lista de medicamentos o formulario · lista de medicamentos o formulario planes de cuidado...

Programa de Farmacia de Triple-S Salud, Inc. Pharmacy Program from Triple-S Salud Inc.

Lista de Medicamentos o Formulario Planes de Cuidado Coordinado y Otros

Planes Comerciales de Libre Selección 2017

Drug List for Coordinated Care Plans

and other Commercial Plans 2017

AXIS II: Revisado Abril 2016/ Axis II: Updated April 2016 TSS-PROD-0065-2016-A / TSS-PROD-0064-2016-B

Lista de Medicamentos AXIS II 2017 / Drugs List AXIS II 2017 2 Rev. Abril 2016 / April 2016

TABLA DE CONTENIDO/ TABLE OF CONTENTS INTRODUCCIÓN / INTRODUCTION ...................................................................................................................... 3

PARTE I - DISEÑO DE LA LISTA DE MEDICAMENTOS / PART I - DRUG LIST DESIGN .................................. 4

Presentación de la Lista de Medicamentos / Drug List Presentation.................................................................. 4

¿Cómo usar esta Lista de Medicamentos o Formulario? / How do I use this Drug List? ................................... 4

Nivel 1 - Medicamentos Genéricos / Level 1 - Generic Drugs ........................................................................ 6

Nivel 2 – Medicamentos Preferidos / Level 2 – Preferred Drugs .................................................................... 6

Nivel 3 – Medicamentos No Preferidos / Level 3 – Non-Preferred Drugs....................................................... 6

Nivel 4 – Productos Especializados Preferidos / Level 4 – Preferred Specialty Products .............................. 7

Nivel 5 – Productos Especializados No-Preferidos / Level 5 – Non-Preferred Specialty Products ................ 7

¿La Lista de Medicamentos puede cambiar?/ The Drug List can change? ........................................................ 7

Guías de Referencia / Reference Guidelines ...................................................................................................... 8

Límites de cantidad (LC) / Limits on the amount to be dispensed (QL) .......................................................... 8

Límites de especialidad médica (LE) / Medical specialty limits (SL) ............................................................... 8

Medicamentos que requieren preautorización (PA) / Drugs that need a preauthorization (PA) ..................... 8

Programa de Terapia Escalonada (TE) / Step Therapy Program (ST) ........................................................... 9

Límites de Edad (AL) / Age Limits ................................................................................................................... 9

Uso de medicamentos de investigación o experimentales / Use of investigational or experimental drugs.... 9

Éditos de Análisis de Utilización (DUR) / Edits for Drug Utilization Analysis (DUR) ......................................... 10

Procedimiento para Solicitar una Excepción Médica / Procedure to Ask for a Medical Exception .................. 11

Leyenda para los Símbolos y Abreviaturas / Legend for Symbols and Abbreviations ..................................... 13

Derechos Reservados / Reserved Rights ......................................................................................................... 14

PARTE II – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD FÍSICA / PART II - DRUG BY THERAPEUTIC CLASSIFICATION – PHYSICAL HEALTH ................................................................................. 15

PARTE III – MEDICAMENTOS POR CLASE TERAPEUTICA – EMERGENCIA / PART III - DRUG BY THERAPEUTIC CLASSIFICATION – EMERGENCY ........................................................................................... 68

PARTE IV – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD MENTAL / PART IV - DRUG BY THERAPEUTIC CLASSIFICATION – MENTAL HEALTH .................................................................................... 75

PARTE VI – APENDICES / PART VI – APPENDIXES ......................................................................................... 84

Apéndice I - Quimioterapias Orales / Appendix I – Oral Chemotherapies ........................................................ 84

Apéndice II – Límites de Especialidad (LE) / Appendix II – Specialty Limits (SL) ............................................ 86

Apéndice III – Límites de Especialidad (LE) Salud Mental / Appendix III - Specialty Limits (SL) Mental Health

........................................................................................................................................................................... 97

Apéndice IV – Terapias Escalonadas (TE) / Appendix IV - Step Therapies (ST) ........................................... 102

Apéndice V – Solicitud de Excepción Médica / Appendix V - Medical Exception Application ........................ 105

PARTE VII – INDICE / PART VII – INDEX .......................................................................................................... 106


INTRODUCCIÓN / INTRODUCTION

Esta Lista de Medicamentos o Formulario se divide en siete partes.

This Drug List is divided into three parts. La primera parte es un resumen que te provee información sobre la forma en que se diseñó la Lista de Medicamentos o Formulario. También se incluye una descripción de los éditos de análisis de utilización para validar dosis e identificar terapias duplicadas. Estos éditos están disponibles a través del sistema de procesamiento y adjudicación de reclamaciones de MC-21 Corp. The first part is an outline that gives you information about the way the Drug List was designed. It has a description of the edits used to check dose and find duplicate therapies. These edits are part of the claim system of MC-21 Corp.

La segunda, tercera, cuarta y quinta parte contiene los medicamentos por clasificación terapéutica que deben ser recetados por los proveedores dentro de la red, incluyendo una sección que identifica los medicamentos de salud mental. Además, contiene una lista de los medicamentos que pueden ser recetados por proveedores tanto dentro como fuera de la red por considerarse medicamentos para tratamiento en sala de emergencia.

The second, third, fourth and fifth part has drugs by therapeutic classes that may be prescribed by plan doctors, as well as a section that lists mental health drugs. Also, it has a list of drugs that may be prescribed by doctors in or out of our plan, as they are considered as drugs used for emergency room treatment.

La sexta parte contiene los apéndices y la séptima parte contiene una lista por orden alfabético (Índice) de los medicamentos disponibles en la Lista o Formulario. The sixth part has the appendixes and the seventh part has the drugs listed in alphabetical order (Index).

El Comité de Farmacia y Terapéutica revisa esta Lista de Medicamentos o Formulario una vez durante la vigencia de la póliza. The Therapeutics and Pharmacy Committee change this Drug List once while the plan is active. Para obtener una copia de la Lista de Medicamentos, para más información o si necesita ayuda, llame a nuestro Centro de Llamadas al 787-774-6060 o libre de cargos al 1-800-981-3241. Los usuarios del sistema TTY/TDD deben llamar al 787-792-1370 o libre de cargos al 1-866-215-1999. El horario de servicio es de lunes a viernes, de 7:30 a.m. a 8:00 p.m., sábados de 9:00 a.m. a 6:00 p.m. y domingos de 11:00 a.m. a 5:00 p.m. (AST, Tiempo Estándar del Atlántico). Además, puedes visitar nuestros Centros de Servicio o portal de Internet en www.ssspr.com. If you need a copy of the Prescription Drug List, for more information or if you need help, call our Call Center at 787-774-6060 or toll free at 1-800-981-3241. TTY/TDD users should call 787-792-1370 or toll free at 1-866-215-1999. Hours are Monday to Friday, from 7:30 a.m. to 8:00 p.m., Saturdays from 9:00 a.m. to 6:00 p.m. and Sundays from 11:00 a.m. to 5:00 p.m. (AST, Atlantic Standard Time). Also, you can visit our Service Centers or website at www.ssspr.com.


PARTE I - DISEÑO DE LA LISTA DE MEDICAMENTOS / PART I - DRUG

LIST DESIGN

Presentación de la Lista de Medicamentos / Drug List Presentation En el ejemplo a continuación se ilustra la información que se provee para los medicamentos incluidos en esta Lista de Medicamentos o Formulario.

These examples show how the drug information is presented in this Drug List.

Medicamentos (Drugs) Nivel (Level) Instrucciones (Instructions)

Analgesics/ Analgésicos

Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100 mg, 200 mg, 400mg, 50mg 3

ST

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium er oral tablet extended release 24 hr* 100 mg

1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

Medicamentos Genéricos = Letras Minúscula en negrillas / Medicamentos de Marca = LETRAS MAYUSCULAS Generic drugs = lowercase bold / Brand Name Drugs = UPPERCASE

Para cada medicamento incluido en esta Lista o Formulario aparece su presentación, el nombre comercial, el nivel y si tiene alguna instrucción especial.

For all drugs in this List dose form, trademark name of the drug, level, and any special instruction will appear.

¿Cómo usar esta Lista de Medicamentos o Formulario? / How do I use this Drug List

or Formulary?

La manera más fácil en que puedes conseguir los medicamentos en la Lista de Medicamentos o Formulario es buscando el medicamento en el Índice. El Índice provee una lista por orden alfabético de todos los medicamentos incluidos en este documento. Ambos, medicamentos de marca como genéricos están incluidos en el Índice. Busca el Índice y encuentra el medicamento. Al lado del medicamento, está el número de la página donde encontrarás cómo está cubierto. Voltea a la página indicada en el Índice y encuentra el nombre del medicamento en las columnas. The easiest way that you can find the drugs is seeking it in the Index. The Index gives an alphabetical list of all of the drugs in this document. Both brand-name and generic drugs are listed in the Index. Look in the Index and find the drug. Next to the drug, you will see the page number where you can find it. Turn to the page listed in the Index and find the name of the drug in the columns.

¿Cuánto pagas por los medicamentos cubiertos?/ How much you will pay for covered drugs?

Los medicamentos en la Lista de Medicamentos o Formulario se clasifican por niveles, excepto aquellos con $0 copago según requiere la Ley Federal. Estos niveles identifican los diferentes niveles de costo compartido, o sea, lo que pagas por los medicamentos en la receta. Estos niveles son los siguientes:


Nivel 1 – Medicamentos Genéricos

Nivel 2 – Medicamentos Preferidos

Nivel 3 – Medicamentos No Preferidos

Nivel 4 – Productos Especializados Preferidos

Nivel 5 – Productos Especializados No Preferidos The drugs in the Drug List are arranged by levels, except for those with $0 copay as required by Federal Law. These levels below point out the cost-sharing per type of drug, that is, what you pay for the drugs in your doctors order:

Level 1 – Generic Drugs Level 2 – Preferred Drugs Level 3 – Non-Preferred Drugs Level 4 – Preferred Specialty Products Level 5 – Non Preferred Specialty Products

Debes verificar en el beneficio de farmacia cuál es el copago o coaseguro que pagarás por el medicamento, dependiendo en el nivel que se encuentra. Tendrás acceso a unos medicamentos preventivos específicos, a los cuales les aplican $0 copago, si son recetados o suministrados por proveedores participantes según requiere el gobierno federal. A continuación los medicamentos incluidos en esta ley:

Anticonceptivos aprobados por la FDA (incluyendo OTC y con receta médica)1

Fluoruro (hasta los 6 años) Aspirina (con límite de cantidad de una 1 tab / diaria; pacientes mayores de 18 años) Hierro (hasta los 12 meses) Ácido fólico (sólo para mujeres)

Tamoxifen (Nolvadex®) y raloxifene (Evista®) (soló cuando se utilice como preventivo) Medicamentos para cesar de fumar (se cubre el despacho de medicamentos para

cesar el uso del tabaco aprobados por la FDA por 90 días consecutivos en un intento y hasta dos intentos por año)

Vitamina D para pacientes mayores de 65 años

You must make sure which will be the copay or coinsurance that you will pay for each drug in your plan document, based on the level they are in. These drugs will have cero ($0) copay when prescribed by plan doctors, as required by Federal Law:

FDA approved contraceptives (OTC and prescription) 2

Fluoride (up to 6 years) Aspirin (with amount limit of 1 tab / day; over 18 years) Iron (up to 12 months) Folic acid (females only) Tamoxifen (Nolvadex®) and raloxifene (Evista®) (only when use as preventive) FDA drugs approved for quitting the use of tobacco are covered for 90 consecutive days in one

try and up to two tries per year) Vitamin D for patients over 65 years

1 Aplica a los siguientes anticonceptivos: Condón Femenino y Masculino, Contraceptivos Orales e

Inyectables, Dispositivo Intrauterino (IUD), Diafragma, Mirena IUD®, Plan B

®, Espermicidas (OTC foam),

Ortho Evra Patc®, Nuvaring

®.

2 Applies to these contraceptives: Female and Male Condom, Oral and Injectable Contraceptives, Intrauterine Device

(IUD), Diaphragm, IUD Mirena ®, Plan B ®, Spermicides (Foam OTC), Ortho Evra Patc ®, NuvaRing ®.


Nivel 1 - Medicamentos Genéricos / Level 1 - Generic Drugs

Este nivel incluye medicamentos genéricos. Un medicamento genérico tiene el mismo ingrediente activo en la fórmula que un medicamento de marca. Los medicamentos genéricos usualmente cuestan menos que los medicamentos de marca y están aprobados por la Administración Federal de Drogas y Alimentos (FDA, por sus siglas en inglés).

This tier includes generic drugs. A generic drug has the identical amounts of the same active ingredient(s) as the brand name drug. They cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).

Los medicamentos disponibles genéricos están escritos en letras negrillas minúsculas en la Lista de Medicamentos o Formulario (ejemplo, nabumetone).

Drugs with a generic version available are listed in lowercase bold (e.g., nabumetone) within the Drug List.

Tu cubierta de farmacia requiere el despacho de medicamentos genéricos como primera opción, excepto para aquellos medicamentos de marca incluidos en la Lista de Medicamentos o Formulario para tu cubierta de farmacia, para el cual no exista el genérico. The generic drugs must be dispensed as the first choice always, except for those brand-name drugs covered in the Drug List for which the generic choices do not exist.

Nivel 2 – Medicamentos Preferidos / Level 2 – Preferred Drugs

Este nivel incluye medicamentos de marca que han sido seleccionados por el Comité de Farmacia y Terapéutica como agentes preferidos luego de su evaluación de seguridad, eficacia y costo. Los mismos están identificados a la derecha como Nivel 2. En aquellas clases terapéuticas donde no hay genéricos disponibles, te exhortamos a que utilices como primera alternativa aquellos medicamentos identificados como preferidos. This tier includes generic drugs and brand name drugs that have been classified by the Therapeutics and Pharmacy Committee as preferred agents after an in-depth review in terms of safety, efficiency and cost. These are identified with a Level 2 placed to the right of the name of the drug. In those therapeutic classes where there are no generic drugs, we suggest you to use as first choice those drugs named as preferred.

Nivel 3 – Medicamentos No Preferidos / Level 3 – Non-Preferred Drugs

Este nivel incluye medicamentos genéricos y medicamentos de marca no preferidos de mayor costo que en los niveles 1 y 2. Están clasificados como no preferidos porque existen alternativas en los niveles anteriores con menos efectos secundarios o que son más costo-efectivos. Si obtienes un medicamento genérico o de marca del Nivel 3, tendrás que pagar un costo mayor por el medicamento. This tier includes non-preferred generic drugs and brand name drugs with a higher cost than tier 1 and 2. They are classified as non-preferred because there are other choices in the other levels with lesser reactions or are more cost effective. If the person gets a brand or generic drug from Level 3, will have to pay more for that drug.


Nivel 4 – Productos Especializados Preferidos / Level 4 – Preferred Specialty Products

Los medicamentos especializados requieren una administración y/o un manejo especial, por su composición compleja. Estos se utilizan para el tratamiento de condiciones crónicas y de alto riesgo que requieren un manejo especial de la condición. Specialty Drugs need special handling due to their complex composition. These are used for the treating high risk and life-long health problems that need special handling.

El Nivel 4 identifica los medicamentos o productos en la Lista de Medicamentos que se ofrecen bajo el Programa de Medicamentos para Condiciones Especiales. Los medicamentos en este nivel incluyen medicamentos genéricos, biosimilares (genéricos de productos biológicos) y de marca a un costo menor que el Nivel 5 y un arreglo especial para su despacho. The Level 4 identify the drugs or products in the Drug List that are offered under the Drug Program Special Health Problems. The drugs in this tier include generics, biosimilars (generic biologics) and brand at a lower cost the level 5 and a special handling for supply.

Nivel 5 – Productos Especializados No-Preferidos / Level 5 – Non-Preferred Specialty

Products

El Nivel 5 incluye los Medicamentos Especializados No Preferidos. Los medicamentos en este nivel también tienen un arreglo especial para su despacho con la diferencia de que aplica un costo mayor que los del Nivel 4. Estos se utilizan también para el tratamiento de condiciones crónicas y de alto riesgo que requieren una administración y manejo especial. The Level 5 includes Non-Preferred Specialized Drugs. The drugs in this level also have a special handling for its supply, but have a higher copayment when compared to drugs from Level 4. These are used to treat life-long and high-risk health problems that need special handling and administration.

¿La Lista de Medicamentos puede cambiar?/ The Drug List can change?

Sí, el Comité de Farmacia y Terapéutica revisa la Lista de Medicamentos varias veces al año. De acuerdo a las decisiones del Comité anualmente se pueden estar incluyendo medicamentos en la Lista. Generalmente, un medicamento puede ser descontinuado o su cobertura cambiar cuando su versión genérica está disponible o alguna información relacionada a seguridad o efectividad son publicadas. Yes, the Therapeutics and Pharmacy Committee reviews the Drug List continuously. Based on the decisions of the Committee drugs are added or removed from the list once a year. As a rule a drug is discontinued or its coverage status is changed when a generic version is available or new information relating to its safety and efficacy is published.

Constantemente el FDA está aprobando medicamentos genéricos una vez la patente del medicamento de marca vence. Cuando la versión genérica de un medicamento de marca (que no tenía versión genérica) llega a estar disponible, se evalúa su costo y se determina si se incluye o no. Si se determina incluir la versión genérica del medicamento, el sistema se actualiza para que le cubra el mismo. Por tal razón, el medicamento de marca cambia de Nivel. Dependiendo del beneficio de farmacia deberás utilizar el medicamento genérico (si la cubierta requiere la utilización mandatoria de genéricos) y/o el deducible puede ser mayor.


The FDA is constantly approving generic drugs once the brand drug’s patient expires. When the generic version of a brand name drug (that does not have a generic version in the market) is made available, the cost is evaluated and decides whether or not to be included. If it is decided to include the generic version of the drug, the system automatically updates to include it. For that reason, the brand drug changes in level. Based on your plan you may have to use the generic drug (if your health plan mandates the use of generics over brands) or your deductible may be higher

Guías de Referencia / Reference Guidelines

Límites de cantidad (LC) / Limits on the amount to be dispensed (QL)

Ciertos medicamentos tienen un límite en la cantidad a despacharse. Estas cantidades se establecen de acuerdo a lo sugerido por el manufacturero como la cantidad máxima adecuada que no está asociada a efectos adversos y la cual es efectiva para el tratamiento de una condición. En el área de Instrucciones de la lista de medicamentos se identificaron los límites en la cantidad a despacharse, en aquellos medicamentos que aplique. Los límites de cantidad son vigentes al momento de imprimirse esta Lista y está sujeta a cambios. Certain drugs have a limit on the amount to be dispensed. These amounts are established as stated by the manufacturer’s recommendation as to the adequate maximum amount that will not cause adverse effects and which is effective for treating of a health problem. The area of Instruction in the Drug List identifies the amount limits for those that apply. Quantity limits are effective when they are published in this List and is subject to changes.

Límites de especialidad médica (LE) / Medical specialty limits (SL)

Algunos medicamentos tienen un límite en la especialidad médica. Estos límites de especialidad se establecen de acuerdo a la literatura médica actual. Some medications have a limit in the medical specialty. These medical specialty limits are established in accordance with the current medical literature.

Los Apéndices II y III contienen las lista de los medicamentos que tienen límite de especialidad médica. La misma es vigente al momento de imprimirse esta Lista o Formulario y está sujeta a cambios.

Appendix II and III has the list of drugs that has a medical specialty limit. The list is effective at the time it has been published and is subject to changes.

Medicamentos que requieren preautorización (PA) / Drugs that need a preauthorization

(PA)

En un esfuerzo por garantizar la seguridad y el uso correcto de los medicamentos, algunos de ellos necesitarán una preautorización para ser adquiridos. Los mismos se han identificado a la derecha con PA (requiere preautorización), en cuyo caso, la farmacia gestiona la preautorización previo al despacho del medicamento. To guarantee the safe and effective use of drugs there are certain drugs that need a preauthorization before being purchased by the patient. A PA (preauthorization is needed) placed to the right of the name of the drug identifies them, for which, the pharmacy will process the preauthorization before dispensing it to the person.


Los medicamentos que requieren preautorización usualmente son aquellos que requieren que s e cumpla con unos criterios antes de utilizarlos, son candidatos al uso inapropiado o están relacionados con un costo elevado. Aquellos medicamentos que han sido identificados que requieren preautorización deben satisfacer los criterios clínicos establecidos según lo haya determinado el Comité de Farmacia y Terapéutica. Estos criterios clínicos se han desarrollado de acuerdo a la literatura médica actual. The drugs that need a preauthorization are those that need the person meets a specific criteria before its use, are likely to have inappropiate use or are higher in cost. Drugs identified as needing preauthorization should fulfill the clinical criteria as determined by the Therapeutics and Pharmacy Committee. The criteria have been developed as stated by up to date medical literature.

También, tendrán requisito de PA aquellos medicamentos cuyos costos excedan $500.00 (verifica el certificado de beneficio ya que esta cantidad puede ser diferente). La farmacia enviará copia de la receta y se encargaran del proceso. Drugs whose cost goes beyond $500.00 will need a pre-authorization (check your health plan benefits as this quantity could be other). The pharmacy will send a copy of the prescription to the health plan and will take care of the process.

Programa de Terapia Escalonada (TE) / Step Therapy Program (ST)

En algunos casos, requerimos que utilices primero un medicamento como terapia para tu condición antes de que cubramos otro medicamento para esa condición (Terapia Escalonada, ST por sus siglas en inglés). Por ejemplo, si el Medicamento A y el Medicamento B se usan ambos para tratar tu condición médica, nosotros requerimos que utilices primero el Medicamento A. Si el Medicamento A no te funciona, entonces cubriremos el Medicamento B. (Refiérete al Apéndice IV) In some cases, we need you to first try one drug to treat your health problem before we will cover some other drug for that health problem (Step Therapy). For example, if Drug A and Drug B both treat your health problem, we may need you use Drug A first. If Drug A does not work for you, then we will cover Drug B. (Refer to Appendix IV)

Límites de Edad (AL) / Age Limits

Algunos medicamentos tienen un límite de edad. Estos límites están vigentes al momento de imprimirse esta Lista y están sujetos a cambios. Some drugs have a limit due to age. These limits are effective at the time the List is published and are subject to changes

Uso de medicamentos de investigación o experimentales / Use of investigational or

experimental drugs

Los medicamentos recetados para propósitos de investigación, experimentales o no aprobados por la FDA, no se cubren en ningún plan de salud o cubierta de farmacia. Investigational or experimental drugs, or those not approved by the FDA, are not covered by all health plans or your prescription drug coverage.


Las indicaciones no aprobadas por la FDA, no se cubren en ningún plan de salud o cubierta de farmacia. Indications not approved by the FDA, are not covered by all health plans or pharmacy coverage.

Éditos de Análisis de Utilización (DUR) / Edits for Drug Utilization Analysis (DUR)

A través del Programa de Beneficio de Farmacia de Triple-S Salud se han implantado los siguientes éditos de análisis de utilización (DUR, por sus siglas en inglés) con el propósito de evitar complicaciones a los asegurados, ofreciendo un mejor cuidado.

Through the Pharmacy Benefit Management Program, Triple-S Salud has established edits for drug utilization (DUR) to avoid complications to the persons while giving a better care.

Édito de Validación de Dosis - coteja para dosis máximas diarias usando como referencia las

dosis pediátricas, de adultos y geriátricas de acuerdo a la información suministrada por Medi-

Span. En la mayoría de los casos, la dosis máxima es aquella aprobada por la FDA. / Dose

check edits - verify for daily maximum dosages using as reference the child, adult and aged adult dosages as stated by Medi-Span. In most of cases, the maximum dose is the one approved by the FDA.

Medi-Span, parte de la compañía Wolters Kluwer Health, es el proveedor líder de información sobre medicamentos con recetas que provee soluciones para interacciones de medicamentos por medio de una base de datos disponible a miles de profesionales de cuidado de salud a través del mundo entero. Los datos en la base de datos de MediSpan ayudan eficientemente a la seguridad del paciente, reestructurar y unificar todo el sistema de comunicaciones y procesamiento de reclamaciones entre las farmacias y los administradores de beneficios de

farmacia y el cumplimiento con diversas regulaciones. / Medi-Span, a part of Wolters Kluwer

Health, is the leading Provider of prescription Drug information and Drug interactions database solutions available to thousands of Healthcare professionals worldwide. Made part of the existing workflow, Medi-Span data aids in improving patient safety, streamlining and unifying system- wide communications and claims processing between the pharmacies and the pharmacy benefit administrators and compliance with various regulations.

Édito de Terapia Duplicada - verifica el historial de medicamentos del paciente asegurado para

recetas duplicadas, de dos formas: / Duplicate Therapy edits - verify the covered person’s drug

history for duplicate prescriptions, in two ways:

1. el paciente asegurado recibe el mismo medicamento (Ej. mismo ingrediente activo) con

dos recetas distintas (Ej. número de receta distinto, puede ser la misma farmacia o farmacias diferentes). / The covered person gets the same drug (e.g. same active ingredient) with two different prescriptions (e.g. prescription number is different; it could be throughthe same pharmacy or different ones).

2. el paciente asegurado recibe dos medicamentos de la misma clase terapéutica, como por ejemplo, dos antidepresivos o dos analgésicos, entre otros. / The covered person gets two drugs of the same therapeutic class, for example: twon anti-depressants or two analgesics.

Hay ciertas excepciones a estos éditos. Para evitar que el sistema rechace el servicio a los asegurados, nosotros le solicitamos a los médicos y dentistas que incluyan la siguiente información en la receta del paciente:/ There are exceptions to these edits. To


prevent the system from denying the service, we suggest that doctors include the following information in the patient’s prescription:

Cambio en dosis/ Change in dose

Si aumentó la dosis y necesitas más medicamentos antes de tiempo, en este caso se necesitará una carta de justificación de parte del médico indicando el cambio en dosis. La farmacia requerirá una preautorización a MC-21 Corp., luego de que se reciba la información necesaria de la receta. / If the dose increases, and the covered person needs a drug right away, a letter from the doctor justifying the dose change will be needed. The pharmacy will need a preauthorization from MC-21 Corp. after receipt of the needed information on that prescription.

- Si la dosis se determina por su peso, el médico debe indicar su peso y estatura en la

receta. / If the dosage is determined by your weight, the doctor must tell your weight and height

in the prescription.

- Cuando la dosis del medicamento se ajuste de acuerdo a los niveles en sangre, el médico debe indicarlo así en la receta (Ej. ajuste de niveles para tiroides, teofilina, anticonvulsivos

y warfarina). / When the dosage of the drug is adjusted accordingly to blood levels, the physician

must indicate it in the prescription (e.g.: adjustments for thyroid, theophylline, anticonvulsants and warfarin).

- Cuando para la dosis indicada en la receta no existe su presentación farmacéutica. Por ejemplo, la tableta viene de 25 mg y 50 mg pero el paciente necesita 75 mg (dosis indicada y aceptada). La farmacia requerirá una precertificación a MC-21 Corp., luego de que se reciba la información necesaria en la receta (se requiere copia de la receta y hoja de

precertificaciones de MC-21 Corp). / When the dose indicated in the prescription does not exist

in the pharmaceutical dose form of the drug. For example, the tablet exists in 25 mg and 50 mg, but the patient needs a 75 mg dose (dose needed and accepted). The pharmacy will need a pre-authorization from MC-21 Corp. after the receipt of the needed information for the prescription (a copy of the prescription will be required and copy of the precertification form from MC- 21 Corp.).

Procedimiento para Solicitar una Excepción Médica / Procedure to Ask

for a Medical Exception

El asegurado o su representante legal autorizado podrán solicitar que se cubra un

medicamento que no esté excluido del formulario de forma categórica3 utilizando la forma que se encuentra en el Apéndice V. Esta forma se encuentra disponible también en nuestra página web www.ssspr.com.

The covered person or legally authorized representative may ask for coverage of a drug that is not clearly excluded

3 on the form using the form found in Appendix V. This form is also available on our

website www.ssspr.com

3 Exclusión de forma categórica significa que el nombre científico o comercial del medicamento solicitado no está en

la lista de exclusiones del formulario.

3 Exclusion categorically means that the scientific name or trade name requested drug is not on the exclusion list of the

Formulary

http://www.ssspr.com/

http://www.ssspr.com/


Las razones por las cuales un asegurado puede solicitar una excepción médica son:

The reasons why a covered person may ask for a medical exception are:

Medicamentos no cubiertos por el formulario / Drugs not covered by the drug list

Descontinuación de medicamento por motivos que no sean de seguridad o

retiro del mercado por su fabricante/ Drug discontinuation for reasons other than safety or recall by the manufacturer

Excepción al procedimiento de terapia escalonada o limitación de dosis. / Exception

to the step therapy or dose limit

Se requerirá una certificación que incluya la siguiente información:

Certification will be needed to include the following information:

Nombre, número de grupo o número de contrato/ Name, group or contract number

Historial del paciente / Patient History

Diagnóstico primario relacionado con el medicamento de receta objeto de la

solicitud / Main diagnosis linked to the drug subject of the request

Razón para la solicitud de excepción / Reason for Exception Request

Razón por la cual el medicamento solicitado se necesita, o por la cual la excepción en cuanto al procedimiento de terapia escalonada o limitación de dosis es necesaria para el cuidado del

paciente. / The reason why the requested drug is needed, or why the exception for the step

therapy procedure or dose limit is needed for patient care.

