0.6MLSYRINGE

92

unithroid 100mcg tab 111unithroid 112mcg tab 111unithroid 125mcg tab 111unithroid 150mcg tab 111unithroid 175mcg tab 112unithroid 200mcg tab 112unithroid 25mcg tab 112unithroid 300mcg tab 112unithroid 50mcg tab 112unithroid 75mcg tab 112unithroid 88mcg tab 112UPTRAVI 1000MCG TAB 69UPTRAVI 1200MCG TAB 69UPTRAVI 1400MCG TAB 69UPTRAVI 1600MCG TAB 69UPTRAVI 200MCG TAB 69UPTRAVI 400MCG TAB 69UPTRAVI 600MCG TAB 69UPTRAVI 800MCG TAB 69UPTRAVI TITRATIONPACK

69

ursodiol 250mg tab 88ursodiol 300mg cap 88ursodiol 500mg tab 88

Vvalacyclovir 1000mg tab 63valacyclovir 500mg tab 63VALCHLOR 0.016% GEL 78valganciclovir 450mg tab 63valganciclovir 50mg/ml oralsoln

63

valproic acid 250mg cap 30valproic acid 50mg/ml oralsoln

30

valsartan 160mg tab 43valsartan 320mg tab 43valsartan 40mg tab 43valsartan 80mg tab 43VALTOCO 10MG DOSEKIT 10MG/0.1ML PACK

27

VALTOCO 15MG DOSEKIT 7.5MG/0.1ML PACK

27

VALTOCO 20MG DOSEKIT 10MG/0.1ML PACK

27

VALTOCO 5MG DOSEKIT 5MG/0.1ML PACK

27

vancomycin 100mg/ml inj 19vancomycin 125mg cap 19vancomycin 250mg cap 19VANCOMYCIN 250MGINJ

19

vancomycin 50mg/ml inj 19VANCOMYCIN 50MG/MLORAL SOLN

19

vancomycin 5mg/ml inj 19vancomycin 750mg inj 19vandazole 0.75% vaginalgel

116

VAQTA 25UNIT/0.5MLSYRINGE

115

VAQTA 50UNIT/0.5MLINJ

115

VAQTA 50UNIT/1ML INJ 115VAQTA 50UNIT/MLSYRINGE

115

VARIVAX 1350PFU/0.5MLINJ

115

VARIZIG 124.8/1.2ML INJ 104VARUBI 90MG TAB 39

VASCEPA 1GM CAP 40VASCEPA 500MG CAP 40velivet 28 day pack 74VELTASSA 16.8GMPOWDER FOR ORALSUSP

98

VELTASSA 25.2GMPOWDER FOR ORALSUSP

98

VELTASSA 8.4GMPOWDER FOR ORALSUSP

98

VEMLIDY 25MG TAB 63VENCLEXTA10/100/50MG STARTINGPACK

48

VENCLEXTA 100MG TAB 48VENCLEXTA 10MG TAB 48VENCLEXTA 50MG TAB 48venlafaxine 100mg tab 33venlafaxine 150mg er cap 33venlafaxine 25mg tab 33venlafaxine 37.5mg er cap 33venlafaxine 37.5mg tab 33venlafaxine 50mg tab 33venlafaxine 75mg er cap 33venlafaxine 75mg tab 33VENTAVIS 10MCG/MLINH SOLN

69

VENTAVIS 20MCG/MLINH SOLN

69

VENTOLIN 108MCG INH 24verapamil 100mg er cap 67verapamil 120mg er cap 67verapamil 120mg er tab 67verapamil 120mg tab 67verapamil 180mg er cap 68verapamil 180mg er tab 68verapamil 200mg er cap 68verapamil 240mg er cap 68verapamil 240mg er tab 68verapamil 300mg er cap 68VERAPAMIL 360MG SRCAP

68

verapamil 40mg tab 68verapamil 80mg tab 68


155

Índice

VERSACLOZ 50MG/MLSUSP

58

VERZENIO 100MG TAB 52VERZENIO 150MG TAB 52VERZENIO 200MG TAB 52VERZENIO 50MG TAB 52VICTOZA 18MG/3MLPEN INJ

36

VIDEX 125MG DR CAP 62VIDEX 2GM ORAL SOLN 62vienva 28 day pack 74vigabatrin 500mg tab 30vigabatrin 50mg/ml oralsoln

