Amerigroup STAR+PLUS MMP

Lista de medicamentos
cubiertos (formulario)
LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE
LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN.
TXDMKT-0101-16 SP 09.16 SP
Servicios para miembros: 1-855-878-1784 (TTY 711)
Abrimos de lunes a viernes de 8 a.m. a 8 p.m. hora local.
www.myamerigroup.com/TXmmp
H8786_16_24854_T_008_SP CMS Approved 08/25/2015
Identificación del formulario: 16232 Versión: 14
Issued 09/01/2016
H8786_16_24854_T_008_SP CMS Approved 08/25/2015
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) |
Lista de medicinas cubiertas del 2016 (Formulario)
Esta es una lista de las medicinas que los miembros pueden recibir en Amerigroup STAR+PLUS
MMP.
Amerigroup STAR+PLUS MMP es un plan de salud que posee contratos con Medicare y
Texas Medicaid para proporcionar los beneficios de ambos programas a los afiliados.
La Lista de medicinas cubiertas o las redes de farmacias y prestadores pueden cambiar
durante el año. Le enviaremos una notificación antes de hacer algún cambio que afecte su
caso.
Los beneficios o copagos pueden cambiar el 1 de enero de cada año.
Siempre podrá revisar la Lista de medicinas cubiertas actualizada de Amerigroup STAR+PLUS
MMP en Internet en www.myamerigroup.com/TXmmp.
Pueden aplicarse limitaciones, copagos y restricciones. Para obtener más información, llame
a Member Services o lea el Manual para miembros de Amerigroup STAR+PLUS MMP.
Los copagos por medicinas recetadas pueden variar según el nivel de Ayuda adicional que
reciba. Contacte al plan para obtener más detalles.
Puede obtener esta información de forma gratuita en otros formatos, como letra grande,
Braille o audio. Llame al 1-855-878-1784 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m.
hora local. La llamada es gratis.
You can get this information for free in other languages. Call 1-855-878-1784 (TTY 711)
Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free.
Usted puede obtener esta información gratuitamente en otros idiomas. Llame al
1-855-878-1784 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es
gratuita.
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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H8786_16_24854_T_008_SP CMS Approved 08/25/2015
Preguntas frecuentes
Encuentre aquí las respuestas a las preguntas que tiene acerca de esta Lista de medicinas
cubiertas. Puede leer todas las preguntas frecuentes para obtener más información, o bien buscar
una pregunta y una respuesta.
1. ¿Cuáles medicinas con receta se encuentran en la Lista de medicinas
cubiertas? (Abreviamos la Lista de medicinas cubiertas como la
“Lista de medicinas”.)
Las medicinas de la Lista de medicinas cubiertas que comienzan en la página 10 son aquellas
que cubre Amerigroup STAR+PLUS MMP. Estas medicinas se encuentran disponibles en farmacias
dentro de nuestra red. Una farmacia está en nuestra red si tenemos un contrato con ella para que
trabaje con nosotros y le proporcione servicios. Nos referimos a estas farmacias como “farmacias
de la red”.
Amerigroup STAR+PLUS MMP cubrirá todas las medicinas médicamente necesarias en la
Lista de medicinas si:
su médico u otra persona que receta la medicina dice que la necesita para mejorar o
mantenerse sano y
usted presenta la receta en la farmacia de la red de Amerigroup STAR+PLUS MMP.
Es posible que Amerigroup STAR+PLUS MMP cuente con pasos adicionales para tener
acceso a ciertas medicinas (consulte la pregunta N.° 5 más abajo).
También puede ver una lista de medicinas actualizadas que cubrimos en nuestro sitio web
en www.myamerigroup.com/TXmmp o llamando a Member Services al 1-855-878-1784 (TTY
711).
2. ¿La Lista de medicinas va cambiando?
Sí. Amerigroup STAR+PLUS MMP puede agregar o eliminar durante el año algunas medicinas
de la Lista de medicinas. En general, la Lista de medicinas solo cambiará si:
aparece una medicina más barata que funciona de la misma forma que una de la Lista de
medicinas ahora, o
nos enteramos de que una medicina no es segura.
También podemos cambiar nuestras normas en relación con las medicinas. Por ejemplo, podríamos:
Decidir exigir o no exigir una aprobación previa para una medicina. (Aprobación previa es
un permiso de Amerigroup STAR+PLUS MMP antes de poder conseguir una medicina.)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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Agregar o cambiar la cantidad de una medicina que puede obtener (se conoce como “límites
de cantidad”).
Agregar o cambiar las restricciones de una terapia escalonada para una medicina. (Terapia
escalonada significa que debe probar una medicina antes de que cubramos otra medicina.)
(Para obtener más información acerca de estas normas, consulte las páginas 3 y 4.)
Le informaremos cuando una medicina de la Parte D de Medicare que esté tomando se elimine
de la Lista de medicinas. También le informaremos cuando cambiemos las normas con respecto
a la cobertura de una medicina de la Parte D de Medicare. En las preguntas 3, 4 y 7 a continuación
se encuentra más información acerca de lo que ocurre cuando cambia la Lista de medicinas.
Siempre podrá revisar la Lista de medicinas actualizada de Amerigroup STAR+PLUS MMP
en Internet en www.myamerigroup.com/TXmmp. También puede llamar a Member Services
al 1-855-878-1784 (TTY 711) para revisar la Lista de medicinas actual.
3. ¿Qué ocurre cuando aparece una nueva medicina más barata que
funciona de la misma forma que una de la Lista de medicinas ahora?
Si está tomando una medicina de la Parte D de Medicare que se eliminó debido a que aparece
una medicina más barata que funciona igual de bien, se lo informaremos. Se lo haremos saber
con al menos 60 días de anticipación antes de que la eliminemos de la Lista de medicinas o o
cuando solicite su siguiente resurtido. Entonces, podrá obtener un suministro por 60 días de la
medicina antes de que se realice el cambio a dicha Lista. Recibirá una carta por correo donde se
le informará sobre el cambio.
4. ¿Qué ocurre cuando descubrimos que una medicina no es segura?
Si la Administración de Alimentos y Medicamentos (FDA, Food and Drug Administration) indica
que una medicina que está tomando no es segura, nosotros la sacaremos de inmediato de Lista de
medicinas. También le enviaremos una carta para informarle sobre ello. Póngase en contacto con
el médico que receta la medicina tan pronto como reciba la carta.
5. ¿Existen restricciones o límites para la cobertura de medicinas? O,
¿se deben tomar medidas para recibir ciertas medicinas?
Sí, algunas medicinas tienen normas de cobertura o tienen límites acerca de la cantidad que
puede recibir. En algunos casos, debe hacer algo antes de poder recibir la medicina. Por ejemplo:
Aprobación previa (o autorización previa): en el caso de algunas medicinas, usted, su
médico u otra persona que haga la receta deben obtener la aprobación de Amerigroup
STAR+PLUS MMP antes de surtir su receta. Si no tiene la aprobación puede que Amerigroup
STAR+PLUS MMP no cubra la medicina.
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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Límites de cantidades: a veces, Amerigroup STAR+PLUS MMP limita la cantidad de medicina
que puede recibir.
Terapia escalonada: en ocasiones, Amerigroup STAR+PLUS MMP exige que usted realice
una terapia escalonada. Esto significa que tendrá que probar medicinas en cierto orden por
su condición médica. Es posible que tenga que probar una medicina antes de que cubramos
otra. Si su médico cree que la primera medicina no funciona para usted, entonces cubriremos
la segunda.
Puede averiguar si su medicina tiene exigencias o límites adicionales revisando las tablas en las
páginas 10-131. También puede recibir más información visitando nuestro sitio web
www.myamerigroup.com/TXmmp. Hemos publicado documentos en Internet que explican nuestras
estricciones de autorización previa y las restricciones de terapia escalonada. También puede
pedirnos que le enviemos una copia.
Puede solicitar una “excepción” a estos límites. Consulte la pregunta 11 para obtener más
información acerca de las excepciones.
Si usted se encuentra en un centro de enfermería u otra instalación de atención de largo
plazo y necesita una medicina que no se encuentra en la Lista de medicinas, o si no puede
recibir fácilmente la medicina que necesita, podemos ayudarlo. Cubriremos un suministro de
emergencia de 31 días de la medicina que necesite (a menos que tenga una receta por
menos días), independientemente de si es o no un miembro nuevo de Amerigroup
STAR+PLUS MMP. Esto le dará tiempo para que hable con su médico u otra persona que
realice la receta. Este profesional puede ayudarle a decidir si hay una medicina similar en
la Lista de medicinas que pueda tomar en su lugar o si hay una excepción. Consulte la
pregunta 11 para obtener más información acerca de las excepciones.
6. ¿De qué manera sabrá si la medicina que desea tomar tiene
limitaciones o si hay medidas que se deban tomar para recibir la
medicina?
La Lista de medicinas cubiertas en la página 10 tiene una columna etiquetada “Medidas,
restricciones o límites necesarios en uso”.
7. ¿Qué ocurre si cambiamos nuestras normas sobre cómo cubrimos
algunas medicinas? Por ejemplo, si agregamos autorización
(aprobación) previa, límites de cantidad o restricciones de terapia
escalonada para una medicina.
Le informaremos si agregamos aprobación previa, límites de cantidad o restricciones de terapia
escalonada para una medicina. Se lo haremos saber con al menos 60 días de anticipación antes
de que se agreguen restricciones o cuando solicite su siguiente resurtido. Entonces, podrá obtener
un suministro por 60 días de la medicina antes de que se realice el cambio a dicha Lista. Esto le
entrega tiempo para que hable con su médico u otra persona que realice la receta sobre qué tiene
que hacer después.
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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8. ¿Cómo puede encontrar una medicina en la Lista de medicinas?
Existen dos formas para encontrar una medicina:
Puede buscar en orden alfabético (si sabe cómo se escribe la medicina) o
Puede buscar por condición médica.
Para buscar en orden alfabético, vaya a la sección Listado alfabético. Puede buscarla en la
página 132 y luego buscar el nombre de la medicina en la lista.
Para buscar por condición médica, busque la sección llamada “Lista de medicamentos por
condición médica” en la página 10. Las medicinas en esta sección están agrupadas en categorías
basadas en el tipo de afección médica para los que se utilizan. Por ejemplo, si tiene una condición
cardíaca, debe ver en la categoría Cardiovascular/Hipertensión/Lípidos. Ahí es donde encontrará
medicinas para el tratamiento de condiciones cardíacas.
9. ¿Qué ocurre si la medicina que desea tomar no se encuentra en la
Lista de medicinas?
Si no ve su medicina en la Lista de medicinas, llame a Member Services al 1-855-878-1784 (TTY
711) y haga su consulta sobre él. Si se enteró de que Amerigroup STAR+PLUS MMP no cubrirá
la medicina, puede realizar una de estas opciones:
Solicitar a Member Services una lista de medicinas como la que usted desea tomar. Luego
debe mostrar dicha lista a su médico u otra persona que realice la receta. Este profesional
puede recetar una medicina de la Lista de medicinas que sea similar al que desea tomar. O
Puede solicitar al plan de salud que haga una excepción con respecto a la cobertura de su
medicina. Consulte la pregunta 11 para obtener más información acerca de las excepciones.
10. ¿Qué ocurre si usted es un miembro nuevo de Amerigroup
STAR+PLUS MMP y no puede encontrar su medicina en la Lista de
medicinas o tiene un problema para obtener su medicina?
Podemos ayudarlo. Debemos cubrir hasta 31 días de suministro temporal de su medicina, según
sea necesario, durante los primeros 90 días como miembro de Amerigroup STAR+PLUS MMP.
Esto le dará tiempo para que hable con su médico u otra persona que realice la receta. Este
profesional puede ayudarle a decidir si hay una medicina similar en la Lista de medicinas que
pueda tomar en su lugar o si hay una excepción.
Cubriremos hasta 31 días de suministro temporal de su medicina si:
está tomando una medicina que no se encuentra en nuestra Lista de medicinas o
las normas del plan de salud no le permiten obtener la cantidad que solicita su prestador o
la medicina requiere una aprobación previa por parte de Amerigroup STAR+PLUS MMP, o
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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está tomando una medicina que forma parte de una restricción de terapia escalonada.
Si se encuentra viviendo en centro de enfermería u otra instalación de atención de largo plazo,
puede resurtir su receta durante hasta 98 días. Puede resurtir la medicinas varias veces durante
sus primeros 90 días en el plan. Esto da tiempo a quien le receta la medicina para que cambie
sus medicinas a aquellas que se encuentran en la Lista de medicinas o para que pida una
excepción.
Cubriremos un suministro temporal de 31 días de su medicina para cubrir los cambios de nivel
de atención.
11. ¿Puede pedir una excepción para la cobertura de su medicina?
Sí. Puede pedir a Amerigroup STAR+PLUS MMP que haga una excepción para que cubra una
medicina que no se encuentra en la Lista de medicinas.
También puede solicitarnos que cambiemos las normas para su medicina.
Por ejemplo, Amerigroup STAR+PLUS MMP puede limitar la cantidad de medicina que
cubriremos. Si su medicina tiene un límite, puede pedirnos a nosotros cambiemos el límite
y que cubra mayor cantidad.
Otros ejemplos: Puede pedirnos a nosotros que omitamos las restricciones de terapia
escalonada o las exigencias de aprobación previa.
12. ¿Cuánto tiempo se requiere para recibir una excepción?
En primer lugar, debemos recibir una declaración de quien le recepta la medicina donde respalde
su solicitud de excepción. Después de que recibamos la declaración, le entregaremos una decisión
sobre su solicitud de excepción en 72 horas.
Si usted o quien le recetó la medicina creen que su salud podría verse dañada si tiene que esperar
72 horas por una decisión, puede solicitar una excepción urgente. Esta es una decisión más
rápida. Si quien le recetó la medicina respalda su solicitud, le entregaremos una decisión 24 horas
dentro de las 24 horas en que se reciba la declaración de respaldo de quien recetó la medicina.
13. ¿Cómo puede solicitar una excepción?
Para solicitar una excepción, llame a su coordinador de servicio. Su coordinador de servicio
trabajará con usted y su prestador para ayudarle a solicitar una excepción.
14. ¿Qué son las medicinas genéricas?
Medicinas genéricas son aquellas que están fabricadas con los mismos ingredientes activos de
las medicinas con nombre de marca. Generalmente, cuestan menos que la medicina con nombre
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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de marca y no tienen nombres bien conocidos. Las medicinas genéricas cuentan con aprobación
de la FDA.
Amerigroup STAR+PLUS MMP cubre medicinas con nombre de marca y medicinas genéricas.
15. ¿Qué son las medicinas de venta sin receta?
OTC es el acrónimo en inglés para “over-the-counter” (de venta sin receta). Amerigroup
STAR+PLUS MMP cubre algunas medicinas vendidas en el mostrador cuando están escritas
como recetas por su prestador.
Puede leer la Lista de medicinas de Amerigroup STAR+PLUS MMP para ver las medicinas de
venta sin receta que están cubiertas.
16. ¿Amerigroup STAR+PLUS MMP cubre productos que no sean
medicinas de venta sin receta?
Amerigroup STAR+PLUS MMP cubre algunos productos que no son medicinas de venta sin receta
cuando están escritas como recetas por su prestador.
Puede leer la Lista de medicinas de Amerigroup STAR+PLUS MMP para ver qué productos que
no son medicinas de venta sin receta están cubiertos.
17. ¿Qué es su copago?
Puede leer la Lista de medicinas de Amerigroup STAR+PLUS MMP para obtener información
sobre el copago para cada medicina.
Los miembros de Amerigroup STAR+PLUS MMP que viven en centros de enfermería u otras
instalaciones de atención de largo plazo no tendrán copagos. Algunos miembros que reciben
atención de largo plazo en la comunidad tampoco tendrán copagos.
Los copagos se indican por niveles. Los niveles son grupos de medicinas con el mismo copago.
Las medicinas de Nivel 1 son medicinas (genéricas y de marca preferidas) de la Parte D de
Medicare. El copago será de $0.
Las medicinas de Nivel 2 son medicinas (genéricas y de marca preferidas y no preferidas)
de la Parte D de Medicare. El copago será desde $0 a $7.40, dependiendo de su nivel de
elegibilidad de Texas Medicaid.
Las medicinas de Nivel 3 son medicinas recetadas de marca y genérica aprobadas de Texas
Medicaid (estatal). El copago será de $0.
Las medicinas de Nivel 4 son medicinas de venta sin receta aprobadas de Texas Medicaid
(estatal). Las medicinas de venta sin receta cubiertas requieren una recepta de su prestador.
El copago será de $0.
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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Lista de medicinas por condición médica
La siguiente Lista de medicinas cubiertas que comienza en la siguiente página le entrega
información sobre las medicinas que cubre Amerigroup STAR+PLUS MMP. Si tiene problemas
para encontrar su medicina en la lista, use el índice que comienza en la página 132.
La primera columna de la tabla indica el nombre de la medicina. Las medicinas con nombre de
marca están en mayúsculas (por ejemplo, ABELCET) y las medicinas genéricas se indican en
minúscula y cursiva (por ejemplo, fluconazole).
La información en la columna de medidas, restricciones o límites necesarios en uso le indican si
Amerigroup STAR+PLUS MMP tiene normas para la cobertura de su medicina.
Estos son los significados de los códigos que se utilizan en la columna “Medidas,
restricciones o límites necesarios en uso”:
B/D: esta medicina recetada puede tener cobertura conforme a la Parte B o D de Medicare
dependiendo de las circunstancias. Es necesario que se deba enviar información donde se
describa el uso y marco de la medicina para tomar la determinación.
HI: infusión casera. Esta medicina recetada puede cubrirse conforme a nuestro beneficio
médico. Para mayor información, llame a Servicios para miembros.
LA: disponibilidad limitada. Esta receta puede estar disponible solo en ciertas farmacias.
Para mayor información, llame a Servicios para miembros.
MO: medicina de pedido por correo. Esta medicina recetada se encuentra disponible a través
de nuestro servicio de pedido por correo, así como mediante nuestras farmacias de la red
minorista. Considere el uso de pedido por correo para medicinas de largo plazo
(mantenimiento) (como medicinas para hipertensión). Las farmacias de la red minorista
pueden ser más apropiadas para recetas de corto plazo (como antibióticos).
PAR: autorización previa requerida. El plan exige que usted o su médico obtengan una
autorización previa para ciertas medicinas. Esto significa que necesitará obtener una
aprobación antes de surtir sus recetas. Si no obtiene la aprobación, no podemos cubrir la
medicina.
QLL: límite de cantidad. Para ciertas medicinas, el plan limita la cantidad de medicina que
cubriremos.
ST: Tratamiento escalonado. En algunos casos, el plan exige que primero pruebe ciertas
medicinas para tratar su condición médica antes de que cubramos otra medicina para esa
condición. Por ejemplo, si tanto la medicina A como la medicina B tratan su condición médica,
no podemos cubrir la medicina B a menos que primero pruebe la medicina A. Si la medicina
A no funciona para usted, entonces cubriremos la medicina B.
Nota: el asterisco (*) junto a la medicina indica que la medicina no es una “medicina de la Parte
D.” El monto que paga cuando surte una receta para su medicina no cuenta para los costos totales
de su medicina (es decir, el monto que paga no ayuda a calificar para cobertura catastrófica).
Además, si recibe ayuda adicional para pagar sys recetas, no obtendrá ninguna ayuda adicional
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
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para pagar estas medicinas. Estas medicinas también tienen diferentes normas para apelaciones.
Una apelación es una manera formal para pedirnos que revisemos una decisión de cobertura y
cambiarla si cree que cometimos un error. Por ejemplo, podemos decidir que una medicina que
desea no esté cubierta o que deje de estar cubierta por Medicare o Texas Medicaid. Si usted o
su médico no están de acuerdo con nuestra decisión, pueden apelar. Para solicitar instrucciones
sobre cómo apelar, llame a Member Services al 1-855-878-1784 (TTY 711). También puede leer
el Manual para miembros para saber cómo apelar a una decisión.
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
TXDMKT-0101-16 SP 09.16 SP
9
Lista de medicamentos por condición médica
Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de
condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe
buscar en la categoría Cardiovascular/hipertensión/lípidos. Es donde encontrará medicamentos para
tratar condiciones cardiacas.
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ABELCET
$0-$7.40 (Tier 2)
B/D PAR; MO
AMBISOME
$0-$7.40 (Tier 2)
B/D PAR; MO
amphotericin b
$0-$7.40 (Tier 2)
B/D PAR; MO
CANCIDAS
$0-$7.40 (Tier 2)
B/D PAR; MO
clotrimazole mucous membrane
$0-$7.40 (Tier 2)
MO
ERAXIS(WATER DILUENT)
$0-$7.40 (Tier 2)
PAR; MO
fluconazole
$0-$7.40 (Tier 2)
MO
fluconazole in dextrose(iso-o)
$0-$7.40 (Tier 2)
FLUCONAZOLE IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 100 MG/50 ML
$0-$7.40 (Tier 2)
fluconazole in nacl (iso-osm) intravenous piggyback
200 mg/100 ml
$0-$7.40 (Tier 2)
fluconazole in nacl (iso-osm) intravenous piggyback
400 mg/200 ml
$0-$7.40 (Tier 2)
flucytosine
$0-$7.40 (Tier 2)
MO
griseofulvin microsize oral suspension
$0-$7.40 (Tier 2)
MO
griseofulvin ultramicrosize
$0-$7.40 (Tier 2)
MO
itraconazole
$0-$7.40 (Tier 2)
PAR; MO
ketoconazole oral
$0-$7.40 (Tier 2)
MO
NOXAFIL ORAL SUSPENSION
$0-$7.40 (Tier 2)
PAR; MO; QLL (630 per 30 days)
nystatin oral suspension
$0-$7.40 (Tier 2)
MO
nystatin oral tablet
$0-$7.40 (Tier 2)
MO
terbinafine hcl oral
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
10
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
voriconazole intravenous
$0-$7.40 (Tier 2)
MO
voriconazole oral suspension for reconstitution
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
voriconazole oral tablet 200 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
voriconazole oral tablet 50 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
abacavir
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
abacavir-lamivudine-zidovudine
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
acyclovir oral capsule
$0-$7.40 (Tier 2)
MO
acyclovir oral suspension 200 mg/5 ml
$0-$7.40 (Tier 2)
MO
acyclovir oral tablet
$0-$7.40 (Tier 2)
MO
acyclovir sodium intravenous solution
$0-$7.40 (Tier 2)
B/D PAR; MO
adefovir
$0-$7.40 (Tier 2)
MO
amantadine hcl oral capsule
$0-$7.40 (Tier 2)
MO
amantadine hcl oral tablet
$0-$7.40 (Tier 2)
MO
APTIVUS ORAL CAPSULE
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
APTIVUS ORAL SOLUTION
$0-$7.40 (Tier 2)
QLL (380 per 30 days)
ATRIPLA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
BARACLUDE ORAL SOLUTION
$0-$7.40 (Tier 2)
PAR; MO
cidofovir
$0-$7.40 (Tier 2)
B/D PAR; MO
COMPLERA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
DAKLINZA ORAL TABLET 30 MG, 60 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
DAKLINZA ORAL TABLET 90 MG
$0-$7.40 (Tier 2)
PAR; QLL (30 per 30 days)
DESCOVY
$0-$7.40 (Tier 2)
QLL (30 per 30 days)
didanosine oral capsule,delayed release(dr/ec) 125
mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
didanosine oral capsule,delayed release(dr/ec) 200
mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
ANTIVIRALS
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
11
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
didanosine oral capsule,delayed release(dr/ec) 250
mg, 400 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
EDURANT
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
EMTRIVA ORAL CAPSULE
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
EMTRIVA ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (850 per 30 days)
entecavir
$0-$7.40 (Tier 2)
PAR; MO
EPIVIR HBV ORAL SOLUTION
$0-$7.40 (Tier 2)
MO
EPIVIR ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (900 per 30 days)
EPZICOM
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
EVOTAZ
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
famciclovir oral tablet 125 mg, 250 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
famciclovir oral tablet 500 mg
$0-$7.40 (Tier 2)
MO; QLL (21 per 7 days)
foscarnet
$0-$7.40 (Tier 2)
B/D PAR
FUZEON SUBCUTANEOUS RECON SOLN
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
ganciclovir sodium
$0-$7.40 (Tier 2)
MO
GENVOYA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
HARVONI
$0-$7.40 (Tier 2)
PAR; MO; QLL (28 per 28 days)
INTELENCE ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
INTELENCE ORAL TABLET 200 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
INTELENCE ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
INVIRASE ORAL CAPSULE
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
INVIRASE ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
ISENTRESS ORAL POWDER IN PACKET
$0-$7.40 (Tier 2)
MO
ISENTRESS ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 100
MG
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 25
MG
$0-$7.40 (Tier 2)
MO; QLL (720 per 30 days)
KALETRA ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
KALETRA ORAL TABLET 100-25 MG
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
12
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
KALETRA ORAL TABLET 200-50 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
lamivudine oral solution
$0-$7.40 (Tier 2)
MO; QLL (900 per 30 days)
lamivudine oral tablet 100 mg
$0-$7.40 (Tier 2)
MO
lamivudine oral tablet 150 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
lamivudine oral tablet 300 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
lamivudine-zidovudine
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
LEXIVA ORAL SUSPENSION
$0-$7.40 (Tier 2)
MO; QLL (1800 per 30 days)
LEXIVA ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
nevirapine oral suspension
$0-$7.40 (Tier 2)
MO; QLL (1200 per 30 days)
nevirapine oral tablet
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100
mg
$0-$7.40 (Tier 2)
MO
nevirapine oral tablet extended release 24 hr 400
mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
NORVIR ORAL CAPSULE
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
NORVIR ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
NORVIR ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
ODEFSEY
$0-$7.40 (Tier 2)
QLL (30 per 30 days)
OLYSIO
$0-$7.40 (Tier 2)
PAR; MO
PREZCOBIX
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
PREZISTA ORAL SUSPENSION
$0-$7.40 (Tier 2)
MO; QLL (400 per 30 days)
PREZISTA ORAL TABLET 150 MG
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
PREZISTA ORAL TABLET 600 MG, 800 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
PREZISTA ORAL TABLET 75 MG
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
RELENZA DISKHALER
$0-$7.40 (Tier 2)
MO; QLL (60 per 180 days)
RESCRIPTOR ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
RESCRIPTOR ORAL TABLET, DISPERSIBLE
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
RETROVIR INTRAVENOUS
$0-$7.40 (Tier 2)
MO
REYATAZ ORAL CAPSULE 150 MG, 200 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
REYATAZ ORAL CAPSULE 300 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
13
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
REYATAZ ORAL POWDER IN PACKET
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
ribasphere oral capsule
$0-$7.40 (Tier 2)
PAR; MO
ribasphere oral tablet 200 mg
$0-$7.40 (Tier 2)
PAR; MO
ribavirin oral capsule
$0-$7.40 (Tier 2)
PAR; MO
ribavirin oral tablet 200 mg
$0-$7.40 (Tier 2)
PAR; MO
rimantadine
$0-$7.40 (Tier 2)
MO
SELZENTRY
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
SOVALDI
$0-$7.40 (Tier 2)
PAR; MO
stavudine oral capsule 15 mg, 20 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
stavudine oral capsule 30 mg, 40 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
stavudine oral recon soln
$0-$7.40 (Tier 2)
MO; QLL (2400 per 30 days)
STRIBILD
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
SUSTIVA ORAL CAPSULE 200 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
SUSTIVA ORAL CAPSULE 50 MG
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
SUSTIVA ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
SYNAGIS
$0-$7.40 (Tier 2)
PAR; MO; LA
TAMIFLU
$0-$7.40 (Tier 2)
MO
TECHNIVIE
$0-$7.40 (Tier 2)
PAR; MO; QLL (56 per 28 days)
TIVICAY ORAL TABLET 10 MG, 25 MG
$0-$7.40 (Tier 2)
QLL (60 per 30 days)
TIVICAY ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
TRIUMEQ
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TRUVADA ORAL TABLET 100-150 MG, 133200 MG, 167-250 MG
$0-$7.40 (Tier 2)
QLL (30 per 30 days)
TRUVADA ORAL TABLET 200-300 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TYBOST
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TYZEKA
$0-$7.40 (Tier 2)
PAR; MO
valacyclovir
$0-$7.40 (Tier 2)
MO; QLL (30 per 2 days)
valganciclovir
$0-$7.40 (Tier 2)
MO
VIDEX 2 GRAM PEDIATRIC
$0-$7.40 (Tier 2)
MO; QLL (1200 per 30 days)
VIDEX 4 GRAM PEDIATRIC
$0-$7.40 (Tier 2)
MO; QLL (1200 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
14
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
VIEKIRA PAK
$0-$7.40 (Tier 2)
PAR; MO
VIRACEPT ORAL TABLET 250 MG
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
VIRACEPT ORAL TABLET 625 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG
$0-$7.40 (Tier 2)
MO
VIRAZOLE
$0-$7.40 (Tier 2)
PAR; MO
VIREAD ORAL POWDER
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
VIREAD ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
VITEKTA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
ZEPATIER
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
ZIAGEN ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (960 per 30 days)
zidovudine oral capsule
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
zidovudine oral syrup
$0-$7.40 (Tier 2)
MO; QLL (1920 per 30 days)
zidovudine oral tablet
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
cefaclor oral capsule
$0-$7.40 (Tier 2)
MO
cefaclor oral suspension for reconstitution 125 mg/
5 ml
$0-$7.40 (Tier 2)
cefaclor oral suspension for reconstitution 250 mg/
5 ml, 375 mg/5 ml
$0-$7.40 (Tier 2)
MO
cefaclor oral tablet extended release 12 hr
$0-$7.40 (Tier 2)
MO
cefadroxil oral capsule
$0-$7.40 (Tier 2)
MO
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
$0-$7.40 (Tier 2)
MO
cefadroxil oral tablet
$0-$7.40 (Tier 2)
MO
cefazolin in dextrose (iso-os) intravenous piggyback
1 gram/50 ml
$0-$7.40 (Tier 2)
MO
CEFAZOLIN IN DEXTROSE (ISO-OS)
INTRAVENOUS PIGGYBACK 2 GRAM/50 ML
$0-$7.40 (Tier 2)
MO
cefazolin injection recon soln 1 gram, 500 mg
$0-$7.40 (Tier 2)
MO
cefazolin injection recon soln 10 gram, 20 gram
$0-$7.40 (Tier 2)
CEPHALOSPORINS
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
15
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CEFAZOLIN INJECTION RECON SOLN 100
GRAM, 300 G
$0-$7.40 (Tier 2)
cefazolin intravenous
$0-$7.40 (Tier 2)
cefdinir
$0-$7.40 (Tier 2)
MO
cefepime
$0-$7.40 (Tier 2)
MO
cefoxitin in dextrose, iso-osm
$0-$7.40 (Tier 2)
cefoxitin intravenous recon soln 1 gram
$0-$7.40 (Tier 2)
cefoxitin intravenous recon soln 10 gram, 2 gram
$0-$7.40 (Tier 2)
cefpodoxime
$0-$7.40 (Tier 2)
MO
cefprozil
$0-$7.40 (Tier 2)
MO
ceftazidime injection recon soln 1 gram, 2 gram
$0-$7.40 (Tier 2)
MO
ceftazidime injection recon soln 6 gram
$0-$7.40 (Tier 2)
ceftriaxone in dextrose,iso-os
$0-$7.40 (Tier 2)
MO
ceftriaxone injection recon soln 1 gram, 2 gram,
250 mg, 500 mg
$0-$7.40 (Tier 2)
MO
ceftriaxone injection recon soln 10 gram
$0-$7.40 (Tier 2)
CEFTRIAXONE INJECTION RECON SOLN 100
GRAM
$0-$7.40 (Tier 2)
ceftriaxone intravenous
$0-$7.40 (Tier 2)
MO
cefuroxime axetil oral tablet
$0-$7.40 (Tier 2)
MO
cefuroxime sodium intraveneous vial injection recon
soln 1.5 gram, 750 mg
$0-$7.40 (Tier 2)
MO
cefuroxime sodium intraveneous vial intravenous
recon soln 7.5 gram
$0-$7.40 (Tier 2)
cephalexin oral capsule 250 mg, 500 mg
$0-$7.40 (Tier 2)
MO
cephalexin oral suspension for reconstitution
$0-$7.40 (Tier 2)
MO
cephalexin oral tablet
$0-$7.40 (Tier 2)
MO
TEFLARO
$0-$7.40 (Tier 2)
MO
MO
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin intravenous recon soln 500 mg
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
16
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
azithromycin intravenous recon soln 500 mg (2 mg/
ml)
$0-$7.40 (Tier 2)
azithromycin oral
$0-$7.40 (Tier 2)
MO
clarithromycin oral suspension for reconstitution
$0-$7.40 (Tier 2)
MO
clarithromycin oral tablet
$0-$7.40 (Tier 2)
MO
clarithromycin oral tablet extended release 24 hr
$0-$7.40 (Tier 2)
MO; QLL (28 per 2 days)
e.e.s. 400 oral tablet
$0-$7.40 (Tier 2)
MO
ery-tab
$0-$7.40 (Tier 2)
MO
erythrocin (as stearate) oral tablet 250 mg
$0-$7.40 (Tier 2)
MO
ERYTHROCIN INTRAVENOUS RECON SOLN
500 MG
$0-$7.40 (Tier 2)
erythromycin ethylsuccinate oral tablet
$0-$7.40 (Tier 2)
MO
erythromycin oral tablet
$0-$7.40 (Tier 2)
MO
ALBENZA
$0-$7.40 (Tier 2)
MO
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION
$0-$7.40 (Tier 2)
MO; QLL (180 per 3 days)
ALINIA ORAL TABLET
$0-$7.40 (Tier 2)
MO
AMIKACIN INJECTION SOLUTION 1,000 MG/
4 ML
$0-$7.40 (Tier 2)
MO
amikacin injection solution 500 mg/2 ml
$0-$7.40 (Tier 2)
MO
atovaquone
$0-$7.40 (Tier 2)
PAR; MO
atovaquone-proguanil
$0-$7.40 (Tier 2)
MO
AZACTAM IN DEXTROSE (ISO-OSM)
$0-$7.40 (Tier 2)
aztreonam
$0-$7.40 (Tier 2)
baciim
$0-$7.40 (Tier 2)
BILTRICIDE
$0-$7.40 (Tier 2)
CAPASTAT
$0-$7.40 (Tier 2)
CAYSTON
$0-$7.40 (Tier 2)
chloramphenicol sod succinate
$0-$7.40 (Tier 2)
MISCELLANEOUS ANTIINFECTIVES
?
MO
MO
PAR; MO; LA
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
17
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
chloroquine phosphate oral
$0-$7.40 (Tier 2)
MO
clindamycin hcl
$0-$7.40 (Tier 2)
MO
clindamycin phosphate injection
$0-$7.40 (Tier 2)
MO
CLINDAMYCIN PHOSPHATE INTRAVENOUS
SOLUTION 300 MG/2 ML
$0-$7.40 (Tier 2)
clindamycin phosphate intravenous solution 600
mg/4 ml
$0-$7.40 (Tier 2)
clindamycin phosphate intravenous solution 900
mg/6 ml
$0-$7.40 (Tier 2)
colistin (colistimethate na)
$0-$7.40 (Tier 2)
MO
DAPSONE
$0-$7.40 (Tier 2)
MO
DARAPRIM
$0-$7.40 (Tier 2)
MO
ethambutol
$0-$7.40 (Tier 2)
MO
gentamicin injection
$0-$7.40 (Tier 2)
MO
GENTAMICIN SULFATE (PED) (PF)
$0-$7.40 (Tier 2)
MO
GENTAMICIN SULFATE (PF) INTRAVENOUS
SOLUTION 100 MG/10 ML
$0-$7.40 (Tier 2)
MO
GENTAMICIN SULFATE (PF) INTRAVENOUS
SOLUTION 60 MG/6 ML
$0-$7.40 (Tier 2)
gentamicin sulfate (pf) intravenous solution 80 mg/
8 ml
$0-$7.40 (Tier 2)
hydroxychloroquine oral
$0-$7.40 (Tier 2)
MO
imipenem-cilastatin
$0-$7.40 (Tier 2)
MO
INVANZ INJECTION
$0-$7.40 (Tier 2)
MO
isoniazid oral
$0-$7.40 (Tier 2)
MO
ivermectin oral
$0-$7.40 (Tier 2)
MO
linezolid intravenous
$0-$7.40 (Tier 2)
linezolid oral suspension for reconstitution
$0-$7.40 (Tier 2)
PAR; MO; QLL (1800 per 2 days)
linezolid oral tablet
$0-$7.40 (Tier 2)
PAR; MO; QLL (28 per 2 days)
LINEZOLID-0.9% SODIUM CHLORIDE
$0-$7.40 (Tier 2)
mefloquine
$0-$7.40 (Tier 2)
MO
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
18
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
meropenem
$0-$7.40 (Tier 2)
MO
METRO I.V.
$0-$7.40 (Tier 2)
MO
metronidazole in nacl (iso-os)
$0-$7.40 (Tier 2)
MO
metronidazole oral
$0-$7.40 (Tier 2)
MO
NEBUPENT
$0-$7.40 (Tier 2)
B/D PAR; MO
neomycin
$0-$7.40 (Tier 2)
MO
paromomycin
$0-$7.40 (Tier 2)
MO
PASER
$0-$7.40 (Tier 2)
MO
PENTAM
$0-$7.40 (Tier 2)
MO
PRIFTIN
$0-$7.40 (Tier 2)
MO
PRIMAQUINE
$0-$7.40 (Tier 2)
MO
pyrazinamide
$0-$7.40 (Tier 2)
MO
rifabutin
$0-$7.40 (Tier 2)
MO
rifampin
$0-$7.40 (Tier 2)
MO
RIFATER
$0-$7.40 (Tier 2)
MO
SIRTURO
$0-$7.40 (Tier 2)
PAR; MO; LA
STREPTOMYCIN INTRAMUSCULAR
$0-$7.40 (Tier 2)
MO
SYNERCID
$0-$7.40 (Tier 2)
tobramycin in 0.225 % nacl
$0-$7.40 (Tier 2)
tobramycin sulfate injection recon soln
$0-$7.40 (Tier 2)
tobramycin sulfate injection solution
$0-$7.40 (Tier 2)
MO
TRECATOR
$0-$7.40 (Tier 2)
MO
TYGACIL
$0-$7.40 (Tier 2)
MO
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 200 MG/100 ML
$0-$7.40 (Tier 2)
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 600 MG/300 ML
$0-$7.40 (Tier 2)
MO
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
$0-$7.40 (Tier 2)
PAR; MO; QLL (1800 per 2 days)
?
B/D PAR; MO; QLL (280 per 28 days)
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
19
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
PENICILLINS
amoxicillin oral capsule
$0-$7.40 (Tier 2)
MO
amoxicillin oral suspension for reconstitution
$0-$7.40 (Tier 2)
MO
amoxicillin oral tablet
$0-$7.40 (Tier 2)
MO
amoxicillin oral tablet,chewable 125 mg, 250 mg
$0-$7.40 (Tier 2)
MO
amoxicillin-pot clavulanate
$0-$7.40 (Tier 2)
MO
ampicillin
$0-$7.40 (Tier 2)
MO
ampicillin sodium injection
$0-$7.40 (Tier 2)
MO
ampicillin sodium intravenous
$0-$7.40 (Tier 2)
ampicillin-sulbactam injection recon soln 1.5 gram,
3 gram
$0-$7.40 (Tier 2)
ampicillin-sulbactam injection recon soln 15 gram
$0-$7.40 (Tier 2)
ampicillin-sulbactam intravenous recon soln 1.5
gram
$0-$7.40 (Tier 2)
ampicillin-sulbactam intravenous recon soln 3 gram
$0-$7.40 (Tier 2)
MO
BICILLIN C-R
$0-$7.40 (Tier 2)
MO
BICILLIN L-A
$0-$7.40 (Tier 2)
MO
dicloxacillin
$0-$7.40 (Tier 2)
MO
nafcillin injection
$0-$7.40 (Tier 2)
MO
nafcillin intravenous recon soln 2 gram
$0-$7.40 (Tier 2)
MO
oxacillin injection
$0-$7.40 (Tier 2)
MO
oxacillin intravenous
$0-$7.40 (Tier 2)
PENICILLIN G POT IN DEXTROSE
$0-$7.40 (Tier 2)
penicillin g potassium
$0-$7.40 (Tier 2)
MO
penicillin g procaine intramuscular syringe 1.2
million unit/2 ml
$0-$7.40 (Tier 2)
MO
penicillin g procaine intramuscular syringe 600,000
unit/ml
$0-$7.40 (Tier 2)
penicillin g sodium
$0-$7.40 (Tier 2)
MO
penicillin v potassium
$0-$7.40 (Tier 2)
MO
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
20
escalonada
Nombre de la medicina
piperacillin-tazobactam
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
MO
QUINOLONES
ciprofloxacin
$0-$7.40 (Tier 2)
ciprofloxacin (mixture) oral tablet, er multiphase
24 hr 1,000 mg
$0-$7.40 (Tier 2)
MO; QLL (14 per 2 days)
ciprofloxacin (mixture) oral tablet, er multiphase
24 hr 500 mg
$0-$7.40 (Tier 2)
MO; QLL (3 per 2 days)
ciprofloxacin hcl oral tablet
$0-$7.40 (Tier 2)
MO
ciprofloxacin lactate intravenous solution 200 mg/
20 ml
$0-$7.40 (Tier 2)
MO
ciprofloxacin lactate intravenous solution 400 mg/
40 ml
$0-$7.40 (Tier 2)
levofloxacin intravenous
$0-$7.40 (Tier 2)
MO
levofloxacin oral tablet
$0-$7.40 (Tier 2)
MO; QLL (14 per 2 days)
moxifloxacin
$0-$7.40 (Tier 2)
MO; QLL (21 per 2 days)
ofloxacin oral tablet 400 mg
$0-$7.40 (Tier 2)
MO
sulfadiazine oral
$0-$7.40 (Tier 2)
MO
sulfamethoxazole-trimethoprim
$0-$7.40 (Tier 2)
MO
demeclocycline
$0-$7.40 (Tier 2)
MO
DOXY-100
$0-$7.40 (Tier 2)
MO
doxycycline hyclate intravenous
$0-$7.40 (Tier 2)
doxycycline hyclate oral capsule
$0-$7.40 (Tier 2)
MO
doxycycline hyclate oral tablet
$0-$7.40 (Tier 2)
MO
doxycycline hyclate oral tablet,delayed release (dr/
ec) 100 mg, 150 mg, 75 mg
$0-$7.40 (Tier 2)
MO
doxycycline monohydrate oral capsule
$0-$7.40 (Tier 2)
MO
doxycycline monohydrate oral tablet
$0-$7.40 (Tier 2)
MO
minocycline oral capsule
$0-$7.40 (Tier 2)
MO
minocycline oral tablet
$0-$7.40 (Tier 2)
MO
SULFA'S / RELATED AGENTS
TETRACYCLINES
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
21
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
MO
methenamine hippurate
$0-$7.40 (Tier 2)
MO
nitrofurantoin macrocrystal oral capsule 50 mg
$0-$7.40 (Tier 2)
PAR; MO
trimethoprim
$0-$7.40 (Tier 2)
MO
tetracycline
URINARY TRACT AGENTS
VANCOMYCIN
VANCOMYCIN IN 0.9% SODIUM CL
INTRAVENOUS PIGGYBACK 500 MG/100 ML,
750 MG/150 ML
$0-$7.40 (Tier 2)
vancomycin in dextrose 5 % intravenous piggyback
1 gram/200 ml
$0-$7.40 (Tier 2)
vancomycin in dextrose 5 % intravenous piggyback
500 mg/100 ml
$0-$7.40 (Tier 2)
VANCOMYCIN IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 750 MG/150 ML
$0-$7.40 (Tier 2)
vancomycin intravenous
$0-$7.40 (Tier 2)
MO
VANCOMYCIN INTRAVENOUS
$0-$7.40 (Tier 2)
MO
vancomycin oral capsule 125 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (40 per 2 days)
vancomycin oral capsule 250 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (80 per 2 days)
MO
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine crystalline
$0-$7.40 (Tier 2)
PAR; MO
dexrazoxane hcl intravenous recon soln 250 mg
$0-$7.40 (Tier 2)
dexrazoxane hcl intravenous recon soln 500 mg
$0-$7.40 (Tier 2)
MO
ELITEK
$0-$7.40 (Tier 2)
PAR; MO
FUSILEV
$0-$7.40 (Tier 2)
MO
KEPIVANCE
$0-$7.40 (Tier 2)
leucovorin calcium injection recon soln 100 mg,
350 mg, 50 mg
$0-$7.40 (Tier 2)
MO
LEUCOVORIN CALCIUM INJECTION RECON
SOLN 200 MG
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
22
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
LEUCOVORIN CALCIUM INJECTION RECON
SOLN 500 MG
$0-$7.40 (Tier 2)
leucovorin calcium oral
$0-$7.40 (Tier 2)
MO
mesna
$0-$7.40 (Tier 2)
MO
MESNEX ORAL
$0-$7.40 (Tier 2)
MO
XGEVA
$0-$7.40 (Tier 2)
PAR; MO; QLL (1.7 per 28 days)
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ABRAXANE
$0-$7.40 (Tier 2)
MO
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 2 MG, 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 3 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
AFINITOR ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
AFINITOR ORAL TABLET 2.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
AFINITOR ORAL TABLET 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
AFINITOR ORAL TABLET 7.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (40 per 30 days)
ALECENSA
$0-$7.40 (Tier 2)
MO
ALIMTA
$0-$7.40 (Tier 2)
PAR; MO
anastrozole
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
ARRANON
$0-$7.40 (Tier 2)
ARZERRA
$0-$7.40 (Tier 2)
PAR; MO
AVASTIN
$0-$7.40 (Tier 2)
PAR; MO
azacitidine
$0-$7.40 (Tier 2)
PAR; MO
azathioprine
$0-$7.40 (Tier 2)
B/D PAR; MO
azathioprine sodium
$0-$7.40 (Tier 2)
B/D PAR
BELEODAQ
$0-$7.40 (Tier 2)
PAR; MO
BENDEKA
$0-$7.40 (Tier 2)
MO
bexarotene
$0-$7.40 (Tier 2)
PAR; MO
bicalutamide
$0-$7.40 (Tier 2)
MO
BICNU
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
23
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
bleomycin
$0-$7.40 (Tier 2)
MO
BLINCYTO
$0-$7.40 (Tier 2)
PAR; MO
BOSULIF ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
BOSULIF ORAL TABLET 500 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
BUSULFEX
$0-$7.40 (Tier 2)
CABOMETYX ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
PAR; LA; QLL (90 per 30 days)
CABOMETYX ORAL TABLET 40 MG, 60 MG
$0-$7.40 (Tier 2)
PAR; LA; QLL (30 per 30 days)
CAPRELSA ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (90 per 30 days)
CAPRELSA ORAL TABLET 300 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
carboplatin intravenous solution
$0-$7.40 (Tier 2)
MO
CELLCEPT INTRAVENOUS
$0-$7.40 (Tier 2)
B/D PAR; MO
cisplatin
$0-$7.40 (Tier 2)
MO
cladribine
$0-$7.40 (Tier 2)
MO
CLOLAR
$0-$7.40 (Tier 2)
MO
COMETRIQ ORAL CAPSULE 100 MG/DAY(80
MG X1-20 MG X1)
$0-$7.40 (Tier 2)
PAR; MO; QLL (56 per 28 days)
COMETRIQ ORAL CAPSULE 140 MG/DAY(80
MG X1-20 MG X3)
$0-$7.40 (Tier 2)
PAR; MO; QLL (112 per 28 days)
COMETRIQ ORAL CAPSULE 60 MG/DAY (20
MG X 3/DAY)
$0-$7.40 (Tier 2)
PAR; MO; QLL (84 per 28 days)
COTELLIC
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (90 per 30 days)
cyclophosphamide oral capsule
$0-$7.40 (Tier 2)
B/D PAR; MO
cyclosporine intravenous
$0-$7.40 (Tier 2)
B/D PAR
cyclosporine modified
$0-$7.40 (Tier 2)
B/D PAR; MO
cyclosporine oral capsule
$0-$7.40 (Tier 2)
B/D PAR; MO
CYRAMZA
$0-$7.40 (Tier 2)
PAR; MO
cytarabine
$0-$7.40 (Tier 2)
MO
CYTARABINE (PF) INJECTION SOLUTION 100
MG/5 ML (20 MG/ML)
$0-$7.40 (Tier 2)
MO
cytarabine (pf) injection solution 2 gram/20 ml (100
mg/ml)
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
24
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CYTARABINE (PF) INJECTION SOLUTION 20
MG/ML
$0-$7.40 (Tier 2)
dacarbazine
$0-$7.40 (Tier 2)
MO
DARZALEX
$0-$7.40 (Tier 2)
MO; LA
daunorubicin intravenous solution
$0-$7.40 (Tier 2)
decitabine
$0-$7.40 (Tier 2)
DOCEFREZ INTRAVENOUS RECON SOLN 20
MG
$0-$7.40 (Tier 2)
DOCETAXEL INTRAVENOUS SOLUTION 10
MG/ML, 160 MG/16 ML (10 MG/ML), 160 MG/
8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML)
$0-$7.40 (Tier 2)
docetaxel intravenous solution 20 mg/ml (1 ml), 80
mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
$0-$7.40 (Tier 2)
doxorubicin intravenous recon soln
$0-$7.40 (Tier 2)
doxorubicin intravenous solution
$0-$7.40 (Tier 2)
MO
DROXIA
$0-$7.40 (Tier 2)
MO
EMCYT
$0-$7.40 (Tier 2)
MO
EMPLICITI
$0-$7.40 (Tier 2)
B/D PAR; MO
ENVARSUS XR
$0-$7.40 (Tier 2)
B/D PAR; MO
epirubicin intravenous solution 200 mg/100 ml
$0-$7.40 (Tier 2)
epirubicin intravenous solution 50 mg/25 ml
$0-$7.40 (Tier 2)
MO
ERBITUX
$0-$7.40 (Tier 2)
PAR; MO
ERIVEDGE
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
ERWINAZE
$0-$7.40 (Tier 2)
PAR; MO
ETOPOPHOS
$0-$7.40 (Tier 2)
MO
etoposide intravenous
$0-$7.40 (Tier 2)
MO
EVOMELA
$0-$7.40 (Tier 2)
exemestane
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
FARESTON
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
FARYDAK ORAL CAPSULE 10 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
FARYDAK ORAL CAPSULE 15 MG, 20 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
?
MO
MO
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
25
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
FASLODEX
$0-$7.40 (Tier 2)
PAR; MO
FIRMAGON KIT W DILUENT SYRINGE
$0-$7.40 (Tier 2)
PAR; MO
fludarabine intravenous recon soln
$0-$7.40 (Tier 2)
MO
FLUDARABINE INTRAVENOUS SOLUTION
$0-$7.40 (Tier 2)
fluorouracil intravenous
$0-$7.40 (Tier 2)
MO
FLUOROURACIL INTRAVENOUS
$0-$7.40 (Tier 2)
MO
flutamide
$0-$7.40 (Tier 2)
MO
FOLOTYN
$0-$7.40 (Tier 2)
MO
GAZYVA
$0-$7.40 (Tier 2)
PAR; MO
gemcitabine intravenous recon soln 1 gram, 200
mg
$0-$7.40 (Tier 2)
MO
GEMCITABINE INTRAVENOUS RECON SOLN
2 GRAM
$0-$7.40 (Tier 2)
GEMCITABINE INTRAVENOUS SOLUTION 1
GRAM/26.3 ML (38 MG/ML), 200 MG/5.26 ML
(38 MG/ML)
$0-$7.40 (Tier 2)
GEMCITABINE INTRAVENOUS SOLUTION 2
GRAM/52.6 ML (38 MG/ML)
$0-$7.40 (Tier 2)
gengraf oral capsule 100 mg, 25 mg
$0-$7.40 (Tier 2)
B/D PAR; MO
gengraf oral capsule 50 mg
$0-$7.40 (Tier 2)
B/D PAR
gengraf oral solution
$0-$7.40 (Tier 2)
B/D PAR; MO
GILOTRIF
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
GLEEVEC ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
GLEEVEC ORAL TABLET 400 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
GLEOSTINE
$0-$7.40 (Tier 2)
MO
HALAVEN
$0-$7.40 (Tier 2)
PAR; MO
HERCEPTIN
$0-$7.40 (Tier 2)
PAR; MO
HEXALEN
$0-$7.40 (Tier 2)
MO
hydroxyurea
$0-$7.40 (Tier 2)
MO
IBRANCE
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
ICLUSIG ORAL TABLET 15 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
26
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ICLUSIG ORAL TABLET 45 MG
$0-$7.40 (Tier 2)
idarubicin
$0-$7.40 (Tier 2)
ifosfamide intravenous recon soln
$0-$7.40 (Tier 2)
IFOSFAMIDE INTRAVENOUS SOLUTION
$0-$7.40 (Tier 2)
imatinib oral tablet 100 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
imatinib oral tablet 400 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
IMBRUVICA
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
INLYTA ORAL TABLET 1 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
INLYTA ORAL TABLET 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
IRESSA
$0-$7.40 (Tier 2)
MO
irinotecan intravenous solution 100 mg/5 ml, 40
mg/2 ml
$0-$7.40 (Tier 2)
MO
IRINOTECAN INTRAVENOUS SOLUTION 500
MG/25 ML
$0-$7.40 (Tier 2)
ISTODAX
$0-$7.40 (Tier 2)
PAR; MO
IXEMPRA
$0-$7.40 (Tier 2)
MO
JAKAFI ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (150 per 30 days)
JAKAFI ORAL TABLET 15 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (100 per 30 days)
JAKAFI ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (75 per 30 days)
JAKAFI ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
JAKAFI ORAL TABLET 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
JEVTANA
$0-$7.40 (Tier 2)
MO
KADCYLA
$0-$7.40 (Tier 2)
PAR; MO
KEYTRUDA
$0-$7.40 (Tier 2)
PAR; MO
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1/DAY)
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
LENVIMA ORAL CAPSULE 14 MG/DAY(10
MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2)
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
LENVIMA ORAL CAPSULE 18 MG/DAY (10
MG X 1-4 MG X2)
$0-$7.40 (Tier 2)
PAR; QLL (90 per 30 days)
?
