1. No category

Blue Cross and Blue Shield of Illinois
Lista de medicamentos
de 2016 del Plan de
salud familiar
LEA LO SIGUIENTE:
ESTE DOCUMENTO CONTIENE
INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRE ESTE PLAN.
Este formulario fue actualizado el 07/18/2016.
CFHPRX16
229793.0716
¿Qué es la lista de medicamentos del
Blue Cross Community Family Health Plan
(el “plan”)?
La lista de medicamentos (a veces denominada
“formulario”) es una lista que enumera los
medicamentos que pueden estar cubiertos por
el plan. Para que los medicamentos enumerados
estén cubiertos, usted debe cumplir con
lo siguiente:
• tener la necesidad médica de obtenerlos;
• abastecer las recetas en una farmacia
de la red;
• seguir otras normas del plan.
Para obtener más información sobre cómo
abastecer sus recetas, consulte el Manual
para miembros.
¿Cuánto tendré que pagar?
No debe pagar nada por los
medicamentos cubiertos.
Sí, puede cambiar.
La cobertura puede cambiar en los
siguientes casos:
• cuando esté disponible un nuevo
medicamento genérico;
• cuando nueva información sobre un
medicamento demuestra que este no es
seguro o que es menos eficaz.
Cuando se realicen cambios en la lista de
medicamentos, se lo notificaremos por escrito.
¿Cómo utilizo la lista de medicamentos?
Hay dos formas de buscar un medicamento en la
lista comenzando en la página 1.
1. Por categoría
• La lista de medicamentos cubiertos que
comienza en la página 1 brinda
información sobre los medicamentos
cubiertos por el Blue Cross Community
Family Health Plan. Si tiene dificultades
para encontrar el medicamento que busca
en la lista, consulte el índice que comienza
al final de este cuadernillo.
–– La información que aparecen en la
columna “Acciones necesarias,
restricciones o límites de uso” indican
si Blue Cross Community Family Health
Plan tiene alguna norma para cubrir
su medicamento.
• Los medicamentos se enumeran en
categorías, o grupos, según el tipo de
afección que tratan. (Por ejemplo, los
medicamentos que se utilizan para tratar
enfermedades cardíacas se enumeran en
“Agentes cardiovasculares”).
• Si sabe qué afección trata su
medicamento, busque ese grupo
en la lista.
• Luego, busque el medicamento dentro
de ese grupo.
2. Listado en orden alfabético
• Busque su medicamento al final de
este cuadernillo.
• Al lado del medicamento verá el número
de página donde puede encontrar la
información de la cobertura.
Lista de medicamentos
¿La lista de medicamentos puede cambiar?
–– En la primera columna del cuadro
figura el nombre del medicamento.
Los medicamentos de marca aparecen
en letra mayúscula (por ejemplo,
CIPRO) y los medicamentos genéricos
aparecen en letra cursiva minúscula
(por ejemplo ciprofloxacin).
¿Qué son los medicamentos genéricos?
Los medicamentos genéricos son aprobados por
la Administración de Drogas y Alimentos (FDA)
por tener el mismo ingrediente activo que el
medicamento de marca, pero generalmente
cuestan menos. El plan cubre medicamentos
de marca y medicamentos genéricos
¿Existe algún límite en mi cobertura?
Las condiciones o los límites adicionales que
tienen algunos medicamentos cubiertos pueden
incluir los siguientes:
• Autorización previa: Es posible que usted o
su médico deban obtener aprobación antes
i
de abastecer sus recetas. Si no obtiene la
aprobación, es posible que el plan no cubra
el medicamento.
• Límites de cantidad: El plan limita
la cantidad que cubrirá de algunos
medicamentos.
Lista de medicamentos
• Terapia escalonada: En algunos casos,
el plan requiere que primero pruebe
determinados medicamentos antes de
cubrir otro medicamento. Por ejemplo,
si el medicamento A y el medicamento B
tratan su enfermedad, es posible que el plan
no cubra el medicamento B, a menos que
usted pruebe el medicamento A primero.
Si el medicamento A no funciona en su caso,
entonces el plan cubrirá el medicamento B.
¿Qué categorías de medicamentos no están
cubiertas en la lista de medicamentos
del plan?
Las siguientes categorías de medicamentos no
están cubiertas por su plan:
–– medicamentos para el tratamiento
de la anorexia, la pérdida de peso
o el aumento de peso;
–– productos químicos a granel;
Puede averiguar si su medicamento tiene alguna
condición o límite adicional consultando la lista
que comienza en la página 1. Encontrará nuestra
información de contacto más abajo, y la fecha en
que actualizamos la lista en la portada y
contraportada.
–– medicamentos con fines cosméticos;
¿El plan paga medicamentos de venta libre?
–– medicamentos experimentales
y en investigación;
Sí, el plan paga algunos medicamentos de
venta libre (OTC) si tiene una receta válida de
su médico, y puede obtenerlos sin costo alguno.
Se deben recetar y entregar medicamentos
genéricos cuando estén disponibles. Estos
medicamentos deben abastecerse en una
farmacia de la red por un suministro de 30 días.
¿Qué sucede si mi medicamento no figura en
la lista de medicamentos?
Comuníquese con Atención al Cliente y pregunte
si el medicamento está cubierto. Si le informan
que el plan no cubre su medicamento, tiene
dos opciones:
• Hable con su médico para determinar si debe
probar primero otro medicamento de
nuestra lista antes de solicitar una excepción.
• Pregunte en Atención al Cliente cómo
solicitar una excepción para que cubramos su
medicamento. Envíe una declaración de su
médico para respaldar su solicitud. Debemos
tomar una decisión dentro de los 24 horas de
la recepción de la declaración de su médico.
ii
Por lo general, solo aprobamos las solicitudes de
excepción si otros medicamentos incluidos en
nuestra lista, o los limites adicionales de uso,
harían que su tratamiento sea menos eficaz o
serían perjudiciales para su salud.
–– agentes de diagnóstico;
–– medicamentos clasificados como
ineficaces por la Implementación
del Estudio de la Eficacia de los
Medicamentos (DESI);
–– medicamentos contra la disfunción
eréctil para tratar la impotencia;
–– medicamentos para la fertilidad;
–– medicamentos anestésicos generales;
–– medicamentos de venta libre no
incluidos de otra manera en la lista
de medicamentos del plan;
–– Suministros o equipos
médicos quirúrgicos.
Para obtener más información
Asistencia lingüística
Si usted tuviese cualquier pregunta, por favor
llame a Atención al Cliente al:
Usted puede obtener este documento en
español o hablar con alguien, de forma gratuita,
acerca de esta información en otros idiomas.
Llame al 1-877-723-7702 (TTY/TDD: 711). La
llamada es gratuita. Usted también puede llamar
al Atención al Cliente, de forma gratuita, para
solicitar esta información en otros formatos
alternos tales como en Braille, en letra grande y
de otras maneras. Llame sin cargos al:
1-877-723-7702 (TTY/TDD: 711). Las horas de
oficina son de 8:00 a. m. a 8:00 p. m., Hora Centro,
los 7 días de la semana. Se usarán tecnologías
alternativas (por ejemplo, correo de voz) los fines
de semana y los días feriados federales. Si deja
un mensaje, un representante de Atención al
Cliente le llamará en el transcurso de un día
laboral, a más tardar. La llamada es gratuita.
1-877-723-7702 (TTY/TDD 711). Las horas de
oficina son de 8:00 a. m. a 8:00 p. m., Hora Centro,
los 7 días de la semana. Se usarán tecnologías
alternativas (por ejemplo, correo de voz) los fines
de semana y los días feriados federales. Si deja
un mensaje, un representante de Atención al
Cliente le llamará en el transcurso de un día
laboral, a más tardar. La llamada es gratuita.
Lista de medicamentos
iii
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
amoxicillin & k clavulanate
MEDICAMENTOS ANTIINFECCIOSOS
tab 875-125 mg
PENICILINAS
(Augmentin)
AMOXICILLIN –
$0 (2)
ampicillin cap 250 mg
amoxicillin (trihydrate)
ampicillin cap 500 mg
chew tab 125 mg
dicloxacillin sodium cap
AMOXICILLIN –
$0 (2)
250 mg
amoxicillin (trihydrate)
chew tab 250 mg
dicloxacillin sodium cap
500 mg
$0 (1)
amoxicillin (trihydrate) cap
250 mg
penicillin v potassium for
soln 125 mg/5ml
$0 (1)
amoxicillin (trihydrate) cap
500 mg
penicillin v potassium for
soln 250 mg/5ml
$0 (1)
amoxicillin (trihydrate) for
susp 125 mg/5ml
penicillin v potassium tab
250 mg
$0 (1)
amoxicillin (trihydrate) for
susp 200 mg/5ml
penicillin v potassium tab
500 mg
$0 (1)
amoxicillin (trihydrate) for
susp 250 mg/5ml
CEFALOSPORINAS
$0 (1)
amoxicillin (trihydrate) for
cefaclor cap 250 mg
susp 400 mg/5ml
cefaclor cap 500 mg
$0 (1)
amoxicillin (trihydrate) tab
cefadroxil cap 500 mg
875 mg
cefadroxil for susp
$0 (1)
amoxicillin & k
250 mg/5ml
clavulanate for susp
cefadroxil for susp
200-28.5 mg/5ml
500 mg/5ml
$0 (1)
amoxicillin & k
cefadroxil tab 1 gm
clavulanate for susp
250-62.5 mg/5ml
cefdinir cap 300 mg
(Augmentin)
cefdinir for susp
$0 (1)
amoxicillin & k clavulanate
125 mg/5ml
for susp 400-57 mg/5ml
cefdinir for susp
$0 (1)
amoxicillin & k
250 mg/5ml
clavulanate for susp
cefixime for susp
600-42.9 mg/5ml
100 mg/5ml (Suprax)
(Augmentin es-600)
cefixime for susp
$0 (1)
amoxicillin & k clavulanate
200 mg/5ml (Suprax)
tab 250-125 mg
cefprozil for susp
$0 (1)
amoxicillin & k clavulanate
125 mg/5ml
tab 500-125 mg
(Augmentin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
1
2016
Nombre del
medicamento
cefprozil for susp
250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftriaxone sodium for inj
250 mg
ceftriaxone sodium for inj
500 mg (Rocephin)
ceftriaxone sodium for inj
1 gm (Rocephin)
ceftriaxone sodium for inj
2 gm
cefuroxime axetil tab
250 mg (Ceftin)
cefuroxime axetil tab
500 mg (Ceftin)
cephalexin cap 250 mg
(Keflex)
cephalexin cap 500 mg
(Keflex)
cephalexin for susp
125 mg/5ml
cephalexin for susp
250 mg/5ml
SUPRAX – cefixime cap
400 mg
SUPRAX – cefixime chew
tab 100 mg
SUPRAX – cefixime chew
tab 200 mg
SUPRAX – cefixime for
susp 100 mg/5ml
SUPRAX – cefixime for
susp 200 mg/5ml
SUPRAX – cefixime for
susp 500 mg/5ml
MACRÓLIDOS
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
AZITHROMYCIN –
azithromycin powd pack
for susp 1 gm
$0 (1)
azithromycin for susp
$0 (1)
100 mg/5ml (Zithromax)
$0 (1)
azithromycin for susp
200 mg/5ml (Zithromax)
$0 (1)
azithromycin tab 250 mg
(Zithromax)
$0 (1)
azithromycin tab 500 mg
(Zithromax)
$0 (1)
azithromycin tab 600 mg
(Zithromax)
$0 (1)
clarithromycin for susp
125 mg/5ml
$0 (1)
clarithromycin for susp
250 mg/5ml (Biaxin)
$0 (1)
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
$0 (1)
clarithromycin tab 250 mg
(Biaxin)
$0 (1)
clarithromycin tab 500 mg
(Biaxin)
$0 (1)
E.E.S. 400 – erythromycin
ethylsuccinate tab
$0 (2)
400 mg
ERY-TAB – erythromycin
$0 (2)
tab delayed release
250 mg
$0 (2)
ERY-TAB – erythromycin
tab delayed release
$0 (2)
333 mg
ERY-TAB – erythromycin
$0 (2)
tab delayed release
500 mg
$0 (2)
ERYTHROMYCIN
ETHYLSUCCINA
– erythromycin
ethylsuccinate tab
400 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
2
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Nombre del
medicamento
TETRACICLINAS
demeclocycline hcl tab
150 mg
demeclocycline hcl tab
300 mg
doxycycline hyclate cap
50 mg
doxycycline hyclate cap
100 mg (Vibramycin)
doxycycline hyclate tab
delayed release 50 mg
(Doryx)
doxycycline hyclate tab
delayed release 200 mg
(Doryx)
doxycycline hyclate tab
20 mg
doxycycline hyclate tab
100 mg
doxycycline monohydrate
cap 50 mg
doxycycline monohydrate
cap 100 mg (Monodox)
doxycycline monohydrate
for susp 25 mg/5ml
(Vibramycin)
doxycycline monohydrate
tab 50 mg (Adoxa)
doxycycline monohydrate
tab 75 mg (Adoxa)
doxycycline monohydrate
tab 100 mg (Adoxa pak
1/100)
minocycline hcl cap
50 mg (Minocin)
minocycline hcl cap
75 mg (Minocin)
minocycline hcl cap
100 mg (Minocin)
minocycline hcl tab 50 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
minocycline hcl tab 75 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
minocycline hcl tab
100 mg
tetracycline hcl cap
250 mg (Tetracycline
hcl)
tetracycline hcl cap
500 mg (Tetracycline
hcl)
FLUOROQUINOLONAS
ciprofloxacin for oral
susp 250 mg/5ml (5%)
(5 gm/100ml) (Cipro)
ciprofloxacin for oral susp
500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
ciprofloxacin hcl tab
250 mg (base equiv)
(Cipro)
ciprofloxacin hcl tab
500 mg (base equiv)
(Cipro)
ciprofloxacin hcl tab
750 mg (base equiv)
levofloxacin oral soln
25 mg/ml (Levaquin)
levofloxacin tab 250 mg
(Levaquin)
levofloxacin tab 500 mg
(Levaquin)
levofloxacin tab 750 mg
(Levaquin)
AMINOGLUCÓSIDOS
neomycin sulfate tab
500 mg
paromomycin sulfate cap
250 mg
tobramycin nebu soln
300 mg/5ml (Tobi)
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
3
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
TOBRAMYCIN SULFATE
$0 (2)
griseofulvin microsize tab
– tobramycin sulfate inj
500 mg (Grifulvin v)
2 gm/50ml (40 mg/ml)
griseofulvin ultramicrosize
(base equiv)
tab 125 mg (Gris-peg)
griseofulvin ultramicrosize
TUBERCULOSIS
tab 250 mg (Gris-peg)
$0 (1)
ethambutol hcl tab
itraconazole cap 100 mg
100 mg (Myambutol)
(Sporanox)
$0 (1)
ethambutol hcl tab
ketoconazole tab 200 mg
400 mg (Myambutol)
$0 (1)
isoniazid tab 100 mg
NOXAFIL – posaconazole
tab delayed release
$0 (1)
isoniazid tab 300 mg
100 mg
PRIFTIN – rifapentine tab
$0 (2)
NOXAFIL
– posaconazole
150 mg
susp 40 mg/ml
$0 (1)
pyrazinamide tab 500 mg
nystatin oral powder
$0 (1)
rifabutin cap 150 mg
nystatin tab 500000 unit
(Mycobutin)
terbinafine hcl tab 250 mg
$0 (1)
rifampin cap 150 mg
(Lamisil)
(Rifadin)
voriconazole for susp
$0 (1)
rifampin cap 300 mg
40 mg/ml (Vfend)
(Rifadin)
voriconazole tab 50 mg
INFECCIONES FÚNGICAS
(Vfend)
$0 (1)
fluconazole for susp
voriconazole tab 200 mg
10 mg/ml (Diflucan)
(Vfend)
$0 (1)
fluconazole for susp
INFECCIONES VIRALES
40 mg/ml (Diflucan)
Citomegalovirus
$0 (1)
fluconazole tab 50 mg
(Diflucan)
VALCYTE – valganciclovir
hcl for soln 50 mg/ml
$0 (1)
fluconazole tab 100 mg
(base equiv)
(Diflucan)
valganciclovir hcl tab
$0 (1)
fluconazole tab 150 mg
450 mg (Valcyte)
(Diflucan)
$0 (1)
fluconazole tab 200 mg
Hepatitis
(Diflucan)
adefovir dipivoxil tab
$0 (1)
flucytosine cap 250 mg
10 mg (Hepsera)
(Ancobon)
BARACLUDE – entecavir
$0 (1)
flucytosine cap 500 mg
oral soln 0.05 mg/ml
(Ancobon)
DAKLINZA – daclatasvir
$0 (1)
griseofulvin microsize
dihydrochloride tab
susp 125 mg/5ml
30 mg (base equivalent)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
4
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA
$0 (2)
PA
$0 (1)
$0 (1)
$0 (1)
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (2)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
PA, SP
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
DAKLINZA – daclatasvir
$0 (2)
PA, SP
PEGASYS PROCLICK –
dihydrochloride tab
peginterferon alfa-2a inj
60 mg (base equivalent)
135 mcg/0.5ml
DAKLINZA – daclatasvir
$0 (2)
PA, SP
PEGASYS PROCLICK –
dihydrochloride tab
peginterferon alfa-2a inj
90 mg (base equivalent)
180 mcg/0.5ml
$0 (1)
entecavir tab 0.5 mg
ribavirin cap 200 mg
(Baraclude)
(Rebetol)
$0 (1)
entecavir tab 1 mg
ribavirin tab 200 mg
(Baraclude)
(Copegus)
EPIVIR HBV – lamivudine
$0 (2)
QL
SOVALDI – sofosbuvir tab
oral soln 5 mg/ml
400 mg
HARVONI – ledipasvir$0 (2)
PA, SP
Herpes
sofosbuvir tab
acyclovir cap 200 mg
90-400 mg
(Zovirax)
$0 (1)
QL
lamivudine tab 100 mg
acyclovir susp
(Epivir hbv)
200 mg/5ml (Zovirax)
PEG-INTRON REDIPEN
$0 (2)
PA, SP
acyclovir tab 400 mg
– peginterferon alfa-2b
(Zovirax)
for inj kit 50 mcg/0.5ml
acyclovir tab 800 mg
PEG-INTRON REDIPEN
$0 (2)
PA, SP
(Zovirax)
– peginterferon alfa-2b
famciclovir tab 125 mg
for inj kit 80 mcg/0.5ml
(Famvir)
PEG-INTRON REDIPEN
$0 (2)
PA, SP
valacyclovir hcl tab
– peginterferon alfa-2b
500 mg (Valtrex)
for inj kit 120 mcg/0.5ml
valacyclovir hcl tab 1 gm
PEG-INTRON REDIPEN
$0 (2)
PA, SP
(Valtrex)
– peginterferon alfa-2b
VIH/SIDA
for inj kit 150 mcg/0.5ml
abacavir
sulfate tab
PEG-INTRON REDIPEN
$0 (2)
PA, SP
300 mg (base equiv)
PAK 4 – peginterferon
(Ziagen)
alfa-2b for inj kit
120 mcg/0.5ml
abacavir sulfatelamivudine-zidovudine
PEGASYS –
$0 (2)
PA, SP
tab 300-150-300 mg
peginterferon alfa-2a inj
(Trizivir)
180 mcg/ml
APTIVUS
– tipranavir cap
PEGASYS –
$0 (2)
PA, SP
250 mg
peginterferon alfa-2a inj
180 mcg/0.5ml
APTIVUS – tipranavir oral
soln 100 mg/ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (1)
SP
$0 (1)
SP
$0 (2)
PA, SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
5
2016
Nombre del
medicamento
ATRIPLA – efavirenzemtricitabine-tenofovir
df tab 600-200-300 mg
COMPLERA –
emtricitabine-rilpivirinetenofovir df tab
200-25-300 mg
CRIXIVAN – indinavir
sulfate cap 200 mg
CRIXIVAN – indinavir
sulfate cap 400 mg
didanosine delayed
release capsule 125 mg
(Videx ec)
didanosine delayed
release capsule 200 mg
(Videx ec)
didanosine delayed
release capsule 250 mg
(Videx ec)
didanosine delayed
release capsule 400 mg
(Videx ec)
EDURANT – rilpivirine
hcl tab 25 mg (base
equivalent)
EMTRIVA – emtricitabine
caps 200 mg
EMTRIVA – emtricitabine
soln 10 mg/ml
EPZICOM – abacavir
sulfate-lamivudine tab
600-300 mg
EVOTAZ – atazanavir
sulfate-cobicistat tab
300-150 mg (base
equiv)
FUZEON – enfuvirtide for
inj 90 mg
GENVOYA – elvitegravcobic-emtricitab-
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
tenofov af tab
$0 (2)
QL
150-150-200-10 mg
INTELENCE – etravirine
tab 25 mg
$0 (2)
QL
INTELENCE – etravirine
tab 100 mg
INTELENCE – etravirine
$0 (2)
QL
tab 200 mg
INVIRASE – saquinavir
$0 (2)
QL
mesylate cap 200 mg
INVIRASE – saquinavir
$0 (1)
QL
mesylate tab 500 mg
ISENTRESS – raltegravir
potassium tab 400 mg
$0 (1)
QL
(base equiv)
ISENTRESS – raltegravir
potassium packet for
$0 (1)
QL
susp 100 mg (base
equiv)
ISENTRESS – raltegravir
$0 (1)
QL
potassium chew tab
25 mg (base equiv)
ISENTRESS – raltegravir
$0 (2)
QL
potassium chew tab
100 mg (base equiv)
KALETRA – lopinavir$0 (2)
QL
ritonavir soln
400-100 mg/5ml
(80-20 mg/ml)
$0 (2)
QL
KALETRA – lopinavirritonavir tab 100-25 mg
$0 (2)
QL
KALETRA – lopinavirritonavir tab 200-50 mg
$0 (2)
QL
lamivudine oral soln
10 mg/ml (Epivir)
lamivudine tab 150 mg
(Epivir)
$0 (2)
QL, SP
lamivudine tab 300 mg
(Epivir)
$0 (2)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
6
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
QL
RESCRIPTOR –
lamivudine-zidovudine tab
delavirdine mesylate tab
150-300 mg (Combivir)
100 mg
LEXIVA – fosamprenavir
$0 (2)
QL
calcium tab 700 mg
RESCRIPTOR –
delavirdine mesylate tab
(base equiv)
200 mg
LEXIVA – fosamprenavir
$0 (2)
QL
calcium susp 50 mg/ml
REYATAZ – atazanavir
sulfate oral powder
(base equiv)
packet 50 mg (base
$0 (1)
QL
nevirapine tab sr 24hr
equiv)
100 mg (Viramune xr)
REYATAZ – atazanavir
$0 (1)
QL
nevirapine tab sr 24hr
sulfate cap 150 mg
400 mg (Viramune xr)
(base equiv)
$0 (1)
QL
nevirapine tab 200 mg
REYATAZ
– atazanavir
(Viramune)
sulfate cap 200 mg
NORVIR – ritonavir cap
$0 (2)
QL
(base equiv)
100 mg
REYATAZ – atazanavir
NORVIR – ritonavir tab
$0 (2)
QL
sulfate cap 300 mg
100 mg
(base equiv)
NORVIR – ritonavir oral
$0 (2)
QL
SELZENTRY – maraviroc
soln 80 mg/ml
tab 150 mg
PREZCOBIX – darunavir$0 (2)
QL
SELZENTRY
– maraviroc
cobicistat tab
tab 300 mg
800-150 mg
stavudine
cap 15 mg
PREZISTA – darunavir
$0 (2)
QL
(Zerit)
ethanolate susp
stavudine cap 20 mg
100 mg/ml (base equiv)
(Zerit)
PREZISTA – darunavir
$0 (2)
QL
stavudine cap 30 mg
ethanolate tab 75 mg
(Zerit)
(base equiv)
stavudine cap 40 mg
PREZISTA – darunavir
$0 (2)
QL
(Zerit)
ethanolate tab 150 mg
(base equiv)
stavudine for oral soln
1 mg/ml (Zerit)
PREZISTA – darunavir
$0 (2)
QL
ethanolate tab 600 mg
STRIBILD – elvitegravcobic-emtricitab(base equiv)
tenofovdf tab
PREZISTA – darunavir
$0 (2)
QL
150-150-200-300 mg
ethanolate tab 800 mg
SUSTIVA – efavirenz tab
(base equiv)
600 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
7
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
SUSTIVA – efavirenz cap
$0 (2)
QL
VITEKTA – elvitegravir tab
50 mg
85 mg
SUSTIVA – efavirenz cap
$0 (2)
QL
VITEKTA – elvitegravir tab
200 mg
150 mg
TIVICAY – dolutegravir
$0 (2)
QL
ZIAGEN – abacavir
sodium tab 50 mg (base
sulfate soln 20 mg/ml
equiv)
(base equiv)
TRIUMEQ – abacavir$0 (2)
QL
zidovudine cap 100 mg
dolutegravir-lamivudine
(Retrovir)
tab 600-50-300 mg
zidovudine syrup 10 mg/
TRUVADA –
$0 (2)
QL
ml (Retrovir)
emtricitabine-tenofovir
zidovudine tab 300 mg
disoproxil fumarate tab
Influenza
200-300 mg
RELENZA DISKHALER –
VIDEX – didanosine for
$0 (2)
QL
zanamivir aero powder
soln 2 gm
breath activated 5 mg/
VIDEX – didanosine for
$0 (2)
QL
blister
soln 4 gm
MALARIA
VIRACEPT – nelfinavir
$0 (2)
QL
atovaquone-proguanil
mesylate tab 250 mg
hcl tab 62.5-25 mg
VIRACEPT – nelfinavir
$0 (2)
QL
(Malarone)
mesylate tab 625 mg
atovaquone-proguanil
VIRAMUNE – nevirapine
$0 (2)
QL
hcl tab 250-100 mg
susp 50 mg/5ml
(Malarone)
VIREAD – tenofovir
$0 (2)
QL
chloroquine phosphate
disoproxil fumarate oral
tab 250 mg
powder 40 mg/gm
chloroquine phosphate
VIREAD – tenofovir
$0 (2)
QL
tab 500 mg (Aralen)
disoproxil fumarate tab
DARAPRIM –
150 mg
pyrimethamine tab
VIREAD – tenofovir
$0 (2)
QL
25 mg
disoproxil fumarate tab
hydroxychloroquine
200 mg
sulfate tab 200 mg
VIREAD – tenofovir
$0 (2)
QL
(Plaquenil)
disoproxil fumarate tab
mefloquine hcl tab
250 mg
250 mg
VIREAD – tenofovir
$0 (2)
QL
PRIMAQUINE
disoproxil fumarate tab
PHOSPHATE –
300 mg
primaquine phosphate
tab 26.3 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
8
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (1)
quinine sulfate cap
sulfamethoxazole324 mg (Qualaquin)
trimethoprim tab
400-80 mg (Bactrim)
INFECCIONES DE PARÁSITOS
$0 (1)
sulfamethoxazoleALBENZA – albendazole
$0 (2)
trimethoprim
tab
tab 200 mg
800-160 mg (Bactrim
BILTRICIDE –
$0 (2)
ds)
praziquantel tab 600 mg
$0 (1)
trimethoprim tab 100 mg
$0 (1)
ivermectin tab 3 mg
$0 (1)
vancomycin hcl cap
(Stromectol)
125 mg (Vancocin hcl)
OTROS ANTIINFECCIOSOS
$0 (1)
vancomycin hcl cap
$0 (1)
atovaquone susp
250 mg (Vancocin hcl)
750 mg/5ml (Mepron)
XIFAXAN – rifaximin tab
$0 (2)
PA, QL
$0 (1)
bacitracin intramuscular
200 mg
for soln 50000 unit
XIFAXAN – rifaximin tab
$0 (2)
PA, QL
$0 (1)
clindamycin hcl cap
550 mg
75 mg (Cleocin)
ZYVOX – linezolid for
$0 (2)
QL
$0 (1)
clindamycin hcl cap
susp 100 mg/5ml
150 mg (Cleocin)
AGENTES DE INMUNIZACIÓN
$0 (1)
clindamycin hcl cap
SYNAGIS – palivizumab
$0 (2)
PA, SP
300 mg (Cleocin)
im soln 50 mg/0.5ml
$0 (1)
clindamycin palmitate
SYNAGIS – palivizumab
$0 (2)
PA, SP
hcl for soln 75 mg/5ml
im
soln
100
mg/ml
(base equiv) (Cleocin
MEDICAMENTOS PARA EL CÁNCER
pediatric gr)
ACTIMMUNE –
$0 (2)
SP
$0 (1)
dapsone tab 25 mg
interferon
gamma-1b
$0 (1)
dapsone tab 100 mg
inj 100 mcg/0.5ml
$0 (1)
QL
linezolid for susp
(2000000 unit/0.5ml)
100 mg/5ml (Zyvox)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
$0 (1)
QL
linezolid tab 600 mg
tab 2.5 mg
(Zyvox)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
$0 (1)
metronidazole cap
tab 5 mg
375 mg (Flagyl)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
$0 (1)
metronidazole tab 250 mg
tab 7.5 mg
(Flagyl)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
$0 (1)
metronidazole tab 500 mg
tab 10 mg
(Flagyl)
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
$0 (1)
sulfamethoxazoleeverolimus tab for oral
trimethoprim susp
susp 2 mg
200-40 mg/5ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
9
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
imatinib mesylate
everolimus tab for oral
tab 100 mg (base
susp 3 mg
equivalent) (Gleevec)
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
imatinib mesylate
everolimus tab for oral
tab 400 mg (base
susp 5 mg
equivalent) (Gleevec)
ALKERAN – melphalan
$0 (2)
LENVIMA 10MG DAILY
tab 2 mg
DOSE – lenvatinib cap
therapy pack 10 mg
$0 (1)
anastrozole tab 1 mg
(10 mg daily dose)
(Arimidex)
LENVIMA 14MG DAILY
$0 (1)
PA, QL, SP
bexarotene cap 75 mg
DOSE – lenvatinib cap
(Targretin)
therapy pack 10 & 4 mg
$0 (1)
bicalutamide tab 50 mg
(14 mg daily dose)
(Casodex)
LENVIMA 18MG DAILY
$0 (1)
PA, SP
capecitabine tab 150 mg
DOSE – lenvatinib cap
(Xeloda)
therapy pack 10 & 4
$0 (1)
PA, SP
capecitabine tab 500 mg
(2) mg (18 mg daily
(Xeloda)
dose)
COTELLIC – cobimetinib
$0 (2)
PA, QL
LENVIMA 20MG DAILY
fumarate tab 20 mg
DOSE – lenvatinib cap
(base equivalent)
therapy pack 10 (2) mg
$0 (1)
exemestane tab 25 mg
(20 mg daily dose)
(Aromasin)
LENVIMA 24MG DAILY
$0 (1)
flutamide cap 125 mg
DOSE – lenvatinib cap
GLEEVEC – imatinib
$0 (2)
PA, QL, SP
therapy pack 10 (2) &
mesylate tab 100 mg
4 mg (24 mg daily dose)
(base equivalent)
LENVIMA 8MG DAILY
GLEEVEC – imatinib
$0 (2)
PA, QL, SP
DOSE – lenvatinib cap
mesylate tab 400 mg
therapy pack 4 (2) mg
(base equivalent)
(8 mg daily dose)
$0 (1)
hydroxyurea cap 500 mg
letrozole tab 2.5 mg
(Hydrea)
(Femara)
IBRANCE – palbociclib
$0 (2)
PA, QL, SP
LEUCOVORIN CALCIUM
cap 75 mg
– leucovorin calcium tab
10 mg
IBRANCE – palbociclib
$0 (2)
PA, QL, SP
cap 100 mg
LEUCOVORIN CALCIUM
– leucovorin calcium tab
IBRANCE – palbociclib
$0 (2)
PA, QL, SP
15 mg
cap 125 mg
leucovorin calcium tab
5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
10
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
PA, QL, SP
$0 (1)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL
$0 (1)
$0 (2)
$0 (2)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
leucovorin calcium tab
25 mg
LEUKERAN –
chlorambucil tab 2 mg
LYNPARZA – olaparib cap
50 mg
megestrol acetate susp
40 mg/ml (Megace oral)
megestrol acetate tab
20 mg
megestrol acetate tab
40 mg
MEKINIST – trametinib
dimethyl sulfoxide
tab 0.5 mg (base
equivalent)
MEKINIST – trametinib
dimethyl sulfoxide tab
2 mg (base equivalent)
mercaptopurine tab 50 mg
(Purinethol)
METHOTREXATE
SODIUM –
methotrexate sodium inj
250 mg/10ml (25 mg/ml)
methotrexate sodium tab
2.5 mg (base equiv)
MYLERAN – busulfan tab
2 mg
NEXAVAR – sorafenib
tosylate tab 200 mg
(base equivalent)
SPRYCEL – dasatinib tab
20 mg
SPRYCEL – dasatinib tab
50 mg
SPRYCEL – dasatinib tab
70 mg
SPRYCEL – dasatinib tab
80 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
SPRYCEL – dasatinib tab
100 mg
$0 (2)
SPRYCEL – dasatinib tab
140 mg
$0 (2)
PA, QL, SP
STIVARGA – regorafenib
tab 40 mg
$0 (1)
SUTENT – sunitinib
malate cap 12.5 mg
(base equivalent)
$0 (1)
SUTENT – sunitinib
malate cap 25 mg (base
$0 (1)
equivalent)
SUTENT – sunitinib
$0 (2)
PA, QL, SP
malate cap 37.5 mg
(base equivalent)
SUTENT – sunitinib
malate cap 50 mg (base
$0 (2)
PA, QL, SP
equivalent)
tamoxifen citrate tab
10 mg (base equivalent)
$0 (1)
tamoxifen citrate tab
20 mg (base equivalent)
$0 (2)
TARCEVA – erlotinib
hcl tab 25 mg (base
equivalent)
$0 (1)
TARCEVA – erlotinib
hcl tab 100 mg (base
equivalent)
$0 (2)
TARCEVA – erlotinib
hcl tab 150 mg (base
$0 (2)
QL, SP
equivalent)
TASIGNA – nilotinib hcl
cap 150 mg (base
$0 (2)
PA, QL, SP
equivalent)
TASIGNA – nilotinib hcl
$0 (2)
PA, QL, SP
cap 200 mg (base
equivalent)
$0 (2)
PA, QL, SP
temozolomide cap 5 mg
(Temodar)
$0 (2)
PA, QL, SP
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (1)
$0 (1)
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
11
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
SP
temozolomide cap 20 mg
dexamethasone tab 4 mg
(Temodar)
dexamethasone tab 6 mg
$0 (1)
SP
temozolomide cap
fludrocortisone acetate
100 mg (Temodar)
tab 0.1 mg
$0 (1)
SP
temozolomide cap
hydrocortisone tab 5 mg
140 mg (Temodar)
(Cortef)
$0 (1)
SP
temozolomide cap
hydrocortisone tab 10 mg
180 mg (Temodar)
(Cortef)
$0 (1)
SP
temozolomide cap
hydrocortisone tab 20 mg
250 mg (Temodar)
(Cortef)
$0 (1)
PA, SP
tretinoin cap 10 mg
methylprednisolone tab
VOTRIENT – pazopanib
hcl tab 200 mg (base
equiv)
XALKORI – crizotinib cap
200 mg
XALKORI – crizotinib cap
250 mg
ZELBORAF –
vemurafenib tab 240 mg
(base equivalent)
ZYTIGA – abiraterone
acetate tab 250 mg
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
HORMONAS, DIABETES Y MEDICAMENTOS
RELACIONADOS
CORTICOSTEROIDES
CORTISONE ACETATE
– cortisone acetate tab
25 mg
DEXAMETHASONE –
dexamethasone soln
0.5 mg/5ml
dexamethasone elixir
0.5 mg/5ml
dexamethasone tab
0.5 mg
dexamethasone tab
0.75 mg
dexamethasone tab
1.5 mg
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
12
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
4 mg (Medrol)
methylprednisolone tab
8 mg (Medrol)
methylprednisolone tab
16 mg (Medrol)
methylprednisolone tab
32 mg (Medrol)
prednisolone sod phosph
oral soln 6.7 mg/5ml
(5 mg/5ml base)
(Pediapred)
prednisolone sod
phosphate oral soln
15 mg/5ml (base equiv)
prednisolone syrup
15 mg/5ml (usp solution
equivalent) (Prelone)
PREDNISONE –
prednisone tab 50 mg
PREDNISONE –
prednisone oral soln
5 mg/5ml
prednisone tab 1 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
prednisone tab 2.5 mg
$0 (1)
prednisone tab 5 mg
$0 (1)
prednisone tab 10 mg
$0 (1)
prednisone tab 20 mg
$0 (1)
HORMONAS MASCULINAS
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
ANDRODERM –
testosterone td patch
24hr 2 mg/24hr
ANDRODERM –
testosterone td patch
24hr 4 mg/24hr
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
methyltestosterone cap
10 mg (Testred)
testosterone cypionate
im inj in oil 100 mg/ml
(Depo-testosterone)
testosterone cypionate
im inj in oil 200 mg/ml
(Depo-testosterone)
testosterone enanthate im
inj in oil 200 mg/ml
testosterone td gel
25 mg/2.5gm (1%)
(Androgel)
testosterone td gel
50 mg/5gm (1%)
(Androgel)
testosterone td gel
12.5 mg/act (1%)
(Androgel pump)
ESTRÓGENOS
COMBIPATCH –
estradiol-norethindrone
ace td pttw
0.05-0.14 mg/day
COMBIPATCH –
estradiol-norethindrone
ace td pttw
0.05-0.25 mg/day
DIVIGEL – estradiol td gel
0.25 mg/0.25gm (0.1%)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
PA, QL
DIVIGEL – estradiol td gel
0.5 mg/0.5gm (0.1%)
DIVIGEL – estradiol td gel
1 mg/gm (0.1%)
$0 (2)
PA, QL
estradiol & norethindrone
acetate tab 0.5-0.1 mg
$0 (1)
(Activella)
estradiol & norethindrone
$0 (1)
acetate tab 1-0.5 mg
$0 (1)
(Activella)
$0 (1)
estradiol tab 0.5 mg
(Estrace)
$0 (1)
QL
estradiol tab 1 mg
(Estrace)
estradiol tab 2 mg
$0 (1)
QL
(Estrace)
estradiol td patch twice
weekly 0.025 mg/24hr
$0 (1)
QL
(Vivelle-dot)
estradiol td patch twice
$0 (1)
PA, QL
weekly 0.0375 mg/24hr
(Vivelle-dot)
estradiol td patch twice
$0 (1)
PA, QL
weekly 0.05 mg/24hr
(Vivelle-dot)
estradiol td patch twice
$0 (1)
PA, QL
weekly 0.075 mg/24hr
(Vivelle-dot)
estradiol td patch twice
weekly 0.1 mg/24hr
$0 (2)
(Vivelle-dot)
estradiol td patch weekly
0.025 mg/24hr (Climara)
estradiol td patch weekly
$0 (2)
0.0375 mg/24hr
(Climara)
estradiol td patch weekly
0.05 mg/24hr (Climara)
$0 (2)
estradiol td patch weekly
0.06 mg/24hr (Climara)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
13
2016
Nombre del
medicamento
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol td patch weekly
0.1 mg/24hr (Climara)
estradiol valerate im in oil
20 mg/ml (Delestrogen)
estradiol valerate im in oil
40 mg/ml (Delestrogen)
ESTROPIPATE –
estropipate tab 0.75 mg
ESTROPIPATE –
estropipate tab 1.5 mg
ESTROPIPATE –
estropipate tab 3 mg
norethindrone acetateethinyl estradiol tab
0.5 mg-2.5 mcg (Femhrt
low dose)
norethindrone acetateethinyl estradiol tab
1 mg-5 mcg
PREMPRO –
conjugated estrogenmedroxyprogest acetate
tab 0.3-1.5 mg
PREMPRO –
conjugated estrogenmedroxyprogest acetate
tab 0.45-1.5 mg
PREMPRO –
conjugated estrogenmedroxyprogest acetate
tab 0.625-5 mg
PROGESTINAS
medroxyprogesterone
acetate tab 2.5 mg
(Provera)
medroxyprogesterone
acetate tab 5 mg
(Provera)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
medroxyprogesterone
acetate tab 10 mg
(Provera)
$0 (1)
QL
megestrol acetate susp
625 mg/5ml (Megace
$0 (1)
es)
norethindrone
acetate tab
$0 (1)
5 mg (Aygestin)
progesterone
im in oil
$0 (2)
50 mg/ml
progesterone micronized
$0 (2)
cap 100 mg
(Prometrium)
$0 (2)
progesterone micronized
cap 200 mg
$0 (1)
(Prometrium)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
14
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
MÉTODOS ANTICONCEPTIVOS
BREVICON-28 –
$0 (2)
norethindrone &
ethinyl estradiol tab
0.5 mg-35 mcg
CONDOMS – various
$0 (3)
DEPO-PROVERA
CONTRACEPTIV –
medroxyprogesterone
acetate im susp 150 mg/
ml
DEPO-SUBQ
PROVERA 104 –
medroxyprogesterone
acetate subcutaneous
susp 104 mg/0.65ml
DESOGEN – desogestrel
& ethinyl estradiol tab
0.15 mg-30 mcg
DIAPHRAGMS – various
$0 (2)
ELLA – ulipristal acetate
tab 30 mg
ESTROSTEP FE –
norethindrone ac-
$0 (2)
PA
QL
SP
ST
QL
$0 (2)
$0 (2)
QL
$0 (2)
QL
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Nombre del
medicamento
ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
FALESSA – levonorgesteth estrad tab
0.1 mg-20 mcg & fa tab
1 mg kit
LEVONORGESTREL
– levonorgestrel tab
0.75 mg
levonorgestrel tab 1.5 mg
(Plan b one-step)
levonorgestrel-ethinyl
estradiol (continuous)
tab 90-20 mcg
LO LOESTRIN FE –
norethin-eth estradiolfe tab 1 mg-10 mcg
(24)/10 mcg (2)
LOESTRIN 1.5/30-21
– norethindrone ace
& ethinyl estradiol tab
1.5 mg-30 mcg
medroxyprogesterone
acetate im susp 150 mg/
ml (Depo-provera
contrac)
MIRENA – levonorgestrel
releasing iud 20 mcg/
day (52 mg total)
MODICON –
norethindrone &
ethinyl estradiol tab
0.5 mg-35 mcg
NECON 10/11-28
– norethindroneeth estradiol tab
0.5-35/1-35 mg-mcg
(10/11)
NEXPLANON –
etonogestrel subdermal
implant 68 mg
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
NORINYL 1+35 –
$0 (2)
QL
norethindrone &
ethinyl estradiol tab
$0 (2)
QL
1 mg-35 mcg
NUVARING –
$0 (2)
QL
etonogestrel-ethinyl
estradiol va ring
$0 (2)
0.120-0.015 mg/24hr
OGESTREL – norgestrel
$0 (2)
QL
& ethinyl estradiol tab
$0 (3)
0.5 mg-50 mcg
$0 (1)
QL
oral contraceptives –
$0 (1)
QL
all generics
ORTHO TRI-CYCLEN
$0 (2)
QL
LO – norgestimate$0 (2)
QL
eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
ORTHO-NOVUM
1/35
$0 (2)
QL
$0 (2)
QL
– norethindrone &
ethinyl estradiol tab
1 mg-35 mcg
ORTHO-NOVUM 7/7/7
$0 (2)
QL
$0 (1)
– norethindroneeth estradiol tab
0.5-35/0.75-35/1-35 mgmcg
$0 (2)
OVCON-35 –
$0 (2)
QL
norethindrone &
ethinyl estradiol tab
$0 (2)
QL
0.4 mg-35 mcg
PARAGARD
$0 (2)
INTRAUTERINE COP –
copper iud
$0 (2)
QL
PLAN B ONE-STEP
$0 (3)
– levonorgestrel tab
1.5 mg
SKYLA – levonorgestrel
$0 (2)
releasing iud 14 mcg/
$0 (2)
day (13.5 mg total)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
15
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
TRI-NORINYL 28
$0 (2)
QL
glipizide-metformin hcl tab
– norethindrone5-500 mg
eth estradiol tab
GLUCAGON
0.5-35/1-35/0.5-35 mgEMERGENCY KIT
mcg
– glucagon (rdna) for inj
XULANE –
$0 (2)
QL
kit 1 mg
norelgestromin-ethinyl
glyburide micronized tab
estradiol td ptwk
1.5 mg (Glynase)
150-35 mcg/24hr
glyburide micronized tab
ZOVIA 1/50E –
$0 (2)
QL
3 mg (Glynase)
ethynodiol diacetate
glyburide micronized tab
& ethinyl estradiol tab
6 mg (Glynase)
1 mg-50 mcg
glyburide tab 1.25 mg
DIABETES
glyburide tab 2.5 mg
$0 (1)
acarbose tab 25 mg
glyburide tab 5 mg
(Precose)
glyburide-metformin
$0 (1)
acarbose tab 50 mg
tab 1.25-250 mg
(Precose)
(Glucovance)
$0 (1)
acarbose tab 100 mg
glyburide-metformin
(Precose)
tab 2.5-500 mg
$0 (1)
glimepiride tab 1 mg
(Glucovance)
(Amaryl)
glyburide-metformin tab
$0 (1)
glimepiride tab 2 mg
5-500 mg (Glucovance)
(Amaryl)
JANUMET – sitagliptin$0 (1)
glimepiride tab 4 mg
metformin hcl tab
(Amaryl)
50-500 mg
$0 (1)
glipizide tab sr 24hr
JANUMET – sitagliptin2.5 mg (Glucotrol xl)
metformin hcl tab
$0 (1)
glipizide tab sr 24hr 5 mg
50-1000 mg
(Glucotrol xl)
JANUMET XR –
$0 (1)
glipizide tab sr 24hr
sitagliptin-metformin hcl
10 mg (Glucotrol xl)
tab sr 24hr 50-500 mg
$0 (1)
glipizide tab 5 mg
JANUMET XR –
(Glucotrol)
sitagliptin-metformin hcl
$0 (1)
glipizide tab 10 mg
tab sr 24hr 50-1000 mg
(Glucotrol)
JANUMET XR –
$0 (1)
glipizide-metformin hcl tab
sitagliptin-metformin
2.5-250 mg
hcl tab sr 24hr
100-1000 mg
$0 (1)
glipizide-metformin hcl tab
2.5-500 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
16
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
JANUVIA – sitagliptin
phosphate tab 25 mg
(base equiv)
JANUVIA – sitagliptin
phosphate tab 50 mg
(base equiv)
JANUVIA – sitagliptin
phosphate tab 100 mg
(base equiv)
metformin hcl tab sr 24hr
500 mg (Glucophage xr)
metformin hcl tab sr 24hr
750 mg (Glucophage xr)
metformin hcl tab 500 mg
(Glucophage)
metformin hcl tab 850 mg
(Glucophage)
metformin hcl tab
1000 mg (Glucophage)
nateglinide tab 60 mg
(Starlix)
nateglinide tab 120 mg
(Starlix)
pioglitazone hcl tab 15 mg
(base equiv) (Actos)
pioglitazone hcl tab 30 mg
(base equiv) (Actos)
pioglitazone hcl tab 45 mg
(base equiv) (Actos)
repaglinide tab 0.5 mg
(Prandin)
repaglinide tab 1 mg
(Prandin)
repaglinide tab 2 mg
(Prandin)
TOLAZAMIDE –
tolazamide tab 250 mg
VICTOZA – liraglutide
soln pen-injector
18 mg/3ml (6 mg/ml)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
QL
DIABETES - INSULINAS
$0 (2)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL, ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
Insulinas de acción rápida
HUMALOG – insulin lispro
(human) soln cartridge
100 unit/ml
HUMALOG – insulin lispro
(human) inj 100 unit/ml
HUMALOG KWIKPEN –
insulin lispro (human)
soln pen-injector 100
unit/ml
HUMALOG KWIKPEN –
insulin lispro (human)
soln pen-injector 200
unit/ml
NOVOLOG – insulin
aspart inj 100 unit/ml
NOVOLOG FLEXPEN –
insulin aspart soln peninjector 100 unit/ml
NOVOLOG PENFILL
– insulin aspart soln
cartridge 100 unit/ml
Insulinas de acción corta
HUMULIN R – insulin
regular (human) inj 100
unit/ml
HUMULIN R U-500
(CONCENTR – insulin
regular (human) inj 500
unit/ml
HUMULIN R U-500
KWIKPEN – insulin
regular (human) soln
pen-injector 500 unit/ml
NOVOLIN R – insulin
regular (human) inj 100
unit/ml
PA
QL
SP
ST
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
17
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
NOVOLIN R RELION –
$0 (2)
QL
NOVOLIN N RELION –
insulin regular (human)
insulin nph (human)
inj 100 unit/ml
(isophane) inj 100 unit/
ml
Insulinas de acción intermedia
NOVOLIN 70/30 – insulin
HUMALOG MIX 50/50
$0 (2)
QL
nph isophane & regular
– insulin lispro prot &
human inj 100 unit/ml
lispro (human) inj 100
(70-30)
unit/ml (50-50)
NOVOLIN 70/30 RELION
HUMALOG MIX 50/50
$0 (2)
QL
– insulin nph isophane
KWIKPEN – insulin
& regular human inj 100
lispro prot & lispro sus
unit/ml (70-30)
pen-inj 100 unit/ml
NOVOLOG MIX 70/30
(50-50)
– insulin aspart prot &
HUMALOG MIX 75/25
$0 (2)
QL
aspart (human) inj 100
– insulin lispro prot &
unit/ml (70-30)
lispro (human) inj 100
NOVOLOG
MIX 70/30
unit/ml (75-25)
PREFILL – insulin
HUMALOG MIX 75/25
$0 (2)
QL
aspart prot & aspart
KWIKPEN – insulin
sus pen-inj 100 unit/ml
lispro prot & lispro sus
(70-30)
pen-inj 100 unit/ml
(75-25)
HUMULIN N – insulin nph
(human) (isophane) inj
100 unit/ml
HUMULIN N KWIKPEN
– insulin nph (human)
(isophane) susp peninjector 100 unit/ml
HUMULIN 70/30 – insulin
nph isophane & regular
human inj 100 unit/ml
(70-30)
HUMULIN 70/30
KWIKPEN – insulin nph
& regular susp pen-inj
100 unit/ml (70-30)
NOVOLIN N – insulin nph
(human) (isophane) inj
100 unit/ml
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
18
Insulinas basales
LANTUS –
insulin glargine inj 100
unit/ml
LANTUS SOLOSTAR –
insulin glargine soln
pen-injector 100 unit/ml
LEVEMIR – insulin
detemir inj 100 unit/ml
LEVEMIR FLEXTOUCH –
insulin detemir soln peninjector 100 unit/ml
TOUJEO SOLOSTAR
– insulin glargine soln
pen-injector 300 unit/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
REGULACIÓN DE LA TIROIDES
$0 (1)
levothyroxine sodium tab
25 mcg (Synthroid)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (1)
levothyroxine sodium tab
thyroid tab 90 mg (1
50 mcg (Synthroid)
1/2 grain) (Armour
thyroid)
$0 (1)
levothyroxine sodium tab
75 mcg (Synthroid)
HORMONA DEL CRECIMIENTO
$0 (1)
levothyroxine sodium tab
OMNITROPE –
$0 (2)
PA, SP
88 mcg (Synthroid)
somatropin for inj
$0 (1)
levothyroxine sodium tab
5.8 mg
100 mcg (Synthroid)
OMNITROPE –
$0 (2)
PA, SP
$0 (1)
levothyroxine sodium tab
somatropin inj
112 mcg (Synthroid)
5 mg/1.5ml
$0 (1)
levothyroxine sodium tab
OMNITROPE –
$0 (2)
PA, SP
125 mcg (Synthroid)
somatropin inj
10 mg/1.5ml
$0 (1)
levothyroxine sodium tab
137 mcg (Synthroid)
OTRAS HORMONAS Y MEDICAMENTOS
$0 (1)
levothyroxine sodium tab
RELACIONADOS
150 mcg (Synthroid)
ALENDRONATE SODIUM
$0 (2)
QL
$0 (1)
levothyroxine sodium tab
– alendronate sodium
175 mcg (Synthroid)
tab 40 mg
$0 (1)
levothyroxine sodium tab
$0 (1)
QL
alendronate sodium tab
200 mcg (Synthroid)
5 mg
$0 (1)
levothyroxine sodium tab
$0 (1)
QL
alendronate sodium tab
300 mcg (Synthroid)
10 mg
$0 (1)
liothyronine sodium tab
$0 (1)
QL
alendronate sodium tab
5 mcg (Cytomel)
35 mg
$0 (1)
liothyronine sodium tab
$0 (1)
QL
alendronate sodium tab
25 mcg (Cytomel)
70 mg (Fosamax)
$0 (1)
liothyronine sodium tab
$0 (1)
cabergoline tab 0.5 mg
50 mcg (Cytomel)
$0 (1)
calcitonin (salmon)
$0 (1)
methimazole tab 5 mg
nasal soln 200 unit/act
(Tapazole)
(Miacalcin)
$0 (1)
methimazole tab 10 mg
$0 (1)
calcitriol cap 0.25 mcg
(Tapazole)
(Rocaltrol)
$0 (1)
propylthiouracil tab 50 mg
$0 (1)
calcitriol cap 0.5 mcg
(Rocaltrol)
$0 (1)
thyroid tab 30 mg
(1/2 grain) (Armour
$0 (1)
calcitriol oral soln 1 mcg/
thyroid)
ml (Rocaltrol)
$0 (1)
thyroid tab 60 mg
$0 (1)
desmopressin acetate
(1 grain) (Armour
nasal soln 0.01%
thyroid)
(refrigerated) (Ddavp)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
19
2016
Nombre del
medicamento
desmopressin acetate
nasal spray soln 0.01%
(Ddavp)
desmopressin acetate
nasal spray soln 0.01%
(refrigerated)
desmopressin acetate tab
0.1 mg (Ddavp)
desmopressin acetate tab
0.2 mg (Ddavp)
ETIDRONATE DISODIUM
– etidronate disodium
tab 400 mg
FORTEO – teriparatide
(recombinant) inj
600 mcg/2.4ml
ibandronate sodium
tab 150 mg (base
equivalent) (Boniva)
levocarnitine oral soln
1 gm/10ml (10%)
(Carnitor)
levocarnitine tab 330 mg
(Carnitor)
methylergonovine
maleate tab 0.2 mg
MIFEPREX – mifepristone
tab 200 mg
octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
(Sandostatin)
octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
(Sandostatin)
octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
(Sandostatin)
octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
(Sandostatin)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
octreotide acetate inj
1000 mcg/ml (1 mg/ml)
(Sandostatin)
$0 (1)
PROLIA – denosumab inj
60 mg/ml
raloxifene hcl tab 60 mg
$0 (1)
(Evista)
SENSIPAR – cinacalcet
hcl tab 30 mg (base
$0 (1)
equiv)
$0 (2)
SENSIPAR – cinacalcet
hcl tab 60 mg (base
equiv)
$0 (2)
PA, QL, SP
SENSIPAR – cinacalcet
hcl tab 90 mg (base
equiv)
$0 (1)
QL
STIMATE – desmopressin
acetate nasal soln
1.5 mg/ml
$0 (1)
STRENSIQ – asfotase
alfa subcutaneous inj
18 mg/0.45ml
$0 (1)
STRENSIQ – asfotase
alfa subcutaneous inj
28 mg/0.7ml
$0 (1)
STRENSIQ – asfotase
alfa subcutaneous inj
$0 (2)
40 mg/ml
STRENSIQ – asfotase
$0 (1)
SP
alfa subcutaneous inj
80 mg/0.8ml
$0 (1)
SP
$0 (1)
SP
$0 (1)
SP
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
20
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
SP
$0 (2)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
MEDICAMENTOS PARA EL CORAZÓN Y LA
CIRCULACIÓN
INHIBIDORES DE LA ENZIMA CONVERTIDORA DE
ANGIOTENSINA (ACE, POR SU SIGLA EN INGLÉS)
Y COMBINACIONES
$0 (1)
benazepril &
hydrochlorothiazide tab
5-6.25 mg
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin
hct)
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin
hct)
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
(Lotensin)
benazepril hcl tab 20 mg
(Lotensin)
benazepril hcl tab 40 mg
(Lotensin)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
25-15 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
25-25 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
50-15 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
hydrochlorothiazide tab
$0 (1)
50-25 mg
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
$0 (1)
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
$0 (1)
enalapril maleate tab
2.5 mg (Vasotec)
enalapril maleate tab
$0 (1)
5 mg (Vasotec)
enalapril
maleate tab
$0 (1)
10 mg (Vasotec)
enalapril
maleate tab
$0 (1)
20 mg (Vasotec)
fosinopril
sodium &
$0 (1)
hydrochlorothiazide tab
10-12.5 mg
$0 (1)
fosinopril sodium &
$0 (1)
hydrochlorothiazide tab
$0 (1)
20-12.5 mg
$0 (1)
fosinopril sodium tab
$0 (2)
10 mg
fosinopril sodium tab
20 mg
fosinopril sodium tab
40 mg
$0 (2)
lisinopril &
hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
lisinopril &
hydrochlorothiazide tab
$0 (2)
20-12.5 mg (Zestoretic)
lisinopril &
hydrochlorothiazide tab
20-25 mg (Zestoretic)
lisinopril tab 2.5 mg
$0 (2)
(Zestril)
lisinopril tab 5 mg (Prinivil)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
21
2016
Nombre del
medicamento
lisinopril tab 10 mg
(Prinivil)
lisinopril tab 20 mg
(Prinivil)
lisinopril tab 30 mg
(Zestril)
lisinopril tab 40 mg
(Zestril)
moexipril hcl tab 7.5 mg
(Univasc)
moexipril hcl tab 15 mg
(Univasc)
moexiprilhydrochlorothiazide tab
7.5-12.5 mg
moexiprilhydrochlorothiazide tab
15-12.5 mg (Uniretic)
moexiprilhydrochlorothiazide tab
15-25 mg
perindopril erbumine tab
2 mg
perindopril erbumine tab
4 mg (Aceon)
perindopril erbumine tab
8 mg (Aceon)
quinapril hcl tab 5 mg
(Accupril)
quinapril hcl tab 10 mg
(Accupril)
quinapril hcl tab 20 mg
(Accupril)
quinapril hcl tab 40 mg
(Accupril)
quinaprilhydrochlorothiazide tab
10-12.5 mg (Accuretic)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
quinaprilhydrochlorothiazide tab
20-12.5 mg (Accuretic)
$0 (1)
quinaprilhydrochlorothiazide tab
$0 (1)
20-25 mg (Accuretic)
ramipril
cap 1.25 mg
$0 (1)
(Altace)
ramipril
cap 2.5 mg
$0 (1)
(Altace)
ramipril cap 5 mg (Altace)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
22
ramipril cap 10 mg
(Altace)
trandolapril tab 1 mg
(Mavik)
trandolapril tab 2 mg
(Mavik)
trandolapril tab 4 mg
(Mavik)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
ANTAGONISTAS DE LOS RECEPTORES DE
ANGIOTENSINA II (ARBS, POR SU SIGLA EN
INGLÉS) Y COMBINACIONES
$0 (1)
irbesartan tab 75 mg
(Avapro)
$0 (1)
irbesartan tab 150 mg
(Avapro)
$0 (1)
irbesartan tab 300 mg
(Avapro)
$0 (1)
irbesartanhydrochlorothiazide tab
150-12.5 mg (Avalide)
$0 (1)
irbesartanhydrochlorothiazide tab
300-12.5 mg (Avalide)
$0 (1)
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
$0 (1)
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
losartan potassium &
atenolol & chlorthalidone
hydrochlorothiazide tab
tab 50-25 mg (Tenoretic
100-25 mg (Hyzaar)
50)
$0 (1)
losartan potassium tab
atenolol & chlorthalidone
25 mg (Cozaar)
tab 100-25 mg
(Tenoretic 100)
$0 (1)
losartan potassium tab
atenolol tab 25 mg
50 mg (Cozaar)
(Tenormin)
$0 (1)
losartan potassium tab
atenolol tab 50 mg
100 mg (Cozaar)
(Tenormin)
$0 (1)
valsartan tab 40 mg
atenolol tab 100 mg
(Diovan)
(Tenormin)
$0 (1)
valsartan tab 80 mg
betaxolol hcl tab 10 mg
(Diovan)
(Kerlone)
$0 (1)
valsartan tab 160 mg
betaxolol hcl tab 20 mg
(Diovan)
(Kerlone)
$0 (1)
valsartan tab 320 mg
bisoprolol &
(Diovan)
hydrochlorothiazide tab
$0 (1)
valsartan2.5-6.25 mg (Ziac)
hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
bisoprolol &
hydrochlorothiazide tab
$0 (1)
valsartan5-6.25 mg (Ziac)
hydrochlorothiazide tab
160-12.5 mg (Diovan
bisoprolol &
hct)
hydrochlorothiazide tab
10-6.25 mg (Ziac)
$0 (1)
valsartanbisoprolol fumarate tab
hydrochlorothiazide tab
160-25 mg (Diovan hct)
5 mg (Zebeta)
$0 (1)
valsartanbisoprolol fumarate tab
hydrochlorothiazide tab
10 mg (Zebeta)
320-12.5 mg (Diovan
carvedilol tab 3.125 mg
hct)
(Coreg)
$0 (1)
valsartancarvedilol tab 6.25 mg
hydrochlorothiazide tab
(Coreg)
320-25 mg (Diovan hct)