30

vigadrone 500mg oral soln 30VIIBRYD 10/20MGSTARTER PACK

32

VIIBRYD 10MG TAB 32VIIBRYD 20MG TAB 32VIIBRYD 40MG TAB 33VIMPAT 100MG TAB 29VIMPAT 10MG/ML ORALSOLN

29

VIMPAT 150MG TAB 29VIMPAT 200MG TAB 30VIMPAT 50MG TAB 30VIRACEPT 250MG TAB 62VIRACEPT 625MG TAB 62VIREAD 150MG TAB 62VIREAD 200MG TAB 63VIREAD 250MG TAB 63VIREAD 40MG/GM ORALPOWDER

63

VITRAKVI 100MG CAP 52VITRAKVI 20MG/MLORAL SOLN

53

VITRAKVI 25MG CAP 53VIVITROL 380MG INJ 38VIZIMPRO 15MG TAB 53VIZIMPRO 30MG TAB 53VIZIMPRO 45MG TAB 53voriconazole 200mg inj 40voriconazole 200mg tab 40voriconazole 40mg/ml susp 40voriconazole 50mg tab 40

VOSEVI 400-100-100MGTAB

63

VOTRIENT 200MG TAB 53VRAYLAR 1.5/3MGMIXED PACK

56

VRAYLAR 1.5MG CAP 56VRAYLAR 3MG CAP 56VRAYLAR 4.5MG CAP 56VRAYLAR 6MG CAP 56vyfemla 28 day pack 74vylibra 28 day pack 74VYNDAMAX 61MG CAP 69

WWAKIX 17.8MG TAB 9WAKIX 4.45MG TAB 9warfarin sodium 10mg tab 25warfarin sodium 1mg tab 25warfarin sodium 2.5mg tab 25warfarin sodium 2mg tab 25warfarin sodium 3mg tab 25warfarin sodium 4mg tab 25warfarin sodium 5mg tab 25warfarin sodium 6mg tab 25warfarin sodium 7.5mg tab 25wixela 100-50mcg inh 24wixela 250-50mcg inh 24wixela 500-50mcg inh 24wymzya fe 28 day pack 74

XXALKORI 200MG CAP 53XALKORI 250MG CAP 53XARELTO 10MG TAB 25XARELTO 15MG TAB 25XARELTO 2.5MG TAB 25XARELTO 20MG TAB 25XARELTO STARTERPACK

25

XATMEP 2.5MG/MLORAL SOLN

48

XELJANZ 10MG TAB 12XELJANZ 5MG TAB 12XGEVA 120MG/1.7ML INJ 84XIFAXAN 200MG TAB 18XIFAXAN 550MG TAB 18

XIGDUO 10-1000MG XRTAB

35


35

XIGDUO 2.5-1000MG XRTAB

35


35


35

XOFLUZA 20MGTHERAPY PACK

64

XOFLUZA 40MGTHERAPY PACK

64

XOLAIR 150MG INJ 22XOLAIR 150MG/ML PFINJ

22

XOLAIR 75MG/0.5ML PFINJ

22

XOSPATA 40MG TAB 53XPOVIO 100MG ONCEWEEKLY PACK

49

XPOVIO 60MG ONCEWEEKLY PACK

49

XPOVIO 80MG ONCEWEEKLY PACK

49

XPOVIO 80MG TWICEWEEKLY PACK

49

XTAMPZA 13.5MG ERCAP

15

XTAMPZA 18MG ER CAP 15XTAMPZA 27MG ER CAP 15XTAMPZA 36MG ER CAP 16XTAMPZA 9MG ER CAP 16XTANDI 40MG CAP 49XULANE 150-35MCGPATCH

74

XULTOPHY100UNIT-3.6MG/ML PENINJ

35

XYREM 500MG/MLORAL SOLN

106

YYF-VAX 4000UNIT/MLINJ

115


156

Índice

Zzafirlukast 10mg tab 23zafirlukast 20mg tab 23zaleplon 10mg cap 93zaleplon 5mg cap 93zarah 3-0.03mg pack 74ZARXIO 300MCG/0.5MLSYRINGE

92

ZARXIO 480MCG/0.8MLSYRINGE

92

ZEJULA 100MG CAP 53ZELBORAF 240MG TAB 53ZEMAIRA 1000MG INJ 108zenatane 10mg cap 77zenatane 20mg cap 77zenatane 30mg cap 77zenatane 40mg cap 77ZENPEP10000-32000-42000UNITDR CAP

82

ZENPEP15000-47000-63000UNITDR CAP

82


82


82


82


82


82

ZERBAXA 1.5GM INJ 69zidovudine 100mg cap 63zidovudine 10mg/ml oralsoln

63

zidovudine 300mg tab 63ZIEXTENZO 6MG/0.6MLSYRINGE

92

ziprasidone 20mg cap 56ziprasidone 40mg cap 56ziprasidone 60mg cap 56ziprasidone 80mg cap 56ZIRGAN 0.15% OPHTHGEL