La solicitud de excepción médica será revisada por profesionales de la salud con experiencia en el manejo de medicamentos. Las determinaciones tomadas corresponderán a los beneficios y exclusiones que se disponen en la cubierta. El asegurado será notificado de la decisión mediante carta o correo electrónico (según solicitado). The medical exception request will be reviewed by health professionals with expertise in medication management. The determinations made will consider the benefits and exclusions in your coverage. The covered person will be notified of the decision by letter or email (as requested).


Leyenda para los Símbolos y Abreviaturas / Legend for Symbols and Abbreviations

Símbolos / Abreviaturas (Symbols /Abbreviations)

Descripción (Description)

AL Medicamentos para los cuales existe algún límite de edad/ Medications for which an age limit exists

Cap Cápsula/ Capsule

Conc Concentrado/ Concentrated

Cr Crema / Cream

ER, SR, CR Acción prolongada, acción sostenida, acción controlada/ Extended release, sustained release, controlled release

Inh Inhalador/ Inhaler

Inj Inyectable/ Injectable

GL Límite de Género/ Gender Limit

Lot Loción / Lotion

Negrilla/ Bold Medicamento tiene genérico disponible en todas las presentaciones/ Medication has a generic available in all its dosage forms

Nivel 1/ Level 1 Medicamentos genéricos / Generic drugs

Nivel 2/ Level 2 Medicamentos preferidos / Preferred drugs

Nivel 3/ Level 3 Medicamentos no preferidos / Non-Preferred drugs

Nivel 4/ Level 4 Productos especializados preferidos / Preferred Specialty Products

Nivel 5/ Level 5 Productos especializados no preferidos / Non-Preferred Specialty Products

Oint Ungüento / Ointment

Oph Oftálmico / Ophthalmic

PA

Preautorización. La farmacia es responsable de solicitar y obtener una precertificación de MC-21 Corp. o Triple-S Salud, antes de despacharse el medicamento./ Preautorization. The pharmacy is responsible to request and obtain a prior authorization from MC-21 Corp. or Triple-S Salud before dispensing the drug.

QL Medicamentos para los cuales existe algún límite en la cantidad que la farmacia puede despachar / Medications for which a dispensing limit exists

SHA Champú / Shampoo

SL

Medicamentos para los cuales existe algún límite en la especialidad médica que debe manejar la terapia con estos productos / Medications for which a limit in the medical specialty exists that must manage the therapy with these products

Sl Sublingual / Sublingual

SNC Sistema Nervioso Central / Central Nervous System

Soln Solución / Solution

ST Terapia Escalonada / Step Therapy

Supp Supositorio/ Suppository

Susp Suspensión / Suspension

Tab Tableta / Tablet

Td Transdérmico / Transdermal


Derechos Reservados / Reserved Rights

Esta Lista de Medicamentos o Formulario es una propiedad literaria. MC-21 Corp. y Triple-S Salud, Inc. son los propietarios de los derechos de autor. Bajo ninguna circunstancia se podrá copiar o distribuir esta Lista ni cualquier porción de ésta sin el consentimiento escrito de MC-21 Corp. y Triple-S Salud, Inc. This Drug List is a literary property. MC-21 Corp. and Triple-S Salud, Inc. are the proprietors of the author’s rights. Under no circumstances may this List be copied or distributed in whole or any part without the written approval of MC-21 Corp. and Triple-S Salud, Inc


PARTE II – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD FÍSICA / PART II - DRUG BY THERAPEUTIC CLASSIFICATION – PHYSICAL HEALTH

Medicamentos Genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayusculas / Brand name drugs = UPPERCASE

SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) Nivel (Level) Instrucciones (Instructions)

Analgesics [Analgésicos]

Nonsteroidal Anti-Inflammatory Drugs [Anti-Inflamatorios No Esteroidales]

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 3 ST


diclofenac sodium er oral tablet extended release 24 hr* 100 mg

1

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

1

etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg

3

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

indomethacin oral capsule 25 mg, 50 mg 1

ketorolac tromethamine injection solution 15 mg/ml 1 QL (40 ML per 5 days)

ketorolac tromethamine injection solution 30 mg/ml 1 QL (20 ML per 5 days)

meloxicam oral tablet 15 mg, 7.5 mg 1

nabumetone oral tablet 500 mg, 750 mg 1

naproxen oral suspension 125 mg/5ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium oral tablet 275 mg, 550 mg 1

salsalate oral tablet 500 mg, 750 mg 1

sulindac oral tablet 150 mg, 200 mg 1

Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración]

fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL (10 PATCHES per 30 days)

morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

1 QL (2 TABS per 1 day)

oxycodone hcl er oral 10 mg, 20 mg, 40 mg, 80 mg 3 QL (2 TABS per 1 day)

OXYCONTIN ORAL 15 MG, 30 MG, 60 MG 3 QL (2 TABS per 1 day)

Opioid Analgesics, Short-Acting [Analgésicos Opiodes, Corta Duración]

acetaminophen-codeine #2 oral tablet 300-15 mg 1 QL (12 TABS per 1 day)





acetaminophen-codeine oral solution 120-12 mg/5ml 1 QL (90 ML per 1 day)

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

1 QL (6 CAPS per 1 day)

butalbital-apap-caffeine oral capsule 50-325-40 mg 1

butalbital-apap-caffeine oral tablet 50-325-40 mg 1

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

1 QL (6 CAPS per 1 day)

CAPITAL/CODEINE ORAL SUSPENSION 120-12 MG/5ML 3 QL (90 ML per 1 day)

DEMEROL INJECTION SOLUTION 100 MG/2ML, 25 MG/0.5ML

3

DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML, 4 MG/ML

3 QL (200 ML per 30 days)

fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

3

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-acetaminophen oral tablet 2.5-325 mg 1 QL (12 TABS per 1 day)

hydrocodone-acetaminophen oral tablet 5-300 mg, 5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 2.5- 200 mg, 5-200 mg, 7.5-200 mg


hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml


hydromorphone hcl pf injection solution 10 mg/ml 1 QL (200 ML per 30 days)

meperidine hcl injection solution 10 mg/ml, 25 mg/ml 3


morphine sulfate (concentrate) oral solution 100 mg/5ml

1 QL (6 ML per 1 day)

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml

1

morphine sulfate oral solution 10 mg/5ml 1 QL (60 ML per 1 day)

morphine sulfate oral solution 20 mg/5ml 1 QL (30 ML per 1 day)

morphine sulfate oral tablet 15 mg 1 QL (4 TABS per 1 day)

morphine sulfate oral tablet 30 mg 1 QL (2 TABS per 1 day)

oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 QL (6 TABS per 1 day)

oxycodone hcl oral tablet 5 mg 1 QL (12 TABS per 1 day)

oxycodone-acetaminophen oral tablet 10-325 mg 1 QL (6 TABS per 1 day)

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg


oxycodone-acetaminophen oral tablet 7.5-325 mg 1 QL (8 TABS per 1 day)

tramadol hcl oral tablet 50 mg 1 QL (12 TABS per 1 day)

tramadol-acetaminophen oral tablet 37.5-325 mg




Anesthetics [Anestesicos]

Local Anesthetics [Anestésico Local]

lidocaine external ointment 5 % 1 QL (50 GM per 15 days)

lidocaine external patch 5 % 3 PA; QL (3 PATCHES per 1 day)

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 2 % 1

lidocaine hcl external gel 2 % 1 QL (85 GM per 15 days)

lidocaine hcl external solution 4 % 1 QL (100 ML per 15 days)

lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 % 1

lidocaine viscous mouth/throat solution 2 % 1 QL (100 ML per 15 days)

Anti-Addiction/Substance Abuse Treatment Agents [Tratamiento De Abuso De Sustancias/Contra La Addición]

Alcohol Deterrents/Anti-Craving [Disuasivos De Alcohol/Anti-Ansiedad]

naltrexone hcl oral tablet 50 mg 3

Opioid Reversal Agent [Reversión De Efecto Opioide]

naloxone hcl injection solution 0.4 mg/ml 3 PA

naloxone hcl injection solution 1 mg/ml 3

Smoking Cessation Agents [Cesación De Fumar]

bupropion hcl er (smoking det) oral tablet extended release 12 hr* 150 mg

1

NICOTROL INHALATION INHALER 10 MG 3

Antibacterials [Antibacterianos]

Aminoglycosides [Aminoglicósidos]

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

3

gentamicin sulfate external cream 0.1 % 3 QL (30 GM per 15 days)

gentamicin sulfate external ointment 0.1 % 3 QL (30 GM per 15 days)

gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml

1

gentamicin sulfate intravenous* solution 10 mg/ml 1

gentamicin sulfate ophthalmic ointment 0.3 % 1 QL (3.5 GM per 15 days)

gentamicin sulfate ophthalmic solution 0.3 % 1 QL (15 ML per 15 days)

neomycin sulfate oral tablet 500 mg 1

paromomycin sulfate oral capsule 250 mg 3

tobramycin ophthalmic solution 0.3 % 1 QL (5 ML per 15 days)

tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml

1

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %


TOBREX OPHTHALMIC OINTMENT 0.3 % 3 QL (3.5 GM per 15 days)

Antibacterials, Other [Antibacterianos, Otros]

acetic acid otic solution 2 % 3 QL (15 ML per 15 days)

acetic acid-aluminum acetate otic solution 2 % 3 QL (60 ML per 15 days)



bacitracin ophthalmic ointment 500 unit/gm 3 QL (3.5 GM per 15 days)

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

1 QL (3.5 GM per 15 days)

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1

clindamycin phosphate external solution 1 % 1 QL (60 ML per 15 days)

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml

1

clindamycin phosphate intravenous* solution 150 mg/ml, 600 mg/4ml, 900 mg/6ml

1

clindamycin phosphate vaginal cream 2 % 1 QL (40 GM per 15 days);

colistimethate sodium injection solution reconstituted 150 mg

3

CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

3

hydrocortisone-acetic acid otic solution 1-2 % 3 QL (10 ML per 15 days)

LINCOCIN INJECTION SOLUTION 300 MG/ML 3

methenamine hippurate oral tablet 1 gm 1

metronidazole external gel 0.75 % 3 QL (45 GM per 15 days)

metronidazole external cream 0.75 % 3 QL (45 GM per 15 days)

metronidazole external lotion 0.75 % 3 QL (59 ML per 15 days)

metronidazole oral capsule 375 mg 1

metronidazole oral tablet 250 mg, 500 mg 1

metronidazole vaginal 0.75 % 1 QL (70 GM per 15 days); GL

mupirocin external ointment 2 % 1 QL (22 GM per 15 days)

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000


neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1


neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1


neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25


neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

3 QL (7.5 ML per 15 days)

neomycin-polymyxin-hc otic solution 3.5-10000-1 1 QL (10 ML per 15 days)

neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 QL (10 ML per 15 days)

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg 3

nitrofurantoin macrocrystal oral capsule 50 mg 1

nitrofurantoin monohyd macro oral capsule 100 mg 3

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%


silver sulfadiazine external cream 1 % 1 QL (400 GM per 15 days)

SIVEXTRO ORAL TABLET 200 MG 3 PA; SL



trimethoprim oral tablet 100 mg 1

TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

3

vancomycin hcl intravenous* solution reconstituted 1000 mg, 500 mg, 750 mg

3

vancomycin hcl oral capsule 125 mg, 250 mg 3

XIFAXAN ORAL TABLET 200 MG, 550 MG 3

Beta-Lactam, Cephalosporins [Cefalosporinas, Beta-Lactámicas]

cefaclor oral capsule 250 mg, 500 mg 1

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

1

cefadroxil oral tablet 1 gm 1

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 mg

3

cefazolin sodium intravenous* solution reconstituted 1 gm

3

cefdinir oral capsule 300 mg 1

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefepime hcl injection solution reconstituted 1gm, 2gm 3

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

1

cefpodoxime proxetil oral tablet 100 mg, 200 mg 1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

cefprozil oral tablet 250 mg, 500 mg 1

ceftazidime injection solution reconstituted 1 gm, 2 gm 3

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

3

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg

3

cephalexin oral capsule 250 mg, 500 mg, 750 mg 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

FORTAZ INJECTION SOLUTION RECONSTITUTED 500 MG

3

ZINACEF INTRAVENOUS* SOLUTION RECONSTITUTED 750 MG

3

Beta-Lactam, Other [Beta-Lactámicos, Otros]

imipenem-cilastatin intravenous* solution reconstituted 250 mg, 500 mg

3

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM 3



Beta-Lactam, Penicillins [Penicilinas, Beta-Lactámicas]

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin-pot clavulanate er oral tablet extended release 12 hr* 1000-62.5 mg

1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400- 57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

1

ampicillin oral capsule 250 mg, 500 mg 1

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg

3

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

3

BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML

3

BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML

3

BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML

3

dicloxacillin sodium oral capsule 250 mg, 500 mg 1

oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm

1

penicillin g procaine intramuscular* suspension 600000 unit/ml

3

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral tablet 250 mg, 500 mg 1

piperacillin sod-tazobactam so intravenous* solution reconstituted 2-0.25 gm, 3-0.375 gm, 36-4.5 gm, 4-0.5 gm

3

TIMENTIN INTRAVENOUS* SOLUTION RECONSTITUTED 3.1 GM

3

Macrolides [Macrolidos]

erythromycin external 2 % 1 QL (60 GM per 15 days)

erythromycin external solution 2 % 1 QL (60 ML per 15 days)

Macrolides [Macrólidos]

azithromycin oral packet 1 gm 1



azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

clarithromycin oral tablet 250 mg, 500 mg 1

E.S.P. oral suspension reconstituted 200-600 mg/5ml 1

ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

3

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

3

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

3

ERYTHROCIN LACTOBIONATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG

3

ERYTHROCIN STEARATE ORAL TABLET 250 MG 3

erythromycin base oral capsule delayed release particles 250 mg

1

erythromycin base oral tablet 250 mg, 500 mg 3

erythromycin ethylsuccinate oral tablet 400 mg 3

erythromycin ophthalmic ointment 5 mg/gm 1 QL (3.5 GM per 15 days)

Quinolones [Quinolonas]

CIPRO HC OTIC SUSPENSION 0.2-1 % 3 QL (10 ML per 15 days)

CIPRODEX OTIC SUSPENSION 0.3-0.1 % 2 QL (7.5 ML per 15 days)

ciprofloxacin hcl ophthalmic solution 0.3 % 1 QL (10 ML per 15 days)

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

ciprofloxacin intravenous* solution 200 mg/20ml 3

ciprofloxacin intravenous* solution 400 mg/40ml 1

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

3

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg

3 QL (14 TABS per 30 days)

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 500 mg

3 QL (28 TABS per 30 days)

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

MOXEZA OPHTHALMIC SOLUTION 0.5 % 2 QL (3 ML per 15 days)

moxifloxacin hcl oral tablet 400 mg 3

ofloxacin ophthalmic solution 0.3 % 1 QL (10 ML per 15 days)

ofloxacin otic solution 0.3 % 1 QL (20 ML per 15 days)

VIGAMOX OPHTHALMIC SOLUTION 0.5 % 2 QL (3 ML per 15 days)

Sulfonamides [Sulfonamidas]

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 QL (10 ML per 15 days)



BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 3 QL (3.5 GM per 15 days)

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %


sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim intravenous* solution 400-80 mg/5ml

1

sulfamethoxazole-trimethoprim oral suspension 200- 40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1

Tetracyclines [Tetraciclinas]

demeclocycline hcl oral tablet 150 mg, 300 mg 3

doxycycline hyclate oral capsule 100 mg, 50 mg 3

doxycycline hyclate oral tablet 100 mg 3


doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

3

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1

tetracycline hcl oral capsule 250 mg, 500 mg 3

VIBRAMYCIN ORAL SYRUP 50 MG/5ML 3

Anticonvulsants [Anticonvulsivantes]

Anticonvulsants, Other [Anticonvulsivantes, Otros]

levetiracetam intravenous* solution 500 mg/5ml 3

levetiracetam oral solution 100 mg/ml 1

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

1

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50MG 3

Calcium Channel Modifying Agents [Modificadores De Canales De Calcio]

CELONTIN ORAL CAPSULE 300 MG 3

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5ml 1

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

3 ST

LYRICA ORAL SOLUTION 20 MG/ML 3 ST

zonisamide oral capsule 100 mg, 25 mg, 50 mg 1

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents [Aumentadores Del Ácido Gamma-Aminobutírico]

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 AL (greater than 18 years)

divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg

3

divalproex sodium oral capsule sprinkle 125 mg 1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1



gabapentin oral capsule 100 mg, 300 mg, 400 mg 1

gabapentin oral solution 250 mg/5ml 1

gabapentin oral tablet 600 mg, 800 mg 1

GABITRIL ORAL TABLET 12 MG, 16 MG 3

ONFI ORAL TABLET 10 MG, 20 MG, 5 MG 3

phenobarbital oral elixir 20 mg/5ml 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

primidone oral tablet 250 mg, 50 mg 1

tiagabine hcl oral tablet 2 mg, 4 mg 1

valproate sodium intravenous* solution 500 mg/5ml 1

valproic acid oral capsule 250 mg 1

valproic acid oral syrup 250 mg/5ml 1

Glutamate Reducing Agents [Reductores De Glutamato]

felbamate oral suspension 600 mg/5ml 1

felbamate oral tablet 400 mg, 600 mg 1

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

topiramate oral capsule sprinkle 15 mg, 25 mg 1

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

Sodium Channel Agents [Canales De Sodio]

BANZEL ORAL SUSPENSION 40 MG/ML 3

BANZEL ORAL TABLET 200 MG, 400 MG 3

carbamazepine er oral tablet extended release 12 hr* 200 mg, 400 mg

3

carbamazepine oral suspension 100 mg/5ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet chewable 100 mg 1

DILANTIN ORAL CAPSULE 30 MG 3

oxcarbazepine oral suspension 300 mg/5ml 1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1

PEGANONE ORAL TABLET 250 MG 3

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium injection solution 50 mg/ml 1

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

3

VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML 3



VIMPAT ORAL SOLUTION 10 MG/ML 3 AL (greater than or equal to 17 years)

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50MG 3 AL (greater than or equal to 17 years)

Antidementia Agents [Antidemencia]

Antidementia Agents, Other [Antidemencia, Otros]

ergoloid mesylates oral tablet 1 mg 3

Cholinesterase Inhibitors [Inhibidores De Colinesterasa]

donepezil hcl oral tablet 10 mg, 5 mg 1

donepezil hcl oral tablet dispersible 10 mg, 5 mg 1

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

1

galantamine hydrobromide oral solution 4 mg/ml 1

galantamine hydrobromide oral tablet 12 mg, 4mg, 8mg 1

memantine hcl oral tablet 10 mg, 5 (28)-10 (21)mg, 5 mg 3

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 28-10 MG

2

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

1

rivastigmine transdermal patch 24 hr 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

3 PA; QL (1 EA per 1 day)

N-Methyl-D-Aspartate (Nmda) Receptor Antagonist [Antagonista Del Receptor Nmda]

memantine hcl oral solution 2 mg/ml 3

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

2

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG

2

Antidepressants [Antidepresivos]

Antidepressants, Other [Antidepresivos, Otros]

bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg

1 SL

bupropion hcl oral tablet 100 mg, 75 mg 1 SL

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 SL

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 SL

Monoamine Oxidase Inhibitors [Inhibidores De Monoamino Oxidasa]

EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

3 PA; SL

MARPLAN ORAL TABLET 10 MG 3 SL

phenelzine sulfate oral tablet 15 mg 1 SL

tranylcypromine sulfate oral tablet 10 mg 3 SL

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) [SSRIs/SNRIs (Inhibidores De La Recaptación Selectiva De Serotonina / Inhibidores De La Recaptación De Serotonina Y Norepinefrina)]

citalopram hydrobromide oral solution 10 mg/5ml 1 SL



citalopram hydrobromide oral tablet 10mg, 20mg, 40mg 1 SL

duloxetine hcl oral capsule delayed release particles 20 mg

1 PA; SL; QL (3 CAPS per 1 day)

duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg

1 PA; SL; QL (2 CAPS per 1 day)

escitalopram oxalate oral solution 5 mg/5ml 1 SL

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 SL

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 SL

fluoxetine hcl oral solution 20 mg/5ml 1 SL

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 SL

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 1 SL

paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg

3 SL

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 SL

PAXIL ORAL SUSPENSION 10 MG/5ML 3 SL

sertraline hcl oral concentrate 20 mg/ml 1 SL

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SL

trazodone hcl oral tablet 100mg, 150 mg, 300 mg, 50mg 1 SL

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

1 SL

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

1 SL

Tricyclics [Tricíclicos]

amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 SL

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 SL

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 3 SL

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 SL

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 SL

doxepin hcl oral concentrate 10 mg/ml 1 SL

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 SL

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1 SL

trimipramine maleate oral capsule 100 mg, 25mg, 50mg 1 SL

Antiemetics [Antieméticos]

Antiemetics, Other [Antieméticos, Otros]

diphenhydramine hcl injection solution 50 mg/ml 3

meclizine hcl oral tablet 12.5 mg, 25 mg 1

metoclopramide hcl oral solution 5 mg/5ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1



pharbedryl oral capsule 50 mg 1

promethazine hcl injection solution 25 mg/ml, 50 mg/ml 1

promethazine hcl oral syrup 6.25 mg/5ml 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1

promethazine hcl suppository 12.5 mg, 25 mg, 50 mg 3

trimethobenzamide hcl oral capsule 300 mg 1

Emetogenic Therapy Adjuncts [Adjuvantes Para Terapia Emetogénica]

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1

EMEND ORAL CAPSULE 125 MG 3 PA; SL; QL (1 CAPS per 7 days)

EMEND ORAL CAPSULE 80 & 125 MG 3 PA; SL; QL (3 CAPS per 7 days)

EMEND ORAL CAPSULE 80 MG 3 PA; SL; QL (2 CAPS per 7 days)

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

5

ondansetron hcl oral tablet 4 mg, 8 mg 1

ondansetron oral tablet dispersible 4 mg, 8 mg 1

Antifungals [Antifungales]


CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG

4 PA; SL

ciclopirox external solution 8 % 3 QL (6.6 ML per 90 days)

clotrimazole external cream 1 % 1 QL (45 GM per 15 days)

clotrimazole external solution 1 % 1 QL (30 ML per 15 days)

clotrimazole mouth/throat troche 10 mg 1

clotrimazole-betamethasone external cream 1-0.05 % 3 AL (greater than or equal to 18 years); QL (45 GM per 15 days)

clotrimazole-betamethasone external lotion 1-0.05 % 3 AL (greater than or equal to 18 years); QL (30 ML per 15 days)

econazole nitrate external cream 1 % 1 QL (85 GM per 15 days)

ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG

4 PA; SL

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

1

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1

flucytosine oral capsule 250 mg, 500 mg 3

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 3

itraconazole oral capsule 100 mg 3

ketoconazole external cream 2 % 1 QL (60 GM per 15 days)

ketoconazole external shampoo 2 % 1 QL (120 ML per 15 days)

ketoconazole oral tablet 200 mg 1

MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG

4 PA; SL

NATACYN OPHTHALMIC SUSPENSION 5 % 3 QL (15 ML per 15 days)



nystatin external cream 100000 unit/gm 1 QL (30 GM per 15 days)

nystatin external ointment 100000 unit/gm 1 QL (30 GM per 15 days)

nystatin mouth/throat suspension 100000 unit/ml 1

nystatin oral tablet 500000 unit 1

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

3 QL (60 GM per 15 days)

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%


terbinafine hcl oral tablet 250 mg 1 QL (84 TABS per 90 days)

terconazole vaginal cream 0.4 % 1 QL (45 GM per 15 days); GL

terconazole vaginal cream 0.8 % 1 QL (20 GM per 15 days); GL

terconazole vaginal suppository 80 mg 3 QL (3 SUPP per 15 days); GL

voriconazole oral tablet 200 mg, 50 mg 3 PA; SL

Antigout Agents [Antigota]


allopurinol oral tablet 100 mg, 300 mg 1

colchicine oral tablet 0.6 mg 3

colchicine-probenecid oral tablet 0.5-500 mg 1

probenecid oral tablet 500 mg 1

Anti-Inflammatory Agents [Anti-Inflamatorios]

Glucocorticoids [Glucocorticoides]

A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 100 MG

3

budesonide er oral capsule extended release 24 hour 3mg

3 PA,SL

cortisone acetate oral tablet 25 mg 3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 3

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1MG/ML

3

dexamethasone oral elixir 0.5 mg/5ml 1

dexamethasone oral solution 0.5 mg/5ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5mg, 2 mg, 4 mg, 6 mg

1

dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4mg/ml

1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

MEDROL ORAL TABLET 2 MG 3

methylprednisolone acetate injection suspension 40mg/ml, 80 mg/ml

1

methylprednisolone oral tablet 16 mg, 32mg, 4mg, 8mg 1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

3



MILLIPRED ORAL TABLET 5 MG 3

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5mg, 50 mg

1

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG

3

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG

3

Antimigraine Agents [Antimigraña]

Ergot Alkaloids [Alcaloides De Ergotamina]

dihydroergotamine mesylate nasal solution 4 mg/ml 3

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 3

Serotonin (5-Ht) 1B/1D Receptor Agonists [Agonistas Del Receptor De Serotonina]

RELPAX ORAL TABLET 20 MG, 40 MG 3 ST; QL (6 TABS per 30 days)

sumatriptan succinate oral tablet 100 mg 1 QL (9 TABS per 30 days)

sumatriptan succinate oral tablet 25 mg, 50 mg 1 QL (18 TABS per 30 days)

sumatriptan succinate subcutaneous* solution 6 mg/0.5ml


Antimyasthenic Agents [Antimiasténicos]

Parasympathomimetics [Parasimpatomiméticos]

MESTINON ORAL SYRUP 60 MG/5ML 3

pyridostigmine bromide er oral tablet extendedrelease* 180 mg

3

pyridostigmine bromide oral tablet 60 mg 1

Antimycobacterials [Antimicobacterianos]

Antimycobacterials, Other [Antimicobacterianos, Otros]

dapsone oral tablet 100 mg, 25 mg 3

rifabutin oral capsule 150 mg 3

Antituberculars [Antituberculosos]

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

3

cycloserine oral capsule 250 mg 3

ethambutol hcl oral tablet 100 mg, 400 mg 1

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1

PASER ORAL PACKET 4 GM 3

PRIFTIN ORAL TABLET 150 MG 3

rifampin intravenous* solution reconstituted 600 mg 3

rifampin oral capsule 150 mg, 300 mg 1

RIFATER ORAL TABLET 50-120-300 MG 3

TRECATOR ORAL TABLET 250 MG

3



Antineoplastics [Antineoplásicos]

Retinoids [Retinoides]

PANRETIN EXTERNAL 0.1 % 5 QL (60 GM per 15 days)

TARGRETIN EXTERNAL 1 % 5 QL (60 GM per 15 days)

Antiparasitics [Antiparasitarios]

Anthelmintics [Antihelmínticos]

ALBENZA ORAL TABLET 200 MG 3

BILTRICIDE ORAL TABLET 600 MG 3

ivermectin oral tablet 3 mg 3

Antiprotozoals [Antiprotozoarios]

ALINIA ORAL SUSPENSION RECONSTITUTED 100MG/5ML


ALINIA ORAL TABLET 500 MG 3 QL (6 TABS per 3 days)

atovaquone oral suspension 750 mg/5ml 3

atovaquone-proguanil hcl oral tablet 250-100 mg 3 QL (12 TABS per 365 days)

atovaquone-proguanil hcl oral tablet 62.5-25 mg 3 QL (48 TABS per 365 days)

chloroquine phosphate oral tablet 250 mg, 500 mg 1

COARTEM ORAL TABLET 20-120 MG 3 QL (24 TABS per 365 days)

DARAPRIM ORAL TABLET 25 MG 5 PA,SL

hydroxychloroquine sulfate oral tablet 200 mg 1

mefloquine hcl oral tablet 250 mg 3

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

3

PENTAM INJECTION SOLUTION RECONSTITUTED 300MG

3

primaquine phosphate oral tablet 26.3 mg 3

quinine sulfate oral capsule 324 mg 3 QL (42 CAPS per 365 days)

