mmm-pha-qrg-707-11-120115-s ela relax oro (p) · farmacia de la red de nuestro plan y se sigan...

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MMM-PHA-QRG-707-11-120115-S

ELA RELAX – Oro (HMO POS)

Formulario 2015 (Lista de medicamentos cubiertos)

FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN

HPMS ID: 15380, Versión # 19 Este formulario fue actualizado el 1 de diciembre de 2015. Para información más reciente, o para otras preguntas, por favor, comuníquese con el Departamento de Servicios al Afiliado de Medicare y Mucho Más al 787-620-2397 (Área Metro), 1-866-333-5470 (libre de cargos), o usuarios de TTY deben llamar al 1-866-333-5469, lunes a domingo, de 8:00 a.m. a 8:00 p.m., o visite www.mmm-pr.com. Aviso para afiliados actuales: Este formulario ha cambiado desde el año pasado. Por favor, revise este documento para asegurarse de que aún incluye los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a “nosotros”, “nuestro” significa Medicare y Mucho Más. Cuando se refiere a “el plan” o “nuestro plan” significa ELA Relax - Oro (HMO POS). Este documento incluye una lista de los medicamentos (formulario) cubiertos por el plan que está actualizado al 1 de diciembre de 2015. Para una versión del formulario actualizada, por favor, comuníquese con nosotros. Nuestra información de contacto, al igual que la fecha en que este formulario fue actualizado, aparece en la portada y contraportada. Los beneficiarios deben utilizar farmacias dentro de la red para acceder a su beneficio de medicamentos recetados. Beneficios, formulario, red de farmacias, las primas y/o copagos/coaseguros pueden cambiar el 1 de enero de 2016, y de vez en cuando durante el año.

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¿Qué es el Formulario de ELA Relax - Oro? Un formulario es una lista de medicamentos cubiertos, seleccionados por nuestro plan, en consulta con un equipo de proveedores de salud, que representa las terapias de medicamentos recetados que se consideran parte necesaria de un programa de tratamiento de calidad. Nuestro plan generalmente cubrirá los medicamentos que aparecen en nuestro formulario, siempre que el medicamento sea médicamente necesario, la receta se adquiera en una farmacia de la red de nuestro plan y se sigan otras reglas del plan. Para más información sobre cómo ordenar sus medicamentos, refiérase a su Evidencia de Cubierta (EOC, por sus siglas en inglés). ¿Puede cambiar el Formulario (lista de medicamentos)? Generalmente, si está tomando un medicamento disponible en nuestro formulario del 2015, que estaba cubierto al principio de año, no descontinuaremos o reduciremos la cubierta del medicamento durante el año de cubierta 2015, a menos que salga al mercado un medicamento genérico nuevo y menos costoso o que surja nueva información que sea adversa sobre la seguridad y efectividad del medicamento. Otros tipos de cambios en el formulario, como eliminar un medicamento de nuestro formulario, no afectarán a los beneficiarios que al momento estén tomando dicho medicamento. El mismo continuará disponible por el mismo costo que corresponde para esos afiliados que lo toman, por el resto de la cubierta anual. Consideramos que es importante que usted siga teniendo acceso por lo que resta del año de cubierta a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en aquellos casos en los que pueda ahorrar dinero adicional o podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario o añadimos preautorización, límites de cantidad y/o restricciones de terapias escalonadas para un medicamento o elevamos un medicamento a un nivel de costo compartido más alto, debemos notificarles el cambio a los beneficiarios afectados al menos 60 días antes de que dicho cambio entre en vigor, o en el momento en que el afiliado solicite una repetición del medicamento, y en ese momento el afiliado recibirá un suplido del medicamento para 60 días. Si la Administración de Drogas y Alimentos (FDA, por sus siglas en inglés) considera que un medicamento incluido en nuestro formulario no es seguro o si el fabricante del medicamento retira el medicamento del mercado, lo eliminaremos de inmediato de nuestro formulario y notificaremos a los afiliados que toman este medicamento. El formulario adjunto es vigente a partir del 1 de enero de 2015. Para información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y contraportada de este formulario. En caso de cambios al formulario que no sean de mantenimiento que ocurran a mitad de año, se les notificará a todos los afiliados afectados por correo (por lo menos 60 días antes de que el cambio sea efectivo). Además, el formulario impreso se actualizará la primera semana del mes de efectividad. El formulario impreso se publicará en nuestro portal de Internet www.mmm-pr.com. ¿Cómo utilizo el Formulario? Hay dos maneras de encontrar su medicamento en el formulario: Condición médica El formulario comienza en la página 9. En este formulario, los medicamentos están agrupados por categoría según el tipo de condición médica que tratan. Por ejemplo, los medicamentos que se utilizan para tratar una condición cardíaca aparecen listados bajo la categoría “Agentes Cardiovasculares/Dislipidémicos”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 7. Luego, busque el nombre del medicamento dentro de esa categoría.

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Listado alfabético Si no está seguro de la categoría en la que debe realizar su búsqueda, busque su medicamento en el índice que comienza en la página 127. El índice ofrece una lista alfabética de todos los medicamentos incluidos en este documento. En el índice se enumeran, tanto los medicamentos de marca, como los medicamentos genéricos. Vea el índice y busque su medicamento. Junto al medicamento verá el número de la página en la que podrá encontrar información sobre la cubierta. Vaya a la página que se indica en el índice y busque el nombre de su medicamento en la primera columna de la lista. ¿Qué son los medicamentos genéricos? Nuestro plan ofrece cubierta para medicamentos de marca y medicamentos genéricos. Un medicamento genérico está aprobado por la FDA como que tiene el mismo ingrediente activo que el medicamento de marca. Los medicamentos genéricos usualmente cuestan menos que los medicamentos de marca. ¿Existe alguna restricción en mi cubierta? Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales para la cubierta. Estos requisitos y límites pueden incluir:

• Preautorización: Nuestro plan exige que el afiliado obtenga preautorización para ciertos medicamentos. Esto significa que necesitará la aprobación de nuestro plan antes de adquirir la receta. Si no obtiene la aprobación del plan, es posible que nuestro plan no cubra el medicamento.

• Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento

cubierto por nuestro plan. Por ejemplo, nuestro plan establece la cantidad de 30 tabletas por receta para irbesartan. Esto puede ser adicional a un suplido regular para un (1) mes o tres (3) meses.

• Terapia escalonada: En ciertos casos, nuestro plan exige que se trate primero la condición médica con

ciertos medicamentos antes de cubrir otro medicamento para esa condición. Por ejemplo, si el Medicamento A y el Medicamento B se usan para tratar una condición médica en particular, es posible que nuestro plan no cubra el Medicamento B, a menos que primero utilice el Medicamento A. Si el Medicamento A no funciona en su caso, nuestro plan cubrirá el Medicamento B.

Usted puede verificar si su medicamento tiene algún requisito o límite adicional, consultando el formulario que empieza en la página 9. También puede obtener información adicional sobre las restricciones que se aplican a medicamentos específicos cubiertos en su formulario, visitando nuestra página de Internet. Nosotros publicamos documentos en línea que explican nuestras restricciones de preautorización y terapia escalonada. También nos puede solicitar que le enviemos una copia. Nuestra información de contacto, al igual que la fecha en que este formulario fue actualizado, aparece en la portada y contraportada. Usted puede solicitar que nuestro plan haga una excepción a estas restricciones o límites, o que le facilite una lista de medicamentos similares que puedan tratar su condición de salud. Consulte la sección: “¿Cómo solicito una excepción al Formulario de ELA Relax - Oro?”, en la página 4, para información sobre cómo puede solicitar una excepción. ¿Qué sucede si mi medicamento no aparece en el Formulario? Si su medicamento no aparece en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicios al Afiliado y verificar si el medicamento está cubierto. Si le notifican que nuestro plan no ofrece cubierta para su medicamento, tiene dos opciones:

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• Puede pedirle a Servicios al Afiliado una lista de medicamentos similares cubiertos por nuestro plan.

Cuando reciba la lista, muéstresela a su médico y solicite que le recete un medicamento que esté cubierto por nuestro plan.

• Puede solicitar a nuestro plan que haga una excepción y le cubra el medicamento. Consulte la información

a continuación para saber cómo solicitar una excepción. ¿Cómo solicito una excepción al Formulario de ELA Relax - Oro? Puede pedirle a nuestro plan que haga una excepción en las reglas de cubierta. Hay varios tipos de excepciones que usted puede pedir:

• Puede pedir que cubramos su medicamento, aun cuando no aparezca en nuestro formulario. Si es aprobado, el medicamento será cubierto al nivel de costo compartido predeterminado, y usted no podrá solicitar que se provea el medicamento a un nivel de costo compartido menor.

• Puede pedir que cubramos su medicamento en un nivel menor de costo compartido, si el medicamento no está en el nivel de especialidad. Si es aprobado, esto bajará la cantidad que usted debe pagar por su medicamento.

• Puede pedir que obviemos las restricciones o límites de cubierta para su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Si el medicamento tiene un límite de cantidad, puede pedir que obviemos el límite y le proporcionemos una cubierta mayor.

Generalmente, nuestro plan sólo aprobará la solicitud de excepción si los medicamentos alternos incluidos en el formulario, el medicamento de nivel más bajo o las restricciones adicionales de uso no serían igualmente efectivos para el tratamiento de la condición o le podrían causar efectos clínicos adversos. Usted debe comunicarse con nosotros para solicitar una decisión inicial de cubierta para una excepción al formulario, de nivel o a las restricciones de uso. Cuando solicite una excepción al formulario, de nivel o de restricción de uso, tendrá que presentar una declaración de su médico o profesional que le receta, que respalde su solicitud. Por lo general, debemos tomar una decisión en un plazo de 72 horas después de recibir la declaración de su médico primario o del médico que prescribe. Puede solicitar una excepción acelerada (rápida) si usted o su médico entienden que su salud podría verse seriamente afectada si espera 72 horas por la decisión. Si se le concede su petición de acelerar la autorización, debemos darle una decisión en o antes de 24 horas después de haber recibido la declaración de su médico primario o del médico que prescribe. ¿Qué hago antes de hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como afiliado nuevo o afiliado existente en nuestro plan, usted puede estar tomando medicamentos que no están en nuestro formulario, o puede estar tomando un medicamento que está en nuestro formulario pero su capacidad para obtenerlo es limitada. Por ejemplo, podría necesitar nuestra autorización antes de obtener su receta. Usted debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que nosotros cubramos, o solicitar una excepción al formulario para que nosotros podamos cubrir el medicamento que usted toma. Mientras usted habla con su médico para determinar la mejor decisión, nosotros podríamos cubrirle su medicamento, en ciertos casos, durante los primeros 90 días en que usted sea afiliado de nuestro plan.

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Para cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtenerlo es limitada, nosotros cubriremos un suplido temporal de 30 días (a menos que usted tenga una receta para menos días) a través de una farmacia de nuestra red. Después de su primer suplido de 30 días, no pagaremos por esos medicamentos, aunque usted haya sido afiliado del plan por menos de 90 días. Si usted es residente de una facilidad de cuidado prolongado, cubriremos un suplido de transición temporal de al menos 91 y hasta 98 días, de acuerdo con los incrementos en despacho (a menos que tenga una receta para menos días). Nosotros cubriremos más de una repetición de esos medicamentos por los primeros 90 días en que usted esté afiliado a nuestro plan. Si necesita un medicamento que no está en nuestro formulario, o si su capacidad para obtenerlo es limitada pero usted ya pasó los primeros 90 días de afiliación en nuestro plan, le cubriremos un suplido de emergencia de 31 días de ese medicamento (a menos que usted tenga una receta para menos días) mientras usted consigue una excepción al formulario. Para aquellos afiliados que se han dado de alta de un hospital o de una facilidad de cuidado, para ir a su casa, o si su habilidad para obtener medicamentos es limitada, nuestro plan proveerá un suplido temporal de 30 días de medicamentos que no están en nuestro formulario, mientras le pide a su médico que le recete un medicamento similar que esté cubierto por nuestro plan. Para más información Para información más detallada sobre la cubierta de medicamentos recetados que ofrece nuestro plan, por favor consulte su Evidencia de Cubierta y otros materiales del plan. Si tiene alguna pregunta sobre nuestro plan, por favor comuníquese con nosotros. Nuestra información de contacto, al igual que la fecha en que este formulario fue actualizado, aparece en la portada y contraportada. Si tiene preguntas generales sobre la cubierta de medicamentos recetados de Medicare, por favor comuníquese con Medicare al 1-800-MEDICARE (1-800-633-4227), 24 horas al día/7 días a la semana. Usuarios de TTY deben llamar al 1-877-486-2048. O visite www.medicare.gov. Formulario de ELA Relax - Oro El formulario a continuación ofrece información sobre la cubierta de los medicamentos cubiertos por nuestro plan. Si tiene dificultad para localizar un medicamento en la lista, consulte el índice que comienza en la página 127. La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca aparecen en letra mayúscula (por ejemplo, ADVAIR) y los medicamentos genéricos aparecen en letra cursiva (itálica) minúscula (por ejemplo, duloxetine). La información que aparece en la columna de Requisitos/Límites indica si nuestro plan establece algún requisito especial para la cubierta del medicamento.

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Estructura de niveles Antes de que el costo total anual de medicamentos (pagados tanto por usted, como por MMM) alcance los $2,960.00, usted pagará lo siguiente por medicamentos recetados:

ELA Relax - Oro

(HMO POS)

Nivel Medicamento*

Copago por cantidad

al detal (30 días)

Copago por cantidad

al detal (90 días)

Copago por orden por correo (90 días)

1 Genérico Preferido $2.00 $6.00 $4.00 2 Marca Preferida $5.00 $15.00 $10.00 3 Marca No Preferida $10.00 $30.00 $20.00 4 Especialidad 25% 25% 25%

*10% de coaseguro para medicamentos de Disfunción Eréctil (hasta 4 pastillas por mes) Luego de que su costo total anual de medicamentos alcance $2,960.00, usted recibe cubierta limitada por el plan en ciertos medicamentos hasta que su costo de bolsillo anual por medicamentos alcance $4,700.00. El plan ofrece cubierta adicional durante la brecha para los siguientes niveles:

ELA Relax - Oro

(HMO POS)

Nivel Medicamento

Copago por cantidad

al detal (30 días)

1 Genérico Preferido 65% o $5.00 max 2 Marca Preferida 45% o $20.00 max 3 Marca No Preferida 65% o $35.00 max 4 Especialidad 30%

Luego de que los gastos de su bolsillo alcancen los $4,700.00 en el año, usted pagará la cantidad mayor entre:

• 5% de coaseguro, o • $2.65 por medicamentos genéricos o medicamentos de marca preferida y $6.60 por todos los demás

medicamentos Para información más detallada sobre cómo los niveles de copago son aplicados, por favor revise su Evidencia de Cubierta (EOC, por sus siglas en inglés). Símbolos y abreviaturas utilizadas en el Formulario PA - medicamentos que requieren preautorización QL (##/##) - medicamentos con límite de cantidad; la cantidad en paréntesis especifica la cantidad límite que le podemos suplir en el número máximo autorizado de días. ST - terapia escalonada LA - medicamentos con acceso limitado (ej. Medicamentos de especialidad) MT - medicamentos de mantenimiento – suplido de 90 días (farmacias contratadas y envío por correo) CG - medicamentos cubiertos durante su brecha de cubierta ED – medicamentos excluidos de la parte D, disponibles en su formulario

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Tabla de Contenido Agentes Antidemencia.............................................................................................................................................. 9

Agentes Antigota .................................................................................................................................................... 10

Agentes Antiinflamatorios ..................................................................................................................................... 10

Agentes Antimiasténicos ........................................................................................................................................ 13

Agentes Cardiovasculares ..................................................................................................................................... 13

Agentes Del Sistema Nervioso Central ................................................................................................................. 24

Agentes Dermatológicos ......................................................................................................................................... 26

Agentes Gastrointestinales .................................................................................................................................... 28

Agentes Genitourinarios ........................................................................................................................................ 31

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Adrenal) ..................................................... 32

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Modificadores/Hormonas Sexuales)........ 36

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Pituitaria) ................................................... 41

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Prostaglandinas) ....................................... 42

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Tiroides) ..................................................... 42

Agentes Hormonales, Supresores (Adrenal) ........................................................................................................ 43

Agentes Hormonales, Supresores (Paratiroide) .................................................................................................. 43

Agentes Hormonales, Supresores (Pituitaria) ..................................................................................................... 43

Agentes Hormonales, Supresores (Tiroides) ........................................................................................................ 44

Agentes Inmunológicos .......................................................................................................................................... 45

Agentes Oftálmicos ................................................................................................................................................. 51

Agentes Orales Y Dentales .................................................................................................................................... 54

Agentes Óticos ........................................................................................................................................................ 55

Agentes Para Desórdenes Del Sueño .................................................................................................................... 55

Agentes Para El Tratamiento De La Bipolaridad ............................................................................................... 56

Agentes Para El Tratamiento De La Migraña..................................................................................................... 58

Agentes Para El Tratamiento De Parkinson........................................................................................................ 59

Agentes Para El Tratamientode Abuso De Sustancias. Anti-Adicción ............................................................. 61

Agentes Para La Enfermedad Inflamatoria Intestinal ....................................................................................... 62

Agentes Parael Tratamiento De La Espasticidad ............................................................................................... 64

Agentes Parala Enfermedad Metabólica Del Hueso ........................................................................................... 64

Agentes Pulmonares/ Tracto Respiratorio ........................................................................................................... 65

Analgésicos .............................................................................................................................................................. 71

Anestésicos .............................................................................................................................................................. 75

Ansiolíticos .............................................................................................................................................................. 76

Antibióticos ............................................................................................................................................................. 77

Anticonvulsivos ....................................................................................................................................................... 87

Antidepresivos ........................................................................................................................................................ 91

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Antieméticos ............................................................................................................................................................ 95

Antifungales ............................................................................................................................................................ 96

Antimicobacteriales ................................................................................................................................................ 99

Antineoplásicos ....................................................................................................................................................... 99

Antiparasíticos ...................................................................................................................................................... 105

Antisicóticos .......................................................................................................................................................... 106

Antivirales ............................................................................................................................................................. 109

Modificadores/Reemplazos De Enzima .............................................................................................................. 115

Nutrientes Terapéuticos / Minerales / Electrolitos ............................................................................................ 116

Productos Sanguíneos / Modificadores / Expansores De Volumen ................................................................. 119

Reguladores De Glucosa En Sangre ................................................................................................................... 122

Relajantes Musculo Esqueletales ........................................................................................................................ 126

Vea información sobre qué significan las abreviaturas y símbolos en esta tabla, en la página 6. CG: Le proveemos cubierta adicional por este medicamento en su brecha de cubierta. Por favor, refiérase a su Evidencia de Cubierta para más información acerca de esta cubierta. ED: Este medicamento, normalmente no está cubierto en un Plan de Medicamentos Recetados de Medicare. La cantidad que usted paga cuando usted compra una receta para este medicamento no cuenta para sus costos totales de medicamentos (es decir, la cantidad que usted paga no le ayuda a cualificar para la cobertura catastrófica). Además, si usted está recibiendo ayuda adicional para pagar por sus medicamentos recetados, usted no obtendrá ayuda adicional para pagar por este medicamento.

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Medicamentos Medicamento de Referencia

Nivel Requisitos/Límites

Agentes Antidemencia

Antagonistas Del Receptor De N-Metil-D-Aspartato (Nmda)

memantine hcl oral tablet 10 mg, 5 mg NAMENDA 1 PA; MT

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

NAMENDA TITRATION PAK

1 PA

NAMENDA ORAL SOLUTION 10 MG/5ML

2 PA; MT; QL (300 per 30 days)

NAMENDA ORAL TABLET 10 MG, 5 MG

2 PA; MT

NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG

2 PA

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

2 PA; MT

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

2 PA; MT

Inhibidores De Colinesterasa

donepezil hcl oral tablet 10 mg, 5 mg ARICEPT 1 MT; QL (30 per 30 days)

donepezil hcl oral tablet 23 mg ARICEPT 1 MT; QL (30 per 30 days)

donepezil hcl oral tablet dispersible 10 mg, 5 mg

ARICEPT ODT 1 MT; QL (30 per 30 days)

EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR

2 MT

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

RAZADYNE ER 1 MT

galantamine hydrobromide oral solution 4 mg/ml

RAZADYNE 1 MT


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

RAZADYNE 1 MT

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

EXELON 1 MT

Agentes Antigota

Agentes Antigota

allopurinol oral tablet 100 mg, 300 mg ZYLOPRIM 1 MT

colchicine oral capsule 0.6 mg MITIGARE 1

colchicine oral tablet 0.6 mg COLCRYS 1

colchicine-probenecid oral tablet 0.5-500 mg

1 MT

probenecid oral tablet 500 mg 1

Agentes Antiinflamatorios

Antiinflamatorios No-Esteroidales

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

CELEBREX 1 PA; MT; QL (60 per 30 days)

diclofenac potassium oral tablet 50 mg CATAFLAM 1

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

VOLTAREN-XR 1

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

1

diflunisal oral tablet 500 mg 1

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

1

etodolac oral capsule 200 mg 1

etodolac oral tablet 400 mg, 500 mg 1

fenoprofen calcium oral tablet 600 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1

ibuprofen oral suspension 100 mg/5ml CHILDRENS ADVIL 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1


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ketoprofen er oral capsule extended release 24 hour 200 mg

1

ketoprofen oral capsule 50 mg, 75 mg 1

meclofenamate sodium oral capsule 100 mg, 50 mg

1

mefenamic acid oral capsule 250 mg PONSTEL 1

meloxicam oral tablet 15 mg, 7.5 mg MOBIC 1 QL (30 per 30 days)

nabumetone oral tablet 500 mg, 750 mg 1

naproxen dr oral tablet delayed release 375 mg, 500 mg

EC-NAPROSYN 1

naproxen oral suspension 125 mg/5ml NAPROSYN 1

naproxen oral tablet 250 mg, 375 mg, 500 mg

NAPROSYN 1

naproxen sodium oral tablet 275 mg ANAPROX 1

naproxen sodium oral tablet 550 mg ANAPROX DS 1

oxaprozin oral tablet 600 mg DAYPRO 1

oxycodone-ibuprofen oral tablet 5-400 mg 1 QL (120 per 30 days)

piroxicam oral capsule 10 mg, 20 mg FELDENE 1

sulindac oral tablet 150 mg 1

sulindac oral tablet 200 mg CLINORIL 1

tolmetin sodium oral capsule 400 mg 1

tolmetin sodium oral tablet 600 mg 1

Glucocorticoides

betamethasone dipropionate aug external cream 0.05 %

DIPROLENE AF 1

betamethasone dipropionate aug external lotion 0.05 %

DIPROLENE 1

betamethasone dipropionate aug external ointment 0.05 %

DIPROLENE 1

betamethasone dipropionate external cream 0.05 %

1


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betamethasone dipropionate external lotion 0.05 %

