Lista de Medicamentos Cubiertos Vademécum de 2016

GuildNet
Gold Plus FIDA Plan

MMP-POS
Lista de medicamentos cubiertos (Vademécum) de 2016
Este vademécum se actualizó el 8/19/2015. Para obtener información más reciente o si tiene otras preguntas,
comuníquese con el Plan al 800-815-0000 o, para usuarios de teléfonos de texto (TTY), al 800-662-1220. Se atiende de
lunes a domingo, de 8 a.m. a 8 p.m., o visite www.guildnetny.org.
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H0811_GN252Sp_MEM16_Formulary_Accepted
GuildNet Gold Plus FIDA Plan | 2016
Lista de medicamentos cubiertos (Vademécum)
Esta es una lista de medicamentos que pueden recibir los participantes del plan GuildNet Gold
Plus FIDA.
 El GuildNet Gold Plus FIDA es un plan de gestión de cuidados que trabaja con Medicare y el
Departamento de Salud del estado de Nueva York (Medicaid) para proporcionar los
beneficios de ambos programas a los participantes a través de la demostración Fully
Integrated Duals Advantage (FIDA).
 La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores puede cambiar a lo
largo del año. Le enviaremos una notificación antes de hacer algún cambio que le pueda afectar.
 Los beneficios pueden cambiar el 1º de enero de cada año.
 Siempre puede revisar la lista actualizada de medicamentos cubiertos del plan GuildNet Gold
Plus FIDA en www.guildnetny.org o llamando a Servicios del Participante al número 1-800-
815-0000. Los usuarios de TTY/TDD, deben llamar al 1-800-662-1220.
 Puede haber limitaciones y restricciones. Para obtener más información, llame a Servicios del
Participante del plan GuildNet Gold Plus FIDA o lea el Manual del Participante de GuildNet
Gold Plus FIDA Plan.
 No se aceptan copagos por ningún medicamento cubierto.
 Puede obtener esta información de forma gratuita en otros formatos como letra grande, braille
o audio. Llame al 1-800-815-0000 o TTY 1-800-662-1220 entre las 8 a.m. y las 8 p.m., de
lunes a domingo. La llamada es gratuita.
 You can get this information for free in other languages. Call 1-800-815-0000 or TTY/TDD
1-800-662-1220, Monday through Sunday, 8am to 8pm. The call is free.
 Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o
TTY/TDD al 1-800-662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis.
 Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde
1-800-815-0000 o 1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD),
da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita.
Si tiene alguna pregunta, llame al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a
? domingo, de 8 a.m. a 8 p.m. Los usuarios de TTY/TDD deben llamar al 1-800-662-1220. La
llamada es gratuita. Para más información, visite www.guildnetny.org.
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 您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／語障人士專線
(TTY/TDD) 1-800-662-1220，星期一至星期日上午 8 時至晚上 8 時。撥打該電話免費。
 Вы можете бесплатно получить эту информацию на других языках. Позвоните по

телефону 1-800-815-0000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника
по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный.
 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa
TTY/TDD 1-800-662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis.
 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후

8시 사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는
무료입니다.
 El estado de Nueva York ha creado un programa de defensoría del participante llamado

Independent Consumer Advocacy Network (ICAN) para proporcionarle a los participantes
ayuda confidencial y gratuita en cualquier servicio ofrecido por el plan GuildNet Gold Plus
FIDA. Puede comunicarse con ICAN llamando gratis al 1-844-614-8800 o en línea en
icannys.org.
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Preguntas frecuentes (FAQ)
Aquí podrá encontrar respuestas a sus preguntas acerca de la lista de medicamentos cubiertos.
Puede leer todas las FAQ para obtener información o buscar una pregunta con su respuesta.
1. ¿Qué medicamentos de prescripción están en la lista de

medicamentos cubiertos?
(llamaremos a la lista de medicamentos cubiertos la “lista de
medicamentos” para abreviar).
Los medicamentos de la lista de medicamentos cubiertos que empieza en la página 2 son los
medicamentos cubiertos por el plan GuildNet Gold Plus FIDA. Estos medicamentos están
disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos
un acuerdo con ellos para que trabajen con nosotros y le brinden servicios. Denominamos a
estas farmacias “farmacias de la red”.
 El plan GuildNet Gold Plus FIDA cubrirá todos los medicamentos de la lista de medicamentos si:
 su médico u otro recetador de la red le dice que necesita los medicamentos para mejorar
su salud o mantenerse saludable;
 el medicamento es médicamente necesario para su enfermedad y
 usted surte la prescripción en una farmacia de la red del plan GuildNet Gold Plus FIDA.
 El plan GuildNet Gold Plus FIDA puede tener pasos adicionales para acceder a ciertos
medicamentos (consulte la pregunta no. 5 a continuación). En algunos casos, es posible que
deba hacer algo antes de poder recibir su medicamento, como probar otros primero.
También puede ver una lista actualizada de medicamentos que cubrimos en nuestro sitio web en
www.guildnetny.org o llamar a Servicios para Participantes al 1-800-815-0000. Los usuarios de
TTY/TDD, deben llamar al 1-800-662-1220.
2. ¿La lista de medicamentos cambia en algún momento?

Sí. El plan GuildNet Gold Plus FIDA puede agregar o quitar medicamentos de la lista de
medicamentos durante el año. Por lo general, la lista de medicamentos solo cambia si:
 aparece un nuevo medicamento que funciona tan bien como un medicamento que está en
la lista de medicamentos actual o
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 tenemos conocimiento de que un medicamento no es seguro.
También podemos cambiar nuestras normas sobre los medicamentos. Por ejemplo, podemos:
 Decidir si exigiremos o no una aprobación previa para un medicamento. (La aprobación

previa es el permiso del plan GuildNet Gold Plus FIDA o de su equipo interdisciplinario
(IDT) antes de que pueda obtener un medicamento).
 Agregar o cambiar la cantidad de medicamento que puede recibir (llamado “cantidades limitadas”).
 Agregar o cambiar restricciones de terapia escalonada sobre un medicamento. (Terapia
escalonada significa que debe probar un medicamento antes de que cubramos otro).
(Para obtener más información sobre estas normas de medicamentos consulte la página iv.)
Le informaremos cuando un medicamento que esté tomando se elimine de la lista de

medicamentos. También le informaremos cuando cambiemos nuestras normas para la cobertura
de un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que
sucede cuando cambia la lista de medicamentos.
 Siempre puede consultar la lista de medicamentos actualizada del plan GuildNet Gold Plus
FIDA en línea en www.guildnetny.org. También puede llamar a Servicios para Participantes
al 1-800-815-0000 para verificar la lista de medicamentos actual. Los usuarios de TTY/TDD,
deben llamar al 1-800-662-1220.
3. ¿Qué sucede cuando aparece un medicamento más económico

que funciona tan bien como un medicamento actual de la lista de
medicamentos?
Si aparece un medicamento más económico que funciona tan bien como un medicamento actual
de la lista de medicamentos:
 Su farmacéutico puede darle el medicamento más económico la próxima vez que usted
surta su prescripción. Si usted y su proveedor deciden que el medicamento más
económico no es conveniente para usted, su proveedor puede informar al farmacéutico
que debe seguir entregándole el medicamento que toma actualmente.
 El plan GuildNet Gold Plus FIDA puede decidir eliminar el medicamento más costoso de
la lista de medicamentos. Si usted toma un medicamento que eliminamos de la lista de
medicamentos porque aparece un medicamento más económico que funciona igual, le
iv
informaremos al menos 60 días antes de eliminarlo de la lista de medicamentos o cuando
usted solicite el resurtido. Entonces podrá recibir un suministro de 60 días del
medicamento antes de que se haga el cambio en la lista de medicamentos. Recibirá una
carta al menos 60 días antes de la entrada en vigencia del cambio.
4. ¿Qué sucede cuando descubrimos que un medicamento no es seguro?

Si la Administración de Drogas y Alimentos (FDA) indica que un medicamento que usted toma no
es seguro, lo quitaremos de la lista de medicamentos de inmediato. También le enviaremos una
carta y lo llamaremos para informarle que el medicamento no seguro se ha eliminado de la lista
de medicamentos. Si recibe esta carta, debe llamar a su administrador de atención o médico que
emite la prescripción para obtener una prescripción de reemplazo.
5. ¿Existen restricciones o límites sobre la cobertura de

medicamentos? ¿O hay algo que deba hacer para poder obtener
ciertos medicamentos?
Sí, algunos medicamentos tienen normas de cobertura o límites respecto de la cantidad que
puede recibir. En algunos casos, usted, su médico o algún otro recetador deben hacer algo antes
de poder obtener el medicamento. Por ejemplo:
 Aprobación previa (o autorización previa): Para algunos medicamentos, usted, su

médico u otro recetador deben obtener aprobación del plan GuildNet Gold Plus FIDA o de
su equipo interdisciplinario (IDT) antes de surtir la prescripción. Si no recibe la aprobación,
el plan GuildNet Gold Plus FIDA tal vez no cubra el medicamento.
 Cantidades limitadas: En ocasiones, el plan GuildNet Gold Plus FIDA limita la cantidad de
medicamento que puede obtener
 Terapia escalonada: A veces el plan GuildNet Gold Plus FIDA le exige realizar una terapia
escalonada. Esto significa que tendrá que probar medicamentos en un cierto orden para su
enfermedad. Es posible que deba probar un medicamento antes de que cubramos otro. Si
su médico considera que el primer medicamento no es conveniente para usted, entonces
cubriremos el segundo.
Puede saber si su medicamento tiene límites o requisitos adicionales consultando las tablas que
aparecen a partir de la página 2. También puede obtener más información al visitar nuestro sitio
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web www.guildnetny.org Publicamos en línea documentos que explican nuestras restricciones de
autorización previa y terapia escalonada. También puede pedirnos una copia.
Puede solicitar una “excepción” a estos límites. Consulte la pregunta 11 para obtener más
información sobre las excepciones.
 Si se encuentra en un centro de cuidados para ancianos u otro centro de atención prolongada

y necesita un medicamento que no está en la lista de medicamentos, o si no puede obtener
con facilidad el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de
emergencia de 31 días del medicamento que necesite (a menos que tenga una prescripción
para menos días), sea o no un nuevo participante del plan GuildNet Gold Plus FIDA. Esto le
dará tiempo para hablar con su médico u otro recetador. Este lo podrá ayudar a decidir si
existe un medicamento similar en la lista de medicamentos que pueda tomar en lugar del otro
o si debe solicitar una excepción. Consulte la pregunta 11 para obtener más información
sobre las excepciones.
6. ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si

hay algo que debe hacer para obtener el medicamento?
La lista de medicamentos cubiertos de la página 2 tiene una columna llamada “Acciones
necesarias, restricciones o límites sobre el uso”.
7. ¿Qué sucede si cambiamos nuestras normas sobre cómo cubrimos

ciertos medicamentos? Por ejemplo, si agregamos la autorización
previa (aprobación), cantidades limitadas o restricciones de terapia
escalonada a un medicamento.
Le informaremos si agregamos la aprobación previa, cantidades limitadas o restricciones de
terapia escalonada a un medicamento. Le informaremos al menos 60 días antes de agregar la
restricción o la próxima vez que solicite un resurtido. Entonces podrá recibir un suministro de 60
días del medicamento antes de que se haga el cambio en la lista de medicamentos. Esto le dará
tiempo para hablar con su médico u otro recetador sobre qué se debe hacer a continuación.
8. ¿Cómo puede encontrar un medicamento en la lista de

medicamentos?
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Existen dos maneras de encontrar un medicamento:
 Puede buscar por orden alfabético (si sabe cómo se escribe el nombre del medicamento) o
 Puede buscar por enfermedad.
Para buscar por orden alfabético, ingrese en la sección de Listado alfabético en la página 137.
Luego busque el nombre de su medicamento en la lista.
Para buscar por enfermedad, encuentre la sección titulada “Lista de medicamentos por
enfermedad” en la página 2. Luego busque su enfermedad. Por ejemplo, si tiene una enfermedad
cardíaca, deberá buscar en la categoría: Cardiovascular, Hipertensión/Lípidos. Allí es donde
encontrará los medicamentos para tratar enfermedades cardíacas.
9. ¿Qué sucede si el medicamento que desea tomar no aparece en la

lista de medicamentos?
Si no ve su medicamento en la lista de medicamentos, llame a Servicios para Participantes al
1-800-815-0000 (los usuarios de TTY/TDD deben llamar al 1-800-662-1220) y consulte al respecto. Si
se entera de que el plan GuildNet Gold Plus FIDA no cubre el medicamento, puede hacer lo siguiente:
 Pida a Servicios para Participantes que le brinde una lista de los medicamentos que sean
como el que usted desea. Luego, muestre la lista a su médico o recetador. Este puede recetar
un medicamento de la lista de medicamentos que sea similar al que usted desea. O bien
 Puede pedir al plan o a su equipo interdisciplinario (IDT) que hagan una excepción para
cubrir su medicamento. Consulte la pregunta 11 para obtener más información sobre las
excepciones.
10. ¿Qué sucede si es un nuevo participante del plan GuildNet Gold

Plus FIDA y no puede encontrar su medicamento en la lista de
medicamentos o tiene un problema para obtener su medicamento?
Podemos ayudarlo. Debemos cubrir hasta 90 días de suministros temporales de su
medicamento, según sea necesario, durante los primeros 90 días en que usted sea participante
del plan GuildNet Gold Plus FIDA. Esto le dará tiempo para hablar con su médico u otro
recetador. Este lo podrá ayudar a decidir si existe un medicamento similar en la lista de
medicamentos que pueda tomar en lugar del otro o si debe solicitar una excepción.
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Cubriremos hasta 90 días de suministros temporales de su medicamento si:
 toma un medicamento que no está en nuestra lista de medicamentos o
 las normas del plan de salud no le permiten recibir la cantidad que ordenó su recetador o
 el medicamento requiere la aprobación previa del plan GuildNet Gold Plus FIDA o de su
equipo interdisciplinario (IDT) o
 toma un medicamento que forma parte de una restricción de terapia escalonada.
Si vive en un centro de cuidados para ancianos u otro centro de atención prolongada, puede
resurtir su prescripción
hasta por 98 días. Durante esos 90 días, puede resurtir el medicamento múltiples veces. Esto le
da tiempo al recetador para que cambie sus medicamentos por aquellos que aparecen en la lista
de medicamentos o para que pida una excepción.
Si es miembro actual de nuestro plan y experimenta un cambio en el nivel de atención, como una
admisión o alta de un centro de atención prolongada, tendrá permitido un resurtido anticipado de sus
medicamentos, según sea necesario, para ayudarlo en la transición a su nuevo nivel de atención.
11. ¿Puede solicitar una excepción para cubrir su medicamento?
Sí. Puede solicitar al plan GuildNet Gold Plus FIDA o a su equipo interdisciplinario (IDT) que
haga una excepción para cubrir un medicamento que no aparece en la lista de medicamentos.
También puede solicitar al plan GuildNet Gold Plus FIDA o a su IDT que cambie las normas
sobre su medicamento.
 Por ejemplo, el plan GuildNet Gold Plus FIDA puede limitar la cantidad de medicamento
que cubriremos. Si su medicamento tiene un límite, puede solicitarnos, tanto a nosotros
como a su IDT, que cambiemos el límite para cubrir más.
 Otros ejemplos: Puede solicitarnos, a nosotros o a su IDT, que eliminemos las restricciones
de terapia escalonada o los requisitos de aprobación previa.
12. ¿Cuánto tarda en obtenerse una excepción?
Primero, el plan GuildNet Gold Plus FIDA o su equipo interdisciplinario (IDT) deben recibir una
declaración del recetador, fundamentando su solicitud de excepción. Después de recibir la
declaración, usted recibirá una decisión sobre su solicitud de excepción en un plazo de 72 horas.
viii
Si usted o el recetador consideran que su salud puede verse perjudicada si tiene que esperar 72
horas para obtener la decisión, puede solicitar una excepción acelerada. Esta es una decisión
más rápida. Si el recetador fundamenta su solicitud, recibirá la decisión en un plazo de 24 horas
desde la recepción de la declaración respaldatoria del recetador.
13. ¿Cómo puede solicitar una excepción?
Para solicitar una excepción, llame a su administrador de atención. Su administrador de atención

trabajará con usted y su proveedor para ayudarlo a solicitar una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos tienen la misma composición de ingredientes que los de marca.
Generalmente tienen un costo menor que los de marca y no tienen nombres conocidos. Los
medicamentos genéricos están aprobados por la Administración de Drogas y Alimentos (FDA).
El plan GuildNet Gold Plus FIDA cubre tanto medicamentos de marca como genéricos.
15. ¿Qué son los medicamentos OTC?
OTC viene del inglés over-the-counter que significa medicamentos de venta libre. El plan GuildNet
Gold Plus FIDA cubre algunos medicamentos de venta libre cuando su proveedor los prescribe.
Puede consultar la lista de medicamentos del plan GuildNet Gold Plus FIDA para saber qué
medicamentos de venta libre están cubiertos.
Los ejemplos de medicamentos de venta libre cubiertos son: aspirina, paracetamol, Advil,
antiácidos, medicamentos para refriados y alergias, cremas antibióticas, laxantes, parches y
chicles de nicotina y vitaminas.
16. ¿Cubre el plan GuildNet Gold Plus FIDA los productos de venta
libre que no sean medicamentos?
El plan GuildNet Gold Plus FIDA cubre algunos productos de venta libre que no son
medicamentos cuando su proveedor los prescribe.
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Puede consultar la lista de medicamentos del plan GuildNet Gold Plus FIDA para saber qué
productos de venta libre que no son medicamentos están cubiertos. Los ejemplos incluyen:
protectores solares (SPF 15+), champú tópico Sebex y pomada A&D.
Los artículos adicionales de venta libre que no están incluidos en la lista de medicamentos se
pueden obtener usando su tarjeta OTC del plan GuildNet Gold Plus FIDA en alguna farmacia
participante. Los artículos cubiertos por su tarjeta del Plan OTC incluyen: curitas, caramelos para
la tos, dentífrico y medias de soporte médico de alta y baja compresión. Para mayor información,
lea el Capítulo 4 de su Manual del Participante.
17. ¿Cuál es su copago?
No se le cobrará copago por medicamentos de la lista de medicamentos.
18. ¿Qué son los niveles de medicamentos?
Cada medicamento de la lista de medicamentos cubiertos pertenece a uno de estos cuatro niveles.
 Nivel 1: medicamentos genéricos de Medicare Parte D.
 Nivel 2: medicamentos de marca de Medicare Parte D.
 Nivel 3: medicamentos prescritos cubiertos por Medicaid (no de la Parte D).
 Nivel 4: artículos de venta libre (OTC).
Todos los medicamentos y artículos de nuestra lista de medicamentos tienen un copago de $0.
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Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la siguiente página le brinda información
sobre los medicamentos cubiertos por el plan GuildNet Gold Plus FIDA. Si tiene problemas para
encontrar su medicamento en la lista, consulte el ìndice que comienza en la página 137.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca
aparecen en mayúsculas (por ejemplo, SYNTHROID) y los genéricos aparecen en minúscula y
cursiva (por ejemplo, atenolol).
La información en la columna de acciones necesarias, restricciones o límites sobre el uso le

informa si el plan GuildNet Gold Plus FIDA tiene normas para cubrir su medicamento.
Nota: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la

Parte D”. Estos medicamentos tienen normas diferentes para las apelaciones. Una apelación es
una manera formal de pedir una revisión y cambio en la decisión de cobertura si usted considera
que hubo un error. Por ejemplo, el plan GuildNet Gold Plus FIDA o su equipo interdisciplinario
(IDT) pueden decidir que un medicamento que usted desea no esté cubierto o que Medicare o
Medicaid dejen de cubrirlo.
Si usted, su doctor o algún otro recetador no está de acuerdo con la decisión, puede apelar. Para
solicitar instrucciones sobre cómo apelar, llame a Servicios para Participantes al 1-800-815-0000
(los usuarios de TTY/TDD deben llamar al 1-800-662-1220) o a Defensoría del Participante de
FIDA al 1-844-614-8800 (TTY 711). También puede leer el Manual del Participante para saber
cómo apelar una decisión.
xi
xii
Abajo podrá encontrar una lista de abreviaciones que pueden aparecer en las siguientes páginas en la columna
de requerimientos/límites, que le dice si hay algún requerimiento especial para el financiamiento de su
medicamento.
Lista de abreviaciones
*: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la Parte D”.

Estos medicamentos tienen normas diferentes para las apelaciones. Una apelación es una manera formal de
pedir una revisión y cambio en la decisión de cobertura si usted considera que hubo un error. Por ejemplo, el
plan GuildNet Gold Plus FIDA o su equipo interdisciplinario (IDT) pueden decidir que un medicamento que
usted desea no esté cubierto o que Medicare o Medicaid dejen de cubrirlo. Si usted, su doctor o algún otro
recetador no está de acuerdo con la decisión, puede apelar. Para solicitar instrucciones sobre cómo apelar,
llame a Servicios para Participantes al 1-800-815-0000; los usuarios de TTY/TDD deben llamar al 1-800-662-
1220 o a la Defensoría del Participante (ICAN) al 1-844-614-8800. También puede leer el Manual del
Participante para saber cómo apelar una decisión.
B/D PA: Este medicamento de prescripción puede estar cubierto por Medicare Parte B o D, dependiendo de
las circunstancias. Puede ser necesario presentar información que describa el uso y entorno del medicamento
para poder determinarlo.
LA: Disponibilidad limitada. Este medicamento de prescripción puede estar disponible solo en ciertas
farmacias. Para obtener más información, llame a Servicios al Cliente.
MO: Medicamento de pedido por correo. Este medicamento por prescripción está disponible a través de
nuestro servicio de pedido por correo, así como también a través de nuestra red de farmacias minoristas.
Considere usar el servicio de pedido por correo para sus medicamentos a largo plazo (de mantenimiento,
como los medicamentos para la hipertensión). Las red de farmacias minoristas pueden ser más adecuadas para
las prescripciones a corto plazo (como los antibióticos).
PA: Autorización previa. El plan le exige a usted o a su médico obtener autorización previa para ciertos
medicamentos Esto significa que deberá recibir la aprobación antes de surtir sus prescripciones. Si no recibe
aprobación, tal vez no cubramos el medicamento.
QL: Cantidades limitadas. Para ciertos medicamentos, el plan limita la cantidad que cubriremos.
ST: Terapia escalonada. En algunos casos el plan le exige que primero pruebe otros medicamentos para tratar
su enfermedad, antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento
A y el B tratan su enfermedad, tal vez no cubramos el Medicamento B a menos que usted pruebe el A
primero. Si el Medicamento A no es adecuado para usted, cubriremos el B.
Lista de medicamentos por enfermedad

Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de enfermedad para el
que es usado. Por ejemplo, si tiene una enfermedad cardíaca, deberá buscar en la categoría: Cardiovascular,
Hipertensión/Lípidos. Allí es donde encontrará los medicamentos para tratar enfermedades cardíacas.
Si tiene alguna pregunta, llame Al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a domingo
entre las 8 a.m. y las 8 p.m. Los usuarios de TTY/TDD, deben llamar al 1-800-662-1220. La llamada es
gratuita. Para más información, visite www.guildnetny.org.
1
NOMBRE DEL MEDICAMENTO NIVEL CUÁNTO LE ACCIONES NECESARIAS,
COSTARÁ EL RESTRICCIONES O
MEDICAMENTO LÍMITES DE USO
ANTIINFECCIOSOS
AGENTES ANTIFÚNGICOS
ABELCET INTRAVENOUS SUSPENSION 2 $0 B/D PA; MO
AMBISOME INTRAVENOUS SUSPENSION 2 $0 B/D PA; MO
FOR RECONSTITUTION
amphotericin b injection recon soln 1 $0 B/D PA; MO
CANCIDAS INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
clotrimazole mucous membrane troche 1 $0 MO
fluconazole in dextrose(iso-o) intravenous 1 $0 B/D PA
piggyback 400 mg/200 ml
fluconazole oral suspension for reconstitution 1 $0 MO
fluconazole oral tablet 1 $0 MO
flucytosine oral capsule 1 $0 MO
griseofulvin microsize oral suspension 1 $0 MO
griseofulvin microsize oral tablet 1 $0 MO
griseofulvin ultramicrosize oral tablet 1 $0 MO
itraconazole oral capsule 1 $0 MO; QL (120 per 30 days)
ketoconazole oral tablet 1 $0 MO
NOXAFIL ORAL SUSPENSION 2 $0 MO
nystatin oral suspension 1 $0 MO
nystatin oral tablet 1 $0 MO
terbinafine hcl oral tablet 1 $0 MO; QL (90 per 365 days)
voriconazole intravenous solution 1 $0 B/D PA; MO
VORICONAZOLE ORAL SUSPENSION 2 $0 MO
FOR RECONSTITUTION
VORICONAZOLE ORAL TABLET 200 MG 2 $0 MO
voriconazole oral tablet 50 mg 1 $0 MO
ANTIVIRALES
abacavir oral tablet 1 $0 MO
Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.
Si tiene alguna pregunta, llame al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a domingo
2
abacavir-lamivudine-zidovudine oral tablet 1 $0 MO
acyclovir oral capsule 1 $0 MO
acyclovir oral suspension 200 mg/5 ml 1 $0 MO
acyclovir oral tablet 1 $0 MO
acyclovir sodium intravenous solution 1 $0 B/D PA; MO
ADEFOVIR ORAL TABLET 2 $0 MO
amantadine hcl oral capsule 1 $0 MO
amantadine hcl oral solution 1 $0 MO
amantadine hcl oral tablet 1 $0 MO
APTIVUS ORAL CAPSULE 2 $0 MO
APTIVUS ORAL SOLUTION 2 $0
ATRIPLA ORAL TABLET 2 $0 MO
BARACLUDE ORAL SOLUTION 2 $0 MO
CIDOFOVIR INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
COMPLERA ORAL TABLET 2 $0 MO
CRIXIVAN ORAL CAPSULE 200 MG, 400 2 $0 MO
MG
didanosine oral capsule,delayed release(dr/ec) 1 $0 MO
EDURANT ORAL TABLET 2 $0 MO
EMTRIVA ORAL CAPSULE 2 $0 MO
EMTRIVA ORAL SOLUTION 2 $0 MO
ENTECAVIR ORAL TABLET 2 $0 MO
EPIVIR HBV ORAL SOLUTION 2 $0 MO
EPIVIR ORAL SOLUTION 2 $0 MO
EPZICOM ORAL TABLET 2 $0 MO
EVOTAZ ORAL TABLET 2 $0 MO
famciclovir oral tablet 125 mg 1 $0 MO; QL (21 per 10 days)
3
foscarnet intravenous solution 1 $0 MO
FUZEON SUBCUTANEOUS RECON SOLN 2 $0 MO
ganciclovir sodium intravenous recon soln 1 $0 B/D PA; MO
HARVONI ORAL TABLET 2 $0 PA; MO; QL (28 per 28 days)
INTELENCE ORAL TABLET 100 MG, 200 2 $0 MO
MG
INTELENCE ORAL TABLET 25 MG 2 $0
INVIRASE ORAL CAPSULE 2 $0 MO
INVIRASE ORAL TABLET 2 $0 MO
ISENTRESS ORAL POWDER IN PACKET 2 $0 MO
ISENTRESS ORAL TABLET 2 $0 MO
ISENTRESS ORAL TABLET,CHEWABLE 2 $0 MO
KALETRA ORAL SOLUTION 2 $0 MO
KALETRA ORAL TABLET 2 $0 MO
lamivudine oral solution 1 $0 MO
lamivudine oral tablet 1 $0 MO
LAMIVUDINE-ZIDOVUDINE ORAL 2 $0 MO
TABLET
LEXIVA ORAL SUSPENSION 2 $0 MO
LEXIVA ORAL TABLET 2 $0 MO
nevirapine oral suspension 1 $0 MO
nevirapine oral tablet 1 $0 MO
nevirapine oral tablet extended release 24 hr 1 $0 MO
NORVIR ORAL CAPSULE 2 $0 MO
NORVIR ORAL SOLUTION 2 $0 MO
NORVIR ORAL TABLET 2 $0 MO
PREZCOBIX ORAL TABLET 2 $0 MO
PREZISTA ORAL SUSPENSION 2 $0 MO
4
PREZISTA ORAL TABLET 150 MG, 600 2 $0 MO
MG, 75 MG, 800 MG
RELENZA DISKHALER INHALATION 2 $0 MO; QL (60 per 180 days)
BLISTER WITH DEVICE
RESCRIPTOR ORAL TABLET 2 $0 MO
RESCRIPTOR ORAL TABLET, 2 $0 MO
DISPERSIBLE
RETROVIR INTRAVENOUS SOLUTION 2 $0 MO
REYATAZ ORAL CAPSULE 150 MG, 200 2 $0 MO
MG, 300 MG
REYATAZ ORAL POWDER IN PACKET 2 $0 MO
ribavirin oral capsule 1 $0 PA; MO
ribavirin oral tablet 200 mg 1 $0 PA; MO
rimantadine oral tablet 1 $0 MO
SELZENTRY ORAL TABLET 2 $0 MO
SOVALDI ORAL TABLET 2 $0 PA; MO; QL (30 per 30 days)
stavudine oral capsule 1 $0 MO
stavudine oral recon soln 1 $0 MO
STRIBILD ORAL TABLET 2 $0 MO
SUSTIVA ORAL CAPSULE 2 $0 MO
SUSTIVA ORAL TABLET 2 $0 MO
SYNAGIS INTRAMUSCULAR SOLUTION 2 $0 PA; MO; LA
50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30 MG 2 $0 MO; QL (84 per 180 days)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG 2 $0 MO; QL (42 per 180 days)
TAMIFLU ORAL SUSPENSION FOR 2 $0 MO; QL (600 per 180 days)
RECONSTITUTION
TIVICAY ORAL TABLET 2 $0 MO
TRIUMEQ ORAL TABLET 2 $0 MO
TRUVADA ORAL TABLET 2 $0 MO
5
TYBOST ORAL TABLET 2 $0 MO
TYZEKA ORAL TABLET 2 $0 MO
valacyclovir oral tablet 1 $0 MO; QL (30 per 30 days)
VALCYTE ORAL RECON SOLN 2 $0 MO
VALGANCICLOVIR ORAL TABLET 2 $0 MO
VIDEX 2 GRAM PEDIATRIC ORAL 2 $0 MO
RECON SOLN
VIEKIRA PAK ORAL TABLETS,DOSE 2 $0 PA; MO; QL (112 per 28
PACK days)
VIRACEPT ORAL TABLET 2 $0 MO
VIRAMUNE XR ORAL TABLET 2 $0 MO
EXTENDED RELEASE 24 HR 100 MG
VIRAZOLE INHALATION RECON SOLN 2 $0 B/D PA; MO
VIREAD ORAL POWDER 2 $0 MO
VIREAD ORAL TABLET 2 $0 MO
VITEKTA ORAL TABLET 2 $0 MO
ZIAGEN ORAL SOLUTION 2 $0 MO
zidovudine oral capsule 1 $0 MO
zidovudine oral syrup 1 $0 MO
zidovudine oral tablet 1 $0 MO
CEFALOSPORINAS
cefaclor oral capsule 1 $0 MO
cefaclor oral tablet extended release 12 hr 1 $0 MO
cefadroxil oral capsule 1 $0 MO
cefadroxil oral suspension for reconstitution 1 $0 MO
250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 $0 MO
cefazolin in dextrose (iso-os) intravenous 1 $0 B/D PA; MO
piggyback 1 gram/50 ml, 2 gram/50 ml
6
cefazolin injection recon soln 1 gram, 500 mg 1 $0 B/D PA; MO
cefazolin injection recon soln 10 gram 1 $0 B/D PA
cefdinir oral capsule 1 $0 MO
cefdinir oral suspension for reconstitution 1 $0 MO
cefditoren pivoxil oral tablet 200 mg 1 $0 MO
cefepime injection recon soln 1 $0 B/D PA; MO
cefixime oral suspension for reconstitution 1 $0 MO
cefotaxime injection recon soln 1 gram, 2 1 $0 B/D PA
gram, 500 mg
cefotetan injection recon soln 1 $0
cefotetan intravenous recon soln 1 $0
cefoxitin in dextrose, iso-osm intravenous 1 $0 B/D PA
piggyback
cefoxitin intravenous recon soln 1 gram 1 $0 B/D PA; MO
cefoxitin intravenous recon soln 10 gram, 2 1 $0 B/D PA
gram
cefpodoxime oral suspension for reconstitution 1 $0 MO
cefpodoxime oral tablet 1 $0 MO
cefprozil oral suspension for reconstitution 1 $0 MO
cefprozil oral tablet 1 $0 MO
ceftazidime injection recon soln 1 gram, 2 1 $0 B/D PA; MO
gram
ceftazidime injection recon soln 6 gram 1 $0
ceftriaxone injection recon soln 10 gram 1 $0 B/D PA
ceftriaxone injection recon soln 250 mg, 500 1 $0 B/D PA; MO
mg
ceftriaxone intravenous recon soln 1 $0 B/D PA; MO
cefuroxime axetil oral tablet 1 $0 MO
cefuroxime sodium injection recon soln 1.5 1 $0 B/D PA; MO
gram, 750 mg
7
cefuroxime sodium intravenous recon soln 1 $0 B/D PA
cephalexin oral capsule 1 $0 MO
cephalexin oral suspension for reconstitution 1 $0 MO
cephalexin oral tablet 1 $0 MO
SUPRAX ORAL CAPSULE 2 $0 MO
SUPRAX ORAL SUSPENSION FOR 2 $0 MO
RECONSTITUTION 100 MG/5 ML, 200
MG/5 ML
SUPRAX ORAL SUSPENSION FOR 2 $0
RECONSTITUTION 500 MG/5 ML
SUPRAX ORAL TABLET,CHEWABLE 2 $0 MO
TEFLARO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
ERITROMICINAS / OTROS MACRÓLIDOS
azithromycin intravenous recon soln 500 mg 1 $0 B/D PA; MO
azithromycin intravenous recon soln 500 mg (2 1 $0 B/D PA
mg/ml)
azithromycin oral packet 1 $0 MO
azithromycin oral suspension for reconstitution 1 $0 MO
azithromycin oral tablet 1 $0 MO
clarithromycin oral suspension for 1 $0 MO
reconstitution
clarithromycin oral tablet 1 $0 MO
clarithromycin oral tablet extended release 24 1 $0 MO
hr
e.e.s. 400 oral tablet 1 $0 MO
ERYPED 200 ORAL SUSPENSION FOR 2 $0 MO
RECONSTITUTION
ERYTHROCIN (AS STEARATE) ORAL 2 $0 MO
TABLET 250 MG
ERYTHROCIN INTRAVENOUS RECON 2 $0 B/D PA
SOLN 500 MG
8
erythromycin ethylsuccinate oral tablet 1 $0 MO
erythromycin oral capsule,delayed 1 $0 MO
release(dr/ec)
erythromycin oral tablet 1 $0 MO
ANTIINFECCIOSOS DIVERSOS
ALBENZA ORAL TABLET 2 $0 MO
ALINIA ORAL SUSPENSION FOR 2 $0 MO; QL (180 per 30 days)
RECONSTITUTION
ALINIA ORAL TABLET 2 $0 MO; QL (12 per 30 days)
amikacin injection solution 500 mg/2 ml 1 $0 B/D PA; MO
ATOVAQUONE ORAL SUSPENSION 2 $0 MO
atovaquone-proguanil oral tablet 1 $0 MO
aztreonam injection recon soln 1 gram 1 $0 MO
baciim intramuscular recon soln 1 $0 B/D PA
bacitracin intramuscular recon soln 1 $0 B/D PA; MO
CAPASTAT INJECTION RECON SOLN 2 $0 B/D PA
CAYSTON INHALATION SOLUTION FOR 2 $0 MO; QL (84 per 28 days)
NEBULIZATION
chloramphenicol sod succinate intravenous 1 $0 B/D PA
recon soln
chloroquine phosphate oral tablet 1 $0 MO
clindamycin hcl oral capsule 1 $0 MO
clindamycin pediatric oral recon soln 1 $0
clindamycin phosphate intravenous solution 1 $0 B/D PA; MO
600 mg/4 ml
COARTEM ORAL TABLET 2 $0 MO
COLISTIN (COLISTIMETHATE NA) 2 $0 B/D PA; MO
INJECTION RECON SOLN
CUBICIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
CYCLOSERINE ORAL CAPSULE 1 $0 MO
9
DAPSONE ORAL TABLET 2 $0 MO
DARAPRIM ORAL TABLET 2 $0 MO
ethambutol oral tablet 1 $0 MO
gentamicin in nacl (iso-osm) intravenous 1 $0 B/D PA; MO
gentamicin in nacl (iso-osm) intravenous 1 $0 MO
gentamicin in nacl (iso-osm) intravenous 1 $0
piggyback 70 mg/50 ml, 80 mg/50 ml, 90
mg/100 ml
GENTAMICIN IN NACL (ISO-OSM) 2 $0 B/D PA
INTRAVENOUS PIGGYBACK 80 MG/100
ML
gentamicin injection solution 40 mg/ml 1 $0 B/D PA; MO
hydroxychloroquine oral tablet 1 $0 MO
imipenem-cilastatin intravenous recon soln 1 $0 B/D PA; MO
INVANZ INJECTION RECON SOLN 2 $0 B/D PA; MO
INVANZ INTRAVENOUS RECON SOLN 2 $0 B/D PA
isoniazid injection solution 1 $0
isoniazid oral solution 1 $0 MO
isoniazid oral tablet 1 $0 MO
ivermectin oral tablet 1 $0 MO
LINEZOLID INTRAVENOUS 2 $0 PA
PARENTERAL SOLUTION
LINEZOLID ORAL TABLET 2 $0 PA; MO
mefloquine oral tablet 1 $0 MO
meropenem intravenous recon soln 500 mg 1 $0 B/D PA; MO
metronidazole in nacl (iso-os) intravenous 1 $0 MO
piggyback
metronidazole oral capsule 1 $0 MO
10
metronidazole oral tablet 1 $0 MO
NEBUPENT INHALATION RECON SOLN 2 $0 B/D PA; MO
neomycin oral tablet 1 $0 MO
paromomycin oral capsule 1 $0 MO
PASER ORAL GRANULES DR FOR SUSP 2 $0 MO
IN PACKET
PENTAM INJECTION RECON SOLN 2 $0 B/D PA; MO
polymyxin b sulfate injection recon soln 1 $0
PRIFTIN ORAL TABLET 2 $0 MO
PRIMAQUINE ORAL TABLET 2 $0 MO
pyrazinamide oral tablet 1 $0 MO
quinine sulfate oral capsule 1 $0 PA; MO
rifabutin oral capsule 1 $0 MO
rifampin intravenous recon soln 1 $0 B/D PA; MO
rifampin oral capsule 1 $0 MO
SIRTURO ORAL TABLET 2 $0 MO; LA
STREPTOMYCIN INTRAMUSCULAR 2 $0 B/D PA; MO
RECON SOLN
SYNERCID INTRAVENOUS RECON SOLN 2 $0 B/D PA
tinidazole oral tablet 1 $0 MO
TOBRAMYCIN IN 0.225 % NACL 2 $0 B/D PA; MO
INHALATION SOLUTION FOR
NEBULIZATION
tobramycin in 0.9 % nacl intravenous 1 $0 MO
tobramycin sulfate injection solution 1 $0 B/D PA; MO
TRECATOR ORAL TABLET 2 $0 MO
TYGACIL INTRAVENOUS RECON SOLN 2 $0 MO
XIFAXAN ORAL TABLET 550 MG 2 $0 MO
11
ZYVOX INTRAVENOUS PARENTERAL 2 $0 PA; MO
SOLUTION 600 MG/300 ML
ZYVOX ORAL SUSPENSION FOR 2 $0 PA; MO
RECONSTITUTION
ZYVOX ORAL TABLET 2 $0 PA; MO
PENICILINAS
amoxicillin oral capsule 1 $0 MO
amoxicillin oral suspension for reconstitution 1 $0 MO
amoxicillin oral tablet 1 $0 MO
amoxicillin oral tablet,chewable 125 mg, 250 1 $0 MO
mg
amoxicillin-pot clavulanate oral suspension for 1 $0 MO
reconstitution
amoxicillin-pot clavulanate oral tablet 1 $0 MO
amoxicillin-pot clavulanate oral tablet 1 $0 MO
extended release 12 hr
amoxicillin-pot clavulanate oral 1 $0 MO
tablet,chewable
ampicillin oral capsule 1 $0 MO
ampicillin oral suspension for reconstitution 1 $0 MO
ampicillin sodium injection recon soln 1 gram, 1 $0 B/D PA; MO
10 gram, 125 mg
ampicillin sodium intravenous recon soln 1 $0 B/D PA
ampicillin-sulbactam injection recon soln 15 1 $0 B/D PA
gram
ampicillin-sulbactam injection recon soln 3 1 $0 B/D PA; MO
gram
ampicillin-sulbactam intravenous recon soln 1 $0
1.5 gram
BICILLIN C-R INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
12
BICILLIN L-A INTRAMUSCULAR 2 $0 MO
SYRINGE
dicloxacillin oral capsule 1 $0 MO
NAFCILLIN IN DEXTROSE ISO-OSM 2 $0 B/D PA
INTRAVENOUS PIGGYBACK 1 GRAM/50
ML
nafcillin injection recon soln 1 gram 1 $0 B/D PA; MO
NAFCILLIN INJECTION RECON SOLN 10 2 $0 B/D PA; MO
GRAM
nafcillin intravenous recon soln 2 gram 2 $0 B/D PA; MO
oxacillin in dextrose(iso-osm) intravenous 1 $0 B/D PA
piggyback 1 gram/50 ml
OXACILLIN IN DEXTROSE(ISO-OSM) 2 $0 B/D PA; MO
INTRAVENOUS PIGGYBACK 2 GRAM/50
ML
OXACILLIN INJECTION RECON SOLN 10 2 $0 B/D PA; MO
GRAM
oxacillin intravenous recon soln 2 gram 1 $0 B/D PA
penicillin g potassium injection recon soln 5 1 $0 B/D PA; MO
million unit
penicillin g procaine intramuscular syringe 1.2 1 $0 B/D PA; MO
million unit/2 ml
penicillin g procaine intramuscular syringe 1 $0 B/D PA
600,000 unit/ml
penicillin g sodium injection recon soln 1 $0 B/D PA; MO
penicillin v potassium oral recon soln 1 $0 MO
penicillin v potassium oral tablet 1 $0 MO
piperacillin-tazobactam intravenous recon soln 1 $0 B/D PA; MO
2.25 gram, 3.375 gram, 4.5 gram
QUINOLONAS
AVELOX IN NACL (ISO-OSMOTIC) 2 $0 B/D PA; MO
INTRAVENOUS PIGGYBACK
13
ciprofloxacin (mixture) oral tablet, er 1 $0 MO
multiphase 24 hr
ciprofloxacin hcl oral tablet 1 $0 MO
ciprofloxacin lactate intravenous solution 400 1 $0 B/D PA
mg/40 ml
ciprofloxacin oral suspension,microcapsule 1 $0
recon
levofloxacin in d5w intravenous piggyback 500 1 $0 MO
mg/100 ml
levofloxacin intravenous solution 1 $0 B/D PA; MO
levofloxacin oral solution 1 $0 MO
levofloxacin oral tablet 1 $0 MO
moxifloxacin oral tablet 1 $0 MO
ofloxacin oral tablet 400 mg 1 $0
SULFATOS / AGENTES RELACIONADOS
sulfadiazine oral tablet 1 $0 MO
sulfamethoxazole-trimethoprim intravenous 1 $0 B/D PA; MO
solution
sulfamethoxazole-trimethoprim oral suspension 1 $0 MO
sulfamethoxazole-trimethoprim oral tablet 1 $0 MO
TETRACICLINAS
demeclocycline oral tablet 1 $0 MO
doxy-100 intravenous recon soln 1 $0 B/D PA; MO
doxycycline hyclate intravenous recon soln 1 $0 B/D PA
doxycycline hyclate oral capsule 1 $0 MO
doxycycline hyclate oral tablet 100 mg, 20 mg 1 $0 MO
doxycycline hyclate oral tablet 50 mg 1 $0
doxycycline hyclate oral tablet,delayed release 1 $0 MO
(dr/ec)
doxycycline monohydrate oral capsule 1 $0 MO
14
doxycycline monohydrate oral tablet 1 $0 MO
minocycline oral capsule 1 $0 MO
minocycline oral tablet 1 $0 MO
minocycline oral tablet extended release 24 hr 1 $0 MO
morgidox oral capsule 1 $0 MO
ORACEA ORAL CAPSULE,IR & DELAY 2 $0 MO
REL,BIPHASE
tetracycline oral capsule 1 $0 MO
AGENTES DEL TRACTO URINARIO
methenamine hippurate oral tablet 1 $0 MO
nitrofurantoin macrocrystal oral capsule 100 1 $0 PA; MO
mg, 50 mg
nitrofurantoin monohyd/m-cryst oral capsule 1 $0 PA; MO
trimethoprim oral tablet 1 $0 MO
VANCOMICINA
vancomycin intravenous recon soln 1,000 mg, 1 $0 B/D PA; MO
10 gram, 500 mg
VANCOMYCIN INTRAVENOUS RECON 1 $0 B/D PA; MO
SOLN 750 MG
VANCOMYCIN ORAL CAPSULE 2 $0 MO
MEDICAMENTOS
ANTINEOPLÁSTICOS /
INMUNOSUPRESORES
AGENTES ADICIONALES
AMIFOSTINE CRYSTALLINE 2 $0 B/D PA; MO
INTRAVENOUS RECON SOLN
dexrazoxane hcl intravenous recon soln 250 mg 1 $0 B/D PA
ELITEK INTRAVENOUS RECON SOLN 1.5 2 $0 B/D PA
MG
leucovorin calcium injection recon soln 100 1 $0 B/D PA; MO
mg, 350 mg
15
leucovorin calcium oral tablet 1 $0 MO
LEVOLEUCOVORIN CALCIUM 2 $0 B/D PA
INTRAVENOUS SOLUTION
mesna intravenous solution 1 $0 B/D PA; MO
MESNEX ORAL TABLET 2 $0 MO
XGEVA SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO
MEDICAMENTOS ANTINEOPLÁSTICOS /
INMUNOSUPRESORES
ABRAXANE INTRAVENOUS 2 $0 B/D PA; MO
SUSPENSION FOR RECONSTITUTION
adrucil intravenous solution 500 mg/10 ml 1 $0 B/D PA; MO
AFINITOR DISPERZ ORAL TABLET FOR 2 $0 PA; MO
SUSPENSION
AFINITOR ORAL TABLET 2 $0 PA; MO
ALIMTA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
500 MG
anastrozole oral tablet 1 $0 MO
ASTAGRAF XL ORAL 2 $0 B/D PA; MO
CAPSULE,EXTENDED RELEASE 24HR
AVASTIN INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
AZACITIDINE INJECTION RECON SOLN 2 $0 MO
AZASAN ORAL TABLET 2 $0 B/D PA; MO
azathioprine oral tablet 1 $0 B/D PA; MO
BELEODAQ INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
bicalutamide oral tablet 1 $0 MO
BICNU INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
bleomycin injection recon soln 30 unit 1 $0 B/D PA; MO
BOSULIF ORAL TABLET 2 $0 PA; MO
BUSULFEX INTRAVENOUS SOLUTION 2 $0 B/D PA
16
CAPRELSA ORAL TABLET 2 $0 MO
carboplatin intravenous solution 1 $0 B/D PA; MO
CELLCEPT INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
CELLCEPT ORAL SUSPENSION FOR 2 $0 B/D PA; MO
RECONSTITUTION
cisplatin intravenous solution 1 $0 B/D PA; MO
cladribine intravenous solution 1 $0 B/D PA; MO
COMETRIQ ORAL CAPSULE 2 $0 PA; MO
CYCLOPHOSPHAMIDE ORAL CAPSULE 2 $0 B/D PA; MO
cyclosporine intravenous solution 1 $0 B/D PA
cyclosporine modified oral capsule 1 $0 B/D PA; MO
cyclosporine modified oral solution 1 $0 B/D PA; MO
cyclosporine oral capsule 1 $0 B/D PA; MO
cytarabine injection solution 1 $0 B/D PA; MO
dacarbazine intravenous recon soln 200 mg 1 $0 B/D PA; MO
daunorubicin intravenous solution 1 $0 B/D PA
DAUNOXOME INTRAVENOUS SOLUTION 2 $0 MO
DECITABINE INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
doxorubicin intravenous solution 50 mg/25 ml 1 $0 B/D PA; MO
DROXIA ORAL CAPSULE 2 $0 MO
ELIGARD SUBCUTANEOUS SYRINGE 2 $0 PA; MO
EMCYT ORAL CAPSULE 2 $0 MO
EPIRUBICIN INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
50 MG/25 ML
ERIVEDGE ORAL CAPSULE 2 $0 PA; MO
ERWINAZE INTRAMUSCULAR RECON 2 $0 PA; MO
SOLN
etoposide intravenous solution 1 $0 B/D PA; MO
exemestane oral tablet 1 $0 MO
17
FARESTON ORAL TABLET 2 $0 MO
FARYDAK ORAL CAPSULE 2 $0 PA; MO
FASLODEX INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO
FLUDARABINE INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
fluorouracil intravenous solution 2.5 gram/50 1 $0 B/D PA; MO
ml
flutamide oral capsule 1 $0 MO
GAZYVA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
GEMCITABINE INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN 1 GRAM
gengraf oral capsule 1 $0 B/D PA; MO
gengraf oral solution 1 $0 B/D PA; MO
GILOTRIF ORAL TABLET 2 $0 PA; MO
GLEEVEC ORAL TABLET 100 MG 2 $0 PA; MO
GLEEVEC ORAL TABLET 400 MG 2 $0 PA; MO; QL (60 per 30 days)
GLEOSTINE ORAL CAPSULE 2 $0 MO
HERCEPTIN INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
HEXALEN ORAL CAPSULE 2 $0 MO
hydroxyurea oral capsule 1 $0 MO
IBRANCE ORAL CAPSULE 2 $0 PA; MO; QL (21 per 28 days)
ICLUSIG ORAL TABLET 2 $0 PA; MO
idarubicin intravenous solution 1 $0 B/D PA
IFOSFAMIDE INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN 1 GRAM
IMBRUVICA ORAL CAPSULE 2 $0 PA; MO
INLYTA ORAL TABLET 2 $0 PA; MO
IRINOTECAN INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
100 MG/5 ML
18
ISTODAX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 2 $0 PA; MO
MG, 5 MG
JAKAFI ORAL TABLET 25 MG 2 $0 PA; MO; QL (60 per 30 days)
KADCYLA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
100 MG
KEYTRUDA INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
LENVIMA ORAL CAPSULE 2 $0 PA; MO
letrozole oral tablet 1 $0 MO
LEUKERAN ORAL TABLET 2 $0 MO
leuprolide subcutaneous kit 1 $0 MO
LOMUSTINE ORAL CAPSULE 2 $0 MO
LUPRON DEPOT (3 MONTH) 2 $0 PA; MO
INTRAMUSCULAR SYRINGE KIT
LUPRON DEPOT INTRAMUSCULAR 2 $0 PA; MO
SYRINGE KIT
LUPRON DEPOT-PED INTRAMUSCULAR 2 $0 PA; MO
KIT 11.25 MG, 15 MG
LYNPARZA ORAL CAPSULE 2 $0 PA; MO
LYSODREN ORAL TABLET 2 $0 MO
MATULANE ORAL CAPSULE 2 $0 MO
megestrol oral tablet 1 $0 PA; MO
MEKINIST ORAL TABLET 2 $0 PA; MO
melphalan hcl intravenous recon soln 1 $0 B/D PA
mercaptopurine oral tablet 1 $0 MO
methotrexate sodium (pf) injection recon soln 1 $0 B/D PA
19
methotrexate sodium (pf) injection solution 1 $0 B/D PA; MO
methotrexate sodium oral tablet 1 $0 B/D PA; MO
mitomycin intravenous recon soln 20 mg 1 $0 B/D PA; MO
mitoxantrone intravenous concentrate 1 $0 B/D PA; MO
MUSTARGEN INJECTION RECON SOLN 2 $0 B/D PA; MO
mycophenolate mofetil oral capsule 1 $0 B/D PA; MO
mycophenolate mofetil oral suspension for 1 $0 B/D PA; MO
reconstitution
mycophenolate mofetil oral tablet 1 $0 B/D PA; MO
mycophenolate sodium oral tablet,delayed 1 $0 B/D PA; MO
release (dr/ec)
NEORAL ORAL CAPSULE 2 $0 B/D PA; MO
NEORAL ORAL SOLUTION 2 $0 B/D PA; MO
NEXAVAR ORAL TABLET 2 $0 PA; MO
NILANDRON ORAL TABLET 2 $0 MO
NULOJIX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
OCTREOTIDE ACETATE INJECTION 2 $0 PA; MO
SOLUTION 1,000 MCG/ML, 500 MCG/ML
octreotide acetate injection solution 100 1 $0 PA; MO
mcg/ml, 200 mcg/ml, 50 mcg/ml
octreotide acetate injection syringe 100 mcg/ml 1 $0 PA; MO
(1 ml), 50 mcg/ml (1 ml)
octreotide acetate injection syringe 500 mcg/ml 2 $0 PA; MO
(1 ml)
ONCASPAR INJECTION SOLUTION 2 $0 PA; MO
OPDIVO INTRAVENOUS SOLUTION 40 2 $0 PA; MO
MG/4 ML
OXALIPLATIN INTRAVENOUS 2 $0 B/D PA; MO
SOLUTION 100 MG/20 ML
PACLITAXEL INTRAVENOUS 2 $0 B/D PA; MO
CONCENTRATE
20
PERJETA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
POMALYST ORAL CAPSULE 2 $0 PA; MO
PURIXAN ORAL SUSPENSION 2 $0 MO
RAPAMUNE ORAL SOLUTION 2 $0 B/D PA; MO
RAPAMUNE ORAL TABLET 2 $0 B/D PA; MO
REVLIMID ORAL CAPSULE 2 $0 PA; MO; LA
RHEUMATREX ORAL TABLETS,DOSE 2 $0 B/D PA; MO
PACK 2.5 MG
RHEUMATREX ORAL TABLETS,DOSE 2 $0 B/D PA
PACK 2.5 MG (DOSE PACK 12), 2.5 MG
(DOSE PACK 16), 2.5 MG (DOSE PACK 20),
2.5 MG (DOSE PACK 8)
RITUXAN INTRAVENOUS 2 $0 PA; MO
CONCENTRATE
SANDIMMUNE ORAL CAPSULE 2 $0 B/D PA; MO
SANDIMMUNE ORAL SOLUTION 2 $0 B/D PA; MO
SANDOSTATIN LAR DEPOT 2 $0 PA; MO
INTRAMUSCULAR KIT
SIGNIFOR SUBCUTANEOUS SOLUTION 2 $0 PA; MO
SIMULECT INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
20 MG
sirolimus oral tablet 1 $0 B/D PA; MO
SOLTAMOX ORAL SOLUTION 2 $0 MO
SOMATULINE DEPOT SUBCUTANEOUS 2 $0 B/D PA; MO
SYRINGE
SPRYCEL ORAL TABLET 100 MG, 140 MG, 2 $0 PA; MO; QL (30 per 30 days)
80 MG
SPRYCEL ORAL TABLET 20 MG, 50 MG 2 $0 PA; MO
SPRYCEL ORAL TABLET 70 MG 2 $0 PA; MO; QL (60 per 30 days)
STIVARGA ORAL TABLET 2 $0 PA; MO
SUTENT ORAL CAPSULE 2 $0 PA; MO
21
SYNRIBO SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO
TABLOID ORAL TABLET 2 $0 MO
tacrolimus oral capsule 0.5 mg, 1 mg 1 $0 B/D PA; MO
TACROLIMUS ORAL CAPSULE 5 MG 2 $0 B/D PA; MO
TAFINLAR ORAL CAPSULE 2 $0 PA; MO
tamoxifen oral tablet 1 $0 MO
TARCEVA ORAL TABLET 100 MG, 25 MG 2 $0 PA; MO
TARCEVA ORAL TABLET 150 MG 2 $0 PA; MO; QL (30 per 30 days)
TARGRETIN ORAL CAPSULE 2 $0 PA; MO
TARGRETIN TOPICAL GEL 2 $0 MO
TASIGNA ORAL CAPSULE 2 $0 PA; MO
THALOMID ORAL CAPSULE 2 $0 PA; MO
toposar intravenous solution 1 $0 B/D PA; MO
TOPOTECAN INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
TREANDA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
100 MG
TREANDA INTRAVENOUS SOLUTION 45 2 $0 B/D PA; MO
MG/0.5 ML
TRELSTAR INTRAMUSCULAR 2 $0 B/D PA; MO
TRELSTAR INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO
11.25 MG/2 ML, 3.75 MG/2 ML
TRETINOIN (CHEMOTHERAPY) ORAL 2 $0 MO
CAPSULE
TRISENOX INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
TYKERB ORAL TABLET 2 $0 PA; MO
VELCADE INJECTION RECON SOLN 2 $0 B/D PA; MO
VINBLASTINE INTRAVENOUS 2 $0 B/D PA; MO
SOLUTION
22
vincasar pfs intravenous solution 1 mg/ml 1 $0 B/D PA
vincristine intravenous solution 1 mg/ml 1 $0 B/D PA; MO
vinorelbine intravenous solution 50 mg/5 ml 1 $0 B/D PA; MO
VOTRIENT ORAL TABLET 2 $0 PA; MO
XALKORI ORAL CAPSULE 2 $0 PA; MO
XTANDI ORAL CAPSULE 2 $0 PA; MO; QL (120 per 30
days)
YERVOY INTRAVENOUS SOLUTION 50 2 $0 PA; MO
MG/10 ML (5 MG/ML)
ZALTRAP INTRAVENOUS SOLUTION 100 2 $0 B/D PA; MO
MG/4 ML (25 MG/ML)
ZELBORAF ORAL TABLET 2 $0 PA; MO
ZOLINZA ORAL CAPSULE 2 $0 MO
ZORTRESS ORAL TABLET 2 $0 B/D PA; MO
ZYDELIG ORAL TABLET 2 $0 PA; MO
ZYKADIA ORAL CAPSULE 2 $0 PA; MO; QL (150 per 30
days)
ZYTIGA ORAL TABLET 2 $0 MO
MEDICAMENTOS AUTÓNOMOS /
CNS, NEUROLOGÍA / PSIQUIATRÍA
ANTICONVULSIVOS
APTIOM ORAL TABLET 2 $0 PA; MO
BANZEL ORAL SUSPENSION 2 $0 MO
BANZEL ORAL TABLET 2 $0 PA; MO
carbamazepine oral capsule, er multiphase 12 1 $0 MO
hr
carbamazepine oral suspension 100 mg/5 ml 1 $0 MO
carbamazepine oral tablet 1 $0 MO
carbamazepine oral tablet extended release 12 1 $0 MO
hr
23
carbamazepine oral tablet,chewable 1 $0 MO
CELONTIN ORAL CAPSULE 300 MG 2 $0 MO
clonazepam oral tablet 1 $0 PA; MO
clonazepam oral tablet,disintegrating 1 $0 PA; MO
DIASTAT RECTAL KIT 2 $0 PA; MO
diazepam rectal kit 1 $0 PA; MO
DILANTIN 30 MG ORAL CAPSULE 2 $0 MO
divalproex oral capsule, sprinkle 1 $0 MO
divalproex oral tablet extended release 24 hr 1 $0 MO
divalproex oral tablet,delayed release (dr/ec) 1 $0 MO
epitol oral tablet 1 $0 MO
ethosuximide oral capsule 1 $0 MO
ethosuximide oral solution 1 $0 MO
felbamate oral suspension 1 $0 MO
felbamate oral tablet 1 $0 MO
fosphenytoin injection solution 100 mg pe/2 ml 1 $0 B/D PA; MO
FYCOMPA ORAL TABLET 2 $0 PA; MO
gabapentin oral capsule 1 $0 MO
gabapentin oral solution 250 mg/5 ml 1 $0 MO
gabapentin oral tablet 600 mg, 800 mg 1 $0 MO
GABITRIL ORAL TABLET 12 MG, 16 MG 2 $0 MO
lamotrigine oral tablet 1 $0 MO
lamotrigine oral tablet extended release 24hr 1 $0 MO
lamotrigine oral tablet, chewable dispersible 1 $0 MO
lamotrigine oral tablet,disintegrating 1 $0 MO
lamotrigine oral tablets,dose pack 25 mg (35) 1 $0
levetiracetam in nacl (iso-os) intravenous 1 $0 B/D PA
piggyback 1,000 mg/100 ml, 1,500 mg/100 ml
24
levetiracetam in nacl (iso-os) intravenous 1 $0 B/D PA; MO
levetiracetam intravenous solution 1 $0 B/D PA; MO
levetiracetam oral solution 100 mg/ml 1 $0 MO
levetiracetam oral tablet 1 $0 MO
levetiracetam oral tablet extended release 24 1 $0 MO
hr
LYRICA ORAL CAPSULE 2 $0 MO
LYRICA ORAL SOLUTION 2 $0 MO
ONFI ORAL SUSPENSION 2 $0 PA; MO
ONFI ORAL TABLET 10 MG, 20 MG 2 $0 PA; MO
oxcarbazepine oral suspension 1 $0 MO
oxcarbazepine oral tablet 1 $0 MO
PEGANONE ORAL TABLET 2 $0 MO
phenobarbital oral elixir 1 $0 PA; MO
phenobarbital oral tablet 100 mg 1 $0 PA
phenobarbital oral tablet 15 mg, 16.2 mg, 30 1 $0 PA; MO
mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
PHENYTEK ORAL CAPSULE 2 $0 MO
phenytoin oral suspension 125 mg/5 ml 1 $0 MO
phenytoin oral tablet,chewable 1 $0 MO
phenytoin sodium extended oral capsule 1 $0 MO
phenytoin sodium intravenous solution 1 $0 B/D PA; MO
phenytoin sodium intravenous syringe 1 $0 B/D PA
POTIGA ORAL TABLET 2 $0 PA; MO
primidone oral tablet 1 $0 MO
SABRIL ORAL POWDER IN PACKET 2 $0 PA; MO
SABRIL ORAL TABLET 2 $0 PA; MO
TEGRETOL XR ORAL TABLET 2 $0 MO
EXTENDED RELEASE 12 HR 100 MG
25
tiagabine oral tablet 1 $0 MO
topiramate oral capsule, sprinkle 1 $0 PA; MO
TOPIRAMATE ORAL 2 $0 PA; MO
CAPSULE,SPRINKLE,ER 24HR
topiramate oral tablet 1 $0 PA; MO
valproate sodium intravenous solution 1 $0 B/D PA; MO
valproic acid (as sodium salt) oral solution 250 1 $0 MO
mg/5 ml
valproic acid oral capsule 1 $0 MO
VIMPAT INTRAVENOUS SOLUTION 2 $0 PA
VIMPAT ORAL SOLUTION 2 $0 PA; MO
VIMPAT ORAL TABLET 2 $0 PA; MO
zonisamide oral capsule 1 $0 PA; MO
AGENTES ANTI-PARKINSON
APOKYN SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO
AZILECT ORAL TABLET 2 $0 MO
benztropine injection solution 1 $0 B/D PA; MO
benztropine oral tablet 1 $0 PA; MO
bromocriptine oral capsule 1 $0 MO
bromocriptine oral tablet 1 $0 MO
carbidopa oral tablet 1 $0 MO
carbidopa-levodopa oral tablet 1 $0 MO
carbidopa-levodopa oral tablet extended 1 $0 MO
release
carbidopa-levodopa oral tablet,disintegrating 1 $0 MO
carbidopa-levodopa-entacapone oral tablet 1 $0 MO
entacapone oral tablet 1 $0 MO
NEUPRO TRANSDERMAL PATCH 24 2 $0 PA; MO
HOUR
26
pramipexole oral tablet 1 $0 MO
pramipexole oral tablet extended release 24 hr 1 $0 MO
0.375 mg, 0.75 mg, 1.5 mg
ropinirole oral tablet 1 $0 MO
ropinirole oral tablet extended release 24 hr 1 $0 MO
selegiline hcl oral capsule 1 $0 MO
selegiline hcl oral tablet 1 $0 MO
tolcapone oral tablet 1 $0 MO
trihexyphenidyl oral elixir 1 $0 PA; MO
trihexyphenidyl oral tablet 1 $0 PA; MO
MIGRAÑAS / TERAPIA DE CEFALEA EN
RACIMOS
dihydroergotamine injection solution 1 $0 MO
migergot rectal suppository 1 $0 MO
naratriptan oral tablet 1 $0 MO; QL (18 per 28 days)
rizatriptan oral tablet 1 $0 MO; QL (36 per 30 days)
rizatriptan oral tablet,disintegrating 1 $0 MO; QL (36 per 30 days)