carvedilol tab 12.5 mg
(Coreg)
BETA BLOQUEADORES Y COMBINACINES
carvedilol tab 25 mg
$0 (1)
acebutolol hcl cap 200 mg
(Coreg)
(Sectral)
labetalol hcl tab 100 mg
$0 (1)
acebutolol hcl cap 400 mg
(Trandate)
(Sectral)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
23
2016
Nombre del
medicamento
labetalol hcl tab 200 mg
(Trandate)
labetalol hcl tab 300 mg
(Trandate)
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor
hct)
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor
hct)
metoprolol &
hydrochlorothiazide tab
100-50 mg
metoprolol succinate tab
sr 24hr 25 mg (tartrate
equiv) (Toprol xl)
metoprolol succinate tab
sr 24hr 50 mg (tartrate
equiv) (Toprol xl)
metoprolol succinate tab
sr 24hr 100 mg (tartrate
equiv) (Toprol xl)
metoprolol succinate tab
sr 24hr 200 mg (tartrate
equiv) (Toprol xl)
metoprolol tartrate tab
25 mg
metoprolol tartrate tab
50 mg (Lopressor)
metoprolol tartrate tab
100 mg (Lopressor)
nadolol tab 20 mg
(Corgard)
nadolol tab 40 mg
(Corgard)
nadolol tab 80 mg
(Corgard)
pindolol tab 5 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
pindolol tab 10 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
24
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
propranolol hcl cap sr
24hr 60 mg (Inderal la)
propranolol hcl cap sr
24hr 80 mg (Inderal la)
propranolol hcl cap sr
24hr 120 mg (Inderal la)
propranolol hcl cap sr
24hr 160 mg (Inderal la)
propranolol hcl tab 10 mg
$0 (1)
propranolol hcl tab 20 mg
$0 (1)
propranolol hcl tab 40 mg
$0 (1)
propranolol hcl tab 60 mg
$0 (1)
propranolol hcl tab 80 mg
$0 (1)
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
hydrochlorothiazide tab
40-25 mg
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
BLOQUEADORES DE CANAL DE CALCIO Y
COMBINACIONES
$0 (1)
amlodipine besylate tab
2.5 mg (Norvasc)
$0 (1)
amlodipine besylate tab
5 mg (Norvasc)
$0 (1)
amlodipine besylate tab
10 mg (Norvasc)
$0 (1)
amlodipine besylatebenazepril hcl cap
2.5-10 mg (Lotrel)
$0 (1)
amlodipine besylatebenazepril hcl cap
5-10 mg (Lotrel)
$0 (1)
amlodipine besylatebenazepril hcl cap
5-20 mg (Lotrel)
$0 (1)
amlodipine besylatebenazepril hcl cap
5-40 mg (Lotrel)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
amlodipine besylatebenazepril hcl cap
10-20 mg (Lotrel)
amlodipine besylatebenazepril hcl cap
10-40 mg (Lotrel)
amlodipine besylatevalsartan tab 5-160 mg
(Exforge)
amlodipine besylatevalsartan tab 5-320 mg
(Exforge)
amlodipine besylatevalsartan tab 10-160 mg
(Exforge)
amlodipine besylatevalsartan tab 10-320 mg
(Exforge)
diltiazem hcl cap sr 12hr
60 mg
diltiazem hcl cap sr 12hr
90 mg
diltiazem hcl cap sr 12hr
120 mg
diltiazem hcl cap sr 24hr
120 mg
diltiazem hcl cap sr 24hr
180 mg
diltiazem hcl cap sr 24hr
240 mg
diltiazem hcl coated
beads cap sr 24hr
120 mg (Cardizem cd)
diltiazem hcl coated
beads cap sr 24hr
180 mg (Cardizem cd)
diltiazem hcl coated
beads cap sr 24hr
240 mg (Cardizem cd)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
diltiazem hcl coated
beads cap sr 24hr
300 mg (Cardizem cd)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 120 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 180 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 240 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 300 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 360 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 420 mg (Tiazac)
$0 (1)
diltiazem hcl tab 30 mg
(Cardizem)
$0 (1)
diltiazem hcl tab 60 mg
(Cardizem)
$0 (1)
diltiazem hcl tab 90 mg
$0 (1)
diltiazem hcl tab 120 mg
(Cardizem)
$0 (1)
felodipine tab sr 24hr
2.5 mg
$0 (1)
felodipine tab sr 24hr
5 mg
felodipine tab sr 24hr
$0 (1)
10 mg
isradipine cap 2.5 mg
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
isradipine cap 5 mg
$0 (1)
nicardipine hcl cap 20 mg
$0 (1)
nicardipine hcl cap 30 mg
$0 (1)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
25
2016
Nombre del
medicamento
nifedipine cap 10 mg
(Procardia)
nifedipine cap 20 mg
nifedipine tab sr 24hr
30 mg (Adalat cc)
nifedipine tab sr 24hr
60 mg (Adalat cc)
nifedipine tab sr 24hr
90 mg (Adalat cc)
nifedipine tab sr 24hr
osmotic release 30 mg
(Procardia xl)
nifedipine tab sr 24hr
osmotic release 60 mg
(Procardia xl)
nifedipine tab sr 24hr
osmotic release 90 mg
(Procardia xl)
nimodipine cap 30 mg
trandolapril-verapamil hcl
tab cr 1-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-180 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 4-240 mg (Tarka)
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
verapamil hcl cap sr 24hr
120 mg (Verelan)
verapamil hcl cap sr 24hr
180 mg (Verelan)
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
verapamil hcl cap sr 24hr
240 mg (Verelan)
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
verapamil hcl cap sr 24hr
360 mg (Verelan)
$0 (1)
verapamil hcl tab cr
120 mg (Calan sr)
$0 (1)
verapamil hcl tab cr
180 mg (Calan sr)
$0 (1)
verapamil hcl tab cr
240 mg (Calan sr)
$0 (1)
verapamil hcl tab 40 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
26
verapamil hcl tab 80 mg
(Calan)
verapamil hcl tab 120 mg
(Calan)
DOLOR EN EL PECHO
ISOSORBIDE DINITRATE
– isosorbide dinitrate tab
30 mg
ISOSORBIDE DINITRATE
ER – isosorbide dinitrate
tab cr 40 mg
isosorbide dinitrate tab
5 mg (Isordil titradose)
isosorbide dinitrate tab
10 mg
isosorbide dinitrate tab
20 mg
isosorbide mononitrate
tab sr 24hr 30 mg
(Imdur)
isosorbide mononitrate
tab sr 24hr 60 mg
(Imdur)
isosorbide mononitrate
tab sr 24hr 120 mg
(Imdur)
isosorbide mononitrate
tab 10 mg
isosorbide mononitrate
tab 20 mg
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
nitroglycerin cap cr
cholestyramine light
2.5 mg
powder packets 4 gm
$0 (1)
nitroglycerin cap cr
cholestyramine light
6.5 mg
powder 4 gm/dose
(Questran light)
$0 (1)
nitroglycerin cap cr 9 mg
cholestyramine powder
$0 (1)
nitroglycerin td patch 24hr
packets 4 gm
0.1 mg/hr (Nitro-dur)
(Questran)
$0 (1)
nitroglycerin td patch 24hr
cholestyramine
powder
0.2 mg/hr (Nitro-dur)
4 gm/dose (Questran)
$0 (1)
nitroglycerin td patch 24hr
choline fenofibrate cap dr
0.4 mg/hr (Nitro-dur)
45 mg (fenofibric acid
$0 (1)
nitroglycerin td patch 24hr
equiv) (Trilipix)
0.6 mg/hr (Nitro-dur)
choline fenofibrate cap dr
NITROSTAT –
$0 (2)
135 mg (fenofibric acid
nitroglycerin sl tab
equiv) (Trilipix)
0.3 mg
colestipol
hcl granule
NITROSTAT –
$0 (2)
packets 5 gm (Colestid
nitroglycerin sl tab
flavored)
0.4 mg
colestipol hcl granules
NITROSTAT –
$0 (2)
5 gm (Colestid flavored)
nitroglycerin sl tab
colestipol hcl tab 1 gm
0.6 mg
(Colestid)
RANEXA – ranolazine tab
$0 (2)
fenofibrate micronized
sr 12hr 500 mg
cap 43 mg
RANEXA – ranolazine tab
$0 (2)
fenofibrate micronized
sr 12hr 1000 mg
cap 67 mg (Lofibra)
REDUCCIÓN DEL COLESTEROL
fenofibrate micronized
$0 (1)
atorvastatin calcium tab
cap 130 mg
10 mg (base equivalent)
fenofibrate micronized
(Lipitor)
cap 134 mg (Lofibra)
$0 (1)
atorvastatin calcium tab
fenofibrate micronized
20 mg (base equivalent)
cap 200 mg (Lofibra)
(Lipitor)
fenofibrate tab 48 mg
$0 (1)
atorvastatin calcium tab
(Tricor)
40 mg (base equivalent)
fenofibrate tab 54 mg
(Lipitor)
(Lofibra)
$0 (1)
atorvastatin calcium tab
fenofibrate tab 145 mg
80 mg (base equivalent)
(Tricor)
(Lipitor)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
27
2016
Nombre del
medicamento
fenofibrate tab 160 mg
(Lofibra)
fluvastatin sodium tab sr
24 hr 80 mg (Lescol xl)
gemfibrozil tab 600 mg
(Lopid)
lovastatin tab 10 mg
lovastatin tab 20 mg
(Mevacor)
lovastatin tab 40 mg
(Mevacor)
PRALUENT – alirocumab
subcutaneous soln peninjector 75 mg/ml
PRALUENT – alirocumab
subcutaneous soln peninjector 150 mg/ml
PRALUENT – alirocumab
subcutaneous soln
prefilled syringe 75 mg/
ml
PRALUENT – alirocumab
subcutaneous soln
prefilled syringe 150 mg/
ml
pravastatin sodium tab
10 mg
pravastatin sodium tab
20 mg (Pravachol)
pravastatin sodium tab
40 mg (Pravachol)
pravastatin sodium tab
80 mg (Pravachol)
REPATHA – evolocumab
subcutaneous soln
prefilled syringe 140 mg/
ml
REPATHA SURECLICK
– evolocumab
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
subcutaneous
soln
auto$0 (1)
injector 140 mg/ml
$0 (1)
rosuvastatin
calcium tab
$0 (1)
5 mg (Crestor)
$0 (1)
rosuvastatin
calcium tab
$0 (1)
10 mg (Crestor)
$0 (1)
rosuvastatin calcium tab
$0 (1)
20
mg
(Crestor)
$0 (1)
$0 (1)
rosuvastatin calcium tab
40
mg
(Crestor)
$0 (1)
$0 (1)
simvastatin tab 5 mg
(Zocor)
$0 (2)
PA, QL, SP
$0 (1)
simvastatin tab 10 mg
(Zocor)
$0 (1)
simvastatin tab 20 mg
$0 (2)
PA, QL, SP
(Zocor)
$0 (1)
simvastatin tab 40 mg
(Zocor)
$0 (2)
PA, QL, SP
$0 (1)
simvastatin tab 80 mg
(Zocor)
WELCHOL – colesevelam
$0 (2)
hcl
tab
625
mg
$0 (2)
PA, QL, SP
WELCHOL – colesevelam
$0 (2)
hcl packet for susp
3.75 gm
$0 (1)
RETENCIÓN DE LÍQUIDOS
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
28
ACETAZOLAMIDE –
acetazolamide tab
125 mg
acetazolamide cap sr
12hr 500 mg (Diamox)
acetazolamide tab
250 mg
amiloride &
hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
$0 (2)
bumetanide tab 0.5 mg
$0 (1)
bumetanide tab 1 mg
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
bumetanide tab 2 mg
spironolactone tab 25 mg
(Aldactone)
CHLOROTHIAZIDE
$0 (2)
spironolactone tab 50 mg
– chlorothiazide tab
(Aldactone)
250 mg
spironolactone tab
$0 (1)
chlorothiazide tab 500 mg
100 mg (Aldactone)
CHLORTHALIDONE
$0 (2)
torsemide tab 5 mg
– chlorthalidone tab
(Demadex)
50 mg
torsemide tab 10 mg
$0 (1)
chlorthalidone tab 25 mg
(Demadex)
$0 (1)
furosemide oral soln
torsemide tab 20 mg
10 mg/ml
(Demadex)
$0 (1)
furosemide tab 20 mg
torsemide tab 100 mg
(Lasix)
(Demadex)
$0 (1)
furosemide tab 40 mg
triamterene &
(Lasix)
hydrochlorothiazide cap
$0 (1)
furosemide tab 80 mg
37.5-25 mg (Dyazide)
(Lasix)
triamterene &
$0 (1)
hydrochlorothiazide cap
hydrochlorothiazide
12.5 mg (Microzide)
tab 37.5-25 mg
$0 (1)
hydrochlorothiazide tab
(Maxzide-25)
12.5 mg
triamterene &
$0 (1)
hydrochlorothiazide tab
hydrochlorothiazide tab
25 mg
75-50 mg (Maxzide)
$0 (1)
hydrochlorothiazide tab
TRIAMTERENE/
50 mg
HYDROCHLOROTH
$0 (1)
indapamide tab 1.25 mg
– triamterene &
hydrochlorothiazide cap
$0 (1)
indapamide tab 2.5 mg
50-25 mg
$0 (1)
methazolamide tab 25 mg
(Neptazane)
RITMO CARDÍACO
$0 (1)
methazolamide tab 50 mg
amiodarone hcl tab
(Neptazane)
200 mg (Cordarone)
$0 (1)
metolazone tab 2.5 mg
disopyramide phosphate
(Zaroxolyn)
cap 100 mg (Norpace)
$0 (1)
metolazone tab 5 mg
disopyramide phosphate
(Zaroxolyn)
cap 150 mg (Norpace)
$0 (1)
metolazone tab 10 mg
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
$0 (1)
spironolactone &
dofetilide cap 250 mcg
hydrochlorothiazide tab
(0.25 mg) (Tikosyn)
25-25 mg (Aldactazide)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
29
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
dofetilide cap 500 mcg
sotalol hcl (afib/afl) tab
(0.5 mg) (Tikosyn)
160 mg (Betapace af)
$0 (1)
flecainide acetate tab
sotalol hcl tab 80 mg
50 mg
(Betapace)
$0 (1)
flecainide acetate tab
sotalol hcl tab 120 mg
100 mg
(Betapace)
$0 (1)
flecainide acetate tab
sotalol hcl tab 160 mg
150 mg
(Betapace)
$0 (1)
mexiletine hcl cap 150 mg
sotalol hcl tab 240 mg
mexiletine hcl cap 200 mg
$0 (1)
mexiletine hcl cap 250 mg
$0 (1)
MULTAQ – dronedarone
hcl tab 400 mg (base
equivalent)
propafenone hcl cap sr
12hr 225 mg (Rythmol
sr)
propafenone hcl cap sr
12hr 325 mg (Rythmol
sr)
propafenone hcl cap sr
12hr 425 mg (Rythmol
sr)
propafenone hcl tab
150 mg (Rythmol)
propafenone hcl tab
225 mg (Rythmol)
propafenone hcl tab
300 mg
QUINIDINE SULFATE
– quinidine sulfate tab
200 mg
QUINIDINE SULFATE
– quinidine sulfate tab
300 mg
sotalol hcl (afib/afl) tab
80 mg (Betapace af)
sotalol hcl (afib/afl) tab
120 mg (Betapace af)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
30
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
OTROS MEDICAMENTOS RELACIONADOS CON
EL CORAZÓN
ADCIRCA – tadalafil tab
$0 (2)
PA, QL, SP
20 mg (pah)
$0 (1)
clonidine hcl tab 0.1 mg
(Catapres)
$0 (1)
clonidine hcl tab 0.2 mg
(Catapres)
$0 (1)
clonidine hcl tab 0.3 mg
(Catapres)
$0 (1)
clonidine hcl td patch
weekly 0.1 mg/24hr
(Catapres-tts-1)
$0 (1)
clonidine hcl td patch
weekly 0.2 mg/24hr
(Catapres-tts-2)
$0 (1)
clonidine hcl td patch
weekly 0.3 mg/24hr
(Catapres-tts-3)
DIGOXIN – digoxin oral
$0 (2)
soln 0.05 mg/ml
$0 (1)
digoxin tab 125 mcg
(0.125 mg) (Lanoxin)
$0 (1)
digoxin tab 250 mcg
(0.25 mg) (Lanoxin)
$0 (1)
doxazosin mesylate tab
1 mg (Cardura)
$0 (1)
doxazosin mesylate tab
2 mg (Cardura)
$0 (1)
doxazosin mesylate tab
4 mg (Cardura)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
doxazosin mesylate tab
8 mg (Cardura)
guanfacine hcl tab 1 mg
(Tenex)
guanfacine hcl tab 2 mg
(Tenex)
hydralazine hcl tab 10 mg
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
$0 (1)
TRACLEER – bosentan
$0 (2)
PA, QL, SP
tab 125 mg
$0 (1)
EQUIPOS PARA PICADURAS DE ABEJAS
EPIPEN 2-PAK
– epinephrine
solution auto-injector
0.3 mg/0.3ml (1:1000)
EPIPEN-JR 2-PAK
– epinephrine
solution auto-injector
0.15 mg/0.3ml (1:2000)
$0 (1)
$0 (1)
hydralazine hcl tab 25 mg
$0 (1)
hydralazine hcl tab 50 mg
$0 (1)
hydralazine hcl tab
100 mg
methyldopa tab 250 mg
$0 (1)
methyldopa tab 500 mg
$0 (1)
midodrine hcl tab 2.5 mg
$0 (1)
midodrine hcl tab 5 mg
$0 (1)
midodrine hcl tab 10 mg
$0 (1)
minoxidil tab 2.5 mg
$0 (1)
minoxidil tab 10 mg
$0 (1)
OPSUMIT – macitentan
tab 10 mg
phenoxybenzamine hcl
cap 10 mg (Dibenzyline)
prazosin hcl cap 1 mg
(Minipress)
prazosin hcl cap 2 mg
(Minipress)
prazosin hcl cap 5 mg
(Minipress)
sildenafil citrate tab 20 mg
(Revatio)
terazosin hcl cap 1 mg
$0 (2)
terazosin hcl cap 2 mg
$0 (1)
terazosin hcl cap 5 mg
$0 (1)
terazosin hcl cap 10 mg
$0 (1)
TRACLEER – bosentan
tab 62.5 mg
$0 (2)
PA, QL, SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
PA, QL, SP
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL
$0 (2)
QL
AGENTES RESPIRATORIOS
$0 (1)
$0 (1)
$0 (2)
PA, QL, SP
ANTIHISTAMÍNICOS
carbinoxamine maleate
soln 4 mg/5ml
carbinoxamine maleate
tab 4 mg
cetirizine hcl chew tab
5 mg
cetirizine hcl chew tab
10 mg
cetirizine hcl oral soln
1 mg/ml (5 mg/5ml)
cetirizine hcl oral soln
1 mg/ml (5 mg/5ml)
cetirizine hcl tab 5 mg
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (3)
$0 (3)
cetirizine hcl tab 10 mg
$0 (3)
chlorpheniramine maleate
tab 4 mg
clemastine fumarate tab
1.34 mg (1 mg base
equiv)
clemastine fumarate tab
2.68 mg
cyproheptadine hcl syrup
2 mg/5ml
cyproheptadine hcl tab
4 mg
$0 (3)
PA
QL
SP
ST
$0 (3)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
31
2016
Nombre del
medicamento
desloratadine tab 5 mg
(Clarinex)
diphenhydramine hcl cap
25 mg
diphenhydramine hcl cap
50 mg
diphenhydramine hcl cap
50 mg
diphenhydramine hcl elixir
12.5 mg/5ml
diphenhydramine hcl
liquid 12.5 mg/5ml
diphenhydramine hcl tab
25 mg
fexofenadine hcl susp
30 mg/5ml (6 mg/ml)
fexofenadine hcl tab
60 mg
fexofenadine hcl tab
180 mg
levocetirizine
dihydrochloride tab
5 mg (Xyzal)
loratadine syrup 5 mg/5ml
loratadine tab 10 mg
promethazine hcl suppos
12.5 mg
promethazine hcl suppos
25 mg
promethazine hcl suppos
50 mg
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab
12.5 mg
promethazine hcl tab
25 mg
promethazine hcl tab
50 mg
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
$0 (1)
PRODUCTOS NASALES
$0 (1)
QL
azelastine hcl nasal spray
$0 (3)
0.1% (137 mcg/spray)
$0 (1)
QL
flunisolide nasal soln
$0 (1)
25 mcg/act (0.025%)
(Flunisolide)
$0 (3)
$0 (1)
QL
fluticasone propionate
nasal susp 50 mcg/act
$0 (1)
(Flonase)
$0 (1)
QL
ipratropium bromide nasal
$0 (3)
soln 0.03% (21 mcg/
spray) (Atrovent)
$0 (3)
$0 (1)
QL
ipratropium bromide nasal
soln 0.06% (42 mcg/
spray) (Atrovent)
$0 (3)
$0 (1)
QL
mometasone furoate
nasal susp 50 mcg/act
$0 (3)
(Nasonex)
$0 (3)
phenylephrine hcl tab
$0 (3)
10 mg
$0 (3)
saline nasal spray 0.65%
$0 (1)
$0 (1)
QL
triamcinolone acetonide
nasal aerosol
$0 (3)
suspension 55 mcg/act
(Nasacort aq)
$0 (3)
TOS/RESFRÍO/ALERGIA
$0 (1)
$0 (1)
acetylcysteine inhal soln
10%
$0 (1)
$0 (1)
acetylcysteine inhal soln
20%
$0 (1)
$0 (1)
benzonatate cap 100 mg
(Tessalon
perles)
$0 (1)
$0 (1)
benzonatate cap 150 mg
(Zonatuss)
$0 (1)
$0 (1)
benzonatate cap 200 mg
$0 (1)
BROHIST D –
$0 (3)
brompheniramine &
phenylephrine tab
$0 (1)
4-10 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
32
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
brompheniramine &
phenylephrine elixir
1-2.5 mg/5ml
brompheniramine &
phenylephrine susp
6-10 mg/5ml
brompheniramine &
pseudoephedrine tab sr
12hr 6-45 mg
chlorpheniramine &
phenylephrine liquid
4-10 mg/5ml
chlorpheniramine &
phenylephrine tab
4-10 mg
dextromethorphanguaifenesin liquid
10-100 mg/5ml
DIMETAPP COLD
& ALLERGY –
brompheniramine &
phenylephrine chew tab
1-2.5 mg
diphenhydraminephenylephrine liq
6.25-2.5 mg/5ml
diphenhydraminephenylephrine soln
12.5-5 mg/5ml
ED CHLORPED D –
chlorpheniramine &
phenylephrine liquid
2-5 mg/ml
guaifenesin liquid
100 mg/5ml
guaifenesin-codeine soln
100-10 mg/5ml
hydrocod polstchlorphen polst er susp
10-8 mg/5ml (Tussionex
pennkineti)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (3)
hydrocodone w/
homatropine syrup
5-1.5 mg/5ml
$0 (3)
hydrocodone w/
homatropine tab
5-1.5 mg
$0 (1)
phenylephrine w/ dm-gg
liqd 5-10-200 mg/5ml
phenylephrine$0 (3)
brompheniramine-dm
elixir 2.5-1-5 mg/5ml
phenylephrine$0 (3)
guaifenesin liqd
7.5-100 mg/5ml
(1.5-20 mg/ml)
$0 (3)
phenylephrineguaifenesin tab
10-400 mg
$0 (3)
phenylephrinepromethazine w/
codeine syrup
5-6.25-10 mg/5ml
promethazine &
$0 (3)
phenylephrine syrup
6.25-5 mg/5ml
promethazine w/ codeine
$0 (3)
syrup 6.25-10 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
$0 (3)
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
pseudoephed$0 (3)
bromphen-dm syrup
30-2-10 mg/5ml
$0 (3)
RELHIST – bromphen
tan-phenyleph tan chew
$0 (1)
tab 6-15 mg
RELHIST BP –
brompheniramine &
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
33
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
phenylephrine tab
ADVAIR DISKUS –
4-10 mg
fluticasone-salmeterol
aer powder ba
RU-HIST D –
$0 (3)
250-50 mcg/dose
brompheniramine &
phenylephrine tab
ADVAIR DISKUS –
4-10 mg
fluticasone-salmeterol
aer powder ba
$0 (1)
sodium chloride soln nebu
500-50 mcg/dose
0.9%
ADVAIR HFA –
$0 (1)
sodium chloride soln nebu
fluticasone-salmeterol
3%
inhal aerosol
$0 (1)
sodium chloride soln nebu
45-21 mcg/act
7% (Hyper-sal)
ADVAIR HFA –
$0 (1)
sodium chloride soln nebu
fluticasone-salmeterol
10%
inhal aerosol
TRIAMINIC COLD
$0 (3)
115-21 mcg/act
& ALLERGY –
ADVAIR
HFA –
chlorpheniramine &
fluticasone-salmeterol
phenylephrine syrup
inhal aerosol
1-2.5 mg/5ml
230-21 mcg/act
TRIAMINIC COLD
$0 (3)
albuterol sulfate soln nebu
& ALLERGY –
0.083% (2.5 mg/3ml)
brompheniramine &
albuterol sulfate soln nebu
phenylephrine syrup
0.5% (5 mg/ml)
1-2.5 mg/5ml
albuterol sulfate soln
TRIAMINIC COLD/
$0 (3)
nebu 0.63 mg/3ml (base
COUGH NIGH –
equiv)
diphenhydraminephenylephrine oral strip
albuterol sulfate soln
12.5-5 mg
nebu 1.25 mg/3ml (base
equiv)
TRIAMINIC NIGHT
$0 (3)
TIME COLD –
albuterol sulfate syrup
diphenhydramine2 mg/5ml
phenylephrine syrup
albuterol sulfate tab sr
6.25-2.5 mg/5ml
12hr 4 mg (Vospire er)
ASMA/ENFERMEDAD PULMONAR OBSTRUCTIVA
albuterol sulfate tab sr
CRÓNICA (EPOC)
12hr 8 mg (Vospire er)
ADVAIR DISKUS –
$0 (2)
QL
albuterol sulfate tab 2 mg
fluticasone-salmeterol
albuterol sulfate tab 4 mg
aer powder ba
ARNUITY ELLIPTA –
100-50 mcg/dose
fluticasone furoate
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
34
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Nombre del
medicamento
aerosol powder breath
activ 100 mcg/act
ARNUITY ELLIPTA –
fluticasone furoate
aerosol powder breath
activ 200 mcg/act
ASMANEX TWISTHALER
120 ME – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
14 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
30 MET – mometasone
furoate inhal powd
110 mcg/inh (breath
activated)
ASMANEX TWISTHALER
30 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
60 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
7 METE – mometasone
furoate inhal powd
110 mcg/inh (breath
activated)
ATROVENT HFA –
ipratropium bromide hfa
inhal aerosol 17 mcg/act
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
budesonide inhalation
susp 0.25 mg/2ml
(Pulmicort)
$0 (2)
QL
budesonide inhalation
susp 0.5 mg/2ml
(Pulmicort)
$0 (2)
QL
budesonide inhalation
susp 1 mg/2ml
(Pulmicort)
COMBIVENT RESPIMAT
– ipratropium-albuterol
$0 (2)
QL
inhal aerosol soln
20-100 mcg/act
CROMOLYN SODIUM –
cromolyn sodium soln
nebu 20 mg/2ml
$0 (2)
QL
DULERA – mometasone
furoate-formoterol
fumarate aerosol
100-5 mcg/act
DULERA – mometasone
$0 (2)
QL
furoate-formoterol
fumarate aerosol
200-5 mcg/act
FLOVENT DISKUS –
fluticasone propionate
$0 (2)
QL
aer pow ba 50 mcg/
blister
FLOVENT DISKUS –
fluticasone propionate
aer pow ba 100 mcg/
$0 (2)
QL
blister
FLOVENT DISKUS –
fluticasone propionate
aer pow ba 250 mcg/
blister
$0 (2)
QL
FLOVENT HFA –
fluticasone propionate
hfa inhal aero 44 mcg/
act (50/valve)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
35
2016
Nombre del
medicamento
FLOVENT HFA –
fluticasone propionate
hfa inhal aer 110 mcg/
act (125/valve)
FLOVENT HFA –
fluticasone propionate
hfa inhal aer 220 mcg/
act (250/valve)
INCRUSE ELLIPTA
– umeclidinium br
aero powd breath act
62.5 mcg/inh (base eq)
ipratropium bromide inhal
soln 0.02%
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu
0.31 mg/3ml (base
equiv) (Xopenex)
levalbuterol hcl soln nebu
0.63 mg/3ml (base
equiv) (Xopenex)
levalbuterol hcl soln nebu
1.25 mg/3ml (base
equiv) (Xopenex)
montelukast sodium chew
tab 4 mg (base equiv)
(Singulair)
montelukast sodium chew
tab 5 mg (base equiv)
(Singulair)
montelukast sodium
oral granules packet
4 mg (base equiv)
(Singulair)
montelukast sodium tab
10 mg (base equiv)
(Singulair)
QVAR – beclomethasone
diprop inhal aero soln
40 mcg/act (50/valve)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
QL
QVAR – beclomethasone
diprop inhal aero soln
80 mcg/act (100/valve)
SEREVENT DISKUS –
salmeterol xinafoate aer
$0 (2)
QL
pow ba 50 mcg/dose
(base equiv)
SPIRIVA HANDIHALER
– tiotropium bromide
$0 (2)
QL
monohydrate inhal cap
18 mcg (base equiv)
SPIRIVA RESPIMAT
– tiotropium bromide
$0 (1)
QL
monohydrate inhal
aerosol 1.25 mcg/act
$0 (1)
QL
SYMBICORT –
budesonide-formoterol
$0 (1)
QL
fumarate dihyd aerosol
80-4.5 mcg/act
SYMBICORT –
$0 (1)
QL
budesonide-formoterol
fumarate dihyd aerosol
160-4.5 mcg/act
$0 (1)
QL
terbutaline sulfate tab
2.5 mg
terbutaline sulfate tab
$0 (1)
5 mg
theophylline soln
80 mg/15ml
$0 (1)
theophylline tab sr 12hr
100 mg
$0 (1)
theophylline tab sr 12hr
200 mg
theophylline tab sr 12hr
300 mg
$0 (1)
theophylline tab sr 12hr
450 mg
theophylline tab sr 24hr
$0 (2)
QL
400 mg
theophylline tab sr 24hr
600 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
36
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
VENTOLIN HFA –
$0 (2)
QL
KONSYL-D – psyllium
albuterol sulfate inhal
powder 52.3%
aero 108 mcg/act
lactulose solution
(90mcg base equiv)
10 gm/15ml
magnesium citrate soln
OTROS MEDICAMENTOS RESPIRATORIOS
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
METAMUCIL
tab 150 mg
MULTIHEALTH FIB –
psyllium powder 55.46%
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
packet 50 mg
METAMUCIL
MULTIHEALTH FIB –
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
psyllium powder 63%
packet 75 mg
METAMUCIL SMOOTH
PULMOZYME – dornase
$0 (2)
SP
TEXTURE – psyllium
alfa inhal soln 1 mg/ml
powder 63%
MEDICAMENTOS GASTROINTESTINALES
PEDIA-LAX – glycerin
LAXANTES
liquid suppos 2.8 gm
$0 (1)
bisacodyl tab & peg 3350(2.7 ml)
kcl-sod bicarb-nacl for
peg 3350-kcl-sod bicarbsoln kit
nacl for soln 420 gm
$0 (3)
bisacodyl tab delayed
(Nulytely/flavor pack)
release 5 mg
peg 3350-kcl-na bicarb$0 (3)
docusate sodium cap
nacl-na sulfate for soln
100 mg
236 gm (Golytely)
$0 (3)
docusate sodium cap
peg 3350-kcl-na bicarb250 mg
nacl-na sulfate for soln
$0 (3)
docusate sodium liquid
240 gm (Colyte-flavor
150 mg/15ml
packs)
FLEET LIQUID
$0 (3)
polyethylene glycol 3350
GLYCERIN SUP
oral powder
– glycerin enema
polyethylene glycol 3350
adult 5.4 gm/average
oral powder
delivered dose
polyethylene glycol 3350
$0 (3)
glycerin suppos 1 gm
oral packet
$0 (3)
glycerin suppos 2 gm
polyethylene glycol 3350
oral packet
$0 (3)
glycerin suppos 80.7%
psyllium
powder 28.3%
KONSYL – psyllium
$0 (3)
powder 60.3%
psyllium powder 30%
KONSYL – psyllium
$0 (3)
psyllium powder 30.9%
powder 71.67%
psyllium powder 33%
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
37
2016
Nombre del
medicamento
psyllium powder 48.57%
psyllium powder 49%
psyllium powder 58.6%
psyllium powder 95%
sennosides tab 8.6 mg
ANTIDIARREICOS
bismuth subsalicylate
susp 262 mg/15ml
diphenoxylate w/ atropine
tab 2.5-0.025 mg
(Lomotil)
loperamide hcl cap 2 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (3)
chlordiazepoxide hclclidinium bromide cap
$0 (3)
5-2.5 mg (Librax)
$0 (3)
cimetidine hcl soln
$0 (3)
300 mg/5ml
$0 (3)
cimetidine tab 200 mg
$0 (3)
$0 (1)
$0 (1)
loperamide hcl liq
1 mg/5ml (0.2 mg/ml)
loperamide hcl tab 2 mg
$0 (3)
opium tincture 1% (10 mg/
ml) (morphine equiv)
$0 (1)
ANTIÁCIDOS
alum & mag hydroxidesimethicone susp
200-200-20 mg/5ml
alum & mag hydroxidesimethicone susp
400-400-40 mg/5ml
calcium carbonate
(antacid) chew tab
500 mg
calcium carbonate
(antacid) chew tab
750 mg
calcium carbonate
(antacid) chew tab
1000 mg
magnesium oxide tab
400 mg
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
ÚLCERA/ENFERMEDAD POR REFLUJO
GASTROESOFÁGICO (ERGE)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
38
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
cimetidine tab 300 mg
$0 (1)
cimetidine tab 400 mg
$0 (1)
cimetidine tab 800 mg
$0 (1)
dicyclomine hcl cap
10 mg (Bentyl)
dicyclomine hcl inj 10 mg/
ml (Bentyl)
dicyclomine hcl oral soln
10 mg/5ml
dicyclomine hcl tab 20 mg
(Bentyl)
famotidine for susp
40 mg/5ml (Pepcid)
famotidine tab 10 mg
$0 (1)
famotidine tab 20 mg
(Pepcid)
famotidine tab 40 mg
(Pepcid)
glycopyrrolate tab 1 mg
(Robinul)
glycopyrrolate tab 2 mg
(Robinul forte)
hyoscyamine sulfate elixir
0.125 mg/5ml
hyoscyamine sulfate soln
0.125 mg/ml
hyoscyamine sulfate
tab disp 0.125 mg
(Anaspaz)
hyoscyamine sulfate tab
sl 0.125 mg (Levsin/sl)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
hyoscyamine sulfate
tab sr 12hr 0.375 mg
(Levbid)
hyoscyamine sulfate tab
0.125 mg (Levsin)
lansoprazole cap
delayed release 15 mg
(Prevacid)
lansoprazole cap
delayed release 30 mg
(Prevacid)
methscopolamine
bromide tab 2.5 mg
(Pamine)
methscopolamine
bromide tab 5 mg
(Pamine forte)
misoprostol tab 100 mcg
(Cytotec)
misoprostol tab 200 mcg
(Cytotec)
NIZATIDINE – nizatidine
oral soln 15 mg/ml
nizatidine cap 150 mg
nizatidine cap 300 mg
(Axid)
omeprazole cap delayed
release 10 mg (Prilosec)
omeprazole cap delayed
release 20 mg (Prilosec)
omeprazole cap delayed
release 40 mg (Prilosec)
pantoprazole sodium ec
tab 20 mg (base equiv)
(Protonix)
pantoprazole sodium ec
tab 40 mg (base equiv)
(Protonix)
rabeprazole sodium ec
tab 20 mg (Aciphex)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
ranitidine hcl syrup 15 mg/
ml (75 mg/5ml)
ranitidine hcl tab 75 mg
$0 (1)
ranitidine hcl tab 150 mg
$0 (1)
QL
$0 (1)
QL
NAUSEAS Y VÓMITOS
EMEND – aprepitant
capsule therapy pack 80
& 125 mg
EMEND – aprepitant
capsule 40 mg
EMEND – aprepitant
capsule 80 mg
EMEND – aprepitant
capsule 125 mg
fructose-dextrosephosphoric acid oral
soln
meclizine hcl tab 12.5 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
(Zantac)
ranitidine hcl tab 300 mg
(Zantac)
sucralfate tab 1 gm
(Carafate)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (3)
$0 (1)
meclizine hcl tab 25 mg
$0 (1)
ondansetron hcl oral soln
4 mg/5ml (Zofran)
ondansetron hcl tab 4 mg
(Zofran)
ondansetron hcl tab 8 mg
(Zofran)
ondansetron hcl tab
24 mg
ondansetron orally
disintegrating tab 4 mg
(Zofran odt)
ondansetron orally
disintegrating tab 8 mg
(Zofran odt)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
39
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
20000-68000-109000
$0 (1)
prochlorperazine maleate
unit
tab 5 mg (Compazine)
ZENPEP
– pancrelipase
$0 (2)
$0 (1)
prochlorperazine maleate
(lip-prot-amyl) dr cap
tab 10 mg (Compazine)
25000-85000-136000
$0 (1)
prochlorperazine suppos
unit
25 mg
ZENPEP – pancrelipase
$0 (2)
$0 (1)
trimethobenzamide hcl
(lip-prot-amyl)
dr
cap
cap 300 mg (Tigan)
40000-136000-218000
ENZIMAS DIGESTIVAS
unit
CREON – pancrelipase
$0 (2)
OTROS MEDICAMENTOS GASTROINTESTINALES
(lip-prot-amyl) dr cap
$0 (1)
alosetron hcl tab 0.5 mg
3000-9500-15000 unit
(base equiv) (Lotronex)
CREON – pancrelipase
$0 (2)
$0 (1)
alosetron
hcl tab 1 mg
(lip-prot-amyl) dr cap
(base equiv) (Lotronex)
6000-19000-30000 unit
ASACOL
HD –
$0 (2)
CREON – pancrelipase
$0 (2)
mesalamine tab delayed
(lip-prot-amyl) dr cap
release 800 mg
12000-38000-60000 unit
$0 (1)
balsalazide disodium cap
CREON – pancrelipase
$0 (2)
750
mg
(Colazal)
(lip-prot-amyl) dr cap
$0 (1)
calcium acetate
24000-76000-120000
(phosphate
binder)
cap
unit
667 mg (169 mg ca)
CREON – pancrelipase
$0 (2)
(Phoslo)
(lip-prot-amyl) dr cap
$0 (1)
calcium acetate
36000-114000-180000
(phosphate binder) tab
unit
667 mg (Eliphos)
ZENPEP – pancrelipase
$0 (2)
CANASA – mesalamine
$0 (2)
(lip-prot-amyl) dr cap
suppos
1000
mg
3000-10000-16000 unit
$0 (1)
cromolyn sodium oral
ZENPEP – pancrelipase
$0 (2)
conc
100
mg/5ml
(lip-prot-amyl) dr cap
(Gastrocrom)
5000-17000-27000 unit
DELZICOL
– mesalamine
$0 (2)
ZENPEP – pancrelipase
$0 (2)
cap dr 400 mg
(lip-prot-amyl) dr cap
10000-34000-55000 unit
$0 (1)
lactulose
(encephalopathy)
ZENPEP – pancrelipase
$0 (2)
solution 10 gm/15ml
(lip-prot-amyl) dr cap
15000-51000-82000 unit
$0 (1)
mesalamine enema 4 gm
ZENPEP – pancrelipase
$0 (2)
$0 (1)
metoclopramide hcl soln
(lip-prot-amyl) dr cap
5 mg/5ml (10 mg/10ml)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
40
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
metoclopramide hcl tab
5 mg (Reglan)
metoclopramide hcl tab
10 mg (Reglan)
RENAGEL – sevelamer
hcl tab 400 mg
RENAGEL – sevelamer
hcl tab 800 mg
simethicone chew tab
80 mg
simethicone susp
40 mg/0.6ml
sulfasalazine tab delayed
release 500 mg
(Azulfidine en-tabs)
sulfasalazine tab 500 mg
(Azulfidine)
ursodiol cap 300 mg
(Actigall)
ursodiol tab 250 mg (Urso
250)
ursodiol tab 500 mg (Urso
forte)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
nitrofurantoin
macrocrystalline cap
100 mg (Macrodantin)
$0 (1)
nitrofurantoin
monohydrate
$0 (2)
macrocrystalline cap
100 mg (Macrobid)
$0 (2)
nitrofurantoin susp
25 mg/5ml (Furadantin)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
MEDICAMENTOS GENITOURINARIOS
INFECCIONES DEL TRACTO URINARIO
$0 (1)
methenamine hippurate
tab 1 gm (Hiprex)
$0 (1)
methenamine mandelate
tab 1 gm
$0 (1)
methenaminehyoscamine-meth bluesod phos cap 120 mg
$0 (1)
nitrofurantoin
macrocrystalline cap
25 mg (Macrodantin)
$0 (1)
nitrofurantoin
macrocrystalline cap
50 mg (Macrodantin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
ESPASMOS DEL TRACTO URINARIO
$0 (1)
bethanechol chloride tab
5 mg (Urecholine)
$0 (1)
bethanechol chloride tab
10 mg (Urecholine)
$0 (1)
bethanechol chloride tab
25 mg (Urecholine)
$0 (1)
bethanechol chloride tab
50 mg (Urecholine)
$0 (1)
darifenacin hydrobromide
tab sr 24hr 7.5 mg (base
equiv) (Enablex)
$0 (1)
darifenacin hydrobromide
tab sr 24hr 15 mg (base
equiv) (Enablex)
$0 (1)
flavoxate hcl tab 100 mg
oxybutynin chloride syrup
5 mg/5ml
oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 10 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl)
oxybutynin chloride tab
5 mg
tolterodine tartrate tab
1 mg (Detrol)
tolterodine tartrate tab
2 mg (Detrol)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
41
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
trospium chloride cap sr
dutasteride-tamsulosin hcl
24hr 60 mg
cap 0.5-0.4 mg (Jalyn)
$0 (1)
trospium chloride tab
finasteride tab 5 mg
20 mg
(Proscar)
glycine irrigation soln
PRODUCTOS VAGINALES
1.5%
$0 (1)
clindamycin phosphate
neomycin-polymyxin
vaginal cream 2%
b gu irrigation soln
(Cleocin)
(Neosporin gu irrigan)
$0 (3)
clotrimazole vaginal
phenazopyridine hcl tab
cream 2%
100 mg (Pyridium)
$0 (1)
metronidazole vaginal gel
phenazopyridine
hcl tab
0.75% (Metrogel200 mg (Pyridium)
vaginal)
pot
& sod citrates
$0 (3)
miconazole nitrate vaginal
w/ cit ac soln
cream 2%
550-500-334 mg/5ml
NONOXYNOL-9 – various
$0 (3)
potassium citrate & citric
$0 (1)
terconazole vaginal cream
acid powder pack
0.4% (Terazol 7)
3300-1002 mg
$0 (1)
terconazole vaginal cream
potassium citrate
0.8% (Terazol 3)
& citric acid soln
$0 (1)
terconazole vaginal
1100-334 mg/5ml
suppos 80 mg
potassium citrate tab cr 5
$0 (3)
tioconazole vaginal oint
meq (540 mg) (Urocit-k
6.5%
5)
VAGIFEM – estradiol
$0 (2)
potassium citrate tab
vaginal tab 10 mcg
cr 10 meq (1080 mg)
OTROS MEDICAMENTOS GENITOURINARIOS
(Urocit-k 10)
$0 (1)
acetic acid irrigation soln
potassium citrate tab
0.25%
cr 15 meq (1620 mg)
(Urocit-k 15)
$0 (1)
alfuzosin hcl tab sr 24hr
10 mg (Uroxatral)
sodium chloride irrigation
soln 0.9%
AVODART – dutasteride
$0 (2)
cap 0.5 mg
sodium citrate & citric acid
soln 500-334 mg/5ml
CYSTAGON – cysteamine
$0 (2)
SP
(Shohls solution modi)
bitartrate cap 50 mg
tamsulosin
hcl cap 0.4 mg
CYSTAGON – cysteamine
$0 (2)
SP
(Flomax)
bitartrate cap 150 mg
dutasteride cap 0.5 mg
(Avodart)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
42
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
MEDICAMENTOS DEL SISTEMA NERVIOSO CENTRAL
ANSIEDAD
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
alprazolam tab sr 24hr
0.5 mg (Xanax xr)
alprazolam tab sr 24hr
1 mg (Xanax xr)
alprazolam tab sr 24hr
2 mg (Xanax xr)
alprazolam tab sr 24hr
3 mg (Xanax xr)
alprazolam tab 0.25 mg
(Xanax)
alprazolam tab 0.5 mg
(Xanax)
alprazolam tab 1 mg
(Xanax)
alprazolam tab 2 mg
(Xanax)
buspirone hcl tab 5 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
diazepam tab 10 mg
(Valium)
$0 (1)
HYDROXYZINE HCL –
hydroxyzine hcl im soln
25 mg/ml
$0 (1)
hydroxyzine hcl im soln
50 mg/ml
$0 (1)
hydroxyzine hcl syrup
10 mg/5ml
$0 (1)
hydroxyzine hcl tab 10 mg
$0 (1)
hydroxyzine hcl tab 25 mg
$0 (1)
$0 (1)
$0 (1)
buspirone hcl tab 10 mg
$0 (1)
buspirone hcl tab 15 mg
$0 (1)
buspirone hcl tab 30 mg
$0 (1)
chlordiazepoxide hcl cap
5 mg
chlordiazepoxide hcl cap
10 mg
chlordiazepoxide hcl cap
25 mg
clorazepate dipotassium
tab 3.75 mg (Tranxene
t)
clorazepate dipotassium
tab 7.5 mg (Tranxene t)
clorazepate dipotassium
tab 15 mg (Tranxene t)
diazepam conc 5 mg/ml
$0 (1)
diazepam tab 2 mg
(Valium)
diazepam tab 5 mg
(Valium)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
hydroxyzine hcl tab 50 mg
$0 (1)
HYDROXYZINE
PAMOATE –
hydroxyzine pamoate
cap 100 mg
hydroxyzine pamoate cap
25 mg (Vistaril)
hydroxyzine pamoate cap
50 mg (Vistaril)
lorazepam conc 2 mg/ml
(Lorazepam intensol)
lorazepam tab 0.5 mg
(Ativan)
lorazepam tab 1 mg
(Ativan)
lorazepam tab 2 mg
(Ativan)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
DEPRESIÓN
amitriptyline hcl tab 10 mg
$0 (1)
amitriptyline hcl tab 25 mg
$0 (1)
amitriptyline hcl tab 50 mg
$0 (1)
amitriptyline hcl tab 75 mg
$0 (1)
amitriptyline hcl tab
100 mg
amitriptyline hcl tab
150 mg
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
43
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
bupropion hcl tab sr 12hr
desipramine hcl tab
150 mg (Wellbutrin sr)
150 mg (Norpramin)
$0 (1)
DOXEPIN HCL – doxepin
bupropion hcl tab sr 12hr
hcl cap 75 mg
200 mg (Wellbutrin sr)
$0 (1)
bupropion hcl tab sr 24hr
doxepin hcl cap 10 mg
150 mg (Wellbutrin xl)
doxepin hcl cap 25 mg
$0 (1)
bupropion hcl tab sr 24hr
doxepin hcl cap 50 mg
300 mg (Wellbutrin xl)
doxepin hcl cap 100 mg
$0 (1)
bupropion hcl tab 75 mg
doxepin hcl cap 150 mg
(Wellbutrin)
doxepin hcl conc 10 mg/
$0 (1)
bupropion hcl tab 100 mg
ml
(Wellbutrin)
duloxetine hcl enteric
$0 (1)
citalopram hydrobromide
coated pellets cap
oral soln 10 mg/5ml
20 mg (Cymbalta)
$0 (1)
citalopram hydrobromide
duloxetine hcl enteric
tab 10 mg (base equiv)
coated pellets cap
(Celexa)
30 mg (Cymbalta)
$0 (1)
citalopram hydrobromide
duloxetine
hcl enteric
tab 20 mg (base equiv)
coated pellets cap
(Celexa)
60 mg (Cymbalta)
$0 (1)
citalopram hydrobromide
escitalopram oxalate soln
tab 40 mg (base equiv)
5 mg/5ml (base equiv)
(Celexa)
(Lexapro)
$0 (1)
clomipramine hcl cap
escitalopram oxalate
25 mg (Anafranil)
tab 5 mg (base equiv)
$0 (1)
clomipramine hcl cap
(Lexapro)
50 mg (Anafranil)
escitalopram oxalate tab
$0 (1)
clomipramine hcl cap
10 mg (base equiv)
75 mg (Anafranil)
(Lexapro)
$0 (1)
desipramine hcl tab
escitalopram oxalate tab
10 mg (Norpramin)
20 mg (base equiv)
$0 (1)
desipramine hcl tab
(Lexapro)
25 mg (Norpramin)
fluoxetine hcl cap 10 mg
$0 (1)
desipramine hcl tab
(Prozac)
50 mg (Norpramin)
fluoxetine hcl cap 20 mg
$0 (1)
desipramine hcl tab
(Prozac)
75 mg (Norpramin)
fluoxetine hcl cap 40 mg
$0 (1)
desipramine hcl tab
(Prozac)
100 mg (Norpramin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
44
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
fluoxetine hcl solution
20 mg/5ml
fluoxetine hcl tab 10 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
mirtazapine tab 45 mg
(Remeron)
$0 (1)
nefazodone hcl tab 50 mg
fluoxetine hcl tab 20 mg
$0 (1)
fluvoxamine maleate tab
25 mg
fluvoxamine maleate tab
50 mg
fluvoxamine maleate tab
100 mg
imipramine hcl tab 10 mg
(Tofranil)
imipramine hcl tab 25 mg
(Tofranil)
imipramine hcl tab 50 mg
(Tofranil)
imipramine pamoate cap
75 mg
imipramine pamoate cap
100 mg
imipramine pamoate cap
125 mg
imipramine pamoate cap
150 mg
mirtazapine orally
disintegrating tab 15 mg
(Remeron soltab)
mirtazapine orally
disintegrating tab 30 mg
(Remeron soltab)
mirtazapine orally
disintegrating tab 45 mg
(Remeron soltab)
mirtazapine tab 7.5 mg
$0 (1)
mirtazapine tab 15 mg
(Remeron)
mirtazapine tab 30 mg
(Remeron)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
nefazodone hcl tab
250 mg
NORTRIPTYLINE HCL
– nortriptyline hcl soln
10 mg/5ml
nortriptyline hcl cap 10 mg
(Pamelor)
nortriptyline hcl cap 25 mg
(Pamelor)
nortriptyline hcl cap 50 mg
(Pamelor)
nortriptyline hcl cap 75 mg
(Pamelor)
paroxetine hcl tab 10 mg
(Paxil)
paroxetine hcl tab 20 mg
(Paxil)
paroxetine hcl tab 30 mg
(Paxil)
paroxetine hcl tab 40 mg
(Paxil)
phenelzine sulfate tab
15 mg (Nardil)
sertraline hcl oral conc
20 mg/ml (Zoloft)
sertraline hcl tab 25 mg
(Zoloft)
sertraline hcl tab 50 mg
(Zoloft)
sertraline hcl tab 100 mg
(Zoloft)
tranylcypromine sulfate
tab 10 mg (Parnate)
trazodone hcl tab 50 mg
$0 (1)
trazodone hcl tab 100 mg
$0 (1)
trazodone hcl tab 150 mg
$0 (1)
PA
QL
SP
ST
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
45
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
trimipramine maleate cap
aripiprazole tab 15 mg
25 mg (Surmontil)
(Abilify)
$0 (1)
trimipramine maleate cap
aripiprazole tab 15 mg
50 mg (Surmontil)
(Abilify)
$0 (1)
trimipramine maleate cap
aripiprazole tab 20 mg
100 mg (Surmontil)
(Abilify)
$0 (1)
venlafaxine hcl cap sr
aripiprazole tab 20 mg
24hr 37.5 mg (base
(Abilify)
equivalent) (Effexor xr)
aripiprazole tab 30 mg
$0 (1)
venlafaxine hcl cap sr
(Abilify)
24hr 75 mg (base
aripiprazole tab 30 mg
equivalent) (Effexor xr)
(Abilify)
$0 (1)
venlafaxine hcl cap sr
chlorpromazine hcl tab
24hr 150 mg (base
10 mg
equivalent) (Effexor xr)
chlorpromazine hcl tab
$0 (1)
venlafaxine hcl tab 25 mg
25 mg
$0 (1)
venlafaxine hcl tab
chlorpromazine hcl tab
37.5 mg
50 mg
$0 (1)
venlafaxine hcl tab 50 mg
chlorpromazine hcl tab
100 mg
$0 (1)
venlafaxine hcl tab 75 mg
chlorpromazine hcl tab
$0 (1)
venlafaxine hcl tab
200 mg
100 mg
clozapine orally
TRASTORNOS PSICÓTICOS Y BIPOLARES
disintegrating tab 25 mg
$0 (1)
QL
aripiprazole oral solution
(Fazaclo)
1 mg/ml
clozapine orally
$0 (1)
aripiprazole oral solution
disintegrating tab
1 mg/ml
100 mg (Fazaclo)
$0 (1)
QL
aripiprazole tab 2 mg
clozapine tab 25 mg
(Abilify)
(Clozaril)
$0 (1)
QL
aripiprazole tab 2 mg
clozapine tab 50 mg
(Abilify)
clozapine tab 100 mg
$0 (1)
QL
aripiprazole tab 5 mg
(Clozaril)
(Abilify)
clozapine tab 200 mg
$0 (1)
QL
aripiprazole tab 5 mg
fluphenazine decanoate
(Abilify)
inj 25 mg/ml
$0 (1)
QL
aripiprazole tab 10 mg
FLUPHENAZINE HCL –
(Abilify)
fluphenazine hcl elixir
$0 (1)
QL
aripiprazole tab 10 mg
2.5 mg/5ml
(Abilify)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
46
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
FLUPHENAZINE HCL –
fluphenazine hcl oral
conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab
2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab
10 mg
haloperidol decanoate im
soln 50 mg/ml (Haldol
decanoate 50)
haloperidol decanoate im
soln 100 mg/ml (Haldol
decanoate 100)
haloperidol lactate oral
conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
LITHIUM – lithium oral
solution 8 meq/5ml
lithium carbonate cap
150 mg (Lithium
carbonate)
lithium carbonate cap
300 mg
lithium carbonate cap
600 mg (Lithium
carbonate)
lithium carbonate tab cr
300 mg (Lithobid)
lithium carbonate tab cr
450 mg
lithium carbonate tab
300 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
loxapine succinate cap
5 mg
loxapine succinate cap
$0 (1)
10 mg
loxapine succinate cap
$0 (1)
25 mg
loxapine succinate cap
$0 (1)
50 mg
$0 (1)
olanzapine for im inj
10 mg (Zyprexa)
$0 (1)
olanzapine orally
disintegrating tab 5 mg
(Zyprexa zydis)
$0 (1)
olanzapine orally
disintegrating tab 10 mg
(Zyprexa zydis)
$0 (1)
olanzapine orally
disintegrating tab 15 mg
$0 (1)
(Zyprexa zydis)
$0 (1)
olanzapine orally
$0 (1)
disintegrating tab 20 mg
$0 (1)
(Zyprexa zydis)
olanzapine tab 2.5 mg
$0 (1)
(Zyprexa)
$0 (1)
olanzapine tab 5 mg
$0 (2)
(Zyprexa)
olanzapine tab 7.5 mg
$0 (1)
(Zyprexa)
olanzapine tab 10 mg
(Zyprexa)
$0 (1)
olanzapine tab 15 mg
(Zyprexa)
$0 (1)
olanzapine tab 20 mg
(Zyprexa)
paliperidone tab sr 24hr
$0 (1)
1.5 mg (Invega)
paliperidone
tab sr 24hr
$0 (1)
3 mg (Invega)
paliperidone
tab sr 24hr
$0 (1)
6 mg (Invega)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
47
2016
Nombre del
medicamento
paliperidone tab sr 24hr
9 mg (Invega)
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
quetiapine fumarate tab
25 mg (Seroquel)
quetiapine fumarate tab
50 mg (Seroquel)
quetiapine fumarate tab
100 mg (Seroquel)
quetiapine fumarate tab
200 mg (Seroquel)
quetiapine fumarate tab
300 mg (Seroquel)
quetiapine fumarate tab
400 mg (Seroquel)
risperidone orally
disintegrating tab
0.25 mg
risperidone orally
disintegrating tab
0.5 mg (Risperdal mtab)
risperidone orally
disintegrating tab 1 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 2 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 3 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 4 mg
(Risperdal m-tab)
risperidone soln 1 mg/ml
(Risperdal)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
risperidone tab 0.25 mg
(Risperdal)
$0 (1)
risperidone tab 0.5 mg
(Risperdal)
$0 (1)
risperidone tab 1 mg
$0 (1)
(Risperdal)
$0 (1)
risperidone tab 2 mg
$0 (1)
QL
(Risperdal)
risperidone tab 3 mg
$0 (1)
QL
(Risperdal)
risperidone tab 4 mg
$0 (1)
QL
(Risperdal)
thioridazine hcl tab 10 mg
$0 (1)
QL
thioridazine hcl tab 25 mg
48
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
QL
thioridazine hcl tab
100 mg
thiothixene cap 1 mg
QL
thiothixene cap 2 mg
$0 (1)
thiothixene cap 5 mg
$0 (1)
thiothixene cap 10 mg
$0 (1)
trifluoperazine hcl tab
1 mg
trifluoperazine hcl tab
2 mg
trifluoperazine hcl tab
5 mg
trifluoperazine hcl tab
10 mg
ziprasidone hcl cap 20 mg
(Geodon)
ziprasidone hcl cap 40 mg
(Geodon)
ziprasidone hcl cap 60 mg
(Geodon)
ziprasidone hcl cap 80 mg
(Geodon)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL
$0 (1)
QL
$0 (1)
$0 (1)
thioridazine hcl tab 50 mg
$0 (1)
$0 (1)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
MEDICAMENTOS PARA EL SUEÑO
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
sr 24hr 5 mg (Adderall
$0 (1)
estazolam tab 1 mg
xr)
$0 (1)
estazolam tab 2 mg
amphetamine$0 (1)
QL
eszopiclone tab 1 mg
dextroamphetamine cap
(Lunesta)
sr 24hr 10 mg (Adderall
$0 (1)
QL
eszopiclone tab 2 mg
xr)
(Lunesta)
amphetamine$0 (1)
QL
eszopiclone tab 3 mg
dextroamphetamine cap
(Lunesta)
sr 24hr 15 mg (Adderall
PHENOBARBITAL –
$0 (2)
xr)
phenobarbital tab 15 mg
amphetaminePHENOBARBITAL –
$0 (2)
dextroamphetamine cap
phenobarbital tab 30 mg
sr 24hr 20 mg (Adderall
PHENOBARBITAL –
$0 (2)
xr)
phenobarbital tab 60 mg
amphetaminePHENOBARBITAL –
$0 (2)
dextroamphetamine cap
phenobarbital tab
sr 24hr 25 mg (Adderall
100 mg
xr)
$0 (1)
phenobarbital elixir
amphetamine20 mg/5ml
dextroamphetamine cap
sr 24hr 30 mg (Adderall
$0 (1)
phenobarbital tab 16.2 mg
xr)
$0 (1)
phenobarbital tab 32.4 mg
amphetamine$0 (1)
phenobarbital tab 64.8 mg
dextroamphetamine tab
$0 (1)
phenobarbital tab 97.2 mg
5 mg (Adderall)
$0 (1)
temazepam cap 15 mg
amphetamine(Restoril)
dextroamphetamine tab
$0 (1)
temazepam cap 30 mg
7.5 mg (Adderall)
(Restoril)
amphetamine$0 (1)
QL
zaleplon cap 5 mg
dextroamphetamine tab
(Sonata)
10 mg (Adderall)
$0 (1)
QL
zaleplon cap 10 mg
amphetamine(Sonata)
dextroamphetamine tab
12.5 mg (Adderall)
$0 (1)
QL
zolpidem tartrate tab 5 mg
(Ambien)
amphetaminedextroamphetamine tab
$0 (1)
QL
zolpidem tartrate tab
15 mg (Adderall)
10 mg (Ambien)
amphetamineHIPERACTIVIDAD/NARCOLEPSIA
dextroamphetamine tab
$0 (1)
QL
amphetamine20 mg (Adderall)
dextroamphetamine cap
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
49
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
QL
amphetaminedextroamphetamine
dextroamphetamine tab
sulfate cap sr 24hr 5 mg
30 mg (Adderall)
(Dexedrine)
$0 (1)
PA, QL
armodafinil tab 50 mg
dextroamphetamine
(Nuvigil)
sulfate cap sr 24hr
10 mg (Dexedrine)
$0 (1)
PA, QL
armodafinil tab 150 mg
dextroamphetamine
(Nuvigil)
sulfate cap sr 24hr
$0 (1)
PA, QL
armodafinil tab 200 mg
15 mg (Dexedrine)
(Nuvigil)
dextroamphetamine
$0 (1)
PA, QL
armodafinil tab 250 mg
sulfate oral solution
(Nuvigil)
5 mg/5ml (Procentra)
$0 (1)
caffeine citrate oral soln
dextroamphetamine
60 mg/3ml (10 mg/ml
sulfate tab 5 mg
base equiv) (Cafcit)
dextroamphetamine
$0 (1)
QL
clonidine hcl tab sr 12hr
sulfate tab 10 mg
0.1 mg (Kapvay)
guanfacine
hcl tab sr
$0 (1)
QL
dexmethylphenidate
24hr 1 mg (base equiv)
hcl cap sr 24 hr 5 mg
(Intuniv)
(Focalin xr)
guanfacine hcl tab sr
$0 (1)
QL
dexmethylphenidate hcl
24hr 2 mg (base equiv)
cap sr 24 hr 10 mg
(Intuniv)
(Focalin xr)
guanfacine hcl tab sr
$0 (1)
QL
dexmethylphenidate hcl
24hr 3 mg (base equiv)
cap sr 24 hr 15 mg
(Intuniv)
(Focalin xr)
guanfacine hcl tab sr
$0 (1)
QL
dexmethylphenidate hcl
24hr 4 mg (base equiv)
cap sr 24 hr 20 mg
(Intuniv)
(Focalin xr)
methamphetamine hcl tab
$0 (1)
QL
dexmethylphenidate hcl
5 mg (Desoxyn)
cap sr 24 hr 30 mg
(Focalin xr)
methylphenidate hcl cap
cr 10 mg (cd) (Metadate
$0 (1)
QL
dexmethylphenidate hcl
cd)
cap sr 24 hr 40 mg
(Focalin xr)
methylphenidate hcl cap
cr 20 mg (cd) (Metadate
$0 (1)
QL
dexmethylphenidate hcl
cd)
tab 2.5 mg (Focalin)
methylphenidate hcl cap
$0 (1)
QL
dexmethylphenidate hcl
cr 30 mg (cd) (Metadate
tab 5 mg (Focalin)
cd)
$0 (1)
QL
dexmethylphenidate hcl
tab 10 mg (Focalin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
50
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
methylphenidate hcl cap
cr 40 mg (cd) (Metadate
