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AlphaCare of New York 2016 Formulario (Lista de medicamentos cubiertos) FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Este vademécum se actualizó el 06/01/2016. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con AlphaCare of New York, Member Services llamando al 855-652-5742 o, para los usuarios de TTY, 711, Lunes - Domingo de 8:00 AM – 8:00 PM, o visite www.alphacare.com H9122_SPCOFORMMAD091415 HPMS Approved Formulary 16299 Version #15 i Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Examine este documento para asegurarse de que aún contiene lo medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a “nosotros,” “nos,” o “nuestro,” quiere decir AlphaCare of New York. Cuando se refiere a “plan” o “nuestro plan,” quiere decir AlphaCare Renew, AlphaCare Reliance or AlphaCare Total. Este documento incluye lista de medicamentos (formulario) para nuestro plan que está al día el January 1, 2016. Para el formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las cubiertas delantera y trasera. Generalmente, debe utilizar farmacias de red para utilizar su beneficio de medicamentos de receta. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1 de enero de 2016, y de vez en cuando durante el año. ¿Qué es el Formulario del AlphaCare of New York? Un formulario es una lista de medicamentos cubiertos seleccionados por AlphaCare consultando con un equipo de proveedores de atención médica, que representa las terapias de receta que se cree son parte necesaria de un programa de tratamiento de calidad. Generalmente, AlphaCare cubrirá los medicamentos enumerados en nuestro formulario siempre que el medicamento sea necesario por motivos médicos, la receta se surta en una farmacia de la red de AlphaCare y se sigan otras reglas del plan. Para mayor información acerca de cómo surtir sus recetas, examine su Evidencia de Cobertura. ¿Puede cambiar el Formulario (lista de medicamentos)? Generalmente, si está tomando un medicamento de nuestro formulario de 2016 que estaba cubierto al principio del año, no eliminaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016 excepto cuando un medicamento genérico nuevo y menos caro esté disponible o cuando se divulgue nueva información adversa acerca de la seguridad o eficacia de un medicamento. Otros tipos de cambios al formulario, tales como quitar un medicamento del mismo, no afectarán a los miembros que estén tomando el medicamento actualmente. Seguirá estando disponible al mismo costo compartido para los miembros que lo tomen durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que pueda ahorrar más dinero o podamos garantizar su seguridad. Si quitamos medicamentos de nuestro formulario [o] añadimos, después de obtener autorización, límites de cantidades y/o restricciones de terapia en pasos que afecten a un medicamento o trasladamos un medicamento a un nivel más alto de costo compartido, debemos notificar a los miembros afectados del cambio al menos 60 días antes de que entre en vigor, o en el momento en que el miembro solicite que se le repita la receta del medicamento, cuando el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Medicamentos considera que uno de los medicamentos de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está al día el 8/19/2015. Para obtener información actualizada acerca de los ii medicamentos cubiertos por AlphaCare, póngase en contacto con nosotros. Nuestra información de contacto aparece en las cubiertas delantera y trasera. En caso de cualquier medio año cambios en el formulario no mantenimiento, AlphaCare le enviará por correo una hoja de erratas para actualizar su formulario impreso. ¿Cómo se utiliza el Formulario? Hay dos maneras de encontrar su medicamento en el formulario: Condición Médica El formulario empieza en la página 1. Los medicamentos de este formulario están agrupados en categorías según el tipo de condición médica para el tratamiento de la cual se utilizan. Por ejemplo, los medicamentos que se utilizan para tratar una condición cardiaca se enumeran bajo la categoría, “Agentes cardiovasculares”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza abajo. Después, busque su medicamento bajo el nombre de la categoría. Lista Alfabética Si no está seguro de la categoría bajo la cual buscar, debe buscar su medicamento en el Índice que empieza en la página 112. El Índice da una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se enumeran en el Índice. Mire en el Índice para encontrar su medicamento. Al lado de su medicamento verá el número de la página donde puede encontrar información de cobertura. Vaya a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista. ¿Qué son medicamentos genéricos? AlphaCare cubre tanto medicamentos de marca como los medicamentos genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) indicando que tiene el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los medicamentos de marca. ¿Hay restricciones en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: Autorización Previa: AlphaCare requiere que usted [o su médico] obtenga autorización previa para ciertos medicamentos. Esto quiere decir que necesitará obtener la aprobación de AlphaCare antes de surtir sus recetas. Si no obtiene aprobación, es posible que AlphaCare no cubra el medicamento. iii Límites de Cantidad: Para ciertos medicamentos, AlphaCare limita la cantidad de medicamento que cubrirá AlphaCare. Por ejemplo, AlphaCare proporciona 6 per 30 dias por receta para sumatriptan. Esto puede ser además de un suministro estándar de un mes o tres meses. Terapia en Pasos: En algunos casos, AlphaCare requiere que pruebe primero ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan su condición médica, es posible que AlphaCare no cubra el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no le va bien, AlphaCare cubrirá entonces el Medicamento B. Puede averiguar si su medicamento tiene requisitos o límites adicionales mirando en el formulario que empieza en la página 1. También puede obtener más información acerca de las restricciones aplicadas a medicamentos específicos cubiertos visitando nuestro sitio Web. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera. Puede pedirle a AlphaCare que haga una excepción a estas restricciones a límites, o pedirle una lista de otros medicamentos parecidos que puedan tratar su condición médica. Vea la sección, “¿Qué tengo que hacer para solicitar una excepción al formulario de AlphaCare’s?” en la página v para ver información acerca de la manera de solicitar una excepción. ¿Qué son medicamentos que no necesitan receta (Over The Counter - OTC)? Los medicamentos OTC son medicamentos que no necesitan receta que, generalmente, no están cubiertos por un Plan de Medicamentos de Receta de Medicare. AlphaCare paga ciertos medicamentos OTC. AlphaCare proveerá estos medicamentos OTC sin costo para usted. El costo para AlphaCare de estos medicamentos OTC no contará para sus costos totales de medicamentos de Parte D (es decir, la cantidad que paga usted no cuenta para la falta de cobertura). DROGA Forma de dosificación Generic Name (Reference Brand Name) cetirizine hydrochloride (Zyrtec) Comprimidos masticables, solución, tabletas cetirizine hydrochloride/ pseudoephedrine hydrochloride (Zyrtec-D) 12 Horas Tablets loratadine (Claritin) Solución, Tablets loratadine/ pseudoephedrine sulfate (Claritin-D) 12 Horas Tablets 24 Horas Tablets ketotifen fumarate (Zaditor) Gotas iv ¿Qué pasa si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), lo primero que debe hacer es ponerse en contacto con Servicios de Miembros y preguntar si está cubierto su medicamento. Si averigua que AlphaCare no cubre su medicamento, tiene dos opciones: Puede pedirle a Servicios de Miembros una lista de medicamentos parecidos que estén cubiertos por AlphaCare. Cuando reciba la lista, enséñesela a su médico y pídale que le recete un medicamento parecido que esté cubierto por AlphaCare. Le puede pedir a AlphaCare que haga una excepción y cubra su medicamento. Vea la información que aparece a continuación para ver cómo solicitar una excepción. ¿Cómo se solicita una excepción al Formulario de AlphaCare? Le puede pedir a AlphaCare que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede pedirnos que hagamos. Puede pedirnos que cubramos un medicamento del formulario a un nivel más bajo de costo compartido si este medicamento no está en el nivel de especialidad. Si se aprueba, esto reduciría la cantidad que debe pagar usted por su medicamento. Puede pedirnos que demos una exención para las restricciones o límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, AlphaCare limita la cantidad de medicamento que cubrimos. Si su medicamento tiene un límite de cantidad, pude pedirnos que otorguemos una exención para el límite y que cubramos una cantidad mayor. Generalmente, AlphaCare solamente aprobará su solicitud de excepción si los medicamentos de alternativa incluidos en el formulario del plan, el medicamento de costo compartido más bajo o las restricciones de utilización adicionales no serían tan efectivas en el tratamiento de su condición y/o harían que usted tuviera efectos médicos adversos. Debe ponerse en contacto con nosotros para pedirnos una decisión de cobertura inicial para una excepción al formulario, o de las restricciones de utilización. Cuando solicite una excepción al formulario, o de restricciones de utilización, debe presentar una declaración de su recetador o médico apoyando su solicitud. Generalmente, tenemos que tomar una decisión dentro de las 72 horas siguientes a recibir la declaración de apoyo de su recetador. Puede solicitar una excepción acelerada (rápida) si usted o su médico cree que su salud podría verse severamente dañada si espera 72 horas para recibir una decisión. Si su solicitud de acelerar se concede, debemos darle una decisión no más de 24 horas después de recibir una declaración de apoyo de su médico u otro recetador. v ¿Qué hago antes de poder hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo de o si continua en nuestro plan, puede que esté tomando medicamentos que no estén en nuestro formulario. O puede que esté tomando un medicamento que esté en el formulario pero su habilidad de obtenerlo sea limitada. Por ejemplo, puede que necesite autorización previa nuestra antes de poder surtir su receta. Debe hablar con su médico para decidir si debería cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el rumbo correcto que seguir, puede que cubramos su medicamento en ciertos casos durante los primeros 90 días que sea miembro de nuestro plan. Para cada uno de sus medicamentos que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta que indique un número de días menor) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aún si ha sido miembro del plan menos de 90 días. Si es residente de una clínica de cuidado de largo plazo, permitiremos que repita su receta hasta que le hayamos provisto un suministro de transición de 91 días, consistente con el incremento de suministro (a menos que tenga una receta que indique un número menor de días). Cubriremos más de una repetición de estos medicamentos durante los primeros 90 días que sea miembro de nuestro plan. Si necesita un medicamento que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, pero ya han pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta que indique un número menor de días) mientras tramita una excepción al formulario. Miembros con cambios los niveles de atención pueden ponerse en contacto con nosotros (o tienen su médico o prescriptor contacto con nosotros) para solicitar los suministros de transición de medicamentos durante sus transiciones de atención. AlphaCare no suministrará un relleno de transición para los medicamentos que son medicamentos no aprobados por la Parte D. Para mayor información Para obtener información más detallada acerca de su cobertura de medicamentos de receta de AlphaCare, examine su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas acerca de AlphaCare, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera. Si tiene preguntas generales acerca de la cobertura de medicamentos de receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día / 7 días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov. vi Formulario de AlphaCare’s El formulario that begins on page 1 proporciona información de cobertura acerca de <some of> los medicamentos cubiertos por AlphaCare. Si tiene dificultades para encontrar su medicamento en la lista, vaya al Índice que empieza en la página 139. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en letras mayúsculas (por ejemplo, SUPRAX) y los medicamentos genéricos aparecen en cursiva minúscula (por ejemplo, cephalexin). La información de la columna de Requisitos/Límites le dice si AlphaCare tiene algún requisito especial para la cobertura de su medicamento. vii LEGEND NIVEL NOMBRE 0 OTC 1 Genericos Preferidos 2 Genericos 3 Marcas Preferidos 4 Marcas No Preferido 5 Especialidad SIMBOLO QL PA NOMBRE DESCRIPCION Quantity Limit Hay un limite en la cantidad de este droga que es qbiertos por receta, o dento de un tiempo especifico marco. Prior Authorization Usted (o su médico) esta obligado a obtener antes autorización antes de surtir su receta para este medicamento. Sin la autorización previa, es posible que no cubra este droga. ST Step Therapy En algunos casos, es posible que deba probar primero cierta medicamentos para tratar su afección médica antes de que cubrir otros fármacos para esa condicion. LA Limited Access Este medicamento con receta está limitada a ciertas farmacias. MO Mail Order Este medicamento tambien puede estar disponible a traves correo. 1 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Analgesics butalbital-acetaminophen tab 50-325 mg 2 PA, QL (180 PER 30 DAYS), MO (Mail Order) butalbital-apap-caffeine (cap 50-325-40 mg, tab 50-325-40 mg, 50-325-40 mg) 2 PA, QL (180 PER 30 DAYS), MO (Mail Order) butalbital-apap-caffeine cap 50-300-40 mg 4 PA, QL (180 PER 30 DAYS), MO (Mail Order) butalbital-aspirin-caffeine cap 50-325-40 mg 2 PA, QL (180 PER 30 DAYS), MO (Mail Order) VANATOL LQ SOLUTION 50-325-40 MG/15ML 4 PA, QL (2700 PER 30 DAYS), MO (Mail Order) CELEBREX (CAP 50 MG, CAP 200 MG, CAP 400 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) CELEBREX CAP 100 MG 4 QL (90 PER 30 DAYS), MO (Mail Order) celecoxib (cap 50 mg, cap 200 mg, cap 400 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) celecoxib cap 100 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) diclofenac potassium tab 50 mg 2 MO (Mail Order) diclofenac sodium (tab dr 25 mg, 75 mg, tab dr 75 mg) 2 MO (Mail Order) diclofenac sodium (tab dr 50 mg, 50 mg) 1 MO (Mail Order) diclofenac sodium tab 24h 100 mg 1 MO (Mail Order) diclofenac sodium gel 1 % 3 diclofenac sodium solution 1.5 % 4 MO (Mail Order) diclofenac-misoprostol (tab dr 50-0.2 mg, tab dr 75-0.2 mg) 4 MO (Mail Order) diflunisal tab 500 mg 2 MO (Mail Order) etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg) 2 MO (Mail Order) etodolac er (tab 400 mg, tab 500 mg, tab 600 mg) 2 MO (Mail Order) Nonsteroidal Anti-inflammatory DROGAs Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 2 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fenoprofen calcium (cap 400 mg, tab 600 mg) 4 MO (Mail Order) FLECTOR (1.3 %, PATCH 1.3 %) 4 PA, MO (Mail Order) flurbiprofen (tab 50 mg, tab 100 mg) 2 MO (Mail Order) ibuprofen (400 mg, tab 400 mg, tab 600 mg, 600 mg, tab 800 mg, 800 mg) 1 MO (Mail Order) ibuprofen suspension 100 mg/5ml 2 MO (Mail Order) INDOCIN SUSPENSION 25 MG/5ML 4 PA, MO (Mail Order) indomethacin (25 mg, cap 25 mg, 50 mg, cap 50 mg) 1 PA, MO (Mail Order) indomethacin cap 75 mg 2 PA, MO (Mail Order) ketoprofen (cap 50 mg, cap 75 mg) 2 MO (Mail Order) ketoprofen cap 24h 200 mg 4 MO (Mail Order) ketorolac tromethamine (15 mg/ml, solution 15 mg/ml) 2 PA, QL (40 PER 30 DAYS), MO (Mail Order) ketorolac tromethamine (solution 30 mg/ml, 30 mg/ml, solution 60 mg/2ml) 2 PA, QL (20 PER 30 DAYS), MO (Mail Order) ketorolac tromethamine solution 60 mg/2ml 2 PA, QL (20 PER 30 DAYS), MO (Mail Order) ketorolac tromethamine solution 60 mg/2ml 2 QL (20 PER 30 DAYS), MO (Mail Order) ketorolac tromethamine tab 10 mg 2 PA, QL (20 PER 5 DAYS), MO (Mail Order) meclofenamate sodium (cap 50 mg, cap 100 mg) 4 MO (Mail Order) mefenamic acid cap 250 mg 4 MO (Mail Order) meloxicam suspension 7.5 mg/5ml 4 QL (300 PER 30 DAYS), MO (Mail Order) meloxicam tab 15 mg 1 QL (30 PER 30 DAYS), MO (Mail Order) meloxicam tab 7.5 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) nabumetone (500 mg, tab 500 mg, tab 750 mg, 750 mg) 2 MO (Mail Order) naproxen (tab 250 mg, 250 mg, tab 375 mg, 375 mg, 500 mg, tab 500 mg) 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 3 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL naproxen dr (tab 375 mg, tab 500 mg) 1 MO (Mail Order) naproxen kit tab 500 mg 1 MO (Mail Order) naproxen sodium (tab 275 mg, tab 550 mg) 1 MO (Mail Order) naproxen suspension 125 mg/5ml 2 MO (Mail Order) oxaprozin tab 600 mg 2 MO (Mail Order) PENNSAID SOLUTION 2 % 3 MO (Mail Order) piroxicam (cap 10 mg, cap 20 mg) 2 MO (Mail Order) sulindac (tab 150 mg, tab 200 mg) 1 MO (Mail Order) tolmetin sodium cap 400 mg 2 MO (Mail Order) tolmetin sodium tab 600 mg 4 MO (Mail Order) VOLTAREN GEL 1 % 3 MO (Mail Order) ZIPSOR CAP 25 MG 4 ST, MO (Mail Order) buprenorphine hcl (solution 0.3 mg/ml, 0.3 mg/ml) 4 MO (Mail Order) BUTRANS (PATCH 5 MCG/HR, PATCH 7.5 MCG/HR, PATCH 10 MCG/HR, PATCH 15 MCG/HR, PATCH 20 MCG/HR) 3 QL (4 PER 28 DAYS), MO (Mail Order) EMBEDA (CAP ER 20-0.8 MG, CAP ER 803.2 MG) 3 QL (120 PER 30 DAYS), MO (Mail Order) EMBEDA (CAP ER 30-1.2 MG, CAP ER 50-2 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) EMBEDA CAP ER 100-4 MG 3 QL (90 PER 30 DAYS), MO (Mail Order) EMBEDA CAP ER 60-2.4 MG 3 QL (180 PER 30 DAYS), MO (Mail Order) EXALGO (16 MG, 32 MG) 5 QL (180 PER 30 DAYS), MO (Mail Order) EXALGO TB24 DETER 12 MG 4 QL (180 PER 30 DAYS), MO (Mail Order) EXALGO TB24 DETER 8 MG 3 QL (180 PER 30 DAYS), MO (Mail Order) fentanyl (12 mcg/hr, patch 72hr 12 mcg/hr, patch 72hr 37.5 mcg/hr) 4 QL (15 PER 30 DAYS), MO (Mail Order) Opioid Analgesics, Long-acting Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 4 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fentanyl (25 mcg/hr, patch 72hr 50 mcg/hr, patch 72hr 25 mcg/hr) 2 QL (15 PER 30 DAYS), MO (Mail Order) fentanyl (patch 62.5 mcg/hr, patch 87.5 mcg/hr) 5 QL (15 PER 30 DAYS), MO (Mail Order) fentanyl (patch 72hr 75 mcg/hr, patch 72hr 100 mcg/hr, 75 mcg/hr, 100 mcg/hr) 4 QL (30 PER 30 DAYS), MO (Mail Order) hydromorphone hcl er (er 12 mg, er 16 mg, er 32 mg) 5 QL (180 PER 30 DAYS), MO (Mail Order) hydromorphone hcl er tb24 deter 8 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) levorphanol tartrate tab 2 mg 4 QL (480 PER 30 DAYS), MO (Mail Order) methadone hcl (10 mg/ml, solution 10 mg/ml) 5 MO (Mail Order) methadone hcl (5 mg/5ml, 10 mg/5ml) 2 QL (1800 PER 30 DAYS), MO (Mail Order) methadone hcl tab 10 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) methadone hcl tab 5 mg 1 QL (360 PER 30 DAYS), MO (Mail Order) methadose tab 10 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) morphine sulfate er (er 100 mg, er 200 mg, tab 100 mg, tab 200 mg) 4 QL (180 PER 30 DAYS), MO (Mail Order) morphine sulfate er (er 15 mg, er 30 mg, tab 15 mg, tab 30 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) morphine sulfate er (er 60 mg, cap 24h 50 mg, cap 24h 60 mg, cap 24h 30 mg, cap 24h 10 mg, cap 24h 20 mg, cap 24h 80 mg, tab 60 mg) 4 QL (120 PER 30 DAYS), MO (Mail Order) morphine sulfate er beads (cap 30 mg, cap 45 mg, cap 60 mg, cap 75 mg, cap 90 mg) 4 QL (120 PER 30 DAYS), MO (Mail Order) morphine sulfate er beads cap er 24h 120 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) morphine sulfate cap 24h 100 mg 5 QL (180 PER 30 DAYS), MO (Mail Order) NUCYNTA ER (TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB 200 MG, TAB 250 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 5 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL OPANA ER (ER TB12 DETER 30 MG, ER TB12 DETER 40 MG, TAB 12H 30 MG, TAB 12H 40 MG) 5 QL (120 PER 30 DAYS), MO (Mail Order) OPANA ER (ER TB12 DETER 5 MG, ER TB12 DETER 15 MG, ER TB12 DETER 7.5 MG, ER TB12 DETER 20 MG, ER TB12 DETER 10 MG, TAB 12H 7.5 MG, TAB 12H 5 MG, TAB 12H 20 MG, TAB 12H 15 MG, TAB 12H 10 MG) oxycodone hcl er (er 10 mg, er 20 mg, er 40 mg, er tb12 deter 30 mg, er tb12 deter 15 mg, er tb12 deter 10 mg, er tb12 deter 20 mg, er tb12 deter 40 mg, er tb12 deter 60 mg) 3 QL (120 PER 30 DAYS), MO (Mail Order) oxycodone hcl er (er 80 mg, er tb12 deter 80 mg) 3 QL (180 PER 30 DAYS), MO (Mail Order) OXYCONTIN (10 MG, TB12 DETER 60 MG, TB12 DETER 40 MG, TB12 DETER 30 MG, TB12 DETER 20 MG, TB12 DETER 10 MG, TB12 DETER 15 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG) 3 QL (120 PER 30 DAYS), MO (Mail Order) OXYCONTIN (TB12 DETER 80 MG, 80 MG) 3 QL (180 PER 30 DAYS), MO (Mail Order) oxymorphone hcl er (tab 7.5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg, tab 40 mg) 4 QL (120 PER 30 DAYS), MO (Mail Order) oxymorphone hcl tab 12h 5 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) tramadol hcl er (biphasic) (er (biphasic) tab er 100 mg, er (biphasic) tab er 300 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) tramadol hcl er (biphasic) tab er 24h 200 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) tramadol hcl er (tab 100 mg, tab 300 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) tramadol hcl tab 24h 200 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) 5 PA, QL (120 PER 30 DAYS), MO (Mail Order) 3 QL (120 PER 30 DAYS), MO (Mail Order) Opioid Analgesics, Short-acting ABSTRAL (TAB 100 MCG, TAB 200 MCG, TAB 300 MCG, TAB 400 MCG, TAB 600 MCG, TAB 800 MCG) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 6 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL acetaminophen-codeine #2 tab 300-15 mg 1 QL (390 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine #3 (300-30 mg, tab 300-30 mg) 1 QL (360 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine #4 tab 300-60 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine (solution 120-12 mg/5ml, 120-12 mg/5ml) 1 QL (4500 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine tab 300-15 mg 1 QL (390 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine tab 300-30 mg 1 QL (360 PER 30 DAYS), MO (Mail Order) acetaminophen-codeine tab 300-60 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) ascomp-codeine cap 50-325-40-30 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) butalbital-apap-caff-cod cap 50-300-40-30 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) butalbital-apap-caff-cod cap 50-325-40-30 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) butorphanol tartrate (2 mg/ml, solution 2 mg/ml) 4 MO (Mail Order) butorphanol tartrate (solution 1 mg/ml, 1 mg/ml) 2 MO (Mail Order) butorphanol tartrate solution 10 mg/ml 2 QL (5 PER 1 DAYS), MO (Mail Order) codeine sulfate (60 mg, tab 60 mg) 4 QL (180 PER 30 DAYS), MO (Mail Order) codeine sulfate (tab 15 mg, tab 30 mg, 30 mg) 2 QL (180 PER 30 DAYS), MO (Mail Order) duramorph (0.5 mg/ml, 1 mg/ml) 2 MO (Mail Order) endocet (tab 5-325 mg, tab 7.5-325 mg, tab 10-325 mg) 2 QL (360 PER 30 DAYS), MO (Mail Order) fentanyl citrate (400 mcg, loz handle 400 mcg, loz handle 600 mcg, 600 mcg, 800 mcg, loz handle 800 mcg, loz handle 1200 mcg, 1200 mcg, loz handle 1600 mcg, 1600 mcg) 5 PA, QL (120 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 7 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fentanyl citrate (loz handle 200 mcg, 200 mcg) 4 PA, QL (120 PER 30 DAYS), MO (Mail Order) hydrocodone-acetaminophen (2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml) 2 QL (5550 PER 30 DAYS), MO (Mail Order) hydrocodone-acetaminophen (tab 2.5-325 mg, tab 5-325 mg, tab 10-325 mg) 2 QL (360 PER 30 DAYS), MO (Mail Order) hydrocodone-acetaminophen (tab 5-300 mg, tab 7.5-325 mg, tab 7.5-300 mg) 2 QL (390 PER 30 DAYS), MO (Mail Order) hydrocodone-acetaminophen solution 10-325 mg/15ml 2 QL (5400 PER 30 DAYS), MO (Mail Order) hydrocodone-acetaminophen tab 10-300 mg 4 QL (390 PER 30 DAYS), MO (Mail Order) hydrocodone-ibuprofen tab 7.5-200 mg 2 QL (150 PER 30 DAYS), MO (Mail Order) hydromorphone hcl (1 mg/ml, 2 mg/ml, 4 mg/ml, 10 mg/ml, 50 mg/5ml) 4 MO (Mail Order) hydromorphone hcl (tab 4 mg, tab 8 mg) 2 QL (360 PER 30 DAYS), MO (Mail Order) hydromorphone hcl liquid 1 mg/ml 4 QL (4800 PER 30 DAYS), MO (Mail Order) hydromorphone hcl pf (10 mg/ml, 50 mg/5ml, 500 mg/50ml) 4 MO (Mail Order) hydromorphone hcl tab 2 mg 1 QL (360 PER 30 DAYS), MO (Mail Order) lorcet plus tab 7.5-325 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) morphine sulfate (2 mg/ml, 8 mg/ml) 2 MO (Mail Order) morphine sulfate (concentrate) ((concentrate) 20 mg/ml, (concentrate) solution 100 mg/5ml) 2 QL (540 PER 30 DAYS), MO (Mail Order) morphine sulfate (pf) ((pf) 2 mg/ml, (pf) 4 mg/ml, (pf) 8 mg/ml, (pf) 10 mg/ml) 2 MO (Mail Order) morphine sulfate (tab 15 mg, 15 mg, 30 mg, tab 30 mg) 2 QL (360 PER 30 DAYS), MO (Mail Order) morphine sulfate solution 10 mg/5ml 2 QL (3600 PER 30 DAYS), MO (Mail Order) morphine sulfate solution 100 mg/5ml 2 QL (540 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 8 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL morphine sulfate solution 20 mg/5ml 2 QL (2700 PER 30 DAYS), MO (Mail Order) nalbuphine hcl (10 mg/ml, solution 10 mg/ml, solution 20 mg/ml, 20 mg/ml) 4 MO (Mail Order) oxycodone hcl (20 mg/ml, conc 100 mg/5ml) 4 QL (360 PER 30 DAYS), MO (Mail Order) oxycodone hcl (5 mg, cap 5 mg) 4 QL (480 PER 30 DAYS), MO (Mail Order) oxycodone hcl (5 mg/5ml, solution 5 mg/5ml) 2 QL (7200 PER 30 DAYS), MO (Mail Order) oxycodone hcl (tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) 2 QL (480 PER 30 DAYS), MO (Mail Order) oxycodone-acetaminophen (tab 2.5-325 mg, tab 5-325 mg, tab 7.5-325 mg, tab 10-325 mg) 2 QL (360 PER 30 DAYS), MO (Mail Order) oxycodone-aspirin tab 4.8355-325 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) oxycodone-ibuprofen tab 5-400 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) oxymorphone hcl tab 10 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) oxymorphone hcl tab 5 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) PRIMLEV (TAB 7.5-300 MG, TAB 10-300 MG) 5 QL (390 PER 30 DAYS), MO (Mail Order) PRIMLEV TAB 5-300 MG 4 QL (390 PER 30 DAYS), MO (Mail Order) tramadol hcl (tab 50 mg, 50 mg) 1 QL (240 PER 30 DAYS), MO (Mail Order) tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 PER 30 DAYS), MO (Mail Order) vicodin es tab 7.5-300 mg 2 QL (390 PER 30 DAYS), MO (Mail Order) vicodin hp tab 10-300 mg 4 QL (390 PER 30 DAYS), MO (Mail Order) vicodin tab 5-300 mg 2 QL (390 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 9 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL zamicet solution 10-325 mg/15ml 2 QL (5400 PER 30 DAYS), MO (Mail Order) lidocaine hcl (gel 2 %, solution 4 %) 2 MO (Mail Order) lidocaine hcl (pf) solution 0.5 % 1 PA - Part B vs D Determination, MO (Mail Order) lidocaine hcl (pf) solution 2 % 2 PA - Part B vs D Determination, MO (Mail Order) lidocaine hcl solution 0.5 % 1 PA - Part B vs D Determination, MO (Mail Order) lidocaine hcl solution 2 % 2 PA - Part B vs D Determination, MO (Mail Order) lidocaine ointment 5 % 2 MO (Mail Order) lidocaine patch 5 % 4 PA, QL (90 PER 30 DAYS), MO (Mail Order) lidocaine viscous solution 2 % 1 MO (Mail Order) lidocaine-prilocaine (cream 2.5-2.5 %, kit 2.52.5 %) 2 MO (Mail Order) livixil pak kit 2.5-2.5 % 2 MO (Mail Order) lp lite pak kit 2.5-2.5 % 2 MO (Mail Order) premium lidocaine ointment 5 % 2 MO (Mail Order) Anesthetics Local Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium tab dr 333 mg 4 MO (Mail Order) disulfiram tab 250 mg 2 MO (Mail Order) disulfiram tab 500 mg 4 MO (Mail Order) naltrexone hcl tab 50 mg 2 MO (Mail Order) VIVITROL RECON SUSP 380 MG 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 10 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Opioid Dependence Treatments buprenorphine hcl (tab 2 mg, tab 8 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) buprenorphine hcl-naloxone hcl (tab 2-0.5 mg, tab 8-2 mg) 4 QL (90 PER 30 DAYS), MO (Mail Order) SUBOXONE (2-0.5 MG, 8-2 MG) 4 QL (90 PER 30 DAYS), MO (Mail Order) SUBOXONE (4-1 MG, 12-3 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) ZUBSOLV (TAB 1.4-0.36 MG, TAB 5.7-1.4 MG) 4 QL (90 PER 30 DAYS), MO (Mail Order) ZUBSOLV SL TAB 11.4-2.9 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) ZUBSOLV SL TAB 2.9-0.71 MG 4 QL (150 PER 30 DAYS), MO (Mail Order) ZUBSOLV SL TAB 8.6-2.1 MG 4 QL (60 PER 30 DAYS), MO (Mail Order) 2 MO (Mail Order) buproban tab er 12h 150 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) CHANTIX (TAB 0.5 MG, TAB 1 MG) 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) CHANTIX CONTINUING MONTH PAK TAB 1 MG 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1 MG X 42 4 PA, QL (53 PER 28 DAYS), MO (Mail Order) NICOTROL INHALER 10 MG 4 QL (3024 PER 180 DAYS), MO (Mail Order) NICOTROL NS SOLUTION 10 MG/ML 3 QL (720 PER 180 DAYS), MO (Mail Order) Opioid Reversal Agents naloxone hcl solution 1 mg/ml Smoking Cessation Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 11 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Antibacterials Aminoglycosides amikacin sulfate (1 gm/4ml, 500 mg/2ml) 2 MO (Mail Order) BETHKIS NEBU SOLN 300 MG/4ML 5 PA - Part B vs D Determination, MO (Mail Order) gentak ointment 0.3 % 2 MO (Mail Order) gentamicin in saline (0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%) 2 MO (Mail Order) gentamicin in saline (0.9-0.9 mg/ml-%, 1.40.9 mg/ml-%) 3 MO (Mail Order) gentamicin sulfate (0.3 %, solution 0.3 %) 1 MO (Mail Order) gentamicin sulfate (cream 0.1 %, ointment 0.1 %, ointment 0.3 %, solution 40 mg/ml) 2 MO (Mail Order) gentamicin sulfate solution 10 mg/ml 4 MO (Mail Order) neomycin sulfate tab 500 mg 2 MO (Mail Order) paromomycin sulfate cap 250 mg 4 MO (Mail Order) streptomycin sulfate recon soln 1 gm 4 MO (Mail Order) tobramycin (0.3 %, solution 0.3 %) 1 MO (Mail Order) tobramycin nebu soln 300 mg/5ml 5 PA - Part B vs D Determination, MO (Mail Order) tobramycin pak nebu soln 300 mg/5ml 5 PA - Part B vs D Determination, MO (Mail Order) tobramycin sulfate (recon soln 1.2 gm, solution 1.2 gm/30ml, solution 2 gm/50ml, solution 10 mg/ml, solution 80 mg/2ml) 2 MO (Mail Order) tobrasol solution 0.3 % 1 MO (Mail Order) TOBREX OINTMENT 0.3 % 4 MO (Mail Order) baciim recon soln 50000 unit 2 MO (Mail Order) bacitracin (ointment 500 unit/gm, recon soln 50000 unit) 2 MO (Mail Order) Antibacterials, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 12 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL BACTROBAN NASAL OINTMENT 2 % 3 MO (Mail Order) chloramphenicol sod succinate recon soln 1 gm 4 MO (Mail Order) CLEOCIN SUPPOS 100 MG 4 MO (Mail Order) clindamycin hcl (cap 