1

betamethasone dipropionate external ointment 0.05 %

1

betamethasone valerate external cream 0.1 %

1

betamethasone valerate external lotion 0.1 %

1

betamethasone valerate external ointment 0.1 %

1

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

2

cortisone acetate oral tablet 25 mg 1

dexamethasone intensol oral concentrate 1 mg/ml

1

dexamethasone oral elixir 0.5 mg/5ml BAYCADRON 1

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

1

dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

1

hydrocortisone oral tablet 20 mg, 5 mg CORTEF 1

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

DEPO-MEDROL 1

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

MEDROL 1

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

SOLU-MEDROL 1

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

2

prednisolone acetate ophthalmic suspension 1 %

PRED FORTE 1

prednisolone sodium phosphate ophthalmic solution 1 %

1


13



prednisolone sodium phosphate oral solution 15 mg/5ml

ORAPRED 1


1

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

PEDIAPRED 1

prednisone intensol oral concentrate 5 mg/ml

1

prednisone oral solution 5 mg/5ml 1

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

1

prednisone oral tablet 20 mg DELTASONE 1

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

veripred 20 oral solution 20 mg/5ml 1

Agentes Antimiasténicos

Parasimpatomiméticos

guanidine hcl oral tablet 125 mg 1

MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG

2

pyridostigmine bromide er oral tablet extendedrelease* 180 mg

MESTINON 1

pyridostigmine bromide oral tablet 60 mg MESTINON 1

Agentes Cardiovasculares

Agentes Bloqueadores Alfa-Adrenérgicos

DIBENZYLINE ORAL CAPSULE 10 MG

2

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

CARDURA 1 MT

phenoxybenzamine hcl oral capsule 10 mg DIBENZYLINE 1

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

MINIPRESS 1 MT


14



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

1 MT

Agentes Bloqueadores Beta-Adrenérgicos

acebutolol hcl oral capsule 200 mg, 400 mg

SECTRAL 1 MT

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

betaxolol hcl oral tablet 10 mg, 20 mg KERLONE 1 MT

bisoprolol fumarate oral tablet 10 mg, 5 mg

ZEBETA 1 MT

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

COREG 1 MT

labetalol hcl intravenous* solution 5 mg/ml

1

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

TRANDATE 1 MT

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

TOPROL XL 1 MT

metoprolol tartrate intravenous* solution 1 mg/ml

LOPRESSOR 1

metoprolol tartrate oral tablet 100 mg, 50 mg

LOPRESSOR 1 MT

metoprolol tartrate oral tablet 25 mg 1 MT

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

pindolol oral tablet 10 mg, 5 mg 1 MT

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

INDERAL LA 1 MT

propranolol hcl intravenous* solution 1 mg/ml

1

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

1 MT


15



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

1 MT

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

1 MT

Agentes Bloqueadores De Canales De Calcio

afeditab cr oral tablet extended release 24 hr* 30 mg, 60 mg

1 MT

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

NORVASC 1 MT

cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1 MT

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

TIAZAC 1 MT

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg

CARTIA XT 1 MT

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

CARDIZEM CD 1 MT

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

1 MT

diltiazem hcl intravenous* solution 50 mg/10ml

1

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

CARDIZEM 1 MT

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg

1 MT

dilt-xr oral capsule extended release 24 hour 240 mg

DILACOR XR 1 MT

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

1 MT

isradipine oral capsule 2.5 mg, 5 mg 1 MT

matzim la oral tablet extended release 24 hr* 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1 MT


16



nicardipine hcl oral capsule 20 mg, 30 mg 1 MT

nifedical xl oral tablet extended release 24 hr* 30 mg

1 MT

nifedical xl oral tablet extended release 24 hr* 60 mg

1 MT

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

PROCARDIA XL 1 MT

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

NIFEDICAL XL 1 MT

nimodipine oral capsule 30 mg NIMOTOP 1 MT

nisoldipine er oral tablet extended release 24 hr* 20 mg, 30 mg, 40 mg

1 MT

taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1 MT

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

VERELAN PM 1 MT

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

VERELAN 1 MT

verapamil hcl er oral capsule extended release 24 hour 360 mg

VERELAN 1 MT

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

ISOPTIN SR 1 MT

verapamil hcl er oral tablet extendedrelease* 240 mg

CALAN SR 1 MT

verapamil hcl oral tablet 120 mg, 80 mg CALAN 1 MT

verapamil hcl oral tablet 40 mg 1 MT

Agentes Cardiovasculares

amiloride-hydrochlorothiazide oral tablet 5-50 mg

1 MT

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

LOTREL 1 MT


17



amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg

EXFORGE 1 MT; QL (30 per 30 days)

amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

EXFORGE HCT 1 MT; QL (30 per 30 days)

atenolol-chlorthalidone oral tablet 100-25 mg

TENORETIC 100 1 MT

atenolol-chlorthalidone oral tablet 50-25 mg

TENORETIC 50 1 MT

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

LOTENSIN HCT 1 MT

benazepril-hydrochlorothiazide oral tablet 5-6.25 mg

1 MT

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG

3 ST; MT; QL (30 per 30 days)

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

ZIAC 1 MT

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

ATACAND HCT 1 MT; QL (30 per 30 days)

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

1 MT

clorpres oral tablet 0.1-15 mg, 0.2-15 mg 1 MT

DEMSER ORAL CAPSULE 250 MG 2

enalapril-hydrochlorothiazide oral tablet 10-25 mg

VASERETIC 1 MT

enalapril-hydrochlorothiazide oral tablet 5-12.5 mg

1 MT

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

1 MT

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

AVALIDE 1 MT; QL (30 per 30 days)

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

ZESTORETIC 1 MT


18



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

HYZAAR 1 MT

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

LOPRESSOR HCT 1 MT

metoprolol-hydrochlorothiazide oral tablet 100-50 mg

1 MT

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

UNIRETIC 1 MT

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

CORZIDE 1 MT

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

1 MT

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

ACCURETIC 1 MT

spironolactone-hctz oral tablet 25-25 mg ALDACTAZIDE 1 MT

triamterene-hctz oral capsule 37.5-25 mg DYAZIDE 1 MT

triamterene-hctz oral capsule 50-25 mg 1 MT

triamterene-hctz oral tablet 37.5-25 mg MAXZIDE-25 1 MT

triamterene-hctz oral tablet 75-50 mg MAXZIDE 1 MT

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

DIOVAN HCT 1 MT; QL (30 per 30 days)

VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG


Agentes Cardiovasculares, Otros

digoxin injection solution 0.25 mg/ml LANOXIN 1

digoxin oral solution 0.05 mg/ml 1 MT

digoxin oral tablet 0.125 mg DIGITEK 1 MT; QL (30 per 30 days)

digoxin oral tablet 250 mcg DIGITEK 1 MT

LANOXIN ORAL TABLET 0.0625 MG 2 MT; QL (60 per 30 days)


19



LANOXIN ORAL TABLET 0.125 MG 2 MT; QL (30 per 30 days)

LANOXIN ORAL TABLET 0.25 MG 2 MT

LANOXIN ORAL TABLET 187.5 MCG 2 MT

pentoxifylline er oral tablet extendedrelease* 400 mg

TRENTAL 1 MT

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


Agonistas Alfa-Adrenérgicos

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

CATAPRES 1 MT

guanfacine hcl oral tablet 1 mg, 2 mg TENEX 1 PA; MT

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

1

Antagonista Receptores Angiotensina Ii (Arb)

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG


candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

ATACAND 1 MT; QL (30 per 30 days)

irbesartan oral tablet 150 mg, 300 mg, 75 mg

AVAPRO 1 MT; QL (30 per 30 days)

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

COZAAR 1 MT

valsartan oral tablet 160 mg, 40 mg, 80 mg

DIOVAN 1 MT; QL (60 per 30 days)

valsartan oral tablet 320 mg DIOVAN 1 MT; QL (30 per 30 days)

Antiarrítmicos

amiodarone hcl oral tablet 200 mg CORDARONE 1 MT

amiodarone hcl oral tablet 400 mg PACERONE 1 MT

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

TAMBOCOR 1 MT


20



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

1 MT

MULTAQ ORAL TABLET 400 MG 3 QL (60 per 30 days)

pacerone oral tablet 100 mg, 200 mg, 400 mg

1 MT

procainamide hcl injection solution 500 mg/ml

1

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

RYTHMOL SR 1 MT

propafenone hcl oral tablet 150 mg, 225 mg

RYTHMOL 1 MT

propafenone hcl oral tablet 300 mg 1 MT

quinidine gluconate er oral tablet extendedrelease* 324 mg

1 MT

quinidine sulfate oral tablet 200 mg, 300 mg

1 MT

sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1 MT

sotalol hcl (af) oral tablet 120 mg BETAPACE AF 1 MT

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

SORINE 1 MT

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

2 MT

Dislipidémicos, Derivados De Acido Fíbrico

fenofibrate micronized oral capsule 130 mg, 43 mg

ANTARA 1 MT

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

LOFIBRA 1 MT

fenofibrate oral tablet 145 mg, 48 mg TRICOR 1 MT; QL (30 per 30 days)

fenofibrate oral tablet 160 mg LOFIBRA 1 MT

fenofibrate oral tablet 54 mg LOFIBRA 1 MT; QL (30 per 30 days)


21



fenofibric acid oral capsule delayed release 135 mg, 45 mg

TRILIPIX 1 MT; QL (30 per 30 days)

gemfibrozil oral tablet 600 mg LOPID 1 MT

Dislipidémicos, Inhibidores De La Reductasa De Hmg Coa

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

LIPITOR 1 MT; QL (30 per 30 days)

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG


fluvastatin sodium oral capsule 20 mg LESCOL 1 MT; QL (30 per 30 days)

fluvastatin sodium oral capsule 40 mg LESCOL 1 MT; QL (60 per 30 days)

lovastatin oral tablet 10 mg 1 MT

lovastatin oral tablet 20 mg, 40 mg MEVACOR 1 MT

pravastatin sodium oral tablet 10 mg 1 MT; QL (30 per 30 days)

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

PRAVACHOL 1 MT; QL (30 per 30 days)

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

ZOCOR 1 MT; QL (30 per 30 days)

Dislipidémicos, Otros

cholestyramine light oral packet 4 gm QUESTRAN LIGHT 1 MT

colestipol hcl oral granules 5 gm COLESTID FLAVORED 1 MT

colestipol hcl oral tablet 1 gm COLESTID 1 MT

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG


LOVAZA ORAL CAPSULE 1 GM 2 PA; MT; QL (120 per 30 days)

NIASPAN ORAL TABLET EXTENDEDRELEASE* 1000 MG, 500 MG, 750 MG

2 QL (60 per 30 days)

omega-3-acid ethyl esters oral capsule 1 gm

LOVAZA 1 PA; QL (120 per 30 days)


22



prevalite oral powder 4 gm/dose 1 MT

WELCHOL ORAL PACKET 3.75 GM 2 MT

WELCHOL ORAL TABLET 625 MG 2 MT

ZETIA ORAL TABLET 10 MG 2 ST; MT; QL (30 per 30 days)

Díureticos, Ahorradores De Potasio

amiloride hcl oral tablet 5 mg 1 MT

eplerenone oral tablet 25 mg, 50 mg INSPRA 1 MT

spironolactone oral tablet 100 mg, 25 mg, 50 mg

ALDACTONE 1 MT

Díureticos, Asa De Henle

bumetanide injection solution 0.25 mg/ml 1

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

furosemide injection solution 10 mg/ml 1

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

1 MT

furosemide oral tablet 20 mg, 40 mg, 80 mg

LASIX 1 MT

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

DEMADEX 1 MT

Díureticos, Inhibidores De La Anhidrasa Carbónica

acetazolamide er oral capsule extended release 12 hour 500 mg

DIAMOX SEQUELS 1 MT

acetazolamide oral tablet 125 mg, 250 mg 1 MT

methazolamide oral tablet 25 mg, 50 mg NEPTAZANE 1 MT

Díureticos, Tiazidas

chlorothiazide oral tablet 250 mg, 500 mg 1 MT

chlorthalidone oral tablet 25 mg, 50 mg 1 MT

hydrochlorothiazide oral capsule 12.5 mg MICROZIDE 1 MT

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1 MT


23



indapamide oral tablet 1.25 mg, 2.5 mg 1 MT

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

AVALIDE 1 MT; QL (30 per 30 days)

methyclothiazide oral tablet 5 mg 1 MT

metolazone oral tablet 10 mg 1 MT

metolazone oral tablet 2.5 mg, 5 mg ZAROXOLYN 1 MT

Inhibidores Convertidor De La Enzima De Angiotensina ( Ace)

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

LOTENSIN 1 MT

benazepril hcl oral tablet 5 mg 1 MT

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

1 MT

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

VASOTEC 1 MT

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

1 MT

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

ZESTRIL 1 MT

lisinopril oral tablet 20 mg, 5 mg PRINIVIL 1 MT

moexipril hcl oral tablet 15 mg, 7.5 mg UNIVASC 1 MT

perindopril erbumine oral tablet 2 mg 1 MT

perindopril erbumine oral tablet 4 mg, 8 mg

ACEON 1 MT

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

ACCUPRIL 1 MT

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

ALTACE 1 MT

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

Vasodilatadores, Actúan Directo En Arteria

hydralazine hcl injection solution 20 mg/ml

1


24



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

1

minoxidil oral tablet 10 mg, 2.5 mg 1

Vasodilatadores, Actúan Directo En Arteria / Vena

isosorbide dinitrate er oral tablet extendedrelease* 40 mg

1 MT

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

1 MT

isosorbide dinitrate oral tablet 5 mg ISORDIL TITRADOSE 1 MT

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

IMDUR 1 MT

isosorbide mononitrate oral tablet 10 mg, 20 mg

1 MT

nitro-bid transdermal ointment 2 % 1 MT

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

NITRO-DUR 1 MT

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

2 MT

Agentes Del Sistema Nervioso Central

Agentes Fibromialgia

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

CYMBALTA 1 MT

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

2 PA; MT

LYRICA ORAL SOLUTION 20 MG/ML 2 PA; MT

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

2 PA; MT

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

2 PA

Agentes Para El Desórden De Déficit De Atención E Hiperactividad, Anfetamina


25



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

ADDERALL 1 PA

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg

DEXEDRINE 1

Agentes Para El Desórden De Déficit De Atención E Hiperactividad, No-Anfetamina

INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR* 1 MG, 2 MG, 3 MG, 4 MG

2

metadate er oral tablet extendedrelease* 20 mg

1

methylphenidate hcl er oral tablet extendedrelease* 18 mg

CONCERTA 1

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

2 PA; QL (60 per 30 days)

Agentes Para El Tratamiento De Esclerosis Múltiple

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG

4 PA; LA; QL (60 per 30 days)

AVONEX INTRAMUSCULAR* KIT 30 MCG


AVONEX PEN INTRAMUSCULAR* KIT 30 MCG/0.5ML


AVONEX PREFILLED INTRAMUSCULAR* KIT 30 MCG/0.5ML


BETASERON SUBCUTANEOUS* KIT 0.3 MG


COPAXONE SUBCUTANEOUS* 20 MG/ML

4 PA


26



COPAXONE SUBCUTANEOUS* 40 MG/ML


GILENYA ORAL CAPSULE 0.5 MG 4 PA; QL (30 per 30 days)

mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml

1 PA

PLEGRIDY STARTER PACK SUBCUTANEOUS* 63 & 94 MCG/0.5ML

4 PA

PLEGRIDY SUBCUTANEOUS* 125 MCG/0.5ML

4 PA; MT

TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML

4 PA; LA

Sistema Nervioso Central, Otros

estazolam oral tablet 1 mg, 2 mg 1 QL (30 per 30 days)

NUEDEXTA ORAL CAPSULE 20-10 MG

2

RILUTEK ORAL TABLET 50 MG 4 PA

riluzole oral tablet 50 mg RILUTEK 4 PA

tetrabenazine oral tablet 12.5 mg, 25 mg XENAZINE 4 PA; MT

XENAZINE ORAL TABLET 12.5 MG, 25 MG

4 PA; MT; LA

Agentes Dermatológicos

Agentes Dermatológicos

8-MOP ORAL CAPSULE 10 MG 2 PA

adapalene external 0.1 %, 0.3 % DIFFERIN 1 PA

adapalene external cream 0.1 % DIFFERIN 1 PA

ammonium lactate external cream 12 % LAC-HYDRIN 1

ammonium lactate external lotion 12 % AMLACTIN 1

amnesteem oral capsule 10 mg, 20 mg, 40 mg

1

benzoyl peroxide-erythromycin external 5-3 %

BENZAMYCIN 1


27



betamethasone dipropionate external lotion 0.05 %

1

calcipotriene external cream 0.005 % DOVONEX 1

calcipotriene external ointment 0.005 % CALCITRENE 1

calcipotriene external solution 0.005 % 1

calcitriol external ointment 3 mcg/gm VECTICAL 1

claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg

1

clotrimazole-betamethasone external cream 1-0.05 %

LOTRISONE 1

doxycycline hyclate oral capsule 50 mg 1

doxycycline hyclate oral tablet delayed release 75 mg

1

doxycycline monohydrate oral tablet 100 mg, 50 mg

ADOXA 1

ELIDEL EXTERNAL CREAM 1 % 2 ST

fluocinonide external cream 0.1 % VANOS 1

fluorouracil external cream 0.5 % CARAC 1

fluorouracil external cream 5 % 1

fluorouracil external solution 2 %, 5 % 1

fluticasone propionate external cream 0.05 %

CUTIVATE 1

fluticasone propionate external lotion 0.05 %

CUTIVATE 1

fluticasone propionate external ointment 0.005 %

CUTIVATE 1

imiquimod external cream 5 % ALDARA 1

methoxsalen rapid oral capsule 10 mg OXSORALEN ULTRA 4 PA

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

1

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

1

podofilox external solution 0.5 % CONDYLOX 1


28



REGRANEX EXTERNAL 0.01 % 4 PA; QL (30 per 30 days)

risedronate sodium oral tablet delayed release 35 mg

ATELVIA 1 MT; QL (4 per 30 days)

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

2

selenium sulfide external lotion 2.5 % SELSUN 1

SOLARAZE TRANSDERMAL 3 % 2 PA

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

4 PA

STELARA SUBCUTANEOUS* 45 MG/0.5ML, 90 MG/ML

4 PA

tacrolimus external ointment 0.03 %, 0.1 %

PROTOPIC 1 ST

TAZORAC EXTERNAL 0.05 %, 0.1 % 2 PA

tretinoin external 0.01 %, 0.025 % RETIN-A 1 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

RETIN-A 1 PA

VALCHLOR EXTERNAL 0.016 % 4 PA

VOLTAREN TRANSDERMAL 1 % 2

ZONALON EXTERNAL CREAM 5 % 2

Agentes Gastrointestinales

Agentes Gastrointestinales, Otros

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

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

LOMOTIL 1

loperamide hcl oral capsule 2 mg 1

metoclopramide hcl injection solution 5 mg/ml

1

metoclopramide hcl oral solution 5 mg/5ml

1


29



metoclopramide hcl oral tablet 10 mg, 5 mg

REGLAN 1

proctozone-hc cream 2.5 % 1

RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML

2 PA

ursodiol oral capsule 300 mg ACTIGALL 1 MT

ursodiol oral tablet 250 mg URSO 250 1 MT

ursodiol oral tablet 500 mg URSO FORTE 1 MT

Agentes Síndrome Irritable Del Intestino

alosetron hcl oral tablet 0.5 mg, 1 mg LOTRONEX 4 PA; MT

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

2

budesonide er oral capsule extended release 24 hour 3 mg

ENTOCORT EC 4

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

2 MT; QL (180 per 30 days)

LOTRONEX ORAL TABLET 0.5 MG, 1 MG

4 PA; MT

Antagonista Del Receptor De Histamina 2 (H2)

cimetidine hcl oral solution 300 mg/5ml 1

cimetidine oral tablet 200 mg TAGAMET HB 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg

1

famotidine oral suspension reconstituted 40 mg/5ml

PEPCID 1

famotidine oral tablet 20 mg, 40 mg PEPCID 1

nizatidine oral capsule 150 mg, 300 mg AXID 1

nizatidine oral solution 15 mg/ml AXID 1

ranitidine hcl injection solution 150 mg/6ml

ZANTAC 1 PA


30



ranitidine hcl oral capsule 150 mg, 300 mg

1

ranitidine hcl oral syrup 15 mg/ml ZANTAC 1

ranitidine hcl oral tablet 150 mg, 300 mg ZANTAC 1

Antiespasmódicos, Gastrointestinal

dicyclomine hcl oral capsule 10 mg BENTYL 1

dicyclomine hcl oral solution 10 mg/5ml 1

dicyclomine hcl oral tablet 20 mg BENTYL 1

glycopyrrolate injection solution 4 mg/20ml

ROBINUL 1

glycopyrrolate oral tablet 1 mg ROBINUL 1

glycopyrrolate oral tablet 2 mg ROBINUL-FORTE 1

methscopolamine bromide oral tablet 2.5 mg

PAMINE 1

TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1 MG/3DAYS

3

Inhibidores De La Bomba De Protones

lansoprazole oral capsule delayed release 15 mg, 30 mg

PREVACID 1 QL (30 per 30 days)

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

PRILOSEC 1 QL (30 per 30 days)

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

PROTONIX 1 QL (30 per 30 days)

Laxantes

constulose oral solution 10 gm/15ml 1

enulose oral solution 10 gm/15ml 1

gavilyte-c oral solution reconstituted 240 gm

1

lactulose oral solution 10 gm/15ml 1

polyethylene glycol 3350 oral powder CLEARLAX 1

Protectores

carafate oral suspension 1 gm/10ml 1


31



misoprostol oral tablet 100 mcg, 200 mcg CYTOTEC 1

sucralfate oral tablet 1 gm CARAFATE 1

Agentes Genitourinarios

Agentes Genitourinarios, Otros

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

URECHOLINE 1

CIALIS ORAL TABLET 2.5 MG, 5 MG, 10 MG, 20 MG

ED; QL (4 per 30 days)

CUPRIMINE ORAL CAPSULE 250 MG 3

ELMIRON ORAL CAPSULE 100 MG 2

LEVITRA OTAL TABLET 2.5 MG, 5 MG, 10 MG, 20 MG


potassium citrate er oral tablet extendedrelease* 15 meq (1620 mg)

UROCIT-K 15 1

sodium phenylbutyrate oral powder 3 gm/tsp

BUPHENYL 4 PA

VIAGRA ORAL TABLET 25 MG, 50 MG, 100 MG


Agentes Hipertrofia Beninga De La Próstata

AVODART ORAL CAPSULE 0.5 MG 3 MT; QL (30 per 30 days)

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

CARDURA 1 MT

finasteride oral tablet 5 mg PROSCAR 1 MT

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

MINIPRESS 1 MT

tamsulosin hcl oral capsule 0.4 mg FLOMAX 1 MT

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

1 MT

Antiespasmódicos, Otros


32



ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR* 15 MG, 7.5 MG

2 ST; QL (30 per 30 days)

flavoxate hcl oral tablet 100 mg 1

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

DITROPAN XL 1

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

DITROPAN XL 1 QL (30 per 30 days)

oxybutynin chloride oral syrup 5 mg/5ml 1

oxybutynin chloride oral tablet 5 mg 1

trospium chloride oral tablet 20 mg SANCTURA 1

Enlazadores De Fósfato

calcium acetate oral capsule 667 mg PHOSLO 1

RENVELA ORAL PACKET 0.8 GM, 2.4 GM

2

RENVELA ORAL TABLET 800 MG 2

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Adrenal)

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Adrenal)

alclometasone dipropionate external cream 0.05 %

ACLOVATE 1

alclometasone dipropionate external ointment 0.05 %

1

amcinonide external cream 0.1 % 1

amcinonide external lotion 0.1 % 1

amcinonide external ointment 0.1 % 1

betamethasone dipropionate aug external cream 0.05 %

DIPROLENE AF 1

betamethasone dipropionate aug external lotion 0.05 %

DIPROLENE 1

betamethasone dipropionate aug external ointment 0.05 %

DIPROLENE 1


33



betamethasone dipropionate external cream 0.05 %

1

betamethasone dipropionate external ointment 0.05 %

1

betamethasone valerate external cream 0.1 %

1

betamethasone valerate external lotion 0.1 %

1

betamethasone valerate external ointment 0.1 %

1

clobetasol propionate e external cream 0.05 %

TEMOVATE E 1

clobetasol propionate external 0.05 % TEMOVATE 1

clobetasol propionate external ointment 0.05 %

TEMOVATE 1

clobetasol propionate external solution 0.05 %

CORMAX SCALP APPLICATION

1


DERMATOP EXTERNAL CREAM 0.1 %

3

desonide external cream 0.05 % DESOWEN 1

desonide external lotion 0.05 % DESOWEN 1

desonide external ointment 0.05 % DESOWEN 1

desoximetasone external 0.05 % TOPICORT 1

desoximetasone external cream 0.05 %, 0.25 %

TOPICORT 1

desoximetasone external ointment 0.25 % TOPICORT 1


1



1


34



dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

1

diflorasone diacetate external cream 0.05 %

1

diflorasone diacetate external ointment 0.05 %

APEXICON 1

fludrocortisone acetate oral tablet 0.1 mg 1

fluocinolone acetonide external cream 0.01 %

1

fluocinolone acetonide external cream 0.025 %

SYNALAR 1

fluocinolone acetonide external ointment 0.025 %

SYNALAR 1

fluocinolone acetonide external solution 0.01 %

SYNALAR 1

fluocinolone acetonide otic oil 0.01 % DERMOTIC 1

fluocinonide external 0.05 % 1

fluocinonide external cream 0.1 % VANOS 1

fluocinonide external ointment 0.05 % 1

fluocinonide external solution 0.05 % 1

fluocinonide-e external cream 0.05 % 1

fluticasone propionate external cream 0.05 %

CUTIVATE 1


CUTIVATE 1

fluticasone propionate external ointment 0.005 %

CUTIVATE 1

halobetasol propionate external cream 0.05 %

ULTRAVATE 1

halobetasol propionate external ointment 0.05 %

ULTRAVATE 1

hydrocortisone butyr lipo base external cream 0.1 %

LOCOID LIPOCREAM 1


35



hydrocortisone external cream 1 % NEOSPORIN ECZEMA

ESSENT MAX ST 1

hydrocortisone external cream 2.5 % PROCTOZONE-HC 1

hydrocortisone external lotion 2.5 % 1

hydrocortisone external ointment 1 % CORTIZONE-10 1

hydrocortisone external ointment 2.5 % 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