cd)
methylphenidate hcl cap
cr 50 mg (cd) (Metadate
cd)
methylphenidate hcl cap
cr 60 mg (cd) (Metadate
cd)
methylphenidate hcl
cap sr 24hr 20 mg (la)
(Ritalin la)
methylphenidate hcl
cap sr 24hr 30 mg (la)
(Ritalin la)
methylphenidate hcl
cap sr 24hr 40 mg (la)
(Ritalin la)
methylphenidate hcl chew
tab 2.5 mg (Methylin)
methylphenidate hcl chew
tab 5 mg (Methylin)
methylphenidate hcl chew
tab 10 mg (Methylin)
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 18 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 27 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 36 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 54 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sr 24hr 18 mg
$0 (1)
QL
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
$0 (1)
QL
sr 24hr 27 mg
METHYLPHENIDATE
HCL ER –
$0 (1)
QL
methylphenidate hcl tab
sr 24hr 36 mg
METHYLPHENIDATE
$0 (1)
QL
HCL ER –
methylphenidate hcl tab
sr 24hr 54 mg
$0 (1)
QL
methylphenidate hcl soln
5 mg/5ml (Methylin)
methylphenidate
hcl soln
$0 (1)
QL
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
$0 (1)
QL
10 mg
methylphenidate hcl tab cr
$0 (1)
QL
20 mg (Ritalin sr)
methylphenidate hcl tab
$0 (2)
QL
5 mg (Ritalin)
methylphenidate hcl tab
10 mg (Ritalin)
$0 (2)
QL
methylphenidate hcl tab
20 mg (Ritalin)
modafinil tab 100 mg
(Provigil)
$0 (2)
QL
modafinil tab 200 mg
(Provigil)
STRATTERA –
atomoxetine hcl cap
$0 (2)
QL
10 mg (base equiv)
STRATTERA –
atomoxetine hcl cap
18 mg (base equiv)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
51
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
STRATTERA –
$0 (2)
PA, QL
BETASERON – interferon
atomoxetine hcl cap
beta-1b for inj kit 0.3 mg
25 mg (base equiv)
COPAXONE – glatiramer
acetate soln prefilled
STRATTERA –
$0 (2)
PA, QL
atomoxetine hcl cap
syringe 20 mg/ml
40 mg (base equiv)
COPAXONE – glatiramer
acetate soln prefilled
STRATTERA –
$0 (2)
PA, QL
atomoxetine hcl cap
syringe 40 mg/ml
60 mg (base equiv)
glatiramer acetate soln
STRATTERA –
$0 (2)
PA, QL
prefilled syringe 20 mg/
atomoxetine hcl cap
ml (Copaxone)
80 mg (base equiv)
REBIF – interferon
beta-1a soln pref syr
STRATTERA –
$0 (2)
PA, QL
atomoxetine hcl cap
22 mcg/0.5ml (12mu/ml)
100 mg (base equiv)
REBIF – interferon
beta-1a soln pref syr
VYVANSE –
$0 (2)
QL
lisdexamfetamine
44 mcg/0.5ml (24mu/ml)
dimesylate cap 10 mg
REBIF REBIDOSE –
interferon beta-1a soln
VYVANSE –
$0 (2)
QL
lisdexamfetamine
auto-inj 22 mcg/0.5ml
dimesylate cap 20 mg
(12mu/ml)
VYVANSE –
$0 (2)
QL
REBIF REBIDOSE –
lisdexamfetamine
interferon beta-1a soln
dimesylate cap 30 mg
auto-inj 44 mcg/0.5ml
(24mu/ml)
VYVANSE –
$0 (2)
QL
lisdexamfetamine
REBIF REBIDOSE
TITRATION – interferon
dimesylate cap 40 mg
beta-1a auto-inj
VYVANSE –
$0 (2)
QL
6x8.8 mcg/0.2ml &
lisdexamfetamine
6x22 mcg/0.5ml
dimesylate cap 50 mg
REBIF TITRATION PACK
VYVANSE –
$0 (2)
QL
– interferon beta-1a pref
lisdexamfetamine
syr 6x8.8 mcg/0.2ml &
dimesylate cap 60 mg
6x22 mcg/0.5ml
VYVANSE –
$0 (2)
QL
TECFIDERA – dimethyl
lisdexamfetamine
fumarate capsule
dimesylate cap 70 mg
delayed release 120 mg
ESCLEROSIS MÚLTIPLE
TECFIDERA – dimethyl
AMPYRA – dalfampridine
$0 (2)
PA, QL, SP
fumarate capsule
tab sr 12hr 10 mg
delayed release 240 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
52
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (1)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
$0 (2)
QL, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
TECFIDERA STARTER
$0 (2)
QL, SP
donepezil hydrochloride
PACK – dimethyl
tab 10 mg (Aricept)
fumarate capsule dr
GALANTAMINE
starter pack 120 mg &
HYDROBROMIDE
240 mg
– galantamine
hydrobromide oral soln
OTROS MEDICAMENTOS DEL SISTEMA
4 mg/ml
NERVIOSO CENTRAL
memantine hcl oral
$0 (1)
acamprosate calcium tab
solution 2 mg/ml
delayed release 333 mg
(Namenda)
(Campral)
memantine hcl tab 5 mg
$0 (1)
QL
bupropion hcl (smoking
(Namenda)
deterrent) tab sr 12hr
memantine hcl tab 10 mg
150 mg (Zyban)
(Namenda)
CHANTIX – varenicline
$0 (2)
QL
memantine hcl tab 5 mg
tartrate tab 0.5 mg
(28) & 10 mg (21)
(base equiv)
titration pak (Namenda
CHANTIX – varenicline
$0 (2)
QL
titration pak)
tartrate tab 1 mg (base
naltrexone hcl tab 50 mg
equiv)
(Revia)
CHANTIX CONTINUING
$0 (2)
QL
nicotine polacrilex gum
MONTH – varenicline
2 mg
tartrate tab 1 mg (base
equiv)
nicotine polacrilex gum
4 mg
CHANTIX STARTING
$0 (2)
QL
MONTH PA –
nicotine td patch 24hr
varenicline tartrate tab
7 mg/24hr
0.5 mg x 11 & tab 1 mg
nicotine td patch 24hr
x 42 pack
14 mg/24hr
$0 (1)
disulfiram tab 250 mg
nicotine td patch 24hr
(Antabuse)
21 mg/24hr
$0 (1)
disulfiram tab 500 mg
NUEDEXTA –
(Antabuse)
dextromethorphan hbr$0 (1)
donepezil hydrochloride
quinidine sulfate cap
orally disintegrating tab
20-10 mg
5 mg
pimozide tab 1 mg (Orap)
$0 (1)
donepezil hydrochloride
pimozide tab 2 mg (Orap)
orally disintegrating tab
rivastigmine tartrate cap
10 mg (Aricept odt)
1.5 mg (Exelon)
$0 (1)
donepezil hydrochloride
rivastigmine tartrate cap
tab 5 mg (Aricept)
3 mg (Exelon)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
QL
$0 (3)
QL
$0 (3)
QL
$0 (3)
QL
$0 (3)
QL
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
53
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
rivastigmine tartrate cap
acetaminophen tab
4.5 mg (Exelon)
325 mg
$0 (1)
rivastigmine tartrate cap
acetaminophen tab
6 mg (Exelon)
500 mg
$0 (1)
rivastigmine td patch 24hr
aspirin chew tab 81 mg
4.6 mg/24hr (Exelon)
aspirin tab delayed
$0 (1)
rivastigmine td patch 24hr
release 81 mg
9.5 mg/24hr (Exelon)
aspirin tab delayed
$0 (1)
rivastigmine td patch 24hr
release 325 mg
13.3 mg/24hr (Exelon)
aspirin tab 325 mg
$0 (1)
QL, SP
tetrabenazine tab 12.5 mg
butalbital-acetaminophen
(Xenazine)
tab 50-325 mg
$0 (1)
QL, SP
tetrabenazine tab 25 mg
butalbital-acetaminophen(Xenazine)
caffeine cap
XYREM – sodium oxybate
$0 (2)
PA, QL, SP
50-300-40 mg (Fioricet)
oral solution 500 mg/ml
butalbital-acetaminophenMEDICAMENTOS PARA ALIVIAR EL DOLOR
MEDICAMENTOS NO ESTUPEFACIENTES
$0 (3)
acetaminophen cap
500 mg
$0 (3)
acetaminophen chew tab
80 mg
$0 (3)
acetaminophen chew tab
160 mg
$0 (3)
acetaminophen
dispersible tab 80 mg
$0 (3)
acetaminophen liquid
160 mg/5ml
$0 (3)
acetaminophen soln
100 mg/ml
$0 (3)
acetaminophen soln
160 mg/5ml
$0 (3)
acetaminophen suppos
120 mg
$0 (3)
acetaminophen susp
80 mg/0.8ml
$0 (3)
acetaminophen susp
160 mg/5ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
54
caffeine cap
50-325-40 mg
butalbital-acetaminophencaffeine tab
50-325-40 mg (Esgic)
butalbital-aspirin-caffeine
cap 50-325-40 mg
(Fiorinal)
diflunisal tab 500 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
salsalate tab 500 mg
$0 (1)
salsalate tab 750 mg
$0 (1)
MEDICAMENTOS ESTUPEFACIENTES
$0 (1)
acetaminophen
w/ codeine soln
120-12 mg/5ml
$0 (1)
acetaminophen w/
codeine tab 300-15 mg
(Tylenol/codeine)
$0 (1)
acetaminophen w/
codeine tab 300-30 mg
(Tylenol/codeine #3)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
acetaminophen w/
codeine sulfate tab 15 mg
codeine tab 300-60 mg
(Codeine sulfate)
(Tylenol/codeine #4)
codeine sulfate tab 30 mg
$0 (1)
acetaminophen-caffeinecodeine sulfate tab 60 mg
dihydrocodeine cap
fentanyl citrate lozenge
320.5-30-16 mg (Trezix)
on a handle 200 mcg
BUNAVAIL –
$0 (2)
QL
(Actiq)
buprenorphine-naloxone
fentanyl citrate lozenge
buccal film 2.1-0.3 mg
on a handle 400 mcg
(base equiv)
(Actiq)
BUNAVAIL –
$0 (2)
QL
fentanyl citrate lozenge
buprenorphine-naloxone
on a handle 600 mcg
buccal film 4.2-0.7 mg
(Actiq)
(base equiv)
fentanyl citrate lozenge
BUNAVAIL –
$0 (2)
QL
on a handle 800 mcg
buprenorphine-naloxone
(Actiq)
buccal film 6.3-1 mg
fentanyl citrate lozenge
(base equiv)
on a handle 1200 mcg
$0 (1)
QL
buprenorphine hcl sl tab
(Actiq)
2 mg (base equiv)
fentanyl citrate lozenge
$0 (1)
QL
buprenorphine hcl sl tab
on a handle 1600 mcg
8 mg (base equiv)
(Actiq)
$0 (1)
QL
buprenorphine hclfentanyl td patch 72hr
naloxone hcl sl tab
12 mcg/hr (Duragesic)
2-0.5 mg (base equiv)
fentanyl td patch 72hr
$0 (1)
QL
buprenorphine hcl25 mcg/hr (Duragesic)
naloxone hcl sl tab
fentanyl td patch 72hr
8-2 mg (base equiv)
50 mcg/hr (Duragesic)
$0 (1)
butalbital-acetaminophenfentanyl td patch 72hr
caff w/ cod cap
75 mcg/hr (Duragesic)
50-300-40-30 mg
fentanyl td patch 72hr
(Fioricet/codeine)
100 mcg/hr (Duragesic)
$0 (1)
butalbital-acetaminophenhydrocodonecaff w/ cod cap
acetaminophen soln
50-325-40-30 mg
7.5-325 mg/15ml
$0 (1)
butalbital-aspirin(Hycet)
caff w/ codeine cap
hydrocodone50-325-40-30 mg
acetaminophen soln
(Fiorinal/codeine #3)
10-325 mg/15ml
$0 (1)
QL
butorphanol tartrate nasal
(Zamicet)
soln 10 mg/ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
55
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
hydrocodonemethadone hcl soln
acetaminophen tab
10 mg/5ml (Methadone
2.5-325 mg
hcl)
$0 (1)
hydrocodonemethadone hcl tab for oral
acetaminophen tab
susp 40 mg
10-325 mg (Norco)
methadone hcl tab 5 mg
$0 (1)
hydrocodone(Dolophine hcl)
acetaminophen tab
methadone hcl tab 10 mg
5-325 mg (Norco)
(Dolophine)
$0 (1)
hydrocodoneMORPHINE SULFATE
acetaminophen tab
– morphine sulfate tab
7.5-325 mg (Norco)
15 mg
$0 (1)
hydrocodoneMORPHINE SULFATE
acetaminophen tab
– morphine sulfate tab
10-300 mg (Xodol)
30 mg
$0 (1)
hydrocodone-ibuprofen
MORPHINE SULFATE –
tab 5-200 mg
morphine sulfate suppos
(Reprexain)
5 mg
$0 (1)
hydrocodone-ibuprofen
MORPHINE SULFATE –
tab 7.5-200 mg
morphine sulfate suppos
(Vicoprofen)
10 mg
$0 (1)
hydromorphone hcl liqd
MORPHINE SULFATE –
1 mg/ml (Dilaudid)
morphine sulfate suppos
$0 (1)
20 mg
hydromorphone hcl tab
2 mg (Dilaudid)
MORPHINE SULFATE –
morphine sulfate suppos
$0 (1)
hydromorphone hcl tab
30 mg
4 mg (Dilaudid)
$0 (1)
hydromorphone hcl tab
morphine sulfate cap sr
8 mg (Dilaudid)
24hr 10 mg (Kadian)
$0 (1)
meperidine hcl tab 50 mg
morphine sulfate cap sr
(Demerol)
24hr 20 mg (Kadian)
$0 (1)
meperidine hcl tab
morphine sulfate cap sr
100 mg (Demerol)
24hr 30 mg (Kadian)
$0 (1)
methadone hcl conc
morphine sulfate cap sr
10 mg/ml (Methadose)
24hr 50 mg (Kadian)
$0 (1)
methadone hcl soln
morphine sulfate cap sr
5 mg/5ml (Methadone
24hr 60 mg (Kadian)
hcl)
morphine sulfate cap sr
24hr 80 mg (Kadian)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
56
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
morphine sulfate cap sr
24hr 100 mg (Kadian)
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
30 mg
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
45 mg
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
60 mg
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
75 mg
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
90 mg
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
120 mg
morphine sulfate oral soln
10 mg/5ml
morphine sulfate oral soln
20 mg/5ml
morphine sulfate oral soln
100 mg/5ml (20 mg/ml)
morphine sulfate tab cr
15 mg (Ms contin)
morphine sulfate tab cr
30 mg (Ms contin)
morphine sulfate tab cr
60 mg (Ms contin)
morphine sulfate tab cr
100 mg (Ms contin)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
morphine sulfate tab cr
200 mg (Ms contin)
$0 (2)
QL
OXYCODONE HCL
$0 (2)
$0 (2)
QL
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (2)
oxycodone hcl soln
5 mg/5ml (Oxycodone
hcl)
oxycodone hcl tab 5 mg
(Roxicodone)
oxycodone hcl tab 10 mg
$0 (1)
oxycodone hcl tab 15 mg
(Roxicodone)
oxycodone hcl tab 20 mg
$0 (1)
oxycodone hcl tab 30 mg
(Roxicodone)
oxycodone w/
acetaminophen soln
5-325 mg/5ml (Roxicet)
oxycodone w/
acetaminophen tab
2.5-325 mg (Percocet)
oxycodone w/
acetaminophen tab
5-325 mg (Percocet)
oxycodone w/
acetaminophen tab
7.5-325 mg (Percocet)
oxycodone w/
acetaminophen tab
10-325 mg (Percocet)
oxycodone-aspirin
tab 4.8355-325 mg
(Percodan)
oxycodone-ibuprofen tab
5-400 mg
oxymorphone hcl tab sr
12hr 5 mg
oxymorphone hcl tab sr
12hr 7.5 mg
oxymorphone hcl tab sr
12hr 10 mg
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
57
2016
Nombre del
medicamento
oxymorphone hcl tab sr
12hr 15 mg
oxymorphone hcl tab sr
12hr 20 mg
oxymorphone hcl tab sr
12hr 30 mg
oxymorphone hcl tab sr
12hr 40 mg
oxymorphone hcl tab
5 mg (Opana)
oxymorphone hcl tab
10 mg (Opana)
SUBOXONE –
buprenorphine hclnaloxone hcl sl film
2-0.5 mg (base equiv)
SUBOXONE –
buprenorphine hclnaloxone hcl sl film
4-1 mg (base equiv)
SUBOXONE –
buprenorphine hclnaloxone hcl sl film
8-2 mg (base equiv)
SUBOXONE –
buprenorphine hclnaloxone hcl sl film
12-3 mg (base equiv)
tramadol hcl tab 50 mg
(Ultram)
tramadol-acetaminophen
tab 37.5-325 mg
(Ultracet)
ZUBSOLV –
buprenorphine hclnaloxone hcl sl tab
1.4-0.36 mg (base eq)
ZUBSOLV –
buprenorphine hclnaloxone hcl sl tab
2.9-0.71 mg (base eq)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
ZUBSOLV –
buprenorphine hclnaloxone hcl sl tab
$0 (1)
QL
5.7-1.4 mg (base eq)
ZUBSOLV –
$0 (1)
QL
buprenorphine hclnaloxone hcl sl tab
$0 (1)
QL
8.6-2.1 mg (base eq)
ZUBSOLV –
$0 (1)
buprenorphine hclnaloxone hcl sl tab
$0 (1)
11.4-2.9 mg (base eq)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
$0 (2)
QL
$0 (2)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
58
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
ARTRITIS REUMATOIDEA Y OSTEOARTRITIS
$0 (1)
QL, ST
celecoxib cap 50 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 100 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 200 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 400 mg
(Celebrex)
$0 (1)
diclofenac potassium tab
50 mg (Cataflam)
$0 (1)
diclofenac sod dr tab
75 mg & capsaicin
cr 0.025% ther pack
(Derma silkrx diclopa)
$0 (1)
diclofenac sodium tab
delayed release 25 mg
$0 (1)
diclofenac sodium tab
delayed release 50 mg
$0 (1)
diclofenac sodium tab
delayed release 75 mg
$0 (1)
diclofenac sodium tab sr
24hr 100 mg (Voltarenxr)
ENBREL – etanercept
$0 (2)
QL, SP, ST
subcutaneous soln
prefilled syringe
25 mg/0.5ml
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
– adalimumab penENBREL – etanercept
$0 (2)
QL, SP, ST
injector kit 40 mg/0.8ml
subcutaneous soln
prefilled syringe 50 mg/
ibuprofen cap 200 mg
ml
ibuprofen susp
ENBREL SURECLICK
$0 (2)
QL, SP, ST
100 mg/5ml
– etanercept
ibuprofen susp
subcutaneous solution
100 mg/5ml
auto-injector 50 mg/ml
ibuprofen tab 200 mg
$0 (1)
etodolac cap 200 mg
ibuprofen tab 400 mg
$0 (1)
etodolac cap 300 mg
ibuprofen tab 600 mg
$0 (1)
etodolac tab sr 24hr
ibuprofen tab 800 mg
400 mg
indomethacin cap cr
$0 (1)
etodolac tab sr 24hr
75 mg
600 mg
indomethacin
cap 25 mg
$0 (1)
etodolac tab 400 mg
indomethacin cap 50 mg
$0 (1)
etodolac tab 500 mg
flurbiprofen tab 50 mg
$0 (1)
flurbiprofen tab 100 mg
$0 (1)
HUMIRA – adalimumab
prefilled syringe kit
10 mg/0.2ml
HUMIRA – adalimumab
prefilled syringe kit
20 mg/0.4ml
HUMIRA – adalimumab
prefilled syringe kit
40 mg/0.8ml
HUMIRA PEDIATRIC
CROHNS D –
adalimumab prefilled
syringe kit 40 mg/0.8ml
HUMIRA PEN –
adalimumab peninjector kit 40 mg/0.8ml
HUMIRA PEN-CROHNS
DISEASE – adalimumab
pen-injector kit
40 mg/0.8ml
HUMIRA PENPSORIASIS STAR
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (2)
$0 (2)
QL, SP, ST
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL, SP, ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
ketoprofen cap 50 mg
$0 (1)
ketoprofen cap 75 mg
$0 (1)
KETOROLAC
TROMETHAMINE –
ketorolac tromethamine
inj 60 mg/2ml (30 mg/
ml)
ketorolac tromethamine
im inj 60 mg/2ml
(30 mg/ml)
ketorolac tromethamine
tab 10 mg
leflunomide tab 10 mg
(Arava)
leflunomide tab 20 mg
(Arava)
meloxicam tab 7.5 mg
(Mobic)
meloxicam tab 15 mg
(Mobic)
nabumetone tab 500 mg
$0 (2)
nabumetone tab 750 mg
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
59
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
IMITREX – sumatriptan
naproxen sodium tab
nasal spray 5 mg/act
sr 24hr 375 mg (base
equiv) (Naprelan)
IMITREX – sumatriptan
nasal spray 20 mg/act
$0 (1)
naproxen sodium tab
sr 24hr 500 mg (base
naratriptan hcl tab 1 mg
equiv) (Naprelan)
(base equiv) (Amerge)
$0 (3)
naproxen sodium tab
naratriptan hcl tab 2.5 mg
220 mg
(base equiv) (Amerge)
$0 (1)
naproxen sodium tab
rizatriptan benzoate oral
275 mg (Anaprox)
disintegrating tab 5 mg
$0 (1)
(base eq) (Maxalt-mlt)
naproxen sodium tab
550 mg (Anaprox ds)
rizatriptan benzoate oral
$0 (1)
naproxen susp
disintegrating tab 10 mg
(base eq) (Maxalt-mlt)
125 mg/5ml (Naprosyn)
$0 (1)
naproxen tab ec 375 mg
rizatriptan benzoate tab
(Ec-naprosyn)
5 mg (base equivalent)
(Maxalt)
$0 (1)
naproxen tab ec 500 mg
rizatriptan benzoate tab
(Ec-naprosyn)
10 mg (base equivalent)
$0 (1)
naproxen tab 250 mg
(Maxalt)
(Naprosyn)
SUMATRIPTAN
$0 (1)
naproxen tab 375 mg
SUCCINATE –
(Naprosyn)
sumatriptan succinate
$0 (1)
naproxen tab 500 mg
solution prefilled syringe
(Naprosyn)
6 mg/0.5ml
$0 (1)
piroxicam cap 10 mg
sumatriptan succinate inj
(Feldene)
6 mg/0.5ml (Imitrex)
$0 (1)
piroxicam cap 20 mg
sumatriptan succinate
(Feldene)
solution auto-injector
$0 (1)
sulindac tab 150 mg
4 mg/0.5ml (Imitrex
$0 (1)
sulindac tab 200 mg
statdose sys)
sumatriptan succinate
MIGRAÑAS
solution auto-injector
$0 (1)
QL
almotriptan malate tab
6 mg/0.5ml (Imitrex
6.25 mg (Axert)
statdose sys)
$0 (1)
QL
almotriptan malate tab
sumatriptan succinate
12.5 mg (Axert)
solution cartridge
$0 (1)
QL
frovatriptan succinate
4 mg/0.5ml (Imitrex
tab 2.5 mg (base
statdose ref)
equivalent) (Frova)
sumatriptan succinate
solution cartridge
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
60
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
6 mg/0.5ml (Imitrex
clonazepam orally
statdose ref)
disintegrating tab
0.125 mg
$0 (1)
QL
sumatriptan succinate tab
25 mg (Imitrex)
clonazepam orally
disintegrating tab
$0 (1)
QL
sumatriptan succinate tab
0.25 mg
50 mg (Imitrex)
clonazepam
orally
$0 (1)
QL
sumatriptan succinate tab
disintegrating tab
100 mg (Imitrex)
0.5 mg
GOTA
clonazepam orally
$0 (1)
allopurinol tab 100 mg
disintegrating tab 1 mg
(Zyloprim)
clonazepam orally
$0 (1)
allopurinol tab 300 mg
disintegrating tab 2 mg
(Zyloprim)
clonazepam tab 0.5 mg
$0 (1)
colchicine w/ probenecid
(Klonopin)
tab 0.5-500 mg
clonazepam tab 1 mg
$0 (1)
probenecid tab 500 mg
(Klonopin)
MEDICAMENTOS NEUROMUSCULARES
clonazepam tab 2 mg
CONVULSIONES
(Klonopin)
$0 (1)
carbamazepine cap sr
DIASTAT ACUDIAL –
12hr 100 mg (Carbatrol)
diazepam rectal gel
delivery system 10 mg
$0 (1)
carbamazepine cap sr
12hr 200 mg (Carbatrol)
DIASTAT ACUDIAL –
diazepam rectal gel
$0 (1)
carbamazepine cap sr
delivery system 20 mg
12hr 300 mg (Carbatrol)
DIASTAT PEDIATRIC
$0 (1)
carbamazepine chew tab
– diazepam rectal gel
100 mg
delivery system 2.5 mg
$0 (1)
carbamazepine susp
DIAZEPAM
– diazepam
100 mg/5ml (Tegretol)
rectal gel delivery
$0 (1)
carbamazepine tab sr
system 2.5 mg
12hr 100 mg (TegretolDIAZEPAM – diazepam
xr)
rectal gel delivery
$0 (1)
carbamazepine tab sr
system 10 mg
12hr 200 mg (TegretolDIAZEPAM – diazepam
xr)
rectal gel delivery
$0 (1)
carbamazepine tab sr
system 20 mg
12hr 400 mg (TegretolDILANTIN – phenytoin
xr)
sodium extended cap
$0 (1)
carbamazepine tab
30 mg
200 mg (Tegretol)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
61
2016
Nombre del
medicamento
divalproex sodium tab
delayed release 125 mg
(Depakote)
divalproex sodium tab
delayed release 250 mg
(Depakote)
divalproex sodium tab
delayed release 500 mg
(Depakote)
divalproex sodium tab sr
24 hr 250 mg (Depakote
er)
divalproex sodium tab sr
24 hr 500 mg (Depakote
er)
ethosuximide cap 250 mg
(Zarontin)
ethosuximide soln
250 mg/5ml (Zarontin)
felbamate susp
600 mg/5ml (Felbatol)
felbamate tab 400 mg
(Felbatol)
felbamate tab 600 mg
(Felbatol)
gabapentin cap 100 mg
(Neurontin)
gabapentin cap 300 mg
(Neurontin)
gabapentin cap 400 mg
(Neurontin)
gabapentin oral soln
250 mg/5ml (Neurontin)
gabapentin tab 600 mg
(Neurontin)
gabapentin tab 800 mg
(Neurontin)
lamotrigine orally
disintegrating tab 25 mg
(Lamictal odt)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
lamotrigine orally
disintegrating tab 50 mg
(Lamictal odt)
$0 (1)
lamotrigine orally
disintegrating tab
100 mg (Lamictal odt)
$0 (1)
lamotrigine orally
disintegrating tab
200 mg (Lamictal odt)
$0 (1)
lamotrigine tab chewable
dispersible 5 mg
(Lamictal chewable di)
$0 (1)
lamotrigine tab chewable
dispersible 25 mg
(Lamictal chewable di)
$0 (1)
lamotrigine tab disp
25 mg (21) & 50 mg (7)
titration kit (Lamictal odt)
$0 (1)
lamotrigine tab disp
50 mg (42) & 100 mg
$0 (1)
(14) titration kit
(Lamictal odt)
$0 (1)
lamotrigine tab disp 25
(14) & 50 mg (14) &
$0 (1)
100 mg (7) kit (Lamictal
odt)
$0 (1)
lamotrigine tab sr 24hr
25 mg (Lamictal xr)
$0 (1)
lamotrigine tab sr 24hr
50 mg (Lamictal xr)
$0 (1)
lamotrigine tab sr 24hr
100 mg (Lamictal xr)
$0 (1)
lamotrigine tab sr 24hr
200 mg (Lamictal xr)
$0 (1)
lamotrigine tab sr 24hr
250 mg (Lamictal xr)
$0 (1)
lamotrigine tab sr 24hr
300 mg (Lamictal xr)
$0 (1)
lamotrigine tab 25 mg
(Lamictal)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
62
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
lamotrigine tab 100 mg
(Lamictal)
lamotrigine tab 150 mg
(Lamictal)
lamotrigine tab 200 mg
(Lamictal)
levetiracetam oral soln
100 mg/ml (Keppra)
levetiracetam tab sr 24hr
500 mg (Keppra xr)
levetiracetam tab sr 24hr
750 mg (Keppra xr)
levetiracetam tab 250 mg
(Keppra)
levetiracetam tab 500 mg
(Keppra)
levetiracetam tab 750 mg
(Keppra)
levetiracetam tab
1000 mg (Keppra)
LYRICA – pregabalin soln
20 mg/ml
LYRICA – pregabalin cap
25 mg
LYRICA – pregabalin cap
50 mg
LYRICA – pregabalin cap
75 mg
LYRICA – pregabalin cap
100 mg
LYRICA – pregabalin cap
150 mg
LYRICA – pregabalin cap
200 mg
LYRICA – pregabalin cap
225 mg
LYRICA – pregabalin cap
300 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
oxcarbazepine susp
300 mg/5ml (60 mg/ml)
(Trileptal)
$0 (1)
oxcarbazepine tab
150 mg (Trileptal)
$0 (1)
oxcarbazepine tab
300 mg (Trileptal)
$0 (1)
oxcarbazepine tab
600 mg (Trileptal)
$0 (1)
phenytoin chew tab 50 mg
(Dilantin infatabs)
$0 (1)
phenytoin sodium
extended cap 100 mg
$0 (1)
(Dilantin)
phenytoin sodium
$0 (1)
extended cap 200 mg
(Phenytek)
$0 (1)
phenytoin sodium
extended cap 300 mg
$0 (1)
(Phenytek)
phenytoin susp
$0 (2)
QL
125 mg/5ml (Dilantin)
primidone tab 50 mg
$0 (2)
QL
(Mysoline)
primidone tab 250 mg
$0 (2)
QL
(Mysoline)
TEGRETOL-XR –
$0 (2)
QL
carbamazepine tab sr
12hr 100 mg
$0 (2)
QL
tiagabine hcl tab 2 mg
(Gabitril)
$0 (2)
QL
tiagabine hcl tab 4 mg
(Gabitril)
$0 (2)
QL
topiramate sprinkle
cap 15 mg (Topamax
$0 (2)
QL
sprinkle)
topiramate sprinkle
$0 (2)
QL
cap 25 mg (Topamax
sprinkle)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
63
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
topiramate tab 25 mg
carbidopa & levodopa
(Topamax)
orally disintegrating tab
10-100 mg
$0 (1)
topiramate tab 50 mg
carbidopa & levodopa
(Topamax)
orally disintegrating tab
$0 (1)
topiramate tab 100 mg
25-100 mg
(Topamax)
carbidopa
& levodopa
$0 (1)
topiramate tab 200 mg
orally disintegrating tab
(Topamax)
25-250 mg
$0 (1)
valproate sodium syrup
carbidopa & levodopa tab
250 mg/5ml (base
cr 25-100 mg (Sinemet
equiv) (Depakene)
cr)
$0 (1)
valproic acid cap 250 mg
carbidopa & levodopa tab
(Depakene)
cr 50-200 mg (Sinemet
$0 (1)
zonisamide cap 25 mg
cr)
(Zonegran)
carbidopa & levodopa tab
$0 (1)
zonisamide cap 50 mg
10-100 mg (Sinemet)
$0 (1)
zonisamide cap 100 mg
carbidopa & levodopa tab
(Zonegran)
25-100 mg (Sinemet)
ENFERMEDAD DE PARKINSON
carbidopa & levodopa tab
$0 (1)
amantadine hcl cap
25-250 mg (Sinemet)
100 mg
carbidopa tab 25 mg
$0 (1)
amantadine hcl syrup
(Lodosyn)
50 mg/5ml
entacapone tab 200 mg
AZILECT – rasagiline
$0 (2)
(Comtan)
mesylate tab 0.5 mg
pramipexole
(base equiv)
dihydrochloride tab sr
AZILECT – rasagiline
$0 (2)
24hr 0.375 mg (Mirapex
mesylate tab 1 mg
er)
(base equiv)
pramipexole
$0 (1)
benztropine mesylate tab
dihydrochloride tab sr
0.5 mg
24hr 2.25 mg (Mirapex
$0 (1)
benztropine mesylate tab
er)
1 mg
pramipexole
$0 (1)
benztropine mesylate tab
dihydrochloride tab sr
2 mg
24hr 3 mg (Mirapex er)
$0 (1)
bromocriptine mesylate
pramipexole
cap 5 mg (Parlodel)
dihydrochloride tab sr
24hr 4.5 mg (Mirapex
$0 (1)
bromocriptine mesylate
er)
tab 2.5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
64
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
pramipexole
dihydrochloride tab
0.125 mg (Mirapex)
pramipexole
dihydrochloride tab
0.25 mg (Mirapex)
pramipexole
dihydrochloride tab
0.5 mg (Mirapex)
pramipexole
dihydrochloride tab
0.75 mg (Mirapex)
pramipexole
dihydrochloride tab
1 mg (Mirapex)
pramipexole
dihydrochloride tab
1.5 mg (Mirapex)
ropinirole hydrochloride
tab 0.25 mg (Requip)
ropinirole hydrochloride
tab 0.5 mg (Requip)
ropinirole hydrochloride
tab 1 mg (Requip)
ropinirole hydrochloride
tab 2 mg (Requip)
ropinirole hydrochloride
tab 3 mg (Requip)
ropinirole hydrochloride
tab 4 mg (Requip)
ropinirole hydrochloride
tab 5 mg (Requip)
selegiline hcl cap 5 mg
(Eldepryl)
selegiline hcl tab 5 mg
tolcapone tab 100 mg
(Tasmar)
trihexyphenidyl hcl elixir
0.4 mg/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
trihexyphenidyl hcl tab
2 mg
trihexyphenidyl hcl tab
$0 (1)
5 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
RELAJANTES MUSCULARES
$0 (1)
baclofen tab 10 mg
baclofen tab 20 mg
$0 (1)
carisoprodol tab 250 mg
(Soma)
chlorzoxazone tab
500 mg (Parafon forte
dsc)
cyclobenzaprine hcl tab
5 mg
cyclobenzaprine hcl tab
10 mg
dantrolene sodium cap
25 mg (Dantrium)
dantrolene sodium cap
50 mg (Dantrium)
dantrolene sodium cap
100 mg
methocarbamol tab
500 mg (Robaxin)
methocarbamol tab
750 mg (Robaxin-750)
orphenadrine citrate tab sr
12hr 100 mg
tizanidine hcl tab 2 mg
$0 (1)
$0 (1)
QL
tizanidine hcl tab 4 mg
(Zanaflex)
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
OTROS MEDICAMENTOS NEUROMUSCULARES
$0 (1)
pyridostigmine bromide
tab cr 180 mg (Mestinon
timespan)
$0 (1)
pyridostigmine bromide
tab 60 mg (Mestinon)
$0 (1)
riluzole tab 50 mg
(Rilutek)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
65
2016
Nombre del
medicamento
SUPLEMENTOS
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
niacin tab 50 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
niacin tab 100 mg
$0 (3)
$0 (3)
niacin tab 500 mg
$0 (3)
cholecalciferol cap 1000
unit
cholecalciferol cap 2000
unit
cholecalciferol cap 5000
unit
cholecalciferol cap 10000
unit
cholecalciferol cap 50000
unit
cholecalciferol chew tab
400 unit
cholecalciferol oral liquid
400 unit/ml
cholecalciferol tab 400
unit
cholecalciferol tab 1000
unit
cholecalciferol tab 2000
unit
cholecalciferol tab 5000
unit
cholecalciferol tab 50000
unit
DECARA – cholecalciferol
cap 25000 unit
ergocalciferol cap 50000
unit (Drisdol)
MEPHYTON –
phytonadione tab 5 mg
niacin cap cr 250 mg
$0 (3)
NIACIN TR – niacin tab cr
1000 mg
thiamine hcl tab 50 mg
$0 (3)
thiamine hcl tab 100 mg
$0 (3)
niacin cap cr 500 mg
$0 (3)
niacin tab cr 250 mg
$0 (3)
niacin tab cr 500 mg
$0 (3)
niacin tab cr 750 mg
$0 (3)
VITAMINAS
ascorbic acid tab 500 mg
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (2)
$0 (3)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
66
MULTIVITAMINAS
AQUADEKS – multiple
vitamins w/ minerals cap
AQUADEKS – multiple
vitamins w/ minerals
chew tab
b-complex w/ c &
folic acid cap 1 mg
(Nephrocaps)
b-complex w/ c & folic
acid tab
b-complex w/ c & folic
acid tab 1 mg (Nephrovite rx)
b-complex w/ c & folic
acid tab 5 mg
b-complex w/ c-biotinminerals & folic acid tab
5 mg (Diatx zn)
multiple vitamin tab
multiple vitamins w/ iron
tab
multiple vitamins w/
minerals & fa tab
1.25 mg (Corvite)
multiple vitamins w/
minerals cap
multiple vitamins w/
minerals chew tab
multiple vitamins w/
minerals tab (Strovite
forte)
PA
QL
SP
ST
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
pediatric multiple vitamin
w/ c & fa chew tab
pediatric multiple vitamin
w/ c soln 35 mg/ml
pediatric multiple vitamin
w/ minerals & c drops
45 mg/ml
pediatric multiple
vitamins w/ fl-fe drops
0.25-10 mg/ml
pediatric multiple vitamins
w/ fluoride chew tab
0.25 mg
pediatric multiple vitamins
w/ fluoride chew tab
0.5 mg
pediatric multiple vitamins
w/ fluoride chew tab
1 mg
pediatric multiple vitamins
w/ fluoride soln 0.25 mg/
ml
pediatric multiple vitamins
w/ fluoride soln 0.5 mg/
ml
pediatric vitamins acd w/
fluoride soln 0.25 mg/ml
pediatric vitamins acd w/
fluoride soln 0.5 mg/ml
pediatric vitamins adc
drops 1500 unit-400
unit-35 mg/ml
speciality vitamin product
tab
TRI-VI-SOL – pediatric
vitamins adc drops 750
unit-400 unit-35 mg/ml
TRI-VIT/FLUORIDE/IRON
– pediatric vitamins
acd fluoride & fe drops
0.25-10 mg/ml
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
$0 (3)
MINERALES Y ELECTROLITOS
$0 (3)
calcium carbonate tab
$0 (3)
1250 mg (500 mg
elemental ca)
$0 (3)
$0 (3)
calcium carbonatecholecalciferol tab
500 mg-200 unit
$0 (1)
$0 (3)
calcium carbonatecholecalciferol tab
600 mg-400 unit
$0 (1)
$0 (3)
calcium carbonate-vitamin
d tab 250 mg-125 unit
$0 (3)
calcium carbonate-vitamin
$0 (1)
d tab 500 mg-200 unit
$0 (3)
calcium carbonate-vitamin
d tab 600 mg-400 unit
$0 (1)
$0 (3)
calcium citrate tab 950 mg
(200 mg elemental ca)
$0 (3)
calcium citrate-vitamin
$0 (1)
d tab 315 mg-200 unit
(elemental ca)
$0 (3)
calcium w/ vitamin d tab
$0 (1)
600 mg-200 unit
K-PHOS – potassium
$0 (2)
phosphate monobasic
$0 (1)
tab 500 mg
$0 (3)
oral electrolyte solution
$0 (1)
$0 (1)
pot bicarbonate & chloride
effer tab 25 meq
$0 (3)
$0 (1)
pot phos monobasic w/
sod phos di & monobas
tab 155-852-130mg (K$0 (1)
phos neutral)
$0 (1)
potassium bicarbonate
$0 (3)
effer tab 25 meq
$0 (1)
potassium chloride cap cr
8 meq (Micro-k)
$0 (2)
$0 (1)
potassium chloride cap cr
10 meq (Micro-k)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
67
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
POTASSIUM CHLORIDE
$0 (2)
DIALYVITE OMEGA-3
ER – potassium chloride
CONCENT – omega-3
tab cr 8 meq (600 mg)
fatty acids cap 600 mg
$0 (1)
potassium chloride
docosahexaenoic acid
microencapsulated crys
cap 200 mg
cr tab 10 meq
OCEAN BLUE MINICAPS
OMEGA – omega-3
$0 (1)
potassium chloride
fatty acids cap 350 mg
microencapsulated crys
cr tab 20 meq
OMEGA POWER –
omega-3 fatty acids cap
$0 (1)
potassium chloride oral
1050 mg
soln 10% (20 meq/15ml)
$0 (1)
OMEGA-3 – omega-3
potassium chloride oral
fatty acids cap 1400 mg
soln 20% (40 meq/15ml)
$0 (1)
OMEGA-3 IQ – omega-3
potassium chloride
fatty acids chew tab
powder packet 20 meq
240 mg
$0 (1)
potassium chloride tab cr
OMEGA-3 2100 –
8 meq (600 mg)
omega-3 fatty acids cap
$0 (1)
potassium chloride tab cr
1050 mg
10 meq (K-tab)
omega-3 fatty acids cap
SODIUM FLUORIDE
$0 (2)
500 mg
– sodium fluoride tab
1 mg f (from 2.2 mg naf)
omega-3 fatty acids cap
435 mg
$0 (1)
sodium fluoride chew tab
omega-3 fatty acids cap
0.25 mg f (from 0.55 mg
naf) (Luride)
1000 mg
$0 (1)
sodium fluoride chew tab
omega-3 fatty acids cap
0.5 mg f (from 1.1 mg
1200 mg
naf) (Luride)
omega-3 fatty acids
$0 (1)
sodium fluoride chew tab
cap delayed release
1000 mg
1 mg f (from 2.2 mg naf)
(Luride)
omega-3 fatty acids
$0 (1)
sodium fluoride soln
cap delayed release
1200 mg
0.125 mg/drop f
(0.275 mg/drop naf)
PRO NUTRIENTS
OMEGA 3 – omega-3
$0 (1)
sodium fluoride soln
fatty acids cap delayed
0.5 mg/ml f (from
release 332.5 mg
1.1 mg/ml naf) (Luride)
VP-PRECIP –
OTROS SUPLEMENTOS
flaxseed oil-evening
primrose-bilberry cap
250-125-10 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
68
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
ALPHANATE/VON
MEDICAMENTOS MODIFICADORES DE SANGRE
WILLEBRAND –
ADVATE – antihemophilic
$0 (2)
SP
antihemophilic factor/
factor rahf-pfm for inj
vwf (human) for inj 1500
250 unit
unit
ADVATE – antihemophilic
$0 (2)
SP
ALPHANATE/VON
factor rahf-pfm for inj
WILLEBRAND –
500 unit
antihemophilic factor/
ADVATE – antihemophilic
$0 (2)
SP
vwf (human) for inj 2000
factor rahf-pfm for inj
unit
1000 unit
ALPHANINE SD –
ADVATE – antihemophilic
$0 (2)
SP
coagulation factor ix for
factor rahf-pfm for inj
inj 500 unit
1500 unit
ALPHANINE SD –
ADVATE – antihemophilic
$0 (2)
SP
coagulation factor ix for
factor rahf-pfm for inj
inj 1000 unit
2000 unit
ALPHANINE SD –
ADVATE – antihemophilic
$0 (2)
SP
coagulation factor ix for
factor rahf-pfm for inj
inj 1500 unit
3000 unit
ALPROLIX – coagulation
ADVATE – antihemophilic
$0 (2)
SP
factor ix (recomb) (rfixfc)
factor rahf-pfm for inj
for inj 500 unit
4000 unit
ALPROLIX – coagulation
AGGRENOX – aspirin$0 (2)
factor ix (recomb) (rfixfc)
dipyridamole cap sr
for inj 1000 unit
12hr 25-200 mg
ALPROLIX – coagulation
ALPHANATE/VON
$0 (2)
SP
factor ix (recomb) (rfixfc)
WILLEBRAND –
for inj 2000 unit
antihemophilic factor/
ALPROLIX – coagulation
vwf (human) for inj 250
factor ix (recomb) (rfixfc)
unit
for inj 3000 unit
ALPHANATE/VON
$0 (2)
SP
anagrelide
hcl cap 0.5 mg
WILLEBRAND –
(Agrylin)
antihemophilic factor/
anagrelide
hcl cap 1 mg
vwf (human) for inj 500
unit
ARANESP ALBUMIN
FREE – darbepoetin
ALPHANATE/VON
$0 (2)
SP
alfa soln prefilled
WILLEBRAND –
syringe 10 mcg/0.4ml
antihemophilic factor/
vwf (human) for inj 1000
ARANESP ALBUMIN
unit
FREE – darbepoetin
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
$0 (1)
$0 (2)
PA, SP
$0 (2)
PA, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
69
2016
Nombre del
medicamento
alfa soln prefilled
syringe 25 mcg/0.42ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 40 mcg/0.4ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 60 mcg/0.3ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 100 mcg/0.5ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 150 mcg/0.3ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 200 mcg/0.4ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 300 mcg/0.6ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 500 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 25 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 40 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 60 mcg/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 100 mcg/ml
$0 (2)
PA, SP
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 200 mcg/ml
$0 (2)
PA, SP
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 300 mcg/ml
ASPIRIN/
$0 (2)
PA, SP
DIPYRIDAMOLE –
aspirin-dipyridamole cap
sr 12hr 25-200 mg
BEBULIN – factor
$0 (2)
PA, SP
ix complex for inj
200-1200 unit
BENEFIX – coagulation
factor ix (recombinant)
$0 (2)
PA, SP
for inj 250 unit
BENEFIX – coagulation
factor ix (recombinant)
for inj 500 unit
$0 (2)
PA, SP
BENEFIX – coagulation
factor ix (recombinant)
for inj 1000 unit
BENEFIX – coagulation
$0 (2)
PA, SP
factor ix (recombinant)
for inj 2000 unit
BENEFIX – coagulation
factor ix (recombinant)
$0 (2)
PA, SP
for inj 3000 unit
cilostazol tab 50 mg
(Pletal)
$0 (2)
PA, SP
cilostazol tab 100 mg
(Pletal)
clopidogrel bisulfate tab
$0 (2)
PA, SP
75 mg (base equiv)
(Plavix)
clopidogrel bisulfate tab
300 mg (base equiv)
(Plavix)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
70
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
CORIFACT – factor xiii
$0 (2)
SP
ELOCTATE –
concentrate (human) for
antihemophilic factor
inj kit 1000-1600 unit
(recomb) rfviiifc for inj
1500 unit
$0 (1)
cyanocobalamin inj
ELOCTATE –
1000 mcg/ml
antihemophilic factor
$0 (3)
cyanocobalamin tab cr
(recomb) rfviiifc for inj
1000 mcg
2000 unit
$0 (3)
cyanocobalamin tab sl
ELOCTATE –
2500 mcg
antihemophilic factor
$0 (3)
cyanocobalamin tab
(recomb) rfviiifc for inj
100 mcg
3000 unit
$0 (3)
cyanocobalamin tab
enoxaparin sodium inj
250 mcg
30 mg/0.3ml (Lovenox)
$0 (3)
cyanocobalamin tab
enoxaparin sodium inj
500 mcg
40 mg/0.4ml (Lovenox)
$0 (3)
cyanocobalamin tab
enoxaparin sodium inj
1000 mcg
60 mg/0.6ml (Lovenox)
$0 (1)
dipyridamole tab 25 mg
enoxaparin sodium inj
(Persantine)
80 mg/0.8ml (Lovenox)
$0 (1)
dipyridamole tab 50 mg
enoxaparin sodium inj
(Persantine)
100 mg/ml (Lovenox)
$0 (1)
dipyridamole tab 75 mg
enoxaparin sodium inj
(Persantine)
120 mg/0.8ml (Lovenox)
ELOCTATE –
$0 (2)
SP
enoxaparin sodium inj
antihemophilic factor
150 mg/ml (Lovenox)
(recomb) rfviiifc for inj
enoxaparin
sodium inj
250 unit
300 mg/3ml (Lovenox)
ELOCTATE –
$0 (2)
SP
EPOGEN
– epoetin alfa
antihemophilic factor
inj 2000 unit/ml
(recomb) rfviiifc for inj
EPOGEN – epoetin alfa
500 unit
inj 3000 unit/ml
ELOCTATE –
$0 (2)
SP
antihemophilic factor
EPOGEN – epoetin alfa
inj 4000 unit/ml
(recomb) rfviiifc for inj
750 unit
EPOGEN – epoetin alfa
inj 10000 unit/ml
ELOCTATE –
$0 (2)
SP
antihemophilic factor
EPOGEN – epoetin alfa
(recomb) rfviiifc for inj
inj 20000 unit/ml
1000 unit
fe fum-iron polysacch
complex-fa-b cmplx-c1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
71
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
zn-mn-cu cap (Tandem
fondaparinux sodium
plus)
subcutaneous inj
5 mg/0.4ml (Arixtra)
$0 (1)
fe fumarate w/ b12vit c-fa-ifc cap
fondaparinux sodium
110-0.015-75-0.5-240 mg
subcutaneous inj
7.5 mg/0.6ml (Arixtra)
$0 (1)
fe fumarate-vit c-vit
b12-fa cap 460 (151
fondaparinux sodium
fe)-60-0.01-1 mg
subcutaneous inj
10 mg/0.8ml (Arixtra)
FEIBA – antiinhibitor
$0 (2)
SP
coagulant complex for
HELIXATE FS –
inj
antihemophilic factor
(recombinant) for inj kit
$0 (1)
ferrous fumarate-fa-b
250 unit
complex-c-zn-mg-mn-cu
tab 106-1 mg
HELIXATE FS –
antihemophilic factor
$0 (1)
ferrous fumarate-folic acid
(recombinant) for inj kit
tab 324-1 mg
500 unit
$0 (3)
ferrous sulfate tab ec
HELIXATE FS –
325 mg (65 mg fe
antihemophilic factor
equivalent)
(recombinant) for inj kit
$0 (3)
ferrous sulfate tab 325 mg
1000 unit
(65 mg elemental fe)
HELIXATE FS –
FIRAZYR – icatibant
$0 (2)
QL, SP
antihemophilic factor
acetate inj 30 mg/3ml
(recombinant) for inj kit
(base equivalent)
2000 unit
$0 (3)
folic acid tab 400 mcg
HELIXATE FS –
$0 (3)
folic acid tab 800 mcg
antihemophilic factor
$0 (1)
folic acid tab 1 mg
(recombinant) for inj kit
$0 (1)
folic acid-vitamin b63000 unit
vitamin b12 tab
HEMOFIL M –
2.2-25-0.5 mg
antihemophilic factor
$0 (1)
folic acid-vitamin b6(human) for inj 250 unit
vitamin b12 tab
HEMOFIL M –
2.2-25-1 mg (Folgard rx)
antihemophilic factor
$0 (1)
folic acid-vitamin b6(human) for inj 500 unit
vitamin b12 tab
HEMOFIL M –
2.5-25-1 mg
antihemophilic factor
$0 (1)
QL
fondaparinux sodium
(human) for inj 1000 unit
subcutaneous inj
HEMOFIL M –
2.5 mg/0.5ml (Arixtra)
antihemophilic factor
(human) for inj 1700 unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
72
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
250-600 unit
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
500-1200 unit
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
1000-2400 unit
iron combination cap
iron polysacch complexvit b12-fa cap
150-0.025-1 mg
iron-docusate-b12-folic
acid-c-e-cu-biotin tab
150-1 mg (Hematron-af)
iron-folic acid-vit c-vit
b6-vit b12-zinc tab
150-1.25 mg (Corvite
150)
iron-vit c-vit b12-folic acid
tab 100-250-0.025-1 mg
(Icar-c plus)
KOATE-DVI –
antihemophilic factor
(human) for inj 250 unit
KOATE-DVI –
antihemophilic factor
(human) for inj 500 unit
KOATE-DVI –
antihemophilic factor
(human) for inj 1000 unit
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
250 unit
KOGENATE FS –
antihemophilic factor
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
(recombinant) for inj kit
$0 (2)
SP
500 unit
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
$0 (2)
SP
1000 unit
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
$0 (2)
SP
2000 unit
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
$0 (1)
3000 unit
$0 (1)
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
$0 (1)
250 unit
KOGENATE FS BIO-SET
– antihemophilic factor
$0 (1)
(recombinant) for inj kit
500 unit
KOGENATE FS BIO-SET
– antihemophilic factor
$0 (1)
(recombinant) for inj kit
1000 unit
KOGENATE
FS BIO-SET
$0 (2)
SP
– antihemophilic factor
(recombinant) for inj kit
2000 unit
$0 (2)
SP
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
$0 (2)
SP
3000 unit
KOVALTRY –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj 250
unit
KOVALTRY –
antihemophilic factor
$0 (2)
SP
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
73
2016
Nombre del
medicamento
(recombinant) for inj 500
unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
1000 unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
2000 unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
3000 unit
MONOCLATE-P –
antihemophilic factor
(human) for inj kit 250
unit
MONOCLATE-P –
antihemophilic factor
(human) for inj kit 1000
unit
MONOCLATE-P –
antihemophilic factor
(human) for inj kit 1500
unit
MONONINE –
coagulation factor ix for
inj 500 unit
MONONINE –
coagulation factor ix for
inj 1000 unit
NEUPOGEN – filgrastim
soln prefilled syringe
300 mcg/0.5ml
NEUPOGEN – filgrastim
soln prefilled syringe
480 mcg/0.8ml
(600 mcg/ml)
NEUPOGEN – filgrastim
inj 300 mcg/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
NEUPOGEN – filgrastim
inj 480 mcg/1.6ml
(300 mcg/ml)
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj 250
unit
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj 500
unit
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
1000 unit
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
1500 unit
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
2000 unit
$0 (2)
SP
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
3000 unit
$0 (2)
SP
NOVOSEVEN RT –
coagulation factor viia
(recomb) for inj 1 mg
$0 (2)
SP
(1000 mcg)
NOVOSEVEN RT –
coagulation factor viia
$0 (2)
SP
(recomb) for inj 2 mg
(2000 mcg)
NOVOSEVEN RT –
$0 (2)
SP
coagulation factor viia
(recomb) for inj 5 mg
(5000 mcg)
NOVOSEVEN RT –
$0 (2)
SP
coagulation factor viia
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
74
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
(recomb) for inj 8 mg
(8000 mcg)
NUWIQ – antihemophilic
factor (recombinant) for
inj 250 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 500 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 1000 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 2000 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 250 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 500 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 1000 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 2000 unit
OBIZUR – antihemophilic
factor (recomb porc)
rpfviii for inj 500 unit
pentoxifylline tab cr
400 mg
PROCRIT – epoetin alfa
inj 2000 unit/ml
PROCRIT – epoetin alfa
inj 3000 unit/ml
PROCRIT – epoetin alfa
inj 4000 unit/ml
PROCRIT – epoetin alfa
inj 10000 unit/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
PROCRIT – epoetin alfa
inj 20000 unit/ml
$0 (2)
SP
PROCRIT – epoetin alfa
inj 40000 unit/ml
PROFILNINE – factor ix
$0 (2)
SP
complex for inj 500 unit
PROFILNINE – factor ix
complex for inj 1000 unit
$0 (2)
SP
PROFILNINE – factor ix
complex for inj 1500 unit
PROFILNINE SD – factor
$0 (2)
SP
ix complex for inj 500
unit
PROFILNINE SD – factor
$0 (2)
SP
ix complex for inj 1000
unit
PROFILNINE SD – factor
$0 (2)
SP
ix complex for inj 1500
unit
RECOMBINATE –
$0 (2)
SP
antihemophilic factor
(recombinant) for inj
220-400 unit
$0 (2)
SP
RECOMBINATE –
antihemophilic factor
(recombinant) for inj
$0 (2)
SP
401-800 unit
RECOMBINATE –
antihemophilic factor
$0 (1)
(recombinant) for inj
801-1240 unit
$0 (2)
PA, SP
RECOMBINATE –
antihemophilic factor
(recombinant) for inj
$0 (2)
PA, SP
1241-1800 unit
RECOMBINATE –
$0 (2)
PA, SP
antihemophilic factor
(recombinant) for inj
$0 (2)
PA, SP
1801-2400 unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
75
2016
Nombre del
medicamento
RIXUBIS – coagulation
factor ix (recombinant)
for inj 250 unit
RIXUBIS – coagulation
factor ix (recombinant)
for inj 500 unit
RIXUBIS – coagulation
factor ix (recombinant)
for inj 1000 unit
RIXUBIS – coagulation
factor ix (recombinant)
for inj 2000 unit
RIXUBIS – coagulation
factor ix (recombinant)
for inj 3000 unit
tranexamic acid tab
650 mg (Lysteda)
TRETTEN – coagulation
factor xiii a-subunit for
inj 2000-3125 unit
warfarin sodium tab 1 mg
(Coumadin)
warfarin sodium tab 2 mg
(Coumadin)
warfarin sodium tab
2.5 mg (Coumadin)
warfarin sodium tab 3 mg
(Coumadin)
warfarin sodium tab 4 mg
(Coumadin)
warfarin sodium tab 5 mg
(Coumadin)
warfarin sodium tab 6 mg
(Coumadin)
warfarin sodium tab
7.5 mg (Coumadin)
warfarin sodium tab
10 mg (Coumadin)
XARELTO – rivaroxaban
tab 10 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
SP
XARELTO – rivaroxaban
tab 15 mg
XARELTO – rivaroxaban
tab 20 mg
$0 (2)
SP
XARELTO STARTER
PACK – rivaroxaban
$0 (2)
SP
tab starter therapy pack
15 mg & 20 mg
XYNTHA – antihemophilic
factor recombinant paf
$0 (2)
SP
for inj kit 250 unit
XYNTHA – antihemophilic
factor recombinant paf
$0 (2)
SP
for inj kit 500 unit
XYNTHA – antihemophilic
factor recombinant paf
$0 (1)
for inj kit 1000 unit
$0 (2)
SP
XYNTHA – antihemophilic
factor recombinant paf
for inj kit 2000 unit
$0 (1)
XYNTHA SOLOFUSE –
antihemophilic factor
recombinant paf for inj
$0 (1)
kit 250 unit
XYNTHA SOLOFUSE –
$0 (1)
antihemophilic factor
recombinant paf for inj
$0 (1)
kit 500 unit
XYNTHA
SOLOFUSE –
$0 (1)
antihemophilic factor
recombinant paf for inj
$0 (1)
kit 1000 unit
XYNTHA SOLOFUSE –
$0 (1)
antihemophilic factor
recombinant paf for inj
$0 (1)
kit 2000 unit
XYNTHA SOLOFUSE –
$0 (1)
antihemophilic factor
recombinant paf for inj
$0 (2)
QL
kit 3000 unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
76
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
ZARXIO – filgrastim-sndz
$0 (2)
SP
sulfacetamide sodium
soln prefilled syringe
ophth soln 10%
300 mcg/0.5ml
(Bleph-10)
ZARXIO – filgrastim-sndz
$0 (2)
SP
tobramycin ophth soln
soln prefilled syringe
0.3% (Tobrex)
480 mcg/0.8ml
trifluridine ophth soln 1%
(Viroptic)
MEDICAMENTOS TÓPICOS
OJO
Antinfecciosos
BACITRACIN – bacitracin
ophth oint 500 unit/gm
bacitracin-polymyxin b
ophth oint
ciprofloxacin hcl ophth
soln 0.3% (Ciloxan)
erythromycin ophth oint
5 mg/gm
gentamicin sulfate ophth
oint 0.3%
gentamicin sulfate ophth
soln 0.3% (Garamycin)
levofloxacin ophth soln
0.5%
NATACYN – natamycin
ophth susp 5%
neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin
neomycin-polymygramicid op sol
1.75-10000-0.025mgunt-mg/ml (Neosporin)
ofloxacin ophth soln 0.3%
(Ocuflox)
polymyxin b-trimethoprim
ophth soln 10000 unit/
ml-0.1% (Polytrim)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
Esteroides y productos de combinación
$0 (1)
bacitracin-polymyxinneomycin-hc ophth oint
1%
DEXAMETHASONE
$0 (2)
SODIUM PHOSPHATE
– dexamethasone
sodium phosphate
ophth soln 0.1%
$0 (1)
fluorometholone ophth
susp 0.1% (Fml liquifilm)
LOTEMAX – loteprednol
$0 (2)
etabonate ophth susp
0.5%
$0 (1)
neomycin-polymyxindexamethasone ophth
oint 0.1% (Maxitrol)
$0 (1)
neomycin-polymyxindexamethasone ophth
susp 0.1% (Maxitrol)
$0 (1)
prednisolone acetate
ophth susp 1% (Pred
forte)
PREDNISOLONE
$0 (2)
SODIUM PHOSP –
prednisolone sodium
phosphate ophth soln
1%
$0 (1)
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
$0 (1)
tobramycindexamethasone
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
77
2016
Nombre del
medicamento
ophth susp 0.3-0.1%
(Tobradex)
ZYLET – loteprednol
etabonate-tobramycin
ophth susp 0.5-0.3%
Glaucoma
ALPHAGAN P –
brimonidine tartrate
ophth soln 0.1%
apraclonidine hcl ophth
soln 0.5% (base
equivalent) (Iopidine)
AZOPT – brinzolamide
ophth susp 1%
betaxolol hcl ophth soln
0.5%
brimonidine tartrate ophth
soln 0.2%
carteolol hcl ophth soln
1%
dorzolamide hcl ophth