150 mg, 300 mg, cap 300 mg) 1 MO (Mail Order) clindamycin hcl cap 75 mg 2 MO (Mail Order) clindamycin palmitate hcl recon soln 75 mg/5ml 4 MO (Mail Order) clindamycin phosphate (cream 2 %, solution 9 gm/60ml, solution 300 mg/2ml, solution 600 mg/4ml, solution 900 mg/6ml, solution 9000 mg/60ml) 2 MO (Mail Order) clindamycin phosphate in d5w (300 mg/50ml, 600 mg/50ml, 900 mg/50ml) 4 MO (Mail Order) CLINDESSE CREAM 2 % 4 MO (Mail Order) colistimethate sodium recon soln 150 mg 5 MO (Mail Order) CUBICIN RECON SOLN 500 MG 5 MO (Mail Order) FLAGYL CAP 375 MG 4 MO (Mail Order) linezolid (recon susp 100 mg/5ml, solution 600 mg/300ml, tab 600 mg) 5 PA, MO (Mail Order) linezolid in sodium chloride solution 600-0.9 mg/300ml-% 5 PA, MO (Mail Order) methenamine hippurate tab 1 gm 2 MO (Mail Order) methenamine mandelate tab 1 gm 2 MO (Mail Order) metronidazole (cap 375 mg, cream 0.75 %, gel 0.75 %, 0.75 %, tab 500 mg) 2 MO (Mail Order) metronidazole (gel 1 %, lotion 0.75 %) 4 MO (Mail Order) metronidazole in nacl (5-0.79 mg/ml-%, solution 5-0.79 mg/ml-%, solution 500-0.79 mg/100ml-%) 2 MO (Mail Order) metronidazole tab 250 mg 1 MO (Mail Order) MONUROL PACKET 3 GM 4 MO (Mail Order) mupirocin calcium cream 2 % 2 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 13 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL mupirocin ointment 2 % 1 MO (Mail Order) neomycin-polymyxin b gu solution 40-200000 2 MO (Mail Order) nitrofurantoin macrocrystal (cap 25 mg, cap 50 mg, cap 100 mg) 2 QL (90 PER 365 OVER TIME), MO (Mail Order) nitrofurantoin monohyd macro cap 100 mg 2 QL (90 PER 365 OVER TIME), MO (Mail Order) nitrofurantoin suspension 25 mg/5ml 4 MO (Mail Order) NORITATE CREAM 1 % 5 MO (Mail Order) polymyxin b sulfate recon soln 500000 unit 4 MO (Mail Order) PRIMSOL SOLUTION 50 MG/5ML 4 MO (Mail Order) sulfamethoxazole-tmp ds tab 800-160 mg 1 MO (Mail Order) sulfamethoxazole-trimethoprim (200-40 mg/5ml, suspension 200-40 mg/5ml, suspension 800-160 mg/20ml) 2 MO (Mail Order) sulfamethoxazole-trimethoprim (400-80 mg, tab 400-80 mg, tab 800-160 mg) 1 MO (Mail Order) sulfamethoxazole-trimethoprim solution 40080 mg/5ml 4 MO (Mail Order) SULFAMYLON CREAM 85 MG/GM 3 MO (Mail Order) SYNERCID RECON SOLN 150-350 MG 5 MO (Mail Order) trimethoprim tab 100 mg 1 MO (Mail Order) TYGACIL (RECON SOLN 50 MG, 50 MG) 5 MO (Mail Order) vancomycin hcl (cap 125 mg, cap 250 mg) 5 PA, MO (Mail Order) vancomycin hcl (recon soln 10 gm, recon soln 500 mg, recon soln 1000 mg, 1000 mg, recon soln 5000 mg) 2 MO (Mail Order) vandazole gel 0.75 % 2 MO (Mail Order) vitazol cream 0.75 % 2 MO (Mail Order) XIFAXAN (TAB 200 MG, TAB 550 MG) 5 MO (Mail Order) ZYVOX (RECON SUSP 100 MG/5ML, SOLUTION 200 MG/100ML, SOLUTION 600 MG/300ML, TAB 600 MG) 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 14 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Beta-lactam, Cephalosporins AVYCAZ RECON SOLN 2-0.5 GM 5 MO (Mail Order) cefaclor (cap 250 mg, cap 500 mg) 2 MO (Mail Order) cefaclor tab 12h 500 mg 2 MO (Mail Order) cefadroxil (recon susp 250 mg/5ml, recon susp 500 mg/5ml, tab 1 gm) 2 MO (Mail Order) cefadroxil cap 500 mg 1 MO (Mail Order) cefazolin sodium (recon soln 1 gm, recon soln 10 gm, recon soln 20 gm, recon soln 500 mg, solution 1-5 gm-%, 10 gm, 500 mg) 2 MO (Mail Order) cefazolin sodium-dextrose (recon soln 1-4 gm-%, solution 2-4 gm/100ml-%) 2 MO (Mail Order) cefdinir (cap 300 mg, recon susp 125 mg/5ml, recon susp 250 mg/5ml) 2 MO (Mail Order) cefepime hcl (recon soln 1 gm, recon soln 2 gm, solution 1 gm/50ml, 2 gm, solution 2 gm/100ml) 4 MO (Mail Order) cefepime-dextrose (soln 1 gm/50ml, soln 2 gm/50ml) 4 MO (Mail Order) cefixime (100 mg/5ml, 200 mg/5ml) 3 MO (Mail Order) CEFOTAN RECON SOLN 2 GM 4 MO (Mail Order) cefotaxime sodium (recon soln 1 gm, 1 gm, 2 gm, recon soln 2 gm, recon soln 500 mg, 500 mg) 2 MO (Mail Order) cefotetan disodium (soln 2 gm, soln 10 gm) 4 MO (Mail Order) cefotetan disodium recon soln 1 gm 4 cefoxitin sodium (soln 2 gm, soln 10 gm) 4 MO (Mail Order) cefoxitin sodium recon soln 1 gm 2 MO (Mail Order) cefpodoxime proxetil (50 mg/5ml, 100 mg/5ml) 4 MO (Mail Order) cefpodoxime proxetil (tab 100 mg, tab 200 mg) 2 MO (Mail Order) cefprozil (125 mg/5ml, recon susp 125 mg/5ml, 250 mg/5ml, recon susp 250 mg/5ml, tab 250 mg, tab 500 mg) 2 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 15 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ceftazidime (soln 2 gm, soln 6 gm) 4 MO (Mail Order) ceftazidime and dextrose recon soln 1 gm/50ml 2 MO (Mail Order) ceftazidime and dextrose recon soln 2 gm/50ml 4 MO (Mail Order) ceftazidime recon soln 1 gm 2 MO (Mail Order) ceftriaxone sodium (recon soln 1 gm, 1 gm, recon soln 2 gm, 500 mg, recon soln 500 mg) 4 MO (Mail Order) ceftriaxone sodium (recon soln 1 gm, recon soln 10 gm, recon soln 100 gm, 250 mg, recon soln 250 mg) 2 MO (Mail Order) cefuroxime axetil (250 mg, tab 250 mg, 500 mg, tab 500 mg) 2 MO (Mail Order) cefuroxime sodium (1.5 gm, recon soln 1.5 gm) 4 MO (Mail Order) cefuroxime sodium (7.5 gm, recon soln 7.5 gm, 750 mg, recon soln 750 mg) 2 MO (Mail Order) cephalexin (cap 250 mg, cap 500 mg) 1 MO (Mail Order) cephalexin (recon susp 125 mg/5ml, recon susp 250 mg/5ml, tab 250 mg, tab 500 mg) 2 MO (Mail Order) cephalexin cap 750 mg 4 MO (Mail Order) SUPRAX (CAP 400 MG, CHEW TAB 100 MG, CHEW TAB 200 MG, RECON SUSP 100 MG/5ML, RECON SUSP 200 MG/5ML, RECON SUSP 500 MG/5ML) 3 MO (Mail Order) tazicef (soln 2 gm, soln 6 gm) 4 MO (Mail Order) tazicef recon soln 1 gm 2 MO (Mail Order) tazicef recon soln 2 gm 4 TEFLARO (SOLN 400 MG, SOLN 600 MG) 5 Beta-lactam, Other MO (Mail Order) MO (Mail Order) AZACTAM IN DEXTROSE (1 GM, SOLUTION 1 GM, 2 GM, SOLUTION 2 GM) 4 aztreonam (soln 1 gm, soln 2 gm) 4 MO (Mail Order) imipenem-cilastatin (soln 250 mg, soln 500 mg) 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 16 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL INVANZ RECON SOLN 1 GM 3 MO (Mail Order) meropenem (soln 1 gm, soln 500 mg) 4 MO (Mail Order) 1 MO (Mail Order) 2 MO (Mail Order) amoxicillin-pot clavulanate (tab 500-125 mg, tab 875-125 mg) 1 MO (Mail Order) amoxicillin-pot clavulanate tab 12h 1000-62.5 mg 2 MO (Mail Order) amoxicillin-pot clavulanate recon susp 25062.5 mg/5ml 4 MO (Mail Order) ampicillin (cap 250 mg, cap 500 mg, recon susp 125 mg/5ml) 1 MO (Mail Order) ampicillin recon susp 250 mg/5ml 2 MO (Mail Order) ampicillin sodium (1 gm, recon soln 1 gm, 2 gm, recon soln 2 gm, recon soln 10 gm, 10 gm, recon soln 125 mg, recon soln 250 mg, 500 mg, recon soln 500 mg) 4 MO (Mail Order) ampicillin-sulbactam recon soln 15 (10-5) gm 4 MO (Mail Order) ampicillin-sulbactam sodium (soln 1.5 (1-0.5) gm, soln 3 (2-1) gm, soln 15 (10-5) gm) 4 MO (Mail Order) AUGMENTIN RECON SUSP 125-31.25 MG/5ML 4 MO (Mail Order) BACTOCILL IN DEXTROSE SOLUTION 1 GM/50ML 4 MO (Mail Order) BACTOCILL IN DEXTROSE SOLUTION 2 GM/50ML 5 MO (Mail Order) BICILLIN C-R 900/300 SUSPENSION 900000-300000 UNIT/2ML 4 MO (Mail Order) Beta-lactam, Penicillins amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg, chew tab 250 mg, recon susp 125 mg/5ml, recon susp 200 mg/5ml, recon susp 250 mg/5ml, recon susp 400 mg/5ml, tab 500 mg, tab 875 mg) amoxicillin-pot clavulanate (chew tab 20028.5 mg, chew tab 400-57 mg, recon susp 200-28.5 mg/5ml, recon susp 400-57 mg/5ml, recon susp 600-42.9 mg/5ml, tab 250-125 mg) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 17 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL BICILLIN C-R SUSPENSION 1200000 UNIT/2ML 4 MO (Mail Order) BICILLIN L-A (600000 UNIT/ML, 1200000 UNIT/2ML, 2400000 UNIT/4ML) 4 MO (Mail Order) dicloxacillin sodium (cap 250 mg, cap 500 mg) 2 MO (Mail Order) nafcillin sodium (soln 1 gm, soln 10 gm) 5 MO (Mail Order) nafcillin sodium (soln 1 gm, soln 2 gm) 4 MO (Mail Order) nafcillin sodium in dextrose solution 1 gm/50ml 5 MO (Mail Order) NALLPEN IN DEXTROSE SOLUTION 2 GM/100ML 5 MO (Mail Order) oxacillin sodium (soln 1 gm, soln 2 gm) 4 MO (Mail Order) oxacillin sodium recon soln 10 gm 5 MO (Mail Order) penicillin g pot in dextrose (40000 unit/ml, 60000 unit/ml) 4 MO (Mail Order) penicillin g potassium (soln 5000000, soln 20000000) 4 MO (Mail Order) penicillin g sodium recon soln 5000000 unit 5 MO (Mail Order) penicillin v potassium (recon soln 125 mg/5ml, recon soln 250 mg/5ml, tab 250 mg, tab 500 mg) 1 MO (Mail Order) piperacillin sod-tazobactam so (d-tazobactam ln 3-0.375 gm, d-tazobactam ln 3.375 (30.375) gm, d-tazobactam ln 4-0.5 gm, dtazobactam ln 4.5 (4-0.5) gm, d-tazobactam ln 36-4.5 gm) 4 MO (Mail Order) 3 MO (Mail Order) AZASITE SOLUTION 1 % 3 MO (Mail Order) azithromycin (250 mg, tab 250 mg, tab 500 mg) 1 MO (Mail Order) azithromycin (packet 1 gm, recon soln 500 mg, recon susp 100 mg/5ml, recon susp 200 mg/5ml, tab 600 mg) 2 MO (Mail Order) ZOSYN (2-0.25 GM/50ML, 3-0.375 GM/50ML) Macrolides Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 18 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL clarithromycin (recon susp 125 mg/5ml, 250 mg, tab 250 mg, tab 500 mg) 2 MO (Mail Order) clarithromycin tab 24h 500 mg 2 MO (Mail Order) clarithromycin recon susp 250 mg/5ml 4 MO (Mail Order) DIFICID TAB 200 MG 5 PA, MO (Mail Order) E.E.S. GRANULES RECON SUSP 200 MG/5ML 3 MO (Mail Order) ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR 500 MG) 3 MO (Mail Order) ERYPED 200 RECON SUSP 200 MG/5ML 3 MO (Mail Order) ERYPED 400 RECON SUSP 400 MG/5ML 3 MO (Mail Order) ERYTHROCIN LACTOBIONATE RECON SOLN 500 MG 5 MO (Mail Order) ERYTHROCIN STEARATE TAB 250 MG 4 MO (Mail Order) erythromycin (5 mg/gm, ointment 5 mg/gm) 2 MO (Mail Order) erythromycin base (cp dr part 250 mg, tab 250 mg, tab 500 mg) 4 MO (Mail Order) erythromycin ethylsuccinate tab 400 mg 4 MO (Mail Order) ilotycin ointment 5 mg/gm 1 MO (Mail Order) KETEK (TAB 300 MG, TAB 400 MG) 4 PA, MO (Mail Order) PCE (TAB DR 333 MG, TAB DR 500 MG) 4 MO (Mail Order) ZMAX RECON SUSP 2 GM 4 MO (Mail Order) BESIVANCE SUSPENSION 0.6 % 3 MO (Mail Order) CILOXAN OINTMENT 0.3 % 3 MO (Mail Order) CIPRO (250 MG/5ML (5%), 500 MG/5ML (10%)) 4 MO (Mail Order) ciprofloxacin (200 mg/20ml, solution 200 mg/20ml, solution 400 mg/40ml, 400 mg/40ml) 2 MO (Mail Order) 4 MO (Mail Order) Quinolones ciprofloxacin (250 mg/5ml (5%), 500 mg/5ml (10%)) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 19 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ciprofloxacin hcl (solution 0.3 %, 250 mg, tab 250 mg, tab 500 mg, 500 mg, tab 750 mg) 1 MO (Mail Order) ciprofloxacin hcl tab 100 mg 4 MO (Mail Order) ciprofloxacin in d5w (solution 200 mg/100ml, 200 mg/100ml, solution 400 mg/200ml, 400 mg/200ml) 2 MO (Mail Order) ciprofloxacin-ciproflox hcl er (tab 500 mg, tab 1000 mg) 2 MO (Mail Order) gatifloxacin solution 0.5 % 2 MO (Mail Order) levofloxacin (solution 0.5 %, tab 250 mg, tab 500 mg, tab 750 mg) 2 MO (Mail Order) levofloxacin in d5w ( 250 mg/50ml, 500 mg/100ml, 750 mg/150ml) 2 MO (Mail Order) levofloxacin solution 25 mg/ml 4 MO (Mail Order) MOXEZA SOLUTION 0.5 % 3 MO (Mail Order) moxifloxacin hcl (solution 400 mg/250ml, tab 400 mg) 4 MO (Mail Order) ofloxacin (solution 0.3 %, tab 400 mg) 2 MO (Mail Order) VIGAMOX SOLUTION 0.5 % 3 MO (Mail Order) silver sulfadiazine cream 1 % 2 MO (Mail Order) ssd af cream 1 % 2 MO (Mail Order) ssd cream 1 % 2 MO (Mail Order) sulfacetamide sodium (ointment 10 %, solution 10 %) 2 MO (Mail Order) sulfadiazine tab 500 mg 4 MO (Mail Order) 4 MO (Mail Order) doxy 100 recon soln 100 mg 4 MO (Mail Order) doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg, 100 mg) 2 MO (Mail Order) doxycycline hyclate (recon soln 100 mg, tab dr 75 mg, tab dr 100 mg, tab dr 150 mg) 4 MO (Mail Order) Sulfonamides Tetracyclines demeclocycline hcl (150 mg, tab 150 mg, 300 mg, tab 300 mg) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 20 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL doxycycline monohydrate (50 mg, cap 50 mg, cap 75 mg, cap 100 mg, tab 50 mg, tab 75 mg, 75 mg, tab 100 mg, 100 mg) 2 MO (Mail Order) doxycycline monohydrate (cap 150 mg, recon susp 25 mg/5ml, tab 150 mg) 4 MO (Mail Order) minocycline hcl (50 mg, cap 75 mg, cap 100 mg, tab 50 mg) 2 MO (Mail Order) minocycline hcl (75 mg, tab 75 mg, tab 100 mg, 100 mg) 4 MO (Mail Order) minocycline hcl cap 50 mg 1 MO (Mail Order) minocycline hcl er (tab 90 mg, tab 135 mg) 2 MO (Mail Order) minocycline hcl tab 24h 45 mg 4 MO (Mail Order) tetracycline hcl (cap 250 mg, cap 500 mg, 500 mg) 4 MO (Mail Order) VIBRAMYCIN SYRUP 50 MG/5ML 4 MO (Mail Order) levetiracetam (solution 100 mg/ml, 500 mg, tab 500 mg, 750 mg, tab 750 mg, 1000 mg, tab 1000 mg) 2 MO (Mail Order) levetiracetam (tab 250 mg, 250 mg) 1 MO (Mail Order) levetiracetam er (tab 500 mg, tab 750 mg) 2 MO (Mail Order) levetiracetam in nacl (500 mg/100ml, 1000 mg/100ml, 1500 mg/100ml) 4 MO (Mail Order) levetiracetam solution 500 mg/5ml 4 MO (Mail Order) POTIGA (TAB 200 MG, TAB 300 MG, TAB 400 MG) 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) POTIGA TAB 50 MG 4 PA - FOR NEW STARTS ONLY, QL (270 PER 30 DAYS), MO (Mail Order) Anticonvulsants Anticonvulsants, Other SPRITAM (TAB 250 MG, TAB 500 MG, TAB 750 MG, TAB 1,000 MG) 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 21 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Calcium Channel Modifying Agents CELONTIN CAP 300 MG 4 MO (Mail Order) ethosuximide cap 250 mg 2 MO (Mail Order) ethosuximide solution 250 mg/5ml 4 MO (Mail Order) zonisamide (25 mg, cap 25 mg, cap 50 mg, 50 mg, 100 mg, cap 100 mg) 2 MO (Mail Order) Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam (0.5 mg, tab 0.5 mg, tab 1 mg) 1 QL (90 PER 30 DAYS), MO (Mail Order) clonazepam (tab 2 mg, 2 mg) 1 QL (300 PER 30 DAYS), MO (Mail Order) clonazepam (tab disp 0.125 mg, tab disp 0.25 mg, tab disp 0.5 mg, tab disp 1 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) clonazepam tab disp 2 mg 2 QL (300 PER 30 DAYS), MO (Mail Order) DIASTAT ACUDIAL (GEL 10 MG, GEL 20 MG) 4 MO (Mail Order) DIASTAT PEDIATRIC GEL 2.5 MG 4 MO (Mail Order) diazepam (gel 2.5 mg, gel 10 mg, gel 20 mg) 4 MO (Mail Order) divalproex sodium (cap sprink 125 mg, tab dr 125 mg, tab dr 250 mg, tab dr 500 mg) 2 MO (Mail Order) divalproex sodium tab 24h 250 mg 2 MO (Mail Order) divalproex sodium tab 24h 500 mg 4 MO (Mail Order) gabapentin (cap 100 mg, 100 mg, cap 300 mg, 300 mg) 1 MO (Mail Order) gabapentin (solution 250 mg/5ml, 400 mg, cap 400 mg, tab 600 mg, tab 800 mg, 800 mg) 2 MO (Mail Order) GABITRIL (TAB 12 MG, TAB 16 MG) 4 MO (Mail Order) ONFI (SUSPENSION 2.5 MG/ML, TAB 10 MG) 4 MO (Mail Order) ONFI TAB 20 MG 5 MO (Mail Order) phenobarbital (elixir 20 mg/5ml, solution 20 mg/5ml) 2 PA - FOR NEW STARTS ONLY, QL (1500 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 22 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL phenobarbital (tab 15 mg, tab 16.2 mg, tab 30 mg, tab 32.4 mg, tab 64.8 mg) 2 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) phenobarbital tab 100 mg 2 phenobarbital tab 60 mg 1 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail Order) phenobarbital tab 97.2 mg 2 primidone (50 mg, tab 50 mg, tab 250 mg, 250 mg) 2 MO (Mail Order) SABRIL (PACKET 500 MG, TAB 500 MG) 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) tiagabine hcl (tab 2 mg, tab 4 mg) 4 MO (Mail Order) valproate sodium (100 mg/ml, 500 mg/5ml) 4 MO (Mail Order) valproic acid (syrup 250 mg/5ml, 250 mg, cap 250 mg, solution 250 mg/5ml) 2 MO (Mail Order) felbamate (tab 400 mg, tab 600 mg) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) felbamate suspension 600 mg/5ml 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) FYCOMPA (TAB 4 MG, TAB 6 MG, TAB 8 MG, TAB 10 MG, TAB 12 MG) 4 MO (Mail Order) FYCOMPA TAB 2 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) LAMICTAL STARTER (25 (35) MG, 25 (42)100 (7) MG) 4 MO (Mail Order) LAMICTAL STARTER (KIT 25 (84)-100(14) MG, 25 (84)-100(14) MG) 5 MO (Mail Order) lamotrigine (25 (21)-50 (7) mg, 25 50 100 mg) 4 MO (Mail Order) lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg) 1 MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) Glutamate Reducing Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 23 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL lamotrigine (tab 5 mg, tab 25 mg) 2 MO (Mail Order) lamotrigine er (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg, tab 250 mg, tab 300 mg) 4 MO (Mail Order) lamotrigine kit 50 (42)-100(14) mg 5 MO (Mail Order) topiramate (cap 15 mg, cap 25 mg) 2 MO (Mail Order) topiramate (tab 25 mg, 25 mg, tab 50 mg, 50 mg, tab 100 mg, 100 mg, tab 200 mg, 200 mg) 1 MO (Mail Order) topiramate er (er 25 mg, er 50 mg, er 100 mg, er 150 mg, er 200 mg) 4 MO (Mail Order) APTIOM (TAB 600 MG, TAB 800 MG) 5 QL (60 PER 30 DAYS), MO (Mail Order) APTIOM TAB 200 MG 4 QL (60 PER 30 DAYS), MO (Mail Order) APTIOM TAB 400 MG 5 QL (30 PER 30 DAYS), MO (Mail Order) BANZEL (SUSPENSION 40 MG/ML, TAB 200 MG, TAB 400 MG) 5 MO (Mail Order) carbamazepine (suspension 100 mg/5ml, 100 mg/5ml, chew tab 100 mg, tab 200 mg, 200 mg) 2 MO (Mail Order) carbamazepine er (cap 100 mg, cap 200 mg, cap 300 mg, tab 100 mg, tab 200 mg) 2 MO (Mail Order) carbamazepine tab 12h 400 mg 4 MO (Mail Order) CEREBYX (100 MG PE/2ML, 500 MG PE/10ML) 4 MO (Mail Order) DILANTIN CAP 30 MG 3 MO (Mail Order) epitol tab 200 mg 2 MO (Mail Order) fosphenytoin sodium (100 mg pe/2ml, solution 100 mg pe/2ml, solution 500 mg pe/10ml, 500 mg pe/10ml) 2 MO (Mail Order) oxcarbazepine (150 mg, tab 150 mg, 300 mg, tab 300 mg, tab 600 mg, 600 mg) 2 MO (Mail Order) oxcarbazepine suspension 300 mg/5ml 4 MO (Mail Order) Sodium Channel Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 24 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL OXTELLAR XR (TAB ER 150 MG, TAB ER 300 MG, TAB ER 600 MG) 4 MO (Mail Order) PEGANONE TAB 250 MG 4 MO (Mail Order) phenytoin (chew tab 50 mg, 125 mg/5ml, suspension 125 mg/5ml) 2 MO (Mail Order) phenytoin infatabs chew tab 50 mg 2 MO (Mail Order) phenytoin sodium extended (cap 100 mg, cap 200 mg, cap 300 mg) 2 MO (Mail Order) phenytoin sodium solution 50 mg/ml 1 MO (Mail Order) TEGRETOL-XR TAB ER 12H 100 MG 4 MO (Mail Order) VIMPAT (SOLUTION 10 MG/ML, SOLUTION 200 MG/20ML, TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB 200 MG) 4 MO (Mail Order) 3 PA, MO (Mail Order) 1 MO (Mail Order) donepezil hcl tab 23 mg 4 MO (Mail Order) donepezil hcl tab disp 10 mg 2 MO (Mail Order) EXELON (PATCH 4.6 MG/, PATCH 9.5 MG/, PATCH 13.3 MG/) 4 MO (Mail Order) galantamine hydrobromide (tab 4 mg, 4 mg, 8 mg, tab 8 mg, tab 12 mg, 12 mg) 2 MO (Mail Order) galantamine hydrobromide er (cap 8 mg, cap 16 mg, cap 24 mg) 2 MO (Mail Order) galantamine hydrobromide solution 4 mg/ml 4 MO (Mail Order) rivastigmine (patch 4.6 mg/, patch 9.5 mg/, patch 13.3 mg/) 4 MO (Mail Order) rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg, cap 6 mg) 2 MO (Mail Order) Antidementia Agents Antidementia Agents, Other ergoloid mesylates tab 1 mg Cholinesterase Inhibitors donepezil hcl (tab 5 mg, tab 10 mg, tab disp 5 mg) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 25 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (solution 2 mg/ml, tab 5 mg, tab 5 (28)-10 (21) mg, tab 10 mg) 4 PA, MO (Mail Order) NOMBRENDA (SOLUTION 10 MG/5ML, TAB 5 4 MG, TAB 10 MG) NOMBRENDA TITRATION PAK TAB 5 (28)-10 4 (21) MG NOMBRENDA XR (CAP ER 7 MG, CAP ER 14 3 MG, CAP ER 21 MG, CAP ER 28 MG) NOMBRENDA XR TITRATION PACK CAP ER 3 24H 7 & 14 & 21 &28 MG PA, MO (Mail Order) PA, MO (Mail Order) PA, QL (30 PER 30 DAYS), MO (Mail Order) PA, QL (30 PER 30 DAYS), MO (Mail Order) Antidepressants Antidepressants, Other bupropion hcl (100 mg, tab 100 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) bupropion hcl (75 mg, tab 75 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) bupropion hcl er (sr) (er (sr) tab er 150 mg, er (sr) tab er 200 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) bupropion hcl er (sr) tab er 12h 100 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) bupropion hcl er (xl) tab er 24h 150 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) bupropion hcl er (xl) tab er 24h 300 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) chlordiazepoxide-amitriptyline (tab 5-12.5 mg, tab 10-25 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) FORFIVO XL TAB ER 24H 450 MG 3 QL (30 PER 30 DAYS), MO (Mail Order) maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg) 2 MO (Mail Order) mirtazapine (tab 15 mg, 15 mg, tab 30 mg, 30 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) mirtazapine (tab 7.5 mg, tab 45 mg, tab disp 15 mg, tab disp 30 mg, tab disp 45 mg, 45 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 26 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL olanzapine-fluoxetine hcl (cap 3-25 mg, cap 6-25 mg, cap 6-50 mg, cap 12-50 mg, cap 1225 mg) 4 MO (Mail Order) perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab 4-10 mg, tab 4-25 mg, tab 4-50 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) EMSAM (PATCH 6 MG/, PATCH 9 MG/, PATCH 12 MG/) 5 ST, QL (30 PER 30 DAYS), MO (Mail Order) MARPLAN TAB 10 MG 4 MO (Mail Order) phenelzine sulfate tab 15 mg 2 MO (Mail Order) tranylcypromine sulfate tab 10 mg 4 MO (Mail Order) Monoamine Oxidase Inhibitors SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor) BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) citalopram hydrobromide (tab 10 mg, 10 mg, 20 mg, tab 20 mg, tab 40 mg, 40 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) citalopram hydrobromide solution 10 mg/5ml 2 QL (600 PER 30 DAYS), MO (Mail Order) desvenlafaxine tab 24h 100 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) desvenlafaxine tab 24h 50 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) desvenlafaxine fumarate tab 24h 100 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) desvenlafaxine fumarate tab 24h 50 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) duloxetine hcl (dr 20 mg, dr 30 mg) 4 QL (60 PER 30 DAYS), MO (Mail Order) duloxetine hcl cp dr part 60 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) escitalopram oxalate solution 5 mg/5ml 4 QL (600 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 27 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL FETZIMA (CAP ER 20 MG, CAP ER 40 MG, CAP ER 80 MG, CAP ER 120 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) FETZIMA TITRATION CP24 THPK 20 & 40 MG 4 ST, QL (28 PER 28 DAYS), MO (Mail Order) fluoxetine hcl (10 mg, cap 10 mg, tab 10 mg) 1 QL (90 PER 30 DAYS), MO (Mail Order) fluoxetine hcl (cap 20 mg, 20 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) fluoxetine hcl cap 40 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) fluoxetine hcl cap dr 90 mg 4 QL (4 PER 28 DAYS), MO (Mail Order) fluoxetine hcl solution 20 mg/5ml 2 QL (600 PER 30 DAYS), MO (Mail Order) fluoxetine hcl tab 20 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) fluoxetine hcl tab 60 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) fluvoxamine maleate (tab 25 mg, 25 mg, 50 mg, tab 50 mg, tab 100 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) fluvoxamine maleate er (cap 100 mg, cap 150 mg) 4 QL (60 PER 30 DAYS), MO (Mail Order) KHEDEZLA TAB ER 24H 100 MG 4 QL (120 PER 30 DAYS), MO (Mail Order) KHEDEZLA TAB ER 24H 50 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab 250 mg) 2 MO (Mail Order) paroxetine hcl (10 mg, tab 10 mg) 1 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) 1 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) paroxetine hcl (20 mg, tab 20 mg) paroxetine hcl (tab 30 mg, 30 mg) 1 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 28 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL paroxetine hcl (tab 40 mg, 40 mg) 1 PA - FOR NEW STARTS ONLY, QL (45 PER 30 DAYS), MO (Mail Order) paroxetine hcl er (er 25 mg, tab 24h 25 mg) 4 paroxetine hcl tab 24h 12.5 mg 2 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) paroxetine hcl tab 24h 37.5 mg PAXIL SUSPENSION 10 MG/5ML 4 4 PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (900 PER 30 DAYS), MO (Mail Order) PRISTIQ TAB ER 24H 100 MG 3 QL (120 PER 30 DAYS), MO (Mail Order) PRISTIQ TAB ER 24H 50 MG 3 QL (30 PER 30 DAYS), MO (Mail Order) sertraline hcl (50 mg, tab 50 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) sertraline hcl (tab 100 mg, 100 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) sertraline hcl (tab 25 mg, 25 mg) 1 QL (45 PER 30 DAYS), MO (Mail Order) sertraline hcl conc 20 mg/ml 2 QL (300 PER 30 DAYS), MO (Mail Order) trazodone hcl (50 mg, tab 50 mg, tab 100 mg, 100 mg, tab 150 mg, 150 mg) 1 MO (Mail Order) trazodone hcl tab 300 mg 2 MO (Mail Order) venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 75 mg, tab 100 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) venlafaxine hcl er (cap 150 mg, tab 150 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) venlafaxine hcl er (cap 37.5 mg, cap 75 mg, tab 37.5 mg, tab 75 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) venlafaxine hcl tab 24h 225 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 29 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL venlafaxine hcl tab 50 mg 2 QL (210 PER 30 DAYS), MO (Mail Order) VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) VIIBRYD STARTER PACK KIT 10 & 20 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor PRISTIQ TAB ER 24H 25 MG 3 QL (30 PER 30 DAYS), MO (Mail Order) amitriptyline hcl (tab 10 mg, 25 mg, tab 25 mg) 1 PA - FOR NEW STARTS ONLY, MO (Mail Order) amitriptyline hcl (tab 50 mg, tab 75 mg, tab 100 mg, 150 mg, tab 150 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) clomipramine hcl (cap 25 mg, cap 50 mg, cap 75 mg) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) desipramine hcl tab 150 mg 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg, cap 150 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) doxepin hcl conc 10 mg/ml 1 PA - FOR NEW STARTS ONLY, MO (Mail Order) imipramine hcl (tab 25 mg, tab 50 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) imipramine hcl tab 10 mg 1 PA - FOR NEW STARTS ONLY, MO (Mail Order) imipramine pamoate (cap 75 mg, cap 100 mg, cap 150 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) imipramine pamoate cap 125 mg 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) Tricyclics Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 30 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL nortriptyline hcl (cap 10 mg, cap 25 mg, 25 mg, cap 50 mg, cap 75 mg) 1 PA - FOR NEW STARTS ONLY, MO (Mail Order) nortriptyline hcl solution 10 mg/5ml 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) protriptyline hcl (tab 5 mg, tab 10 mg) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) SURMONTIL (CAP 25 MG, CAP 50 MG, CAP 100 MG) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) trimipramine maleate (cap 25 mg, cap 50 mg, cap 100 mg) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) compro suppos 25 mg 2 MO (Mail Order) meclizine hcl tab 12.5 mg 1 MO (Mail Order) meclizine hcl tab 25 mg 2 MO (Mail Order) metoclopramide hcl (5 mg/5ml, 5 mg/ml, 10 mg/10ml) 2 MO (Mail Order) metoclopramide hcl (tab 5 mg, tab 10 mg) 1 MO (Mail Order) metoclopramide hcl (tab disp 5 mg, tab disp 10 mg) 5 MO (Mail Order) prochlorperazine edisylate solution 5 mg/ml 4 MO (Mail Order) prochlorperazine maleate (tab 5 mg, tab 10 mg) 1 MO (Mail Order) prochlorperazine suppos 25 mg 2 MO (Mail Order) TRANSDERM-SCOP PATCH 72HR 1 MG/3DAYS 4 QL (10 PER 30 DAYS), MO (Mail Order) ALOXI (0.075 MG/1.5ML, SOLUTION 0.25 MG/5ML) 5 MO (Mail Order) ANZEMET (SOLUTION 20 MG/ML, 20 MG/ML) 4 MO (Mail Order) ANZEMET TAB 100 MG 4 PA - Part B vs D Determination, QL (3 PER 3 DAYS), MO (Mail Order) Antiemetics Antiemetics, Other Emetogenic Therapy Adjuncts Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 31 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ANZEMET TAB 50 MG 5 PA - Part B vs D Determination, QL (6 PER 3 DAYS), MO (Mail Order) dronabinol (cap 2.5 mg, cap 5 mg) 4 PA, QL (180 PER 30 DAYS), MO (Mail Order) dronabinol cap 10 mg 4 PA, MO (Mail Order) EMEND (CAP 40 MG, CAP 80 MG, CAP 80 & 125 MG, CAP 125 MG) 4 PA, MO (Mail Order) granisetron hcl (0.1 mg/ml, solution 0.1 mg/ml) 2 MO (Mail Order) granisetron hcl (solution 1 mg/ml, 1 mg/ml, solution 4 mg/4ml, 4 mg/4ml) 4 MO (Mail Order) granisetron hcl (tab 1 mg, 1 mg) 2 PA - Part B vs D Determination, QL (6 PER 3 DAYS), MO (Mail Order) ondansetron hcl (solution 4 mg/2ml, 4 mg/2ml, solution 40 mg/20ml, 40 mg/20ml) 2 MO (Mail Order) ondansetron hcl (tab 4 mg, 4 mg, 8 mg, tab 8 mg, tab 24 mg) 2 PA - Part B vs D Determination, MO (Mail Order) ondansetron hcl solution 4 mg/5ml 4 PA - Part B vs D Determination, MO (Mail Order) ondansetron tab disp 4 mg 1 PA - Part B vs D Determination, MO (Mail Order) ondansetron tab disp 8 mg 2 PA - Part B vs D Determination, MO (Mail Order) SANCUSO PATCH 3.1 MG/24HR 5 QL (2 PER 28 DAYS), MO (Mail Order) ABELCET SUSPENSION 5 MG/ML 5 PA - Part B vs D Determination, MO (Mail Order) AMBISOME RECON SUSP 50 MG 5 PA - Part B vs D Determination, MO (Mail Order) amphotericin b recon soln 50 mg 4 PA - Part B vs D Determination, MO (Mail Order) CANCIDAS RECON SOLN 50 MG 5 MO (Mail Order) Antifungals Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 32 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL CANCIDAS RECON SOLN 70 MG 4 MO (Mail Order) ciclopirox (gel 0.77 %, shampoo 1 %, solution 8 %) 2 MO (Mail Order) ciclopirox olamine (0.77 %, cream 0.77 %, suspension 0.77 %) 2 MO (Mail Order) ciclopirox treatment kit 8 % 2 MO (Mail Order) clotrimazole (cream 1 %, lozenge 10 mg, solution 1 %, troche 10 mg) 2 MO (Mail Order) CRESEMBA (CAP 186 MG, RECON SOLN 372 MG) 5 PA, MO (Mail Order) econazole nitrate cream 1 % 4 MO (Mail Order) ERAXIS (SOLN 50 MG, SOLN 100 MG) 5 MO (Mail Order) EXELDERM (1 %, CREAM 1 %, SOLUTION 1 %) 4 MO (Mail Order) fluconazole (150 mg, tab 150 mg) 1 MO (Mail Order) fluconazole (recon susp 10 mg/ml, recon susp 40 mg/ml, 50 mg, tab 50 mg, tab 100 mg, tab 200 mg, 200 mg) 2 MO (Mail Order) fluconazole in dextrose (200 mg/100ml, 400 mg/200ml) 2 MO (Mail Order) fluconazole in sodium chloride (200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%) 2 MO (Mail Order) flucytosine (cap 250 mg, cap 500 mg) 5 MO (Mail Order) griseofulvin microsize suspension 125 mg/5ml 2 MO (Mail Order) griseofulvin microsize tab 500 mg 4 MO (Mail Order) griseofulvin ultramicrosize (tab 125 mg, tab 250 mg) 4 MO (Mail Order) GYNAZOLE-1 CREAM 2 % 4 MO (Mail Order) itraconazole cap 100 mg 4 PA, MO (Mail Order) ketoconazole (cream 2 %, 200 mg, tab 200 mg) 2 MO (Mail Order) ketoconazole foam 2 % 4 MO (Mail Order) ketoconazole shampoo 2 % 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 33 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL LAMISIL (125 MG, 187.5 MG) 4 MO (Mail Order) MENTAX CREAM 1 % 4 MO (Mail Order) MICONAZOLE 3 SUPPOS 200 MG 2 MO (Mail Order) naftifine hcl cream 1 % 4 MO (Mail Order) NAFTIN (CREAM 2 %, GEL 1 %, GEL 2 %) 4 MO (Mail Order) NATACYN SUSPENSION 5 % 3 MO (Mail Order) NOXAFIL (SUSPENSION 40 MG/ML, TAB DR 100 MG) 5 PA, MO (Mail Order) nyamyc