CORTEF 1

hydrocortisone valerate external cream 0.2 %

1

hydrocortisone valerate external ointment 0.2 %

WESTCORT 1

KENALOG INJECTION SUSPENSION 40 MG/ML

2

methylprednisolone (pak) oral tablet 4 mg MEDROL (PAK) 1


DEPO-MEDROL 1


MEDROL 1

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

SOLU-MEDROL 1

mometasone furoate external cream 0.1 % ELOCON 1

mometasone furoate external ointment 0.1 %

ELOCON 1

mometasone furoate external solution 0.1 %

ELOCON 1

prednicarbate external ointment 0.1 % DERMATOP 1


ORAPRED 1


1


PEDIAPRED 1


36




1



1


proctozone-hc cream 2.5 % 1

triamcinolone acetonide external cream 0.025 %, 0.5 %

1

triamcinolone acetonide external cream 0.1 %

TRIDERM 1

triamcinolone acetonide external lotion 0.025 %, 0.1 %

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triderm external cream 0.1 % 1


Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Modificadores/Hormonas Sexuales)

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Modificadores/Hormonas Sexuales)

apri oral tablet 0.15-30 mg-mcg 1

aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1

aviane oral tablet 0.1-20 mg-mcg 1

balziva oral tablet 0.4-35 mg-mcg 1

COMBIPATCH TRANSDERMAL PATCH BIWEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY


cryselle-28 oral tablet 0.3-30 mg-mcg 1

cyclafem 1/35 oral tablet 1-35 mg-mcg 1


37



cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

OCELLA 1

emoquette oral tablet 0.15-30 mg-mcg 1

enpresse-28 oral tablet 1

estradiol-norethindrone acet oral tablet 0.5-0.1 mg

MIMVEY LO 1 PA

estradiol-norethindrone acet oral tablet 1-0.5 mg

ACTIVELLA 1 PA

gildagia oral tablet 0.4-35 mg-mcg 1

junel 1.5/30 oral tablet 1.5-30 mg-mcg 1

junel 1/20 oral tablet 1-20 mg-mcg 1

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1

junel fe 1/20 oral tablet 1-20 mg-mcg 1

junel fe 24 oral tablet 1-20 mg-mcg(24) 1

kariva oral tablet 0.15-0.02/0.01 mg (21/5)

1

kelnor 1/35 oral tablet 1-35 mg-mcg 1

lessina oral tablet 0.1-20 mg-mcg 1

levonest oral tablet 1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

JOLESSA 1

levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg

1

loryna oral tablet 3-0.02 mg 1

low-ogestrel oral tablet 0.3-30 mg-mcg 1

lutera oral tablet 0.1-20 mg-mcg 1

marlissa oral tablet 0.15-30 mg-mcg PORTIA-28 1

microgestin 1.5/30 oral tablet 1.5-30 mg-mcg

1

microgestin 1/20 oral tablet 1-20 mg-mcg 1


38



microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg

1

microgestin fe 1/20 oral tablet 1-20 mg-mcg

1

mononessa oral tablet 0.25-35 mg-mcg 1

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg

1

necon 1/35 (28) oral tablet 1-35 mg-mcg 1

necon 10/11 (28) oral tablet 35 mcg 1

necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

1

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg

FEMHRT LOW DOSE 1 PA; MT

norethindrone-eth estradiol oral tablet 1-5 mg-mcg

JINTELI 1 PA; MT

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg

1

nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1

nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

1

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

3

ogestrel oral tablet 0.5-50 mg-mcg 1

orsythia oral tablet 0.1-20 mg-mcg 1

portia-28 oral tablet 0.15-30 mg-mcg 1

PREMPHASE ORAL TABLET 0.625-5 MG


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


previfem oral tablet 0.25-35 mg-mcg 1

quasense oral tablet 0.15-0.03 mg 1

reclipsen oral tablet 0.15-30 mg-mcg 1


39



sprintec 28 oral tablet 0.25-35 mg-mcg 1

sronyx oral tablet 0.1-20 mg-mcg 1

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg

1

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg

1

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

1

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

1

trivora (28) oral tablet 1

velivet oral tablet 0.1/0.125/0.15 -0.025 mg

1

VYFEMLA ORAL TABLET 0.4-35 MG-MCG

3

zovia 1/35e (28) oral tablet 1-35 mg-mcg 1

zovia 1/50e (28) oral tablet 1-50 mg-mcg 1

Agentes Modificadores Del Receptor Selectivo De Estrógeno

raloxifene hcl oral tablet 60 mg EVISTA 1 MT

Agonistas De Progesterona / Antagonistas

ELLA ORAL TABLET 30 MG 2

Andrógenos

ANDROGEL PUMP TRANSDERMAL 20.25 MG/ACT (1.62%)

2

ANDROGEL TRANSDERMAL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

3 MT

ANDROGEL TRANSDERMAL 50 MG/5GM (1%)

2

AXIRON TRANSDERMAL SOLUTION 30 MG/ACT

2


40



danazol oral capsule 100 mg, 200 mg, 50 mg

1

METHITEST ORAL TABLET 10 MG 2

testosterone cypionate intramuscular* solution 200 mg/ml

DEPO-TESTOSTERONE

1

testosterone enanthate intramuscular* solution 200 mg/ml

1

testosterone transdermal 10 mg/act (2%) FORTESTA 1 MT

testosterone transdermal 25 mg/2.5gm (1%), 50 mg/5gm (1%)

ANDROGEL 1 MT

Esteroides Anabólicos

oxandrolone oral tablet 10 mg OXANDRIN 4 PA; QL (60 per 30 days)

oxandrolone oral tablet 2.5 mg OXANDRIN 1 PA; QL (60 per 30 days)

Estrógenos

ESTRACE VAGINAL CREAM 0.1 MG/GM

2 MT

estradiol oral tablet 0.5 mg, 1 mg, 2 mg ESTRACE 1 PA

estradiol transdermal patch biweekly 0.025 mg/24hr

MINIVELLE 1 PA; QL (10 per 35 days)

estradiol transdermal patch biweekly 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

VIVELLE-DOT 1 PA; QL (10 per 35 days)

estropipate oral tablet 0.75 mg ORTHO-EST 0.625 1 PA

estropipate oral tablet 1.5 mg ORTHO-EST 1.25 1 PA

estropipate oral tablet 3 mg 1 PA


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

2 PA

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24HR



41



PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

2 PA

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

2 PA

PREMARIN VAGINAL CREAM 0.625 MG/GM

2 MT

VAGIFEM VAGINAL TABLET 10 MCG

2 MT

Progestina

camila oral tablet 0.35 mg 1

DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML

2

errin oral tablet 0.35 mg 1


medroxyprogesterone acetate intramuscular* suspension 150 mg/ml

DEPO-PROVERA 1 QL (1 per 90 days)

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

PROVERA 1

megestrol acetate oral suspension 40 mg/ml

MEGACE ORAL 1 PA

megestrol acetate oral suspension 625 mg/5ml

MEGACE ES 1 PA

megestrol acetate oral tablet 20 mg, 40 mg

1 PA

norethindrone acetate oral tablet 5 mg AYGESTIN 1 MT

norethindrone oral tablet 0.35 mg CAMILA 1 MT

progesterone micronized oral capsule 100 mg, 200 mg

PROMETRIUM 1 MT

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Pituitaria)

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Pituitaria)

desmopressin ace rhinal tube nasal solution 0.01 %

DDAVP RHINAL TUBE 1


42



desmopressin ace spray refrig nasal solution 0.01 %

MINIRIN 1

desmopressin acetate injection solution 4 mcg/ml

DDAVP 1 PA

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

DDAVP 1

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG

4 PA

INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML

4 PA; LA

NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

4 PA

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Prostaglandinas)

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Prostaglandinas)

misoprostol oral tablet 200 mcg CYTOTEC 1

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Tiroides)

Agentes Hormonales, Estimulantes / Reemplazo / Modificación (Tiroides)

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 175 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

UNITHROID 1 MT

levothyroxine sodium oral tablet 125 mcg LEVOXYL 1 MT

levothyroxine sodium oral tablet 137 mcg, 150 mcg, 200 mcg, 300 mcg

SYNTHROID 1 MT

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1 MT


43



liothyronine sodium intravenous* solution 10 mcg/ml

TRIOSTAT 1

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

CYTOMEL 1 MT

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

2 MT

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1 MT

Agentes Hormonales, Supresores (Adrenal)

Agentes Hormonales, Supresores (Adrenal)

LYSODREN ORAL TABLET 500 MG 2

Agentes Hormonales, Supresores (Paratiroide)

Agentes Hormonales, Supresores (Paratiroide)

SENSIPAR ORAL TABLET 30 MG 2 QL (60 per 30 days)



Agentes Hormonales, Supresores (Pituitaria)

Agentes Hormonales, Supresores (Pituitaria)

bromocriptine mesylate oral capsule 5 mg PARLODEL 1 MT

bromocriptine mesylate oral tablet 2.5 mg PARLODEL 1 MT

cabergoline oral tablet 0.5 mg 1 QL (20 per 30 days)

ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG

2 PA

leuprolide acetate injection kit 1 mg/0.2ml 1 PA


44



LUPANETA PACK COMBINATION KIT 11.25 & 5 MG


LUPANETA PACK COMBINATION KIT 3.75 & 5 MG


LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG, 22.5 MG, 3.75 MG, 30 MG, 45 MG, 7.5 MG

4 PA

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG, 15 MG

4 PA

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

SANDOSTATIN 1 PA

octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml

SANDOSTATIN 4 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 MG, 30 MG

4 PA

SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

4 PA

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

4 PA

SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 25 MG, 30 MG

4 PA; MT

SYNAREL NASAL SOLUTION 2 MG/ML

4 PA

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG, 3.75 MG

4 PA

Agentes Hormonales, Supresores (Tiroides)

Agentes Antitiroides


45



methimazole oral tablet 10 mg, 5 mg TAPAZOLE 1 MT

propylthiouracil oral tablet 50 mg 1 MT

Agentes Inmunológicos

Agentes Inmunizantes, Pasivos

GAMASTAN S/D INTRAMUSCULAR* INJECTABLE

2 PA

GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/200ML

4 PA

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML

2 PA

HYPERRAB S/D INTRAMUSCULAR* INJECTABLE 150 UNIT/ML

3

SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML

4 PA

Agentes Inmunológicos

leflunomide oral tablet 10 mg, 20 mg ARAVA 1 QL (30 per 30 days)

SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML

4 PA

Agentes Para Angioedema

CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT

4 PA

FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML


RUCONEST INTRAVENOUS* SOLUTION RECONSTITUTED 2100 UNIT

4 PA

Inmunomoduladores

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

4 PA

ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000 UNIT/0.5ML

4 PA


46



ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG

4 PA

KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/4ML

4 PA

KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

4 PA

leflunomide oral tablet 10 mg, 20 mg ARAVA 1 QL (30 per 30 days)

RIDAURA ORAL CAPSULE 3 MG 2

TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML

4 PA; LA

Inmunosupresores

ACTEMRA SUBCUTANEOUS* 162 MG/0.9ML

4 PA

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

4 PA

AFINITOR ORAL TABLET 2.5 MG 4 PA

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG

2 PA; MT

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG

4 PA; MT

ATGAM INTRAVENOUS* INJECTABLE 50 MG/ML

4 PA

AZASAN ORAL TABLET 100 MG, 75 MG

2 PA; MT

azathioprine oral tablet 50 mg IMURAN 1 PA; MT

BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 120 MG

2 PA

CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML

4 PA; MT

cyclosporine intravenous* solution 50 mg/ml

SANDIMMUNE 1 PA

cyclosporine modified oral capsule 100 mg, 25 mg

GENGRAF 1 PA; MT


47



cyclosporine modified oral capsule 50 mg 1 PA; MT

cyclosporine modified oral solution 100 mg/ml

GENGRAF 1 PA; MT

cyclosporine oral capsule 100 mg, 25 mg SANDIMMUNE 1 PA; MT

ELIDEL EXTERNAL CREAM 1 % 2 ST

ENBREL SUBCUTANEOUS* 25 MG/0.5ML


ENBREL SUBCUTANEOUS* 50 MG/ML


ENBREL SUBCUTANEOUS* KIT 25 MG


ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML


gengraf oral capsule 100 mg, 25 mg 1 PA; MT

gengraf oral solution 100 mg/ml 1 PA; MT

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML


HUMIRA SUBCUTANEOUS* 10 MG/0.2ML



4 PA; QL (0.8 per 30 days)



KINERET SUBCUTANEOUS* 100 MG/0.67ML

4 PA

mercaptopurine oral tablet 50 mg PURINETHOL 1

methotrexate oral tablet 2.5 mg 1 PA

methotrexate sodium (pf) injection solution 1 gm/40ml

1 PA

methotrexate sodium injection solution reconstituted 1 gm

1 PA

mycophenolate mofetil oral capsule 250 mg

CELLCEPT 1 PA; MT


48



mycophenolate mofetil oral suspension reconstituted 200 mg/ml

CELLCEPT 1 PA; MT

mycophenolate mofetil oral tablet 500 mg CELLCEPT 1 PA; MT

mycophenolic acid oral tablet delayed release 180 mg

MYFORTIC 1 PA; MT

mycophenolic acid oral tablet delayed release 360 mg

MYFORTIC 4 PA; MT

NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG

4 PA

ORENCIA INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG

4 PA

ORENCIA SUBCUTANEOUS* 125 MG/ML

4 PA

OTEZLA ORAL 10 & 20 & 30 MG 4 PA; QL (27 per 14 days)

OTEZLA ORAL TABLET 30 MG 4 PA; QL (60 per 30 days)

PROGRAF ORAL CAPSULE 0.5 MG, 1 MG

2 PA; MT

PROGRAF ORAL CAPSULE 5 MG 4 PA; MT

RAPAMUNE ORAL SOLUTION 1 MG/ML

2 PA; MT

REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

4 PA

SIMPONI SUBCUTANEOUS* 50 MG/0.5ML, 100 MG/ML

4 PA

sirolimus oral tablet 0.5 mg, 1 mg RAPAMUNE 1 PA; MT

sirolimus oral tablet 2 mg RAPAMUNE 4 PA; MT

tacrolimus oral capsule 0.5 mg, 1 mg PROGRAF 1 PA; MT

tacrolimus oral capsule 5 mg HECORIA 4 PA; MT

ZORTRESS ORAL TABLET 0.25 MG 2 PA; MT

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG

4 PA; MT


49



Vacunas

ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED

2

ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5 LF-MCG/0.5

2

BCG VACCINE INJECTION INJECTABLE

2

BEXSERO INTRAMUSCULAR* 2

BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5

2

CERVARIX INTRAMUSCULAR* SUSPENSION

2

COMVAX INTRAMUSCULAR* SUSPENSION 7.5-5 MCG/0.5ML

2

DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5

2

DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION 25-5 LFU/0.5ML

2

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

2 PA

GARDASIL 9 INTRAMUSCULAR* SUSPENSION

2

GARDASIL INTRAMUSCULAR* SUSPENSION

2

HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

2

IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5 UNIT/ML

2

INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10

2

IPOL INJECTION INJECTABLE 2


50



IPOL INJECTION INJECTABLE 3

IXIARO INTRAMUSCULAR* SUSPENSION

2

MENACTRA INTRAMUSCULAR* INJECTABLE

2

MENOMUNE SUBCUTANEOUS* INJECTABLE

2

MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED

2

M-M-R II SUBCUTANEOUS* INJECTABLE

2

PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML

2

PROQUAD SUBCUTANEOUS* INJECTABLE

2

QUADRACEL INTRAMUSCULAR* SUSPENSION

2

RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED

2

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

2 PA

ROTARIX ORAL SUSPENSION RECONSTITUTED

2

ROTATEQ ORAL SOLUTION 2

TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU

2

TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML

2

TRUMENBA INTRAMUSCULAR* 2

TWINRIX INTRAMUSCULAR* SUSPENSION 720-20

2


51



TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML

2

VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML

2

VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

3

VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML

2

VARIZIG INTRAMUSCULAR* SOLUTION 125 UNIT/1.2ML

4

YF-VAX SUBCUTANEOUS* INJECTABLE

2

ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 19400 UNT/0.65ML

2

Agentes Oftálmicos

Agentes Ofálmicos Para Alergia

cromolyn sodium ophthalmic solution 4 % 1

PATADAY OPHTHALMIC SOLUTION 0.2 %

2

PAZEO OPHTHALMIC SOLUTION 0.7 %

2

Agentes Ofálmicos Para Glaucoma

acetazolamide oral tablet 125 mg, 250 mg 1 MT

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

2 MT

apraclonidine hcl ophthalmic solution 0.5 %

IOPIDINE 1 MT

AZOPT OPHTHALMIC SUSPENSION 1 %


betaxolol hcl ophthalmic solution 0.5 % 1 MT

bimatoprost ophthalmic solution 0.03 % LUMIGAN 1 QL (2.5 per 30 days)


52



brimonidine tartrate ophthalmic solution 0.15 %

ALPHAGAN P 1 MT

brimonidine tartrate ophthalmic solution 0.2 %

1 MT

carteolol hcl ophthalmic solution 1 % 1 MT

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

2 MT

dorzolamide hcl ophthalmic solution 2 % TRUSOPT 1 MT

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

COSOPT 1 MT

levobunolol hcl ophthalmic solution 0.5 % BETAGAN 1 MT

methazolamide oral tablet 25 mg, 50 mg NEPTAZANE 1 MT

metipranolol ophthalmic solution 0.3 % OPTIPRANOLOL 1 MT

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

2

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

ISOPTO CARPINE 1 MT

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %


timolol maleate ophthalmic solution 0.25 %, 0.5 %

TIMOPTIC 1 MT

Agentes Ofálmicos Para La Inflamació0

dexamethasone sodium phosphate ophthalmic solution 0.1 %

1

diclofenac sodium ophthalmic solution 0.1 %

VOLTAREN 1

fluorometholone ophthalmic suspension 0.1 %

FML LIQUIFILM 1

flurbiprofen sodium ophthalmic solution 0.03 %

OCUFEN 1

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

3

FML OPHTHALMIC OINTMENT 0.1 % 2


53



ketorolac tromethamine ophthalmic solution 0.4 %

ACULAR LS 1

ketorolac tromethamine ophthalmic solution 0.5 %

ACULAR 1

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

2

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

2

prednisolone sodium phosphate ophthalmic solution 1 %

1

VEXOL OPHTHALMIC SUSPENSION 1 %

3

Agentes Oftálmicos

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

POLYCIN 1

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

NEO-POLYCIN HC 1

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

2

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

NEO-POLYCIN 1

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

MAXITROL 1

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

MAXITROL 1

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

NEOSPORIN 1

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

1

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

POLYTRIM 1

prednisolone acetate ophthalmic suspension 1 %

PRED FORTE 1


54



sulfacetamide sodium ophthalmic ointment 10 %

1

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

1

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

TOBRADEX 1

Agentes Oftálmicos, Otros

atropine sulfate ophthalmic solution 1 % 1 MT

naphazoline hcl ophthalmic solution 0.1 % 1

proparacaine hcl ophthalmic solution 0.5 %

ALCAINE 1

RESTASIS OPHTHALMIC EMULSION 0.05 %



1

Prostaglandinas Oftálmicas Y Análogos De Prostamida

latanoprost ophthalmic solution 0.005 % XALATAN 1 MT; QL (2.5 per 30 days)

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

2 MT; QL (2.5 per 30 days)

travoprost ophthalmic solution 0.004 % 1 MT

Agentes Orales Y Dentales

Agentes Orales Y Dentales

chlorhexidine gluconate mouth/throat solution 0.12 %

PAROEX 1

doxycycline hyclate oral capsule 100 mg VIBRAMYCIN 1


doxycycline hyclate oral tablet 100 mg, 20 mg

1

doxycycline monohydrate oral tablet 150 mg

ADOXA PAK 1/150 1


55




ADOXA 1

minocycline hcl er oral tablet extended release 24 hr* 135 mg, 45 mg, 90 mg

SOLODYN 1

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

MINOCIN 1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

DYNACIN 1

periogard mouth/throat solution 0.12 % 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg SALAGEN 1

triamcinolone acetonide mouth/throat paste 0.1 %

ORALONE 1

Agentes Óticos

Agentes Óticos

acetasol hc otic solution 2-1 % 1

CIPRODEX OTIC SUSPENSION 0.3-0.1 %

2

hydrocortisone-acetic acid otic solution 1-2 %

VOSOL HC 1

neomycin-polymyxin-hc otic solution 1 % CORTISPORIN 1

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

1

Agentes Para Desórdenes Del Sueño

Agentes Para El Desórden Del Sueño, Otros

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

1 PA; MT

doxepin hcl oral concentrate 10 mg/ml 1 PA; MT

HETLIOZ ORAL CAPSULE 20 MG 4 PA; QL (30 per 30 days)

modafinil oral tablet 100 mg, 200 mg PROVIGIL 1 PA; QL (30 per 30 days)

ROZEREM ORAL TABLET 8 MG 2 QL (30 per 30 days)


56



XYREM ORAL SOLUTION 500 MG/ML

4 LA

Moduladores Del Receptor De Gaba

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

RESTORIL 1 QL (30 per 30 days)

zaleplon oral capsule 10 mg, 5 mg SONATA 1 PA; QL (30 per 30 days)

zolpidem tartrate er oral tablet extendedrelease* 12.5 mg, 6.25 mg

AMBIEN CR 1 PA; QL (30 per 30 days)

zolpidem tartrate oral tablet 10 mg, 5 mg AMBIEN 1 PA; QL (30 per 30 days)

Agentes Para El Tratamiento De La Bipolaridad

Agentes Bipolares, Otros

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG

2 ST

olanzapine intramuscular* solution reconstituted 10 mg

ZYPREXA 1

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg

ZYPREXA 1 MT

olanzapine oral tablet 20 mg ZYPREXA 1 MT

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

ZYPREXA ZYDIS 1 MT

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

SEROQUEL 1 MT

quetiapine fumarate oral tablet 25 mg, 50 mg

SEROQUEL 1 PA; MT

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 25 MG

2 ST

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG, 50 MG

4 ST


57



risperidone oral solution 1 mg/ml RISPERDAL 1 MT; QL (480 per 30 days)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