soln 2% (Trusopt)
dorzolamide hcl-timolol
maleate ophth soln
22.3-6.8 mg/ml (Cosopt)
latanoprost ophth soln
0.005% (Xalatan)
levobunolol hcl ophth soln
0.5% (Betagan)
METIPRANOLOL –
metipranolol ophth soln
0.3%
pilocarpine hcl ophth soln
1% (Isopto carpine)
pilocarpine hcl ophth soln
2% (Isopto carpine)
pilocarpine hcl ophth soln
4% (Isopto carpine)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
timolol maleate ophth gel
forming soln 0.25%
(Timoptic-xe)
$0 (2)
timolol maleate ophth gel
forming soln 0.5%
(Timoptic-xe)
timolol
maleate ophth soln
$0 (2)
0.25% (Timoptic)
timolol maleate ophth soln
0.5% (Timoptic)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
78
QL
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
Otros productos oculares
artificial tear ophth
solution
ATROPINE SULFATE –
atropine sulfate ophth
oint 1%
atropine sulfate ophth
soln 1% (Isopto
atropine)
azelastine hcl ophth soln
0.05% (Optivar)
cromolyn sodium ophth
soln 4%
cyclopentolate hcl ophth
soln 0.5% (Cyclogyl)
cyclopentolate hcl ophth
soln 1% (Cyclogyl)
cyclopentolate hcl ophth
soln 2% (Cyclogyl)
diclofenac sodium ophth
soln 0.1%
epinastine hcl ophth soln
0.05% (Elestat)
flurbiprofen sodium ophth
soln 0.03% (Ocufen)
ketorolac tromethamine
ophth soln 0.4% (Acular
ls)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
ketorolac tromethamine
ophth soln 0.5%
(Acular)
ketotifen fumarate ophth
soln 0.025% (base
equiv)
NAPHAZOLINE HCL –
naphazoline hcl ophth
soln 0.1%
olopatadine hcl ophth soln
0.1% (base equivalent)
(Patanol)
phenylephrine hcl ophth
soln 2.5%
phenylephrine hcl ophth
soln 10%
proparacaine hcl ophth
soln 0.5% (Alcaine)
tetracaine hcl ophth soln
0.5%
tetrahydroz-dextran-pegpovidone ophth soln
0.05-0.1-1-1%
OÍDO
acetic acid otic soln 2%
antipyrine-benzocaine
otic soln 54-14 mg/ml
(5.4-1.4%)
carbamide peroxide 6.5%
otic soln
CIPRODEX –
ciprofloxacindexamethasone otic
susp 0.3-0.1%
hydrocortisone w/ acetic
acid otic soln 1-2%
(Vosol hc)
neomycin-polymyxinhc otic soln 1%
(Cortisporin)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
neomycin-polymyxinhc otic susp 3.5 mg/
ml-10000 unit/ml-1%
$0 (3)
ofloxacin otic soln 0.3%
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
$0 (2)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
BOCA Y GARGANTA (local)
$0 (1)
cevimeline hcl cap 30 mg
(Evoxac)
$0 (1)
chlorhexidine gluconate
soln 0.12% (Peridex)
$0 (1)
clotrimazole troche 10 mg
lidocaine hcl viscous soln
2%
nystatin susp 100000 unit/
ml
pilocarpine hcl tab 5 mg
(Salagen)
pilocarpine hcl tab 7.5 mg
(Salagen)
sodium fluoride cream
1.1% (Prevident 5000
plus)
sodium fluoride gel 1.1%
(0.5% f) (Prevident
fluoride)
triamcinolone acetonide
dental paste 0.1%
AGENTES ANORRECTALES
CORTIFOAM –
hydrocortisone acetate
rectal foam 10% (90 mg/
dose)
hydrocortisone enema
100 mg/60ml
(Cortenema)
hydrocortisone rectal
cream 1% (Proctocort)
hydrocortisone rectal
cream 2.5% (Anusol-hc)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
CONDICIONES/PRODUCTOS DE LA PIEL
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
79
2016
Nombre del
medicamento
Acné
adapalene cream 0.1%
(Differin)
adapalene gel 0.1%
(Differin)
adapalene gel 0.3%
(Differin)
benzoyl peroxide cloth 6%
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
isotretinoin cap 40 mg
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
benzoyl peroxide liq 10%
$0 (1)
benzoyl peroxide lotion
6%
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
clindamycin phosphbenzoyl peroxide
(refrig) gel 1.2 (1)-5%
(Duac)
clindamycin
phosphate gel 1%
(Cleocin-t)
clindamycin phosphate
lotion 1% (Cleocin-t)
clindamycin phosphate
soln 1% (Cleocin-t)
clindamycin phosphate
swab 1% (Cleocin-t)
DIFFERIN – adapalene
lotion 0.1%
erythromycin gel 2%
(Erygel)
erythromycin pads 2%
$0 (1)
erythromycin soln 2%
$0 (1)
FINACEA – azelaic
acid gel 15%
isotretinoin cap 10 mg
$0 (2)
isotretinoin cap 20 mg
$0 (1)
isotretinoin cap 30 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
80
PA
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
metronidazole cream
0.75% (Metrocream)
metronidazole gel 0.75%
$0 (1)
metronidazole gel 1%
(Metrogel)
sulfacetamide sodium
lotion 10% (acne)
(Klaron)
sulfacetamide sodium w/
sulfur emulsion 10-1%
sulfacetamide sodium w/
sulfur emulsion 10-5%
TAZORAC – tazarotene
cream 0.05%
TAZORAC – tazarotene
cream 0.1%
TAZORAC –
tazarotene gel 0.05%
TAZORAC –
tazarotene gel 0.1%
tretinoin cream 0.025%
(Retin-a)
tretinoin cream 0.05%
(Retin-a)
tretinoin cream 0.1%
(Retin-a)
tretinoin gel 0.01% (Retina)
tretinoin gel 0.025%
(Retin-a)
tretinoin gel 0.05%
(Atralin)
tretinoin microsphere gel
0.04% (Retin-a micro)
tretinoin microsphere gel
0.1% (Retin-a micro)
$0 (1)
Antinfecciosos
bacitracin oint 500 unit/gm
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA
$0 (2)
PA
$0 (2)
PA
$0 (2)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
bacitracin-polymyxin b
oint
CENTANY – mupirocin
oint 2%
ciclopirox olamine cream
0.77% (base equiv)
ciclopirox olamine susp
0.77% (base equiv)
ciclopirox shampoo 1%
(Loprox shampoo)
ciclopirox solution kit 8%
(Ciclodan solution ki)
ciclopirox solution 8%
(Penlac Nail Lacquer)
CICLOPIROX TOPICAL
SOLUTI – ciclopirox
solution 8% & vitamin e
5% topical kit
clotrimazole cream 1%
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (3)
miconazole nitrate aerosol
pow 2%
$0 (2)
miconazole nitrate cream
2%
$0 (1)
mupirocin oint 2%
(Bactroban)
$0 (1)
naftifine hcl cream 2%
(Naftin)
$0 (1)
neomycin-bacitracinpolymyxin oint
$0 (1)
nystatin cream 100000
unit/gm
$0 (1)
nystatin oint 100000 unit/
gm
$0 (2)
nystatin topical powder
$0 (1)
clotrimazole soln 1%
$0 (1)
clotrimazole w/
betamethasone cream
1-0.05% (Lotrisone)
diclofenac sod soln 1.5%
& capsaicin cream
0.025% ther pack
(Dermacinrx lexitral)
diclofenac sodium gel 1%
(Voltaren)
econazole nitrate cream
1%
GENTAMICIN SULFATE
– gentamicin sulfate
cream 0.1%
GENTAMICIN SULFATE
– gentamicin sulfate oint
0.1%
ketoconazole cream 2%
$0 (1)
ketoconazole shampoo
2% (Nizoral)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
oxiconazole nitrate cream
1% (Oxistat)
silver sulfadiazine cream
1% (Silvadene)
tolnaftate aerosol 1%
$0 (1)
ZOVIRAX – acyclovir
cream 5%
$0 (2)
Corticosteroides
alclometasone
dipropionate cream
0.05% (Aclovate)
alclometasone
dipropionate oint 0.05%
betamethasone
dipropionate augmented
cream 0.05% (Diprolene
af)
betamethasone
dipropionate
augmented gel 0.05%
betamethasone
dipropionate augmented
lotion 0.05% (Diprolene)
PA
QL
SP
ST
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
81
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
betamethasone
fluocinolone acetonide
dipropionate augmented
cream 0.01%
oint 0.05% (Diprolene)
fluocinolone acetonide
$0 (1)
betamethasone
cream 0.025% (Synalar)
dipropionate cream
fluocinolone acetonide
0.05%
oil 0.01% (scalp oil)
$0 (1)
(Derma-smoothe/fs sca)
betamethasone
dipropionate lotion
fluocinolone acetonide
0.05%
oint 0.025% (Synalar)
$0 (1)
betamethasone
fluocinolone acetonide
dipropionate oint 0.05%
soln 0.01% (Synalar)
$0 (1)
betamethasone valerate
fluocinonide cream 0.05%
cream 0.1%
fluocinonide emulsified
$0 (1)
betamethasone valerate
base cream 0.05%
lotion 0.1%
fluocinonide gel 0.05%
$0 (1)
betamethasone valerate
fluocinonide oint 0.05%
oint 0.1%
fluocinonide soln 0.05%
$0 (1)
clobetasol propionate
flurandrenolide cream
cream 0.05%
0.05% (Cordran)
(Temovate)
fluticasone propionate
$0 (1)
clobetasol propionate
cream 0.05% (Cutivate)
emollient base cream
0.05% (Temovate e)
fluticasone propionate oint
0.005% (Cutivate)
$0 (1)
clobetasol propionate gel
0.05% (Temovate)
halobetasol propionate
cream 0.05% (Ultravate)
$0 (1)
clobetasol propionate oint
0.05% (Temovate)
halobetasol propionate
oint 0.05% (Ultravate)
$0 (1)
clobetasol propionate soln
0.05% (Temovate)
hydrocortisone butyrate
oint 0.1% (Locoid)
$0 (1)
desonide cream 0.05%
(Desowen)
hydrocortisone cream
0.5%
$0 (1)
desonide oint 0.05%
(Desowen)
hydrocortisone cream 1%
DESOXIMETASONE –
$0 (2)
hydrocortisone cream 1%
desoximetasone cream
hydrocortisone cream
0.05%
2.5%
$0 (1)
desoximetasone cream
hydrocortisone lotion
0.25% (Topicort)
2.5%
EPIFOAM – pramoxine-hc
$0 (2)
hydrocortisone oint 0.5%
aerosol foam 1-1%
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
82
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
hydrocortisone oint 1%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate
cream 0.2%
hydrocortisone valerate
oint 0.2% (Westcort)
mometasone furoate
cream 0.1% (Elocon)
mometasone furoate oint
0.1% (Elocon)
mometasone furoate
solution 0.1% (lotion)
(Elocon)
prednicarbate cream
0.1% (Dermatop)
prednicarbate oint 0.1%
(Dermatop)
triamcinolone acetonide
cream 0.025%
triamcinolone acetonide
cream 0.1%
triamcinolone acetonide
cream 0.5%
triamcinolone acetonide
lotion 0.025%
triamcinolone acetonide
lotion 0.1%
triamcinolone acetonide
oint 0.025%
triamcinolone acetonide
oint 0.1%
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
CEM-UREA – urea soln
45%
$0 (3)
ELIDEL – pimecrolimus
$0 (1)
cream 1%
$0 (1)
fluorouracil cream 5%
(Efudex)
$0 (1)
fluorouracil soln 2%
$0 (2)
$0 (1)
$0 (1)
imiquimod cream 5%
(Aldara)
lactic acid (ammonium
lactate) lotion 12% (Lachydrin)
lidocaine hcl cream 3%
$0 (1)
$0 (1)
lidocaine hcl gel 2%
$0 (1)
$0 (1)
lidocaine hcl soln 4%
(Xylocaine)
lidocaine oint 5%
$0 (1)
lidocaine patch 5%
(Lidoderm)
lidocaine-prilocaine cream
kit 2.5-2.5%
lidocaine-prilocaine cream
2.5-2.5% (Emla)
malathion lotion 0.5%
(Ovide)
methoxsalen rapid cap
10 mg (Oxsoralen ultra)
permethrin cream 5%
(Elimite)
permethrin creme rinse
1%
permethrin lotion 1%
$0 (1)
podofilox soln 0.5%
(Condylox)
QC CALAMINE –
calamine lotion
selenium sulfide lotion
2.5%
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
ST
$0 (1)
fluorouracil soln 5%
$0 (1)
Otros productos para la piel
$0 (1)
calcipotriene cream
0.005% (Dovonex)
$0 (1)
calcipotriene oint 0.005%
calcipotriene soln 0.005%
(50 mcg/ml)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (3)
$0 (1)
$0 (1)
PA, QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
83
2016
Nombre del
medicamento
selenium sulfidepyrithione zinc in urea
shampoo 2.25%
SM CALAMINE –
calamine lotion
tacrolimus oint 0.03%
(Protopic)
tacrolimus oint 0.1%
(Protopic)
VALCHLOR –
mechlorethamine
hcl gel 0.016% (base
equivalent)
vitamins a & d oint
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
COMPACT, INSTANT,
$0 (1)
SMARTVIEW;
ACCUTREND
CALIBRATION LIQUID
$0 (3)
– BAYER BREEZE 2,
CONTOUR
$0 (1)
ST
CHEMSTRIP-K, UGK
$0 (1)
ST
$0 (2)
SP
$0 (3)
zinc oxide oint 20%
$0 (3)
zinc oxide oint 40%
$0 (3)
zinc oxide oint 10%
$0 (3)
ZYCLARA – imiquimod
cream 3.75%
ZYCLARA PUMP –
imiquimod cream 2.5%
ZYCLARA PUMP –
imiquimod cream 3.75%
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
CATEGORÍAS MISCELÁNEAS (incluyen los
suministros y los dispositivos)
SUMINISTROS PARA LA DIABETES
ALCOHOL PREP PADS,
$0 (3)
SWABS – various
BAYER Blood Glucose
$0 (3)
Monitoring System –
BREEZE 2, CONTOUR,
CONTOUR NEXT/EZ/
LINK/USB
Blood Glucose Monitoring
$0 (3)
System – various
CALIBRATION LIQUID
$0 (2)
– ACCU-CHEK
ACTIVE, AVIVA,
COMFORT CURVE,
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
84
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
INSULIN PEN NEEDLES
- VARIOUS
INSULIN SYRINGES VARIOUS
LANCETS – VARIOUS
$0 (2)
QL
$0 (2)
QL
ROCHE Blood Glucose
Monitoring System –
ACCU-CHEK AVIVA
PLUS/COMPACT/
NANO SMARTVIEW
TEST STRIPS – BAYER
ASCENSIA AUTODISC,
BREEZE 2, CONTOUR,
CONTOUR NEXT
TEST STRIPS –
ROCHE ACCU-CHEK
ACTIVE, AVIVA, AVIVA
PLUS, COMFORT
CURVE, COMPACT,
SMARTVIEW
TEST STRIPS – ROCHE
ACCUTREND
$0 (3)
$0 (2)
$0 (2)
QL, ST
$0 (2)
QL, ST
$0 (2)
QL, ST
INHALADOR RESPIRATORIO-DISPOSITIVOS DE
ASISTENCIA
PEAK FLOW METER –
$0 (3)
various
RESPIRATORY
$0 (3)
THERAPY SUPPLIES –
various
SPACER/AEROSOL$0 (2)
HOLDING CHAMBERS
– VARIOUS
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
SPACER/AEROSOL$0 (3)
mycophenolate sodium
HOLDING CHAMBERS
tab dr 360 mg
– various
(mycophenolic acid
equiv) (Myfortic)
MEDICAMENTOS MISCELÁNEOS
REVLIMID – lenalidomide
$0 (1)
azathioprine tab 50 mg
caps 2.5 mg
(Imuran)
REVLIMID
– lenalidomide
CHEMET – succimer cap
$0 (2)
cap 5 mg
100 mg
REVLIMID
– lenalidomide
CUPRIMINE –
$0 (2)
SP
cap 10 mg
penicillamine cap
REVLIMID – lenalidomide
250 mg
cap 15 mg
$0 (1)
cyclosporine cap 25 mg
REVLIMID – lenalidomide
(Sandimmune)
cap 20 mg
$0 (1)
cyclosporine cap 100 mg
REVLIMID – lenalidomide
(Sandimmune)
cap 25 mg
CYCLOSPORINE
$0 (2)
ringer's solution for
MODIFIED –
irrigation
cyclosporine modified
sirolimus tab 0.5 mg
cap 50 mg
(Rapamune)
$0 (1)
cyclosporine modified cap
sirolimus tab 1 mg
25 mg (Neoral)
(Rapamune)
$0 (1)
cyclosporine modified cap
sirolimus tab 2 mg
100 mg (Neoral)
(Rapamune)
$0 (1)
cyclosporine modified oral
sodium polystyrene
soln 100 mg/ml (Neoral)
sulfonate oral susp
$0 (1)
irrigation solution,
15 gm/60ml (Sps)
physiological
sodium polystyrene
$0 (1)
lactated ringer's for
sulfonate powder
irrigation
(Kayexalate)
$0 (1)
mycophenolate mofetil
sodium polystyrene
cap 250 mg (Cellcept)
sulfonate rectal susp
$0 (1)
mycophenolate mofetil
30 gm/120ml
for oral susp 200 mg/ml
tacrolimus
cap 0.5 mg
(Cellcept)
(Prograf)
$0 (1)
mycophenolate mofetil tab
tacrolimus cap 1 mg
500 mg (Cellcept)
(Prograf)
$0 (1)
mycophenolate sodium
tacrolimus cap 5 mg
tab dr 180 mg
(Prograf)
(mycophenolic acid
equiv) (Myfortic)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
85
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
THALOMID – thalidomide
$0 (2)
PA, QL, SP
cap 50 mg
THALOMID – thalidomide
$0 (2)
PA, QL, SP
cap 100 mg
THALOMID – thalidomide
$0 (2)
PA, QL, SP
cap 150 mg
$0 (1)
water for irrigation, sterile
irrigation soln
ZORTRESS – everolimus
$0 (2)
tab 0.25 mg
ZORTRESS – everolimus
$0 (2)
tab 0.5 mg
ZORTRESS – everolimus
$0 (2)
tab 0.75 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
86
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
ÍNDICE
A
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg (Trizivir)......................................................................... 5
abacavir sulfate tab 300 mg (base equiv) (Ziagen)............. 5
acamprosate calcium tab delayed release 333 mg
(Campral).......................................................................... 53
acarbose tab 25 mg (Precose).......................................... 16
acarbose tab 50 mg (Precose).......................................... 16
acarbose tab 100 mg (Precose)........................................ 16
acebutolol hcl cap 200 mg (Sectral).................................. 23
acebutolol hcl cap 400 mg (Sectral).................................. 23
acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16
mg (Trezix)........................................................................ 55
acetaminophen cap 500 mg.............................................. 54
acetaminophen chew tab 80 mg....................................... 54
acetaminophen chew tab 160 mg..................................... 54
acetaminophen dispersible tab 80 mg.............................. 54
acetaminophen liquid 160 mg/5ml..................................... 54
acetaminophen soln 100 mg/ml.........................................54
acetaminophen soln 160 mg/5ml.......................................54
acetaminophen suppos 120 mg........................................ 54
acetaminophen susp 80 mg/0.8ml.....................................54
acetaminophen susp 160 mg/5ml......................................54
acetaminophen tab 325 mg............................................... 54
acetaminophen tab 500 mg............................................... 54
acetaminophen w/ codeine soln 120-12 mg/5ml............... 54
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).............................................................................54
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)....................................................................... 54
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4)....................................................................... 55
ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 28
acetazolamide cap sr 12hr 500 mg (Diamox)................... 28
acetazolamide tab 250 mg................................................ 28
acetic acid irrigation soln 0.25%........................................ 42
acetic acid otic soln 2%..................................................... 79
acetylcysteine inhal soln 10%............................................32
acetylcysteine inhal soln 20%............................................32
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)...........................................................9
acyclovir cap 200 mg (Zovirax)........................................... 5
acyclovir susp 200 mg/5ml (Zovirax)................................... 5
acyclovir tab 400 mg (Zovirax)............................................ 5
acyclovir tab 800 mg (Zovirax)............................................ 5
adapalene cream 0.1% (Differin)....................................... 80
adapalene gel 0.1% (Differin)............................................ 80
adapalene gel 0.3% (Differin)............................................ 80
ADCIRCA – tadalafil tab 20 mg (pah)............................... 30
adefovir dipivoxil tab 10 mg (Hepsera)................................4
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose.............................................................. 34
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
250-50 mcg/dose.............................................................. 34
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
500-50 mcg/dose.............................................................. 34
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act.............................................................................. 34
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................. 34
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................. 34
ADVATE – antihemophilic factor rahf-pfm for inj 250
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 500
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 1000
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 1500
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 2000
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 3000
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 4000
unit..................................................................................... 69
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg........................................................................................ 9
AFINITOR DISPERZ – everolimus tab for oral susp 3
mg...................................................................................... 10
AFINITOR DISPERZ – everolimus tab for oral susp 5
mg...................................................................................... 10
AFINITOR – everolimus tab 2.5 mg.................................... 9
AFINITOR – everolimus tab 5 mg....................................... 9
AFINITOR – everolimus tab 7.5 mg.................................... 9
AFINITOR – everolimus tab 10 mg..................................... 9
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg...................................................................................... 69
ALBENZA – albendazole tab 200 mg................................. 9
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).............. 34
albuterol sulfate soln nebu 0.5% (5 mg/ml)....................... 34
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......34
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......34
albuterol sulfate syrup 2 mg/5ml....................................... 34
albuterol sulfate tab 2 mg.................................................. 34
albuterol sulfate tab 4 mg.................................................. 34
albuterol sulfate tab sr 12hr 4 mg (Vospire er).................. 34
albuterol sulfate tab sr 12hr 8 mg (Vospire er).................. 34
alclometasone dipropionate cream 0.05% (Aclovate)....... 81
alclometasone dipropionate oint 0.05%............................ 81
ALCOHOL PREP PADS, SWABS – various..................... 84
ALENDRONATE SODIUM – alendronate sodium tab 40
mg...................................................................................... 19
alendronate sodium tab 5 mg............................................ 19
alendronate sodium tab 10 mg.......................................... 19
alendronate sodium tab 35 mg.......................................... 19
alendronate sodium tab 70 mg (Fosamax)....................... 19
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)....................... 42
87
2016
ALKERAN – melphalan tab 2 mg...................................... 10
allopurinol tab 100 mg (Zyloprim)...................................... 61
allopurinol tab 300 mg (Zyloprim)...................................... 61
almotriptan malate tab 6.25 mg (Axert)............................. 60
almotriptan malate tab 12.5 mg (Axert)............................. 60
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 40
alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 40
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%..... 78
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 250 unit............................................. 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 500 unit............................................. 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 1000 unit........................................... 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 1500 unit........................................... 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 2000 unit........................................... 69
ALPHANINE SD – coagulation factor ix for inj 500
unit..................................................................................... 69
ALPHANINE SD – coagulation factor ix for inj 1000
unit..................................................................................... 69
ALPHANINE SD – coagulation factor ix for inj 1500
unit..................................................................................... 69
alprazolam tab 0.25 mg (Xanax)....................................... 43
alprazolam tab 0.5 mg (Xanax)......................................... 43
alprazolam tab 1 mg (Xanax)............................................ 43
alprazolam tab 2 mg (Xanax)............................................ 43
alprazolam tab sr 24hr 0.5 mg (Xanax xr).........................43
alprazolam tab sr 24hr 1 mg (Xanax xr)............................43
alprazolam tab sr 24hr 2 mg (Xanax xr)............................43
alprazolam tab sr 24hr 3 mg (Xanax xr)............................43
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
500 unit............................................................................. 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
1000 unit........................................................................... 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
2000 unit........................................................................... 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
3000 unit........................................................................... 69
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml............................................................................... 38
alum & mag hydroxide-simethicone susp 400-400-40
mg/5ml............................................................................... 38
amantadine hcl cap 100 mg.............................................. 64
amantadine hcl syrup 50 mg/5ml...................................... 64
amiloride & hydrochlorothiazide tab 5-50 mg.................... 28
amiloride hcl tab 5 mg....................................................... 28
amiodarone hcl tab 200 mg (Cordarone).......................... 29
amitriptyline hcl tab 10 mg.................................................43
amitriptyline hcl tab 25 mg.................................................43
amitriptyline hcl tab 50 mg.................................................43
amitriptyline hcl tab 75 mg.................................................43
amitriptyline hcl tab 100 mg...............................................43
amitriptyline hcl tab 150 mg...............................................43
88
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................... 25
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................... 25
amlodipine besylate tab 2.5 mg (Norvasc)........................ 24
amlodipine besylate tab 5 mg (Norvasc)........................... 24
amlodipine besylate tab 10 mg (Norvasc)......................... 24
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)............................................................................25
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)............................................................ 1
amoxicillin & k clavulanate tab 250-125 mg........................ 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................... 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125
mg........................................................................................ 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250
mg........................................................................................ 1
amoxicillin (trihydrate) cap 250 mg......................................1
amoxicillin (trihydrate) cap 500 mg......................................1
amoxicillin (trihydrate) for susp 125 mg/5ml........................1
amoxicillin (trihydrate) for susp 200 mg/5ml........................1
amoxicillin (trihydrate) for susp 250 mg/5ml........................1
amoxicillin (trihydrate) for susp 400 mg/5ml........................1
amoxicillin (trihydrate) tab 875 mg...................................... 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)...................................................................... 49
2016
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................... 50
ampicillin cap 250 mg.......................................................... 1
ampicillin cap 500 mg.......................................................... 1
AMPYRA – dalfampridine tab sr 12hr 10 mg.................... 52
anagrelide hcl cap 1 mg.................................................... 69
anagrelide hcl cap 0.5 mg (Agrylin)...................................69
anastrozole tab 1 mg (Arimidex)....................................... 10
ANDRODERM – testosterone td patch 24hr 2
mg/24hr............................................................................. 13
ANDRODERM – testosterone td patch 24hr 4
mg/24hr............................................................................. 13
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)......................................................................... 79
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)........................................................................... 78
APTIVUS – tipranavir cap 250 mg...................................... 5
APTIVUS – tipranavir oral soln 100 mg/ml......................... 5
AQUADEKS – multiple vitamins w/ minerals cap..............66
AQUADEKS – multiple vitamins w/ minerals chew tab..... 66
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
100 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
200 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
300 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml......................................... 69
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml....................................... 69
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml......................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml......................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 500 mcg/ml............................................ 70
aripiprazole oral solution 1 mg/ml......................................46
aripiprazole tab 2 mg (Abilify)............................................ 46
aripiprazole tab 5 mg (Abilify)............................................ 46
aripiprazole tab 10 mg (Abilify).......................................... 46
aripiprazole tab 15 mg (Abilify).......................................... 46
aripiprazole tab 20 mg (Abilify).......................................... 46
aripiprazole tab 30 mg (Abilify).......................................... 46
armodafinil tab 50 mg (Nuvigil)..........................................50
armodafinil tab 150 mg (Nuvigil)........................................50
armodafinil tab 200 mg (Nuvigil)........................................50
armodafinil tab 250 mg (Nuvigil)........................................50
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act.................................................. 34
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act.................................................. 35
artificial tear ophth solution ...............................................78
ASACOL HD – mesalamine tab delayed release 800
mg...................................................................................... 40
ascorbic acid tab 500 mg.................................................. 66
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 7 METE – mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 14 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 60 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASPIRIN/DIPYRIDAMOLE – aspirin-dipyridamole cap sr
12hr 25-200 mg................................................................ 70
aspirin chew tab 81 mg..................................................... 54
aspirin tab delayed release 81 mg.................................... 54
aspirin tab delayed release 325 mg.................................. 54
aspirin tab 325 mg............................................................. 54
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......23
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)................................................................................... 23
atenolol tab 25 mg (Tenormin).......................................... 23
atenolol tab 50 mg (Tenormin).......................................... 23
atenolol tab 100 mg (Tenormin)........................................ 23
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor).............................................................................. 27
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor).............................................................................. 27
89
2016
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor).............................................................................. 27
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor).............................................................................. 27
atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)........ 8
atovaquone-proguanil hcl tab 250-100 mg (Malarone)....... 8
atovaquone susp 750 mg/5ml (Mepron)............................. 9
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................. 6
ATROPINE SULFATE – atropine sulfate ophth oint
1%..................................................................................... 78
atropine sulfate ophth soln 1% (Isopto atropine)...............78
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act........................................................................ 35
AVODART – dutasteride cap 0.5 mg.................................42
azathioprine tab 50 mg (Imuran)....................................... 85
azelastine hcl nasal spray 0.1% (137 mcg/spray)............. 32
azelastine hcl ophth soln 0.05% (Optivar).........................78
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)................................................................................. 64
AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 64
AZITHROMYCIN – azithromycin powd pack for susp 1
gm........................................................................................ 2
azithromycin for susp 100 mg/5ml (Zithromax)................... 2
azithromycin for susp 200 mg/5ml (Zithromax)................... 2
azithromycin tab 250 mg (Zithromax).................................. 2
azithromycin tab 500 mg (Zithromax).................................. 2
azithromycin tab 600 mg (Zithromax).................................. 2
AZOPT – brinzolamide ophth susp 1%............................. 78
B
BACITRACIN – bacitracin ophth oint 500 unit/gm............ 77
bacitracin intramuscular for soln 50000 unit........................9
bacitracin oint 500 unit/gm................................................. 80
bacitracin-polymyxin b oint ............................................... 81
bacitracin-polymyxin b ophth oint...................................... 77
bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 77
baclofen tab 10 mg............................................................ 65
baclofen tab 20 mg............................................................ 65
balsalazide disodium cap 750 mg (Colazal)......................40
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4
BAYER Blood Glucose Monitoring System – BREEZE 2,
CONTOUR, CONTOUR NEXT/EZ/LINK/USB................. 84
b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 66
b-complex w/ c & folic acid tab..........................................66
b-complex w/ c & folic acid tab 5 mg................................ 66
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)....... 66
b-complex w/ c-biotin-minerals & folic acid tab 5 mg (Diatx
zn)...................................................................................... 66
BEBULIN – factor ix complex for inj 200-1200 unit........... 70
benazepril & hydrochlorothiazide tab 5-6.25 mg............... 20
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct).................................................................... 21
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct).................................................................... 21
90
benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin
hct).....................................................................................21
benazepril hcl tab 5 mg..................................................... 21
benazepril hcl tab 10 mg (Lotensin).................................. 21
benazepril hcl tab 20 mg (Lotensin).................................. 21
benazepril hcl tab 40 mg (Lotensin).................................. 21
BENEFIX – coagulation factor ix (recombinant) for inj 250
unit..................................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj 500
unit..................................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj
1000 unit........................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj
2000 unit........................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj
3000 unit........................................................................... 70
benzonatate cap 200 mg................................................... 32
benzonatate cap 100 mg (Tessalon perles)...................... 32
benzonatate cap 150 mg (Zonatuss).................................32
benzoyl peroxide cloth 6%................................................. 80
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin).................................................................... 80
benzoyl peroxide liq 10%................................................... 80
benzoyl peroxide lotion 6%................................................ 80
benztropine mesylate tab 0.5 mg...................................... 64
benztropine mesylate tab 1 mg......................................... 64
benztropine mesylate tab 2 mg......................................... 64
betamethasone dipropionate augmented cream 0.05%
(Diprolene af).................................................................... 81
betamethasone dipropionate augmented gel 0.05%.........81
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)........................................................................ 81
betamethasone dipropionate augmented oint 0.05%
(Diprolene)........................................................................ 82
betamethasone dipropionate cream 0.05%.......................82
betamethasone dipropionate lotion 0.05%........................ 82
betamethasone dipropionate oint 0.05%........................... 82
betamethasone valerate cream 0.1%................................ 82
betamethasone valerate lotion 0.1%................................. 82
betamethasone valerate oint 0.1%.................................... 82
BETASERON – interferon beta-1b for inj kit 0.3 mg......... 52
betaxolol hcl ophth soln 0.5%............................................78
betaxolol hcl tab 10 mg (Kerlone)..................................... 23
betaxolol hcl tab 20 mg (Kerlone)..................................... 23
bethanechol chloride tab 5 mg (Urecholine)..................... 41
bethanechol chloride tab 10 mg (Urecholine)................... 41
bethanechol chloride tab 25 mg (Urecholine)................... 41
bethanechol chloride tab 50 mg (Urecholine)................... 41
bexarotene cap 75 mg (Targretin)..................................... 10
bicalutamide tab 50 mg (Casodex)....................................10
BILTRICIDE – praziquantel tab 600 mg.............................. 9
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit....................................................................................... 37
bisacodyl tab delayed release 5 mg.................................. 37
bismuth subsalicylate susp 262 mg/15ml.......................... 38
2016
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)................................................................................. 23
bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)...... 23
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................. 23
bisoprolol fumarate tab 5 mg (Zebeta).............................. 23
bisoprolol fumarate tab 10 mg (Zebeta)............................ 23
Blood Glucose Monitoring System – various.................... 84
BREVICON-28 – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg........................................................................ 14
brimonidine tartrate ophth soln 0.2%.................................78
BROHIST D – brompheniramine & phenylephrine tab 4-10
mg...................................................................................... 32
bromocriptine mesylate cap 5 mg (Parlodel).....................64
bromocriptine mesylate tab 2.5 mg................................... 64
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml..... 33
brompheniramine & phenylephrine susp 6-10 mg/5ml......33
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg...................................................................................... 33
budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 35
budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 35
budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 35
bumetanide tab 0.5 mg...................................................... 28
bumetanide tab 1 mg......................................................... 28
bumetanide tab 2 mg......................................................... 29
BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv)................................................................55
BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv)................................................................55
BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1
mg (base equiv)................................................................55
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)................................................................................. 55
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)................................................................................. 55
buprenorphine hcl sl tab 2 mg (base equiv)...................... 55
buprenorphine hcl sl tab 8 mg (base equiv)...................... 55
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).............................................................................. 53
bupropion hcl tab 75 mg (Wellbutrin)................................ 44
bupropion hcl tab 100 mg (Wellbutrin).............................. 44
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).............. 43
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).............. 44
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).............. 44
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).............. 44
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).............. 44
buspirone hcl tab 5 mg...................................................... 43
buspirone hcl tab 10 mg.................................................... 43
buspirone hcl tab 15 mg.................................................... 43
buspirone hcl tab 30 mg.................................................... 43
butalbital-acetaminophen-caffeine cap 50-325-40 mg...... 54
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)............................................................................ 54
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................... 54
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg...................................................................................... 55
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine)........................................................ 55
butalbital-acetaminophen tab 50-325 mg.......................... 54
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)..... 54
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................... 55
butorphanol tartrate nasal soln 10 mg/ml.......................... 55
C
cabergoline tab 0.5 mg...................................................... 19
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
(Cafcit)............................................................................... 50
calcipotriene cream 0.005% (Dovonex)............................ 83
calcipotriene oint 0.005%................................................... 83
calcipotriene soln 0.005% (50 mcg/ml)............................. 83
calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)..... 19
calcitriol cap 0.25 mcg (Rocaltrol)..................................... 19
calcitriol cap 0.5 mcg (Rocaltrol)....................................... 19
calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 19
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca) (Phoslo)...................................................................... 40
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)............................................................................ 40
calcium carbonate (antacid) chew tab 500 mg..................38
calcium carbonate (antacid) chew tab 750 mg..................38
calcium carbonate (antacid) chew tab 1000 mg................38
calcium carbonate-cholecalciferol tab 500 mg-200
unit..................................................................................... 67
calcium carbonate-cholecalciferol tab 600 mg-400
unit..................................................................................... 67
calcium carbonate tab 1250 mg (500 mg elemental
ca)...................................................................................... 67
calcium carbonate-vitamin d tab 250 mg-125 unit............ 67
calcium carbonate-vitamin d tab 500 mg-200 unit............ 67
calcium carbonate-vitamin d tab 600 mg-400 unit............ 67
calcium citrate tab 950 mg (200 mg elemental ca)........... 67
calcium citrate-vitamin d tab 315 mg-200 unit (elemental
ca)...................................................................................... 67
calcium w/ vitamin d tab 600 mg-200 unit......................... 67
CALIBRATION LIQUID – ACCU-CHEK ACTIVE,
AVIVA, COMFORT CURVE, COMPACT, INSTANT,
SMARTVIEW; ACCUTREND........................................... 84
CALIBRATION LIQUID – BAYER BREEZE 2,
CONTOUR........................................................................ 84
CANASA – mesalamine suppos 1000 mg........................ 40
capecitabine tab 150 mg (Xeloda).....................................10
capecitabine tab 500 mg (Xeloda).....................................10
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg................................... 21
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-25 mg................................... 21
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-15 mg................................... 21
91
2016
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-25 mg................................... 21
captopril tab 12.5 mg......................................................... 21
captopril tab 25 mg............................................................ 21
captopril tab 50 mg............................................................ 21
captopril tab 100 mg.......................................................... 21
carbamazepine cap sr 12hr 100 mg (Carbatrol)............... 61
carbamazepine cap sr 12hr 200 mg (Carbatrol)............... 61
carbamazepine cap sr 12hr 300 mg (Carbatrol)............... 61
carbamazepine chew tab 100 mg..................................... 61
carbamazepine susp 100 mg/5ml (Tegretol)..................... 61
carbamazepine tab 200 mg (Tegretol).............................. 61
carbamazepine tab sr 12hr 100 mg (Tegretol-xr).............. 61
carbamazepine tab sr 12hr 200 mg (Tegretol-xr).............. 61
carbamazepine tab sr 12hr 400 mg (Tegretol-xr).............. 61
carbamide peroxide 6.5% otic soln................................... 79
carbidopa & levodopa orally disintegrating tab 10-100
mg...................................................................................... 64
carbidopa & levodopa orally disintegrating tab 25-100
mg...................................................................................... 64
carbidopa & levodopa orally disintegrating tab 25-250
mg...................................................................................... 64
carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).......64
carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).......64
carbidopa & levodopa tab 10-100 mg (Sinemet)...............64