PAR; MO; QLL (30 per 30 days)
MO
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
27
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
LENVIMA ORAL CAPSULE 24 MG/DAY(10
MG X 2-4 MG X 1)
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG
X 2), 8 MG/DAY (4 MG X 2) (60 PACK)
$0-$7.40 (Tier 2)
PAR; QLL (60 per 30 days)
letrozole
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
LEUKERAN
$0-$7.40 (Tier 2)
MO
leuprolide subcutaneous kit
$0-$7.40 (Tier 2)
PAR; MO
LONSURF
$0-$7.40 (Tier 2)
PAR; MO
LUPRON DEPOT INTRAMUSCULAR SYRINGE
KIT 3.75 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (1 per 28 days)
LUPRON DEPOT INTRAMUSCULAR SYRINGE
KIT 7.5 MG
$0-$7.40 (Tier 2)
PAR; MO
LUPRON DEPOT-PED INTRAMUSCULAR KIT
7.5 MG (PED)
$0-$7.40 (Tier 2)
PAR; MO; QLL (1 per 28 days)
LYNPARZA
$0-$7.40 (Tier 2)
PAR; MO; QLL (480 per 30 days)
LYSODREN
$0-$7.40 (Tier 2)
MO
MATULANE
$0-$7.40 (Tier 2)
MO
MEGESTROL ORAL SUSPENSION 400 MG/10
ML (10 ML), 800 MG/20 ML (20 ML)
$0-$7.40 (Tier 2)
PAR
megestrol oral suspension 400 mg/10 ml (40 mg/
ml)
$0-$7.40 (Tier 2)
PAR; MO
megestrol oral tablet
$0-$7.40 (Tier 2)
PAR; MO
MEKINIST ORAL TABLET 0.5 MG
$0-$7.40 (Tier 2)
PAR; QLL (90 per 30 days)
MEKINIST ORAL TABLET 2 MG
$0-$7.40 (Tier 2)
PAR; QLL (30 per 30 days)
melphalan hcl
$0-$7.40 (Tier 2)
mercaptopurine
$0-$7.40 (Tier 2)
MO
methotrexate sodium
$0-$7.40 (Tier 2)
MO
methotrexate sodium (pf) injection recon soln
$0-$7.40 (Tier 2)
methotrexate sodium (pf) injection solution
$0-$7.40 (Tier 2)
MO
mitomycin
$0-$7.40 (Tier 2)
MO
mitoxantrone
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
28
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MUSTARGEN
$0-$7.40 (Tier 2)
MO
mycophenolate mofetil
$0-$7.40 (Tier 2)
B/D PAR; MO
mycophenolate sodium
$0-$7.40 (Tier 2)
B/D PAR; MO
NEXAVAR
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (120 per 30 days)
NILANDRON
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
NINLARO
$0-$7.40 (Tier 2)
PAR; MO; QLL (3 per 28 days)
NIPENT
$0-$7.40 (Tier 2)
MO
NULOJIX
$0-$7.40 (Tier 2)
PAR; MO
octreotide acetate
$0-$7.40 (Tier 2)
PAR; MO
ODOMZO
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
ONCASPAR
$0-$7.40 (Tier 2)
PAR; MO
OPDIVO
$0-$7.40 (Tier 2)
PAR; MO
oxaliplatin intravenous recon soln 100 mg
$0-$7.40 (Tier 2)
MO
oxaliplatin intravenous recon soln 50 mg
$0-$7.40 (Tier 2)
oxaliplatin intravenous solution
$0-$7.40 (Tier 2)
MO
paclitaxel
$0-$7.40 (Tier 2)
MO
PERJETA
$0-$7.40 (Tier 2)
PAR; MO
POMALYST ORAL CAPSULE 1 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
POMALYST ORAL CAPSULE 2 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
POMALYST ORAL CAPSULE 3 MG, 4 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
PORTRAZZA
$0-$7.40 (Tier 2)
MO
PROGRAF INTRAVENOUS
$0-$7.40 (Tier 2)
B/D PAR; MO
PURIXAN
$0-$7.40 (Tier 2)
PAR; MO
RAPAMUNE ORAL SOLUTION
$0-$7.40 (Tier 2)
B/D PAR; MO
REVLIMID ORAL CAPSULE 10 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (60 per 30 days)
REVLIMID ORAL CAPSULE 15 MG, 2.5 MG,
20 MG, 25 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
REVLIMID ORAL CAPSULE 5 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (150 per 30 days)
RITUXAN
$0-$7.40 (Tier 2)
PAR; MO
SIGNIFOR
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
29
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
SIMULECT INTRAVENOUS RECON SOLN 10
MG
$0-$7.40 (Tier 2)
B/D PAR
SIMULECT INTRAVENOUS RECON SOLN 20
MG
$0-$7.40 (Tier 2)
B/D PAR; MO
sirolimus
$0-$7.40 (Tier 2)
B/D PAR; MO
SOLTAMOX
$0-$7.40 (Tier 2)
MO
SOMATULINE DEPOT
$0-$7.40 (Tier 2)
PAR; MO
SPRYCEL
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
STIVARGA
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
SUTENT ORAL CAPSULE 12.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50
MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
SYNRIBO
$0-$7.40 (Tier 2)
PAR; MO
TABLOID
$0-$7.40 (Tier 2)
MO
tacrolimus oral
$0-$7.40 (Tier 2)
B/D PAR; MO
TAFINLAR
$0-$7.40 (Tier 2)
PAR; QLL (120 per 30 days)
TAGRISSO ORAL TABLET 40 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (60 per 30 days)
TAGRISSO ORAL TABLET 80 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
tamoxifen
$0-$7.40 (Tier 2)
MO
TARCEVA ORAL TABLET 100 MG, 150 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
TARCEVA ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
TARGRETIN ORAL
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
TARGRETIN TOPICAL
$0-$7.40 (Tier 2)
PAR; MO
TASIGNA
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
TECENTRIQ
$0-$7.40 (Tier 2)
LA; QLL (20 per 21 days)
THALOMID ORAL CAPSULE 100 MG, 50 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
THALOMID ORAL CAPSULE 150 MG, 200 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
thiotepa
$0-$7.40 (Tier 2)
MO
toposar
$0-$7.40 (Tier 2)
MO
topotecan intravenous recon soln
$0-$7.40 (Tier 2)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
30
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
TOPOTECAN INTRAVENOUS SOLUTION
$0-$7.40 (Tier 2)
MO
TORISEL
$0-$7.40 (Tier 2)
MO
TREANDA INTRAVENOUS RECON SOLN
$0-$7.40 (Tier 2)
MO
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION
$0-$7.40 (Tier 2)
MO; QLL (1 per 168 days)
TRELSTAR INTRAMUSCULAR SYRINGE 11.25
MG/2 ML, 3.75 MG/2 ML
$0-$7.40 (Tier 2)
MO
TRELSTAR INTRAMUSCULAR SYRINGE 22.5
MG/2 ML
$0-$7.40 (Tier 2)
MO; QLL (1 per 168 days)
tretinoin (chemotherapy)
$0-$7.40 (Tier 2)
MO
TREXALL
$0-$7.40 (Tier 2)
MO
TRISENOX
$0-$7.40 (Tier 2)
MO
TYKERB
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (180 per 30 days)
UNITUXIN
$0-$7.40 (Tier 2)
MO
VECTIBIX
$0-$7.40 (Tier 2)
PAR; MO
VELCADE
$0-$7.40 (Tier 2)
PAR; MO
VENCLEXTA ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; LA; QLL (60 per 30 days)
VENCLEXTA ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
PAR; LA; QLL (120 per 30 days)
VENCLEXTA ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
PAR; LA; QLL (30 per 30 days)
VENCLEXTA STARTING PACK
$0-$7.40 (Tier 2)
PAR; LA; QLL (42 per 365 days)
vinblastine intravenous solution
$0-$7.40 (Tier 2)
MO
VINCASAR PFS INTRAVENOUS SOLUTION 1
MG/ML
$0-$7.40 (Tier 2)
VINCASAR PFS INTRAVENOUS SOLUTION 2
MG/2 ML
$0-$7.40 (Tier 2)
MO
vincristine
$0-$7.40 (Tier 2)
MO
vinorelbine
$0-$7.40 (Tier 2)
MO
VOTRIENT
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
XALKORI
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
XTANDI
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
YERVOY
$0-$7.40 (Tier 2)
PAR; MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
31
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
YONDELIS
$0-$7.40 (Tier 2)
MO
ZALTRAP
$0-$7.40 (Tier 2)
PAR; MO
ZANOSAR
$0-$7.40 (Tier 2)
MO
ZELBORAF
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
ZOLINZA
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
ZORTRESS
$0-$7.40 (Tier 2)
B/D PAR; MO
ZYDELIG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
ZYKADIA
$0-$7.40 (Tier 2)
PAR; MO; QLL (150 per 30 days)
ZYTIGA
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
APTIOM
$0-$7.40 (Tier 2)
ST; MO
BANZEL ORAL SUSPENSION
$0-$7.40 (Tier 2)
PAR; MO; QLL (2400 per 30 days)
BANZEL ORAL TABLET 200 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (480 per 30 days)
BANZEL ORAL TABLET 400 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
BRIVIACT INTRAVENOUS
$0-$7.40 (Tier 2)
PAR
BRIVIACT ORAL SOLUTION
$0-$7.40 (Tier 2)
PAR; QLL (600 per 30 days)
BRIVIACT ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; QLL (600 per 30 days)
BRIVIACT ORAL TABLET 100 MG, 75 MG
$0-$7.40 (Tier 2)
PAR; QLL (60 per 30 days)
BRIVIACT ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
PAR; QLL (240 per 30 days)
BRIVIACT ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
PAR; QLL (120 per 30 days)
carbamazepine oral capsule, er multiphase 12 hr
$0-$7.40 (Tier 2)
MO
carbamazepine oral suspension 100 mg/5 ml
$0-$7.40 (Tier 2)
MO
carbamazepine oral suspension 200 mg/10 ml
$0-$7.40 (Tier 2)
carbamazepine oral tablet
$0-$7.40 (Tier 2)
carbamazepine oral tablet extended release 12 hr
100 mg
$0-$7.40 (Tier 2)
carbamazepine oral tablet extended release 12 hr
200 mg, 400 mg
$0-$7.40 (Tier 2)
MO
carbamazepine oral tablet,chewable
$0-$7.40 (Tier 2)
MO
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
32
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CELONTIN ORAL CAPSULE 300 MG
$0-$7.40 (Tier 2)
MO
clonazepam oral tablet 0.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (1200 per 30 days)
clonazepam oral tablet 1 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (600 per 30 days)
clonazepam oral tablet 2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
clonazepam oral tablet,disintegrating 0.125 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (4800 per 30 days)
clonazepam oral tablet,disintegrating 0.25 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (2400 per 30 days)
clonazepam oral tablet,disintegrating 0.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (1200 per 30 days)
clonazepam oral tablet,disintegrating 1 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (600 per 30 days)
clonazepam oral tablet,disintegrating 2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
diazepam rectal kit 12.5-15-17.5-20 mg
$0-$7.40 (Tier 2)
MO
diazepam rectal kit 2.5 mg, 5-7.5-10 mg
$0-$7.40 (Tier 2)
MO; QLL (2 per 2 days)
DILANTIN EXTENDED CAPSULES
$0-$7.40 (Tier 2)
MO
DILANTIN INFATABS
$0-$7.40 (Tier 2)
MO
DILANTIN ORAL CAPSULES 30 MG
$0-$7.40 (Tier 2)
MO
divalproex
$0-$7.40 (Tier 2)
MO
epitol
$0-$7.40 (Tier 2)
MO
EQUETRO ORAL CAPSULE, ER MULTIPHASE
12 HR 100 MG
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
EQUETRO ORAL CAPSULE, ER MULTIPHASE
12 HR 200 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
EQUETRO ORAL CAPSULE, ER MULTIPHASE
12 HR 300 MG
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
ethosuximide
$0-$7.40 (Tier 2)
MO
felbamate
$0-$7.40 (Tier 2)
MO
fosphenytoin
$0-$7.40 (Tier 2)
MO
FYCOMPA ORAL SUSPENSION
$0-$7.40 (Tier 2)
QLL (720 per 30 days)
FYCOMPA ORAL TABLET 10 MG, 12 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
FYCOMPA ORAL TABLET 2 MG
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
FYCOMPA ORAL TABLET 4 MG
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
FYCOMPA ORAL TABLET 6 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
33
Nombre de la medicina
FYCOMPA ORAL TABLET 8 MG
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
gabapentin oral capsule 100 mg
$0 (Tier 1)
MO; QLL (1080 per 30 days)
gabapentin oral capsule 300 mg
$0 (Tier 1)
MO; QLL (360 per 30 days)
gabapentin oral capsule 400 mg
$0 (Tier 1)
MO; QLL (270 per 30 days)
gabapentin oral solution 250 mg/5 ml
$0-$7.40 (Tier 2)
MO; QLL (2160 per 30 days)
GABAPENTIN ORAL SOLUTION 250 MG/5 ML
(5 ML), 300 MG/6 ML (6 ML)
$0-$7.40 (Tier 2)
QLL (2160 per 30 days)
gabapentin oral tablet 600 mg
$0 (Tier 1)
MO; QLL (180 per 30 days)
gabapentin oral tablet 800 mg
$0 (Tier 1)
MO; QLL (135 per 30 days)
GABITRIL ORAL TABLET 12 MG, 16 MG
$0-$7.40 (Tier 2)
MO
lamotrigine oral tablet
$0-$7.40 (Tier 2)
MO
lamotrigine oral tablet, chewable dispersible
$0-$7.40 (Tier 2)
MO
levetiracetam in nacl (iso-os) intravenous piggyback
1,000 mg/100 ml, 1,500 mg/100 ml
$0-$7.40 (Tier 2)
levetiracetam in nacl (iso-os) intravenous piggyback
500 mg/100 ml
$0-$7.40 (Tier 2)
MO
levetiracetam intravenous
$0-$7.40 (Tier 2)
MO
levetiracetam oral solution 100 mg/ml
$0-$7.40 (Tier 2)
MO
LEVETIRACETAM ORAL SOLUTION 500 MG/
5 ML (5 ML)
$0-$7.40 (Tier 2)
levetiracetam oral tablet
$0-$7.40 (Tier 2)
MO
levetiracetam oral tablet extended release 24 hr 500
mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
levetiracetam oral tablet extended release 24 hr 750
mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
LYRICA ORAL CAPSULE 100 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (180 per 30 days)
LYRICA ORAL CAPSULE 150 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
LYRICA ORAL CAPSULE 200 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
LYRICA ORAL CAPSULE 225 MG, 300 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
LYRICA ORAL CAPSULE 25 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (720 per 30 days)
LYRICA ORAL CAPSULE 50 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (360 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
34
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
LYRICA ORAL CAPSULE 75 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
LYRICA ORAL SOLUTION
$0-$7.40 (Tier 2)
PAR; MO; QLL (900 per 30 days)
ONFI ORAL SUSPENSION
$0-$7.40 (Tier 2)
PAR; MO; QLL (480 per 30 days)
ONFI ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
ONFI ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
oxcarbazepine
$0-$7.40 (Tier 2)
MO
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR 600 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
PEGANONE
$0-$7.40 (Tier 2)
MO
phenobarbital oral elixir
$0-$7.40 (Tier 2)
PAR; MO; QLL (3000 per 30 days)
phenobarbital oral tablet 100 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
phenobarbital oral tablet 15 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (800 per 30 days)
phenobarbital oral tablet 16.2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (741 per 30 days)
phenobarbital oral tablet 30 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (400 per 30 days)
phenobarbital oral tablet 32.4 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (370 per 30 days)
phenobarbital oral tablet 60 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (200 per 30 days)
phenobarbital oral tablet 64.8 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (185 per 30 days)
phenobarbital oral tablet 97.2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (123 per 30 days)
PHENYTEK
$0-$7.40 (Tier 2)
MO
PHENYTOIN ORAL SUSPENSION 100 MG/4
ML
$0-$7.40 (Tier 2)
phenytoin oral suspension 125 mg/5 ml
$0-$7.40 (Tier 2)
MO
phenytoin oral tablet,chewable
$0-$7.40 (Tier 2)
MO
phenytoin sodium extended
$0-$7.40 (Tier 2)
MO
phenytoin sodium intravenous solution
$0-$7.40 (Tier 2)
MO
phenytoin sodium intravenous syringe
$0-$7.40 (Tier 2)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
35
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
POTIGA ORAL TABLET 200 MG, 300 MG, 400
MG
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
POTIGA ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
MO; QLL (270 per 30 days)
primidone
$0-$7.40 (Tier 2)
MO
roweepra
$0-$7.40 (Tier 2)
SABRIL
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (180 per 30 days)
SPRITAM ORAL TABLET FOR SUSPENSION
1,000 MG, 250 MG, 500 MG
$0-$7.40 (Tier 2)
PAR; QLL (60 per 30 days)
SPRITAM ORAL TABLET FOR SUSPENSION
750 MG
$0-$7.40 (Tier 2)
PAR; QLL (120 per 30 days)
tiagabine
$0-$7.40 (Tier 2)
MO
topiramate oral capsule, sprinkle
$0-$7.40 (Tier 2)
PAR; MO
topiramate oral tablet 100 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (480 per 30 days)
topiramate oral tablet 200 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
topiramate oral tablet 25 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (1920 per 30 days)
topiramate oral tablet 50 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (960 per 30 days)
valproate sodium
$0-$7.40 (Tier 2)
MO
valproic acid
$0-$7.40 (Tier 2)
MO
valproic acid (as sodium salt) oral solution 250 mg/
5 ml
$0-$7.40 (Tier 2)
MO
VALPROIC ACID (AS SODIUM SALT) ORAL
SOLUTION 250 MG/5 ML (5 ML), 500 MG/10
ML (10 ML)
$0-$7.40 (Tier 2)
VIMPAT INTRAVENOUS
$0-$7.40 (Tier 2)
QLL (1200 per 30 days)
VIMPAT ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (1200 per 30 days)
VIMPAT ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
VIMPAT ORAL TABLET 150 MG
$0-$7.40 (Tier 2)
MO; QLL (80 per 30 days)
VIMPAT ORAL TABLET 200 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
VIMPAT ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
zonisamide
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
36
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ANTIPARKINSONISM AGENTS
APOKYN
$0-$7.40 (Tier 2)
PAR; MO; LA
AZILECT
$0-$7.40 (Tier 2)
MO
benztropine oral
$0-$7.40 (Tier 2)
PAR; MO
bromocriptine
$0-$7.40 (Tier 2)
MO
carbidopa-levodopa
$0-$7.40 (Tier 2)
MO
entacapone
$0-$7.40 (Tier 2)
MO
NEUPRO
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
pramipexole oral tablet
$0-$7.40 (Tier 2)
MO
ropinirole oral tablet
$0-$7.40 (Tier 2)
MO
selegiline hcl
$0-$7.40 (Tier 2)
MO
tolcapone
$0-$7.40 (Tier 2)
MO
MIGRAINE / CLUSTER HEADACHE THERAPY
dihydroergotamine injection
$0-$7.40 (Tier 2)
PAR; MO
ERGOMAR
$0-$7.40 (Tier 2)
MO
rizatriptan
$0-$7.40 (Tier 2)
MO; QLL (12 per 30 days)
sumatriptan succinate oral
$0-$7.40 (Tier 2)
MO; QLL (9 per 30 days)
sumatriptan succinate subcutaneous cartridge
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
sumatriptan succinate subcutaneous pen injector
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
sumatriptan succinate subcutaneous solution
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg/
0.5 ml
$0-$7.40 (Tier 2)
QLL (4 per 30 days)
zolmitriptan
$0-$7.40 (Tier 2)
MO; QLL (9 per 30 days)
ZOMIG NASAL
$0-$7.40 (Tier 2)
MO; QLL (6 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (60 per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (12 per 28 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
37
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
donepezil oral tablet 10 mg, 5 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
donepezil oral tablet,disintegrating
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
galantamine oral capsule,ext rel. pellets 24 hr
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
galantamine oral solution
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
galantamine oral tablet
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
GILENYA
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
GLATOPA
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
memantine oral solution
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
memantine oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
memantine oral tablet 5 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
NAMENDA ORAL SOLUTION
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR
DOSE PACK
$0-$7.40 (Tier 2)
MO; QLL (56 per 365 days)
NAMENDA XR ORAL CAPSULE,SPRINKLE,
ER 24HR
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
NAMZARIC
$0-$7.40 (Tier 2)
MO
NUEDEXTA
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
rivastigmine
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
rivastigmine tartrate
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
TECFIDERA
$0-$7.40 (Tier 2)
PAR; MO
tetrabenazine oral tablet 12.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
tetrabenazine oral tablet 25 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
TYSABRI
$0-$7.40 (Tier 2)
PAR; MO; LA
XENAZINE ORAL TABLET 12.5 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (240 per 30 days)
XENAZINE ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (120 per 30 days)
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
baclofen
$0-$7.40 (Tier 2)
MO
cyclobenzaprine oral tablet
$0-$7.40 (Tier 2)
PAR; MO
dantrolene
$0-$7.40 (Tier 2)
MO
MESTINON ORAL SYRUP
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
38
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MESTINON TIMESPAN
$0-$7.40 (Tier 2)
MO
pyridostigmine bromide
$0-$7.40 (Tier 2)
MO
tizanidine oral tablet
$0-$7.40 (Tier 2)
MO
acetaminophen-codeine oral solution 120 mg-12
mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml
$0-$7.40 (Tier 2)
QLL (4500 per 30 days)
acetaminophen-codeine oral solution 120-12 mg/5
ml
$0-$7.40 (Tier 2)
MO; QLL (4500 per 30 days)
ACETAMINOPHEN-CODEINE ORAL
SOLUTION 240 MG-24 MG /10 ML (10 ML)
$0-$7.40 (Tier 2)
QLL (4500 per 30 days)
acetaminophen-codeine oral tablet 300-15 mg
$0-$7.40 (Tier 2)
MO; QLL (390 per 30 days)
acetaminophen-codeine oral tablet 300-30 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
acetaminophen-codeine oral tablet 300-60 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
buprenorphine hcl injection solution
$0-$7.40 (Tier 2)
MO; QLL (150 per 30 days)
buprenorphine hcl injection syringe
$0-$7.40 (Tier 2)
QLL (150 per 30 days)
buprenorphine hcl sublingual tablet 2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
buprenorphine hcl sublingual tablet 8 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
BUTALBITAL COMPOUND W/CODEINE
$0-$7.40 (Tier 2)
PAR; MO; QLL (180 per 30 days)
duramorph (pf) injection solution 0.5 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
duramorph (pf) injection solution 1 mg/ml
$0-$7.40 (Tier 2)
QLL (180 per 30 days)
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325
mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
fentanyl citrate
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
$0-$7.40 (Tier 2)
ST; MO; QLL (15 per 30 days)
HYDROCODONE-ACETAMINOPHEN ORAL
SOLUTION 2.5-167 MG/5 ML
$0-$7.40 (Tier 2)
QLL (2700 per 30 days)
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml
$0-$7.40 (Tier 2)
MO; QLL (2700 per 30 days)
hydrocodone-acetaminophen oral tablet 10-300 mg,
5-300 mg, 7.5-300 mg
$0-$7.40 (Tier 2)
MO; QLL (390 per 30 days)
NARCOTIC ANALGESICS
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
39
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
hydrocodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
hydrocodone-ibuprofen oral tablet 10-200 mg, 5200 mg, 7.5-200 mg
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
hydromorphone oral tablet 2 mg, 4 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
hydromorphone oral tablet 8 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
levorphanol tartrate
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
methadone injection
$0-$7.40 (Tier 2)
QLL (150 per 30 days)
METHADONE INTENSOL
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
methadone oral concentrate
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
methadone oral solution 10 mg/5 ml
$0-$7.40 (Tier 2)
MO; QLL (900 per 30 days)
methadone oral solution 5 mg/5 ml
$0-$7.40 (Tier 2)
MO; QLL (1800 per 30 days)
methadone oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
methadone oral tablet 5 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
METHADOSE ORAL CONCENTRATE
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
morphine (pf) injection solution 0.5 mg/ml
$0-$7.40 (Tier 2)
morphine (pf) injection solution 1 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
MORPHINE (PF) INTRAVENOUS PATIENT
CONTROL.ANALGESIA SOLN 150 MG/30 ML
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
MORPHINE (PF) INTRAVENOUS PATIENT
CONTROL.ANALGESIA SOLN 30 MG/30 ML
$0-$7.40 (Tier 2)
QLL (180 per 30 days)
morphine concentrate oral solution
$0-$7.40 (Tier 2)
MO; QLL (270 per 30 days)
MORPHINE INTRAVENOUS CARTRIDGE
$0-$7.40 (Tier 2)
QLL (120 per 30 days)
MORPHINE INTRAVENOUS SOLUTION 10
MG/ML, 50 MG/ML
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
MORPHINE INTRAVENOUS SOLUTION 100
MG/4 ML, 25 MG/ML, 250 MG/10 ML
$0-$7.40 (Tier 2)
QLL (120 per 30 days)
MORPHINE INTRAVENOUS SOLUTION 4 MG/
ML, 8 MG/ML
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
morphine intravenous syringe 2 mg/ml, 4 mg/ml
$0-$7.40 (Tier 2)
QLL (120 per 30 days)
morphine oral capsule, er multiphase 24 hr 120 mg,
75 mg, 90 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
40
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
morphine oral capsule, er multiphase 24 hr 30 mg,
45 mg, 60 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
morphine oral capsule,extend.release pellets 100
mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
morphine oral solution 20 mg/5 ml (4 mg/ml)
$0-$7.40 (Tier 2)
MO; QLL (1350 per 30 days)
morphine oral tablet 15 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
morphine oral tablet 30 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
morphine oral tablet extended release 100 mg, 15
mg, 30 mg, 60 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
morphine oral tablet extended release 200 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
oxycodone oral capsule
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
oxycodone oral concentrate
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
oxycodone oral tablet 10 mg, 5 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
oxycodone oral tablet 15 mg
$0-$7.40 (Tier 2)
MO; QLL (540 per 30 days)
oxycodone oral tablet 20 mg, 30 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
oxycodone-acetaminophen oral solution
$0-$7.40 (Tier 2)
QLL (1800 per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
oxycodone-aspirin
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
NON-NARCOTIC ANALGESICS
acephen rectal suppository 120 mg, 650 mg
$0 (Tier 4)
MO; [*]
acephen rectal suppository 325 mg
$0 (Tier 4)
[*]
ACETA-GESIC
$0 (Tier 4)
[*]
acetaminophen oral tablet 325 mg
$0 (Tier 4)
MO; [*]
all day pain relief
$0 (Tier 4)
[*]
all day relief
$0 (Tier 4)
MO; [*]
arthritis pain relief (acetam)
$0 (Tier 4)
[*]
aspir-low
$0 (Tier 4)
MO; [*]
aspirin oral tablet
$0 (Tier 4)
MO; [*]
aspirin oral tablet,chewable
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
41
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
aspirin oral tablet,delayed release (dr/ec) 325 mg,
81 mg
$0 (Tier 4)
MO; [*]
buprenorphine-naloxone sublingual tablet 2-0.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (360 per 30 days)
buprenorphine-naloxone sublingual tablet 8-2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
butorphanol tartrate injection solution 1 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
butorphanol tartrate injection solution 2 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
butorphanol tartrate nasal
$0-$7.40 (Tier 2)
MO; QLL (5 per 28 days)
child ibuprofen
$0 (Tier 4)
[*]
children's aspirin
$0 (Tier 4)
MO; [*]
children's ibuprofen
$0 (Tier 4)
MO; [*]
children's mapap
$0 (Tier 4)
[*]
children's pain-fever relief oral liquid
$0 (Tier 4)
MO; [*]
children's pain-fever relief oral suspension
$0 (Tier 4)
MO; [*]
CHILDREN'S PAIN-FEVER RELIEF ORAL
TABLET,CHEWABLE
$0 (Tier 4)
MO; [*]
children's q-pap
$0 (Tier 4)
MO; [*]
diclofenac potassium
$0-$7.40 (Tier 2)
MO
diclofenac sodium oral
$0-$7.40 (Tier 2)
MO
diclofenac sodium topical gel 1 %
$0-$7.40 (Tier 2)
QLL (1000 per 30 days)
diflunisal
$0-$7.40 (Tier 2)
MO
diphenhydramine-acetaminophen
$0 (Tier 4)
[*]
ed-apap
$0 (Tier 4)
[*]
effervescent pain relief oral tablet, effervescent 3251,916-1,000 mg
$0 (Tier 4)
[*]
etodolac oral capsule 200 mg
$0-$7.40 (Tier 2)
MO
etodolac oral tablet
$0-$7.40 (Tier 2)
MO
etodolac oral tablet extended release 24 hr
$0-$7.40 (Tier 2)
MO
fenoprofen oral tablet
$0-$7.40 (Tier 2)
MO
flurbiprofen
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
HISTAFLEX
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
42
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ibu-drops
$0 (Tier 4)
[*]
ibuprofen jr strength
$0 (Tier 4)
[*]
ibuprofen oral capsule
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
ibuprofen oral suspension
ibuprofen oral tablet 200 mg
$0 (Tier 4)
MO; [*]
$0-$7.40 (Tier 2)
MO
infant's ibuprofen
$0 (Tier 4)
[*]
infants ibu-drops
$0 (Tier 4)
[*]
junior mapap
$0 (Tier 4)
MO; [*]
mapap (acetaminophen) oral capsule
$0 (Tier 4)
MO; [*]
mapap (acetaminophen) oral liquid
$0 (Tier 4)
MO; [*]
mapap (acetaminophen) oral suspension
$0 (Tier 4)
[*]
mapap (acetaminophen) oral tablet
$0 (Tier 4)
MO; [*]
mapap (acetaminophen) oral tablet,chewable
$0 (Tier 4)
MO; [*]
mapap arthritis pain
$0 (Tier 4)
MO; [*]
mapap extra strength
$0 (Tier 4)
MO; [*]
mapap pm
$0 (Tier 4)
MO; [*]
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
meclofenamate oral
$0-$7.40 (Tier 2)
MO
meloxicam oral suspension
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
meloxicam oral tablet
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
$0 (Tier 4)
[*]
nabumetone
$0-$7.40 (Tier 2)
MO
nalbuphine injection solution 10 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
nalbuphine injection solution 20 mg/ml
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
naloxone
$0-$7.40 (Tier 2)
MO
naltrexone
$0-$7.40 (Tier 2)
MO
naproxen
$0-$7.40 (Tier 2)
MO
migraine formula
naproxen sodium oral tablet 220 mg
naproxen sodium oral tablet 275 mg, 550 mg
?
$0 (Tier 4)
$0-$7.40 (Tier 2)
MO; [*]
MO
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
43
Nombre de la medicina
non-aspirin pm
oxaprozin
pain and fever
piroxicam
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
$0-$7.40 (Tier 2)
MO; [*]
MO
q-pap extra strength
$0 (Tier 4)
MO; [*]
q-pap oral drops
$0 (Tier 4)
MO; [*]
q-pap oral liquid
$0 (Tier 4)
MO; [*]
q-pap oral tablet 325 mg
$0 (Tier 4)
[*]
q-pap oral tablet 500 mg
$0 (Tier 4)
MO; [*]
SUBOXONE SUBLINGUAL FILM 12-3 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (360 per 30 days)
SUBOXONE SUBLINGUAL FILM 4-1 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (180 per 30 days)
SUBOXONE SUBLINGUAL FILM 8-2 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
sulindac oral
$0-$7.40 (Tier 2)
MO
tolmetin
$0-$7.40 (Tier 2)
MO
tramadol oral tablet
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
tramadol-acetaminophen
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
VOLTAREN GEL TOPICAL GEL 1 %
$0-$7.40 (Tier 2)
MO; QLL (1000 per 30 days)
ABILIFY MAINTENA
$0-$7.40 (Tier 2)
MO; QLL (1 per 28 days)
ADASUVE
$0-$7.40 (Tier 2)
alprazolam oral tablet
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
amitriptyline
$0-$7.40 (Tier 2)
PAR; MO
amoxapine
$0-$7.40 (Tier 2)
MO
PSYCHOTHERAPEUTIC DRUGS
aripiprazole oral solution
$0 (Tier 1)
PAR; MO; QLL (900 per 30 days)
aripiprazole oral tablet 10 mg
$0 (Tier 1)
PAR; MO; QLL (90 per 30 days)
aripiprazole oral tablet 15 mg
$0 (Tier 1)
PAR; MO; QLL (60 per 30 days)
aripiprazole oral tablet 2 mg
$0 (Tier 1)
PAR; MO; QLL (450 per 30 days)
aripiprazole oral tablet 20 mg, 30 mg
$0 (Tier 1)
PAR; MO; QLL (30 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
44
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
aripiprazole oral tablet 5 mg
$0 (Tier 1)
PAR; MO; QLL (180 per 30 days)
aripiprazole oral tablet,disintegrating 10 mg
$0 (Tier 1)
PAR; MO; QLL (90 per 30 days)
aripiprazole oral tablet,disintegrating 15 mg
$0 (Tier 1)
PAR; MO; QLL (60 per 30 days)
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED REL SYRING 441 MG/1.6 ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (1.6 per 30 days)
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED REL SYRING 662 MG/2.4 ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (2.4 per 30 days)
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED REL SYRING 882 MG/3.2 ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (3.2 per 30 days)
bupropion hcl oral tablet 100 mg
$0-$7.40 (Tier 2)
MO; QLL (135 per 30 days)
bupropion hcl oral tablet 75 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
bupropion hcl oral tablet extended release 100 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
bupropion hcl oral tablet extended release 150 mg,
200 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
bupropion hcl oral tablet extended release 24 hr
150 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
bupropion hcl oral tablet extended release 24 hr
300 mg
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
buspirone
$0-$7.40 (Tier 2)
MO
chlorpromazine
$0-$7.40 (Tier 2)
PAR; MO
citalopram oral solution
$0-$7.40 (Tier 2)
MO; QLL (600 per 30 days)
citalopram oral tablet 10 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
citalopram oral tablet 20 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
citalopram oral tablet 40 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
clomipramine
$0-$7.40 (Tier 2)
PAR; MO
clorazepate dipotassium
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
clozapine oral tablet 100 mg
$0 (Tier 1)
MO; QLL (270 per 30 days)
clozapine oral tablet 200 mg
$0 (Tier 1)
MO; QLL (135 per 30 days)
clozapine oral tablet 25 mg
$0 (Tier 1)
MO; QLL (1080 per 30 days)
clozapine oral tablet 50 mg
$0 (Tier 1)
MO; QLL (540 per 30 days)
clozapine oral tablet,disintegrating 100 mg
$0 (Tier 1)
QLL (270 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
45
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
clozapine oral tablet,disintegrating 12.5 mg
$0 (Tier 1)
QLL (2160 per 30 days)
clozapine oral tablet,disintegrating 150 mg
$0 (Tier 1)
QLL (180 per 30 days)
clozapine oral tablet,disintegrating 200 mg
$0 (Tier 1)
QLL (135 per 30 days)
clozapine oral tablet,disintegrating 25 mg
$0 (Tier 1)
QLL (1080 per 30 days)
desipramine oral
$0-$7.40 (Tier 2)
MO
DESVENLAFAXINE FUMARATE ORAL
TABLET EXTENDED RELEASE 24HR 100 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
DESVENLAFAXINE FUMARATE ORAL
TABLET EXTENDED RELEASE 24HR 50 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 50 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
desvenlafaxine oral tablet extended release 24hr
100 mg
$0-$7.40 (Tier 2)
QLL (120 per 30 days)
desvenlafaxine oral tablet extended release 24hr 50
mg
$0-$7.40 (Tier 2)
QLL (240 per 30 days)
dextroamphetamine oral capsule, extended release
10 mg, 5 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
dextroamphetamine oral capsule, extended release
15 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
dextroamphetamine oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
dextroamphetamine oral tablet 5 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
dextroamphetamine-amphetamine oral tablet 10
mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
dextroamphetamine-amphetamine oral tablet 30
mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
diazepam injection solution
$0-$7.40 (Tier 2)
diazepam injection syringe
$0-$7.40 (Tier 2)
MO
diazepam intensol
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
diazepam oral concentrate
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
diazepam oral solution 5 mg/5 ml (1 mg/ml)
$0-$7.40 (Tier 2)
PAR; MO; QLL (1200 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
46
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1
MG/ML, 5 ML)
$0-$7.40 (Tier 2)
PAR; QLL (1200 per 30 days)
diazepam oral tablet 10 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
diazepam oral tablet 2 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (600 per 30 days)
diazepam oral tablet 5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
doxepin oral
$0-$7.40 (Tier 2)
PAR; MO
duloxetine oral capsule,delayed release(dr/ec) 20
mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 30
mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 40
mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 60
mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
EMSAM
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
ergoloid
$0-$7.40 (Tier 2)
PAR; MO
escitalopram oxalate oral solution
$0-$7.40 (Tier 2)
MO; QLL (600 per 30 days)
escitalopram oxalate oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
escitalopram oxalate oral tablet 20 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
escitalopram oxalate oral tablet 5 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
FANAPT ORAL TABLET 1 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (720 per 30 days)
FANAPT ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
ST; QLL (72 per 30 days)
FANAPT ORAL TABLET 12 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (60 per 30 days)
FANAPT ORAL TABLET 2 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (360 per 30 days)
FANAPT ORAL TABLET 4 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (180 per 30 days)
FANAPT ORAL TABLET 6 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (120 per 30 days)
FANAPT ORAL TABLET 8 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (90 per 30 days)
FANAPT ORAL TABLETS,DOSE PACK
$0-$7.40 (Tier 2)
ST; MO; QLL (16 per 365 days)
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK
$0-$7.40 (Tier 2)
PAR; MO; QLL (56 per 365 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
47
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 80 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 20 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (180 per 30 days)
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 40 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
fluoxetine oral capsule 10 mg
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
fluoxetine oral capsule 20 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
fluoxetine oral capsule 40 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
fluoxetine oral solution
$0-$7.40 (Tier 2)
MO; QLL (600 per 30 days)
fluoxetine oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
fluoxetine oral tablet 20 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
fluphenazine decanoate
$0 (Tier 1)
MO
fluphenazine hcl
$0 (Tier 1)
MO
fluvoxamine oral tablet 100 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
fluvoxamine oral tablet 25 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
fluvoxamine oral tablet 50 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
GEODON INTRAMUSCULAR
$0-$7.40 (Tier 2)
MO
guanfacine oral tablet extended release 24 hr
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
guanidine
$0-$7.40 (Tier 2)
MO
haloperidol
$0 (Tier 1)
MO
haloperidol decanoate
$0 (Tier 1)
MO
haloperidol lactate
$0 (Tier 1)
MO
HETLIOZ
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
imipramine hcl
$0-$7.40 (Tier 2)
PAR; MO
INVEGA ORAL TABLET EXTENDED RELEASE
24HR 1.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
INVEGA ORAL TABLET EXTENDED RELEASE
24HR 3 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
INVEGA ORAL TABLET EXTENDED RELEASE
24HR 6 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
48
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
INVEGA ORAL TABLET EXTENDED RELEASE
24HR 9 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
INVEGA SUSTENNA
$0-$7.40 (Tier 2)
MO; QLL (2 per 28 days)
INVEGA TRINZA INTRAMUSCULAR SYRINGE
273 MG/0.875 ML
$0-$7.40 (Tier 2)
MO; QLL (0.875 per 90 days)
INVEGA TRINZA INTRAMUSCULAR SYRINGE
410 MG/1.315 ML
$0-$7.40 (Tier 2)
MO; QLL (1.315 per 90 days)
INVEGA TRINZA INTRAMUSCULAR SYRINGE
546 MG/1.75 ML
$0-$7.40 (Tier 2)
MO; QLL (1.75 per 90 days)
INVEGA TRINZA INTRAMUSCULAR SYRINGE
819 MG/2.625 ML
$0-$7.40 (Tier 2)
MO; QLL (2.625 per 90 days)
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 100 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 50 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
LATUDA ORAL TABLET 120 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
LATUDA ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
LATUDA ORAL TABLET 40 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
LATUDA ORAL TABLET 60 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (75 per 30 days)
LATUDA ORAL TABLET 80 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
lithium carbonate
$0 (Tier 1)
MO
lithium citrate oral solution 8 meq/5 ml
$0 (Tier 1)
MO
lorazepam oral tablet
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
loxapine succinate
$0-$7.40 (Tier 2)
MO
maprotiline oral tablet 25 mg
$0-$7.40 (Tier 2)
MO; QLL (270 per 30 days)
maprotiline oral tablet 50 mg
$0-$7.40 (Tier 2)
MO; QLL (135 per 30 days)
maprotiline oral tablet 75 mg
$0-$7.40 (Tier 2)
MO
MARPLAN
$0-$7.40 (Tier 2)
MO
methylphenidate oral tablet
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
mirtazapine oral tablet 15 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
mirtazapine oral tablet 30 mg
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
49
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
mirtazapine oral tablet 45 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
mirtazapine oral tablet 7.5 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
mirtazapine oral tablet,disintegrating 15 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
mirtazapine oral tablet,disintegrating 30 mg
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
mirtazapine oral tablet,disintegrating 45 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
modafinil oral tablet 100 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
modafinil oral tablet 200 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
molindone
$0-$7.40 (Tier 2)
nefazodone oral tablet 100 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
nefazodone oral tablet 150 mg
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
nefazodone oral tablet 200 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
nefazodone oral tablet 250 mg
$0-$7.40 (Tier 2)
MO; QLL (72 per 30 days)
nefazodone oral tablet 50 mg
$0-$7.40 (Tier 2)
MO; QLL (360 per 30 days)
nortriptyline
$0-$7.40 (Tier 2)
MO
NUPLAZID
$0-$7.40 (Tier 2)
PAR; LA; QLL (60 per 30 days)
olanzapine intramuscular
$0 (Tier 1)
MO; QLL (60 per 30 days)
olanzapine oral tablet 10 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
olanzapine oral tablet 15 mg
$0 (Tier 1)
MO; QLL (40 per 30 days)
olanzapine oral tablet 2.5 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
olanzapine oral tablet 20 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
olanzapine oral tablet 5 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
olanzapine oral tablet 7.5 mg
$0 (Tier 1)
MO; QLL (80 per 30 days)
olanzapine oral tablet,disintegrating 10 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
olanzapine oral tablet,disintegrating 15 mg
$0 (Tier 1)
MO; QLL (40 per 30 days)
olanzapine oral tablet,disintegrating 20 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
olanzapine oral tablet,disintegrating 5 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
ORAP
paliperidone oral tablet extended release 24hr 1.5
mg
$0-$7.40 (Tier 2)
$0 (Tier 1)
MO
PAR; MO; QLL (240 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
50
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
paliperidone oral tablet extended release 24hr 3
mg
$0 (Tier 1)
PAR; MO; QLL (120 per 30 days)
paliperidone oral tablet extended release 24hr 6
mg
$0 (Tier 1)
PAR; MO; QLL (60 per 30 days)
paliperidone oral tablet extended release 24hr 9
mg
$0 (Tier 1)
PAR; MO; QLL (30 per 30 days)
paroxetine hcl oral tablet 10 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
paroxetine hcl oral tablet 20 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
paroxetine hcl oral tablet 30 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
paroxetine hcl oral tablet 40 mg
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
paroxetine hcl oral tablet extended release 24 hr
12.5 mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
paroxetine hcl oral tablet extended release 24 hr
25 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
paroxetine hcl oral tablet extended release 24 hr
37.5 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
PAXIL ORAL SUSPENSION
$0-$7.40 (Tier 2)
MO; QLL (900 per 30 days)
perphenazine
$0 (Tier 1)
MO
phenelzine
$0 (Tier 1)
MO
pimozide
$0-$7.40 (Tier 2)
MO
protriptyline
$0-$7.40 (Tier 2)
MO
quetiapine oral tablet 100 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
quetiapine oral tablet 200 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
quetiapine oral tablet 25 mg
$0 (Tier 1)
MO; QLL (960 per 30 days)
quetiapine oral tablet 300 mg
$0 (Tier 1)
MO; QLL (80 per 30 days)
quetiapine oral tablet 400 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
quetiapine oral tablet 50 mg
$0 (Tier 1)
MO; QLL (480 per 30 days)
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
REXULTI ORAL TABLET 3 MG, 4 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
51
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/
2 ML
$0-$7.40 (Tier 2)
MO; QLL (2 per 28 days)
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 50 MG/2 ML
$0-$7.40 (Tier 2)
MO
risperidone oral solution
$0 (Tier 1)
MO; QLL (480 per 30 days)
risperidone oral tablet 0.25 mg
$0 (Tier 1)
MO; QLL (1920 per 30 days)
risperidone oral tablet 0.5 mg
$0 (Tier 1)
MO; QLL (960 per 30 days)
risperidone oral tablet 1 mg
$0 (Tier 1)
MO; QLL (480 per 30 days)
risperidone oral tablet 2 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
risperidone oral tablet 3 mg
$0 (Tier 1)
MO; QLL (150 per 30 days)
risperidone oral tablet 4 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
risperidone oral tablet,disintegrating 0.25 mg
$0 (Tier 1)
MO; QLL (1920 per 30 days)
risperidone oral tablet,disintegrating 0.5 mg
$0 (Tier 1)
MO; QLL (960 per 30 days)
risperidone oral tablet,disintegrating 1 mg
$0 (Tier 1)
MO; QLL (480 per 30 days)
risperidone oral tablet,disintegrating 2 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
risperidone oral tablet,disintegrating 3 mg
$0 (Tier 1)
MO; QLL (150 per 30 days)
risperidone oral tablet,disintegrating 4 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
ROZEREM
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 2.5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (240 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (150 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 200 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (80 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
52
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 400 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 50 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (480 per 30 days)
sertraline oral concentrate
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
sertraline oral tablet 100 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
sertraline oral tablet 25 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
sertraline oral tablet 50 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
sleep aid (doxylamine)
$0 (Tier 4)
[*]
STRATTERA ORAL CAPSULE 10 MG, 18 MG,
25 MG, 40 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
STRATTERA ORAL CAPSULE 100 MG, 60 MG,
80 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
SURMONTIL
$0-$7.40 (Tier 2)
PAR; MO
temazepam oral capsule 15 mg, 22.5 mg, 30 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
thioridazine
$0 (Tier 1)
PAR; MO
thiothixene
$0 (Tier 1)
MO
tranylcypromine
$0-$7.40 (Tier 2)
MO
trazodone
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
trifluoperazine
TRINTELLIX ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
ST; QLL (60 per 30 days)
TRINTELLIX ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
ST; QLL (30 per 30 days)
TRINTELLIX ORAL TABLET 5 MG
$0-$7.40 (Tier 2)
ST; QLL (120 per 30 days)
venlafaxine oral capsule,extended release 24hr 150
mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
venlafaxine oral capsule,extended release 24hr 37.5
mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
venlafaxine oral capsule,extended release 24hr 75
mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
venlafaxine oral tablet 100 mg
$0-$7.40 (Tier 2)
MO; QLL (113 per 30 days)
venlafaxine oral tablet 25 mg
$0-$7.40 (Tier 2)
MO; QLL (450 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
53
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
venlafaxine oral tablet 37.5 mg
$0-$7.40 (Tier 2)
MO; QLL (300 per 30 days)
venlafaxine oral tablet 50 mg
$0-$7.40 (Tier 2)
MO; QLL (225 per 30 days)
venlafaxine oral tablet 75 mg
$0-$7.40 (Tier 2)
MO; QLL (150 per 30 days)
venlafaxine oral tablet extended release 24hr 150
mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
venlafaxine oral tablet extended release 24hr 37.5
mg
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
venlafaxine oral tablet extended release 24hr 75
mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
VERSACLOZ
$0-$7.40 (Tier 2)
QLL (600 per 30 days)
VIIBRYD ORAL TABLET 10 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (120 per 30 days)
VIIBRYD ORAL TABLET 20 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (60 per 30 days)
VIIBRYD ORAL TABLET 40 MG
$0-$7.40 (Tier 2)
ST; MO; QLL (30 per 30 days)
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG
(7)- 20 MG (23)
$0-$7.40 (Tier 2)
ST; MO; QLL (30 per 30 days)
VRAYLAR ORAL CAPSULE
$0-$7.40 (Tier 2)
PAR; QLL (30 per 30 days)
VRAYLAR ORAL CAPSULE,DOSE PACK
$0-$7.40 (Tier 2)
PAR; QLL (7 per 365 days)
XYREM
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (540 per 30 days)
zaleplon oral capsule 10 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
zaleplon oral capsule 5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
zenzedi oral tablet 10 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (180 per 30 days)
zenzedi oral tablet 5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
ziprasidone hcl oral capsule 20 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
ziprasidone hcl oral capsule 40 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
ziprasidone hcl oral capsule 60 mg, 80 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
zolpidem oral tablet
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210 MG,
405 MG
$0-$7.40 (Tier 2)
PAR; QLL (2 per 28 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 300 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (2 per 28 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
54
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone intravenous solution
$0-$7.40 (Tier 2)
B/D PAR; MO
AMIODARONE INTRAVENOUS SYRINGE
$0-$7.40 (Tier 2)
B/D PAR
amiodarone oral
$0-$7.40 (Tier 2)
MO
dofetilide
$0-$7.40 (Tier 2)
flecainide
$0-$7.40 (Tier 2)
MO
lidocaine (pf) intravenous solution
$0-$7.40 (Tier 2)
MO
LIDOCAINE (PF) INTRAVENOUS SYRINGE
$0-$7.40 (Tier 2)
mexiletine
$0-$7.40 (Tier 2)
MO
MULTAQ
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
pacerone oral tablet 100 mg, 200 mg, 400 mg
$0-$7.40 (Tier 2)
MO
procainamide injection solution 100 mg/ml
$0-$7.40 (Tier 2)
MO
procainamide injection solution 500 mg/ml
$0-$7.40 (Tier 2)
propafenone oral tablet
$0-$7.40 (Tier 2)
MO
quinidine sulfate oral tablets oral tablet 200 mg,
300 mg
$0-$7.40 (Tier 2)
MO
sorine oral tablet 120 mg, 160 mg, 80 mg
$0 (Tier 1)
MO
sorine oral tablet 240 mg
$0 (Tier 1)
sotalol af oral tablet 120 mg
$0 (Tier 1)
MO
SOTALOL AF ORAL TABLET 160 MG, 80 MG
$0-$7.40 (Tier 2)
MO
sotalol oral tablet 120 mg
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
acebutolol
$0 (Tier 1)
MO
afeditab cr
$0 (Tier 1)
MO
amiloride
$0-$7.40 (Tier 2)
MO
amiloride-hydrochlorothiazide
$0-$7.40 (Tier 2)
MO
sotalol oral tablet 160 mg, 240 mg, 80 mg
TIKOSYN
ANTIHYPERTENSIVE THERAPY
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
55
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
amlodipine besylate oral tablet 10 mg, 2.5 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
amlodipine besylate oral tablet 5 mg
$0 (Tier 1)
MO; QLL (45 per 30 days)
amlodipine-benazepril
$0 (Tier 1)
MO
amlodipine-valsartan
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
amlodipine-valsartan-hcthiazid
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
atenolol
$0 (Tier 1)
MO
atenolol-chlorthalidone
$0 (Tier 1)
MO
AZOR
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
benazepril
$0 (Tier 1)
MO
benazepril-hydrochlorothiazide
$0 (Tier 1)
MO
betaxolol oral
$0 (Tier 1)
MO
bisoprolol fumarate
$0 (Tier 1)
MO
bisoprolol-hydrochlorothiazide
$0 (Tier 1)
MO
bumetanide
$0-$7.40 (Tier 2)
MO
BYSTOLIC
$0-$7.40 (Tier 2)
MO
candesartan oral tablet 16 mg, 4 mg, 8 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
candesartan oral tablet 32 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
candesartan-hydrochlorothiazid oral tablet 16-12.5
mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
candesartan-hydrochlorothiazid oral tablet 32-12.5
mg, 32-25 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
captopril
$0 (Tier 1)
MO
captopril-hydrochlorothiazide
$0 (Tier 1)
MO
cartia xt
$0 (Tier 1)
MO
carvedilol
$0 (Tier 1)
MO
chlorothiazide
$0-$7.40 (Tier 2)
MO
chlorothiazide sodium
$0-$7.40 (Tier 2)
MO
chlorthalidone oral tablet 25 mg, 50 mg
$0-$7.40 (Tier 2)
MO
clonidine hcl oral tablet
$0-$7.40 (Tier 2)
MO
clonidine transdermal patches
$0-$7.40 (Tier 2)
MO; QLL (4 per 28 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
56
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
COREG CR
$0-$7.40 (Tier 2)
ST; MO
DEMSER
$0-$7.40 (Tier 2)
MO
dilt-xr
$0 (Tier 1)
MO
diltiazem hcl intravenous
$0 (Tier 1)
diltiazem hcl oral capsule, extended release 120
mg, 240 mg, 300 mg
$0-$7.40 (Tier 2)
MO
diltiazem hcl oral capsule, extended release 180
mg, 360 mg, 420 mg
$0 (Tier 1)
MO
diltiazem hcl oral capsule,ext release degradable
$0-$7.40 (Tier 2)
MO
diltiazem hcl oral capsule,extended release 12 hr
$0 (Tier 1)
MO
diltiazem hcl oral capsule,extended release 24hr
120 mg, 240 mg, 300 mg
$0 (Tier 1)
MO
diltiazem hcl oral capsule,extended release 24hr
180 mg, 360 mg
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
doxazosin
$0 (Tier 1)
MO
enalapril maleate
$0 (Tier 1)
MO
enalapril-hydrochlorothiazide
$0 (Tier 1)
MO
eplerenone
$0-$7.40 (Tier 2)
MO
eprosartan
$0 (Tier 1)
MO; QLL (30 per 30 days)
felodipine oral er
$0 (Tier 1)
MO
fosinopril
$0 (Tier 1)
MO
fosinopril-hydrochlorothiazide
$0 (Tier 1)
MO
furosemide injection
$0-$7.40 (Tier 2)
MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
diltiazem hcl oral tablet
diltiazem hcl oral tablet extended release 24 hr
furosemide oral tablet
hydralazine
hydrochlorothiazide
indapamide
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
57
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
irbesartan
$0 (Tier 1)
MO; QLL (30 per 30 days)
irbesartan-hydrochlorothiazide oral tablet 150-12.5
mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
irbesartan-hydrochlorothiazide oral tablet 300-12.5
mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
isradipine
$0 (Tier 1)
MO
labetalol intravenous solution
$0 (Tier 1)
MO
labetalol oral
$0 (Tier 1)
MO
lisinopril
$0 (Tier 1)
MO
lisinopril-hydrochlorothiazide
$0 (Tier 1)
MO
losartan oral tablet 100 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
losartan oral tablet 25 mg, 50 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
losartan-hydrochlorothiazide
$0 (Tier 1)
MO; QLL (30 per 30 days)
methyclothiazide
$0-$7.40 (Tier 2)
MO
metolazone
$0-$7.40 (Tier 2)
MO
metoprolol succinate
$0 (Tier 1)
MO
metoprolol ta-hydrochlorothiaz
$0 (Tier 1)
MO
metoprolol tartrate intravenous solution
$0 (Tier 1)
MO
metoprolol tartrate intravenous syringe
$0-$7.40 (Tier 2)
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
$0 (Tier 1)
metoprolol tartrate oral tablet 37.5 mg, 75 mg
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
moexipril
$0 (Tier 1)
MO
moexipril-hydrochlorothiazide
$0 (Tier 1)
MO
nadolol
$0 (Tier 1)
MO
nadolol-bendroflumethiazide
$0 (Tier 1)
MO
nicardipine intravenous solution
$0 (Tier 1)
MO
nicardipine oral
$0 (Tier 1)
MO
nifedical xl
$0 (Tier 1)
MO
minoxidil oral
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
58
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
nimodipine
$0 (Tier 1)
MO
perindopril erbumine
$0 (Tier 1)
MO
pindolol
$0 (Tier 1)
MO
prazosin oral
$0 (Tier 1)
MO
propranolol intravenous
$0 (Tier 1)
propranolol oral
$0 (Tier 1)
MO
propranolol-hydrochlorothiazid
$0 (Tier 1)
MO
quinapril
$0 (Tier 1)
MO
quinapril-hydrochlorothiazide
$0 (Tier 1)
MO
ramipril
$0 (Tier 1)
MO
spironolacton-hydrochlorothiaz
$0-$7.40 (Tier 2)
MO
spironolactone
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
nifedipine oral tablet extended release
nifedipine oral tablet extended release 24hr
taztia xt
TEKTURNA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TEKTURNA HCT
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
telmisartan oral tablet 20 mg, 40 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
telmisartan oral tablet 80 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
telmisartan-amlodipine
$0 (Tier 1)
MO; QLL (30 per 30 days)
telmisartan-hydrochlorothiazid oral tablet 40-12.5
mg, 80-25 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
telmisartan-hydrochlorothiazid oral tablet 80-12.5
mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
terazosin
$0 (Tier 1)
MO
timolol maleate oral
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
torsemide oral
trandolapril
triamterene-hydrochlorothiazid oral capsule 37.525 mg
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
59
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
triamterene-hydrochlorothiazid oral tablet
$0-$7.40 (Tier 2)
MO
TRIBENZOR
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
valsartan oral tablet 160 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
valsartan oral tablet 320 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
valsartan oral tablet 40 mg, 80 mg
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
valsartan-hydrochlorothiazide
$0 (Tier 1)
MO; QLL (30 per 30 days)
verapamil intravenous solution
$0 (Tier 1)
MO
verapamil intravenous syringe
$0-$7.40 (Tier 2)
verapamil oral capsule, 24 hr er pellet ct
$0 (Tier 1)
MO
verapamil oral capsule,ext rel. pellets 24 hr
$0 (Tier 1)
MO
verapamil oral tablet
$0 (Tier 1)
MO
verapamil oral tablet extended release 120 mg (24
hours)
$0-$7.40 (Tier 2)
MO
verapamil oral tablet extended release 120 mg, 180
mg, 240 mg
$0 (Tier 1)
MO
DIGITEK ORAL TABLET 125 MCG
$0-$7.40 (Tier 2)
MO
DIGOX ORAL TABLET 125 MCG
$0-$7.40 (Tier 2)
MO
digoxin oral solution 50 mcg/ml
$0-$7.40 (Tier 2)
MO
digoxin oral tablet 125 mcg
$0-$7.40 (Tier 2)
MO
LANOXIN ORAL TABLET 125 MCG, 62.5 MCG
$0-$7.40 (Tier 2)
MO
AGGRENOX
$0-$7.40 (Tier 2)
ST; MO; QLL (60 per 30 days)
aspirin-dipyridamole
$0-$7.40 (Tier 2)
ST; MO; QLL (60 per 30 days)
BRILINTA
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
cilostazol
$0-$7.40 (Tier 2)
MO
CARDIAC GLYCOSIDES
COAGULATION THERAPY
clopidogrel oral tablet 300 mg
$0 (Tier 1)
MO; QLL (1 per 30 days)
clopidogrel oral tablet 75 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
COUMADIN ORAL
$0-$7.40 (Tier 2)
MO
EFFIENT
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
60
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ELIQUIS ORAL TABLET 2.5 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
ELIQUIS ORAL TABLET 5 MG
$0-$7.40 (Tier 2)
MO; QLL (74 per 30 days)
enoxaparin subcutaneous solution
$0-$7.40 (Tier 2)
MO; QLL (84 per 30 days)
enoxaparin subcutaneous syringe 100 mg/ml, 150
mg/ml
$0-$7.40 (Tier 2)
MO; QLL (28 per 30 days)
enoxaparin subcutaneous syringe 120 mg/0.8 ml,
80 mg/0.8 ml
$0-$7.40 (Tier 2)
MO; QLL (22.4 per 30 days)
enoxaparin subcutaneous syringe 30 mg/0.3 ml
$0-$7.40 (Tier 2)
MO; QLL (8.4 per 30 days)
enoxaparin subcutaneous syringe 40 mg/0.4 ml
$0-$7.40 (Tier 2)
MO; QLL (11.2 per 30 days)
enoxaparin subcutaneous syringe 60 mg/0.6 ml
$0-$7.40 (Tier 2)
MO; QLL (16.8 per 30 days)
fondaparinux subcutaneous syringe 10 mg/0.8 ml
$0-$7.40 (Tier 2)
MO; QLL (24 per 30 days)
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml
$0-$7.40 (Tier 2)
MO; QLL (15 per 30 days)
fondaparinux subcutaneous syringe 5 mg/0.4 ml
$0-$7.40 (Tier 2)
MO; QLL (12 per 30 days)
fondaparinux subcutaneous syringe 7.5 mg/0.6 ml
$0-$7.40 (Tier 2)
MO; QLL (18 per 30 days)
HEPARIN (PORCINE) IN 5 % DEX
INTRAVENOUS PARENTERAL SOLUTION 12,
500 UNIT/250 ML
$0-$7.40 (Tier 2)
B/D PAR
heparin (porcine) in 5 % dex intravenous parenteral
solution 25,000 unit/250 ml(100 unit/ml), 25,000
unit/500 ml (50 unit/ml)
$0-$7.40 (Tier 2)
MO
HEPARIN (PORCINE) IN NACL (PF)
INTRAVENOUS PARENTERAL SOLUTION 1,
000 UNIT/500 ML, 2,000 UNIT/1,000 ML
$0-$7.40 (Tier 2)
B/D PAR
HEPARIN (PORCINE) INJECTION CARTRIDGE
$0-$7.40 (Tier 2)
B/D PAR; MO
heparin (porcine) injection solution
$0-$7.40 (Tier 2)
B/D PAR; MO
HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION 12,
500 UNIT/250 ML
$0-$7.40 (Tier 2)
B/D PAR
HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION 25,
000 UNIT/250 ML
$0-$7.40 (Tier 2)
HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION 25,
000 UNIT/500 ML
$0-$7.40 (Tier 2)
?