RISPERDAL 1 MT

risperidone oral tablet dispersible 0.25 mg 1 MT

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg

RISPERIDONE M-TAB 1 MT

risperidone oral tablet dispersible 3 mg, 4 mg

RISPERDAL M-TAB 1 MT

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG

2 ST; MT

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

GEODON 1 MT

Estabilizadores De Animo

carbamazepine oral suspension 100 mg/5ml

TEGRETOL 1 MT

carbamazepine oral tablet 200 mg TEGRETOL 1 MT

carbamazepine oral tablet chewable 100 mg

1 MT

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

DEPAKOTE ER 1 MT

divalproex sodium oral capsule sprinkle 125 mg

DEPAKOTE SPRINKLES

1 MT

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

DEPAKOTE 1 MT

epitol oral tablet 200 mg 1 MT

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

LAMICTAL 1 MT

lamotrigine oral tablet chewable 25 mg, 5 mg

LAMICTAL 1 MT

lithium carbonate er oral tablet extendedrelease* 300 mg

LITHOBID 1 MT

lithium carbonate er oral tablet extendedrelease* 450 mg

1 MT


58



lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1 MT

lithium carbonate oral tablet 300 mg 1 MT

lithium oral solution 8 meq/5ml 1 MT

TEGRETOL ORAL SUSPENSION 100 MG/5ML

2 MT

TEGRETOL ORAL TABLET 200 MG 2 MT

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

2 MT


2 MT


2 MT

valproic acid oral capsule 250 mg DEPAKENE 1 MT

valproic acid oral syrup 250 mg/5ml DEPAKENE 1 MT

Agentes Para El Tratamiento De La Migraña

Agentes Para El Tratamiento De La Migraña

methylergonovine maleate oral tablet 0.2 mg

METHERGINE 1

Agonistas Del Receptor De Serotonina (5-Ht) 1B/1D

naratriptan hcl oral tablet 1 mg, 2.5 mg AMERGE 1 QL (18 per 28 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg

MAXALT 1 QL (27 per 28 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

MAXALT-MLT 1 QL (27 per 28 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

IMITREX 1 QL (18 per 28 days)

sumatriptan succinate refill subcutaneous* 6 mg/0.5ml

IMITREX STATDOSE REFILL


sumatriptan succinate subcutaneous* 6 mg/0.5ml

IMITREX STATDOSE SYSTEM



59



sumatriptan succinate subcutaneous* solution 6 mg/0.5ml

IMITREX 1 QL (8 per 28 days)

Alcaloides De Ergotamina

dihydroergotamine mesylate injection solution 1 mg/ml

D.H.E. 45 1

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG

2

migergot suppository 2-100 mg 1

Profilácticos

BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT

2 PA


DEPAKOTE ER 1 MT


DEPAKOTE SPRINKLES

1 MT


DEPAKOTE 1 MT

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

1 MT

topiramate oral capsule sprinkle 15 mg, 25 mg

TOPAMAX SPRINKLE 1 MT

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

TOPAMAX 1 MT



Agentes Para El Tratamiento De Parkinson

Agentes Para El Tratamiento De Parkinson

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

STALEVO 50 1 MT


STALEVO 75 1 MT


60



carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

STALEVO 100 1 MT


STALEVO 125 1 MT


STALEVO 150 1 MT

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg

STALEVO 200 1 MT

Agentes Para El Tratamiento De Parkinson, Otros

amantadine hcl oral capsule 100 mg 1 MT

amantadine hcl oral syrup 50 mg/5ml 1 MT

amantadine hcl oral tablet 100 mg 1 MT

entacapone oral tablet 200 mg COMTAN 1 MT

TASMAR ORAL TABLET 100 MG 4 PA; MT

tolcapone oral tablet 100 mg TASMAR 4 MT

Agonista De Dopamina

APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML

4 PA; LA

bromocriptine mesylate oral capsule 5 mg PARLODEL 1 MT

bromocriptine mesylate oral tablet 2.5 mg PARLODEL 1 MT

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


pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.375 mg, 3 mg, 4.5 mg

MIRAPEX ER 1 MT

pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.75 mg, 1.5 mg

MIRAPEX ER 1 MT

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

MIRAPEX 1 MT


61



ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

REQUIP XL 1 MT

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

REQUIP 1 MT

Anticolinérgico

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

1 PA

diphenhydramine hcl injection solution 50 mg/ml

1

trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA; MT

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA; MT

Inhibidores De Monoamino Oxidasa B (Mao-B)

AZILECT ORAL TABLET 0.5 MG, 1 MG

2 MT

selegiline hcl oral capsule 5 mg ELDEPRYL 1 MT

selegiline hcl oral tablet 5 mg 1 MT

Precursores De Dopamina /Inhibidores De Decarboxilasa De L-Amino Acido

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

SINEMET CR 1 MT

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

SINEMET 1 MT

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

PARCOPA 1 MT

Agentes Para El Tratamientode Abuso De Sustancias. Anti-Adicción

Agentes Para Revertimiento De Opioides

naloxone hcl injection solution 1 mg/ml 1

Agentes Para Sesación De Fumar


62



CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG


CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

2 PA

NICOTROL INHALATION INHALER 10 MG

2

NICOTROL NS NASAL SOLUTION 10 MG/ML

2

Disuasores De Alcohol / Medicamentos Para Controlar El Deseo

acamprosate calcium oral tablet delayed release 333 mg

CAMPRAL 1

ANTABUSE ORAL TABLET 250 MG, 500 MG

2

disulfiram oral tablet 250 mg, 500 mg ANTABUSE 1

naltrexone hcl oral tablet 50 mg DEPADE 1

Tratamiento Dependencia De Opioides

buprenorphine hcl sublingual tablet sublingual 8 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg

SUBOXONE 1 PA

naltrexone hcl oral tablet 50 mg DEPADE 1

Agentes Para La Enfermedad Inflamatoria Intestinal

Aminosalicilatos

balsalazide disodium oral capsule 750 mg COLAZAL 1

CANASA SUPPOSITORY 1000 MG 2

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG


DIPENTUM ORAL CAPSULE 250 MG 2 MT


63



mesalamine-cleanser kit 4 gm ROWASA 1

PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG


PENTASA ORAL CAPSULE EXTENDED RELEASE* 500 MG


Glucocorticoides

budesonide er oral capsule extended release 24 hour 3 mg

ENTOCORT EC 4


DERMATOP EXTERNAL CREAM 0.1 %

3


1



1

hydrocortisone enema 100 mg/60ml COLOCORT 1

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

CORTEF 1

methylprednisolone (pak) oral tablet 4 mg MEDROL (PAK) 1


DEPO-MEDROL 1


MEDROL 1


ORAPRED 1


PEDIAPRED 1


1



1


64





Sulfonamidas

sulfasalazine oral tablet 500 mg SULFAZINE 1 MT

sulfazine ec oral tablet delayed release 500 mg

1 MT

Agentes Parael Tratamiento De La Espasticidad

Agentes Parael Tratamiento De La Espasticidad

baclofen oral tablet 10 mg, 20 mg 1


2 PA


4 PA

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

DANTRIUM 1

tizanidine hcl oral tablet 2 mg 1

tizanidine hcl oral tablet 4 mg ZANAFLEX 1

Agentes Parala Enfermedad Metabólica Del Hueso

Agentes Parala Enfermedad Metabólica Del Hueso

alendronate sodium oral solution 70 mg/75ml

1 MT

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

FOSAMAX 1 MT; QL (30 per 30 days)

alendronate sodium oral tablet 35 mg, 70 mg

FOSAMAX 1 MT; QL (4 per 28 days)

calcitonin (salmon) nasal solution 200 unit/act

MIACALCIN 1 MT

calcitriol intravenous* solution 1 mcg/ml CALCIJEX 1 PA

calcitriol oral capsule 0.25 mcg, 0.5 mcg ROCALTROL 1 PA


65



calcitriol oral solution 1 mcg/ml ROCALTROL 1 PA

etidronate disodium oral tablet 200 mg 1

etidronate disodium oral tablet 400 mg DIDRONEL 1

FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML


fortical nasal solution 200 unit/act 1 MT

ibandronate sodium intravenous* solution 3 mg/3ml

BONIVA 1 PA; MT

ibandronate sodium oral tablet 150 mg BONIVA 1 MT; QL (1 per 30 days)

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

2 PA

NATPARA SUBCUTANEOUS* 100 MCG, 25 MCG, 50 MCG, 75 MCG


pamidronate disodium intravenous* solution 30 mg/10ml, 90 mg/10ml

1 PA

PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML

2 PA

risedronate sodium oral tablet 150 mg ACTONEL 1 MT; QL (1 per 30 days)

XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML

4 PA

zoledronic acid intravenous* concentrate 4 mg/5ml

ZOMETA 1 PA

zoledronic acid intravenous* solution 5 mg/100ml

RECLAST 1 PA

ZOMETA INTRAVENOUS* SOLUTION 4 MG/100ML

4 PA

Agentes Pulmonares/ Tracto Respiratorio

Agentes Del Tracto Respiratorios, Otros


66



ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5-25 MCG/INH


ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG

4 PA; LA

TYZINE NASAL SOLUTION 0.05 % 2

Agentes Para Fibrosis Cística

ORKAMBI ORAL TABLET 200-125 MG


PULMOZYME INHALATION SOLUTION 1 MG/ML

4 PA

Agentes Pulmonares/ Tracto Respiratorio

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT


ESBRIET ORAL CAPSULE 267 MG 4 PA; QL (270 per 30 days)

PULMOZYME INHALATION SOLUTION 1 MG/ML

4 PA

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG


Antihipertensivos Pulmonares

ADCIRCA ORAL TABLET 20 MG 4 PA; MT; QL (60 per 30 days)

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG



67



LETAIRIS ORAL TABLET 10 MG, 5 MG


OPSUMIT ORAL TABLET 10 MG 4 PA; QL (30 per 30 days)

REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

4 PA; LA

sildenafil citrate oral tablet 20 mg REVATIO 1 PA; MT; QL (90 per 30 days)

TRACLEER ORAL TABLET 125 MG, 62.5 MG


Antihistaminas

azelastine hcl nasal solution 0.1 % ASTELIN 1 QL (30 per 25 days)

azelastine hcl nasal solution 0.15 % ASTEPRO 1 QL (60 per 30 days)

cyproheptadine hcl oral syrup 2 mg/5ml 1 PA

cyproheptadine hcl oral tablet 4 mg 1 PA

desloratadine oral tablet 5 mg CLARINEX 1 QL (30 per 30 days)

desloratadine oral tablet dispersible 2.5 mg, 5 mg

CLARINEX REDITABS 1 QL (30 per 30 days)


1

levocetirizine dihydrochloride oral tablet 5 mg

XYZAL 1 QL (30 per 30 days)

Antiinflamatorios, Corticoesteroides Inhalados





budesonide nasal suspension 32 mcg/act RHINOCORT AQUA 1


68



flunisolide nasal solution 25 mcg/act (0.025%)

1


CUTIVATE 1

fluticasone propionate nasal suspension 50 mcg/act

FLONASE 1 QL (16 per 30 days)

QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT


QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT


Antileucotrienos

montelukast sodium oral packet 4 mg SINGULAIR 1 QL (30 per 30 days)

montelukast sodium oral tablet 10 mg SINGULAIR 1 QL (30 per 30 days)

montelukast sodium oral tablet chewable 4 mg, 5 mg

SINGULAIR 1 QL (30 per 30 days)

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR* 600 MG

2 PA

ZYFLO ORAL TABLET 600 MG 2 PA

Broncodilatadores, Anticolonérgicos

ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT


INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH


ipratropium bromide nasal solution 0.03 %

ATROVENT 1 QL (30 per 30 days)

ipratropium bromide nasal solution 0.06 %

ATROVENT 1 QL (15 per 30 days)

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG


SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 2.5 MCG/ACT


Broncodilatadores, Simpatómimeticos


69







albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8 mg

VOSPIRE ER 1 MT

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

1 PA; MT

albuterol sulfate oral syrup 2 mg/5ml 1 MT

albuterol sulfate oral tablet 2 mg, 4 mg 1 MT

BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-25 MCG/INH


BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 200-25 MCG/INH


DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT


epinephrine injection 0.3 mg/0.3ml EPIPEN 2-PAK 1 QL (4 per 2 days)

EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML

2 QL (4 per 2 days)

EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML

2 QL (4 per 2 days)

FORADIL AEROLIZER INHALATION CAPSULE 12 MCG


metaproterenol sulfate oral syrup 10 mg/5ml

1 MT

metaproterenol sulfate oral tablet 10 mg, 20 mg

1 MT


70



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 injection solution 1 mg/ml

1

terbutaline sulfate oral tablet 2.5 mg, 5 mg

1 MT

XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT


Estabilizadores De Mastocitos

cromolyn sodium inhalation nebulization solution 20 mg/2ml

1 PA; MT

cromolyn sodium oral concentrate 100 mg/5ml

GASTROCROM 1

Inhibidores De Fósfodiesterasa, Enfermedad De Las Vías Respiratorias

aminophylline intravenous* solution 25 mg/ml

1

DALIRESP ORAL TABLET 500 MCG 2 MT

theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg

THEOCHRON 1

theophylline er oral tablet extended release 12 hr* 450 mg

1


71



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

1

theophylline oral solution 80 mg/15ml 1 MT

Analgésicos

Analgésicos

acetaminophen-codeine #2 oral tablet 300-15 mg



TYLENOL WITH CODEINE #3



TYLENOL WITH CODEINE #4


acetaminophen-codeine oral solution 120-12 mg/5ml

1

ascomp-codeine oral capsule 50-325-40-30 mg

1 PA

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

FIORICET/CODEINE 1 PA; QL (180 per 30 days)

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

HYCET 1

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

XODOL 1 QL (180 per 30 days)

hydrocodone-acetaminophen oral tablet 10-325 mg

NORCO 1 QL (180 per 30 days)

hydrocodone-acetaminophen oral tablet 2.5-325 mg

VERDROCET 1

hydrocodone-acetaminophen oral tablet 5-300 mg

VICODIN 1 QL (180 per 30 days)

hydrocodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg

LORTAB 1 QL (180 per 30 days)

hydrocodone-ibuprofen oral tablet 7.5-200 mg

VICOPROFEN 1 QL (120 per 30 days)


72



oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

PERCOCET 1 QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 2.5-325 mg

ENDOCET 1 QL (180 per 30 days)

oxycodone-aspirin oral tablet 4.8355-325 mg

ENDODAN 1

tramadol-acetaminophen oral tablet 37.5-325 mg

ULTRACET 1 QL (40 per 5 days)

vicodin es oral tablet 7.5-300 mg 1 QL (180 per 30 days)

vicodin hp oral tablet 10-300 mg 1 QL (180 per 30 days)

vicodin oral tablet 5-300 mg 1 QL (180 per 30 days)

Analgésicos Opioides, Corta Duración

butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml

1

butorphanol tartrate nasal solution 10 mg/ml

1 QL (5 per 3 days)

DEMEROL INJECTION SOLUTION 50 MG/ML

2 PA

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

ACTIQ 4 PA; QL (120 per 30 days)

fentanyl transdermal patch 72 hr 100 mcg/hr

DURAGESIC-100 1 PA; QL (10 per 30 days)









hydrocodone-acetaminophen oral tablet 2.5-325 mg

VERDROCET 1


73



hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg

DILAUDID 1

hydromorphone hcl pf injection solution 500 mg/50ml

DILAUDID-HP 1

meperidine hcl injection solution 100 mg/ml, 25 mg/ml

DEMEROL 1 PA

morphine sulfate (pf) intravenous* solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

1 PA

oxycodone hcl oral capsule 5 mg 1

oxycodone hcl oral concentrate 100 mg/5ml

1

oxycodone hcl oral solution 5 mg/5ml 1

oxycodone hcl oral tablet 10 mg, 20 mg 1

oxycodone hcl oral tablet 15 mg, 30 mg, 5 mg

ROXICODONE 1

oxymorphone hcl oral tablet 10 mg, 5 mg OPANA 1

tramadol hcl oral tablet 50 mg ULTRAM 1 QL (240 per 30 days)

Analgésicos Opioides, Larga Duración

duramorph injection solution 0.5 mg/ml, 1 mg/ml

ASTRAMORPH 1 PA

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

ACTIQ 4 PA; QL (120 per 30 days)







fentanyl transdermal patch 72 hr 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr





74





levorphanol tartrate oral tablet 2 mg 1

methadone hcl injection solution 10 mg/ml 1 PA

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

1

methadone hcl oral tablet 10 mg, 5 mg DOLOPHINE 1

morphine sulfate (concentrate) oral solution 20 mg/ml

1

morphine sulfate er oral tablet extendedrelease* 100 mg

MS CONTIN 1 QL (90 per 30 days)

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

MS CONTIN 1 QL (90 per 30 days)

morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

1

morphine sulfate oral tablet 15 mg, 30 mg 1

Antiinflamatorios No-Esteroidales

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

CELEBREX 1 PA; MT; QL (60 per 30 days)

diclofenac potassium oral tablet 50 mg CATAFLAM 1

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

VOLTAREN-XR 1

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

1

diflunisal oral tablet 500 mg 1

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

1

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1

fenoprofen calcium oral tablet 600 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1

ibuprofen oral suspension 100 mg/5ml CHILDRENS ADVIL 1


75



ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

ketoprofen er oral capsule extended release 24 hour 200 mg

1

ketoprofen oral capsule 50 mg, 75 mg 1

meclofenamate sodium oral capsule 100 mg, 50 mg

1

mefenamic acid oral capsule 250 mg PONSTEL 1

meloxicam oral tablet 15 mg, 7.5 mg MOBIC 1 QL (30 per 30 days)

nabumetone oral tablet 500 mg, 750 mg 1

naproxen dr oral tablet delayed release 375 mg, 500 mg

EC-NAPROSYN 1

naproxen oral suspension 125 mg/5ml NAPROSYN 1

naproxen oral tablet 250 mg, 375 mg, 500 mg

NAPROSYN 1

naproxen sodium oral tablet 275 mg ANAPROX 1

naproxen sodium oral tablet 550 mg ANAPROX DS 1

oxaprozin oral tablet 600 mg DAYPRO 1

oxycodone-ibuprofen oral tablet 5-400 mg 1 QL (120 per 30 days)

piroxicam oral capsule 10 mg, 20 mg FELDENE 1

sulindac oral tablet 150 mg 1

sulindac oral tablet 200 mg CLINORIL 1

tolmetin sodium oral capsule 400 mg 1

tolmetin sodium oral tablet 600 mg 1

VOLTAREN TRANSDERMAL 1 % 2

Anestésicos

Anestésicos Locales

lidocaine external ointment 5 % 1

lidocaine external patch 5 % LIDODERM 1 PA

lidocaine hcl (pf) injection solution 0.5 % XYLOCAINE-MPF 1 PA

lidocaine hcl external 2 % GLYDO 1


76



lidocaine hcl external solution 4 % XYLOCAINE 1

lidocaine hcl injection solution 2 % XYLOCAINE 1

lidocaine viscous mouth/throat solution 2 %

1

lidocaine-prilocaine external cream 2.5-2.5 %

RELADOR PAK 1 PA

Ansiolíticos

Anxiolíticos, Otros

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

1

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

1 PA; MT


SILENOR ORAL TABLET 3 MG, 6 MG 3 ST; QL (30 per 30 days)

Benzodiazepinas

alprazolam er oral tablet extended release 24 hr* 0.5 mg, 1 mg, 2 mg, 3 mg

XANAX XR 1 QL (120 per 30 days)

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

XANAX 1

alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

NIRAVAM 1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KLONOPIN 1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

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

TRANXENE-T 1

diazepam oral solution 1 mg/ml 1

diazepam oral tablet 10 mg, 2 mg, 5 mg VALIUM 1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg ATIVAN 1

Ssris / Snris


CYMBALTA 1 MT


77



escitalopram oxalate oral solution 5 mg/5ml

LEXAPRO 1 MT

escitalopram oxalate oral tablet 10 mg LEXAPRO 1 MT; QL (60 per 30 days)



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

PAXIL CR 1 MT

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

PAXIL 1 MT

PAXIL ORAL SUSPENSION 10 MG/5ML

2 ST; MT

sertraline hcl oral concentrate 20 mg/ml ZOLOFT 1 MT

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

ZOLOFT 1 MT

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

EFFEXOR XR 1 MT

venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 37.5 mg, 75 mg

1 MT

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

1 MT

Antibióticos

Aminoglicósidos

gentak ophthalmic ointment 0.3 % 1

gentamicin sulfate external cream 0.1 % 1

gentamicin sulfate external ointment 0.1 %

1

gentamicin sulfate injection solution 40 mg/ml

1

gentamicin sulfate intravenous* solution 10 mg/ml

1


78



gentamicin sulfate ophthalmic ointment 0.3 %

GENTAK 1

gentamicin sulfate ophthalmic solution 0.3 %

GARAMYCIN 1

neomycin sulfate oral tablet 500 mg 1

neomycin-polymyxin b gu irrigation solution 40-200000

NEOSPORIN GU IRRIGANT

1

paromomycin sulfate oral capsule 250 mg 1

STREPTOMYCIN SULFATE INTRAMUSCULAR* SOLUTION RECONSTITUTED 1 GM

2

tobramycin inhalation nebulization solution 300 mg/5ml

KITABIS PAK 4 PA; QL (280 per 28 days)

tobramycin ophthalmic solution 0.3 % TOBREX 1

tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml

1 PA

Antibacteriales, Otros

acetic acid otic solution 2 % VOSOL 1

alcohol pads pad 70 % RELION ALCOHOL

SWABS 1 QL (100 per 30 days)

baciim intramuscular* solution reconstituted 50000 unit

1

bacitracin intramuscular* solution reconstituted 50000 unit

1

bacitracin ophthalmic ointment 500 unit/gm

1

chloramphenicol sod succinate intravenous* solution reconstituted 1 gm

1 PA

clindamax external 1 % 1

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

CLEOCIN 1

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

CLEOCIN 1

clindamycin phosphate external 1 % CLINDAGEL 1


79



clindamycin phosphate external foam 1 % EVOCLIN 1

clindamycin phosphate external lotion 1 %

CLINDAMAX 1

clindamycin phosphate external solution 1 %

CLEOCIN-T 1

clindamycin phosphate external swab 1 % CLINDACIN-P 1

clindamycin phosphate intravenous* solution 600 mg/4ml

CLEOCIN PHOSPHATE 1 PA

clindamycin phosphate vaginal cream 2 % CLEOCIN 1

CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

4 PA

linezolid intravenous* solution 2 mg/ml ZYVOX 4

linezolid oral tablet 600 mg ZYVOX 4 PA

methenamine hippurate oral tablet 1 gm UREX 1

metronidazole external 0.75 % ROSADAN 1

metronidazole external 1 % METROGEL 1

metronidazole external cream 0.75 % METROCREAM 1

metronidazole external lotion 0.75 % METROLOTION 1

metronidazole in nacl intravenous* solution 500-0.79 mg/100ml-%

1

metronidazole oral tablet 250 mg, 500 mg FLAGYL 1

metronidazole vaginal 0.75 % METROGEL-VAGINAL 1

mupirocin calcium external cream 2 % BACTROBAN 1

mupirocin external ointment 2 % CENTANY 1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

MACRODANTIN 1

nitrofurantoin monohyd macro oral capsule 100 mg

MACROBID 1

nitrofurantoin oral suspension 25 mg/5ml FURADANTIN 1

polymyxin b sulfate injection solution reconstituted 500000 unit

1


80



SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 200 MG


SIVEXTRO ORAL TABLET 200 MG 4 PA; QL (6 per 6 days)

trimethoprim oral tablet 100 mg 1

TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

2 PA

vancomycin hcl intravenous* solution reconstituted 1000 mg

1 PA

vancomycin hcl oral capsule 125 mg, 250 mg

VANCOCIN HCL 4

vandazole vaginal 0.75 % 1

ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

4 PA

ZYVOX ORAL TABLET 600 MG 4 PA

Antibióticos

colistimethate sodium injection solution reconstituted 150 mg

COLY-MYCIN M 1 PA

SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED 150-350 MG

4 PA

Betalactámico, Cefalosporina

cefaclor er oral tablet extended release 12 hr* 500 mg

1

cefaclor oral capsule 250 mg, 500 mg 1

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

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

1

cefdinir oral capsule 300 mg 1


81



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

1

cefepime hcl injection solution reconstituted 1 gm, 2 gm

MAXIPIME 1

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

SUPRAX 1

cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm

1 PA

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

ceftriaxone sodium injection solution reconstituted 250 mg

1 PA

ceftriaxone sodium injection solution reconstituted 500 mg

ROCEPHIN 1 PA

ceftriaxone sodium intravenous* solution reconstituted 1 gm

1 PA

cefuroxime axetil oral tablet 250 mg, 500 mg

CEFTIN 1

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

ZINACEF 1 PA

cephalexin oral capsule 250 mg, 500 mg KEFLEX 1

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

1

cephalexin oral tablet 250 mg, 500 mg 1

SUPRAX ORAL CAPSULE 400 MG 2

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

2


82



SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

2

TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG

3 PA

Betalactámico, Otros

AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 2 GM

4 PA

aztreonam injection solution reconstituted 1 gm

AZACTAM 1

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

PRIMAXIN IV 1 PA

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

2 PA

meropenem intravenous* solution reconstituted 500 mg

MERREM 1 PA

Betalactámico, Penicilinas

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 oral tablet chewable 125 mg, 250 mg