Pediculicides/Scabicides [Pediculicidas/Escabicidas]

EURAX EXTERNAL CREAM 10 % 3 QL (60 GM per 30 days)

EURAX EXTERNAL LOTION 10 % 3 QL (60 ML per 30 days)

lindane external lotion 1 % 3 ST; QL (60 ML per 30 days)

lindane external shampoo 1 % 3 QL (60 ML per 30 days)

permethrin external cream 5 % 1 QL (60 GM per 30 days)

Antiparkinson Agents [Antiparkinson]

Anticholinergics [Anticolinérgicos]

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1

trihexyphenidyl hcl oral elixir 0.4 mg/ml 1

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1

Antiparkinson Agents, Others [Antiparkinson, Otros]

amantadine hcl oral capsule 100 mg 1



carbidopa-levodopa-entacapone oral tablet 12.5-50- 200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125- 200 mg, 37.5-150-200 mg, 50-200-200 mg

1

entacapone oral tablet 200 mg 3

tolcapone oral tablet 100 mg 3

Dopamine Agonist [Agonistas De Dopamine]

APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML 4

bromocriptine mesylate oral capsule 5 mg 3

bromocriptine mesylate oral tablet 2.5 mg 1

NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8MG/24HR

3

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors [Precursores De Dopamina/Inhibidores Del L-Amino Acid Decarboxylase]

carbidopa oral tablet 25 mg 3

carbidopa-levodopa er oral tablet extendedrelease* 25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

Monoamine Oxidase B (Mao-B) Inhibitors [Inhibidores De Mao-B]

AZILECT ORAL TABLET 0.5 MG, 1 MG 3 ST

selegiline hcl oral capsule 5 mg 1

Antipsychotics [Antipsicóticos]

1St Generation/Typical [1Ra Generación/Típicos]

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

1 PA

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

1

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1

prochlorperazine edisylate injection solution 5 mg/ml 1 PA

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine suppository 25 mg

1

Antispasticity Agents [Antiespasticidad]

Antispasticity [Antiespasticidad]

baclofen oral tablet 10 mg, 20 mg 1

dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1

tizanidine hcl oral tablet 2 mg, 4 mg

1



Antivirals [Antivirales]

Anti-Cytomegalovirus (Cmv) Agents [Anti-Citomegalovirus]

FOSCAVIR INTRAVENOUS* SOLUTION 24 MG/ML 4

ganciclovir sodium intravenous* solution reconstituted 500 mg

4

Valganciclovir hcl oral tablet 450 mg

5

Anti-Hepatitis B (Hbv) Agents [Anti-Hepatitis B]

adefovir dipivoxil oral tablet 10 mg 4 PA; SL

BARACLUDE ORAL SOLUTION 0.05 MG/ML 4 PA; SL

entecavir oral tablet 0.5 mg, 1 mg 4 PA; SL

EPIVIR HBV ORAL SOLUTION 5 MG/ML 3 PA; SL

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

5 PA; SL

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

5 PA; SL

lamivudine oral tablet 100 mg 1 PA; SL

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML

5 PA; SL

PEGASYS SUBCUTANEOUS* SOLUTION 180MCG/0.5ML, 180 MCG/ML

5 PA; SL

TYZEKA ORAL TABLET 600 MG 4 PA; SL

Anti-Hepatitis C (Hcv) Agents [Anti- Hepatitis C]

HARVONI ORAL TABLET 90-400 MG 4

PA; SL; AL (greater than or equal to 18 years)

INFERGEN SUBCUTANEOUS* INJECTABLE 15MCG/0.5ML

5 PA; SL

PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120MCG/0.5ML, 50 MCG/0.5ML

4 PA; SL

PEG-INTRON SUBCUTANEOUS* KIT 150 MCG/0.5ML, 80 MCG/0.5ML

5 PA; SL

ribavirin oral capsule 200 mg 4 PA; SL

ribavirin oral tablet 200 mg 4 PA; SL

SOVALDI ORAL TABLET 400 MG 4 PA; SL; AL (greater than or equal to 18 years)

Antiherpetic Agents [Antiherpéticos]

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5ml 1

acyclovir oral tablet 400 mg, 800 mg 1

acyclovir sodium intravenous* solution reconstituted 1000 mg, 500 mg

3

famciclovir oral tablet 125 mg, 500 mg 1 QL (21 TABS per 7 days)

famciclovir oral tablet 250 mg 1 QL (2 TABS per 1 day)



trifluridine ophthalmic solution 1 % 3 QL (7.5 ML per 15 days)

valacyclovir hcl oral tablet 1 gm, 500 mg 1

Anti-Hiv Agents, Integrase Inhibitors (Insti) [Anti-Vih, Inhibidor De Integrasa]

ISENTRESS ORAL TABLET 400 MG 3

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 3

STRIBILD ORAL TABLET 150-150-200-300 MG 3

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) [Anti-Vih, Inhibidores No Nucleósidos De La Transciptasa Reversa]

abacavir-lamivudine-zidovudine oral tablet 300-150- 300 mg

3

ATRIPLA ORAL TABLET 600-200-300 MG 3

COMPLERA ORAL TABLET 200-25-300 MG 3

EDURANT ORAL TABLET 25 MG 3

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG 3 PA; SL

nevirapine er oral tablet extended release 24 hr* 100 mg, 400 mg

3

nevirapine oral suspension 50 mg/5ml 3

nevirapine oral tablet 200 mg 3

RESCRIPTOR ORAL TABLET 100 MG, 200 MG 3

SUSTIVA ORAL CAPSULE 200 MG, 50 MG 3

SUSTIVA ORAL TABLET 600 MG 3

TRIUMEQ ORAL TABLET 600-50-300 MG 3

Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) [Anti-Vih, Inhibidores Nucleósidos Y Nucleótidos De La Transcriptasa Reversa]

abacavir sulfate oral tablet 300 mg 3

didanosine oral capsule delayed release 125 mg, 200mg, 250 mg, 400 mg

1

EMTRIVA ORAL CAPSULE 200 MG 3

EMTRIVA ORAL SOLUTION 10 MG/ML 3

EPZICOM ORAL TABLET 600-300 MG 3

EVOTAZ ORAL TABLET 300-150 MG 3

lamivudine oral solution 10 mg/ml 3

lamivudine oral tablet 150 mg, 300 mg 1

lamivudine-zidovudine oral tablet 150-300 mg 3

PREZCOBIX ORAL TABLET 800-150 MG 3

RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML 3

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1

stavudine oral solution reconstituted 1 mg/ml 1

TRUVADA ORAL TABLET 200-300 MG 3

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM 3

VIREAD ORAL POWDER 40 MG/GM 3 PA; SL



VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300MG

3 PA; SL

ZIAGEN ORAL SOLUTION 20 MG/ML 3

zidovudine oral capsule 100 mg 1

zidovudine oral syrup 50 mg/5ml 1

zidovudine oral tablet 300 mg 1

Anti-Hiv Agents, Others [Anti-Vih, Otros]

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG

5 PA; SL

SELZENTRY ORAL TABLET 150 MG, 300 MG 3 PA; SL

TYBOST ORAL TABLET 150 MG 3

Anti-Hiv Agents, Protease Inhibitors [Anti-Vih, Inhibidores De La Proteasa]

APTIVUS ORAL CAPSULE 250 MG 3 PA; SL

APTIVUS ORAL SOLUTION 100 MG/ML 3 PA; SL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 3

INVIRASE ORAL CAPSULE 200 MG 3

INVIRASE ORAL TABLET 500 MG 3

KALETRA ORAL SOLUTION 400-100 MG/5ML 3

KALETRA ORAL TABLET 100-25 MG, 200-50 MG 3

LEXIVA ORAL SUSPENSION 50 MG/ML 3

LEXIVA ORAL TABLET 700 MG 3

NORVIR ORAL CAPSULE 100 MG 3

NORVIR ORAL SOLUTION 80 MG/ML 3

NORVIR ORAL TABLET 100 MG 3

PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75MG, 800 MG

3

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 3

VIRACEPT ORAL TABLET 250 MG, 625 MG 3

Anti-Influenza Agents [Antiinfluenza]

RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER

3

rimantadine hcl oral tablet 100 mg 1

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG 3

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6MG/ML

3

Anxiolytics [Ansiolíticos]

Anxiolytics, Other [Ansiolíticos, Otros]

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1 SL

hydroxyzine pamoate oral capsule 100mg, 25mg, 50mg

1 SL



Benzodiazepines [Benzodiazepinas]

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 SL; AL (greater than 18 years)

clorazepate dipotassium oral tablet 15mg, 3.75mg, 7.5mg

1 SL; AL (greater than 18 years)

diazepam oral tablet 10 mg, 2 mg, 5 mg 1 SL; AL (greater than 18 years)

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 SL; AL (greater than 18 years)

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 SL; AL (greater than 18 years)

Blood Glucose Regulators [Reguladores De Glucosa En Sangre]

Antidiabetic Agents [Antidiabéticos]

acarbose oral tablet 100 mg, 25 mg, 50 mg 1

BYDUREON SUBCUTANEOUS* 2 MG 2 ST; QL (4 EA per 28 days)

BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG

2 ST; QL (4 EA per 28 days)

BYETTA 10 MCG PEN SUBCUTANEOUS* 10MCG/0.04ML

2 ST; QL (2.4 ML per 30 days)

BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML 2 ST; QL (1.2 ML per 30 DAYs)

glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg

1

glipizide oral tablet 10 mg, 5 mg 1

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5- 500 mg, 5-500 mg

1

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

glyburide-metformin oral tablet 1.25-250 mg, 2.5- 500 mg, 5-500 mg

1

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG 3 ST

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG 2

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG

2

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 2

JARDIANCE ORAL TABLET 10 MG, 25 MG 2 ST

JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG

3

metformin hcl er oral tablet extended release 24 hr* 500 mg, 750 mg

1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1

nateglinide oral tablet 120 mg, 60 mg 1

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1 ST

SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML 3 PA; SL; QL (13.5 ML per 30 days)

SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML 3 PA; SL; QL (13.5 ML per 30 days)



TRADJENTA ORAL TABLET 5 MG 3

VICTOZA SUBCUTANEOUS* 18 MG/3ML 2 ST; QL (9 ML per 30 days)

Glycemic Agents [Glicémicos]

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG

3

PROGLYCEM ORAL SUSPENSION 50 MG/ML 3

Insulins [Insulinas]

APIDRA INJECTION SOLUTION 100 UNIT/ML 3 QL (120 ML per 90 days)

HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML


HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 2 QL (120 ML per 90 days)

HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML


HUMULIN N SUBCUTANEOUS* SUSPENSION 100UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML 2 QL (120 ML per 90 days)

LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML 2 QL (120 ML per 90 days)

RELION R INJECTION SOLUTION 100 UNIT/ML 2 QL (120 ML per 90 days)

Blood Glucose Regulators [Reguladores De Glucosa En Sangre]

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG 3 ST


SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG

2 ST

Blood Products/ Modifiers/ Volume Expanders [Productos Para La Sangre/Modificadores/Expansores De Volumen]

Anticoagulants [Anticoagulantes]

enoxaparin sodium injection solution 300 mg/3ml 3

enoxaparin sodium subcutaneous* solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

3

fondaparinux sodium subcutaneous* solution 10mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

3

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

1

PRADAXA ORAL CAPSULE 150 MG, 75 MG 3 PA

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

XARELTO ORAL TABLET 10 MG 2

XARELTO ORAL TABLET 15 MG, 20 MG 2 PA

XARELTO STARTER PACK ORAL 15 & 20 MG

2 PA



Antihemophilics [Antihemofílicos]

ADVATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT

4 PA; SL

adynovate intravenous* solution reconstituted 1000unit, 2000 unit, 250 unit, 500 unit

5 PA; SL

ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

5 PA; SL

ALPHANINE SD INTRAVENOUS* SOLUTION RECONSTITUTED 1500 UNIT

5 PA; SL

ALPROLIX INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5 PA; SL

BEBULIN INTRAVENOUS* SOLUTION RECONSTITUTED 200-1200 UNIT

5 PA; SL

COAGADEX INTRAVENOUS* SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT

5 PA; SL

ELOCTATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT, 750 UNIT

5 PA; SL

FEIBA INTRAVENOUS* SOLUTION RECONSTITUTED 5 PA; SL

HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

5 PA; SL

HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 1501-2000 UNIT, 1700 UNIT, 220-400UNIT, 401-800 UNIT, 801-1500 UNIT

4 PA; SL

HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

5 PA; SL

IDELVION INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500UNIT

5 PA; SL

KOGENATE FS INTRAVENOUS* KIT 1000 UNIT, 2000UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5 PA; SL

KOVALTY INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5 PA; SL

MONOCLATE-P INTRAVENOUS* KIT 1000 UNIT, 1500UNIT, 250 UNIT, 500 UNIT

5 PA; SL

MONONINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT

5 PA; SL

NOVOEIGHT INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT

5 PA; SL

NOVOSEVEN INTRAVENOUS* SOLUTION RECONSTITUTED 2400 MCG

5 PA; SL



NOVOSEVEN RT INTRAVENOUS* SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG

5 PA; SL

OBIZUR INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT

5 PA; SL

PROFILNINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT

5 PA; SL

RECOMBINATE INTRAVENOUS* SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT

4 PA; SL

RIXUBIS INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT

5 PA; SL

WILATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT

5 PA; SL

XYNTHA INTRAVENOUS* KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

5 PA; SL

XYNTHA SOLOFUSE INTRAVENOUS* KIT 3000 UNIT 5 PA; SL

Blood Formation Modifiers [Modificadores De La Formación De Sangre]

LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG

5 SL

NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG

5

NEUPOGEN INJECTION 300 MCG/0.5ML, 480MCG/0.8ML

5

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480MCG/1.6ML

5

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000UNIT/ML, 40000 UNIT/ML

4 PA

PROMACTA ORAL TABLET 12.5MG, 25MG, 50MG, 75MG

5 PA; AL (greater than or equal to 18 years)

Coagulants [Coagulantes]

tranexamic acid intravenous* solution 100 mg/ml 4 QL (1600 ML per 8 days)

Platelet Modifying Agents [Modificadores De Plaquetas]

anagrelide hcl oral capsule 0.5 mg, 1 mg 1

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

3

BRILINTA ORAL TABLET 60 MG, 90 MG 3 PA; SL

cilostazol oral tablet 100 mg, 50 mg 1

clopidogrel bisulfate oral tablet 75 mg 1

EFFIENT ORAL TABLET 10 MG, 5 MG 3 PA; SL

ticlopidine hcl oral tablet 250 mg 1

Cardiovascular Agents [Cardiovasculares]

Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1



clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr

3

guanfacine hcl oral tablet 1 mg, 2 mg 1

methyldopa oral tablet 250 mg, 500 mg 1

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1

Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

Angiotensin Ii Receptor Antagonists [Antagonistas Del Receptor Angiotensina Ii]

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

1

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

1

losartan potassium-hctz oral tablet 100-12.5 mg, 100- 25 mg, 50-12.5 mg

1

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina]

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

3

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

moexipril hcl oral tablet 15 mg, 7.5 mg 1

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

3



perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

3

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

Antiarrhythmics [Antiarrítmicos]

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg 3

disopyramide phosphate oral capsule 100 mg, 150 mg 1

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

3

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1

quinidine gluconate er oral tablet extendedrelease* 324 mg

1

quinidine sulfate er oral tablet extendedrelease* 300 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg 1

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3

Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]

acebutolol hcl oral capsule 200 mg, 400 mg 1

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

betaxolol hcl oral tablet 10 mg, 20 mg 1

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1

metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

3

pindolol oral tablet 10 mg, 5 mg 1

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

1



propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1

propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360mg

1

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

nicardipine hcl oral capsule 20 mg, 30 mg 1

nifedipine er oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg

1

nifedipine er osmotic release oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg

1

nimodipine oral capsule 30 mg 3

verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg

1

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

Cardiovascular Agents, Other [Cardiovasculares, Otros]

CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT

4 PA

digoxin oral tablet 125 mcg, 250 mcg 1

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML 5 PA; AL (greater than 18 years)

pentoxifylline er oral tablet extendedrelease* 400 mg 1

phenoxybenzamine hcl oral capsule 10 mg 3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG

3 PA; SL

Diuretics, Carbonic Anhydrase Inhibitors [Diuréticos Inhibidores De Anhidrasa Carbónica]

acetazolamide oral tablet 125 mg, 250 mg 1

methazolamide oral tablet 25 mg, 50 mg 1

Diuretics, Loop [Diuréticos Del Asa]

bumetanide injection solution 0.25 mg/ml 1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

furosemide injection solution 10 mg/ml 1



furosemide oral solution 10 mg/ml, 8 mg/ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1

Diuretics, Potassium-Sparing [Diuréticos Conservadores De Potasio]

ALDACTAZIDE ORAL TABLET 50-50 MG 3 ST

amiloride hcl oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

eplerenone oral tablet 25 mg, 50 mg 3 ST

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolactone-hctz oral tablet 25-25 mg 1

triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg 1

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

Diuretics, Thiazide [Diuréticos Tiazidas]

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 100 mg, 25 mg, 50 mg 1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

Dyslipidemics, Fibric Acid Derivatives [Dislipidémicos, Derivados De Ácido Fíbrico]

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 1

fenofibric acid oral capsule delayed release 135 mg, 45mg

1

gemfibrozil oral tablet 600 mg 1

Dyslipidemics, Hmg Coa Reductase Inhibitors [Dislipidémicos, Inhibidores De La Reductasa De Hmg Coa]

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80mg

1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

simvastatin oral tablet 80 mg 1 PA

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG 2 ST

VYTORIN ORAL TABLET 10-80 MG 2 PA

Dyslipidemics, Other [Dislipidémicos, Otros]

cholestyramine light oral packet 4 gm 3

cholestyramine light oral powder 4 gm/dose 1

cholestyramine oral packet 4 gm 3

cholestyramine oral powder 4 gm/dose 1

colestipol hcl oral granules 5 gm 1



colestipol hcl oral tablet 1 gm 1

niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 500 mg, 750 mg

1

omega-3-acid ethyl esters oral capsule 1 gm 3 QL (360 CAPS per 90 days)

WELCHOL ORAL PACKET 3.75 GM 3

WELCHOL ORAL TABLET 625 MG 3

ZETIA ORAL TABLET 10 MG 2 ST

Vasodilators, Direct-Acting Arterial [Vasodilatadores, Arteriales]

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

minoxidil oral tablet 10 mg, 2.5 mg 1

Vasodilators, Direct-Acting Arterial/Venous [Vasodilatadores, Arteriales/Venosos]

ISORDIL TITRADOSE ORAL TABLET 40 MG 3

isosorbide dinitrate er oral tablet extendedrelease* 40mg

1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5mg

1

isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg

1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3MG, 0.4 MG, 0.6 MG

3


Combinations, Others [Combinaciones, Otros]

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103MG

2 PA; SL

Central Nervous System Agents [Sistema Nervioso Central]

Adhd, Amphetamines [Anfetaminas, Adhd]

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg

1 ST; SL; AL (less than or equal to 18 years); QL (3 TABS per 1 day)

amphetamine-dextroamphetamine oral tablet 30 mg 1 ST; SL; AL (less than or equal to 18 years); QL (1 TABS per 1 day)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg

1 SL; AL (less than or equal to 18 years); QL (4 CAPS per 1 day)

dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg

1 SL; AL (less than or equal to 18 years); QL (3 CAPS per 1 day)

dextroamphetamine sulfate oral tablet 5 mg 1 SL; AL (less than or equal to 18 years); QL (3 TABS per 1 day)

Adhd, Non-Amphetamines [No-Anfetaminas, Adhd]

clonidine hcl er oral tablet extended release 12 hr* 0.1mg

3 SL; QL (1 TABS per 1 day)

methylphenidate hcl er oral tablet extendedrelease* 10mg

1 AL (less than or equal to 18 years); QL (1 TABS per 1 day)



methylphenidate hcl er oral tablet extendedrelease* 20mg

1 SL; AL (less than or equal to 18 years); QL (1 TABS per 1 day)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 SL; AL (less than or equal to 18 years); QL (3 TABS per 1 day)

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40MG

3 PA; ST; SL; AL (less than or equal to 18 years); QL (3 CAPS per 1 day)

STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 3 PA; ST; SL; AL (less than or equal to 18 years); QL (1 CAPS per 1 day)

Central Nervous System Agents, Others [Sistema Nervioso Central, Otros]

BOTOX INJECTION SOLUTION RECONSTITUTED 100UNIT, 200 UNIT

5 PA

DYSPORT INTRAMUSCULAR* SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT

5 PA

MYOBLOC INTRAMUSCULAR* SOLUTION 10000UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML

5 PA

riluzole oral tablet 50 mg 4 PA

tetrabenazine oral tablet 12.5 mg, 25 mg 5

XEOMIN INTRAMUSCULAR* SOLUTION RECONSTITUTED 100 UNIT, 50 UNIT

5 PA

Multiple Sclerosis Agents [Esclerosis Múltiple]

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG

5 PA; SL

AVONEX INTRAMUSCULAR* KIT 30 MCG 4 PA; SL

AVONEX PEN INTRAMUSCULAR* 30 MCG/0.5ML 4 PA; SL

AVONEX PREFILLED INTRAMUSCULAR* 30 MCG/0.5ML 4 PA; SL

COPAXONE SUBCUTANEOUS* 20 MG/ML 4 PA; SL; QL (1 ML per 1 DAY)

COPAXONE SUBCUTANEOUS* 40 MG/ML 4 PA; SL; QL (12 ML per 30 days)

EXTAVIA SUBCUTANEOUS* KIT 0.3 MG 4 PA; SL

GILENYA ORAL CAPSULE 0.5 MG 5 PA; SL

REBIF REBIDOSE SUBCUTANEOUS* 22 MCG/0.5ML, 44MCG/0.5ML

5 PA; SL

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X22 MCG

5 PA; SL

REBIF SUBCUTANEOUS* 22 MCG/0.5ML, 44 MCG/0.5ML 5 PA; SL

REBIF TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X22 MCG

5 PA; SL

TYSABRI INTRAVENOUS* CONCENTRATE 300MG/15ML

5 PA; SL

Dental And Oral Agents [Dentales Y Orales]

Dental And Oral Agents [Dentales Y Orales]

chlorhexidine gluconate mouth/throat solution 0.12 % 1 QL (473 ML per 15 days)

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

triamcinolone acetonide mouth/throat paste 0.1 % 3 QL (5 GM per 15 days)



Dermatological Agents [Dermatologicos]


ABSORICA ORAL CAPSULE 25 MG, 35 MG 3

AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG 1

CLARAVIS ORAL CAPSULE 30 MG 1

tretinoin external 0.01 %, 0.025 % 3 SL; AL (less than or equal to 23 years); QL (45 GM per 15 days)

tretinoin external cream 0.025 %, 0.05 %, 0.1 % 3 SL; AL (less than or equal to 23 years); QL (45 GM per 15 days)

Dermatological Agents [Dermatológicos]

Dermatological Agents [Dermatológicos]

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 3

ammonium lactate external cream 12 % 1 QL (385 GM per 15 days)

ammonium lactate external lotion 12 % 1 QL (420 ML per 15 days)

calcipotriene external cream 0.005 % 3 QL (120 GM per 15 days)

calcipotriene external solution 0.005 % 3 QL (60 GM per 15 days)

calcitriol external ointment 3 mcg/gm 3 QL (100 GM per 15 days)

CONDYLOX EXTERNAL 0.5 % 3 QL (3.5 GM per 15 days)

diclofenac sodium transdermal 3 % 3 QL (100 GM per 15 days)

ELIDEL EXTERNAL CREAM 1 % 3 ST; QL (100 GM per 15 days)

fluorouracil external cream 0.5 % 3 QL (30 GM per 15 days)

fluorouracil external cream 5 % 1 QL (40 GM per 15 days)

imiquimod external cream 5 % 3 QL (12 GM per 15 days)

methoxsalen rapid oral capsule 10 mg 3

podofilox external solution 0.5 % 3 QL (3.5 ML per 15 days)

REGRANEX EXTERNAL 0.01 % 5 PA; QL (15 GM per 15 days)

SANTYL EXTERNAL OINTMENT 250 UNIT/GM 3 QL (30 GM per 15 days)

selenium sulfide external lotion 2.5 % 1 QL (120 ML per 15 days)

sodium chloride irrigation solution 0.9 % 1

tacrolimus external ointment 0.03 %, 0.1 % 3 ST; QL (100 GM per 15 days)

TAZORAC EXTERNAL 0.05 %, 0.1 % 3 PA; QL (100 GM per 15 days)

TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % 3 PA; QL (60 GM per 15 days)

Enzyme Replacements/Modifiers [Reemplazo De Enzimas/Modificadores]

Enzyme Replacements/Modifiers [Reemplazo De Enzimas/Modificadores]

ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML 5 PA; SL

ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML 5 PA; SL

BUPHENYL ORAL TABLET 500 MG 5 PA; SL

CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

5 PA; SL

CYSTADANE ORAL POWDER 5 PA; SL

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 5 PA; SL



ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML 5 PA; SL

ELELYSO INTRAVENOUS* SOLUTION RECONSTITUTED 200 UNIT

5 PA; SL

FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG, 5 MG

5 PA; SL

KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA; SL

NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML 5 PA; SL

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5 PA; SL

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200UNIT

3

sodium phenylbutyrate oral powder 3 gm/tsp 5 PA; SL

VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

5 PA; SL

ZAVESCA ORAL CAPSULE 100 MG 5 PA; SL

Gastrointestinal Agents [Gastrointestinales]

Antispasmodics, Gastrointestinal [Antiespasmódicos, Gastrointestinales]

dicyclomine hcl oral capsule 10 mg 1

dicyclomine hcl oral tablet 20 mg 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

methscopolamine bromide oral tablet 2.5 mg, 5 mg 1

Gastrointestinal Agents, Others [Gastrointestinales, Otros]

cromolyn sodium oral concentrate 100 mg/5ml 1

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

FULYZAQ ORAL TABLET DELAYED RELEASE 125 MG 5 PA; SL; QL (2 TABS per 1 day)

loperamide hcl oral capsule 2 mg 1

RELISTOR SUBCUTANEOUS* KIT 12 MG/0.6ML 3 PA

ursodiol oral capsule 300 mg 1

ursodiol oral tablet 250 mg, 500 mg 1

Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De Histamina2 (H2)]

cimetidine hcl oral solution 300 mg/5ml 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg 1

famotidine intravenous* solution 20 mg/2ml 1

famotidine oral tablet 20 mg, 40 mg 1

ranitidine hcl injection solution 1000 mg/40ml, 150mg/6ml, 50 mg/2ml

1

ranitidine hcl oral syrup 75 mg/5ml 1

ranitidine hcl oral tablet 150 mg, 300 mg 1

Irritable Bowel Syndrome Agents [Sindrome De Colon Irritado]

alosetron hcl oral tablet 0.5 mg, 1 mg 3



Irritable Bowel Syndrome Agents [Síndrome De Colon Irritado]

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 PA; QL (2 CAPS per 1 day)

Laxatives [Laxantes]

lactulose encephalopathy oral solution 10 gm/15ml 1

lactulose oral solution 10 gm/15ml 1

peg 3350/electrolytes oral solution reconstituted 240gm


peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

1

peg-3350/electrolytes oral solution reconstituted 236gm


Protectants [Protectores]