powder 100000 unit/gm 2 MO (Mail Order) nystatin (cream 100000 unit/gm, ointment 100000 unit/gm, powder, powder 100000 unit/gm, suspension 100000 unit/ml, 100000 unit/gm, tab 500000 unit) 2 MO (Mail Order) nystatin-triamcinolone (cream 100000-0.1 unit/gm-%, ointment 100000-0.1 unit/gm-%) 4 MO (Mail Order) nystop powder 100000 unit/gm 2 MO (Mail Order) ONMEL TAB 200 MG 5 PA, MO (Mail Order) oxiconazole nitrate cream 1 % 4 MO (Mail Order) OXISTAT (LOTION 1 %, 1 %, CREAM 1 %) 4 MO (Mail Order) SPORANOX SOLUTION 10 MG/ML 5 PA, MO (Mail Order) terbinafine hcl (250 mg, tab 250 mg) 1 MO (Mail Order) terconazole (cream 0.4 %, cream 0.8 %, 0.8 %, suppos 80 mg) 2 MO (Mail Order) VFEND RECON SUSP 40 MG/ML 5 MO (Mail Order) voriconazole (recon soln 200 mg, tab 50 mg) 4 MO (Mail Order) voriconazole (recon susp 40 mg/ml, tab 200 mg) 5 MO (Mail Order) zazole (0.4 %, 0.8 %) 2 MO (Mail Order) allopurinol (100 mg, tab 100 mg, tab 300 mg) 1 MO (Mail Order) colchicine-probenecid tab 0.5-500 mg 2 MO (Mail Order) Antigout Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 34 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL COLCRYS TAB 0.6 MG 3 QL (120 PER 30 DAYS), MO (Mail Order) probenecid tab 500 mg 2 MO (Mail Order) ULORIC (TAB 40 MG, TAB 80 MG) 3 ST, MO (Mail Order) CAFERGOT TAB 1-100 MG 4 MO (Mail Order) dihydroergotamine mesylate solution 1 mg/ml 4 MO (Mail Order) dihydroergotamine mesylate solution 4 mg/ml 5 MO (Mail Order) ERGOMAR SL TAB 2 MG 3 MO (Mail Order) MIGERGOT SUPPOS 2-100 MG 5 QL (20 PER 28 DAYS), MO (Mail Order) almotriptan malate (tab 6.25 mg, tab 12.5 mg) 4 QL (12 PER 30 DAYS), MO (Mail Order) AXERT (TAB 6.25 MG, TAB 12.5 MG) 4 ST, QL (12 PER 30 DAYS), MO (Mail Order) FROVA TAB 2.5 MG 4 ST, QL (18 PER 30 DAYS), MO (Mail Order) frovatriptan succinate tab 2.5 mg 4 QL (18 PER 30 DAYS), MO (Mail Order) naratriptan hcl (tab 1 mg, tab 2.5 mg) 2 QL (9 PER 30 DAYS), MO (Mail Order) RELPAX (TAB 20 MG, TAB 40 MG) 4 ST, QL (6 PER 30 DAYS), MO (Mail Order) rizatriptan benzoate (tab 5 mg, tab 10 mg, tab disp 5 mg, tab disp 10 mg) 2 QL (12 PER 30 DAYS), MO (Mail Order) sumatriptan (5 mg/act, 20 mg/act) 4 QL (6 PER 30 DAYS), MO (Mail Order) sumatriptan succinate (soln a-inj 4 mg/0.5ml, soln a-inj 6 mg/0.5ml, 6 mg/0.5ml, soln prsyr 6 mg/0.5ml, solution 6 mg/0.5ml) 4 QL (4 PER 30 DAYS), MO (Mail Order) sumatriptan succinate (tab 25 mg, tab 50 mg, 50 mg, tab 100 mg, 100 mg) 2 QL (9 PER 30 DAYS), MO (Mail Order) Antimigraine Agents Ergot Alkaloids Serotonin (5-HT) 1b/1d Receptor Agonists Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 35 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL sumatriptan succinate refill (soln 4 mg/0.5ml, soln 6 mg/0.5ml) 4 QL (4 PER 30 DAYS), MO (Mail Order) zolmitriptan (tab 2.5 mg, tab 5 mg, tab disp 2.5 mg, tab disp 5 mg) 4 QL (9 PER 30 DAYS), MO (Mail Order) guanidine hcl tab 125 mg 4 MO (Mail Order) MESTINON (SYRUP 60 MG/5ML, TAB ER 180 MG) 3 MO (Mail Order) pyridostigmine bromide tab 180 mg 3 MO (Mail Order) pyridostigmine bromide tab 60 mg 2 MO (Mail Order) dapsone (tab 25 mg, tab 100 mg) 3 MO (Mail Order) rifabutin cap 150 mg 4 MO (Mail Order) CAPASTAT SULFATE RECON SOLN 1 GM 4 MO (Mail Order) cycloserine cap 250 mg 4 MO (Mail Order) ethambutol hcl (tab 100 mg, tab 400 mg) 2 MO (Mail Order) isoniazid (solution 100 mg/ml, syrup 50 mg/5ml) 4 MO (Mail Order) isoniazid (tab 100 mg, 300 mg, tab 300 mg) 1 MO (Mail Order) PASER PACKET 4 GM 4 MO (Mail Order) PRIFTIN TAB 150 MG 4 MO (Mail Order) pyrazinamide tab 500 mg 4 MO (Mail Order) rifampin (cap 150 mg, cap 300 mg) 2 MO (Mail Order) rifampin recon soln 600 mg 4 MO (Mail Order) RIFATER TAB 50-120-300 MG 4 MO (Mail Order) Antimyasthenic Agents Parasympathomimetics Antimycobacterials Antimycobacterials, Other Antituberculars Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 36 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SIRTURO TAB 100 MG 5 PA, MO (Mail Order) TRECATOR TAB 250 MG 4 MO (Mail Order) Antineoplastics Alkylating Agents BENDEKA SOLUTION 100 MG/4ML 5 BICNU RECON SOLN 100 MG 5 MO (Mail Order) BUSULFEX SOLUTION 6 MG/ML 5 MO (Mail Order) carboplatin (recon soln 150 mg, solution 50 mg/5ml, solution 150 mg/15ml, solution 450 mg/45ml, solution 600 mg/60ml) 2 MO (Mail Order) cisplatin (50 mg/50ml, 100 mg/100ml, 200 mg/200ml) 2 MO (Mail Order) cyclophosphamide (cap 25 mg, cap 50 mg) 4 PA - Part B vs D Determination, MO (Mail Order) dacarbazine recon soln 200 mg 4 MO (Mail Order) EMCYT CAP 140 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) GLEOSTINE (CAP 5 MG, CAP 10 MG, CAP 40 MG, CAP 100 MG) 3 MO (Mail Order) HEXALEN (50 MG, CAP 50 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ifosfamide (recon soln 1 gm, recon soln 3 gm, solution 1 gm/20ml, solution 3 gm/60ml) 4 MO (Mail Order) LEUKERAN TAB 2 MG 4 MO (Mail Order) MATULANE CAP 50 MG 5 LA, MO (Mail Order) melphalan hcl recon soln 50 mg 5 MO (Mail Order) MUSTARGEN RECON SOLN 10 MG 5 MO (Mail Order) oxaliplatin (50 mg, recon soln 50 mg, solution 50 mg/10ml, 50 mg/10ml, solution 100 mg/20ml, 100 mg/20ml, recon soln 100 mg, 100 mg) 5 MO (Mail Order) thiotepa recon soln 15 mg 5 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 37 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL TREANDA (SOLN 25 MG, SOLN 100 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) VALCHLOR GEL 0.016 % 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) YONDELIS RECON SOLN 1 MG 5 MO (Mail Order) ZANOSAR RECON SOLN 1 GM 5 MO (Mail Order) bicalutamide tab 50 mg 2 MO (Mail Order) flutamide cap 125 mg 2 MO (Mail Order) NILANDRON TAB 150 MG 5 MO (Mail Order) XTANDI CAP 40 MG 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail Order) ZYTIGA TAB 250 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) Antiandrogens Antiangiogenic Agents POMALYST (CAP 1 MG, CAP 2 MG, CAP 3 MG, CAP 4 MG) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG, CAP 15 MG, CAP 20 MG, CAP 25 MG) 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) THALOMID (CAP 50 MG, CAP 100 MG, CAP 150 MG, CAP 200 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) FARESTON TAB 60 MG 5 MO (Mail Order) FASLODEX SOLUTION 250 MG/5ML 5 MO (Mail Order) SOLTAMOX SOLUTION 10 MG/5ML 4 MO (Mail Order) tamoxifen citrate (tab 10 mg, tab 20 mg) 2 MO (Mail Order) adrucil (2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml) 2 PA - Part B vs D Determination, MO (Mail Order) ALIMTA (SOLN 100 MG, SOLN 500 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) Antiestrogens/Modifiers Antimetabolites Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 38 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ARRANON SOLUTION 5 MG/ML 5 MO (Mail Order) azacitidine recon susp 100 mg 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) cladribine solution 10 mg/10ml 5 PA - Part B vs D Determination, MO (Mail Order) CLOLAR (1 MG/ML, SOLUTION 1 MG/ML) 5 MO (Mail Order) cytarabine (pf) solution 100 mg/ml 2 PA - Part B vs D Determination, MO (Mail Order) cytarabine (pf) solution 20 mg/ml 4 PA - Part B vs D Determination, MO (Mail Order) cytarabine (soln 1 gm, soln 2 gm) 2 PA - Part B vs D Determination, MO (Mail Order) cytarabine solution 20 mg/ml 4 PA - Part B vs D Determination, MO (Mail Order) DACOGEN (RECON SOLN 50 MG, 50 MG) 5 MO (Mail Order) decitabine recon soln 50 mg 5 MO (Mail Order) DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG) 3 MO (Mail Order) ELITEK (SOLN 1.5 MG, SOLN 7.5 MG) 5 MO (Mail Order) fluorouracil (1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml) 2 PA - Part B vs D Determination, MO (Mail Order) FOLOTYN (20 MG/ML, 40 MG/2ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) gemcitabine hcl (soln 1 gm, soln 2 gm, soln 200 mg) 5 MO (Mail Order) hydroxyurea cap 500 mg 2 MO (Mail Order) LONSURF TAB 15-6.14 MG 5 PA - FOR NEW STARTS ONLY, QL (300 PER 30 DAYS), MO (Mail Order) LONSURF TAB 20-8.19 MG 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO (Mail Order) mercaptopurine tab 50 mg 2 MO (Mail Order) NIPENT RECON SOLN 10 MG 5 MO (Mail Order) PURIXAN 20 MG/ML ORAL SUSP 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 39 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL TABLOID TAB 40 MG 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) VIDAZA RECON SUSP 100 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ABRAXANE RECON SUSP 100 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ALECENSA CAP 150 MG 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO (Mail Order) amifostine recon soln 500 mg 5 MO (Mail Order) BELEODAQ RECON SOLN 500 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) bleomycin sulfate (soln 15, soln 30) 4 PA - Part B vs D Determination, MO (Mail Order) COSMEGEN RECON SOLN 0.5 MG 5 MO (Mail Order) daunorubicin hcl (injectable 5 mg/ml, recon soln 20 mg) 4 MO (Mail Order) DAUNOXOME INJECTABLE 2 MG/ML 5 MO (Mail Order) dexrazoxane (soln 250 mg, soln 500 mg) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) DOCEFREZ RECON SOLN 20 MG 5 MO (Mail Order) docetaxel (conc 20 mg/ml, conc 80 mg/4ml, conc 140 mg/7ml, conc 160 mg/8ml, solution 20 mg/2ml, solution 80 mg/8ml, solution 160 mg/16ml, solution 200 mg/20ml) 5 MO (Mail Order) docetaxel (non-alcohol) ((non-alcohol) 20 mg/ml, (non-alcohol) 80 mg/4ml, (nonalcohol) 160 mg/8ml) 5 MO (Mail Order) DOXIL INJECTABLE 2 MG/ML 5 doxorubicin hcl (recon soln 10 mg, recon soln 50 mg, solution 2 mg/ml) 2 PA - Part B vs D Determination, MO (Mail Order) epirubicin hcl (50 mg/25ml, 200 mg/100ml) 4 MO (Mail Order) ERWINAZE RECON SOLN 10000 UNIT 5 MO (Mail Order) FARYDAK (CAP 10 MG, CAP 15 MG, CAP 20 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) Antineoplastics, Other MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 40 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fludarabine phosphate (recon soln 50 mg, solution 50 mg/2ml) 4 MO (Mail Order) FUSILEV RECON SOLN 50 MG 5 MO (Mail Order) HALAVEN SOLUTION 1 MG/2ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) idarubicin hcl (5 mg/5ml, 10 mg/10ml, 20 mg/20ml) 5 MO (Mail Order) IMLYGIC SUSPENSION 1000000 UNIT/ML 4 MO (Mail Order) IMLYGIC SUSPENSION 100000000 UNIT/ML 5 MO (Mail Order) irinotecan hcl (solution 40 mg/2ml, 40 mg/2ml, 100 mg/5ml, solution 100 mg/5ml, solution 500 mg/25ml) 4 MO (Mail Order) ISTODAX RECON SOLN 10 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) IXEMPRA KIT (SOLN 15 MG, SOLN 45 MG) 5 MO (Mail Order) JEVTANA SOLUTION 60 MG/1.5ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) leucovorin calcium (recon soln 350 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) leucovorin calcium (recon soln 50 mg, recon soln 100 mg, recon soln 200 mg, tab 15 mg, tab 25 mg) 4 MO (Mail Order) levoleucovorin calcium pf solution 250 mg/25ml 5 MO (Mail Order) levoleucovorin calcium solution 175 mg/17.5ml 5 MO (Mail Order) LYNPARZA CAP 50 MG 5 PA - FOR NEW STARTS ONLY, QL (480 PER 30 DAYS), MO (Mail Order) mesna solution 100 mg/ml 4 MO (Mail Order) MESNEX TAB 400 MG 5 MO (Mail Order) mitomycin (recon soln 5 mg, 20 mg, recon soln 20 mg, recon soln 40 mg) 5 MO (Mail Order) mitoxantrone hcl (20 mg/10ml, 25 mg/12.5ml, 30 mg/15ml) 3 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 41 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG) 5 PA - FOR NEW STARTS ONLY, QL (3 PER 28 DAYS), MO (Mail Order) ONCASPAR SOLUTION 750 UNIT/ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) paclitaxel (30 mg/5ml, 100 mg/16.7ml, 300 mg/50ml) 4 MO (Mail Order) PROLEUKIN RECON SOLN 22000000 UNIT 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) SYNRIBO RECON SOLN 3.5 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) TAXOTERE CONC 20 MG/ML 5 TAXOTERE CONC 80 MG/4ML 5 MO (Mail Order) TRISENOX SOLUTION 10 MG/10ML 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) VELCADE RECON SOLN 3.5 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) vinblastine sulfate (recon soln 10 mg, solution 1 mg/ml) 2 PA - Part B vs D Determination, MO (Mail Order) vincasar pfs solution 1 mg/ml 1 PA - Part B vs D Determination, MO (Mail Order) vincristine sulfate solution 1 mg/ml 2 PA - Part B vs D Determination, MO (Mail Order) vinorelbine tartrate (10 mg/ml, 50 mg/5ml) 4 MO (Mail Order) ZOLINZA CAP 100 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) anastrozole tab 1 mg 1 MO (Mail Order) exemestane tab 25 mg 4 MO (Mail Order) letrozole tab 2.5 mg 1 MO (Mail Order) ETOPOPHOS RECON SOLN 100 MG 5 MO (Mail Order) etoposide (1 gm/50ml, 100 mg/5ml, 500 mg/25ml) 2 MO (Mail Order) Aromatase Inhibitors, 3rd Generation Enzyme Inhibitors Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 42 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL toposar (1 gm/50ml, 100 mg/5ml, 500 mg/25ml) 2 MO (Mail Order) topotecan hcl recon soln 4 mg 5 MO (Mail Order) AFINITOR (TAB 2.5 MG, TAB 5 MG, TAB 7.5 MG, TAB 10 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) AFINITOR DISPERZ (TAB 2 MG, TAB 3 MG, TAB 5 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) BOSULIF (TAB 100 MG, TAB 500 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) CAPRELSA (TAB 100 MG, TAB 300 MG) 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) COMETRIQ (100 MG DAILY DOSE) KIT 1 X 80 & 1 X 20 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) COMETRIQ (140 MG DAILY DOSE) KIT 1 X 80 & 3 X 20 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) COMETRIQ (60 MG DAILY DOSE) KIT 20 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) COTELLIC TAB 20 MG 5 PA - FOR NEW STARTS ONLY, LA, QL (90 PER 30 DAYS), MO (Mail Order) ERIVEDGE CAP 150 MG 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) Molecular Target Inhibitors GILOTRIF (TAB 20 MG, TAB 30 MG, TAB 40 MG) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) GLEEVEC (TAB 100 MG, TAB 400 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) IBRANCE (CAP 75 MG, CAP 100 MG, CAP 125 MG) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) ICLUSIG TAB 15 MG 5 ICLUSIG TAB 45 MG 5 PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 43 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL imatinib mesylate (tab 100 mg, tab 400 mg) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) IMBRUVICA CAP 140 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) INLYTA TAB 1 MG 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO (Mail Order) INLYTA TAB 5 MG 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail Order) IRESSA TAB 250 MG JAKAFI (TAB 5 MG, TAB 10 MG, TAB 15 MG, TAB 20 MG, TAB 25 MG) 5 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, LA, QL (60 PER 30 DAYS), MO (Mail Order) LENVIMA 10 MG DAILY DOSE CAP THPK 10 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) LENVIMA 14 MG DAILY DOSE CAP THPK 10 & 4 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) LENVIMA 20 MG DAILY DOSE CAP THPK 10 (2) MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) LENVIMA 24 MG DAILY DOSE CAP THPK 10 (2) & 4 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) MEKINIST (TAB 0.5 MG, TAB 2 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) NEXAVAR TAB 200 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ODOMZO CAP 200 MG 5 PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS), MO (Mail Order) SPRYCEL (TAB 20 MG, TAB 50 MG, TAB 70 MG, TAB 80 MG, TAB 100 MG, TAB 140 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) STIVARGA TAB 40 MG SUTENT (CAP 37.5 MG, CAP 50 MG) 5 5 PA - FOR NEW STARTS ONLY, QL (84 PER 28 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 44 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SUTENT CAP 12.5 MG 5 PA - FOR NEW STARTS ONLY, QL (210 PER 30 DAYS), MO (Mail Order) SUTENT CAP 25 MG 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) TAFINLAR (CAP 50 MG, CAP 75 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) TARCEVA TAB 100 MG 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail Order) TARCEVA TAB 150 MG 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (Mail Order) TARCEVA TAB 25 MG TASIGNA (CAP 150 MG, CAP 200 MG) 5 5 PA - FOR NEW STARTS ONLY, QL (540 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, MO (Mail Order) TORISEL SOLUTION 25 MG/ML 5 MO (Mail Order) TYKERB TAB 250 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) VOTRIENT TAB 200 MG 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO (Mail Order) XALKORI (CAP 200 MG, CAP 250 MG) 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) ZALTRAP (100 MG/4ML, 200 MG/8ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ZELBORAF TAB 240 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ZYDELIG (TAB 100 MG, TAB 150 MG) 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) ZYKADIA CAP 150 MG 5 PA - FOR NEW STARTS ONLY, QL (150 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 45 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Monoclonal Antibodies AVASTIN (100 MG/4ML, 400 MG/16ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) CYRAMZA (100 MG/10ML, 500 MG/50ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) DARZALEX SOLUTION 100 MG/5ML 5 PA - FOR NEW STARTS ONLY, LA, MO (Mail Order) DARZALEX SOLUTION 400 MG/20ML 5 MO (Mail Order) EMPLICITI (SOLN 300 MG, SOLN 400 MG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ERBITUX SOLUTION 100 MG/50ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) HERCEPTIN RECON SOLN 440 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) KADCYLA RECON SOLN 100 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) KEYTRUDA (RECON SOLN 50 MG, SOLUTION 100 MG/4ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) OPDIVO SOLUTION 40 MG/4ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) PERJETA SOLUTION 420 MG/14ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) PORTRAZZA SOLUTION 800 MG/50ML 5 MO (Mail Order) RITUXAN SOLUTION 500 MG/50ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) SYLVANT RECON SOLN 100 MG 5 PA, MO (Mail Order) TAGRISSO (TAB 40 MG, TAB 80 MG) 5 PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS), MO (Mail Order) VECTIBIX SOLUTION 100 MG/5ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) YERVOY SOLUTION 50 MG/10ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 46 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Retinoids bexarotene cap 75 mg 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) PANRETIN GEL 0.1 % 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) TARGRETIN (CAP 75 MG, GEL 1 %) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) tretinoin cap 10 mg 5 MO (Mail Order) ALBENZA TAB 200 MG 3 MO (Mail Order) BILTRICIDE TAB 600 MG 3 MO (Mail Order) ivermectin tab 3 mg 2 MO (Mail Order) STROMECTOL TAB 3 MG 3 MO (Mail Order) ALINIA (RECON SUSP 100 MG/5ML, TAB 500 MG) 4 MO (Mail Order) atovaquone suspension 750 mg/5ml 5 MO (Mail Order) atovaquone-proguanil hcl (tab 62.5-25 mg, tab 250-100 mg) 2 MO (Mail Order) chloroquine phosphate (tab 250 mg, tab 500 mg) 2 MO (Mail Order) COARTEM TAB 20-120 MG 4 MO (Mail Order) DARAPRIM TAB 25 MG 3 MO (Mail Order) hydroxychloroquine sulfate tab 200 mg 2 MO (Mail Order) mefloquine hcl tab 250 mg 2 MO (Mail Order) MEPRON SUSPENSION 750 MG/5ML 5 MO (Mail Order) NEBUPENT RECON SOLN 300 MG 4 PA - Part B vs D Determination, MO (Mail Order) PENTAM RECON SOLN 300 MG 4 MO (Mail Order) Antiparasitics Anthelmintics Antiprotozoals Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 47 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL primaquine phosphate tab 26.3 mg 2 MO (Mail Order) quinine sulfate cap 324 mg 4 PA, MO (Mail Order) tinidazole (tab 250 mg, tab 500 mg) 4 MO (Mail Order) EURAX (CREAM 10 %, LOTION 10 %) 4 MO (Mail Order) lindane (lotion 1 %, shampoo 1 %) 4 MO (Mail Order) malathion lotion 0.5 % 4 MO (Mail Order) permethrin cream 5 % 2 MO (Mail Order) benztropine mesylate (0.5 mg, tab 0.5 mg, 1 mg, tab 1 mg) 1 PA, MO (Mail Order) benztropine mesylate (tab 2 mg, 2 mg) 2 PA, MO (Mail Order) benztropine mesylate solution 1 mg/ml 4 MO (Mail Order) trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 5 mg) 2 PA, MO (Mail Order) trihexyphenidyl hcl tab 2 mg 1 PA, MO (Mail Order) amantadine hcl (cap 100 mg, tab 100 mg) 2 MO (Mail Order) amantadine hcl syrup 50 mg/5ml 1 MO (Mail Order) entacapone tab 200 mg 4 MO (Mail Order) TASMAR TAB 100 MG 5 MO (Mail Order) tolcapone tab 100 mg 5 MO (Mail Order) APOKYN SOLUTION 10 MG/ML 5 QL (60 PER 30 DAYS), MO (Mail Order) bromocriptine mesylate (cap 5 mg, tab 2.5 mg) 4 MO (Mail Order) pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) 2 MO (Mail Order) Pediculicides/Scabicides Antiparkinson Agents Anticholinergics Antiparkinson Agents, Other Dopamine Agonists Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 48 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL pramipexole dihydrochloride er (tab 0.375 mg, tab 2.25 mg, tab 3 mg, tab 4.5 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) pramipexole dihydrochloride er (tab 0.75 mg, tab 1.5 mg) 4 QL (90 PER 30 DAYS), MO (Mail Order) ropinirole hcl (tab 0.25 mg, tab 1 mg, tab 2 mg) 2 MO (Mail Order) ropinirole hcl (tab 0.5 mg, tab 3 mg, tab 4 mg, tab 5 mg) 1 MO (Mail Order) ropinirole hcl er (tab 2 mg, tab 4 mg) 2 MO (Mail Order) ropinirole hcl er (tab 6 mg, tab 8 mg, tab 12 mg) 4 MO (Mail Order) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa tab 25 mg 5 MO (Mail Order) carbidopa-levodopa (10-100 mg, tab 10-100 mg, tab 25-250 mg, tab 25-100 mg, tab disp 10-100 mg, tab disp 25-250 mg, tab disp 25100 mg, 25-250 mg, 25-100 mg) 2 MO (Mail Order) carbidopa-levodopa er (er 25-100 mg, er 50200 mg, tab 25-100 mg, tab 50-200 mg) 2 MO (Mail Order) carbidopa-levodopa-entacapone (tab 12.5-50200 mg, tab 18.75-75-200 mg, tab 25-100200 mg, tab 31.25-125-200 mg, tab 37.5-150200 mg, tab 50-200-200 mg) 4 MO (Mail Order) AZILECT (TAB 0.5 MG, TAB 1 MG) 3 MO (Mail Order) selegiline hcl (cap 5 mg, tab 5 mg) 2 MO (Mail Order) ZELAPAR TAB DISP 1.25 MG 5 MO (Mail Order) 4 MO (Mail Order) 2 MO (Mail Order) Monoamine Oxidase B (MAO-B) Inhibitors Antipsychotics 1st Generation/Typical chlorpromazine hcl (solution 25 mg/ml, solution 50 mg/2ml, tab 50 mg, tab 100 mg, tab 200 mg) chlorpromazine hcl (tab 10 mg, tab 25 mg) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 49 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fluphenazine decanoate solution 25 mg/ml 4 MO (Mail Order) fluphenazine hcl (conc 5 mg/ml, elixir 2.5 mg/5ml, tab 5 mg, tab 10 mg) 2 MO (Mail Order) fluphenazine hcl (tab 1 mg, tab 2.5 mg) 1 MO (Mail Order) fluphenazine hcl solution 2.5 mg/ml 4 MO (Mail Order) haloperidol (tab 0.5 mg, tab 1 mg, 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) haloperidol decanoate (50 mg/ml, solution 50 mg/ml, solution 100 mg/ml) 2 MO (Mail Order) haloperidol lactate (conc 2 mg/ml, 5 mg/ml, solution 5 mg/ml) 2 MO (Mail Order) haloperidol tab 20 mg 4 MO (Mail Order) loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap 50 mg) 2 MO (Mail Order) molindone hcl (tab 5 mg, tab 10 mg, tab 25 mg) 4 MO (Mail Order) ORAP (TAB 1 MG, TAB 2 MG) 3 MO (Mail Order) perphenazine (tab 2 mg, tab 4 mg, tab 8 mg) 2 MO (Mail Order) perphenazine tab 16 mg 4 MO (Mail Order) pimozide (tab 1 mg, tab 2 mg) 3 MO (Mail Order) thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg) 2 MO (Mail Order) trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) ABILIFY (TAB 2 MG, TAB 5 MG, TAB 10 MG, TAB 15 MG, TAB 20 MG, TAB 30 MG) 5 QL (30 PER 30 DAYS), MO (Mail Order) ABILIFY MAINTENA (300 MG, 400 MG) 5 MO (Mail Order) aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) 5 QL (30 PER 30 DAYS), MO (Mail Order) aripiprazole (tab disp 10 mg, tab disp 15 mg) 5 QL (60 PER 30 DAYS), MO (Mail Order) 2nd Generation/Atypical Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 50 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL aripiprazole solution 1 mg/ml 4 QL (750 PER 30 DAYS), MO (Mail Order) ARISTADA (441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML) 5 MO (Mail Order) FANAPT (TAB 1 MG, TAB 2 MG, TAB 4 MG, TAB 6 MG) 4 ST, QL (60 PER 30 DAYS), MO (Mail Order) FANAPT (TAB 8 MG, TAB 10 MG, TAB 12 MG) 5 ST, QL (60 PER 30 DAYS), MO (Mail Order) FANAPT TITRATION PACK TAB 1 & 2 & 4 & 6 MG 4 ST, QL (8 PER 30 DAYS), MO (Mail Order) GEODON RECON SOLN 20 MG 4 MO (Mail Order) INVEGA (TAB ER 1.5 MG, TAB ER 3 MG, TAB ER 6 MG, TAB ER 9 MG) 5 MO (Mail Order) INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML 5 QL (0.75 PER 28 DAYS), MO (Mail Order) INVEGA SUSTENNA SUSPENSION 156 MG/ML 5 QL (1 PER 28 DAYS), MO (Mail Order) INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML 5 QL (1.5 PER 28 DAYS), MO (Mail Order) INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML 4 QL (0.25 PER 28 DAYS), MO (Mail Order) INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML 5 QL (0.5 PER 28 DAYS), MO (Mail Order) INVEGA TRINZA (273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML) 5 ST, MO (Mail Order) LATUDA (TAB 20 MG, TAB 40 MG, TAB 60 MG, TAB 120 MG) 5 QL (30 PER 30 DAYS), MO (Mail Order) LATUDA TAB 80 MG 5 QL (60 PER 30 DAYS), MO (Mail Order) olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab disp 5 mg, tab disp 10 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) olanzapine (tab disp 15 mg, tab disp 20 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) olanzapine recon soln 10 mg 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 51 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL paliperidone er (tab 1.5 mg, tab 3 mg, tab 6 mg, tab 9 mg) 5 MO (Mail Order) quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg, tab 300 mg, tab 400 mg) 2 MO (Mail Order) REXULTI (TAB 0.25 MG, TAB 0.5 MG, TAB 1 MG, TAB 2 MG, TAB 3 MG, TAB 4 MG) 5 QL (30 PER 30 DAYS), MO (Mail Order) RISPERDAL CONSTA (12.5 MG, 25 MG) 4 QL (4 PER 28 DAYS), MO (Mail Order) RISPERDAL CONSTA (37.5 MG, 50 MG) 5 QL (4 PER 28 DAYS), MO (Mail Order) risperidone (solution 1 mg/ml, tab 0.5 mg, tab 3 mg, tab 4 mg, tab disp 0.5 mg, tab disp 1 mg, tab disp 2 mg, tab disp 4 mg) 2 MO (Mail Order) risperidone (tab 0.25 mg, tab 1 mg, tab 2 mg) 1 MO (Mail Order) risperidone (tab disp 0.25 mg, tab disp 3 mg) 4 MO (Mail Order) risperidone m-tab (tab disp 0.5 mg, tab disp 1 mg, tab disp 2 mg, tab disp 4 mg) 2 MO (Mail Order) risperidone m-tab tab disp 3 mg 4 MO (Mail Order) SAPHRIS (TAB 5 MG, TAB 10 MG) 4 MO (Mail Order) SAPHRIS SL TAB 2.5 MG 5 MO (Mail Order) SEROQUEL XR (TAB ER 50 MG, TAB ER 150 MG, TAB ER 200 MG, TAB ER 300 MG, TAB ER 400 MG) 3 MO (Mail Order) VRAYLAR (CAP 1.5 MG, CAP 3 MG, CAP 4.5 MG, CAP 6 MG) 5 ST, QL (30 PER 30 DAYS) VRAYLAR CAP THPK 1.5 & 3 MG 4 ST, QL (7 PER 30 DAYS) ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80 mg) 2 MO (Mail Order) ZYPREXA RELPREVV (210 MG, 300 MG, 405 MG) 5 MO (Mail Order) clozapine (tab 25 mg, tab 50 mg, tab disp 12.5 mg, 100 mg, tab 100 mg, tab 200 mg) 2 MO (Mail Order) clozapine (tab disp 25 mg, tab disp 100 mg, tab disp 150 mg) 4 MO (Mail Order) Treatment-Resistant Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 52 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL clozapine tab disp 200 mg 5 MO (Mail Order) FAZACLO TAB DISP 150 MG 4 MO (Mail Order) FAZACLO TAB DISP 200 MG 5 MO (Mail Order) VERSACLOZ SUSPENSION 50 MG/ML 5 MO (Mail Order) Antivirals Anti-HIVAgents, Integrase Inhibitors (INSTI) GENVOYA TAB 150-150-200-10 MG 5 MO (Mail Order) ISENTRESS (CHEW TAB 100 MG, PACKET 100 MG, TAB 400 MG) 5 MO (Mail Order) ISENTRESS CHEW TAB 25 MG 3 MO (Mail Order) TIVICAY TAB 50 MG 5 MO (Mail Order) VITEKTA (TAB 85 MG, TAB 150 MG) 5 MO (Mail Order) Anti-HIVAgents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) EDURANT TAB 25 MG 5 MO (Mail Order) INTELENCE (TAB 100 MG, TAB 200 MG) 5 MO (Mail Order) INTELENCE TAB 25 MG 4 MO (Mail Order) nevirapine er (tab 100 mg, tab 400 mg) 4 MO (Mail Order) nevirapine suspension 50 mg/5ml 4 MO (Mail Order) nevirapine tab 200 mg 2 MO (Mail Order) ODEFSEY TAB 200-25-25 MG 5 MO (Mail Order) RESCRIPTOR (TAB 100 MG, TAB 200 MG) 4 MO (Mail Order) SUSTIVA (CAP 200 MG, TAB 600 MG) 5 MO (Mail Order) SUSTIVA CAP 50 MG 4 MO (Mail Order) VIRAMUNE SUSPENSION 50 MG/5ML 4 MO (Mail Order) VIRAMUNE XR TAB ER 24H 100 MG 3 MO (Mail Order) VIRAMUNE XR TAB ER 24H 400 MG 5 MO (Mail Order) Anti-HIVAgents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate tab 300 mg 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 53 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL abacavir-lamivudine-zidovudine tab 300-150300 mg 5 MO (Mail Order) didanosine (cap dr 125 mg, 250 mg, cap dr 250 mg) 2 MO (Mail Order) didanosine (cap dr 200 mg, 400 mg, cap dr 400 mg) 4 MO (Mail Order) EMTRIVA (CAP 200 MG, SOLUTION 10 MG/ML) 4 MO (Mail Order) EPIVIR (SOLUTION 10 MG/ML, TAB 150 MG, TAB 300 MG) 3 MO (Mail Order) EPZICOM TAB 600-300 MG 5 MO (Mail Order) lamivudine (tab 150 mg, tab 300 mg) 4 MO (Mail Order) lamivudine solution 10 mg/ml 3 MO (Mail Order) lamivudine-zidovudine tab 150-300 mg 4 MO (Mail Order) RETROVIR SOLUTION 10 MG/ML 4 MO (Mail Order) stavudine (cap 15 mg, recon soln 1 mg/ml) 4 MO (Mail Order) stavudine (cap 20 mg, cap 30 mg, cap 40 mg) 2 MO (Mail Order) TRIZIVIR TAB 300-150-300 MG 5 MO (Mail Order) TRUVADA TAB 200-300 MG 5 MO (Mail Order) VIDEX (SOLN 2 GM, SOLN 4 GM) 4 MO (Mail Order) VIREAD (POWDER 40 MG/GM, TAB 200 MG, TAB 250 MG, TAB 300 MG) 5 MO (Mail Order) VIREAD TAB 150 MG 4 MO (Mail Order) ZIAGEN SOLUTION 20 MG/ML 3 MO (Mail Order) zidovudine (cap 100 mg, syrup 50 mg/5ml, 300 mg, tab 300 mg) 2 MO (Mail Order) ATRIPLA TAB 600-200-300 MG 5 MO (Mail Order) COMPLERA TAB 200-25-300 MG 5 MO (Mail Order) EVOTAZ TAB 300-150 MG 5 MO (Mail Order) FUZEON (KIT 90 MG, RECON SOLN 90 MG) 5 MO (Mail Order) PREZCOBIX TAB 800-150 MG 5 MO (Mail Order) Anti-HIVAgents, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 54 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SELZENTRY (TAB 150 MG, TAB 300 MG) 5 MO (Mail Order) STRIBILD TAB 150-150-200-300 MG 5 MO (Mail Order) TRIUMEQ TAB 600-50-300 MG 5 MO (Mail Order) TYBOST TAB 150 MG 4 MO (Mail Order) APTIVUS (CAP 250 MG, SOLUTION 100 MG/ML) 5 MO (Mail Order) CRIXIVAN (CAP 200 MG, CAP 400 MG) 3 MO (Mail Order) INVIRASE CAP 200 MG 4 MO (Mail Order) INVIRASE TAB 500 MG 5 MO (Mail Order) KALETRA (SOLUTION 400-100 MG/5ML, TAB 100-25 MG) 4 MO (Mail Order) KALETRA TAB 200-50 MG 5 MO (Mail Order) LEXIVA SUSPENSION 50 MG/ML 4 MO (Mail Order) LEXIVA TAB 700 MG 5 MO (Mail Order) NORVIR (CAP 100 MG, SOLUTION 80 MG/ML, TAB 100 MG) 4 MO (Mail Order) PREZISTA (SUSPENSION 100 MG/ML, TAB 600 MG, TAB 800 MG) 5 MO (Mail Order) PREZISTA (TAB 75 MG, TAB 150 MG) 4 MO (Mail Order) REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300 MG, PACKET 50 MG) 5 MO (Mail Order) VIRACEPT (TAB 250 MG, TAB 625 MG) 5 MO (Mail Order) cidofovir solution 75 mg/ml 5 MO (Mail Order) ganciclovir sodium recon soln 500 mg 4 PA - Part B vs D Determination, MO (Mail Order) VALCYTE (RECON SOLN 50 MG/ML, TAB 450 MG) 5 MO (Mail Order) valganciclovir hcl tab 450 mg 5 MO (Mail Order) ZIRGAN GEL 0.15 % 4 MO (Mail Order) Anti-HIVAgents, Protease Inhibitors Anti-cytomegalovirus (CMV) Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 