2015 Drug Formulary AL, EP,FR, LA, ME, OR, RI, SB, SD, SF, SJ, SC
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QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD ARIPIPRAZOLE TABLET 30 TABS IN 30 DAYS ABILIFY ARIPIPRAZOLE ORAL SOLUTION 900 ML IN 30 DAYS ABILIFY DISCMELT 10 MG ARIPIPRAZOLE TAB RAPDIS 30 TABS IN 30 DAYS ABILIFY DISCMELT 15 MG ARIPIPRAZOLE TAB RAPDIS 60 TABS IN 30 DAYS ACARBOSE 100 MG ACARBOSE TABLET 90 TABS IN 30 DAYS ACARBOSE 25 MG ACARBOSE TABLET 360 TABS IN 30 DAYS ACARBOSE 50 MG ACARBOSE TABLET 180 TABS IN 30 DAYS ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE ORAL SOLUTION 1800 ML IN 30 DAYS ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINETABLET 120 TABS IN 30 DAYS ACTONEL 35 MG RISEDRONATE SODIUM TABLET 4 TABS IN 28 DAYS ACTONEL 5 MG RISEDRONATE SODIUM TABLET 30 TABS IN 30 DAYS ACYCLOVIR ACYCLOVIR TOPICAL OINT. 30 GM IN 30 DAYS ADVAIR DISKUS FLUTICASONE/SALMETEROL INHALATION DISK 60 CAPS IN 30 DAYS ADVAIR HFA 120 ACTU FLUTICASONE/SALMETEROL AEROSOL 12 GM IN 30 DAYS ADVAIR HFA 60 ACTU FLUTICASONE/SALMETEROL AEROSOL 8 GM IN 30 DAYS ALENDRONATE 35 MG, 70MG ALENDRONATE SODIUM TABLET 4 TABS IN 28 DAYS ALENDRONATE 5MG, 10MG, 40MG ALENDRONATE SODIUM TABLET 30 TABS IN 30 DAYS ALFUZOSIN HCL ER ALFUZOSIN HCL TAB ER 24H 30 TABS IN 30 DAYS ALPRAZOLAM .25 MG, .5MG, 1MG ALPRAZOLAM TABLET 120 TABS IN 30 DAYS ALPRAZOLAM 2 MG ALPRAZOLAM TABLET 60 TABS IN 30 DAYS AMLODIPINE-BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL CAPSULE ANORO ELLIPTA UMECLIDINIUM BRM/VILANTEROL TR INHALATION DISK60 CAPS IN 30 DAYS APTIOM 200 MG, 400MG ESLICARBAZEPINE ACETATE TABLET 30 TABS IN 30 DAYS APTIOM 600 MG ESLICARBAZEPINE ACETATE TABLET 60 TABS IN 30 DAYS ASCOMP WITH CODEINE CODEINE/BUTALBITAL/ASA/CAFFEIN CAPSULE 180 CAPS IN 30 DAYS ATELVIA RISEDRONATE SODIUM 4 TABS IN 28 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY TABLET DR 30 CAPS IN 30 DAYS 29 QUANTITY LIMITS TABLE ABILIFY QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD QUANTITY LIMITS TABLE BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD AVODART DUTASTERIDE CAPSULE 30 CAPS IN 30 DAYS AZELASTINE HCL AZELASTINE HCL NASAL SPRAY 30 ML IN 30 DAYS AZILECT RASAGILINE MESYLATE TABLET 30 TABS IN 30 DAYS AZITHROMYCIN AZITHROMYCIN ORAL PACKETS 2 GM IN 30 DAYS AZITHROMYCIN 100 MG/5ML AZITHROMYCIN ORAL SUSP 2 ML IN 30 DAYS AZITHROMYCIN 200 MG/5ML AZITHROMYCIN ORAL SUSP 67.5 ML IN 30 DAYS AZITHROMYCIN 250 MG, 500MG AZITHROMYCIN TABLET 6 TABS IN 30 DAYS