1

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

AUGMENTIN XR 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

AUGMENTIN 1


83



amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml

AUGMENTIN ES-600 1

amoxicillin-pot clavulanate oral tablet 250-125 mg

1

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

AUGMENTIN 1

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg

AUGMENTIN 1

amoxicillin-pot clavulanate oral tablet chewable 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

1 PA

ampicillin sodium intravenous* solution reconstituted 10 gm

1 PA

ampicillin-sulbactam sodium injection solution reconstituted 3 (2-1) gm

UNASYN 1 PA

ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm

1 PA

bactocill in dextrose intravenous* solution 1 gm/50ml

1

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

2

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

2

dicloxacillin sodium oral capsule 250 mg, 500 mg

1

nafcillin sodium injection solution reconstituted 1 gm

1 PA

oxacillin sodium injection solution reconstituted 2 gm

1


84



penicillin g potassium injection solution reconstituted 5000000 unit

PFIZERPEN-G 1

penicillin g procaine intramuscular* suspension 600000 unit/ml

1

penicillin g sodium injection solution reconstituted 5000000 unit

1

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 3-0.375 gm, 4-0.5 gm

ZOSYN 1

Macrólidos

AZASITE OPHTHALMIC SOLUTION 1 %

3

azithromycin intravenous* solution reconstituted 500 mg

ZITHROMAX 1

azithromycin oral packet 1 gm ZITHROMAX 1 QL (1 per 30 days)

azithromycin oral suspension reconstituted 100 mg/5ml

ZITHROMAX 1 QL (75 per 5 days)

azithromycin oral suspension reconstituted 200 mg/5ml

ZITHROMAX 1 QL (68 per 5 days)

azithromycin oral tablet 250 mg ZITHROMAX 1 QL (8 per 7 days)

azithromycin oral tablet 250 mg ZITHROMAX 1 QL (6 per 5 days)

azithromycin oral tablet 500 mg ZITHROMAX TRI-PAK 1 QL (4 per 4 days)

azithromycin oral tablet 600 mg ZITHROMAX 1

clarithromycin er oral tablet extended release 24 hr* 500 mg

BIAXIN XL 1

clarithromycin oral suspension reconstituted 125 mg/5ml

1

clarithromycin oral suspension reconstituted 250 mg/5ml

BIAXIN 1

clarithromycin oral tablet 250 mg, 500 mg BIAXIN 1


85



ery external pad 2 % 1

ERYTHROCIN LACTOBIONATE INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

3 PA

erythrocin stearate oral tablet 250 mg 1

erythromycin base oral tablet 250 mg, 500 mg

1

erythromycin ethylsuccinate oral tablet 400 mg

E.E.S. 400 1

erythromycin external 2 % ERYGEL 1

erythromycin external solution 2 % 1

erythromycin ophthalmic ointment 5 mg/gm

ILOTYCIN 1

Quinolonas

AVELOX ABC PACK ORAL TABLET 400 MG

2

ciprofloxacin hcl ophthalmic solution 0.3 %

CILOXAN 1

ciprofloxacin hcl oral tablet 100 mg 1

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

CIPRO 1

ciprofloxacin in d5w intravenous* solution 200 mg/100ml

CIPRO IN D5W 1

ciprofloxacin intravenous* solution 400 mg/40ml

1

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

CIPRO 1

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg, 500 mg

CIPRO XR 1

gatifloxacin ophthalmic solution 0.5 % ZYMAXID 1

levofloxacin in d5w intravenous* solution 500 mg/100ml

LEVAQUIN 1


86



levofloxacin intravenous* solution 25 mg/ml

1

levofloxacin ophthalmic solution 0.5 % 1

levofloxacin oral solution 25 mg/ml LEVAQUIN 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

LEVAQUIN 1

moxifloxacin hcl oral tablet 400 mg AVELOX 1 QL (21 per 21 days)

ofloxacin ophthalmic solution 0.3 % OCUFLOX 1

ofloxacin oral tablet 400 mg 1

ofloxacin otic solution 0.3 % 1

VIGAMOX OPHTHALMIC SOLUTION 0.5 %

3

Sulfonamidas

silver sulfadiazine external cream 1 % THERMAZENE 1

ssd external cream 1 % 1

sulfacetamide sodium external suspension 10 %

KLARON 1


1

sulfacetamide sodium ophthalmic solution 10 %

BLEPH-10 1

sulfadiazine oral tablet 500 mg 1

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

1

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

SULFATRIM PEDIATRIC

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

BACTRIM 1

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

BACTRIM DS 1

Tetraciclinas

demeclocycline hcl oral tablet 150 mg, 300 mg

1


87



doxycycline hyclate intravenous* solution reconstituted 100 mg

DOXY 100 1 PA

doxycycline hyclate oral capsule 100 mg VIBRAMYCIN 1


doxycycline hyclate oral tablet 100 mg, 20 mg

1

doxycycline hyclate oral tablet delayed release 100 mg, 75 mg

1

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

VIBRAMYCIN 1

doxycycline monohydrate oral tablet 150 mg

ADOXA PAK 1/150 1


ADOXA 1

minocycline hcl er oral tablet extended release 24 hr* 135 mg, 45 mg, 90 mg

SOLODYN 1

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

MINOCIN 1

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg

DYNACIN 1

Anticonvulsivos

Agentes De Aumento De Ácido Gamma-Aminobutírico (Gaba)

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KLONOPIN 1

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

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

TRANXENE-T 1

diazepam oral solution 1 mg/ml 1

diazepam oral tablet 10 mg, 2 mg, 5 mg VALIUM 1


DEPAKOTE ER 1 MT


DEPAKOTE SPRINKLES

1 MT


88




DEPAKOTE 1 MT

gabapentin oral capsule 100 mg, 300 mg, 400 mg

NEURONTIN 1 MT

gabapentin oral solution 250 mg/5ml NEURONTIN 1 MT

gabapentin oral tablet 600 mg, 800 mg NEURONTIN 1 MT

lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg

LAMICTAL ODT 1 MT

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg ATIVAN 1

ONFI ORAL SUSPENSION 2.5 MG/ML 2

ONFI ORAL TABLET 10 MG, 20 MG 2

phenobarbital oral elixir 20 mg/5ml 1 PA

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

1 PA

primidone oral tablet 250 mg, 50 mg MYSOLINE 1 MT

SABRIL ORAL PACKET 500 MG 4 PA; MT; LA

SABRIL ORAL TABLET 500 MG 4 PA; MT; LA

tiagabine hcl oral tablet 2 mg, 4 mg GABITRIL 1 MT

valproate sodium intravenous* solution 500 mg/5ml

DEPACON 1



Agentes De Canales De Sodio

APTIOM ORAL TABLET 200 MG 3 PA; MT; QL (30 per 30 days)

APTIOM ORAL TABLET 400 MG, 800 MG


APTIOM ORAL TABLET 600 MG 4 PA; MT; QL (60 per 30 days)

BANZEL ORAL SUSPENSION 40 MG/ML

2 PA; MT

BANZEL ORAL TABLET 200 MG 2 PA; MT


89



BANZEL ORAL TABLET 400 MG 4 PA; MT

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

TEGRETOL-XR 1 MT

carbamazepine oral suspension 100 mg/5ml

TEGRETOL 1 MT

carbamazepine oral tablet 200 mg TEGRETOL 1 MT

carbamazepine oral tablet chewable 100 mg

1 MT

DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG

2 MT

DILANTIN ORAL CAPSULE 100 MG 2 MT

DILANTIN ORAL CAPSULE 30 MG 2 MT

DILANTIN ORAL SUSPENSION 125 MG/5ML

2 MT

epitol oral tablet 200 mg 1 MT

fosphenytoin sodium injection solution 100 mg pe/2ml

CEREBYX 1 PA

oxcarbazepine oral suspension 300 mg/5ml

TRILEPTAL 1 MT

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

TRILEPTAL 1 MT

PEGANONE ORAL TABLET 250 MG 2 MT

phenytoin oral suspension 125 mg/5ml DILANTIN 1 MT

phenytoin oral tablet chewable 50 mg DILANTIN INFATABS 1 MT

phenytoin sodium extended oral capsule 100 mg

DILANTIN 1 MT

phenytoin sodium injection solution 50 mg/ml

1

TEGRETOL ORAL SUSPENSION 100 MG/5ML

2 MT

TEGRETOL ORAL TABLET 200 MG 2 MT


2 MT


90




2 MT


2 MT

TRILEPTAL ORAL SUSPENSION 300 MG/5ML

2 MT

VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML

2

VIMPAT ORAL SOLUTION 10 MG/ML 2 MT

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

2 MT

Agentes Modificadores De Canales De Calcio

CELONTIN ORAL CAPSULE 300 MG 2 MT

ethosuximide oral capsule 250 mg ZARONTIN 1 MT

ethosuximide oral solution 250 mg/5ml ZARONTIN 1 MT

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

2 PA; MT

LYRICA ORAL SOLUTION 20 MG/ML 2 PA; MT

zonisamide oral capsule 100 mg, 25 mg ZONEGRAN 1 MT

zonisamide oral capsule 50 mg 1 MT

Agentes Reductores De Glutamato

felbamate oral suspension 600 mg/5ml FELBATOL 1 MT

felbamate oral tablet 400 mg, 600 mg FELBATOL 1 MT

FELBATOL ORAL SUSPENSION 600 MG/5ML

2 MT

FELBATOL ORAL TABLET 400 MG, 600 MG

2 MT

FYCOMPA ORAL TABLET 10 MG, 12 MG

3 PA; MT

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG, 8 MG

3 PA


91



lamotrigine er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

LAMICTAL XR 1 MT

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

LAMICTAL 1 MT

lamotrigine oral tablet chewable 25 mg, 5 mg

LAMICTAL 1 MT

topiramate er oral 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

QUDEXY XR 1 MT

topiramate oral capsule sprinkle 15 mg, 25 mg

TOPAMAX SPRINKLE 1 MT

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

TOPAMAX 1 MT

Anticonvulsivos, Otros

diazepam 10 mg, 20 mg DIASTAT ACUDIAL 1

diazepam 2.5 mg DIASTAT PEDIATRIC 1

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

KEPPRA XR 1 MT

levetiracetam in nacl intravenous* solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

1 MT

levetiracetam intravenous* solution 500 mg/5ml

KEPPRA 1

levetiracetam oral solution 100 mg/ml KEPPRA 1 MT

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

KEPPRA 1 MT

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

2 MT

Antidepresivos

Antidepresivos

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg

SYMBYAX 1 MT


92



perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1 PA; MT

Antidepresivos, Otros

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG

4 ST


4 ST; MT

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG

2 ST

ABILIFY ORAL TABLET 20 MG, 30 MG

4 ST

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

ABILIFY 1 MT

buproban oral tablet extended release 12 hr* 150 mg

1

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

WELLBUTRIN SR 1 MT

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

BUDEPRION SR 1 MT

bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg

WELLBUTRIN XL 1 MT

bupropion hcl oral tablet 100 mg, 75 mg WELLBUTRIN 1 MT

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

1 MT

mirtazapine oral tablet 15 mg, 30 mg, 45 mg

REMERON 1 MT

mirtazapine oral tablet 7.5 mg 1 MT

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

REMERON SOLTAB 1 MT

nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1 MT


93



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

1 MT

Inhibidores De Monoamino Oxidasa

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

2 MT

MARPLAN ORAL TABLET 10 MG 2 MT

NARDIL ORAL TABLET 15 MG 2 MT

phenelzine sulfate oral tablet 15 mg NARDIL 1 MT

tranylcypromine sulfate oral tablet 10 mg PARNATE 1 MT

Ssris / Snris

BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG

3 ST; MT

citalopram hydrobromide oral solution 10 mg/5ml

1 MT

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

CELEXA 1 MT

desvenlafaxine er oral tablet extended release 24 hr* 100 mg, 50 mg

KHEDEZLA 1


CYMBALTA 1 MT

escitalopram oxalate oral solution 5 mg/5ml

LEXAPRO 1 MT




FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG

3 ST; MT

FETZIMA TITRATION ORAL 20 & 40 MG

3 ST


94



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

PROZAC 1 MT

fluoxetine hcl oral capsule delayed release 90 mg

PROZAC WEEKLY 1 MT; QL (4 per 28 days)

fluoxetine hcl oral solution 20 mg/5ml 1 MT

fluoxetine hcl oral tablet 10 mg, 20 mg 1 MT

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg

LUVOX CR 1 MT

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

1 MT

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

PAXIL CR 1 MT

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

PAXIL 1 MT

PAXIL ORAL SUSPENSION 10 MG/5ML

2 ST; MT

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 25 MG, 50 MG

2 ST; MT

sertraline hcl oral concentrate 20 mg/ml ZOLOFT 1 MT

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

ZOLOFT 1 MT

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

EFFEXOR XR 1 MT

venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 37.5 mg, 75 mg

1 MT

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

1 MT

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

2 ST; MT

Tricíclicos

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

1 PA; MT


95



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

1 MT

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

ANAFRANIL 1 PA; MT

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

NORPRAMIN 1 MT

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

1 PA; MT


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

TOFRANIL 1 PA; MT

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

TOFRANIL-PM 1 PA; MT

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

PAMELOR 1 MT

nortriptyline hcl oral solution 10 mg/5ml 1 MT

protriptyline hcl oral tablet 10 mg, 5 mg VIVACTIL 1 MT

SILENOR ORAL TABLET 3 MG, 6 MG 3 ST; QL (30 per 30 days)

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

3 PA

Antieméticos

Antiemético, Otros

chlorpromazine hcl injection solution 25 mg/ml

1

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

1 MT

compro suppository 25 mg 1


1

meclizine hcl oral tablet 12.5 mg ANTIVERT 1

meclizine hcl oral tablet 25 mg DRAMAMINE LESS

DROWSY 1


96



metoclopramide hcl injection solution 5 mg/ml

1

metoclopramide hcl oral solution 5 mg/5ml

1

metoclopramide hcl oral tablet 10 mg, 5 mg

REGLAN 1

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

1 MT

prochlorperazine edisylate injection solution 5 mg/ml

1

prochlorperazine maleate oral tablet 10 mg, 5 mg

COMPAZINE 1 MT

prochlorperazine suppository 25 mg COMPRO 1

TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1 MG/3DAYS

3

Terapia Adyuvante Emetogénica

dronabinol oral capsule 10 mg MARINOL 4 PA; QL (60 per 30 days)

dronabinol oral capsule 2.5 mg, 5 mg MARINOL 1 PA

EMEND ORAL CAPSULE 125 MG, 40 MG

2 PA; QL (1 per 1 day)

EMEND ORAL CAPSULE 80 & 125 MG 2 PA; QL (3 per 3 days)

EMEND ORAL CAPSULE 80 MG 2 PA; QL (2 per 2 days)

granisetron hcl oral tablet 1 mg 1 PA; QL (2 per 1 day)

ondansetron hcl injection solution 4 mg/2ml

1 PA

ondansetron hcl oral solution 4 mg/5ml ZOFRAN 1 PA; QL (150 per 5 days)

ondansetron hcl oral tablet 24 mg 1 PA; QL (1 per 1 day)

ondansetron hcl oral tablet 4 mg, 8 mg ZOFRAN 1 PA; QL (12 per 5 days)

ondansetron oral tablet dispersible 4 mg, 8 mg

ZOFRAN ODT 1 PA; QL (12 per 5 days)

Antifungales


97



Antifungales

ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML

4 PA

AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG

4 PA

amphotericin b injection solution reconstituted 50 mg

1 PA

CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG

4 PA

ciclopirox external 0.77 % LOPROX 1

ciclopirox external solution 8 % PENLAC 1

ciclopirox olamine external cream 0.77 % CICLODAN 1

ciclopirox olamine external suspension 0.77 %

1

clotrimazole external cream 1 % LOTRIMIN AF FOR

HER 1

clotrimazole external solution 1 % FUNGICURE

INTENSIVE/NAILGUARD

1

clotrimazole mouth/throat troche 10 mg 1

econazole nitrate external cream 1 % 1

ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

2 PA

EXELDERM EXTERNAL CREAM 1 % 3

fluconazole in dextrose intravenous* solution 400 mg/200ml

1 PA

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

DIFLUCAN 1

fluconazole oral tablet 100 mg, 200 mg, 50 mg

DIFLUCAN 1

fluconazole oral tablet 150 mg DIFLUCAN 1 QL (2 per 7 days)

flucytosine oral capsule 250 mg, 500 mg ANCOBON 4


98



griseofulvin microsize oral suspension 125 mg/5ml

1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

GRIS-PEG 1

itraconazole oral capsule 100 mg SPORANOX PULSEPAK


ketoconazole external cream 2 % 1

ketoconazole external shampoo 2 % NIZORAL 1

ketoconazole oral tablet 200 mg 1

miconazole 3 vaginal suppository 200 mg 1 QL (3 per 3 days)

MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

4 PA

MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

2 PA

NATACYN OPHTHALMIC SUSPENSION 5 %

2

NOXAFIL ORAL SUSPENSION 40 MG/ML

4

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

4

nyamyc external powder 100000 unit/gm 1

nystatin external cream 100000 unit/gm 1

nystatin external ointment 100000 unit/gm 1

nystatin external powder 100000 unit/gm NYSTOP 1

nystatin mouth/throat suspension 100000 unit/ml

1

nystatin oral tablet 500000 unit 1

nystop external powder 100000 unit/gm 1

terbinafine hcl oral tablet 250 mg LAMISIL 1

terconazole vaginal cream 0.4 % TERAZOL 7 1 QL (45 per 7 days)

terconazole vaginal cream 0.8 % TERAZOL 3 1

terconazole vaginal suppository 80 mg 1 QL (3 per 3 days)


99



VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML

4

voriconazole intravenous* solution reconstituted 200 mg

VFEND IV 1

voriconazole oral tablet 200 mg, 50 mg VFEND 4

ZOLINZA ORAL CAPSULE 100 MG 4 PA

Antimicobacteriales

Antimicobacteriales, Otros

DAPSONE ORAL TABLET 100 MG, 25 MG

2

rifabutin oral capsule 150 mg MYCOBUTIN 1

Antituberculares

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

2

ethambutol hcl oral tablet 100 mg, 400 mg MYAMBUTOL 1

isoniazid injection solution 100 mg/ml 1

isoniazid oral syrup 50 mg/5ml 1

isoniazid oral tablet 100 mg, 300 mg 1

PASER ORAL PACKET 4 GM 2

pyrazinamide oral tablet 500 mg 1

rifampin intravenous* solution reconstituted 600 mg

RIFADIN 1

rifampin oral capsule 150 mg, 300 mg RIFADIN 1

TRECATOR ORAL TABLET 250 MG 2

Antineoplásicos

Agentes Alquilantes

cyclophosphamide oral capsule 25 mg, 50 mg

1 PA; MT

HEXALEN ORAL CAPSULE 50 MG 4 PA

LEUKERAN ORAL TABLET 2 MG 2

lomustine oral capsule 10 mg, 100 mg, 40 mg

CEENU 1


100



MATULANE ORAL CAPSULE 50 MG 4 PA

thiotepa injection solution reconstituted 15 mg

4 PA

TREANDA INTRAVENOUS* SOLUTION 45 MG/0.5ML

4 PA

VALCHLOR EXTERNAL 0.016 % 4 PA

Agentes Antiangiogénicos

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

4 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

4 PA; LA

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

4 PA

Antiandrógenos

bicalutamide oral tablet 50 mg CASODEX 1

flutamide oral capsule 125 mg 1

NILANDRON ORAL TABLET 150 MG 2

XTANDI ORAL CAPSULE 40 MG 4 QL (120 per 30 days)

ZYTIGA ORAL TABLET 250 MG 4 PA

Anticuerpos Monoclonales

ARZERRA INTRAVENOUS* CONCENTRATE 100 MG/5ML

4 PA

CYRAMZA INTRAVENOUS* SOLUTION 100 MG/10ML, 500 MG/50ML

4 PA

KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/4ML

4 PA

KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

4 PA

OPDIVO INTRAVENOUS* SOLUTION 40 MG/4ML

4 PA

RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML

4 PA


101



SYLVANT INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG

4 PA

Antimetabolitos

hydroxyurea oral capsule 500 mg HYDREA 1

PURIXAN ORAL SUSPENSION 2000 MG/100ML

3

TABLOID ORAL TABLET 40 MG 2

Antineoplásicos

ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML

3 PA

ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

4 PA

AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML

2 PA

AVASTIN INTRAVENOUS* SOLUTION 400 MG/16ML

4 PA

azacitidine injection suspension reconstituted 100 mg

VIDAZA 4 PA

BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

4 PA

DAUNOXOME INTRAVENOUS* INJECTABLE 2 MG/ML

3 PA

decitabine intravenous* solution reconstituted 50 mg

DACOGEN 4 PA

ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG

4 PA

ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT

4 PA

FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML

4 PA

HALAVEN INTRAVENOUS* SOLUTION 1 MG/2ML

4 PA


102



levoleucovorin calcium intravenous* solution 175 mg/17.5ml

1

LYNPARZA ORAL CAPSULE 50 MG 4 PA

mesna intravenous* solution 100 mg/ml MESNEX 1 PA

PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED 22000000 UNIT

4 PA

TREANDA INTRAVENOUS* SOLUTION 45 MG/0.5ML

4 PA

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

4 PA

Antineoplásicos, Otros

amifostine intravenous* solution reconstituted 500 mg

ETHYOL 4 PA

leucovorin calcium injection solution reconstituted 100 mg, 350 mg

1 PA

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

1

mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml

1 PA

ONCASPAR INJECTION SOLUTION 750 UNIT/ML

4 PA

REVLIMID ORAL CAPSULE 2.5 MG, 20 MG

4 PA; LA

SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG

4 PA

ZALTRAP INTRAVENOUS* SOLUTION 100 MG/4ML

4 PA

Inhibidores Aromatasa, Tercera Generación

anastrozole oral tablet 1 mg ARIMIDEX 1 MT

exemestane oral tablet 25 mg AROMASIN 1 MT

letrozole oral tablet 2.5 mg FEMARA 1 MT

Inhibidores De Enzimas


103



FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG


IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


ZOLINZA ORAL CAPSULE 100 MG 4 PA

ZYDELIG ORAL TABLET 100 MG, 150 MG


Inhibidores Diana Moleculares

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

4 PA

BOSULIF ORAL TABLET 100 MG 4

BOSULIF ORAL TABLET 500 MG 4 QL (30 per 30 days)

CAPRELSA ORAL TABLET 100 MG, 300 MG

4 LA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

4 PA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

4 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

4 PA

ERIVEDGE ORAL CAPSULE 150 MG 4 PA

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG

4 PA

GLEEVEC ORAL TABLET 100 MG, 400 MG

4 PA

ICLUSIG ORAL TABLET 15 MG 4 PA

ICLUSIG ORAL TABLET 45 MG 4 PA; QL (30 per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 4 PA

INLYTA ORAL TABLET 1 MG, 5 MG 4 PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