55 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Anti-hepatitis B (HBV) Agents adefovir dipivoxil tab 10 mg 5 MO (Mail Order) BARACLUDE (SOLUTION 0.05 MG/ML, TAB 0.5 MG, TAB 1 MG) 5 MO (Mail Order) entecavir (tab 0.5 mg, tab 1 mg) 5 MO (Mail Order) EPIVIR HBV (SOLUTION 5 MG/ML, TAB 100 MG) 3 MO (Mail Order) HEPSERA TAB 10 MG 5 MO (Mail Order) INTRON A (RECON SOLN 10000000 UNIT, RECON SOLN 18000000 UNIT, RECON SOLN 50000000 UNIT, SOLUTION 6000000 UNIT/ML, SOLUTION 10000000 UNIT/ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) lamivudine tab 100 mg 4 MO (Mail Order) TYZEKA TAB 600 MG 5 MO (Mail Order) DAKLINZA (TAB 30 MG, TAB 60 MG) 5 PA, QL (28 PER 28 DAYS), MO (Mail Order) HARVONI TAB 90-400 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) OLYSIO CAP 150 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) PEG-INTRON (50 MCG/0.5ML, 80 MCG/0.5ML, 120 MCG/0.5ML, 150 MCG/0.5ML) 5 PA, MO (Mail Order) PEGASYS (KIT 180 MCG/0.5ML, SOLUTION 180 MCG/ML, SOLUTION 180 MCG/0.5ML) 5 PA, MO (Mail Order) PEGASYS PROCLICK (135 MCG/0.5ML, 180 MCG/0.5ML) 5 PA, MO (Mail Order) PEGINTRON (50 MCG/0.5ML, 80 MCG/0.5ML, 120 MCG/0.5ML, 150 MCG/0.5ML) 5 PA, MO (Mail Order) REBETOL SOLUTION 40 MG/ML 5 MO (Mail Order) RIBASPHERE (CAP 200 MG, TAB 200 MG, TAB 400 MG) 3 MO (Mail Order) RIBASPHERE TAB 600 MG 5 MO (Mail Order) Anti-hepatitis C (HCV) Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 56 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ribavirin (cap 200 mg, tab 200 mg) 3 MO (Mail Order) SOVALDI TAB 400 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) TECHNIVIE TAB 12.5-75-50 MG 5 PA, QL (56 PER 28 DAYS), MO (Mail Order) VIEKIRA PAK TAB THPK 12.5-75-50 &250 MG 5 PA, QL (112 PER 28 DAYS), MO (Mail Order) ZEPANIVEL TAB 50-100 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) RELENZA DISKHALER AER POW BA 5 MG/BLISTER 4 MO (Mail Order) rimantadine hcl tab 100 mg 2 MO (Mail Order) TAMIFLU (CAP 30 MG, CAP 45 MG, CAP 75 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) TAMIFLU RECON SUSP 6 MG/ML 3 QL (375 PER 30 DAYS), MO (Mail Order) acyclovir (cap 200 mg, 200 mg, tab 400 mg, 400 mg) 1 MO (Mail Order) acyclovir (suspension 200 mg/5ml, tab 800 mg, 800 mg) 2 MO (Mail Order) acyclovir ointment 5 % 4 MO (Mail Order) acyclovir sodium (recon soln 500 mg, solution 50 mg/ml) 4 PA - Part B vs D Determination, MO (Mail Order) DENAVIR CREAM 1 % 5 MO (Mail Order) famciclovir (tab 125 mg, tab 250 mg, tab 500 mg) 2 MO (Mail Order) trifluridine solution 1 % 4 MO (Mail Order) valacyclovir hcl (tab 1 gm, tab 500 mg) 2 MO (Mail Order) Anti-influenza Agents Antiherpetic Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 57 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Anxiolytics Anxiolytics, Other buspirone hcl (5 mg, tab 5 mg, tab 10 mg, tab 15 mg) 1 MO (Mail Order) buspirone hcl (tab 7.5 mg, tab 30 mg) 2 MO (Mail Order) hydroxyzine hcl (solution 10 mg/5ml, 25 mg, solution 50 mg/ml, syrup 10 mg/5ml, tab 25 mg, tab 50 mg, 50 mg) 2 PA, MO (Mail Order) hydroxyzine hcl (tab 10 mg, 10 mg, solution 25 mg/ml) 1 PA, MO (Mail Order) hydroxyzine pamoate (cap 25 mg, cap 50 mg) 1 PA, MO (Mail Order) hydroxyzine pamoate cap 100 mg 2 PA, MO (Mail Order) meprobamate tab 200 mg 2 PA, MO (Mail Order) meprobamate tab 400 mg 4 PA, MO (Mail Order) alprazolam (tab 0.25 mg, 0.25 mg, 0.5 mg, tab 0.5 mg, tab 1 mg, 1 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) alprazolam (tab disp 0.25 mg, tab disp 0.5 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) alprazolam er (er 0.5 mg, er 1 mg, tab 24h 1 mg, tab 24h 0.5 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) alprazolam er (er 2 mg, tab 24h 2 mg) 2 QL (150 PER 30 DAYS), MO (Mail Order) alprazolam er (er 3 mg, tab 24h 3 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) ALPRAZOLAM INTENSOL CONC 1 MG/ML 4 QL (300 PER 30 DAYS), MO (Mail Order) alprazolam tab 2 mg 1 QL (150 PER 30 DAYS), MO (Mail Order) alprazolam tab disp 1 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) alprazolam tab disp 2 mg 4 QL (150 PER 30 DAYS), MO (Mail Order) Benzodiazepines Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 58 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL alprazolam xr (tab er 0.5 mg, tab er 1 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) alprazolam xr tab er 24h 2 mg 2 QL (150 PER 30 DAYS), MO (Mail Order) alprazolam xr tab er 24h 3 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) chlordiazepoxide hcl cap 10 mg 1 QL (240 PER 30 DAYS), MO (Mail Order) chlordiazepoxide hcl cap 25 mg 1 QL (360 PER 30 DAYS), MO (Mail Order) chlordiazepoxide hcl cap 5 mg 1 QL (120 PER 30 DAYS), MO (Mail Order) clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg) 1 QL (180 PER 30 DAYS), MO (Mail Order) clorazepate dipotassium tab 15 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) diazepam (2 mg, tab 2 mg) 1 QL (300 PER 30 DAYS), MO (Mail Order) diazepam (tab 10 mg, 10 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) diazepam (tab 5 mg, 5 mg) 1 QL (240 PER 30 DAYS), MO (Mail Order) diazepam conc 5 mg/ml 4 QL (240 PER 30 DAYS), MO (Mail Order) diazepam intensol conc 5 mg/ml 4 QL (240 PER 30 DAYS), MO (Mail Order) diazepam solution 1 mg/ml 2 QL (1200 PER 30 DAYS), MO (Mail Order) lorazepam (tab 0.5 mg, tab 1 mg) 1 QL (90 PER 30 DAYS), MO (Mail Order) lorazepam conc 2 mg/ml 2 QL (150 PER 30 DAYS), MO (Mail Order) lorazepam intensol conc 2 mg/ml 2 QL (150 PER 30 DAYS), MO (Mail Order) lorazepam tab 2 mg 1 QL (150 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 59 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL oxazepam (cap 10 mg, cap 15 mg, cap 30 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) EQUETRO (CAP ER 100 MG, CAP ER 200 MG, CAP ER 300 MG) 3 MO (Mail Order) lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg) 1 MO (Mail Order) lithium carbonate er (er 450 mg, tab 450 mg) 1 MO (Mail Order) lithium carbonate tab 300 mg 2 MO (Mail Order) lithium carbonate tab 300 mg 2 MO (Mail Order) lithium solution 8 meq/5ml 2 MO (Mail Order) acarbose tab 100 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) acarbose tab 25 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) acarbose tab 50 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) AVANDIA TAB 2 MG 4 PA, QL (120 PER 30 DAYS), MO (Mail Order) AVANDIA TAB 4 MG 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) BYDUREON (PEN 2 MG, RECON SUSP 2 MG) 3 ST, QL (4 PER 28 DAYS), MO (Mail Order) BYETTA 10 MCG PEN (10 MCG SOLN 10 MCG/0.04ML, 10 MCG 10 MCG/0.04ML) 4 ST, QL (2.4 PER 30 DAYS), MO (Mail Order) BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML 4 ST, QL (1.2 PER 30 DAYS), MO (Mail Order) CYCLOSET TAB 0.8 MG 4 PA, QL (180 PER 30 DAYS), MO (Mail Order) Bipolar Agents Mood Stabilizers Blood Glucose Regulators Antidiabetic Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 60 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL glimepiride tab 1 mg 1 QL (240 PER 30 DAYS), MO (Mail Order) glimepiride tab 2 mg 1 QL (120 PER 30 DAYS), MO (Mail Order) glimepiride tab 4 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) glipizide (10 mg, tab 10 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) glipizide (tab 5 mg, 5 mg) 1 QL (240 PER 30 DAYS), MO (Mail Order) glipizide er (er 10 mg, tab 24h 10 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) glipizide tab 24h 2.5 mg 1 QL (240 PER 30 DAYS), MO (Mail Order) glipizide tab 24h 5 mg 1 QL (120 PER 30 DAYS), MO (Mail Order) glipizide xl tab er 24h 10 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) glipizide xl tab er 24h 2.5 mg 1 QL (240 PER 30 DAYS), MO (Mail Order) glipizide xl tab er 24h 5 mg 1 QL (120 PER 30 DAYS), MO (Mail Order) glipizide-metformin hcl (tab 2.5-250 mg, 2.5250 mg) 2 QL (240 PER 30 DAYS), MO (Mail Order) glipizide-metformin hcl (tab 2.5-500 mg, 2.5500 mg, 5-500 mg, tab 5-500 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) GLUMETZA TAB ER 24H 1000 MG 4 QL (60 PER 30 DAYS), MO (Mail Order) GLUMETZA TAB ER 24H 500 MG 4 QL (120 PER 30 DAYS), MO (Mail Order) glyburide (1.25 mg, tab 1.25 mg) 1 PA, QL (480 PER 30 DAYS), MO (Mail Order) glyburide (2.5 mg, tab 2.5 mg) 1 PA, QL (240 PER 30 DAYS), MO (Mail Order) glyburide (5 mg, tab 5 mg) 2 PA, QL (120 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 61 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL glyburide micronized tab 1.5 mg 1 PA, QL (240 PER 30 DAYS), MO (Mail Order) glyburide micronized tab 3 mg 1 PA, QL (120 PER 30 DAYS), MO (Mail Order) glyburide micronized tab 6 mg 1 PA, QL (60 PER 30 DAYS), MO (Mail Order) glyburide-metformin (1.25-250 mg, tab 1.25250 mg) 1 PA, QL (240 PER 30 DAYS), MO (Mail Order) glyburide-metformin (2.5-500 mg, tab 2.5-500 mg, 5-500 mg, tab 5-500 mg) 2 PA, QL (120 PER 30 DAYS), MO (Mail Order) GLYSET TAB 100 MG 4 ST, QL (90 PER 30 DAYS), MO (Mail Order) GLYSET TAB 25 MG 4 ST, QL (360 PER 30 DAYS), MO (Mail Order) GLYSET TAB 50 MG 4 ST, QL (180 PER 30 DAYS), MO (Mail Order) INVOKAMET (TAB 50-500 MG, TAB 50-1000 MG, TAB 150-500 MG, TAB 150-1000 MG) 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) INVOKANA (TAB 100 MG, TAB 300 MG) 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) JANUMET (TAB 50-500 MG, TAB 50-1000 MG) 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) JANUMET XR (TAB ER 50-500 MG, TAB ER 100-1000 MG) 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) JANUMET XR TAB ER 24H 50-1000 MG 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) JANUVIA TAB 100 MG 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) JANUVIA TAB 25 MG 3 ST, QL (120 PER 30 DAYS), MO (Mail Order) JANUVIA TAB 50 MG 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) JARDIANCE (TAB 10 MG, TAB 25 MG) 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) JENTADUETO (TAB 2.5-1000 MG, TAB 2.5850 MG, TAB 2.5-500 MG) 4 ST, QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 62 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL KAZANO (TAB 12.5-500 MG, TAB 12.5-1000 MG) 4 ST, QL (60 PER 30 DAYS), MO (Mail Order) KOMBIGLYZE XR (TAB ER 5-500 MG, TAB ER 5-1000 MG) 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) metformin hcl (1000 mg, tab 1000 mg) 1 QL (75 PER 30 DAYS), MO (Mail Order) metformin hcl (500 mg, tab 500 mg) 1 QL (150 PER 30 DAYS), MO (Mail Order) metformin hcl (850 mg, tab 850 mg) 1 QL (90 PER 30 DAYS), MO (Mail Order) metformin hcl er (er 750 mg, tab 24h 750 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) metformin hcl er (mod) tab er 24h 1000 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) metformin hcl er (mod) tab er 24h 500 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) metformin hcl er (osm) (er (osm) tab er 500 mg, er (osm) tab er 1000 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) metformin hcl tab 24h 500 mg 1 QL (120 PER 30 DAYS), MO (Mail Order) nateglinide tab 120 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) nateglinide tab 60 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) NESINA (TAB 6.25 MG, TAB 12.5 MG, TAB 25 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) ONGLYZA TAB 2.5 MG 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) ONGLYZA TAB 5 MG 3 ST, QL (30 PER 30 DAYS), MO (Mail Order) OSENI (TAB 12.5-15 MG, TAB 12.5-30 MG, TAB 12.5-45 MG, TAB 25-15 MG, TAB 25-45 MG, TAB 25-30 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) pioglitazone hcl (tab 30 mg, tab 45 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 63 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL pioglitazone hcl tab 15 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) pioglitazone hcl-glimepiride (tab 30-4 mg, tab 30-2 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, -metformin tab 15-850 mg) 4 QL (90 PER 30 DAYS), MO (Mail Order) repaglinide tab 0.5 mg 4 QL (960 PER 30 DAYS), MO (Mail Order) repaglinide tab 1 mg 4 QL (480 PER 30 DAYS), MO (Mail Order) repaglinide tab 2 mg 4 QL (240 PER 30 DAYS), MO (Mail Order) RIOMET SOLUTION 500 MG/5ML 4 QL (750 PER 30 DAYS), MO (Mail Order) SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML 5 QL (10.8 PER 30 DAYS), MO (Mail Order) SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML 4 QL (6 PER 30 DAYS), MO (Mail Order) SYNJARDY (TAB 5-1000 MG, TAB 5-500 MG, TAB 12.5-1000 MG, TAB 12.5-500 MG) 3 ST, QL (60 PER 30 DAYS), MO (Mail Order) tolazamide tab 250 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) tolazamide tab 500 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) tolbutamide tab 500 mg 2 QL (180 PER 30 DAYS), MO (Mail Order) TRADJENTA TAB 5 MG 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) TRULICITY (SOLN 0.75 MG/0.5ML, SOLN 1.5 MG/0.5ML) 3 ST, QL (2 PER 28 DAYS), MO (Mail Order) VICTOZA SOLN PEN 18 MG/3ML 3 ST, QL (9 PER 30 DAYS), MO (Mail Order) GLUCAGEN HYPOKIT RECON SOLN 1 MG 4 MO (Mail Order) GLUCAGON EMERGENCY KIT 1 MG 3 MO (Mail Order) Glycemic Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 64 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PROGLYCEM SUSPENSION 50 MG/ML 5 MO (Mail Order) APIDRA OPTICLIK 100 UNIT/ML 3 MO (Mail Order) APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML 3 MO (Mail Order) APIDRA SOLUTION 100 UNIT/ML 3 MO (Mail Order) HUMALOG (SOLN CART 100 UNIT/ML, SOLUTION 100 UNIT/ML) 3 MO (Mail Order) HUMALOG KWIKPEN (SOLN 100 UNIT/ML, SOLN 200 UNIT/ML) 3 MO (Mail Order) HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100 UNIT/ML 3 MO (Mail Order) HUMALOG MIX 50/50 SUSPENSION (50-50) 100 UNIT/ML 3 MO (Mail Order) HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100 UNIT/ML 3 MO (Mail Order) HUMALOG MIX 75/25 SUSPENSION (75-25) 100 UNIT/ML 3 MO (Mail Order) HUMULIN 70/30 KWIKPEN SUSP PEN (7030) 100 UNIT/ML 3 MO (Mail Order) HUMULIN 70/30 PEN SUSP PEN (70-30) 100 UNIT/ML 3 MO (Mail Order) HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML 3 MO (Mail Order) HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML 3 MO (Mail Order) HUMULIN N PEN SUSP PEN 100 UNIT/ML 3 MO (Mail Order) HUMULIN N SUSPENSION 100 UNIT/ML 3 MO (Mail Order) HUMULIN R SOLUTION 100 UNIT/ML 3 MO (Mail Order) HUMULIN R U-500 (CONCENTRATED) SOLUTION 500 UNIT/ML 3 PA - Part B vs D Determination, MO (Mail Order) HUMULIN R U-500 KWIKPEN SOLN PEN 500 UNIT/ML 3 LANTUS FOR OPTICLIK SOLN CART 100 UNIT/ML 3 Insulins MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 65 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL LANTUS SOLOSTAR (SOLN PEN 100 UNIT/ML, 100 UNIT/ML) 3 MO (Mail Order) LANTUS SOLUTION 100 UNIT/ML 3 MO (Mail Order) LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML 3 MO (Mail Order) LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML 3 MO (Mail Order) LEVEMIR SOLUTION 100 UNIT/ML 3 MO (Mail Order) NOVOLIN 70/30 RELION SUSPENSION (7030) 100 UNIT/ML 3 MO (Mail Order) NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML 3 MO (Mail Order) NOVOLIN N RELION SUSPENSION 100 UNIT/ML 3 MO (Mail Order) NOVOLIN N SUSPENSION 100 UNIT/ML 3 MO (Mail Order) NOVOLIN R RELION SOLUTION 100 UNIT/ML 3 MO (Mail Order) NOVOLIN R SOLUTION 100 UNIT/ML 3 MO (Mail Order) NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML 3 MO (Mail Order) NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100 UNIT/ML 3 MO (Mail Order) NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML 3 MO (Mail Order) NOVOLOG PENFILL SOLN CART 100 UNIT/ML 3 MO (Mail Order) NOVOLOG SOLUTION 100 UNIT/ML 3 MO (Mail Order) TOUJEO SOLOSTAR SOLN PEN 300 UNIT/ML 3 MO (Mail Order) Blood Products/Modifiers/Volume Expanders Anticoagulants argatroban (50 mg/50ml, 100 mg/ml, 125 mg/125ml) 5 PA - Part B vs D Determination, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 66 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL argatroban in sodium chloride solution 250 mg/250ml 5 PA - Part B vs D Determination, MO (Mail Order) COUMADIN (TAB 1 MG, TAB 2 MG, TAB 2.5 MG, TAB 3 MG, TAB 4 MG, TAB 5 MG, TAB 6 MG, TAB 7.5 MG, TAB 10 MG) 3 MO (Mail Order) ELIQUIS (TAB 2.5 MG, TAB 5 MG) 3 MO (Mail Order) enoxaparin sodium (100 mg/ml, 150 mg/ml) 5 QL (60 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 120 mg/0.8ml 5 QL (48 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 30 mg/0.3ml 4 QL (18 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 300 mg/3ml 4 QL (90 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 40 mg/0.4ml 4 QL (24 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 60 mg/0.6ml 4 QL (36 PER 30 DAYS), MO (Mail Order) enoxaparin sodium solution 80 mg/0.8ml 4 QL (48 PER 30 DAYS), MO (Mail Order) fondaparinux sodium solution 10 mg/0.8ml 5 QL (24 PER 30 DAYS), MO (Mail Order) fondaparinux sodium solution 2.5 mg/0.5ml 4 QL (15 PER 30 DAYS), MO (Mail Order) fondaparinux sodium solution 5 mg/0.4ml 5 QL (12 PER 30 DAYS), MO (Mail Order) fondaparinux sodium solution 7.5 mg/0.6ml 5 QL (18 PER 30 DAYS), MO (Mail Order) FRAGMIN (2500 UNIT/0.2ML, 5000 UNIT/0.2ML) 4 QL (12 PER 30 DAYS), MO (Mail Order) FRAGMIN (25000 UNIT/ML, 95000 UNIT/3.8ML) 5 QL (22.8 PER 30 DAYS), MO (Mail Order) FRAGMIN SOLUTION 10000 UNIT/ML 5 QL (30 PER 30 DAYS), MO (Mail Order) FRAGMIN SOLUTION 12500 UNIT/0.5ML 5 QL (15 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 67 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL FRAGMIN SOLUTION 15000 UNIT/0.6ML 5 QL (18 PER 30 DAYS), MO (Mail Order) FRAGMIN SOLUTION 18000 UNT/0.72ML 5 QL (21.6 PER 30 DAYS), MO (Mail Order) FRAGMIN SOLUTION 7500 UNIT/0.3ML 5 QL (9 PER 30 DAYS), MO (Mail Order) heparin (porcine) in d5w ((porcine)40-5 unit/ml-%, (porcine)50-5 unit/ml-%, (porcine)solution 40-5 unit/ml-%, (porcine)solution 50-5 unit/ml-%) 2 PA - Part B vs D Determination, MO (Mail Order) heparin sod (porcine) in d5w ((porcine)100 unit/ml, (porcine)solution 100 unit/ml) 2 PA - Part B vs D Determination, MO (Mail Order) heparin sodium (porcine) ((porcine) 1000 unit/ml, (porcine) solution 1000 unit/ml, (porcine) solution 5000 unit/ml, (porcine) solution 10000 unit/ml) 2 PA - Part B vs D Determination, MO (Mail Order) heparin sodium (porcine) solution 20000 unit/ml 4 PA - Part B vs D Determination, MO (Mail Order) jantoven (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg) 1 MO (Mail Order) PRADAXA (CAP 75 MG, CAP 110 MG, CAP 150 MG) 3 MO (Mail Order) warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg, tab 4 mg, 5 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg) 1 MO (Mail Order) XARELTO (TAB 10 MG, TAB 15 MG, TAB 20 MG) 3 MO (Mail Order) XARELTO STARTER PACK TAB THPK 15 & 20 MG 3 MO (Mail Order) anagrelide hcl (cap 0.5 mg, cap 1 mg) 2 MO (Mail Order) ARANESP (ALBUMIN FREE) (FREE) 25 MCG/ML, FREE) 40 MCG/ML) 4 PA, QL (4 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) (FREE) 60 MCG/ML, FREE) 100 MCG/ML, FREE) 200 MCG/ML, FREE) 300 MCG/ML) 5 PA, QL (4 PER 28 DAYS), MO (Mail Order) Blood Formation Modifiers Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 68 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ARANESP (ALBUMIN FREE) SOLN PRSYR 100 MCG/0.5ML 5 PA, QL (2 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 150 MCG/0.3ML 5 PA, QL (1.2 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 200 MCG/0.4ML 5 PA, QL (1.6 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 25 MCG/0.42ML 4 PA, QL (1.7 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 300 MCG/0.6ML 5 PA, QL (2.4 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 40 MCG/0.4ML 4 PA, QL (1.6 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 500 MCG/ML 5 PA, QL (1 PER 21 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLN PRSYR 60 MCG/0.3ML 4 PA, QL (1.2 PER 28 DAYS), MO (Mail Order) ARANESP (ALBUMIN FREE) SOLUTION 10 MCG/0.4ML 4 PA, QL (3.2 PER 28 DAYS), MO (Mail Order) EPOGEN SOLUTION 10000 UNIT/ML 4 PA, QL (12 PER 28 DAYS), MO (Mail Order) GRANIX (SOLN 300 MCG/0.5ML, SOLN 480 MCG/0.8ML) 5 PA, MO (Mail Order) LEUKINE (RECON SOLN 250 MCG, 250 MCG) 5 PA, MO (Mail Order) MOZOBIL SOLUTION 24 MG/1.2ML 5 PA, MO (Mail Order) NEULASTA ONPRO PREF SY KT 6 MG/0.6ML 5 PA, MO (Mail Order) NEULASTA SOLN PRSYR 6 MG/0.6ML 5 PA, MO (Mail Order) NEUPOGEN (SOLN PRSYR 300 MCG/0.5ML, SOLN PRSYR 480 MCG/0.8ML, SOLUTION 300 MCG/ML, SOLUTION 480 MCG/1.6ML) 5 PA, MO (Mail Order) PROCRIT (2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML) 4 PA, QL (15 PER 30 DAYS), MO (Mail Order) PROCRIT SOLUTION 10000 UNIT/ML 4 PA, QL (12 PER 28 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 69 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PROCRIT SOLUTION 20000 UNIT/ML 5 PA, QL (12 PER 28 DAYS), MO (Mail Order) PROCRIT SOLUTION 40000 UNIT/ML 5 PA, MO (Mail Order) PROMACTA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB 75 MG) 5 PA, MO (Mail Order) ZARXIO (SOLN 300 MCG/0.5ML, SOLN 480 MCG/0.8ML) 5 PA, MO (Mail Order) tranexamic acid solution 1000 mg/10ml 3 MO (Mail Order) tranexamic acid tab 650 mg 3 QL (30 PER 28 DAYS), MO (Mail Order) AGGRENOX CAP ER 12H 25-200 MG 3 QL (60 PER 30 DAYS), MO (Mail Order) aspirin-dipyridamole cap 12h 25-200 mg 3 QL (60 PER 30 DAYS), MO (Mail Order) BRILINTA (TAB 60 MG, TAB 90 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) cilostazol (tab 100 mg, 100 mg) 1 MO (Mail Order) cilostazol tab 50 mg 2 MO (Mail Order) clopidogrel bisulfate tab 300 mg 4 QL (3 PER 30 DAYS), MO (Mail Order) clopidogrel bisulfate tab 75 mg 1 QL (30 PER 30 DAYS), MO (Mail Order) EFFIENT (TAB 5 MG, TAB 10 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) clonidine hcl (patch 0.2 mg/24hr, patch 0.3 mg/24hr) 4 QL (8 PER 28 DAYS), MO (Mail Order) clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg) 1 MO (Mail Order) Coagulants Platelet Modifying Agents Cardiovascular Agents Alpha-adrenergic Agonists Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 70 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL clonidine hcl patch wk 0.1 mg/24hr 2 QL (4 PER 28 DAYS), MO (Mail Order) guanfacine hcl (tab 1 mg, tab 2 mg) 1 PA, MO (Mail Order) methyldopa tab 250 mg 1 PA, MO (Mail Order) methyldopa tab 500 mg 2 PA, MO (Mail Order) methyldopate hcl solution 250 mg/5ml 2 PA, MO (Mail Order) midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) DIBENZYLINE CAP 10 MG 5 MO (Mail Order) doxazosin mesylate (1 mg, tab 1 mg, 2 mg, tab 2 mg, tab 4 mg, 4 mg, tab 8 mg) 2 MO (Mail Order) phenoxybenzamine hcl cap 10 mg 5 MO (Mail Order) prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg) 2 MO (Mail Order) reserpine (tab 0.1 mg, tab 0.25 mg) 2 PA, MO (Mail Order) BENICAR (TAB 20 MG, TAB 40 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) BENICAR TAB 5 MG 3 QL (60 PER 30 DAYS), MO (Mail Order) candesartan cilexetil (tab 4 mg, tab 32 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) candesartan cilexetil tab 16 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) candesartan cilexetil tab 8 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) DIOVAN (TAB 40 MG, TAB 80 MG, TAB 160 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) DIOVAN TAB 320 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) EDARBI (TAB 40 MG, TAB 80 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) eprosartan mesylate tab 600 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) Alpha-adrenergic Blocking Agents Angiotensin II Receptor Antagonists Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 71 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL irbesartan tab 150 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) irbesartan tab 300 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) irbesartan tab 75 mg 1 QL (90 PER 30 DAYS), MO (Mail Order) losartan potassium (tab 25 mg, tab 50 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) losartan potassium tab 100 mg 1 QL (30 PER 30 DAYS), MO (Mail Order) telmisartan (tab 20 mg, tab 40 mg, tab 80 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) valsartan (tab 40 mg, tab 80 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) valsartan tab 160 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) valsartan tab 320 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg, tab 5 mg, 10 mg, tab 10 mg, tab 20 mg, tab 40 mg) 1 MO (Mail Order) captopril (tab 12.5 mg, tab 25 mg, 50 mg, tab 50 mg) 2 MO (Mail Order) captopril tab 100 mg 4 MO (Mail Order) enalapril maleate (tab 2.5 mg, 2.5 mg, 5 mg, tab 5 mg, tab 10 mg, 10 mg, 20 mg, tab 20 mg) 1 MO (Mail Order) EPANED RECON SOLN 1 MG/ML 4 MO (Mail Order) fosinopril sodium (tab 10 mg, 10 mg, tab 20 mg, 20 mg, 40 mg, tab 40 mg) 1 MO (Mail Order) lisinopril (tab 2.5 mg, 2.5 mg, tab 5 mg, 5 mg, tab 10 mg, 10 mg, 20 mg, tab 20 mg, tab 30 mg, 40 mg, tab 40 mg) 1 MO (Mail Order) moexipril hcl (tab 7.5 mg, tab 15 mg) 2 MO (Mail Order) perindopril erbumine (tab 4 mg, tab 8 mg) 2 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 72 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL perindopril erbumine tab 2 mg 2 QL (240 PER 30 DAYS), MO (Mail Order) quinapril hcl (tab 5 mg, 5 mg, tab 10 mg, 10 mg, 20 mg, tab 20 mg, tab 40 mg, 40 mg) 2 MO (Mail Order) ramipril (cap 1.25 mg, 1.25 mg, cap 2.5 mg, 2.5 mg, 5 mg, cap 5 mg, 10 mg, cap 10 mg) 2 MO (Mail Order) trandolapril (tab 1 mg, 1 mg, tab 2 mg, 2 mg, 4 mg, tab 4 mg) 2 MO (Mail Order) amiodarone hcl (200 mg, tab 200 mg) 1 MO (Mail Order) amiodarone hcl (solution 150 mg/3ml, 150 mg/3ml, solution 450 mg/9ml, solution 900 mg/18ml) 2 MO (Mail Order) amiodarone hcl tab 400 mg 4 MO (Mail Order) disopyramide phosphate (cap 100 mg, cap 150 mg) 2 PA, MO (Mail Order) flecainide acetate (50 mg, tab 50 mg, 100 mg, tab 100 mg, tab 150 mg, 150 mg) 2 MO (Mail Order) mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg) 2 MO (Mail Order) MULTAQ TAB 400 MG 3 PA, QL (60 PER 30 DAYS), MO (Mail Order) pacerone tab 200 mg 1 MO (Mail Order) procainamide hcl (100 mg/ml, 500 mg/ml) 2 MO (Mail Order) propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg) 2 MO (Mail Order) propafenone hcl er (cap 225 mg, cap 325 mg, cap 425 mg) 4 MO (Mail Order) quinidine gluconate er (er 324 mg, tab 324 mg) 4 MO (Mail Order) quinidine gluconate solution 80 mg/ml 4 MO (Mail Order) quinidine sulfate (300 mg, tab 300 mg) 2 MO (Mail Order) quinidine sulfate (tab 200 mg, 200 mg) 1 MO (Mail Order) sorine (tab 120 mg, tab 160 mg, tab 240 mg) 2 MO (Mail Order) Antiarrhythmics Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 73 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL sorine tab 80 mg 1 MO (Mail Order) sotalol hcl (af) ((af) 120 mg, (af) tab 120 mg, (af) tab 160 mg) 2 MO (Mail Order) sotalol hcl (af) tab 80 mg 1 MO (Mail Order) sotalol hcl (tab 120 mg, tab 160 mg, tab 240 mg) 2 MO (Mail Order) sotalol hcl solution 150 mg/10ml 5 MO (Mail Order) sotalol hcl tab 80 mg 1 MO (Mail Order) TIKOSYN (CAP 125 MCG, CAP 250 MCG, CAP 500 MCG) 4 MO (Mail Order) acebutolol hcl (cap 200 mg, cap 400 mg) 2 MO (Mail Order) atenolol (tab 25 mg, 25 mg, tab 50 mg, 50 mg, tab 100 mg, 100 mg) 1 MO (Mail Order) betaxolol hcl (tab 10 mg, tab 20 mg) 2 MO (Mail Order) bisoprolol fumarate (tab 5 mg, tab 10 mg) 2 MO (Mail Order) BYSTOLIC (TAB 5 MG, TAB 10 MG) 3 QL (90 PER 30 DAYS), MO (Mail Order) BYSTOLIC TAB 2.5 MG 3 QL (30 PER 30 DAYS), MO (Mail Order) BYSTOLIC TAB 20 MG 3 QL (60 PER 30 DAYS), MO (Mail Order) carvedilol (tab 3.125 mg, 3.125 mg, tab 6.25 mg, 6.25 mg, 12.5 mg, tab 12.5 mg, tab 25 mg, 25 mg) 1 MO (Mail Order) INNOPRAN XL (CAP ER 24H 120 MG, CAP ER 24H 80 MG, 80 MG, 120 MG) 4 MO (Mail Order) labetalol hcl (tab 100 mg, 100 mg, 200 mg, tab 200 mg, tab 300 mg) 2 MO (Mail Order) labetalol hcl solution 5 mg/ml 1 MO (Mail Order) metoprolol succinate er (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) 2 MO (Mail Order) metoprolol tartrate (1 mg/ml, 5 mg/5ml) 2 MO (Mail Order) metoprolol tartrate (tab 25 mg, 25 mg, 50 mg, tab 50 mg, tab 100 mg, 100 mg) 1 MO (Mail Order) Beta-adrenergic Blocking Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 74 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL nadolol (tab 20 mg, tab 40 mg, tab 80 mg) 2 MO (Mail Order) pindolol (tab 5 mg, tab 10 mg) 2 MO (Mail Order) propranolol hcl (10 mg, tab 10 mg, tab 20 mg, 20 mg, tab 40 mg, tab 60 mg, tab 80 mg) 1 MO (Mail Order) propranolol hcl (solution 1 mg/ml, 1 mg/ml, solution 20 mg/5ml, solution 40 mg/5ml) 2 MO (Mail Order) propranolol hcl er (cap 60 mg, cap 80 mg, cap 120 mg, cap 160 mg) 2 MO (Mail Order) timolol maleate (tab 5 mg, tab 10 mg) 2 MO (Mail Order) timolol maleate tab 20 mg 4 MO (Mail Order) afeditab cr tab er 24h 30 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) afeditab cr tab er 24h 60 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) amlodipine besylate (2.5 mg, tab 2.5 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) amlodipine besylate (tab 10 mg, 10 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) amlodipine besylate (tab 5 mg, 5 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) cartia xt (cap er 120 mg, cap er 180 mg, cap er 240 mg, cap er 300 mg) 2 MO (Mail Order) dilt-cd (cap er 120 mg, cap er 180 mg, cap er 240 mg) 2 MO (Mail Order) dilt-xr (cap er 120 mg, cap er 180 mg, cap er 240 mg) 2 MO (Mail Order) diltiazem cd (cap er 120 mg, cap er 180 mg, cap er 240 mg) 2 MO (Mail Order) diltiazem hcl (recon soln 100 mg, solution 25 mg/5ml, solution 50 mg/10ml, solution 125 mg/25ml) 2 MO (Mail Order) diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120 mg) 1 MO (Mail Order) diltiazem hcl cd cap er 24h 360 mg 2 MO (Mail Order) Calcium Channel Blocking Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 75 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL diltiazem hcl er (cap 12h 60 mg, cap 12h 120 mg, cap 12h 90 mg, cap 24h 180 mg, cap 24h 120 mg, cap 24h 240 mg) 2 MO (Mail Order) diltiazem hcl er beads (cap 120 mg, cap 180 mg, cap 240 mg, cap 360 mg, cap 420 mg) 2 MO (Mail Order) diltiazem hcl er beads cap er 24h 300 mg 4 MO (Mail Order) diltiazem hcl er coated beads (er 120 mg, er 180 mg, er 240 mg, cap 24h 240 mg, cap 24h 360 mg, cap 24h 120 mg, cap 24h 180 mg) 2 MO (Mail Order) diltiazem hcl er coated beads cap er 24h 300 mg 4 MO (Mail Order) diltiazem hcl-dextrose solution 125-5 mg/125ml-% 2 MO (Mail Order) felodipine er (tab 2.5 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) isradipine (cap 2.5 mg, cap 5 mg) 2 MO (Mail Order) matzim la (tab er 180 mg, tab er 240 mg, tab er 300 mg, tab er 360 mg, tab er 420 mg) 2 MO (Mail Order) nicardipine hcl (20 mg, cap 20 mg) 2 MO (Mail Order) nicardipine hcl (cap 30 mg, solution 2.5 mg/ml, 2.5 mg/ml, 30 mg) 4 MO (Mail Order) nifedical xl tab er 24h 30 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) nifedical xl tab er 24h 60 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) nifedipine er osmotic (er 30 mg, tab 24h 30 mg) 2 QL (120 PER 30 DAYS), MO (Mail Order) nifedipine er osmotic (er 60 mg, tab 24h 60 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) nifedipine er osmotic (er 90 mg, tab 24h 90 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) nifedipine tab 24h 30 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) nifedipine tab 24h 60 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) nifedipine