sumatriptan nasal spray,non-aerosol 1 $0 MO
sumatriptan succinate oral tablet 1 $0 MO; QL (9 per 30 days)
sumatriptan succinate subcutaneous cartridge 1 $0 MO; QL (10 per 30 days)
4 mg/0.5 ml
sumatriptan succinate subcutaneous pen 1 $0 MO; QL (10 per 30 days)
injector
sumatriptan succinate subcutaneous solution 1 $0 MO; QL (10 per 30 days)
zolmitriptan oral tablet 1 $0 MO; QL (12 per 30 days)
zolmitriptan oral tablet,disintegrating 1 $0 MO; QL (12 per 30 days)
MISCELLANEOUS NEUROLOGICAL
THERAPY
AMPYRA ORAL TABLET EXTENDED 2 $0 PA; MO
RELEASE 12 HR
27
COPAXONE SUBCUTANEOUS SYRINGE 2 $0 PA; MO; QL (30 per 30 days)
20 MG/ML
COPAXONE SUBCUTANEOUS SYRINGE 2 $0 PA; MO; QL (12 per 28 days)
40 MG/ML
donepezil oral tablet 1 $0 MO; QL (30 per 30 days)
donepezil oral tablet,disintegrating 1 $0 MO; QL (30 per 30 days)
EXELON TRANSDERMAL PATCH 24 2 $0 MO; QL (30 per 30 days)
HOUR
galantamine oral capsule,ext rel. pellets 24 hr 1 $0 MO; QL (30 per 30 days)
galantamine oral solution 1 $0 MO
galantamine oral tablet 1 $0 MO
GILENYA ORAL CAPSULE 2 $0 MO
GLATOPA SUBCUTANEOUS SYRINGE 2 $0 PA; MO
HORIZANT ORAL TABLET EXTENDED 2 $0 MO
RELEASE
NAMENDA ORAL SOLUTION 2 $0 PA; MO
NAMENDA ORAL TABLET 2 $0 PA; MO
NAMENDA TITRATION PAK ORAL 2 $0 PA; MO
TABLETS,DOSE PACK
NUEDEXTA ORAL CAPSULE 2 $0 MO
rivastigmine tartrate oral capsule 1.5 mg 1 $0 MO; QL (240 per 30 days)
rivastigmine tartrate oral capsule 3 mg 1 $0 MO; QL (120 per 30 days)
rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 $0 MO; QL (60 per 30 days)
TECFIDERA ORAL CAPSULE,DELAYED 2 $0 MO
RELEASE(DR/EC)
TYSABRI INTRAVENOUS SOLUTION 2 $0 PA; MO
XENAZINE ORAL TABLET 2 $0 PA; MO; LA
RELAJANTES MUSCULARES / TERAPIA
ANTIESPASMÓDICA
baclofen oral tablet 1 $0 MO
28
cyclobenzaprine oral tablet 1 $0 PA; MO
dantrolene oral capsule 1 $0 MO
meprobamate oral tablet 1 $0 PA; MO
MESTINON ORAL SYRUP 2 $0 MO
MESTINON TIMESPAN ORAL TABLET 2 $0 MO
EXTENDED RELEASE
metaxalone oral tablet 1 $0 PA; MO
pyridostigmine bromide oral tablet 1 $0 MO
regonol injection solution 2 $0 B/D PA
tizanidine oral capsule 1 $0 MO
tizanidine oral tablet 1 $0 MO
ANALGÉSICOS NARCÓTICOS
acetaminophen-codeine oral solution 300 mg- 1 $0 QL (4500 per 30 days)
30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15 mg, 1 $0 MO; QL (360 per 30 days)
300-30 mg
acetaminophen-codeine oral tablet 300-60 mg 1 $0 MO; QL (180 per 30 days)
buprenorphine hcl injection syringe 1 $0 B/D PA; QL (267 per 30
days)
buprenorphine hcl sublingual tablet 2 mg 1 $0 MO; QL (300 per 30 days)
buprenorphine hcl sublingual tablet 8 mg 1 $0 MO; QL (75 per 30 days)
butalbital-acetaminop-caf-cod oral capsule 1 $0 PA; MO; QL (360 per 30
days)
codeine sulfate oral tablet 1 $0 MO; QL (180 per 30 days)
diskets oral tablet,soluble 1 $0 QL (30 per 30 days)
DURAMORPH (PF) INJECTION SOLUTION 2 $0 B/D PA; MO; QL (4000 per
0.5 MG/ML 30 days)
DURAMORPH (PF) INJECTION SOLUTION 2 $0 B/D PA; QL (2000 per 30
1 MG/ML days)
endocet oral tablet 10-325 mg, 5-325 mg, 7.5- 1 $0 MO; QL (360 per 30 days)
325 mg
29
endocet oral tablet 2.5-325 mg 1 $0 QL (360 per 30 days)
FENTANYL CITRATE BUCCAL LOZENGE 2 $0 PA; MO; QL (39 per 30 days)
ON A HANDLE 1,200 MCG
ON A HANDLE 1,600 MCG
FENTANYL CITRATE BUCCAL LOZENGE 2 $0 PA; MO; QL (120 per 30
ON A HANDLE 200 MCG days)
FENTANYL CITRATE BUCCAL LOZENGE 2 $0 PA; MO; QL (116 per 30
ON A HANDLE 400 MCG days)
ON A HANDLE 600 MCG
ON A HANDLE 800 MCG
fentanyl transdermal patch 72 hour 100 mcg/hr 1 $0 MO; QL (9 per 30 days)
fentanyl transdermal patch 72 hour 12 mcg/hr, 1 $0 MO; QL (10 per 30 days)
25 mcg/hr, 50 mcg/hr, 75 mcg/hr
hydrocodone-acetaminophen oral solution 10- 1 $0 QL (5550 per 30 days)
325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163
mg/7.5ml(7.5ml)
hydrocodone-acetaminophen oral solution 7.5- 1 $0 MO; QL (5550 per 30 days)
325 mg/15 ml
hydrocodone-acetaminophen oral tablet 10- 1 $0 MO; QL (360 per 30 days)
300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-
325 mg, 7.5-300 mg, 7.5-325 mg
hydrocodone-ibuprofen oral tablet 1 $0 MO; QL (50 per 30 days)
hydromorphone (pf) injection solution 10 1 $0 B/D PA; MO; QL (120 per 30
mg/ml days)
hydromorphone oral liquid 1 $0 MO; QL (1500 per 30 days)
hydromorphone oral tablet 1 $0 MO; QL (180 per 30 days)
ibuprofen-oxycodone oral tablet 1 $0 MO; QL (28 per 30 days)
30
KADIAN ORAL 2 $0 MO; QL (60 per 30 days)
CAPSULE,EXTEND.RELEASE PELLETS
200 MG
levorphanol tartrate oral tablet 1 $0 MO; QL (120 per 30 days)
methadone injection solution 1 $0 B/D PA; QL (160 per 30
days)
methadone intensol oral concentrate 1 $0 MO; QL (120 per 30 days)
methadone oral concentrate 1 $0 MO; QL (120 per 30 days)
methadone oral solution 10 mg/5 ml 1 $0 MO; QL (600 per 30 days)
methadone oral solution 5 mg/5 ml 1 $0 MO; QL (1200 per 30 days)
methadone oral tablet 10 mg 1 $0 MO; QL (120 per 30 days)
methadone oral tablet 5 mg 1 $0 MO; QL (240 per 30 days)
methadone oral tablet,soluble 1 $0 QL (30 per 30 days)
methadose oral concentrate 1 $0 MO; QL (120 per 30 days)
methadose oral tablet,soluble 1 $0 MO; QL (30 per 30 days)
morphine (pf) injection solution 0.5 mg/ml 1 $0 B/D PA; QL (2400 per 30
days)
morphine (pf) injection solution 1 mg/ml 1 $0 B/D PA; MO; QL (1200 per
30 days)
morphine concentrate oral solution 1 $0 MO; QL (300 per 30 days)
morphine intravenous syringe 10 mg/ml 1 $0 B/D PA; QL (200 per 30
days)
morphine intravenous syringe 8 mg/ml 1 $0 B/D PA; QL (250 per 30
days)
morphine oral capsule, er multiphase 24 hr 120 1 $0 MO; QL (50 per 30 days)
mg
morphine oral capsule, er multiphase 24 hr 30 1 $0 MO; QL (60 per 30 days)
mg, 45 mg, 60 mg, 75 mg, 90 mg
morphine oral capsule,extend.release pellets 1 $0 MO; QL (60 per 30 days)
morphine oral solution 1 $0 MO; QL (900 per 30 days)
morphine oral tablet 1 $0 MO; QL (180 per 30 days)
31
morphine oral tablet extended release 100 mg 1 $0 MO; QL (60 per 30 days)
morphine oral tablet extended release 15 mg, 1 $0 MO; QL (90 per 30 days)
30 mg, 60 mg
morphine oral tablet extended release 200 mg 1 $0 MO; QL (30 per 30 days)
oxycodone oral capsule 1 $0 MO; QL (360 per 30 days)
oxycodone oral concentrate 1 $0 MO; QL (180 per 30 days)
oxycodone oral solution 1 $0 MO; QL (1200 per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg 1 $0 MO; QL (180 per 30 days)
oxycodone oral tablet 30 mg 1 $0 MO; QL (134 per 30 days)
oxycodone oral tablet 5 mg 1 $0 MO; QL (360 per 30 days)
oxycodone-acetaminophen oral tablet 10-325 1 $0 MO; QL (360 per 30 days)
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
oxycodone-aspirin oral tablet 1 $0 MO; QL (360 per 30 days)
oxymorphone oral tablet 10 mg 1 $0 MO; QL (200 per 30 days)
oxymorphone oral tablet 5 mg 1 $0 MO; QL (180 per 30 days)
oxymorphone oral tablet extended release 12 1 $0 MO; QL (90 per 30 days)
hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
hr 30 mg
hr 40 mg
reprexain oral tablet 1 $0 MO; QL (50 per 30 days)
zamicet oral solution 1 $0 QL (5550 per 30 days)
ANALGÉSICOS NO NARCÓTICOS
ACEPHEN RECTAL SUPPOSITORY 120 4 $0 MO; *
MG, 650 MG
ACEPHEN RECTAL SUPPOSITORY 325 4 $0 *
MG
acetadryl oral tablet 4 $0 *
acetaminophen extra strength oral tablet 4 $0 *
32
acetaminophen oral drops,suspension 4 $0 *
acetaminophen oral liquid 4 $0 *
acetaminophen oral tablet 4 $0 MO; *
acetaminophen pm extra str oral tablet 4 $0 *
acetaminophen pm oral tablet 4 $0 *
acetaminophen rectal suppository 120 mg, 650 4 $0 *
mg
added strength headache relief oral tablet 4 $0 *
ADDED STRENGTH PAIN RELIEVER 4 $0 *
ORAL TABLET
adult low dose aspirin oral tablet,delayed 4 $0 MO; *
release (dr/ec)
aspir-81 oral tablet,delayed release (dr/ec) 4 $0 *
aspirin childrens oral tablet,chewable 4 $0 *
aspirin low dose oral tablet,delayed release 4 $0 MO; *
(dr/ec)
aspirin low-strength oral tablet,chewable 4 $0 *
aspirin oral tablet 325 mg 4 $0 MO; *
aspirin oral tablet,chewable 4 $0 MO; *
aspirin oral tablet,delayed release (dr/ec) 325 4 $0 MO; *
mg, 500 mg, 81 mg
aspirin oral tablet,delayed release (dr/ec) 650 4 $0 *
mg
aspirin rectal suppository 4 $0 MO; *
aspirin, buffered oral tablet 4 $0 *
aspir-trin oral tablet,delayed release (dr/ec) 4 $0 MO; *
athenol oral tablet 4 $0 *
bayer advanced oral tablet 4 $0 *
bayer aspirin oral tablet 4 $0 MO; *
bufferin oral tablet 325 mg 4 $0 *
33
buprenorphine-naloxone sublingual tablet 1 $0 MO; QL (90 per 30 days)
butorphanol tartrate injection solution 1 mg/ml 1 $0 MO; QL (720 per 30 days)
butorphanol tartrate injection solution 2 mg/ml 1 $0 MO; QL (360 per 30 days)
butorphanol tartrate nasal spray,non-aerosol 1 $0 MO; QL (40 per 30 days)
celecoxib oral capsule 1 $0 MO
child aspirin oral tablet,chewable 4 $0 *
child pain rel-fever reducer rectal suppository 4 $0 *
children's aspirin oral tablet,chewable 4 $0 MO; *
children's fever reducing rectal suppository 4 $0 *
children's pain relief oral liquid 4 $0 *
children's silapap oral liquid 4 $0 *
diclofenac potassium oral tablet 1 $0 MO
diclofenac sodium oral tablet extended release 1 $0 MO
24 hr
diclofenac sodium oral tablet,delayed release 1 $0 MO
(dr/ec)
diclofenac sodium topical drops 1 $0 MO
diclofenac-misoprostol oral tablet,ir & delay 1 $0 MO
rel,biphasic
diflunisal oral tablet 1 $0 MO
diphenhydramine-acetaminophen oral tablet 4 $0 *
e.c. prin oral tablet,delayed release (dr/ec) 4 $0 *
ecotrin low strength oral tablet,delayed release 4 $0 MO; *
(dr/ec)
enteric coated aspirin oral tablet,delayed 4 $0 *
release (dr/ec)
etodolac oral capsule 1 $0 MO
etodolac oral tablet 1 $0 MO
etodolac oral tablet extended release 24 hr 1 $0 MO
34
ex-strength medi-tabs oral tablet 4 $0 *
ex-strength medi-tabs pm oral tablet 4 $0 *
fenoprofen oral tablet 1 $0 MO
fever reducer rectal suppository 4 $0 *
feverall rectal suppository 120 mg, 325 mg, 4 $0 *
650 mg
flurbiprofen oral tablet 1 $0 MO
headache formula added str oral tablet 4 $0 *
headache formula oral tablet 4 $0 *
headache pm oral tablet 4 $0 *
headache relief (asa-acet-caf) oral tablet 4 $0 *
ibu-drops oral drops,suspension 4 $0 *
ibuprofen ib oral tablet 4 $0 *
ibuprofen oral capsule 4 $0 *
ibuprofen oral drops,suspension 4 $0 *
ibuprofen oral suspension 1 $0 MO
ibuprofen oral tablet 100 mg 4 $0 *
ibuprofen oral tablet 200 mg 4 $0 MO; *
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 $0 MO
infants ibu-drops oral drops,suspension 4 $0 *
infant's ibuprofen oral drops,suspension 4 $0 *
INFANT'S MEDI-PROFEN ORAL 4 $0 *
DROPS,SUSPENSION
infant's non-aspirin oral drops,suspension 4 $0 *
INFANT'S PAIN RELIEF ORAL 4 $0 *
DROPS,SUSPENSION 80 MG/0.8 ML
infant's pain reliever oral drops,suspension 4 $0 *
infants profenib oral drops,suspension 4 $0 *
i-prin oral tablet 4 $0 *
ketoprofen oral capsule 1 $0 MO
35
ketoprofen oral capsule,ext rel. pellets 24 hr 1 $0 MO
200 mg
lite coat aspirin oral tablet 4 $0 *
lo-dose aspirin oral tablet,delayed release 4 $0 *
(dr/ec)
MAPAP (ACETAMINOPHEN) ORAL 4 $0 MO; *
CAPSULE
masophen oral tablet 4 $0 *
meclofenamate oral capsule 1 $0 MO
medi-profen oral tablet 4 $0 *
medi-tabs oral tablet 4 $0 *
medi-tabs pm oral tablet 4 $0 *
mefenamic acid oral capsule 1 $0 MO
meloxicam oral suspension 1 $0 MO
meloxicam oral tablet 1 $0 MO
migraine formula oral tablet 4 $0 *
migraine pain reliever oral tablet 4 $0 *
migraine relief oral tablet 4 $0 *
nabumetone oral tablet 1 $0 MO
nalbuphine injection solution 10 mg/ml 1 $0 B/D PA; MO; QL (200 per 30
days)
nalbuphine injection solution 20 mg/ml 1 $0 B/D PA; MO; QL (100 per 30
days)
naloxone injection syringe 1 mg/ml 1 $0 MO
naltrexone oral tablet 1 $0 MO
NAPRELAN CR ORAL TABLET, ER 2 $0 MO
MULTIPHASE 24 HR
naproxen oral suspension 1 $0 MO
naproxen oral tablet 1 $0 MO
naproxen oral tablet,delayed release (dr/ec) 1 $0 MO
36
naproxen sodium oral tablet 275 mg, 550 mg 1 $0 MO
non-aspirin extra strength oral capsule 4 $0 *
non-aspirin extra strength oral liquid 4 $0 *
non-aspirin extra strength oral tablet 4 $0 *
non-aspirin nightime oral tablet 4 $0 *
non-aspirin oral tablet 4 $0 *
non-aspirin pain relief oral tablet 500 mg 4 $0 *
non-aspirin pain relief pm oral tablet 4 $0 *
non-aspirin pm oral tablet 4 $0 *
NUCYNTA ER ORAL TABLET EXTENDED 2 $0 MO
RELEASE 12 HR
NUCYNTA ORAL TABLET 2 $0 MO
oxaprozin oral tablet 1 $0 MO
pain relief adult oral liquid 4 $0 *
pain relief extra strength oral tablet 4 $0 *
pain relief oral capsule 4 $0 *
pain relief oral liquid 4 $0 *
pain relief oral tablet 500 mg 4 $0 *
pain relief pm oral tablet 4 $0 *
pain relief pm rapid release oral tablet 4 $0 *
pain relief regular strength oral tablet 4 $0 *
pain reliever (acetam-aspirin) oral tablet 4 $0 *
pain reliever extra strength oral tablet 4 $0 *
pain reliever oral capsule 4 $0 *
pain reliever oral tablet 4 $0 *
pain reliever pm ex-strength oral tablet 4 $0 *
pain reliever pm oral tablet 25-500 mg 4 $0 *
pain-off oral tablet 4 $0 *
pamprin max oral tablet 4 $0 *
37
percogesic extra strength oral tablet 4 $0 MO; *
percogesic oral tablet 4 $0 *
pharbetol oral tablet 4 $0 *
piroxicam oral capsule 1 $0 MO
provil oral tablet 4 $0 *
severe allergy oral tablet 4 $0 *
SUBOXONE SUBLINGUAL FILM 12-3 MG 2 $0 MO; QL (60 per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 2 $0 MO; QL (90 per 30 days)
4-1 MG, 8-2 MG
sulindac oral tablet 1 $0 MO
super pain relief oral tablet 4 $0 *
tactinal extra strength oral tablet 4 $0 *
tactinal oral tablet 4 $0 *
tolmetin oral capsule 1 $0 MO
tolmetin oral tablet 1 $0 MO
tramadol oral tablet 1 $0 MO; QL (240 per 30 days)
tramadol oral tablet extended release 24 hr 1 $0 MO; QL (30 per 30 days)
100 mg, 200 mg
tramadol oral tablet, er multiphase 24 hr 300 1 $0 MO; QL (30 per 30 days)
mg
tramadol-acetaminophen oral tablet 1 $0 MO; QL (240 per 30 days)
TRI-BUFFERED ASPIRIN ORAL TABLET 4 $0 MO; *
tylophen oral capsule 4 $0 *
VOLTAREN GEL TOPICAL GEL 1 % 2 $0 ST; MO
wal-profen oral capsule 4 $0 *
wal-profen oral tablet 4 $0 *
MEDICAMENTOS PSICOTERAPÉUTICOS
ABILIFY DISCMELT ORAL 2 $0 MO; QL (90 per 30 days)
TABLET,DISINTEGRATING 10 MG
38
ABILIFY MAINTENA INTRAMUSCULAR 2 $0 B/D PA; MO
SUSPENSION,EXTENDED REL RECON 300
MG
ABILIFY MAINTENA INTRAMUSCULAR 2 $0 B/D PA
SUSPENSION,EXTENDED REL SYRING
ABILIFY ORAL TABLET 10 MG 2 $0 MO; QL (90 per 30 days)
ABILIFY ORAL TABLET 15 MG, 20 MG 2 $0 MO; QL (60 per 30 days)
alprazolam oral tablet 1 $0 PA; MO
alprazolam oral tablet extended release 24 hr 1 $0 PA; MO
alprazolam oral tablet,disintegrating 1 $0 PA; MO
amitriptyline oral tablet 1 $0 PA; MO
amoxapine oral tablet 1 $0 MO
amphetamine salt combo oral tablet 1 $0 MO
aripiprazole oral tablet 10 mg 1 $0 MO; QL (90 per 30 days)
ARIPIPRAZOLE ORAL TABLET 20 MG 2 $0 MO; QL (60 per 30 days)
ARIPIPRAZOLE ORAL TABLET 30 MG 2 $0 MO; QL (30 per 30 days)
BRINTELLIX ORAL TABLET 2 $0 MO
BRISDELLE ORAL CAPSULE 2 $0 MO
bupropion hcl oral tablet 1 $0 MO
bupropion hcl oral tablet extended release 1 $0 MO
bupropion hcl oral tablet extended release 24 1 $0 MO
hr
buspirone oral tablet 1 $0 MO
chlorpromazine injection solution 1 $0 MO
39
chlorpromazine oral tablet 1 $0 MO
citalopram oral solution 1 $0 MO
citalopram oral tablet 1 $0 MO
clomipramine oral capsule 1 $0 PA; MO
clonidine hcl oral tablet extended release 12 hr 1 $0 MO
clorazepate dipotassium oral tablet 1 $0 PA; MO
clozapine oral tablet 100 mg, 25 mg, 50 mg 1 $0 MO
clozapine oral tablet 200 mg 1 $0
clozapine oral tablet,disintegrating 100 mg, 1 $0
12.5 mg, 25 mg
CLOZAPINE ORAL 2 $0
TABLET,DISINTEGRATING 150 MG, 200
MG
desipramine oral tablet 1 $0 MO
dexmethylphenidate oral capsule,er biphasic 1 $0 MO
50-50
dexmethylphenidate oral tablet 1 $0 MO
dextroamphetamine oral capsule, extended 1 $0 MO
release
dextroamphetamine oral tablet 1 $0 MO
dextroamphetamine-amphetamine oral 1 $0 MO
capsule,extended release 24hr
diazepam intensol oral concentrate 1 $0 PA; MO
diazepam oral solution 5 mg/5 ml 1 $0 PA; MO
diazepam oral tablet 1 $0 PA; MO
doxepin oral capsule 1 $0 PA; MO
doxepin oral concentrate 1 $0 PA; MO
duloxetine oral capsule,delayed release(dr/ec) 1 $0 MO
EMSAM TRANSDERMAL PATCH 24 2 $0 MO
HOUR
40
ergoloid oral tablet 1 $0 PA; MO
escitalopram oxalate oral solution 1 $0 MO
escitalopram oxalate oral tablet 1 $0 MO
eszopiclone oral tablet 1 $0 MO; QL (30 per 30 days)
FANAPT ORAL TABLET 2 $0 MO; QL (60 per 30 days)
FANAPT ORAL TABLETS,DOSE PACK 2 $0 MO; QL (8 per 28 days)
FAZACLO ORAL 2 $0
TABLET,DISINTEGRATING 150 MG, 200
MG
FETZIMA ORAL CAPSULE,EXT REL 24HR 2 $0 MO; QL (30 per 30 days)
DOSE PACK
FETZIMA ORAL CAPSULE,EXTENDED 2 $0 MO; QL (30 per 30 days)
RELEASE 24 HR
fluoxetine oral capsule 1 $0 MO
fluoxetine oral capsule,delayed release(dr/ec) 1 $0 MO
fluoxetine oral solution 1 $0 MO
fluoxetine oral tablet 10 mg, 20 mg 1 $0 MO
FLUOXETINE ORAL TABLET 60 MG 2 $0 MO
fluphenazine decanoate injection solution 1 $0 B/D PA; MO
fluphenazine hcl injection solution 1 $0 B/D PA; MO
fluphenazine hcl oral concentrate 1 $0 MO
fluphenazine hcl oral elixir 1 $0 MO
fluphenazine hcl oral tablet 1 $0 MO
fluvoxamine oral capsule,extended release 1 $0 MO
24hr
fluvoxamine oral tablet 1 $0 MO
FORFIVO XL ORAL TABLET EXTENDED 2 $0 MO
RELEASE 24 HR
GEODON INTRAMUSCULAR RECON 2 $0 B/D PA; MO
SOLN
guanfacine oral tablet extended release 24 hr 1 $0 MO
41
guanidine oral tablet 1 $0 MO
haloperidol decanoate intramuscular solution 1 $0 B/D PA; MO
haloperidol lactate injection solution 1 $0 B/D PA; MO
haloperidol lactate oral concentrate 1 $0 MO
haloperidol oral tablet 1 $0 MO
HETLIOZ ORAL CAPSULE 2 $0 PA; MO; QL (30 per 30 days)
imipramine hcl oral tablet 1 $0 PA; MO
imipramine pamoate oral capsule 1 $0 PA; MO
INVEGA ORAL TABLET EXTENDED 2 $0 MO; QL (30 per 30 days)
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
INVEGA ORAL TABLET EXTENDED 2 $0 MO; QL (60 per 30 days)
RELEASE 24HR 6 MG
INVEGA SUSTENNA INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
INVEGA TRINZA INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
IRENKA ORAL CAPSULE,DELAYED 2 $0 MO
RELEASE(DR/EC)
KHEDEZLA ORAL TABLET EXTENDED 2 $0 MO
RELEASE 24HR
LATUDA ORAL TABLET 2 $0 MO
lithium carbonate oral capsule 1 $0 MO
lithium carbonate oral tablet 1 $0 MO
lithium carbonate oral tablet extended release 1 $0 MO
lithium citrate oral solution 8 meq/5 ml 1 $0 MO
lorazepam intensol oral concentrate 1 $0 PA; MO
lorazepam oral tablet 1 $0 PA; MO
loxapine succinate oral capsule 1 $0 MO
maprotiline oral tablet 1 $0 MO
MARPLAN ORAL TABLET 2 $0 MO
42
metadate er oral tablet extended release 1 $0 MO
methamphetamine oral tablet 1 $0 MO
methylphenidate oral capsule, er biphasic 30- 1 $0 MO
70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule,er biphasic 50-50 1 $0 MO
methylphenidate oral solution 1 $0 MO
methylphenidate oral tablet 1 $0 MO
methylphenidate oral tablet extended release 1 $0 MO
methylphenidate oral tablet extended release 1 $0 MO
24hr 18 mg
mirtazapine oral tablet 1 $0 MO
mirtazapine oral tablet,disintegrating 1 $0 MO
modafinil oral tablet 1 $0 PA; MO
nefazodone oral tablet 1 $0 MO
nortriptyline oral capsule 1 $0 MO
nortriptyline oral solution 1 $0 MO
olanzapine intramuscular recon soln 1 $0 MO
olanzapine oral tablet 1 $0 MO
olanzapine oral tablet,disintegrating 1 $0 MO
olanzapine-fluoxetine oral capsule 1 $0 MO
ORAP ORAL TABLET 2 $0 MO
oxazepam oral capsule 1 $0 PA; MO
paroxetine hcl oral tablet 1 $0 MO
paroxetine hcl oral tablet extended release 24 1 $0 MO
hr
PAXIL ORAL SUSPENSION 2 $0 MO
perphenazine oral tablet 1 $0 MO
perphenazine-amitriptyline oral tablet 1 $0 PA; MO
phenelzine oral tablet 1 $0 MO
43
PRISTIQ ORAL TABLET EXTENDED 2 $0 MO
RELEASE 24 HR
protriptyline oral tablet 1 $0 MO
quetiapine oral tablet 1 $0 MO
RISPERDAL CONSTA INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
risperidone oral solution 1 $0 MO
risperidone oral tablet 1 $0 MO
risperidone oral tablet,disintegrating 1 $0 MO
ROZEREM ORAL TABLET 2 $0 MO; QL (30 per 30 days)
SAPHRIS (BLACK CHERRY) 2 $0 MO; QL (60 per 30 days)
SUBLINGUAL TABLET 10 MG, 5 MG
SAPHRIS (BLACK CHERRY) 2 $0 MO
SUBLINGUAL TABLET 2.5 MG
SEROQUEL XR ORAL TABLET 2 $0 MO
EXTENDED RELEASE 24 HR
sertraline oral concentrate 1 $0 MO
sertraline oral tablet 1 $0 MO
STRATTERA ORAL CAPSULE 2 $0 MO
SURMONTIL ORAL CAPSULE 2 $0 PA; MO
temazepam oral capsule 1 $0 PA; MO
thioridazine oral tablet 1 $0 PA; MO
thiothixene oral capsule 1 $0 MO
tranylcypromine oral tablet 1 $0 MO
trazodone oral tablet 1 $0 MO
trifluoperazine oral tablet 1 $0 MO
venlafaxine oral capsule,extended release 24hr 1 $0 MO
venlafaxine oral tablet 1 $0 MO
venlafaxine oral tablet extended release 24hr 1 $0 MO
150 mg, 37.5 mg, 75 mg
44
VERSACLOZ ORAL SUSPENSION 2 $0
VIIBRYD ORAL TABLET 2 $0 MO
VIIBRYD ORAL TABLETS,DOSE PACK 10 2 $0 MO; QL (30 per 30 days)
MG (7)-20 MG (7)-40 MG (16)
XYREM ORAL SOLUTION 2 $0 MO; LA
ziprasidone hcl oral capsule 1 $0 MO
zolpidem oral tablet 1 $0 MO; QL (30 per 30 days)
zolpidem oral tablet,ext release multiphase 1 $0 MO; QL (30 per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR 2 $0 B/D PA
SUSPENSION FOR RECONSTITUTION 210
MG
CARDIOVASCULAR,
HIPERTENSIÓN / LÍPIDOS
AGENTES ANTIARRÍTMICOS
amiodarone intravenous solution 1 $0 B/D PA; MO
amiodarone intravenous syringe 1 $0
amiodarone oral tablet 1 $0 MO
flecainide oral tablet 1 $0 MO
mexiletine oral capsule 1 $0 MO
MULTAQ ORAL TABLET 2 $0 MO
pacerone oral tablet 100 mg, 200 mg, 400 mg 1 $0 MO
procainamide injection solution 100 mg/ml 1 $0 MO
procainamide injection solution 500 mg/ml 1 $0
propafenone oral capsule,extended release 12 1 $0 MO
hr
propafenone oral tablet 1 $0 MO
quinidine gluconate injection solution 1 $0 MO
quinidine gluconate oral tablet extended 1 $0 MO
release
quinidine sulfate oral tablet 1 $0 MO
45
sorine oral tablet 120 mg, 160 mg, 80 mg 1 $0 MO
sorine oral tablet 240 mg 1 $0
sotalol af oral tablet 120 mg 1 $0 MO
sotalol oral tablet 160 mg, 240 mg, 80 mg 1 $0 MO
TIKOSYN ORAL CAPSULE 2 $0 MO
TERAPIA ANTIHIPERTENSIVA
acebutolol oral capsule 1 $0 MO
afeditab cr oral tablet extended release 1 $0 MO
amiloride oral tablet 1 $0 MO
amiloride-hydrochlorothiazide oral tablet 1 $0 MO
amlodipine oral tablet 1 $0 MO
amlodipine-benazepril oral capsule 1 $0 MO
amlodipine-valsartan oral tablet 1 $0 MO
amlodipine-valsartan-hcthiazid oral tablet 1 $0 MO
atenolol oral tablet 1 $0 MO
atenolol-chlorthalidone oral tablet 1 $0 MO
AZOR ORAL TABLET 2 $0 MO
benazepril oral tablet 1 $0 MO
benazepril-hydrochlorothiazide oral tablet 1 $0 MO
BENICAR HCT ORAL TABLET 2 $0 MO
BENICAR ORAL TABLET 2 $0 MO; QL (30 per 30 days)
betaxolol oral tablet 1 $0 MO
bisoprolol fumarate oral tablet 1 $0 MO
bisoprolol-hydrochlorothiazide oral tablet 1 $0 MO
bumetanide injection solution 1 $0 MO
bumetanide oral tablet 1 $0 MO
BYSTOLIC ORAL TABLET 2 $0 MO
candesartan oral tablet 1 $0 MO
46
candesartan-hydrochlorothiazid oral tablet 1 $0 MO
captopril oral tablet 1 $0 MO
captopril-hydrochlorothiazide oral tablet 1 $0 MO
cartia xt oral capsule,extended release 24hr 1 $0 MO
carvedilol oral tablet 1 $0 MO
chlorothiazide oral tablet 1 $0 MO
chlorothiazide sodium intravenous recon soln 1 $0 MO
chlorthalidone oral tablet 25 mg, 50 mg 1 $0 MO
clonidine hcl oral tablet 1 $0 MO
clonidine transdermal patch weekly 1 $0 MO
COREG CR ORAL CAPSULE, ER 2 $0 ST; MO
MULTIPHASE 24 HR
DEMSER ORAL CAPSULE 2 $0 PA; MO
diltiazem hcl intravenous recon soln 1 $0 B/D PA
diltiazem hcl intravenous solution 1 $0 B/D PA
diltiazem hcl oral capsule, extended release 1 $0 MO
180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended release 12 1 $0 MO
hr
diltiazem hcl oral capsule,extended release 1 $0 MO
24hr 120 mg, 240 mg, 300 mg
diltiazem hcl oral tablet 1 $0 MO
diltiazem hcl oral tablet extended release 24 hr 1 $0
180 mg, 300 mg, 420 mg
diltiazem hcl oral tablet extended release 24 hr 1 $0 MO
240 mg, 360 mg
dilt-xr oral capsule,ext release degradable 1 $0 MO
doxazosin oral tablet 1 $0 MO
enalapril maleate oral tablet 1 $0 MO
enalapril-hydrochlorothiazide oral tablet 1 $0 MO
47
EPANED ORAL RECON SOLN 2 $0 MO
eplerenone oral tablet 1 $0 MO
eprosartan oral tablet 1 $0 MO
felodipine oral tablet extended release 24 hr 1 $0 MO
fosinopril oral tablet 1 $0 MO
fosinopril-hydrochlorothiazide oral tablet 1 $0 MO
furosemide injection solution 1 $0 B/D PA; MO
furosemide injection syringe 1 $0 B/D PA; MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 $0 MO
furosemide oral tablet 1 $0 MO
hydralazine injection solution 1 $0 B/D PA; MO
hydralazine oral tablet 1 $0 MO
hydrochlorothiazide oral capsule 1 $0 MO
hydrochlorothiazide oral tablet 1 $0 MO
indapamide oral tablet 1 $0 MO
irbesartan oral tablet 1 $0 MO
irbesartan-hydrochlorothiazide oral tablet 1 $0 MO
isradipine oral capsule 1 $0 MO
labetalol intravenous solution 1 $0 B/D PA; MO
labetalol intravenous syringe 20 mg/4 ml (5 1 $0 B/D PA
mg/ml)
labetalol oral tablet 1 $0 MO
lisinopril oral tablet 1 $0 MO
lisinopril-hydrochlorothiazide oral tablet 1 $0 MO
losartan oral tablet 1 $0 MO
losartan-hydrochlorothiazide oral tablet 1 $0 MO
matzim la oral tablet extended release 24 hr 1 $0 MO
methyclothiazide oral tablet 1 $0 MO
48
methyldopa-hydrochlorothiazide oral tablet 1 $0 PA; MO
metolazone oral tablet 1 $0 MO
metoprolol succinate oral tablet extended 1 $0 MO
release 24 hr
metoprolol ta-hydrochlorothiaz oral tablet 1 $0 MO
metoprolol tartrate intravenous solution 1 $0 B/D PA; MO
metoprolol tartrate oral tablet 1 $0 MO
minoxidil oral tablet 1 $0 MO
moexipril oral tablet 1 $0 MO
moexipril-hydrochlorothiazide oral tablet 1 $0 MO
nadolol oral tablet 1 $0 MO
nadolol-bendroflumethiazide oral tablet 1 $0 MO
nicardipine intravenous solution 1 $0 MO
nicardipine oral capsule 1 $0 MO
nifedical xl oral tablet extended release 24hr 1 $0 MO
nifedipine oral tablet extended release 24hr 1 $0 MO
nimodipine oral capsule 1 $0 MO
perindopril erbumine oral tablet 1 $0 MO
pindolol oral tablet 1 $0 MO
prazosin oral capsule 1 $0 MO
propranolol intravenous solution 1 $0 B/D PA
propranolol oral capsule,extended release 24 1 $0 MO
hr
propranolol oral solution 1 $0 MO
propranolol oral tablet 1 $0 MO
propranolol-hydrochlorothiazid oral tablet 1 $0 MO
quinapril oral tablet 1 $0 MO
quinapril-hydrochlorothiazide oral tablet 1 $0 MO
ramipril oral capsule 1 $0 MO
49
REMODULIN INJECTION SOLUTION 2 $0 B/D PA; MO
reserpine oral tablet 1 $0 PA; MO
spironolactone oral tablet 1 $0 MO
spironolacton-hydrochlorothiaz oral tablet 1 $0 MO
taztia xt oral capsule, extended release 1 $0 MO
TEKAMLO ORAL TABLET 2 $0 MO
TEKTURNA HCT ORAL TABLET 2 $0 MO
TEKTURNA ORAL TABLET 2 $0 MO
telmisartan oral tablet 1 $0 MO
telmisartan-hydrochlorothiazid oral tablet 1 $0 MO
terazosin oral capsule 1 $0 MO
timolol maleate oral tablet 1 $0 MO
torsemide oral tablet 1 $0 MO
trandolapril oral tablet 1 $0 MO
trandolapril-verapamil oral tablet, ir & er, 1 $0 MO
biphasic 24hr
triamterene-hydrochlorothiazid oral capsule 1 $0 MO
triamterene-hydrochlorothiazid oral tablet 1 $0 MO
valsartan oral tablet 1 $0 MO
valsartan-hydrochlorothiazide oral tablet 1 $0 MO
verapamil intravenous solution 1 $0 B/D PA; MO
verapamil intravenous syringe 1 $0 B/D PA
verapamil oral capsule, 24 hr er pellet ct 1 $0 MO
verapamil oral capsule,ext rel. pellets 24 hr 1 $0 MO
verapamil oral tablet 1 $0 MO
verapamil oral tablet extended release 1 $0 MO
GLUCÓSIDOS CARDÍACOS
digitek oral tablet 1 $0 PA; MO
50
digox oral tablet 1 $0 MO
digoxin injection solution 1 $0 PA; MO
digoxin oral solution 50 mcg/ml 1 $0 PA; MO
digoxin oral tablet 1 $0 PA; MO
LANOXIN ORAL TABLET 2 $0 PA; MO
TERAPIA DE COAGULACIÓN
AGGRENOX ORAL CAPSULE, ER 2 $0 MO
MULTIPHASE 12 HR
BRILINTA ORAL TABLET 2 $0 MO
cilostazol oral tablet 1 $0 MO
clopidogrel oral tablet 300 mg 1 $0 MO; QL (1 per 30 days)
clopidogrel oral tablet 75 mg 1 $0 MO
COUMADIN ORAL TABLET 2 $0 MO
EFFIENT ORAL TABLET 2 $0 MO
ELIQUIS ORAL TABLET 2 $0 MO
enoxaparin subcutaneous solution 1 $0 MO; QL (180 per 30 days)
enoxaparin subcutaneous syringe 100 mg/ml 1 $0 MO; QL (60 per 30 days)
ENOXAPARIN SUBCUTANEOUS 2 $0 MO; QL (48 per 30 days)
SYRINGE 120 MG/0.8 ML
ENOXAPARIN SUBCUTANEOUS 2 $0 MO; QL (60 per 30 days)
SYRINGE 150 MG/ML
enoxaparin subcutaneous syringe 30 mg/0.3 ml 1 $0 MO; QL (18 per 30 days)
FONDAPARINUX SUBCUTANEOUS 2 $0 MO; QL (24 per 30 days)
SYRINGE 10 MG/0.8 ML
fondaparinux subcutaneous syringe 2.5 mg/0.5 1 $0 MO; QL (15 per 30 days)
ml
51
fondaparinux subcutaneous syringe 5 mg/0.4 1 $0 MO; QL (12 per 30 days)
ml
FONDAPARINUX SUBCUTANEOUS 2 $0 MO; QL (18 per 30 days)
SYRINGE 7.5 MG/0.6 ML
FRAGMIN SUBCUTANEOUS SOLUTION 2 $0 MO; QL (30 per 30 days)
FRAGMIN SUBCUTANEOUS SYRINGE 2 $0 MO; QL (30 per 30 days)
10,000 ANTI-XA UNIT/ML
12,500 ANTI-XA UNIT/0.5 ML
FRAGMIN SUBCUTANEOUS SYRINGE 2 $0 MO; QL (21.6 per 30 days)