carbidopa & levodopa tab 25-100 mg (Sinemet)...............64
carbidopa & levodopa tab 25-250 mg (Sinemet)...............64
carbidopa tab 25 mg (Lodosyn).........................................64
carbinoxamine maleate soln 4 mg/5ml.............................. 31
carbinoxamine maleate tab 4 mg...................................... 31
carisoprodol tab 250 mg (Soma)....................................... 65
carteolol hcl ophth soln 1%............................................... 78
carvedilol tab 3.125 mg (Coreg)........................................ 23
carvedilol tab 6.25 mg (Coreg).......................................... 23
carvedilol tab 12.5 mg (Coreg).......................................... 23
carvedilol tab 25 mg (Coreg)............................................. 23
cefaclor cap 250 mg............................................................ 1
cefaclor cap 500 mg............................................................ 1
cefadroxil cap 500 mg..........................................................1
cefadroxil for susp 250 mg/5ml........................................... 1
cefadroxil for susp 500 mg/5ml........................................... 1
cefadroxil tab 1 gm.............................................................. 1
cefdinir cap 300 mg............................................................. 1
cefdinir for susp 125 mg/5ml............................................... 1
cefdinir for susp 250 mg/5ml............................................... 1
cefixime for susp 100 mg/5ml (Suprax)...............................1
cefixime for susp 200 mg/5ml (Suprax)...............................1
cefprozil for susp 125 mg/5ml............................................. 1
cefprozil for susp 250 mg/5ml............................................. 2
cefprozil tab 250 mg............................................................ 2
cefprozil tab 500 mg............................................................ 2
ceftriaxone sodium for inj 2 gm........................................... 2
ceftriaxone sodium for inj 1 gm (Rocephin)........................ 2
ceftriaxone sodium for inj 250 mg....................................... 2
ceftriaxone sodium for inj 500 mg (Rocephin).................... 2
cefuroxime axetil tab 250 mg (Ceftin)................................. 2
92
cefuroxime axetil tab 500 mg (Ceftin)................................. 2
celecoxib cap 50 mg (Celebrex)........................................ 58
celecoxib cap 100 mg (Celebrex)...................................... 58
celecoxib cap 200 mg (Celebrex)...................................... 58
celecoxib cap 400 mg (Celebrex)...................................... 58
CEM-UREA – urea soln 45%............................................ 83
CENTANY – mupirocin oint 2%......................................... 81
cephalexin cap 250 mg (Keflex).......................................... 2
cephalexin cap 500 mg (Keflex).......................................... 2
cephalexin for susp 125 mg/5ml..........................................2
cephalexin for susp 250 mg/5ml..........................................2
cetirizine hcl chew tab 5 mg.............................................. 31
cetirizine hcl chew tab 10 mg............................................ 31
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................31
cetirizine hcl tab 5 mg........................................................ 31
cetirizine hcl tab 10 mg...................................................... 31
cevimeline hcl cap 30 mg (Evoxac)...................................79
CHANTIX CONTINUING MONTH – varenicline tartrate
tab 1 mg (base equiv)...................................................... 53
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 53
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)................................................................................. 53
CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 53
CHEMET – succimer cap 100 mg..................................... 85
CHEMSTRIP-K, UGK......................................................... 84
chlordiazepoxide hcl cap 5 mg.......................................... 43
chlordiazepoxide hcl cap 10 mg........................................ 43
chlordiazepoxide hcl cap 25 mg........................................ 43
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax).............................................................................. 38
chlorhexidine gluconate soln 0.12% (Peridex).................. 79
chloroquine phosphate tab 250 mg..................................... 8
chloroquine phosphate tab 500 mg (Aralen)....................... 8
CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 29
chlorothiazide tab 500 mg................................................. 29
chlorpheniramine & phenylephrine liquid 4-10 mg/5ml..... 33
chlorpheniramine & phenylephrine tab 4-10 mg............... 33
chlorpheniramine maleate tab 4 mg.................................. 31
chlorpromazine hcl tab 10 mg........................................... 46
chlorpromazine hcl tab 25 mg........................................... 46
chlorpromazine hcl tab 50 mg........................................... 46
chlorpromazine hcl tab 100 mg......................................... 46
chlorpromazine hcl tab 200 mg......................................... 46
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 29
chlorthalidone tab 25 mg................................................... 29
chlorzoxazone tab 500 mg (Parafon forte dsc)................. 65
cholecalciferol cap 1000 unit............................................. 66
cholecalciferol cap 2000 unit............................................. 66
cholecalciferol cap 5000 unit............................................. 66
cholecalciferol cap 10000 unit........................................... 66
cholecalciferol cap 50000 unit........................................... 66
cholecalciferol chew tab 400 unit...................................... 66
cholecalciferol oral liquid 400 unit/ml.................................66
cholecalciferol tab 400 unit................................................ 66
cholecalciferol tab 1000 unit.............................................. 66
2016
cholecalciferol tab 2000 unit.............................................. 66
cholecalciferol tab 5000 unit.............................................. 66
cholecalciferol tab 50000 unit............................................ 66
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................... 27
cholestyramine light powder packets 4 gm....................... 27
cholestyramine powder 4 gm/dose (Questran)................. 27
cholestyramine powder packets 4 gm (Questran).............27
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix).............................................................................. 27
choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
(Trilipix).............................................................................. 27
ciclopirox olamine cream 0.77% (base equiv)...................81
ciclopirox olamine susp 0.77% (base equiv)..................... 81
ciclopirox shampoo 1% (Loprox shampoo)....................... 81
ciclopirox solution kit 8% (Ciclodan solution ki).................81
ciclopirox solution 8% (Penlac Nail Lacquer).................... 81
CICLOPIROX TOPICAL SOLUTI – ciclopirox solution 8%
& vitamin e 5% topical kit................................................ 81
cilostazol tab 50 mg (Pletal).............................................. 70
cilostazol tab 100 mg (Pletal)............................................ 70
cimetidine hcl soln 300 mg/5ml......................................... 38
cimetidine tab 200 mg........................................................38
cimetidine tab 300 mg........................................................38
cimetidine tab 400 mg........................................................38
cimetidine tab 800 mg........................................................38
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%............................................................................ 79
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
(Cipro)..................................................................................3
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................... 3
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...................... 77
ciprofloxacin hcl tab 750 mg (base equiv)........................... 3
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)............... 3
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)............... 3
citalopram hydrobromide oral soln 10 mg/5ml.................. 44
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)............................................................................. 44
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)............................................................................. 44
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)............................................................................. 44
clarithromycin for susp 125 mg/5ml.....................................2
clarithromycin for susp 250 mg/5ml (Biaxin)....................... 2
clarithromycin tab 250 mg (Biaxin)...................................... 2
clarithromycin tab 500 mg (Biaxin)...................................... 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)............... 2
clemastine fumarate tab 2.68 mg...................................... 31
clemastine fumarate tab 1.34 mg (1 mg base equiv)........ 31
clindamycin hcl cap 75 mg (Cleocin)...................................9
clindamycin hcl cap 150 mg (Cleocin).................................9
clindamycin hcl cap 300 mg (Cleocin).................................9
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
(Cleocin pediatric gr).......................................................... 9
clindamycin phosphate gel 1% (Cleocin-t)........................ 80
clindamycin phosphate lotion 1% (Cleocin-t).................... 80
clindamycin phosphate soln 1% (Cleocin-t)...................... 80
clindamycin phosphate swab 1% (Cleocin-t).................... 80
clindamycin phosphate vaginal cream 2% (Cleocin).........42
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................... 80
clobetasol propionate cream 0.05% (Temovate)............... 82
clobetasol propionate emollient base cream 0.05%
(Temovate e)..................................................................... 82
clobetasol propionate gel 0.05% (Temovate).................... 82
clobetasol propionate oint 0.05% (Temovate)................... 82
clobetasol propionate soln 0.05% (Temovate).................. 82
clomipramine hcl cap 25 mg (Anafranil)............................ 44
clomipramine hcl cap 50 mg (Anafranil)............................ 44
clomipramine hcl cap 75 mg (Anafranil)............................ 44
clonazepam orally disintegrating tab 0.125 mg................. 61
clonazepam orally disintegrating tab 0.25 mg................... 61
clonazepam orally disintegrating tab 0.5 mg..................... 61
clonazepam orally disintegrating tab 1 mg........................ 61
clonazepam orally disintegrating tab 2 mg........................ 61
clonazepam tab 0.5 mg (Klonopin)....................................61
clonazepam tab 1 mg (Klonopin).......................................61
clonazepam tab 2 mg (Klonopin).......................................61
clonidine hcl tab 0.1 mg (Catapres).................................. 30
clonidine hcl tab 0.2 mg (Catapres).................................. 30
clonidine hcl tab 0.3 mg (Catapres).................................. 30
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).........................50
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................. 30
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2).................................................................................. 30
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3).................................................................................. 30
clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........70
clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......70
clorazepate dipotassium tab 3.75 mg (Tranxene t)........... 43
clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 43
clorazepate dipotassium tab 15 mg (Tranxene t).............. 43
clotrimazole cream 1%.......................................................81
clotrimazole soln 1%.......................................................... 81
clotrimazole troche 10 mg................................................. 79
clotrimazole vaginal cream 2%.......................................... 42
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)......................................................................... 81
clozapine orally disintegrating tab 25 mg (Fazaclo).......... 46
clozapine orally disintegrating tab 100 mg (Fazaclo)........ 46
clozapine tab 50 mg...........................................................46
clozapine tab 200 mg.........................................................46
clozapine tab 25 mg (Clozaril)........................................... 46
clozapine tab 100 mg (Clozaril)......................................... 46
codeine sulfate tab 30 mg................................................. 55
codeine sulfate tab 60 mg................................................. 55
codeine sulfate tab 15 mg (Codeine sulfate).................... 55
colchicine w/ probenecid tab 0.5-500 mg.......................... 61
colestipol hcl granule packets 5 gm (Colestid
flavored)............................................................................ 27
93
2016
colestipol hcl granules 5 gm (Colestid flavored)................27
colestipol hcl tab 1 gm (Colestid)...................................... 27
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................. 13
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................. 13
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................ 35
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg................................................................... 6
CONDOMS – various......................................................... 14
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml................................................................................. 52
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml................................................................................. 52
CORIFACT – factor xiii concentrate (human) for inj kit
1000-1600 unit.................................................................. 71
CORTIFOAM – hydrocortisone acetate rectal foam 10%
(90 mg/dose).....................................................................79
CORTISONE ACETATE – cortisone acetate tab 25
mg...................................................................................... 12
COTELLIC – cobimetinib fumarate tab 20 mg (base
equivalent)......................................................................... 10
CREON – pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit...................................................... 40
CREON – pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit.................................................... 40
CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit.................................................. 40
CREON – pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit................................................ 40
CREON – pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit.............................................. 40
CRIXIVAN – indinavir sulfate cap 200 mg...........................6
CRIXIVAN – indinavir sulfate cap 400 mg...........................6
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................... 35
cromolyn sodium ophth soln 4%....................................... 78
cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)..... 40
CUPRIMINE – penicillamine cap 250 mg......................... 85
cyanocobalamin inj 1000 mcg/ml...................................... 71
cyanocobalamin tab cr 1000 mcg......................................71
cyanocobalamin tab 100 mcg............................................ 71
cyanocobalamin tab 250 mcg............................................ 71
cyanocobalamin tab 500 mcg............................................ 71
cyanocobalamin tab 1000 mcg.......................................... 71
cyanocobalamin tab sl 2500 mcg...................................... 71
cyclobenzaprine hcl tab 5 mg............................................ 65
cyclobenzaprine hcl tab 10 mg.......................................... 65
cyclopentolate hcl ophth soln 0.5% (Cyclogyl).................. 78
cyclopentolate hcl ophth soln 1% (Cyclogyl)..................... 78
cyclopentolate hcl ophth soln 2% (Cyclogyl)..................... 78
cyclosporine cap 25 mg (Sandimmune)............................ 85
cyclosporine cap 100 mg (Sandimmune).......................... 85
cyclosporine modified cap 25 mg (Neoral)........................ 85
cyclosporine modified cap 100 mg (Neoral)...................... 85
94
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg................................................................................ 85
cyclosporine modified oral soln 100 mg/ml (Neoral)......... 85
cyproheptadine hcl syrup 2 mg/5ml...................................31
cyproheptadine hcl tab 4 mg............................................. 31
CYSTAGON – cysteamine bitartrate cap 50 mg............... 42
CYSTAGON – cysteamine bitartrate cap 150 mg............. 42
D
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base
equivalent)........................................................................... 4
DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base
equivalent)........................................................................... 5
DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base
equivalent)........................................................................... 5
danazol cap 50 mg............................................................ 13
danazol cap 100 mg.......................................................... 13
danazol cap 200 mg.......................................................... 13
dantrolene sodium cap 100 mg......................................... 65
dantrolene sodium cap 25 mg (Dantrium)......................... 65
dantrolene sodium cap 50 mg (Dantrium)......................... 65
dapsone tab 25 mg.............................................................. 9
dapsone tab 100 mg............................................................ 9
DARAPRIM – pyrimethamine tab 25 mg.............................8
darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)
(Enablex)........................................................................... 41
darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)
(Enablex)........................................................................... 41
DECARA – cholecalciferol cap 25000 unit........................ 66
DELZICOL – mesalamine cap dr 400 mg......................... 40
demeclocycline hcl tab 150 mg........................................... 3
demeclocycline hcl tab 300 mg........................................... 3
DEPO-PROVERA CONTRACEPTIV –
medroxyprogesterone acetate im susp 150 mg/ml......... 14
DEPO-SUBQ PROVERA 104 – medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 14
desipramine hcl tab 10 mg (Norpramin)............................ 44
desipramine hcl tab 25 mg (Norpramin)............................ 44
desipramine hcl tab 50 mg (Norpramin)............................ 44
desipramine hcl tab 75 mg (Norpramin)............................ 44
desipramine hcl tab 100 mg (Norpramin).......................... 44
desipramine hcl tab 150 mg (Norpramin).......................... 44
desloratadine tab 5 mg (Clarinex)..................................... 32
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)..............................................................................19
desmopressin acetate nasal spray soln 0.01%
(Ddavp)..............................................................................20
desmopressin acetate nasal spray soln 0.01%
(refrigerated)..................................................................... 20
desmopressin acetate tab 0.1 mg (Ddavp)....................... 20
desmopressin acetate tab 0.2 mg (Ddavp)....................... 20
DESOGEN – desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg........................................................................ 14
desonide cream 0.05% (Desowen)................................... 82
desonide oint 0.05% (Desowen)........................................82
desoximetasone cream 0.25% (Topicort).......................... 82
2016
DESOXIMETASONE – desoximetasone cream
0.05%................................................................................ 82
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 12
dexamethasone elixir 0.5 mg/5ml...................................... 12
DEXAMETHASONE SODIUM PHOSPHATE –
dexamethasone sodium phosphate ophth soln 0.1%...... 77
dexamethasone tab 0.5 mg............................................... 12
dexamethasone tab 0.75 mg............................................. 12
dexamethasone tab 1.5 mg............................................... 12
dexamethasone tab 4 mg.................................................. 12
dexamethasone tab 6 mg.................................................. 12
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 50
dexmethylphenidate hcl tab 5 mg (Focalin)...................... 50
dexmethylphenidate hcl tab 10 mg (Focalin).................... 50
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)........................................................................ 50
dextroamphetamine sulfate tab 5 mg................................ 50
dextroamphetamine sulfate tab 10 mg.............................. 50
dextromethorphan-guaifenesin liquid 10-100 mg/5ml....... 33
DIALYVITE OMEGA-3 CONCENT – omega-3 fatty acids
cap 600 mg....................................................................... 68
DIAPHRAGMS – various................................................... 14
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg................................................................................ 61
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg................................................................................ 61
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg.................................................................. 61
diazepam conc 5 mg/ml..................................................... 43
DIAZEPAM – diazepam rectal gel delivery system 2.5
mg...................................................................................... 61
DIAZEPAM – diazepam rectal gel delivery system 10
mg...................................................................................... 61
DIAZEPAM – diazepam rectal gel delivery system 20
mg...................................................................................... 61
diazepam tab 2 mg (Valium)..............................................43
diazepam tab 5 mg (Valium)..............................................43
diazepam tab 10 mg (Valium)............................................43
diclofenac potassium tab 50 mg (Cataflam)...................... 58
diclofenac sod dr tab 75 mg & capsaicin cr 0.025% ther
pack (Derma silkrx diclopa)............................................. 58
diclofenac sodium gel 1% (Voltaren)................................. 81
diclofenac sodium ophth soln 0.1%................................... 78
diclofenac sodium tab delayed release 25 mg.................. 58
diclofenac sodium tab delayed release 50 mg.................. 58
diclofenac sodium tab delayed release 75 mg.................. 58
diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr)......... 58
diclofenac sod soln 1.5% & capsaicin cream 0.025% ther
pack (Dermacinrx lexitral)................................................ 81
dicloxacillin sodium cap 250 mg.......................................... 1
dicloxacillin sodium cap 500 mg.......................................... 1
dicyclomine hcl cap 10 mg (Bentyl)...................................38
dicyclomine hcl inj 10 mg/ml (Bentyl)................................ 38
dicyclomine hcl oral soln 10 mg/5ml................................. 38
dicyclomine hcl tab 20 mg (Bentyl)................................... 38
didanosine delayed release capsule 125 mg (Videx ec)..... 6
didanosine delayed release capsule 200 mg (Videx ec)..... 6
didanosine delayed release capsule 250 mg (Videx ec)..... 6
didanosine delayed release capsule 400 mg (Videx ec)..... 6
DIFFERIN – adapalene lotion 0.1%.................................. 80
diflunisal tab 500 mg.......................................................... 54
DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 30
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 30
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 30
DILANTIN – phenytoin sodium extended cap 30 mg........ 61
diltiazem hcl cap sr 12hr 60 mg........................................ 25
diltiazem hcl cap sr 12hr 90 mg........................................ 25
diltiazem hcl cap sr 12hr 120 mg...................................... 25
diltiazem hcl cap sr 24hr 120 mg...................................... 25
diltiazem hcl cap sr 24hr 180 mg...................................... 25
diltiazem hcl cap sr 24hr 240 mg...................................... 25
diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl extended release beads cap sr 24hr 120 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 180 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 240 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 300 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 360 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 420 mg
(Tiazac)............................................................................. 25
diltiazem hcl tab 90 mg...................................................... 25
diltiazem hcl tab 30 mg (Cardizem)...................................25
95
2016
diltiazem hcl tab 60 mg (Cardizem)...................................25
diltiazem hcl tab 120 mg (Cardizem).................................25
DIMETAPP COLD & ALLERGY – brompheniramine &
phenylephrine chew tab 1-2.5 mg................................... 33
diphenhydramine hcl cap 25 mg....................................... 32
diphenhydramine hcl cap 50 mg....................................... 32
diphenhydramine hcl elixir 12.5 mg/5ml............................ 32
diphenhydramine hcl liquid 12.5 mg/5ml........................... 32
diphenhydramine hcl tab 25 mg........................................ 32
diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml....... 33
diphenhydramine-phenylephrine soln 12.5-5 mg/5ml....... 33
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 38
dipyridamole tab 25 mg (Persantine)................................ 71
dipyridamole tab 50 mg (Persantine)................................ 71
dipyridamole tab 75 mg (Persantine)................................ 71
disopyramide phosphate cap 100 mg (Norpace).............. 29
disopyramide phosphate cap 150 mg (Norpace).............. 29
disulfiram tab 250 mg (Antabuse)..................................... 53
disulfiram tab 500 mg (Antabuse)..................................... 53
divalproex sodium tab delayed release 125 mg
(Depakote)........................................................................ 62
divalproex sodium tab delayed release 250 mg
(Depakote)........................................................................ 62
divalproex sodium tab delayed release 500 mg
(Depakote)........................................................................ 62
divalproex sodium tab sr 24 hr 250 mg (Depakote er)...... 62
divalproex sodium tab sr 24 hr 500 mg (Depakote er)...... 62
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 13
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 13
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 13
docosahexaenoic acid cap 200 mg................................... 68
docusate sodium cap 100 mg........................................... 37
docusate sodium cap 250 mg........................................... 37
docusate sodium liquid 150 mg/15ml................................ 37
dofetilide cap 125 mcg (0.125 mg) (Tikosyn).................... 29
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...................... 29
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................ 30
donepezil hydrochloride orally disintegrating tab 5 mg..... 53
donepezil hydrochloride orally disintegrating tab 10 mg
(Aricept odt)...................................................................... 53
donepezil hydrochloride tab 5 mg (Aricept).......................53
donepezil hydrochloride tab 10 mg (Aricept).....................53
dorzolamide hcl ophth soln 2% (Trusopt).......................... 78
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/
ml (Cosopt)....................................................................... 78
doxazosin mesylate tab 1 mg (Cardura)........................... 30
doxazosin mesylate tab 2 mg (Cardura)........................... 30
doxazosin mesylate tab 4 mg (Cardura)........................... 30
doxazosin mesylate tab 8 mg (Cardura)........................... 31
doxepin hcl cap 10 mg...................................................... 44
doxepin hcl cap 25 mg...................................................... 44
doxepin hcl cap 50 mg...................................................... 44
doxepin hcl cap 100 mg.................................................... 44
doxepin hcl cap 150 mg.................................................... 44
doxepin hcl conc 10 mg/ml................................................ 44
DOXEPIN HCL – doxepin hcl cap 75 mg..........................44
96
doxycycline hyclate cap 50 mg............................................3
doxycycline hyclate cap 100 mg (Vibramycin).................... 3
doxycycline hyclate tab delayed release 50 mg (Doryx)..... 3
doxycycline hyclate tab delayed release 200 mg
(Doryx)................................................................................. 3
doxycycline hyclate tab 20 mg............................................ 3
doxycycline hyclate tab 100 mg.......................................... 3
doxycycline monohydrate cap 50 mg.................................. 3
doxycycline monohydrate cap 100 mg (Monodox)..............3
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)........................................................................ 3
doxycycline monohydrate tab 50 mg (Adoxa)..................... 3
doxycycline monohydrate tab 75 mg (Adoxa)..................... 3
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................. 3
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act......................................................35
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act......................................................35
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)......................................................................... 44
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)......................................................................... 44
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)......................................................................... 44
dutasteride cap 0.5 mg (Avodart)...................................... 42
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............42
E
econazole nitrate cream 1%.............................................. 81
ED CHLORPED D – chlorpheniramine & phenylephrine
liquid 2-5 mg/ml................................................................ 33
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 6
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........2
ELIDEL – pimecrolimus cream 1%....................................83
ELLA – ulipristal acetate tab 30 mg.................................. 14
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
250 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
500 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
750 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
1000 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
1500 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
2000 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
3000 unit........................................................................... 71
EMEND – aprepitant capsule 40 mg................................. 39
EMEND – aprepitant capsule 80 mg................................. 39
EMEND – aprepitant capsule 125 mg............................... 39
EMEND – aprepitant capsule therapy pack 80 & 125
mg...................................................................................... 39
EMTRIVA – emtricitabine caps 200 mg.............................. 6
2016
EMTRIVA – emtricitabine soln 10 mg/ml............................. 6
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg...................................................................................... 21
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)......................................................................... 21
enalapril maleate tab 2.5 mg (Vasotec).............................21
enalapril maleate tab 5 mg (Vasotec)............................... 21
enalapril maleate tab 10 mg (Vasotec)............................. 21
enalapril maleate tab 20 mg (Vasotec)............................. 21
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml...................................................................... 58
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml........................................................................... 59
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml........................................ 59
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 71
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 71
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 71
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 71
enoxaparin sodium inj 100 mg/ml (Lovenox).................... 71
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 71
enoxaparin sodium inj 150 mg/ml (Lovenox).................... 71
enoxaparin sodium inj 300 mg/3ml (Lovenox).................. 71
entacapone tab 200 mg (Comtan).....................................64
entecavir tab 0.5 mg (Baraclude)........................................ 5
entecavir tab 1 mg (Baraclude)........................................... 5
EPIFOAM – pramoxine-hc aerosol foam 1-1%................. 82
epinastine hcl ophth soln 0.05% (Elestat)......................... 78
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................... 31
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................ 31
EPIVIR HBV – lamivudine oral soln 5 mg/ml...................... 5
EPOGEN – epoetin alfa inj 2000 unit/ml........................... 71
EPOGEN – epoetin alfa inj 3000 unit/ml........................... 71
EPOGEN – epoetin alfa inj 4000 unit/ml........................... 71
EPOGEN – epoetin alfa inj 10000 unit/ml......................... 71
EPOGEN – epoetin alfa inj 20000 unit/ml......................... 71
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg........................................................................................ 6
ergocalciferol cap 50000 unit (Drisdol).............................. 66
ERY-TAB – erythromycin tab delayed release 250 mg....... 2
ERY-TAB – erythromycin tab delayed release 333 mg....... 2
ERY-TAB – erythromycin tab delayed release 500 mg....... 2
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg................................................. 2
erythromycin gel 2% (Erygel)............................................ 80
erythromycin ophth oint 5 mg/gm...................................... 77
erythromycin pads 2%....................................................... 80
erythromycin soln 2%.........................................................80
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................... 44
escitalopram oxalate tab 5 mg (base equiv) (Lexapro)..... 44
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................... 44
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................... 44
estazolam tab 1 mg........................................................... 49
estazolam tab 2 mg........................................................... 49
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)...........................................................................13
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)...........................................................................13
estradiol tab 0.5 mg (Estrace)........................................... 13
estradiol tab 1 mg (Estrace).............................................. 13
estradiol tab 2 mg (Estrace).............................................. 13
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................... 13
estradiol td patch twice weekly 0.0375 mg/24hr (Vivelledot).................................................................................... 13
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................... 13
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................... 13
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................... 13
estradiol td patch weekly 0.025 mg/24hr (Climara)........... 13
estradiol td patch weekly 0.0375 mg/24hr (Climara)......... 13
estradiol td patch weekly 0.05 mg/24hr (Climara)............. 13
estradiol td patch weekly 0.06 mg/24hr (Climara)............. 13
estradiol td patch weekly 0.075 mg/24hr (Climara)........... 14
estradiol td patch weekly 0.1 mg/24hr (Climara)............... 14
estradiol valerate im in oil 20 mg/ml (Delestrogen)........... 14
estradiol valerate im in oil 40 mg/ml (Delestrogen)........... 14
ESTROPIPATE – estropipate tab 0.75 mg........................ 14
ESTROPIPATE – estropipate tab 1.5 mg.......................... 14
ESTROPIPATE – estropipate tab 3 mg............................. 14
ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg.................................................... 14
eszopiclone tab 1 mg (Lunesta)........................................ 49
eszopiclone tab 2 mg (Lunesta)........................................ 49
eszopiclone tab 3 mg (Lunesta)........................................ 49
ethambutol hcl tab 100 mg (Myambutol)............................. 4
ethambutol hcl tab 400 mg (Myambutol)............................. 4
ethosuximide cap 250 mg (Zarontin)................................. 62
ethosuximide soln 250 mg/5ml (Zarontin)......................... 62
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg...................................................................................... 20
etodolac cap 200 mg......................................................... 59
etodolac cap 300 mg......................................................... 59
etodolac tab 400 mg.......................................................... 59
etodolac tab 500 mg.......................................................... 59
etodolac tab sr 24hr 400 mg............................................. 59
etodolac tab sr 24hr 600 mg............................................. 59
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)........................................................................ 6
exemestane tab 25 mg (Aromasin)................................... 10
F
FALESSA – levonorgest-eth estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit.................................................................. 15
97
2016
famciclovir tab 125 mg (Famvir).......................................... 5
famotidine for susp 40 mg/5ml (Pepcid)............................38
famotidine tab 10 mg......................................................... 38
famotidine tab 20 mg (Pepcid).......................................... 38
famotidine tab 40 mg (Pepcid).......................................... 38
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg...................................................................................... 72
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg...................................................................................... 72
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap
(Tandem plus)................................................................... 71
FEIBA – antiinhibitor coagulant complex for inj.................72
felbamate susp 600 mg/5ml (Felbatol).............................. 62
felbamate tab 400 mg (Felbatol)....................................... 62
felbamate tab 600 mg (Felbatol)....................................... 62
felodipine tab sr 24hr 2.5 mg.............................................25
felodipine tab sr 24hr 5 mg................................................25
felodipine tab sr 24hr 10 mg..............................................25
fenofibrate micronized cap 43 mg..................................... 27
fenofibrate micronized cap 130 mg................................... 27
fenofibrate micronized cap 67 mg (Lofibra).......................27
fenofibrate micronized cap 134 mg (Lofibra).....................27
fenofibrate micronized cap 200 mg (Lofibra).....................27
fenofibrate tab 54 mg (Lofibra).......................................... 27
fenofibrate tab 160 mg (Lofibra)........................................ 28
fenofibrate tab 48 mg (Tricor)............................................ 27
fenofibrate tab 145 mg (Tricor).......................................... 27
fentanyl citrate lozenge on a handle 200 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 400 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 600 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 800 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 1200 mcg (Actiq)..... 55
fentanyl citrate lozenge on a handle 1600 mcg (Actiq)..... 55
fentanyl td patch 72hr 12 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 25 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 50 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 75 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 100 mcg/hr (Duragesic)................. 55
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg...................................................................................... 72
ferrous fumarate-folic acid tab 324-1 mg.......................... 72
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)......... 72
ferrous sulfate tab 325 mg (65 mg elemental fe).............. 72
fexofenadine hcl susp 30 mg/5ml (6 mg/ml)..................... 32
fexofenadine hcl tab 60 mg............................................... 32
fexofenadine hcl tab 180 mg............................................. 32
FINACEA – azelaic acid gel 15%...................................... 80
finasteride tab 5 mg (Proscar)........................................... 42
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................... 72
flavoxate hcl tab 100 mg................................................... 41
flecainide acetate tab 50 mg............................................. 30
flecainide acetate tab 100 mg........................................... 30
flecainide acetate tab 150 mg........................................... 30
FLEET LIQUID GLYCERIN SUP – glycerin enema adult
5.4 gm/average delivered dose....................................... 37
98
FLOVENT DISKUS – fluticasone propionate aer pow ba
50 mcg/blister................................................................... 35
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................. 35
FLOVENT DISKUS – fluticasone propionate aer pow ba
250 mcg/blister................................................................. 35
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve).......................................................... 36
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve).......................................................... 36
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................ 35
fluconazole for susp 10 mg/ml (Diflucan)............................ 4
fluconazole for susp 40 mg/ml (Diflucan)............................ 4
fluconazole tab 50 mg (Diflucan)......................................... 4
fluconazole tab 100 mg (Diflucan)....................................... 4
fluconazole tab 150 mg (Diflucan)....................................... 4
fluconazole tab 200 mg (Diflucan)....................................... 4
flucytosine cap 250 mg (Ancobon)...................................... 4
flucytosine cap 500 mg (Ancobon)...................................... 4
fludrocortisone acetate tab 0.1 mg.................................... 12
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................... 32
fluocinolone acetonide cream 0.01%................................ 82
fluocinolone acetonide cream 0.025% (Synalar)............... 82
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)................................................................ 82
fluocinolone acetonide oint 0.025% (Synalar)................... 82
fluocinolone acetonide soln 0.01% (Synalar).................... 82
fluocinonide cream 0.05%................................................. 82
fluocinonide emulsified base cream 0.05%....................... 82
fluocinonide gel 0.05%....................................................... 82
fluocinonide oint 0.05%...................................................... 82
fluocinonide soln 0.05%..................................................... 82
fluorometholone ophth susp 0.1% (Fml liquifilm).............. 77
fluorouracil cream 5% (Efudex)......................................... 83
fluorouracil soln 2%............................................................ 83
fluorouracil soln 5%............................................................ 83
fluoxetine hcl cap 10 mg (Prozac)..................................... 44
fluoxetine hcl cap 20 mg (Prozac)..................................... 44