tab 24h 90 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 76 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL nimodipine cap 30 mg 5 MO (Mail Order) nisoldipine er (tab 20 mg, tab 30 mg, tab 40 mg) 4 MO (Mail Order) nisoldipine er (tab 8.5 mg, tab 17 mg, tab 25.5 mg, tab 34 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) taztia xt (cap er 24h 360 mg, cap er 24h 240 mg, cap er 24h 300 mg, cap er 24h 180 mg, cap er 24h 120 mg, 120 mg, 180 mg, 240 mg, 300 mg, 360 mg) 2 MO (Mail Order) verapamil hcl (solution 2.5 mg/ml, tab 40 mg) 2 MO (Mail Order) verapamil hcl (tab 80 mg, 120 mg, tab 120 mg) 1 MO (Mail Order) verapamil hcl er (er 180 mg, cap 24h 240 mg, cap 24h 200 mg, cap 24h 360 mg, cap 24h 180 mg, cap 24h 300 mg, cap 24h 120 mg, cap 24h 100 mg) 2 MO (Mail Order) verapamil hcl er (er 240 mg, tab 120 mg, tab 180 mg, tab 240 mg) 1 MO (Mail Order) ALDACTAZIDE TAB 50-50 MG 4 MO (Mail Order) amiloride-hydrochlorothiazide tab 5-50 mg 1 MO (Mail Order) amlodipine besy-benazepril hcl (cap 2.5-10 mg, cap 5-20 mg, cap 5-10 mg, cap 5-40 mg, cap 10-40 mg, cap 10-20 mg) 2 MO (Mail Order) amlodipine besylate-valsartan (tab 5-160 mg, tab 5-320 mg, tab 10-160 mg, tab 10-320 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) amlodipine-atorvastatin (tab 2.5-40 mg, tab 2.5-20 mg, tab 2.5-10 mg, tab 5-40 mg, tab 520 mg, tab 5-10 mg, tab 5-80 mg, tab 10-10 mg, tab 10-20 mg, tab 10-80 mg, tab 10-40 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) amlodipine-valsartan-hctz (tab 5-160-12.5 mg, tab 5-160-25 mg, tab 10-160-25 mg, tab 10-320-25 mg, tab 10-160-12.5 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) atenolol-chlorthalidone (tab 50-25 mg, 50-25 mg, tab 100-25 mg) 1 MO (Mail Order) AZOR (TAB 5-20 MG, TAB 5-40 MG, TAB 10-40 MG, TAB 10-20 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) Cardiovascular Agents, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 77 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL benazepril-hydrochlorothiazide (5-6.25 mg, tab 5-6.25 mg, 10-12.5 mg, tab 10-12.5 mg, tab 20-25 mg, tab 20-12.5 mg, 20-12.5 mg, 20-25 mg) 2 MO (Mail Order) BENICAR HCT (TAB 20-12.5 MG, 20-12.5 MG, TAB 40-25 MG, 40-12.5 MG, TAB 4012.5 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) BIDIL TAB 20-37.5 MG 3 MO (Mail Order) bisoprolol-hydrochlorothiazide (2.5-6.25 mg, tab 2.5-6.25 mg, 5-6.25 mg, tab 5-6.25 mg, tab 10-6.25 mg) 1 MO (Mail Order) candesartan cilexetil-hctz (tab 32-25 mg, tab 32-12.5 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) candesartan cilexetil-hctz tab 16-12.5 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) captopril-hydrochlorothiazide (tab 25-15 mg, tab 25-25 mg, tab 50-15 mg, tab 50-25 mg) 2 MO (Mail Order) CLORPRES (0.1-15 MG, TAB 0.1-15 MG, 0.2-15 MG, TAB 0.2-15 MG, TAB 0.3-15 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) CORLANOR (TAB 5 MG, TAB 7.5 MG) 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) DEMSER CAP 250 MG 5 QL (480 PER 30 DAYS), MO (Mail Order) digitek tab 125 mcg 2 QL (60 PER 30 DAYS), MO (Mail Order) digitek tab 250 mcg 2 PA, MO (Mail Order) digoxin (0.05 mg/ml, solution 0.05 mg/ml, tab 250 mcg) 2 PA, MO (Mail Order) digoxin (solution 0.25 mg/ml, 0.25 mg/ml) 4 PA, MO (Mail Order) digoxin tab 125 mcg 2 QL (60 PER 30 DAYS), MO (Mail Order) EDARBYCLOR (TAB 40-12.5 MG, TAB 40-25 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) enalapril-hydrochlorothiazide (tab 5-12.5 mg, 5-12.5 mg, tab 10-25 mg, 10-25 mg) 1 MO (Mail Order) ENTRESTO (TAB 24-26 MG, TAB 49-51 MG, TAB 97-103 MG) 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 78 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fosinopril sodium-hctz (tab 10-12.5 mg, tab 20-12.5 mg) 2 MO (Mail Order) irbesartan-hydrochlorothiazide tab 150-12.5 mg 2 MO (Mail Order) irbesartan-hydrochlorothiazide tab 300-12.5 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) LANOXIN (TAB 187.5 MCG, TAB 250 MCG) 3 PA, MO (Mail Order) LANOXIN TAB 125 MCG 3 QL (60 PER 30 DAYS), MO (Mail Order) LANOXIN TAB 62.5 MCG 3 QL (120 PER 30 DAYS), MO (Mail Order) lisinopril-hydrochlorothiazide (tab 10-12.5 mg, tab 20-25 mg, tab 20-12.5 mg) 1 MO (Mail Order) losartan potassium-hctz (tab 100-25 mg, tab 100-12.5 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) losartan potassium-hctz tab 50-12.5 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) methyldopa-hydrochlorothiazide (tab 250-25 mg, tab 250-15 mg) 2 PA, MO (Mail Order) metoprolol-hydrochlorothiazide (tab 50-25 mg, tab 100-50 mg, tab 100-25 mg) 2 MO (Mail Order) moexipril-hydrochlorothiazide (tab 7.5-12.5 mg, tab 15-12.5 mg, tab 15-25 mg) 2 MO (Mail Order) nadolol-bendroflumethiazide (tab 40-5 mg, tab 80-5 mg) 2 MO (Mail Order) NORTHERA (CAP 200 MG, CAP 300 MG) 5 PA, QL (180 PER 30 DAYS), MO (Mail Order) NORTHERA CAP 100 MG 5 PA, QL (90 PER 30 DAYS), MO (Mail Order) pentoxifylline tab 400 mg 2 MO (Mail Order) propranolol-hctz (tab 40-25 mg, tab 80-25 mg) 2 MO (Mail Order) quinapril-hydrochlorothiazide (tab 10-12.5 mg, tab 20-25 mg, tab 20-12.5 mg) 2 MO (Mail Order) RANEXA (TAB ER 12H 1000 MG, 1000 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 79 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL RANEXA (TAB ER 12H 500 MG, 500 MG) 3 QL (120 PER 30 DAYS), MO (Mail Order) spironolactone-hctz tab 25-25 mg 2 MO (Mail Order) telmisartan-amlodipine (tab 40-5 mg, tab 4010 mg, tab 80-10 mg, tab 80-5 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) telmisartan-hctz (tab 40-12.5 mg, tab 80-12.5 mg, tab 80-25 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) triamterene-hctz (cap 37.5-25 mg, tab 37.525 mg, tab 75-50 mg) 1 MO (Mail Order) triamterene-hctz cap 50-25 mg 2 MO (Mail Order) TRIBENZOR (TAB 20-5-12.5 MG, TAB 40-512.5 MG, TAB 40-10-12.5 MG, TAB 40-10-25 MG, TAB 40-5-25 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab 160-25 mg, tab 160-12.5 mg, tab 320-25 mg, tab 320-12.5 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) acetazolamide (tab 125 mg, tab 250 mg) 2 MO (Mail Order) acetazolamide cap 12h 500 mg 2 MO (Mail Order) acetazolamide sodium recon soln 500 mg 2 MO (Mail Order) bumetanide (solution 0.25 mg/ml, tab 0.5 mg) 2 MO (Mail Order) bumetanide (tab 1 mg, tab 2 mg) 1 MO (Mail Order) EDECRIN TAB 25 MG 4 MO (Mail Order) furosemide (10 mg/ml, solution 10 mg/ml) 2 PA - Part B vs D Determination, MO (Mail Order) furosemide (20 mg, tab 20 mg, 40 mg, tab 40 mg, 80 mg, tab 80 mg) 1 MO (Mail Order) furosemide (8 mg/ml, 10 mg/ml) 2 MO (Mail Order) torsemide (5 mg, tab 5 mg, tab 10 mg, 10 mg, 20 mg, tab 20 mg, tab 100 mg, 100 mg) 1 MO (Mail Order) Diuretics, Carbonic Anhydrase Inhibitors Diuretics, Loop Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 80 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Diuretics, Potassium-sparing amiloride hcl tab 5 mg 2 MO (Mail Order) DYRENIUM (CAP 50 MG, CAP 100 MG) 4 MO (Mail Order) eplerenone tab 25 mg 2 QL (120 PER 30 DAYS), MO (Mail Order) eplerenone tab 50 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) spironolactone (tab 25 mg, tab 50 mg) 1 MO (Mail Order) spironolactone tab 100 mg 2 MO (Mail Order) chlorothiazide (tab 250 mg, tab 500 mg) 2 MO (Mail Order) chlorothiazide sodium recon soln 500 mg 4 PA - Part B vs D Determination, MO (Mail Order) chlorthalidone (tab 25 mg, tab 50 mg) 2 MO (Mail Order) DIURIL SUSPENSION 250 MG/5ML 3 MO (Mail Order) hydrochlorothiazide (12.5 mg, cap 12.5 mg, tab 12.5 mg, tab 25 mg, 25 mg, tab 50 mg, 50 mg) 1 MO (Mail Order) indapamide (tab 1.25 mg, tab 2.5 mg) 1 MO (Mail Order) methyclothiazide tab 5 mg 2 MO (Mail Order) metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg) 2 MO (Mail Order) fenofibrate (cap 50 mg, tab 48 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) fenofibrate (tab 145 mg, tab 160 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) fenofibrate cap 150 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) fenofibrate micronized (cap 134 mg, cap 200 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) fenofibrate micronized (cap 43 mg, cap 67 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) Diuretics, Thiazide Dyslipidemics, Fibric Acid Derivatives Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 81 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fenofibrate micronized cap 130 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) fenofibrate tab 54 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) fenofibric acid cap dr 135 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) fenofibric acid cap dr 45 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) gemfibrozil (tab 600 mg, 600 mg) 1 MO (Mail Order) Dyslipidemics, HMG CoA Reductase Inhibitors ALTOPREV (TAB ER 20 MG, TAB ER 40 MG, TAB ER 60 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) CRESTOR (TAB 5 MG, TAB 10 MG, TAB 20 MG, TAB 40 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) fluvastatin sodium cap 20 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) fluvastatin sodium cap 40 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) fluvastatin sodium tab 24h 80 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) LIVALO (TAB 1 MG, TAB 2 MG, TAB 4 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) lovastatin (10 mg, tab 10 mg) 1 QL (240 PER 30 DAYS), MO (Mail Order) lovastatin (20 mg, tab 20 mg) 1 QL (120 PER 30 DAYS), MO (Mail Order) lovastatin (tab 40 mg, 40 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) pravastatin sodium (10 mg, tab 10 mg, tab 20 mg, 20 mg, 40 mg, tab 40 mg, 80 mg, tab 80 mg) 2 MO (Mail Order) simvastatin (80 mg, tab 80 mg) 1 PA, MO (Mail Order) simvastatin (tab 5 mg, tab 10 mg, 10 mg, tab 20 mg, 20 mg, 40 mg, tab 40 mg) 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 82 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Dyslipidemics, Other cholestyramine (packet 4 gm, powder 4 gm/dose) 2 MO (Mail Order) cholestyramine light (packet 4 gm, powder 4 gm/dose) 2 MO (Mail Order) colestipol hcl (granules 5 gm, packet 5 gm, tab 1 gm) 2 MO (Mail Order) JUXTAPID (CAP 30 MG, CAP 40 MG, CAP 60 MG) 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) JUXTAPID (CAP 5 MG, CAP 10 MG) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) JUXTAPID CAP 20 MG 5 PA, QL (90 PER 30 DAYS), MO (Mail Order) KYNAMRO SOLN PRSYR 200 MG/ML 5 PA, MO (Mail Order) LOVAZA CAP 1 GM 4 QL (120 PER 30 DAYS), MO (Mail Order) micronized colestipol hcl tab 1 gm 2 MO (Mail Order) niacin er (antihyperlipidemic) (er (antihyperlipidemic) tab er 750 mg, er (antihyperlipidemic) tab er 1000 mg) 4 QL (60 PER 30 DAYS), MO (Mail Order) niacin er (antihyperlipidemic) tab er 500 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) NIACOR TAB 500 MG 2 MO (Mail Order) omega-3-acid ethyl esters cap 1 gm 4 QL (120 PER 30 DAYS), MO (Mail Order) PRALUENT (SOLN PEN 75 MG/ML, SOLN PEN 150 MG/ML, SOLN PRSYR 75 MG/ML, SOLN PRSYR 150 MG/ML) 5 PA, LA, QL (2 PER 28 DAYS), MO (Mail Order) prevalite (packet 4 gm, powder 4 gm/dose) 2 MO (Mail Order) REPATHA SOLN PRSYR 140 MG/ML 5 PA, QL (3 PER 28 DAYS), MO (Mail Order) REPATHA SURECLICK SOLN A-INJ 140 MG/ML 5 PA, QL (3 PER 28 DAYS), MO (Mail Order) VASCEPA CAP 1 GM 4 QL (120 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 83 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL VYTORIN (TAB 10-40 MG, TAB 10-20 MG, TAB 10-10 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) VYTORIN TAB 10-80 MG 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) WELCHOL (PACKET 3.75 GM, TAB 625 MG) 3 MO (Mail Order) ZETIA TAB 10 MG 3 QL (30 PER 30 DAYS), MO (Mail Order) hydralazine hcl (solution 20 mg/ml, tab 100 mg) 2 MO (Mail Order) hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg) 1 MO (Mail Order) minoxidil tab 10 mg 2 MO (Mail Order) minoxidil tab 2.5 mg 1 MO (Mail Order) ISORDIL TITRADOSE TAB 40 MG 4 MO (Mail Order) isosorbide dinitrate (tab 5 mg, 5 mg, 10 mg, tab 10 mg, 20 mg, tab 20 mg, tab 30 mg) 2 MO (Mail Order) isosorbide dinitrate er (er 40 mg, tab 40 mg) 2 MO (Mail Order) isosorbide mononitrate (tab 10 mg, tab 20 mg) 1 MO (Mail Order) isosorbide mononitrate er (er 30 mg, er 60 mg, tab 24h 30 mg, tab 24h 60 mg) 1 MO (Mail Order) isosorbide mononitrate tab 24h 120 mg 2 MO (Mail Order) minitran (patch 0.1 mg/hr, patch 0.2 mg/hr, patch 0.4 mg/hr, patch 0.6 mg/hr) 2 MO (Mail Order) NITRO-BID OINTMENT 2 % 4 MO (Mail Order) NITRO-DUR (PATCH 0.3 MG/HR, PATCH 0.8 MG/HR) 4 MO (Mail Order) nitroglycerin (aero soln 400 mcg/spray, solution 0.4 mg/spray) 4 MO (Mail Order) nitroglycerin (patch 24hr 0.1 mg/hr, patch 24hr 0.4 mg/hr, patch 24hr 0.2 mg/hr, patch 24hr 0.6 mg/hr, solution 5 mg/ml) 2 MO (Mail Order) Vasodilators, Direct-acting Arterial Vasodilators, Direct-acting Arterial/Venous Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 84 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL NITROSTAT (TAB 0.3 MG, TAB 0.4 MG, TAB 0.6 MG) 3 MO (Mail Order) Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphet er (cap 5 mg, cap 10 mg, cap 15 mg, cap 20 mg, cap 25 mg, cap 30 mg) 4 QL (60 PER 30 DAYS), MO (Mail Order) amphetamine-dextroamphetamine (tab 10 mg, tab 12.5 mg, tab 15 mg, tab 30 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) amphetamine-dextroamphetamine tab 20 mg 2 QL (90 PER 30 DAYS), MO (Mail Order) amphetamine-dextroamphetamine tab 5 mg 2 QL (360 PER 30 DAYS), MO (Mail Order) amphetamine-dextroamphetamine tab 7.5 mg 2 QL (240 PER 30 DAYS), MO (Mail Order) dexedrine tab 10 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) dexedrine tab 5 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) dextroamphetamine sulfate cap 24h 10 mg 4 QL (150 PER 30 DAYS), MO (Mail Order) dextroamphetamine sulfate cap 24h 15 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) dextroamphetamine sulfate cap 24h 5 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) dextroamphetamine sulfate tab 10 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) dextroamphetamine sulfate tab 5 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl tab 12h 0.1 mg 4 QL (120 PER 30 DAYS), MO (Mail Order) DAYTRANA (PATCH 10 MG/9HR, PATCH 15 MG/9HR, PATCH 20 MG/9HR, PATCH 30 MG/9HR) 4 QL (30 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 85 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) dexmethylphenidate hcl er (cap 15 mg, cap 30 mg) 4 MO (Mail Order) dexmethylphenidate hcl er (cap 5 mg, cap 10 mg, cap 40 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) dexmethylphenidate hcl cap 24h 20 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) FOCALIN XR (CAP ER 5 MG, CAP ER 10 MG, CAP ER 25 MG, CAP ER 35 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) FOCALIN XR CAP ER 24H 20 MG 4 QL (60 PER 30 DAYS), MO (Mail Order) guanfacine hcl er (tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg) 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) INTUNIV (TAB ER 1 MG, TAB ER 2 MG, TAB ER 3 MG, TAB ER 4 MG) 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) metadate tab 20 mg 4 QL (90 PER 30 DAYS), MO (Mail Order) METHYLIN (10 MG, CHEW TAB 10 MG) 4 QL (180 PER 30 DAYS), MO (Mail Order) METHYLIN (CHEW TAB 2.5 MG, 2.5 MG, CHEW TAB 5 MG) 4 QL (90 PER 30 DAYS), MO (Mail Order) methylphenidate hcl (tab 2.5 mg, tab 5 mg) 4 QL (90 PER 30 DAYS), MO (Mail Order) methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) methylphenidate hcl chew tab 10 mg 4 QL (180 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (cd) (er (cd) cap er 10 mg, er (cd) cap er 40 mg, er (cd) cap er 50 mg, er (cd) cap er 60 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (cd) cap er 20 mg 4 QL (90 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (cd) cap er 30 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (tab 10 mg, tab 20 mg) 2 QL (90 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 86 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL methylphenidate hcl er (tab 18 mg, tab 27 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (tab 36 mg, tab 54 mg) 4 MO (Mail Order) methylphenidate hcl er (la) cap er 24h 20 mg 4 QL (90 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (la) cap er 24h 30 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) methylphenidate hcl er (la) cap er 24h 40 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) methylphenidate hcl solution 10 mg/5ml 4 QL (900 PER 30 DAYS), MO (Mail Order) methylphenidate hcl solution 5 mg/5ml 4 QL (1800 PER 30 DAYS), MO (Mail Order) QUILLIVANT XR RECON SUSP 25 MG/5ML 4 QL (360 PER 30 DAYS), MO (Mail Order) RITALIN LA CAP ER 24H 10 MG 4 QL (180 PER 30 DAYS), MO (Mail Order) RITALIN LA CAP ER 24H 60 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) STRATTERA (CAP 10 MG, CAP 18 MG, CAP 25 MG, CAP 40 MG) 4 ST, QL (60 PER 30 DAYS), MO (Mail Order) STRATTERA (CAP 60 MG, CAP 80 MG, CAP 100 MG) 4 ST, QL (30 PER 30 DAYS), MO (Mail Order) NAMZARIC (CAP ER 14-10 MG, CAP ER 2810 MG) 3 PA, QL (30 PER 30 DAYS), MO (Mail Order) NUEDEXTA CAP 20-10 MG 4 MO (Mail Order) riluzole tab 50 mg 3 MO (Mail Order) tetrabenazine (tab 12.5 mg, tab 25 mg) 5 PA, MO (Mail Order) XENAZINE (TAB 12.5 MG, TAB 25 MG) 5 PA, LA, MO (Mail Order) 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) Central Nervous System, Other Fibromyalgia Agents LYRICA (CAP 25 MG, CAP 50 MG, CAP 75 MG, CAP 100 MG, CAP 150 MG, CAP 200 MG, CAP 225 MG, CAP 300 MG, SOLUTION 20 MG/ML) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 87 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB 100 MG) 3 QL (60 PER 30 DAYS), MO (Mail Order) SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG 3 QL (55 PER 30 DAYS), MO (Mail Order) AMPYRA TAB ER 12H 10 MG 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) AUBAGIO (TAB 7 MG, TAB 14 MG) 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) AVONEX KIT 30 MCG 5 PA, MO (Mail Order) AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML 5 PA, MO (Mail Order) AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML 5 PA, MO (Mail Order) BETASERON KIT 0.3 MG 5 PA, MO (Mail Order) COPAXONE SOLN PRSYR 20 MG/ML 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) COPAXONE SOLN PRSYR 40 MG/ML 5 PA, MO (Mail Order) EXTAVIA KIT 0.3 MG 5 PA, MO (Mail Order) GILENYA CAP 0.5 MG 5 PA, QL (28 PER 28 DAYS), MO (Mail Order) glatopa soln prsyr 20 mg/ml 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) REBIF (SOLN 22 MCG/0.5ML, SOLN 44 MCG/0.5ML) 5 PA, MO (Mail Order) REBIF REBIDOSE (SOLN 22 MCG/0.5ML, SOLN 44 MCG/0.5ML) 5 PA, MO (Mail Order) REBIF REBIDOSE TITRATION PACK SOLN A-INJ 6X8.8 & 6X22 MCG 5 PA, MO (Mail Order) REBIF TITRATION PACK SOLN PRSYR 6X8.8 & 6X22 MCG 5 PA, MO (Mail Order) TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC 120 & 240 MG) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) TYSABRI CONC 300 MG/15ML 5 PA, MO (Mail Order) Multiple Sclerosis Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 88 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Dental and Oral Agents cevimeline hcl cap 30 mg 4 MO (Mail Order) chlorhexidine gluconate (solution 0.12 %, 0.12 %) 1 MO (Mail Order) doxycycline hyclate tab 20 mg 2 MO (Mail Order) KEPIVANCE (RECON SOLN 6.25 MG, 6.25 MG) 5 MO (Mail Order) periogard solution 0.12 % 1 MO (Mail Order) pilocarpine hcl (tab 5 mg, tab 7.5 mg) 2 MO (Mail Order) triamcinolone acetonide paste 0.1 % 2 MO (Mail Order) acitretin (cap 10 mg, cap 17.5 mg, cap 25 mg) 5 MO (Mail Order) adapalene (cream 0.1 %, gel 0.1 %, gel 0.3 %) 4 MO (Mail Order) ala cort cream 1 % 1 MO (Mail Order) alclometasone dipropionate (cream 0.05 %, ointment 0.05 %) 2 MO (Mail Order) amcinonide (cream 0.1 %, lotion 0.1 %, ointment 0.1 %) 4 MO (Mail Order) ammonium lactate (cream 12 %, lotion 12 %) 2 MO (Mail Order) APEXICON E CREAM 0.05 % 4 MO (Mail Order) ATRALIN GEL 0.05 % 4 PA, MO (Mail Order) avita (cream 0.025 %, gel 0.025 %) 2 PA, MO (Mail Order) AZELEX CREAM 20 % 4 MO (Mail Order) benzoyl peroxide-erythromycin gel 5-3 % 2 MO (Mail Order) betamethasone dipropionate (cream 0.05 %, lotion 0.05 %, ointment 0.05 %) 2 MO (Mail Order) betamethasone dipropionate aug (cream 0.05 %, gel 0.05 %, lotion 0.05 %, ointment 0.05 %) 2 MO (Mail Order) Dermatological Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 89 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL betamethasone valerate (cream 0.1 %, lotion 0.1 %, ointment 0.1 %) 2 MO (Mail Order) betamethasone valerate foam 0.12 % 4 MO (Mail Order) calcipotriene (cream 0.005 %, ointment 0.005 %, solution 0.005 %) 4 MO (Mail Order) calcipotriene-betameth diprop ointment 0.005-0.064 % 5 MO (Mail Order) CAPEX SHAMPOO 0.01 % 4 MO (Mail Order) CARAC CREAM 0.5 % 5 MO (Mail Order) claravis (cap 10 mg, cap 20 mg, cap 30 mg, cap 40 mg) 4 MO (Mail Order) clindamycin phos-benzoyl perox gel 1-5 % 4 MO (Mail Order) clindamycin phosphate (gel 1 %, lotion 1 %, solution 1 %, swab 1 %, 1 %) 2 MO (Mail Order) clindamycin phosphate foam 1 % 4 MO (Mail Order) clobetasol propionate (0.05 %, cream 0.05 %, foam 0.05 %, lotion 0.05 %, ointment 0.05 %, shampoo 0.05 %) 4 MO (Mail Order) clobetasol propionate (gel 0.05 %, solution 0.05 %) 2 MO (Mail Order) clobetasol propionate e cream 0.05 % 4 MO (Mail Order) clobetasol propionate emulsion foam 0.05 % 4 MO (Mail Order) CLOBEX SPRAY LIQUID 0.05 % 4 MO (Mail Order) clodan shampoo 0.05 % 4 MO (Mail Order) clotrimazole-betamethasone cream 1-0.05 % 2 MO (Mail Order) clotrimazole-betamethasone lotion 1-0.05 % 4 MO (Mail Order) CONDYLOX GEL 0.5 % 4 MO (Mail Order) CORDRAN TAPE 4 MCG/SQCM 4 MO (Mail Order) cormax scalp application solution 0.05 % 2 MO (Mail Order) cormax solution 0.05 % 2 MO (Mail Order) CORTISPORIN CREAM 3.5-10000-0.5 3 MO (Mail Order) CORTISPORIN OINTMENT 1 % 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 90 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL COSENTYX SENSOREADY PEN SOLN AINJ 150 MG/ML 5 PA, MO (Mail Order) COSENTYX SOLN PRSYR 150 MG/ML 5 PA, MO (Mail Order) desonide (cream 0.05 %, lotion 0.05 %) 4 MO (Mail Order) desonide ointment 0.05 % 2 MO (Mail Order) desoximetasone (cream 0.05 %, gel 0.05 %, ointment 0.05 %, ointment 0.25 %) 4 MO (Mail Order) desoximetasone cream 0.25 % 2 MO (Mail Order) diclofenac sodium gel 3 % 5 MO (Mail Order) DIFFERIN LOTION 0.1 % 4 MO (Mail Order) diflorasone diacetate (cream 0.05 %, ointment 0.05 %, 0.05 %) 4 MO (Mail Order) doxepin hcl cream 5 % 4 MO (Mail Order) doxycycline cap dr 40 mg 4 MO (Mail Order) ELIDEL CREAM 1 % 4 ST, MO (Mail Order) EPIDUO FORTE GEL 0.3-2.5 % 4 MO (Mail Order) EPIDUO GEL 0.1-2.5 % 4 MO (Mail Order) ery pad 2 % 2 MO (Mail Order) erythromycin (gel 2 %, solution 2 %) 2 MO (Mail Order) FINACEA (FOAM 15 %, GEL 15 %) 3 MO (Mail Order) FINACEA PLUS KIT 15 % 3 MO (Mail Order) fluocinolone acetonide (cream 0.01 %, cream 0.025 %, ointment 0.025 %) 2 MO (Mail Order) fluocinolone acetonide body oil 0.01 % 4 MO (Mail Order) fluocinolone acetonide scalp oil 0.01 % 4 MO (Mail Order) fluocinolone acetonide solution 0.01 % 4 MO (Mail Order) fluocinonide (cream 0.05 %, gel 0.05 %, ointment 0.05 %, solution 0.05 %) 2 MO (Mail Order) fluocinonide cream 0.1 % 5 MO (Mail Order) fluocinonide-e cream 0.05 % 2 MO (Mail Order) fluorouracil (solution 2 %, 5 %, solution 5 %) 2 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 91 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL fluorouracil cream 0.5 % 5 MO (Mail Order) fluorouracil cream 5 % 4 MO (Mail Order) fluticasone propionate (cream 0.05 %, ointment 0.005 %) 2 MO (Mail Order) fluticasone propionate lotion 0.05 % 4 MO (Mail Order) halobetasol propionate (0.05 %, cream 0.05 %, ointment 0.05 %) 4 MO (Mail Order) HALOG (CREAM 0.1 %, OINTMENT 0.1 %) 4 MO (Mail Order) hydrocortisone (cream 1 %, cream 2.5 %, ointment 1 %, ointment 2.5 %) 1 MO (Mail Order) hydrocortisone 1 % 1 hydrocortisone butyr lipo base cream 0.1 % 4 MO (Mail Order) hydrocortisone butyrate (0.1 %, ointment 0.1 %, solution 0.1 %) 2 MO (Mail Order) hydrocortisone butyrate cream 0.1 % 4 MO (Mail Order) hydrocortisone lotion 2.5 % 2 MO (Mail Order) hydrocortisone valerate (cream 0.2 %, ointment 0.2 %) 4 MO (Mail Order) imiquimod cream 5 % 4 MO (Mail Order) KENALOG AERO SOLN 0.147 MG/GM 3 MO (Mail Order) lokara lotion 0.05 % 4 MO (Mail Order) methoxsalen rapid cap 10 mg 5 PA, MO (Mail Order) MIRVASO GEL 0.33 % 4 MO (Mail Order) mometasone furoate (0.1 %, cream 0.1 %) 1 MO (Mail Order) mometasone furoate (ointment 0.1 %, solution 0.1 %) 2 MO (Mail Order) myorisan cap 30 mg 4 MO (Mail Order) ORACEA CAP DR 40 MG 4 MO (Mail Order) OXSORALEN ULTRA CAP 10 MG 5 PA, MO (Mail Order) PANDEL CREAM 0.1 % 4 MO (Mail Order) PICATO (GEL 0.015 %, GEL 0.05 %) 3 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 92 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL podofilox solution 0.5 % 2 MO (Mail Order) prednicarbate (cream 0.1 %, ointment 0.1 %) 2 MO (Mail Order) PROTOPIC (0.03 %, 0.1 %) 4 MO (Mail Order) PRUDOXIN CREAM 5 % 4 MO (Mail Order) REGRANEX GEL 0.01 % 5 PA, MO (Mail Order) SANTYL (250 UNIT/GM, OINTMENT 250 UNIT/GM) 4 MO (Mail Order) selenium sulfide lotion 2.5 % 2 MO (Mail Order) SOLARAZE GEL 3 % 5 MO (Mail Order) STELARA (SOLN 45 MG/0.5ML, SOLN 90 MG/ML) 5 PA, MO (Mail Order) sulfacetamide sodium (acne) lotion 10 % 2 MO (Mail Order) sulfacetamide sodium suspension 10 % 2 MO (Mail Order) tacrolimus (0.03 %, 0.1 %) 4 MO (Mail Order) TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %, GEL 0.1 %) 4 PA, MO (Mail Order) tretinoin (cream 0.025 %, cream 0.05 %, gel 0.025 %) 2 PA, MO (Mail Order) tretinoin (cream 0.1 %, gel 0.01 %, gel 0.05 %) 4 PA, MO (Mail Order) tretinoin microsphere (gel 0.04 %, gel 0.1 %) 4 PA, MO (Mail Order) tretinoin microsphere pump (pump gel 0.04 %, pump gel 0.1 %) 4 PA, MO (Mail Order) triamcinolone acetonide (cream 0.025 %, cream 0.1 %, ointment 0.025 %) 1 MO (Mail Order) triamcinolone acetonide (cream 0.5 %, lotion 0.025 %, lotion 0.1 %, ointment 0.1 %, 0.1 %, ointment 0.5 %, 0.5 %) 2 MO (Mail Order) triamcinolone acetonide aero soln 0.147 mg/gm 3 MO (Mail Order) triderm cream 0.1 % 1 MO (Mail Order) UVADEX SOLUTION 20 MCG/ML 4 MO (Mail Order) VELTIN GEL 1.2-0.025 % 4 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 93 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL ZYCLARA CREAM 3.75 % 5 MO (Mail Order) ZYCLARA PUMP (PUMP 2.5 %, PUMP 3.75 %) 5 MO (Mail Order) ADAGEN SOLUTION 250 UNIT/ML 5 LA, MO (Mail Order) ALDURAZYME SOLUTION 2.9 MG/5ML 5 MO (Mail Order) BUPHENYL POWDER 3 GM/TSP 5 CEREZYME (SOLN 200, SOLN 400) 5 PA, MO (Mail Order) CREON (DR 3000-9500, DR 6000, DR 12000, DR 24000, DR 36000) 3 MO (Mail Order) CYSTADANE POWDER 5 MO (Mail Order) CYSTAGON (CAP 50 MG, CAP 150 MG) 4 LA, MO (Mail Order) ELAPRASE SOLUTION 6 MG/3ML 5 MO (Mail Order) FABRAZYME (SOLN 5 MG, SOLN 35 MG) 5 MO (Mail Order) KUVAN (PACKET 500 MG, TAB SOL 100 MG) 5 MO (Mail Order) LUMIZYME RECON SOLN 50 MG 5 MO (Mail Order) MYOZYME RECON SOLN 50 MG 5 MO (Mail Order) NAGLAZYME SOLUTION 1 MG/ML 5 MO (Mail Order) ORFADIN (CAP 2 MG, 2 MG, CAP 5 MG, CAP 10 MG) 5 LA, MO (Mail Order) RAVICTI LIQUID 1.1 GM/ML 5 MO (Mail Order) sodium phenylbutyrate powder 3 gm/tsp 5 MO (Mail Order) STRENSIQ (18 MG/0.45ML, 28 MG/0.7ML) 5 MO (Mail Order) STRENSIQ (40 MG/ML, 80 MG/0.8ML) 5 PA, LA, MO (Mail Order) SUCRAID (SOLUTION 8500 UNIT/ML, 8500 UNIT/ML) 5 LA, MO (Mail Order) VPRIV RECON SOLN 400 UNIT 5 PA, MO (Mail Order) ZAVESCA CAP 100 MG 5 PA, LA, MO (Mail Order) ZENPEP (DR 3000-10000, DR 5000, DR 10000, DR 15000, DR 20000, DR 25000, DR 40000) 3 MO (Mail Order) Enzyme Replacement/Modifiers Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 94 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Gastrointestinal Agents Antispasmodics, Gastrointestinal CUVPOSA SOLUTION 1 MG/5ML 4 MO (Mail Order) dicyclomine hcl (10 mg, cap 10 mg, tab 20 mg, 20 mg) 1 PA, MO (Mail Order) dicyclomine hcl solution 10 mg/5ml 2 PA, MO (Mail Order) dicyclomine hcl solution 10 mg/ml 2 PA glycopyrrolate (0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml) 4 MO (Mail Order) glycopyrrolate (tab 1 mg, tab 2 mg) 2 MO (Mail Order) methscopolamine bromide tab 2.5 mg 2 MO (Mail Order) methscopolamine bromide tab 5 mg 4 MO (Mail Order) propantheline bromide tab 15 mg 2 MO (Mail Order) amoxicill-clarithro-lansopraz misc 4 MO (Mail Order) CHENODAL TAB 250 MG 5 MO (Mail Order) CHOLBAM (CAP 50 MG, CAP 250 MG) 5 MO (Mail Order) GATTEX (5 MG, KIT 5 MG) 5 PA, MO (Mail Order) loperamide hcl cap 2 mg 2 MO (Mail Order) RELISTOR (KIT 12 MG/0.6ML, SOLUTION 8 MG/0.4ML, SOLUTION 12 MG/0.6ML) 5 PA, MO (Mail Order) SAIZEN RECON SOLN 8.8 MG 5 PA, MO (Mail Order) ursodiol (cap 300 mg, tab 250 mg, tab 500 mg) 4 MO (Mail Order) cimetidine (tab 200 mg, tab 400 mg, tab 800 mg, 800 mg) 2 MO (Mail Order) cimetidine hcl solution 300 mg/5ml 2 MO (Mail Order) cimetidine tab 300 mg 1 MO (Mail Order) Gastrointestinal Agents, Other Histamine2 (H2) Receptor Antagonists Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 95 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL famotidine (tab 20 mg, 20 mg, tab 40 mg, 40 mg) 1 MO (Mail Order) famotidine premixed solution 20-0.9 mg/50ml% 2 MO (Mail Order) nizatidine (cap 150 mg, cap 300 mg) 2 MO (Mail Order) nizatidine solution 15 mg/ml 4 MO (Mail Order) ranitidine hcl (cap 150 mg, cap 300 mg, syrup 15 mg/ml, syrup 75 mg/5ml, syrup 150 mg/10ml) 2 MO (Mail Order) ranitidine hcl (solution 50 mg/2ml, solution 150 mg/6ml, 150 mg, tab 150 mg, 300 mg, solution 1000 mg/40ml, tab 300 mg) 1 MO (Mail Order) alosetron hcl (tab 0.5 mg, tab 1 mg) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) AMITIZA (CAP 8 MCG, CAP 24 MCG) 3 QL (60 PER 30 DAYS), MO (Mail Order) LINZESS (CAP 145 MCG, CAP 290 MCG) 3 QL (30 PER 30 DAYS), MO (Mail Order) LOTRONEX (TAB 0.5 MG, TAB 1 MG) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) constulose solution 10 gm/15ml 2 MO (Mail Order) enulose solution 10 gm/15ml 2 MO (Mail Order) gavilyte-c recon soln 240 gm 1 MO (Mail Order) gavilyte-g recon soln 236 gm 2 MO (Mail Order) gavilyte-h kit 5-210 mg-gm 2 MO (Mail Order) gavilyte-n with flavor pack recon soln 420 gm 2 MO (Mail Order) generlac solution 10 gm/15ml 2 MO (Mail Order) KRISTALOSE (10 GM, 20 GM) 3 MO (Mail Order) lactulose (solution 10 gm/15ml, 10 gm/15ml, solution 20 gm/30ml) 2 MO (Mail Order) peg 3350-kcl-na bicarb-nacl recon soln 420 gm 2 MO (Mail Order) Irritable Bowel Syndrome Agents Laxatives Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 96 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL peg-3350/electrolytes recon soln 236 gm 2 MO (Mail Order) polyethylene glycol 3350 (3350 packet, 3350 powder) 2 MO (Mail Order) SUPREP BOWEL PREP SOLUTION 3 MO (Mail Order) trilyte recon soln 420 gm 2 MO (Mail Order) CARAFATE SUSPENSION 1 GM/10ML 4 MO (Mail Order) misoprostol (tab 100 mcg, tab 200 mcg) 2 MO (Mail Order) sucralfate tab 1 gm 2 MO (Mail Order) DEXILANT (CAP DR 30 MG, CAP DR 60 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) esomeprazole magnesium (cap dr 20 mg, cap dr 40 mg) 3 QL (60 PER 30 DAYS), MO (Mail Order) esomeprazole sodium (soln 20 mg, soln 40 mg) 4 MO (Mail Order) esomeprazole