2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-
XA UNIT/0.2 ML
heparin (porcine) in 5 % dex intravenous 1 $0 B/D PA
parenteral solution 20,000 unit/500 ml (40
unit/ml), 25,000 unit/250 ml(100 unit/ml)
heparin (porcine) in 5 % dex intravenous 1 $0 B/D PA; MO
parenteral solution 25,000 unit/500 ml (50
unit/ml)
heparin (porcine) in nacl (pf) intravenous 1 $0 B/D PA
parenteral solution 1,000 unit/500 ml
heparin (porcine) in nacl (pf) intravenous 2 $0 B/D PA
parenteral solution 2,000 unit/1,000 ml
heparin (porcine) injection solution 1 $0 B/D PA; MO
heparin, porcine (pf) injection syringe 1 $0 B/D PA; MO
jantoven oral tablet 1 $0 MO
MEPHYTON ORAL TABLET 3 $0 MO; *
52
pentoxifylline oral tablet extended release 1 $0 MO
PRADAXA ORAL CAPSULE 2 $0 ST; MO
PROMACTA ORAL TABLET 2 $0 PA; MO
tranexamic acid intravenous solution 1 $0 B/D PA; MO
VITAMIN K INJECTION SOLUTION 3 $0 MO; *
VITAMIN K1 INJECTION SOLUTION 3 $0 MO; *
warfarin oral tablet 1 $0 MO
XARELTO ORAL TABLET 2 $0 MO
XARELTO ORAL TABLETS,DOSE PACK 2 $0 MO
AGENTES QUE BAJAN EL COLESTEROL /
LÍPIDOS
amlodipine-atorvastatin oral tablet 1 $0 MO
atorvastatin oral tablet 1 $0 MO
cholestyramine light oral powder in packet 1 $0 MO
colestipol oral granules 1 $0 MO
colestipol oral tablet 1 $0 MO
CRESTOR ORAL TABLET 2 $0 MO
fenofibrate micronized oral capsule 1 $0 MO
fenofibrate nanocrystallized oral tablet 1 $0 MO
fenofibrate oral tablet 160 mg, 54 mg 1 $0 MO
fenofibric acid (choline) oral capsule,delayed 1 $0 MO
release(dr/ec)
fluvastatin oral capsule 1 $0 MO
gemfibrozil oral tablet 1 $0 MO
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 2 $0 PA; MO; LA
5 MG
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 2 $0 PA; MO
60 MG
lovastatin oral tablet 1 $0 MO
niacin oral tablet 4 $0 MO; *
53
niacin oral tablet extended release 24 hr 1 $0 MO
niacin oral tablet extended release 250 mg, 500 4 $0 MO; *
mg, 750 mg
omega-3 acid ethyl esters oral capsule 1 $0 MO
pravastatin oral tablet 1 $0 MO
prevalite oral powder 1 $0 MO
simvastatin oral tablet 1 $0 MO
VYTORIN 10-10 ORAL TABLET 2 $0 MO
WELCHOL ORAL POWDER IN PACKET 2 $0 MO
WELCHOL ORAL TABLET 2 $0 MO
ZETIA ORAL TABLET 2 $0 MO
AGENTES CARDIOVASCULARES VARIOS
RANEXA ORAL TABLET EXTENDED 2 $0 MO
RELEASE 12 HR
VECAMYL ORAL TABLET 2 $0
NITRATOS
ISORDIL ORAL TABLET 2 $0 MO
isosorbide dinitrate oral tablet 1 $0 MO
isosorbide dinitrate oral tablet extended 1 $0 MO
release
isosorbide mononitrate oral tablet 1 $0 MO
isosorbide mononitrate oral tablet extended 1 $0 MO
release 24 hr
nitro-bid transdermal ointment 1 $0 MO
nitroglycerin intravenous solution 1 $0 B/D PA
nitroglycerin transdermal patch 24 hour 1 $0 MO
54
nitroglycerin translingual spray,non-aerosol 1 $0 MO
NITROSTAT SUBLINGUAL TABLET 2 $0 MO
DERMATOLÓGICOS / TERAPIA
TÓPICA
ANTIPSORIÁTICO / ANTISEBORRÉICO
acitretin oral capsule 10 mg 1 $0 MO
ACITRETIN ORAL CAPSULE 17.5 MG, 25 2 $0 MO
MG
calcipotriene topical cream 1 $0 MO
calcipotriene topical ointment 1 $0 MO
calcipotriene topical solution 1 $0 MO
calcitrene topical ointment 2 $0 MO
calcitriol topical ointment 1 $0 MO
COSENTYX PEN (2 PENS) 2 $0 ST; MO
SUBCUTANEOUS PEN INJECTOR
COSENTYX PEN SUBCUTANEOUS PEN 2 $0 ST; MO
INJECTOR
selenium sulfide topical suspension 1 $0 MO
TERAPIA DE QUEMADOS
silver sulfadiazine topical cream 1 $0 MO
ssd topical cream 1 $0 MO
QUERATOLÍTICOS
SAL-PLANT TOPICAL GEL 4 $0 MO; *
wart remover topical gel 4 $0 *
DERMATOLÓGICOS VARIOS
ammonium lactate topical cream 1 $0 MO
ammonium lactate topical lotion 1 $0 MO
CARAC TOPICAL CREAM 2 $0 MO
diaper rash relief topical ointment 4 $0 *
55
diclofenac sodium topical gel 1 $0 PA; MO
ELIDEL TOPICAL CREAM 2 $0 ST; MO
fluorouracil topical cream 1 $0 MO
fluorouracil topical solution 1 $0 MO
imiquimod topical cream in packet 1 $0 MO
methoxsalen rapid oral capsule 1 $0 MO
PANRETIN TOPICAL GEL 2 $0 MO
podofilox topical solution 1 $0 MO
REGRANEX TOPICAL GEL 2 $0 MO; QL (30 per 30 days)
tacrolimus topical ointment 1 $0 MO
VALCHLOR TOPICAL GEL 2 $0 MO
zinc oxide topical ointment 4 $0 *
zinc oxide topical ointment 20 % 4 $0 MO; *
ZYCLARA TOPICAL CREAM IN 2 $0 MO
METERED-DOSE PUMP 2.5 %
ZYCLARA TOPICAL CREAM IN PACKET 2 $0 MO
TERAPIA PARA EL ACNÉ
adapalene topical cream 1 $0 PA; MO
adapalene topical gel 1 $0 PA; MO
amnesteem oral capsule 1 $0 MO
benzoyl peroxide topical lotion 5 % 4 $0 MO; *
claravis oral capsule 1 $0 MO
clindamycin phosphate topical foam 1 $0 MO
clindamycin phosphate topical gel 1 $0 MO
clindamycin phosphate topical lotion 1 $0 MO
clindamycin phosphate topical solution 1 $0 MO
clindamycin phosphate topical swab 1 $0 MO
56
clindamycin-benzoyl peroxide topical gel 1-5 1 $0 MO
%
ery pads topical swab 1 $0 MO
erythromycin with ethanol topical gel 1 $0 MO
erythromycin with ethanol topical solution 1 $0 MO
erythromycin with ethanol topical swab 1 $0 MO
erythromycin-benzoyl peroxide topical gel 1 $0 MO
metronidazole topical cream 1 $0 MO
metronidazole topical gel 1 $0 MO
metronidazole topical lotion 1 $0 MO
rosadan topical cream 1 $0 MO
rosadan topical gel 1 $0 MO
TAZORAC TOPICAL CREAM 2 $0 MO
TAZORAC TOPICAL GEL 2 $0 MO
tretinoin microspheres topical gel with pump 1 $0 PA; MO
tretinoin topical cream 1 $0 PA; MO
tretinoin topical gel 1 $0 PA; MO
ANESTÉSICOS TÓPICOS
lidocaine (pf) injection solution 10 mg/ml (1 1 $0 B/D PA; MO
%), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
lidocaine (pf) injection solution 15 mg/ml (1.5 1 $0 B/D PA
%)
lidocaine hcl injection solution 10 mg/ml (1 %), 1 $0 B/D PA; MO
20 mg/ml (2 %)
lidocaine hcl laryngotracheal solution 1 $0 MO
lidocaine hcl mucous membrane gel 1 $0 MO
lidocaine hcl mucous membrane jelly in 1 $0 MO
applicator
lidocaine hcl mucous membrane solution 2 % 1 $0
57
lidocaine hcl mucous membrane solution 4 % 1 $0 MO
(40 mg/ml)
lidocaine hcl urethral gel 1 $0
lidocaine topical adhesive patch,medicated 1 $0 PA; MO
lidocaine topical ointment 1 $0 MO
lidocaine-prilocaine topical cream 1 $0 MO
lta pre-attached laryngotracheal solution 1 $0
ANTIBACTERIALES TÓPICOS
bacitracin topical ointment 4 $0 MO; *
bacitracin zinc topical packet 4 $0 *
bacitraycin plus topical ointment 500 4 $0 *
unit/gram
gentamicin topical cream 1 $0 MO
gentamicin topical ointment 1 $0 MO
mupirocin calcium topical cream 1 $0 MO
mupirocin topical ointment 1 $0 MO
sulfacetamide sodium (acne) topical suspension 1 $0 MO
TRIPLE ANTIBIOTIC TOPICAL 4 $0 MO; *
OINTMENT
ANTIFÚNGIDOS TÓPICOS
antifungal (tolnaftate) topical cream 4 $0 *
ANTIFUNGAL (TOLNAFTATE) TOPICAL 4 $0 MO; *
POWDER
athlete's foot (terbinafine) topical cream 4 $0 *
athlete's foot (tolnaftate) topical cream 4 $0 *
athlete's foot af topical cream 4 $0 *
baza antifungal topical cream 4 $0 MO; *
ciclodan topical cream 1 $0 MO
ciclodan topical solution 1 $0 MO
58
ciclopirox topical cream 1 $0 MO
ciclopirox topical gel 1 $0 MO
ciclopirox topical shampoo 1 $0 MO
ciclopirox topical solution 1 $0 MO
ciclopirox topical suspension 1 $0 MO
clotrimazole topical cream 1 $0 MO
clotrimazole topical solution 1 $0 MO
clotrimazole-betamethasone topical cream 1 $0 MO
clotrimazole-betamethasone topical lotion 1 $0 MO
econazole topical cream 1 $0 MO
inzo antifungal topical cream 4 $0 *
jock itch (terbinafine) topical cream 4 $0 *
ketoconazole topical cream 1 $0 MO
ketoconazole topical shampoo 1 $0 MO
micatin topical cream 4 $0 *
miconazole nitrate topical cream 4 $0 MO; *
nuzole topical cream 4 $0 *
nyamyc topical powder 1 $0 MO
nystatin topical cream 1 $0 MO
nystatin topical ointment 1 $0 MO
nystatin topical powder 1 $0 MO
nystatin-triamcinolone topical cream 1 $0 MO
nystatin-triamcinolone topical ointment 1 $0 MO
nystop topical powder 1 $0 MO
podactin topical powder 4 $0 *
secura antifungal topical cream 4 $0 MO; *
tolnaftate topical cream 4 $0 *
tolnaftate topical powder 4 $0 *
ANTIVIRALES TÓPICOS
59
ABREVA TOPICAL CREAM 4 $0 MO; *
acyclovir topical ointment 1 $0 MO
DENAVIR TOPICAL CREAM 2 $0 MO
CORTICOSTEROIDES TÓPICOS
ala-cort topical cream 1 $0 MO
alclometasone topical cream 1 $0 MO
alclometasone topical ointment 1 $0 MO
amcinonide topical cream 1 $0 MO
amcinonide topical lotion 1 $0 MO
amcinonide topical ointment 1 $0 MO
beta-hc topical lotion 4 $0 MO; *
betamethasone dipropionate topical cream 1 $0 MO
betamethasone dipropionate topical lotion 1 $0 MO
betamethasone dipropionate topical ointment 1 $0 MO
betamethasone valerate topical cream 1 $0 MO
betamethasone valerate topical foam 1 $0 MO
betamethasone valerate topical lotion 1 $0 MO
betamethasone valerate topical ointment 1 $0 MO
betamethasone, augmented topical cream 1 $0 MO
betamethasone, augmented topical gel 1 $0 MO
betamethasone, augmented topical lotion 1 $0 MO
betamethasone, augmented topical ointment 1 $0 MO
clobetasol topical foam 1 $0 MO
clobetasol topical gel 1 $0 MO
clobetasol topical lotion 1 $0 MO
clobetasol topical ointment 1 $0 MO
clobetasol topical shampoo 1 $0 MO
clobetasol topical solution 1 $0 MO
60
clobetasol-emollient topical cream 1 $0 MO
cormax topical solution 1 $0 MO
dermarest eczema (hydrocort) topical lotion 4 $0 *
desonide topical cream 1 $0 MO
desonide topical lotion 1 $0 MO
desonide topical ointment 1 $0 MO
desoximetasone topical cream 1 $0 MO
desoximetasone topical gel 1 $0 MO
desoximetasone topical ointment 1 $0 MO
diflorasone topical cream 1 $0 MO
diflorasone topical ointment 1 $0 MO
fluocinolone topical cream 1 $0 MO
fluocinolone topical oil 1 $0 MO
fluocinolone topical ointment 1 $0 MO
fluocinolone topical solution 1 $0 MO
fluocinonide topical cream 0.1 % 1 $0 MO
fluocinonide topical gel 1 $0 MO
fluocinonide topical ointment 1 $0 MO
fluocinonide topical solution 1 $0 MO
fluocinonide-e topical cream 1 $0 MO
fluticasone topical cream 1 $0 MO
fluticasone topical lotion 1 $0 MO
fluticasone topical ointment 1 $0 MO
halobetasol propionate topical cream 1 $0 MO
halobetasol propionate topical ointment 1 $0 MO
HYDRO SKIN TOPICAL LOTION 4 $0 MO; *
hydrocortisone acetate topical cream 4 $0 *
hydrocortisone butyrate topical ointment 1 $0 MO
hydrocortisone butyrate topical solution 1 $0 MO
61
hydrocortisone butyr-emollient topical cream 1 $0 MO
hydrocortisone topical cream 1 %, 2.5 % 1 $0 MO
hydrocortisone topical lotion 2.5 % 1 $0 MO
hydrocortisone topical ointment 1 %, 2.5 % 1 $0 MO
hydrocortisone valerate topical cream 1 $0 MO
hydrocortisone valerate topical ointment 1 $0 MO
MEDI-CORTISONE TOPICAL CREAM 4 $0 *
mometasone topical cream 1 $0 MO
mometasone topical ointment 1 $0 MO
mometasone topical solution 1 $0 MO
prednicarbate topical cream 1 $0 MO
prednicarbate topical ointment 1 $0 MO
triamcinolone acetonide topical aerosol 1 $0 MO
triamcinolone acetonide topical cream 1 $0 MO
triamcinolone acetonide topical lotion 1 $0 MO
triamcinolone acetonide topical ointment 0.025 1 $0 MO
%, 0.1 %, 0.5 %
trianex topical ointment 1 $0 MO
triderm topical cream 1 $0 MO
ENZIMAS TÓPICAS
SANTYL TOPICAL OINTMENT 2 $0 MO
ESCABICIDAS / PEDICULICIDAS
TÓPICOS
lice killing (permethrin) topical liquid 4 $0 *
lice treatment (permethrin) topical liquid 4 $0 *
LICE TREATMENT TOPICAL LIQUID 1 % 4 $0 *
lindane topical lotion 1 $0 MO
lindane topical shampoo 1 $0 MO
62
malathion topical lotion 1 $0 MO
permethrin topical cream 1 $0 MO
permethrin topical liquid 4 $0 MO; *
PYRETHRIN LICE TREATMENT M 4 $0 *
TOPICAL LIQUID
DIAGNÓSTICOS / AGENTES VARIOS
SOLUCIONES DE IRRIGACIÓN
lactated ringers irrigation solution 1 $0 MO
neomycin-polymyxin b gu irrigation solution 1 $0 MO
AGENTES VARIOS
acamprosate oral tablet,delayed release (dr/ec) 1 $0 MO
ADAGEN INTRAMUSCULAR SOLUTION 2 $0 B/D PA; MO
alendronate oral tablet 40 mg 1 $0 MO; QL (30 per 30 days)
anagrelide oral capsule 1 $0 MO
ARALAST NP INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN 500 MG
CARBAGLU ORAL TABLET, 2 $0 PA; MO; LA
DISPERSIBLE
cevimeline oral capsule 1 $0 MO
CHEMET ORAL CAPSULE 2 $0 MO
CLINIMIX 4.25%/D5W SULFIT FREE 2 $0 B/D PA
INTRAVENOUS PARENTERAL SOLUTION
CLINIMIX E 2.75%/D10W SUL FREE 2 $0 B/D PA
CLINIMIX E 2.75%/D5W SULF FREE 2 $0 B/D PA
d10 % & 0.45 % sodium chloride intravenous 1 $0
parenteral solution
d2.5 %-0.45 % sodium chloride intravenous 1 $0 B/D PA
parenteral solution
63
d5 % and 0.9 % sodium chloride intravenous 1 $0 B/D PA; MO
parenteral solution
d5 %-0.45 % sodium chloride intravenous 1 $0 B/D PA; MO
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous 1 $0 B/D PA
parenteral solution
dextrose 10 % in water (d10w) intravenous 1 $0 B/D PA; MO
parenteral solution
dextrose 20 % in water (d20w) intravenous 1 $0 B/D PA
parenteral solution
syringe
parenteral solution
parenteral solution
parenteral solution
dextrose 5 %-lactated ringers intravenous 1 $0 B/D PA; MO
parenteral solution
dextrose 5%-0.2 % sod chloride intravenous 1 $0 B/D PA
parenteral solution
dextrose 5%-0.3 % sod.chloride intravenous 1 $0 B/D PA
parenteral solution
parenteral solution
syringe
parenteral solution
dextrose with sodium chloride intravenous 1 $0 B/D PA
parenteral solution
disulfiram oral tablet 1 $0 MO
64
etidronate disodium oral tablet 1 $0 MO
EXJADE ORAL TABLET, DISPERSIBLE 2 $0 MO
FERRIPROX ORAL TABLET 2 $0 PA; MO
FOSRENOL ORAL POWDER IN PACKET 2 $0
FOSRENOL ORAL TABLET,CHEWABLE 2 $0 MO
INCRELEX SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO
KIONEX ORAL POWDER 2 $0 MO
levocarnitine (with sugar) oral solution 1 $0 B/D PA; MO
levocarnitine intravenous solution 1 $0 B/D PA; MO
levocarnitine oral tablet 1 $0 B/D PA; MO
midodrine oral tablet 1 $0 MO
NORTHERA ORAL CAPSULE 2 $0 PA; MO
pilocarpine hcl oral tablet 1 $0 MO
RAVICTI ORAL LIQUID 2 $0 PA; MO
RENVELA ORAL POWDER IN PACKET 2 $0 MO
riluzole oral tablet 1 $0 MO
risedronate oral tablet 30 mg 1 $0 MO
sodium chloride 0.9 % intravenous parenteral 1 $0 MO
solution
sodium chloride irrigation solution 1 $0 MO
sodium polystyrene (sorb free) oral suspension 1 $0
SYPRINE ORAL CAPSULE 2 $0 MO
VELPHORO ORAL TABLET,CHEWABLE 2 $0 MO
zoledronic acid-mannitol-water intravenous 1 $0 B/D PA; MO
solution
DISUASORIOS DEL TABACO
buproban oral tablet extended release 1 $0 MO
CHANTIX CONTINUING MONTH BOX 2 $0 MO
ORAL TABLET
65
CHANTIX ORAL TABLET 2 $0 MO
CHANTIX STARTING MONTH BOX ORAL 2 $0 MO
TABLETS,DOSE PACK
nicotine (polacrilex) buccal gum 4 $0 MO; *
nicotine (polacrilex) buccal lozenge 2 mg 4 $0 MO; *
nicotine transdermal patch 24 hour 14 mg/24 4 $0 MO; *
hr, 21 mg/24 hr, 7 mg/24 hr
NICOTROL INHALATION CARTRIDGE 2 $0 MO
NICOTROL NS NASAL SPRAY,NON- 2 $0 MO
AEROSOL
nts step 1 transdermal patch 24 hour 4 $0 *
quit 2 buccal gum 4 $0 *
quit 4 buccal gum 4 $0 *
stop smoking aid buccal lozenge 4 $0 *
MEDICAMENTOS PARA OÍDOS,
NARIZ Y GARGANTA
AGENTES VARIOS
12 HOUR NASAL SPRAY NASAL 4 $0 *
SPRAY,NON-AEROSOL
afrin no drip(oxymetazolin) nasal mist 4 $0 *
altamist nasal aerosol,spray 4 $0 *
AYR SALINE NASAL DROPS 4 $0 MO; *
azelastine nasal aerosol,spray 1 $0 MO; QL (60 per 30 days)
azelastine nasal spray,non-aerosol 1 $0 MO; QL (60 per 30 days)
chlorhexidine gluconate mucous membrane 1 $0 MO
mouthwash
denta 5000 plus dental cream 1 $0 MO
dentagel dental gel 1 $0 MO
DRISTAN LONG LASTING NASAL MIST 4 $0 *
66
ipratropium bromide nasal spray,non-aerosol 1 $0 MO; QL (60 per 30 days)
0.03 %
ipratropium bromide nasal spray,non-aerosol 1 $0 MO; QL (30 per 30 days)
0.06 %
little remedies nasal aerosol,spray 4 $0 *
nasal moisturizing nasal aerosol,spray 4 $0 *
NASAL SPRAY (OXYMETAZOLINE) 4 $0 *
NASAL SPRAY,NON-AEROSOL
nasal spray (sodium chloride) nasal 4 $0 *
aerosol,spray
OCEAN NASAL NASAL AEROSOL,SPRAY 4 $0 MO; *
olopatadine nasal spray,non-aerosol 1 $0 MO; QL (30.5 per 30 days)
oralone dental paste 1 $0 MO
periogard mucous membrane mouthwash 1 $0 MO
saline mist nasal aerosol,spray 4 $0 MO; *
saline nasal mist nasal aerosol,spray 4 $0 *
saline nasal nasal aerosol,spray 4 $0 *
saline nose nasal aerosol,spray 4 $0 *
sf 5000 plus dental cream 1 $0 MO
sf dental gel 1 $0 MO
sinex ultra fine mist 12-hour nasal mist 4 $0 *
sinus relief (oxymetazoline) nasal mist 4 $0 *
triamcinolone acetonide dental paste 1 $0 MO
vicks qlearquil(oxymetazoline) nasal mist 4 $0 *
PREPARACIONES ÓTICAS VARIAS
acetasol hc otic drops 1 $0 MO
acetic acid otic solution 1 $0 MO
fluocinolone acetonide oil otic drops 1 $0 MO
hydrocortisone-acetic acid otic drops 1 $0 MO
ofloxacin otic drops 1 $0 MO
67
ESTEROIDES ÓTICOS / ANTIBIÓTICOS
CORTISPORIN-TC OTIC 2 $0 MO
DROPS,SUSPENSION
neomycin-polymyxin-hc otic drops,suspension 1 $0 MO
neomycin-polymyxin-hc otic solution 1 $0 MO
ENDOCRINO / DIABETES
HORMONAS SUPRARRENALES
ACTHAR H.P. INJECTION GEL 2 $0 PA; MO
A-HYDROCORT INJECTION RECON SOLN 2 $0 B/D PA; MO
cortisone oral tablet 1 $0 MO
dexamethasone intensol oral drops 1 $0 MO
dexamethasone oral elixir 1 $0 MO
dexamethasone oral tablet 1 $0 MO
dexamethasone sodium phosphate injection 1 $0 B/D PA; MO
solution
fludrocortisone oral tablet 1 $0 MO
hydrocortisone oral tablet 1 $0 MO
KENALOG INJECTION SUSPENSION 2 $0 MO
methylprednisolone acetate injection 1 $0 B/D PA; MO
suspension
methylprednisolone oral tablet 1 $0 MO
methylprednisolone oral tablets,dose pack 1 $0 MO
methylprednisolone sodium succ injection 1 $0 B/D PA; MO
recon soln 125 mg, 40 mg
millipred oral tablet 1 $0 MO
prednisolone sodium phosphate oral solution 1 $0 MO
15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5
ml (6.7 mg/5 ml)
prednisolone sodium phosphate oral 1 $0 MO
tablet,disintegrating
68
prednisone intensol oral concentrate 1 $0 MO
prednisone oral solution 1 $0 MO
prednisone oral tablet 1 $0 MO
prednisone oral tablets,dose pack 10 mg 1 $0 MO
RAYOS ORAL TABLET,DELAYED 2 $0 MO
RELEASE (DR/EC)
SOLU-CORTEF (PF) INJECTION RECON 2 $0 B/D PA; MO
SOLN 100 MG/2 ML, 250 MG/2 ML
triamcinolone acetonide injection suspension 1 $0 MO
10 mg/ml
triamcinolone acetonide injection suspension 1 $0
40 mg/ml
veripred 20 oral solution 1 $0
AGENTES ANTITIROIDEOS
methimazole oral tablet 10 mg, 5 mg 1 $0 MO
propylthiouracil oral tablet 1 $0 MO
TERAPIA PARA DIABETES
acarbose oral tablet 1 $0 MO
ACTOPLUS MET XR ORAL TABLET, ER 2 $0 ST; MO; QL (60 per 30 days)
MULTIPHASE 24 HR 15-1,000 MG
ACTOPLUS MET XR ORAL TABLET, ER 2 $0 ST; MO; QL (30 per 30 days)
MULTIPHASE 24 HR 30-1,000 MG
ALCOHOL PADS TOPICAL PADS, 2 $0 MO
MEDICATED
BYDUREON SUBCUTANEOUS PEN 2 $0 MO
INJECTOR
BYDUREON SUBCUTANEOUS 2 $0 MO
SUSPENSION,EXTENDED REL RECON
BYETTA SUBCUTANEOUS PEN 2 $0 MO
INJECTOR
CYCLOSET ORAL TABLET 2 $0 ST; MO
FARXIGA ORAL TABLET 2 $0 MO
69
GAUZE PADS 2X2 2 $0 MO
glimepiride oral tablet 1 $0 MO
glipizide oral tablet 1 $0 MO
glipizide oral tablet extended release 24hr 1 $0 MO
glipizide-metformin oral tablet 2.5-250 mg 1 $0 MO; QL (240 per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5- 1 $0 MO; QL (120 per 30 days)
500 mg
GLUCAGEN HYPOKIT INJECTION RECON 2 $0 MO
SOLN
GLUCAGON EMERGENCY KIT (HUMAN) 2 $0 MO
INJECTION KIT
HUMALOG KWIKPEN SUBCUTANEOUS 2 $0 MO
INSULIN PEN
HUMALOG MIX 50-50 KWIKPEN 2 $0 MO
SUBCUTANEOUS INSULIN PEN
HUMALOG MIX 50-50 SUBCUTANEOUS 2 $0 MO
SUSPENSION
HUMALOG MIX 75-25 KWIKPEN 2 $0 MO
HUMALOG MIX 75-25 SUBCUTANEOUS 2 $0 MO
SUSPENSION
HUMALOG SUBCUTANEOUS 2 $0 MO
CARTRIDGE
HUMALOG SUBCUTANEOUS SOLUTION 2 $0 MO
100 UNIT/ML
HUMALOG SUBCUTANEOUS SOLUTION 2 $0
100 UNIT/ML (PREFILLED SYRINGE)
HUMULIN 70/30 KWIKPEN 2 $0 MO
HUMULIN 70/30 SUBCUTANEOUS 2 $0 MO
SUSPENSION
70
HUMULIN N KWIKPEN SUBCUTANEOUS 2 $0 MO
INSULIN PEN
HUMULIN N SUBCUTANEOUS 2 $0 MO
SUSPENSION
HUMULIN R INJECTION SOLUTION 2 $0 MO
HUMULIN R U-500 "CONCENTRATED" 2 $0 MO
SUBCUTANEOUS SOLUTION
INSULIN PEN NEEDLE 2 $0 MO
INSULIN SYRINGE (DISP) U-100 0.3 ML, 2 $0 MO
1/2 ML, 1 ML
JANUMET ORAL TABLET 2 $0 MO; QL (60 per 30 days)
JANUMET XR ORAL TABLET, ER 2 $0 MO; QL (60 per 30 days)
MULTIPHASE 24 HR
JANUVIA ORAL TABLET 2 $0 MO; QL (30 per 30 days)
JARDIANCE ORAL TABLET 2 $0 MO
KOMBIGLYZE XR ORAL TABLET, ER 2 $0 MO; QL (60 per 30 days)
MULTIPHASE 24 HR 2.5-1,000 MG
KOMBIGLYZE XR ORAL TABLET, ER 2 $0 MO; QL (30 per 30 days)
MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
LEVEMIR FLEXTOUCH SUBCUTANEOUS 2 $0 MO
INSULIN PEN
LEVEMIR SUBCUTANEOUS SOLUTION 2 $0 MO
metformin oral tablet 1 $0 MO
metformin oral tablet extended release 24 hr 1 $0 MO
metformin oral tablet extended release 24hr 1 $0 MO
1,000 mg
nateglinide oral tablet 1 $0 MO
NEEDLES, INSULIN DISP.,SAFETY 2 $0 MO
NOVOFINE NEEDLE 2 $0 MO
NOVOLIN 70/30 SUBCUTANEOUS 2 $0 MO
SUSPENSION
71
NOVOLIN N SUBCUTANEOUS 2 $0 MO
SUSPENSION
NOVOLIN R INJECTION SOLUTION 2 $0 MO
NOVOLOG FLEXPEN SUBCUTANEOUS 2 $0 MO
INSULIN PEN
NOVOLOG MIX 70-30 FLEXPEN 2 $0 MO
NOVOLOG MIX 70-30 SUBCUTANEOUS 2 $0 MO
SOLUTION
NOVOLOG PENFILL SUBCUTANEOUS 2 $0 MO
CARTRIDGE
NOVOLOG SUBCUTANEOUS SOLUTION 2 $0 MO
NOVOTWIST NEEDLE 2 $0 MO
ONGLYZA ORAL TABLET 2 $0 MO; QL (30 per 30 days)
pioglitazone oral tablet 1 $0 MO
pioglitazone-glimepiride oral tablet 1 $0 MO; QL (30 per 30 days)
pioglitazone-metformin oral tablet 1 $0 MO; QL (90 per 30 days)
PROGLYCEM ORAL SUSPENSION 2 $0 MO
repaglinide oral tablet 0.5 mg 1 $0 MO; QL (930 per 30 days)
repaglinide oral tablet 1 mg 1 $0 MO; QL (480 per 30 days)
repaglinide oral tablet 2 mg 1 $0 MO; QL (240 per 30 days)
SYMLINPEN 120 SUBCUTANEOUS PEN 2 $0 MO
INJECTOR
SYMLINPEN 60 SUBCUTANEOUS PEN 2 $0 MO
INJECTOR
tolazamide oral tablet 1 $0 MO
tolbutamide oral tablet 1 $0 MO
VICTOZA 3-PAK SUBCUTANEOUS PEN 2 $0 MO
INJECTOR
XIGDUO XR ORAL TABLET, IR & ER, 2 $0 MO
BIPHASIC 24HR
72
HORMONAS VARIAS
ALDURAZYME INTRAVENOUS 2 $0 B/D PA; MO
SOLUTION
ANDROGEL TRANSDERMAL GEL IN 2 $0 MO
METERED-DOSE PUMP
ANDROGEL TRANSDERMAL GEL IN 2 $0 MO
PACKET
ANDROID ORAL CAPSULE 2 $0 MO
cabergoline oral tablet 1 $0 MO; QL (20 per 30 days)
calcitonin (salmon) nasal spray,non-aerosol 1 $0 MO
calcitriol intravenous solution 1 mcg/ml 1 $0 B/D PA; MO
calcitriol oral capsule 1 $0 B/D PA; MO
calcitriol oral solution 1 $0 B/D PA; MO
CEREZYME INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN 400 UNIT
chorionic gonadotropin, human intramuscular 1 $0 PA; MO
recon soln
danazol oral capsule 1 $0 MO
desmopressin injection solution 1 $0 MO
desmopressin nasal solution 1 $0 MO
desmopressin nasal spray,non-aerosol 1 $0 MO
desmopressin oral tablet 1 $0 MO
ELAPRASE INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
ELELYSO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
FABRAZYME INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN 35 MG
fortical nasal spray,non-aerosol 1 $0 MO
KORLYM ORAL TABLET 2 $0 PA; MO
KUVAN ORAL TABLET,SOLUBLE 2 $0 PA; MO
MIACALCIN INJECTION SOLUTION 2 $0 B/D PA; MO
73
MYOZYME INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
NAGLAZYME INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
NATPARA SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO
novarel intramuscular recon soln 1 $0 PA; MO
OXANDROLONE ORAL TABLET 10 MG 2 $0 MO
oxandrolone oral tablet 2.5 mg 1 $0 MO
pamidronate intravenous solution 1 $0 B/D PA; MO
paricalcitol oral capsule 1 $0 B/D PA; MO
PREGNYL INTRAMUSCULAR RECON 2 $0 PA; MO
SOLN
SAMSCA ORAL TABLET 15 MG 2 $0 PA; MO; QL (30 per 30 days)
SAMSCA ORAL TABLET 30 MG 2 $0 PA; MO; QL (60 per 30 days)
SENSIPAR ORAL TABLET 2 $0 MO
SOMAVERT SUBCUTANEOUS RECON 2 $0 B/D PA; MO
SOLN
SYNAREL NASAL SPRAY,NON-AEROSOL 2 $0 MO
testosterone enanthate intramuscular oil 1 $0 B/D PA; MO
VPRIV INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
ZAVESCA ORAL CAPSULE 2 $0 MO
ZEMPLAR INTRAVENOUS SOLUTION 2 $0 B/D PA; MO
zoledronic acid intravenous solution 1 $0 B/D PA; MO
ZOMETA INTRAVENOUS SOLUTION 4 2 $0 B/D PA; MO
MG/100 ML
HORMONAS TIROIDEAS
LEVOTHYROXINE INTRAVENOUS 2 $0 MO
RECON SOLN 100 MCG
levothyroxine oral tablet 1 $0 MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 1 $0 MO
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg,
50 mcg, 75 mcg, 88 mcg
74
liothyronine intravenous solution 1 $0 MO
liothyronine oral tablet 1 $0 MO
SYNTHROID ORAL TABLET 2 $0 MO
unithroid oral tablet 100 mcg, 112 mcg, 125 1 $0 MO
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300
mcg, 50 mcg, 75 mcg, 88 mcg
GASTROENTEROLOGÍA
ANTIDIARRÉICOS / ANTIESPASMÓDICOS
anti-diarrhea oral tablet 4 $0 *
ANTI-DIARRHEAL (LOPERAMIDE) ORAL 4 $0 MO; *
TABLET
anti-diarrheal oral suspension 4 $0 *
atropine injection syringe 0.05 mg/ml, 0.1 1 $0
mg/ml
BISMATROL ORAL SUSPENSION 262 4 $0 MO; *
MG/15 ML
BISMATROL ORAL TABLET,CHEWABLE 4 $0 *
bismuth maximum strength oral suspension 4 $0 *
bismuth oral suspension 4 $0 *
bismuth oral tablet,chewable 4 $0 *
diamode oral tablet 4 $0 *
diarrhea relief (bismuth subs) oral suspension 4 $0 *
dicyclomine oral capsule 1 $0 PA; MO
dicyclomine oral solution 1 $0 PA; MO
dicyclomine oral tablet 1 $0 PA; MO
diotame oral tablet,chewable 4 $0 *
glycopyrrolate injection solution 1 $0 MO
glycopyrrolate oral tablet 1 $0 MO
kaopectate (bismuth subsalicy) oral suspension 4 $0 MO; *
kaopectate ex str (bismuth ss) oral suspension 4 $0 *
75
k-pec antidiarrheal (bism sub) oral suspension 4 $0 *
loperamide oral capsule 1 $0 MO
loperamide oral tablet 4 $0 *
medi-bismuth oral tablet,chewable 4 $0 *
methscopolamine oral tablet 1 $0 MO
pepto-bismol oral tablet,chewable 4 $0 MO; *
pink bismuth maximum strength oral 4 $0 *
suspension
pink bismuth oral suspension 4 $0 *
pink bismuth oral tablet,chewable 4 $0 MO; *
soothe regular strength oral suspension 4 $0 *
stomach relief max strength oral suspension 4 $0 *
stomach relief oral suspension 4 $0 *
stomach relief oral tablet,chewable 4 $0 *
stomach relief original oral suspension 4 $0 *
AGENTES GASTROINTESTINALES
VARIOS
ACID GONE ANTACID ORAL 4 $0 *
SUSPENSION
ADVANCED ANTACID-ANTIGAS ORAL 4 $0 *
SUSPENSION
ALMACONE ORAL SUSPENSION 4 $0 *
ALMACONE-2 ORAL SUSPENSION 4 $0 *
alophen oral tablet,delayed release (dr/ec) 4 $0 *
aluminum hydroxide gel oral suspension 320 4 $0 MO; *
mg/5 ml
aluminum hydroxide gel oral suspension 600 4 $0 *
mg/5 ml
AMITIZA ORAL CAPSULE 2 $0 MO; QL (60 per 30 days)
antacid anti-gas double str oral suspension 4 $0 *
76
antacid anti-gas oral suspension 4 $0 *
antacid extra-strength oral suspension 4 $0 *
antacid liquid oral suspension 4 $0 *
antacid maximum strength oral suspension 4 $0 *
antacid oral suspension 4 $0 *
antacid oral tablet,chewable 550-110 mg 4 $0 *
antacid plus anti-gas oral suspension 4 $0 *
antacid regular strength oral suspension 4 $0 *
ANTACID TABLET ORAL 4 $0 *
TABLET,CHEWABLE
antacid ultra strength oral tablet,chewable 4 $0 *
1,177 mg
antacid with simethicone oral suspension 4 $0 *
antacid-antigas oral suspension 4 $0 *
antacid-simethicone ds oral suspension 4 $0 *
APRISO ORAL CAPSULE,EXTENDED 2 $0 MO
RELEASE 24HR
balsalazide oral capsule 1 $0 MO
bisacodyl oral tablet,delayed release (dr/ec) 4 $0 MO; *
bisa-lax oral tablet,delayed release (dr/ec) 4 $0 *
BUDESONIDE ORAL 2 $0 MO
CAPSULE,DELAYED,EXTEND.RELEASE
CANASA RECTAL SUPPOSITORY 2 $0 MO
child suppository rectal suppository 4 $0 *
children's pepto oral tablet,chewable 4 $0 *
CIMZIA POWDER FOR RECONST 2 $0 B/D PA; ST; MO
SUBCUTANEOUS KIT
CIMZIA SUBCUTANEOUS SYRINGE KIT 2 $0 ST; MO
citrate of magnesia oral solution 4 $0 *
CLEARLAX ORAL POWDER 4 $0 MO; *
77
col-rite oral capsule 4 $0 *
comfort gel extra strength oral suspension 4 $0 *
comfort gel oral suspension 4 $0 *
compro rectal suppository 1 $0 MO
constulose oral solution 1 $0 MO
cromolyn oral concentrate 1 $0 MO
CYSTADANE ORAL POWDER 2 $0 MO
dimenhydrinate oral tablet 4 $0 MO; *
DIOCTO ORAL LIQUID 4 $0 *
DIPENTUM ORAL CAPSULE 2 $0 MO
DOC-Q-LACE ORAL CAPSULE 4 $0 MO; *
docu oral liquid 4 $0 MO; *
docu soft oral capsule 4 $0 *
docusate sodium oral capsule 4 $0 MO; *
docusil oral capsule 4 $0 *
DRONABINOL ORAL CAPSULE 10 MG 2 $0 B/D PA; MO; QL (60 per 30
days)
dronabinol oral capsule 2.5 mg, 5 mg 1 $0 B/D PA; MO; QL (60 per 30
days)
dss oral capsule 250 mg 4 $0 *
ducodyl oral tablet,delayed release (dr/ec) 4 $0 *
dulcolax stool softener (dss) oral capsule 4 $0 MO; *
EMEND ORAL CAPSULE 125 MG 2 $0 B/D PA; MO; QL (2 per 30
days)
day)
days)
EMEND ORAL CAPSULE,DOSE PACK 2 $0 B/D PA; MO; QL (3 per 3
days)
78
ENEMA RECTAL ENEMA 19-7 GRAM/118 4 $0 *
ML
enulose oral solution 1 $0 MO
FIBER (CALCIUM POLYCARBOPHIL) 4 $0 MO; *
ORAL TABLET
fiber (psyllium husk/sugar) oral powder 4 $0 *
FIBER (WITH ASPARTAME) ORAL 4 $0 *
POWDER
fiber laxative (husk/sugar) oral powder 4 $0 *
fiber laxative (methylcellulo) oral tablet 4 $0 *
fiber laxative (psyllium) s/f oral powder 4 $0 *
FIBER ORAL POWDER 4 $0 *
fiber smooth (sucrose) oral powder 4 $0 *
fiber smooth oral powder 4 $0 *
fiber therapy (ca polycarboph) oral tablet 4 $0 *
FIBER THERAPY (PSYLLIUM SEED) 4 $0 *
ORAL POWDER
fiber therapy (psyllium) oral powder 4 $0 *
FIBER THERAPY ORAL POWDER 4 $0 *