B/D PAR; MO
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
61
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
HEPARIN, PORCINE (PF) INJECTION
SOLUTION
$0-$7.40 (Tier 2)
MO
jantoven
$0-$7.40 (Tier 2)
MO
MEPHYTON
$0 (Tier 3)
MO; [*]
pentoxifylline
$0-$7.40 (Tier 2)
MO
PRADAXA
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
75 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
PROMACTA ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (60 per 30 days)
tranexamic acid intravenous
$0-$7.40 (Tier 2)
MO
vitamin k1 injection
$0 (Tier 3)
MO; [*]
warfarin
$0 (Tier 1)
MO
XARELTO ORAL TABLET 10 MG, 20 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
XARELTO ORAL TABLET 15 MG
$0-$7.40 (Tier 2)
MO; QLL (42 per 30 days)
XARELTO ORAL TABLETS,DOSE PACK
$0-$7.40 (Tier 2)
MO; QLL (102 per 365 days)
LIPID/CHOLESTEROL LOWERING AGENTS
ALTOPREV
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
amlodipine-atorvastatin
$0 (Tier 1)
MO; QLL (30 per 30 days)
atorvastatin
$0 (Tier 1)
MO; QLL (30 per 30 days)
cholestyramine (with sugar)
$0-$7.40 (Tier 2)
MO
cholestyramine light
$0-$7.40 (Tier 2)
MO
colestipol
$0-$7.40 (Tier 2)
MO
CRESTOR
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
fenofibrate nanocrystallized 48 mg, 145 mg
$0-$7.40 (Tier 2)
MO
fenofibrate oral tablet 160 mg, 54 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
gemfibrozil oral
$0-$7.40 (Tier 2)
MO
JUXTAPID
$0-$7.40 (Tier 2)
PAR; MO; LA
lovastatin oral tablet 10 mg, 20 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
62
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
lovastatin oral tablet 40 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
niacin oral capsule, extended release 250 mg
$0 (Tier 4)
MO; [*]
niacin oral tablet 100 mg, 50 mg, 500 mg
$0 (Tier 4)
MO; [*]
niacin oral tablet extended release 24 hr 1,000 mg,
750 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
niacin oral tablet extended release 24 hr 500 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
niacin oral tablet extended release 250 mg, 500 mg
$0 (Tier 4)
MO; [*]
NIACOR
$0-$7.40 (Tier 2)
MO
omega-3 acid ethyl esters
$0-$7.40 (Tier 2)
PAR; MO
PRALUENT PEN
$0-$7.40 (Tier 2)
PAR; MO; QLL (2 per 28 days)
PRALUENT SYRINGE
$0-$7.40 (Tier 2)
PAR; MO; QLL (2 per 28 days)
pravastatin
$0 (Tier 1)
MO; QLL (30 per 30 days)
prevalite
$0-$7.40 (Tier 2)
MO
REPATHA SURECLICK
$0-$7.40 (Tier 2)
PAR; MO; QLL (3 per 28 days)
REPATHA SYRINGE
$0-$7.40 (Tier 2)
PAR; MO; QLL (3 per 28 days)
rosuvastatin
$0-$7.40 (Tier 2)
QLL (30 per 30 days)
simvastatin
$0 (Tier 1)
MO; QLL (30 per 30 days)
SLO-NIACIN ORAL TABLET EXTENDED
RELEASE 250 MG
$0 (Tier 4)
MO; [*]
slo-niacin oral tablet extended release 500 mg
$0 (Tier 4)
MO; [*]
VASCEPA
$0-$7.40 (Tier 2)
MO
WELCHOL
$0-$7.40 (Tier 2)
MO
ZETIA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
MISCELLANEOUS CARDIOVASCULAR AGENTS
RANEXA
$0-$7.40 (Tier 2)
VECAMYL
$0-$7.40 (Tier 2)
MO
NITRATES
isosorbide dinitrate oral
$0-$7.40 (Tier 2)
MO
isosorbide mononitrate
$0-$7.40 (Tier 2)
MO
nitro-bid
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
63
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
nitroglycerin intravenous
$0-$7.40 (Tier 2)
B/D PAR
nitroglycerin transdermal patch 24 hour
$0-$7.40 (Tier 2)
MO
NITROSTAT
$0-$7.40 (Tier 2)
MO
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin
$0-$7.40 (Tier 2)
MO
calcipotriene scalp
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
calcipotriene topical
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
selenium sulfide topical lotion
$0-$7.40 (Tier 2)
MO
silver sulfadiazine
$0-$7.40 (Tier 2)
MO
ssd
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
BURN THERAPY
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate
blue gel
$0 (Tier 4)
MO; [*]
COATS ALOE ANALGESIC
$0 (Tier 4)
MO; [*]
COATS ALOE MOISTURIZING
$0 (Tier 4)
[*]
COATS ALOE TOPICAL CREAM
$0 (Tier 4)
MO; [*]
COATS ALOE TOPICAL GEL
$0 (Tier 4)
MO; [*]
DR. SMITH'S DIAPER
$0 (Tier 4)
MO; [*]
DR. SMITH'S DIAPER RASH
$0 (Tier 4)
[*]
DR. SMITH'S RASH-SKIN TOPICAL AEROSOL,
SPRAY
$0 (Tier 4)
[*]
ELIDEL
$0-$7.40 (Tier 2)
PAR; MO; QLL (100 per 90 days)
fluorouracil topical cream 5 %
$0-$7.40 (Tier 2)
MO
fluorouracil topical solution
$0-$7.40 (Tier 2)
MO
imiquimod
$0-$7.40 (Tier 2)
MO
ITCH-X TOPICAL GEL
$0 (Tier 4)
MO; [*]
MEDICATED BODY POWDER TOPICAL
POWDER 0.15 %
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
64
escalonada
Nombre de la medicina
methoxsalen rapid
OFF DEEP WOODS DRY
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
PAR; MO
$0 (Tier 4)
[*]
OXSORALEN
$0-$7.40 (Tier 2)
MO
PANRETIN
$0-$7.40 (Tier 2)
MO
PICATO
$0-$7.40 (Tier 2)
MO
podofilox
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
REPEL SPORTSMEN MAX
tacrolimus topical
$0-$7.40 (Tier 2)
PAR; MO; QLL (100 per 90 days)
thera-gesic topical cream 15-1 %
$0 (Tier 4)
MO; [*]
trixaicin
$0 (Tier 4)
MO; [*]
TRIXAICIN HP
$0 (Tier 4)
MO; [*]
UVADEX
$0-$7.40 (Tier 2)
VALCHLOR
$0-$7.40 (Tier 2)
MO
vits a and d-white pet-lanolin topical ointment
$0 (Tier 4)
MO; [*]
white petrolatum topical ointment
$0 (Tier 4)
MO; [*]
Z-BUM
$0 (Tier 4)
[*]
zinc oxide topical ointment 20 %
$0 (Tier 4)
MO; [*]
ACNE MEDICATION TOPICAL GEL
$0 (Tier 4)
MO; [*]
ACNE MEDICATION TOPICAL LOTION 10 %
$0 (Tier 4)
MO; [*]
THERAPY FOR ACNE
adapalene topical gel 0.3 %
$0-$7.40 (Tier 2)
MO
adapalene topical gel with pump
$0-$7.40 (Tier 2)
MO
benzoyl peroxide topical foam
$0 (Tier 4)
[*]
benzoyl peroxide topical gel 10 %, 2.5 %, 5 %
$0 (Tier 4)
MO; [*]
clindamycin phosphate topical
$0-$7.40 (Tier 2)
MO
ery pads
$0-$7.40 (Tier 2)
MO
erythromycin with ethanol
$0-$7.40 (Tier 2)
MO
erythromycin-benzoyl peroxide
$0-$7.40 (Tier 2)
MO
metronidazole topical cream
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
65
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
metronidazole topical gel 0.75 %
$0-$7.40 (Tier 2)
MO
metronidazole topical lotion
$0-$7.40 (Tier 2)
MO
ROSADAN TOPICAL CREAM
$0-$7.40 (Tier 2)
MO
TAZORAC
$0-$7.40 (Tier 2)
PAR; MO
tretinoin topical cream
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
tretinoin topical gel 0.01 %, 0.025 %
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
TOPICAL ANESTHETICS
dibucaine
$0 (Tier 4)
MO; [*]
LIDOCAINE (PF) INJECTION SOLUTION 15
MG/ML (1.5 %)
$0-$7.40 (Tier 2)
lidocaine (pf) injection solution 20 mg/ml (2 %), 40
mg/ml (4 %), 5 mg/ml (0.5 %)
$0-$7.40 (Tier 2)
MO
lidocaine hcl injection solution 20 mg/ml (2 %), 5
mg/ml (0.5 %)
$0-$7.40 (Tier 2)
MO
lidocaine hcl laryngotracheal
$0-$7.40 (Tier 2)
MO
lidocaine hcl mucous membrane
$0-$7.40 (Tier 2)
MO
lidocaine hcl urethral
$0-$7.40 (Tier 2)
MO
lidocaine topical adhesive patch,medicated
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
lidocaine topical ointment
$0-$7.40 (Tier 2)
MO
LIDOCAINE VISCOUS
$0-$7.40 (Tier 2)
MO
lidocaine-prilocaine topical cream
$0-$7.40 (Tier 2)
MO
TOPICAL ANTIBACTERIALS
bacitracin topical ointment
$0 (Tier 4)
MO; [*]
bacitracin zinc topical ointment
$0 (Tier 4)
MO; [*]
gentamicin topical
$0-$7.40 (Tier 2)
MO
mupirocin calcium
$0-$7.40 (Tier 2)
MO
mupirocin topical ointment
$0-$7.40 (Tier 2)
MO
povidone-iodine topical ointment
$0 (Tier 4)
MO; [*]
povidone-iodine topical solution 10 %
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
sulfacetamide sodium (acne)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
66
escalonada
Nombre de la medicina
SULFAMYLON TOPICAL CREAM
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
MO
triple antibiotic plus
$0 (Tier 4)
[*]
triple antibiotic topical ointment
$0 (Tier 4)
MO; [*]
triple antibiotic topical ointment in packet
$0 (Tier 4)
MO; [*]
antifungal (tolnaftate) topical cream
$0 (Tier 4)
[*]
antifungal (tolnaftate) topical powder
$0 (Tier 4)
MO; [*]
antifungal cream
$0 (Tier 4)
[*]
antifungal spray
$0 (Tier 4)
[*]
TOPICAL ANTIFUNGALS
CICLODAN TOPICAL SOLUTION
$0-$7.40 (Tier 2)
PAR; MO
ciclopirox topical cream
$0-$7.40 (Tier 2)
MO
ciclopirox topical gel
$0-$7.40 (Tier 2)
MO
ciclopirox topical shampoo
$0-$7.40 (Tier 2)
MO
ciclopirox topical solution
$0-$7.40 (Tier 2)
PAR; MO
ciclopirox topical suspension
$0-$7.40 (Tier 2)
MO
clotrimazole topical
$0-$7.40 (Tier 2)
MO
clotrimazole-betamethasone
$0-$7.40 (Tier 2)
MO
econazole topical
$0-$7.40 (Tier 2)
MO
FUNGOID TINCTURE TOPICAL TINCTURE
ketoconazole topical
miconazole nitrate topical cream
$0 (Tier 4)
$0-$7.40 (Tier 2)
$0 (Tier 4)
MO; [*]
MO
MO; [*]
nystatin topical
$0-$7.40 (Tier 2)
MO
nystatin-triamcinolone
$0-$7.40 (Tier 2)
MO
nystop
$0-$7.40 (Tier 2)
MO
terbinafine hcl topical
$0 (Tier 4)
MO; [*]
tolnaftate topical cream
$0 (Tier 4)
[*]
tolnaftate topical powder
$0 (Tier 4)
[*]
zeasorb (miconazole)
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
67
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
TOPICAL ANTIVIRALS
acyclovir topical
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
DENAVIR
$0-$7.40 (Tier 2)
MO; QLL (5 per 2 days)
ala-cort topical cream
$0-$7.40 (Tier 2)
MO
alclometasone
$0-$7.40 (Tier 2)
MO
amcinonide
$0-$7.40 (Tier 2)
MO
betamethasone dipropionate
$0-$7.40 (Tier 2)
MO
betamethasone valerate topical cream
$0-$7.40 (Tier 2)
MO
betamethasone valerate topical lotion
$0-$7.40 (Tier 2)
MO
betamethasone valerate topical ointment
$0-$7.40 (Tier 2)
MO
betamethasone, augmented
$0-$7.40 (Tier 2)
MO
CAPEX
$0-$7.40 (Tier 2)
MO
clobetasol scalp
$0-$7.40 (Tier 2)
MO
clobetasol topical cream
$0-$7.40 (Tier 2)
MO
clobetasol topical foam
$0-$7.40 (Tier 2)
MO
clobetasol topical gel
$0-$7.40 (Tier 2)
MO
clobetasol topical ointment
$0-$7.40 (Tier 2)
MO
clobetasol-emollient topical cream
$0-$7.40 (Tier 2)
MO
cormax scalp
$0-$7.40 (Tier 2)
DERMATOP TOPICAL OINTMENT
$0-$7.40 (Tier 2)
MO
desonide
$0-$7.40 (Tier 2)
MO
desoximetasone
$0-$7.40 (Tier 2)
MO
diflorasone
$0-$7.40 (Tier 2)
MO
fluocinolone
$0-$7.40 (Tier 2)
MO
fluocinolone and shower cap
$0-$7.40 (Tier 2)
MO
fluocinonide topical cream 0.05 %
$0-$7.40 (Tier 2)
MO
fluocinonide topical gel
$0-$7.40 (Tier 2)
MO
fluocinonide topical ointment
$0-$7.40 (Tier 2)
MO
TOPICAL CORTICOSTEROIDS
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
68
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
fluocinonide topical solution
$0-$7.40 (Tier 2)
MO
fluocinonide-e
$0-$7.40 (Tier 2)
MO
fluticasone topical
$0-$7.40 (Tier 2)
MO
halobetasol propionate
$0-$7.40 (Tier 2)
MO
HALOG
$0-$7.40 (Tier 2)
MO
hydrocortisone topical cream 0.5 %
$0 (Tier 4)
MO; [*]
hydrocortisone topical cream 1 %, 2.5 %
$0-$7.40 (Tier 2)
MO
hydrocortisone topical lotion 2.5 %
$0-$7.40 (Tier 2)
MO
hydrocortisone topical ointment 0.5 %
$0 (Tier 4)
MO; [*]
hydrocortisone topical ointment 1 %, 2.5 %
$0-$7.40 (Tier 2)
MO
hydrocortisone valerate
$0-$7.40 (Tier 2)
MO
HYDROCORTISONE-MIN OIL-WHT PET
$0-$7.40 (Tier 2)
MO
hydroskin topical lotion
$0 (Tier 4)
MO; [*]
mometasone topical
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide topical cream
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide topical lotion
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
$0-$7.40 (Tier 2)
MO
trianex
$0-$7.40 (Tier 2)
MO
triderm topical cream
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TOPICAL ENZYMES
SANTYL
TOPICAL SCABICIDES / PEDICULICIDES
CUTTER BACKWOODS
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
permethrin topical cream
$0-$7.40 (Tier 2)
MO
permethrin topical liquid
$0 (Tier 4)
MO; [*]
REPEL SPORTSMEN
$0 (Tier 4)
[*]
lindane topical shampoo
OFF DEEP WOODS
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
69
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
DIAGNOSTICS / MISCELLANEOUS AGENTS
ANTIDOTES
$0-$7.40 (Tier 2)
MO
lactated ringers irrigation
$0-$7.40 (Tier 2)
MO
neomycin-polymyxin b gu
$0-$7.40 (Tier 2)
MO
ringers irrigation
$0-$7.40 (Tier 2)
MO
acamprosate
$0-$7.40 (Tier 2)
MO
ADAGEN
$0-$7.40 (Tier 2)
MO
alendronate oral tablet 40 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
anagrelide
$0-$7.40 (Tier 2)
MO
ARALAST NP
$0-$7.40 (Tier 2)
PAR; MO; LA
BUPHENYL ORAL TABLET
$0-$7.40 (Tier 2)
PAR; MO
acetylcysteine intravenous
IRRIGATING SOLUTIONS
MISCELLANEOUS AGENTS
calcium with boron
$0 (Tier 4)
[*]
CARBAGLU
$0-$7.40 (Tier 2)
PAR; MO; LA
CLINIMIX 4.25%/D5W SULFIT FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 2.75%/D10W SUL FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 2.75%/D5W SULF FREE
$0-$7.40 (Tier 2)
B/D PAR
d10 %-0.45 % sodium chloride
$0-$7.40 (Tier 2)
d2.5 %-0.45 % sodium chloride
$0-$7.40 (Tier 2)
d5 % and 0.9 % sodium chloride
$0-$7.40 (Tier 2)
MO
d5 %-0.45 % sodium chloride
$0-$7.40 (Tier 2)
MO
dextrose 10 % and 0.2 % nacl
$0-$7.40 (Tier 2)
dextrose 10 % in water (d10w)
$0-$7.40 (Tier 2)
dextrose 25 % in water (d25w)
$0-$7.40 (Tier 2)
DEXTROSE 30 % IN WATER (D30W)
$0-$7.40 (Tier 2)
DEXTROSE 40 % IN WATER (D40W)
$0-$7.40 (Tier 2)
dextrose 5 % in water (d5w)
$0-$7.40 (Tier 2)
MO
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
70
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
dextrose 5 %-lactated ringers
$0-$7.40 (Tier 2)
MO
dextrose 5%-0.2 % sod chloride
$0-$7.40 (Tier 2)
dextrose 5%-0.3 % sod.chloride
$0-$7.40 (Tier 2)
DEXTROSE 50 % IN WATER (D50W)
INTRAVENOUS PARENTERAL SOLUTION
$0-$7.40 (Tier 2)
DEXTROSE 50 % IN WATER (D50W)
INTRAVENOUS SYRINGE
$0-$7.40 (Tier 2)
dextrose 70 % in water (d70w)
$0-$7.40 (Tier 2)
dextrose with sodium chloride
$0-$7.40 (Tier 2)
disulfiram
$0-$7.40 (Tier 2)
MO
EXJADE
$0-$7.40 (Tier 2)
PAR; MO; LA
MO
MO
GLUTOSE 15
$0 (Tier 4)
MO; [*]
GLUTOSE 45
$0 (Tier 4)
MO; [*]
INCRELEX
$0-$7.40 (Tier 2)
PAR; MO; LA
kionex
$0-$7.40 (Tier 2)
MO
levocarnitine (with sugar)
$0-$7.40 (Tier 2)
B/D PAR; MO
levocarnitine oral tablet
$0-$7.40 (Tier 2)
MO
midodrine
$0-$7.40 (Tier 2)
MO
ORFADIN ORAL CAPSULE
$0-$7.40 (Tier 2)
LA
pilocarpine hcl oral
$0-$7.40 (Tier 2)
MO
PROLASTIN-C
$0-$7.40 (Tier 2)
PAR; LA
RAVICTI
$0-$7.40 (Tier 2)
PAR; MO; QLL (525 per 30 days)
RENAGEL
$0-$7.40 (Tier 2)
ST; MO
RENVELA ORAL POWDER IN PACKET 0.8
GRAM
$0-$7.40 (Tier 2)
MO; QLL (180 per 30 days)
RENVELA ORAL POWDER IN PACKET 2.4
GRAM
$0-$7.40 (Tier 2)
MO; QLL (90 per 30 days)
RENVELA ORAL TABLET
$0-$7.40 (Tier 2)
MO; QLL (270 per 30 days)
riluzole
$0-$7.40 (Tier 2)
MO
sodium chloride 0.9 % intravenous
$0-$7.40 (Tier 2)
MO
SODIUM CHLORIDE 0.9 % INTRAVENOUS
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
71
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
sodium chloride irrigation
$0-$7.40 (Tier 2)
MO
sodium polystyrene (sorb free)
$0-$7.40 (Tier 2)
MO
sodium polystyrene sulfonate oral powder
$0-$7.40 (Tier 2)
MO
sodium polystyrene sulfonate oral suspension
$0-$7.40 (Tier 2)
sodium polystyrene sulfonate rectal
$0-$7.40 (Tier 2)
SODIUM POLYSTYRENE SULFONATE
RECTAL
$0-$7.40 (Tier 2)
SPS ORAL
$0-$7.40 (Tier 2)
SPS RECTAL
$0-$7.40 (Tier 2)
SUSPENDOL-S
$0 (Tier 4)
MO
MO; [*]
SYPRINE
$0-$7.40 (Tier 2)
MO
water for irrigation, sterile
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
central vite
$0 (Tier 4)
[*]
complete premium vitamin
$0 (Tier 4)
[*]
MISCELLANEOUS DEVICES
Pediatric mask for inhaler
NEUTRACEUTICALS
SMOKING DETERRENTS
buproban
$0-$7.40 (Tier 2)
QLL (60 per 30 days)
CHANTIX
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
CHANTIX CONTINUING MONTH BOX
$0-$7.40 (Tier 2)
PAR; MO; QLL (56 per 28 days)
CHANTIX STARTING MONTH BOX
$0-$7.40 (Tier 2)
PAR; MO; QLL (106 per 365 days)
NICODERM CQ
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
nicorelief
$0 (Tier 4)
MO; [*]
NICORETTE BUCCAL GUM
$0 (Tier 4)
MO; [*]
NICORETTE BUCCAL LOZENGE
$0 (Tier 4)
MO; [*]; QLL (20 per 1 day)
nicotine (polacrilex) buccal gum
$0 (Tier 4)
MO; [*]
nicotine (polacrilex) buccal lozenge
$0 (Tier 4)
MO; [*]; QLL (20 per 1 day)
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
72
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
NICOTROL NS
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
azelastine nasal
$0-$7.40 (Tier 2)
MO; QLL (30 per 25 days)
chlorhexidine gluconate mucous membrane
$0-$7.40 (Tier 2)
MO
deep sea nasal
$0 (Tier 4)
[*]
ENTSOL NASAL GEL
$0 (Tier 4)
[*]
EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ipratropium bromide nasal
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
MUCINEX SINUS-MAX
$0 (Tier 4)
[*]
nasal decongestant (oxymetazl)
$0 (Tier 4)
MO; [*]
nasal spray 12 hour nasal spray,non-aerosol
$0 (Tier 4)
[*]
nose drops
$0 (Tier 4)
[*]
NRS NASAL RELIEF
$0 (Tier 4)
[*]
PAROEX ORAL RINSE
$0-$7.40 (Tier 2)
MO
periogard
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide dental
$0-$7.40 (Tier 2)
MO
TYZINE NASAL DROPS 0.05 %
$0-$7.40 (Tier 2)
MO
acetic acid otic
$0-$7.40 (Tier 2)
MO
acetic acid-aluminum acetate
$0-$7.40 (Tier 2)
MO
ear drops (carbamide peroxide)
$0 (Tier 4)
[*]
EAR WAX TREATMENT
$0 (Tier 4)
[*]
fluocinolone acetonide oil
$0-$7.40 (Tier 2)
MO
hydrocortisone-acetic acid
$0-$7.40 (Tier 2)
MO
ofloxacin otic
$0-$7.40 (Tier 2)
MO
CIPRODEX
$0-$7.40 (Tier 2)
MO
COLY-MYCIN S
$0-$7.40 (Tier 2)
MO
neomycin-polymyxin-hc otic
$0-$7.40 (Tier 2)
MO
MISCELLANEOUS OTIC PREPARATIONS
OTIC STEROID / ANTIBIOTIC
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
73
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P.
$0-$7.40 (Tier 2)
PAR; MO
cortisone
$0-$7.40 (Tier 2)
MO
dexamethasone
$0-$7.40 (Tier 2)
MO
DEXAMETHASONE SODIUM PHOS (PF)
$0-$7.40 (Tier 2)
MO
dexamethasone sodium phosphate injection
$0-$7.40 (Tier 2)
MO
fludrocortisone
$0-$7.40 (Tier 2)
MO
hydrocortisone oral
$0-$7.40 (Tier 2)
MO
methylprednisolone acetate
$0-$7.40 (Tier 2)
MO
methylprednisolone oral tablets
$0-$7.40 (Tier 2)
MO
methylprednisolone sodium succ injection recon
soln 125 mg, 40 mg
$0-$7.40 (Tier 2)
MO
methylprednisolone sodium succ intravenous
$0-$7.40 (Tier 2)
MO
prednisolone oral solution 15 mg/5 ml
$0-$7.40 (Tier 2)
MO
prednisolone sodium phosphate oral solution 15
mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
$0-$7.40 (Tier 2)
MO
prednisolone sodium phosphate oral tablet,
disintegrating
$0-$7.40 (Tier 2)
MO
prednisone intensol
$0-$7.40 (Tier 2)
MO
prednisone oral
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide injection suspension 10
mg/ml
$0-$7.40 (Tier 2)
MO
triamcinolone acetonide injection suspension 40
mg/ml
$0-$7.40 (Tier 2)
ANTITHYROID AGENTS
IOSAT
$0 (Tier 4)
[*]
methimazole oral tablet 10 mg, 5 mg
$0-$7.40 (Tier 2)
MO
propylthiouracil
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
THYROSAFE
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
74
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
DIABETES THERAPY
acarbose oral tablet 100 mg
$0 (Tier 1)
MO; QLL (90 per 30 days)
acarbose oral tablet 25 mg
$0 (Tier 1)
MO; QLL (360 per 30 days)
acarbose oral tablet 50 mg
$0 (Tier 1)
MO; QLL (180 per 30 days)
alcohol pads
$0 (Tier 1)
MO
BYDUREON
$0-$7.40 (Tier 2)
MO; QLL (4 per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 10
MCG/DOSE(250 MCG/ML) 2.4 ML
$0-$7.40 (Tier 2)
MO; QLL (2.4 per 30 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 5
MCG/DOSE (250 MCG/ML) 1.2 ML
$0-$7.40 (Tier 2)
MO; QLL (1.2 per 30 days)
CYCLOSET
$0-$7.40 (Tier 2)
ST; MO; QLL (180 per 30 days)
GAUZE PADS 2 X 2
$0 (Tier 1)
MO; QLL (200 per 30 days)
glimepiride oral tablet 1 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
glimepiride oral tablet 2 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
glimepiride oral tablet 4 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
glipizide oral tablet 10 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
glipizide oral tablet 5 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
glipizide oral tablet extended release 24hr 10 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
glipizide oral tablet extended release 24hr 5 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
glipizide-metformin oral tablet 2.5-250 mg
$0 (Tier 1)
MO; QLL (240 per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
GLUCAGEN HYPOKIT
$0 (Tier 1)
MO
GLUCAGON EMERGENCY KIT (HUMAN)
$0 (Tier 1)
MO
HUMALOG
$0 (Tier 1)
MO
HUMALOG KWIKPEN
$0 (Tier 1)
MO
HUMALOG MIX 50-50
$0 (Tier 1)
MO
HUMALOG MIX 50-50 KWIKPEN
$0 (Tier 1)
MO
HUMALOG MIX 75-25
$0 (Tier 1)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
75
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
HUMALOG MIX 75-25 KWIKPEN
$0 (Tier 1)
MO
HUMAPEN LUXURA HD
$0 (Tier 1)
MO; QLL (200 per 30 days)
HUMULIN 70/30
$0 (Tier 1)
MO
HUMULIN 70/30 KWIKPEN
$0 (Tier 1)
MO
HUMULIN N
$0 (Tier 1)
MO
HUMULIN N KWIKPEN
$0 (Tier 1)
MO
HUMULIN R
$0 (Tier 1)
MO
HUMULIN R U-500 (CONC) KWIKPEN
$0 (Tier 1)
HUMULIN R U-500 (CONCENTRATED)
$0 (Tier 1)
MO
insulin pen needle
$0 (Tier 1)
MO; QLL (200 per 30 days)
INSULIN SYRINGE (DISP) U-100 SYRINGE 0.3
ML, 1 ML, 1/2 ML
$0 (Tier 1)
MO; QLL (200 per 30 days)
JANUMET
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
JANUVIA ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
JANUVIA ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
JANUVIA ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
JARDIANCE
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
JENTADUETO
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
LANTUS
$0 (Tier 1)
MO
LANTUS SOLOSTAR
$0 (Tier 1)
MO
LEVEMIR
$0 (Tier 1)
MO
LEVEMIR FLEXTOUCH
$0 (Tier 1)
MO
metformin oral tablet 1,000 mg
$0 (Tier 1)
MO; QLL (76 per 30 days)
metformin oral tablet 500 mg
$0 (Tier 1)
MO; QLL (153 per 30 days)
metformin oral tablet 850 mg
$0 (Tier 1)
MO; QLL (90 per 30 days)
metformin oral tablet extended release 24 hr 500
mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
76
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
metformin oral tablet extended release 24 hr 750
mg
$0 (Tier 1)
MO; QLL (80 per 30 days)
metformin oral tablet extended release 24hr 1,000
mg
$0 (Tier 1)
MO; QLL (75 per 30 days)
metformin oral tablet extended release 24hr 500
mg
$0 (Tier 1)
MO; QLL (150 per 30 days)
nateglinide oral tablet 120 mg
$0 (Tier 1)
MO; QLL (90 per 30 days)
nateglinide oral tablet 60 mg
$0 (Tier 1)
MO; QLL (180 per 30 days)
needles, insulin disp.,safety
$0 (Tier 1)
MO; QLL (200 per 30 days)
NOVOPEN ECHO
$0 (Tier 1)
MO; QLL (200 per 30 days)
pioglitazone oral tablet 15 mg
$0 (Tier 1)
MO; QLL (90 per 30 days)
pioglitazone oral tablet 30 mg
$0 (Tier 1)
MO; QLL (45 per 30 days)
pioglitazone oral tablet 45 mg
$0 (Tier 1)
MO; QLL (30 per 30 days)
pioglitazone-glimepiride
$0 (Tier 1)
MO; QLL (30 per 30 days)
pioglitazone-metformin
$0 (Tier 1)
MO; QLL (90 per 30 days)
PROGLYCEM
$0-$7.40 (Tier 2)
MO
repaglinide-metformin
$0-$7.40 (Tier 2)
MO; QLL (150 per 30 days)
SYMLINPEN 120
$0-$7.40 (Tier 2)
PAR; MO; QLL (11 per 30 days)
SYMLINPEN 60
$0-$7.40 (Tier 2)
PAR; MO; QLL (6 per 30 days)
SYNJARDY
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
TANZEUM
$0-$7.40 (Tier 2)
MO; QLL (4 per 28 days)
tolazamide oral tablet 250 mg
$0 (Tier 1)
MO; QLL (120 per 30 days)
tolazamide oral tablet 500 mg
$0 (Tier 1)
MO; QLL (60 per 30 days)
tolbutamide
$0 (Tier 1)
MO; QLL (180 per 30 days)
TOUJEO SOLOSTAR
$0-$7.40 (Tier 2)
MO
TRADJENTA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
TRULICITY
$0-$7.40 (Tier 2)
MO; QLL (2 per 28 days)
VICTOZA 2-PAK
$0-$7.40 (Tier 2)
MO; QLL (9 per 30 days)
VICTOZA 3-PAK
$0-$7.40 (Tier 2)
MO; QLL (9 per 30 days)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
77
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MISCELLANEOUS HORMONES
ALDURAZYME
$0-$7.40 (Tier 2)
PAR; MO
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25 GRAM
(1.62 %)
$0-$7.40 (Tier 2)
PAR; MO; QLL (150 per 30 days)
ANDROGEL TRANSDERMAL GEL IN PACKET
1.62 % (20.25 MG/1.25 GRAM)
$0-$7.40 (Tier 2)
PAR; MO; QLL (112.5 per 30 days)
ANDROGEL TRANSDERMAL GEL IN PACKET
1.62 % (40.5 MG/2.5 GRAM)
$0-$7.40 (Tier 2)
PAR; MO; QLL (150 per 30 days)
ANDROXY
$0-$7.40 (Tier 2)
PAR; MO
cabergoline
$0-$7.40 (Tier 2)
MO
calcitonin (salmon)
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
calcitriol intravenous solution 1 mcg/ml
$0-$7.40 (Tier 2)
MO
calcitriol oral
$0-$7.40 (Tier 2)
B/D PAR; MO
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT
$0-$7.40 (Tier 2)
PAR; MO
danazol oral
$0-$7.40 (Tier 2)
MO
desmopressin injection
$0-$7.40 (Tier 2)
MO
desmopressin nasal
$0-$7.40 (Tier 2)
MO
desmopressin oral
$0-$7.40 (Tier 2)
MO
doxercalciferol intravenous
$0-$7.40 (Tier 2)
B/D PAR
doxercalciferol oral
$0-$7.40 (Tier 2)
B/D PAR; MO
ELAPRASE
$0-$7.40 (Tier 2)
PAR; MO
FABRAZYME
$0-$7.40 (Tier 2)
PAR; MO
KORLYM
$0-$7.40 (Tier 2)
PAR; MO
KUVAN ORAL TABLET,SOLUBLE
$0-$7.40 (Tier 2)
PAR; MO
MIACALCIN INJECTION
$0-$7.40 (Tier 2)
B/D PAR; MO
MYOZYME
$0-$7.40 (Tier 2)
PAR; MO
NAGLAZYME
$0-$7.40 (Tier 2)
PAR; MO; LA
NATPARA
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (2 per 28 days)
oxandrolone oral tablet 10 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
78
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
oxandrolone oral tablet 2.5 mg
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
pamidronate intravenous recon soln
$0-$7.40 (Tier 2)
MO
pamidronate intravenous solution 30 mg/10 ml (3
mg/ml), 90 mg/10 ml (9 mg/ml)
$0-$7.40 (Tier 2)
MO
pamidronate intravenous solution 60 mg/10 ml (6
mg/ml)
$0-$7.40 (Tier 2)
B/D PAR; MO
paricalcitol oral
$0-$7.40 (Tier 2)
B/D PAR; MO
SENSIPAR ORAL TABLET 30 MG, 60 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
SENSIPAR ORAL TABLET 90 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
SOMAVERT
$0-$7.40 (Tier 2)
PAR; MO
STIMATE
$0-$7.40 (Tier 2)
MO
SYNAREL
$0-$7.40 (Tier 2)
PAR; MO
testosterone cypionate
$0-$7.40 (Tier 2)
MO
testosterone enanthate
$0-$7.40 (Tier 2)
MO
testosterone transdermal gel
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
testosterone transdermal gel in metered-dose pump
1.25 gram/ actuation (1 %)
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
testosterone transdermal gel in metered-dose pump
10 mg/0.5 gram /actuation
$0-$7.40 (Tier 2)
PAR; MO; QLL (120 per 30 days)
testosterone transdermal gel in packet 1 % (25 mg/
2.5gram)
$0-$7.40 (Tier 2)
PAR; MO; QLL (225 per 30 days)
testosterone transdermal gel in packet 1 % (50 mg/
5 gram)
$0-$7.40 (Tier 2)
PAR; MO; QLL (300 per 30 days)
VPRIV
$0-$7.40 (Tier 2)
PAR; MO
ZAVESCA
$0-$7.40 (Tier 2)
PAR; MO; LA
ZEMPLAR INTRAVENOUS
$0-$7.40 (Tier 2)
B/D PAR; MO
zoledronic acid intravenous recon soln 4 mg
$0-$7.40 (Tier 2)
PAR
zoledronic acid intravenous solution 4 mg/5 ml
$0-$7.40 (Tier 2)
PAR; MO
ZOMETA INTRAVENOUS SOLUTION 4 MG/
100 ML
$0-$7.40 (Tier 2)
PAR; MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
79
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
THYROID HORMONES
$0 (Tier 1)
MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg,
75 mcg, 88 mcg
$0-$7.40 (Tier 2)
MO
liothyronine oral
$0-$7.40 (Tier 2)
MO
SYNTHROID
$0-$7.40 (Tier 2)
MO
UNITHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG,
25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
$0-$7.40 (Tier 2)
MO
levothyroxine oral
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
anti-diarrheal (loperamide) oral tablet
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml
$0 (Tier 4)
MO; [*]
$0-$7.40 (Tier 2)
bismatrol oral suspension 262 mg/15 ml
$0 (Tier 4)
MO; [*]
bismatrol oral suspension 525 mg/15 ml
$0 (Tier 4)
[*]
bismatrol oral tablet,chewable
$0 (Tier 4)
[*]
dicyclomine oral capsule
$0-$7.40 (Tier 2)
MO
dicyclomine oral solution
$0-$7.40 (Tier 2)
MO
dicyclomine oral tablet
$0-$7.40 (Tier 2)
MO
diphenoxylate-atropine
$0-$7.40 (Tier 2)
MO
glycopyrrolate oral
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
kao-tin (bismuth subsalicylat)
loperamide oral capsule
loperamide oral liquid 1 mg/5 ml
$0 (Tier 4)
MO; [*]
loperamide oral liquid 1 mg/7.5 ml
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
PEPTIC RELIEF ORAL TABLET,CHEWABLE
$0 (Tier 4)
[*]
pink bismuth oral tablet,chewable
$0 (Tier 4)
MO; [*]
OPIUM TINCTURE
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
80
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MISCELLANEOUS GASTROINTESTINAL AGENTS
acid gone antacid
$0 (Tier 4)
[*]
actidose/sorbitol oral suspension 50 gram/240 ml
$0 (Tier 4)
[*]
almacone oral suspension
$0 (Tier 4)
[*]
almacone-2
$0 (Tier 4)
[*]
alosetron
aluminum hydroxide gel oral suspension 320 mg/5
ml
AMITIZA
$0-$7.40 (Tier 2)
$0 (Tier 4)
PAR; MO; QLL (60 per 30 days)
MO; [*]
$0-$7.40 (Tier 2)
MO
antacid
$0 (Tier 4)
[*]
antacid anti-gas
$0 (Tier 4)
[*]
antacid extra-strength oral suspension 200-200-20
mg/5 ml
$0 (Tier 4)
[*]
antacid plus anti-gas oral suspension 200-200-20
mg/5 ml
$0 (Tier 4)
[*]
anti-nausea liquid
$0 (Tier 4)
[*]
anu-med
$0 (Tier 4)
MO; [*]
APRISO
$0-$7.40 (Tier 2)
MO
ASACOL HD
$0-$7.40 (Tier 2)
MO
balsalazide
$0-$7.40 (Tier 2)
MO
bisac-evac
$0 (Tier 4)
MO; [*]
bisacodyl oral
$0 (Tier 4)
MO; [*]
bisacodyl rectal
$0 (Tier 4)
MO; [*]
biscolax
$0 (Tier 4)
MO; [*]
budesonide oral
$0-$7.40 (Tier 2)
MO
CANASA
$0-$7.40 (Tier 2)
MO
CIMZIA
$0-$7.40 (Tier 2)
PAR; MO; QLL (6 per 28 days)
CIMZIA POWDER FOR RECONST
$0-$7.40 (Tier 2)
PAR; MO; QLL (6 per 28 days)
CIMZIA STARTER KIT
$0-$7.40 (Tier 2)
PAR; MO; QLL (6 per 28 days)
COLACE ORAL CAPSULE 100 MG
?
