Lista de Medicamentos - Blue Cross and Blue Shield of Illinois

Blue Cross Community
Integrated Care Plan (ICP)SM
Lista de medicamentos 2016
Este documento contiene información sobre
los medicamentos que cubre este plan.
Este formulario fue actualizado el 09/19/2016.
Lista de medicamentos
¿Qué es la lista de medicamentos
de Blue Cross Community ICP Plan
(el "plan")?
La lista de medicamentos (a veces denominada "formulario")
es una lista que enumera los medicamentos que pueden
estar cubiertos por el plan. Para que los medicamentos
enumerados estén cubiertos, usted debe cumplir con
lo siguiente:
•tener la necesidad médica de obtenerlos;
•abastecer las recetas en una farmacia de la red;
•seguir otras normas del plan.
Para obtener más información sobre cómo abastecer sus
recetas, consulte el Manual para miembros.
¿Cuánto tendré que pagar?
No debe pagar nada por los medicamentos cubiertos.
¿La lista de medicamentos
puede cambiar?
Sí, puede cambiar.
¿Cómo utilizo la lista de medicamentos?
1. Por categoría
•Los medicamentos se enumeran en categorías, o
grupos, según el tipo de afección que tratan.
(Por ejemplo, los medicamentos que se utilizan
para tratar enfermedades cardíacas se enumeran
en "Heart and Circulatory Drugs" [Medicamentos
cardiovasculares]).
•Si sabe qué afección trata su medicamento, busque
ese grupo en la lista.
•Luego, busque el medicamento dentro de ese grupo.
2. Listado en orden alfabético
•Busque su medicamento en el índice.
•Al lado del medicamento verá el número de página
donde puede encontrar la información de la
cobertura.
¿Qué son los medicamentos genéricos?
Los medicamentos genéricos son aprobados por la
Administración de Drogas y Alimentos (FDA) por tener
el mismo ingrediente activo que el medicamento de
marca, pero generalmente cuestan menos. El plan cubre
medicamentos de marca y medicamentos genéricos.
La cobertura puede cambiar en los siguientes casos:
• cuando esté disponible un nuevo medicamento genérico;
• cuando nueva información sobre un medicamento
demuestra que este no es seguro o que es menos eficaz.
Cuando se realicen cambios en la lista de medicamentos, se
lo notificaremos por escrito.
i
Blue Cross Community Integrated Care Plan (ICP)
¿Existe algún límite en mi cobertura?
Las condiciones o los límites adicionales que tienen algunos
medicamentos cubiertos pueden incluir los siguientes:
•Autorización previa: Es posible que usted o su médico
deban obtener aprobación antes de abastecer las recetas.
Si no obtiene la aprobación, es posible que el plan no
cubra el medicamento.
•Límites de cantidad: El plan limita la cantidad que
cubrirá de algunos medicamentos.
•Terapia escalonada: En algunos casos, el plan requiere
que usted primero pruebe determinados medicamentos
antes de cubrir otro. Por ejemplo, si el medicamento A y
el medicamento B tratan su enfermedad, es posible que
el plan no cubra el medicamento B, a menos que usted
pruebe el medicamento A primero. Si el medicamento
A no funciona en su caso, entonces el plan cubrirá el
medicamento B.
Por lo general, solo aprobamos las solicitudes de excepción
si otros medicamentos incluidos en nuestra lista, o los
límites adicionales de uso, harían que su tratamiento sea
menos eficaz o serían perjudiciales para su salud.
¿Qué categorías de medicamentos
no están cubiertas en la lista de
medicamentos del plan?
Las siguientes categorías de medicamentos no están
cubiertas por su plan:
•medicamentos para el tratamiento de la anorexia, la
pérdida de peso o el aumento de peso;
•productos químicos a granel;
•medicamentos con fines cosméticos;
•agentes de diagnóstico;
Puede averiguar si su medicamento tiene alguna condición
o límite adicional consultando la lista que comienza en la
página 1.
•medicamentos clasificados como ineficaces por la
Implementación del Estudio de la Eficacia de los
Medicamentos (DESI);
¿El plan paga medicamentos de
venta libre?
•medicamentos contra la disfunción eréctil para tratar
la impotencia;
Sí, el plan paga algunos medicamentos de venta libre
si usted tiene una receta válida de su médico. Puede
obtenerlos sin costo alguno.
•medicamentos anestésicos generales;
¿Qué sucede si mi medicamento no
figura en la lista de medicamentos?
Comuníquese con Atención al Cliente y pregunte si el
medicamento está cubierto. Si le informan que el plan no
cubre su medicamento, tiene dos opciones:
•Hable con su médico para determinar si debe probar
primero otro medicamento de nuestra lista antes de
solicitar una excepción.
•Pregunte en Atención al Cliente cómo solicitar una
excepción para que cubramos su medicamento. Envíe
una declaración de su médico para respaldar su solicitud.
Debemos tomar una decisión dentro de los 24 horas de la
recepción de la declaración de su médico.
ii
•medicamentos experimentales y en investigación;
•medicamentos para la fertilidad;
•medicamentos de venta libre no incluidos de otra manera
en la lista de medicamentos del plan;
•suministros o equipos médicos quirúrgicos.
Lista de medicamentos
Para obtener más información
Para obtener más detalles sobre la cobertura de
medicamentos de su plan, consulte el Manual para miembros
y los demás materiales del plan.
Si usted tuviese cualquier pregunta, por favor llame a
Atención al Cliente al: 1-888-657-1211 (TTY/TDD 711). Las
horas de oficina son de 8:00 a. m. a 8:00 p. m., Hora Centro,
los 7 días de la semana. Se usarán tecnologías alternativas
(por ejemplo, correo de voz) los fines de semana y los días
feriados federales. Si deja un mensaje, un representante
de Atención al Cliente le llamará en el transcurso de un día
laboral, a más tardar. La llamada es gratuita.
Asistencia lingüística
Servicios de interpretación
Podemos coordinar que alguien lo ayude a comunicarse con
nosotros en su idioma. Estos servicios son gratuitos. Si su
médico no habla su idioma, podemos coordinar para que
un traductor lo ayude. Llame a Servicios para Miembros al
número que figura más arriba.
Problemas de audición y visión
Para nuestros miembros con problemas de audición y visión,
ofrecemos un servicio de TTY/TDD sin cargo. Llame al 711,
la línea está disponible las 24 horas del día, los 7 días de
la semana.
Otros idiomas y formatos: Puede obtener una copia de
este cuadernillo y del Manual para miembros en español
en nuestro sitio web, www.bcbsilcommunityicp.com.
También ofrecemos los materiales en otros idiomas, en letra
grande, audio y braille a través de Atención al Cliente.
Lista de medicamentos de venta libre
de Blue Cross Community ICP Plan
El plan cubre una amplia selección de productos de venta
libre. Estos se enumeran a continuación y requieren una
orden emitida por su médico. Se deben recetar y entregar
medicamentos genéricos cuando estén disponibles. Los
productos deben abastecerse en una farmacia de la red del
plan por un suministro de hasta 30 días.
Lista de medicamentos de venta libre
Analgésicos*
Acetaminophen (genérico)
Antiácidos*
Calcium carbonate (genérico);
Aluminum/magnesium hydroxide (genérico)
Antibióticos*
Bacitracin (genérico); Clotrimazole (genérico);
Miconazole (genérico); Neomycin/Bacitracin/Polymyxin
(genéricos); Tioconazole, Tolnaftate (genéricos)
Antidiarreicos*
Loperamide (genérico); Pink bismuth (genérico)
Antieméticos*
Meclizine (genérico)
Antiflatulentos*
Simethicone (genérico)
Antihistamínicos*
Chlorpheniramine (genérico); Clemastine (genérico);
Diphenhydramine (genérico); Cetirizine (genérico);
Fexofenadine (genérico); Loratadine (genérico)
Antitusivos*
Guaifenesin con DM (genérico)
iii
Blue Cross Community Integrated Care Plan (ICP)
Medicamentos para la tos
y el resfrío*
Brompheniramine y phenylephrine, Chlorpheniramine y
phenylephrine, Diphenhydramine y phenylephrine,
Guaifenesin con PE (genérico); Guaifenesin con CF (genérico)
Diluyentes*
Sodium chloride (genérico)
Productos para equipos
médicos duraderos*
Suministros para pruebas de diabetes, medidores de flujo máximo, espaciadores
Preparados para los oídos*
Carbamide peroxide (genérico)
Electrolitos*
Electrolyte solution (genérico)
Expectorantes*
Guaifenesin (genérico)
Anticonceptivos*
Condones, Levonorgestrel (anticonceptivo oral de emergencia), Nonoxinol-9
Antagonistas de los receptores
H2*
Famotidine (genérico); Ranitidine (genérico)
Laxantes*
Bisacodyl (genérico); Docusate sodium (genérico);
Magnesium citrate (genérico); Polyethylene Glycol 3350,
Psyllium (genérico); Sennosides (genérico)
Descongestivos nasales*
Phenylephrine (genérico); Saline, aerosol nasal (genérico)
Antiinflamatorios no esteroides*
Aspirin (genérico); Ibuprofen (genérico); Naproxen (genérico)
Preparados oftálmicos*
Lágrimas artificiales (genéricas); Ketotifen (genérico);
Naphazoline con pheniramine (genérico)
Pediculicidas*
Permethrin (genérico)
Hiedra venenosa*
Calamine (genérico); Hydrocortisone (genérico)
Protectores*
Zinc oxide (genérico)
Inhibidores de la bomba de
protones*
Lansoprazole (genérico); Omeprazole (genérico)
Para dejar de fumar*
Goma de mascar con nicotine (genérica); parche de nicotine (genérico)
Vitaminas y minerales*
Calcium carbonate con vitamin D (genérico);
Calcium citrate con vitamin D (genérico);
Ferrous gluconate (genérico); Ferrous sulfate (genérico);
Folic acid (genérico); multivitaminas (genérico);
multivitaminas con hierro (genérico); Nicotinic acid (genérico);
multivitaminas para niños (genérico); multivitaminas prenatales (genérico); Vitamin C
(genérico); Vitamin D (genérico)
*Se deben recetar y entregar medicamentos genéricos cuando estén disponibles.
iv
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
amoxicillin & k clavulanate
MEDICAMENTOS ANTIINFECCIOSOS
tab 875-125 mg
PENICILINAS
(Augmentin)
AMOXICILLIN –
$0 (2)
ampicillin cap 250 mg
amoxicillin (trihydrate)
ampicillin cap 500 mg
chew tab 125 mg
dicloxacillin sodium cap
AMOXICILLIN –
$0 (2)
250 mg
amoxicillin (trihydrate)
chew tab 250 mg
dicloxacillin sodium cap
500 mg
$0 (1)
amoxicillin (trihydrate) cap
250 mg
penicillin v potassium for
soln 125 mg/5ml
$0 (1)
amoxicillin (trihydrate) cap
500 mg
penicillin v potassium for
soln 250 mg/5ml
$0 (1)
amoxicillin (trihydrate) for
susp 125 mg/5ml
penicillin v potassium tab
250 mg
$0 (1)
amoxicillin (trihydrate) for
susp 200 mg/5ml
penicillin v potassium tab
500 mg
$0 (1)
amoxicillin (trihydrate) for
susp 250 mg/5ml
CEFALOSPORINAS
$0 (1)
amoxicillin (trihydrate) for
cefaclor cap 250 mg
susp 400 mg/5ml
cefaclor cap 500 mg
$0 (1)
amoxicillin (trihydrate) tab
cefadroxil cap 500 mg
875 mg
cefadroxil for susp
$0 (1)
amoxicillin & k
250 mg/5ml
clavulanate for susp
cefadroxil for susp
200-28.5 mg/5ml
500 mg/5ml
$0 (1)
amoxicillin & k
cefadroxil tab 1 gm
clavulanate for susp
250-62.5 mg/5ml
CEFAZOLIN SODIUM –
(Augmentin)
cefazolin sodium for inj
20 gm
$0 (1)
amoxicillin & k clavulanate
for susp 400-57 mg/5ml
cefdinir cap 300 mg
$0 (1)
amoxicillin & k
cefdinir for susp
clavulanate for susp
125 mg/5ml
600-42.9 mg/5ml
cefdinir for susp
(Augmentin es-600)
250 mg/5ml
$0 (1)
amoxicillin & k clavulanate
cefixime for susp
tab 250-125 mg
100 mg/5ml (Suprax)
$0 (1)
amoxicillin & k clavulanate
cefixime for susp
tab 500-125 mg
200 mg/5ml (Suprax)
(Augmentin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
1
2016
Nombre del
medicamento
cefprozil for susp
125 mg/5ml
cefprozil for susp
250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftriaxone sodium for inj
250 mg
ceftriaxone sodium for inj
500 mg (Rocephin)
ceftriaxone sodium for inj
1 gm (Rocephin)
ceftriaxone sodium for inj
2 gm
cefuroxime axetil tab
250 mg (Ceftin)
cefuroxime axetil tab
500 mg (Ceftin)
cephalexin cap 250 mg
(Keflex)
cephalexin cap 500 mg
(Keflex)
cephalexin for susp
125 mg/5ml
cephalexin for susp
250 mg/5ml
SUPRAX – cefixime cap
400 mg
SUPRAX – cefixime chew
tab 100 mg
SUPRAX – cefixime chew
tab 200 mg
SUPRAX – cefixime for
susp 100 mg/5ml
SUPRAX – cefixime for
susp 200 mg/5ml
SUPRAX – cefixime for
susp 500 mg/5ml
MACRÓLIDOS
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
AZITHROMYCIN –
azithromycin powd pack
for susp 1 gm
$0 (1)
azithromycin for susp
100 mg/5ml (Zithromax)
$0 (1)
azithromycin for susp
$0 (1)
200 mg/5ml (Zithromax)
$0 (1)
azithromycin tab 250 mg
(Zithromax)
$0 (1)
azithromycin tab 500 mg
(Zithromax)
$0 (1)
azithromycin tab 600 mg
(Zithromax)
$0 (1)
clarithromycin for susp
125 mg/5ml
$0 (1)
clarithromycin for susp
250 mg/5ml (Biaxin)
$0 (1)
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
$0 (1)
clarithromycin tab 250 mg
(Biaxin)
$0 (1)
clarithromycin tab 500 mg
(Biaxin)
$0 (1)
E.E.S. 400 – erythromycin
ethylsuccinate tab
$0 (1)
400 mg
ERYTHROMYCIN
$0 (2)
ETHYLSUCCINA
– erythromycin
$0 (2)
ethylsuccinate tab
400 mg
$0 (2)
TETRACICLINAS
demeclocycline hcl tab
$0 (2)
150 mg
demeclocycline hcl tab
$0 (2)
300 mg
doxycycline hyclate cap
$0 (2)
50 mg
doxycycline hyclate cap
100 mg (Vibramycin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
2
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Nombre del
medicamento
doxycycline hyclate tab
delayed release 50 mg
(Doryx)
doxycycline hyclate tab
delayed release 75 mg
doxycycline hyclate tab
20 mg
doxycycline hyclate tab
100 mg
doxycycline monohydrate
cap 50 mg
doxycycline monohydrate
cap 100 mg (Monodox)
doxycycline monohydrate
for susp 25 mg/5ml
(Vibramycin)
doxycycline monohydrate
tab 50 mg (Adoxa)
doxycycline monohydrate
tab 75 mg (Adoxa)
doxycycline monohydrate
tab 100 mg (Adoxa pak
1/100)
minocycline hcl cap
50 mg (Minocin)
minocycline hcl cap
75 mg (Minocin)
minocycline hcl cap
100 mg (Minocin)
minocycline hcl tab 50 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
ciprofloxacin for oral
susp 250 mg/5ml (5%)
(5 gm/100ml) (Cipro)
$0 (1)
ciprofloxacin for oral susp
500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
$0 (1)
ciprofloxacin hcl tab
250 mg (base equiv)
$0 (1)
(Cipro)
ciprofloxacin hcl tab
$0 (1)
500 mg (base equiv)
(Cipro)
$0 (1)
ciprofloxacin hcl tab
750 mg (base equiv)
$0 (1)
levofloxacin oral soln
25 mg/ml (Levaquin)
levofloxacin
tab 250 mg
$0 (1)
(Levaquin)
levofloxacin
tab 500 mg
$0 (1)
(Levaquin)
levofloxacin tab 750 mg
$0 (1)
(Levaquin)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
minocycline hcl tab 75 mg
$0 (1)
minocycline hcl tab
100 mg
tetracycline hcl cap
250 mg (Tetracycline
hcl)
tetracycline hcl cap
500 mg (Tetracycline
hcl)
$0 (1)
$0 (1)
$0 (1)
FLUOROQUINOLONAS
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
AMINOGLUCÓSIDOS
neomycin sulfate tab
500 mg
paromomycin sulfate cap
250 mg
tobramycin nebu soln
300 mg/5ml (Tobi)
TOBRAMYCIN SULFATE
– tobramycin sulfate
inj 10 mg/ml (base
equivalent)
TOBRAMYCIN SULFATE
– tobramycin sulfate inj
2 gm/50ml (40 mg/ml)
(base equiv)
TUBERCULOSIS
ethambutol hcl tab
100 mg (Myambutol)
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL, SP
$0 (2)
$0 (2)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
3
2016
Nombre del
medicamento
ethambutol hcl tab
400 mg (Myambutol)
isoniazid tab 100 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
itraconazole cap 100 mg
(Sporanox)
$0 (1)
ketoconazole tab 200 mg
isoniazid tab 300 mg
$0 (1)
PRIFTIN – rifapentine tab
150 mg
pyrazinamide tab 500 mg
$0 (2)
rifabutin cap 150 mg
(Mycobutin)
rifampin cap 150 mg
(Rifadin)
rifampin cap 300 mg
(Rifadin)
$0 (1)
INFECCIONES FÚNGICAS
fluconazole for susp
10 mg/ml (Diflucan)
fluconazole for susp
40 mg/ml (Diflucan)
fluconazole tab 50 mg
(Diflucan)
fluconazole tab 100 mg
(Diflucan)
fluconazole tab 150 mg
(Diflucan)
fluconazole tab 200 mg
(Diflucan)
flucytosine cap 250 mg
(Ancobon)
flucytosine cap 500 mg
(Ancobon)
griseofulvin microsize
susp 125 mg/5ml
griseofulvin microsize tab
500 mg (Grifulvin v)
griseofulvin ultramicrosize
tab 125 mg (Gris-peg)
griseofulvin ultramicrosize
tab 250 mg (Gris-peg)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
4
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
NOXAFIL – posaconazole
tab delayed release
100 mg
NOXAFIL – posaconazole
susp 40 mg/ml
nystatin oral powder
$0 (2)
PA
$0 (2)
PA
nystatin tab 500000 unit
$0 (1)
terbinafine hcl tab 250 mg
(Lamisil)
voriconazole for susp
40 mg/ml (Vfend)
voriconazole tab 50 mg
(Vfend)
voriconazole tab 200 mg
(Vfend)
$0 (1)
$0 (1)
$0 (1)
PA
$0 (1)
PA
$0 (1)
PA
INFECCIONES VIRALES
Citomegalovirus
VALCYTE – valganciclovir
hcl for soln 50 mg/ml
(base equiv)
valganciclovir hcl for soln
50 mg/ml (base equiv)
(Valcyte)
valganciclovir hcl tab
450 mg (Valcyte)
Hepatitis
adefovir dipivoxil tab
10 mg (Hepsera)
BARACLUDE – entecavir
oral soln 0.05 mg/ml
DAKLINZA – daclatasvir
dihydrochloride tab
30 mg (base equivalent)
DAKLINZA – daclatasvir
dihydrochloride tab
60 mg (base equivalent)
PA
QL
SP
ST
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
PA, SP
$0 (2)
PA, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
DAKLINZA – daclatasvir
$0 (2)
PA, SP
ribavirin cap 200 mg
dihydrochloride tab
(Rebetol)
90 mg (base equivalent)
ribavirin tab 200 mg
$0 (1)
entecavir tab 0.5 mg
(Copegus)
(Baraclude)
SOVALDI – sofosbuvir tab
400 mg
$0 (1)
entecavir tab 1 mg
(Baraclude)
ZEPATIER – elbasvirgrazoprevir tab
HARVONI – ledipasvir$0 (2)
PA, SP
sofosbuvir tab
50-100 mg
90-400 mg
Herpes
$0 (1)
QL
lamivudine tab 100 mg
acyclovir cap 200 mg
(Epivir hbv)
(Zovirax)
PEG-INTRON REDIPEN
$0 (2)
PA, SP
acyclovir susp
– peginterferon alfa-2b
200 mg/5ml (Zovirax)
for inj kit 50 mcg/0.5ml
acyclovir tab 400 mg
PEG-INTRON REDIPEN
$0 (2)
PA, SP
(Zovirax)
– peginterferon alfa-2b
acyclovir tab 800 mg
for inj kit 80 mcg/0.5ml
(Zovirax)
PEG-INTRON REDIPEN
$0 (2)
PA, SP
famciclovir tab 125 mg
– peginterferon alfa-2b
(Famvir)
for inj kit 120 mcg/0.5ml
valacyclovir hcl tab
PEG-INTRON REDIPEN
$0 (2)
PA, SP
500 mg (Valtrex)
– peginterferon alfa-2b
valacyclovir
hcl tab 1 gm
for inj kit 150 mcg/0.5ml
(Valtrex)
PEG-INTRON REDIPEN
$0 (2)
PA, SP
VIH/SIDA
PAK 4 – peginterferon
alfa-2b for inj kit
abacavir sulfate tab
120 mcg/0.5ml
300 mg (base equiv)
(Ziagen)
PEGASYS –
$0 (2)
PA, SP
peginterferon alfa-2a inj
abacavir sulfate180 mcg/ml
lamivudine-zidovudine
tab 300-150-300 mg
PEGASYS –
$0 (2)
PA, SP
(Trizivir)
peginterferon alfa-2a inj
180 mcg/0.5ml
APTIVUS – tipranavir cap
250 mg
PEGASYS PROCLICK –
$0 (2)
PA, SP
peginterferon alfa-2a inj
APTIVUS – tipranavir oral
135 mcg/0.5ml
soln 100 mg/ml
PEGASYS PROCLICK –
$0 (2)
PA, SP
ATRIPLA – efavirenzpeginterferon alfa-2a inj
emtricitabine-tenofovir
180 mcg/0.5ml
df tab 600-200-300 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
SP
$0 (1)
SP
$0 (2)
PA, SP
$0 (2)
PA
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
5
2016
Nombre del
medicamento
COMPLERA –
emtricitabine-rilpivirinetenofovir df tab
200-25-300 mg
CRIXIVAN – indinavir
sulfate cap 200 mg
CRIXIVAN – indinavir
sulfate cap 400 mg
DESCOVY –
emtricitabine-tenofovir
alafenamide fumarate
tab 200-25 mg
didanosine delayed
release capsule 125 mg
(Videx ec)
didanosine delayed
release capsule 200 mg
(Videx ec)
didanosine delayed
release capsule 250 mg
(Videx ec)
didanosine delayed
release capsule 400 mg
(Videx ec)
EDURANT – rilpivirine
hcl tab 25 mg (base
equivalent)
EMTRIVA – emtricitabine
caps 200 mg
EMTRIVA – emtricitabine
soln 10 mg/ml
EPZICOM – abacavir
sulfate-lamivudine tab
600-300 mg
EVOTAZ – atazanavir
sulfate-cobicistat tab
300-150 mg (base
equiv)
FUZEON – enfuvirtide for
inj 90 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
QL
GENVOYA – elvitegravcobic-emtricitabtenofov af tab
150-150-200-10 mg
$0 (2)
QL
INTELENCE – etravirine
tab 25 mg
$0 (2)
QL
INTELENCE – etravirine
tab 100 mg
$0 (2)
QL
INTELENCE – etravirine
tab 200 mg
INVIRASE – saquinavir
mesylate cap 200 mg
$0 (1)
QL
INVIRASE – saquinavir
mesylate tab 500 mg
ISENTRESS – raltegravir
$0 (1)
QL
potassium tab 400 mg
(base equiv)
ISENTRESS – raltegravir
$0 (1)
QL
potassium packet for
susp 100 mg (base
equiv)
$0 (1)
QL
ISENTRESS – raltegravir
potassium chew tab
25 mg (base equiv)
$0 (2)
QL
ISENTRESS – raltegravir
potassium chew tab
100 mg (base equiv)
$0 (2)
QL
KALETRA – lopinavirritonavir soln
$0 (2)
QL
400-100 mg/5ml
(80-20 mg/ml)
$0 (2)
QL
KALETRA – lopinavirritonavir tab 100-25 mg
KALETRA – lopinavirritonavir tab 200-50 mg
$0 (2)
QL
lamivudine oral soln
10 mg/ml (Epivir)
lamivudine tab 150 mg
$0 (2)
QL, SP
(Epivir)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
6
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
lamivudine tab 300 mg
(Epivir)
lamivudine-zidovudine tab
150-300 mg (Combivir)
LEXIVA – fosamprenavir
calcium tab 700 mg
(base equiv)
LEXIVA – fosamprenavir
calcium susp 50 mg/ml
(base equiv)
nevirapine tab sr 24hr
100 mg (Viramune xr)
nevirapine tab sr 24hr
400 mg (Viramune xr)
nevirapine tab 200 mg
(Viramune)
NORVIR – ritonavir cap
100 mg
NORVIR – ritonavir tab
100 mg
NORVIR – ritonavir oral
soln 80 mg/ml
ODEFSEY –
emtricitabine-rilpivirinetenofovir af tab
200-25-25 mg
PREZCOBIX – darunavircobicistat tab
800-150 mg
PREZISTA – darunavir
ethanolate susp
100 mg/ml (base equiv)
PREZISTA – darunavir
ethanolate tab 75 mg
(base equiv)
PREZISTA – darunavir
ethanolate tab 150 mg
(base equiv)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
PREZISTA – darunavir
ethanolate tab 600 mg
(base equiv)
$0 (1)
QL
PREZISTA – darunavir
ethanolate tab 800 mg
$0 (2)
QL
(base equiv)
RESCRIPTOR –
delavirdine mesylate tab
$0 (2)
QL
100 mg
RESCRIPTOR –
delavirdine mesylate tab
$0 (1)
QL
200 mg
REYATAZ – atazanavir
$0 (1)
QL
sulfate oral powder
packet 50 mg (base
$0 (1)
QL
equiv)
REYATAZ – atazanavir
$0 (2)
QL
sulfate cap 150 mg
(base equiv)
$0 (2)
QL
REYATAZ – atazanavir
sulfate cap 200 mg
$0 (2)
QL
(base equiv)
REYATAZ – atazanavir
$0 (2)
QL
sulfate cap 300 mg
(base equiv)
SELZENTRY – maraviroc
tab 150 mg
$0 (2)
QL
SELZENTRY – maraviroc
tab 300 mg
stavudine cap 15 mg
$0 (2)
QL
(Zerit)
stavudine cap 20 mg
(Zerit)
$0 (2)
QL
stavudine cap 30 mg
(Zerit)
stavudine cap 40 mg
$0 (2)
QL
(Zerit)
stavudine for oral soln
1 mg/ml (Zerit)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
7
2016
Nombre del
medicamento
STRIBILD – elvitegravcobic-emtricitabtenofovdf tab
150-150-200-300 mg
SUSTIVA – efavirenz tab
600 mg
SUSTIVA – efavirenz cap
50 mg
SUSTIVA – efavirenz cap
200 mg
TIVICAY – dolutegravir
sodium tab 10 mg (base
equiv)
TIVICAY – dolutegravir
sodium tab 25 mg (base
equiv)
TIVICAY – dolutegravir
sodium tab 50 mg (base
equiv)
TRIUMEQ – abacavirdolutegravir-lamivudine
tab 600-50-300 mg
TRUVADA –
emtricitabine-tenofovir
disoproxil fumarate tab
100-150 mg
TRUVADA –
emtricitabine-tenofovir
disoproxil fumarate tab
133-200 mg
TRUVADA –
emtricitabine-tenofovir
disoproxil fumarate tab
167-250 mg
TRUVADA –
emtricitabine-tenofovir
disoproxil fumarate tab
200-300 mg
VIDEX – didanosine for
soln 2 gm
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
QL
VIDEX – didanosine for
soln 4 gm
VIRACEPT – nelfinavir
mesylate tab 250 mg
$0 (2)
QL
VIRACEPT – nelfinavir
mesylate tab 625 mg
$0 (2)
QL
VIRAMUNE – nevirapine
susp 50 mg/5ml
$0 (2)
QL
VIREAD – tenofovir
disoproxil fumarate oral
$0 (2)
QL
powder 40 mg/gm
VIREAD – tenofovir
disoproxil fumarate tab
$0 (2)
QL
150 mg
VIREAD – tenofovir
disoproxil fumarate tab
$0 (2)
QL
200 mg
VIREAD – tenofovir
disoproxil fumarate tab
$0 (2)
QL
250 mg
VIREAD – tenofovir
disoproxil fumarate tab
$0 (2)
QL
300 mg
VITEKTA – elvitegravir tab
85 mg
VITEKTA – elvitegravir tab
$0 (2)
QL
150 mg
ZIAGEN – abacavir
sulfate soln 20 mg/ml
(base equiv)
$0 (2)
QL
zidovudine cap 100 mg
(Retrovir)
zidovudine syrup 10 mg/
ml (Retrovir)
$0 (2)
QL
zidovudine tab 300 mg
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
8
QL
Influenza
RELENZA DISKHALER –
zanamivir aero powder
breath activated 5 mg/
blister
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
TAMIFLU – oseltamivir
phosphate for susp
6 mg/ml (base equiv)
TAMIFLU – oseltamivir
phosphate cap 30 mg
(base equiv)
TAMIFLU – oseltamivir
phosphate cap 45 mg
(base equiv)
TAMIFLU – oseltamivir
phosphate cap 75 mg
(base equiv)
MALARIA
atovaquone-proguanil
hcl tab 62.5-25 mg
(Malarone)
atovaquone-proguanil
hcl tab 250-100 mg
(Malarone)
chloroquine phosphate
tab 250 mg
chloroquine phosphate
tab 500 mg (Aralen)
DARAPRIM –
pyrimethamine tab
25 mg
hydroxychloroquine
sulfate tab 200 mg
(Plaquenil)
mefloquine hcl tab
250 mg
PRIMAQUINE
PHOSPHATE –
primaquine phosphate
tab 26.3 mg
quinine sulfate cap
324 mg (Qualaquin)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
QL
BILTRICIDE –
praziquantel tab 600 mg
ivermectin tab 3 mg
$0 (2)
QL
(Stromectol)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
INFECCIONES DE PARÁSITOS
ALBENZA – albendazole
$0 (2)
tab 200 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL
QL
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
OTROS ANTIINFECCIOSOS
atovaquone susp
750 mg/5ml (Mepron)
bacitracin intramuscular
for soln 50000 unit
clindamycin hcl cap
75 mg (Cleocin)
clindamycin hcl cap
150 mg (Cleocin)
clindamycin hcl cap
300 mg (Cleocin)
clindamycin palmitate
hcl for soln 75 mg/5ml
(base equiv) (Cleocin
pediatric gr)
dapsone tab 25 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
dapsone tab 100 mg
$0 (1)
linezolid for susp
100 mg/5ml (Zyvox)
linezolid tab 600 mg
(Zyvox)
metronidazole cap
375 mg (Flagyl)
metronidazole tab 250 mg
(Flagyl)
metronidazole tab 500 mg
(Flagyl)
sulfamethoxazoletrimethoprim susp
200-40 mg/5ml
sulfamethoxazoletrimethoprim tab
400-80 mg (Bactrim)
sulfamethoxazoletrimethoprim tab
$0 (1)
QL
$0 (1)
QL
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
9
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
800-160 mg (Bactrim
ALKERAN – melphalan
ds)
tab 2 mg
$0 (1)
trimethoprim tab 100 mg
anastrozole tab 1 mg
(Arimidex)
$0 (1)
vancomycin hcl cap
bexarotene cap 75 mg
125 mg (Vancocin hcl)
(Targretin)
$0 (1)
vancomycin hcl cap
bicalutamide tab 50 mg
250 mg (Vancocin hcl)
(Casodex)
XIFAXAN – rifaximin tab
$0 (2)
PA, QL
200 mg
capecitabine tab 150 mg
(Xeloda)
XIFAXAN – rifaximin tab
$0 (2)
PA, QL
550 mg
capecitabine tab 500 mg
(Xeloda)
ZYVOX – linezolid for
$0 (2)
QL
susp 100 mg/5ml
COTELLIC – cobimetinib
fumarate tab 20 mg
AGENTES DE INMUNIZACIÓN
(base equivalent)
SYNAGIS – palivizumab
$0 (2)
PA, SP
CYTARABINE –
im soln 50 mg/0.5ml
cytarabine inj 20 mg/ml
SYNAGIS – palivizumab
$0 (2)
PA, SP
exemestane tab 25 mg
im soln 100 mg/ml
(Aromasin)
MEDICAMENTOS PARA EL CÁNCER
flutamide cap 125 mg
ACTIMMUNE –
$0 (2)
SP
GLEEVEC – imatinib
interferon gamma-1b
mesylate tab 100 mg
inj 100 mcg/0.5ml
(base equivalent)
(2000000 unit/0.5ml)
GLEEVEC – imatinib
AFINITOR – everolimus
$0 (2)
PA, QL, SP
mesylate tab 400 mg
tab 2.5 mg
(base equivalent)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
hydroxyurea cap 500 mg
tab 5 mg
(Hydrea)
AFINITOR – everolimus
$0 (2)
PA, QL, SP
IBRANCE – palbociclib
tab 7.5 mg
cap 75 mg
AFINITOR – everolimus
$0 (2)
PA, QL, SP
IBRANCE – palbociclib
tab 10 mg
cap 100 mg
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
IBRANCE – palbociclib
everolimus tab for oral
cap 125 mg
susp 2 mg
imatinib mesylate
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
tab 100 mg (base
everolimus tab for oral
equivalent) (Gleevec)
susp 3 mg
imatinib
mesylate
AFINITOR DISPERZ –
$0 (2)
PA, QL, SP
tab 400 mg (base
everolimus tab for oral
equivalent) (Gleevec)
susp 5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
10
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (1)
$0 (1)
PA, QL, SP
$0 (1)
$0 (1)
PA, SP
$0 (1)
PA, SP
$0 (2)
PA, QL
$0 (2)
$0 (1)
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
PA, QL, SP
$0 (1)
PA, QL, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
LENVIMA 10 MG DAILY
DOSE – lenvatinib cap
therapy pack 10 mg
(10 mg daily dose)
LENVIMA 14 MG DAILY
DOSE – lenvatinib cap
therapy pack 10 & 4 mg
(14 mg daily dose)
LENVIMA 18 MG DAILY
DOSE – lenvatinib cap
therapy pack 10 & 4
(2) mg (18 mg daily
dose)
LENVIMA 20 MG DAILY
DOSE – lenvatinib cap
therapy pack 10 (2) mg
(20 mg daily dose)
LENVIMA 24 MG DAILY
DOSE – lenvatinib cap
therapy pack 10 (2) &
4 mg (24 mg daily dose)
LENVIMA 8 MG DAILY
DOSE – lenvatinib cap
therapy pack 4 (2) mg
(8 mg daily dose)
letrozole tab 2.5 mg
(Femara)
LEUCOVORIN CALCIUM
– leucovorin calcium tab
10 mg
LEUCOVORIN CALCIUM
– leucovorin calcium tab
15 mg
leucovorin calcium tab
5 mg
leucovorin calcium tab
25 mg
LEUKERAN –
chlorambucil tab 2 mg
LYNPARZA – olaparib cap
50 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
PA, QL, SP
megestrol acetate susp
40 mg/ml (Megace oral)
megestrol acetate tab
20 mg
$0 (2)
PA, QL, SP
megestrol acetate tab
40 mg
MEKINIST – trametinib
dimethyl sulfoxide
$0 (2)
PA, QL
tab 0.5 mg (base
equivalent)
MEKINIST – trametinib
dimethyl sulfoxide tab
2 mg (base equivalent)
$0 (2)
PA, QL, SP
mercaptopurine tab 50 mg
(Purinethol)
METHOTREXATE
SODIUM –
$0 (2)
PA, QL, SP
methotrexate sodium inj
250 mg/10ml (25 mg/ml)
methotrexate sodium tab
2.5 mg (base equiv)
$0 (2)
PA, QL
MYLERAN – busulfan tab
2 mg
NEXAVAR – sorafenib
tosylate tab 200 mg
$0 (1)
(base equivalent)
SPRYCEL – dasatinib tab
$0 (2)
20 mg
SPRYCEL – dasatinib tab
50 mg
$0 (2)
SPRYCEL – dasatinib tab
70 mg
SPRYCEL – dasatinib tab
$0 (1)
80 mg
SPRYCEL – dasatinib tab
$0 (1)
100 mg
SPRYCEL – dasatinib tab
$0 (2)
140 mg
STIVARGA – regorafenib
$0 (2)
PA, QL, SP
tab 40 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
$0 (2)
$0 (1)
$0 (2)
$0 (2)
QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
11
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
SUTENT – sunitinib
$0 (2)
QL, SP
$0 (1)
SP
temozolomide cap
malate cap 12.5 mg
180 mg (Temodar)
(base equivalent)
$0 (1)
SP
temozolomide cap
SUTENT – sunitinib
$0 (2)
QL, SP
250 mg (Temodar)
malate cap 25 mg (base
$0 (1)
PA, SP
tretinoin cap 10 mg
equivalent)
VOTRIENT – pazopanib
$0 (2)
PA, QL, SP
SUTENT – sunitinib
$0 (2)
QL, SP
hcl tab 200 mg (base
malate cap 37.5 mg
equiv)
(base equivalent)
XALKORI – crizotinib cap
$0 (2)
PA, QL, SP
SUTENT – sunitinib
$0 (2)
QL, SP
200 mg
malate cap 50 mg (base
XALKORI – crizotinib cap
$0 (2)
PA, QL, SP
equivalent)
250 mg
$0 (1)
tamoxifen citrate tab
ZELBORAF –
$0 (2)
PA, QL, SP
10 mg (base equivalent)
vemurafenib tab 240 mg
$0 (1)
tamoxifen citrate tab
(base equivalent)
20 mg (base equivalent)
ZYTIGA – abiraterone
$0 (2)
PA, QL, SP
TARCEVA – erlotinib
$0 (2)
QL, SP
acetate tab 250 mg
hcl tab 25 mg (base
HORMONAS, DIABETES Y MEDICAMENTOS
equivalent)
RELACIONADOS
TARCEVA – erlotinib
$0 (2)
QL, SP
CORTICOSTEROIDES
hcl tab 100 mg (base
CORTISONE ACETATE
$0 (2)
equivalent)
–
cortisone
acetate
tab
TARCEVA – erlotinib
$0 (2)
QL, SP
25 mg
hcl tab 150 mg (base
DEXAMETHASONE –
$0 (2)
equivalent)
dexamethasone
soln
TASIGNA – nilotinib hcl
$0 (2)
PA, QL, SP
0.5 mg/5ml
cap 150 mg (base
$0 (1)
dexamethasone
elixir
equivalent)
0.5 mg/5ml
TASIGNA – nilotinib hcl
$0 (2)
PA, QL, SP
$0 (1)
dexamethasone tab
cap 200 mg (base
0.5
mg
equivalent)
$0 (1)
dexamethasone tab
$0 (1)
SP
temozolomide cap 5 mg
0.75
mg
(Temodar)
$0 (1)
dexamethasone tab
$0 (1)
SP
temozolomide cap 20 mg
1.5
mg
(Temodar)
$0 (1)
dexamethasone tab 4 mg
$0 (1)
SP
temozolomide cap
100 mg (Temodar)
$0 (1)
dexamethasone tab 6 mg
$0 (1)
SP
temozolomide cap
$0 (1)
fludrocortisone acetate
140 mg (Temodar)
tab 0.1 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
12
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
hydrocortisone tab 5 mg
methyltestosterone cap
(Cortef)
10 mg (Testred)
$0 (1)
hydrocortisone tab 10 mg
testosterone cypionate
(Cortef)
im inj in oil 100 mg/ml
(Depo-testosterone)
$0 (1)
hydrocortisone tab 20 mg
testosterone cypionate
(Cortef)
im inj in oil 200 mg/ml
$0 (1)
methylprednisolone tab
(Depo-testosterone)
4 mg (Medrol)
testosterone
enanthate im
$0 (1)
methylprednisolone tab
inj in oil 200 mg/ml
8 mg (Medrol)
testosterone td gel
$0 (1)
methylprednisolone tab
25 mg/2.5gm (1%)
16 mg (Medrol)
(Androgel)
$0 (1)
methylprednisolone tab
testosterone td gel
32 mg (Medrol)
50 mg/5gm (1%)
$0 (1)
prednisolone sod phosph
(Androgel)
oral soln 6.7 mg/5ml
testosterone
td gel
(5 mg/5ml base)
12.5 mg/act (1%)
(Pediapred)
(Androgel pump)
$0 (1)
prednisolone sod
phosphate oral soln
ESTRÓGENOS
15 mg/5ml (base equiv)
COMBIPATCH –
$0 (1)
prednisolone syrup
estradiol-norethindrone
15 mg/5ml (usp solution
ace td pttw
equivalent) (Prelone)
0.05-0.14 mg/day
PREDNISONE –
$0 (2)
COMBIPATCH –
prednisone tab 50 mg
estradiol-norethindrone
ace td pttw
PREDNISONE –
$0 (2)
0.05-0.25 mg/day
prednisone oral soln
5 mg/5ml
DIVIGEL – estradiol td gel
0.25 mg/0.25gm (0.1%)
$0 (1)
prednisone tab 1 mg
DIVIGEL – estradiol td gel
$0 (1)
prednisone tab 2.5 mg
0.5 mg/0.5gm (0.1%)
$0 (1)
prednisone tab 5 mg
DIVIGEL – estradiol td gel
$0 (1)
prednisone tab 10 mg
1 mg/gm (0.1%)
$0 (1)
prednisone tab 20 mg
estradiol & norethindrone
acetate tab 0.5-0.1 mg
HORMONAS MASCULINAS
(Activella)
$0 (1)
danazol cap 50 mg
estradiol
& norethindrone
$0 (1)
danazol cap 100 mg
acetate tab 1-0.5 mg
$0 (1)
danazol cap 200 mg
(Activella)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
13
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
ESTROPIPATE –
estradiol tab 0.5 mg
estropipate tab 1.5 mg
(Estrace)
$0 (1)
ESTROPIPATE –
estradiol tab 1 mg
estropipate tab 3 mg
(Estrace)
$0 (1)
estradiol tab 2 mg
norethindrone acetate(Estrace)
ethinyl estradiol tab
0.5 mg-2.5 mcg (Femhrt
$0 (1)
QL
estradiol td patch twice
low dose)
weekly 0.025 mg/24hr
(Vivelle-dot)
norethindrone acetateethinyl estradiol tab
$0 (1)
QL
estradiol td patch twice
1 mg-5 mcg
weekly 0.0375 mg/24hr
PREMPRO –
(Vivelle-dot)
conjugated estrogen$0 (1)
QL
estradiol td patch twice
medroxyprogest acetate
weekly 0.05 mg/24hr
tab 0.3-1.5 mg
(Vivelle-dot)
PREMPRO –
$0 (1)
QL
estradiol td patch twice
conjugated estrogenweekly 0.075 mg/24hr
medroxyprogest acetate
(Vivelle-dot)
tab 0.45-1.5 mg
$0 (1)
QL
estradiol td patch twice
PREMPRO –
weekly 0.1 mg/24hr
conjugated estrogen(Vivelle-dot)
medroxyprogest acetate
$0 (1)
QL
estradiol td patch weekly
tab 0.625-5 mg
0.025 mg/24hr (Climara)
PROGESTINAS
$0 (1)
QL
estradiol td patch weekly
0.0375 mg/24hr
medroxyprogesterone
(Climara)
acetate tab 2.5 mg
(Provera)
$0 (1)
QL
estradiol td patch weekly
0.05 mg/24hr (Climara)
medroxyprogesterone
acetate tab 5 mg
$0 (1)
QL
estradiol td patch weekly
(Provera)
0.06 mg/24hr (Climara)
medroxyprogesterone
$0 (1)
QL
estradiol td patch weekly
acetate tab 10 mg
0.075 mg/24hr (Climara)
(Provera)
$0 (1)
QL
estradiol td patch weekly
megestrol acetate susp
0.1 mg/24hr (Climara)
625 mg/5ml (Megace
$0 (1)
estradiol valerate im in oil
es)
20 mg/ml (Delestrogen)
norethindrone acetate tab
$0 (1)
estradiol valerate im in oil
5 mg (Aygestin)
40 mg/ml (Delestrogen)
progesterone im in oil
ESTROPIPATE –
$0 (2)
50 mg/ml
estropipate tab 0.75 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
14
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
ml (Depo-provera
$0 (1)
progesterone micronized
contrac)
cap 100 mg
(Prometrium)
MIRENA – levonorgestrel
releasing iud 20 mcg/
$0 (1)
progesterone micronized
day (52 mg total)
cap 200 mg
(Prometrium)
NECON 10/11-28
– norethindroneMÉTODOS ANTICONCEPTIVOS
eth estradiol tab
CONDOMS – various
$0 (3)
0.5-35/1-35 mg-mcg
DEPO-PROVERA
$0 (2)
(10/11)
CONTRACEPTIV –
NEXPLANON –
medroxyprogesterone
etonogestrel subdermal
acetate im susp 150 mg/
implant 68 mg
ml
NUVARING –
DEPO-SUBQ
$0 (2)
etonogestrel-ethinyl
PROVERA 104 –
estradiol va ring
medroxyprogesterone
0.120-0.015 mg/24hr
acetate subcutaneous
OGESTREL – norgestrel
susp 104 mg/0.65ml
& ethinyl estradiol tab
DIAPHRAGMS – various
$0 (2)
QL
0.5 mg-50 mcg
ELLA – ulipristal acetate
$0 (2)
oral contraceptives –
tab 30 mg
all generics
FALESSA – levonorgest$0 (2)
QL
PARAGARD
eth estrad tab
INTRAUTERINE COP –
0.1 mg-20 mcg & fa tab
copper iud
1 mg kit
PLAN B ONE-STEP
LEVONORGESTREL
$0 (2)
– levonorgestrel tab
– levonorgestrel tab
1.5 mg
0.75 mg
SKYLA – levonorgestrel
$0 (3)
levonorgestrel tab 1.5 mg
releasing iud 14 mcg/
(Plan b one-step)
day (13.5 mg total)
$0 (1)
QL
levonorgestrel-ethinyl
XULANE –
estradiol (continuous)
norelgestromin-ethinyl
tab 90-20 mcg
estradiol td ptwk
LO LOESTRIN FE –
$0 (2)
QL
150-35 mcg/24hr
norethin-eth estradiolZOVIA 1/50E –
fe tab 1 mg-10 mcg
ethynodiol diacetate
(24)/10 mcg (2)
& ethinyl estradiol tab
$0 (1)
medroxyprogesterone
1 mg-50 mcg
acetate im susp 150 mg/
DIABETES
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
QL
$0 (2)
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (2)
$0 (3)
$0 (2)
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
15
2016
Nombre del
medicamento
acarbose tab 25 mg
(Precose)
acarbose tab 50 mg
(Precose)
acarbose tab 100 mg
(Precose)
glimepiride tab 1 mg
(Amaryl)
glimepiride tab 2 mg
(Amaryl)
glimepiride tab 4 mg
(Amaryl)
glipizide tab sr 24hr
2.5 mg (Glucotrol xl)
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
glipizide tab sr 24hr
10 mg (Glucotrol xl)
glipizide tab 5 mg
(Glucotrol)
glipizide tab 10 mg
(Glucotrol)
glipizide-metformin hcl tab
2.5-250 mg
glipizide-metformin hcl tab
2.5-500 mg
glipizide-metformin hcl tab
5-500 mg
GLUCAGON
EMERGENCY KIT
– glucagon (rdna) for inj
kit 1 mg
glyburide micronized tab
1.5 mg (Glynase)
glyburide micronized tab
3 mg (Glynase)
glyburide micronized tab
6 mg (Glynase)
glyburide tab 1.25 mg
glyburide tab 2.5 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
glyburide tab 5 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
16
glyburide-metformin
tab 1.25-250 mg
(Glucovance)
glyburide-metformin
tab 2.5-500 mg
(Glucovance)
glyburide-metformin tab
5-500 mg (Glucovance)
JANUMET – sitagliptinmetformin hcl tab
50-500 mg
JANUMET – sitagliptinmetformin hcl tab
50-1000 mg
JANUMET XR –
sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
JANUMET XR –
sitagliptin-metformin hcl
tab sr 24hr 50-1000 mg
JANUMET XR –
sitagliptin-metformin
hcl tab sr 24hr
100-1000 mg
JANUVIA – sitagliptin
phosphate tab 25 mg
(base equiv)
JANUVIA – sitagliptin
phosphate tab 50 mg
(base equiv)
JANUVIA – sitagliptin
phosphate tab 100 mg
(base equiv)
metformin hcl tab sr 24hr
500 mg (Glucophage xr)
metformin hcl tab sr 24hr
750 mg (Glucophage xr)
metformin hcl tab 500 mg
(Glucophage)
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
NOVOLOG – insulin
metformin hcl tab 850 mg
aspart inj 100 unit/ml
(Glucophage)
$0 (1)
NOVOLOG FLEXPEN –
metformin hcl tab
insulin aspart soln pen1000 mg (Glucophage)
injector 100 unit/ml
$0 (1)
nateglinide tab 60 mg
NOVOLOG PENFILL
(Starlix)
– insulin aspart soln
$0 (1)
nateglinide tab 120 mg
cartridge 100 unit/ml
(Starlix)
pioglitazone hcl tab 15 mg
(base equiv) (Actos)
pioglitazone hcl tab 30 mg
(base equiv) (Actos)
pioglitazone hcl tab 45 mg
(base equiv) (Actos)
repaglinide tab 0.5 mg
(Prandin)
repaglinide tab 1 mg
(Prandin)
repaglinide tab 2 mg
(Prandin)
TOLAZAMIDE –
tolazamide tab 250 mg
VICTOZA – liraglutide
soln pen-injector
18 mg/3ml (6 mg/ml)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
QL, ST
DIABETES - INSULINAS
Insulinas de acción rápida
HUMALOG – insulin lispro
(human) soln cartridge
100 unit/ml
HUMALOG – insulin lispro
(human) inj 100 unit/ml
HUMALOG KWIKPEN –
insulin lispro (human)
soln pen-injector 100
unit/ml
HUMALOG KWIKPEN –
insulin lispro (human)
soln pen-injector 200
unit/ml
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
Insulinas de acción corta
HUMULIN R – insulin
regular (human) inj 100
unit/ml
HUMULIN R U-500
(CONCENTR – insulin
regular (human) inj 500
unit/ml
HUMULIN R U-500
KWIKPEN – insulin
regular (human) soln
pen-injector 500 unit/ml
NOVOLIN R – insulin
regular (human) inj 100
unit/ml
NOVOLIN R RELION –
insulin regular (human)
inj 100 unit/ml
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
Insulinas de acción intermedia
HUMALOG MIX 50/50
$0 (2)
– insulin lispro prot &
lispro (human) inj 100
unit/ml (50-50)
HUMALOG MIX 50/50
$0 (2)
KWIKPEN – insulin
lispro prot & lispro sus
pen-inj 100 unit/ml
(50-50)
HUMALOG MIX 75/25
$0 (2)
– insulin lispro prot &
lispro (human) inj 100
unit/ml (75-25)
PA
QL
SP
ST
QL
QL
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
17
2016
Nombre del
medicamento
HUMALOG MIX 75/25
KWIKPEN – insulin
lispro prot & lispro sus
pen-inj 100 unit/ml
(75-25)
HUMULIN N – insulin nph
(human) (isophane) inj
100 unit/ml
HUMULIN N KWIKPEN
– insulin nph (human)
(isophane) susp peninjector 100 unit/ml
HUMULIN 70/30 – insulin
nph isophane & regular
human inj 100 unit/ml
(70-30)
HUMULIN 70/30
KWIKPEN – insulin nph
& regular susp pen-inj
100 unit/ml (70-30)
NOVOLIN N – insulin nph
(human) (isophane) inj
100 unit/ml
NOVOLIN N RELION –
insulin nph (human)
(isophane) inj 100 unit/
ml
NOVOLIN 70/30 – insulin
nph isophane & regular
human inj 100 unit/ml
(70-30)
NOVOLIN 70/30 RELION
– insulin nph isophane
& regular human inj 100
unit/ml (70-30)
NOVOLOG MIX 70/30
– insulin aspart prot &
aspart (human) inj 100
unit/ml (70-30)
NOVOLOG MIX 70/30
PREFILL – insulin
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
aspart prot & aspart
$0 (2)
QL
sus pen-inj 100 unit/ml
(70-30)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
18
Insulinas basales
LANTUS –
insulin glargine inj 100
unit/ml
LANTUS SOLOSTAR –
insulin glargine soln
pen-injector 100 unit/ml
LEVEMIR – insulin
detemir inj 100 unit/ml
LEVEMIR FLEXTOUCH –
insulin detemir soln peninjector 100 unit/ml
TOUJEO SOLOSTAR
– insulin glargine soln
pen-injector 300 unit/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
REGULACIÓN DE LA TIROIDES
$0 (1)
levothyroxine sodium tab
25 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
50 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
75 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
88 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
100 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
112 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
125 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
137 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
150 mcg (Synthroid)
$0 (1)
levothyroxine sodium tab
175 mcg (Synthroid)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
levothyroxine sodium tab
alendronate sodium tab
200 mcg (Synthroid)
5 mg
$0 (1)
levothyroxine sodium tab
alendronate sodium tab
300 mcg (Synthroid)
10 mg
$0 (1)
liothyronine sodium tab
alendronate sodium tab
5 mcg (Cytomel)
35 mg
$0 (1)
liothyronine sodium tab
alendronate sodium tab
25 mcg (Cytomel)
70 mg (Fosamax)
$0 (1)
liothyronine sodium tab
cabergoline tab 0.5 mg
50 mcg (Cytomel)
calcitonin (salmon)
$0 (1)
methimazole tab 5 mg
nasal soln 200 unit/act
(Tapazole)
(Miacalcin)
$0 (1)
methimazole tab 10 mg
calcitriol cap 0.25 mcg
(Tapazole)
(Rocaltrol)
$0 (1)
propylthiouracil tab 50 mg
calcitriol cap 0.5 mcg
(Rocaltrol)
$0 (1)
thyroid tab 30 mg
calcitriol oral soln 1 mcg/
(1/2 grain) (Armour
thyroid)
ml (Rocaltrol)
$0 (1)
thyroid tab 60 mg
desmopressin acetate
(1 grain) (Armour
nasal soln 0.01%
thyroid)
(refrigerated) (Ddavp)
$0 (1)
thyroid tab 90 mg (1
desmopressin acetate
1/2 grain) (Armour
nasal spray soln 0.01%
thyroid)
(Ddavp)
desmopressin acetate
HORMONA DEL CRECIMIENTO
nasal spray soln 0.01%
OMNITROPE –
$0 (2)
PA, SP
(refrigerated)
somatropin for inj
desmopressin acetate tab
5.8 mg
0.1 mg (Ddavp)
OMNITROPE –
$0 (2)
PA, SP
desmopressin acetate tab
somatropin inj
0.2 mg (Ddavp)
5 mg/1.5ml
ETIDRONATE DISODIUM
OMNITROPE –
$0 (2)
PA, SP
– etidronate disodium
somatropin inj
tab 400 mg
10 mg/1.5ml
FORTEO – teriparatide
OTRAS HORMONAS Y MEDICAMENTOS
(recombinant) inj
RELACIONADOS
600 mcg/2.4ml
ALENDRONATE SODIUM
$0 (2)
QL
ibandronate sodium
– alendronate sodium
tab 150 mg (base
tab 40 mg
equivalent) (Boniva)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
PA, QL, SP
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
19
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
STRENSIQ – asfotase
$0 (2)
levocarnitine oral soln
alfa subcutaneous inj
1 gm/10ml (10%)
18 mg/0.45ml
(Carnitor)
$0 (1)
STRENSIQ – asfotase
$0 (2)
levocarnitine tab 330 mg
alfa subcutaneous inj
(Carnitor)
28 mg/0.7ml
$0 (1)
methylergonovine
STRENSIQ – asfotase
$0 (2)
maleate tab 0.2 mg
alfa subcutaneous inj
MIFEPREX – mifepristone
$0 (2)
40 mg/ml
tab 200 mg
STRENSIQ – asfotase
$0 (2)
$0 (1)
SP
octreotide acetate inj
alfa
subcutaneous
inj
50 mcg/ml (0.05 mg/ml)
80 mg/0.8ml
(Sandostatin)
$0 (1)
SP
octreotide acetate inj
MEDICAMENTOS PARA EL CORAZÓN Y LA
CIRCULACIÓN
100 mcg/ml (0.1 mg/ml)
(Sandostatin)
INHIBIDORES DE LA ENZIMA CONVERTIDORA DE
$0 (1)
SP
octreotide acetate inj
ANGIOTENSINA (ACE, POR SU SIGLA EN INGLÉS)
200 mcg/ml (0.2 mg/ml)
Y COMBINACIONES
(Sandostatin)
$0 (1)
benazepril &
$0 (1)
SP
octreotide acetate inj
hydrochlorothiazide tab
500 mcg/ml (0.5 mg/ml)
5-6.25 mg
(Sandostatin)
$0 (1)
benazepril &
$0 (1)
SP
octreotide acetate inj
hydrochlorothiazide tab
1000 mcg/ml (1 mg/ml)
10-12.5 mg (Lotensin
(Sandostatin)
hct)
PROLIA – denosumab inj
$0 (2)
$0 (1)
benazepril &
60 mg/ml
hydrochlorothiazide tab
20-12.5 mg (Lotensin
$0 (1)
raloxifene hcl tab 60 mg
hct)
(Evista)
$0 (1)
benazepril &
SENSIPAR – cinacalcet
$0 (2)
hydrochlorothiazide tab
hcl tab 30 mg (base
20-25 mg (Lotensin hct)
equiv)
$0 (1)
benazepril hcl tab 5 mg
SENSIPAR – cinacalcet
$0 (2)
hcl tab 60 mg (base
$0 (1)
benazepril hcl tab 10 mg
equiv)
(Lotensin)
SENSIPAR – cinacalcet
$0 (2)
$0 (1)
benazepril hcl tab 20 mg
hcl tab 90 mg (base
(Lotensin)
equiv)
$0 (1)
benazepril hcl tab 40 mg
STIMATE – desmopressin
$0 (2)
(Lotensin)
acetate nasal soln
$0 (1)
captopril tab 12.5 mg
1.5 mg/ml
$0 (1)
captopril tab 25 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
20
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
captopril tab 50 mg
captopril tab 100 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
25-15 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
25-25 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
50-15 mg
CAPTOPRIL/
HYDROCHLOROTHIA
– captopril &
hydrochlorothiazide tab
50-25 mg
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
enalapril maleate tab
2.5 mg (Vasotec)
enalapril maleate tab
5 mg (Vasotec)
enalapril maleate tab
10 mg (Vasotec)
enalapril maleate tab
20 mg (Vasotec)
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
fosinopril sodium &
hydrochlorothiazide tab
$0 (1)
20-12.5 mg
$0 (2)
fosinopril sodium tab
10 mg
fosinopril sodium tab
20 mg
fosinopril sodium tab
$0 (2)
40 mg
lisinopril &
hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
lisinopril &
$0 (2)
hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
lisinopril &
hydrochlorothiazide tab
20-25 mg (Zestoretic)
$0 (2)
lisinopril tab 2.5 mg
(Zestril)
lisinopril tab 5 mg (Prinivil)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
lisinopril tab 10 mg
(Prinivil)
lisinopril tab 20 mg
(Prinivil)
lisinopril tab 30 mg
(Zestril)
lisinopril tab 40 mg
(Zestril)
moexipril hcl tab 7.5 mg
(Univasc)
moexipril hcl tab 15 mg
(Univasc)
moexiprilhydrochlorothiazide tab
7.5-12.5 mg
moexiprilhydrochlorothiazide tab
15-12.5 mg (Uniretic)
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
21
2016
Nombre del
medicamento
moexiprilhydrochlorothiazide tab
15-25 mg
perindopril erbumine tab
2 mg
perindopril erbumine tab
4 mg (Aceon)
perindopril erbumine tab
8 mg (Aceon)
quinapril hcl tab 5 mg
(Accupril)
quinapril hcl tab 10 mg
(Accupril)
quinapril hcl tab 20 mg
(Accupril)
quinapril hcl tab 40 mg
(Accupril)
quinaprilhydrochlorothiazide tab
10-12.5 mg (Accuretic)
quinaprilhydrochlorothiazide tab
20-12.5 mg (Accuretic)
quinaprilhydrochlorothiazide tab
20-25 mg (Accuretic)
ramipril cap 1.25 mg
(Altace)
ramipril cap 2.5 mg
(Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg
(Altace)
trandolapril tab 1 mg
(Mavik)
trandolapril tab 2 mg
(Mavik)
trandolapril tab 4 mg
(Mavik)
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
$0 (1)
ANTAGONISTAS DE LOS RECEPTORES DE
ANGIOTENSINA II (ARBS, POR SU SIGLA EN
INGLÉS) Y COMBINACIONES
$0 (1)
$0 (1)
candesartan cilexetilhydrochlorothiazide tab
$0 (1)
16-12.5 mg (Atacand
hct)
$0 (1)
$0 (1)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand
$0 (1)
hct)
$0 (1)
candesartan cilexetil$0 (1)
hydrochlorothiazide tab
32-25 mg (Atacand hct)
$0 (1)
$0 (1)
irbesartan tab 75 mg
(Avapro)
$0 (1)
$0 (1)
irbesartan tab 150 mg
(Avapro)
$0 (1)
$0 (1)
irbesartan tab 300 mg
(Avapro)
$0 (1)
irbesartan$0 (1)
hydrochlorothiazide tab
150-12.5 mg (Avalide)
$0 (1)
irbesartan$0 (1)
hydrochlorothiazide tab
300-12.5 mg (Avalide)
$0 (1)
losartan potassium &
$0 (1)
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
$0 (1)
$0 (1)
losartan potassium &
hydrochlorothiazide
tab
$0 (1)
100-12.5 mg (Hyzaar)
$0 (1)
$0 (1)
losartan potassium &
hydrochlorothiazide tab
$0 (1)
100-25 mg (Hyzaar)
$0 (1)
losartan potassium tab
$0 (1)
25 mg (Cozaar)
$0 (1)