4 PA


104



LENVIMA 10 MG DAILY DOSE ORAL 10 MG


LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG


LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG


LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG


MEKINIST ORAL TABLET 0.5 MG, 2 MG

4 PA

NEXAVAR ORAL TABLET 200 MG 4 PA; LA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

4 PA

STIVARGA ORAL TABLET 40 MG 4 PA; QL (120 per 30 days)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

4 PA

TAFINLAR ORAL CAPSULE 50 MG, 75 MG

4 PA

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

4 PA

TASIGNA ORAL CAPSULE 150 MG, 200 MG

4 PA

TYKERB ORAL TABLET 250 MG 4 PA; LA

VOTRIENT ORAL TABLET 200 MG 4 PA

XALKORI ORAL CAPSULE 200 MG, 250 MG

4 PA

ZELBORAF ORAL TABLET 240 MG 4 PA

ZYKADIA ORAL CAPSULE 150 MG 4 PA

Modificadores/Antiestrógenos

EMCYT ORAL CAPSULE 140 MG 2

FARESTON ORAL TABLET 60 MG 2 MT


105



SOLTAMOX ORAL SOLUTION 10 MG/5ML

2 PA; MT

tamoxifen citrate oral tablet 10 mg, 20 mg 1 MT

Retinoides

bexarotene oral capsule 75 mg TARGRETIN 4 PA

PANRETIN EXTERNAL 0.1 % 4 PA

TARGRETIN ORAL CAPSULE 75 MG 4 PA

tretinoin external 0.01 %, 0.025 % RETIN-A 1 PA

tretinoin external cream 0.025 %, 0.05 %, 0.1 %

RETIN-A 1 PA

tretinoin oral capsule 10 mg 4

Antiparasíticos

Antihelminticos

ALBENZA ORAL TABLET 200 MG 2

ivermectin oral tablet 3 mg STROMECTOL 1

Antiprotozoales

ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML

2

ALINIA ORAL TABLET 500 MG 2

atovaquone oral suspension 750 mg/5ml MEPRON 4 PA

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

MALARONE 1

chloroquine phosphate oral tablet 250 mg 1

chloroquine phosphate oral tablet 500 mg ARALEN 1

COARTEM ORAL TABLET 20-120 MG 3 QL (24 per 30 days)

DARAPRIM ORAL TABLET 25 MG 2

hydroxychloroquine sulfate oral tablet 200 mg

PLAQUENIL 1

mefloquine hcl oral tablet 250 mg 1

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

2 PA


106



PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

2 PA

PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG

2

quinine sulfate oral capsule 324 mg QUALAQUIN 1

Pediculicidas / Escabicidas

lindane external lotion 1 % 1

lindane external shampoo 1 % 1

permethrin external cream 5 % ACTICIN 1

Antisicóticos

Primera Generación, Típicos

chlorpromazine hcl injection solution 25 mg/ml

1

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

1 MT

fluphenazine decanoate injection solution 25 mg/ml

1

fluphenazine hcl injection solution 2.5 mg/ml

1

fluphenazine hcl oral concentrate 5 mg/ml 1 MT

fluphenazine hcl oral elixir 2.5 mg/5ml 1 MT

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

1 MT

haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml

HALDOL DECANOATE 1

haloperidol lactate injection solution 5 mg/ml

HALDOL 1

haloperidol lactate oral concentrate 2 mg/ml

1 MT

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1 MT

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

LOXITANE 1 MT


107



ORAP ORAL TABLET 1 MG, 2 MG 2 MT

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

1 MT

prochlorperazine edisylate injection solution 5 mg/ml

1

prochlorperazine maleate oral tablet 10 mg, 5 mg

COMPAZINE 1 MT

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1 PA; MT

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1 PA; MT

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

1 MT

Resistente A Tratamiento

clozapine oral tablet 100 mg, 25 mg CLOZARIL 1

clozapine oral tablet 200 mg, 50 mg 1

clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg

FAZACLO 1

clozapine oral tablet dispersible 150 mg, 200 mg

FAZACLO 1 MT

FAZACLO ORAL TABLET DISPERSIBLE 150 MG, 200 MG

3

VERSACLOZ ORAL SUSPENSION 50 MG/ML

3

Segunda Generación, Atípicos


4 ST

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG

2 ST

ABILIFY ORAL TABLET 20 MG, 30 MG

4 ST

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

2 ST


108



FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG

2 ST

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG

2 ST

INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG, 9 MG

2 ST; MT

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML

4 ST

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 MG/0.25ML, 78 MG/0.5ML

2 ST

LATUDA ORAL TABLET 120 MG 4 ST; MT

LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG, 80 MG

2 ST; MT

olanzapine intramuscular* solution reconstituted 10 mg

ZYPREXA 1

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg

ZYPREXA 1 MT

olanzapine oral tablet 20 mg ZYPREXA 1 MT

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg

ZYPREXA ZYDIS 1 MT

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

SEROQUEL 1 MT

quetiapine fumarate oral tablet 25 mg, 50 mg

SEROQUEL 1 PA; MT

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

4 ST; QL (30 per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 25 MG

2 ST


109



RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG, 50 MG

4 ST

risperidone oral solution 1 mg/ml RISPERDAL 1 MT; QL (480 per 30 days)

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

RISPERDAL 1 MT

risperidone oral tablet dispersible 0.25 mg 1 MT

risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg

RISPERIDONE M-TAB 1 MT

risperidone oral tablet dispersible 3 mg, 4 mg

RISPERDAL M-TAB 1 MT

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG

2 ST; MT

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

GEODON 1 MT

Antivirales

Agentes Anti-Citomegalovirus (Cmv)

ganciclovir sodium intravenous* solution reconstituted 500 mg

CYTOVENE 1 PA

VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML

4

valganciclovir hcl oral tablet 450 mg VALCYTE 4 MT

Agentes Anti-Hepatitis B (Hbv)

adefovir dipivoxil oral tablet 10 mg HEPSERA 4 PA; MT

BARACLUDE ORAL SOLUTION 0.05 MG/ML

2 PA; MT

entecavir oral tablet 0.5 mg, 1 mg BARACLUDE 4 PA; MT

EPIVIR HBV ORAL SOLUTION 5 MG/ML

2 MT

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

2 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

2 PA


110



lamivudine oral solution 10 mg/ml EPIVIR 1 MT

lamivudine oral tablet 100 mg EPIVIR HBV 1 MT

lamivudine oral tablet 150 mg, 300 mg EPIVIR 1 MT

ribasphere oral capsule 200 mg 1 PA

ribasphere oral tablet 200 mg 1 PA


RIBASPHERE ORAL TABLET 600 MG 4 PA

ribavirin oral capsule 200 mg REBETOL 1 PA

ribavirin oral tablet 200 mg MODERIBA 1 PA

TYZEKA ORAL TABLET 600 MG 4 PA; MT

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

4 PA

VIREAD ORAL POWDER 40 MG/GM 4 MT

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

4 MT

Agentes Anti-Hepatitis C (Hcv)

HARVONI ORAL TABLET 90-400 MG 4 PA; QL (28 per 28 days)

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

2 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

2 PA

INTRON A INJECTION SOLUTION RECONSTITUTED 18000000 UNIT, 50000000 UNIT

4 PA; MT

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML


PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML



111



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


ribasphere oral capsule 200 mg 1 PA



RIBASPHERE ORAL TABLET 600 MG 4 PA

RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG

4 PA

ribavirin oral capsule 200 mg REBETOL 1 PA

ribavirin oral tablet 200 mg MODERIBA 1 PA

SOVALDI ORAL TABLET 400 MG 4 PA; QL (28 per 28 days)

SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG

4 PA

VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM

4 PA

Agentes Anti-Herpéticos

acyclovir oral capsule 200 mg ZOVIRAX 1

acyclovir oral suspension 200 mg/5ml ZOVIRAX 1

acyclovir oral tablet 400 mg, 800 mg ZOVIRAX 1

acyclovir sodium intravenous* solution 50 mg/ml

1 PA

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

famciclovir oral tablet 250 mg FAMVIR 1 QL (60 per 30 days)

trifluridine ophthalmic solution 1 % VIROPTIC 1

valacyclovir hcl oral tablet 1 gm, 500 mg VALTREX 1 QL (30 per 30 days)

VIROPTIC OPHTHALMIC SOLUTION 1 %

2

Agentes Anti-Hiv, Inhibidores De Integrasa (Insti)

ISENTRESS ORAL PACKET 100 MG 2


112



ISENTRESS ORAL TABLET 400 MG 4 MT

ISENTRESS ORAL TABLET CHEWABLE 100 MG

4 MT

ISENTRESS ORAL TABLET CHEWABLE 25 MG

2 MT

STRIBILD ORAL TABLET 150-150-200-300 MG

4 MT

TIVICAY ORAL TABLET 50 MG 4 MT

VITEKTA ORAL TABLET 150 MG, 85 MG

4 MT

Agentes Anti-Hiv, Inhibidores De Proteasa

APTIVUS ORAL CAPSULE 250 MG 4 MT

APTIVUS ORAL SOLUTION 100 MG/ML

4 MT

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2 MT

EVOTAZ ORAL TABLET 300-150 MG 4 MT

INVIRASE ORAL CAPSULE 200 MG 2 MT

INVIRASE ORAL TABLET 500 MG 4 MT

KALETRA ORAL SOLUTION 400-100 MG/5ML

4 MT

KALETRA ORAL TABLET 100-25 MG 2 MT

KALETRA ORAL TABLET 200-50 MG 4 MT

LEXIVA ORAL SUSPENSION 50 MG/ML

2 MT

LEXIVA ORAL TABLET 700 MG 4 MT

NORVIR ORAL CAPSULE 100 MG 2 MT

NORVIR ORAL SOLUTION 80 MG/ML 2 MT

NORVIR ORAL TABLET 100 MG 2 MT

PREZCOBIX ORAL TABLET 800-150 MG

4 MT


113



PREZISTA ORAL SUSPENSION 100 MG/ML

2 MT

PREZISTA ORAL TABLET 150 MG, 75 MG

2 MT

PREZISTA ORAL TABLET 600 MG, 800 MG

4 MT

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

4 MT

REYATAZ ORAL PACKET 50 MG 4 MT

VIRACEPT ORAL TABLET 250 MG, 625 MG

4 MT

Agentes Anti-Hiv, Inhibidores No-Nucleósidos De La Trascriptasa Reversa (Nnrti)

COMPLERA ORAL TABLET 200-25-300 MG

4 MT

EDURANT ORAL TABLET 25 MG 4 MT

INTELENCE ORAL TABLET 100 MG, 200 MG

4 MT

INTELENCE ORAL TABLET 25 MG 2 MT

nevirapine er oral tablet extended release 24 hr* 400 mg

VIRAMUNE XR 1 MT

nevirapine oral suspension 50 mg/5ml VIRAMUNE 1

nevirapine oral tablet 200 mg VIRAMUNE 1 MT

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

2 MT

SUSTIVA ORAL CAPSULE 200 MG, 50 MG

2 MT

SUSTIVA ORAL TABLET 600 MG 2 MT

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG

2 MT

Agentes Anti-Hiv, Inhibidores Nucleósidos Y Nucleótidos De La Trascriptasa Reversa (Nrti)


114



abacavir sulfate oral tablet 300 mg ZIAGEN 1 MT

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

TRIZIVIR 4 MT

ATRIPLA ORAL TABLET 600-200-300 MG

4 MT

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

VIDEX EC 1 MT

EMTRIVA ORAL CAPSULE 200 MG 2 MT

EMTRIVA ORAL SOLUTION 10 MG/ML

2 MT

EPZICOM ORAL TABLET 600-300 MG 4 MT

lamivudine oral solution 10 mg/ml EPIVIR 1 MT

lamivudine oral tablet 100 mg EPIVIR HBV 1 MT

lamivudine oral tablet 150 mg, 300 mg EPIVIR 1 MT

lamivudine-zidovudine oral tablet 150-300 mg

COMBIVIR 1 MT

RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML

2

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

ZERIT 1 MT

stavudine oral solution reconstituted 1 mg/ml

ZERIT 1 MT

TRUVADA ORAL TABLET 200-300 MG

4 MT

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM

2 MT

VIREAD ORAL POWDER 40 MG/GM 4 MT

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

4 MT

ZIAGEN ORAL SOLUTION 20 MG/ML 2 MT

zidovudine oral capsule 100 mg RETROVIR 1 MT

zidovudine oral syrup 50 mg/5ml RETROVIR 1 MT

zidovudine oral tablet 300 mg RETROVIR 1 MT


115



Agentes Anti-Hiv, Otros

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG

4 MT

SELZENTRY ORAL TABLET 150 MG, 300 MG

4 MT

TRIUMEQ ORAL TABLET 600-50-300 MG

4 MT

TYBOST ORAL TABLET 150 MG 3 MT

Agentes Anti-Influenza

amantadine hcl oral capsule 100 mg 1 MT

amantadine hcl oral syrup 50 mg/5ml 1 MT

amantadine hcl oral tablet 100 mg 1 MT

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


rimantadine hcl oral tablet 100 mg FLUMADINE 1

TAMIFLU ORAL CAPSULE 30 MG 2 QL (84 per 180 days)



TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

2 QL (600 per 180 days)

Modificadores/Reemplazos De Enzima

Modificadores/Reemplazos De Enzima

ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML

4 PA

ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML

4 PA

CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

4 PA


116



CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

2 MT

CYSTADANE ORAL POWDER 2

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

2 MT; LA

ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML

4 PA

ELELYSO INTRAVENOUS* SOLUTION RECONSTITUTED 200 UNIT

4 PA

FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG

4 PA

KUVAN ORAL PACKET 500 MG 4 PA

KUVAN ORAL TABLET SOLUBLE 100 MG

4 PA; LA

MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG

4 PA

NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML

4 PA; LA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

4 PA; LA

ZAVESCA ORAL CAPSULE 100 MG 4 PA; LA; QL (90 per 30 days)

Nutrientes Terapéuticos / Minerales / Electrolitos

Electrólitos / Modificadores De Minerales

CHEMET ORAL CAPSULE 100 MG 2

EXJADE ORAL TABLET SOLUBLE 125 MG

2 PA; LA

EXJADE ORAL TABLET SOLUBLE 250 MG, 500 MG

4 PA; LA


117



sodium polystyrene sulfonate oral suspension 15 gm/60ml

SPS 1

SYPRINE ORAL CAPSULE 250 MG 4

Electrólitos / Reemplazo De Minerales

AMMONIUM CHLORIDE INTRAVENOUS* SOLUTION 5 MEQ/ML

2

klor-con 10 oral tablet extendedrelease* 10 meq

1 MT

klor-con m15 oral tablet extendedrelease* 15 meq

1 MT

klor-con m20 oral tablet extendedrelease* 20 meq

1 MT

klor-con oral tablet extendedrelease* 8 meq

1 MT

magnesium sulfate injection solution 50 % 1

OSMOPREP ORAL TABLET 1.102-0.398 GM

2

potassium chloride crys er oral tablet extendedrelease* 10 meq

KLOR-CON M10 1 MT

potassium chloride crys er oral tablet extendedrelease* 20 meq

KLOR-CON M20 1 MT

potassium chloride er oral capsule extended release* 10 meq, 8 meq

MICRO-K 1 MT

potassium chloride in nacl intravenous* solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

1 PA

potassium chloride intravenous* solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/100ml

1 PA

sodium chloride injection solution 2.5 meq/ml

1 PA

sodium chloride intravenous* solution 0.45 %, 0.9 %, 3 %, 5 %

1 PA


118



sodium chloride irrigation solution 0.9 % ARGYLE STERILE

SALINE 1

SUPREP BOWEL PREP ORAL SOLUTION

3

Nutrientes Terapéuticos / Minerales / Electrolitos

AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 %

2 PA

AMINOSYN II INTRAVENOUS* SOLUTION 15 %

2 PA

AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

2 PA

AMINOSYN M INTRAVENOUS* SOLUTION 3.5 %

2 PA

AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

2 PA

AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 %

2 PA

AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 %

2 PA

dextrose in lactated ringers intravenous* solution 5 %

1 PA

dextrose intravenous* solution 10 %, 5 % 1 PA

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 PA

fomepizole intravenous* solution 1 gm/ml ANTIZOL 1 PA

INTRALIPID INTRAVENOUS* EMULSION 30 %

2 PA

kcl in dextrose-nacl intravenous* solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

1 PA


119



kcl-lactated ringers-d5w intravenous* solution 20 meq/l

1 PA

lactated ringers intravenous* solution 1 PA

lactated ringers irrigation solution 1 PA

levocarnitine oral solution 1 gm/10ml CARNITOR SF 1 PA

levocarnitine oral tablet 330 mg CARNITOR 1 PA

liposyn iii intravenous* emulsion 10 % 1 PA

liposyn iii intravenous* emulsion 20 % 1 PA

potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-%

1 PA

prenatal oral tablet 27-1 mg M-VIT 1

ringers intravenous* solution 1

ringers irrigation irrigation solution TIS-U-SOL 1 PA

sodium lactate intravenous* solution 5 meq/ml

1

sterile water for irrigation irrigation solution

ARGYLE STERILE WATER

1

TPN ELECTROLYTES INTRAVENOUS* SOLUTION

2

Productos Sanguíneos / Modificadores / Expansores De Volumen

Agentes Modificadores De Plaquetas

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

2 ST; MT

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

AGGRENOX 1 MT

BRILINTA ORAL TABLET 90 MG 3 PA

cilostazol oral tablet 100 mg, 50 mg PLETAL 1 MT

clopidogrel bisulfate oral tablet 300 mg PLAVIX 1

clopidogrel bisulfate oral tablet 75 mg PLAVIX 1 MT

Anticoagulantes


120



COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

2 MT

enoxaparin sodium injection solution 300 mg/3ml

LOVENOX 1 PA; QL (30 per 30 days)

enoxaparin sodium subcutaneous* solution 100 mg/ml


enoxaparin sodium subcutaneous* solution 120 mg/0.8ml


enoxaparin sodium subcutaneous* solution 150 mg/ml










fondaparinux sodium subcutaneous* solution 10 mg/0.8ml

ARIXTRA 4 PA; QL (24 per 30 days)

fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml


fondaparinux sodium subcutaneous* solution 5 mg/0.4ml


fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml


heparin (porcine) in d5w intravenous* solution 40-5 unit/ml-%, 50-5 unit/ml-%

1 PA

heparin sod (porcine) in d5w intravenous* solution 100 unit/ml

1 PA

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

1 PA


121



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

1 MT

PRADAXA ORAL CAPSULE 150 MG, 75 MG

2 PA; MT

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

COUMADIN 1 MT

warfarin sodium oral tablet 2 mg, 4 mg, 5 mg

JANTOVEN 1 MT

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

2 PA; MT

XARELTO STARTER PACK ORAL 15 & 20 MG

2 PA

Coagulantes

CYKLOKAPRON INTRAVENOUS* SOLUTION 100 MG/ML

2

tranexamic acid intravenous* solution 100 mg/ml

CYKLOKAPRON 1

tranexamic acid oral tablet 650 mg LYSTEDA 1

Modificadores De La Formación De Sangre

anagrelide hcl oral capsule 0.5 mg AGRYLIN 1 MT

anagrelide hcl oral capsule 1 mg 1 MT

LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG

4 PA

MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML

4 PA

NEULASTA SUBCUTANEOUS* SOLUTION 6 MG/0.6ML


NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG


NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML



122



NEUPOGEN INJECTION SOLUTION 480 MCG/0.8ML


NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML


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

2 PA

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

4 PA

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

4 PA; LA

Reguladores De Glucosa En Sangre

Agentes Antidiabéticos

acarbose oral tablet 100 mg, 25 mg, 50 mg

PRECOSE 1 MT; QL (90 per 30 days)

BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML

2 PA; MT; QL (4.8 per 30 days)

BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML


CYCLOSET ORAL TABLET 0.8 MG 2 MT

FARXIGA ORAL TABLET 10 MG 2 PA; MT; QL (30 per 30 days)

FARXIGA ORAL TABLET 5 MG 2 PA; QL (60 per 30 days)

glimepiride oral tablet 1 mg, 2 mg, 4 mg AMARYL 1 MT; QL (60 per 30 days)

glipizide er oral tablet extended release 24 hr* 10 mg

GLUCOTROL XL 1 MT; QL (60 per 30 days)

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

GLUCOTROL XL 1 MT; QL (30 per 30 days)

glipizide oral tablet 10 mg, 5 mg GLUCOTROL 1 MT; QL (120 per 30 days)

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

GLYNASE 1 PA; MT; QL (60 per 30 days)


123



glyburide oral tablet 1.25 mg DIABETA 1 PA; MT; QL (60 per 30 days)

glyburide oral tablet 2.5 mg 1 PA; MT; QL (60 per 30 days)

glyburide oral tablet 5 mg 1 PA; MT; QL (120 per 30 days)

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG


INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG


INVOKAMET ORAL TABLET 50-500 MG


INVOKANA ORAL TABLET 100 MG 3 PA; QL (90 per 30 days)

INVOKANA ORAL TABLET 300 MG 3 PA; QL (30 per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


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


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

GLUCOPHAGE XR 1 MT; QL (60 per 30 days)

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

GLUCOPHAGE XR 1 MT; QL (90 per 30 days)

metformin hcl oral tablet 1000 mg GLUCOPHAGE 1 MT; QL (60 per 30 days)

metformin hcl oral tablet 500 mg, 850 mg GLUCOPHAGE 1 MT; QL (90 per 30 days)

ONGLYZA ORAL TABLET 2.5 MG, 5 MG


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

ACTOS 1 MT; QL (30 per 30 days)

repaglinide oral tablet 0.5 mg, 1 mg PRANDIN 1 MT; QL (120 per 30 days)


124



repaglinide oral tablet 2 mg PRANDIN 1 MT; QL (240 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML


SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML


tolazamide oral tablet 250 mg 1 MT; QL (120 per 30 days)

tolazamide oral tablet 500 mg 1 MT; QL (60 per 30 days)

tolbutamide oral tablet 500 mg 1 MT; QL (180 per 30 days)

TRADJENTA ORAL TABLET 5 MG 2 PA; MT; QL (30 per 30 days)

WELCHOL ORAL PACKET 3.75 GM 2 MT

WELCHOL ORAL TABLET 625 MG 2 MT

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HR* 10-1000 MG, 10-500 MG, 5-1000 MG, 5-500 MG


Agentes Glicémicos

GLUCAGON EMERGENCY INJECTION KIT 1 MG

2

PROGLYCEM ORAL SUSPENSION 50 MG/ML

2

Insulinas

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML


BD INSULIN SYRINGE U-100 1 ML 2 MT; QL (100 per 30 days)

BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML


CAREONE INSULIN SYRINGE 31G X 5/16" 0.3 ML

BD INSULIN SYRINGE 2 MT; QL (100 per 30 days)

CURITY GAUZE PAD 2"X2" 2 MT


125



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


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


HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML


LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML


LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML


Reguladores De Glucosa En Sangre

glipizide-metformin hcl oral tablet 2.5-250 mg

METAGLIP 1 MT; QL (120 per 30 days)

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


glyburide-metformin oral tablet 1.25-250 mg

GLUCOVANCE 1 PA; MT; QL (60 per 30 days)

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

GLUCOVANCE 1 PA; MT; QL (120 per 30 days)

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



126



KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG


KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG


metformin hcl er (osm) oral tablet extended release 24 hr* 1000 mg

FORTAMET 1 MT; QL (60 per 30 days)

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

DUETACT 1 MT; QL (30 per 30 days)

pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg

ACTOPLUS MET 1 MT; QL (90 per 30 days)