$0 (Tier 4)
MO; [*]
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
81
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
colocort
$0-$7.40 (Tier 2)
MO
compro
$0-$7.40 (Tier 2)
PAR; MO
constulose
$0-$7.40 (Tier 2)
MO
CREON
$0-$7.40 (Tier 2)
MO
CYSTADANE
$0-$7.40 (Tier 2)
MO
DELZICOL ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
$0-$7.40 (Tier 2)
MO
dimenhydrinate oral
$0 (Tier 4)
MO; [*]
diocto oral liquid
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
DIPENTUM
doc-q-lace
$0 (Tier 4)
MO; [*]
doc-q-lax
$0 (Tier 4)
MO; [*]
docu
$0 (Tier 4)
MO; [*]
docusate calcium
$0 (Tier 4)
MO; [*]
docusate sodium oral capsule 100 mg
$0 (Tier 4)
MO; [*]
docusate sodium oral capsule 250 mg
$0 (Tier 4)
[*]
DOCUSOL
$0 (Tier 4)
[*]
DOCUSOL KIDS
$0 (Tier 4)
[*]
DOCUSOL PLUS
$0 (Tier 4)
[*]
dok oral capsule 100 mg
$0 (Tier 4)
MO; [*]
dok oral capsule 250 mg
$0 (Tier 4)
[*]
dok oral tablet
$0 (Tier 4)
MO; [*]
dok plus
$0 (Tier 4)
[*]
dronabinol
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (120 per 30 days)
EMEND ORAL CAPSULE 125 MG
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (5 per 30 days)
EMEND ORAL CAPSULE 40 MG
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (1 per 2 days)
EMEND ORAL CAPSULE 80 MG
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (10 per 30 days)
EMEND ORAL CAPSULE,DOSE PACK
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (15 per 30 days)
ENEMA RECTAL ENEMA 19-7 GRAM/118 ML
$0 (Tier 4)
[*]
ENEMEEZ
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
82
escalonada
Nombre de la medicina
ENEMEEZ PLUS
enulose
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0 (Tier 4)
$0-$7.40 (Tier 2)
MO; [*]
MO
fiber (calcium polycarbophil)
$0 (Tier 4)
MO; [*]
fiber laxative (psyllium husk)
$0 (Tier 4)
MO; [*]
fiber-lax
$0 (Tier 4)
MO; [*]
FLEET PEDIATRIC
$0 (Tier 4)
MO; [*]
formula em solution
$0 (Tier 4)
[*]
gas relief extra strength oral capsule
$0 (Tier 4)
[*]
gas relief oral capsule
$0 (Tier 4)
[*]
gas relief oral drops,suspension
$0 (Tier 4)
MO; [*]
gas relief oral tablet,chewable
$0 (Tier 4)
MO; [*]
GAS RELIEF ORAL TABLET,CHEWABLE
$0 (Tier 4)
MO; [*]
GATTEX 30-VIAL
$0-$7.40 (Tier 2)
MO
GATTEX ONE-VIAL
$0-$7.40 (Tier 2)
MO
gavilyte-c
$0-$7.40 (Tier 2)
MO
gavilyte-g
$0-$7.40 (Tier 2)
MO
gavilyte-n
$0-$7.40 (Tier 2)
MO
generlac
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
HEMORRHOIDAL SUPPOSITORY
hydrocortisone rectal cream 2.5 %
$0-$7.40 (Tier 2)
hydrocortisone rectal enema
$0-$7.40 (Tier 2)
MO
infants gas relief
$0 (Tier 4)
[*]
kao-tin (docusate calcium)
$0 (Tier 4)
[*]
lactulose
$0-$7.40 (Tier 2)
MO
LIALDA
$0-$7.40 (Tier 2)
MO
LINZESS
$0-$7.40 (Tier 2)
MO
liquid antacid oral suspension 200-200-20 mg/5 ml
$0 (Tier 4)
[*]
magnesium oral tablet 250 mg
$0 (Tier 4)
[*]
MAGTAB
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
83
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MAJOR-PREP HEMORRHOIDAL RECTAL
OINTMENT 0.25-14-74.9 %
$0 (Tier 4)
[*]
masanti double strength
$0 (Tier 4)
[*]
meclizine oral tablet 12.5 mg, 25 mg
$0-$7.40 (Tier 2)
MO
mesalamine rectal
$0-$7.40 (Tier 2)
MO
mesalamine with cleansing wipe
$0-$7.40 (Tier 2)
MO
metoclopramide hcl injection solution
$0-$7.40 (Tier 2)
MO
METOCLOPRAMIDE HCL INJECTION
SYRINGE
$0-$7.40 (Tier 2)
metoclopramide hcl oral solution
$0-$7.40 (Tier 2)
MO
metoclopramide hcl oral tablet
$0-$7.40 (Tier 2)
MO
mi-acid gas relief
$0 (Tier 4)
[*]
mi-acid oral suspension
$0 (Tier 4)
MO; [*]
milk of magnesia
$0 (Tier 4)
MO; [*]
milk of magnesia concentrated
$0 (Tier 4)
MO; [*]
mintox maximum strength
$0 (Tier 4)
MO; [*]
MOVIPREP
$0-$7.40 (Tier 2)
MO
mytab gas
$0 (Tier 4)
[*]
mytab gas maximum strength
$0 (Tier 4)
[*]
natural fiber laxative (sugar) oral powder 3.4 gram/
7 gram
$0 (Tier 4)
[*]
natural fiber laxative therapy
$0 (Tier 4)
[*]
ondansetron hcl (pf) injection solution
$0-$7.40 (Tier 2)
MO
ondansetron hcl (pf) injection syringe
$0-$7.40 (Tier 2)
ondansetron hcl intravenous
$0-$7.40 (Tier 2)
MO
ondansetron hcl oral solution
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (450 per 30 days)
ondansetron hcl oral tablet 24 mg
$0-$7.40 (Tier 2)
B/D PAR; QLL (30 per 30 days)
ondansetron hcl oral tablet 4 mg, 8 mg
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (90 per 30 days)
ondansetron odt
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (90 per 30 days)
peg 3350-electrolytes oral recon soln 236-22.746.74 -5.86 gram
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
84
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
peg 3350-electrolytes oral recon soln 240-22.726.72 -5.84 gram
$0-$7.40 (Tier 2)
peg-electrolyte soln
$0-$7.40 (Tier 2)
$0 (Tier 4)
[*]
PENTASA
$0-$7.40 (Tier 2)
MO
polyethylene glycol 3350 oral powder
$0-$7.40 (Tier 2)
MO
peg3350
polyethylene glycol 3350 oral powder in packet
$0 (Tier 4)
prochlorperazine edisylate injection solution 10
mg/2 ml (5 mg/ml)
$0-$7.40 (Tier 2)
PAR; MO
prochlorperazine maleate oral
$0-$7.40 (Tier 2)
PAR; MO
prochlorperazine maleate rectal
$0-$7.40 (Tier 2)
PAR; MO
procto-pak
$0-$7.40 (Tier 2)
MO
proctosol hc
$0-$7.40 (Tier 2)
MO
proctozone-hc
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
reguloid oral capsule
MO; [*]
RELISTOR SUBCUTANEOUS SOLUTION
$0-$7.40 (Tier 2)
PAR; MO
RELISTOR SUBCUTANEOUS SYRINGE
$0-$7.40 (Tier 2)
PAR; MO
REMICADE
$0-$7.40 (Tier 2)
PAR; MO
RULOX
$0 (Tier 4)
[*]
sani-supp (adult)
$0 (Tier 4)
MO; [*]
sani-supp (infant)
$0 (Tier 4)
MO; [*]
senexon
$0 (Tier 4)
MO; [*]
senna lax
$0 (Tier 4)
MO; [*]
senna oral syrup 8.8 mg/5 ml
$0 (Tier 4)
MO; [*]
senna oral tablet
$0 (Tier 4)
[*]
SENNA PLUS
$0 (Tier 4)
MO; [*]
senna with docusate sodium
$0 (Tier 4)
[*]
SENNALAX-S
$0 (Tier 4)
MO; [*]
simethicone oral capsule 180 mg
$0 (Tier 4)
[*]
simethicone oral drops,suspension
$0 (Tier 4)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
85
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
sodium bicarbonate oral
$0 (Tier 4)
MO; [*]
stool softener oral capsule 100 mg, 240 mg
$0 (Tier 4)
MO; [*]
$0-$7.40 (Tier 2)
MO
travel sickness
$0 (Tier 4)
[*]
TRAVEL SICKNESS (MECLIZINE)
$0 (Tier 4)
MO; [*]
sulfasalazine
ursodiol
$0-$7.40 (Tier 2)
MO
ZENPEP
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
ULCER THERAPY
acid reducer (famotidine) oral tablet 20 mg
DEXILANT
$0-$7.40 (Tier 2)
ST; MO; QLL (30 per 30 days)
famotidine (pf)
$0-$7.40 (Tier 2)
MO
famotidine (pf)-nacl (iso-os)
$0-$7.40 (Tier 2)
famotidine intravenous
$0-$7.40 (Tier 2)
MO
famotidine oral suspension
$0-$7.40 (Tier 2)
MO
famotidine oral tablet 10 mg
famotidine oral tablet 20 mg, 40 mg
HEARTBURN RELIEF (LANSOPRAZOLE)
ORAL CAPSULE,DELAYED RELEASE(DR/EC)
15 MG
$0 (Tier 4)
$0-$7.40 (Tier 2)
MO; [*]
MO
$0 (Tier 4)
[*]; QLL (30 per 30 days)
lansoprazole oral capsule,delayed release(dr/ec)
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
misoprostol
$0-$7.40 (Tier 2)
MO
omeprazole magnesium
$0 (Tier 4)
[*]
omeprazole oral capsule,delayed release(dr/ec)
$0 (Tier 1)
MO; QLL (30 per 30 days)
omeprazole oral tablet,delayed release (dr/ec)
$0 (Tier 4)
MO; [*]
pantoprazole intravenous
pantoprazole oral
$0-$7.40 (Tier 2)
$0 (Tier 1)
MO
MO; QLL (30 per 30 days)
PROTONIX INTRAVENOUS
$0-$7.40 (Tier 2)
MO
ranitidine hcl injection
$0-$7.40 (Tier 2)
MO
ranitidine hcl oral syrup
$0-$7.40 (Tier 2)
MO
ranitidine hcl oral tablet 150 mg, 300 mg
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
86
escalonada
Nombre de la medicina
ranitidine hcl oral tablet 75 mg
sucralfate oral tablet
ZEGERID OTC
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0 (Tier 4)
$0-$7.40 (Tier 2)
$0 (Tier 4)
MO; [*]
MO
MO; [*]
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE
$0-$7.40 (Tier 2)
PAR; MO
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML, 25
MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/
ML
$0-$7.40 (Tier 2)
PAR; MO
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE
$0-$7.40 (Tier 2)
PAR; MO
ARCALYST
$0-$7.40 (Tier 2)
PAR; MO
AVONEX (WITH ALBUMIN)
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
AVONEX INTRAMUSCULAR PEN INJECTOR
KIT
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
AVONEX INTRAMUSCULAR SYRINGE
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
AVONEX INTRAMUSCULAR SYRINGE KIT
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
EXTAVIA SUBCUTANEOUS KIT
$0-$7.40 (Tier 2)
PAR; MO
EXTAVIA SUBCUTANEOUS RECON SOLN
$0-$7.40 (Tier 2)
PAR
ILARIS (PF)
$0-$7.40 (Tier 2)
PAR; MO; LA
INTRON A INJECTION
$0-$7.40 (Tier 2)
PAR; MO
NEUPOGEN
$0-$7.40 (Tier 2)
PAR; MO
NORDITROPIN FLEXPRO
$0-$7.40 (Tier 2)
PAR; MO
OMNITROPE
$0-$7.40 (Tier 2)
PAR; MO
PEGASYS
$0-$7.40 (Tier 2)
PAR; MO
PEGASYS PROCLICK
$0-$7.40 (Tier 2)
PAR; MO
PEGINTRON
$0-$7.40 (Tier 2)
PAR; MO
PEGINTRON REDIPEN
$0-$7.40 (Tier 2)
PAR; MO
PROCRIT
$0-$7.40 (Tier 2)
PAR; MO; QLL (12 per 28 days)
PROLEUKIN
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
87
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
REBIF (WITH ALBUMIN)
$0-$7.40 (Tier 2)
PAR; MO
REBIF REBIDOSE
$0-$7.40 (Tier 2)
PAR; MO
REBIF TITRATION PACK
$0-$7.40 (Tier 2)
PAR; MO
SYLATRON
$0-$7.40 (Tier 2)
PAR; MO
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF)
$0 (Tier 1)
MO
ADACEL(TDAP ADOLESN/ADULT)(PF)
$0 (Tier 1)
MO
ATGAM
$0-$7.40 (Tier 2)
B/D PAR
BCG VACCINE, LIVE (PF)
$0-$7.40 (Tier 2)
MO
BEXSERO (PF)
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
BOOSTRIX TDAP
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM, 6
GRAM
$0-$7.40 (Tier 2)
PAR; MO
CERVARIX VACCINE (PF)
$0 (Tier 1)
MO
DAPTACEL (DTAP PEDIATRIC) (PF)
$0 (Tier 1)
MO
ENGERIX-B (PF)
$0 (Tier 1)
B/D PAR; MO
ENGERIX-B PEDIATRIC (PF)
$0 (Tier 1)
B/D PAR; MO
GAMASTAN S/D
$0-$7.40 (Tier 2)
PAR; MO
GAMMAGARD LIQUID
$0-$7.40 (Tier 2)
PAR; MO
GAMMAGARD S-D (IGA < 1 MCG/ML)
$0-$7.40 (Tier 2)
PAR; MO
GAMMAPLEX
$0-$7.40 (Tier 2)
PAR; MO
GAMUNEX-C
$0-$7.40 (Tier 2)
PAR; MO
GARDASIL (PF)
$0-$7.40 (Tier 2)
MO
GARDASIL 9 (PF)
$0-$7.40 (Tier 2)
MO
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
$0 (Tier 1)
MO
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,
440 ELISA UNIT/ML
$0 (Tier 1)
MO
HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML
$0 (Tier 1)
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
88
escalonada
Nombre de la medicina
HIBERIX (PF)
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0 (Tier 1)
IMOVAX RABIES VACCINE (PF)
$0-$7.40 (Tier 2)
MO
INFANRIX (DTAP) (PF)
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
IXIARO (PF)
$0-$7.40 (Tier 2)
MO
M-M-R II (PF)
$0 (Tier 1)
MO
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
$0-$7.40 (Tier 2)
MO
MENOMUNE - A/C/Y/W-135
$0-$7.40 (Tier 2)
MENOMUNE - A/C/Y/W-135 (PF)
$0-$7.40 (Tier 2)
MO
MENVEO A-C-Y-W-135-DIP (PF)
$0-$7.40 (Tier 2)
MO
OCTAGAM
$0-$7.40 (Tier 2)
PAR; MO
IPOL INJECTION SUSPENSION
PEDVAX HIB (PF)
$0 (Tier 1)
MO
PRIVIGEN
$0-$7.40 (Tier 2)
PAR; MO
PROQUAD (PF)
$0-$7.40 (Tier 2)
MO
QUADRACEL (PF)
$0-$7.40 (Tier 2)
RABAVERT (PF)
$0-$7.40 (Tier 2)
MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION
$0 (Tier 1)
B/D PAR; MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML
$0 (Tier 1)
MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
$0 (Tier 1)
ROTARIX
ROTATEQ VACCINE
tetanus,diphtheria tox ped(pf)
TETANUS-DIPHTHERIA TOXOIDS-TD
$0-$7.40 (Tier 2)
$0 (Tier 1)
MO
$0-$7.40 (Tier 2)
MO
$0 (Tier 1)
MO
THYMOGLOBULIN
$0-$7.40 (Tier 2)
B/D PAR
TICE BCG
$0-$7.40 (Tier 2)
MO
TRUMENBA
$0-$7.40 (Tier 2)
TWINRIX (PF)
?
$0 (Tier 1)
MO
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
89
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
TYPHIM VI INTRAMUSCULAR SOLUTION
$0-$7.40 (Tier 2)
TYPHIM VI INTRAMUSCULAR SYRINGE
$0-$7.40 (Tier 2)
MO
VAQTA (PF) INTRAMUSCULAR SUSPENSION
$0-$7.40 (Tier 2)
MO
VAQTA (PF) INTRAMUSCULAR SYRINGE
$0-$7.40 (Tier 2)
VARIVAX (PF)
$0-$7.40 (Tier 2)
MO
VARIZIG
$0-$7.40 (Tier 2)
MO
YF-VAX (PF)
$0-$7.40 (Tier 2)
MO
ZOSTAVAX (PF)
$0-$7.40 (Tier 2)
MO
MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol
$0-$7.40 (Tier 2)
MO
colchicine-probenecid
$0-$7.40 (Tier 2)
MO
COLCRYS
$0-$7.40 (Tier 2)
MO
probenecid
$0-$7.40 (Tier 2)
MO
ULORIC
$0-$7.40 (Tier 2)
ST; MO
alendronate oral solution
$0-$7.40 (Tier 2)
MO; QLL (300 per 28 days)
alendronate oral tablet 10 mg, 5 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
alendronate oral tablet 35 mg, 70 mg
$0-$7.40 (Tier 2)
MO; QLL (4 per 28 days)
BONIVA INTRAVENOUS
$0-$7.40 (Tier 2)
B/D PAR; MO
FORTEO
$0-$7.40 (Tier 2)
PAR; MO; QLL (3 per 28 days)
ibandronate intravenous solution
$0-$7.40 (Tier 2)
B/D PAR; MO
ibandronate intravenous syringe
$0-$7.40 (Tier 2)
MO
ibandronate oral
$0-$7.40 (Tier 2)
MO; QLL (1 per 28 days)
PROLIA
$0-$7.40 (Tier 2)
PAR; MO; QLL (2 per 365 days)
raloxifene
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
ACTEMRA INTRAVENOUS
$0-$7.40 (Tier 2)
PAR; MO
ACTEMRA INTRAVENOUS VIAL
$0-$7.40 (Tier 2)
PAR; MO
OSTEOPOROSIS THERAPY
OTHER RHEUMATOLOGICALS
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
90
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
BENLYSTA
$0-$7.40 (Tier 2)
PAR; MO
DEPEN TITRATABS
$0-$7.40 (Tier 2)
MO
ENBREL SUBCUTANEOUS RECON SOLN
$0-$7.40 (Tier 2)
PAR; MO; QLL (8 per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 25 MG/
0.5ML (0.51)
$0-$7.40 (Tier 2)
PAR; MO; QLL (4.08 per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 50 MG/
ML (0.98 ML)
$0-$7.40 (Tier 2)
PAR; MO; QLL (8 per 28 days)
ENBREL SURECLICK
$0-$7.40 (Tier 2)
PAR; MO; QLL (8 per 28 days)
HUMIRA PEDIATRIC CROHN'S START
$0-$7.40 (Tier 2)
PAR; MO; QLL (4.8 per 365 days)
HUMIRA PEN
$0-$7.40 (Tier 2)
PAR; MO; QLL (3.2 per 28 days)
HUMIRA PEN CROHN'S-UC-HS START
$0-$7.40 (Tier 2)
PAR; MO; QLL (9.6 per 365 days)
HUMIRA PEN PSORIASIS STARTER
$0-$7.40 (Tier 2)
PAR; MO; QLL (3.2 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (2 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 40
MG/0.8 ML
$0-$7.40 (Tier 2)
PAR; MO; QLL (3.2 per 28 days)
KINERET
$0-$7.40 (Tier 2)
PAR; MO; QLL (28 per 28 days)
leflunomide
$0-$7.40 (Tier 2)
MO
ORENCIA
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
ORENCIA (WITH MALTOSE)
$0-$7.40 (Tier 2)
PAR; MO
RIDAURA
$0-$7.40 (Tier 2)
MO
SAVELLA ORAL TABLET 100 MG
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
SAVELLA ORAL TABLET 12.5 MG
$0-$7.40 (Tier 2)
MO; QLL (480 per 30 days)
SAVELLA ORAL TABLET 25 MG
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
SAVELLA ORAL TABLET 50 MG
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
SAVELLA ORAL TABLETS,DOSE PACK
$0-$7.40 (Tier 2)
MO; QLL (110 per 365 days)
SIMPONI
$0-$7.40 (Tier 2)
PAR; MO; QLL (1 per 28 days)
$0-$7.40 (Tier 2)
MO
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
camila
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
91
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
DEPO-PROVERA INTRAMUSCULAR
SOLUTION 400 MG/ML
$0-$7.40 (Tier 2)
MO
errin
$0-$7.40 (Tier 2)
MO
ESTRACE VAGINAL
$0-$7.40 (Tier 2)
MO
estradiol oral
$0-$7.40 (Tier 2)
PAR; MO
estradiol transdermal patch weekly
$0-$7.40 (Tier 2)
PAR; MO; QLL (4 per 28 days)
ESTRING
$0-$7.40 (Tier 2)
MO; QLL (1 per 90 days)
FEMRING
$0-$7.40 (Tier 2)
MO; QLL (1 per 90 days)
lyza
$0-$7.40 (Tier 2)
MO
medroxyprogesterone
$0-$7.40 (Tier 2)
MO
MENEST
$0-$7.40 (Tier 2)
PAR; MO
nora-be
$0-$7.40 (Tier 2)
MO
norethindrone (contraceptive)
$0-$7.40 (Tier 2)
MO
norethindrone acetate
$0-$7.40 (Tier 2)
MO
ORTHO MICRONOR
$0-$7.40 (Tier 2)
MO
PREMARIN ORAL
$0-$7.40 (Tier 2)
PAR; MO
PREMARIN VAGINAL
$0-$7.40 (Tier 2)
MO
PREMPRO
$0-$7.40 (Tier 2)
PAR; MO
progesterone micronized
$0-$7.40 (Tier 2)
ST; MO
$0-$7.40 (Tier 2)
MO
MISCELLANEOUS OB/GYN
clindamycin phosphate vaginal
clotrimazole vaginal cream
metronidazole vaginal
$0 (Tier 4)
$0-$7.40 (Tier 2)
MO; [*]
MO
miconazole 7
$0 (Tier 4)
MO; [*]
miconazole nitrate vaginal cream
$0 (Tier 4)
MO; [*]
miconazole nitrate vaginal suppository
$0 (Tier 4)
[*]
miconazole-3 vaginal suppository
$0-$7.40 (Tier 2)
MO; QLL (6 per 30 days)
NUVARING
$0-$7.40 (Tier 2)
MO
terconazole
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
tioconazole-1
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
92
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
tranexamic acid oral
$0-$7.40 (Tier 2)
MO
XULANE
$0-$7.40 (Tier 2)
MO
ORAL CONTRACEPTIVES / RELATED AGENTS
ALTAVERA (28)
$0-$7.40 (Tier 2)
MO
ALYACEN 1/35 (28)
$0-$7.40 (Tier 2)
MO
ALYACEN 7/7/7 (28)
$0-$7.40 (Tier 2)
MO
apri
$0-$7.40 (Tier 2)
MO
aranelle (28)
$0-$7.40 (Tier 2)
MO
aviane
$0-$7.40 (Tier 2)
MO
AZURETTE (28)
$0-$7.40 (Tier 2)
MO
blisovi fe 1.5/30 (28)
$0-$7.40 (Tier 2)
MO
CAZIANT (28)
$0-$7.40 (Tier 2)
MO
cryselle (28)
$0-$7.40 (Tier 2)
MO
cyclafem 1/35 (28)
$0-$7.40 (Tier 2)
MO
cyclafem 7/7/7 (28)
$0-$7.40 (Tier 2)
MO
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
$0-$7.40 (Tier 2)
MO
econtra ez
$0 (Tier 4)
[*]
ELINEST
$0-$7.40 (Tier 2)
MO
ELLA
$0-$7.40 (Tier 2)
MO
enpresse
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
falmina (28)
$0-$7.40 (Tier 2)
MO
gildagia
$0-$7.40 (Tier 2)
MO
GILDESS FE 1.5/30 (28)
$0-$7.40 (Tier 2)
MO
GILDESS FE 1/20 (28)
$0-$7.40 (Tier 2)
MO
junel 1.5/30 (21)
$0-$7.40 (Tier 2)
MO
junel 1/20 (21)
$0-$7.40 (Tier 2)
MO
junel fe 1.5/30 (28)
$0-$7.40 (Tier 2)
MO
junel fe 1/20 (28)
$0-$7.40 (Tier 2)
MO
FALLBACK SOLO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
93
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
kariva (28)
$0-$7.40 (Tier 2)
MO
kelnor 1/35 (28)
$0-$7.40 (Tier 2)
MO
LARIN 1/20 (21)
$0-$7.40 (Tier 2)
MO
LARIN FE 1.5/30 (28)
$0-$7.40 (Tier 2)
MO
LARIN FE 1/20 (28)
$0-$7.40 (Tier 2)
MO
lessina
$0-$7.40 (Tier 2)
MO
levonest (28)
$0-$7.40 (Tier 2)
MO
levonorg-eth estrad triphasic
$0-$7.40 (Tier 2)
levonorgestrel-ethinyl estrad oral tablet 0.15-0.03
mg
$0-$7.40 (Tier 2)
MO
levonorgestrel-ethinyl estrad oral tablets,dose pack,
3 month
$0-$7.40 (Tier 2)
MO
LOW-OGESTREL (28)
$0-$7.40 (Tier 2)
MO
lutera (28)
$0-$7.40 (Tier 2)
MO
marlissa
$0-$7.40 (Tier 2)
MO
MICROGESTIN 1.5/30 (21)
$0-$7.40 (Tier 2)
MO
MICROGESTIN 1/20 (21)
$0-$7.40 (Tier 2)
MO
MICROGESTIN FE 1.5/30 (28)
$0-$7.40 (Tier 2)
MO
MICROGESTIN FE 1/20 (28)
$0-$7.40 (Tier 2)
MO
MONO-LINYAH
$0-$7.40 (Tier 2)
MO
mononessa (28)
$0-$7.40 (Tier 2)
MO
MY WAY
$0 (Tier 4)
[*]
MYZILRA
$0-$7.40 (Tier 2)
MO
necon 0.5/35 (28)
$0-$7.40 (Tier 2)
MO
necon 1/35 (28)
$0-$7.40 (Tier 2)
MO
necon 1/50 (28)
$0-$7.40 (Tier 2)
MO
necon 10/11 (28)
$0-$7.40 (Tier 2)
MO
necon 7/7/7 (28)
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
NEXT CHOICE ONE DOSE
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
94
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
norgestimate-ethinyl estradiol oral tablet 0.18/
0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg
$0-$7.40 (Tier 2)
MO
nortrel 0.5/35 (28)
$0-$7.40 (Tier 2)
MO
nortrel 1/35 (21)
$0-$7.40 (Tier 2)
MO
nortrel 1/35 (28)
$0-$7.40 (Tier 2)
MO
nortrel 7/7/7 (28)
$0-$7.40 (Tier 2)
MO
ocella
$0-$7.40 (Tier 2)
MO
ogestrel (28)
$0-$7.40 (Tier 2)
MO
OPCICON ONE-STEP
$0 (Tier 4)
[*]
PLAN B ONE-STEP
$0 (Tier 4)
MO; [*]
portia
$0-$7.40 (Tier 2)
MO
previfem
$0-$7.40 (Tier 2)
MO
reclipsen (28)
$0-$7.40 (Tier 2)
MO
sprintec (28)
$0-$7.40 (Tier 2)
MO
SYEDA
$0-$7.40 (Tier 2)
MO
tri-previfem (28)
$0-$7.40 (Tier 2)
MO
tri-sprintec (28)
$0-$7.40 (Tier 2)
MO
trivora (28)
$0-$7.40 (Tier 2)
MO
velivet triphasic regimen (28)
$0-$7.40 (Tier 2)
MO
VIORELE (28)
$0-$7.40 (Tier 2)
MO
ZARAH
$0-$7.40 (Tier 2)
MO
zenchent (28)
$0-$7.40 (Tier 2)
MO
zovia 1/35e (28)
$0-$7.40 (Tier 2)
MO
zovia 1/50e (28)
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
OXYTOCICS
methylergonovine oral
OPHTHALMOLOGY
ANTIBIOTICS
bacitracin ophthalmic
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
95
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
bacitracin-polymyxin b ophthalmic
$0-$7.40 (Tier 2)
MO
BESIVANCE
$0-$7.40 (Tier 2)
MO
ciprofloxacin hcl ophthalmic
$0-$7.40 (Tier 2)
MO
erythromycin ophthalmic
$0-$7.40 (Tier 2)
MO
gentak ophthalmic ointment
$0-$7.40 (Tier 2)
MO
gentamicin ophthalmic
$0-$7.40 (Tier 2)
MO
NEO-POLYCIN
$0-$7.40 (Tier 2)
MO
neomycin-bacitracin-polymyxin
$0-$7.40 (Tier 2)
MO
neomycin-polymyxin-gramicidin
$0-$7.40 (Tier 2)
MO
ofloxacin ophthalmic
$0-$7.40 (Tier 2)
MO
POLYCIN
$0-$7.40 (Tier 2)
polymyxin b sulf-trimethoprim
$0-$7.40 (Tier 2)
MO
tobramycin
$0-$7.40 (Tier 2)
MO
VIGAMOX
$0-$7.40 (Tier 2)
MO
trifluridine
$0-$7.40 (Tier 2)
MO
ZIRGAN
$0-$7.40 (Tier 2)
MO
betaxolol ophthalmic
$0-$7.40 (Tier 2)
MO
BETIMOL
$0-$7.40 (Tier 2)
MO
BETOPTIC S
$0-$7.40 (Tier 2)
MO
carteolol
$0-$7.40 (Tier 2)
MO
levobunolol ophthalmic drops 0.5 %
$0-$7.40 (Tier 2)
MO
metipranolol
$0-$7.40 (Tier 2)
timolol maleate ophthalmic
$0-$7.40 (Tier 2)
MO
TIMOPTIC OCUDOSE (PF)
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
ANTIVIRALS
BETA-BLOCKERS
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
96
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
DIRECT ACTING MIOTICS
PILOCARPINE HCL OPHTHALMIC DROPS 1
%, 2 %, 4 %
$0-$7.40 (Tier 2)
MO
MISCELLANEOUS OPHTHALMOLOGICS
akwa tears (polyvinyl alcohol)
$0 (Tier 4)
MO; [*]
artificial tears (petro/min)
$0 (Tier 4)
MO; [*]
artificial tears (polyvin alc)
$0 (Tier 4)
MO; [*]
azelastine ophthalmic
$0-$7.40 (Tier 2)
MO
cromolyn ophthalmic
$0-$7.40 (Tier 2)
MO
FRESHKOTE
$0 (Tier 4)
MO; [*]
ISOPTO TEARS
$0 (Tier 4)
MO; [*]
liquitears
$0 (Tier 4)
MO; [*]
lubricating plus
$0 (Tier 4)
[*]
lubrifresh pm
$0 (Tier 4)
MO; [*]
MURO 128 OPHTHALMIC DROPS
$0 (Tier 4)
MO; [*]
PATADAY
$0-$7.40 (Tier 2)
MO
PAZEO
$0-$7.40 (Tier 2)
MO
PURALUBE
$0 (Tier 4)
MO; [*]
REFRESH CELLUVISC
$0 (Tier 4)
MO; [*]
REFRESH LACRI-LUBE
$0 (Tier 4)
MO; [*]
REFRESH PLUS
$0 (Tier 4)
MO; [*]
RESTASIS
sodium chloride ophthalmic
$0-$7.40 (Tier 2)
$0 (Tier 4)
MO
MO; [*]
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
flurbiprofen ophthalmic drops
$0-$7.40 (Tier 2)
MO
ILEVRO
$0-$7.40 (Tier 2)
MO
ketorolac ophthalmic
$0-$7.40 (Tier 2)
MO
NEVANAC
$0-$7.40 (Tier 2)
MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
97
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ORAL DRUGS FOR GLAUCOMA
acetazolamide
$0-$7.40 (Tier 2)
MO
acetazolamide sodium
$0-$7.40 (Tier 2)
MO
methazolamide oral
$0-$7.40 (Tier 2)
MO
AZOPT
$0-$7.40 (Tier 2)
MO
bimatoprost
$0-$7.40 (Tier 2)
MO
COMBIGAN
$0-$7.40 (Tier 2)
MO
dorzolamide
$0-$7.40 (Tier 2)
MO
dorzolamide-timolol
$0-$7.40 (Tier 2)
MO
latanoprost
$0-$7.40 (Tier 2)
MO
LUMIGAN OPHTHALMIC DROPS 0.01 %
$0-$7.40 (Tier 2)
MO
TRAVATAN Z
$0-$7.40 (Tier 2)
MO; QLL (5 per 30 days)
OTHER GLAUCOMA DRUGS
STEROID-ANTIBIOTIC COMBINATIONS
NEO-POLYCIN HC
$0-$7.40 (Tier 2)
neomycin-bacitracin-poly-hc
$0-$7.40 (Tier 2)
MO
neomycin-polymyxin b-dexameth
$0-$7.40 (Tier 2)
MO
neomycin-polymyxin-hc ophthalmic
$0-$7.40 (Tier 2)
MO
tobramycin-dexamethasone ophthalmic suspension
$0-$7.40 (Tier 2)
MO
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE S.O.P.
$0-$7.40 (Tier 2)
MO
sulfacetamide-prednisolone
$0-$7.40 (Tier 2)
MO
dexamethasone sodium phosphate ophthalmic
$0-$7.40 (Tier 2)
MO
fluorometholone
$0-$7.40 (Tier 2)
MO
prednisolone acetate
$0-$7.40 (Tier 2)
MO
prednisolone sodium phosphate ophthalmic
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
STEROIDS
SULFONAMIDES
sulfacetamide sodium ophthalmic drops
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
98
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
SYMPATHOMIMETICS
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
$0-$7.40 (Tier 2)
MO
apraclonidine
$0-$7.40 (Tier 2)
MO
brimonidine
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
$0 (Tier 4)
[*]
VASOCONSTRICTOR DECONGESTANTS
eye drops (tetrahydrozoline)
naphazoline
OPTI-CLEAR
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
12 hour decongestant
$0 (Tier 4)
[*]
ALA-HIST DM
$0 (Tier 4)
MO; [*]
ala-hist ir
$0 (Tier 4)
MO; [*]
ALA-HIST PE
$0 (Tier 4)
MO; [*]
all day allergy (cetirizine) oral tablet
$0 (Tier 4)
[*]; QLL (30 per 30 days)
all day allergy (cetirizine) oral tablet,chewable
$0 (Tier 4)
MO; [*]
all day allergy-d
$0 (Tier 4)
MO; [*]
all-nite cold-flu
$0 (Tier 4)
[*]
ALLER-CHLOR
$0 (Tier 4)
MO; [*]
allergy (chlorpheniramine)
$0 (Tier 4)
MO; [*]
allergy 4-hour
$0 (Tier 4)
[*]
allergy relief (clemastine)
$0 (Tier 4)
MO; [*]
allergy relief (loratadine) oral solution
$0 (Tier 4)
[*]
allergy relief (loratadine) oral tablet
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
allergy relief d-24
$0 (Tier 4)
[*]
allergy relief(diphenhydramin) oral liquid
$0 (Tier 4)
[*]
allfen dm
$0 (Tier 4)
MO; [*]
ap-hist dm
$0 (Tier 4)
[*]
aprodine
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
99
Nombre de la medicina
arbinoxa
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
$0-$7.40 (Tier 2)
PAR; MO
banophen allergy
$0 (Tier 4)
MO; [*]
banophen oral capsule 25 mg
$0 (Tier 4)
MO; [*]
banophen oral capsule 50 mg
$0 (Tier 4)
[*]
banophen oral liquid
$0 (Tier 4)
MO; [*]
benzonatate
$0 (Tier 3)
MO; [*]
BROMFED DM
$0 (Tier 3)
MO; [*]
brompheniramine-pseudoeph-dm oral syrup
$0 (Tier 3)
MO; [*]
brotapp
$0 (Tier 4)
MO; [*]
brotapp dm
$0 (Tier 4)
MO; [*]
cetirizine oral solution 1 mg/ml
$0 (Tier 4)
MO; [*]; QLL (300 per 30 days)
cetirizine oral tablet
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
cetirizine oral tablet,chewable
$0 (Tier 4)
MO; [*]
cetirizine-pseudoephedrine
$0 (Tier 4)
MO; [*]
cheratussin ac
$0 (Tier 3)
MO; [*]
cheratussin dac
$0 (Tier 3)
MO; [*]
chest congestion relief
$0 (Tier 4)
[*]
chest congestion relief pe
$0 (Tier 4)
[*]
CHILD DELSYM COUGH+CHEST DM
$0 (Tier 4)
[*]
CHILD DELSYM COUGH+COLD
$0 (Tier 4)
[*]
CHILD MUCINEX CHEST CONGESTION
$0 (Tier 4)
[*]
CHILD MUCINEX CONGESTION-COUGH
$0 (Tier 4)
[*]
CHILD MUCINEX M-S COLD DAY-NTE
$0 (Tier 4)
[*]
CHILD MUCINEX STUFFY NOSE-COLD
$0 (Tier 4)
MO; [*]
children's allergy (diphenhyd) oral liquid
$0 (Tier 4)
[*]
children's cetirizine oral solution
$0 (Tier 4)
[*]; QLL (300 per 30 days)
children's cetirizine oral tablet,chewable
$0 (Tier 4)
MO; [*]
CHILDREN'S CLARITIN ORAL TABLET,
CHEWABLE
$0 (Tier 4)
MO; [*]
children's cold and cough dm
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
100
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CHILDREN'S MUCINEX COLD-FEVER
$0 (Tier 4)
[*]
CHILDREN'S MUCINEX COUGH
$0 (Tier 4)
[*]
CHILDREN'S MUCINEX MULTI-SYMP
$0 (Tier 4)
[*]
CHILDREN'S MUCINEX NIGHT TIME
$0 (Tier 4)
[*]
children's silfedrine
$0 (Tier 4)
[*]
CHLO TUSS
$0 (Tier 4)
MO; [*]
CHLORPHEN SR
$0 (Tier 4)
[*]
chlorpheniramine maleate oral tablet extended
release
$0 (Tier 4)
MO; [*]
CLARITIN-D 12 HOUR
$0 (Tier 4)
MO; [*]
clemastine oral tablet 2.68 mg
$0-$7.40 (Tier 2)
PAR; MO
codeine-guaifenesin
$0 (Tier 3)
MO; [*]
complete allergy medicine oral capsule
$0 (Tier 4)
[*]
complete allergy oral liquid
$0 (Tier 4)
[*]
CONGESTION RELIEF (IBUPROF-PE)
$0 (Tier 4)
[*]
cough dm er
$0 (Tier 4)
[*]
cough syrup dm
$0 (Tier 4)
[*]
cough-sore throat night
$0 (Tier 4)
[*]
DALLERGY (CHLORPHENIRAMINE-PE) ORAL
DROPS 1-2.5 MG/ML
$0 (Tier 4)
[*]
DALLERGY (DEXBROMPHENIRAMN-PE)
ORAL TABLET
$0 (Tier 4)
MO; [*]
dayhist allergy
$0 (Tier 4)
[*]
DAYTIME COLD-FLU RELIEF (PE) ORAL
CAPSULE
$0 (Tier 4)
[*]
DECONEX DMX
$0 (Tier 4)
MO; [*]
DECONEX IR
$0 (Tier 4)
MO; [*]
DELSYM 12 HOUR
$0 (Tier 4)
MO; [*]
DELSYM COUGH-CHEST CONGEST DM
$0 (Tier 4)
[*]
DELSYM COUGH-COLD DAYTIME
$0 (Tier 4)
[*]
DELSYM COUGH-COLD NIGHTTIME
$0 (Tier 4)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
101
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
dextromethorphan polistirex
$0 (Tier 4)
[*]
dimaphen (pe)
$0 (Tier 4)
MO; [*]
dimaphen dm
$0 (Tier 4)
MO; [*]
diphenhist oral liquid
$0 (Tier 4)
MO; [*]
diphenhydramine hcl injection solution 50 mg/ml
$0-$7.40 (Tier 2)
PAR; MO
diphenhydramine hcl injection syringe
$0-$7.40 (Tier 2)
PAR; MO
diphenhydramine hcl oral capsule 25 mg
$0 (Tier 4)
MO; [*]
diphenhydramine hcl oral capsule 50 mg
$0 (Tier 4)
PAR; MO; [*]
DURAFLU ORAL TABLET 60-20-200-500 MG
$0 (Tier 4)
MO; [*]
ed a-hist
$0 (Tier 4)
MO; [*]
ed a-hist dm oral liquid
$0 (Tier 4)
MO; [*]
ED A-HIST DM ORAL TABLET
$0 (Tier 4)
[*]
ed a-hist pse
$0 (Tier 4)
[*]
ed bron gp
$0 (Tier 4)
[*]
ED CHLORPED D
$0 (Tier 4)
[*]
ed chlorped jr
$0 (Tier 4)
[*]
ED-CHLORPED
$0 (Tier 4)
[*]
ed-chlortan
$0 (Tier 4)
MO; [*]
endacof - dm
$0 (Tier 4)
[*]
epinephrine injection syringe 0.1 mg/ml
$0-$7.40 (Tier 2)
MO
EPIPEN 2-PAK
$0-$7.40 (Tier 2)
MO; QLL (2 per 2 days)
EPIPEN JR 2-PAK
$0-$7.40 (Tier 2)
MO; QLL (2 per 2 days)
fexofenadine oral suspension
$0 (Tier 4)
[*]
fexofenadine oral tablet 180 mg, 60 mg
$0 (Tier 4)
MO; [*]
FLOWTUSS
$0 (Tier 3)
[*]
guaifenesin ac
$0 (Tier 3)
[*]
guaifenesin oral liquid
$0 (Tier 4)
[*]
GUAIFENESIN ORAL TABLET EXTENDED
RELEASE 12HR 1,200 MG
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
102
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
guaifenesin oral tablet extended release 12hr 600
mg
$0 (Tier 4)
MO; [*]
HISTEX (TRIPROLIDINE)
$0 (Tier 4)
[*]
HISTEX DM
$0 (Tier 4)
[*]
HISTEX PD
$0 (Tier 4)
[*]
HISTEX PE
$0 (Tier 4)
[*]
HYCOFENIX
$0 (Tier 3)
MO; [*]
hydrocodone-chlorpheniramine
$0 (Tier 3)
MO; [*]
hydrocodone-cpm-pseudoephed
$0 (Tier 3)
MO; [*]
hydrocodone-homatropine oral syrup 5-1.5 mg/5
ml
$0 (Tier 3)
MO; [*]
hydrocodone-homatropine oral tablet
$0 (Tier 3)
MO; [*]
hydromet
$0 (Tier 3)
MO; [*]
iophen c-nr
$0 (Tier 3)
MO; [*]
iophen dm-nr
$0 (Tier 4)
MO; [*]
iophen-nr
$0 (Tier 4)
MO; [*]
J-MAX
$0 (Tier 4)
MO; [*]
J-TAN D PD
$0 (Tier 4)
MO; [*]
J-TAN PD
$0 (Tier 4)
MO; [*]
kidkare cough/cold
$0 (Tier 4)
[*]
levocetirizine oral tablet
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
LODRANE D
$0 (Tier 4)
MO; [*]
lohist - d
$0 (Tier 4)
MO; [*]
lohist-dm
$0 (Tier 3)
MO; [*]
lorata-dine d
$0 (Tier 4)
[*]
loratadine oral solution
$0 (Tier 4)
MO; [*]
loratadine oral tablet
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
loratadine oral tablet,disintegrating
$0 (Tier 4)
MO; [*]; QLL (30 per 30 days)
loratadine-d
$0 (Tier 4)
MO; [*]
LORTUSS DM
$0 (Tier 4)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
103
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
LORTUSS EX ORAL SYRUP
$0 (Tier 3)
[*]
LORTUSS LQ
$0 (Tier 4)
[*]
M-END DMX
$0 (Tier 4)
[*]
M-END MAX D
$0 (Tier 3)
MO; [*]
mapap cold formula
$0 (Tier 4)
[*]
mapap sinus max strength (pe)
$0 (Tier 4)
[*]
maxiphen
$0 (Tier 4)
MO; [*]
MAXIPHEN DM
$0 (Tier 4)
[*]
mucaphed
$0 (Tier 4)
[*]
mucinex
$0 (Tier 4)
MO; [*]
MUCINEX COLD,FLU,SORE THROAT
$0 (Tier 4)
[*]
MUCINEX COUGH MINI-MELTS
$0 (Tier 4)
MO; [*]
mucinex d
$0 (Tier 4)
MO; [*]
mucinex d maximum strength
$0 (Tier 4)
MO; [*]
mucinex dm
$0 (Tier 4)
MO; [*]
mucinex fast-max cold-flu-thrt oral tablet
$0 (Tier 4)
[*]
MUCINEX FAST-MAX COLD-SINUS
$0 (Tier 4)
[*]
MUCINEX FAST-MAX CONGEST-COUGH
ORAL LIQUID
$0 (Tier 4)
MO; [*]
MUCINEX FAST-MAX CONGEST-COUGH
ORAL TABLET
$0 (Tier 4)
[*]
MUCINEX FAST-MAX DAY-NITE CONG ORAL
TABLETS, SEQUENTIAL
$0 (Tier 4)
[*]
MUCINEX FAST-MAX DM MAX
$0 (Tier 4)
[*]
MUCINEX FAST-MAX NITE COLD-FLU ORAL
LIQUID
$0 (Tier 4)
[*]
MUCINEX FAST-MAX SEVERE COLD ORAL
LIQUID
$0 (Tier 4)
[*]
MUCINEX FST-MX DY-NT COLD(DPH) ORAL
LIQUID, SEQUENTIAL
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
104
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MUCINEX MINI-MELTS ORAL GRANULES IN
PACKET 100 MG
$0 (Tier 4)
MO; [*]
MUCINEX SINUS-MAX D-N (DIPHEN) ORAL
TABLETS, SEQUENTIAL
$0 (Tier 4)
[*]
mucinex sinus-max pressur-pain oral tablet
$0 (Tier 4)
[*]
mucinex sinus-max sev congestn oral tablet
$0 (Tier 4)
[*]
MUCUS RELIEF ER ORAL TABLET
EXTENDED RELEASE 12HR 600 MG
$0 (Tier 4)
[*]
mucus relief oral tablet 400 mg
$0 (Tier 4)
MO; [*]
mucus relief sinus
$0 (Tier 4)
[*]
nasal decongestant (pe) oral tablet 10 mg
$0 (Tier 4)
[*]
nasal decongestant (pseudoeph) oral tablet
$0 (Tier 4)
[*]
NASOPEN PE
$0 (Tier 4)
[*]
nighttime sleep aid (diphen) oral tablet
$0 (Tier 4)
[*]
NINJACOF
$0 (Tier 4)
[*]
NINJACOF-A
$0 (Tier 4)
[*]
NINJACOF-XG
$0 (Tier 3)
MO; [*]
NITE TIME COLD-FLU RELIEF ORAL
CAPSULE
$0 (Tier 4)
[*]
nohist-dm
$0 (Tier 4)
MO; [*]
nohist-lq
$0 (Tier 4)
[*]
non-drowsy allergy
$0 (Tier 4)
[*]; QLL (30 per 30 days)
ORGAN-I NR
$0 (Tier 4)
MO; [*]
PAIN RELIEF SINUS PE
$0 (Tier 4)
[*]
pediatric cough and cold oral liquid 1-15-5 mg/5
ml
$0 (Tier 4)
[*]
phenylhistine dh
$0 (Tier 3)
MO; [*]
POLY HIST PD
$0 (Tier 4)
[*]
POLY-HIST DM (THONZYLAMINE)
$0 (Tier 4)
[*]
POLY-VENT DM ORAL TABLET 60-20-380 MG
$0 (Tier 4)
[*]
POLY-VENT IR ORAL TABLET 60-380 MG
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
105
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
promethazine injection solution
$0-$7.40 (Tier 2)
PAR; MO
promethazine oral tablet 12.5 mg, 25 mg
$0-$7.40 (Tier 2)
PAR; MO
promethazine vc-codeine
$0 (Tier 3)
MO; [*]
promethazine-codeine
$0 (Tier 3)
MO; [*]
promethazine-dm
$0 (Tier 3)
MO; [*]
PROMETHEGAN RECTAL SUPPOSITORY 12.5
MG
$0-$7.40 (Tier 2)
PAR; MO
pseudoephedrine hcl oral liquid
$0 (Tier 4)
MO; [*]
pseudoephedrine hcl oral tablet 30 mg
$0 (Tier 4)
MO; [*]
pseudoephedrine-guaifenesin
$0 (Tier 4)
MO; [*]
pyrilamine-phenylephrine oral tablet
$0 (Tier 4)
[*]
q-dryl oral capsule
$0 (Tier 4)
[*]
q-dryl oral liquid
$0 (Tier 4)
MO; [*]
q-tussin
$0 (Tier 4)
[*]
q-tussin dm
$0 (Tier 4)
[*]
quenalin
$0 (Tier 4)
[*]
RESCON
$0 (Tier 4)
[*]
RESCON-DM
$0 (Tier 4)
MO; [*]
rescon-gg
$0 (Tier 4)
MO; [*]
RESPAIRE-30
$0 (Tier 4)
MO; [*]
restfully sleep
$0 (Tier 4)
[*]
REZIRA
$0 (Tier 3)
MO; [*]
robafen
$0 (Tier 4)
MO; [*]
robafen cf (phenylephrine)
$0 (Tier 4)
MO; [*]
robafen cough
$0 (Tier 4)
MO; [*]
robafen dm
$0 (Tier 4)
MO; [*]
robafen dm cough
$0 (Tier 4)
[*]
robafen dm cough-chest congest
$0 (Tier 4)
[*]
RU-HIST D
$0 (Tier 4)
MO; [*]
RYMED (DEXCHLORPHENIRAMINE-PE)
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
106
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
rynex dm
$0 (Tier 4)
[*]
rynex pe
$0 (Tier 4)
[*]
rynex pse
$0 (Tier 4)
[*]
siladryl sa
$0 (Tier 4)
[*]
silphen cough
$0 (Tier 4)
[*]
siltussin dm das
$0 (Tier 4)
[*]
siltussin sa
$0 (Tier 4)
MO; [*]
siltussin-dm
$0 (Tier 4)
[*]
SORE THROAT AND COUGH
$0 (Tier 4)
[*]
STAHIST AD ORAL LIQUID
$0 (Tier 4)
[*]
STAHIST AD ORAL TABLET
$0 (Tier 4)
MO; [*]
sudogest
$0 (Tier 4)
MO; [*]
sudogest 12-hour
$0 (Tier 4)
MO; [*]
sudogest pe
$0 (Tier 4)
MO; [*]
sudogest sinus and allergy
$0 (Tier 4)
[*]
tussin dm oral liquid
$0 (Tier 4)
[*]
tussin dm oral syrup 10-100 mg/5 ml
$0 (Tier 4)
MO; [*]
tussin expectorant
$0 (Tier 4)
[*]
tussin oral liquid
$0 (Tier 4)
[*]
TUSSIONEX PENNKINETIC ER
$0 (Tier 3)
MO; [*]
VANACOF
$0 (Tier 4)
MO; [*]
VANAHIST PD
$0 (Tier 4)
[*]
VIRTUSSIN AC
$0 (Tier 3)
MO; [*]
ZONATUSS
$0 (Tier 3)
MO; [*]
ZUTRIPRO
$0 (Tier 3)
MO; [*]
$0 (Tier 1)
B/D PAR; MO
ADEMPAS
$0-$7.40 (Tier 2)
PAR; MO; LA
ADVAIR DISKUS
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
PULMONARY AGENTS
acetylcysteine
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
107
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ADVAIR HFA
$0-$7.40 (Tier 2)
MO; QLL (12 per 30 days)
AEROSPAN
$0-$7.40 (Tier 2)
QLL (18 per 30 days)
albuterol sulfate inhalation solution for nebulization
0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)
$0 (Tier 1)
B/D PAR; MO; QLL (360 per 30 days)
ALBUTEROL SULFATE INHALATION
SOLUTION FOR NEBULIZATION 2.5 MG/0.5
ML
$0 (Tier 1)
B/D PAR; MO; QLL (60 per 30 days)
albuterol sulfate inhalation solution for nebulization
5 mg/ml
$0 (Tier 1)
B/D PAR; MO; QLL (60 per 30 days)
albuterol sulfate oral
$0 (Tier 1)
MO
ANORO ELLIPTA
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
ARNUITY ELLIPTA
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
ASMANEX HFA
$0-$7.40 (Tier 2)
MO; QLL (13 per 30 days)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES)
$0-$7.40 (Tier 2)
MO; QLL (0.14 per 30 days)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES), 220 MCG (14 DOSES)
$0-$7.40 (Tier 2)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (120 DOSES), 220 MCG (30 DOSES), 220
MCG (60 DOSES)
$0-$7.40 (Tier 2)
MO; QLL (0.24 per 30 days)
ATROVENT HFA
$0-$7.40 (Tier 2)
MO; QLL (26 per 30 days)
BREO ELLIPTA
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
CINRYZE
$0-$7.40 (Tier 2)
PAR; MO
COMBIVENT RESPIMAT
$0-$7.40 (Tier 2)
MO; QLL (8 per 30 days)
cromolyn inhalation
$0 (Tier 1)
B/D PAR; MO; QLL (240 per 30 days)
cromolyn nasal
$0 (Tier 4)
MO; [*]
DALIRESP
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
DULERA
$0-$7.40 (Tier 2)
MO; QLL (13 per 30 days)
ESBRIET
$0-$7.40 (Tier 2)
PAR; QLL (270 per 30 days)
FIRAZYR
$0-$7.40 (Tier 2)
PAR; MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
108
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION, 50 MCG/
ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (240 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (12 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (24 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 44 MCG/ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (11 per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
$0 (Tier 1)
MO; QLL (75 per 30 days)
fluticasone nasal
$0 (Tier 1)
MO; QLL (16 per 30 days)
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
FORADIL AEROLIZER
ipratropium bromide inhalation
$0 (Tier 1)
B/D PAR; MO
ipratropium-albuterol
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (540 per 30 days)
KALYDECO ORAL TABLET
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
LETAIRIS
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (30 per 30 days)
levalbuterol hcl inhalation solution for nebulization
0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml
$0 (Tier 1)
B/D PAR; MO; QLL (270 per 30 days)
levalbuterol hcl inhalation solution for nebulization
0.63 mg/3 ml
$0 (Tier 1)
B/D PAR; MO; QLL (540 per 30 days)
metaproterenol
$0 (Tier 1)
MO
mometasone nasal
$0-$7.40 (Tier 2)
QLL (17 per 30 days)
montelukast
$0 (Tier 1)
MO; QLL (30 per 30 days)
NASONEX
$0-$7.40 (Tier 2)
MO; QLL (17 per 30 days)
OFEV ORAL CAPSULE 150 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (60 per 30 days)
PERFOROMIST
$0-$7.40 (Tier 2)
B/D PAR; MO; QLL (120 per 30 days)
PROAIR HFA
$0-$7.40 (Tier 2)
MO; QLL (18 per 30 days)
PROAIR RESPICLICK
$0-$7.40 (Tier 2)
MO; QLL (2 per 30 days)
PULMOZYME
$0-$7.40 (Tier 2)
B/D PAR; MO
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
109
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
QVAR INHALATION AEROSOL 40 MCG/
ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (9 per 30 days)
QVAR INHALATION AEROSOL 80 MCG/
ACTUATION
$0-$7.40 (Tier 2)
MO; QLL (18 per 30 days)
S2 RACEPINEPHRINE
$0 (Tier 4)
MO; [*]
SEREVENT DISKUS
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
sildenafil oral
$0-$7.40 (Tier 2)
PAR; MO; QLL (90 per 30 days)
SPIRIVA RESPIMAT
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
SPIRIVA WITH HANDIHALER
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
STIOLTO RESPIMAT
$0-$7.40 (Tier 2)
MO; QLL (4 per 30 days)
terbutaline oral
$0 (Tier 1)
MO
terbutaline subcutaneous
$0 (Tier 1)
MO
theophylline oral tablet extended release
$0 (Tier 1)
MO
theophylline oral tablet extended release 12 hr
$0 (Tier 1)
MO
TRACLEER
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (60 per 30 days)
VENTAVIS
$0-$7.40 (Tier 2)
PAR; MO
VENTOLIN HFA
$0-$7.40 (Tier 2)
MO; QLL (36 per 30 days)
XOLAIR
$0-$7.40 (Tier 2)
PAR; MO; LA; QLL (6 per 28 days)
XOPENEX HFA
$0-$7.40 (Tier 2)
MO; QLL (45 per 30 days)
$0 (Tier 1)
MO; QLL (60 per 30 days)
MYRBETRIQ
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
oxybutynin chloride oral syrup
$0-$7.40 (Tier 2)
MO; QLL (600 per 30 days)
oxybutynin chloride oral tablet