strontium cap dr 49.3 mg 3 QL (60 PER 30 DAYS), MO (Mail Order) KAPIDEX (30 MG, 60 MG) 4 QL (60 PER 30 DAYS), MO (Mail Order) lansoprazole (cap dr 15 mg, cap dr 30 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) omeprazole (10 mg, cap dr 10 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) omeprazole (cap dr 20 mg, 20 mg, cap dr 40 mg, 40 mg) 1 QL (60 PER 30 DAYS), MO (Mail Order) omeprazole-sodium bicarbonate (cap 201100 mg, cap 40-1100 mg) 4 QL (60 PER 30 DAYS), MO (Mail Order) pantoprazole sodium tab dr 20 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) pantoprazole sodium tab dr 40 mg 1 QL (60 PER 30 DAYS), MO (Mail Order) PRILOSEC PACKET 10 MG 3 MO (Mail Order) Protectants Proton Pump Inhibitors Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 97 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PRILOSEC PACKET 2.5 MG 4 MO (Mail Order) rabeprazole sodium tab dr 20 mg 2 MO (Mail Order) flavoxate hcl tab 100 mg 2 MO (Mail Order) MYRBETRIQ (TAB ER 25 MG, TAB ER 50 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) oxybutynin chloride (5 mg, tab 5 mg) 2 MO (Mail Order) oxybutynin chloride er (tab 5 mg, tab 10 mg, tab 15 mg) 2 MO (Mail Order) tolterodine tartrate er (cap 2 mg, cap 4 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) tolterodine tartrate tab 1 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) tolterodine tartrate tab 2 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) TOVIAZ (TAB ER 4 MG, TAB ER 8 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) trospium chloride cap 24h 60 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) trospium chloride tab 20 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) VESICARE (TAB 5 MG, TAB 10 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) alfuzosin hcl tab 24h 10 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) CARDURA XL (TAB ER 4 MG, TAB ER 8 MG) 4 QL (30 PER 30 DAYS), MO (Mail Order) CIALIS (TAB 2.5 MG, TAB 5 MG) 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) dutasteride cap 0.5 mg 3 QL (30 PER 30 DAYS), MO (Mail Order) Genitourinary Agents Antispasmodics, Urinary Benign Prostatic Hypertrophy Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 98 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL dutasteride-tamsulosin hcl cap 0.5-0.4 mg 4 QL (60 PER 30 DAYS), MO (Mail Order) finasteride tab 5 mg 1 QL (30 PER 30 DAYS), MO (Mail Order) RAPAFLO (CAP 4 MG, CAP 8 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) tamsulosin hcl cap 0.4 mg 2 QL (60 PER 30 DAYS), MO (Mail Order) terazosin hcl (cap 1 mg, 1 mg, 2 mg, cap 2 mg, cap 5 mg, 5 mg, cap 10 mg) 1 MO (Mail Order) bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab 50 mg) 2 MO (Mail Order) CUPRIMINE CAP 250 MG 5 ST, MO (Mail Order) DEPEN TITRATABS TAB 250 MG 5 MO (Mail Order) ELMIRON (CAP 100 MG, 100 MG) 4 MO (Mail Order) calcium acetate (phos binder) cap 667 mg 4 MO (Mail Order) ELIPHOS TAB 667 MG 2 MO (Mail Order) FOSRENOL (750 MG, 1000 MG) 4 MO (Mail Order) FOSRENOL (TAB 500 MG, TAB 750 MG, TAB 1000 MG) 5 MO (Mail Order) PHOSLO CAP 667 MG 3 MO (Mail Order) PHOSLYRA SOLUTION 667 MG/5ML 3 MO (Mail Order) RENAGEL (TAB 400 MG, TAB 800 MG) 3 MO (Mail Order) RENVELA (PACKET 0.8 GM, PACKET 2.4 GM, TAB 800 MG) 3 MO (Mail Order) VELPHORO CHEW TAB 500 MG 4 MO (Mail Order) Genitourinary Agents, Other Phosphate Binders Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) A-HYDROCORT RECON SOLN 100 MG 2 MO (Mail Order) ACTHAR HP GEL 80 UNIT/ML 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 99 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL clobetasol propionate liquid 0.05 % 4 MO (Mail Order) cortisone acetate tab 25 mg 2 MO (Mail Order) DEPO-MEDROL SUSPENSION 20 MG/ML 3 MO (Mail Order) dexamethasone (elixir 0.5 mg/5ml, tab 2 mg, tab 6 mg) 2 MO (Mail Order) dexamethasone (tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 4 mg) 1 MO (Mail Order) DEXAMETHASONE INTENSOL CONC 1 MG/ML 2 MO (Mail Order) dexamethasone sod phosphate pf solution 10 mg/ml 1 MO (Mail Order) dexamethasone sodium phosphate (4 mg/ml, 10 mg/ml, 20 mg/5ml, 120 mg/30ml) 1 MO (Mail Order) DEXPAK 13 DAY TAB THPK 1.5 MG (51) 4 MO (Mail Order) fludrocortisone acetate tab 0.1 mg 2 MO (Mail Order) HP ACTHAR GEL 80 UNIT/ML 5 PA, MO (Mail Order) hydrocortisone (tab 5 mg, 5 mg, 10 mg, tab 10 mg, tab 20 mg, 20 mg) 2 MO (Mail Order) KENALOG (10 MG/ML, 40 MG/ML) 4 MO (Mail Order) MEDROL TAB 2 MG 3 MO (Mail Order) methylprednisolone (pak) tab 4 mg 2 MO (Mail Order) methylprednisolone (tab 4 mg, tab 8 mg, tab 16 mg, tab 32 mg, tab thpk 4 mg) 2 MO (Mail Order) methylprednisolone acetate (40 mg/ml, 80 mg/ml) 2 MO (Mail Order) methylprednisolone sodium succ (soln 40 mg, soln 125 mg, soln 500 mg, soln 1000 mg) 2 MO (Mail Order) MILLIPRED TAB 5 MG 4 MO (Mail Order) prednisolone (solution 15 mg/5ml, syrup 15 mg/5ml) 2 MO (Mail Order) prednisolone sodium phosphate (6.7 (5 base) mg/5ml, 15 mg/5ml, 25 mg/5ml) 2 MO (Mail Order) prednisone (tab 1 mg, tab 2.5 mg, tab 5 mg, 5 mg, tab 10 mg, 10 mg, tab 20 mg, 20 mg, tab 50 mg) 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 100 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PREDNISONE INTENSOL CONC 5 MG/ML 2 MO (Mail Order) prednisone solution 5 mg/5ml 2 MO (Mail Order) PSORCON CREAM 0.05 % 4 MO (Mail Order) RAYOS (TAB DR 1 MG, TAB DR 2 MG, TAB DR 5 MG) 5 PA - Part B vs D Determination, MO (Mail Order) SOLU-CORTEF (RECON SOLN 100 MG, RECON SOLN 250 MG, 250 MG, RECON SOLN 500 MG, 500 MG, RECON SOLN 1000 MG) 4 MO (Mail Order) SOLU-MEDROL RECON SOLN 2 GM 3 MO (Mail Order) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonadotropin recon soln 10000 unit 4 PA, MO (Mail Order) desmopressin ace rhinal tube solution 0.01 % 2 MO (Mail Order) desmopressin ace spray refrig solution 0.01 % 4 MO (Mail Order) desmopressin acetate (tab 0.1 mg, tab 0.2 mg) 2 MO (Mail Order) desmopressin acetate solution 4 mcg/ml 4 MO (Mail Order) desmopressin acetate spray solution 0.01 % 4 MO (Mail Order) GENOTROPIN (SOLN 5 MG, SOLN 12 MG) 5 PA, MO (Mail Order) GENOTROPIN MINIQUICK (SOLN 0.4 MG, SOLN 0.6 MG, SOLN 0.8 MG, SOLN 1 MG, SOLN 1.2 MG, SOLN 1.4 MG, SOLN 1.6 MG, SOLN 1.8 MG, SOLN 2 MG) 5 PA, MO (Mail Order) GENOTROPIN MINIQUICK RECON SOLN 0.2 MG 4 PA, MO (Mail Order) HUMATROPE (SOLN 5 MG, SOLN 6 MG, SOLN 12 MG, SOLN 24 MG) 5 PA, MO (Mail Order) INCRELEX SOLUTION 40 MG/4ML 5 PA, MO (Mail Order) NORDITROPIN FLEXPRO (5 MG/1.5ML, 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML) 5 PA, MO (Mail Order) NORDITROPIN NORDIFLEX PEN (5 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML) 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 101 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL novarel recon soln 10000 unit 4 PA, MO (Mail Order) NUTROPIN AQ NUSPIN 10 SOLUTION 10 MG/2ML 5 PA, MO (Mail Order) NUTROPIN AQ NUSPIN 20 SOLUTION 20 MG/2ML 5 PA, MO (Mail Order) NUTROPIN AQ NUSPIN 5 SOLUTION 5 MG/2ML 5 PA, MO (Mail Order) NUTROPIN AQ PEN (10 MG/2ML, 20 MG/2ML) 5 PA, MO (Mail Order) OMNITROPE (5 MG/1.5ML, RECON SOLN 5.8 MG, SOLUTION 5 MG/1.5ML, SOLUTION 10 MG/1.5ML) 5 PA, MO (Mail Order) pregnyl recon soln 10000 unit 4 PA, MO (Mail Order) SAIZEN CLICK.EASY RECON SOLN 8.8 MG 5 PA, MO (Mail Order) SAIZEN RECON SOLN 5 MG 5 PA, MO (Mail Order) STIMATE (SOLUTION 1.5 MG/ML, 1.5 MG/ML) 4 MO (Mail Order) ZOMACTON (SOLN 5 MG, SOLN 10 MG) 5 PA, MO (Mail Order) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM TAB 300 MG 5 PA, MO (Mail Order) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 TAB 50 MG 5 PA, MO (Mail Order) oxandrolone (tab 2.5 mg, tab 10 mg) 3 PA, MO (Mail Order) ANDRODERM (PATCH 2 MG/, PATCH 4 MG/) 3 PA, QL (30 PER 30 DAYS), MO (Mail Order) ANDROGEL (GEL 20.25 MG/1.25GM (1.62%), GEL 40.5 MG/2.5GM (1.62%)) 3 PA, QL (150 PER 30 DAYS), MO (Mail Order) ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%) 3 PA, QL (150 PER 30 DAYS), MO (Mail Order) Androgens Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 102 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL danazol (cap 50 mg, cap 100 mg) 2 MO (Mail Order) danazol cap 200 mg 4 MO (Mail Order) STRIANT MISC 30 MG 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) testosterone cypionate (100 mg/ml, 200 mg/ml) 2 PA, MO (Mail Order) testosterone enanthate solution 200 mg/ml 2 PA, MO (Mail Order) amethia tab 0.15-0.03 &0.01 mg 1 MO (Mail Order) amethyst tab 90-20 mcg 1 MO (Mail Order) ANGELIQ (TAB 0.25-0.5 MG, TAB 0.5-1 MG) 4 PA, MO (Mail Order) apri tab 0.15-30 mg-mcg 1 MO (Mail Order) aranelle tab 0.5/1/0.5-35 mg-mcg 1 MO (Mail Order) ashlyna tab 0.15-0.03 &0.01 mg 1 MO (Mail Order) aubra tab 0.1-20 mg-mcg 1 MO (Mail Order) aviane tab 0.1-20 mg-mcg 1 MO (Mail Order) balziva tab 0.4-35 mg-mcg 1 MO (Mail Order) bekyree tab 0.15-0.02/0.01 mg (21/5) 1 MO (Mail Order) blisovi 24 fe tab 1-20 mg-mcg(24) 1 MO (Mail Order) blisovi fe 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) blisovi fe 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) briellyn tab 0.4-35 mg-mcg 1 MO (Mail Order) CLIMARA PRO PATCH WK 0.045-0.015 MG/DAY 4 PA, MO (Mail Order) COMBIPATCH (PATCH 0.05-0.14 MG/DAY, PATCH 0.05-0.25 MG/DAY) 4 PA, MO (Mail Order) cryselle-28 tab 0.3-30 mg-mcg 1 MO (Mail Order) cyclafem 1/35 tab 1-35 mg-mcg 1 MO (Mail Order) cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg 1 MO (Mail Order) delyla tab 0.1-20 mg-mcg 1 MO (Mail Order) Estrogens Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 103 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL DEPO-ESTRADIOL OIL 5 MG/ML 4 MO (Mail Order) desogestrel-ethinyl estradiol tab 0.150.02/0.01 mg (21/5) 1 MO (Mail Order) drospirenone-ethinyl estradiol (tab 3-0.03 mg, tab 3-0.02 mg) 1 MO (Mail Order) ELESTRIN (GEL 0.52 MG/0.87 GM (0.06%), 0.52 MG/0.87 GM (0.06%)) 4 PA, MO (Mail Order) emoquette tab 0.15-30 mg-mcg 1 MO (Mail Order) enpresse-28 tab 1 MO (Mail Order) ESTRACE CREAM 0.1 MG/GM 4 MO (Mail Order) estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr, patch 0.05 mg/24hr, patch 0.06 mg/24hr, patch 0.075 mg/24hr, patch 0.1 mg/24hr) 2 PA, MO (Mail Order) estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr, patch 0.05 mg/24hr, patch 0.075 mg/24hr, patch 0.1 mg/24hr) 3 PA, MO (Mail Order) estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg) 1 PA, MO (Mail Order) estradiol valerate (oil 20 mg/ml, 20 mg/ml, 40 mg/ml, oil 40 mg/ml) 2 MO (Mail Order) estradiol-norethindrone acet (tab 0.5-0.1 mg, tab 1-0.5 mg) 2 PA, MO (Mail Order) ESTRING RING 2 MG 3 QL (1 PER 90 DAYS), MO (Mail Order) estropipate (tab 0.75 mg, tab 1.5 mg, 1.5 mg, tab 3 mg) 2 PA, MO (Mail Order) falmina tab 0.1-20 mg-mcg 1 MO (Mail Order) FEMHRT LOW DOSE TAB 0.5-2.5 MG-MCG 3 PA, MO (Mail Order) FEMRING (FEM0.05 MG/24HR, FEM0.1 MG/24HR) 4 QL (1 PER 90 DAYS), MO (Mail Order) fyavolv (tab 0.5-2.5, tab 1-5) 2 PA GENERESS FE CHEW TAB 0.8-25 MG-MCG 4 MO (Mail Order) gianvi tab 3-0.02 mg 1 MO (Mail Order) gildagia tab 0.4-35 mg-mcg 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 104 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL gildess 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) gildess 24 fe tab 1-20 mg-mcg(24) 1 MO (Mail Order) introvale tab 0.15-0.03 mg 1 MO (Mail Order) jinteli tab 1-5 mg-mcg 2 PA, MO (Mail Order) juleber tab 0.15-30 mg-mcg 1 MO (Mail Order) junel 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) junel 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) junel fe 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) junel fe 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) junel fe 24 tab 1-20 mg-mcg(24) 1 MO (Mail Order) kaitlib fe chew tab 0.8-25 mg-mcg 1 MO (Mail Order) kariva tab 0.15-0.02/0.01 mg (21/5) 1 MO (Mail Order) kelnor 1/35 tab 1-35 mg-mcg 1 MO (Mail Order) kimidess tab 0.15-0.02/0.01 mg (21/5) 1 MO (Mail Order) larin 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) larin 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) larin fe 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) larin fe 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) layolis fe chew tab 0.8-25 mg-mcg 1 MO (Mail Order) leena tab 0.5/1/0.5-35 mg-mcg 1 MO (Mail Order) lessina tab 0.1-20 mg-mcg 1 MO (Mail Order) levonest tab 1 MO (Mail Order) levonorg-eth estrad triphasic tab 1 MO (Mail Order) levonorgest-eth estrad 91-day (tab 0.15-0.03 &0.01 mg, tab 0.15-0.03 mg) 1 MO (Mail Order) levonorgestrel-ethinyl estrad (tab 0.1-20 mgmcg, tab 90-20 mcg) 1 MO (Mail Order) levora 0.15/30 (28) tab 0.15-30 mg-mcg 1 MO (Mail Order) LO LOESTRIN FE TAB 1 MG-10 MCG / 10 MCG 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 105 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL lomedia 24 fe tab 1-20 mg-mcg(24) 1 MO (Mail Order) lopreeza (tab 0.5-0.1 mg, tab 1-0.5 mg) 2 PA, MO (Mail Order) loryna tab 3-0.02 mg 1 MO (Mail Order) lutera tab 0.1-20 mg-mcg 1 MO (Mail Order) marlissa tab 0.15-30 mg-mcg 1 MO (Mail Order) MENEST (TAB 0.3 MG, TAB 0.625 MG, TAB 1.25 MG, TAB 2.5 MG) 3 PA, MO (Mail Order) microgestin 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) microgestin 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) microgestin fe 1.5/30 tab 1.5-30 mg-mcg 1 MO (Mail Order) microgestin fe 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) mimvey lo tab 0.5-0.1 mg 2 PA, MO (Mail Order) mimvey tab 1-0.5 mg 2 PA, MO (Mail Order) MINASTRIN 24 FE CHEW TAB 1-20 MGMCG(24) 4 MO (Mail Order) mononessa tab 0.25-35 mg-mcg 1 MO (Mail Order) necon 0.5/35 (28) tab 0.5-35 mg-mcg 1 MO (Mail Order) necon 1/35 (28) tab 1-35 mg-mcg 1 MO (Mail Order) NECON 1/50 (28) TAB 1-50 MG-MCG 1 MO (Mail Order) NECON 10/11 (28) TAB 35 MCG 1 MO (Mail Order) necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg 1 MO (Mail Order) nikki tab 3-0.02 mg 1 MO (Mail Order) norethin ace-eth estrad-fe tab 1-20 mgmcg(24) 1 MO (Mail Order) norethin-eth estradiol-fe chew tab 0.8-25 mgmcg 1 MO (Mail Order) norethindrone-eth estradiol (tab 0.5-2.5, tab 1-5) 2 PA, MO (Mail Order) norgestim-eth estrad triphasic tab 0.18/0.215/0.25 mg-25 mcg 1 MO (Mail Order) nortrel 0.5/35 (28) tab 0.5-35 mg-mcg 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 106 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL nortrel 1/35 (21) tab 1-35 mg-mcg 1 MO (Mail Order) nortrel 1/35 (28) tab 1-35 mg-mcg 1 MO (Mail Order) nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg 1 MO (Mail Order) NUVARING RING 0.12-0.015 MG/24HR 3 MO (Mail Order) ocella tab 3-0.03 mg 1 MO (Mail Order) OGESTREL TAB 0.5-50 MG-MCG 1 MO (Mail Order) orsythia tab 0.1-20 mg-mcg 1 MO (Mail Order) ORTHO TRI-CYCLEN LO TAB 0.18/0.215/0.25 MG-25 MCG 4 MO (Mail Order) pimtrea tab 0.15-0.02/0.01 mg (21/5) 1 MO (Mail Order) pirmella 1/35 tab 1-35 mg-mcg 1 MO (Mail Order) portia-28 tab 0.15-30 mg-mcg 1 MO (Mail Order) PREFEST TAB 1/1-0.09 MG (15/15) 4 PA, MO (Mail Order) PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG, TAB 0.9 MG, TAB 1.25 MG) 3 PA, MO (Mail Order) PREMARIN CREAM 0.625 MG/GM 3 MO (Mail Order) PREMPHASE TAB 0.625-5 MG 3 PA, MO (Mail Order) PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB 0.625-5 MG, TAB 0.625-2.5 MG) 3 PA, MO (Mail Order) previfem tab 0.25-35 mg-mcg 1 MO (Mail Order) quasense tab 0.15-0.03 mg 1 MO (Mail Order) reclipsen tab 0.15-30 mg-mcg 1 MO (Mail Order) setlakin tab 0.15-0.03 mg 1 MO (Mail Order) sprintec 28 tab 0.25-35 mg-mcg 1 MO (Mail Order) sronyx tab 0.1-20 mg-mcg 1 MO (Mail Order) tarina fe 1/20 tab 1-20 mg-mcg 1 MO (Mail Order) tri-legest fe tab 1-20/1-30/1-35 mg-mcg 1 MO (Mail Order) tri-lo-estarylla tab 0.18/0.215/0.25 mg-25 mcg 1 MO (Mail Order) tri-lo-sprintec tab 0.18/0.215/0.25 mg-25 mcg 1 MO (Mail Order) tri-previfem tab 0.18/0.215/0.25 mg-35 mcg 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 107 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg 1 MO (Mail Order) trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg 1 MO (Mail Order) trinessa lo tab 0.18/0.215/0.25 mg-25 mcg 1 MO (Mail Order) trivora (28) tab 1 MO (Mail Order) velivet tab 0.1/0.125/0.15 -0.025 mg 1 MO (Mail Order) vestura tab 3-0.02 mg 1 MO (Mail Order) vienva tab 0.1-20 mg-mcg 1 MO (Mail Order) VIVELLE-DOT (PATCH 0.025 MG/24HR, PATCH 0.0375 MG/24HR, PATCH 0.05 MG/24HR, PATCH 0.075 MG/24HR, PATCH 0.1 MG/24HR) 3 PA, MO (Mail Order) vyfemla tab 0.4-35 mg-mcg 1 MO (Mail Order) wymzya fe chew tab 0.4-35 mg-mcg 1 MO (Mail Order) XULANE PATCH WK 150-35 MCG/24HR 2 MO (Mail Order) zenchent (tab 0.4-35, 0.4-35) 1 MO (Mail Order) zenchent fe chew tab 0.4-35 mg-mcg 1 MO (Mail Order) zovia 1/35e (28) tab 1-35 mg-mcg 1 MO (Mail Order) ZOVIA 1/50E (28) TAB 1-50 MG-MCG 1 MO (Mail Order) camila tab 0.35 mg 1 MO (Mail Order) CRINONE (GEL 4 %, GEL 8 %) 4 MO (Mail Order) deblitane tab 0.35 mg 1 MO (Mail Order) DEPO-PROVERA SUSPENSION 400 MG/ML 4 MO (Mail Order) DEPO-SUBQ PROVERA 104 SUSPENSION 104 MG/0.65ML 4 MO (Mail Order) errin tab 0.35 mg 1 MO (Mail Order) jolivette tab 0.35 mg 1 MO (Mail Order) lyza tab 0.35 mg 1 MO (Mail Order) MAKENA OIL 250 MG/ML 5 PA, MO (Mail Order) medroxyprogesterone acetate (suspension 150 mg/ml, tab 2.5 mg, tab 5 mg, tab 10 mg) 1 MO (Mail Order) Progestins Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 108 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL MEGACE ES SUSPENSION 625 MG/5ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) megestrol acetate (suspension 40 mg/ml, suspension 400 mg/10ml, tab 20 mg, tab 40 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) megestrol acetate suspension 625 mg/5ml 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) nora-be tab 0.35 mg 1 MO (Mail Order) norethindrone acetate tab 5 mg 2 MO (Mail Order) norethindrone tab 0.35 mg 1 MO (Mail Order) norlyroc tab 0.35 mg 1 MO (Mail Order) progesterone micronized (cap 100 mg, cap 200 mg) 2 MO (Mail Order) sharobel tab 0.35 mg 1 MO (Mail Order) Selective Estrogen Receptor Modifying Agents DUAVEE TAB 0.45-20 MG 3 PA, MO (Mail Order) raloxifene hcl tab 60 mg 3 QL (30 PER 30 DAYS), MO (Mail Order) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300 mcg) 2 MO (Mail Order) levothyroxine sodium recon soln 100 mcg 5 MO (Mail Order) levothyroxine sodium tab 25 mcg 1 MO (Mail Order) levoxyl (tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg) 2 MO (Mail Order) levoxyl tab 25 mcg 1 MO (Mail Order) liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg) 2 MO (Mail Order) liothyronine sodium solution 10 mcg/ml 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 109 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SYNTHROID (TAB 25 MCG, TAB 50 MCG, TAB 75 MCG, TAB 88 MCG, TAB 100 MCG, TAB 112 MCG, TAB 125 MCG, TAB 137 MCG, TAB 150 MCG, TAB 175 MCG, TAB 200 MCG, TAB 300 MCG) 3 MO (Mail Order) THYROLAR-1 TAB 60 (12.5-50) MG (MCG) 4 MO (Mail Order) THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG) 4 MO (Mail Order) THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG) 4 MO (Mail Order) THYROLAR-2 TAB 120 (25-100) MG (MCG) 4 MO (Mail Order) THYROLAR-3 TAB 180 (37.5-150) MG (MCG) 4 MO (Mail Order) unithroid (tab 25 mcg, tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300 mcg) 2 MO (Mail Order) Hormonal Agents, Suppressant (Adrenal) LYSODREN TAB 500 MG MO (Mail Order) 5 Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TAB 30 MG 3 QL (60 PER 30 DAYS), MO (Mail Order) SENSIPAR TAB 60 MG 5 QL (60 PER 30 DAYS), MO (Mail Order) SENSIPAR TAB 90 MG 5 QL (120 PER 30 DAYS), MO (Mail Order) cabergoline (tab 0.5 mg, 0.5 mg) 2 MO (Mail Order) EGRIFTA (SOLN 1 MG, SOLN 2 MG) 5 PA, MO (Mail Order) ELIGARD (7.5 MG, 22.5 MG, 30 MG, 45 MG) 4 PA, MO (Mail Order) FIRMAGON RECON SOLN 120 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) FIRMAGON RECON SOLN 80 MG 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) Hormonal Agents, Suppressant (Pituitary) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 110 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL leuprolide acetate kit 1 mg/0.2ml 4 PA, MO (Mail Order) LUPANETA PACK (3.755MG, 11.255MG) 5 PA, MO (Mail Order) LUPRON DEPOT (3.75 MG, 7.5 MG, 11.25 MG, 22.5 MG, 30 MG, 45 MG) 4 PA, MO (Mail Order) LUPRON DEPOT-PED (11.25 MG, 15 MG) 4 PA, MO (Mail Order) octreotide acetate (50 mcg/ml, 100 mcg/ml, 200 mcg/ml, 1000 mcg/5ml) 4 PA, MO (Mail Order) octreotide acetate (500 mcg/ml, 1000 mcg/ml) 5 PA, MO (Mail Order) SANDOSTATIN LAR DEPOT (10 MG, 20 MG, 30 MG) 5 PA, MO (Mail Order) SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) 5 PA, MO (Mail Order) SOMATULINE DEPOT (SOLUTION 60 MG/0.2ML, SOLUTION 90 MG/0.3ML, SOLUTION 120 MG/0.5ML, 120 MG/0.5ML) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) SOMAVERT (SOLN 10 MG, SOLN 15 MG, SOLN 20 MG, SOLN 25 MG, SOLN 30 MG) 5 PA, MO (Mail Order) SYNAREL SOLUTION 2 MG/ML 5 MO (Mail Order) TRELSTAR (3.75 MG, 11.25 MG) 5 PA, MO (Mail Order) TRELSTAR DEPOT MIXJECT RECON SUSP 3.75 MG 5 PA, MO (Mail Order) TRELSTAR LA MIXJECT RECON SUSP 11.25 MG 5 PA, MO (Mail Order) TRELSTAR MIXJECT RECON SUSP 22.5 MG 5 PA, MO (Mail Order) methimazole (tab 5 mg, 10 mg, tab 10 mg) 1 MO (Mail Order) propylthiouracil tab 50 mg 2 MO (Mail Order) Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 111 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Immunological Agents Angioedema (HAE) Agents BERINERT KIT 500 UNIT 5 PA, LA, MO (Mail Order) CINRYZE RECON SOLN 500 UNIT 5 PA, LA, MO (Mail Order) FIRAZYR SOLUTION 30 MG/3ML 5 PA, MO (Mail Order) RUCONEST RECON SOLN 2100 UNIT 5 PA, MO (Mail Order) AZASAN (TAB 75 MG, TAB 100 MG) 3 PA - Part B vs D Determination, MO (Mail Order) azathioprine tab 50 mg 2 PA - Part B vs D Determination, MO (Mail Order) CELLCEPT INTRAVENOUS RECON SOLN 500 MG 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) CELLCEPT RECON SUSP 200 MG/ML 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) CIMZIA KIT 2 X 200 MG 5 PA, MO (Mail Order) CIMZIA PREFILLED KIT 2 X 200 MG/ML 5 PA, MO (Mail Order) CIMZIA STARTER KIT KIT 6 X 200 MG/ML 5 PA, MO (Mail Order) cyclosporine (cap 25 mg, 100 mg, cap 100 mg) 4 PA - Part B vs D Determination, MO (Mail Order) cyclosporine modified (cap 100 mg, solution 100 mg/ml) 4 PA - Part B vs D Determination, MO (Mail Order) cyclosporine modified (cap 25 mg, cap 50 mg) 2 PA - Part B vs D Determination, MO (Mail Order) cyclosporine solution 50 mg/ml 4 MO (Mail Order) ENBREL (SOLN 25 MG/0.5ML, SOLN 50 MG/ML) 5 PA, QL (7.84 PER 28 DAYS), MO (Mail Order) ENBREL RECON SOLN 25 MG 5 PA, QL (8 PER 28 DAYS), MO (Mail Order) ENBREL SURECLICK SOLN A-INJ 50 MG/ML 5 PA, QL (7.84 PER 28 DAYS), MO (Mail Order) gengraf (cap 25 mg, cap 100 mg, solution 100 mg/ml) 4 PA - Part B vs D Determination, MO (Mail Order) Immune Suppressants Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 112 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL HUMIRA (10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML) 5 PA, QL (2 PER 28 DAYS), MO (Mail Order) HUMIRA PEDIATRIC CROHNS START PREF SY KT 40 MG/0.8ML 5 PA, QL (3 PER 28 DAYS), MO (Mail Order) HUMIRA PEN PEN KIT 40 MG/0.8ML 5 PA, QL (2 PER 28 DAYS), MO (Mail Order) HUMIRA PEN-CROHNS STARTER PEN KIT 40 MG/0.8ML 5 PA, QL (6 PER 28 DAYS), MO (Mail Order) HUMIRA PEN-PSORIASIS STARTER PEN KIT 40 MG/0.8ML 5 PA, QL (2 PER 28 DAYS), MO (Mail Order) KINERET SOLN PRSYR 100 MG/0.67ML 5 PA, QL (20.1 PER 30 DAYS), MO (Mail Order) methotrexate sodium (pf) ((pf) 1 gm/40ml, (pf) 50 mg/2ml, (pf) 250 mg/10ml) 1 MO (Mail Order) methotrexate sodium recon soln 1 gm 2 MO (Mail Order) methotrexate tab 2.5 mg 2 MO (Mail Order) mycophenolate mofetil (cap 250 mg, tab 500 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) mycophenolate mofetil recon susp 200 mg/ml 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) mycophenolic acid (tab dr 180 mg, tab dr 360 mg) 4 PA - Part B vs D Determination, MO (Mail Order) NULOJIX RECON SOLN 250 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) ORENCIA RECON SOLN 250 MG 5 PA, QL (80 PER 28 DAYS), MO (Mail Order) ORENCIA SOLN PRSYR 125 MG/ML 5 PA, QL (4 PER 28 DAYS), MO (Mail Order) PROGRAF CAP 5 MG 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) PROGRAF SOLUTION 5 MG/ML 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) RAPAMUNE (SOLUTION 1 MG/ML, TAB 1 MG, TAB 2 MG) 5 PA - Part B vs D Determination, MO (Mail Order) REMICADE RECON SOLN 100 MG 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 113 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL RHEUMATREX TAB 2.5 MG 4 MO (Mail Order) SANDIMMUNE CAP 100 MG 5 PA - Part B vs D Determination, MO (Mail Order) SANDIMMUNE SOLUTION 100 MG/ML 4 PA - Part B vs D Determination, MO (Mail Order) sirolimus (tab 1 mg, tab 2 mg) 5 PA - Part B vs D Determination, MO (Mail Order) sirolimus tab 0.5 mg 4 PA - Part B vs D Determination, MO (Mail Order) tacrolimus (cap 0.5 mg, cap 1 mg) 2 PA - FOR NEW STARTS ONLY, MO (Mail Order) tacrolimus cap 5 mg 4 PA - FOR NEW STARTS ONLY, MO (Mail Order) TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15 MG) 4 MO (Mail Order) XELJANZ TAB 5 MG 5 PA, MO (Mail Order) XELJANZ XR TAB ER 24H 11 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) ZORTRESS TAB 0.25 MG 4 ZORTRESS TAB 0.5 MG 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) ZORTRESS TAB 0.75 MG 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) PA - FOR NEW STARTS ONLY, MO (Mail Order) Immunizing Agents, Passive ATGAM INJECTABLE 50 MG/ML 5 MO (Mail Order) BIVIGAM (5 GM/50ML, 10 GM/100ML) 5 PA, MO (Mail Order) CARIMUNE NF (SOLN 3 GM, SOLN 6 GM, SOLN 12 GM) 5 PA, MO (Mail Order) FLEBOGAMMA DIF (5 GM/50ML, 10 GM/100ML, 20 GM/200ML) 5 PA, MO (Mail Order) GAMASTAN S/D INJECTABLE 3 PA, MO (Mail Order) GAMMAGARD (1 GM/10ML, 2.5 GM/25ML, 5 GM/50ML, 10 GM/100ML, 20 GM/200ML, 30 GM/300ML) 5 PA, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 114 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL GAMMAGARD S/D (S/D SOLN 0.5 GM, S/D SOLN 2.5 GM, S/D SOLN 5 GM, S/D SOLN 10 GM) 5 PA, MO (Mail Order) GAMMAGARD S/D LESS IGA (S/D SOLN 5 GM, S/D SOLN 10 GM) 5 PA, MO (Mail Order) GAMMAKED (1 GM/10ML, 2.5 GM/25ML, 5 GM/50ML, 10 GM/100ML, 20 GM/200ML) 5 PA, MO (Mail Order) GAMMAPLEX (2.5 GM/50ML, 5 GM/100ML, 10 GM/200ML, 20 GM/400ML) 5 PA, MO (Mail Order) GAMUNEX (1 GM/10ML, 2.5 GM/25ML, 5 GM/50ML, 10 GM/100ML, 20 GM/200ML) 5 PA, MO (Mail Order) GAMUNEX-C (1 GM/10ML, 2.5 GM/25ML, 5 GM/50ML, 10 GM/100ML, 20 GM/200ML, 40 GM/400ML) 5 PA, MO (Mail Order) OCTAGAM (1 GM/20ML, 2 GM/20ML, 2.5 GM/50ML, 5 GM/50ML, 5 GM/100ML, 10 GM/200ML, 10 GM/100ML, 20 GM/200ML, 25 GM/500ML) 5 PA, MO (Mail Order) PRIVIGEN (5 GM/50ML, 10 GM/100ML, 20 GM/200ML, 40 GM/400ML) 5 PA, MO (Mail Order) THYMOGLOBULIN RECON SOLN 25 MG 5 MO (Mail Order) 5 PA, MO (Mail Order) 5 MO (Mail Order) ARCALYST RECON SOLN 220 MG 5 PA, LA, MO (Mail Order) BENLYSTA (SOLN 120 MG, SOLN 400 MG) 5 PA, MO (Mail Order) ILARIS RECON SOLN 180 MG 5 PA, LA, MO (Mail Order) leflunomide (tab 10 mg, 10 mg, 20 mg, tab 20 mg) 2 MO (Mail Order) OTEZLA (TAB 30 MG, TAB THPK 10 & 20 & 30 MG, 30 MG) 5 PA, MO (Mail Order) RIDAURA CAP 3 MG 5 MO (Mail Order) SIMULECT RECON SOLN 20 MG 5 MO (Mail Order) Immunomodulators ACTEMRA (SOLN PRSYR 162 MG/0.9ML, SOLUTION 80 MG/4ML, SOLUTION 200 MG/10ML, SOLUTION 400 MG/20ML) ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 115 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL SYLATRON (4 X 200 MCG, 4 X 300 MCG, 4 X 600 MCG, 200 MCG, 300 MCG, 600 MCG) 5 PA - FOR NEW STARTS ONLY, MO (Mail Order) SYNAGIS SOLUTION 50 MG/0.5ML 5 MO (Mail Order) ACTHIB RECON SOLN 3 MO (Mail Order) ADACEL SUSPENSION 5-2-15.5 LFMCG/0.5 3 MO (Mail Order) BEXSERO SUSP PRSYR 3 MO (Mail Order) BOOSTRIX (5-2.5-18.5, SUSPENSION 5-2.518.5) 3 MO (Mail Order) CERVARIX SUSPENSION 3 MO (Mail Order) DAPTACEL SUSPENSION 10-15-5 3 MO (Mail Order) diphtheria-tetanus toxoids dt suspension 25-5 lfu/0.5ml 2 MO (Mail Order) ENGERIX-B (SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML, SUSPENSION 20 MCG/ML, 20 MCG/ML) 3 PA - Part B vs D Determination, MO (Mail Order) Vaccines GARDASIL 9 (9 SUSP PRSYR, 9 SUSPENSION) 3 MO (Mail Order) GARDASIL SUSPENSION 3 MO (Mail Order) HAVRIX (SUSPENSION 720 U/0.5ML, 720 U/0.5ML, 1440 U/ML, SUSPENSION 1440 U/ML) 3 MO (Mail Order) IMOVAX RABIES INJECTABLE 2.5 UNIT/ML 4 PA - Part B vs D Determination, MO (Mail Order) INFANRIX (25-58-10, SUSPENSION 25-5810) 3 MO (Mail Order) IPOL INJECTABLE 3 MO (Mail Order) IXIARO SUSPENSION 3 MO (Mail Order) M-M-R II INJECTABLE 3 MO (Mail Order) MENACTRA INJECTABLE 3 MO (Mail Order) MENOMUNE INJECTABLE 3 MO (Mail Order) MENVEO RECON SOLN 3 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 116 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PEDVAX HIB SUSPENSION 7.5 MCG/0.5ML 3 MO (Mail Order) PROQUAD INJECTABLE 3 MO (Mail Order) QUADRACEL SUSPENSION 3 MO (Mail Order) RABAVERT RECON SUSP 4 PA - Part B vs D Determination, MO (Mail Order) RECOMBIVAX HB (5 MCG/0.5ML, 10 MCG/ML, 40 MCG/ML) 3 PA - Part B vs D Determination, MO (Mail Order) ROTARIX RECON SUSP 3 MO (Mail Order) ROTATEQ SOLUTION 3 MO (Mail Order) TENIVAC INJECTABLE 5-2 LFU 3 MO (Mail Order) tetanus-diphtheria toxoids td suspension 2-2 lf/0.5ml 2 MO (Mail Order) TRUMENBA SUSP PRSYR 3 MO (Mail Order) TWINRIX SUSPENSION 720-20 3 MO (Mail Order) TYPHIM VI SOLUTION 25 MCG/0.5ML 3 MO (Mail Order) VAQTA (25 UNIT/0.5ML, 50 UNIT/ML) 3 MO (Mail Order) VARIVAX INJECTABLE 1350 PFU/0.5ML 3 MO (Mail Order) VARIZIG (RECON SOLN 125 UNIT, SOLUTION 125 UNIT/1.2ML) 5 MO (Mail Order) YF-VAX INJECTABLE 3 MO (Mail Order) ZOSTAVAX RECON SOLN 19400 UNT/0.65ML 3 MO (Mail Order) APRISO CAP ER 24H 0.375 GM 3 MO (Mail Order) balsalazide disodium (cap 750 mg, 750 mg) 2 MO (Mail Order) CANASA SUPPOS 1000 MG 5 MO (Mail Order) DIPENTUM CAP 250 MG 5 MO (Mail Order) LIALDA TAB DR 1.2 GM 3 MO (Mail Order) mesalamine enema 4 gm 4 MO (Mail Order) Inflammatory Bowel Disease Agents Aminosalicylates Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 117 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL mesalamine-cleanser kit 4 gm 4 MO (Mail Order) PENTASA CAP ER 250 MG 4 MO (Mail Order) PENTASA CAP ER 500 MG 5 MO (Mail Order) budesonide cp dr part 3 mg 4 MO (Mail Order) colocort enema 100 mg/60ml 2 MO (Mail Order) hydrocortisone enema 100 mg/60ml 2 MO (Mail Order) procto-pak cream 1 % 2 MO (Mail Order) proctosol hc cream 2.5 % 2 MO (Mail Order) proctozone-hc cream 2.5 % 2 MO (Mail Order) UCERIS TAB ER 24H 9 MG 5 ST, MO (Mail Order) 2 MO (Mail Order) alendronate sodium (35 mg, tab 35 mg, 70 mg, tab 70 mg) 1 QL (4 PER 28 DAYS), MO (Mail Order) alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg) 1 QL (30 PER 30 DAYS), MO (Mail Order) alendronate sodium solution 70 mg/75ml 2 QL (300 PER 28 DAYS), MO (Mail Order) ATELVIA TAB DR 35 MG 4 QL (4 PER 28 DAYS), MO (Mail Order) BINOSTO EFFER TAB 70 MG 4 QL (4 PER 28 DAYS), MO (Mail Order) calcitonin (salmon) solution 200 unit/act 2 MO (Mail Order) calcitriol (cap 0.5 mcg, solution 1 mcg/ml) 2 PA - Part B vs D Determination, MO (Mail Order) calcitriol cap 0.25 mcg 1 PA - Part B vs D Determination, MO (Mail Order) calcitriol solution 1 mcg/ml 4 PA - Part B vs D Determination, MO (Mail