FIBER THERAPY ORAL TABLET 4 $0 *
fiber-lax oral tablet 4 $0 MO; *
fiber-tabs oral tablet 4 $0 *
flanax antacid oral suspension 4 $0 *
foaming antacid oral suspension 4 $0 *
foaming antacid oral tablet,chewable 4 $0 *
GATTEX ONE-VIAL SUBCUTANEOUS 2 $0 PA; MO
KIT
gavilax oral powder 4 $0 MO; *
gavilyte-c oral recon soln 1 $0 MO
gavilyte-g oral recon soln 1 $0 MO
79
gavilyte-n oral recon soln 1 $0 MO
generlac oral solution 1 $0 MO
gentlelax oral powder 4 $0 *
geri-kot oral tablet 4 $0 *
geri-lanta oral suspension 4 $0 *
geri-mox antacid-antigas oral suspension 4 $0 *
glycerin (adult) rectal suppository 4 $0 *
glycerin (child) rectal suppository 4 $0 *
glycolax oral powder 4 $0 *
granisetron (pf) intravenous solution 100 1 $0 B/D PA; MO
mcg/ml
granisetron hcl intravenous solution 1 mg/ml (1 1 $0 B/D PA; MO
ml)
granisetron hcl oral tablet 1 $0 B/D PA; MO; QL (2 per 1
day)
hydrocortisone rectal enema 1 $0 MO
KONSYL (SUGAR) ORAL POWDER 3.4 4 $0 *
GRAM/11 GRAM
KONSYL SUGAR-FREE ORAL POWDER 4 $0 MO; *
IN PACKET
lactulose oral solution 10 gram/15 ml 1 $0 MO
laxa clear oral powder 4 $0 *
laxacin oral tablet 4 $0 *
laxative (glycerin-pediatric) rectal suppository 4 $0 *
laxative maximum strength oral tablet 4 $0 *
laxative oral tablet 15 mg, 17.2 mg, 25 mg 4 $0 *
laxative oral tablet,delayed release (dr/ec) 4 $0 *
laxative peg 3350 oral powder 4 $0 *
laxative pills oral tablet 4 $0 *
80
laxative plus stool softener oral tablet 4 $0 *
laxative-senna oral tablet 4 $0 *
LIALDA ORAL TABLET,DELAYED 2 $0 MO
RELEASE (DR/EC)
LINZESS ORAL CAPSULE 2 $0 MO; QL (30 per 30 days)
liquid antacid oral suspension 200-200-20 4 $0 *
mg/5 ml
LOTRONEX ORAL TABLET 2 $0 MO
magnesium citrate oral solution 4 $0 MO; *
masanti double strength oral suspension 4 $0 *
meclizine oral tablet 12.5 mg, 25 mg 1 $0 MO
meclizine oral tablet,chewable 4 $0 MO; *
medi-lax oral tablet 4 $0 *
medi-laxx oral tablet 4 $0 *
medi-natural oral tablet 4 $0 *
medi-natural senna-stool oral tablet 4 $0 *
mesalamine with cleansing wipe rectal enema 1 $0 MO
kit
metoclopramide hcl injection solution 1 $0 B/D PA; MO
metoclopramide hcl injection syringe 1 $0 B/D PA
metoclopramide hcl oral solution 1 $0 MO
metoclopramide hcl oral tablet 1 $0 MO
MI-ACID ORAL TABLET,CHEWABLE 4 $0 *
MILK OF MAGNESIA ORAL SUSPENSION 4 $0 MO; *
mineral oil extra heavy oral oil 4 $0 *
MOTION SICKNESS ORAL TABLET 4 $0 *
motion sickness relief oral tablet 4 $0 *
MOVIPREP ORAL POWDER IN PACKET 2 $0 MO
natural fiber laxative (sugar) oral powder , 3.4 4 $0 *
gram/12 gram
81
natural fiber laxative smooth oral powder 4 $0 *
natural laxative oral tablet 4 $0 *
natural veg laxative(sennosid) oral tablet 4 $0 *
natural vegetable (psyllium) oral powder 4 $0 *
natural vegetable oral powder 4 $0 *
natural vegetable powder oral powder 4 $0 *
ondansetron hcl (pf) injection solution 1 $0 B/D PA; MO
ondansetron hcl (pf) injection syringe 1 $0 B/D PA
ondansetron hcl oral solution 1 $0 B/D PA; MO; QL (150 per 5
days)
ondansetron hcl oral tablet 24 mg 1 $0 B/D PA; QL (1 per 1 day)
ondansetron hcl oral tablet 4 mg, 8 mg 1 $0 B/D PA; MO; QL (12 per 5
days)
ondansetron oral tablet,disintegrating 1 $0 B/D PA; MO; QL (12 per 5
days)
p-col rite oral tablet 4 $0 *
peg 3350-electrolytes oral recon soln 236- 1 $0 MO
22.74-6.74 -5.86 gram
peg 3350-electrolytes oral recon soln 240- 1 $0
22.72-6.72 -5.84 gram
peg-3350 with flavor packs oral recon soln 1 $0
peg-electrolyte soln oral recon soln 1 $0
peri-colace oral tablet 4 $0 MO; *
polyethylene glycol 3350 oral powder 1 $0 MO
powderlax oral powder 4 $0 *
prochlorperazine edisylate injection solution 1 $0 MO
10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 1 $0 MO
prochlorperazine rectal suppository 1 $0 MO
procto-pak rectal cream 1 $0 MO
82
proctosol hc rectal cream 1 $0 MO
proctozone-hc rectal cream 1 $0 MO
purelax oral powder 4 $0 *
REGULOID ORAL POWDER 4 $0 MO; *
RELISTOR SUBCUTANEOUS SOLUTION 2 $0 MO
RELISTOR SUBCUTANEOUS SYRINGE 2 $0 MO
REMICADE INTRAVENOUS RECON SOLN 2 $0 PA; MO
ri-gel ii oral suspension 4 $0 *
ri-gel oral suspension 4 $0 *
riginic oral suspension 4 $0 *
ri-mox oral suspension 4 $0 *
ri-mox plus oral suspension 4 $0 *
SANCUSO TRANSDERMAL PATCH 2 $0 B/D PA; MO; QL (2 per 15
WEEKLY days)
SANI-SUPP (ADULT) RECTAL 4 $0 MO; *
SUPPOSITORY
SENEXON-S ORAL TABLET 4 $0 MO; *
senna lax oral tablet 4 $0 MO; *
senna laxative oral tablet 4 $0 *
SENNA ORAL TABLET 4 $0 *
senna plus oral tablet 4 $0 MO; *
senna-extra oral tablet 4 $0 *
senna-s oral tablet 4 $0 MO; *
senno oral tablet 4 $0 *
sennosides-docusate sodium oral tablet 4 $0 *
sen-o-tab oral tablet 4 $0 *
silace oral liquid 4 $0 MO; *
sodium bicarbonate oral tablet 650 mg 4 $0 MO; *
soluble fiber oral tablet 4 $0 *
83
stimulant laxative plus oral tablet 4 $0 *
stool softener oral capsule 100 mg, 50 mg 4 $0 *
stool softener oral capsule 250 mg 4 $0 MO; *
stool softener oral liquid 4 $0 *
stool softener-laxative oral tablet 4 $0 *
stool softener-stimulant laxat oral tablet 4 $0 *
sulfasalazine oral tablet 1 $0 MO
sulfazine ec oral tablet,delayed release (dr/ec) 1 $0 MO
sulfazine oral tablet 1 $0 MO
suppository adult rectal suppository 4 $0 *
TRANSDERM-SCOP TRANSDERMAL 2 $0 MO; QL (10 per 30 days)
PATCH 72 HOUR
travel sickness oral tablet 4 $0 *
trilyte with flavor packets oral recon soln 1 $0 MO
ursodiol oral capsule 1 $0 MO
ursodiol oral tablet 1 $0 MO
vegetable laxative oral tablet 4 $0 *
wal-mucil fiber (aspartame) oral powder 4 $0 *
wal-mucil natural fiber lax oral powder 4 $0 *
woman's laxative oral tablet,delayed release 4 $0 *
(dr/ec)
women's gentle laxative(bisac) oral 4 $0 *
tablet,delayed release (dr/ec)
women's laxative (bisacodyl) oral 4 $0 *
tablet,delayed release (dr/ec)
women's stool softener oral capsule 4 $0 *
ZENPEP ORAL CAPSULE,DELAYED 2 $0 MO
RELEASE(DR/EC)
TERAPIA DE ÚLCERA
84
acid control (ranitidine) oral tablet 150 mg 4 $0 *
acid controller oral tablet 4 $0 *
acid reducer (famotidine) oral tablet 4 $0 *
acid reducer (ranitidine) oral tablet 4 $0 *
amoxicil-clarithromy-lansopraz oral combo 1 $0 MO
pack
CARAFATE ORAL SUSPENSION 2 $0 MO
cimetidine hcl oral solution 1 $0 MO
cimetidine oral tablet 1 $0 MO
DEXILANT ORAL CAPSULE,BIPHASE 2 $0 MO
DELAYED RELEAS
esomeprazole sodium intravenous recon soln 1 $0 B/D PA
famotidine (pf) intravenous solution 1 $0 B/D PA; MO
famotidine (pf)-nacl (iso-os) intravenous 1 $0 B/D PA
piggyback
famotidine oral suspension 1 $0 MO
famotidine oral tablet 10 mg 4 $0 MO; *
famotidine oral tablet 20 mg, 40 mg 1 $0 MO
heartburn prevention oral tablet 4 $0 *
heartburn relief (ranitidine) oral tablet 4 $0 *
lansoprazole oral capsule,delayed 1 $0 MO
release(dr/ec)
misoprostol oral tablet 1 $0 MO
nizatidine oral capsule 1 $0 MO
nizatidine oral solution 1 $0 MO
omeprazole oral capsule,delayed release(dr/ec) 1 $0 MO
omeprazole oral tablet,delayed release (dr/ec) 4 $0 MO; *
pantoprazole oral tablet,delayed release 1 $0 MO
(dr/ec)
pepcid ac oral tablet 20 mg 4 $0 MO; *
85
ranitidine hcl injection solution 25 mg/ml 1 $0 B/D PA; MO
ranitidine hcl oral capsule 1 $0 MO
ranitidine hcl oral syrup 1 $0 MO
ranitidine hcl oral tablet 150 mg, 300 mg 1 $0 MO
ranitidine hcl oral tablet 75 mg 4 $0 MO; *
sucralfate oral tablet 1 $0 MO
wal-zan 150 oral tablet 4 $0 *
zantac maximum strength oral tablet 4 $0 MO; *
INMUNOLOGÍA, VACUNAS /
BIOTECNOLOGÍA
MEDICAMENTOS DE BIOTECNOLOGÍA
ACTIMMUNE SUBCUTANEOUS 2 $0 PA; MO
SOLUTION
ARCALYST SUBCUTANEOUS RECON 2 $0 PA; MO
SOLN
AVONEX (WITH ALBUMIN) 2 $0 PA; MO; QL (4 per 28 days)
INTRAMUSCULAR KIT
AVONEX INTRAMUSCULAR PEN 2 $0 PA; MO; QL (2 per 28 days)
INJECTOR KIT
AVONEX INTRAMUSCULAR SYRINGE 2 $0 PA; MO; QL (2 per 28 days)
KIT
EGRIFTA SUBCUTANEOUS RECON SOLN 2 $0 PA
1 MG
EXTAVIA SUBCUTANEOUS KIT 2 $0 PA; MO; QL (15 per 30 days)
ILARIS (PF) SUBCUTANEOUS RECON 2 $0 PA; MO; LA
SOLN
INTRON A INJECTION RECON SOLN 2 $0 B/D PA; MO
INTRON A INJECTION SOLUTION 6 2 $0 B/D PA; MO
MILLION UNIT/ML
LEUKINE INJECTION RECON SOLN 2 $0 PA; MO
86
MOZOBIL SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO
NEUMEGA SUBCUTANEOUS RECON 2 $0 B/D PA; MO; QL (21 per 21
SOLN days)
NEUPOGEN INJECTION SOLUTION 2 $0 PA; MO
NEUPOGEN INJECTION SYRINGE 2 $0 PA; MO
NORDITROPIN FLEXPRO 2 $0 PA; MO
SUBCUTANEOUS PEN INJECTOR 10
MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
NORDITROPIN NORDIFLEX 2 $0 PA; MO
SUBCUTANEOUS PEN INJECTOR
PEGINTRON REDIPEN SUBCUTANEOUS 2 $0 PA; MO; QL (5 per 30 days)
PEN INJECTOR KIT
PEGINTRON SUBCUTANEOUS KIT 2 $0 PA; MO; QL (5 per 30 days)
PROCRIT INJECTION SOLUTION 10,000 2 $0 PA; MO; QL (24 per 30 days)
UNIT/ML, 2,000 UNIT/ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION SOLUTION 40,000 2 $0 PA; MO; QL (6 per 30 days)
UNIT/ML
PROLEUKIN INTRAVENOUS RECON 2 $0 B/D PA; MO
SOLN
REBIF (WITH ALBUMIN) 2 $0 PA; MO; QL (6 per 28 days)
SUBCUTANEOUS SYRINGE
REBIF REBIDOSE SUBCUTANEOUS PEN 2 $0 PA; MO; QL (6 per 28 days)
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
REBIF REBIDOSE SUBCUTANEOUS PEN 2 $0 PA; MO; QL (4.2 per 180
INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML days)
(6)
REBIF TITRATION PACK 2 $0 PA; MO; QL (6 per 28 days)
SYLATRON SUBCUTANEOUS KIT 2 $0 PA; MO
VACUNAS / INMUNOLÓGICOS VARIOS
87
ACTHIB (PF) INTRAMUSCULAR RECON 2 $0 MO
SOLN
ADACEL(TDAP ADOLESN/ADULT)(PF) 2 $0 MO
INTRAMUSCULAR SUSPENSION
ADACEL(TDAP ADOLESN/ADULT)(PF) 2 $0 MO
INTRAMUSCULAR SYRINGE
BCG VACCINE, LIVE (PF) 2 $0 B/D PA
PERCUTANEOUS SUSPENSION FOR
RECONSTITUTION
BEXSERO (PF) INTRAMUSCULAR 2 $0
SYRINGE
BOOSTRIX TDAP INTRAMUSCULAR 2 $0 MO
SUSPENSION
BOOSTRIX TDAP INTRAMUSCULAR 2 $0 MO
SYRINGE
CERVARIX VACCINE (PF) 2 $0 MO
COMVAX (PF) INTRAMUSCULAR 2 $0 MO
SUSPENSION
DAPTACEL (DTAP PEDIATRIC) (PF) 2 $0 MO
ENGERIX-B (PF) INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
ENGERIX-B PEDIATRIC (PF) 2 $0 B/D PA; MO
ENGERIX-B PEDIATRIC (PF) 2 $0 B/D PA
fomepizole intravenous solution 1 $0 B/D PA; MO
GAMMAGARD LIQUID INJECTION 2 $0 PA; MO
SOLUTION
GAMUNEX-C INJECTION SOLUTION 1 2 $0 PA; MO
GRAM/10 ML (10 %)
88
GARDASIL (PF) INTRAMUSCULAR 2 $0 MO
SUSPENSION
GARDASIL (PF) INTRAMUSCULAR 2 $0 MO
SYRINGE
GARDASIL 9 (PF) INTRAMUSCULAR 2 $0 MO
SUSPENSION
GARDASIL 9 (PF) INTRAMUSCULAR 2 $0 MO
SYRINGE
HAVRIX (PF) INTRAMUSCULAR 2 $0 MO
SUSPENSION 1,440 ELISA UNIT/ML
HAVRIX (PF) INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE 1,440 ELISA UNIT/ML
HAVRIX (PF) INTRAMUSCULAR 2 $0
SYRINGE 720 ELISA UNIT/0.5 ML
HYPERRAB S/D (PF) INTRAMUSCULAR 2 $0
SOLUTION
IMOVAX RABIES VACCINE (PF) 2 $0 MO
INTRAMUSCULAR RECON SOLN
INFANRIX (DTAP) (PF) 2 $0 MO
INFANRIX (DTAP) (PF) 2 $0 MO
IPOL INJECTION SUSPENSION 2 $0 MO
IPOL INJECTION SYRINGE 2 $0 MO
IXIARO (PF) INTRAMUSCULAR SYRINGE 2 $0 MO
KINRIX (PF) INTRAMUSCULAR 2 $0
SUSPENSION
KINRIX (PF) INTRAMUSCULAR SYRINGE 2 $0
MENACTRA (PF) INTRAMUSCULAR 2 $0 MO
SOLUTION
MENOMUNE - A/C/Y/W-135 (PF) 2 $0 MO
SUBCUTANEOUS RECON SOLN
89
MENVEO A-C-Y-W-135-DIP (PF) 2 $0 MO
INTRAMUSCULAR KIT
M-M-R II (PF) SUBCUTANEOUS RECON 2 $0 MO
SOLN
PEDVAX HIB (PF) INTRAMUSCULAR 2 $0 MO
SOLUTION
PROQUAD (PF) SUBCUTANEOUS 2 $0
QUADRACEL (PF) INTRAMUSCULAR 2 $0
SUSPENSION
RABAVERT (PF) INTRAMUSCULAR 2 $0 MO
RECOMBIVAX HB (PF) 2 $0 B/D PA; MO
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF) 2 $0 B/D PA; MO
INTRAMUSCULAR SYRINGE 10 MCG/ML
RECOMBIVAX HB (PF) 2 $0 B/D PA
INTRAMUSCULAR SYRINGE 5 MCG/0.5
ML
ROTARIX ORAL SUSPENSION FOR 2 $0
RECONSTITUTION
ROTATEQ VACCINE ORAL SUSPENSION 2 $0 MO
TENIVAC (PF) INTRAMUSCULAR 2 $0 MO
SYRINGE
tetanus toxoid,adsorbed (pf) intramuscular 1 $0 B/D PA; MO
suspension
TETANUS,DIPHTHERIA TOX PED(PF) 2 $0 MO
TETANUS-DIPHTHERIA TOXOIDS-TD 2 $0 B/D PA; MO
TRUMENBA INTRAMUSCULAR SYRINGE 2 $0
90
TWINRIX (PF) INTRAMUSCULAR 2 $0 B/D PA; MO
SUSPENSION
TWINRIX (PF) INTRAMUSCULAR 2 $0 B/D PA; MO
SYRINGE
TYPHIM VI INTRAMUSCULAR 2 $0
SOLUTION
TYPHIM VI INTRAMUSCULAR SYRINGE 2 $0 MO
VAQTA (PF) INTRAMUSCULAR 2 $0 B/D PA; MO
SUSPENSION 25 UNIT/0.5 ML
VAQTA (PF) INTRAMUSCULAR 2 $0 MO
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR SYRINGE 2 $0
VARIVAX (PF) SUBCUTANEOUS 2 $0 MO
VARIZIG INTRAMUSCULAR SOLUTION 2 $0
YF-VAX (PF) SUBCUTANEOUS 2 $0 MO
ZOSTAVAX (PF) SUBCUTANEOUS 2 $0 MO; QL (1 per 365 days)
MUSULOESQUELÉTICO /
REUMATOLOGÍA
TERAPIA DE GOTA
allopurinol oral tablet 1 $0 MO
colchicine-probenecid oral tablet 1 $0 MO
COLCRYS ORAL TABLET 2 $0 MO
probenecid oral tablet 1 $0 MO
ULORIC ORAL TABLET 2 $0 MO
TERAPIA DE OSTEOPORÓSIS
alendronate oral solution 1 $0 MO; QL (375 per 30 days)
alendronate oral tablet 10 mg, 5 mg 1 $0 MO; QL (30 per 30 days)
alendronate oral tablet 35 mg, 70 mg 1 $0 MO; QL (5 per 30 days)
91
FORTEO SUBCUTANEOUS PEN 2 $0 MO; QL (2.4 per 28 days)
INJECTOR
ibandronate oral tablet 1 $0 MO; QL (1 per 30 days)
PROLIA SUBCUTANEOUS SYRINGE 2 $0 B/D PA; MO
raloxifene oral tablet 1 $0 MO
risedronate oral tablet 150 mg, 35 mg, 5 mg 1 $0 MO
risedronate oral tablet 35 mg (12 pack) 1 $0
risedronate oral tablet,delayed release (dr/ec) 1 $0 MO
OTROS REUMATOLÓGICOS
ACTEMRA INTRAVENOUS SOLUTION 2 $0 B/D PA; ST; MO
200 MG/10 ML (20 MG/ML)
BENLYSTA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO
120 MG
CUPRIMINE ORAL CAPSULE 2 $0 MO
DEPEN TITRATABS ORAL TABLET 2 $0 PA; MO
ENBREL SUBCUTANEOUS RECON SOLN 2 $0 MO; QL (8 per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 25 2 $0 MO; QL (4 per 28 days)
MG/0.5ML (0.51)
ENBREL SUBCUTANEOUS SYRINGE 50 2 $0 MO; QL (8 per 28 days)
MG/ML (0.98 ML)
ENBREL SURECLICK SUBCUTANEOUS 2 $0 MO; QL (8 per 28 days)
PEN INJECTOR
HUMIRA CROHN'S DIS START PCK 2 $0 MO; QL (4.8 per 180 days)
SUBCUTANEOUS PEN INJECTOR KIT
HUMIRA PED CROHN'S STARTER PK 2 $0 MO; QL (6 per 28 days)
SUBCUTANEOUS SYRINGE KIT
HUMIRA SUBCUTANEOUS SYRINGE KIT 2 $0 MO; QL (1.2 per 28 days)
10 MG/0.2 ML
20 MG/0.4 ML
92
40 MG/0.8 ML
leflunomide oral tablet 1 $0 MO; QL (30 per 30 days)
ORENCIA (WITH MALTOSE) 2 $0 B/D PA; ST; MO
INTRAVENOUS RECON SOLN
SAVELLA ORAL TABLET 2 $0 MO; QL (60 per 30 days)
SAVELLA ORAL TABLETS,DOSE PACK 2 $0 MO; QL (60 per 30 days)
OBSTETRICIA / GINECOLOGÍA
ESTRÓGENOS / PROGESTINA
camila oral tablet 1 $0 MO
COMBIPATCH TRANSDERMAL PATCH 2 $0 MO
SEMIWEEKLY
DELESTROGEN INTRAMUSCULAR OIL 2 $0 B/D PA; MO
10 MG/ML
DEPO-PROVERA INTRAMUSCULAR 2 $0 B/D PA; MO
SOLUTION
DEPO-SUBQ PROVERA 104 2 $0 MO
errin oral tablet 1 $0 MO
ESTRACE VAGINAL CREAM 2 $0 MO
estradiol oral tablet 1 $0 PA; MO
estradiol transdermal patch semiweekly 1 $0 MO
estradiol transdermal patch weekly 1 $0 MO
estradiol valerate intramuscular oil 20 mg/ml, 1 $0 B/D PA; MO
40 mg/ml
heather oral tablet 1 $0 MO
jencycla oral tablet 1 $0 MO
JINTELI ORAL TABLET 2 $0 MO
jolivette oral tablet 1 $0 MO
lyza oral tablet 1 $0 MO
93
medroxyprogesterone intramuscular 1 $0 MO; QL (1 per 90 days)
suspension
medroxyprogesterone intramuscular syringe 1 $0 MO; QL (1 per 90 days)
medroxyprogesterone oral tablet 1 $0 MO
norethindrone (contraceptive) oral tablet 1 $0 MO
norethindrone acetate oral tablet 1 $0 MO
PREMARIN INJECTION RECON SOLN 2 $0 B/D PA; MO
PREMARIN VAGINAL CREAM 2 $0 MO
progesterone micronized oral capsule 1 $0 MO
VAGIFEM VAGINAL TABLET 2 $0 MO
VIVELLE-DOT TRANSDERMAL PATCH 2 $0 MO
SEMIWEEKLY
OG/GYN VARIOS
3-day vaginal vaginal cream 4 $0 *
CLEOCIN VAGINAL SUPPOSITORY 2 $0 MO
clindamycin phosphate vaginal cream 1 $0 MO
clotrimazole 3 day vaginal cream 4 $0 MO; *
clotrimazole vaginal cream 4 $0 MO; *
clotrimazole-3 vaginal cream 4 $0 *
clotrimazole-7 vaginal cream 4 $0 *
metronidazole vaginal gel 1 $0 MO
miconazole 7 vaginal suppository 4 $0 MO; *; QL (7 per 30 days)
miconazole nitrate vaginal suppository 4 $0 *; QL (7 per 30 days)
miconazole-3 vaginal suppository 1 $0 MO; QL (3 per 3 days)
NUVARING VAGINAL RING 2 $0 MO
terconazole vaginal cream 1 $0 MO
terconazole vaginal suppository 1 $0 MO; QL (3 per 3 days)
tranexamic acid oral tablet 1 $0 MO
94
vandazole vaginal gel 1 $0 MO
ANTICONCEPTIVOS ORALES / AGENTES
RELACIONADOS
altavera (28) oral tablet 1 $0 MO
alyacen 1/35 (28) oral tablet 1 $0 MO
alyacen 7/7/7 (28) oral tablet 1 $0 MO
amethia lo oral tablets,dose pack,3 month 1 $0 MO
amethia oral tablets,dose pack,3 month 1 $0 MO
amethyst oral tablet 1 $0 MO
apri oral tablet 1 $0 MO
aranelle (28) oral tablet 1 $0 MO
ashlyna oral tablets,dose pack,3 month 1 $0 MO
aubra oral tablet 1 $0 MO
aviane oral tablet 1 $0 MO
azurette (28) oral tablet 1 $0 MO
balziva (28) oral tablet 1 $0 MO
briellyn oral tablet 1 $0 MO
camrese lo oral tablets,dose pack,3 month 1 $0 MO
camrese oral tablets,dose pack,3 month 1 $0 MO
caziant (28) oral tablet 1 $0 MO
chateal oral tablet 1 $0 MO
cryselle (28) oral tablet 1 $0 MO
cyclafem 1/35 (28) oral tablet 1 $0 MO
cyclafem 7/7/7 (28) oral tablet 1 $0 MO
dasetta 1/35 (28) oral tablet 1 $0 MO
dasetta 7/7/7 (28) oral tablet 1 $0 MO
daysee oral tablets,dose pack,3 month 1 $0 MO
elinest oral tablet 1 $0 MO
ELLA ORAL TABLET 2 $0 MO
95
emoquette oral tablet 1 $0 MO
enpresse oral tablet 1 $0 MO
enskyce oral tablet 1 $0 MO
estarylla oral tablet 1 $0 MO
falmina (28) oral tablet 1 $0 MO
gildess fe oral tablet 1 $0 MO
gildess oral tablet 1 $0 MO
introvale oral tablets,dose pack,3 month 1 $0 MO
jolessa oral tablets,dose pack,3 month 1 $0 MO
junel 1.5/30 (21) oral tablet 1 $0 MO
junel 1/20 (21) oral tablet 1 $0 MO
junel fe 1.5/30 (28) oral tablet 1 $0 MO
junel fe 1/20 (28) oral tablet 1 $0 MO
junel fe 24 oral tablet 1 $0 MO
kariva (28) oral tablet 1 $0 MO
kelnor 1/35 (28) oral tablet 1 $0 MO
kurvelo oral tablet 1 $0 MO
l norgest/e.estradiol-e.estrad oral tablets,dose 1 $0 MO
pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)
l norgest/e.estradiol-e.estrad oral tablets,dose 1 $0
pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)
lessina oral tablet 1 $0 MO
levonorgestrel oral tablet 1.5 mg 4 $0 *
levonorgestrel-ethinyl estrad oral tablet 0.1-20 1 $0 MO
mg-mcg, 0.15-0.03 mg
levonorgestrel-ethinyl estrad oral tablet 90-20 1 $0
mcg
levonorgestrel-ethinyl estrad oral tablets,dose 1 $0 MO
pack,3 month
96
levora-28 oral tablet 1 $0 MO
low-ogestrel (28) oral tablet 1 $0 MO
lutera (28) oral tablet 1 $0 MO
marlissa oral tablet 1 $0 MO
microgestin 1.5/30 (21) oral tablet 1 $0 MO
microgestin 1/20 (21) oral tablet 1 $0 MO
microgestin fe 1.5/30 (28) oral tablet 1 $0 MO
microgestin fe 1/20 (28) oral tablet 1 $0 MO
mono-linyah oral tablet 1 $0 MO
mononessa (28) oral tablet 1 $0 MO
myzilra oral tablet 1 $0 MO
necon 0.5/35 (28) oral tablet 1 $0 MO
necon 1/35 (28) oral tablet 1 $0 MO
necon 10/11 (28) oral tablet 1 $0 MO
necon 7/7/7 (28) oral tablet 1 $0 MO
NEXT CHOICE ONE DOSE ORAL TABLET 4 $0 *
norgestimate-ethinyl estradiol oral tablet 1 $0 MO
nortrel 0.5/35 (28) oral tablet 1 $0 MO
nortrel 1/35 (21) oral tablet 1 $0 MO
nortrel 1/35 (28) oral tablet 1 $0 MO
nortrel 7/7/7 (28) oral tablet 1 $0 MO
ogestrel (28) oral tablet 1 $0 MO
orsythia oral tablet 1 $0 MO
philith oral tablet 1 $0 MO
pirmella oral tablet 1 $0 MO
portia oral tablet 1 $0 MO
previfem oral tablet 1 $0 MO
quasense oral tablets,dose pack,3 month 1 $0 MO
reclipsen (28) oral tablet 1 $0 MO
97
sprintec (28) oral tablet 1 $0 MO
sronyx oral tablet 1 $0 MO
syeda oral tablet 1 $0 MO
tilia fe oral tablet 1 $0 MO
tri-estarylla oral tablet 1 $0 MO
tri-legest fe oral tablet 1 $0 MO
tri-linyah oral tablet 1 $0 MO
trinessa (28) oral tablet 1 $0 MO
tri-previfem (28) oral tablet 1 $0 MO
tri-sprintec (28) oral tablet 1 $0 MO
trivora (28) oral tablet 1 $0 MO
velivet triphasic regimen (28) oral tablet 1 $0 MO
vestura (28) oral tablet 1 $0 MO
viorele (28) oral tablet 1 $0 MO
wera (28) oral tablet 1 $0 MO
wymzya fe oral tablet,chewable 1 $0 MO
zarah oral tablet 1 $0 MO
zenchent (28) oral tablet 1 $0 MO
zenchent fe oral tablet,chewable 1 $0 MO
zeosa oral tablet,chewable 1 $0 MO
zovia 1/35e (28) oral tablet 1 $0 MO
zovia 1/50e (28) oral tablet 1 $0 MO
OXITOCINAS
METHYLERGONOVINE INJECTION 1 $0 B/D PA; MO
SOLUTION
methylergonovine oral tablet 1 $0 MO
OFTALMOLOGÍA
ANTIBIÓTICOS
98
AZASITE OPHTHALMIC DROPS 2 $0 MO
bacitracin ophthalmic ointment 1 $0 MO
bacitracin-polymyxin b ophthalmic ointment 1 $0 MO
CILOXAN OPHTHALMIC OINTMENT 2 $0 MO
ciprofloxacin hcl ophthalmic drops 1 $0 MO
erythromycin ophthalmic ointment 1 $0 MO
garamycin ophthalmic drops 1 $0
gatifloxacin ophthalmic drops 1 $0 MO
gentak ophthalmic ointment 1 $0 MO
gentamicin ophthalmic drops 1 $0 MO
gentamicin ophthalmic ointment 1 $0 MO
levofloxacin ophthalmic drops 1 $0 MO
NATACYN OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
neomycin-bacitracin-polymyxin ophthalmic 1 $0 MO
ointment
neomycin-polymyxin-gramicidin ophthalmic 1 $0 MO
drops
neo-polycin ophthalmic ointment 1 $0
ofloxacin ophthalmic drops 1 $0 MO
polycin ophthalmic ointment 1 $0
polymyxin b sulf-trimethoprim ophthalmic 1 $0 MO
drops
tobramycin ophthalmic drops 1 $0 MO
TOBREX OPHTHALMIC OINTMENT 2 $0 MO
VIGAMOX OPHTHALMIC DROPS 2 $0 MO
ANTIVIRALES
trifluridine ophthalmic drops 1 $0 MO
ZIRGAN OPHTHALMIC GEL 2 $0 MO
BETA-BLOQUEADORES
99
betaxolol ophthalmic drops 1 $0 MO
BETIMOL OPHTHALMIC DROPS 0.25 % 2 $0 MO
BETOPTIC S OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
carteolol ophthalmic drops 1 $0 MO
levobunolol ophthalmic drops 0.5 % 1 $0 MO
metipranolol ophthalmic drops 1 $0 MO
timolol maleate ophthalmic drops 1 $0 MO
timolol maleate ophthalmic gel forming 1 $0 MO
solution
MIÓTICOS INHIBIDORES DE
COLINESTERASA
PHOSPHOLINE IODIDE OPHTHALMIC 2 $0 MO
DROPS
MIDRIASIS CICLOPÉGICA
cyclopentolate ophthalmic drops 1 % 1 $0 MO
cyclopentolate ophthalmic drops 2 % 1 $0
tropicamide ophthalmic drops 1 $0 MO
MIÓTICOS DE ACCIÓN DIRECTA
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 1 $0 MO
%
OFTALMOLÓGICOS VARIOS
AKWA TEARS (POLYVINYL ALCOHOL) 4 $0 MO; *
OPHTHALMIC DROPS
AKWA TEARS OPHTHALMIC OINTMENT 4 $0 MO; *
altachlore ophthalmic drops 4 $0 *
altachlore ophthalmic ointment 4 $0 *
ARTIFICIAL TEARS (PETRO/MIN) 4 $0 MO; *
OPHTHALMIC OINTMENT
100
ARTIFICIAL TEARS OPHTHALMIC 4 $0 *
DROPS 0.5-0.6 %
artificial tears(hypromellose) ophthalmic drops 4 $0 *
azelastine ophthalmic drops 1 $0 MO
cromolyn ophthalmic drops 1 $0 MO
epinastine ophthalmic drops 1 $0 MO
for sty relief ophthalmic ointment 4 $0 *
gonak ophthalmic drops 4 $0 *
goniosoft ophthalmic drops 4 $0 *
goniotaire ophthalmic drops 4 $0 *
goniovisc ophthalmic drops 4 $0 MO; *
LASTACAFT OPHTHALMIC DROPS 2 $0 MO
LUBRICANT EYE (PG-PEG 400) 4 $0 *
OPHTHALMIC DROPS
lubricant eye (polyv alcohol) ophthalmic drops 4 $0 *
lubricant eye ophthalmic ointment 56.8-41.5 %, 4 $0 *
83-15 %
LUBRICATING PLUS OPHTHALMIC 4 $0 *
DROPPERETTE
NATURAL BALANCE OPHTHALMIC 4 $0 MO; *
DROPS
PATADAY OPHTHALMIC DROPS 2 $0 ST; MO
polyvinyl alcohol ophthalmic drops 4 $0 *
pure & gentle eye ophthalmic drops 4 $0 *
RESTASIS OPHTHALMIC DROPPERETTE 2 $0 MO; QL (60 per 30 days)
sochlor ophthalmic drops 4 $0 *
sochlor ophthalmic ointment 4 $0 *
sodium chloride ophthalmic drops 4 $0 MO; *
sodium chloride ophthalmic ointment 4 $0 MO; *
tears again ophthalmic drops 4 $0 MO; *
101
tears again ophthalmic ointment 4 $0 MO; *
AGENTES ANTIINFLAMATORIOS SIN
ESTEROIDES
bromfenac ophthalmic drops 1 $0 MO
diclofenac sodium ophthalmic drops 1 $0 MO
flurbiprofen sodium ophthalmic drops 1 $0 MO
ILEVRO OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
ketorolac ophthalmic drops 1 $0 MO
MEDICAMENTOS ORALES PARA
GLAUCOMA
acetazolamide oral capsule, extended release 1 $0 MO
acetazolamide oral tablet 1 $0 MO
acetazolamide sodium injection recon soln 1 $0 MO
methazolamide oral tablet 1 $0 MO
OTROS MEDICAMENTOS PARA
GLAUCOMA
AZOPT OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
COMBIGAN OPHTHALMIC DROPS 2 $0 MO
dorzolamide ophthalmic drops 1 $0 MO
dorzolamide-timolol ophthalmic drops 1 $0 MO
latanoprost ophthalmic drops 1 $0 MO
LUMIGAN OPHTHALMIC DROPS 0.01 % 2 $0 MO; QL (2.5 per 30 days)
travoprost (benzalkonium) ophthalmic drops 1 $0 MO
COMBINACIONES ESTEROIDE-
ANTIBIÓTICO
neomycin-bacitracin-poly-hc ophthalmic 1 $0 MO
ointment
102
neomycin-polymyxin b-dexameth ophthalmic 1 $0 MO
drops,suspension
neomycin-polymyxin b-dexameth ophthalmic 1 $0 MO
ointment
neomycin-polymyxin-hc ophthalmic 1 $0 MO
drops,suspension
neo-polycin hc ophthalmic ointment 1 $0
TOBRADEX ST OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
tobramycin-dexamethasone ophthalmic 1 $0 MO
drops,suspension
ESTEROIDES
ALREX OPHTHALMIC 2 $0 MO
DROPS,SUSPENSION
dexamethasone sodium phosphate ophthalmic 1 $0 MO
drops
DUREZOL OPHTHALMIC DROPS 2 $0 MO
fluorometholone ophthalmic drops,suspension 1 $0 MO
FML S.O.P. OPHTHALMIC OINTMENT 2 $0 MO
prednisolone acetate ophthalmic 1 $0 MO
drops,suspension
prednisolone sodium phosphate ophthalmic 1 $0 MO
drops
COMBINACIONES ESTEROIDE-
SULFAMIDA
BLEPHAMIDE S.O.P. OPHTHALMIC 2 $0 MO
OINTMENT
sulfacetamide-prednisolone ophthalmic drops 1 $0 MO
SULFAMIDAS
sulfacetamide sodium ophthalmic drops 1 $0 MO
sulfacetamide sodium ophthalmic ointment 1 $0 MO
SIMPATICOMIMÉTICOS
103
ALPHAGAN P OPHTHALMIC DROPS 0.1 % 2 $0 MO
apraclonidine ophthalmic drops 1 $0 MO
brimonidine ophthalmic drops 1 $0 MO
DESCONGESTIONANTES
VASOCONTRICTORES
naphazoline ophthalmic drops 1 $0 MO
RESPIRACIÓN Y ALERGIAS
AGENTES ANTIESTAMÍNICOS /
ANTIALÉRGICOS
12 hour decongestant oral tablet extended 4 $0 *
release
adult cough formula dm max oral liquid 4 $0 *
adult tussin chest congestion oral liquid 4 $0 *
adult tussin cough congest dm oral liquid 4 $0 *
adult tussin dm oral syrup 4 $0 *
adult tussin multi-symp cold oral liquid 4 $0 *
ALAVERT D-12 ALLERGY-SINUS ORAL 4 $0 MO; *; QL (68 per 30 days)
TABLET EXTENDED RELEASE 12 HR
aler-cap oral capsule 4 $0 *
ALL DAY ALLERGY (CETIRIZINE) ORAL 4 $0 *
SOLUTION
all day allergy (cetirizine) oral tablet 4 $0 MO; *; QL (34 per 30 days)
all day allergy-d oral tablet extended release 4 $0 MO; *; QL (68 per 30 days)
12 hr
allerclear d-12hr oral tablet extended release 4 $0 *; QL (68 per 30 days)
12 hr
allerclear oral tablet 4 $0 *; QL (34 per 30 days)
aller-ease oral tablet 180 mg 4 $0 *; QL (34 per 30 days)
aller-ease oral tablet 60 mg 4 $0 *; QL (68 per 30 days)
aller-fex oral tablet 4 $0 *; QL (34 per 30 days)
104
allergy & congestion relief oral tablet extended 4 $0 *; QL (68 per 30 days)
release 12 hr
allergy (chlorpheniramine) oral tablet 4 $0 MO; *
allergy 4-hour oral tablet 4 $0 *
allergy complete-d oral tablet extended release 4 $0 *; QL (68 per 30 days)
12 hr
allergy d-12 oral tablet extended release 12 hr 4 $0 *; QL (68 per 30 days)
allergy medication oral capsule 4 $0 *
allergy medicine oral capsule 4 $0 *
allergy relief (cetirizine) oral tablet 4 $0 *; QL (34 per 30 days)
allergy relief (fexofenadine) oral tablet 180 mg 4 $0 *; QL (34 per 30 days)
allergy relief (fexofenadine) oral tablet 60 mg 4 $0 *; QL (68 per 30 days)
ALLERGY RELIEF (LORATADINE) ORAL 4 $0 *
SOLUTION
allergy relief (loratadine) oral tablet 4 $0 MO; *; QL (34 per 30 days)
allergy relief (loratadine) oral 4 $0 *; QL (34 per 30 days)
tablet,disintegrating
allergy relief d12 oral tablet extended release 4 $0 *; QL (68 per 30 days)
12 hr
allergy relief(chlorpheniramn) oral tablet 4 $0 *
allergy relief(diphenhydramin) oral capsule 4 $0 *
allergy relief-d (cetirizine) oral tablet extended 4 $0 *; QL (68 per 30 days)
release 12 hr
allergy relief-d (loratadine) oral tablet 4 $0 *; QL (68 per 30 days)
extended release 12 hr
allergy-time oral tablet 4 $0 *
aller-tec d oral tablet extended release 12 hr 4 $0 *; QL (68 per 30 days)
aller-tec oral tablet 4 $0 *; QL (34 per 30 days)
allfen oral tablet 4 $0 *
ambi 60pse-400gfn oral tablet 4 $0 MO; *
ambi 60pse-4cpm oral tablet 4 $0 *
105
antitussive dm oral syrup 4 $0 *
APRODINE ORAL TABLET 4 $0 MO; *
benzonatate oral capsule 100 mg, 200 mg 3 $0 MO; *
biobron sf oral liquid 4 $0 *
biocotron oral liquid 4 $0 *
biogil oral liquid 4 $0 *
broncotron ped oral liquid 4 $0 *
BROTAPP DM ORAL ELIXIR 4 $0 *
BROTAPP ORAL LIQUID 4 $0 MO; *
cetiri-d oral tablet extended release 12 hr 4 $0 *; QL (68 per 30 days)
cetirizine oral solution 1 mg/ml 1 $0 MO
cetirizine oral tablet 4 $0 MO; *; QL (34 per 30 days)
cetirizine oral tablet,chewable 4 $0 MO; *; QL (34 per 30 days)
cetirizine-pseudoephedrine oral tablet extended 4 $0 MO; *; QL (68 per 30 days)
release 12 hr
chest congestion relief d oral tablet 4 $0 *
CHEST CONGESTION RELIEF ORAL 4 $0 *
TABLET
CHEST CONGESTION RELIEF PE ORAL 4 $0 *
TABLET
chest-sinus congestion relief oral tablet 4 $0 *
child allergy relf(cetirizine) oral solution 4 $0 *
child chest congestion + cough oral liquid 4 $0 *
child delsym cough+chest dm oral liquid 4 $0 *
child mucinex chest congestion oral liquid 4 $0 *
CHILD MUCUS RELIEF COUGH ORAL 4 $0 *
LIQUID