AZITHROMYCIN 600 MG AZITHROMYCIN TABLET 8 TABS IN 30 DAYS AZOPT BRINZOLAMIDE OPHT SUSP 15 ML IN 30 DAYS BUPROPION XL BUPROPION HCL TAB ER 24H 30 TABS IN 30 DAYS BUTALB-CAFF-APAP-CODEIN BUTALBIT/ACETAMIN/CAFF/CODEINE CAPSULE 180 CAPS IN 30 DAYS BUTALBITAL COMP-CODEINE CODEINE/BUTALBITAL/ASA/CAFFEIN CAPSULE 120 CAPS IN 30 DAYS CALCIPOTRIENE CALCIPOTRIENE TOPICAL CREAM 60 GM IN 30 DAYS CALCIPOTRIENE CALCIPOTRIENE TOPICAL SOLUTION 60 ML IN 30 DAYS CARISOPRODOL CARISOPRODOL TABLET 90 TABS IN 30 DAYS CHLORZOXAZONE CHLORZOXAZONE TABLET 180 TABS IN 30 DAYS CLORAZEPATE 15 MG CLORAZEPATE DIPOTASSIUM TABLET 180 TABS IN 30 DAYS CLORAZEPATE 3.75 MG, 7.5MG CLORAZEPATE DIPOTASSIUM TABLET 120 TABS IN 30 DAYS CODEINE SULFATE CODEINE SULFATE 120 TABS IN 30 DAYS COMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL SULFATE AEROSOL 8 GM IN 30 DAYS COMFORT PAC-CYCLOBENZAPRINE CYCLOBENZ HCL/IRR CNTR-IRR CB2 KIT 90 TABS IN 30 DAYS CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL TABLET 90 TABS IN 30 DAYS DIAZEPAM DIAZEPAM KIT 5 SUPP IN 30 DAYS DIAZEPAM DIAZEPAM ORAL SOLUTION 1200 ML IN 30 DAYS DIAZEPAM DIAZEPAM TABLET 120 TABS IN 30 DAYS DIFFERIN ADAPALENE MED. SWAB 45 GM IN 30 DAYS 30 TABLET 2015 CARE1ST MEDICARE DRUG FORMULARY QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD DIGOXIN TABLET 30 TABS IN 30 DAYS DORZOLAMIDE HCL DORZOLAMIDE HCL OPHT DROPS 10 ML IN 30 DAYS DORZOLAMIDE-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEAT OPHT DROPS10 ML IN 30 DAYS DOXERCALCIFEROL 0.5 MCG DOXERCALCIFEROL CAPSULE 30 CAPS IN 30 DAYS DOXERCALCIFEROL 1 MCG DOXERCALCIFEROL CAPSULE 90 CAPS IN 30 DAYS EDURANT RILPIVIRINE HCL TABLET 30 TABS IN 30 DAYS ELIDEL PIMECROLIMUS TOPICAL CREAM 30 GM IN 30 DAYS ELLA ULIPRISTAL ACETATE TABLET 1 TABS IN 30 DAYS ENDOCET OXYCODONE HCL/ACETAMINOPHEN TABLET 120 TABS IN 30 DAYS ENDODAN OXYCODONE HCL/ASPIRIN TABLET 120 TABS IN 30 DAYS FENTANYL FENTANYL PATCH 10 PATCH IN 30 DAYS FENTANYL CITRATE FENTANYL CITRATE LOZENGE HD 120 LOZ IN 30 DAYS FINASTERIDE FINASTERIDE TABLET 30 TABS IN 30 DAYS FORTEO TERIPARATIDE INJECTION KIT 3 UNIT IN 28 DAYS FYCOMPA 10MG, 12MG PERAMPANEL TABLET 30 TABS IN 30 DAYS FYCOMPA 2MG, 4MG, 8MG PERAMPANEL TABLET 30 TABS IN 30 DAYS FYCOMPA 6MG PERAMPANEL TABLET 60 TABS IN 30 DAYS GLIMEPIRIDE 1 MG GLIMEPIRIDE TABLET 240 TABS IN 30 DAYS GLIMEPIRIDE 2 MG GLIMEPIRIDE TABLET 120 TABS IN 30 DAYS GLIMEPIRIDE 4 MG GLIMEPIRIDE TABLET 60 TABS IN 30 DAYS GLIP/METFORMIN 2.5-250 MG GLIPIZIDE/METFORMIN HCL TABLET 