Order) Glucocorticoids Sulfonamides sulfasalazine (tab 500 mg, tab dr 500 mg) Metabolic Bone Disease Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 118 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL doxercalciferol (cap 0.5 mcg, cap 2.5 mcg) 4 PA - Part B vs D Determination, MO (Mail Order) doxercalciferol cap 1 mcg 5 PA - Part B vs D Determination, MO (Mail Order) doxercalciferol solution 4 mcg/2ml 2 PA - Part B vs D Determination, MO (Mail Order) etidronate disodium (tab 200 mg, tab 400 mg) 2 MO (Mail Order) FORTEO SOLUTION 600 MCG/2.4ML 5 PA, MO (Mail Order) ibandronate sodium tab 150 mg 2 QL (1 PER 28 DAYS), MO (Mail Order) MIACALCIN SOLUTION 200 UNIT/ML 5 PA, MO (Mail Order) pamidronate disodium (30 mg/10ml, recon soln 30 mg, recon soln 90 mg, solution 30 mg/10ml, 90 mg/10ml, solution 90 mg/10ml) 2 PA - Part B vs D Determination, MO (Mail Order) pamidronate disodium solution 6 mg/ml 3 MO (Mail Order) paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg) 4 PA - Part B vs D Determination, MO (Mail Order) PROLIA SOLUTION 60 MG/ML 4 PA, MO (Mail Order) RECLAST SOLUTION 5 MG/100ML 4 MO (Mail Order) risedronate sodium (tab 35 mg, tab dr 35 mg) 4 QL (4 PER 28 DAYS), MO (Mail Order) risedronate sodium (tab 5 mg, tab 30 mg) 4 QL (30 PER 30 DAYS), MO (Mail Order) risedronate sodium tab 150 mg 4 QL (1 PER 28 DAYS), MO (Mail Order) XGEVA SOLUTION 120 MG/1.7ML 5 PA, MO (Mail Order) zoledronic acid conc 4 mg/5ml 4 PA - Part B vs D Determination, MO (Mail Order) zoledronic acid solution 5 mg/100ml 4 MO (Mail Order) argyle sterile water solution 2 MO (Mail Order) BOTOX (SOLN 100, SOLN 200) 4 PA, MO (Mail Order) GAUZE PADS & DRESSINGS - PADS 2 X 2 3 MO (Mail Order) Miscellaneous Therapeutic Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 119 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL INSULIN PEN NEEDLE 3 INSULIN PEN NEEDLE 3 INSULIN SYRINGE (DISP) U-100 0.3 ML 3 INSULIN SYRINGE (DISP) U-100 0.3 ML 3 INSULIN SYRINGE (DISP) U-100 1 ML 3 INSULIN SYRINGE (DISP) U-100 1 ML 3 INSULIN SYRINGE (DISP) U-100 1/2 ML 3 INSULIN SYRINGE (DISP) U-100 1/2 ML 3 ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD 3 isopropyl alcohol 0.7 ml/ml medicated pad 3 KANUMA SOLUTION 20 MG/10ML 5 PA lactated ringers solution 2 MO (Mail Order) methylergonovine maleate tab 0.2 mg 5 MO (Mail Order) NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG) 5 PA, MO (Mail Order) NEEDLES, INSULIN DISP., SAFETY 3 MO (Mail Order) physiolyte solution 4 MO (Mail Order) physiosol irrigation solution 4 MO (Mail Order) RECTIV OINTMENT 0.4 % 4 MO (Mail Order) ringers irrigation solution 1 MO (Mail Order) sodium chloride solution 0.9 % 1 MO (Mail Order) sterile water for irrigation solution 2 MO (Mail Order) ak-poly-bac ointment 500-10000 unit/gm 2 MO (Mail Order) bacitra-neomycin-polymyxin-hc ointment 1 % 2 MO (Mail Order) bacitracin-polymyxin b ointment 500-10000 unit/gm 2 MO (Mail Order) MO (Mail Order) MO (Mail Order) MO (Mail Order) MO (Mail Order) MO (Mail Order) Ophthalmic Agents Ophthalmic Agents, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 120 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % 3 MO (Mail Order) BLEPHAMIDE SUSPENSION 10-0.2 % 3 MO (Mail Order) CYSTARAN SOLUTION 0.44 % 5 MO (Mail Order) LACRISERT INSERT 5 MG 4 MO (Mail Order) naphazoline hcl solution 0.1 % 1 MO (Mail Order) neomycin-bacitracin zn-polymyx ointment 5400-10000 2 MO (Mail Order) neomycin-polymyxin-dexameth (ointment 3.510000-0.1, suspension 3.5-10000-0.1) 2 MO (Mail Order) neomycin-polymyxin-gramicidin solution 1.7510000-.025 2 MO (Mail Order) neomycin-polymyxin-hc suspension 3.510000-1 2 MO (Mail Order) polymyxin b-trimethoprim solution 10000-0.1 unit/ml-% 1 MO (Mail Order) PRED-G S.O.P. OINTMENT 0.3-0.6 % 3 MO (Mail Order) PRED-G SUSPENSION 0.3-1 % 4 MO (Mail Order) proparacaine hcl solution 0.5 % 1 MO (Mail Order) RESTASIS EMULSION 0.05 % 3 QL (60 PER 30 DAYS), MO (Mail Order) sulfacetamide-prednisolone solution 10-0.23 % 2 MO (Mail Order) TOBRADEX ST SUSPENSION 0.3-0.05 % 4 MO (Mail Order) tobramycin-dexamethasone suspension 0.30.1 % 2 MO (Mail Order) ZYLET SUSPENSION 0.5-0.3 % 4 MO (Mail Order) ALOCRIL SOLUTION 2 % 4 MO (Mail Order) ALOMIDE SOLUTION 0.1 % 4 MO (Mail Order) azelastine hcl solution 0.05 % 2 MO (Mail Order) BEPREVE SOLUTION 1.5 % 4 MO (Mail Order) cromolyn sodium solution 4 % 1 MO (Mail Order) Ophthalmic Anti-allergy Agents Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 121 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL EMADINE SOLUTION 0.05 % 4 MO (Mail Order) epinastine hcl solution 0.05 % 2 MO (Mail Order) LASTACAFT SOLUTION 0.25 % 3 MO (Mail Order) olopatadine hcl solution 0.1 % 3 MO (Mail Order) PATADAY SOLUTION 0.2 % 3 MO (Mail Order) PATANOL SOLUTION 0.1 % 3 MO (Mail Order) PAZEO SOLUTION 0.7 % 3 MO (Mail Order) ACUVAIL SOLUTION 0.45 % 4 MO (Mail Order) ALREX SUSPENSION 0.2 % 3 MO (Mail Order) bromfenac sodium (once-daily) solution 0.09 % 4 MO (Mail Order) bromfenac sodium solution 0.09 % 4 MO (Mail Order) dexamethasone sodium phosphate solution 0.1 % 2 MO (Mail Order) diclofenac sodium solution 0.1 % 1 MO (Mail Order) DUREZOL EMULSION 0.05 % 3 MO (Mail Order) FLAREX SUSPENSION 0.1 % 3 MO (Mail Order) flurbiprofen sodium solution 0.03 % 1 MO (Mail Order) FML FORTE SUSPENSION 0.25 % 3 MO (Mail Order) FML OINTMENT 0.1 % 3 MO (Mail Order) ILEVRO SUSPENSION 0.3 % 3 MO (Mail Order) ketorolac tromethamine (0.4 %, 0.5 %) 2 MO (Mail Order) LOTEMAX (GEL 0.5 %, OINTMENT 0.5 %, SUSPENSION 0.5 %) 4 MO (Mail Order) MAXIDEX SUSPENSION 0.1 % 3 MO (Mail Order) NEVANAC SUSPENSION 0.1 % 3 MO (Mail Order) PRED MILD SUSPENSION 0.12 % 3 MO (Mail Order) prednisolone acetate suspension 1 % 2 MO (Mail Order) prednisolone sodium phosphate solution 1 % 2 MO (Mail Order) Ophthalmic Anti-inflammatories Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 122 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL PROLENSA SOLUTION 0.07 % 4 MO (Mail Order) VEXOL SUSPENSION 1 % 3 MO (Mail Order) ALPHAGAN P SOLUTION 0.1 % 3 MO (Mail Order) apraclonidine hcl solution 0.5 % 2 MO (Mail Order) AZOPT SUSPENSION 1 % 3 MO (Mail Order) betaxolol hcl solution 0.5 % 2 MO (Mail Order) BETIMOL (0.25 %, 0.5 %) 4 MO (Mail Order) brimonidine tartrate solution 0.15 % 2 MO (Mail Order) brimonidine tartrate solution 0.2 % 1 MO (Mail Order) carteolol hcl solution 1 % 1 MO (Mail Order) COMBIGAN SOLUTION 0.2-0.5 % 3 MO (Mail Order) dorzolamide hcl solution 2 % 2 MO (Mail Order) dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml 2 MO (Mail Order) IOPIDINE SOLUTION 1 % 4 MO (Mail Order) levobunolol hcl solution 0.5 % 2 MO (Mail Order) methazolamide (25 mg, tab 25 mg, tab 50 mg, 50 mg) 4 MO (Mail Order) metipranolol solution 0.3 % 2 MO (Mail Order) PHOSPHOLINE IODIDE RECON SOLN 0.125 % 3 MO (Mail Order) pilocarpine hcl (solution 1 %, 1 %, solution 2 %, 2 %, solution 4 %, 4 %) 2 MO (Mail Order) SIMBRINZA SUSPENSION 1-0.2 % 4 MO (Mail Order) timolol maleate (0.25 %, 0.5 %) 1 MO (Mail Order) timolol maleate (gel soln 0.25 %, gel soln 0.5 %) 2 MO (Mail Order) Ophthalmic Antiglaucoma Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost solution 0.03 % 3 MO (Mail Order) latanoprost solution 0.005 % 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 123 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL LUMIGAN SOLUTION 0.01 % 3 MO (Mail Order) TRAVATAN Z SOLUTION 0.004 % 3 MO (Mail Order) travoprost solution 0.004 % 2 MO (Mail Order) acetic acid solution 2 % 2 MO (Mail Order) CIPRO HC SUSPENSION 0.2-1 % 3 MO (Mail Order) CIPRODEX SUSPENSION 0.3-0.1 % 3 MO (Mail Order) CORTISPORIN-TC SUSPENSION 3.3-3-100.5 MG/ML 4 MO (Mail Order) fluocinolone acetonide oil 0.01 % 4 MO (Mail Order) hydrocortisone-acetic acid solution 1-2 % 2 MO (Mail Order) neomycin-polymyxin-hc (solution 1 %, solution 3.5-10000-1, suspension 3.5-100001) 2 MO (Mail Order) ofloxacin solution 0.3 % 2 MO (Mail Order) Otic Agents Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids AEROSPAN AERO SOLN 80 MCG/ACT 4 ST, QL (17.8 PER 30 DAYS), MO (Mail Order) ASMANEX 120 METERED DOSES AER POW BA 220 MCG/INH 4 MO (Mail Order) ASMANEX 30 METERED DOSES (30 110 MCG/INH, 30 220 MCG/INH) 4 MO (Mail Order) ASMANEX 60 METERED DOSES AER POW BA 220 MCG/INH 4 MO (Mail Order) ASMANEX HFA (100 MCG/ACT, 200 MCG/ACT) 4 MO (Mail Order) BECONASE AQ SUSPENSION 42 MCG/SPRAY 4 QL (50 PER 30 DAYS), MO (Mail Order) budesonide (0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml) 4 PA - Part B vs D Determination, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 124 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL budesonide suspension 32 mcg/act 4 QL (17.2 PER 30 DAYS), MO (Mail Order) FLOVENT DISKUS (50 MCG/BLIST, 100 MCG/BLIST, 250 MCG/BLIST) 3 QL (120 PER 30 DAYS), MO (Mail Order) FLOVENT HFA (110 MCG/ACT, 220 MCG/ACT) 3 QL (24 PER 30 DAYS), MO (Mail Order) FLOVENT HFA AEROSOL 44 MCG/ACT 3 QL (21.2 PER 30 DAYS), MO (Mail Order) flunisolide solution 25 mcg/act (0.025%) 2 MO (Mail Order) fluticasone propionate suspension 50 mcg/act 1 QL (16 PER 30 DAYS), MO (Mail Order) mometasone furoate suspension 50 mcg/act 4 QL (34 PER 30 DAYS), MO (Mail Order) NASONEX SUSPENSION 50 MCG/ACT 4 QL (34 PER 30 DAYS), MO (Mail Order) PULMICORT SUSPENSION 1 MG/2ML 5 PA - Part B vs D Determination, MO (Mail Order) QVAR AERO SOLN 40 MCG/ACT 3 QL (17.4 PER 30 DAYS), MO (Mail Order) QVAR AERO SOLN 80 MCG/ACT 3 QL (26.1 PER 30 DAYS), MO (Mail Order) ASTEPRO SOLUTION 0.15 % 3 QL (60 PER 30 DAYS), MO (Mail Order) azelastine hcl (0.1 %, 0.15 %, 137 mcg/spray) 2 QL (60 PER 30 DAYS), MO (Mail Order) cetirizine hcl (solution 1 mg/ml, 1 mg/ml, syrup 1 mg/ml, syrup 5 mg/5ml) 1 MO (Mail Order) clemastine fumarate tab 2.68 mg 2 PA, MO (Mail Order) cyproheptadine hcl (syrup 2 mg/5ml, 4 mg, tab 4 mg) 2 PA, MO (Mail Order) desloratadine tab 5 mg 2 MO (Mail Order) diphenhydramine hcl (50 mg/ml, solution 50 mg/ml) 2 PA - Part B vs D Determination, MO (Mail Order) diphenhydramine hcl elixir 12.5 mg/5ml 1 PA, MO (Mail Order) Antihistamines Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 125 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL kls aller-tec childrens solution 1 mg/ml 0 levocetirizine dihydrochloride solution 2.5 mg/5ml 2 QL (300 PER 30 DAYS), MO (Mail Order) levocetirizine dihydrochloride tab 5 mg 2 QL (30 PER 30 DAYS), MO (Mail Order) olopatadine hcl solution 0.6 % 4 QL (30.5 PER 30 DAYS), MO (Mail Order) PATANASE SOLUTION 0.6 % 3 QL (30.5 PER 30 DAYS), MO (Mail Order) phenadoz suppos 12.5 mg 4 PA, MO (Mail Order) phenergan (12.5 mg, 50 mg) 4 PA, MO (Mail Order) phenergan suppos 25 mg 2 PA, MO (Mail Order) promethazine hcl (12.5 mg, 25 mg) 4 PA, MO (Mail Order) promethazine hcl (solution 25 mg/ml, solution 50 mg/ml, tab 25 mg, 25 mg/ml, tab 50 mg, 50 mg/ml) 2 PA, MO (Mail Order) promethazine hcl (solution 6.25 mg/5ml, syrup 6.25 mg/5ml, tab 12.5 mg) 1 PA, MO (Mail Order) promethazine hcl suppos 50 mg 5 PA, MO (Mail Order) promethegan (25 mg, 50 mg) 4 PA, MO (Mail Order) montelukast sodium (tab 4 mg, tab 5 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) montelukast sodium packet 4 mg 4 QL (30 PER 30 DAYS), MO (Mail Order) montelukast sodium tab 10 mg 1 QL (30 PER 30 DAYS), MO (Mail Order) zafirlukast (tab 10 mg, tab 20 mg) 2 QL (60 PER 30 DAYS), MO (Mail Order) ZYFLO (600 MG, TAB 600 MG) 5 ST, QL (120 PER 30 DAYS), MO (Mail Order) ZYFLO CR (TAB ER 12H 600 MG, 600 MG) 5 ST, QL (120 PER 30 DAYS), MO (Mail Order) Antileukotrienes Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 126 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Bronchodilators, Anticholinergic ATROVENT HFA AERO SOLN 17 MCG/ACT 3 QL (25.8 PER 30 DAYS), MO (Mail Order) ipratropium bromide solution 0.02 % 2 PA - Part B vs D Determination, MO (Mail Order) ipratropium bromide solution 0.03 % 2 QL (30 PER 28 DAYS), MO (Mail Order) ipratropium bromide solution 0.06 % 2 QL (45 PER 30 DAYS), MO (Mail Order) SPIRIVA HANDIHALER CAP 18 MCG 3 QL (30 PER 30 DAYS), MO (Mail Order) SPIRIVA RESPIMAT (SOLN 1.25 MCG/ACT, SOLN 2.5 MCG/ACT) 3 QL (4 PER 30 DAYS), MO (Mail Order) ADRENALIN (1 MG/ML, 30 MG/30ML) 4 MO (Mail Order) albuterol sulfate (nebu soln 0.63 mg/3ml, nebu soln 1.25 mg/3ml, nebu soln (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, nebu soln (5 mg/ml) 0.5%) 2 PA - Part B vs D Determination, MO (Mail Order) albuterol sulfate (syrup 2 mg/5ml, 2 mg/5ml) 1 MO (Mail Order) albuterol sulfate (tab 2 mg, tab 4 mg) 4 MO (Mail Order) ARCAPTA NEOHALER CAP 75 MCG 4 QL (30 PER 30 DAYS), MO (Mail Order) BROVANA NEBU SOLN 15 MCG/2ML 4 PA - Part B vs D Determination, QL (120 PER 30 DAYS), MO (Mail Order) epinephrine soln a-inj 0.15 mg/0.15ml 4 ST, MO (Mail Order) EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML 3 MO (Mail Order) EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML 3 MO (Mail Order) EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML 3 MO (Mail Order) EPIPEN SOLN A-INJ 0.3 MG/0.3ML 3 MO (Mail Order) FORADIL AEROLIZER CAP 12 MCG 3 QL (60 PER 30 DAYS), MO (Mail Order) Bronchodilators, Sympathomimetic Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 127 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL levalbuterol hcl (soln 0.31 mg/3ml, soln 0.63 mg/3ml, soln 1.25 mg/3ml, soln 1.25 mg/0.5ml) 4 PA - Part B vs D Determination, MO (Mail Order) metaproterenol sulfate (syrup 10 mg/5ml, tab 10 mg, tab 20 mg) 2 MO (Mail Order) PERFOROMIST NEBU SOLN 20 MCG/2ML 4 PA - Part B vs D Determination, QL (120 PER 30 DAYS), MO (Mail Order) PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT 3 QL (25.5 PER 30 DAYS), MO (Mail Order) PROAIR RESPICLICK AER POW BA 108 (90 BASE) MCG/ACT 3 QL (3 PER 30 DAYS), MO (Mail Order) SEREVENT DISKUS AER POW BA 50 MCG/DOSE 3 QL (60 PER 30 DAYS), MO (Mail Order) STRIVERDI RESPIMAT AERO SOLN 2.5 MCG/ACT 4 QL (4 PER 30 DAYS), MO (Mail Order) terbutaline sulfate (tab 2.5 mg, tab 5 mg) 2 MO (Mail Order) terbutaline sulfate solution 1 mg/ml 5 MO (Mail Order) VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT 3 QL (54 PER 30 DAYS), MO (Mail Order) CAYSTON RECON SOLN 75 MG 5 LA, MO (Mail Order) KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150 MG) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) ORKAMBI TAB 200-125 MG 5 PA, LA, QL (120 PER 30 DAYS), MO (Mail Order) TOBI PODHALER CAP 28 MG 5 QL (240 PER 30 DAYS), MO (Mail Order) cromolyn sodium conc 100 mg/5ml 5 MO (Mail Order) cromolyn sodium nebu soln 20 mg/2ml 3 PA - Part B vs D Determination, MO (Mail Order) Cystic Fibrosis Agents Mast Cell Stabilizers Phosphodiesterase Inhibitors, Airways Disease aminophylline solution 25 mg/ml 2 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 128 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL DALIRESP TAB 500 MCG 4 PA, MO (Mail Order) theophylline er (tab 12h 200 mg, tab 12h 450 mg, tab 12h 100 mg, tab 12h 300 mg, tab 24h 400 mg, tab 24h 600 mg) 2 MO (Mail Order) theophylline solution 80 mg/15ml 4 MO (Mail Order) ADCIRCA TAB 20 MG 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) ADEMPAS (TAB 0.5 MG, TAB 1 MG, TAB 1.5 MG, TAB 2 MG, TAB 2.5 MG) 5 PA, MO (Mail Order) LETAIRIS (TAB 5 MG, TAB 10 MG) 5 PA - FOR NEW STARTS ONLY, LA, QL (30 PER 30 DAYS), MO (Mail Order) OPSUMIT TAB 10 MG 5 PA, LA, QL (30 PER 30 DAYS), MO (Mail Order) ORENITRAM (TAB ER 1 MG, TAB ER 2.5 MG) 5 PA, MO (Mail Order) ORENITRAM TAB ER 0.125 MG 4 PA, QL (180 PER 30 DAYS), MO (Mail Order) ORENITRAM TAB ER 0.25 MG 5 PA, QL (180 PER 30 DAYS), MO (Mail Order) REMODULIN (1 MG/ML, 2.5 MG/ML, 5 MG/ML, 10 MG/ML) 5 PA, LA, MO (Mail Order) REVATIO RECON SUSP 10 MG/ML 5 PA, QL (180 PER 30 DAYS), MO (Mail Order) REVATIO SOLUTION 10 MG/12.5ML 5 PA, MO (Mail Order) sildenafil citrate solution 10 mg/12.5ml 5 PA, MO (Mail Order) sildenafil citrate tab 20 mg 2 PA, QL (90 PER 30 DAYS), MO (Mail Order) TRACLEER (TAB 62.5 MG, TAB 125 MG) 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (Mail Order) Pulmonary Antihypertensives UPTRAVI (TAB 200 MCG, TAB 400 MCG, TAB 600 MCG, TAB 800 MCG, TAB 1000 MCG, TAB 1200 MCG, TAB 1400 MCG, TAB 1600 MCG) 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 129 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL UPTRAVI TAB THPK 200 & 800 MCG 5 PA, MO (Mail Order) VENTAVIS (10 MCG/ML, 20 MCG/ML) 5 PA, LA, MO (Mail Order) acetylcysteine (10 %, 20 %) 2 PA - Part B vs D Determination, MO (Mail Order) ADVAIR DISKUS (100-50 MCG/DOSE, 25050 MCG/DOSE, 500-50 MCG/DOSE) 3 QL (60 PER 30 DAYS), MO (Mail Order) ADVAIR HFA (45-21 MCG/ACT, 115-21 MCG/ACT, 230-21 MCG/ACT) 3 QL (12 PER 30 DAYS), MO (Mail Order) ANORO ELLIPTA AER POW BA 62.5-25 MCG/INH 3 QL (60 PER 30 DAYS), MO (Mail Order) ARALAST NP (SOLN 400 MG, SOLN 500 MG, SOLN 800 MG, SOLN 1000 MG) 5 PA, LA, MO (Mail Order) ARALAST RECON SOLN 800 MG 5 PA, LA, MO (Mail Order) BREO ELLIPTA (100-25 MCG/INH, 200-25 MCG/INH) 3 MO (Mail Order) COMBIVENT RESPIMAT AERO SOLN 20100 MCG/ACT 3 QL (8 PER 30 DAYS), MO (Mail Order) DULERA (100-5 MCG/ACT, 200-5 MCG/ACT) 4 QL (13 PER 30 DAYS), MO (Mail Order) DYMISTA SUSPENSION 137-50 MCG/ACT 3 QL (23.1 PER 30 DAYS), MO (Mail Order) ESBRIET CAP 267 MG 5 PA, LA, QL (270 PER 30 DAYS), MO (Mail Order) GLASSIA SOLUTION 1000 MG/50ML 5 PA, LA, MO (Mail Order) ipratropium-albuterol (solution 0.5-2.5 (3) mg/3ml, 0.5-2.5 (3) mg/3ml) 2 PA - Part B vs D Determination, MO (Mail Order) OFEV (CAP 100 MG, CAP 150 MG) 5 PA, LA, QL (60 PER 30 DAYS), MO (Mail Order) PROLASTIN-C RECON SOLN 1000 MG 5 PA, LA, MO (Mail Order) PULMOZYME SOLUTION 1 MG/ML 5 PA - Part B vs D Determination, MO (Mail Order) SEMPREX-D CAP 8-60 MG 4 MO (Mail Order) SYMBICORT (80-4.5 MCG/ACT, 160-4.5 MCG/ACT) 3 QL (10.2 PER 30 DAYS), MO (Mail Order) Respiratory Tract Agents, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 130 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL TYZINE SOLUTION 0.05 % 3 MO (Mail Order) VIRAZOLE RECON SOLN 6 GM 5 MO (Mail Order) XOLAIR RECON SOLN 150 MG 5 PA, MO (Mail Order) ZEMAIRA RECON SOLN 1000 MG 5 PA, LA, MO (Mail Order) NUCALA RECON SOLN 100 MG 5 PA STIOLTO RESPIMAT AERO SOLN 2.5-2.5 MCG/ACT 3 QL (4 PER 30 DAYS), MO (Mail Order) baclofen (tab 10 mg, 10 mg, tab 20 mg, 20 mg) 2 MO (Mail Order) carisoprodol (350 mg, tab 350 mg) 2 PA, QL (120 PER 30 DAYS), MO (Mail Order) carisoprodol tab 250 mg 4 PA, QL (120 PER 30 DAYS), MO (Mail Order) chlorzoxazone tab 500 mg 2 PA, QL (180 PER 30 DAYS), MO (Mail Order) cyclobenzaprine hcl (5 mg, tab 5 mg, tab 10 mg) 2 PA, QL (90 PER 30 DAYS), MO (Mail Order) cyclobenzaprine hcl tab 7.5 mg 4 PA, QL (90 PER 30 DAYS), MO (Mail Order) dantrolene sodium (cap 50 mg, cap 100 mg) 4 MO (Mail Order) dantrolene sodium cap 25 mg 2 MO (Mail Order) ed baclofen tab 10 mg 2 MO (Mail Order) GABLOFEN (50 MCG/ML, 10000 MCG/20ML) 3 PA - Part B vs D Determination, MO (Mail Order) GABLOFEN SOLUTION 40000 MCG/20ML 5 PA - Part B vs D Determination, MO (Mail Order) LIORESAL (0.05 MG/ML, 10 MG/20ML) 3 PA - Part B vs D Determination, MO (Mail Order) LIORESAL (10 MG/5ML, 40 MG/20ML) 5 PA - Part B vs D Determination, MO (Mail Order) methocarbamol tab 500 mg 2 PA, QL (270 PER 30 DAYS), MO (Mail Order) Skeletal Muscle Relaxants Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 131 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL methocarbamol tab 750 mg 2 PA, QL (180 PER 30 DAYS), MO (Mail Order) orphenadrine citrate tab 12h 100 mg 2 PA, QL (60 PER 30 DAYS), MO (Mail Order) tizanidine hcl (cap 2 mg, cap 4 mg, cap 6 mg) 4 MO (Mail Order) tizanidine hcl (tab 2 mg, tab 4 mg, 4 mg) 2 MO (Mail Order) estazolam (tab 1 mg, tab 2 mg) 2 QL (30 PER 30 DAYS), MO (Mail Order) eszopiclone (tab 1 mg, tab 2 mg, tab 3 mg) 2 PA, QL (30 PER 30 DAYS), MO (Mail Order) temazepam (cap 15 mg, 15 mg, cap 30 mg, 30 mg) 1 QL (60 PER 365 OVER TIME), MO (Mail Order) temazepam (cap 7.5 mg, cap 22.5 mg) 2 QL (60 PER 365 OVER TIME), MO (Mail Order) zaleplon (cap 5 mg, 5 mg, cap 10 mg, 10 mg) 2 PA, QL (90 PER 365 OVER TIME), MO (Mail Order) zolpidem tartrate (5 mg, tab 5 mg, 10 mg, tab 10 mg) 1 PA, QL (90 PER 365 OVER TIME), MO (Mail Order) zolpidem tartrate er (tab 6.25 mg, tab 12.5 mg) 2 PA, QL (90 PER 365 OVER TIME), MO (Mail Order) BELSOMRA (TAB 5 MG, TAB 10 MG, TAB 15 MG, TAB 20 MG) 3 QL (30 PER 30 DAYS), MO (Mail Order) BUTISOL SODIUM TAB 30 MG 4 PA, QL (180 PER 30 DAYS), MO (Mail Order) HETLIOZ CAP 20 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) modafinil (tab 200 mg, 200 mg) 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) modafinil tab 100 mg 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) Sleep Disorder Agents GABA Receptor Modulators Sleep Disorders, Other Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 132 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL NUVIGIL (TAB 150 MG, TAB 200 MG, TAB 250 MG) 4 PA, QL (30 PER 30 DAYS), MO (Mail Order) NUVIGIL TAB 50 MG 4 PA, QL (60 PER 30 DAYS), MO (Mail Order) ROZEREM TAB 8 MG 4 QL (30 PER 30 DAYS), MO (Mail Order) SECONAL CAP 100 MG 4 PA, MO (Mail Order) XYREM SOLUTION 500 MG/ML 5 PA, LA, QL (540 PER 30 DAYS), MO (Mail Order) Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers EXJADE (TAB 125 MG, TAB 250 MG, TAB 500 MG) 5 MO (Mail Order) FERRIPROX TAB 500 MG 5 PA, MO (Mail Order) JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG) 5 PA, MO (Mail Order) kionex (powder, suspension 15 gm/60ml) 2 MO (Mail Order) SAMSCA TAB 15 MG 5 PA, QL (30 PER 30 DAYS), MO (Mail Order) SAMSCA TAB 30 MG 5 PA, QL (60 PER 30 DAYS), MO (Mail Order) sodium polystyrene sulfonate (powder, suspension 15 gm/60ml, suspension 30 gm/120ml, suspension 50 gm/200ml) 2 MO (Mail Order) sps suspension 15 gm/60ml 2 MO (Mail Order) SYPRINE CAP 250 MG 5 ST, MO (Mail Order) CARBAGLU TAB 200 MG 5 LA, MO (Mail Order) ISOLYTE-S PH 7.4 SOLUTION 4 MO (Mail Order) ISOLYTE-S SOLUTION 4 MO (Mail Order) k-sol (20 meq/15ml (10%), 40 meq/15ml (20%)) 4 MO (Mail Order) Electrolyte/Mineral Replacement Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 133 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL klor-con 10 tab er 10 meq 2 MO (Mail Order) klor-con m10 tab er 10 meq 2 MO (Mail Order) KLOR-CON M15 TAB ER 15 MEQ 3 MO (Mail Order) klor-con m20 tab er 20 meq 2 MO (Mail Order) klor-con sprinkle (cap er 8, cap er 10) 2 MO (Mail Order) klor-con tab er 8 meq 2 MO (Mail Order) magnesium sulfate solution 50 % 2 MO (Mail Order) normal saline flush (solution 0.9 %, 0.9 %) 1 MO (Mail Order) NORMOSOL-R PH 7.4 SOLUTION 4 MO (Mail Order) NORMOSOL-R SOLUTION 4 MO (Mail Order) PLASMA-LYTE 148 SOLUTION 4 MO (Mail Order) PLASMA-LYTE A SOLUTION 4 MO (Mail Order) potassium chloride (0.4 meq/ml, 2 meq/ml, 20 meq/50ml, 40 meq/100ml) 1 PA - Part B vs D Determination, MO (Mail Order) potassium chloride (20 meq/15ml (10%), 40 meq/15ml (20%)) 4 MO (Mail Order) potassium chloride (packet 20 meq, solution 10 meq/50ml, solution 10 meq/100ml, solution 20 meq/100ml) 1 MO (Mail Order) potassium chloride crys er (er 10, er 20, tab 10, tab 20) 2 MO (Mail Order) potassium chloride er (cap 8, cap 10, tab 8, tab 10) 2 MO (Mail Order) potassium chloride in nacl (20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%) 2 MO (Mail Order) potassium citrate er (tab 5 (540 mg), tab 10 (1080 mg)) 2 MO (Mail Order) potassium citrate tab 15 meq (1620 mg) 4 MO (Mail Order) sodium chloride (0.45 %, solution 0.45 %, solution 3 %) 2 MO (Mail Order) sodium chloride (2.5 meq/ml, 5 %) 4 MO (Mail Order) sodium chloride (solution 0.9 %, 0.9 %) 1 MO (Mail Order) sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 1 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 134 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL sodium lactate solution 5 meq/ml 2 MO (Mail Order) AMINOSYN II (7 %, 10 %) 4 PA - Part B vs D Determination, MO (Mail Order) aminosyn ii/electrolytes solution 8.5 % 2 PA - Part B vs D Determination, MO (Mail Order) AMINOSYN M SOLUTION 3.5 % 4 PA - Part B vs D Determination, MO (Mail Order) AMINOSYN-HBC SOLUTION 7 % 4 PA - Part B vs D Determination, MO (Mail Order) AMINOSYN-PF (7 %, 10 %) 4 PA - Part B vs D Determination, MO (Mail Order) AMINOSYN-RF SOLUTION 5.2 % 4 PA - Part B vs D Determination, MO (Mail Order) AMINOSYN/ELECTROLYTES SOLUTION 7 % 4 PA - Part B vs D Determination, MO (Mail Order) aminosyn/electrolytes solution 8.5 % 2 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (2.75/10) SOLUTION 2.75 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (2.75/5) SOLUTION 2.75 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (4.25/10) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (4.25/25) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (4.25/5) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (5/15) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (5/20) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX E/DEXTROSE (5/25) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (2.75/5) SOLUTION 2.75 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (4.25/10) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 135 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL CLINIMIX/DEXTROSE (4.25/20) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (4.25/25) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (4.25/5) SOLUTION 4.25 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (5/15) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (5/20) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) CLINIMIX/DEXTROSE (5/25) SOLUTION 5 % 4 PA - Part B vs D Determination, MO (Mail Order) dextrose (10 %, solution 10 %) 1 MO (Mail Order) dextrose (solution 5 %, 5 %) 2 MO (Mail Order) dextrose in lactated ringers ( 5 %, solution 5 %) 2 MO (Mail Order) dextrose-nacl (solution 2.5-0.45 %, 5-0.9 %, solution 5-0.2 %, 5-0.45 %, solution 5-0.9 %, solution 5-0.45 %, solution 5-0.33 %, solution 5-0.225 %, solution 10-0.45 %, solution 100.2 %) 2 MO (Mail Order) FREAMINE HBC SOLUTION 6.9 % 4 PA - Part B vs D Determination, MO (Mail Order) HEPATAMINE SOLUTION 8 % 4 PA - Part B vs D Determination, MO (Mail Order) intralipid emulsion 20 % 4 PA - Part B vs D Determination, MO (Mail Order) IONOSOL-B IN D5W SOLUTION 4 MO (Mail Order) IONOSOL-MB IN D5W SOLUTION 4 MO (Mail Order) ISOLYTE-P IN D5W SOLUTION 4 MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 136 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL kcl in dextrose-nacl (solution 10-5-0.45 meq/l%-%, solution 20-5-0.225 meq/l-%-%, solution 20-5-0.2 meq/l-%-%, solution 20-50.45 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-50.33 meq/l-%-%, solution 20-5-0.33 meq/l-%%, solution 20-5-0.9 meq/l-%-%, solution 305-0.45 meq/l-%-%, solution 40-5-0.45 meq/l%-%, solution 40-5-0.9 meq/l-%-%) kcl-lactated ringers-d5w solution 20 meq/l 2 MO (Mail Order) 2 MO (Mail Order) lactated ringers (, solution) 2 MO (Mail Order) levocarnitine (solution 1 gm/10ml, solution 200 mg/ml, tab 330 mg) 2 PA - Part B vs D Determination, MO (Mail Order) NEPHRAMINE SOLUTION 5.4 % 4 PA - Part B vs D Determination, MO (Mail Order) NORMOSOL-M IN D5W SOLUTION 2 MO (Mail Order) NORMOSOL-R IN D5W SOLUTION 3 MO (Mail Order) nutrilipid emulsion 20 % 4 PA - Part B vs D Determination, MO (Mail Order) PLASMA-LYTE-56 IN D5W SOLUTION 4 MO (Mail Order) potassium chloride in dextrose (20-5 meq/l-%, 40-5 meq/l-%) 2 MO (Mail Order) premasol (6 %, 10 %) 4 PA - Part B vs D Determination, MO (Mail Order) PROCALAMINE SOLUTION 3 % 4 PA - Part B vs D Determination, MO (Mail Order) PROSOL SOLUTION 20 % 4 PA - Part B vs D Determination, MO (Mail Order) ringers solution 2 MO (Mail Order) tpn electrolytes (conc, solution) 2 MO (Mail Order) TRAVASOL SOLUTION 10 % 4 PA - Part B vs D Determination, MO (Mail Order) TROPHAMINE SOLUTION 10 % 4 PA - Part B vs D Determination, MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 137 AlphaCare 16299 (List of Covered DROGAs) DROGA NOMBRE DROGA REQUISITOS / LÍMITES NIVEL Uncategorized Unclassified cetirizine hcl tab 5 mg 0 childrens loratadine solution 5 mg/5ml 0 cyclopentolate hcl solution 0.5 % 2 MO (Mail Order) DERMACINRX TICANASE PAK THER PACK 50-2.7 MCG/ACT-% 5 MO (Mail Order) eye itch relief solution 0.025 % 0 HYPERHEP B S/D SOLUTION 5 kls aller-tec d tab er 12h 5-120 mg 0 kls allerclear d-12hr tab er 12h 5-120 mg 0 kls allerclear d-24hr tab er 24h 10-240 mg 0 KRYSTEXXA SOLUTION 8 MG/ML 5 MO (Mail Order) LILETTA IUD 18.6 MCG/DAY 5 MO (Mail Order) loradamed tab 10 mg 0 nitroglycerin er (cap 2.5 mg, cap 6.5 mg, cap 9 mg) 2 ra cetirizine childrens chew tab 10 mg 0 wal-itin allergy reditabs tab disp 10 mg 0 wal-zyr solution 0.025 % 0 MO (Mail Order) MO (Mail Order) Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por ir a la pagina 1. 