$0-$7.40 (Tier 2)
MO; QLL (120 per 30 days)
oxybutynin chloride oral tablet extended release
24hr 10 mg, 15 mg
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
oxybutynin chloride oral tablet extended release
24hr 5 mg
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
tolterodine oral capsule,extended release 24hr
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
zafirlukast
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
110
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
tolterodine oral tablet
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
TOVIAZ
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
trospium oral tablet
$0-$7.40 (Tier 2)
MO; QLL (60 per 30 days)
VESICARE
$0-$7.40 (Tier 2)
MO; QLL (30 per 30 days)
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin
$0-$7.40 (Tier 2)
MO
finasteride oral tablet 5 mg
$0-$7.40 (Tier 2)
MO
tamsulosin
$0-$7.40 (Tier 2)
MO
$0-$7.40 (Tier 2)
MO
CIALIS ORAL TABLET 2.5 MG, 5 MG
$0-$7.40 (Tier 2)
PAR; MO; QLL (30 per 30 days)
CYSTAGON
$0-$7.40 (Tier 2)
MO; LA
potassium citrate oral tablet extended release 10
meq (1,080 mg), 5 meq (540 mg)
$0-$7.40 (Tier 2)
MO
CHOLINERGIC STIMULANTS
bethanechol chloride
MISCELLANEOUS UROLOGICALS
VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
antacid (calcium carbonate) oral tablet,chewable
200 mg calcium (500 mg)
$0 (Tier 4)
[*]
ANTACID EXT STR (CALCIUM CARB)
$0 (Tier 4)
[*]
antacid extra-strength oral tablet,chewable 300 mg
(750 mg)
$0 (Tier 4)
[*]
CAL-GEST ANTACID
$0 (Tier 4)
MO; [*]
CALCET CREAMY BITES
$0 (Tier 4)
MO; [*]
calci-chew
$0 (Tier 4)
MO; [*]
calcitrate
$0 (Tier 4)
MO; [*]
CALCITRATE-VITAMIN D
$0 (Tier 4)
MO; [*]
calcium 500 + d oral tablet 500 mg(1,250mg) -200
unit
$0 (Tier 4)
MO; [*]
calcium 500 with d
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
111
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
calcium 600
$0 (Tier 4)
[*]
calcium 600 + d(3) oral tablet 600 mg(1,500mg) 200 unit, 600 mg(1,500mg) -400 unit
$0 (Tier 4)
MO; [*]
CALCIUM 600 WITH VITAMIN D3 ORAL
CAPSULE 600 MG(1,500MG) -400 UNIT
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
calcium acetate oral capsule
CALCIUM ANTACID ORAL TABLET,
CHEWABLE 200 MG CALCIUM (500 MG)
$0 (Tier 4)
MO; [*]
CALCIUM ANTACID ORAL TABLET,
CHEWABLE 300 MG (750 MG)
$0 (Tier 4)
[*]
calcium carbonate oral suspension
$0 (Tier 4)
MO; [*]
calcium carbonate oral tablet 500 mg calcium (1,
250 mg), 600 mg (1,500 mg)
$0 (Tier 4)
MO; [*]
calcium carbonate oral tablet,chewable 500 mg
calcium (1,250 mg)
$0 (Tier 4)
[*]
calcium carbonate-vitamin d3 oral tablet 500 mg
(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit,
500mg (1,250mg) -600 unit
$0 (Tier 4)
[*]
calcium carbonate-vitamin d3 oral tablet 600 mg
(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit,
600 mg(1,500mg) -800 unit
$0 (Tier 4)
MO; [*]
calcium carbonate-vitamin d3 oral tablet,chewable
500 mg(1,250mg) -400 unit
$0 (Tier 4)
MO; [*]
calcium citrate + d with mag
$0 (Tier 4)
[*]
calcium citrate-vitamin d3 oral tablet 200-125 mgunit
$0 (Tier 4)
[*]
calcium citrate-vitamin d3 oral tablet 315-200 mgunit, 315-250 mg-unit
$0 (Tier 4)
MO; [*]
calcium gluconate oral tablet 45 mg (500 mg)
$0 (Tier 4)
MO; [*]
calcium with vitamin d
$0 (Tier 4)
[*]
calcium-magnesium
$0 (Tier 4)
[*]
calcium-magnesium-zinc oral tablet
$0 (Tier 4)
[*]
calcium-magnesium-zinc oral tablet 333-133-5 mg
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
112
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CALTRATE 600 + D
$0 (Tier 4)
MO; [*]
CALTRATE WITH VITAMIN D3
$0 (Tier 4)
MO; [*]
chelated zinc
$0 (Tier 4)
MO; [*]
citrus calcium oral tablet 315-250 mg-unit
$0 (Tier 4)
MO; [*]
$0-$7.40 (Tier 2)
MO
electrolytes-dextrose
$0 (Tier 4)
[*]
ENFAMIL ENFALYTE
$0 (Tier 4)
[*]
hi-cal plus vit d
$0 (Tier 4)
[*]
dextrose-kcl-nacl
K-TAB ORAL TABLET EXTENDED RELEASE
8 MEQ
$0-$7.40 (Tier 2)
KLOR-CON 10
$0-$7.40 (Tier 2)
MO
KLOR-CON 8
$0-$7.40 (Tier 2)
MO
KLOR-CON M10
$0-$7.40 (Tier 2)
MO
KLOR-CON M15
$0-$7.40 (Tier 2)
MO
KLOR-CON M20
$0-$7.40 (Tier 2)
MO
lactated ringers intravenous
$0-$7.40 (Tier 2)
MO
laxative dietary supplement
$0 (Tier 4)
[*]
MAGNESIUM (OXIDE/AA CHELATE)
$0 (Tier 4)
MO; [*]
MAGNESIUM AMINO ACID CHELATE ORAL
TABLET 27 MG
$0 (Tier 4)
[*]
magnesium gluconate oral tablet 30 mg (550 mg)
$0 (Tier 4)
[*]
magnesium oral tablet 30 mg
$0 (Tier 4)
[*]
magnesium oxide oral capsule 500 mg
$0 (Tier 4)
[*]
magnesium oxide oral tablet 400 mg, 420 mg, 500
mg
$0 (Tier 4)
MO; [*]
MAGNESIUM SULFATE IN WATER
INTRAVENOUS PARENTERAL SOLUTION
$0-$7.40 (Tier 2)
MAGNESIUM SULFATE IN WATER
INTRAVENOUS PIGGYBACK 2 GRAM/50 ML
(4 %), 4 GRAM/50 ML (8 %)
$0-$7.40 (Tier 2)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
113
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
MAGNESIUM SULFATE IN WATER
INTRAVENOUS PIGGYBACK 4 GRAM/100 ML
(4 %)
$0-$7.40 (Tier 2)
MO
magnesium sulfate injection solution
$0-$7.40 (Tier 2)
MO
magnesium sulfate injection syringe
$0-$7.40 (Tier 2)
MG-PLUS-PROTEIN
$0 (Tier 4)
MO; [*]
MONOCAL
$0 (Tier 4)
MO; [*]
NORMOSOL-R
$0-$7.40 (Tier 2)
NORMOSOL-R IN 5 % DEXTROSE
$0-$7.40 (Tier 2)
NU-MAG
$0 (Tier 4)
[*]
oralyte
$0 (Tier 4)
[*]
ORAZINC
$0 (Tier 4)
MO; [*]
OS-CAL 500 + D3
$0 (Tier 4)
MO; [*]
OSTEO-PORETICAL
$0 (Tier 4)
MO; [*]
oysco 500/d oral tablet
$0 (Tier 4)
MO; [*]
oysco d
$0 (Tier 4)
MO; [*]
oysco-500
$0 (Tier 4)
MO; [*]
oyster shell + d3
$0 (Tier 4)
[*]
oyster shell calcium 500
$0 (Tier 4)
MO; [*]
oyster shell calcium and mag
$0 (Tier 4)
[*]
oyster shell calcium-vit d3
$0 (Tier 4)
MO; [*]
PEDIALYTE ADVANCED CARE
$0 (Tier 4)
[*]
pedialyte freezer pops
$0 (Tier 4)
[*]
pedialyte oral solution
$0 (Tier 4)
MO; [*]
pedialyte singles
$0 (Tier 4)
[*]
pediatric electrolyte oral solution
$0 (Tier 4)
[*]
pediatric freezer pops
$0 (Tier 4)
[*]
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/l
$0-$7.40 (Tier 2)
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
$0-$7.40 (Tier 2)
MO
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
114
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
potassium chloride in 0.9%nacl intravenous
parenteral solution 20 meq/l
$0-$7.40 (Tier 2)
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40 meq/l
$0-$7.40 (Tier 2)
potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l
$0-$7.40 (Tier 2)
potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l
$0-$7.40 (Tier 2)
potassium chloride intravenous piggyback 10 meq/
100 ml, 20 meq/100 ml, 40 meq/100 ml
$0-$7.40 (Tier 2)
POTASSIUM CHLORIDE INTRAVENOUS
PIGGYBACK 10 MEQ/50 ML
$0-$7.40 (Tier 2)
POTASSIUM CHLORIDE INTRAVENOUS
PIGGYBACK 20 MEQ/50 ML, 30 MEQ/100 ML
$0-$7.40 (Tier 2)
potassium chloride intravenous solution
$0-$7.40 (Tier 2)
MO
potassium chloride oral capsule, extended release
$0 (Tier 1)
MO
potassium chloride oral tablet extended release
$0 (Tier 1)
MO
potassium chloride oral tablet,er particles/crystals
$0 (Tier 1)
MO
potassium chloride-0.45 % nacl
$0-$7.40 (Tier 2)
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 20 meq/l
$0-$7.40 (Tier 2)
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 30 meq/l, 40 meq/l
$0-$7.40 (Tier 2)
potassium chloride-d5-0.3%nacl intravenous
parenteral solution 20 meq/l
$0-$7.40 (Tier 2)
potassium chloride-d5-0.9%nacl intravenous
parenteral solution 20 meq/l
$0-$7.40 (Tier 2)
potassium chloride-d5-0.9%nacl intravenous
parenteral solution 40 meq/l
$0-$7.40 (Tier 2)
ringers intravenous
$0-$7.40 (Tier 2)
MO
MO
MO
MO
selenium oral tablet 100 mcg, 50 mcg
$0 (Tier 4)
MO; [*]
selenium oral tablet 200 mcg
$0 (Tier 4)
[*]
selenium oral tablet,delayed release (dr/ec)
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
115
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
SLOW-MAG
$0 (Tier 4)
MO; [*]
sodium chloride 0.45 % intravenous parenteral
solution
$0-$7.40 (Tier 2)
MO
SODIUM CHLORIDE 0.45 % INTRAVENOUS
PIGGYBACK
$0-$7.40 (Tier 2)
sodium chloride 3 %
$0-$7.40 (Tier 2)
sodium chloride 5 %
$0-$7.40 (Tier 2)
sodium chloride intravenous
$0-$7.40 (Tier 2)
MO
SUPER CALCIUM
$0 (Tier 4)
[*]
zinc
$0 (Tier 4)
[*]
zinc gluconate oral lozenge
$0 (Tier 4)
[*]
zinc gluconate oral tablet 100 mg
$0 (Tier 4)
[*]
zinc gluconate oral tablet 50 mg
$0 (Tier 4)
MO; [*]
zinc sulfate oral capsule
$0 (Tier 4)
MO; [*]
zinc sulfate oral tablet
$0 (Tier 4)
[*]
ZINC-15
$0 (Tier 4)
MO; [*]
zinc-220
$0 (Tier 4)
[*]
MO
MISCELLANEOUS NUTRITION PRODUCTS
AMINOSYN 8.5 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN 8.5 %-ELECTROLYTES
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN II 10 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN II 7 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN II 8.5 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN II 8.5 %-ELECTROLYTES
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN M 3.5 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN-HBC 7%
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN-PF 10 %
$0-$7.40 (Tier 2)
B/D PAR
AMINOSYN-PF 7 % (SULFITE-FREE)
$0-$7.40 (Tier 2)
B/D PAR
calcium citrate malate-vit d3
CLINIMIX 5%/D15W SULFITE FREE
$0 (Tier 4)
$0-$7.40 (Tier 2)
[*]
B/D PAR
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
116
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CLINIMIX 5%/D25W SULFITE-FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX 2.75%/D5W SULFIT FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX 4.25%-D20W SULF-FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX 4.25%-D25W SULF-FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX 4.25%/D10W SULF FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX 5%-D20W(SULFITE-FREE)
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 4.25%/D10W SUL FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 4.25%/D25W SUL FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 4.25%/D5W SULF FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 5%/D15W SULFIT FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 5%/D20W SULFIT FREE
$0-$7.40 (Tier 2)
B/D PAR
CLINIMIX E 5%/D25W SULFIT FREE
$0-$7.40 (Tier 2)
B/D PAR
FORTAVIT
$0 (Tier 3)
[*]
FREAMINE III 10 %
$0-$7.40 (Tier 2)
B/D PAR
HEPATAMINE 8%
$0-$7.40 (Tier 2)
B/D PAR
intralipid intravenous emulsion 20 %
$0-$7.40 (Tier 2)
B/D PAR; MO
ISOLYTE-P IN 5 % DEXTROSE
$0-$7.40 (Tier 2)
NORMOSOL-M IN 5 % DEXTROSE
$0-$7.40 (Tier 2)
NORMOSOL-R PH 7.4
$0-$7.40 (Tier 2)
PLASMA-LYTE 148
$0-$7.40 (Tier 2)
PLASMA-LYTE-56 IN 5 % DEXTROSE
$0-$7.40 (Tier 2)
travasol 10 %
$0-$7.40 (Tier 2)
B/D PAR; MO
TROPHAMINE 10 %
$0-$7.40 (Tier 2)
B/D PAR; MO
TROPHAMINE 6%
$0-$7.40 (Tier 2)
B/D PAR
VITAMINS / HEMATINICS
ABANEU-SL
$0 (Tier 4)
[*]
acerola c-500
$0 (Tier 4)
[*]
actical
$0 (Tier 4)
MO; [*]
ACTIVE FE
$0 (Tier 3)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
117
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
ALBA-LYBE
$0 (Tier 4)
[*]
animal shape vitamins
$0 (Tier 4)
[*]
apatate forte
$0 (Tier 4)
[*]
APETEX
$0 (Tier 4)
[*]
APETIGEN
$0 (Tier 4)
[*]
apetigen plus oral liquid
$0 (Tier 4)
[*]
APETIGEN PLUS ORAL TABLET
$0 (Tier 4)
MO; [*]
AQUADEKS
$0 (Tier 4)
MO; [*]
aquasol e
$0 (Tier 4)
MO; [*]
ascorbic acid (vitamin c) oral granules
$0 (Tier 4)
[*]
ascorbic acid (vitamin c) oral tablet 250 mg, 500
mg
$0 (Tier 4)
[*]
ascorbic acid (vitamin c) oral tablet extended
release 1,000 mg
$0 (Tier 4)
MO; [*]
ascorbic acid (vitamin c) oral tablet extended
release 1,500 mg
$0 (Tier 4)
[*]
ascorbic acid (vitamin c) oral tablet,chewable
$0 (Tier 4)
[*]
b complex 1
$0 (Tier 4)
[*]
b complex w-vit c
$0 (Tier 4)
[*]
b complex-vitamin b12
$0 (Tier 4)
MO; [*]
b-complex oral tablet
$0 (Tier 4)
[*]
b-complex with vitamin c oral capsule
$0 (Tier 4)
MO; [*]
b-complex with vitamin c oral tablet
$0 (Tier 4)
MO; [*]
b-complex with vitamin c oral tablet extended
release
$0 (Tier 4)
[*]
BACMIN
$0 (Tier 3)
MO; [*]
bal b-100
$0 (Tier 4)
[*]
bal b-50
$0 (Tier 4)
[*]
balance b-100
$0 (Tier 4)
[*]
balance b-50
$0 (Tier 4)
[*]
balanced b-100 oral tablet 0.4 mg, 100 mg
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
118
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
balanced b-50 oral tablet
$0 (Tier 4)
[*]
bee-zee
$0 (Tier 4)
[*]
beta carotene oral capsule 25,000 unit
$0 (Tier 4)
MO; [*]
BIOCAL
$0 (Tier 4)
[*]
biosupp
$0 (Tier 4)
[*]
biotin oral capsule 2,500 mcg, 5 mg
$0 (Tier 4)
MO; [*]
biotin oral tablet 1 mg, 300 mcg
$0 (Tier 4)
MO; [*]
biovol
$0 (Tier 4)
[*]
c 1000-bioflavonoids-rose hips
$0 (Tier 4)
[*]
c complex
$0 (Tier 4)
[*]
c-500 oral tablet,chewable
$0 (Tier 4)
[*]
CALCET PETITES
$0 (Tier 4)
MO; [*]
calcium 600 + minerals
$0 (Tier 4)
[*]
calcium carbonate-vit d3-min oral tablet
$0 (Tier 4)
[*]
calcium carbonate-vit d3-min oral tablet,chewable
600 mg (1,500 mg)-200 unit
$0 (Tier 4)
[*]
calcium soft chew oral tablet,chewable 500-200-40
mg-unit-mcg
$0 (Tier 4)
[*]
calcium-magnesium-copper-zinc
$0 (Tier 4)
[*]
calcium-vitamin d3-vitamin k oral tablet,chewable
500-200-40 mg-unit-mcg
$0 (Tier 4)
[*]
CALTRATE 600+D PLUS MINERALS
$0 (Tier 4)
MO; [*]
centamin
$0 (Tier 4)
[*]
central vite with lutein
$0 (Tier 4)
[*]
central-vite cardio
$0 (Tier 4)
[*]
CENTRAL-VITE ENERGY
$0 (Tier 4)
[*]
central-vite men's under 50
$0 (Tier 4)
[*]
central-vite oral tablet 18-400 mg-mcg
$0 (Tier 4)
[*]
central-vite select
$0 (Tier 4)
[*]
central-vite senior
$0 (Tier 4)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
119
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
CENTRAL-VITE WOMEN'S MATURE
$0 (Tier 4)
[*]
central-vite women's under 50
$0 (Tier 4)
[*]
centratex
$0 (Tier 3)
MO; [*]
CENTRUM COMPLETE
$0 (Tier 4)
MO; [*]
CENTRUM KIDS
$0 (Tier 4)
MO; [*]
CENTRUM MEN
$0 (Tier 4)
[*]
CENTRUM ORAL LIQUID
$0 (Tier 4)
MO; [*]
CENTRUM ORAL TABLET,CHEWABLE
$0 (Tier 4)
[*]
CENTRUM SILVER ORAL TABLET
$0 (Tier 4)
MO; [*]
CENTRUM SILVER WOMEN
$0 (Tier 4)
MO; [*]
CENTRUM SPECIALIST HEART
$0 (Tier 4)
MO; [*]
CENTRUM ULTRA MEN'S
$0 (Tier 4)
[*]
century adults 50+
$0 (Tier 4)
[*]
century cardio
$0 (Tier 4)
[*]
century oral tablet 18-400 mg-mcg
$0 (Tier 4)
[*]
century ultimate men's oral tablet 8 mg iron- 200
mcg-600 mcg
$0 (Tier 4)
[*]
century ultimate women's
$0 (Tier 4)
[*]
CEREFOLIN
$0 (Tier 4)
MO; [*]
cerovite
$0 (Tier 4)
MO; [*]
cerovite advanced formula
$0 (Tier 4)
MO; [*]
cerovite jr
$0 (Tier 4)
[*]
certavite senior-antioxidant
$0 (Tier 4)
MO; [*]
certavite-antioxid (iron gluc) oral liquid 9 mg iron/
15 ml
$0 (Tier 4)
MO; [*]
certavite-antioxidant
$0 (Tier 4)
MO; [*]
chewable-vite
$0 (Tier 4)
MO; [*]
chewable-vite with iron
$0 (Tier 4)
[*]
child vitamin with minerals
$0 (Tier 4)
[*]
child's chewable vitamins/iron oral tablet,chewable
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
120
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
child's vitamin with iron
$0 (Tier 4)
[*]
children's chewable vitamin
$0 (Tier 4)
[*]
CHILDREN'S CHEWABLES
$0 (Tier 4)
[*]
CHILDREN'S CHEWABLES EXTRA C
$0 (Tier 4)
[*]
CHILDREN'S CHEWABLES WITH IRON
$0 (Tier 4)
[*]
children's iron
$0 (Tier 4)
[*]
childs chew vite
$0 (Tier 4)
[*]
childs/iron
$0 (Tier 4)
MO; [*]
cholecalciferol (vitamin d3) oral drops 400 unit/ml
$0 (Tier 4)
MO; [*]
compete
$0 (Tier 4)
[*]
complete multivitamin oral tablet
$0 (Tier 4)
[*]
complete multivitamin-mineral oral tablet
$0 (Tier 4)
[*]
complete oral tablet 18-500-300-250 mg-mcg-mcgmcg
$0 (Tier 4)
[*]
complete senior oral tablet 0.4-300-250 mg-mcgmcg
$0 (Tier 4)
MO; [*]
complex b-100 oral tablet extended release
$0 (Tier 4)
MO; [*]
CORAL CALCIUM ORAL CAPSULE 185-50-100
MG-MG-UNIT
$0 (Tier 4)
[*]
coral calcium oral capsule 200-100-100 mg-mgunit
$0 (Tier 4)
[*]
corvita
$0 (Tier 3)
MO; [*]
CORVITE
$0 (Tier 3)
MO; [*]
CORVITE 150 ORAL TABLET 150 MG IRON1 MG
$0 (Tier 3)
MO; [*]
CORVITE FE ORAL TABLET 150 MG IRON- 1
MG
$0 (Tier 3)
MO; [*]
CORVITE FREE
$0 (Tier 3)
MO; [*]
cyanocobalamin (vitamin b-12) oral liquid
$0 (Tier 4)
[*]
cyanocobalamin (vitamin b-12) oral tablet 1,000
mcg, 500 mcg
$0 (Tier 4)
[*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
121
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
cyanocobalamin (vitamin b-12) oral tablet extended
release
$0 (Tier 4)
[*]
daily multiple for men
$0 (Tier 4)
[*]
daily multiple for men 50+
$0 (Tier 4)
[*]
DAILY MULTIPLE FOR WOMEN
$0 (Tier 4)
[*]
daily multiple for women 50+
$0 (Tier 4)
[*]
daily multiple oral tablet
$0 (Tier 4)
[*]
DAILY MULTIPLE ORAL TABLET 400-120
MCG-MG
$0 (Tier 4)
[*]
daily multiple vitamins/iron
$0 (Tier 4)
[*]
daily multivitamin-minerals
$0 (Tier 4)
[*]
daily vitamin with iron and ca
$0 (Tier 4)
[*]
daily vites/iron
$0 (Tier 4)
MO; [*]
daily-vite
$0 (Tier 4)
MO; [*]
dialyvite 800
$0 (Tier 4)
MO; [*]
DIALYVITE 800 WITH IRON
$0 (Tier 3)
MO; [*]
dino-life
$0 (Tier 4)
[*]
dino-life with extra c
$0 (Tier 4)
[*]
dino-life with iron-zinc
$0 (Tier 4)
[*]
DRISDOL ORAL CAPSULE
$0 (Tier 3)
MO; [*]
duofer
$0 (Tier 4)
[*]
ECEE PLUS
$0 (Tier 4)
MO; [*]
ENLYTE (FERROUS GLYCINE)
$0 (Tier 3)
MO; [*]
ergocalciferol (vitamin d2) oral capsule
$0 (Tier 3)
MO; [*]
ergocalciferol (vitamin d2) oral drops
$0 (Tier 4)
MO; [*]
ezfe 200
$0 (Tier 4)
MO; [*]
fe c
$0 (Tier 4)
MO; [*]
FER-IN-SOL
$0 (Tier 4)
MO; [*]
fer-iron
$0 (Tier 4)
[*]
FERATE ORAL TABLET 240 MG (27 MG IRON)
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
122
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
FERGON
$0 (Tier 4)
MO; [*]
FERIVA 21-7 TABLET
$0 (Tier 3)
MO; [*]
FERIVA FA (SUMALATE)
$0 (Tier 3)
MO; [*]
ferosul oral elixir
$0 (Tier 4)
[*]
FEROSUL ORAL TABLET
$0 (Tier 4)
MO; [*]
FERRALET 90 DUAL-IRON DELIVERY
$0 (Tier 3)
MO; [*]
ferraplus 90
$0 (Tier 3)
MO; [*]
ferretts
$0 (Tier 4)
MO; [*]
FERRETTS IPS
$0 (Tier 4)
MO; [*]
ferrex 150
$0 (Tier 4)
MO; [*]
ferrex 150 forte
$0 (Tier 3)
MO; [*]
FERRIC X-150
$0 (Tier 4)
[*]
FERRIMIN 150
$0 (Tier 4)
MO; [*]
ferro-time
$0 (Tier 4)
MO; [*]
ferrocite
$0 (Tier 4)
MO; [*]
ferrous fumarate oral tablet 324 mg (106 mg iron)
$0 (Tier 4)
MO; [*]
ferrous gluconate oral tablet 236 mg (27 mg iron)
$0 (Tier 4)
[*]
ferrous gluconate oral tablet 240 mg (27 mg iron),
324 mg (37.5 mg iron), 324 mg (38 mg iron), 325
mg (36 mg iron)
$0 (Tier 4)
MO; [*]
ferrous sulfate oral drops
$0 (Tier 4)
MO; [*]
ferrous sulfate oral elixir
$0 (Tier 4)
MO; [*]
ferrous sulfate oral liquid
$0 (Tier 4)
MO; [*]
ferrous sulfate oral solution
$0 (Tier 4)
MO; [*]
ferrous sulfate oral tablet 325 mg (65 mg iron)
$0 (Tier 4)
MO; [*]
FERROUS SULFATE ORAL TABLET
EXTENDED RELEASE
$0 (Tier 4)
MO; [*]
ferrous sulfate oral tablet,delayed release (dr/ec)
$0 (Tier 4)
MO; [*]
ferrousul
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
FLUORITAB ORAL TABLET,CHEWABLE 1
MG FLUORIDE (2.2 MG)
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
123
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
FOCALGIN DSS
$0 (Tier 3)
[*]
folic acid injection
$0 (Tier 3)
MO; [*]
folic acid oral tablet 1 mg
$0 (Tier 3)
MO; [*]
folic acid-vit b6-vit b12 oral tablet 0.5-5-0.2 mg
$0 (Tier 4)
[*]
folitab
$0 (Tier 4)
MO; [*]
foltabs 800
$0 (Tier 4)
MO; [*]
foltanx
$0 (Tier 4)
MO; [*]
fosfree
$0 (Tier 4)
MO; [*]
full spectrum b-vitamin c
$0 (Tier 4)
[*]
FUSION PLUS
$0 (Tier 3)
MO; [*]
gummy dinos oral tablet,chewable 200 mcg
$0 (Tier 4)
[*]
HAIR VITAMINS
$0 (Tier 4)
[*]
hair,skin and nails oral tablet
$0 (Tier 4)
[*]
HARD NAIL
$0 (Tier 4)
[*]
HEMATRON
$0 (Tier 3)
[*]
HEMOCYTE
$0 (Tier 4)
MO; [*]
HEMOCYTE-F
$0 (Tier 3)
MO; [*]
HEMOCYTE-PLUS
$0 (Tier 3)
MO; [*]
high potency iron
$0 (Tier 4)
[*]
honey bears
$0 (Tier 4)
[*]
honey bears with iron-zinc
$0 (Tier 4)
[*]
I.L.X. B-12
$0 (Tier 4)
MO; [*]
ICAPS
$0 (Tier 4)
MO; [*]
ICAPS AREDS ORAL TABLET,DELAYED
RELEASE (DR/EC)
$0 (Tier 4)
MO; [*]
ICAPS MV
$0 (Tier 4)
MO; [*]
icaps plus
$0 (Tier 4)
[*]
ICAR ORAL SUSPENSION
$0 (Tier 4)
MO; [*]
ICAR-C
$0 (Tier 4)
MO; [*]
iferex 150
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
124
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
iferex 150 forte
$0 (Tier 3)
MO; [*]
infed
$0 (Tier 3)
MO; [*]
INTEGRA
$0 (Tier 4)
MO; [*]
INTEGRA F
$0 (Tier 3)
MO; [*]
INTEGRA PLUS
$0 (Tier 3)
MO; [*]
iron (ferrous sulfate)
$0 (Tier 4)
[*]
iron high potency
$0 (Tier 4)
[*]
iron oral tablet 325 mg (65 mg iron)
$0 (Tier 4)
[*]
iron oral tablet extended release 159 mg (45 mg
iron)
$0 (Tier 4)
[*]
iron-vitamin c
$0 (Tier 4)
MO; [*]
IROSPAN 24/6
$0 (Tier 3)
MO; [*]
l-methyl-b6-b12
$0 (Tier 4)
MO; [*]
l-methyl-mc
$0 (Tier 4)
MO; [*]
LIFE-PACK MEN'S
$0 (Tier 4)
[*]
LIFE-PACK WOMEN'S
$0 (Tier 4)
[*]
LITTLE ANIMALS
$0 (Tier 4)
[*]
LITTLE ANIMALS-IRON ORAL TABLET,
CHEWABLE
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
LUDENT FLUORIDE ORAL TABLET,
CHEWABLE 1 MG FLUORIDE (2.2 MG)
lysiplex plus oral liquid
$0 (Tier 4)
MO; [*]
MEDTYCHOLL-B COMPLEX-LIVER
$0 (Tier 4)
[*]
MEGA MULTI FOR WOMEN
$0 (Tier 4)
[*]
mega multiple/chelated mineral
$0 (Tier 4)
[*]
MEGA MULTIVITAMIN FOR MEN
$0 (Tier 4)
[*]
MEGA MULTIVITAMIN WITH MINERAL
ORAL TABLET 13.5-200-250 MG-MCG-MCG
$0 (Tier 4)
[*]
men's multi-vitamin
$0 (Tier 4)
[*]
MERIBIN
$0 (Tier 4)
MO; [*]
metafolbic
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
125
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
multi-delyn
$0 (Tier 4)
MO; [*]
multi-delyn with iron
$0 (Tier 4)
[*]
multi-vitamin hp/minerals
$0 (Tier 4)
[*]
multilex
$0 (Tier 4)
MO; [*]
multilex-t and m
$0 (Tier 4)
MO; [*]
multiple vitamin-minerals
$0 (Tier 4)
[*]
multivitamin oral tablet
$0 (Tier 4)
MO; [*]
multivitamin with iron
$0 (Tier 4)
[*]
multivitamin with minerals oral tablet
$0 (Tier 4)
MO; [*]
my-vitalife
$0 (Tier 4)
[*]
myferon 150
$0 (Tier 4)
MO; [*]
MYFERON 150 FORTE
$0 (Tier 3)
MO; [*]
NEPHRO-VITE
$0 (Tier 4)
MO; [*]
NEPHRON FA
$0 (Tier 3)
MO; [*]
nephronex
$0 (Tier 4)
[*]
NOVAFERRUM 125
$0 (Tier 4)
[*]
NOVAFERRUM 50
$0 (Tier 4)
[*]
NOVAFERRUM ORAL DROPS
$0 (Tier 4)
[*]
NU-IRON
$0 (Tier 4)
MO; [*]
NUTRICAP
$0 (Tier 3)
[*]
NUTRIVIT
$0 (Tier 4)
[*]
once daily
$0 (Tier 4)
[*]
ONCOVITE
$0 (Tier 4)
MO; [*]
one daily energy oral tablet
$0 (Tier 4)
[*]
one daily essential oral tablet , 0.4 mg
$0 (Tier 4)
[*]
one daily maximum
$0 (Tier 4)
[*]
one daily men's 50+
$0 (Tier 4)
[*]
one daily multi-vit w-mineral
$0 (Tier 4)
[*]
one daily multivitamin oral tablet
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
126
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
one daily oral tablet
$0 (Tier 4)
[*]
one daily plus iron
$0 (Tier 4)
[*]
one daily with iron
$0 (Tier 4)
[*]
ONE DAILY WOMEN 50 PLUS
$0 (Tier 4)
[*]
one daily women's oral tablet 27-0.4 mg
$0 (Tier 4)
[*]
oyster shell calcium with d
$0 (Tier 4)
[*]
pantothenic acid
$0 (Tier 4)
MO; [*]
PERIDIN-C
$0 (Tier 4)
MO; [*]
poly-iron
$0 (Tier 4)
MO; [*]
poly-iron 150 forte
$0 (Tier 3)
MO; [*]
poly-vita
$0 (Tier 4)
[*]
poly-vita (iron)
$0 (Tier 4)
[*]
poly-vitamin
$0 (Tier 4)
[*]
poly-vitamin with iron
$0 (Tier 4)
[*]
poly-vitamins
$0 (Tier 4)
[*]
polyvitamin/iron
$0 (Tier 4)
[*]
$0-$7.40 (Tier 2)
MO
PREVENT
$0 (Tier 4)
[*]
PRO FE
$0 (Tier 4)
MO; [*]
PROFERRIN ES
$0 (Tier 4)
MO; [*]
PROFERRIN-FORTE
$0 (Tier 3)
MO; [*]
PROTECT IRON
$0 (Tier 3)
[*]
pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg,
50 mg
$0 (Tier 4)
[*]
RABANO YODADO
$0 (Tier 4)
[*]
rena-vite
$0 (Tier 4)
MO; [*]
riboflavin (vitamin b2) oral tablet 100 mg
$0 (Tier 4)
[*]
risacal-d
$0 (Tier 4)
MO; [*]
se-tan plus
$0 (Tier 3)
MO; [*]
SENIOR TABS
$0 (Tier 4)
[*]
prenatal vitamin oral tablet
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
127
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
sentry oral tablet 18-500-300-250 mg-mcg-mcgmcg
$0 (Tier 4)
[*]
SENTRY SENIOR ORAL TABLET 500-300-250
MCG
$0 (Tier 4)
[*]
SIDEROL ORAL TABLET
$0 (Tier 4)
MO; [*]
slow release iron oral tablet extended release 143
mg (45 mg iron), 47.5 mg iron
$0 (Tier 4)
[*]
SLOW RELEASE IRON ORAL TABLET
EXTENDED RELEASE 159 MG (45 MG IRON)
$0 (Tier 4)
[*]
sodium fluoride oral tablet
$0-$7.40 (Tier 2)
MO
sodium fluoride oral tablet,chewable 1 mg fluoride
(2.2 mg)
$0-$7.40 (Tier 2)
MO
spectravite adult 50+ oral tablet
$0 (Tier 4)
[*]
spectravite advanced formula oral tablet 18-400
mg-mcg
$0 (Tier 4)
[*]
spectravite men's
$0 (Tier 4)
[*]
spectravite senior oral tablet 500-300-250 mcg
$0 (Tier 4)
[*]
spectravite ultra women
$0 (Tier 4)
[*]
SPECTRAVITE ULTRA WOMEN'S SR
$0 (Tier 4)
[*]
strawberry c
$0 (Tier 4)
[*]
stress formula
$0 (Tier 4)
[*]
STRESS FORMULA 600 C
$0 (Tier 4)
[*]
stress formula advanced
$0 (Tier 4)
[*]
STRESS FORMULA ENERGY
$0 (Tier 4)
[*]
stress formula with iron
$0 (Tier 4)
MO; [*]
stress formula with iron(sulf)
$0 (Tier 4)
[*]
stress formula with zinc
$0 (Tier 4)
MO; [*]
STROVITE FORTE
$0 (Tier 3)
MO; [*]
STROVITE ONE
$0 (Tier 3)
MO; [*]
SUPER B COMPLEX + C
$0 (Tier 4)
[*]
super b complex-vitamin c
$0 (Tier 4)
[*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
128
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
SUPER B-50 COMPLEX
$0 (Tier 4)
[*]
super b/c
$0 (Tier 4)
[*]
SUPER MULTIPLE ORAL TABLET
$0 (Tier 4)
[*]
SUPER MULTIVITAMIN
$0 (Tier 4)
[*]
super thera vite m
$0 (Tier 4)
MO; [*]
superplex-t
$0 (Tier 4)
[*]
SUPERVITE (EC)
$0 (Tier 3)
MO; [*]
support
$0 (Tier 4)
MO; [*]
SUPPORT-500
$0 (Tier 3)
MO; [*]
tab-a-vite
$0 (Tier 4)
MO; [*]
tab-a-vite-minerals
$0 (Tier 4)
[*]
tab-a-vite/iron
$0 (Tier 4)
MO; [*]
TANDEM DUAL ACTION
$0 (Tier 4)
MO; [*]
TANDEM PLUS
$0 (Tier 3)
MO; [*]
taron forte
$0 (Tier 3)
MO; [*]
thera
$0 (Tier 4)
[*]
thera m plus (ferrous fumarat)
$0 (Tier 4)
MO; [*]
thera vitamin
$0 (Tier 4)
MO; [*]
thera-m oral tablet
$0 (Tier 4)
[*]
thera-m oral tablet 9 mg iron-400 mcg
$0 (Tier 4)
MO; [*]
thera-tabs
$0 (Tier 4)
[*]
therapeutic liquid
$0 (Tier 4)
[*]
therapeutic m + beta-carotene
$0 (Tier 4)
[*]
therapeutic-m oral tablet 9 mg iron-400 mcg
$0 (Tier 4)
[*]
therapeutic-m vitamin/minerals oral tablet 27-0.4
mg
$0 (Tier 4)
[*]
theratrum complete with lutein
$0 (Tier 4)
[*]
therems
$0 (Tier 4)
MO; [*]
THEREMS-H
$0 (Tier 4)
MO; [*]
therems-m
$0 (Tier 4)
MO; [*]
?
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784 (TTY 711), de
lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis. Para obtener más información,
visite www.myamerigroup.com/TXmmp.
129
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
thiamine hcl (vitamin b1) oral tablet 100 mg, 250
mg
$0 (Tier 4)
[*]
total b/c
$0 (Tier 4)
[*]
TOTALDAY MULTIPLE
$0 (Tier 4)
[*]
TRI-VI-SOL
$0 (Tier 4)
MO; [*]
tri-vita
$0 (Tier 4)
[*]
tri-vitamin
$0 (Tier 4)
MO; [*]
ULTRA B-100 COMPLEX ORAL TABLET
$0 (Tier 4)
[*]
unicomplex-m
$0 (Tier 4)
MO; [*]
v-c forte
$0 (Tier 3)
MO; [*]
VIC-FORTE
$0 (Tier 3)
[*]
VITA-BEE WITH C
$0 (Tier 4)
MO; [*]
vitamin a oral capsule 10,000 unit
$0 (Tier 4)
MO; [*]
vitamin a oral capsule 8,000 unit
$0 (Tier 4)
[*]
vitamin b complex
$0 (Tier 4)
[*]
vitamin b complex with c
$0 (Tier 4)
[*]
vitamin b-1
$0 (Tier 4)
MO; [*]
vitamin b-12 oral tablet
$0 (Tier 4)
MO; [*]
vitamin b-12 oral tablet extended release 1,000 mcg
$0 (Tier 4)
MO; [*]
vitamin b-12 oral tablet extended release 2,000 mcg
$0 (Tier 4)
[*]
vitamin b-12 sublingual tablet 2,500 mcg
$0 (Tier 4)
MO; [*]
vitamin b-2 oral tablet 100 mg, 25 mg
$0 (Tier 4)
MO; [*]
vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg
$0 (Tier 4)
MO; [*]
vitamin c cough drops
$0 (Tier 4)
[*]
vitamin c drops
$0 (Tier 4)
[*]
vitamin c oral capsule, extended release
$0 (Tier 4)
MO; [*]
vitamin c oral lozenge
$0 (Tier 4)
[*]
vitamin c oral powder effervescent in packet
$0 (Tier 4)
[*]
vitamin c oral syrup
$0 (Tier 4)
MO; [*]
vitamin c oral tablet 1,000 mg, 250 mg, 500 mg
$0 (Tier 4)
MO; [*]
B/D: se requiere autorización previa, solo determinación de Parte D versus Parte B LA: disponibilidad limitada
MO: pedido por correo PAR: se requiere autorización previa QLL: límite en el nivel de cantidad ST: terapia
130
escalonada
Nombre de la medicina
Cuánto le costará la Medidas, restricciones o límites
medicina (nivel) necesarios en uso
vitamin c oral tablet extended release 1,000 mg
$0 (Tier 4)
[*]
vitamin c oral tablet extended release 500 mg
$0 (Tier 4)
MO; [*]
vitamin c oral tablet,chewable 250 mg, 500 mg
$0 (Tier 4)
MO; [*]
vitamin c with rose hips oral tablet
$0 (Tier 4)
MO; [*]
vitamin d2
$0 (Tier 3)
MO; [*]
vitamin e (dl, acetate) oral capsule 100 unit, 400
unit
$0 (Tier 4)
MO; [*]
vitamin e acetate
$0 (Tier 4)
[*]
vitamin e mixed oral capsule
$0 (Tier 4)
[*]
vitamin e oral capsule 1,000 unit, 200 unit, 400 unit
$0 (Tier 4)
MO; [*]
vitamin e oral capsule 100 unit, 600 unit
$0 (Tier 4)
[*]
vitamin e oral drops 100 unit/0.25 ml, 50 unit/ml
$0 (Tier 4)
[*]
vitamins a and d
$0 (Tier 4)
[*]
vitamins and minerals
$0 (Tier 4)
[*]
vitamins b complex oral capsule
$0 (Tier 4)
MO; [*]
vitamins for hair oral tablet
$0 (Tier 4)
[*]
wee care
$0 (Tier 4)
[*]
WHOLE SOURCE MULTI-VITAMINS
$0 (Tier 4)
[*]
women's daily formula oral tablet 18 mg iron-400
mcg-500 mg ca
$0 (Tier 4)
[*]
ZINC (WITH A AND C) LOZENGES
$0 (Tier 4)
[*]
zinc sulfate-vitamin c
$0 (Tier 4)
[*]
zoo chews
$0 (Tier 4)
[*]
ZOO FRIENDS ORIGINAL
$0 (Tier 4)
[*]
?
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131
Índice
1
12 hour decongestant ....... 99
A
abacavir ............................ 11
abacavir-lamivudinezidovudine ......................... 11
ABANEU-SL .................. 117
ABELCET ........................ 10
ABILIFY MAINTENA .... 44
ABRAXANE .................... 23
acamprosate ...................... 70
acarbose oral tablet 100
mg ..................................... 75
acarbose oral tablet 25
mg ..................................... 75
acarbose oral tablet 50
mg ..................................... 75
acebutolol ......................... 55
acephen rectal suppository 120
mg, 650 mg ....................... 41
acephen rectal suppository 325
mg ..................................... 41
acerola c-500 .................. 117
ACETA-GESIC ................ 41
acetaminophen oral tablet 325
mg ..................................... 41
acetaminophen-codeine oral
solution 120 mg-12 mg /5 ml
(5 ml), 300 mg-30 mg /12.5
ml ...................................... 39
acetaminophen-codeine oral
solution 120-12 mg/5 ml .... 39
ACETAMINOPHENCODEINE ORAL SOLUTION
240 MG-24 MG /10 ML (10
ML) ................................... 39
acetaminophen-codeine oral
tablet 300-15 mg ............... 39
acetaminophen-codeine oral
tablet 300-30 mg ............... 39
acetaminophen-codeine oral
tablet 300-60 mg ............... 39
acetazolamide ................... 98
acetazolamide sodium ...... 98
acetic acid otic .................. 73
?
acetic acid-aluminum
acetate ............................... 73
acetylcysteine .................. 107
acetylcysteine
intravenous ....................... 70
acid gone antacid ............. 81
acid reducer (famotidine) oral
tablet 20 mg ...................... 86
acitretin ............................. 64
ACNE MEDICATION
TOPICAL GEL ................. 65
ACNE MEDICATION
TOPICAL LOTION 10
% ....................................... 65
ACTEMRA
INTRAVENOUS .............. 90
ACTEMRA INTRAVENOUS
VIAL ................................. 90
ACTHAR H.P. .................. 74
ACTHIB (PF) ................... 88
actical ............................. 117
actidose/sorbitol oral
suspension 50 gram/240
ml ...................................... 81
ACTIMMUNE ................. 87
ACTIVE FE .................... 117
acyclovir oral capsule ....... 11
acyclovir oral suspension 200
mg/5 ml ............................. 11
acyclovir oral tablet .......... 11
acyclovir sodium intravenous
solution ............................. 11
acyclovir topical ............... 68
ADACEL(TDAP ADOLESN/
ADULT)(PF) ..................... 88
ADAGEN ......................... 70
adapalene topical gel 0.3
% ....................................... 65
adapalene topical gel with
pump ................................. 65
ADASUVE ....................... 44
adefovir ............................. 11
ADEMPAS ..................... 107
ADVAIR DISKUS .......... 107
ADVAIR HFA ................ 108
AEROSPAN ................... 108
afeditab cr ......................... 55
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION
2 MG, 5 MG ..................... 23
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION
3 MG ................................. 23
AFINITOR ORAL TABLET
10 MG ............................... 23
AFINITOR ORAL TABLET
2.5 MG .............................. 23
AFINITOR ORAL TABLET
5 MG ................................. 23
AFINITOR ORAL TABLET
7.5 MG .............................. 23
AGGRENOX .................... 60
akwa tears (polyvinyl
alcohol) ............................. 97
ala-cort topical cream ...... 68
ALA-HIST DM ................ 99
ala-hist ir .......................... 99
ALA-HIST PE .................. 99
ALBA-LYBE .................. 118
ALBENZA ....................... 17
albuterol sulfate inhalation
solution for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml, 2.5 mg
/3 ml (0.083 %) ............... 108
ALBUTEROL SULFATE
INHALATION SOLUTION
FOR NEBULIZATION 2.5
MG/0.5 ML ..................... 108
albuterol sulfate inhalation
solution for nebulization 5 mg/
ml .................................... 108
albuterol sulfate oral ...... 108
alclometasone ................... 68
alcohol pads ...................... 75
ALDURAZYME .............. 78
ALECENSA ..................... 23
alendronate oral solution ... 90
alendronate oral tablet 10 mg,
5 mg .................................. 90
alendronate oral tablet 35 mg,
70 mg ................................ 90
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TXDMKT-0101-16 SP 09.16 SP
132
alendronate oral tablet 40
mg ..................................... 70
alfuzosin .......................... 111
ALIMTA ........................... 23
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTION ........ 17
ALINIA ORAL
TABLET ........................... 17
all day allergy (cetirizine) oral
tablet ................................. 99
all day allergy (cetirizine) oral
tablet,chewable ................. 99
all day allergy-d ................ 99
all day pain relief .............. 41
all day relief ...................... 41
all-nite cold-flu ................. 99
ALLER-CHLOR .............. 99
allergy 4-hour ................... 99
allergy relief d-24 ............. 99
allergy relief
(clemastine) ...................... 99
allergy relief (loratadine) oral
solution ............................. 99
allergy relief (loratadine) oral
tablet ................................. 99
allergy relief(diphenhydramin)
oral liquid ......................... 99
allergy
(chlorpheniramine) ........... 99
allfen dm ........................... 99
allopurinol ........................ 90
almacone oral
suspension ......................... 81
almacone-2 ....................... 81
alosetron ........................... 81
ALPHAGAN P
OPHTHALMIC DROPS 0.1
% ....................................... 99
alprazolam oral tablet ...... 44
ALTAVERA (28) .............. 93
ALTOPREV ...................... 62
aluminum hydroxide gel oral
suspension 320 mg/5 ml .... 81
ALYACEN 1/35 (28) ........ 93
ALYACEN 7/7/7 (28) ....... 93
amantadine hcl oral
capsule .............................. 11
?
amantadine hcl oral
tablet ................................. 11
AMBISOME ..................... 10
amcinonide ....................... 68
amifostine crystalline ........ 22
AMIKACIN INJECTION
SOLUTION 1,000 MG/4
ML .................................... 17
amikacin injection solution
500 mg/2 ml ...................... 17
amiloride ........................... 55
amiloridehydrochlorothiazide .......... 55
AMINOSYN 8.5 % ........ 116
AMINOSYN 8.5 %ELECTROLYTES .......... 116
AMINOSYN II 10 % ...... 116
AMINOSYN II 7 % ........ 116
AMINOSYN II 8.5 % ..... 116
AMINOSYN II 8.5 %ELECTROLYTES .......... 116
AMINOSYN M 3.5 % .... 116
AMINOSYN-HBC 7% .... 116
AMINOSYN-PF 10 % .... 116
AMINOSYN-PF 7 %
(SULFITE-FREE) ........... 116
amiodarone intravenous
solution ............................. 55
AMIODARONE
INTRAVENOUS
SYRINGE ......................... 55
amiodarone oral ............... 55
AMITIZA ......................... 81
amitriptyline ..................... 44
amlodipine besylate oral tablet
10 mg, 2.5 mg ................... 56
amlodipine besylate oral tablet
5 mg .................................. 56
amlodipine-atorvastatin .... 62
amlodipine-benazepril ...... 56
amlodipine-valsartan ........ 56
amlodipine-valsartanhcthiazid ........................... 56
ammonium lactate ............ 64
amoxapine ......................... 44
amoxicillin oral capsule .... 20
amoxicillin oral suspension for
reconstitution .................... 20
amoxicillin oral tablet ...... 20
amoxicillin oral tablet,
chewable 125 mg, 250
mg ..................................... 20
amoxicillin-pot
clavulanate ....................... 20
amphotericin b .................. 10
ampicillin .......................... 20
ampicillin sodium
injection ............................ 20
ampicillin sodium
intravenous ....................... 20
ampicillin-sulbactam injection
recon soln 1.5 gram, 3
gram .................................. 20
ampicillin-sulbactam injection
recon soln 15 gram ........... 20
ampicillin-sulbactam
intravenous recon soln 1.5
gram .................................. 20
ampicillin-sulbactam
intravenous recon soln 3
gram .................................. 20
AMPYRA ......................... 37
anagrelide ......................... 70
anastrozole ........................ 23
ANDROGEL
TRANSDERMAL GEL IN
METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62
%) ..................................... 78
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/
1.25 GRAM) ..................... 78
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (40.5 MG/
2.5 GRAM) ....................... 78
ANDROXY ...................... 78
animal shape vitamins .... 118
ANORO ELLIPTA ......... 108
antacid .............................. 81
antacid anti-gas ................ 81
ANTACID EXT STR
(CALCIUM CARB) ....... 111
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TXDMKT-0101-16 SP 09.16 SP
133
antacid extra-strength oral
suspension 200-200-20 mg/5
ml ...................................... 81
antacid extra-strength oral
tablet,chewable 300 mg (750
mg) .................................. 111
antacid plus anti-gas oral
suspension 200-200-20 mg/5
ml ...................................... 81
antacid (calcium carbonate)
oral tablet,chewable 200 mg
calcium (500 mg) ............ 111
anti-diarrheal (loperamide)
oral tablet ......................... 80
anti-nausea liquid ............. 81
antifungal cream ............... 67
antifungal spray ................ 67
antifungal (tolnaftate) topical
cream ................................ 67
antifungal (tolnaftate) topical
powder .............................. 67
anu-med ............................ 81
ap-hist dm ......................... 99
apatate forte .................... 118
APETEX ......................... 118
APETIGEN ..................... 118
apetigen plus oral
liquid ............................... 118
APETIGEN PLUS ORAL
TABLET ......................... 118
APOKYN ......................... 37
apraclonidine .................... 99
apri ................................... 93
APRISO ............................ 81
aprodine ............................ 99
APTIOM ........................... 32
APTIVUS ORAL
CAPSULE ......................... 11
APTIVUS ORAL
SOLUTION ...................... 11
AQUADEKS .................. 118
aquasol e ......................... 118
ARALAST NP .................. 70
aranelle (28) ..................... 93
ARANESP (IN
POLYSORBATE)
INJECTION SOLUTION 100
MCG/ML, 200 MCG/ML, 25
?