CHILD MUCUS RELIEF EXPECTORANT 4 $0 *
ORAL LIQUID
106
children's allergy complete oral solution 4 $0 *
children's allergy relief(lor) oral solution 4 $0 *
children's allergy(cetirizine) oral solution 4 $0 *
children's aller-tec oral solution 4 $0 *
children's cetirizine oral solution 4 $0 *
children's cetirizine oral tablet,chewable 4 $0 MO; *; QL (34 per 30 days)
children's chest congestion oral liquid 4 $0 *
CHILDREN'S COLD & COUGH DM ORAL 4 $0 *
SOLUTION
children's cold & cough oral solution 4 $0 *
children's cough oral liquid 4 $0 *
children's dibromm dm cold & c oral solution 4 $0 *
children's mucinex cough oral liquid 4 $0 *
CHILDREN'S SILFEDRINE ORAL LIQUID 4 $0 *
children's wal-zyr oral solution 4 $0 *
children's wal-zyr oral tablet,chewable 4 $0 *; QL (34 per 30 days)
child's all day allergy(cetir) oral solution 4 $0 *
chlorhist oral tablet 4 $0 *
chlorpheniramine maleate oral tablet 4 $0 *
chlortabs oral tablet 4 $0 *
CLARINEX ORAL SYRUP 2 $0 MO
clemastine oral syrup 1 $0 PA; MO
clemastine oral tablet 2.68 mg 1 $0 PA; MO
CODITUSS DM ORAL LIQUID 4 $0 MO; *
cold & cough dm oral solution 4 $0 *
cold & cough elixir oral solution 4 $0 *
COLD HEAD CONGESTION NIGHTTIME 4 $0 *
ORAL TABLET
cold multi-symptom (chlorphen) oral tablet 4 $0 *
107
complete allergy medicine oral capsule 4 $0 *
complete allergy oral capsule 4 $0 *
CONGESTAC ORAL TABLET 4 $0 *
cough & cold mucus relief cf oral liquid 4 $0 *
cough & cold oral liquid 4 $0 *
cough control (dextromethorph) oral capsule 4 $0 *
cough control (guaifenesin) oral liquid 4 $0 *
cough control cf (pe) oral liquid 4 $0 *
cough control dm max oral liquid 4 $0 *
cough control dm oral liquid 4 $0 *
cough control dm oral syrup 4 $0 *
cough formula dm oral syrup 4 $0 *
cough relief oral capsule 4 $0 *
COUGH SUPPRESSANT-EXPECTORANT 4 $0 *
ORAL SYRUP
cough syrup dm oral syrup 4 $0 *
COUGHTAB ORAL TABLET 4 $0 *
cyproheptadine oral syrup 1 $0 PA; MO
cyproheptadine oral tablet 1 $0 PA; MO
delsym cough+chest congest dm oral liquid 4 $0 *
desgen dm oral liquid 5-10-100 mg/5 ml 4 $0 *
desloratadine oral tablet 1 $0 MO
desloratadine oral tablet,disintegrating 1 $0 MO
despec-dm (phenyleph-dm-guaif) oral liquid 5- 4 $0 *
10-100 mg/5 ml
diabetic siltussin das-na oral liquid 4 $0 *
diabetic siltussin-dm max str oral liquid 4 $0 *
diabetic siltussin-dm oral liquid 4 $0 *
diabetic tussin dm oral liquid 10-100 mg/5 ml 4 $0 MO; *
108
diabetic tussin dm oral liquid 10-200 mg/5 ml 4 $0 *
diabetic tussin ex oral liquid 4 $0 MO; *
diabetic tussin max st oral liquid 4 $0 MO; *
diabetic tussin mucus relief oral liquid 4 $0 *
diphedryl oral capsule 4 $0 *
diphenhydramine hcl injection solution 50 1 $0 B/D PA; MO
mg/ml
diphenhydramine hcl oral capsule 4 $0 MO; *
dm max oral liquid 4 $0 *
double-tussin dm oral liquid 4 $0 *
ENDACOF - DM ORAL SOLUTION 4 $0 *
endacon oral liquid 4 $0 *
epinephrine injection auto-injector 0.3 mg/0.3 1 $0 MO
ml (1:1,000)
epinephrine injection syringe 0.1 mg/ml 1 $0 B/D PA; MO
(1:10,000)
EPIPEN 2-PAK INJECTION AUTO- 2 $0 MO; QL (4 per 2 days)
INJECTOR
EPIPEN JR 2-PAK INJECTION AUTO- 2 $0 MO; QL (4 per 2 days)
INJECTOR
expectorant oral liquid 4 $0 *
fenesin ir oral tablet 4 $0 *
fenesin pe ir oral tablet 4 $0 *
fexofenadine oral tablet 180 mg 4 $0 MO; *; QL (34 per 30 days)
fexofenadine oral tablet 60 mg 4 $0 MO; *; QL (68 per 30 days)
geri-tussin oral liquid 4 $0 *
g-tron oral liquid 4 $0 *
guaiasorb dm oral liquid 4 $0 *
guaifenesin oral liquid 4 $0 *
guaifenesin oral tablet 200 mg 4 $0 MO; *
109
guaifenesin oral tablet extended release 12hr 4 $0 MO; *
guaifenesin-dm oral liquid 4 $0 *
hydroxyzine hcl intramuscular solution 1 $0 B/D PA; MO
intense cough reliever oral liquid 30-200 mg/5 4 $0 *
ml
KIDKARE COUGH/COLD ORAL LIQUID 4 $0 *
levocetirizine oral solution 1 $0 MO
levocetirizine oral tablet 1 $0 MO; QL (30 per 30 days)
liquibid d-r oral tablet 4 $0 *
loradamed oral tablet 4 $0 MO; *; QL (34 per 30 days)
loratadine oral solution 4 $0 MO; *
loratadine oral tablet 4 $0 MO; *; QL (34 per 30 days)
loratadine oral tablet,disintegrating 4 $0 MO; *; QL (34 per 30 days)
loratadine-d oral tablet extended release 12 hr 4 $0 MO; *; QL (68 per 30 days)
maxiphen oral tablet 4 $0 MO; *
medifin expectorant mucus rlf oral liquid 4 $0 *
medi-phedrine oral tablet 4 $0 *
medi-phedrine oral tablet extended release 4 $0 *
medi-phedryl oral capsule 4 $0 *
medi-tussin dm diabetic oral liquid 4 $0 *
medi-tussin dm oral syrup 4 $0 *
medi-tussin oral liquid 4 $0 *
mucinex allergy oral tablet 4 $0 *; QL (34 per 30 days)
MUCINEX DM ORAL TABLET EXTENDED 4 $0 MO; *
RELEASE 12 HR
mucinex fast-max dm max oral liquid 4 $0 *
mucinex oral tablet extended release 12hr 600 4 $0 MO; *
mg
mucosa oral tablet 4 $0 *
110
mucus dm max oral tablet extended release 12 4 $0 *
hr
mucus dm oral tablet extended release 12 hr 4 $0 *
mucus relief chest oral tablet 4 $0 *
mucus relief cough oral liquid 4 $0 *
mucus relief d (phenylephrine) oral tablet 4 $0 *
mucus relief d (pseudoephed) oral tablet 4 $0 *
mucus relief er oral tablet extended release 4 $0 *
12hr
mucus relief oral tablet 200 mg 4 $0 *
mucus relief oral tablet 400 mg 4 $0 MO; *
multi-symptom cold night time oral tablet 4 $0 *
NASAL DECONGESTANT (PSEUDOEPH) 4 $0 *
ORAL LIQUID
NASAL DECONGESTANT (PSEUDOEPH) 4 $0 *
ORAL TABLET
nasal decongestant (pseudoeph) oral tablet 4 $0 *
extended release
neo-tuss oral liquid 4 $0 *
night time cold oral tablet 4 $0 *
organ-i nr oral tablet 4 $0 MO; *
pediatric cough & cold oral liquid 1-15-5 mg/5 4 $0 *
ml
pharbechlor oral tablet 4 $0 *
pharbedryl oral capsule 4 $0 *
pres gen oral liquid 4 $0 *
promethazine oral tablet 1 $0 PA; MO
pseudoephedrine hcl oral liquid 4 $0 MO; *
pseudoephedrine hcl oral tablet 30 mg 4 $0 MO; *
pseudoephedrine hcl oral tablet 60 mg 4 $0 *
111
pseudoephedrine hcl oral tablet extended 4 $0 MO; *
release
refenesen oral tablet 4 $0 *
refenesen pe oral tablet 4 $0 *
ri-tussin dm oral syrup 4 $0 *
ri-tussin oral liquid 4 $0 *
SCOT-TUSSIN DM ORAL LIQUID 4 $0 *
siltussin dm das oral liquid 4 $0 *
SILTUSSIN SA ORAL LIQUID 4 $0 MO; *
siltussin-dm oral syrup 4 $0 *
sinus & allergy non-drowsy oral tablet 4 $0 *
extended release
sinus 12 hour oral tablet extended release 4 $0 *
sorbugen nr oral liquid 4 $0 *
SUDOGEST SINUS & ALLERGY ORAL 4 $0 *
TABLET
suphedrin 12 hour oral tablet extended release 4 $0 *
suphedrin oral liquid 4 $0 *
suphedrin oral tablet 4 $0 *
suphedrine 12 hour oral tablet extended 4 $0 *
release
suphedrine oral tablet 4 $0 *
tusnel diabetic oral liquid 4 $0 *
tussin cf cough-cold oral liquid 4 $0 *
TUSSIN CF ORAL LIQUID 4 $0 MO; *
tussin chest congestion oral liquid 4 $0 *
tussin cough &chest congestion oral liquid 4 $0 *
tussin cough (dm only) oral capsule 4 $0 *
tussin cough dm oral liquid 4 $0 *
112
tussin dm clear oral syrup 4 $0 *
tussin dm cough & chest oral liquid 4 $0 *
tussin dm cough & chest oral syrup 4 $0 *
tussin dm cough oral syrup 4 $0 *
tussin dm max oral liquid 4 $0 *
tussin dm oral liquid 4 $0 *
TUSSIN DM ORAL SYRUP 10-100 MG/5 4 $0 *
ML
tussin expectorant oral liquid 4 $0 *
tussin honey oral liquid 4 $0 *
tussin oral liquid 4 $0 *
tussin oral tablet 4 $0 *
tussi-pres oral liquid 4 $0 *
valu-dryl allergy oral capsule 4 $0 *
valu-tapp oral liquid 4 $0 *
vicks qlearquil allergy oral tablet 4 $0 *; QL (34 per 30 days)
wal-dryl allergy oral capsule 4 $0 *
wal-fex allergy oral tablet 180 mg 4 $0 *; QL (34 per 30 days)
wal-itin oral tablet 4 $0 *; QL (34 per 30 days)
wal-zyr (cetirizine) oral tablet 4 $0 *; QL (34 per 30 days)
AGENTES PULMONARES
acetylcysteine solution 1 $0 B/D PA; MO
ADCIRCA ORAL TABLET 2 $0 PA; MO; QL (60 per 30 days)
ADEMPAS ORAL TABLET 2 $0 PA; MO; LA
ADVAIR DISKUS INHALATION BLISTER 2 $0 MO; QL (120 per 30 days)
WITH DEVICE
ADVAIR HFA INHALATION HFA 2 $0 MO; QL (24 per 30 days)
AEROSOL INHALER
113
albuterol sulfate inhalation solution for 1 $0 B/D PA; MO; QL (360 per 30
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 days)
mg /3 ml (0.083 %)
albuterol sulfate inhalation solution for 1 $0 B/D PA; MO; QL (60 per 30
nebulization 5 mg/ml days)
albuterol sulfate oral syrup 1 $0 MO
albuterol sulfate oral tablet 1 $0 MO
albuterol sulfate oral tablet extended release 1 $0 MO
12 hr
ANORO ELLIPTA INHALATION BLISTER 2 $0 MO
WITH DEVICE
ASMANEX HFA INHALATION HFA 2 $0 MO; QL (26 per 30 days)
AEROSOL INHALER
ASMANEX TWISTHALER INHALATION 2 $0 MO; QL (2 per 30 days)
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES), 220 MCG (120
DOSES), 220 MCG (30 DOSES), 220 MCG
(60 DOSES)
ASMANEX TWISTHALER INHALATION 2 $0 QL (2 per 30 days)
110 MCG (7 DOSES), 220 MCG (14 DOSES)
ATROVENT HFA INHALATION HFA 2 $0 MO; QL (26 per 30 days)
AEROSOL INHALER
budesonide inhalation suspension for 1 $0 B/D PA; MO; QL (120 per 30
nebulization 0.25 mg/2 ml, 0.5 mg/2 ml days)
budesonide nasal spray,non-aerosol 1 $0 MO
CINRYZE INTRAVENOUS RECON SOLN 2 $0 PA; MO
COMBIVENT RESPIMAT INHALATION 2 $0 MO; QL (8 per 30 days)
MIST
cromolyn inhalation solution for nebulization 1 $0 B/D PA; MO; QL (240 per 30
days)
DALIRESP ORAL TABLET 2 $0 MO
114
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 2 $0 MO
ML
ESBRIET ORAL CAPSULE 2 $0 PA; MO
FIRAZYR SUBCUTANEOUS SYRINGE 2 $0 PA; MO
FLOVENT DISKUS INHALATION 2 $0 MO; QL (120 per 30 days)
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50 MCG/ACTUATION
FLOVENT DISKUS INHALATION 2 $0 MO; QL (300 per 30 days)
BLISTER WITH DEVICE 250
MCG/ACTUATION
FLOVENT HFA INHALATION HFA 2 $0 MO; QL (12 per 30 days)
AEROSOL INHALER 110
MCG/ACTUATION
AEROSOL INHALER 220
MCG/ACTUATION
AEROSOL INHALER 44 MCG/ACTUATION
flunisolide nasal spray,non-aerosol 25 mcg 1 $0 MO; QL (50 per 30 days)
(0.025 %)
fluticasone nasal spray,suspension 1 $0 MO; QL (16 per 30 days)
FORADIL AEROLIZER INHALATION 2 $0 MO; QL (60 per 30 days)
CAPSULE, W/INHALATION DEVICE
ipratropium bromide inhalation solution 1 $0 B/D PA; MO; QL (315 per 30
days)
ipratropium-albuterol inhalation solution for 1 $0 B/D PA; MO; QL (540 per 30
nebulization days)
KALYDECO ORAL GRANULES IN 2 $0 PA; MO; QL (60 per 30 days)
PACKET
KALYDECO ORAL TABLET 2 $0 PA; MO; QL (60 per 30 days)
LETAIRIS ORAL TABLET 2 $0 PA; MO; QL (30 per 30 days)
levalbuterol hcl inhalation solution for 1 $0 B/D PA; MO
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml
115
levalbuterol hcl inhalation solution for 1 $0 B/D PA; MO; QL (90 per 30
nebulization 1.25 mg/0.5 ml days)
metaproterenol oral syrup 1 $0 MO
metaproterenol oral tablet 1 $0 MO
montelukast oral granules in packet 1 $0 MO
montelukast oral tablet 1 $0 MO
montelukast oral tablet,chewable 1 $0 MO
NASONEX NASAL SPRAY,NON- 2 $0 MO; QL (51 per 30 days)
AEROSOL
OFEV ORAL CAPSULE 2 $0 PA; MO; QL (60 per 30 days)
OPSUMIT ORAL TABLET 2 $0 PA; MO; LA
PERFOROMIST INHALATION SOLUTION 2 $0 B/D PA; MO; QL (120 per 30
FOR NEBULIZATION days)
PROAIR HFA INHALATION HFA 2 $0 MO; QL (18 per 30 days)
AEROSOL INHALER
PROVENTIL HFA INHALATION HFA 2 $0 MO; QL (20 per 30 days)
AEROSOL INHALER
PULMOZYME INHALATION SOLUTION 2 $0 B/D PA; MO
SEREVENT DISKUS INHALATION 2 $0 MO; QL (120 per 30 days)
BLISTER WITH DEVICE
sildenafil oral tablet 1 $0 PA; MO; QL (90 per 30 days)
SYMBICORT INHALATION HFA 2 $0 MO; QL (20 per 30 days)
AEROSOL INHALER
terbutaline oral tablet 1 $0 MO
terbutaline subcutaneous solution 1 $0 B/D PA; MO
theochron oral tablet extended release 12 hr 1 $0
theophylline oral solution 1 $0
theophylline oral tablet extended release 1 $0 MO
theophylline oral tablet extended release 12 hr 1 $0 MO
triamcinolone acetonide nasal aerosol,spray 1 $0 MO; QL (17 per 30 days)
116
TUDORZA PRESSAIR INHALATION 2 $0 MO
400 MCG/ACTUATION
TUDORZA PRESSAIR INHALATION 2 $0
400 MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION HFA 2 $0 MO; QL (54 per 30 days)
AEROSOL INHALER
VERAMYST NASAL SPRAY,SUSPENSION 2 $0 MO; QL (20 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 2 $0 PA; MO; QL (8.4 per 28 days)
zafirlukast oral tablet 1 $0 MO
UROLÓGICOS
ANTICOLINÉRGICOS /
ANTIESPASMÓDICOS
flavoxate oral tablet 1 $0 MO
GELNIQUE TRANSDERMAL GEL IN 2 $0 ST; MO
PACKET
MYRBETRIQ ORAL TABLET EXTENDED 2 $0 MO
RELEASE 24 HR
oxybutynin chloride oral syrup 1 $0 MO
oxybutynin chloride oral tablet 1 $0 MO
oxybutynin chloride oral tablet extended 1 $0 MO
release 24hr
tolterodine oral capsule,extended release 24hr 1 $0 MO
tolterodine oral tablet 1 $0 MO
trospium oral capsule,extended release 24hr 1 $0 MO
trospium oral tablet 1 $0 MO
VESICARE ORAL TABLET 2 $0 MO
TERAPIA DE HIPERPLASIA BENINGNA
DE PRÓSTATA
alfuzosin oral tablet extended release 24 hr 1 $0 MO
117
finasteride oral tablet 5 mg 1 $0 MO
tamsulosin oral capsule,extended release 24hr 1 $0 MO
ESTIMULANTES COLINÉRGICOS
bethanechol chloride oral tablet 1 $0 MO
UROLÓGICOS VARIOS
CIALIS ORAL TABLET 2.5 MG, 5 MG 2 $0 PA; MO; QL (30 per 30 days)
CYSTAGON ORAL CAPSULE 2 $0 MO
ELMIRON ORAL CAPSULE 2 $0 MO
potassium citrate oral tablet extended release 1 $0 MO
10 meq (1,080 mg), 5 meq (540 mg)
VITAMINAS, HEMATÍNICOS /
ELECTROLITOS
ELECTROLITOS
alcalak oral tablet,chewable 4 $0 *
antacid ext str (calcium carb) oral 4 $0 *
tablet,chewable
ANTACID EXTRA-STRENGTH ORAL 4 $0 *
TABLET,CHEWABLE
antacid oral tablet,chewable 200 mg calcium 4 $0 *
(500 mg)
antacid ultra strength oral tablet,chewable 400 4 $0 *
mg (1,000 mg)
CALCITRATE ORAL TABLET 4 $0 MO; *
calcium 500 + d (d3) oral tablet 4 $0 *
calcium 500 + d oral tablet 500 mg(1,250mg) - 4 $0 MO; *
200 unit
calcium 500 + d oral tablet 500 mg(1,250mg) - 4 $0 *
400 unit
calcium 500 + d oral tablet,chewable 4 $0 MO; *
calcium 500 oral tablet 4 $0 *
118
calcium 500 with d oral tablet 4 $0 MO; *
CALCIUM 600 + D(3) ORAL TABLET 600 4 $0 MO; *
MG(1,500MG) -200 UNIT, 600
MG(1,500MG) -400 UNIT
calcium 600 oral tablet 4 $0 *
calcium 600 with vitamin d3 oral tablet 4 $0 *
calcium 600 with vitamin d3 oral 4 $0 MO; *
tablet,chewable
calcium acetate oral capsule 1 $0 MO
calcium acetate oral tablet 667 mg 1 $0 MO
calcium antacid oral tablet,chewable 200 mg 4 $0 MO; *
calcium (500 mg)
CALCIUM ANTACID ORAL 4 $0 *
TABLET,CHEWABLE 300 MG (750 MG)
calcium antacid oral tablet,chewable 320 mg 4 $0 *
(750 mg), 400 mg (1,000 mg)
calcium antacid tropical oral tablet,chewable 4 $0 *
calcium carbonate oral tablet 500 mg calcium 4 $0 MO; *
(1,250 mg), 600 mg (1,500 mg)
calcium carbonate oral tablet,chewable 200 mg 4 $0 *
calcium (500 mg), 400 mg (1,000 mg)
calcium carbonate-vitamin d3 oral tablet 500 4 $0 *
mg(1,250mg) -125 unit, 500 mg(1,250mg) -200
unit, 500mg (1,250mg) -600 unit
calcium carbonate-vitamin d3 oral tablet 600 4 $0 MO; *
mg(1,500mg) -200 unit, 600 mg(1,500mg) -400
unit
calcium carbonate-vitamin d3 oral 4 $0 MO; *
tablet,chewable 500-100 mg-unit
calcium citrate + d oral tablet 4 $0 *
calcium citrate + oral tablet 4 $0 *
calcium citrate oral tablet 200 mg (950 mg) 4 $0 *
calcium citrate oral tablet 250 mg calcium 4 $0 MO; *
119
calcium citrate-vitamin d3 oral tablet 200-125 4 $0 *
mg-unit
calcium citrate-vitamin d3 oral tablet 315-200 4 $0 MO; *
mg-unit
calcium gluconate oral tablet 45 mg (500 mg) 4 $0 MO; *
calcium gluconate oral tablet 60 mg (650 mg) 4 $0 *
calcium with vitamin d oral tablet 4 $0 *
calcium+d oral tablet 500 mg(1,250mg) -200 4 $0 *
unit
CITRUS CALCIUM ORAL TABLET 200 MG 4 $0 *
CALCIUM -250 UNIT
CITRUS CALCIUM ORAL TABLET 315-250 4 $0 MO; *
MG-UNIT
dextrose-kcl-nacl intravenous solution 1 $0 B/D PA
eliphos oral tablet 1 $0 MO
flavor chews antacid oral tablet,chewable 4 $0 *
hi-cal plus vit d oral tablet 4 $0 *
high potency calcium oral tablet 4 $0 *
klor-con 10 oral tablet extended release 1 $0 MO
klor-con 8 oral tablet extended release 1 $0 MO
klor-con m15 oral tablet,er particles/crystals 1 $0 MO
klor-con m20 oral tablet,er particles/crystals 1 $0 MO
klor-con oral packet 1 $0 MO
k-tab oral tablet extended release 8 meq 1 $0
lactated ringers intravenous parenteral 1 $0 MO
solution
laxative dietary supplement oral tablet 4 $0 *
MAG 64 ORAL TABLET EXTENDED 4 $0 MO; *
RELEASE
magnesium oxide oral tablet 4 $0 MO; *
120
magnesium sulfate injection solution 1 $0 B/D PA; MO
magnesium sulfate injection syringe 1 $0 B/D PA
NORMOSOL-R IN 5 % DEXTROSE 2 $0 B/D PA
oral electrolytes oral solution 4 $0 *
ORALYTE ORAL SOLUTION 4 $0 *
oyster shell + d3 oral tablet 4 $0 *
oyster shell calcium 500 oral tablet 4 $0 MO; *
oyster shell calcium-vit d3 oral tablet 250-125 4 $0 MO; *
mg-unit
oystercal-d oral tablet 4 $0 *
PEDIALYTE ORAL SOLUTION 4 $0 MO; *
pedialyte singles oral solution 4 $0 *
pediatric electrolyte oral solution 4 $0 *
pediatric freezer pops oral solution 4 $0 *
potassium bicarb and chloride oral tablet, 1 $0 MO
effervescent
potassium chlorid-d5-0.45%nacl intravenous 1 $0 B/D PA
parenteral solution 10 meq/l, 30 meq/l, 40
meq/l
potassium chlorid-d5-0.45%nacl intravenous 1 $0 B/D PA; MO
parenteral solution 20 meq/l
potassium chloride in 0.9%nacl intravenous 1 $0 B/D PA
parenteral solution 20 meq/l, 40 meq/l
potassium chloride in 5 % dex intravenous 1 $0 B/D PA
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
potassium chloride in lr-d5 intravenous 1 $0 B/D PA; MO
potassium chloride intravenous piggyback 10 1 $0
meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40
meq/100 ml
121
potassium chloride intravenous solution 1 $0 MO
potassium chloride oral capsule, extended 1 $0 MO
release
potassium chloride oral liquid 1 $0 MO
potassium chloride oral tablet extended release 1 $0 MO
8 meq
potassium chloride oral tablet,er 1 $0 MO
particles/crystals
potassium chloride-0.45 % nacl intravenous 1 $0
parenteral solution
potassium chloride-d5-0.2%nacl intravenous 1 $0 B/D PA; MO
potassium chloride-d5-0.2%nacl intravenous 1 $0 B/D PA
parenteral solution 30 meq/l, 40 meq/l
potassium chloride-d5-0.9%nacl intravenous 1 $0 B/D PA; MO
ringers intravenous parenteral solution 1 $0 B/D PA
smooth antacid oral tablet,chewable 4 $0 *
sodium chloride 0.45 % intravenous parenteral 1 $0 MO
solution
sodium chloride 3 % intravenous parenteral 1 $0 MO
solution
sodium chloride 5 % intravenous parenteral 1 $0
solution
sodium chloride intravenous parenteral 1 $0 MO
solution
sodium lactate intravenous solution 1 $0
super calcium oral tablet 4 $0 *
122
TUMS ULTRA ORAL 4 $0 MO; *
TABLET,CHEWABLE 400 MG (1,000 MG)
ultra strength antacid oral tablet,chewable 4 $0 *
ultra strength calcium antacid oral 4 $0 *
tablet,chewable
PRODUCTOS VARIOS DE NUTRICIÓN
amino acids 15 % intravenous parenteral 1 $0 B/D PA
solution
AMINOSYN 10 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN 8.5 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN 8.5 %-ELECTROLYTES 2 $0 B/D PA
AMINOSYN II 10 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
PARENTERAL SOLUTION
PARENTERAL SOLUTION
AMINOSYN II 8.5 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN II 8.5 %-ELECTROLYTES 2 $0 B/D PA
AMINOSYN M 3.5 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN-HBC 7% INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN-PF 10 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
AMINOSYN-PF 7 % (SULFITE-FREE) 2 $0 B/D PA
123
AMINOSYN-RF 5.2 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
CLINIMIX 5%/D15W SULFITE FREE 2 $0 B/D PA
CLINIMIX 5%/D25W SULFITE-FREE 2 $0 B/D PA
CLINIMIX 2.75%/D5W SULFIT FREE 2 $0 B/D PA
CLINIMIX 4.25%/D10W SULF FREE 2 $0 B/D PA
CLINIMIX 4.25%-D20W SULF-FREE 2 $0 B/D PA
CLINIMIX 4.25%-D25W SULF-FREE 2 $0 B/D PA
CLINIMIX 5%-D20W(SULFITE-FREE) 2 $0 B/D PA
CLINIMIX E 4.25%/D5W SULF FREE 2 $0 B/D PA
CLINIMIX E 5%/D15W SULFIT FREE 2 $0 B/D PA
electrolyte-48 in d5w intravenous parenteral 1 $0 B/D PA
solution
HEPATAMINE 8% INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
124
INTRALIPID INTRAVENOUS EMULSION 2 $0 B/D PA; MO
20 %
INTRALIPID INTRAVENOUS EMULSION 2 $0 B/D PA
30 %
IONOSOL-B IN D5W INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
IONOSOL-MB IN D5W INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
ISOLYTE-P IN 5 % DEXTROSE 2 $0
ISOLYTE-S INTRAVENOUS PARENTERAL 2 $0
SOLUTION
liposyn iii intravenous emulsion 10 % 1 $0 B/D PA
liposyn iii intravenous emulsion 20 % 1 $0 B/D PA; MO
NEPHRAMINE 5.4 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
NORMOSOL-M IN 5 % DEXTROSE 2 $0 B/D PA
NORMOSOL-R PH 7.4 INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
PLASMA-LYTE 148 INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
PLASMA-LYTE-56 IN 5 % DEXTROSE 2 $0 B/D PA
PREMASOL 10 % INTRAVENOUS 2 $0 B/D PA; MO
PARENTERAL SOLUTION
PREMASOL 6 % INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
PROCALAMINE 3% INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
125
PROSOL 20 % INTRAVENOUS 2 $0 B/D PA; MO
PARENTERAL SOLUTION
TRAVASOL 10 % INTRAVENOUS 2 $0 B/D PA; MO
PARENTERAL SOLUTION
TROPHAMINE 10 % INTRAVENOUS 2 $0 B/D PA; MO
PARENTERAL SOLUTION
TROPHAMINE 6% INTRAVENOUS 2 $0 B/D PA
PARENTERAL SOLUTION
VITAMINAS / HEMATÍNICOS
a thru z advanced formula oral tablet 4 $0 *
a thru z select 50+ formula oral tablet 4 $0 *
a thru z select oral tablet 500-300-250 mcg 4 $0 *
abc plus oral tablet 4 $0 MO; *
animal chews oral tablet,chewable 4 $0 *
animal shapes complete oral tablet,chewable 4 $0 *
AQUASOL E ORAL DROPS 4 $0 MO; *
ascorbic acid oral tablet 250 mg, 500 mg 4 $0 *
ascorbic acid oral tablet,chewable 4 $0 *
ascorbic acid with rose hips oral tablet 4 $0 *
b complex-vitamin c-folic acid oral tablet 4 $0 MO; *
BALANCED B-100 ORAL TABLET 100 MG 4 $0 *
b-complex with vitamin c oral tablet 4 $0 MO; *
beta carotene oral capsule 4 $0 MO; *
biotin oral capsule 2,500 mcg, 5 mg 4 $0 MO; *
biotin oral tablet 1 mg, 300 mcg 4 $0 MO; *
biotin oral tablet 800 mcg 4 $0 *
c-1000 oral tablet 4 $0 *
c-1000 with rose hips oral tablet 4 $0 *
126
c-500 oral tablet,chewable 4 $0 *
CALCIDOL ORAL DROPS 4 $0 *
centamin oral liquid 4 $0 *
central vite with lutein oral tablet 4 $0 *
central-vite oral tablet 18-400 mg-mcg 4 $0 *
central-vite senior oral tablet 4 $0 *
central-vite with lycopene oral tablet 4 $0 *
central-vite women's under 50 oral tablet 4 $0 *
century adults 50+ oral tablet 4 $0 *
century mature oral tablet 0.4-300-250 mg- 4 $0 *
mcg-mcg, 500-300-250 mcg
century oral tablet 18-400 mg-mcg 4 $0 *
century ultimate women's oral tablet 18-400 4 $0 *
mg-mcg
CEROVITE ADVANCED FORMULA ORAL 4 $0 MO; *
TABLET
CEROVITE ORAL LIQUID 4 $0 MO; *
CERTAVITE SENIOR-ANTIOXIDANT 4 $0 MO; *
ORAL TABLET
chewable multi vitamin oral tablet,chewable 4 $0 *
child vitamin with minerals oral 4 $0 *
tablet,chewable
children's chewable complete oral 4 $0 *
tablet,chewable
children's chewable oral tablet,chewable 4 $0 *
children's chewable vitamin oral 4 $0 *
tablet,chewable
children's chewable w/minerals oral 4 $0 *
tablet,chewable
children's iron oral drops 4 $0 *
127
children's multivit w/extra c oral 4 $0 *
tablet,chewable
children's vitamin with iron oral 4 $0 *
tablet,chewable
CHILD'S CHEWABLE VITAMINS/IRON 4 $0 *
ORAL TABLET,CHEWABLE
child's vitamin with iron oral tablet,chewable 4 $0 *
child's vitamin with vitamin c oral 4 $0 *
tablet,chewable
cholecalciferol (vitamin d3) oral capsule 1,000 4 $0 MO; *
unit, 5,000 unit, 50,000 unit
cholecalciferol (vitamin d3) oral capsule 4 $0 *
10,000 unit, 2,000 unit, 400 unit
complete 50+ oral tablet 4 $0 *
complete multi 50+ oral tablet 4 $0 *
complete multivitamin oral tablet 4 $0 *
complete multivitamin-mineral oral tablet 4 $0 *
complete senior oral tablet 0.4-300-250 mg- 4 $0 MO; *
mcg-mcg
cyanocobalamin (vitamin b-12) injection 3 $0 MO; *
solution
D-2000 ORAL CAPSULE 4 $0 MO; *
daily multiple oral tablet 18-400 mg-mcg 4 $0 *
daily multivitamin with iron oral tablet 4 $0 *
daily vitamin formula + iron oral tablet 4 $0 *
dialyvite 800 oral tablet 4 $0 MO; *
dialyvite vitamin d oral capsule 4 $0 MO; *
dino-life oral tablet,chewable 4 $0 *
dino-life with extra c oral tablet,chewable 4 $0 *
dino-life with iron-zinc oral tablet,chewable 4 $0 *
128
ELDERTONIC ORAL ELIXIR 4 $0 MO; *
ergocalciferol (vitamin d2) oral capsule 3 $0 MO; *
ergocalciferol (vitamin d2) oral drops 4 $0 MO; *
essentia oral tablet 4 $0 *
ezfe 200 oral capsule 4 $0 MO; *
FERATE ORAL TABLET 240 MG (27 MG 4 $0 MO; *
IRON)
FER-IRON ORAL DROPS 4 $0 *
FERREX 150 ORAL CAPSULE 4 $0 MO; *
ferrous gluconate oral tablet 236 mg (27 mg 4 $0 *
iron), 256 mg (28 mg iron)
ferrous gluconate oral tablet 240 mg (27 mg 4 $0 MO; *
iron), 324 mg (36 mg iron), 324 mg (38 mg
iron), 325 mg (36 mg iron)
ferrous sulfate oral drops 4 $0 MO; *
ferrous sulfate oral liquid 4 $0 MO; *
ferrous sulfate oral solution 4 $0 MO; *
ferrous sulfate oral tablet,delayed release 4 $0 MO; *
(dr/ec)
fluoritab oral tablet,chewable 0.5 mg fluoride 1 $0 MO
(1.1 mg)
folic acid oral tablet 1 mg 3 $0 MO; *
folic acid oral tablet 400 mcg, 800 mcg 4 $0 MO; *
fruit c oral tablet,chewable 4 $0 *
fruit c-500 oral tablet,chewable 4 $0 *
full spectrum b-vitamin c oral tablet 4 $0 *
GERIATON ORAL LIQUID 4 $0 *
gummi bear multivitamin oral tablet,chewable 4 $0 *
gummy swirls oral tablet,chewable 4 $0 *
honey bears oral tablet,chewable 4 $0 *
129
honey bears with iron-zinc oral tablet,chewable 4 $0 *
hydroxocobalamin intramuscular solution 3 $0 MO; *
iferex 150 oral capsule 4 $0 MO; *
iron high potency oral tablet 4 $0 *
kid's vitamins + extra c oral tablet,chewable 4 $0 *
kid's vitamins + iron oral tablet,chewable 4 $0 *
kid's vitamins oral tablet,chewable 4 $0 *
little animals oral tablet,chewable 4 $0 *
little animals-iron oral tablet,chewable 4 $0 *
lumitene oral capsule 4 $0 *
lysiplex plus oral liquid 4 $0 MO; *
multi complete with iron oral tablet 4 $0 *
multi-day with iron oral tablet 4 $0 *
MULTI-DELYN ORAL LIQUID 4 $0 MO; *
MULTI-DELYN WITH IRON ORAL LIQUID 4 $0 *
multivital platinum oral tablet 500-300-250 4 $0 *
mcg
multivitamin with minerals oral liquid 4 $0 *
multi-vite oral tablet 4 $0 *
myferon 150 oral capsule 4 $0 MO; *
NEPHRONEX ORAL LIQUID 4 $0 *
one daily multivitamin-iron oral tablet 4 $0 *
one daily plus iron oral tablet 18-400 mg-mcg 4 $0 *
one daily women's health oral tablet 4 $0 *
one daily women's oral tablet 18 mg iron-400 4 $0 *
mcg-450 mg ca
one-a-day teen advantage oral tablet 4 $0 *
pantothenic acid oral tablet 4 $0 MO; *
POLY-IRON ORAL CAPSULE 4 $0 MO; *
130
POLY-VITAMIN ORAL DROPS 4 $0 *
POLY-VITAMIN WITH IRON ORAL 4 $0 *
DROPS 1,500 UNIT-400 UNIT-10 MG/ML
POLYVITAMIN/IRON ORAL 4 $0 *
TABLET,CHEWABLE
POLY-VITAMINS ORAL 4 $0 *
TABLET,CHEWABLE
prenatal vitamin oral tablet 1 $0
PROSIGHT ORAL TABLET 4 $0 *
pyridoxine injection solution 3 $0 MO; *
pyridoxine oral tablet 100 mg, 25 mg, 50 mg 4 $0 *
pyridoxine oral tablet 250 mg 4 $0 MO; *
RENA-VITE ORAL TABLET 4 $0 MO; *
sentry oral tablet 18-400 mg-mcg 4 $0 *
sentry senior oral tablet 4 $0 *
sodium fluoride oral tablet 1 $0
soothing pureway-c oral tablet 4 $0 *
spectravite adult 50+ oral tablet 4 $0 *
spectravite advanced formula oral tablet 4 $0 *
spectravite senior oral tablet 500-300-250 mcg 4 $0 *
spectravite ultra women oral tablet 4 $0 *
stress 500 oral tablet 4 $0 *
stress formula 600 c oral tablet 4 $0 *
STRESS FORMULA ORAL TABLET 4 $0 *
STRESS FORMULA WITH IRON ORAL 4 $0 MO; *
TABLET
super b complex-vitamin c oral tablet 4 $0 *
super b-50 complex oral capsule 4 $0 *
THERA VITAMIN ORAL TABLET 4 $0 MO; *
THERA-M ORAL TABLET 4 $0 *
131
THERA-M ORAL TABLET 9 MG IRON-400 4 $0 MO; *
MCG
therapeutic-m oral tablet 9 mg iron-400 mcg 4 $0 *
thera-tabs m oral tablet 4 $0 *
thiamine hcl injection solution 3 $0 MO; *
thiamine hcl oral tablet 100 mg, 50 mg 4 $0 *
thiamine hcl oral tablet 250 mg 4 $0 MO; *
TRI-VITA ORAL DROPS 4 $0 *
TRI-VITAMIN ORAL DROPS 4 $0 MO; *
vitacel (with lutein) oral tablet 4 $0 MO; *
vitalets oral tablet,chewable 4 $0 *
vitamin a oral capsule 10,000 unit 4 $0 MO; *
vitamin a oral capsule 25,000 unit, 8,000 unit 4 $0 *
vitamin b complex oral capsule 4 $0 *
VITAMIN B-1 ORAL TABLET 4 $0 MO; *
VITAMIN B-12 ORAL TABLET 1,000 MCG, 4 $0 MO; *
500 MCG
VITAMIN B-6 ORAL TABLET 100 MG, 25 4 $0 MO; *
MG, 50 MG
vitamin b-6 oral tablet 200 mg, 250 mg 4 $0 *
vitamin c oral tablet 1,000 mg, 250 mg 4 $0 MO; *
vitamin c oral tablet 100 mg 4 $0 *
VITAMIN C ORAL TABLET,CHEWABLE 4 $0 MO; *
500 MG
vitamin c with rose hips oral tablet 4 $0 MO; *
VITAMIN D2 ORAL CAPSULE 3 $0 MO; *
vitamin d3 oral capsule 1,000 unit, 2,000 unit, 4 $0 MO; *
400 unit
vitamin e (dl, acetate) oral capsule 400 unit 4 $0 MO; *
132
vitamin e oral capsule 100 unit, 200 unit, 400 4 $0 MO; *
unit
VITAMINS B COMPLEX ORAL CAPSULE 4 $0 MO; *
yelets oral tablet 4 $0 *
zoo chews oral tablet,chewable 4 $0 *
133
Índice
1 ACITRETIN ......................... 55 AKWA TEARS