losartan potassium tab
$0 (1)
50 mg (Cozaar)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
22
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
losartan potassium tab
atenolol tab 50 mg
100 mg (Cozaar)
(Tenormin)
$0 (1)
valsartan tab 40 mg
atenolol tab 100 mg
(Diovan)
(Tenormin)
$0 (1)
valsartan tab 80 mg
betaxolol hcl tab 10 mg
(Diovan)
(Kerlone)
$0 (1)
valsartan tab 160 mg
betaxolol hcl tab 20 mg
(Diovan)
(Kerlone)
$0 (1)
valsartan tab 320 mg
bisoprolol &
(Diovan)
hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
$0 (1)
valsartanbisoprolol &
hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
hydrochlorothiazide tab
5-6.25 mg (Ziac)
$0 (1)
valsartanbisoprolol &
hydrochlorothiazide tab
160-12.5 mg (Diovan
hydrochlorothiazide tab
10-6.25 mg (Ziac)
hct)
$0 (1)
valsartanbisoprolol fumarate tab
hydrochlorothiazide tab
5 mg (Zebeta)
160-25 mg (Diovan hct)
bisoprolol fumarate tab
$0 (1)
valsartan10 mg (Zebeta)
hydrochlorothiazide tab
carvedilol tab 3.125 mg
320-12.5 mg (Diovan
(Coreg)
hct)
carvedilol tab 6.25 mg
$0 (1)
valsartan(Coreg)
hydrochlorothiazide tab
carvedilol tab 12.5 mg
320-25 mg (Diovan hct)
(Coreg)
BETA BLOQUEADORES Y COMBINACINES
carvedilol tab 25 mg
(Coreg)
$0 (1)
acebutolol hcl cap 200 mg
(Sectral)
labetalol hcl tab 100 mg
(Trandate)
$0 (1)
acebutolol hcl cap 400 mg
(Sectral)
labetalol hcl tab 200 mg
(Trandate)
$0 (1)
atenolol & chlorthalidone
tab 50-25 mg (Tenoretic
labetalol hcl tab 300 mg
50)
(Trandate)
$0 (1)
atenolol & chlorthalidone
metoprolol &
tab 100-25 mg
hydrochlorothiazide tab
(Tenoretic 100)
50-25 mg (Lopressor
hct)
$0 (1)
atenolol tab 25 mg
(Tenormin)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
23
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (1)
metoprolol &
propranolol hcl cap sr
hydrochlorothiazide tab
24hr 160 mg (Inderal la)
100-25 mg (Lopressor
$0 (1)
propranolol hcl tab 10 mg
hct)
$0 (1)
propranolol hcl tab 20 mg
$0 (1)
metoprolol &
$0 (1)
propranolol hcl tab 40 mg
hydrochlorothiazide tab
$0 (1)
propranolol hcl tab 60 mg
100-50 mg
$0 (1)
propranolol hcl tab 80 mg
$0 (1)
metoprolol succinate tab
sr 24hr 25 mg (tartrate
PROPRANOLOL/
$0 (2)
equiv) (Toprol xl)
HYDROCHLOROTH
– propranolol &
$0 (1)
metoprolol succinate tab
hydrochlorothiazide tab
sr 24hr 50 mg (tartrate
40-25 mg
equiv) (Toprol xl)
$0 (1)
metoprolol succinate tab
BLOQUEADORES DE CANAL DE CALCIO Y
sr 24hr 100 mg (tartrate
COMBINACIONES
equiv) (Toprol xl)
$0 (1)
amlodipine besylate tab
$0 (1)
metoprolol succinate tab
2.5 mg (Norvasc)
sr 24hr 200 mg (tartrate
$0 (1)
amlodipine besylate tab
equiv) (Toprol xl)
5 mg (Norvasc)
$0 (1)
metoprolol tartrate tab
$0 (1)
amlodipine besylate tab
25 mg
10 mg (Norvasc)
$0 (1)
metoprolol tartrate tab
$0 (1)
amlodipine besylate50 mg (Lopressor)
benazepril hcl cap
$0 (1)
metoprolol tartrate tab
2.5-10 mg (Lotrel)
100 mg (Lopressor)
$0 (1)
amlodipine besylate$0 (1)
nadolol tab 20 mg
benazepril hcl cap
(Corgard)
5-10 mg (Lotrel)
$0 (1)
nadolol tab 40 mg
$0 (1)
amlodipine besylate(Corgard)
benazepril hcl cap
$0 (1)
nadolol tab 80 mg
5-20 mg (Lotrel)
(Corgard)
$0 (1)
amlodipine besylate$0 (1)
pindolol tab 5 mg
benazepril hcl cap
5-40 mg (Lotrel)
$0 (1)
pindolol tab 10 mg
$0 (1)
amlodipine besylate$0 (1)
propranolol hcl cap sr
benazepril
hcl
cap
24hr 60 mg (Inderal la)
10-20 mg (Lotrel)
$0 (1)
propranolol hcl cap sr
$0 (1)
amlodipine
besylate24hr 80 mg (Inderal la)
benazepril hcl cap
$0 (1)
propranolol hcl cap sr
10-40 mg (Lotrel)
24hr 120 mg (Inderal la)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
24
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
amlodipine besylatevalsartan tab 5-160 mg
(Exforge)
amlodipine besylatevalsartan tab 5-320 mg
(Exforge)
amlodipine besylatevalsartan tab 10-160 mg
(Exforge)
amlodipine besylatevalsartan tab 10-320 mg
(Exforge)
diltiazem hcl cap sr 12hr
60 mg
diltiazem hcl cap sr 12hr
90 mg
diltiazem hcl cap sr 12hr
120 mg
diltiazem hcl cap sr 24hr
120 mg
diltiazem hcl cap sr 24hr
180 mg
diltiazem hcl cap sr 24hr
240 mg
diltiazem hcl coated
beads cap sr 24hr
120 mg (Cardizem cd)
diltiazem hcl coated
beads cap sr 24hr
180 mg (Cardizem cd)
diltiazem hcl coated
beads cap sr 24hr
240 mg (Cardizem cd)
diltiazem hcl coated
beads cap sr 24hr
300 mg (Cardizem cd)
diltiazem hcl extended
release beads cap sr
24hr 120 mg (Tiazac)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 180 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 240 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 300 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 360 mg (Tiazac)
$0 (1)
diltiazem hcl extended
release beads cap sr
24hr 420 mg (Tiazac)
$0 (1)
diltiazem hcl tab 30 mg
(Cardizem)
$0 (1)
diltiazem hcl tab 60 mg
(Cardizem)
$0 (1)
diltiazem hcl tab 90 mg
$0 (1)
diltiazem hcl tab 120 mg
(Cardizem)
$0 (1)
felodipine tab sr 24hr
2.5 mg
$0 (1)
felodipine tab sr 24hr
5 mg
felodipine tab sr 24hr
$0 (1)
10 mg
isradipine cap 2.5 mg
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
isradipine cap 5 mg
$0 (1)
nicardipine hcl cap 20 mg
$0 (1)
nicardipine hcl cap 30 mg
$0 (1)
nifedipine cap 10 mg
(Procardia)
nifedipine cap 20 mg
$0 (1)
nifedipine tab sr 24hr
30 mg (Adalat cc)
nifedipine tab sr 24hr
60 mg (Adalat cc)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
25
2016
Nombre del
medicamento
nifedipine tab sr 24hr
90 mg (Adalat cc)
nifedipine tab sr 24hr
osmotic release 30 mg
(Procardia xl)
nifedipine tab sr 24hr
osmotic release 60 mg
(Procardia xl)
nifedipine tab sr 24hr
osmotic release 90 mg
(Procardia xl)
nimodipine cap 30 mg
trandolapril-verapamil hcl
tab cr 1-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-180 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 4-240 mg (Tarka)
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
verapamil hcl cap sr 24hr
120 mg (Verelan)
verapamil hcl cap sr 24hr
180 mg (Verelan)
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
verapamil hcl cap sr 24hr
240 mg (Verelan)
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
verapamil hcl cap sr 24hr
360 mg (Verelan)
verapamil hcl tab cr
120 mg (Calan sr)
verapamil hcl tab cr
180 mg (Calan sr)
verapamil hcl tab cr
240 mg (Calan sr)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
verapamil hcl tab 40 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
26
verapamil hcl tab 80 mg
(Calan)
verapamil hcl tab 120 mg
(Calan)
DOLOR EN EL PECHO
ISOSORBIDE DINITRATE
ER – isosorbide dinitrate
tab cr 40 mg
isosorbide dinitrate tab
5 mg (Isordil titradose)
isosorbide dinitrate tab
10 mg
isosorbide dinitrate tab
20 mg
isosorbide dinitrate tab
30 mg
isosorbide mononitrate
tab sr 24hr 30 mg
(Imdur)
isosorbide mononitrate
tab sr 24hr 60 mg
(Imdur)
isosorbide mononitrate
tab sr 24hr 120 mg
(Imdur)
isosorbide mononitrate
tab 10 mg
isosorbide mononitrate
tab 20 mg
nitroglycerin cap cr
2.5 mg
nitroglycerin cap cr
6.5 mg
nitroglycerin cap cr 9 mg
nitroglycerin sl tab 0.3 mg
(Nitrostat)
nitroglycerin sl tab 0.4 mg
(Nitrostat)
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
nitroglycerin sl tab 0.6 mg
cholestyramine powder
(Nitrostat)
4 gm/dose (Questran)
$0 (1)
nitroglycerin td patch 24hr
choline fenofibrate cap dr
0.1 mg/hr (Nitro-dur)
45 mg (fenofibric acid
equiv) (Trilipix)
$0 (1)
nitroglycerin td patch 24hr
choline fenofibrate cap dr
0.2 mg/hr (Nitro-dur)
135 mg (fenofibric acid
$0 (1)
nitroglycerin td patch 24hr
equiv) (Trilipix)
0.4 mg/hr (Nitro-dur)
colestipol
hcl granule
$0 (1)
nitroglycerin td patch 24hr
packets 5 gm (Colestid
0.6 mg/hr (Nitro-dur)
flavored)
NITROSTAT –
$0 (2)
colestipol hcl granules
nitroglycerin sl tab
5 gm (Colestid flavored)
0.3 mg
colestipol hcl tab 1 gm
NITROSTAT –
$0 (2)
(Colestid)
nitroglycerin sl tab
0.4 mg
fenofibrate micronized
cap 43 mg
NITROSTAT –
$0 (2)
nitroglycerin sl tab
fenofibrate micronized
0.6 mg
cap 67 mg (Lofibra)
fenofibrate micronized
REDUCCIÓN DEL COLESTEROL
cap 130 mg
$0 (1)
atorvastatin calcium tab
fenofibrate
micronized
10 mg (base equivalent)
cap 134 mg (Lofibra)
(Lipitor)
fenofibrate
micronized
$0 (1)
atorvastatin calcium tab
cap 200 mg (Lofibra)
20 mg (base equivalent)
fenofibrate tab 48 mg
(Lipitor)
(Tricor)
$0 (1)
atorvastatin calcium tab
fenofibrate tab 54 mg
40 mg (base equivalent)
(Lofibra)
(Lipitor)
fenofibrate tab 145 mg
$0 (1)
atorvastatin calcium tab
(Tricor)
80 mg (base equivalent)
(Lipitor)
fenofibrate tab 160 mg
(Lofibra)
$0 (1)
cholestyramine light
powder packets 4 gm
fluvastatin sodium tab sr
24 hr 80 mg (Lescol xl)
$0 (1)
cholestyramine light
powder 4 gm/dose
gemfibrozil tab 600 mg
(Questran light)
(Lopid)
$0 (1)
cholestyramine powder
lovastatin tab 10 mg
packets 4 gm
lovastatin tab 20 mg
(Questran)
(Mevacor)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
27
2016
Nombre del
medicamento
lovastatin tab 40 mg
(Mevacor)
PRALUENT – alirocumab
subcutaneous soln peninjector 75 mg/ml
PRALUENT – alirocumab
subcutaneous soln peninjector 150 mg/ml
PRALUENT – alirocumab
subcutaneous soln
prefilled syringe 75 mg/
ml
PRALUENT – alirocumab
subcutaneous soln
prefilled syringe 150 mg/
ml
pravastatin sodium tab
10 mg
pravastatin sodium tab
20 mg (Pravachol)
pravastatin sodium tab
40 mg (Pravachol)
pravastatin sodium tab
80 mg (Pravachol)
REPATHA – evolocumab
subcutaneous soln
prefilled syringe 140 mg/
ml
REPATHA SURECLICK
– evolocumab
subcutaneous soln autoinjector 140 mg/ml
rosuvastatin calcium tab
5 mg (Crestor)
rosuvastatin calcium tab
10 mg (Crestor)
rosuvastatin calcium tab
20 mg (Crestor)
rosuvastatin calcium tab
40 mg (Crestor)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
simvastatin tab 5 mg
(Zocor)
$0 (2)
PA, QL, SP
simvastatin tab 10 mg
(Zocor)
simvastatin tab 20 mg
$0 (2)
PA, QL, SP
(Zocor)
simvastatin tab 40 mg
(Zocor)
$0 (2)
PA, QL, SP
simvastatin tab 80 mg
(Zocor)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
28
PA, QL, SP
PA, QL, SP
PA, QL, SP
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
RETENCIÓN DE LÍQUIDOS
ACETAZOLAMIDE –
acetazolamide tab
125 mg
acetazolamide cap sr
12hr 500 mg (Diamox)
acetazolamide tab
250 mg
amiloride &
hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
bumetanide tab 0.5 mg
$0 (1)
bumetanide tab 1 mg
$0 (1)
bumetanide tab 2 mg
$0 (1)
CHLOROTHIAZIDE
– chlorothiazide tab
250 mg
chlorothiazide tab 500 mg
$0 (2)
CHLORTHALIDONE
– chlorthalidone tab
50 mg
chlorthalidone tab 25 mg
$0 (2)
furosemide oral soln
10 mg/ml
furosemide tab 20 mg
(Lasix)
furosemide tab 40 mg
(Lasix)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
furosemide tab 80 mg
triamterene &
(Lasix)
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
$0 (1)
hydrochlorothiazide cap
triamterene &
12.5 mg (Microzide)
hydrochlorothiazide
$0 (1)
hydrochlorothiazide tab
tab 37.5-25 mg
12.5 mg
(Maxzide-25)
$0 (1)
hydrochlorothiazide tab
triamterene &
25 mg
hydrochlorothiazide tab
$0 (1)
hydrochlorothiazide tab
75-50 mg (Maxzide)
50 mg
TRIAMTERENE/
$0 (1)
indapamide tab 1.25 mg
HYDROCHLOROTH
$0 (1)
indapamide tab 2.5 mg
– triamterene &
$0 (1)
methazolamide tab 25 mg
hydrochlorothiazide cap
(Neptazane)
50-25 mg
$0 (1)
methazolamide tab 50 mg
RITMO CARDÍACO
(Neptazane)
amiodarone hcl tab
$0 (1)
metolazone tab 2.5 mg
200 mg (Cordarone)
(Zaroxolyn)
disopyramide phosphate
$0 (1)
metolazone tab 5 mg
cap 100 mg (Norpace)
(Zaroxolyn)
disopyramide phosphate
$0 (1)
metolazone tab 10 mg
cap 150 mg (Norpace)
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
spironolactone tab 25 mg
(Aldactone)
spironolactone tab 50 mg
(Aldactone)
spironolactone tab
100 mg (Aldactone)
torsemide tab 5 mg
(Demadex)
torsemide tab 10 mg
(Demadex)
torsemide tab 20 mg
(Demadex)
torsemide tab 100 mg
(Demadex)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
dofetilide cap 250 mcg
(0.25 mg) (Tikosyn)
dofetilide cap 500 mcg
(0.5 mg) (Tikosyn)
flecainide acetate tab
50 mg
flecainide acetate tab
100 mg
flecainide acetate tab
150 mg
mexiletine hcl cap 150 mg
$0 (1)
mexiletine hcl cap 200 mg
$0 (1)
mexiletine hcl cap 250 mg
$0 (1)
MULTAQ – dronedarone
hcl tab 400 mg (base
equivalent)
$0 (2)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
29
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
propafenone hcl cap sr
clonidine hcl tab 0.1 mg
12hr 225 mg (Rythmol
(Catapres)
sr)
clonidine hcl tab 0.2 mg
$0 (1)
propafenone hcl cap sr
(Catapres)
12hr 325 mg (Rythmol
clonidine hcl tab 0.3 mg
sr)
(Catapres)
$0 (1)
propafenone hcl cap sr
clonidine hcl td patch
12hr 425 mg (Rythmol
weekly 0.1 mg/24hr
sr)
(Catapres-tts-1)
$0 (1)
propafenone hcl tab
clonidine hcl td patch
150 mg (Rythmol)
weekly 0.2 mg/24hr
$0 (1)
(Catapres-tts-2)
propafenone hcl tab
225 mg (Rythmol)
clonidine hcl td patch
$0 (1)
propafenone hcl tab
weekly 0.3 mg/24hr
(Catapres-tts-3)
300 mg
$0 (1)
DIGOXIN – digoxin oral
quinidine gluconate tab cr
soln 0.05 mg/ml
324 mg
QUINIDINE SULFATE
$0 (2)
digoxin tab 125 mcg
– quinidine sulfate tab
(0.125 mg) (Lanoxin)
200 mg
digoxin tab 250 mcg
QUINIDINE SULFATE
$0 (2)
(0.25 mg) (Lanoxin)
– quinidine sulfate tab
doxazosin mesylate tab
300 mg
1 mg (Cardura)
$0 (1)
sotalol hcl (afib/afl) tab
doxazosin mesylate tab
80 mg (Betapace af)
2 mg (Cardura)
$0 (1)
sotalol hcl (afib/afl) tab
doxazosin mesylate tab
120 mg (Betapace af)
4 mg (Cardura)
$0 (1)
sotalol hcl (afib/afl) tab
doxazosin mesylate tab
160 mg (Betapace af)
8 mg (Cardura)
$0 (1)
sotalol hcl tab 80 mg
guanfacine hcl tab 1 mg
(Betapace)
(Tenex)
$0 (1)
sotalol hcl tab 120 mg
guanfacine hcl tab 2 mg
(Betapace)
(Tenex)
$0 (1)
sotalol hcl tab 160 mg
hydralazine hcl tab 10 mg
(Betapace)
hydralazine hcl tab 25 mg
$0 (1)
sotalol hcl tab 240 mg
hydralazine hcl tab 50 mg
OTROS MEDICAMENTOS RELACIONADOS CON
hydralazine hcl tab
EL CORAZÓN
100 mg
ADCIRCA – tadalafil tab
$0 (2)
PA, QL, SP
methyldopa tab 250 mg
20 mg (pah)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
30
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
methyldopa tab 500 mg
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
OPSUMIT – macitentan
tab 10 mg
phenoxybenzamine hcl
cap 10 mg (Dibenzyline)
prazosin hcl cap 1 mg
(Minipress)
prazosin hcl cap 2 mg
(Minipress)
prazosin hcl cap 5 mg
(Minipress)
sildenafil citrate tab 20 mg
(Revatio)
terazosin hcl cap 1 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
UPTRAVI – selexipag tab
1000 mcg
$0 (1)
UPTRAVI – selexipag tab
$0 (1)
1200 mcg
$0 (1)
UPTRAVI – selexipag tab
$0 (1)
1400 mcg
$0 (1)
UPTRAVI – selexipag tab
1600 mcg
$0 (2)
PA, QL, SP
$0 (1)
$0 (1)
$0 (1)
PA, QL, SP
$0 (1)
terazosin hcl cap 2 mg
$0 (1)
terazosin hcl cap 5 mg
$0 (1)
terazosin hcl cap 10 mg
$0 (1)
TRACLEER – bosentan
tab 62.5 mg
TRACLEER – bosentan
tab 125 mg
UPTRAVI – selexipag tab
therapy pack 200 mcg
(140) & 800 mcg (60)
UPTRAVI – selexipag tab
200 mcg
UPTRAVI – selexipag tab
400 mcg
UPTRAVI – selexipag tab
600 mcg
UPTRAVI – selexipag tab
800 mcg
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
EQUIPOS PARA PICADURAS DE ABEJAS
EPIPEN 2-PAK
$0 (2)
– epinephrine
solution auto-injector
0.3 mg/0.3ml (1:1000)
EPIPEN-JR 2-PAK
$0 (2)
– epinephrine
solution auto-injector
0.15 mg/0.3ml (1:2000)
$0 (1)
$0 (1)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, QL
PA, QL
QL
QL
AGENTES RESPIRATORIOS
ANTIHISTAMÍNICOS
carbinoxamine maleate
soln 4 mg/5ml
carbinoxamine maleate
tab 4 mg
cetirizine hcl chew tab
5 mg
cetirizine hcl chew tab
10 mg
cetirizine hcl oral soln
1 mg/ml (5 mg/5ml)
cetirizine hcl oral soln
1 mg/ml (5 mg/5ml)
cetirizine hcl tab 5 mg
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (3)
$0 (3)
cetirizine hcl tab 10 mg
$0 (3)
chlorpheniramine maleate
tab 4 mg
clemastine fumarate tab
1.34 mg (1 mg base
equiv)
$0 (3)
PA
QL
SP
ST
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
31
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
clemastine fumarate tab
promethazine hcl tab
2.68 mg
12.5 mg
$0 (1)
cyproheptadine hcl syrup
promethazine hcl tab
2 mg/5ml
25 mg
$0 (1)
cyproheptadine hcl tab
promethazine hcl tab
4 mg
50 mg
$0 (1)
desloratadine tab 5 mg
PRODUCTOS NASALES
(Clarinex)
azelastine hcl nasal spray
$0 (3)
diphenhydramine hcl cap
0.1% (137 mcg/spray)
25 mg
flunisolide nasal soln
$0 (1)
diphenhydramine hcl cap
25 mcg/act (0.025%)
50 mg
(Flunisolide)
$0 (3)
diphenhydramine hcl cap
fluticasone propionate
50 mg
nasal susp 50 mcg/act
$0 (1)
diphenhydramine hcl elixir
(Flonase)
12.5 mg/5ml
ipratropium bromide nasal
$0 (3)
diphenhydramine hcl
soln 0.03% (21 mcg/
liquid 12.5 mg/5ml
spray) (Atrovent)
$0 (3)
diphenhydramine hcl tab
ipratropium bromide nasal
25 mg
soln 0.06% (42 mcg/
spray) (Atrovent)
$0 (3)
fexofenadine hcl susp
30 mg/5ml (6 mg/ml)
mometasone furoate
nasal susp 50 mcg/act
$0 (3)
fexofenadine hcl tab
(Nasonex)
60 mg
phenylephrine
hcl tab
$0 (3)
fexofenadine hcl tab
10 mg
180 mg
saline nasal spray 0.65%
$0 (1)
levocetirizine
dihydrochloride tab
triamcinolone acetonide
5 mg (Xyzal)
nasal aerosol
$0 (3)
loratadine syrup 5 mg/5ml
suspension 55 mcg/act
(Nasacort aq)
$0 (3)
loratadine tab 10 mg
promethazine hcl suppos
12.5 mg
promethazine hcl suppos
25 mg
promethazine hcl suppos
50 mg
promethazine hcl syrup
6.25 mg/5ml
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
32
TOS/RESFRÍO/ALERGIA
acetylcysteine inhal soln
10%
acetylcysteine inhal soln
20%
BENZONATATE –
benzonatate cap
150 mg
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
benzonatate cap 100 mg
guaifenesin liquid
(Tessalon perles)
100 mg/5ml
$0 (1)
benzonatate cap 200 mg
guaifenesin-codeine soln
100-10 mg/5ml
BROHIST D –
$0 (3)
hydrocod polstbrompheniramine &
chlorphen polst er susp
phenylephrine tab
10-8 mg/5ml (Tussionex
4-10 mg
pennkineti)
$0 (3)
brompheniramine &
hydrocodone
w/
phenylephrine elixir
homatropine syrup
1-2.5 mg/5ml
5-1.5 mg/5ml
$0 (3)
brompheniramine &
hydrocodone w/
phenylephrine susp
homatropine tab
6-10 mg/5ml
5-1.5 mg
$0 (1)
brompheniramine &
phenylephrine w/ dm-gg
pseudoephedrine tab sr
liqd 5-10-200 mg/5ml
12hr 6-45 mg
phenylephrine$0 (3)
chlorpheniramine &
brompheniramine-dm
phenylephrine liquid
elixir 2.5-1-5 mg/5ml
4-10 mg/5ml
phenylephrine$0 (3)
chlorpheniramine &
guaifenesin liqd
phenylephrine tab
7.5-100 mg/5ml
4-10 mg
(1.5-20 mg/ml)
$0 (3)
dextromethorphanphenylephrineguaifenesin liquid
guaifenesin tab
10-100 mg/5ml
10-400 mg
DIMETAPP COLD
$0 (3)
phenylephrine& ALLERGY –
promethazine w/
brompheniramine &
codeine syrup
phenylephrine chew tab
5-6.25-10 mg/5ml
1-2.5 mg
promethazine &
$0 (3)
diphenhydraminephenylephrine syrup
phenylephrine liq
6.25-5 mg/5ml
6.25-2.5 mg/5ml
promethazine w/ codeine
$0 (3)
diphenhydraminesyrup 6.25-10 mg/5ml
phenylephrine soln
12.5-5 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
ED CHLORPED D –
$0 (3)
chlorpheniramine &
pseudoeph-chlorphen
phenylephrine liquid
w/ hydrocodone soln
2-5 mg/ml
60-4-5 mg/5ml (Zutripro)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
33
2016
Nombre del
medicamento
pseudoephedbromphen-dm syrup
30-2-10 mg/5ml
RELHIST – bromphen
tan-phenyleph tan chew
tab 6-15 mg
RELHIST BP –
brompheniramine &
phenylephrine tab
4-10 mg
RU-HIST D –
brompheniramine &
phenylephrine tab
4-10 mg
sodium chloride soln nebu
0.9%
sodium chloride soln nebu
3%
sodium chloride soln nebu
7% (Hyper-sal)
sodium chloride soln nebu
10%
TRIAMINIC COLD
& ALLERGY –
chlorpheniramine &
phenylephrine syrup
1-2.5 mg/5ml
TRIAMINIC COLD
& ALLERGY –
brompheniramine &
phenylephrine syrup
1-2.5 mg/5ml
TRIAMINIC COLD/
COUGH NIGH –
diphenhydraminephenylephrine oral strip
12.5-5 mg
TRIAMINIC NIGHT
TIME COLD –
diphenhydramine-
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
phenylephrine syrup
$0 (1)
6.25-2.5 mg/5ml
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
34
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
ASMA/ENFERMEDAD PULMONAR OBSTRUCTIVA
CRÓNICA (EPOC)
ADVAIR DISKUS –
$0 (2)
QL
fluticasone-salmeterol
aer powder ba
100-50 mcg/dose
ADVAIR DISKUS –
$0 (2)
QL
fluticasone-salmeterol
aer powder ba
250-50 mcg/dose
ADVAIR DISKUS –
$0 (2)
QL
fluticasone-salmeterol
aer powder ba
500-50 mcg/dose
$0 (1)
QL
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
$0 (1)
QL
albuterol sulfate soln nebu
0.5% (5 mg/ml)
$0 (1)
QL
albuterol sulfate soln
nebu 0.63 mg/3ml (base
equiv)
$0 (1)
QL
albuterol sulfate soln
nebu 1.25 mg/3ml (base
equiv)
$0 (1)
albuterol sulfate syrup
2 mg/5ml
$0 (1)
albuterol sulfate tab sr
12hr 4 mg (Vospire er)
$0 (1)
albuterol sulfate tab sr
12hr 8 mg (Vospire er)
$0 (1)
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
$0 (1)
ARNUITY ELLIPTA –
fluticasone furoate
aerosol powder breath
activ 100 mcg/act
ARNUITY ELLIPTA –
fluticasone furoate
$0 (2)
QL
$0 (2)
QL
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
aerosol powder breath
activ 200 mcg/act
ASMANEX TWISTHALER
120 ME – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
14 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
30 MET – mometasone
furoate inhal powd
110 mcg/inh (breath
activated)
ASMANEX TWISTHALER
30 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
60 MET – mometasone
furoate inhal powd
220 mcg/inh (breath
activated)
ASMANEX TWISTHALER
7 METE – mometasone
furoate inhal powd
110 mcg/inh (breath
activated)
ATROVENT HFA –
ipratropium bromide hfa
inhal aerosol 17 mcg/act
budesonide inhalation
susp 0.25 mg/2ml
(Pulmicort)
budesonide inhalation
susp 0.5 mg/2ml
(Pulmicort)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
budesonide inhalation
susp 1 mg/2ml
(Pulmicort)
$0 (2)
QL
COMBIVENT RESPIMAT
– ipratropium-albuterol
inhal aerosol soln
20-100 mcg/act
$0 (2)
QL
CROMOLYN SODIUM –
cromolyn sodium soln
nebu 20 mg/2ml
DULERA – mometasone
furoate-formoterol
$0 (2)
QL
fumarate aerosol
100-5 mcg/act
DULERA – mometasone
furoate-formoterol
fumarate aerosol
$0 (2)
QL
200-5 mcg/act
FLOVENT DISKUS –
fluticasone propionate
aer pow ba 50 mcg/
blister
$0 (2)
QL
FLOVENT DISKUS –
fluticasone propionate
aer pow ba 100 mcg/
blister
FLOVENT DISKUS –
$0 (2)
QL
fluticasone propionate
aer pow ba 250 mcg/
blister
FLOVENT HFA –
fluticasone propionate
$0 (2)
QL
hfa inhal aero 44 mcg/
act (50/valve)
FLOVENT HFA –
$0 (1)
QL
fluticasone propionate
hfa inhal aer 110 mcg/
act (125/valve)
$0 (1)
QL
FLOVENT HFA –
fluticasone propionate
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
35
2016
Nombre del
medicamento
hfa inhal aer 220 mcg/
act (250/valve)
INCRUSE ELLIPTA
– umeclidinium br
aero powd breath act
62.5 mcg/inh (base eq)
ipratropium bromide inhal
soln 0.02%
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu
0.31 mg/3ml (base
equiv) (Xopenex)
levalbuterol hcl soln nebu
0.63 mg/3ml (base
equiv) (Xopenex)
levalbuterol hcl soln nebu
1.25 mg/3ml (base
equiv) (Xopenex)
montelukast sodium chew
tab 4 mg (base equiv)
(Singulair)
montelukast sodium chew
tab 5 mg (base equiv)
(Singulair)
montelukast sodium
oral granules packet
4 mg (base equiv)
(Singulair)
montelukast sodium tab
10 mg (base equiv)
(Singulair)
QVAR – beclomethasone
diprop inhal aero soln
40 mcg/act (50/valve)
QVAR – beclomethasone
diprop inhal aero soln
80 mcg/act (100/valve)
SEREVENT DISKUS –
salmeterol xinafoate aer
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
pow ba 50 mcg/dose
(base equiv)
$0 (2)
QL
SPIRIVA HANDIHALER
– tiotropium bromide
monohydrate inhal cap
18 mcg (base equiv)
$0 (1)
QL
SPIRIVA RESPIMAT
– tiotropium bromide
monohydrate inhal
$0 (1)
QL
aerosol 1.25 mcg/act
SYMBICORT –
$0 (1)
QL
budesonide-formoterol
fumarate dihyd aerosol
80-4.5 mcg/act
$0 (1)
QL
SYMBICORT –
budesonide-formoterol
fumarate dihyd aerosol
$0 (1)
QL
160-4.5 mcg/act
terbutaline sulfate tab
2.5 mg
$0 (1)
terbutaline sulfate tab
5 mg
theophylline soln
$0 (1)
80 mg/15ml
theophylline tab sr 12hr
100 mg
$0 (1)
theophylline tab sr 12hr
200 mg
theophylline tab sr 12hr
$0 (1)
300 mg
theophylline tab sr 12hr
450 mg
$0 (2)
QL
theophylline tab sr 24hr
400 mg
theophylline tab sr 24hr
$0 (2)
QL
600 mg
VENTOLIN HFA –
albuterol sulfate inhal
$0 (2)
QL
aero 108 mcg/act
(90mcg base equiv)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
36
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
METAMUCIL
OTROS MEDICAMENTOS RESPIRATORIOS
MULTIHEALTH FIB –
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
psyllium powder 55.46%
tab 150 mg
METAMUCIL
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
MULTIHEALTH FIB –
packet 50 mg
psyllium powder 63%
KALYDECO – ivacaftor
$0 (2)
PA, QL, SP
METAMUCIL
SMOOTH
packet 75 mg
TEXTURE – psyllium
PULMOZYME – dornase
$0 (2)
SP
powder 63%
alfa inhal soln 1 mg/ml
PEDIA-LAX – glycerin
MEDICAMENTOS GASTROINTESTINALES
liquid suppos 2.8 gm
LAXANTES
(2.7 ml)
$0 (1)
bisacodyl tab & peg 3350peg 3350-kcl-sod bicarbkcl-sod bicarb-nacl for
nacl for soln 420 gm
soln kit
(Nulytely/flavor pack)
$0 (3)
bisacodyl tab delayed
peg 3350-kcl-na bicarbrelease 5 mg
nacl-na sulfate for soln
236 gm (Golytely)
$0 (3)
docusate sodium cap
100 mg
peg 3350-kcl-na bicarbnacl-na sulfate for soln
$0 (3)
docusate sodium cap
240 gm (Colyte-flavor
250 mg
packs)
$0 (3)
docusate sodium liquid
polyethylene glycol 3350
150 mg/15ml
oral powder
FLEET LIQUID
$0 (3)
polyethylene glycol 3350
GLYCERIN SUP
oral powder
– glycerin enema
adult 5.4 gm/average
polyethylene glycol 3350
delivered dose
oral packet
$0 (3)
glycerin suppos 1 gm
polyethylene glycol 3350
oral packet
$0 (3)
glycerin suppos 2 gm
psyllium powder 28.3%
$0 (3)
glycerin suppos 80.7%
KONSYL – psyllium
powder 60.3%
KONSYL – psyllium
powder 71.67%
KONSYL-D – psyllium
powder 52.3%
lactulose solution
10 gm/15ml
magnesium citrate soln
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
psyllium powder 30%
$0 (3)
psyllium powder 30.9%
$0 (3)
$0 (3)
psyllium powder 33%
$0 (3)
psyllium powder 48.57%
$0 (3)
psyllium powder 49%
$0 (3)
psyllium powder 58.6%
$0 (3)
psyllium powder 95%
$0 (3)
sennosides tab 8.6 mg
$0 (3)
$0 (3)
$0 (1)
$0 (3)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
37
2016
Nombre del
medicamento
ANTIDIARREICOS
bismuth subsalicylate
susp 262 mg/15ml
diphenoxylate w/ atropine
tab 2.5-0.025 mg
(Lomotil)
loperamide hcl cap 2 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
cimetidine tab 400 mg
$0 (3)
$0 (1)
$0 (1)
loperamide hcl liq
1 mg/5ml (0.2 mg/ml)
loperamide hcl tab 2 mg
$0 (3)
opium tincture 1% (10 mg/
ml) (morphine equiv)
$0 (1)
ANTIÁCIDOS
alum & mag hydroxidesimethicone susp
200-200-20 mg/5ml
alum & mag hydroxidesimethicone susp
400-400-40 mg/5ml
calcium carbonate
(antacid) chew tab
500 mg
calcium carbonate
(antacid) chew tab
750 mg
calcium carbonate
(antacid) chew tab
1000 mg
magnesium oxide tab
400 mg
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
ÚLCERA/ENFERMEDAD POR REFLUJO
GASTROESOFÁGICO (ERGE)
$0 (1)
chlordiazepoxide hclclidinium bromide cap
5-2.5 mg (Librax)
$0 (1)
cimetidine hcl soln
300 mg/5ml
$0 (1)
cimetidine tab 200 mg
cimetidine tab 300 mg
cimetidine tab 800 mg
$0 (1)
dicyclomine hcl cap
10 mg (Bentyl)
dicyclomine hcl inj 10 mg/
ml (Bentyl)
dicyclomine hcl oral soln
10 mg/5ml
dicyclomine hcl tab 20 mg
(Bentyl)
famotidine for susp
40 mg/5ml (Pepcid)
famotidine tab 10 mg
$0 (1)
famotidine tab 20 mg
(Pepcid)
famotidine tab 40 mg
(Pepcid)
glycopyrrolate tab 1 mg
(Robinul)
glycopyrrolate tab 2 mg
(Robinul forte)
hyoscyamine sulfate elixir
0.125 mg/5ml
hyoscyamine sulfate soln
0.125 mg/ml
hyoscyamine sulfate
tab disp 0.125 mg
(Anaspaz)
hyoscyamine sulfate tab
sl 0.125 mg (Levsin/sl)
hyoscyamine sulfate
tab sr 12hr 0.375 mg
(Levbid)
hyoscyamine sulfate tab
0.125 mg (Levsin)
lansoprazole cap
delayed release 15 mg
(Prevacid)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
38
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
2016
Nombre del
medicamento
lansoprazole cap
delayed release 30 mg
(Prevacid)
methscopolamine
bromide tab 2.5 mg
(Pamine)
methscopolamine
bromide tab 5 mg
(Pamine forte)
misoprostol tab 100 mcg
(Cytotec)
misoprostol tab 200 mcg
(Cytotec)
NIZATIDINE – nizatidine
oral soln 15 mg/ml
nizatidine cap 150 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
sucralfate tab 1 gm
(Carafate)
NAUSEAS Y VÓMITOS
EMEND – aprepitant
capsule therapy pack 80
& 125 mg
EMEND – aprepitant
capsule 40 mg
EMEND – aprepitant
capsule 80 mg
EMEND – aprepitant
capsule 125 mg
fructose-dextrosephosphoric acid oral
soln
meclizine hcl tab 12.5 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
nizatidine cap 300 mg
(Axid)
omeprazole cap delayed
release 10 mg (Prilosec)
omeprazole cap delayed
release 20 mg (Prilosec)
omeprazole cap delayed
release 40 mg (Prilosec)
pantoprazole sodium ec
tab 20 mg (base equiv)
(Protonix)
pantoprazole sodium ec
tab 40 mg (base equiv)
(Protonix)
rabeprazole sodium ec
tab 20 mg (Aciphex)
ranitidine hcl syrup 15 mg/
ml (75 mg/5ml)
ranitidine hcl tab 75 mg
$0 (1)
ranitidine hcl tab 150 mg
(Zantac)
ranitidine hcl tab 300 mg
(Zantac)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL
QL
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (3)
$0 (1)
meclizine hcl tab 25 mg
$0 (1)
ondansetron hcl oral soln
4 mg/5ml (Zofran)
ondansetron hcl tab 4 mg
(Zofran)
ondansetron hcl tab 8 mg
(Zofran)
ondansetron hcl tab
24 mg
ondansetron orally
disintegrating tab 4 mg
(Zofran odt)
ondansetron orally
disintegrating tab 8 mg
(Zofran odt)
prochlorperazine maleate
tab 5 mg (Compazine)
prochlorperazine maleate
tab 10 mg (Compazine)
prochlorperazine suppos
25 mg
trimethobenzamide hcl
cap 300 mg (Tigan)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
39
2016
Nombre del
medicamento
ENZIMAS DIGESTIVAS
CREON – pancrelipase
(lip-prot-amyl) dr cap
3000-9500-15000 unit
CREON – pancrelipase
(lip-prot-amyl) dr cap
6000-19000-30000 unit
CREON – pancrelipase
(lip-prot-amyl) dr cap
12000-38000-60000 unit
CREON – pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000
unit
CREON – pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000
unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
3000-10000-16000 unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
5000-17000-27000 unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
10000-34000-55000 unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
15000-51000-82000 unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000
unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000
unit
ZENPEP – pancrelipase
(lip-prot-amyl) dr cap
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
40000-136000-218000
unit
$0 (2)
OTROS MEDICAMENTOS GASTROINTESTINALES
$0 (1)
alosetron hcl tab 0.5 mg
(base equiv) (Lotronex)
$0 (2)
$0 (1)
alosetron hcl tab 1 mg
(base equiv) (Lotronex)
$0 (2)
ASACOL HD –
$0 (2)
mesalamine tab delayed
release 800 mg
$0 (2)
$0 (1)
balsalazide disodium cap
750 mg (Colazal)
$0 (1)
calcium acetate
(phosphate binder) cap
$0 (2)
667 mg (169 mg ca)
(Phoslo)
$0 (1)
calcium acetate
(phosphate binder) tab
$0 (2)
667 mg (Eliphos)
CANASA – mesalamine
$0 (2)
suppos 1000 mg
$0 (2)
$0 (1)
cromolyn sodium oral
conc 100 mg/5ml
(Gastrocrom)
$0 (2)
DELZICOL – mesalamine
$0 (2)
cap dr 400 mg
$0 (1)
lactulose
$0 (2)
(encephalopathy)
solution 10 gm/15ml
MESALAMINE DR –
$0 (2)
$0 (2)
mesalamine tab delayed
release 800 mg
$0 (1)
mesalamine enema 4 gm
$0 (2)
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
40
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
metoclopramide hcl tab
5 mg (Reglan)
metoclopramide hcl tab
10 mg (Reglan)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
RENAGEL – sevelamer
hcl tab 400 mg
RENAGEL – sevelamer
hcl tab 800 mg
simethicone chew tab
80 mg
simethicone susp
40 mg/0.6ml
sulfasalazine tab delayed
release 500 mg
(Azulfidine en-tabs)
sulfasalazine tab 500 mg
(Azulfidine)
ursodiol cap 300 mg
(Actigall)
ursodiol tab 250 mg (Urso
250)
ursodiol tab 500 mg (Urso
forte)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
macrocrystalline cap
$0 (2)
100 mg (Macrobid)
nitrofurantoin
susp
$0 (2)
25 mg/5ml (Furadantin)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
MEDICAMENTOS GENITOURINARIOS
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
ESPASMOS DEL TRACTO URINARIO
$0 (1)
bethanechol chloride tab
5 mg (Urecholine)
$0 (1)
bethanechol chloride tab
10 mg (Urecholine)
$0 (1)
bethanechol chloride tab
25 mg (Urecholine)
$0 (1)
bethanechol chloride tab
50 mg (Urecholine)
$0 (1)
darifenacin hydrobromide
tab sr 24hr 7.5 mg (base
equiv) (Enablex)
$0 (1)
darifenacin hydrobromide
tab sr 24hr 15 mg (base
equiv) (Enablex)
$0 (1)
flavoxate hcl tab 100 mg
INFECCIONES DEL TRACTO URINARIO
$0 (1)
methenamine hippurate
tab 1 gm (Hiprex)
$0 (1)
methenamine mandelate
tab 1 gm
$0 (1)
methenaminehyoscamine-meth bluesod phos cap 120 mg
$0 (1)
nitrofurantoin
macrocrystalline cap
25 mg (Macrodantin)
$0 (1)
nitrofurantoin
macrocrystalline cap
50 mg (Macrodantin)
$0 (1)
nitrofurantoin
macrocrystalline cap
100 mg (Macrodantin)
$0 (1)
nitrofurantoin
monohydrate
oxybutynin chloride syrup
5 mg/5ml
oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 10 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl)
oxybutynin chloride tab
5 mg
tolterodine tartrate tab
1 mg (Detrol)
tolterodine tartrate tab
2 mg (Detrol)
trospium chloride cap sr
24hr 60 mg
trospium chloride tab
20 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
PRODUCTOS VAGINALES
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
41
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (1)
clindamycin phosphate
glycine irrigation soln
vaginal cream 2%
1.5%
(Cleocin)
$0 (1)
neomycin-polymyxin
$0 (3)
clotrimazole vaginal
b gu irrigation soln
(Neosporin gu irrigan)
cream 2%
$0 (1)
$0 (1)
metronidazole vaginal gel
phenazopyridine hcl tab
0.75% (Metrogel100 mg (Pyridium)
vaginal)
$0 (1)
phenazopyridine hcl tab
$0 (3)
miconazole nitrate vaginal
200 mg (Pyridium)
cream 2%
$0 (1)
pot & sod citrates
NONOXYNOL-9 – various
$0 (3)
w/ cit ac soln
550-500-334 mg/5ml
$0 (1)
terconazole vaginal cream
$0 (1)
potassium citrate & citric
0.4% (Terazol 7)
acid
powder
pack
$0 (1)
terconazole vaginal cream
3300-1002 mg
0.8% (Terazol 3)
$0 (1)
potassium citrate
$0 (1)
terconazole vaginal
&
citric
acid
soln
suppos 80 mg
1100-334 mg/5ml
$0 (3)
tioconazole vaginal oint
$0 (1)
potassium
citrate tab cr 5
6.5%
meq (540 mg) (Urocit-k
VAGIFEM – estradiol
$0 (2)
5)
vaginal tab 10 mcg
$0 (1)
potassium citrate tab
OTROS MEDICAMENTOS GENITOURINARIOS
cr 10 meq (1080 mg)
$0 (1)
acetic acid irrigation soln
(Urocit-k 10)
0.25%
$0 (1)
potassium citrate tab
$0 (1)
alfuzosin hcl tab sr 24hr
cr 15 meq (1620 mg)
10 mg (Uroxatral)
(Urocit-k 15)
AVODART – dutasteride
$0 (2)
$0 (1)
sodium chloride irrigation
cap 0.5 mg
soln 0.9%
CYSTAGON – cysteamine
$0 (2)
SP
$0 (1)
sodium citrate & citric acid
bitartrate cap 50 mg
soln 500-334 mg/5ml
CYSTAGON – cysteamine
$0 (2)
SP
(Shohls solution modi)
bitartrate cap 150 mg
$0 (1)
tamsulosin hcl cap 0.4 mg
$0 (1)
dutasteride cap 0.5 mg
(Flomax)
(Avodart)
MEDICAMENTOS DEL SISTEMA NERVIOSO CENTRAL
$0 (1)
dutasteride-tamsulosin hcl
ANSIEDAD
cap 0.5-0.4 mg (Jalyn)
$0 (1)
alprazolam tab sr 24hr
$0 (1)
finasteride tab 5 mg
0.5 mg (Xanax xr)
(Proscar)
$0 (1)
alprazolam tab sr 24hr
1 mg (Xanax xr)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
42
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
alprazolam tab sr 24hr
2 mg (Xanax xr)
alprazolam tab sr 24hr
3 mg (Xanax xr)
alprazolam tab 0.25 mg
(Xanax)
alprazolam tab 0.5 mg
(Xanax)
alprazolam tab 1 mg
(Xanax)
alprazolam tab 2 mg
(Xanax)
buspirone hcl tab 5 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
hydroxyzine hcl im soln
50 mg/ml
$0 (1)
hydroxyzine hcl syrup
10 mg/5ml
$0 (1)
hydroxyzine hcl tab 10 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
buspirone hcl tab 10 mg
$0 (1)
buspirone hcl tab 15 mg
$0 (1)
buspirone hcl tab 30 mg
$0 (1)
chlordiazepoxide hcl cap
5 mg
chlordiazepoxide hcl cap
10 mg
chlordiazepoxide hcl cap
25 mg
clorazepate dipotassium
tab 3.75 mg (Tranxene
t)
clorazepate dipotassium
tab 7.5 mg (Tranxene t)
clorazepate dipotassium
tab 15 mg (Tranxene t)
diazepam conc 5 mg/ml
$0 (1)
diazepam tab 2 mg
(Valium)
diazepam tab 5 mg
(Valium)
diazepam tab 10 mg
(Valium)
HYDROXYZINE HCL –
hydroxyzine hcl im soln
25 mg/ml
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
hydroxyzine hcl tab 25 mg
$0 (1)
hydroxyzine hcl tab 50 mg
$0 (1)
HYDROXYZINE
PAMOATE –
hydroxyzine pamoate
cap 100 mg
hydroxyzine pamoate cap
25 mg (Vistaril)
hydroxyzine pamoate cap
50 mg (Vistaril)
lorazepam conc 2 mg/ml
(Lorazepam intensol)
lorazepam tab 0.5 mg
(Ativan)
lorazepam tab 1 mg
(Ativan)
lorazepam tab 2 mg
(Ativan)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
DEPRESIÓN
amitriptyline hcl tab 10 mg
$0 (1)
amitriptyline hcl tab 25 mg
$0 (1)
amitriptyline hcl tab 50 mg
$0 (1)
amitriptyline hcl tab 75 mg
$0 (1)
amitriptyline hcl tab
100 mg
amitriptyline hcl tab
150 mg
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
43
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
bupropion hcl tab sr 24hr
doxepin hcl cap 25 mg
150 mg (Wellbutrin xl)
doxepin hcl cap 50 mg
$0 (1)
bupropion hcl tab sr 24hr
doxepin hcl cap 100 mg
300 mg (Wellbutrin xl)
doxepin hcl cap 150 mg
$0 (1)
bupropion hcl tab 75 mg
doxepin hcl conc 10 mg/
(Wellbutrin)
ml
$0 (1)
bupropion hcl tab 100 mg
duloxetine hcl enteric
(Wellbutrin)
coated pellets cap
$0 (1)
citalopram hydrobromide
20 mg (Cymbalta)
oral soln 10 mg/5ml
duloxetine hcl enteric
$0 (1)
citalopram hydrobromide
coated pellets cap
tab 10 mg (base equiv)
30 mg (Cymbalta)
(Celexa)
duloxetine hcl enteric
$0 (1)
citalopram hydrobromide
coated pellets cap
tab 20 mg (base equiv)
60 mg (Cymbalta)
(Celexa)
escitalopram oxalate soln
$0 (1)
citalopram hydrobromide
5 mg/5ml (base equiv)
tab 40 mg (base equiv)
(Lexapro)
(Celexa)
escitalopram oxalate
$0 (1)
clomipramine hcl cap
tab 5 mg (base equiv)
25 mg (Anafranil)
(Lexapro)
$0 (1)
clomipramine hcl cap
escitalopram oxalate tab
50 mg (Anafranil)
10 mg (base equiv)
$0 (1)
clomipramine hcl cap
(Lexapro)
75 mg (Anafranil)
escitalopram oxalate tab
$0 (1)
desipramine hcl tab
20 mg (base equiv)
10 mg (Norpramin)
(Lexapro)
$0 (1)
desipramine hcl tab
fluoxetine hcl cap 10 mg
25 mg (Norpramin)
(Prozac)
$0 (1)
desipramine hcl tab
fluoxetine hcl cap 20 mg
50 mg (Norpramin)
(Prozac)
$0 (1)
desipramine hcl tab
fluoxetine hcl cap 40 mg
75 mg (Norpramin)
(Prozac)
$0 (1)
desipramine hcl tab
fluoxetine hcl solution
100 mg (Norpramin)
20 mg/5ml
$0 (1)
desipramine hcl tab
fluoxetine hcl tab 10 mg
150 mg (Norpramin)
fluoxetine hcl tab 20 mg
DOXEPIN HCL – doxepin
$0 (2)
fluvoxamine maleate tab
hcl cap 75 mg
25 mg
$0 (1)
doxepin hcl cap 10 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
44
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
fluvoxamine maleate tab
50 mg
fluvoxamine maleate tab
100 mg
imipramine hcl tab 10 mg
(Tofranil)
imipramine hcl tab 25 mg
(Tofranil)
imipramine hcl tab 50 mg
(Tofranil)
imipramine pamoate cap
75 mg
imipramine pamoate cap
100 mg
imipramine pamoate cap
125 mg
imipramine pamoate cap
150 mg
mirtazapine orally
disintegrating tab 15 mg
(Remeron soltab)
mirtazapine orally
disintegrating tab 30 mg
(Remeron soltab)
mirtazapine orally
disintegrating tab 45 mg
(Remeron soltab)
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg
(Remeron)
mirtazapine tab 30 mg
(Remeron)
mirtazapine tab 45 mg
(Remeron)
nefazodone hcl tab 50 mg
nefazodone hcl tab
250 mg
NORTRIPTYLINE HCL
– nortriptyline hcl soln
10 mg/5ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
nortriptyline hcl cap 10 mg
(Pamelor)
$0 (1)
nortriptyline hcl cap 25 mg
(Pamelor)
$0 (1)
nortriptyline hcl cap 50 mg
(Pamelor)
$0 (1)
nortriptyline hcl cap 75 mg
(Pamelor)
$0 (1)
paroxetine hcl tab 10 mg
(Paxil)
$0 (1)
paroxetine hcl tab 20 mg
(Paxil)
$0 (1)
paroxetine hcl tab 30 mg
(Paxil)
$0 (1)
paroxetine hcl tab 40 mg
(Paxil)
$0 (1)
phenelzine sulfate tab
15 mg (Nardil)
$0 (1)
sertraline hcl oral conc
20 mg/ml (Zoloft)
sertraline hcl tab 25 mg
$0 (1)
(Zoloft)
sertraline hcl tab 50 mg
(Zoloft)
$0 (1)
sertraline hcl tab 100 mg
(Zoloft)
tranylcypromine sulfate
$0 (1)
tab 10 mg (Parnate)
$0 (1)
trazodone hcl tab 50 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
trazodone hcl tab 100 mg
$0 (1)
trazodone hcl tab 150 mg
$0 (1)
trimipramine maleate cap
25 mg (Surmontil)
trimipramine maleate cap
50 mg (Surmontil)
trimipramine maleate cap
100 mg (Surmontil)
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
45
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
venlafaxine hcl cap sr
aripiprazole tab 20 mg
24hr 37.5 mg (base
(Abilify)
equivalent) (Effexor xr)
aripiprazole tab 30 mg
$0 (1)
venlafaxine hcl cap sr
(Abilify)
24hr 75 mg (base
aripiprazole tab 30 mg
equivalent) (Effexor xr)
(Abilify)
$0 (1)
venlafaxine hcl cap sr
chlorpromazine hcl tab
24hr 150 mg (base
10 mg
equivalent) (Effexor xr)
chlorpromazine hcl tab
$0 (1)
venlafaxine hcl tab 25 mg
25 mg
$0 (1)
venlafaxine hcl tab
chlorpromazine hcl tab
37.5 mg
50 mg
$0 (1)
venlafaxine hcl tab 50 mg
chlorpromazine hcl tab
100 mg
$0 (1)
venlafaxine hcl tab 75 mg
chlorpromazine hcl tab
$0 (1)
venlafaxine hcl tab
200 mg
100 mg
clozapine orally
TRASTORNOS PSICÓTICOS Y BIPOLARES
disintegrating tab 25 mg
$0 (1)
QL
aripiprazole oral solution
(Fazaclo)
1 mg/ml
clozapine orally
$0 (1)
aripiprazole oral solution
disintegrating tab
1 mg/ml
100 mg (Fazaclo)
$0 (1)
QL
aripiprazole tab 2 mg
clozapine tab 25 mg
(Abilify)
(Clozaril)
$0 (1)
QL
aripiprazole tab 2 mg
clozapine tab 50 mg
(Abilify)
clozapine tab 100 mg
$0 (1)
QL
aripiprazole tab 5 mg
(Clozaril)
(Abilify)
clozapine tab 200 mg
$0 (1)
QL
aripiprazole tab 5 mg
fluphenazine decanoate
(Abilify)
inj 25 mg/ml
$0 (1)
QL
aripiprazole tab 10 mg
FLUPHENAZINE HCL –
(Abilify)
fluphenazine hcl elixir
$0 (1)
QL
aripiprazole tab 10 mg
2.5 mg/5ml
(Abilify)
FLUPHENAZINE HCL –
$0 (1)
QL
aripiprazole tab 15 mg
fluphenazine hcl oral
(Abilify)
conc 5 mg/ml
$0 (1)
QL
aripiprazole tab 15 mg
fluphenazine hcl tab 1 mg
(Abilify)
fluphenazine hcl tab
$0 (1)
QL
aripiprazole tab 20 mg
2.5 mg
(Abilify)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
46
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
fluphenazine hcl tab 5 mg
loxapine succinate cap
50 mg
$0 (1)
fluphenazine hcl tab
olanzapine for im inj
10 mg
10 mg (Zyprexa)
$0 (1)
haloperidol decanoate im
olanzapine orally
soln 50 mg/ml (Haldol
disintegrating tab 5 mg
decanoate 50)
(Zyprexa zydis)
$0 (1)
haloperidol decanoate im
olanzapine orally
soln 100 mg/ml (Haldol
disintegrating tab 10 mg
decanoate 100)
(Zyprexa zydis)
$0 (1)
haloperidol lactate oral
olanzapine orally
conc 2 mg/ml
disintegrating tab 15 mg
$0 (1)
haloperidol tab 0.5 mg
(Zyprexa zydis)
$0 (1)
haloperidol tab 1 mg
olanzapine orally
$0 (1)
haloperidol tab 2 mg
disintegrating tab 20 mg
$0 (1)
haloperidol tab 5 mg
(Zyprexa zydis)
$0 (1)
haloperidol tab 10 mg
olanzapine tab 2.5 mg
(Zyprexa)
$0 (1)
haloperidol tab 20 mg
olanzapine
tab 5 mg
LITHIUM – lithium oral
$0 (2)
(Zyprexa)
solution 8 meq/5ml
olanzapine tab 7.5 mg
$0 (1)
lithium carbonate cap
(Zyprexa)
150 mg (Lithium
olanzapine tab 10 mg
carbonate)
(Zyprexa)
$0 (1)
lithium carbonate cap
olanzapine tab 15 mg
300 mg
(Zyprexa)
$0 (1)
lithium carbonate cap
olanzapine tab 20 mg
600 mg (Lithium
(Zyprexa)
carbonate)
paliperidone tab sr 24hr
$0 (1)
lithium carbonate tab cr
1.5 mg (Invega)
300 mg (Lithobid)
paliperidone tab sr 24hr
$0 (1)
lithium carbonate tab cr
3 mg (Invega)
450 mg
paliperidone tab sr 24hr
$0 (1)
lithium carbonate tab
6 mg (Invega)
300 mg
paliperidone tab sr 24hr
$0 (1)
loxapine succinate cap
9 mg (Invega)
5 mg
perphenazine
tab 2 mg
$0 (1)
loxapine succinate cap
10 mg
perphenazine tab 4 mg
$0 (1)
loxapine succinate cap
perphenazine tab 8 mg
25 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
47
2016
Nombre del
medicamento
perphenazine tab 16 mg
quetiapine fumarate tab
25 mg (Seroquel)
quetiapine fumarate tab
50 mg (Seroquel)
quetiapine fumarate tab
100 mg (Seroquel)
quetiapine fumarate tab
200 mg (Seroquel)
quetiapine fumarate tab
300 mg (Seroquel)
quetiapine fumarate tab
400 mg (Seroquel)
risperidone orally
disintegrating tab
0.25 mg
risperidone orally
disintegrating tab
0.5 mg (Risperdal mtab)
risperidone orally
disintegrating tab 1 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 2 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 3 mg
(Risperdal m-tab)
risperidone orally
disintegrating tab 4 mg
(Risperdal m-tab)
risperidone soln 1 mg/ml
(Risperdal)
risperidone tab 0.25 mg
(Risperdal)
risperidone tab 0.5 mg
(Risperdal)
risperidone tab 1 mg
(Risperdal)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
risperidone tab 2 mg
(Risperdal)
$0 (1)
QL
risperidone tab 3 mg
(Risperdal)
$0 (1)
QL
risperidone tab 4 mg
(Risperdal)
$0 (1)
QL
thioridazine hcl tab 10 mg
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
48
QL
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
thioridazine hcl tab 25 mg
$0 (1)
thioridazine hcl tab 50 mg
$0 (1)
thioridazine hcl tab
100 mg
thiothixene cap 1 mg
$0 (1)
thiothixene cap 2 mg
$0 (1)
thiothixene cap 5 mg
$0 (1)
thiothixene cap 10 mg
$0 (1)
trifluoperazine hcl tab
1 mg
trifluoperazine hcl tab
2 mg
trifluoperazine hcl tab
5 mg
trifluoperazine hcl tab
10 mg
ziprasidone hcl cap 20 mg
(Geodon)
ziprasidone hcl cap 40 mg
(Geodon)
ziprasidone hcl cap 60 mg
(Geodon)
ziprasidone hcl cap 80 mg
(Geodon)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
MEDICAMENTOS PARA EL SUEÑO
$0 (1)
estazolam tab 1 mg
estazolam tab 2 mg
$0 (1)
eszopiclone tab 1 mg
(Lunesta)
eszopiclone tab 2 mg
(Lunesta)
$0 (1)
QL
$0 (1)
QL
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
QL
eszopiclone tab 3 mg
amphetamine(Lunesta)
dextroamphetamine cap
sr 24hr 15 mg (Adderall
PHENOBARBITAL –
$0 (2)
xr)
phenobarbital tab 15 mg
amphetaminePHENOBARBITAL –
$0 (2)
dextroamphetamine cap
phenobarbital tab 30 mg
sr 24hr 20 mg (Adderall
PHENOBARBITAL –
$0 (2)
xr)
phenobarbital tab 60 mg
amphetaminePHENOBARBITAL –
$0 (2)
dextroamphetamine cap
phenobarbital tab
sr 24hr 25 mg (Adderall
100 mg
xr)
$0 (1)
phenobarbital elixir
amphetamine20 mg/5ml
dextroamphetamine cap
$0 (1)
phenobarbital tab 16.2 mg
sr 24hr 30 mg (Adderall
$0 (1)
phenobarbital tab 32.4 mg
xr)
$0 (1)
phenobarbital tab 64.8 mg
amphetaminedextroamphetamine tab
$0 (1)
phenobarbital tab 97.2 mg
5 mg (Adderall)
$0 (1)
temazepam cap 15 mg
amphetamine(Restoril)
dextroamphetamine tab
$0 (1)
temazepam cap 30 mg
7.5 mg (Adderall)
(Restoril)
amphetamine$0 (1)
QL
zaleplon cap 5 mg
dextroamphetamine tab
(Sonata)
10 mg (Adderall)
$0 (1)
QL
zaleplon cap 10 mg
amphetamine(Sonata)
dextroamphetamine tab
$0 (1)
QL
zolpidem tartrate tab 5 mg
12.5 mg (Adderall)
(Ambien)
amphetamine$0 (1)
QL
zolpidem tartrate tab
dextroamphetamine tab
10 mg (Ambien)
15 mg (Adderall)
HIPERACTIVIDAD/NARCOLEPSIA
amphetamine$0 (1)
PA, QL
amphetaminedextroamphetamine tab
dextroamphetamine cap
20 mg (Adderall)
sr 24hr 5 mg (Adderall
amphetaminexr)
dextroamphetamine tab
$0 (1)
PA, QL
amphetamine30 mg (Adderall)
dextroamphetamine cap
ARMODAFINIL –
sr 24hr 10 mg (Adderall
armodafinil tab 200 mg
xr)
armodafinil tab 50 mg
(Nuvigil)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (2)
PA, QL
$0 (1)
PA, QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
49
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
PA, QL
armodafinil tab 150 mg
dextroamphetamine
(Nuvigil)
sulfate cap sr 24hr
15 mg (Dexedrine)
$0 (1)
PA, QL
armodafinil tab 250 mg
dextroamphetamine
(Nuvigil)
sulfate oral solution
$0 (1)
caffeine citrate oral soln
5 mg/5ml (Procentra)
60 mg/3ml (10 mg/ml
base equiv) (Cafcit)
dextroamphetamine
sulfate tab 5 mg
$0 (1)
PA, QL
clonidine hcl tab sr 12hr
dextroamphetamine
0.1 mg (Kapvay)
sulfate tab 10 mg
$0 (1)
PA, QL
dexmethylphenidate
guanfacine hcl tab sr
hcl cap sr 24 hr 5 mg
(Focalin xr)
24hr 1 mg (base equiv)
(Intuniv)
$0 (1)
PA, QL
dexmethylphenidate hcl
guanfacine hcl tab sr
cap sr 24 hr 10 mg
(Focalin xr)
24hr 2 mg (base equiv)
(Intuniv)
$0 (1)
PA, QL
dexmethylphenidate hcl
guanfacine hcl tab sr
cap sr 24 hr 15 mg
(Focalin xr)
24hr 3 mg (base equiv)
(Intuniv)
$0 (1)
PA, QL
dexmethylphenidate hcl
guanfacine hcl tab sr
cap sr 24 hr 20 mg
(Focalin xr)
24hr 4 mg (base equiv)
(Intuniv)
$0 (1)
PA, QL
dexmethylphenidate hcl
methamphetamine hcl tab
cap sr 24 hr 30 mg
(Focalin xr)
5 mg (Desoxyn)
$0 (1)
PA, QL
dexmethylphenidate hcl
methylphenidate hcl cap
cap sr 24 hr 40 mg
cr 10 mg (cd) (Metadate
(Focalin xr)
cd)
$0 (1)
PA, QL
dexmethylphenidate hcl
methylphenidate hcl cap
tab 2.5 mg (Focalin)
cr 20 mg (cd) (Metadate
cd)
$0 (1)
PA, QL
dexmethylphenidate hcl
methylphenidate hcl cap
tab 5 mg (Focalin)
cr 30 mg (cd) (Metadate
$0 (1)
PA, QL
dexmethylphenidate hcl
cd)
tab 10 mg (Focalin)
methylphenidate
hcl cap
$0 (1)
PA, QL
dextroamphetamine
cr 40 mg (cd) (Metadate