MCG/ML, 300 MCG/ML, 40
MCG/ML, 60 MCG/ML .... 87
ARANESP (IN
POLYSORBATE)
INJECTION SYRINGE .... 87
arbinoxa .......................... 100
ARCALYST ..................... 87
aripiprazole oral
solution ............................. 44
aripiprazole oral tablet 10
mg ..................................... 44
aripiprazole oral tablet 15
mg ..................................... 44
aripiprazole oral tablet 2
mg ..................................... 44
aripiprazole oral tablet 20 mg,
30 mg ................................ 44
aripiprazole oral tablet 5
mg ..................................... 45
aripiprazole oral tablet,
disintegrating 10 mg ......... 45
aripiprazole oral tablet,
disintegrating 15 mg ......... 45
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 441 MG/1.6
ML .................................... 45
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 662 MG/2.4
ML .................................... 45
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 882 MG/3.2
ML .................................... 45
ARNUITY ELLIPTA ..... 108
ARRANON ...................... 23
arthritis pain relief
(acetam) ............................ 41
artificial tears (petro/
min) ................................... 97
artificial tears (polyvin
alc) .................................... 97
ARZERRA ....................... 23
ASACOL HD ................... 81
ascorbic acid (vitamin c) oral
granules .......................... 118
ascorbic acid (vitamin c) oral
tablet 250 mg, 500 mg .... 118
ascorbic acid (vitamin c) oral
tablet extended release 1,000
mg ................................... 118
ascorbic acid (vitamin c) oral
tablet extended release 1,500
mg ................................... 118
ascorbic acid (vitamin c) oral
tablet,chewable ............... 118
ASMANEX HFA ............ 108
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (30
DOSES) .......................... 108
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (7
DOSES), 220 MCG (14
DOSES) .......................... 108
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 220 MCG (120
DOSES), 220 MCG (30
DOSES), 220 MCG (60
DOSES) .......................... 108
aspir-low ........................... 41
aspirin oral tablet ............. 41
aspirin oral tablet,
chewable ........................... 41
aspirin oral tablet,delayed
release (dr/ec) 325 mg, 81
mg ..................................... 42
aspirin-dipyridamole ........ 60
atenolol ............................. 56
atenolol-chlorthalidone .... 56
ATGAM ............................ 88
atorvastatin ....................... 62
atovaquone ....................... 17
atovaquone-proguanil ....... 17
ATRIPLA .......................... 11
atropine injection syringe 0.05
mg/ml, 0.1 mg/ml .............. 80
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TXDMKT-0101-16 SP 09.16 SP
134
ATROVENT HFA .......... 108
AVASTIN .......................... 23
aviane ............................... 93
AVONEX
INTRAMUSCULAR PEN
INJECTOR KIT ................ 87
AVONEX
INTRAMUSCULAR
SYRINGE ......................... 87
AVONEX
INTRAMUSCULAR
SYRINGE KIT ................. 87
AVONEX (WITH
ALBUMIN) ...................... 87
azacitidine ......................... 23
AZACTAM IN DEXTROSE
(ISO-OSM) ....................... 17
azathioprine ...................... 23
azathioprine sodium ......... 23
azelastine nasal ................ 73
azelastine ophthalmic ....... 97
AZILECT ......................... 37
azithromycin intravenous
recon soln 500 mg ............. 16
azithromycin intravenous
recon soln 500 mg (2 mg/
ml) ..................................... 17
azithromycin oral .............. 17
AZOPT ............................. 98
AZOR ............................... 56
aztreonam ......................... 17
AZURETTE (28) .............. 93
B
b complex 1 ..................... 118
b complex w-vit c ............ 118
b complex-vitamin b12 .... 118
b-complex oral tablet ...... 118
b-complex with vitamin c oral
capsule ............................ 118
b-complex with vitamin c oral
tablet ............................... 118
b-complex with vitamin c oral
tablet extended release .... 118
baciim ............................... 17
bacitracin ophthalmic ....... 95
bacitracin topical
ointment ............................ 66
?
bacitracin zinc topical
ointment ............................ 66
bacitracin-polymyxin b
ophthalmic ........................ 96
baclofen ............................ 38
BACMIN ........................ 118
bal b-100 ......................... 118
bal b-50 ........................... 118
balance b-100 ................. 118
balance b-50 ................... 118
balanced b-100 oral tablet 0.4
mg, 100 mg ...................... 118
balanced b-50 oral
tablet ............................... 119
balsalazide ........................ 81
banophen allergy ............ 100
banophen oral capsule 25
mg ................................... 100
banophen oral capsule 50
mg ................................... 100
banophen oral liquid ...... 100
BANZEL ORAL
SUSPENSION .................. 32
BANZEL ORAL TABLET
200 MG ............................. 32
BANZEL ORAL TABLET
400 MG ............................. 32
BARACLUDE ORAL
SOLUTION ...................... 11
BCG VACCINE, LIVE
(PF) ................................... 88
bee-zee ............................ 119
BELEODAQ ..................... 23
benazepril ......................... 56
benazeprilhydrochlorothiazide .......... 56
BENDEKA ....................... 23
BENLYSTA ...................... 91
benzonatate ..................... 100
benzoyl peroxide topical
foam .................................. 65
benzoyl peroxide topical gel
10 %, 2.5 %, 5 % .............. 65
benztropine oral ................ 37
BESIVANCE .................... 96
beta carotene oral capsule 25,
000 unit ........................... 119
betamethasone
dipropionate ...................... 68
betamethasone valerate topical
cream ................................ 68
betamethasone valerate topical
lotion ................................. 68
betamethasone valerate topical
ointment ............................ 68
betamethasone,
augmented ......................... 68
betaxolol ophthalmic ........ 96
betaxolol oral .................... 56
bethanechol chloride ....... 111
BETIMOL ........................ 96
BETOPTIC S .................... 96
bexarotene ......................... 23
BEXSERO (PF) ................ 88
bicalutamide ..................... 23
BICILLIN C-R ................. 20
BICILLIN L-A ................. 20
BICNU .............................. 23
BILTRICIDE .................... 17
bimatoprost ....................... 98
BIOCAL ......................... 119
biosupp ............................ 119
biotin oral capsule 2,500 mcg,
5 mg ................................ 119
biotin oral tablet 1 mg, 300
mcg .................................. 119
biovol .............................. 119
bisac-evac ......................... 81
bisacodyl oral ................... 81
bisacodyl rectal ................. 81
biscolax ............................. 81
bismatrol oral suspension 262
mg/15 ml ........................... 80
bismatrol oral suspension 525
mg/15 ml ........................... 80
bismatrol oral tablet,
chewable ........................... 80
bisoprolol fumarate .......... 56
bisoprololhydrochlorothiazide .......... 56
bleomycin .......................... 24
BLEPHAMIDE S.O.P. ..... 98
BLINCYTO ...................... 24
blisovi fe 1.5/30 (28) ......... 93
blue gel ............................. 64
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TXDMKT-0101-16 SP 09.16 SP
135
BONIVA
INTRAVENOUS .............. 90
BOOSTRIX TDAP ........... 88
BOSULIF ORAL TABLET
100 MG ............................. 24
BOSULIF ORAL TABLET
500 MG ............................. 24
BREO ELLIPTA ............. 108
BRILINTA ........................ 60
brimonidine ....................... 99
BRIVIACT
INTRAVENOUS .............. 32
BRIVIACT ORAL
SOLUTION ...................... 32
BRIVIACT ORAL TABLET
10 MG ............................... 32
BRIVIACT ORAL TABLET
100 MG, 75 MG ............... 32
BRIVIACT ORAL TABLET
25 MG ............................... 32
BRIVIACT ORAL TABLET
50 MG ............................... 32
BROMFED DM ............. 100
bromocriptine ................... 37
brompheniramine-pseudoephdm oral syrup .................. 100
brotapp ............................ 100
brotapp dm ...................... 100
budesonide oral ................ 81
bumetanide ....................... 56
BUPHENYL ORAL
TABLET ........................... 70
buprenorphine hcl injection
solution ............................. 39
buprenorphine hcl injection
syringe .............................. 39
buprenorphine hcl sublingual
tablet 2 mg ........................ 39
buprenorphine hcl sublingual
tablet 8 mg ........................ 39
buprenorphine-naloxone
sublingual tablet 2-0.5
mg ..................................... 42
buprenorphine-naloxone
sublingual tablet 8-2 mg .... 42
buproban ........................... 72
bupropion hcl oral tablet 100
mg ..................................... 45
?
bupropion hcl oral tablet 75
mg ..................................... 45
bupropion hcl oral tablet
extended release 100 mg .... 45
bupropion hcl oral tablet
extended release 150 mg, 200
mg ..................................... 45
bupropion hcl oral tablet
extended release 24 hr 150
mg ..................................... 45
bupropion hcl oral tablet
extended release 24 hr 300
mg ..................................... 45
buspirone .......................... 45
BUSULFEX ..................... 24
BUTALBITAL COMPOUND
W/CODEINE .................... 39
butorphanol tartrate injection
solution 1 mg/ml ............... 42
butorphanol tartrate injection
solution 2 mg/ml ............... 42
butorphanol tartrate
nasal ................................. 42
BYDUREON .................... 75
BYETTA SUBCUTANEOUS
PEN INJECTOR 10 MCG/
DOSE(250 MCG/ML) 2.4
ML .................................... 75
BYETTA SUBCUTANEOUS
PEN INJECTOR 5 MCG/
DOSE (250 MCG/ML) 1.2
ML .................................... 75
BYSTOLIC ....................... 56
C
c 1000-bioflavonoids-rose
hips .................................. 119
c complex ........................ 119
c-500 oral tablet,
chewable ......................... 119
cabergoline ....................... 78
CABOMETYX ORAL
TABLET 20 MG ............... 24
CABOMETYX ORAL
TABLET 40 MG, 60
MG .................................... 24
CAL-GEST ANTACID ... 111
CALCET CREAMY
BITES ............................. 111
CALCET PETITES ........ 119
calci-chew ....................... 111
calcipotriene scalp ............ 64
calcipotriene topical ......... 64
calcitonin (salmon) ........... 78
calcitrate ......................... 111
CALCITRATE-VITAMIN
D ...................................... 111
calcitriol intravenous solution
1 mcg/ml ........................... 78
calcitriol oral .................... 78
calcium 500 + d oral tablet
500 mg(1,250mg) -200
unit .................................. 111
calcium 500 with d .......... 111
calcium 600 ..................... 112
calcium 600 + d(3) oral tablet
600 mg(1,500mg) -200 unit,
600 mg(1,500mg) -400
unit .................................. 112
calcium 600 + minerals ... 119
CALCIUM 600 WITH
VITAMIN D3 ORAL
CAPSULE 600 MG(1,500MG)
-400 UNIT ...................... 112
calcium acetate oral
capsule ............................ 112
CALCIUM ANTACID ORAL
TABLET,CHEWABLE 200
MG CALCIUM (500
MG) ................................. 112
CALCIUM ANTACID ORAL
TABLET,CHEWABLE 300
MG (750 MG) ................. 112
calcium carbonate oral
suspension ....................... 112
calcium carbonate oral tablet
500 mg calcium (1,250 mg),
600 mg (1,500 mg) .......... 112
calcium carbonate oral tablet,
chewable 500 mg calcium (1,
250 mg) ........................... 112
calcium carbonate-vit d3-min
oral tablet ........................ 119
calcium carbonate-vit d3-min
oral tablet,chewable 600 mg
(1,500 mg)-200 unit ........ 119
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TXDMKT-0101-16 SP 09.16 SP
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calcium carbonate-vitamin d3
oral tablet 500 mg(1,250mg) 200 unit, 500 mg(1,250mg) 400 unit, 500mg (1,250mg) 600 unit ........................... 112
calcium carbonate-vitamin d3
oral tablet 600 mg(1,500mg) 200 unit, 600 mg(1,500mg) 400 unit, 600 mg(1,500mg) 800 unit ........................... 112
calcium carbonate-vitamin d3
oral tablet,chewable 500 mg(1,
250mg) -400 unit ............. 112
calcium citrate + d with
mag ................................. 112
calcium citrate malate-vit
d3 .................................... 116
calcium citrate-vitamin d3 oral
tablet 200-125 mg-unit .... 112
calcium citrate-vitamin d3 oral
tablet 315-200 mg-unit, 315250 mg-unit ..................... 112
calcium gluconate oral tablet
45 mg (500 mg) ............... 112
calcium soft chew oral tablet,
chewable 500-200-40 mg-unitmcg .................................. 119
calcium with boron ........... 70
calcium with vitamin d .... 112
calcium-magnesium ........ 112
calcium-magnesium-copperzinc .................................. 119
calcium-magnesium-zinc oral
tablet ............................... 112
calcium-magnesium-zinc oral
tablet 333-133-5 mg ........ 112
calcium-vitamin d3-vitamin k
oral tablet,chewable 500-20040 mg-unit-mcg ............... 119
CALTRATE 600 + D ...... 113
CALTRATE 600+D PLUS
MINERALS .................... 119
CALTRATE WITH
VITAMIN D3 ................. 113
camila ............................... 91
CANASA .......................... 81
CANCIDAS ...................... 10
?
candesartan oral tablet 16 mg,
4 mg, 8 mg ........................ 56
candesartan oral tablet 32
mg ..................................... 56
candesartanhydrochlorothiazid oral tablet
16-12.5 mg ........................ 56
candesartanhydrochlorothiazid oral tablet
32-12.5 mg, 32-25 mg ....... 56
CAPASTAT ....................... 17
CAPEX ............................. 68
CAPRELSA ORAL TABLET
100 MG ............................. 24
CAPRELSA ORAL TABLET
300 MG ............................. 24
captopril ........................... 56
captoprilhydrochlorothiazide .......... 56
CARBAGLU .................... 70
carbamazepine oral capsule,
er multiphase 12 hr ........... 32
carbamazepine oral
suspension 100 mg/5 ml .... 32
carbamazepine oral
suspension 200 mg/10 ml ... 32
carbamazepine oral
tablet ................................. 32
carbamazepine oral tablet
extended release 12 hr 100
mg ..................................... 32
carbamazepine oral tablet
extended release 12 hr 200 mg,
400 mg .............................. 32
carbamazepine oral tablet,
chewable ........................... 32
carbidopa-levodopa .......... 37
carboplatin intravenous
solution ............................. 24
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON
SOLN 12 GRAM, 6
GRAM .............................. 88
carteolol ............................ 96
cartia xt ............................. 56
carvedilol .......................... 56
CAYSTON ........................ 17
CAZIANT (28) ................. 93
cefaclor oral capsule ........ 15
cefaclor oral suspension for
reconstitution 125 mg/5
ml ...................................... 15
cefaclor oral suspension for
reconstitution 250 mg/5 ml,
375 mg/5 ml ...................... 15
cefaclor oral tablet extended
release 12 hr ..................... 15
cefadroxil oral capsule ..... 15
cefadroxil oral suspension for
reconstitution 250 mg/5 ml,
500 mg/5 ml ...................... 15
cefadroxil oral tablet ........ 15
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/
50 ml ................................. 15
CEFAZOLIN IN DEXTROSE
(ISO-OS) INTRAVENOUS
PIGGYBACK 2 GRAM/50
ML .................................... 15
cefazolin injection recon soln
1 gram, 500 mg ................. 15
cefazolin injection recon soln
10 gram, 20 gram ............. 15
CEFAZOLIN INJECTION
RECON SOLN 100 GRAM,
300 G ................................ 16
cefazolin intravenous ........ 16
cefdinir .............................. 16
cefepime ............................ 16
cefoxitin in dextrose, isoosm .................................... 16
cefoxitin intravenous recon
soln 1 gram ....................... 16
cefoxitin intravenous recon
soln 10 gram, 2 gram ........ 16
cefpodoxime ...................... 16
cefprozil ............................ 16
ceftazidime injection recon
soln 1 gram, 2 gram .......... 16
ceftazidime injection recon
soln 6 gram ....................... 16
ceftriaxone in dextrose,isoos ....................................... 16
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TXDMKT-0101-16 SP 09.16 SP
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ceftriaxone injection recon
soln 1 gram, 2 gram, 250 mg,
500 mg .............................. 16
ceftriaxone injection recon
soln 10 gram ..................... 16
CEFTRIAXONE INJECTION
RECON SOLN 100
GRAM .............................. 16
ceftriaxone intravenous .... 16
cefuroxime axetil oral
tablet ................................. 16
cefuroxime sodium
intraveneous vial injection
recon soln 1.5 gram, 750
mg ..................................... 16
cefuroxime sodium
intraveneous vial intravenous
recon soln 7.5 gram .......... 16
CELLCEPT
INTRAVENOUS .............. 24
CELONTIN ORAL
CAPSULE 300 MG .......... 33
centamin .......................... 119
central vite ........................ 72
central vite with lutein .... 119
central-vite cardio ........... 119
CENTRAL-VITE
ENERGY ........................ 119
central-vite men's under
50 .................................... 119
central-vite oral tablet 18-400
mg-mcg ........................... 119
central-vite select ............ 119
central-vite senior ........... 119
CENTRAL-VITE WOMEN'S
MATURE ........................ 120
central-vite women's under
50 .................................... 120
centratex ......................... 120
CENTRUM
COMPLETE ................... 120
CENTRUM KIDS .......... 120
CENTRUM MEN ........... 120
CENTRUM ORAL
LIQUID .......................... 120
CENTRUM ORAL TABLET,
CHEWABLE .................. 120
?
CENTRUM SILVER ORAL
TABLET ......................... 120
CENTRUM SILVER
WOMEN ......................... 120
CENTRUM SPECIALIST
HEART ........................... 120
CENTRUM ULTRA
MEN'S ............................ 120
century adults 50+ .......... 120
century cardio ................. 120
century oral tablet 18-400 mgmcg ................................. 120
century ultimate men's oral
tablet 8 mg iron- 200 mcg-600
mcg ................................. 120
century ultimate
women's .......................... 120
cephalexin oral capsule 250
mg, 500 mg ....................... 16
cephalexin oral suspension for
reconstitution .................... 16
cephalexin oral tablet ....... 16
CEREFOLIN .................. 120
CEREZYME
INTRAVENOUS RECON
SOLN 400 UNIT .............. 78
cerovite ........................... 120
cerovite advanced
formula ........................... 120
cerovite jr ........................ 120
certavite seniorantioxidant ...................... 120
certavite-antioxid (iron gluc)
oral liquid 9 mg iron/15
ml .................................... 120
certavite-antioxidant ....... 120
CERVARIX VACCINE
(PF) ................................... 88
cetirizine oral solution 1 mg/
ml .................................... 100
cetirizine oral tablet ........ 100
cetirizine oral tablet,
chewable ......................... 100
cetirizinepseudoephedrine ............. 100
CHANTIX ........................ 72
CHANTIX CONTINUING
MONTH BOX .................. 72
CHANTIX STARTING
MONTH BOX .................. 72
chelated zinc ................... 113
cheratussin ac ................. 100
cheratussin dac ............... 100
chest congestion relief .... 100
chest congestion relief
pe .................................... 100
chewable-vite .................. 120
chewable-vite with iron .... 120
CHILD DELSYM
COUGH+CHEST DM .... 100
CHILD DELSYM
COUGH+COLD ............. 100
child ibuprofen .................. 42
CHILD MUCINEX CHEST
CONGESTION ............... 100
CHILD MUCINEX
CONGESTIONCOUGH .......................... 100
CHILD MUCINEX M-S
COLD DAY-NTE ........... 100
CHILD MUCINEX STUFFY
NOSE-COLD ................. 100
child vitamin with
minerals .......................... 120
child's chewable vitamins/iron
oral tablet,chewable ....... 120
child's vitamin with iron ... 121
children's allergy (diphenhyd)
oral liquid ....................... 100
children's aspirin .............. 42
children's cetirizine oral
solution ........................... 100
children's cetirizine oral tablet,
chewable ......................... 100
children's chewable
vitamin ............................ 121
CHILDREN'S
CHEWABLES ................ 121
CHILDREN'S CHEWABLES
EXTRA C ....................... 121
CHILDREN'S CHEWABLES
WITH IRON ................... 121
CHILDREN'S CLARITIN
ORAL TABLET,
CHEWABLE .................. 100
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TXDMKT-0101-16 SP 09.16 SP
138
children's cold and cough
dm ................................... 100
children's ibuprofen .......... 42
children's iron ................. 121
children's mapap ............... 42
CHILDREN'S MUCINEX
COLD-FEVER ............... 101
CHILDREN'S MUCINEX
COUGH .......................... 101
CHILDREN'S MUCINEX
MULTI-SYMP ................ 101
CHILDREN'S MUCINEX
NIGHT TIME ................. 101
children's pain-fever relief oral
liquid ................................. 42
children's pain-fever relief oral
suspension ......................... 42
CHILDREN'S PAIN-FEVER
RELIEF ORAL TABLET,
CHEWABLE .................... 42
children's q-pap ................ 42
children's silfedrine ........ 101
childs chew vite ............... 121
childs/iron ....................... 121
CHLO TUSS .................. 101
chloramphenicol sod
succinate ........................... 17
chlorhexidine gluconate
mucous membrane ............ 73
chloroquine phosphate
oral ................................... 18
chlorothiazide ................... 56
chlorothiazide sodium ....... 56
CHLORPHEN SR .......... 101
chlorpheniramine maleate oral
tablet extended release .... 101
chlorpromazine ................. 45
chlorthalidone oral tablet 25
mg, 50 mg ......................... 56
cholecalciferol (vitamin d3)
oral drops 400 unit/ml .... 121
cholestyramine light ......... 62
cholestyramine (with
sugar) ................................ 62
CIALIS ORAL TABLET 2.5
MG, 5 MG ....................... 111
CICLODAN TOPICAL
SOLUTION ...................... 67
?
ciclopirox topical cream .... 67
ciclopirox topical gel ........ 67
ciclopirox topical
shampoo ............................ 67
ciclopirox topical
solution ............................. 67
ciclopirox topical
suspension ......................... 67
cidofovir ............................ 11
cilostazol ........................... 60
CIMZIA ............................ 81
CIMZIA POWDER FOR
RECONST ........................ 81
CIMZIA STARTER KIT ... 81
CINRYZE ....................... 108
CIPRODEX ...................... 73
ciprofloxacin ..................... 21
ciprofloxacin hcl
ophthalmic ........................ 96
ciprofloxacin hcl oral
tablet ................................. 21
ciprofloxacin lactate
intravenous solution 200 mg/
20 ml ................................. 21
ciprofloxacin lactate
intravenous solution 400 mg/
40 ml ................................. 21
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 1,
000 mg .............................. 21
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 500
mg ..................................... 21
cisplatin ............................ 24
citalopram oral solution .... 45
citalopram oral tablet 10
mg ..................................... 45
citalopram oral tablet 20
mg ..................................... 45
citalopram oral tablet 40
mg ..................................... 45
citrus calcium oral tablet 315250 mg-unit ..................... 113
cladribine .......................... 24
clarithromycin oral suspension
for reconstitution .............. 17
clarithromycin oral
tablet ................................. 17
clarithromycin oral tablet
extended release 24 hr ...... 17
CLARITIN-D 12
HOUR ............................. 101
clemastine oral tablet 2.68
mg ................................... 101
clindamycin hcl ................. 18
clindamycin phosphate
injection ............................ 18
CLINDAMYCIN
PHOSPHATE
INTRAVENOUS SOLUTION
300 MG/2 ML ................... 18
clindamycin phosphate
intravenous solution 600 mg/4
ml ...................................... 18
clindamycin phosphate
intravenous solution 900 mg/6
ml ...................................... 18
clindamycin phosphate
topical ............................... 65
clindamycin phosphate
vaginal .............................. 92
CLINIMIX 2.75%/D5W
SULFIT FREE ................ 117
CLINIMIX 4.25%-D20W
SULF-FREE ................... 117
CLINIMIX 4.25%-D25W
SULF-FREE ................... 117
CLINIMIX 4.25%/D10W
SULF FREE .................... 117
CLINIMIX 4.25%/D5W
SULFIT FREE .................. 70
CLINIMIX 5%-D20W
(SULFITE-FREE) ........... 117
CLINIMIX 5%/D15W
SULFITE FREE .............. 116
CLINIMIX 5%/D25W
SULFITE-FREE ............. 117
CLINIMIX E 2.75%/D10W
SUL FREE ........................ 70
CLINIMIX E 2.75%/D5W
SULF FREE ...................... 70
CLINIMIX E 4.25%/D10W
SUL FREE ...................... 117
CLINIMIX E 4.25%/D25W
SUL FREE ...................... 117
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TXDMKT-0101-16 SP 09.16 SP
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CLINIMIX E 4.25%/D5W
SULF FREE .................... 117
CLINIMIX E 5%/D15W
SULFIT FREE ................ 117
CLINIMIX E 5%/D20W
SULFIT FREE ................ 117
CLINIMIX E 5%/D25W
SULFIT FREE ................ 117
clobetasol scalp ................ 68
clobetasol topical cream .... 68
clobetasol topical foam ..... 68
clobetasol topical gel ........ 68
clobetasol topical
ointment ............................ 68
clobetasol-emollient topical
cream ................................ 68
CLOLAR .......................... 24
clomipramine .................... 45
clonazepam oral tablet 0.5
mg ..................................... 33
clonazepam oral tablet 1
mg ..................................... 33
clonazepam oral tablet 2
mg ..................................... 33
clonazepam oral tablet,
disintegrating 0.125 mg .... 33
clonazepam oral tablet,
disintegrating 0.25 mg ...... 33
clonazepam oral tablet,
disintegrating 0.5 mg ........ 33
clonazepam oral tablet,
disintegrating 1 mg ........... 33
clonazepam oral tablet,
disintegrating 2 mg ........... 33
clonidine hcl oral tablet .... 56
clonidine transdermal
patches .............................. 56
clopidogrel oral tablet 300
mg ..................................... 60
clopidogrel oral tablet 75
mg ..................................... 60
clorazepate dipotassium .... 45
clotrimazole mucous
membrane ......................... 10
clotrimazole topical .......... 67
clotrimazole vaginal
cream ................................ 92
?
clotrimazolebetamethasone .................. 67
clozapine oral tablet 100
mg ..................................... 45
clozapine oral tablet 200
mg ..................................... 45
clozapine oral tablet 25
mg ..................................... 45
clozapine oral tablet 50
mg ..................................... 45
clozapine oral tablet,
disintegrating 100 mg ....... 45
clozapine oral tablet,
disintegrating 12.5 mg ...... 46
clozapine oral tablet,
disintegrating 150 mg ....... 46
clozapine oral tablet,
disintegrating 200 mg ....... 46
clozapine oral tablet,
disintegrating 25 mg ......... 46
COATS ALOE
ANALGESIC ................... 64
COATS ALOE
MOISTURIZING ............. 64
COATS ALOE TOPICAL
CREAM ............................ 64
COATS ALOE TOPICAL
GEL .................................. 64
codeine-guaifenesin ........ 101
COLACE ORAL CAPSULE
100 MG ............................. 81
colchicine-probenecid ....... 90
COLCRYS ........................ 90
colestipol ........................... 62
colistin (colistimethate
na) ..................................... 18
colocort ............................. 82
COLY-MYCIN S .............. 73
COMBIGAN .................... 98
COMBIVENT
RESPIMAT ..................... 108
COMETRIQ ORAL
CAPSULE 100 MG/DAY(80
MG X1-20 MG X1) .......... 24
COMETRIQ ORAL
CAPSULE 140 MG/DAY(80
MG X1-20 MG X3) .......... 24
COMETRIQ ORAL
CAPSULE 60 MG/DAY (20
MG X 3/DAY) .................. 24
compete ........................... 121
COMPLERA ..................... 11
complete allergy medicine oral
capsule ............................ 101
complete allergy oral
liquid ............................... 101
complete multivitamin oral
tablet ............................... 121
complete multivitamin-mineral
oral tablet ....................... 121
complete oral tablet 18-500300-250 mg-mcg-mcgmcg ................................. 121
complete premium
vitamin .............................. 72
complete senior oral tablet
0.4-300-250 mg-mcgmcg ................................. 121
complex b-100 oral tablet
extended release .............. 121
compro .............................. 82
CONGESTION RELIEF
(IBUPROF-PE) ............... 101
constulose ......................... 82
COPAXONE
SUBCUTANEOUS SYRINGE
20 MG/ML ........................ 37
COPAXONE
SUBCUTANEOUS SYRINGE
40 MG/ML ........................ 37
CORAL CALCIUM ORAL
CAPSULE 185-50-100 MGMG-UNIT ....................... 121
coral calcium oral capsule
200-100-100 mg-mgunit .................................. 121
COREG CR ...................... 57
cormax scalp ..................... 68
cortisone ........................... 74
corvita ............................. 121
CORVITE ....................... 121
CORVITE 150 ORAL
TABLET 150 MG IRON- 1
MG .................................. 121
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TXDMKT-0101-16 SP 09.16 SP
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CORVITE FE ORAL
TABLET 150 MG IRON- 1
MG .................................. 121
CORVITE FREE ............ 121
COTELLIC ....................... 24
cough dm er .................... 101
cough syrup dm ............... 101
cough-sore throat night ... 101
COUMADIN ORAL ........ 60
CREON ............................. 82
CRESTOR ........................ 62
CRIXIVAN ORAL CAPSULE
200 MG ............................. 11
CRIXIVAN ORAL CAPSULE
400 MG ............................. 11
cromolyn inhalation ........ 108
cromolyn nasal ................ 108
cromolyn ophthalmic ........ 97
cryselle (28) ...................... 93
CUTTER
BACKWOODS ................ 69
cyanocobalamin (vitamin b-12)
oral liquid ....................... 121
cyanocobalamin (vitamin b-12)
oral tablet 1,000 mcg, 500
mcg ................................. 121
cyanocobalamin (vitamin b-12)
oral tablet extended
release ............................. 122
cyclafem 1/35 (28) ............ 93
cyclafem 7/7/7 (28) ........... 93
cyclobenzaprine oral
tablet ................................. 38
cyclophosphamide oral
capsule .............................. 24
CYCLOSET ..................... 75
cyclosporine intravenous ... 24
cyclosporine modified ....... 24
cyclosporine oral
capsule .............................. 24
CYRAMZA ...................... 24
CYSTADANE .................. 82
CYSTAGON ................... 111
cytarabine ......................... 24
CYTARABINE (PF)
INJECTION SOLUTION 100
MG/5 ML (20 MG/ML) .... 24
?
cytarabine (pf) injection
solution 2 gram/20 ml (100
mg/ml) ............................... 24
CYTARABINE (PF)
INJECTION SOLUTION 20
MG/ML ............................. 25
D
d10 %-0.45 % sodium
chloride ............................. 70
d2.5 %-0.45 % sodium
chloride ............................. 70
d5 % and 0.9 % sodium
chloride ............................. 70
d5 %-0.45 % sodium
chloride ............................. 70
dacarbazine ...................... 25
daily multiple for men ..... 122
daily multiple for men
50+ ................................. 122
DAILY MULTIPLE FOR
WOMEN ......................... 122
daily multiple for women
50+ ................................. 122
daily multiple oral
tablet ............................... 122
DAILY MULTIPLE ORAL
TABLET 400-120 MCGMG .................................. 122
daily multiple vitamins/
iron .................................. 122
daily multivitaminminerals .......................... 122
daily vitamin with iron and
ca .................................... 122
daily vites/iron ................ 122
daily-vite ......................... 122
DAKLINZA ORAL TABLET
30 MG, 60 MG ................. 11
DAKLINZA ORAL TABLET
90 MG ............................... 11
DALIRESP ..................... 108
DALLERGY
(CHLORPHENIRAMINE-PE)
ORAL DROPS 1-2.5 MG/
ML .................................. 101
DALLERGY
(DEXBROMPHENIRAMNPE) ORAL TABLET ...... 101
danazol oral ...................... 78
dantrolene ......................... 38
DAPSONE ........................ 18
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 88
DARAPRIM ..................... 18
DARZALEX ..................... 25
daunorubicin intravenous
solution ............................. 25
dayhist allergy ................ 101
DAYTIME COLD-FLU
RELIEF (PE) ORAL
CAPSULE ...................... 101
decitabine ......................... 25
DECONEX DMX ........... 101
DECONEX IR ................ 101
deep sea nasal ................... 73
DELSYM 12 HOUR ...... 101
DELSYM COUGH-CHEST
CONGEST DM .............. 101
DELSYM COUGH-COLD
DAYTIME ...................... 101
DELSYM COUGH-COLD
NIGHTTIME .................. 101
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) .......... 82
demeclocycline .................. 21
DEMSER .......................... 57
DENAVIR ......................... 68
DEPEN TITRATABS ....... 91
DEPO-PROVERA
INTRAMUSCULAR
SOLUTION 400 MG/
ML .................................... 92
DERMATOP TOPICAL
OINTMENT ..................... 68
DESCOVY ....................... 11
desipramine oral ............... 46
desmopressin injection ...... 78
desmopressin nasal ........... 78
desmopressin oral ............. 78
desonide ............................ 68
desoximetasone ................. 68
DESVENLAFAXINE
FUMARATE ORAL TABLET
EXTENDED RELEASE 24HR
100 MG ............................. 46
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TXDMKT-0101-16 SP 09.16 SP
141
DESVENLAFAXINE
FUMARATE ORAL TABLET
EXTENDED RELEASE 24HR
50 MG ............................... 46
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24 HR 100
MG .................................... 46
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24 HR 50
MG .................................... 46
desvenlafaxine oral tablet
extended release 24hr 100
mg ..................................... 46
desvenlafaxine oral tablet
extended release 24hr 50
mg ..................................... 46
dexamethasone ................. 74
DEXAMETHASONE
SODIUM PHOS (PF) ....... 74
dexamethasone sodium
phosphate injection ........... 74
dexamethasone sodium
phosphate ophthalmic ....... 98
DEXILANT ...................... 86
dexrazoxane hcl intravenous
recon soln 250 mg ............. 22
dexrazoxane hcl intravenous
recon soln 500 mg ............. 22
dextroamphetamine oral
capsule, extended release 10
mg, 5 mg ........................... 46
dextroamphetamine oral
capsule, extended release 15
mg ..................................... 46
dextroamphetamine oral tablet
10 mg ................................ 46
dextroamphetamine oral tablet
5 mg .................................. 46
dextroamphetamineamphetamine oral tablet 10
mg, 12.5 mg, 15 mg, 20 mg, 5
mg, 7.5 mg ........................ 46
dextroamphetamineamphetamine oral tablet 30
mg ..................................... 46
?
dextromethorphan
polistirex ......................... 102
dextrose 10 % and 0.2 %
nacl ................................... 70
dextrose 10 % in water
(d10w) ............................... 70
dextrose 25 % in water
(d25w) ............................... 70
DEXTROSE 30 % IN
WATER (D30W) .............. 70
DEXTROSE 40 % IN
WATER (D40W) .............. 70
dextrose 5 % in water
(d5w) ................................. 70
dextrose 5 %-lactated
ringers ............................... 71
dextrose 5%-0.2 % sod
chloride ............................. 71
dextrose 5%-0.3 %
sod.chloride ...................... 71
DEXTROSE 50 % IN
WATER (D50W)
INTRAVENOUS
PARENTERAL
SOLUTION ...................... 71
DEXTROSE 50 % IN
WATER (D50W)
INTRAVENOUS
SYRINGE ......................... 71
dextrose 70 % in water
(d70w) ............................... 71
dextrose with sodium
chloride ............................. 71
dextrose-kcl-nacl ............. 113
dialyvite 800 ................... 122
DIALYVITE 800 WITH
IRON .............................. 122
diazepam injection
solution ............................. 46
diazepam injection
syringe .............................. 46
diazepam intensol ............. 46
diazepam oral
concentrate ....................... 46
diazepam oral solution 5 mg/5
ml (1 mg/ml) ..................... 46
DIAZEPAM ORAL
SOLUTION 5 MG/5 ML (1
MG/ML, 5 ML) ................ 47
diazepam oral tablet 10
mg ..................................... 47
diazepam oral tablet 2
mg ..................................... 47
diazepam oral tablet 5
mg ..................................... 47
diazepam rectal kit 12.5-1517.5-20 mg ........................ 33
diazepam rectal kit 2.5 mg, 57.5-10 mg .......................... 33
dibucaine .......................... 66
diclofenac potassium ........ 42
diclofenac sodium oral ..... 42
diclofenac sodium topical gel
1 % .................................... 42
dicloxacillin ...................... 20
dicyclomine oral capsule ... 80
dicyclomine oral solution ... 80
dicyclomine oral tablet ..... 80
didanosine oral capsule,
delayed release(dr/ec) 125
mg ..................................... 11
didanosine oral capsule,
delayed release(dr/ec) 200
mg ..................................... 11
didanosine oral capsule,
delayed release(dr/ec) 250 mg,
400 mg .............................. 12
diflorasone ........................ 68
diflunisal ........................... 42
DIGITEK ORAL TABLET
125 MCG .......................... 60
DIGOX ORAL TABLET 125
MCG ................................. 60
digoxin oral solution 50 mcg/
ml ...................................... 60
digoxin oral tablet 125
mcg ................................... 60
dihydroergotamine
injection ............................ 37
DILANTIN EXTENDED
CAPSULES ...................... 33
DILANTIN INFATABS .... 33
DILANTIN ORAL
CAPSULES 30 MG .......... 33
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TXDMKT-0101-16 SP 09.16 SP
142
dilt-xr ................................ 57
diltiazem hcl intravenous ... 57
diltiazem hcl oral capsule,
extended release 120 mg, 240
mg, 300 mg ....................... 57
diltiazem hcl oral capsule,
extended release 180 mg, 360
mg, 420 mg ....................... 57
diltiazem hcl oral capsule,ext
release degradable ............ 57
diltiazem hcl oral capsule,
extended release 12 hr ...... 57
diltiazem hcl oral capsule,
extended release 24hr 120 mg,
240 mg, 300 mg ................ 57
diltiazem hcl oral capsule,
extended release 24hr 180 mg,
360 mg .............................. 57
diltiazem hcl oral tablet .... 57
diltiazem hcl oral tablet
extended release 24 hr ...... 57
dimaphen dm .................. 102
dimaphen (pe) ................. 102
dimenhydrinate oral ......... 82
dino-life ........................... 122
dino-life with extra c ....... 122
dino-life with iron-zinc .... 122
diocto oral liquid .............. 82
DIPENTUM ..................... 82
diphenhist oral liquid ..... 102
diphenhydramine hcl injection
solution 50 mg/ml ........... 102
diphenhydramine hcl injection
syringe ............................ 102
diphenhydramine hcl oral
capsule 25 mg ................. 102
diphenhydramine hcl oral
capsule 50 mg ................. 102
diphenhydramineacetaminophen .................. 42
diphenoxylate-atropine ..... 80
disulfiram .......................... 71
divalproex ......................... 33
doc-q-lace ......................... 82
doc-q-lax ........................... 82
DOCEFREZ INTRAVENOUS
RECON SOLN 20 MG ..... 25
?
DOCETAXEL
INTRAVENOUS SOLUTION
10 MG/ML, 160 MG/16 ML
(10 MG/ML), 160 MG/8 ML
(20 MG/ML), 20 MG/2 ML
(10 MG/ML) ..................... 25
docetaxel intravenous solution
20 mg/ml (1 ml), 80 mg/4 ml
(20 mg/ml), 80 mg/8 ml (10
mg/ml) ............................... 25
docu .................................. 82
docusate calcium .............. 82
docusate sodium oral capsule
100 mg .............................. 82
docusate sodium oral capsule
250 mg .............................. 82
DOCUSOL ....................... 82
DOCUSOL KIDS ............. 82
DOCUSOL PLUS ............ 82
dofetilide ........................... 55
dok oral capsule 100 mg .... 82
dok oral capsule 250 mg .... 82
dok oral tablet ................... 82
dok plus ............................. 82
donepezil oral tablet 10 mg, 5
mg ..................................... 38
donepezil oral tablet,
disintegrating .................... 38
dorzolamide ...................... 98
dorzolamide-timolol ......... 98
doxazosin .......................... 57
doxepin oral ...................... 47
doxercalciferol
intravenous ....................... 78
doxercalciferol oral .......... 78
doxorubicin intravenous recon
soln ................................... 25
doxorubicin intravenous
solution ............................. 25
DOXY-100 ....................... 21
doxycycline hyclate
intravenous ....................... 21
doxycycline hyclate oral
capsule .............................. 21
doxycycline hyclate oral
tablet ................................. 21
doxycycline hyclate oral tablet,
delayed release (dr/ec) 100
mg, 150 mg, 75 mg ........... 21
doxycycline monohydrate oral
capsule .............................. 21
doxycycline monohydrate oral
tablet ................................. 21
DR. SMITH'S DIAPER .... 64
DR. SMITH'S DIAPER
RASH ............................... 64
DR. SMITH'S RASH-SKIN
TOPICAL AEROSOL,
SPRAY .............................. 64
DRISDOL ORAL
CAPSULE ...................... 122
dronabinol ......................... 82
drospirenone-ethinyl estradiol
oral tablet 3-0.03 mg ........ 93
DROXIA ........................... 25
DULERA ........................ 108
duloxetine oral capsule,
delayed release(dr/ec) 20
mg ..................................... 47
duloxetine oral capsule,
delayed release(dr/ec) 30
mg ..................................... 47
duloxetine oral capsule,
delayed release(dr/ec) 40
mg ..................................... 47
duloxetine oral capsule,
delayed release(dr/ec) 60
mg ..................................... 47
duofer .............................. 122
DURAFLU ORAL TABLET
60-20-200-500 MG ......... 102
duramorph (pf) injection
solution 0.5 mg/ml ............ 39
duramorph (pf) injection
solution 1 mg/ml ............... 39
E
e.e.s. 400 oral tablet ......... 17
ear drops (carbamide
peroxide) ........................... 73
EAR WAX
TREATMENT .................. 73
ECEE PLUS ................... 122
econazole topical .............. 67
econtra ez .......................... 93
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TXDMKT-0101-16 SP 09.16 SP
143
ed a-hist .......................... 102
ed a-hist dm oral liquid ... 102
ED A-HIST DM ORAL
TABLET ......................... 102
ed a-hist pse .................... 102
ed bron gp ....................... 102
ED CHLORPED D ......... 102
ed chlorped jr ................. 102
ed-apap ............................. 42
ED-CHLORPED ............ 102
ed-chlortan ..................... 102
EDURANT ....................... 12
effervescent pain relief oral
tablet, effervescent 325-1,9161,000 mg ........................... 42
EFFIENT .......................... 60
ELAPRASE ...................... 78
electrolytes-dextrose ....... 113
ELIDEL ............................ 64
ELINEST .......................... 93
ELIQUIS ORAL TABLET 2.5
MG .................................... 61
ELIQUIS ORAL TABLET 5
MG .................................... 61
ELITEK ............................ 22
ELLA ................................ 93
EMCYT ............................ 25
EMEND ORAL CAPSULE
125 MG ............................. 82
EMEND ORAL CAPSULE 40
MG .................................... 82
EMEND ORAL CAPSULE 80
MG .................................... 82
EMEND ORAL CAPSULE,
DOSE PACK .................... 82
EMPLICITI ...................... 25
EMSAM ........................... 47
EMTRIVA ORAL
CAPSULE ........................ 12
EMTRIVA ORAL
SOLUTION ...................... 12
enalapril maleate .............. 57
enalaprilhydrochlorothiazide .......... 57
ENBREL SUBCUTANEOUS
RECON SOLN ................. 91
?
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML
(0.51) ................................ 91
ENBREL SUBCUTANEOUS
SYRINGE 50 MG/ML (0.98
ML) ................................... 91
ENBREL SURECLICK .... 91
endacof - dm ................... 102
endocet oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg ....... 39
ENEMA RECTAL ENEMA
19-7 GRAM/118 ML ........ 82
ENEMEEZ ....................... 82
ENEMEEZ PLUS ............. 83
ENFAMIL
ENFALYTE .................... 113
ENGERIX-B PEDIATRIC
(PF) ................................... 88
ENGERIX-B (PF) ............ 88
ENLYTE (FERROUS
GLYCINE) ...................... 122
enoxaparin subcutaneous
solution ............................. 61
enoxaparin subcutaneous
syringe 100 mg/ml, 150 mg/
ml ...................................... 61
enoxaparin subcutaneous
syringe 120 mg/0.8 ml, 80 mg/
0.8 ml ................................ 61
enoxaparin subcutaneous
syringe 30 mg/0.3 ml ........ 61
enoxaparin subcutaneous
syringe 40 mg/0.4 ml ........ 61
enoxaparin subcutaneous
syringe 60 mg/0.6 ml ........ 61
enpresse ............................ 93
entacapone ........................ 37
entecavir ........................... 12
ENTSOL NASAL GEL .... 73
enulose .............................. 83
ENVARSUS XR ............... 25
epinephrine injection syringe
0.1 mg/ml ........................ 102
EPIPEN 2-PAK ............... 102
EPIPEN JR 2-PAK ......... 102
epirubicin intravenous solution
200 mg/100 ml .................. 25
epirubicin intravenous solution
50 mg/25 ml ...................... 25
epitol ................................. 33
EPIVIR HBV ORAL
SOLUTION ...................... 12
EPIVIR ORAL
SOLUTION ...................... 12
eplerenone ......................... 57
eprosartan ......................... 57
EPZICOM ......................... 12
EQUETRO ORAL CAPSULE,
ER MULTIPHASE 12 HR 100
MG .................................... 33
EQUETRO ORAL CAPSULE,
ER MULTIPHASE 12 HR 200
MG .................................... 33
EQUETRO ORAL CAPSULE,
ER MULTIPHASE 12 HR 300
MG .................................... 33
ERAXIS(WATER
DILUENT) ....................... 10
ERBITUX ......................... 25
ergocalciferol (vitamin d2)
oral capsule .................... 122
ergocalciferol (vitamin d2)
oral drops ........................ 122
ergoloid ............................. 47
ERGOMAR ...................... 37
ERIVEDGE ...................... 25
errin .................................. 92
ERWINAZE ..................... 25
ery pads ............................ 65
ery-tab ............................... 17
ERYTHROCIN
INTRAVENOUS RECON
SOLN 500 MG ................. 17
erythrocin (as stearate) oral
tablet 250 mg .................... 17
erythromycin ethylsuccinate
oral tablet ......................... 17
erythromycin ophthalmic ... 96
erythromycin oral tablet .... 17
erythromycin with
ethanol .............................. 65
erythromycin-benzoyl
peroxide ............................ 65
ESBRIET ........................ 108
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TXDMKT-0101-16 SP 09.16 SP
144
escitalopram oxalate oral
solution ............................. 47
escitalopram oxalate oral
tablet 10 mg ...................... 47
escitalopram oxalate oral
tablet 20 mg ...................... 47
escitalopram oxalate oral
tablet 5 mg ........................ 47
ESTRACE VAGINAL ...... 92
estradiol oral .................... 92
estradiol transdermal patch
weekly ............................... 92
ESTRING ......................... 92
ethambutol ........................ 18
ethosuximide ..................... 33
etodolac oral capsule 200
mg ..................................... 42
etodolac oral tablet ........... 42
etodolac oral tablet extended
release 24 hr ..................... 42
ETOPOPHOS ................... 25
etoposide intravenous ....... 25
EVOMELA ....................... 25
EVOTAZ .......................... 12
exemestane ........................ 25
EXJADE ........................... 71
EXTAVIA
SUBCUTANEOUS KIT .... 87
EXTAVIA
SUBCUTANEOUS RECON
SOLN ................................ 87
eye drops
(tetrahydrozoline) ............. 99
ezfe 200 ........................... 122
F
FABRAZYME .................. 78
FALLBACK SOLO .......... 93
falmina (28) ...................... 93
famciclovir oral tablet 125 mg,
250 mg .............................. 12
famciclovir oral tablet 500
mg ..................................... 12
famotidine intravenous ..... 86
famotidine oral
suspension ......................... 86
famotidine oral tablet 10
mg ..................................... 86
?
famotidine oral tablet 20 mg,
40 mg ................................ 86
famotidine (pf) .................. 86
famotidine (pf)-nacl (isoos) ..................................... 86
FANAPT ORAL TABLET 1
MG .................................... 47
FANAPT ORAL TABLET 10
MG .................................... 47
FANAPT ORAL TABLET 12
MG .................................... 47
FANAPT ORAL TABLET 2
MG .................................... 47
FANAPT ORAL TABLET 4
MG .................................... 47
FANAPT ORAL TABLET 6
MG .................................... 47
FANAPT ORAL TABLET 8
MG .................................... 47
FANAPT ORAL TABLETS,
DOSE PACK .................... 47
FARESTON ...................... 25
FARYDAK ORAL CAPSULE
10 MG ............................... 25
FARYDAK ORAL CAPSULE
15 MG, 20 MG ................. 25
FASLODEX ...................... 26
fe c .................................. 122
felbamate .......................... 33
felodipine oral er .............. 57
FEMRING ........................ 92
fenofibrate micronized oral
capsule 134 mg, 200 mg, 67
mg ..................................... 62
fenofibrate nanocrystallized 48
mg, 145 mg ....................... 62
fenofibrate oral tablet 160 mg,
54 mg ................................ 62
fenoprofen oral tablet ....... 42
fentanyl citrate .................. 39
fentanyl transdermal patch 72
hour 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/
hr ....................................... 39
FER-IN-SOL .................. 122
fer-iron ............................ 122
FERATE ORAL TABLET 240
MG (27 MG IRON) ........ 122
FERGON ........................ 123
FERIVA 21-7
TABLET ......................... 123
FERIVA FA
(SUMALATE) ................ 123
ferosul oral elixir ............ 123
FEROSUL ORAL
TABLET ......................... 123
FERRALET 90 DUAL-IRON
DELIVERY .................... 123
ferraplus 90 .................... 123
ferretts ............................. 123
FERRETTS IPS .............. 123
ferrex 150 ........................ 123
ferrex 150 forte ............... 123
FERRIC X-150 ............... 123
FERRIMIN 150 .............. 123
ferro-time ........................ 123
ferrocite ........................... 123
ferrous fumarate oral tablet
324 mg (106 mg iron) ..... 123
ferrous gluconate oral tablet
236 mg (27 mg iron) ....... 123
ferrous gluconate oral tablet
240 mg (27 mg iron), 324 mg
(37.5 mg iron), 324 mg (38 mg
iron), 325 mg (36 mg
iron) ................................ 123
ferrous sulfate oral
drops ............................... 123
ferrous sulfate oral
elixir ................................ 123
ferrous sulfate oral
liquid ............................... 123
ferrous sulfate oral
solution ........................... 123
ferrous sulfate oral tablet 325
mg (65 mg iron) .............. 123
FERROUS SULFATE ORAL
TABLET EXTENDED
RELEASE ....................... 123
ferrous sulfate oral tablet,
delayed release (dr/ec) .... 123
ferrousul .......................... 123
FETZIMA ORAL CAPSULE,
EXT REL 24HR DOSE
PACK ................................ 47
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TXDMKT-0101-16 SP 09.16 SP
145
FETZIMA ORAL CAPSULE,
EXTENDED RELEASE 24
HR 120 MG, 80 MG ......... 48
FETZIMA ORAL CAPSULE,
EXTENDED RELEASE 24
HR 20 MG ........................ 48
FETZIMA ORAL CAPSULE,
EXTENDED RELEASE 24
HR 40 MG ........................ 48
fexofenadine oral
suspension ....................... 102
fexofenadine oral tablet 180
mg, 60 mg ....................... 102
fiber laxative (psyllium
husk) ................................. 83
fiber (calcium
polycarbophil) .................. 83
fiber-lax ............................ 83
finasteride oral tablet 5
mg .................................... 111
FIRAZYR ....................... 108
FIRMAGON KIT W
DILUENT SYRINGE ...... 26
flecainide .......................... 55
FLEET PEDIATRIC ......... 83
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 100 MCG/
ACTUATION ................. 109
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 250 MCG/
ACTUATION, 50 MCG/
ACTUATION ................. 109
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION ....... 109
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION ....... 109
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION ....... 109
FLOWTUSS ................... 102
fluconazole ........................ 10
?
fluconazole in dextrose(isoo) ....................................... 10
FLUCONAZOLE IN NACL
(ISO-OSM) INTRAVENOUS
PIGGYBACK 100 MG/50
ML .................................... 10
fluconazole in nacl (iso-osm)
intravenous piggyback 200 mg/
100 ml ............................... 10
fluconazole in nacl (iso-osm)
intravenous piggyback 400 mg/
200 ml ............................... 10
flucytosine ......................... 10
fludarabine intravenous recon
soln ................................... 26
FLUDARABINE
INTRAVENOUS
SOLUTION ...................... 26
fludrocortisone .................. 74
flunisolide nasal spray,nonaerosol 25 mcg (0.025
%) ................................... 109
fluocinolone ...................... 68
fluocinolone acetonide
oil ...................................... 73
fluocinolone and shower
cap .................................... 68
fluocinonide topical cream
0.05 % ............................... 68
fluocinonide topical gel .... 68
fluocinonide topical
ointment ............................ 68
fluocinonide topical
solution ............................. 69
fluocinonide-e ................... 69
FLUORITAB ORAL
TABLET,CHEWABLE 1 MG
FLUORIDE (2.2 MG) .... 123
fluorometholone ................ 98
fluorouracil intravenous .... 26
FLUOROURACIL
INTRAVENOUS .............. 26
fluorouracil topical cream 5
% ....................................... 64
fluorouracil topical
solution ............................. 64
fluoxetine oral capsule 10
mg ..................................... 48
fluoxetine oral capsule 20
mg ..................................... 48
fluoxetine oral capsule 40
mg ..................................... 48
fluoxetine oral solution ..... 48
fluoxetine oral tablet 10
mg ..................................... 48
fluoxetine oral tablet 20
mg ..................................... 48
fluphenazine decanoate .... 48
fluphenazine hcl ................ 48
flurbiprofen ....................... 42
flurbiprofen ophthalmic
drops ................................. 97
flutamide ........................... 26
fluticasone nasal ............. 109
fluticasone topical ............. 69
fluvoxamine oral tablet 100
mg ..................................... 48
fluvoxamine oral tablet 25
mg ..................................... 48
fluvoxamine oral tablet 50
mg ..................................... 48
FOCALGIN DSS ............ 124
folic acid injection .......... 124
folic acid oral tablet 1
mg ................................... 124
folic acid-vit b6-vit b12 oral
tablet 0.5-5-0.2 mg ......... 124
folitab .............................. 124
FOLOTYN ....................... 26
foltabs 800 ...................... 124
foltanx ............................. 124
fondaparinux subcutaneous
syringe 10 mg/0.8 ml ........ 61
fondaparinux subcutaneous
syringe 2.5 mg/0.5 ml ....... 61
fondaparinux subcutaneous
syringe 5 mg/0.4 ml .......... 61
fondaparinux subcutaneous
syringe 7.5 mg/0.6 ml ....... 61
FORADIL
AEROLIZER .................. 109
formula em solution .......... 83
FORTAVIT ...................... 117
FORTEO ........................... 90
foscarnet ........................... 12
fosfree ............................. 124
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TXDMKT-0101-16 SP 09.16 SP
146
fosinopril ........................... 57
fosinoprilhydrochlorothiazide .......... 57
fosphenytoin ...................... 33
FREAMINE III 10 % ...... 117
FRESHKOTE ................... 97
full spectrum b-vitamin
c ...................................... 124
FUNGOID TINCTURE
TOPICAL TINCTURE ..... 67
furosemide injection .......... 57
furosemide oral solution 10
mg/ml, 40 mg/5 ml (8 mg/
ml) ..................................... 57
furosemide oral tablet ....... 57
FUSILEV .......................... 22
FUSION PLUS ............... 124
FUZEON SUBCUTANEOUS
RECON SOLN ................. 12
FYCOMPA ORAL
SUSPENSION .................. 33
FYCOMPA ORAL TABLET
10 MG, 12 MG ................. 33
FYCOMPA ORAL TABLET
2 MG ................................. 33
FYCOMPA ORAL TABLET
4 MG ................................. 33
FYCOMPA ORAL TABLET
6 MG ................................. 33
FYCOMPA ORAL TABLET
8 MG ................................. 34
G
gabapentin oral capsule 100
mg ..................................... 34
gabapentin oral capsule 300
mg ..................................... 34
gabapentin oral capsule 400
mg ..................................... 34
gabapentin oral solution 250
mg/5 ml ............................. 34
GABAPENTIN ORAL
SOLUTION 250 MG/5 ML (5
ML), 300 MG/6 ML (6
ML) ................................... 34
gabapentin oral tablet 600
mg ..................................... 34
gabapentin oral tablet 800
mg ..................................... 34
?