12 hour decongestant .......... 104 ACTEMRA .......................... 92 (POLYVINYL ALCOHOL)
12 HOUR NASAL SPRAY . 66 ACTHAR H.P. ..................... 68 ........................................100
3 ACTHIB (PF) ....................... 88 ala-cort ..................................60
3-day vaginal ........................ 94 ACTIMMUNE ..................... 86 ALAVERT D-12 ALLERGY-
A ACTOPLUS MET XR ......... 69 SINUS.............................104
a thru z advanced formula .. 126 acyclovir ........................... 3, 60 ALBENZA .............................9
a thru z select ...................... 126 acyclovir sodium .................... 3 albuterol sulfate ..................114
a thru z select 50+ formula . 126 ADACEL(TDAP alcalak .................................118
abacavir .................................. 2 ADOLESN/ADULT)(PF) 88 alclometasone .......................60
abacavir-lamivudine- ADAGEN ............................. 63 ALCOHOL PADS ................69
zidovudine .......................... 3 adapalene .............................. 56 ALDURAZYME ..................73
abc plus ............................... 126 ADCIRCA .......................... 113 alendronate .....................63, 91
ABELCET .............................. 2 added strength headache relief aler-cap ............................... 104
ABILIFY .............................. 39 .......................................... 33 alfuzosin .............................117
ABILIFY DISCMELT ......... 38 ADDED STRENGTH PAIN ALIMTA...............................16
ABILIFY MAINTENA ........ 39 RELIEVER ....................... 33 ALINIA ..................................9
ABRAXANE ........................ 16 ADEFOVIR ............................ 3 all day allergy (cetirizine) ...104
ABREVA ............................. 60 ADEMPAS ......................... 113 ALL DAY ALLERGY
acamprosate .......................... 63 adrucil ................................... 16 (CETIRIZINE) ...............104
acarbose ................................ 69 adult cough formula dm max all day allergy-d ..................104
acebutolol ............................. 46 ........................................ 104 allerclear .............................104
ACEPHEN ........................... 32 adult low dose aspirin ........... 33 allerclear d-12hr..................104
acetadryl ............................... 32 adult tussin chest congestion aller-ease .............................104
acetaminophen ...................... 33 ........................................ 104 aller-fex............................... 104
acetaminophen extra strength adult tussin cough congest dm allergy & congestion relief .105
.......................................... 32 ........................................ 104 allergy (chlorpheniramine) .105
acetaminophen pm................ 33 adult tussin dm.................... 104 allergy 4-hour .....................105
acetaminophen pm extra str.. 33 adult tussin multi-symp cold allergy complete-d ..............105
acetaminophen-codeine ........ 29 ........................................ 104 allergy d-12 .........................105
acetasol hc ............................ 67 ADVAIR DISKUS ............. 113 allergy medication ..............105
acetazolamide ..................... 102 ADVAIR HFA ................... 113 allergy medicine .................105
acetazolamide sodium ........ 102 ADVANCED ANTACID- allergy relief (cetirizine) .....105
acetic acid ............................. 67 ANTIGAS ........................ 76 allergy relief (fexofenadine)
acetylcysteine ..................... 113 afeditab cr ............................. 46 ........................................105
acid control (ranitidine) ........ 85 AFINITOR ........................... 16 allergy relief (loratadine) ....105
acid controller ....................... 85 AFINITOR DISPERZ .......... 16 ALLERGY RELIEF
ACID GONE ANTACID ..... 76 afrin no drip(oxymetazolin).. 66 (LORATADINE) ............105
acid reducer (famotidine) ..... 85 AGGRENOX........................ 51 allergy relief d12.................105
acid reducer (ranitidine) ....... 85 A-HYDROCORT ................. 68 allergy relief(chlorpheniramn)
acitretin ................................. 55 AKWA TEARS .................. 100 ........................................105
134
allergy relief(diphenhydramin) AMINOSYN II 8.5 %- antacid liquid ........................77
........................................ 105
ELECTROLYTES.......... 123 antacid maximum strength ...77
allergy relief-d (cetirizine) . 105 AMINOSYN M 3.5 %........ 123 antacid plus anti-gas .............77
allergy relief-d (loratadine) 105 AMINOSYN-HBC 7%....... 123 antacid regular strength ........77
allergy-time ........................ 105
AMINOSYN-PF 10 % ....... 123 ANTACID TABLET ............77
aller-tec ............................... 105
AMINOSYN-PF 7 % antacid ultra strength ....77, 118
aller-tec d ............................ 105
(SULFITE-FREE) .......... 123 antacid with simethicone ......77
allfen ................................... 105
AMINOSYN-RF 5.2 % ...... 124 antacid-antigas ......................77
allopurinol ............................ 91
amiodarone ........................... 45 antacid-simethicone ds .........77
ALMACONE ....................... 76 AMITIZA ............................. 76 anti-diarrhea ..........................75
ALMACONE-2 .................... 76 amitriptyline ......................... 39 anti-diarrheal.........................75
alophen ................................. 76
amlodipine ............................ 46 ANTI-DIARRHEAL
ALPHAGAN P ................... 104 amlodipine-atorvastatin ........ 53 (LOPERAMIDE) ..............75
alprazolam ............................ 39
amlodipine-benazepril .......... 46 antifungal (tolnaftate) ...........58
ALREX............................... 103amlodipine-valsartan ............ 46 ANTIFUNGAL
altachlore ............................ 100
amlodipine-valsartan-hcthiazid (TOLNAFTATE) .............58
altamist ................................. 66
.......................................... 46 antitussive dm .....................106
altavera (28).......................... 95
ammonium lactate ................ 55 APOKYN .............................26
aluminum hydroxide gel....... 76 amnesteem ............................ 56 apraclonidine ......................104
alyacen 1/35 (28) .................. 95 amoxapine ............................ 39 apri ........................................95
alyacen 7/7/7 (28) ................. 95 amoxicil-clarithromy-lansopraz APRISO ................................ 77
amantadine hcl........................ 3 .......................................... 85 APRODINE ........................106
ambi 60pse-400gfn ............. 105 amoxicillin ............................ 12 APTIOM ...............................23
ambi 60pse-4cpm ............... 105 amoxicillin-pot clavulanate .. 12 APTIVUS ...............................3
AMBISOME .......................... 2 amphetamine salt combo ...... 39 AQUASOL E......................126
amcinonide ........................... 60
amphotericin b ........................ 2 ARALAST NP......................63
amethia ................................. 95
ampicillin .............................. 12 aranelle (28) ..........................95
amethia lo ............................. 95
ampicillin sodium ................. 12 ARCALYST .........................86
amethyst ............................... 95
ampicillin-sulbactam ............ 12 aripiprazole ...........................39
AMIFOSTINE AMPYRA ............................. 27 ARIPIPRAZOLE ..................39
CRYSTALLINE............... 15 anagrelide ............................. 63 ARTIFICIAL TEARS ........101
amikacin ................................. 9
anastrozole ............................ 16 ARTIFICIAL TEARS
amiloride............................... 46
ANDROGEL ........................ 73 (PETRO/MIN) ................100
amiloride-hydrochlorothiazide ANDROID............................ 73 artificial tears(hypromellose)
.......................................... 46
animal chews ...................... 126 ........................................101
amino acids 15 % ............... 123 animal shapes complete ...... 126 ascorbic acid .......................126
AMINOSYN 10 % ............. 123 ANORO ELLIPTA............. 114 ascorbic acid with rose hips 126
AMINOSYN 8.5 % ............ 123 antacid .......................... 77, 118 ashlyna ..................................95
AMINOSYN 8.5 %- antacid anti-gas ..................... 77 ASMANEX HFA ...............114
ELECTROLYTES ......... 123 antacid anti-gas double str .... 76 ASMANEX TWISTHALER
AMINOSYN II 10 % ......... 123 antacid ext str (calcium carb) ........................................114
AMINOSYN II 15 % ......... 123 ........................................ 118 aspir-81 .................................33
AMINOSYN II 7 % ........... 123 antacid extra-strength ........... 77 aspirin ...................................33
AMINOSYN II 8.5 % ........ 123 ANTACID EXTRA- aspirin childrens....................33
STRENGTH ................... 118 aspirin low dose ....................33
135
aspirin low-strength .............. 33 baclofen ................................ 28 bisoprolol fumarate ...............46
aspirin, buffered ................... 33 BALANCED B-100 ........... 126 bisoprolol-hydrochlorothiazide
aspir-trin ............................... 33 balsalazide ............................ 77 ..........................................46
ASTAGRAF XL .................. 16 balziva (28) ........................... 95 bleomycin .............................16
atenolol ................................. 46 BANZEL .............................. 23 BLEPHAMIDE S.O.P. .......103
atenolol-chlorthalidone......... 46 BARACLUDE........................ 3 BOOSTRIX TDAP ...............88
athenol .................................. 33 bayer advanced ..................... 33 BOSULIF .............................16
athlete's foot (terbinafine) .... 58 bayer aspirin ......................... 33 briellyn ..................................95
athlete's foot (tolnaftate) ....... 58 baza antifungal ..................... 58 BRILINTA ...........................51
athlete's foot af ..................... 58 BCG VACCINE, LIVE (PF) 88 brimonidine.........................104
atorvastatin ........................... 53 b-complex with vitamin c ... 126 BRINTELLIX .......................39
ATOVAQUONE .................... 9 BELEODAQ ........................ 16 BRISDELLE.........................39
atovaquone-proguanil ............. 9 benazepril ............................. 46 bromfenac ...........................102
ATRIPLA ............................... 3 benazepril-hydrochlorothiazide bromocriptine .......................26
atropine ................................. 75 .......................................... 46 broncotron ped ....................106
ATROVENT HFA ............. 114 BENICAR ............................ 46 BROTAPP ..........................106
aubra ..................................... 95 BENICAR HCT ................... 46 BROTAPP DM ...................106
AVASTIN ............................ 16 BENLYSTA ......................... 92 budesonide ..........................114
AVELOX IN NACL (ISO- benzonatate ......................... 106 BUDESONIDE.....................77
OSMOTIC)....................... 13 benzoyl peroxide .................. 56 bufferin .................................33
aviane ................................... 95 benztropine ........................... 26 bumetanide ...........................46
AVONEX ............................. 86 beta carotene ....................... 126 buprenorphine hcl .................29
AVONEX (WITH ALBUMIN) beta-hc .................................. 60 buprenorphine-naloxone .......34
.......................................... 86 betamethasone dipropionate . 60 buproban ...............................65
AYR SALINE ...................... 66 betamethasone valerate......... 60 bupropion hcl ........................39
AZACITIDINE .................... 16 betamethasone, augmented ... 60 buspirone ..............................39
AZASAN.............................. 16 betaxolol ....................... 46, 100 BUSULFEX .........................16
AZASITE ............................. 99 bethanechol chloride........... 118 butalbital-acetaminop-caf-cod
azathioprine .......................... 16 BETIMOL .......................... 100 ..........................................29
azelastine ...................... 66, 101 BETOPTIC S ...................... 100 butorphanol tartrate ..............34
AZILECT ............................. 26 BEXSERO (PF) .................... 88 BYDUREON ........................69
azithromycin ........................... 8 bicalutamide ......................... 16 BYETTA ..............................69
AZOPT ............................... 102 BICILLIN C-R ..................... 12 BYSTOLIC...........................46
AZOR ................................... 46 BICILLIN L-A ..................... 13 C
aztreonam ............................... 9 BICNU.................................. 16 c-1000 .................................126
azurette (28).......................... 95 biobron sf............................ 106 c-1000 with rose hips..........126
B biocotron ............................. 106 c-250 ...................................126
b complex-vitamin c-folic acid biogil ................................... 106 c-500 ...................................127
........................................ 126 biotin................................... 126 cabergoline ...........................73
baciim ..................................... 9 bisacodyl ............................... 77 CALCIDOL ........................127
bacitracin .................... 9, 58, 99 bisa-lax ................................. 77 calcipotriene .........................55
bacitracin zinc ...................... 58 BISMATROL ....................... 75 calcitonin (salmon) ...............73
bacitracin-polymyxin b ........ 99 bismuth ................................. 75 CALCITRATE ...................118
bacitraycin plus .................... 58 bismuth maximum strength .. 75 calcitrene...............................55
136
calcitriol .......................... 55, 73 carteolol .............................. 100 CERTAVITE SENIOR-
calcium 500 ........................ 118 cartia xt ................................. 47 ANTIOXIDANT ............127
calcium 500 + d .................. 118 carvedilol .............................. 47 CERVARIX VACCINE (PF)
calcium 500 + d (d3) .......... 118 CAYSTON ............................. 9 ..........................................88
calcium 500 with d ............. 119 caziant (28) ........................... 95 cetiri-d.................................106
calcium 600 ........................ 119 cefaclor ................................... 6 cetirizine .............................106
CALCIUM 600 + D(3) ....... 119 cefadroxil ................................ 6 cetirizine-pseudoephedrine .106
calcium 600 with vitamin d3 cefazolin ................................. 7 cevimeline.............................63
........................................ 119 cefazolin in dextrose (iso-os) . 6 CHANTIX ............................66
calcium acetate ................... 119 cefdinir.................................... 7 CHANTIX CONTINUING
calcium antacid ................... 119 cefditoren pivoxil ................... 7 MONTH BOX ..................65
CALCIUM ANTACID ...... 119 cefepime ................................. 7 CHANTIX STARTING
calcium antacid tropical ..... 119 cefixime .................................. 7 MONTH BOX ..................66
calcium carbonate ............... 119 cefotaxime .............................. 7 chateal ...................................95
calcium carbonate-vitamin d3 cefotetan ................................. 7 CHEMET ..............................63
........................................ 119 cefoxitin .................................. 7 CHEST CONGESTION
calcium citrate .................... 119 cefoxitin in dextrose, iso-osm 7 RELIEF...........................106
calcium citrate + ................. 119 cefpodoxime ........................... 7 chest congestion relief d .....106
calcium citrate + d .............. 119 cefprozil .................................. 7 CHEST CONGESTION
calcium citrate-vitamin d3 .. 120 ceftazidime ............................. 7 RELIEF PE .....................106
calcium gluconate ............... 120 ceftriaxone .............................. 7 chest-sinus congestion relief
calcium with vitamin d ....... 120 cefuroxime axetil .................... 7 ........................................106
calcium+d ........................... 120 cefuroxime sodium ............. 7, 8 chewable multi vitamin ......127
camila ................................... 93 celecoxib ............................... 34 child allergy relf(cetirizine) 106
camrese ................................. 95 CELLCEPT .......................... 17 child aspirin ..........................34
camrese lo ............................. 95 CELLCEPT INTRAVENOUS child chest congestion + cough
CANASA ............................. 77 .......................................... 17 ........................................106
CANCIDAS ........................... 2 CELONTIN .......................... 24 child delsym cough+chest dm
candesartan ........................... 46 centamin ............................. 127 ........................................106
candesartan-hydrochlorothiazid central vite with lutein ........ 127 child mucinex chest congestion
.......................................... 47 central-vite .......................... 127 ........................................106
CAPASTAT ........................... 9 central-vite senior ............... 127 CHILD MUCUS RELIEF
CAPRELSA ......................... 17 central-vite with lycopene .. 127 COUGH ..........................106
captopril ................................ 47 central-vite women's under 50 CHILD MUCUS RELIEF
captopril-hydrochlorothiazide ........................................ 127 EXPECTORANT ...........106
.......................................... 47 century ................................ 127 child pain rel-fever reducer ..34
CARAC ................................ 55 century adults 50+ .............. 127 child suppository ..................77
CARAFATE ......................... 85 century mature .................... 127 child vitamin with minerals 127
CARBAGLU ........................ 63 century ultimate women's ... 127 children's allergy complete .107
carbamazepine ................ 23, 24 cephalexin ............................... 8 children's allergy relief(lor) 107
carbidopa .............................. 26 CEREZYME ........................ 73 children's allergy(cetirizine)
carbidopa-levodopa .............. 26 CEROVITE ........................ 127 ........................................107
carbidopa-levodopa- CEROVITE ADVANCED children's aller-tec ...............107
entacapone ........................ 26 FORMULA .................... 127 children's aspirin ...................34
carboplatin ............................ 17 children's cetirizine .............107
137
children's chest congestion . 107 chorionic gonadotropin, human
CLINIMIX 4.25%/D5W
children's chewable ............ 127 .......................................... 73
SULFIT FREE ..................63
children's chewable complete CIALIS ............................... 118
CLINIMIX 4.25%-D20W
........................................ 127 ciclodan ................................ 58
SULF-FREE ...................124
children's chewable vitamin127 ciclopirox .............................. 59
CLINIMIX 4.25%-D25W
children's chewable w/minerals CIDOFOVIR .......................... 3
SULF-FREE ...................124
........................................ 127 cilostazol............................... 51
CLINIMIX 5%-
children's cold & cough ...... 107 CILOXAN ............................ 99
D20W(SULFITE-FREE) 124
CHILDREN'S COLD & cimetidine ............................. 85
CLINIMIX E 2.75%/D10W
COUGH DM .................. 107 cimetidine hcl ....................... 85
SUL FREE ........................63
children's cough .................. 107 CIMZIA ................................ 77
children's dibromm dm cold & CIMZIA POWDER FOR SULF FREE......................63
c ...................................... 107 RECONST ........................ 77
children's fever reducing ...... 34 CINRYZE ........................... 114
SUL FREE ......................124
children's iron ..................... 127 ciprofloxacin ......................... 14
children's mucinex cough ... 107 ciprofloxacin (mixture)......... 14
SUL FREE ......................124
children's multivit w/extra c128 ciprofloxacin hcl ............. 14, 99
children's pain relief ............. 34 ciprofloxacin lactate ............. 14
SULF FREE....................124
children's pepto..................... 77 cisplatin ................................ 17
CLINIMIX E 5%/D15W
children's silapap .................. 34 citalopram ............................. 40
SULFIT FREE ................124
CHILDREN'S SILFEDRINE citrate of magnesia................ 77
CLINIMIX E 5%/D20W
........................................ 107 CITRUS CALCIUM .......... 120 SULFIT FREE ................124
children's vitamin with iron 128 cladribine .............................. 17
CLINIMIX E 5%/D25W
children's wal-zyr ............... 107 claravis.................................. 56
SULFIT FREE ................124
child's all day allergy(cetir) 107 CLARINEX ........................ 107
clobetasol ..............................60
CHILD'S CHEWABLE clarithromycin ........................ 8
clobetasol-emollient .............61
VITAMINS/IRON ......... 128 CLEARLAX ......................... 77
clomipramine ........................40
child's vitamin with iron ..... 128 clemastine ........................... 107
clonazepam ...........................24
child's vitamin with vitamin c CLEOCIN ............................. 94
clonidine ...............................47
........................................ 128 clindamycin hcl ...................... 9
clonidine hcl ...................40, 47
chloramphenicol sod succinate clindamycin pediatric ............. 9
clopidogrel ............................51
............................................ 9 clindamycin phosphate .... 9, 56,
clorazepate dipotassium........40
chlorhexidine gluconate ....... 66 94 clotrimazole ................2, 59, 94
chlorhist .............................. 107 clindamycin-benzoyl peroxideclotrimazole 3 day ................94
chloroquine phosphate............ 9 .......................................... 57
clotrimazole-3 .......................94
chlorothiazide ....................... 47 CLINIMIX 5%/D15W clotrimazole-7 .......................94
chlorothiazide sodium .......... 47 SULFITE FREE ............. 124
clotrimazole-betamethasone .59
chlorpheniramine maleate .. 107 CLINIMIX 5%/D25W clozapine ...............................40
chlorpromazine ............... 39, 40 SULFITE-FREE ............. 124
CLOZAPINE ........................40
chlortabs ............................. 107 CLINIMIX 2.75%/D5W COARTEM.............................9
chlorthalidone ....................... 47 SULFIT FREE ................ 124
codeine sulfate ......................29
cholecalciferol (vitamin d3)128 CLINIMIX 4.25%/D10W CODITUSS DM .................107
cholestyramine light ............. 53 SULF FREE ................... 124
colchicine-probenecid...........91
COLCRYS ............................91
138
cold & cough dm ................ 107 cough formula dm .............. 108 danazol ..................................73
cold & cough elixir............. 107 cough relief ......................... 108 dantrolene .............................29
COLD HEAD CONGESTION COUGH SUPPRESSANT- DAPSONE ............................10
NIGHTTIME .................. 107 EXPECTORANT ........... 108 DAPTACEL (DTAP
cold multi-symptom cough syrup dm .................. 108 PEDIATRIC) (PF) ............88
(chlorphen) ..................... 107 COUGHTAB ...................... 108 DARAPRIM .........................10
colestipol .............................. 53 COUMADIN ........................ 51 dasetta 1/35 (28) ...................95
COLISTIN CRESTOR ............................ 53 dasetta 7/7/7 (28) ..................95
(COLISTIMETHATE NA) 9 CRIXIVAN ............................ 3 daunorubicin .........................17
col-rite .................................. 78 cromolyn ............... 78, 101, 114 DAUNOXOME ....................17
COMBIGAN ...................... 102 cryselle (28) .......................... 95 daysee ...................................95
COMBIPATCH .................... 93 CUBICIN................................ 9 DECITABINE ......................17
COMBIVENT RESPIMAT 114 CUPRIMINE ........................ 92 DELESTROGEN .................93
COMETRIQ ......................... 17 cyanocobalamin (vitamin b-12) delsym cough+chest congest
comfort gel ........................... 78 ........................................ 128 dm ...................................108
comfort gel extra strength .... 78 cyclafem 1/35 (28)................ 95 demeclocycline .....................14
COMPLERA .......................... 3 cyclafem 7/7/7 (28) .............. 95 DEMSER ..............................47
complete 50+ ...................... 128 cyclobenzaprine .................... 29 DENAVIR ............................60
complete allergy ................. 108 cyclopentolate ..................... 100 denta 5000 plus .....................66
complete allergy medicine . 108 CYCLOPHOSPHAMIDE .... 17 dentagel.................................66
complete multi 50+ ............ 128 CYCLOSERINE .................... 9 DEPEN TITRATABS ..........92
complete multivitamin........ 128 CYCLOSET ......................... 69 DEPO-PROVERA ................93
complete multivitamin-mineral cyclosporine.......................... 17 DEPO-SUBQ PROVERA 104
........................................ 128 cyclosporine modified .......... 17 ..........................................93
complete senior .................. 128 cyproheptadine ................... 108 dermarest eczema (hydrocort)
compro .................................. 78 CYSTADANE ...................... 78 ..........................................61
COMVAX (PF) .................... 88 CYSTAGON ...................... 118 desgen dm ...........................108
CONGESTAC .................... 108 cytarabine ............................. 17 desipramine...........................40
constulose ............................. 78 D desloratadine .......................108
COPAXONE ........................ 28 d10 % & 0.45 % sodium desmopressin ........................73
COREG CR .......................... 47 chloride ............................. 63 desonide ................................ 61
cormax .................................. 61 d2.5 %-0.45 % sodium desoximetasone.....................61
cortisone ............................... 68 chloride ............................. 63 despec-dm (phenyleph-dm-
CORTISPORIN-TC ............. 68 D-2000 ................................ 128 guaif)............................... 108
COSENTYX PEN ................ 55 d5 % and 0.9 % sodium dexamethasone .....................68
COSENTYX PEN (2 PENS) 55 chloride ............................. 64 dexamethasone intensol ........68
cough & cold ...................... 108 d5 %-0.45 % sodium chloride dexamethasone sodium
cough & cold mucus relief cf .......................................... 64 phosphate ..................68, 103
........................................ 108 dacarbazine ........................... 17 DEXILANT ..........................85
cough control daily multiple ...................... 128 dexmethylphenidate ..............40
(dextromethorph)............ 108 daily multivitamin with iron dexrazoxane hcl ....................15
cough control (guaifenesin) 108 ........................................ 128 dextroamphetamine ..............40
cough control cf (pe) .......... 108 daily vitamin formula + iron dextroamphetamine-
cough control dm ................ 108 ........................................ 128 amphetamine.....................40
cough control dm max ........ 108 DALIRESP ......................... 114
139
dextrose 10 % and 0.2 % nacl diclofenac-misoprostol ......... 34 DRISTAN LONG LASTING
.......................................... 64 dicloxacillin .......................... 13 ..........................................66
dextrose 10 % in water (d10w) dicyclomine .......................... 75 dronabinol .............................78
.......................................... 64 didanosine............................... 3 DRONABINOL ....................78
dextrose 20 % in water (d20w) diflorasone ............................ 61 DROXIA...............................17
.......................................... 64 diflunisal ............................... 34 dss .........................................78
dextrose 25 % in water (d25w) digitek ................................... 50 ducodyl .................................78
.......................................... 64 digox ..................................... 51 dulcolax stool softener (dss) .78
dextrose 30 % in water (d30w) digoxin .................................. 51 duloxetine .............................40
.......................................... 64 dihydroergotamine................ 27 DURAMORPH (PF) ............29
dextrose 40 % in water (d40w) DILANTIN 30 MG .............. 24 DUREZOL .........................103
.......................................... 64 diltiazem hcl ......................... 47 E
dextrose 5 % in water (d5w) 64 dilt-xr .................................... 47 e.c. prin .................................34
dextrose 5 %-lactated ringers64 dimenhydrinate ..................... 78 e.e.s. 400 .................................8
dextrose 5%-0.2 % sod dino-life .............................. 128 econazole ..............................59
chloride ............................. 64 dino-life with extra c .......... 128 ecotrin low strength ..............34
dextrose 5%-0.3 % dino-life with iron-zinc ....... 128 EDURANT .............................3
sod.chloride ...................... 64 DIOCTO ............................... 78 EFFIENT ..............................51
dextrose 50 % in water (d50w) diotame ................................. 75 EGRIFTA .............................86
.......................................... 64 DIPENTUM ......................... 78 ELAPRASE ..........................73
dextrose 70 % in water (d70w) diphedryl ............................. 109 ELDERTONIC ...................129
.......................................... 64 diphenhydramine hcl .......... 109 electrolyte-48 in d5w ..........124
dextrose with sodium chloride diphenhydramine- ELELYSO ............................73
.......................................... 64 acetaminophen .................. 34 ELIDEL ................................ 56
dextrose-kcl-nacl ................ 120 diskets ................................... 29 ELIGARD.............................17
diabetic siltussin das-na...... 108 disulfiram.............................. 64 elinest ....................................95
diabetic siltussin-dm........... 108 divalproex ............................. 24 eliphos.................................120
diabetic siltussin-dm max str dm max ............................... 109 ELIQUIS...............................51
........................................ 108 DOC-Q-LACE...................... 78 ELITEK ................................ 15
diabetic tussin dm ....... 108, 109 docu ...................................... 78 ELIXOPHYLLIN ...............115
diabetic tussin ex ................ 109 docu soft ............................... 78 ELLA ....................................95
diabetic tussin max st ......... 109 docusate sodium ................... 78 ELMIRON ..........................118
diabetic tussin mucus relief 109 docusil .................................. 78 EMCYT ................................ 17
dialyvite 800 ....................... 128 donepezil .............................. 28 EMEND ................................ 78
dialyvite vitamin d .............. 128 dorzolamide ........................ 102 emoquette .............................96
diamode ................................ 75 dorzolamide-timolol ........... 102 EMSAM ...............................40
diaper rash relief ................... 55 double-tussin dm ................ 109 EMTRIVA ..............................3
diarrhea relief (bismuth subs) doxazosin .............................. 47 enalapril maleate ...................47
.......................................... 75 doxepin ................................. 40 enalapril-hydrochlorothiazide
DIASTAT ............................. 24 doxorubicin........................... 17 ..........................................47
diazepam......................... 24, 40 doxy-100 ............................... 14 ENBREL...............................92
diazepam intensol ................. 40 doxycycline hyclate .............. 14 ENBREL SURECLICK .......92
diclofenac potassium ............ 34 doxycycline monohydrate ... 14, ENDACOF - DM ...............109
diclofenac sodium .. 34, 56, 102 15 endacon ............................... 109
140
endocet ........................... 29, 30 ESTRACE ............................ 93 FERRIPROX ........................65
ENEMA................................ 79 estradiol ................................ 93 ferrous gluconate ................129
ENGERIX-B (PF) ................ 88 estradiol valerate................... 93 ferrous sulfate .....................129
ENGERIX-B PEDIATRIC eszopiclone ........................... 41 FETZIMA .............................41
(PF) ................................... 88 ethambutol ............................ 10 fever reducer .........................35
enoxaparin ............................ 51 ethosuximide ........................ 24 feverall ..................................35
ENOXAPARIN .................... 51 etidronate disodium .............. 65 fexofenadine .......................109
enpresse ................................ 96 etodolac ................................ 34 FIBER ...................................79
enskyce ................................. 96 etoposide............................... 17 FIBER (CALCIUM
entacapone ............................ 26 EVOTAZ ................................ 3 POLYCARBOPHIL) ........79
ENTECAVIR ......................... 3 EXELON .............................. 28 fiber (psyllium husk/sugar)...79
enteric coated aspirin ............ 34 exemestane ........................... 17 FIBER (WITH ASPARTAME)
enulose.................................. 79 EXJADE ............................... 65 ..........................................79
EPANED .............................. 48 expectorant ......................... 109 fiber laxative (husk/sugar) ....79
epinastine............................ 101 ex-strength medi-tabs ........... 35 fiber laxative (methylcellulo)
epinephrine ......................... 109 ex-strength medi-tabs pm ..... 35 ..........................................79
EPIPEN 2-PAK .................. 109 EXTAVIA ............................ 86 fiber laxative (psyllium) s/f ..79
EPIPEN JR 2-PAK ............. 109 ezfe 200 .............................. 129 fiber smooth ..........................79
EPIRUBICIN ....................... 17 F fiber smooth (sucrose) ..........79
epitol ..................................... 24 FABRAZYME ..................... 73 FIBER THERAPY ...............79
EPIVIR ................................... 3 falmina (28) .......................... 96 fiber therapy (ca polycarboph)
EPIVIR HBV.......................... 3 famciclovir.............................. 3 ..........................................79
eplerenone ............................ 48 famotidine............................. 85 FIBER THERAPY
eprosartan ............................. 48 famotidine (pf) ...................... 85 (PSYLLIUM SEED) ........79
EPZICOM .............................. 3 famotidine (pf)-nacl (iso-os) 85 fiber therapy (psyllium) ........79
ergocalciferol (vitamin d2) . 129 FANAPT .............................. 41 fiber-lax ................................ 79
ergoloid................................. 41 FARESTON ......................... 18 fiber-tabs ...............................79
ERIVEDGE .......................... 17 FARXIGA ............................ 69 finasteride ...........................118
errin ...................................... 93 FARYDAK ........................... 18 FIRAZYR ...........................115
ERWINAZE ......................... 17 FASLODEX ......................... 18 flanax antacid........................79
ery pads ................................ 57 FAZACLO............................ 41 flavor chews antacid ...........120
ERYPED 200 ......................... 8 felbamate .............................. 24 flavoxate .............................117
ERYTHROCIN ...................... 8 felodipine .............................. 48 flecainide ..............................45
ERYTHROCIN (AS fenesin ir ............................. 109 FLOVENT DISKUS ..........115
STEARATE) ...................... 8 fenesin pe ir ........................ 109 FLOVENT HFA .................115
erythromycin .................... 9, 99 fenofibrate ............................ 53 fluconazole .............................2
erythromycin ethylsuccinate .. 9 fenofibrate micronized ......... 53 fluconazole in dextrose(iso-o) 2
erythromycin with ethanol ... 57 fenofibrate nanocrystallized . 53 flucytosine ..............................2
erythromycin-benzoyl peroxide fenofibric acid (choline) ....... 53 FLUDARABINE ..................18
.......................................... 57 fenoprofen ............................ 35 fludrocortisone ......................68
ESBRIET ............................ 115 fentanyl ................................. 30 flunisolide ...........................115
escitalopram oxalate ............. 41 FENTANYL CITRATE ....... 30 fluocinolone ..........................61
esomeprazole sodium ........... 85 FERATE ............................. 129 fluocinolone acetonide oil ....67
essentia ............................... 129 FER-IRON.......................... 129 fluocinonide ..........................61
estarylla ................................ 96 FERREX 150 ...................... 129 fluocinonide-e .......................61
141
fluoritab .............................. 129 garamycin ............................. 99 glycopyrrolate .......................75
fluorometholone ................. 103 GARDASIL (PF) .................. 89 gonak ..................................101
fluorouracil ..................... 18, 56 GARDASIL 9 (PF) ............... 89 goniosoft .............................101
fluoxetine.............................. 41 gatifloxacin ........................... 99 goniotaire ............................101
FLUOXETINE ..................... 41 GATTEX ONE-VIAL .......... 79 goniovisc.............................101
fluphenazine decanoate ........ 41 GAUZE PAD ....................... 70 granisetron (pf) .....................80
fluphenazine hcl ................... 41 gavilax .................................. 79 granisetron hcl ......................80
flurbiprofen........................... 35 gavilyte-c .............................. 79 griseofulvin microsize ............2
flurbiprofen sodium ............ 102 gavilyte-g .............................. 79 griseofulvin ultramicrosize .....2
flutamide............................... 18 gavilyte-n .............................. 80 g-tron ..................................109
fluticasone .................... 61, 115 GAZYVA ............................. 18 guaiasorb dm ......................109
fluvastatin ............................. 53 GELNIQUE ........................ 117 guaifenesin ..................109, 110
fluvoxamine.......................... 41 GEMCITABINE .................. 18 guaifenesin-dm ...................110
FML S.O.P. ........................ 103 gemfibrozil ........................... 53 guanfacine.............................41
foaming antacid .................... 79 generlac ................................ 80 guanidine ..............................42
folic acid ............................. 129 gengraf .................................. 18 gummi bear multivitamin ...129
fomepizole ............................ 88 gentak ................................... 99 gummy swirls .....................129
fondaparinux................... 51, 52 gentamicin ................ 10, 58, 99 H
FONDAPARINUX ........ 51, 52 gentamicin in nacl (iso-osm) 10 halobetasol propionate ..........61
for sty relief ........................ 101 GENTAMICIN IN NACL haloperidol ............................42
FORADIL AEROLIZER ... 115 (ISO-OSM) ....................... 10 haloperidol decanoate ...........42
FORFIVO XL ...................... 41 gentlelax ............................... 80 haloperidol lactate ................42
FORTEO .............................. 92 GEODON ............................. 41 HARVONI ..............................4
fortical .................................. 73 GERIATON........................ 129 HAVRIX (PF) ......................89
foscarnet ................................. 4 geri-kot ................................. 80 headache formula..................35
fosinopril .............................. 48 geri-lanta ............................... 80 headache formula added str ..35
fosinopril-hydrochlorothiazide geri-mox antacid-antigas ...... 80 headache pm .........................35
.......................................... 48 geri-tussin ........................... 109 headache relief (asa-acet-caf)
fosphenytoin ......................... 24 gildess ................................... 96 ..........................................35
FOSRENOL ......................... 65 gildess fe ............................... 96 heartburn prevention .............85
FRAGMIN ........................... 52 GILENYA ............................ 28 heartburn relief (ranitidine) ..85
fruit c .................................. 129 GILOTRIF ............................ 18 heather ..................................93
fruit c-500 ........................... 129 GLATOPA ........................... 28 heparin (porcine) ..................52
full spectrum b-vitamin c ... 129 GLEEVEC ............................ 18 heparin (porcine) in 5 % dex 52
furosemide ............................ 48 GLEOSTINE ........................ 18 heparin (porcine) in nacl (pf) 52
FUZEON ................................ 4 glimepiride............................ 70 heparin, porcine (pf) .............52
FYCOMPA .......................... 24 glipizide ................................ 70 HEPATAMINE 8% ............124
G glipizide-metformin .............. 70 HERCEPTIN ........................18
gabapentin ............................ 24 GLUCAGEN HYPOKIT ..... 70 HETLIOZ .............................42
GABITRIL ........................... 24 GLUCAGON EMERGENCY HEXALEN ...........................18
galantamine .......................... 28 KIT (HUMAN)................. 70 hi-cal plus vit d ...................120
GAMMAGARD LIQUID .... 88 glycerin (adult) ..................... 80 high potency calcium ..........120
GAMUNEX-C ..................... 88 glycerin (child) ..................... 80 honey bears .........................129
ganciclovir sodium ................. 4 glycolax ................................ 80 honey bears with iron-zinc .130
142
HORIZANT ......................... 28 ibuprofen ib .......................... 35 ipratropium-albuterol ..........115
HUMALOG ......................... 70 ibuprofen-oxycodone............ 30 i-prin .....................................35
HUMALOG KWIKPEN ...... 70 ICLUSIG .............................. 18 irbesartan ..............................48
HUMALOG MIX 50-50 ...... 70 idarubicin .............................. 18 irbesartan-hydrochlorothiazide
HUMALOG MIX 50-50 iferex 150 ............................ 130 ..........................................48
KWIKPEN ....................... 70 IFOSFAMIDE ...................... 18 IRENKA ...............................42
HUMALOG MIX 75-25 ...... 70 ILARIS (PF) ......................... 86 IRINOTECAN ......................18
HUMALOG MIX 75-25 ILEVRO ............................. 102 iron high potency ................130
KWIKPEN ....................... 70 IMBRUVICA ....................... 18 ISENTRESS ...........................4
HUMIRA ........................ 92, 93 imipenem-cilastatin .............. 10 ISOLYTE-P IN 5 %
HUMIRA CROHN'S DIS imipramine hcl ...................... 42 DEXTROSE ...................125
START PCK .................... 92 imipramine pamoate ............. 42 ISOLYTE-S ........................125
HUMIRA PED CROHN'S imiquimod ............................ 56 isoniazid ................................ 10
STARTER PK .................. 92 IMOVAX RABIES VACCINE ISORDIL ..............................54
HUMULIN 70/30 ................. 70 (PF) ................................... 89 isosorbide dinitrate ...............54
HUMULIN 70/30 KWIKPEN INCRELEX .......................... 65 isosorbide mononitrate .........54
.......................................... 70 indapamide ........................... 48 isradipine ..............................48
HUMULIN N ....................... 71 INFANRIX (DTAP) (PF) ..... 89 ISTODAX.............................19
HUMULIN N KWIKPEN .... 71 infants ibu-drops ................... 35 itraconazole.............................2
HUMULIN R ....................... 71 infant's ibuprofen .................. 35 ivermectin .............................10
HUMULIN R U-500 ............ 71 INFANT'S MEDI-PROFEN 35 IXIARO (PF) ........................89
hydralazine ........................... 48 infant's non-aspirin ............... 35 J
HYDRO SKIN ..................... 61 INFANT'S PAIN RELIEF ... 35 JAKAFI ................................ 19
hydrochlorothiazide .............. 48 infant's pain reliever ............. 35 jantoven ................................ 52
hydrocodone-acetaminophen 30 infants profenib..................... 35 JANUMET ...........................71
hydrocodone-ibuprofen ........ 30 INLYTA ............................... 18 JANUMET XR .....................71
hydrocortisone .......... 62, 68, 80 INSULIN PEN NEEDLE ..... 71 JANUVIA .............................71
hydrocortisone acetate .......... 61 INSULIN SYRINGE (DISP) JARDIANCE ........................71
hydrocortisone butyrate ........ 61 U-100 0.3 ML, 1/2 ML, 1 jencycla .................................93
hydrocortisone butyr-emollient ML .................................... 71 JINTELI ................................ 93
.......................................... 62 INTELENCE .......................... 4 jock itch (terbinafine) ...........59
hydrocortisone valerate ........ 62 intense cough reliever ......... 110 jolessa ...................................96
hydrocortisone-acetic acid.... 67 INTRALIPID...................... 125 jolivette .................................93
hydromorphone .................... 30 INTRON A ........................... 86 junel 1.5/30 (21) ...................96
hydromorphone (pf) ............. 30 introvale ................................ 96 junel 1/20 (21) ......................96
hydroxocobalamin .............. 130 INVANZ ............................... 10 junel fe 1.5/30 (28) ...............96
hydroxychloroquine ............. 10 INVEGA ............................... 42 junel fe 1/20 (28) ..................96
hydroxyurea .......................... 18 INVEGA SUSTENNA ......... 42 junel fe 24 .............................96
hydroxyzine hcl .................. 110 INVEGA TRINZA ............... 42 JUXTAPID ...........................53
HYPERRAB S/D (PF) ......... 89 INVIRASE ............................. 4 K
I inzo antifungal ...................... 59 KADCYLA...........................19
ibandronate ........................... 92 IONOSOL-B IN D5W........ 125 KADIAN ..............................31
IBRANCE ............................ 18 IONOSOL-MB IN D5W .... 125 KALETRA .............................4
ibu-drops............................... 35 IPOL ..................................... 89 KALYDECO ......................115
ibuprofen .............................. 35 ipratropium bromide ..... 67, 115
143
kaopectate (bismuth subsalicy) LASTACAFT ..................... 101 LIALDA ...............................81
.......................................... 75 latanoprost .......................... 102 lice killing (permethrin) ........62
kaopectate ex str (bismuth ss) LATUDA.............................. 42 LICE TREATMENT ............62
.......................................... 75 laxa clear............................... 80 lice treatment (permethrin) ...62
kariva (28) ............................ 96 laxacin .................................. 80 lidocaine ...............................58
kelnor 1/35 (28) .................... 96 laxative ................................. 80 lidocaine (pf) ........................57
KENALOG........................... 68 laxative (glycerin-pediatric) . 80 lidocaine hcl....................57, 58
ketoconazole ..................... 2, 59 laxative dietary supplement 120 lidocaine-prilocaine ..............58
ketoprofen....................... 35, 36 laxative maximum strength .. 80 lindane ..................................62
ketorolac ............................. 102 laxative peg 3350.................. 80 LINEZOLID .........................10
KEYTRUDA ........................ 19 laxative pills ......................... 80 LINZESS ..............................81
KHEDEZLA......................... 42 laxative plus stool softener ... 81 liothyronine...........................75
KIDKARE COUGH/COLD laxative-senna ....................... 81 liposyn iii ............................125
........................................ 110 leflunomide........................... 93 liquibid d-r ..........................110
kid's vitamins ...................... 130 LENVIMA............................ 19 liquid antacid ........................81
kid's vitamins + extra c ....... 130 lessina ................................... 96 lisinopril ................................ 48
kid's vitamins + iron ........... 130 LETAIRIS .......................... 115 lisinopril-hydrochlorothiazide
KINRIX (PF) ........................ 89 letrozole ................................ 19 ..........................................48
KIONEX............................... 65 leucovorin calcium ......... 15, 16 lite coat aspirin .....................36
klor-con .............................. 120 LEUKERAN ........................ 19 lithium carbonate ..................42
klor-con 10 ......................... 120 LEUKINE ............................. 86 lithium citrate........................42
klor-con 8 ........................... 120 leuprolide .............................. 19 little animals .......................130
klor-con m15 ...................... 120 levalbuterol hcl ........... 115, 116 little animals-iron................130
klor-con m20 ...................... 120 LEVEMIR ............................ 71 little remedies .......................67
KOMBIGLYZE XR ............. 71 LEVEMIR FLEXTOUCH ... 71 lo-dose aspirin ......................36
KONSYL (SUGAR) ............ 80 levetiracetam ........................ 25 LOMUSTINE .......................19
KONSYL SUGAR-FREE .... 80 levetiracetam in nacl (iso-os) loperamide ............................76
KORLYM............................. 73 .................................... 24, 25 loradamed ...........................110
k-pec antidiarrheal (bism sub) levobunolol ......................... 100 loratadine ............................110
.......................................... 76 levocarnitine ......................... 65 loratadine-d .........................110
k-tab.................................... 120 levocarnitine (with sugar)..... 65 lorazepam .............................42
kurvelo .................................. 96 levocetirizine ...................... 110 lorazepam intensol ................42
KUVAN ............................... 73 levofloxacin .................... 14, 99 losartan .................................48
L levofloxacin in d5w .............. 14 losartan-hydrochlorothiazide 48
l norgest/e.estradiol-e.estrad . 96 LEVOLEUCOVORIN LOTRONEX.........................81
labetalol ................................ 48 CALCIUM........................ 16 lovastatin...............................53
lactated ringers ............. 63, 120 levonorgestrel ....................... 96 low-ogestrel (28) ..................97
lactulose................................ 80 levonorgestrel-ethinyl estrad 96 loxapine succinate ................42
lamivudine .............................. 4 levora-28 ............................... 97 lta pre-attached .....................58
LAMIVUDINE- levorphanol tartrate............... 31 lubricant eye .......................101
ZIDOVUDINE ................... 4 levothyroxine ........................ 74 LUBRICANT EYE (PG-PEG
lamotrigine ........................... 24 LEVOTHYROXINE ............ 74 400) .................................101
LANOXIN ............................ 51 levoxyl .................................. 74 lubricant eye (polyv alcohol)
lansoprazole .......................... 85 LEXIVA ................................. 4 ........................................101
144
LUBRICATING PLUS ...... 101 medi-profen .......................... 36 methyldopa-
LUMIGAN ......................... 102 medi-tabs .............................. 36 hydrochlorothiazide ..........49
lumitene .............................. 130 medi-tabs pm ........................ 36 methylergonovine .................98
LUPRON DEPOT ................ 19 medi-tussin ......................... 110 METHYLERGONOVINE ...98
LUPRON DEPOT (3 medi-tussin dm ................... 110 methylphenidate ...................43
MONTH) .......................... 19 medi-tussin dm diabetic...... 110 methylprednisolone ..............68
LUPRON DEPOT (4 medroxyprogesterone ........... 94 methylprednisolone acetate ..68
MONTH) .......................... 19 mefenamic acid..................... 36 methylprednisolone sodium
LUPRON DEPOT (6 mefloquine ............................ 10 succ ...................................68
MONTH) .......................... 19 megestrol .............................. 19 metipranolol ........................100
LUPRON DEPOT-PED ....... 19 MEKINIST ........................... 19 metoclopramide hcl ..............81
lutera (28) ............................. 97 meloxicam ............................ 36 metolazone ............................49
LYNPARZA......................... 19 melphalan hcl ....................... 19 metoprolol succinate .............49
LYRICA ............................... 25 MENACTRA (PF) ............... 89 metoprolol ta-hydrochlorothiaz
lysiplex plus........................ 130 MENOMUNE - A/C/Y/W-135 ..........................................49
LYSODREN......................... 19 (PF) ................................... 89 metoprolol tartrate ................49
lyza ....................................... 93 MENVEO A-C-Y-W-135-DIP metronidazole .....10, 11, 57, 94
M (PF) ................................... 90 metronidazole in nacl (iso-os)
MAG 64.............................. 120 MEPHYTON ........................ 52 ..........................................10
magnesium citrate ................ 81 meprobamate ........................ 29 mexiletine .............................45
magnesium oxide................ 120 mercaptopurine ..................... 19 MIACALCIN .......................73
magnesium sulfate .............. 121 meropenem ........................... 10 MI-ACID ..............................81
malathion .............................. 63 mesalamine with cleansing micatin ..................................59
MAPAP wipe .................................. 81 miconazole 7 .........................94
(ACETAMINOPHEN) ..... 36 mesna .................................... 16 miconazole nitrate ..........59, 94
maprotiline ........................... 42 MESNEX.............................. 16 miconazole-3 ........................94
marlissa................................. 97 MESTINON ......................... 29 microgestin 1.5/30 (21) ........97
MARPLAN .......................... 42 MESTINON TIMESPAN .... 29 microgestin 1/20 (21) ...........97
masanti double strength ........ 81 metadate er ........................... 43 microgestin fe 1.5/30 (28) ....97
masophen .............................. 36 metaproterenol .................... 116 microgestin fe 1/20 (28) .......97
MATULANE ....................... 19 metaxalone............................ 29 midodrine ..............................65
matzim la .............................. 48 metformin ............................. 71 migergot ................................ 27
maxiphen ............................ 110 methadone ............................ 31 migraine formula ..................36
meclizine .............................. 81 methadone intensol ............... 31 migraine pain reliever ...........36
meclofenamate ..................... 36 methadose ............................. 31 migraine relief ......................36
medi-bismuth........................ 76 methamphetamine ................ 43 MILK OF MAGNESIA ........81
MEDI-CORTISONE ............ 62 methazolamide.................... 102 millipred ...............................68
medifin expectorant mucus rlf methenamine hippurate ........ 15 mineral oil extra heavy .........81
........................................ 110 methimazole ......................... 69 minocycline ..........................15
medi-lax................................ 81 methotrexate sodium ............ 20 minoxidil...............................49
medi-laxx.............................. 81 methotrexate sodium (pf)19, 20 mirtazapine ...........................43
medi-natural ......................... 81 methoxsalen rapid................. 56 misoprostol ...........................85
medi-natural senna-stool ...... 81 methscopolamine .................. 76 mitomycin .............................20
medi-phedrine..................... 110 methyclothiazide .................. 48 mitoxantrone .........................20
medi-phedryl ...................... 110 M-M-R II (PF) ......................90
145
modafinil .............................. 43 mupirocin calcium ................ 58 natural laxative .....................82
moexipril .............................. 49 MUSTARGEN ..................... 20 natural veg laxative(sennosid)
moexipril-hydrochlorothiazide mycophenolate mofetil ......... 20 ..........................................82
.......................................... 49 mycophenolate sodium ......... 20 natural vegetable ...................82
mometasone.......................... 62 myferon 150 ....................... 130 natural vegetable (psyllium) .82
mono-linyah ......................... 97 MYOZYME ......................... 74 natural vegetable powder ......82
mononessa (28) .................... 97 MYRBETRIQ .................... 117 NEBUPENT .........................11
montelukast ........................ 116 myzilra .................................. 97 necon 0.5/35 (28) ..................97
morgidox .............................. 15 N necon 1/35 (28) .....................97
morphine......................... 31, 32 nabumetone .......................... 36 necon 10/11 (28) ...................97
morphine (pf)........................ 31 nadolol .................................. 49 necon 7/7/7 (28) ....................97
morphine concentrate ........... 31 nadolol-bendroflumethiazide 49 NEEDLES, INSULIN
MOTION SICKNESS .......... 81 nafcillin ................................. 13 DISP.,SAFETY ................71
motion sickness relief ........... 81 NAFCILLIN ......................... 13 nefazodone ............................43
MOVIPREP .......................... 81 NAFCILLIN IN DEXTROSE neomycin ..............................11
moxifloxacin......................... 14 ISO-OSM.......................... 13 neomycin-bacitracin-poly-hc
MOZOBIL............................ 87 NAGLAZYME ..................... 74 ........................................102
mucinex .............................. 110 nalbuphine ............................ 36 neomycin-bacitracin-
mucinex allergy .................. 110 naloxone ............................... 36 polymyxin .........................99
MUCINEX DM .................. 110 naltrexone ............................. 36 neomycin-polymyxin b gu ....63
mucinex fast-max dm max . 110 NAMENDA.......................... 28 neomycin-polymyxin b-
mucosa................................ 110 NAMENDA TITRATION dexameth.........................103
mucus dm ........................... 111 PAK .................................. 28 neomycin-polymyxin-
mucus dm max ................... 111 naphazoline......................... 104 gramicidin .........................99
mucus relief ........................ 111 NAPRELAN CR .................. 36 neomycin-polymyxin-hc......68,
mucus relief chest ............... 111 naproxen ............................... 36 103
mucus relief cough ............. 111 naproxen sodium .................. 37 neo-polycin ...........................99
mucus relief d (phenylephrine) naratriptan ............................. 27 neo-polycin hc ....................103
........................................ 111 nasal decongestant NEORAL ..............................20
mucus relief d (pseudoephed) (pseudoeph) .................... 111 neo-tuss ............................... 111
........................................ 111 NASAL DECONGESTANT NEPHRAMINE 5.4 %........125
mucus relief er .................... 111 (PSEUDOEPH) .............. 111 NEPHRONEX ....................130
MULTAQ ............................. 45 nasal moisturizing................. 67 NEUMEGA ..........................87
multi complete with iron .... 130 NASAL SPRAY NEUPOGEN.........................87
multi-day with iron ............. 130 (OXYMETAZOLINE) ..... 67 NEUPRO ..............................26
MULTI-DELYN ................ 130 nasal spray (sodium chloride) nevirapine ...............................4
MULTI-DELYN WITH IRON .......................................... 67 NEXAVAR...........................20
........................................ 130 NASONEX ......................... 116 NEXT CHOICE ONE DOSE
multi-symptom cold night time NATACYN .......................... 99 ..........................................97
........................................ 111 nateglinide ............................ 71 niacin .............................. 53, 54
multivital platinum ............. 130 NATPARA ........................... 74 nicardipine ............................49
multivitamin with minerals 130 NATURAL BALANCE ..... 101 nicotine .................................66
multi-vite ............................ 130 natural fiber laxative (sugar) 81 nicotine (polacrilex)..............66
mupirocin ............................. 58 natural fiber laxative smooth 82 NICOTROL ..........................66
146
NICOTROL NS.................... 66 NOVOLOG FLEXPEN ........ 72 oralone ..................................67
nifedical xl ............................ 49 NOVOLOG MIX 70-30 ....... 72 ORALYTE .........................121
nifedipine.............................. 49 NOVOLOG MIX 70-30 ORAP ...................................43
night time cold .................... 111 FLEXPEN ........................ 72 ORENCIA (WITH
NILANDRON ...................... 20 NOVOLOG PENFILL ......... 72 MALTOSE) ......................93
nimodipine............................ 49 NOVOTWIST ...................... 72 organ-i nr ............................111
nitro-bid ................................ 54 NOXAFIL .............................. 2 orsythia .................................97
nitrofurantoin macrocrystal .. 15 nts step 1 ............................... 66 oxacillin ................................ 13
nitrofurantoin monohyd/m- NUCYNTA .......................... 37 OXACILLIN ........................13
cryst .................................. 15 NUCYNTA ER .................... 37 oxacillin in dextrose(iso-osm)
nitroglycerin ................... 54, 55 NUEDEXTA ........................ 28 ..........................................13
NITROSTAT ........................ 55 NULOJIX ............................. 20 OXACILLIN IN
nizatidine .............................. 85 NUVARING ......................... 94 DEXTROSE(ISO-OSM) ..13
non-aspirin ............................ 37 nuzole ................................... 59 OXALIPLATIN ...................20
non-aspirin extra strength ..... 37 nyamyc ................................. 59 oxandrolone ..........................74
non-aspirin nightime ............ 37 nystatin ............................. 2, 59 OXANDROLONE ...............74
non-aspirin pain relief .......... 37 nystatin-triamcinolone .......... 59 oxaprozin ..............................37
non-aspirin pain relief pm .... 37 nystop ................................... 59 oxazepam ..............................43
non-aspirin pm...................... 37 O oxcarbazepine .......................25
NORDITROPIN FLEXPRO 87 OCEAN NASAL .................. 67 oxybutynin chloride ............117
NORDITROPIN NORDIFLEX octreotide acetate .................. 20 oxycodone.............................32
.......................................... 87 OCTREOTIDE ACETATE .. 20 oxycodone-acetaminophen ...32
norethindrone (contraceptive) OFEV.................................. 116 oxycodone-aspirin ................32
.......................................... 94 ofloxacin ................... 14, 67, 99 oxymorphone ........................32
norethindrone acetate ........... 94 ogestrel (28) .......................... 97 oyster shell + d3..................121
norgestimate-ethinyl estradiol olanzapine............................. 43 oyster shell calcium 500 .....121
.......................................... 97 olanzapine-fluoxetine ........... 43 oyster shell calcium-vit d3..121
NORMOSOL-M IN 5 % olopatadine ........................... 67 oystercal-d ..........................121
DEXTROSE ................... 125 omega-3 acid ethyl esters ..... 54 P
NORMOSOL-R IN 5 % omeprazole ........................... 85 pacerone ................................ 45
DEXTROSE ................... 121 ONCASPAR......................... 20 PACLITAXEL .....................20
NORMOSOL-R PH 7.4 ..... 125 ondansetron .......................... 82 pain relief ..............................37
NORTHERA ........................ 65 ondansetron hcl..................... 82 pain relief adult .....................37
nortrel 0.5/35 (28) ................ 97 ondansetron hcl (pf).............. 82 pain relief extra strength .......37
nortrel 1/35 (21) ................... 97 one daily multivitamin-iron 130 pain relief pm ........................37
nortrel 1/35 (28) ................... 97 one daily plus iron .............. 130 pain relief pm rapid release ..37
nortrel 7/7/7 (28) .................. 97 one daily women's .............. 130 pain relief regular strength....37
nortriptyline .......................... 43 one daily women's health ... 130 pain reliever ..........................37
NORVIR................................. 4 one-a-day teen advantage ... 130 pain reliever (acetam-aspirin)
novarel .................................. 74 ONFI..................................... 25 ..........................................37
NOVOFINE ......................... 71 ONGLYZA ........................... 72 pain reliever extra strength ...37
NOVOLIN 70/30.................. 71 OPDIVO ............................... 20 pain reliever pm ....................37
NOVOLIN N ........................ 72 OPSUMIT .......................... 116 pain reliever pm ex-strength .37
NOVOLIN R ........................ 72 ORACEA.............................. 15 pain-off .................................37
NOVOLOG .......................... 72 oral electrolytes .................. 121 pamidronate ..........................74
147
pamprin max ......................... 37 phenelzine............................. 43 potassium chloride in 0.9%nacl
PANRETIN .......................... 56 phenobarbital ........................ 25 ........................................121
pantoprazole ......................... 85 PHENYTEK ......................... 25 potassium chloride in 5 % dex
pantothenic acid.................. 130 phenytoin .............................. 25 ........................................121
paricalcitol ............................ 74 phenytoin sodium ................. 25 potassium chloride in lr-d5 .121
paromomycin ........................ 11 phenytoin sodium extended .. 25 potassium chloride-0.45 % nacl
paroxetine hcl ....................... 43 philith.................................... 97 ........................................122
PASER ................................. 11 PHOSPHOLINE IODIDE .. 100 potassium chloride-d5-
PATADAY ......................... 101 pilocarpine hcl .............. 65, 100 0.2%nacl .........................122
PAXIL .................................. 43 pindolol................................. 49 potassium chloride-d5-
p-col rite ............................... 82 pink bismuth ......................... 76 0.3%nacl .........................122
PEDIALYTE ...................... 121 pink bismuth maximum potassium chloride-d5-
pedialyte singles ................. 121 strength ............................. 76 0.9%nacl .........................122
pediatric cough & cold ....... 111 pioglitazone .......................... 72 potassium citrate .................118
pediatric electrolyte ............ 121 pioglitazone-glimepiride ...... 72 POTIGA ...............................25
pediatric freezer pops ......... 121 pioglitazone-metformin ........ 72 powderlax .............................82
PEDVAX HIB (PF) .............. 90 piperacillin-tazobactam ........ 13 PRADAXA ...........................53
peg 3350-electrolytes ........... 82 pirmella................................. 97 pramipexole ..........................27
peg-3350 with flavor packs .. 82 piroxicam .............................. 38 pravastatin.............................54
PEGANONE ........................ 25 PLASMA-LYTE 148 ......... 125 prazosin.................................49
peg-electrolyte soln .............. 82 PLASMA-LYTE A ............ 125 prednicarbate ........................62
PEGINTRON ....................... 87 PLASMA-LYTE-56 IN 5 % prednisolone acetate ...........103
PEGINTRON REDIPEN ..... 87 DEXTROSE ................... 125 prednisolone sodium phosphate
penicillin g potassium........... 13 podactin ................................ 59 ..................................68, 103
penicillin g procaine ............. 13 podofilox .............................. 56 prednisone.............................69
penicillin g sodium ............... 13 polycin .................................. 99 prednisone intensol ...............69
penicillin v potassium........... 13 polyethylene glycol 3350 ..... 82 PREGNYL ............................74
PENTAM ............................. 11 POLY-IRON ...................... 130 PREMARIN .........................94
pentoxifylline ....................... 53 polymyxin b sulfate .............. 11 PREMASOL 10 % .............125
pepcid ac ............................... 85 polymyxin b sulf-trimethoprim PREMASOL 6 % ...............125
pepto-bismol ......................... 76 .......................................... 99 prenatal vitamin oral tablet .131
percogesic ............................. 38 polyvinyl alcohol ................ 101 pres gen ............................... 111
percogesic extra strength ...... 38 POLY-VITAMIN ............... 131 prevalite ................................ 54
PERFOROMIST ................ 116 POLY-VITAMIN WITH previfem ................................ 97
peri-colace ............................ 82 IRON .............................. 131 PREZCOBIX ..........................4
perindopril erbumine ............ 49 POLYVITAMIN/IRON ..... 131 PREZISTA .........................4, 5
periogard............................... 67 POLY-VITAMINS ............. 131 PRIFTIN ...............................11
PERJETA ............................. 21 POMALYST ........................ 21 PRIMAQUINE .....................11
permethrin ............................ 63 portia..................................... 97 primidone ..............................25
perphenazine......................... 43 potassium bicarb and chloride PRISTIQ ...............................44
perphenazine-amitriptyline... 43 ........................................ 121 PROAIR HFA ....................116
pharbechlor ......................... 111 potassium chlorid-d5- probenecid ............................91
pharbedryl........................... 111 0.45%nacl ....................... 121 procainamide ........................45
pharbetol ............................... 38 potassium chloride...... 121, 122 PROCALAMINE 3% .........125
148
prochlorperazine ................... 82 quit 4 ..................................... 66 ringers .................................122
prochlorperazine edisylate.... 82 R risedronate ......................65, 92
prochlorperazine maleate ..... 82 RABAVERT (PF) ................ 90 RISPERDAL CONSTA .......44
PROCRIT ............................. 87 raloxifene .............................. 92 risperidone ............................44
procto-pak............................. 82 ramipril ................................. 49 ri-tussin ............................... 112
proctosol hc .......................... 83 RANEXA ............................. 54 ri-tussin dm .........................112
proctozone-hc ....................... 83 ranitidine hcl ......................... 86 RITUXAN ............................21
progesterone micronized ...... 94 RAPAMUNE........................ 21 rivastigmine tartrate ..............28
PROGLYCEM ..................... 72 RAVICTI .............................. 65 rizatriptan ..............................27
PROLEUKIN ....................... 87 RAYOS ................................ 69 ropinirole ..............................27
PROLIA ............................... 92 REBIF (WITH ALBUMIN) . 87 rosadan ..................................57
PROMACTA........................ 53 REBIF REBIDOSE .............. 87 ROTARIX ............................90
promethazine ...................... 111 REBIF TITRATION PACK. 87 ROTATEQ VACCINE .........90
propafenone .......................... 45 reclipsen (28) ........................ 97 ROZEREM ...........................44
propranolol ........................... 49 RECOMBIVAX HB (PF) .... 90 S
propranolol-hydrochlorothiazid refenesen ............................. 112 SABRIL ................................ 25
.......................................... 49 refenesen pe ........................ 112 saline mist .............................67
propylthiouracil .................... 69 regonol .................................. 29 saline nasal............................67
PROQUAD (PF) .................. 90 REGRANEX ........................ 56 saline nasal mist ....................67
PROSIGHT ........................ 131 REGULOID.......................... 83 saline nose ............................67
PROSOL 20 % ................... 126 RELENZA DISKHALER ...... 5 SAL-PLANT ........................55
protriptyline .......................... 44 RELISTOR ........................... 83 SAMSCA ..............................74
PROVENTIL HFA ............. 116 REMICADE ......................... 83 SANCUSO ...........................83
provil .................................... 38 REMODULIN ...................... 50 SANDIMMUNE...................21
pseudoephedrine hcl ... 111, 112 RENA-VITE ....................... 131 SANDOSTATIN LAR
PULMOZYME................... 116 RENVELA ........................... 65 DEPOT .............................21
pure & gentle eye ............... 101 repaglinide ............................ 72 SANI-SUPP (ADULT) .........83
purelax .................................. 83 reprexain ............................... 32 SANTYL ..............................62
PURIXAN ............................ 21 RESCRIPTOR ........................ 5 SAPHRIS (BLACK
pyrazinamide ........................ 11 reserpine ............................... 50 CHERRY).........................44
PYRETHRIN LICE RESTASIS.......................... 101 SAVELLA ............................93
TREATMENT M ............. 63 RETROVIR ............................ 5 SCOT-TUSSIN DM ...........112
pyridostigmine bromide ....... 29 REVLIMID .......................... 21 secura antifungal ...................59
pyridoxine........................... 131 REYATAZ ............................. 5 selegiline hcl .........................27
Q RHEUMATREX .................. 21 selenium sulfide ....................55
QUADRACEL (PF) ............. 90 ribavirin .................................. 5 SELZENTRY .........................5
quasense ............................... 97 rifabutin ................................ 11 SENEXON-S ........................83
quetiapine ............................. 44 rifampin ................................ 11 SENNA .................................83
quinapril ............................... 49 ri-gel ..................................... 83 senna lax ...............................83
quinapril-hydrochlorothiazide ri-gel ii .................................. 83 senna laxative .......................83
.......................................... 49 riginic.................................... 83 senna plus .............................83
quinidine gluconate .............. 45 riluzole .................................. 65 senna-extra ............................83
quinidine sulfate ................... 45 rimantadine ............................. 5 senna-s ..................................83
quinine sulfate ...................... 11 ri-mox ................................... 83 senno .....................................83
quit 2..................................... 66 ri-mox plus ........................... 83 sennosides-docusate sodium .83
149
sen-o-tab ............................... 83 sorbugen nr ......................... 112 sulfamethoxazole-trimethoprim
SENSIPAR ........................... 74 sorine .................................... 46 ..........................................14
sentry .................................. 131 sotalol ................................... 46 sulfasalazine .........................84
sentry senior ....................... 131 sotalol af ............................... 46 sulfazine ................................ 84
SEREVENT DISKUS ........ 116 SOVALDI .............................. 5 sulfazine ec ...........................84
SEROQUEL XR .................. 44 spectravite adult 50+ .......... 131 sulindac .................................38
sertraline ............................... 44 spectravite advanced formula sumatriptan ...........................27
severe allergy........................ 38 ........................................ 131 sumatriptan succinate ...........27
sf 67 spectravite senior ................ 131 super b complex-vitamin c .131
sf 5000 plus .......................... 67 spectravite ultra women...... 131 super b-50 complex ............131
SIGNIFOR ........................... 21 spironolactone ...................... 50 super calcium ......................122
silace ..................................... 83 spironolacton-hydrochlorothiaz super pain relief ....................38
sildenafil ............................. 116 .......................................... 50 suphedrin ............................112
siltussin dm das .................. 112 sprintec (28) .......................... 98 suphedrin 12 hour ...............112
SILTUSSIN SA .................. 112 SPRYCEL ............................ 21 suphedrine...........................112
siltussin-dm ........................ 112 sronyx ................................... 98 suphedrine 12 hour .............112
silver sulfadiazine ................. 55 ssd ......................................... 55 suppository adult ..................84
SIMULECT .......................... 21 stavudine................................. 5 SUPRAX ................................8
simvastatin............................ 54 stimulant laxative plus .......... 84 SURMONTIL .......................44
sinex ultra fine mist 12-hour 67 STIVARGA .......................... 21 SUSTIVA ...............................5
sinus & allergy non-drowsy 112 stomach relief ....................... 76 SUTENT ...............................21
sinus 12 hour ...................... 112 stomach relief max strength . 76 syeda .....................................98
sinus relief (oxymetazoline) . 67 stomach relief original .......... 76 SYLATRON .........................87
sirolimus ............................... 21 stool softener ........................ 84 SYMBICORT .....................116
SIRTURO ............................. 11 stool softener-laxative .......... 84 SYMLINPEN 120 ................72
smooth antacid.................... 122 stool softener-stimulant laxat84 SYMLINPEN 60 ..................72
sochlor ................................ 101 stop smoking aid ................... 66 SYNAGIS ...............................5
sodium bicarbonate .............. 83 STRATTERA ....................... 44 SYNAREL ............................74
sodium chloride .... 65, 101, 122 STREPTOMYCIN ............... 11 SYNERCID ..........................11
sodium chloride 0.45 %...... 122 stress 500 ............................ 131 SYNRIBO.............................22
sodium chloride 0.9 %.......... 65 STRESS FORMULA ......... 131 SYNTHROID .......................75
sodium chloride 3 %........... 122 stress formula 600 c ............ 131 SYPRINE .............................65
sodium chloride 5 %........... 122 STRESS FORMULA WITH T
sodium fluoride .................. 131 IRON .............................. 131 TABLOID.............................22
sodium lactate..................... 122 STRIBILD .............................. 5 tacrolimus .......................22, 56
sodium polystyrene (sorb free) SUBOXONE ........................ 38 TACROLIMUS ....................22
.......................................... 65 sucralfate .............................. 86 tactinal ..................................38
SOLTAMOX ........................ 21 SUDOGEST SINUS & tactinal extra strength ...........38
soluble fiber .......................... 83 ALLERGY ..................... 112 TAFINLAR ..........................22
SOLU-CORTEF (PF)........... 69 sulfacetamide sodium ......... 103 TAMIFLU ..............................5
SOMATULINE DEPOT ...... 21 sulfacetamide sodium (acne) 58 tamoxifen ..............................22
SOMAVERT ........................ 74 sulfacetamide-prednisolone 103 tamsulosin ...........................118
soothe regular strength ......... 76 sulfadiazine........................... 14 TARCEVA ...........................22
soothing pureway-c ............ 131 TARGRETIN .......................22
150
TASIGNA ............................ 22 TOBRAMYCIN IN 0.225 % trihexyphenidyl .....................27
TAZORAC ........................... 57 NACL ............................... 11 tri-legest fe ............................98
taztia xt ................................. 50 tobramycin in 0.9 % nacl ...... 11 tri-linyah ...............................98
tears again ................... 101, 102 tobramycin sulfate ................ 11 trilyte with flavor packets .....84
TECFIDERA ........................ 28 tobramycin-dexamethasone 103 trimethoprim .........................15
TEFLARO .............................. 8 TOBREX .............................. 99 trinessa (28) ..........................98
TEGRETOL XR ................... 25 tolazamide ............................ 72 TRIPLE ANTIBIOTIC .........58
TEKAMLO .......................... 50 tolbutamide ........................... 72 tri-previfem (28) ...................98
TEKTURNA ........................ 50 tolcapone .............................. 27 TRISENOX ..........................22
TEKTURNA HCT ............... 50 tolmetin................................. 38 tri-sprintec (28) .....................98
telmisartan ............................ 50 tolnaftate ............................... 59 TRIUMEQ ..............................5
telmisartan-hydrochlorothiazid tolterodine........................... 117 TRI-VITA ...........................132
.......................................... 50 topiramate ............................. 26 TRI-VITAMIN ...................132
temazepam ............................ 44 TOPIRAMATE .................... 26 trivora (28) ............................98
TENIVAC (PF) .................... 90 toposar .................................. 22 TROPHAMINE 10 %.........126
terazosin ............................... 50 TOPOTECAN ...................... 22 TROPHAMINE 6%............126
terbinafine hcl ......................... 2 torsemide .............................. 50 tropicamide .........................100
terbutaline ........................... 116 tramadol ................................ 38 trospium .............................. 117
terconazole ........................... 94 tramadol-acetaminophen ...... 38 TRUMENBA ........................90
testosterone enanthate .......... 74 trandolapril ........................... 50 TRUVADA.............................5
tetanus toxoid,adsorbed (pf) . 90 trandolapril-verapamil .......... 50 TUDORZA PRESSAIR .....117
TETANUS,DIPHTHERIA tranexamic acid............... 53, 94 TUMS ULTRA ...................123
TOX PED(PF) .................. 90 TRANSDERM-SCOP .......... 84 tusnel diabetic .....................112
TETANUS-DIPHTHERIA tranylcypromine.................... 44 tussin ...................................113
TOXOIDS-TD.................. 90 TRAVASOL 10 % ............. 126 TUSSIN CF ........................112
tetracycline ........................... 15 travel sickness....................... 84 tussin cf cough-cold ............112
THALOMID......................... 22 travoprost (benzalkonium) . 102 tussin chest congestion .......112
theochron ............................ 116 trazodone .............................. 44 tussin cough &chest congestion
theophylline ........................ 116 TREANDA ........................... 22 ........................................112
THERA VITAMIN ............ 131 TRECATOR ......................... 11 tussin cough (dm only) .......112
THERA-M .................. 131, 132 TRELSTAR .......................... 22 tussin cough dm ..................112
therapeutic-m ...................... 132 tretinoin ................................ 57 tussin dm .............................113
thera-tabs m ........................ 132 TRETINOIN TUSSIN DM .......................113
thiamine hcl ........................ 132 (CHEMOTHERAPY) ...... 22 tussin dm clear ....................113
thioridazine ........................... 44 tretinoin microspheres .......... 57 tussin dm cough ..................113
thiothixene ............................ 44 triamcinolone acetonide 62, 67, tussin dm cough & chest.....113
tiagabine ............................... 26 69, 116 tussin dm max .....................113
TIKOSYN ............................ 46 triamterene-hydrochlorothiazid tussin expectorant ...............113
tilia fe.................................... 98 .......................................... 50 tussin honey ........................113
timolol maleate ............. 50, 100 trianex ................................... 62 tussi-pres .............................113
tinidazole .............................. 11 TRI-BUFFERED ASPIRIN . 38 TWINRIX (PF) .....................91
TIVICAY ............................... 5 triderm .................................. 62 TYBOST.................................6
tizanidine .............................. 29 tri-estarylla............................ 98 TYGACIL.............................11
TOBRADEX ST ................ 103 trifluoperazine ...................... 44 TYKERB ..............................22
tobramycin ............................ 99 trifluridine............................. 99 tylophen ................................ 38
151
TYPHIM VI ......................... 91 vestura (28) ........................... 98 VPRIV ..................................74
TYSABRI ............................. 28 vicks qlearquil allergy ........ 113 VYTORIN 10-10 ..................54
TYZEKA ................................ 6 vicks qlearquil(oxymetazoline) VYTORIN 10-20 ..................54
U .......................................... 67 VYTORIN 10-40 ..................54
ULORIC ............................... 91 VICTOZA 3-PAK ................ 72 VYTORIN 10-80 ..................54
ultra strength antacid .......... 123 VIDEX 2 GRAM PEDIATRIC W
ultra strength calcium antacid ............................................ 6 wal-dryl allergy ..................113
........................................ 123 VIEKIRA PAK....................... 6 wal-fex allergy ....................113
unithroid ............................... 75 VIGAMOX ........................... 99 wal-itin ................................ 113
ursodiol ................................. 84 VIIBRYD ............................. 45 wal-mucil fiber (aspartame) .84
V VIMPAT ............................... 26 wal-mucil natural fiber lax ...84
VAGIFEM ............................ 94 VINBLASTINE.................... 22 wal-profen.............................38
valacyclovir ............................ 6 vincasar pfs ........................... 23 wal-zan 150 ..........................86
VALCHLOR ........................ 56 vincristine ............................. 23 wal-zyr (cetirizine) .............113
VALCYTE ............................. 6 vinorelbine ............................ 23 warfarin.................................53
VALGANCICLOVIR ............ 6 viorele (28) ........................... 98 wart remover .........................55
valproate sodium .................. 26 VIRACEPT ............................ 6 WELCHOL...........................54
valproic acid ......................... 26 VIRAMUNE XR .................... 6 wera (28) ...............................98
valproic acid (as sodium salt) VIRAZOLE ............................ 6 woman's laxative ..................84
.......................................... 26 VIREAD ................................. 6 women's gentle laxative(bisac)
valsartan ............................... 50 vitacel (with lutein) ............ 132 ..........................................84
valsartan-hydrochlorothiazide vitalets ................................ 132 women's laxative (bisacodyl)84
.......................................... 50 vitamin a ............................. 132 women's stool softener .........84
valu-dryl allergy ................. 113 vitamin b complex .............. 132 wymzya fe ............................98
valu-tapp ............................. 113 VITAMIN B-1 .................... 132 X
vancomycin .......................... 15 VITAMIN B-12 .................. 132 XALKORI ............................23
VANCOMYCIN .................. 15 vitamin b-6 ......................... 132 XARELTO ...........................53
vandazole .............................. 95 VITAMIN B-6 .................... 132 XENAZINE ..........................28
VAQTA (PF) ........................ 91 vitamin c ............................. 132 XGEVA ................................ 16
VARIVAX (PF) ................... 91 VITAMIN C ....................... 132 XIFAXAN ............................11
VARIZIG ............................. 91 vitamin c with rose hips...... 132 XIGDUO XR ........................72
VECAMYL .......................... 54 VITAMIN D2 ..................... 132 XOLAIR .............................117
vegetable laxative ................. 84 vitamin d3 ........................... 132 XTANDI ...............................23
VELCADE ........................... 22 vitamin e ............................. 133 XYREM ................................ 45
velivet triphasic regimen (28) vitamin e (dl, acetate) ......... 132 Y
.......................................... 98 VITAMIN K ......................... 53 yelets ...................................133
VELPHORO......................... 65 VITAMIN K1 ....................... 53 YERVOY .............................23
venlafaxine ........................... 44 VITAMINS B COMPLEX . 133 YF-VAX (PF) .......................91
VENTOLIN HFA ............... 117 VITEKTA ............................... 6 Z
VERAMYST ...................... 117 VIVELLE-DOT.................... 94 zafirlukast ...........................117
verapamil .............................. 50 VOLTAREN GEL ................ 38 ZALTRAP ............................23
veripred 20............................ 69 voriconazole ........................... 2 zamicet ..................................32
VERSACLOZ ...................... 45 VORICONAZOLE ................. 2 zantac maximum strength .....86
VESICARE ........................ 117 VOTRIENT .......................... 23 zarah .....................................98
152
ZAVESCA ........................... 74 ziprasidone hcl ...................... 45 ZORTRESS ..........................23
ZELBORAF ......................... 23 ZIRGAN ............................... 99 ZOSTAVAX (PF) ................91
ZEMPLAR ........................... 74 zoledronic acid ..................... 74 zovia 1/35e (28) ....................98
zenchent (28) ........................ 98 zoledronic acid-mannitol-water zovia 1/50e (28) ....................98
zenchent fe............................ 98 .......................................... 65 ZYCLARA ...........................56
ZENPEP ............................... 84 ZOLINZA ............................. 23 ZYDELIG .............................23
zeosa ..................................... 98 zolmitriptan .......................... 27 ZYKADIA ............................23
ZETIA .................................. 54 zolpidem ............................... 45 ZYPREXA RELPREVV ......45
ZIAGEN ................................. 6 ZOMETA ............................. 74 ZYTIGA ...............................23
zidovudine .............................. 6 zonisamide ............................ 26 ZYVOX ................................ 12
zinc oxide ............................. 56 zoo chews ........................... 133
153
Este vademécum se actualizó el 8/19/2015. Para obtener información más reciente o si tiene otras preguntas,
comuníquese con el Plan al 800-815-0000 o, para usuarios de teléfonos de texto (TTY), al 800-662-1220. Se atiende de
lunes a domingo, de 8 a.m. a 8 p.m., o visite www.guildnetny.org.