fluoxetine hcl cap 40 mg (Prozac)..................................... 44
fluoxetine hcl solution 20 mg/5ml...................................... 45
fluoxetine hcl tab 10 mg.................................................... 45
fluoxetine hcl tab 20 mg.................................................... 45
fluphenazine decanoate inj 25 mg/ml................................ 46
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................... 46
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml....................................................................................... 47
fluphenazine hcl tab 1 mg................................................. 47
fluphenazine hcl tab 2.5 mg.............................................. 47
fluphenazine hcl tab 5 mg................................................. 47
fluphenazine hcl tab 10 mg............................................... 47
flurandrenolide cream 0.05% (Cordran)............................ 82
flurbiprofen sodium ophth soln 0.03% (Ocufen)................ 78
flurbiprofen tab 50 mg........................................................ 59
2016
flurbiprofen tab 100 mg...................................................... 59
flutamide cap 125 mg........................................................ 10
fluticasone propionate cream 0.05% (Cutivate)................ 82
fluticasone propionate nasal susp 50 mcg/act
(Flonase)........................................................................... 32
fluticasone propionate oint 0.005% (Cutivate).................. 82
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)..............28
fluvoxamine maleate tab 25 mg........................................ 45
fluvoxamine maleate tab 50 mg........................................ 45
fluvoxamine maleate tab 100 mg...................................... 45
folic acid tab 400 mcg........................................................ 72
folic acid tab 800 mcg........................................................ 72
folic acid tab 1 mg............................................................. 72
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........72
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............72
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard
rx)...................................................................................... 72
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).............................................................................. 72
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml.......................................................................... 20
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg...................................................................................... 21
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg...................................................................................... 21
fosinopril sodium tab 10 mg.............................................. 21
fosinopril sodium tab 20 mg.............................................. 21
fosinopril sodium tab 40 mg.............................................. 21
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova)............................................................................... 60
fructose-dextrose-phosphoric acid oral soln .................... 39
furosemide oral soln 10 mg/ml.......................................... 29
furosemide tab 20 mg (Lasix)............................................ 29
furosemide tab 40 mg (Lasix)............................................ 29
furosemide tab 80 mg (Lasix)............................................ 29
FUZEON – enfuvirtide for inj 90 mg.................................... 6
G
gabapentin cap 100 mg (Neurontin).................................. 62
gabapentin cap 300 mg (Neurontin).................................. 62
gabapentin cap 400 mg (Neurontin).................................. 62
gabapentin oral soln 250 mg/5ml (Neurontin)................... 62
gabapentin tab 600 mg (Neurontin)...................................62
gabapentin tab 800 mg (Neurontin)...................................62
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml...................................... 53
gemfibrozil tab 600 mg (Lopid).......................................... 28
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%.................................................................................. 81
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%.................................................................................. 81
gentamicin sulfate ophth oint 0.3%................................... 77
gentamicin sulfate ophth soln 0.3% (Garamycin)..............77
GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg............................................................ 6
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)....................................................................... 52
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 10
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 10
glimepiride tab 1 mg (Amaryl)........................................... 16
glimepiride tab 2 mg (Amaryl)........................................... 16
glimepiride tab 4 mg (Amaryl)........................................... 16
glipizide-metformin hcl tab 2.5-250 mg............................. 16
glipizide-metformin hcl tab 2.5-500 mg............................. 16
glipizide-metformin hcl tab 5-500 mg................................ 16
glipizide tab 5 mg (Glucotrol).............................................16
glipizide tab 10 mg (Glucotrol)...........................................16
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)......................... 16
glipizide tab sr 24hr 5 mg (Glucotrol xl)............................ 16
glipizide tab sr 24hr 10 mg (Glucotrol xl).......................... 16
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................. 16
glyburide-metformin tab 1.25-250 mg (Glucovance)......... 16
glyburide-metformin tab 2.5-500 mg (Glucovance)........... 16
glyburide-metformin tab 5-500 mg (Glucovance).............. 16
glyburide micronized tab 1.5 mg (Glynase).......................16
glyburide micronized tab 3 mg (Glynase)..........................16
glyburide micronized tab 6 mg (Glynase)..........................16
glyburide tab 1.25 mg........................................................ 16
glyburide tab 2.5 mg.......................................................... 16
glyburide tab 5 mg............................................................. 16
glycerin suppos 80.7%....................................................... 37
glycerin suppos 1 gm......................................................... 37
glycerin suppos 2 gm......................................................... 37
glycine irrigation soln 1.5%................................................ 42
glycopyrrolate tab 1 mg (Robinul)..................................... 38
glycopyrrolate tab 2 mg (Robinul forte)............................. 38
griseofulvin microsize susp 125 mg/5ml..............................4
griseofulvin microsize tab 500 mg (Grifulvin v)................... 4
griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............4
griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............4
guaifenesin-codeine soln 100-10 mg/5ml..........................33
guaifenesin liquid 100 mg/5ml........................................... 33
guanfacine hcl tab 1 mg (Tenex)....................................... 31
guanfacine hcl tab 2 mg (Tenex)....................................... 31
guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv)..... 50
H
halobetasol propionate cream 0.05% (Ultravate).............. 82
halobetasol propionate oint 0.05% (Ultravate).................. 82
99
2016
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50)................................................................... 47
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)................................................................. 47
haloperidol lactate oral conc 2 mg/ml................................47
haloperidol tab 0.5 mg....................................................... 47
haloperidol tab 1 mg.......................................................... 47
haloperidol tab 2 mg.......................................................... 47
haloperidol tab 5 mg.......................................................... 47
haloperidol tab 10 mg........................................................ 47
haloperidol tab 20 mg........................................................ 47
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 5
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 250 unit........................................................................ 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 500 unit........................................................................ 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 1000 unit...................................................................... 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 2000 unit...................................................................... 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 3000 unit...................................................................... 72
HEMOFIL M – antihemophilic factor (human) for inj 250
unit..................................................................................... 72
HEMOFIL M – antihemophilic factor (human) for inj 500
unit..................................................................................... 72
HEMOFIL M – antihemophilic factor (human) for inj 1000
unit..................................................................................... 72
HEMOFIL M – antihemophilic factor (human) for inj 1700
unit..................................................................................... 72
HUMALOG – insulin lispro (human) inj 100 unit/ml...........17
HUMALOG – insulin lispro (human) soln cartridge 100
unit/ml................................................................................ 17
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 100 unit/ml........................................................... 17
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 200 unit/ml........................................................... 17
HUMALOG MIX 50/50 – insulin lispro prot & lispro
(human) inj 100 unit/ml (50-50)....................................... 18
HUMALOG MIX 75/25 – insulin lispro prot & lispro
(human) inj 100 unit/ml (75-25)....................................... 18
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 18
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 18
HUMATE-P – antihemophilic factor/vwf (human) for inj
250-600 unit...................................................................... 73
HUMATE-P – antihemophilic factor/vwf (human) for inj
500-1200 unit.................................................................... 73
HUMATE-P – antihemophilic factor/vwf (human) for inj
1000-2400 unit.................................................................. 73
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml............................................................................59
HUMIRA – adalimumab prefilled syringe kit 20
mg/0.4ml............................................................................59
100
HUMIRA – adalimumab prefilled syringe kit 40
mg/0.8ml............................................................................59
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................... 59
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml............................................................................59
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml.................................................... 59
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml.................................................... 59
HUMULIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)...................................................... 18
HUMULIN 70/30 KWIKPEN – insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................... 18
HUMULIN N – insulin nph (human) (isophane) inj 100
unit/ml................................................................................ 18
HUMULIN N KWIKPEN – insulin nph (human) (isophane)
susp pen-injector 100 unit/ml........................................... 18
HUMULIN R – insulin regular (human) inj 100 unit/ml...... 17
HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml.................................................... 17
HUMULIN R U-500 KWIKPEN – insulin regular (human)
soln pen-injector 500 unit/ml............................................ 17
hydralazine hcl tab 10 mg................................................. 31
hydralazine hcl tab 25 mg................................................. 31
hydralazine hcl tab 50 mg................................................. 31
hydralazine hcl tab 100 mg............................................... 31
hydrochlorothiazide cap 12.5 mg (Microzide)................... 29
hydrochlorothiazide tab 12.5 mg....................................... 29
hydrochlorothiazide tab 25 mg.......................................... 29
hydrochlorothiazide tab 50 mg.......................................... 29
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................... 55
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet)........................................................................... 55
hydrocodone-acetaminophen tab 2.5-325 mg...................56
hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 56
hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 56
hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 56
hydrocodone-acetaminophen tab 10-300 mg (Xodol)....... 56
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)........... 56
hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)....... 56
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml............ 33
hydrocodone w/ homatropine tab 5-1.5 mg.......................33
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)......................................................33
hydrocortisone butyrate oint 0.1% (Locoid)....................... 82
hydrocortisone cream 0.5%............................................... 82
hydrocortisone cream 1%.................................................. 82
hydrocortisone cream 2.5%............................................... 82
hydrocortisone enema 100 mg/60ml (Cortenema)............ 79
hydrocortisone lotion 2.5%................................................ 82
hydrocortisone oint 0.5%................................................... 82
hydrocortisone oint 1%...................................................... 83
hydrocortisone oint 2.5%................................................... 83
hydrocortisone rectal cream 2.5% (Anusol-hc)................. 79
2016
hydrocortisone rectal cream 1% (Proctocort).................... 79
hydrocortisone tab 5 mg (Cortef).......................................12
hydrocortisone tab 10 mg (Cortef).....................................12
hydrocortisone tab 20 mg (Cortef).....................................12
hydrocortisone valerate cream 0.2%................................. 83
hydrocortisone valerate oint 0.2% (Westcort)................... 83
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)...................................................................................... 79
hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................56
hydromorphone hcl tab 2 mg (Dilaudid)............................ 56
hydromorphone hcl tab 4 mg (Dilaudid)............................ 56
hydromorphone hcl tab 8 mg (Dilaudid)............................ 56
hydroxychloroquine sulfate tab 200 mg (Plaquenil)............ 8
hydroxyurea cap 500 mg (Hydrea).................................... 10
HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/
ml....................................................................................... 43
hydroxyzine hcl im soln 50 mg/ml..................................... 43
hydroxyzine hcl syrup 10 mg/5ml...................................... 43
hydroxyzine hcl tab 10 mg.................................................43
hydroxyzine hcl tab 25 mg.................................................43
hydroxyzine hcl tab 50 mg.................................................43
hydroxyzine pamoate cap 25 mg (Vistaril)........................ 43
hydroxyzine pamoate cap 50 mg (Vistaril)........................ 43
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg.............................................................................. 43
hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 38
hyoscyamine sulfate soln 0.125 mg/ml............................. 38
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...........38
hyoscyamine sulfate tab 0.125 mg (Levsin)...................... 39
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)...............38
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)......... 39
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)............................................................................. 20
IBRANCE – palbociclib cap 75 mg....................................10
IBRANCE – palbociclib cap 100 mg..................................10
IBRANCE – palbociclib cap 125 mg..................................10
ibuprofen cap 200 mg........................................................ 59
ibuprofen susp 100 mg/5ml............................................... 59
ibuprofen tab 200 mg......................................................... 59
ibuprofen tab 400 mg......................................................... 59
ibuprofen tab 600 mg......................................................... 59
ibuprofen tab 800 mg......................................................... 59
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................... 10
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................... 10
imipramine hcl tab 10 mg (Tofranil)................................... 45
imipramine hcl tab 25 mg (Tofranil)................................... 45
imipramine hcl tab 50 mg (Tofranil)................................... 45
imipramine pamoate cap 75 mg........................................ 45
imipramine pamoate cap 100 mg...................................... 45
imipramine pamoate cap 125 mg...................................... 45
imipramine pamoate cap 150 mg...................................... 45
imiquimod cream 5% (Aldara)........................................... 83
IMITREX – sumatriptan nasal spray 5 mg/act...................60
IMITREX – sumatriptan nasal spray 20 mg/act.................60
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq).............................................. 36
indapamide tab 1.25 mg.................................................... 29
indapamide tab 2.5 mg...................................................... 29
indomethacin cap cr 75 mg............................................... 59
indomethacin cap 25 mg................................................... 59
indomethacin cap 50 mg................................................... 59
INSULIN PEN NEEDLES - VARIOUS............................... 84
INSULIN SYRINGES - VARIOUS...................................... 84
INTELENCE – etravirine tab 25 mg.................................... 6
INTELENCE – etravirine tab 100 mg.................................. 6
INTELENCE – etravirine tab 200 mg.................................. 6
INVIRASE – saquinavir mesylate cap 200 mg.................... 6
INVIRASE – saquinavir mesylate tab 500 mg.....................6
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 36
ipratropium bromide inhal soln 0.02%............................... 36
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)...........................................................................32
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)...........................................................................32
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)............................................................................ 22
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)............................................................................ 22
irbesartan tab 75 mg (Avapro)........................................... 22
irbesartan tab 150 mg (Avapro)......................................... 22
irbesartan tab 300 mg (Avapro)......................................... 22
iron combination cap.......................................................... 73
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af).................................................................... 73
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)..................................................................... 73
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg...................................................................................... 73
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c
plus)................................................................................... 73
irrigation solution, physiological......................................... 85
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv)........................................................................ 6
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv)........................................................................ 6
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv)..................................................................6
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................... 6
isoniazid tab 100 mg............................................................ 4
isoniazid tab 300 mg............................................................ 4
ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr
40 mg................................................................................ 26
ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30
mg...................................................................................... 26
isosorbide dinitrate tab 10 mg........................................... 26
isosorbide dinitrate tab 20 mg........................................... 26
isosorbide dinitrate tab 5 mg (Isordil titradose)................. 26
101
2016
isosorbide mononitrate tab 10 mg..................................... 26
isosorbide mononitrate tab 20 mg..................................... 26
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)............ 26
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)............ 26
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).......... 26
isotretinoin cap 10 mg........................................................80
isotretinoin cap 20 mg........................................................80
isotretinoin cap 30 mg........................................................80
isotretinoin cap 40 mg........................................................80
isradipine cap 2.5 mg.........................................................25
isradipine cap 5 mg............................................................25
itraconazole cap 100 mg (Sporanox).................................. 4
ivermectin tab 3 mg (Stromectol)........................................ 9
J
JANUMET – sitagliptin-metformin hcl tab 50-500 mg....... 16
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg..... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-500 mg......................................................................... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-1000 mg....................................................................... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
100-1000 mg.....................................................................16
JANUVIA – sitagliptin phosphate tab 25 mg (base
equiv)................................................................................. 17
JANUVIA – sitagliptin phosphate tab 50 mg (base
equiv)................................................................................. 17
JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv)................................................................................. 17
K
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)..................................................................... 6
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 6
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 6
KALYDECO – ivacaftor packet 50 mg............................... 37
KALYDECO – ivacaftor packet 75 mg............................... 37
KALYDECO – ivacaftor tab 150 mg.................................. 37
ketoconazole cream 2%.....................................................81
ketoconazole shampoo 2% (Nizoral)................................. 81
ketoconazole tab 200 mg.................................................... 4
ketoprofen cap 50 mg........................................................ 59
ketoprofen cap 75 mg........................................................ 59
ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml)....... 59
KETOROLAC TROMETHAMINE – ketorolac
tromethamine inj 60 mg/2ml (30 mg/ml).......................... 59
ketorolac tromethamine ophth soln 0.5% (Acular)............ 79
ketorolac tromethamine ophth soln 0.4% (Acular ls).........78
ketorolac tromethamine tab 10 mg.................................... 59
ketotifen fumarate ophth soln 0.025% (base equiv).......... 79
KOATE-DVI – antihemophilic factor (human) for inj 250
unit..................................................................................... 73
KOATE-DVI – antihemophilic factor (human) for inj 500
unit..................................................................................... 73
KOATE-DVI – antihemophilic factor (human) for inj 1000
unit..................................................................................... 73
102
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 250 unit................................................................... 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 500 unit................................................................... 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 1000 unit................................................................. 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 2000 unit................................................................. 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 3000 unit................................................................. 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 250 unit...................................... 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 500 unit...................................... 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 1000 unit.................................... 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 2000 unit.................................... 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 3000 unit.................................... 73
KONSYL-D – psyllium powder 52.3%............................... 37
KONSYL – psyllium powder 60.3%................................... 37
KONSYL – psyllium powder 71.67%................................. 37
KOVALTRY – antihemophilic factor (recombinant) for inj
250 unit............................................................................. 73
KOVALTRY – antihemophilic factor (recombinant) for inj
500 unit............................................................................. 73
KOVALTRY – antihemophilic factor (recombinant) for inj
1000 unit........................................................................... 74
KOVALTRY – antihemophilic factor (recombinant) for inj
2000 unit........................................................................... 74
KOVALTRY – antihemophilic factor (recombinant) for inj
3000 unit........................................................................... 74
K-PHOS – potassium phosphate monobasic tab 500
mg...................................................................................... 67
L
labetalol hcl tab 100 mg (Trandate)................................... 23
labetalol hcl tab 200 mg (Trandate)................................... 24
labetalol hcl tab 300 mg (Trandate)................................... 24
lactated ringer's for irrigation............................................. 85
lactic acid (ammonium lactate) lotion 12% (Lachydrin)............................................................................... 83
lactulose (encephalopathy) solution 10 gm/15ml.............. 40
lactulose solution 10 gm/15ml........................................... 37
lamivudine oral soln 10 mg/ml (Epivir)................................ 6
lamivudine tab 150 mg (Epivir)............................................ 6
lamivudine tab 300 mg (Epivir)............................................ 6
lamivudine tab 100 mg (Epivir hbv)..................................... 5
lamivudine-zidovudine tab 150-300 mg (Combivir)............. 7
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................... 62
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................... 62
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................... 62
2016
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................... 62
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)...................................................................... 62
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)...................................................................... 62
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit
(Lamictal odt).................................................................... 62
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit
(Lamictal odt).................................................................... 62
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit
(Lamictal odt).................................................................... 62
lamotrigine tab 25 mg (Lamictal)....................................... 62
lamotrigine tab 100 mg (Lamictal)..................................... 63
lamotrigine tab 150 mg (Lamictal)..................................... 63
lamotrigine tab 200 mg (Lamictal)..................................... 63
lamotrigine tab sr 24hr 25 mg (Lamictal xr)...................... 62
lamotrigine tab sr 24hr 50 mg (Lamictal xr)...................... 62
lamotrigine tab sr 24hr 100 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 200 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 250 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 300 mg (Lamictal xr).................... 62
LANCETS – VARIOUS...................................................... 84
lansoprazole cap delayed release 15 mg (Prevacid)........ 39
lansoprazole cap delayed release 30 mg (Prevacid)........ 39
LANTUS – insulin glargine inj 100 unit/ml......................... 18
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml........................................................................ 18
latanoprost ophth soln 0.005% (Xalatan).......................... 78
leflunomide tab 10 mg (Arava).......................................... 59
leflunomide tab 20 mg (Arava).......................................... 59
LENVIMA 14MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)................................ 10
LENVIMA 18MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 (2) mg (18 mg daily dose)........................... 10
LENVIMA 24MG DAILY DOSE – lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)........................... 10
LENVIMA 10MG DAILY DOSE – lenvatinib cap therapy
pack 10 mg (10 mg daily dose)....................................... 10
LENVIMA 20MG DAILY DOSE – lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................. 10
LENVIMA 8MG DAILY DOSE – lenvatinib cap therapy
pack 4 (2) mg (8 mg daily dose)..................................... 10
letrozole tab 2.5 mg (Femara)........................................... 10
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg...................................................................................... 10
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg...................................................................................... 10
leucovorin calcium tab 5 mg.............................................. 10
leucovorin calcium tab 25 mg............................................ 11
LEUKERAN – chlorambucil tab 2 mg................................11
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
LEVEMIR FLEXTOUCH – insulin detemir soln peninjector 100 unit/ml........................................................... 18
LEVEMIR – insulin detemir inj 100 unit/ml........................ 18
levetiracetam oral soln 100 mg/ml (Keppra)..................... 63
levetiracetam tab 250 mg (Keppra)................................... 63
levetiracetam tab 500 mg (Keppra)................................... 63
levetiracetam tab 750 mg (Keppra)................................... 63
levetiracetam tab 1000 mg (Keppra)................................. 63
levetiracetam tab sr 24hr 500 mg (Keppra xr).................. 63
levetiracetam tab sr 24hr 750 mg (Keppra xr).................. 63
levobunolol hcl ophth soln 0.5% (Betagan)....................... 78
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)........... 20
levocarnitine tab 330 mg (Carnitor)................................... 20
levocetirizine dihydrochloride tab 5 mg (Xyzal)................. 32
levofloxacin ophth soln 0.5%............................................. 77
levofloxacin oral soln 25 mg/ml (Levaquin)......................... 3
levofloxacin tab 250 mg (Levaquin).....................................3
levofloxacin tab 500 mg (Levaquin).....................................3
levofloxacin tab 750 mg (Levaquin).....................................3
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg.................................................................................... 15
LEVONORGESTREL – levonorgestrel tab 0.75 mg......... 15
levonorgestrel tab 1.5 mg (Plan b one-step)..................... 15
levothyroxine sodium tab 25 mcg (Synthroid)................... 18
levothyroxine sodium tab 50 mcg (Synthroid)................... 19
levothyroxine sodium tab 75 mcg (Synthroid)................... 19
levothyroxine sodium tab 88 mcg (Synthroid)................... 19
levothyroxine sodium tab 100 mcg (Synthroid)................. 19
levothyroxine sodium tab 112 mcg (Synthroid)................. 19
levothyroxine sodium tab 125 mcg (Synthroid)................. 19
levothyroxine sodium tab 137 mcg (Synthroid)................. 19
levothyroxine sodium tab 150 mcg (Synthroid)................. 19
levothyroxine sodium tab 175 mcg (Synthroid)................. 19
levothyroxine sodium tab 200 mcg (Synthroid)................. 19
levothyroxine sodium tab 300 mcg (Synthroid)................. 19
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................... 7
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................... 7
lidocaine hcl cream 3%...................................................... 83
lidocaine hcl gel 2%........................................................... 83
lidocaine hcl soln 4% (Xylocaine)...................................... 83
lidocaine hcl viscous soln 2%............................................ 79
lidocaine oint 5%................................................................ 83
lidocaine patch 5% (Lidoderm).......................................... 83
lidocaine-prilocaine cream 2.5-2.5% (Emla)......................83
lidocaine-prilocaine cream kit 2.5-2.5%............................. 83
linezolid for susp 100 mg/5ml (Zyvox).................................9
linezolid tab 600 mg (Zyvox)............................................... 9
liothyronine sodium tab 5 mcg (Cytomel).......................... 19
liothyronine sodium tab 25 mcg (Cytomel)........................ 19
liothyronine sodium tab 50 mcg (Cytomel)........................ 19
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)........................................................................ 21
103
2016
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)........................................................................ 21
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)........................................................................ 21
lisinopril tab 5 mg (Prinivil)................................................ 21
lisinopril tab 10 mg (Prinivil).............................................. 22
lisinopril tab 20 mg (Prinivil).............................................. 22
lisinopril tab 2.5 mg (Zestril).............................................. 21
lisinopril tab 30 mg (Zestril)............................................... 22
lisinopril tab 40 mg (Zestril)............................................... 22
lithium carbonate cap 300 mg........................................... 47
lithium carbonate cap 150 mg (Lithium carbonate)........... 47
lithium carbonate cap 600 mg (Lithium carbonate)........... 47
lithium carbonate tab cr 450 mg........................................ 47
lithium carbonate tab cr 300 mg (Lithobid)........................ 47
lithium carbonate tab 300 mg............................................ 47
LITHIUM – lithium oral solution 8 meq/5ml....................... 47
LOESTRIN 1.5/30-21 – norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................ 15
LO LOESTRIN FE – norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2).........................................................15
loperamide hcl cap 2 mg................................................... 38
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)........................... 38
loperamide hcl tab 2 mg.................................................... 38
loratadine syrup 5 mg/5ml................................................. 32
loratadine tab 10 mg.......................................................... 32
lorazepam conc 2 mg/ml (Lorazepam intensol)................ 43
lorazepam tab 0.5 mg (Ativan).......................................... 43
lorazepam tab 1 mg (Ativan)............................................. 43
lorazepam tab 2 mg (Ativan)............................................. 43
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
(Hyzaar).............................................................................22
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar)...................................................................... 22
losartan potassium & hydrochlorothiazide tab 100-25 mg
(Hyzaar).............................................................................23
losartan potassium tab 25 mg (Cozaar)............................ 23
losartan potassium tab 50 mg (Cozaar)............................ 23
losartan potassium tab 100 mg (Cozaar).......................... 23
LOTEMAX – loteprednol etabonate ophth susp 0.5%...... 77
lovastatin tab 10 mg...........................................................28
lovastatin tab 20 mg (Mevacor)......................................... 28
lovastatin tab 40 mg (Mevacor)......................................... 28
loxapine succinate cap 5 mg............................................. 47
loxapine succinate cap 10 mg........................................... 47
loxapine succinate cap 25 mg........................................... 47
loxapine succinate cap 50 mg........................................... 47
LYNPARZA – olaparib cap 50 mg..................................... 11
LYRICA – pregabalin cap 25 mg....................................... 63
LYRICA – pregabalin cap 50 mg....................................... 63
LYRICA – pregabalin cap 75 mg....................................... 63
LYRICA – pregabalin cap 100 mg..................................... 63
LYRICA – pregabalin cap 150 mg..................................... 63
LYRICA – pregabalin cap 200 mg..................................... 63
LYRICA – pregabalin cap 225 mg..................................... 63
LYRICA – pregabalin cap 300 mg..................................... 63
104
LYRICA – pregabalin soln 20 mg/ml................................. 63
M
magnesium citrate soln...................................................... 37
magnesium oxide tab 400 mg........................................... 38
malathion lotion 0.5% (Ovide)........................................... 83
meclizine hcl tab 12.5 mg.................................................. 39
meclizine hcl tab 25 mg..................................................... 39
medroxyprogesterone acetate im susp 150 mg/ml (Depoprovera contrac)............................................................... 15
medroxyprogesterone acetate tab 2.5 mg (Provera)........ 14
medroxyprogesterone acetate tab 5 mg (Provera)........... 14
medroxyprogesterone acetate tab 10 mg (Provera)......... 14
mefloquine hcl tab 250 mg.................................................. 8
megestrol acetate susp 625 mg/5ml (Megace es)............ 14
megestrol acetate susp 40 mg/ml (Megace oral).............. 11
megestrol acetate tab 20 mg............................................. 11
megestrol acetate tab 40 mg............................................. 11
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent).............................................................. 11
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 11
meloxicam tab 7.5 mg (Mobic).......................................... 59
meloxicam tab 15 mg (Mobic)........................................... 59
memantine hcl oral solution 2 mg/ml (Namenda)..............53
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pak)....................................................53
memantine hcl tab 5 mg (Namenda)................................. 53
memantine hcl tab 10 mg (Namenda)............................... 53
meperidine hcl tab 50 mg (Demerol)................................. 56
meperidine hcl tab 100 mg (Demerol)............................... 56
MEPHYTON – phytonadione tab 5 mg............................. 66
mercaptopurine tab 50 mg (Purinethol)............................. 11
mesalamine enema 4 gm.................................................. 40
METAMUCIL MULTIHEALTH FIB – psyllium powder
55.46%.............................................................................. 37
METAMUCIL MULTIHEALTH FIB – psyllium powder
63%................................................................................... 37
METAMUCIL SMOOTH TEXTURE – psyllium powder
63%................................................................................... 37
metformin hcl tab 500 mg (Glucophage)........................... 17
metformin hcl tab 850 mg (Glucophage)........................... 17
metformin hcl tab 1000 mg (Glucophage)......................... 17
metformin hcl tab sr 24hr 500 mg (Glucophage xr).......... 17
metformin hcl tab sr 24hr 750 mg (Glucophage xr).......... 17
methadone hcl conc 10 mg/ml (Methadose)..................... 56
methadone hcl soln 5 mg/5ml (Methadone hcl)................ 56
methadone hcl soln 10 mg/5ml (Methadone hcl).............. 56
methadone hcl tab for oral susp 40 mg............................ 56
methadone hcl tab 10 mg (Dolophine).............................. 56
methadone hcl tab 5 mg (Dolophine hcl).......................... 56
methamphetamine hcl tab 5 mg (Desoxyn)...................... 50
methazolamide tab 25 mg (Neptazane)............................ 29
methazolamide tab 50 mg (Neptazane)............................ 29
methenamine hippurate tab 1 gm (Hiprex)........................41
2016
methenamine-hyoscamine-meth blue-sod phos cap 120
mg...................................................................................... 41
methenamine mandelate tab 1 gm.................................... 41
methimazole tab 5 mg (Tapazole)..................................... 19
methimazole tab 10 mg (Tapazole)................................... 19
methocarbamol tab 750 mg (Robaxin-750)....................... 65
methocarbamol tab 500 mg (Robaxin).............................. 65
METHOTREXATE SODIUM – methotrexate sodium inj
250 mg/10ml (25 mg/ml).................................................. 11
methotrexate sodium tab 2.5 mg (base equiv).................. 11
methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 83
methscopolamine bromide tab 2.5 mg (Pamine).............. 39
methscopolamine bromide tab 5 mg (Pamine forte)......... 39
methyldopa tab 250 mg..................................................... 31
methyldopa tab 500 mg..................................................... 31
methylergonovine maleate tab 0.2 mg.............................. 20
methylphenidate hcl cap cr 10 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 20 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)...... 51
methylphenidate hcl cap cr 50 mg (cd) (Metadate cd)...... 51
methylphenidate hcl cap cr 60 mg (cd) (Metadate cd)...... 51
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)..... 51
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)..... 51
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)..... 51
methylphenidate hcl chew tab 2.5 mg (Methylin).............. 51
methylphenidate hcl chew tab 5 mg (Methylin)................. 51
methylphenidate hcl chew tab 10 mg (Methylin)............... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 27 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 36 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 54 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 18 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 27 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 36 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 54 mg................................................................... 51
methylphenidate hcl soln 5 mg/5ml (Methylin).................. 51
methylphenidate hcl soln 10 mg/5ml (Methylin)................ 51
methylphenidate hcl tab cr 10 mg..................................... 51
methylphenidate hcl tab cr 20 mg (Ritalin sr).................... 51
methylphenidate hcl tab 5 mg (Ritalin).............................. 51
methylphenidate hcl tab 10 mg (Ritalin)............................ 51
methylphenidate hcl tab 20 mg (Ritalin)............................ 51