Relajantes Musculo Esqueletales

Relajantes Musculo Esqueletales

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

FLEXERIL 1 PA

tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg

ZANAFLEX 1

127

8

8-MOP .................................... 26 A

abacavir sulfate ............. 113, 114 abacavir-lamivudine-zidovudine

.......................................... 114 ABELCET ........................ 96, 97 ABILIFY ........................ 92, 107 ABILIFY MAINTENA .. 92, 107 acamprosate calcium .............. 62 acarbose ................................ 122 acebutolol hcl ......................... 14 acetaminophen-codeine .......... 71 acetaminophen-codeine #2 ..... 71 acetaminophen-codeine #3 ..... 71 acetaminophen-codeine #4 ..... 71 acetasol hc .............................. 55 acetazolamide ................... 22, 51 acetazolamide er ..................... 22 acetic acid ............................... 78 ACTEMRA ...................... 45, 46 ACTHIB ................................. 49 ACTIMMUNE ....................... 45 acyclovir ............................... 111 acyclovir sodium .................. 111 ADACEL ................................ 49 ADAGEN ............................. 115 adapalene ................................ 26 ADCIRCA .............................. 66 adefovir dipivoxil ................. 109 ADEMPAS ............................. 66 ADRUCIL ............................ 101 ADVAIR DISKUS .... 66, 67, 68,

69 ADVAIR HFA ........... 66, 67, 69 afeditab cr ............................... 15 AFINITOR ..................... 46, 103 AFINITOR DISPERZ ............ 46 AGGRENOX ....................... 119 ALBENZA ........................... 105 albuterol sulfate ...................... 69 albuterol sulfate er .................. 69 alclometasone dipropionate .... 32 alcohol pads ............................ 78 ALDURAZYME .................. 115 alendronate sodium ................ 64 ALIMTA .............................. 101 ALINIA ................................ 105

allopurinol .............................. 10 alosetron hcl ........................... 29 ALPHAGAN P ....................... 51 alprazolam .............................. 76 alprazolam er .......................... 76 amantadine hcl ................ 60, 115 AMBISOME .......................... 97 amcinonide ............................. 32 amifostine ............................. 102 amiloride hcl ........................... 22 amiloride-hydrochlorothiazide16 aminophylline ......................... 70 AMINOSYN II ..................... 118 AMINOSYN

II/ELECTROLYTES ........ 118 AMINOSYN M .................... 118 AMINOSYN/ELECTROLYTE

S ........................................ 118 AMINOSYN-HBC ............... 118 AMINOSYN-PF ................... 118 amiodarone hcl ....................... 19 AMITIZA ............................... 29 amitriptyline hcl ..................... 94 amlodipine besy-benazepril hcl

............................................ 16 amlodipine besylate ................ 15 amlodipine besylate-valsartan 17 amlodipine-valsartan-hctz ...... 17 AMMONIUM CHLORIDE . 117 ammonium lactate .................. 26 amnesteem .............................. 26 amoxapine .............................. 95 amoxicillin .............................. 82 amoxicillin-pot clavulanate ... 82,

83 amoxicillin-pot clavulanate er 82 amphetamine-

dextroamphetamine ...... 24, 25 amphotericin b ........................ 97 ampicillin ................................ 83 ampicillin sodium ................... 83 ampicillin-sulbactam sodium . 83 AMPYRA ............................... 25 anagrelide hcl ....................... 121 anastrozole ............................ 102 ANDROGEL .......................... 39 ANDROGEL PUMP .............. 39 ANORO ELLIPTA........... 65, 66

ANTABUSE ........................... 62 APOKYN ............................... 60 apraclonidine hcl .................... 51 apri .......................................... 36 APTIOM ................................. 88 APTIVUS ............................. 112 ARALAST NP........................ 66 aranelle ................................... 36 ARCALYST ........................... 46 aripiprazole ............................. 92 ARZERRA ........................... 100 ascomp-codeine ...................... 71 aspirin-dipyridamole er ........ 119 ASSURE ID INSULIN

SAFETY SYR .................. 124 ASTAGRAF XL ..................... 46 atenolol ................................... 14 atenolol-chlorthalidone ........... 17 ATGAM ................................. 46 atorvastatin calcium ................ 21 atovaquone ............................ 105 atovaquone-proguanil hcl ..... 105 ATRIPLA ............................. 114 atropine sulfate ....................... 54 ATROVENT HFA.................. 68 AVASTIN............................. 101 AVELOX ABC PACK ........... 85 aviane ...................................... 36 AVODART............................. 31 AVONEX ............................... 25 AVONEX PEN ....................... 25 AVONEX PREFILLED ......... 25 AXIRON................................. 39 azacitidine ............................. 101 AZACTAM IN DEXTROSE . 82 AZASAN ................................ 46 AZASITE ............................... 84 azathioprine ............................ 46 azelastine hcl .......................... 67 AZILECT ............................... 61 azithromycin ........................... 84 AZOPT ................................... 51 aztreonam ............................... 82 B

baciim ..................................... 78 bacitracin ................................ 78 bacitracin-polymyxin b ........... 53

Índice

128

bacitra-neomycin-polymyxin-hc ............................................ 53

baclofen .................................. 64 bactocill in dextrose ............... 83 balsalazide disodium .............. 62 balziva .................................... 36 BANZEL .......................... 88, 89 BARACLUDE ..................... 109 BCG VACCINE ..................... 49 BD INSULIN SYRINGE ..... 124 BD SAFETYGLIDE INSULIN

SYRINGE......................... 124 BELEODAQ ........................ 101 benazepril hcl ......................... 23 benazepril-hydrochlorothiazide

............................................ 17 BENICAR .............................. 19 BENICAR HCT ..................... 17 BENLYSTA ........................... 46 benzoyl peroxide-erythromycin

............................................ 26 benztropine mesylate .............. 61 betamethasone dipropionate .. 11,

12, 27, 33 betamethasone dipropionate aug

...................................... 11, 32 betamethasone valerate .... 12, 33 BETASERON ........................ 25 betaxolol hcl ..................... 14, 51 bethanechol chloride .............. 31 bexarotene ............................ 105 BEXSERO .............................. 49 bicalutamide ......................... 100 BICILLIN C-R ....................... 83 BICILLIN C-R 900/300 ......... 83 bimatoprost ............................. 51 bisoprolol fumarate ................ 14 bisoprolol-hydrochlorothiazide

............................................ 17 BLEPHAMIDE ................ 12, 53 BOOSTRIX ............................ 49 BOSULIF ............................. 103 BOTOX ............................ 59, 64 BREO ELLIPTA .................... 69 BRILINTA ........................... 119 brimonidine tartrate ................ 52 BRINTELLIX ........................ 93 bromocriptine mesylate .... 43, 60 budesonide .............................. 67 budesonide er.................... 29, 63 bumetanide ............................. 22

buprenorphine hcl ................... 62 buprenorphine hcl-naloxone hcl

............................................ 62 buproban ................................. 92 bupropion hcl .......................... 92 bupropion hcl er (sr) ............... 92 bupropion hcl er (xl) ............... 92 buspirone hcl .......................... 76 butalbital-apap-caff-cod ......... 71 butorphanol tartrate ................ 72 BYETTA 10 MCG PEN....... 122 BYETTA 5 MCG PEN......... 122 C

cabergoline ............................. 43 calcipotriene ........................... 27 calcitonin (salmon) ................. 64 calcitriol ...................... 27, 64, 65 calcium acetate ....................... 32 camila ..................................... 41 CANASA................................ 62 CANCIDAS............................ 97 candesartan cilexetil ............... 19 candesartan cilexetil-hctz ....... 17 CAPASTAT SULFATE ......... 99 CAPRELSA.......................... 103 captopril .................................. 23 captopril-hydrochlorothiazide 17 carafate ................................... 30 carbamazepine .................. 57, 89 carbamazepine er .................... 89 carbidopa-levodopa ................ 61 carbidopa-levodopa er ............ 61 carbidopa-levodopa-entacapone

...................................... 59, 60 CAREONE INSULIN

SYRINGE ......................... 124 carteolol hcl ............................ 52 cartia xt ................................... 15 carvedilol ................................ 14 cefaclor ................................... 80 cefaclor er ............................... 80 cefadroxil ................................ 80 cefazolin sodium..................... 80 cefdinir.............................. 80, 81 cefepime hcl ........................... 81 cefixime .................................. 81 cefoxitin sodium ..................... 81 cefpodoxime proxetil .............. 81 cefprozil .................................. 81 ceftriaxone sodium ................. 81 cefuroxime axetil .................... 81

cefuroxime sodium ................. 81 celecoxib ........................... 10, 74 CELLCEPT ............................ 46 CELONTIN ............................ 90 cephalexin ............................... 81 CEREZYME......................... 115 CERVARIX ............................ 49 CHANTIX .............................. 62 CHANTIX CONTINUING

MONTH PAK .............. 61, 62 CHANTIX STARTING

MONTH PAK .................... 62 CHEMET .............................. 116 chloramphenicol sod succinate

............................................ 78 chlorhexidine gluconate.......... 54 chloroquine phosphate .......... 105 chlorothiazide ......................... 22 chlorpromazine hcl ......... 95, 106 chlorthalidone ......................... 22 cholestyramine light ............... 21 ciclopirox ................................ 97 ciclopirox olamine .................. 97 cilostazol ............................... 119 cimetidine ............................... 29 cimetidine hcl ......................... 29 CINRYZE ............................... 45 CIPRODEX ............................ 55 ciprofloxacin ........................... 85 ciprofloxacin hcl ..................... 85 ciprofloxacin in d5w ............... 85 ciprofloxacin-ciproflox hcl er . 85 citalopram hydrobromide ....... 93 claravis .................................... 27 clarithromycin......................... 84 clarithromycin er .................... 84 clindamax ............................... 78 clindamycin hcl ...................... 78 clindamycin palmitate hcl....... 78 clindamycin phosphate ..... 78, 79 clobetasol propionate .............. 33 clobetasol propionate e ........... 33 clomipramine hcl .................... 95 clonazepam ....................... 76, 87 clonidine hcl ........................... 19 clopidogrel bisulfate ............. 119 clorazepate dipotassium.... 76, 87 clorpres ................................... 17 clotrimazole ............................ 97 clotrimazole-betamethasone ... 27 clozapine ............................... 107

129

COARTEM .......................... 105 colchicine ............................... 10 colchicine-probenecid ............ 10 colestipol hcl .......................... 21 colistimethate sodium ............. 80 COMBIGAN .......................... 52 COMBIPATCH ...................... 36 COMBIVENT RESPIMAT ... 66 COMETRIQ (100 MG DAILY

DOSE) .............................. 103 COMETRIQ (140 MG DAILY

DOSE) .............................. 103 COMETRIQ (60 MG DAILY

DOSE) .............................. 103 COMPLERA ........................ 113 compro .................................... 95 COMVAX .............................. 49 constulose ............................... 30 COPAXONE .................... 25, 26 cortisone acetate ......... 12, 33, 63 COUMADIN ................ 119, 120 CREON ................................ 116 CRESTOR .............................. 21 CRIXIVAN .......................... 112 cromolyn sodium .............. 51, 70 cryselle-28 .............................. 36 CUBICIN ............................... 79 CUPRIMINE .......................... 31 CURITY GAUZE ................ 124 cyclafem 1/35 ......................... 36 cyclafem 7/7/7 ........................ 37 cyclobenzaprine hcl .............. 126 cyclophosphamide .................. 99 CYCLOSET ......................... 122 cyclosporine ..................... 46, 47 cyclosporine modified ...... 46, 47 CYKLOKAPRON ................ 121 cyproheptadine hcl ................. 67 CYRAMZA .......................... 100 CYSTADANE ...................... 116 CYSTAGON ........................ 116 D

DALIRESP ............................. 70 danazol ................................... 40 dantrolene sodium .................. 64 DAPSONE ............................. 99 DAPTACEL ........................... 49 DARAPRIM ......................... 105 DAUNOXOME .................... 101 decitabine ............................. 101 DELZICOL ...................... 29, 62

demeclocycline hcl ................. 86 DEMEROL ............................. 72 DEMSER ................................ 17 DEPO-PROVERA.................. 41 DERMATOP .................... 33, 63 desipramine hcl....................... 95 desloratadine ........................... 67 desmopressin ace rhinal tube .. 41 desmopressin ace spray refrig 42 desmopressin acetate .............. 42 desonide .................................. 33 desoximetasone ...................... 33 desvenlafaxine er .................... 93 dexamethasone ........... 12, 33, 63 dexamethasone intensol ... 12, 33,

63 dexamethasone sodium

phosphate ................ 12, 34, 52 dextroamphetamine sulfate er 25 dextrose ................................ 118 dextrose in lactated ringers ... 118 dextrose-nacl ........................ 118 diazepam ..................... 76, 87, 91 DIBENZYLINE ..................... 13 diclofenac potassium ........ 10, 74 diclofenac sodium....... 10, 52, 74 diclofenac sodium er ........ 10, 74 dicloxacillin sodium ............... 83 dicyclomine hcl ...................... 30 didanosine ............................. 114 diflorasone diacetate ............... 34 diflunisal ........................... 10, 74 digoxin .................................... 18 dihydroergotamine mesylate .. 59 DILANTIN ............................. 89 DILANTIN INFATABS ........ 89 diltiazem hcl ........................... 15 diltiazem hcl er ....................... 15 diltiazem hcl er beads ............. 15 diltiazem hcl er coated beads.. 15 dilt-xr ...................................... 15 DIPENTUM ........................... 62 diphenhydramine hcl .. 61, 67, 95 diphenoxylate-atropine ........... 28 DIPHTHERIA-TETANUS

TOXOIDS DT .................... 49 disulfiram................................ 62 divalproex sodium 57, 59, 87, 88 divalproex sodium er .. 57, 59, 87 donepezil hcl............................. 9 dorzolamide hcl ...................... 52

dorzolamide hcl-timolol mal .. 52 doxazosin mesylate ........... 13, 31 doxepin hcl ................. 55, 76, 95 doxycycline hyclate .... 27, 54, 87 doxycycline monohydrate 27, 54,

55, 87 dronabinol ............................... 96 drospirenone-ethinyl estradiol 37 DULERA ................................ 69 duloxetine hcl ............. 24, 76, 93 duramorph............................... 73 E

econazole nitrate ..................... 97 EDURANT ........................... 113 ELAPRASE .......................... 116 ELELYSO ............................ 116 ELIDEL ............................ 27, 47 ELIGARD............................... 43 ELITEK ................................ 101 ELLA ...................................... 39 ELMIRON .............................. 31 EMCYT ................................ 104 EMEND .................................. 96 emoquette ............................... 37 EMSAM ................................. 93 EMTRIVA ............................ 114 ENABLEX ....................... 31, 32 enalapril maleate ..................... 23 enalapril-hydrochlorothiazide. 17 ENBREL................................. 47 ENBREL SURECLICK ......... 47 endocet .................................... 71 ENGERIX-B........................... 49 enoxaparin sodium................ 120 enpresse-28 ............................. 37 entacapone .............................. 60 entecavir ............................... 109 enulose .................................... 30 epinephrine ............................. 69 EPIPEN 2-PAK ...................... 69 EPIPEN JR 2-PAK ................. 69 epitol ................................. 57, 89 EPIVIR HBV ........................ 109 eplerenone............................... 22 EPZICOM............................. 114 ERAXIS .................................. 97 ERGOMAR ............................ 59 ERIVEDGE .......................... 103 errin......................................... 41 ERWINAZE ......................... 101 ery ........................................... 85

130

ERYTHROCIN LACTOBIONATE ............. 85

erythrocin stearate .................. 85 erythromycin .......................... 85 erythromycin base .................. 85 erythromycin ethylsuccinate .. 85 ESBRIET ................................ 66 escitalopram oxalate ......... 77, 93 estazolam ................................ 26 ESTRACE .............................. 40 estradiol .................................. 40 estradiol-norethindrone acet ... 37 estropipate .............................. 40 ethambutol hcl ........................ 99 ethosuximide .......................... 90 etidronate disodium ................ 65 etodolac ............................ 10, 74 etodolac er ........................ 10, 74 EVOTAZ .............................. 112 EXELDERM .......................... 97 EXELON .................................. 9 exemestane ........................... 102 EXJADE ............................... 116 F

FABRAZYME ..................... 116 famciclovir ........................... 111 famotidine............................... 29 FANAPT .............................. 107 FANAPT TITRATION PACK

.......................................... 108 FARESTON ......................... 104 FARXIGA ............................ 122 FARYDAK................... 102, 103 FASLODEX ......................... 101 FAZACLO ........................... 107 felbamate ................................ 90 FELBATOL ........................... 90 felodipine er............................ 15 fenofibrate .............................. 20 fenofibrate micronized ........... 20 fenofibric acid ........................ 21 fenoprofen calcium ........... 10, 74 fentanyl ....................... 72, 73, 74 fentanyl citrate .................. 72, 73 FETZIMA............................... 93 FETZIMA TITRATION ........ 93 finasteride ............................... 31 FIRAZYR ............................... 45 flavoxate hcl ........................... 32 flecainide acetate .................... 19 fluconazole ............................. 97

fluconazole in dextrose ........... 97 flucytosine .............................. 97 fludrocortisone acetate ........... 34 flunisolide ............................... 68 fluocinolone acetonide ........... 34 fluocinonide ...................... 27, 34 fluocinonide-e ......................... 34 fluorometholone ..................... 52 fluorouracil ............................. 27 fluoxetine hcl .......................... 94 fluphenazine decanoate ........ 106 fluphenazine hcl ................... 106 flurbiprofen ....................... 10, 74 flurbiprofen sodium ................ 52 flutamide ............................... 100 fluticasone propionate 27, 34, 68 fluvastatin sodium .................. 21 fluvoxamine maleate .............. 94 fluvoxamine maleate er .......... 94 FML ........................................ 52 FML FORTE .......................... 52 fomepizole ............................ 118 fondaparinux sodium ............ 120 FORADIL AEROLIZER ....... 69 FORTEO ................................ 65 fortical .................................... 65 fosinopril sodium .................... 23 fosinopril sodium-hctz ............ 17 fosphenytoin sodium .............. 89 furosemide .............................. 22 FUZEON .............................. 115 FYCOMPA ............................. 90 G

gabapentin .............................. 88 galantamine hydrobromide . 9, 10 galantamine hydrobromide er ... 9 GAMASTAN S/D .................. 45 GAMMAPLEX ...................... 45 GAMUNEX-C........................ 45 ganciclovir sodium ............... 109 GARDASIL ............................ 49 GARDASIL 9 ......................... 49 gatifloxacin ............................. 85 gavilyte-c ................................ 30 gemfibrozil ............................. 21 gengraf .................................... 47 gentak ..................................... 77 gentamicin sulfate............. 77, 78 GEODON ....................... 56, 108 gildagia ................................... 37 GILENYA .............................. 26

GILOTRIF ............................ 103 GLEEVEC ............................ 103 glimepiride ............................ 122 glipizide ................................ 122 glipizide er ............................ 122 glipizide-metformin hcl ........ 125 GLUCAGON EMERGENCY

.......................................... 124 glyburide ............................... 123 glyburide micronized ............ 122 glyburide-metformin............. 125 glycopyrrolate ......................... 30 GLYSET ............................... 123 granisetron hcl ........................ 96 griseofulvin microsize ............ 98 griseofulvin ultramicrosize ..... 98 guanfacine hcl ......................... 19 guanidine hcl .......................... 13 H

HALAVEN ........................... 101 halobetasol propionate ............ 34 haloperidol ............................ 106 haloperidol decanoate ........... 106 haloperidol lactate ................ 106 HARVONI ............................ 110 HAVRIX................................. 49 heparin (porcine) in d5w ...... 120 heparin sod (porcine) in d5w 120 heparin sodium (porcine) ...... 120 HETLIOZ ............................... 55 HEXALEN ............................. 99 HUMALOG .......................... 125 HUMALOG MIX 50/50 ....... 125 HUMALOG MIX 75/25 ....... 125 HUMATROPE ....................... 42 HUMIRA ................................ 47 HUMIRA PEN-CROHNS

STARTER .......................... 47 HUMULIN 70/30 ................. 125 HUMULIN N ....................... 125 HUMULIN R........................ 125 HUMULIN R U-500

(CONCENTRATED) ....... 125 hydralazine hcl.................. 23, 24 hydrochlorothiazide ................ 22 hydrocodone-acetaminophen . 71,

72 hydrocodone-ibuprofen .......... 71 hydrocortisone ............ 12, 35, 63 hydrocortisone butyr lipo base34 hydrocortisone valerate .......... 35

131

hydrocortisone-acetic acid...... 55 hydromorphone hcl ................ 73 hydromorphone hcl pf ............ 73 hydroxychloroquine sulfate .. 105 hydroxyurea .......................... 101 HYPERRAB S/D ................... 45 I

ibandronate sodium ................ 65 IBRANCE ............................ 103 ibuprofen .................... 10, 74, 75 ICLUSIG .............................. 103 IMBRUVICA ....................... 103 imipenem-cilastatin ................ 82 imipramine hcl........................ 95 imipramine pamoate ............... 95 imiquimod .............................. 27 IMOVAX RABIES ................ 49 INCRELEX ............................ 42 INCRUSE ELLIPTA.............. 68 indapamide ............................. 23 INFANRIX ............................. 49 INLYTA ............................... 103 INTELENCE ........................ 113 INTRALIPID ....................... 118 INTRON A ................... 109, 110 INTUNIV ............................... 25 INVANZ................................. 82 INVEGA............................... 108 INVEGA SUSTENNA ......... 108 INVIRASE ........................... 112 INVOKAMET ...................... 123 INVOKANA ........................ 123 IPOL ................................. 49, 50 ipratropium bromide ............... 68 irbesartan ................................ 19 irbesartan-hydrochlorothiazide

...................................... 17, 23 ISENTRESS ................. 111, 112 isoniazid ................................. 99 isosorbide dinitrate ................. 24 isosorbide dinitrate er ............. 24 isosorbide mononitrate ........... 24 isosorbide mononitrate er ....... 24 isradipine ................................ 15 itraconazole ............................ 98 ivermectin ............................. 105 IXIARO .................................. 50 J

JAKAFI ................................ 103 jantoven ................................ 121 JANUMET ........................... 125

JANUVIA ............................. 123 JENTADUETO .................... 123 junel 1.5/30 ............................. 37 junel 1/20 ................................ 37 junel fe 1.5/30 ......................... 37 junel fe 1/20 ............................ 37 junel fe 24 ............................... 37 JUXTAPID ............................. 21 K

KALETRA ........................... 112 kariva ...................................... 37 kcl in dextrose-nacl .............. 118 kcl-lactated ringers-d5w ....... 119 kelnor 1/35 .............................. 37 KENALOG ............................. 35 ketoconazole ........................... 98 ketoprofen ......................... 11, 75 ketoprofen er..................... 11, 75 ketorolac tromethamine .......... 53 KEYTRUDA .................. 46, 100 KINERET ............................... 47 klor-con ................................ 117 klor-con 10 ........................... 117 klor-con m15 ........................ 117 klor-con m20 ........................ 117 KOMBIGLYZE XR ............. 126 KUVAN................................ 116 L

labetalol hcl ............................ 14 lactated ringers ..................... 119 lactulose .................................. 30 lamivudine .................... 110, 114 lamivudine-zidovudine ......... 114 lamotrigine.................. 57, 88, 91 lamotrigine er ......................... 91 LANOXIN ........................ 18, 19 lansoprazole ............................ 30 LANTUS .............................. 125 latanoprost .............................. 54 LATUDA.............................. 108 leflunomide ....................... 45, 46 LENVIMA 10 MG DAILY