Lista de Medicamentos Cubiertos Vademécum de 2016

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GuildNet

Gold Plus FIDA Plan

 Los beneficios pueden cambiar el 1º de enero de cada año.

 No se aceptan copagos por ningún medicamento cubierto.

 Вы можете бесплатно получить эту информацию на других языках. Позвоните по

 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후

 El estado de Nueva York ha creado un programa de defensoría del participante llamado

1. ¿Qué medicamentos de prescripción están en la lista de

2. ¿La lista de medicamentos cambia en algún momento?

 Decidir si exigiremos o no una aprobación previa para un medicamento. (La aprobación

Le informaremos cuando un medicamento que esté tomando se elimine de la lista de

3. ¿Qué sucede cuando aparece un medicamento más económico

4. ¿Qué sucede cuando descubrimos que un medicamento no es seguro?

5. ¿Existen restricciones o límites sobre la cobertura de

 Aprobación previa (o autorización previa): Para algunos medicamentos, usted, su

 Si se encuentra en un centro de cuidados para ancianos u otro centro de atención prolongada

6. ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si

7. ¿Qué sucede si cambiamos nuestras normas sobre cómo cubrimos

8. ¿Cómo puede encontrar un medicamento en la lista de

 Puede buscar por enfermedad.

9. ¿Qué sucede si el medicamento que desea tomar no aparece en la

10. ¿Qué sucede si es un nuevo participante del plan GuildNet Gold

 toma un medicamento que forma parte de una restricción de terapia escalonada.

11. ¿Puede solicitar una excepción para cubrir su medicamento?

12. ¿Cuánto tarda en obtenerse una excepción?

13. ¿Cómo puede solicitar una excepción?

Para solicitar una excepción, llame a su administrador de atención. Su administrador de atención

14. ¿Qué son los medicamentos genéricos?

15. ¿Qué son los medicamentos OTC?

17. ¿Cuál es su copago?

No se le cobrará copago por medicamentos de la lista de medicamentos.

18. ¿Qué son los niveles de medicamentos?

 Nivel 1: medicamentos genéricos de Medicare Parte D.

 Nivel 2: medicamentos de marca de Medicare Parte D.

 Nivel 3: medicamentos prescritos cubiertos por Medicaid (no de la Parte D).

 Nivel 4: artículos de venta libre (OTC).

La información en la columna de acciones necesarias, restricciones o límites sobre el uso le

Nota: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la

*: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la Parte D”.

Lista de medicamentos por enfermedad

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.

: El junto a un medicamento quiere decir que el medicamento no es un “medicamento de la Parte D”.