sulfate cap sr 24hr 5 mg
cd)
(Dexedrine)
methylphenidate hcl cap
$0 (1)
PA, QL
dextroamphetamine
cr 50 mg (cd) (Metadate
sulfate cap sr 24hr
cd)
10 mg (Dexedrine)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
50
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
methylphenidate hcl cap
cr 60 mg (cd) (Metadate
cd)
methylphenidate hcl
cap sr 24hr 20 mg (la)
(Ritalin la)
methylphenidate hcl
cap sr 24hr 30 mg (la)
(Ritalin la)
methylphenidate hcl
cap sr 24hr 40 mg (la)
(Ritalin la)
methylphenidate hcl chew
tab 2.5 mg (Methylin)
methylphenidate hcl chew
tab 5 mg (Methylin)
methylphenidate hcl chew
tab 10 mg (Methylin)
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 18 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 27 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 36 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sa osm 54 mg
METHYLPHENIDATE
HCL ER –
methylphenidate hcl tab
sr 24hr 18 mg
METHYLPHENIDATE
HCL ER –
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
methylphenidate hcl tab
$0 (1)
PA, QL
sr 24hr 27 mg
METHYLPHENIDATE
HCL ER –
$0 (1)
PA, QL
methylphenidate hcl tab
sr 24hr 36 mg
METHYLPHENIDATE
$0 (1)
PA, QL
HCL ER –
methylphenidate hcl tab
sr 24hr 54 mg
$0 (1)
PA, QL
methylphenidate hcl soln
5 mg/5ml (Methylin)
methylphenidate hcl soln
$0 (1)
PA, QL
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
$0 (1)
PA, QL
10 mg
methylphenidate hcl tab cr
$0 (1)
PA, QL
20 mg (Ritalin sr)
methylphenidate hcl tab
$0 (2)
PA, QL
5 mg (Ritalin)
methylphenidate hcl tab
10 mg (Ritalin)
$0 (2)
PA, QL
methylphenidate hcl tab
20 mg (Ritalin)
modafinil tab 100 mg
(Provigil)
$0 (2)
PA, QL
modafinil tab 200 mg
(Provigil)
STRATTERA –
atomoxetine hcl cap
$0 (2)
PA, QL
10 mg (base equiv)
STRATTERA –
atomoxetine hcl cap
18 mg (base equiv)
$0 (2)
PA, QL
STRATTERA –
atomoxetine hcl cap
25 mg (base equiv)
STRATTERA –
$0 (2)
PA, QL
atomoxetine hcl cap
40 mg (base equiv)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (1)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
51
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
6x8.8
mcg/0.2ml
&
STRATTERA –
$0 (2)
PA, QL
6x22 mcg/0.5ml
atomoxetine hcl cap
60 mg (base equiv)
REBIF TITRATION PACK
$0 (2)
QL, SP
– interferon beta-1a pref
STRATTERA –
$0 (2)
PA, QL
syr 6x8.8 mcg/0.2ml &
atomoxetine hcl cap
6x22 mcg/0.5ml
80 mg (base equiv)
TECFIDERA – dimethyl
$0 (2)
QL, SP
STRATTERA –
$0 (2)
PA, QL
fumarate
capsule
atomoxetine hcl cap
delayed release 120 mg
100 mg (base equiv)
TECFIDERA
– dimethyl
$0 (2)
QL, SP
ESCLEROSIS MÚLTIPLE
fumarate capsule
AMPYRA – dalfampridine
$0 (2)
PA, QL, SP
delayed release 240 mg
tab sr 12hr 10 mg
TECFIDERA STARTER
$0 (2)
QL, SP
COPAXONE – glatiramer
$0 (2)
QL, SP
PACK – dimethyl
acetate soln prefilled
fumarate capsule dr
syringe 20 mg/ml
starter pack 120 mg &
COPAXONE – glatiramer
$0 (2)
QL, SP
240 mg
acetate soln prefilled
OTROS MEDICAMENTOS DEL SISTEMA
syringe 40 mg/ml
NERVIOSO CENTRAL
EXTAVIA – interferon
$0 (2)
QL, SP
$0 (1)
acamprosate calcium tab
beta-1b for inj kit 0.3 mg
delayed
release
333
mg
$0 (1)
QL, SP
glatiramer acetate soln
(Campral)
prefilled syringe 20 mg/
$0 (1)
QL
bupropion hcl (smoking
ml (Copaxone)
deterrent)
tab
sr
12hr
REBIF – interferon
$0 (2)
QL, SP
150 mg (Zyban)
beta-1a soln pref syr
CHANTIX
– varenicline
$0 (2)
QL
22 mcg/0.5ml (12mu/ml)
tartrate tab 0.5 mg
REBIF – interferon
$0 (2)
QL, SP
(base equiv)
beta-1a soln pref syr
CHANTIX – varenicline
$0 (2)
QL
44 mcg/0.5ml (24mu/ml)
tartrate
tab
1
mg
(base
REBIF REBIDOSE –
$0 (2)
QL, SP
equiv)
interferon beta-1a soln
CHANTIX CONTINUING
$0 (2)
QL
auto-inj 22 mcg/0.5ml
MONTH
–
varenicline
(12mu/ml)
tartrate tab 1 mg (base
REBIF REBIDOSE –
$0 (2)
QL, SP
equiv)
interferon beta-1a soln
CHANTIX STARTING
$0 (2)
QL
auto-inj 44 mcg/0.5ml
MONTH
PA
–
(24mu/ml)
varenicline tartrate tab
REBIF REBIDOSE
$0 (2)
QL, SP
0.5 mg x 11 & tab 1 mg
TITRATION – interferon
x 42 pack
beta-1a auto-inj
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
52
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (3)
QL
disulfiram tab 250 mg
nicotine td patch 24hr
(Antabuse)
21 mg/24hr
$0 (1)
NUEDEXTA –
$0 (2)
disulfiram tab 500 mg
dextromethorphan hbr(Antabuse)
quinidine sulfate cap
$0 (1)
donepezil hydrochloride
20-10 mg
orally disintegrating tab
$0 (1)
5 mg
pimozide tab 1 mg (Orap)
$0 (1)
donepezil hydrochloride
$0 (1)
pimozide tab 2 mg (Orap)
orally disintegrating tab
$0 (1)
rivastigmine tartrate cap
10 mg (Aricept odt)
1.5 mg (Exelon)
$0 (1)
donepezil hydrochloride
$0 (1)
rivastigmine tartrate cap
tab 5 mg (Aricept)
3 mg (Exelon)
$0 (1)
donepezil hydrochloride
$0 (1)
rivastigmine tartrate cap
tab 10 mg (Aricept)
4.5 mg (Exelon)
GALANTAMINE
$0 (2)
$0 (1)
rivastigmine tartrate cap
HYDROBROMIDE
6 mg (Exelon)
– galantamine
$0 (1)
rivastigmine td patch 24hr
hydrobromide oral soln
4.6 mg/24hr (Exelon)
4 mg/ml
$0 (1)
rivastigmine td patch 24hr
$0 (1)
memantine hcl oral
9.5 mg/24hr (Exelon)
solution 2 mg/ml
$0 (1)
rivastigmine td patch 24hr
(Namenda)
13.3 mg/24hr (Exelon)
$0 (1)
memantine hcl tab 5 mg
$0 (1)
QL, SP
tetrabenazine
tab 12.5 mg
(Namenda)
(Xenazine)
$0 (1)
memantine hcl tab 10 mg
$0 (1)
QL, SP
tetrabenazine
tab 25 mg
(Namenda)
(Xenazine)
$0 (1)
memantine hcl tab 5 mg
VIVITROL – naltrexone
$0 (2)
SP
(28) & 10 mg (21)
for
im
extended
release
titration pak (Namenda
susp 380 mg
titration pak)
XYREM – sodium oxybate
$0 (2)
PA, QL, SP
$0 (1)
naltrexone hcl tab 50 mg
oral
solution
500
mg/ml
(Revia)
MEDICAMENTOS PARA ALIVIAR EL DOLOR
$0 (3)
QL
nicotine polacrilex gum
2 mg
MEDICAMENTOS NO ESTUPEFACIENTES
$0 (3)
QL
nicotine polacrilex gum
$0 (3)
acetaminophen cap
4 mg
500 mg
$0 (3)
QL
nicotine td patch 24hr
$0 (3)
acetaminophen chew tab
7 mg/24hr
80 mg
$0 (3)
QL
nicotine td patch 24hr
$0 (3)
acetaminophen chew tab
14 mg/24hr
160 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
53
2016
Nombre del
medicamento
acetaminophen
dispersible tab 80 mg
acetaminophen liquid
160 mg/5ml
acetaminophen soln
100 mg/ml
acetaminophen soln
160 mg/5ml
acetaminophen suppos
120 mg
acetaminophen susp
80 mg/0.8ml
acetaminophen susp
160 mg/5ml
acetaminophen tab
325 mg
acetaminophen tab
500 mg
aspirin chew tab 81 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (3)
salsalate tab 500 mg
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
aspirin tab delayed
release 81 mg
aspirin tab delayed
release 325 mg
aspirin tab 325 mg
$0 (3)
butalbital-acetaminophen
tab 50-325 mg
butalbital-acetaminophencaffeine cap
50-300-40 mg (Fioricet)
butalbital-acetaminophencaffeine cap
50-325-40 mg
butalbital-acetaminophencaffeine tab
50-325-40 mg (Esgic)
butalbital-aspirin-caffeine
cap 50-325-40 mg
(Fiorinal)
diflunisal tab 500 mg
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
54
salsalate tab 750 mg
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
MEDICAMENTOS ESTUPEFACIENTES
$0 (1)
acetaminophen
w/ codeine soln
120-12 mg/5ml
$0 (1)
acetaminophen w/
codeine tab 300-15 mg
(Tylenol/codeine)
$0 (1)
acetaminophen w/
codeine tab 300-30 mg
(Tylenol/codeine #3)
$0 (1)
acetaminophen w/
codeine tab 300-60 mg
(Tylenol/codeine #4)
$0 (1)
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
BUNAVAIL –
$0 (2)
buprenorphine-naloxone
buccal film 2.1-0.3 mg
(base equiv)
BUNAVAIL –
$0 (2)
buprenorphine-naloxone
buccal film 4.2-0.7 mg
(base equiv)
BUNAVAIL –
$0 (2)
buprenorphine-naloxone
buccal film 6.3-1 mg
(base equiv)
$0 (1)
buprenorphine hcl sl tab
2 mg (base equiv)
$0 (1)
buprenorphine hcl sl tab
8 mg (base equiv)
$0 (1)
buprenorphine hclnaloxone hcl sl tab
2-0.5 mg (base equiv)
$0 (1)
buprenorphine hclnaloxone hcl sl tab
8-2 mg (base equiv)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL
QL
QL
QL
QL
QL
QL
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
butalbital-acetaminophenfentanyl td patch 72hr
caff w/ cod cap
50 mcg/hr (Duragesic)
50-300-40-30 mg
fentanyl td patch 72hr
(Fioricet/codeine)
75 mcg/hr (Duragesic)
$0 (1)
butalbital-acetaminophenfentanyl td patch 72hr
caff w/ cod cap
100 mcg/hr (Duragesic)
50-325-40-30 mg
hydrocodone$0 (1)
butalbital-aspirinacetaminophen soln
caff w/ codeine cap
7.5-325 mg/15ml
50-325-40-30 mg
(Hycet)
(Fiorinal/codeine #3)
hydrocodone$0 (1)
QL
butorphanol tartrate nasal
acetaminophen soln
soln 10 mg/ml
10-325 mg/15ml
$0 (1)
QL
codeine sulfate tab 15 mg
(Zamicet)
(Codeine sulfate)
hydrocodone$0 (1)
QL
codeine sulfate tab 30 mg
acetaminophen tab
2.5-325 mg
$0 (1)
QL
codeine sulfate tab 60 mg
hydrocodone$0 (1)
PA, QL
fentanyl citrate lozenge
acetaminophen tab
on a handle 200 mcg
10-325 mg (Norco)
(Actiq)
hydrocodone$0 (1)
PA, QL
fentanyl citrate lozenge
acetaminophen tab
on a handle 400 mcg
5-325 mg (Norco)
(Actiq)
hydrocodone$0 (1)
PA, QL
fentanyl citrate lozenge
acetaminophen tab
on a handle 600 mcg
7.5-325 mg (Norco)
(Actiq)
hydrocodone$0 (1)
PA, QL
fentanyl citrate lozenge
acetaminophen tab
on a handle 800 mcg
10-300 mg (Xodol)
(Actiq)
hydrocodone-ibuprofen
$0 (1)
PA, QL
fentanyl citrate lozenge
tab 5-200 mg
on a handle 1200 mcg
(Reprexain)
(Actiq)
hydrocodone-ibuprofen
$0 (1)
PA, QL
fentanyl citrate lozenge
tab 7.5-200 mg
on a handle 1600 mcg
(Vicoprofen)
(Actiq)
hydromorphone hcl liqd
$0 (1)
QL
fentanyl td patch 72hr
1 mg/ml (Dilaudid)
12 mcg/hr (Duragesic)
hydromorphone hcl tab
$0 (1)
QL
fentanyl td patch 72hr
2 mg (Dilaudid)
25 mcg/hr (Duragesic)
hydromorphone hcl tab
4 mg (Dilaudid)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
55
2016
Nombre del
medicamento
hydromorphone hcl tab
8 mg (Dilaudid)
meperidine hcl tab 50 mg
(Demerol)
meperidine hcl tab
100 mg (Demerol)
methadone hcl conc
10 mg/ml (Methadose)
methadone hcl soln
5 mg/5ml (Methadone
hcl)
methadone hcl soln
10 mg/5ml (Methadone
hcl)
methadone hcl tab for oral
susp 40 mg
methadone hcl tab 5 mg
(Dolophine hcl)
methadone hcl tab 10 mg
(Dolophine)
MORPHINE SULFATE
– morphine sulfate tab
15 mg
MORPHINE SULFATE
– morphine sulfate tab
30 mg
MORPHINE SULFATE –
morphine sulfate suppos
5 mg
MORPHINE SULFATE –
morphine sulfate suppos
10 mg
MORPHINE SULFATE –
morphine sulfate suppos
20 mg
MORPHINE SULFATE –
morphine sulfate suppos
30 mg
morphine sulfate cap sr
24hr 10 mg (Kadian)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
morphine sulfate cap sr
24hr 20 mg (Kadian)
$0 (1)
QL
morphine sulfate cap sr
24hr 30 mg (Kadian)
$0 (1)
QL
morphine sulfate cap sr
24hr 50 mg (Kadian)
$0 (1)
QL
morphine sulfate cap sr
24hr 60 mg (Kadian)
$0 (1)
QL
morphine sulfate cap sr
24hr 80 mg (Kadian)
morphine sulfate cap sr
$0 (1)
QL
24hr 100 mg (Kadian)
MORPHINE SULFATE
ER – morphine sulfate
$0 (1)
QL
beads cap sr 24hr
30 mg
$0 (1)
QL
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
$0 (1)
QL
45 mg
MORPHINE SULFATE
$0 (2)
QL
ER – morphine sulfate
beads cap sr 24hr
60 mg
$0 (2)
QL
MORPHINE SULFATE
ER – morphine sulfate
beads cap sr 24hr
$0 (2)
75 mg
MORPHINE SULFATE
ER – morphine sulfate
$0 (2)
beads cap sr 24hr
90 mg
MORPHINE SULFATE
$0 (2)
ER – morphine sulfate
beads cap sr 24hr
120 mg
$0 (2)
morphine sulfate oral soln
10 mg/5ml
morphine
sulfate oral soln
$0 (1)
QL
20 mg/5ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
56
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
QL
OXYCODONE/
morphine sulfate oral soln
ACETAMINOPHEN
100 mg/5ml (20 mg/ml)
– oxycodone w/
$0 (1)
QL
morphine sulfate tab cr
acetaminophen soln
15 mg (Ms contin)
5-325 mg/5ml
$0 (1)
QL
morphine sulfate tab cr
OXYCODONE/
30 mg (Ms contin)
IBUPROFEN –
$0 (1)
QL
morphine sulfate tab cr
oxycodone-ibuprofen
60 mg (Ms contin)
tab 5-400 mg
$0 (1)
QL
morphine sulfate tab cr
oxymorphone hcl tab sr
100 mg (Ms contin)
12hr 5 mg
$0 (1)
QL
morphine sulfate tab cr
oxymorphone
hcl tab sr
200 mg (Ms contin)
12hr 7.5 mg
OXYCODONE HCL
$0 (2)
QL
oxymorphone hcl tab sr
$0 (1)
QL
oxycodone hcl soln
12hr 10 mg
5 mg/5ml (Oxycodone
oxymorphone hcl tab sr
hcl)
12hr 15 mg
$0 (1)
QL
oxycodone hcl tab 5 mg
oxymorphone hcl tab sr
(Roxicodone)
12hr 20 mg
$0 (1)
QL
oxycodone hcl tab 10 mg
oxymorphone hcl tab sr
$0 (1)
QL
oxycodone hcl tab 15 mg
12hr 30 mg
(Roxicodone)
oxymorphone hcl tab sr
$0 (1)
QL
oxycodone hcl tab 20 mg
12hr 40 mg
$0 (1)
QL
oxycodone hcl tab 30 mg
oxymorphone hcl tab
(Roxicodone)
5 mg (Opana)
$0 (1)
oxycodone w/
oxymorphone hcl tab
acetaminophen tab
10 mg (Opana)
2.5-325 mg (Percocet)
SUBOXONE –
$0 (1)
oxycodone w/
buprenorphine hclacetaminophen tab
naloxone hcl sl film
5-325 mg (Percocet)
2-0.5 mg (base equiv)
$0 (1)
oxycodone w/
SUBOXONE –
acetaminophen tab
buprenorphine hcl7.5-325 mg (Percocet)
naloxone hcl sl film
$0 (1)
oxycodone w/
4-1 mg (base equiv)
acetaminophen tab
SUBOXONE –
10-325 mg (Percocet)
buprenorphine hcl$0 (1)
oxycodone-aspirin
naloxone hcl sl film
tab 4.8355-325 mg
8-2 mg (base equiv)
(Percodan)
SUBOXONE –
buprenorphine hcl1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
57
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
naloxone hcl sl film
diclofenac sodium tab
12-3 mg (base equiv)
delayed release 50 mg
$0 (1)
QL
tramadol hcl tab 50 mg
diclofenac sodium tab
(Ultram)
delayed release 75 mg
$0 (1)
tramadol-acetaminophen
diclofenac sodium tab sr
tab 37.5-325 mg
24hr 100 mg (Voltaren(Ultracet)
xr)
ZUBSOLV –
$0 (2)
QL
ENBREL – etanercept
buprenorphine hclsubcutaneous soln
naloxone hcl sl tab
prefilled syringe
1.4-0.36 mg (base eq)
25 mg/0.5ml
ZUBSOLV –
$0 (2)
QL
ENBREL – etanercept
buprenorphine hclsubcutaneous soln
naloxone hcl sl tab
prefilled syringe 50 mg/
2.9-0.71 mg (base eq)
ml
ZUBSOLV –
$0 (2)
QL
ENBREL SURECLICK
buprenorphine hcl– etanercept
naloxone hcl sl tab
subcutaneous solution
5.7-1.4 mg (base eq)
auto-injector 50 mg/ml
ZUBSOLV –
$0 (2)
QL
etodolac cap 200 mg
buprenorphine hcletodolac cap 300 mg
naloxone hcl sl tab
etodolac tab sr 24hr
8.6-2.1 mg (base eq)
400 mg
ZUBSOLV –
$0 (2)
QL
etodolac tab sr 24hr
buprenorphine hcl600 mg
naloxone hcl sl tab
etodolac tab 400 mg
11.4-2.9 mg (base eq)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
ARTRITIS REUMATOIDEA Y OSTEOARTRITIS
$0 (1)
QL, ST
celecoxib cap 50 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 100 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 200 mg
(Celebrex)
$0 (1)
QL, ST
celecoxib cap 400 mg
(Celebrex)
$0 (1)
diclofenac potassium tab
50 mg (Cataflam)
$0 (1)
diclofenac sodium tab
delayed release 25 mg
etodolac tab 500 mg
$0 (1)
flurbiprofen tab 50 mg
$0 (1)
flurbiprofen tab 100 mg
$0 (1)
HUMIRA – adalimumab
prefilled syringe kit
10 mg/0.2ml
HUMIRA – adalimumab
prefilled syringe kit
20 mg/0.4ml
HUMIRA – adalimumab
prefilled syringe kit
40 mg/0.8ml
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
$0 (2)
QL, SP, ST
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
58
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
HUMIRA PEDIATRIC
$0 (2)
QL, SP, ST
ketorolac tromethamine
CROHNS D –
tab 10 mg
adalimumab prefilled
leflunomide tab 10 mg
syringe kit 40 mg/0.8ml
(Arava)
HUMIRA PEN –
$0 (2)
QL, SP, ST
leflunomide tab 20 mg
adalimumab pen(Arava)
injector kit 40 mg/0.8ml
meloxicam tab 7.5 mg
HUMIRA PEN-CROHNS
$0 (2)
QL, SP, ST
(Mobic)
DISEASE – adalimumab
meloxicam tab 15 mg
pen-injector kit
(Mobic)
40 mg/0.8ml
nabumetone tab 500 mg
HUMIRA PEN$0 (2)
QL, SP, ST
nabumetone tab 750 mg
PSORIASIS STAR
naproxen sodium tab
– adalimumab pensr 24hr 375 mg (base
injector kit 40 mg/0.8ml
equiv) (Naprelan)
$0 (3)
ibuprofen cap 200 mg
naproxen sodium tab
$0 (1)
ibuprofen susp
sr 24hr 500 mg (base
100 mg/5ml
equiv) (Naprelan)
$0 (3)
ibuprofen susp
naproxen sodium tab
100 mg/5ml
220 mg
$0 (3)
ibuprofen tab 200 mg
naproxen sodium tab
$0 (1)
ibuprofen tab 400 mg
275 mg (Anaprox)
$0 (1)
ibuprofen tab 600 mg
naproxen sodium tab
550 mg (Anaprox ds)
$0 (1)
ibuprofen tab 800 mg
naproxen
susp
$0 (1)
indomethacin cap cr
125 mg/5ml (Naprosyn)
75 mg
naproxen tab ec 375 mg
$0 (1)
indomethacin cap 25 mg
(Ec-naprosyn)
$0 (1)
indomethacin cap 50 mg
naproxen tab ec 500 mg
$0 (1)
ketoprofen cap 50 mg
(Ec-naprosyn)
$0 (1)
ketoprofen cap 75 mg
naproxen tab 250 mg
KETOROLAC
$0 (2)
(Naprosyn)
TROMETHAMINE –
naproxen tab 375 mg
ketorolac tromethamine
(Naprosyn)
inj 60 mg/2ml (30 mg/
naproxen tab 500 mg
ml)
(Naprosyn)
$0 (1)
ketorolac tromethamine
piroxicam cap 10 mg
im inj 60 mg/2ml
(Feldene)
(30 mg/ml)
piroxicam cap 20 mg
(Feldene)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
59
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
$0 (1)
QL
sulindac tab 150 mg
sumatriptan succinate inj
6
mg/0.5ml
(Imitrex)
$0 (1)
sulindac tab 200 mg
$0 (1)
QL
sumatriptan succinate
MIGRAÑAS
solution auto-injector
$0 (1)
QL
almotriptan malate tab
4 mg/0.5ml (Imitrex
6.25 mg (Axert)
statdose sys)
$0 (1)
QL
almotriptan malate tab
$0 (1)
QL
sumatriptan succinate
12.5 mg (Axert)
solution auto-injector
$0 (1)
QL
frovatriptan succinate
6 mg/0.5ml (Imitrex
tab 2.5 mg (base
statdose sys)
equivalent) (Frova)
$0 (1)
QL
sumatriptan succinate
IMITREX – sumatriptan
$0 (2)
QL
solution cartridge
nasal spray 5 mg/act
4 mg/0.5ml (Imitrex
statdose ref)
IMITREX – sumatriptan
$0 (2)
QL
nasal spray 20 mg/act
$0 (1)
QL
sumatriptan succinate
solution cartridge
$0 (1)
QL
naratriptan hcl tab 1 mg
6 mg/0.5ml (Imitrex
(base equiv) (Amerge)
statdose ref)
$0 (1)
QL
naratriptan hcl tab 2.5 mg
$0 (1)
QL
sumatriptan
succinate tab
(base equiv) (Amerge)
25 mg (Imitrex)
$0 (1)
QL
rizatriptan benzoate oral
$0 (1)
QL
sumatriptan succinate tab
disintegrating tab 5 mg
50 mg (Imitrex)
(base eq) (Maxalt-mlt)
$0 (1)
QL
sumatriptan succinate tab
$0 (1)
QL
rizatriptan benzoate oral
100 mg (Imitrex)
disintegrating tab 10 mg
(base eq) (Maxalt-mlt)
GOTA
$0 (1)
QL
rizatriptan benzoate tab
$0 (1)
allopurinol tab 100 mg
5 mg (base equivalent)
(Zyloprim)
(Maxalt)
$0 (1)
allopurinol tab 300 mg
$0 (1)
QL
rizatriptan benzoate tab
(Zyloprim)
10 mg (base equivalent)
$0 (1)
colchicine w/ probenecid
(Maxalt)
tab 0.5-500 mg
$0 (1)
QL
sumatriptan nasal spray
$0 (1)
probenecid tab 500 mg
5 mg/act (Imitrex)
MEDICAMENTOS NEUROMUSCULARES
$0 (1)
QL
sumatriptan nasal spray
20 mg/act (Imitrex)
CONVULSIONES
SUMATRIPTAN
$0 (2)
QL
$0 (1)
carbamazepine cap sr
SUCCINATE –
12hr 100 mg (Carbatrol)
sumatriptan succinate
$0 (1)
carbamazepine cap sr
solution prefilled syringe
12hr 200 mg (Carbatrol)
6 mg/0.5ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
60
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
DIASTAT ACUDIAL –
carbamazepine cap sr
diazepam rectal gel
12hr 300 mg (Carbatrol)
delivery system 20 mg
$0 (1)
carbamazepine chew tab
DIASTAT PEDIATRIC
100 mg
– diazepam rectal gel
$0 (1)
carbamazepine susp
delivery system 2.5 mg
100 mg/5ml (Tegretol)
DIAZEPAM
– diazepam
$0 (1)
carbamazepine tab sr
rectal gel delivery
12hr 100 mg (Tegretolsystem 2.5 mg
xr)
DIAZEPAM – diazepam
$0 (1)
carbamazepine tab sr
rectal gel delivery
12hr 200 mg (Tegretolsystem 10 mg
xr)
DIAZEPAM – diazepam
$0 (1)
carbamazepine tab sr
rectal gel delivery
12hr 400 mg (Tegretolsystem 20 mg
xr)
DILANTIN – phenytoin
$0 (1)
carbamazepine tab
sodium extended cap
200 mg (Tegretol)
30 mg
$0 (1)
clonazepam orally
divalproex sodium tab
disintegrating tab
delayed release 125 mg
0.125 mg
(Depakote)
$0 (1)
clonazepam orally
divalproex
sodium tab
disintegrating tab
delayed release 250 mg
0.25 mg
(Depakote)
$0 (1)
clonazepam orally
divalproex sodium tab
disintegrating tab
delayed release 500 mg
0.5 mg
(Depakote)
$0 (1)
clonazepam orally
divalproex sodium tab sr
disintegrating tab 1 mg
24 hr 250 mg (Depakote
$0 (1)
clonazepam orally
er)
disintegrating tab 2 mg
divalproex sodium tab sr
$0 (1)
clonazepam tab 0.5 mg
24 hr 500 mg (Depakote
(Klonopin)
er)
$0 (1)
clonazepam tab 1 mg
ethosuximide cap 250 mg
(Klonopin)
(Zarontin)
$0 (1)
clonazepam tab 2 mg
ethosuximide soln
(Klonopin)
250 mg/5ml (Zarontin)
DIASTAT ACUDIAL –
$0 (2)
felbamate susp
diazepam rectal gel
600 mg/5ml (Felbatol)
delivery system 10 mg
felbamate tab 400 mg
(Felbatol)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
61
2016
Nombre del
medicamento
felbamate tab 600 mg
(Felbatol)
gabapentin cap 100 mg
(Neurontin)
gabapentin cap 300 mg
(Neurontin)
gabapentin cap 400 mg
(Neurontin)
gabapentin oral soln
250 mg/5ml (Neurontin)
gabapentin tab 600 mg
(Neurontin)
gabapentin tab 800 mg
(Neurontin)
lamotrigine orally
disintegrating tab 25 mg
(Lamictal odt)
lamotrigine orally
disintegrating tab 50 mg
(Lamictal odt)
lamotrigine orally
disintegrating tab
100 mg (Lamictal odt)
lamotrigine orally
disintegrating tab
200 mg (Lamictal odt)
lamotrigine tab chewable
dispersible 5 mg
(Lamictal chewable di)
lamotrigine tab chewable
dispersible 25 mg
(Lamictal chewable di)
lamotrigine tab disp
25 mg (21) & 50 mg (7)
titration kit (Lamictal odt)
lamotrigine tab disp
50 mg (42) & 100 mg
(14) titration kit
(Lamictal odt)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
lamotrigine tab disp 25
(14) & 50 mg (14) &
100 mg (7) kit (Lamictal
$0 (1)
odt)
lamotrigine tab sr 24hr
$0 (1)
25 mg (Lamictal xr)
lamotrigine
tab sr 24hr
$0 (1)
50 mg (Lamictal xr)
lamotrigine
tab sr 24hr
$0 (1)
100 mg (Lamictal xr)
lamotrigine tab sr 24hr
$0 (1)
200 mg (Lamictal xr)
lamotrigine tab sr 24hr
$0 (1)
250 mg (Lamictal xr)
lamotrigine tab sr 24hr
$0 (1)
300 mg (Lamictal xr)
lamotrigine tab 25 mg
(Lamictal)
$0 (1)
lamotrigine tab 100 mg
(Lamictal)
$0 (1)
lamotrigine tab 150 mg
(Lamictal)
lamotrigine tab 200 mg
$0 (1)
(Lamictal)
levetiracetam oral soln
100 mg/ml (Keppra)
$0 (1)
levetiracetam tab sr 24hr
500 mg (Keppra xr)
levetiracetam tab sr 24hr
$0 (1)
750 mg (Keppra xr)
levetiracetam tab 250 mg
(Keppra)
$0 (1)
levetiracetam tab 500 mg
(Keppra)
levetiracetam tab 750 mg
$0 (1)
(Keppra)
levetiracetam tab
1000 mg (Keppra)
LYRICA – pregabalin soln
20 mg/ml
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
62
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
QL, ST
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
LYRICA – pregabalin cap
$0 (2)
QL, ST
$0 (1)
primidone tab 250 mg
25 mg
(Mysoline)
LYRICA – pregabalin cap
$0 (2)
QL, ST
TEGRETOL-XR –
$0 (2)
50 mg
carbamazepine tab sr
12hr 100 mg
LYRICA – pregabalin cap
$0 (2)
QL, ST
75 mg
$0 (1)
tiagabine hcl tab 2 mg
(Gabitril)
LYRICA – pregabalin cap
$0 (2)
QL, ST
100 mg
$0 (1)
tiagabine hcl tab 4 mg
(Gabitril)
LYRICA – pregabalin cap
$0 (2)
QL, ST
150 mg
$0 (1)
topiramate sprinkle
cap 15 mg (Topamax
LYRICA – pregabalin cap
$0 (2)
QL, ST
sprinkle)
200 mg
$0 (1)
topiramate sprinkle
LYRICA – pregabalin cap
$0 (2)
QL, ST
cap 25 mg (Topamax
225 mg
sprinkle)
LYRICA – pregabalin cap
$0 (2)
QL, ST
$0 (1)
topiramate tab 25 mg
300 mg
(Topamax)
$0 (1)
oxcarbazepine susp
$0 (1)
topiramate tab 50 mg
300 mg/5ml (60 mg/ml)
(Topamax)
(Trileptal)
$0 (1)
topiramate tab 100 mg
$0 (1)
oxcarbazepine tab
(Topamax)
150 mg (Trileptal)
$0 (1)
topiramate
tab 200 mg
$0 (1)
oxcarbazepine tab
(Topamax)
300 mg (Trileptal)
$0 (1)
valproate
sodium syrup
$0 (1)
oxcarbazepine tab
250 mg/5ml (base
600 mg (Trileptal)
equiv) (Depakene)
$0 (1)
phenytoin chew tab 50 mg
$0 (1)
valproic acid cap 250 mg
(Dilantin infatabs)
(Depakene)
$0 (1)
phenytoin sodium
$0 (1)
zonisamide cap 25 mg
extended cap 100 mg
(Zonegran)
(Dilantin)
$0 (1)
zonisamide cap 50 mg
$0 (1)
phenytoin sodium
extended cap 200 mg
$0 (1)
zonisamide cap 100 mg
(Phenytek)
(Zonegran)
$0 (1)
phenytoin sodium
ENFERMEDAD DE PARKINSON
extended cap 300 mg
$0 (1)
amantadine hcl cap
(Phenytek)
100 mg
$0 (1)
phenytoin susp
$0 (1)
amantadine hcl syrup
125 mg/5ml (Dilantin)
50 mg/5ml
$0 (1)
primidone tab 50 mg
$0 (1)
benztropine mesylate tab
(Mysoline)
0.5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
63
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
24hr 2.25 mg (Mirapex
$0 (1)
benztropine mesylate tab
er)
1 mg
pramipexole
$0 (1)
benztropine mesylate tab
dihydrochloride tab sr
2 mg
24hr 3 mg (Mirapex er)
$0 (1)
bromocriptine mesylate
pramipexole
cap 5 mg (Parlodel)
dihydrochloride tab sr
$0 (1)
bromocriptine mesylate
24hr 4.5 mg (Mirapex
tab 2.5 mg
er)
$0 (1)
carbidopa & levodopa
pramipexole
orally disintegrating tab
dihydrochloride tab
10-100 mg
0.125 mg (Mirapex)
$0 (1)
carbidopa & levodopa
pramipexole
orally disintegrating tab
dihydrochloride tab
25-100 mg
0.25 mg (Mirapex)
$0 (1)
carbidopa & levodopa
pramipexole
orally disintegrating tab
dihydrochloride tab
25-250 mg
0.5 mg (Mirapex)
$0 (1)
carbidopa & levodopa tab
pramipexole
cr 25-100 mg (Sinemet
dihydrochloride tab
cr)
0.75 mg (Mirapex)
$0 (1)
carbidopa & levodopa tab
pramipexole
cr 50-200 mg (Sinemet
dihydrochloride tab
cr)
1 mg (Mirapex)
$0 (1)
carbidopa & levodopa tab
pramipexole
10-100 mg (Sinemet)
dihydrochloride tab
$0 (1)
carbidopa & levodopa tab
1.5 mg (Mirapex)
25-100 mg (Sinemet)
ropinirole hydrochloride
$0 (1)
carbidopa & levodopa tab
tab 0.25 mg (Requip)
25-250 mg (Sinemet)
ropinirole hydrochloride
$0 (1)
carbidopa tab 25 mg
tab 0.5 mg (Requip)
(Lodosyn)
ropinirole hydrochloride
$0 (1)
entacapone tab 200 mg
tab 1 mg (Requip)
(Comtan)
ropinirole hydrochloride
$0 (1)
pramipexole
tab 2 mg (Requip)
dihydrochloride tab sr
ropinirole hydrochloride
24hr 0.375 mg (Mirapex
tab 3 mg (Requip)
er)
ropinirole hydrochloride
$0 (1)
pramipexole
tab 4 mg (Requip)
dihydrochloride tab sr
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
64
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
ropinirole hydrochloride
tab 5 mg (Requip)
selegiline hcl cap 5 mg
(Eldepryl)
selegiline hcl tab 5 mg
tolcapone tab 100 mg
(Tasmar)
trihexyphenidyl hcl elixir
0.4 mg/ml
trihexyphenidyl hcl tab
2 mg
trihexyphenidyl hcl tab
5 mg
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
(nivel)
(nivel)
medicamento
el uso
el uso
$0 (1)
$0 (1)
QL
tizanidine hcl tab 4 mg
(Zanaflex)
$0 (1)
OTROS MEDICAMENTOS NEUROMUSCULARES
NEOSTIGMINE
METHYLSULFATE
– neostigmine
methylsulfate inj 0.5 mg/
ml (1:2000)
NEOSTIGMINE
METHYLSULFATE
– neostigmine
methylsulfate inj 1 mg/
ml
pyridostigmine bromide
tab cr 180 mg (Mestinon
timespan)
pyridostigmine bromide
tab 60 mg (Mestinon)
riluzole tab 50 mg
(Rilutek)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
RELAJANTES MUSCULARES
$0 (1)
baclofen tab 10 mg
baclofen tab 20 mg
$0 (1)
carisoprodol tab 250 mg
(Soma)
chlorzoxazone tab
500 mg (Parafon forte
dsc)
cyclobenzaprine hcl tab
5 mg
cyclobenzaprine hcl tab
10 mg
dantrolene sodium cap
25 mg (Dantrium)
dantrolene sodium cap
50 mg (Dantrium)
dantrolene sodium cap
100 mg
methocarbamol tab
500 mg (Robaxin)
methocarbamol tab
750 mg (Robaxin-750)
orphenadrine citrate tab sr
12hr 100 mg
tizanidine hcl tab 2 mg
$0 (1)
$0 (1)
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
SUPLEMENTOS
VITAMINAS
ascorbic acid tab 500 mg
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
QL
cholecalciferol cap 1000
unit
cholecalciferol cap 2000
unit
cholecalciferol cap 5000
unit
cholecalciferol cap 10000
unit
cholecalciferol cap 50000
unit
cholecalciferol chew tab
400 unit
cholecalciferol oral liquid
400 unit/ml
cholecalciferol tab 400
unit
PA
QL
SP
ST
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
65
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (3)
cholecalciferol tab 1000
b-complex w/ c & folic
unit
acid tab 1 mg (Nephrovite rx)
$0 (3)
cholecalciferol tab 2000
b-complex w/ c & folic
unit
acid tab 5 mg
$0 (3)
cholecalciferol tab 5000
FOLBEE PLUS CZ – bunit
complex w/ c-biotin$0 (3)
cholecalciferol tab 50000
minerals & folic acid tab
unit
5 mg
DECARA – cholecalciferol
$0 (3)
multiple vitamin tab
cap 25000 unit
multiple vitamins w/ iron
$0 (1)
ergocalciferol cap 50000
tab
unit (Drisdol)
multiple vitamins w/
MEPHYTON –
$0 (2)
minerals & fa tab
phytonadione tab 5 mg
1.25 mg (Corvite)
$0 (3)
niacin cap cr 250 mg
multiple
vitamins w/
$0 (3)
niacin cap cr 500 mg
minerals cap
$0 (3)
niacin tab cr 250 mg
multiple vitamins w/
$0 (3)
niacin tab cr 500 mg
minerals cap
$0 (3)
niacin tab cr 750 mg
multiple vitamins w/
minerals chew tab
$0 (3)
niacin tab 50 mg
multiple vitamins w/
$0 (3)
niacin tab 100 mg
minerals tab (Strovite
$0 (3)
niacin tab 500 mg
forte)
NIACIN TR – niacin tab cr
$0 (3)
pediatric multiple vitamin
1000 mg
w/ c & fa chew tab
$0 (3)
thiamine hcl tab 50 mg
pediatric multiple vitamin
$0 (3)
thiamine hcl tab 100 mg
w/ c soln 35 mg/ml
pediatric multiple vitamin
MULTIVITAMINAS
w/ minerals & c drops
AQUADEKS – multiple
$0 (3)
45 mg/ml
vitamins w/ minerals cap
pediatric multiple
AQUADEKS – multiple
$0 (3)
vitamins w/ fl-fe drops
vitamins w/ minerals
0.25-10 mg/ml
chew tab
pediatric multiple vitamins
$0 (1)
b-complex w/ c &
w/ fluoride chew tab
folic acid cap 1 mg
0.25 mg
(Nephrocaps)
pediatric
multiple vitamins
$0 (1)
b-complex w/ c & folic
w/ fluoride chew tab
acid tab
0.5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
66
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (2)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (3)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
pediatric multiple vitamins
calcium carbonate-vitamin
w/ fluoride chew tab
d tab 600 mg-400 unit
1 mg
calcium citrate tab 950 mg
$0 (1)
pediatric multiple vitamins
(200 mg elemental ca)
w/ fluoride soln 0.25 mg/
calcium citrate-vitamin
ml
d tab 315 mg-200 unit
$0 (1)
(elemental ca)
pediatric multiple vitamins
w/ fluoride soln 0.5 mg/
calcium w/ vitamin d tab
ml
600 mg-200 unit
$0 (1)
pediatric vitamins acd w/
K-PHOS – potassium
fluoride soln 0.25 mg/ml
phosphate monobasic
$0 (1)
tab 500 mg
pediatric vitamins acd w/
fluoride soln 0.5 mg/ml
oral electrolyte solution
$0 (3)
pediatric vitamins adc
pot bicarbonate & chloride
drops 1500 unit-400
effer tab 25 meq
unit-35 mg/ml
pot phos monobasic w/
$0 (1)
speciality vitamin product
sod phos di & monobas
tab
tab 155-852-130mg (KTRI-VI-SOL – pediatric
$0 (3)
phos neutral)
vitamins adc drops 750
potassium bicarbonate
unit-400 unit-35 mg/ml
effer tab 25 meq
TRI-VIT/FLUORIDE/IRON
$0 (2)
potassium chloride cap cr
– pediatric vitamins
8 meq (Micro-k)
acd fluoride & fe drops
potassium chloride cap cr
0.25-10 mg/ml
10 meq (Micro-k)
MINERALES Y ELECTROLITOS
$0 (3)
calcium carbonate tab
1250 mg (500 mg
elemental ca)
$0 (3)
calcium carbonatecholecalciferol tab
500 mg-200 unit
$0 (3)
calcium carbonatecholecalciferol tab
600 mg-400 unit
$0 (3)
calcium carbonate-vitamin
d tab 250 mg-125 unit
$0 (3)
calcium carbonate-vitamin
d tab 500 mg-200 unit
POTASSIUM CHLORIDE
ER – potassium chloride
tab cr 8 meq (600 mg)
potassium chloride
microencapsulated crys
cr tab 10 meq
potassium chloride
microencapsulated crys
cr tab 20 meq
potassium chloride oral
soln 10% (20 meq/15ml)
potassium chloride oral
soln 20% (40 meq/15ml)
potassium chloride
powder packet 20 meq
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
$0 (3)
$0 (3)
$0 (3)
$0 (2)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
67
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
$0 (1)
OMEGA-3 2100 –
$0 (3)
potassium chloride tab cr
omega-3 fatty acids cap
8 meq (600 mg)
1050 mg
$0 (1)
potassium chloride tab cr
$0 (3)
omega-3 fatty acids cap
10 meq (K-tab)
500
mg
SODIUM FLUORIDE
$0 (2)
– sodium fluoride tab
$0 (3)
omega-3 fatty acids cap
1 mg f (from 2.2 mg naf)
435 mg
$0 (1)
$0 (3)
sodium fluoride chew tab
omega-3 fatty acids cap
0.25 mg f (from 0.55 mg
1000 mg
naf) (Luride)
$0 (3)
omega-3 fatty acids cap
$0 (1)
sodium fluoride chew tab
1200 mg
0.5 mg f (from 1.1 mg
$0 (3)
omega-3 fatty acids
naf) (Luride)
cap delayed release
$0 (1)
1000 mg
sodium fluoride chew tab
1 mg f (from 2.2 mg naf)
$0 (3)
omega-3 fatty acids
(Luride)
cap delayed release
$0 (1)
1200 mg
sodium fluoride soln
0.125 mg/drop f
PRO NUTRIENTS
$0 (3)
(0.275 mg/drop naf)
OMEGA 3 – omega-3
$0 (1)
fatty acids cap delayed
sodium fluoride soln
release 332.5 mg
0.5 mg/ml f (from
1.1 mg/ml naf) (Luride)
VP-PRECIP –
$0 (2)
flaxseed
oil-evening
OTROS SUPLEMENTOS
primrose-bilberry cap
DIALYVITE OMEGA-3
$0 (3)
250-125-10 mg
CONCENT – omega-3
MEDICAMENTOS MODIFICADORES DE SANGRE
fatty acids cap 600 mg
ADVATE – antihemophilic
$0 (2)
SP
$0 (3)
docosahexaenoic acid
factor rahf-pfm for inj
cap 200 mg
250 unit
OCEAN BLUE MINICAPS
$0 (3)
ADVATE – antihemophilic
$0 (2)
SP
OMEGA – omega-3
factor rahf-pfm for inj
fatty acids cap 350 mg
500 unit
OMEGA POWER –
$0 (3)
ADVATE – antihemophilic
$0 (2)
SP
omega-3 fatty acids cap
factor rahf-pfm for inj
1050 mg
1000 unit
OMEGA-3 – omega-3
$0 (3)
ADVATE – antihemophilic
$0 (2)
SP
fatty acids cap 1400 mg
factor
rahf-pfm
for
inj
OMEGA-3 IQ – omega-3
$0 (3)
1500 unit
fatty acids chew tab
240 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
68
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
vwf (human) for inj 1000
ADVATE – antihemophilic
$0 (2)
SP
unit
factor rahf-pfm for inj
2000 unit
ALPHANATE/VON
WILLEBRAND –
ADVATE – antihemophilic
$0 (2)
SP
antihemophilic factor/
factor rahf-pfm for inj
vwf (human) for inj 1500
3000 unit
unit
ADVATE – antihemophilic
$0 (2)
SP
ALPHANATE/VON
factor rahf-pfm for inj
WILLEBRAND –
4000 unit
antihemophilic factor/
ADYNOVATE –
$0 (2)
vwf (human) for inj 2000
antihemophilic factor
unit
recomb pegylated for inj
ALPHANINE
SD –
250 unit
coagulation factor ix for
ADYNOVATE –
$0 (2)
inj 500 unit
antihemophilic factor
ALPHANINE SD –
recomb pegylated for inj
coagulation factor ix for
500 unit
inj 1000 unit
ADYNOVATE –
$0 (2)
ALPHANINE SD –
antihemophilic factor
coagulation factor ix for
recomb pegylated for inj
inj 1500 unit
1000 unit
ALPROLIX
– coagulation
ADYNOVATE –
$0 (2)
factor ix (recomb) (rfixfc)
antihemophilic factor
for inj 500 unit
recomb pegylated for inj
2000 unit
ALPROLIX – coagulation
factor ix (recomb) (rfixfc)
AGGRENOX – aspirin$0 (2)
for inj 1000 unit
dipyridamole cap sr
12hr 25-200 mg
ALPROLIX – coagulation
factor ix (recomb) (rfixfc)
ALPHANATE/VON
$0 (2)
SP
for inj 2000 unit
WILLEBRAND –
antihemophilic factor/
ALPROLIX – coagulation
vwf (human) for inj 250
factor ix (recomb) (rfixfc)
unit
for inj 3000 unit
ALPHANATE/VON
$0 (2)
SP
anagrelide hcl cap 0.5 mg
WILLEBRAND –
(Agrylin)
antihemophilic factor/
anagrelide hcl cap 1 mg
vwf (human) for inj 500
ARANESP ALBUMIN
unit
FREE – darbepoetin
ALPHANATE/VON
$0 (2)
SP
alfa soln prefilled
WILLEBRAND –
syringe 10 mcg/0.4ml
antihemophilic factor/
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
$0 (1)
$0 (2)
PA, SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
69
2016
Nombre del
medicamento
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 25 mcg/0.42ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 40 mcg/0.4ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 60 mcg/0.3ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 100 mcg/0.5ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 150 mcg/0.3ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 200 mcg/0.4ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 300 mcg/0.6ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln prefilled
syringe 500 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 25 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 40 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 60 mcg/ml
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
PA, SP
ARANESP ALBUMIN
FREE – darbepoetin
alfa soln inj 100 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
$0 (2)
PA, SP
alfa soln inj 200 mcg/ml
ARANESP ALBUMIN
FREE – darbepoetin
$0 (2)
PA, SP
alfa soln inj 300 mcg/ml
ASPIRIN/
DIPYRIDAMOLE –
aspirin-dipyridamole cap
$0 (2)
PA, SP
sr 12hr 25-200 mg
BEBULIN – factor
ix complex for inj
200-1200 unit
$0 (2)
PA, SP
BENEFIX – coagulation
factor ix (recombinant)
for inj 250 unit
BENEFIX – coagulation
$0 (2)
PA, SP
factor ix (recombinant)
for inj 500 unit
BENEFIX – coagulation
factor ix (recombinant)
$0 (2)
PA, SP
for inj 1000 unit
BENEFIX – coagulation
factor ix (recombinant)
for inj 2000 unit
$0 (2)
PA, SP
BENEFIX – coagulation
factor ix (recombinant)
for inj 3000 unit
BRILINTA – ticagrelor tab
$0 (2)
PA, SP
60 mg
BRILINTA – ticagrelor tab
90 mg
$0 (2)
PA, SP
cilostazol tab 50 mg
(Pletal)
cilostazol tab 100 mg
$0 (2)
PA, SP
(Pletal)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
70
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
$0 (2)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
ELOCTATE –
clopidogrel bisulfate tab
antihemophilic factor
75 mg (base equiv)
(recomb) rfviiifc for inj
(Plavix)
250 unit
$0 (1)
clopidogrel bisulfate tab
ELOCTATE –
300 mg (base equiv)
antihemophilic factor
(Plavix)
(recomb) rfviiifc for inj
COAGADEX –
$0 (2)
500 unit
coagulation factor x
ELOCTATE –
(human) for inj 250 unit
antihemophilic factor
COAGADEX –
$0 (2)
(recomb) rfviiifc for inj
coagulation factor x
750 unit
(human) for inj 500 unit
ELOCTATE –
CORIFACT – factor xiii
$0 (2)
SP
antihemophilic factor
concentrate (human) for
(recomb) rfviiifc for inj
inj kit 1000-1600 unit
1000 unit
$0 (1)
cyanocobalamin inj
ELOCTATE
–
1000 mcg/ml
antihemophilic factor
$0 (3)
cyanocobalamin tab cr
(recomb) rfviiifc for inj
1000 mcg
1500 unit
$0 (3)
cyanocobalamin tab sl
ELOCTATE –
2500 mcg
antihemophilic factor
$0 (3)
cyanocobalamin tab
(recomb) rfviiifc for inj
100 mcg
2000 unit
$0 (3)
cyanocobalamin tab
ELOCTATE –
250 mcg
antihemophilic factor
$0 (3)
cyanocobalamin tab
(recomb) rfviiifc for inj
500 mcg
3000 unit
$0 (3)
cyanocobalamin tab
enoxaparin sodium inj
1000 mcg
30 mg/0.3ml (Lovenox)
$0 (1)
dipyridamole tab 25 mg
enoxaparin sodium inj
(Persantine)
40 mg/0.4ml (Lovenox)
$0 (1)
dipyridamole tab 50 mg
enoxaparin sodium inj
(Persantine)
60 mg/0.6ml (Lovenox)
$0 (1)
dipyridamole tab 75 mg
enoxaparin sodium inj
(Persantine)
80 mg/0.8ml (Lovenox)
ELIQUIS – apixaban tab
$0 (2)
QL
enoxaparin sodium inj
2.5 mg
100 mg/ml (Lovenox)
ELIQUIS – apixaban tab
$0 (2)
QL
enoxaparin sodium inj
5 mg
120 mg/0.8ml (Lovenox)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
71
2016
Nombre del
medicamento
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
QL
folic acid tab 400 mcg
enoxaparin sodium inj
150 mg/ml (Lovenox)
enoxaparin sodium inj
300 mg/3ml (Lovenox)
EPOGEN – epoetin alfa
inj 2000 unit/ml
EPOGEN – epoetin alfa
inj 3000 unit/ml
EPOGEN – epoetin alfa
inj 4000 unit/ml
EPOGEN – epoetin alfa
inj 10000 unit/ml
EPOGEN – epoetin alfa
inj 20000 unit/ml
fe fum-iron polysacch
complex-fa-b cmplx-czn-mn-cu cap (Tandem
plus)
fe fumarate w/ b12vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
fe fumarate-vit c-vit
b12-fa cap 460 (151
fe)-60-0.01-1 mg
FEIBA – antiinhibitor
coagulant complex for
inj
ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu
tab 106-1 mg
ferrous fumarate-folic acid
tab 324-1 mg
ferrous sulfate tab ec
325 mg (65 mg fe
equivalent)
ferrous sulfate tab 325 mg
(65 mg elemental fe)
FIRAZYR – icatibant
acetate inj 30 mg/3ml
(base equivalent)
$0 (1)
QL
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (1)
$0 (1)
$0 (1)
$0 (2)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (2)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
72
SP
QL, SP
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (3)
folic acid tab 800 mcg
$0 (3)
folic acid tab 1 mg
$0 (1)
folic acid-vitamin b6vitamin b12 tab
2.2-25-0.5 mg
folic acid-vitamin b6vitamin b12 tab
2.2-25-1 mg (Folgard rx)
folic acid-vitamin b6vitamin b12 tab
2.5-25-1 mg
fondaparinux sodium
subcutaneous inj
2.5 mg/0.5ml (Arixtra)
fondaparinux sodium
subcutaneous inj
5 mg/0.4ml (Arixtra)
fondaparinux sodium
subcutaneous inj
7.5 mg/0.6ml (Arixtra)
fondaparinux sodium
subcutaneous inj
10 mg/0.8ml (Arixtra)
HELIXATE FS –
antihemophilic factor
(recombinant) for inj kit
250 unit
HELIXATE FS –
antihemophilic factor
(recombinant) for inj kit
500 unit
HELIXATE FS –
antihemophilic factor
(recombinant) for inj kit
1000 unit
HELIXATE FS –
antihemophilic factor
(recombinant) for inj kit
2000 unit
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (1)
QL
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
HELIXATE FS –
antihemophilic factor
(recombinant) for inj kit
3000 unit
HEMOFIL M –
antihemophilic factor
(human) for inj 250 unit
HEMOFIL M –
antihemophilic factor
(human) for inj 500 unit
HEMOFIL M –
antihemophilic factor
(human) for inj 1000 unit
HEMOFIL M –
antihemophilic factor
(human) for inj 1700 unit
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
250-600 unit
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
500-1200 unit
HUMATE-P –
antihemophilic factor/
vwf (human) for inj
1000-2400 unit
IDELVION – coagulation
factor ix (recomb) (rixfp) for inj 250 unit
IDELVION – coagulation
factor ix (recomb) (rixfp) for inj 500 unit
IDELVION – coagulation
factor ix (recomb) (rixfp) for inj 1000 unit
IDELVION – coagulation
factor ix (recomb) (rixfp) for inj 2000 unit
iron combination cap
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
SP
iron polysacch complexvit b12-fa cap
150-0.025-1 mg
iron-docusate-b12-folic
$0 (2)
SP
acid-c-e-cu-biotin tab
150-1 mg (Hematron-af)
iron-folic acid-vit c-vit
$0 (2)
SP
b6-vit b12-zinc tab
150-1.25 mg (Corvite
150)
$0 (2)
SP
KOATE-DVI –
antihemophilic factor
(human) for inj 250 unit
$0 (2)
SP
KOATE-DVI –
antihemophilic factor
(human) for inj 500 unit
$0 (2)
SP
KOATE-DVI –
antihemophilic factor
(human) for inj 1000 unit
KOGENATE FS –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj kit
250 unit
KOGENATE FS –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj kit
500 unit
KOGENATE FS –
antihemophilic factor
$0 (2)
(recombinant) for inj kit
1000 unit
$0 (2)
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
2000 unit
$0 (2)
KOGENATE FS –
antihemophilic factor
(recombinant) for inj kit
$0 (2)
3000 unit
KOGENATE FS BIO-SET
– antihemophilic factor
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (1)
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
73
2016
Nombre del
medicamento
(recombinant) for inj kit
250 unit
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
500 unit
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
1000 unit
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
2000 unit
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit
3000 unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj 250
unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj 500
unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
1000 unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
2000 unit
KOVALTRY –
antihemophilic factor
(recombinant) for inj
3000 unit
MONOCLATE-P –
antihemophilic factor
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
(human) for inj kit 250
unit
$0 (2)
SP
MONOCLATE-P –
antihemophilic factor
(human) for inj kit 1000
unit
$0 (2)
SP
MONOCLATE-P –
antihemophilic factor
(human) for inj kit 1500
unit
$0 (2)
SP
MONONINE –
coagulation factor ix for
inj 500 unit
MONONINE –
coagulation factor ix for
$0 (2)
SP
inj 1000 unit
NEUPOGEN – filgrastim
soln prefilled syringe
$0 (2)
SP
300 mcg/0.5ml
NEUPOGEN – filgrastim
soln prefilled syringe
480 mcg/0.8ml
$0 (2)
SP
(600 mcg/ml)
NEUPOGEN – filgrastim
inj 300 mcg/ml
NEUPOGEN – filgrastim
$0 (2)
SP
inj 480 mcg/1.6ml
(300 mcg/ml)
NOVOEIGHT –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj 250
unit
NOVOEIGHT –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj 500
unit
NOVOEIGHT –
antihemophilic factor
$0 (2)
SP
(recombinant) for inj
1000 unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
74
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
1500 unit
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
2000 unit
NOVOEIGHT –
antihemophilic factor
(recombinant) for inj
3000 unit
NOVOSEVEN RT –
coagulation factor viia
(recomb) for inj 1 mg
(1000 mcg)
NOVOSEVEN RT –
coagulation factor viia
(recomb) for inj 2 mg
(2000 mcg)
NOVOSEVEN RT –
coagulation factor viia
(recomb) for inj 5 mg
(5000 mcg)
NOVOSEVEN RT –
coagulation factor viia
(recomb) for inj 8 mg
(8000 mcg)
NUWIQ – antihemophilic
factor (recombinant) for
inj 250 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 500 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 1000 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj 2000 unit
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (2)
SP
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 250 unit
NUWIQ – antihemophilic
factor (recombinant) for
$0 (2)
SP
inj kit 500 unit
NUWIQ – antihemophilic
factor (recombinant) for
$0 (2)
SP
inj kit 1000 unit
NUWIQ – antihemophilic
factor (recombinant) for
inj kit 2000 unit
$0 (2)
SP
OBIZUR – antihemophilic
factor (recomb porc)
rpfviii for inj 500 unit
pentoxifylline tab cr
$0 (2)
SP
400 mg
PROCRIT – epoetin alfa
inj 2000 unit/ml
PROCRIT – epoetin alfa
$0 (2)
SP
inj 3000 unit/ml
PROCRIT – epoetin alfa
inj 4000 unit/ml
PROCRIT – epoetin alfa
$0 (2)
SP
inj 10000 unit/ml
PROCRIT – epoetin alfa
inj 20000 unit/ml
PROCRIT – epoetin alfa
$0 (2)
SP
inj 40000 unit/ml
PROFILNINE – factor ix
complex for inj 500 unit
$0 (2)
SP
PROFILNINE – factor ix
complex for inj 1000 unit
PROFILNINE
– factor ix
$0 (2)
SP
complex for inj 1500 unit
PROFILNINE SD – factor
ix complex for inj 500
$0 (2)
SP
unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (1)
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
PA, SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
75
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
PROFILNINE SD – factor
$0 (2)
SP
tranexamic acid tab
ix complex for inj 1000
650 mg (Lysteda)
unit
TRETTEN – coagulation
factor xiii a-subunit for
PROFILNINE SD – factor
$0 (2)
SP
ix complex for inj 1500
inj 2000-3125 unit
unit
warfarin sodium tab 1 mg
RECOMBINATE –
$0 (2)
SP
(Coumadin)
antihemophilic factor
warfarin sodium tab 2 mg
(recombinant) for inj
(Coumadin)
220-400 unit
warfarin sodium tab
RECOMBINATE –
$0 (2)
SP
2.5 mg (Coumadin)
antihemophilic factor
warfarin sodium tab 3 mg
(recombinant) for inj
(Coumadin)
401-800 unit
warfarin sodium tab 4 mg
RECOMBINATE –
$0 (2)
SP
(Coumadin)
antihemophilic factor
warfarin sodium tab 5 mg
(recombinant) for inj
(Coumadin)
801-1240 unit
warfarin sodium tab 6 mg
RECOMBINATE –
$0 (2)
SP
(Coumadin)
antihemophilic factor
warfarin sodium tab
(recombinant) for inj
7.5 mg (Coumadin)
1241-1800 unit
warfarin sodium tab
RECOMBINATE –
$0 (2)
SP
10 mg (Coumadin)
antihemophilic factor
XARELTO – rivaroxaban
(recombinant) for inj
tab 10 mg
1801-2400 unit
XARELTO – rivaroxaban
RIXUBIS – coagulation
$0 (2)
SP
tab 15 mg
factor ix (recombinant)
XARELTO – rivaroxaban
for inj 250 unit
tab 20 mg
RIXUBIS – coagulation
$0 (2)
SP
XARELTO STARTER
factor ix (recombinant)
PACK – rivaroxaban
for inj 500 unit
tab starter therapy pack
RIXUBIS – coagulation
$0 (2)
SP
15 mg & 20 mg
factor ix (recombinant)
XYNTHA – antihemophilic
for inj 1000 unit
factor recombinant paf
RIXUBIS – coagulation
$0 (2)
SP
for inj kit 250 unit
factor ix (recombinant)
XYNTHA
– antihemophilic
for inj 2000 unit
factor recombinant paf
RIXUBIS – coagulation
$0 (2)
SP
for inj kit 500 unit
factor ix (recombinant)
for inj 3000 unit
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
76
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (2)
SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
QL
$0 (2)
SP
$0 (2)
SP
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
XYNTHA – antihemophilic
$0 (2)
SP
$0 (1)
ciprofloxacin hcl ophth
factor recombinant paf
soln 0.3% (Ciloxan)
for inj kit 1000 unit
$0 (1)
erythromycin ophth oint
XYNTHA – antihemophilic
$0 (2)
SP
5 mg/gm
factor recombinant paf
$0 (1)
gentamicin sulfate ophth
for inj kit 2000 unit
oint 0.3%
XYNTHA SOLOFUSE –
$0 (2)
SP
$0 (1)
gentamicin sulfate ophth
antihemophilic factor
soln 0.3% (Garamycin)
recombinant paf for inj
$0 (1)
levofloxacin ophth soln
kit 250 unit
0.5%
XYNTHA SOLOFUSE –
$0 (2)
SP
NATACYN – natamycin
$0 (2)
antihemophilic factor
ophth susp 5%
recombinant paf for inj
$0 (1)
neomycin-bacitrac
kit 500 unit
zn-polymyx
XYNTHA SOLOFUSE –
$0 (2)
SP
5(3.5)mg-400unt-10000unt
antihemophilic factor
op oin
recombinant paf for inj
$0 (1)
neomycin-polymykit 1000 unit
gramicid op sol
XYNTHA SOLOFUSE –
$0 (2)
SP
1.75-10000-0.025mgantihemophilic factor
unt-mg/ml (Neosporin)
recombinant paf for inj
$0 (1)
ofloxacin ophth soln 0.3%
kit 2000 unit
(Ocuflox)
XYNTHA SOLOFUSE –
$0 (2)
SP
$0 (1)
polymyxin b-trimethoprim
antihemophilic factor
ophth soln 10000 unit/
recombinant paf for inj
ml-0.1% (Polytrim)
kit 3000 unit
$0 (1)
sulfacetamide sodium
ZARXIO – filgrastim-sndz
$0 (2)
SP
ophth soln 10%
soln prefilled syringe
(Bleph-10)
300 mcg/0.5ml
$0 (1)
tobramycin ophth soln
ZARXIO – filgrastim-sndz
$0 (2)
SP
0.3% (Tobrex)
soln prefilled syringe
$0 (1)
trifluridine ophth soln 1%
480 mcg/0.8ml
(Viroptic)
MEDICAMENTOS TÓPICOS
OJO
Antinfecciosos
BACITRACIN – bacitracin
ophth oint 500 unit/gm
bacitracin-polymyxin b
ophth oint
$0 (2)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Esteroides y productos de combinación
$0 (1)