CARAFATE ORAL SUSPENSION 1 GM/10ML 3

misoprostol oral tablet 100 mcg, 200 mcg 3

sucralfate oral tablet 1 gm 1

Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]

cvs lansoprazole oral capsule delayed release 15 mg OTC

cvs omeprazole oral capsule delayed release 20.6 (20 base) mg

OTC

cvs omeprazole oral tablet delayed release 20 mg OTC

eq lansoprazole oral capsule delayed release 15 mg OTC

eq omeprazole magnesium oral capsule delayed release 20 mg

OTC

eq omeprazole oral tablet delayed release 20 mg OTC

eql omeprazole oral tablet delayed release 20 mg OTC

gnp lansoprazole oral capsule delayed release 15 mg OTC

gnp omeprazole oral tablet delayed release 20 mg OTC

heartburn treatment 24 hour oral capsule delayed release 15 mg

OTC

hm lansoprazole oral capsule delayed release 15 mg OTC

hm omeprazole oral tablet delayed release 20 mg OTC

kls lansoprazole oral capsule delayed release 15 mg OTC

kls omeprazole oral tablet delayed release 20 mg OTC

kp omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg

OTC

lansoprazole capsule delayed release 15 mg oral (otc) 15 mg

OTC

lansoprazole capsule delayed release 15 mg oral (rx) 15 mg

1 ST

lansoprazole oral capsule delayed release 30 mg 1 ST

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20MG

OTC



NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20MG

OTC

omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg

OTC

omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

1

omeprazole oral tablet delayed release 20 mg OTC

omeprazole-sodium bicarbonate capsule 20-1100 mg oral (otc) 20-1100 mg

OTC

omeprazole-sodium bicarbonate capsule 20-1100 mg oral (rx) 20-1100 mg

1 ST

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

1

PREVACID 24HR ORAL CAPSULE DELAYED RELEASE 15 MG

OTC

PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG 1 ST

PRILOSEC OTC ORAL TABLET DELAYED RELEASE 20MG

OTC

PROTONIX INTRAVENOUS* SOLUTION RECONSTITUTED 40 MG

3

px omeprazole oral tablet delayed release 20 mg OTC

qc omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg

OTC

ra lansoprazole oral capsule delayed release 15 mg OTC

ra omeprazole oral tablet delayed release 20 mg OTC

ra omeprazole-sodium bicarb oral capsule 20-1100 mg OTC

sb omeprazole oral tablet delayed release 20 mg OTC

sm lansoprazole oral capsule delayed release 15 mg OTC

sm omeprazole oral tablet delayed release 20 mg OTC

sw omeprazole oral tablet delayed release 20 mg OTC

tgt omeprazole oral tablet delayed release 20 mg OTC

ZEGERID ORAL CAPSULE 20-1100 MG 1 ST

ZEGERID OTC ORAL CAPSULE 20-1100 MG OTC

Genitourinary Agents [Genitourinarios]

Antispasmodics, Urinary [Antiespasmódicos, Urinarios]

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 MG, 50 MG

3 ST

oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg

1

oxybutynin chloride oral tablet 5 mg 1

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

1

tolterodine tartrate oral tablet 1 mg, 2 mg 1



Benign Prostatic Hypertrophy Agents [Hipertrofia Prostática Benigna]

finasteride oral tablet 5 mg 1 GL

tamsulosin hcl oral capsule 0.4 mg 1 GL

Genitourinary Agents, Others [Genitourinarios, Otros]

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

DEPEN TITRATABS ORAL TABLET 250 MG 3

ELMIRON ORAL CAPSULE 100 MG 3

flavoxate hcl oral tablet 100 mg 1

phenazopyridine hcl oral tablet 100 mg, 200 mg 1

Phosphate Binders [Enlazadores De Fosfato]

calcium acetate oral capsule 667 mg 1

RENAGEL ORAL TABLET 400 MG, 800 MG 3 PA; SL

RENVELA ORAL PACKET 0.8 GM, 2.4 GM 2 PA; SL

RENVELA ORAL TABLET 800 MG 2 PA; SL

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) [Hormonales, Estimulante/Reemplazo/Modificador (Adrenal)]

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) [Hormonales, Estimulante/Reemplazo/Modificador (Adrenal)]

alclometasone dipropionate external cream 0.05 % 1 QL (60 GM per 15 days)

alclometasone dipropionate external ointment 0.05 % 1 QL (60 GM per 15 days)

betamethasone dipropionate aug external cream 0.05% 3 QL (50 GM per 15 days)

betamethasone dipropionate aug external lotion 0.05 % 3 QL (60 ML per 15 days)

betamethasone dipropionate aug external ointment 0.05 %


betamethasone dipropionate external cream 0.05 % 1 QL (45 GM per 15 days)

betamethasone dipropionate external lotion 0.05 % 1 QL (60 ML per 15 days)

betamethasone dipropionate external ointment 0.05 % 1 QL (45 GM per 15 days)

betamethasone valerate external cream 0.1 % 1 QL (45 GM per 15 days)

betamethasone valerate external lotion 0.1 % 1 QL (60 ML per 15 days)

betamethasone valerate external ointment 0.1 % 1 QL (45 GM per 15 days)

clobetasol propionate e external cream 0.05 % 1 QL (60 GM per 15 days)

clobetasol propionate external 0.05 % 1 QL (60 GM per 15 days)

clobetasol propionate external ointment 0.05 % 1 QL (60 GM per 15 days)

clobetasol propionate external solution 0.05 % 1 QL (50 ML per 15 days)

desonide external cream 0.05 % 3 QL (60 GM per 15 days)

desonide external lotion 0.05 % 3 QL (118 ML per 30 days)

desonide external ointment 0.05 % 3 QL (60 GM per 15 days)

fludrocortisone acetate oral tablet 0.1 mg 1

fluocinolone acetonide body external oil 0.01 % 1 QL (118.28 ML per 15 days)

fluocinolone acetonide external cream 0.01 %, 0.025 % 1 QL (60 GM per 15 days)



fluocinolone acetonide external ointment 0.025 % 1 QL (60 GM per 15 days)

fluocinolone acetonide external solution 0.01 % 3 QL (60 ML per 15 days)

fluocinonide external 0.05 % 1 QL (60 GM per 15 days)

fluocinonide external ointment 0.05 % 1 QL (60 GM per 15 days)

fluocinonide external solution 0.05 % 1 QL (60 ML per 15 days)

fluocinonide-e external cream 0.05 % 1 QL (60 GM per 15 days)

fluticasone propionate external cream 0.05 % 1 QL (60 GM per 15 days)

fluticasone propionate external ointment 0.005 % 1 QL (60 GM per 15 days)

halobetasol propionate external cream 0.05 % 3 QL (50 GM per 15 days)

halobetasol propionate external ointment 0.05 % 3 QL (50 GM per 15 days)

hydrocortisone enema 100 mg/60ml 1

hydrocortisone external cream 1 % 1 QL (30 GM per 15 days)

hydrocortisone external cream 2.5 % 1 QL (60 GM per 15 days)

hydrocortisone external lotion 2.5 % 1 QL (118 ML per 30 days)

hydrocortisone external ointment 1 % 1 QL (30 GM per 15 days)

hydrocortisone external ointment 2.5 % 1 QL (60 GM per 15 days)

hydrocortisone valerate external cream 0.2 % 1 QL (60 ML per 15 days)

hydrocortisone valerate external ointment 0.2 % 1 QL (60 GMG per 15 days)

mometasone furoate external cream 0.1 % 1 QL (45 GM per 15 days)

mometasone furoate external ointment 0.1 % 1 QL (45 GM per 15 days)

mometasone furoate external solution 0.1 % 1 QL (60 ML per 15 days)

PROCTOSOL HC CREAM 2.5 % 1 QL (30 GM per 15 days)

scalacort external lotion 2 % 1 QL (30 ML per 15 days)

triamcinolone acetonide external cream 0.025 %, 0.1 % 1 QL (454 GM per 15 days)

triamcinolone acetonide external cream 0.5 % 1 QL (15 GM per 15 days)

triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 QL (60 G per 15 days)

triamcinolone acetonide external ointment 0.025 %, 0.1%


triamcinolone acetonide external ointment 0.5 % 1 QL (15 GM per 15 days)

TRIANEX EXTERNAL OINTMENT 0.05 % 3 QL (120 GM per 15 days)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) [Hormonales, Estimulante/Reemplazo/Modificador (Pituitaria)]


chorionic gonadotropin intramuscular* solution reconstituted 10000 unit

5 PA; SL

desmopressin ace spray refrig nasal solution 0.01 % 3 QL (15 ML per 30 days)

desmopressin acetate injection solution 4 mcg/ml 3

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1

desmopressin acetate spray nasal solution 0.01 % 3

INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML 5 PA; SL



STIMATE NASAL SOLUTION 1.5 MG/ML 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) [Hormonales, Estimulante/Reemplazo/Modificador (Hormonas Sexuales/Modificadores)]

Androgens [Androgenos]

ANDROGEL PUMP TRANSDERMAL 20.25 MG/ACT (1.62%)

3 QL (75 GM per 30 days); GL

ANDROGEL TRANSDERMAL 20.25 MG/1.25GM (1.62%) 3 QL (37.5 GM per 30 days); GL

ANDROGEL TRANSDERMAL 40.5 MG/2.5GM (1.62%) 3 QL (75 GM per 30 days); GL

danazol oral capsule 100 mg, 200 mg, 50 mg 1 GL

oxandrolone oral tablet 10 mg, 2.5 mg 3 GL

testosterone cypionate intramuscular* solution 100mg/ml, 200 mg/ml

3 GL

testosterone enanthate intramuscular* solution 200mg/ml

3 GL

testosterone transdermal 10 mg/act (2%) 3 QL (2 TABS per 1 day); GL

testosterone transdermal 12.5 mg/act (1%) 3 QL (150 GM per 30 days); GL

testosterone transdermal 25 mg/2.5gm (1%) 3 QL (2.5 GM per 1 day); GL

testosterone transdermal 50 mg/5gm (1%) 3 QL (5 GM per 1 day); GL

Estrogens [Estrógenos]

ESTRACE VAGINAL CREAM 0.1 MG/GM 3 QL (42.5 GM per 30 days); GL

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 GL

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr

3 GL

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 GL

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5MG

3 GL

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

2 GL

PREMARIN VAGINAL CREAM 0.625 MG/GM 3 QL (45 GM per 30 days); GL

VAGIFEM VAGINAL TABLET 10 MCG 2 GL

Progestins [Progestinas]

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY

3 GL

medroxyprogesterone acetate oral tablet 10 mg, 2.5mg, 5 mg

1 GL

norethindrone acetate oral tablet 5 mg 3 GL

PREMPHASE ORAL TABLET 0.625-5 MG 2 GL

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

2 GL

progesterone micronized oral capsule 100 mg, 200 mg

3 GL



Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) [Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)]

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) [Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)]

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

2

Hormonal Agents, Suppressant (Parathyroid) [Hormonales, Supresores (Paratiroide)]


SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG 3 PA; SL

Hormonal Agents, Suppressant (Pituitary) [Hormonales, Supresores (Pituitaria)]


cabergoline oral tablet 0.5 mg 3

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG, 11.25 MG (PED), 15 MG, 30 MG (PED)

3 PA

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 7.5 MG 3 PA; SL

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

4 PA; SL

SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

5 PA; SL

SYNAREL NASAL SOLUTION 2 MG/ML 5 PA; SL

Hormonal Agents, Suppressant (Thyroid) [Hormonales, Supresores (Tiroide)]

Antithyroid Agents [Antitiroide]

methimazole oral tablet 10 mg, 5 mg 1

propylthiouracil oral tablet 50 mg 1

Immunological Agents [Inmunológicos]

Immune Suppressants [Supresores Inmunológicos]

azathioprine oral tablet 50 mg 1 SL

ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML 4 PA; SL

ENBREL SUBCUTANEOUS* KIT 25 MG 4 PA; SL

ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML 4 PA; SL

HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML 4 PA; SL

HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

4 PA; SL

methotrexate oral tablet 2.5 mg 1

methotrexate sodium (pf) injection solution 25 mg/ml 3

methotrexate sodium injection solution 25 mg/ml 1

mycophenolate mofetil oral capsule 250 mg 1 SL



mycophenolate mofetil oral suspension reconstituted 200 mg/ml

3 SL

mycophenolate mofetil oral tablet 500 mg 1 SL

ORENCIA INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG

5 PA; SL

ORENCIA SUBCUTANEOUS* 125 MG/ML 5 PA; SL

REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

5 PA; SL

RHEUMATREX ORAL TABLET 2.5 MG 3

Immunomodulators [Inmunomoduladores]

ACTEMRA INTRAVENOUS* SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML

5 PA; SL

ACTEMRA SUBCUTANEOUS* 162 MG/0.9ML 5 PA; SL

ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG

5 PA; SL

leflunomide oral tablet 10 mg, 20 mg 1

RIDAURA ORAL CAPSULE 3 MG 3

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG

5 PA; SL

Inflammatory Bowel Disease Agents [Enfermedad Inflamatoria Intestinal]

Aminosalicylates [Aminosalicilatos]

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

3

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

3

CANASA SUPPOSITORY 1000 MG 2

DIPENTUM ORAL CAPSULE 250 MG 3

mesalamine enema 4 gm 3

mesalamine-cleanser kit 4 gm 3

PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG, 500 MG

3

Aminosalicylates [Aminosalícilatos]

balsalazide disodium oral capsule 750 mg 1


sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet delayed release 500 mg 1

Metabolic Bone Disease Agents [Enfermedad Del Metabolismo Del Hueso]

Metabolic Bone Disease Agents [Enfermedad Del Metabolismo Del Hueso]

alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

1

calcitonin (salmon) nasal solution 200 unit/act 3 QL (11.1 ML per 90 days)

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1



etidronate disodium oral tablet 200 mg, 400 mg 1

FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML 4 PA; SL; QL (2.4 ML per 28 days)

ibandronate sodium intravenous* solution 3 mg/3ml 4 PA; SL

MIACALCIN INJECTION SOLUTION 200 UNIT/ML 3

paricalcitol intravenous* solution 2 mcg/ml, 5 mcg/ml 3 PA; SL

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 PA; SL

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML 5 PA; QL (1 ML per 180 days); SL

zoledronic acid intravenous* solution 5 mg/100ml 4 PA; QL (100 ML per 365 days)

Ophthalmic Agents [Oftálmicos]

Ophthalmic Agents, Other [Oftálmicos, Otros]

naphazoline hcl ophthalmic solution 0.1 % 1 QL (15 ML per 15 days)

RESTASIS OPHTHALMIC EMULSION 0.05 % 3 PA; SL; QL (30 ML per 15 days)

Ophthalmic Anti-Allergy Agents [Antialérgicos Oftálmicos]

ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION 0.025 %

OTC

ALAWAY OPHTHALMIC SOLUTION 0.025 % OTC

allergy eye drops ophthalmic solution 0.025 % OTC

CLARITIN EYE OPHTHALMIC SOLUTION 0.025 % OTC

cromolyn sodium ophthalmic solution 4 % 1 QL (10 ML per 15 days)

cvs allergy eye drops ophthalmic solution 0.025 % OTC

cvs eye itch relief ophthalmic solution 0.025 % OTC

eq eye itch relief ophthalmic solution 0.025 % OTC

eq itchy eye drops ophthalmic solution 0.025 % OTC

eye itch relief ophthalmic solution 0.025 % OTC

gnp eye itch relief ophthalmic solution 0.025 % OTC

gnp itchy eye ophthalmic solution 0.025 % OTC

hm eye itch relief ophthalmic solution 0.025 % OTC

ketotifen fumarate ophthalmic solution 0.025 % OTC

kp ketotifen fumarate ophthalmic solution 0.025 % OTC

olopatadine hcl ophthalmic solution 0.1 % 1 ST; QL (5 ML per 15 days)

PATANOL OPHTHALMIC SOLUTION 0.1 % 2 ST; QL (5 ML per 15 days)

ra antihistamine eye drops ophthalmic solution 0.025% OTC

ra eye itch relief ophthalmic solution 0.025 % OTC

sm eye itch relief ophthalmic solution 0.025 % OTC

tgt eye itch relief ophthalmic solution 0.025 % OTC

THERA TEARS ALLERGY OPHTHALMIC SOLUTION 0.025 %

OTC

WAL-ZYR OPHTHALMIC SOLUTION 0.025 % OTC

ZADITOR OPHTHALMIC SOLUTION 0.025 % OTC

ZYRTEC ITCHY EYE OPHTHALMIC SOLUTION 0.025 %

OTC



Ophthalmic Antiglaucoma Agents [Antiglaucoma Oftálmicos]

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % 2 QL (15 ML per 30 days)

AZOPT OPHTHALMIC SUSPENSION 1 % 2 ST; QL (15 ML per 30 days)

betaxolol hcl ophthalmic solution 0.5 % 3 QL (15 ML per 30 days)

brimonidine tartrate ophthalmic solution 0.15 % 3 QL (15 ML per 30 days)

brimonidine tartrate ophthalmic solution 0.2 % 1 QL (15 ML per 30 days)

carteolol hcl ophthalmic solution 1 % 3 QL (15 ML per 30 days)

COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 QL (10 ML per 30 days)

dorzolamide hcl ophthalmic solution 2 % 1 QL (10 ML per 30 days)

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml


levobunolol hcl ophthalmic solution 0.25 % 1 QL (10 ML per 30 days)

levobunolol hcl ophthalmic solution 0.5 % 1 QL (15 ML per 30 days)

metipranolol ophthalmic solution 0.3 % 3 QL (10 ML per 30 days)

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %


timolol maleate ophthalmic solution 0.25 %, 0.5 % 1 QL (15 ML per 30 days)

Ophthalmic Antiinflammatories [Antiinflamatorios Oftálmicos]

ACUVAIL OPHTHALMIC SOLUTION 0.45 % 3 QL (5 ML per 15 days)

dexamethasone sodium phosphate ophthalmic solution 0.1 %


diclofenac sodium ophthalmic solution 0.1 % 1 QL (5 ML per 15 days)

flurbiprofen sodium ophthalmic solution 0.03 % 1 QL (2.5 ML per 15 days)

ketorolac tromethamine ophthalmic solution 0.4 % 1 QL (5 ML per 15 days)

ketorolac tromethamine ophthalmic solution 0.5 % 1 QL (12 ML per 15 days)

prednisolone acetate ophthalmic suspension 1 % 3 QL (15 ML per 15 days)

Ophthalmic Prostaglandins And Prostamides [Prostaglandinas Y Prostamidas Oftálmicas]

latanoprost ophthalmic solution 0.005 % 1 QL (2.5 ML per 30 days)

LUMIGAN OPHTHALMIC SOLUTION 0.01 % 2 QL (7.5 ML per 30 days)

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % 2 QL (5 ML per 30 days)

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % 3 QL (30 ML per 30 days)

Otic Agents [Óticos]

Otic Agents [Óticos]

fluocinolone acetonide otic oil 0.01 % 3 QL (20 ML per 15 days)

Respiratory Tract Agents [Tracto Respiratorio]

Antihistamines [Antihistamínicos]

ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

ALAVERT ORAL TABLET 10 MG OTC

ALAVERT ORAL TABLET DISPERSIBLE 10 MG OTC

all day allergy childrens oral solution 1 mg/ml, 5mg/5ml OTC



all day allergy childrens oral tablet chewable 10 mg OTC

all day allergy d oral tablet extended release 12 hr* 5-120 mg

OTC

all day allergy d-12 oral tablet extended release 12 hr* 5-120 mg

OTC

all day allergy oral capsule 10 mg OTC

all day allergy oral tablet 10 mg OTC

all day allergy-d oral tablet extended release 12 hr* 5-120 mg

OTC

ALLEGRA ALLERGY CHILDRENS ORAL SUSPENSION 30 MG/5ML

OTC

ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG OTC

ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE 30 MG

OTC

ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG OTC

ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG

OTC

ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 24 HR* 180-240 MG

OTC

aller-ease oral tablet 180 mg, 60 mg OTC

allergy 24-hr oral tablet 180 mg OTC

allergy d-12 oral tablet extended release 12 hr* 5-120mg

OTC

allergy oral tablet 10 mg OTC

allergy oral tablet dispersible 10 mg OTC

allergy relief child oral syrup 5 mg/5ml OTC

allergy relief childrens oral solution 5 mg/5ml OTC

allergy relief childrens oral syrup 5 mg/5ml OTC

allergy relief childrens oral tablet chewable 10 mg OTC

allergy relief childrens oral tablet dispersible 10 mg OTC

allergy relief d oral tablet extended release 24 hr* 10-240 mg

OTC

allergy relief d-24 oral tablet extended release 24 hr* 10-240 mg

OTC

allergy relief for kids oral syrup 5 mg/5ml OTC

allergy relief oral syrup 5 mg/5ml OTC

allergy relief oral tablet 10 mg, 180 mg, 60 mg OTC

allergy relief oral tablet dispersible 10 mg OTC

allergy relief/nasal decongest oral tablet extended release 24 hr* 10-240 mg

OTC

allergy relief-d oral tablet extended release 12 hr* 5-120mg

OTC



allergy relief-d oral tablet extended release 24 hr* 10-240 mg

OTC

allergy/congestion relief oral tablet extended release 12 hr* 5-120 mg

OTC

allergy/congestion relief oral tablet extended release 24 hr* 10-240 mg

OTC

azelastine hcl nasal solution 0.1 % 1 QL (30 ML per 25 days)

azelastine hcl nasal solution 0.15 % 3 QL (30 ML per 25 days)

cetirizine hcl allergy child oral solution 5 mg/5ml OTC

cetirizine hcl childrens alrgy oral syrup 1 mg/ml OTC

cetirizine hcl childrens oral solution 1 mg/ml, 5 mg/5ml OTC

cetirizine hcl hives relief oral solution 5 mg/5ml OTC

cetirizine hcl oral syrup 1 mg/ml OTC

cetirizine hcl oral tablet 10 mg, 5 mg OTC

cetirizine hcl oral tablet chewable 10 mg, 5 mg OTC

cetirizine-pseudoephedrine er oral tablet extended release 12 hr* 5-120 mg

OTC

childrens loratadine oral solution 5 mg/5ml OTC

childrens loratadine oral syrup 5 mg/5ml OTC

CLARITIN ORAL CAPSULE 10 MG OTC

CLARITIN ORAL SYRUP 5 MG/5ML OTC

CLARITIN ORAL TABLET 10 MG OTC

CLARITIN ORAL TABLET CHEWABLE 5 MG OTC

CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG, 5 MG

OTC

CLARITIN-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

CLARITIN-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG

OTC

CLEAR-ATADINE D ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG

OTC

cvs allergy relief childrens oral solution 5 mg/5ml OTC

cvs allergy relief childrens oral suspension 30 mg/5ml OTC

cvs allergy relief childrens oral syrup 5 mg/5ml OTC

cvs allergy relief d oral tablet extended release 12 hr* 60-120 mg

OTC

cvs allergy relief oral capsule 10 mg OTC

cvs allergy relief oral tablet 10 mg, 180 mg, 60 mg OTC

cvs allergy relief oral tablet dispersible 10 mg OTC

cvs allergy relief-d oral tablet extended release 12 hr* 5-120 mg

OTC

cvs allergy relief-d12 oral tablet extended release 12 hr* 5-120 mg

OTC



cvs indoor/outdoor allergy rlf oral tablet 10 mg OTC

cvs indoor/outdoor allergy rlf oral tablet chewable 10mg

OTC

cvs loratadine oral tablet 10 mg OTC

cvs loratadine-d 24 hour oral tablet extended release 24 hr* 10-240 mg

OTC

eq allergy & congestion relief oral tablet extended release 12 hr* 5-120 mg

OTC

eq allergy relief (cetirizine) oral solution 1 mg/ml OTC

eq allergy relief (cetirizine) oral tablet 10 mg OTC

eq allergy relief childrens oral solution 5 mg/5ml OTC

eq allergy relief childrens oral syrup 5 mg/5ml OTC

eq allergy relief d 24 hour oral tablet extended release 24 hr* 10-240 mg

OTC

eq allergy relief oral tablet 10 mg, 180 mg OTC

eq allergy-d oral tablet extended release 12 hr* 5-120mg

OTC

eq childrens loratadine oral syrup 5 mg/5ml OTC

eq loratadine oral tablet 10 mg OTC

eql all day allergy childrens oral solution 5 mg/5ml OTC

eql all day allergy oral tablet 10 mg OTC

eql all day allergy-d oral tablet extended release 12 hr* 5-120 mg

OTC

eql aller-ease oral tablet 180 mg OTC

eql allergy relief oral tablet 10 mg OTC

eql allergy relief oral tablet dispersible 10 mg OTC

eql allergy/congestion relief oral tablet extended release 24 hr* 10-240 mg

OTC

eql childrens loratadine oral syrup 5 mg/5ml OTC

fexofenadine hcl childrens oral suspension 30 mg/5ml OTC

fexofenadine hcl oral tablet 180 mg, 60 mg OTC

fexofenadine-pseudoephed er oral tablet extended release 12 hr* 60-120 mg

OTC

fexofenadine-pseudoephed er oral tablet extended release 24 hr* 180-240 mg

OTC

gnp all day allergy childrens oral solution 1 mg/ml, 5mg/5ml

OTC

gnp all day allergy childrens oral syrup 5 mg/5ml OTC

gnp all day allergy oral tablet 10 mg OTC

gnp all day allergy-d oral tablet extended release 12 hr* 5-120 mg

OTC

gnp allergy & congestion oral tablet extended release 24 hr* 10-240 mg

OTC



gnp allergy relief oral tablet 180 mg OTC

gnp allergy relief oral tablet dispersible 10 mg OTC

gnp allergy-d allergy & conges oral tablet extended release 12 hr* 60-120 mg

OTC

gnp loratadine childrens oral syrup 5 mg/5ml OTC

gnp loratadine oral syrup 5 mg/5ml OTC

gnp loratadine oral tablet 10 mg OTC

gnp loratadine-d 12hr oral tablet extended release 12 hr* 5-120 mg

OTC

gnp loratadine-d 24 hour oral tablet extended release 24 hr* 10-240 mg

OTC

goodsense all day allergy oral tablet 10 mg OTC

hm all day allergy oral tablet 10 mg OTC

hm allergy & congestion oral tablet extended release 12 hr* 5-120 mg

OTC

hm allergy complete childrens oral solution 5 mg/5ml OTC

hm allergy complete-d oral tablet extended release 12 hr* 5-120 mg

OTC

hm allergy relief oral tablet 10 mg OTC

hm allergy relief oral tablet dispersible 10 mg OTC

hm allergy relief/nasal decong oral tablet extended release 24 hr* 10-240 mg

OTC

hm cetirizine hcl childrens oral solution 5 mg/5ml OTC

hm fexofenadine hcl oral tablet 180 mg, 60 mg OTC

hm loratadine childrens oral syrup 5 mg/5ml OTC

hm loratadine oral tablet 10 mg OTC

KLS ALLERCLEAR D-12HR ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

KLS ALLERCLEAR D-24HR ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG

OTC

KLS ALLERCLEAR ORAL TABLET 10 MG OTC

KLS ALLER-FEX ORAL TABLET 180 MG OTC

KLS ALLER-TEC CHILDRENS ORAL SOLUTION 1MG/ML OTC

KLS ALLER-TEC D ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

KLS ALLER-TEC ORAL TABLET 10 MG OTC

kp cetirizine hcl oral tablet 10 mg, 5 mg OTC

kp fexofenadine hcl oral tablet 180 mg, 60 mg OTC

kp loratadine oral tablet 10 mg OTC

levocetirizine dihydrochloride oral tablet 5 mg 1 ST

loradamed oral tablet 10 mg OTC

loratadine allergy relief oral tablet dispersible 10 mg OTC



loratadine childrens oral solution 5 mg/5ml OTC

loratadine childrens oral syrup 5 mg/5ml OTC

loratadine hives relief oral solution 5 mg/5ml OTC

loratadine oral tablet 10 mg OTC

loratadine-d 12hr oral tablet extended release 12 hr* 5-120 mg

OTC

loratadine-d 24hr oral tablet extended release 24 hr* 10-240 mg

OTC

meijer allergy relief oral tablet 10 mg OTC

meijer allergy relief oral tablet dispersible 10 mg OTC

meijer allergy relief-d oral tablet extended release 12 hr* 5-120 mg

OTC

meijer allergy/congestion oral tablet extended release 24 hr* 10-240 mg

OTC

meijer loratadine oral syrup 5 mg/5ml OTC

mm loratadine-d 24 hour oral tablet extended release 24 hr* 10-240 mg

OTC

MUCINEX ALLERGY ORAL TABLET 180 MG OTC

olopatadine hcl nasal solution 0.6 % 3 QL (30.5 GM per 30 days)

px allergy relief cetirizine oral tablet 10 mg OTC

px allergy relief d (loratid) oral tablet extended release 12 hr* 5-120 mg

OTC

px allergy relief d oral tablet extended release 12 hr* 5-120 mg

OTC

px allergy relief d oral tablet extended release 24 hr* 10-240 mg

OTC

px allergy relief loratadine oral tablet 10 mg OTC

px allergy relief oral tablet 180 mg OTC

px allergy relief oral tablet dispersible 10 mg OTC

px childrens allergy oral solution 5 mg/5ml OTC

qc all day allergy oral tablet 10 mg OTC

qc allergy relief childrens oral syrup 1 mg/ml, 5 mg/5ml OTC

qc allergy relief oral tablet dispersible 10 mg OTC

qc loratadine allergy relief oral tablet 10 mg OTC

qc loratadine-d oral tablet extended release 24 hr* 10-240 mg

OTC

QLEARQUIL 24 HOUR RELIEF ORAL TABLET 10 MG OTC

ra allergy relief childrens oral syrup 5 mg/5ml OTC

ra allergy relief oral tablet 10 mg, 180 mg OTC

ra allergy relief oral tablet dispersible 10 mg OTC

ra allergy relief-d oral tablet extended release 12 hr* 60-120 mg

OTC



ra allergy/congestion relief oral tablet extended release 12 hr* 5-120 mg

OTC

ra cetiri-d oral tablet extended release 12 hr* 5-120 mg OTC

ra cetirizine childrens oral tablet chewable 10 mg OTC

ra cetirizine hcl child allrgy oral syrup 5 mg/5ml OTC

ra cetirizine oral tablet 10 mg OTC

ra lorata-d oral tablet extended release 24 hr* 10-240mg OTC

ra loratadine childrens oral syrup 5 mg/5ml OTC

ra loratadine oral syrup 5 mg/5ml OTC

ra loratadine oral tablet 10 mg OTC

ra loratadine oral tablet dispersible 10 mg OTC

sb allergy oral tablet 10 mg OTC

sb allergy relief oral tablet dispersible 10 mg OTC

sb allergy relief/nasal decong oral tablet extended release 24 hr* 10-240 mg

OTC

sb cetirizine hcl childrens oral syrup 1 mg/ml OTC

sb loratadine allergy relief oral tablet 10 mg OTC

sb loratadine oral syrup 5 mg/5ml OTC

sb loratadine oral tablet 10 mg OTC

SHOPKO ALLERGY RELIEF-D (CETI) ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