101

ZOLINZA 100MG CAP 53zolmitriptan 2.5mg odt 95zolmitriptan 2.5mg tab 95zolmitriptan 5mg odt 95zolmitriptan 5mg tab 95zolpidem tartrate 10mg tab 93zolpidem tartrate 5mg tab 93ZOMIG 2.5MG NASALSPRAY

95

ZOMIG 5MG NASALSPRAY

95

zonisamide 100mg cap 30zonisamide 25mg cap 30zonisamide 50mg cap 30ZORTRESS 0.25MG TAB 98ZORTRESS 0.5MG TAB 98ZORTRESS 0.75MG TAB 98ZORTRESS 1MG TAB 98ZOSTAVAX19400UNIT/0.65ML INJ

115

ZOSYN 40-5MG/ML INJ 105ZOSYN 60-7.5MG/ML INJ105zovia 1/35e 28 day pack 74ZUBSOLV 11.4-2.9MG SLTAB

17

ZUBSOLV 1.4-0.36MG SLTAB

17


17


17


17

ZYCLARA 2.5% CREAM 81ZYDELIG 100MG TAB 53ZYDELIG 150MG TAB 53ZYKADIA 150MG TAB 53ZYLET 0.5-0.3% OPHTHSUSP

102

ZYPREXA 210MG INJ 58


157

DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF LONGEVITY HEALTH PLAN © 2019 Longevity Health Plan H9590_2020NDNIL_C

Non-Discrimination Notice

Longevity Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Longevity Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Longevity Health Plan:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters• Written information in other formats (e.g., large print, audio, accessible electronic formats,

Braille, other formats)

Provides free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Longevity Health Plan’s Member Services at the contact information below.

If you believe that Longevity Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Longevity Health Plan, P.O. Box 5850, Glen Allen, VA 23058; (888) 808-8995; (TTY 711); fax: 800-335-0270; email: [email protected].

You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Longevity Health Plan Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services at the Office for Civil Rights Complaint Portal, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building Washington, DC 20201, 1-800-368-1019 TTY/TDD: 1-800-537-7637 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

mailto:[email protected]

mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

H9590_2020MLIIL_C

Multi-Language Interpreter Services

Arabic (رقم ھاتف الصم 9770-886-888-1 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم

).711والبكم:

Chinese

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-886-9770 (TTY:711)。

French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-886-9770 (ATS : 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Rufnummer: 1-888-886-9770 (TTY: 711).

Greek ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-888-886-9770 (TTY: 711).

Gujarati

જો તમે [ગજુરાતી] બોલો છો, તો ભાષા સહાય સેવાઓ તમારા માટે મફતઉપલબ્ધ છે. 1-888-886-

9770 ને કૉલ કરો (ટી.ટી.વાય: 711).

Hindi

ध्यान द�: य�द आप िहंदी बोलते ह� तो आपके �लए मफु्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1-888-886-9770

(TTY: 711) पर कॉल कर�।

Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-886-9770 (TTY: 711).

Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-886-9770 (TTY: 711) 번으로 전화해 주십시오.

Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-888-886-9770 (TTY: 711).

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-886-9770 (телетайп: 711).

H9590_2020MLIIL_C

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-886-9770 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-886-9770 (TTY: 711).

Urdu

۔ کال کریں دستیاب ہیں زبان کی مدد کی خدمات مفت میں اردو بولتے ہیں، تو آپ کو آپ اگر 9770-886-888-1خبردار:(TTY: 711).

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-886-9770 (TTY: 711).


Longevity Health Plan (HMO I-SNP) es un plan HMO con un contrato de Medicare. La inscripción en Longevity Health Plan (HMO I-SNP) depende de la renovación del contrato.

Este formulario se actualizó el 5/1/2020. Para más información actualizada u otras preguntas, comuníquese con Servicios para los miembros de Longevity Health Plan (HMO I-SNP) al 888-886-9770 o, para los usuarios de TTY, al 711, en el Horario de atención al público: de 8:00 a. m. a 8:00 p. m., siete días a la semana (excepto el Día de Acción de Gracias y Navidad) del 1 de octubre al 31 de marzo, y de lunes a viernes (excepto los días festivos) del 1 de abril al 30 de septiembre, o visite LongevityHealthPlan.com.

Mayo de 2019 H9590_2020Form_C 161

http://www.LongevityHealthPlan.com

longevity health plan (hmo i-snp) illinois - formulario de ......con servicios para los miembros de...

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