bacitracin-polymyxinneomycin-hc ophth oint
1%
DEXAMETHASONE
$0 (2)
SODIUM PHOSPHATE
– dexamethasone
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
77
2016
Acciones
Acciones
Cuánto le
Cuánto
le
necesarias,
necesarias,
costará el
costará el
restricciones
restricciones
medicamento o límites en
medicamento o límites en
Nombre del
Nombre del
(nivel)
(nivel)
medicamento
medicamento
el uso
el uso
sodium phosphate
$0 (1)
carteolol hcl ophth soln
ophth soln 0.1%
1%
$0 (1)
fluorometholone ophth
$0 (1)
dorzolamide hcl ophth
susp 0.1% (Fml liquifilm)
soln 2% (Trusopt)
LOTEMAX – loteprednol
$0 (2)
$0 (1)
dorzolamide hcl-timolol
etabonate ophth susp
maleate ophth soln
0.5%
22.3-6.8 mg/ml (Cosopt)
$0 (1)
neomycin-polymyxin$0 (1)
QL
latanoprost ophth soln
dexamethasone ophth
0.005% (Xalatan)
oint 0.1% (Maxitrol)
$0 (1)
levobunolol hcl ophth soln
$0 (1)
neomycin-polymyxin0.5% (Betagan)
dexamethasone ophth
METIPRANOLOL –
$0 (2)
susp 0.1% (Maxitrol)
metipranolol ophth soln
$0 (1)
prednisolone acetate
0.3%
ophth susp 1% (Pred
$0 (1)
pilocarpine hcl ophth soln
forte)
1% (Isopto carpine)
PREDNISOLONE
$0 (2)
$0 (1)
pilocarpine hcl ophth soln
SODIUM PHOSP –
2% (Isopto carpine)
prednisolone sodium
$0 (1)
pilocarpine hcl ophth soln
phosphate ophth soln
4% (Isopto carpine)
1%
$0 (1)
timolol maleate ophth gel
$0 (1)
sulfacetamide sodiumforming soln 0.25%
prednisolone ophth soln
(Timoptic-xe)
10-0.23(0.25)%
$0 (1)
timolol maleate ophth gel
$0 (1)
tobramycinforming soln 0.5%
dexamethasone
(Timoptic-xe)
ophth susp 0.3-0.1%
$0 (1)
timolol maleate ophth soln
(Tobradex)
0.25% (Timoptic)
Glaucoma
$0 (1)
timolol maleate ophth soln
ALPHAGAN P –
$0 (2)
0.5% (Timoptic)
brimonidine tartrate
Otros productos oculares
ophth soln 0.1%
$0 (3)
artificial tear ophth
$0 (1)
apraclonidine hcl ophth
solution
soln 0.5% (base
ATROPINE SULFATE –
$0 (2)
equivalent) (Iopidine)
atropine sulfate ophth
$0 (1)
betaxolol hcl ophth soln
soln 1%
0.5%
ATROPINE SULFATE –
$0 (2)
$0 (1)
brimonidine tartrate ophth
atropine sulfate ophth
soln 0.2%
oint 1%
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
78
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Nombre del
medicamento
azelastine hcl ophth soln
0.05% (Optivar)
cromolyn sodium ophth
soln 4%
cyclopentolate hcl ophth
soln 0.5% (Cyclogyl)
cyclopentolate hcl ophth
soln 1% (Cyclogyl)
cyclopentolate hcl ophth
soln 2% (Cyclogyl)
diclofenac sodium ophth
soln 0.1%
epinastine hcl ophth soln
0.05% (Elestat)
flurbiprofen sodium ophth
soln 0.03% (Ocufen)
ketorolac tromethamine
ophth soln 0.4% (Acular
ls)
ketorolac tromethamine
ophth soln 0.5%
(Acular)
ketotifen fumarate ophth
soln 0.025% (base
equiv)
olopatadine hcl ophth soln
0.1% (base equivalent)
(Patanol)
phenylephrine hcl ophth
soln 2.5%
phenylephrine hcl ophth
soln 10%
proparacaine hcl ophth
soln 0.5% (Alcaine)
tetracaine hcl ophth soln
0.5%
tetrahydroz-dextran-pegpovidone ophth soln
0.05-0.1-1-1%
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
acetic acid otic soln 2%
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
OÍDO
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
antipyrine-benzocaine
otic soln 54-14 mg/ml
(5.4-1.4%)
carbamide peroxide 6.5%
otic soln
CIPRODEX –
ciprofloxacindexamethasone otic
susp 0.3-0.1%
hydrocortisone w/ acetic
acid otic soln 1-2%
(Vosol hc)
neomycin-polymyxinhc otic soln 1%
(Cortisporin)
neomycin-polymyxinhc otic susp 3.5 mg/
ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (3)
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
BOCA Y GARGANTA (local)
$0 (1)
cevimeline hcl cap 30 mg
(Evoxac)
$0 (1)
chlorhexidine gluconate
soln 0.12% (Peridex)
$0 (1)
clotrimazole troche 10 mg
lidocaine hcl viscous soln
2%
nystatin susp 100000 unit/
ml
pilocarpine hcl tab 5 mg
(Salagen)
pilocarpine hcl tab 7.5 mg
(Salagen)
sodium fluoride cream
1.1% (Prevident 5000
plus)
sodium fluoride gel 1.1%
(0.5% f) (Prevident
fluoride)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
79
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
triamcinolone acetonide
clindamycin phosphate
dental paste 0.1%
soln 1% (Cleocin-t)
clindamycin phosphate
AGENTES ANORRECTALES
swab 1% (Cleocin-t)
CORTIFOAM –
$0 (2)
DIFFERIN – adapalene
hydrocortisone acetate
lotion 0.1%
rectal foam 10% (90 mg/
erythromycin gel 2%
dose)
(Erygel)
$0 (1)
hydrocortisone enema
erythromycin pads 2%
100 mg/60ml
(Cortenema)
erythromycin soln 2%
$0 (1)
hydrocortisone rectal
isotretinoin cap 10 mg
cream 1% (Proctocort)
isotretinoin cap 20 mg
$0 (1)
hydrocortisone rectal
isotretinoin cap 30 mg
cream 2.5% (Anusol-hc)
isotretinoin cap 40 mg
CONDICIONES/PRODUCTOS DE LA PIEL
metronidazole cream
Acné
0.75% (Metrocream)
$0 (1)
PA
adapalene cream 0.1%
metronidazole gel 0.75%
(Differin)
metronidazole gel 1%
$0 (1)
PA
adapalene gel 0.1%
(Metrogel)
(Differin)
sulfacetamide sodium
$0 (1)
PA
adapalene gel 0.3%
lotion 10% (acne)
(Differin)
(Klaron)
$0 (1)
benzoyl peroxide cloth 6%
sulfacetamide sodium w/
$0 (1)
benzoyl peroxide liq 10%
sulfur emulsion 10-1%
$0 (1)
benzoyl peroxide lotion
sulfacetamide sodium w/
6%
sulfur emulsion 10-5%
$0 (1)
benzoyl peroxideTAZORAC – tazarotene
erythromycin gel 5-3%
cream 0.05%
(Benzamycin)
TAZORAC – tazarotene
$0 (1)
clindamycin phosphcream 0.1%
benzoyl peroxide
TAZORAC –
(refrig) gel 1.2 (1)-5%
tazarotene gel 0.05%
(Duac)
TAZORAC –
$0 (1)
clindamycin
tazarotene gel 0.1%
phosphate gel 1%
tretinoin cream 0.025%
(Cleocin-t)
(Retin-a)
$0 (1)
clindamycin phosphate
tretinoin cream 0.05%
lotion 1% (Cleocin-t)
(Retin-a)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
80
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
$0 (2)
PA
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA
$0 (2)
PA
$0 (2)
PA
$0 (2)
PA
$0 (1)
PA
$0 (1)
PA
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
PA
GENTAMICIN SULFATE
tretinoin cream 0.1%
– gentamicin sulfate
(Retin-a)
cream 0.1%
$0 (1)
PA
tretinoin gel 0.01% (RetinGENTAMICIN SULFATE
a)
– gentamicin sulfate oint
$0 (1)
PA
tretinoin gel 0.025%
0.1%
(Retin-a)
ketoconazole
cream 2%
$0 (1)
PA
tretinoin gel 0.05%
(Atralin)
ketoconazole shampoo
2% (Nizoral)
$0 (1)
PA
tretinoin microsphere gel
0.04% (Retin-a micro)
miconazole nitrate aerosol
pow 2%
$0 (1)
PA
tretinoin microsphere gel
0.1% (Retin-a micro)
miconazole nitrate cream
2%
Antinfecciosos
mupirocin oint 2%
$0 (3)
bacitracin oint 500 unit/gm
(Bactroban)
$0 (3)
bacitracin-polymyxin b
naftifine hcl cream 2%
oint
(Naftin)
CENTANY – mupirocin
$0 (2)
neomycin-bacitracinoint 2%
polymyxin oint
$0 (1)
ciclopirox olamine cream
nystatin cream 100000
0.77% (base equiv)
unit/gm
$0 (1)
ciclopirox olamine susp
nystatin oint 100000 unit/
0.77% (base equiv)
gm
$0 (1)
ciclopirox shampoo 1%
nystatin topical powder
(Loprox shampoo)
ciclopirox solution kit 8%
(Ciclodan solution ki)
ciclopirox solution 8%
(Penlac Nail Lacquer)
clotrimazole cream 1%
$0 (1)
PA
$0 (1)
PA
clotrimazole soln 1%
$0 (1)
clotrimazole w/
betamethasone cream
1-0.05% (Lotrisone)
diclofenac sodium gel 1%
(Voltaren)
econazole nitrate cream
1%
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
oxiconazole nitrate cream
1% (Oxistat)
silver sulfadiazine cream
1% (Silvadene)
tolnaftate aerosol 1%
$0 (1)
ZOVIRAX – acyclovir
cream 5%
$0 (2)
Corticosteroides
alclometasone
dipropionate cream
0.05% (Aclovate)
alclometasone
dipropionate oint 0.05%
betamethasone
dipropionate augmented
PA
QL
SP
ST
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
81
2016
Nombre del
medicamento
cream 0.05% (Diprolene
af)
betamethasone
dipropionate
augmented gel 0.05%
betamethasone
dipropionate augmented
lotion 0.05% (Diprolene)
betamethasone
dipropionate augmented
oint 0.05% (Diprolene)
betamethasone
dipropionate cream
0.05%
betamethasone
dipropionate lotion
0.05%
betamethasone
dipropionate oint 0.05%
betamethasone valerate
cream 0.1%
betamethasone valerate
lotion 0.1%
betamethasone valerate
oint 0.1%
clobetasol propionate
cream 0.05%
(Temovate)
clobetasol propionate
emollient base cream
0.05% (Temovate e)
clobetasol propionate gel
0.05% (Temovate)
clobetasol propionate oint
0.05% (Temovate)
clobetasol propionate soln
0.05% (Temovate)
desonide cream 0.05%
(Desowen)
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
desonide oint 0.05%
(Desowen)
$0 (1)
DESOXIMETASONE –
desoximetasone cream
0.05%
$0 (1)
desoximetasone cream
0.25% (Topicort)
fluocinolone acetonide
$0 (1)
cream 0.01%
fluocinolone acetonide
cream 0.025% (Synalar)
$0 (1)
fluocinolone acetonide
oil 0.01% (scalp oil)
(Derma-smoothe/fs sca)
$0 (1)
fluocinolone acetonide
oint 0.025% (Synalar)
fluocinolone acetonide
$0 (1)
soln 0.01% (Synalar)
fluocinonide cream 0.05%
$0 (1)
fluocinonide emulsified
base cream 0.05%
$0 (1)
fluocinonide gel 0.05%
$0 (2)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
fluocinonide oint 0.05%
$0 (1)
fluocinonide soln 0.05%
$0 (1)
$0 (1)
flurandrenolide cream
0.05% (Cordran)
fluticasone propionate
cream 0.05% (Cutivate)
fluticasone propionate oint
0.005% (Cutivate)
halobetasol propionate
cream 0.05% (Ultravate)
halobetasol propionate
oint 0.05% (Ultravate)
hydrocortisone butyrate
oint 0.1% (Locoid)
hydrocortisone cream
0.5%
hydrocortisone cream 1%
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
82
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
PA
QL
SP
ST
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (1)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (3)
hydrocortisone cream 1%
calcipotriene cream
0.005% (Dovonex)
$0 (1)
hydrocortisone cream
calcipotriene oint 0.005%
2.5%
hydrocortisone lotion
2.5%
hydrocortisone oint 0.5%
$0 (1)
hydrocortisone oint 1%
$0 (1)
hydrocortisone oint 1%
$0 (3)
hydrocortisone oint 2.5%
$0 (1)
hydrocortisone valerate
cream 0.2%
hydrocortisone valerate
oint 0.2% (Westcort)
mometasone furoate
cream 0.1% (Elocon)
mometasone furoate oint
0.1% (Elocon)
mometasone furoate
solution 0.1% (lotion)
(Elocon)
prednicarbate cream
0.1% (Dermatop)
prednicarbate oint 0.1%
(Dermatop)
triamcinolone acetonide
cream 0.025%
triamcinolone acetonide
cream 0.1%
triamcinolone acetonide
cream 0.5%
triamcinolone acetonide
lotion 0.025%
triamcinolone acetonide
lotion 0.1%
triamcinolone acetonide
oint 0.025%
triamcinolone acetonide
oint 0.1%
$0 (1)
$0 (3)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
Otros productos para la piel
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (1)
$0 (1)
calcipotriene soln 0.005%
(50 mcg/ml)
CEM-UREA – urea soln
45%
ELIDEL – pimecrolimus
cream 1%
fluorouracil cream 5%
(Efudex)
fluorouracil soln 2%
$0 (1)
fluorouracil soln 5%
$0 (1)
imiquimod cream 5%
(Aldara)
lactic acid (ammonium
lactate) lotion 12% (Lachydrin)
lidocaine hcl cream 3%
$0 (1)
lidocaine hcl gel 2%
$0 (1)
lidocaine hcl soln 4%
(Xylocaine)
lidocaine oint 5%
$0 (1)
lidocaine patch 5%
(Lidoderm)
lidocaine-prilocaine cream
kit 2.5-2.5%
lidocaine-prilocaine cream
2.5-2.5% (Emla)
malathion lotion 0.5%
(Ovide)
methoxsalen rapid cap
10 mg (Oxsoralen ultra)
permethrin cream 5%
(Elimite)
permethrin creme rinse
1%
permethrin lotion 1%
$0 (1)
PA
QL
SP
ST
$0 (2)
$0 (2)
ST
$0 (1)
$0 (1)
QL
$0 (3)
$0 (1)
$0 (1)
PA, QL
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (3)
$0 (3)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
83
2016
Nombre del
medicamento
podofilox soln 0.5%
(Condylox)
QC CALAMINE –
calamine lotion
selenium sulfide lotion
2.5%
selenium sulfidepyrithione zinc in urea
shampoo 2.25%
SM CALAMINE –
calamine lotion
tacrolimus oint 0.03%
(Protopic)
tacrolimus oint 0.1%
(Protopic)
VALCHLOR –
mechlorethamine
hcl gel 0.016% (base
equivalent)
vitamins a & d oint
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
$0 (1)
CALIBRATION LIQUID
– BAYER BREEZE 2,
CONTOUR
$0 (3)
CHEMSTRIP-K, UGK
$0 (1)
INSULIN PEN NEEDLES
- VARIOUS
$0 (1)
INSULIN SYRINGES VARIOUS
LANCETS – BAYER
$0 (3)
ASCENSIA
TEST STRIPS - BAYER
$0 (1)
ST
ASCENSIA
$0 (1)
ST
$0 (2)
SP
$0 (3)
zinc oxide oint 20%
$0 (3)
zinc oxide oint 40%
$0 (3)
zinc oxide oint 10%
$0 (3)
ZYCLARA – imiquimod
cream 3.75%
ZYCLARA PUMP –
imiquimod cream 2.5%
ZYCLARA PUMP –
imiquimod cream 3.75%
$0 (2)
PA, QL
$0 (2)
PA, QL
$0 (2)
PA, QL
CATEGORÍAS MISCELÁNEAS (incluyen los
suministros y los dispositivos)
SUMINISTROS PARA LA DIABETES
ALCOHOL PREP PADS,
$0 (3)
SWABS – various
BAYER Blood Glucose
$0 (3)
Monitoring System –
BREEZE 2, CONTOUR,
CONTOUR NEXT/EZ/
LINK/USB
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
84
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
$0 (2)
$0 (2)
QL
$0 (2)
QL
$0 (2)
$0 (2)
QL, ST
INHALADOR RESPIRATORIO-DISPOSITIVOS DE
ASISTENCIA
PEAK FLOW METER –
$0 (3)
various
RESPIRATORY
$0 (3)
THERAPY SUPPLIES –
various
SPACER/AEROSOL$0 (2)
HOLDING CHAMBERS
– VARIOUS
SPACER/AEROSOL$0 (3)
HOLDING CHAMBERS
– various
MEDICAMENTOS MISCELÁNEOS
$0 (1)
azathioprine tab 50 mg
(Imuran)
CHEMET – succimer cap
$0 (2)
100 mg
$0 (1)
cyclosporine cap 25 mg
(Sandimmune)
$0 (1)
cyclosporine cap 100 mg
(Sandimmune)
CYCLOSPORINE
$0 (2)
MODIFIED –
cyclosporine modified
cap 50 mg
$0 (1)
cyclosporine modified cap
25 mg (Neoral)
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
Nombre del
(nivel)
medicamento
medicamento
el uso
$0 (1)
REVLIMID – lenalidomide
cyclosporine modified cap
cap 20 mg
50 mg (Cyclosporine
modifie)
REVLIMID – lenalidomide
cap 25 mg
$0 (1)
cyclosporine modified cap
100 mg (Neoral)
ringer's solution for
$0 (1)
cyclosporine modified oral
irrigation
soln 100 mg/ml (Neoral)
sirolimus tab 0.5 mg
DEPEN TITRATABS
$0 (2)
SP
(Rapamune)
– penicillamine tab
sirolimus tab 1 mg
250 mg
(Rapamune)
$0 (1)
irrigation solution,
sirolimus tab 2 mg
physiological
(Rapamune)
$0 (1)
lactated ringer's for
sodium polystyrene
irrigation
sulfonate oral susp
$0 (1)
15 gm/60ml (Sps)
mycophenolate mofetil
cap 250 mg (Cellcept)
sodium polystyrene
$0 (1)
mycophenolate mofetil
sulfonate powder
(Kayexalate)
for oral susp 200 mg/ml
(Cellcept)
sodium polystyrene
$0 (1)
mycophenolate mofetil tab
sulfonate rectal susp
30 gm/120ml
500 mg (Cellcept)
$0 (1)
mycophenolate sodium
tacrolimus cap 0.5 mg
tab dr 180 mg
(Prograf)
(mycophenolic acid
tacrolimus cap 1 mg
equiv) (Myfortic)
(Prograf)
$0 (1)
mycophenolate sodium
tacrolimus cap 5 mg
tab dr 360 mg
(Prograf)
(mycophenolic acid
THALOMID – thalidomide
equiv) (Myfortic)
cap 50 mg
NARCAN – naloxone hcl
$0 (2)
THALOMID – thalidomide
nasal spray 4 mg/0.1ml
cap 100 mg
REVLIMID – lenalidomide
$0 (2)
PA, QL, SP
THALOMID – thalidomide
caps 2.5 mg
cap 150 mg
REVLIMID – lenalidomide
$0 (2)
PA, QL, SP
water for irrigation, sterile
cap 5 mg
irrigation soln
REVLIMID – lenalidomide
$0 (2)
PA, QL, SP
ZORTRESS – everolimus
cap 10 mg
tab 0.25 mg
REVLIMID – lenalidomide
$0 (2)
PA, QL, SP
ZORTRESS – everolimus
cap 15 mg
tab 0.5 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
PA
QL
SP
ST
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
(nivel)
el uso
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (1)
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (2)
PA, QL, SP
$0 (1)
$0 (2)
$0 (2)
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
85
2016
Acciones
Cuánto le
necesarias,
costará el
restricciones
medicamento o límites en
Nombre del
(nivel)
medicamento
el uso
ZORTRESS – everolimus
$0 (2)
tab 0.75 mg
1 = Medicamentos genéricos
2 = Medicamentos de marca
3 = Medicamentos de venta libre
86
PA
QL
SP
ST
= Autorización previa
= Límites de cantidad
= Medicamento especializado
= Terapia escalonada
2016
ÍNDICE
A
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg (Trizivir)......................................................................... 5
abacavir sulfate tab 300 mg (base equiv) (Ziagen)............. 5
acamprosate calcium tab delayed release 333 mg
(Campral).......................................................................... 52
acarbose tab 25 mg (Precose).......................................... 16
acarbose tab 50 mg (Precose).......................................... 16
acarbose tab 100 mg (Precose)........................................ 16
acebutolol hcl cap 200 mg (Sectral).................................. 23
acebutolol hcl cap 400 mg (Sectral).................................. 23
acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16
mg (Trezix)........................................................................ 54
acetaminophen cap 500 mg.............................................. 53
acetaminophen chew tab 80 mg....................................... 53
acetaminophen chew tab 160 mg..................................... 53
acetaminophen dispersible tab 80 mg.............................. 54
acetaminophen liquid 160 mg/5ml..................................... 54
acetaminophen soln 100 mg/ml.........................................54
acetaminophen soln 160 mg/5ml.......................................54
acetaminophen suppos 120 mg........................................ 54
acetaminophen susp 80 mg/0.8ml.....................................54
acetaminophen susp 160 mg/5ml......................................54
acetaminophen tab 325 mg............................................... 54
acetaminophen tab 500 mg............................................... 54
acetaminophen w/ codeine soln 120-12 mg/5ml............... 54
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).............................................................................54
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)....................................................................... 54
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4)....................................................................... 54
ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 28
acetazolamide cap sr 12hr 500 mg (Diamox)................... 28
acetazolamide tab 250 mg................................................ 28
acetic acid irrigation soln 0.25%........................................ 42
acetic acid otic soln 2%..................................................... 79
acetylcysteine inhal soln 10%............................................32
acetylcysteine inhal soln 20%............................................32
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml).........................................................10
acyclovir cap 200 mg (Zovirax)........................................... 5
acyclovir susp 200 mg/5ml (Zovirax)................................... 5
acyclovir tab 400 mg (Zovirax)............................................ 5
acyclovir tab 800 mg (Zovirax)............................................ 5
adapalene cream 0.1% (Differin)....................................... 80
adapalene gel 0.1% (Differin)............................................ 80
adapalene gel 0.3% (Differin)............................................ 80
ADCIRCA – tadalafil tab 20 mg (pah)............................... 30
adefovir dipivoxil tab 10 mg (Hepsera)................................4
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose.............................................................. 34
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
250-50 mcg/dose.............................................................. 34
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
500-50 mcg/dose.............................................................. 34
ADVATE – antihemophilic factor rahf-pfm for inj 250
unit..................................................................................... 68
ADVATE – antihemophilic factor rahf-pfm for inj 500
unit..................................................................................... 68
ADVATE – antihemophilic factor rahf-pfm for inj 1000
unit..................................................................................... 68
ADVATE – antihemophilic factor rahf-pfm for inj 1500
unit..................................................................................... 68
ADVATE – antihemophilic factor rahf-pfm for inj 2000
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 3000
unit..................................................................................... 69
ADVATE – antihemophilic factor rahf-pfm for inj 4000
unit..................................................................................... 69
ADYNOVATE – antihemophilic factor recomb pegylated
for inj 250 unit.................................................................. 69
ADYNOVATE – antihemophilic factor recomb pegylated
for inj 500 unit.................................................................. 69
ADYNOVATE – antihemophilic factor recomb pegylated
for inj 1000 unit................................................................ 69
ADYNOVATE – antihemophilic factor recomb pegylated
for inj 2000 unit................................................................ 69
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg...................................................................................... 10
AFINITOR DISPERZ – everolimus tab for oral susp 3
mg...................................................................................... 10
AFINITOR DISPERZ – everolimus tab for oral susp 5
mg...................................................................................... 10
AFINITOR – everolimus tab 2.5 mg.................................. 10
AFINITOR – everolimus tab 5 mg..................................... 10
AFINITOR – everolimus tab 7.5 mg.................................. 10
AFINITOR – everolimus tab 10 mg................................... 10
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg...................................................................................... 69
ALBENZA – albendazole tab 200 mg................................. 9
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).............. 34
albuterol sulfate soln nebu 0.5% (5 mg/ml)....................... 34
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......34
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......34
albuterol sulfate syrup 2 mg/5ml....................................... 34
albuterol sulfate tab 2 mg.................................................. 34
albuterol sulfate tab 4 mg.................................................. 34
albuterol sulfate tab sr 12hr 4 mg (Vospire er).................. 34
albuterol sulfate tab sr 12hr 8 mg (Vospire er).................. 34
alclometasone dipropionate cream 0.05% (Aclovate)....... 81
alclometasone dipropionate oint 0.05%............................ 81
ALCOHOL PREP PADS, SWABS – various..................... 84
ALENDRONATE SODIUM – alendronate sodium tab 40
mg...................................................................................... 19
alendronate sodium tab 5 mg............................................ 19
alendronate sodium tab 10 mg.......................................... 19
alendronate sodium tab 35 mg.......................................... 19
87
2016
alendronate sodium tab 70 mg (Fosamax)....................... 19
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)....................... 42
ALKERAN – melphalan tab 2 mg...................................... 10
allopurinol tab 100 mg (Zyloprim)...................................... 60
allopurinol tab 300 mg (Zyloprim)...................................... 60
almotriptan malate tab 6.25 mg (Axert)............................. 60
almotriptan malate tab 12.5 mg (Axert)............................. 60
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 40
alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 40
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%..... 78
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 250 unit............................................. 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 500 unit............................................. 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 1000 unit........................................... 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 1500 unit........................................... 69
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 2000 unit........................................... 69
ALPHANINE SD – coagulation factor ix for inj 500
unit..................................................................................... 69
ALPHANINE SD – coagulation factor ix for inj 1000
unit..................................................................................... 69
ALPHANINE SD – coagulation factor ix for inj 1500
unit..................................................................................... 69
alprazolam tab 0.25 mg (Xanax)....................................... 43
alprazolam tab 0.5 mg (Xanax)......................................... 43
alprazolam tab 1 mg (Xanax)............................................ 43
alprazolam tab 2 mg (Xanax)............................................ 43
alprazolam tab sr 24hr 0.5 mg (Xanax xr).........................42
alprazolam tab sr 24hr 1 mg (Xanax xr)............................42
alprazolam tab sr 24hr 2 mg (Xanax xr)............................43
alprazolam tab sr 24hr 3 mg (Xanax xr)............................43
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
500 unit............................................................................. 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
1000 unit........................................................................... 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
2000 unit........................................................................... 69
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
3000 unit........................................................................... 69
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml............................................................................... 38
alum & mag hydroxide-simethicone susp 400-400-40
mg/5ml............................................................................... 38
amantadine hcl cap 100 mg.............................................. 63
amantadine hcl syrup 50 mg/5ml...................................... 63
amiloride & hydrochlorothiazide tab 5-50 mg.................... 28
amiloride hcl tab 5 mg....................................................... 28
amiodarone hcl tab 200 mg (Cordarone).......................... 29
amitriptyline hcl tab 10 mg.................................................43
amitriptyline hcl tab 25 mg.................................................43
amitriptyline hcl tab 50 mg.................................................43
amitriptyline hcl tab 75 mg.................................................43
amitriptyline hcl tab 100 mg...............................................43
88
amitriptyline hcl tab 150 mg...............................................43
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................... 24
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................... 24
amlodipine besylate tab 2.5 mg (Norvasc)........................ 24
amlodipine besylate tab 5 mg (Norvasc)........................... 24
amlodipine besylate tab 10 mg (Norvasc)......................... 24
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)............................................................................25
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)............................................................................25
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)............................................................ 1
amoxicillin & k clavulanate tab 250-125 mg........................ 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................... 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125
mg........................................................................................ 1
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250
mg........................................................................................ 1
amoxicillin (trihydrate) cap 250 mg......................................1
amoxicillin (trihydrate) cap 500 mg......................................1
amoxicillin (trihydrate) for susp 125 mg/5ml........................1
amoxicillin (trihydrate) for susp 200 mg/5ml........................1
amoxicillin (trihydrate) for susp 250 mg/5ml........................1
amoxicillin (trihydrate) for susp 400 mg/5ml........................1
amoxicillin (trihydrate) tab 875 mg...................................... 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)...................................................................... 49
2016
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)...................................................................... 49
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................... 49
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................... 49
ampicillin cap 250 mg.......................................................... 1
ampicillin cap 500 mg.......................................................... 1
AMPYRA – dalfampridine tab sr 12hr 10 mg.................... 52
anagrelide hcl cap 1 mg.................................................... 69
anagrelide hcl cap 0.5 mg (Agrylin)...................................69
anastrozole tab 1 mg (Arimidex)....................................... 10
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)......................................................................... 79
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)........................................................................... 78
APTIVUS – tipranavir cap 250 mg...................................... 5
APTIVUS – tipranavir oral soln 100 mg/ml......................... 5
AQUADEKS – multiple vitamins w/ minerals cap..............66
AQUADEKS – multiple vitamins w/ minerals chew tab..... 66
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60
mcg/ml............................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
100 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
200 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
300 mcg/ml....................................................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml......................................... 69
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml......................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml......................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml....................................... 70
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 500 mcg/ml............................................ 70
aripiprazole oral solution 1 mg/ml......................................46
aripiprazole tab 2 mg (Abilify)............................................ 46
aripiprazole tab 5 mg (Abilify)............................................ 46
aripiprazole tab 10 mg (Abilify).......................................... 46
aripiprazole tab 15 mg (Abilify).......................................... 46
aripiprazole tab 20 mg (Abilify).......................................... 46
aripiprazole tab 30 mg (Abilify).......................................... 46
ARMODAFINIL – armodafinil tab 200 mg......................... 49
armodafinil tab 50 mg (Nuvigil)..........................................49
armodafinil tab 150 mg (Nuvigil)........................................50
armodafinil tab 250 mg (Nuvigil)........................................50
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act.................................................. 34
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act.................................................. 34
artificial tear ophth solution ...............................................78
ASACOL HD – mesalamine tab delayed release 800
mg...................................................................................... 40
ascorbic acid tab 500 mg.................................................. 65
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 7 METE – mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 14 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASMANEX TWISTHALER 60 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 35
ASPIRIN/DIPYRIDAMOLE – aspirin-dipyridamole cap sr
12hr 25-200 mg................................................................ 70
aspirin chew tab 81 mg..................................................... 54
aspirin tab delayed release 81 mg.................................... 54
aspirin tab delayed release 325 mg.................................. 54
aspirin tab 325 mg............................................................. 54
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......23
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)................................................................................... 23
atenolol tab 25 mg (Tenormin).......................................... 23
atenolol tab 50 mg (Tenormin).......................................... 23
atenolol tab 100 mg (Tenormin)........................................ 23
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor).............................................................................. 27
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor).............................................................................. 27
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor).............................................................................. 27
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor).............................................................................. 27
atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)........ 9
89
2016
atovaquone-proguanil hcl tab 250-100 mg (Malarone)....... 9
atovaquone susp 750 mg/5ml (Mepron)............................. 9
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................. 5
ATROPINE SULFATE – atropine sulfate ophth oint
1%..................................................................................... 78
ATROPINE SULFATE – atropine sulfate ophth soln
1%..................................................................................... 78
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act........................................................................ 35
AVODART – dutasteride cap 0.5 mg.................................42
azathioprine tab 50 mg (Imuran)....................................... 84
azelastine hcl nasal spray 0.1% (137 mcg/spray)............. 32
azelastine hcl ophth soln 0.05% (Optivar).........................79
AZITHROMYCIN – azithromycin powd pack for susp 1
gm........................................................................................ 2
azithromycin for susp 100 mg/5ml (Zithromax)................... 2
azithromycin for susp 200 mg/5ml (Zithromax)................... 2
azithromycin tab 250 mg (Zithromax).................................. 2
azithromycin tab 500 mg (Zithromax).................................. 2
azithromycin tab 600 mg (Zithromax).................................. 2
B
BACITRACIN – bacitracin ophth oint 500 unit/gm............ 77
bacitracin intramuscular for soln 50000 unit........................9
bacitracin oint 500 unit/gm................................................. 81
bacitracin-polymyxin b oint ............................................... 81
bacitracin-polymyxin b ophth oint...................................... 77
bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 77
baclofen tab 10 mg............................................................ 65
baclofen tab 20 mg............................................................ 65
balsalazide disodium cap 750 mg (Colazal)......................40
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4
BAYER Blood Glucose Monitoring System – BREEZE 2,
CONTOUR, CONTOUR NEXT/EZ/LINK/USB................. 84
b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 66
b-complex w/ c & folic acid tab..........................................66
b-complex w/ c & folic acid tab 5 mg................................ 66
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)....... 66
BEBULIN – factor ix complex for inj 200-1200 unit........... 70
benazepril & hydrochlorothiazide tab 5-6.25 mg............... 20
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct).................................................................... 20
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct).................................................................... 20
benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin
hct).....................................................................................20
benazepril hcl tab 5 mg..................................................... 20
benazepril hcl tab 10 mg (Lotensin).................................. 20
benazepril hcl tab 20 mg (Lotensin).................................. 20
benazepril hcl tab 40 mg (Lotensin).................................. 20
BENEFIX – coagulation factor ix (recombinant) for inj 250
unit..................................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj 500
unit..................................................................................... 70
90
BENEFIX – coagulation factor ix (recombinant) for inj
1000 unit........................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj
2000 unit........................................................................... 70
BENEFIX – coagulation factor ix (recombinant) for inj
3000 unit........................................................................... 70
BENZONATATE – benzonatate cap 150 mg..................... 32
benzonatate cap 200 mg................................................... 33
benzonatate cap 100 mg (Tessalon perles)...................... 33
benzoyl peroxide cloth 6%................................................. 80
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin).................................................................... 80
benzoyl peroxide liq 10%................................................... 80
benzoyl peroxide lotion 6%................................................ 80
benztropine mesylate tab 0.5 mg...................................... 63
benztropine mesylate tab 1 mg......................................... 64
benztropine mesylate tab 2 mg......................................... 64
betamethasone dipropionate augmented cream 0.05%
(Diprolene af).................................................................... 81
betamethasone dipropionate augmented gel 0.05%.........82
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)........................................................................ 82
betamethasone dipropionate augmented oint 0.05%
(Diprolene)........................................................................ 82
betamethasone dipropionate cream 0.05%.......................82
betamethasone dipropionate lotion 0.05%........................ 82
betamethasone dipropionate oint 0.05%........................... 82
betamethasone valerate cream 0.1%................................ 82
betamethasone valerate lotion 0.1%................................. 82
betamethasone valerate oint 0.1%.................................... 82
betaxolol hcl ophth soln 0.5%............................................78
betaxolol hcl tab 10 mg (Kerlone)..................................... 23
betaxolol hcl tab 20 mg (Kerlone)..................................... 23
bethanechol chloride tab 5 mg (Urecholine)..................... 41
bethanechol chloride tab 10 mg (Urecholine)................... 41
bethanechol chloride tab 25 mg (Urecholine)................... 41
bethanechol chloride tab 50 mg (Urecholine)................... 41
bexarotene cap 75 mg (Targretin)..................................... 10
bicalutamide tab 50 mg (Casodex)....................................10
BILTRICIDE – praziquantel tab 600 mg.............................. 9
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit....................................................................................... 37
bisacodyl tab delayed release 5 mg.................................. 37
bismuth subsalicylate susp 262 mg/15ml.......................... 38
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)................................................................................. 23
bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)...... 23
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................. 23
bisoprolol fumarate tab 5 mg (Zebeta).............................. 23
bisoprolol fumarate tab 10 mg (Zebeta)............................ 23
BRILINTA – ticagrelor tab 60 mg...................................... 70
BRILINTA – ticagrelor tab 90 mg...................................... 70
brimonidine tartrate ophth soln 0.2%.................................78
BROHIST D – brompheniramine & phenylephrine tab 4-10
mg...................................................................................... 33
2016
bromocriptine mesylate cap 5 mg (Parlodel).....................64
bromocriptine mesylate tab 2.5 mg................................... 64
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml..... 33
brompheniramine & phenylephrine susp 6-10 mg/5ml......33
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg...................................................................................... 33
budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 35
budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 35
budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 35
bumetanide tab 0.5 mg...................................................... 28
bumetanide tab 1 mg......................................................... 28
bumetanide tab 2 mg......................................................... 28
BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv)................................................................54
BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv)................................................................54
BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1
mg (base equiv)................................................................54
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)................................................................................. 54
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)................................................................................. 54
buprenorphine hcl sl tab 2 mg (base equiv)...................... 54
buprenorphine hcl sl tab 8 mg (base equiv)...................... 54
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).............................................................................. 52
bupropion hcl tab 75 mg (Wellbutrin)................................ 44
bupropion hcl tab 100 mg (Wellbutrin).............................. 44
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).............. 43
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).............. 43
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).............. 43
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).............. 44
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).............. 44
buspirone hcl tab 5 mg...................................................... 43
buspirone hcl tab 10 mg.................................................... 43
buspirone hcl tab 15 mg.................................................... 43
buspirone hcl tab 30 mg.................................................... 43
butalbital-acetaminophen-caffeine cap 50-325-40 mg...... 54
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)............................................................................ 54
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................... 54
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg...................................................................................... 55
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine)........................................................ 55
butalbital-acetaminophen tab 50-325 mg.......................... 54
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)..... 54
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................... 55
butorphanol tartrate nasal soln 10 mg/ml.......................... 55
C
cabergoline tab 0.5 mg...................................................... 19
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
(Cafcit)............................................................................... 50
calcipotriene cream 0.005% (Dovonex)............................ 83
calcipotriene oint 0.005%................................................... 83
calcipotriene soln 0.005% (50 mcg/ml)............................. 83
calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)..... 19
calcitriol cap 0.25 mcg (Rocaltrol)..................................... 19
calcitriol cap 0.5 mcg (Rocaltrol)....................................... 19
calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 19
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca) (Phoslo)...................................................................... 40
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)............................................................................ 40
calcium carbonate (antacid) chew tab 500 mg..................38
calcium carbonate (antacid) chew tab 750 mg..................38
calcium carbonate (antacid) chew tab 1000 mg................38
calcium carbonate-cholecalciferol tab 500 mg-200
unit..................................................................................... 67
calcium carbonate-cholecalciferol tab 600 mg-400
unit..................................................................................... 67
calcium carbonate tab 1250 mg (500 mg elemental
ca)...................................................................................... 67
calcium carbonate-vitamin d tab 250 mg-125 unit............ 67
calcium carbonate-vitamin d tab 500 mg-200 unit............ 67
calcium carbonate-vitamin d tab 600 mg-400 unit............ 67
calcium citrate tab 950 mg (200 mg elemental ca)........... 67
calcium citrate-vitamin d tab 315 mg-200 unit (elemental
ca)...................................................................................... 67
calcium w/ vitamin d tab 600 mg-200 unit......................... 67
CALIBRATION LIQUID – BAYER BREEZE 2,
CONTOUR........................................................................ 84
CANASA – mesalamine suppos 1000 mg........................ 40
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg
(Atacand hct).................................................................... 22
candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg
(Atacand hct).................................................................... 22
candesartan cilexetil-hydrochlorothiazide tab 32-25 mg
(Atacand hct).................................................................... 22
capecitabine tab 150 mg (Xeloda).....................................10
capecitabine tab 500 mg (Xeloda).....................................10
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg................................... 21
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-25 mg................................... 21
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-15 mg................................... 21
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 50-25 mg................................... 21
captopril tab 12.5 mg......................................................... 20
captopril tab 25 mg............................................................ 20
captopril tab 50 mg............................................................ 21
captopril tab 100 mg.......................................................... 21
carbamazepine cap sr 12hr 100 mg (Carbatrol)............... 60
carbamazepine cap sr 12hr 200 mg (Carbatrol)............... 60
carbamazepine cap sr 12hr 300 mg (Carbatrol)............... 61
carbamazepine chew tab 100 mg..................................... 61