SHOPKO ALLERGY RELIEF-D (LORA) ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

SHOPKO ALLERGY RELIEF-D (LORA) ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG

OTC

sm all day allergy childrens oral solution 1 mg/ml, 5mg/5ml

OTC

sm all day allergy oral tablet 10 mg OTC

sm all day allergy-d oral tablet extended release 12 hr* 5-120 mg

OTC

sm allergy relief loratadine oral tablet 10 mg OTC

sm allergy relief oral tablet dispersible 10 mg OTC

sm childrens loratadine oral syrup 5 mg/5ml OTC

sm fexofenadine hcl oral tablet 180 mg, 60 mg OTC

sm loratadine allergy relief oral tablet dispersible 10mg OTC

sm loratadine d oral tablet extended release 12 hr* 5-120 mg

OTC

sm lorata-dine d oral tablet extended release 24 hr* 10-240 mg

OTC

sm loratadine oral syrup 5 mg/5ml OTC

sm loratadine oral tablet 10 mg OTC

sm loratadine oral tablet dispersible 10 mg OTC



sw allergy relief oral tablet 10 mg OTC

sw allergy relief-d oral tablet extended release 12 hr* 5-120 mg

OTC

tgt all day allergy childrens oral solution 5 mg/5ml OTC

tgt all day allergy childrens oral syrup 5 mg/5ml OTC

tgt all day allergy relief oral tablet 10 mg OTC

tgt all day allergy-d oral tablet extended release 12 hr* 5-120 mg

OTC

tgt allergy relief oral tablet 10 mg, 180 mg OTC

tgt allergy relief oral tablet dispersible 10 mg OTC

tgt allergy/congestion relief oral tablet extended release 12 hr* 5-120 mg

OTC

tgt allergy/congestion relief oral tablet extended release 24 hr* 10-240 mg

OTC

tgt allergy+ congestion relief oral tablet extended release 12 hr* 5-120 mg, 60-120 mg

OTC

tgt loratadine childrens oral syrup 5 mg/5ml OTC

TRIAMINIC ALLERCHEWS ORAL TABLET DISPERSIBLE 10 MG

OTC

WAL-FEX ALLERGY ORAL TABLET 180 MG, 60 MG OTC

WAL-FEX CHILDRENS ORAL SUSPENSION 30 MG/5ML OTC

WAL-FEX D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG

OTC

WAL-FEX D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 24 HR* 180-240 MG

OTC

WAL-ITIN ALLERGY REDITABS ORAL TABLET DISPERSIBLE 10 MG

OTC

WAL-ITIN ALLER-MELTS ORAL TABLET DISPERSIBLE 10 MG

OTC

WAL-ITIN CHILDRENS ORAL SOLUTION 5 MG/5ML OTC

WAL-ITIN D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG

OTC

WAL-ITIN D ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

WAL-ITIN ORAL SYRUP 5 MG/5ML OTC

WAL-ITIN ORAL TABLET 10 MG OTC

WAL-VERT ORAL TABLET DISPERSIBLE 10 MG OTC

WAL-ZYR ALL DAY ALLERGY CHILD ORAL SOLUTION 5 MG/5ML

OTC

WAL-ZYR CHILDRENS ORAL SOLUTION 1 MG/ML, 5 MG/5ML

OTC

WAL-ZYR CHILDRENS ORAL TABLET CHEWABLE 10 MG, 5 MG

OTC



WAL-ZYR D ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

WAL-ZYR ORAL TABLET 10 MG OTC

ZYRTEC ALLERGY ORAL CAPSULE 10 MG OTC

ZYRTEC ALLERGY ORAL TABLET 10 MG OTC

ZYRTEC CHILDRENS ALLERGY ORAL SYRUP 1 MG/ML, 5 MG/5ML

OTC

ZYRTEC CHILDRENS ALLERGY ORAL TABLET CHEWABLE 10 MG, 5 MG

OTC

ZYRTEC CHILDRENS HIVES RELIEF ORAL SYRUP 1 MG/ML

OTC

ZYRTEC HIVES RELIEF ORAL TABLET 10 MG OTC

ZYRTEC-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG

OTC

Anti-Inflammatories, Inhaled Corticosteroids [Anti-Inflamatorios, Corticosteroides Inhalados]

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50MCG/DOSE, 500-50 MCG/DOSE

2 QL (60 DOSE per 30 days)

ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT

2 QL (30 PACK per 30 days)

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220MCG/INH


ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110MCG/INH


budesonide inhalation suspension 0.25 mg/2ml, 0.5mg/2ml


budesonide inhalation suspension 1 mg/2ml 3 QL (60 ML per 30 days)

DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT


FLONASE ALLERGY RELIEF NASAL SUSPENSION 50MCG/ACT

OTC

FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

2 QL (60 DOSE per 30 days)

FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT


FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT 2 QL (21.2 GM per 30 days)

flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (25 ML per 15 days)

fluticasone propionate suspension 50 mcg/act nasal (otc) 50 mcg/act

OTC

fluticasone propionate suspension 50 mcg/act nasal (rx) 50 mcg/act

1 QL (16 GM per 15 DAYs)



NASACORT ALLERGY 24HR CHILDREN NASAL AEROSOL† 55 MCG/ACT

OTC

NASACORT ALLERGY 24HR NASAL AEROSOL† 55MCG/ACT

OTC

nasal allergy 24 hour nasal aerosol† 55 mcg/act OTC

QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT 2 QL (17.4 GM per 30 days)

QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT 2 QL (8.7 GM per 30 days)

SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT


triamcinolone acetonide nasal aerosol† 55 mcg/act 1 ST; QL (16.5 GM per 30 days)

VERAMYST NASAL SUSPENSION 27.5 MCG/SPRAY 3 ST; QL (10 GM per 20 days)

Antileukotrienes [Antileukotrienos]

montelukast sodium oral packet 4 mg 3

montelukast sodium oral tablet 10 mg 1

montelukast sodium oral tablet chewable 4 mg, 5 mg 1

zafirlukast oral tablet 10 mg, 20 mg 3

Bronchodilators, Anticholinergic [Broncodilatadores, Anticolinérgicos]

ATROVENT HFA INHALATION AEROSOL, SOLUTION 17MCG/ACT


COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT


ipratropium bromide inhalation solution 0.02 % 1 QL (300 ML per 30 days)

ipratropium bromide nasal solution 0.03 % 1 QL (30 ML per 15 days)

ipratropium bromide nasal solution 0.06 % 1 QL (15 ML per 15 days)

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 QL (1 CAPS per 1 day)

SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT


TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT

2 QL (1 EA per 30 days)

Bronchodilators, Sympathomimetic [Broncodilatadores, Simpatomiméticos]

albuterol sulfate inhalation nebulization solution (2.5mg/3ml) 0.083%, 1.25 mg/3ml


albuterol sulfate inhalation nebulization solution (5mg/ml) 0.5%, 0.63 mg/3ml


albuterol sulfate oral syrup 2 mg/5ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 3

epinephrine injection 0.3 mg/0.3ml 3

EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML 3

FORADIL AEROLIZER INHALATION CAPSULE 12 MCG 2 QL (2 GM per 1 day)

PROAIR HFA INHALATION AEROSOL, SOLUTION 108(90 BASE) MCG/ACT




PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH ACTIVATED 108 (90 BASE)MCG/ACT


PROVENTIL HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT


SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE


STRIVERDI RESPIMAT INHALATION AEROSOL, SOLUTION 2.5 MCG/ACT


terbutaline sulfate oral tablet 2.5 mg, 5 mg 1

XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT 3 QL (30 GM per 30 days)

Cystic Fibrosis Agents [Fibrosis Quística]

tobramycin inhalation nebulization solution 300mg/5ml 4 PA

Mast Cell Stabilizers [Estabilizadores De Mastocitos]

cromolyn sodium inhalation nebulization solution 20mg/2ml


Phosphodiesterase Inhibitors, Airways Disease [Inhibidores De La Fosfodiesterasa, Enfermedad De Las Vías Respiratorias]

aminophylline intravenous* solution 25 mg/ml 1

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 3

LUFYLLIN ORAL TABLET 200 MG, 400 MG 3

theophylline er oral tablet extended release 12 hr* 100mg, 200 mg, 300 mg, 450 mg

1

theophylline er oral tablet extended release 24 hr* 400mg, 600 mg

1

Pulmonary Antihypertensives [Anti-Hipertensivos Pulmonales]

LETAIRIS ORAL TABLET 10 MG, 5 MG 4 PA; SL

sildenafil citrate oral tablet 20 mg 4 PA; SL; AL (greater than or equal to 18 years)

TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 PA; SL

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20MCG/ML

5 PA; SL

Respiratory Tract Agents, Others [Tracto Respiratorio, Otros]

acetylcysteine inhalation solution 10 % 1 QL (600 ML per 15 days)

acetylcysteine inhalation solution 20 % 1 QL (300 ML per 15 days)

ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 500 MG, 800 MG

5 PA; SL

cheratussin ac oral syrup 100-10 mg/5ml 1

PULMOZYME INHALATION SOLUTION 1 MG/ML 5 PA; SL

TYZINE NASAL SOLUTION 0.05 % 3 QL (15 ML per 15 days)

TYZINE NASAL SOLUTION 0.1 % 3 QL (30 ML per 15 days)

ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG

5 PA; SL



Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]


chlorzoxazone oral tablet 500 mg 1

cyclobenzaprine hcl oral tablet 10 mg 1

methocarbamol oral tablet 500 mg, 750 mg 1

Sleep Disorder Agents [Desórdenes Del Sueño]

Gaba Receptor Modulators [Moduladores Del Receptor De Gaba]

estazolam oral tablet 1 mg, 2 mg 1 AL (greater than 18 years); QL (1 TABS per 1 day)

temazepam oral capsule 15 mg, 30 mg 1 AL (greater than 18 years); QL (1 CAPS per 1 day)

zaleplon oral capsule 10 mg 1 QL (2 CAPS per 1 day)

zaleplon oral capsule 5 mg 1 QL (1 CAPS per 1 day)

zolpidem tartrate oral tablet 10 mg, 5 mg 1 QL (1 TABS per 1 day)

Sleep Disorder, Other [Desórdenes Del Sueño, Otros]

BUTISOL SODIUM ORAL TABLET 30 MG, 50 MG 3

modafinil oral tablet 100 mg, 200 mg 3 PA; SL

Therapeutic Nutrients/Minerals/Electrolytes [Nutrientes Terapéuticos/Minerales/Electrólitos]

Electrolytes/Minerals Modifiers [Electrólitos/Modificadores De Minerales]

EXJADE ORAL TABLET SOLUBLE 125MG, 250MG, 500MG

5 PA; SL

FERRIPROX ORAL SOLUTION 100 MG/ML 4 PA; SL

FERRIPROX ORAL TABLET 500 MG 4 PA; SL

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG 5 PA; SL; AL (Greater than 2 years old)

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 15gm/60ml

1

Electrolytes/Minerals Replacement [Remplazo De Electrólitos/Minerales]

AMINOSYN II INTRAVENOUS* SOLUTION 7 %, 8.5 % 3

AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

3

AMINOSYN M INTRAVENOUS* SOLUTION 3.5 % 3

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS* SOLUTION 2.75 %

3


3


3


3

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 %

3




3


3

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 %

3


3


3


3


3

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 %

3

CLINIMIX/DEXTROSE (5/20) INTRAVENOUS* SOL 5 % 3

CLINIMIX/DEXTROSE (5/25) INTRAVENOUS* SOLUTION 5 %

3

dextrose in lactated ringers intravenous* solution 5 % 1

dextrose intravenous* solution 10 %, 5 % 1

dextrose-nacl intravenous* solution 10-0.2 %, 10-0.45%, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45%, 5-0.9 %

1

FREAMINE III INTRAVENOUS* SOLUTION 10 % 3

HEPATAMINE INTRAVENOUS* SOLUTION 8 % 3

ISOLYTE-S INTRAVENOUS* SOLUTION 3

lactated ringers intravenous* solution 1

levocarnitine oral solution 1 gm/10ml 1

levocarnitine oral tablet 330 mg 1

LIPOSYN III INTRAVENOUS* EMULSION 10 % 3

fat emulsion iv soln 30% 1

NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % 3

nutrilipid intravenous* emulsion 20 % 1

PLENAMINE INTRAVENOUS* SOLUTION 15 % 1

potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq

1

potassium chloride er oral capsule extended release* 10 meq, 8 meq

1

potassium chloride er oral tablet extendedrelease* 10meq, 8 meq

1

potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/100ml

1



potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)

1

PREMASOL INTRAVENOUS* SOLUTION 6 % 1

PROCALAMINE INTRAVENOUS* SOLUTION 3 % 3

ringers intravenous* solution 1

sodium chloride injection solution 2.5 meq/ml 1

sodium chloride intravenous* solution 0.45 %, 0.9 % 1

Lista de Medicamentos AXIS II 2017 / Drugs List AXIS II 2017 Rev. Abril 2016

68

PARTE III – MEDICAMENTOS POR CLASE TERAPEUTICA – EMERGENCIA / PART

III - DRUG BY THERAPEUTIC CLASSIFICATION – EMERGENCY

Medicamentos Genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayusculas / Brand name drugs = UPPERCASE

EMERGENCIA / EMERGENCY Medicamentos (Drugs) Nivel (Level) Instrucciones (Instructions)


Nonsteroidal Anti-Inflammatory Drugs [Anti- Inflamatorios No Esteroidales]





naproxen sodium oral tablet 275 mg, 550 mg 1

salsalate oral tablet 500 mg, 750 mg 1


acetaminophen-codeine #2 oral tablet 300-15 mg 1



acetaminophen-codeine oral solution 120-12 mg/5ml 1

butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 mg

1


CAPITAL/CODEINE ORAL SUSPENSION 120-12 MG/5ML 3

tramadol hcl oral tablet 50 mg 1

Anesthetics [Anestesicos]

Local Anesthetics [Anestésico Local]

lidocaine viscous mouth/throat solution 2 % 1



gentamicin sulfate external cream 0.1 % 3

gentamicin sulfate external ointment 0.1 % 3

gentamicin sulfate ophthalmic ointment 0.3 % 1

gentamicin sulfate ophthalmic solution 0.3 % 1

tobramycin ophthalmic solution 0.3 % 1

TOBREX OPHTHALMIC OINTMENT 0.3 % 3


acetic acid otic solution 2 % 3

acetic acid-aluminum acetate otic solution 2 % 3

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1

hydrocortisone-acetic acid otic solution 1-2 % 3



69


mupirocin external ointment 2 % 1

neomycin-polymyxin-hc otic solution 3.5-10000-1 1

neomycin-polymyxin-hc otic suspension 3.5-10000-1 1




silver sulfadiazine external cream 1 % 1



cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

1


cefdinir oral suspension reconstituted 125 mg/5ml, 250mg/5ml

1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1


cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1




1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400- 57 mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

1


ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

1

penicillin v potassium oral solution reconstituted 125mg/5ml, 250 mg/5ml

1



azithromycin oral packet 1 gm 1

azithromycin oral suspension reconstituted 100mg/5ml, 200 mg/5ml

1



70


clarithromycin oral suspension reconstituted 125mg/5ml, 250 mg/5ml

1


E.S.P. oral suspension reconstituted 200-600 mg/5ml 1

ERYTHROCIN STEARATE ORAL TABLET 250 MG 3

erythromycin base oral capsule delayed release particles 250 mg

1




CIPRO HC OTIC SUSPENSION 0.2-1 % 3

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg 1

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

3

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

ofloxacin otic solution 0.3 % 1


sulfamethoxazole-trimethoprim oral suspension 200- 40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1


doxycycline hyclate oral capsule 100 mg, 50 mg 3




VIBRAMYCIN ORAL SYRUP 50 MG/5ML 3


Gamma-Aminobutyric Acid (Gaba) Augmenting Agents [Aumentadores del Ácido Gamma-Aminobutírico]

phenobarbital oral elixir 20 mg/5ml 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

Sodium Channel Agents [Canales de Sodio]

DILANTIN ORAL CAPSULE 30 MG 3

phenytoin oral suspension 125 mg/5ml 1

phenytoin oral tablet chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200mg, 300 mg

1

phenytoin sodium injection solution 50 mg/ml 1


Antiemetics, Other [Antieméticos, Otros]

metoclopramide hcl oral solution 5 mg/5ml 1


71


metoclopramide hcl oral tablet 10 mg, 5 mg 1

pharbedryl oral capsule 50 mg 1

promethazine hcl oral syrup 6.25 mg/5ml 1

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1

promethazine hcl suppository 12.5 mg, 25 mg, 50 mg 3

trimethobenzamide hcl oral capsule 300 mg 1



clotrimazole mouth/throat troche 10 mg 1

nystatin mouth/throat suspension 100000 unit/ml 1



colchicine oral tablet 0.6 mg 3


Glucocorticoids [Glucocorticoides]

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1MG/ML

3

dexamethasone oral elixir 0.5 mg/5ml 1

dexamethasone oral solution 0.5 mg/5ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5mg, 2 mg, 4 mg, 6 mg

1

methylprednisolone oral tablet 16 mg, 32mg, 4mg, 8mg 1

MILLIPRED ORAL TABLET 5 MG 3

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5mg

1


Pediculicides/Scabicides [Pediculicidas/Escabicidas]

lindane external lotion 1 % 3


1St Generation/Typical [1Ra Generación/Típicos]

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine suppository 25 mg

1


Antiherpetic Agents [Antiherpéticos]

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5ml 1

acyclovir oral tablet 400 mg, 800 mg 1



hydroxyzine pamoate oral capsule 100mg, 25mg, 50mg 1


72


Blood Glucose Regulators [Reguladores de Glucosa en Sangre]


glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg

1

glipizide oral tablet 10 mg, 5 mg 1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1

Insulins [Insulinas]

HUMULIN R INJECTION SOLUTION 100 UNIT/ML 2

RELION R INJECTION SOLUTION 100 UNIT/ML 2

Blood Products/ Modifiers/ Volume Expanders [Productos para la Sangre/Modificadores/Expansores de Volumen]

Anticoagulants [Anticoagulantes]

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

Platelet Modifying Agents [Modificadores de Plaquetas]

clopidogrel bisulfate oral tablet 75 mg 1


Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

Angiotensin II Receptor Antagonists [Antagonistas del Receptor Angiotensina II]

losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores de la Enzima Convertidora de Angiotensina]

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5mg 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

1

Calcium Channel Blocking Agents [Bloqueadores de Canales de Calcio]

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg

1

Diuretics, Loop [Diuréticos del ASA]

furosemide oral solution 10 mg/ml, 8 mg/ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1


73


Diuretics, Thiazide [Diuréticos Tiazidas]

hydrochlorothiazide oral tablet 25 mg, 50 mg 1

Vasodilators, Direct-Acting Arterial/Venous [Vasodilatadores, Arteriales/Venosos]

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3MG, 0.4 MG, 0.6 MG

3


Gastrointestinal Agents, Others [Gastrointestinales, Otros]

diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml 1

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

Histamine2 (H2) Receptor Antagonists [Antagonistas del Receptor de Histamina2 (H2)]

cimetidine hcl oral solution 300 mg/5ml 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg 1

ranitidine hcl oral syrup 75 mg/5ml 1

ranitidine hcl oral tablet 300 mg 1

Proton Pump Inhibitors [Inhibidores de la Bomba de Protones]

omeprazole oral capsule delayed release 10 mg, 20 mg 1


Genitourinary Agents, Others [Genitourinarios, Otros]

phenazopyridine hcl oral tablet 100 mg, 200 mg 1


Ophthalmic Antiinflammatories [Antiinflamatorios Oftálmicos]

prednisolone acetate ophthalmic suspension 1 % 3


Bronchodilators, Anticholinergic [Broncodilatadores, Anticolinérgicos]

ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT

3

ipratropium bromide inhalation solution 0.02 % 1

Bronchodilators, Sympathomimetic [Broncodilatadores, Simpatomiméticos]

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 1.25 mg/3ml

1

albuterol sulfate oral syrup 2 mg/5ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 3

PROAIR HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT

2

PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH ACTIVATED 108 (90 BASE) MCG/ACT

2

PROVENTIL HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT

2

terbutaline sulfate oral tablet 2.5 mg, 5 mg 1

XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT 3


74


Respiratory Tract Agents, Others [Tracto Respiratorio, Otros]

cheratussin ac oral syrup 100-10 mg/5ml 1



cyclobenzaprine hcl oral tablet 10 mg 1


75

PARTE IV – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD MENTAL / PART IV - DRUG BY THERAPEUTIC CLASSIFICATION – MENTAL HEALTH

Medicamentos Genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos Originales = LETRAS MAYUSCULAS / Brand Name Drugs = UPPERCASE

SALUD MENTAL / MENTAL HEALTH


Anti-Addiction/Substance Abuse Treatment Agents [Tratamiento de Abuso de Sustancias/Contra la Addición]

Alcohol Deterrents/Anti-Craving [Disuasivos de Alcohol/Anti-Ansiedad]

acamprosate calcium oral tablet delayed release 333mg

3 SL

disulfiram oral tablet 250 mg, 500 mg

3 SL

Opioid Dependence Treatment [Tratamiento Contra la Dependencia a Opiodes]

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

3 PA; QL(2 TABS per 1 day); SL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


SUBOXONE SUBLINGUAL FILM 2-0.5 MG 3 PA; QL(12 TABS per 1 day); SL

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG, 8-2MG



Gamma-Aminobutyric Acid (Gaba) Augmenting Agents [Aumentadores del Ácido Gamma-Aminobutírico]

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 AL (greater than 18 years)

divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg

3

divalproex sodium oral capsule sprinkle 125 mg 1

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1

valproic acid oral capsule 250 mg 1

valproic acid oral syrup 250 mg/5ml

1

Glutamate Reducing Agents [Reductores de Glutamato]

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet chewable 25 mg, 5 mg 1

Sodium Channel Agents [Canales de Sodio]

carbamazepine er oral tablet extended release 12 hr* 200 mg, 400 mg

3

carbamazepine oral suspension 100 mg/5ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet chewable 100 mg 1

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

3


76





bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg

1 SL

bupropion hcl oral tablet 100 mg, 75 mg 1 SL

mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1 SL

mirtazapine oral tablet 7.5 mg 1 SL

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 SL

Monoamine Oxidase Inhibitors [Inhibidores de Monoamino Oxidasa]

EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

3 PA; SL

MARPLAN ORAL TABLET 10 MG 3 SL

phenelzine sulfate oral tablet 15 mg 1 SL

tranylcypromine sulfate oral tablet 10 mg 3 SL

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) [SSRIs/SNRIs (Inhibidores de la Recaptación Selectiva de Serotonina / Inhibidores de la Recaptación de Serotonina y Norepinefrina)]

citalopram hydrobromide oral solution 10 mg/5ml 1 SL

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

1 SL

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

1 PA; ST; SL

escitalopram oxalate oral solution 5 mg/5ml 1 SL

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 SL

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 SL

fluoxetine hcl oral solution 20 mg/5ml 1 SL

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 SL

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 1 SL

paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg, 25 mg, 37.5 mg

3 SL

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 SL

PAXIL ORAL SUSPENSION 10 MG/5ML 3 SL

sertraline hcl oral concentrate 20 mg/ml 1 SL

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SL

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50mg

1 SL

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

1 SL

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50mg, 75 mg

1 SL


amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

1 SL


77



amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 SL

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 3 SL

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 SL

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1 SL

doxepin hcl oral concentrate 10 mg/ml 1 SL

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 SL

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1 SL

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

1 SL


1st Generation/Typical [1ra Generación/Típicos]

chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml

1 PA; SL

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

1 SL

fluphenazine decanoate injection solution 25 mg/ml 1 PA; SL

fluphenazine hcl injection solution 2.5 mg/ml 1 PA; SL

fluphenazine hcl oral concentrate 5 mg/ml 1 SL

fluphenazine hcl oral elixir 2.5 mg/5ml 1 SL

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 SL

haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml

3 PA; SL

haloperidol lactate injection solution 5 mg/ml 3 PA; SL

haloperidol lactate oral concentrate 2 mg/ml 1 SL

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1 SL

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1 SL

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 SL

pimozide oral tablet 1 mg, 2 mg 3 SL

prochlorperazine edisylate injection solution 5 mg/ml 1 PA; SL

prochlorperazine maleate oral tablet 10 mg, 5 mg 1 SL

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50mg 1 PA

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 SL

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 SL

2nd Generation/Atypical [2da Generación/Atípicos]

ABILIFY INTRAMUSCULAR* SOLUTION 9.75 MG/1.3ML 3 PA; SL

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30mg, 5 mg

3 PA; SL


78



olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

1 SL

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

1 SL

quetiapine fumarate oral tablet 25 mg, 50 mg 1 PA; SL

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

4 PA; SL

risperidone oral solution 1 mg/ml 1 SL

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

1 SL

risperidone oral tablet dispersible 0.25 mg 3 PA; SL

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg 3 PA; SL

risperidone oral tablet dispersible 3 mg, 4 mg 3 PA; SL

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80mg

1 SL

Treatment-Resistant [Resistentes a Tratamiento]

clozapine oral tablet 100 mg, 25 mg 3 PA; SL

clozapine oral tablet 200 mg, 50 mg

3 PA; SL



buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1 SL

hydroxyzine pamoate oral capsule 100 mg 1 SL

hydroxyzine pamoate oral capsule 25 mg, 50 mg 1 SL


alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 AL (greater than 18 years); SL

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

1 AL (greater than 18 years); SL

diazepam oral tablet 10 mg, 2 mg, 5 mg


lorazepam oral tablet 0.5 mg, 1 mg, 2 mg


oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 AL (greater than 18 years); SL

Bipolar Agents [Bipolaridad]

Mood Stabilizers [Estabilizadores del Ánimo]

lithium carbonate er oral tablet extendedrelease* 300mg

1 SL

lithium carbonate er oral tablet extendedrelease* 450mg

1 SL

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 SL

lithium oral solution 8 meq/5ml

1 SL


79




ADHD, Amphetamines [Anfetaminas, ADHD]

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1 ST; AL (less than or equal to 18 years); PA; SL

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

1 AL (less than or equal to 18 years); SL

dextroamphetamine sulfate oral tablet 5 mg 1 AL (less than or equal to 18 years); SL

ADHD, Non-Amphetamines [No-Anfetaminas, ADHD]

clonidine hcl er oral tablet extended release 12 hr* 0.1 mg

3 SL

methylphenidate hcl er oral tablet extendedrelease* 20 mg

1 AL (less than or equal to 18 years); SL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 AL (less than or equal to 18 years); SL

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

3 PA; ST; AL (less than or equal to 18 years); SL

Sleep Disorder Agents [Desórdenes del Sueño]

GABA Receptor Modulators [Moduladores del Receptor de GABA]

estazolam oral tablet 1 mg, 2 mg 1 AL (greater than 18 years); SL

temazepam oral capsule 15 mg, 30 mg 1 AL (greater than 18 years): SL

zaleplon oral capsule 10 mg, 5 mg 1 SL

zolpidem tartrate oral tablet 10 mg, 5 mg 1 SL

Sleep Disorder, Other [Desórdenes del Sueño, Otros]

modafinil oral tablet 100 mg, 200 mg 3 PA; SL


80

PARTE V – MEDICAMENTOS POR CLASE TERAPEUTICA – DENTAL / PART V -

DRUG BY THERAPEUTIC CLASSIFICATION – DENTAL

Medicamentos Genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos Originales = LETRAS MAYUSCULAS / Brand Name Drugs = UPPERCASE

DENTAL

Medicamentos (Drugs) Nivel (Level)


Nonsteroidal Anti-Inflammatory Drugs [Anti-Inflamatorios No Esteroidales]

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 3


diclofenac sodium oral tablet delayed release 50 mg, 75 mg 1

etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg 3

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1



ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml 1


naproxen oral suspension 125 mg/5ml 1


naproxen sodium oral tablet 275 mg 1

naproxen sodium oral tablet 550 mg 1

sulindac oral tablet 150 mg 1

sulindac oral tablet 200 mg 1

Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración]

fentanyl transdermal patch 72 hr 100 mcg/hr 1





oxycodone hcl er oral 10 mg, 20 mg, 40 mg, 80 mg 3





acetaminophen-codeine oral solution 120-12 mg/5ml 1

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1

butalbital-apap-caffeine oral capsule 50-325-40 mg 1


butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg 1


81

DENTAL


hydrocodone-ibuprofen oral tablet 7.5-200 mg 1


oxycodone hcl oral tablet 15 mg, 30 mg, 5 mg 1

oxycodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg 1

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg 1

tramadol hcl oral tablet 50 mg 1

tramadol-acetaminophen oral tablet 37.5-325 mg 1



neomycin sulfate oral tablet 500 mg 1


clindamycin hcl oral capsule 150 mg, 300 mg 1

metronidazole oral capsule 375 mg 1





SIVEXTRO ORAL TABLET 200 MG 3

trimethoprim oral tablet 100 mg 1

vancomycin hcl oral capsule 125 mg, 250 mg 3



cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml 1

cefadroxil oral tablet 1 gm 1

cefazolin sodium injection solution reconstituted 1 gm, 500 mg 3

cefazolin sodium intravenous* solution reconstituted 1 gm 3


cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml 1

cefpodoxime proxetil oral tablet 100 mg, 200 mg 1

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1


ceftriaxone sodium injection solution reconstituted 250 mg 3

ceftriaxone sodium injection solution reconstituted 500 mg 3

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1




82

DENTAL



1

amoxicillin oral tablet 875 mg 1

amoxicillin-pot clavulanate er oral tablet extended release 12 hr* 1000-62.5 mg 1

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml

1

amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml 1

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml 1

amoxicillin-pot clavulanate oral tablet 250-125 mg 1

amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg 1


AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML 3

BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML 3

BICILLIN L-A INTRAMUSCULAR* SUSPENSION 600000 UNIT/ML 3

dicloxacillin sodium oral capsule 250 mg, 500 mg 1

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml 1



azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1


clarithromycin oral suspension reconstituted 125 mg/5ml 1

clarithromycin oral suspension reconstituted 250 mg/5ml 1


ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML 3

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG 3




ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg 1

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%) 3

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg, 500 mg 3


sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg 1

sulfamethoxazole-trimethoprim oral tablet 800-160 mg 1


demeclocycline hcl oral tablet 150 mg, 300 mg 3

doxycycline hyclate oral capsule 100 mg 3

doxycycline hyclate oral capsule 50 mg 3


83

DENTAL



minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1


Antimycobacterials [Antimicobacterianos]

Antimycobacterials, Other [Antimicobacterianos, Otros]

dapsone oral tablet 100 mg, 25 mg 3


Antiprotozoals [Antiprotozoarios]

atovaquone oral suspension 750 mg/5ml 3

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG 3


84

PARTE VI – APENDICES / PART VI – APPENDIXES

Apéndice I - Quimioterapias Orales / Appendix I – Oral Chemotherapies

Dentro del formulario están incluidos medicamentos de quimioterapia oral. Triple-S cubrirá estos medicamentos con un co-aseguro. La siguiente tabla contiene una lista de cuáles son estos productos. / The formulary includes oral chemotherapies. Triple S will cover those medications with a copay.