240 TABS IN 30 DAYS GLIP/METFORMIN 2.5-500MG GLIPIZIDE/METFORMIN HCL TABLET 120 TABS IN 30 DAYS GLIP/METFORMIN 5-500MG GLIPIZIDE/METFORMIN HCL TABLET 120 TABS IN 30 DAYS GLIPIZIDE 10 MG GLIPIZIDE TABLET 120 TABS IN 30 DAYS GLIPIZIDE 5 MG GLIPIZIDE TABLET 60 TABS IN 30 DAYS GLIPIZIDE ER 10 MG GLIPIZIDE TAB ER 24 60 TABS IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY 31 QUANTITY LIMITS TABLE DIGOX QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD QUANTITY LIMITS TABLE BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD GLIPIZIDE ER 2.5 MG GLIPIZIDE TAB ER 24 240 TABS IN 30 DAYS GLIPIZIDE ER 5 MG GLIPIZIDE TAB ER 24 120 TABS IN 30 DAYS GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT INJECTION KIT 2 UNIT IN 30 DAYS GLYBURIDE 1.25 MG GLYBURIDE TABLET 480 TABS IN 30 DAYS GLYBURIDE 2.5 MG GLYBURIDE TABLET 240 TABS IN 30 DAYS GLYBURIDE 5 MG GLYBURIDE TABLET 120 TABS IN 30 DAYS GLYBURIDE MICRONIZED 1.5 MG GLYBURIDE,MICRONIZED TABLET 240 TABS IN 30 DAYS GLYBURIDE MICRONIZED 3 MG GLYBURIDE,MICRONIZED TABLET 120 TABS IN 30 DAYS GLYBURIDE MICRONIZED 6 MG GLYBURIDE,MICRONIZED TABLET 60 TABS IN 30 DAYS GLYBURIDE-METFORMIN 1.25-250MG GLYBURIDE/METFORMIN TABLET 240 TABS IN 30 DAYS GLYBURIDE-METFORMIN 2.5-500MG GLYBURIDE/METFORMIN TABLET 120 TABS IN 30 DAYS GLYBURIDE-METFORMIN 5-500MG GLYBURIDE/METFORMIN TABLET 120 TABS IN 30 DAYS GLYSET 100 MG MIGLITOL TABLET 90 TABS IN 30 DAYS GLYSET 25 MG MIGLITOL TABLET 360 TABS IN 30 DAYS GLYSET 50 MG MIGLITOL TABLET 180 TABS IN 30 DAYS HOMATROPINE HYDROBROMIDE HOMATROPINE HBR OPHT DROPS 5 ML IN 30 DAYS HYDROCODONE BIT-IBUPROFEN HYDROCODONE/IBUPROFEN TABLET HYDROCODONE-APAP HYDROCODONE/ACETAMINOPHEN ORAL SOLUTION 1800 ML IN 30 DAYS HYDROCODONE-APAP HYDROCODONE/ACETAMINOPHENTABLET 120 TABS IN 30 DAYS HYDROCODONE-IBUPROFEN HYDROCODONE/IBUPROFEN TABLET 120 TABS IN 30 DAYS HYDROMORPHONE HCL HYDROMORPHONE HCL TABLET 120 TABS IN 30 DAYS IBANDRONATE SODIUM IBANDRONATE SODIUM TABLET 1 TABS IN 30 DAYS IMIQUIMOD IMIQUIMOD TOPICAL CREAM 12 GM IN 30 DAYS INVEGA PALIPERIDONE TAB ER 24 30 TABS IN 30 DAYS INVIRASE SAQUINAVIR MESYLATE CAPSULE 300 CAPS IN 30 DAYS ISENTRESS RALTEGRAVIR POTASSIUM ORAL POWD PACK 32 120 TABS IN 30 DAYS 60 GM IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD RALTEGRAVIR POTASSIUM TAB CHEW 180 TABS IN 30 DAYS ISENTRESS 25 MG RALTEGRAVIR POTASSIUM TAB CHEW 120 TABS IN 30 DAYS JANUMET SITAGLIPTIN PHOS/METFORMIN HCL TABLET 60 TABS IN 30 DAYS JANUMET XR 100-1000MG SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 60 TABS IN 30 DAYS JANUMET XR 50-1000 MG SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 60 TABS IN 30 DAYS JANUMET XR 50MG-500MG SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 30 TABS IN 30 DAYS JANUVIA SITAGLIPTIN PHOSPHATE 30 TABS IN 30 DAYS JENTADUETO LINAGLIPTIN/METFORMIN HCL TABLET 60 TABS IN 30 DAYS KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE INJECTION 20 ML IN 30 DAYS KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINEINJECTION CART 20 ML IN 30 DAYS KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINETABLET 20 TABS IN 30 DAYS LAZANDA FENTANYL CITRATE NASAL SPRAY 75 ML IN 30 DAYS LEVETIRACETAM ER 500 MG LEVETIRACETAM TAB ER 24H 180 TABS IN 30 DAYS LEVETIRACETAM ER 750 MG LEVETIRACETAM TAB ER 24H 120 TABS IN 30 DAYS LEVOBUNOLOL HCL LEVOBUNOLOL HCL OPHT DROPS 15 ML IN 30 DAYS LORAZEPAM LORAZEPAM TABLET 120 TABS IN 30 DAYS LORCET HYDROCODONE/ACETAMINOPHEN TABLET 120 TABS IN 30 DAYS LORCET HD HYDROCODONE/ACETAMINOPHEN TABLET 120 TABS IN 30 DAYS LORCET PLUS HYDROCODONE/ACETAMINOPHEN TABLET 120 TABS IN 30 DAYS MEPERIDINE HCL MEPERIDINE HCL ORAL SOLUTION 600 ML IN 30 DAYS MEPERIDINE HCL MEPERIDINE HCL TABLET 120 TABS IN 30 DAYS METFORMIN ER 1000 MG, 750 MG METFORMIN HCL TAB ER 24 60 TABS IN 30 DAYS METFORMIN HCL 1000 MG METFORMIN HCL TABLET 60 TABS IN 30 DAYS METFORMIN HCL 500 MG METFORMIN HCL TABLET 150 TABS IN 30 DAYS METFORMIN HCL 850 MG METFORMIN HCL TABLET 90 TABS IN 30 DAYS METFORMIN HCL ER 500 MG METFORMIN HCL TAB ER 24H 120 TABS IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY TABLET 33 QUANTITY LIMITS TABLE ISENTRESS 100 MG QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD QUANTITY LIMITS TABLE BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD METHADONE HCL METHADONE HCL ORAL SOLUTION 1800 ML IN 30 DAYS METHADONE HCL METHADONE HCL TABLET 120 TABS IN 30 DAYS METHADONE INTENSOL METHADONE HCL ORAL CONC 1800 ML IN 30 DAYS METHADOSE METHADONE HCL TABLET SOL 120 TABS IN 30 DAYS METHOCARBAMOL 500 MG METHOCARBAMOL TABLET 240 TABS IN 30 DAYS METHOCARBAMOL 750 MG METHOCARBAMOL TABLET 180 TABS IN 30 DAYS METOPROLOL SUCCINATE 100 MG METOPROLOL SUCCINATE TAB ER 24H 30 TABS IN 30 DAYS METOPROLOL SUCCINATE 200 MG METOPROLOL SUCCINATE TAB ER 24H 60 TABS IN 30 DAYS METOPROLOL SUCCINATE 25 MG METOPROLOL SUCCINATE TAB ER 24H 30 TABS IN 30 DAYS METOPROLOL SUCCINATE 50 MG METOPROLOL SUCCINATE TAB ER 24H 30 TABS IN 30 DAYS MORPHINE SULFATE MORPHINE SULFATE ORAL