carbamazepine susp 100 mg/5ml (Tegretol)..................... 61
carbamazepine tab 200 mg (Tegretol).............................. 61
91
2016
carbamazepine tab sr 12hr 100 mg (Tegretol-xr).............. 61
carbamazepine tab sr 12hr 200 mg (Tegretol-xr).............. 61
carbamazepine tab sr 12hr 400 mg (Tegretol-xr).............. 61
carbamide peroxide 6.5% otic soln................................... 79
carbidopa & levodopa orally disintegrating tab 10-100
mg...................................................................................... 64
carbidopa & levodopa orally disintegrating tab 25-100
mg...................................................................................... 64
carbidopa & levodopa orally disintegrating tab 25-250
mg...................................................................................... 64
carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).......64
carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).......64
carbidopa & levodopa tab 10-100 mg (Sinemet)...............64
carbidopa & levodopa tab 25-100 mg (Sinemet)...............64
carbidopa & levodopa tab 25-250 mg (Sinemet)...............64
carbidopa tab 25 mg (Lodosyn).........................................64
carbinoxamine maleate soln 4 mg/5ml.............................. 31
carbinoxamine maleate tab 4 mg...................................... 31
carisoprodol tab 250 mg (Soma)....................................... 65
carteolol hcl ophth soln 1%............................................... 78
carvedilol tab 3.125 mg (Coreg)........................................ 23
carvedilol tab 6.25 mg (Coreg).......................................... 23
carvedilol tab 12.5 mg (Coreg).......................................... 23
carvedilol tab 25 mg (Coreg)............................................. 23
cefaclor cap 250 mg............................................................ 1
cefaclor cap 500 mg............................................................ 1
cefadroxil cap 500 mg..........................................................1
cefadroxil for susp 250 mg/5ml........................................... 1
cefadroxil for susp 500 mg/5ml........................................... 1
cefadroxil tab 1 gm.............................................................. 1
CEFAZOLIN SODIUM – cefazolin sodium for inj 20 gm..... 1
cefdinir cap 300 mg............................................................. 1
cefdinir for susp 125 mg/5ml............................................... 1
cefdinir for susp 250 mg/5ml............................................... 1
cefixime for susp 100 mg/5ml (Suprax)...............................1
cefixime for susp 200 mg/5ml (Suprax)...............................1
cefprozil for susp 125 mg/5ml............................................. 2
cefprozil for susp 250 mg/5ml............................................. 2
cefprozil tab 250 mg............................................................ 2
cefprozil tab 500 mg............................................................ 2
ceftriaxone sodium for inj 2 gm........................................... 2
ceftriaxone sodium for inj 1 gm (Rocephin)........................ 2
ceftriaxone sodium for inj 250 mg....................................... 2
ceftriaxone sodium for inj 500 mg (Rocephin).................... 2
cefuroxime axetil tab 250 mg (Ceftin)................................. 2
cefuroxime axetil tab 500 mg (Ceftin)................................. 2
celecoxib cap 50 mg (Celebrex)........................................ 58
celecoxib cap 100 mg (Celebrex)...................................... 58
celecoxib cap 200 mg (Celebrex)...................................... 58
celecoxib cap 400 mg (Celebrex)...................................... 58
CEM-UREA – urea soln 45%............................................ 83
CENTANY – mupirocin oint 2%......................................... 81
cephalexin cap 250 mg (Keflex).......................................... 2
cephalexin cap 500 mg (Keflex).......................................... 2
cephalexin for susp 125 mg/5ml..........................................2
cephalexin for susp 250 mg/5ml..........................................2
92
cetirizine hcl chew tab 5 mg.............................................. 31
cetirizine hcl chew tab 10 mg............................................ 31
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................31
cetirizine hcl tab 5 mg........................................................ 31
cetirizine hcl tab 10 mg...................................................... 31
cevimeline hcl cap 30 mg (Evoxac)...................................79
CHANTIX CONTINUING MONTH – varenicline tartrate
tab 1 mg (base equiv)...................................................... 52
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 52
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)................................................................................. 52
CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 52
CHEMET – succimer cap 100 mg..................................... 84
CHEMSTRIP-K, UGK......................................................... 84
chlordiazepoxide hcl cap 5 mg.......................................... 43
chlordiazepoxide hcl cap 10 mg........................................ 43
chlordiazepoxide hcl cap 25 mg........................................ 43
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax).............................................................................. 38
chlorhexidine gluconate soln 0.12% (Peridex).................. 79
chloroquine phosphate tab 250 mg..................................... 9
chloroquine phosphate tab 500 mg (Aralen)....................... 9
CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 28
chlorothiazide tab 500 mg................................................. 28
chlorpheniramine & phenylephrine liquid 4-10 mg/5ml..... 33
chlorpheniramine & phenylephrine tab 4-10 mg............... 33
chlorpheniramine maleate tab 4 mg.................................. 31
chlorpromazine hcl tab 10 mg........................................... 46
chlorpromazine hcl tab 25 mg........................................... 46
chlorpromazine hcl tab 50 mg........................................... 46
chlorpromazine hcl tab 100 mg......................................... 46
chlorpromazine hcl tab 200 mg......................................... 46
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 28
chlorthalidone tab 25 mg................................................... 28
chlorzoxazone tab 500 mg (Parafon forte dsc)................. 65
cholecalciferol cap 1000 unit............................................. 65
cholecalciferol cap 2000 unit............................................. 65
cholecalciferol cap 5000 unit............................................. 65
cholecalciferol cap 10000 unit........................................... 65
cholecalciferol cap 50000 unit........................................... 65
cholecalciferol chew tab 400 unit...................................... 65
cholecalciferol oral liquid 400 unit/ml.................................65
cholecalciferol tab 400 unit................................................ 65
cholecalciferol tab 1000 unit.............................................. 66
cholecalciferol tab 2000 unit.............................................. 66
cholecalciferol tab 5000 unit.............................................. 66
cholecalciferol tab 50000 unit............................................ 66
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................... 27
cholestyramine light powder packets 4 gm....................... 27
cholestyramine powder 4 gm/dose (Questran)................. 27
cholestyramine powder packets 4 gm (Questran).............27
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix).............................................................................. 27
2016
choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
(Trilipix).............................................................................. 27
ciclopirox olamine cream 0.77% (base equiv)...................81
ciclopirox olamine susp 0.77% (base equiv)..................... 81
ciclopirox shampoo 1% (Loprox shampoo)....................... 81
ciclopirox solution kit 8% (Ciclodan solution ki).................81
ciclopirox solution 8% (Penlac Nail Lacquer).................... 81
cilostazol tab 50 mg (Pletal).............................................. 70
cilostazol tab 100 mg (Pletal)............................................ 70
cimetidine hcl soln 300 mg/5ml......................................... 38
cimetidine tab 200 mg........................................................38
cimetidine tab 300 mg........................................................38
cimetidine tab 400 mg........................................................38
cimetidine tab 800 mg........................................................38
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%............................................................................ 79
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
(Cipro)..................................................................................3
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................... 3
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...................... 77
ciprofloxacin hcl tab 750 mg (base equiv)........................... 3
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)............... 3
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)............... 3
citalopram hydrobromide oral soln 10 mg/5ml.................. 44
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)............................................................................. 44
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)............................................................................. 44
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)............................................................................. 44
clarithromycin for susp 125 mg/5ml.....................................2
clarithromycin for susp 250 mg/5ml (Biaxin)....................... 2
clarithromycin tab 250 mg (Biaxin)...................................... 2
clarithromycin tab 500 mg (Biaxin)...................................... 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)............... 2
clemastine fumarate tab 2.68 mg...................................... 32
clemastine fumarate tab 1.34 mg (1 mg base equiv)........ 31
clindamycin hcl cap 75 mg (Cleocin)...................................9
clindamycin hcl cap 150 mg (Cleocin).................................9
clindamycin hcl cap 300 mg (Cleocin).................................9
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
(Cleocin pediatric gr).......................................................... 9
clindamycin phosphate gel 1% (Cleocin-t)........................ 80
clindamycin phosphate lotion 1% (Cleocin-t).................... 80
clindamycin phosphate soln 1% (Cleocin-t)...................... 80
clindamycin phosphate swab 1% (Cleocin-t).................... 80
clindamycin phosphate vaginal cream 2% (Cleocin).........42
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................... 80
clobetasol propionate cream 0.05% (Temovate)............... 82
clobetasol propionate emollient base cream 0.05%
(Temovate e)..................................................................... 82
clobetasol propionate gel 0.05% (Temovate).................... 82
clobetasol propionate oint 0.05% (Temovate)................... 82
clobetasol propionate soln 0.05% (Temovate).................. 82
clomipramine hcl cap 25 mg (Anafranil)............................ 44
clomipramine hcl cap 50 mg (Anafranil)............................ 44
clomipramine hcl cap 75 mg (Anafranil)............................ 44
clonazepam orally disintegrating tab 0.125 mg................. 61
clonazepam orally disintegrating tab 0.25 mg................... 61
clonazepam orally disintegrating tab 0.5 mg..................... 61
clonazepam orally disintegrating tab 1 mg........................ 61
clonazepam orally disintegrating tab 2 mg........................ 61
clonazepam tab 0.5 mg (Klonopin)....................................61
clonazepam tab 1 mg (Klonopin).......................................61
clonazepam tab 2 mg (Klonopin).......................................61
clonidine hcl tab 0.1 mg (Catapres).................................. 30
clonidine hcl tab 0.2 mg (Catapres).................................. 30
clonidine hcl tab 0.3 mg (Catapres).................................. 30
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).........................50
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................. 30
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2).................................................................................. 30
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3).................................................................................. 30
clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........71
clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......71
clorazepate dipotassium tab 3.75 mg (Tranxene t)........... 43
clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 43
clorazepate dipotassium tab 15 mg (Tranxene t).............. 43
clotrimazole cream 1%.......................................................81
clotrimazole soln 1%.......................................................... 81
clotrimazole troche 10 mg................................................. 79
clotrimazole vaginal cream 2%.......................................... 42
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)......................................................................... 81
clozapine orally disintegrating tab 25 mg (Fazaclo).......... 46
clozapine orally disintegrating tab 100 mg (Fazaclo)........ 46
clozapine tab 50 mg...........................................................46
clozapine tab 200 mg.........................................................46
clozapine tab 25 mg (Clozaril)........................................... 46
clozapine tab 100 mg (Clozaril)......................................... 46
COAGADEX – coagulation factor x (human) for inj 250
unit..................................................................................... 71
COAGADEX – coagulation factor x (human) for inj 500
unit..................................................................................... 71
codeine sulfate tab 30 mg................................................. 55
codeine sulfate tab 60 mg................................................. 55
codeine sulfate tab 15 mg (Codeine sulfate).................... 55
colchicine w/ probenecid tab 0.5-500 mg.......................... 60
colestipol hcl granule packets 5 gm (Colestid
flavored)............................................................................ 27
colestipol hcl granules 5 gm (Colestid flavored)................27
colestipol hcl tab 1 gm (Colestid)...................................... 27
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................. 13
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................. 13
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................ 35
93
2016
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg................................................................... 6
CONDOMS – various......................................................... 15
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml................................................................................. 52
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml................................................................................. 52
CORIFACT – factor xiii concentrate (human) for inj kit
1000-1600 unit.................................................................. 71
CORTIFOAM – hydrocortisone acetate rectal foam 10%
(90 mg/dose).....................................................................80
CORTISONE ACETATE – cortisone acetate tab 25
mg...................................................................................... 12
COTELLIC – cobimetinib fumarate tab 20 mg (base
equivalent)......................................................................... 10
CREON – pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit...................................................... 40
CREON – pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit.................................................... 40
CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit.................................................. 40
CREON – pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit................................................ 40
CREON – pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit.............................................. 40
CRIXIVAN – indinavir sulfate cap 200 mg...........................6
CRIXIVAN – indinavir sulfate cap 400 mg...........................6
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................... 35
cromolyn sodium ophth soln 4%....................................... 79
cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)..... 40
cyanocobalamin inj 1000 mcg/ml...................................... 71
cyanocobalamin tab cr 1000 mcg......................................71
cyanocobalamin tab 100 mcg............................................ 71
cyanocobalamin tab 250 mcg............................................ 71
cyanocobalamin tab 500 mcg............................................ 71
cyanocobalamin tab 1000 mcg.......................................... 71
cyanocobalamin tab sl 2500 mcg...................................... 71
cyclobenzaprine hcl tab 5 mg............................................ 65
cyclobenzaprine hcl tab 10 mg.......................................... 65
cyclopentolate hcl ophth soln 0.5% (Cyclogyl).................. 79
cyclopentolate hcl ophth soln 1% (Cyclogyl)..................... 79
cyclopentolate hcl ophth soln 2% (Cyclogyl)..................... 79
cyclosporine cap 25 mg (Sandimmune)............................ 84
cyclosporine cap 100 mg (Sandimmune).......................... 84
cyclosporine modified cap 50 mg (Cyclosporine
modifie)..............................................................................85
cyclosporine modified cap 25 mg (Neoral)........................ 84
cyclosporine modified cap 100 mg (Neoral)...................... 85
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg................................................................................ 84
cyclosporine modified oral soln 100 mg/ml (Neoral)......... 85
cyproheptadine hcl syrup 2 mg/5ml...................................32
cyproheptadine hcl tab 4 mg............................................. 32
CYSTAGON – cysteamine bitartrate cap 50 mg............... 42
CYSTAGON – cysteamine bitartrate cap 150 mg............. 42
94
CYTARABINE – cytarabine inj 20 mg/ml.......................... 10
D
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base
equivalent)........................................................................... 4
DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base
equivalent)........................................................................... 4
DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base
equivalent)........................................................................... 5
danazol cap 50 mg............................................................ 13
danazol cap 100 mg.......................................................... 13
danazol cap 200 mg.......................................................... 13
dantrolene sodium cap 100 mg......................................... 65
dantrolene sodium cap 25 mg (Dantrium)......................... 65
dantrolene sodium cap 50 mg (Dantrium)......................... 65
dapsone tab 25 mg.............................................................. 9
dapsone tab 100 mg............................................................ 9
DARAPRIM – pyrimethamine tab 25 mg.............................9
darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)
(Enablex)........................................................................... 41
darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)
(Enablex)........................................................................... 41
DECARA – cholecalciferol cap 25000 unit........................ 66
DELZICOL – mesalamine cap dr 400 mg......................... 40
demeclocycline hcl tab 150 mg........................................... 2
demeclocycline hcl tab 300 mg........................................... 2
DEPEN TITRATABS – penicillamine tab 250 mg.............. 85
DEPO-PROVERA CONTRACEPTIV –
medroxyprogesterone acetate im susp 150 mg/ml......... 15
DEPO-SUBQ PROVERA 104 – medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 15
DESCOVY – emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg.................................................................... 6
desipramine hcl tab 10 mg (Norpramin)............................ 44
desipramine hcl tab 25 mg (Norpramin)............................ 44
desipramine hcl tab 50 mg (Norpramin)............................ 44
desipramine hcl tab 75 mg (Norpramin)............................ 44
desipramine hcl tab 100 mg (Norpramin).......................... 44
desipramine hcl tab 150 mg (Norpramin).......................... 44
desloratadine tab 5 mg (Clarinex)..................................... 32
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)..............................................................................19
desmopressin acetate nasal spray soln 0.01%
(Ddavp)..............................................................................19
desmopressin acetate nasal spray soln 0.01%
(refrigerated)..................................................................... 19
desmopressin acetate tab 0.1 mg (Ddavp)....................... 19
desmopressin acetate tab 0.2 mg (Ddavp)....................... 19
desonide cream 0.05% (Desowen)................................... 82
desonide oint 0.05% (Desowen)........................................82
desoximetasone cream 0.25% (Topicort).......................... 82
DESOXIMETASONE – desoximetasone cream
0.05%................................................................................ 82
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 12
dexamethasone elixir 0.5 mg/5ml...................................... 12
2016
DEXAMETHASONE SODIUM PHOSPHATE –
dexamethasone sodium phosphate ophth soln 0.1%...... 77
dexamethasone tab 0.5 mg............................................... 12
dexamethasone tab 0.75 mg............................................. 12
dexamethasone tab 1.5 mg............................................... 12
dexamethasone tab 4 mg.................................................. 12
dexamethasone tab 6 mg.................................................. 12
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr)...................................................................................... 50
dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 50
dexmethylphenidate hcl tab 5 mg (Focalin)...................... 50
dexmethylphenidate hcl tab 10 mg (Focalin).................... 50
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)....................................................................... 50
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)........................................................................ 50
dextroamphetamine sulfate tab 5 mg................................ 50
dextroamphetamine sulfate tab 10 mg.............................. 50
dextromethorphan-guaifenesin liquid 10-100 mg/5ml....... 33
DIALYVITE OMEGA-3 CONCENT – omega-3 fatty acids
cap 600 mg....................................................................... 68
DIAPHRAGMS – various................................................... 15
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg................................................................................ 61
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg................................................................................ 61
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg.................................................................. 61
diazepam conc 5 mg/ml..................................................... 43
DIAZEPAM – diazepam rectal gel delivery system 2.5
mg...................................................................................... 61
DIAZEPAM – diazepam rectal gel delivery system 10
mg...................................................................................... 61
DIAZEPAM – diazepam rectal gel delivery system 20
mg...................................................................................... 61
diazepam tab 2 mg (Valium)..............................................43
diazepam tab 5 mg (Valium)..............................................43
diazepam tab 10 mg (Valium)............................................43
diclofenac potassium tab 50 mg (Cataflam)...................... 58
diclofenac sodium gel 1% (Voltaren)................................. 81
diclofenac sodium ophth soln 0.1%................................... 79
diclofenac sodium tab delayed release 25 mg.................. 58
diclofenac sodium tab delayed release 50 mg.................. 58
diclofenac sodium tab delayed release 75 mg.................. 58
diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr)......... 58
dicloxacillin sodium cap 250 mg.......................................... 1
dicloxacillin sodium cap 500 mg.......................................... 1
dicyclomine hcl cap 10 mg (Bentyl)...................................38
dicyclomine hcl inj 10 mg/ml (Bentyl)................................ 38
dicyclomine hcl oral soln 10 mg/5ml................................. 38
dicyclomine hcl tab 20 mg (Bentyl)................................... 38
didanosine delayed release capsule 125 mg (Videx ec)..... 6
didanosine delayed release capsule 200 mg (Videx ec)..... 6
didanosine delayed release capsule 250 mg (Videx ec)..... 6
didanosine delayed release capsule 400 mg (Videx ec)..... 6
DIFFERIN – adapalene lotion 0.1%.................................. 80
diflunisal tab 500 mg.......................................................... 54
DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 30
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 30
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 30
DILANTIN – phenytoin sodium extended cap 30 mg........ 61
diltiazem hcl cap sr 12hr 60 mg........................................ 25
diltiazem hcl cap sr 12hr 90 mg........................................ 25
diltiazem hcl cap sr 12hr 120 mg...................................... 25
diltiazem hcl cap sr 24hr 120 mg...................................... 25
diltiazem hcl cap sr 24hr 180 mg...................................... 25
diltiazem hcl cap sr 24hr 240 mg...................................... 25
diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem
cd)...................................................................................... 25
diltiazem hcl extended release beads cap sr 24hr 120 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 180 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 240 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 300 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 360 mg
(Tiazac)............................................................................. 25
diltiazem hcl extended release beads cap sr 24hr 420 mg
(Tiazac)............................................................................. 25
diltiazem hcl tab 90 mg...................................................... 25
diltiazem hcl tab 30 mg (Cardizem)...................................25
diltiazem hcl tab 60 mg (Cardizem)...................................25
diltiazem hcl tab 120 mg (Cardizem).................................25
DIMETAPP COLD & ALLERGY – brompheniramine &
phenylephrine chew tab 1-2.5 mg................................... 33
diphenhydramine hcl cap 25 mg....................................... 32
diphenhydramine hcl cap 50 mg....................................... 32
diphenhydramine hcl elixir 12.5 mg/5ml............................ 32
diphenhydramine hcl liquid 12.5 mg/5ml........................... 32
diphenhydramine hcl tab 25 mg........................................ 32
95
2016
diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml....... 33
diphenhydramine-phenylephrine soln 12.5-5 mg/5ml....... 33
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 38
dipyridamole tab 25 mg (Persantine)................................ 71
dipyridamole tab 50 mg (Persantine)................................ 71
dipyridamole tab 75 mg (Persantine)................................ 71
disopyramide phosphate cap 100 mg (Norpace).............. 29
disopyramide phosphate cap 150 mg (Norpace).............. 29
disulfiram tab 250 mg (Antabuse)..................................... 53
disulfiram tab 500 mg (Antabuse)..................................... 53
divalproex sodium tab delayed release 125 mg
(Depakote)........................................................................ 61
divalproex sodium tab delayed release 250 mg
(Depakote)........................................................................ 61
divalproex sodium tab delayed release 500 mg
(Depakote)........................................................................ 61
divalproex sodium tab sr 24 hr 250 mg (Depakote er)...... 61
divalproex sodium tab sr 24 hr 500 mg (Depakote er)...... 61
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 13
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 13
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 13
docosahexaenoic acid cap 200 mg................................... 68
docusate sodium cap 100 mg........................................... 37
docusate sodium cap 250 mg........................................... 37
docusate sodium liquid 150 mg/15ml................................ 37
dofetilide cap 125 mcg (0.125 mg) (Tikosyn).................... 29
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...................... 29
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................ 29
donepezil hydrochloride orally disintegrating tab 5 mg..... 53
donepezil hydrochloride orally disintegrating tab 10 mg
(Aricept odt)...................................................................... 53
donepezil hydrochloride tab 5 mg (Aricept).......................53
donepezil hydrochloride tab 10 mg (Aricept).....................53
dorzolamide hcl ophth soln 2% (Trusopt).......................... 78
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/
ml (Cosopt)....................................................................... 78
doxazosin mesylate tab 1 mg (Cardura)........................... 30
doxazosin mesylate tab 2 mg (Cardura)........................... 30
doxazosin mesylate tab 4 mg (Cardura)........................... 30
doxazosin mesylate tab 8 mg (Cardura)........................... 30
doxepin hcl cap 10 mg...................................................... 44
doxepin hcl cap 25 mg...................................................... 44
doxepin hcl cap 50 mg...................................................... 44
doxepin hcl cap 100 mg.................................................... 44
doxepin hcl cap 150 mg.................................................... 44
doxepin hcl conc 10 mg/ml................................................ 44
DOXEPIN HCL – doxepin hcl cap 75 mg..........................44
doxycycline hyclate cap 50 mg............................................2
doxycycline hyclate cap 100 mg (Vibramycin).................... 2
doxycycline hyclate tab delayed release 75 mg.................. 3
doxycycline hyclate tab delayed release 50 mg (Doryx)..... 3
doxycycline hyclate tab 20 mg............................................ 3
doxycycline hyclate tab 100 mg.......................................... 3
doxycycline monohydrate cap 50 mg.................................. 3
doxycycline monohydrate cap 100 mg (Monodox)..............3
96
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)........................................................................ 3
doxycycline monohydrate tab 50 mg (Adoxa)..................... 3
doxycycline monohydrate tab 75 mg (Adoxa)..................... 3
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................. 3
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act......................................................35
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act......................................................35
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)......................................................................... 44
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)......................................................................... 44
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)......................................................................... 44
dutasteride cap 0.5 mg (Avodart)...................................... 42
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............42
E
econazole nitrate cream 1%.............................................. 81
ED CHLORPED D – chlorpheniramine & phenylephrine
liquid 2-5 mg/ml................................................................ 33
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 6
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........2
ELIDEL – pimecrolimus cream 1%....................................83
ELIQUIS – apixaban tab 2.5 mg....................................... 71
ELIQUIS – apixaban tab 5 mg.......................................... 71
ELLA – ulipristal acetate tab 30 mg.................................. 15
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
250 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
500 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
750 unit............................................................................. 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
1000 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
1500 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
2000 unit........................................................................... 71
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
3000 unit........................................................................... 71
EMEND – aprepitant capsule 40 mg................................. 39
EMEND – aprepitant capsule 80 mg................................. 39
EMEND – aprepitant capsule 125 mg............................... 39
EMEND – aprepitant capsule therapy pack 80 & 125
mg...................................................................................... 39
EMTRIVA – emtricitabine caps 200 mg.............................. 6
EMTRIVA – emtricitabine soln 10 mg/ml............................. 6
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg...................................................................................... 21
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)......................................................................... 21
enalapril maleate tab 2.5 mg (Vasotec).............................21
enalapril maleate tab 5 mg (Vasotec)............................... 21
2016
enalapril maleate tab 10 mg (Vasotec)............................. 21
enalapril maleate tab 20 mg (Vasotec)............................. 21
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml...................................................................... 58
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml........................................................................... 58
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml........................................ 58
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 71
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 71
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 71
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 71
enoxaparin sodium inj 100 mg/ml (Lovenox).................... 71
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 71
enoxaparin sodium inj 150 mg/ml (Lovenox).................... 72
enoxaparin sodium inj 300 mg/3ml (Lovenox).................. 72
entacapone tab 200 mg (Comtan).....................................64
entecavir tab 0.5 mg (Baraclude)........................................ 5
entecavir tab 1 mg (Baraclude)........................................... 5
epinastine hcl ophth soln 0.05% (Elestat)......................... 79
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................... 31
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................ 31
EPOGEN – epoetin alfa inj 2000 unit/ml........................... 72
EPOGEN – epoetin alfa inj 3000 unit/ml........................... 72
EPOGEN – epoetin alfa inj 4000 unit/ml........................... 72
EPOGEN – epoetin alfa inj 10000 unit/ml......................... 72
EPOGEN – epoetin alfa inj 20000 unit/ml......................... 72
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg........................................................................................ 6
ergocalciferol cap 50000 unit (Drisdol).............................. 66
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg................................................. 2
erythromycin gel 2% (Erygel)............................................ 80
erythromycin ophth oint 5 mg/gm...................................... 77
erythromycin pads 2%....................................................... 80
erythromycin soln 2%.........................................................80
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................... 44
escitalopram oxalate tab 5 mg (base equiv) (Lexapro)..... 44
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................... 44
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................... 44
estazolam tab 1 mg........................................................... 48
estazolam tab 2 mg........................................................... 48
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)...........................................................................13
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)...........................................................................13
estradiol tab 0.5 mg (Estrace)........................................... 14
estradiol tab 1 mg (Estrace).............................................. 14
estradiol tab 2 mg (Estrace).............................................. 14
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................... 14
estradiol td patch twice weekly 0.0375 mg/24hr (Vivelledot).................................................................................... 14
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................... 14
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................... 14
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................... 14
estradiol td patch weekly 0.025 mg/24hr (Climara)........... 14
estradiol td patch weekly 0.0375 mg/24hr (Climara)......... 14
estradiol td patch weekly 0.05 mg/24hr (Climara)............. 14
estradiol td patch weekly 0.06 mg/24hr (Climara)............. 14
estradiol td patch weekly 0.075 mg/24hr (Climara)........... 14
estradiol td patch weekly 0.1 mg/24hr (Climara)............... 14
estradiol valerate im in oil 20 mg/ml (Delestrogen)........... 14
estradiol valerate im in oil 40 mg/ml (Delestrogen)........... 14
ESTROPIPATE – estropipate tab 0.75 mg........................ 14
ESTROPIPATE – estropipate tab 1.5 mg.......................... 14
ESTROPIPATE – estropipate tab 3 mg............................. 14
eszopiclone tab 1 mg (Lunesta)........................................ 48
eszopiclone tab 2 mg (Lunesta)........................................ 48
eszopiclone tab 3 mg (Lunesta)........................................ 49
ethambutol hcl tab 100 mg (Myambutol)............................. 3
ethambutol hcl tab 400 mg (Myambutol)............................. 4
ethosuximide cap 250 mg (Zarontin)................................. 61
ethosuximide soln 250 mg/5ml (Zarontin)......................... 61
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg...................................................................................... 19
etodolac cap 200 mg......................................................... 58
etodolac cap 300 mg......................................................... 58
etodolac tab 400 mg.......................................................... 58
etodolac tab 500 mg.......................................................... 58
etodolac tab sr 24hr 400 mg............................................. 58
etodolac tab sr 24hr 600 mg............................................. 58
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)........................................................................ 6
exemestane tab 25 mg (Aromasin)................................... 10
EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................52
F
FALESSA – levonorgest-eth estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit.................................................................. 15
famciclovir tab 125 mg (Famvir).......................................... 5
famotidine for susp 40 mg/5ml (Pepcid)............................38
famotidine tab 10 mg......................................................... 38
famotidine tab 20 mg (Pepcid).......................................... 38
famotidine tab 40 mg (Pepcid).......................................... 38
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg...................................................................................... 72
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg...................................................................................... 72
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap
(Tandem plus)................................................................... 72
FEIBA – antiinhibitor coagulant complex for inj.................72
felbamate susp 600 mg/5ml (Felbatol).............................. 61
felbamate tab 400 mg (Felbatol)....................................... 61
97
2016
felbamate tab 600 mg (Felbatol)....................................... 62
felodipine tab sr 24hr 2.5 mg.............................................25
felodipine tab sr 24hr 5 mg................................................25
felodipine tab sr 24hr 10 mg..............................................25
fenofibrate micronized cap 43 mg..................................... 27
fenofibrate micronized cap 130 mg................................... 27
fenofibrate micronized cap 67 mg (Lofibra).......................27
fenofibrate micronized cap 134 mg (Lofibra).....................27
fenofibrate micronized cap 200 mg (Lofibra).....................27
fenofibrate tab 54 mg (Lofibra).......................................... 27
fenofibrate tab 160 mg (Lofibra)........................................ 27
fenofibrate tab 48 mg (Tricor)............................................ 27
fenofibrate tab 145 mg (Tricor).......................................... 27
fentanyl citrate lozenge on a handle 200 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 400 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 600 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 800 mcg (Actiq)....... 55
fentanyl citrate lozenge on a handle 1200 mcg (Actiq)..... 55
fentanyl citrate lozenge on a handle 1600 mcg (Actiq)..... 55
fentanyl td patch 72hr 12 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 25 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 50 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 75 mcg/hr (Duragesic)................... 55
fentanyl td patch 72hr 100 mcg/hr (Duragesic)................. 55
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg...................................................................................... 72
ferrous fumarate-folic acid tab 324-1 mg.......................... 72
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)......... 72
ferrous sulfate tab 325 mg (65 mg elemental fe).............. 72
fexofenadine hcl susp 30 mg/5ml (6 mg/ml)..................... 32
fexofenadine hcl tab 60 mg............................................... 32
fexofenadine hcl tab 180 mg............................................. 32
finasteride tab 5 mg (Proscar)........................................... 42
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................... 72
flavoxate hcl tab 100 mg................................................... 41
flecainide acetate tab 50 mg............................................. 29
flecainide acetate tab 100 mg........................................... 29
flecainide acetate tab 150 mg........................................... 29
FLEET LIQUID GLYCERIN SUP – glycerin enema adult
5.4 gm/average delivered dose....................................... 37
FLOVENT DISKUS – fluticasone propionate aer pow ba
50 mcg/blister................................................................... 35
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................. 35
FLOVENT DISKUS – fluticasone propionate aer pow ba
250 mcg/blister................................................................. 35
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve).......................................................... 35
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve).......................................................... 35
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................ 35
fluconazole for susp 10 mg/ml (Diflucan)............................ 4
fluconazole for susp 40 mg/ml (Diflucan)............................ 4
fluconazole tab 50 mg (Diflucan)......................................... 4
98
fluconazole tab 100 mg (Diflucan)....................................... 4
fluconazole tab 150 mg (Diflucan)....................................... 4
fluconazole tab 200 mg (Diflucan)....................................... 4
flucytosine cap 250 mg (Ancobon)...................................... 4
flucytosine cap 500 mg (Ancobon)...................................... 4
fludrocortisone acetate tab 0.1 mg.................................... 12
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................... 32
fluocinolone acetonide cream 0.01%................................ 82
fluocinolone acetonide cream 0.025% (Synalar)............... 82
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)................................................................ 82
fluocinolone acetonide oint 0.025% (Synalar)................... 82
fluocinolone acetonide soln 0.01% (Synalar).................... 82
fluocinonide cream 0.05%................................................. 82
fluocinonide emulsified base cream 0.05%....................... 82
fluocinonide gel 0.05%....................................................... 82
fluocinonide oint 0.05%...................................................... 82
fluocinonide soln 0.05%..................................................... 82
fluorometholone ophth susp 0.1% (Fml liquifilm).............. 78
fluorouracil cream 5% (Efudex)......................................... 83
fluorouracil soln 2%............................................................ 83