138 Alphabetical Listing A A-HYDROCORT abacavir sulfate abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY MAINTENA ABRAXANE ABSTRAL acamprosate calcium acarbose acebutolol hcl acetaminophen-codeine acetaminophen-codeine #2 acetaminophen-codeine #3 acetaminophen-codeine #4 acetazolamide acetazolamide er acetazolamide sodium acetic acid acetylcysteine acitretin ACTEMRA ACTHAR HP ACTHIB ACTIMMUNE ACUVAIL acyclovir acyclovir sodium ADACEL ADAGEN adapalene ADCIRCA adefovir dipivoxil ADEMPAS ADRENALIN adrucil ADVAIR DISKUS ADVAIR HFA AEROSPAN 99 53 54 32 50 50 40 6 10 60 74 7 7 7 7 80 80 80 124 130 89 115 99 116 115 122 57 57 116 94 89 129 56 129 127 38 130 130 124 139 afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX ak-poly-bac ala cort ALBENZA albuterol sulfate alclometasone dipropionate ALDACTAZIDE ALDURAZYME ALECENSA alendronate sodium alfuzosin hcl er ALIMTA ALINIA allopurinol almotriptan malate ALOCRIL ALOMIDE alosetron hcl ALOXI ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL alprazolam xr ALREX ALTOPREV amantadine hcl AMBISOME amcinonide amethia amethyst amifostine amikacin sulfate amiloride hcl amiloride-hydrochlorothiazide aminophylline AMINOSYN II aminosyn ii/electrolytes 75 43 43 70 120 89 47 127 89 77 94 40 118 98 38 47 34 35 121 121 96 31 123 58 58 58 59 122 82 48 32 89 103 103 40 12 81 77 128 135 135 AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF AMINOSYN/ELECTROLYTES aminosyn/electrolytes amiodarone hcl AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin amlodipine-valsartan-hctz ammonium lactate amoxapine amoxicill-clarithro-lansopraz amoxicillin amoxicillin-pot clavulanate amoxicillin-pot clavulanate er amphetamine-dextroamphet er amphetamine-dextroamphetamine amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam ampicillin-sulbactam sodium AMPYRA ANADROL-50 anagrelide hcl anastrozole ANDRODERM ANDROGEL ANDROGEL PUMP ANGELIQ ANORO ELLIPTA ANZEMET APEXICON E APIDRA APIDRA OPTICLIK APIDRA SOLOSTAR 135 135 135 135 135 135 73 96 30 77 75 77 77 77 89 30 95 17 17 17 85 85 32 17 17 17 17 88 102 68 42 102 102 102 103 130 31,32 89 65 65 65 140 APOKYN apraclonidine hcl apri APRISO APTIOM APTIVUS ARALAST ARALAST NP aranelle ARANESP (ALBUMIN FREE) ARCALYST ARCAPTA NEOHALER argatroban argatroban in sodium chloride argyle sterile water aripiprazole ARISTADA ARRANON ascomp-codeine ashlyna ASMANEX 120 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-dipyridamole er ASTEPRO ATELVIA atenolol atenolol-chlorthalidone ATGAM atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRALIN ATRIPLA ATROVENT HFA AUBAGIO aubra AUGMENTIN AVANDIA AVASTIN 48 123 103 117 24 55 130 130 103 68,69 115 127 66 67 119 50,51 51 39 7 103 124 124 124 124 70 125 118 74 77 114 82 47 47 89 54 127 88 103 17 60 46 aviane avita AVONEX AVONEX PEN AVONEX PREFILLED AVYCAZ AXERT azacitidine AZACTAM IN DEXTROSE AZASAN AZASITE azathioprine azelastine hcl AZELEX AZILECT azithromycin AZOPT AZOR aztreonam 103 89 88 88 88 15 35 39 16 112 18 112 121,125 89 49 18 123 77 16 B baciim bacitra-neomycin-polymyxin-hc bacitracin bacitracin-polymyxin b baclofen BACTOCILL IN DEXTROSE BACTROBAN NASAL balsalazide disodium balziva BANZEL BARACLUDE BECONASE AQ bekyree BELEODAQ BELSOMRA benazepril hcl benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT 12 120 12 120 131 17 13 117 103 24 56 124 103 40 132 72 78 37 71 78 141 BENLYSTA benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BERINERT BESIVANCE betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl bethanechol chloride BETHKIS BETIMOL bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN C-R 900/300 BICILLIN L-A BICNU BIDIL BILTRICIDE bimatoprost BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin sulfate BLEPHAMIDE BLEPHAMIDE S.O.P. blisovi 24 fe blisovi fe 1.5/30 blisovi fe 1/20 BOOSTRIX BOSULIF BOTOX BREO ELLIPTA briellyn BRILINTA brimonidine tartrate 115 89 48 121 112 19 89 89 90 88 74,123 99 12 123 47 116 38 18 17 18 37 78 47 123 118 74 78 114 40 121 121 103 103 103 116 43 119 130 103 70 123 BRINTELLIX bromfenac sodium bromfenac sodium (once-daily) bromocriptine mesylate BROVANA budesonide bumetanide BUPHENYL buprenorphine hcl buprenorphine hcl-naloxone hcl buproban bupropion hcl bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl BUSULFEX butalbital-acetaminophen butalbital-apap-caff-cod butalbital-apap-caffeine butalbital-aspirin-caffeine BUTISOL SODIUM butorphanol tartrate BUTRANS BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN BYSTOLIC 27 122 122 48 127 118,124,125 80 94 4,11 11 11 26 26 26 58 37 2 7 2 2 132 7 4 60 60 60 74 C cabergoline CAFERGOT calcipotriene calcipotriene-betameth diprop calcitonin (salmon) calcitriol calcium acetate (phos binder) camila CANASA CANCIDAS candesartan cilexetil candesartan cilexetil-hctz 110 35 90 90 118 118 99 108 117 32,33 71 78 142 CAPASTAT SULFATE CAPEX CAPRELSA captopril captopril-hydrochlorothiazide CARAC CARAFATE CARBAGLU carbamazepine carbamazepine er carbidopa carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone carboplatin CARDURA XL CARIMUNE NF carisoprodol carteolol hcl cartia xt carvedilol CAYSTON cefaclor cefaclor er cefadroxil cefazolin sodium cefazolin sodium-dextrose cefdinir cefepime hcl cefepime-dextrose cefixime CEFOTAN cefotaxime sodium cefotetan disodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftazidime and dextrose ceftriaxone sodium cefuroxime axetil 36 90 43 72 78 90 97 133 24 24 49 49 49 49 37 98 114 131 123 75 74 128 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 16 16 16 16 cefuroxime sodium 16 CELEBREX 2 celecoxib 2 CELLCEPT 112 CELLCEPT INTRAVENOUS 112 CELONTIN 22 cephalexin 16 CEREBYX 24 CEREZYME 94 CERVARIX 116 cetirizine hcl 125,138 89 cevimeline hcl CHANTIX 11 CHANTIX CONTINUING MONTH PAK 11 CHANTIX STARTING MONTH PAK 11 CHENODAL 95 childrens loratadine 138 chloramphenicol sod succinate 13 chlordiazepoxide hcl 59 chlordiazepoxide-amitriptyline 26 chlorhexidine gluconate 89 chloroquine phosphate 47 chlorothiazide 81 chlorothiazide sodium 81 chlorpromazine hcl 49 chlorthalidone 81 chlorzoxazone 131 CHOLBAM 95 83 cholestyramine 83 cholestyramine light chorionic gonadotropin 101 CIALIS 98 33 ciclopirox 33 ciclopirox olamine ciclopirox treatment 33 cidofovir 55 cilostazol 70 CILOXAN 19 cimetidine 95 cimetidine hcl 95 CIMZIA 112 143 CIMZIA PREFILLED CIMZIA STARTER KIT CINRYZE CIPRO CIPRO HC CIPRODEX ciprofloxacin ciprofloxacin hcl ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er cisplatin citalopram hydrobromide cladribine claravis clarithromycin clarithromycin er clemastine fumarate CLEOCIN CLIMARA PRO clindamycin hcl clindamycin palmitate hcl clindamycin phos-benzoyl perox clindamycin phosphate clindamycin phosphate in d5w CLINDESSE CLINIMIX E/DEXTROSE (2.75/10) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/10) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/10) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) 112 112 112 19 124 124 19 20 20 20 37 27 39 90 19 19 125 13 103 13 13 90 13,90 13 13 135 135 135 135 135 135 135 135 135 135 136 136 136 136 136 136 clobetasol propionate clobetasol propionate e clobetasol propionate emulsion CLOBEX SPRAY clodan CLOLAR clomipramine hcl clonazepam clonidine hcl clonidine hcl er clopidogrel bisulfate clorazepate dipotassium CLORPRES clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate colchicine-probenecid COLCRYS colestipol hcl colistimethate sodium colocort COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMPLERA compro CONDYLOX constulose COPAXONE CORDRAN CORLANOR cormax cormax scalp application cortisone acetate CORTISPORIN CORTISPORIN-TC 90,100 90 90 90 90 39 30 22 70,71 85 70 59 78 33 90 52,53 47 7 34 35 83 13 118 123 103 130 43 43 43 54 31 90 96 88 90 78 90 90 100 90 124 144 COSENTYX COSENTYX SENSOREADY PEN COSMEGEN COTELLIC COUMADIN CREON CRESEMBA CRESTOR CRINONE CRIXIVAN cromolyn sodium cryselle-28 CUBICIN CUPRIMINE CUVPOSA cyclafem 1/35 cyclafem 7/7/7 cyclobenzaprine hcl cyclopentolate hcl cyclophosphamide cycloserine CYCLOSET cyclosporine cyclosporine modified cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) 91 91 40 43 67 94 33 82 108 55 121,128 103 13 99 95 103 103 131 138 37 36 60 112 112 125 46 94 94 121 39 39 D dacarbazine DACOGEN DAKLINZA DALIRESP danazol dantrolene sodium dapsone DAPTACEL 37 39 56 129 103 131 36 116 DARAPRIM DARZALEX daunorubicin hcl DAUNOXOME DAYTRANA deblitane decitabine delyla demeclocycline hcl DEMSER DENAVIR DEPEN TITRATABS DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA 104 DERMACINRX TICANASE PAK desipramine hcl desloratadine desmopressin ace rhinal tube desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine er desvenlafaxine fumarate er dexamethasone DEXAMETHASONE INTENSOL dexamethasone sod phosphate pf dexamethasone sodium phosphate dexedrine DEXILANT dexmethylphenidate hcl dexmethylphenidate hcl er DEXPAK 13 DAY dexrazoxane dextroamphetamine sulfate dextroamphetamine sulfate er dextrose 47 46 40 40 85 108 39 103 20 78 57 99 104 100 108 108 138 30 125 101 101 101 101 104 91 91 27 27 100 100 100 100,122 85 97 86 86 100 40 85 85 136 145 dextrose in lactated ringers dextrose-nacl DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam diazepam intensol DIBENZYLINE diclofenac potassium diclofenac sodium diclofenac sodium er diclofenac-misoprostol dicloxacillin sodium dicyclomine hcl didanosine DIFFERIN DIFICID diflorasone diacetate diflunisal digitek digoxin dihydroergotamine mesylate DILANTIN dilt-cd dilt-xr diltiazem cd diltiazem hcl diltiazem hcl cd diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads diltiazem hcl-dextrose DIOVAN DIPENTUM diphenhydramine hcl diphtheria-tetanus toxoids dt disopyramide phosphate disulfiram DIURIL divalproex sodium divalproex sodium er DOCEFREZ 136 136 22 22 22,59 59 71 2 2,91,122 2 2 18 95 54 91 19 91 2 78 78 35 24 75 75 75 75 75 76 76 76 76 71 117 125 116 73 10 81 22 22 40 docetaxel docetaxel (non-alcohol) donepezil hcl dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate doxepin hcl doxercalciferol DOXIL doxorubicin hcl doxy 100 doxycycline doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol DROXIA DUAVEE DULERA duloxetine hcl duramorph DUREZOL dutasteride dutasteride-tamsulosin hcl DYMISTA DYRENIUM 40 40 25 123 123 71 30,91 119 40 40 20 91 20,89 21 32 104 39 109 130 27 7 122 98 99 130 81 E E.E.S. GRANULES econazole nitrate ed baclofen EDARBI EDARBYCLOR EDECRIN EDURANT EFFIENT EGRIFTA ELAPRASE ELESTRIN ELIDEL ELIGARD 19 33 131 71 78 80 53 70 110 94 104 91 110 146 ELIPHOS ELIQUIS ELITEK ELMIRON EMADINE EMBEDA EMCYT EMEND emoquette EMPLICITI EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endocet ENGERIX-B enoxaparin sodium enpresse-28 entacapone entecavir ENTRESTO enulose EPANED EPIDUO EPIDUO FORTE epinastine hcl epinephrine EPIPEN EPIPEN 2-PAK EPIPEN JR EPIPEN JR 2-PAK epirubicin hcl epitol EPIVIR EPIVIR HBV eplerenone EPOGEN eprosartan mesylate EPZICOM 99 67 39 99 122 4 37 32 104 46 27 54 72 78 112 112 7 116 67 104 48 56 78 96 72 91 91 122 127 127 127 127 127 40 24 54 56 81 69 71 54 EQUETRO ERAXIS ERBITUX ergoloid mesylates ERGOMAR ERIVEDGE errin ERWINAZE ery ERY-TAB ERYPED 200 ERYPED 400 ERYTHROCIN LACTOBIONATE ERYTHROCIN STEARATE erythromycin erythromycin base erythromycin ethylsuccinate ESBRIET escitalopram oxalate esomeprazole magnesium esomeprazole sodium esomeprazole strontium estazolam ESTRACE estradiol estradiol valerate estradiol-norethindrone acet ESTRING estropipate eszopiclone ethambutol hcl ethosuximide etidronate disodium etodolac etodolac er ETOPOPHOS etoposide EURAX EVOTAZ EXALGO EXELDERM 60 33 46 25 35 43 108 40 91 19 19 19 19 19 19,91 19 19 130 27 97 97 97 132 104 104 104 104 104 104 132 36 22 119 2 2 42 42 48 54 4 33 147 EXELON exemestane EXJADE EXTAVIA eye itch relief 25 42 133 88 138 F FABRAZYME falmina famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine er FEMHRT LOW DOSE FEMRING fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fentanyl fentanyl citrate FERRIPROX FETZIMA FETZIMA TITRATION FINACEA FINACEA PLUS finasteride FIRAZYR FIRMAGON FLAGYL FLAREX flavoxate hcl FLEBOGAMMA DIF flecainide acetate 94 104 57 95,96 96 51 51 38 40 38 53 23 76 104 104 81,82 81,82 82 3 4,5 7,8 133 28 28 91 91 99 112 110 13 122 98 114 73 FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in dextrose fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide-e fluorouracil fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluvastatin sodium fluvastatin sodium er fluvoxamine maleate fluvoxamine maleate er FML FML FORTE FOCALIN XR FOLOTYN fondaparinux sodium FORADIL AEROLIZER FORFIVO XL FORTEO fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium FOSRENOL FRAGMIN FREAMINE HBC 3 125 125 33 33 33 33 41 100 125 91,124 91 91 91 91 39,91,92 28 50 50 3 122 38 92,125 82 82 28 28 122 122 86 39 67 127 26 119 72 79 24 99 67,68 136 148 FROVA frovatriptan succinate furosemide FUSILEV FUZEON fyavolv FYCOMPA 35 35 80 41 54 104 23 G 22 gabapentin 22 GABITRIL 131 GABLOFEN 25 galantamine hydrobromide 25 galantamine hydrobromide er 114 GAMASTAN S/D 114 GAMMAGARD 115 GAMMAGARD S/D 115 GAMMAGARD S/D LESS IGA 115 GAMMAKED 115 GAMMAPLEX 115 GAMUNEX 115 GAMUNEX-C 55 ganciclovir sodium 116 GARDASIL 116 GARDASIL 9 20 gatifloxacin 95 GATTEX GAUZE PADS & DRESSINGS - PADS 2 X 119 2 96 gavilyte-c 96 gavilyte-g gavilyte-h 96 96 gavilyte-n with flavor pack gemcitabine hcl 39 gemfibrozil 82 GENERESS FE 104 generlac 96 112 gengraf 101 GENOTROPIN GENOTROPIN MINIQUICK 101 gentak 12 gentamicin in saline gentamicin sulfate GENVOYA GEODON gianvi gildagia gildess 1.5/30 gildess 24 fe GILENYA GILOTRIF GLASSIA glatopa GLEEVEC GLEOSTINE glimepiride glipizide glipizide er glipizide xl glipizide-metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY GLUMETZA glyburide glyburide micronized glyburide-metformin glycopyrrolate GLYSET granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er guanidine hcl GYNAZOLE-1 12 12 53 51 104 104 105 105 88 43 130 88 43 37 61 61 61 61 61 64 64 61 61 62 62 95 62 32 69 33 33 71 86 36 33 H HALAVEN halobetasol propionate HALOG haloperidol 41 92 92 50 149 haloperidol decanoate 50 haloperidol lactate 50 HARVONI 56 116 HAVRIX 68 heparin (porcine) in d5w heparin sod (porcine) in d5w 68 heparin sodium (porcine) 68 HEPATAMINE 136 HEPSERA 56 HERCEPTIN 46 HETLIOZ 132 HEXALEN 37 HP ACTHAR 100 HUMALOG 65 HUMALOG KWIKPEN 65 HUMALOG MIX 50/50 65 HUMALOG MIX 50/50 KWIKPEN 65 HUMALOG MIX 75/25 65 HUMALOG MIX 75/25 KWIKPEN 65 HUMATROPE 101 113 HUMIRA HUMIRA PEDIATRIC CROHNS START 113 HUMIRA PEN 113 HUMIRA PEN-CROHNS STARTER 113 HUMIRA PEN-PSORIASIS STARTER 113 HUMULIN 70/30 65 HUMULIN 70/30 KWIKPEN 65 HUMULIN 70/30 PEN 65 HUMULIN N 65 HUMULIN N KWIKPEN 65 HUMULIN N PEN 65 HUMULIN R 65 HUMULIN R U-500 (CONCENTRATED) 65 HUMULIN R U-500 KWIKPEN 65 hydralazine hcl 84 hydrochlorothiazide 81 hydrocodone-acetaminophen 8 hydrocodone-ibuprofen 8 92,100,118 hydrocortisone hydrocortisone butyr lipo base 92 hydrocortisone butyrate 92 hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hcl hydromorphone hcl er hydromorphone hcl pf hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERHEP B S/D 92 124 8 5 8 47 39 58 58 138 I ibandronate sodium 119 IBRANCE 43 3 ibuprofen ICLUSIG 43 idarubicin hcl 41 ifosfamide 37 ILARIS 115 ILEVRO 122 ilotycin 19 imatinib mesylate 44 IMBRUVICA 44 imipenem-cilastatin 16 imipramine hcl 30 imipramine pamoate 30 imiquimod 92 IMLYGIC 41 IMOVAX RABIES 116 INCRELEX 101 indapamide 81 INDOCIN 3 indomethacin 3 indomethacin er 3 INFANRIX 116 INLYTA 44 INNOPRAN XL 74 INSULIN PEN NEEDLE 120 INSULIN SYRINGE (DISP) U-100 0.3 ML 120 INSULIN SYRINGE (DISP) U-100 1 ML 120 INSULIN SYRINGE (DISP) U-100 1/2 ML 120 150 INTELENCE 53 intralipid 136 INTRON A 56 introvale 105 INTUNIV 86 INVANZ 17 INVEGA 51 INVEGA SUSTENNA 51 51 INVEGA TRINZA INVIRASE 55 INVOKAMET 62 INVOKANA 62 IONOSOL-B IN D5W 136 IONOSOL-MB IN D5W 136 IOPIDINE 123 116 IPOL 127 ipratropium bromide ipratropium-albuterol 130 irbesartan 72 irbesartan-hydrochlorothiazide 79 IRESSA 44 irinotecan hcl 41 ISENTRESS 53 ISOLYTE-P IN D5W 136 ISOLYTE-S 133 ISOLYTE-S PH 7.4 133 36 isoniazid ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD 120 isopropyl alcohol 0.7 ml/ml medicated pad120 ISORDIL TITRADOSE 84 isosorbide dinitrate 84 isosorbide dinitrate er 84 isosorbide mononitrate 84 isosorbide mononitrate er 84 isradipine 76 ISTODAX 41 itraconazole 33 ivermectin 47 IXEMPRA KIT 41 116 IXIARO J JADENU JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA jinteli jolivette juleber junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 JUXTAPID 133 44 68 62 62 62 62 62 41 105 108 105 105 105 105 105 105 83 K k-sol KADCYLA kaitlib fe KALETRA KALYDECO KANUMA KAPIDEX kariva KAZANO kcl in dextrose-nacl kcl-lactated ringers-d5w kelnor 1/35 KENALOG KEPIVANCE KETEK ketoconazole ketoprofen ketoprofen er ketorolac tromethamine 133 46 105 55 128 120 97 105 63 137 137 105 92,100 89 19 33 3 3 3,122 151 KEYTRUDA KHEDEZLA kimidess KINERET kionex klor-con klor-con 10 klor-con m10 KLOR-CON M15 klor-con m20 klor-con sprinkle kls aller-tec childrens kls aller-tec d kls allerclear d-12hr kls allerclear d-24hr KOMBIGLYZE XR KORLYM KRISTALOSE KRYSTEXXA KUVAN KYNAMRO 46 28 105 113 133 134 134 134 134 134 134 126 138 138 138 63 102 96 138 94 83 L labetalol hcl LACRISERT lactated ringers lactulose LAMICTAL STARTER LAMISIL lamivudine lamivudine-zidovudine lamotrigine lamotrigine er LANOXIN lansoprazole LANTUS LANTUS FOR OPTICLIK LANTUS SOLOSTAR larin 1.5/30 larin 1/20 larin fe 1.5/30 74 121 120,137 96 23 34 54,56 54 23,24 24 79 97 66 65 66 105 105 105 larin fe 1/20 LASTACAFT latanoprost LATUDA layolis fe leena leflunomide LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH levetiracetam levetiracetam er levetiracetam in nacl levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levoleucovorin calcium levoleucovorin calcium pf levonest levonorg-eth estrad triphasic levonorgest-eth estrad 91-day levonorgestrel-ethinyl estrad levora 0.15/30 (28) levorphanol tartrate levothyroxine sodium levoxyl LEXIVA 105 122 123 51 105 105 115 44 44 44 44 105 129 42 41 37 69 111 128 66 66 66 21 21 21 123 137 126 20 20 41 41 105 105 105 105 105 5 109 109 55 152 LIALDA lidocaine lidocaine hcl lidocaine hcl (pf) lidocaine viscous lidocaine-prilocaine LILETTA lindane linezolid linezolid in sodium chloride LINZESS LIORESAL liothyronine sodium lisinopril lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er LIVALO livixil pak LO LOESTRIN FE lokara lomedia 24 fe LONSURF loperamide hcl lopreeza loradamed lorazepam lorazepam intensol lorcet plus loryna losartan potassium losartan potassium-hctz LOTEMAX LOTRONEX lovastatin LOVAZA loxapine succinate lp lite pak LUMIGAN LUMIZYME 117 10 10 10 10 10 138 48 13 13 96 131 109 72 79 60 60 60 82 10 105 92 106 39 95 106 138 59 59 8 106 72 79 122 96 82 83 50 10 124 94 LUPANETA PACK LUPRON DEPOT LUPRON DEPOT-PED lutera LYNPARZA LYRICA LYSODREN lyza 111 111 111 106 41 87 110 108 M M-M-R II magnesium sulfate MAKENA malathion maprotiline hcl marlissa MARPLAN MATULANE matzim la MAXIDEX meclizine hcl meclofenamate sodium MEDROL medroxyprogesterone acetate mefenamic acid mefloquine hcl MEGACE ES megestrol acetate MEKINIST meloxicam melphalan hcl memantine hcl MENACTRA MENEST MENOMUNE MENTAX MENVEO meprobamate MEPRON mercaptopurine meropenem 116 134 108 48 26 106 27 37 76 122 31 3 100 108 3 47 109 109 44 3 37 26 116 106 116 34 116 58 47 39 17 153 mesalamine mesalamine-cleanser mesna MESNEX MESTINON metadate er metaproterenol sulfate metformin hcl metformin hcl er metformin hcl er (mod) metformin hcl er (osm) methadone hcl methadose methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate hcl methylergonovine maleate METHYLIN methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methylprednisolone (pak) methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er 117 118 41 41 36 86 128 63 63 63 63 5 5 123 13 13 111 131,132 113 113 113 92 95 81 71 79 71 120 86 86,87 86,87 86 87 100 100 100 100 123 31 81 74 metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole metronidazole in nacl mexiletine hcl MIACALCIN MICONAZOLE 3 microgestin 1.5/30 microgestin 1/20 microgestin fe 1.5/30 microgestin fe 1/20 micronized colestipol hcl midodrine hcl MIGERGOT MILLIPRED mimvey mimvey lo MINASTRIN 24 FE minitran minocycline hcl minocycline hcl er minoxidil mirtazapine MIRVASO misoprostol mitomycin mitoxantrone hcl modafinil moexipril hcl moexipril-hydrochlorothiazide molindone hcl mometasone furoate mononessa montelukast sodium MONUROL morphine sulfate morphine sulfate (concentrate) morphine sulfate (pf) morphine sulfate er morphine sulfate er beads MOXEZA 74 79 13 13 73 119 34 106 106 106 106 83 71 35 100 106 106 106 84 21 21 84 26 92 97 41 41 132 72 79 50 92,125 106 126 13 8,9 8 8 5 5 20 154 moxifloxacin hcl MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN mycophenolate mofetil mycophenolic acid myorisan MYOZYME MYRBETRIQ 20 69 73 14 13 37 113 113 92 94 98 N nabumetone nadolol nadolol-bendroflumethiazide nafcillin sodium nafcillin sodium in dextrose naftifine hcl NAFTIN NAGLAZYME nalbuphine hcl NALLPEN IN DEXTROSE naloxone hcl naltrexone hcl NOMBRENDA NOMBRENDA TITRATION PAK NOMBRENDA XR NOMBRENDA XR TITRATION PACK NAMZARIC naphazoline hcl naproxen naproxen dr naproxen kit naproxen sodium naratriptan hcl NASONEX NATACYN nateglinide NATPARA NEBUPENT 3 75 79 18 18 34 34 94 9 18 11 10 26 26 26 26 87 121 3,4 4 4 4 35 125 34 63 120 47 necon 0.5/35 (28) 106 necon 1/35 (28) 106 NECON 1/50 (28) 106 NECON 10/11 (28) 106 necon 7/7/7 106 NEEDLES, INSULIN DISP., SAFETY 120 nefazodone hcl 28 neomycin sulfate 12 neomycin-bacitracin zn-polymyx 121 neomycin-polymyxin b gu 14 neomycin-polymyxin-dexameth 121 neomycin-polymyxin-gramicidin 121 neomycin-polymyxin-hc 121,124 NEPHRAMINE 137 63 NESINA NEULASTA 69 NEULASTA ONPRO 69 NEUPOGEN 69 NEVANAC 122 53 nevirapine nevirapine er 53 NEXAVAR 44 niacin er (antihyperlipidemic) 83 NIACOR 83 nicardipine hcl 76 NICOTROL 11 NICOTROL NS 11 nifedical xl 76 nifedipine er 76 nifedipine er osmotic 76 nikki 106 NILANDRON 38 77 nimodipine NINLARO 42 NIPENT 39 nisoldipine er 77 NITRO-BID 84 NITRO-DUR 84 nitrofurantoin 14 nitrofurantoin macrocrystal 14 nitrofurantoin monohyd macro 14 155 nitroglycerin nitroglycerin er NITROSTAT nizatidine nora-be NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN norethin ace-eth estrad-fe norethin-eth estradiol-fe norethindrone norethindrone acetate norethindrone-eth estradiol norgestim-eth estrad triphasic NORITATE norlyroc normal saline flush NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W NORMOSOL-R PH 7.4 NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 nortriptyline hcl NORVIR novarel NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA 84 138 85 96 109 101 101 106 106 109 109 106 106 14 109 134 137 134 137 134 79 106 107 107 107 31 55 102 66 66 66 66 66 66 66 66 66 66 66 34 131 NUCYNTA ER NUEDEXTA NULOJIX nutrilipid NUTROPIN AQ NUSPIN 10 NUTROPIN AQ NUSPIN 20 NUTROPIN AQ NUSPIN 5 NUTROPIN AQ PEN NUVARING NUVIGIL nyamyc nystatin nystatin-triamcinolone nystop 5 87 113 137 102 102 102 102 107 133 34 34 34 34 O ocella OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin OGESTREL olanzapine olanzapine-fluoxetine hcl olopatadine hcl OLYSIO omega-3-acid ethyl esters omeprazole omeprazole-sodium bicarbonate OMNITROPE ONCASPAR ondansetron ondansetron hcl ONFI ONGLYZA ONMEL OPANA ER OPDIVO OPSUMIT 107 115 111 53 44 130 20,124 107 51 27 122,126 56 83 97 97 102 42 32 32 22 63 34 6 46 129 156 ORACEA ORAP ORENCIA ORENITRAM ORFADIN ORKAMBI orphenadrine citrate er orsythia ORTHO TRI-CYCLEN LO OSENI OTEZLA oxacillin sodium oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole nitrate OXISTAT OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxybutynin chloride er oxycodone hcl oxycodone hcl er oxycodone-acetaminophen oxycodone-aspirin oxycodone-ibuprofen OXYCONTIN oxymorphone hcl oxymorphone hcl er 92 50 113 129 94 128 132 107 107 63 115 18 37 102 4 60 24 34 34 92 25 98 98 9 6 9 9 9 6 9 6 P pacerone paclitaxel paliperidone er pamidronate disodium PANDEL PANRETIN pantoprazole sodium paricalcitol 73 42 52 119 92 47 97 119 paromomycin sulfate paroxetine hcl paroxetine hcl er PASER PATADAY PATANASE PATANOL PAXIL PAZEO PCE PEDVAX HIB peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEG-INTRON PEGANONE PEGASYS PEGASYS PROCLICK PEGINTRON penicillin g pot in dextrose penicillin g potassium penicillin g sodium penicillin v potassium PENNSAID PENTAM PENTASA pentoxifylline er PERFOROMIST perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline phenadoz phenelzine sulfate phenergan phenobarbital phenoxybenzamine hcl phenytoin phenytoin infatabs phenytoin sodium 12 28,29 29 36 122 126 122 29 122 19 117 96 97 56 25 56 56 56 18 18 18 18 4 47 118 79 128 72,73 89 46 48 50 27 126 27 126 22,23 71 25 25 25 157 phenytoin sodium extended PHOSLO PHOSLYRA PHOSPHOLINE IODIDE physiolyte physiosol irrigation PICATO pilocarpine hcl pimozide pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so pirmella 1/35 piroxicam PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN D5W podofilox polyethylene glycol 3350 polymyxin b sulfate polymyxin b-trimethoprim POMALYST portia-28 PORTRAZZA potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er POTIGA PRADAXA PRALUENT pramipexole dihydrochloride pramipexole dihydrochloride er pravastatin sodium prazosin hcl PRED MILD 25 99 99 123 120 120 92 89,123 50 107 75 63,64 64 64 18 107 4 134 134 137 93 97 14 121 38 107 46 134 134 134 137 134 134 21 68 83 48 49 82 71 122 PRED-G PRED-G S.O.P. prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate prednisone PREDNISONE INTENSOL PREFEST pregnyl PREMARIN premasol premium lidocaine PREMPHASE PREMPRO prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC primaquine phosphate primidone PRIMLEV PRIMSOL PRISTIQ PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-pak proctosol hc proctozone-hc progesterone micronized PROGLYCEM 121 121 93 100 122 100,122 100,101 101 107 102 107 137 10 107 107 83 107 54 55 36 97,98 48 23 9 14 29,30 115 128 128 35 73 137 31 31 31 69,70 118 118 118 109 65 158 PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl promethegan propafenone hcl propafenone hcl er propantheline bromide proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL PROTOPIC protriptyline hcl PRUDOXIN PSORCON PULMICORT PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide pyridostigmine bromide er 113 130 123 42 119 70 126 126 73 73 95 121 75 75 79 111 117 137 93 31 93 101 125 130 39 36 36 36 Q QUADRACEL quasense quetiapine fumarate QUILLIVANT XR quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate quinidine gluconate er quinidine sulfate quinine sulfate QVAR 117 107 52 87 73 79 73 73 73 48 125 R ra cetirizine childrens 138 RABAVERT 117 rabeprazole sodium 98 raloxifene hcl 109 ramipril 73 RANEXA 79,80 ranitidine hcl 96 RAPAFLO 99 RAPAMUNE 113 RAVICTI 94 RAYOS 101 REBETOL 56 REBIF 88 REBIF REBIDOSE 88 REBIF REBIDOSE TITRATION PACK 88 REBIF TITRATION PACK 88 RECLAST 119 reclipsen 107 RECOMBIVAX HB 117 RECTIV 120 REGRANEX 93 RELENZA DISKHALER 57 RELISTOR 95 35 RELPAX 113 REMICADE REMODULIN 129 RENAGEL 99 RENVELA 99 repaglinide 64 REPATHA 83 REPATHA SURECLICK 83 RESCRIPTOR 53 reserpine 71 RESTASIS 121 RETROVIR 54 REVATIO 129 REVLIMID 38 REXULTI 52 REYATAZ 55 159 RHEUMATREX RIBASPHERE ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine hcl ringers ringers irrigation RIOMET risedronate sodium RISPERDAL CONSTA risperidone risperidone m-tab RITALIN LA RITUXAN rivastigmine rivastigmine tartrate rizatriptan benzoate ropinirole hcl ropinirole hcl er ROTARIX ROTATEQ ROZEREM RUCONEST 114 56 57 115 36 36 36 87 57 137 120 64 119 52 52 52 87 46 25 25 35 49 49 117 117 133 112 S SABRIL SAIZEN SAIZEN CLICK.EASY SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK SECONAL 23 95,102 102 133 32 114 111 93 52 88 88 133 selegiline hcl 49 selenium sulfide 93 SELZENTRY 55 SEMPREX-D 130 SENSIPAR 110 SEREVENT DISKUS 128 SEROQUEL XR 52 sertraline hcl 29 setlakin 107 sharobel 109 SIGNIFOR 111 sildenafil citrate 129 silver sulfadiazine 20 SIMBRINZA 123 SIMULECT 115 82 simvastatin sirolimus 114 SIRTURO 37 sodium chloride 120,134 sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 134 135 sodium lactate sodium phenylbutyrate 94 sodium polystyrene sulfonate 133 SOLARAZE 93 SOLTAMOX 38 SOLU-CORTEF 101 SOLU-MEDROL 101 SOMATULINE DEPOT 111 SOMAVERT 111 sorine 73,74 sotalol hcl 74 sotalol hcl (af) 74 SOVALDI 57 SPIRIVA HANDIHALER 127 SPIRIVA RESPIMAT 127 spironolactone 81 spironolactone-hctz 80 SPORANOX 34 sprintec 28 107 SPRITAM 21 160 SPRYCEL sps sronyx ssd ssd af stavudine STELARA sterile water for irrigation STIMATE STIOLTO RESPIMAT STIVARGA STRATTERA STRENSIQ streptomycin sulfate STRIANT STRIBILD STRIVERDI RESPIMAT STROMECTOL SUBOXONE SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-tmp ds sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulindac sumatriptan sumatriptan succinate sumatriptan succinate refill SUPRAX SUPREP BOWEL PREP SURMONTIL SUSTIVA SUTENT SYLATRON SYLVANT SYMBICORT 44 133 107 20 20 54 93 120 102 131 44 87 94 12 103 55 128 47 11 94 97 20,93 93 121 20 14 14 14 118 4 35 35 36 16 97 31 53 44,45 116 46 130 SYMLINPEN 120 SYMLINPEN 60 SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYNTHROID SYPRINE 64 64 116 111 14 64 42 110 133 T TABLOID tacrolimus TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN tarina fe 1/20 TASIGNA TASMAR TAXOTERE tazicef TAZORAC taztia xt TECFIDERA TECHNIVIE TEFLARO TEGRETOL-XR telmisartan telmisartan-amlodipine telmisartan-hctz temazepam TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole testosterone cypionate 40 93,114 45 46 57 38 99 45 47 107 45 48 42 16 93 77 88 57 16 25 72 80 80 132 117 99 34 128 34 103 161 testosterone enanthate tetanus-diphtheria toxoids td tetrabenazine tetracycline hcl THALOMID theophylline theophylline er thioridazine hcl thiotepa thiothixene THYMOGLOBULIN THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 tiagabine hcl TIKOSYN timolol maleate tinidazole TIVICAY tizanidine hcl TOBI PODHALER TOBRADEX ST tobramycin tobramycin pak tobramycin sulfate tobramycin-dexamethasone tobrasol TOBREX tolazamide tolbutamide tolcapone tolmetin sodium tolterodine tartrate tolterodine tartrate er topiramate topiramate er toposar topotecan hcl TORISEL 103 117 87 21 38 129 129 50 37 50 115 110 110 110 110 110 23 74 75,123 48 53 132 128 121 12 12 12 121 12 12 64 64 48 4 98 98 24 24 43 43 45 torsemide TOUJEO SOLOSTAR TOVIAZ tpn electrolytes TRACLEER TRADJENTA tramadol hcl tramadol hcl er tramadol hcl er (biphasic) tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVASOL TRAVATAN Z travoprost trazodone hcl TREANDA TRECATOR TRELSTAR TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin tretinoin microsphere tretinoin microsphere pump TREXALL tri-legest fe tri-lo-estarylla tri-lo-sprintec tri-previfem tri-sprintec triamcinolone acetonide triamterene-hctz TRIBENZOR triderm trifluoperazine hcl trifluridine trihexyphenidyl hcl trilyte 80 66 98 137 129 64 9 6 6 9 73 70 31 27 137 124 124 29 38 37 111 111 111 111 47,93 93 93 114 107 107 107 107 108 89,93 80 80 93 50 57 48 97 162 trimethoprim trimipramine maleate trinessa (28) trinessa lo TRISENOX TRIUMEQ trivora (28) TRIZIVIR TROPHAMINE trospium chloride trospium chloride er TRULICITY TRUMENBA TRUVADA TWINRIX TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA TYZINE 14 31 108 108 42 55 108 54 137 98 98 64 117 54 117 55 14 45 117 88 56 131 U UCERIS ULORIC unithroid UPTRAVI ursodiol UVADEX 118 35 110 129,130 95 93 V valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide VANATOL LQ 57 38 55 55 23 23 72 80 2 vancomycin hcl vandazole VAQTA VARIVAX VARIZIG VASCEPA VECTIBIX VELCADE velivet VELPHORO VELTIN venlafaxine hcl venlafaxine hcl er VENTAVIS VENTOLIN HFA verapamil hcl verapamil hcl er VERSACLOZ VESICARE vestura VEXOL VFEND VIBRAMYCIN vicodin vicodin es vicodin hp VICTOZA VIDAZA VIDEX VIEKIRA PAK vienva VIGAMOX VIIBRYD VIIBRYD STARTER PACK VIMPAT vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VIRACEPT VIRAMUNE 14 14 117 117 117 83 46 42 108 99 93 29,30 29 130 128 77 77 53 98 108 123 34 21 9 9 9 64 40 54 57 108 20 30 30 25 42 42 42 42 55 53 163 VIRAMUNE XR VIRAZOLE VIREAD vitazol VITEKTA VIVELLE-DOT VIVITROL VOLTAREN voriconazole VOTRIENT VPRIV VRAYLAR vyfemla VYTORIN 53 131 54 14 53 108 10 4 34 45 94 52 108 84 W wal-itin allergy reditabs wal-zyr warfarin sodium WELCHOL wymzya fe 138 138 68 84 108 X XALKORI XARELTO XARELTO STARTER PACK XELJANZ XELJANZ XR XENAZINE XGEVA XIFAXAN XOLAIR XTANDI XULANE XYREM 45 68 68 114 114 87 119 14 131 38 108 133 Y YERVOY YF-VAX YONDELIS 46 117 38 Z zafirlukast zaleplon ZALTRAP zamicet ZANOSAR ZARXIO ZAVESCA zazole ZELAPAR ZELBORAF ZEMAIRA zenchent zenchent fe ZENPEP ZEPANIVEL ZETIA ZIAGEN zidovudine ziprasidone hcl ZIPSOR ZIRGAN ZMAX zoledronic acid ZOLINZA zolmitriptan zolpidem tartrate zolpidem tartrate er ZOMACTON zonisamide ZORTRESS ZOSTAVAX ZOSYN zovia 1/35e (28) ZOVIA 1/50E (28) ZUBSOLV ZYCLARA ZYCLARA PUMP ZYDELIG ZYFLO 126 132 45 10 38 70 94 34 49 45 131 108 108 94 57 84 54 54 52 4 55 19 119 42 36 132 132 102 22 114 117 18 108 108 11 94 94 45 126 164 ZYFLO CR ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX 126 45 121 52 38 14 Este vademécum se actualizó el 06/01/2016. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con AlphaCare of New York, Member Services llamando al 855-652-5742 o, para los usuarios de TTY, 711, Lunes - Domingo de 8:00 AM – 8:00 PM, o visite www.alphacare.com