SOLUTION 1800 ML IN 30 DAYS MORPHINE SULFATE MORPHINE SULFATE RECTAL SUPP 120 SUPP IN 30 DAYS MORPHINE SULFATE MORPHINE SULFATE TABLET 120 TABS IN 30 DAYS MORPHINE SULFATE ER MORPHINE SULFATE TABLET ER 90 TABS IN 30 DAYS MUPIROCIN MUPIROCIN TOPICAL OINT. 22 GM IN 30 DAYS NAPHAZOLINE W/ANTAZOLINE NAPHAZOLINE HCL/ANTAZOLINE OPHT DROPS 15 ML IN 30 DAYS NEOMYCIN W/DEXAMETHASONE NEOMYCIN SULFATE/DEX NA PH OPHT DROPS 5 ML IN 30 DAYS OLANZAPINE OLANZAPINE TABLET 30 TABS IN 30 DAYS OLANZAPINE ODT OLANZAPINE TAB RAPDIS 30 TABS IN 30 DAYS OMEPRAZOLE 10 MG, 20 MG OMEPRAZOLE CAPSULE DR 60 CAPS IN 30 DAYS OMEPRAZOLE 40MG OMEPRAZOLE CAPSULE DR 30 CAPS IN 30 DAYS OXYCODONE HCL OXYCODONE HCL CAPSULE 120 CAPS IN 30 DAYS OXYCODONE HCL OXYCODONE HCL ORAL CONC 250 ML IN 30 DAYS OXYCODONE HCL OXYCODONE HCL ORAL SOLUTION 250 ML IN 30 DAYS OXYCODONE HCL OXYCODONE HCL TABLET 120 TABS IN 30 DAYS OXYCODONE HCL-APAP OXYCODONE HCL/ACETAMINOPHEN TABLET 34 120 TABS IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD OXYCODONE HCL/ASPIRIN TABLET 120 TABS IN 30 DAYS OXYCODONE-ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN TABLET 120 TABS IN 30 DAYS OXYCONTIN OXYCODONE HCL TAB ER 12H 60 TABS IN 30 DAYS PATANOL OLOPATADINE HCL OPHT DROPS 5 ML IN 30 DAYS PEG 3350-ELECTROLYTE PEG 3350/NA SULF,BICARB,CL/KCL ORAL SOLUTION 4000 ML IN 30 DAYS PENTASA MESALAMINE CAPSULE ER 480 CAPS IN 30 DAYS PHENYLEPHRINE HCL PHENYLEPHRINE HCL OPHT DROPS 15 ML IN 30 DAYS PILOCARPINE HCL PILOCARPINE HCL OPHT DROPS 15 ML IN 30 DAYS PIOGLITAZONE HCL PIOGLITAZONE HCL TABLET 30 TABS IN 30 DAYS POTIGA EZOGABINE TABLET 270 TABS IN 30 DAYS PREZISTA DARUNAVIR ETHANOLATE ORAL SUSP 360 ML IN 30 DAYS PREZISTA DARUNAVIR ETHANOLATE TABLET 60 TABS IN 30 DAYS PROAIR HFA ALBUTEROL SULFATE AEROSOL 17 GM IN 30 DAYS QUETIAPINE FUMARATE QUETIAPINE FUMARATE TABLET 90 TABS IN 30 DAYS RALOXIFENE HCL RALOXIFENE HCL TABLET 30 TABS IN 30 DAYS REGRANEX BECAPLERMIN TOPICAL GEL 15 GM IN 30 DAYS RELENZA ZANAMIVIR INHALATION DISK 56 CAPS IN 180 DAYS REPREXAIN HYDROCODONE/IBUPROFEN TABLET 120 TABS IN 30 DAYS RESTASIS CYCLOSPORINE OPHT DROPS 64 ML IN 30 DAYS RISEDRONATE SODIUM 150 MG RISEDRONATE SODIUM TABLET 1 TABS IN 30 DAYS RISPERIDONE RISPERIDONE ORAL SOLUTION 240 ML IN 30 DAYS RISPERIDONE RISPERIDONE TABLET 60 TABS IN 30 DAYS RISPERIDONE ODT RISPERIDONE TAB RAPDIS 60 TABS IN 30 DAYS RIZATRIPTAN RIZATRIPTAN BENZOATE TAB RAPDIS 12 TABS IN 30 DAYS RIZATRIPTAN RIZATRIPTAN BENZOATE TABLET 12 TABS IN 30 DAYS ROXICET OXYCODONE