fluorouracil soln 5%............................................................ 83
fluoxetine hcl cap 10 mg (Prozac)..................................... 44
fluoxetine hcl cap 20 mg (Prozac)..................................... 44
fluoxetine hcl cap 40 mg (Prozac)..................................... 44
fluoxetine hcl solution 20 mg/5ml...................................... 44
fluoxetine hcl tab 10 mg.................................................... 44
fluoxetine hcl tab 20 mg.................................................... 44
fluphenazine decanoate inj 25 mg/ml................................ 46
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................... 46
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml....................................................................................... 46
fluphenazine hcl tab 1 mg................................................. 46
fluphenazine hcl tab 2.5 mg.............................................. 46
fluphenazine hcl tab 5 mg................................................. 47
fluphenazine hcl tab 10 mg............................................... 47
flurandrenolide cream 0.05% (Cordran)............................ 82
flurbiprofen sodium ophth soln 0.03% (Ocufen)................ 79
flurbiprofen tab 50 mg........................................................ 58
flurbiprofen tab 100 mg...................................................... 58
flutamide cap 125 mg........................................................ 10
fluticasone propionate cream 0.05% (Cutivate)................ 82
fluticasone propionate nasal susp 50 mcg/act
(Flonase)........................................................................... 32
fluticasone propionate oint 0.005% (Cutivate).................. 82
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)..............27
fluvoxamine maleate tab 25 mg........................................ 44
fluvoxamine maleate tab 50 mg........................................ 45
fluvoxamine maleate tab 100 mg...................................... 45
FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &
folic acid tab 5 mg............................................................ 66
folic acid tab 400 mcg........................................................ 72
folic acid tab 800 mcg........................................................ 72
folic acid tab 1 mg............................................................. 72
2016
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........72
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............72
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard
rx)...................................................................................... 72
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).............................................................................. 72
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).............................................................................. 72
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml.......................................................................... 19
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg...................................................................................... 21
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg...................................................................................... 21
fosinopril sodium tab 10 mg.............................................. 21
fosinopril sodium tab 20 mg.............................................. 21
fosinopril sodium tab 40 mg.............................................. 21
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova)............................................................................... 60
fructose-dextrose-phosphoric acid oral soln .................... 39
furosemide oral soln 10 mg/ml.......................................... 28
furosemide tab 20 mg (Lasix)............................................ 28
furosemide tab 40 mg (Lasix)............................................ 28
furosemide tab 80 mg (Lasix)............................................ 29
FUZEON – enfuvirtide for inj 90 mg.................................... 6
G
gabapentin cap 100 mg (Neurontin).................................. 62
gabapentin cap 300 mg (Neurontin).................................. 62
gabapentin cap 400 mg (Neurontin).................................. 62
gabapentin oral soln 250 mg/5ml (Neurontin)................... 62
gabapentin tab 600 mg (Neurontin)...................................62
gabapentin tab 800 mg (Neurontin)...................................62
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml...................................... 53
gemfibrozil tab 600 mg (Lopid).......................................... 27
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%.................................................................................. 81
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%.................................................................................. 81
gentamicin sulfate ophth oint 0.3%................................... 77
gentamicin sulfate ophth soln 0.3% (Garamycin)..............77
GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg............................................................ 6
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)....................................................................... 52
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 10
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 10
glimepiride tab 1 mg (Amaryl)........................................... 16
glimepiride tab 2 mg (Amaryl)........................................... 16
glimepiride tab 4 mg (Amaryl)........................................... 16
glipizide-metformin hcl tab 2.5-250 mg............................. 16
glipizide-metformin hcl tab 2.5-500 mg............................. 16
glipizide-metformin hcl tab 5-500 mg................................ 16
glipizide tab 5 mg (Glucotrol).............................................16
glipizide tab 10 mg (Glucotrol)...........................................16
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)......................... 16
glipizide tab sr 24hr 5 mg (Glucotrol xl)............................ 16
glipizide tab sr 24hr 10 mg (Glucotrol xl).......................... 16
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................. 16
glyburide-metformin tab 1.25-250 mg (Glucovance)......... 16
glyburide-metformin tab 2.5-500 mg (Glucovance)........... 16
glyburide-metformin tab 5-500 mg (Glucovance).............. 16
glyburide micronized tab 1.5 mg (Glynase).......................16
glyburide micronized tab 3 mg (Glynase)..........................16
glyburide micronized tab 6 mg (Glynase)..........................16
glyburide tab 1.25 mg........................................................ 16
glyburide tab 2.5 mg.......................................................... 16
glyburide tab 5 mg............................................................. 16
glycerin suppos 80.7%....................................................... 37
glycerin suppos 1 gm......................................................... 37
glycerin suppos 2 gm......................................................... 37
glycine irrigation soln 1.5%................................................ 42
glycopyrrolate tab 1 mg (Robinul)..................................... 38
glycopyrrolate tab 2 mg (Robinul forte)............................. 38
griseofulvin microsize susp 125 mg/5ml..............................4
griseofulvin microsize tab 500 mg (Grifulvin v)................... 4
griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............4
griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............4
guaifenesin-codeine soln 100-10 mg/5ml..........................33
guaifenesin liquid 100 mg/5ml........................................... 33
guanfacine hcl tab 1 mg (Tenex)....................................... 30
guanfacine hcl tab 2 mg (Tenex)....................................... 30
guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv)..... 50
guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv)..... 50
H
halobetasol propionate cream 0.05% (Ultravate).............. 82
halobetasol propionate oint 0.05% (Ultravate).................. 82
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50)................................................................... 47
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)................................................................. 47
haloperidol lactate oral conc 2 mg/ml................................47
haloperidol tab 0.5 mg....................................................... 47
haloperidol tab 1 mg.......................................................... 47
haloperidol tab 2 mg.......................................................... 47
haloperidol tab 5 mg.......................................................... 47
haloperidol tab 10 mg........................................................ 47
haloperidol tab 20 mg........................................................ 47
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 5
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 250 unit........................................................................ 72
99
2016
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 500 unit........................................................................ 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 1000 unit...................................................................... 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 2000 unit...................................................................... 72
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 3000 unit...................................................................... 73
HEMOFIL M – antihemophilic factor (human) for inj 250
unit..................................................................................... 73
HEMOFIL M – antihemophilic factor (human) for inj 500
unit..................................................................................... 73
HEMOFIL M – antihemophilic factor (human) for inj 1000
unit..................................................................................... 73
HEMOFIL M – antihemophilic factor (human) for inj 1700
unit..................................................................................... 73
HUMALOG – insulin lispro (human) inj 100 unit/ml...........17
HUMALOG – insulin lispro (human) soln cartridge 100
unit/ml................................................................................ 17
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 100 unit/ml........................................................... 17
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 200 unit/ml........................................................... 17
HUMALOG MIX 50/50 – insulin lispro prot & lispro
(human) inj 100 unit/ml (50-50)....................................... 17
HUMALOG MIX 75/25 – insulin lispro prot & lispro
(human) inj 100 unit/ml (75-25)....................................... 17
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 17
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 18
HUMATE-P – antihemophilic factor/vwf (human) for inj
250-600 unit...................................................................... 73
HUMATE-P – antihemophilic factor/vwf (human) for inj
500-1200 unit.................................................................... 73
HUMATE-P – antihemophilic factor/vwf (human) for inj
1000-2400 unit.................................................................. 73
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml............................................................................58
HUMIRA – adalimumab prefilled syringe kit 20
mg/0.4ml............................................................................58
HUMIRA – adalimumab prefilled syringe kit 40
mg/0.8ml............................................................................58
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................... 59
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml............................................................................59
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml.................................................... 59
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml.................................................... 59
HUMULIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)...................................................... 18
HUMULIN 70/30 KWIKPEN – insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................... 18
100
HUMULIN N – insulin nph (human) (isophane) inj 100
unit/ml................................................................................ 18
HUMULIN N KWIKPEN – insulin nph (human) (isophane)
susp pen-injector 100 unit/ml........................................... 18
HUMULIN R – insulin regular (human) inj 100 unit/ml...... 17
HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml.................................................... 17
HUMULIN R U-500 KWIKPEN – insulin regular (human)
soln pen-injector 500 unit/ml............................................ 17
hydralazine hcl tab 10 mg................................................. 30
hydralazine hcl tab 25 mg................................................. 30
hydralazine hcl tab 50 mg................................................. 30
hydralazine hcl tab 100 mg............................................... 30
hydrochlorothiazide cap 12.5 mg (Microzide)................... 29
hydrochlorothiazide tab 12.5 mg....................................... 29
hydrochlorothiazide tab 25 mg.......................................... 29
hydrochlorothiazide tab 50 mg.......................................... 29
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................... 55
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet)........................................................................... 55
hydrocodone-acetaminophen tab 2.5-325 mg...................55
hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 55
hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 55
hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 55
hydrocodone-acetaminophen tab 10-300 mg (Xodol)....... 55
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)........... 55
hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)....... 55
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml............ 33
hydrocodone w/ homatropine tab 5-1.5 mg.......................33
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)......................................................33
hydrocortisone butyrate oint 0.1% (Locoid)....................... 82
hydrocortisone cream 0.5%............................................... 82
hydrocortisone cream 1%.................................................. 83
hydrocortisone cream 2.5%............................................... 83
hydrocortisone enema 100 mg/60ml (Cortenema)............ 80
hydrocortisone lotion 2.5%................................................ 83
hydrocortisone oint 0.5%................................................... 83
hydrocortisone oint 1%...................................................... 83
hydrocortisone oint 2.5%................................................... 83
hydrocortisone rectal cream 2.5% (Anusol-hc)................. 80
hydrocortisone rectal cream 1% (Proctocort).................... 80
hydrocortisone tab 5 mg (Cortef).......................................13
hydrocortisone tab 10 mg (Cortef).....................................13
hydrocortisone tab 20 mg (Cortef).....................................13
hydrocortisone valerate cream 0.2%................................. 83
hydrocortisone valerate oint 0.2% (Westcort)................... 83
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)...................................................................................... 79
hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................55
hydromorphone hcl tab 2 mg (Dilaudid)............................ 55
hydromorphone hcl tab 4 mg (Dilaudid)............................ 55
hydromorphone hcl tab 8 mg (Dilaudid)............................ 56
hydroxychloroquine sulfate tab 200 mg (Plaquenil)............ 9
hydroxyurea cap 500 mg (Hydrea).................................... 10
2016
HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/
ml....................................................................................... 43
hydroxyzine hcl im soln 50 mg/ml..................................... 43
hydroxyzine hcl syrup 10 mg/5ml...................................... 43
hydroxyzine hcl tab 10 mg.................................................43
hydroxyzine hcl tab 25 mg.................................................43
hydroxyzine hcl tab 50 mg.................................................43
hydroxyzine pamoate cap 25 mg (Vistaril)........................ 43
hydroxyzine pamoate cap 50 mg (Vistaril)........................ 43
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg.............................................................................. 43
hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 38
hyoscyamine sulfate soln 0.125 mg/ml............................. 38
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...........38
hyoscyamine sulfate tab 0.125 mg (Levsin)...................... 38
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)...............38
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)......... 38
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)............................................................................. 19
IBRANCE – palbociclib cap 75 mg....................................10
IBRANCE – palbociclib cap 100 mg..................................10
IBRANCE – palbociclib cap 125 mg..................................10
ibuprofen cap 200 mg........................................................ 59
ibuprofen susp 100 mg/5ml............................................... 59
ibuprofen tab 200 mg......................................................... 59
ibuprofen tab 400 mg......................................................... 59
ibuprofen tab 600 mg......................................................... 59
ibuprofen tab 800 mg......................................................... 59
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj
250 unit............................................................................. 73
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj
500 unit............................................................................. 73
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj
1000 unit........................................................................... 73
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj
2000 unit........................................................................... 73
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................... 10
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................... 10
imipramine hcl tab 10 mg (Tofranil)................................... 45
imipramine hcl tab 25 mg (Tofranil)................................... 45
imipramine hcl tab 50 mg (Tofranil)................................... 45
imipramine pamoate cap 75 mg........................................ 45
imipramine pamoate cap 100 mg...................................... 45
imipramine pamoate cap 125 mg...................................... 45
imipramine pamoate cap 150 mg...................................... 45
imiquimod cream 5% (Aldara)........................................... 83
IMITREX – sumatriptan nasal spray 5 mg/act...................60
IMITREX – sumatriptan nasal spray 20 mg/act.................60
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq).............................................. 36
indapamide tab 1.25 mg.................................................... 29
indapamide tab 2.5 mg...................................................... 29
indomethacin cap cr 75 mg............................................... 59
indomethacin cap 25 mg................................................... 59
indomethacin cap 50 mg................................................... 59
INSULIN PEN NEEDLES - VARIOUS............................... 84
INSULIN SYRINGES - VARIOUS...................................... 84
INTELENCE – etravirine tab 25 mg.................................... 6
INTELENCE – etravirine tab 100 mg.................................. 6
INTELENCE – etravirine tab 200 mg.................................. 6
INVIRASE – saquinavir mesylate cap 200 mg.................... 6
INVIRASE – saquinavir mesylate tab 500 mg.....................6
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 36
ipratropium bromide inhal soln 0.02%............................... 36
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)...........................................................................32
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)...........................................................................32
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)............................................................................ 22
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)............................................................................ 22
irbesartan tab 75 mg (Avapro)........................................... 22
irbesartan tab 150 mg (Avapro)......................................... 22
irbesartan tab 300 mg (Avapro)......................................... 22
iron combination cap.......................................................... 73
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af).................................................................... 73
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)..................................................................... 73
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg...................................................................................... 73
irrigation solution, physiological......................................... 85
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv)........................................................................ 6
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv)........................................................................ 6
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv)..................................................................6
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................... 6
isoniazid tab 100 mg............................................................ 4
isoniazid tab 300 mg............................................................ 4
ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr
40 mg................................................................................ 26
isosorbide dinitrate tab 10 mg........................................... 26
isosorbide dinitrate tab 20 mg........................................... 26
isosorbide dinitrate tab 30 mg........................................... 26
isosorbide dinitrate tab 5 mg (Isordil titradose)................. 26
isosorbide mononitrate tab 10 mg..................................... 26
isosorbide mononitrate tab 20 mg..................................... 26
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)............ 26
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)............ 26
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).......... 26
isotretinoin cap 10 mg........................................................80
isotretinoin cap 20 mg........................................................80
isotretinoin cap 30 mg........................................................80
isotretinoin cap 40 mg........................................................80
101
2016
isradipine cap 2.5 mg.........................................................25
isradipine cap 5 mg............................................................25
itraconazole cap 100 mg (Sporanox).................................. 4
ivermectin tab 3 mg (Stromectol)........................................ 9
J
JANUMET – sitagliptin-metformin hcl tab 50-500 mg....... 16
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg..... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-500 mg......................................................................... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-1000 mg....................................................................... 16
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
100-1000 mg.....................................................................16
JANUVIA – sitagliptin phosphate tab 25 mg (base
equiv)................................................................................. 16
JANUVIA – sitagliptin phosphate tab 50 mg (base
equiv)................................................................................. 16
JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv)................................................................................. 16
K
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)..................................................................... 6
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 6
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 6
KALYDECO – ivacaftor packet 50 mg............................... 37
KALYDECO – ivacaftor packet 75 mg............................... 37
KALYDECO – ivacaftor tab 150 mg.................................. 37
ketoconazole cream 2%.....................................................81
ketoconazole shampoo 2% (Nizoral)................................. 81
ketoconazole tab 200 mg.................................................... 4
ketoprofen cap 50 mg........................................................ 59
ketoprofen cap 75 mg........................................................ 59
ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml)....... 59
KETOROLAC TROMETHAMINE – ketorolac
tromethamine inj 60 mg/2ml (30 mg/ml).......................... 59
ketorolac tromethamine ophth soln 0.5% (Acular)............ 79
ketorolac tromethamine ophth soln 0.4% (Acular ls).........79
ketorolac tromethamine tab 10 mg.................................... 59
ketotifen fumarate ophth soln 0.025% (base equiv).......... 79
KOATE-DVI – antihemophilic factor (human) for inj 250
unit..................................................................................... 73
KOATE-DVI – antihemophilic factor (human) for inj 500
unit..................................................................................... 73
KOATE-DVI – antihemophilic factor (human) for inj 1000
unit..................................................................................... 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 250 unit................................................................... 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 500 unit................................................................... 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 1000 unit................................................................. 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 2000 unit................................................................. 73
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 3000 unit................................................................. 73
102
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 250 unit...................................... 73
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 500 unit...................................... 74
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 1000 unit.................................... 74
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 2000 unit.................................... 74
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 3000 unit.................................... 74
KONSYL-D – psyllium powder 52.3%............................... 37
KONSYL – psyllium powder 60.3%................................... 37
KONSYL – psyllium powder 71.67%................................. 37
KOVALTRY – antihemophilic factor (recombinant) for inj
250 unit............................................................................. 74
KOVALTRY – antihemophilic factor (recombinant) for inj
500 unit............................................................................. 74
KOVALTRY – antihemophilic factor (recombinant) for inj
1000 unit........................................................................... 74
KOVALTRY – antihemophilic factor (recombinant) for inj
2000 unit........................................................................... 74
KOVALTRY – antihemophilic factor (recombinant) for inj
3000 unit........................................................................... 74
K-PHOS – potassium phosphate monobasic tab 500
mg...................................................................................... 67
L
labetalol hcl tab 100 mg (Trandate)................................... 23
labetalol hcl tab 200 mg (Trandate)................................... 23
labetalol hcl tab 300 mg (Trandate)................................... 23
lactated ringer's for irrigation............................................. 85
lactic acid (ammonium lactate) lotion 12% (Lachydrin)............................................................................... 83
lactulose (encephalopathy) solution 10 gm/15ml.............. 40
lactulose solution 10 gm/15ml........................................... 37
lamivudine oral soln 10 mg/ml (Epivir)................................ 6
lamivudine tab 150 mg (Epivir)............................................ 6
lamivudine tab 300 mg (Epivir)............................................ 7
lamivudine tab 100 mg (Epivir hbv)..................................... 5
lamivudine-zidovudine tab 150-300 mg (Combivir)............. 7
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................... 62
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................... 62
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................... 62
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................... 62
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)...................................................................... 62
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)...................................................................... 62
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit
(Lamictal odt).................................................................... 62
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit
(Lamictal odt).................................................................... 62
2016
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit
(Lamictal odt).................................................................... 62
lamotrigine tab 25 mg (Lamictal)....................................... 62
lamotrigine tab 100 mg (Lamictal)..................................... 62
lamotrigine tab 150 mg (Lamictal)..................................... 62
lamotrigine tab 200 mg (Lamictal)..................................... 62
lamotrigine tab sr 24hr 25 mg (Lamictal xr)...................... 62
lamotrigine tab sr 24hr 50 mg (Lamictal xr)...................... 62
lamotrigine tab sr 24hr 100 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 200 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 250 mg (Lamictal xr).................... 62
lamotrigine tab sr 24hr 300 mg (Lamictal xr).................... 62
LANCETS – BAYER ASCENSIA....................................... 84
lansoprazole cap delayed release 15 mg (Prevacid)........ 38
lansoprazole cap delayed release 30 mg (Prevacid)........ 39
LANTUS – insulin glargine inj 100 unit/ml......................... 18
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml........................................................................ 18
latanoprost ophth soln 0.005% (Xalatan).......................... 78
leflunomide tab 10 mg (Arava).......................................... 59
leflunomide tab 20 mg (Arava).......................................... 59
LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)................................ 11
LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 (2) mg (18 mg daily dose)........................... 11
LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)........................... 11
LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy
pack 10 mg (10 mg daily dose)....................................... 11
LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................. 11
LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy
pack 4 (2) mg (8 mg daily dose)..................................... 11
letrozole tab 2.5 mg (Femara)........................................... 11
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg...................................................................................... 11
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg...................................................................................... 11
leucovorin calcium tab 5 mg.............................................. 11
leucovorin calcium tab 25 mg............................................ 11
LEUKERAN – chlorambucil tab 2 mg................................11
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex).......................................................................... 36
LEVEMIR FLEXTOUCH – insulin detemir soln peninjector 100 unit/ml........................................................... 18
LEVEMIR – insulin detemir inj 100 unit/ml........................ 18
levetiracetam oral soln 100 mg/ml (Keppra)..................... 62
levetiracetam tab 250 mg (Keppra)................................... 62
levetiracetam tab 500 mg (Keppra)................................... 62
levetiracetam tab 750 mg (Keppra)................................... 62
levetiracetam tab 1000 mg (Keppra)................................. 62
levetiracetam tab sr 24hr 500 mg (Keppra xr).................. 62
levetiracetam tab sr 24hr 750 mg (Keppra xr).................. 62
levobunolol hcl ophth soln 0.5% (Betagan)....................... 78
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)........... 20
levocarnitine tab 330 mg (Carnitor)................................... 20
levocetirizine dihydrochloride tab 5 mg (Xyzal)................. 32
levofloxacin ophth soln 0.5%............................................. 77
levofloxacin oral soln 25 mg/ml (Levaquin)......................... 3
levofloxacin tab 250 mg (Levaquin).....................................3
levofloxacin tab 500 mg (Levaquin).....................................3
levofloxacin tab 750 mg (Levaquin).....................................3
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg.................................................................................... 15
LEVONORGESTREL – levonorgestrel tab 0.75 mg......... 15
levonorgestrel tab 1.5 mg (Plan b one-step)..................... 15
levothyroxine sodium tab 25 mcg (Synthroid)................... 18
levothyroxine sodium tab 50 mcg (Synthroid)................... 18
levothyroxine sodium tab 75 mcg (Synthroid)................... 18
levothyroxine sodium tab 88 mcg (Synthroid)................... 18
levothyroxine sodium tab 100 mcg (Synthroid)................. 18
levothyroxine sodium tab 112 mcg (Synthroid)................. 18
levothyroxine sodium tab 125 mcg (Synthroid)................. 18
levothyroxine sodium tab 137 mcg (Synthroid)................. 18
levothyroxine sodium tab 150 mcg (Synthroid)................. 18
levothyroxine sodium tab 175 mcg (Synthroid)................. 18
levothyroxine sodium tab 200 mcg (Synthroid)................. 19
levothyroxine sodium tab 300 mcg (Synthroid)................. 19
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................... 7
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................... 7
lidocaine hcl cream 3%...................................................... 83
lidocaine hcl gel 2%........................................................... 83
lidocaine hcl soln 4% (Xylocaine)...................................... 83
lidocaine hcl viscous soln 2%............................................ 79
lidocaine oint 5%................................................................ 83
lidocaine patch 5% (Lidoderm).......................................... 83
lidocaine-prilocaine cream 2.5-2.5% (Emla)......................83
lidocaine-prilocaine cream kit 2.5-2.5%............................. 83
linezolid for susp 100 mg/5ml (Zyvox).................................9
linezolid tab 600 mg (Zyvox)............................................... 9
liothyronine sodium tab 5 mcg (Cytomel).......................... 19
liothyronine sodium tab 25 mcg (Cytomel)........................ 19
liothyronine sodium tab 50 mcg (Cytomel)........................ 19
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)........................................................................ 21
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)........................................................................ 21
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)........................................................................ 21
lisinopril tab 5 mg (Prinivil)................................................ 21
lisinopril tab 10 mg (Prinivil).............................................. 21
lisinopril tab 20 mg (Prinivil).............................................. 21
lisinopril tab 2.5 mg (Zestril).............................................. 21
lisinopril tab 30 mg (Zestril)............................................... 21
lisinopril tab 40 mg (Zestril)............................................... 21
lithium carbonate cap 300 mg........................................... 47
103
2016
lithium carbonate cap 150 mg (Lithium carbonate)........... 47
lithium carbonate cap 600 mg (Lithium carbonate)........... 47
lithium carbonate tab cr 450 mg........................................ 47
lithium carbonate tab cr 300 mg (Lithobid)........................ 47
lithium carbonate tab 300 mg............................................ 47
LITHIUM – lithium oral solution 8 meq/5ml....................... 47
LO LOESTRIN FE – norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2).........................................................15
loperamide hcl cap 2 mg................................................... 38
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)........................... 38
loperamide hcl tab 2 mg.................................................... 38
loratadine syrup 5 mg/5ml................................................. 32
loratadine tab 10 mg.......................................................... 32
lorazepam conc 2 mg/ml (Lorazepam intensol)................ 43
lorazepam tab 0.5 mg (Ativan).......................................... 43
lorazepam tab 1 mg (Ativan)............................................. 43
lorazepam tab 2 mg (Ativan)............................................. 43
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
(Hyzaar).............................................................................22
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar)...................................................................... 22
losartan potassium & hydrochlorothiazide tab 100-25 mg
(Hyzaar).............................................................................22
losartan potassium tab 25 mg (Cozaar)............................ 22
losartan potassium tab 50 mg (Cozaar)............................ 22
losartan potassium tab 100 mg (Cozaar).......................... 23
LOTEMAX – loteprednol etabonate ophth susp 0.5%...... 78
lovastatin tab 10 mg...........................................................27
lovastatin tab 20 mg (Mevacor)......................................... 27
lovastatin tab 40 mg (Mevacor)......................................... 28
loxapine succinate cap 5 mg............................................. 47
loxapine succinate cap 10 mg........................................... 47
loxapine succinate cap 25 mg........................................... 47
loxapine succinate cap 50 mg........................................... 47
LYNPARZA – olaparib cap 50 mg..................................... 11
LYRICA – pregabalin cap 25 mg....................................... 63
LYRICA – pregabalin cap 50 mg....................................... 63
LYRICA – pregabalin cap 75 mg....................................... 63
LYRICA – pregabalin cap 100 mg..................................... 63
LYRICA – pregabalin cap 150 mg..................................... 63
LYRICA – pregabalin cap 200 mg..................................... 63
LYRICA – pregabalin cap 225 mg..................................... 63
LYRICA – pregabalin cap 300 mg..................................... 63
LYRICA – pregabalin soln 20 mg/ml................................. 62
M
magnesium citrate soln...................................................... 37
magnesium oxide tab 400 mg........................................... 38
malathion lotion 0.5% (Ovide)........................................... 83
meclizine hcl tab 12.5 mg.................................................. 39
meclizine hcl tab 25 mg..................................................... 39
medroxyprogesterone acetate im susp 150 mg/ml (Depoprovera contrac)............................................................... 15
medroxyprogesterone acetate tab 2.5 mg (Provera)........ 14
medroxyprogesterone acetate tab 5 mg (Provera)........... 14
medroxyprogesterone acetate tab 10 mg (Provera)......... 14
104
mefloquine hcl tab 250 mg.................................................. 9
megestrol acetate susp 625 mg/5ml (Megace es)............ 14
megestrol acetate susp 40 mg/ml (Megace oral).............. 11
megestrol acetate tab 20 mg............................................. 11
megestrol acetate tab 40 mg............................................. 11
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent).............................................................. 11
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 11
meloxicam tab 7.5 mg (Mobic).......................................... 59
meloxicam tab 15 mg (Mobic)........................................... 59
memantine hcl oral solution 2 mg/ml (Namenda)..............53
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pak)....................................................53
memantine hcl tab 5 mg (Namenda)................................. 53
memantine hcl tab 10 mg (Namenda)............................... 53
meperidine hcl tab 50 mg (Demerol)................................. 56
meperidine hcl tab 100 mg (Demerol)............................... 56
MEPHYTON – phytonadione tab 5 mg............................. 66
mercaptopurine tab 50 mg (Purinethol)............................. 11
MESALAMINE DR – mesalamine tab delayed release 800
mg...................................................................................... 40
mesalamine enema 4 gm.................................................. 40
METAMUCIL MULTIHEALTH FIB – psyllium powder
55.46%.............................................................................. 37
METAMUCIL MULTIHEALTH FIB – psyllium powder
63%................................................................................... 37
METAMUCIL SMOOTH TEXTURE – psyllium powder
63%................................................................................... 37
metformin hcl tab 500 mg (Glucophage)........................... 16
metformin hcl tab 850 mg (Glucophage)........................... 17
metformin hcl tab 1000 mg (Glucophage)......................... 17
metformin hcl tab sr 24hr 500 mg (Glucophage xr).......... 16
metformin hcl tab sr 24hr 750 mg (Glucophage xr).......... 16
methadone hcl conc 10 mg/ml (Methadose)..................... 56
methadone hcl soln 5 mg/5ml (Methadone hcl)................ 56
methadone hcl soln 10 mg/5ml (Methadone hcl).............. 56
methadone hcl tab for oral susp 40 mg............................ 56
methadone hcl tab 10 mg (Dolophine).............................. 56
methadone hcl tab 5 mg (Dolophine hcl).......................... 56
methamphetamine hcl tab 5 mg (Desoxyn)...................... 50
methazolamide tab 25 mg (Neptazane)............................ 29
methazolamide tab 50 mg (Neptazane)............................ 29
methenamine hippurate tab 1 gm (Hiprex)........................41
methenamine-hyoscamine-meth blue-sod phos cap 120
mg...................................................................................... 41
methenamine mandelate tab 1 gm.................................... 41
methimazole tab 5 mg (Tapazole)..................................... 19
methimazole tab 10 mg (Tapazole)................................... 19
methocarbamol tab 750 mg (Robaxin-750)....................... 65
methocarbamol tab 500 mg (Robaxin).............................. 65
METHOTREXATE SODIUM – methotrexate sodium inj
250 mg/10ml (25 mg/ml).................................................. 11
methotrexate sodium tab 2.5 mg (base equiv).................. 11
methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 83
methscopolamine bromide tab 2.5 mg (Pamine).............. 39
2016
methscopolamine bromide tab 5 mg (Pamine forte)......... 39
methyldopa tab 250 mg..................................................... 30
methyldopa tab 500 mg..................................................... 31
methylergonovine maleate tab 0.2 mg.............................. 20
methylphenidate hcl cap cr 10 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 20 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 50 mg (cd) (Metadate cd)...... 50
methylphenidate hcl cap cr 60 mg (cd) (Metadate cd)...... 51
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)..... 51
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)..... 51
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)..... 51
methylphenidate hcl chew tab 2.5 mg (Methylin).............. 51
methylphenidate hcl chew tab 5 mg (Methylin)................. 51
methylphenidate hcl chew tab 10 mg (Methylin)............... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 27 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 36 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 54 mg.................................................................. 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 18 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 27 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 36 mg................................................................... 51
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sr 24hr 54 mg................................................................... 51
methylphenidate hcl soln 5 mg/5ml (Methylin).................. 51
methylphenidate hcl soln 10 mg/5ml (Methylin)................ 51
methylphenidate hcl tab cr 10 mg..................................... 51
methylphenidate hcl tab cr 20 mg (Ritalin sr).................... 51
methylphenidate hcl tab 5 mg (Ritalin).............................. 51
methylphenidate hcl tab 10 mg (Ritalin)............................ 51
methylphenidate hcl tab 20 mg (Ritalin)............................ 51
methylprednisolone tab 4 mg (Medrol).............................. 13