DOSE................................ 104 LENVIMA 14 MG DAILY



DOSE................................ 104 lessina ..................................... 37 LETAIRIS .............................. 67

letrozole ................................ 102 leucovorin calcium ............... 102 LEUKERAN........................... 99 LEUKINE ............................. 121 leuprolide acetate .................... 43 LEVEMIR ............................ 125 levetiracetam........................... 91 levetiracetam er ...................... 91 levetiracetam in nacl ............... 91 levobunolol hcl ....................... 52 levocarnitine ......................... 119 levocetirizine dihydrochloride 67 levofloxacin ............................ 86 levofloxacin in d5w ................ 85 levoleucovorin calcium ........ 102 levonest ................................... 37 levonorgest-eth estrad 91-day. 37 levora 0.15/30 (28) ................. 37 levorphanol tartrate ................. 74 levothyroxine sodium ............. 42 levoxyl .................................... 42 LEXIVA ............................... 112 lidocaine ................................. 75 lidocaine hcl...................... 75, 76 lidocaine hcl (pf)..................... 75 lidocaine viscous .................... 76 lidocaine-prilocaine ................ 76 lindane .................................. 106 linezolid .................................. 79 liothyronine sodium ................ 43 liposyn iii .............................. 119 lisinopril .................................. 23 lisinopril-hydrochlorothiazide 17 lithium..................................... 58 lithium carbonate .................... 58 lithium carbonate er ................ 57 lomustine ................................ 99 loperamide hcl ........................ 28 lorazepam ......................... 76, 88 loryna ...................................... 37 losartan potassium .................. 19 losartan potassium-hctz .......... 18 LOTRONEX........................... 29 lovastatin................................. 21 LOVAZA ................................ 21 low-ogestrel ............................ 37 loxapine succinate ................ 106 LUMIGAN ............................. 54 LUPANETA PACK ............... 44 LUPRON DEPOT .................. 44 LUPRON DEPOT-PED ......... 44

132

lutera ....................................... 37 LYNPARZA......................... 102 LYRICA ........................... 24, 90 LYSODREN........................... 43 M

magnesium sulfate ................ 117 maprotiline hcl........................ 92 marlissa....................... 37, 40, 41 MARPLAN ............................ 93 MATULANE ....................... 100 matzim la ................................ 15 meclizine hcl .......................... 95 meclofenamate sodium ..... 11, 75 medroxyprogesterone acetate . 41 mefenamic acid ................ 11, 75 mefloquine hcl ...................... 105 megestrol acetate .................... 41 MEKINIST ........................... 104 meloxicam ........................ 11, 75 memantine hcl .......................... 9 MENACTRA ......................... 50 MENEST ................................ 40 MENOMUNE ........................ 50 MENOSTAR .......................... 40 MENVEO ............................... 50 meperidine hcl ........................ 73 mercaptopurine ....................... 47 meropenem ............................. 82 mesalamine-cleanser .............. 63 mesna .................................... 102 MESTINON ........................... 13 metadate er ............................. 25 metaproterenol sulfate ............ 69 metformin hcl ....................... 123 metformin hcl er ................... 123 metformin hcl er (osm) ......... 126 methadone hcl ........................ 74 methazolamide ................. 22, 52 methenamine hippurate .......... 79 methimazole ..................... 44, 45 METHITEST .......................... 40 methotrexate ........................... 47 methotrexate sodium .............. 47 methotrexate sodium (pf) ....... 47 methoxsalen rapid .................. 27 methscopolamine bromide ..... 30 methyclothiazide .................... 23 methylergonovine maleate ..... 58 methylphenidate hcl er ........... 25 methylprednisolone .... 12, 35, 63 methylprednisolone (pak) . 35, 63

methylprednisolone acetate ... 12, 35, 63

methylprednisolone sodium succ ...................................... 12, 35

metipranolol............................ 52 metoclopramide hcl .... 28, 29, 96 metolazone.............................. 23 metoprolol succinate er .......... 14 metoprolol tartrate .................. 14 metoprolol-hydrochlorothiazide

............................................ 18 metronidazole ......................... 79 metronidazole in nacl ............. 79 mexiletine hcl ......................... 20 MIACALCIN ......................... 65 miconazole 3........................... 98 microgestin 1.5/30 .................. 37 microgestin 1/20 ..................... 37 microgestin fe 1.5/30 .............. 38 microgestin fe 1/20 ................. 38 midodrine hcl .......................... 19 migergot.................................. 59 minocycline hcl ................ 55, 87 minocycline hcl er ............ 55, 87 minoxidil ................................ 24 mirtazapine ............................. 92 misoprostol ....................... 31, 42 mitoxantrone hcl ............. 26, 102 M-M-R II ................................ 50 modafinil ................................ 55 moexipril hcl........................... 23 moexipril-hydrochlorothiazide

............................................ 18 mometasone furoate ............... 35 mononessa .............................. 38 montelukast sodium ................ 68 morphine sulfate ..................... 74 morphine sulfate (concentrate)

............................................ 74 morphine sulfate (pf) .............. 73 morphine sulfate er ................. 74 moxifloxacin hcl ..................... 86 MOZOBIL ............................ 121 MULTAQ ............................... 20 mupirocin................................ 79 mupirocin calcium .................. 79 MYCAMINE .......................... 98 mycophenolate mofetil ..... 47, 48 mycophenolic acid .................. 48 MYOZYME ......................... 116

N

nabumetone....................... 11, 75 nadolol .................................... 14 nadolol-bendroflumethiazide .. 18 nafcillin sodium ...................... 83 NAGLAZYME ..................... 116 naloxone hcl............................ 61 naltrexone hcl ......................... 62 NAMENDA .............................. 9 NAMENDA TITRATION PAK

.............................................. 9 NAMENDA XR ....................... 9 NAMENDA XR TITRATION

PACK ................................... 9 naphazoline hcl ....................... 54 naproxen ........................... 11, 75 naproxen dr ....................... 11, 75 naproxen sodium .............. 11, 75 naratriptan hcl ......................... 58 NARDIL ................................. 93 NATACYN............................. 98 NATPARA ............................. 65 NEBUPENT ......................... 105 necon 0.5/35 (28) .................... 38 necon 1/35 (28) ....................... 38 necon 10/11 (28) ..................... 38 necon 7/7/7 ............................. 38 nefazodone hcl ........................ 92 neomycin sulfate ..................... 78 neomycin-bacitracin zn-

polymyx .............................. 53 neomycin-polymyxin b gu ...... 78 neomycin-polymyxin-dexameth

............................................ 53 neomycin-polymyxin-

gramicidin ........................... 53 neomycin-polymyxin-hc... 53, 55 NEULASTA ......................... 121 NEUMEGA .......................... 121 NEUPOGEN................. 121, 122 NEUPRO ................................ 60 NEVANAC............................. 53 nevirapine ............................. 113 nevirapine er ......................... 113 NEXAVAR........................... 104 NIASPAN ............................... 21 nicardipine hcl ........................ 16 NICOTROL ............................ 62 NICOTROL NS ...................... 62 nifedical xl .............................. 16 nifedipine er osmotic .............. 16

133

NILANDRON ...................... 100 nimodipine .............................. 16 nisoldipine er .......................... 16 nitro-bid .................................. 24 nitrofurantoin .......................... 79 nitrofurantoin macrocrystal .... 79 nitrofurantoin monohyd macro

............................................ 79 nitroglycerin ........................... 24 NITROSTAT .......................... 24 nizatidine ................................ 29 NORDITROPIN FLEXPRO .. 42 norethindrone ......................... 41 norethindrone acetate ............. 41 norethindrone-eth estradiol .... 38 nortrel 0.5/35 (28) .................. 38 nortrel 1/35 (21) ..................... 38 nortrel 1/35 (28) ..................... 38 nortrel 7/7/7 ............................ 38 nortriptyline hcl ...................... 95 NORVIR............................... 112 NOXAFIL .............................. 98 NUEDEXTA .......................... 26 NULOJIX ............................... 48 NUVARING........................... 38 nyamyc ................................... 98 nystatin ................................... 98 nystatin-triamcinolone ............ 27 nystop ..................................... 98 O

octreotide acetate .................... 44 ofloxacin ................................. 86 ogestrel ................................... 38 olanzapine....................... 56, 108 olanzapine-fluoxetine hcl ....... 91 omega-3-acid ethyl esters ....... 21 omeprazole ............................. 30 ONCASPAR ........................ 102 ondansetron ............................ 96 ondansetron hcl ...................... 96 ONFI....................................... 88 ONGLYZA........................... 123 OPDIVO ............................... 100 OPSUMIT .............................. 67 ORAP ................................... 107 ORENCIA .............................. 48 ORFADIN ............................ 116 ORKAMBI ............................. 66 orsythia ................................... 38 OSMOPREP ......................... 117 OTEZLA ................................ 48

oxacillin sodium ..................... 83 oxandrolone ............................ 40 oxaprozin .......................... 11, 75 oxcarbazepine ......................... 89 oxybutynin chloride ................ 32 oxybutynin chloride er............ 32 oxycodone hcl......................... 73 oxycodone-acetaminophen ..... 72 oxycodone-aspirin .................. 72 oxycodone-ibuprofen........ 11, 75 oxymorphone hcl .................... 73 P

pacerone.................................. 20 pamidronate disodium ............ 65 PANRETIN .......................... 105 pantoprazole sodium............... 30 paromomycin sulfate .............. 78 paroxetine hcl ................... 77, 94 paroxetine hcl er ............... 77, 94 PASER.................................... 99 PATADAY ............................. 51 PAXIL .............................. 77, 94 PAZEO ................................... 51 PEDVAX HIB ........................ 50 PEGANONE .......................... 89 PEGASYS ............................ 111 PEGASYS PROCLICK ....... 110 penicillin g potassium ............. 84 penicillin g procaine ............... 84 penicillin g sodium ................. 84 penicillin v potassium ............. 84 PENTAM.............................. 106 PENTASA .............................. 63 pentoxifylline er ..................... 19 perindopril erbumine .............. 23 periogard ................................. 55 permethrin ............................ 106 perphenazine ................... 96, 107 perphenazine-amitriptyline ..... 92 phenelzine sulfate ................... 93 phenobarbital .......................... 88 phenoxybenzamine hcl ........... 13 phenytoin ................................ 89 phenytoin sodium ................... 89 phenytoin sodium extended .... 89 PHOSPHOLINE IODIDE ...... 52 pilocarpine hcl .................. 52, 55 pindolol ................................... 14 pioglitazone hcl .................... 123 pioglitazone hcl-glimepiride. 126

pioglitazone hcl-metformin hcl .......................................... 126

piperacillin sod-tazobactam so84 piroxicam .......................... 11, 75 PLEGRIDY ............................ 26 PLEGRIDY STARTER PACK

............................................ 26 podofilox................................. 27 polyethylene glycol 3350 ....... 30 polymyxin b sulfate ................ 79 polymyxin b-trimethoprim ..... 53 POMALYST......................... 100 portia-28 ................................. 38 potassium chloride ................ 117 potassium chloride crys er .... 117 potassium chloride er ............ 117 potassium chloride in dextrose

.......................................... 119 potassium chloride in nacl .... 117 potassium citrate er ................. 31 POTIGA ................................. 91 PRADAXA ........................... 121 pramipexole dihydrochloride .. 60 pramipexole dihydrochloride er

............................................ 60 pravastatin sodium .................. 21 prazosin hcl ....................... 13, 31 PRED MILD ..................... 12, 53 prednicarbate .......................... 35 prednisolone acetate ......... 12, 53 prednisolone sodium phosphate

.................... 12, 13, 35, 53, 63 prednisone............. 13, 36, 63, 64 prednisone intensol ..... 13, 36, 63 PREMARIN ........................... 41 PREMPHASE......................... 38 PREMPRO ............................. 38 prenatal ................................. 119 prevalite .................................. 22 previfem .................................. 38 PREZCOBIX ........................ 112 PREZISTA ........................... 113 PRIMAQUINE PHOSPHATE

.......................................... 106 primidone ................................ 88 PRISTIQ ................................. 94 PROAIR HFA ........................ 70 PROAIR RESPICLICK.......... 70 probenecid .............................. 10 procainamide hcl .................... 20 prochlorperazine ..................... 96

134

prochlorperazine edisylate..... 96, 107

prochlorperazine maleate 96, 107 PROCRIT ............................. 122 proctozone-hc ................... 29, 36 progesterone micronized ........ 41 PROGLYCEM ..................... 124 PROGRAF ............................. 48 PROLEUKIN ....................... 102 PROLIA ................................. 65 PROMACTA ........................ 122 propafenone hcl ...................... 20 propafenone hcl er .................. 20 proparacaine hcl ..................... 54 propranolol hcl ................. 14, 15 propranolol hcl er ................... 14 propranolol-hctz ..................... 18 propylthiouracil ...................... 45 PROQUAD............................. 50 protriptyline hcl ...................... 95 PROVENTIL HFA ................. 70 PULMOZYME....................... 66 PURIXAN ............................ 101 pyrazinamide .......................... 99 pyridostigmine bromide ......... 13 pyridostigmine bromide er ..... 13 Q

QUADRACEL ....................... 50 quasense ................................. 38 quetiapine fumarate ........ 56, 108 quinapril hcl............................ 23 quinapril-hydrochlorothiazide 18 quinidine gluconate er ............ 20 quinidine sulfate ..................... 20 quinine sulfate ...................... 106 QVAR..................................... 68 R

RABAVERT .......................... 50 raloxifene hcl .......................... 39 ramipril ................................... 23 RANEXA ............................... 19 ranitidine hcl ..................... 29, 30 RAPAMUNE ......................... 48 reclipsen ................................. 38 RECOMBIVAX HB .............. 50 REGRANEX .......................... 28 RELENZA DISKHALER .... 115 RELISTOR ............................. 29 REMICADE ........................... 48 REMODULIN ........................ 67 RENVELA ............................. 32

repaglinide .................... 123, 124 RESCRIPTOR ...................... 113 RESTASIS.............................. 54 RETROVIR .......................... 114 REVLIMID .................. 100, 102 REXULTI ............................. 108 REYATAZ ........................... 113 ribasphere ..................... 110, 111 RIBASPHERE.............. 110, 111 RIBASPHERE RIBAPAK ... 111 ribavirin ........................ 110, 111 RIDAURA .............................. 46 rifabutin .................................. 99 rifampin .................................. 99 RILUTEK ............................... 26 riluzole .................................... 26 rimantadine hcl ..................... 115 ringers ................................... 119 ringers irrigation ................... 119 risedronate sodium ........... 28, 65 RISPERDAL CONSTA 56, 108,

109 risperidone ...................... 57, 109 RITUXAN ............................ 100 rivastigmine tartrate ................ 10 rizatriptan benzoate ................ 58 ropinirole hcl .......................... 61 ropinirole hcl er ...................... 61 ROTARIX .............................. 50 ROTATEQ ............................. 50 ROZEREM ............................. 55 RUCONEST ........................... 45 S

SABRIL .................................. 88 SANDOSTATIN LAR DEPOT

............................................ 44 SANTYL ................................ 28 SAPHRIS........................ 57, 109 SAVELLA .............................. 24 SAVELLA TITRATION PACK

............................................ 24 selegiline hcl ........................... 61 selenium sulfide ...................... 28 SELZENTRY ....................... 115 SENSIPAR ............................. 43 SEREVENT DISKUS ............ 70 sertraline hcl ..................... 77, 94 sildenafil citrate ...................... 67 SILENOR ......................... 76, 95 silver sulfadiazine ................... 86 SIMBRINZA .......................... 52

SIMPONI ................................ 48 simvastatin .............................. 21 sirolimus ................................. 48 SIVEXTRO ............................ 80 sodium chloride ............ 117, 118 sodium lactate ....................... 119 sodium phenylbutyrate ........... 31 sodium polystyrene sulfonate

.......................................... 117 SOLARAZE ........................... 28 SOLTAMOX ........................ 105 SOMATULINE DEPOT ........ 44 SOMAVERT .......................... 44 SORIATANE ......................... 28 sorine ...................................... 20 sotalol hcl................................ 20 sotalol hcl (af) ......................... 20 SOVALDI............................. 111 SPIRIVA HANDIHALER ..... 68 SPIRIVA RESPIMAT ............ 68 spironolactone......................... 22 spironolactone-hctz................. 18 sprintec 28 .............................. 39 SPRYCEL............................. 104 sronyx ..................................... 39 ssd ........................................... 86 stavudine ............................... 114 STELARA .............................. 28 sterile water for irrigation ..... 119 STIVARGA .......................... 104 STRATTERA ......................... 25 STREPTOMYCIN SULFATE

............................................ 78 STRIBILD ............................ 112 STRIVERDI RESPIMAT ...... 70 sucralfate................................. 31 sulfacetamide sodium ....... 54, 86 sulfacetamide-prednisolone ... 13,

54 sulfadiazine ............................. 86 sulfamethoxazole-trimethoprim

............................................ 86 sulfasalazine ........................... 64 sulfazine ec ............................. 64 sulindac ............................. 11, 75 sumatriptan succinate ....... 58, 59 sumatriptan succinate refill ..... 58 SUPRAX .......................... 81, 82 SUPREP BOWEL PREP ...... 118 SURMONTIL ......................... 95 SUSTIVA ............................. 113

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SUTENT............................... 104 SYLATRON......................... 111 SYLVANT ........................... 101 SYMLINPEN 120 ................ 124 SYMLINPEN 60 .................. 124 SYNAGIS............................... 45 SYNAREL ............................. 44 SYNERCID ............................ 80 SYNRIBO ............................ 102 SYNTHROID ......................... 43 SYPRINE ............................. 117 T

TABLOID ............................ 101 tacrolimus ......................... 28, 48 TAFINLAR .......................... 104 TAMIFLU ............................ 115 tamoxifen citrate ................... 105 tamsulosin hcl ......................... 31 TARCEVA ........................... 104 TARGRETIN ....................... 105 TASIGNA ............................ 104 TASMAR ............................... 60 TAZORAC ............................. 28 taztia xt ................................... 16 TEFLARO .............................. 82 TEGRETOL ..................... 58, 89 TEGRETOL-XR ........ 58, 89, 90 temazepam .............................. 56 TENIVAC .............................. 50 terazosin hcl...................... 14, 31 terbinafine hcl ......................... 98 terbutaline sulfate ................... 70 terconazole ............................. 98 testosterone ............................. 40 testosterone cypionate ............ 40 testosterone enanthate ............ 40 TETANUS-DIPHTHERIA

TOXOIDS TD .................... 50 tetrabenazine........................... 26 THALOMID......................... 100 theophylline ............................ 71 theophylline er .................. 70, 71 thioridazine hcl ..................... 107 thiotepa ................................. 100 thiothixene ............................ 107 tiagabine hcl ........................... 88 TIKOSYN .............................. 20 timolol maleate ........... 15, 52, 59 TIVICAY ............................. 112 tizanidine hcl .................. 64, 126 tobramycin .............................. 78

tobramycin sulfate .................. 78 tobramycin-dexamethasone .... 54 tolazamide ............................ 124 tolbutamide ........................... 124 tolcapone ................................ 60 tolmetin sodium ................ 11, 75 topiramate ......................... 59, 91 topiramate er ........................... 91 torsemide ................................ 22 TPN ELECTROLYTES ....... 119 TRACLEER ........................... 67 TRADJENTA ....................... 124 tramadol hcl ............................ 73 tramadol-acetaminophen ........ 72 trandolapril ............................. 23 tranexamic acid..................... 121 TRANSDERM-SCOP ...... 30, 96 tranylcypromine sulfate .......... 93 travoprost ................................ 54 trazodone hcl .......................... 93 TREANDA ................... 100, 102 TRECATOR ........................... 99 TRELSTAR MIXJECT .......... 44 tretinoin .......................... 28, 105 triamcinolone acetonide ... 36, 55 triamterene-hctz ...................... 18 triderm .................................... 36 trifluoperazine hcl................. 107 trifluridine ............................. 111 trihexyphenidyl hcl ................. 61 tri-legest fe .............................. 39 TRILEPTAL ........................... 90 trimethoprim ........................... 80 trinessa (28) ............................ 39 tri-previfem ............................. 39 tri-sprintec .............................. 39 TRIUMEQ ............................ 115 trivora (28) .............................. 39 trospium chloride .................... 32 TRUMENBA.......................... 50 TRUVADA .......................... 114 TWINRIX ............................... 50 TYBOST .............................. 115 TYGACIL .............................. 80 TYKERB .............................. 104 TYPHIM VI ........................... 51 TYSABRI ......................... 26, 46 TYZEKA .............................. 110 TYZINE.................................. 66 U

unithroid ................................. 43

ursodiol ................................... 29 V

VAGIFEM .............................. 41 valacyclovir hcl .................... 111 VALCHLOR .................. 28, 100 VALCYTE ........................... 109 valganciclovir hcl ................. 109 valproate sodium .................... 88 valproic acid ............... 58, 59, 88 valsartan .................................. 19 valsartan-hydrochlorothiazide 18 vancomycin hcl ....................... 80 vandazole ................................ 80 VAQTA .................................. 51 VARIVAX .............................. 51 VARIZIG ................................ 51 VELCADE ........................... 102 velivet ..................................... 39 venlafaxine hcl.................. 77, 94 venlafaxine hcl er ............. 77, 94 verapamil hcl .......................... 16 verapamil hcl er ...................... 16 veripred 20 .................. 13, 36, 64 VERSACLOZ....................... 107 VEXOL................................... 53 VFEND ................................... 99 vicodin .................................... 72 vicodin es ................................ 72 vicodin hp ............................... 72 VIDEX .................................. 114 VIGAMOX ............................. 86 VIIBRYD ............................... 94 VIMPAT ................................. 90 VIRACEPT........................... 113 VIRAMUNE XR .................. 113 VIRAZOLE .................. 110, 111 VIREAD ....................... 110, 114 VIROPTIC ............................ 111 VITEKTA ............................. 112 VOLTAREN..................... 28, 75 voriconazole ........................... 99 VOTRIENT .......................... 104 VYFEMLA ............................. 39 VYTORIN .............................. 18 W

warfarin sodium .................... 121 WELCHOL..................... 22, 124 X

XALKORI ............................ 104 XARELTO ........................... 121

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XARELTO STARTER PACK .......................................... 121

XENAZINE ............................ 26 XGEVA .................................. 65 XIGDUO XR........................ 124 XOLAIR ................................. 66 XOPENEX HFA .................... 70 XTANDI............................... 100 XYREM ................................. 56 Y

YF-VAX ................................. 51 Z

zaleplon .................................. 56

ZALTRAP ............................ 102 ZAVESCA............................ 116 ZELBORAF ......................... 104 ZETIA .................................... 22 ZIAGEN ............................... 114 zidovudine ............................ 114 ziprasidone hcl ................ 57, 109 zoledronic acid ....................... 65 ZOLINZA ....................... 99, 103 zolpidem tartrate ..................... 56 zolpidem tartrate er ................. 56 ZOMETA ............................... 65 ZONALON ............................. 28

zonisamide .............................. 90 ZORTRESS ............................ 48 ZOSTAVAX........................... 51 zovia 1/35e (28) ...................... 39 zovia 1/50e (28) ...................... 39 ZYDELIG ............................. 103 ZYFLO ................................... 68 ZYFLO CR ............................. 68 ZYKADIA ............................ 104 ZYTIGA ............................... 100 ZYVOX .................................. 80

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Este formulario fue actualizado el 1 de diciembre de 2015. Para información más reciente, o para otras preguntas, por favor, comuníquese con el Departamento de Servicios al Afiliado de MMM al 787-620-2397 (Área Metro), 1-866-333-5470 (libre de cargos), o usuarios de TTY deben llamar al 1-866-333-5469, lunes a domingo de 8:00 a.m. a 8:00 p.m. o visite www.mmm-pr.com. MMM Healthcare, LLC es un plan HMO con un contrato Medicare. La afiliación en MMM depende de la renovación del contrato. Este documento podría estar disponible en diferentes formatos, incluyendo Braille, letras grandes, audio o en otros idiomas. Por favor comuníquese con nuestro número de Servicios al Afiliado al 787-620-2397 (Área Metro), 1-866-333-5470 (libre de cargos) para información adicional de lunes a domingo, de 8:00 a.m. a 8:00 p.m. (Usuarios TTY deben llamar al 1-866-333-5469). Servicios al Afiliado también ofrece servicios de intérprete de idiomas de manera gratuita para afiliados que no hablen español. This document may be available in alternate formats such as Braille, large print, audio or other languages. Please contact our Member Services number at 787-620-2397 (Metro Area) or 1-866-333-5470 (toll free) for additional information, Monday through Sunday; from 8:00 a.m. to 8:00 p.m. (TTY users should call 1-866-333-5469). Member Services also offers free language interpreter services available for non-Spanish speaking members. H4003 – MMM Healthcare, LLC Y0049_2015 1085 0002 2 File & Use 09022014 CMS Accepted

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