HCL/ACETAMINOPHEN TABLET 2015 CARE1ST MEDICARE DRUG FORMULARY 120 TABS IN 30 DAYS 35 QUANTITY LIMITS TABLE OXYCODONE HCL-ASPIRIN QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD QUANTITY LIMITS TABLE BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD SENSIPAR CINACALCET HCL TABLET 30 TABS IN 30 DAYS SIROLIMUS SIROLIMUS TABLET 30 TABS IN 30 DAYS SPIRIVA TIOTROPIUM BROMIDE INHALATION CAPSULE 30 CAPS IN 30 DAYS SUMATRIPTAN SUMATRIPTAN NASAL SPRAY SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE TABLET 9 TABS IN 30 DAYS SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE INJECTION CART 4 ML IN 30 DAYS TAMIFLU OSELTAMIVIR PHOSPHATE ORAL SUSP 360 ML IN 180 DAYS TAMIFLU 30MG OSELTAMIVIR PHOSPHATE CAPSULE 56 CAPS IN 180 DAYS TAMIFLU 45MG, 75MG OSELTAMIVIR PHOSPHATE CAPSULE 28 CAPS IN 180 DAYS TAMSULOSIN HCL TAMSULOSIN HCL CAP ER 24H 60 CAPS IN 30 DAYS TEMAZEPAM TEMAZEPAM CAPSULE 30 CAPS IN 30 DAYS TOLAZAMIDE TOLAZAMIDE TABLET 60 TABS IN 30 DAYS TOLBUTAMIDE TOLBUTAMIDE TABLET 180 TABS IN 30 DAYS TOLTERODINE TARTRATE TOLTERODINE TARTRATE TABLET 60 TABS IN 30 DAYS TOLTERODINE TARTRATE ER TOLTERODINE TARTRATE CAP ER 24H 30 CAPS IN 30 DAYS TRADJENTA LINAGLIPTIN TABLET 30 TABS IN 30 DAYS TRAMADOL HCL TRAMADOL HCL TABLET 240 TABS IN 30 DAYS TRAMADOL-ACETAMINOPHEN TRAMADOL HCL/ACETAMINOPHEN TABLET 240 TABS IN 30 DAYS TRAVATAN Z TRAVOPROST 5 ML IN 30 DAYS TRAVOPROST TRAVOPROST (BENZALKONIUM) OPHT DROPS 5 ML IN 30 DAYS TRIAZOLAM TRIAZOLAM TABLET 30 TABS IN 30 DAYS TROKENDI XR 100MG TOPIRAMATE CAP ER 24H 90 CAPS IN 30 DAYS TROKENDI XR 200MG TOPIRAMATE CAP ER 24H 240 CAPS IN 30 DAYS TROKENDI XR 25MG TOPIRAMATE CAP ER 24H 90 CAPS IN 30 DAYS TROKENDI XR 50MG TOPIRAMATE CAP ER 24H 90 CAPS IN 30 DAYS VENTOLIN HFA ALBUTEROL SULFATE AEROSOL 36 GM IN 30 DAYS 36 OPHT DROPS 9 ML IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD BRAND DRUG NAME NOMBRE DE MARCA GENERIC DRUG NAME NOMBRE GENERICO FORMULATION FORMA FARMACEUTICA QUANTITY LIMIT LIMITE DE CANTIDAD LACOSAMIDE INTRAVENOUS (IV) 200 ML IN 5 DAYS ZAFIRLUKAST ZAFIRLUKAST TABLET 60 TABS IN 30 DAYS ZIPRASIDONE HCL 20 MG, 40 MG ZIPRASIDONE HCL CAPSULE 60 CAPS IN 30 DAYS ZIPRASIDONE HCL 60 MG, 80 MG ZIPRASIDONE HCL CAPSULE 120 CAPS IN 30 DAYS ZMAX AZITHROMYCIN ORAL SUS ER REC 60 ML IN 30 DAYS ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE TABLET 30 TABS IN 30 DAYS ZOVIRAX ACYCLOVIR TOPICAL CREAM 10 GM IN 30 DAYS 2015 CARE1ST MEDICARE DRUG FORMULARY 37 QUANTITY LIMITS TABLE VIMPAT