GABITRIL ORAL TABLET
12 MG, 16 MG ................. 34
galantamine oral capsule,ext
rel. pellets 24 hr ................ 38
galantamine oral
solution ............................. 38
galantamine oral tablet .... 38
GAMASTAN S/D ............. 88
GAMMAGARD
LIQUID ............................ 88
GAMMAGARD S-D (IGA <
1 MCG/ML) ...................... 88
GAMMAPLEX ................ 88
GAMUNEX-C .................. 88
ganciclovir sodium ........... 12
GARDASIL 9 (PF) ........... 88
GARDASIL (PF) .............. 88
gas relief extra strength oral
capsule .............................. 83
gas relief oral capsule ...... 83
gas relief oral drops,
suspension ......................... 83
gas relief oral tablet,
chewable ........................... 83
GAS RELIEF ORAL
TABLET,CHEWABLE ..... 83
GATTEX 30-VIAL ........... 83
GATTEX ONE-VIAL ...... 83
GAUZE PADS 2 X 2 ........ 75
gavilyte-c .......................... 83
gavilyte-g .......................... 83
gavilyte-n .......................... 83
GAZYVA .......................... 26
gemcitabine intravenous recon
soln 1 gram, 200 mg ......... 26
GEMCITABINE
INTRAVENOUS RECON
SOLN 2 GRAM ................ 26
GEMCITABINE
INTRAVENOUS SOLUTION
1 GRAM/26.3 ML (38 MG/
ML), 200 MG/5.26 ML (38
MG/ML) ........................... 26
GEMCITABINE
INTRAVENOUS SOLUTION
2 GRAM/52.6 ML (38 MG/
ML) ................................... 26
gemfibrozil oral ................ 62
generlac ............................ 83
gengraf oral capsule 100 mg,
25 mg ................................ 26
gengraf oral capsule 50
mg ..................................... 26
gengraf oral solution ........ 26
gentak ophthalmic
ointment ............................ 96
gentamicin injection ......... 18
gentamicin ophthalmic ..... 96
GENTAMICIN SULFATE
(PED) (PF) ........................ 18
GENTAMICIN SULFATE
(PF) INTRAVENOUS
SOLUTION 100 MG/10
ML .................................... 18
GENTAMICIN SULFATE
(PF) INTRAVENOUS
SOLUTION 60 MG/6
ML .................................... 18
gentamicin sulfate (pf)
intravenous solution 80 mg/8
ml ...................................... 18
gentamicin topical ............ 66
GENVOYA ....................... 12
GEODON
INTRAMUSCULAR ........ 48
gildagia ............................. 93
GILDESS FE 1.5/30 (28) ... 93
GILDESS FE 1/20 (28) .... 93
GILENYA ......................... 38
GILOTRIF ........................ 26
GLATOPA ........................ 38
GLEEVEC ORAL TABLET
100 MG ............................. 26
GLEEVEC ORAL TABLET
400 MG ............................. 26
GLEOSTINE .................... 26
glimepiride oral tablet 1
mg ..................................... 75
glimepiride oral tablet 2
mg ..................................... 75
glimepiride oral tablet 4
mg ..................................... 75
glipizide oral tablet 10
mg ..................................... 75
glipizide oral tablet 5 mg ... 75
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TXDMKT-0101-16 SP 09.16 SP
147
glipizide oral tablet extended
release 24hr 10 mg ........... 75
glipizide oral tablet extended
release 24hr 2.5 mg .......... 75
glipizide oral tablet extended
release 24hr 5 mg ............. 75
glipizide-metformin oral tablet
2.5-250 mg ........................ 75
glipizide-metformin oral tablet
2.5-500 mg, 5-500 mg ....... 75
GLUCAGEN HYPOKIT ... 75
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 75
GLUTOSE 15 ................... 71
GLUTOSE 45 ................... 71
glycopyrrolate oral ........... 80
griseofulvin microsize oral
suspension ......................... 10
griseofulvin
ultramicrosize ................... 10
guaifenesin ac ................. 102
guaifenesin oral liquid .... 102
GUAIFENESIN ORAL
TABLET EXTENDED
RELEASE 12HR 1,200
MG .................................. 102
guaifenesin oral tablet
extended release 12hr 600
mg ................................... 103
guanfacine oral tablet
extended release 24 hr ...... 48
guanidine .......................... 48
gummy dinos oral tablet,
chewable 200 mcg .......... 124
H
HAIR VITAMINS .......... 124
hair,skin and nails oral
tablet ............................... 124
HALAVEN ....................... 26
halobetasol propionate ..... 69
HALOG ............................ 69
haloperidol ....................... 48
haloperidol decanoate ...... 48
haloperidol lactate ............ 48
HARD NAIL .................. 124
HARVONI ........................ 12
?
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION .................. 88
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 1,440 ELISA
UNIT/ML ......................... 88
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 720 ELISA UNIT/
0.5 ML .............................. 88
HEARTBURN RELIEF
(LANSOPRAZOLE) ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 15
MG .................................... 86
HEMATRON .................. 124
HEMOCYTE .................. 124
HEMOCYTE-F .............. 124
HEMOCYTE-PLUS ....... 124
HEMORRHOIDAL
SUPPOSITORY ................ 83
HEPARIN (PORCINE) IN 5
% DEX INTRAVENOUS
PARENTERAL SOLUTION
12,500 UNIT/250 ML ...... 61
heparin (porcine) in 5 % dex
intravenous parenteral
solution 25,000 unit/250 ml
(100 unit/ml), 25,000 unit/500
ml (50 unit/ml) .................. 61
HEPARIN (PORCINE) IN
NACL (PF) INTRAVENOUS
PARENTERAL SOLUTION
1,000 UNIT/500 ML, 2,000
UNIT/1,000 ML ............... 61
HEPARIN (PORCINE)
INJECTION
CARTRIDGE .................... 61
heparin (porcine) injection
solution ............................. 61
HEPARIN, PORCINE (PF)
INJECTION
SOLUTION ...................... 62
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
12,500 UNIT/250 ML ...... 61
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/250 ML ...... 61
HEPARIN(PORCINE) IN
0.45% NACL
INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/500 ML ...... 61
HEPATAMINE 8% ......... 117
HERCEPTIN .................... 26
HETLIOZ ......................... 48
HEXALEN ....................... 26
hi-cal plus vit d ............... 113
HIBERIX (PF) .................. 89
high potency iron ............ 124
HISTAFLEX ..................... 42
HISTEX DM .................. 103
HISTEX PD .................... 103
HISTEX PE .................... 103
HISTEX
(TRIPROLIDINE) .......... 103
honey bears ..................... 124
honey bears with ironzinc .................................. 124
HUMALOG ...................... 75
HUMALOG KWIKPEN ... 75
HUMALOG MIX 50-50 .... 75
HUMALOG MIX 50-50
KWIKPEN ........................ 75
HUMALOG MIX 75-25 .... 75
HUMALOG MIX 75-25
KWIKPEN ........................ 76
HUMAPEN LUXURA
HD .................................... 76
HUMIRA PEDIATRIC
CROHN'S START ............ 91
HUMIRA PEN ................. 91
HUMIRA PEN CROHN'SUC-HS START ................. 91
HUMIRA PEN PSORIASIS
STARTER ......................... 91
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2
ML, 20 MG/0.4 ML .......... 91
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TXDMKT-0101-16 SP 09.16 SP
148
HUMIRA SUBCUTANEOUS
SYRINGE KIT 40 MG/0.8
ML .................................... 91
HUMULIN 70/30 ............. 76
HUMULIN 70/30
KWIKPEN ........................ 76
HUMULIN N ................... 76
HUMULIN N
KWIKPEN ........................ 76
HUMULIN R .................... 76
HUMULIN R U-500 (CONC)
KWIKPEN ........................ 76
HUMULIN R U-500
(CONCENTRATED) ........ 76
HYCOFENIX ................. 103
hydralazine ....................... 57
hydrochlorothiazide .......... 57
HYDROCODONEACETAMINOPHEN ORAL
SOLUTION 2.5-167 MG/5
ML .................................... 39
hydrocodone-acetaminophen
oral solution 7.5-325 mg/15
ml ...................................... 39
hydrocodone-acetaminophen
oral tablet 10-300 mg, 5-300
mg, 7.5-300 mg ................. 39
hydrocodone-acetaminophen
oral tablet 10-325 mg, 5-325
mg, 7.5-325 mg ................. 40
hydrocodonechlorpheniramine ........... 103
hydrocodone-cpmpseudoephed ................... 103
hydrocodone-homatropine oral
syrup 5-1.5 mg/5 ml ........ 103
hydrocodone-homatropine oral
tablet ............................... 103
hydrocodone-ibuprofen oral
tablet 10-200 mg, 5-200 mg,
7.5-200 mg ........................ 40
hydrocortisone oral .......... 74
hydrocortisone rectal cream
2.5 % ................................. 83
hydrocortisone rectal
enema ................................ 83
hydrocortisone topical cream
0.5 % ................................. 69
?
hydrocortisone topical cream
1 %, 2.5 % ........................ 69
hydrocortisone topical lotion
2.5 % ................................. 69
hydrocortisone topical
ointment 0.5 % .................. 69
hydrocortisone topical
ointment 1 %, 2.5 % ......... 69
hydrocortisone valerate .... 69
hydrocortisone-acetic
acid ................................... 73
HYDROCORTISONE-MIN
OIL-WHT PET ................. 69
hydromet ......................... 103
hydromorphone oral tablet 2
mg, 4 mg ........................... 40
hydromorphone oral tablet 8
mg ..................................... 40
hydroskin topical lotion .... 69
hydroxychloroquine oral .... 18
hydroxyurea ...................... 26
I
I.L.X. B-12 ..................... 124
ibandronate intravenous
solution ............................. 90
ibandronate intravenous
syringe .............................. 90
ibandronate oral ............... 90
IBRANCE ......................... 26
ibu-drops ........................... 43
ibuprofen jr strength ......... 43
ibuprofen oral capsule ...... 43
ibuprofen oral
suspension ......................... 43
ibuprofen oral tablet 200
mg ..................................... 43
ibuprofen oral tablet 400 mg,
600 mg, 800 mg ................ 43
ICAPS ............................. 124
ICAPS AREDS ORAL
TABLET,DELAYED
RELEASE (DR/EC) ....... 124
ICAPS MV ..................... 124
icaps plus ........................ 124
ICAR ORAL
SUSPENSION ................ 124
ICAR-C ........................... 124
ICLUSIG ORAL TABLET 15
MG .................................... 26
ICLUSIG ORAL TABLET 45
MG .................................... 27
idarubicin ......................... 27
iferex 150 ........................ 124
iferex 150 forte ................ 125
ifosfamide intravenous recon
soln ................................... 27
IFOSFAMIDE
INTRAVENOUS
SOLUTION ...................... 27
ILARIS (PF) ..................... 87
ILEVRO ........................... 97
imatinib oral tablet 100
mg ..................................... 27
imatinib oral tablet 400
mg ..................................... 27
IMBRUVICA ................... 27
imipenem-cilastatin .......... 18
imipramine hcl .................. 48
imiquimod ......................... 64
IMOVAX RABIES VACCINE
(PF) ................................... 89
INCRELEX ...................... 71
indapamide ....................... 57
INFANRIX (DTAP)
(PF) ................................... 89
infant's ibuprofen .............. 43
infants gas relief ............... 83
infants ibu-drops ............... 43
infed ................................ 125
INLYTA ORAL TABLET 1
MG .................................... 27
INLYTA ORAL TABLET 5
MG .................................... 27
insulin pen needle ............. 76
INSULIN SYRINGE (DISP)
U-100 SYRINGE 0.3 ML, 1
ML, 1/2 ML ...................... 76
INTEGRA ....................... 125
INTEGRA F ................... 125
INTEGRA PLUS ............ 125
INTELENCE ORAL TABLET
100 MG ............................. 12
INTELENCE ORAL TABLET
200 MG ............................. 12
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TXDMKT-0101-16 SP 09.16 SP
149
INTELENCE ORAL TABLET
25 MG ............................... 12
intralipid intravenous emulsion
20 % ................................ 117
INTRON A INJECTION ... 87
INVANZ INJECTION ...... 18
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR
1.5 MG .............................. 48
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR
3 MG ................................. 48
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR
6 MG ................................. 48
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR
9 MG ................................. 49
INVEGA SUSTENNA ..... 49
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 273 MG/0.875
ML .................................... 49
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 410 MG/1.315
ML .................................... 49
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 546 MG/1.75
ML .................................... 49
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 819 MG/2.625
ML .................................... 49
INVIRASE ORAL
CAPSULE ........................ 12
INVIRASE ORAL
TABLET ........................... 12
iophen c-nr ...................... 103
iophen dm-nr .................. 103
iophen-nr ........................ 103
IOSAT ............................... 74
IPOL INJECTION
SUSPENSION .................. 89
ipratropium bromide
inhalation ........................ 109
?
ipratropium bromide
nasal ................................. 73
ipratropium-albuterol ..... 109
irbesartan ......................... 58
irbesartan-hydrochlorothiazide
oral tablet 150-12.5 mg .... 58
irbesartan-hydrochlorothiazide
oral tablet 300-12.5 mg .... 58
IRESSA ............................ 27
irinotecan intravenous solution
100 mg/5 ml, 40 mg/2 ml ... 27
IRINOTECAN
INTRAVENOUS SOLUTION
500 MG/25 ML ................. 27
iron high potency ............ 125
iron oral tablet 325 mg (65 mg
iron) ................................ 125
iron oral tablet extended
release 159 mg (45 mg
iron) ................................ 125
iron (ferrous sulfate) ....... 125
iron-vitamin c .................. 125
IROSPAN 24/6 ............... 125
ISENTRESS ORAL
POWDER IN PACKET .... 12
ISENTRESS ORAL
TABLET ........................... 12
ISENTRESS ORAL TABLET,
CHEWABLE 100 MG ...... 12
ISENTRESS ORAL TABLET,
CHEWABLE 25 MG ........ 12
ISOLYTE-P IN 5 %
DEXTROSE ................... 117
isoniazid oral .................... 18
ISOPTO TEARS ............... 97
isosorbide dinitrate oral .... 63
isosorbide mononitrate ..... 63
isradipine .......................... 58
ISTODAX ......................... 27
ITCH-X TOPICAL GEL ... 64
itraconazole ...................... 10
ivermectin oral .................. 18
IXEMPRA ........................ 27
IXIARO (PF) .................... 89
J
J-MAX ............................ 103
J-TAN D PD ................... 103
J-TAN PD ....................... 103
JAKAFI ORAL TABLET 10
MG .................................... 27
JAKAFI ORAL TABLET 15
MG .................................... 27
JAKAFI ORAL TABLET 20
MG .................................... 27
JAKAFI ORAL TABLET 25
MG .................................... 27
JAKAFI ORAL TABLET 5
MG .................................... 27
jantoven ............................ 62
JANUMET ....................... 76
JANUMET XR ORAL
TABLET, ER MULTIPHASE
24 HR 100-1,000 MG ....... 76
JANUMET XR ORAL
TABLET, ER MULTIPHASE
24 HR 50-1,000 MG, 50-500
MG .................................... 76
JANUVIA ORAL TABLET
100 MG ............................. 76
JANUVIA ORAL TABLET
25 MG ............................... 76
JANUVIA ORAL TABLET
50 MG ............................... 76
JARDIANCE .................... 76
JENTADUETO ................. 76
JEVTANA ........................ 27
junel 1.5/30 (21) ............... 93
junel 1/20 (21) .................. 93
junel fe 1.5/30 (28) ........... 93
junel fe 1/20 (28) .............. 93
junior mapap .................... 43
JUXTAPID ....................... 62
K
K-TAB ORAL TABLET
EXTENDED RELEASE 8
MEQ ............................... 113
KADCYLA ....................... 27
KALETRA ORAL
SOLUTION ...................... 12
KALETRA ORAL TABLET
100-25 MG ....................... 12
KALETRA ORAL TABLET
200-50 MG ....................... 13
KALYDECO ORAL
TABLET ......................... 109
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TXDMKT-0101-16 SP 09.16 SP
150
kao-tin (bismuth
subsalicylat) ...................... 80
kao-tin (docusate
calcium) ............................ 83
kariva (28) ........................ 94
kelnor 1/35 (28) ................ 94
KEPIVANCE .................... 22
ketoconazole oral .............. 10
ketoconazole topical ......... 67
ketorolac ophthalmic ........ 97
KEYTRUDA .................... 27
KHEDEZLA ORAL TABLET
EXTENDED RELEASE 24HR
100 MG ............................. 49
KHEDEZLA ORAL TABLET
EXTENDED RELEASE 24HR
50 MG ............................... 49
kidkare cough/cold .......... 103
KINERET ......................... 91
kionex ................................ 71
KLOR-CON 10 ............... 113
KLOR-CON 8 ................. 113
KLOR-CON M10 ........... 113
KLOR-CON M15 ........... 113
KLOR-CON M20 ........... 113
KORLYM ......................... 78
KUVAN ORAL TABLET,
SOLUBLE ........................ 78
L
l-methyl-b6-b12 .............. 125
l-methyl-mc ..................... 125
labetalol intravenous
solution ............................. 58
labetalol oral .................... 58
lactated ringers
intravenous ..................... 113
lactated ringers
irrigation ........................... 70
lactulose ............................ 83
lamivudine oral solution .... 13
lamivudine oral tablet 100
mg ..................................... 13
lamivudine oral tablet 150
mg ..................................... 13
lamivudine oral tablet 300
mg ..................................... 13
lamivudine-zidovudine ...... 13
lamotrigine oral tablet ...... 34
?
lamotrigine oral tablet,
chewable dispersible ......... 34
LANOXIN ORAL TABLET
125 MCG, 62.5 MCG ....... 60
lansoprazole oral capsule,
delayed release(dr/ec) ...... 86
LANTUS .......................... 76
LANTUS SOLOSTAR ..... 76
LARIN 1/20 (21) .............. 94
LARIN FE 1.5/30 (28) ..... 94
LARIN FE 1/20 (28) ........ 94
latanoprost ........................ 98
LATUDA ORAL TABLET
120 MG ............................. 49
LATUDA ORAL TABLET 20
MG .................................... 49
LATUDA ORAL TABLET 40
MG .................................... 49
LATUDA ORAL TABLET 60
MG .................................... 49
LATUDA ORAL TABLET 80
MG .................................... 49
laxative dietary
supplement ...................... 113
leflunomide ....................... 91
LENVIMA ORAL CAPSULE
10 MG/DAY (10 MG X 1/
DAY) ................................. 27
LENVIMA ORAL CAPSULE
14 MG/DAY(10 MG X 1-4
MG X 1), 20 MG/DAY (10
MG X 2) ........................... 27
LENVIMA ORAL CAPSULE
18 MG/DAY (10 MG X 1-4
MG X2) ............................ 27
LENVIMA ORAL CAPSULE
24 MG/DAY(10 MG X 2-4
MG X 1) ........................... 28
LENVIMA ORAL CAPSULE
8 MG/DAY (4 MG X 2), 8
MG/DAY (4 MG X 2) (60
PACK) ............................... 28
lessina ............................... 94
LETAIRIS ....................... 109
letrozole ............................ 28
leucovorin calcium injection
recon soln 100 mg, 350 mg, 50
mg ..................................... 22
LEUCOVORIN CALCIUM
INJECTION RECON SOLN
200 MG ............................. 22
LEUCOVORIN CALCIUM
INJECTION RECON SOLN
500 MG ............................. 23
leucovorin calcium oral .... 23
LEUKERAN ..................... 28
leuprolide subcutaneous
kit ...................................... 28
levalbuterol hcl inhalation
solution for nebulization 0.31
mg/3 ml, 1.25 mg/0.5 ml, 1.25
mg/3 ml ........................... 109
levalbuterol hcl inhalation
solution for nebulization 0.63
mg/3 ml ........................... 109
LEVEMIR ........................ 76
LEVEMIR
FLEXTOUCH .................. 76
levetiracetam in nacl (iso-os)
intravenous piggyback 1,000
mg/100 ml, 1,500 mg/100
ml ...................................... 34
levetiracetam in nacl (iso-os)
intravenous piggyback 500 mg/
100 ml ............................... 34
levetiracetam
intravenous ....................... 34
levetiracetam oral solution 100
mg/ml ................................ 34
LEVETIRACETAM ORAL
SOLUTION 500 MG/5 ML (5
ML) ................................... 34
levetiracetam oral tablet .... 34
levetiracetam oral tablet
extended release 24 hr 500
mg ..................................... 34
levetiracetam oral tablet
extended release 24 hr 750
mg ..................................... 34
levobunolol ophthalmic drops
0.5 % ................................. 96
levocarnitine oral tablet .... 71
levocarnitine (with
sugar) ................................ 71
levocetirizine oral
tablet ............................... 103
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TXDMKT-0101-16 SP 09.16 SP
151
levofloxacin intravenous .... 21
levofloxacin oral tablet ..... 21
levonest (28) ..................... 94
levonorg-eth estrad
triphasic ............................ 94
levonorgestrel-ethinyl estrad
oral tablet 0.15-0.03 mg .... 94
levonorgestrel-ethinyl estrad
oral tablets,dose pack,3
month ................................ 94
levorphanol tartrate .......... 40
levothyroxine oral ............. 80
levoxyl oral tablet 100 mcg,
112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg,
25 mcg, 50 mcg, 75 mcg, 88
mcg ................................... 80
LEXIVA ORAL
SUSPENSION .................. 13
LEXIVA ORAL
TABLET ........................... 13
LIALDA ........................... 83
lidocaine hcl injection solution
20 mg/ml (2 %), 5 mg/ml (0.5
%) ..................................... 66
lidocaine hcl
laryngotracheal ................ 66
lidocaine hcl mucous
membrane ......................... 66
lidocaine hcl urethral ....... 66
lidocaine topical adhesive
patch,medicated ................ 66
lidocaine topical
ointment ............................ 66
LIDOCAINE VISCOUS ... 66
LIDOCAINE (PF)
INJECTION SOLUTION 15
MG/ML (1.5 %) ................ 66
lidocaine (pf) injection
solution 20 mg/ml (2 %), 40
mg/ml (4 %), 5 mg/ml (0.5
%) ..................................... 66
lidocaine (pf) intravenous
solution ............................. 55
LIDOCAINE (PF)
INTRAVENOUS
SYRINGE ......................... 55
?
lidocaine-prilocaine topical
cream ................................ 66
LIFE-PACK MEN'S ....... 125
LIFE-PACK
WOMEN'S ...................... 125
lindane topical shampoo .... 69
linezolid intravenous ........ 18
linezolid oral suspension for
reconstitution .................... 18
linezolid oral tablet ........... 18
LINEZOLID-0.9% SODIUM
CHLORIDE ...................... 18
LINZESS .......................... 83
liothyronine oral ............... 80
liquid antacid oral suspension
200-200-20 mg/5 ml ......... 83
liquitears ........................... 97
lisinopril ........................... 58
lisinoprilhydrochlorothiazide .......... 58
lithium carbonate .............. 49
lithium citrate oral solution 8
meq/5 ml ........................... 49
LITTLE ANIMALS ....... 125
LITTLE ANIMALS-IRON
ORAL TABLET,
CHEWABLE .................. 125
LODRANE D ................. 103
lohist - d .......................... 103
lohist-dm ......................... 103
LONSURF ........................ 28
loperamide oral capsule .... 80
loperamide oral liquid 1 mg/5
ml ...................................... 80
loperamide oral liquid 1 mg/
7.5 ml ................................ 80
lorata-dine d ................... 103
loratadine oral solution ... 103
loratadine oral tablet ...... 103
loratadine oral tablet,
disintegrating .................. 103
loratadine-d .................... 103
lorazepam oral tablet ....... 49
LORTUSS DM ............... 103
LORTUSS EX ORAL
SYRUP ........................... 104
LORTUSS LQ ................ 104
losartan oral tablet 100
mg ..................................... 58
losartan oral tablet 25 mg, 50
mg ..................................... 58
losartanhydrochlorothiazide .......... 58
lovastatin oral tablet 10 mg,
20 mg ................................ 62
lovastatin oral tablet 40
mg ..................................... 63
LOW-OGESTREL (28) .... 94
loxapine succinate ............ 49
lubricating plus ................. 97
lubrifresh pm ..................... 97
LUDENT FLUORIDE ORAL
TABLET,CHEWABLE 1 MG
FLUORIDE (2.2 MG) .... 125
LUMIGAN OPHTHALMIC
DROPS 0.01 % ................. 98
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 3.75 MG ... 28
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 7.5 MG .... 28
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 7.5
MG (PED) ........................ 28
lutera (28) ......................... 94
LYNPARZA ...................... 28
LYRICA ORAL CAPSULE
100 MG ............................. 34
LYRICA ORAL CAPSULE
150 MG ............................. 34
LYRICA ORAL CAPSULE
200 MG ............................. 34
LYRICA ORAL CAPSULE
225 MG, 300 MG ............. 34
LYRICA ORAL CAPSULE
25 MG ............................... 34
LYRICA ORAL CAPSULE
50 MG ............................... 34
LYRICA ORAL CAPSULE
75 MG ............................... 35
LYRICA ORAL
SOLUTION ...................... 35
lysiplex plus oral liquid ... 125
LYSODREN ..................... 28
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TXDMKT-0101-16 SP 09.16 SP
152
lyza .................................... 92
M
M-END DMX ................. 104
M-END MAX D ............. 104
M-M-R II (PF) .................. 89
MAGNESIUM AMINO ACID
CHELATE ORAL TABLET
27 MG ............................. 113
magnesium gluconate oral
tablet 30 mg (550 mg) ..... 113
magnesium oral tablet 250
mg ..................................... 83
magnesium oral tablet 30
mg ................................... 113
magnesium oxide oral capsule
500 mg ............................ 113
magnesium oxide oral tablet
400 mg, 420 mg, 500
mg ................................... 113
MAGNESIUM SULFATE IN
WATER INTRAVENOUS
PARENTERAL
SOLUTION .................... 113
MAGNESIUM SULFATE IN
WATER INTRAVENOUS
PIGGYBACK 2 GRAM/50
ML (4 %), 4 GRAM/50 ML (8
%) .................................... 113
MAGNESIUM SULFATE IN
WATER INTRAVENOUS
PIGGYBACK 4 GRAM/100
ML (4 %) ........................ 114
magnesium sulfate injection
solution ........................... 114
magnesium sulfate injection
syringe ............................. 114
MAGNESIUM (OXIDE/AA
CHELATE) ..................... 113
MAGTAB ......................... 83
MAJOR-PREP
HEMORRHOIDAL RECTAL
OINTMENT 0.25-14-74.9
% ....................................... 84
mapap arthritis pain ......... 43
mapap cold formula ........ 104
mapap extra strength ........ 43
mapap pm ......................... 43
?
mapap sinus max strength
(pe) .................................. 104
mapap (acetaminophen) oral
capsule .............................. 43
mapap (acetaminophen) oral
liquid ................................. 43
mapap (acetaminophen) oral
suspension ......................... 43
mapap (acetaminophen) oral
tablet ................................. 43
mapap (acetaminophen) oral
tablet,chewable ................. 43
maprotiline oral tablet 25
mg ..................................... 49
maprotiline oral tablet 50
mg ..................................... 49
maprotiline oral tablet 75
mg ..................................... 49
marlissa ............................ 94
MARPLAN ....................... 49
masanti double strength .... 84
MATULANE .................... 28
maxiphen ......................... 104
MAXIPHEN DM ............ 104
meclizine oral tablet 12.5 mg,
25 mg ................................ 84
meclofenamate oral .......... 43
MEDICATED BODY
POWDER TOPICAL
POWDER 0.15 % ............. 64
medroxyprogesterone ........ 92
MEDTYCHOLL-B
COMPLEX-LIVER ........ 125
mefloquine ........................ 18
MEGA MULTI FOR
WOMEN ......................... 125
mega multiple/chelated
mineral ............................ 125
MEGA MULTIVITAMIN
FOR MEN ...................... 125
MEGA MULTIVITAMIN
WITH MINERAL ORAL
TABLET 13.5-200-250 MGMCG-MCG ..................... 125
MEGESTROL ORAL
SUSPENSION 400 MG/10
ML (10 ML), 800 MG/20 ML
(20 ML) ............................ 28
megestrol oral suspension 400
mg/10 ml (40 mg/ml) ........ 28
megestrol oral tablet ......... 28
MEKINIST ORAL TABLET
0.5 MG .............................. 28
MEKINIST ORAL TABLET
2 MG ................................. 28
meloxicam oral
suspension ......................... 43
meloxicam oral tablet ....... 43
melphalan hcl ................... 28
memantine oral solution .... 38
memantine oral tablet 10
mg ..................................... 38
memantine oral tablet 5
mg ..................................... 38
men's multi-vitamin ......... 125
MENACTRA (PF)
INTRAMUSCULAR
SOLUTION ...................... 89
MENEST .......................... 92
MENOMUNE - A/C/Y/W135 .................................... 89
MENOMUNE - A/C/Y/W-135
(PF) ................................... 89
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 89
MEPHYTON .................... 62
mercaptopurine ................. 28
MERIBIN ....................... 125
meropenem ........................ 19
mesalamine rectal ............. 84
mesalamine with cleansing
wipe ................................... 84
mesna ................................ 23
MESNEX ORAL .............. 23
MESTINON ORAL
SYRUP ............................. 38
MESTINON
TIMESPAN ....................... 39
metafolbic ....................... 125
metaproterenol ................ 109
metformin oral tablet 1,000
mg ..................................... 76
metformin oral tablet 500
mg ..................................... 76
metformin oral tablet 850
mg ..................................... 76
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
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TXDMKT-0101-16 SP 09.16 SP
153
metformin oral tablet extended
release 24 hr 500 mg ........ 76
metformin oral tablet extended
release 24 hr 750 mg ........ 77
metformin oral tablet extended
release 24hr 1,000 mg ...... 77
metformin oral tablet extended
release 24hr 500 mg ......... 77
methadone injection .......... 40
METHADONE
INTENSOL ....................... 40
methadone oral
concentrate ....................... 40
methadone oral solution 10
mg/5 ml ............................. 40
methadone oral solution 5 mg/
5 ml ................................... 40
methadone oral tablet 10
mg ..................................... 40
methadone oral tablet 5
mg ..................................... 40
METHADOSE ORAL
CONCENTRATE ............. 40
methazolamide oral .......... 98
methenamine hippurate .... 22
methimazole oral tablet 10 mg,
5 mg .................................. 74
methotrexate sodium ......... 28
methotrexate sodium (pf)
injection recon soln ........... 28
methotrexate sodium (pf)
injection solution .............. 28
methoxsalen rapid ............ 65
methyclothiazide ............... 58
methylergonovine oral ...... 95
methylphenidate oral
tablet ................................. 49
methylprednisolone
acetate ............................... 74
methylprednisolone oral
tablets ............................... 74
methylprednisolone sodium
succ injection recon soln 125
mg, 40 mg ......................... 74
methylprednisolone sodium
succ intravenous ............... 74
metipranolol ..................... 96
?
metoclopramide hcl injection
solution ............................. 84
METOCLOPRAMIDE HCL
INJECTION SYRINGE .... 84
metoclopramide hcl oral
solution ............................. 84
metoclopramide hcl oral
tablet ................................. 84
metolazone ........................ 58
metoprolol succinate ......... 58
metoprolol tahydrochlorothiaz ............... 58
metoprolol tartrate
intravenous solution ......... 58
metoprolol tartrate
intravenous syringe .......... 58
metoprolol tartrate oral tablet
100 mg, 25 mg, 50 mg ...... 58
metoprolol tartrate oral tablet
37.5 mg, 75 mg ................. 58
METRO I.V. ..................... 19
metronidazole in nacl (isoos) ..................................... 19
metronidazole oral ............ 19
metronidazole topical
cream ................................ 65
metronidazole topical gel 0.75
% ....................................... 66
metronidazole topical
lotion ................................. 66
metronidazole vaginal ...... 92
mexiletine .......................... 55
MG-PLUS-PROTEIN ..... 114
mi-acid gas relief .............. 84
mi-acid oral suspension .... 84
MIACALCIN
INJECTION ...................... 78
miconazole 7 ..................... 92
miconazole nitrate topical
cream ................................ 67
miconazole nitrate vaginal
cream ................................ 92
miconazole nitrate vaginal
suppository ....................... 92
miconazole-3 vaginal
suppository ....................... 92
MICROGESTIN 1.5/30
(21) ................................... 94
MICROGESTIN 1/20
(21) ................................... 94
MICROGESTIN FE 1.5/30
(28) ................................... 94
MICROGESTIN FE 1/20
(28) ................................... 94
midodrine .......................... 71
migraine formula .............. 43
milk of magnesia ............... 84
milk of magnesia
concentrated ..................... 84
minocycline oral capsule ... 21
minocycline oral tablet ..... 21
minoxidil oral ................... 58
mintox maximum
strength ............................. 84
mirtazapine oral tablet 15
mg ..................................... 49
mirtazapine oral tablet 30
mg ..................................... 49
mirtazapine oral tablet 45
mg ..................................... 50
mirtazapine oral tablet 7.5
mg ..................................... 50
mirtazapine oral tablet,
disintegrating 15 mg ......... 50
mirtazapine oral tablet,
disintegrating 30 mg ......... 50
mirtazapine oral tablet,
disintegrating 45 mg ......... 50
misoprostol ....................... 86
mitomycin ......................... 28
mitoxantrone ..................... 28
modafinil oral tablet 100
mg ..................................... 50
modafinil oral tablet 200
mg ..................................... 50
moexipril ........................... 58
moexiprilhydrochlorothiazide .......... 58
molindone ......................... 50
mometasone nasal .......... 109
mometasone topical .......... 69
MONO-LINYAH .............. 94
MONOCAL .................... 114
mononessa (28) ................. 94
montelukast ..................... 109
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
Para obtener más información, visite www.myamerigroup.com/TXmmp.
TXDMKT-0101-16 SP 09.16 SP
154
morphine concentrate oral
solution ............................. 40
MORPHINE INTRAVENOUS
CARTRIDGE .................... 40
MORPHINE INTRAVENOUS
SOLUTION 10 MG/ML, 50
MG/ML ............................. 40
MORPHINE INTRAVENOUS
SOLUTION 100 MG/4 ML,
25 MG/ML, 250 MG/10
ML .................................... 40
MORPHINE INTRAVENOUS
SOLUTION 4 MG/ML, 8 MG/
ML .................................... 40
morphine intravenous syringe
2 mg/ml, 4 mg/ml .............. 40
morphine oral capsule, er
multiphase 24 hr 120 mg, 75
mg, 90 mg ......................... 40
morphine oral capsule, er
multiphase 24 hr 30 mg, 45
mg, 60 mg ......................... 41
morphine oral capsule,
extend.release pellets 100 mg,
20 mg, 30 mg, 50 mg, 60 mg,
80 mg ................................ 41
morphine oral solution 20 mg/
5 ml (4 mg/ml) .................. 41
morphine oral tablet 15
mg ..................................... 41
morphine oral tablet 30
mg ..................................... 41
morphine oral tablet extended
release 100 mg, 15 mg, 30 mg,
60 mg ................................ 41
morphine oral tablet extended
release 200 mg .................. 41
morphine (pf) injection
solution 0.5 mg/ml ............ 40
morphine (pf) injection
solution 1 mg/ml ............... 40
MORPHINE (PF)
INTRAVENOUS PATIENT
CONTROL.ANALGESIA
SOLN 150 MG/30 ML ..... 40
MORPHINE (PF)
INTRAVENOUS PATIENT
?
CONTROL.ANALGESIA
SOLN 30 MG/30 ML ....... 40
MOVIPREP ...................... 84
moxifloxacin ..................... 21
mucaphed ........................ 104
mucinex ........................... 104
MUCINEX COLD,FLU,SORE
THROAT ........................ 104
MUCINEX COUGH MINIMELTS ........................... 104
mucinex d ........................ 104
mucinex d maximum
strength ........................... 104
mucinex dm ..................... 104
mucinex fast-max cold-flu-thrt
oral tablet ....................... 104
MUCINEX FAST-MAX
COLD-SINUS ................ 104
MUCINEX FAST-MAX
CONGEST-COUGH ORAL
LIQUID .......................... 104
MUCINEX FAST-MAX
CONGEST-COUGH ORAL
TABLET ......................... 104
MUCINEX FAST-MAX
DAY-NITE CONG ORAL
TABLETS,
SEQUENTIAL ............... 104
MUCINEX FAST-MAX DM
MAX ............................... 104
MUCINEX FAST-MAX NITE
COLD-FLU ORAL
LIQUID .......................... 104
MUCINEX FAST-MAX
SEVERE COLD ORAL
LIQUID .......................... 104
MUCINEX FST-MX DY-NT
COLD(DPH) ORAL LIQUID,
SEQUENTIAL ............... 104
MUCINEX MINI-MELTS
ORAL GRANULES IN
PACKET 100 MG ........... 105
MUCINEX SINUSMAX ................................. 73
MUCINEX SINUS-MAX DN (DIPHEN) ORAL
TABLETS,
SEQUENTIAL ............... 105
mucinex sinus-max pressurpain oral tablet ............... 105
mucinex sinus-max sev
congestn oral tablet ........ 105
MUCUS RELIEF ER ORAL
TABLET EXTENDED
RELEASE 12HR 600
MG .................................. 105
mucus relief oral tablet 400
mg ................................... 105
mucus relief sinus ........... 105
MULTAQ .......................... 55
multi-delyn ...................... 126
multi-delyn with iron ....... 126
multi-vitamin hp/
minerals .......................... 126
multilex ........................... 126
multilex-t and m .............. 126
multiple vitaminminerals .......................... 126
multivitamin oral tablet ... 126
multivitamin with iron ..... 126
multivitamin with minerals
oral tablet ....................... 126
mupirocin calcium ............ 66
mupirocin topical
ointment ............................ 66
MURO 128 OPHTHALMIC
DROPS ............................. 97
MUSTARGEN .................. 29
MY WAY .......................... 94
my-vitalife ....................... 126
mycophenolate mofetil ...... 29
mycophenolate sodium ..... 29
myferon 150 .................... 126
MYFERON 150
FORTE ............................ 126
MYOZYME ..................... 78
MYRBETRIQ ................. 110
mytab gas .......................... 84
mytab gas maximum
strength ............................. 84
MYZILRA ........................ 94
N
nabumetone ....................... 43
nadolol .............................. 58
nadololbendroflumethiazide ......... 58
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
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TXDMKT-0101-16 SP 09.16 SP
155
nafcillin injection .............. 20
nafcillin intravenous recon
soln 2 gram ....................... 20
NAGLAZYME ................. 78
nalbuphine injection solution
10 mg/ml ........................... 43
nalbuphine injection solution
20 mg/ml ........................... 43
naloxone ........................... 43
naltrexone ......................... 43
NAMENDA ORAL
SOLUTION ...................... 38
NAMENDA XR ORAL CAP,
SPRINKLE,ER 24HR DOSE
PACK ................................ 38
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER
24HR ................................. 38
NAMZARIC ..................... 38
naphazoline ....................... 99
naproxen ........................... 43
naproxen sodium oral tablet
220 mg .............................. 43
naproxen sodium oral tablet
275 mg, 550 mg ................ 43
nasal decongestant
(oxymetazl) ....................... 73
nasal decongestant (pe) oral
tablet 10 mg .................... 105
nasal decongestant
(pseudoeph) oral tablet .... 105
nasal spray 12 hour nasal
spray,non-aerosol ............. 73
NASONEX ..................... 109
NASOPEN PE ................ 105
nateglinide oral tablet 120
mg ..................................... 77
nateglinide oral tablet 60
mg ..................................... 77
NATPARA ........................ 78
natural fiber laxative
therapy .............................. 84
natural fiber laxative (sugar)
oral powder 3.4 gram/7
gram .................................. 84
NEBUPENT ..................... 19
necon 0.5/35 (28) .............. 94
necon 1/35 (28) ................. 94
?
necon 1/50 (28) ................. 94
necon 10/11 (28) ............... 94
necon 7/7/7 (28) ................ 94
needles, insulin disp.,
safety ................................. 77
nefazodone oral tablet 100
mg ..................................... 50
nefazodone oral tablet 150
mg ..................................... 50
nefazodone oral tablet 200
mg ..................................... 50
nefazodone oral tablet 250
mg ..................................... 50
nefazodone oral tablet 50
mg ..................................... 50
NEO-POLYCIN ................ 96
NEO-POLYCIN HC ......... 98
neomycin ........................... 19
neomycin-bacitracin-polyhc ...................................... 98
neomycin-bacitracinpolymyxin .......................... 96
neomycin-polymyxin b
gu ...................................... 70
neomycin-polymyxin bdexameth ........................... 98
neomycin-polymyxingramicidin ......................... 96
neomycin-polymyxin-hc
ophthalmic ........................ 98
neomycin-polymyxin-hc
otic .................................... 73
NEPHRO-VITE .............. 126
NEPHRON FA ............... 126
nephronex ....................... 126
NEUPOGEN ..................... 87
NEUPRO .......................... 37
NEVANAC ....................... 97
nevirapine oral
suspension ......................... 13
nevirapine oral tablet ....... 13
nevirapine oral tablet extended
release 24 hr 100 mg ........ 13
nevirapine oral tablet extended
release 24 hr 400 mg ........ 13
NEXAVAR ........................ 29
NEXT CHOICE ONE
DOSE ................................ 94
niacin oral capsule, extended
release 250 mg .................. 63
niacin oral tablet 100 mg, 50
mg, 500 mg ....................... 63
niacin oral tablet extended
release 24 hr 1,000 mg, 750
mg ..................................... 63
niacin oral tablet extended
release 24 hr 500 mg ........ 63
niacin oral tablet extended
release 250 mg, 500 mg .... 63
NIACOR ........................... 63
nicardipine intravenous
solution ............................. 58
nicardipine oral ................ 58
NICODERM CQ .............. 72
nicorelief ........................... 72
NICORETTE BUCCAL
GUM ................................. 72
NICORETTE BUCCAL
LOZENGE ........................ 72
nicotine transdermal patch 24
hour 14 mg/24 hr, 21 mg/24
hr, 7 mg/24 hr ................... 72
nicotine (polacrilex) buccal
gum ................................... 72
nicotine (polacrilex) buccal
lozenge .............................. 72
NICOTROL NS ................ 73
nifedical xl ........................ 58
nifedipine oral tablet extended
release ............................... 59
nifedipine oral tablet extended
release 24hr ...................... 59
nighttime sleep aid (diphen)
oral tablet ....................... 105
NILANDRON .................. 29
nimodipine ........................ 59
NINJACOF ..................... 105
NINJACOF-A ................. 105
NINJACOF-XG .............. 105
NINLARO ........................ 29
NIPENT ............................ 29
NITE TIME COLD-FLU
RELIEF ORAL
CAPSULE ...................... 105
nitro-bid ............................ 63
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TXDMKT-0101-16 SP 09.16 SP
156
nitrofurantoin macrocrystal
oral capsule 50 mg ........... 22
nitroglycerin intravenous ... 64
nitroglycerin transdermal
patch 24 hour .................... 64
NITROSTAT ..................... 64
nohist-dm ........................ 105
nohist-lq .......................... 105
non-aspirin pm .................. 44
non-drowsy allergy ......... 105
nora-be ............................. 92
NORDITROPIN
FLEXPRO ........................ 87
norethindrone acetate ....... 92
norethindrone
(contraceptive) .................. 92
norgestimate-ethinyl estradiol
oral tablet 0.18/0.215/0.25 mg35 mcg (28), 0.25-35 mgmcg ................................... 95
NORMOSOL-M IN 5 %
DEXTROSE ................... 117
NORMOSOL-R .............. 114
NORMOSOL-R IN 5 %
DEXTROSE ................... 114
NORMOSOL-R PH 7.4 ... 117
nortrel 0.5/35 (28) ............ 95
nortrel 1/35 (21) ............... 95
nortrel 1/35 (28) ............... 95
nortrel 7/7/7 (28) .............. 95
nortriptyline ...................... 50
NORVIR ORAL
CAPSULE ........................ 13
NORVIR ORAL
SOLUTION ...................... 13
NORVIR ORAL
TABLET ........................... 13
nose drops ......................... 73
NOVAFERRUM 125 ...... 126
NOVAFERRUM 50 ........ 126
NOVAFERRUM ORAL
DROPS ........................... 126
NOVOPEN ECHO ........... 77
NOXAFIL ORAL
SUSPENSION .................. 10
NRS NASAL RELIEF ..... 73
NU-IRON ....................... 126
NU-MAG ........................ 114
?
NUEDEXTA ..................... 38
NULOJIX ......................... 29
NUPLAZID ...................... 50
NUTRICAP .................... 126
NUTRIVIT ..................... 126
NUVARING ..................... 92
nystatin oral suspension .... 10
nystatin oral tablet ............ 10
nystatin topical ................. 67
nystatin-triamcinolone ...... 67
nystop ................................ 67
O
ocella ................................ 95
OCTAGAM ...................... 89
octreotide acetate .............. 29
ODEFSEY ........................ 13
ODOMZO ......................... 29
OFEV ORAL CAPSULE 150
MG .................................. 109
OFF DEEP WOODS ........ 69
OFF DEEP WOODS
DRY .................................. 65
ofloxacin ophthalmic ........ 96
ofloxacin oral tablet 400
mg ..................................... 21
ofloxacin otic .................... 73
ogestrel (28) ...................... 95
olanzapine
intramuscular ................... 50
olanzapine oral tablet 10
mg ..................................... 50
olanzapine oral tablet 15
mg ..................................... 50
olanzapine oral tablet 2.5
mg ..................................... 50
olanzapine oral tablet 20
mg ..................................... 50
olanzapine oral tablet 5
mg ..................................... 50
olanzapine oral tablet 7.5
mg ..................................... 50
olanzapine oral tablet,
disintegrating 10 mg ......... 50
olanzapine oral tablet,
disintegrating 15 mg ......... 50
olanzapine oral tablet,
disintegrating 20 mg ......... 50
olanzapine oral tablet,
disintegrating 5 mg ........... 50
OLYSIO ............................ 13
omega-3 acid ethyl esters ... 63
omeprazole magnesium .... 86
omeprazole oral capsule,
delayed release(dr/ec) ...... 86
omeprazole oral tablet,delayed
release (dr/ec) ................... 86
OMNITROPE ................... 87
ONCASPAR ..................... 29
once daily ........................ 126
ONCOVITE .................... 126
ondansetron hcl
intravenous ....................... 84
ondansetron hcl oral
solution ............................. 84
ondansetron hcl oral tablet 24
mg ..................................... 84
ondansetron hcl oral tablet 4
mg, 8 mg ........................... 84
ondansetron hcl (pf) injection
solution ............................. 84
ondansetron hcl (pf) injection
syringe .............................. 84
ondansetron odt ................ 84
one daily energy oral
tablet ............................... 126
one daily essential oral tablet
, 0.4 mg ........................... 126
one daily maximum ......... 126
one daily men's 50+ ........ 126
one daily multi-vit wmineral ............................ 126
one daily multivitamin oral
tablet ............................... 126
one daily oral tablet ........ 127
one daily plus iron .......... 127
one daily with iron .......... 127
ONE DAILY WOMEN 50
PLUS .............................. 127
one daily women's oral tablet
27-0.4 mg ........................ 127
ONFI ORAL
SUSPENSION .................. 35
ONFI ORAL TABLET 10
MG .................................... 35
Si tiene consultas, llame a Amerigroup STAR+PLUS MMP al 1-855-878-1784
(TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratis.