methylprednisolone tab 8 mg (Medrol).............................. 13
methylprednisolone tab 16 mg (Medrol)............................ 13
methylprednisolone tab 32 mg (Medrol)............................ 13
methyltestosterone cap 10 mg (Testred)........................... 13
METIPRANOLOL – metipranolol ophth soln 0.3%............78
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)............. 40
metoclopramide hcl tab 5 mg (Reglan)............................. 40
metoclopramide hcl tab 10 mg (Reglan)........................... 40
metolazone tab 10 mg....................................................... 29
metolazone tab 2.5 mg (Zaroxolyn)...................................29
metolazone tab 5 mg (Zaroxolyn)......................................29
metoprolol & hydrochlorothiazide tab 100-50 mg..............24
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..................................................................23
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..................................................................24
metoprolol succinate tab sr 24hr 25 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 50 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 100 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol succinate tab sr 24hr 200 mg (tartrate equiv)
(Toprol xl).......................................................................... 24
metoprolol tartrate tab 25 mg............................................ 24
metoprolol tartrate tab 50 mg (Lopressor).........................24
metoprolol tartrate tab 100 mg (Lopressor).......................24
metronidazole cap 375 mg (Flagyl)..................................... 9
metronidazole cream 0.75% (Metrocream)....................... 80
metronidazole gel 0.75%................................................... 80
metronidazole gel 1% (Metrogel).......................................80
metronidazole tab 250 mg (Flagyl)...................................... 9
metronidazole tab 500 mg (Flagyl)...................................... 9
metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 42
mexiletine hcl cap 150 mg................................................. 29
mexiletine hcl cap 200 mg................................................. 29
mexiletine hcl cap 250 mg................................................. 29
miconazole nitrate aerosol pow 2%...................................81
miconazole nitrate cream 2%............................................ 81
miconazole nitrate vaginal cream 2%................................42
midodrine hcl tab 2.5 mg................................................... 31
midodrine hcl tab 5 mg...................................................... 31
midodrine hcl tab 10 mg.................................................... 31
MIFEPREX – mifepristone tab 200 mg............................. 20
minocycline hcl cap 50 mg (Minocin).................................. 3
minocycline hcl cap 75 mg (Minocin).................................. 3
minocycline hcl cap 100 mg (Minocin)................................ 3
minocycline hcl tab 50 mg................................................... 3
minocycline hcl tab 75 mg................................................... 3
minocycline hcl tab 100 mg................................................. 3
minoxidil tab 2.5 mg........................................................... 31
minoxidil tab 10 mg............................................................ 31
MIRENA – levonorgestrel releasing iud 20 mcg/day (52
mg total)............................................................................ 15
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)................................................................................ 45
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)................................................................................ 45
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)................................................................................ 45
mirtazapine tab 7.5 mg...................................................... 45
mirtazapine tab 15 mg (Remeron).....................................45
mirtazapine tab 30 mg (Remeron).....................................45
mirtazapine tab 45 mg (Remeron).....................................45
misoprostol tab 100 mcg (Cytotec)....................................39
misoprostol tab 200 mcg (Cytotec)....................................39
modafinil tab 100 mg (Provigil).......................................... 51
modafinil tab 200 mg (Provigil).......................................... 51
moexipril hcl tab 7.5 mg (Univasc).................................... 21
moexipril hcl tab 15 mg (Univasc)..................................... 21
moexipril-hydrochlorothiazide tab 7.5-12.5 mg................. 21
moexipril-hydrochlorothiazide tab 15-25 mg..................... 22
105
2016
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)............................................................................ 21
mometasone furoate cream 0.1% (Elocon)....................... 83
mometasone furoate nasal susp 50 mcg/act
(Nasonex).......................................................................... 32
mometasone furoate oint 0.1% (Elocon)........................... 83
mometasone furoate solution 0.1% (lotion) (Elocon)........ 83
MONOCLATE-P – antihemophilic factor (human) for inj kit
250 unit............................................................................. 74
MONOCLATE-P – antihemophilic factor (human) for inj kit
1000 unit........................................................................... 74
MONOCLATE-P – antihemophilic factor (human) for inj kit
1500 unit........................................................................... 74
MONONINE – coagulation factor ix for inj 500 unit........... 74
MONONINE – coagulation factor ix for inj 1000 unit......... 74
montelukast sodium chew tab 4 mg (base equiv)
(Singulair).......................................................................... 36
montelukast sodium chew tab 5 mg (base equiv)
(Singulair).......................................................................... 36
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair).............................................................. 36
montelukast sodium tab 10 mg (base equiv)
(Singulair).......................................................................... 36
morphine sulfate cap sr 24hr 10 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 20 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 30 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 50 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 60 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 80 mg (Kadian)................... 56
morphine sulfate cap sr 24hr 100 mg (Kadian)................. 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 30 mg................................................................... 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 45 mg................................................................... 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 60 mg................................................................... 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 75 mg................................................................... 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 90 mg................................................................... 56
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 120 mg................................................................. 56
MORPHINE SULFATE – morphine sulfate suppos 5
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 10
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 20
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate suppos 30
mg...................................................................................... 56
MORPHINE SULFATE – morphine sulfate tab 15 mg...... 56
MORPHINE SULFATE – morphine sulfate tab 30 mg...... 56
morphine sulfate oral soln 10 mg/5ml............................... 56
morphine sulfate oral soln 20 mg/5ml............................... 56
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)........... 57
morphine sulfate tab cr 15 mg (Ms contin)........................57
106
morphine sulfate tab cr 30 mg (Ms contin)........................57
morphine sulfate tab cr 60 mg (Ms contin)........................57
morphine sulfate tab cr 100 mg (Ms contin)......................57
morphine sulfate tab cr 200 mg (Ms contin)......................57
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)......................................................................... 29
multiple vitamins w/ iron tab ............................................. 66
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite).............................................................................66
multiple vitamins w/ minerals cap...................................... 66
multiple vitamins w/ minerals chew tab............................. 66
multiple vitamins w/ minerals tab (Strovite forte)...............66
multiple vitamin tab ........................................................... 66
mupirocin oint 2% (Bactroban).......................................... 81
mycophenolate mofetil cap 250 mg (Cellcept).................. 85
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)........................................................................... 85
mycophenolate mofetil tab 500 mg (Cellcept)................... 85
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv) (Myfortic)................................................................ 85
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv) (Myfortic)................................................................ 85
MYLERAN – busulfan tab 2 mg........................................ 11
N
nabumetone tab 500 mg.................................................... 59
nabumetone tab 750 mg.................................................... 59
nadolol tab 20 mg (Corgard)............................................. 24
nadolol tab 40 mg (Corgard)............................................. 24
nadolol tab 80 mg (Corgard)............................................. 24
naftifine hcl cream 2% (Naftin).......................................... 81
naltrexone hcl tab 50 mg (Revia)...................................... 53
naproxen sodium tab 220 mg............................................ 59
naproxen sodium tab 275 mg (Anaprox)........................... 59
naproxen sodium tab 550 mg (Anaprox ds)...................... 59
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)......................................................................... 59
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)......................................................................... 59
naproxen susp 125 mg/5ml (Naprosyn)............................ 59
naproxen tab ec 375 mg (Ec-naprosyn)............................ 59
naproxen tab ec 500 mg (Ec-naprosyn)............................ 59
naproxen tab 250 mg (Naprosyn)......................................59
naproxen tab 375 mg (Naprosyn)......................................59
naproxen tab 500 mg (Naprosyn)......................................59
naratriptan hcl tab 1 mg (base equiv) (Amerge)............... 60
naratriptan hcl tab 2.5 mg (base equiv) (Amerge).............60
NARCAN – naloxone hcl nasal spray 4 mg/0.1ml.............85
NATACYN – natamycin ophth susp 5%............................ 77
nateglinide tab 60 mg (Starlix)...........................................17
nateglinide tab 120 mg (Starlix).........................................17
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11).............................................15
nefazodone hcl tab 50 mg................................................. 45
nefazodone hcl tab 250 mg............................................... 45
neomycin-bacitracin-polymyxin oint .................................. 81
2016
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin................................................................................ 77
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml (Neosporin)...................................................... 77
neomycin-polymyxin b gu irrigation soln (Neosporin gu
irrigan)............................................................................... 42
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)........................................................................... 78
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)........................................................................... 78
neomycin-polymyxin-hc otic soln 1% (Cortisporin)........... 79
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/
ml-1%................................................................................ 79
neomycin sulfate tab 500 mg.............................................. 3
NEOSTIGMINE METHYLSULFATE – neostigmine
methylsulfate inj 1 mg/ml................................................. 65
NEOSTIGMINE METHYLSULFATE – neostigmine
methylsulfate inj 0.5 mg/ml (1:2000)................................65
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 74
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/
ml)...................................................................................... 74
NEUPOGEN – filgrastim soln prefilled syringe 300
mcg/0.5ml.......................................................................... 74
NEUPOGEN – filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)...................................................74
nevirapine tab 200 mg (Viramune)...................................... 7
nevirapine tab sr 24hr 100 mg (Viramune xr)..................... 7
nevirapine tab sr 24hr 400 mg (Viramune xr)..................... 7
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 11
NEXPLANON – etonogestrel subdermal implant 68
mg...................................................................................... 15
niacin cap cr 250 mg......................................................... 66
niacin cap cr 500 mg......................................................... 66
niacin tab cr 250 mg.......................................................... 66
niacin tab cr 500 mg.......................................................... 66
niacin tab cr 750 mg.......................................................... 66
niacin tab 50 mg................................................................ 66
niacin tab 100 mg.............................................................. 66
niacin tab 500 mg.............................................................. 66
NIACIN TR – niacin tab cr 1000 mg................................. 66
nicardipine hcl cap 20 mg..................................................25
nicardipine hcl cap 30 mg..................................................25
nicotine polacrilex gum 2 mg............................................. 53
nicotine polacrilex gum 4 mg............................................. 53
nicotine td patch 24hr 7 mg/24hr.......................................53
nicotine td patch 24hr 14 mg/24hr.....................................53
nicotine td patch 24hr 21 mg/24hr.....................................53
nifedipine cap 20 mg..........................................................25
nifedipine cap 10 mg (Procardia)...................................... 25
nifedipine tab sr 24hr 30 mg (Adalat cc)........................... 25
nifedipine tab sr 24hr 60 mg (Adalat cc)........................... 25
nifedipine tab sr 24hr 90 mg (Adalat cc)........................... 26
nifedipine tab sr 24hr osmotic release 30 mg (Procardia
xl)....................................................................................... 26
nifedipine tab sr 24hr osmotic release 60 mg (Procardia
xl)....................................................................................... 26
nifedipine tab sr 24hr osmotic release 90 mg (Procardia
xl)....................................................................................... 26
nimodipine cap 30 mg........................................................26
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................... 41
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................... 41
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................... 41
nitrofurantoin monohydrate macrocrystalline cap 100 mg
(Macrobid)......................................................................... 41
nitrofurantoin susp 25 mg/5ml (Furadantin)...................... 41
nitroglycerin cap cr 2.5 mg................................................ 26
nitroglycerin cap cr 6.5 mg................................................ 26
nitroglycerin cap cr 9 mg................................................... 26
nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 26
nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 26
nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 27
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 27
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 27
NITROSTAT – nitroglycerin sl tab 0.3 mg......................... 27
NITROSTAT – nitroglycerin sl tab 0.4 mg......................... 27
NITROSTAT – nitroglycerin sl tab 0.6 mg......................... 27
nizatidine cap 150 mg........................................................ 39
nizatidine cap 300 mg (Axid)............................................. 39
NIZATIDINE – nizatidine oral soln 15 mg/ml..................... 39
NONOXYNOL-9 – various................................................. 42
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................... 14
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose).................................................... 14
norethindrone acetate tab 5 mg (Aygestin)....................... 14
nortriptyline hcl cap 10 mg (Pamelor)............................... 45
nortriptyline hcl cap 25 mg (Pamelor)............................... 45
nortriptyline hcl cap 50 mg (Pamelor)............................... 45
nortriptyline hcl cap 75 mg (Pamelor)............................... 45
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................... 45
NORVIR – ritonavir cap 100 mg.......................................... 7
NORVIR – ritonavir oral soln 80 mg/ml............................... 7
NORVIR – ritonavir tab 100 mg.......................................... 7
NOVOEIGHT – antihemophilic factor (recombinant) for inj
250 unit............................................................................. 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
500 unit............................................................................. 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
1000 unit........................................................................... 74
NOVOEIGHT – antihemophilic factor (recombinant) for inj
1500 unit........................................................................... 75
NOVOEIGHT – antihemophilic factor (recombinant) for inj
2000 unit........................................................................... 75
107
2016
NOVOEIGHT – antihemophilic factor (recombinant) for inj
3000 unit........................................................................... 75
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)...................................................... 18
NOVOLIN 70/30 RELION – insulin nph isophane &
regular human inj 100 unit/ml (70-30)............................. 18
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml....................................................................................... 18
NOVOLIN N RELION – insulin nph (human) (isophane) inj
100 unit/ml........................................................................ 18
NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 17
NOVOLIN R RELION – insulin regular (human) inj 100
unit/ml................................................................................ 17
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml........................................................................ 17
NOVOLOG – insulin aspart inj 100 unit/ml....................... 17
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 18
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)............................. 18
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml................................................................................ 17
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
1 mg (1000 mcg).............................................................. 75
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
2 mg (2000 mcg).............................................................. 75
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
5 mg (5000 mcg).............................................................. 75
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
8 mg (8000 mcg).............................................................. 75
NOXAFIL – posaconazole susp 40 mg/ml.......................... 4
NOXAFIL – posaconazole tab delayed release 100 mg..... 4
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg........................................................................... 53
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................ 15
NUWIQ – antihemophilic factor (recombinant) for inj kit
250 unit............................................................................. 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
500 unit............................................................................. 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
1000 unit........................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj kit
2000 unit........................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 250
unit..................................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 500
unit..................................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 1000
unit..................................................................................... 75
NUWIQ – antihemophilic factor (recombinant) for inj 2000
unit..................................................................................... 75
nystatin cream 100000 unit/gm......................................... 81
nystatin oint 100000 unit/gm..............................................81
nystatin oral powder............................................................. 4
nystatin susp 100000 unit/ml............................................. 79
108
nystatin tab 500000 unit...................................................... 4
nystatin topical powder ..................................................... 81
O
OBIZUR – antihemophilic factor (recomb porc) rpfviii for
inj 500 unit........................................................................ 75
OCEAN BLUE MINICAPS OMEGA – omega-3 fatty acids
cap 350 mg....................................................................... 68
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)..................................................................... 20
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)..................................................................... 20
ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg..................................................................... 7
ofloxacin ophth soln 0.3% (Ocuflox).................................. 77
ofloxacin otic soln 0.3%..................................................... 79
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................... 15
olanzapine for im inj 10 mg (Zyprexa)............................... 47
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)................................................................................. 47
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)................................................................................. 47
olanzapine tab 2.5 mg (Zyprexa).......................................47
olanzapine tab 5 mg (Zyprexa)..........................................47
olanzapine tab 7.5 mg (Zyprexa).......................................47
olanzapine tab 10 mg (Zyprexa)........................................47
olanzapine tab 15 mg (Zyprexa)........................................47
olanzapine tab 20 mg (Zyprexa)........................................47
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)............................................................................ 79
omega-3 fatty acids cap delayed release 1000 mg ......... 68
omega-3 fatty acids cap delayed release 1200 mg ......... 68
omega-3 fatty acids cap 500 mg ...................................... 68
omega-3 fatty acids cap 435 mg ...................................... 68
omega-3 fatty acids cap 1000 mg .................................... 68
omega-3 fatty acids cap 1200 mg .................................... 68
OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg..... 68
OMEGA-3 – omega-3 fatty acids cap 1400 mg................ 68
OMEGA-3 2100 – omega-3 fatty acids cap 1050 mg....... 68
OMEGA POWER – omega-3 fatty acids cap 1050 mg..... 68
omeprazole cap delayed release 10 mg (Prilosec)........... 39
omeprazole cap delayed release 20 mg (Prilosec)........... 39
omeprazole cap delayed release 40 mg (Prilosec)........... 39
OMNITROPE – somatropin for inj 5.8 mg......................... 19
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 19
2016
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 19
ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 39
ondansetron hcl tab 24 mg................................................ 39
ondansetron hcl tab 4 mg (Zofran).................................... 39
ondansetron hcl tab 8 mg (Zofran).................................... 39
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................... 39
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................... 39
opium tincture 1% (10 mg/ml) (morphine equiv)............... 38
OPSUMIT – macitentan tab 10 mg................................... 31
oral contraceptives – all generics...................................... 15
oral electrolyte solution ..................................................... 67
orphenadrine citrate tab sr 12hr 100 mg........................... 65
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................... 63
oxcarbazepine tab 150 mg (Trileptal)................................ 63
oxcarbazepine tab 300 mg (Trileptal)................................ 63
oxcarbazepine tab 600 mg (Trileptal)................................ 63
oxiconazole nitrate cream 1% (Oxistat).............................81
oxybutynin chloride syrup 5 mg/5ml.................................. 41
oxybutynin chloride tab 5 mg.............................................41
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)........... 41
oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..........41
oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..........41
OXYCODONE/ACETAMINOPHEN – oxycodone w/
acetaminophen soln 5-325 mg/5ml..................................57
OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab
5-400 mg........................................................................... 57
oxycodone-aspirin tab 4.8355-325 mg (Percodan)........... 57
OXYCODONE HCL............................................................ 57
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).................57
oxycodone hcl tab 10 mg.................................................. 57
oxycodone hcl tab 20 mg.................................................. 57
oxycodone hcl tab 5 mg (Roxicodone).............................. 57
oxycodone hcl tab 15 mg (Roxicodone)............................ 57
oxycodone hcl tab 30 mg (Roxicodone)............................ 57
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet).......................................................................... 57
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet).......................................................................... 57
oxymorphone hcl tab 5 mg (Opana)..................................57
oxymorphone hcl tab 10 mg (Opana)................................57
oxymorphone hcl tab sr 12hr 5 mg................................... 57
oxymorphone hcl tab sr 12hr 7.5 mg................................ 57
oxymorphone hcl tab sr 12hr 10 mg................................. 57
oxymorphone hcl tab sr 12hr 15 mg................................. 57
oxymorphone hcl tab sr 12hr 20 mg................................. 57
oxymorphone hcl tab sr 12hr 30 mg................................. 57
oxymorphone hcl tab sr 12hr 40 mg................................. 57
P
paliperidone tab sr 24hr 1.5 mg (Invega).......................... 47
paliperidone tab sr 24hr 3 mg (Invega)............................. 47
paliperidone tab sr 24hr 6 mg (Invega)............................. 47
paliperidone tab sr 24hr 9 mg (Invega)............................. 47
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................... 39
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................... 39
PARAGARD INTRAUTERINE COP – copper iud............. 15
paromomycin sulfate cap 250 mg....................................... 3
paroxetine hcl tab 10 mg (Paxil)........................................45
paroxetine hcl tab 20 mg (Paxil)........................................45
paroxetine hcl tab 30 mg (Paxil)........................................45
paroxetine hcl tab 40 mg (Paxil)........................................45
PEAK FLOW METER – various........................................ 84
PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml)........ 37
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml
........................................................................................... 66
pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
........................................................................................... 66
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
........................................................................................... 66
pediatric multiple vitamins w/ fluoride chew tab 1 mg ...... 67
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
........................................................................................... 67
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ...... 67
pediatric multiple vitamin w/ c & fa chew tab.................... 66
pediatric multiple vitamin w/ c soln 35 mg/ml ................... 66
pediatric multiple vitamin w/ minerals & c drops 45 mg/
ml....................................................................................... 66
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ........... 67
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ............. 67
pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml
........................................................................................... 67
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml..............5
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml.........5
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml............................................................................ 5
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml............................................................................ 5
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b
for inj kit 120 mcg/0.5ml..................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
50 mcg/0.5ml...................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
80 mcg/0.5ml...................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
120 mcg/0.5ml.................................................................... 5
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
150 mcg/0.5ml.................................................................... 5
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs).........................................................37
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................... 37
109
2016
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/
flavor pack)....................................................................... 37
penicillin v potassium for soln 125 mg/5ml......................... 1
penicillin v potassium for soln 250 mg/5ml......................... 1
penicillin v potassium tab 250 mg....................................... 1
penicillin v potassium tab 500 mg....................................... 1
pentoxifylline tab cr 400 mg...............................................75
perindopril erbumine tab 2 mg...........................................22
perindopril erbumine tab 4 mg (Aceon)............................. 22
perindopril erbumine tab 8 mg (Aceon)............................. 22
permethrin cream 5% (Elimite).......................................... 83
permethrin creme rinse 1%............................................... 83
permethrin lotion 1%.......................................................... 83
perphenazine tab 2 mg...................................................... 47
perphenazine tab 4 mg...................................................... 47
perphenazine tab 8 mg...................................................... 47
perphenazine tab 16 mg.................................................... 48
phenazopyridine hcl tab 100 mg (Pyridium)...................... 42
phenazopyridine hcl tab 200 mg (Pyridium)...................... 42
phenelzine sulfate tab 15 mg (Nardil)............................... 45
phenobarbital elixir 20 mg/5ml...........................................49
PHENOBARBITAL – phenobarbital tab 15 mg................. 49
PHENOBARBITAL – phenobarbital tab 30 mg................. 49
PHENOBARBITAL – phenobarbital tab 60 mg................. 49
PHENOBARBITAL – phenobarbital tab 100 mg............... 49
phenobarbital tab 16.2 mg................................................. 49
phenobarbital tab 32.4 mg................................................. 49
phenobarbital tab 64.8 mg................................................. 49
phenobarbital tab 97.2 mg................................................. 49
phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............31
phenylephrine-brompheniramine-dm elixir 2.5-1-5
mg/5ml............................................................................... 33
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)............................................................................... 33
phenylephrine-guaifenesin tab 10-400 mg........................ 33
phenylephrine hcl ophth soln 2.5%................................... 79
phenylephrine hcl ophth soln 10%.................................... 79
phenylephrine hcl tab 10 mg............................................. 32
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml............................................................................... 33
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml................. 33
phenytoin chew tab 50 mg (Dilantin infatabs)................... 63
phenytoin sodium extended cap 100 mg (Dilantin)........... 63
phenytoin sodium extended cap 200 mg (Phenytek)........ 63
phenytoin sodium extended cap 300 mg (Phenytek)........ 63
phenytoin susp 125 mg/5ml (Dilantin)............................... 63
pilocarpine hcl ophth soln 1% (Isopto carpine)................. 78
pilocarpine hcl ophth soln 2% (Isopto carpine)................. 78
pilocarpine hcl ophth soln 4% (Isopto carpine)................. 78
pilocarpine hcl tab 5 mg (Salagen)....................................79
pilocarpine hcl tab 7.5 mg (Salagen).................................79
pimozide tab 1 mg (Orap)..................................................53
pimozide tab 2 mg (Orap)..................................................53
pindolol tab 5 mg............................................................... 24
pindolol tab 10 mg............................................................. 24
pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 17
110
pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 17
pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 17
piroxicam cap 10 mg (Feldene)......................................... 59
piroxicam cap 20 mg (Feldene)......................................... 59
PLAN B ONE-STEP – levonorgestrel tab 1.5 mg............. 15
podofilox soln 0.5% (Condylox)......................................... 84
polyethylene glycol 3350 oral packet................................ 37
polyethylene glycol 3350 oral powder............................... 37
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
(Polytrim)........................................................................... 77
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......42
potassium bicarbonate effer tab 25 meq........................... 67
potassium chloride cap cr 8 meq (Micro-k)....................... 67
potassium chloride cap cr 10 meq (Micro-k)..................... 67
POTASSIUM CHLORIDE ER – potassium chloride tab cr
8 meq (600 mg)................................................................ 67
potassium chloride microencapsulated crys cr tab 10
meq....................................................................................67
potassium chloride microencapsulated crys cr tab 20
meq....................................................................................67
potassium chloride oral soln 10% (20 meq/15ml)............. 67
potassium chloride oral soln 20% (40 meq/15ml)............. 67
potassium chloride powder packet 20 meq....................... 67
potassium chloride tab cr 10 meq (K-tab)......................... 68
potassium chloride tab cr 8 meq (600 mg)........................68
potassium citrate & citric acid powder pack 3300-1002
mg...................................................................................... 42
potassium citrate & citric acid soln 1100-334 mg/5ml....... 42
potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)........ 42
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)..................................................................................... 42
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15)..................................................................................... 42
pot bicarbonate & chloride effer tab 25 meq..................... 67
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)..................................... 67
PRALUENT – alirocumab subcutaneous soln pen-injector
75 mg/ml........................................................................... 28
PRALUENT – alirocumab subcutaneous soln pen-injector
150 mg/ml......................................................................... 28
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 75 mg/ml.............................................................. 28
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 150 mg/ml............................................................ 28
pramipexole dihydrochloride tab 0.125 mg (Mirapex)....... 64
pramipexole dihydrochloride tab 0.25 mg (Mirapex)......... 64
pramipexole dihydrochloride tab 0.5 mg (Mirapex)........... 64
pramipexole dihydrochloride tab 0.75 mg (Mirapex)......... 64
pramipexole dihydrochloride tab 1 mg (Mirapex).............. 64
pramipexole dihydrochloride tab 1.5 mg (Mirapex)........... 64
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er)...................................................................... 64
pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex
er)...................................................................................... 64
pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex
er)...................................................................................... 64
2016
pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex
er)...................................................................................... 64
pravastatin sodium tab 10 mg........................................... 28
pravastatin sodium tab 20 mg (Pravachol)........................28
pravastatin sodium tab 40 mg (Pravachol)........................28
pravastatin sodium tab 80 mg (Pravachol)........................28
prazosin hcl cap 1 mg (Minipress).................................... 31
prazosin hcl cap 2 mg (Minipress).................................... 31
prazosin hcl cap 5 mg (Minipress).................................... 31
prednicarbate cream 0.1% (Dermatop)............................. 83
prednicarbate oint 0.1% (Dermatop)................................. 83
prednisolone acetate ophth susp 1% (Pred forte)............. 78
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 78
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv)................................................................................. 13
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)............................................................. 13
prednisolone syrup 15 mg/5ml (usp solution equivalent)
(Prelone)............................................................................13
PREDNISONE – prednisone oral soln 5 mg/5ml.............. 13
PREDNISONE – prednisone tab 50 mg............................13
prednisone tab 1 mg.......................................................... 13
prednisone tab 2.5 mg....................................................... 13
prednisone tab 5 mg.......................................................... 13
prednisone tab 10 mg........................................................ 13
prednisone tab 20 mg........................................................ 13
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg..................................................... 14
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................... 14
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................... 14
PREZCOBIX – darunavir-cobicistat tab 800-150 mg.......... 7
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 75 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 600 mg (base
equiv)................................................................................... 7
PREZISTA – darunavir ethanolate tab 800 mg (base
equiv)................................................................................... 7
PRIFTIN – rifapentine tab 150 mg...................................... 4
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg............................................................................... 9
primidone tab 50 mg (Mysoline)........................................ 63
primidone tab 250 mg (Mysoline)...................................... 63
probenecid tab 500 mg...................................................... 60
prochlorperazine maleate tab 5 mg (Compazine)............. 39
prochlorperazine maleate tab 10 mg (Compazine)........... 39
prochlorperazine suppos 25 mg........................................ 39
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 75
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 75
PROCRIT – epoetin alfa inj 20000 unit/ml........................ 75
PROCRIT – epoetin alfa inj 40000 unit/ml........................ 75
PROFILNINE – factor ix complex for inj 500 unit.............. 75
PROFILNINE – factor ix complex for inj 1000 unit............ 75
PROFILNINE – factor ix complex for inj 1500 unit............ 75
PROFILNINE SD – factor ix complex for inj 500 unit........ 75
PROFILNINE SD – factor ix complex for inj 1000 unit...... 76
PROFILNINE SD – factor ix complex for inj 1500 unit...... 76
progesterone im in oil 50 mg/ml........................................ 14
progesterone micronized cap 100 mg (Prometrium)......... 15
progesterone micronized cap 200 mg (Prometrium)......... 15
PROLIA – denosumab inj 60 mg/ml.................................. 20
promethazine & phenylephrine syrup 6.25-5 mg/5ml........33
promethazine-dm syrup 6.25-15 mg/5ml...........................33
promethazine hcl suppos 12.5 mg.................................... 32
promethazine hcl suppos 25 mg....................................... 32
promethazine hcl suppos 50 mg....................................... 32
promethazine hcl syrup 6.25 mg/5ml................................ 32
promethazine hcl tab 12.5 mg........................................... 32
promethazine hcl tab 25 mg.............................................. 32
promethazine hcl tab 50 mg.............................................. 32
promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 33
PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap
delayed release 332.5 mg............................................... 68
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)............ 30
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)............ 30
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)............ 30
propafenone hcl tab 300 mg..............................................30
propafenone hcl tab 150 mg (Rythmol)............................. 30
propafenone hcl tab 225 mg (Rythmol)............................. 30
proparacaine hcl ophth soln 0.5% (Alcaine)......................79
PROPRANOLOL/HYDROCHLOROTH – propranolol &
hydrochlorothiazide tab 40-25 mg................................... 24
propranolol hcl cap sr 24hr 60 mg (Inderal la).................. 24
propranolol hcl cap sr 24hr 80 mg (Inderal la).................. 24
propranolol hcl cap sr 24hr 120 mg (Inderal la)................ 24
propranolol hcl cap sr 24hr 160 mg (Inderal la)................ 24
propranolol hcl tab 10 mg.................................................. 24
propranolol hcl tab 20 mg.................................................. 24
propranolol hcl tab 40 mg.................................................. 24
propranolol hcl tab 60 mg.................................................. 24
propranolol hcl tab 80 mg.................................................. 24
propylthiouracil tab 50 mg................................................. 19
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).............................................................. 33
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml......... 34
psyllium powder 28.3%...................................................... 37
psyllium powder 30%......................................................... 37
psyllium powder 30.9%...................................................... 37
psyllium powder 33%......................................................... 37
psyllium powder 48.57%.................................................... 37
psyllium powder 49%......................................................... 37
psyllium powder 58.6%...................................................... 37
psyllium powder 95%......................................................... 37
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............37
111
2016
pyrazinamide tab 500 mg.................................................... 4
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)...........................................................................65
pyridostigmine bromide tab 60 mg (Mestinon).................. 65
Q
QC CALAMINE – calamine lotion......................................84
quetiapine fumarate tab 25 mg (Seroquel)........................48
quetiapine fumarate tab 50 mg (Seroquel)........................48
quetiapine fumarate tab 100 mg (Seroquel)......................48
quetiapine fumarate tab 200 mg (Seroquel)......................48
quetiapine fumarate tab 300 mg (Seroquel)......................48
quetiapine fumarate tab 400 mg (Seroquel)......................48