Quimioterapias Orales / Oral Chemotherapies

Medicamento (Drug)


AFINITOR

AFINITOR DISPERZ

anastrozole oral

bexarotene

bicalutamide

BOSULIF

CAPRELSA

COMETRIQ (100 MG DAILY DOSE)



EMCYT

ERIVEDGE

exemestane

FARESTON

flutamide

GLEEVEC

GLEOSTINE ORAL CAPSULE 5 MG

HEXALEN

hydroxyurea oral

ICLUSIG

INLYTA

JAKAFI

letrozole oral

leucovorin calcium oral

LEUKERAN

lomustine

LONSURF

MATULANE

mercaptopurine oral

MESNEX ORAL

NEXAVAR

NILANDRON

POMALYST


85

Quimioterapias Orales / Oral Chemotherapies

Medicamento (Drug)

REVLIMID

SPRYCEL

STIVARGA

SUTENT

TABLOID

TARCEVA

TASIGNA

THALOMID

tretinoin oral

TYKERB

VOTRIENT

XALKORI

XTANDI

ZELBORAF

ZOLINZA

ZYTIGA

Hormonal Agents, Suppressant (Adrenal) [Hormonales, Supresores (Adrenal)]

LYSODREN


86

Apéndice II – Límites de Especialidad (LE) / Appendix II – Specialty Limits (SL)

En el formulario encontrarán medicamentos asociados a las iniciales SL. SL significa que estos medicamentos requieren que un especialista evalúe el paciente y los recete. La siguiente tabla contiene los nombres de estos productos e indica el especialista que debe recetarlos.

The formulary includes drugs associated to the LE initials. LE means that those medications require that a specialist evaluates the patient and prescribe it. The following table shows which are those products and indicates the specialist that must prescribe them.

Límites de Especialidad (LE) / Specialty Limits (SL)

Producto / Product Especialidad / Specialty


ENTOCORT EC Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist


SIVEXTRO Infectólogo, Medicina Interna / Infectologist, Internal medicine


AMOXAPINE

Generalista, Medicina Interna, Pediatra, Obstetra & Ginecólogo, Neurólogo, Neurólogo Pediatrico, Medicina de Familia, Psiquiatra, Psiquiatra Pediátrico / General Practitioner, Internal Medicine, Pediatrician, Obstetrician & Gynecologist , Neurologist, Pedriatric Neurologist, Pediatrician, Family Medicine, Pediatric Psychiatrist, Psychiatrist

ANAFRANIL


CELEXA


CYMBALTA


DESYREL


EFFEXOR



87

Límites de Especialidad (LE) / Specialty Limits (SL) Producto / Product Especialidad / Specialty

EFFEXOR XR


ELAVIL


EMSAM


LEXAPRO


LUDIOMIL


LUVOX


MARPLAN


NARDIL


NORPRAMIN



88


PAMELOR


PARNATE


PAXIL


PAXIL CR


PROZAC


REMERON


SINEQUAN


SURMONTIL


TOFRANIL



89


WELLBUTRIN


WELLBUTRIN SR


ZOLOFT



EMEND Oncólogo / Oncologist


CANCIDAS Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist

ERAXIS Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist

MYCAMINE Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist

VFEND Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist


AFINITOR Hematólogo, Neurocirujano, Neurólogo, Oncológo, Urológo / Hematologist, Neurosurgeon, Neurologist, Oncologist, Urologist

AFINITOR DISPERZ Hematólogo, Neurocirujano, Neurólogo, Oncológo, Urológo / Hematologist, Neurosurgeon, Neurologist, Oncologist, Urologist

BOSULIF Hematólogo-Oncólogo / Hematologist-Oncologist

CAPRELSA Endocrinólogo, Hematólogo, Oncólogo / Endocrinologist, Hematologist, Oncologist

COMETRIQ Endocrinólogo, Hematólogo, Oncólogo / Endocrinologist, Hematologist, Oncologist

ERIVEDGE Dermatólogo, Hematólogo, Oncólogo / Dermatologist, Hematologist, Oncologist

GLEEVEC Hematólogo-Oncólogo / Hematologist-Oncologist

ICLUSIG Hematólogo-Oncólogo / Hematologist-Oncologist

INLYTA Hematólogo, Oncológo, Urólogo / Hematologist, Oncologist, Urologist

JAKAFI Hematólogo-Oncólogo / Hematologist-Oncologist

LONSURF Hematólogo-Oncólogo / Hematologist-Oncologist


90


NEXAVAR Gastroenterólogo, Hematólogo, Oncológo, Urólogo / Gastroenterologist, Hematologist, Oncologist, Urologist

POMALYST Hematólogo-Oncólogo / Hematologist-Oncologist

REVLIMID Hematólogo-Oncólogo / Hematologist-Oncologist

SPRYCEL Hematólogo-Oncólogo / Hematologist-Oncologist

STIVARGA Hematólogo-Oncólogo / Hematologist-Oncologist

SUTENT Gastroenterólogo, Hematólogo, Oncológo, Urólogo / Gastroenterologist, Hematologist, Oncologist, Urologist

TARCEVA Oncólogo / Oncologist

TASIGNA Hematólogo-Oncólogo / Hematologist-Oncologist

THALOMID Dermatólogo, Hematólogo, Oncólogo / Dermatologist, Hematologist, Oncologist

TYKERB Hematólogo-Oncólogo / Hematologist-Oncologist

VOTRIENT Hematólogo, Oncológo, Urólogo / Hematologist, Oncologist, Urologist

XALKORI Hematólogo-Oncólogo / Hematologist-Oncologist

XTANDI Hematólogo-Oncólogo / Hematologist-Oncologist

ZELBORAF Hematólogo-Oncólogo / Hematologist-Oncologist

ZYTIGA Hematólogo-Oncólogo / Hematologist-Oncologist


APTIVUS Infectólogo / Infectologist

BARACLUDE Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

EPIVIR HBV Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

FUZEON Infectólogo / Infectologist

HARVONI Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

HEPSERA Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

INFERGEN Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

INTELENCE Infectólogo / Infectologist

INTRON A Gastroenterólogo, Ginécologo, Hematólogo, Infectólogo, Oncológo, Urólogo / Gastroenterologist, Gynecologist, Hematologist, Infectologist, Oncologist, Urologist

PEGASYS/PEGASYS PROCLICK Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

PEG-INTRON Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

REBETOL Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

SELZENTRY Infectólogo / Infectologist

SOVALDI Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

TYZEKA Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist

VIREAD Gastroenterólogo, Infectólogo / Gastroenterologist, Infectologist


ATIVAN



91


BUSPAR


SERAX


TRANXENE T


VALIUM


VISTARIL


XANAX


Blood Glucose Regulators [Reguladores de Glucosa en Sangre]

SYMLIN PEN Endocrinólogo, Generalista Internista / Endocrinologist, General Practitioner, Internal Medicine

Blood Products/ Modifiers/ Volume Expanders [Productos para la Sangre/Modificadores/Expansores de Volumen]

ADVATE Hematólogo / Hematologist

ADYNOVATE Hematólogo / Hematologist

ALPHANATE/VWF COMPLEX/HUMAN Hematólogo / Hematologist

ALPHANINE SD Hematólogo / Hematologist

ALPROLIX Hematólogo / Hematologist

BEBULIN/BEBULIN VH Hematólogo / Hematologist

BENEFIX/RIXUBIS Hematólogo / Hematologist

BRILINTA Primera receta: Cardiólogo, Internista / First Prescription: Cardiologist, Internal Medicine

COAGADEX Hematólogo / Hematologist


92


EFFIENT Primera receta: Cardiólogo, Internista / First Prescription: Cardiologist, Internal Medicine

ELOCTATE Hematólogo / Hematologist

FEIBA VH/FEIBA NF Hematólogo / Hematologist

HELIXATE FS Hematólogo / Hematologist

HEMOFIL M Hematólogo / Hematologist

HUMATE-P Hematólogo / Hematologist

IDELVION Hematólogo / Hematologist

KOATE-DVI Hematólogo / Hematologist

KOGENATE FS Hematólogo / Hematologist

KOVALTY Hematólogo / Hematologist

LEUKINE Oncólogo / Oncologist

MONOCLATE-P Hematólogo / Hematologist

MONONINE Hematólogo / Hematologist

NEUMEGA Oncólogo / Oncologist

NEUPOGEN Hematólogo-Oncólogo / Hematologist-Oncologist

NOVOEIGHT Hematólogo / Hematologist

NOVOSEVEN Hematólogo / Hematologist

NOVOSEVEN RT Hematólogo / Hematologist

NUWIQ Hematólogo / Hematologist

OBIZUR Hematólogo / Hematologist

PROFILNINE SD Hematólogo / Hematologist

RECOMBINATE Hematólogo / Hematologist

SYNAREL Ginecólogo / Gynecologist

WILATE Hematólogo / Hematologist

XYNTHA Hematólogo / Hematologist

XYNTHA SOLOFUSE Hematólogo / Hematologist


RANEXA Cardiólogo / Cardiologist

ENTRESTO Cardiólogo / Cardiologist


ADDERALL Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

AMPYRA Neurólogo, Psiquiatra - Rehabilitacion / Neurologist, Physiatric - Rehabilitation

AVONEX Neurólogo / Neurologist

COPAXONE Neurólogo / Neurologist

DEXEDRINE SR Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist


93


DEXTROSTAT Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

EXTAVIA Neurólogo / Neurologist

GILENYA Neurólogo / Neurologist

KAPVAY

Medicina Interna , Médico de Familia, Neurólogo, Neurólogo Pediátrico , Pediatra, Psiquatra, Psiquiatra Niños y Adolescentes, Pulmonólogo / Internal Medicine, Family Physician, Neurologist, Pediatrician, Pediatric Neurologist, Psychiatrist, Pediatric psychiatrist, Pneumologist, Pulmonologist

REBIF Neurólogo / Neurologist

RITALIN Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

RITALIN SR/METADATE ER Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

STRATTERA Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

PROVIGIL Neumólogo, Neurólogo, Neurólogo Pedriatrico, Psiquiatra, Psiquiatra Pediatrico / Pneumologist, Pulmonologist, Neurologist, Pedriatric Neurologist, Psychiatrist, Pediatric Psychiatrist

TYSABRI Gastroenterólogo, Neurólogo / Gastroenterologist, Neurologist


RETIN-A Dermatólogo, Pedriatra / Dermatologist, Pediatrician

Enzyme Replacements/Modifiers [Reemplazo de Enzimas/Modificadores]

ADAGEN Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

ALDURAZYME Endocrinólogo, Especialista en Desórdenes Genéticos o Metabólicos / Endocrinologist, Specialist in Metabolic or Genetic Disorders

BUPHENYL Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

CEREZYME Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

CYSTADANE Cardiólogo, Endocrinólogo, Genetista/Cardiologist, Endocrinologist, Geneticist

CYSTAGON Nefrólogo, Nefrólogo Pediatrico / Nephrologist, Pediatric Nephrologist

ELAPRASE Endocrinólogo, Especialista en Desórdenes Genéticos o Metabólicos / Endocrinologist, Specialist in Metabolic or Genetic Disorders


94


ELELYSO Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

FABRAZYME Cardiólogo, Especialista en Desórdenes Genéticos o Metabólicos, Nefrólogo / Cardiologist, Specialist in Genetic or Metabolic Disorders, Nephrologist

KUVAN Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

NAGLAZYME Endocrinólogo, Especialista en Desórdenes Genéticos o Metabólicos / Endocrinologist, Specialist in Metabolic or Genetic Disorders

ORFADIN Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

VPRIV Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders

ZAVESCA Especialista en Desórdenes Genéticos o Metabólicos / Specialist in Genetic or Metabolic Disorders


FULYZAQ Infectólogo / Infectologist


RENAGEL Nefrólogo / Nephrologist

RENVELA Nefrólogo / Nephrologist


INCRELEX Endocrinólogo / Endocrinologist

NOVAREL Endocrinólogo / Endocrinologist


SENSIPAR Endocrinólogo, Hematólogo, Nefrólogo, Oncólogo / Endocrinologist, Hematologist, Nephrologist, Oncologist


GENOTROPIN Endocrinólogo, Gastroenterólogo, Infectólogo / Endocrinologist, Gastroenterologist, Infectologist

LUPRON DEPOT-PED Ginecologo, Pediatra, Endocrinólogo/ Ginecologist, Pediatric, Endocrinologist

NORDITROPIN FLEXPRO Endocrinólogo, Gastroenterólogo, Infectólogo / Endocrinologist, Gastroenterologist, Infectologist

SANDOSTATIN Endocrinólogo, Gastroenterólogo, Hematólogo, Oncólogo / Endocrinologist, Gastroenterologist, Hematologist, Oncologist

SEROSTIM Endocrinólogo, Gastroenterólogo, Infectólogo / Endocrinologist, Gastroenterologist, Infectologist

SOMAVERT Endocrinólogo / Endocrinologist

ZORBTIVE Endocrinólogo, Gastroenterólogo, Infectólogo / Endocrinologist, Gastroenterologist, Infectologist

Immunological Agents [Inmunológicos]

ACTEMRA Reumatólogo / Rheumatologist


95


ACTEMRA SC Reumatólogo / Rheumatologist

ARCALYST Especialista en Desórdenes Genéticos o Metabólicos, Inmunólogo, Reumatólogo / Specialist in Genetic or Metabolic Disorders, Inmunologist, Rheumatologist

CELLCEPT Reumatólogo / Rheumatologist

ENBREL Dermatologist, Gastroenterologist, Rheumatologist, /Dermatólogo, Gastroenterólogo, Reumatólogo

HUMIRA Dermatologist, Gastroenterologist, Ginecologist, Rheumatologist, / Dermatólogo, Gastroenterólogo, Ginecólogo,Reumatólogo

IMURAN Dermatólogo, Gastroenterólogo, Nefrólogo, Neumólogo, Reumatólogo / Dermatologist, Gastroenterologist, Nephrologist, Pneumologist, Pulmonologist, Rheumatologist

ORENCIA Reumatólogo / Rheumatologist

REMICADE Dermatologist, Gastroenterologist, Rheumatologist, /Dermatólogo, Gastroenterólogo, Reumatólogo

XOLAIR Alergista, Neumólogo / Allergist , Pneumologist, Pulmonologist

Metabolic Bone Disease Agents [Enfermedad del Metabolismo del Hueso]

BONIVA Endocrinólogo, Reumatólogo / Endocrinologist, Rheumatologist

FORTEO Endocrinólogo, Reumatólogo / Endocrinologist, Rheumatologist

PROLIA Endocrinólogo, Reumatólogo / Endocrinologist, Rheumatologist

ZEMPLAR Nefrólogo / Nephrologist

ZOLEDRONIC ACID Endocrinólogo, Reumatólogo / Endocrinologist, Rheumatologist


RESTASIS Oftalmólogo / Ophthalmologist


ARALAST NP Especialista en Desórdenes Genéticos o Metabólicos, Neumólogo / Specialist in Genetic or Metabolic Disorders, Pneumologist, Pulmonologist

LETAIRIS Cardiólogo, Intensivista, Neumólogo / Cardiologist, Intensivist, Pneumologist, Pulmonologist

PROLASTIN Especialista en Desórdenes Genéticos o Metabólicos, Neumólogo / Specialist in Genetic or Metabolic Disorders, Pneumologist, Pulmonologist

PULMOZYME Especialista en Desórdenes Genéticos o Metabólicos, Internista, Neumólogo, Pediatra / Specialist in Genetic or Metabolic Disorders, Internal Medicine, Pneumologist, Pulmonologist, Pediatrician

REVATIO Cardiólogo, Intensivista, Neumólogo / Cardiologist, Intensivist, Pneumologist, Pulmonologist

TRACLEER Cardiólogo, Intensivista, Neumólogo / Cardiologist, Intensivist, Pneumologist, Pulmonologist

VENTAVIS Cardiólogo, Intensivista, Neumólogo / Cardiologist, Intensivist, Pneumologist, Pulmonologist


96


ZEMAIRA Especialista en Desórdenes Genéticos o Metabólicos, Neumólogo / Specialist in Genetic or Metabolic Disorders, Pneumologist, Pulmonologist

Therapeutic Nutrients/Minerals/Electrolytes [Nutrientes Terapéuticos/Minerales/Electrólitos]

EXJADE Hematólogo-Oncólogo / Hematologist-Oncologist

FERRIPROX Hematólogo-Oncólogo / Hematologist-Oncologist

JADENU Hematólogo-Oncólogo / Hematologist-Oncologist


97

Apéndice III – Límites de Especialidad (LE) Salud Mental / Appendix III - Specialty

Limits (SL) Mental Health

En el formulario encontrarán medicamentos asociados a las iniciales SL. SL significa que estos medicamentos requieren que un especialista evalúe el paciente y los recete. La siguiente tabla contiene los nombres de estos productos e indica el especialista que debe recetarlos. / The formulary includes drugs associated to the LE initials. LE means that those medications require that a specialist evaluates the patient and prescribe it. The following table shows which are those products and indicates the specialist that must prescribe them.

Límites de Especialidad Salud Mental / Specialty Limits Mental Health


Anti-Addiction/Substance Abuse Treatment Agents [Tratamiento de abuso de Sustancias/Contra la Addición]

Alcohol Deterrents/Anti-craving [Disuasivos de Alcohol/Anti-ansiedad]

ANTABUSE Psiquiatra, Psiquiatra Pediátrico / Pediatric Psychiatrist, Psychiatrist

CAMPRAL Psiquiatra, Psiquiatra Pediátrico / Pediatric Psychiatrist, Psychiatrist

Opioid Dependence Treatment [Tratamiento Contra la Dependencia a Opiodes]

SUBOXONE

Médico cumple requisitos, notificó a HHS y está listado en SAMSHA para prescribir Buprenorphine o Buprenorphine/Naloxone / Prescriber meets qualifying requirements, has notified the HHS of their intent to prescribe Buprenorphine or Buprenorphine/Naloxone and is listed on the Physician Locator at SAMSHA

SUBUTEX

Médico cumple requisitos, notificó a HHS y está listado en SAMSHA para prescribir Buprenorphine o Buprenorphine/Naloxone / Prescriber meets qualifying requirements, has notified the HHS of their intent to prescribe Buprenorphine or Buprenorphine/Naloxone and is listed on the Physician Locator at SAMSHA



REMERON Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

WELLBUTRIN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

WELLBUTRIN SR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

Monoamine Oxidase Inhibitors [Inhibidores de Monoamino Oxidasa]

EMSAM Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


98



MARPLAN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

NARDIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PARNATE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) [SSRIs/SNRIs (Inhibidores de la Recaptación Selectiva de Serotonina / Inhibidores de la Recaptación de Serotonina y Norepinefrina)]

CELEXA Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

DESYREL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

EFFEXOR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

EFFEXOR XR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

LEXAPRO Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

LUDIOMIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

LUVOX Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PAXIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PAXIL CR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PROZAC Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

ZOLOFT Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


AMOXAPINE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


99



ANAFRANIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

ELAVIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

NORPRAMIN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PAMELOR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

SINEQUAN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

SURMONTIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

TOFRANIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


1st Generation/Typical [1ra Generación/Típicos]

COMPAZINE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

HALDOL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

HALDOL DECANOATE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

LOXITANE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

MELLARIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

NAVANE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PROLIXIN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

STELAZINE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

THORAZINE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


100



TRILAFON Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

2nd Generation/Atypical [2da Generación/Atípicos]

ABILIFY Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

GEODON Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

RISPERDAL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

RISPERDAL CONSTA Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

SEROQUEL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

ZYPREXA Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

Treatment-Resistant [Resistentes a Tratamiento]

CLOZARIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist



BUSPAR Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

VISTARIL Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


ATIVAN Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

SERAX Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

TRANXENE T Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

VALIUM Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

XANAX Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

Bipolar Agents [Bipolaridad]

Mood Stabilizers [Estabilizadores del Ánimo]

LITHIUM CARBONATE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


101



LITHIUM CITRATE Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

LITHOBID Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist


ADHD, Amphetamines [Anfetaminas, ADHD]

ADDERALL Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

DEXEDRINE SR Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

DEXTROSTAT Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

ADHD, Non-amphetamines [No-Anfetaminas, ADHD]

KAPVAY Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

RITALIN Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

RITALIN SR/METADATE ER Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

STRATTERA Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist

Sleep Disorder Agents [Desórdenes del Sueño]

GABA Receptor Modulators [Moduladores del Receptor de GABA]

AMBIEN Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

PROSOM Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

RESTORIL Psiquiatra, Psiquiatra Pediatrico / Pediatric Psychiatrist, Psychiatrist

SONATA Neurólogo, Neurólogo Pediatrico, Psiquiatra, Psiquiatra Pediatric / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist

Sleep Disorder, Other [Desórdenes del Sueño, Otros]

PROVIGIL Neurólogo, Neurólogo Pediatrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist


102

Apéndice IV – Terapias Escalonadas (TE) / Appendix IV - Step Therapies (ST) En este formulario se encuentran incluidos medicamentos asociados a las iniciales ST. ST significa terapia escalonada donde el paciente utiliza medicamentos del primer paso antes de utilizar los medicamentos identificados como segundo paso. En la siguiente tabla se identifican los medicamentos del primer y segundo paso. / The formulary includes drugs associated to the ST abbreviation. ST means step therapy, where the patient uses step one drugs before using the drugs identified as second step. The following table identified the medications used as first and second step.

Terapias Escalonadas / Step Therapies

Nombre de la Terapia Escalonada (Step Therapy Description)

Medicamentos (Drugs)

Abilify Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Risperidone, Olanzapine, Ziprasidone Paso 2/Step 2: Abilify / Aripiprazole

ADHD Agents Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Methylphenidate or dextroamphetamine Paso 2/Step 2: Amphetamine & Dextroamphetamine / Adderall, Atomoxetine / Strattera

Aldosterone Antagonists Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Spironolactone or spironolactone/hctz 25MG-25MG generic Paso 2/Step 2: Inspra / Eplerenone, Aldactazide 50MG-50MG

Alpha Glucosidase Inhibitors Sistema buscará 60 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 60 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Acarbose Paso 2/Step 2: Miglitol / Glyset

Calcineurin Inhibitors Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Topical steroid/ammonium lactate Paso 2/Step 2: Use of Pimecrolimus / Elidel, Tacrolimus / Protopic

Carbonic anhidrase Inhibitors Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Dorzolamide generic Paso 2/Step 2: Brinzolamide / Azopt

Celecoxib (Celebrex) Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: NSAIDs Paso 2/Step 2: Celebrex/ Celecoxib


103




Ezetimibe (Zetia), Ezetimibe- simvastatin (Vytorin) Sistema buscará 60 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 60 days of use for Step 1 drugs in the last 180 days. . Paso 1/Step 1: Use of Statins or combinations generic first. Paso 2/Step 2: Ezetimibe-Simvastatin / Vytorin, Ezetimibe / Zetia

Fluticasone Generic First Sistema buscará uso de 1 medicamento en el Paso 1 en los últimos 180 dias /System will search for 1 prescription of use for Step 1 drugs in the last 180 days Paso 1/Step 1: Fluticasone/ OTC or generic, Triamcinolone/OTC first Paso 2/Step 2: Fluticasone Furoate / Veramyst, Triamcinolone Acetonide / Nasacort

GLP-1 Inhibitors Sistema buscará 60 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 60 days of use for Step 1 drugs in the last 180 days. . Paso 1/Step 1: Biguanides or sulfonylureas or glitazones Paso 2/Step 2: Exenatide / Byetta, Exenatide Extended Release / Bydureon, liraglutide / Victoza

Histamine1 (H1) Blocking Agents, Midly/Nonsedating Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. . Paso 1/Step 1: Zyrtec OTC/Claritin OTC/Allegra OTC or fexofenadine Paso 2/Step 2: Levocetirizine Dihydrochloride / Xyzal

Mirabregon (Myrbetriq) Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Oxybutinin/tolterodine Paso 2/Step 2: Mirabegron / Myrbetriq

Mometasone furoate (Asmanex) Sistema buscará uso de 1 medicamento en el Paso 1 en los últimos 180 dias /System will search for 1 prescription of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Beclomethasone / Qvar, fluticasone propionate / Flovent, Fluticasone Furoate/ Arnuity Ellipta Paso 2/Step 2: Mometasone/ Asmanex

Ocular allergies - OTC First Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Ketotifen OTC first Paso 2/Step 2: Olopatadine / Patanol

Pediculicides (Lindane) Sistema buscará 15 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 15 days of use for Step 1 drugs in the last 180 days. . Paso 1/Step 1: Permethrin Cream Paso 2/Step 2: Lindane

Pregabalin (Lyrica) Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Anticonvulsants/TCA/Duloxetine Paso 2/Step 2: Pregabalin / Lyrica


104




Proton Pump Inhibitors Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Prilosec OTC/Prevacid OTC/ZegeridOTC/ Nexium OTC or omeprazole/pantoprazole generic Paso 2/Step 2: Lansoprazole RX

Rasagiline (Azylet) Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Selegiline Paso 2/Step 2: Rasagiline / Azilect

Repaglinide Sistema buscará 60 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 60 days of use for Step 1 drugs in the last 180 days. . Paso 1/Step 1: Nateglinide Paso 2/Step 2: Repaglinide / Prandin

Triptans Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Sumatriptan Paso 2/Step 2: Eletriptan / Relpax

Sodium-Glucose Co-Transporter 2 Inhibitor Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: Biguanides or sulfonylureas or glitazones. Paso 2/Step 2: Empagliflozin/ Jardiance, Empagliflozin-Metformin Hcl/ Synjardy

SGLT2+DPP4 ST (Glyxambi) Sistema buscará 30 dias de uso del medicamento en el Paso 1 en los últimos 180 dias /System will search for 30 days of use for Step 1 drugs in the last 180 days. Paso 1/Step 1: MET, SU, TZD, GLP-1, a-glucosidase inhibitors, DPP4-I, SGLT-2 I or combinations. Paso 2/Step 2: Empagliflozin-Linagliptin/ Glyxambi


105

Apéndice V – Solicitud de Excepción Médica / Appendix V - Medical Exception

Application

Nombre del Paciente y Representante Personal (si aplica): __________________________________

Núm. Contrato ______________________ Núm. de Grupo: ____________________

Se solicita la aprobación de:

Medicamento no está incluido en el formulario

Cubierta continuada para medicamento que se descontinuar

Excepción a un procedimiento de manejo de medicamento (ei, terapia escalonada)

Excepción a un procedimiento de limitación de dosis

Razones para la solicitud de excepción médica:

En el formulario no figura un medicamento clínicamente aceptable para tratar la condición del paciente.