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TXDMKT-0101-16 SP 09.16 SP
157
ONFI ORAL TABLET 20
MG .................................... 35
OPCICON ONE-STEP ..... 95
OPDIVO ........................... 29
OPIUM TINCTURE ........ 80
OPTI-CLEAR ................... 99
oralyte ............................. 114
ORAP ............................... 50
ORAZINC ....................... 114
ORENCIA ........................ 91
ORENCIA (WITH
MALTOSE) ...................... 91
ORFADIN ORAL
CAPSULE ........................ 71
ORGAN-I NR ................. 105
ORTHO MICRONOR ...... 92
OS-CAL 500 + D3 .......... 114
OSTEO-PORETICAL .... 114
oxacillin injection ............. 20
oxacillin intravenous ........ 20
oxaliplatin intravenous recon
soln 100 mg ....................... 29
oxaliplatin intravenous recon
soln 50 mg ......................... 29
oxaliplatin intravenous
solution ............................. 29
oxandrolone oral tablet 10
mg ..................................... 78
oxandrolone oral tablet 2.5
mg ..................................... 79
oxaprozin .......................... 44
oxcarbazepine ................... 35
OXSORALEN .................. 65
OXTELLAR XR ORAL
TABLET EXTENDED
RELEASE 24 HR 150
MG .................................... 35
OXTELLAR XR ORAL
TABLET EXTENDED
RELEASE 24 HR 300
MG .................................... 35
OXTELLAR XR ORAL
TABLET EXTENDED
RELEASE 24 HR 600
MG .................................... 35
oxybutynin chloride oral
syrup ............................... 110
?
oxybutynin chloride oral
tablet ............................... 110
oxybutynin chloride oral tablet
extended release 24hr 10 mg,
15 mg .............................. 110
oxybutynin chloride oral tablet
extended release 24hr 5
mg ................................... 110
oxycodone oral capsule .... 41
oxycodone oral
concentrate ....................... 41
oxycodone oral tablet 10 mg,
5 mg .................................. 41
oxycodone oral tablet 15
mg ..................................... 41
oxycodone oral tablet 20 mg,
30 mg ................................ 41
oxycodone-acetaminophen
oral solution ...................... 41
oxycodone-acetaminophen
oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325
mg ..................................... 41
oxycodone-aspirin ............ 41
oysco 500/d oral tablet .... 114
oysco d ............................ 114
oysco-500 ........................ 114
oyster shell + d3 ............. 114
oyster shell calcium 500 ... 114
oyster shell calcium and
mag ................................. 114
oyster shell calcium with
d ...................................... 127
oyster shell calcium-vit
d3 .................................... 114
P
pacerone oral tablet 100 mg,
200 mg, 400 mg ................ 55
paclitaxel .......................... 29
pain and fever ................... 44
PAIN RELIEF SINUS
PE ................................... 105
paliperidone oral tablet
extended release 24hr 1.5
mg ..................................... 50
paliperidone oral tablet
extended release 24hr 3
mg ..................................... 51
paliperidone oral tablet
extended release 24hr 6
mg ..................................... 51
paliperidone oral tablet
extended release 24hr 9
mg ..................................... 51
pamidronate intravenous recon
soln ................................... 79
pamidronate intravenous
solution 30 mg/10 ml (3 mg/
ml), 90 mg/10 ml (9 mg/
ml) ..................................... 79
pamidronate intravenous
solution 60 mg/10 ml (6 mg/
ml) ..................................... 79
PANRETIN ....................... 65
pantoprazole intravenous ... 86
pantoprazole oral ............. 86
pantothenic acid ............. 127
paricalcitol oral ................ 79
PAROEX ORAL RINSE ... 73
paromomycin .................... 19
paroxetine hcl oral tablet 10
mg ..................................... 51
paroxetine hcl oral tablet 20
mg ..................................... 51
paroxetine hcl oral tablet 30
mg ..................................... 51
paroxetine hcl oral tablet 40
mg ..................................... 51
paroxetine hcl oral tablet
extended release 24 hr 12.5
mg ..................................... 51
paroxetine hcl oral tablet
extended release 24 hr 25
mg ..................................... 51
paroxetine hcl oral tablet
extended release 24 hr 37.5
mg ..................................... 51
PASER .............................. 19
PATADAY ......................... 97
PAXIL ORAL
SUSPENSION .................. 51
PAZEO .............................. 97
PEDIALYTE ADVANCED
CARE .............................. 114
pedialyte freezer pops ..... 114
pedialyte oral solution .... 114
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TXDMKT-0101-16 SP 09.16 SP
158
pedialyte singles .............. 114
pediatric cough and cold oral
liquid 1-15-5 mg/5 ml ..... 105
pediatric electrolyte oral
solution ........................... 114
pediatric freezer pops ..... 114
Pediatric mask for
inhaler ............................... 72
PEDVAX HIB (PF) .......... 89
peg 3350-electrolytes oral
recon soln 236-22.74-6.74 5.86 gram .......................... 84
peg 3350-electrolytes oral
recon soln 240-22.72-6.72 5.84 gram .......................... 85
peg-electrolyte soln ........... 85
peg3350 ............................ 85
PEGANONE ..................... 35
PEGASYS ........................ 87
PEGASYS PROCLICK .... 87
PEGINTRON ................... 87
PEGINTRON REDIPEN ... 87
PENICILLIN G POT IN
DEXTROSE ..................... 20
penicillin g potassium ....... 20
penicillin g procaine
intramuscular syringe 1.2
million unit/2 ml ............... 20
penicillin g procaine
intramuscular syringe 600,000
unit/ml ............................... 20
penicillin g sodium ........... 20
penicillin v potassium ....... 20
PENTAM .......................... 19
PENTASA ........................ 85
pentoxifylline .................... 62
PEPTIC RELIEF ORAL
TABLET,CHEWABLE ..... 80
PERFOROMIST ............. 109
PERIDIN-C .................... 127
perindopril erbumine ........ 59
periogard .......................... 73
PERJETA .......................... 29
permethrin topical cream ... 69
permethrin topical liquid ... 69
perphenazine ..................... 51
phenelzine ......................... 51
phenobarbital oral elixir ... 35
?
phenobarbital oral tablet 100
mg ..................................... 35
phenobarbital oral tablet 15
mg ..................................... 35
phenobarbital oral tablet 16.2
mg ..................................... 35
phenobarbital oral tablet 30
mg ..................................... 35
phenobarbital oral tablet 32.4
mg ..................................... 35
phenobarbital oral tablet 60
mg ..................................... 35
phenobarbital oral tablet 64.8
mg ..................................... 35
phenobarbital oral tablet 97.2
mg ..................................... 35
phenylhistine dh .............. 105
PHENYTEK ..................... 35
PHENYTOIN ORAL
SUSPENSION 100 MG/4
ML .................................... 35
phenytoin oral suspension 125
mg/5 ml ............................. 35
phenytoin oral tablet,
chewable ........................... 35
phenytoin sodium
extended ............................ 35
phenytoin sodium intravenous
solution ............................. 35
phenytoin sodium intravenous
syringe .............................. 35
PHOSPHOLINE
IODIDE ............................ 96
PICATO ............................ 65
PILOCARPINE HCL
OPHTHALMIC DROPS 1 %,
2 %, 4 % ........................... 97
pilocarpine hcl oral .......... 71
pimozide ............................ 51
pindolol ............................. 59
pink bismuth oral tablet,
chewable ........................... 80
pioglitazone oral tablet 15
mg ..................................... 77
pioglitazone oral tablet 30
mg ..................................... 77
pioglitazone oral tablet 45
mg ..................................... 77
pioglitazone-glimepiride .... 77
pioglitazone-metformin ..... 77
piperacillin-tazobactam .... 21
piroxicam .......................... 44
PLAN B ONE-STEP ........ 95
PLASMA-LYTE 148 ...... 117
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................... 117
podofilox ........................... 65
POLY HIST PD .............. 105
POLY-HIST DM
(THONZYLAMINE) ..... 105
poly-iron ......................... 127
poly-iron 150 forte .......... 127
POLY-VENT DM ORAL
TABLET 60-20-380
MG .................................. 105
POLY-VENT IR ORAL
TABLET 60-380 MG ..... 105
poly-vita .......................... 127
poly-vita (iron) ................ 127
poly-vitamin .................... 127
poly-vitamin with iron ..... 127
poly-vitamins .................. 127
POLYCIN ......................... 96
polyethylene glycol 3350 oral
powder .............................. 85
polyethylene glycol 3350 oral
powder in packet ............... 85
polymyxin b sulftrimethoprim ..................... 96
polyvitamin/iron .............. 127
POMALYST ORAL
CAPSULE 1 MG .............. 29
POMALYST ORAL
CAPSULE 2 MG .............. 29
POMALYST ORAL
CAPSULE 3 MG, 4 MG ... 29
portia ................................ 95
PORTRAZZA ................... 29
potassium chlorid-d50.45%nacl intravenous
parenteral solution 10 meq/l,
30 meq/l, 40 meq/l ........... 114
potassium chlorid-d50.45%nacl intravenous
parenteral solution 20 meq/
l ....................................... 114
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TXDMKT-0101-16 SP 09.16 SP
159
potassium chloride in
0.9%nacl intravenous
parenteral solution 20 meq/
l ....................................... 115
potassium chloride in 5 % dex
intravenous parenteral
solution 20 meq/l, 30 meq/l, 40
meq/l ............................... 115
potassium chloride in lr-d5
intravenous parenteral
solution 20 meq/l ............. 115
potassium chloride in lr-d5
intravenous parenteral
solution 40 meq/l ............. 115
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
meq/100 ml, 40 meq/100
ml .................................... 115
POTASSIUM CHLORIDE
INTRAVENOUS
PIGGYBACK 10 MEQ/50
ML .................................. 115
POTASSIUM CHLORIDE
INTRAVENOUS
PIGGYBACK 20 MEQ/50
ML, 30 MEQ/100 ML .... 115
potassium chloride intravenous
solution ........................... 115
potassium chloride oral
capsule, extended
release ............................. 115
potassium chloride oral tablet
extended release .............. 115
potassium chloride oral tablet,
er particles/crystals ........ 115
potassium chloride-0.45 %
nacl ................................. 115
potassium chloride-d50.2%nacl intravenous
parenteral solution 20 meq/
l ....................................... 115
potassium chloride-d50.2%nacl intravenous
parenteral solution 30 meq/l,
40 meq/l .......................... 115
potassium chloride-d50.3%nacl intravenous
?
parenteral solution 20 meq/
l ....................................... 115
potassium chloride-d50.9%nacl intravenous
parenteral solution 20 meq/
l ....................................... 115
potassium chloride-d50.9%nacl intravenous
parenteral solution 40 meq/
l ....................................... 115
potassium citrate oral tablet
extended release 10 meq (1,
080 mg), 5 meq (540
mg) .................................. 111
POTIGA ORAL TABLET 200
MG, 300 MG, 400 MG ..... 36
POTIGA ORAL TABLET 50
MG .................................... 36
povidone-iodine topical
ointment ............................ 66
povidone-iodine topical
solution 10 % .................... 66
PRADAXA ....................... 62
PRALUENT PEN ............. 63
PRALUENT SYRINGE .... 63
pramipexole oral tablet .... 37
pravastatin ........................ 63
prazosin oral ..................... 59
prednisolone acetate ......... 98
prednisolone oral solution 15
mg/5 ml ............................. 74
prednisolone sodium
phosphate ophthalmic ....... 98
prednisolone sodium
phosphate oral solution 15 mg/
5 ml (3 mg/ml), 5 mg base/5 ml
(6.7 mg/5 ml) .................... 74
prednisolone sodium
phosphate oral tablet,
disintegrating .................... 74
prednisone intensol ........... 74
prednisone oral ................. 74
PREMARIN ORAL .......... 92
PREMARIN VAGINAL .... 92
PREMPRO ....................... 92
prenatal vitamin oral
tablet ............................... 127
prevalite ............................ 63
PREVENT ...................... 127
previfem ............................ 95
PREZCOBIX .................... 13
PREZISTA ORAL
SUSPENSION .................. 13
PREZISTA ORAL TABLET
150 MG ............................. 13
PREZISTA ORAL TABLET
600 MG, 800 MG ............. 13
PREZISTA ORAL TABLET
75 MG ............................... 13
PRIFTIN ........................... 19
PRIMAQUINE ................. 19
primidone .......................... 36
PRIVIGEN ....................... 89
PRO FE ........................... 127
PROAIR HFA ................. 109
PROAIR RESPICLICK ... 109
probenecid ........................ 90
procainamide injection
solution 100 mg/ml ........... 55
procainamide injection
solution 500 mg/ml ........... 55
prochlorperazine edisylate
injection solution 10 mg/2 ml
(5 mg/ml) .......................... 85
prochlorperazine maleate
oral ................................... 85
prochlorperazine maleate
rectal ................................. 85
PROCRIT ......................... 87
procto-pak ......................... 85
proctosol hc ...................... 85
proctozone-hc ................... 85
PROFERRIN ES ............ 127
PROFERRIN-FORTE .... 127
progesterone micronized .... 92
PROGLYCEM .................. 77
PROGRAF
INTRAVENOUS .............. 29
PROLASTIN-C ................ 71
PROLEUKIN ................... 87
PROLIA ............................ 90
PROMACTA ORAL TABLET
12.5 MG, 25 MG, 75
MG .................................... 62
PROMACTA ORAL TABLET
50 MG ............................... 62
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TXDMKT-0101-16 SP 09.16 SP
160
promethazine injection
solution ........................... 106
promethazine oral tablet 12.5
mg, 25 mg ....................... 106
promethazine vccodeine ............................ 106
promethazine-codeine ..... 106
promethazine-dm ............ 106
PROMETHEGAN RECTAL
SUPPOSITORY 12.5
MG .................................. 106
propafenone oral tablet .... 55
propranolol intravenous .... 59
propranolol oral ............... 59
propranololhydrochlorothiazid ............ 59
propylthiouracil ................ 74
PROQUAD (PF) ............... 89
PROTECT IRON ............ 127
PROTONIX
INTRAVENOUS .............. 86
protriptyline ...................... 51
pseudoephedrine hcl oral
liquid ............................... 106
pseudoephedrine hcl oral
tablet 30 mg .................... 106
pseudoephedrineguaifenesin ...................... 106
PULMOZYME ............... 109
PURALUBE ..................... 97
PURIXAN ........................ 29
pyrazinamide .................... 19
pyridostigmine bromide .... 39
pyridoxine (vitamin b6) oral
tablet 100 mg, 25 mg, 50
mg ................................... 127
pyrilamine-phenylephrine oral
tablet ............................... 106
Q
q-dryl oral capsule ......... 106
q-dryl oral liquid ............ 106
q-pap extra strength .......... 44
q-pap oral drops ............... 44
q-pap oral liquid ............... 44
q-pap oral tablet 325 mg ... 44
q-pap oral tablet 500 mg ... 44
q-tussin ........................... 106
q-tussin dm ...................... 106
?
QUADRACEL (PF) ......... 89
quenalin .......................... 106
quetiapine oral tablet 100
mg ..................................... 51
quetiapine oral tablet 200
mg ..................................... 51
quetiapine oral tablet 25
mg ..................................... 51
quetiapine oral tablet 300
mg ..................................... 51
quetiapine oral tablet 400
mg ..................................... 51
quetiapine oral tablet 50
mg ..................................... 51
quinapril ........................... 59
quinaprilhydrochlorothiazide .......... 59
quinidine sulfate oral tablets
oral tablet 200 mg, 300
mg ..................................... 55
QVAR INHALATION
AEROSOL 40 MCG/
ACTUATION ................. 110
QVAR INHALATION
AEROSOL 80 MCG/
ACTUATION ................. 110
R
RABANO YODADO ..... 127
RABAVERT (PF) ............. 89
raloxifene .......................... 90
ramipril ............................. 59
RANEXA ......................... 63
ranitidine hcl injection ...... 86
ranitidine hcl oral syrup .... 86
ranitidine hcl oral tablet 150
mg, 300 mg ....................... 86
ranitidine hcl oral tablet 75
mg ..................................... 87
RAPAMUNE ORAL
SOLUTION ...................... 29
RAVICTI .......................... 71
REBIF REBIDOSE .......... 88
REBIF TITRATION
PACK ................................ 88
REBIF (WITH
ALBUMIN) ...................... 88
reclipsen (28) .................... 95
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION .................. 89
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SYRINGE 10 MCG/ML .... 89
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SYRINGE 5 MCG/0.5
ML .................................... 89
REFRESH CELLUVISC ... 97
REFRESH LACRILUBE ................................ 97
REFRESH PLUS .............. 97
reguloid oral capsule ........ 85
RELENZA
DISKHALER ................... 13
RELISTOR
SUBCUTANEOUS
SOLUTION ...................... 85
RELISTOR
SUBCUTANEOUS
SYRINGE ......................... 85
REMICADE ..................... 85
rena-vite .......................... 127
RENAGEL ....................... 71
RENVELA ORAL POWDER
IN PACKET 0.8 GRAM .... 71
RENVELA ORAL POWDER
IN PACKET 2.4 GRAM .... 71
RENVELA ORAL
TABLET ........................... 71
repaglinide-metformin ...... 77
REPATHA
SURECLICK .................... 63
REPATHA SYRINGE ...... 63
REPEL SPORTSMEN ...... 69
REPEL SPORTSMEN
MAX ................................. 65
RESCON ........................ 106
RESCON-DM ................. 106
rescon-gg ........................ 106
RESCRIPTOR ORAL
TABLET ........................... 13
RESCRIPTOR ORAL
TABLET,
DISPERSIBLE ................. 13
RESPAIRE-30 ................ 106
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TXDMKT-0101-16 SP 09.16 SP
161
RESTASIS ........................ 97
restfully sleep .................. 106
RETROVIR
INTRAVENOUS .............. 13
REVLIMID ORAL CAPSULE
10 MG ............................... 29
REVLIMID ORAL CAPSULE
15 MG, 2.5 MG, 20 MG, 25
MG .................................... 29
REVLIMID ORAL CAPSULE
5 MG ................................. 29
REXULTI ORAL TABLET
0.25 MG, 0.5 MG, 1 MG, 2
MG .................................... 51
REXULTI ORAL TABLET 3
MG, 4 MG ........................ 51
REYATAZ ORAL CAPSULE
150 MG, 200 MG ............. 13
REYATAZ ORAL CAPSULE
300 MG ............................. 13
REYATAZ ORAL POWDER
IN PACKET ...................... 14
REZIRA .......................... 106
ribasphere oral capsule .... 14
ribasphere oral tablet 200
mg ..................................... 14
ribavirin oral capsule ....... 14
ribavirin oral tablet 200
mg ..................................... 14
riboflavin (vitamin b2) oral
tablet 100 mg .................. 127
RIDAURA ........................ 91
rifabutin ............................ 19
rifampin ............................ 19
RIFATER .......................... 19
riluzole .............................. 71
rimantadine ....................... 14
ringers intravenous ......... 115
ringers irrigation .............. 70
risacal-d .......................... 127
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25
MG/2 ML, 37.5 MG/2
ML .................................... 52
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 50 MG/2 ML ... 52
?
risperidone oral solution ... 52
risperidone oral tablet 0.25
mg ..................................... 52
risperidone oral tablet 0.5
mg ..................................... 52
risperidone oral tablet 1
mg ..................................... 52
risperidone oral tablet 2
mg ..................................... 52
risperidone oral tablet 3
mg ..................................... 52
risperidone oral tablet 4
mg ..................................... 52
risperidone oral tablet,
disintegrating 0.25 mg ...... 52
risperidone oral tablet,
disintegrating 0.5 mg ........ 52
risperidone oral tablet,
disintegrating 1 mg ........... 52
risperidone oral tablet,
disintegrating 2 mg ........... 52
risperidone oral tablet,
disintegrating 3 mg ........... 52
risperidone oral tablet,
disintegrating 4 mg ........... 52
RITUXAN ........................ 29
rivastigmine ...................... 38
rivastigmine tartrate ......... 38
rizatriptan ......................... 37
robafen ............................ 106
robafen cf
(phenylephrine) ............... 106
robafen cough ................. 106
robafen dm ...................... 106
robafen dm cough ........... 106
robafen dm cough-chest
congest ............................ 106
ropinirole oral tablet ........ 37
ROSADAN TOPICAL
CREAM ............................ 66
rosuvastatin ....................... 63
ROTARIX ......................... 89
ROTATEQ VACCINE ...... 89
roweepra ........................... 36
ROZEREM ....................... 52
RU-HIST D .................... 106
RULOX ............................ 85
RYMED
(DEXCHLORPHENIRAMINEPE) .................................. 106
rynex dm ......................... 107
rynex pe .......................... 107
rynex pse ......................... 107
S
S2
RACEPINEPHRINE ...... 110
SABRIL ............................ 36
sani-supp (adult) ............... 85
sani-supp (infant) .............. 85
SANTYL .......................... 69
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 10 MG ............... 52
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 2.5 MG .............. 52
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 5 MG ................. 52
SAVELLA ORAL TABLET
100 MG ............................. 91
SAVELLA ORAL TABLET
12.5 MG ............................ 91
SAVELLA ORAL TABLET
25 MG ............................... 91
SAVELLA ORAL TABLET
50 MG ............................... 91
SAVELLA ORAL TABLETS,
DOSE PACK .................... 91
se-tan plus ....................... 127
selegiline hcl ..................... 37
selenium oral tablet 100 mcg,
50 mcg ............................. 115
selenium oral tablet 200
mcg .................................. 115
selenium oral tablet,delayed
release (dr/ec) ................. 115
selenium sulfide topical
lotion ................................. 64
SELZENTRY ................... 14
senexon ............................. 85
SENIOR TABS ............... 127
senna lax ........................... 85
senna oral syrup 8.8 mg/5
ml ...................................... 85
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TXDMKT-0101-16 SP 09.16 SP
162
senna oral tablet ............... 85
SENNA PLUS .................. 85
senna with docusate
sodium ............................... 85
SENNALAX-S ................. 85
SENSIPAR ORAL TABLET
30 MG, 60 MG ................. 79
SENSIPAR ORAL TABLET
90 MG ............................... 79
sentry oral tablet 18-500-300250 mg-mcg-mcg-mcg .... 128
SENTRY SENIOR ORAL
TABLET 500-300-250
MCG ............................... 128
SEREVENT DISKUS .... 110
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 150
MG .................................... 52
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 200
MG .................................... 52
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 300
MG .................................... 52
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 400
MG .................................... 53
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 50
MG .................................... 53
sertraline oral
concentrate ....................... 53
sertraline oral tablet 100
mg ..................................... 53
sertraline oral tablet 25
mg ..................................... 53
sertraline oral tablet 50
mg ..................................... 53
SIDEROL ORAL
TABLET ......................... 128
SIGNIFOR ........................ 29
siladryl sa ....................... 107
sildenafil oral .................. 110
?
silphen cough .................. 107
siltussin dm das ............... 107
siltussin sa ...................... 107
siltussin-dm ..................... 107
silver sulfadiazine ............. 64
simethicone oral capsule 180
mg ..................................... 85
simethicone oral drops,
suspension ......................... 85
SIMPONI .......................... 91
SIMULECT INTRAVENOUS
RECON SOLN 10 MG ..... 30
SIMULECT INTRAVENOUS
RECON SOLN 20 MG ..... 30
simvastatin ........................ 63
sirolimus ........................... 30
SIRTURO ......................... 19
sleep aid (doxylamine) ...... 53
SLO-NIACIN ORAL
TABLET EXTENDED
RELEASE 250 MG .......... 63
slo-niacin oral tablet extended
release 500 mg .................. 63
slow release iron oral tablet
extended release 143 mg (45
mg iron), 47.5 mg iron .... 128
SLOW RELEASE IRON
ORAL TABLET EXTENDED
RELEASE 159 MG (45 MG
IRON) ............................. 128
SLOW-MAG .................. 116
sodium bicarbonate oral .... 86
sodium chloride 0.45 %
intravenous parenteral
solution ........................... 116
SODIUM CHLORIDE 0.45 %
INTRAVENOUS
PIGGYBACK ................. 116
sodium chloride 0.9 %
intravenous ....................... 71
SODIUM CHLORIDE 0.9 %
INTRAVENOUS .............. 71
sodium chloride 3 % ....... 116
sodium chloride 5 % ....... 116
sodium chloride
intravenous ..................... 116
sodium chloride
irrigation ........................... 72
sodium chloride
ophthalmic ........................ 97
sodium fluoride oral
tablet ............................... 128
sodium fluoride oral tablet,
chewable 1 mg fluoride (2.2
mg) .................................. 128
sodium polystyrene sulfonate
oral powder ...................... 72
sodium polystyrene sulfonate
oral suspension ................. 72
sodium polystyrene sulfonate
rectal ................................. 72
SODIUM POLYSTYRENE
SULFONATE RECTAL .... 72
sodium polystyrene (sorb
free) ................................... 72
SOLTAMOX ..................... 30
SOMATULINE DEPOT .... 30
SOMAVERT ..................... 79
SORE THROAT AND
COUGH .......................... 107
sorine oral tablet 120 mg, 160
mg, 80 mg ......................... 55
sorine oral tablet 240 mg ... 55
sotalol af oral tablet 120
mg ..................................... 55
SOTALOL AF ORAL
TABLET 160 MG, 80
MG .................................... 55
sotalol oral tablet 120
mg ..................................... 55
sotalol oral tablet 160 mg, 240
mg, 80 mg ......................... 55
SOVALDI ......................... 14
spectravite adult 50+ oral
tablet ............................... 128
spectravite advanced formula
oral tablet 18-400 mgmcg ................................. 128
spectravite men's ............. 128
spectravite senior oral tablet
500-300-250 mcg ............ 128
spectravite ultra women ... 128
SPECTRAVITE ULTRA
WOMEN'S SR ................ 128
SPIRIVA RESPIMAT ..... 110
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TXDMKT-0101-16 SP 09.16 SP
163
SPIRIVA WITH
HANDIHALER .............. 110
spironolactonhydrochlorothiaz ............... 59
spironolactone .................. 59
sprintec (28) ...................... 95
SPRITAM ORAL TABLET
FOR SUSPENSION 1,000
MG, 250 MG, 500 MG ..... 36
SPRITAM ORAL TABLET
FOR SUSPENSION 750
MG .................................... 36
SPRYCEL ......................... 30
SPS ORAL ........................ 72
SPS RECTAL ................... 72
ssd ..................................... 64
STAHIST AD ORAL
LIQUID .......................... 107
STAHIST AD ORAL
TABLET ......................... 107
stavudine oral capsule 15 mg,
20 mg ................................ 14
stavudine oral capsule 30 mg,
40 mg ................................ 14
stavudine oral recon soln ... 14
STIMATE ......................... 79
STIOLTO RESPIMAT .... 110
STIVARGA ...................... 30
stool softener oral capsule 100
mg, 240 mg ....................... 86
STRATTERA ORAL
CAPSULE 10 MG, 18 MG, 25
MG, 40 MG ...................... 53
STRATTERA ORAL
CAPSULE 100 MG, 60 MG,
80 MG ............................... 53
strawberry c .................... 128
STREPTOMYCIN
INTRAMUSCULAR ........ 19
stress formula .................. 128
STRESS FORMULA 600
C ..................................... 128
stress formula
advanced ......................... 128
STRESS FORMULA
ENERGY ........................ 128
stress formula with iron ... 128
?
stress formula with iron
(sulf) ................................ 128
stress formula with zinc ... 128
STRIBILD ........................ 14
STROVITE FORTE ....... 128
STROVITE ONE ............ 128
SUBOXONE SUBLINGUAL
FILM 12-3 MG ................. 44
SUBOXONE SUBLINGUAL
FILM 2-0.5 MG ................ 44
SUBOXONE SUBLINGUAL
FILM 4-1 MG ................... 44
SUBOXONE SUBLINGUAL
FILM 8-2 MG ................... 44
sucralfate oral tablet ........ 87
sudogest .......................... 107
sudogest 12-hour ............ 107
sudogest pe ..................... 107
sudogest sinus and
allergy ............................. 107
sulfacetamide sodium
ophthalmic drops .............. 98
sulfacetamide sodium
(acne) ................................ 66
sulfacetamideprednisolone ..................... 98
sulfadiazine oral ............... 21
sulfamethoxazoletrimethoprim ..................... 21
SULFAMYLON TOPICAL
CREAM ............................ 67
sulfasalazine ..................... 86
sulindac oral ..................... 44
sumatriptan succinate
oral ................................... 37
sumatriptan succinate
subcutaneous cartridge .... 37
sumatriptan succinate
subcutaneous pen
injector .............................. 37
sumatriptan succinate
subcutaneous solution ...... 37
sumatriptan succinate
subcutaneous syringe 6 mg/0.5
ml ...................................... 37
SUPER B COMPLEX +
C ..................................... 128
super b complex-vitamin
c ...................................... 128
SUPER B-50
COMPLEX ..................... 129
super b/c ......................... 129
SUPER CALCIUM ........ 116
SUPER MULTIPLE ORAL
TABLET ......................... 129
SUPER
MULTIVITAMIN ........... 129
super thera vite m ........... 129
superplex-t ...................... 129
SUPERVITE (EC) .......... 129
support ............................ 129
SUPPORT-500 ............... 129
SURMONTIL ................... 53
SUSPENDOL-S ............... 72
SUSTIVA ORAL CAPSULE
200 MG ............................. 14
SUSTIVA ORAL CAPSULE
50 MG ............................... 14
SUSTIVA ORAL
TABLET ........................... 14
SUTENT ORAL CAPSULE
12.5 MG ............................ 30
SUTENT ORAL CAPSULE
25 MG, 37.5 MG, 50
MG .................................... 30
SYEDA ............................. 95
SYLATRON ..................... 88
SYMLINPEN 120 ............ 77
SYMLINPEN 60 .............. 77
SYNAGIS ......................... 14
SYNAREL ........................ 79
SYNERCID ...................... 19
SYNJARDY ..................... 77
SYNRIBO ......................... 30
SYNTHROID ................... 80
SYPRINE ......................... 72
T
tab-a-vite ......................... 129
tab-a-vite-minerals ......... 129
tab-a-vite/iron ................. 129
TABLOID ......................... 30
tacrolimus oral .................. 30
tacrolimus topical ............. 65
TAFINLAR ....................... 30
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TXDMKT-0101-16 SP 09.16 SP
164
TAGRISSO ORAL TABLET
40 MG ............................... 30
TAGRISSO ORAL TABLET
80 MG ............................... 30
TAMIFLU ......................... 14
tamoxifen .......................... 30
tamsulosin ....................... 111
TANDEM DUAL
ACTION ......................... 129
TANDEM PLUS ............. 129
TANZEUM ....................... 77
TARCEVA ORAL TABLET
100 MG, 150 MG ............. 30
TARCEVA ORAL TABLET
25 MG ............................... 30
TARGRETIN ORAL ........ 30
TARGRETIN TOPICAL ... 30
taron forte ....................... 129
TASIGNA ......................... 30
TAZORAC ........................ 66
taztia xt ............................. 59
TECENTRIQ .................... 30
TECFIDERA .................... 38
TECHNIVIE ..................... 14
TEFLARO ........................ 16
TEKTURNA ..................... 59
TEKTURNA HCT ............ 59
telmisartan oral tablet 20 mg,
40 mg ................................ 59
telmisartan oral tablet 80
mg ..................................... 59
telmisartan-amlodipine ..... 59
telmisartan-hydrochlorothiazid
oral tablet 40-12.5 mg, 80-25
mg ..................................... 59
telmisartan-hydrochlorothiazid
oral tablet 80-12.5 mg ...... 59
temazepam oral capsule 15
mg, 22.5 mg, 30 mg .......... 53
terazosin ........................... 59
terbinafine hcl oral ........... 10
terbinafine hcl topical ....... 67
terbutaline oral ............... 110
terbutaline
subcutaneous ................... 110
terconazole ........................ 92
testosterone cypionate ...... 79
testosterone enanthate ...... 79
?
testosterone transdermal
gel ..................................... 79
testosterone transdermal gel
in metered-dose pump 1.25
gram/ actuation (1 %) ...... 79
testosterone transdermal gel
in metered-dose pump 10 mg/
0.5 gram /actuation .......... 79
testosterone transdermal gel
in packet 1 % (25 mg/
2.5gram) ........................... 79
testosterone transdermal gel
in packet 1 % (50 mg/5
gram) ................................ 79
tetanus,diphtheria tox ped
(pf) .................................... 89
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 89
tetrabenazine oral tablet 12.5
mg ..................................... 38
tetrabenazine oral tablet 25
mg ..................................... 38
tetracycline ....................... 22
THALOMID ORAL
CAPSULE 100 MG, 50
MG .................................... 30
THALOMID ORAL
CAPSULE 150 MG, 200
MG .................................... 30
theophylline oral tablet
extended release .............. 110
theophylline oral tablet
extended release 12 hr .... 110
thera ................................ 129
thera m plus (ferrous
fumarat) .......................... 129
thera vitamin ................... 129
thera-gesic topical cream 151 % .................................... 65
thera-m oral tablet .......... 129
thera-m oral tablet 9 mg iron400 mcg .......................... 129
thera-tabs ........................ 129
therapeutic liquid ............ 129
therapeutic m + betacarotene .......................... 129
therapeutic-m oral tablet 9 mg
iron-400 mcg ................... 129
therapeutic-m vitamin/
minerals oral tablet 27-0.4
mg ................................... 129
theratrum complete with
lutein ............................... 129
therems ............................ 129
THEREMS-H ................. 129
therems-m ....................... 129
thiamine hcl (vitamin b1) oral
tablet 100 mg, 250 mg .... 130
thioridazine ....................... 53
thiotepa ............................. 30
thiothixene ........................ 53
THYMOGLOBULIN ....... 89
THYROSAFE ................... 74
tiagabine ........................... 36
TICE BCG ........................ 89
TIKOSYN ......................... 55
timolol maleate
ophthalmic ........................ 96
timolol maleate oral ......... 59
TIMOPTIC OCUDOSE
(PF) ................................... 96
tioconazole-1 .................... 92
TIVICAY ORAL TABLET 10
MG, 25 MG ...................... 14
TIVICAY ORAL TABLET 50
MG .................................... 14
tizanidine oral tablet ......... 39
tobramycin ........................ 96
tobramycin in 0.225 %
nacl ................................... 19
tobramycin sulfate injection
recon soln .......................... 19
tobramycin sulfate injection
solution ............................. 19
tobramycin-dexamethasone
ophthalmic suspension ...... 98
tolazamide oral tablet 250
mg ..................................... 77
tolazamide oral tablet 500
mg ..................................... 77
tolbutamide ....................... 77
tolcapone .......................... 37
tolmetin ............................. 44
tolnaftate topical cream .... 67
tolnaftate topical powder ... 67
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TXDMKT-0101-16 SP 09.16 SP
165
tolterodine oral capsule,
extended release 24hr ..... 110
tolterodine oral tablet ..... 111
topiramate oral capsule,
sprinkle ............................. 36
topiramate oral tablet 100
mg ..................................... 36
topiramate oral tablet 200
mg ..................................... 36
topiramate oral tablet 25
mg ..................................... 36
topiramate oral tablet 50
mg ..................................... 36
toposar .............................. 30
topotecan intravenous recon
soln ................................... 30
TOPOTECAN
INTRAVENOUS
SOLUTION ...................... 31
TORISEL .......................... 31
torsemide oral ................... 59
total b/c ........................... 130
TOTALDAY
MULTIPLE ..................... 130
TOUJEO SOLOSTAR ...... 77
TOVIAZ .......................... 111
TRACLEER .................... 110
TRADJENTA ................... 77
tramadol oral tablet .......... 44
tramadol-acetaminophen ... 44
trandolapril ....................... 59
tranexamic acid
intravenous ....................... 62
tranexamic acid oral ......... 93
tranylcypromine ................ 53
travasol 10 % .................. 117
TRAVATAN Z ................... 98
travel sickness ................... 86
TRAVEL SICKNESS
(MECLIZINE) .................. 86
trazodone .......................... 53
TREANDA INTRAVENOUS
RECON SOLN ................. 31
TRECATOR ...................... 19
TRELSTAR
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION ........ 31
?
TRELSTAR
INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML,
3.75 MG/2 ML .................. 31
TRELSTAR
INTRAMUSCULAR
SYRINGE 22.5 MG/2
ML .................................... 31
tretinoin topical cream ...... 66
tretinoin topical gel 0.01 %,
0.025 % ............................. 66
tretinoin (chemotherapy) ... 31
TREXALL ........................ 31
tri-previfem (28) ................ 95
tri-sprintec (28) ................ 95
TRI-VI-SOL ................... 130
tri-vita ............................. 130
tri-vitamin ....................... 130
triamcinolone acetonide
dental ................................ 73
triamcinolone acetonide
injection suspension 10 mg/
ml ...................................... 74
triamcinolone acetonide
injection suspension 40 mg/
ml ...................................... 74
triamcinolone acetonide
topical cream .................... 69
triamcinolone acetonide
topical lotion ..................... 69
triamcinolone acetonide
topical ointment 0.025 %, 0.1
%, 0.5 % ........................... 69
triamterenehydrochlorothiazid oral
capsule 37.5-25 mg ........... 59
triamterenehydrochlorothiazid oral
tablet ................................. 60
trianex ............................... 69
TRIBENZOR .................... 60
triderm topical cream ....... 69
trifluoperazine .................. 53
trifluridine ......................... 96
trimethoprim ..................... 22
TRINTELLIX ORAL
TABLET 10 MG ............... 53
TRINTELLIX ORAL
TABLET 20 MG ............... 53
TRINTELLIX ORAL
TABLET 5 MG ................. 53
triple antibiotic plus .......... 67
triple antibiotic topical
ointment ............................ 67
triple antibiotic topical
ointment in packet ............. 67
TRISENOX ...................... 31
TRIUMEQ ........................ 14
trivora (28) ....................... 95
trixaicin ............................. 65
TRIXAICIN HP ................ 65
TROPHAMINE 10 % ..... 117
TROPHAMINE 6% ........ 117
trospium oral tablet ......... 111
TRULICITY ..................... 77
TRUMENBA .................... 89
TRUVADA ORAL TABLET
100-150 MG, 133-200 MG,
167-250 MG ..................... 14
TRUVADA ORAL TABLET
200-300 MG ..................... 14
tussin dm oral liquid ....... 107
tussin dm oral syrup 10-100
mg/5 ml ........................... 107
tussin expectorant ........... 107
tussin oral liquid ............. 107
TUSSIONEX PENNKINETIC
ER ................................... 107
TWINRIX (PF) ................. 89
TYBOST ........................... 14
TYGACIL ......................... 19
TYKERB .......................... 31
TYPHIM VI
INTRAMUSCULAR
SOLUTION ...................... 90
TYPHIM VI
INTRAMUSCULAR
SYRINGE ......................... 90
TYSABRI ......................... 38
TYZEKA .......................... 14
TYZINE NASAL DROPS
0.05 % ............................... 73
U
ULORIC ........................... 90
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TXDMKT-0101-16 SP 09.16 SP
166
ULTRA B-100 COMPLEX
ORAL TABLET ............. 130
unicomplex-m ................. 130
UNITHROID ORAL TABLET
100 MCG, 112 MCG, 125
MCG, 150 MCG, 175 MCG,
200 MCG, 25 MCG, 300
MCG, 50 MCG, 75 MCG, 88
MCG ................................. 80
UNITUXIN ....................... 31
ursodiol ............................. 86
UVADEX .......................... 65
V
v-c forte ........................... 130
valacyclovir ...................... 14
VALCHLOR ..................... 65
valganciclovir ................... 14
valproate sodium .............. 36
valproic acid ..................... 36
valproic acid (as sodium salt)
oral solution 250 mg/5
ml ...................................... 36
VALPROIC ACID (AS
SODIUM SALT) ORAL
SOLUTION 250 MG/5 ML (5
ML), 500 MG/10 ML (10
ML) ................................... 36
valsartan oral tablet 160
mg ..................................... 60
valsartan oral tablet 320
mg ..................................... 60
valsartan oral tablet 40 mg, 80
mg ..................................... 60
valsartanhydrochlorothiazide .......... 60
VANACOF ..................... 107
VANAHIST PD .............. 107
VANCOMYCIN IN 0.9%
SODIUM CL
INTRAVENOUS
PIGGYBACK 500 MG/100
ML, 750 MG/150 ML ....... 22
vancomycin in dextrose 5 %
intravenous piggyback 1 gram/
200 ml ............................... 22
vancomycin in dextrose 5 %
intravenous piggyback 500 mg/
100 ml ............................... 22
?
VANCOMYCIN IN
DEXTROSE 5 %
INTRAVENOUS
PIGGYBACK 750 MG/150
ML .................................... 22
vancomycin intravenous .... 22
VANCOMYCIN
INTRAVENOUS .............. 22
vancomycin oral capsule 125
mg ..................................... 22
vancomycin oral capsule 250
mg ..................................... 22
VAQTA (PF)
INTRAMUSCULAR
SUSPENSION .................. 90
VAQTA (PF)
INTRAMUSCULAR
SYRINGE ......................... 90
VARIVAX (PF) ................. 90
VARIZIG .......................... 90
VASCEPA ......................... 63
VECAMYL ...................... 63
VECTIBIX ....................... 31
VELCADE ....................... 31
velivet triphasic regimen
(28) ................................... 95
VENCLEXTA ORAL
TABLET 10 MG ............... 31
VENCLEXTA ORAL
TABLET 100 MG ............. 31
VENCLEXTA ORAL
TABLET 50 MG ............... 31
VENCLEXTA STARTING
PACK ................................ 31
venlafaxine oral capsule,
extended release 24hr 150
mg ..................................... 53
venlafaxine oral capsule,
extended release 24hr 37.5
mg ..................................... 53
venlafaxine oral capsule,
extended release 24hr 75
mg ..................................... 53
venlafaxine oral tablet 100
mg ..................................... 53
venlafaxine oral tablet 25
mg ..................................... 53
venlafaxine oral tablet 37.5
mg ..................................... 54
venlafaxine oral tablet 50
mg ..................................... 54
venlafaxine oral tablet 75
mg ..................................... 54
venlafaxine oral tablet
extended release 24hr 150
mg ..................................... 54
venlafaxine oral tablet
extended release 24hr 37.5
mg ..................................... 54
venlafaxine oral tablet
extended release 24hr 75
mg ..................................... 54
VENTAVIS ..................... 110
VENTOLIN HFA ........... 110
verapamil intravenous
solution ............................. 60
verapamil intravenous
syringe .............................. 60
verapamil oral capsule, 24 hr
er pellet ct ......................... 60
verapamil oral capsule,ext rel.
pellets 24 hr ...................... 60
verapamil oral tablet ........ 60
verapamil oral tablet extended
release 120 mg (24
hours) ................................ 60
verapamil oral tablet extended
release 120 mg, 180 mg, 240
mg ..................................... 60
VERSACLOZ ................... 54
VESICARE ..................... 111
VIC-FORTE ................... 130
VICTOZA 2-PAK ............. 77
VICTOZA 3-PAK ............. 77
VIDEX 2 GRAM
PEDIATRIC ...................... 14
VIDEX 4 GRAM
PEDIATRIC ...................... 14
VIEKIRA PAK ................. 15
VIGAMOX ....................... 96
VIIBRYD ORAL TABLET 10
MG .................................... 54
VIIBRYD ORAL TABLET 20
MG .................................... 54
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TXDMKT-0101-16 SP 09.16 SP
167
VIIBRYD ORAL TABLET 40
MG .................................... 54
VIIBRYD ORAL TABLETS,
DOSE PACK 10 MG (7)- 20
MG (23) ............................ 54
VIMPAT
INTRAVENOUS .............. 36
VIMPAT ORAL
SOLUTION ...................... 36
VIMPAT ORAL TABLET
100 MG ............................. 36
VIMPAT ORAL TABLET
150 MG ............................. 36
VIMPAT ORAL TABLET
200 MG ............................. 36
VIMPAT ORAL TABLET 50
MG .................................... 36
vinblastine intravenous
solution ............................. 31
VINCASAR PFS
INTRAVENOUS SOLUTION
1 MG/ML .......................... 31
VINCASAR PFS
INTRAVENOUS SOLUTION
2 MG/2 ML ....................... 31
vincristine ......................... 31
vinorelbine ........................ 31
VIORELE (28) ................. 95
VIRACEPT ORAL TABLET
250 MG ............................. 15
VIRACEPT ORAL TABLET
625 MG ............................. 15
VIRAMUNE XR ORAL
TABLET EXTENDED
RELEASE 24 HR 100
MG .................................... 15
VIRAZOLE ...................... 15
VIREAD ORAL
POWDER ......................... 15
VIREAD ORAL
TABLET ........................... 15
VIRTUSSIN AC ............. 107
VITA-BEE WITH C ....... 130
vitamin a oral capsule 10,000
unit .................................. 130
vitamin a oral capsule 8,000
unit .................................. 130
vitamin b complex ........... 130
?
vitamin b complex with
c ...................................... 130
vitamin b-1 ...................... 130
vitamin b-12 oral tablet ... 130
vitamin b-12 oral tablet
extended release 1,000
mcg ................................. 130
vitamin b-12 oral tablet
extended release 2,000
mcg ................................. 130
vitamin b-12 sublingual tablet
2,500 mcg ....................... 130
vitamin b-2 oral tablet 100 mg,
25 mg .............................. 130
vitamin b-6 oral tablet 100 mg,
25 mg, 50 mg .................. 130
vitamin c cough drops ..... 130
vitamin c drops ............... 130
vitamin c oral capsule,
extended release .............. 130
vitamin c oral lozenge ..... 130
vitamin c oral powder
effervescent in packet ...... 130
vitamin c oral syrup ........ 130
vitamin c oral tablet 1,000 mg,
250 mg, 500 mg .............. 130
vitamin c oral tablet extended
release 1,000 mg ............. 131
vitamin c oral tablet extended
release 500 mg ................ 131
vitamin c oral tablet,chewable
250 mg, 500 mg .............. 131
vitamin c with rose hips oral
tablet ............................... 131
vitamin d2 ....................... 131
vitamin e acetate ............. 131
vitamin e mixed oral
capsule ............................ 131
vitamin e oral capsule 1,000
unit, 200 unit, 400 unit .... 131
vitamin e oral capsule 100
unit, 600 unit ................... 131
vitamin e oral drops 100 unit/
0.25 ml, 50 unit/ml .......... 131
vitamin e (dl, acetate) oral
capsule 100 unit, 400
unit .................................. 131
vitamin k1 injection .......... 62
vitamins a and d .............. 131
vitamins and minerals ..... 131
vitamins b complex oral
capsule ............................ 131
vitamins for hair oral
tablet ............................... 131
VITEKTA ......................... 15
vits a and d-white pet-lanolin
topical ointment ................ 65
VOLTAREN GEL TOPICAL
GEL 1 % ........................... 44
voriconazole intravenous ... 11
voriconazole oral suspension
for reconstitution ............... 11
voriconazole oral tablet 200
mg ..................................... 11
voriconazole oral tablet 50
mg ..................................... 11
VOTRIENT ...................... 31
VPRIV .............................. 79
VRAYLAR ORAL
CAPSULE ........................ 54
VRAYLAR ORAL
CAPSULE,DOSE PACK ... 54
W
warfarin ............................ 62
water for irrigation,
sterile ................................ 72
wee care .......................... 131
WELCHOL ....................... 63
white petrolatum topical
ointment ............................ 65
WHOLE SOURCE MULTIVITAMINS ..................... 131
women's daily formula oral
tablet 18 mg iron-400 mcg-500
mg ca .............................. 131
X
XALKORI ........................ 31
XARELTO ORAL TABLET
10 MG, 20 MG ................. 62
XARELTO ORAL TABLET
15 MG ............................... 62
XARELTO ORAL TABLETS,
DOSE PACK .................... 62
XENAZINE ORAL TABLET
12.5 MG ............................ 38
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TXDMKT-0101-16 SP 09.16 SP
168
XENAZINE ORAL TABLET
25 MG ............................... 38
XGEVA ............................. 23
XOLAIR ......................... 110
XOPENEX HFA ............. 110
XTANDI ........................... 31
XULANE .......................... 93
XYREM ............................ 54
Y
YERVOY .......................... 31
YF-VAX (PF) ................... 90
YONDELIS ...................... 32
Z
Z-BUM ............................. 65
zafirlukast ........................ 110
zaleplon oral capsule 10
mg ..................................... 54
zaleplon oral capsule 5
mg ..................................... 54
ZALTRAP ......................... 32
ZANOSAR ....................... 32
ZARAH ............................ 95
ZAVESCA ........................ 79
zeasorb (miconazole) ........ 67
ZEGERID OTC ................ 87
ZELBORAF ..................... 32
ZEMPLAR
INTRAVENOUS .............. 79
zenchent (28) .................... 95
ZENPEP ........................... 86
zenzedi oral tablet 10 mg ... 54
zenzedi oral tablet 5 mg .... 54
ZEPATIER ........................ 15
ZETIA ............................... 63
ZIAGEN ORAL
SOLUTION ...................... 15
?
zidovudine oral capsule .... 15
zidovudine oral syrup ....... 15
zidovudine oral tablet ....... 15
zinc .................................. 116
zinc gluconate oral
lozenge ............................ 116
zinc gluconate oral tablet 100
mg ................................... 116
zinc gluconate oral tablet 50
mg ................................... 116
zinc oxide topical ointment 20
% ....................................... 65
zinc sulfate oral capsule ... 116
zinc sulfate oral tablet .... 116
zinc sulfate-vitamin c ...... 131
ZINC (WITH A AND C)
LOZENGES ................... 131
ZINC-15 .......................... 116
zinc-220 ........................... 116
ziprasidone hcl oral capsule
20 mg ................................ 54
ziprasidone hcl oral capsule
40 mg ................................ 54
ziprasidone hcl oral capsule
60 mg, 80 mg .................... 54
ZIRGAN ........................... 96
zoledronic acid intravenous
recon soln 4 mg ................. 79
zoledronic acid intravenous
solution 4 mg/5 ml ............ 79
ZOLINZA ......................... 32
zolmitriptan ....................... 37
zolpidem oral tablet .......... 54
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100
ML .................................... 79
ZOMIG NASAL ............... 37
ZONATUSS .................... 107
zonisamide ........................ 36
zoo chews ........................ 131
ZOO FRIENDS
ORIGINAL ..................... 131
ZORTRESS ...................... 32
ZOSTAVAX (PF) .............. 90
zovia 1/35e (28) ................ 95
zovia 1/50e (28) ................ 95
ZUTRIPRO ..................... 107
ZYDELIG ......................... 32
ZYKADIA ........................ 32
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG,
405 MG ............................. 54
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 300
MG .................................... 54
ZYTIGA ........................... 32
ZYVOX INTRAVENOUS
PARENTERAL SOLUTION
200 MG/100 ML ............... 19
ZYVOX INTRAVENOUS
PARENTERAL SOLUTION
600 MG/300 ML ............... 19
ZYVOX ORAL
SUSPENSION FOR
RECONSTITUTION ........ 19
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TXDMKT-0101-16 SP 09.16 SP
169
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notificación antes de hacer algún cambio que afecte su caso.
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(TTY 711), Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free.
Usted puede obtener esta información gratuitamente en otros idiomas. Llame al
1-855-878-1784 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita.
Puede obtener esta información de forma gratuita en otros formatos, como letra grande, Braille o audio. Llámenos al
1-855-878-1784 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m., hora local. La llamada es gratis.
H8786_16_24854_T_008_SP CMS Approved 08/25/2015
Identificación del formulario: 16232 Versión: 14
Issued 09/01/2016