quinapril hcl tab 5 mg (Accupril)........................................ 22
quinapril hcl tab 10 mg (Accupril)...................................... 22
quinapril hcl tab 20 mg (Accupril)...................................... 22
quinapril hcl tab 40 mg (Accupril)...................................... 22
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)......................................................................... 22
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)......................................................................... 22
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)......................................................................... 22
quinidine gluconate tab cr 324 mg.................................... 30
QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 30
QUINIDINE SULFATE – quinidine sulfate tab 300 mg...... 30
quinine sulfate cap 324 mg (Qualaquin)............................. 9
QVAR – beclomethasone diprop inhal aero soln 40 mcg/
act (50/valve).................................................................... 36
QVAR – beclomethasone diprop inhal aero soln 80 mcg/
act (100/valve).................................................................. 36
R
rabeprazole sodium ec tab 20 mg (Aciphex).................... 39
raloxifene hcl tab 60 mg (Evista)....................................... 20
ramipril cap 1.25 mg (Altace)............................................ 22
ramipril cap 2.5 mg (Altace).............................................. 22
ramipril cap 5 mg (Altace)................................................. 22
ramipril cap 10 mg (Altace)............................................... 22
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 39
ranitidine hcl tab 75 mg..................................................... 39
ranitidine hcl tab 150 mg (Zantac).....................................39
ranitidine hcl tab 300 mg (Zantac).....................................39
REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml).......................................................................... 52
REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml).......................................................................... 52
REBIF REBIDOSE – interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)........................................................ 52
REBIF REBIDOSE – interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)........................................................ 52
REBIF REBIDOSE TITRATION – interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 52
REBIF TITRATION PACK – interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................ 52
112
RECOMBINATE – antihemophilic factor (recombinant) for
inj 220-400 unit................................................................. 76
RECOMBINATE – antihemophilic factor (recombinant) for
inj 401-800 unit................................................................. 76
RECOMBINATE – antihemophilic factor (recombinant) for
inj 801-1240 unit............................................................... 76
RECOMBINATE – antihemophilic factor (recombinant) for
inj 1241-1800 unit............................................................. 76
RECOMBINATE – antihemophilic factor (recombinant) for
inj 1801-2400 unit............................................................. 76
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister......................................................... 8
RELHIST BP – brompheniramine & phenylephrine tab
4-10 mg............................................................................. 34
RELHIST – bromphen tan-phenyleph tan chew tab 6-15
mg...................................................................................... 34
RENAGEL – sevelamer hcl tab 400 mg............................ 41
RENAGEL – sevelamer hcl tab 800 mg............................ 41
repaglinide tab 0.5 mg (Prandin)....................................... 17
repaglinide tab 1 mg (Prandin).......................................... 17
repaglinide tab 2 mg (Prandin).......................................... 17
REPATHA – evolocumab subcutaneous soln prefilled
syringe 140 mg/ml............................................................ 28
REPATHA SURECLICK – evolocumab subcutaneous soln
auto-injector 140 mg/ml....................................................28
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 7
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 7
RESPIRATORY THERAPY SUPPLIES – various............. 84
REVLIMID – lenalidomide cap 5 mg................................. 85
REVLIMID – lenalidomide cap 10 mg............................... 85
REVLIMID – lenalidomide cap 15 mg............................... 85
REVLIMID – lenalidomide cap 20 mg............................... 85
REVLIMID – lenalidomide cap 25 mg............................... 85
REVLIMID – lenalidomide caps 2.5 mg............................ 85
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate cap 200 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate cap 300 mg (base
equiv)................................................................................... 7
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv)........................................................................ 7
ribavirin cap 200 mg (Rebetol)............................................ 5
ribavirin tab 200 mg (Copegus)........................................... 5
rifabutin cap 150 mg (Mycobutin)........................................ 4
rifampin cap 150 mg (Rifadin)............................................. 4
rifampin cap 300 mg (Rifadin)............................................. 4
riluzole tab 50 mg (Rilutek)................................................65
ringer's solution for irrigation..............................................85
risperidone orally disintegrating tab 0.25 mg.................... 48
risperidone orally disintegrating tab 0.5 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 1 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 2 mg (Risperdal mtab).................................................................................... 48
2016
risperidone orally disintegrating tab 3 mg (Risperdal mtab).................................................................................... 48
risperidone orally disintegrating tab 4 mg (Risperdal mtab).................................................................................... 48
risperidone soln 1 mg/ml (Risperdal).................................48
risperidone tab 0.25 mg (Risperdal).................................. 48
risperidone tab 0.5 mg (Risperdal).................................... 48
risperidone tab 1 mg (Risperdal)....................................... 48
risperidone tab 2 mg (Risperdal)....................................... 48
risperidone tab 3 mg (Risperdal)....................................... 48
risperidone tab 4 mg (Risperdal)....................................... 48
rivastigmine tartrate cap 1.5 mg (Exelon)......................... 53
rivastigmine tartrate cap 3 mg (Exelon)............................ 53
rivastigmine tartrate cap 4.5 mg (Exelon)......................... 53
rivastigmine tartrate cap 6 mg (Exelon)............................ 53
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon).............. 53
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon).............. 53
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)............ 53
RIXUBIS – coagulation factor ix (recombinant) for inj 250
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 500
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 1000
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 2000
unit..................................................................................... 76
RIXUBIS – coagulation factor ix (recombinant) for inj 3000
unit..................................................................................... 76
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
(Maxalt-mlt)....................................................................... 60
rizatriptan benzoate oral disintegrating tab 10 mg (base
eq) (Maxalt-mlt).................................................................60
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)............................................................................. 60
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)............................................................................. 60
ropinirole hydrochloride tab 0.25 mg (Requip).................. 64
ropinirole hydrochloride tab 0.5 mg (Requip).................... 64
ropinirole hydrochloride tab 1 mg (Requip)....................... 64
ropinirole hydrochloride tab 2 mg (Requip)....................... 64
ropinirole hydrochloride tab 3 mg (Requip)....................... 64
ropinirole hydrochloride tab 4 mg (Requip)....................... 64
ropinirole hydrochloride tab 5 mg (Requip)....................... 65
rosuvastatin calcium tab 5 mg (Crestor)........................... 28
rosuvastatin calcium tab 10 mg (Crestor)......................... 28
rosuvastatin calcium tab 20 mg (Crestor)......................... 28
rosuvastatin calcium tab 40 mg (Crestor)......................... 28
RU-HIST D – brompheniramine & phenylephrine tab 4-10
mg...................................................................................... 34
S
saline nasal spray 0.65%................................................... 32
salsalate tab 500 mg..........................................................54
salsalate tab 750 mg..........................................................54
selegiline hcl cap 5 mg (Eldepryl)..................................... 65
selegiline hcl tab 5 mg....................................................... 65
selenium sulfide lotion 2.5%.............................................. 84
selenium sulfide-pyrithione zinc in urea shampoo
2.25%................................................................................ 84
SELZENTRY – maraviroc tab 150 mg................................ 7
SELZENTRY – maraviroc tab 300 mg................................ 7
sennosides tab 8.6 mg...................................................... 37
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 20
SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)......... 20
SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)......... 20
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)............................................... 36
sertraline hcl oral conc 20 mg/ml (Zoloft).......................... 45
sertraline hcl tab 25 mg (Zoloft)........................................ 45
sertraline hcl tab 50 mg (Zoloft)........................................ 45
sertraline hcl tab 100 mg (Zoloft)...................................... 45
sildenafil citrate tab 20 mg (Revatio)................................. 31
silver sulfadiazine cream 1% (Silvadene)......................... 81
simethicone chew tab 80 mg............................................. 41
simethicone susp 40 mg/0.6ml.......................................... 41
simvastatin tab 5 mg (Zocor)............................................. 28
simvastatin tab 10 mg (Zocor)........................................... 28
simvastatin tab 20 mg (Zocor)........................................... 28
simvastatin tab 40 mg (Zocor)........................................... 28
simvastatin tab 80 mg (Zocor)........................................... 28
sirolimus tab 0.5 mg (Rapamune)..................................... 85
sirolimus tab 1 mg (Rapamune)........................................ 85
sirolimus tab 2 mg (Rapamune)........................................ 85
SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5
mg total)............................................................................ 15
SM CALAMINE – calamine lotion......................................84
sodium chloride irrigation soln 0.9%..................................42
sodium chloride soln nebu 0.9%....................................... 34
sodium chloride soln nebu 3%.......................................... 34
sodium chloride soln nebu 10%........................................ 34
sodium chloride soln nebu 7% (Hyper-sal)....................... 34
sodium citrate & citric acid soln 500-334 mg/5ml (Shohls
solution modi)................................................................... 42
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).............................................................................. 68
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).............................................................................. 68
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).............................................................................. 68
sodium fluoride cream 1.1% (Prevident 5000 plus).......... 79
sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)...... 79
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................... 68
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................... 68
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).............................................................................. 68
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).................................................................................. 85
sodium polystyrene sulfonate powder (Kayexalate)..........85
sodium polystyrene sulfonate rectal susp 30
gm/120ml...........................................................................85
113
2016
sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 30
sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 30
sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 30
sotalol hcl tab 240 mg....................................................... 30
sotalol hcl tab 80 mg (Betapace).......................................30
sotalol hcl tab 120 mg (Betapace).....................................30
sotalol hcl tab 160 mg (Betapace).....................................30
SOVALDI – sofosbuvir tab 400 mg..................................... 5
SPACER/AEROSOL-HOLDING CHAMBERS –
various............................................................................... 84
SPACER/AEROSOL-HOLDING CHAMBERS –
VARIOUS.......................................................................... 84
speciality vitamin product tab............................................ 67
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv).................. 36
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................... 36
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)..................................................................... 29
spironolactone tab 25 mg (Aldactone)...............................29
spironolactone tab 50 mg (Aldactone)...............................29
spironolactone tab 100 mg (Aldactone)............................ 29
SPRYCEL – dasatinib tab 20 mg...................................... 11
SPRYCEL – dasatinib tab 50 mg...................................... 11
SPRYCEL – dasatinib tab 70 mg...................................... 11
SPRYCEL – dasatinib tab 80 mg...................................... 11
SPRYCEL – dasatinib tab 100 mg.................................... 11
SPRYCEL – dasatinib tab 140 mg.................................... 11
stavudine cap 15 mg (Zerit).................................................7
stavudine cap 20 mg (Zerit).................................................7
stavudine cap 30 mg (Zerit).................................................7
stavudine cap 40 mg (Zerit).................................................7
stavudine for oral soln 1 mg/ml (Zerit)................................ 7
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml....................................................................................... 20
STIVARGA – regorafenib tab 40 mg................................. 11
STRATTERA – atomoxetine hcl cap 10 mg (base
equiv)................................................................................. 51
STRATTERA – atomoxetine hcl cap 18 mg (base
equiv)................................................................................. 51
STRATTERA – atomoxetine hcl cap 25 mg (base
equiv)................................................................................. 51
STRATTERA – atomoxetine hcl cap 40 mg (base
equiv)................................................................................. 51
STRATTERA – atomoxetine hcl cap 60 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 80 mg (base
equiv)................................................................................. 52
STRATTERA – atomoxetine hcl cap 100 mg (base
equiv)................................................................................. 52
STRENSIQ – asfotase alfa subcutaneous inj 18
mg/0.45ml......................................................................... 20
STRENSIQ – asfotase alfa subcutaneous inj 28
mg/0.7ml............................................................................20
STRENSIQ – asfotase alfa subcutaneous inj 40 mg/
ml....................................................................................... 20
114
STRENSIQ – asfotase alfa subcutaneous inj 80
mg/0.8ml............................................................................20
STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg.......................................................... 8
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)...................................................... 57
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)................................................................57
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)................................................................57
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
12-3 mg (base equiv)....................................................... 57
sucralfate tab 1 gm (Carafate)...........................................39
sulfacetamide sodium lotion 10% (acne) (Klaron).............80
sulfacetamide sodium ophth soln 10% (Bleph-10)............ 77
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................. 78
sulfacetamide sodium w/ sulfur emulsion 10-1%.............. 80
sulfacetamide sodium w/ sulfur emulsion 10-5%.............. 80
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml......... 9
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim).............................................................................. 9
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim
ds)........................................................................................ 9
sulfasalazine tab delayed release 500 mg (Azulfidine entabs)...................................................................................41
sulfasalazine tab 500 mg (Azulfidine)................................41
sulindac tab 150 mg...........................................................60
sulindac tab 200 mg...........................................................60
sumatriptan nasal spray 5 mg/act (Imitrex)....................... 60
sumatriptan nasal spray 20 mg/act (Imitrex)..................... 60
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................60
sumatriptan succinate solution auto-injector 4 mg/0.5ml
(Imitrex statdose sys)....................................................... 60
sumatriptan succinate solution auto-injector 6 mg/0.5ml
(Imitrex statdose sys)....................................................... 60
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)........................................................ 60
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)........................................................ 60
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................... 60
sumatriptan succinate tab 25 mg (Imitrex)........................ 60
sumatriptan succinate tab 50 mg (Imitrex)........................ 60
sumatriptan succinate tab 100 mg (Imitrex)...................... 60
SUPRAX – cefixime cap 400 mg........................................ 2
SUPRAX – cefixime chew tab 100 mg................................ 2
SUPRAX – cefixime chew tab 200 mg................................ 2
SUPRAX – cefixime for susp 100 mg/5ml.......................... 2
SUPRAX – cefixime for susp 200 mg/5ml.......................... 2
SUPRAX – cefixime for susp 500 mg/5ml.......................... 2
SUSTIVA – efavirenz cap 50 mg......................................... 8
SUSTIVA – efavirenz cap 200 mg....................................... 8
SUSTIVA – efavirenz tab 600 mg....................................... 8
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 12
2016
SUTENT – sunitinib malate cap 25 mg (base
equivalent)......................................................................... 12
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 12
SUTENT – sunitinib malate cap 50 mg (base
equivalent)......................................................................... 12
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.....................................................36
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act...................................................36
SYNAGIS – palivizumab im soln 50 mg/0.5ml.................. 10
SYNAGIS – palivizumab im soln 100 mg/ml..................... 10
T
tacrolimus cap 0.5 mg (Prograf)........................................ 85
tacrolimus cap 1 mg (Prograf)........................................... 85
tacrolimus cap 5 mg (Prograf)........................................... 85
tacrolimus oint 0.03% (Protopic)........................................84
tacrolimus oint 0.1% (Protopic)..........................................84
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)................................................................................... 9
TAMIFLU – oseltamivir phosphate cap 45 mg (base
equiv)................................................................................... 9
TAMIFLU – oseltamivir phosphate cap 75 mg (base
equiv)................................................................................... 9
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................... 9
tamoxifen citrate tab 10 mg (base equivalent).................. 12
tamoxifen citrate tab 20 mg (base equivalent).................. 12
tamsulosin hcl cap 0.4 mg (Flomax)................................. 42
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 12
TARCEVA – erlotinib hcl tab 100 mg (base
equivalent)......................................................................... 12
TARCEVA – erlotinib hcl tab 150 mg (base
equivalent)......................................................................... 12
TASIGNA – nilotinib hcl cap 150 mg (base
equivalent)......................................................................... 12
TASIGNA – nilotinib hcl cap 200 mg (base
equivalent)......................................................................... 12
TAZORAC – tazarotene cream 0.05%.............................. 80
TAZORAC – tazarotene cream 0.1%................................ 80
TAZORAC – tazarotene gel 0.05%................................... 80
TAZORAC – tazarotene gel 0.1%..................................... 80
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................. 52
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................. 52
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 52
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 63
temazepam cap 15 mg (Restoril)...................................... 49
temazepam cap 30 mg (Restoril)...................................... 49
temozolomide cap 5 mg (Temodar)................................... 12
temozolomide cap 20 mg (Temodar)................................. 12
temozolomide cap 100 mg (Temodar)............................... 12
temozolomide cap 140 mg (Temodar)............................... 12
temozolomide cap 180 mg (Temodar)............................... 12
temozolomide cap 250 mg (Temodar)............................... 12
terazosin hcl cap 1 mg...................................................... 31
terazosin hcl cap 2 mg...................................................... 31
terazosin hcl cap 5 mg...................................................... 31
terazosin hcl cap 10 mg.................................................... 31
terbinafine hcl tab 250 mg (Lamisil).................................... 4
terbutaline sulfate tab 2.5 mg............................................ 36
terbutaline sulfate tab 5 mg............................................... 36
terconazole vaginal cream 0.4% (Terazol 7)..................... 42
terconazole vaginal cream 0.8% (Terazol 3)..................... 42
terconazole vaginal suppos 80 mg.................................... 42
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)..................................................................... 13
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)..................................................................... 13
testosterone enanthate im inj in oil 200 mg/ml.................. 13
testosterone td gel 12.5 mg/act (1%) (Androgel
pump)................................................................................ 13
testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 13
testosterone td gel 50 mg/5gm (1%) (Androgel)............... 13
TEST STRIPS - BAYER ASCENSIA................................. 84
tetrabenazine tab 12.5 mg (Xenazine).............................. 53
tetrabenazine tab 25 mg (Xenazine)................................. 53
tetracaine hcl ophth soln 0.5%.......................................... 79
tetracycline hcl cap 250 mg (Tetracycline hcl).................... 3
tetracycline hcl cap 500 mg (Tetracycline hcl).................... 3
tetrahydroz-dextran-peg-povidone ophth soln
0.05-0.1-1-1%................................................................... 79
THALOMID – thalidomide cap 50 mg............................... 85
THALOMID – thalidomide cap 100 mg............................. 85
THALOMID – thalidomide cap 150 mg............................. 85
theophylline soln 80 mg/15ml............................................ 36
theophylline tab sr 12hr 100 mg........................................ 36
theophylline tab sr 12hr 200 mg........................................ 36
theophylline tab sr 12hr 300 mg........................................ 36
theophylline tab sr 12hr 450 mg........................................ 36
theophylline tab sr 24hr 400 mg........................................ 36
theophylline tab sr 24hr 600 mg........................................ 36
thiamine hcl tab 50 mg...................................................... 66
thiamine hcl tab 100 mg.................................................... 66
thioridazine hcl tab 10 mg................................................. 48
thioridazine hcl tab 25 mg................................................. 48
thioridazine hcl tab 50 mg................................................. 48
thioridazine hcl tab 100 mg............................................... 48
thiothixene cap 1 mg..........................................................48
thiothixene cap 2 mg..........................................................48
thiothixene cap 5 mg..........................................................48
thiothixene cap 10 mg........................................................48
thyroid tab 30 mg (1/2 grain) (Armour thyroid).................. 19
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)............... 19
thyroid tab 60 mg (1 grain) (Armour thyroid)..................... 19
tiagabine hcl tab 2 mg (Gabitril)........................................ 63
tiagabine hcl tab 4 mg (Gabitril)........................................ 63
timolol maleate ophth gel forming soln 0.25% (Timopticxe)...................................................................................... 78
115
2016
timolol maleate ophth gel forming soln 0.5% (Timopticxe)...................................................................................... 78
timolol maleate ophth soln 0.25% (Timoptic).................... 78
timolol maleate ophth soln 0.5% (Timoptic)...................... 78
tioconazole vaginal oint 6.5%............................................ 42
TIVICAY – dolutegravir sodium tab 10 mg (base equiv)..... 8
TIVICAY – dolutegravir sodium tab 25 mg (base equiv)..... 8
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 8
tizanidine hcl tab 2 mg....................................................... 65
tizanidine hcl tab 4 mg (Zanaflex)..................................... 65
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)......................................................................... 78
tobramycin nebu soln 300 mg/5ml (Tobi)............................ 3
tobramycin ophth soln 0.3% (Tobrex)................................ 77
TOBRAMYCIN SULFATE – tobramycin sulfate inj 2
gm/50ml (40 mg/ml) (base equiv)...................................... 3
TOBRAMYCIN SULFATE – tobramycin sulfate inj 10 mg/
ml (base equivalent)........................................................... 3
TOLAZAMIDE – tolazamide tab 250 mg........................... 17
tolcapone tab 100 mg (Tasmar)........................................ 65
tolnaftate aerosol 1%......................................................... 81
tolterodine tartrate tab 1 mg (Detrol)................................. 41
tolterodine tartrate tab 2 mg (Detrol)................................. 41
topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 63
topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 63
topiramate tab 25 mg (Topamax)...................................... 63
topiramate tab 50 mg (Topamax)...................................... 63
topiramate tab 100 mg (Topamax).................................... 63
topiramate tab 200 mg (Topamax).................................... 63
torsemide tab 5 mg (Demadex)......................................... 29
torsemide tab 10 mg (Demadex)....................................... 29
torsemide tab 20 mg (Demadex)....................................... 29
torsemide tab 100 mg (Demadex)..................................... 29
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml........................................................................ 18
TRACLEER – bosentan tab 62.5 mg................................ 31
TRACLEER – bosentan tab 125 mg................................. 31
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 58
tramadol hcl tab 50 mg (Ultram)........................................58
trandolapril tab 1 mg (Mavik)............................................. 22
trandolapril tab 2 mg (Mavik)............................................. 22
trandolapril tab 4 mg (Mavik)............................................. 22
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)........... 26
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)........... 26
tranexamic acid tab 650 mg (Lysteda).............................. 76
tranylcypromine sulfate tab 10 mg (Parnate).................... 45
trazodone hcl tab 50 mg.................................................... 45
trazodone hcl tab 100 mg.................................................. 45
trazodone hcl tab 150 mg.................................................. 45
tretinoin cap 10 mg............................................................ 12
tretinoin cream 0.025% (Retin-a).......................................80
tretinoin cream 0.05% (Retin-a).........................................80
tretinoin cream 0.1% (Retin-a)...........................................81
tretinoin gel 0.05% (Atralin)............................................... 81
116
tretinoin gel 0.01% (Retin-a).............................................. 81
tretinoin gel 0.025% (Retin-a)............................................ 81
tretinoin microsphere gel 0.04% (Retin-a micro)............... 81
tretinoin microsphere gel 0.1% (Retin-a micro)................. 81
TRETTEN – coagulation factor xiii a-subunit for inj
2000-3125 unit.................................................................. 76
triamcinolone acetonide cream 0.025%............................ 83
triamcinolone acetonide cream 0.1%................................ 83
triamcinolone acetonide cream 0.5%................................ 83
triamcinolone acetonide dental paste 0.1%...................... 80
triamcinolone acetonide lotion 0.025%.............................. 83
triamcinolone acetonide lotion 0.1%.................................. 83
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)...................................................... 32
triamcinolone acetonide oint 0.025%................................ 83
triamcinolone acetonide oint 0.1%.....................................83
TRIAMINIC COLD/COUGH NIGH – diphenhydraminephenylephrine oral strip 12.5-5 mg.................................. 34
TRIAMINIC COLD & ALLERGY – brompheniramine &
phenylephrine syrup 1-2.5 mg/5ml.................................. 34
TRIAMINIC COLD & ALLERGY – chlorpheniramine &
phenylephrine syrup 1-2.5 mg/5ml.................................. 34
TRIAMINIC NIGHT TIME COLD – diphenhydraminephenylephrine syrup 6.25-2.5 mg/5ml............................. 34
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg...................................29
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)........................................................................... 29
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)..................................................................... 29
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)...........................................................................29
trifluoperazine hcl tab 1 mg............................................... 48
trifluoperazine hcl tab 2 mg............................................... 48
trifluoperazine hcl tab 5 mg............................................... 48
trifluoperazine hcl tab 10 mg............................................. 48
trifluridine ophth soln 1% (Viroptic)....................................77
trihexyphenidyl hcl elixir 0.4 mg/ml....................................65
trihexyphenidyl hcl tab 2 mg.............................................. 65
trihexyphenidyl hcl tab 5 mg.............................................. 65
trimethobenzamide hcl cap 300 mg (Tigan)...................... 39
trimethoprim tab 100 mg.................................................... 10
trimipramine maleate cap 25 mg (Surmontil).................... 45
trimipramine maleate cap 50 mg (Surmontil).................... 45
trimipramine maleate cap 100 mg (Surmontil).................. 45
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................... 8
TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400
unit-35 mg/ml.................................................................... 67
TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd
fluoride & fe drops 0.25-10 mg/ml................................... 67
trospium chloride cap sr 24hr 60 mg.................................41
trospium chloride tab 20 mg.............................................. 41
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 100-150 mg.................................................................. 8
2016
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 133-200 mg.................................................................. 8
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 167-250 mg.................................................................. 8
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg.................................................................. 8
U
UPTRAVI – selexipag tab 200 mcg................................... 31
UPTRAVI – selexipag tab 400 mcg................................... 31
UPTRAVI – selexipag tab 600 mcg................................... 31
UPTRAVI – selexipag tab 800 mcg................................... 31
UPTRAVI – selexipag tab 1000 mcg................................. 31
UPTRAVI – selexipag tab 1200 mcg................................. 31
UPTRAVI – selexipag tab 1400 mcg................................. 31
UPTRAVI – selexipag tab 1600 mcg................................. 31
UPTRAVI – selexipag tab therapy pack 200 mcg (140) &
800 mcg (60).................................................................... 31
ursodiol cap 300 mg (Actigall)........................................... 41
ursodiol tab 250 mg (Urso 250).........................................41
ursodiol tab 500 mg (Urso forte)....................................... 41
V
VAGIFEM – estradiol vaginal tab 10 mcg......................... 42
valacyclovir hcl tab 1 gm (Valtrex).......................................5
valacyclovir hcl tab 500 mg (Valtrex)...................................5
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)......................................................................... 84
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................... 4
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte).............................................................................. 4
valganciclovir hcl tab 450 mg (Valcyte)............................... 4
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)....................................................................... 63
valproic acid cap 250 mg (Depakene)...............................63
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan
hct).....................................................................................23
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).....................................................................................23
valsartan tab 40 mg (Diovan)............................................ 23
valsartan tab 80 mg (Diovan)............................................ 23
valsartan tab 160 mg (Diovan).......................................... 23
valsartan tab 320 mg (Diovan).......................................... 23
vancomycin hcl cap 125 mg (Vancocin hcl)...................... 10
vancomycin hcl cap 250 mg (Vancocin hcl)...................... 10
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)........................................................................ 46
venlafaxine hcl tab 25 mg..................................................46
venlafaxine hcl tab 37.5 mg...............................................46
venlafaxine hcl tab 50 mg..................................................46
venlafaxine hcl tab 75 mg..................................................46
venlafaxine hcl tab 100 mg................................................46
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 36
verapamil hcl cap sr 24hr 120 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 180 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 240 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 360 mg (Verelan)..................... 26
verapamil hcl cap sr 24hr 100 mg (Verelan pm)............... 26
verapamil hcl cap sr 24hr 200 mg (Verelan pm)............... 26
verapamil hcl cap sr 24hr 300 mg (Verelan pm)............... 26
verapamil hcl tab cr 120 mg (Calan sr)............................. 26
verapamil hcl tab cr 180 mg (Calan sr)............................. 26
verapamil hcl tab cr 240 mg (Calan sr)............................. 26
verapamil hcl tab 40 mg.................................................... 26
verapamil hcl tab 80 mg (Calan)....................................... 26
verapamil hcl tab 120 mg (Calan)..................................... 26
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)...................................................................................... 17
VIDEX – didanosine for soln 2 gm...................................... 8
VIDEX – didanosine for soln 4 gm...................................... 8
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 8
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 8
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 8
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm..................................................................................8
VIREAD – tenofovir disoproxil fumarate tab 150 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 200 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 250 mg...........8
VIREAD – tenofovir disoproxil fumarate tab 300 mg...........8
vitamins a & d oint............................................................. 84
VITEKTA – elvitegravir tab 85 mg....................................... 8
VITEKTA – elvitegravir tab 150 mg..................................... 8
VIVITROL – naltrexone for im extended release susp 380
mg...................................................................................... 53
voriconazole for susp 40 mg/ml (Vfend)..............................4
voriconazole tab 50 mg (Vfend).......................................... 4
voriconazole tab 200 mg (Vfend)........................................ 4
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 12
VP-PRECIP – flaxseed oil-evening primrose-bilberry cap
250-125-10 mg................................................................. 68
W
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
sodium
sodium
sodium
sodium
sodium
sodium
sodium
sodium
tab
tab
tab
tab
tab
tab
tab
tab
1 mg (Coumadin).............................. 76
2 mg (Coumadin).............................. 76
2.5 mg (Coumadin)........................... 76
3 mg (Coumadin).............................. 76
4 mg (Coumadin).............................. 76
5 mg (Coumadin).............................. 76
6 mg (Coumadin).............................. 76
7.5 mg (Coumadin)........................... 76
117
2016
warfarin sodium tab 10 mg (Coumadin)............................ 76
water for irrigation, sterile irrigation soln........................... 85
X
XALKORI – crizotinib cap 200 mg.....................................12
XALKORI – crizotinib cap 250 mg.....................................12
XARELTO – rivaroxaban tab 10 mg.................................. 76
XARELTO – rivaroxaban tab 15 mg.................................. 76
XARELTO – rivaroxaban tab 20 mg.................................. 76
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................... 76
XIFAXAN – rifaximin tab 200 mg.......................................10
XIFAXAN – rifaximin tab 550 mg.......................................10
XULANE – norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr.............................................................. 15
XYNTHA – antihemophilic factor recombinant paf for inj kit
250 unit............................................................................. 76
XYNTHA – antihemophilic factor recombinant paf for inj kit
500 unit............................................................................. 76
XYNTHA – antihemophilic factor recombinant paf for inj kit
1000 unit........................................................................... 77
XYNTHA – antihemophilic factor recombinant paf for inj kit
2000 unit........................................................................... 77
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 250 unit.................................. 77
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 500 unit.................................. 77
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 1000 unit................................ 77
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 2000 unit................................ 77
XYNTHA SOLOFUSE – antihemophilic factor
recombinant paf for inj kit 3000 unit................................ 77
XYREM – sodium oxybate oral solution 500 mg/ml.......... 53
Y
Z
zaleplon cap 5 mg (Sonata).............................................. 49
zaleplon cap 10 mg (Sonata)............................................ 49
ZARXIO – filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml.......................................................................... 77
ZARXIO – filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml.......................................................................... 77
ZELBORAF – vemurafenib tab 240 mg (base
equivalent)......................................................................... 12
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit.................................................... 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit.................................................. 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit.................................................. 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit................................................ 40
118
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit................................................ 40
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit.............................................. 40
ZEPATIER – elbasvir-grazoprevir tab 50-100 mg............... 5
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)..... 8
zidovudine cap 100 mg (Retrovir)....................................... 8
zidovudine syrup 10 mg/ml (Retrovir)..................................8
zidovudine tab 300 mg.........................................................8
zinc oxide oint 10%............................................................ 84
zinc oxide oint 20%............................................................ 84
zinc oxide oint 40%............................................................ 84
ziprasidone hcl cap 20 mg (Geodon)................................ 48
ziprasidone hcl cap 40 mg (Geodon)................................ 48
ziprasidone hcl cap 60 mg (Geodon)................................ 48
ziprasidone hcl cap 80 mg (Geodon)................................ 48
zolpidem tartrate tab 5 mg (Ambien)................................. 49
zolpidem tartrate tab 10 mg (Ambien)............................... 49
zonisamide cap 50 mg....................................................... 63
zonisamide cap 25 mg (Zonegran)....................................63
zonisamide cap 100 mg (Zonegran)..................................63
ZORTRESS – everolimus tab 0.25 mg............................. 85
ZORTRESS – everolimus tab 0.5 mg............................... 85
ZORTRESS – everolimus tab 0.75 mg............................. 86
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg.................................................................... 15
ZOVIRAX – acyclovir cream 5%....................................... 81
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq)......................................................58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq)......................................................58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq).................................................................... 58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq).................................................................... 58
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
11.4-2.9 mg (base eq)...................................................... 58
ZYCLARA – imiquimod cream 3.75%............................... 84
ZYCLARA PUMP – imiquimod cream 2.5%......................84
ZYCLARA PUMP – imiquimod cream 3.75%....................84
ZYTIGA – abiraterone acetate tab 250 mg....................... 12
ZYVOX – linezolid for susp 100 mg/5ml........................... 10
Blue Cross and Blue Shield of Illinois, una división de Health Care Service Corporation (HCSC), una empresa mutua de reserva
legal, una licenciataria independiente de Blue Cross and Blue Shield Association.
ILICPRX16
227605.0916