methylprednisolone tab 4 mg (Medrol).............................. 12
methylprednisolone tab 8 mg (Medrol).............................. 12
methylprednisolone tab 16 mg (Medrol)............................ 12
methylprednisolone tab 32 mg (Medrol)............................ 12
methyltestosterone cap 10 mg (Testred)........................... 13
METIPRANOLOL – metipranolol ophth soln 0.3%............78
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)............. 40
metoclopramide hcl tab 5 mg (Reglan)............................. 41
metoclopramide hcl tab 10 mg (Reglan)........................... 41
metolazone tab 10 mg....................................................... 29
metolazone tab 2.5 mg (Zaroxolyn)...................................29
metolazone tab 5 mg (Zaroxolyn)......................................29
metoprolol & hydrochlorothiazide tab 100-50 mg..............24
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..................................................................24
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..................................................................24
metoprolol succinate tab sr 24hr 25 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 50 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 100 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 200 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol tartrate tab 25 mg............................................ 24
metoprolol tartrate tab 50 mg (Lopressor).........................24
metoprolol tartrate tab 100 mg (Lopressor).......................24
metronidazole cap 375 mg (Flagyl)..................................... 9
metronidazole cream 0.75% (Metrocream)....................... 80
metronidazole gel 0.75%................................................... 80
metronidazole gel 1% (Metrogel).......................................80
metronidazole tab 250 mg (Flagyl)...................................... 9
metronidazole tab 500 mg (Flagyl)...................................... 9
metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 42
mexiletine hcl cap 150 mg................................................. 30
mexiletine hcl cap 200 mg................................................. 30
mexiletine hcl cap 250 mg................................................. 30
miconazole nitrate aerosol pow 2%...................................81
miconazole nitrate cream 2%............................................ 81
miconazole nitrate vaginal cream 2%................................42
midodrine hcl tab 2.5 mg................................................... 31
midodrine hcl tab 5 mg...................................................... 31
midodrine hcl tab 10 mg.................................................... 31
MIFEPREX – mifepristone tab 200 mg............................. 20
minocycline hcl cap 50 mg (Minocin).................................. 3
minocycline hcl cap 75 mg (Minocin).................................. 3
minocycline hcl cap 100 mg (Minocin)................................ 3
minocycline hcl tab 50 mg................................................... 3
minocycline hcl tab 75 mg................................................... 3
minocycline hcl tab 100 mg................................................. 3
minoxidil tab 2.5 mg........................................................... 31
minoxidil tab 10 mg............................................................ 31
MIRENA – levonorgestrel releasing iud 20 mcg/day (52
mg total)............................................................................ 15
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)................................................................................ 45
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)................................................................................ 45
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)................................................................................ 45
105
2016
mirtazapine tab 7.5 mg...................................................... 45
mirtazapine tab 15 mg (Remeron).....................................45
mirtazapine tab 30 mg (Remeron).....................................45
mirtazapine tab 45 mg (Remeron).....................................45
misoprostol tab 100 mcg (Cytotec)....................................39
misoprostol tab 200 mcg (Cytotec)....................................39
modafinil tab 100 mg (Provigil).......................................... 51
modafinil tab 200 mg (Provigil).......................................... 51
MODICON – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg........................................................................ 15
moexipril hcl tab 7.5 mg (Univasc).................................... 22
moexipril hcl tab 15 mg (Univasc)..................................... 22
moexipril-hydrochlorothiazide tab 7.5-12.5 mg................. 22
moexipril-hydrochlorothiazide tab 15-25 mg..................... 22
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)............................................................................ 22
mometasone furoate cream 0.1% (Elocon)....................... 83
mometasone furoate nasal susp 50 mcg/act
(Nasonex).......................................................................... 32
mometasone furoate oint 0.1% (Elocon)........................... 83
mometasone furoate solution 0.1% (lotion) (Elocon)........ 83
MONOCLATE-P – antihemophilic factor (human) for inj kit
250 unit............................................................................. 74
MONOCLATE-P – antihemophilic factor (human) for inj kit
1000 unit........................................................................... 74
MONOCLATE-P – antihemophilic factor (human) for inj kit
1500 unit........................................................................... 74
MONONINE – coagulation factor ix for inj 500 unit........... 74
MONONINE – coagulation factor ix for inj 1000 unit......... 74
montelukast sodium chew tab 4 mg (base equiv)
(Singulair).......................................................................... 36
montelukast sodium chew tab 5 mg (base equiv)
(Singulair).......................................................................... 36
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair).............................................................. 36
montelukast sodium tab 10 mg (base equiv)
(Singulair).......................................................................... 36
morphine sulfate cap sr 24hr 10 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 20 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 30 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 50 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 60 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 80 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 100 mg (Kadian)................. 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 30 mg................................................................... 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 45 mg................................................................... 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 60 mg................................................................... 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 75 mg................................................................... 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 90 mg................................................................... 57
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 120 mg................................................................. 57
106
MORPHINE SULFATE – morphine sulfate suppos 5
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 10
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 20
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 30
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate tab 15 mg...... 56
MORPHINE SULFATE – morphine sulfate tab 30 mg...... 56
morphine sulfate oral soln 10 mg/5ml............................... 57
morphine sulfate oral soln 20 mg/5ml............................... 57
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)........... 57
morphine sulfate tab cr 15 mg (Ms contin)........................57
morphine sulfate tab cr 30 mg (Ms contin)........................57
morphine sulfate tab cr 60 mg (Ms contin)........................57
morphine sulfate tab cr 100 mg (Ms contin)......................57
morphine sulfate tab cr 200 mg (Ms contin)......................57
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)......................................................................... 30
multiple vitamins w/ iron tab ............................................. 66
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite).............................................................................66
multiple vitamins w/ minerals cap...................................... 66
multiple vitamins w/ minerals chew tab............................. 66
multiple vitamins w/ minerals tab (Strovite forte)...............66
multiple vitamin tab ........................................................... 66
mupirocin oint 2% (Bactroban).......................................... 81
mycophenolate mofetil cap 250 mg (Cellcept).................. 85
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)........................................................................... 85
mycophenolate mofetil tab 500 mg (Cellcept)................... 85
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv) (Myfortic)................................................................ 85
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv) (Myfortic)................................................................ 85
MYLERAN – busulfan tab 2 mg........................................ 11
N
nabumetone tab 500 mg.................................................... 59
nabumetone tab 750 mg.................................................... 59
nadolol tab 20 mg (Corgard)............................................. 24
nadolol tab 40 mg (Corgard)............................................. 24
nadolol tab 80 mg (Corgard)............................................. 24
naftifine hcl cream 2% (Naftin).......................................... 81
naltrexone hcl tab 50 mg (Revia)...................................... 53
NAPHAZOLINE HCL – naphazoline hcl ophth soln
0.1%.................................................................................. 79
naproxen sodium tab 220 mg............................................ 60
naproxen sodium tab 275 mg (Anaprox)........................... 60
naproxen sodium tab 550 mg (Anaprox ds)...................... 60
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)......................................................................... 60
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)......................................................................... 60
naproxen susp 125 mg/5ml (Naprosyn)............................ 60
2016
naproxen tab ec 375 mg (Ec-naprosyn)............................ 60
naproxen tab ec 500 mg (Ec-naprosyn)............................ 60
naproxen tab 250 mg (Naprosyn)......................................60
naproxen tab 375 mg (Naprosyn)......................................60
naproxen tab 500 mg (Naprosyn)......................................60
naratriptan hcl tab 1 mg (base equiv) (Amerge)............... 60
naratriptan hcl tab 2.5 mg (base equiv) (Amerge).............60
NATACYN – natamycin ophth susp 5%............................ 77
nateglinide tab 60 mg (Starlix)...........................................17
nateglinide tab 120 mg (Starlix).........................................17
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11).............................................15
nefazodone hcl tab 50 mg................................................. 45
nefazodone hcl tab 250 mg............................................... 45
neomycin-bacitracin-polymyxin oint .................................. 81
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin................................................................................ 77
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml (Neosporin)...................................................... 77
neomycin-polymyxin b gu irrigation soln (Neosporin gu
irrigan)............................................................................... 42
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)........................................................................... 77
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)........................................................................... 77
neomycin-polymyxin-hc otic soln 1% (Cortisporin)........... 79
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/
ml-1%................................................................................ 79
neomycin sulfate tab 500 mg.............................................. 3
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 74
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/
ml)...................................................................................... 74
NEUPOGEN – filgrastim soln prefilled syringe 300
mcg/0.5ml.......................................................................... 74
NEUPOGEN – filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)...................................................74
nevirapine tab 200 mg (Viramune)...................................... 7
nevirapine tab sr 24hr 100 mg (Viramune xr)..................... 7
nevirapine tab sr 24hr 400 mg (Viramune xr)..................... 7
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 11
NEXPLANON – etonogestrel subdermal implant 68
mg...................................................................................... 15
niacin cap cr 250 mg......................................................... 66
niacin cap cr 500 mg......................................................... 66
niacin tab cr 250 mg.......................................................... 66
niacin tab cr 500 mg.......................................................... 66
niacin tab cr 750 mg.......................................................... 66
niacin tab 50 mg................................................................ 66
niacin tab 100 mg.............................................................. 66
niacin tab 500 mg.............................................................. 66
NIACIN TR – niacin tab cr 1000 mg................................. 66
nicardipine hcl cap 20 mg..................................................25
nicardipine hcl cap 30 mg..................................................25
nicotine polacrilex gum 2 mg............................................. 53
nicotine polacrilex gum 4 mg............................................. 53
nicotine td patch 24hr 7 mg/24hr.......................................53
nicotine td patch 24hr 14 mg/24hr.....................................53
nicotine td patch 24hr 21 mg/24hr.....................................53
nifedipine cap 20 mg..........................................................26
nifedipine cap 10 mg (Procardia)...................................... 26
nifedipine tab sr 24hr 30 mg (Adalat cc)........................... 26
nifedipine tab sr 24hr 60 mg (Adalat cc)........................... 26
nifedipine tab sr 24hr 90 mg (Adalat cc)........................... 26
nifedipine tab sr 24hr osmotic release 30 mg (Procardia
xl)....................................................................................... 26
nifedipine tab sr 24hr osmotic release 60 mg (Procardia
xl)....................................................................................... 26
nifedipine tab sr 24hr osmotic release 90 mg (Procardia
xl)....................................................................................... 26
nimodipine cap 30 mg........................................................26
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................... 41
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................... 41
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................... 41
nitrofurantoin monohydrate macrocrystalline cap 100 mg
(Macrobid)......................................................................... 41
nitrofurantoin susp 25 mg/5ml (Furadantin)...................... 41
nitroglycerin cap cr 2.5 mg................................................ 27
nitroglycerin cap cr 6.5 mg................................................ 27
nitroglycerin cap cr 9 mg................................................... 27
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 27
NITROSTAT – nitroglycerin sl tab 0.3 mg......................... 27
NITROSTAT – nitroglycerin sl tab 0.4 mg......................... 27
NITROSTAT – nitroglycerin sl tab 0.6 mg......................... 27
nizatidine cap 150 mg........................................................ 39
nizatidine cap 300 mg (Axid)............................................. 39
NIZATIDINE – nizatidine oral soln 15 mg/ml..................... 39
NONOXYNOL-9 – various................................................. 42
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................... 14
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose).................................................... 14
norethindrone acetate tab 5 mg (Aygestin)....................... 14
NORINYL 1+35 – norethindrone & ethinyl estradiol tab 1
mg-35 mcg........................................................................ 15
nortriptyline hcl cap 10 mg (Pamelor)............................... 45
nortriptyline hcl cap 25 mg (Pamelor)............................... 45
nortriptyline hcl cap 50 mg (Pamelor)............................... 45
nortriptyline hcl cap 75 mg (Pamelor)............................... 45
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................... 45
NORVIR – ritonavir cap 100 mg.......................................... 7
NORVIR – ritonavir oral soln 80 mg/ml............................... 7
NORVIR – ritonavir tab 100 mg.......................................... 7
NOVOEIGHT – antihemophilic factor (recombinant) for inj
250 unit............................................................................. 74
107
2016
NOVOEIGHT – antihemophilic factor (recombinant) for inj
500 unit............................................................................. 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
1000 unit........................................................................... 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
1500 unit........................................................................... 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
2000 unit........................................................................... 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
3000 unit........................................................................... 74
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)...................................................... 18
NOVOLIN 70/30 RELION – insulin nph isophane &
regular human inj 100 unit/ml (70-30)............................. 18
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml....................................................................................... 18
NOVOLIN N RELION – insulin nph (human) (isophane) inj
100 unit/ml........................................................................ 18
NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 17
NOVOLIN R RELION – insulin regular (human) inj 100
unit/ml................................................................................ 18
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml........................................................................ 17
NOVOLOG – insulin aspart inj 100 unit/ml....................... 17
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 18
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)............................. 18
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml................................................................................ 17
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
1 mg (1000 mcg).............................................................. 74
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
2 mg (2000 mcg).............................................................. 74
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
5 mg (5000 mcg).............................................................. 74
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
8 mg (8000 mcg).............................................................. 74
NOXAFIL – posaconazole susp 40 mg/ml.......................... 4
NOXAFIL – posaconazole tab delayed release 100 mg..... 4
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg........................................................................... 53
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................ 15
NUWIQ – antihemophilic factor (recombinant) for inj kit
250 unit............................................................................. 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
500 unit............................................................................. 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
1000 unit........................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
2000 unit........................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 250
unit..................................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 500
unit..................................................................................... 75
108
NUWIQ – antihemophilic factor (recombinant) for inj 1000
unit..................................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 2000
unit..................................................................................... 75
nystatin cream 100000 unit/gm......................................... 81
nystatin oint 100000 unit/gm..............................................81
nystatin oral powder............................................................. 4
nystatin susp 100000 unit/ml............................................. 79
nystatin tab 500000 unit...................................................... 4
nystatin topical powder ..................................................... 81
O
OBIZUR – antihemophilic factor (recomb porc) rpfviii for
inj 500 unit........................................................................ 75
OCEAN BLUE MINICAPS OMEGA – omega-3 fatty acids
cap 350 mg....................................................................... 68
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)..................................................................... 20
ofloxacin ophth soln 0.3% (Ocuflox).................................. 77
ofloxacin otic soln 0.3%..................................................... 79
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................... 15
olanzapine for im inj 10 mg (Zyprexa)............................... 47
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)................................................................................. 47
olanzapine tab 2.5 mg (Zyprexa).......................................47
olanzapine tab 5 mg (Zyprexa)..........................................47
olanzapine tab 7.5 mg (Zyprexa).......................................47
olanzapine tab 10 mg (Zyprexa)........................................47
olanzapine tab 15 mg (Zyprexa)........................................47
olanzapine tab 20 mg (Zyprexa)........................................47
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)............................................................................ 79
omega-3 fatty acids cap delayed release 1000 mg ......... 68
omega-3 fatty acids cap delayed release 1200 mg ......... 68
omega-3 fatty acids cap 500 mg ...................................... 68
omega-3 fatty acids cap 435 mg ...................................... 68
omega-3 fatty acids cap 1000 mg .................................... 68
omega-3 fatty acids cap 1200 mg .................................... 68
OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg..... 68
OMEGA-3 – omega-3 fatty acids cap 1400 mg................ 68
OMEGA-3 2100 – omega-3 fatty acids cap 1050 mg....... 68
2016
OMEGA POWER – omega-3 fatty acids cap 1050 mg..... 68
omeprazole cap delayed release 10 mg (Prilosec)........... 39
omeprazole cap delayed release 20 mg (Prilosec)........... 39
omeprazole cap delayed release 40 mg (Prilosec)........... 39
OMNITROPE – somatropin for inj 5.8 mg......................... 19
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 19
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 19
ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 39
ondansetron hcl tab 24 mg................................................ 39
ondansetron hcl tab 4 mg (Zofran).................................... 39
ondansetron hcl tab 8 mg (Zofran).................................... 39
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................... 39
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................... 39
opium tincture 1% (10 mg/ml) (morphine equiv)............... 38
OPSUMIT – macitentan tab 10 mg................................... 31
oral contraceptives – all generics...................................... 15
oral electrolyte solution ..................................................... 67
orphenadrine citrate tab sr 12hr 100 mg........................... 65
ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................ 15
ORTHO-NOVUM 1/35 – norethindrone & ethinyl estradiol
tab 1 mg-35 mcg.............................................................. 15
ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg.................................. 15
OVCON-35 – norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg........................................................................ 15
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................... 63
oxcarbazepine tab 150 mg (Trileptal)................................ 63
oxcarbazepine tab 300 mg (Trileptal)................................ 63
oxcarbazepine tab 600 mg (Trileptal)................................ 63
oxiconazole nitrate cream 1% (Oxistat).............................81
oxybutynin chloride syrup 5 mg/5ml.................................. 41
oxybutynin chloride tab 5 mg.............................................41
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)........... 41
oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..........41
oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..........41
oxycodone-aspirin tab 4.8355-325 mg (Percodan)........... 57
OXYCODONE HCL............................................................ 57
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).................57
oxycodone hcl tab 10 mg.................................................. 57
oxycodone hcl tab 20 mg.................................................. 57
oxycodone hcl tab 5 mg (Roxicodone).............................. 57
oxycodone hcl tab 15 mg (Roxicodone)............................ 57
oxycodone hcl tab 30 mg (Roxicodone)............................ 57
oxycodone-ibuprofen tab 5-400 mg................................... 57
oxycodone w/ acetaminophen soln 5-325 mg/5ml
(Roxicet)............................................................................ 57
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet).......................................................................... 57
oxymorphone hcl tab 5 mg (Opana)..................................58
oxymorphone hcl tab 10 mg (Opana)................................58
oxymorphone hcl tab sr 12hr 5 mg................................... 57
oxymorphone hcl tab sr 12hr 7.5 mg................................ 57
oxymorphone hcl tab sr 12hr 10 mg................................. 57
oxymorphone hcl tab sr 12hr 15 mg................................. 58
oxymorphone hcl tab sr 12hr 20 mg................................. 58
oxymorphone hcl tab sr 12hr 30 mg................................. 58
oxymorphone hcl tab sr 12hr 40 mg................................. 58
P
paliperidone tab sr 24hr 1.5 mg (Invega).......................... 47
paliperidone tab sr 24hr 3 mg (Invega)............................. 47
paliperidone tab sr 24hr 6 mg (Invega)............................. 47
paliperidone tab sr 24hr 9 mg (Invega)............................. 48
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................... 39
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................... 39
PARAGARD INTRAUTERINE COP – copper iud............. 15
paromomycin sulfate cap 250 mg....................................... 3
paroxetine hcl tab 10 mg (Paxil)........................................45
paroxetine hcl tab 20 mg (Paxil)........................................45
paroxetine hcl tab 30 mg (Paxil)........................................45
paroxetine hcl tab 40 mg (Paxil)........................................45
PEAK FLOW METER – various........................................ 84
PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml)........ 37
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml
........................................................................................... 67
pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
........................................................................................... 67
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
........................................................................................... 67
pediatric multiple vitamins w/ fluoride chew tab 1 mg ...... 67
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
........................................................................................... 67
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ...... 67
pediatric multiple vitamin w/ c & fa chew tab.................... 67
pediatric multiple vitamin w/ c soln 35 mg/ml ................... 67
pediatric multiple vitamin w/ minerals & c drops 45 mg/
ml....................................................................................... 67
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ........... 67
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ............. 67
pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml
........................................................................................... 67
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml..............5
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml.........5
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml............................................................................ 5
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml............................................................................ 5
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b
for inj kit 120 mcg/0.5ml..................................................... 5
109
2016
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
50 mcg/0.5ml...................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
80 mcg/0.5ml...................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
120 mcg/0.5ml.................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
150 mcg/0.5ml.................................................................... 5
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs).........................................................37
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................... 37
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/
flavor pack)....................................................................... 37
penicillin v potassium for soln 125 mg/5ml......................... 1
penicillin v potassium for soln 250 mg/5ml......................... 1
penicillin v potassium tab 250 mg....................................... 1
penicillin v potassium tab 500 mg....................................... 1
pentoxifylline tab cr 400 mg...............................................75
perindopril erbumine tab 2 mg...........................................22
perindopril erbumine tab 4 mg (Aceon)............................. 22
perindopril erbumine tab 8 mg (Aceon)............................. 22
permethrin cream 5% (Elimite).......................................... 83
permethrin creme rinse 1%............................................... 83
permethrin lotion 1%.......................................................... 83
perphenazine tab 2 mg...................................................... 48
perphenazine tab 4 mg...................................................... 48
perphenazine tab 8 mg...................................................... 48
perphenazine tab 16 mg.................................................... 48
phenazopyridine hcl tab 100 mg (Pyridium)...................... 42
phenazopyridine hcl tab 200 mg (Pyridium)...................... 42
phenelzine sulfate tab 15 mg (Nardil)............................... 45
phenobarbital elixir 20 mg/5ml...........................................49
PHENOBARBITAL – phenobarbital tab 15 mg................. 49
PHENOBARBITAL – phenobarbital tab 30 mg................. 49
PHENOBARBITAL – phenobarbital tab 60 mg................. 49
PHENOBARBITAL – phenobarbital tab 100 mg............... 49
phenobarbital tab 16.2 mg................................................. 49
phenobarbital tab 32.4 mg................................................. 49
phenobarbital tab 64.8 mg................................................. 49
phenobarbital tab 97.2 mg................................................. 49
phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............31
phenylephrine-brompheniramine-dm elixir 2.5-1-5
mg/5ml............................................................................... 33
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)............................................................................... 33
phenylephrine-guaifenesin tab 10-400 mg........................ 33
phenylephrine hcl ophth soln 2.5%................................... 79
phenylephrine hcl ophth soln 10%.................................... 79
phenylephrine hcl tab 10 mg............................................. 32
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml............................................................................... 33
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml................. 33
phenytoin chew tab 50 mg (Dilantin infatabs)................... 63
phenytoin sodium extended cap 100 mg (Dilantin)........... 63
phenytoin sodium extended cap 200 mg (Phenytek)........ 63
110
phenytoin sodium extended cap 300 mg (Phenytek)........ 63
phenytoin susp 125 mg/5ml (Dilantin)............................... 63
pilocarpine hcl ophth soln 1% (Isopto carpine)................. 78
pilocarpine hcl ophth soln 2% (Isopto carpine)................. 78
pilocarpine hcl ophth soln 4% (Isopto carpine)................. 78
pilocarpine hcl tab 5 mg (Salagen)....................................79
pilocarpine hcl tab 7.5 mg (Salagen).................................79
pimozide tab 1 mg (Orap)..................................................53
pimozide tab 2 mg (Orap)..................................................53
pindolol tab 5 mg............................................................... 24
pindolol tab 10 mg............................................................. 24
pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 17
pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 17
pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 17
piroxicam cap 10 mg (Feldene)......................................... 60
piroxicam cap 20 mg (Feldene)......................................... 60
PLAN B ONE-STEP – levonorgestrel tab 1.5 mg............. 15
podofilox soln 0.5% (Condylox)......................................... 83
polyethylene glycol 3350 oral packet................................ 37
polyethylene glycol 3350 oral powder............................... 37
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
(Polytrim)........................................................................... 77
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......42
potassium bicarbonate effer tab 25 meq........................... 67
potassium chloride cap cr 8 meq (Micro-k)....................... 67
potassium chloride cap cr 10 meq (Micro-k)..................... 67
POTASSIUM CHLORIDE ER – potassium chloride tab cr
8 meq (600 mg)................................................................ 68
potassium chloride microencapsulated crys cr tab 10
meq....................................................................................68
potassium chloride microencapsulated crys cr tab 20
meq....................................................................................68
potassium chloride oral soln 10% (20 meq/15ml)............. 68
potassium chloride oral soln 20% (40 meq/15ml)............. 68
potassium chloride powder packet 20 meq....................... 68
potassium chloride tab cr 10 meq (K-tab)......................... 68
potassium chloride tab cr 8 meq (600 mg)........................68
potassium citrate & citric acid powder pack 3300-1002
mg...................................................................................... 42
potassium citrate & citric acid soln 1100-334 mg/5ml....... 42
potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)........ 42
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)..................................................................................... 42
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15)..................................................................................... 42
pot bicarbonate & chloride effer tab 25 meq..................... 67
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)..................................... 67
PRALUENT – alirocumab subcutaneous soln pen-injector
75 mg/ml........................................................................... 28
PRALUENT – alirocumab subcutaneous soln pen-injector
150 mg/ml......................................................................... 28
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 75 mg/ml.............................................................. 28
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 150 mg/ml............................................................ 28
2016
pramipexole dihydrochloride tab 0.125 mg (Mirapex)....... 65
pramipexole dihydrochloride tab 0.25 mg (Mirapex)......... 65
pramipexole dihydrochloride tab 0.5 mg (Mirapex)........... 65
pramipexole dihydrochloride tab 0.75 mg (Mirapex)......... 65
pramipexole dihydrochloride tab 1 mg (Mirapex).............. 65
pramipexole dihydrochloride tab 1.5 mg (Mirapex)........... 65
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er)...................................................................... 64
pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex
er)...................................................................................... 64
pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex
er)...................................................................................... 64
pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex
er)...................................................................................... 64
pravastatin sodium tab 10 mg........................................... 28
pravastatin sodium tab 20 mg (Pravachol)........................28
pravastatin sodium tab 40 mg (Pravachol)........................28
pravastatin sodium tab 80 mg (Pravachol)........................28
prazosin hcl cap 1 mg (Minipress).................................... 31
prazosin hcl cap 2 mg (Minipress).................................... 31
prazosin hcl cap 5 mg (Minipress).................................... 31
prednicarbate cream 0.1% (Dermatop)............................. 83
prednicarbate oint 0.1% (Dermatop)................................. 83
prednisolone acetate ophth susp 1% (Pred forte)............. 77
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 77
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv)................................................................................. 12
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)............................................................. 12
prednisolone syrup 15 mg/5ml (usp solution equivalent)
(Prelone)............................................................................12
PREDNISONE – prednisone oral soln 5 mg/5ml.............. 12
PREDNISONE – prednisone tab 50 mg............................12
prednisone tab 1 mg.......................................................... 12
prednisone tab 2.5 mg....................................................... 12
prednisone tab 5 mg.......................................................... 12
prednisone tab 10 mg........................................................ 12
prednisone tab 20 mg........................................................ 12
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg..................................................... 14
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................... 14
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................... 14
PREZCOBIX – darunavir-cobicistat tab 800-150 mg.......... 7
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 75 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 600 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 800 mg (base
equiv)................................................................................... 7
PRIFTIN – rifapentine tab 150 mg...................................... 4
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg............................................................................... 8
primidone tab 50 mg (Mysoline)........................................ 63
primidone tab 250 mg (Mysoline)...................................... 63
probenecid tab 500 mg...................................................... 61
prochlorperazine maleate tab 5 mg (Compazine)............. 40
prochlorperazine maleate tab 10 mg (Compazine)........... 40
prochlorperazine suppos 25 mg........................................ 40
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 75
PROCRIT – epoetin alfa inj 20000 unit/ml........................ 75
PROCRIT – epoetin alfa inj 40000 unit/ml........................ 75
PROFILNINE – factor ix complex for inj 500 unit.............. 75
PROFILNINE – factor ix complex for inj 1000 unit............ 75
PROFILNINE – factor ix complex for inj 1500 unit............ 75
PROFILNINE SD – factor ix complex for inj 500 unit........ 75
PROFILNINE SD – factor ix complex for inj 1000 unit...... 75
PROFILNINE SD – factor ix complex for inj 1500 unit...... 75
progesterone im in oil 50 mg/ml........................................ 14
progesterone micronized cap 100 mg (Prometrium)......... 14
progesterone micronized cap 200 mg (Prometrium)......... 14
PROLIA – denosumab inj 60 mg/ml.................................. 20
promethazine & phenylephrine syrup 6.25-5 mg/5ml........33
promethazine-dm syrup 6.25-15 mg/5ml...........................33
promethazine hcl suppos 12.5 mg.................................... 32
promethazine hcl suppos 25 mg....................................... 32
promethazine hcl suppos 50 mg....................................... 32
promethazine hcl syrup 6.25 mg/5ml................................ 32
promethazine hcl tab 12.5 mg........................................... 32
promethazine hcl tab 25 mg.............................................. 32
promethazine hcl tab 50 mg.............................................. 32
promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 33
PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap
delayed release 332.5 mg............................................... 68
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)............ 30
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)............ 30
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)............ 30
propafenone hcl tab 300 mg..............................................30
propafenone hcl tab 150 mg (Rythmol)............................. 30
propafenone hcl tab 225 mg (Rythmol)............................. 30
proparacaine hcl ophth soln 0.5% (Alcaine)......................79
PROPRANOLOL/HYDROCHLOROTH – propranolol &
hydrochlorothiazide tab 40-25 mg................................... 24
propranolol hcl cap sr 24hr 60 mg (Inderal la).................. 24
propranolol hcl cap sr 24hr 80 mg (Inderal la).................. 24
propranolol hcl cap sr 24hr 120 mg (Inderal la)................ 24
propranolol hcl cap sr 24hr 160 mg (Inderal la)................ 24
propranolol hcl tab 10 mg.................................................. 24
propranolol hcl tab 20 mg.................................................. 24
propranolol hcl tab 40 mg.................................................. 24
propranolol hcl tab 60 mg.................................................. 24
propranolol hcl tab 80 mg.................................................. 24
propylthiouracil tab 50 mg................................................. 19
111
2016
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).............................................................. 33
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml......... 33
psyllium powder 28.3%...................................................... 37
psyllium powder 30%......................................................... 37
psyllium powder 30.9%...................................................... 37
psyllium powder 33%......................................................... 37
psyllium powder 48.57%.................................................... 38
psyllium powder 49%......................................................... 38
psyllium powder 58.6%...................................................... 38
psyllium powder 95%......................................................... 38
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............37
pyrazinamide tab 500 mg.................................................... 4