El medicamento que procede conforme a la terapia escalonada es ineficaz para la condición o el paciente, es

probable que cause daño al paciente o y ya el paciente se encontraba en un nivel más avanzado bajo otro

plan médico.

La dosis disponible para medicamento probablemente es ineficaz para la condición o el paciente.

Historial breve del paciente:

Diagnóstico primario relacionado con el medicamento de receta objeto de la solicitud (incluya código y descripción):

Descripción de la necesidad médica de medicamento para el cual se solicita la excepción: (Incluya hoja adicional de ser necesario)

Nombre de la Persona que expide la receta # de Proveedor (NPI)

Firma Fecha

Forma: CSS-AS-04-002


106

PARTE VII – INDICE / PART VII – INDEX

abacavir sulfate ..................................... 32 abacavir-lamivudine-zidovudine ......... 32 Abilify .................................................... 102 ABILIFY .......................................... 77, 100 ABSORICA ............................................ 44 acamprosate calcium ........................ 75 acarbose ................................................ 34 Acarbose .............................................. 102 acebutolol hcl ........................................ 39 acetaminophen-codeine .......... 16, 68, 80 acetaminophen-codeine #2 ..... 15, 68, 80 acetaminophen-codeine #3 ..... 15, 68, 80 acetaminophen-codeine #4 ..... 15, 68, 80 acetazolamide ....................................... 40 acetic acid ........................................ 17, 68 acetic acid-aluminum acetate ....... 17, 68 acetylcysteine ........................................ 64 acitretin ................................................... 44 ACTEMRA ....................................... 52, 94 ACTEMRA SC ....................................... 95 ACUVAIL ................................................ 54 acyclovir ........................................... 31, 71 acyclovir sodium ................................... 31 ADAGEN .......................................... 44, 93 Adderall ................................................ 102 ADDERALL .................................... 92, 101 adefovir dipivoxil ................................... 31 ADVAIR DISKUS .................................. 62 ADVAIR HFA ......................................... 62 ADVATE ........................................... 36, 91 adynovate .............................................. 36 ADYNOVATE ........................................ 91 AFINITOR ........................................ 84, 89 AFINITOR DISPERZ ...................... 84, 89 A-HYDROCORT ................................... 27 ALAVERT .............................................. 54 ALAVERT ALLERGY/SINUS .............. 54 ALAWAY ................................................ 53 ALAWAY CHILDRENS ALLERGY ..... 53 ALBENZA .............................................. 29 albuterol sulfate ............................... 63, 73 alclometasone dipropionate ................ 48 Aldactazide .......................................... 102 ALDACTAZIDE ..................................... 41 ALDURAZYME ............................... 44, 93 alendronate sodium .............................. 52 ALINIA .................................................... 29 all day allergy ........................................ 55 all day allergy childrens ................. 54, 55 all day allergy d ..................................... 55 all day allergy d-12 ............................... 55 all day allergy-d ..................................... 55 ALLEGRA ALLERGY ........................... 55 ALLEGRA ALLERGY CHILDRENS ... 55 Allegra OTC ......................................... 103 ALLEGRA-D ALLERGY &

CONGESTION ................................. 55 aller-ease ............................................... 55 allergy ..................................................... 55

allergy 24-hr .......................................... 55 allergy d-12 ........................................... 55 allergy eye drops .................................. 53 allergy relief ........................................... 55 allergy relief child .................................. 55 allergy relief childrens .......................... 55 allergy relief d........................................ 55 allergy relief d-24 .................................. 55 allergy relief for kids ............................. 55 allergy relief/nasal decongest ............. 55 allergy relief-d ................................. 55, 56 allergy/congestion relief ....................... 56 allopurinol .............................................. 27 alosetron hcl .......................................... 45 ALPHAGAN P ....................................... 54 ALPHANATE ......................................... 91 ALPHANATE/VWF COMPLEX/HUMAN

........................................................... 36 ALPHANINE SD ............................. 36, 91 alprazolam ....................................... 34, 78 ALPROLIX ....................................... 36, 91 amantadine hcl ..................................... 29 AMBIEN ............................................... 101 amikacin sulfate .................................... 17 amiloride hcl .......................................... 41 amiloride-hydrochlorothiazide............. 41 aminophylline ........................................ 64 AMINOSYN II ........................................ 65 AMINOSYN II/ELECTROLYTES........ 65 AMINOSYN M ....................................... 65 amiodarone hcl ..................................... 39 AMITIZA................................................. 46 amitriptyline hcl ............................... 25, 76 amlodipine besy-benazepril hcl .......... 38 amlodipine besylate ............................. 40 ammonium lactate ................................ 44 AMNESTEEM ....................................... 44 amoxapine ....................................... 25, 77 AMOXAPINE ................................... 86, 98 amoxicillin ............................. 20, 69, 81, 82 amoxicillin-pot clavulanate ....... 20, 69, 82 amoxicillin-pot clavulanate er ....... 20, 82 amphetamine-dextroamphetamine ... 42,

79 ampicillin ..................................... 20, 69, 82 ampicillin sodium .................................. 20 AMPYRA ......................................... 43, 92 ANAFRANIL .................................... 86, 99 anagrelide hcl........................................ 37 anastrozole ............................................ 84 ANDROGEL .......................................... 50 ANDROGEL PUMP ............................. 50 ANTABUSE ........................................... 97 APIDRA ................................................. 35 APOKYN ................................................ 30 APRISO ................................................. 52 APTIVUS ......................................... 33, 90 ARALAST NP.................................. 64, 95 ARCALYST ..................................... 52, 95

aripiprazole ............................................ 77 Aripiprazole .......................................... 102 Arnuity Ellipta ....................................... 103 ARNUITY ELLIPTA............................... 62 ASACOL HD .......................................... 52 Asmanex .............................................. 103 ASMANEX 120 METERED DOSES .. 62 ASMANEX 30 METERED DOSES ..... 62 aspirin-dipyridamole er ......................... 37 atenolol ............................................. 39, 72 atenolol-chlorthalidone ................... 39, 72 ATIVAN .......................................... 90, 100 Atomoxetine ......................................... 102 atorvastatin calcium .............................. 41 atovaquone ...................................... 29, 83 atovaquone-proguanil hcl .................... 29 ATRIPLA ................................................ 32 ATROVENT HFA ............................ 63, 73 AUGMENTIN ................................... 20, 82 AVONEX .......................................... 43, 92 AVONEX PEN ....................................... 43 AVONEX PREFILLED .......................... 43 azathioprine ........................................... 51 azelastine hcl ......................................... 56 Azilect ................................................... 104 AZILECT................................................. 30 azithromycin ......................... 20, 21, 69, 82 AZOPT .................................................... 54 bacitracin ................................................ 18 bacitracin-polymyxin b .......................... 18 baclofen .................................................. 30 balsalazide disodium ............................ 52 BANZEL ................................................. 23 BARACLUDE ................................... 31, 90 BEBULIN .......................................... 36, 91 BEBULIN VH ......................................... 91 benazepril hcl ........................................ 38 benazepril-hydrochlorothiazide ........... 38 BENEFIX ................................................ 91 benztropine mesylate ........................... 29 betamethasone dipropionate ............... 48 betamethasone dipropionate aug ....... 48 betamethasone valerate ...................... 48 betaxolol hcl ..................................... 39, 54 bethanechol chloride ............................ 48 bexarotene ....................................... 29, 84 bicalutamide ........................................... 84 BICILLIN C-R ......................................... 20 BICILLIN C-R 900/300 ................... 20, 82 BICILLIN L-A ................................... 20, 82 BILTRICIDE ........................................... 29 bisoprolol fumarate ............................... 39 bisoprolol-hydrochlorothiazide ............ 39 BLEPHAMIDE ....................................... 21 BLEPHAMIDE S.O.P. ........................... 22 BONIVA .................................................... 95 BOSULIF .......................................... 84, 89 BOTOX ................................................... 43 BRILINTA ......................................... 37, 91


107

brimonidine tartrate .............................. 54 Brinzolamide / Azopt .......................... 102 bromocriptine mesylate ........................ 30 budesonide ............................................ 62 budesonide er ....................................... 27 bumetanide ............................................ 40 BUPHENYL ..................................... 44, 93 buprenorphine hcl ................................. 75 buprenorphine hcl-naloxone hcl ......... 75 bupropion hcl ................................... 24, 76 bupropion hcl er (smoking det) ........... 17 bupropion hcl er (sr) ....................... 24, 76 BUSPAR ........................................ 91, 100 buspirone hcl ................................... 33, 78 butalbital-apap-caff-cod ................. 16, 80 butalbital-apap-caffeine ........... 16, 68, 80 butalbital-asa-caff-codeine ............ 16, 80 BUTISOL SODIUM ............................... 65 Bydureon .............................................. 103 BYDUREON .......................................... 34 Byetta ................................................... 103 BYETTA 10 MCG PEN ........................ 34 BYETTA 5 MCG PEN .......................... 34 cabergoline ............................................ 51 calcipotriene .......................................... 44 calcitonin (salmon) ................................ 52 calcitriol ............................................ 44, 52 calcium acetate ..................................... 48 CAMPRAL ............................................. 97 CANASA ................................................ 52 CANCIDAS ...................................... 26, 89 CAPASTAT SULFATE ......................... 28 CAPITAL/CODEINE ....................... 16, 68 CAPRELSA ..................................... 84, 89 captopril............................................ 38, 72 captopril-hydrochlorothiazide ........ 38, 72 CARAFATE ........................................... 46 carbamazepine ............................... 23, 75 carbamazepine er ........................... 23, 75 carbidopa ............................................... 30 carbidopa-levodopa .............................. 30 carbidopa-levodopa er ......................... 30 carbidopa-levodopa-entacapone ........ 30 carteolol hcl ........................................... 54 carvedilol ................................................ 39 cefaclor ....................................... 19, 69, 81 cefadroxil .................................... 19, 69, 81 cefazolin sodium ............................. 19, 81 cefdinir ........................................ 19, 69, 81 cefepime hcl .......................................... 19 cefpodoxime proxetil ...................... 19, 81 cefprozil ...................................... 19, 69, 81 ceftazidime............................................. 19 ceftriaxone sodium ......................... 19, 81 cefuroxime axetil ............................. 19, 81 cefuroxime sodium ............................... 19 Celebrex ............................................... 102 celecoxib ........................................ 15, 80 Celecoxib ............................................. 102 CELEXA ........................................... 86, 98 CELLCEPT ............................................ 95 CELONTIN............................................. 22

cephalexin .................................. 19, 69, 81 CEREZYME .................................... 44, 93 cetirizine hcl .......................................... 56 cetirizine hcl allergy child .................... 56 cetirizine hcl childrens ......................... 56 cetirizine hcl childrens alrgy ................ 56 cetirizine hcl hives relief ...................... 56 cetirizine-pseudoephedrine er ............ 56 cheratussin ac ................................. 64, 74 childrens loratadine .............................. 56 chlorhexidine gluconate ....................... 43 chloroquine phosphate ........................ 29 chlorothiazide ........................................ 41 chlorpromazine hcl ......................... 30, 77 chlorthalidone........................................ 41 chlorzoxazone ....................................... 65 cholestyramine ...................................... 41 cholestyramine light ............................. 41 chorionic gonadotropin ........................ 49 ciclopirox ................................................ 26 cilostazol ................................................ 37 cimetidine ........................................ 45, 73 cimetidine hcl .................................. 45, 73 CINRYZE ............................................... 40 CIPRO HC ....................................... 21, 70 CIPRODEX ........................................... 21 ciprofloxacin ............................... 21, 70, 82 ciprofloxacin hcl ......................... 21, 70, 82 ciprofloxacin-ciproflox hcl er ......... 21, 82 citalopram hydrobromide .......... 24, 25, 76 CLARAVIS ............................................. 44 clarithromycin ............................. 21, 70, 82 CLARITIN .............................................. 56 CLARITIN EYE ..................................... 53 Claritin OTC ........................................ 103 CLARITIN REDITABS ......................... 56 CLARITIN-D 12 HOUR ........................ 56 CLARITIN-D 24 HOUR ........................ 56 CLEAR-ATADINE D ............................. 56 CLIMARA PRO ..................................... 50 clindamycin hcl .......................... 18, 68, 81 clindamycin phosphate ........................ 18 CLINIMIX E/DEXTROSE (2.75/10) .... 65 CLINIMIX E/DEXTROSE (2.75/5) ...... 65 CLINIMIX E/DEXTROSE (4.25/25) .... 65 CLINIMIX E/DEXTROSE (4.25/5) ...... 65 CLINIMIX E/DEXTROSE (5/15) ......... 65 CLINIMIX E/DEXTROSE (5/20) ......... 66 CLINIMIX E/DEXTROSE (5/25) ......... 66 CLINIMIX/DEXTROSE (2.75/5) ......... 66 CLINIMIX/DEXTROSE (4.25/10) ....... 66 CLINIMIX/DEXTROSE (4.25/20) ....... 66 CLINIMIX/DEXTROSE (4.25/25) ....... 66 CLINIMIX/DEXTROSE (4.25/5) ......... 66 CLINIMIX/DEXTROSE (5/15) ............. 66 CLINIMIX/DEXTROSE (5/20) ............. 66 CLINIMIX/DEXTROSE (5/25) ............. 66 clobetasol propionate ........................... 48 clobetasol propionate e ....................... 48 clomipramine hcl ............................ 25, 77 clonazepam ..................................... 22, 75 clonidine hcl ............................... 37, 38, 72

clonidine hcl er ................................ 42, 79 clopidogrel bisulfate ........................ 37, 72 clorazepate dipotassium ................ 34, 78 clotrimazole ...................................... 26, 71 clotrimazole-betamethasone ............... 26 clozapine ................................................ 78 CLOZARIL ........................................... 100 COAGADEX .................................... 36, 91 COARTEM ............................................. 29 colchicine ......................................... 27, 71 colchicine-probenecid ........................... 27 colestipol hcl .................................... 41, 42 colistimethate sodium ........................... 18 COMBIVENT RESPIMAT .................... 63 COMETRIQ ..................................... 84, 89 COMETRIQ (100 MG DAILY DOSE) . 84 COMETRIQ (140 MG DAILY DOSE) . 84 COMETRIQ (60 MG DAILY DOSE) ... 84 COMPAZINE ......................................... 99 COMPLERA ........................................... 32 CONDYLOX ........................................... 44 COPAXONE .................................... 43, 92 cortisone acetate ................................... 27 COSOPT PF .......................................... 54 CRIXIVAN .............................................. 33 cromolyn sodium ....................... 45, 53, 64 CUBICIN................................................. 18 cvs allergy eye drops ............................ 53 cvs allergy relief .................................... 56 cvs allergy relief childrens.................... 56 cvs allergy relief d ................................. 56 cvs allergy relief-d ................................. 56 cvs allergy relief-d12............................. 56 cvs eye itch relief .................................. 53 cvs indoor/outdoor allergy rlf ............... 57 cvs lansoprazole ................................... 46 cvs loratadine ........................................ 57 cvs loratadine-d 24 hour ...................... 57 cvs omeprazole ..................................... 46 cyclobenzaprine hcl ........................ 65, 74 cycloserine ............................................. 28 CYMBALTA ........................................... 86 CYSTADANE ................................... 44, 93 CYSTAGON ..................................... 44, 93 danazol ................................................... 50 dantrolene sodium ................................ 30 dapsone ............................................ 28, 83 DARAPRIM ............................................ 29 demeclocycline hcl .......................... 22, 82 DEMEROL ............................................. 16 DEPEN TITRATABS ............................ 48 DEPO-MEDROL ................................... 27 desipramine hcl ............................... 25, 77 desmopressin ace spray refrig ............ 49 desmopressin acetate .......................... 49 desmopressin acetate spray ............... 49 desonide ................................................. 48 DESYREL ........................................ 86, 98 dexamethasone ............................... 27, 71 DEXAMETHASONE INTENSOL .. 27, 71 dexamethasone sodium phosphate .. 27,

54


108

DEXEDRINE SR ........................... 92, 101 dextroamphetamine ................ 42, 79, 102 dextroamphetamine sulfate ........... 42, 79 dextroamphetamine sulfate er ...... 42, 79 dextrose ................................................. 66 dextrose in lactated ringers ................. 66 dextrose-nacl ......................................... 66 DEXTROSTAT .............................. 93, 101 diazepam ......................................... 34, 78 diclofenac potassium ...................... 15, 80 diclofenac sodium ............... 15, 44, 54, 80 diclofenac sodium er ............................ 15 dicloxacillin sodium ......................... 20, 82 dicyclomine hcl ...................................... 45 didanosine ............................................. 32 digoxin .................................................... 40 dihydroergotamine mesylate ............... 28 DILANTIN ........................................ 23, 70 DILAUDID .............................................. 16 diltiazem hcl ........................................... 40 diltiazem hcl er ...................................... 40 diltiazem hcl er beads .......................... 40 diltiazem hcl er coated beads ............. 40 DIPENTUM ............................................ 52 diphenhydramine hcl ............................ 25 diphenoxylate-atropine................... 45, 73 disopyramide phosphate ..................... 39 disulfiram ................................................ 75 divalproex sodium ........................... 22, 75 divalproex sodium er ...................... 22, 75 donepezil hcl ......................................... 24 dorzolamide ......................................... 102 dorzolamide hcl ..................................... 54 dorzolamide hcl-timolol mal ................. 54 doxazosin mesylate .............................. 38 doxepin hcl....................................... 25, 77 doxycycline hyclate ............ 22, 70, 82, 83 doxycycline monohydrate .................... 22 dronabinol .............................................. 26 DULERA ................................................ 62 Duloxetine ............................................ 103 duloxetine hcl .................................. 25, 76 DYSPORT ............................................. 43 E.S.P. ............................................... 21, 70 econazole nitrate .................................. 26 EDURANT ............................................. 32 EFFEXOR .................................. 86, 87, 98 EFFEXOR XR ................................. 87, 98 EFFIENT .......................................... 37, 92 ELAPRASE ...................................... 45, 93 ELAVIL ............................................. 87, 99 ELELYSO ........................................ 45, 94 Eletriptan .............................................. 104 Elidel ..................................................... 102 ELIDEL ................................................... 44 ELIXOPHYLLIN .................................... 64 ELMIRON .............................................. 48 ELOCTATE ...................................... 36, 92 EMCYT ................................................... 84 EMEND ............................................ 26, 89 Empagliflozin-Linagliptin .................... 104 Empagliflozin-Metformin .................... 104

EMSAM ................................. 24, 76, 87, 97 EMTRIVA ............................................... 32 enalapril maleate ............................ 38, 72 enalapril-hydrochlorothiazide ........ 38, 72 ENBREL .......................................... 51, 95 ENBREL SURECLICK ......................... 51 enoxaparin sodium ............................... 35 entacapone ........................................... 30 entecavir ................................................ 31 ENTOCORT EC ................................... 86 ENTRESTO ..................................... 42, 92 epinephrine ........................................... 63 EPIPEN JR 2-PAK ............................... 63 EPIVIR HBV .................................... 31, 90 eplerenone ............................................ 41 Eplerenone .......................................... 102 EPZICOM .............................................. 32 eq allergy & congestion relief ............. 57 eq allergy relief ..................................... 57 eq allergy relief (cetirizine) .................. 57 eq allergy relief childrens .................... 57 eq allergy relief d 24 hour .................... 57 eq allergy-d ........................................... 57 eq childrens loratadine ........................ 57 eq eye itch relief ................................... 53 eq itchy eye drops ................................ 53 eq lansoprazole .................................... 46 eq loratadine ......................................... 57 eq omeprazole ...................................... 46 eq omeprazole magnesium ................ 46 eql all day allergy .................................. 57 eql all day allergy childrens ................. 57 eql all day allergy-d .............................. 57 eql aller-ease ........................................ 57 eql allergy relief .................................... 57 eql allergy/congestion relief ................ 57 eql childrens loratadine........................ 57 eql omeprazole ..................................... 46 ERAXIS ............................................ 26, 89 ergoloid mesylates ............................... 24 ERGOMAR ............................................ 28 ERIVEDGE ...................................... 84, 89 ERYPED 200 .................................. 21, 82 ERYPED 400 .................................. 21, 82 ERY-TAB ......................................... 21, 82 ERYTHROCIN LACTOBIONATE ...... 21 ERYTHROCIN STEARATE .......... 21, 70 erythromycin.................................... 20, 21 erythromycin base ..................... 21, 70, 82 erythromycin ethylsuccinate .... 21, 70, 82 escitalopram oxalate ...................... 25, 76 estazolam ........................................ 65, 79 ESTRACE ............................................. 50 estradiol ................................................. 50 estropipate ............................................. 50 ethambutol hcl ...................................... 28 ethosuximide ......................................... 22 etidronate disodium .............................. 53 etodolac ........................................... 15, 80 etodolac er ....................................... 15, 80 EURAX................................................... 29 EVOTAZ ................................................ 32

exemestane ........................................... 84 Exenatide ............................................. 103 EXJADE ........................................... 65, 96 EXTAVIA .......................................... 43, 93 eye itch relief ......................................... 53 FABRAZYME ................................... 45, 94 famciclovir .............................................. 31 famotidine............................................... 45 FARESTON ........................................... 84 FEIBA ..................................................... 36 FEIBA NF ............................................... 92 FEIBA VH ............................................... 92 felbamate ............................................... 23 fenofibrate .............................................. 41 fenofibrate micronized .......................... 41 fenofibric acid ........................................ 41 fentanyl ............................................. 15, 80 fentanyl citrate ....................................... 16 FERRIPROX .................................... 65, 96 fexofenadine ........................................ 103 fexofenadine hcl .................................... 57 fexofenadine hcl childrens ................... 57 fexofenadine-pseudoephed er ............ 57 finasteride............................................... 48 FIRAZYR ................................................ 40 flavoxate hcl ........................................... 48 flecainide acetate .................................. 39 FLONASE ALLERGY RELIEF ............ 62 Flovent .................................................. 103 FLOVENT DISKUS ............................... 62 FLOVENT HFA...................................... 62 fluconazole ............................................. 26 flucytosine .............................................. 26 fludrocortisone acetate ......................... 48 flunisolide ............................................... 62 fluocinolone acetonide ............. 48, 49, 54 fluocinolone acetonide body ................ 48 fluocinonide ............................................ 49 fluocinonide-e ........................................ 49 fluorouracil ............................................. 44 fluoxetine hcl .................................... 25, 76 fluphenazine decanoate ....................... 77 fluphenazine hcl .................................... 77 flurbiprofen ............................................. 15 flurbiprofen sodium ............................... 54 flutamide ................................................. 84 Fluticasone........................................... 103 fluticasone propionate .................... 49, 62 fluvoxamine maleate....................... 25, 76 fondaparinux sodium ............................ 35 FORADIL AEROLIZER ........................ 63 FORTAZ ................................................. 19 FORTEO .......................................... 53, 95 FOSCAVIR ............................................. 31 fosinopril sodium ................................... 38 fosinopril sodium-hctz ........................... 38 FREAMINE III ........................................ 66 FULYZAQ......................................... 45, 94 furosemide ................................. 40, 41, 72 FUZEON........................................... 33, 90 gabapentin ............................................. 23 GABITRIL ............................................... 23


109

galantamine hydrobromide .................. 24 galantamine hydrobromide er ............. 24 ganciclovir sodium ................................ 31 gemfibrozil ............................................. 41 GENOTROPIN ...................................... 94 gentamicin sulfate ........................... 17, 68 GEODON ............................................. 100 GILENYA ......................................... 43, 93 GLEEVEC ........................................ 84, 89 GLEOSTINE .................................... 29, 84 glimepiride ....................................... 34, 72 glipizide ............................................ 34, 72 glipizide er ........................................ 34, 72 glipizide-metformin hcl ......................... 34 GLUCAGEN HYPOKIT ........................ 35 glyburide ................................................ 34 glyburide micronized ............................ 34 glyburide-metformin .............................. 34 glycopyrrolate ........................................ 45 Glyset ................................................... 102 GLYSET ................................................. 34 Glyxambi .............................................. 104 GLYXAMBI ............................................ 35 gnp all day allergy ................................. 57 gnp all day allergy childrens ................ 57 gnp all day allergy-d ............................. 57 gnp allergy & congestion ..................... 57 gnp allergy relief.................................... 58 gnp allergy-d allergy & conges ........... 58 gnp eye itch relief.................................. 53 gnp itchy eye ......................................... 53 gnp lansoprazole .................................. 46 gnp loratadine ....................................... 58 gnp loratadine childrens ....................... 58 gnp loratadine-d 12hr ........................... 58 gnp loratadine-d 24 hour ..................... 58 gnp omeprazole .................................... 46 goodsense all day allergy .................... 58 griseofulvin ultramicrosize ................... 26 guanfacine hcl ....................................... 38 HALDOL ................................................. 99 HALDOL DECANOATE ....................... 99 halobetasol propionate......................... 49 haloperidol ............................................. 77 haloperidol decanoate .......................... 77 haloperidol lactate ................................ 77 HARVONI ........................................ 31, 90 heartburn treatment 24 hour ............... 46 HELIXATE FS ....................................... 92 HEMOFIL M..................................... 36, 92 heparin sodium (porcine) ..................... 35 HEPATAMINE ....................................... 66 HEPSERA .............................................. 90 HEXALEN .............................................. 84 hm all day allergy .................................. 58 hm allergy & congestion ...................... 58 hm allergy complete childrens ............ 58 hm allergy complete-d .......................... 58 hm allergy relief ..................................... 58 hm allergy relief/nasal decong ............ 58 hm cetirizine hcl childrens ................... 58 hm eye itch relief ................................... 53

hm fexofenadine hcl ............................. 58 hm lansoprazole ................................... 46 hm loratadine ........................................ 58 hm loratadine childrens ....................... 58 hm omeprazole ..................................... 46 HUMALOG ............................................ 35 HUMALOG MIX 50/50 ......................... 35 HUMALOG MIX 75/25 ......................... 35 HUMATE-P ..................................... 36, 92 HUMIRA........................................... 51, 95 HUMIRA PEN ....................................... 51 HUMULIN 70/30 ................................... 35 HUMULIN N .......................................... 35 HUMULIN R .................................... 35, 72 hydralazine hcl ...................................... 42 hydrochlorothiazide ........................ 41, 73 hydrocodone-acetaminophen ....... 16, 80 hydrocodone-ibuprofen.................. 16, 81 hydrocortisone ................................ 27, 49 hydrocortisone valerate ....................... 49 hydrocortisone-acetic acid ............ 18, 68 hydromorphone hcl .............................. 16 hydromorphone hcl pf .......................... 16 hydroxychloroquine sulfate ................. 29 hydroxyurea .......................................... 84 hydroxyzine pamoate ................ 33, 71, 78 ibandronate sodium ............................. 53 ibuprofen ..................................... 15, 68, 80 ICLUSIG .......................................... 84, 89 IDELVION ........................................ 36, 92 imipenem-cilastatin .............................. 19 imipramine hcl ................................. 25, 77 imiquimod .............................................. 44 IMURAN................................................. 95 INCRELEX ...................................... 49, 94 indapamide ............................................ 41 indomethacin .............................. 15, 68, 80 INFERGEN ...................................... 31, 90 INLYTA ............................................ 84, 89 Inspra ................................................... 102 INTELENCE .................................... 32, 90 INTRON A ....................................... 31, 90 INVANZ .................................................. 19 INVIRASE .............................................. 33 ipratropium bromide ....................... 63, 73 irbesartan............................................... 38 irbesartan-hydrochlorothiazide ........... 38 ISENTRESS .......................................... 32 ISOLYTE-S ........................................... 66 isoniazid ................................................. 28 ISORDIL TITRADOSE ......................... 42 isosorbide dinitrate ............................... 42 isosorbide dinitrate er .......................... 42 isosorbide mononitrate ........................ 42 isosorbide mononitrate er .................... 42 itraconazole ........................................... 26 ivermectin .............................................. 29 JADENU .......................................... 65, 96 JAKAFI ............................................. 84, 89 JANUMET ............................................. 34 JANUMET XR ....................................... 34 JANUVIA ............................................... 34