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)...........................................................................65
pyridostigmine bromide tab 60 mg (Mestinon).................. 65
Q
QC CALAMINE – calamine lotion......................................83
quetiapine fumarate tab 25 mg (Seroquel)........................48
quetiapine fumarate tab 50 mg (Seroquel)........................48
quetiapine fumarate tab 100 mg (Seroquel)......................48
quetiapine fumarate tab 200 mg (Seroquel)......................48
quetiapine fumarate tab 300 mg (Seroquel)......................48
quetiapine fumarate tab 400 mg (Seroquel)......................48
quinapril hcl tab 5 mg (Accupril)........................................ 22
quinapril hcl tab 10 mg (Accupril)...................................... 22
quinapril hcl tab 20 mg (Accupril)...................................... 22
quinapril hcl tab 40 mg (Accupril)...................................... 22
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)......................................................................... 22
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)......................................................................... 22
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)......................................................................... 22
QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 30
QUINIDINE SULFATE – quinidine sulfate tab 300 mg...... 30
quinine sulfate cap 324 mg (Qualaquin)............................. 9
QVAR – beclomethasone diprop inhal aero soln 40 mcg/
act (50/valve).................................................................... 36
QVAR – beclomethasone diprop inhal aero soln 80 mcg/
act (100/valve).................................................................. 36
R
rabeprazole sodium ec tab 20 mg (Aciphex).................... 39
raloxifene hcl tab 60 mg (Evista)....................................... 20
ramipril cap 1.25 mg (Altace)............................................ 22
ramipril cap 2.5 mg (Altace).............................................. 22
ramipril cap 5 mg (Altace)................................................. 22
ramipril cap 10 mg (Altace)............................................... 22
RANEXA – ranolazine tab sr 12hr 500 mg....................... 27
RANEXA – ranolazine tab sr 12hr 1000 mg..................... 27
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 39
ranitidine hcl tab 75 mg..................................................... 39
ranitidine hcl tab 150 mg (Zantac).....................................39
ranitidine hcl tab 300 mg (Zantac).....................................39
112
REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml).......................................................................... 52
REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml).......................................................................... 52
REBIF REBIDOSE – interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)........................................................ 52
REBIF REBIDOSE – interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)........................................................ 52
REBIF REBIDOSE TITRATION – interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 52
REBIF TITRATION PACK – interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................ 52
RECOMBINATE – antihemophilic factor (recombinant) for
inj 220-400 unit................................................................. 75
RECOMBINATE – antihemophilic factor (recombinant) for
inj 401-800 unit................................................................. 75
RECOMBINATE – antihemophilic factor (recombinant) for
inj 801-1240 unit............................................................... 75
RECOMBINATE – antihemophilic factor (recombinant) for
inj 1241-1800 unit............................................................. 75
RECOMBINATE – antihemophilic factor (recombinant) for
inj 1801-2400 unit............................................................. 75
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister......................................................... 8
RELHIST BP – brompheniramine & phenylephrine tab
4-10 mg............................................................................. 33
RELHIST – bromphen tan-phenyleph tan chew tab 6-15
mg...................................................................................... 33
RENAGEL – sevelamer hcl tab 400 mg............................ 41
RENAGEL – sevelamer hcl tab 800 mg............................ 41
repaglinide tab 0.5 mg (Prandin)....................................... 17
repaglinide tab 1 mg (Prandin).......................................... 17
repaglinide tab 2 mg (Prandin).......................................... 17
REPATHA – evolocumab subcutaneous soln prefilled
syringe 140 mg/ml............................................................ 28
REPATHA SURECLICK – evolocumab subcutaneous soln
auto-injector 140 mg/ml....................................................28
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 7
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 7
RESPIRATORY THERAPY SUPPLIES – various............. 84
REVLIMID – lenalidomide cap 5 mg................................. 85
REVLIMID – lenalidomide cap 10 mg............................... 85
REVLIMID – lenalidomide cap 15 mg............................... 85
REVLIMID – lenalidomide cap 20 mg............................... 85
REVLIMID – lenalidomide cap 25 mg............................... 85
REVLIMID – lenalidomide caps 2.5 mg............................ 85
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate cap 200 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate cap 300 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv)........................................................................ 7
ribavirin cap 200 mg (Rebetol)............................................ 5
ribavirin tab 200 mg (Copegus)........................................... 5
2016
rifabutin cap 150 mg (Mycobutin)........................................ 4
rifampin cap 150 mg (Rifadin)............................................. 4
rifampin cap 300 mg (Rifadin)............................................. 4
riluzole tab 50 mg (Rilutek)................................................65
ringer's solution for irrigation..............................................85
risperidone orally disintegrating tab 0.25 mg.................... 48
risperidone orally disintegrating tab 0.5 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 1 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 2 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 3 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 4 mg (Risperdal mtab).................................................................................... 48
risperidone soln 1 mg/ml (Risperdal).................................48
risperidone tab 0.25 mg (Risperdal).................................. 48
risperidone tab 0.5 mg (Risperdal).................................... 48
risperidone tab 1 mg (Risperdal)....................................... 48
risperidone tab 2 mg (Risperdal)....................................... 48
risperidone tab 3 mg (Risperdal)....................................... 48
risperidone tab 4 mg (Risperdal)....................................... 48
rivastigmine tartrate cap 1.5 mg (Exelon)......................... 53
rivastigmine tartrate cap 3 mg (Exelon)............................ 53
rivastigmine tartrate cap 4.5 mg (Exelon)......................... 54
rivastigmine tartrate cap 6 mg (Exelon)............................ 54
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon).............. 54
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon).............. 54
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)............ 54
RIXUBIS – coagulation factor ix (recombinant) for inj 250
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 500
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 1000
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 2000
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 3000
unit..................................................................................... 76
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
(Maxalt-mlt)....................................................................... 60
rizatriptan benzoate oral disintegrating tab 10 mg (base
eq) (Maxalt-mlt).................................................................60
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)............................................................................. 60
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)............................................................................. 60
ROCHE Blood Glucose Monitoring System
– ACCU-CHEK AVIVA PLUS/COMPACT/NANO
SMARTVIEW.................................................................... 84
ropinirole hydrochloride tab 0.25 mg (Requip).................. 65
ropinirole hydrochloride tab 0.5 mg (Requip).................... 65
ropinirole hydrochloride tab 1 mg (Requip)....................... 65
ropinirole hydrochloride tab 2 mg (Requip)....................... 65
ropinirole hydrochloride tab 3 mg (Requip)....................... 65
ropinirole hydrochloride tab 4 mg (Requip)....................... 65
ropinirole hydrochloride tab 5 mg (Requip)....................... 65
rosuvastatin calcium tab 5 mg (Crestor)........................... 28
rosuvastatin calcium tab 10 mg (Crestor)......................... 28
rosuvastatin calcium tab 20 mg (Crestor)......................... 28
rosuvastatin calcium tab 40 mg (Crestor)......................... 28
RU-HIST D – brompheniramine & phenylephrine tab 4-10
mg...................................................................................... 34
S
saline nasal spray 0.65%................................................... 32
salsalate tab 500 mg..........................................................54
salsalate tab 750 mg..........................................................54
selegiline hcl cap 5 mg (Eldepryl)..................................... 65
selegiline hcl tab 5 mg....................................................... 65
selenium sulfide lotion 2.5%.............................................. 83
selenium sulfide-pyrithione zinc in urea shampoo
2.25%................................................................................ 84
SELZENTRY – maraviroc tab 150 mg................................ 7
SELZENTRY – maraviroc tab 300 mg................................ 7
sennosides tab 8.6 mg...................................................... 38
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 20
SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)......... 20
SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)......... 20
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)............................................... 36
sertraline hcl oral conc 20 mg/ml (Zoloft).......................... 45
sertraline hcl tab 25 mg (Zoloft)........................................ 45
sertraline hcl tab 50 mg (Zoloft)........................................ 45
sertraline hcl tab 100 mg (Zoloft)...................................... 45
sildenafil citrate tab 20 mg (Revatio)................................. 31
silver sulfadiazine cream 1% (Silvadene)......................... 81
simethicone chew tab 80 mg............................................. 41
simethicone susp 40 mg/0.6ml.......................................... 41
simvastatin tab 5 mg (Zocor)............................................. 28
simvastatin tab 10 mg (Zocor)........................................... 28
simvastatin tab 20 mg (Zocor)........................................... 28
simvastatin tab 40 mg (Zocor)........................................... 28
simvastatin tab 80 mg (Zocor)........................................... 28
sirolimus tab 0.5 mg (Rapamune)..................................... 85
sirolimus tab 1 mg (Rapamune)........................................ 85
sirolimus tab 2 mg (Rapamune)........................................ 85
SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5
mg total)............................................................................ 15
SM CALAMINE – calamine lotion......................................84
sodium chloride irrigation soln 0.9%..................................42
sodium chloride soln nebu 0.9%....................................... 34
sodium chloride soln nebu 3%.......................................... 34
sodium chloride soln nebu 10%........................................ 34
sodium chloride soln nebu 7% (Hyper-sal)....................... 34
sodium citrate & citric acid soln 500-334 mg/5ml (Shohls
solution modi)................................................................... 42
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).............................................................................. 68
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).............................................................................. 68
113
2016
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).............................................................................. 68
sodium fluoride cream 1.1% (Prevident 5000 plus).......... 79
sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)...... 79
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................... 68
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................... 68
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).............................................................................. 68
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).................................................................................. 85
sodium polystyrene sulfonate powder (Kayexalate)..........85
sodium polystyrene sulfonate rectal susp 30
gm/120ml...........................................................................85
sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 30
sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 30
sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 30
sotalol hcl tab 240 mg....................................................... 30
sotalol hcl tab 80 mg (Betapace).......................................30
sotalol hcl tab 120 mg (Betapace).....................................30
sotalol hcl tab 160 mg (Betapace).....................................30
SOVALDI – sofosbuvir tab 400 mg..................................... 5
SPACER/AEROSOL-HOLDING CHAMBERS –
various............................................................................... 85
SPACER/AEROSOL-HOLDING CHAMBERS –
VARIOUS.......................................................................... 84
speciality vitamin product tab............................................ 67
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv).................. 36
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................... 36
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)..................................................................... 29
spironolactone tab 25 mg (Aldactone)...............................29
spironolactone tab 50 mg (Aldactone)...............................29
spironolactone tab 100 mg (Aldactone)............................ 29
SPRYCEL – dasatinib tab 20 mg...................................... 11
SPRYCEL – dasatinib tab 50 mg...................................... 11
SPRYCEL – dasatinib tab 70 mg...................................... 11
SPRYCEL – dasatinib tab 80 mg...................................... 11
SPRYCEL – dasatinib tab 100 mg.................................... 11
SPRYCEL – dasatinib tab 140 mg.................................... 11
stavudine cap 15 mg (Zerit).................................................7
stavudine cap 20 mg (Zerit).................................................7
stavudine cap 30 mg (Zerit).................................................7
stavudine cap 40 mg (Zerit).................................................7
stavudine for oral soln 1 mg/ml (Zerit)................................ 7
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml....................................................................................... 20
STIVARGA – regorafenib tab 40 mg................................. 11
STRATTERA – atomoxetine hcl cap 10 mg (base
equiv)................................................................................. 51
STRATTERA – atomoxetine hcl cap 18 mg (base
equiv)................................................................................. 51
114
STRATTERA – atomoxetine hcl cap 25 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 40 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 60 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 80 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 100 mg (base
equiv)................................................................................. 52
STRENSIQ – asfotase alfa subcutaneous inj 18
mg/0.45ml......................................................................... 20
STRENSIQ – asfotase alfa subcutaneous inj 28
mg/0.7ml............................................................................20
STRENSIQ – asfotase alfa subcutaneous inj 40 mg/
ml....................................................................................... 20
STRENSIQ – asfotase alfa subcutaneous inj 80
mg/0.8ml............................................................................20
STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg.......................................................... 7
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)...................................................... 58
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)................................................................58
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)................................................................58
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
12-3 mg (base equiv)....................................................... 58
sucralfate tab 1 gm (Carafate)...........................................39
sulfacetamide sodium lotion 10% (acne) (Klaron).............80
sulfacetamide sodium ophth soln 10% (Bleph-10)............ 77
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................. 77
sulfacetamide sodium w/ sulfur emulsion 10-1%.............. 80
sulfacetamide sodium w/ sulfur emulsion 10-5%.............. 80
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml......... 9
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim).............................................................................. 9
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim
ds)........................................................................................ 9
sulfasalazine tab delayed release 500 mg (Azulfidine entabs)...................................................................................41
sulfasalazine tab 500 mg (Azulfidine)................................41
sulindac tab 150 mg...........................................................60
sulindac tab 200 mg...........................................................60
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................60
sumatriptan succinate solution auto-injector 4 mg/0.5ml
(Imitrex statdose sys)....................................................... 60
sumatriptan succinate solution auto-injector 6 mg/0.5ml
(Imitrex statdose sys)....................................................... 60
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)........................................................ 60
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)........................................................ 60
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................... 60
2016
sumatriptan succinate tab 25 mg (Imitrex)........................ 61
sumatriptan succinate tab 50 mg (Imitrex)........................ 61
sumatriptan succinate tab 100 mg (Imitrex)...................... 61
SUPRAX – cefixime cap 400 mg........................................ 2
SUPRAX – cefixime chew tab 100 mg................................ 2
SUPRAX – cefixime chew tab 200 mg................................ 2
SUPRAX – cefixime for susp 100 mg/5ml.......................... 2
SUPRAX – cefixime for susp 200 mg/5ml.......................... 2
SUPRAX – cefixime for susp 500 mg/5ml.......................... 2
SUSTIVA – efavirenz cap 50 mg......................................... 8
SUSTIVA – efavirenz cap 200 mg....................................... 8
SUSTIVA – efavirenz tab 600 mg....................................... 7
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 11
SUTENT – sunitinib malate cap 25 mg (base
equivalent)......................................................................... 11
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 11
SUTENT – sunitinib malate cap 50 mg (base
equivalent)......................................................................... 11
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.....................................................36
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act...................................................36
SYNAGIS – palivizumab im soln 50 mg/0.5ml.................... 9
SYNAGIS – palivizumab im soln 100 mg/ml....................... 9
T
tacrolimus cap 0.5 mg (Prograf)........................................ 85
tacrolimus cap 1 mg (Prograf)........................................... 85
tacrolimus cap 5 mg (Prograf)........................................... 85
tacrolimus oint 0.03% (Protopic)........................................84
tacrolimus oint 0.1% (Protopic)..........................................84
tamoxifen citrate tab 10 mg (base equivalent).................. 11
tamoxifen citrate tab 20 mg (base equivalent).................. 11
tamsulosin hcl cap 0.4 mg (Flomax)................................. 42
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 11
TARCEVA – erlotinib hcl tab 100 mg (base
equivalent)......................................................................... 11
TARCEVA – erlotinib hcl tab 150 mg (base
equivalent)......................................................................... 11
TASIGNA – nilotinib hcl cap 150 mg (base
equivalent)......................................................................... 11
TASIGNA – nilotinib hcl cap 200 mg (base
equivalent)......................................................................... 11
TAZORAC – tazarotene cream 0.05%.............................. 80
TAZORAC – tazarotene cream 0.1%................................ 80
TAZORAC – tazarotene gel 0.05%................................... 80
TAZORAC – tazarotene gel 0.1%..................................... 80
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................. 52
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................. 52
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 53
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 63
temazepam cap 15 mg (Restoril)...................................... 49
temazepam cap 30 mg (Restoril)...................................... 49
temozolomide cap 5 mg (Temodar)................................... 11
temozolomide cap 20 mg (Temodar)................................. 12
temozolomide cap 100 mg (Temodar)............................... 12
temozolomide cap 140 mg (Temodar)............................... 12
temozolomide cap 180 mg (Temodar)............................... 12
temozolomide cap 250 mg (Temodar)............................... 12
terazosin hcl cap 1 mg...................................................... 31
terazosin hcl cap 2 mg...................................................... 31
terazosin hcl cap 5 mg...................................................... 31
terazosin hcl cap 10 mg.................................................... 31
terbinafine hcl tab 250 mg (Lamisil).................................... 4
terbutaline sulfate tab 2.5 mg............................................ 36
terbutaline sulfate tab 5 mg............................................... 36
terconazole vaginal cream 0.4% (Terazol 7)..................... 42
terconazole vaginal cream 0.8% (Terazol 3)..................... 42
terconazole vaginal suppos 80 mg.................................... 42
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)..................................................................... 13
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)..................................................................... 13
testosterone enanthate im inj in oil 200 mg/ml.................. 13
testosterone td gel 12.5 mg/act (1%) (Androgel
pump)................................................................................ 13
testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 13
testosterone td gel 50 mg/5gm (1%) (Androgel)............... 13
TEST STRIPS – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 84
TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,
AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT,
SMARTVIEW.................................................................... 84
TEST STRIPS – ROCHE ACCUTREND...........................84
tetrabenazine tab 12.5 mg (Xenazine).............................. 54
tetrabenazine tab 25 mg (Xenazine)................................. 54
tetracaine hcl ophth soln 0.5%.......................................... 79
tetracycline hcl cap 250 mg (Tetracycline hcl).................... 3
tetracycline hcl cap 500 mg (Tetracycline hcl).................... 3
tetrahydroz-dextran-peg-povidone ophth soln
0.05-0.1-1-1%................................................................... 79
THALOMID – thalidomide cap 50 mg............................... 86
THALOMID – thalidomide cap 100 mg............................. 86
THALOMID – thalidomide cap 150 mg............................. 86
theophylline soln 80 mg/15ml............................................ 36
theophylline tab sr 12hr 100 mg........................................ 36
theophylline tab sr 12hr 200 mg........................................ 36
theophylline tab sr 12hr 300 mg........................................ 36
theophylline tab sr 12hr 450 mg........................................ 36
theophylline tab sr 24hr 400 mg........................................ 36
theophylline tab sr 24hr 600 mg........................................ 36
thiamine hcl tab 50 mg...................................................... 66
thiamine hcl tab 100 mg.................................................... 66
thioridazine hcl tab 10 mg................................................. 48
thioridazine hcl tab 25 mg................................................. 48
thioridazine hcl tab 50 mg................................................. 48
thioridazine hcl tab 100 mg............................................... 48
115
2016
thiothixene cap 1 mg..........................................................48
thiothixene cap 2 mg..........................................................48
thiothixene cap 5 mg..........................................................48
thiothixene cap 10 mg........................................................48
thyroid tab 30 mg (1/2 grain) (Armour thyroid).................. 19
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)............... 19
thyroid tab 60 mg (1 grain) (Armour thyroid)..................... 19
tiagabine hcl tab 2 mg (Gabitril)........................................ 63
tiagabine hcl tab 4 mg (Gabitril)........................................ 63
timolol maleate ophth gel forming soln 0.25% (Timopticxe)...................................................................................... 78
timolol maleate ophth gel forming soln 0.5% (Timopticxe)...................................................................................... 78
timolol maleate ophth soln 0.25% (Timoptic).................... 78
timolol maleate ophth soln 0.5% (Timoptic)...................... 78
tioconazole vaginal oint 6.5%............................................ 42
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 8
tizanidine hcl tab 2 mg....................................................... 65
tizanidine hcl tab 4 mg (Zanaflex)..................................... 65
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)......................................................................... 77
tobramycin nebu soln 300 mg/5ml (Tobi)............................ 3
tobramycin ophth soln 0.3% (Tobrex)................................ 77
TOBRAMYCIN SULFATE – tobramycin sulfate inj 2
gm/50ml (40 mg/ml) (base equiv)...................................... 4
TOLAZAMIDE – tolazamide tab 250 mg........................... 17
tolcapone tab 100 mg (Tasmar)........................................ 65
tolnaftate aerosol 1%......................................................... 81
tolterodine tartrate tab 1 mg (Detrol)................................. 41
tolterodine tartrate tab 2 mg (Detrol)................................. 41
topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 63
topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 63
topiramate tab 25 mg (Topamax)...................................... 64
topiramate tab 50 mg (Topamax)...................................... 64
topiramate tab 100 mg (Topamax).................................... 64
topiramate tab 200 mg (Topamax).................................... 64
torsemide tab 5 mg (Demadex)......................................... 29
torsemide tab 10 mg (Demadex)....................................... 29
torsemide tab 20 mg (Demadex)....................................... 29
torsemide tab 100 mg (Demadex)..................................... 29
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml........................................................................ 18
TRACLEER – bosentan tab 62.5 mg................................ 31
TRACLEER – bosentan tab 125 mg................................. 31
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 58
tramadol hcl tab 50 mg (Ultram)........................................58
trandolapril tab 1 mg (Mavik)............................................. 22
trandolapril tab 2 mg (Mavik)............................................. 22
trandolapril tab 4 mg (Mavik)............................................. 22
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)........... 26
tranexamic acid tab 650 mg (Lysteda).............................. 76
tranylcypromine sulfate tab 10 mg (Parnate).................... 45
trazodone hcl tab 50 mg.................................................... 45
116
trazodone hcl tab 100 mg.................................................. 45
trazodone hcl tab 150 mg.................................................. 45
tretinoin cap 10 mg............................................................ 12
tretinoin cream 0.025% (Retin-a).......................................80
tretinoin cream 0.05% (Retin-a).........................................80
tretinoin cream 0.1% (Retin-a)...........................................80
tretinoin gel 0.05% (Atralin)............................................... 80
tretinoin gel 0.01% (Retin-a).............................................. 80
tretinoin gel 0.025% (Retin-a)............................................ 80
tretinoin microsphere gel 0.04% (Retin-a micro)............... 80
tretinoin microsphere gel 0.1% (Retin-a micro)................. 80
TRETTEN – coagulation factor xiii a-subunit for inj
2000-3125 unit.................................................................. 76
triamcinolone acetonide cream 0.025%............................ 83
triamcinolone acetonide cream 0.1%................................ 83
triamcinolone acetonide cream 0.5%................................ 83
triamcinolone acetonide dental paste 0.1%...................... 79
triamcinolone acetonide lotion 0.025%.............................. 83
triamcinolone acetonide lotion 0.1%.................................. 83
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)...................................................... 32
triamcinolone acetonide oint 0.025%................................ 83
triamcinolone acetonide oint 0.1%.....................................83
TRIAMINIC COLD/COUGH NIGH – diphenhydraminephenylephrine oral strip 12.5-5 mg.................................. 34
TRIAMINIC COLD & ALLERGY – brompheniramine &
phenylephrine syrup 1-2.5 mg/5ml.................................. 34
TRIAMINIC COLD & ALLERGY – chlorpheniramine &
phenylephrine syrup 1-2.5 mg/5ml.................................. 34
TRIAMINIC NIGHT TIME COLD – diphenhydraminephenylephrine syrup 6.25-2.5 mg/5ml............................. 34
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg...................................29
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)........................................................................... 29
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)..................................................................... 29
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)...........................................................................29
trifluoperazine hcl tab 1 mg............................................... 48
trifluoperazine hcl tab 2 mg............................................... 48
trifluoperazine hcl tab 5 mg............................................... 48
trifluoperazine hcl tab 10 mg............................................. 48
trifluridine ophth soln 1% (Viroptic)....................................77
trihexyphenidyl hcl elixir 0.4 mg/ml....................................65
trihexyphenidyl hcl tab 2 mg.............................................. 65
trihexyphenidyl hcl tab 5 mg.............................................. 65
trimethobenzamide hcl cap 300 mg (Tigan)...................... 40
trimethoprim tab 100 mg...................................................... 9
trimipramine maleate cap 25 mg (Surmontil).................... 46
trimipramine maleate cap 50 mg (Surmontil).................... 46
trimipramine maleate cap 100 mg (Surmontil).................. 46
TRI-NORINYL 28 – norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg.............................................. 16
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................... 8
2016
TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400
unit-35 mg/ml.................................................................... 67
TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd
fluoride & fe drops 0.25-10 mg/ml................................... 67
trospium chloride cap sr 24hr 60 mg.................................42
trospium chloride tab 20 mg.............................................. 42
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg.................................................................. 8
U
ursodiol cap 300 mg (Actigall)........................................... 41
ursodiol tab 250 mg (Urso 250).........................................41
ursodiol tab 500 mg (Urso forte)....................................... 41
V
VAGIFEM – estradiol vaginal tab 10 mcg......................... 42
valacyclovir hcl tab 1 gm (Valtrex).......................................5
valacyclovir hcl tab 500 mg (Valtrex)...................................5
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)......................................................................... 84
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................... 4
valganciclovir hcl tab 450 mg (Valcyte)............................... 4
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)....................................................................... 64
valproic acid cap 250 mg (Depakene)...............................64
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).....................................................................................23
valsartan tab 40 mg (Diovan)............................................ 23
valsartan tab 80 mg (Diovan)............................................ 23
valsartan tab 160 mg (Diovan).......................................... 23
valsartan tab 320 mg (Diovan).......................................... 23
vancomycin hcl cap 125 mg (Vancocin hcl)........................ 9
vancomycin hcl cap 250 mg (Vancocin hcl)........................ 9
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl tab 25 mg..................................................46
venlafaxine hcl tab 37.5 mg...............................................46
venlafaxine hcl tab 50 mg..................................................46
venlafaxine hcl tab 75 mg..................................................46
venlafaxine hcl tab 100 mg................................................46
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 37
verapamil hcl cap sr 24hr 120 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 180 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 240 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 360 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 100 mg (Verelan pm)............... 26
verapamil hcl cap sr 24hr 200 mg (Verelan pm)............... 26
verapamil hcl cap sr 24hr 300 mg (Verelan pm)............... 26
verapamil hcl tab cr 120 mg (Calan sr)............................. 26
verapamil hcl tab cr 180 mg (Calan sr)............................. 26
verapamil hcl tab cr 240 mg (Calan sr)............................. 26
verapamil hcl tab 40 mg.................................................... 26
verapamil hcl tab 80 mg (Calan)....................................... 26
verapamil hcl tab 120 mg (Calan)..................................... 26
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)...................................................................................... 17
VIDEX – didanosine for soln 2 gm...................................... 8
VIDEX – didanosine for soln 4 gm...................................... 8
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 8
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 8
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 8
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm..................................................................................8
VIREAD – tenofovir disoproxil fumarate tab 150 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 200 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 250 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 300 mg...........8
vitamins a & d oint............................................................. 84
VITEKTA – elvitegravir tab 85 mg....................................... 8
VITEKTA – elvitegravir tab 150 mg..................................... 8
voriconazole for susp 40 mg/ml (Vfend)..............................4
voriconazole tab 50 mg (Vfend).......................................... 4
voriconazole tab 200 mg (Vfend)........................................ 4
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 12
VP-PRECIP – flaxseed oil-evening primrose-bilberry cap
250-125-10 mg................................................................. 68
VYVANSE – lisdexamfetamine dimesylate cap 10 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 20 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 30 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 40 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 50 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 60 mg..... 52
VYVANSE – lisdexamfetamine dimesylate cap 70 mg..... 52
W
warfarin sodium tab 1 mg (Coumadin).............................. 76
warfarin sodium tab 2 mg (Coumadin).............................. 76
warfarin sodium tab 2.5 mg (Coumadin)........................... 76
warfarin sodium tab 3 mg (Coumadin).............................. 76
warfarin sodium tab 4 mg (Coumadin).............................. 76
warfarin sodium tab 5 mg (Coumadin).............................. 76
warfarin sodium tab 6 mg (Coumadin).............................. 76
warfarin sodium tab 7.5 mg (Coumadin)........................... 76
warfarin sodium tab 10 mg (Coumadin)............................ 76
water for irrigation, sterile irrigation soln........................... 86
WELCHOL – colesevelam hcl packet for susp 3.75
gm...................................................................................... 28
WELCHOL – colesevelam hcl tab 625 mg........................ 28
117
2016
X
XALKORI – crizotinib cap 200 mg.....................................12
XALKORI – crizotinib cap 250 mg.....................................12
XARELTO – rivaroxaban tab 10 mg.................................. 76
XARELTO – rivaroxaban tab 15 mg.................................. 76
XARELTO – rivaroxaban tab 20 mg.................................. 76
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................... 76
XIFAXAN – rifaximin tab 200 mg.........................................9
XIFAXAN – rifaximin tab 550 mg.........................................9
XULANE – norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr.............................................................. 16
XYNTHA – antihemophilic factor recombinant paf for inj kit
250 unit............................................................................. 76
XYNTHA – antihemophilic factor recombinant paf for inj kit
500 unit............................................................................. 76
XYNTHA – antihemophilic factor recombinant paf for inj kit
1000 unit........................................................................... 76
XYNTHA – antihemophilic factor recombinant paf for inj kit
2000 unit........................................................................... 76
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 250 unit.................................. 76
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 500 unit.................................. 76
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 1000 unit................................ 76
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 2000 unit................................ 76
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 3000 unit................................ 76
XYREM – sodium oxybate oral solution 500 mg/ml.......... 54
Y
Z
zaleplon cap 5 mg (Sonata).............................................. 49
zaleplon cap 10 mg (Sonata)............................................ 49
ZARXIO – filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml.......................................................................... 77
ZARXIO – filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml.......................................................................... 77
ZELBORAF – vemurafenib tab 240 mg (base
equivalent)......................................................................... 12
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit.................................................... 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit.................................................. 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit.................................................. 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit................................................ 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit................................................ 40
118
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit.............................................. 40
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)..... 8
zidovudine cap 100 mg (Retrovir)....................................... 8
zidovudine syrup 10 mg/ml (Retrovir)..................................8
zidovudine tab 300 mg.........................................................8
zinc oxide oint 10%............................................................ 84
zinc oxide oint 20%............................................................ 84
zinc oxide oint 40%............................................................ 84
ziprasidone hcl cap 20 mg (Geodon)................................ 48
ziprasidone hcl cap 40 mg (Geodon)................................ 48
ziprasidone hcl cap 60 mg (Geodon)................................ 48
ziprasidone hcl cap 80 mg (Geodon)................................ 48
zolpidem tartrate tab 5 mg (Ambien)................................. 49
zolpidem tartrate tab 10 mg (Ambien)............................... 49
zonisamide cap 50 mg....................................................... 64
zonisamide cap 25 mg (Zonegran)....................................64
zonisamide cap 100 mg (Zonegran)..................................64
ZORTRESS – everolimus tab 0.25 mg............................. 86
ZORTRESS – everolimus tab 0.5 mg............................... 86
ZORTRESS – everolimus tab 0.75 mg............................. 86
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg.................................................................... 16
ZOVIRAX – acyclovir cream 5%....................................... 81
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq)......................................................58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq)......................................................58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq).................................................................... 58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq).................................................................... 58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
11.4-2.9 mg (base eq)...................................................... 58
ZYCLARA – imiquimod cream 3.75%............................... 84
ZYCLARA PUMP – imiquimod cream 2.5%......................84
ZYCLARA PUMP – imiquimod cream 3.75%....................84
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%............................................................................ 78
ZYTIGA – abiraterone acetate tab 250 mg....................... 12
ZYVOX – linezolid for susp 100 mg/5ml............................. 9
Este formulario fue actualizado el 07/18/2016.
Blue Cross and Blue Shield of Illinois, una división de
Health Care Service Corporation, a Mutual Legal Reserve
Company (HCSC), un Licenciatario Independiente de
Blue Cross and Blue Shield Association.