Jardiance .............................................. 104 JARDIANCE .......................................... 34 JENTADUETO ...................................... 34 KALETRA ............................................... 33 KAPVAY ......................................... 93, 101 ketoconazole ......................................... 26 ketorolac tromethamine ........... 15, 54, 80 ketotifen fumarate ................................. 53 KLS ALLERCLEAR............................... 58 KLS ALLERCLEAR D-12HR ............... 58 KLS ALLERCLEAR D-24HR ............... 58 KLS ALLER-FEX ................................... 58 KLS ALLER-TEC .................................. 58 KLS ALLER-TEC CHILDRENS........... 58 KLS ALLER-TEC D............................... 58 kls lansoprazole .................................... 46 kls omeprazole ...................................... 46 KOATE-DVI ........................................... 92 KOGENATE FS ............................... 36, 92 KOVALTY............................................... 92 kp cetirizine hcl ...................................... 58 kp fexofenadine hcl ............................... 58 kp ketotifen fumarate ............................ 53 kp loratadine .......................................... 58 kp omeprazole magnesium ................. 46 KUVAN ............................................. 45, 94 labetalol hcl ............................................ 39 lactated ringers ...................................... 66 lactulose ................................................. 46 lactulose encephalopathy .................... 46 lamivudine ........................................ 31, 32 lamivudine-zidovudine .......................... 32 lamotrigine ....................................... 23, 75 lansoprazole .......................................... 46 Lansoprazole ....................................... 104 LANTUS ................................................. 35 latanoprost ............................................. 54 leflunomide............................................. 52 LETAIRIS ......................................... 64, 95 letrozole .................................................. 84 leucovorin calcium ................................ 84 LEUKERAN ........................................... 84 LEUKINE .......................................... 37, 92 levetiracetam ......................................... 22 levobunolol hcl ....................................... 54 levocarnitine ........................................... 66 Levocetirizine ....................................... 103 levocetirizine dihydrochloride .............. 58 levofloxacin ...................................... 21, 70 levothyroxine sodium ............................ 51 LEXAPRO ........................................ 87, 98 LEXIVA ................................................... 33 lidocaine ................................................ 17 lidocaine hcl ........................................... 17 lidocaine hcl (pf) .................................... 17 lidocaine viscous ............................. 17, 68 LINCOCIN .............................................. 18 lindane .............................................. 29, 71 Lindane ................................................. 103 liothyronine sodium ............................... 51 LIPOSYN III ........................................... 66 liraglutide .............................................. 103


110

lisinopril .................................................. 38 lisinopril-hydrochlorothiazide ............... 38 lithium ..................................................... 78 lithium carbonate .................................. 78 LITHIUM CARBONATE ..................... 100 lithium carbonate er .............................. 78 LITHIUM CITRATE ............................. 101 LITHOBID ............................................ 101 lomustine ................................................ 84 LONSURF ........................................ 84, 89 loperamide hcl ....................................... 45 loradamed .............................................. 58 loratadine ............................................... 59 loratadine allergy relief ......................... 58 loratadine childrens .............................. 59 loratadine hives relief ........................... 59 loratadine-d 12hr ................................... 59 loratadine-d 24hr ................................... 59 lorazepam ........................................ 34, 78 losartan potassium ......................... 38, 72 losartan potassium-hctz ................. 38, 72 loxapine succinate ................................ 77 LOXITANE ............................................. 99 LUDIOMIL ........................................ 87, 98 LUFYLLIN .............................................. 64 LUMIGAN .............................................. 54 LUPRON DEPOT-PED .................. 51, 94 LUVOX ............................................. 87, 98 Lyrica .................................................... 103 LYRICA .................................................. 22 LYSODREN........................................... 85 maprotiline hcl ................................. 25, 76 MARPLAN ........................... 24, 76, 87, 98 MATULANE ........................................... 84 meclizine hcl .......................................... 25 MEDROL ................................................ 27 medroxyprogesterone acetate ............ 50 mefloquine hcl ....................................... 29 meijer allergy relief ............................... 59 meijer allergy relief-d ............................ 59 meijer allergy/congestion ..................... 59 meijer loratadine ................................... 59 MELLARIL ............................................. 99 meloxicam .............................................. 15 memantine hcl ....................................... 24 MENEST ................................................ 50 meperidine hcl ................................. 16, 81 mercaptopurine ..................................... 84 mesalamine ........................................... 52 mesalamine-cleanser ........................... 52 MESNEX ................................................ 84 MESTINON ............................................ 28 METADATE ER ............................ 93, 101 metformin hcl ................................... 34, 72 metformin hcl er .................................... 34 methazolamide ...................................... 40 methenamine hippurate ....................... 18 methimazole .......................................... 51 methocarbamol ..................................... 65 methotrexate ......................................... 51 methotrexate sodium ............................ 51 methotrexate sodium (pf) ..................... 51

methoxsalen rapid ................................ 44 methscopolamine bromide .................. 45 methyldopa ............................................ 38 methylphenidate ................ 42, 43, 79, 102 methylphenidate hcl ....................... 43, 79 methylphenidate hcl er ............. 42, 43, 79 methylprednisolone ........................ 27, 71 methylprednisolone acetate ................ 27 methylprednisolone sodium succ ....... 27 metipranolol ........................................... 54 metoclopramide hcl ................... 25, 70, 71 metolazone ............................................ 41 metoprolol succinate er ....................... 39 metoprolol tartrate .......................... 39, 72 metoprolol-hydrochlorothiazide .... 39, 72 metronidazole ............................ 18, 68, 81 mexiletine hcl ........................................ 39 MIACALCIN ........................................... 53 midodrine hcl ......................................... 38 Miglitol .................................................. 102 MILLIPRED ..................................... 28, 71 minocycline hcl ............................... 22, 83 minoxidil ................................................. 42 Mirabegron .......................................... 103 mirtazapine ...................................... 24, 76 misoprostol ............................................ 46 mm loratadine-d 24 hour ..................... 59 modafinil .......................................... 65, 79 moexipril hcl .......................................... 38 moexipril-hydrochlorothiazide ............. 38 mometasone furoate ............................ 49 Mometasone furoate .......................... 103 MONOCLATE-P ............................. 36, 92 MONONINE .................................... 36, 92 montelukast sodium ............................. 63 morphine sulfate ................................... 16 morphine sulfate (concentrate) ........... 16 morphine sulfate (pf) ............................ 16 morphine sulfate er .............................. 15 MOXEZA ............................................... 21 moxifloxacin hcl .................................... 21 MUCINEX ALLERGY ........................... 59 mupirocin ......................................... 18, 69 MYCAMINE ..................................... 26, 89 mycophenolate mofetil ................... 51, 52 MYOBLOC ............................................ 43 Myrbetriq .............................................. 103 MYRBETRIQ ......................................... 47 nabumetone ............................... 15, 68, 80 nadolol ................................................... 39 nadolol-bendroflumethiazide............... 39 NAGLAZYME .................................. 45, 94 naloxone hcl .......................................... 17 naltrexone hcl........................................ 17 NAMENDA XR ...................................... 24 NAMENDA XR TITRATION PACK .... 24 NAMZARIC ........................................... 24 naphazoline hcl ..................................... 53 naproxen ..................................... 15, 68, 80 naproxen sodium ....................... 15, 68, 80 NARDIL ............................................ 87, 98 Nasacort .............................................. 103

NASACORT ALLERGY 24HR ............ 63 NASACORT ALLERGY 24HR

CHILDREN ....................................... 63 nasal allergy 24 hour ............................ 63 NATACYN .............................................. 26 nateglinide .............................................. 34 Nateglinide ........................................... 104 NAVANE................................................. 99 NEBUPENT ..................................... 29, 83 neomycin sulfate ............................. 17, 81 neomycin-bacitracin zn-polymyx ......... 18 neomycin-polymyxin-dexameth .......... 18 neomycin-polymyxin-gramicidin .......... 18 neomycin-polymyxin-hc ................. 18, 69 NEPHRAMINE ...................................... 66 NEUMEGA ....................................... 37, 92 NEUPOGEN .................................... 37, 92 NEUPRO ................................................ 30 nevirapine............................................... 32 nevirapine er .......................................... 32 NEXAVAR ........................................ 84, 90 Nexium ................................................. 104 NEXIUM 24HR ................................ 46, 47 niacin er (antihyperlipidemic) .............. 42 nicardipine hcl........................................ 40 NICOTROL ............................................ 17 nifedipine er ........................................... 40 nifedipine er osmotic release .............. 40 NILANDRON ......................................... 84 nimodipine .............................................. 40 nitrofurantoin macrocrystal ...... 18, 69, 81 nitrofurantoin monohyd macro 18, 69, 81 nitroglycerin ........................................... 42 NITROSTAT .................................... 42, 73 NORDITROPIN FLEXPRO .................. 94 norethindrone acetate .......................... 50 NORPACE CR ...................................... 39 NORPRAMIN ................................... 87, 99 nortriptyline hcl ................................ 25, 77 NORVIR ................................................. 33 NOVAREL .............................................. 94 NOVOEIGHT ................................... 36, 92 NOVOSEVEN .................................. 36, 92 NOVOSEVEN RT ........................... 37, 92 nutrilipid .................................................. 66 NUWIQ ................................................... 92 nystatin ............................................. 27, 71 nystatin-triamcinolone .......................... 27 obizur ...................................................... 37 OBIZUR .................................................. 92 octreotide acetate ................................. 51 ofloxacin ........................................... 21, 70 olanzapine .............................................. 78 Olanzapine ........................................... 102 Olopatadine ......................................... 103 olopatadine hcl ................................ 53, 59 omega-3-acid ethyl esters ................... 42 omeprazole ...................................... 47, 73 omeprazole magnesium ....................... 47 omeprazole-sodium bicarbonate ........ 47 ondansetron ........................................... 26 ondansetron hcl ..................................... 26


111

ONFI ....................................................... 23 ORENCIA ........................................ 52, 95 ORFADIN ......................................... 45, 94 oxacillin sodium ..................................... 20 oxandrolone ........................................... 50 oxazepam ........................................ 34, 78 oxcarbazepine ....................................... 23 oxybutinin/tolterodine ......................... 103 oxybutynin chloride ............................... 47 oxybutynin chloride er .......................... 47 oxycodone hcl ................................. 16, 81 oxycodone hcl er ............................. 15, 80 oxycodone-acetaminophen ........... 16, 81 OXYCONTIN ......................................... 15 PAMELOR ....................................... 88, 99 PANCREAZE ........................................ 45 PANRETIN............................................. 29 pantoprazole sodium ............................ 47 paricalcitol .............................................. 53 PARNATE ........................................ 88, 98 paromomycin sulfate ............................ 17 paroxetine hcl .................................. 25, 76 paroxetine hcl er ............................. 25, 76 PASER ................................................... 28 Patanol ................................................. 103 PATANOL .............................................. 53 PAXIL ................................... 25, 76, 88, 98 PAXIL CR ........................................ 88, 98 peg 3350/electrolytes ........................... 46 peg 3350-kcl-na bicarb-nacl ................ 46 peg-3350/electrolytes ........................... 46 PEGANONE .......................................... 23 PEGASYS ........................................ 31, 90 PEGASYS PROCLICK .................. 31, 90 PEG-INTRON .................................. 31, 90 PEG-INTRON REDIPEN ..................... 31 penicillin g procaine .............................. 20 penicillin v potassium ............... 20, 69, 82 PENTAM ................................................ 29 PENTASA .............................................. 52 pentoxifylline er ..................................... 40 perindopril erbumine ............................ 39 permethrin .............................................. 29 Permethrin ........................................... 103 perphenazine................................... 30, 77 pharbedryl ........................................ 26, 71 phenazopyridine hcl ....................... 48, 73 phenelzine sulfate ........................... 24, 76 phenobarbital................................... 23, 70 phenoxybenzamine hcl ........................ 40 phenytoin ......................................... 23, 70 phenytoin sodium............................ 23, 70 phenytoin sodium extended .......... 23, 70 PHOSPHOLINE IODIDE ..................... 54 pilocarpine hcl ....................................... 43 Pimecrolimus ....................................... 102 pimozide ................................................. 77 pindolol ................................................... 39 pioglitazone hcl ..................................... 34 piperacillin sod-tazobactam so ........... 20 PLENAMINE .......................................... 66 podofilox ................................................. 44

polymyxin b-trimethoprim .................... 18 POMALYST ..................................... 84, 90 potassium chloride ............................... 66 potassium chloride crys er .................. 66 potassium chloride er ........................... 66 potassium citrate er .............................. 67 POTIGA ................................................. 22 PRADAXA ............................................. 35 pramipexole dihydrochloride ............... 30 Prandin ................................................ 104 pravastatin sodium ............................... 41 prazosin hcl ........................................... 38 prednisolone acetate ..................... 54, 73 prednisone ....................................... 28, 71 Pregabalin ........................................... 103 PREMARIN ........................................... 50 PREMASOL .......................................... 67 PREMPHASE ....................................... 50 PREMPRO ............................................ 50 Prevacid ............................................... 104 PREVACID ............................................ 47 PREVACID 24HR ................................. 47 PREZCOBIX ......................................... 32 PREZISTA ............................................. 33 PRIFTIN ................................................. 28 Prilosec ................................................ 104 PRILOSEC OTC ................................... 47 primaquine phosphate ......................... 29 primidone ............................................... 23 PROAIR HFA .................................. 63, 73 PROAIR RESPICLICK .................. 64, 73 probenecid ............................................. 27 PROCALAMINE ................................... 67 prochlorperazine ............................. 30, 71 prochlorperazine edisylate ............ 30, 77 prochlorperazine maleate ......... 30, 71, 77 PROCRIT .............................................. 37 PROCTOSOL HC................................. 49 PROFILNINE ........................................ 37 PROFILNINE SD .................................. 92 progesterone micronized ..................... 50 PROGLYCEM ....................................... 35 PROLASTIN .......................................... 95 PROLIA .................................................. 53 PROLIXIN .............................................. 99 PROMACTA .......................................... 37 promethazine hcl ............................ 26, 71 propafenone hcl .................................... 39 propranolol hcl ...................................... 40 propranolol hcl er .................................. 39 propranolol-hctz .................................... 40 propylthiouracil ...................................... 51 PROSOM ............................................. 101 PROTONIX ........................................... 47 Protopic ................................................ 102 PROVENTIL HFA ........................... 64, 73 PROVIGIL ..................................... 93, 101 PROZAC .......................................... 88, 98 PULMOZYME ................................. 64, 95 px allergy relief ...................................... 59 px allergy relief cetirizine ..................... 59 px allergy relief d .................................. 59

px allergy relief d (loratid) .................... 59 px allergy relief loratadine .................... 59 px childrens allergy ............................... 59 px omeprazole ....................................... 47 pyridostigmine bromide ........................ 28 pyridostigmine bromide er ................... 28 qc all day allergy ................................... 59 qc allergy relief ...................................... 59 qc allergy relief childrens ..................... 59 qc loratadine allergy relief .................... 59 qc loratadine-d ....................................... 59 qc omeprazole magnesium ................. 47 QLEARQUIL 24 HOUR RELIEF ......... 59 quetiapine fumarate .............................. 78 quinapril hcl ............................................ 39 quinapril-hydrochlorothiazide .............. 39 quinidine gluconate er .......................... 39 quinidine sulfate .................................... 39 quinidine sulfate er ................................ 39 quinine sulfate ....................................... 29 Qvar ...................................................... 103 QVAR...................................................... 63 ra allergy relief ....................................... 59 ra allergy relief childrens ...................... 59 ra allergy relief-d ................................... 59 ra allergy/congestion relief ................... 60 ra antihistamine eye drops .................. 53 ra cetiri-d ................................................ 60 ra cetirizine ............................................. 60 ra cetirizine childrens ............................ 60 ra cetirizine hcl child allrgy ................... 60 ra eye itch relief ..................................... 53 ra lansoprazole ...................................... 47 ra lorata-d ............................................... 60 ra loratadine ........................................... 60 ra loratadine childrens .......................... 60 ra omeprazole........................................ 47 ra omeprazole-sodium bicarb .............. 47 ramipril .................................................... 39 RANEXA........................................... 40, 92 ranitidine hcl ..................................... 45, 73 Rasagiline ............................................ 104 REBETOL .............................................. 90 REBIF ............................................... 43, 93 REBIF REBIDOSE ................................ 43 REBIF REBIDOSE TITRATION PACK

........................................................... 43 REBIF TITRATION PACK ................... 43 RECOMBINATE .............................. 37, 92 REGRANEX ........................................... 44 RELENZA DISKHALER ....................... 33 RELION R ........................................ 35, 72 RELISTOR ............................................. 45 Relpax .................................................. 104 RELPAX ................................................. 28 REMERON ....................................... 88, 97 REMICADE ...................................... 52, 95 RENAGEL ........................................ 48, 94 RENVELA ........................................ 48, 94 repaglinide ............................................. 34 Repaglinide .......................................... 104 RESCRIPTOR ....................................... 32


112

RESTASIS ....................................... 53, 95 RESTORIL ........................................... 101 RETIN-A ................................................. 93 RETROVIR ............................................ 32 REVATIO ............................................... 95 REVLIMID ........................................ 85, 90 REYATAZ .............................................. 33 RHEUMATREX ..................................... 52 ribavirin ................................................... 31 RIDAURA ............................................... 52 rifabutin .................................................. 28 rifampin .................................................. 28 RIFATER ................................................ 28 riluzole .................................................... 43 rimantadine hcl ...................................... 33 ringers .................................................... 67 RISPERDAL ........................................ 100 RISPERDAL CONSTA................. 78, 100 risperidone ............................................. 78 Risperidone ......................................... 102 RITALIN ......................................... 93, 101 RITALIN SR ......................................... 101 rivastigmine ........................................... 24 rivastigmine tartrate .............................. 24 rixubis ..................................................... 37 RIXUBIS ................................................. 91 ropinirole hcl .......................................... 30 salsalate ........................................... 15, 68 SANDOSTATIN .................................... 94 SANTYL ................................................. 44 sb allergy ................................................ 60 sb allergy relief ...................................... 60 sb allergy relief/nasal decong ............. 60 sb cetirizine hcl childrens ..................... 60 sb loratadine .......................................... 60 sb loratadine allergy relief ................... 60 sb omeprazole ....................................... 47 scalacort ................................................. 49 Selegiline ............................................. 104 selegiline hcl .......................................... 30 selenium sulfide .................................... 44 SELZENTRY ................................... 33, 90 SENSIPAR....................................... 51, 94 SERAX ........................................... 91, 100 SEREVENT DISKUS ........................... 64 SEROQUEL......................................... 100 SEROSTIM ............................................ 94 sertraline hcl .................................... 25, 76 SHOPKO ALLERGY RELIEF-D (CETI)

........................................................... 60 SHOPKO ALLERGY RELIEF-D

(LORA) .............................................. 60 sildenafil citrate ..................................... 64 silver sulfadiazine ........................... 18, 69 simvastatin ............................................. 41 SINEQUAN ...................................... 88, 99 SIVEXTRO................................. 18, 81, 86 sm all day allergy .................................. 60 sm all day allergy childrens ................. 60 sm all day allergy-d .............................. 60 sm allergy relief ..................................... 60 sm allergy relief loratadine .................. 60

sm childrens loratadine........................ 60 sm eye itch relief .................................. 53 sm fexofenadine hcl ............................. 60 sm lansoprazole ................................... 47 sm loratadine ........................................ 60 sm loratadine allergy relief .................. 60 sm loratadine d ..................................... 60 sm lorata-dine d .................................... 60 sm lorata-dine d .................................... 60 sm lorata-dine d .................................... 60 sm omeprazole ..................................... 47 sodium chloride .............................. 44, 67 sodium phenylbutyrate ........................ 45 sodium polystyrene sulfonate ............. 65 SOLU-CORTEF .................................... 28 SOLU-MEDROL ................................... 28 SOMAVERT .................................... 51, 94 SONATA .............................................. 101 sotalol hcl............................................... 40 sotalol hcl (af)........................................ 40 SOVALDI ......................................... 31, 90 SPIRIVA HANDIHALER ...................... 63 SPIRIVA RESPIMAT ........................... 63 spironolactone .............................. 41, 102 spironolactone-hctz .............................. 41 SPRYCEL ........................................ 85, 90 stavudine ............................................... 32 STELAZINE ........................................... 99 STIMATE ............................................... 50 STIVARGA ...................................... 85, 90 Strattera ............................................... 102 STRATTERA ...................... 43, 79, 93, 101 STRIBILD .............................................. 32 STRIVERDI RESPIMAT ...................... 64 SUBOXONE .................................... 75, 97 SUBUTEX ............................................. 97 sucralfate ............................................... 46 sulfacetamide-prednisolone ................ 22 sulfadiazine ..................................... 22, 82 sulfamethoxazole-trimethoprim ... 22, 70,

82 sulfasalazine ......................................... 52 sulindac ............................................ 15, 80 Sumatriptan ......................................... 104 sumatriptan succinate .......................... 28 SURMONTIL ................................... 88, 99 SUSTIVA ............................................... 32 SUTENT .......................................... 85, 90 sw allergy relief ..................................... 61 sw allergy relief-d ................................. 61 sw omeprazole ...................................... 47 SYMBICORT ......................................... 63 SYMLIN PEN ........................................ 91 SYMLINPEN 120 .................................. 34 SYMLINPEN 60 .................................... 34 SYNAREL ........................................ 51, 92 Synjardy ............................................... 104 SYNJARDY ........................................... 35 SYNTHROID ......................................... 51 TABLOID ............................................... 85 tacrolimus .............................................. 44 Tacrolimus ........................................... 102

TAMIFLU ................................................ 33 tamsulosin hcl ........................................ 48 TARCEVA ........................................ 85, 90 TARGRETIN .......................................... 29 TASIGNA ......................................... 85, 90 TAZORAC .............................................. 44 TEGRETOL-XR ............................... 23, 75 temazepam ...................................... 65, 79 terazosin hcl ........................................... 38 terbinafine hcl ........................................ 27 terbutaline sulfate ............................ 64, 73 terconazole ............................................ 27 testosterone ........................................... 50 testosterone cypionate ......................... 50 testosterone enanthate ........................ 50 tetrabenazine ......................................... 43 tetracycline hcl ........................... 22, 70, 83 tgt all day allergy childrens .................. 61 tgt all day allergy relief ......................... 61 tgt all day allergy-d ................................ 61 tgt allergy relief ...................................... 61 tgt allergy/congestion relief .................. 61 tgt allergy+ congestion relief ............... 61 tgt eye itch relief .................................... 53 tgt loratadine childrens ......................... 61 tgt omeprazole ....................................... 47 THALOMID ...................................... 85, 90 theophylline er ....................................... 64 THERA TEARS ALLERGY .................. 53 thioridazine hcl ...................................... 77 thiothixene .............................................. 77 THORAZINE .......................................... 99 tiagabine hcl ........................................... 23 ticlopidine hcl ......................................... 37 TIKOSYN ............................................... 39 TIMENTIN .............................................. 20 timolol maleate ................................ 40, 54 tizanidine hcl .......................................... 30 tobramycin ................................. 17, 64, 68 tobramycin sulfate ................................. 17 tobramycin-dexamethasone ................ 17 TOBREX........................................... 17, 68 TOFRANIL ....................................... 88, 99 tolcapone ................................................ 30 tolterodine tartrate ................................. 47 tolterodine tartrate er ............................ 47 topiramate .............................................. 23 torsemide ............................................... 41 TRACLEER ...................................... 64, 95 TRADJENTA ......................................... 35 tramadol hcl ............................... 16, 68, 81 tramadol-acetaminophen ............... 16, 81 trandolapril ............................................. 39 tranexamic acid ..................................... 37 TRANXENE T ................................ 91, 100 tranylcypromine sulfate .................. 24, 76 TRAVATAN Z ........................................ 54 trazodone hcl ................................... 25, 76 TRECATOR ........................................... 28 tretinoin ............................................. 44, 85 triamcinolone acetonide ........... 43, 49, 63 TRIAMINIC ALLERCHEWS ................ 61


113

triamterene-hctz .................................... 41 TRIANEX ............................................... 49 trifluoperazine hcl.................................. 77 trifluridine ............................................... 32 trihexyphenidyl hcl ................................ 29 TRILAFON ........................................... 100 trimethobenzamide hcl ................... 26, 71 trimethoprim..................................... 19, 81 trimipramine maleate ...................... 25, 77 TRIUMEQ .............................................. 32 TRUVADA .............................................. 32 TUDORZA PRESSAIR ........................ 63 TYBOST ................................................. 33 TYGACIL ................................................ 19 TYKERB ........................................... 85, 90 TYSABRI .......................................... 43, 93 TYZEKA ........................................... 31, 90 TYZINE .................................................. 64 ursodiol ................................................... 45 VAGIFEM ............................................... 50 valacyclovir hcl ...................................... 32 valganciclovir hcl ................................... 31 VALIUM .......................................... 91, 100 valproate sodium .................................. 23 valproic acid..................................... 23, 75 valsartan ................................................ 38 valsartan-hydrochlorothiazide ............. 38 vancomycin hcl ............................... 19, 81 venlafaxine hcl ................................ 25, 76 venlafaxine hcl er ............................ 25, 76 VENTAVIS ....................................... 64, 95 Veramyst .............................................. 103 VERAMYST ........................................... 63 verapamil hcl ................................... 40, 72 verapamil hcl er ..................................... 40 VFEND ................................................... 89 VIBRAMYCIN .................................. 22, 70 Victoza.................................................. 103 VICTOZA ............................................... 35

VIDEX .................................................... 32 VIGAMOX .............................................. 21 VIMPAT ........................................... 23, 24 VIRACEPT ............................................ 33 VIREAD ...................................... 32, 33, 90 VISTARIL ....................................... 91, 100 voriconazole .......................................... 27 VOTRIENT ...................................... 85, 90 VPRIV .............................................. 45, 94 Vytorin .................................................. 103 VYTORIN ............................................... 41 WAL-FEX ALLERGY ........................... 61 WAL-FEX CHILDRENS ....................... 61 WAL-FEX D ALLERGY &

CONGESTION ................................ 61 WAL-ITIN ............................................... 61 WAL-ITIN ALLERGY REDITABS ....... 61 WAL-ITIN ALLER-MELTS ................... 61 WAL-ITIN CHILDRENS ....................... 61 WAL-ITIN D ........................................... 61 WAL-ITIN D 24 HOUR ......................... 61 WAL-VERT ............................................ 61 WAL-ZYR ........................................ 53, 62 WAL-ZYR ALL DAY ALLERGY CHILD

........................................................... 61 WAL-ZYR CHILDRENS ...................... 61 WAL-ZYR D .......................................... 62 warfarin sodium .............................. 35, 72 WELCHOL ............................................. 42 WELLBUTRIN ................................. 89, 97 WILATE ........................................... 37, 92 XALKORI ......................................... 85, 90 XANAX ........................................... 91, 100 XARELTO .............................................. 35 XARELTO STARTER PACK .............. 35 XEOMIN................................................. 43 XIFAXAN ............................................... 19 XOLAIR ............................................ 52, 95 XOPENEX HFA .............................. 64, 73

XTANDI ............................................ 85, 90 XYNTHA ........................................... 37, 92 XYNTHA SOLOFUSE .................... 37, 92 Xyzal ..................................................... 103 ZADITOR ............................................... 53 zafirlukast ............................................... 63 zaleplon ............................................ 65, 79 ZAVESCA ........................................ 45, 94 Zegerid ................................................. 104 ZEGERID ............................................... 47 ZEGERID OTC ...................................... 47 ZELBORAF ...................................... 85, 90 ZEMAIRA ............................................... 64 ZEMPLAR .............................................. 95 ZETIA...................................................... 42 ZIAGEN .................................................. 33 zidovudine .............................................. 33 ZINACEF ................................................ 19 ZIOPTAN ................................................ 54 Ziprasidone .......................................... 102 ziprasidone hcl ...................................... 78 zoledronic acid ...................................... 53 ZOLINZA ................................................ 85 ZOLOFT ........................................... 89, 98 zolpidem tartrate ............................. 65, 79 zonisamide ............................................. 22 ZORBTIVE ............................................. 94 ZYPREXA ............................................ 100 ZYRTEC ALLERGY .............................. 62 ZYRTEC CHILDRENS ALLERGY ...... 62 ZYRTEC CHILDRENS HIVES RELIEF

........................................................... 62 ZYRTEC HIVES RELIEF ..................... 62 ZYRTEC ITCHY EYE ........................... 53 Zyrtec OTC .......................................... 103 ZYRTEC-D ALLERGY &

CONGESTION ................................. 62 ZYTIGA ............................................ 85, 90

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